Ong Cases Final-1

SCHOOL OF MEDICINE AND DENTISTRY
OBSTETRICS AND GYNAECOLOGY CASE BOOK
NAME: KYEKYE CEDRIC ETORNAM
ID: 10620110
YEAR: SECOND CLINICAL YEAR
TEAM: JUNIOR CLERKSHIP TEAM A
SENIOR CLERKSHIP TEAM B
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TABLE OF CONTENT
GYNAECOLOGICAL CASES
A CASE OF OVARIAN CANCER………………………………………………… 3
A CASE OF INFERTILITY………………………………………………………... 13
A CASE OF ECTOPIC PREGNANCY……………………………………………. 19
A CASE OF FAMILY PLANNING………………………………………………... 28
A CASE OF MANUAL VACUUM ASPIRATION……………………………….. 33
OBSTETRIC CASES
LABOUR CASES
SPONTANEOUS VAGINAL DELIVERY (Case 1)………………………………. 40
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OVARIAN CANCER
Name: Madam V. M.
Age: 56 years
Parity: P7 (3D)
Last Normal Menstrual Period: about 5 years ago (post-menopausal)
Date of Admission: 18th August, 2022
Date of Discharge: 24th August, 2022
HISTORY:
Presenting Complaints
1. Abdominal distension – about a month duration

2. Abdominal pain – about a month duration
History of Presenting Complaints
She was in her usual state of health until about a month ago, when she noticed that her
abdomen was unusually distending. She also started experiencing severe sudden lower
abdominal pains around the same time she noticed the abdominal distension. The pains were
constant, non-radiating, stabbing in nature and had a severity of 9 out of 10. It had no
relieving factors. The pain affected her sleep as she felt it more when lying down. The
abdominal distension was also associated with early satiety, constipation and reduced urine
output. She visited three health facilities where she was asked to do some labs and scan after
which she was then referred to Korle-bu Teaching Hospital for further management. Upon
arrival here, she was admitted and has been given some medications and has had some blood
tests done. She had a surgery on the 19 th of August, 2022. She was monitored for some days
and was discharged on 24th of August, 2022.
On Direct Questioning
She has lost weight, but has no drenching night sweats. She experienced easy fatigability and
palpitations, but no dizziness, headaches, or dyspnoea. She has early satiety, no vomiting or
diarrhoea but had constipation. She had no fever, chills, haematuria, melena or bleeding from
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any other orifice. There was also no abnormal vaginal discharge but she experienced some
back pains. Her sister had breast cancer and was treated, but no family history of ovarian or
colon cancer.
Systemic Enquiry
Cardiovascular - She had no chest pain, dyspnoea, orthopnoea, paroxysmal nocturnal

dyspnoea.
Respiratory- She had no cough, dyspnoea, wheeze or running nose.
Gastrointestinal- She had no jaundice
Genitourinary -She had no dysuria or urgency.
Musculoskeletal- She had no joint pain, weakness or muscle pain.
Central nervous system- She had no syncope, convulsions, blurred vision or hearing
difficulties
Past Medical History
She has never been admitted prior to her current condition. She has never been transfused
with blood, nor had any surgeries. She does not have sickle cell disease, asthma,
hypertension, diabetes or any other chronic disease.
Drug History
She’s not on any routine medications. Since her admission, she has been taking Naclofen
(75mg three times a day), intramuscular tramadol (100mg two times a day), and
subcutaneous clexane (80mg daily). She has no known food or drug allergies, and does not
take herbal medication.
Gynaecological History
 Menstrual history: She has been post-menopausal for about 5 years now. Menarche
was at 16 years. She used to have a regular monthly cycle, with an average bleeding
duration of 2-3 days. She used to have heavy bleeds and changed her pad three times
a day with occasional clots about the size of the 10 pesewa coin. She sometimes
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experienced flooding and used to have primary dysmenorrhea but no inter menstrual
bleed.
 Sexual history: Coitarche was at 15 years. She has had 2 lifetime sexual partners. She
has no history of dyspareunia or post coital bleed. She has never used any family
planning method before. She has never had any sexually transmitted disease or
previous gynaecological surgery. She has not had a PAP smear done before. She does
not practice self-breast examination and has also never had a clinical breast exam. She
has no abnormal vaginal discharge.
Past Obstetric History
She is P7 (3D)
First pregnancy was about 37 years ago and the last pregnancy was 16 years ago. All seven
pregnancies did not have any complications. She delivered all them via spontaneous vaginal
delivery, and the puerperium was uneventful. She breastfed each child for a maximum for 1
year. With exception of the second, fourth and last children who are deceased, all the rest are
currently alive and doing well. She said one of them died from a thyroid disease but she
doesn’t know the cause of death for the other two.
Family History
Her parents died of old age. She is the last of 5 children, one of her siblings died of stroke.
The others are doing well. There is no family history of Diabetes, Asthma, Sickle Cell or
Hypertension. Her sister had treatment for breast cancer.
Social History
Her husband died about 12 years ago. He was the father to her first 4 children. The father to
her last 3 children is alive. She lives at Agona Nsaba. She sells fried fish. She stopped
schooling at Primary 4. She is not enrolled on the National Health Insurance Scheme. She
does not smoke but has a past history of alcohol intake. She accepts blood transfusion.
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Summary
Madam V.M., 55 years, P7 (3D), who is about 5 years post-menopausal, who presented with
a month history abdominal pain and abdominal distention associated with early satiety and
some anaemia symptoms.
PHYSICAL EXAMINATION
General examination:
I saw a middle aged woman who looked well and not in any obvious respiratory
distress. She was mildly pale and afebrile (36.0 oC). She was not jaundiced and not
cyanosed, hydration was normal, had no digital clubbing, no peripheral
lymphadenopathy and no pedal oedema. She had no anterior neck swellings.
Cardiovascular examination:
Her pulse rate was 104 beats per minute, regular and of good volume. Blood
pressure was 100/70mmHg. Apex was in the 5th left intercostal space, mid-
clavicular line. 1st and 2nd heart sounds were present and normal, no murmurs.
Respiratory Examination:
Chest moved with respiration; respiratory rate was 18 cycles per minute. Her chest
expansion was adequate and symmetrical. There was no tenderness in all zones,
percussion notes were dull at the lung bases, air entry was normal in all lung zones.
Breast:
Both breasts were symmetrical with everted nipples. There were no skin changes, ulcers or
nodules. There were no masses palpable. There was no nipple discharge.
Abdominal Examination:
Her abdomen was uniformly distended but moved with respiration. There were no
scars or scarification marks and no visibly distended vessels. Abdomen was soft.
Liver, spleen and 2 kidneys were not palpable, a mass was felt centrally. Fluid
thrill was positive.
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INVESTIGATIONS
 Full Blood Count:
o Haemoglobin 9.0g/dl
o White Cell Count 9.29 x 109/l,
o Platelets 366 x 109/l
 Blood Urea, Electrolyte and Creatinine (BUE & Cr)

o S – Sodium (Na) 140 mmol/L
o S – Potassium (K) 4.3 mmol/L
o S – Chloride (Cl.) 102 mmol/L
o S – Urea 2.5 mmol/L
o Creatinine, serum 71 umol/L
 Abdomino-pelvic Ultrasound Scan:

