An Obstetric case study
Chief Complaint (CC): “I am here due to severe abdominal pain at 32+3 weeks gestation.”
History of Present Illness (HPI): The client B.T is a 35yo female who presented to the clinic with severe abdominal pain at 32+3 weeks gestation. The client reports that the pain has persisted for three hours following the sudden onset. She reported experiencing the pain over her previous cesarean scar predominantly. The severity of the pain is making it hard for her to move position. She adds that the pain is accompanied by uncontrollable vomiting. She also reported collapsing earlier while at home. She denies bleeding or vaginal loss. The client had been booked under consultant care following two cesarean deliveries previously. An ultrasound scan had been conducted at 31 weeks to check the fetal state and the volume of the amniotic fluid. The results indicated that fetal weight exceeded 90th centile, a type 4 anterior placenta praevia that covered the internal cervical completely, and normal liquor volume. Her gynecologist scheduled another scan after the placental localization scan at 36 weeks gestation. Additionally, the client would deliver via elective repeat cesarean section was planned. This decision was made following two past cesarean deliveries. The first emergency cesarean was recommended by her gynecologist at 42 weeks gestation following fetal distress while in labor. The second one was an elective cesarean preferred by the client following the first experience. Additionally, the client reported surgical management of a previous miscarriage two years ago.
Referral source: Patient
Source and reliability: The source is highly-reliable since the client walked to the clinic today following a sudden onset of severe abdominal pains.
Menstruation: The client got her monthly periods at 14 years. She reports having a regular cycle of 28 days. Her period lasts for 3 to 4 days. She has a heavy flow accompanied by abdominal cramps. The client reported that cramps are more severe on day one and reduce over time. However, the client denies receiving her monthly periods in the last 8 months.
Contraceptives: The client reports using the daily pill in the last three years. She a single pill daily at night before retiring to bed without skipping. The pill has been effective in preventing pregnancy. The client reported conceiving after discontinuing her pills. She denies side effects associated with the pill such as dizziness or nausea.
Vaginal and cervical examination: Her last Pap smear test was conducted in 2020. The client reported that the examination results were normal.
Obstetric history: The client reports two previous pregnancies and one miscarriage. During both pregnancies, she delivered via caesarian section. The first one was an emergency cesarean, which was recommended by her gynecologist at 42 weeks gestation following fetal distress while in labor. The second one was an elective cesarean.
Sexual history: The client is heterosexual and she is sexually active with a single intimate partner.
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GYN problems: The client reported being diagnosed with urinary tract infection (UTI) in 2019, and was treated using antibiotics. She denies incidents of recurring UTIs. The client reports being diagnosed with an ovarian cyst in 2018.
General Medical History
Medications: The client is not under any medication.
Allergies: The client denies known food, drug, or environmental allergies.
Past Medical History (PMH): Denies history of chronic illnesses.
Past Surgical History (PSH): Reports two caesarian deliveries. Denies other surgical procedures.
Personal/Social History: The client is a lawyer, currently working with a new law firm based in the city. She has been married for the past 7 years. She lives with her husband and their two kids (5yo daughter and 2yo son) in a four-bedroom bungalow, located on the city’s outskirts. The client is currently a part-time student pursuing a master’s degree in law. She enjoys spending time with her family during her off days or over the weekend. The client also likes spending her free time at the gym or swimming pool. She reports being a social drinker. She takes 2 to 4 beers when she goes out with her friends over the weekend. The client denies cigarette smoking or using other illegal substances, including cocaine and heroin. She reports taking a glass of coffee daily in the evening. She takes a minimum of 6 glasses of water daily. She reports being an active church member and participating in church activities.
Health Maintenance: The client visits her gynecologist for a Pap smear every 2 years. The last Pap smear test was conducted in 2020 and the results were normal. She also takes a balanced diet and engages in physical activities, including jogging, swimming, and morning run.
Immunization History: All her childhood immunizations are up to date. She received COVID-19 immunization in October 2020.
Significant Family History: The client reports that her both parents are alive. Her father is 72 yo with a history of diabetes type 2 Mellitus and hypertension. Her mother is 65yo with high blood cholesterol, obesity, and breast cancer. The client has three siblings who are all healthy with no known chronic illnesses. However, a younger sister aged 33 years had a miscarriage last year, losing her fetus at 24 weeks. Her maternal grandmother died of breast cancer at 85 years. Her maternal grandfather is alive at 90 years with prostate cancer and hypertension. Her paternal grandmother died of hypertension at 83 years. Her paternal grandfather died of a cardiovascular attack at 87 years.
Review of Systems:
General: The client denies weakness, fatigue, or night sweat.
HEENT: The client denies head trauma or headache. She denies visual loss, eye discharge, or eye pain. The client denies ear pain, hearing difficulty, or ear discharge. She denies nasal blockage, sneezing, runny nose, or nose bleeding. The client denies difficulty in swallowing.
SKIN: She denies rashes, cracking, or itchiness.
Breast: Denies breast masses.
CARDIOVASCULAR: She denies palpitations or nocturnal orthopnea.
