PAMANTASAN NG LUNGSOD NG MAYNILA

COLLEGE OF MEDICINE
Intramuros, Manila, Philippines

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

INTEGRATED CASES

Submitted by: Group 10 - 3A

PINLAC, Vienne D. 2016-70076

QUEQQUEGAN, Benroi M. 2016-70077

QUINTON, Noel Angelo 2016-70078

RAÑOLA, Missia Avva B. 2016-70079

RIOS, Kyra Christine A. 2016-70083

ROLDAN, Brummel A. 2016-70133

April 6, 2019
Discuss the comprehensive and complete management for each case. Justify your answer. Include the
discussion of possible complication/s which may arise in the case.

CASE 1
G5P4, PU 38 weeks, myoma in lower uterine segment measuring 10 x 10 cm. IE - cervix 2 cm
open, intact bag of waters, presenting part cannot be palpated.

Management of the delivery

According to Cunningham, et al. (2014), a classical cesarean incision is indicated if there would
be difficulty in exposing or safely entering the lower uterine segment, such as in this patient with a lower
uterine segment myoma. In addition, since the patient has a 10 x 10 cm myoma, which is large, a
peripartum hysterectomy is also indicated. For this case, vertical midline incision laparotomy is the better
choice for a better visualization and wider area of exploration during cesarean delivery and peripartum
hysterectomy. Every effort should be made to avoid transecting the myoma during hysterotomy.

The obstetrician should first obtain informed consent from the patient before doing the procedure
of choice. This should make the patient aware of her diagnosis, and contain a discussion of medical and
surgical care alternatives, procedure goals and limitations, and surgical risks. For the anesthesia, regional
analgesia is preferred for cesarean delivery. An antacid should be given shortly before regional analgesia
to minimize lung injury risk from aspiration. (Cunningham, et al., 2014).

In women with large anterior lower uterine segment myoma, a third trimester hemoglobin level of
at least 9.5 to 10 mg/dL is desirable, because they are at high risk of intrapartum or postpartum
hemorrhage at the time of cesarean delivery. Preoperative placement of bilateral iliac artery balloon
catheters, use of a cell saver, and availability of blood products in a cooler should be considered on a
case-by-case basis (Ouyang & Norwitz, 2019).

Once the woman is supine, a wedge beneath the right hip should be placed to aid venous return
and avoid hypotension. Fetal heart sounds should be documented in the operating room prior to surgery.
If hair obscures the operative field, it should be removed the day of surgery by clipping, and not by
shaving. An indwelling catheter is typically placed to collapse the bladder away from the hysterotomy
incision, to avery urinary retention secondary to regional analgesia, and to allow accurate postoperative
urine measurement. In addition, the patient should be given thromboprophylaxis, which will be
discontinued once the woman ambulates, usually a day after the procedure. Also, a 1-g dose of cefazolin
shall be given for infection prophylaxis, which is administered as soon as feasible. In addition, either
chlorhexidine or povidone-iodine solutions can be used to prepare the abdominal wall skin to prevent
wound infection (Cunningham, et al., 2014).

For closure, any laparotomy sponges are removed, and the paracolic gutters and cul-de-sac are
gently suctioned of blood and amniotic fluid.For surgical safety, an instrument, sponge, and needle count
before and after surgery is crucial. If counts are not reconciled following abdominal or vaginal
examination, then radiographic imaging for retained foreign objects is obtained. The abdominal incision is
then closed in layers. As each layers are closed, bleeding sites are located, clamped, and ligated or
coagulated with an electrosurgical blade. The rectus abdominis muscles are allowed to fall in place. The
rectus muscle may be approximated with 1 or 2 figure-of-eight sutures of 0 or No. 1 chromic gut suture
The overlying rectus fascia is closed by a continuous, non-locking technique with a delayed-absorbable
suture. The subcutaneous tissues usually need not be closed if it is less than 2 cm thick. With thicker
layers, closure is recommended to minimize seroma or hematoma formation. Skin is closed with a
running subcuticular stitch using 4-0 delayed-absorbable suture (Cunningham, et al., 2014).
Complications
Leiomyomas, or myomas, are benign smooth muscle tumors of the uterus. The potential effects
of myomas on pregnancy and the potential effects of pregnancy on myomas are a frequent clinical
concern since these tumors are common in women of reproductive age. Most pregnant women with
myomas do not have any complications during pregnancy related to the fibroids. Larger myomas (>5 cm
in diameter) like in the case, are more likely to grow than smaller myomas. Pain is the most common
problem; the frequency correlates with size and is especially high in women with myomas of > 5 cm in
diameter. In addition, there may be a slightly increased risk of obstetrical complications such as
postpartum hemorrhage, and placental abruption, but all studies do not show an increased risk of adverse
events.

