OB Case Pres

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    OB CaseRejante, Tito Guillermo Sabong,Lerezyl Salazar, Zara MicahSantiago, Mahalla MaeSeeres,Anna Mercedita Sengco,

    Catherine Tirado, AnnaShemei Uy, Jhoana MichelleVergara, Larraine Yap, RowelDavid

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    General Data ADZ

    22 years old

    Female Filipino

    Married

    Housewife

    Catholic

    1392 Sta. Maria St., Tamaraw Hills, Valenzuela City Consulted for the 2nd time at FUMC on November

    6, 2012.

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    Chief Complaint

    Enlarging Abdomen

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    History of Present Pregnancy

    LMP: March 23, 2012

    PMP: March 13, 2012

    EDC: December 30, 2012

    AOG: 31 3/7 weeks

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    First Trimester

    (+) Dizziness

    Vomiting every morning

    (+) cessation of menses for one month pasther expected menstrual period

    PT with positive result (last week of April, 2012 ) (+) monthly prenatal check-ups TVS confirmed pregnancy Multivitamins, ferrous sulfate and folic acid

    (+) fever (late 1st trimester) paracetamol

    (-) other maternal illnesses (-) exposure to radiation (-) teratogenic drugs were reported.

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    Second Trimester

    Quickening -16-18 weeks AOG

    (-) morning vomiting episodes

    (+) monthly prenatal check-ups

    Multivitamins and ferrous sulfate continued (-) maternal illness, exposure to radiation

    and intake of teratogenic drugs

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    Second Trimester

    Pelvic ultrasound (September 28, 2012) (34 weeksand 4 days AOG) Pregnancy uterine 32 weeks and 4 days by fetal

    biometry live, single fetus in cephalic presentation BPD=82.5 mm 33 weeks 0 days FL=65.3 mm 33 weeks 2 days AC=296.5 mm 33 weeks 5 days HC=293.3 mm 31 weeks 0 days AFI = 12.5 cm Real time scan shows fetal cardiac activity of 157 bpm

    and somatic movements Placenta is in posterior, left, grade II-III maturity,

    adequate amniotic fluid Estimated fetal weight of 2201 g UTZ EDD = January 19, 2013.

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    Third Trimester

    (+) Monthly prenatal check-ups

    Multivitamins and ferrous sulfatecontinued

    (-) Maternal illnesses and teratogenicexposure

    Fetal movements were noted

    (-) Reports of hypogastric pain and anyvaginal bleeding or discharge

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    Past Medical History

    Complete childhood vaccination

    (+) mumps, chickenpox and measles

    during childhood (-) history of drug abuse, violent

    tendencies, or suicidal attempts

    (-) drug or food allergies

    (-) history of blood transfusion Hospitalizations: 2008 and 2010 for

    childbirth via LTCS and repeat LTCS

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    Family Medical History

    (+) diabetes (Paternal).

    (+) hypertension (Paternal)

    (-) asthma

    (-) allergies

    (-) TB

    (-) CAD (-) malignancies

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    Personal and Social History Born and raised in Valenzuela City

    High school graduate

    Fatherjeepney, motherwife

    Currently a full-time housewife

    1.5 pack years Occasional alcoholic beverage drinker

    Stopped upon knowledge of pregnancy

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    OB Gyne Gistory G3P2 (2002)

    Menarche -12 years old

    3 days duration 1-2 moderately soaked pads/day (+) dysmenorrhea (-) medications

    Subsequent menses Irregular (every 1-2 months) 3 days duration 1-2 pads/day, moderately-soaked (-) dysmenorrhea

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    OB Gyne History Coitarche - 18 and 2 sexual partner Last coitus - March 2012

    (+) OCP use after the delivery of first baby

    injectable contraceptives for 6 months(+ headaches) OCP

    (-) history of any STI

    G1 -2008, term, male, CS for breech presentation,

    done at FUMC, no complications, 5.8 lbs G2 -2010, term, female, CS for repeat, done at

