Case #1: A 35-yr-old is admitted at 38 3/7 weeks in active labor. History: Gestational DM, on insulin, history of hyperemesis in 1st trimester, resolved. Pt has bicornuate uterus, with fetus in right side.
Hospital Course: After 2 hours a vaginal exam is performed showing little progress, only at 3 cm, due to irregular and weak contractions. Pitocin augmentation is given per protocol. An IUPC is inserted after administration of epidural. Pt rechecked several hours later, fetal head is still at -2, failure to descend. Pt taken to OR for LTCS, delivery of a viable male infant. On POD #2, pt noted to be hemorrhaging blood. Is returned to OR for exploration. Site is reopened, with retained POC found and removed. Two units PRBCs given.
Case# 2. A 38-yr-old primigravida is admitted at 42 1/7 weeks gestation for repeat induction of labor with Pitocin. Pt is Somalian, status post female circumcision with infibulation. Medications on admit: Xanax for anxiety disorder, atenolol for chronic HTN. Pt progressed to full dilation in 5 hours, taken to delivery suite. Consent obtained for anterior episiotomy with approval to leave open. Pt had precipitous 2nd stage with delivery of a viable female infant. Nuchal cord x 1. Examination revealed high vaginal laceration, repaired. Coccygeal fracture noted on 1st PP day, due to fetal head during delivery.
Case #3: 26-yr-old primigravida with history of genital herpes (last outbreak 3 years ago, not on antiviral therapy), hypothyroidism on replacement therapy, s/p bariatric surgery, and s/p cervical conization 2 yrs prior to admission is now admitted in active labor. After 3 hrs a vaginal exam reveals presentation of fetal face and hand. Midline episiotomy performed. Maternal pushing efforts not effective, felt due to shoulder dystocia. McRoberts maneuver and suprapubic pressure applied with resolution of dystocia. Delivery of a viable female infant. Perineum examined, showing extension of episiotomy, repaired. After 1 hour post-delivery, placenta shows no sign of release from uterus. Manually extracted.
Answers:
Case #1: Principal Diagnosis: 652.51
Secondary Diagnoses: 648.81, 654.01, 653.11, 666.22, V27.0, V58.67
Procedures: 74.1, 99.04.
Case #2: Principal Diagnosis: 645.21
Secondary diagnoses: 665.41, 663.21, 665.61, 661.31, 642.01, 648.41, 300.00, V27.0
Procedures: 73.59, 73.6, 73.4, 75.69
Case #3: Principal Diagnosis: 660.41
Secondary Diagnoses: 652.41, ?652.7/81 for hand, 664.11, 654.61, 648.11, 244.9, 649.21, V12.09, V27.0
Procedures: 73.59, 73.6, 75.69, 75.4
Note: Answers are author's views. Please refer to the ICD-9-CM for answers.
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