Download committee on maternal and perinatal welfare

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
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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.
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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.
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