CASE

DISCUSSION
ADMISSION 1

GENERAL DATA CHIEF COMPLAINT

Name: Paragas, Shella Jaro Headache
Age: 34 F
Birthdate: 12/16/1986
Address: Dagupan City
Education: High School
Unemployed
Date of admission: 10/06/2021
REVIEW OF SYSTEMS

GENERAL (-) fever

HEAD (+) dizziness

EYES (-) blurring of vision

NOSE No pertinent findings

BREAST No pertinent findings

ABDOMEN (-) epigastric pain, (+) hypogastric pain

EXTREMITIES No pertinent findings

OB SCORE
DATE MANNER PLACE STATUS COMPLICATION

G1 2005 CS LIVE PPH

G2 2006 VDAC RIMC DECEASED due to

dengue

G3 2011 CS RIMC - History of

uterine rupture
as claimed by
the patient

G4 Miscarriage

G5 Miscarriage

G6 Present pregnancy
PHYSICAL EXAMINATION
Vital signs: Chest
Symmetrical chest wall expansion,
HBP: 160/120
clear breath sounds
GBP: 130/100

CBP: 130/80 Abdomen:

FH: 24 cm
FHT: 140

IE: cervix 3cm, 50% effaced,

cephalic, station -3, +BOW, +show
BPS 9/17/2021 by Dr. Prado

Single, live, intrauterine pregnancy in

cephalic presentation with good cardiac
and somatic activities. 29 weeks and 2
days by average fetal biometry. Placenta
anterior grade 2. Low normal amniotic fluid
BPS 8/8

Sonographic estimated fetal weight is 1351

gms.
 ADMITTING DIAGNOSIS
G6P3 (3022) PU 34, 1/7 weeks AOG, CIL, prev 2x (2005, 2011, R1MC) CHVD with
superimposed preeclampsia
PLAN
● Dexamethasone
● BP control
● Anticonvulsant
● CTG
● Repeat CS with BTL
FINAL DIAGNOSIS
G6P4 (3123) PU, 34 1/7 weeks AOG, CIPL, prev CS 2x (2005, 2011, R1MC), CHVD
with superimposed preeclampsia. S/p delivered via LTCS with BTL, to a live baby girl,
BW: 1650g, BL: 46cm, AS: 8,9, Ballard’s score: 34 AGA, poor OB history grand
multigravida
CASE DISCUSSION
Chronic hypertensive vascular
disease with superimposed
preeclampsia
 Chronic hypertensive vascular disease
with superimposed preeclampsia
● Criteria for hypertension — During pregnancy, hypertension is defined as systolic blood pressure
≥140 mmHg and/or diastolic blood pressure ≥90 mmHg.
● Chronic hypertension is defined as hypertension that precedes pregnancy or is present on at least
two occasions before the 20th week of gestation or persists longer than 12 weeks postpartum.
● Preeclampsia is considered superimposed when it occurs in a woman with preexisting
chronic hypertension
● It is characterized by worsening or resistant hypertension (especially acutely), the new
onset of proteinuria or a sudden increase in proteinuria, and/or significant new end-organ
dysfunction after 20 weeks of gestation or postpartum in a woman with chronic
hypertension
● Often accompanied by fetal growth restriction
● Risk factors:
○ Older women
Risk factors for preeclampsia
● History of preeclampsia
● Chronic hypertension
● Prepregnancy overweight or obesity
● Chronic kidney disease
● Multifetal pregnancy
● Nulliparity
● Family history of preeclampsia
● Prior pregnancy complications associated with placental insufficiency
● Advanced maternal age
Diagnosis
● It can be challenging to diagnose preeclampsia in women with chronic hypertension
because their blood pressures are already elevated and proteinuria may be present before
pregnancy.
● Superimposed preeclampsia should be considered if blood pressure increases in pregnancy
and especially if there is new-onset proteinuria or worsening of prepregnancy proteinuria.
● Laboratory abnormalities (thrombocytopenia, elevated liver function tests, and increasing
serum creatinine) will also often distinguish preeclampsia from worsening of underlying
hypertension
● Diagnostic criteria for proteinuria - at least 300 mg of protein in a 24 hour urine sample
Management
Blood pressure goals in pregnancy
● Antihypertensive treatment has not been shown to reduce superimposed
preeclampsia, placental abruption, or growth restriction or to improve neonatal
outcome
● ACOG recommends that blood pressures in women with uncomplicated
hypertension be maintained between 120/80 and 160/105 mm Hg
● For women with chronic hypertension who enter pregnancy not on
antihypertensive treatment, ACOG recommends initiating antihypertensive
treatment when blood pressures are consistently >160 mm Hg systolic and/or
>105 mm Hg diastolic
Management
Prevention of Preeclampsia
● For women with chronic hypertension, superimposed preeclampsia is the major adverse
pregnancy outcome
● There are currently are no effective preventive measures to decrease this risk.
● Large, randomized, placebo-controlled studies have demonstrated that the use of calcium
supplementation low-dose aspirin or antioxidant supplementation with vitamin C and E does not
decrease the risk for preeclampsia.
Management
Expectant management for preeclampsia Management for preeclampsia with severe
without severe features features
● Twice weekly BP monitoring ● Fluid management
● Weekly laboratory tests (CBC, ● Seizure prevention
creatinine levels, ALT, AST) ● Lowering BP
● Twice weekly fetal nonstress testing ● Expediting delivery
● Weekly amniotic fluid indices
Seizure prophylaxis is not required unless
severe features develop
ADMISSION 4

