Dr. Atia AfreenDGO Student

Mymensingh Medical College

A 35 years lady presented with 12 weeks amenorrhoea with per vaginal bleeding.

Name: Mrs. YasminName: Mrs. Yasmin

Age: 35 yearsAge: 35 years

Religion: IslamReligion: Islam

Occupation: House WifeOccupation: House Wife

Address: Bank Colony, Jamalpur.Address: Bank Colony, Jamalpur.

Date of admission: 12Date of admission: 12thth March 2012 March 2012

Date of examination: 12Date of examination: 12thth March 2012 March 2012

Particulars of the Patient

Pregnancy for 12 weeks.

Per vaginal bleeding for one

day

Mild lower abdominal pain

for 12 hours.

History of present illness

According to the patient’s statement, she was reasonably allright 12 weeks back. Then she became pregnant with the usual sign symptoms of pregnancy. She had no h/o antenatal check up. About one day prior to her admission she noticed sudden onset of per vaginal bleeding. At first bleeding was scanty in amount which was increasing gradually & was aggravated by minor stress like defaecation & diminished by rest.

She also complained of mild lower abdominal pain which was intermittent and radiating towards the back. Pain was not associated with nausea & vomiting. Her bowel & bladder habit was normal. With the above mentioned complaints she was admitted in this hospital for proper management.

History of present illness…….

History of past illnessHistory of past illness

She had no history of D.M., HTN, Tuberculosis, & other medical diseases.

She had undergone LUCS for three times. The last LUCS was performed on February,2008.

She had no history of D.M., HTN, Tuberculosis, & other medical diseases.

She had undergone LUCS for three times. The last LUCS was performed on February,2008.

Personal History: Nothing contributory

Family History: Nothing contributory

Socio-economic History: Belongs to middle class family.

Immunization History: She is immunized

against Tetanus & Hepatitis B virus as

per schedule.

Drug History: Nothing contributory.

Contraceptive History: Couple practiced

barrier

method .

Immunization History: She is immunized

against Tetanus & Hepatitis B virus as

per schedule.

Drug History: Nothing contributory.

Contraceptive History: Couple practiced

barrier

method .

Menstrual History

• Menarche: at the age of 13 years• Menstrual period: 3-5 days• Menstrual cycle:28±2 days • Menstrual flow: averege• LMP:10/12/2011• EDD: 17/09/2012

Obstetrical HistoryObstetrical History

Married forMarried for : 16 years: 16 years GravidaGravida : 4th: 4th ParaPara : 3(LUCS)+0: 3(LUCS)+0 StillbirthStillbirth : 1: 1 ALCALC : 4 years: 4 years

General Physical Examination

Appearance: AnxiousBody built: AverageDicubitus: On choiceWeight: 60 kgHeight:5 ft 3 inchesPulse: 90 beats/min Blood pressure: 100/70 mm of HgRespiratory rate:18/min

General Physical Examination….

Temperature: 36.5 ⁰ cAnaemia/ Pallor:mildJaundice: absentCyanosis:absent Oedema:absent Dehydration-nilLymphnode: not palpableThyroid gland: not enlarged

Systemic ExaminationSystemic Examination

Cardiovascular system : NADRespiratory system : NADAlimentary system : NADNervous System : NAD

PER ABDOMINAL EXAMINATIONPER ABDOMINAL EXAMINATION

Inspection:

Umbilicus was centrally placed & inverted. A transverse scar measuring about 4” was present 1” above the symphysis pubis.

Palpation:

Abdomen was soft and non tender. Fundal height-not palpable

Percussion: not done. Auscultation: Bowel sound present

Inspection:

Umbilicus was centrally placed & inverted. A transverse scar measuring about 4” was present 1” above the symphysis pubis.

Palpation:

Abdomen was soft and non tender. Fundal height-not palpable

Percussion: not done. Auscultation: Bowel sound present

Pelvic ExaminationPelvic Examination

o Inspection:Vulva and vagina :Looks apparently healthy.

P/V bleeding-presento Per Speculum Examination: Cervix was broad,bluish

in colour. Fresh blood comes out from os.o Bimanual Examination: Cervix was soft, broad,distended & the uterus was

about 12 weeks of size.OS was closed. Fornices were not tender & had no adenexal masses.

o Inspection:Vulva and vagina :Looks apparently healthy.

P/V bleeding-presento Per Speculum Examination: Cervix was broad,bluish

in colour. Fresh blood comes out from os.o Bimanual Examination: Cervix was soft, broad,distended & the uterus was

about 12 weeks of size.OS was closed. Fornices were not tender & had no adenexal masses.

