Week 9 Assignment 1: Case Study

Week 9 Assignment 1: Case Study

 

Week 9 Case Study Worksheet

Valencia Week 24 Prenatal Visit: Bleeding

Subjective Information

Based on the provided case study, the 34-year-old African American female patient by the name of Valenciapresents to the clinic during her 24-week prenatal visit with a chief complaint of cramping, moderate vaginal bleeding, and yellow discharge. She however denies itching, irritations, dysuria, urinary frequency, or vaginal odor. She has a history of two pregnancies and one birth (gravida 2 para 1). She also reports being in a monogamous relationship with the same boyfriend through all her pregnancies.

Additional subjective data is however needed for further assessment of the patient’s pregnancy and presenting chief complaints. For instance, the patient needs to explain the characteristics of the cramping such as sharp or dull, constant and comes in intervals, and whether it’s sudden or excruciating (Al‐Memar et al., 2019). The patients also need to specify the severity of the associated symptoms such as vaginal bleeding. Other relevant subjective information needed include the patient history of substance use, past surgical history, and past medical history. The patient should also be able to explain whether she has been using medication such as antibiotics, which are associated with vaginal bleeding during pregnancy.

Objective Information

From the objective portion of the patient history, her blood pressure is 128/88, which indicates prehypertension or high normal. The patient also has a BMI of 29.29 increased from the initially recorded BMI of 21.12, which is slightly above the normal weight gain during pregnancy(Klahr et al., 2019). Her fetal heart rate is also elevated, 155 bpm, but within the normal range (120-160 bpm) recommended by most international clinical guidelines. Upon conducting a further examination, it was noted that the patient’s fundal height is 26 cm. Urine tests show negative results for nitrates, glucose, and proteins.

Additionally, it is necessary to palpate the patient’s abdomen for further evaluation of the location and severity of the patient’s cramping and determine her uterine size. Ultrasonography results are also needed to confirm normal placenta and vessel location (Vandana, 2019). Speculum examination may also be necessary. If the ultrasound displays normal results, then digital examination can be introduced to determine cervical dilation and effacement.

Assessment

The patient presents with vaginal bleeding during her 24^th-week prenatal visit, which may indicate abruptio placentae, placenta previa, and vasa previa. However, she also reports cramping and yellow discharge which may suggest the possibility of a sexually transmitted infection(Klahr et al., 2019). She however denies vaginal odor and irritations which are common signs of infection. As such, the most possible differential diagnoses include:

1. Abruptio placentae-occurs when the placenta detaches from the uterus sooner than expected, normally after the 20^th week of pregnancy (‌El Miski et al., 2021). Clinical presentations normally include uterine pain, vaginal bleeding, and haemorrhagic shock among others. The patient in the provided case study displayed symptoms of cramping and vaginal bleeding during her 24^th-week prenatal visit, which support this diagnosis. Consequently, she is also prehypertensive which is associated with increased risks of abruptio placentae. she is however negative for disseminated intravascular coagulation and hemorrhagic shock, hence ultrasonography is needed to confirm the diagnosis.
2. Placenta previa-occurs in case of abnormal implantation of the placenta near or over the internal cervical os. Patients will normally display painless vaginal bleeding bright red after the 20^th week of pregnancy(Jain et al., 2020). It is common among patients who are older to present with a history of complications of pregnancy like Jackie. Some patients may present with uterine contractions in addition to the bleeding. However, for the case of Jackie, her vaginal bleeding is associated with cramping and yellow discharge, which disqualifies this diagnosis.
3. Vasa Previa-occurs when the membrane containing the fatal blood vessels that connect the umbilical cord and placenta overlie are within 2cm from the internal cervical os. It is associated with painless vaginal bleeding, fetal bradycardia, and rupture of membranes. Transvaginal ultrasound is needed to confirm this diagnosis (‌Wahane et al., 2020). However, the patient in the provided case study only presented with vaginal bleeding associated with cramping and yellow discharge, which disqualifies this diagnosis.

Plan

Further assessment and/or diagnostic tests: Tests that should be ordered include complete blood count (CBC), type and screen, ultrasonography, and possibly Kleihauer-Betke testing (Klahr et al., 2019). If the bleeding is severe, then disseminated intravascular coagulation tests should also be ordered. Additional tests include a test for infections such as UTI, chlamydia, and gonorrhea.

Treatments: IV fluid resuscitation, starting with normal saline solution 20mL/kg. Blood transfusion should be considered if the patient does not respond to 2l normal saline solution, continue bleeding or display abnormal vital signs or lab tests (Jain et al., 2020).

Education:The patient should be educated on the importance of being hospitalized so that her fetus can be monitored and treated as needed(‌El Miski et al., 2021).

Referrals: An Obstetrician-Gynecologist (Ob-Gyn) should be called upon for further assessment of the patient’s condition, to determine the actual course of her symptoms(‌Wahane et al., 2020).

