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OBSTETRICS-GYNECOLOGY CASE PRESENTATION

Jul 19, 2014

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OBSTETRICS-GYNECOLOGY CASE PRESENTATION. YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial Medical Center June 28, 2011. GENERAL DATA. J.M. 40 year-old female M arried R esiding at Quezon City

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OBSTETRICS-GYNECOLOGY CASE PRESENTATION YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino 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 palpebralconjunctivae • 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)

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: Anictericsclerae, pink palepebral conjunctiva • Cardiovascular: Adynamicprecordium, 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 • Adnexaeare clear

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

LABORATORY TESTS • June 19, 2011

June 20, 2011

June 21, 2011

June 21, 2001

June 22, 2011

June 23, 2011

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 • Cefalexin500 mg/capq 8° x7 days • Mefenamicacid 500 mg/capq 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 • Ampicillin2 grams/IV, (-) ANST • 1 unitVoluven

Underwent emergency Total Abdominal Hysterectomy under subarachnoid block • Vital signs - stable • 2 units of PRBCs - transfused • Blood loss intra-op - 800-900 cc

Ketorolac30 mg IV loading, then 15 mg IVq 6° x4 doses (-) ANST • Tramadol150 mg loading then Tramadol drip 300 mg in 500 cc D5W at 21 gtts/min • Omeprazole40 mg IV OD while on NPO • Metoclopramide10 mg PRN for vomiting • Ampicillin1 gram IVq 6° (-) ANST • Metronidazole500 mg IVq 8° x3 doses (-)ANST • Cconsciousand 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 • overdistendeduterus (macrosomia, hydramnios, multifetalpregnancy) • oxytocinaugmentation 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, hemolysisd/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 • oxytocinshould 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 fundalmassage • 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

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Obstetrics n Gynaecology MADE EASY

• CLINICAL CASES (GYNAECOLOGY)

CLINICAL CASES (OBSTETRICS)

• PRACTICAL OBG

CASE 1 – ANEMIA IN PREGNANCY

CASE 2 – PREGNANCY INDUCED HYPERTENSION (PRE-ECLAMPSIA)

CASE 3 – PREVIOUS CAESAREAN SECTION

CASE 4 – Rh NEGATIVE PREGNANCY

CASE 5 – HEART DISEASE IN PREGNANCY – 1

CASE 6 – HEART DISEASE IN PREGNANCY – 2

1. CASE OF ANAEMIA IN PREGNANCY

Name – Vasanthamma                                                                   Husband’S Name – Bailanjappa Age – 30 years                                                                              Age – 35 years Address – Nelamangala                                                                  Occupation – Coolie Occupation – Housewife                                                                  Income – Rs. 3300/month Religion – Hindu                                                                             SE Status – Upper Lower class

G 3 P 2 L 2 comes with 8 months of amenorrhea

PRESENTING COMPLAINTS – Easy fatigability since 2 months

HISTORY OF PRESENTING COMPLAINTS:

• Patient presents with 8 months of amenorrhea with easy fatigability since 2 months.  Previously, the patient was able to do her household work, but for the past 2 months, she gets tired even with minimal work.  On walking about 50 m, patient complains of fatigability, giddiness, blurring of vision which is relived on rest.
• No history of increased bleeding during menses prior to pregnancy.
• No history of exertional dyspnea, palpitation, PND, pedal edema or giddiness.
• No history of bleeding or leak PV.
• No history of bleeding PR or malena.
• No history of passing worms in the stools.
• No history of fever with chills and burning micturation.
• No history of cough with expectoration, hemoptysis, evening rise of temperature or contact with a known case of tuberculosis.
• No history of drug intake (anti-malarial drugs or aspirin).
• No history of any yellowish discolouration of skin and sclera.
• Not a known diabetic or hypertensive.

