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Title: threatened preterm labour

Summary

26 years old Malay lady primigravida at 34th week from period of amenorrhea presented
with abdominal pain, slight show, associated with history of two threatened preterm
labour due to urinary tract infection and falling, two previous gynaecological surgical
histories –endometriosis and ovarian polyps.
Introduction

a. Background of the study

Preterm labour is defined as the presence of uterine contractions of sufficient frequency


and intensity to effect progressive effacement and dilation of the cervix prior to term
gestation (between 20 and 37 wk).

Risk factors for preterm birth include demographic characteristics, behavioural factors,
and aspects of obstetric history such as previous preterm birth. Demographic factors for
preterm labour include non-white race, extremes of maternal age (<17 y or >35 y), low
socioeconomic status, and low pre-pregnancy weight. Preterm labour and birth can be
associated with stressful life situations (eg, domestic violence; close family death;
insecurity over food, home, or partner; work and home environment) either indirectly by
associated risk behaviours.

As the cause of labor still remains elusive, the exact cause of preterm birth is also
unsolved. Labor is a complex process involving many factors. Generally, four different
pathways have been identified that can result in preterm birth and have considerable
evidence: precocious fetal endocrine activation, uterine overdistension, decidual
bleeding, and intrauterine inflammation/infection.

b. Rational and significance of choosing the case

Threatened preterm labour is a very hard topic to be study without reference point.
Therefore, this case has been selected for study of threatened preterm labour based on
few actors; this is not a complicated case of threatened preterm labour, there are multiple
factors that may results the threatened preterm labour presentation in this case which
includes present presentation and the patient’s history.

Thus, the case itself can be easily said as an example multiple causative case of
threatened preterm labour that is very well presented such it can help the researcher to
understand and comprehend the meaning of threatened preterm labour.
History of Admission

a. Patient’s biography

Name initials : Mdm N.A


Age : 26
Sex : Female
Religion : Islam
Civil status : married
Race : Malay
Occupation : government officer
Admission : 1/3/2010
Clerking : 2/3/2010

b. Chief complaint
Patient is currently G1 P0 at 34 weeks 4 days POA. She came by herself, with abdominal
pain associated with slight show, no leaking. Fetal movement was present and good.

History of presenting illness

Prior to the admission, patient had history of 2 previous threatened preterm labours due to
urinary tract infection at 25+ weeks and from falling at 28 weeks, injuring her right thigh
–just involving soft tissue injury.

On the day of admission, patient was doing normal household chores when she suddenly
feels sudden back pain similar to the previous threatened preterm labour episodes. The
pain was associated with per vaginal bleeding –noted by blood at her sarong. She
mentioned that the contraction was not regular and not very consistent.

Immediately, she went to the hospital and admitted into antenatal care for observation.
Review of system

system Finding

no significant findings such as palpitation, lower limb edema,


Cardiovascular
orthopnea, syncope, dizziness, etc.
No significant findings such as moon features, exophthalmos,
Endocrine
tremor, acrommegaly, etc.
No significant findings such as diarrhea, constipation, altered
Gastrointestinal
bowel movement, etc.
No significant findings such as dysuria, oliguria, hematouria,
Genitourinary
incontinence, nocturia, etc.
No significant findings such as pallor, jaundice or bleeding
Hematopoietic
tendency, etc.

Musculoskeletal No significant findings such as myalgia, arthargia or arthritis,


arthritis, etc.

No significant findings such as recurrent headaches, fits, blurring


Neurologic
of vision or drowsiness, etc.
No finger clubbing, no accessory muscle used during respiration,
Respiratory no shortness of breath, no noisy breathing, no hemoptysis, no
night sweats.
No significant findings. The skin color is normal according to his
Skin, hair, nails race; with hair growth distribution is normal. Nail is normal, no
clubbing, koilonychia, leukonychia, etc.
Normal head size, shape and symmetry; no skull enlargement,
Head and neck bossing, etc. no significant findings of the neck such as webbing,
goiter, etc.

Reproductive As stated
Comprehensive health history

a. Antenatal history
This is an unplanned but wanted pregnancy. She noticed that she pregnant after had
missed about 2 weeks of her period, confirmed by pregnancy test kit. Her L.M.P was
2.7.2009 (sure of date) and E.D.D is 9/4/2010, confirmed by scan. First scan was done at
18th week, and the latest was at 32nd week with parameters corresponds to date. She was
screened for VDRL, HIV, hepatitis B and it was negative. She was normortensive,
normoglycemic and no significant glycosuria was recorded.

b. Obstetric history
She is primigravida

c. Gynaecology history
She attained menarche at 14 years old with regular cycle of 30 days with flow of 7 days.
She does not experiencing dysmenorrhoea, menorrhagia, postcoital bleed and no deep
dyspareunia. She claimed never took any contraception pill before. She had history of
ovarian cyst and went for surgery at HUSM 2005, history of endometriosis and went for
surgery at HKL 2006.

