Ruptured Ectopic Pregnancy - Assignment Example

Case Studies: Obstetrics Student’s Name Institutional Affiliation Case Study: Obstetrics Case Study One History Call to: X is a 22-year-old woman presenting with severe lower abdominal pain accompanied by shoulder tip pain. PMx: Depression controlled by the antidepressant venlafaxine 75mg. The patient has no known drug allergies. She has an IUD in-situ as a form of pregnancy control method. Vital Signs: Respiratory rate - 22 breaths per minute (Tachypnoea) Pulse rate - (tachycardia) at 110 bpm SaO2 - 98% at room temperature Temperature - 36.5oC Blood pressure - 90/60 tending towards hypotensive Provisional Diagnosis Ruptured ectopic pregnancy Differential diagnosis Pelvic Inflammatory disease, Miscarriage, Endometritis, uterine fibroids, Polycystic ovarian syndrome. Epidemiology/Aetiology/Pathophysiology The incidence of ectopic pregnancies in Australia is estimated to be about 1.62% and it was also reported that three deaths occurred from ectopic pregnancies between the years 2006 and 2010 (NPESU, 2013). However, the prevalence has been decreasing compared to the prevalence in the late 20th century. The patient is a woman of reproductive age. She has her IUD in place but this is not a guarantee to rule out pregnancy as cases of pregnancies have been reported even with the use of IUD devices (Hubacher, Finer & Espey, 2011). Pregnancy with an IUD still in place has been associated with complications such as miscarriages and ectopic pregnancies (Li et al., 2014). Most common site of the ectopic pregnancies is the fallopian tube. The various regions of the fallopian tube are not designed to expand effectively with the enlargement of the gestation. Therefore, as the embryo grows the fallopian tube area where implantation had occurred is prone to rupture. This is what may have occurred in this patient. With a ruptured fallopian tube, injury to the tube can result in massive bleeding manifesting as PV bleeding (Sepillian, 2014). Bleeding can result in massive losses of blood and body fluids that may result in a drop in blood volume, venous return, cardiac output and blood pressure. The baroreceptors detect the decrease in blood volume and stimulate a sympathetic increase in heart rate manifesting as tachycardia in the patient (Sepillian, 2014). A significant decrease in blood volume is accompanied by a reduction in tissue oxygenation because of impaired perfusion. The result is tachypnoea to compensate for the tissue hypo-oxygenation as a result of hypoperfusion. The increase in bleeding may result in anaemia or even haemorrhagic shock (Bonanno, 2011). Pelvic inflammatory disease (PID) can also be an aetiology behind an ectopic pregnancy but a lack of fever and history of sexually transmitted infections with abnormal discharge from the vagina may rule out this (Li et al., 2014). PID also commonly presents with a lower abdominal pain that is bilateral which is not the case with ectopic pregnancy which often presents with unilateral lower abdominal pain. Endometritis may be ruled by a dearth of a history of abnormal discharge from the vagina, nor a history of bleeding between cycles and lack of STI history (Li et al., 2014). Polycystic ovary syndrome may be ruled out due to a lack of history of irregular length of her menstrual cycle, interspersed amenorrhoea and a lack of symptoms such as acne and hirsutism. A miscarriage may be ruled out later through a transvaginal ultrasound to examine where implantation had taken place (Sepillian, 2014). Investigations Vaginal examination to ascertain the bleeding is recommended. Laboratory investigations such as assessment of beta-human chorionic gonadotropin levels to determine the presence of pregnancy or an ectopic pregnancy shall be done (Sepillian. 