SALIENT FEATURESSALIENT FEATURES

Mrs. Yasmin 35 years old, housewife , 4th gravida with h/o three LUCS at term was admitted on 12th March 2012 at her 12 weeks of pregnancy with the complaint of per vaginal bleeding for the past one day associated with mild lower abdominal pain which was intermittent in nature. She seeks medical advice as per vaginal bleeding was gradually increasing.

Mrs. Yasmin 35 years old, housewife , 4th gravida with h/o three LUCS at term was admitted on 12th March 2012 at her 12 weeks of pregnancy with the complaint of per vaginal bleeding for the past one day associated with mild lower abdominal pain which was intermittent in nature. She seeks medical advice as per vaginal bleeding was gradually increasing.

SALIENT FEATURES…..SALIENT FEATURES…..

Her medical history was unremarkable, with no previous h/o pelvic inflammatory disease, or insertion of intrauterine devices. She practiced barrier method for contraception. Her menstrual cycle was regular with average flow. On examination the patient was found anxious, mildly anaemic, non icteric & non oedematous. Her blood pressure was 100/70 mm of Hg, pulse-90 beats/min.

Her medical history was unremarkable, with no previous h/o pelvic inflammatory disease, or insertion of intrauterine devices. She practiced barrier method for contraception. Her menstrual cycle was regular with average flow. On examination the patient was found anxious, mildly anaemic, non icteric & non oedematous. Her blood pressure was 100/70 mm of Hg, pulse-90 beats/min.

SALIENT FEATURES…..SALIENT FEATURES…..

The abdomen was soft & no evidence of tenderness, guarding and rigidity. Pelvic examination revealed vulva &vagina apparently healthy, Cervix was soft, broad & distended & the size of uterus was about 12 weeks . Os was closed with fresh bleeding escaping through os. No fornicial tenderness & had no adnexal masses.

The abdomen was soft & no evidence of tenderness, guarding and rigidity. Pelvic examination revealed vulva &vagina apparently healthy, Cervix was soft, broad & distended & the size of uterus was about 12 weeks . Os was closed with fresh bleeding escaping through os. No fornicial tenderness & had no adnexal masses.

Clinical Diagnosis

4th gravida with threatened abortion with previous h/o three

c/s

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Cervical ectopic pregnancy Pregnancy with cervical fibroid Molar pregnancy.

Cervical ectopic pregnancy Pregnancy with cervical fibroid Molar pregnancy.

InvestigationsInvestigations

GeneralBlood for Hb: 9.8 gm/dlRandom blood sugar: 5.7 mmol/L Blood grouping & Rh typing: B positiveVDRL Test: Non reactiveUrine R/M/E: Sugar-nil Pus cell-1-2/HPF

Albumin-nil

RBC-nil

GeneralBlood for Hb: 9.8 gm/dlRandom blood sugar: 5.7 mmol/L Blood grouping & Rh typing: B positiveVDRL Test: Non reactiveUrine R/M/E: Sugar-nil Pus cell-1-2/HPF

Albumin-nil

RBC-nil

Investigations……Investigations……

Specific Ultrasonogram of lower abdomen-12+1

weeks of gestational age of cervical pregnancy with empty uterine cavity.

Serum beta HCG- 20,000 IU/L

Specific Ultrasonogram of lower abdomen-12+1

weeks of gestational age of cervical pregnancy with empty uterine cavity.

Serum beta HCG- 20,000 IU/L

Confirmed diagnosisConfirmed diagnosis

4th gravida with 12 weeks cervical ectopic pregnancy with previous h/o three c/s.

4th gravida with 12 weeks cervical ectopic pregnancy with previous h/o three c/s.

Management

AIM- Termination of pregnancy

Management…

Definitive management- Termination of pregnancy was done by

dilatation,evacuation & currettage under general anaesthesia. Curettage revealed products of conception from the distended cervical canal. The amount of product curetted out corresponded to about 12 weeks of pregnancy.

Management………

Profuse haemorrhage continued despite of curettage and pressure, the cervix appeared like a elongated flabby loose fold of tissue. Foley’s catheter tamponade was attempted, failing which exploratory laparotomy with total abdominal hysterectomy was performed to save the life of patient. Patient was taransfused 3 units of blood peroperatively.

Management………

After hysterectomy specimen was sent for histopathological examination.

Management………

Her post operative period was uneventful and she recovered well.