Massive ascites secondary to liver cirrhosis, complex left ovarian cyst
 Abdomino-pelvic CT Scan:
1. Heterogeneous liver parenchyma with irregular surface + reduced
enhancement, dilated portal vessels with massive ascites, features of liver
cirrhosis with portal hypertension
2. Complex ovarian lesions with peritoneal and mesenteric lesions,

massive ascites, features suggestive of metastatic serous
cystadenocarcinoma
3. Cholelithiasis
 CA-125 :
45, 467.8 U/ml
IMPRESSION / DIAGNOSIS
Ovarian CA, Ovarian cyst
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PLAN:
The patient was to be prepared for surgery (Exploratory Laparotomy, TAH +
BSO); was sent for anaesthetic review. Blood was taken for grouping and cross-
matching. IV fluids (2L Normal saline, 2L Ringers lactate, 1L Dextrose saline) and
items for surgery were to be gotten.
Pre-Op Management:
The following medications and items were requested and bought by the patient;
 IV Amoxiclav 1.2g bd × 24 hrs
 Tab Amoxiclav 625mg bd × 7 days
 IV Flagyl 500mg × 24 hrs
 Tab Flagyl 500mg tid × 7 days
 Supp diclofenac 100mg bd × 5 days
 Subcut Clexane 40mg daily × 3 after 12 hrs
 IV Paracetamol 1g 6 hourly
 Tab Paracetamol 1g tid × 3 days
 IM Pethidine 100mg 6 hourly x 24 hours
OPERATION FINDINGS AND PROCEDURE

 Operation: Exploratory Laparotomy + Total Abdominal Hysterectomy +
Bilateral Salpingo-oophorectomy.
 Indication: Advanced Ovarian Ca.
 Surgeon: Dr. N
 Assistant: Dr. I and Dr. Q
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 Anesthesia: General
 Findings:
 There was a bilateral ovarian mass 10cm-right, 8cm-left.
 Multilobulated with peritoneal seedlings on ovary, mesentery,
bowel, liver, spleen and peritoneum.
 Some nodules were greater than 3 cm
 Procedure: Under general anaesthesia and aseptic conditions, patient was
placed supine, cleaned and draped aseptically. The abdomen was entered
using midline incision, and ascites drained. The uterus was accessed using
blunt dissection and was then exteriorized and inspected. The bowel was
packed away from the field and a deaver’s retractor was placed. The round
ligament was identified, doubly clamped, cut and ligated. The
infundibulopelvic ligament was identified doubly clamped, cut, ligated and
transfixed on both sides. The uterovesical peritoneum was dissected and
bladder freed and pushed down off the lower uterine segment. Uterine
vessels were identified, skeletonized, doubly clamped, cut and ligated on
both sides of the uterus. The uterosacral and cardinal ligaments were
clamped, cut and ligated. The junction between the uterus and cervix was
identified and doubly clamped. At the level of the internal os, the uterus
was amputated from the vaginal vault. The vault was then closed and the
corners secured to the cardinal ligaments on both sides. Haemostasis was
secured after thorough inspection of the bleeders. Abdomen was closed in
layers using vicryl 1 for fascia and subcut. The skin was closed in
subcuticular fashion using vicryl O. immediate post op condition was
satisfactory.
POST OP MANAGEMENT
Plan:
 Her vitals were to be monitored quarter hourly until stable and then 4
hourly.
 Strict fluid input and output monitoring for 24 hours.
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 Urethral catheter to be kept in situ for 24 hours
 Keep nil per os till bowel function returns
 The following requirements were also given accordingly:
 IV fluids: 1L DNS, 1L R/L, 1L N/S for 24hrs
 IV Amoxiclav 1.2g 8 hourly *24hrs
 IV Metronidazole 500mg 8 hourly * 24hrs
 IV Paracetamol 1g 6 hourly *24hrs
 IM Pethidine 100mg 6hrly * 24hrs
 Suppository Diclofenac 100mg bd * 5/7
Post-Operative Day 1
She complained about pain at the incision site.
There was no fever or chills, no anaemic symptoms and no chest pain.
On examination, she looked stable, she was mildly pale, was afebrile (36.4 ˚C) and
anicteric. Her hydration was satisfactory. Her pulse was 82 bpm, regular and of
good volume. Blood pressure was 102/70 mmHg. 1st and 2nd heart sounds were
present and normal. Respiratory rate was 20 cycles per minute; air entry was
adequate bilaterally.
Abdomen was full, soft, moved with respiration. There was tenderness at the
incision site. Bowel sounds were present. Urine output was 1550mls and clear at
11:40am.
Plan: The patient was to start taking oral sips, and complete IV antibiotics. She
was put on IV fluids (1L N/S, 1L R/L, 0.5L D/S) for 24hrs, SC Clexane 40mg
daily, urethral catheter to be removed, sample to be sent for histopathology. She
was to mobilize out of bed.
She complained about pain at the incision site. There was no fever or chills, no
anaemic symptoms and no chest pain.
On examination, she was mildly pale, afebrile, anicteric, temperature was 36.5˚C
hydration was satisfactory. Her pulse was 98bpm. Blood pressure was 100/72
mmHg. 1st and 2nd heart sounds were present and normal.
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Abdomen was full, soft, moved with respiration, tenderness at incision site. Wound
dressing was clean and dry. Bowel sounds were present and normal. Had been
transfused with two units of blood.
Plan: The patient was to start light diet; take oral antibiotics, subcutaneous clexane
40mg daily, to do a Full Blood Count.
Post-Operative Days 3
The patient was stable and had no complaints. On examination, she was mildly
pale, afebrile, anicteric, temperature was 36.5˚C hydration was satisfactory. Her
pulse was 80bpm. Blood pressure was 107/74 mmHg. Abdomen was full, soft,
moved with respiration, there was mild discharge from the wound. The
examination findings were normal. Wound site was dry and clean.
Plan: Patient was to have a closed wound dressing, wound swab taken for culture
and sensitivity, continue with current management and send sample for
histopathology.
moved with respiration, there was mild discharge from the wound, haemoglobin
was 10.7, platelet was 189, White Blood Cells was 13.74 from Full Blood Count
done on 21st August, 2022.
Plan: Patient was to have a closed wound dressing, review wound swab culture
and sensitivity results and continue current management.
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moved with respiration, wound dressing was clean and dry. Results from wound
swab showed gram negative bacilli
Plan: Patient was to be discharged and return in two weeks with histopathology
results. She was to start oral levofloxacin 500mg daily × 7/7. She was also
prescribed fesolate 200mg bd and vitamin C 1g daily.
CRITICAL APPRAISAL
The patient was managed well and was satisfied with her treatment.
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SECONDARY INFERTILITY
Name: Madam D. A.
Age: 34 years
Parity: P2 (1D)+3(TOP)
Last menstrual period: 6th July, 2022
Address: Tetegu
Occupation: Seamstress
HISTORY
Presenting Complaint: Inability to conceive of 6 years duration
History of presenting complaint: Patient was in her usual state of health and has been trying
to conceive after giving birth to her second child in 2015 with her husband. She stays with
her husband and they have sex three times a week on the average. Last year she visited a
peripheral facility where she was asked to do an abdominal ultrasound scan which revealed
normal appearing uterus and left uterus and simple tiny right ovarian cyst. Her husband was
then asked to come to come to the hospital to which he refused so there was no progress.
However, on Thursday the 21st of July 2022, she reported to the Korle bu Polyclinic where
she showed them the scan she did a year ago. Her husband was then requested to do a semen
analysis test in Korle bu which showed severe low sperm count and was hence referred to
Korle Bu Teaching Hospital for further treatment. On arrival at the gynae clinic, a urine
pregnancy test was done which tested negative.
On direct questioning: She couldn’t recall the age of menarche. She has a regular 28 day
menstrual cycle with 3 days of bleeding. She uses 2 sanitary pads per day. She doesn’t have
dysmenorrhea nor breast tenderness and knows her fertile period. She had no acne, oily skin
or abnormal excess hair growth on her face or chest. She did not experience heat intolerance,
cold intolerance, constipation or diarrhea. She had no experience headache, blurred vision or
any type of breast discharge. She noticed a recent increase in weight evidenced by the need
for new clothes.
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She did not experience abdominal pain, fever or any abnormal vaginal discharge. She had no
history of gynaecological surgery. She has unprotected sexual intercourse with her husband
3times a week and her husband achieves a full sustained erection with ejaculation during sex.
Her husband does not wear tight fitting nylon under wear and neither does he work around
heat. He does not have a previous history of mumps and has never had any hernia surgery. He
does not have any other children elsewhere.
Systemic enquiry
 General: She eats well and sleeps adequately
 Cardiovascular system: She has no exertional dyspnoea, chest pain, orthopnoea
 Respiratory system: She has no dyspnoea, cough, wheeze
 Gastrointestinal system: She has no abdominal distension, vomiting ,nausea
 Genitourinary system : She has no dysuria, straining, nocturia
 Central Nervous System : She has no loss of smell or seizures
 Musculoskeletal system: She has no joint pain ,muscle pain
Gynaecological history
 Menstrual history: As stated above. She pass clots but tiny in size and there is no
flooding. She doesn’t experience dysmenorrhoea. She has no vaginal discharge.
 Sexual history: Coitarche was at 17 years. She has had 2 lifetime sexual partners.
She doesn’t experience dyspareunia or post coital bleeding.
 She is not currently using any method of contraception but used the combined oral
contraceptive pills for about a month in the year of 2010. She stopped after she met
her husband. Her partner doesn’t use any contraception.
 She does breast self-examination. She has not done a pap smear before. She has not
undergone any gynaecological surgery before.
Past obstetric history: P2 (1D) +3TOP

