Obstetrics Case Write Up

Name: Luqman Hafizuddin bin Harun

Student ID: 112914099151
Title: Preterm Prelabour Rupture of Membrane In View of Induction of
Labour
Lecturer Name: 1. Prof Dr Che Anuar Che Yaakob

2. Dr. Abdul Aziz bin Mahamad

Patient Profile

Name: Madam Wahida binti Wahid Occupation: Housewife

Age: 28 years old Reference Number: 445921

Gender: Female Gravida: 2 Parity: 1

Ethnic: Malay Last Menstrual Period: 3/12/2017

Religion: Islam Estimated Due Date: 1/9/2018

Address: Kg Pintu Geng, Kota Bharu Period of Amenorrhea: 32 weeks 1 day

Chief Complaint

Patient is admitted due to passing per vaginal fluid 4 hour prior admission

History of Presenting Illness

Based on the statement of the patient, she was completely alright until this morning at 7 am
when she noticed gushing of clear fluid from her vagina. She experienced 2 episodes as the
second episode was at 9 am with the same symptoms. It was sudden onset and the fluid is
colorless and odorless. She had soaked about half of skirt for both episodes. There was no
specific aggregative and relieving factor.

However, there was no signs of labor such as shows and uterine contraction. She also had
no fever and no abdominal pain. No dysuria, hematuria and polyuria. There was no history
of fall or massage.
Antenatal History

This is an unplanned pregnancy. She noticed her pregnancy when she had amenorrhea
about 4 weeks then she bought urine pregnancy test at pharmacy and was tested twice.
Both the results were positive. Then, she when to Polyclinic to confirm her pregnancy. She
done again urine pregnancy test at the clinic and the result also was positive. Her first
booking was done at 8 weeks of period of amenorrhea at Klinik Kesihatan Wakaf Che Yeh.
Upon booking, her height was 158 cm and body weight was 50kg with BMI 20.02 with was in
normal range. She had done a series of blood investigations, which includes blood group B
rhesus+, HIV and VRDL screening. The result was normal with non-reactive result. Her Hb
level was normal which 12.4 g/dL is. There was no glycosuria or proteinuria present. Her
blood pressure also was in normal range, 120/70 mmHg.

Her 1st Ultrasound scan was done during the first booking and showed a singleton, viable
fetus with no any abnormality and the estimated date of delivery was confirmed. Next
ultrasound is done at 20 weeks of period of amenorrhea. The result showed normal fetal
growth and subsequent to estimated date of delivery .Her third ultrasound was done at 30
weeks of period of amenorrhea and the placenta was at anterior part of the uterus the fetus
was already in cephalic presentation with longitudinal lie, fetal biometry corresponded to
gestational age and the estimated fetal weight was 2.5kg.She also had done Oral Glucose
Tolerance Test (OGTT) once in evidence of family history of Diabetes Mellitus and the result
was 6.4 mmol/dL which is normal in range. She was immunized with ATT (anti-tetanus
toxoid) during 23 weeks of gestation for the 1st dosage and next dosage at 26 weeks of
gestation. Total her visit to Klinik Kesihatan Wakaf Bhary was 10 times and all the results of
investigations throughout the checkup were normal.

Past Obstetrics History

She was on Gravida 2 Para 1. She had her first pregnancy at 23 years old and delivered by
normal spontaneous vaginal delivery with no any complication. The baby weight is 2.5kg.
Currently, her son is 4 years old boy.
Menstrual History

Patient reached menarche at age of 12 years old. The duration of menses is 5-6 days and
regular cycle of 28 days. Peak flow is on 1stday with 3 pads per day. Dysmenorrhea is
present during 1st day till 2rd day and relieved by painkiller and ointment.

Gynaecology History

She had vaginal discharge and increase during the pregnancy. The discharge was whitish in
colour, sticky, and foul smelling. It also caused itchiness at the area. The discharge usually
appears on the pad. There was not associated with dysuria, hematuria or any fever. During
the visit to Klinik Kesihatan Wakaf Che Yeh , she was prescribed with antibiotics and cream
to reduce the discharge.

Otherwise, she never take HPV vaccine and Oral Contracetive Pills. She also did not do Pap
Smear in her entire life.

Past Medical History

Patient do not have any chronic illness and never been hospitalize before due to serious
illness.

Past Surgical History

Patient do not have any surgical intervention before.

