OBSTETRICS
AND GYNECOLOGIC
CASE PRESENTATION
Prepared by:
IMPERIAL, Annabelle R.
San Beda College of Medicine
N.G.
16 year old
G1P0
LMP: March 1, 2011
Chief Complaint
Vomiting
History of Present Illness
2 DAYS prior to consult
Nausea and vomiting
(+) 20 episodes of vomiting
recently ingested food
No medication taken
No consult done
History of Present Illness
1 DAY prior to consult
Persistence of nausea and vomiting
(+) loss of appetite
(+) >20 episodes of vomiting recently
ingested food and water
No medication taken
No consult done
History of Present Illness
DAY of consult
Persistence of nausea and vomiting
(+) loss of appetite
(+) >20 episodes of vomiting recently
ingested food and water
Prompted patient to consult in
QMMC OB-ER
OBSTETRIC HISTORY
G1P0
LMP: March 1, 2011
AOG : 17 weeks 5 days
EDD: December 8, 2011
Menstrual History
Menarche: 10 years old
Coitarche: 15 years old
Menstrual cycle: 28-30 day cycle
Duration: 3-4 days
Using 3-4 pads fully soaked
Past Medical History
No previous hospitalization.
No allergies to food and drugs.
Family History
No heredofamilial diseases.
Social History
Non smoker
Non alcohol beverage drinker
Review of Systems
General :
(-)Weight loss (42kg to 41kg), (-) Fever, (-) Chills
(+) weakness (-) anorexia
Cardio-Respi:
(-)Chest pain, (-)Dyspnea (-) Hemoptysis
(-)Cough, (-) Palpitations, (-)Edema
GIT:
(-)Dysphagia, (-) Heartburn, (-) Indigestion
(+) Loss of appetite (-) Diarrhea (-)Constipation
GUT:
(-)Urgency (-)Frequency (-)Nocturia (-)Dysuria
(-)Hematuria (-)Incontinence
Physical Examination
BP: 110/70
PR: 80 bpm
RR: 16 cpm
Temp: Afebrile
GS: Conscious, coherent, NICRD
HEENT: AS, PPC, (+) sunken
eyeballs
Heart: AP, normal rate and rhythm,
(-) murmur
Extremities: Full ROM
Physical Examination
Abdomen:
Globular with inverted umbilicus
(-)straie gravidarum
(-) linea nigra
(-) tenderness in all 4 quadrants
FH – bet symphysis pubis and
umbilicus
Auscultation: normoactive bowel
sound; FHT=NA
Leopold’s Maneuver: NA
Physical Examination
External Genitalia:
Adequate hair distribution, no mass or
lesion in the labia, perineum and anus
Clinical Pelvimetry
Flat, soft uterus enlarged to 16-18
weeks size, no contraction, (-) AMT
Admitting Diagnosis
G1P0 PU 17w 5d AOG NIL
Hyperemesis Gravidarum
Course in the Wards
July 2, 2011
IVF D5LR 1L x 8
Dx : CBC with BT, U/A, Na, K, Cl
Meds:
- Metochlopromide 1 amp TIV q8
-Incorporate 1 amp Benutrex C to
D5LR 1L x 8 hrs
Small frequent feedings
VS q4
Course in the Wards
July 3, 2011
IVF D5LR 1L x 8
Meds:
- Kalium Durule tab 1 tab TID x 5 days
Small frequent feedings
VS q4
Diagnostic Studies
Sodium
135
135 – 145
Potasium
3.3
3.5 – 5.1
Chloride
95
97 - 107
Diagnostic Studies
RBC
5.02 x10 ^12/L
4.2 – 5.4
Hgb
139 g/L
120 – 160
Hct
0.41%
0.36 – 0.47
MCV
82.3 fL
80 – 96
MCH
27.7 pg
27-31
MCHC
33.7%
32 – 36
RDW
14.7
11.6 – 14.6
Platelet
Adequate
WBC
13
5 – 10
Neutrophils
0.8876
0.500 – 0.700
Lymphocytes
0.063
0.200 – 0.700
Basophils
0.001
0.000 - .0200
Eosinophils
0.004
0.000 - 0.600
Monocytes
0.045
0.020 - 0.090
Diagnostic Studies
Color
Dark Yellow
Transparency
Turbid
Reaction
8.0
Specific Gravity
1.010
WBC
3 – 10
RBC
0.3
Epithelial cell
Few
Albumin
Trace
Sugar
Negative
Crystals
Amorphous
phosphate: Many
HYPEREMESIS GRAVIDARUM (HG)
70-85% of pregnant patients experience nausea
& vomiting
2-5 % of these women experience HG
vomiting severe enough to cause weight loss,
dehydration, alkalosis or hypokalemia
HYPEREMESIS GRAVIDARUM (HG)
RISK FACTORS
hyperthyroidism
molar pregnancy
gastrointestinal disorders
infection
HYPEREMESIS GRAVIDARUM (HG)
ETIOLOGY
unknown
rising levels of HCG
estrogen, progesterone, leptin, GH, prolactin ,
thyroxine, ACTH
Psychological component
HYPEREMESIS GRAVIDARUM (HG)
SIGNS & SYMPTOMS
 nausea/vomiting in early pregnancy
 weight loss
 dehydration
 weakness
 subtle PE signs
HYPEREMESIS GRAVIDARUM (HG)
DIFFERENTIALS
ACUTE ABDOMEN
HISTORY, PE
GASTRITIS/PUD
HISTORY OF VOMITING
ENDOSCOPY
PREECLAMPSIA/HTN
HISTORY / PE
LIVER FUNCTION TESTS
CBC, LDH, BUN, CREA
HYPEREMESIS GRAVIDARUM (HG)
DIFFERENTIALS
LIVER DISEASE
HISTORY, PE
LFT
HEPATITIS PROFILE
THYROID DISEASES
HISTORY/PE
FT4, TSH
MOLAR PREGNANCY
HISTORY /PE
ULTRASOUND
HYPEREMESIS GRAVIDARUM (HG)
DIAGNOSIS
 History/PE
 CBC
 Urinalysis
 serum electrolytes
 Ultrasound
HYPEREMESIS GRAVIDARUM (HG)
MANAGEMENT
 GOAL: control nausea and vomiting
 Antiemetic
 Small frequent feedings
 Adequate hydration
 Ice chips
 Reassurance
HYPEREMESIS GRAVIDARUM (HG)
MANAGEMENT
 1st line fails
 Hospitalization
 Dehyration
 Ketosis
 Electrolyte deficits
 Acid base imbalance
CORRECTED
HYPEREMESIS GRAVIDARUM (HG)
COMPLICATIONS
 Dehydration
 electrolyte imbalance
 renal failure
 Wernicke’s Encephalopathy
(Thiamine deficiency)
 Vitamin K deficiency : maternal coagulopathy
or fetal intracranial hemorrhage
HYPEREMESIS GRAVIDARUM (HG)
COMPLICATIONS
Mallory Weiss tears
Characterized by upper gastro-intestinal bleeding
secondary to longitudinal mucosal lacerations at
the gastroesophageal junction or gastric cardia.
HYPEREMESIS GRAVIDARUM (HG)
COMPLICATIONS
 Boerhaave syndrome
characterized by upper gastrointestinal
bleeding secondary to transmural perforation
of the esophagus