A. Pain
Pain in myomas are typically due to fibroid degeneration or, rarely, torsion. Rapid growth
of fibroids can result in a relative decrease in perfusion, leading to ischemia and necrosis (red
degeneration) and release of prostaglandins. Myomas that are pedunculated are at risk of torsion
and necrosis, but this is much less common than degeneration.

Painful myomas may require hospitalization for pain management. Supportive care and
administration of acetaminophen as the initial intervention are recommended. The short-term use
of opioids in standard doses or a course of nonsteroidal anti-inflammatory drugs (NSAIDs) can be
given when pain is not controlled by these measures. However, NSAID use should be limited to
pregnancies less than 32 weeks of gestation because of the possibility of inducing premature
closure of the ductus arteriosus, neonatal pulmonary hypertension, oligohydramnios, and
fetal/neonatal platelet dysfunction (Ouyang & Norwitz, 2019).

B. Postpartum Hemorrhage
Several studies have reported an increased risk of postpartum hemorrhage in
pregnancies complicated by fibroids, especially if the fibroids are large (>3 cm) and located
behind the placenta, or the delivery is by cesarean. Pathophysiologically, fibroids could
predispose to postpartum hemorrhage by decreasing both the force and coordination of uterine
contractions, thereby leading to uterine atony. That is why hysterectomy may be done to prevent
massive postpartum hemorrhage secondary to uterine atony (Ouyang & Norwitz, 2019).

C. Placental Abruption
Numerous studies have reported that antepartum bleeding is more common in
pregnancies with fibroids. The location of the fibroid in relation to the placenta appears to be an
important determinant and implies that bleeding is related to abruption. The authors suggested
that the decidua overlying a fibroid may have reduced blood flow, leading to placental ischemia
and decidual necrosis, making the area more susceptible to antepartum bleeding and abruption.
However, since the placenta is normally located in the fundus and the patient in the case has her
myoma in the lower uterine segment, placental abruption is not be expected to occur (Ouyang &
Norwitz, 2019).

CASE 2
G1P0, PU 38 weeks, twin pregnancy, breech-cephalic presentation, not in labor.

Management of the delivery

 The optimal planned mode of delivery for twins remains controversial. Options for delivery route
of cephalic-noncephalic twin pairs include cesarean delivery of both twins or vaginal delivery with
intrapartum external cephalic version or internal version of the second twin.

If the first fetus is nonvertex, cesarean delivery is typically performed. Problems are similar
between first twin presenting as breech and a breech singleton pregnancy. Indications for cesarean
delivery include the following: if the fetus is unusually large and aftercoming head is larger than the birth
canal; the fetal body is small, and delivery of the extremities and trunk through an inadequately effaced
and dilated cervix causes the relatively larger head to become trapped above the cervix; the umbilical
cord prolapses. In the event that these problems are anticipated before delivery, cesarean may be
preferred with a viable-size fetus. For uncomplicated twin pregnancy, the aim is vaginal delivery if the first
twin is cephalic, regardless of the presentation of the second twin. Some obstetricians, however, still
prefer to perform cesarean delivery if the first twin presents as breech even when it is uncomplicated.

Locked twins refer to twin pair with the first presenting as breech and the second cotwin as
cephalic. As the first breech twin passes through the birth canal, the chin locks between the neck and
chin of the second twin. The preferred delivery route is via cesarean.

