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Case discuss of abnormal labor

Case discuss of abnormal labor
Case discuss of abnormal labor

C a s e d i s c u s s

C a s e1

Li ,age26,her chief complaint is amenorrhea for 40 weeks, abdominal pain accompanied bloody discharge for 6 hours. Her menstrual cycle is normal. When missing a menstrual period for 10 days, she has felt nausea and vomiting. she never felt abdominal pain before. 6 hours ago, she felt intermittent abdominal pain, accompanied by vaginal bleeding. The amount of blood is just a little.

Please write the possible diagnosis of this case.

Please write the treatment plan of this case.

Diagnosis basis:

Symptoms: 1. Amenorrhea 2.morning sickness 3.fetal movements

Signs: 1. progressive enlargement of the uterus 2.fetal heart sounds

B-US: BPD 9.5cm, Amniotic fluid volume: moderate,

Au ultrasound scan can assess the growth of the fetus, a possible multiple pregnancy, the location of the placenta and the amount of amniotic fluid.

In this case some tissue is retained, bleeding and pain result. The uterus may be smaller than expected for the period of amenorrhea and the cervix is open. The amount of bleeding varies, but it can be severe enough to provoke hypovolamic shock.

Diagnosis: incomplete abortion

Plan:

the patient should require hospitalization

Type and cross-match for possible blood transfusion

Dilation and curettage should be performed for possible retained tissue. Evacuate the uterus promptly.suction is most effective. Intravenous oxytocin prior to uterine instrumentation decreases the possibility of uterine performation.

Essentials of diagnosis:

Suprapubic pain and uterine cramping

V aginal bleeding

Cervical dilatation

Extrusion of products of conception

Disappearance of symptoms and signs of pregnancy

Nagative pregnancy test or quantitative ?-hcG that is not properly

increasing

Adverse ultrasonic findings (eg,empty gestational sac,fetal disorganization,lack of fetal growthManagement:

The chief risks associated with retained products are hamorrhage and sepsis. Suction curettage of the uterus is usually necessary to remove the remaining products of conception and prevent further bleeding and infection. If the bleeding is severe there may be shock, an intravenous line should be established and blood given. And then perform evacuation.

●Types of abortion:

Threatened abortion

Inevitable abortion

Incomplete abortion

Complete abortion

Missed abortion

Septic abortion

Recurrent abortion

C a s e2A female, 27 years old, she complain amenorrhea of 48 days followed by spotting for 10 days, left-lateral abdominal pain like tearing for 2 hours. then the abdominal pain become severe and diffuse to whole abdomen. She felt dizzy and weakness. And then she was sent to our hospital.

PE: BP90/50mmHg P 110beats/min she was pale. Low abdominal tenderness is positive. The shifting-dullness is positive.

PV:cervix is closed, touched cervix is positive. Uterus is slight enlargement and softness. A mass is palpated on the left adnexa.

assistant test:

urine hCG is positive.

culdcentesis: 5ml non-cloting blood was obtained.

Please write the diagnosis of this case according to the history and examination.

write the scheme of treatment.

Diagnosis:

ectopic pregnancy

Hypovolemic shock

Diagnosis history amenorrhea, irregular bleeding, abdominal pain so on. clinical presentation symptoms; signs: before tubal abortion and rupture it is difficult to diagnose. The physical examination in the patient with ectopic pregnancy depending on whether the gestation is early and unruptured or more advanced and ruptured with a hemoperitoneum. When the patient have internal hemorrhage the symptoms of hypovolemic shock

present. A rapid, feeble pulse may develop along with sweaty and pallid skin, air hunger, restlessness, and anxiety.As hemorrhage continues, the pulse rate rises,the blood pressure falls, the urine flow dimishes, and blood loss anemia develops.

Abdominal examination:Abdominal tenderness is the most common physical finding present in the great majority of cases.The tenderness is classically unilateral and in lower quadrant, rebound tenderness, guarding, and rigidity are usually not present except in those cases with significant hemoperitoneum. However abscence of pertoneal signs should not be used to exclude the diagnosis of ectopic pregnancy.

Pelvic examination:The uterus is normal sized or slightly enlarged in 97% of cases and is often noted to be soft secondary to the effects of placental. Addintionally, cul-de-sac fullness may be noted with hemoperitoneum pooling posterior to the uterus. The extreme tenderness on fornix palpation or movement of the cervix; the uterus floats as if in water.

other test and examnition pregnancy tests pregnancy tests currently are not useful in diagnosing a tubal pregnancy. A positive test does not guratee that the pregnancy is in the tuve, nor does a negative test rule out the possibility. Characteristically,serum levels of hCG are lower with tubal pregnancy than with intrauterine pregnancy.

ultrasonography Ultrasound scan is helpful in making the diagnosis of tubal pregancy. If a gestational sac is found intrauterine cavitythe tubal pregancy rule out. In general,it is rarely for pregnancy in tubal and in uterine meantime. If a typical gestational sac is identified out the uterus,a direct diagnosis can be made.

