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F

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A CASE
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PRESENTATION
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Presented by:
I Cannu, Ma. Angelica Goldamier C.
A
F
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t
General Data
a GT
l 37 / Married
February 12, 1981
M
a Roman Catholic
c
San Pablo, Isabela
r
o
Date of Admission: March 14, 2018 1st
s hospitalization
o Date of Discharge: March 17, 2018
m
I  Presented by:
a  Cannu, Ma. Angelica Goldamier C.
F
e
t
Chief Complaint
a
l

M
a
c
r
o
s
o
m
I  Presented by:
a  Cannu, Ma. Angelica Goldamier C.
F
e History2 ½of Present
months prior to
Illness
t admission,
a Advised for
l ultrasound and give
birth at a hospital
due to large fundic
M height

a Prenatal check up -4x


No ultrasound done

c Few hours prior to


r admission,
Delfin albano
o Hospital
s
o
m
I  Presented by:
a  Cannu, Ma. Angelica Goldamier C.
F
e
t Past Medical History
a
l
(-)HTN
M (-)operations
(-) DM
a (-)hospital
c (-)TB
lization
r (-) Cancer
o
s
o
m
I  Presented by:
a  Cannu, Ma. Angelica Goldamier C.
F
e
t
Menstrual History
a 16
l Regular,
moderate
M flow
a 2 pads per
day in 5 Menstrual LMP:
c
r days History unknown
o
(-)
s
o
dysmen
m
orrhea
I  Presented by:
a  Cannu, Ma. Angelica Goldamier C.
F
e
t
Sexual History
a
l
18
M Sexual
a partner-2
exhubby Sexual
c (-)STD
r and History
present
o Pills
s from
o 2006-
m 2010
I  Presented by:
a  Cannu, Ma. Angelica Goldamier C.
F
e
t
Obstetrical History
a
l
1998 • 2000 • 2003
M G1 term G3
a
G2 • term • term
Home • home • home
c
r 206
o
s G4 term
o home Unknown weight
m
I  Presented by:
No complications
a  Cannu, Ma. Angelica Goldamier C.
F
e
t
Obstetrical History
a
l
• 2010 • 2011 • 2012
M G5• term G6 • term G7 • term
a • home • home • home
c
r 2015
o
s G8 term
o home Unknown weight
m
I  Presented by:
No complications
a  Cannu, Ma. Angelica Goldamier C.
F
e Obstetrical History
t
a
l • 2018
M G9 • term
a • CVMC
c
r
o
s G9 p9(9009) 4138g
o
m 38,37,34,56
I 4138 g, LGA at 40-41
a  Presented by: weeks Ballard Score
 Cannu, Ma. Angelica Goldamier C.
F
e Family History
t HTN
a DM
HTN
Asthma
l DM Heart disease
Cancer Cancer
M GIT GIT disorders
a disorders Endometriosis
c Dysmenorrhea
r
o
s HTN
o DM
m Cancer
GIT disorders
I Dysmenorrhea
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
F
e Personal and Social History
t
a
l
M
Non- gradeschool
a Non smoker
alcoholic graduate
housewife
c
r
o
s
o
m
I
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
F
e Review of Systems
t
(-)weight loss (-)conjunctivitis
a (-)weakness (-) tonsillitis
l (-)fatigue (-)ear pain
(-)ear discharges
(-)itching
M (-)rashes (-)hematuria
(-)paresthesia (-)dysuria
a (-)polyuria
c (-)hemoptysis (-)oliguria
r (-)dyspnea (-)edema
o (-)polydipsia (-)dyspareunia
s (-)polyphagia
o (-)constipation
(-)hematochezia (-)bleeding
m (-)diarrhea (-) easy bruising
I
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
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e Physical Examination
t
a
Pt is conscious, coherent, not in
l cardiorespiratory distress, large
built(endomorphic), looks tall, in
M pain
a
c
r 120/80, 36.5,20,85
o (-) cyanosis, (-) jaundice, (-) rashes,
s (-)pallor
o Good turgor,warm to touch
m
I
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
F
e Physical Examination
t
a normocephalic with normal
hair distribution, pink
l palpebral conjunctiva,
anicteric sclera, moist lips,
M (-) CLAD
a
c
r (-) scar, (-) intercostal
o retractions; symmetric Adynamic precordium,PMI at
s 5th ICS MCL, no apical
chest expansion, clear heave, no thrills, normal
o breath sounds rate and rhythm, no murmurs.
m
I
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
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e Physical Examination
t
a  MSE: Patient
l is oriented to
time, place
M and person.
a
c  Cerebellum- Globular, with linea nigra, fundic
height of 38cm, with fetal heart
r Patient has tones of 140’s
o no
Internal Examination: 9cm
s nystagmus dilated, 80% effaced, cephalic,
o intact bag of water, st -2
m
(-)deformities, (-)edema, full
I and equal pulses, no
a  Presented by: limitations in range of motion,
 Cannu, Ma. Angelica Goldamier C. CRT <2 sec
f
e Salient Features
t
a 37 / Married large built,
looks tall;
l G9 p9(9009) endomorphic
M
LMP:unknown
a Fundic height of 38cm
c
r Internal Examination: 9cm
o dilated, 80% effaced, cephalic,
s intact bag of water, st -2
4138 g, LGA at 40-
o 41 weeks Ballard
m Score
I 38,37,34,56
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
f
e ER level
t Problem Assessment Intervention
a MARCH 14 , 2018
8:55PM
G9 P8 (8008) Pregnancy
uterine, term by fundic
 NPO

