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OBGYNE

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OBGYNE

  1. 1. Davao Medical School Foundation Hospital Medical Drive, Bajada, Davao City [ OB-Gynecolo Kirbe A. Labarcon gy ACa s e
  2. 2. What is the True essence of Being A Woman?BIRTH
  3. 3. GENERALDATAP.B.29 G2P1 (1001)MarriedBajada, Davao CityDoA: May 28, 2012 9:40 PM
  4. 4. CHIEFCOMPLAINT Vaginal Spotting LMP: September (2nd wk), 2011 5days X 2-3 pads/day PMP: August 2011 4-5 days X 2-3 pads/day
  5. 5. HISTORY OF PRESENTILLNESS +Irregular, tolerable uterine In the Morning + Tolerable uterine contractions, +persistent uterine contraction contraction -Vaginal spotting + associated with fetal -no other associated +Routine PNCU movement symptoms IE= 1cm dilatation -Vaginal discharges + Routine PNCU IE=1cm dilatation (-)signs & symptoms +Advised admission -admission for x3 days scheduled CS-Consultation Metronidazole 500mg/tab BID Nifedipines 5mg/tab QID Duvadilan Tab TID
  6. 6. Work upAdmitting Impression: PU 35 2/7 wks AOG, CILP, G2P1 (1001)ABCABDOMEN: L1Breech L2Right L3Cephalic FH: 33cm EFW: 3.03kg FHT: 145-150bpm Cephalic presentationINTERAL EXAMINATION:External Genitalia: Grossly normal Cervix: Length: 3 cmVagina: (+) thick whitish vaginal discharge Dilatation: 1 cm Effacement: Closed % Posterior IBOW Station -3LABORATORIES: CBC, PC; UA; Gram Stain of Vaginal discharge; BPSFINAL DIAGNOSIS: PU 35-36 wks AOG, IPTL-Controlled, G2P1 (1001) Previous CS (Uterine Didelphys) Bacterial VaginosisFig.1 A) Ultrasound image B) Biophysical Score C) Ultrasound Report
  7. 7. ᵜBajada, Davao CityᵜMarried with 1daughterᵜNon-smokersᵜEmployed:Certified Public AccountantᵜAbove minimumᵜNon-smokerᵜNon-alcoholic beverage drinkerᵜNo food preference or special diet regimen.
  8. 8. [ + ] HPN (Father – unknown maintenance med) INTERNAL[ + ] DM (Father – unknown maintenance med)[ - ] Heart Diseases[ - ] Asthma[ - ] No similar illness to that of the px
  9. 9. Medical (-) HPN (+) Allergies (-) DM + Meds: NSAIDS (-) Asthma - Foods Denies previous hospitalizationSurgical Denies previous surgical operationPsychiatric No psychiatric history
  10. 10. Family Size : 4Menarche : 18 yoCoitarche: 21yrs old X 1 sexual partnerOCP: (-) usageMenstrual cycle: 28-35days X 5days X 3soaking pads/dayOB-ScorePregnancy Pregnancy Gestation Present Year Sex Birthweight Complications Order Outcome Completed Status G1 LSTCS 2011 FT F 2.85kg Healthy none G2 -present pregnancy-
  11. 11. Present PregnancyLMP: September 13, 2011 X 5days X 2-3soaking pads/dayDATE OF QUICKENING : December, 2011 (~3mons AOG)EDD: June 20, 2012AOG: 37 6/7 weeksULTRASOUND : >5x (1st: October, 2011; ~8weeks AOG) (last: May 18, 2012; ~35 3/7wks AOG)PRENATAL VISIT: >x5HEALTHCARE PROVIDER: OB-GynecologistIMMUNIZATION: OCP: (-) Tetanus (-) Hep B (-) othersTotal Weight Gain: 65 -52 = 13klg BP: 120/80mmHgHgb: 119 g/dL Urine Lab: NormalSugar: Normal
  12. 12. REVIEW OFSYSTEM(-) MB (-) IUGR (+) Premature Labor(-) Infection LG Tract (-) Infertitlity 12days PTA(-) HPN (+) Uterine contraction (+) Genitourinary(-) Cardiac x 1mon 12days PTA(-) Renal (+) UTI Bacterial Vaginosis(-) DM/Metabolic 3mons AOG (+) Previous CS(-) Respiratory Cefalexin 500mg/cap 2011(-) Fetal wastage 1cap TID x 7days(+)
  13. 13. PHYSICAL EXAMGeneral: Patient came in per wheelchair. The patient was examined in lying position.She was awake, well-groomed, cooperative andnot in respiratory distress BMI was 21.6, weighing 52kg and 5’1standing
  14. 14. PHYSICAL EXAMA. Vital SignsTemperature: 36.30C (Afebrile)Blood Pressure: 120/70 mm Hg (Normotensive)Respiratory Rate: 22 breaths/min (Tachypneic).Cardiac Rate: 85bpm (Non-tachycardic).
