OBSTETRICS AND GYNECOLOGIC CASE PRESENTATION

Prepared by:

IMPERIAL, Annabelle R.San Beda College of Medicine

N.G.

16 year old

G1P0

LMP: March 1, 2011

Chief Complaint

Vomiting

History of Present Illness

2 DAYS prior to consult

Nausea and vomiting

(+) 20 episodes of vomiting recently ingested food

No medication taken

No consult done

History of Present Illness

1 DAY prior to consult

Persistence of nausea and vomiting(+) loss of appetite

(+) >20 episodes of vomiting recently ingested food and water

No medication taken No consult done

History of Present Illness

DAY of consult

Persistence of nausea and vomiting(+) loss of appetite

(+) >20 episodes of vomiting recently ingested food and water

Prompted patient to consult in QMMC OB-ER

OBSTETRIC HISTORY

G1P0LMP: March 1, 2011AOG : 17 weeks 5 days EDD: December 8, 2011

Menstrual History

Menarche: 10 years oldCoitarche: 15 years oldMenstrual cycle: 28-30 day

cycleDuration: 3-4 daysUsing 3-4 pads fully soaked

Past Medical HistoryNo previous hospitalization.

No allergies to food and drugs.

Family HistoryNo heredofamilial diseases.

Social History

Non smokerNon alcohol beverage drinker

Review of Systems

General :(-)Weight loss (42kg to 41kg), (-) Fever, (-) Chills (+) weakness (-) anorexia

Cardio-Respi:(-)Chest pain, (-)Dyspnea (-) Hemoptysis (-)Cough, (-) Palpitations, (-)Edema

GIT: (-)Dysphagia, (-) Heartburn, (-) Indigestion (+) Loss of appetite (-) Diarrhea (-)Constipation

GUT: (-)Urgency (-)Frequency (-)Nocturia (-)Dysuria(-)Hematuria (-)Incontinence

Physical Examination

BP: 110/70PR: 80 bpmRR: 16 cpmTemp: Afebrile

GS: Conscious, coherent, NICRDHEENT: AS, PPC, (+) sunken

eyeballsHeart: AP, normal rate and

rhythm, (-) murmurExtremities: Full ROM

Physical Examination

Abdomen:

Globular with inverted umbilicus (-)straie gravidarum (-) linea nigra(-) tenderness in all 4 quadrants FH – bet symphysis pubis and umbilicus

Auscultation: normoactive bowel sound; FHT=NA

Leopold’s Maneuver: NA

Physical Examination

External Genitalia: Adequate hair distribution, no mass or lesion in the labia, perineum and anus

Clinical Pelvimetry

Flat, soft uterus enlarged to 16-18 weeks size, no contraction, (-) AMT

Admitting Diagnosis

G1P0 PU 17w 5d AOG NIL Hyperemesis Gravidarum

Course in the Wards

July 2, 2011

IVF D5LR 1L x 8Dx : CBC with BT, U/A, Na, K, Cl

Meds:- Metochlopromide 1 amp TIV q8- Incorporate 1 amp Benutrex C to

D5LR 1L x 8 hrs

Small frequent feedingsVS q4

Course in the Wards

July 3, 2011

IVF D5LR 1L x 8

Meds:- Kalium Durule tab 1 tab TID x 5 days

Small frequent feedingsVS q4

Diagnostic Studies

Sodium 135 135 – 145

Potasium 3.3 3.5 – 5.1

Chloride 95 97 - 107

Diagnostic StudiesRBC 5.02 x10

^12/L4.2 – 5.4

Hgb 139 g/L 120 – 160

Hct 0.41% 0.36 – 0.47

MCV 82.3 fL 80 – 96

MCH 27.7 pg 27-31

MCHC 33.7% 32 – 36

RDW 14.7 11.6 – 14.6

Platelet Adequate

WBC 13 5 – 10

Neutrophils 0.8876 0.500 – 0.700

Lymphocytes

0.063 0.200 – 0.700

Basophils 0.001 0.000 - .0200

Eosinophils 0.004 0.000 - 0.600

Monocytes 0.045 0.020 - 0.090

Diagnostic StudiesColor Dark Yellow

Transparency Turbid

Reaction 8.0

Specific Gravity 1.010

WBC 3 – 10

RBC 0.3

Epithelial cell Few

Albumin Trace

Sugar Negative

Crystals Amorphous phosphate: Many

HYPEREMESIS GRAVIDARUM (HG)

70-85% of pregnant patients experience nausea & vomiting

2-5 % of these women experience HG

vomiting severe enough to cause weight loss, dehydration, alkalosis or hypokalemia

HYPEREMESIS GRAVIDARUM (HG)

RISK FACTORS hyperthyroidismmolar pregnancygastrointestinal disordersinfection

HYPEREMESIS GRAVIDARUM (HG)

ETIOLOGY unknown

rising levels of HCG estrogen, progesterone, leptin, GH, prolactin , thyroxine, ACTHPsychological component

HYPEREMESIS GRAVIDARUM (HG)

SIGNS & SYMPTOMS nausea/vomiting in early pregnancy weight loss dehydration weakness subtle PE signs

HYPEREMESIS GRAVIDARUM (HG)

DIFFERENTIALS

ACUTE ABDOMEN HISTORY, PE

GASTRITIS/PUD HISTORY OF VOMITING ENDOSCOPY

PREECLAMPSIA/HTN HISTORY / PELIVER FUNCTION TESTSCBC, LDH, BUN, CREA

HYPEREMESIS GRAVIDARUM (HG)DIFFERENTIALS

LIVER DISEASE HISTORY, PELFT HEPATITIS PROFILE

THYROID DISEASES HISTORY/PEFT4, TSH

MOLAR PREGNANCY HISTORY /PEULTRASOUND

HYPEREMESIS GRAVIDARUM (HG)

DIAGNOSIS

History/PE CBC Urinalysis serum electrolytes Ultrasound

HYPEREMESIS GRAVIDARUM (HG)

MANAGEMENT

GOAL: control nausea and vomiting Antiemetic Small frequent feedings Adequate hydration Ice chips Reassurance

HYPEREMESIS GRAVIDARUM (HG)

MANAGEMENT 1st line fails Hospitalization Dehyration Ketosis Electrolyte deficits Acid base imbalance

CORRECTED

HYPEREMESIS GRAVIDARUM (HG)

COMPLICATIONS Dehydration

electrolyte imbalance renal failure

Wernicke’s Encephalopathy (Thiamine deficiency)

Vitamin K deficiency : maternal coagulopathy or fetal intracranial hemorrhage

HYPEREMESIS GRAVIDARUM (HG)

COMPLICATIONS

Mallory Weiss tearsCharacterized by upper gastro-intestinal bleeding secondary to longitudinal mucosal lacerations at the gastroesophageal junction or gastric cardia.

HYPEREMESIS GRAVIDARUM (HG)

COMPLICATIONS

Boerhaave syndrome - characterized by upper gastrointestinal bleeding secondary to transmural perforation of the esophagus