OB PRECEPTORIALS

Group 3
ARDIENTE, ARIAS, ARIOLA, HENARES, JAVIER, JAYPE, PRIO, QUIRAO, QUIZAN
 01
ABOUT THE
PATIENT
You can enter a subtitle here if you need it
 Good afternoon everyone, good afternoon doc.. I
am Bianca Arias, one of the reporters of Group 3

General Data So, This is a case of RD, 29years old, Female,

Patient name: R.D Married, resides in Bacolod city..she was
admitted last February 20,2023 in a tertiary
hospital in bacolod city due to the chief
Patient age: 29 years old complaint of severe abdominal pain

Sex: Female

Civil Status: Married

Address: Bacolod City

Date of Admission: February 20, 2023

Family History

● Sister: has goiter and hyperthyroidism

● Mother: has hypertension and arthritis

● Father: once treated for tuberculosis, is

now apparently well
 CHIEF
COMPLAINT
Severe Abdominal Pain
READ History of Present Illness
2 days PTA,
patient had episodes of vaginal spotting staining her underwear, associated with
some pain in the hypogastric area, felt more pronounced on ambulation. It was
noted to be more right sided. She had no fever, nausea or vomiting.

3 hours PTA,
patient stood up after sitting for about an hour from a low stool while doing her
laundry. She then felt a more piercing pain on the hypogastric area. Pain
intensified over the next 2 hours and she also felt some dizziness. Thus, she
was brought to the emergency room of CLMMRH where she was
subsequently admitted.
Past Medical History

Hospitalized once
during childhood due
to Typhoid Fever

No food or drug
allergies
Personal and Social History

● Works as a call center agent for 3 years

● Occasionally smokes 5 sticks/day
● Drinks beer mostly on the weekends
● Lives with her husband and 2 children in a house
made of mixed materials beside a creek.
 imp 28,2022
December
aoonweeksisnay aooinweeksslabaysr.ee

Obstetrical History Epeoctober.com

T P At
G4P3 (2102)
YEAR AOG MODE OF GENDER COMPLICATIONS PLACE
DELIVERY

G1 May, 2017 Full Term NSVD N/A None CLMMRH

i
G2 Aug, 2018 Preterm NSVD Male Died 2 days old; CLMMRH
(7 months) complications of
prematurity

G3 July, 2020 Full Term CS Female CLMMRH

G4 7 5/7 wks Ectopic Pregnancy CLMMRH

AOG by
LMP
 Gynecologic History
MENARCHE HISTORY
1 ● Had menarche at 12 yrs old
● Irregular
● Frequency: occuring every 30-40 days
● Duration: 3-4 days
● Volume: consuming 3 pads/day
● LMP: December 28, 2022; lasted 4 days

2 SEXUAL HISTORY
● First coitus at 18 yrs old
● 2 sexual partners prior to her marriage 6 yrs ago
● Used Trust pills for a year but stopped because she sometimes forget to take them
● Opted to have injectable contraceptives at the local health center for about 6 months
but also stopped when the pandemic started.
 Gynecologic History

3 GYNECOLOGIC SYMPTOMS
● Pap smear done last March 2021 after complaining of foul smelling vaginal discharges.
● Cannot recall the result but was given medications in the form of vaginal suppository
as treatment to be inserted for 7 days
● She only complied taking it for 3 days and discontinued because she claimed to have already
felt better
 Physical Examination
Vital Signs
Result Normal Values Correlation

Blood Pressure 90/60 mmHg SBP </= 120mmHg Hypotensive

DBP </= 80 mmHg

Heart Rate 110 bpm 60-100 bpm Tachycardic

Respiratory Rate 22 cpm 12-20 cpm Tachypneic

Temperature 36.7 degrees 36.5-37.5 C Normal

Celsius
 Physical Examination
Anthropometrics

● Weight: 55kg
● Height: 5’1”
● BMI = weight in Kg / height in m2
● BMI = 22.92 (Normal BMI = 18.5-24.9)
 Physical Examination
HEENT: Symmetrical head and neck, pale conjunctiva, moist oral mucosa,

no facial edema, no neck masses

CHEST & LUNGS: Symmetric chest expansion, clear breath sounds in all lung fields

HEART: Distinct heart sounds, rapid cardiac rate and rhythm, no murmurs,

no JV distention

ABDOMEN: flat, tender to deep palpation and with abdominal guarding.

