Obs&Gynae Case Presentations

8/3/2019 Obs&Gynae Case Presentations

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Obstetrics and Gynaecology

Case PresentationNatrah Abd Manan


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Learning Points

Paraumbilical hernia in adult

Management of pregnant women undergoingnon-obstetric surgery

Red blood cell isoimmunization


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The case

VC, a 35 year old G5 P4+1

She is 19/40 pregnant

BIBA on Wednesday at 10am

3x vomiting, bile stained

Sudden onset abdominal pain


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History of Presenting Complaint

Vomiting since 8.30am

Bile stained, no blood

Feels sick afterwards

Abdominal pain

Sudden onset

10/10 Intermittent in nature

labour pain


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History of presenting complaint

No urinary problem, no vaginal bleeding

No complications


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Past obstetric history

4 pregnancies

1: LSCS (fibroid)

2: ventouse-assisted

3: complete miscarriage, early gestation

4: LSCS (Back problem)


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Past gynaecological history

Fibroid in 2006


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Past medical history

Paraumbilical hernia for 2 years (since 2009)

Back problem; sciatica protruding disc L4 L5

Migraine

Medication: nil

NKDA


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Others

Past psych history: nil of note

Family history: nil of note

Social history: non smoker, occasional drinker,lives with husband and 3 children


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Physical examination

T 36.1

HR 74

RR 16

02 sat 99% on room air

BP 99/59


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Physical examination

FHR=147

No fetal movement

Fundus palpable

Abdomen tender ++

Discoloured paraumbilical hernia with green

discharge


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Diagnosis

Ruptured paraumbilical hernia with small bowelobstruction


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Management

Surgical: paraumbilical hernia repair + bowelresection

Pethidine 50 mg IM

Prochlorperazine (Stemetil) 12.5 mg IM

Paracetamol 1 g IV

Tinzaparin (Innohep) 3500 iu SC Prophylactic anti-D IM 1500 unit


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Paraumbilical hernia in adult Introduction

Acquired

F:M=3:1 3rd most common cause of SBO (adhesion and

malignancy being 1st and 2nd respectively)

Association increased intra-abdominal pressure due to

obesity, abdominal distension, ascites, andpregnancy


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Paraumbilical hernia in adult

Repair

Surgical: open or laparoscopic


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Management of pregnant womenundergoing non-obstetric surgery Elective surgeries are best avoided

Operation rate 0.75%

Concerns include:

Teratogenesis

Miscarriage

Hemorrhage


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IssuesSurgical Anaesthesia

Thrombophylaxis

Antibiotic prophylaxis Timing

Prophylactic glucocorticoids

Prophylactic tocolytics

Surgical approach

Fetal heart rate monitoring

Postoperative care

Delivery

General anaesthesia

Risk of difficult intubation Desaturation

Aspiration

Hemodynamic instability

Anaesthetic drugs issue

Recovering fromanaesthesia

Newborn effects

Regional anaesthesia


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Outcome No association between surgical procedures and

incidence of adverse reproductive outcome.

The rate of congenital malformations andunexplained stillbirths similar to women whodid not undergo non-obstetric surgery.

The rates of low birthweight infants (due to

prematurity and growth restriction) and earlyneonatal death (death within seven days ofbirth) were significantly increased in womenwho had had surgery.


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Red blood cell isoimmunization

Production of antibodies by mothers immunesystem in response to antigen on fetal red cells

that enter her circulation.

Antibodies then cross the placenta

Causing fetal red blood cell destruction


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Pathophysiology1) blood group2) sensitization

Aetiology

Manifestationsof rhesus disease

Management ofisoimmunization

Prevention:using anti-D

Epidemiology


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Epidemiology

15% of Caucasian women, fewer in African orAsian

Perinatal deaths due to rhesus disease are raredue to:

Use of anti-D

Smaller family size Good Mx of isoimmunization


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Pathophysiology

Blood group

Rhesus system

Three gene pairs: C/c, D/d, E/e

DD and Dd rh +ve

dd rh ve

Sensitization Mixing of fetal and matenal blood

Production of antibodies

Destruction of fetal RBC rh haemolytic disease


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Aetiology

Lack of prophylactic anti-D

Other antibodies e.g anti-c, anti-E and anti-Kell


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Manifestations of rhesus disease

Neonatal jaundice

Neonatal anaemia

In utero anaemia

If worsens:

cardiac failure

ascites oedema (hydrops)

fetal death


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Prevention: using anti-D Offer blood test at booking and 34 weeks Offer anti-D to rh ve women at 28 and 34 weeks After any bleeding or potentially sensitizing events

TOP/ ERPC after miscarriage Ectopic pregnancy Vaginal bleeding


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References http://www.uptodate.com/contents/prevention-of-venous-

thromboembolic-disease-in-surgical-patients?source=related_link http://www.uptodate.com/contents/management-of-pregnant-

women-undergoing-nonobstetric-surgery?source=related_link http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1%7E150#H16

http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf http://www.uptodate.com.libgate.library.nuigalway.ie/contents/ma

nagement-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150

IMPEY, L. & CHILD, T. (2008) Obstetrics and Gynaecology, Wiley-Blackwell Publication.
http://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdfhttp://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.uptodate.com.libgate.library.nuigalway.ie/contents/management-of-rhesus-rh-alloimmunization-in-pregnancy?source=search_result&search=management+pregnant&selectedTitle=14~150http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdfhttp://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/overview-of-abdominal-wall-hernias?source=search_result&search=paaumbilical+hernia&selectedTitle=1~150http://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/management-of-pregnant-women-undergoing-nonobstetric-surgery?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_linkhttp://www.uptodate.com/contents/prevention-of-venous-thromboembolic-disease-in-surgical-patients?source=related_link


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