Case Presentation
Intern Dr Ishan Subedi
Patient Particulars
Name: Mrs. P K Parity: 0
Age: 22 years Last menstrual period: 2080/12/19
Address: Nawalparasi Expected date of delivery:
2081/09/26
Occupation:
Period of gestation:33 weeks
Religion: Hindu
Date of admission: 2081/08/10
Education:
Date of examination: 2081/08/10
Gravida: 1
Chief complaints
1. Cessation of menstruation since 7 months
2. Abdominal pain since 1 day
History of present illness
● She was apparently well 1 day back when she started experiencing pain in
abdominal and lower back which is increasing in severity, frequency and
duration. It is associated with hardening of uterus. There is radiation of pain to
back and thigh. It is not relieved by medication. There is also some watery
discharge p/v which is non foul smelling and not blood stained.
History of present pregnancy
1st trimester
● Her pregnancy was diagnosed in a nearby health post by urine examination 1 month
after cessation of menstruation.
● There was no history of p/v bleeding or discharge.
● There was history of increased frequency of micturition, but no history of burning
micturition and suprapubic pain or fever.
● She started taking folic acid after diagnosis of pregnancy.
● No X-ray exposure and usg examination was normal.
● H/O morning sickness present.
2nd trimester
● Active fetal movement perceived at about 5th month of gestation
● Iron and calcium tablets taken
● USG check up at 5th month of gestation
● No p/v bleed, discharge, burning micturition , fever
● No history of headache, blurring of vision
● TT vaccination at 5th month of gestation and 6th
● No H/O xray exposure
3rd trimester
● Continued iron and folic acid
● Perceived fetal movement multiple times per day
● No h/o blurring of vision, headache, epigastric pain
● ANC visit
● No h/o trauma or X-ray exposure
Obstetric history
1. Gravida: 1
2. Para: 0
3. Abortion: 0
4. Living: 0
5. Death: 0
Married years back
Menstrual history
1. Menarche:
2. Interval:
3. Duration:
4. Dysmenorrhoea: Absent
5. Amount of flow: Average
Past history
1. Patient is not a known case of hypertension, diabetes, thyroid disorder
2. Patient has no surgical history
Family history
1. There is no known case of Hypertension, diabetes, hemoglobinopathy,
twinning or congenital malformation or consanguineous marriage in her family.
Personal history
1. Contraception:
2. Alcohol, smoking or habit forming drugs:
3. Adequate sleep
4. Good appetite and is a non vegetarian
5. Good bowel and bladder habit
Socioeconomic history
Differential diagnosis
Examination
She is conscious, cooperative, well oriented to time, place and person lying in her
bed and is in distress.
Vitals:
1. Pulse: 80 beats per minute
2. Temperature: 98 degree fahrenheit
3. Blood pressure: 150/110 mm hg on right and 160/110 mm hg on left arm
4. Respiratory rate : 18 breaths/ minute
5. SpO2: 99% in room air
Head to toe assessment
● Pallor, icterus, lymphadenopathy, clubbing, cyanosis, oedema, dehydration
are absent.
Abdominal examination
Inspection :
● Abdomen is distended, ovoid
● All quadrants move equally with respiration
● Linea nigra visible
● Umbilicus is circular and everted
● Hernial sites are intact
Palpation
● Temperature over abdominal wall is normal
● Uterus is palpable, contacted and measures about 32 week of gestation
● Fetal movements are palpable to some extent
● Fundal grip: Broad, soft, irregular fell
● Lateral grip: on right there is smooth, curved and resistant feel suggestive of
back and on left there is knob like structure
● Pawlik’s grip: Hard, rounded structure was felt which is not freely mobile
● Pelvic grip: palpating hands donot converge towards each other
PV findings:
● OS: fully dilated
● Head station : +1
● Membrane : absent
Auscultation
● Fetal heart sound heard below umbilicus at right: 86 bpm
Provisional diagnosis
● 22 Years Primi at 33 WOG in second stage of labour
Investigations
08/10
● Hb: 14.4 gm/dl
● Wbc: 13300 cells
● Platelets: 188000
● PT/INR: 15 sec/ 1.11
● Serology: non reactive
● RBS: 99.4 mg/dl
● RFT: urea(18.5 mg/dl), creatinine(0.46 mg/dl)
● LFT: SGOT(98 U/L), SGPT(80.48 U/L), ALP(700 U/L)
● Urine R/E: Light yellow, clear, acidic, no sugar and albumin, pus cells:0-2/HPF,
RBC: nil, Epithelial cells : 1-3/ HPF, no crystals and cast
8/11
● LFT: Bilirubin (total): 0.91 mg/dl, bilirubin(direct): 0.25 mg/dl,SGOT: 93U/L
SGPT: 83.2 U/L, ALP: 788.1 U/L
8/12
● 11.2 gm/dl
Procedures done
● Patient received on 5:30 PM AND she delivered a 1.24 kg male at 6:00 pm
through spontaneous vaginal delivery with episiotomy with 1 loop cord around
the neck with manual removal of placenta.
● Approx blood loss was 400ml
● Post delivery vitals BP: 140/100 mm hg on right and 150/100 mm hg on left
arm, other parameters within normal range
● Episiotomy site repaired
● Fundal massage provided
Medication
● INJ. Synto 10 U IM
● INJ. Ketorol 30 mg IV stat
● TAB. Miso 3 tab P/R
● IVF RL 500 ml with 10U synto
8/11
● Patient complained of pain in episiotomy site since morning
● Re-exploration done at episiotomy site and vulval hematoma extracted and
resutured the site.
Neonate
● Babe shifted to NICU for observation.
Vitals after delivery:
● Temperature: 97.4 degree Fahrenheit
● Heart rate: 146 / minute
● Respiration rate: 52 breaths per hour
● SpO2: 97% in RA
● Babe kept in NICU for days
Final diagnosis
● 22 Years P1L1 following vaginal delivery with episiotomy with 1 loop cord
around the neck with manual removal of placenta with vulval hematoma repair
Medications
8/10
1. T. cefexime 200 mg PO BD
2. T. metron 400 mg PO TDS
3. T. pantop 40 mg PO BD
4. T. Paracetamol 500 mg PO TDS
8/11
● INJ. XONE 1gm IV BD
● INJ. METRON 500 mg IV TDS
● INJ. TRANOSTAT 500 mg IV TDS
● INJ. PANTOP 40 mg IV BD
● TAB. FLEXON 1 tab PO TDS
● SYP. LACTULOSE 15 ml PO stat and HS
8/12
● TAB. CHYMORAL FORTE 1 tab PO TDS
● TAB. VITAMIN C 1 tab PO BD
Treatment at discharge
● CAP. AMOXICILLIN 500 mg PO TDS 5 days
● TAB. Paracetamol 500 mg PO TDS 5 days
● TAB. PANTOP 40 mg PO BD 5 days
● CAP. FERRONY-FZ 1 cap PO OD 3 months
● TAB. XIBONE 1 tab PO OD 3 months
Advice at discharge:
● Exclusive breast feeding
● Immunize as per schedule
● Follow up after 2 weeks/ SOS
THANK YOU