After vaginal delivery of the first twin, the presenting part of the second twin is carefully
ascertained through abdominal, vaginal, and intrauterine examination. Historically, if the first twin is
cephalic, the second twin will be breech in 39-52% of cases. If the fetal head of the second twin is fixed in
the birth canal, moderate fundal pressure is applied and membranes are ruptured. Afterward, digital
examination of the cervix is repeated to exclude cord prolapse. Labor is then allowed to resume. If
contractions do not begin within 10 minutes, dilute oxytocin may be administered to stimulate
contractions. External cephalic version applies pressure to the maternal abdomen to bring the fetal head
to the pelvic brim. Frequently offered to non-laboring women with uncomplicated breech pregnancy
approaching full term to reduce the need for cesarean section.

If the breech fetus presents immediately over the pelvic inlet but is not fixed in the birth canal, the
presenting part can be guided into the pelvis by one hand in the vagina, while a second hand exerts
moderate pressure caudally on the uterine fundus. Likewise, an assistant may guide the presenting part
with manipulation of the abdomen. Internal version refers to maneuvers with one hand inside the uterus to
bring one or both feet through a fully dilated cervix. Performed less commonly, and used almost
exclusively in the second stage of labor in conjunction with breech extraction to effect delivery of a
second twin with persistence transverse or oblique lie. Breech extraction was considered superior to
external cephalic version. A presenting shoulder may be converted into a cephalic presentation. If the
breech is not over the pelvic inlet and cannot be positioned by gentle pressure or if uterine bleeding
develops, delivery of the cotwin may be more difficult. Intrauterine fetal manipulation with adequate
anesthesia to relax the fetus for vaginal delivery may be done. Internal podalic version turns a fetus to
breech presentation by placing a hand inside the uterus. The fetal feet are grasped by the obstetrician
and pulled to effect delivery by breech extraction. If the obstetrician is not skilled enough to perform this,
prompt cesarean delivery may commence instead.

The safest interval between delivery of the first and second twins was cited to be less than 30
minutes. Breech extraction may be preferable to version since a prolonged intertwin delivery time has
been associated with poorer second twin outcome. Continuous fetal monitoring during the course of labor
improves fetal outcomes even if inter-delivery period extends beyond 30 minutes. A prolonged interval is
associated with worsening cord blood gas values – umbilical arterial pH is significantly lower after an
interval exceeding 15 minutes.
 Cesarean delivery may be necessary for delivery of a second twin after vaginal delivery of the
first cotwin and is considered safe only if the birthweight is greater than 1,500 grams. Indications for such
include the following: second fetus is much larger than the first and is presenting as breech, or the cervix
promptly contracts and thickens after delivery of the first twin. However, this is the least desirable delivery
route but may be required to prevent intrapartum complications such as umbilical cord prolapse, placental
abruption, contracting cervix, and fetal distress; however, this method shows the worst fetal outcomes.

Complications
Multiple pregnancies have high rates of mortality and morbidity when compared to single
pregnancies. This is mainly due to prematurity, complications close to delivery, and placental
insufficiency. The risks are related to chorionicity: monochorionic pregnancies have higher incidence of
perinatal mortality, higher admission to intensive are, and low birth weight. A study showed that the risk of
fetal death increases significantly between 37 and 38 weeks of gestation in twin pregnancy, gradually
declining as it reaches full term. It is thus recommended to increase fetal surveillance after 34 weeks of
gestation in cases of multiple pregnancies (Ko, et al., 2018). Other conditions that may raise the risk of
mortality and perinatal morbidity include: prematurity, intrauterine growth restriction and fetal
malformations. Approximately 55% of twin pregnancies present with prematurity with both short term and
long term adverse consequences. Higher rates of maternal morbidities are also found in multiple
gestations compared to singletons. There is a higher risk of pre-eclampsia and, diabetes and post-partum
complications such as uterine atony and postpartum hemorrhage (Santana, et al., 2018).

