Pamantasan ng Lungsod ng Maynila

College of Medicine
Department of Obstetrics
and Gynecology

OBSTETRICS 2
CASE REPORT

GROUP 4
SECTION 3A

DY, JOHN ALBERT

FARILLAS, ENA LAUREN
FERMIN, ALYSSA NICOLE
GNILO, EMY
GONZAGA, SAHARA NESLI
GONZAGA, VALERIE
HARDIN, MARY ROSE
JAVIER, KEVIN
THE CASE

A 30 year old G5P4 at 30 weeks AOG consulted in the ER because of lumbrosacral pains of 6
hours duration. She has been having irregular contractions for the past 2 weeks but patient did
not consult due to lack of time. Patient relates that she lives on the 5th floor in a building with no
elevator. She goes to work everyday and has to go up and down those flights of stairs daily.
She is a grade school teacher. Patient has had no previous prenatal check-ups.

Her mother has siblings who are twin boy and girl

Pertinent PR: vital signs: BP 120/80 mmHg, PR 88/in, RR- 20/min, weight- 180 lb, height- 58in

FHT- 120bpm in the right and 160 bpm in the left

Uterus contracting strongly every 3 minutes, fundic height is 35cm, numerous fetal parts are
palpated

IE- cervix 2cm dilated, 0.5cm long, intact bag of waters, cephalic, floating

Urinalysis: protein- trace pus cells- 20-30/hpf

Sugar- negative RBC- 0-2

RBS- 120grams/dL
FBS- 90gm/dl
HBA1c- 5.5%

Guide Questions

1. Enumerate the lifestyle conditions which increase the risk for this mother. Explain
why.

One of the things to be taken into consideration, with regards to the mother’s lifestyle
that poses a risk on her pregnancy, is the fact that she has to climb the stairs everyday in her
home and even in her workplace.
As recommended by the American College of Obstetrics and Gynecologists (ACOG), it
is important for a pregnant woman to do some regular physical exercise as part of living a
healthy lifestyle. In most cases, moderate exercises can be beneficial for both the mother and
the baby. However, if done too much or without proper consult from the doctor, these exercises
may cause problems during pregnancy.
Climbing the stairs can continue just as before during the first trimester. However, after
the first trimester just like the case of the patient, when the abdomen starts to protrude, there is
an increased risk of trauma to the fetus due to fall. Also, fall can result to miscarriage and later
in pregnancy can trigger early labor symptoms. Contributing factor to the risk of falling is the
enlarged abdomen, which causes a change in the center of gravity of the mother thus change in
balance.
Moreover, climbing stairs can exaggerate the sacroiliac joint problem of the mother,
given that the mother is already experiencing back pains.
Another thing to consider is the type of work the mother has. Since she is a grade school
teacher, her work may involve prolonged postures at extreme ranges, like sitting or standing
and leaning over a desk or workstation. This type of job increases the risk of developing
pregnancy pelvic pain.
And lastly, the patient has had no previous prenatal check-ups. This should be the
primary thing the patient should have done in order to assess her pregnancy status, to seek
consult regarding her situation, and to prevent further pregnancy related problems.

2. What are the three most important problems in this case? What are the bases for your
diagnosis? Give the definition and diagnostics of each diagnosis.

MULTIFETAL GESTATION
Multifetal gestation is the state wherein a mother is pregnant with more than a single
fetus; the term encompasses twins, triplets, and higher-order multiples. Majority of multifetal
pregnancies involve dizygotic or fraternal twins, wherein two ova are fertilized by two different
sperm in one cycle; less commonly, monozygotic or identical twins are conceived, wherein a
single fertilized ovum divides into two or more fetuses. The increase in incidence of multifetal
gestation may be attributed to infertility therapy. Further, multifetal gestations are at higher risk
for developing malformations and twin-twin transfusion syndrome, as well as preeclampsia,
postpartum hemorrhage, and maternal death.
History and clinical examination may support or refute the suspicion of multifetal
gestation. Factors weakly associated with the occurrence of multifetal gestation include
maternal personal or family history of twins, advanced maternal age, high parity, and large
maternal size. On the other hand, factors more strongly associated with the phenomenon
include recent administration of clomiphene citrate, gonadotropins, or pregnancy accomplished
by ART. Measurement of fundal height; and observation of a larger than expected uterine size
during the second trimester is characteristic of multifetal gestation. In twin pregnancies, at 20 to
30 weeks AOG, fundal heights were reported to be 5 cm greater than the expected values for
singletons of the same AOG. Fetal parts may also be palpated during physical examination,
though this method is difficult before the third trimester, especially in cases wherein a twin
overlies the other twin, when the mother is obese, and in the presence of hydramnios. Fetal
heart action may also be detected in the late first trimester, with Doppler ultrasonic equipment. If
the fetal hearts’ rates are distinct from one another, it is also possible to identify two fetal
heartbeats. Also, at 18-20 weeks AOG, an aural fetal stethoscope can identify fetal heart
sounds in twins.
Diagnosis of multifetal gestation may be done through the use of ultrasonography,
which may be done as early as the first trimester. The presence separate gestational sacs is
characteristic of multifetal pregnancies. The chorionicity may also be determined through
ultrasound; dichorionicity is supported by the observation of a thick dividing membrane, while a
thin dividing membrane characterizes monochorionic pregnancies. It is also ideal to identify two
fetal heads or abdomens (or more, depending on the case) in the same image plane to avoid
scanning the same fetus twice, and misinterpreting it as a multifetal gestation. Examination of
the placenta and membranes following delivery also aids in establishing zygosity and
chorionicity. Biochemical tests are not helpful because although hCG levels are higher in
multifetal pregnancies, they are not so high as to allow a definite diagnosis and are thus
unreliable.