For the 3 termination of pregnancies, she couldn’t recall the years they occurred. However,
they were all at 8 weeks of gestation. She visited the hospital where manual vacuum
aspiration was done. She had no post abortal complications
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Her second pregnancy ended in 2004. She delivered at 9 months via a caesarean section on
account of a big baby. She attended antenatal and pregnancy was uneventful. She delivered at
a peripheral hospital in Kumasi. She breast fed for a year. Child was a male. He passed away
at 1 year and cause of death was not known.
Her third pregnancy ended in 2015. She was diagnosed of being retro positive during one of
her antenatal visit. She was put on antiretroviral drugs and has been compliant since then. She
delivered at 9 months via spontaneous vaginal delivery. Delivery was in the car on her way to
the hospital She had a tear while delivering thus on arrival at the hospital she had a perineal
suture. Baby was male and cried at birth. She could not recall the birth weight .She breastfed
the child for a year as well. Baby was also given prophylactics against the retroviral infection.
Child tested negative. He is alive and doing well. She bled profusely after delivery thus was
admitted for 2 weeks and transfused 3 units of blood.
Past medical and surgical history: She doesn’t have hypertension, diabetes mellitus, asthma
or sickle cell disease. She was diagnosed of retro virus infection in 2015 and has been a
regular attendant at the retro clinic at Akawe. She has had 2 previous admission on account of
caesarean section and postpartum haemorrhage. She has had surgery in the past and has been
transfused 3 units of blood.
Drug history: She is currently on her antiretroviral drugs. She has no known drug allergies.
She used herbal medications in the past to boost her immunity.
Family history: Both parents are alive and have no known chronic condition. She is the
fourth of eleven children. There’s no family history of hypertension, diabetes milletus,
asthma or sickle cell disease. There’s no family history of breast cancer, ovarian cancer or
any malignancies.
Social history: She is married and stays with her husband and son at Tetegu. She has a valid
NHIS card. She doesn’t smoke or use recreational drugs or take alcohol drinks
Her husband is a 38 year old mechanic and taxi driver. He doesn’t smoke but take alcoholic
drinks occasionally. She is a Christian and accepts blood transfusion.
SUMMARY
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I have presented Madam D.A., 34 years P2 (1D) +3 TOP who presented with 6 years duration
of inability to conceive. She has noticed a recent weight gain. She was diagnosed retro
positive in 2015 and has been compliant on the medication, she has past history of C/S and
PPH.
General Examination:
I saw a young woman, who looked well. She was not pale or jaundiced and was adequately
hydrated. There was no peripheral lymphadenopathy, pedal oedema, cyanosis, clubbing or an
anterior neck swelling. She has no acne, or facial hairs . Her weight was 79kg and her height was
154cm. Her Body Mass Index was 31.6kg/meter square which means she is obese
Breast Examination:
Breasts looked symmetrical, with no ulcers or sores. There was no dimpling or retraction of
the skin. Nipples were everted. There was no palpable breast lump in both breasts. The
axillary, supraclavicular and infraclavicular lymph nodes were not palpable. There was no
nipple discharge.
Cardiovascular System: Her pulse rate was 86 beats per minute It was regular, of good volume
and non-collapsing. The arterial walls were not palpable. Blood pressure was 116/80mmHg. Apex
beat was at the left 5th Intercostal space in the mid clavicular line. The trachea was centrally placed.
Heart sounds I and II present and normal, no murmurs, no added sounds.
Respiratory system: Respiratory rate was 20 cycles per minute. She had no area of tenderness on
the chest, air entry was adequate bilaterally and breath sounds were vesicular with no added sounds
and no crepitations at lung bases.
Central Nervous System: She was alert and conscious .She was well oriented in time, place
and person
Abdomen: Her abdomen looked full and moved with respiration. The umbilicus was everted
and there were no scarification marks. There was a transverse suprapubic surgical scar. She
has female hair distribution.
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On light palpation, there was no tenderness or masses felt. On deep palpation, both the
spleen and liver were not palpable. The two kidneys were not bimanually palpable .There
were no masses arising out of the pelvis.
There was no shifting dullness. Bowel sounds were present and normal.
Pelvic exam: Normal looking vulvovagina. No obvious lesion in the cervix or vagina.
No adnexal tenderness. No cervical motion tenderness. Uterus was about 8 week size.
IMPRESSION/ DIAGNOSIS: Secondary infertility
INVESTIGATIONS
Semen analysis (27/07/22)
Volume - 1.5ml
Motility - 5%L
Liquefaction - complete
Agglutination - NIL
PH - 8.0 (abnormal)
Count - 750,000
Viability - 35%
Morphology - 20 (ideal looking cells, 60% abnormal head 10% bent necks
Testicular cells - 0
Pus cells- 4
Epithelial cells- 1
Red blood cells- 0
Comment: Oligoastheniteratozospermia
PLAN:
Proxeed plus 1 sachet BD x 3/12
AMH
Pelvic scan
Tab folic acid 5mg daily
Hysterosalpingogram
High vaginal swab
For review in two weeks
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CRITICAL APPRAISAL
This case was managed well. Both partners were properly investigated for the possible causes
of their infertility. Her partner had a semen analysis done which showed he had reduced
sperm count.
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RUPTURED ECTOPIC PREGNANCY
Name: Madam. M. O.
Registration No: AAX0100
Age: 39years
Last menstrual period: 12th June, 2022
Parity: G7P7
Date of Admission: 26th July, 2022
Date of Discharge: 28th July, 2022
HISTORY:
Presenting Complaints: 1. bleeding per vaginum – 4 days duration.
2. Lower abdominal pain – 4 days duration.
History of Presenting Complaints:
Patient was in her usual state of health until 4 days prior to presentation when she started
experiencing severe intermittent sharp abdominal pains which was sudden and colicky in
nature. She felt the pain more in the left lumber and peri-umbilical regions. There were no
relieving or exacerbating factors, it was associated with nausea and she graded it 10/10.
Bleeding per vaginum also started 4 days prior to presentation, it was scanty, bright red but
altered over time and she changed her pad twice a day. She visited Kaneshie polyclinic a day
before presentation where some labs and scans were done which showed extrauterine
pregnancy. She was then referred to the Korle-bu Teaching Hospital for further management.
On arrival at gynae emergency, some labs and abdominopelvic ultrasound were done and an
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ectopic pregnancy was confirmed. She was then taken to theatre and a left salpingectomy was
done which was successful
On Direct Questioning:
She had palpitations but no dizziness, no easy fatigability. She had no nausea, headache,
vomiting or a feeling of enlarging of her abdomen. She had no fever, chills or vaginal
discharge and no right hypochondriac pain
Systemic Enquiry
General -She had no weight loss, no loss of appetite, rigors or malaise.
Cardiovascular - She had no chest pain, dyspnoea, orthopnoea or paroxysmal nocturnal

