OBSTETRICS

AND
GYNECOLOGY
CASE PRESENTATION

SIMBULAN, ROSE ANNE B.

BLOCK E
SAN BEDA UNIVERSITY- COLLEGE OF MEDICINE
GENERAL • M.S
• 29/F
DATA • Single
• Filipino
• Catholic
• From Quezon City
• Born on March 9, 1990

• Date of admission: March 9, 2019

• Time of Admission: 12:30 pm
CHIEF • vaginal bleeding
COMPLAINT (11 hours postpartum)
HISTORY • Few hours prior to admission,
S/P non-institutional delivery (Murphy Lying in Clinic) to a

OF live boy
(+) persistent, heavy vaginal bleeding- characterized as

PRESENT dark red in color with passage of chunks of blood clots

(+) dizziness
ILLNESS (+) difficulty of breathing
(+) palpitations
No other symptoms noted such as fever, vomiting, chest
pain, and loss of consciousness. No medications taken.

Persistence of symptoms with accompanying ,

hypotension, diaphoresis and generalized weakness
prompted referral to our institution. Hence, admitted.
NO • LMP:June 23, 2018

ROUTINE • PMP: May 20, 2018

• AOG: 38 weeks 3 days
PRENATAL • EDC: March 30, 2019
CHECK UP • (+) good fetal movement, >10
movements in 2 hours
DANGER • (-) seizure
SIGNS OF • (-) hyperemesis

PREGNANCY • (-) edema

• (-) fever
• (-) severe headache
• (-) abdominal pain
• (-) blurring of vision
ANTENATAL • G5P5 (5005)

HISTORY • No prenatal check ups

• No ultrasound and laboratories done
• No prenatal medications taken
• Unplanned pregnancy
• (+) exposure to passive cigarette smoke
• No known exposure to teratogen and
chemicals.
 PAST • (-) HPN, DM

MEDICAL • (-) Thyroid, Heart, Kidney and Liver

Disease
HISTORY • (-) Neurologic/ seizure disorder
• (-) PTB, Pneumonia, Asthma
• (-) Blood disorders
• (-) previous hospitalizations, surgery
and blood transfusion
• (-) allergy to foods and medications
 FAMILY • (+) Hypertension

HISTORY • (+) DM
• (-) Thyroid, Heart, Kidney and Liver
Disease
• (-) Neurologic/ seizure disorder
• (-) PTB, Pneumonia, Asthma
• (-) Blood disorders
• (-) previous hospitalizations, surgery
and blood transfusion
• (-) allergy to foods and medications
PERSONAL • Non-smoker
/SOCIAL • Alcoholic beverage drinker
HISTORY • Denies illicit drug use
OBSTETRIC HISTORY
G5P5 (5005)
Gravidity Year Delivery Place Attendant Fetal Complication
outcome

G1 2008 NSD QMMC MD Live, Term none

G2 2012 NSD QMMC MD Live, Term none

G3 2013 NSD QMMC MD Live, Term none

G4 2016 NSD QMMC MD Live, Term none

G5 2019 NSD NID -> Murphy Midwife Live, Term none

Lying in Clinic
MENSTRUAL • M- 12 years old
HISTORY • I- 30 days- regular
• D- 3-5 days
• A- 3 pads per day, fully soaked
• S- no dysmenorrhea
 SEXUAL • Age at 1st sexual contact:
HISTORY unrecalled
• (+) promiscuous sexual
behavior
• (+) Multiple sexual partners
• (-) Dyspareunia and post coital
bleeding
• History of STD: unknown
GYNECOLOGIC • No pap smear done
HISTORY • No contraception use (OCP,
DMPA, IUD, Barrier, Natural)
IMMUNIZATION • No vaccinations given
HISTORY during past pregnancies.
REVIEW • GENERAL: (-) easy fatigability, (-) night sweats, (-)
weight loss, (-) sleep disturbance, (-) fever

OF • SKIN: (-) rash, (-) pruritus, (-) pigmentation (-)

petechiae (-) jaundice, (-) cyanosis

SYSTEMS • HEENT: (-) hearing loss, (-) tinnitus, (-) loss of smell,
(-) epistaxis, (-) changes in vision, (-)
lymphadenopathy, (-) sore throat
• RESPIRATORY: (-) chest pain (-) cough (-) colds (-)
hemoptysis, (-) exercise tolerance
• GASTROINTESTINAL: (-) abdominal pain, (-) loss of
appetite ,(-) dysphagia, (-) nausea, (-) vomiting, (-)
hematemesis, (-) indigestion, (-) heartburn, (-)
jaundice,(-) constipation, (-) diarrhea
REVIEW • CARDIOVASCULAR: (-) chest pain, (-) shortness
of breath, (-) orthopnea/PND (-) ankle swelling

