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 Leopolds 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 Potasium Chloride 135 3.3 95 135 145 3.5 5.1 97 - 107

Diagnostic Studies
RBC Hgb Hct MCV MCH MCHC 5.02 x10 ^12/L 139 g/L 0.41% 82.3 fL 27.7 pg 33.7% 4.2 5.4 120 160 0.36 0.47 80 96 27-31 32 36

RDW Platelet
WBC Neutrophils Lymphocytes Basophils Eosinophils Monocytes

14.7 Adequate
13 0.8876 0.063 0.001 0.004 0.045

11.6 14.6
5 10 0.500 0.700 0.200 0.700 0.000 - .0200 0.000 - 0.600 0.020 - 0.090

Diagnostic Studies
Color Transparency Reaction Specific Gravity WBC RBC Epithelial cell Dark Yellow Turbid 8.0 1.010 3 10 0.3 Few

Albumin Sugar
Crystals

Trace Negative
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
PREECLAMPSIA/HTN

HISTORY OF VOMITING ENDOSCOPY

HISTORY / PE LIVER FUNCTION TESTS CBC, LDH, BUN, CREA

HYPEREMESIS GRAVIDARUM (HG)

DIFFERENTIALS

LIVER DISEASE

HISTORY, PE LFT HEPATITIS PROFILE

HISTORY/PE FT4, TSH HISTORY /PE ULTRASOUND

THYROID DISEASES MOLAR PREGNANCY

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

Wernickes 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