dyspnoea, no oedema
Respiratory- She had no cough, wheeze nor running nose.
Gastrointestinal- She had no diarrhea or costipation, no abdominal distension.
Genitourinary -She had no dysuria, no haematuria or urgency but there was frequency
Musculoskeletal- She had no joint pain, weakness or muscle pain.
Central nervous system- She had no syncope, convulsions, blurred vision or hearing
difficulties
Gynecological history:
 Menstrual history: Her menarche was at 15 years. She has a regular menstrual cycle in
which she bleeds for 4 days. She changes three sanitary pads a day which are moderately
soaked. She passes no clots. She experiences no dysmenorrhea, flooding, or inter-
menstrual bleeding.
 Sexual history: Coitarche was at age 18 and has had 2 sexual partners since then. She
neither experiences dyspareunia nor post coital bleeding. She used implants for three
years from 2008 and also had depo-provera in 2017 which she used for a year. She has no
history of STIs, Genital Tract Infections or gynecological surgeries. She has no vaginal
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discharge. She practices breast self-exam but has not had a formal breast exam. She
hasn’t had a Pap smear test done before
Obstetrics history:
She is G7P7
Her first pregnancy ended 23 years ago in 1999 and her last pregnancy ended 3 years ago in
2019. All births were by spontaneous vaginal deliveries. She experienced no problems during
and after the pregnancies. She had 4 males and 3 females and had an episiotomy in her fourth
pregnancy. All her children are alive and doing well.
Past Medical and Surgical history: She has no history of hypertension, sickle cell disease,
asthma, diabetes mellitus or any other chronic disease. She has had no previous admissions
on account of a medical illness; no previous blood transfusions and no previous surgeries.
Drug History: She was on IV paracetamol and metronidazole, she has taken herbal
medication before and has no food or drug allergies
Family History: Both parents are alive. Mother has diabetes. She has no family history of
hypertension, sickle cell, or asthma.
Social History: Patient lives with her husband at Kwashiman. She’s a food vendor, her
highest level of education is Junior High School. She is a Christian and accepts blood
transfusion. She has an active NHIS. She does not drink alcohol nor smoke.
Summary:
39 year old, Ms. C. A., P7, with LMP of 12/06/2022, who was referred to KBTH from Korle-
bu polyclinic on account of an ectopic gestation. She presented with a 4 day history of lower
abdominal pain and bleeding per vaginum. She is symptomatic of anaemia.
I saw a young lady who looked well, not in any obvious respiratory distress. She was afebrile
(37.1oC), anicteric, mildly pale but not cyanosed. Hydration was satisfactory, not warm to
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touch, has no neck masses or peripheral lymphadenopathy. She had no pedal oedema. Wt –
55kg, Ht – 1.52m, BMI – 23.8kg/m2. She’s within normal BMI range.
Cardiovascular system:
Her pulse rate was 90bpm, regular rhythm and volume, blood pressure was 126/74mmhg.
Apex beat was at left fifth intercostal space, midclavicular line. Heart sounds 1 and 2 were
present and normal and no added sounds, no murmurs.
Respiratory system:
Her respiratory rate was 24 cycles per minute, SPO2-99% in room air, chest movement was
adequate and symmetrical. Trachea was central. There were no areas of tenderness on the
chest. The air entry was adequate bilaterally. Breath sounds were vesicular. No added sounds,
no crepitations at the lung bases.
Central Nervous System:
Patient was conscious and alert
Breast:
Both breasts were symmetrical, everted nipples, no ulcers or nodules, no differential warmth,
not tender and no masses palpable. No nipple discharge or axillary lymphadenopathy.
Abdomen:
Her abdomen looked full, soft, moved with respiration, the umbilicus was flat, no surgical
scars or scarifications were present and had normal female hair distribution. The spleen, liver
and both kidneys were not palpated. There was generalised tenderness, guarding and rebound
tenderness. Bowel sounds were present and normal.
Vaginal Examination:
The vulva looked healthy; the urethra and bartholin glands were not palpable. There was
cervical excitation tenderness.
Speculum examination:
The vulva looked normal and vagina cervix was posterior. There was altered blood on the
cervical os.
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Culdocentesis:
About 10mls of non-clotting blood was aspirated.
INVESTIGATIONS:
 Abdominopelvic Ultrasound Scan:

Uterus: Appears anteverted, homogenous in echo pattern, uniform echotexture, and
normal in size measuring (8.01× 4.33× 5.71) cm with uniform myometrial echoes.
The endometrium shows normal thickness. No cyesis seen.
Cul-de-sac: Mild free fluid noted.
Adnexal: Left adnexa noted with fluid-filled sac with no fetal pole or yolk sac and
enclosed rim suggestive of gestation which measured 1.45cm corresponding to a
gestational age of 5 weeks, 2 days. There is mild fluid seen within the Pouch of
Morrison.
Impression: Ectopic pregnancy
 Urine R/E
COLOUR STRAW
PH 6
UROBIL. NORMAL
SG 1.020
BLOOD +
GLU NEG
KETONES NEG
PROTEIN NEG
NITRITE NEG
LEUCOCYTE TRACE
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PLUS CELLS 6
EPITHELIAL CELLS 5
RBC 10
 FBC
WBC 9.3× 109/l
RBC 3.3×1012/l
HB 9.7g/dl
MCV 89.1fl
MCH 29.3×10pg
PLT 147× 109/l
IMPRESSION / DIAGNOSIS
Ruptured ectopic pregnancy
PLAN:
Blood was taken for grouping and cross matching against 2 units of blood, BUE & Cr, was to
prepare for exploratory laparotomy
The following medications and items were obtained from the pharmacy for the patient;
 IV Amoxiclav 1.2g bd × 24 hrs
 IV Flagyl 500mg tds× 24 hrs
 IV Paracetamol 1g qid ×24 hrs
 Tab Paracetamol 1g tid × 3 days
 IM Pethidine 100mg tds
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 1L RL, 1L NS, 1L DNS
 IV Gelofusine 500mls stat
OPERATION FINDINGS AND PROCEDURE:
 Operation: Laparotomy + left salpingectomy

