CLINICAL REPORT

PHASE III
OBSTETRIC AND GYNECOLOGY POSTING
NAME

: MUHAMMAD EIDI IDHAM BIN KASSIM

MATRIX ID

: 107471

YEAR

:5

GROUP

:4

SUPERVISOR

: DR NIK AHMAD ZUKY NIK LAH

IDENTIFICATION DATA
NAME

: MISS FITRIYANEE SULONG

R/N

: B581511

AGE

: 18 YEARS OLD

SEX

: FEMALE

RACE

: THAILAND

MARITAL STATUS

: MARRIED

OCCUPATION

: HOUSEWIFE

DATE OF ADMISSION : 19th MAY 2015

DATE OF CLERKING : 20th MAY 2015

LAST MESTRUAL PERIOD : 11th SEPTEMBER 2014 (FOLLOW

NAEGELES RULE sure of date, regular menstrual period, not on
breastfeeding, not on hormonal therapy)
EXPECTED DATE OF DELIVERY : 18th JUNE 2015
PERIOD OF AMENORRHEA

: 35 WEEKS + 5 DAYS

GRAVIDA

:1

PARAGRAVIDA

: 0 +1 (MISCARRIAGE)

FIRST ULTRASOUND SCAN

: IN DECEMBER AT 12 WEEKS
(singleton, viable fetus, the parameter corresponds with period of amenorrhea)
INFORMANT

CHIEF COMPLAINT
Contraction pain on the day of admission

: THE PATIENT

HISTORY OF PRESENTING ILLNESS

Patient presented with contraction pain on the day of admission. It started 3 hours prior, from
the fundus and radiated to the back. It was regular, constant in intensity and present once in
every 30 to 40 minutes. It was associated with the presence of show per vaginally, which
described by the patient as brownish, jelly-like fluid. There was no leaking liquor at that time.
However, on further questioning, patient admitted to having experience leaking of liquor 2
days prior to her presentation. She suddenly felt gushing of fluid, later dribbling, coming out
and soaked her pant. The fluid was colorless and odorless. She had to use 1 pad and it was
almost fully soaked with the fluid. It was followed by contraction pain, lasted for 1-2 minutes
and resolved spontaneously after that. She told that the fetal movement was good and active.
She had been free for 1 day of any symptoms of labor until she presented with contraction
pain and show.
Besides that, she did not have fever. She also did not have symptoms of urinary tract infection
such as painful micturition, frequency and lower abdominal pain. She did not experience any
trauma to the abdomen before, nor did she take any traditional medication. She also denied
the event of sexual intercourse or abdominal massage before the leaking. Regular antenatal
follow-up revealed that she had normal blood pressure and no glucose in the urine.
Subsequent antenatal scan also showed that the fetus weight was of normal range, so was the
amount of liquor.
Currently, patient still had the contraction pain, twice in 30 minutes and constant in intensity,
but there was no liquor flowing out.

SYSTEMIC REVIEW
Cardiovascular
No chest pain
No paroxysmal nocturnal dyspnoea
No orthopnea
No palpitation

Respiratory
No cough
No shortness of breath

Gastrointestinal
No abdominal pain
No jaundice
No altered bowel habit
No loss of weight and appetite
No melena and hematochezia

Genitourinary
No hematuria
No dysuria
No sense of incomplete voiding
No urgency
No hesitancy

Nervous system
No change in visual, smell, taste, hearing and speech
No headache
No fits

HISTORY OF PRESENTING PREGNANCY

This was planned and wanted pregnancy. She suspected her pregnancy after she missed 1
month of her expected menstrual period. She did urinary pregnancy test at Klinik Kesihatan
Kedai Lalat and the result was positive.
Booking was done at Klinik Kesihatan Tawang at 12 weeks of period of gestation in
December 2015 as well as the first ultrasounde. The ultrasound revealed singleton, viable
fetus and the parameter corresponded with period of amenorrhea. The results during booking:
Blood pressure : 110/90 Normal (patient was unsure of the value)
Hemoglobin : Low (patient was unsure of the value)
Blood group : A +ve
Urine albumin and glucose : Negative
HIV/VDRL, TPHA : Not reactive
Height : 150 cm
Weight : 44 kg from 40 kg

She was prescribed with iron, folate and vitamin b complex for her pregnancy. Quickening
was felt at 20 weeks period of gestation. She told that the fetal movement was increased in
intensity and frequency. She completed all the immunizations. She experienced signs and
symptoms of pregnancy such as nausea and vomiting.
She did not do Modified Oral Glucose Tolerance Test (MOGTT) since she had no risk factors
of gestational diabetes mellitus.
She attended all her antenal check up regularly at Klinik Tawang which was once/month
until 28 weeks of POA followed by twice a month. All the check up revealed that the
symphysiofundal height and fetal corresponded to POA. She told that for all her follow up,
her blood pressure, hemoglobin were borderlinel.

