PATIENT PROFILE

Name : Noramilah Binti Zainal

Age : 20 years old
Parity : G2P1
DOA : 24/09/2018 (1725)
DOE : 25/09/2018
BED. : no 17 ward 10
LMP. : 24/01/2018
EDD : 31/10/2018
Gestation : 34 weeks 6 days
R/N : 44463
Address : Segamat,Johor
Marital Status : Married

CHIEF COMPLAINTS

● Complain of fall today at home

● Contraction pain on & off since fall
● Decreased fetal movements since fall

HISTORY OF PRESENTING ILLNESS

Patient had a fall at about 10am at home.She fell due to slippery floor in her kid’s room.Claimed
daughter spilled hair oil on floor.Patient fell on her back supine,no head trauma.Post fall no loss
of consciousness,mild pain on her back,but noticed no leaking or bleeding.

She also experienced on and off mild contractions pain over her abdomen few minutes after the
fall.Since fall she claimed that the foetal movements decreased.From the fall at 10am to
admission to ward at 6:30pm,she counted only 6 kicks.Usually complete 10 kicks by 3:00 pm
everyday.

Otherwise,no show,no leaking liquor,no fever or UTI symptoms,no per vaginal bleeding.

In ED,blood and urine was taken for investigation and she was taken to labour room for further
management.Abdominal ultrasound was done and fetal heart beat seen and showed to mother
and CTG was reactive.Per vaginal examination revealed no show,or leaking liquor and the
cervix os was not open.She was then transferred to ward 10.

ANTENATAL HISTORY
1​st​ Trimester

This is an unplanned pregnancy booked at KD Tanjung Perak.​She did urine pregnancy test at
home after missing period for 2months.At booking was found to be at 13 weeks of
gestation.Routine blood and urine investigations were done.Body weight,height and Blood
pressure taken.No history of fever,rash,vaginal discharge,bleeding or dysuria in first trimester
Went for follow up scan on 15/05/2018.

● Booking weight : 45kg

● Booking BP: 115/76 mmHg
● Booking HB : 12.3 g/dL
● Group : Blood group O+ve
● VDRL,HIV,Hep B : non reactive
● Urine analysis : normal

2​nd​ Trimester

She felt quickening at 20th week of gestation.2 tetanus toxoid injections were given with
monthly interval.Her blood pressure was normal and weight gain was good.MGTT done at 20th
and 28th week and it was normal.Anomaly scan was done and no anomalies found.Three scans
done showed foetus growth corresponds to period of gestation .She was started on T.Iberet 1/1
OD in view of anaemia diagnosed at 21 weeks Hb 9.2g/dL,serum Ferritin 10.4.Adviced to
consume more green leafy vegetables,fish and nuts.No fever,leaking,bleeding history in second
trimester.

3rd Trimester

3 ultrasound scans done showed good fetal growth.Good fetal movement appreciated by
mother.Fetal kick chart started at 30 weeks.Usually completes 10 kicks by 3pm everday.Hb
improved to 10.5 g/dL.T.Iberet continued.No history of leaking or bleeding.No other complaints
till the fall.

PAST OBSTETRIC HISTORY

-G2P1
-Delivered a term baby girl via SVD in Hospital Segamat in May 2016.Birth weight 2.7kgs,no
complications.Healthy,breastfed till 2 years old.
-History of anaemia in last pregnancy,on T.Iberet OD
-Post partum Hb was 6 g/dL and transfused 2 pints of packed cells.
-​Told her prenatal Hb was 8 g/dL,unsure of PPH

MENSTRUAL AND GYNAE HISTORY

-She attained menarche at 13 years old with regular 28-30 days cycle with 5-6 days of flow.No
dysmenorrhea or excessive bleeding.
-Pap smear not done
-Contraception : IM Depo for 1 year after delivery (​ 4 injections )

FAMILY HISTORY

-Both parents have diabetes mellitus and hypertension on medications

-She is youngest among 3 siblings
-​No history of twins or consanguineous marriage
-No congenital anomalies or blood disorders among family members

