Moderator – Dr.
Rajeshwari M
CASE DISCUSSION Presenters – Dr. Nirupa,
Dr. Vaishnavi, Dr. Shravanthi
Name- Mrs. XYZ
Age- 22 years
IP No.- 68931
Date of admission – 25/02/23
Occupation- House wife
Education- 6th std
Husband’s name- Mr. ABC
Occupation – Construction worker
Education – 8th std
Socio economic status- Class 4 According to Modified Kuppuswamy
Classification
Address- AP Mudanur/ TQ Hunasagi/ DT Yatagiri
CHIEF COMPLAINTS
Patient with H/o 9 Months of Amenorrhoea, with active foetal
movements, came with complaints of pain abdomen since 4 am
today morning (5 hours prior to admission) and complaints of PV
Leak since 7 am today morning (2 hours prior to admission).
HISTORY OF PRESENTING COMPLAINTS
Patient, with h/o 9 months of amenorrhoea, with active foetal
movements, came with complaints of pain abdomen since 4 am today
morning (5 hours prior to admission), which was insidious in onset,
gradually progressive in nature, dull aching type, radiating to thigh and
back, with no aggravating or relieving factors.
Patient also gives h/o PV Leak since 7 am today morning (2 hours prior
to admission), which was insidious in onset, was clear in colour, non
blood stained and non foul smelling.
No h/o bowel or bladder disturbances
No h/o fever with chills
No h/o burning micturition
No h/o PV Bleed
ANC HISTORY - BOOKED AND IMMUNISED
Trimester 1:
Spontaneous conception
Pregnancy detected by Urine Pregnancy Test and confirmed by Early
Pregnancy Scan
Folic Acid Supplementation taken.
No h/o fever with chills
No h/o PV Spotting
No h/o exposure to radiation or intake of teratogenic drugs
Trimester 2
Quickening felt at 5 months of amenorrhoea
1 dose of TT Injection taken
Anomaly Scan done – no anomalies detected
Iron and Calcium supplements taken
No h/o high BP Recordings or high sugar levels
Trimester 3:
Growth Scan done
Iron and Calcium Supplements taken
Came with the above complaints
OBSTETRIC HISTORY
Married Life of 4 years, Non consanguineous marriage
Obstetric Score – G2P1L1
I – Female, 2 years ago, B. Wt - 2.5 kgs, FTVD, Alive and Healthy
II – Present pregnancy, spontaneous conception
MENSTRUAL HISTORY
LMP – 01/06/2023
EDD – 08/03/2023
POG –38 weeks 2 days
According to 7 weeks scan
EDD – 10/03/2023
POG – 38 weeks 0 days
Past History – Not a k/c/o DM/HTN/TB/ Asthma/ Thyroid or Cardiac
disease/Epilepsy
Family History – Nothing significant
Personal History – Mixed diet
Appetite adequate
Sleep undisturbed
Bowel and Bladder habits – Normal and Regular
No h/o substance abuse
GENERAL PHYSICAL EXAMINATION
Patient is conscious, co-operative and well oriented to time, place
and person. She is moderately built and nourished
Weight - 84 kg Height - 155 cm
Vitals:
PR – 88 bpm
BP – 130/80 mmHg
SpO2 – 98% on room air
Temp – Afebrile (98.6 F)
RR – 18 cpm
Pallor Absent
Pedal Edema Absent
Icterus/Cyanosis/Clubbing/Lymphadenopathy – Absent
B/L Breast
Spine No Abnormalities Detected
Thyroid
SYSTEMIC EXAMINATION
CVS: S1 S1 heard, No murmurs
RS: B/L NVBS heard, No added sounds
CNS: No focal Neurological Deficit
Per Abdomen:
Inspection:
Abdomen markedly enlarged, looks globular with full flanks
Skin shiny with Large Stria Gravidarum Present
Umbilicus- Central and everted
Palpation:
Abdominal Girth = 98 cm
Symphysio fundal height = 36 cm
1-2 contractions/5 – 10 seconds/10 minutes
Foetal parts not well appreciated.
Cephalic presentation, Freely floating head.
Auscultation:
FHS present
FHR = 146 bpm
Per Vaginal Examination:
Cervical Os 1 to 2 cm dilated
10 - 20 % effaced
Head high up
Membranes absent
Active PV Leak present – Liquor Clear
Pelvis adequate: Sub pubic angle – obtuse
Intertuberous distance – admits 4 knuckles
PROVISIONAL DIAGNOSIS
G2P1L1 with 38 weeks 2 days period of gestation with Cephalic
Presentation in latent labour
INVESTIGATION
CBC:
Hb – 10.7 gm/Dl Blood Group – O positive
PCV – 31.5
MCV – 90 HIV – Negative
HbsAg – Negative
MCH – 30.6
MCHC – 34
RBS – 78 Mg/dL
RDW – 15.4 TSH – 4.84
RBC – 3.5
TC – 17300 (N88/ L9/ E0.3/ M2.9/ B0.1) CRP - <5
Platelet – 2.99 Lakhs
Obstetric Scan (25/02/2023):
Single Live Intrauterine Foetus corresponding to 38 to 39 weeks period
of gestation with Moderate Polyhydramnios.
Cephalic Presentation
Placenta – Anterior
Amniotic Fluid: AFI = 21 cm
Cervical Length = 3.1 cm
FINAL DIAGNOSIS
G2P1L1 with 38 weeks 2 days period of gestation with Cephalic
Presentation in latent labour.
DELIVERY NOTES
Under all aseptic precautions, under good uterine contractions,
under the effect of 2.5 U of Oxytocin, patient delivered a live MALE
baby of Birth weight 3.1kg at 2.45 pm on 25/02/2023 under
Cephalic Presentation with APGAR Score – 7/10 and 8/10.
Baby cried after stimulation.
Cord clamped and cut. Placenta and membranes delivered in toto.
RMLE given and sutured in layers.
Inj. OXYTOCIN 10 IU IV given in 500 ml RL.
BABY DETAILS
Baby was shifted to NICU i/v/o RDS and was on O2 hood for 2
days, was gradually weaned off to room air and shifted to mother’s
side.
THANK YOU