 Indication: Ruptured ampullary gestation (right)
 Surgeon: Dr. A
 Assistant: Dr. M
 Anaesthetist: Dr. K and team
 Findings: Uterine size - 10/57. Ruptured left ampullary ectopic gestation, normal right
tube and ovary, normal left ovary. Haemoperitoneum of about 400mls. Estimated blood
loss – 600ml
 Procedure: Under general anaesthsia, patient was scrubbed and draped. Abdomen was
entered via a Pfannenstiel incision deepened into the peritoneum. Above findings were
seen. Left salpingectomy done and haemostasis secured. Abdomen was cleared of blood.
Abdomen was closed in layers. Vicryl 1 to rectus sheath and subcutaneous tissue. Vicryl
0 to skin. Post op condition satisfactory.
POST OP MANAGEMENT
The vitals were to be monitored quarter hourly while on the recovery ward for full recovery
from anaesthesia. The following requirements were also given accordingly:
o Haemotransfused with 1 unit of blood intra-operatively
o IVF 3L (1L normal saline, 1L ringers lactate, 1L dextrose saline) in 24hrs
o IV Augmentin 1.2g bd x 24hrs
o IV Flagyl 500mg tds x 24hrs
o IM Pethidine 100mg 8hrly x 24hrs
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o Monitor fluid input and output
o Supp. diclofenac 100mg bd * 5 days
She complained of mild abdominal pains but no symptoms of anaemia.
On examination, she was not in any obvious respiratory distress. Patient was pale, not
jaundiced and afebrile, hydration was satisfactory. She was conscious and alert. Her Blood
Pressure-119/68mmHg, Pulse- 80bpm regular and of good volume. Respiratory rate was
20cpm. Abdomen was full, soft and moved with respiration, had mild tenderness at the
incision site. The incision site was dry and clean. Bowel sounds were present and normal.
Plan: To remove urethral catheter and encourage ambulation. To start oral antibiotics after
IVS
The patient was stable and had no complaints. She was asymptomatic of anaemia. She was
feeding and ambulating well.
On examination, she was pale, not jaundiced, afebrile, anicteric, hydration was
satisfactory. Respiratory rate was 20 cpm. Her pulse was 82 bpm. Blood pressure
was 120/76 mmHg. 1st and 2nd heart sounds were present and normal.
Abdomen was full, soft, moved with respiration, mild tenderness at incision site.
Wound dressing was clean and dry. CNS - she was conscious and alert
Plan: She was to start oral antibiotics, supp diclofenac and haematinics
Post-operative day 3
Patient had no complaints and was asymptomatic of anaemia.
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On examination, she was pale, not jaundiced, afebrile, anicteric, hydration was
satisfactory, no pedal oedema. She was conscious and alert. Her pulse was 74 bpm.
Blood pressure was 100/68mmHg. 1st and 2nd heart sounds were present and
normal.
Abdomen was full, soft, moved with respiration, mild tenderness at incision site.
Wound dressing was clean and dry. CNS - she was conscious and alert.
FBC Results- WBC - 5.08× 109/l, HB - 8.3g/dl, PLT - 192× 109/l
Plan: To continue medications, prepare for possible discharge after reviewing FBC results.
CRITICAL APPRAISAL:
The case was managed well and the patient was satisfied with treatment.
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FAMILY PLANNING
Name: B. K.
Age: 47
Last Menstrual Period: could not remember
Parity: P3+1(SA)
Date: 15th July, 2022
HISTORY:
Presenting Complaint:
Intrauterine contraceptive device (IUCD) removal and reinsertion on account of due date
History of Presenting Complaint:
Client had an IUD inserted in 2012 September (10 years ago) after giving birth to her third
child. She opted for Depo-Provera in 27/01/2010 but changed to IUD due to the adverse side
effects she experienced (headaches and generally feeling unwell). The IUD was inserted on
21/04/10 but removed a month later because she wanted to conceive. She then got CuT380A
inserted on 4/09/12 after giving birth to her third child and has had it till date. She presented
today to have it removed and a new one reinserted.
On Direct Questioning: She had no lower abdominal pain, no vaginal discharge, had not
experienced any cramping during menstruation or heavy and longer bleeds. She has not
gotten pregnant since she got the IUD inserted. There were no changes in her weight and she
had no headaches, dizziness or palpitations.
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Systemic Enquiry:
Nil of note
Gynaecological history:
Menstrual history: Menarche was at 19 years. She has a regular 28-day cycle with a flow
duration of 5 days with small clots. There is menorrhagia and she changes pads 2-3 times in a
day but no flooding. She has no dysmenorrhea and intermenstrual bleed.
Sexual history: Coitarche was at 22 and she has had 2 lifetime sexual partners. She has no
post coital bleed or dyspareunia and has not treated any STIs.
Contraceptives history: She used depo for 2 months and stopped due to side effects. She’s
currently using an IUD.
She has had no gynaecological surgeries. She had a pap smear done in the past and was told
results were normal. She has no history of STIs or vaginal discharge. She examines her
breasts occasionally but has never had a clinical breast exam. She took the HPV vaccine a
few years ago.
Obstetric history:
She is Para 3+1SA
1st pregnancy ended in April 2002. Pregnancy was planned and welcomed. She was a
regular antenatal attendant and antenatal period was uneventful. She gave birth to a
female baby at term by spontaneous vaginal delivery. She had postpartum
haemorrhage (PPH) which was managed at the hospital. Child is currently alive and
well
2nd pregnancy ended in August 2004 and she was a regular antenatal attendant,
antenatal pregnancy and puerperium period was uneventful. She gave birth to male
baby at term via spontaneous vaginal delivery. Child is currently alive and doing well.
3rd pregnancy ended in 2010. It ended in the first trimester via a spontaneous abortion.
She went to the hospital after and she had no post-abortion complications
29 | P a g e
4th pregnancy ended in March 2012. She was a regular antenatal attendant and was
diagnosed with hypertension in pregnancy in her third trimester. She gave birth to a
female baby via spontaneous vaginal delivery and she had PPH. Child is currently
alive and doing well.
Past Medical and Surgical History:
She is a known hypertensive of 10 years and compliant on medications. She has no diabetes,
sickle cell disease or asthma. She has had no admissions, no blood transfusions and no
surgeries
Drug history: Amlodipine and lisinopril 10mg daily routinely. She has taken herbal
medication in the past for malaria and for covid-19 prophylaxis. She is allergic to pepper and
there is no known drug allergies
Family history: Both parents are alive and well. Mother has hypertension and diabetes. She
is the 5th of thirteen siblings all of whom are alive and well.
Social history: Client is married and lives at Korle-bu with husband and three children. She
is a government worker and her highest level of education is tertiary. Her husband is a 56
year old lecturer. She neither smokes nor drinks alcohol. She accepts blood transfusions and
has an active NHIS.
Summary:
Madam B.K. is a 47-year-old P3+1SA who presented to the family planning unit with a request
for IUD removal and reinsertion on account of due date. She had menorrhagia but is
asymptomatic for anaemia. She experienced no adverse effects and was satisfied with the use
of the IUD as a method of contraceptive. She is a hypertensive of 10 years, is compliant on
medication and has a past history of postpartum haemorrhage.
General examination: I examined a middle-aged woman who looked well, not in any
obvious respiratory distress, there was no pallor or jaundice and she was afebrile. Oral
30 | P a g e
hygiene and hydration was satisfactory. There was no cervical lymphadenopathy and no
anterior neck swelling.
Her weight was 89kg, height 165.4cm BMI – 32kgm-2
Cardiovascular examination: Her pulse was 82bpm was regular, good volume, non-
collapsing and arterial wall not palpable. Blood Pressure was 134/92mmHg. Apex beat was
in the left 5th intercostal space midclavicular line. Heart sounds 1 and 2 were present and
normal, and there were no murmurs and no added sounds.
Respiratory: Her respiratory rate was 20 cycles per minute, air entry was adequate
bilaterally in all lung zones. Breath sounds were vesicular with no added sounds
Abdomen: Abdomen was full, moved with respiration, no scars or scarifications marks,
umbilicus was inverted and there was normal female pattern hair distribution. There was no
tenderness or masses felt. The liver and spleen were not palpable and the two kidneys not bi-
manually ballotable. There was no shifting dullness. Bowel sounds were present and normal.
Pelvic: There were normal findings on examination of the pelvis.
Pre procedure:
The patient’s vitals, height and weight were checked. She was asked about the last time she
has sexual intercourse, her last menstrual period and if she has any symptoms of pregnancy.
Counselling:
She was counselled on the removal process and what to expect as well as the reinsertion
process.
Procedure:
The no touch technique was used.
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The necessary equipment was acquired and a trolley set up. A bimanual exam was performed
to determine the position of the uterus. The uterus was retroverted. A vaginal speculum was
passed and the cervical os was cleaned with poverdine. The ends of the string was grasped
with an artery forceps and the woman was asked to cough, with each cough, the IUD was
pulled out with controlled traction. Next, the os was cleaned again and a tenaculum was used
to hold the cervix at the 11 and 1 o’clock positions. A uterine sound was passed to determine
the length of the uterus (which was 8cm). The no touch technique was used to load the IUD
CuT380A into the insertion tube and the flange was put at the 8cm mark. The loaded
insertion tube was passed into the cervical os and the IUD released into the uterus. The
cervical os was cleaned again and the tenaculum and speculum removed and put in a sterile
solution. The ends of the string was pushed back into the vaginal canal.
Post Procedure:
A review date was booked in 6 weeks and the woman was counselled on possible pain, how
to feel for the strings and to report to the clinic if she has any complications like vaginal
discharge, excess bleeding, severe abdominal pain, expulsion of the IUD or missing strings
and infection prevention.
CRITICAL APPRAISAL:
The client after using the IUD in the past had a good knowledge and was well informed
before reporting which facilitated the clerking and counselling of the patient. The client was
satisfied with her management.
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MANUAL VACUUM ASPIRATION
Name: Madam G. H.
Case Number: AAX6338
Age: 22 years
Last Menstrual Period: 7th April, 2022
Parity: G2P0+1 TOF
Date of Admission: 12th July, 2022
Date of Discharge: 12th July, 2022
HISTORY:
Presenting complaint:
Bleeding per vaginum of 2 weeks duration.
History of presenting complaint:
Patient was 12 weeks pregnant and was in her usual state of health until she started bleeding
per vaginum 2 weeks prior to presentation after carrying a heavy bucket of water which she
used to wash. The blood was scanty and dark red in colour with clots about the size of a 10
pesewa coin. The number of sanitary pads she used were two and neither of the two pads
were soaked. The bleeding was associated with lower abdominal pain which also started on
33 | P a g e
the day she bled. The pain was constant, non-radiating, stabbing in nature and had no
exacerbating or relieving factors. She rated the pain as 6 out of 10. Patient therefore reported
to the Kasoa Polyclinic that same day where she had a scan done and was told the baby was
well. However, the bleeding still persisted so she reported to the Kaneshie Polyclinic a week
after where she was examined and had another scan done. She was told the baby had died.
She was therefore referred to Korle-bu Teaching Hospital Gynae Emergency on account of
absent fetal heart rate. She had some scans and laboratory investigations done and was
scheduled for a Manual Vacuum Aspiration the same day. She was admitted at Chenard A to
await the procedure.
On direct questioning:
She had fever, no chills, no rigors or malaise. There was dizziness, palpitations, headaches
and easy fatigability. She experienced creamish, offensive vaginal discharge which was still
present on the day of presentation.
Systemic Enquiry:
General- There was weight loss and anorexia
Cardiovascular - She had no chest pain, dyspnoea, orthopnoea or paroxysmal nocturnal