Performing maneuvers for successful delivery of the twins also pose fetal and maternal
complications. Internal podalic version and breech extraction may increase the risk of cord prolapse,
shoulder presentation with prolapsed arm, skeletal injury, visceral injury, neural injury, hypoxic brain
injury, and ultimately, perinatal death. Maternal complications include uterine rupture, vaginal and
perineal trauma, placental abruption, postpartum hemorrhage, and ascending infection (Webster &
Loughney, 2011).

CASE 3
G3P2, PU 37 weeks, previous CS for breech, present pregnancy IE-cervix fully dilated, ruptured
BOW, cephalic presentation, station +4.

Management of the delivery

A vaginal delivery is more proper for this case since it has been noted in the case that the baby is
already at station +4 and internal examination shows a full dilated cervix. The weeks of gestation also is
noted to be at 37 weeks, and is considered term already. It is also noted that there is a term rupture of
membranes but it is not given in the case whether the mother is in labor. To determine whether it is
indeed a rupture of membrane, a history of vaginal leakage of fluid from the vagina which is characterized
as a gushing flow should be elicited. After history taking, a prompt speculum examination should be done
to visualize the gross vaginal pooling of the amniotic fluid. Since the presenting part and the gestational
age have already been determined, ultrasonography would only be useful here to assess the amniotic
fluid. A fluid sample should be tested to determine the pH; a vaginal secretion has a more acidic pH
compared to the amniotic fluid (Cunningham et al., 2014).

Because the baby is almost ready to be delivered, hospitalization is indicated for the mother. In
addition, admission to a hospital would help immediately address the problems which may arise such as
umbilical cord prolapse that causes hypoxia and eventual death of the baby. It should also always be
noted that the lungs have fully matured first before the delivery of the baby.
 Labor ideally should be waited so delivery will be much easier and faster. In a study of Mondal
and Kanoongo (2018), labor starts within 24 hours in the majority of PROM cases (85-90%), but 10-15%
of the cases result in delayed labor. Waiting for labor to initiate should not be more than 24 hours since
there would be an increased substantial fetomaternal complications. The use of oxytocin to induce labor
could be utilized to hasten the delivery of the baby. However, since there is PROM, complications such as
umbilical cord prolapse should be suspected and this causes fetal distress. The use of fetal heart
monitors should be done to determine deceleration of fetal heart tones which may indicate fetal distress.
If in case fetal distress is present, a forceps delivery should be utilized. Specifically, the procedure will
most likely be an outlet forceps because the fetal skull has already reached the pelvic floor and the
station is already at +4 (outlet forceps is stations +3, +4, and +5).

One of the fetal indications of forceps delivery is prolapse of the umbilical cord and non-
reassuring FHR pattern, both of which may arise from PROM. In addition, prerequisites for a successful
forceps application include (1) deeply engaged head, (2) fetus presents as vertex or by face with chin
anterior, (3) the position of the fetal head is precisely known, (4) the cervix is completely dilated, (5) the
membranes have ruptured, and (6) there should be no cephalopelvic disproportion. In this case, (1), (4),
and (5) are present in the case. There is a cephalic presentation and the physician should determine first
if the presenting part is the vertex or face with chin anterior. To do this, the internal examination should
include the assessment of the anterior and posterior fontanel, and the sagittal suture. This will also
determine the exact position of the baby and is helpful in placing the forceps properly during the delivery.
For the preparation of the delivery, an epidural anesthesia should be used. If the mother has a full
bladder, a catheter should be inserted. This is important because a full bladder will most likely be injured.
A vacuum delivery may also be used because it will less likely injure the maternal tissues, and it offers
less intracranial pressure during traction.

If in cases the forceps delivery is not successful, a CS is usually resorted to. As a physician, a
cesarean section should be anticipated after the unsuccessful forceps (trial forceps). However, there
would be times wherein a physician is almost sure to deliver the baby vaginally but difficulty of the
process is not anticipated (failed forceps).

