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Case Presentation

Case Presentation. Obstestrics 성균관대학교 의과대학 m5 손의영 Pt ID : 17001406 주 0 희 37/F. Chief Complain. Amenorrhea for 38 + 5 weeks w/ vaginal bleeding Onset : 2011-06-12 PM 09:00 부증상 : previous C-sec Large for Gestational Age. Obstetric History. Para : (1) - (0) - (1)(1,0) - (1)(1,0)

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Case Presentation

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  1. Case Presentation Obstestrics 성균관대학교 의과대학 m5 손의영 Pt ID : 17001406 주0희37/F

  2. Chief Complain • Amenorrhea for 38 + 5 weeksw/ vaginal bleeding • Onset : 2011-06-12 PM 09:00 • 부증상 : previous C-sec Large for Gestational Age

  3. Obstetric History • Para : (1) - (0) - (1)(1,0) - (1)(1,0) • 최종 월경 시작일 : 2010-09-14 • 분만예정일 : 2010-06-21

  4. Present Illness • Routine OB Lab : 특이사항 (No) • HBsAb/Ag (+/-), Rubella IgG/IgM(+/-) • Last Pap : 2008-10 특이사항(No) • Serum screening test : Quad test • 결과 (+) Down syndrome • Amniocentesis : Karyotype ( Normal) • 50g OGTT : ▲181mg/dL • 100g OGTT : ( 83 - 113 - 111 - 102 )mg/dL • CBC : 특이사항 (No)

  5. Present Illness • Vaginal bleeding 2회로 ER 내원, 경과 관찰 후 퇴원 • 2011.04.07 (PA29+2wks) • 2011.04.28 (PA32+2wks) • 2011.06.12(PA38+5wks)오버나이트 패드에 1/3 blood clot 양상으로 피비침 있어서 r/o Placenta previapartialis의심하에 본원 응급실 통하여 입원. • Speculum exam : 2x2cm sized blood clot, mild bleeding, no erosion on cervix • Labor feel / pain (-/-)

  6. Other History • PMHx. • HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - ) • 약물력: (No) • 수술력: 2005-08-05 AIS -> Conization at SMC by F. 김태중Uterine cervix, conization: Chronic cervicitiswith squamousmetaplasia and mild glandular atypia • FHx. • 당뇨 : (+) • 고혈압 (-), 유전질환 (-) • SHx. • Marriage : 기혼 • smoking: no • alcohol: no

  7. Review of System • Obstetric symptoms • Fetal movement (Yes) • Uterine contraction (No) • Vaginal bleeding (Yes) • Watery vaginal discharge (No) • General symptoms • 임신 전 체중 : 67kg 현재 체중 : 83kg • 그 외 이상 소견 없음

  8. Physical Exam • General appearance • Not so ill looking • Mental status : Alert • Abdomen • Palpitation : Distended d/t pregnancy • Tenderness (No) • Rebound tenderness (No)

  9. Physical Exam • 산과 진찰소견 • FHR : Normal by USG • Presenting part : Cephalic • Rupture of membrane ( No) • Vaginal bleeding (Yes) : amount – 오버나이트 패드 1/3 적시는 정도 for 1hr

  10. Assessment • Pregnancy: 38 + 5 주 (2011-06-12 기준) • R/O placenta previa

  11. Plan • 진단계획 USG NST Check vaginal bleeding • 치료계획 Elective or Emergent C/sec 6/16 Time C/sec • 퇴원계획 수술 후 합병증 없을 시 PP#4 퇴원

  12. Hospital Course • 2011-06-13 (38+6 weeks) • C-sec : Emergent Low segment transverse • Baby 1 • 남아 (4.29)kg • APGAR Score : 1min 9pts, 5min 9pts • MS (0) CN (1) GA ( No) • 분만시간 : 11:18 • NR • 수술후진단명 • Placenta previamarginalis • Previous cesarean delivery • Macrosomia • s/p conization

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