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CASE

PRESENTATION

OB PGI

OBJECTIVES

To review and discuss the history and PE


of the patient.
To enumerate differential diagnoses of
the case.
To discuss the different diagnostic and
treatment modalities
To discuss the final diagnosis of the
patient and correlate the pertinent
clinical findings.
To site some updates and insights in the
management of the presented case

GENERAL DATA

Name: Dagohoy, Lorelyn


Age: 26 yo
Sex: Female
Marital Status: Single
Occupation: housewife
Date of Birth: November 16, 1990
Place of Birth: Mandaue City Cebu

GENERAL DATA

Residence: Basak Mandaue Cebu


Nationality: Filipino
Religion: Roman Catholic
# of admission: 1st
Place of Admission: VSMMC
Date of Admission: November 17, 2016

MENSTRUAL HISTORY

Menarche: at age 13, with a duration of 7


days, consuming 2 fully soaked pads per
day
Subsequent menstruation: Irregular
interval of 25-30days, with a duration of 37 days, consuming 1 minimally soaked pad.
Dysmenorrhea was noted, no medications
taken
No intermenstrual bleeding

LMP: April 26, 2016


PMP: 3rd week of March, 2016

OBSTETRIC HISTORY
Obstetric score: G2P0(0010)
Previous Pregnancies:
G1- 2015, Spontaneous abortion,
18 wks AOG
no D/C done
G2- Present pregnancy
LMP: April 26, 2016
EDC: January 31, 2017
AOG: 29 2/7 Weeks

PRENATAL HISTORY

1st PNC- June 2016 at 2 months Age of


Gestation
at Vicente Gullas Memorial Hospital
by an Obstetrician.
Laboratories taken

CBC
U/A
HbSAg
Blood typing,
FBS, 75 g OGTT,
Papsmear

PRENATAL HISTORY
PELVIC UTZ (11/17/16 )
Pregnancy Uterine, at 28 weeks 6 days (+/- 2
weeks) by fetal biometry, live ,singleton , cephalic
presentation.
Placenta right anterofundal, grade 2 highlying.
Low normal amniotic fluid volume/ borderline
oligohydramnios (AFI=7.4 cm).
EFW is withing the 10 th-90th percentile of the
normal growth curve pattern for a 28 week fetus.
Cervical funneling noted with cervical length of
1.7 cm

Taken at 21 weeks AOG


FASTING 128 mg/dL
BLOOD
SUGAR

Slightly increased

100-g
glucose
FASTING

5.2 mmol/L

Within normal

1 HR

9.2 mmol/L

Within normal

2 HR

9.4 mmol/L
8.8 mmol/L

Slightly increased

3 HR

Slightly increased

PRENATAL HISTORY

URINALYSIS
- gross: Light yellow, hazy
- ph: 6
- specific gravity: 1.010
-Protein: NEGATIVE
-Glucose: NEGATIVE
-Microscopic
-RBC: 0-1 /HPF
-WBC: 0-2/HPF
-Epith.: moderate
-Bacteria: few

PRENATAL HISTORY

CBC
-WBC: 13.83x 10 ^9/L
-HGB: 124 g/L
-HTC: 0.36 L/L
-RBC: 4.12
-PLT: 254 x 10 ^9/L
-Neutrophils: 84.70
-Lymphocytes: 11.90
-Monocytes: 3.20
-Eosinophils : 0.10
-Basophils: 0.10

PRENATAL HISTORY

HbSagNonreactive
Bloodtype- A
(+)

PRENATAL HISTORY

Medications
Folic acid tab OD PO,
Ferrous sulfate tab OD PO
Diet:
2 glasses of milk per day
1 banana per meal

Vaccination- 1 dose Tetanus toxoid at 5


months AOG
Maternal illness- productive cough at 25
weeks AOG

Cephalexin 500mg tab TID for 7 days was taken

PRENATAL HISTORY
Frequent travel within Cebu
province noted
Occasional coitus with partner
noted
Last PNC- November 16, 2016,
29 1/7 wks AOG

CONTRACEPTIVE
HISTORY

No ORAL CONTRACEPTIVE USE

SEXUAL HISTORY
Coitarche- 14 years old
5 partners

Regularity, sexual interest,


function, and satisfaction
were all good

No dyspareunia
No post coital bleeding noted

PAST MEDICAL HISTORY

Childhood diseases include mumps


at 8 yrs old and chickenpox at age
10.
Non hypertensive
non diabetic
non asthmatic
No cardiac problem
no previous surgeries done
no recent trauma or accidents
no consultations to a psychiatrist

