OB-GYN CASE

REPORT

Katrina Mae Ramos

SBC Medicine 2012

GEN DATA and CHIEF COMPLAINT

L.C., a 38 yo G3P2 (2002), married Filipino,
Catholic, presently residing at Brgy Holy
Spirit, Quezon City admitted at QMMC last
June 19, 2011
Chief Complaint: vaginal bleeding x few hrs

HISTORY OF PRESENT PREGNANCY

LMP: December 4, 2011
AOG: 28 1/7 wks

HISTORY OF PRESENT PREGNANCY

Few hours PTA
Moderate bloody vaginal discharge;
(+) hypogastric pain (Gr. 5/10)
An hour PTA

Profuse bloody vaginal discharge

ANTENATAL HISTORY
4 PNCUs at local health center
Daily multivitamins intake with FeSo4
Good diet with regular intake of milk and

water

REVIEW OF SYSTEMS
General Survey: (-) weight gain, fever, chills,
Skin: (-) rashes, pruritus
Head and Neck: (-) headache
CNS: (-) loss of consciousness, nausea
CVS: (-) easy fatigability, palpitations
Respiratory: (-) difficulty of breathing, chest pain,

cough, hemoptysis
GIT: (-) vomiting, polydipsia, vomiting, dysphagia
GUT: (-) polyuria, diarrhea, constipation, dysuria,
hematuria
Musculoskeletal: (+) pelvic pain, (+) bipedal
edema

PAST MEDICAL HISTORY

(+) HPN 2011
(-) DM, heart dse, PTB, anemia
(-) prior surgery, trauma, blood

transfusions
(-) allergies to food or meds

FAMILY HISTORY
PERSONAL & SOCIAL HISTORY
Maternal & Paternal: u/r
Personal/Social History: u/r

MENSTRUAL & SEXUAL

HISTORY
Menarche : 14 yo
Interval: regular, 28-30 days
Duration: 3-4 days
Amount: 1-2 pads/days
Sx: none

Sexual History
Coitarche: 17 yo with her husband
(-) STDs

OBSTETRIC HISTORY
Gravi
da
G1

Year

Term

1994

G2

1996

FT
(NSD)
FT
(NSD)

G3

2011

Place of
Delivery
home

Complicati
ons
(-)

home

(-)

Present Pregnancy

CONTRACEPTIVE HISTORY
none

PHYSICAL EXAM: General

Survey
conscious, coherent, ambulatory, NICRD

Vital Signs:
BP: 140/110 mmHg
HR: 92 bpm
RR: 18
Temp: 37.1C

PHYSICAL EXAM: Head & Neck

SKIN: good skin turgor, (-) clubbing and cyanosis

HEENT:
Head: normocephalic
Eyes: not bulging or protruding, pale palpebral
conjunctiva, anicteric sclera,
Ears: (-) visible masses, tenderness, discharge
Nose: symmetrical, midline septum, no nasal flaring
Throat: moist oral mucosa, no swelling,tongue
midline, (-) TPC
Neck: supple neck, trachea on midline, thyroid is
not enlarged, (-) LAD

PHYSICAL EXAM: Thorax

Inspection: no supraclavicular or

intercostal retractions, (-) use of accessory

muscles, no masses, lesions,
Palpation: (-) tenderness, symmetrical
chest expansion
Percussion: resonant
Auscultation: clear breath sounds

PHYSICAL EXAM: CVS

Inspection: no visible pulses
Palpation: AB palpated at 5th ICS LMCL, (-)

heaves/thrills
Auscultation: normal rate, regular rhythm,
no murmurs

PHYSICAL EXAM: Abdomen

Inspection: abdomen globular; (-) visible

pulsations, dilated veins; (+) linea nigra,

(+) striae gravidarum
Auscultation: NABS, (-) organomegaly, FHT:
not appreciated by stet & doppler
Palpation: FH=28 cm

PHYSICAL EXAM: Pelvic

Internal Exam (IE): 3 cm cervical dilatation,

50% effaced, cephalic presentation,

floating, (+) BOW

EXTREMITIES: (+) pallor, (+) bipedal

edema, no cyanosis, +2 pulses on both

extremities

ADMITTING DIAGNOSIS

IUFD 28 1/7 wks AOG CIBL G3P2

(2002) Abruptio Placenta sec to
PES

 Plan: Trial of Labor

Date of Operation: June 19, 2011
Post-Op Diagnosis:

G3P3 (2102) IUFD 28 1/7 wks AOG del via

NSD to a dead boy, Abruptio Placenta, PES

COURSE IN THE WARDS

June 19, 2011 (Date of Admission)
NPO, vital signs monitoring q1, IFC
Diagnostics ordered: CBC with APC & BT, PT/PTT, CT & BT,
UA, BUN, Crea, AST, ALT, LDH, Na, K, Cl
Meds ordered: MgSO4, Hydra 5mg TIV q20 mins
(>160/100)
Internal Exam (IE): 4 cm, 60% effaced, st. -2, (-) BOW
after 2 hrs
hypertensive; other vital signs were stable
For LTCS I + BTL
7:30 PM s/p NSD
IVF with oxytocin
advised to start oral meds: Cefuroxime, Mefenamic Acid,

