Ectopic Pregnancy

This is the case of M.G. 24/F Single Building 16, RM 102, Filinvest Housing, Alabang, Muntinlupa City Unemployed Roman Catholic Currently living with her boyfriend

Chief Complaint
Abdominal pain

History of the Present Illness

1 day PTC

(+) lower back pain 3/10 in severity, non-radiating (-)dysuria (-) foul-smelling discharge (-) fever (-) urinary frequency (-) consult (-) meds

HPI
3 hours PTC

(+) sudden onset of severe hypogastric pain (+) 10/10 in severity (+) nausea (+) difficulty of urination (-) vomiting (-) fever (-) anorexia (-) vaginal bleeding

(-) consult with a Hilot and was advised to go to the hospital due to severe pain

Past Medical History

NO previous Hospitalization
No medical conditions noted

Past Surgical History

No previous surgeries

Obstetrical History
G3P2 (2002)
No. pregnancy

Year

Outcome

Sex boy boy

Manner of Delivery

Birthweight

Place of Delivery

Complic ations

G1 G2 G3

2007 2009

NSD NSD

2.7 kg 2.7kg

Muntinlupa lying-in Muntinnlupa Lying-in

none none

Present pregnancy

MENSTRUAL HISTORY
Menarch:14 years old

Duration: 5-7 days Amount: 2 moderate-fully soaked pads on the 1st 3 days and 2 minimally soaked pads per day on the last 4 days of menstruation

Abnormalities: no dysmenorrhea

GYNE HISTORY
The patient was never been diagnosed of any

gynecologic diseases in the past Never had pap smear family planning method used- withdrawal method

SEXUAL HISTORY
1st sexual contact: 18 y/o with her 1st boyfriend
She is currently living with her 2nd boyfriend who

is the father of her 2 children (-) dyspareunia and post-coital bleeding Last sexual contact:

REVIEW of SYSTEMS
GENERAL: (+)abdominal pain, (-) fever (-) chills INTEGUMENTARY: (+) pallor, (-) cyanosis,

(-) jaundice, (-) rashes (-) easy bruisibility

HEAD: (-) lesions (-) swelling (-) headache EYES: (-) tearing (-) redness EARS: (-) discharge

NOSE: (-) sneezing, (-) colds, (-) nosebleeds, (-) discharges

MOUTH & THROAT: (-) gum bleeding, (-) swelling NECK: (-) Mass (-) lesions (-) cervical LAD

REVIEW of SYSTEMS
PULMONARY: (-) dyspnea, (-) cyanosis
CARDIO: (-) dyspnea, (-) cyanosis (-) palpitation GUT: (+) abdominal Pain (-) vaginal bleeding

REVIEW of SYSTEMS
HEMATOLOGIC: (-) bleeding tendencies

(-) varicosities (-) bruising (-) petechiae, (-) hematoma

ENDOCRINE: (-) polyphagia, (-) polyuria,

(-) hyperactivity (-) heat/cold intolerance (-) profuse sweating

NERVOUS: (-) convulsions (-) tremors (-) fainting

PHYSICAL EXAMINATION
General Survey: The patient is conscious, coherent, cooperative and not in CPD Vital Signs: BP: 80/40 CR: 112 RR: 26 T: 36.5 HEENT: anicteric sclera, pale palpebral conjunctiva, no cervical LAD, no tonsillopharyngitis C/L: SCWE, no retractions, clear breath sounds HEART: AP, tachycardic, no murmur

PHYSICAL EXAMINATION
ABDOMEN: flat with direct and rebound

tenderness on all quadrants INTERNAL EXAM: cervix is closed, with wriggling tenderness, no blood on the examining finger, posterior cul-de-sac noted to be full Bimanual Examination: not assessed due to severe pain

Impression
Severe hypogastric pain T/C UTI , Pregnancy to be ruled out

UTI
Basis for Ruling-in
Severe hypogastric pain Difficulty of Urination

Basis for Ruling-out

No fever noted No dysuria

Basis for Considering Pregnancy

Female
Reproductive age With sexual partner

Management:
Diagnostics:
CBC with platelet Count Urinalysis with Pregnancy

Therapeutics:
Fluid resuscitation

test

Pregnancy Test POSITIVE

Diagnosis:
G3P2 (2002) T/C Ectopic pregnancy 6 1/7 weeks AOG R/O Threatened abortion

Ectopic Pregnancy
Basis for Ruling-in based on History
Amenorrhea severe abdominal pain Difficulty of urination

Basis for Ruling-in based on PE

Hypotension and tachycardia Pale pabpebral conjunctiva Abdomen: direct and

rebound tenderness on all quadrants IE: cervix closed with wriggling tenderness, full Posterior cul-de-sac

Complete Blood Complete

9/19/2011 Hgb Hct WBC Neutro Eosinophils Lymphocytes Monocytes Platelet Count Blood Type 120 .35 16.69 .87 .01 .00 .04 302 O+ 09/20/11 80 .23

During an episode of acute significant hemorrhage, the Initial hematocrit is always the highest 1000ml of blood loss = 3 vol % drop in the hct

Obstetrical Hemorrhage Williams 23rd edition

 Renal blood flow is sensitive to changes in blood

volume. Careful measurement of urine volume reflects the adequacy of renal perfusion and perfusion of vital organs.

Obstetrical Hemorrhage Williams 23rd edition

Urinalysis
Pus Cells: 2-4
RBC: 0-2 Epithelial cells: few

Bacteria: few
Mucus threads: many A. Urates: few Protein: Negative Sugar: Negative

First sign of internal blood loss Decreased urine output tachycardia

MANAGEMENT
B/P: 80/40 CR: 112

PNSS 300cc Fast drip

BP 80/50 CR 110 RR 20
FD 300cc of PNSS BP 80/50 CR 114 RR 21

FD 200cc of PNSS
BP 80/50 CR 112 RR 21

 Crystalloids- or initial volume replacement

- 3:1 ratio (fluid:blood loss)

SHOCK
condition in which circulatory insuffi-ciency prevents adequate vascular perfusion of vital organs

Inadequate urine output Metabolic acidosis Multiple organ failure

 15% to 45% of surgical blood loss is absorbed on

the drapes, laparotomy pads, and other areas.

Massive blood loss has been defined as hemorrhage that results in replacement of 50% of the circulating blood volume in less than 3 hours.

 Urine output decreases to less than 0.5 mL/kg/hr

(20 to 25 mL/hr) as a result of poor perfusion of the kidneys. With further loss of blood the woman becomes agitated, appears weak, and develops skin pallor with cold and clammy extremities. The systolic blood pressure drops below 80 mm Hg. Again, because of adaptive cardiovascular changes, it takes a rapid loss of approximately one third of the blood volume to produce significant hypotension.

Goals of treatment of Shock

replace, restore, and maintain the effective

circulating blood volume and establish normal cellular perfusion and oxygenation provide 1.adequate ventila-tion because poor respiratory gas exchange 2. rapid fluid replacement with adequate amounts of blood and crystalloid solution (normal saline or lactated Ringer's solution) 3:1 rule

 Optimal replacement includes packed red blood

cells and a balanced electrolyte solution, such as lactated Ringer's solution