2014; Marjoribanks, Farquhar, Armstrong, & Showell, 2014). Full blood count and coagulation profile would be necessary to ascertain the extent of blood loss and inform a possible transfusion (Marjoribanks et al., 2014) Treatment Response: A caregiver, the mother, shall be present to aid in the alleviation of patient anxiety. Airway: Airway patency shall be evaluated and maintained Breathing: Ventilation shall be ensured and maintained adequately. Circulation: Establishment of intravenous access shall be necessary. Intravenous fluid replacement shall be done to restore lost fluid volume. Blood transfusion may be necessary to enhance haemodynamic stability and prevent the occurrence of syncope (Benjamins, 2009). Disability: Ensure patient safety is maintained Examination: Examinations shall be minimised except for the ones identified above. Fluids: Intravenous fluid administration of crystalloids shall be necessary. Glucose administration shall also be necessary to prevent nervous deterioration due to hypoglycaemia (Benjamins, 2009). Fluid replacement shall be aimed at administering sufficient fluid for maintenance of a radial pulse. Medication: Pain management using parenteral morphine. Transport Patient transportation to the nearest hospital with specialised obstetric care shall be necessary urgently for further assessment and management that may also involve surgical removal of the ectopic pregnancy. Case Study Two History Call to: Y is a primigravida woman aged 34 years in her 36th week of gestation who has been having complaints of constant but moderate abdominal pain. Her pregnancy was reported to have been uneventful and she had been booked into one the maternity unit of one of the local hospital to undergo parturition. PMX: The patient has no known past medical history. Family Hx: No significant family history though screening, blood test and ultrasound findings showed no abnormalities detected and were up to date. Vital Signs: Respiratory rate - 21/min (tachypnoea). Pulse Rate - 120 beats per minute (tachycardia) SaO2 - 99% at room temperature. Blood pressure – 75/50 (hypotensive) On examination: Pale skin colour Provisional Diagnosis Placental abruption Differential diagnosis Placenta praevia, Uterine rupture, Infection, Disseminated intravascular coagulation Epidemiology/Aetiology/Pathophysiology The patient has experienced an uneventful birth and the foetal heart sounds cannot be detected meaning that the foetus may not be alive (Berhan, 2014; Tasleem H, Tasleem S, Siddique, Nazir & Iqbal, 2011). Foetal compromise or death commonly occurs due to placental complications since the placenta is the primary organ that enables gaseous exchange in the foetus and also supplies nutrients and eliminates foetal waste products (Berhan, 2014). Therefore, placental compromise such as in placental abruption limits or cuts off the supply of the above-mentioned components that are critical for the foetal survival. If the deficiencies are prolonged, the foetus may go into distress and even die while still in the uterus. Placental abruption occurs in premature placental separation from the uterus (Berhan, 2014). Its risk factors that the patient may have experienced include cigarette smoking, consumption of alcohol, short umbilical cord, maternal hypertension and maternal trauma (Deering, 2015). During the separation, bleeding into the decidua commonly occurs. Increase in uterine contractions accompanies the separation. This may be followed by vaginal bleeding although there are cases where PV bleeding is not visible due to pooling of blood behind the placenta. This is the most probable situation with this patient. Formation of haematomas often occurs furthering the separation of the placenta from the uterus, compressing it and worsening foetal blood supply (Deering, 2015). Abdominal pain and tenderness, intrauterine bleeding and uterine contraction are classical symptoms common in placental abruption some of which are experienced by this patient. With an increase in intrauterine haemorrhage, blood pressures may drop due to a decrease in cardiac output as it is observed with this patient. Anaemia symptomatically presenting as paleness on mucous membrane surface and even the skin is also a consequence of the massive haemorrhage (Berhan, 2014). The worldwide prevalence of placental abruption is estimated to be 0.5% to 2% (Berhan, 2014). Perinatal mortality as a result of placental abruption is estimated to be about 20%. Placental abruption is said to be a significant aetiology behind bleeding in the third trimester associated with maternal and foetal morbidity and death (Berhan, 2014). Placental praevia is a possible differential diagnosis but it can be ruled out since this condition often presents with painless vaginal bleeding that halts abruptly and then presents again with labour which are symptoms that are not associated with the patient in this case study (Berhan, 2014). Uterine rupture can be ruled out by cessation