THOMAS JERROLD F.

AGUILA
MD 3
GROUP 1 Subgroup 1
 This is the case of Patient C.R., 31 years old with an
obstetric score of Gravida 2 Parity 1 (1001), Filipino,
Married, Roman Catholic, who is currently residing
at Barangay Balococ, San Carlos City, Pangasinan
admitted for the first time at Virgen Milagrosa
Medical Center last January 12, 2019.
 Hypogastric pain
 Patient C.R. was apparently well until 5 hours prior to
admission, she experienced mild hypogastric pain described
as rubbing pain not relieved by change of position with pain
scale of 5/10 radiating to the lower back lasting for 2
minutes duration 1 minute interval while lying down without
any associated symptoms like vomiting, loss of
consciousness, blurring of vision, difficulty of breathing and
vaginal discharge. Patient did not take any medications.
 1 hour prior to admission, above symptoms persisted with
an increase of pain scale from 5/10 to 7/10 which
prompted the patient to seek consult hence admission in
this institution.
 Her previous hospitalization is significant for
previous child delivery at a lying in clinic
 No previous hospitalization for any disease or
surgeries
 Patient C.R. finished secondary education. She is currently
living with her common law husband for 7 years. Patient
C.R. received childhood vaccines but failed to recall the
dates when she was given.
 Patient C.R. has no known drug/food allergies. She prefers
eating vegetables and drinks about 8 to 10 glasses of water
a day. She sleeps 8-10 hours per day with periods of rest.
 Patient C.R. is staying in a non-congested neighborhood at
Barangay Balococ, San Carlos City, Pangasinan. Their house
is made from concrete materials, 1 story Bungalow with 2
rooms and 5 occupants. They are supplied by CENPELCO for
their electricity and use artesian well for domestic water
purposes. They buy and prepare their food from the market
and consume mineral water for drinking. Their Toilet is
flushed type with septic tank. Garbage disposal is collected
every Wednesday morning.
 Patient C.R. has no hereditary-familial disease
 Present pregnancy:
◦ LMP: May 13, 2018
◦ PMP: Amenorrhea
◦ EDC: February 20, 2019
◦ AOG: 33 weeks and 4 days
 Patient C.R.’s pregnancy was confirmed by a positive
pregnancy test done twice at home. She claimed that the
pregnancy was planned. Her 1st prenatal checkup started
June 2018. She was prescribed of Folic acid 600mcg 1
tablet taken once a day, Calcium 1 tablet 1.5g and
Multivitamins. No pertinent findings such as vomiting or
nape pain were noted.
 Patient C.R. had latest ultrasound dated January 12,
2019 with impression of single alive baby girl
intrauterine, in cephalic presentation with good
cardiac and somatic activities, 33 weeks and 4 days
by average biometry.
 Normal amniotic fluid.
 Sonographic estimated fetal weight is 2500 grams
by HADLOCK
 Total number of prenatal visits was 8 that started
June 2018 and the last visit was January 3, 2019.
 No reported exposures to cigarette smoke and
infection/s to viral diseases such as Rubella,
radiation and toxic chemicals during current
pregnancy.
 No history of alcohol intake and contraceptive
methods used.
 PLACE OF BIRTH BIRTH PRESENT ANOM/
NUMBER OF COMP/AB
PREGNANCY OUTCOME BIRTH DATE AOG SEX WEIGHT STATUS

