Introduction
Mrs N is a 20
years old housekeeper, primigravida at 6 weeks of gestation admitted for per
vaginal bleeding for the past 1 day.
Menstrual
History
She attained menarche 14 years old. Her
cycle is irregular every 22-28 days lasted for not more than 3 days flow.
She does not experience dysmenorrhea,
menorrhagia, intermenstrual bleeding, dyspareunia or post coital bleeding.
Her first day of menstrual period is 28/06/2017.
She is unsure about her revised expected
delivery date (REDD).
History
of Presenting Illness
Patient was not known of underlying
long-standing medical illness and never admitted to ward.
3 days prior to admission, she had 2
episodes of bleeding.
She used 1 pad each day and both episode
was full pad bleeding. The colour was bright red and was not associated with
pain. The bleeding started in the morning and for the 2 days, the bleeding
started again. There was no blood clot and no product of conception. There was
no mucus or vaginal discharge. There was no foul smelling. There was no trauma.
There was no fever and dysuria.
On 11/9/17, she walked in to Patient
Assessment Centre (PAC) at Hospital Kuala Lumpur(HKL). At PAC, ultrasound was
done. The doctor said, there was unknown location of placenta in her uterus.
History
of Present Pregnancy/Antenatal History
This is unplanned pregnancy but
welcomed.
She confirmed her pregnancy by doing
urine pregnancy test (UPT) at Klinik Kesihatan Desa Pandan on 9/9/2017 which
was 4 days ago.
She did not book yet.
Past
Gynaecology History
She has never done any pap smear.
Never undergo operation before such as
myomectomy or D&C.
No previous gynaecology history such as
fibroid, cyst, pelvic inflammatory disease or endometrioma.
Past
Medical History
She has never been warded before due to
any medical illness.
She does not have diabetes, hypertension,
renal disease, cardiovascular disease, thyroid disease, epilepsy and asthma.
Past
Surgical History
During 18 years old, she had appendisectomy
at Hospital Ampang in 2015.
There was no complication.
Drugs
History
No over the counter and herbal
medication.
Allergic
History
No allergic history.
Not having allergy to food or
medication.
Family
History
Her father is still alive currently 44
years old. He is healthy and does not have medical illness such as diabetes,
hypertension and asthma.
Her mother is still alive currently 40
years old. She has diabetes mellitus, hypertension and heart problem.
The patient has 5 siblings. She is the 2nd
out of 5.
There are 2 girls in this family. All of
them does not have gynaecology problems such as fibroid or ovarian cysts.
There were no multiple pregnancies,
fetal abnormalities or malignancy. Otherwise, all siblings are healthy.
Social
History
Patient currently work as housekeeper.
Her husband’s job is despatch. Total family income is about RM3k a month.
Patient is not a smoker, non-alcoholic
and non-drug abuser.
She live at PPR Desa Pandan with her
family. It is flat house with good accommodation utility such as water,
electricity and sanitation.
Summary
Mrs Nurfateha, 20 years old primigravida
at 6th weeks of gestation comes to the hospital due to per vaginal
bleeding past 1 day for further management.
General
Examination
Patient is lying down comfortably with 1
pillow. She is not in distress and well hydrated. She is friendly and cooperative.
Her vitals signs are as follows:
Blood
Pressure – 100/60 mmHg
Pulse
Rate – 72 beats per minute
Respiratory
Rate – 16 breaths per minute
Temperature
– 37 ˚C
Hand
No clubbing, CRT<2 sec, warm and no
palmar erythema
Eyes
No anemia and no jaundice
Mouth
Good oral hygiene, good hydration
status, no angular stomatitis and central cyanosis.
Thyroid
Not swell and no nodules.
Breast
No nodules or discharge(Patient refused)
Legs
No edema and varicose vein.
Systemic
review
CVS
S1 S2 heart sound
heard. No murmur.
RESPI
air entry is good, vesicular breath
sound and no added sound.
