Title: threatened preterm labour

Summary 26 years old Malay lady primigravida at 34th week from period of amenorrhea presented with abdominal pain, slight show, associated with history of two threatened preterm labour due to urinary tract infection and falling, two previous gynaecological surgical histories –endometriosis and ovarian polyps.

Introduction a. Background of the study Preterm labour is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk). Risk factors for preterm birth include demographic characteristics, behavioural factors, and aspects of obstetric history such as previous preterm birth. Demographic factors for preterm labour include non-white race, extremes of maternal age (<17 y or >35 y), low socioeconomic status, and low pre-pregnancy weight. Preterm labour and birth can be associated with stressful life situations (eg, domestic violence; close family death; insecurity over food, home, or partner; work and home environment) either indirectly by associated risk behaviours. As the cause of labor still remains elusive, the exact cause of preterm birth is also unsolved. Labor is a complex process involving many factors. Generally, four different pathways have been identified that can result in preterm birth and have considerable evidence: precocious fetal endocrine activation, uterine overdistension, decidual bleeding, and intrauterine inflammation/infection. b. Rational and significance of choosing the case Threatened preterm labour is a very hard topic to be study without reference point. Therefore, this case has been selected for study of threatened preterm labour based on few actors; this is not a complicated case of threatened preterm labour, there are multiple factors that may results the threatened preterm labour presentation in this case which includes present presentation and the patient’s history. Thus, the case itself can be easily said as an example multiple causative case of threatened preterm labour that is very well presented such it can help the researcher to understand and comprehend the meaning of threatened preterm labour.

History of Admission a. Patient’s biography Name initials Age Sex Religion Civil status Race Occupation Admission Clerking : Mdm N.A : 26 : Female Islam : married : Malay : government officer 1/3/2010 2/3/2010

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b. Chief complaint Patient is currently G1 P0 at 34 weeks 4 days POA. She came by herself, with abdominal pain associated with slight show, no leaking. Fetal movement was present and good.

History of presenting illness Prior to the admission, patient had history of 2 previous threatened preterm labours due to urinary tract infection at 25+ weeks and from falling at 28 weeks, injuring her right thigh –just involving soft tissue injury. On the day of admission, patient was doing normal household chores when she suddenly feels sudden back pain similar to the previous threatened preterm labour episodes. The pain was associated with per vaginal bleeding –noted by blood at her sarong. She mentioned that the contraction was not regular and not very consistent. Immediately, she went to the hospital and admitted into antenatal care for observation.

Review of system system Cardiovascular Endocrine Gastrointestinal Genitourinary Hematopoietic Musculoskeletal Neurologic Respiratory Finding no significant findings such as palpitation, lower limb edema, orthopnea, syncope, dizziness, etc. No significant findings such as moon features, exophthalmos, tremor, acrommegaly, etc. No significant findings such as diarrhea, constipation, altered bowel movement, etc. No significant findings such as dysuria, oliguria, hematouria, incontinence, nocturia, etc. No significant findings such as pallor, jaundice or bleeding tendency, etc. No significant findings such as myalgia, arthargia or arthritis, etc. arthritis, No significant findings such as recurrent headaches, fits, blurring of vision or drowsiness, etc. No finger clubbing, no accessory muscle used during respiration, no shortness of breath, no noisy breathing, no hemoptysis, no night sweats. No significant findings. The skin color is normal according to his race; with hair growth distribution is normal. Nail is normal, no clubbing, koilonychia, leukonychia, etc. Normal head size, shape and symmetry; no skull enlargement, bossing, etc. no significant findings of the neck such as webbing, goiter, etc. As stated

Skin, hair, nails

Head and neck Reproductive

Comprehensive health history a. Antenatal history This is an unplanned but wanted pregnancy. She noticed that she pregnant after had missed about 2 weeks of her period, confirmed by pregnancy test kit. Her L.M.P was 2.7.2009 (sure of date) and E.D.D is 9/4/2010, confirmed by scan. First scan was done at 18th week, and the latest was at 32nd week with parameters corresponds to date. She was screened for VDRL, HIV, hepatitis B and it was negative. She was normortensive, normoglycemic and no significant glycosuria was recorded. b. Obstetric history She is primigravida c. Gynaecology history She attained menarche at 14 years old with regular cycle of 30 days with flow of 7 days. She does not experiencing dysmenorrhoea, menorrhagia, postcoital bleed and no deep dyspareunia. She claimed never took any contraception pill before. She had history of ovarian cyst and went for surgery at HUSM 2005, history of endometriosis and went for surgery at HKL 2006. d. Past medical & surgical history No significant history of medical illness or surgery. 2 previous surgical histories for endometriosis 2006 and ovarian cyst 2005 e. Family history No family history of any medical illness except for hypertension by her mother. No history of multiple pregnancies, malformation, or mental illness in the family f. Social history She is working as assistant information officer at ministry of information. Her husband is entrepreneur. She does not consume alcohol and does not smoke, so does her husband. She denies of any constitutional sex. Currently, she is not experiencing any financial difficulty. g. Allergies and medication history No known drug or food allergies. She is taking supplements provided for her pregnancy.

Physical examination

She was alert, conscious and lying comfortable. Her height is 155 cm, with pregnant weight of 62+kg. Her body mass index is 25.8 kg/m2. Her vital signs were as recorded; Blood pressure Heart rate Respiratory rate Temperature : : : : 103/72 mmHg 100 beat per minute, good volume, regular rhythm 17 breaths per minute 37°C

There is no sign and symptom of anaemia, by pallor or lips cracked. She was well hydrated, no sign of goitre, and there is no oedema at lower limbs. Breast examination was not demonstrated. Her heart sound S1 S2 can be heard with normal intensity, and her lungs were normal. Examination of abdomen shows distended abdomen by gravid uterus with linea nigra, striae gravidarum as evidences. There were also 2 suture scars which are midline marking for previous endometriosis on 2006 and pfannestiel marking for ovarian cyst removal on 2005. The suture area was non tender, and soft at the site. There was no other abnormality. Her size is near term, SFH is 35cm. The presentation of the baby cephalic, with head engagement is 4/5. Estimated baby weight is about 2.0 – 2.2 kg. Contraction was present which is irregular with 1:10:25s. Fetal heart rate taken by the nurse was 153 beats per minute. Previous vaginal examination shows normal os, with 1cm dilatation. The cervix was 3cm thick, and the position of the head is not palpable. The membrane is still intact; therefore the mould and caput cannot be assessed. There was no liquor pooling. Speculum examination reveals that the vagina and cervix to be healthy with the os is open. Show is noted, but there was no pooling of liquor, and no vaginal discharge.

Summary 26 years old Malay lady primigravida at 34th week from period of amenorrhea presented with abdominal pain, slight show and; 1) History of 2 threatened preterm labour 2) History of endometriosis 2006 3) History of ovarian cyst 2005 4) History of UTI 5) History of fall Diagnosis Patient is primigravida currently at 34th week 4 days POA diagnosed as threatened preterm labour. Due to; 1) Irregular contraction with <2:10 2) No cervical dilatation 3) No pooling of liquor

Investigation Investigation Full blood count Grouping, Screening, Hold (GSH) Urine FEME Reason to support To look for haemoglobin, white blood cell and platelet levels. To ensure she is stable enough for any emergency surgery, to rule out any ongoing infection, anaemia that may cause poor tolerance of blood loss during delivery. Patient might need transfusion Basically, to assess renal function in general. Glucose will be significantly high in EDM, GDM. Blood may present in renal tract trauma, inflammation, tumour or even vaginal bleeding contamination as well. If there is any infection, especially for group B streptococcal, Trichomonas vaginalis, Chlamydia trachomatis, neisseria gonorrhoea. Important in determining management of patient

High vaginal swab C&S

Full blood count investigation Wbc Rbc Hgb Hct Mcv Mch Mchc Rdw-cv Plt Neutrophil Lymphocyte Monocyte Eosinophil Basophil % 71 19.6 7.5 1.7 0.2 12.1 4.16 124 37.1 89.2 29.8 33.4 13.7 237 109/L 8.59 2.37 0.91 0.20 0.04 unit 109/L 1012/L g/L fL Pg g/dL % 109/L reference 4-10 3.8-4.8 120-150 36-46 77-97 27-32 315-345 11.6-14.0 150-400 109/L 2-7 1.0-3.0 0.2-1.0 0.02-0.10 0.9-12

Comment During pregnancy there is also an increase in white cells from about 7 x 10^9 to 15 x 10^9 per litre solely due to a neutrophilia. This was noted in her CBC & differential blood result. In spite of this, note that other causes of a raised neutrophil count must be excluded. In her case, clinically she is well with no sign or symptoms suggesting active infection. Urine FEME investigation Specific gravity pH Leukocyte Nitrate Protein Glucose Ketone Bilirubin Erythrocyte 1.020 6.5 2+ -ve 1+ 3+ -ve 1+ -ve Comment No remarkable findings

HVS C&S culture Smear White cell Epithelial cell + cocci - cocci + bacilli - bacilli other No culture/ colony Occasionally Occasionally nil few nil few nil Comment One-third of the pregnant women yielded potential pathogenic organisms in their HVSs. Among these organisms 87% were Monilia and Streptococcus, while the rest were E. coli, Proteus, Klebsiella and Neisseria. Lactobacilli are regarded as a normal flora. Staphylococcus epidermidis and Diphteroids have also been found in significant

percentages (30-60%) in pregnant women. Plan and management 1) Admit antenatal ward 2) CTG in ward, IM nubain 10mg per 6 hourly if reactive 3) Time contraction 4) Strict FKC monitoring 5) To book ventilator 6) Tocolysis 7) IM Dexamethasone 12 mg bd 8) Pad chart –to inform if increase in per vaginal bleeding

Discussion

Preterm labour is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk). The exact mechanism(s) of preterm labour is largely unknown but is believed to include decidual haemorrhage, (eg, abruption, mechanical factors such as uterine overdistension from multiple gestation or polyhydramnios), cervical incompetence (eg, trauma, cone biopsy), uterine distortion (eg, müllerian duct abnormalities, fibroid uterus), cervical inflammation (eg, resulting from bacterial vaginosis [BV], trichomonas), maternal inflammation/fever (eg, urinary tract infection), hormonal changes (eg, mediated by maternal or fetal stress), and uteroplacental insufficiency (eg, hypertension, insulindependent diabetes, drug abuse, smoking, alcohol consumption).1,2 In this case, the patient presented with abdominal pain associated slight show. Patient has strong history suggesting threatened preterm labour with two previous event of threatened preterm labour –history of urinary tract infection in 25th week, history of falling in 28th week. Patient also had history of two gynaecology surgical history – endometriosis on 2006 and ovarian cyst on 2005. Usually, based on the patient’s presentation, contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix at 24-37 weeks’ gestation are indicative of active preterm labour. However, the patient in this case was not indicative for preterm labour as the contraction was not consistent and not sufficient. According to the history, patient had history of urinary tract infection that leads to previous threatened preterm labour in 25+ week of pregnancy. Due to pregnancy, several physiologic changes that occur can cause otherwise healthy women to be more susceptible to serious sequelae from urinary tract infections. These effects have been showed in study done by Duarte et al3 in 2008. Remarkable changes occur in the structure and function of the urinary tract during pregnancy. Blood-volume expansion is accompanied by increases in the glomerular filtration rate (GFR) and urinary output. The ureters undergo tonic relaxation because of the mass production of hormones, particularly progesterone. This loss in tone, along with the increased urinary tract volume, results in urinary stasis that in time promotes bacterial infestation.

Preterm labour may be difficult to diagnose and a potential exists for overtreatment of uterine irritability. Tocolytic agents, while generally safe in appropriate dosages with proper clinical monitoring, have potential morbidity and should only be used after consideration of the risks and benefits of such use. Neonatal morbidity and mortality are greatly affected by gestational age, especially when the pregnancy is less than 28 weeks’ gestation. Tocolytic is the standard management for threatened preterm labour to reduce irregular contraction. Usually, prophylaxis antibiotic will be given to the mother and in case of previous urinary tract infection, antibiotic will be given specifically according to the causative agent.

Conclusion Threatened preterm labour is defined as sign and symptoms that lead to the risk of preterm labour to occur. It is usually presented with irregular contraction and associated with show or liquor, depending on the patient itself. Even though the mechanism is not clearly understand by physician, patient threatened preterm labour usually associated with history of cervical incompetence –trauma, cervical inflammation –previous infection, hormonal changes –maternal or fetal stress, or uteroplacental insufficiency – hypertension, diabetes, etc.

References
1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin.

Assessment of risk factors for preterm birth. Clinical management guidelines for obstetrician-gynecologists. Number 31, October 2001. (Replaces Technical Bulletin number 206, June 1995; Committee Opinion number 172, May 1996; Committee Opinion number 187, September 1997; Committee Opinion number 198, February 1998; and Committee Opinion number 251, January 2001). Obstet Gynecol. Oct 2001;98(4):709-16 2. ACOG practice bulletin. Management of preterm labor. Number 43, May 2003. Int J Gynaecol Obstet. Jul 2003;82(1):127-35. 3. Duarte G, Marcolin AC, Quintana SM, Cavalli RC. [Urinary tract infection in pregnancy]. Rev Bras Ginecol Obstet. Feb 2008;30(2):93-100.