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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