Abdominal
Examination
Inspection
Abdomen is not distended. There was no lineanigra,
no striaegravidarum and no dilated vein.
There is scar at right iliac fossa. It
was transverse scar and about 6cm. The scar well healed, no keloid and no
hyperpigmentation.
Umbilicus is inverted.
There was no hernia orifices and no skin
lesion such as scratches mark.
Palpation
On superficial and deep palpation, there
was no pain and tenderness.
Uterus is unpalpable.
There was no mass in all 9 areas.
Liver and spleen is unpalpable.
Liver span is 10 cm.
Kidney is ballotable.
Auscultation
The bowel sound heard.
I would like to complete my physical
examination with pelvic examination such as vaginal examination, speculum and
bimanual examination.
Investigation
Full blood count
|
|
Results
|
Unit
|
|
Haemoglobin
|
11
|
gm/dL
|
|
Red blood cells
|
4.54
|
1013/L
|
|
Packed cell volume
|
0.38
|
|
|
Mean corpuscular haemoglobin
|
28
|
pg
|
|
White cell count
|
7.7
|
109/L
|
|
Neutrophils
|
1.7
|
109/L
|
|
Leucocytes
|
5.7
|
109/L
|
|
Platelets
|
254
|
109/L
|
Urine pregnancy test (urine hCG)
-UPT was positive
Ultrasound (transvaginal)
-ultrasound showed no sac
Serum B-hCG
-for the first test, the result was 764
IU/L
-after 48 hours, the test was repeated
and the result was 520 IU/L
Management
Expectant
management
-observation for spontaneous resolution
Conservative
a) Medical
IM methotrexate 1mg/kg (single dose) +
actinomycin
b) Surgical
Plan for operative laparoscopy (gold
standard)
Laparotomy for unstable patient
B-hCG follow-up
Diagnosis
Provisional
diagnosis
Ectopic pregnancy
Differential
diagnosis
Incomplete abortion
Salpingitis
Twisted ovarian tumor
Discussion
Usually, patient with ectopic pregnancy
will come to the hospital with symptoms of abnormal vaginal bleeding, lower
abdominal pain and amenorrhea (sometimes the patient may be unaware that she is
pregnant and may interpret a vaginal bleed as a period. But in this patient,
she already knows her pregnancy and have symptoms of per vaginal bleed for past
3 days without abdominal pain.
In examination, tachycardia suggests
blood loss, hypotension and collapse occur in extremis. Also there is rebound
tenderness in abdominal. On pelvic examination, the patient should have pain
when movement of uterus is applied (cervical excitation) also the uterus is
smaller than expected from the gestation and cervical os is closed. But in this
patient, all are normal maybe the blood loss is too minimal. Her body still can
compensate.
In investigation, she already did UPT by
herself to confirmed her pregnancy beforehand. In ultrasound (preferably
transvaginal) does not always show ectopic pregnancy. In this patient,
ultrasound does not show anything maybe because the pregnancy is too early or
the sac might be somewhere else. For serum B-hCG, if maternal level is >1000
IU/L, it will normally shows in ultrasound. But in this patient, the B-hCG is
764 IU/L so it maybe the cause why they cannot detect in ultrasound. After 48
hours, the test was repeated and the result was 520 IU/L which was lesser than
the earlier level. The declining or slower rising levels suggest an ectopic or non-viable
intrauterine pregnancy. Full blood count in this patient is normal.
For the management, this is stable and young
patient which is suit for medical treatment which is IM methotrexate 1mg/kg
single dose. The indication are patient is hemodynamically stable, serum hCG
less than 3000 IU/L and no intra abdominal haemorrhage. Conservative surgery
can be done such as laparoscopically or laparotomy. Laparascope is the gold
standard in this case.
References
1. DC
Dutta’s Textbook of Obstetrics 8th edition
2. Clinical
Protocols in Obstetrics and Gynaecology for Malaysian Hospitals
No comments:
Post a Comment