June 07, 2012

TIKUR ANBESA SPECIALIZED

HOSPITAL

Case Report
Department of Gynecology
&
Obstetrics

Submitted to:
Dr. Sisay Teklu

Prepared by:
Samuel Tesfaye
MDR/3549/02

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Identification:
TikurAnbessa Hospital Hospital no -

Name: Tigist Tesfaye Age: 27 Sex: F Marital status: Married

Occupation: Hair stylist Address: Burayo, Addis Ababa Religion: Orthodox, Christian

Date of admission: 27/09/04 EC

Date of clerking: 30/09/04 EC Ward-D6

Historian: The patient, without language barrier

Chief complaint:
Referral from her ANC clinic

HPP:
This is a 27 years old G3, P2 mother whose last normal menstrual period was on 26/12/03 E.C. (reliable)
making the expected date of delivery on 30/09/04E.C (in 2003, pagume had 6 days) and gestational age of
40 weeks. Menses were regular (every 27-28 days, lasting 3-4 days, and she usually used 2 tampons in a
day, and the flow was not associated with pain or clot) with normal and similar to previous cycle in
amount and duration of flow. She used to take oral contraceptives but stopped two years before she
stopped seeing her period.

A diagnosis of her current pregnancy was made on 7/02/2004 E.C. after she took a pregnancy test at
Burayo health center. She started ANC at Burayo health center at 3 months of pregnancy on 28/3/04 E.C.
Until now she had 6 visits. On her first visit, a thorough history and physical examination was done and
she took an ultrasound and was told that she had a twin pregnancy. Her weight, height and BP were
measured but she doesn’t remember the results. Furthermore, her blood and urine was taken and tested for
1. Hematocrit 2. HBs Ag 3. Blood group and Rh status 4. VDRL 5. RVI testing 6. Fasting blood
sugar

She was found to be non reactive for HIV, and negative for VDRL and HBs Ag. The other results are not
known. She was the given an iron supplement to be taken for two months, 2 tablets per day and was told
to come back after 30 days for her second ANC follow-up. During her second visit, which was on the 4th
months of gestation, she was given the first dose of tetanus toxoid immunization, whereas the second
dose (final) was given during her 3rd visit.

In the 3rd visit, which was on the 5th months of gestation, she was given the final dose of tetanus toxoid
vaccination and instructions for place of delivery. During her 4th and 5th visits, which were on the sixth
and seventh months of gestation, the activities done on the first visit were repeated. in addition, she was
tested for HIV for the second time and she was found to be sero-negative. On her last visit, which was one
week ago, she was told that she was ready to deliver the babies but should deliver in a health institution.
So she was referred to Tikur Anbesa Hospital for delivery.

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She doesn’t know the exact date of her quickening, but she currently perceives fetal movement well,
which is rolling to kicking in type. She used to eat at least four times, during much of her pregnancy, and
usually ate fruits and Vegetables such as lettuce and juice, and ‘Injera’ with ‘wot’ (‘Shiro’, and meat once
per week), with an approximate daily consumption of 2700 Kilocalories. There were no significant events
during the first, second or third trimester.

She came to the emergency GOPD with a referral letter from her ANC clinic with no complaints. She has
a family history of twin pregnancy; both her grandmother and her cousin have had twin pregnancies.

She has a swelling on both feet and legs but not on her face or arms
She has no history vaginal bleeding, discharge or fever.
She has no history of headache, vision disturbances, excessive vomiting
She has no history of epigastric pain, right upper quadrant pain or yellowish discoloration of skin.
She has no history of abnormal body movement or loss of consciousness.
She has no history of cough, shortness of breath or bluish discoloration of skin.
She has no previous history of hypertension, diabetes mellitus.
She has no history of hypertension during previous pregnancies

The pregnancy was planned, wanted and supported. Birth was planned to take place at Tikur
Anbessa Hospital with vaginal delivery and transportation by contract taxi. Money was prepared
to cover the expenses.

Past Obstetric history:

Year GA Place Mode Duratio presentatio outcom Birt Ante/post

of n of n e h wt partum
deliver labor complicatio
y n
1st 1995E Ter TAH 17hrs cephalic Live _ none
C m SVD birth
2n 1996 Ter Buray 13hrs cephalic Live _ none
d EC m o SVD birth
Clinic

Gynecologic History:
She has no sexual history of sexually transmitted diseases or HIV/AIDS. She also has no history
of gynecological operations. Age at menarche was 12. See the HPP for menstrual and
contraceptives history.

Past medical and Surgical history:

She has no history of DM, HTN, Asthma, Thyrotoxicosis, previous blood transfusion, no drug
hypersensitivity.

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Personal history:
She was born and raised in Addis Ababa. She has a 10+2 education. She claims that her husband
earns, on average, 150 birr per week working as a taxi chauffeur and they live in their own 3
room house. She has no habit of smoking, drinking, alcohol or drug abuse.