CHIEF COMPLAINT
GENERAL DATA

Name:Tumanan,roselle
Age:33
HYPOGASTRIC PAIN
DOB:5/2/1988
status:married
Place: dagupan city
INTERNAL EXAMINATION ADMITTING DIAGNOSIS

CERVIX:
1CM DILATION G1P0 pu 40 wks Aog TRANSVERSE LIE in
BEGINNING EFFACEMENT, ACROMION beginning labor
STATION -3
BOW + SHOW

PLAN

LOW TRANSVERSE CESAREAN SECTION

CATEGORY 1 with IUD
CASE DISCUSSION ON TRANSVERSE
PRESENTATION
TRANSVERSE FETAL LIE
DEFINITION:
● The long axis of the fetus is approximately perpendicular to that of the mother.
● shoulder- pelvic inlet
● shoulder presentation in which the side of the mother on which the acromion
rests determines the designation of the lie as right or left acromial.

Diagnosis during leopold maneuver :

● Abdomen-wide
● uterine fundus- extends to only slightly above the umbilicus.
● head -ballotable
● back - anterior--a hard resistance plane extends across the front of the abdomen.
● posterior- irregular nodulations representing fetal small parts are felt
through the abdominal wall.
VAGINAL EXAMINATION:

Early stages of labor

● If the side of the thorax can be reached, it may be recognized by the “gridiron” feel of the ribs.
Further dilation
● The scapula and the clavicle are distinguished on opposite sides of the thorax.
● The position of the axilla indicates the side of the mother toward which the shoulder is directed.
ETIOLOGY

COMMON CAUSES: COMPLICATIONS

● high parity ● Cord or hand prolapse
● preterm fetus ● Obstructed labor
● placenta previa ● Uterine rupture
● abnormal uterine ● Difficult intra operative delivery of
anatomy fetus
● hydramnios ● Birth trauma
● contracted pelvis. ● Postpartum hemorrhage
● A pendulous abdomen
MECHANISM OF LABOR
➔ Spontaneous delivery -fully developed newborn is impossible with a
persistent transverse lie
➔ After rupture of the membranes, if labor continues, the fetal shoulder is
forced into the pelvis, and the corresponding arm frequently prolapses.
➔ .After some descent, the shoulder is arrested by the margins of the
pelvic inlet. As labor continues, the shoulder is impacted firmly in the
upper part of the pelvis.
➔ The uterus then contracts vigorously in an unsuccessful attempt to
overcome the obstacle.
➔ a retraction ring rises increasingly higher and becomes more marked
➔ With this neglected transverse lie, the uterus will eventually rupture.
➔ Even without this complication, morbidity is increased because of the
frequent association with placenta previa, the increased likelihood of
cord prolapse, and the necessity for major operative efforts.
➔ If the fetus is small—usually <800 g—and the pelvis is large, spontaneous delivery is possible
despite persistence of the abnormal lie.
➔ The fetus is compressed with the head forced against its abdomen.
➔ A portion of the thoracic wall below the shoulder thus becomes the most dependent part,
appearing at the vulva.
➔ The head and thorax then pass through the pelvic cavity at the same time.
➔ The fetus, which is doubled upon itself and thus sometimes referred to as conduplicato corpore,
is expelled.
MANAGEMENT
Active labor Before labor or early in labor

