PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY (Foundation), INC

COMMITTEE ON MATERNAL AND PERINATAL WELFARE

MATERNAL MORBIDITY & PERINATAL MORTALITY CONFERENCE
5:00 pm, Wednesday, March 20, 2013
3rd floor, Assembly Hall, POGS Building

CASE PROTOCOL

GeneralData:

ThisisacaseofS.M.,28yearold,G1P0,aRomanCatholic,fromCaloocanCity,whocameinfor
fetalheadentrapment.

PastMedicalHistory:
Nohistoryofhypertension,diabetes,bronchialasthma,tuberculosis,cancer,andprevioussurgeries.

FamilyMedicalHistory:
Nohistoryofhypertension,diabetes,bronchialasthma,tuberculosis,orcancer.

PersonalandSocialHistory:
Patientisahighschoolgraduate,unemployed,withnovices.
Firstcoitusat22yearsold,2nonpromiscuoussexualpartners,()OCP,()IUD,()STD

MenstrualHistory:
She had her menarche at the age of 11, with regular monthly interval, lasting for 34 days
duration, soaking 23 pads per day. Her last menstrual period was February 5, 2012 giving her an
amenorrheaof40weeksand4days.

ObstetricalHistory:
Thisisherfirstpregnancy.

HistoryofPresentIllness:

Three days PTA, patient noted watery vaginal discharge, described as clear and nonfoul
smelling.However,noconsultwasdone.
17hoursPTA,shehadmildirregularuterinecontractions,withwateryvaginaldischarge.Still,no
consultwasdone.
6 hours PTA, the contractions became regular and strong in intensity, she went into labor at
home,attendedbyatraditionalbirthattendant.
4hoursPTA,thebabysheadwasdeliveredbutwithdifficulty deliveringtheshoulder.Fundal
pushingwasattemptedforonehour.Thebabywasthennotedtobecyanotic.Atthatpoint,therewas
around3dippersfullofbloodloss.
2 hours PTA, she was rushed to Salamanca Hospital. The plan then was to do an emergency
cesareansection,however,patienthadoneepisodeofhypotension(aslowas60/40),andpatientwas
thustransferredtoourinstitution.Enroutetoourinstitution,therightkneeofthepatientwasleaning
ontheambulancesidewallfor2hours.

ReviewofSystems:
Unremarkable review of systems except for the weakness of the lower extremity with difficulty
ambulating.

PhysicalExamination:
Patientcameinconscious,coherent,exhausted,stretcherborne.
VitalSigns:BP90/60,CR110,RR20,T36.50C.
Pale palpebral conjunctivae, no cervical lymphadenopathies, no anterior neck masses. There were
abrasionsandbruisesnotedoverthesubcostalareas.

She had equal chest expansion, clear breath sounds, no adventitious lung sounds; an adynamic
precordium,distinctheartsounds,normalrate,regularrhythm,withnomurmurs.
Shehadweakbutequalpulses,nocyanosisnoredemabutwithweaknessofthelowerextremityand
palenailbeds.

Theabdomenwasnontender.Fundicheightwas33cm,estimatedfetalweightwas3.43.6kg,cephalic
inpresentation,withnofetalheartstoneappreciated.

InternalExamination:
The vulva was noted to be edematous, the head of the baby was seen at the introitus. There was
around2cmrightmediolateralepisiotomy.

