Obstetrics Case ProtocolBlock G: Calma, Capili, Coruna, Dagang, Datukon, Dayrit, de Castro, de la Llana, Gayeta, Golepang

General DataST29 year old primigravid MarriedRoman Catholic from Las Pinas,

Reason for ConsultFor prenatal checkup

Past Medical Historyunremarkable

Family Medical Historyunremarkable

Personal/Social/Sexual Historyno vicescollege undergraduatefirst coitus was at 28 years old with one non

promiscuous sexual partnerno history of use of OCPs, IUD, condoms, or

any forms of contraception

Menstrual HistoryMenarche at 15 years old regular intervals, 4-5 days, 3-4 pads per dayno dysmenorrhea nor intermenstrual bleedingLNMP: July 15, 2009PMP: June 2009 AOG: 30 1/7 weeks by amenorrhea

Obstetric HistoryG1P0

History of Present Illness6 months PTC: (+) note of missed menses consult with a

private physician where a PT was done and was (+)

Pt asked to follow-up after 1 month

History of Present Illness5 months PTC: sudden onset hypogastric pain, “humihilab”,

VAS 5/10, nonradiating.no vaginal bleeding , watery vaginal discharge,

fever or dysuria. Consulted a local hopital where an UTZ was

done: SLIUP, cephalic with AOG of 15 weeks and 5 days, normohydramnios, large IM and SS myoma in the lower anterior uterine segment more to the left side.

History of Present IllnessDue to unavailability of an obstetrician, pt was

referred to a LH in Cavite for further management

Pt was admitted for 5 days, given unrecalled antibiotics, and was sent home

THM: Isoxilan 1 tab q6, Amoxicillin 500 mg/cap 1 cap TID x 5 days, Flagystatin suppository per vagina during bedtime x 4 days.

History of Present IllnessPt continued to have her prenatal checkups

with a private obstetrician.Plan was for CS however, due to financial

constraints, pt transferred to our institution for further management.

Review of Systems(-) weight loss, anorexia, fever, blurring of

vision, headache, vomiting, abdominal pain, watery or bloody vaginal discharge, dysuria, edema, decreased fetal movement.

Physical Examinationawake, conscious, coherent, NICRDBP 110/70, HR 80, RR 18, afebrileanicteric sclera, pink conjunctivae, (-) cervical

lymphadenopathy, (-) tonsillopharyngeal congestion, (-) anterior neck mass

equal chest expansion, clear breath sounds, (-) rales/wheezes

(-) thrills or heaves, distinct heart sounds, normal rate regular rhythm, (-) murmurs.

Physical ExaminationAbdomen: globular, NABS, (+) 10 x 11 cm

mass at the left lower quadrant, firm, movable and slightly tender

FH 37 cm, EFW 2.6-2.8 kg, FHT 130s, RLQ, cephalic presentation

IE: NEG, smooth nulliparous vagina, cervix was soft, smooth, (-) AMT

FEP, PNB, (-) cyanosis, (-) edema.

AssessmentPU 36 2/7 weeks AOG EUTZ, CIPTL, Myoma uteriG1 P0.

PlanPt was sent to OBAS immediately due to

preterm labor.

UltrasonographyTV and AP UTZ (09/20/2010) Transvaginal and abdominopelvic ultrasound were done.

Within the gravid uterus is a single live fetus in variable presentation. BPD measures 15 cm compatible with 15 weeks and 5 days. HC measures 11.9 cm compatible with 16 weeks and 0 days. AC measures 9.8 cm compatible with 15 weeks and 6 days. FL measures 1.7 cm compatible with 15 weeks and 2 days. There is good cardiac activity with FHR = 158 bpm. The amount of amniotic fluid appropriate for AOG. The immature placenta is posterior in location. EFBW = 130g. There is a huge well rounded heterogenous solid mass located in the lower anterior uterine segment left side of the uterus measuring 8.9 x 7.6 x 8.4 cm suggestive of myoma.

Ultrasonography  Impression: Single, live intrauterine pregnancy, cephalic

with AOG of 15 weeks and 5 days. Normohydramnios. Large intramural and subserous myoma in the lower anterior uterine segment more to the left side.

UltrasonographyFetal and Obstetrical Sonography (12/02/2009) Number of fetus: single Lie: Vertical breech Somatic movement: active Amniotic fluid: Anechoic normohydramnios Placental location: Posterior grade0 Fetal HR: 134 bpm Estimated fetal weight: 1030 g Fetal sex: Male

ULtrasonographyBiometryBPD 66 mm 27 weeksFL 49 mm 26 weeksHC 240 mm 26 weeksAC 219 mm 26 weeksEstimated AOG: 26 weeks and 2 daysEDC: March 8, 2010

Ultrasonography Impression:Within the gravid uterus is a sinle livefetus

breech at present with estimated AOG of 26 weeks and 2 days by biometry. The fetus is active with good cardiac pulsation and normal amniotic fluid. Placenta is located posterior, high lying, with grade 0. No gross fetal anomaly. Note of left lateral wall myoma measuring 6.8 x 8 cm.

Guide QuestionsWhat are Uterine Myomas? What are the

different types?What is the pathophysiology of the

development of myomas?What are the forms of myoma degeneration?

Differentiate each.What are the effects of myomas in pregnancy?What are the effects of pregnancy on myomas?

Guide QuestionsHow should we work-up the patient?How do we manage our patient?What is the ideal management of myomas

during pregnancy? Include medical and surgical management.