A Transverse lie the membranes intact

Cesarean delivery attempts at external version

( worthwhile in the absence of
complications)

With cesarean delivery, because neither

the feet nor the head of the fetus occupies
the lower uterine segment, a low
transverse incision into the uterus may
lead to difficult fetal extraction. This is
especially true of dorsoanterior
presentations. Therefore, a vertical
hysterotomy incision is often indicated.
ADMISSION 7
GENERAL DATA

ADMISSION NUMBER: A7 782278

NAME: Cave, Mae Angelyn Pacites

AGE: 18 S
DATE OF BIRTH: 7/15/2003
ADDRESS: Bani
EDUCATIONAL ATTAINMENT: High School

DATE ADMITTED: 10/6/2021

CHIEF COMPLAINT

Labor pain
Review of System
General: (-)fever, (-) fatigability
Neck: (-)JVD
Breast : (-) pain, (-) lumps
Cardiovascular: (+) murmur, (-)palpitations
Respiratory: (-) difficulty of breathing, (-) chest pain, (-) Hemoptysis,
Gastrointestinal : (-)regurgitation
Extrimities: (-) edema, (-) numbness
Nervous system: (-) loss of consciousness, (-)syncope, (-) dizziness
Physical examination
GCS: 15 and upon examination the patient was not in
Cardiopulmonary distress

BP: 100/60mmhg
Heart Rate: 110beats/min
Fundic Height: 27 cm
FHT: 140b/min
IE: Cervix is fully dilated, 100% effaced, cephalic in labor,
station +1, intact BOW with Show.
2D ECHO Report: was done on 10/3/2021 by Dr Ramirez
Findings : rheumatic heart disease, severe mitral
regurgitation was found. Thickened and restricted anterior
mitral valve with pseudo prolapse into the left atrium
during systole. Thickened and restricted posterior leaflet.
Both commissure are open moderate tricuspid
regurgitation.
Working diagnosis

G1P0 PU 42wks AOG, cephalic in labor,

teenage pregnancy, gravidocardiac(Rheumatic
Heart Disease)
Plan

● Assisted vaginal delivery(AVD)

● Refer to pedia cardio for co-management
Final diagnosis

G1P1 (1001) PU, term, cephalic, delivered via AVD to a live

baby girl, BW: 2310g, BL: 50cm, AS: 8,9 BS: 37 wks AGA,
Teenage Pregnancy, gravidocardiac(RHD, mitral valve prolapse,
tricuspid regurgitation t/c VSD)
Case Discussion
Rheumatic heart disease
RHD is the most common acquired heart disorder resulting from acute rheumatic
fever. In developing countries, RHD continues to be a major cause of cardiac
morbidity and mortality especially among young femALE in pregnancies
complicated with cardiac disorders.
Morphologic Criteria of RHD
1. Mitral valve thickening >3mm
2. Chordal abnormality
3. Restricted posterior leaflet
4. Aortic leaflet thickening/ irregularity
5. Restricted leaflet motion
6. Aortic prolapse
Criteria for echocardiographic diagnosis of rheumatic
heart disease in individual <20 yrs of age

1. Definite RHD(A,B, C orD )

A. Pathologic MR + more than or equal to morphologic features of RHD of mitral
valve
B. MS mean gradient > 4mmhg
C. Pathologic AR + more than and equal to morphologic features of RHD of aortic
valve
D. Borderline disease of both the MV and AV
02. Borderline RHD (either A, B, C, D)
A. More than and equal to 2 morphologic features of MV without Pathologic MR
or MS
B. Pathologic MR
C. Pathologic AR
03. Normal echocardiographic findings
A. MR that doesnot meet all four doppler criteria(physiologic MR)
B. AR that doesnot meet all four doppler criteria ( physiologic AR)
C. An isolated morphologic feature of RHD of MV( e.g valvular thickening),
without any associated pathologic stenosis or regurgitation.
D. Morphologic feature of rhd of AV e.g valvular thickening without any
associated pathologic stenosis or regurgitation
Ventricular Septal defects