  15. 15. AS, PPC, -CLAD[-] Remarkable lesion AP, -murmurECE, Resonant, CBS -Gross deformities Full range of Motion No Neurologic deficit
  16. 16. PHYSICALAbdomen EXAM Abdomen I : Globular, [+] Striae gravidarum [+] Previous CS scarA: Normal active bowel soundP: Tympanitic all over
  17. 17. PHYSICALAbdomen EXAM Abdomen P : LEOPOLD’s MANUEVER 29 cm L1= Breech L2= Right L3= CephalicFH= 29cmEFW = 2.47klgFHT= 130-140bpm
  18. 18. PHYSICAL EXAMInternal Examination Internal Examination  Grossly Normal PELVIMETRY? (I) : Admits 2 fingers with ease (C): 1-2cm dilatation Beginning effacement Intact bag of water Station -3 (U) : Enlarged to 8-9 months AOG (A) : Non-palpable (D) : No vaginal discharges
  19. 19. SALIENTFEATURES *29 G P (1001) 2 1 *Vaginal spotting *Amenorrhea *Hx of Preterm Labor PE: *Gravid abdomen GenitoUrinary & IE
  20. 20. ADMITTING IMPRESSIONG2P1 (1001),Pregnancy Uterine 37 6/7 weeks Age ofGestation, Breech in latent phase of LaborS/P CS (Non-Reassuring Fetal Heart Rate Pattern)
  21. 21. Course in the WARDCourse in the WARD On admission Please admit NPO post midnight Monitor VS q4o Monitor FHT & POL q4o and record Schedule for repeat CS tomorrow at 8AM Baseline EFM LABS: CBC, PC BT UA IVF: D5LR 1L at 120cc/hr Med: Cefazolin 1grm IVTT (-)ANST Ranitidine 50grm/amp, 1amp IVTT 1hr Prior to OR Metoclopramide 10grm/amp, 1amp IVTT
  22. 22. Course in the WARDCourse in the WARD SURGERY: May 28 (1st HD) VS: 110/70mmHg 36.2oC 78bmp 19cpm Blood loss: <1000cc Preoperative Diagnosis: G2P1 (1001),Pregnancy Uterine 37 6/7 weeks Age of Gestation, Breech in latent phase of Labor S/P CS for NRFHRP Operation Done 10 LSTCS (Right Hemi-Uterus) secondary to Franck breech presentation
  23. 23. Course in the WARDCourse in the WARD Basilio, 2012Figure 2 . Didelphic uterus after fetal delivery.