PERSONAL HISTORY

-Her sleep and appetite is normal

-Takes balanced mixed diet
-No changes in bowel or bladder habits
-Does not smoke or consume alcohol
-No known drug allergies
-Allergic to seafood (prawns,crabs)

SOCIOECONOMIC HISTORY

-Stays with husband and daughter in Felda Palong Timur

-She is full time housewife,supported by husband
-Adequate income and financially stable
-House is 20 minutes away from hospital

OTHER HISTORY

No known medical illness

Not on any medications
No surgical history
No drug allergies
SUMMARY

Puan Noramilah,20 years old G2P1 at 36 weeks + 6 days period of gestation came with on and
off contractions pain and decreased fetal movements after a fall in her house at 10am
today.CTG done was reactive and USG scan is normal.Currently kept for monitoring and
awaiting discharge.

Diagnosis : Threatened preterm labour

GENERAL EXAMINATION

Patient is alert,cooperative and not pale

Patient is lying down in supine position on the bed
She is moderately built and moderately nourished
Her height is 150cm and weight is 52.5kgs. BMI is 23.33kg/m2
Presence of green IV cannula on the dorsum of her right hand
Hands: no pallor in the nail beds and palms
Pulse: 86 beats/min, regular rhythm, normal volume and character
Blood Pressure: 117/78 mmHg taken in sitting position
lPedal edema: absent

Systemic Examination

Cardiovascular system: S1 and S2 heard, no murmurs

Respiratory system: Normal vesicular breath sounds heard, no adventitious sounds

Obstetrics examination

Inspection

Abdomen is uniformly distended

Linea nigra and striae gravidarum present
Umbilicus is centrally placed and flat
All quadrant moves equally with respiration
Fetal movement not seen
Hernial orifices are intact
no scar
Palpation

​Uterus soft,non tender,relaxed

Clinical fundal height: 36 weeks
Symphysio fundal height: 36cm
Fundal grip: irregular, soft to firm mass, not independently ballotable mass felt,
suggestive of fetal buttock
Lateral grip: curved smooth and broad structure felt at the maternal right side suggestive
of fetal spine. Irregular knob like structure felt at the maternal left side suggestive of fetal limbs
2nd pelvic grip: hard, round, independently ballotable mass felt, suggestive of fetal head
The head is 5/5th palpable

Auscultation

Fetal heart sound is heard at the below right side of umbilicus.​Rate 130 beats per minute

Summary of grips

Singleton pregnancy with cephalic presentation in longitudinal lie

Per Vaginal Examination

Vulva/vagina : no abnormality detected

Cervix : 1.5 cm , soft , axial
Os : closed

Investigations

Full Blood Count

group : O +
Hb : 10 g/L
PCV : 28.2 %
Platelets : 454x109 /L
TWBC : 10.9x109 /L

Ferritin. : 10.40ng/ml (n - 10-291)

Iron study
Iron. : 92.4 umol/L (h)
IBCT : 98 umol/L (h)
UIBC : 6 umol/L (n)
% saturation 94.3% (n)
-iron deficiency anaemia

Blood urea : 2.3 ​mmol/L

Na. :134 ​mmol/L
K. : 3.49 ​mmol/L
Cl. : 99.4 ​mmol/L
Creatinine. : 57 ​umol/L

Urine FEME
Glucose : normal
RBC’s : negative
Ketone : negative
Protein : negative
Leucocyte. : negative
Nitrate. : negative
- urinalysis normal,rules out UTI

CTG
Baseline fetal heart rate: 135 beats/min
Baseline variability: 5 – 15 beats/min
Presence of 2 accelerations in 20 minutes
No decelerations
Toco: No uterine contractions
Impression: Reactive CTG

Ultrasound

Date 24/09/2018

POA 34 w + 6d

Fetal Biometry mm weeks

Presentation Cephalic

Fetal heart seen,shown to mother

 CRL/BPD 85.3 34w3d

HC 34.5 34w6d

AC 303.7 34d3d

FL 66.4 34w1d

PLACENTA SITE AUS

AFI 14.4

EFW (kg) 2.443

Final diagnosis : Threatened preterm labour

Management Plan (at ED)

1. Time contraction,monitor FHR

2. CTG BD
3. Tocolysed with T.nifedipine 20 mg STAT then T.nifedipine 10 mg every 15 minutes x 3
4. IM Dexamethasone 12 mg BD x 1/7
5. Strict FKC
6. Trace investigations taken
7. Monitor vital signs every 15 minutes

Management in ward

1. Continue IM Dexamethasone 12 mg 07:30 am tomorrow

2. T.nifedipine 10 mgTDS x1/7
3. BD CTG
4. T.Iberet 1/1 OD

As her CTG was reactive and toco showed no contractions,she was sent to the ward and
discharged the next day.