dyspnoea
Respiratory - She had no cough or dyspnoea.
Gastrointestinal - She had no dysphagia, odynophagia, haematochezia, diarrhoea,

constipation, jaundice
Genitourinary - She had no frequency, nocturia, dysuria, urgency or haematuria
Musculoskeletal - She had no joint pain, weakness or muscle pain.
Central Nervous System - She had no syncope, convulsions, blurred vision or hearing
difficulties.
Past medical history: She was not a known hypertensive or diabetic. She had no asthma or
sickle cell disease. She had no surgeries done and no previous admissions as well. She had no
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previous blood transfusions.
Drug history: Patient was on Tothema, Amoxciclav (1g bd) and Metronidazole (400mg tds)
She had no known allergies and had never used herbal medications.
Past gynaecological history:
Menstrual history: Menarche was at 11 years. She has a regular 30 day cycle, with an
average bleeding duration of 7 days. She changed her sanitary pads about twice a day and the
pads were usually soaked. She does not experience dysmenorrhea, intermenstrual bleeding
and does not pass any clots.
Sexual history: Coitarche was at 18 years. She has had 2 lifetime sexual partners. She had no
history of dyspareunia or post coital bleeding.
She had vaginal discharge. She had no history of any sexually transmitted disease and had no
gynaecological surgeries. She had never had a Pap smear done. She did not practice breast
self-examination and had never had a clinical breast examination performed by a health
professional. She used emergency contraceptives but her partner does not use any form of
contraception.
Past Obstetric History
G2P0+1TOP
st
1 Pregnancy:
It ended in 2021 in a termination of pregnancy in which she took some medications. She
could not remember the gestational age at which it was terminated or the medications she
took. She bled for about 7 days after which the bleeding stopped. She did not have any post-
abortal complications neither did she visit any health facility.
Index pregnancy:
It was planned and welcomed. She found out she was pregnant through a Urine pregnancy
test.
35 | P a g e
Family history: Patient’s mother is alive and well. Patient’s father is deceased. There is no
known family history of hypertension, diabetes, sickle cell disease or asthma. There was a
family history of twin gestation.
Social history: Patient is unmarried. She lives at Kasoa. She does not take in alcohol or
smoke. She has an active NHIS card. She accepts blood transfusion.
Summary:
Madam G. H, a 22 year old, G2P0 +1TOP who was 12 weeks pregnant. She presented with a 2
weeks history of vaginal bleeding and lower abdominal pain. She was symptomatic of
anaemia. She also had creamish, foul smelling vaginal discharge and was scheduled for an
MVA.
I examined a young woman who looked well and not in any obvious respiratory distress.
There was no pallor. She was not cyanosed or jaundiced and oral hydration and hygiene were
o
satisfactory. She was afebrile (36.8 C) and she had no finger clubbing, neck masses,
peripheral lymphadenopathy or pedal oedema. She is 154cm tall and weighed 46.1kg giving a
BMI of 19.45kg/m2 indicating that she is of normal weight.
Cardiovascular System:
Her pulse was 96bpm, regular, of good volume and non-collapsing. The arterial walls were
not palpable. The blood pressure was 107/80 mmHg. The apex beat was in the 5th left
intercostal space mid clavicular line. Heart sounds S1 and S2 were present with no murmurs
or added sounds.
Respiratory System:
Her chest moved with respiration and respiratory rate was 26 cycles per minute. The trachea
was central. She had no areas of tenderness on the chest. Breath sounds were vesicular with
36 | P a g e
no added sounds or crepitation at lung bases.
Breast:
Both breasts were symmetrical with everted nipples. There were no skin changes, ulcers or
nodules. There were no masses palpable. There was no nipple discharge.
Abdomen:
The abdomen was full and moved with respiration, the umbilicus was everted, and there was
no linea nigra. She had no scars or scarification marks. She had normal female hair
distribution. On light palpation, there was tenderness in the left iliac fossa. No masses were
palpated. On deep palpation, the spleen, liver and both kidneys were not palpable. On
auscultation, bowel sounds were present and normal in frequency and intensity.
Vaginal Examination:
On inspection, there was creamish, offensive vaginal discharge in the vulval area. The vulva
looked normal. The Bartholin’s and Skene’s glands were not palpable. The vagina and
cervical areas looked healthy. The cervical os was closed. There was creamish, offensive
discharge and bleeding from the cervix as well.
On bimanual palpation, the cervix was firm in consistency and there was no cervical motion
tenderness. Uterine size was about 12 weeks. There was no adnexal masses or fullness.
Investigations:
Urine pregnancy test - Positive
FBC: Hb – 8.2 g/dl
Ultrasound scan findings (12/07/12):
Scan showed a singleton pregnancy with absent fetal cardiac activity. The crown rump length
was 59mm and gestational age was 12 weeks and 5 days. The amniotic fluid volume was
adequate.
Diagnosis:
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Patient was diagnosed as having a missed abortion.
Pre-operative Management:
Patient was given sublingual tablet Misoprostol 400mcg to abort products of conception.
Procedure:
Patient was first made comfortable in a lithotomy position. The vulva was cleaned and a
Cusco’s speculum passed. The cervix and vagina were disinfected with 10% povidone-iodine
solution. The anterior lip of the cervix was held with a tenaculum and gentle traction applied
to the cervix in order to see the transition between the cervix and the vaginal wall. A
paracervical block was given at three sites around the cervix (2, 8 and 12 o'clock sites) using
rd
2ml of 1% lidocaine. The procedure was done using a 3 generation IPAS MVA aspirator
kit. A size 8 cannula, was used for the procedure together with a manual vacuum. In a
rotating manner, the cannula was slowly and cautiously inserted through the cervical os into
the uterine cavity until it touched the fundus. The contents were aspirated with the charged
manual vacuum syringe. The syringe was disconnected from the cannula when full and
contents emptied. The vacuum was re-established and the syringe reconnected to the cannula
for continuation of the procedure. The uterine contents were emptied. An empty uterus was
indicated by a foamy, reddish-pink aspirate and a gritty feeling upon insertion of the cannula.
The cervix and vagina were cleaned and a pad applied to the vulva. She was sent to the
recovery area on the ward.
Findings:
The cervix was less than 1cm dilated. Uterine size was about 10 week size. 50ml of products
of conception were evacuated. Estimated blood loss was about 100ml.
Post-op Management:
After the procedure, the patient was taken to a recovery area on the ward. She was then
counselled to also avoid sexual intercourse for at least one week and to use condoms when
she wants to have sexual intercourse. She was also advised to report to the hospital if she
