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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 3-7 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
PMP: 3rd week of March, 2016
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 10th-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 Slightly increased


BLOOD
SUGAR

100-g
glucose
FASTING 5.2 mmol/L Within normal
1 HR 9.2 mmol/L Within normal
2 HR 9.4 mmol/L Slightly increased
3 HR 8.8 mmol/L 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

 HbSag- Nonreactive
 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
6-7/10 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,
(-) hypotension
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,
(-) depression or mood changes
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: 37.4°C, 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 dry but not brittle.
Nails have CRT of <2 seconds
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, (+) foveal reflex
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 transillumination
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 exudates

 Teeth: no artificial dentrures; few cavities seen


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 swallowing
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:
 no adventitious breath sounds
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; no abnormal heart sounds
heard such as murmurs or clicks
ABDOMEN
 Inspection:
 gravid, round and protuberant, no swelling,
no observable masses, (+) linea nigra; (+)
striae gravidarum
 No organomegaly noted
 FH: 20cm

 FHT: 140 bpm


Hyperpigmented
areolar

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

Linea nigra

striae
ABDOMEN
 Abdomen
Palpation: Leopold’s 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

 12: tongue at midline; no fasciculations; (+) taste on posterior 1/3 of


tongue
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:
 (-) babinski’s and (-) kernig’s sign
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

S–O–A–P
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
S–O–A–P
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

S–O–A–P
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

S–O–A–P
Day 0 (11/17/16)
O Abdomen
Palpation: Leopold’s 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

S–O–A–P
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

S–O–A–P
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

S–O–A–P
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

S–O–A–P
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

S–O–A–P
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

S–O–A–P
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

S–O–A–P
Day 1 (11/18/16)
O Abdomen
Palpation: Leopold’s 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

S–O–A–P
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 RESULT
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
NEUTROPHIL 84.7 INCREASED
LYMPHOCYTE 11.9 DECREASED
MONOCYTE 3.20 WITHIN NORMAL
COURSE IN THE LABOR ROOM

URINALYSIS RESULT
COLOR YELLOW
TRANSPARENCY HAZY
PH 6
SPEC GRAV 1.010
PROTEIN NEGATIVE
GLUCOSE NEGATIVE
EPITHELIAL MODERATE
BACTERIA FEW
RBC 0-1
WBC 0-1
COURSE IN THE LABOR ROOM

S–O–A–P
Day 1 (11/18/16)
P Termination of Pregnancy
Attach to CTG
Monitor fetal heart rate pattern
COURSE IN THE LABOR ROOM

S–O–A–P
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

S–O–A–P
Day 1 (11/18/16)
BABY DATA:
Sex: Male
Weight: 1390g
Length: 38cm
APGAR Score: 8,9
BS: ???
CASE DISCUSSION