 Dx:
l PR: 76 bpm
height, Cephalic In Labor,
fetal Macrosomia, CBC
RR: 18 cpm Elderly
Temp: 37.4C Grandmultigravida UA
M BP:120/90
BT
a
 Therapeutics
c
 PLRS 1L x 8 hours
r
Ampicillin- Sulbactam 1.5G/ IV
o Q 8 ( ) ANST
s
 For E 1 LSCS + TAH
o
 Hook to baseline EFM
m
 FHT q 15 min
I
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
f
e ER level
t
a HmG= 130 Urine color: straw
Htc=0.399 Transparency: clear
l
Platelet count = 348 pH: 6.5
M WBC count = 20.19 Specific gravity=1.005
a  Neutrophil=85.5 Protein: +
c  Lymphocyte=9 Glucose: -
r  Eosinophil=0.5 WBC: 57
o  Basophil=0.1 RBC:37
s
Epith cell: 17
o
Hyaline cast:0
m
I Bacteria:21
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
f
e OB ward Orders
t Problem Assessment Intervention
MARCH 15 , 2018 G9 P9 (9009) Pregnancy  General Liquid Diet except
a 7:10Am uterine, term, milk and carbonated drinks
then soft diet once with
Cephalic,delivered,
l PR: 87 bpm
RR: 18 cpm
Elderly Grandmultiparida flatus
 Therapeutics
Temp: 37.1C  D5LRS 1L x KVO
Continue Ampicillin-
M BP:100/60 Emergency Primary Low
Segment Section for Fetal Sulbactam 1.5G/ IV Q 8 for 2
a 1st Post op Day Macrosomia followed by more doses then shift to
(-)flatus Total Abdominal Ampicillin- Sulbactam
c (-)bowel movement Hysterectomy under 750mg/tab; 1 tab TID x 7 days
r Spinal Anesthesia to a live
Start 1. Mefenamic Acid
Symmetric chest baby boy
o expansion, clear breath 500mg/tab, 1 tab TID
2. Ascorbic Acid 500mg/tab 1
s sounds
Adynamic precordium
Bw: 4138g, LGA, AS;8/9;
BS-40-41 weeks; tab OD x 30 days
o normal rate and rhythm 3. Ferrous fumarate + Vitamin
Flabby, nabs, soft, non- Fetal Macrosomia B complex/tab, 1 tab Bid x 30
m tender days
 Encourage ambulation
I  May pull out IFCFHT q 15
a  Presented by: min
 Cannu, Ma. Angelica Goldamier C.
f
e OB ward Orders
t Problem Assessment Intervention

a MARCH 16 , 2018 G9 P9 (9009) Pregnancy DAT
6:30Am uterine, term,  For repeat CBC now
 Therapeutics
l PR: 87 bpm
Cephalic,delivered,
Elderly Grandmultiparida  Discontinue IVF once
RR: 18 cpm CBC is okay
Temp: 37.1C Continue oral meds
M BP:120/80 Emergency Primary Low Open wound care
Segment Section for Fetal
a 2nd Post op Day Macrosomia followed by
c (+)flatus
(+)bowel movement
Total Abdominal
Hysterectomy under
r Spinal Anesthesia to a live
Symmetric chest baby boy
o expansion, clear breath
s sounds Bw: 4138g, LGA, AS;8/9;
Adynamic precordium, BS-40-41 weeks;
o normal rate and rhythn
m Dry and well coaptated
wound
Fetal Macrosomia