OF • GENITOURINARY: (-) dysuria, (-) oliguria (-)

polyuria (-) hematuria, (-) incontinence

SYSTEMS • CENTRAL NERVOUS SYSTEM: (-) headache, (-)

syncope, (-) numbness, (-) tingling, (-) memory
loss, (-) motor abnormalities, (-) loss of sensation,
(-) tremors
• MUSKULOSKELETAL: (-) restriction of
movements, (-) myalgia, (-) atrophy (-)edema
• ENDOCRINE: (-) hirsutism, (-) alopecia, (-) polyuria
and polydipsia, (-) excessive sweating
PHYSICAL • General Data: Awake, conscious,
EXAM in cardiorespiratory distress
• Vital Signs upon admission:
BP: 80/60
HR: 140
RR: 34
Temp: 36.5
PHYSICAL • HEENT:

EXAM • Pale palpebral conjunctiva

• Anicteric sclerae
• (-) Eye redness, swelling,
discharge
• (-) Visible polyps, nose discharge
• (-) Cervical lymphadenopathy
• (-) Carotid bruits, brisk upstroke of
carotid pulse
PHYSICAL • Cardio:

EXAM • Adynamic precordium

• (-) Heaves, lifts, and thrills
• PMI and Apex beat at 5th ICS MCL
• Prominent S1 at apex and S2 at
base
• (-) Murmurs, extra heart beats
• (-) splitting, murmur, and opening
snap
PHYSICAL • Lungs:
EXAM • (+) diffuse crackles prominent on
the right lung field
• (-) lags/retractions
• Equal chest expansion
• Intact tactile and vocal fremitus
• Resonance on percussion
• (-) rales, wheezes
PHYSICAL • Musculoskeletal:
EXAM • Full and equal pulses
• No edema
• CRT > 2secs
• (-) restriction of joint movements
PHYSICAL • Abdomen:

EXAM • Globular, soft, non-tender

abdomen
• (-) visible lesions, pigmentations,
bruises, discolorations
• Normoactive bowel sounds

• IE: cervix parous, uterus well

contracted, minimal vaginal
bleeding
 LABORATORY WORK UP
CBC with PC 3/9/2019 3/10/2019 Clinical 3/9/2019 3/10/2019
RBC count 5.25 4.51 Chemistry

Hemoglobin 148 129 Sodium 129 (L) 131 (L)

Hematocrit 0.44 0.38 Potassium 2.80 (L) 3.80

Platelet count 402 400 Chloride 104 112 (H)

AST 21.16 17.01
WBC 12 (H) 9.4
ALT 11 9
Neutrophil 0.71 0.77 (H)
BUN 7
Lymphocytes 0.19 0.16 (L)
Creatinine 110.70 (H) 135.80 (H)
Eosinophil 0.04 0.03
Monocyte 0.06 0.04
 LABORATORY WORK UP
Thyroid 3/10/2019 Hepa Profile 3/9/2019 Coagulation
Function HBsAg 5423.43 R PT 13.5 (H)
Test
HBeAg 0.34 NR PT % Act 73.4
FT3 1.53 (L)
Anti-HBS 0.00 NR INR 1.2
FT4 0.78
Anti-HBE 0.01 R NC 12.8
TSH 2.82
Anti-HBC IgM 0.06 NR APTT
Anti- HAV IgM 0.34 NR APTT 33.7 (H)
Salmonella 3/10/2019
Typhi Anti HCV 0.05 NR NR 25.1

IgG Negative
Immunology
IgM Negative
SYPHILIS 17.68 REACTIVE
(Quanti)
HIV NON-REACTIVE
CHEST X-RAY
 ECG

• SINUS TACHYCARDIA
(D1)
• ASYSTOLE (D3)
 SALIENT
FEATURES
• M.S, 29/F, Single, G5P5 (5005) • No ultrasound and laboratories done
• vaginal bleeding • No prenatal medications taken
(+) persistent, heavy vaginal bleeding- • Unplanned pregnancy
characterized as dark red in color with passage of • (+) exposure to passive cigarette smoke
chunks of blood clots
• (+) promiscuous sexual behavior
(+) dizziness
• (+) Multiple sexual partners
(+) difficulty of breathing
• No previous and present vaccinations.
(+) palpitations
• PE: hypotensive, tachypneic, tachycardic
(+) hypotension, diaphoresis and generalized
weakness Pale PC, crackles, IE: cervix parous, uterus well
contracted, minimal vaginal bleeding
DIFFERENTIAL
DIAGNOSIS Most likely Less likely

(+)MC obstetric trauma (-)mild to moderate bleeding

VULVOVAGINAL
(+) vaginal bleeding due to venous bleeding
(+)episiotomy (-)dyspareunia

LACERATIONS
- modifiable factors
DIFFERENTIAL
DIAGNOSIS
Most likely Less likely

POSTPARTUM (+) vaginal bleeding

Leukocytosis
Fever
Foul-smelling lochia

ENDOMETRITIS Maternal mortality is highest if

infection develops within 4
days of delivery
Uterine tenderness
Only scant discharge may be
present (esp with group B
strep)
DIFFERENTIAL
DIAGNOSIS
Most likely Less likely

RETAINED (+) vaginal bleeding

passage of large clots or flow
(-) fever
Uterine enlargement

PRODUCTS OF that is significantly greater

than menses
Cervical OS typically open

CONCEPTION
leukocytosis

(RPOC)
 PRIMARY • G5P5 (5005) Primary
WORKING Postpartum Hemorrhage,
DIAGNOSIS S/P Non-institutional
delivery
 • Define as loss of 500 ml or more blood after vaginal
delivery or 1000ml or more after CS delivery.