Complications
The possible complications of this case is that there is already rupture membranes, the baby just
reached term and that we do not know the history of the previous CS delivery as we are to do a vaginal
delivery after a Cesarean delivery. The baby is already at station 4+ and so the baby will most likely
delivered spontaneously. To following will address the issues stated:

A. Vaginal birth after Cesarean section

VBAC should be advised only when there is a previous vaginal delivery and if there is only
one previous Cesarean section that uses the Kerr incision. The Cesarean section should be at least
18 months prior the VBAC. In the case, there is no statement if the first pregnancy is through a
vaginal delivery and if the interval from the Cesarean delivery is at least 18 months. A vaginal
delivery after a Cesarean section has major complications of significant difference compared to
subsequent Cesarean delivery as uterine rupture and other major operative complications as bowel
injury and uterine artery ligation (Macones et al, 2015). Uterine rupture also predisposes the mother
to intractable bleeding that might indicate hysterectomy. This bleeding imposes risk of death of the
mother and the baby.
 B. Neonatal complications
One of the complications seen here is there is a rupture of membranes and therefore, the
delivery of the baby is indicated to prevent acquiring infections leading to neonatal sepsis. There
should be IV Antibiotics of Ampicillin and Gentamicin for the neonate if sepsis happens. There is
also no statement of the fetal size so, we cannot really assess if there will be dystocia which is one
complication.

CASE 4
G3P2, PU 37 weeks, transverse lie, estimated fetal weight 4000 grams, ruptured BOW for 12
hours. Mother has DM, uncontrolled.

Management of the delivery

There is a need to perform a cesarian section delivery instead of a normal spontaneous vaginal
delivery for the following reasons:
● Term fetus in transverse lie with ruptured membranes
○ According to Cunningham (2018), spontaneous delivery of a fully developed newborn is
impossible with a persistent transverse lie.
○ Prompt delivery is recommended for term prelabor rupture of membranes, wherein
cesarian delivery would be performed as soon as possible if there are contraindications
for vaginal delivery. This is based primarily on the concern about the increased risks of
maternal and newborn infection with expectant management of ruptured membranes.
Moreover, it would also prevent the occurrence of cord prolapse, reduce both admission
to neonatal sepsis care and maternal chorioamnionitis and/or endometritis (Scorza,
2018).
● Diabetic mother with macrosomic fetus
○ Cunningham (2018) stated that greater than 50% of neonates with a birthweight of at
least 4000 grams were delivered via cesarian section. Varying recommendations exist in
the management of macrosomic babies, with some stating that in diabetic mothers, a
fetal weight of at least 4000 grams would indicate a need for cesarian delivery, in contrast
to the ACOG recommendation in 2016 which recommends cesarian delivery in diabetic
mothers if fetal weight is at least 4500 grams.

Moreover, on the performance of cesarian section, the current condition suggests the need for a
vertical midline incision due to macrosomia. It is also indicated for faster delivery to avoid subjecting the
fetus to distress due to the ruptured BOW. For the uterine incision, a classical incision is indicated as this
is ideal for large fetuses in transverse lie, especially if the membranes have ruptured. As emphasized by
Cunningham (2018), because neither feet nor the head of the fetus occupies the lower uterine segment, a
low transverse incision into the uterus may lead to difficult fetal extraction, thus the need for a vertical
hysterectomy incision.

After delivery, the mother should be adequately hydrated intravenously and given glucose in
sufficient amounts to maintain normoglycemia. Capillary or plasma glucose levels are checked frequently
with administration of regular insulin if indicated.

Administration of prophylactic antibiotics is generally not indicated as the rupture of membranes

was only 12 hours before management. The National Antibiotic Guidelines in 2017 from the Department
of Health of the Philippines suggest the use of prophylactic antibiotics if the rupture was greater than 18
hours before delivery. Prophylaxis would be indicated however if there are signs of infection such as
maternal fever >38ºC and/or foul-smelling or purulent amniotic fluid.

Complications
Several complications may arise from all the conditions surrounding the pregnancy including the
diabetes mellitus and its consequent macrosomia, the transverse lie, and the prelabor rupture of
membranes. These include:
● Hypoglycemia
○ Newborns of diabetic mothers experience a rapid drop in plasma glucose concentration
after delivery attributed to the hyperplasia of the fetal-islet cell induced by chronic
maternal hyperglycemia.

