PRABHAT KC

ROLL NO 33 PAHS 2ND BATCH

LEARNING LOG OBS/GYNE

Learning log

Proforma for clinical case

Part A

Presentation:A 18 year old primi from ramechap came to the maternity ward with theChief complaint of watery discharge for 5 days.

Hospital number: 718158Main diagnosis: G1P1A0 at 32 weeks of gestation with Preterm Prelabor Rupture of Membrane (PROM) syn: Premature rupture of membraneHistory taken: yesPatient examined: yesWhere seen (OPD/ER/ Specialty Ward) : maternity wardWhen seen (insert date): 2072/7/18Age: 18 yearsGender: femaleOccupation: housewifeHistory of Presenting Complaints and associated features-According to the patient she was apparently well 5 days ago when she had watery discharge. The discharge was non-odorous, scanty discharge at first but later on there was heavy discharge which was thick in nature and more during the morning time. There was no associated pain, fever. It wasn’t aggravated by cough or exercise. For two episode it was blood stained. She has got no history the use of the contraception, dyspareunia, urinary symptoms, postcoital bleeding, involuntary passage of urine etc. There is no history of the trauma, anorexia, weight loss and itching in the genital regions the bowel habits were normal.1st trimester: her pregnancy was known by urine pregnancy test and later on confirmed at hospital. There were episodes of nausea and vomiting .there was no increase in the urinary frequency, urgency, dysuria .Her urine, blood and ultrasound report were all normal and was prescribed folic acid2nd trimester: the cessation of the menses continued and there was enlargement of the breast. She perceived foetal movements at 4th month of her pregnancy. She took both the shots of TT vaccine. She continued to take iron, calcium tablets. Her ultrasound report showed no any abnormalities3rd trimester: she has been regularly doing her ANC visits.

Menstrual history:Menarche: at the age of 14Duration of cycle: 28-30 daysFlow: 4-5 daysAmount: moderate

She doesn’t have irregular cycles, heavy bleeding, pain during mensuration, bleeding in between the periods. She hasn’t been taking any medication during the menstruationLMP (Last Menstrual Period): 101th Chaitra 2071 B.S

Obstreics history:She was married at an age of 17 and this is the planned pregnancy.Gravida-1 Parity-1 Living-0 Abortion-0G1P1L0A0

EDD (Expected Delivery Date): 17th poush 2072 B.SGestational age: 32 weeks of gestation

Contraceptive history:They have been using barrier methods of contraception

Systematic enquiryCentral Nervous System: she was feeling dizziness and headache for 2 daysMusculoskeletal: she has tingling of hands and feet’sCardiovascular: not significantRespiratory: not significantGastrointestinal: not significantENT: not significant

Past medical and surgical History-There was no any history of similar illness in the past and no history of the recurrent UTIShe has done no any surgical interventionDrug historyShe hasn’t taken any medicationsKnown drug allergies-She isn’t allergic to the drugs Social historyShe lives in a middle class family.Her husband is a HealthAssitant so he can afford money for her treatment.Family History-She has got total of 8 members in her family...No history of diabetes, hypertension, asthma, tuberculosis.Personal historyShe is non-smoker and non-alcoholicSummary of patient’s ideas, concerns and expectationsIdea: she had no idea how this happened.Concern: what happens if too much water goes? Expectation: heal faster and go home faster

Summary of history18 year old primi at 32 weeks of pregnancy from gorkha presented with pervaginal leakage for 5 days .Her 1st and 2nd trimester visits were uneventful. She is having all her ANC visits and findings were normal

Provisional diagnosis-

Pathological discharge associated with vaginitis and cervicitisUrinary incontinence Preterm Prelabour rupture of membrane

Summary of examinationGeneral examination:Patient was lying comfortably on bed with the IV lock on the right hand. Temperature: 980F (afebrile)Pulse: 72 beats/ minuteRespiratory rate: 24 /minuteNo signs of pallor, icterus, cyanosis, palmer erythema, pedal edema etc.

Inspection of abdomen:Abdomen is symmetrical, no any visible peristalsis, no any surgical scar marks, dilated veins, umbilicus centrally located. Striae gravidarum was presentPalpation:-Abdomen is soft and nontender-No any mass palpable-Fundal height:-The fundal height is of around 34 weeks of gestation, cephalic presentation, Longitudinal lieObstretics grip

1. Fundal grip: broad, soft, irregular mass was felt suggestive of buttocks. It was longitudinal lie

2. Lateral grip: the back was found to be smooth, curved, and resistant whereas the front was found to be irregular, knob like.

3. Pawlik’s grip: the presenting part was not engaged and head could be grasped4. Pelvic grip: head wasn’t engaged

Auscultation-Fetal heart sound heard.-S1, S2 heart sound heart and no additional sound heard.

Examination of cardiovascular system: First heart sound (S1), second heart sound

(S2) and no murmurs were heard.

Examination of respiratory system: Bilateral equal air entry; vesicular breath

sounds were heard bilaterally

The summary of the examination done by the doctors is as follows-Per abdomen: soft nontender, uterus of 32 weeks size-FHS (foetal heart sound) –present-Contraction –absent-Per Speculum: leaking-Per Vaginal: os -1 cm opened-Cervix- uneffaced-Head station: -2

Summary of investigations.2072/7/22UrinalysisCreatinine= 0.3Albumin – nilWbc- 1-2 cells/hpfRbc- 0-2 cells/hpfBacteria – fewEpithelial cells- 0- 2cells/fieldRandom blood sugar= 70 gm/dl

HematologyHaematocrit- 34%Platelets= 239*103/microliter

USG Report on 2072/7/22No of foetus= single, Presentation= cephalic, Lie= longitudinal, Foetal heart rate= 141 beats/min, Placenta = anterior, AFI= 6.7cm, High vaginal swab was taken

Serology:RPR was not reactive

Management including medications-An 18 year old primi lady came to the maternity ward with the chief complaint of the vaginal discharge for 5 days. When she was admitted to the hospital her vitals were normal (BP=110/70, temperature= 98 0F, Pulse= 72 beats/ min).At that time she was given injection dexamethasone 12mg IV stat then after 12 hours. Later on she was given capsule amoxicillin +tab metronidazole. She was planned for USG, monitor FHS (Foetal Heart Sound), investigations for serology, blood group, haematocrit were to be send. Her vitals were normal between the days.

Medication:

Drug name: capsule amoxicillinDose: 500 mgRoute: oral Frequency: Three times a day (TDS)

Indication and planned durationIndication:a) Treat urinary tract infectionb) Sinusitisc) Otitis mediad) Lower respiratory tract infectione) Prolong the latency period

Class of drug and mechanism of actionClass of drug: Extended spectrum penicillin’s (antimicrobials)MOA: This is a cell wall synthesis inhibitors This inhibits cell wall by:

a) Binding to PBP(plasma protein binding)b) Inhibits cross linkingc) Inhibits transpeptidation

Main side effects and monitoringMain side effects:a) Hypersensitivityb) GI distress leading to nausea vomitingc) Gastric ulcerNotes: In a patients with the renal failure penicillin in high dose can cause seizure.

Drug name: Tab metronidazoleDose: 400 mg Route: oral Frequency: Three times a day (TDS)Indication and planned durationIndication:

a) For anaerobic coverage given up to one weeksb) Intestinal amebiasisc) Anaerobic liver abscessThis is actually given for 10 days.

Class of drug and mechanism of actionClass of drug: NitroimidazoleMOA: The nitro group of the metronidazole is chemically reduced in the anaerobic Bacteria when this is reduced the free radical is produced and that free radical Actually destroys the DNA of the bacteria leading to the lysis of the bacteria.Main side effectsa) Disulfiram like effect when taken with alcoholb) Metallic taste alters the taste of food

Nausea headache and dry mouth

Drug name: injection dexamethasoneDose: 12mgRoute: IMFrequency: stat and then after 12 hoursThis is given in two doses.Indication and planned durationIndication:a) Maturation of the lungs of foetusc) Pharmacotherapy - Rheumatoid arthritis - Osteoarthritis - Autoimmune disease

-bronchial asthmad) Interventricular haemorrhagee) Cerebral oedema

Class of drug and mechanism of actionClass of the drug: long acting gulcocorticoidsMOA: It releases transcription factor from heat shock binding protein and induces transcription of different proteins.This also has anti-inflammatory role which is mediated through inhibition of phospholipase 2.Main side effects and monitoringMain side effects:a) Cushing habitusb) Hyperglycaemiac) Delayed healing sd) Osteoporosise) Foetal abnormalities

Part B

What causes this condition (summarize the pathophysiology)?Prelabor Premature rupture of membrane is the rupture of the chorioamnionic membrane beyond 28 week of gestation and before 37 weeks of gestation and prior to onset of labour.When the rupture of membrane occurs occur beyond 37 weeks of gestation but beyond the onset of labour then it is called term PROM when it occur before 37 WOG it is called preterm PROMThe ascending infection from the lower genital tract is the most common because other causes include cigarette smoking, multiple pregnancies, infection, cervical incompetence, low BMI, decreased tensile strength of the membrane, prior preterm labour How may it be prevented?Generally 90% of the term cases spontaneous labour ensues within 24 hours and if gestational age more than 34 weeks’ labour starts spontaneously within 48 hours. One needs to balance the risk of premature birth against the risk of infection (which increase with the time that membranes are ruptured before birth). Amniotic fluid assessment for fetal lung maturity from vaginal pooling consider deliver if mature.US to access GA, anomalies presentation of baby, and AFI (Amniotic Fluid Index)Monitor in hospital for infection, abruption, foetal distress, and preterm labour.If <34 weeks gestation give steroids to decrease incidence of RDS.Antibiotic coverage to prolong latency period (time between ROM and onset of labour) to give a premature foetus time to mature in utero.Fetal testing to ensure fetal well beingDelivery: If infection, foetal distress noted

Commonly presenting featuresGenerally patient present with the history of fluid gush or continued leakage.

Natural history/prognosisVaries with the gestational age;90% of women with PROM at term go into spontaneous labour within 24 hours and 50% of the preterm go into spontaneous labour within 48 hoursComplication include cord prolapse, intrauterine infection (chorioamnionitis) premature delivery, limb contracture, pulmonary hypoplasia, umbilical cord prolapse.

Most useful investigations (look at literature for evidence)Ultrasound was done in order to find out the foetal condition and the level of the amniotic fluid, gestational age

1. Speculum examination was done in order to confirm the rupture of the membrane. The speculum examination shows:

a) Pooling of fluid in the posterior fornixb) May observe the fluid leaking out of cervix on cough.2. Nitrazine (amniotic fluid turn’s nitrazine paper blue)

Low specificity as can be positive with blood, urine or semen.3. Ferning (high salt in amniotic fluid evaporates giving fern like pattern.4. Centrifuged cells stained with 0.1% Nile blue sulphate showing orange blue

coloration of the cells

References:1. Garite TJ. Management of premature rupture of

membranes. Clin Perinatol. 2001;28:837–847.(pubmed)2. Ohlsson A. Treatments of preterm premature rupture of the

membranes: a meta-analysis. Am J Obstet Gynecol. 1989;160:890–906(pubmed)

3. American College of Obstetricians and Gynecologists, authors. Premature Rupture of Membranes.Washington, DC: American College of Obstetricians and Gynecologists; 1998. (ACOG Practice Bulletin No. 1)

Evidence for treatment (quote literature source)There is now substantial evidence to suggest that adjunctive prophylactic (empiric) broad-spectrum antibiotics can significantly prolong latency in the setting of preterm PROM remote from termAdministration of antenatal glucocorticoids (betamethasone, 12 mg IMI q 24 hourly × 2 doses or dexamethasone, 6 mg IMI q 12 hourly × 4 doses) has been shown to decrease the incidence of RDS, IVH, and necrotizing enterocolitis (NEC) by approximately 50%.However, a repeat (salvage) dose or course should be considered if the initial course was completed prior to 28 to 32 weeks of gestation.

References:1. Ohlsson A. Treatments of preterm premature rupture of the

membranes: a meta-analysis. Am J Obstet Gynecol. 1989;160:890–906(pubmed)American College of Obstetricians and Gynecologists,

authors. Premature2. Rupture of Membranes.Washington, DC: American College of

Obstetricians and Gynecologists; 1998. (ACOG Practice Bulletin No. 1)

3. Parry S, Strauss JF., 3rd Preterm premature rupture of the fetal membranes. N Engl J Med.1998;338:663–670.(pubmed)

Student reflection on patient/presentationWhat did I learn from this case?How might this affect the way I manage patients in the future?

The patient that I took was case of Preterm Prelabor Rupture of Membrane.While approaching the patient the patient was pretty comfortable in telling the things that i asked. This case taught me also how to take medical history the patients, develop communication skills and also taught me that I needed to much better in taking history and finding the things which could help me in finding proper diagnosis. I learnt how the patient with the Preterm Premature Rupture of Membrane presents. This gave me opportunity to learn about this condition: its pathophysiology, management aspects.When there is rupture of membrane before 34 weeks of gestation this is kind more serious condition. The patient needs bed rest more and patient is given steroids in order to prevent the foetal respiratory distress syndrome. Patients should also be given antibiotics in order to prevent the infection that might follow like as Group B streptococcus which is more common in the pregnant women’s.Initially when the patient present with the complaints then patients vitals should be checked, blood should be send for CBC, serology test should be done.Patient should be properly counselled about the condition patient is suffering from, what might have caused this condition, what complications dose this condition leads to.If the patient comes with the gestational age between 34 and 36 weeks then delivery can be induced considering that if kept for longer time infection might follow.So I would manage the patient with the Preterm Premature Rupture of membrane as above ways and if any complication rises then consulting with the seniors and other staffs is essential as teamwork, the better option in managing the case.