d. Past medical & surgical history


No significant history of medical illness or surgery. 2 previous surgical histories for
endometriosis 2006 and ovarian cyst 2005

e. Family history
No family history of any medical illness except for hypertension by her mother. No
history of multiple pregnancies, malformation, or mental illness in the family

f. Social history
She is working as assistant information officer at ministry of information. Her husband is
entrepreneur. She does not consume alcohol and does not smoke, so does her husband.
She denies of any constitutional sex. Currently, she is not experiencing any financial
difficulty.

g. Allergies and medication history


No known drug or food allergies. She is taking supplements provided for her pregnancy.
Physical examination

She was alert, conscious and lying comfortable. Her height is 155 cm, with pregnant
weight of 62+kg. Her body mass index is 25.8 kg/m2. Her vital signs were as recorded;

Blood pressure : 103/72 mmHg


Heart rate : 100 beat per minute, good volume, regular rhythm
Respiratory rate : 17 breaths per minute
Temperature : 37°C

There is no sign and symptom of anaemia, by pallor or lips cracked. She was well
hydrated, no sign of goitre, and there is no oedema at lower limbs. Breast examination
was not demonstrated. Her heart sound S1 S2 can be heard with normal intensity, and her
lungs were normal.

Examination of abdomen shows distended abdomen by gravid uterus with linea nigra,
striae gravidarum as evidences. There were also 2 suture scars which are midline marking
for previous endometriosis on 2006 and pfannestiel marking for ovarian cyst removal on
2005. The suture area was non tender, and soft at the site. There was no other
abnormality. Her size is near term, SFH is 35cm. The presentation of the baby cephalic,
with head engagement is 4/5. Estimated baby weight is about 2.0 – 2.2 kg. Contraction
was present which is irregular with 1:10:25s. Fetal heart rate taken by the nurse was 153
beats per minute.

Previous vaginal examination shows normal os, with 1cm dilatation. The cervix was 3cm
thick, and the position of the head is not palpable. The membrane is still intact; therefore
the mould and caput cannot be assessed. There was no liquor pooling. Speculum
examination reveals that the vagina and cervix to be healthy with the os is open. Show is
noted, but there was no pooling of liquor, and no vaginal discharge.
Summary

26 years old Malay lady primigravida at 34th week from period of amenorrhea presented
with abdominal pain, slight show and;
1) History of 2 threatened preterm labour
2) History of endometriosis 2006
3) History of ovarian cyst 2005
4) History of UTI
5) History of fall

Diagnosis

Patient is primigravida currently at 34th week 4 days POA diagnosed as threatened


preterm labour. Due to;
1) Irregular contraction with <2:10
2) No cervical dilatation
3) No pooling of liquor

Investigation

Investigation Reason to support


To look for haemoglobin, white blood cell and platelet
levels. To ensure she is stable enough for any
Full blood count emergency surgery, to rule out any ongoing infection,
anaemia that may cause poor tolerance of blood loss
during delivery.
Grouping, Screening, Hold (GSH) Patient might need transfusion
Basically, to assess renal function in general. Glucose
will be significantly high in EDM, GDM. Blood may
Urine FEME
present in renal tract trauma, inflammation, tumour or
even vaginal bleeding contamination as well.
If there is any infection, especially for group B
streptococcal, Trichomonas vaginalis, Chlamydia
High vaginal swab C&S
trachomatis, neisseria gonorrhoea. Important in
determining management of patient
Full blood count

investigation unit reference


Wbc 12.1 109/L 4-10
Rbc 4.16 1012/L 3.8-4.8
Hgb 124 g/L 120-150
Hct 37.1 36-46
Mcv 89.2 fL 77-97
Mch 29.8 Pg 27-32
Mchc 33.4 g/dL 315-345
Rdw-cv 13.7 % 11.6-14.0
Plt 237 109/L 150-400
% 109/L 109/L
Neutrophil 71 8.59 2-7
Lymphocyte 19.6 2.37 1.0-3.0
Monocyte 7.5 0.91 0.2-1.0
Eosinophil 1.7 0.20 0.02-0.10
Basophil 0.2 0.04 0.9-12

Comment
During pregnancy there is also an increase in white cells from about 7 x 10^9 to 15 x 10^9 per
litre solely due to a neutrophilia. This was noted in her CBC & differential blood result. In spite
of this, note that other causes of a raised neutrophil count must be excluded. In her case,
clinically she is well with no sign or symptoms suggesting active infection.