● Most close spontaneously during childhood defects are

para membranous, physiological derangement are related to
lesion.
● In general, if the defect is less than 1.25 cm2, pulmonary
hypertension and heart failure donot develop.
● If the effective defect size exceeds that of aortic valve
orifice, symptoms rapidly develop> most children undergo
surgical repair before pulmonary hypertension develops.
● Adults with unrepaired large defects develop left ventricular
failure and pulmonary hypertension and have a high incidence
of bacterial endocarditis.
● If pulmonary arterial pressures reaches systemic levels,
however, there is reversal or bidirectional flow- eisenmenger
syndrome. When this develops, the maternal mortality rate is
significantly increased and thus, pregnancy is not generally
advisable.
Mitral Valve Prolapse
● This diagnosis implies the presence of a pathological connective tissue
disorder-often termed myxomatous degeneration which may involve the valve
lealets themselves, the annulus, or the chordae tendineae.
● Mitral insuiciency may develop. Most women with mitral valve prolapse are
asymptomatic and are diagnosed during routine examination or
echocardiography. The few women with symptoms have anxiety, palpitations,
atypical chest pain, dyspnea with exertion, and syncope.
● For women who are symptomatic, beta-blocking drugs diminish sympathetic
tone, relieve chest pain and palpitations, and reduce the risk of life-
threatening arrhythmias.
Management
Evaluation of VSD includes a specialized evaluation of fetal heart(fetal
echocardiogram). As genetic abnormalities may be associated with the
findings, genetic counseling and testing are recommended.
Prenatal consultation with pediatric cardiologist is recommend to discuss
the prognosis and management after birth. Some severe cases surgery is
required, prenatal consultant with pediatric cardiothoracic surgeon and
neonatologist is required.
Diuretics, supplemental oxygen, and pulmonary vasodilator drugs are standard
therapy for symptoms. And anticoagulation is also recommened.

Prostacyclin analogues that can be administered parenterally include epoprostenol

and treprostinil, whereas iloprost is inhaled. Each
has been used in gravidas. Inhaled nitric oxide is an option
that has been employed in cases of acute cardiopulmonary
decompensation.

During labor and delivery, these women are greatest risk

when venous return and right ventricular filling are diminished.
To avoid hypotension, assiduous attention is given to epidural
analgesia induction and to blood loss prevention and treatment
at delivery.
Subgroup 2
CASE DISCUSSION
Subgroup 2
case-2
General data

Name: Sanchez, Rochelle Asuit

Age: 20
Civil Status: Single
Date of Birth: 12/6/2000
Address: San Fabian
Education: College undergraduate
CHIEF COMPLAINT

HYPOGASTRIC PAIN
OB SCORE

DATE MANNER PLACE COMPLICATION

G1 2020 CS R1MC CPD

G2 Present pregnancy
PHYSICAL EXAMINATION

Vitals
HBP: 180/100
GBP :144/80
Abdomen- FH:27cm
FHT:140bpm
IE: cervix is 2cm dilated,beginning effacement,cephalic presentation,floating
+ BOW and no show
Extremities: no edema
Neurologic exam: No neurological symptoms
ULTRASOUND FINDINGS
● SINGLE, LIVE, INTRAUTERINE PREGNANCY, 30 WEEKS AND 6 DAYS
AOG BY FETAL BIOMETRY
● CEPHALIC PRESENTATION
● ANTERIOR PLACENTA, GRADE I
● NORMOHYDRAMNIOS
● SONOGRAPHIC EDC: OCT 13, 2021 +/- 14 DAYS
ADMITTING DIAGNOSIS

G2P1 (1001) Pregnancy uterine 40 1/7 weeks Age of gestation, CIBL, Chronic hyprertensive
vascular disease with Superimposed preeclampsia, prev Low transverse cesarean section 1x
(2020, R1MC, CPD)

PLAN
● Low transverse cesarean section II with Intrauterine device
● BP control
● Anticonvulsants
FINAL DIAGNOSIS