OBSTETRIC HISTORY:

Married Life – 13 years, Non-consanguinous Obstetric index – G 3 P 2 L 2

LMP – 02/11/2006 EDD – 09/07/2007

PRESENT PREGNANCY

• No history of nausea, vomiting or weakness.
• No urinary symptoms
• No drug intake
• No history of craving for abnormal food (pica)
• Quickening in 5 th month
• 1 st ANC visit – 20 weeks, given TT & IFA tablets (consumed)
• Fetal movements present
• No leak or bleed PV
• No h/o pain abdomen

CONTRACEPTIVE HISTORY:

No history of using any contraceptive methods.

MENSTRUAL HISTORY:

Age of Menarche – 13 years Past Cycles – Regular 30 days cycles with flow lasting 5 days, normal quantity, no pain or passing of clots. LMP – 02/11/2006

FAMILY HISTORY:

No history of congenital anomalies or twinning, DM, HTN

PAST HISTORTY:

No history of Tuberculosis, Epilepsy, Asthma No history suggestive of any cardiac ailments. No history of previous surgeries, blood transfusions.

PERSONAL HISTORY:

Diet – Mixed Appetite – Good Sleep – Sound Bowel & Bladder – Regular Habits – Nil

DIET HISTORY:

Consumes – 2100 kcal/day Required – 2400 kcal/day Deficit – 300 kcal/day

GENERAL PHYSICAL EXAMINATION:

Here is a pregnant lady 30 year old, moderately built and nourished, conscious, alert & cooperative.

Pulse                – 84/min, regular, good volume BP                    – 110/68 mm of Hg RR                    – 14/min, regular Temperature       – Patient is afebrile

Pallor                           – Present Icterus                          – Absent Cyanosis                      – Absent Clubbing                       – Absent Edema                         – Absent Lymphadenopathy         – Absent

Thyroid                         – Normal Breasts                         – Normal Spine                            – Normal

Height                          – 146 cm Weight                         – 56 kg BMI                              – 26.27

SYSTEMIC EXAMINATION:

CVS –  S 1 S 2 heard, No murmurs. RS –  NVBS heard, no basal crepts. CNS – NAD. PA – Normal bowel sounds heard

OBSTETRIC EXAMINATION:

INSPECTION:

• Abdomen is uniformly distended, globular in shape
• Umbilicus everted, hernial orifices normal
• Flanks do not appear to be full
• Stria gravidarum and linea nigra present
• No scars over the abdomen
• Abdominal circumference – 76 cm
• Symphysio-fundal height – 28 cm (corresponds to 32 weeks)
• FUNDAL GRIP – Soft, broad & non-ballotable, suggestive of breech
• Lateral Grip –    Knob like structures on the right side suggestive of limb buds                                Uniform resistance on the left side suggestive of spine
• 1 ST PELVIC GRIP – Smooth, hard, ballotable mass suggestive of head
• 2 ND PELVIC GRIP – Fingers converge, head not engaged.
• Uterus is relaxed
• Fetal age = 28*8/7 = 32 weeks
• Fetal weight = (28-12)*155 = 2480 gm

AUSCULTATION:

• Fetal Heart sounds heard along the left spino-umbilical line
• 142/min, regular, rhythmic

30 year old G 3 P 2 L 2 A 0 with 32 weeks of gestation, moderate anemia probably due to iron deficiency, not in labour with no clinical signs of failure.

**********************************************

2. CASE OF PREGNANCY INDUCED HYPERTENSION (PRE-ECLAMPSIA)

Name – Narayanamma                                                                        Husband’s Name – Chandrababu Age – 20 years                                                                                   Age – 25 years Occupation – House wife                                                                     Occupation – Driver Address – Dairy Circle                                                                         Income – Rs.1700/per/month Religion – Hindu                                                                                   SE Status – Upper Middle Class Date of Admission – 10/07/07                                                               Date of examination – 12/07/07

G 2 P 0 A 1 comes with 8 months of amenorrhea.

PRESENTING COMPLAINTS: Generalized edema – since 10 days.

• Patient is a gravida 2 para 0 presents with generalized edema since 10 days, insidious in onset, initially noticed in the lower limbs which have gradually progressed to involve the upper limbs and face.  It is present throughout the day (no diurnal variation), not relieved by overnight rest nor by limb elevation in the morning.
• No history of headache, blurring of vision or syncopal attacks        
• No history of reduced urine output, hematuria.                             
• No history of chest pain, palpitations or breathlessness on exertion or history suggestive of cardiac failure.                                          
• No history of epigastric pain, nausea, vomiting.                             
• No history of DM or HTN.
• No history of jaundice, ascities before 20 weeks of gestation.                  