RESPIRATORY: She denies difficulty in breathing, coughing, or fast breathing.
GASTROINTESTINAL: She denies nausea, abdominal pains, loss of appetite, heartburn, and diarrhea. She reports severe abdominal pain. She reports uncontrollable vomiting that accompanies the abdominal pain.
GENITOURINARY: She denies frequent urination. Reports previous urinary tract infection (UTI) and ovarian cyst diagnosis.
NEUROLOGICAL: The client denies paralysis, headache, dizziness, or numbness. She reports collapsing earlier at home.
MUSCULOSKELETAL: She denies joint stiffness or swelling around the joints.
HEMATOLOGIC: She denies bleeding or bruising.
LMPHATICS: Denies swollen lymph nodes.
PSYCHIATRY: Denies hallucinations, anxiety, suicidal ideations, or depression.
ENDOCRINOLOGIC: Denies polyuria or heat and cold intolerance.
ALLERGIES: Denies rhinitis, asthma, or eczema.
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Vital signs: BP 53/38 mm Hg, RR 16 per minute, pulse 100 bpm; OS 100%.
General: The client is presentable and well-groomed. She looks well-nourished and appears younger than her actual age. The client is in good nutritional status. She seems to be in acute distress. She is attentive throughout the clinical interview and answers interview questions correctly. She expresses her concern over the current state and health condition of her fetus. She seems to be anxious and agitated. Her judgment is good and she is future-oriented. She is alert and oriented to places, events, and persons. The client is future-oriented.
HEENT: Head examination indicated a normocephalic head with no scars. She has long and well-maintained hair, which is evenly distributed on the whole head. Head palpation indicated the absence of tenderness or masses. Eye inspection indicated no eye discharge or excessing tearing. She has clear conjunctiva. Her ears have a normal external auditory canal. No bulging in the tympanic membrane. Nose inspection indicated pink and moist nasal mucous membranes. No tenderness was elicited by the palpation of the sinuses. A throat examination indicated a pink and moist mucous membrane. The client’s uvula is in the midline. No exudate in the posterior pharynx.
Neck: The neck is flexible and moves round in all directions. No swellings or scars were seen on inspection. Palpation indicates that the trachea is in the midline. No tenderness or swelling.
Skin: Her skin is per the ethnicity with no rashes. On palpation, it is warm, well-perfused, with a normal skin turgor.
Cardiovascular: No scars or deformities seen on the chest on examination. No tenderness was detected on palpation. No peripheral pulses or edema. No finger clubbing. Normal rate and rhythm detected. S1 and S2 were heard on auscultation. No added sounds or murmurs.
Respiratory: Her chest moves with respiration on inspection. Palpation detected no tenderness. No palpable masses. Normal breath sounds were heard on auscultation.
Gastrointestinal: A protruding abdomen is seen. On inspection, her abdomen moves with respiration. No hyperpigmentation or scars. Bowel sounds were audible in all quadrants on auscultation. Tympanic sounds were heard on percussion. The abdomen is warm and hard on percussion. On abdominal palpation, an exquisitely tender abdomen with guarding was detected.
Genitourinary: Her pubic hair is neat and shaved on inspection. No vaginal discharge or blood spots were seen. Normal external genitalia. No suprapubic tenderness. The uterus is enlarged.
Neurological: Normal muscle tone and strong and equal bilateral hand grip.
Musculoskeletal: No bone deformities. All limbs are present. No joint swelling. Her strength is 5/5.
i. Cardiotocography: Was performed to monitor the fetal. The tachograph indicated uterine irritability characterized by low amplitude and high frequency.
ii. Full blood count: Haemoglobin level was 11.4 g/dL,
iii. Insertion of a foley urinary catheter: The results indicated a good volume of clear urine.
iv. Mobile ultrasound assessment: Results indicated fetal heart movements and posterior, transverse presentation, and low-lying placenta.
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Primary Diagnosis: Acute Uterine Torsion
The primary diagnosis for this client is uterine torsion, which is a rare condition during pregnancy. A person can rarely experience uterine torsion more than once. This condition is characterized by the rotation of the uterus by more than 45° (Ghalandarpoor-Attar & Ghalandarpoor-Attar, 2022). The rotation occurs on its long axis. The rotation can range between 60° and 720°, with most cases being around 180° (Ghalandarpoor-Attar & Ghalandarpoor-Attar, 2022). The rotation takes place at the junction between the uterine corpus and cervix. It is common to experience a slight rotation of the uterus, which does not exceed 45°during pregnancy. Additionally, this rotation mostly occurs towards the right side. Uterine torsion is attributed to fetal compromise. Approximately 12% of uterine torsion cases are attributed to perinatal mortality (Ghalandarpoor-Attar & Ghalandarpoor-Attar, 2022). Tissue ischemia due to uterine artery compression is the most common cause of uterine torsion. This condition can lead to maternal mortality depending on gestation. Maternal deaths rarely occur among expectant women below 20 weeks gestation. The risk of maternal mortality between 20 and 28 weeks gestation is approximately 17% (Ghalandarpoor-Attar & Ghalandarpoor-Attar, 2022). The prevalence of maternal death is 10% and 9% at 29–34 weeks gestation and term gestation, respectively (Ghalandarpoor-Attar & Ghalandarpoor-Attar, 2022). Overall, uterine torsion is associated with 13% of maternal mortality depending on the degree of torsion and gestation duration.