  24. 24. Course in the WARDCourse in the WARD 1st PostOP S/O > + minimal vaginal bleeding P> + well contracted uterus + adequate urine output + stable VS + Flattus 2nd POSTOP, 19HD S/O > + minimal vaginal bleeding P> + well contracted uterus + adequate urine output + stable VS + Flattus
  25. 25. FINAL1) G P (2002), PUFT DIAGNOSISby 1 LSTCS (Right 2 2 Franck Breech presentation, delivered 0 Hemi-Uterus) to a live birth Baby boy with AS 9,10; BS 38wks; BW 2.85; BL 51cm2) S/P Cesarean Section (Left Hemi Uterus) secondary to NRFHRP3) Uterine didelphys4) Paratubal cyst, Right
  26. 26. UTERUS
  27. 27. 2.5 cm 5 cm 7.5 cmWt: 30 - 40 gm
  28. 28. Fundus uteri Facies vesicalis Facies intestinalisMargo lateralis
  29. 29. 8 LIGAMENTS1 anterior vesicouterine1 posterior rectovaginal2 broad/lateral (ligamentu latum uteri)2 uterosacral2 round ligaments
  30. 30. 2003-11-3 31
  31. 31. 2003-11-3 34
  32. 32. Columbo reported the first documented 300 case BC Strassman 0.1 -3.5 % et al 1961 Grimbizi 4.3 % 20012003-11-3 35
  33. 33. Class III- Uterine Didelphys• Midline fusion of the müllerian ducts is arrested,• ~ 5% of mullerian duct anomalies ( )• ~11% are didelphys uterus ( )• Characterized by 2 hemiuteri, 2 endocervical canals with cervices fused at the lower uterine segment.
  34. 34. 75% ( )
  35. 35. Reported Association with Other Anomalies• ~20% Renal agenesis most commonly ( )• Obstructed unilateral vagina (Wunderlich-Herlyn- Werner syndrome) ( )• Bladder exstrophy with or without vaginal hypoplasia• Congenital vesicovaginal fistula with hypoplastic kidney ( )• Cervical agenesis ( )• Malignancies ( )
  36. 36. Reported Association with Other Anomalies• According to Zhang et al. 2010 Infertility treatment & reproductive performance is poor• Study of 59 (68.6%) live births 21 (24.4%) preterm deliveries 18 (20.9%) spontaneous abortions 2 (2.3%) ectopics,
  37. 37. Diagnosis of Uterine Didelphys• The most frequent complaint ( ). Failure of tampons to obstruct menstrual flow. T Initial pelvic examination Second-trimester spontaneous abortion
  38. 38. Figure 1: Speculum examination reveals a double vagina with two cervices (the right cervix is partly visible) Bhattacharya et al. 2011
  39. 39. Diagnosis of Uterine Didelphys• Hemivaginal obstruction: Onset of dysmenorrhea ( ) Progressive pelvic pain ( ) Unilateral pelvic mass ( ) Marked rectal pain and constipation ( )
  40. 40. Diagnostic Modalities 3) Ultrasound 2) MRI 1) HSG 4) IVPFig Uterus didelphysTransverse fast spin-echo T2-weighted MR images show completeFig Fig Uterus didelphys in Ultrasound of two separate degree ofwith opacification of two .HSG of uterine horns (short arrows),duplication images show catheterization with partial cervices fusion of adjacentcervices (longdivergent noncommunicating endometrial cavities (arrow). widely arrows).
  41. 41. Surgical Procedures•obstructed unilateral vagina Full excision andmarsupialization of the vaginal septum ( )•Hemihysterectomy with or without salpingo-oophorectomy ( )•Strassmann metroplasty ( )
  42. 42. PostOperative ManagementVaginal adenosis is a risk after the septum is removed. Definitive guidelines that monitorfor this condition have not been established,though some experts recommend serial pap smears and colposcopy.
  43. 43. 2003-11-3 48
  44. 44. 2003-11-3 49
  45. 45. D-SURGICAL MEASURES• Musich JR, Behrman SJ. Obsteric outcome before and after metroplasty in women with uterine anomalies. Obstet Gynecol.1978;52:63.• Management and outcome of patients with combined vaginal septum, bifid uterus, and ipsilateral renal agenesis (Herlyn-Werner-Wunderlich syndrome). Gholoum S, Puligandla PS, Hui T, Su W, Quiros E, Laberge JM. J Pediatr Surg. 2006 May;41(5):987-92.• Heinohen PK, Saarikoski S, Pystynen P. Reproductive performance of women with uterine anomalies. Acta Obstet gynecol Scand 1982;61:157.

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