Married Life – 2 years (non – consanguinous marriage) Obstetric index – G 2 P 0 A 1

LMP – 03/11/06 EDD – 10/08/07

PREVIOUS PREGNANCY

• Painless spontaneous abortion at 6 th month following bleeding PV.  Patient had gone for 4 ANC visits, 2 scans, booked and immunized.
• No history of excessive vomiting.                           (Rule out H. mole)
• No history of HTN during pregnancy.
• Morning sickness for 2 months – present.
• Increased frequency of micturation – present.
• No history of easy fatiguability.
• No history of discharge or bleed PV.
• No history of drug intake or radiation exposure.
• No history of Pica.
• Quickening at 5 th month.
• No history of headache, blurred vision or sudden increase in weight.
• Booked and Immunized – 3 ANC visits, 2 TT, 100 IFA, Scan done at 20 th week.
• Fetal movements present.
• No history of bleeding or discharge PV.
• No history of pain abdomen.
• Generalized edema – present.
• Last abortion – 1 year back.

Age of Menarche – 16 years Past Cycles – Regular, 30 day cycle, 4 days flow, no pain or passage of clots. LMP – 03/11/06 No history of any contraceptives used.

FAMILY HISTORY: No history of DM, HTN, asthma, twinning in family.  No history of PIH in mother or                                    sister.

Medical –  No history suggestive of DM/HTN.No history of TB, epilepsy or asthma. Surgical –  No history of blood transfusions or any previous surgical procedures.

Here is a pregnant lady, moderately built and nourished, conscious, alert & cooperative; well oriented to time, place and person.

Pulse                – 86/min, regular, good volume BP                    – 146/92 mm of Hg RR                    – 18/min, regular Temperature       – Patient is afebrile

Pallor                 – Present Icterus               – Absent Cyanosis            – Absent Clubbing             – Absent Edema (pedal)     – Present, Pitting in nature Lymphadenopathy – Absent

Thyroid              – Normal Breasts             – Normal Spine                – Normal Gait                  – Normal

Height              – 160 cm Weight             – 70 kg BMI                  –  27.3

CVS – S 1 S 2 heard, no murmurs. RS – NVBS heard, no additional sounds heard. CNS – Knee jerk – present.  Sensory, motor and cranial nerves – normal. PA – Normal bowel sounds heard

• Abdomen uniformly distended.
• Flanks not full.
• Umbilicus – everted.
• Striae gravidarum, albicans & linea nigra – present.
• No scars over abdomen, no dilated veins.
• Hernial orifices – normal.

PALPATION: (Patient examined in supine position with legs semi flexed).

• Fundal height corresponds to 32 weeks gestation.
• SFH is 28 cm, abdominal circumference – 85 cm.
• Fundal grip – Smooth, broad irregular structure suggestive of breech.
• Lateral Grip – Right – Knob like structures suggestive of limb buds.                                           Left – Uniform curved resistance suggestive of spine.
• 1 st Pelvic Grip – Smooth, round, hard ballotable mass (not engaged) suggestive of head felt at lower pole
• FHS heard along the left spino-umbilical line, mid point.
• Rate – 146/min, regular.

20 year old G 2 A 1 with 32 weeks gestation, single live fetus with cephalic presentation with head not engaged and not in labour, with mild pre-eclampsia (on treatment) complicating her pregnancy.

