Case capsules

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Case studies in obstetric problems like PPROM, vulvovaginitis, ectopic pregnancy, watery leak p/v by Prof.Ayesha Jehan

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Case capsules

  1. 1. Greetings from…
  2. 2. CASE CAPSULES - Prof. Ayesha Jehan Professor of Obstetrics & Gynaecology, Deccan College of Medical Sciences, Hyderabad
  3. 3. CASE 1
  4. 4. CASE 1• 22/F, Primi gravida, c/o 8 months amenorrhoea and ‘watery leak’ P/V• h/o recurrent attacks of VV + UTI since marriage (11 months)• h/o cerclage at 18 weeks GA• e/o genital herpes since 16 weeks of pregnancy• AN Profile: – Hb: 12 g%, Blood group: A positive – OGCT: 90 mg% – VDRL: NR, HIV/HbsAg: Negative – S.TSH: 1.5 uIU/ml, ECG: WNL – CUE: Pus cells: 15-20/HPF, Albumin +, E/C - NIL
  5. 5. .. contd• AN Exam: – Uterus 30 weeks, FH<GA – Irritable, FH + regular, NST reactive – L/E: Herpetic vesicles seen locally over the external genitalia.• P/V – Cx soft, short, watery leak +• P/S – Thin, profuse WD +, Vagina congested. – Cerclage suture + – Watery leak intermixed with WD +• Conclusion: PPROM + VV at 32 weeks
  6. 6. QUESTION 1WHAT IS THE CLINICAL APPROACH INTHIS CASE?
  7. 7. ‘WATERY LEAK’ - DDx1. Vaginal discharge – Physiological vs. Pathological2. Amniotic fluid – Gush vs. Trickle3. Urine
  8. 8. QUESTION 2WHAT IS THE SIGNIFICANCE OFVAGINAL EXAMINATION IN ANC?EFFECTS OF RECURRENT VV INFECTIONSAND PID?
  9. 9. VULVOVAGINITIS• 40-60% of AN cases• Organisms commonly implicated: – Trichomonas – Gardenella – Beta streptococci, Gonococci – Candida – Chlamydia – TORCH, HIV, Koch’s• High vaginal swab, endocervical swab indicated.
  10. 10. VULVOVAGINITIS• VV and PID cause: – Abortions – PPROM: Oligoamnios, CA, Abruptio placenta – Preterm birth – Placental insufficiency: IUGR, IUD – PROM & PTB - Prolonged hospital stay: • Psychosocial strain • Thromboembolic phenomenon • Puerperal sepsis • Neonatal complications
  11. 11. VULVOVAGINITIS – PATHOGENESIS OF FETOMATERNAL EFFECTS MEMBRANE INFLAMMATION PLACENTA FOETUS INSUFFICIENCY TISSUE INJURY Sepsis Infection/anoxia FDHYPOXIA DESTABILIZATION ACTIVATION IUGR OF LYSO MEM OF COX/IL-6/CYT IUD RELEASE OF AA - PG↑ ABNORMAL UTERINE ACTIVITY ↑ IAP CERVICAL CHANGES MATERNAL SEPTICAEMIA PPROM PRETERM BIRTH
  12. 12. QUESTION 3WHAT IS THE CAUSE ANDFOETOMATERNAL EFFECTS OF GENITALHERPES?MODE OF DELIVERY?
  13. 13. GENITAL HERPES• 5% of high risk pregnancies (rising trend)• Caused by HSV-1 & HSV-2 (↑)• M-B transmission in first trimester leads to: – Congenital defects: Microcephaly, intracranial calcifications, micro- ophthalmia, chorioretinitis• M-B transmission in later weeks causes neonatal herpes (SEM, CNS, disseminated herpes)• 80% HSV positive infants are born to asymptomatic mothers.• In primary infection, IgM+ in 7-10 days, IgG low avidity+ in 4 weeks.• Intrauterine foetal infection is high in the absence of IgG (Placental barrier)• Ascending infection from the cervix is common.• PPROM predisposes to IU spread.
  14. 14. GENITAL HERPESRx:• Acyclovir 400mg TID x 7-10 days• Valacyclovir 500mg BD x 7-10 days• Famcyclovir 200mg BD x 7-10 daysObstetric management: (1998 AICOG Guidelines)• No lesion – No LSCS• Primary herpes – LSCS, Recurrent – LSCS +/-• Invasive intrapartum procedures (FBS, CTG) and instrumental deliveries are avoided.
  15. 15. QUESTION 4WHAT IS THE PROTOCOL FORANTENATAL SURVEILLANCE IN CASES OFPPROM?
  16. 16. ANTENATAL SURVEILLANCE PROTOCOL• Twice daily CTG / FH monitoring• Maternal Vitals: PR/Temp q4h• CBP twice weekly (leucocytosis - IUI)• Non-specific inflammatory markers: ESR, CRP• USG: BBP, Doppler study• Repeated high vaginal swabs – DEBATED – ↑ ascending infections??