ASYMPTOMATIC BACTERURIA IN PREGNANCY

Asymptomatic Bacteriuria (ASB) in Pregnancy is defined as the presence of bacteria in
the urine of an asymptomatic patient. It is diagnosed clinically by: (a) >100,000 cfu/mL with one
or more organisms in two consecutive midstream urine specimens or one catheterized urine
specimen, and (b) the absence of symptoms attributable to urinary infection.
However, in this case the diagnosis of ASB was done despite the absence of microbial
count in the given urinalysis result, due to the significant pyuria (>10 wbc/hpf) in the urine
sample of the patient (Philippine Practice Guidelines Group in Infectious Diseases, Grade C). It
should be noted that pyuria is not an accurate screening test for bacteriuria in patients with poor
inflammatory response, e.g. immunosuppressed renal transplant recipients, or patients with
diabetic nephropathy and azotemia, but since the patient has none of these, the high pus cells
in the urine are suggestive of the diagnosis. For a definitive screening of ASB, a urine culture is
recommended (CPG, Grade C).
PRE-TERM LABOR
True labor is uterine contraction that brings about cervical effacement and dilatation. A
term pregnancy is defined as > 37 weeks AOG. Hence, pre-term labor is defined as regular
contractions of the uterus resulting in cervical effacement and dilatation that start before 37
weeks of pregnancy.
During PE and internal examination, the uterus contracting strongly every 3 minutes,
with 2 cm dilatation, and 0.5 cm effacement, suggesting 1st stage of labor. The first stage of
labor begins with regular uterine contraction to full cervical dilatation of 10 cm.

4-6. Choose one of the three problems of the case. What are the unique maternal and
fetal complications associated with this problem?

PRETERM LABOR
MULTIFETAL GESTATION
Fetal Complications
 Low birth weight
 IUGR
 Fetal Demise/Loss


Low Birth Weight

Low birth weight is almost always related to preterm delivery. Low birth weight is
less than 5.5 pounds (2,500 grams). Babies born before 32 weeks and weighing less
than 3.3 pounds (1,500 grams) have an increased risk of developing complications as
newborns.

They are at increased risk for having long-term problems such as mental
retardation, cerebral palsy, vision loss, and hearing loss.

Intrauterine Growth Restriction (IUGR)

Multiple pregnancies grow at approximately the same rate as single pregnancies
up to a certain point. The growth rate of twin pregnancies begins to slow at 30 to 32
weeks.

Triplet pregnancies begin slowing at 27 to 28 weeks, and quadruplet

pregnancies begin slowing at 25 to 26 weeks.

IUGR seems to occur because the placenta cannot handle any more growth and
because the babies are competing for nutrients. Your doctor will monitor the growth of
your babies by ultrasound and by measuring your abdomen.

Fetal Demise or Loss

 Intrauterine fetal demise is extremely uncommon. If the pregnancy is dichorionic
(two chorions present), then intervention may not be necessary.

If the pregnancy has a single chorion, fetal maturity will be assessed to see if
immediate delivery is recommended. In this situation it would be necessary to weigh
the risks between having a premature baby and the risks of remaining in utero.

Birth defects
Multiple birth babies have about twice the risk of congenital (present at birth)
abnormalities including neural tube defects (like spina bifida), gastrointestinal, and heart
abnormalities.

Miscarriage
A phenomenon called the vanishing twin syndrome in which more than 1 fetus is
diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more likely in multiple
pregnancies. This may or may not be accompanied by bleeding. The risk of pregnancy loss is
increased in later trimesters as well.

Twin-to-twin transfusion syndrome

Twin-to-twin transfusion syndrome (TTTS) is a condition of the placenta that develops
only with identical twins that share a placenta. Blood vessels connect within the placenta and
divert blood from one fetus to the other. It happens in about 15% of twins with a shared
placenta.