Live birth via Lying in August 29, 36 WEEKS MALE 2.4kg Alive None
G1 Natural Clinic at San 2011
Spontaneous Carlos City,
Delivery Pangasinan
G2 FEMALE
PRESENT PREGNANCY
 Patient C.R. started menarche at 16 years old. Monthly
menstrual period is regular for 28-30 days cycle lasting for
3 days, consuming 2-4 soaked pads per day without any
associated symptoms of vomiting, spotting or unusual
vaginal discharges.
 First coitus started at 21 years old with her boyfriend and
now her husband.
 No history of abnormal vaginal discharges or previous
gynecologic operations and illnesses like polyps and
myomas.
 No pap smear done nor HPV vaccine received
 GENERAL DATA:  NOSE:
◦ Patient is awake, conscious and ◦ (-) epistaxis, colds, discharges
coherent, oriented to time, place and  MOUTH:
person. ◦ With good appetite
 HEAD: ◦ (-) Vomiting
◦ (-) Headache ◦ (-) Hematemesis
◦ (-) lesions, scars ◦ (-) dysphagia
 EYES:  NECK:
◦ (-) blurring of vision ◦ (-) stiff neck
◦ (-) diplopia
◦ (-) photosensitivity
 EARS:
◦ (-) tinnitus, pain, discharges
 RESPIRATORY SYSTEM:  INTEGUMENTARY SYSTEM:
◦ (-) Cough ◦ (-) Rashes, Pruritus
◦ (-) hematemesis ◦ (-) Edema, hematoma, bruises,
◦ (-) chest pain lesions
◦ (-) difficulty of breathing  GASTRO-INTESTINAL SYSTEM:
◦ (-) shortness of breath ◦ (-) melena, hematochezia
 CARDIOVASCULAR SYSTEM: ◦ (-) abdominal pain, vomiting, back
◦ (-) Palpitations ache, cramping
◦ (-) chest tightness  MUSCULOSKELETAL SYSTEM:
◦ (-) chest pain ◦ (-) Joint pain, back pain, difficulty in
 RENAL SYSTEM: performing ADL’s
◦ (-) Proteinuria, hematuria, bleeding,  CNS:
spotting ◦ (-) Loss of consciousness
◦ (-) dysuria, oliguria, discharges, ◦ (-) Nausea
back pain ◦ (-) Seizures
 General survey:
◦ Patient is conscious, coherent and not in any respiratory distress
◦ V/S : BP = 120/80mmHg, CR = 80BPM, RR = 18, T = 36.8C
◦ Pre-pregnancy weight = 48kg
◦ Present Weight = 56kg
◦ Height = 5’2’’
 HEAD:
◦ Normocephalic, atraumatic, no visible lesions, scars, mass
 EYES:
◦ Pupils equal, round and reactive to light, extraocular muscles intact.
◦ No conjunctivitis, discharges or scleral icterus.
◦ Pink conjunctiva and white sclera noted
 EARS:
◦ Clear external auditory canals, pinna normal in shape and contour,
no auricular pits and skin tags.
◦ Tympanic membrane is grey in color.
◦ Cerumen noted on both ears
 NOSE:
◦ No discharge or blood visible. Septum in midline
 NECK:
◦ No tracheal deviation, no decreased range of motion exercise, no
lymphadenopathy or masses noted.
 CHEST and LUNGS:
◦ Breast engorgement present, no use of accessory muscles during
breathing, tactile fremitus noted, resonant sound heard bilaterally, No
stridor, wheezes, crackles and rubs noted upon auscultation.
 CARDIOVASCULAR:
◦ Quiet precordium, no heaves nor thrills, gallops and murmurs. PMI
heard on 5th intercostal space midclavicular line
 EXTREMITIES:
◦ No edema noted on both legs and feet
◦ Warm to touch with no gross deformities
 ABDOMEN:
◦ Abdomen is globular, no masses, lesions, scar present
◦ Abdominal striae and linea nigra present
◦ Fundal height is 32cm.
◦ Braxton Hick’s contractions present lasting 30 seconds
◦ Fetal Heart tone is 150 beats per minute heard on the RLQ
 LEOPOLD’S MANEUVER
1. Fetal lie is vertical, palpable
limbs at the fundus
2. Location of fetal spine and
extremities is in the right
side of the mother
3. Fetal head is not yet
engaged, no fetal descent
4. Fetal presentation is cephalic
ADMITTING IMPRESSION: G2P1 (1001) pregnancy in utero, 33 weeks in Pre-term Labor
FINAL DIAGNOSIS: G2P1(1001) pregnancy in utero, 33 weeks in Pre-term Labor
DATE/TIME PROGRESS NOTES ORDER TIME POSTED
January 12, 2019  Admit to room of choice
 Consent for hospitalization
4:30 am  Monitor TPR
 Diet as tolerated
4:45am  For CBC and Urinalysis  4:45am
4:50am  D5LE 1L with 2 ampule of  4:50am
Isoxsuprine 10gtts per minute
 Dydrogesterone 1 tablet every 8
hours
 Complete bed rest with bathroom
privileges
 Monitor degree of uterine
contraction and FHT
 Monitor maternal heart rate if
tachycardic
 Regulate Isoxsuprine IV at 5gtts
per min
 Position to patient to left lateral
position
 Administer oxygen at 2-3 l/min
 DATE/TIME PROGRESS NOTES ORDER TIME POSTED
January 13, 2019  Discontinue oxygen inhalation
 Continue Isoxsuprine drip at 5gtts
per minute
 Continue dydrogesterone tablet
TID
 Complete bed rest with bathroom
privileges
 Monitor TPR and uterine
contraction and maternal heart
rate
January 14,2019  May go home with meds
 Dydrogesterone (Duphaston) tablet
daily for 1 week
 Continue Multivitamins 1 tab daily
 Follow up check up on January 21,
2019
 ITEM RESULT NORMAL RANGE Interpretation
HEMOGLOBIN 111 gramS/L F: 120 - 160 grams/L Low
TOTAL RBC COUNT 3.7 x 10/L F: 4.2 - 5.4x 10/L Low
HEMATOCRIT 0.37 0.37 - 0.47 Normal
TOTAL WBC COUNT 8.5 x 10/L 8.5 - 11x10 Normal
Normal 0.79 0.65 - 0.75 High
Physical exam Result Routine Result
Color: yellow Albumin Negative (-)