AdmittingDiagnosis:
_______________________

CourseduringAdmission:
Patientwasbroughtintothedeliveryroom.Helpwasimmediatelysought,bothlegswerelifted
andhyperflexed.Patientwasplacedundergeneralanesthesia.Therightmediolateralepisiotomywas
extended, anterior shoulder disimpaction and rotation of the posterior shoulder were attempted. The
posterior arm was then manually removed. Patient then delivered vaginally a male stillbirth, 3.7 kg,
withlengthof54.5cm,headcircumferenceof38.5cm,abdominalcircumferenceof31cm,crownrump
lengthof38cm,crownheellengthof50cm.Theplacentawasdeliveredafteraminuteandweighed
600 grams, foulsmelling. The umbilical cord was 60 cm, with three vessels.The amniotic fluid was
tobaccostainedandfoulsmelling.Cervicalinspectionwasdoneandtherewerenocervicallacerations.
However, vaginal lacerations and abrasions were noted. Also, the vaginal and cervical tissues were
notedtobefriable.Estimatedbloodlossduringtheprocedurewasaround700ml.Duringtherepairof
episiotomy,therewasnoteofprofusebleedingassociatedwithaflacciduterus.Activemanagementof
the third stage of labor was done which included uterine massage, bimanual compression, 6 tabs of
Misoprostol were inserted per rectum, Methylergonometrine maleate was also given intramuscularly
along with oxytocin infusion (30 units of oxytocin in 1 liter D5NR) and 10 units given intramuscularly.
However uterus remained to be flaccid. Postpartum hysterectomy was immediately performed.
Intraoperatively,theuteruswaspaleandflaccid.Therewereepisodesofhypotension,aslowas7090
palpatory,theheartratewas130140/min,respiratoryrateof2025/min,withoxygensaturationof70
80%.Thetotaloperativetimewas2hoursand30minutes,withapproximately4.5litersofbloodloss
(including700ccfromvaginallacerationsandabrasionsandapproximately3litersathome).2unitsof
PRBC,1unitaliquot,4unitsFFP,3literscrytalloids,and2colloidsweretransfusedduringtheoperation.
Theurineoutputwas30ccfor4hours.Dopaminedripwasimmediatelystartedat38cc/hour.

PerioperativeDiagnosis:
____________________________________
ProceduresDone:
Shoulderdystociadrill,spontaneousvaginaldeliverywithRMLEandrepair,cervicalinspection,uterine
exploration,andexploratorylaparotomy,totalhysterectomyundergeneralanesthesia.

BaselineLaboratories:
CompleteBloodCount
Hgb
98
Hct
0.279
WBC
15.50
Neutrophils
0.66
Lymphocytes
0.23
Monocytes
0.11
Platelet
35
Urinalysis
Brown, turbid, specific gravity 1.030, pH 5.5, CHO 3+, CHON 2+, innumerable RBC, 68 WBC, rare
epithelial cells, 3+ bacteria, negative mucus thread, Coarse granular cast 01/lpf, crystals negative,
bilirubinnegative,urobilinogennormal,ketonestrace,leucocytes2+,nitritenegative,hemoglobin3+

BloodChemistry
BUN
Creatinine
Glucose
Sodiun
Potassium
Chloride
Magnesium
Calcium
AST
ALT
Albumin
ProthrombinTime

10.10
275
7.18
130
4.1
111
0.58
1.95
457
150
8
Referencevalue:11.8
Patientsvalue:22.6
%activity0.48
INR1.83
Referencevalue:35.6
Patientsvalue:82.0

PartialThrombin
Time

PostoperativeCourse:
A central venous pressure line was immediately inserted; the opening pressure was 1418
cmH20. Patient was intubated but awake with spontaneous eye opening and could follow commands.
She was able to communicate with gestures. Her blood pressure was 80110 palpatory, heart rate of
110114/min,withatemperatureof35.936.0 0Cwithoxygensaturationat9298%.Onauscultation,
therewerebilateralrhonchiandcracklesappreciatedfrommidtobaseofbothlungfield.Patienthas
faintpulsesandcoldclammyextremities.Assessmentduringthattimewas:

Clindamycin900mgIVwasstartedandcontinuedevery8hoursaswellasAmikacin750mgIV
every 24 hours. Patient was also started with Dopamine drip and Norepinephrine drip. The 3rd unit
PRBC,1stunitofwholeblood,and2nd4thunitsaliquotweretransfused.Patientwasalsotransfusedwith
freshfrozenplasmaever12hours.Mupirocinointmentwasapplied3xadayontheabrasionsoverthe
subcostalareas.

Onthe3rdpostoperativeday,patientwasextubated.Thewoundwaswellcoaptatedwithno
discharge, no dehiscence, and no erythema. The episiotomy site was wellcoaptated. No vaginal
bleedingandfoulsmellingvaginaldischargenoted.

On the 4th postoperative day, weakness on the right leg was noted. Patient was referred to
RehabilationMedicine,assessmentwascommonperonealnerveinjuryontheright.VitaminBcomplex
was started. The plan was to do electromyography and nerve conduction velocity after 36 weeks.
Elasticbandagewasappliedontherightfoot.IVantibioticswerethenshiftedtooralantibiotics.

Onthe7thpostoperativeday,therewaserythemaandserosanguinousdischargenotedcoming
fromthewound.Vitalsignswerestablewithnofebrileepisode.