  17. 17. QUESTION 5WHAT ARE THE C/F OF THE FOUR MAINCOMPLICATIONS –OLIGOAMNIOS, CA, PTB, FOETALDISTRESS?
  18. 18. QUESTION 6WHAT IS THE MANAGEMENT IN THISCASE?- CONSERVATIVE- ACTIVE
  19. 19. CONSERVATIVE MANAGEMENT• The Rule in: – NIL/minimal signs of infection – NO foetal compromise
  20. 20. CONSERVATIVE MANAGEMENT• Rest and Oxygen therapy• Hydration: IV, Amino infusion +/-• Antibiotics (Parental, oral)• Steroids• Tocolytics• Progesterone, hCG• Counselling and diet
  21. 21. ACTIVE MANAGEMENT• Termination of pregnancy• Cerclage - when to remove?
  22. 22. In our case…..• The patient was managed conservatively for 96 hours, after which pregnancy had to be terminated due to: – ↑ leakage of liqour (AFI: 2) – Severe variable decelerations on CTG (FD) – E/O cord prolapse excluded• LSCS done, alive and healthy female baby weighing 1.8kg delivered, thin MSL, cord friable, placenta showing e/o large retroplacental clots & calcifications.• Baby admitted to NICU for neonatal care.• Puerperum uneventful• Healthy mother & baby discharged on Day 14.
  23. 23. TAKE HOME MESSAGES• A vaginal examination is mandatory in all antenatal cases• High vaginal swab & endocervical swab in early pregnancy helps to predict complications• Most patients remain asymptomatic but can spur surprises• Check couples habits – Smoking, zarda, pan – Multiple partners – Increased sexual activity – In male: DM, UTI, Seminal infections• Most infections are polymicrobial• Prophylactic antibiotics ↓ complications in HR patients.
  24. 24. INTRAPARTUM SCREENING PROGRAMMECDC recommended strategies:• Strategy 1: Vaginal + Rectal swab for all patients at 35-37 weeks.• Strategy 2: Intrapartum antibiotic prophylaxis.• Strategy 3: Combination of 1+2• Strategy 4: Rapid bed side testing in labourDosage recommended:• Metronidazole 2g q24h x 2 days• Benzyl penicillin 3g stat followed by 1.5g q4h x 2days (or)• Metronidazole 200-400mg + Clindamycin 900mg q8h x 2 daysIntrapartum prophylaxis is effective only if given 2 hours before delivery
  25. 25. VACCINES – A LONG TERM SOLUTION??• Vaccination of all women of child bearing age is recommended.• But most pathological organisms have various strains, hence, efficacy is not yet satisfactorily established.
  26. 26. CASE 2
  27. 27. CASE 2A 39 year old woman with 3 children came to the hospital withexcessive bleeding P/V following 2 months amenorrhea. She felt“unmistakably pregnant”.H/O POP usage + (no slip)Cycles irregular/scanty due to POPUPT +Moderately heavy bleeding for 7 days.O/E:GC stable. Afebrile. Tachycardia +BP-110/80mmHg, All systems stable. Pallor+, No goitre.P/A:Soft, Tenderness + pelvic region. No guarding. No s/o peritonitis.Ut NS Fx free Cx excitation –ve, Bleeding PV +, no clots. Os admits tip.
  28. 28. Investigations:Hb: 11g%, B+ve, RBS: 70mg%CUE: few Pus cells, RBC +, UPT +Serum hCG: 215 IU, After 48 hours, S.hCG: 45IUTVS: Ut NS ET 7mm, Left adnexa showing thinwalled ovarian cyst + 2x2cm, ↓free fluid PODCuldocentesis: No blood, 1-2ml clear fluid +
  29. 29. QUESTION 1WHAT IS THE DIAGNOSIS?DEFINITIVEDIFFERENTIALENNUMERATE THE DDX IN THIS CASE…
  30. 30. IN OUR CASE A DIAGNOSIS OFMISCARRIAGE + BENIGN OVARIAN CYSTWAS MADE….
  31. 31. QUESTION 2DOES AN ADNEXAL MASS (CYST)ALWAYS IMPLY ECTOPIC?INCIDENCE OF ADNEXAL CYST IN EP?DEFINITIVE FEATURES OF ECTOPICGESTATION?
  32. 32. DEFINITIVE FEATURES OF ECTOPIC UNRUPTURED RUPTURED• UPT + (SUBMINIMAL TITRES) • SHOCK +• EMPTY UTERINE CAVITY • PERITONITIS ++• GESTATIONAL SAC + FOETAL POLE IN ADNEXA• CULDOCENTESIS – 10ML UNCLOTTED BLOODIn the absence of definitive features, the diagnosis of ectopicpregnancy can be missed.