PAST OBSTETRIC HISTORY

She was married at the age of 17 in 2014. This is the only and non- consanguineous marriage.

PAST GYNECOLOGICAL HYSTORY

She attained menarche at the age of 13 years old with regular cycle of 28-30 days. Her
menses lasts for 8 to 9 days with peak flow between day 1 and 2. She did not have
dysmenorrhea, menorrhagia, intermenstrual or post-coital bleeding.
She had history of miscarriage in 2014 at 20 weeks of period of amenorrhea. No dilatation
and curettage done.
She did not have history of pap smear.

PAST MEDICAL AND SURGICAL HISTORY

She did not have medical and surgical history.

DRUG HISTORY
She was prescribed with folate, iron and vitamin b complex for this pregnancy. She was
compliant to all medications.

FAMILY HISTORY
The patient is the fourth out of 5 siblings. Her parents and siblings were healthy. No family
history of preterm labor in the family.

SOCIAL HISTORY
She is a housewife. Her husband is a contractor with an income of RM5000. She did not
smoke or consume alcohol. Her husband did not smoke or take alcohol.

DIET HISTORY
She claimed to have good appetite throughout her pregnancy. She practiced normal adult diet.

PHYSICAL EXAMINATION
GENERAL EXAMINATION
The patient was lying in supine position supported by one pillow. She was oriented to time,
place and person. She was not in respiratory distress. The hydrational and nutritional statuses
seemed adequate.
VITAL SIGNS
TEMPERATURE

: 37C

BLOOD PRESSURE : 109/68 mmHg

PULSE RATE

: 80 BEATS PER MINUTE

RESPI RATE

: 18 PER MINUTE

URINE DIPSTICK TEST NEGATIVE FOR PROTEIN

HANDS: Both hands were warm, moist and pink. There was no koilonychias, clubbing and
palmar erythema. The capillary refill is within 2 seconds.
WRIST: The pulse rate was 80 beats per minute with normal rhythm and adequate volume.
There was no collapsing pulse.
NECK: There was no obvious neck swelling.
EYES: Both conjunctiva were slightly pale and there was no discoloration of sclera.
MOUTH: There was no angular stomatitis. The oral hygiene was good. The tongue was not
coated. There was no glossitis seen.
LEGS : Her legs were warm and dry. There was pitting edema up to mid shin.

ABDOMINAL EXAMINATION
INSPECTION : This was gravid uterus with the presence of linea nigra and striae
gravidarum. The umbilicus was falt and centrally located. There was no surgical scar. The
fetal movement cannot be seen.
PALPATION : On superficial palpation, the abdomen was soft and non tender. On deep
palpation, uterus was non contractile. The uterine fundus can be felt.
Clinical estimation was 35 weeks. Symphisiofundal height was 34 cm and this height
corresponded to period of amenorrhea.
Fetal examination : It is a singleton fetus in longitudinal lie with cephalic presentation. Fetal
back can be felt and the maternal right side and fetal part was at the left. Fetal movement
cannot be appreciated. The volume of liquor was adequate for gestation and the estimated
weight was 2.4 to 2.6 kg. Fetal heart sound cannot be appreciated. The fetal head was not
engaged.

SPECULUM EXAMINATION Vulva and vagina no abnormality seen. Cervix appeared

pink and healthy. Os looked open. No pooling of liquor.
NEUROLOGICAL SYSTEM : Cranial nerve examination revealed no abnormalities. The
tone, power, reflexes and sensation of the upper and lower limbs were normal. Clonus was
absent.
CARDIOVASCULAR SYSTEM: On auscultation , first and second heart sound were heard.
There was no added sound and murmur.
RESPIRATORY SYSTEM: On auscultation, vesicular breath sounds were heard at both

SUMMARY
Miss Fitreeyani, an 18 year old Thailand lady, Gravida 2 Para 0+ 1 (miscarriage), currently at
35 weeks and 5 days period of amenorrhea presented with pre-term rupture of membrane and
threatened pre-term labor. On physical examination, she was afebrile, per abdomen revealed
singleton fetus, cephalic presentation with longitudinal lie. Liquor volume was adequate. At
this moment she had regular contraction but with no more leaking liquor.