experienced bleeding for more than two weeks and absence of her menstrual period for more
than six months. She was then discharged the same day on the following medications:
38 | P a g e
TAB METRONIDAZOLE 400mg TDS7/7
TAB AMOXCICLAV 1g BD 7/7
TOTHEMA 1 vial BD
SUPPOSITORY DICLOFENAC 100mg BD 5/7
Critical Appraisal:
Patient was well managed. The paracervical block worked effectively as patient was in very
minimal pain. Patient was satisfied with the care she received.
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OBSTETRIC CASES
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LABOUR CASE 1
NAME: Madam S. K.
AGE: 29
GRAVIDITY: G2 P1
EXPECTED DATE OF DELIVERY: 5th July, 2022.
GESTATIONAL AGE: 40 weeks, 3 days
HOSPITAL NUMBER: AAV7808
DATE OF ADMISSION: 4th July, 2022.
RESIDENCE: Santa Maria
OCCUPATION: Bank Teller
ANTENATAL INFORMATION
Patient was a regular antenatal clinic attendant. The pregnancy was planned and welcome.
Booking visit was in the eighth month. Blood, urine, stool were taken for laboratory
investigations and the results were normal but she had a partial G6PD defect.
She had 2 tetanus toxoid and 3 sulphadoxine-pyrimethamine doses.
She received antenatal education on danger signs of pregnancy, birth preparedness and how
to breastfeed.
LABOUR
Patient presented with lower abdominal pains and passage of show.
On examination, she looked well and was not pale. She was afebrile (36.1oC) and anicteric.
Her hydration was satisfactory. Her pulse was 94 beats per minute, regular and of good
volume. Her blood pressure was 130/70mmHg.
The abdomen was symmetrically enlarged and moved with respiration. There was no
tenderness. The liver, spleen and kidneys were not palpable. The symphysiofundal height was
41 | P a g e
39cm. The lie was longitudinal and descent was 3/5. The fetal heart rate was 132 beats per
minute.
DETAILS OF LABOUR
Patient was admitted to labour ward on account of latent phase of labour with temperature of
36.4 degrees Celsius and a pulse rate of 82 beats per minute, regular and of good volume.
1ST STAGE:
She was admitted to labour ward 2 at 2:00pm on 4th July, 2022. She was 7cm dilated on
review at 7:50pm. The presentation was cephalic and the membranes were intact. She was
managed per partograph as attached below.
2ND STAGE:
Patient complained of bearing down and a vaginal examination confirmed full dilatation.
Patient was positioned and encouraged to bear down with contractions. An episiotomy was
done and a live female baby was delivered unto mother’s abdomen at 8:54pm. The birth
weight was 3.970kg was and apgar scores at 1 minute and 5 minutes were 7/10 and 9/10
respectively.
The estimated blood loss was 200ml.
3RD STAGE:
The third stage began at 8:55pm. 10 units of oxytocin was injected intramuscularly into the
patient’s thigh, a few minutes was allowed to pass till the uterus started contracting at which
point the placenta was delivered by controlled downward cord traction with counter pressure
to the uterus. The placenta was delivered at 8:59pm hence the third stage lasted a total of 5
minutes.
IMMEDIATE POSTPARTUM PERIOD:
Episiotomy was sutured under local anaesthesia. Mother was well and had no perineal trauma
or excess blood loss. She was not pale and was not jaundiced. Her hydration status was
42 | P a g e
satisfactory. The uterus was well contracted. Tab cytotec 600mcg was given sublingually to
mother. Both mother and baby were cleaned and kept warm in bed.
Her pulse rate was 78 beats per minute, regular and of good volume. Her blood pressure was
116/72mmHg and her temperature was 36.8 degrees Celsius.
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LABOUR CASE 2
NAME: Madam Y. Y.
AGE: 35
GRAVIDITY: G8 P4+3
EXPECTED DATE OF DELIVERY: 9th February, 2019.
GESTATIONAL AGE: 39 weeks, 3 days
HOSPITAL NUMBER: AAY 3999
DATE OF ADMISSION: 10th August, 2022.
RESIDENCE: Chorkor
OCCUPATION: Fishmonger
Patient was a regular antenatal clinic attendant at James Town Maternity Clinic. The
pregnancy was planned and welcome. Booking visit was in the fourth month. Blood, urine,
stool were taken for laboratory investigations and the results were normal.
She had 1 tetanus toxoid and 4 sulphadoxine-pyrimethamine doses.
to breastfeed.
LABOUR
Patient was referred from James Town Maternity Clinic on account of big abdomen in labour
at 39 weeks, 3 days gestation. Vitals done. On examination, she looked well and was not
pale. She was afebrile (36.0oC) and anicteric. Her hydration was satisfactory. Fetal Heart Rate
was 143bpm. Her pulse was 93 beats per minute, regular and of good volume. Her blood
pressure was 120/70mmHg. IV line was secured and blood samples were taken for Full
Blood Count and grouping and cross matching. Vaginal Examination was done, recorded and
she was sent to labour ward 1 for further management.
44 | P a g e
minute.
DETAILS OF LABOUR
Patient was admitted to labour ward 1 in the first stage of labour with temperature of 37.2
degrees Celsius, blood pressure 125/85mmHg and a pulse rate of 90 beats per minute, regular
and of good volume.
1ST STAGE:
She was admitted to labour ward 1 at 9:10am on 10th August, 2022. She was 6cm dilated.
The presentation was cephalic and the membranes were intact. She was managed per
partograph as attached below.
2ND STAGE:
Patient complained of having bearing down sensation and a vaginal examination was done to
confirm full dilatation. On examination, patient was fully dilated, decent was 0/5 and cervix
was fully effaced. Patient was positioned and encouraged to bear down with contractions and
rest in between contractions. A live male baby was delivered unto mother’s abdomen at
10:57am. 10 units of oxytocin was given on the thigh. The cord was cut and clamped. The
birth weight was 3.900kg and apgar scores at 1 minute and 5 minutes were 8/10 and 9/10
respectively.
3RD STAGE:
A few minutes after oxytocin was given, the placenta, lobes and membranes were delivered
by controlled downward cord traction with counter pressure to the uterus. Blood clots were
expelled. The placenta was delivered at 11:05am hence the third stage lasted a total of 8
minutes. Estimated blood loss was 200mls. 400mcg of cytotec was given rectally and 20units
of synto in 500mls of Ringers Lactate. Perineum was intact on inspection.
45 | P a g e
Condition of mother and baby was fair. Baby and mother were cleaned up and baby shown to
mother for identification. She was not pale and was not jaundiced. Her hydration status was
satisfactory. Her pulse rate was 88bpm, regular and of good volume. Her blood pressure was
122/78mmHg and her temperature was 36.1oC. Respiratory rate was 20cpm.
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LABOUR CASE 3
NAME: Madam J. A.
AGE: 39
GRAVIDITY: G6 P2+3TOP
EXPECTED DATE OF DELIVERY: 21/8/2022
GESTATIONAL AGE: 41 weeks, 1 day
HOSPITAL NUMBER: AAU 7750
DATE OF ADMISSION: 10th August, 2022
Patient was a regular antenatal clinic attendant. The pregnancy was unplanned but welcome.
Booking visit was in the third month. Blood, urine, stool were taken for laboratory
investigations and the results were normal. She has been treated for anaemia once.
Quickening was at 4 months. She had 1 tetanus toxoid and 3 sulphadoxine-pyrimethamine

