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Davao Medical School Foundation

College of Medicine

OBSTETRICS-GYNECOLOGY

In Partial fulfillment of

Requirements in OB-GYNE

SUBMITTTED TO:

DR. RUBY ROBISO

SUBMITTED BY:

CHERIE TAPIAXYLIA SAHARA E. TOCAO

CHERIS VARGAS

MAY 24,2013


2/13

GENERAL DATA

This is a case of AB, a 28 year old primigravida , 38 1/7 weeks AOG who came in due

to watery vaginal discharge.

HISTORY OF PRESENT ILLNESS

One day prior to admission , the patient noticed passage of clear, watery vaginal

discharge,amounting to approximately 250 ml. She claimed to have a steady leakage of small

amount of fluid but no consultation was done.Condition was not associated with vaginal

pruritus, foul smelling discharge ,fever hypogastric or lumbosacral pain.

Eighteen hours prior to admission ,patient still had vaginal discharge now associated

with hypogastric pain radiating to her lumbosacral area occurring intermittently every 5 minutes

lasting for approximately 1 minute . Patient tolerated her condition until 1 hour PTA, patient

sought medical advice with her attending physician . Internal examination was done which

revealed 5 cm cervical dilatation. She was advised for admission in this institution hence

admitted.

PAST MEDICAL HISTORY

The patient is not a known diabetic , hypertensive or asthmatic with no previous history

of any hospitalizations or surgical operations.She also has no known food or drug allergies.

FAMILY HISTORY

No heredofamilial diseases were noted on both sides.

PERSONAL / SOCIAL HISTORY

AB was born and raised in Davao City with a degree in Management Accountancy. She

is currently employed . She got married last 2010.

Her diet consists mostly of carbohydrates, proteins with moderate amounts of fat.She is

not a smoker and only drinks alcoholic beverages occasionally.


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GYNECOLOGIC HISTORY

Patient had her menarche at 9 years old. Subsequent menstrual periods were regular

lasting for 4 days moderate in quantity associated with occasional dysmenorrhea .Patient had

her sexual debut at 18 years old with 1 sexual partner who eventually became her husband.

OBSTETRIC HISTORY

The patient is a primigravid. Her last menstrual period was last August 22, 2012 while

her previous normal menstrual period was last July 2012. Her computed AOG is 38 weeks and 1

day with her expected date of delivery falling on May 29, 2013. She had her first prenatal

check-up at 12 weeks AOG, since then her succeeding prenatal check-ups have been regular

with no unusualities noted. Until about 1 month PTA, when patient noted presence of dysuria ,

fever and flank pains. She sought consultation with her attending physician and was diagnosed

with urinary tract infection and was given ampicillin-Sulbactam, 750 mg tablet, 1 tab BID for 7

days and was advised repeat urinalysis and follow-up checkup after 1 week, patient however,

was non-compliant and did not return for her scheduled check-up.The patient does not have any

history of previous contraceptive use. She had her pap smear last 2012 with normal findings as

claimed.

REVIEW OF SYSTEMS

GENERAL (-) easy fatigability

ENDOCRINE SYSTEM (-) thyroid problems, (-) neck surgery, (-) heat and cold intolerance

SKIN (-) pruritus

HEAD (-) dizziness, (-) headache

EYE (-) pain, (-) excessive lacrimation

EAR (-) tinnitus

NOSE (-) persistent stuffiness, (-) nasal congestion, (-) postnasal drip

MOUTH (-) bleeding gums, (-) dyspnea

THROAT (-) odynophagia, (-) hoarseness

NECK (-) neck surgery, (-) nuchal rigidity, (-) limited motion

BREAST (-) breast pain, (-) abnormal discharge

CARDIAC (-) nocturnal dyspnea, (-) murmurs


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PERIPHERAL VASCULAR (-) claudication

GASTROINTESTINAL (-) change in bowel habits

PULMONARY (-) hemoptysis, (-) asthma

GENITO-URINARY (+) dysuria, (+) urinary frequency

HEMATOPOIETIC (-) easy brusing

MUSCULAR (-) limited ROM

NEUROLOGIC (-) change in orientation

PHYSICAL EXAMINATION

GENERAL

The patient was examined conscious, coherent and responsive.