3. CASE OF PREVIOUS LOWER SEGMENT CAESAREAN SECTION

Name – Anita                                                                                 Husband’s Name – Venkatesh Age – 23 years                                                                               Age – 24 years Address – Atmajyothinagar, Kengeri                                                 Occupation – Painter Occupation – Maid servant                                                               Income –Rs.2600/mnt Religion – Hindu                                                                              SE Status – Lower Middle Class Date of admission – 09/07/2007                                                        Date of examination – 10/07/2007

G 2 P 1 L 1 comes with 9 months of amenorrhea for safe confinement

• Patient comes with 9 months amenorrhea with a history of previous LSCS and was admitted for safe confinement.  Patient had been here for regular ANC checkup on 27/07/2007 and was asked to get admitted as her EDD as per scan was 10/07/2007.
• Patient complaints of backache since today morning in the lower mid-back, non-radiating and not associated with pain abdomen.
• Patient gives history of white discharge since 1 week, non-foul smelling, not associated with fever or itching.
• No history of leak PV or bleeding PV.
• No history of hematuria.
• No history of any change in bladder habits.
• Fetal movements are well perceived.
• No history of Diabetes mellitus or Hypertension.

Married Life – 4 years (non – consanguineous marriage) Parity  index – G 2 P 1 L 1

LMP – 01/11/06 EDD – 08/08/07

PREVIOUS PREGNANCY :

• History of increased vomiting – present.
• History of easy fatigability.
• No history of urinary symptoms.
• No history of pica.
• Quickening at 20 th week.
• History of generalized edema – present.
• No history of headache or blurring of vision.
• Patient was booked and immunized – 6 ANC checkups, 2 USG scans, 2 TT & 100 IFA.
• Uneventful.
• Delivered by Lower Segment Caesarean Section probably due to obstructed labour or non-progression of labour.
• Patient was initially put n trial of labour by administering injections, but since labour pains were not adequate, she was posted for emergency LSCS, after infusing 1 unit of blood.
• Outcome was a live male fetus, 3.7 kg at birth, was immunized and exclusively breast fed for 1 year.
• Mother had no fever or wound discharge in the post-op period.
• Sutures were removed on the 7 th day but had to stay in the hospital for 16 days as the baby had jaundice.
• Last C-section – 3 years back (April 25 th , 2004)

PRESENT PREGNANCY: T 1 , T 2 and T 3 uneventful. EDD-08/08/07

Age of Menarche – 12 years Past Cycles – Regular, 50-70 day cycle, 8-9 days flow, no pain or passage of clots. LMP – 01/11/06 No history of any contraceptives used.

FAMILY HISTORY: No history of DM, HTN.

Medical – No history suggestive of DM/HTN.  No history of TB, epilepsy or asthma. Surgical – No history of blood transfusions or any previous surgical procedures.

Mother is a young lady, moderately built and nourished, conscious, alert & cooperative; well oriented to time, place and person.

Pulse                – 78/min, regular, good volume BP                    – 116/82 mm of Hg RR                    – 18/min, regular Temperature      – Patient is afebrile

Pallor                – Present Icterus               – Absent Cyanosis           – Absent Clubbing            – Absent Edema              – Absent Lymphadenopathy – Absent

Thyroid              – Normal Breasts             – Normal Spine                – Normal Gait                  – Normal

Height                         – 158 cm Weight                         – 51 kg

CVS – S 1 S 2 heard, No murmurs. RS – NVBS heard, no basal crepts. CNS – NAD. PA – NAD

• Distended and flanks are full.
• Umbilicus – normal.
• No dilated veins.
• A vertical right paramedian incision, 14 cm long is seen in the infra-umbilical region, healed by primary intention – no hypertrophy or keiloid formation, no supra-pubic bulge.
• Fundal height corresponds to 32 weeks with flanks full – corresponding to 40 weeks of gestation.
• SFH is 32cm.
• Fundal grip – Broad, soft irregular structure suggestive of breech.
• Lateral Grip – Right – Knob like structures suggestive of Limb buds.                                          Left – Uniform curved resistance suggestive of spine.
• 1 st Pelvic Grip – Smooth, hard ballotable mass.
• 2 nd Pelvic Grip – Fingers diverge.
• Abdominal girth – 95 cm.
• Weight of the fetus (Johnson’s formula) = 3260 gm.
• Age of fetus (Mc Donald’s formula) = 40 weeks.
• No scar tenderness.
• No supra-pubic bulge felt.
• FHS heard along the left spinoumbilical line, mid point.
• Rate – 140/min, regular.