PROBLEM LIST
1. Pre-term rupture of membrane
2. Threatened preterm labor
3. Anemia in pregnancy
4. Teenage pregnancy

DIAGNOSIS
Pre-term labor with pre-term rupture of membrane.

INVESTIGATION.
1) Full blood count to
assess the patient well
being especially the
hemoglobin level and
total white cell count.

2) Transabdominal
ultrasound : to review
Fetal biometry
Fetal heart
Amniotic fluid index
Estimated fetal weight.

3) Cardiotocograph
To monitor fetal heart
rate and uterine
contraction whether the
fetus is compromised or
not
4) High vaginal swab
- To look for infection
that could cause preterm rupture of
membrane and preterm labor
5) Urine FEME
To look for infection that
could cause pre-term
rupture of membrane and
pre-term labor

Hb :11.1./dL
RBC : 3.84X10^12/l
MCV :88.3Fl
MCHC : 32.7 g/dl
WBC : 12.96X10^9/l
HCT : 31.5
PLAT : 303 X10^9/l
All values are in normal range except
that the total white cell count is high
Fetal heart present
Biparietal diameter is 8.44 cm of 34
weeks
Head circumference 30.17 cm of 33
weeks 4 days.
Abdominal circumference 30.64 cm of
34 weeks 4 days.
Femur length 6.67 cm of 34weeks +
4day
Amniotic fluid index : 6
Estimated fetal weight 2406g
Transabdominal Ultrasound revealed
no abnormalities except that the liquor
is a little bit low.
Baseline 140 bpm
BTBV 5-20
Accel positive
Decel negative
CTG was reactive
Pending

MANAGEMENT
.
1. Keep patient in the ward
2. Intramuscular Dexamethasone 12 mg BD for 12 hours interval
3. Erythromycin Ethylsuccinate 400 mg BD
4. Watchout for signs and symptoms of chorionamniotis
5. Pad chart and fetal kick chart monitoring
6. Aim for delivery at 36 weeks, but allow labour if progression is fast

DISCUSSION
The patient initially presented with one episode of leaking liquor, which only lasted for a few
minutes and resolved after that. Two days later she presented with regular contraction pain
and passing out show, which were highly suggestive of pre term labour.
She was at 35 weeks +5 days period of amenorrhea. One issue that we have to know is that
she had spontaneous pre-term rupture of membrane. Due to that, she was at risk of
developing chorioamnionitis, which could be disastrous to both mother and the foetus.
There are many causes of pre-term rupture of membrane. These include:

Infection GBS, gonorrhoea, chlamydia

Cervical incompetence
Obstetric complications previous preterm birth, primid, multiple pregnancy, teenage
pregnancy
Sexual activity
Diet and habit
Iatrogenic trauma
Genetic

From pre-term rupture of membrane, we should alert of some complications that can occur,
such as chorioamnionitis, placenta abruption, prolapsed cord, premature labour or late
congenital abnormalities ( congenital dislocation of the hips and hypoplastic lungs).
Another issue is she was at pre term labour. So the principle of management is to investigate
the cause of both pre-term rupture of membrane and labour. Low and high vaginal swab need
to be taken to rule out infection as the cause of the problems. Besides that, the fact that she
was a case of teenage pregnancy had already put her under those at risk of getting that.
Following that, intervention needs to be done to ensure the safety of both mother and the
foetus. In this case, she was given intramuscular dexamethasone 12 mg BD at 12 hourly
interval, in view of the possibility of her to progress into labour.
Bishop score was done early in the morning to assess the favourability of the cervix. The
score was 7, and that could indicate easier shorter duration of induction of labour, if she was
decided to subject into it. Even though she was having regular contraction, that was not in
increasing trend and only occurred once in 30 minutes interval. That was the reason why she
was aimed to deliver at 36 weeks of period of gestation.
However, the whole assessment should be conducted, include pad chart and foetal kick chart
monitoring. If there is leaking liquor and it continues for more than 24 hours, the patient can
undergo induction of labour and if the signs of labour were so imminent, she can be directly
sent to labour room.
To prevent chorioamnionitis, the patient was given Erythromycin Ethylsuccinate (EES) 400
mg BD, planned for 10 days. It is crucial as well to look for the signs and symptoms of
chorioamnionitis because that could warrant an urgent delivery of the baby.

REFERENCES
1. Obestetric by Ten Teachers, 19th edition, Edited by Philip N Baker and Louise C Kenny
2. Obstetric Today, Ist Edition by Prof Sachchinathan.