OBSTETRICS-GYNECOLOGY CASE PRESENTATION

OBSTETRICS-GYNECOLOGY CASE PRESENTATION

YAMANAKA, Mariko Jennifer L.San Beda College of Medicine

Department of Obstetrics and GynecologyQuirino Memorial Medical Center

June 28, 2011

GENERAL DATA

• J.M.• 40 year-old female• Married• Residing at Quezon City• Seen for the 1st time at the Quirino Memorial

Medical Center-OB-Emergency Room on June 19, 2011

CHIEF COMPLAINT

• Labor pain

HISTORY OF PRESENT ILLNESS

• 5 hours PTA• Abdominal pain

• start from the back running towards her umbilicus• contractions lasting for less than 5 minutes (2x in

5 minutes)• Streak of blood form her vagina

• Persistence of the pain Consult

• 2 hours after consult• NSD to a live baby boy • Blood loss (400-500 cc)

• RR

• 3 hours after consult• Blood loss (300 cc)• Pale palpebral conjunctivae• Pale nail beds• Tachycardiac

• Persistence and progression Immediate intervention

REVIEW OF SYSTEMS • June 19, 2011

• Unremarkable

PAST MEDICAL HISTORY

• No previous surgeries/hospitalizations• No known allergies to food/medications • Immunizations unrecalled• Chicken Pox – elementary • No known co-morbid illnesses• No history of hypertension, Diabetes Mellitus,

Pulmonary Tuberculosis, cancer, asthma

FAMILY HISTORY • Cancer - Mother• (-) Diabetes Mellitus, thyroid diseases, cardiac

diseases, pulmonary diseases, renal diseases

PERSONAL AND SOCIAL HISTORY

• High-school graduate• Housewife• Lives with her husband and 9 children• Nonsmoker, non-alcohol beverage drinker• Denies illicit drug use• Diet - fish, vegetables, and rice• Water source - NAWASA

OBSTETRIC HISTORY • G10P10 (10-0-0-10)

Year Mode of Delivery Place Gender Complications

G1 1990 NSD QMMC Female (-)

G2 1992 NSD QMMC Male (-)

G3 1994 NSD QMMC Female (-)

G4 1996 NSD QMMC Female (-)

G5 1997 NSD QMMC Male (-)

G6 2001 NSD QMMC Female (-)

G7 2005 NSD QMMC Male (-)

G8 2007 NSD QMMC Male (-)

G9 2009 NSD QMMC Female (-)

G10 2011 NSD QMMC Male (-)

• LMP of last pregnancy• September 22, 2010

• AOG• 38 weeks 4/7 by LMP

• EDC• June 29, 2011

ANTENATAL HISTORY • 2 prenatal check-ups at health center• No prenatal diseases and infections• Transabdominal ultrasound – 3rd trimester

• No abnormalities

MENSTRUAL HISTORY • Menarche - 12 y/o• Regular• Duration - 4-6 days• Interval - 28-30-days • Moderate amount (2-3 pads/day)• No dysmenorrhea/headache

SEXUAL HISTORY • First coitus – 18 y/o • 1 sexual partner • No dysparenuria, post-coital bleeding, history

of sexually transmitted diseases

CONTRACEPTIVE HISTORY

• 1990 – 1994 - Trust OCPs, discontinued• 1996 – present - Coitus interruptus

PHYSICAL EXAMINATION

• June 19, 2011 – Upon Admission• BP: 110/70 mmHg, supine PR: 80 bpm, regular• RR: 18 breaths/min Temp: 36.8 C, per axilla • Conscious, coherent, ambulatory, not in cardio-

respiratory distress• HEENT: Anicteric sclerae, pink palepebral conjunctiva• Cardiovascular: Adynamic precordium, normal rate,

regular rhythm• Abdomen: Round, FHT auscultated at 140s/minute on

left lower quadrant

• Internal Exam: • Cervical dilatation: 7-8 cm• Effacement: 70 %• Presentation: Cephalic• Station: -2• (+) Bag of Water

DIAGNOSTIC EXAMINATIONS

• June 6, 2011• OBSTETRIC TRANSABDOMINAL ULTRASONOGRAPHY

• Uterus is regularly enlarged• Single alive fetus, male• Cephalic presentation• Fetal heart rat e-142 bpm• Absence of gross fetal abnormality• Normal Amniotic fluid volume• RUQ- 3.0 cm, LUQ- 3.4 cm, RLQ- 4.0 cm, LLQ- 3.0 cm = 13. 4

cm• Anterior, high-lying, with grade 2 maturity placenta• Adnexae are clear

Fetal Biometry: Measurement: Age of Gestation:

Biparietal Diameter 9.3 cm 37 weeks and 1 day

Femur Length 7.4 cm 38 weeks and 1 day

Abdominal Circumference 34.1 cm 38 weeks and 2 days

Head Circumference 33.5 cm 37 weeks and 6 days

Estimated Fetal Weight: 3448 grams Impression: Pregnancy, 37 weeks and 6 days gestational age