(+) direct and rebound tenderness on the RLQ

GENITALIA: Grossly normal external genitalia noted

INTERNAL EXAMINATION: Cervix is closed, and there is cervical motion tenderness

Uterus is small. The adnexal examination showed tenderness on deep palpation in the
suprapubic area more on the Right, There is scanty bleeding on the examining finger.
 ADMITTING
02 IMPRESSION
 G4P3 (2-1-0-2) T/C Ectopic
Pregnancy, Right, Probably
Ruptured 7 5/7 weeks AOG by
LMP
 SALIENT FEATURES
● Severe piercing right-sided hypogastric pain, more pronounced on
ambulation, with progressive intensity
● Vaginal spotting
● Dizziness
● (+) Smoker
● (+) History of genital infection
● (+) History of OCP use
● (+) History of Surgery (C-section)
● (+) Flat, tender to deep palpation with abdominal guarding
● (+) Hypotension, Tachycardia
● IE: Closed cervix; (+)Cervical motion tenderness
● (+) Adnexal tenderness (right)
 03
DIFFERENTIAL
DIAGNOSIS
 Acute Appendicitis

Most Likely Least Likely

Tender to deep palpation and with abdominal Non-migrating Pain

guarding.

(+) direct and rebound tenderness on the RLQ Fever, Nausea or vomiting (-)
 Pelvic Inflammatory Disease
Most Likely Least Likely

History of Vaginal infection, 2021 (noncompliant to Fever

treatment)

Cervical motion tenderness (-) Nausea, vomiting

Adnexal tenderness in suprapubic area more on the

right, scanty bleeding on IE

Tender to deep palpation and with abdominal

guarding
 Threatened Abortion
Most Likely Least Likely

Scanty Vaginal spotting Dizziness

Closed Cervix Hypotension

Lower abdominal pain Tachycardia

Within the 1st trimester

Cigarette smoking
Labs and Diagnostic Tests

Serum pregnancy test: Positive

Ultrasound
Retroverted average-sized uterus with thickened endometrium,
normal ovaries with corpus luteum on the Right. Superior to the
right of the uterus is a heterogenous mass measuring
approximately 7 x 4 cm. A fetus about 7 weeks old by CRL with no
cardiac activity. Fluid in the cul-de sac approx. 400ml
 05
MANAGEMENT
 MANAGEMENT
ECTOPIC PREGNANCY (TUBAL)

MEDICAL SURGICAL Expectant

Salpingotomy Management
Methotrexate Salpingostomy
Salpingectomy
 SURGICAL MANAGEMENT

SALPINGOSTOMY
SALPINGECTOMY
● Linear incision at the
antimesenteric border
● Tubal resection
● Left unsutured to heal by
● Cornual resection (outer ⅓ of
secondary intention
the interstitial portion

SALPINGOTOMY

● Same as Salpingostomy but

sutured
 SALPINGOTOMY

SALPINGOSTOMY SALPINGECTOMY
 Medical Management
(Tubal Pregnancy)
METHOTREXATE
● Folic acid antagonist
● Success is greatest if gestation
is <6 weeks, tubal mass <3.5
cm in diameter, and fetus not
alive
● More advanced pregnancy may
need multi course therapy or
induced abortion by injection of
KCL
CONTRAINDICATIONS:
● Abdominal Hemorrhage
● Intrauterine pregnancy
PATIENT SELECTION:
● Breastfeeding
● Immunodeficiency
● Hemodynamically stable
● Chronic renal disease
● Normal Hemogram, liver and
● Chronic hepatic disease
renal function
● Chronic pulmonary
disease
● Blood dyscrasia
● PUD
 Medical Management
(Tubal Pregnancy)
(PREDICTORS of SUCCESS) METHOTREXATE

Initial BHCG

ECTOPIC PREGNANCY SIZE

● Fetal Cardiac Activity ● Associated with an increased failure rate

 Medical Management
(Tubal Pregnancy)
METHOTREXATE
 EXPECTANT MANAGEMENT

● Tubal pregnancy only

● Low serum B-HCG
● Diameter of ectopic mass is NOT >3.5
● No intra-abdominal bleeding or rupture

● Spontaneous resolution occurs in 72%

While 28% will need laparoscopic salpingostomy

● Spontaneous resolution may take 4-67 days

(mean of 20 days) for serum HCG to return to
Non-pregnant level
 ECTOPIC
PREGNANCY
 Normal Pregnancy Ectopic Pregnancy

hCG level Doubles every 3 days Reduced

Serum progesterone level Greater than 25ng/ml Less than 5ng/ml

Incidence of ectopic pregnancies:
● Tubal Ectopic Pregnancies occur in 1.3-2.4% of all pregnancies

Risk Factors: Clinical Presentation:

● Previous Ectopic Pregnancy ● Triad of:
● Cigarette Smoking ○ Secondary amenorrhea
First trimester spotting
Fallopian Tube Surgery
○
● ○ Pelvic pain
● Previous Ectopic Surgery ● Further suggestive manifestations:
Pain on movement of the cervix
Infertility
○
● ○ Acute abdominal pain radiating to the
shoulder(s)
○ Abdominal guarding
○ Hypovolemic shock
○ syncope
THANKS!

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