23 year old G 2 P 1 L 1 with full term single intrauterine pregnancy with previous LSCS with longitudinal lie with cephalic presentation not in labour.

4. CASE OF Rh NEGATIVE PREGNANCY

Name – Savita                                                                                   Husband’s Name – Satishchandra Age – 24 years                                                                                  Age – 28 years Occupation – House wife                                                                    Occupation – Clerk Address – Chamrajpet                                                                        Income – Rs. 1000/person/month SE Status – Lower Middle Class Date of Admission – 07/07/07                                                             Date of examination – 11/07/07

G 2 P 1 L o comes with 7 months of amenorrhea for safe confinement.

HISTORY OF PRESENTING COMPLAINTS :

• Patient comes with 7 months amenorrhea for safe confinement.  Patient had been here for regular ANC checkup on 5 th July and was advised to get admitted telling her that her blood group does not match with that of her baby (told to her by a private practitioner).
• No history of generalized weakness and giddiness
• No history of headache, blurred vision or decreased micturition
• No history of edema and pruritis.
• No other systemic complaints.

Married Life – 4 years (non – consanguineous marriage) Obstetric index – G 2 P 1 L 0 A 0 D 1

LMP – 04/12/06 EDD – 11/08/07

• FTD at home, cried soon after birth, weight not measured.
• Booked & Immunized, 5 ANC visits, 2 TT & 100 IFA.
• The baby died 2 days after birth due to unknown reasons.
• Morning sickness for 2 months.
• No history of Urinary symptoms.
• No history of Drug intake.
• No history of headache, blurred vision.
• 2 ANC visits, 2 TT, 100 IFA, 2 scans.
• No bleeding/leak PV.
• In this pregnancy, she was evaluated & her blood group turned out to be B –ve while that of the fetus was O +ve
• No Anti – D injection given.
• No history of abortion, LSCS or IUFD or invasive fetal procedure.
• Previous baby blood group not known.
• Last delivery – 2 years back.

CONTRACEPTIVE HISTORY :

Age of Menarche – 15 years Past Cycles – Regular, 30 day cycle, 4 days flow, no pain or passage of clots. LMP – 04/12/06

GENERAL PHYSICAL EXAMINATION :

Mother is a 24 year old lady, moderately built and nourished, conscious, alert & cooperative.

Pulse                – 82/min, regular, good volume BP                    – 120/50 mm of Hg RR                    – 18/min, regular Temperature       – Afebrile

Pallor                           – Absent Icterus                          – Absent Cyanosis                      – Absent Clubbing                       – Absent Edema                         – Absent Lymphadenopathy         – Absent

Thyroid              – Normal Breasts             – Normal Spine                – Normal Gait                  – Normal

Height              – 156 cm Weight             – 60 kg

SYSTEMIC EXAMINATION :

OBSTETRIC EXAMINATION :

INSPECTION :

PALPATION : (Patient examined in supine position with legs semi flexed).

• Fundal height corresponds to 28 weeks gestation.
• SFH is 25 cm.
• Lateral Grip – Right – Knob like structures suggestive of Limb buds.                                           Left – Uniform curved resistance suggestive of spine.
• 1 st Pelvic Grip – Smooth, round, hard ballot able mass (not engaged) suggestive of Head felt at lower pole.

AUSCULTATION :

DIAGNOSIS :

22 year old G 2 P 1 L o with 7 months amenorrhea, single live fetus, not in labour with Rh –ve pregnancy.

5. CASE OF HEART DISEASE IN PREGNANCY – 1

Name – Chandrakala                                                                           Husband’s Name – Manjunath Age – 32 years                                                                                   Age – 35 years Address – Chikaballapur                                                                      Occupation – Cloth merchant Occupation – Housewife                                                                       Income–Rs.2000/month Religion – Hindu                                                                                  SE Status – Upper Middle Date admission – 12/07/2007                                                               Date of examination– 12/07/2007

G 3 P 1 L 1 A 1 comes with 9 months of amenorrhea for safe confinement of delivery.

