A.P.T., 36 y/o G1P0 (0000)40-41 weeks AOG

CC: Watery Vaginal Discharge

History of Present Illness

History of Present Illness

• LMP: January 18 – 21, 2010• PMP: December 18 – 21, 2010• AOG by LMP: 41-42 weeks• AOG by ultrasound: 40-41 weeks

Review of systems

• No weight loss• No fever, cough, colds, headache• No pruritus, jaundice, cyanosis, pallor• No nausea or vomiting• No diarrhea, constipation• No dysuria, hematuria, edema• No easy bruisability, epistaxis• No polyuria, polydypsia, polyphagia

Past Medical History

• 2008- Stage 1 Invasive ductal CA, s/p right MRM at Perpertual Help Hospital– no chemotherapy done– negative recurrence during check-ups done every

6 months

• No hypertension, diabetes mellitus, asthma, allergies, goiter

• No previous blood transfusion

Family History

• (+) Hypertension – Mother and Father• (+) Bronchial asthma – Maternal Grandfather• (-) cancer, diabetes mellitus, tuberculosis,

epilepsy, heart disease

Personal and Social History

• Non-smoker• Non-alcoholic beverage drinker• Denies illicit drug use or abuse• No exposure to radiation or viral exanthem

Menstrual History

• Menarche:13 y/o• Interval: 28 -30 days• Duration: 3 – 4 days• Amount: 4 pads per day, moderately

soaked• Symptoms: No dysmenorrhea• LMP: January 18 – 21, 2010• PMP: December 18-21, 2010

Marital/Sexual History

• First sexual contact at 27 years old• 1 sexual partner• No post-coital bleeding or dyspareunia• Family planning method: none

Obstetrical HistoryG7P5 (5014)

Date Outcome

G1 2010 Present pregnancy

3/26/10; 9-10 weeks AOG

S> 2 months of missed mensesNo accompanying symptoms noted (+) pregnancy test done 2 weeks PTC

O> BP: 110/60 PR: 82 T: 37 °C Wt: 135 lbs Flabby abdomen, soft, non tenderExternal genitalia: no gross lesionsSpeculum exam: pink, smooth with whitish, mucoid, non-foul smelling dischargeIE: cervix is soft, long, closed, uterus enlarged to 10 weeks size, adnexae no mass/tenderness

A> Pregnancy 9-10 weeks AOG

P> For CBC, TVS for confirmation of pregnancy; Start multivitamins 1 tab OD; TCB with results of UTZ

Ref range Unit 5/29/10Hgb 120-170 g/L 129RBC 4.0-6.0 X10^12/L 3.84HCT 0.37-0.54 0.36Platelet 150-450 X10^9/L 321WBC 4.5-10.0 X10^9/L 8.5Differential CountNeutrophils 0.50-0.70Segmented 0.50-0.70 0.56Lymphocytes 0.20-0.40 0.39Monocytes 0.00-0.07 0.03Eosinophils 0.01-0.04 0.02

CBC (5/29/10)

Ultrasound Report (5/29/10)

• Single live intrauterine pregnancy of about 18 weeks 0 days AOG, Breech presentation, Normal placental implantation and Amniotic fluid volume

• Male• SEFW 212 grams• Amniotic fluid: adequate• Placenta: posterior, high lying, grade 0 in maturity• EDC: October 30, 2010

6/1/10; 19-20 weeks AOG

S> (+) weakness, easy fatigability and occasional dizziness(-) no other symptoms noted(-) danger signs of pregnancy

O> BP: 90/60 PR: 93 T: 37 °C Wt: 145 lbsPink palpebral conjunctiva, anicteric scleraAdynamic precordium, no murmursSymmetrical chest expansion, no retractions, clear breath soundsGlobular abdomen, FH 3 finger-breadths above umbilicus,FHT Doppler (+)

A> Pregnancy 19-20 weeks AOGP> Start Ferrous Sulfate 1 tab OD and Ascorbic acid 1 tab OD

Continue milk BIDRepeat UTZ before next check-up: check uterus and ovariesGet record of breast surgery referral for follow-up c/o High risk clinic

07/12/10; 25 weeks AOG

S> Follow upAsymptomatic with no danger signs of pregnancy

O> BP: 100/60 PR: 94 T: 37 °C Wt: 150.5 lbsPink palpebral conjunctiva, anicteric scleraSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, AB at 5th LICS MCL, no murmursGlobular abdomen, FH 29 cm, FHT 150 bpm, LM1 cephalic, LM2 fetal back right, LM3 breech(+) grade 1 bipedal edema

A> Pregnancy 25 weeks AOG, breechP> Continue Multivitamins, FeSO4, I glass of milk OD

For 50g OGCTTCB after 4 weeks for follow up

08/05/2010

• 50 grams OGCT: 138 mg/dL

08/09/10; 29 weeks AOG

S> Follow upPersistence of edema, ascending up to the kneesNo danger signs of pregnancy