DISCUSSION: • New ACOG definition: cumulative blood loss >1000ml

or blood loss with signs and symptoms of hypovolemia
POSTPARTUM within 24 hrs of birth process

HEMORRHAGE
Types:
• Primary PPH is defined as blood loss greater than 500
mL in the first 24 hours, (early PPH)
• Secondary PPH is excessive blood loss between 24
hours and 12 weeks postpartum, (late PPH)
 Timing
• a. Antepartum- ectopic, abortion
• b. Post-partum

DISCUSSION: • c. Late post-partum

POSTPARTUM • Risk Factors:

HEMORRHAGE •

•
Uterine Atony

Retained placental fragment

• Failure to progress during the second stage of labor

• Morbidly adherent placenta

• Lacerations

• Instrumental delivery

• Large for gestational age newborn

• Hypertensive disorder (preeclampsia, eclampsia, HELLP)

• Induction of labor
DISCUSSION:
POSTPARTUM
HEMORRHAGE
DIAGNOSIS • The diagnosis of postpartum hemorrhage begins with
recognition of excessive bleeding and methodic

AND examination to determine the cause (The Four T’s)

EVALUATION – Tone – Atonic uterus (70% approximate incidence)

– Trauma- Lacerations, hematomas, inversion, rupture
(20% approximate incidence)
– Tissue- Retained tissue, invasive placenta (10%
approximate incidence)
– Thrombin- Coagulopathies (1% approximate incidence)

• ACOG 2017
• CPG 2014
THE 4 T’S
THROMBIN Pre-eclampsia, placental abruption, pyrexia in
labour, bleeding disorder

OF PPH TISSUE Retained Placenta, Succenturiate placenta,

incomplete placental delivery, Placenta accreta,
Retained products of conception RPOC

TONE Placenta previa, overdistention of uterus: multpile

pregnancy, polyhdramios, macrosomia, uterine
relaxants, previous PPH

TRAUMA CS, Episiotomy, Macrosomia

Other Asian, Anemia, Induction, BMI >35, prolonged labor,

age
ESTIMATION • Historically, a decrease in hematocrit of 10% had
been proposed as an alternative marker to define

OF BLOOD postpartum hemorrhage, however determinations of

haemoglobin or haematocrit concentrations are often

LOSS delayed, may not reflect current hematologic status,

and are not clinically useful in the setting of acute post
partum haemorrhage.

• Hypotension and Tachycardia (considerable

s/sx of blood loss) approx. 1,500 ml has
occurred.

ACOG 2017
 DIAGNOSTIC Ultrasound- identify cause of bleeding, helps exclude

MANAGEMENT potential bleeding causes

w/ Color Doppler- vascularity of echogenic intracavitary
material (retained products of conception)
Histopathology- the presence of chorionic villi, which
indicates the persistence of placental tissue

CBC- baseline, monitoring of Hemoglobin, hematocrit

PT,PTT – evaluate coagulation status, possible bleeding

disorder, acute hemorrhage
OTHERS: Electrolytes, 12L ECG, Chest Xray, Urinalysis,
Fecalysis, STD Work up, Hepa Profile, HIV Screening
THERAPEUTIC
MANAGEMENT
GOAL:
• Restore or maintain adequate circulatory
volume to prevent hypo perfusion of vital
organs
• Restore or maintain adequate tissue
oxygenation
• Reverse or prevent coagulopathy
• Eliminate the obstetric cause of PPH
FINAL • Primary Postpartum
DIAGNOSIS Hemorrhage, S/P Non-
institutional delivery, Acute
Gastroenteritis with Severe
signs of Dehydration,
Chronic Hepatitis B low
infectivity, Syphilis
Reactive
CAUSE OF • IMMEDIATE: Hypovolemic Shock
DEATH • ANTECEDENT: Severe
Dehydration sec to Acute
Gastroenteritis
• UNDERLYING:
Immunocomprimised state
(Chronic Hepatitis B, Syphilis
Reactive)
REFERENCES
• William’s Obstetrics 24th Edition
• Clinical Practice Guidelines on Obstetric Hemorrhage
• Americanpregnancy.org
• Prevention and Management of Postpartum
Hemorrhage
https://www.aafp.org/afp/2007/0315/p875.html