  33. 33. QUESTION 3WHAT IS THE MANAGEMENT OFMISCARRIAGE?
  34. 34. MISCARRIAGE - MANAGEMENT• Medical management – Misoprostol – 600-800ug in single/divided doses• Check curettage• Regular follow-up with S.hCG titres/UPT ↓ in 48 hours
  35. 35. QUESTION 4WHAT ARE THE PROGESTERONES USEDAND THEIR DOSAGES IN POP?CAN THEY CAUSEMISCARRIAGES/ECTOPIC? HOW?FAILURE RATE?
  36. 36. PROGESTERONES IN POP• Norethindrone: 0.35mg Cerazette (desogestrel• Norgestrel: 0.075mg 75ug) can cause abrupt follicular development in certain cycles (97-99%• Levonorgestrel: 0.03mg inhibition)• Desogestrel: 0.075mg (75ug)Progesterones alter tubal motility, make the endometrium hostile tonidation, alter cervical mucous.Failure rate: 0.5 to 1%
  37. 37. QUESTION 5WHAT IS YOUR FURTHERCONTRACEPTIVE ADVICE TO THISCOUPLE OF 40-45 YEAR AGE GROUP?
  38. 38. ALTERNATIVE CONTRACEPTIVE ADVICE• Permanent contraception• Barrier methods• Others
  39. 39. TAKE HOME MESSAGES• Contraception is no guarantee against pregnancy.• Every adnexal cyst in EP does not imply an ectopic. Benign ovarian cysts like simple follicular cyst/CL cyst should be kept in mind.• By TVS – incidence of ovarian cyst in EP: 30%• In unruptured ectopic a definitive Dx can be made only in 30% of cases.• S.hCG levels ↑ by 2/3 every 48 hours for 5 weeks on till 8 weeks normally.• At 5 weeks, hCG level is 1000-1500 mIU.• TVS scan is superior to TAS for early Dx of pregnancy site & viability.• By TVS at 5 weeks, GS (>20mm) +; FP+, YS+, hCG level 1000mIU.• By TAS GS is seen when hCG level is 6000 mIU.• Progesterone assays are helpful in predicting miscarriage – > 60 nmol: Healthy pregnancy, < 20 nmol: miscarriage.
  40. 40. RECENT TERMINOLOGIES
  41. 41. RECENT TERMINOLOGIESThe term ABORTION is OUTDATED.1. Pregnancy of uncertain viability: – At 6 weeks: only a regular IU sac. FP+, no cardiac activity. – Nil/↓ bleeding PV – UPT strongly Positive – Rescan in 8-10 days – Common in cases of endocrinopathies
  42. 42. RECENT TERMINOLOGIES2. Pregnancy of uncertain location: – UPT + – No adnexal mass – No IU sac/ FP – – Rescan in 2 weeks/repeat S.hCG titers3. Pregnancy failure: – Recent terminology for abortion – Falling hCG & progesterone levels – ‘Blighted’ / Missed gestation
  43. 43. TOCOGRAPHY –ABNORMAL UTERINE CONTRACTION PATTERNS
  44. 44. ABNORMAL UTERINE CONTRACTION PATTERNS MINOR DEFECTS Causes: • Skewed contraction • CPD • Hypotonus • In. UA • PROM • Polyam • Paired contraction Minor defects per se do not cause foetal compromise. Can lead to major • Polysystole defects.
  45. 45. ABNORMAL UTERINE CONTRACTION PATTERNS MAJOR DEFECTS • Hypertonus Caused by: CPD/POP/Abruptio/ ↑uterotonics • Tachysystole Lead to: • Foetal compromise • Risk of uterine rupture • Uterine tetany
  46. 46. DDxACUTE ABDOMINAL PAIN IN PREGNANCY
  47. 47. ACUTE ABDOMEN IN PREGNANCYCauses related to pregnancy:• Early pregnancy complications – ectopic/miscarriage• Abruptio placenta• Uterine fibroids (red degeneration, infection, torsion)• Chorioamnionitis• Uterine rupture• Severe pre-ecclampsia + HELLP (epigastric pain)• Severe uterine torsion – Normal rotation by 30-40% to right occurs in 80% cases. – If > 90% rotation: Severe torsion• Ovarian tumours (cysts)
  48. 48. ACUTE ABDOMEN IN PREGNANCYCauses unrelated to pregnancy:• Acute appendicitis• UTI + pyelonephritis• Urolithiasis• Cholelithiasis• APD + peptic ulceration• Intestinal obstruction & Crohn’s disease• Acute pancreatitis• Acute fatty liver of pregnancy• Rare blood dyscrasias (sickle crisis, blast crisis)• Peritonitis due to intra-abdominal hemorrhage
  49. 49. Thank You

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