• Patient comes with 9 months amenorrhea for safe confinement with a history of cardiac surgery.
• No history of breathlessness on exertion, palpitations, chest pain, PND, orthopnea, edema of feet.
• No history of any congenital heart disease.
• No history suggestive of CCF, infective endocarditis in the past or present pregnancy.

Married Life – 16 years (non – consanguineous marriage) Obstetric index – G 3 P 1 L 1 A 1

LMP – 15/10/06 EDD – 22/07/07

PREVIOUS PREGNANCY:

G 1 – FTND, Government Hospital, Now 11 years, Cried soon after birth, Weighed 3 kg, Post partum period normal, Booked and immunized, 3 ANC visits, 2TT & 100 IFA received.

G 2 – Aborted at 1½ months gestation (MTP) 6 years ago.

PRESENT PREGNANCY:

• History of nausea and vomiting.
• Quickening at 18 th week.
• No history of headache or blurring of vision or edema.
• Patient was booked and immunized – 4 ANC checkups, 2 TT & 100 IFA.
• Increased frequency of micturItion – present.

MENSTRUAL HISTORY :

Age of Menarche – 15 years Past Cycles – Regular, 30 day cycle, 3 days flow, no pain or passage of clots. LMP – 15/10/06

FAMILY HISTORY: No history of DM, HTN.  No history of any congenital heart disease among relatives.

PAST HISTORTY :

• Patient underwent a cardiac surgery 2 years back when she developed sudden onset of breathlessness though she was on medical treatment for some cardiac ailment for 5 years.  Her previous reports revealed that she was diagnosed to have RSOV with VSD.  She underwent the operation in a government hospital in Putbarti.
• No history of fleeting joint pains or fever in the childhood and patient not on penidure prophylaxis.
• No history of any post-op complications.
• No history suggestive of DM or HTN.
• No history of TB, epilepsy or asthma.

Pulse                – 90/min, regular, good volume, normal character, all PP felt.  JVP – normal BP                    – 130/70 mm of Hg RR                    – 18/min, regular, TA Temperature       – Afebrile

Pallor               – Absent Icterus              – Absent Cyanosis          – Absent Clubbing           – Absent Edema              – Absent Lymphadenopathy – Absent

Thyroid              – Normal Breasts             – Normal Spine                – Normal Gait                  – Normal

Height              – 160 cm Weight             – 60 kg

CARDIO-VASCULAR SYSTEM :

• No precordial bulge.
• Apical impulse – left 4 th inter-costal space, 2 cm lateral to Mid-cavicular line.
• No other abnormal pulsations.
• A linear scar seen over the mid-sternum 15 cm × 2 cm.
• No dilated veins over the chest wall.
• Inspectory findings were confirmed.
• Apex beat – left 4 th inter-costal space, 2 cm lateral to Mid-cavicular line.
• No parasternal heave.
• No thrill felt.
• No abnormal pulsations.

AUSCULTATION

RS – NVBS heard, no basal crepts. CNS – NAD. PA – NAD

• Abdomen is distended, flanks are full.
• No dilated veins or scars or sinuses.
• Shelving Sign – positive.
• Symphysis – fundal height is 30 cm.
• Fundal grip – Broad, soft, non-ballotable, relatively large irregular structure suggestive of breech.
• 1 st Pelvic Grip – Smooth, hard ballotable mass relatively small felt suggestive of head.
• Abdominal girth – 104 cm.
• Weight of fetus (Johnson’s formula) – 2800 gm.
• Age of fetus (Mc Donald’s formula) – 40 weeks.

32 year old G 3 P 1 L 1 A 1 with full term pregnancy with cephalic presentation, not in labour with a previous history of cardiac surgery.

