Download Name UNGRIA, Florence Date Admitted 9/3/2013 Age/GP 41 years

Name
Age/GP
Address
UNGRIA, Florence
41 years old / G2P1 (1-0-0-1)
63 Santa Cecilia Street, San Antonio
Valley 14, Sucat, Paranaque City
Date Admitted
Date of Operation
Case number
9/3/2013
9/3/2013
3939153
Admitting Diagnosis
Pregnancy uterine thirty seven weeks and six days age of gestation,
cephalic, in labor
Status post primary low segment cesarean section for cephalopelvic
disproportion (2000, Paranaque Hospital)
Pre-eclampsia severe
Gravida 2 Para 1 (1-0-0-1)
Intraoperative
Diagnosis
Pregnancy uterine delivered by repeat low segment cesarean section,
cephalic, term, livebirth, appropriate for gestational age
Early postpartum hemorrhage secondary to uterine atony
Status post primary low segment cesarean section for cephalopelvic
disproportion (2000, Paranaque Hospital)
Pre-eclampsia severe
Gravida 2 Para 2 (2-0-0-2)
Procedure
Repeat low segment cesarean section with total hysterectomy under
spinal anesthesia converted to general anesthesia
Final Diagnosis
Pregnancy uterine delivered by repeat low segment cesarean section,
cephalic, term, livebirth, appropriate for gestational age
Early postpartum hemorrhage secondary to uterine atony
Status post repeat low segment cesarean section with total
hysterectomy (September 2013, PGH)
Status post primary low segment cesarean section for cephalopelvic
disproportion (2000, Paranaque Hospital)
Pre-eclampsia severe
Gravida 2 Para 2 (2-0-0-2)
OPERATIVE TECHNIQUE
Patient placed in supine position under spinal anesthesia.
Bladder catheterized aseptically.
Povidone-iodine scrub and antiseptic used for vaginal, perineal and abdominal skin preparation.
Sterile drapes placed.
Previous surgical scar excised
Midline vertical infraumbilical incision done and was carried down to the peritoneum.
Abdominopelvic organs inspected.
Lower uterine segment identified.
Vesicouterine fold identified and incised.
Bladder deflected inferiorly.
Transverse curvilinear incision made over the lower uterine segment.
Baby delivered by gently scooping the head followed by gentle traction to deliver the rest of the body.
Umbilical cord doubly clamped and cut in between clamps after the pulsations stopped.
The baby was latched on.
Placenta delivered spontaneously and inspected.
Uterus repaired in two layers:
1st layer: continuous interlocking stitches using Vicryl 0 atraumatic suture
2nd layer: continuous stitches using Chromic 0 atraumatic suture
Hemostasis.
The uterus was boggy despite continuous uterine massage and maximum medical management.
Proceeded with total hysterectomy.
Anesthesia converted to general anesthesia.
Balfour self-retaining retractors inserted. Visceral packs put in place.
Right and left round ligaments grasped with Kelly clamps, cut and suture-ligated.
Anterior leaves of the right and left broad ligaments opened to the point of reflection of bladder
peritoneum on the uterus.
Bladder separated from the lower uterine segment and upper cervix by careful dissection.
Posterior leaf of the right and left broad ligament incised to the point of origin of the uterosacral
ligaments.
Ureters identified.
Triple clamping of the right and left uterotubal junctions and uteroovarian ligaments followed by cutting
between the medial and middle clamp, double tying beneath the most lateral clamp and suture
ligation beneath the middle clamp.
Uterine vessels exposed and skeletonized.
Uterine vessels triply clamped with Zeppellin’s clamps and doubly suture-ligated.
Straight Heany clamps placed sequentially across the cardinal ligaments, between the uterine vessels
and the uterine isthmus, followed by cutting of the ligament from the uterus and suture ligation.
Uterosacral ligaments clamped, cut, and suture ligated.
Uterus removed by circumferential cutting closely beneath the cervix.
Allis clamps used to secure the stump margins.
Lateral vaginal angles secured with simple interrupted sutures and anchored to the stumps of the
cardinal ligaments. Vaginal margins secured with continuous interlocking stitches using Vicryl O-A
suture using an open vault technique.
Peritoneal washing done. Meticulous hemostasis observed.
Ureters identified and checked. Pelvic and abdominal organs palpated.
Balfour self-retaining retractors and visceral packs removed.
Operative sponge, visceral packs, needle and instrument count complete and verified.
Abdomen closed in anatomic layers.
Fascia: Continuous interlocking stitches using Vicryl O atraumatic suture
Subcutaneous: Interrupted figure-of-eight stitches using plain 2 0 atraumatic sutue
Skin: Subcuticular stitches using Vicry 4 0 atraumatic suture
Antisepsis. Sterile dressing placed.
Patient tolerated the procedure well
OPERATIVE FINDINGS
There was no ascites. The liver, subdiaphragmatic surface, liver, gall bladder, stomach,
pancreas, spleen, kidneys, omentum and appendix were grossly normal.
The lower uterine segment was formed and intact. The amniotic fluid was thinly stained.
Delivered a live baby boy, weighing 2,800 grams in cephalic presentation, 38 weeks by pediatric aging,
APGAR score of 9 remaining 9. The placenta was implanted at the posterior fundal area. The umbilical
cord had 2 arteries and 1 vein.
The uterus was floppy and pale which measured 15 x 12 x 6 cm. On cut section, the
myometrium is 2.8 cm at the posterior fundal area, the endometrium measured 0.6 cm, the uterine canal
measured 12 cm, the endocervical canal measured 3.5 cm. The myometrium measured 2.5 cm
anteriorly and posteriorly.
Both ovaries and fallopian tubes were grossly normal. The rest of the pelvic organs were
grossly normal.
Estimated blood loss: 2500 ml
Mark Q. Antonio, M.D.
Surgeon