Maternal complications in an Elderly Primigravid Medical Presentation

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Slide 1-

Case Discussion
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Demographics Name: M.R.C. Age: 43 Address: Baesa Caloocan City Gender: Female Civil Status: Single Employment Status: Public School Teacher Chief Complaint: Labor Pains Reliability 95% Source: Patient herself
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History of Present Illness 1 day PTC patient came in for follow up check up at MCU OPD, patient experienced regular contractions at 3-5 minute duration without bleeding or watery vaginal discharge. IE was done revealing 2cm dilated cervix. Blood exam tests revealed anemia. Initial baseline CTG was done,was advised for admission but opted for HAMA.
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History of Present Illness Few hours PTC, patient felt hypogastric pain associated with contractions and passage of blood clots per vagina, hence consultation at the ER and was subsequently admitted
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Past Medical History (+)allergy : amoxicillin, seafood (-)asthma, (-)heart disease (-)HPN, (-)DM, (-)TB, (-)CA (-)Thyroid disease Hospitalizations: 2016 Hypersensitivity (Singapore) Surgery: 2017 April (Appendectomy-MCU)
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Past Medical History Immunizations: Tetanus Toxoid 1 Measles Varicella
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Family Medical History (+) DM – mother, siblings (+) Heart disease – mother (+) HPN – mother (+) CA – paternal side (aunt-breast CA)
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Personal Social History Patient is a college graduate, Public School teacher who lives with her elder sister. Sexual partner was her 35 year old ex boyfriend who works at the office.
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Personal Social History (-)smoking, (-)alcoholic beverage Diet: Vegetable and fish Exercise: ZUMBA Source of Water: Distilling Station No prevalent diseases in the community
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OB-Gyne History OB Score: G1 Elderly Primigravid Breastfeeding History: Not applicable Menstrual History: LMP: September 23, 2016 AOG: 37 weeks AOG based on TVS EDC: June 30, 2017 PNMP: October 22, 2016
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OB-Gyne History Menstrual History: Menarche – 13 y/o Interval – Regular 28-30 days Duration: 3-5days Amount: 6 fully soaked pads per day (+) dysmenorrhea day 1-2
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Sexual History Coitarche: 40 y/o Sexual partners: 2 No vulvovaginal infections Last sexual contact: December 2016 No contraceptives used
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Prenatal History 1st Trimester (+) Check ups (+) TVS (+) laboratory (-) illness *unwanted pregnancy
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Prenatal History 2nd Trimester (-) Check ups (-) laboratory (-) illness
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Prenatal History 3rd Trimester (+) admitted for preterm labor 30 weeks AOG at MCU (+) appendicitis, S/P appendectomy (April 5) (+) Upon follow up-check up advised for admission but opted for HAMA (preterm labor, T/C bacterial vaginosis) (-) laboratory (declined for wet smear, KOH and gram stain)
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Prenatal History 3rd Trimester TERM 37 weeks AOG OPD (June 29)– (+) pale palpebral conjunctiva non compliance for 1 month to iron supplement due to gastric irritation Latest Lab results were reviewed revealing Anemia Referred to Perinatology Advised for Admission but opted for HAMA
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Review of Systems General: (+)Easy fatiguability, (-)Fever,(-)Weakness (-)Weight Loss Skin: (-)rashes, (-)itching, (-)urticaria HEENT: (-)blurring of vision, (-)headache, (-)dizziness, (-)otalgia, (-)ringing (-)anosmia, (-)bleeding, (-)swelling of eyes/nose/ears/mouth, (-)odynophagia, (-)soreness CVS: (-)orthopnea, (-)palpitations, (-)edema (-)edema Respiratory: (-)cough, (-)chest pain, (-)dyspnea, (-)shortness of breath GIT: (-)nausea, (-)vomiting,(-)diarrhea, (-)constipation, (-)abdominal pain, (-)heartburn, (-)belching, (-)loss of appetite, (-)hematochezia, (-)melena, (-)dyschezia, (-)incontinence GUT: (-)dysuria, (-)frequency, (-)hesitancy, (-)incontinence (-)urgency, (-)pyuria, (-)hematuria
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Physical Examination HEENT: Normocephalic, no lumps or depression, anicteric sclerae, pale palpebral conjunctiva, patent nares, no nasoaural discharges, pinkish moist oral mucosa, no lesions, no enlarged tonsils, neck is supple, trachea at the midline, no mass, no tenderness, no cervical lymphadenopathy
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Physical Examination Chest: Symmetrical chest expansion, no retractions, no lagging, clear breath sounds, no adventitious sounds (rhonchi, wheezes, crackles)
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Physical Examination Heart: Adynamic precordium, no murmurs, normal rate regular rhythm
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Physical Examination Breast: Not Assessed (patient declined)
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Physical Examination Abdomen: Globular, soft non-tender abdomen, normoactive bowel sounds, (+)palpable uterine contractions FH-32cm FHT-150bpm EFW – 3225g LM1 – breech LM2 – Fetal back at the right LM3 – Cephalic LM4 – Unengaged
Slide 23-