culdo’centesis It is the simplest and most widely used of the other diagnostic methods. It’s purpose is to determine the presence or absence of blood in the pelvic cavity. After the cervix is stabilized with a tenaculum, a needle is inserted through the mucosa of the posterior fornix directly into the cul-de-sac. Aspiration is then attempted. Free bloody fluid is consistent with the diagnosis of intaperitoneal hemorrhage.Intraperitoneal bleeding or a cul-de-sac hematoma can be detected by needle culdocentesis, which can be performed in the outpatient or hopital examining room.A needle is inserted through the posterior fornix of the vagina about 1cm behind the point at which the vaginal wall joins the cervix. If dark or bright red blood flows freely through the needli,the presence of intraperitoneal bleeding is confirmed. If only a small amount of bright red blood can be aspirated, the needle may have perforated a blood vessel and should be withdrawn and reinserted. Failure to obtain blood does not rule out ectopic pregnancy,

there is no intraperitoneal bleeding with early unruptured tubal pregnancy; blood cannot gravitate into a cul-de-sac that is obliterated by adhesions. Finally, the size of the needle may determine the result, bits of blood clot, which may fill the cul-de-sac, can usualy be aspirated through a large needle, whereas only liquid blood can be drawn througn an 18-guage needle.

●treatment

The usual treatment for tubal pregnancy consists of surgical removal of the involved tube and replacement of the blood lost .

Operation : laparotomy

anti-shock: transfusion

C a s e3

A 27 year-old woman, with the complain of amemorrhea for 35 weeks, combining with vaginal bleeding for 2 hours.

About 2 hours ago, vaginal bleeding began suddenly with bright color,and during the following period, without increasingly aggravated. No abdominal pain,but normal fetal quickening existed.

Obstetric examination: height fundus 32cm,abdomen diameter 98cm, fetal present:head,Fetal position:LOA, fetal heart beat:130bpm

P lease write the diagnosis and assistant test of this case according to the history and examination.

w rite the scheme of treatment.

Diagnosis: placenta previa(marginal placenta previa) .

Assistant test:ultrasonography:(marginal placenta previa) (marginal placenta previa) (marginal placenta previa) (marginal placenta previa) .

Essentials of diagnosis

Spotting during first and second trimesters

Sudden, painless,profuse bleeding in third trimester

Initial cramping in 10% cases

Types or degrees: (Fig.)

●There are 3types of placenta previa depending on the degree of

extension of placenta to the lower segment and relation to cervical os.

●Type1(marginal placenta previa): the edge of placenta reaches the

internal os but does not cover it.

●Type 2 (partial pp):the cervical internal os is only

partially covered.

Type3 (complete pp): the placenta completely covers the internal os. ●M anagement of pp.

Admission to hospital :

Expectant treatment:

the cases suitable for expectant treatment are:1) mother is in

good condition with a wide margin of safety to withstand further

bouts of hemorrhage , if occurs. Hemoglobin should ideally be

10g/L or more. 2) duration of pregnancy is less than 37weeks. 3)

active vaginal bleeding is absent.

Conduct of expectant treatment: 1) absolute bed rest is imposed

for at least 5-7 days after the vaginal bleeding ceases. 2) injection

diazepam 10mg is given intramuscularly on admission.3)

investigations4) periodic inspection of the vulval pads and

auscultation of the fetal heart rate are dome. 5) localisation of the

placenta is to be done by the available methods.

●D elivery:

Cesarean section:it is the usual method of choice with placenta previa.

Vaginal delivery:it is usually reserved for patients with a low-lying

implantation and a cephalic presentation and parous women,and cervix is favorable,and there is little or no prospect of salvaging the fetus.

●Complications:

Maternal: antepartum hemorrhage, premature labor, intrapartum

hemorrhage, postpartum hemorrhage and shock, sepsis

Fetul: low birth weight, asphyxia, intrauterine death

C a s e4

●A 23 year-old woman, with the complain of amemorrhea for 30 weeks, hypertension for 1 month,combining with abdominal pain for1 hour.

●PE: Bp160/110mmHg, abdomen is tender,legs,hands and abdomen are edema.

●Obstetric exam: the uterus is irritable,tender,and hypertonic,fetal position and heart beat are unclear.

●Laboratory test:proteinuria is positive(+++)

Please write the diagnosis of this case according to the history and

examination.

write the scheme of treatment.

●D iagnosis:

pre-eclampsia

Abruptio placenta

treatment

Severe preeclampsia or eclampsia:

For the patient who has severe preeclampsia or eclampsia, stabilization with

magnesium sulfate, antihypertensive therapy as indicated, monitoring for maternal and fetal well-being, and delivery by induction or C. S. are required.

Anticonvulsion: Magnesium sulfate has been used to prevent

convulsions. It has virtually no effect on blood pressure. Other

anticonvulsants such as diazepam is infrequently used in obstetrics.

Magnesium sulfate may be administered by intramuscular or

intravenous routes. An initial 4-g loading dose is given intravenously over 20 to 30 min, followed by a constant infusion of 1 to 3 g/hr.

Therapeutic levels are 4 to 7 mEq/liter.

Antihypertensive therapy: it is indicated if the diastolic blood pressure is repeatedly above 110mmHg. The goal of such therapy is to reduce the diastolic pressure to the 90 to 100 mmHg range.

●D elivery:

once anticonvulsant and antihypertensive therapy is established, attention is directed toward delivery.operation(cesarean section)

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