LABORATORY TESTS • June 19, 2011

Result Reference Range

RBC Low 3.66 4.20-5.40

Hemoglobin Low 105 120-160

Hematocrit Low 0.32 .36-.47

• June 20, 2011Result Reference Range

RBC Low 3.33 4.20-5.40

Hemoglobin Low 99 120-160

Hematocrit Low 0.30 .36-.47

Result Reference Range

Hemoglobin Low 96 120-160

Hematocrit Low 0.28 .36-.47

• June 20, 2011

BLOOD TYPING AND CROSSMATCHING RESULTSBlood Type: ARh Group: +

• June 21, 2011Result Reference Range

RBC Low 2.92 4.20-5.40

Hemoglobin Low 85 120-160

Hematocrit Low 0.26 .36-.47

• June 21, 2001

BLOOD CHEMISTRY

Test Name Result Reference Range

Sodium Low 135 136-145

Potassium 4.1 3.4-5.1

Chloride 104 97-107

• June 21, 2011PT, PTT

Parameters Result Reference Range

Prothrombin Time 10.4 secs 10-14 secs

PT INR 0.87 INR

PT % Activity 119.2 %

PT Normal Control 12.0 secs 10-14 secs

APTT 38.8 secs 28-44 secs

APTT Normal Control 35.5 secs 28-44 secs

• June 22, 2011Result Reference Range

RBC Low 3.02 4.20-5.40

Hemoglobin Low 90 120-160

Hematocrit Low 0.27 .36-.47

• June 23, 2011Result Reference Range

RBC Low 3.86 4.20-5.40

Hemoglobin Low 102 120-160

Hematocrit Low 0.34 .36-.47

COURSE IN THE WARDS

• June 19, 2011• Gave birth via normal spontaneous delivery to a

baby boy• Oxytocin IM• Total blood loss (400-500 cc)

• 10 ”u” of oxytocin - incorporated in IVF• Cefalexin 500 mg/cap q 8° x 7 days • Mefenamic acid 500 mg/cap q 6°, PRN for pain• CXR PA view, Na, K, Cl, AST, ALT, LDH, UA • NPO

• June 20, 2011• Blood loss (300 cc) • Pale palpebral conjunctivae, pale nail beds, and

tachycardiac (110-120 bpm)• Hemoglobin and hematocrit (99, .030)• For emergency hysterectomy secondary to uterine

atony• Ampicillin 2 grams/IV, (-) ANST• 1 unit Voluven

• Underwent emergency Total Abdominal Hysterectomy under subarachnoid block

• Vital signs - stable• 2 units of PRBCs - transfused • Blood loss intra-op - 800-900 cc

• Ketorolac 30 mg IV loading, then 15 mg IV q 6° x 4 doses (-) ANST

• Tramadol 150 mg loading then Tramadol drip 300 mg in 500 cc D5W at 21 gtts/min

• Omeprazole 40 mg IV OD while on NPO• Metoclopramide 10 mg PRN for vomiting• Ampicillin 1 gram IV q 6° (-) ANST• Metronidazole 500 mg IV q 8° x 3 doses (-)ANST• Cconscious and coherent, with pallor. UO -

adequate

• June 21, 2011 and June 22, 2011• Same management

• June 23, 2011• Hemoglobin and hematocrit - slightly below

baseline• Clearance for possible discharge

SALIENT FEATURES • 40 year-old, female• G10P10 (10-0-0-10)• Blood loss of approximately 800 cc• Tachycardic• Pale palpebral conjunctiva• Pale nail beds• Low Hemoglobin and Hematocrit

DIAGNOSIS • G10P10 (10-0-0-10) PUFT, cephalic, delivered

via NSD to a live baby boy with AS 9, Postpartum Hemorrhage secondary to Uterine Atony, S/P Total Abdominal Hysterectomy by Subarachnoid Block

DISCUSSION • Uterine Atony is the failure of the uterus to

contract properly following delivery.

• Failure of contraction and retraction of the myometrium prevents hemostasis and leads to an increase in blood loss.

• Predisposing factors:• high parity• precipitous or prolonged labor• general anesthesia• overdistended uterus (macrosomia, hydramnios,

multifetal pregnancy)• oxytocin augmentation or induction of labor• history of PPH• amniotic fluid embolism• magnesium sulfate in laboring patients• constant kneading and squeezing

• Uterine Atony VS Vaginal Lacerations • based on the condition of the uterus• uterus - soft and boggy following infant and

placental delivery• once uterus is well contracted, but still (+)

bright-red bleeding lacerations

• Complications:• vary, depends on the range of degree of severity• Hypovolemia maternal hypotension, shock, acute

tubular necrosis, dilution coagulopathy, cardiac arrest, and death

• BT-related complications – BT reactions, hemolysis d/t ABO incompatibility, viral diseases (hepatitis & HIV infection), acute lung injury, transmission of bacterial endotoxin, transmission of parasitic agents, graft VS host disease, alloimmunization to blood products, and transfusion-related immunosuppression.

• shock, anemia, infection, kidney failure, or brain damage

MANAGEMENT • fundal massage is indicated • 20 units of oxytocin in 1 L of LR or PNSS, IV, 10

ml/min• oxytocin should never be given as an undiluted

bolus dose as serious hypotension or cardiac arrhythmias may follow

• ergot derivatives: methylergonovine .2 mg, IM• may cause hypertension

• prostaglandin: hemabate 250 grams, IM• contraindicated in asthmatic px•

• if unresponsive to multiple administrations oxytocics:

• bimanual uterine compression and fundal massage• begin blood transfusions• explore uterine cavity manually for retained placental

fragments or lacerations• thoroughly inspect the cervix and vagina after adequate

exposure• add a second large-bore intravenous catheter at the

same time as blood is given• insert a foley catheter to monitor urine output (good

renal perfusion measure)

•

• ligation of arteries• B-Lynch suturing of uterus

• Intractable uterine atony hysterectomy

Thank You.