Uterine torsion is characterized by various clinical manifestations, including birth obstruction, vaginal bleeding, abdominal pain, intestinal and urinary symptoms, shock, nausea and vomiting, fetal heart rate changes, hemodynamic instability, increased fundal height, uterine hypertonicity, and decreased fetal movements (Yin et al, 2020). Upon reporting to the clinic, the client complains about severe abdominal pain, occurring over her previous cesarean scar predominantly. She added that the abdominal pain was characterized by uncontrollable vomiting. Therefore, uterine torsion qualifies as the primary diagnosis since it’s characterized by abdominal pain, nausea, and vomiting.
The potential differential diagnoses for this client are listed below starting with the most likely diagnosis.
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Scar dehiscence is a potential diagnosis for this client. This condition is characterized by excessive vaginal bleeding, contractions that reduce in intensity, sudden pain between contractions, abnormal abdominal pain, bulging under the pubic bone, or sudden pain that occurs at the site of a previous uterine scar (Abdelazim et al., 2018). The client might have this condition since she reports sudden and severe abdominal pain, occurring over her previous cesarean scar. However, this condition is ruled out due to the absence of significant symptoms such as pain occurring between contractions, excessive vaginal bleeding, and contractions that reduce in intensity or bulging under the pubic bone.
Uterine rupture is another potential diagnosis for this client. This condition is characterized by sudden and severe uterine pain, regression of the fetus in the womb, uterine contractions, which don’t cease, severe vaginal bleeding or hemorrhaging, or fetal distress (Savukyne et al., 2020). The client qualifies for this diagnosis since she reported sudden and severe abdominal pain, occurring over her previous cesarean scar. Nonetheless, this condition is ruled out due to the absence of significant symptoms, including regression of the fetus in the womb, uterine contractions, which don’t cease, severe vaginal bleeding or hemorrhaging, or fetal distress.
Concealed Placental Abruption
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The last differential diagnosis for this client is concealed placental abruption. This condition is characterized by excessive vaginal bleeding, abdominal pain, uterine rigidity or tenderness, back pain, and uterine contractions (Sharma, 2018). The client reported sudden and severe abdominal pain, occurring over her previous cesarean scar; hence qualifying for this diagnosis. However, concealed placental abruption is ruled out following the absence of significant symptoms, including excessive vaginal bleeding, uterine rigidity or tenderness, back pain, and uterine contractions.
Consent was obtained from the emergency cesarean section before the patient was transferred to the theatre. Fetal heart rate was reduced from 140 bpm to 90 bpm. Upon arriving at the theatre, the fetal heart rate had decreased further to 85 bpm. The healthcare provider administered an anesthetic before performing an emergency cesarean section. The pelvic anatomy was distorted significantly. Additionally, the urinary bladder and ureterovesical peritoneum could not be identified. The ovary and her left fallopian tube had been pulled across the uterine body and were lying on her right side. This incident indicated that the client’s uterine had undergone torsion of about 180° along its longitudinal axis. A curved transverse incision was applied to incise the uterus. The client delivered a live female infant from a transverse lie through a breech extraction. The client was transferred to the neonatal unit where she received continuous positive airway pressure. She was also closely monitored for any health complications. She was discharged after seven days in a stable state. She was advised to return to the clinic after two weeks for follow-up care.
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Abdelazim, I. A., Shikanova, S., Kanshaiym, S., Karimova, B., Sarsembayev, M., & Starchenko, T. (2018). Cesarean section scar dehiscence during pregnancy. Journal of Family Medicine and Primary Care, 7(6), 1561.
Ghalandarpoor-Attar, S. N., & Ghalandarpoor-Attar, S. M. (2022). Uterine torsion as an elusive obstetrical emergency in pregnancy: is there an association between gravid uterus torsion and Ehlers–Danlos syndrome?: a case report. Journal of Medical Case Reports, 16(1), 1-5. https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-022-03409-4
Savukyne, E., Bykovaite-Stankeviciene, R., Machtejeviene, E., Nadisauskiene, R., & Maciuleviciene, R. (2020). Symptomatic uterine rupture: a fifteen year review. Medicina, 56(11), 574. DOI:10.3390/medicina56110574
Sharma, M. K. (2018). Concealed abruptio-placenta and disseminated intravascular coagulopathy: a near fatal management experience in a peripheral center. International Surgery Journal, 5(10), 3430-3432. DOI: http://dx.doi.org/10.18203/2349-2902.isj20184104.
Yin, F. L., Huang, H. X., Zhang, M., Xia, X. K., Xu, H., Liu, T., … & He, H. G. (2020). Clinical analysis of uterine torsion and fibroids in full-term pregnancy: A case report and review of the literature. Journal of International Medical Research, 48(6), 0300060520920404. https://doi.org/10.1177/0300060520920404