Family history:
Her mother died at the age of 46 due to a stomach disease but her father is 57 years old and still
alive. She has 3 siblings: 2 sisters and 1 brother. All are alive and well.

Review of systems:
H.E.E.N.T
Head: no headache, no head injury, no dizziness
Ears: no impaired hearing or discharge, no ringing in the ears
Eyes: no discharge, no redness, no blurred vision
Nose: no discharge, no stuffy nose, no runny nose, no sneezing
Mouth: no dental caries, no bleeding gums, no artificial dentures
Throat: no sore throat, no difficulty in swallowing, no hoarseness of voice

L/G: no mass in the neck, axillae, or groins. There is breast enlargement and tenderness associated with
the pregnancy. No discharge from the nipples. No heat or cold intolerance

Respiratory: no cough, no expectoration, no chest pain, no wheezing, no cyanosis, no night sweats

Cardiovascular: occasional palpitations, no shortness of breath, PND or orthopnea, no chest pain, fatigue

Gastrointestinal: one episode of nausea and vomiting in 1st trimester, no diarrhea, no constipation, no
abdominal pain or heart burn, no change in stool color.

Genitourinary: unquantifiable increased frequency, no dysuria, no urgency, no hesitancy, no dribbling, no

reddish discoloration of urine.

Integumentary: no rash, moist skin, no discoloration, no hair changes, hyperpigmentation on abdomen

along the midline from the umbilicus downwards.

Locomotor system: no history of pain, weakness or swelling of the joints,

Central nervous system: no history of numbness, no paralysis, urine incontinence, seizures or speech
defect

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 Physical examination
General Appearance

She is well looking. The abdomen is grossly distended but she is not in cardio-respiratory distress. She
was lying on a bed in a left lateral position.

Vital Signs:

 Blood pressure (BP): 110/70 mm Hg, (right arm, sitting position) => Normal
 Pulse (P): 108 beats / min (left radial, regular with full volume). =>Normal (for pregnancy)
 Respiratory rate (RR): 24/BPM. => Normal (for pregnancy)
 Temperature (T): 35.80C (axillary). => Normal
 Weight: 75 Kg
 Height: 158 centimeters
 BMI: 30.04

H.E.E.N.T

Head: Proportionate size and shape. No scar, Normal hair distribution.

Ears: Normal contour of pinnae. Clear external ear canal. She responds/turns her face towards the source
of loud sound.

Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus. She has no
excessive lacrimation. The conjunctivae are pink. The sclerae are not icteric. The pupils are equal
in size.

Nose: The nasal septum is not deviated. There is no polyp or unusual discharge.

Mouth and throat The breath has no bad odour (halitosis). The lips show no fissure, ulceration or
herpes. The gums are intact and clean, there is no teeth loss. The tongue and buccal mucosa are
wet. The tonsils are intact.

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 Lymphatic and glandular system

There are no significantly enlarged lymph nodes in all accessible areas. The thyroid gland is also not
enlarged. There is no tremor or lid lag. There is no palpable lump in both breasts.

Respiratory System:

Inspection: There is no cyanosis or clubbing of the fingers. Breathing is shallow and rapid. There is no
use of respiratory accessory muscles.

Palpation: The trachea is central. The total circumferential chest expansion is not done because the
patient was not comfortable.

Tactile fremitus is symmetrically equal.

Percussion: The chest is resonant. Diaphragmatic excursion is not assessed because the patient was not
comfortable.

Auscultation: Breath sounds are vesicular on most part of the chest. Has good air entry bilaterally. No
added sound is appreciated.

Cardiovascular system:

Arteries: BP and pulse (see under vital signs). The pulse volume is normal, the rhythm is regular and
there was no abnormal character or unusual condition of vessel wall. Pulse volume can be tabulated as
follow:

Carotid Brachial Radial Femoral Popliteal DP PT

Right +++ ++ ++ +++ 0 + +
Left +++ ++ ++ +++ 0 + +

Veins: The jugular venous pressure observed at an inclination of 450 is not abnormally raised above the
angle of Louis and there is no hepatojugular reflux. There are no distended veins over the neck, chest
wall, no phlebitis in the legs.

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Precordium (heart):

Inspection: There is no abnormality in shape (no precordial bulge). The precordium is Quiet. The apical
impulse is visible in the left sixth inter space, along the left midclavicular line (8.0 cm lateral from mid-
sternum).

Palpation: The point of maximum impulse is felt where it is visible. It is localized. There is a no
parasternal or apical heave. There is also no thrill anywhere.

Auscultation: Both heart sounds are normal in intensity over each valvular area. P2 is not accentuated.
There is an S3 gallop heard over the mitral area, no opening snap, ejection “click” or pericardial “Knock”.
There is also no murmur.

Gastrointestinal system

Inspection: The abdomen is grossly distended, centrally bulged but moves with respiration. There are not
flank fullness, dilated veins, scares or masses. Both linea nigra and stria gravidarum are present. The
umbilicus is everted. Hernial sites are free.