Follow-up: The patient’s symptoms should be closely monitored to avoid complications associated with the pregnancy (Klahr et al., 2019).

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References

Al‐Memar, M., Vaulet, T., Fourie, H., Nikolic, G., Bobdiwala, S., Saso, S., … & Bourne, T. (2019). Early‐pregnancy events and subsequent antenatal, delivery and neonatal outcomes: prospective cohort study. Ultrasound in Obstetrics & Gynecology, 54(4), 530-537. https://doi.org/10.1002/uog.20262

‌El Miski, F., Benjelloun, A. T., Bouab, M., Lamrissi, A., Fichtali, K., & Bouhya, S. (2021). Spontaneous uterine rupture during the first trimester of a partial molar pregnancy in a scar uterus: A rare case report. International Journal of Surgery Case Reports, 85, 106229. https://doi.org/10.1016/j.ijscr.2021.106229

Jain, V., Bos, H., & Bujold, E. (2020). Guideline No. 402: diagnosis and management of placenta previa. Journal of Obstetrics and Gynaecology Canada, 42(7), 906-917. https://doi.org/10.1016/j.jogc.2019.07.019

Klahr, R., Fox, N. S., Zafman, K., Hill, M. B., Connolly, C. T., & Rebarber, A. (2019). Frequency of spontaneous resolution of vasa previa with advancing gestational age. American Journal of Obstetrics and Gynecology, 221(6), 646-e1. https://doi.org/10.1016/j.ajog.2019.06.040

Vandana, J. (2019). Need of Sonography in Vaginal Bleeding in Early Pregnancy; As a Primary Investigation. Journal of Medical Science and Clinical Research, 7(12). https://doi.org/10.18535/jmscr/v7i12.52

‌Wahane, A., Zele, M., & Patil, B. (2020). A study of maternal and fetal outcomes in cases of abruptio placentae. Parity, 37(4), 2-70.DOI:10.33545/gynae.2020.v4.i4b.624

 

Patient Introduction

Pt is Valencia, a 34-year-old African American female. Gravida 2, para 1. She is still with her current boyfriend in a monogamous relationship.

Initial Physical Exam

• WGT: 124 lbs. Height 64 inches VS 98.4, 76, 16, 126/86
• General appearance: alert, no acute distress, well hydrated, well developed and well-nourished
• Neuro: oriented to all spheres, affect and mood is appropriate
• Head: atraumatic, normocephalic
• Ears: no external deformities, gross hearing intact
• Eyes: no external deformities, gross vision intact
• Nose: no discharge, inflammation or lesions
• Oral: good dentition, no erythema, exudate, lesions. Tongue protrudes midline, positive gag reflex, uvula rises midline with phonation
• Neck: trachea midline, no lymphadenopathy
• Cardiac: 76 regular rhythm, no murmur or gallops
• Lungs: no respiratory distress, no use of any accessory muscles, lungs are clear to auscultation bilaterally, percussion resonant throughout with symmetrical lung expansion
• Breasts: are symmetrical medium size, nipples everted, no asymmetry, skin changes, nipple discharge, masses or tenderness. Negative lymphadenopathy
• Abdomen: non-distended, non-tender, normal bowel sounds in all four quadrants, no hepatosplenomegaly, no hernias.
• Extremities: no clubbing, cyanosis, edema or deformities noted. Full range of motion in all joints, warm to touch, good capillary refill
• External genitalia: normal appearance, normal labia majora and minora, no lesions, masses or lymphadenopathy. Urethra is normal with no discharge
• Internal genitalia: no lesions, adequate pelvic support, no discharge noted
• Cervix: multip, normal and posterior, no cervical motion tenderness, no lesions
• Uterus: smooth, mobile, non-tender measuring about 8 weeks size, adnexa is normal, no masses non-tender

Initial Laboratory

• CBC: Hemoglobin 13.2, hematocrit 38, WBC 7.5, RBC 4.12, platelets 212,000
• Blood type: O negative, negative antibody
• TSH: 1.55
• Rubella: positive
• RPR: non-reactive
• Hepatitis B surface antibody positive: antigen negative
• Hepatitis C antibody negative
• Hepatitis A antibody negative
• HIV: negative
• Varicella: immune.
• Toxoplasmosis: negative
• Tay-Sachs: negative
• Cystic fibrosis: negative
• Urinalysis: normal
• Urine culture: negative
• Gonorrhea culture: negative
• Chlamydia culture: negative
• Pap smear: normal
• Parvo IGM 0.08, IGG 3.73

24 week prenatal visit

Valencia returns to clinic at 24 weeks. Her blood pressure is 128/88. She weighs 172 lbs. Fetal heart tones are 155 beats per minute. Fundal exam is 26 cm. Urine dip negative for protein, glucose, nitrates. She reports cramping, moderate vaginal bleeding and yellow discharge. No vaginal odor, itching or irritation, no urinary frequency or dysuria.