G2P2 (2002) PU 40 1/7 weeks AOG, CIBL, Chronic hyprertensive vascular disease with
Superimposed preeclampsia, prev LTCS 1x (2020, R1MC, CPD) S/p Delivered via LTCS II
with IUD, live Baby girl BW 2580g BL50 cm AS 8,9 BS 37 weeks
CASE DISCUSSION
CHRONIC HYPERTENSIVE VASCULAR DISEASE WITH
SUPERIMPOSED PREECLAMPSIA

● n women with chronic hypertension, the risk of superimposed preeclampsia is increased

in patients with systolic blood pressure of >140 mm Hg, and diastolic blood pressure of
>90 mm Hg

● If new-onset or worsening baseline hypertension is accompanied by new-onset

proteinuria and sudden increase in BP then superimposed preeclampsia is
diagnosed.

● Compared with preeclampsia, superimposed preeclampsia commonly develops

earlier in pregnancy. It also tends to be more severe and often is accompanied
by fetal-growth restriction.
 ● Cases of chronic hypertensive vascular disease (CHVD) with
superimposed preeclampsia are associated with higher stillbirth rates,
● CHVD with superimposed preeclampsia have slightly lower birth
weights. The same associations are present with the proportion of
small for gestation age babies.
● Blood urea nitrogen levels tend to be higher in cases of CHVD with
superimposed preeclampsia
MANAGEMENT

Patient with ≥ 34 wks gestation

● Deliver after maternal stabilization
● Administer magnesium sulfate intrapartum and postpartum to prevent
eclampsia
● Treat with antihypertensives for SBP >160 or DBP >110
● Preeclampsia can worsen or initially present after delivery.
● Women with hypertensive disorders should be monitored as inpatients or
closely at home for 72 hours postpartum.
CASE 5
GENERAL DATA

Name: castro, michelle Alsid

Age: 32
Civil Status: single
Date of Birth: 9/21/1988
Address: Malasiqui
Education: college
CHIEF COMPLAINT

Facial asymmetry
 HISTORY OF PRESENT ILLNESS

2 week history of facial asymmetry with no other associated signs and symptoms. No
history of fever, cough or colds.

Few hours PTA, (+) headache, nape pain and dizziness was noted. Hence, consult.
 PHYSICAL EXAMINATION

HBP: 240/140
GBP: 190/110
CBP -
FH:23cms
FHT: 140 bpm

LUNGS: Symmetrical chest expansion, clear breath sounds

HEART AP, NRRR, (-) No MURMUR

IE: 1cm BE ceph st- 3 +bow no show

Grade 1 bipedal edema

NEURO:
(+) facial asymmetry, right
(+) tongue deviated to the left
Motor fxn : 5/5 on all extremities
 ADMITTING DIAGNOSIS

G4P3(3003) pu 34 1/7 wks AOG, CITPL,CHVD with

superimposed preeclampsia, previous cs 1x (2020, r1mc)

Failed family planning (BTL), t/c Bell’s palsy, r/o CVD

PLAN PROCEDURE DONE

● BP control Repeat cs w/ BTL

● Anticonvulsant
● Dexamethasone
● Repeat cs w/BTL for
preeclampsia w/
severe features
● Refer to IM for
management
 FINAL DIAGNOSIS

G4P4(4004)pu 34 1/7 wks of AOG, CITPL, CHVD

with superimposed preeclampsia
Low transverse cs II w/ bilateral salpingectomy
Baby boy bw 1440 grams BL AS BS to follow
CASE DISCUSSION
Chronic hypertensive vascular disease with superimposed preeclampsia

● Sudden increase in blood pressure in the patient with previously

well controlled blood pressure
● Platelets below 100,000/microliter.
● Pulmonary congestion
● New-onset proteinuria in a patient with no proteinuria previously
● An increase in the proteinuria over previous levels
● Renal insufficiency
● Additional symptoms like RUQ pain and severe headache.
Chronic hypertensive vascular disease with superimposed preeclampsia

RISK FACTORS MANAGEMENT

● Deliver after maternal stabilization

● Administer magnesium sulfate intrapartum

and postpartum to prevent eclampsia
● (+) Bipedal edema
● Treat with antihypertensives for SBP >160 or
● (+) Bells palsy DBP >110
● Failed family planning
● Preeclampsia can worsen or initially present
after delivery.

