PowerPoint Presentation

27 year old

G3P2 (2-0-0-2)

Single

Roman Catholic

Paranaque City

LMP: Jan. 20, 2014

AOG: 39 weeks 5 days

EDC: October 27, 2014

Labor pains

First Trimester

(+) amenorrhea

(+) pregnancy test

(+) nausea/ vomiting

(-) vaginal bleeding, watery or mucoid discharge

(-) ultrasound done

(-) medication taken

(-) consult done

Second Trimester

(+) quickening at 18 wks AOG

(+) consult to Private MD

ultrasound requested but non-compliant

Third Trimester

(-) labor pain

(-) watery vaginal discharge

(-) bloody show

(-) mucoid vaginal discharge

(+) good fetal movement

IMPRESSION:Single, live, intrauterine pregnancy, cephalic presentation of about 40 weeks 3 days AOG based on BPL, FL, ACPlacenta Anterior Grade IIINormohydramnios (AFI 11.1cm)Estimated fetal weight 4188 grams (>90th percentile)BPS SCORE: 8/8

BIOPHYSICAL PROFILE

Paranaque Ultrasound Diagnostic Center

October 24, 2014

History of present illness

five hours prior to admission

Admitted at Happy Home LIC (Paranaque City) for vaginal delivery

one hour prior to admission

Decided to Transfer to hospital per patient request

Past Medical History

No hypertension

No diabetes mellitus

No bronchial asthma

No PTB

No goiter

No Cancer

Family History

No hypertension

No diabetes mellitus

No bronchial asthma

No PTB

No cancer

Personal and Social History

Non-smoker

Non-alcoholic beverage drinker

Denies illicit drug use

Vendor

Menstrual History

Menarche: 14 years old

Interval: regular (28-32 days)

Duration: 4-5 days

Amount: 1-2 pads per day, moderately soaked

Symptoms: no dysmenorrhea

Sexual History

First coitus: 25 years old

Number of sexual partner: 1 partner

(+) use of injectables for 3 months (October to December 2013)

(-) STD

(-) dyspareunia

(-) post-coital bleeding

OB History

G3P2 (2-0-0-2)

(+) PNCU x 3 at Private MD

YearSexOutcomeMethodPlaceFMCG12012MFTNSDParanaque Lying In(-)G22013FFTNSDParanaque Lying in(-)G32014Present pregnancy

Review of Systems

No fever, no chills, no weight gain/loss, no anorexia

No blurring of vision, no hearing loss, no tinnitus, no dizziness, no sorethroat, no gum bleeding

No dyspnea, no cough, no colds, no hemoptysis

No chest pain, no palpitations, no orthopnea, no PND, no easy fatigability, no cyanosis

No abdominal pain, no changes in bowel movement, no nausea/vomiting, no hematochezia, no hematemesis, no melena, no jaundice

No dysuria, no hematuria, no urgency, no frequency, no nocturia

No easy bruisability

No polyuria, no polydipsia, no polyphagia, no heat/cold intolerance

No loss of consciousness, no changes in sensorium, no seizures, no tremors, no weakness, no numbness, no headache

Physical Examination

Conscious, coherent, not in cardiorespiratory distress

110/7098 bpm17 cpm36.8 C

Anicteric sclerae, pink palpebral conjuctivae, no nasoaural discharge, no cervical lymphadenopathy

Symmetric chest expansion, clear breath sounds, no retractions

Adynamic precordium, normal rate and regular rhythm, no murmurs

Globular, soft, normoactive bowel sounds

Fundic height: 33 cm

Estimated fetal weight: 3255 grams

Internal Examination: cervix 9 cm dilated, fully effaced, cephalic, ruptured bag of waters->thickly meconium stained amniotic fluid, station +2

Grossly normal extremities, full and equal pulses, no edema, no cyanosis

X 140s

Present Working Impression

G3P2 (2-0-0-2) Pregnancy Uterine 39 weeks and 2 days AOG cephalic in labor

Plan

Vaginal delivery

Outcome

Baby Boy

APGAR: 9,9

Birthweight: 3700 grams

Birthlength: 53 cm

Pediatric Aging: 38 weeks (LGA)

Postpartum

BP: 100/70

Tachycardic

Uterine massage

Oxytocin 10 u IM

Double line; OXYTCIN DRIP; Methergine IV and IM; Carboprost; Tranexamic Acid

After 20 minutes: manual extraction of placenta done with ease (located anterofundally) revealed incomplete cotyledon

