Question

How make an obstetric history regarding about this case?

Patient GCQ, a 26-year-old woman, married, gravida 2 para 0. The first pregnancy was a spontaneous miscarriage at 12 weeks gestation. GCQ is now in her third trimester and visited the primary care clinic because of a strong uterine contraction which begin irregularly but become regular and predictable. The pain was first felt in lower back and sweep around to the abdomen. The pain continues no matter the activity the woman is doing and increases in duration, intensity, and frequency. The spontaneous rapture of membranes occurred 4 hours ago at home which reported a clear fluid. Upon checking the vital signs, it revealed the following results: BP 140/90, HR 93, RR 20, T- 36.8. Her weight is 153.8lbs and her height is 62 inches. 0ne hour later, contractions become regular in a 50 seconds duration, occurs every 4 minutes with increasing intensity.

The internal examinations revealed that the cervix is 7cm dilated, 80% effaced, vertex presentation in LOA position at +1 station. The FHR is 142b/min with good variability. The client whom previously used the breathing and position techniques learned at the childbirth education session now manifest anxiety and diaphoretic with pounding fist in the bed and pushes her husband away.

Laboratory studies show the following results:

Complete blood count

• Hgb - 12.6g/dl                           WBC – 10,000 per mm³
• Hct   - 38%                                 Platelet count – 300,000/mm³
• Blood type – Type O+

Urinalysis

• Glucose - negative
• Albumin - negative
• Protein -negative

VDRL – negative

Hepatitis B – negative

HIV screening - negative

Antibody screen - negative

AFP - 2.5 MOM

Tuberculosis screening – negative                                                                                          

Answer 1

Presenting Complaints:

26-year-old GCQ in her 32 weeks of pregnancy,came with complaints of rupture of membranes about 4 hours ago at home associated with painful uterine contraction.

History of presenting complaints :- She just completed 36 weeks, and she was having regular antenatal checkups, and she was diagnosed to have high BP. She gives a history of rupture of membrane about 4 hours ago at the house, the fluid was clear fluid. It was associated with the uterine contraction which was less and irregular intially but later on it became regular and predictable. The pain with the contractions were increased, and also the duration and frequency so much she was not able to do her activity. The pain was first felt in lower back and radiating to the abdomen

Marital history :-married,

Personal history: she has history of hypothyridism, and on medication, she has no history of diabetes or hypertension prior to the pregnancy, but in the present pregnancy she was diagnosed to have gestational hypertension, and was advised diet and lifestyle modification.

Family history : her father is diabetic with coronary artery disease,and mother is hypertensive . Ther is no history of any genetic disorder in the family.

Obstetric history : she is gravida 2,

First pregnancy was spontaneous conception, she had regular antenatal checkups, the ultrasound scan was normal , Triple test was done which was also normal, but she gives a history of spontaneous abortion at 12 weeks of gestation, which started with spotting, manual vaccum evacuation was done, post evacuation was symptom free.

Second pregnancy was spontaneous conception after 8 months interval, had regular antenatal checkups, normal anomaly scan, adequate AFI, perceiving good foetal movements.

high BP was diagnosed in the third trimester with bilateral pedal edema.

No history of placenta praevia, ectopic pregnancy,PCOD

Personal history:- Chronic smoker with occasional alcoholic, gives history of stopped both the habits.

General Examination:-

weight is 153.8lbs and height is 62 inches.

T- 36.8 degree celsius

BP 140/90mmof Hg

HR 93 / min

RR 20/ min

Systemic examination:-

CVS:- First and second heart sounds heard, no murmur

RS:- Bilateral equal air entry, no added sound

CNS: no neurological defecit

Obsteteric examination: Inspection :- flanks are full

Palpation:-

Fundal height at the level of umbilicus with flanks full, head is not palpated per abdomen, on the right side there is smooth continous part corresponding the back of the baby, on the left side there is irregular mass corresponding with the limbs of baby, Regular contractions, 50 seconds duration, occurs every 4 minutes with increasing intensity.

Auscultation :FHR is 142b/min with good variability.

Pervaginal examination: Cervix is 7cm dilated, 80% effaced, vertex presentation in LOA position at +1 station.

Laboratory studies shows:-

• Hgb - 12.6g/dl                           WBC – 10,000 per mm³
• Hct   - 38%                                 Platelet count – 300,000/mm³
• Blood type – Type O+

Urinalysis

• Glucose - negative
• Albumin - negative
• Protein -negative

VDRL – negative

Hepatitis B – negative

HIV screening - negative

Antibody screen - negative

AFP - 2.5 MOM

Tuberculosis screening – negative