Page 1 DEPARTMENT OF OBSTETRICS AND GYNECOLOGY CLINICO-PATHOLOGICAL CONFERENCE IN OBSTETRTICS...

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

CLINICO-PATHOLOGICAL CONFERENCE

IN

OBSTETRTICS

Francisco, Jeff-rayFrancisco, ReinardGarcia, JenniferGarcia, Maria ReginaGarcia, Marla MarieGarcia, Roman Karlo

CASE

32 year old female G4P2 (2012) AOG of 38th 2/7 weeks married, housewife, Roman Catholic, high school graduate LMP: November 6, 2008EDC: August 13, 2009

Chief Complaint: vaginal bleeding

HISTORY OF PRESENT ILLNESS

Three hours PTA- Brownish discharge soiling her underwear- Vaginal bleeding of bright red blood- 4 fully soaked pads- Irregular contractions

frequency: 3-4 times/hrduration: 20-40 secondsintensity: moderate

OBSTETRIC HISTORY

• G1- NSD; fullterm• G2- Spontaneous abortion; S/P completion curettage• G3- Emergency CS for chromioamnionitis; fullterm no feto-maternal complications G4 (present pregnancy)- With prenatal care- UTI at 30 wks AOG; treated with cefalexin

PAST HISTORY

- Coitarche at 24; (-) coital bleed/pain, STI- OCP use for 2 years (2005-2007) - (-) allergies, family history of HTN, DM,

lung/cardiovascular diseases, cancer, - (+) asthma, dysmenorrhea- Non-smoker; non alcoholic beverage

drinker

PHYSICAL EXAMINATIONGeneral Survey: -Conscious, coherent, ambulatory, NIRD.Conscious, coherent, ambulatory, NIRD.

Vital Signs: BP- 110/70 mmHg, BP- 110/70 mmHg, HR- 96 bpm, HR- 96 bpm, RR- 28 cpm, RR- 28 cpm, T- 36.5°CT- 36.5°C

HEENT: -Anicetric sclerae, pink conjunctivae; No Anicetric sclerae, pink conjunctivae; No tonsillopharyngeal congestion and cervical tonsillopharyngeal congestion and cervical lymphadenopathy.lymphadenopathy.-Breasts: Symetric, no masses, tenderness, or Breasts: Symetric, no masses, tenderness, or nipple discharge.nipple discharge.

CVS: - Adynamic precordium, normal rate, regular rhythm,

distinct S1 and S2, no murmurs.Chest and Lungs: - Equal chest expansion, clear breath sounds.Abdomen:- Globular, prsence of linea nigra,

FH= 33cm, FHT= 140’s. Leopolds-

I=breech II= fetal back maternal leftIII= Vertex, unenganged.

Pelvic Exam:

Inspection- Normal looking external genitalia, with continuous trickling of blood.

Speculum and internal exam both not done.

Extremities: - With Grade 2 bipedal edema, pinkish nailbeds.

8/1/09 8/3/09

Hgb 103 124

Hct 31 36

RBC 3.7

RBC morphology

Slightly hypochromic, normocytic

CBC result

ADMITTING DIAGNOSIS

Uterine pregnancy at 38 and 2/7 weeks AOG by LMP, Cephalic presentation but not in

labor, G4P2 (2012) with 1 previous CS for chorioamnionitis in 2007;

Placenta previa, in hemorrhage.

COURSE IN THE WARDS

- on admission; underwent emergency classical cesarean section 1 with hysterectomy

- Delivery of a live full term baby girl (birth weight of 3.335 kg, Birth length of 52 cm and APGAR score of 9 and 9)

- Blood loss of approximately 2,100 cc and blood transfusion with 3 units of PRBC

- The patient had stable VS at the Recovery Room, and first post-operative day.

- The patient recuperated well until her discharge on the 4th post-operative day.