On the 10th postoperative day, there was serosanguinous discharge per vagina with necrotic
tissues on the left labial area and distal 3rd of the posterior wall of the vagina. Assessment then
was_______________

Antibiotic was then shifted to Meropenem 500 mg intravenously after 12 hours and perineal
care3xadaywithplainandChlorhexidienewasdone.Theincisionsitewascleaneddailywithhydrogen
peroxideandplainNSS.PatientwasstartedonTramadolandParacetamol3xadayforpain.Thewound
culture studies showed heavy growth of enterococcus species sensitive to Ampicillin and Gentamycin.
Gentamycinwasthenstarted80mgintravenouslyonceaday.

Onthe12thpostoperativeday,thedehiscenceofepisiotomysiteandthenecrosisextendedto
theanalareas.Debridementunderspinalanesthesiawasdone.Perinealscrubbing4xadaywithplain
NSSandChlorhexidieneandthedailycleaningoftheincisionsitewerecontinued.


On the 14th postoperative day (day 2 postwound debridement), the abrasion noted on the
lateral side of the right leg upon admission started to ulcerate. It was cleaned daily with hydrogen
peroxide. HBA1Cwas requested which revealed normal result. Assesment was: _________. She was
startedonMetronidazole1gevery3hoursandAmpicillin2gevery6hoursintravenously.

On the 15th postoperative day (day 3 postwound debridement), rashes were noted on both
lower extremities involving both thighs; patient also noted to have difficulty controlling her urge to
defecate.VaginaltissueculturestudiesshowedlightgrowthofE.colisensitivetoAmpicillin,Cefazolin,
and Gentamycin. Patient was then referred to the Urogyne and Allergy services, the assessment
was_________.Metronidazole1gandAmpicillin2gintravenouslywerecontinuedandLoratadine100
mgtabletwasstarted.Theplanwasforlayeredrepaired,overlappingsphincteroplasty,perineorrhaphy.

On the 16th postoperative day (day 4 postwound debridement), Ampicillin was discontinued
andwasstartedonLevofloxacin750mgonceaday.

Onthe19thpostoperativeday(day7postwounddebridement),granulationtissuewasstarted
toformonthevagina.Continuousperinealscrubbing4xadaywithplainNSSandChlorhexidienewas
done.BulkformingagentintheformofLoperamide5oomgtwotimesadaywasgiven.

Onthe20thpostoperativeday(day8postwounddebridement),perinealscrubbingagentwas
shiftedtoDaikinssolutiondaily.Theplanfortheobstetricanalsphincterinjurywasforreassessment
with Endoanal ultrasound after 6 weeks. Loperamide was discontinued and patient was started on
Lactulose30cc3xaday.

Onthe26thpostoperativeday,patientcomplainedofsoakingherunderwearwithurineevery
timeshefeelstheurgetourinate.

On the 27th postoperative day (day 15 post wounddebridement), upon perineal scrubbing,
therewasanoteofa4x2cmdefectattheanteriorvaginalwall,5cmsfromtheurethralmeatus.Upon
insertion of a foley catheter, the inflated balloon was visualized at the area of defect. Urine culture
studies revealed moderate growth Candida albicans sensitive Ampicillin, Penicillin G and Gentamycin.
Assessmentduringthattimewas_____________.PatientwasreferredtoUrology.Theplanwasfor
diagnosticcystourethroscopy, bilateral stenting. Patient was then started with Ceftriaxone 1 g once a
day.

Onthe29thpostoperativeday,patientunderwentdiagnosticcystourethroscopy,vaginoscopy,
cystoscopy. Intraoperatively, there was 1x2 cm vesicovaginal fistula 5 cm from the urethral meatus.
Therewasseverelyedematousposteriorbladderwallwithfibrindeposits.Methylenebluetestresult
waspositivewhichconfirmedthepresenceofvesicovaginalfistula.

On the 33rd postoperative day (day 21 postwound debridement), patient was started on
Cefixime200mgPO2xaday.Shehadstablevitalsigns,afebrile.Withgoodwoundhealingoftheskin
incision and the pressure ulcer on the lateral side of the right leg, decreasing purulent discharge per
vagina.

Patientwasdischargedonthe36thpostoperativeday(day25postwounddebridement)

LongTermPlans:

1.Repeatcystourethroscopy,bilateralureteralstenting,vaginoscopyafter68weeksforreassessment.
2. For electromyography and nerve conduction velocity for the pudendal nerve injury; and gait retry
withsolidanklefootorthosforthefootdrop.

DischargeDiagnosis: