UNIVERSITY OF THE EAST

Ramon Magsaysay Memorial Medical Center

Department of Obstetrics and Gynecology
Aurora Blvd., Quezon City

NAME: GARCIA, JESSIE POCHOLO G.

GROUP: Group 6A
DATE: May 5, 2020
PAPER: Week 7, Case 1

1. What is the assessment?

● G1P0 (0000), 37 weeks and 6 days AOG by LMP, intrauterine pregnancy, cephalic, NIL, PROM for
8 hours, t/c Intra-amniotic infection, t/c cephalopelvic disproportion/dystocia

2. What is the EFW? (Show the computation)

● EFW= 155 (fundic ht – n)
= 155 (30cm – 12)
= 155 (18)
= 2790g
(where N is 12 if above the ischial spine or if still unengaged)

3. What is the assessment of clinical pelvimetry? Basis?

● Inlet: Adequate and non-contracted
○ The inlet is adequate because the sacral promontory was not reached and was more
than 11.5cm (ideally more than or equal to 11.5cm)
● Midpelvis: Possibly contracted
○ The midpelvis is probably contracted because the ischial spines were prominent instead
of blunt and was measured at 8cm (ideally more than or equal to 10cm)
● Outlet: Adequate and non-contracted
○ The outlet is adequate because a fist can be insinuated between the ischial tuberosities
implying that the outlet was at least more than 8cm
● Other evidence that are essentially normal in the pelvimetry include the parallel side walls, the
curved sacrum and thewide suprapubic arch.

4. What is the Bishop score and how should the score be interpreted?

Dilatation 1 1cm

Effacement 3 80%

Station 2 -1

Cervical Consistency 2 Soft

Cervical Position 1 Midposition

Total Score 9 - indicates that the probability of vaginal delivery after labor induction is similar
to that after spontaneous labor
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Department of Obstetrics and Gynecology
Aurora Blvd., Quezon City

5. What is the management?

● Place patient on NPO
● D5LR 1L for 8hrs
● Augmentation of labor via administration of 10U of oxytocin at 10-12gtts/min to be titrated
accordingly until strong uterine contractions are achieved
● Ampicillin 2g TIV after negative skin test, the Q6 until delivery
● Monitor VS and FHT Q1, and progress of labor

6. What laboratory tests should be requested? Why?

● CBC with PC - parameters would be useful in the assessment of hemodynamic stability,
presence of infection and other potential hematologic complications associated with pregnancy.
● Urinalysis - all pregnant patients should have a complete genitourinary assessment which
includes the urinary tract. The urine should be evaluated to identify if any involvement or
infection of the urinary tract is happening.
● Cervical Swab G/S - patients who are diagnosed to have PROM are at increased risk of having
intrauterine ascending infections. Those who are suspected to have intraamniotic infections
should have a G/S done to confirm and appropriately treat the ongoing infection
● CTG Tracing - a CTG tracing is commonly done to assess fetal well-being especially in cases
with high risk of morbidity or complications
● Maternal Group B Strep Test - a group B Strep infection is a very common pathogen
associated with infections among the pregnant population
● Ferning test - if amniotic fluid leakage is present, an arborization of ice-like crystals can be seen
microscopically
● Beading test - poor crystallization can be seen if cervical mucus is spread and dired on a glass
slide as a result of increased progesterone levels in pregnant women
● Lithmus test - to check if fluid is of amniotic fluid in origin, to test if basic or acidic (amniotic
fluid is basic)

7. Interpret Ferning test and CTG?

● Ferning: Positive
○ A positive ferning test indicates amniotic fluid leakage or in some cases, it may indicate
that the bag of water has already ruptured.

● CTG:
○ Fetal heart rate baseline: 120-125 FHTs/min
○ Acceleration: accelerations up to 140 FHTs/min
○ Variability: with moderate variability
○ Deceleration: no decelerations
○ Contraction: no uterine contractions in 30 minutes
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Department of Obstetrics and Gynecology
Aurora Blvd., Quezon City

8. Is antimicrobial therapy indicated at this time? If yes, why and what should be given?
● According to Williams, the benefit of prophylactic antibiotics in women with ruptured membranes
before labor at term is unclear. However, in those with membranes ruptured more than 18 hours,
antibiotics are instituted for group B streptococcal infections. However, in the case of our patient
with an unknown GBS status, she is still not able to pass the guidelines to consider starting GBS
prophylaxis.
● Still, we would advise our patient to have antimicrobial therapy at this time. Although already at
term, the patient’s bag of water might have potentially ruptured without any signs of labor 8
hours prior to consult. The exposure of the intra-uterine cavity to pathogens during this
timeframe places her at high risk of acquiring intra-amniotic infections. The G/S of her cervical
swab also had many bacteria which supports the notion that pathogens are already present and
an ascending infection may have already begun, hence our decision.
● Penicillins are a common choice in managing patients suspected to have intra-amniotic infections.
Some sources also say that Ampicillin, Gentamicin, Vancomycin (if with allergy) and other
cephalosporins may be used.

9. What is the assessment at this time? Basis?

● G1P0 (0000), 37 weeks and 6 days AOG by LMP, intrauterine pregnancy, cephalic, in
labor, PROM, Intra-amniotic infection, Cephalopelvic Disproportion
● Acute Chorioamnionitis (IAI/Intraamniotic Infection)
○ IAI is a disorder characterized by acute inflammation of the membranes and chorion of
the placenta, typically due to polymicrobial bacterial infection in women whose
membranes have ruptured.
○ The cervical mucus plug, membranes, and placenta provide barriers to ascending and
transplacental infection, so a rupture of membranes removes the barriers hence the
increased risk of ascending infections.
○ A presumptive diagnosis of IAI (suspected triple I) can be made in women with:
■ Fever – ≥39.0°C [102.2°F] or 38.0°C [100.4°F] to 38.9°C [102.02°F] on two
occasions 30 minutes apart, without another clear source PLUS one or more of
the following:
● Baseline fetal heart rate >160 beats/min for ≥10 minutes, excluding
accelerations, decelerations, and periods of marked variability
● Maternal white cell count >15,000/mm3 in the absence of corticosteroids
and ideally showing a left shift (bandemia)
● Purulent-appearing fluid coming from the cervical os visualized by
speculum examination
○ For this case, the patient had a fever of 38.5c with fetal tachycardia at 165bpm and
leukocytosis of 16,500/mm^3
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Department of Obstetrics and Gynecology
Aurora Blvd., Quezon City

10. What is the management? Justify

● Do emergency cesarean section because of the following reasons:
○ The patient is a case of PROM who had only sought consultation around 8 hours after
the rupture of her bag of water which places her at higher risk of IAI. The results of her
ferning test proves that the BOW has already ruptured.
○ Patient is a case of Midpelvis contraction because of the small diameter of her inter-
ischial space and the prominent spinous processes. Though some hospitals would still
continue having a trial of NSD, it is important to consider an emergency C-section in case
the patient truly develops a CPD during labor.
○ The patient already has a 2 time-history of having Bacterial Vaginosis during the
2nd and 3rd trimester.
○ Despite inducing labor and administering antibiotics, the patient had deranged vital
signs at the 6th hour of induction and had increased levels of WBC. These findings
further supports the diagnosis of an IAI or triple I which indicates the consideration of
doing a C-section.

11. What is the histologic diagnosis? Basis?

● Stage 2: Acute Chorioamnionitis
○ Polymorphonuclear leukocytes extends into the fibrous chorion and amnion as seen in
the histologic specimen. Also, (+) neutrophilic infiltrates of membranes and those
overlying chorionic plate can be seen. These observations support the diagnosis of an
infection of both the chorion and the amnion.