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Hospital Exposure Case PresentationMichelle H 07120110086
Patient IdentityName : N.ASex: FemaleAge : 21 Obstetric status : G1P0A0 now 39 weeks pregnantAddress : Kampung PesarStatus : MarriedEducation : High schoolJob: WaitressMedical record no : RSUS.00-60-27-64Date of admission : 19th August 2014 (at 11.00 PM)
History Taking (20th August 2014 at 8.00 AM) Chief complaint : sudden gush of clear fluid out of her vaginaSudden gush of clear fluid out of her vagina with no mucus nor blood at 10.30 PM the day before (30 min before admittance) The fluid is non odorous, but the patient cant recall how much fluid came out. Fluid leakage increases with movement change.She felt mild contractions and cramps in her abdomen that come and go since 4.30 PM (6.5 hours before admittance)Patient complains nausea, vomiting, and felt pain in her lower abdomen since 11.00 AM (12 hours before admittance),but no fever.She urinated more often, but cant determine the exact frequency or when it started. She has no urinary nor bowel problems.
Past history : she was never hospitalized before, no history of surgery, no allergies, her childhood vaccinations were all completed. Shes currently not taking any medications.Pregnancy : on the beginning of her pregnancy she felt nausea, vomiting, fatigue, and headache. No fever, or other complaints during pregnancy.Marriage : she was married at the age of 19Menarche : 12 years oldMenstruation : Last mestrual period was on 15th of November 2013. She got her period once every month for approx. 6 days, 28 days cycle , no bleeding between periods or after intercourse, no pain during menses, occasional yellow-whitish vaginal discharge, but non odorous, non itchy, and no redness. Sexual history : She was sexually active, no multiple partners, and never has any STDs, she didnt have intercourse during pregnancy.
History TakingAntenatal care : monthly visit to the midwife, she was given tetanic injection and iron supplement. Overall, she was in good nutritional state through out her pregnancy.Contraception : she was not on any contraceptionFamily history : her mother and father has hypertension, she has no siblings, her husband has diabetes.Social and economic history : her husband is a taxi driver, they make enough money to take care of the family. Her husband is a smoker, she lives with her husband and parents, and have no pets, no history of recent overseas travel Habit : She is a heavy smoker since she was in junior high school, and smokes 1 pack a day through out her pregnancy. She tried to quit, but failed. She doesnt do drugs or alcohol.
Physical Exam ( 20th August 2014 8.00 AM) Compos mentisVital signs :-BP : 110/90 mmHg-Pulse : 82 / min-RR : 20 /min-Temp : 36.6 cAnthropometric :-Weight : 69 kgs-Height : 151 cmHeadHead : normocephaly and symmetricalSkull : no nodules or masses and depressions when palpatedFace : smooth, uniform consistency and no presence of nodules or masses, no chloasma or rash.
Eyes : sclera anicteric, conjunctiva not anemic, pupil diameter is normal 3mm/3mm. pupils equally round respond to light accommodationEars : The Auricles are symmetrical and has the same color with his facial skin. When palpating for the texture, the auricles are mobile, firm and not tenderNose : The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesionsMouth : lips pink, moist, symmetric and have a smooth texture. The tongue is centrally positioned. It is pink in color, moist and slightly rough. There are presence of thin whitish coating. The uvula is positioned in the midline of the soft palate.
Neck :The neck muscles are equal in size. Patient showed coordinated, smooth head movement with no discomfort. The lymph nodes are not palpable. The trachea is placed in the midline of the neck. The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.IntegumentSkin : uniform in color, unblemished, good skin turgor and normal skin temperatureHair : thick, silky hair and evenly distributed. No signs of infection and infestation observedNails : shape of convex curve, smooth, intact with epidermis. CRT is within normal limit, no nicotine stains
ThoraxLungs : The chest wall is intact with no tenderness and masses. Theres a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations. Tactile fremitus is equal between left and right. No ronchi or wheezing on auscultationHeart : There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts. No gallop or murmur.Breast : symmetrical, hyperpigmentation in areola, normal nipple, no discharge, no lumps, no scar.
ExtremitiesThe extremities are symmetrical in size and length, with mild edema. The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements. There were no presence of bone deformities, tenderness and swelling. There were no joints swelling, tenderness and joints move smoothly. There are some varicosities on both her legs.
Obstetric assessmentInspection : uterus length is larger than broad, which indicates longitudinal lie. Umbilicus is inverted. There are stretch marks, linea nigra, and striae gravidarum, but no scar indicating previous surgery.Palpation : Fundal height is 33cm , single fetus , intrauterus, head presentation, fetal back is on the right side, fetal descent 3/5, contractions every 3 minutes for 40 seconds, symmetrical, medium contraction power, fundal dominant, relaxation, interval, and intensity of contractions are adequate.Estimated fetal weight : 3410 grVaginal examination : portio thin and soft, effacement 50%, cervical dilatation 5cm, membrane ruptured, cephalic presentation, fetal station -1. Amniotic fluid can be observed in the posterior vaginal vault (pooling (+))
Past vaginal exam :PE 1 (19th August 2014 11.00 PM) : cervical dilatation 1 cm, effacement 10 %, no contractionsPE 2 (20th August 2014 04.00 AM) : cervical dilatation 3 cm, effacement 20 %, contractions 2 times in 10 mins for 40 seconds.
Timeline11.00 AM4.30 PM10.30 PM19th August 201420th August 201411.00 PM04.00 AMInduction of labor08.00 AMNausea,Vomiting,Lower abdominalpainMild Contractionsand crampsFluid leakageAdmittanceTo hospitalPE 1 : eff 10 %Cervical dilatation 1 cmMembrane rupturedPooling (+)Nitrazine test +
PE 2 :Eff : 20%Dilatation 3 cm
PE 3 :Eff : 50 %Dilatation 5 cm
CTG interpretation :Fetal heart rate : baseline 150 x / min, reactive, acceleration (+), deceleration (-), active fetal movement, contractions every 3 minutes with moderate power.
Nitrazine testNitrazine test was done on 19th August 2014 at 11.00 PM and the result was positive.
Lab testComplete blood count, MCV,MCH,MCHC, iron profile, bleeding time, clotting time was done, and the result was all within normal limit.
ResumeMrs. N.A 21 y.o G1P0A0 now 39 weeks pregnant came to RSUS with the chief complaint of sudden gush of clear fluid out of her vagina 30 minutes before admittance to RSUS. Fluid leakage increases with movement change. The fluid has no blood, mucus, or foul odor. She also complaints having mild cramping on her abdomen 6.5 hours before. She experienced nausea, vomiting, and pain on her lower abdomen 12 hours before. She didnt have any infections during her pregnancy, and her antenatal care was completed. She is however a heavy smoker (active and passive smoker) since junior high school and smoked through out her pregnancy with the amount of 1 pack a day.
On physical examination, fundal height is 33 cm, single fetus can be palpated, intrauterus, cephalic presentation, fetal back on the right side, fetal descent 3/5, contractions every 3 minutes for 40 seconds, symmetrical, medium contraction power, fundal dominant, relaxation, interval, and intensity of contractions are adequate. Vaginal examination : portio thin and soft, effacement 50%, cervical dilatation 5cm, membrane ruptured, cephalic presentation, fetal station -1 . Amniotic fluid can be observed in the posterior vaginal vault (pooling (+)). Nitrazine test was positive.
Working diagnosis : G1A0P0 21 y.o 39 weeks pregnant inpartu stage 1 active phase of labor with an alive intrauterine single fetus, cephalic presentation, H2 with premature rupture of membraneReasons:Sudden gush of clear fluid from vagina prior to the onset of laborFluid leakage increases with movement changeNo contractions within 1 hour of ruptureAmniotic fluid can be observed in the posterior vaginal vault (pooling (+))Nitrazine test (+)Patient is a heavy smoker (one of the risk factors of PROM)
Additional tests that should be done :Ferning test
Differential diagnosis for fluid leakageFoul smelling fluid, fever/shivering, abdominal pain, fetal heart rate increased -> amnionitisFoul smelling fluid, pruritus, fluor albus, abdominal pain, dysuria -> vaginitis/ cervicitisBloody fluid, abdominal pain, decreased fetal movement, severe hemorrhage -> antepartum hemorrhageFluid mostly composed of mucus, full cervical dilatation, adequate contraction -> beginning of labor
Bishop scoreMrs N.A s bishop score : 7 ( >6 indicates induction can be done by oxytocin infusion, no need to ripen the cervix with prostaglandin or Foley catheter)
ManagementGive IV dextrose 5% + 5 iu oxytocin 24 ml/ hour (induction of labo