CASE PRESENTATION ON NORMAL

PREGNANCY

Moderator : Dr Saravana Prakash

Presentor : Dr Prem
Mrs.Kani Mozhli, 26/ F , primi at 38+ 5 weeks gestational age , coming from a

Arriyakuppam, staff nurse by occupation, belonging to middle socio economic

status ,a booked case in MGMCRI ,H/O amenorrhoea for 9 months came

to hospital for safe confinement of pregnancy

• HOPI:
– Came with h/o 9 months of amenorrhoea
– No h/o bleeding PV or leaking PV
– No h/o fever
– No h/o trauma
– No h/o decreased fetal movements
– No h/o difficulty in breathing ,PND , palpitation on lying supine , on in
night time during sleep
– No h/o headache,vomiting,epigastric pain,no h/o chest pain,cough
with expectoration ,coughing up blood, wheeze , hemoptysis and h/o
swelling of lowerlimbs

• Obstretic History:
– Obstretic index: primi
– LMP : 2/6/2020
– EDD : 9/3/2021
– POG- 38+5 DAYS
• H/o present pregnancy:
1st trimester:
– Spontaneously conceived,
– UPI confirmation was done at 1 monthof amennorhea,
– 2 antenatal visits were made.
– Dating scan was done and told to be normal.
– H/o iron and folic acid intake +.
– No h/o vomiting, fever with rashes, bleeding/discharge PV.
– No h/o radiation exposure/ drug addiction.
– No h/o abdominal pain
– No h/o drug intake for any ailments
– 2nd trimester:
– Quickening felt at 5 th month of amenorrhoea.
– Anomaly scan done and was said to be normal.
– Immunised with 2 doses of TT.
– H/o iron and calcium intake +.
– GDM screening was done and was told negative and Thyroid testing
was told to be normal.
– No h/o increased BP recording , blurring of vision,headache ,pedal
edema ,decreased urine output
– No h/o bleeding/leaking PV/ pain
3rd trimester:
– able to percieve fetal movements well
– No h/o sweating or giddiness on lying supine
– No h/o fever, burning micturation or urgency in micturation
– No h/o reduced urine output ,swelling of limbs and face
– No h/o spotting / leaking PV
– No h/o itching ,pruritis, yellowish discouloration of the skin and clay stool
• Menstrual history:
– Attained Menarche @ 12 years of age
– LMP
– cycles are regular(5/30)
– Normal flow , not associated with pain and clots
• Marital history:
– Married since 1 years.
– non-consanguinous marriage.
– Concieved spontaniously
– No h/o use of contraception
• Past history:
– Not a k/c/o DM, SHTN, BA, Thyroid, and heart disease
• Treatment history:
– No h/o any previous surgeries /hospital admissions
– No h/o blood transfusions
• Personal history:
– Mixed diet,
– normal bowel and bladder habits,
– normal appetite and sleep
– No h/o of any addictions
• Family history: not significant
• Allergic history: no h/o any drug / food allergies
• SUMMARY:
– 26 year old primigravida,with 38 weeks + 5 days of gestation, who is a
booked case, came to our hospital with h/o amenorrhoea for 9
months with no co morbidities with nil significant negative obstretic
history came for safe confinement of pregancy
• General physical examination:
– Patient was conscious, oriented to time,place and person.
– Moderately built and nourished. Height 170cm, weight 80kgs, BMI 27kg/cm2,
– No pallor, icterus, cyanosis, clubbing lymphadenopathy. B/L pitting pedal
edema +.
– Normal hydration status
– IV access + in both upper limbs
• Vitals:
– PR – 86/min, regular in rhythm, good volume, normal in character, all
peripheral pulses felt, no radio-radial or radio-femoral delay.
– BP – 120/70 mmHg taken in supine and left lateral position in the left upper
limb.
– RR – 18/min
– Temperature – Afebrile to touch
• Airway:
– External facial appearance – symmetrical
– Nasal patency- patent
– Neck movements – normal
– Mouth opening > 3FB
– Mallampati- 3
– Mentohyoid > 3 FB/5cm
– Upper lip bite test +1
– No loose tooth / missing tooth/ dentures
• Spine:
– Skin over the spine – Normal,
– Widest spcae : L3L4,
– no deformity or dependant edema
Systemic examination
• Obstetric examination:
– Inspection:
• Linea gravidarum and stria gravidarum present.
• No visible scar, sinuses, dilated veins,umblicus everted in mid line
• Uterine shape spherical.
– Palpation: (patient examined in supine position with leg semi flexed)
• Uterus relaxed, symphysio-fundal height corresponds to 38 weeks of
gestation.
• Fundal grip: broad, soft, irregular, non-ballotable mass suggestive of
fetal buttocks
• Lateral grip: LEFT– bone like continuous resistance felt, suggestive of
fetal spine ; RIGHT – 2-3 firm knob-like irregular projections felt,
suggestive of fetal limb buds.
• 1st pelvic grip:smooth,hard,round,ballotable mass felt suggestive of
head or presenting part
• 2nd pelvic grip:cephalic prominance palpable , diverging – head
engaged
– Auscultation:
• FHR 150/min, heard at the left mid spino-umblical line
• CVS : S1S2 heard, no murmurs
• RS: B/L AE +, no added sounds, RR-18/ mt
• CNS: NFND

• Final summary :
– 26 years old, primi gravida at 38 weeks + 5days, term gestation, with
no co morbidities with single intra uterine gestation with cephalic
presentation with head engaged with good fetal heart rate has come
for safe confinement of pregnancy, comes under ASA2
• Diagnosis :
– 26 year old, primi gravida with term gestation, with no
comorbidities ,with SLIUG, came for safe confinement of pregnancy.