Transparency: slightly turbid Sugar Negative (-)

Reaction: acidic Epithelial cells few

Specific gravity: 1.010 Amorphous cells few

Bacteria Few

RBC 0.1/hpf

WBC 2-3
 Single live intrauterine, in cephalic presentation with good
cardiac and somatic activities, 33 weeks and 4 days by
average biometry
 Normal amniotic fluid
 Sonographic estimated fetal weight is 2500 grams by
HADLOCK
 ISOXSUPRINE
◦ Vasodilators
◦ Relaxes veins and arteries specifically in the uterus, which makes them
wider and allows blood to pass through them more easily.
 DYDROGESTERONE
◦ Progestogen Steroid
◦ Works by regulating the healthy growth and normal shedding of the
womb lining by acting on progesterone receptors in the uterus
◦ Acts directly on the uterus, producing a complete secretory
endometrium in an estrogen-primed uterus.
 FOLIC ACID
◦ Prevents neural tube defects
◦ Women who are pregnant are advised to take 600 mcg of folic acid
per day from fortified foods or supplements.
 CALCIUM CARBONATE
◦ prevents mothers from having pre-eclampsia
◦ helps to regulate the release and storage of neurotransmitters and
hormones, the uptake and binding of amino acids, absorption of
vitamin B 12, and gastrin secretion
◦ When being used as a calcium supplement, it works to increase the
level of calcium in the body.
 Patient CR is a 31 years old with an obstetric score of G2P1
(1001) Filipino, Married, Roman Catholic with a Chief
Complaint of Hypogastric pain with a Final Diagnosis of
G2P1 (1001) pregnancy in utero, 33 weeks and 5 days in
preterm labor.
 During the 2 Days of confinement from January 12-14, 2019 at the
labor room, her vital signs ranges as follows:
◦ BP: 110/70mmHg
◦ RR: 18 breathes per minute
◦ PR: 78 beats per minute
◦ FHT: 140 beats per minute
◦ T: 36.8C
 CBC, Urinalysis and ultrasound was done.
 She was given 6 bottles of D5LRS with Isoxsuprine drip at 5-10
drops per minute. Patient was also prescribed with Dydrogesterone
(Duphaston) 1 tablet every 8 hours. Oxygen was also administered
at 2-3L/ minute.
 Preterm labor is a pathological condition with multiple
etiologies:
◦ Intrauterine infection
 sites for intrauterine infection
 Maternal (bacterial vaginosis, chlamydia)
 Fetal (Syphilis)
 both
◦ Idiopathic spontaneous preterm labor
◦ Maternal nutrition before or during pregnancy BMI
◦ Genetically acquired
 Threatened abortion
 Lifestyle factors:
◦ Cigarette smoking
◦ Inadequate maternal gain
◦ Illicit drug use
◦ Alcohol intake
 Prior Preterm Birth
  The recurrent preterm delivery risk for women whose first delivery
was preterm was increased threefold compared with that of women
whose first neonate was born at term (Spong, 2007)
PLACE OF BIRTH BIRTH PRESENT ANOM/
NUMBER OF COMP/AB
PREGNANCY OUTCOME BIRTH DATE AOG SEX WEIGHT STATUS