    Valenzuela General Hospital, no complications, 5lbs

    G3 -Present

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    Review of Systems

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    Review of Systems

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    Review of Systems

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    Review of Systems

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    PE: General Survey

    Conscious

    Coherent

    Cooperative

    Well-developed

    Ambulatory

    Afebrile

    Fairly nourished

    Oriented X 4

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    PE: Vital Signs

    Temperature: 36.8 C

    Pulse Rate: 78 bpm

    Respiratory Rate: 18 cpm

    Blood Pressure: 90/60 mmHg

    Height: 53

    Weight: 97 kg

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    PE: Skin

    Brown

    Pinkish nail beds

    Good capillary refill

    (-) clubbing of nails noted

    (-) good skin turgor

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    PE: HEENT Eyes Eyebrows thin, black, well-distributed,

    symmetrical Eyelashes black, short, oriented upward,

    outward, no matting No retractions; pink palpebral conjunctivae, no

    lesions Anicteric sclera; cornea transparent, iris brown

    in color; pupils symmetrical, 2-3mm diameter,both eyes (+) direct & consensual pupillaryreflexes; normal accommodation; lenstransparent

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    PE: HEENT Ear: normal, triangular in shape, symmetrical,

    no lesions, deformities or tenderness; both

    external auditory canals have cerumen,cerumen not impacted

    Nose: nose symmetrical, bridge flat; no flaringof alae nasi; patent vestibule with short

    vibrissae; mucosa pinkish in color, no swelling,lesions, secretions or bleeding; nasal septummidline, no perforations

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    PE: HEENT Mouth and Throat

    Lips symmetrical, pinkish in color, moist, smooth, no lesions

    Buccal mucosa pink in color, no lesions

    No tongue deviation on protrusion, frenulum midline

    Gingiva pink; tonsils normal, not swollen, uvula midline

    Teeth incomplete, no dentures

    Neck:

    Skin brown in color, no deformities; trapezius andsternocleidomastoid muscles well-developed, nodeviations, no tenderness

    Trachea midline; thyroid gland not palpable; no difficultyof swallowing was noted; no enlargement of cervicallymph nodes upon palpation

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    PE: Chest and Lumgs Skin is smooth, brown in color

    Symmetrical, no gross deformities

    No lesions

    Normal muscle movement; no lagging, wideningand retractions of ICS

    No superficial blood vessels

    RR18 cpm; no orthopnea or platypnea

    No tenderness or masses

    Equal chest expansion, no lagging

    Equal tactile fremitus

    (+) Resonance

    (+) Vesicular breath; no bronchophony, gophony,whispered pectriloquy, or wheezes.

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    PE: Heart and Blood Vessels Adynamic

    (-) bulging or visible pulsations

    (-) jugular vein distention

    Apical beat - 5th ICS, left MCL No tenderness, masses, heaves, thrills and lifts

    CR 78 bpm, regular, no murmurs, gallops orextra heart sounds

    Carotid pulse is strong, regular and equal,without bruits

    Radial, brachial pulses are strong, regular andequal

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    PE: Abdomen Globular

    Skinbrown with minimal hair, well distributed

    Umbilicus everted, no prominent blood vessels

    Moderate striae (+) Transverse scar at lower abdomen

    No visible peristalsis

    Bowel sounds - normoactive

    FH: 28 cm FHT: 135

    EFW: 2480 grams

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    PE: Pelvic Examination

    Pelvic examination

    Normal looking external genitalia; no gross

    lesions; no bleeding

    Internal examination

    Vagina admits 2 fingers with ease, cervix

    closed, uterus enlarged to AOG

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    PE: Extremities

    Grossly normal

    No cyanosis

    No edema

    Full equal pulses

    Good capillary bed refill

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    Initial Diagnosis

    G3P2 (2002), PU 31 3/7 weeks AOG

    Cephalic, not in labor

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    Plan

    For CBC, Urinalysis, VDRL, HBcAg

    Pap smear on next visit

    FeSO4 1 tab OD

    Multivitamins 1 tab OD

    Advised to increase oral fluid intake

    Advised 10 danger signs of pregnancy Follow-up on November 24, 2012 with lab

    results

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    Final Diagnosis

    G3P3 (3003) PU 39 weeks AOG

    Cephalic delivered repeat LTCS to termBaby Boy

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    Caesarean Section

    Definition: 2 incisions

    Birth of a fetus through:

    An abdominal incision: laparotomy

    A uterine incision: hysterotomy

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    Indications

    Primary

    Dystocia: 37%

    Non-reassuring FHR: 25%

    Abnormal presentation: 20%

    Other: 15%

    Unsuccessful trial of forceps or vacuum:3%

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    Indications

    Repeat cesarean:

    No VBAC attempt: 82%

    Maternal request

    MC indication for a repeat

    Failed VBAC: 17%

    Unsuccessful trial of forceps or vacuum:0.4%

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    Maternal Mortality

    Maternal death: rare, 2.2 in 100 000cesarean deliveries

    9-fold increased risk of maternal death foremergency CD over vaginal

    3-fold increased risk of maternal death for

    elective CD

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    Maternal Morbidity

    Increased 2-fold over vaginal delivery

    Puerperal infection

    Hemorrhage

    Thromboembolism

    Rehospitalisation

    Bladder injury: 1.4 per 1000 procedures Ureteral injury: 0.3 per 1000

    Uterine rupture in subsequent pregnancy

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    CD by Choice Cesarean delivery by maternal request (CDMR)

    Controversial: Avoidance of pelvic floor injury during vaginal birth

    Avoidance of pain during labor & delivery

    Reduction in fetal injury

    Convenience

    National institute of health, ACOG 2007

    Need an informed consent

    Babies at 37 or 38, the mortality is higher

    recommended AOG for CS - 39 weeks unless there is

    evidence of fetal lung maturity With CS , if she only wants to have 1, 2 or 3 children (accreta

    increases 25%)

    Should not be motivated by unavailability of painmanagement for labor

    Ethics - To refuse?

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    TechniquesAbdominal incisions: there are two incisions

    Infraabdominal incisions: there are 2 incisions Vertical incision

    Horizontal incision aka as a bikini cut

    Vertical Quickest to create

    Infant easier to deliver

    Pfannensteil incision Advantage: cosmetic

    Disadvantages: Exposure is not at optimal in repeat surgery, re-entry is more difficult and time consuming Re-entry is difficult b/c of adhesions

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    Techniques

    Uterine incisions: Kerr incision

    MC incision with the least blood loss and chances

    of rupture

    Classical incision 2nd MC type is classical incision. Its a vertical

    incision. Starts from fundus and up to middle of

    uterus.

    T-incision

    If you do a kerr incision first and unable to deliver,

    then you do a classical incision and it ends up to be

    a T-incision

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    Kerr incision:

    Advantages Easier to repair

    less likely to rupture

    does not promote adhesion to bowel or

    omentum to incisional lineDisadvantages

    uterine arteries: so make a U and avoid

    uterine arteries

    if you are anticipating a large baby: i.e.transverse lie or position of baby is

    abnormal

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    Classical section:

    Advantage

    malpresentation

    transverse lie

    multiple fetuses premature, not in labor

    Disadvantage Uterine rupture

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    Indications of Classical CS1. Lower segment cannot be exposed due to thefollowing:a. Bladder densely adherentb. Myoma in lower uterine segmentc. Invasive carcinoma of the cervix.

    2. Transverse lie of a large fetus, especially if the shoulder isimpacted in birth canal and back down

    3. Placenta previa with anterior implantation

    4. Very small fetus, breech presentation and lower segment has

    not thinned out

    5. Massive maternal obesity precluding safe access to loweruterine segment

    6. Multifetal pregnancy

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    Techniques1. Uterine incision

    2. BOW rupture

    3. Head is scooped with one hand

    4. Head is delivered followed by the rest of the

    fetal body

    5. Cord is doubly clamped and cut in between

    6. The placenta is manually extracted and

    delivered. The uterus is inspected for retained

    placental fragments.7. The uterus is repaired in three layers

    8. The ovaries and fallopian tubes are inspected

    9. The abdomen is closed in layers