Вы находитесь на странице: 1из 33

Hospital Exposure

Case Presentation
Michelle H 07120110086

Patient Identity

Name : N.A
Sex: Female
Age : 21
Obstetric status : G1P0A0 now 39 weeks
pregnant
Address : Kampung Pesar
Status : Married
Education : High school
Job: Waitress
Medical record no : RSUS.00-60-27-64
Date 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 vagina
Sudden 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 19
Menarche : 12 years old
Menstruation : 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 Taking
Antenatal 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 contraception
Family 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 mentis
Vital signs :
-BP : 110/90 mmHg
-Pulse : 82 / min
-RR : 20 /min
-Temp : 36.6 c
Anthropometric :
-Weight : 69 kgs
-Height : 151 cm
Head
Head : normocephaly and symmetrical
Skull : no nodules or masses and depressions when palpated
Face : 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
accommodation
Ears : 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 tender
Nose : 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 lesions
Mouth : 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.
Integument
Skin : uniform in color, unblemished, good skin
turgor and normal skin temperature
Hair : thick, silky hair and evenly distributed. No
signs of infection and infestation observed
Nails : shape of convex curve, smooth, intact with
epidermis. CRT is within normal limit, no nicotine
stains

Thorax
Lungs : 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
auscultation
Heart : 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.

Extremities
The 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 assessment
Inspection : 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 gr
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 (+))

Past vaginal exam :


PE 1 (19th August 2014 11.00 PM) :
cervical dilatation 1 cm, effacement
10 %, no contractions
PE 2 (20th August 2014 04.00 AM) :
cervical dilatation 3 cm, effacement
20 %, contractions 2 times in 10
mins for 40 seconds.

Timeline
19th August 2014

11.00 AM

4.30 PM

20th August 2014

11.00 PM

04.00 AM

08.00 AM

Admittance
PE 2 :
Mild
PE 3 :
Nausea,
To hospital
Eff : 20%
Contractions
Eff : 50 %
Vomiting,
PE 1 : eff 10 % Dilatation
and cramps
Dilatation 5 cm
Lower abdominal
Cervical dilatation
3 cm
pain
10.30 PM 1 cm
04.30 AM
Membrane ruptured Induction of labor
Fluid leakage
Pooling (+)
Nitrazine test +

Partograph

Observation notes

CTG

CTG

CTG interpretation :
Fetal heart rate : baseline 150 x / min,
reactive, acceleration (+), deceleration
(-), active fetal movement,
contractions every 3 minutes with
moderate power.

Nitrazine test
Nitrazine test was done on 19th August
2014 at 11.00 PM and the result was
positive.

Lab test
Complete blood count,
MCV,MCH,MCHC, iron profile,
bleeding time, clotting time was
done, and the result was all within
normal limit.

Resume
Mrs. 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
membrane
Reasons:
- Sudden gush of clear fluid from vagina prior to
the onset of labor
- Fluid leakage increases with movement change
- No contractions within 1 hour of rupture
- Amniotic 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


leakage

Foul smelling fluid, fever/shivering, abdominal


pain, fetal heart rate increased -> amnionitis
Foul smelling fluid, pruritus, fluor albus,
abdominal pain, dysuria -> vaginitis/ cervicitis
Bloody fluid, abdominal pain, decreased fetal
movement, severe hemorrhage ->
antepartum hemorrhage
Fluid mostly composed of mucus, full cervical
dilatation, adequate contraction -> beginning
of labor

Bishop score

Mrs 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)

Management
Give IV dextrose 5% + 5 iu oxytocin
24 ml/ hour (induction of labor)
Give IV cefotaxime 1 gr (prophylactic
antibiotic)
Check FHR, contraction, and vaginal
exam every 4 hours
Check vital signs every 30 mins
Prepare for delivery

PROM
Definitions
Premature Rupture of Membranes (PROM)
Rupture of Membranes prior to labor onset
Preterm Premature Rupture of Membranes (PPROM)
PROM that occurs prior to 37 weeks gestation
Complications
Premature Birth (PPROM)
Cord compression
Chorioamnionitis
Abruptio Placentae
Respiratory distress syndrome
Malpresentation

Risk Factors
History of PROM in prior pregnancy
Prior cervical biopsy or cone
Uterine distention
Multiple gestation pregnancy
Tobbaco abuse
Polyhydramnios
Cervical or vaginal infections
Intercourse (unproven)
Amniocentesis

MANAGEMENT ALGORITM

Prognosis
Ad vitam
: dubia at bonam
Ad sanactionam : dubia at bonam
Ad functionam : dubia at bonam

FIFE
Feeling : patient is worried and anxious
Insight : patient knows that her
membrane has ruptured and wants to
deliver the baby as soon as possible
Fear : she fears the baby is unwell
because of the premature rupture
Expectation : she expects the baby to
be delivered well through vaginal
delivery

Reference
Paket pelatihan pelayanan obstetri
dan neonatal emergensi
komprehensif (PONEK)
www.acog.org
www.apgo.org
Buku panduan praktis pelayanan
kesehatan maternal dan neonatal