Urine FEME
investigation
Specific gravity 1.020 Comment
pH 6.5 No remarkable findings
Leukocyte 2+
Nitrate -ve
Protein 1+
Glucose 3+
Ketone -ve
Bilirubin 1+
Erythrocyte -ve
HVS C&S
culture No culture/ colony
Smear Comment
White cell Occasionally One-third of the pregnant women yielded
Epithelial cell Occasionally potential pathogenic organisms in their HVSs.
+ cocci nil Among these organisms 87% were Monilia
- cocci few and Streptococcus, while the rest were E.
+ bacilli nil coli, Proteus, Klebsiella and Neisseria.
- bacilli few Lactobacilli are regarded as a normal flora.
other nil Staphylococcus epidermidis and Diphteroids
have also been found in significant
percentages (30-60%) in pregnant women.

Plan and management

1) Admit antenatal ward


2) CTG in ward, IM nubain 10mg per 6 hourly if reactive
3) Time contraction
4) Strict FKC monitoring
5) To book ventilator
6) Tocolysis
7) IM Dexamethasone 12 mg bd
8) Pad chart –to inform if increase in per vaginal bleeding
Discussion

Preterm labour is defined as the presence of uterine contractions of sufficient frequency


and intensity to effect progressive effacement and dilation of the cervix prior to term
gestation (between 20 and 37 wk).

The exact mechanism(s) of preterm labour is largely unknown but is believed to include
decidual haemorrhage, (eg, abruption, mechanical factors such as uterine overdistension
from multiple gestation or polyhydramnios), cervical incompetence (eg, trauma, cone
biopsy), uterine distortion (eg, müllerian duct abnormalities, fibroid uterus), cervical
inflammation (eg, resulting from bacterial vaginosis [BV], trichomonas), maternal
inflammation/fever (eg, urinary tract infection), hormonal changes (eg, mediated by
maternal or fetal stress), and uteroplacental insufficiency (eg, hypertension, insulin-
dependent diabetes, drug abuse, smoking, alcohol consumption).1,2

In this case, the patient presented with abdominal pain associated slight show. Patient has
strong history suggesting threatened preterm labour with two previous event of
threatened preterm labour –history of urinary tract infection in 25th week, history of
falling in 28th week. Patient also had history of two gynaecology surgical history –
endometriosis on 2006 and ovarian cyst on 2005.

Usually, based on the patient’s presentation, contractions of sufficient frequency and


intensity to effect progressive effacement and dilation of the cervix at 24-37 weeks’
gestation are indicative of active preterm labour. However, the patient in this case was
not indicative for preterm labour as the contraction was not consistent and not sufficient.

According to the history, patient had history of urinary tract infection that leads to
previous threatened preterm labour in 25+ week of pregnancy. Due to pregnancy, several
physiologic changes that occur can cause otherwise healthy women to be more
susceptible to serious sequelae from urinary tract infections. These effects have been
showed in study done by Duarte et al3 in 2008. Remarkable changes occur in the structure
and function of the urinary tract during pregnancy. Blood-volume expansion is
accompanied by increases in the glomerular filtration rate (GFR) and urinary output. The
ureters undergo tonic relaxation because of the mass production of hormones, particularly
progesterone. This loss in tone, along with the increased urinary tract volume, results in
urinary stasis that in time promotes bacterial infestation.
Preterm labour may be difficult to diagnose and a potential exists for overtreatment of
uterine irritability. Tocolytic agents, while generally safe in appropriate dosages with
proper clinical monitoring, have potential morbidity and should only be used after
consideration of the risks and benefits of such use. Neonatal morbidity and mortality are
greatly affected by gestational age, especially when the pregnancy is less than 28 weeks’
gestation.

Tocolytic is the standard management for threatened preterm labour to reduce irregular
contraction. Usually, prophylaxis antibiotic will be given to the mother and in case of
previous urinary tract infection, antibiotic will be given specifically according to the
causative agent.

Conclusion

Threatened preterm labour is defined as sign and symptoms that lead to the risk of
preterm labour to occur. It is usually presented with irregular contraction and associated
with show or liquor, depending on the patient itself. Even though the mechanism is not
clearly understand by physician, patient threatened preterm labour usually associated
with history of cervical incompetence –trauma, cervical inflammation –previous
infection, hormonal changes –maternal or fetal stress, or uteroplacental insufficiency –
hypertension, diabetes, etc.
References

1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin.


Assessment of risk factors for preterm birth. Clinical management guidelines for
obstetrician-gynecologists. Number 31, October 2001. (Replaces Technical Bulletin
number 206, June 1995; Committee Opinion number 172, May 1996; Committee
Opinion number 187, September 1997; Committee Opinion number 198, February
1998; and Committee Opinion number 251, January 2001). Obstet
Gynecol. Oct 2001;98(4):709-16
2. ACOG practice bulletin. Management of preterm labor. Number 43, May 2003. Int J
Gynaecol Obstet. Jul 2003;82(1):127-35.
3. Duarte G, Marcolin AC, Quintana SM, Cavalli RC. [Urinary tract infection in
pregnancy]. Rev Bras Ginecol Obstet. Feb 2008;30(2):93-100.