doses.
to breastfeed.
LABOUR
Patient was G6P2+3TOP, was admitted on 10th August, 2022 at 41 weeks one day gestation on
account of complaints of lower abdominal pains. She was put in bed and examined. On
examination, she looked well and was not pale. She was afebrile and anicteric. Her hydration
was satisfactory. Her pulse was 84 beats per minute, regular and of good volume. Her blood
pressure was 130/90mmHg.
47 | P a g e
minute.
DETAILS OF LABOUR
Patient was admitted to labour ward 2 in the first stage of labour with blood pressure of
135/90 temperature of 35.0oC and a pulse rate of 96 beats per minute, regular and of good
volume.
1ST STAGE:
She was admitted to labour ward 2 at 8:40am on 10th August, 2022. She was 8cm dilated.
The presentation was cephalic and the membranes were intact. She was managed per
partograph as attached below.
2ND STAGE:
Patient complained of bearing down sensation and a vaginal examination confirmed full
dilatation. Descent was 0/5. Patient was positioned and encouraged to bear down with
contractions and relax in between contractions. A live female baby was delivered at 11:23am.
The birth weight was 2.725kg was and apgar scores at 1 minute and 5 minutes were 7/10 and
8/10 respectively. Cord was clamped and sex shown to mother for identification. Skin to skin
was initiated,
3RD STAGE:
10 units of oxytocin was injected intramuscularly into the patient’s thigh, a few minutes was
allowed to pass till the uterus started contracting at which point the placenta was delivered by
controlled downward cord traction with counter pressure to the uterus. The placenta was
delivered at 7:50pm. 20iu of syntocinon in 500mls of normal saline was set up. The placental
membranes and lobes were intact.
48 | P a g e
Mother was well and had no perineal trauma or excess blood loss. She was not pale and was
not jaundiced. Her hydration status was satisfactory. The uterus was well contracted about 22
week size.
Her pulse rate was 90 beats per minute, regular and of good volume. Her blood pressure was
118/85mmHg and her temperature was 35.9 degrees Celsius. SPO2 was 98% and respiratory
rate was 21cpm.
49 | P a g e

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SCHOOL OF MEDICINE AND DENTISTRY

OBSTETRICS AND GYNAECOLOGY CASE BOOK

NAME: KYEKYE CEDRIC ETORNAM

YEAR: SECOND CLINICAL YEAR

TEAM: JUNIOR CLERKSHIP TEAM A

SENIOR CLERKSHIP TEAM B

A CASE OF OVARIAN CANCER………………………………………………… 3

A CASE OF ECTOPIC PREGNANCY……………………………………………. 19

A CASE OF FAMILY PLANNING………………………………………………... 28

A CASE OF MANUAL VACUUM ASPIRATION……………………………….. 33

SPONTANEOUS VAGINAL DELIVERY (Case 1)………………………………. 40

SPONTANEOUS VAGINAL DELIVERY (Case 2)………………………………. 43

SPONTANEOUS VAGINAL DELIVERY (Case 3)………………………………. 46

1. Abdominal distension – about a month duration

History of Presenting Complaints

Cardiovascular - She had no chest pain, dyspnoea, orthopnoea, paroxysmal nocturnal

Respiratory- She had no cough, dyspnoea, wheeze or running nose.

Gastrointestinal- She had no jaundice

Genitourinary -She had no dysuria or urgency.

Musculoskeletal- She had no joint pain, weakness or muscle pain.

Past Medical History

Past Obstetric History

 Blood Urea, Electrolyte and Creatinine (BUE & Cr)

 Abdomino-pelvic Ultrasound Scan:

2. Complex ovarian lesions with peritoneal and mesenteric lesions,

 IV Amoxiclav 1.2g bd × 24 hrs

 Tab Amoxiclav 625mg bd × 7 days

 IV Flagyl 500mg × 24 hrs

 Tab Flagyl 500mg tid × 7 days

 Supp diclofenac 100mg bd × 5 days

 Subcut Clexane 40mg daily × 3 after 12 hrs

 Tab Paracetamol 1g tid × 3 days

 IM Pethidine 100mg 6 hourly x 24 hours

OPERATION FINDINGS AND PROCEDURE

Past obstetric history: P2 (1D) +3TOP

IMPRESSION/ DIAGNOSIS: Secondary infertility

Registration No: AAX0100

Last menstrual period: 12th June, 2022

Date of Admission: 26th July, 2022

Date of Discharge: 28th July, 2022

Presenting Complaints: 1. bleeding per vaginum – 4 days duration.

2. Lower abdominal pain – 4 days duration.

History of Presenting Complaints:

General -She had no weight loss, no loss of appetite, rigors or malaise.

Cardiovascular - She had no chest pain, dyspnoea, orthopnoea or paroxysmal nocturnal

Respiratory- She had no cough, wheeze nor running nose.

Gastrointestinal- She had no diarrhea or costipation, no abdominal distension.

Musculoskeletal- She had no joint pain, weakness or muscle pain.

Central Nervous System:

Patient was conscious and alert

About 10mls of non-clotting blood was aspirated.

 Abdominopelvic Ultrasound Scan:

Cul-de-sac: Mild free fluid noted.

Impression: Ectopic pregnancy

PLT 147× 109/l

Ruptured ectopic pregnancy

 IV Amoxiclav 1.2g bd × 24 hrs

 IV Flagyl 500mg tds× 24 hrs

 IV Paracetamol 1g qid ×24 hrs

 Tab Paracetamol 1g tid × 3 days

 IM Pethidine 100mg tds

 IV Gelofusine 500mls stat

OPERATION FINDINGS AND PROCEDURE: