CASE PRESENTATION

Cada, Joanne Irish DC.SBCM Med clerk

QMMC OB ROTATIONJUNE 21, 2011

IDENTIFYING DATA

• A.A.• 32 y/o• Single • Catholic, Filipino• Antipolo, Rizal• SOURCE OF REALIBILITY OF INFORMATION:

Patient

CHIEF COMPLAINT

• vaginal bleeding

HPI

• 1ST TRI• 2ND TRI – cold intolerance, fatigue with

enlarging mass on her anterior neck. Initial TSH was normal, FT4 elevated. Diagnosed with goiter Jan 2011 at FCLI, given eltroxin 50 mg OD, took it for 11 days only.

• 3rd TRI

ROS

• (+) dysuria• (+) muscle weakness

IMMUNIZATIONS

• (+) completed childhood immunizations. (-) completed ttd. (-) mmr, hepa b.

PAST MEDICAL HISTORY

• (+) goiter Jan 2011- eltroxin 50mg OD poor compliance

FAMILY HISTORY

• (+) DM – mother• (+) HPN – father• (+) Goiter – mother; sister

OBSTETRIC HISTORY

• OB SCORE: G1P0 • LMP: September 24, 2010• EDD: June 29, 2011• AOG: 38 weeks via LMP.

SEXUAL HISTORY

• Coitarche at 25 y/o, husband is only sexual partner, sexually active, no dyspareunia, (-) decrease in libido. No previous STDs.

• General: patient conscious and coherent not in distress, cooperative pleasant. Medium built. HT: 5’2ft, WT: 145 lbs.

• VS: afebrile. RR=22 bpm, BP120/80, HR=92bpm. Regular normal pulse.

• HEENT: (+) thyroidal enlargement 2 by 2 cm. Moves with deglutition. No tenderness, non inflamed, no discharges.

• CHEST AND LUNGS: symmetrical chest. No use of accessory muscles. No tenderness. Equal chest expansion. Equal and normal tactile fremitus. Resonant on percussion. Clear breath sounds. No adventitious breath sounds.

• HEART: no pericardial bulge. No thrills , heaves and friction rub. Good s1 and s2. No s3 and s4. No murmurs.

ABDOMINAL EXAMINATION

• round, large abdomen. (+) linea nigra, straie gravidarum, and striae albicans. (+) fetal movements. FH: 29 cm. longitudinal lie. Cephalic presentation. FHT at RLQ at 140 bpm. L1-nonballotable, L2- fetal parts at left, fetal back at right. L3-fetal head cephalic. L4-not engaged.

• FEMALE GENITALIA: sparse coarse pubic hair. Equal distribution. No lesions.

• EXTREMITIES: no deformities, no joint swellings, no limitation in ROM

• SKIN/NAILS: dark in complexion, no petechiae, no ecchymoses.

INTERNAL EXAM

• 8 cm dilated, 70% effaced, station -2, (-) BOW clear, (+) pool of fluid in cervix.

LABS• UTZ – May 2011

Single live intrauterine pregnancy, presently cephalic. BPS 10/10

• Cogulation Panel – June 2011Nomal results

• CBC - June 2011 Increased WBC 15.6Decreased RBC 4.08Increased neutrophils .803Decreased lymphocytes .138

• TSH/FT4 - March 2011Normal TSHLow FT4 .10

• May 2011Normal TSHNormal FT4

TIME I.E.

3 PM 3 CM/ 80 % EFFACED/ CEPHALIC/STATION -2/ (+) BOW

STARTED HNBB EVERY 4 HOURS4 PM SAME IE

5 PM SAME IE

6 PM SAME IE

7 PM SAME IE

8 PM SAME IE

9 PM 4 CM/ 70 % EFFACED/ ST -2/ CEPHALIC/ + BOW

10 PM SAME IE

11 PM 4 CM/ 70 % EFFACED/ ST -2/ CEPHALIC/ - BOW

AROM DONE

12 MN 4-5 CM/ 70 % EFFACED/ ST -2/ CEPHALIC/ - BOW

1 AM 5 CM/ 80 % EFFACED/ ST -2/ CEPHALIC/ - BOW

2 AM 5- 6 CM/ 80 % EFFACED/ ST -2/ CEPHALIC/ - BOW

3 AM 6 CM/ 80 % EFFACED/ ST -2/ CEPHALIC/ - BOW

CALL FOR AD

• REGULAR NORMAL FHT. RANGES 140-160bpm.

• NO ELEVATIONS ON BLOOD PRESSURE.

• PATIENT WAS NOTED TO BE WARM TO TOUCH BUT AFEBRILE.

• NOTING MILD CONTRACTIONS EVERY 10 -15 MINUTES WITHOUT PROGRESSION.

CALL FOR AD

AROM

D5LR + 10 UNITS OXYTOCINHNBB Q 4HOURS

ADMITTING DIAGNOSIS

• G1P0 Pregnancy uterine 38 weeks AOG, Cephalic In labor, hypothyroidism biochemically euthyroid.

FINAL DIAGNOSIS

• G1P1 (1001) s/p LTCS I secondary to arrest in cervical dilatation secondary to inlet contraction to a live term baby girl.

• T/C UTI

DISCUSSION

DYSTOCIAA. Abnormalities of the expulsive forces

– Uterine dysfunction– Abnormal labor patterns– Rupture of membranes w/o labor– Precipitous labor and delivery

B. Abnormalities of presentation, position, or development of the fetus;

• Abnormalities of the maternal bony pelvis—that is, PELVIC CONTRACTION.;

D. Abnormalities of soft tissues of the reproductive tract that form an obstacle to fetal descent.

Common Clinical Findings in Women with Ineffective Labor

Inadequate cervical dilatation or fetal descent

  Protracted labor—slow progress

  Arrested labor—no progress

  Inadequate expulsive effort—ineffective "pushing"

Fetopelvic disproportion

  Excessive fetal size

  Inadequate pelvic capacity

  Malpresentation or position of fetus

Ruptured membranes without labor

• PROTRACTE ACTIVE-PHASE DILATATION

• ARREST IN DILATATION

• Fetal descent largely follows complete dilatation – no failure of descent

HNBB IV Q1

D5LR + 10 UNITS OXYTOCIN

CAUSES OF ARREST DISORDERS

definition• considered to be contracted if its shortest anteroposterior

diameter is less than 10 cm

• or if the greatest transverse diameter is less than 12 cm.

• anteroposterior diameter of the pelvic inletis commonly approximated by manually measuring the diagonal conjugate, which is about 1.5 cm greater.

• Therefore, inlet contraction usually is defined as a diagonal conjugate of less than 11.5 cm.

PLANS

1. Identification of pregnancy risk factors.

2. Comprehensive antenatal history taking is essential

3. Asses adequate pelvimetry

4. Intrapartum the RCOG Guidelines “The Use of Electronic Fetal Monitoring” identifies the intrapartum risk factors for FHR monitoring. Doppler auscultation, VS every hour

5. Continous IE and labor watch.

6. Induction of labor.

7. Order for follow-up labs.

8. REFER to pediatrics and endocrinologist.

9. Re-evaluate and asses need for CS DELIVERY.

10.Prepare for CS.

11. MANAGE UTI. MANAGE GOITER.