FAMILY MEDICAL
HISTORY
History of Hypertension and
Diabetes mellitus in the
paternal side
No history of asthma,
congenital anomalies nor
multifetal gestation noted

PERSONAL AND SOCIAL

Occasional alcoholic drinker


3 pack per year smoker
Occupation: House wife

CHIEF COMPLAIN

Hypogastric abdominal pain

HISTORY OF PRESENT
ILLNESS

6 days PTC, patient came in for a


regular PNC. Laboratory results were
brought and noted (+) 75 g OGTT.
5
days
PTC,
patient
noted
hypogastric abdominal pain radiating
to
the
flanks
associated
with
frequent uterine contraction. No
bleeding
nor
watery
vaginal
discharge
noted.
Condition
was
tolerated.

HISTORY OF PRESENT
ILLNESS

1 day PTC, increasing hypogastric


abdominal pain occurring once in
every hour, with a pain scale of 67/10 was noted, thus consult at
VGMH was done .IE was done and
showed 1cm dilatation and was
admitted. Dexamethasone was given
for 2 doses and Isoxsuprine drip
(D5W + 5 ampules of Isosuprine).

HISTORY OF PRESENT
ILLNESS

Due to unavailability of incubator and


financial constraints, patient was
referred to VSMMC.

Review of Systems

Skin: (-) rashes, (-) sores, (-)


hyperpigmentation,
(-) jaundice, (-) pallor
Head: (-) headache, (-) lightheadedness
Eyes: (-) blurring of vision
Nose: (-) Congestion
Neck: (-) lymphadenopathy
Respiratory: (-) cough, (-) dyspnea
Circulatory: (-) HPN, (-) chest pain, (-)
edema,

Review of Systems

Gastrointestinal: (-) anorexia, (-) diarrhea, (-)


constipation,
(+) polyphagia
Urinary: (-) dysuria, (-) hematuria, (+) polyuria
Reproductive: (-) menorrhagia, (-) dysmenorrhea, (-)
dyspareunia,
(-) bleeding after coitus, (+) pelvic discomfort
Musculoskeletal: (-) muscle/joint pains, (+)
backache
Hematopoietic: (+) anemia
Metabolic/Endocrine: (-) thyroid conditions
Psychological: (-) seizures, (-) parasthesia,

PHYSICAL EXAMINATION

GENERAL SURVEY

The patient is alert, conscious and


coherent, ambulatory, oriented to
person, place and time, not appear
to be in cardiopulmonary distress,
weak
looking,
cooperative
and
afebrile

VITAL SIGNS

BP: 120/70 mmHg, R arm, sitting


RR: 19 breaths/min, regular rhythm
PR: 88 beats/min, R radial pulse,
regular, bounding
Temperature: 37.4C, axillary
Weight: ~67kgs
Height: 157cm

SKIN, HAIR, AND NAILS


Inspection:
skin
is brown, no lesions, no
cyanosis, no jaundice, no pallor. Hair
is black, evenly distributed, no
ectoparasites. Nails are not cyanotic,
no clubbing, (-) striae gravidarum,
(+) linea negra
Palpation:
skin is warm to touch, good skin
turgor and mobility. Hair is black and

HEAD
Inspection:
normocephalic,
no lumps
lesions, or deformities
Palpation:
no masses, no tenderness

EYES

Gross external eye exam:


no lesions, no masses, no
pain/tenderness
Ocular motility:
full range of extraocular movements
Tonometry:
soft
Fundoscopy:
(+) red orange reflex, clear media,
distinct disc border, cup-disc ratio of 0.3,
AV ratio of 2:3, (-) hemorrhage/exudates,

EARS

Inspection:
symmetrical; no deformities; no lesions, no
discharges, no swelling or redness
Palpation:
no masses or lumps, no tenderness on
mastoid area, no pain when ear is tugged
Otoscopy:
no discharges, few cerumens seen, tympanic
membrane is pearly white and intact; not
retracted or bulged
Auditory exam:
patient can hear whispered words

NOSE

Inspection:
symmetrical,
no deformities, no
lesions, nasal mucosa is pinkish.
Nasal septum is midline and not
perforated; no swelling or redness
Palpation:
No tenderness, no masses or lumps
Sinuses:
maxillary and frontal sinuses are not
tender;
(+)
red
glow
upon

