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PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY (Foundation), INC. COMMITTEE ON MATERNAL AND PERINATAL WELFARE PHILIPPINE PEDIATRIC SOCIETY Southern Tagalog Chapter PERINATAL MORBIDITY CONFERENCE CASE PROTOCOL This is a case of 26 years of age, G6P3 (3022), admitted for the 1st time in our institution last January 25, 2009 at 3pm. Chief complaint: labor pains History of Present Illness: Few hours prior to admission patient had irregular abdominal pains radiating to the lumbosacral area. She noted increase in frequency prompying consult and subsequent admission. Past medical history: unremarkable Family History: unremarkable OB History: G1:1998: Blighted ovum, D&C G2: Blighted ovum, D&C G3: stillbirth G4: 2000, FT, LBG, NSD, BW: 7lbs. G5: 2005, FT, LBB, NSD, Bw: 6.5lbs G6: present pregnancy G6P3 LMP: AOG: 41 weeks and 2 days EDC: 1st trimester: Varicella infection (chickenpox) at 3 mos AOG (+) vesicular rashes, fever: given paracetamol PO (+) intake of Folic acid PO 2nd trimester: (+) intake of Folic acid and multivitamins (+) Congenital Anomaly Scanning: Cleft lip and palate 3rd trimester: Ultrasound showed: Pregnancy uterine, 37 weeks by fetal biometry Live, singleton, in cephalic presentation Adequate amniotic fluid EWF: 2000grams Cleft lip and palate 1 Menstrual History: regularly menstruating, occurring every 28th day of the cycle, lasting for 4 days, using 3-4 pads per day. No dysmenorrhea noted. Personal and social history: 3rd in brood of 5, married to a 28 y/o prosecutor office employee. Patient does not smoke nor drink alcoholic beverages. PE: General Survey: conscious, ambulatory, not in cardio-respiratory distress: Vital signs: BP: 110/80 CR: 90 RR: 16 T: 36.8C SHEENT: pinkish palpebral conjunctivae, anicteric sclera, no lymphadenopathy Chest and Lungs: no retractions, clear breath sounds, Cardiac: adynamic precordium, normal rate regular rhythm, (-) murmurs. Abdomen: globularty enlarged, FH: 28cm, Fht: 140s LM1: breech, LM2: fetal back, LM3: cephalic Extremeties: equal pulses, no edema SE: smooth pinkish cervix, no discharge IE: Cervix: 5 cms, 80% effaced, intact Bow, station -3 ADMITTING DIAGNOSIS: Pregnancy Uterine, 41 weeks and 2 days by LMP, cephalic in labor Course in the Ward: Patient was hook to venoclysis: D5LR 1L to run for 8 hours. She was hooked to CTG with good baseline fetal heart rate of 140s, good variability, with regular and adequate uterine contractions. She underwent trial of labor. After 2 hours her bag of water spontaneously ruptured. However, after 2 hours there was no progress of cervical dilatation, she remained 6 cms, station (-)2 and after 4 hours she remained 7 cms, station (-)2, she then underwent emergency caesarean section under spinal anesthesia. She delivered to a live term girl BW: 1950grams, SGA, with two nuchal cord tightly coiled, AS: 8,9,9, with thickly meconium stained. Cleft lip and palate. Post-operative condition was uneventful. She was discharged after 3 days. Neonatal Condition: After delivery, the neonate was transferred to NICU care. She was given venoclysis. Several work ups were done. She was started on medications. Baby gram showed: normal findings ECG: within normal limits CBG: 5.4mmol Urinalysis: Referral to Ophthalmologist done showed bilateral coloboma vs catarcact, ectopion ou Cranial ultrasound: unremarkable appearance of brain parenchyma. There is no echogenic structure noted. Ventricles are not dilated. Midline structures are in placed. Posterior fossa shows no gross abnormality. 2 Chest X ray: Haziness is seen in left lower lung area Heart not enlarged Diaphragm and sinuses are intact There is segmental gas distention of small intestinal loops liver and spleen not enlarged Renal and psoas shadows are intact There is scanty gas noted in the rectum Impression: Consider possibility of neonatal pneumonia Localized ileus Abdominal ultrasound: normal CBC: hemoglobin: 12.3 mg/dl Hematocrit: 38 WBC: 8.6 Seg. 75 Blood type: AB 2 D echocardiography: Situs solitus Atrio-ventricular, Ventriculo-arterial concordance Atrial septal defect, secundum measuring 0.58cm with left to right shunting All four pulmonary veins Karyotyping was requested. PHYSICAL EXAMINATION: (NEW BORN) GENERAL SURVEY: conscious, ambulatory, not in cardio-respiratory distress. VITAL SIGNS: CR: 128 RR: 58 T: 36C Eyes: coloboma vs cataract bliteral Reddish palpebral sclerae Ectopion bilateral Bilateral cleft lip and palate Chest and Lungs: (+) rales Cardiac: adynamic precordium, normal rate regular rhythm, (-) murmur Abdomen: soft, normoactive bowel sound, 2 arteries and 1 vein Extremeties: full pulses (+) hypospadia Working diagnosis: Congenital Varicella syndrome, vs. Multiple Congenital anomaly Neonatal Pneumonia Patient was started on amikacin 20mg IV OD and Ampicillin 125mg IV q 12hours. Patient was started on NGT feeding. O2 inhalation at 8lpm. Moderate back rest. She had urine output of 1.6cc and bowel movement. On the 2nd day of life she had intercostals retractions, Cefotaxime Iv was started. Aminophylin drip started. On the 3 rd day of life, she developed jaundice. Phototherapy was given. On the 5th day of life, patient’s condition improved. O2 inhalation was discontinued maintaining O2 sat at >90%. Patient was seen by an Ophthalmologist noted lid laxity, OU, lens opacity, OU, papillary reaction, OU, hazy, peeling cornea. To consider keratitis secondary to exposure OU, Lid Laxity, Congenital cataract OU. Solcoseryl gel given. NGT feeding was continued. On the 20 th day of life patient will have obturator fitting….awaits karyotyping and TORCH result. 3 4