VITAL SIGNS

BP: 110/80 mmHg; PR: 91 bpm; RR: 20 bpm; temperature: 36.5 C

Weight: 77kg ; Height: 52

SHEENT:

SKIN:

Ifair complexion, no lesions/scars, no palmar erythema, nails without clubbing and cyanosis

PAmoist and warm with good skin turgor. No palpable lesions, tenderness, lumps noted

HEAD:

Ihair is black in color, no lesions noted

Anon-palpable lymph nodes


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EYES:

Ianicteric sclerae, pink palpebral conjunctivae

EARS:

Ino lumps, lesions noted

PAnon-tender and mobile external ear

NOSE:

Isymmetric, no swelling noted, nasal septum at midline

PAfrontal and maxillary sinuses are not tender

MOUTH:

Ino ulcers/lesions noted, tongue and vulva at midline, no tonsilar enlargement noted

NECK:

Isupple, no nuchal rigidity and gross thyromegaly, trachea at midline, no lesions noted

BREAST:

Ino redness/discharge noted

PAno mass palpated, non-tender

CHEST/LUNGS:

Ino scars/ lesions noted

PAnon-tender

PEresonant

Avesicular breath sounds in most areas without adventitious sounds


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CARDIOVASCULAR:

Iadynamic precordium

PAsymmetric pulses, capillary refill time < 2 sec

Ano murmurs noted. PMI at 5th ICS, left MCL

ABDOMEN

Ino lesions noted

Anormoactive bowel sounds at 5 bowel sounds per minute

PEdullness at RUQ, the rest is tympanic

PAnon-tender

Fundic Height32 cm

Estimated Fetal Weight3100g

Fetal backleft maternal side

PELVIC EXAMINATION

External genitalia grossly normal

SPECULUM EXAMpooling of clear, watery discharge at the posterior vaginal fornix; cervix is

smooth, pinkish in color with no lesions noted

INTERNAL EXAM6cm cervical dilatation; 80% effacement; station -3; midposition; soft consistency;

cephalic presentation; ruptured bag of water; Bishop score 9

EXTREMITIES

Ino lacerations, fissures noted

PAwarm to touch, no edema noted


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MUSCULOSKELETAL

Inormal muscle strength of 5/5, normal ROM, no deformities, atrophy and swelling noted

MENTAL STATUS

The patient is appropriately dressed. She is in supine position and with good grooming. Cooperative with

the interviewer. Mood is congruent with affect and appropriate. Thought process is coherent, no suicidal

ideations or plans. Memory is intact to remote, recent and immediate recall.

CRANIAL NERVES

Iable to smell

IIpupils equally round and reactive to light and accommodation

IIIexhibit normal EOM

IVable to move eyeballs obliquely

Vblinks whenever sclera was lightly touched

VIable to move eyeballs laterally

VIIable to perform different facial expressions

VIIIable to hear loud and soft spoken words

IXable to elicit gag reflex

Xable to swallow without difficulty

XIable to shrug shoulders against resistance

XIIable to protrude tongue at midline and move it side to side

MOTOR:

Muscle strength 5/5

COORDINATION:

Finger to nose test intact


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SENSORY:

Pinprick: intact

Light touch, position and vibration: intact

REFLEX:

Negative primitive reflex

Corneal reflex elicited

ADMITTING IMPRESSION:

G1P0 Pregnancy Uterine 38 1/7 weeks AOG, cephalic in active phase of labor , Premature

Rupture of Membrane

SALIENT FEATURES

28 years old Married G1P0 38 1/7 weeks AOG Passage of watery vaginal discharge Dysuria and urinary frequency Fundic height of 32 cm Speculum examination:

(+) pooling of clear watery discharge at the posterior vaginal fornicus. (+) fluid per cervical os

Internal examination: 6 cm dilatation; 80% effacement; station -3; RBOW, clear; soft; midpostion (BS = 9)


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DIFFERENTIAL DIAGNOSES

Urinary Tract Infection-A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it

affects the lower urinary tract it is known as a simplecystitis when it affects the upper urinary

tract it is known as pyelonephritis .

Ruled in due to: Passage of watery vaginal discharge Dysuria Urinary frequency

Upon admission, we could not totally rule out UTI since further diagnostic work-up is needed such as

urinalysis and the gold standard in diagnosing UTI , urine culture.

BACTERIAL VAGINOSIS-is an abnormal vaginal condition that is characterized by vaginal discharge and results from an

overgrowth of normal bacteria in the vagina.

Ruled in due to the presence of: copius vaginal discharge

We could not totally rule out this condition upon admission, however based on the character of the

patients vaginal discharge this could be ruled out because the discharge in bacterial vaginosis is grayish

in color and has an unpleasant, fishy odor.Ancillary procedure like gram stain is also needed.

Leukorrhea of Pregnancy- Normal vaginal discharge during pregnancy called leukorrheais thin, white, milky and mildsmelling.

Ruled in due to: Passage of watery vaginal discharge

Ruled out based on the character of the vaginal discharge. Whitish, curd like discharge is common in

leukorrhea.

COURSE IN THE WARD

Upon admission, patients vital signs were monitored. Patient was then hooked to a cardiotocogram (CTG), which revealed a Category 1 tracing Labor augmentation with Oxytocin was started.
https://en.wikipedia.org/wiki/Infectionhttps://en.wikipedia.org/wiki/Urinary_systemhttps://en.wikipedia.org/wiki/Cystitishttps://en.wikipedia.org/wiki/Pyelonephritishttp://www.medicinenet.com/script/main/art.asp?articlekey=64117http://www.medicinenet.com/script/main/art.asp?articlekey=64117https://en.wikipedia.org/wiki/Pyelonephritishttps://en.wikipedia.org/wiki/Cystitishttps://en.wikipedia.org/wiki/Urinary_systemhttps://en.wikipedia.org/wiki/Infection


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Progress of labor was monitored, during which time, patient was placed on anintermittent CTG monitoring.

EFM

FRIEDMANS CURVE

Eleven hours after admission, patient delivered via Normal Spontaneous Delivery to alive baby boy in cephalic presentation with Apgar Score of 8 and 9, Ballard Score of 38

weeks and birth weight of 3100g.

Postpartum, patients condition was stable. No active bleeding was noted. Uterus waswell-contracted.

Urinalysis was done and revealed the following results

URINE FLOW CYTOMETRY

WBC 19/UL

RBC 133/UL


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EPITHELIAL CELLS 26/UL

CAST 0/UL

BACTERIA 42/UL

PHYSICAL EXAM

COLOR YELLOW ORANGE

CLARITY SLIGHTLY CLOUDY

REACTION 5.0

SPECIFIC GRAVITY 1.030

CHEMICAL ANALYSIS

GLUCOSE ++

PROTEIN TRACE

Patient was discharged on her 2nd day postpartum, with no unusualities.


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CASE DISCUSSION

Premature Rupture of Membranes

This term defines spontaneous rupture of the fetal membranes before 37 completed weeks and before

labor onset. Such rupture likely has a variety of causes, but many believe intrauterine infection to be a

major predisposing event.

Some studies suggest that the pathogenesis of preterm rupture relates to increased apoptosis of

membranes cellular components and to increased levels of specific proteases in membranes and amniotic

fluid. Much of the membranes tensile strength is provided by the extracellular matrix within the amnion.

Interstitial amnionic collagens, primarily types I and III, are produced in mesenchymal cells and are the

structural component most important for its strength.

Clinical factors associated with PROM

Low socioeconomic status, low body mass index, tobacco use, preterm labor history, UTI, vaginal

bleeding at any time of pregnancy, cerclage, amniocentesis.

DIAGNOSIS

1. Vaginal Speculum Examthe speculum should be sterile as to not introduce microorganisms intothe vaginal vault

- Examine the cervical os for dilatation, free flow of fluid, and pooling of fluid inposterior fornix. Visualization of fluid coming from the cervical os is diagnostic2. NItrazine paper testingvaginal pH is acidic, amniotic fluid pH is alkaline at 7.0-7.73. Fern slidemust allow slide to dry thoroughly prior to examination under microscope. Assess for

arbonization of fluid. Cervical mucous has broad, ferning pattern that is different than the fern of

amniotic fluid

4. Ultrasonographyused to measure pockets of fluid and quantitate AFV to AFI.


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MANAGEMENT

GESTATIONAL AGE MANAGEMENT

TERM (37 weeks) Proceed to delivery Group B Streptococcus prophylaxis recommended

NEAR TERM (34-36 weeks) Same as abovePRETERM (32-33 weeks) Expectant management unless fetal pulmonary

maturity is recommended Antibiotics recommended to prolong latency if no

contraindications exist

Costicosteroids recommended by some experts, butno consensus exists

PRETERM (24-31 weeks) Expectant management Group B Streptococcus prophylaxis recommended Antibiotics recommended to prolong latency, if no

contraindications exist

Single course of corticosteroids recommended No consensus on use of tocolytics

PRETERM (24 weeks) Patient counselling Expectant management/ induction of labor Group B Streptococcus prophylaxis not

recommended

Data incomplete on the use of antibiotics to prolonglatency

Corticosteroids not recommended

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