SUBJECTIVE DATA- 32 y/o female- G4P2 (2012); AOG of 38 2/7 weeks- Vaginal bleeding- Irregular contractions of moderate intensity- Good fetal movement- History of spontaneous abortion; S/P completion

curettage- Emergency CS- Non-smoker; non-alcolic beverage drinker

OBJECTIVE DATA

- Normal VS

- Continuous trickling of blood on pelvic exam

- FH of 33cm; FHT of 140s (normal)

- Bipedal edema, grade 2

- CBC:

low Hgb, Hct and RBC count

slightly hypochromic, normocytic

DIFFERENTIAL DIAGNOSIS:Abruptio placenta

ABRUPTIO PLACENTARULED IN: Risk factors:- increasing maternal age, - multiparity Clinical presentation:- Uterine bleeding Initially brownish discharge followed by bright red

blood bleed- Presence of Uterine contractions

ABRUTIO PLACENTARULED OUT- absence of unremitting abdominal/back pain- Absence of uterine tenderness, often hypertonic

uterus - Absence of other risk factors;

(hydramnios, diabetes mellitus, thrombophilias, uterine tumors like leiomyoma, nephropathy, fibroids, cigarette smoking, alcohol consumption of at least 14 drinks per week, cocaine use, abdominal trauma and maternal type O blood)

- (-) signs of fetal distress

PRIMARY IMPRESSION:Placenta previa

PLACENTA PREVIARULED IN: Risk factors- Increasing maternal age- Multiparity- History of abortion, S/P completion curettage- History of CS, chorioamnionitis Clinical presentation- Painless, persistent vaginal bleeding; bright red

blood- Presence of contractions- (-) signs of fetal distress; unangaged fetal head

Placenta Previa

- Condition in which the placenta implanted in the lower uterine segment within the zone of effacement and dilatation of the cervix

- Leading cause of 3rd trimester bleeding

- Occurs in 1:200 live births

- often associated with placenta accreta.

Diagnosis and Plan of Management

Diagnosis: Clinical presentation:- Painless, persistent vaginal bleeding- (-) signs of fetal distress; unengaged fetal head- (-/+) uterine contractions Presence of Risk Factors:- Increasing maternal age, Multiparity, multiple gestation,

abnormal vascularization of the endometrium caused by scarring or atrophy from previous trauma, surgery or infection, smoking, alcoholic beverages drinking…

definitive diagnosis can be made via a- transabdominal UTZ, or - transvaginal ultrasound

Diagnosis and Plan of Management

Management: 2 possible approaches:

1. cautious surveillance (watchful waiting)

2. active approach

- Delivery of the baby Management prior to delivery:

- correction of blood loss with intravenous fluids

- Blood transfusion

References1Kainer F, Hasbergen U. Emergencies Associated With Pregnancy and Delivery: Peripartum

Hemorrhage. Dtsch Arztebl Int. 2008 September; 105(37): 629–638.

2Lala ABH, Rutherford JM. Massive or recurrent ante partum haemorrhage. Current Obstetrics and Gynaecology. 2002; 12: 226–230.

3Kiondo P, Wandabwa J, Doyle P. Risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda. Afr Health Sci. 2008 March; 8(1): 44–49.

4Neilson JP. In: Ante partum Haemorrhage. Dewhurst text book of Obstetrics and Gynaecology for post graduate students. 6th Ed. Dewhurst , editor. London: Blackwell; 1999.

5Cunningham FG, et al. Williams Obstetrics. 22nd ed. USA: McGraw-Hill Companies, Inc. 2005.

Sakornbut E, et al. Late pregnancy bleeding. American Family Physician. 2007;75:1199.

The Merck Manual, 18th Edition. Abnormalities of Pregnancy: Abruptio placentae; Placenta previa. 2006:2191-2; 2196-7

Current Diagnosis and Treatment: Obstetrics and Gynecology, 10th edition

Robbins Pathologic Basis of Disease. 7th edition.

Board Review Series Pathology. Schneider 3rd edition.

Wikepedia.org

www.pubmedcentral.nih.gov

Page 1 DEPARTMENT OF OBSTETRICS AND GYNECOLOGY CLINICO-PATHOLOGICAL CONFERENCE IN OBSTETRTICS...

Documents

Transcript of Page 1 DEPARTMENT OF OBSTETRICS AND GYNECOLOGY CLINICO-PATHOLOGICAL CONFERENCE IN OBSTETRTICS...