Profuse vaginal bleeding soaking 2 adult diapers

Inspection: no vaginal/cervical lacerations

IE: cervix open, uterus boggy

postpartum hysterectomy

Pakiayos nalang daw to kiel na hindi cluttered

wag daw isang slide langa

Intraoperative Findings

No ascitic fluid

Smooth and grossly normal liver, subdiaphragmatic surface, stomach, spleen, kidney, omentum and intestinal surfaces

No palpable or enlarged paraaortic and pelvic nodes

Uterus enlarged to 18 weeks size with well-defined lower uterine segment

Postpartum uterus: 18 x 10 x 5 cm with smooth, serosal surface. No lesions or masses on cute sections.

Myometrium: 2.5 cm

Endometrium: 0.2 cm, spongy

Uterine cavity: 12 cm, 4 cm of which is the endocervical cavity

Bilateral ovaries and fallopian tubes grossly normal.

Estimated blood loss: 700cc

Endometrium is hemorrhagic

Postoperatively

BP: 90-100/60

HR: 100-110

Assisted ventilation

Adequate urine output: 0.65cc/kg/hr

No vaginal bleeding

Pale palpebral conjunctiva

Clear breath sounds

Correction of anemia

1 unit PRBC transfused

Judicious hydration

Course in the Wards

Complete Blood Count10/27WBC Neutrophils Lymphocytes Monocytes Eosinophils Basophils19.4489.16.04.70.10.1RBC3.38HGB8.7HCT26.9Platelets180Electrolytes 10/27Sodium136Potassium3.5

Course in the Wards

General liquid diet

IVF: PNSS 1L x KVO

Medications continued

IFC maintained (UO: 28 to 125 cc/hr)

Still for transfusion of 2u PRBC

First post-operative day

Course in the Wards

2u PRBC transfused

Diet as tolerated

Medications continued

IFC maintained (UO: 28 to 125 cc/hr)

Referred to Department of Internal Medicine regarding hypokalemia (2.8 mmol/L)

PNSS 1L + 40mEq KCl x 125 cc/hr

Kalium durule TID x 3 days

Second post-operative day

Complete Blood Count10/29WBC Neutrophils Lymphocytes Monocytes Eosinophils Basophils18.68515RBC3.3HGB82HCT25PlateletsElectrolytes 10/29Sodium135.5 Potassium2.82

Course in the Wards

Diet as tolerated

For transfusion of 2u PRBC

Medications continued

Third post-operative day

Course in the Wards

Patient went on HAMA

Fourth post-operative day

Salient Features

General data

27y/o

Antepartum

G3P2 (2-0-0-2)

CC: Labor pains

39w5d AOG

Non-contributory Past, Family and Personal and social, menstrual history

Sexual history: use of injectables monthly x 3 mos (Oct-Dec, 2013)

OBHx: s/p NSD G1 and G2 (Paranaque Lying-in, 2012 and 2013) with no complications

Salient Features

Intrapartum

At the ER, stable vital signs

Fundic height: 33cms

Good heart tone

IE: fully dilated, fully effaced, cephalic, +BOWthickly St+2

Placenta manually extracted with incomplete cotyledon upon inspection

Postpartum

30mins postpartum profuse vaginal bleeding

Boggy and soft uterus

Present Working Impression

G3P3 (3003) PU delivered a term, cephalic live birth

Anemia secondary to Postpartum hemorrhage secondary to placenta accreta

s/p Exploratory Laparotomy Subtotal Hysterectomy for placenta accreta

APPROACH TO DIAGNOSIS

POSTPARTUM HEMORRHAGE

Bleeding from implantation site

Trauma from the Genital Tract

No perineal laceration

No cervical and vaginal laceration

No episiotomy

Hypotonic Myometrium

Retained placental fragments

COAGULOPATHIES

NASA LEFT SIDE DAW YUNG SALIENT FEATURES

SALIENT FEATURES

APPROACH TO DIAGNOSIS

POSTPARTUM HEMORRHAGE

Bleeding from implantation site

Hypotonic Myometrium

Retained placental fragments

Overdistended uterus

Prolonged labor

Chorioamnionitis

High Parity

Oxytocin Induced

Avulsed cotyledon

Abnormally adherent placenta

INCRETA

ACCRETA

PERCRETA

Histopathologic Result

OMS 14 XXXX

October 27, 2014

FINAL HISTOPATHOLGIC FINDINGS

S/P POSTPARTUM SUBTOTAL HYSTERECTOMY (WITH CLINICAL HISTORY OF UTERINE ATONY):

