Case Report

G4P2A1 gravid 29 weeks with Preterm Premature Rupture of Membrane + Chronic Hypertension and Fetal Distress

Counsellordr. Gioseffi Sp.OG

Presented byAngeline Fanardy (406138119)

OBSTETRICS AND GYNECOLOGY CLERKSHIPTARUMANAGARA UNIVERSITYRSUD CIAWI, BOGORPeriod April 13th 2015 June 20th 2015

Hospitalised at RSUD Ciawi on Sunday, May 26th, 2015 (at 10:39 am)Reffered by Cigombong Local Health CentrePatients Identity Name: Mrs. M Age : 32 years old Occupation: House wife Education: Elementary School Race: Sundanese Religion: Moslem Address: Kp. Lebak Pilar 01/02 Caringin

Patients Husbands Identity Name: Mr. MM Age: 37 years old Occupation: self - employed Education: Junior High School Race: Sundanese Religion: Moslem Address: Kp. . Lebak Pilar 01/02 Caringin

AnamnesisWith auto anamnesa on May 26th, 2015 (at 10.30 am)Chief complaint: sudden vaginal fluid lossPresent Illness:Patient came to the Maternal and Neonatal ER on May 26th, 2015 referred by local health center with sudden vaginal fluid loss. Patient had felt her contraction since 2.00 am (26/5/2015) with a regular interval and stronger contraction after each interval. She also reported her sudden vaginal fluid loss at also 2.00am, clear and odorless fluid. There is also output of blood and secret since 7.00 (26/5/2015). She has headache , has no blurred vision, no epigastric pain, no dyspneu, no nausea and no vomitus. This is her 4th pregnancy. The first was born by midwife helped with weight 3,5 kg about 10 years ago. The second one was born also by midwifes helped with weight 2,8kg and died after 2 weeks. She has a history of miscarriage of the third pregnancy with pregnancy age by 3 months. Her first day of her last period is on October 29th, 2014. With a regular menstrual interval of 28/4 days. Estimated delivery date is on August 6th, 2015. Patient has a regular pregnancy checkup for 8 times during her pregnancy. With her last check (May 10th, 2015), her fundal height is 35cm, then frequency of fetal heart rate is regular and normal. Her weight 63kg, with normal blood pressure of 120/70mmHg.Shes already check her pregnany by USG by April 2015 and the result was good.

Medical History: Hypertension (+) since 1 year ago, the patient regularly take medicine (she forgets its name). Diabetes (-) Heart Disease (-) Asthma (-) Irregular menstruation cycle (-) Food and Drugs Allergy (-)

Menstruation History: Menarche : 13 years old Menstrual cycle: 28 days Duration : 4 days Sanitary napkin/day: 2-3 x/days Menstrual pain: (-)

Marriage History: First marriage, during her 21th years old.

History Contraceptives:She mentioned that shes on birth control by piles for 6 years after the first delivery and has been off for 3 years before become pregnant for the fourth times.

Operation History:There is no operation history

Antenatal Care:Regular, monthly visit to midwife, supplement: fe & folic acid (+)

Physical Examinationon May 26th, 2015. (at 10.45 am) General Situation: Moderate pain Awareness: Compos mentis Vital Sign:Blood pressure: 140/80 mmHgHeart Rate: 92 x/minRespiratory rate: 24 x/minTemperature: 37,9oc Body weight: 68 kg Body height: 158 cm

GENERAL EXAMINATION Head Eye: conjunctiva anemic -/- ; sclera icteric -/- Ear : pain -/- ; secret -/- Nose: deviation septum -/- ; secret -/- Throat: Tonsil T1 T1 normal, pharynx hyperaemic -/- Mouth : oral hygiene (+); mucosa normal Neck: trachea in the middle, lymph nodes and thyroid normalThorax Mammae: normal, inverted nipple (-) Pulmoinspection: symetric, retraction (-)palpation: fremitus tactil right = leftpercusion: sonor +/+auscultation: vesicular +/+; rhonchi -/-; wheezing -/- Cor inspection: pulse of ictus cordis can not be seenpalpation: pulse of ictus cordis can not palpable percussion: dull, heart margins within normal limitsauscultation: Heart sounds I/II regular, gallop (-), murmur (-)

AbdomenInspection: bulge, striae gravidarum (+)Auscultation: bowel sound (+) normalPercusion : timpanyPalpation : epigastric pain (-),defense musculaire (-)

Genital Vulva/ vaginal no abnormalities, blood (+), secret (+)

Extremities Warm hand and feet Oedema -/- ; -/- CRT 40 weeks gestation) Congenital heart abnormalityFetal tachycardia is associated with: Excessive fetal movement or uterine stimulation Maternal stress or anxiety Maternal pyrexia Fetal infection Chronic hypoxia Prematurity (15 bpm for more than 15 seconds When accelerations are present, the CTG is said to be reactive. Accelerations are often associated with fetal activity and are considered an indication that the fetus is healthy.

DecelerationsDecelerations are periodic, transient decreases in FHR, usually associated with uterine contractions. They can be subdivided into four main types by their shape and timing in relation to uterine contractions. Uterine contractions must be monitored adequately in order for a deceleration to be correctly classified.

Early decelerationsEarly decelerations tend to occur with each contraction and are uniform in shape. Early FHR decelerations appear as a mirror image of the uterine contraction trace. The onset of the deceleration occurs at the onset of the contraction and the baseline FHR recovers by the end of the contraction. The FHR usually does not fall by more than 40 bpm during an early deceleration.Early decelerations are caused by compression of the fetal head during a contraction. They are often relieved by changing maternal posture and are a normal finding in the second stage of labour. They are not associated with a poor fetal outcome.

Late decelerations (Fig. 4)Late decelerations are uniform in shape on the CTG, but unlike early decelerations start after the peak of the uterine contraction. A deceleration in which the lowest point occurs more than 15 seconds after the peak of the uterine contraction is defined as a late deceleration. They are often associated with a decrease in the variability of the baseline FHR.

Late decelerations are associated with decreased uterine blood flow and can occur as a result of: Hypoxia Placental abruption Cord compression / prolapse Excessive uterine activity Maternal hypotension / hypovolaemiaVariable decelerations Variable decelerations describe FHR decelerations that are both variable in timing and size. They may be accompanied by increased variability of the FHR. They are caused by compression of the umbilical cord and may reflect fetal hypoxia.

Prolonged decelerations/ bradycardia A deceleration with a reduction in FHR of greater than 30 bpm that lasts for at least 2 minutes is termed a prolonged deceleration They are caused by a decrease in oxygen transfer to the fetus so can arise as a consequence of a wide variety of disorders including: Maternal hypotension Umbilical cord compression Uterine hypertonia

CTG Categorisation

Fetal Blood SamplingFetal blood sampling (FBS) involves taking a small sample of blood from the presenting part of the fetus during labour. FBS is advised in the presence of a pathological CTG unless there is clear evidence of severe fetal compromise. If fetal compromise is evident, (e.g. prolonged deceleration of greater than 2 minutes duration), FBS should not be undertaken and the baby should be delivered urgently. Other contraindications to FBS include: Maternal infection (such as HIV, hepatitis, herpes simplex virus) Fetal bleeding disorders Prematurity (