Auscultation: The bowel sound is normoactive. There is no bruit over renal artery, femoral arteries,
abdominal aorta or liver areas. No friction rub over the liver & spleen areas.

Palpation:

 Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was
also no tenderness upon such palpation (no change in facial expression).
 Deep palpation: There was no tenderness (no change in facial expression). The liver was not
palpable below the right costal margin. The spleen was also not palpable.

Percussion: No signs of abdominal fluid collection (shifting dullness or fluid thrill). No flanks or supra
pubic dullness. The total vertical span of the liver along the right midclavicular line was difficult to
assess.

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 Obstetric Palpation

1st – Fundal palpation

A. Fundal height measurement:

a. Finger method: The fundus is 12 fingers above the level of the umbilicus:- 44 weeks
b. Tape measurement: The fundus is 46 centimeters above the symphysis pubis: 46
weeks
B. Fundal content: A soft bulky irregular non-ballotable mass is palpated:- breech

2nd lateral palpation: The longitudinal axis of the uterus aligns parallel to the longitudinal axis of the
mother. A soft irregular mass is palpable on both right and left sides of the mother.

3rd pelvic palpation: Two fetal heads are palpable with two cephalic prominences felt at the same site
and two anterior shoulders, both 4 fingers above the symphysis pubis. The attitude was difficult to assess.

Genitourinary system:

There is no costo-vertebral angle tenderness (no change on facial expression) or mass. The kidneys are
not palpable.

Integumentary system:

The skin is dry and warm. There is no rash, scar or ulcer. Normal hair distribution. There is no abnormal
nail change.

Locomotors system:

There is no muscle or bone tenderness (no change on facial expression) or spasm. There is no gibbus or
tenderness on percussion of the spine. The joints are normal and there is no bony deformity.

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 Nervous system:

Mental Status: The patient is conscious and oriented in person, place and time. She has good immediate,
short term and long term memory.

Cranial Nerves:

N-I: Smells alcohol via each nostril.

N-II: Normal Visual acuity, good visual fields and color appreciation.

N-III, IV & VI: The eyes can move in all directions. There is no nystagmus. The pupils are round and
regular in outline. They react to light directly and consensually and accommodate normally.

N-V: Pain, sensation is intact over the face (she responds by withdrawal). She also responds for light
touch, mildly warm and cold temperature. Contraction of the temporal and masseter muscles is forceful
and visible.

N-VII: The face is symmetrical both at rest and during application of painful stimuli. Otherwise, she can
close both eyes equally and forcefully.

N-VIII: She hears the ticking of a watch bilaterally

N-IX & X: The soft palate rises in the midline when saying “ah!” The gag reflex is intact and there is no
dysphonia or dysphagia.

N-XI: The sternoclediomastoid and trapezius muscles contract on turning the head against resistance and
on shrugging the shoulders against resistance, respectively.

N-XII: The tongue protrudes in the midline and shows no tremor or atrophy

Motor Function:

 Muscle bulk: There is no muscle bulk difference. There is also no spontaneous as well as
induced fasciculation.
 Muscle tone & power:

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 Tone Muscle power
Upper Lower Upper Lower
Right Normotonic Normotonic Five(she can Five(she can
levitate arm upon levitate leg upon
application of full application of full
resisting force) resisting force)
Left Normotonic Normotonic Five(she can Five(she can
levitate arm upon levitate leg upon
application of full application of full
resisting force) resisting force)

Reflexes:

 Superficial reflexes: All the plantar, abdominal, & corneal reflexes are intact.
 Deep tendon reflexes:
Biceps Triceps Supinators Patellar Ankle
Right ++ ++ ++ ++ ++
Left ++ ++ ++ ++ ++

 Clonus: No clonus

Coordination: Cerebellar Finger- to – nose or finger-to – finger and hell-to-shin tests, supination &
pronation of the forearms and the presence or absence of cerebellar ataxia are not assessed because she is
aphasic.

Sensory: Light touch, pain and temperature sensations are intact. Deep pressure, position sense, vibration
and passive movements are well appreciated by the patient. There is no ataxic gait or Romberg’s sign.
Normal recognition of form, size and shape of coin as well as two-point discrimination.

Meningeal signs: Are negative

Summary

 Diagnosis of twin pregnancy by an ultrasound

 Family history of twin pregnancies
 Excessive weight gain
 Advanced uterine size for gestational age

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Assessment:
Risk Assessment: She is a High risk mother because she has a twin pregnancy

Recommendation:
Twin pregnancies should not be allowed to exceed 40 weeks of gestation. Even though the twins
have a cephalic presentation which makes vaginal delivery a recommended route of delivery, the
mother is not in labor. Since induction and augmentation is contraindicated in twin pregnancy,
Caesarean Section is recommended for this patient.

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