● Women with hypertensive disorders should

be monitored as inpatients or closely at home
for 72 hours postpartum.
CASE 8
General Data: Chief Complaint:
Name: L.C. Labor pains
Age: 20/S
Address: Dagupan City
Education: High School
Graduate
CASE 8
Physical Examination: Admitting Diagnosis:
FH: 28 G1P0 Pregnancy uterine 37
FHT: 140 weeks AOG, CIL
IE: cervix fully dilated, fully
ceph, 0, leaking BOW, clear
af with show
CASE 8
Plan:
Trial of labor
CASE 8
Final Diagnosis:
NSD with RMLE with repair to a live baby boy, BW: 2365
g, BL: 50 cm, AS: 9,9, BS: 37 weeks
CASE DISCUSSION
Episiotomy
🞆 Incision of the pedundum - the external genital organs

Mediolateral episiotomy
🞆 Begins at the midline of the fourchette and is directed to the
right or left at an angle 60 degrees off the midline
🞆 This angle accounts for perineal anatomy distortion during
crowning and ultimately yields an incision 45 degrees off the
midline for suturing
CASE DISCUSSION
CASE
DISCUSSION
Subgroup - 3
Admission 3 , 6 & 9
ADMISSION 3

GENERAL DATA:

Name: J.C.
CHIEF COMPLAINT:
Age: 20
Civil Status: Single
Hypogastric pain
Date of Birth: 12/25/2000
Address: Binmaley
Education: High school
graduate
ADMISSION 3

PHYSICAL EXAM ADMITTING

DIAGNOSIS
FH - 28cm
G2P1 (1001) Pregnancy uterine
FHT - 140bpm 40 6/7 weeks Age of gestation,
Frank breech in beginning labor,
Internal Examination- cervix is Prev CS 1x (2015, R1MC)
1cm dilated, beginning
effacement, fetal buttocks,
intact BOW with show
ADMISSION 3

PLAN PROCEDURE
DONE
Repeat CS with Intrauterine
Device Low Transverse Cesarean
Section II with Intrauterine
Device
ADMISSION 3

G2P2 (2002), Pregnancy Uterine, Term, breech,

FINAL previous CS G1 (2015, R1MC) s/p Delivered via
DIAGNOSIS: LTCS II with IUD for Frank breech presentation to a
live baby girl, BW: 3,150g; BL: 54cm; AS: 8,9; BS:
39 weeks AGA
CASE DISCUSSION

BREECH
DELIVERY
Risk Factors
● Early gestational age
● Extremes of amnionic fluid volume
● Multifetal gestation
● Hydrocephaly
● Anencephaly
● Structural uterine abnormalities
● Placenta previa
● Pelvic tumors
● Prior breech delivery.
○ One study found that following one breech delivery, the recurrence rate:
○ second breech presentation: 10 percent
○ Third breech :28 percent

Williams obstetrics 25th edition

Examination

Leopold maneuvers:

● First maneuver- the hard, round fetal head occupies the fundus.
● Second maneuver- identifies the back to be on one side of the abdomen and the small parts on the
other.
● Third maneuver- if not engaged, the softer breech is movable above the pelvic inlet.
● After engagement, the fourth maneuver shows the breech to be beneath the symphysis.
● Accuracy of this palpation varies.
● Thus, with suspected breech presentation-or any presentation other than cephalic- sonographic
evaluation is indicated.
cervical examination:

● with a frank breech, no feet are appreciated, but the fetal ischial tuberosities, sacrum, and anus are
usually palpable.
● After further fetal descent, the external genitalia may also be distinguished.
RECOMMENDATIONS OR FACTORS FAVORING CESAREAN
DELIVERY