O> BP: 110/70 PR: 98 T: 36.3 °C Wt: 150.8 lbsPink palpebral conjunctiva, anicteric scleraSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, AB at 5th LICS MCL, no murmursGlobular abdomen, FH 33 cm, FHT 148 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic(+) grade 2 bipedal edema

A> Pregnancy 29 weeks AOG, cephalic; r/o hydramnios; t/c GDMP> For fetal biometry with AFI determination and 100 g OGTT

Continue Multivitamins, FeSO4, I glass of milk ODTCB with results

Fetal Biometry (8/10/10)

• Single live intrauterine pregnancy of about 29-30 weeks AOG, cephalic presentation

• Male• BPS 8/8• SEFW 1342 grams• AFI: 22.92 cm• Placenta: posterior, grade 1 in maturity• Fetal Biometry:

– BPD: 7.29 cm– AC: 24.86 cm– FL: 5.49 cm– FAC: 24.86 cm

8/23/10

• 100 grams OGTT: – Fasting: 64.8 mg/dL– 1st hour: 104.4 mg/dL – 2nd hour: 90 mg/dL– 3rd hour: 86.4 mg/dL

08/24/10; 31 weeks AOG

S> Follow upAsymptomatic with no danger signs of pregnancy

O> BP: 100/60 PR: 86 T: 36.7 °C Wt: 152 lbsPink palpebral conjunctiva, anicteric scleraSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, AB at 5th LICS MCL, no murmursGlobular abdomen, FH 33 cm, FHT 148 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic(+) grade 1 bipedal edema

A> Pregnancy 31 weeks AOG, cephalic; Breast CA stage 1P> For fetal biometry with AFI determination and 100 g OGTT

Continue Multivitamins, FeSO4, I glass of milk ODAttend mothers’ class 10-11 am SaturdaysRetrieve OR tech and record of management of breast CA TCB after 2 weeks

09/06/10 33 weeks AOG

S> Asymptomatic(-) danger signs (+) good fetal movement

O> BP: 110/80 PR: 92 T: 36.6 °C Wt: 152 lbsPink palpebral conjunctiva, anicteric scleraSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, AB at 5th LICS MCL, no murmursGlobular abdomen, FH 33 cm, FHT 148 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic(+) grade 1 bipedal edema

A> Pregnancy 33 weeks, cephalic; Breast CA stage 1 s/p Right MRM 2008; Elderly Primigravid

P> Continue Multivitamins, FeSO4, I glass of milk ODAttend mother’s class every Saturday 10 amTCB after 2 weeks for follow-up

09/27/10 36 weeks AOG

S> Asymptomatic(-) danger signs (+) good fetal movement

O> BP: 110/70 PR: 89 T: 36.6 °C Wt: 153 lbsRight chest: (+) scar, no masses; Left chest: no mass/tenderness Pink palpebral conjunctiva, anicteric scleraSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, AB at 5th LICS MCL, no murmursGlobular abdomen, FH 36 cm, FHT 122 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic(+) grade 2 bipedal edema

A> Pregnancy 36 weeks, cephalic, not in labor; s/p MRM for breast CA stage 1, in remission; t/c GDM

P> For BPS and 100g OGTTContinue FeSO4 1 cap ODAttend mother’s class every Saturday 10 amTCB with resultsFetal movement counting

Fetal Biometry (10/06/10)

• Single live intrauterine pregnancy of about 35-36 weeks AOG, cephalic presentation, BPS 8/8, SEFW 3005 grams; Polyhydramnios

• Male• AFI: 28.55 cm• Placenta: posterior, grade III• Fetal Biometry:

– BPD: 8.75 cm– HC: 31.93 cm– FL: 6.69 cm– FAC: 34 cm

10/06/10 37-38 weeks AOG

S> Asymptomatic(-) danger signs, (+) irregular painless uterine contractions, (+) good fetal movement

O> BP: 110/70 PR: 89 T: 36.6 °C Wt: 153 lbsRight chest: (+) scar, no masses; Left chest: no mass/tenderness Pink palpebral conjunctiva, anicteric scleraSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, AB at 5th LICS MCL, no murmursGlobular abdomen, FH 36 cm, FHT 122 bpm, LM1 breech, LM2 fetal back right, LM3 cephalic(+) grade 2 bipedal edema

A> Pregnancy 36 weeks, cephalic, not in labor; s/p MRM for breast CA stage 1, in remission; t/c GDM

P> For BPS and 100g OGTTContinue FeSO4 1 cap ODAttend mother’s class every Saturday 10 amTCB with resultsFetal movement counting

10/6/10; 36 weeks AOG

S> 3 days PTC (?) minimal watery vaginal discharge, (-) hypogastric painNo consult done2 days PTC (?) watery vaginal discharge, (+) crampy abdominal pain radiating to the backConsulted at a lying in clinic: IE: 1-2 cm dilated, (?) BOWNo medications givenComplete bed rest with spontaneous resolution of symptoms

O> BP: 100/70 PR: 80 Wt: 144 lbs FH: 30 cm FHT: 138 bpmSpeculum exam: cervix smooth, violaceous, (+) whitish mucoid discharge (-) pooling, (-) Ferning’s testIE: cervix 1 cm, 50% effaced, (+) BOW, cephalic, station -3

A> Pregnancy 32-33 weeks, cephalic, not in labor; (?) Leaking bag of water; Vulvar varicosities; Seizure disorder; Grandmultipara

P> For BPS with AFI nowFollow up with results

BPS (10/11/10)

• Single live intrauterine pregnancy of about 31-32 weeks in cephalic presentation

• BPS 8/8• SEFW 1639 grams• AFI: 15.02 cm• Placenta anterior, grade 1

Urinalysis (9/1/10)

Color L. YellowTransparency ClearpH 6.0Sp. Gravity 1.005Albumin TraceSugar -RBC 0-2hpfPus cell 3-5hpfSquamous cell fewBacteria +Mucus threads ++

Pap Smear (6/22/10)Non specific inflammation

• BPS result noted• Continue Multivitamins, FeSO4 and 1 glass of

milk OD• Still for MRI• Follow up with Neuro with MRI results• Mother’s class every Saturday• Follow up after 2 weeks

MRI REPORT (10/13/10)

Impression: • Consider Mesial Temporal Sclerosis, on the

right, clinical correlation and follow up suggested

Physical Examination on Admission

• Conscious, coherent, not in cardiorespiratory distress• BP 120/80 PR 84 RR 16 T 36.5 °C• Weight: 146 lbs Height: 157.5 cm• Warm moist skin, no active dermatosis• Pink palpebral conjunctivae, anicteric sclerae• Neck not rigid, no palpable cervical lymphadenopathy,

no anterior neck mass• Symmetrical chest expansion, no retractions, clear

breath sounds, no retractions• Adynamic precordium, AB 5th LICS MCL, S1>S2 at the

apex, S2>S1 at the base, no murmurs

• Globular abdomen, FH 30 cm• LM1 - breech LM2 - FBR LM3 – cephalic• FHT 150 bpm• Uterine contractions every 7 minutes 40-50

seconds, mild to moderate• IE: cervix 2-3 cm dilated, 50% effaced, (+) BOW,

cephalic, floating• Extremities: (-) edema, (-) cyanosis; pulses full

and equal

Neurologic Exam

• Alert, awake, oriented to 3 spheres GCS 15 (E4V5M6)

• Intact cranial nerves• MMT: 5/5 on all extremities• Can do APST, FTNT with ease• DTRs ++ on all extremities• No sensory deficit• No Babinski• No nuchal rigidity, Brudzinski, Kernigs

Assessment

• Pregnancy 33-34 weeks cephalic, in preterm labor• Seizure disorder

Plans

• CBC with platelet• Urinalysis• LAT• Refer to Neurology for further evaluation and

management• Watch out for recurrence of seizures

LAT (10/18/10)

A> Pregnancy 33-34 weeks, cephalic, in preterm labor Mesial temporal sclerosisP> Start Isoxsuprine drip (4 ampules in 500 cc D5W)

Betamethasone 12 mg/IM q 24 x 2 doses

Neurology Referral

• A> Generalized Tonic-clonic Seizure secondary to right Mesial Temporal Sclerosis

• P> No contraindication for use of Tocolytic Drugs or any form of delivery– Refer if with seizure recurrence– May give Diazepam 5mg/IV every 8 hours for

active Seizures

NST (4th hour)

CBC (10/18/10)

Ref range Unit

Hgb 120-170 g/L 122RBC 4.0-6.0 X10^12/L 3.66HCT 0.37-0.54 0.36Platelet 150-450 X10^9/L 246WBC 4.5-10.0 X10^9/L 13.10Differential CountNeutrophils 0.50-0.70 0.80Segmented 0.50-0.70 0.80Lymphocytes 0.20-0.40 0.20

Urinalysis (10/18/10)Physical Characteristics

Microscopic Findings

Color Yellow Cells

Transparency turbid RBC – 0-2hpf

Ph 6.0 Pus cell 1-4hpf

Specific Gravity 1.020 Squamous cell +

Chemical Test Bacteria ++

Albumin - Mucus threads ++

Sugar -

2nd HD

• Isoxsuprine 10mg/tab 1 tab every 8 hours

3rd HDDischarge Medications: • Isoxsuprine 10mg/tab, 1 tab every 8 hours x 2 weeks• Multivitamins 1 cap OD• Ferrous Sulfate, 1 cap OD• Milk 1 glass ODSpecial Instructions:• Bed Rest• Avoid Sexual Contact and strenuous activitiesFollow-up or Transfer Instructions:• To come back for follow-up on Oct 29, 2010, 8AM at OB-

OPD• To come back for follow up at Neurology after 1 week

Neurology

• Lamotrigine 50 mg/tab ½ tab ODHS

Thank You!