Family MedicineCase Presentation

Group 7ASMPH 2012

23 July 2010

Purpose of Presentation

• Prolonged hospital stay• Family of limited resources

Identifying Data

• JCC is a 33 y/o, G3P3 (3003), Filipino, Roman Catholic, married woman with 2 children, with a third just delivered. She currently works as a street sweeper; lives as an informal settler near Tomas Morato.

• Self-referred, moderate reliability

Chief Complaint

• Early post-partum abdominal pain and difficulty of breathing, s/p labored NSD

History of Present Illness

• Patient, 33, G3P2(2002), previous “big babies” delivered via NSD, at 40 1/7 wks AOG by LMP, consulted at the OB-ER for persistent vaginal bleeding of few hours duration.

History of Present Illness• Trimestral History– 6 PNCU with 3 prev UTZs done prior to admission. – Biophysical profile done 3 days prior to admission,

EFW = 3731 g; BPP score 8/8

• Abdominal Exam:– FH 31 cm, FHT 120s

• Pelvic examination: – 6 cm dilated, 70% effaced, with cephalic presentation,

station -3, +BOW

History of Present Illness

• Admitting diagnosis– PU 30 1/7 weeks AOG by LMP, CIL, G3P2 (2002);

to consider arrest in descent secondary to feto-pelvic disproportion.

– Patient subsequently consented for BTL

History of Present Illness

• While being monitored, patient was noted to be non-compliant to physician requests to do abdominal and pelvic examinations, noting direct tenderness at sites of examination. No apparent guarding in between contractions.

• No tenderness above the level of the diaphragm. Able to take blood pressure and vital signs, noted to be otherwise unremarkable.

History of Present Illness

• During vaginal delivery of baby, patient was noted to show signs of distress, with vital signs becoming progressively unstable, with palor, hypotonia, tachycardia and tachypnea noted. Blood loss intra-partum was <300 ml.

• Patient was given fluids for resuscitation and Levophed for the suspected shock

History of Present Illness

• Immediately post-partum, patient’s vital signs continued to show signs of instability; little improvement with subsequent decline despite initial PRBCs. CVP showed hypovolemia (~3cm).

• Patient also complained of continued abdominal tenderness, with or without palpation; increasing difficulty of breathing; chest pain initially sharp but progressively becoming heavy “parang may nakadagan”

History of Present Illness

• Initial lab results– CBC: • RBC 2.39 x10 ^ 12 / L LOW• Hgb: 0.59 g/L LOW• Hct: 0.18 LOW• Plt: 191 Normal• WBC: 21.0 HIGH

– Neutrophil 0.909HIGH

– Lymphocytes 0.047 LOW

History of Present Illness

– PT: 15.6s HIGH– APTT: 48.5s HIGH– Glucose: 14.36 mmol/L HIGH– Crea: 116.53 mmol/L HIGH– K+: 2.5 mmol/L LOW– Na+ & Cl- Normal– CKMB: 12 U/L HIGH– Troponin I Normal– Liver Function Test Normal

History of Present Illness

• Patient also repeatedly noted feeling blood dripping/flowing around her genital area, but inspection was negative for external bleeding.

• About 9 hours post-partum, patient again alerted that there was blood gushing out. Inspection revealed heavy vaginal bleeding

• Patient was hence rushed to the OR.

Personal and Social History

• Catholic• Married with 2 children• Non-Smoker, Non-Alcoholic• High school graduate• Lives as an informal settler• Main provider for family; works as a street sweeper• Other Stakeholders: Mother, husband, 2 children

– Husband, 42, is illiterate; unemployed; irregular job as an electrician– Mother is 68 y/o; continues to work as a washer woman to contribute

to finances; does hospital errands for JCC– 2 children 8 y/o and 6 y/o; going to school

Family Genogram

Other Pertinent History

• PMH: Uncertain medical history; Elevated OGTT 50g perinatally.

• FH: Uncertain family history; denies family history of hypertension, diabetes and/or other illnesses.

Review of Systems

• Generalized weakness and fatigue• Lightheadedness• Blurring/dimming of vision• Difficulty of breathing/pleuritic pain• Chest pain and subsequent heaviness• Abdominal pain, whole• Sensations of blood dripping/gushing out her

vagina

Physical Examination

• BP – Persistent hypotension <80 mmHg systole

• RR – Persistent tachypnea > 30 breaths/min• HR – Persistent tachycardia 130-160 bpm • Temp – mild fever 37.8 C axillary

• General survey– Pale, weak, lethargic, coherent

Physical Examination

• HEENT: – Pale palpebral conjunctivae; sclerae anticteric– Pulsating neck veins; no gurgling on auscultation– No lymphadenopathy

• Lungs: – Suprasternal retraction, short breaths, clear breath

sounds• Heart:– Tachycardia, with occasional irregular rate; normal

rhythm

Physical Examination• Abdominal:– Distended and apparently enlarging abdomen– (+) fluid wave– Tympanitic on all four quadrants– Tender on all four quadrants with or without

palpation– No masses felt

• Extremities:– Weak pulses on all extremities; bipedal edema

Assessment

• Post Partum Hemorrhage secondary to Uterine Rupture, s/p NSD, Day 0; consider

• Baby boy, Z, delivered live via NSD, Apgar 1

Diagnostics

• Constant monitoring of vital signs– BP, HR, RR, Temp., CVP

• Laboratory diagnostics– CBC, platelet count, BT, serum electrolytes, CKMB,

Troponin I, urinalysis

• Imaging (X-ray)• ECG

Therapeutic Plan

• Continuous hydration with plain NSS. • Monitoring of vital signs every 30 minutes.• Serial H&H every 4 hours. • Transfusion of packed Red Blood Cells (PRBC)

with hemoglobin < 70 g/L• Electrolyte correction where needed.• Immediate exploratory laparotomy with

continued degradation of vital signs.

Definitive Management

• Serial blood tests• Blood transfusions• Exploratory laparotomy• Subtotal hysterectomy

Course in the Wards

• Unstable vitals requiring 4 day stay at SICU– Intubated• 2 days ambubagging; 1 day mechanical ventilator

– NGT• 4 days

– Intensive monitoring of vital signs and laboratory studies

– On multiple antibiotics, diuretics, IV fluids

• Monitoring at OB High-Risk Ward 5 days

Follow-up Visits

• Baby Z continued to be confined at the NICU, incubated, for 1 month post delivery

• Baby Z currently still being monitored and stabilized at the nursery

• JCC has not gone home, having to breast feed Baby Z every 2-3 hours

• Mother S travels to and from home daily to accompany JCC and bring her food

Family Assessment Tools

• Genogram• Family Timeline• Family Map• Family APGAR• Family SCREEM• Family CEA• Family Meeting• Home Visit