Drug History

Patient was prescribed with pre-pregnancy regimens by Klinik Kesihatan Wakaf Che Yeh .
The drugs are Folic Acid and Vitamin B complex. Patient also have history of taking oral
antibiotic due to vaginal discharged and she finished the antibiotic. She had no allergy to
any drug and food.

Family History

Father is healthy and mother is having Diabetes Mellitus. Currently her mother is on insulin
therapy and proper follow up at Hospital Raja Perempuan Zainab II and well controlled.
Social History

Patient denied smoking and alcohol consumption. Her husband is a smoker. He works as
seller at Siti Khadijah Market and his monthly income is around RM 2500 to RM3000. She
lives with her husband and her son. She denied any housing problem among her family. Her
academic level is until secondary school and her socioeconomical status is middle class.

General Examination

On inspection, Patient was lying down in supine position. She was alert, conscious and
active. She was not in pain or in respiratory distress. The hydration status of the patient is
good. There were no involuntary movement and no severe muscle wasting noted. There
was a peripheral cannulation located at the dorsum of his right hand with no active infusion.

Vital signs:

Temperature: 37.0 C

Blood Pressure: 116/66mmHg

Pulse Rate: 90 beats/min

Respiratory Rate: 16 breathe/min

Pain score: 2/10

On hand examination, her palm warm, moist and pink. No palmar erythema. For the nails,
there was no koilonychias or leuconychias. No sign of clubbing and peripheral cyanosis.
Capillary refills less than 2 seconds. Her pulse was regular in rhythm with good volume and
no radio-radial delay.

On head examination, there was no periorbital edema. No yellow discoloration of the sclera
and her conjunctiva looked a bit pale. She had good oral hygiene. Her tongue was well
coated, pink, moist and no central cyanosis. No glossitis, no tonsil enlargement, no angular
stomatitis.
On neck examination, no any swelling of lymph nodes, and no raise of jugular venous
pressure.

On legs examination, no dilated vein and no scars. The patient also had no pretibial edema.

Specific Examination

Cardiovascular Examination

On inspection, chest skin is normal in color. Move symmetrically with each respiration. No
visible pulsation. No past surgical scars. On palpation, the apex beat was palpable at left 4 th
intercostal space, at mid-clavicular line. On auscultation, S1 and S2 are present with no
murmur.

Respiratory Examination

On inspection, the chest was in normal shape with no scars and dilated veins. The chest
expansion was equal bilaterally. No past surgical scars. No dilatation of vein and visible
pulsation. On percussion, there is equal vocal fremitus and both lungs field were resonance
on percussion. On auscultation, there is equal air entry with no added sounds was heard
such as rhonchi or crepitation.

Abdominal Examination

On examination, the abdomen was distended with no past surgical scars, no dilated vein
and no visible peristalsis. Linea Nigra and striae Gravidarum are present. Umbilicus is
centrally located between xiphisternum with symphysis pubis and it is flattened. On
superficial palpation, the abdomen is soft and non-tender. On deep palpation, liver and
spleen were not palpable. On auscultation, the fetal heart sound was present by using
Pinnard Stethoscope. The uterus size is measured at the fundus until mother’s symphysis
pubis and the result represent 32 weeks size of uterus.
Vaginal Examination

On inspection, per vagina area and the vulva was normal and no redness. On palpation, the
cervix was soft, tubular and 2 cm in length. The membrane also was intact and the cervix os
is 3 cm dilated.

Investigation

Maternal

1. Full Blood Count

White Blood Cell 9.02 x 10^3

Red Blood Cell 4.23 x 10^6

Haemoglobin 13.1 g/dl

Platelet Count 224 x 10^3

2. Vital sign
3. Group Screening Hematology (GSH)
-To check the blood group and Rhesus factor in case the patient needs emergency
blood transfusion due to hemorrhagic shock.
4. Blood Alpha Glutathione S-Transferase
– To excess thrombolysis.
5. Triple Vaginal Swab
- To rule out any bacteria such as Group B Streptococcus or Bacterial Vaginosis
that can cause rupture of amniotic membrane