● Hyperbilirubinemia and Polycythemia

○ While the pathogenesis is uncertain, polycthemia is thought to be a fetal response to
relative hypoxia. Sources of relative hypoxia are hypergycemia-mediated elevations in
maternal affinity for oxygen and fetal oxygen consumption. Along with insulin-like growth
factors, the hypoxia leads to elevated fetal erythropoietin levels and re dcell production.
The polycythemia would eventually cause hyperbilirubinemia as more cells would be
subjected to destruction, thus contributing to hyperbilirubinemia.

● Cardiomyopathy
○ Newborns of diabetic pregnancies may have hypertrophic cardiomyopathy that primarily
affects the interventricular septum, suggested to be due to insulin excess. This may then
lead to obstructive cardiac failure in severe cases.

● Hypocalcemia
○ Hypocalcemia is one of the potential metabolic derangements in neonates of diabetic
mothers, although its cause has not been explained. Theories include aberrations in
magnesium-calcium economy, and asphyxia.

● Long-term Cognitive Development Abnormalities

○ Intrauterine metabolic conditions have long been linked to neurodevelopment in the
offspring. A study of more than 700,000 Swedish-born men has found that the
intelligence quotient of those whose mothers had diabetes during pregnancy averaged 1
to 2 points lower.

● Inheritance of Diabetes
○ The risk of developing type 1 diabetes if either parent is affected is 3 to 5%. Type 2
diabetes has a more genetic component, wherein if both parents are diabetic, then there
is a 40% chance that the neonate would inherit the condition.

● Shoulder dystocia
○ Rates of shoulder dystocia vary greatly and can reach nearly 30% for macrosomic
neonates when maternal diabetis is comorbid.

● Postpartum hemorrhage, Perineal Laceration, Maternal Infection

○ These are related complications which are higher in mothers delivering overgrown
newborns
 ● Fetal injuries
○ Fracture of the clavicle and damage to the nerves of the brachial plexus specifically C5
and C6 may occur in macrosomic patients. This injury can even occur with cesarian
delivery (ACOG, 2016).
○ Compared with AGA, risk of birth injuries would be two-fold in newborns weighing
beween 4000 and 4499 grams (Mandy, 2017).

● Respiratory Distress Syndrome

○ The risk for respiratory distress syndrome has been found to be increased in macrosomic
babies, especially of those from diabetic mothers. Ecker (2017) actually suggests delivery
at the 39th week if there are no other complications for babies of diabetic mothers to
avoid this complication.

● Uterine Rupture
○ Uterine rupture may result from a neglected transverse lie, wherein the uterus would
contract vigorously in an unsuccessful attempt to overcome the obstacle caused by the
arest in fetal descent in the shoulder by the margins of the pelvic inlet.

● Cord Prolapse
○ Cord prolapse has been found to be common in macrosomic neonates, those in
transverse lie, and in prelabor rupture of membranes.

● Neonatal Infection
○ Neonatal infectioin is more likely as the time interval between the rupture of membranes
and delivery is increased.

REFERENCES

American College of Obstetricians and Gynecologists (2016). Practice Bulletin on Fetal Macrosomia
Cunningham, F. G., et al. (2014). Williams obstetrics (24th ed.). New York: McGraw-Hill Education
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J. S. (2018). Williams obstetrics (25th edition.). New York: McGraw-Hill Education.
Ecker, J. (2017). Pregestational Diabetes Mellitus: Obstetrical Issues and Management. Retrieved from:
https://www.uptodate.com/contents/pregestational-diabetes-mellitus-obstetrical-issues-and-
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Santana, E.F.M., Correa, V.M., Bottura, I., Filho, J.P.P. (2018). Time and mode of delivery in
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Challenges, Julio Elito Jr., IntechOpen.
Scorza, W. (2018). Management of Prelabor Rupture of Fetal Membranes at Term. Retrieved
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