POSTPARTUM UTERUS

CONSISTENT WITH PLACENTA ACCRETA

Description

Received specimen labeled uterus which consist of subtotal hysterectomy specimen, weighing 500 grams and measuring 16.0 x 14.0 x 2.5 cm (wall thickness) having tan-brown smooth outer surface. Cut sections of the uterus shows that the endometrium is hemorrhagic, while the myometrium measures 1.0 c, from isthmus to fundus and is also hemorrhagic. Representative sections taken from embedding, labeled: (A1 A3) endomyometrium, block 4;

Microscopic examination of the slides shows aggregation of the red blood cells and decidua on the endometrial layer with internal endometrial glands seen. Decidual cells and chrorionic villi are seen infiltrating the myometrium

Final Diagnosis

G3P3 (3003) PU delivered a term cephalic live birth

Anemia secondary to Postpartum hemorrhage secondary to placenta accreta

s/p Exploratory Laparotomy Subtotal Hysterectomy for placenta accreta

PLACENTA ACCRETA

DEFINITION

Derivation of accreta comes from the Latin ac- +crescereto grow from adhesion or coalescence, to adhere, or to become attached to (Benirschke, 2012).

DEFINITION

include any placental implantation with abnormally firm adherence to myometrium because of partial or total absence of the decidua basalis and imperfect development of the fibrinoid or NITABUCH LAYER.

DEFINITION

abnormal adherence may involve all lobulestotal placenta accreta .

If all or part of a single lobule is abnormally attached, it is described as a focal placenta accreta.

EPIDEMIOLOGY

Once a rare occurrence, placenta accreta is becoming an increasingly common complication of pregnancy, likely related to the increasing rate of cesarean delivery over the last five decades.

Placenta accreta occurs in approximately 1:1000 deliveries with a reported range from 0.04% rising up to 0.9%.

EPIDEMIOLOGY

The median maternal age is around 34 years and the median parity is 2.5.

Risk factors other than a previous cesarean include

submucous myoma

previous curettage

Ashermans syndrome

advanced maternal age

grandmultiparity

smoking

chronic hypertension

EPIDEMIOLOGY

Placenta accreta = villi are attached to the myometrium.

Placenta increta = villi invade the myometrium

Placenta percreta = villi penetrate through the myometrium and to or through the serosa.

In clinical practice, these three variants are encountered in an approximate ratio of 80:15:5, respectively (Wong, 2008).

EPIDEMIOLOGY

currently, the American College of Obstetricians and Gynecologists cites it to be as high as 1 in 533 deliveries. Because of this increasing frequency, accrete syndromes are now one of the most serious problems in obstetrics.

EPIDEMIOLOGY

In addition to their significant contribution to maternal morbidity and mortality, accrete syndromes are a leading cause of intractable postpartum hemorrhage and emergency peripartum hysterectomy (Awan, 2011; Eller, 2011;Rossi, 2010).

EPIDEMIOLOGY

In their review of nearly 10,000 pregnancy-related maternal deaths in the United States, Berg and associates (2010) reported that 8 percent of deaths due to hemorrhage were caused by accrete syndromes.

PATHOPHYSIOLOGY

Presence of Risk Factors

Increased maternal age

Multiparity

Associated or history of placenta previa

Previous uterine surgery or trauma

Cigarette smoking

Elevated prenatal screening MSAFP and free -hCG levels

Other comorbids i.e. Ashermans syndrome, Chronic hypertension

Constitutional endometrial defect

Total/partial decidua basalis deficiency

Deficiency of fibrinoid or Nitabuch layer

Hyperinvasiveness of cytotrophoblasts that control decidual invasion through factors such as angiogenesis and growthexpression

Placental villi anchored, abnormally implanted and adhered, invaded or penetrated to muscle fibers (myometrium) rather than to decidual cells

Retained placental fragments after placental delivery or delayed spontaneous separation of the placenta with total or partial removal of the adherent placenta

Hemorrhage