Live birth via Lying in August 29, 36 WEEKS MALE 2.4kg Alive None
G1 Natural Clinic at San 2011
Spontaneous Carlos City,
Delivery Pangasinan
G2
PRESENT PREGNANCY
 More than a third of women whose first two newborns were
preterm subsequently delivered a third preterm newborn (Spong,
2007).
 Preterm labor is primarily
diagnosed by physical
examination, signs and
symptoms
 Sonography is used to
identify asymptomatic

cervical dilation and
effacement
 Symptoms like:
◦ lower back pain
◦ pelvic pressure
◦ menstrual-like cramps
◦ watery vaginal discharge
Signs and symptoms signaling
preterm labor, including uterine
contractions, appeared only
within 24 hours of preterm
labor (Lams and
coworkers,1994)
1. Cervical Cerclage
◦ First prophylactic cerclage
 History of recurrent mid-trimester losses
 Diagnosed with cervical insufficiency without any threatened preterm
labor
◦ Second prophylactic cerclage
 Short cervix
 Cerclage may reduce preterm birth rates in those women with a prior preterm
birth (Berghella and colleagues, 2005)
◦ Third indication is “rescue” cerclage
 Cervical incompetence  threatened preterm labor
2. Prophylaxis with Progestin Compounds
o In the case of our patient, she was given Dydrogesterone
(Duphaston)
o Administration of progesterone to maintain uterine
quiescence may block preterm labor.
o Human parturition involves functional progesterone withdrawal
mediated by decreased progesterone activity of progesterone
receptors (Ziyan, 2010).
 Penicillin G 5 million units intravenous is administered as a
loading dose, followed by 2.5 to 3 million units every 4 hours
during labor
 The goal of intrapartum antibiotic prophylaxis is to obtain
adequate drug concentrations in the amniotic fluid and fetal
circulation.
 Ampicillin is a reasonable alternative to penicillin G if
penicillin G is unavailable.
 Dosing for ampicillin is 2 gm intravenous load followed by 1
gm intravenous every 4 hours until deliver
1. Managed much the same as described for those with
preterm ruptured membranes
2. If possible, delivery before 34 weeks is delayed
3. Corticosteroids for Fetal Lung Maturation
◦ Corticosteroid therapy was effective in lowering the incidence of
Respiratory Distress Syndrome and neonatal mortality rates if birth was
delayed for at least 24 hours after initiation of betamethasone.
◦ “Rescue Therapy”
◦ Choice of Corticosteroid
 Dexamethasone or Betamethasone
4. Bed Rest
5. Emergency or Rescue Cerclage
6. Tocolysis to Treat Preterm Labor
o Tocolytic agents do not markedly prolong gestation but may delay
delivery in some women for up to 48 hours (American College of
Obstetricians and Gynecologists, 2012)