Obstetrics and Gynaecology Case Presentation

Natrah Abd Manan

Learning Points
Paraumbilical hernia in adult

Management of pregnant women undergoing non-obstetric surgery Red blood cell isoimmunization

The case
VC, a 35 year old G5 P4+1 She is 19/40 pregnant BIBA on Wednesday at 10am 3x vomiting, bile stained Sudden onset abdominal pain

History of Presenting Complaint

Vomiting since 8.30am
Bile stained, no blood Feels sick afterwards

Abdominal pain
Sudden onset 10/10 Intermittent in nature labour pain

History of presenting complaint

No urinary problem, no vaginal bleeding No complications

Past obstetric history

4 pregnancies
1: LSCS (fibroid) 2: ventouse-assisted 3: complete miscarriage, early gestation 4: LSCS (Back problem)

Past gynaecological history

Fibroid in 2006

Past medical history

Paraumbilical hernia for 2 years (since 2009) Back problem; sciatica protruding disc L4 L5 Migraine Medication: nil NKDA

Others
Past psych history: nil of note Family history: nil of note Social history: non smoker, occasional drinker, lives with husband and 3 children

Physical examination
T 36.1 HR 74 RR 16 02 sat 99% on room air BP 99/59

Physical examination
FHR=147 No fetal movement Fundus palpable Abdomen tender ++ Discoloured paraumbilical hernia with green discharge

Diagnosis
Ruptured paraumbilical hernia with small bowel obstruction

Management
Surgical: paraumbilical hernia repair + bowel resection Pethidine 50 mg IM Prochlorperazine (Stemetil) 12.5 mg IM Paracetamol 1 g IV Tinzaparin (Innohep) 3500 iu SC Prophylactic anti-D IM 1500 unit

Paraumbilical hernia in adult

Introduction
Acquired F:M=3:1 3rd most common cause of SBO (adhesion and malignancy being 1st and 2nd respectively)

Association
increased intra-abdominal pressure due to obesity, abdominal distension, ascites, and pregnancy

Paraumbilical hernia in adult

Presentation
Small and asymptomatic
Observation

Soft protuberance at the umbilicus Tenderness - elicited with pressure and palpation

Paraumbilical hernia in adult

Repair
Surgical: open or laparoscopic

Management of pregnant women undergoing non-obstetric surgery

Elective surgeries are best avoided Operation rate 0.75% Concerns include:
Teratogenesis Miscarriage Hemorrhage

Issues
Surgical Anaesthesia

Thrombophylaxis Antibiotic prophylaxis Timing Prophylactic glucocorticoids Prophylactic tocolytics Surgical approach Fetal heart rate monitoring Postoperative care Delivery

General anaesthesia Risk of difficult intubation Desaturation Aspiration Hemodynamic instability Anaesthetic drugs issue Recovering from anaesthesia Newborn effects Regional anaesthesia

Outcome
No association between surgical procedures and incidence of adverse reproductive outcome. The rate of congenital malformations and unexplained stillbirths similar to women who did not undergo non-obstetric surgery. The rates of low birthweight infants (due to prematurity and growth restriction) and early neonatal death (death within seven days of birth) were significantly increased in women who had had surgery.

Red blood cell isoimmunization

Production of antibodies by mothers immune system in response to antigen on fetal red cells that enter her circulation. Antibodies then cross the placenta Causing fetal red blood cell destruction

Pathophysiology 1) blood group 2) sensitization

Epidemiology

Aetiology

Prevention: using anti-D

Manifestations of rhesus disease

Management of isoimmunization

Epidemiology
15% of Caucasian women, fewer in African or Asian Perinatal deaths due to rhesus disease are rare due to:
Use of anti-D Smaller family size Good Mx of isoimmunization

Pathophysiology
Blood group
Rhesus system Three gene pairs: C/c, D/d, E/e DD and Dd rh +ve dd rh ve

Sensitization
Mixing of fetal and matenal blood Production of antibodies Destruction of fetal RBC rh haemolytic disease

Aetiology
Lack of prophylactic anti-D Other antibodies e.g anti-c, anti-E and anti-Kell

Manifestations of rhesus disease

Neonatal jaundice Neonatal anaemia In utero anaemia If worsens:
cardiac failure ascites oedema (hydrops) fetal death

Prevention: using anti-D

Offer blood test at booking and 34 weeks Offer anti-D to rh ve women at 28 and 34 weeks After any bleeding or potentially sensitizing events
TOP/ ERPC after miscarriage Ectopic pregnancy Vaginal bleeding <12 weeks, or if heavy ECV Invasive uterine procedure e.g amniocentesis or chorionic villous sampling Intrauterine death Delivery

After delivery f neonate is rh +ve Kleihauer test

Management
Identification of women at risk of fetal haemolysis and anaemia
Screening for antbodies

Assessing severity of fetal anaemia

Ultrasound Doppler ultrasound: MCA peak systolic velocity

Blood transfusion in utero Delivery for affected fetuses

>36 weeks Check FBC, bilirubin, rhesus group, Coombs test

References
http://www.uptodate.com/contents/prevention-of-venousthromboembolic-disease-in-surgical-patients?source=related_link http://www.uptodate.com/contents/management-of-pregnantwomen-undergoing-nonobstetric-surgery?source=related_link http://www.uptodate.com/contents/overview-of-abdominal-wallhernias?source=search_result&search=paaumbilical+hernia&select edTitle=1%7E150#H16 http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf http://www.uptodate.com.libgate.library.nuigalway.ie/contents/ma nagement-of-rhesus-rh-alloimmunization-inpregnancy?source=search_result&search=management+pregnant& selectedTitle=14~150 IMPEY, L. & CHILD, T. (2008) Obstetrics and Gynaecology, WileyBlackwell Publication.