Fetal

1. Cardiotopograph (CTG)
-To monitor fetal heart rate and uterine contraction.
Differential Diagnosis

1. Preterm Prelabour Rupture of Membrane

2. False Labour
3. Miscarriage

Provisional Diagnosis

Preterm Prelabour Rupture of Membrane at 32 week period of gestation

Discussion

Progression of Labor and Its Management

My patient came to the hospital because of leaking of amniotic fluid with no any sign of
labour such as shows or contraction pain. Based on the presentation,I can conclude that she
had Preterm Prelabour Rupture of Membrane as now her period of gestation was at 32
weeks. Furthermore, no history of trauma or heavy lifting and no per vaginal bleeding also
gave the evidence that the patient was in false labor. So, she was admitted to Antenatal
Ward for further management. Her vital signs are monitored 4 hourly. Fetal heart rate also
been monitored by using Doptone. Houseman incharge plot the strict pad chart to indicate
any colour or odor change of the leaked amniotic fluid. After 18 hours after first episodes of
leaking amniotic fluid, she was given IV Penicillin to prevent neonatal sepsis as she was
chorionamnionitis surveillance. She also been given with Dexamethasone for fetal lung
maturity. After 24 hours, she still did not have any signs of labour so the houseman decide
to induce the labor. Houseman incharge done vaginal examination to take the BISHOP score
of the patient. The result showed the patient’s cervix is favour for labour and the cervix os
opening was 3 cm .. The Cardiotopograph (CTG) device was attached to this patient to
monitor the fetal heart rate and uterine activity to detect any abnormality such as fetal
distress. The houseman prescribed her IV Pitocin to initiate or improve the uterine
contractions in spontaneous vaginal delivery then after 1 hour the uterine contraction was
increase to 3 in 10 minutes with 35 seconds duration . IV normal saline was given to the
patient to prevent hemorrhagic shock during delivery process. After 6 hours, the cervix os
was fully dilated which was 10 cm. Nalbuphine Hydrochloride which is opioid analgesic was
given to the patient intramuscularly to relieve the pain of labor. This opioid does not
interfere the uterine activity so it is safe to be prescribed by to the patient in intrapartum
stage. The dosage must be in recommended range to avoid the side effects such as
sedation, hallucinations and headache. As the patient was in 2nd stage of delivery, the
hospital staffs were encouraged the patient to push once she fell the uterine contraction.
Just less the 5 minutes, the patient safely gave birth a baby boy with birth weight 2.0kg.
Then the umbilical cord was cut and a lateral episiotomy had been done due to the size of
the baby and the suture had done just after delivery to avoid excessive bleeding. After 1
minute of delivery, the Apgar score was taken and gave result 6/10 then after 5 minutes of
delivery, the result improved to 8/10 score. The significant of taking Apgar score at 1 minute
of life is to observe the baby adaptation to the process of delivery. For the 5 minutes is to
observe how the baby can adapt to new environment. The normal score is 7 to 10 that show
the baby in good health. The score that lower than 7 does not mean the baby is unhealthy.
It might just mean that the baby needs some special immediate care such as suctioning the
nasal airway to help him or her breathe. Some reflexes test had be done towards this baby
such as root reflex, suck reflex, Moro reflex, tonic neck reflex, grasp reflex, and step reflex.
Each reflex test has its own significant to check the baby condition, for example, root and
suck reflex, rooting helps the baby become ready to have breastfeeding. When the roof the
baby’s mouth is touched by her mother’s nipple, the baby will begin to suck. This reflex does
not begin until about the 32nd week of pregnancy until fully developed until about 36 weeks.
That is why premature babies may have a weak or immature sucking ability. Fortunately, all
the reflexes were normal. The baby straight away referred to Pediatrician for further
management. They were admitted to the postnatal ward for further monitoring to avoid any
complication such as postpartum bleeding. As the baby still need ventilation support, he had
been admitted at NICU for further close management by more expert pediatric team she
was discharge on after 2nd day of delivery and her baby discharge after one week

Conclusion

In conclusion, the patient had induction of labor at 32 weeks of gestation due to Preterm
Prelabor Rupture of Membrane need to deliver within 24 hours to prevent neonatal sepsis.
Dexamethasone also given to promote fetal lung maturity.
References

N Baker, P, C Kenny, L, (Ed), the Process of Labor, Obstetrics by Ten Teachers, CRC Press, 2011, 19th
Edition; 14:191-194

Monga, A, Dobbs, S, (Ed), Vaginal Disease, Gynecology by Ten Teachers, CRC Press, 2011, 19th
Edition; 15:140