Methyldopa, FeSo4

COURSE IN THE WARDS

June 20, 2011 (Day 1 Post-Op)
BP: 120/90; stable vital signs
repeat laboratory test was done
2 u pRBC was transfused
June 21, 2011 (Day 2 Post-Op)
additional 1 u of pRBC was transfused
June 22, 2011 (Day 3 Post-Op)
additional 1 u of pRBC was transfused

LABORATORY TESTS
CBC Results
June 19 (Pre- June 20 (Day June
22
Op)
1 Post-Op)
(Day
3
Post-Op)
RBC
Hemoglobin

2.20 (L)
59 (L)

2.75 (L)
80 (L)

3.07 (L)
89 (L)

Hematocrit
WBC count
Neutrophils
Lymphocyte

0.18 (L)
26.4 (H)
0.898 (H)
0.070 (L)

0.23 (L)
38.4 (H)
0.883 (H)
0.072 (L)

0.27 (L)
19.2 (H)
N
0.197 (H)

LABORATORY TESTS
Coagulation
June 19 (Pre- June 21 (Day 2
Op)
Post-Op)
Prothrombin 12.3
Time
PT INR

1.02

PT % 72.8
Activity
APTT
35.2

9.1 (L)
0.76
176.4
34.9

LABORATORY TESTS
Glucose
BUN
Crea

Blood Chemistry
3.42 (L)
3.07
73.91 mmol/L

AST
Na
K
Cl
Mg
AST (06/20/11)

53 (H)
136
3.4 (L)
101
0.88
48 (H)

ABRUPTIO PLACENTA
accidental hemorrhage
Incidence: 1/100-1/200 deliveries
Common cause of intrauterine fetal demise
Occurs when all or part of the placenta

separates from the underlying uterine

attachment
premature separation of the normally
implanted placenta

ABRUPTIO PLACENTA
Degree of Detachment:
Partial
Complete
As to Onset
Acute
Chronic
As to Type
External hemorrhage bet. the membranes and uterus
Concealed hemorrhage retained bet the detached
placenta and uterus
Marginal sinus rupture limited to the edge

ABRUPTIO PLACENTA : Risk

Factors
Chronic HPN
Increased age and

parity
Preeclampsia
PROM
Thrombophilias

Maternal trauma

Prior abruption

Smoking

Cocaine use

Uterine leiomyoma

ABRUPTIO PLACENTA : Signs

& Symptoms
Vaginal bleeding* - 80%
Abdominal or back pain and uterine

tenderness - 70%
Fetal distress* - 60%
Abnormal uterine contractions (eg,
hypertonic, high frequency)* - 35%
Idiopathic premature labor - 25%
Fetal death - 15%

Salient Features

Abruptio Placenta

38 yo

More common > 35

28 1/7 wks AOG

Acute
Vaginal bleeding
magnitude of
blood loss
duration

nd

& 3rd trimester

Variable
Continuous

Placenta Previa
More common <19 or >
35

nd
rd
2 & 3 trimester

Variable
Often ceases w/in 1-2
hrs

Moderate
profuse

Red (bright)

Painful

UTZ Findings
(-) fetal heart tone
Internal Exam:
3 cm cervical
dilatation, 50%
effaced, cephalic
presentation,
floating, (+) BOW

PPROM

Before 37 weeks

Sudden gush of
Variable quantity
of clear or slightly
turbid, nearly
colorless liquid

abnormal placentation

Oligohydramnios

Pooling of blood

Leaking bag of
water

Asstd w/ other
obstetric

ABRUPTIO PLACENTA :
Diagnosis
Clot formation retroplacentally
Ultrasonography and doppler imaging
Non-specific markers (thrombomodulin)

significantly elevated

ABRUPTIO PLACENTA
Hemorrhage into the decidua basalis

Decidua splits (thin layer adherent to the

myometrium)

Decidual hematoma

Separation, compression and destruction

placenta

Examination of freshly discovered organ:

circumscribed depression measuring few cms in

ABRUPTIO PLACENTA :
Management
Institute crystalloid fluid resuscitation for the

patient (D5LR or D5W)

Monitor and control of BP, PR, RR, urinary
output
Blood samples drawn for baseline hematocrit,
coagulation studies, blood typing, and
crossmatching
Treatment of associated DIC involves delivery
of the fetus and placenta, restoration of
maternal blood volume, and correction of
coagulation with the use of blood components

ABRUPTIO PLACENTA
Vaginal Delivery
fetus is dead
Cesarean Delivery
live and mature fetus
if vaginal delivery is not imminent

ABRUPTIO PLACENTA :
Complications
Couvelaire uterus
extravasation of blood into the uterine
musculature and beneath the uterine serosa
blue or purple
Acute Renal Failure
massive hemorrhage impaired renal perfusion

Consumptive Coagulopathy