Obstetrics Case Protocol Block G: Calma, Capili, Coruna, Dagang, Datukon, Dayrit, de Castro, de la Llana, Gayeta, Golepang

General Data ST 29 year old primigravid Married Roman Catholic from Las Pinas,

Reason for Consult For prenatal checkup

Past Medical History unremarkable

Family Medical History unremarkable

Personal/Social/Sexual History no vices college undergraduate first coitus was at 28 years old with one non promiscuous sexual partner no history of use of OCPs, IUD, condoms, or any forms of contraception

Menstrual History Menarche at 15 years old regular intervals, 4-5 days, 3-4 pads per day no dysmenorrhea nor intermenstrual bleeding LNMP: July 15, 2009 PMP: June 2009 AOG: 30 1/7 weeks by amenorrhea

Obstetric History G1P0

History of Present Illness 6 months PTC: (+) note of missed menses  consult with a private physician where a PT was done and was (+) Pt asked to follow-up after 1 month

History of Present Illness 5 months PTC: sudden onset hypogastric pain, “humihilab”, VAS 5/10, nonradiating. no vaginal bleeding , watery vaginal discharge, fever or dysuria. Consulted a local hopital where an UTZ was done: SLIUP, cephalic with AOG of 15 weeks and 5 days, normohydramnios, large IM and SS myoma in the lower anterior uterine segment more to the left side.

History of Present Illness Due to unavailability of an obstetrician, pt was referred to a LH in Cavite for further management Pt was admitted for 5 days, given unrecalled antibiotics, and was sent home THM: Isoxilan 1 tab q6, Amoxicillin 500 mg/cap 1 cap TID x 5 days, Flagystatin suppository per vagina during bedtime x 4 days.

History of Present Illness Pt continued to have her prenatal checkups with a private obstetrician. Plan was for CS however, due to financial constraints, pt transferred to our institution for further management.

Review of Systems (-) weight loss, anorexia, fever, blurring of vision, headache, vomiting, abdominal pain, watery or bloody vaginal discharge, dysuria, edema, decreased fetal movement.

Physical Examination awake, conscious, coherent, NICRD BP 110/70, HR 80, RR 18, afebrile anicteric sclera, pink conjunctivae, (-) cervical lymphadenopathy, (-) tonsillopharyngeal congestion, (-) anterior neck mass equal chest expansion, clear breath sounds, (-) rales/wheezes (-) thrills or heaves, distinct heart sounds, normal rate regular rhythm, (-) murmurs.

Physical Examination Abdomen: globular, NABS, (+) 10 x 11 cm mass at the left lower quadrant, firm, movable and slightly tender FH 37 cm, EFW 2.6-2.8 kg, FHT 130s, RLQ, cephalic presentation IE: NEG, smooth nulliparous vagina, cervix was soft, smooth, (-) AMT FEP, PNB, (-) cyanosis, (-) edema.

Assessment PU 36 2/7 weeks AOG EUTZ, CIPTL, Myoma uteri G1 P0.

Plan Pt was sent to OBAS immediately due to preterm labor.

Ultrasonography TV and AP UTZ (09/20/2010) Transvaginal and abdominopelvic ultrasound were done. Within the gravid uterus is a single live fetus in variable presentation. BPD measures 15 cm compatible with 15 weeks and 5 days. HC measures 11.9 cm compatible with 16 weeks and 0 days. AC measures 9.8 cm compatible with 15 weeks and 6 days. FL measures 1.7 cm compatible with 15 weeks and 2 days. There is good cardiac activity with FHR = 158 bpm. The amount of amniotic fluid appropriate for AOG. The immature placenta is posterior in location. EFBW = 130g. There is a huge well rounded heterogenous solid mass located in the lower anterior uterine segment left side of the uterus measuring 8.9 x 7.6 x 8.4 cm suggestive of myoma.

Ultrasonography Impression: Single, live intrauterine pregnancy, cephalic with AOG of 15 weeks and 5 days. Normohydramnios. Large intramural and subserous myoma in the lower anterior uterine segment more to the left side.

Ultrasonography Fetal and Obstetrical Sonography (12/02/2009) Number of fetus: single Lie: Vertical breech Somatic movement: active Amniotic fluid: Anechoic normohydramnios Placental location: Posterior grade0 Fetal HR: 134 bpm Estimated fetal weight: 1030 g Fetal sex: Male

ULtrasonography Biometry BPD 66 mm 27 weeks FL 49 mm 26 weeks HC 240 mm 26 weeks AC 219 mm 26 weeks Estimated AOG: 26 weeks and 2 days EDC: March 8, 2010

Ultrasonography Impression: Within the gravid uterus is a sinle livefetus breech at present with estimated AOG of 26 weeks and 2 days by biometry. The fetus is active with good cardiac pulsation and normal amniotic fluid. Placenta is located posterior, high lying, with grade 0. No gross fetal anomaly. Note of left lateral wall myoma measuring 6.8 x 8 cm.

Guide Questions What are Uterine Myomas? What are the different types? What is the pathophysiology of the development of myomas? What are the forms of myoma degeneration? Differentiate each. What are the effects of myomas in pregnancy? What are the effects of pregnancy on myomas?

Guide Questions How should we work-up the patient? How do we manage our patient? What is the ideal management of myomas during pregnancy? Include medical and surgical management.