I Intact vaginal stump


a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
f
e CBC 2nd Post operative Day
t
HmG= 111
a
Htc=0.34
l Platelet count = 320
M WBC count = 20.32
a  Neutrophil=85.5
c  Lymphocyte=9
r  Eosinophil=0.5
o  Basophil=0.1
s
o
m
I
a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
f
e OB ward Orders
t Problem Assessment Intervention

a MARCH 17 , 2018 G9 P9 (9009) Pregnancy MGH
6:50Am uterine, term,  Continue oral meds
 Daily wound care
l PR: 85 bpm
Cephalic,delivered,
Elderly Grandmultiparida  OPD follow up
RR: 19 cpm
Temp: 36.8 C
M BP:120/80 Emergency Primary Low
Segment Section for Fetal
a 3nd Post op Day Macrosomia followed by
c (+)flatus
(+)bowel movement
Total Abdominal
Hysterectomy under
r Spinal Anesthesia to a live
Symmetric chest baby boy
o expansion, clear breath
s sounds Bw: 4138g, LGA, AS;8/9;
Adynamic prexordium, BS-40-41 weeks;
o normal rate and rhythn
m Dry and well coaptated
wound
Fetal Macrosomia

I Intact vaginal stump


a  Presented by:
 Cannu, Ma. Angelica Goldamier C.
F
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A Definition Epidemiology Risk Factors
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Diagnosis Management Complications
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S William’s Obstetrics and Gynecology 23rd edition
http://www.thefilipinodoctor.com/cpm_pdf/CPM5th%20Maternal%20He
O alth%20(Diabetes%20Mellitus).pdf
M https://emedicine.medscape.com/article/262679-overview#a4
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
F
E Definition
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O >4500g at
S
O
birth (ACOG)
4138 g, LGA at 40-
M 41 weeks Ballard >4000g at
I Presented by: Score
A
birth
Cannu, Ma. Angelica Goldamier C.
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E Epidemiology
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A
L 16-45 % of all pregnancies

M
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C
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I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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E Risk factors
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A
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M
A
C
R Diabetes- GDM and Type II
O Race and ethnic
S factors
O Male gender
M genetics
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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E Diagnosis
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A
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M
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O Adam 12
S
Biomarkers PA-PPA
O
M PP 13
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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Management
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T
A Prophylactic Labor Induction Elective Ceasarean Delivery
-in DM mothers with
L -to obviate further fetal growth macrosomic fetuses with EFW
and reduce potential delivery of >4500g
M complications -in non DM mothers with EFW
-ACOG does not support early of -5000g
A induction -decrease shoulder dystocia
C
R
O
S
O
M
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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E Complications
T
A Cesarean delivery or
L assisted delivery

M
A Birth canal lacerations
C
R
O Uterine atony
S
O Prolonged 1st nd 2nd stage of
M labor
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
F
E Complications
T
A
L
M
A
C
R Shoulder Brachial
O dystocia palsy
S
O
M
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
F
E Complications
T
A
L
M
A
C
R Shoulder Brachial
O dystocia palsy
S
O
M
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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E Complications
T
A
L
M
A
Mazzanti Mc Robert’s
C episiotomy
R manuever manuever
O
S
O
M
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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E Complications
T
A
L
M
A
C Rubin’s Wood Corkscrew
R manuever manuever
O
S
O
M
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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E Complications
T
A
L
M
A
C cleidotomy Zavanelli symphysiotomy
R
O
S
O
M
I Presented by:
A Cannu, Ma. Angelica Goldamier C.
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I Presented by:
A Cannu, Ma. Angelica Goldamier C.