6. CASE OF HEART DISEASE IN PREGNANCY – 2

Name – Farida Taj                                                                                  Husband’s Name – Rehman Age – 25 years                                                                                       Age – 30 years Address – Chikaballapur                                                                         Occupation – Plastic Items seller Occupation – Worker in Agarbatti factory                                                  Income–Rs.3000/month Religion – Hindu                                                                                     SE Status – Upper Middle Class Date of admission – 08/11/2007                                                               Date of examination – 21/11/2007

Primigravida comes with 9 months of amenorrhea

PRESENTING COMPLAINTS :

• Pain abdomen                                           – 13 days.
• Swelling of both lower limbs                       – 13 days.
• Chest pain and breathlessness                   – 8 days.
• Patient gives history of pain abdomen for the past 13 days, over the lower part of the abdomen, moderate intensity, intermittent in nature, each episode lasting about 2 hours and approximately 2-3 episodes per day, relived on medication.
• Patient also complaints of swelling of both the lower limbs since 13 days, insidious in onset, initially present over the feet and has gradually progressed to the knee, present throughout the day, increases on walking and relived on taking rest.  No diurnal variation.  No history of distention of abdomen or puffiness of face.
• Patient also gives a history of chest pain since last 8 days, sudden in onset, over the retrosternal region, progressive, constricting type, non-radiation, moderate severity, aggravated on exertion and relieved on rest.  It is associated with breathlessness, insidious in onset, progressive in nature, initially patient was able to do her routine activities but now she gets breathless after walking a few meters.  It is relieved on rest.
• History of palpitations present.
• No history of bleeding or discharge per vagina.
• No history of orthopnea, PND.
• No history suggestive of CCF, Infective endocarditis.
• No history of fever.
• No history suggestive of thyroid disease.
• No history of any cardiac disease
• Not a known case of DM or HTN.

Married Life – 1 years (non – consanguineous marriage) Parity index – primigravida

LMP – 03/03/07 EDD – 10/12/07

• History of urinary symptoms – present.
• No history of pica, Booked and Immunized.
• Developed swelling of both lower limbs, chest pain and breathlessness as mentioned previously.

Age of Menarche – 15 years Past Cycles – Regular, 30 day cycle, 3 days flow, no pain or passage of clots. LMP – 03/03/07

FAMILY HISTORY : No history of DM, HTN.  No history of any congenital heart disease among relatives.

• No history suggestive of any other congenital heart disease.
• No history of heart surgery.
• No history of previous hospitalization or treatment for heart ailments.

PERSONAL HISTORY :

Pulse                – 99/min, regular, good volume, normal character, all PP felt.  JVP– raised (6 cm). BP                    – 126/90 mm of Hg in left upper limb in supine position. RR                    – 18/min, regular, TA Temperature       – Patient is afebrile

Pallor                – Absent Icterus              – Absent Cyanosis           – Absent Clubbing            – Absent Edema                 – Absent Lymphadenopathy – Absent

Thyroid              – Normal Breasts             – Normal Spine                – Normal Gait                  – Normal

Height             – 160 cm Weight             – 60 kg

CARDIO-VASCULAR SYSTEM:

• No dilated veins over the chest wall, no scars.
• Parasternal heave – present.
• FUNDAL GRIP – Soft, broad & non-ballotable, suggestive of Breech
• Lateral Grip – Knob like structures on the right side suggestive of limb buds                         Uniform resistance on the left side suggestive of spine

25 year old primi with full term pregnancy with cephalic presentation not in labour with cardiac disease (valvular lesion), probably RHD, MS in sinus rhythm, not in failure with no evidence of infective endocarditis.

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3 responses to “ clinical cases (obstetrics) ”.

May 2, 2011 at 8:15 pm

super stuff !! very helpful too !!

January 10, 2013 at 12:22 am

thanks a lot sir…. itz very helpful….

June 13, 2013 at 11:18 pm

Excellent work..really useful too..

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obg case study slideshare

This document summarizes an obstetric case of a 30-year-old pregnant woman. She presents with amenorrhea and easy fatigability for the past 2 months. Her medical history and examination reveal she is anemic, with a hemoglobin level of 7.4g/dl.

The document describes a family case study of the Patel family consisting of 5 members living in Ahmedabad. It includes an assessment of their health, nutrition, sanitation, education and various socioeconomic factors.

Obg case review - Download as a PDF or view online for free.

OBSTETRICS-GYNECOLOGY CASE PRESENTATION YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino 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 ...

