CASE PROTOCOL

Name: D.M.
Age: 20 years old
Adress: Batasan, Quezon city

LMP: September 29-Oct 1, 2019

PMP: August last week
AOG: 37 weeks and 1 day
EDC: July 5, 2020

Chief complaint: Referral from a quarantine facility

History of Present Pregnancy

During her first trimester:

(+) Amenorrhea
Positive pregnancy test done on Dec 9, 2019 (AOG: 10 weeks and 1 day)
No nausea and vomiting
No dizziness
No vaginal discharge/bleeding
No prenatal check-up done
No medications taken
No history of infections, exposure to radiation, or drugs

During her second trimester:

(+) Quickening at her 20th week
(+) Abdominal pain
Prenatal check-up x 1 at Malate Health Center
Pelvic ultrasound done last January 29, 2019 (AOG: 17-week 3d based on LMP) revealing a
single, live intrauterine pregnancy in breech presentation, about 15 weeks and 6 days composite age 
of gestation by BPD, FL and AC measurements
Other laboratories requested were CBC with PC, UA, BTRH, VDRL/RPR, HIV screening and HBsAg
which were all normal
Medications taken were Multivitamins 1 cap OD and Ferrous sulfate 1-tab OD
No history of infections, exposure to radiation, or drugs

During her third trimester:

No subjective complaints
Prenatal check-up x 2 at Batasan Health center
Pelvic ultrasound done at 29weeks and 5 days revealing a Single, live intrauterine pregnancy in
cephalic presentation, about 29 weeks composite age of gestation by BPD, FL and AC
measurements, adequate amniotic fluid index, placenta anterior grade II, estimated fetal weight of
1285 grams
She continually took Multivitamins 1 cap OD and Ferrous sulfate 1-tab OD

History of present illness:

5 days PTC: patient had productive cough with associated low grade fever of 37.8 degrees Celsius, her
body temperature is fluctuating between 37.5 to 37.8 degrees Celsius. Patient also had intermittent
hypogastric pain with associated whitish vaginal discharge. No medications taken, no consult was done.

2 days PTC: persistence of above symptoms now associated with anosmia and muscle pain. There is
also a note of an increase in the intensity and duration of the abdominal pain, she consulted in the health
center where she was referred to a COVID quarantine facility and RT PCR was done. She was advised to
consult in a tertiary hospital due to a high suspicion of COVID infection, however failed to comply

Few hours prior to admission, result of her RT-PCR result revealed positive for COVID infection, she
followed up the result in the quarantine facility and she was immediately transferred in our institution

Past Medical History

No hypertension, diabetes mellitus, bronchial asthma, thyroid and kidney problems

Family History
(+) hypertension (paternal), diabetes mellitus, thyroid and kidney problems

Personal and Social History

Previous smoker; occasional alcoholic beverage drinker, denies illicit drug use
No other whereabouts aside from clinic consults. No known exposure to a symptomatic or COVID
confirmed cases.

Menstrual History
Menarche at 12 years old, lasted for 3 days used 2-3 pads, moderately soaked not associated with
dysmenorrhea
Subsequent menses:
Interval: Regular, 28-30 days
Days: 4-5 days
Amount: 3-4 pads per day, moderately soaked
Symptoms: No dysmenorrhea

Sexual History
Coitarche: 17 years old
Sexual partners: 1
Use of withdrawal method
No use of contraceptive pills, no use of condoms, no IUDs
No dyspareunia
No post-coital bleeding
No sexually transmitted infections

OB History
G2 P1 (1001)

Yea Se Outcom BW Mod Place FMC

r x e e

G 201 F FT 3100  NSD OMM Non

1 8 g C e

G 202 Present Pregnancy
PNCU x 3 at 2 0 Batasan health
center

Physical Exam
Conscious, coherent, not in cardiorespiratory distress
Vital Signs: BP 110/70 mmHg HR 95 RR 18 Temperature: 36.8 C O2 saturation: 99% on
room air
HEENT: Anicteric sclerae, pink palpebral conjunctivae, no NAD, no CLAD
C/L: Symmetrical chest expansion, no retractions, (+) crackles on BLF
 CVS: Adynamic precordium, normal rate regular rhythm, no murmurs
Abdomen: Globular non tender abdomen

29cm

130’s

Leopold’s Maneuver
LM1: Breech palpated on the fundus
LM2: Fetal back on maternal right, fetal small parts on the left
LM3: Head is not engaged
LM4: Cephalic
Pevic exam:
Inspection: Grossly normal external genitalia
Speculum exam: Cervix effaced, no pooling of blood noted, no mucoid/watery discharge noted
Internal Examination:
Nulliparous introitus, admits two fingers with ease
Cervix: Soft, 2 cm dilated, beginning effacement, intact bag of waters, cephalic presentation, station
-2

Extremities: Grossly normal, full equal pulses, no edema, no cyanosis

Laboratories upon admission:

CXR: Bilateral hazy infiltrates suggestive of pneumonia

NPS/OPS – SARS-CoV2 (causative agent

of COVID-19): (swab done 2 days PTA):
viral RNA detected
ASSESSMENT

20-year-old
G2P1(1-0-0-1) Pregnancy Uterine, 37 weeks and 1-day AOG by LMP, cephalic, in beginning labor,
COVID-19, confirmed, mild

Guide Questions:

1. Discuss how the diagnosis of COVID infection was made based on the history and laboratories
2. What Other pertinent information would you elicit in this case?
3. What other diagnostic test would you request in line with a diagnosis of COVID infection

4. How was this patient classified as a mild case of COVID infection? Discuss the different
classifications based on the disease severity?

5. How will you manage this case? (mode of delivery and medications)

6. What are the complications of COVID-19 infection in the course of pregnancy and effects on
neonatal outcome?

7. How will you advise this patient postpartum? (include heath teaching on breast feeding)

8. What are the latest recommendations in managing a pregnant patient with COVID-19 infection?