● Lack of operator experience

● Patient request for cesarean delivery
● Large fetus: >3800 to 4000 grams
● Apparently healthy and viable preterm fetus either with active labor or with indicated delivery
● Severe fetal-growth restriction
● Fetal anomaly incompatible with vaginal delivery
● Prior perinatal death or neonatal birth trauma
● Incomplete or footling breech presentation
● Hyperextended head
● Pelvic contraction or unfavorable pelvic shape determined clinically or with pelvimetry
● Prior cesarean delivery
Complications
● Increased rates of maternal and perinatal morbidity can be anticipated with breech presentations.
● For the mother:
● With either cesarean or vaginal delivery, genital tract laceration can be problematic.
● With cesarean delivery, added stretching of the lower uterine segment by forceps or by a poorly
molded fetal head can extend hysterotomy incisions.
● With vaginal delivery, especially with a thinned lower uterine segment, delivery of the aftercoming
head through an incompletely dilated cervix or application of forceps may cause vaginal wall or
cervical lacerations, and even uterine rupture.
● Manipulations may also extend an episiotomy, create deep perineal tears, and increase infection
risks.
● For the fetus:
● prematurity and its complications are frequently comorbid with breech presentation.
● Rates of congenital anomalies are also greater (Cammu, 2014; Mostello, 2014).
● Compared with cephalic presentation, umbilical cord prolapse is more frequent with breech fetuses
● Birth trauma can include fractures of the humerus, clavicle, and femur (Canpolat, 2010; Matsubara,
2008).
● In some cases, traction may separate scapular, humeral, or femoral epiphyses (Lamrani, 201 1).
● Trauma is more common with vaginal births, but fetal trauma is also seen with cesarean deliveries.
● Some perinatal outcomes may be inherent to the breech position rather than delivery. Like hip dysplasia
ADMISSION 6

General data Chief complaint

● Name: MURLA, KRISZLE JAN
● Age: 29 Lower extremity weakness
● Civil Status: M No known comorbids
● Date of Birth: 11/9/1991
Referred by MD’s Cradle
● Address: Pozorrubio
Birthing home by nurse
● Education: high school
graduation Ragojos w/ letter but no call
ADMISSION 6

HPI Physical examination

● 3 weeks PTA, + bipedal HBP: 190/140 FH: 25cms

edema. No consult done. GBP; 150/90 FHT: 150 bpm

● No meds taken CR: 112 IE: admit tip, scanty
● 3 days PTA, +bipedal bleeding
edema, edema up to the RR; 20
abdominal area
Spo2:
● Consult was done where uts
SCWE, Bibasal crackles tachycardia, regular rhythm,
was requested. Grade 2 pitting bipedal edema on the abdomen,
Lower extremity weakness No known comorbids
ADMISSION 6
Imaging
Ultrasound findings

● Pelvic ultrasound, single live, cephalic, 32 1/7 wks of AOG , baby boy
● Normohydraminous
● Anterior placenta grade II
● Intra - peritoneal fluid collection
● Fluid collection on bilateral maternal pleural area ( left: 70cc, right:
10cc)
ADMISSION 6
PLAN
Preeclampsia workup
CTG
Mod- high back rest
Anticonvulsant
BP control
Dexamethasone
Furosemide
IFC
Refer to IM for co management
ADMISSION 6
Final diagnosis

G1P0 PU 32 1/7 wks of AOG CIBL, PEWSF, pulmonary

congestion
CASE DISCUSSION

Pulmonary Congestion
or Pulmonary Edema
Introduction
Pulmonary edema is defined as the abnormal accumulation of fluid in the interstitial and alveolar spaces of the
lung.

This accumulation can ultimately impair gas exchange by leading to decreased diffusion of carbon dioxide and
oxygen in the alveoli. The resulting impact on oxygenation and ventilation carries significant morbidity and has
the potential to be life threatening if severe.

In the setting of pregnancy, pulmonary edema is relatively rare, but it can present in patients in the antepartum,
intrapartum, and postpartum periods.

Maternal pulmonary edema is particularly concerning as the parturient already has decreased pulmonary
functional reserve because of the physiologic changes associated with pregnancy, increased metabolic needs,
and the gestating fetus is less able to tolerate a hypoxic maternal environment.

Furthermore, several coexisting maternal conditions and complications, such as underlying cardiac disease,
preeclampsia, sepsis, multiple gestations, as well as routinely used treatments (eg, tocolysis) can lead to the
development of pulmonary edema or worsen the severity of the condition.2
The management of hypertensive acute pulmonary oedema in pregnancy

The goals of treatment are:

● Reduce left ventricular preload.