This document presents a case study of an obstetric patient. It includes the student's profile, patient demographic data, medical history, assessment using Gordon's Functional Health Patterns, physical examination findings, and obstetric assessment.

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Case Presentation: A 17-year-old female with abnormal uterine bleeding was referred to our center. Ultrasonographic evaluation revealed a mass with origin in right ovary. Patient was worked up to undergo salpingo-oophorectomy, she felt a dull pain in her left lower limb.

A huge range of obstetrics and gynecology / OBGYN OSCE stations with interactive mark schemes to help you smash your OBGYN OSCEs! We are building the ultimate clinical OSCE database.

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Obstetric Medicine provides the reader with 55 cases of different clinical presentations in obstetric medicine. Each case is presented with a background to the subject area, a summary of the history, and examination findings, and relevant investigation results.

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An Insight into OBG Case Presentation by the 2020 Batch at Believers Church Medical College Hospital: UG Clinic

An insight into obg case presentation by the 2020 batch at believers church medical college hospital.

On the morning of August 31st, 2023, the Believers Church Medical College Hospital (BCMCH) showcased the acumen and dedication of its medical students during an engaging OBG (Obstetrics and Gynecology) case presentation. Organized by the 2020 batch of students, this session not only demonstrated their clinical knowledge and presentation skills but also provided valuable learning experiences for their peers and faculty members alike.

Venue: Lecture Hall 2, BCMCH College Building

The stage was set in Lecture Hall 2, where medical students gathered from various years, alongside faculty members from the Department of OBG/Gynecology. The atmosphere buzzed with anticipation as the 2020 batch prepared to present a carefully selected case study that emphasized the complexities and nuances of obstetric and gynecological care.

A Focus on Real-Life Scenarios

The student presenters chose a compelling case that highlighted important clinical considerations in OBG. Through meticulous research and collaboration, they outlined the patient’s history, presenting complaints, diagnostic challenges, and the management strategies employed. This real-life patient scenario gave attendees invaluable insight into the day-to-day realities of working in obstetrics and gynecology, including the critical thinking and decision-making skills required in practice.

Faculty Moderation and Engagement

Moderated by experienced faculty members from the Department of OBG/Gynecology, the presentation was not just a one-sided affair. The moderators actively engaged the students and audience, prompting discussions that enriched the learning experience. They asked thought-provoking questions, offered clinical pearls, and emphasized the importance of patie nt-centric care, which is at the heart of medical practice. Their insights helped the students understand the depth of knowledge required in this specialization and appreciate the challenges faced by healthcare providers in the field.

The Importance of Collaborative Learning

What stood out during this engaging session was the sense of collaboration among students. The 2020 batch worked together to ensure that each aspect of the case was well-researched and presented cohesively. This effort exemplified the spirit of teamwork that BCMCH strives to instill in its students, preparing them for the collaborative nature of the medical profession. The supportive environment fostered lively discussions and encouraged fellow students to think critically about patient care, diagnosis, and treatment options.

Key Takeaways for Future Practitioners

Events like this case presentation at BCMCH are essential for future healthcare professionals. They allow students to:

Apply Theoretical Knowledge : Through real-life applications, students understand the relevance of their studies.

Enhance Clinical Skills : Presenting cases develops communication skills alongside clinical reasoning.

Foster Teamwork : Collaboration is crucial in healthcare, and working together on presentations helps build this skill.

Engage in Continuous Learning : Interactions with faculty and peers promote a culture of ongoing education and improvement.

The OBG case presentation held at Believers Church Medical College Hospital on August 31st was a testament to the commitment of the 2020 batch to clinical excellence and holistic learning. It was not just an academic exercise; it was an opportunity to reflect on the profound impact that healthcare professionals have on their patients and communities. As these students continue their journey into the medical field, experiences like these will undoubtedly shape their approach to patient care and their professional identities.

We look forward to more such presentations that bridge the gap between theory and practice, shaping well-rounded, compassionate, and skilled healthcare providers for the future.

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Unit 1 introduction to OBG Nursing

Bsc nursing (blaw 213), kerala university of health sciences.

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Course : Bsc nursing (blaw 213)

University : kerala university of health sciences.

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