MOUTH AND THROAT

Inspection:
Lips: no deformities, pink, no lesions, dry
Buccal mucosa: no ulcers; moist
Gums: no lesions, pink, moist
Tongue: midline; no fasciculations; no
ulcers
Hard and soft palate: no masses; no
lesions, no ulcers
Uvula: midline
Pharynx: no swelling or inflammation
Tonsils: symmetrical, no inflammation, no

NECK
Inspection:
trachea is midline; no lesions,
no scars
Palpation:
no
lymphadenopathy,
no
nodules; thyroid not palpable
right and left carotic pulsations
good; thyroid cartilage and
cricoid, rises together upon

BREASTS
Inspection:
no lesions, no inflammation, no
dimpling, no abnormal nipple
discharges, no deformities
Palpation:
no
masses or lumps, no
lymphadenopathy;
no
tenderness

CHEST AND LUNGS

Inspection:
no
gross
chest
deformities,
no
asymmetry,
no
abnormal
chest
retractions; no accessory muscles used
in breathing
Palpation:
no tenderness on chestwall; equal chest
expansion
Percussion:
resonant sounds on lung fields
Auscultation:

CARDIOVASCULAR
SYSTEM

Inspection:
no
gross chest deformities; no visible
pulsations
Palpation:
maximum point of impulse on 5th intercostals
space 5-7cm lateral to midsternal line with
small amplitude
Percussion:
not performed
Auscultation:
apex beat heard in 5th intercostals space 5-7
lateral to the midsternal line; good S1 and S2;

ABDOMEN

Inspection:
gravid, round and protuberant, no
swelling, no observable masses,
(+)
linea
nigra;
(+)
striae
gravidarum

No organomegaly noted
FH: 20cm
FHT: 140 bpm

Hyperpigmen
ted areolar
Distended
abdomen, size of
29 weeks gravid
FH = 20cm

Linea nigra
striae

ABDOMEN

Abdomen
Palpation:

Leopolds Maneuver
L1 breech
L2 fetal back at maternal left side;
fetal
extremities at maternal right side
L3 cephalic
L4 floating
FHT 140 bpm

PELVIC EXAM

EXTERNAL GENITALIA: grossly female,


non edematous
VAGINA: no masses, no lesions
UTERUS: gravid
CERVIX:

Dilatation: 2cm
Effacement: slightly effaced
Position: midposition

PELVIC EXAM

PRESENTATION:

Membranes: intact
Station: -3
Fluid: clear

Adequate pelvimetry

EXTREMITIES
Inspection:
no gross deformities; symmetrical;
parallel to each other; no swelling,
no redness, no inflammation or
lesions; not cyanotic; no edema
Palpation:
warm to touch, no tenderness
Range of motion:
full

NEUROLOGIC EXAM

Mental status exam:


awake, alert, responsive, oriented
to time, place, and person;
appropriate affect; no abnormal
movements;
immediate
and
remote memory intact, fluent
speech; (-) aphasia

NEUROLOGIC EXAM

Cranial nerves:
1: able to smell perfume
2: good visual acuity; able to read nameplate
2, 3: (+) near response test; (+) consensual and direct
papillary reflex
3, 4, 6: intact 6 cardinal directions of gaze
5: able to clench teeth with temporal contractions; intact
facial sensation
7: appropriate facial movements; (+) taste on anterior
2/3 of tongue
8: can hear whispered words both ears; intact balance
9, 10: (+) gag reflex; equal palatal elevation
11: equal shoulder shrug; good sternocleidomastoid
strength

NEUROLOGIC EXAM

Motor:
5/5 on both upper and lower extremities; no
fasciculations, no rigidity; no flaccidity; no
tremors
Sensory:
able to feel pain, temperature, light touch, and
vibration; intact position sense
Reflexes:
+2 all extremities
Cerebellar signs:
(-) ataxia, (-) dysmetria, (-) dysdiadochokinisia
Meningeal Signs:

LOGICAL IMPRESSION

GESTATIONAL DIABETES

POINTS TO SUPPORT:

FBS = 128MG/dL
100g OGTT
2-hr

= 9.4 mmol/L
3-hr = 8.8 mmol/L

Glucose intolerance was discovered at 21


weeks AOG
Previously non-diabetic
History of spontaneous abortion

COURSE
IN THE
E.R.

COURSE IN THE ER
SOAP
Day 0 (11/17/16)
S - Patient was seen and examined.
- Patient complained of hypogastric pain
radiating to the flank area with a pain scale
of 6/10 associated with irregular uterine
contractions with 3-4min interval lasting for
40-50secs.
- No episodes of vomiting, fever and dyspnea.