Discussion

ANAEMIA
Several types of anemia can develop during pregnancy. These include:
- Iron-deficiency anemia
- Folate-deficiency anemia
- Vitamin B12 deficiency

Most common cause is inadequate iron and other nutrients in diet which is needed to making
new blood cells required to support pregnancy.

All pregnant women are at risk for becoming anemic.Risk factors:

- Multiple gestation
- Poor spacing
- Hyperemesis gravidarum
- Teenage pregnancy
- Unbalanced diet
- Prenatal anaemia

The most common symptoms of anemia during pregnancy are:

- Pale skin, lips, and nails

- Feeling tired or weak
- Dizziness
- Shortness of breath
- Rapid heartbeat
- Trouble concentrating

This patient had an asymptomatic anaemia.

Risks of Anemia in Pregnancy

Severe or untreated iron-deficiency anemia during pregnancy can increase risk of having:

- A preterm or low-birth-weight baby

- Neural tube defects
- Blood transfusion
- Postpartum depression
- Baby with anemia
- Child with developmental delays

The probable cause of preterm labour pain in this patient could be because of her anaemia.

Treatment

- Oral iron therapy (this patient on T.Obimin 1/1)

 - Parenteral iron therapy
- Blood transfusions (Hb <6 g/dL)

- Intrapartum : cross matched blood should be available,maternal oxygenation to reduce

fetal hypoxia,strict asepsis to prevent puerperal sepsis,prophylactic forceps in case of
delayed 2​nd​ stage of labour,prophylactic methyl ergometrine 0.2 mg to minimize blood
loss

- Close observation for development if infection,congestive cardiac failure and puerperal

venous thrombosis.Patient discharged with proper contraception for adequate spacing
and hematinics.

PRETERM LABOUR

Diagnosis : there are three criteria to document preterm labour

1. Regular painful and palpable uterine contractions lasting more than 30 seconds with
frequency of four contractions every 20 minutes or 8 contractions every 60 minutes
along with the progressive changes in the cervix ( this patient had on and off
contractions with no changes in cervix)
2. Cervical dilatation > 1cm (Os closed in Patient)
3. Effacement > 80%

Symptoms

1. Uterine contractions
2. Show
3. Sensation of vaginal pressure
4. Increased vaginal discharge
5. Vaginal bleeding

Signs

1. Cervical effacement & dilatation

2. Rupture of membranes
3. Engagement of the presenting part
4. Show
5. Bulging membranes
6. Palpable uterine activity
Goals of management

● Early identification of risk factors (anaemia in this patient)

● Timely diagnosis of preterm labour
● Identifying the etiology of preterm labour to prevent recurrence in future
● Evaluating fetal well being
● Providing prophylactic pharmacologic therapy
● Initiating tocolytics when indicated

Once patient with suspected preterm labour is seen,a vaginal examination is done to confirm if
she is in preterm labour by assessing the cervical length,dilation,station of presenting part.CTG
is then done for uterine contractions and fetal well being.In the management of preterm
labour,the main aim is to postpone labour till beyond 34 weeks of gestation with tocolytic
therapy.

No uterine contraction on CTG and it was reactive.No cervical changes.No action taken in this
patient.

References

1. Obstetrics Today Prof Sachchithanantham,Dr Nagandla Kavita (Anaemia in

pregnancy,Preterm Labour) pages 150-151,272-276
2. https://www.webmd.com/baby/guide/anemia-in-pregnancy#1
3. https://www.acog.org/Patients/FAQs/Preterm-Premature-Labor-and-Birth