Physical Examination Genital Exam: Grossly normal, without lesions, ulceration and discharges. Speculum Exam: Violaceous Cervix, no ulcerations, no lesions, violaceous vaginal wall with whitish discharge, Internal Examination: Cervix is soft, smooth and 3cm dilated and 50% effaced, mid position, no motion tenderness, no adnexal tenderness and masses, station -3, (+) BOW, BS 3
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Physical Examination Extremities: Grossly normal extremities, full normal equal peripheral pulses, no edema Nervous System: Unremarkable
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Admitting Impression G1P0 Pregnancy Uterine 37 1/7 weeks AOG, cephalic in labor, Elderly Primigravid, Anemia probably IDA
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Plan of Management For admission For baseline diagnostic exams For correction of anemia For assisted vaginal delivery For identification of the kind of anemia
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Procedure done Primary low transverse cesarean section for dysfunctional labor secondary to arrest in cervical dilatation under spinal anesthesia
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Outcome G1P1(1001) Term, cephalic delivered via Primary Low Segment Transverse Cesarean Section for arrest in cervical dilatation to a live baby girl, BW 2,700g; Apgar Score 9,9,9; Ballard Score 39 weeks under Spinal Anesthesia, Iron deficiency Anemia, Elderly Primigravid
Slide 29-

Course in the Ward Day 1: June 30, 2017 Patient was admitted and was placed under close monitoring at the LR IE: St -2, 3cm, (+)BOW, soft cervix Set on NPO Baseline CBC APC HBsAg Urinalysis, PT PTT taken at the ER Hooked to electronic fetal monitoring every 2 hours and progress of labor monitored Vital signs, Input and Output monitored
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Course in the Ward Day 1: June 30, 2017 Hyoscine-N-Butyl Bromide 2cc/IV then 1cc/IV every 2 hours Scheduled for Assisted Vaginal Delivery under epidural anesthesia
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Course in the Ward Day 2: July 1, 2017 Started on IV side drip of D5LR 1L + 10 units oxytocin at 12gtts/min IE: St -2, 4cm, 50% effaced (+)BOW, BS 7 Evening primrose given 2 capsules per vagina every 2 hours Protracted labor due to arrest of cervical dilatation Emergency Low segment cesarean section done under spinal anesthesia Delivered to a live baby girl
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Course in the Ward Day 2: July 1, 2017 Transferred to PACU for close monitoring Transfused 1 unit PRBC properly typed and crossmatched
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Course in the Ward Day 3: July 2, 2017 Transferred to ward when the vital signs were stable Post transfusion blood exam 6 hours post BT Resumed to soft diet when flatus and bowel movement were present Started ambulation with care
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Course in the Ward Day 3: July 2, 2017 Transfused another 1 unit of PRBC properly typed and crossmatched Daily wound care
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Course in the Ward Day 4: July 3, 2017 Resumed to regular diet as tolerated Advised assisted ambulation Daily wound care
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Course in the ward Day 5: July 4, 2017 Still for transfusion of the 3rd 1 unit PRBC properly typed and crossmatched Daily wound care
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Course in the Ward Day 6: July 5, 2017 Post transfusion blood exam taken 6 hours after the 3rd unit of PRBC Checked for final assessment and was deemed fit for discharge
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Friedman’s Curve
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Partograph
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Actual Laboratory Results June 30, 2017
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July 2, 2017
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July 6, 2017
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Urinalysis
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Drug Summary
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ANEMIA Anemia is defined as a reduction of the total circulating red cell mass below normal limits. Anemia reduces the oxygen-carrying capacity of the blood, leading to tissue hypoxia Tissue hypoxia would endanger not only the fetus but also the mother
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Diagnosis Signs and symptoms Easy fatiguability Pallor Cyanosis Shortness of breath Dizziness Tingling or crawling feeling in the legs Cold hands and feet Fast or irregular heartbeat Brittle nails Headaches Pica
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Diagnosis Laboratory diagnostics CBC (Hgb, Hct, MCV, MCHC) Serum Ferritin Peripheral Blood smear Hemoglobin Electrophoresis
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Kinds of Anemia Hypoproliferative Anemias IDA Anemia of Chronic Inflammation Thalassemia Sideroblastic Anemia Megaloblastic Anemia Hemolytic Anemia Anemia of Blood Loss
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Normal Range Values
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Hemoglobin Values
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Iron Deficiency Anemia Microcytic , hypochromic Causes Inadequate intake Impaired absorption Increase in demand Chronic blood loss
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Iron Metabolism
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Regulation of Iron Absorption
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Diagnosis of Iron Deficiency Anemia Low hemoglobin and hematocrit On peripheral smear Hypochromia Microcytosis, anisocytosis, poikilocytosis Low MCV, MCHC, MCH High RDW
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Definitions of Iron Status for women
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Iron Deficiency Anemia Treatment Iron therapy Blood transfusion
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Thalassemia The thalassemia syndromes are a heterogeneous group of disorders caused by inherited mutations that decrease the synthesis of either the α-globin or β-globin chains that compose adult hemoglobin, HbA (α2β2), leading to anemia, tissue hypoxia, and red cell hemolysis related to the imbalance in globin chain synthesis.
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Diagnostics Prenatal testing Chorionic villus sampling Done around 11th week Amniocentesis Around 16th week Routine blood exams CBC, MCV, MCHC, Serum Ferritin Hemoglobin Electrophoresis
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Classification of Thalassemia
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Pathogenesis of Thalassemia
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Beta thalassemia Gene mutations
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Treatment Blood transfusion Iron Chelation therapy
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ANEMIA LOW Hgb Low Hct Low MCV Low MCHC Serum Ferritin < 12ug/L > 12 ug/L IDA Hgb Electrophoresis Thalassemia Blood transfusion Iron Chelation Therapy Iron Supplementation Unreponsive to treatment Algorithym for Pregnancy with Anemia
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Maternal complications in an Elderly Primigravid “Pregnancy Outcome in Elderly Primigravidas” Vibha et al. Sept. 20, 2016
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Mode of delivery in elderly primigravid
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Various causes of perinatal outcome
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Conclusion Anemia is a common condition in pregnant women that carries risk for both mother and child. It is crucial to identify the kind of anemia for specific treatment modality.
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Thank YOU