COURSE IN THE ER
SOAP
Day 0 (11/17/16)

O - Vital Signs

BP: 100/60 mmHg, left arm, supine


HR: 98 beats per minute, tachycardic
RR: 21 cycles per minute, tachypneic
Temp: 37.0 C
O2 sat: 99%
-FHT = 140-150 bpm
-CTG: FHR category 1
- FHR pattern: 140-150bpm
- Variability: moderate
- Accelerations: present

COURSE IN THE ER
SOAP
Day 0 (11/17/16)

O Inspection:

gravid, round and protuberant, no


swelling, no observable masses, (+)
linea nigra; (+) striae gravidarum

No organomegaly noted
FH: 20cm

COURSE IN THE ER
SOAP
Day 0 (11/17/16)

O Abdomen
Palpation: Leopolds Maneuver
L1 breech
L2 fetal back at maternal left side;
fetal
extremities at maternal right side
L3 cephalic
L4 floating
FHT 140 bpm

COURSE IN THE ER
SOAP
Day 0 (11/17/16)

O CERVIX:

Dilatation: 2cm
Effacement: slightly effaced
Position: midposition
PRESENTATION:
Membranes: intact
Station: -3
Fluid: clear

COURSE IN THE ER
SOAP
Day 0 (11/17/16)

P Medication:

Dexamethasone 6mg IM now then


every 12 h x 1 more dose
Nifedipine 30mg tab now then
10mg tab every 20min until uterine
contractions percieved or up to
160mg/day

COURSE IN THE ER
SOAP
Day 0 (11/17/16)

P Attach to CTG

Monitor fetal heart rate pattern


Follow up laboratory results:
FBS
Hba1c
CBC

COURSE
IN THE
LABOR
ROOM

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)
S - Patient was seen and examined.
- Patient still complained of hypogastric pain
radiating to the flank area with a pain scale
of 8/10 associated with irregular uterine
contractions with 2-3min interval lasting for
40-50secs.
- No episodes of bleeding, vomiting, fever and
dyspnea.
- good fetal movements was noted

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)

O - Vital Signs

BP: 90/60 mmHg, left arm, supine


HR: 98 beats per minute, tachycardic
RR: 20 cycles per minute, tachypneic
Temp: 37.0 C
O2 sat: 99%
-FHT = 140-150 bpm
-CTG: FHR category 1
- FHR pattern: 140-150bpm
- Variability: moderate
- Accelerations: present

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)

O Inspection:

gravid, round and protuberant, no


swelling, no observable masses, (+)
linea nigra; (+) striae gravidarum

No organomegaly noted
FH: 20cm

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)

O Abdomen
Palpation: Leopolds Maneuver
L1 breech
L2 fetal back at maternal left side;
fetal
extremities at maternal right side
L3 cephalic
L4 floating
FHT 140 bpm

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)

O CERVIX:

Dilatation: 8-9cm
Effacement: 70-80% effaced
Position: midposition
PRESENTATION:
Membranes: ruptured
Station: -3
Fluid: clear

COURSE IN THE LABOR ROOM


CBC

RESUL
T

WBC

13.83

INCREASED

HGB

124

WITHIN NORMAL

HCT

0.36

WITHIN NORMAL

MCV

87.6

MCH

30.10

RBC

4.12

WITHIN NORMAL

PLATELET

254

WITHIN NORMAL

NEUTROPH 84.7
IL

INCREASED

LYMPHOCY
TE

DECREASED

11.9

COURSE IN THE LABOR ROOM


URINALYSIS

RESULT

COLOR

YELLOW

TRANSPARENC
Y

HAZY

PH

SPEC GRAV

1.010

PROTEIN

NEGATIV
E

GLUCOSE

NEGATIV
E

EPITHELIAL

MODERA
TE

BACTERIA

FEW

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)

P Termination of Pregnancy

Attach to CTG
Monitor fetal heart rate pattern

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)

G2 P1 (0111) Pregnancy Uterine


delivered
cephalic
preterm
livebirth via Normal Spontaneous
Delivery;
Gestational
Diabetes
Mellitus

COURSE IN THE LABOR ROOM


SOAP
Day 1 (11/18/16)

BABY DATA:
Sex: Male
Weight: 1390g
Length: 38cm
APGAR Score: 8,9
BS: ???

CASE DISCUSSION