of uterine contractions and lack of evidence of a prolonged deceleration in foetal heart rate and the fact that the patient was a primigravida with an unscarred uterus, which are low-risk factors for uterine rupture (Igwegbe, Eleje & Udegbunam, 2013). An infection would be less likely considering that the patient had been attended to in a standard maternity hospital and the fact that she is not febrile, a common sign of infections. "Disseminated intravascular coagulation [DIC]" may occur as a complication of placental abruption after haemorrhage and consequent massive release of clotting factors. Investigations Vaginal examination in this case due to the risk of opening up the cervix for overt vaginal bleeding. Basic laboratory investigations such as testing for haemoglobin level shall be necessary to inform the need for blood transfusion (Berhan, 2014). Full blood count and clotting profile shall be necessary to rule out DIC and inform its management if present. Infection can also be excluded through the blood count picture. Blood typing and crossmatching shall be necessary, if it had not been done, identify the patient’s rhesus status and prepare for indications for blood transfusion (Berhan, 2014). Treatment Response: The patient shall be in the presence of her husband and reassurance shall be done to relieve her anxiety. Airway: Airway patency shall be assessed, monitored and maintained. Breathing: Breathing shall be monitored while ensuring that ventilation is adequate Circulation: Intravenous access shall be established and volume replacement done to restore lost fluid through haemorrhage. Blood transfusion may be necessary if haemoglobin level falls below specified standard threshold for transfusion. Disability: Ensure patient comfort at all times and monitoring consciousness through AVPU score. Fluids: Crystalloids infusion shall be necessary for volume replacements Medications: paracetamol for pain management. If the mother is found RH-negative, Rh immune globulin shall be administered. Transport Immediate transport to a hospital with an emergency department capable of handling caesarean delivery shall be necessary if the patient fails to deliver vaginally. Case Study Three History Call to: Z is a G3P2 woman in her 41st week of gestation whose membrane have ruptured draining clear liquor. Her labour had commenced 2 hours ago with moderate strength contractions that are spaced 5 minutes apart. The foetal presentation is breech. PMX: asthma controlled by salbutamol when necessary and fibroids. Allergic to penicillins Screening, blood tests and ultrasounds showed no abnormalities detected and they are up to date. Family Hx: Has a living mother and sister with no reported medical conditions Vital Signs: Respiratory - 20 breaths/minute (Mild tachypnoea) Pulse rate - 95 per minute with an amplitude of 2 (Mild tachycardia) Foetal heart rate- 110 bpm (normal) SaO2 - 99% room air Temperature - 36.9oC Blood pressure – 110/70 On examination: Bottoms of the foetus presenting at the cervix Provisional Diagnosis Breech Presentation Epidemiology/Aetiology/Pathophysiology It has been estimated that breech presentation occurs in about 3-4% of deliveries with the risk of breech presentation at delivery decreasing with increase in gestational age (Hehir, 2015). The risk is higher in women who have a history of breech presentation in their previous pregnancy (Hehir, 2015). In breech presentation, the foetus presents with the buttocks first in a longitudinal lie unlike in the normal cephalic presentation. Several factors predispose to breech presentation. These include presence of fibroids or uterine malformations, multiple gestations, placental previa, polyhydramnious, foetal abnormalities such as aneuploidy, neck masses and CNS malformations (Fischer, 2015). This patient has a history of fibroids which is most likely have been the predominant predisposing factor to the breech presentation (Noor et al., 2009). There are three forms of breeches. These include frank breech that is characterised by flexed hips and extended knees and forms the most common breech type, complete breech that is characterised by flexed hips and flexed knees that is also the least occurring form of breech, and the incomplete or footling breech that is characterised by a presenting foot and extension of both or a single hip (Hehir, 2015). Breech presentation