● Reduce left ventricular afterload.
● Reduce/prevent myocardial ischaemia.
● Maintain adequate oxygenation and ventilation with clearance of pulmonary oedema.
Long-term management
Women who suffer from severe pre-eclampsia and experience acute pulmonary oedema are at increased
risk of cardiovascular complications in later life, including hypertension, ischaemic heart disease, stroke
and renal disease.

They should be closely monitored with control of blood pressure until resolution of the initial disease
process and then followed up regularly, with observation for the long-term complications of the disease.

Angiotensin-converting enzymes, whilst contraindicated in pregnancy, are safe to use in the postpartum
period. Risk reduction strategies should be offered, such as weight reduction and smoking cessation
programs, dietary modification, encouragement of regular exercise and control of hypertension.

In women who require long-term treatment, the aims are to modify the underlying cardiac function or
structural pathology.
ADMISSION 9

General data Chief complaint

● Name: D. J.
● Age: 27
watery vaginal discharge
● Civil Status: Single
● Date of Birth: 2/15/1994 No known comorbids
● Address: Malasiqui
● Education: High school grad
ADMISSION 9
Admitting
Physical examination
diagnosis
FH: 27
FHT: 150 G1P0 PU 37 weeks AOG, frank
breech in beginning labor; breech
IE: cervix 1cm, BE, fetal buttocks, -4, leaking BOW, thinly primi; PROM x 4 hours
meconium stained Amniotic fluid, no show
ADMISSION 9
PLAN Procedure done
LTCS I
Hydration

Antibiotics

CTG

For E LTCS I for malpresentation

IMAGING

Pelvic UTS by Dr. De Guzman(8/31/21)

Single, live IU, in breech, averaging 32 6/7 weeks AOG
Efw: 2022 grams
ADMISSION 9
Final diagnosis

G1P1 (1001) PU 37 weeks AOG, frank breech, Term

Delivered via LTCS I to a live Baby girl BW 2650g BL
51cm AS 8,9 bs 37 weeks AGA ; PROM x 4 hours
 DISCUSSION
ON
BREECH PRESENTATION
Breech presentation
● A breech presentation is when the fetus presents buttocks or feet first (rather
than head first – a cephalic presentation).

● It has significant implications in terms of delivery – especially if it occurs at

term (>37 weeks).

● Before the 28th week of pregnancy, about 20% to 25% of babies are breech.
● By the 34th week of pregnancy, most babies will turn, and approximately 5% to
7% will be breech.
● By full term, only 3% to 4% of babies (3 or 4 out of every 100 births) are
breech.
Types of Breech Presentation

In a breech presentation, the fetus presents ‘bottom down’.

There are three main types, depending on the position of the
legs:

● Complete (flexed) breech – both legs are flexed at the

hips and knees (fetus appears to be sitting ‘crossed-
legged’).
● Frank (extended) breech – both legs are flexed at the
hip and extended at the knee. This is the most
common type of breech presentation.
● Footling breech – one or both legs extended at the hip,
so that the foot is the presenting part.
Aetiology and Risk Factors

UTERINE FETAL

Multiparity Prematurity
Uterine malformations (e.g. septate
uterus) Macrosomia

Fibroids Polyhydramnios (raised amniotic fluid

index)
Placenta praevia
Twin pregnancy (or higher order)

Abnormality (e.g. anencephaly)

CLINICAL FEATURES

The diagnosis of breech presentation is of limited significance prior to 32-35 weeks (as the fetus is
likely to revert to a cephalic presentation before delivery).

Breech presentation is usually identified on clinical examination.

Breech presentation can also be suspected if the fetal heart is auscultated higher on the maternal
abdomen.

In around 20% of cases, breech presentation is not diagnosed until labour. This can present with
signs of fetal distress, such as meconium-stained liquor. On vaginal examination, the sacrum or
foot may be felt through the cervical opening
MANAGEMENT
At term, the options for management of breech presentation are

(i) external cephalic version;

(ii) Caesarean section; or

(iii) vaginal breech birth.

COMPLICATIONS

● A major complication of breech presentation is cord prolapse

● Fetal head entrapment
● Premature rupture of membranes
● Birth asphyxia – usually secondary to a delay in delivery.
● Intracranial haemorrhage – as a result of rapid compression of the head during delivery.