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High Risk Conference

SEPTEMBER 27, 2008

M.B.C. 25 y/o, G1P0 24-25 wks AOG

Chief Complaint Hypogastric pain

History of Present Illness


Two days PTA
Hypogastric pain radiating to

the lumbosacral area No passage of blood or watery vaginal discharge Consult with an OB

Abdominal exam: (+) uterine contractions IE: cervix soft, short, closed P> advised admission

Isoxsuprine HCl drip started

History of Present Illness


1 day PTA
Intermittent hypogastric pains
Pelvic UTZ

Impression
Single , live, intrauterine pregnancy, cephalic, 25

weeks AOG, w/ good cardiac & somatic activity; Cervical funneling (0.85cm)

History of Present Illness


1 day PTA
Betamethasone 12mg/IM x 2

doses, 24 hours apart P> for cerclage Transfer to USTH-CD

ADMISSION

Prenatal Check-ups
Prenatal check up at USTH-MAB, ~3x
1st

at 5 mos AOG (8/22/08)


biometry
live, intrauterine pregnancy of about 2021 weeks AOG w/ good cardiac & somatic activity

Fetal

Single,

CBC-

Normal Urinalysis: (+) UTI Cefuroxime 500 mg BID x 7 days

Oral Glucose Tolerance Test

FBS
1st hr 2nd hr

66.8 mg/dl
145.0 mg/dl 110.0 mg/dl

3rd hr

112.0 mg/dl

Review of Systems
No anorexia, weight loss No fever No cough No hearing loss, nasal congestion No polyuria, polydipsia, polyphagia No cyanosis No chest pain No diarrhea, no constipation No dysuria, incontinence

Personal and Social History


Social smoker (5 sticks/occasion) Drinks alcohol occasionally (2x in 6 months; 10

shot glasses of brandy) Denies illicit drug use and abuse

Past Medical History


No diabetes mellitus No hypertension No heart disease No thyroid disease No bronchial asthma

No allergies
No previous hospitalization No previous surgeries

Family History
(+) Diabetes Mellitus - mother (+) Thyroid disease mother (+) Hypertension father

(+) Cancer, prostate maternal grandfather


No heart disease

Menstrual History
Menarche

13 years old Interval 60-90 days Duration 7 days Amount 4-5 pads per day, moderately soaked (+) D1 & D2 Dysmenorrhea

Sexual History
First sexual contact at 18 years old 3 sexual partners Family planning method: condom, withdrawal

(-) Dyspareunia, (-) postcoital bleeding

Physical Examination
Conscious, coherent BP 110/80 PR 80 RR 19 T 36.5 Ht 150 cm Wt 52 kg Warm, moist skin; no active dermatoses Pink palpebral conjunctivae, anicteric sclerae Neck not rigid, no palpable lymph nodes, thyroid not enlarged Symmetrical breasts, no palpable masses nor tenderness, no nipple discharge, no axillary lymphadenopathy

Physical Examination
Adynamic precordium, AB at the 5th LICS, MCL,

No murmurs Symmetric chest expansion, no retractions, clear breath sounds Globular abdomen, FH 24 cm, FHT 142 bpm Speculum Exam: cervix violaceous, smooth, w/ minimal whitish mucoid discharge IE: cervix: soft, short, closed uterus: enlarged to 6 months

Extremities: pulses full and equal, no cyanosis, no

edema

Assessment
Pregnancy 24-25 weeks AOG, threatened preterm labor

Laboratory Tests
CBC Hemoglobin Hematocrit WBC Segmenters Lymphocytes Platelet 99 0.28 14.5 0.89 0.11 300

Laboratory Tests
Urinalysis (9/8/08)
Color Transparency Ph Specific gravity Albumin sugar RBC Pus cell Squamous cell Bacteria Mucus threads Amorphous urate yellow Sl. turbid 7.0 1.010 NEGATIVE NEGATIVE 0-1/hpf 3-5/hpf ++ FEW FEW +++

Plans
Problem #1: Pregnancy 24-25 weeks, threatened preterm labor 1. Complete bed rest, no bathroom privileges 2. Continue tocolysis - 4 ampules Isoxsuprine HCl in 500cc D5W to run at 20ugtts/min to titrate at increments of 5 ugtts/ min 3. For cerclage

Continue multivitamins OD Continue FeSO4 OD Continue milk, 1 glass OD

Course in the Ward

st 1

HD: 9/25/08

S> Good fetal movement No hypogastric pains No bloody or watery vaginal discharge O> BP 110/80 PR 84 RR 18 T 36.5 FHT 148 bpm No uterine contractions P> Continue IV Tocolysis

2nd HD: 9/26/08


S> Good fetal movement Intermittent hypogastric pains No bloody or watery vaginal discharge

O> BP 110/80 PR 72 FHT 146 bpm P> Continue IV tocolysis Cerclage done

RR 19

T 36.6

3rd HD: 9/27/08


S> Good fetal movement Intermittent hypogastric pains No bloody or watery vaginal discharge O> BP 120/70 PR 76 FHT 143 bpm P> Continue IV Tocolysis RR 19 T 36.5

4th HD: 9/28/08


S> Good fetal movement No uterine contractions No bloody or watery vaginal discharge

O> BP 120/80 PR 80 FHT 151 bpm

RR 18

T 36.6

P> Continue IV Tocolysis Start Isoxilan HCl 10 mg/tab, 1 tab q8 hrs For cervical length & funneling determination

5th HD: 9/29/08


S> Good fetal movement No hypogastric pain/uterine contractions No bloody or watery vaginal discharge O> BP 120/80 PR 88 FHT 145 bpm RR 18 T 36.8

P> Continue Isoxilan tablet q 8 hrs

Cervical length and funneling determination

Impression
Funnel length 1.60 cm NARROW BUT DEEP U

FUNNEL Functional cervical length 1.72 cm Hyperechoic foci 1.2 cm from the external os (sutures)

6th HD: 9/30/08


S> Good fetal movement No hypogastric pain/uterine contractions No bloody or watery vaginal discharge O> BP 100/70 PR 80 FHT 144 bpm RR 17 T 36.5

P> Continue Isoxilan tablet q 8 hrs Measure fundic height and weight weekly