usually complicates normal vaginal delivery with a higher perinatal mortality risk associated with it compared to cephalic presentation. Other risks associated with breech presentation include umbilical cord prolapse, head entrapment, injury to the baby's skull, and damage to internal organs during breech vaginal delivery (Hehir, 2015; Fischer, 2015). During breech presentation, the dilated cervix is not filled by the presenting lower end of the baby as it would have been filled in occiput transverse or anterior positions. So when the amniotic sac breaks, the cord can easily drop down through the pelvis into the cervix and be compressed raising the risk of asphyxiating the foetus (Fischer, 2015). Most breech presentation often lead to delivery via the caesarean section since delivery via the vagina necessitates skills and experience from the birth attendant in terms of performing the various manoeuvres required in such delivery. In some hospitals, vaginal breech delivery is not indicated and the patient is immediately booked for caesarean delivery (Noor et al., 2009; Hehir, 2015). Investigations Vaginal examination to ascertain cervical effacement and dilation shall be necessary to rule out false labour. Physical examination of the lower abdomen especially palpation of the uterus may augment the diagnosis of breech presentation. Auscultation to determine foetal heart sounds which may be heard above the location of maternal umbilicus in most breech presentation (Fischer, 2015). Treatment Response: Relieve the patient’s anxiety by requesting the mother, sister and husband to give her company and provide reassurance. Airways: Ensure and maintain patency Breathing: Monitor breathing and ventilation. Circulation: Assessment and monitoring of the patient’s pulse rate and the foetus’ heart rate. Establish IV line in anticipation of fluid administration. Disability: Monitor patient’s consciousness level. Examinations: As identified above. Fluids: Crystalloids administration may be necessary if dehydration or volume depletion occurs Medication: no medication are indicated at this stage. Transport The patient shall need to be transported to a nearby hospital where breech delivery can be done vaginally or through caesarean delivery. References Benjamins, L.J. (2009). Practice guidelines: Evaluation and management of abnormal vaginal bleeding. Journal of Pediatric Health Care, 23(3), 189-193. Berhan, Y. (2014). Predictors of perinatal mortality associated with placenta previa and placental abruption: An experience from a low-income country. Journal of Pregnancy, 2014, 1-10. Bonanno, F.P. (2011). Physiopathology of shock. Journal of Emergencies, Trauma, and Shock, 4(2), 222-232. Deering, H. (2015). Abruptio Placentae. Retrieved from http://emedicine.medscape.com/article/252810-overview#a4 Fischer, R. (2015). Breech presentation. Retrieved from http://emedicine.medscape.com/article/262159-overview#a1 Hehir, M.P. (2015). Trends in vaginal breech delivery. Journal of Epidemiology Community Health, 0, 1-3. Hubacher, D., Finer, L.B. & Espey, E. (2011). Renewed interest in intrauterine contraception in the United States: Evidence and explanation. Contraception, 83(4), 291-294. Igwegbe, A.O., Eleje, G.U. & Udegbunam, O.I. (2013). Risk factors and perinatal outcome of uterine rupture in a low-resource setting. Nigerian Medical Journal, 54(6), 415-419. Li, C., Zhao, W., Meng, C., Ping, H., Quin, G., Cao, S., ... & Zhang, J. (2014). Contraceptive use and the risk of ectopic pregnancy: A multicenter case-control study. PLOS One, 9(12), 1-17. Marjoribansk, J., Farquhar, C., Armstrong, S. & Showell, M. (2014). Pregnant professional pilots report. Retrieved from https://www.caa.govt.nz/medical/Med_Info_Sheets/Pregnant_Pilots_Report.pdf Noor, S., Fawwad, A., Sultana, R. Bashir, R., Qurat-ul-ain, Jalil, H. .... & Khan, A. (2009). Pregnancy with fibroids and its obstetric complication. Journal of Ayub Medical College, 21(4), 37-40. NPESU. (2013). Maternal deaths in Australia 2006-2010. Retrieved from https://npesu.unsw.edu.au/surveillance/maternal-deaths-australia-2006-2010 Sepillian, V.P. (2014). Ectopic pregnancy. Retrieved from http://emedicine.medscape.com/article/2041923-overview#a5 Tasleem, H., Tasleem, S., Siddique, M., Nazir, F. & Iqbal, T. (2011). Outcome of pregnancy in placental abruption. Rawal Medical Journal, 36(1), 57-59. Read More