Maternal Complications
 Preterm Labor/Delivery
 Preeclampsia
 Gestational Diabetes
 Placental Abruption
 Cesarean delivery
 Anemia

Preterm Labor/Delivery
Preterm labor/delivery is defined as delivery before 37 completed weeks of
pregnancy. The length of gestation typically decreases with each additional baby. On
average most single pregnancies last 39 weeks, twin pregnancies 36 weeks, triplets 32
weeks, quadruplets 30 weeks, and quintuplets 29 weeks. Almost 60% of twins are
delivered preterm, while 90% of triplets are preterm.

Higher order pregnancies are almost always preterm. Many times premature
labor is a result of preterm premature rupture of the membranes (PPROM). PPROM is
rupture of the membranes prior to the onset of labor in a patient who is less than 37
weeks of gestation.

Preeclampsia
Preeclampsia, Pregnancy Induced Hypertension (PIH), Toxemia, and high blood
pressure are all synonymous terms. Twin pregnancies are twice as likely to develop
preeclampsia as single pregnancies. Half of triplet pregnancies develop preeclampsia.
 Frequent prenatal care increases the chance of detecting and treating
preeclampsia. Adequate prenatal care also decreases the risk of developing a serious
problem from preeclampsia for both the babies and the mother.

Gestational Diabetes
The increased risk for gestational diabetes in a multiples pregnancy appears to
be a result of the two placentas increasing the resistance to insulin, increased
placental size, and an elevation in placental hormones.

The risk of occurrence of gestational diabetes in a multiples pregnancy is still

being researched at this time. In one study, an increased risk of gestational diabetes
did seem to be apparent, but the doctors involved recommended that further testing be
conducted.

Placental Abruption
Placental abruption is three times more likely to occur in a multiples pregnancy.
This may be linked to the fact that there is an increased risk of developing
preeclampsia. It most often occurs in the third trimester, but the risk significantly
increases once the first baby has been delivered vaginally.

Cesarean Delivery
The typical recommendation for the delivery of triplet s and higher order
multiples is a cesarean, but twins are often delivered vaginally. The vaginal delivery of
twins depends on the presentation of the babies.

Gestational Hypertension
Women with multiple fetuses are more than twice as likely to develop high blood
pressure of pregnancy. This condition often develops earlier and is more severe than pregnancy
with one baby. It can also increase the chance of placental abruption (early detachment of the
placenta).

Anemia
Anemia is more than twice as common in multiple pregnancies as in a single birth.

PRETERM LABOR
Fetal Complications
Preterm birth is the greatest problem associated with preterm labor. Although most
babies are born after 37 weeks, those born preterm are at increased risks for many
complications.

Premature babies are born before their bodies and organ systems have completely
matured. These babies are often small, with low birthweight (less than 2,500 grams or 5.5
pounds), and they may need help breathing, eating, fighting infection, and staying warm. Very
premature babies, those born before 28 weeks, are especially vulnerable. Many of their organs
may not be ready for life outside the mother's uterus and may be too immature to function well.

Some of the problems premature babies may experience include:

 Temperature instability--inability to stay warm due to low body fat.
 Respiratory problems
 o Hyaline membrane disease/respiratory distress syndrome--a condition in which the
air sacs cannot stay open due to lack of surfactant in the lungs.
o Chronic lung disease--long-term respiratory problems caused by injury to the lung
tissue.
o Air leaking out of the normal lung spaces into other tissues
o Incomplete lung development
o Apnea or stopped breathing
 Cardiovascular
o Patent ductus arteriosus (PDA)--a heart condition that causes blood to divert away
from the lungs.
o Too low or too high blood pressure
o Low heart rate (often occurs with apnea)
 Blood and metabolic
o Anemia (may require blood transfusion)
o Jaundice (due to immaturity of liver and gastrointestinal function)
o Too low or too high levels of minerals and other substances in the blood such as
calcium and glucose (sugar)
o Immature kidney function
 Gastrointestinal
o Difficulty feeding (many are unable to coordinate suck and swallow before 35 weeks
gestation)
o Poor digestion
o Necrotizing enterocolitis (NEC)--a serious disease of the intestine common in
premature babies
 Neurologic
o Intraventricular hemorrhage--bleeding in the brain
o Periventricular leukomalacia--softening of tissues of the brain around the ventricles
(the spaces in the brain containing cerebrospinal fluid)
o Poor muscle tone
o Seizures (may be due to bleeding in the brain)
o Retinopathy of prematurity--abnormal growth of the blood vessels in a baby's eye
 Infections (premature infants are more susceptible to infection and may require antibiotics).

Maternal Complications

Complications of preterm delivery in mothers include placental hemorrhage,

hypertension, and premature rupture of membranes.

URINARY TRACT INFECTION

UTIs, which include diseases such as asymptomatic bacteriuria, cystitis and
pyelonephritis, are the most common bacterial infections during pregnancy. Organisms that
cause these arise from the normal perineal flora itself and the most common bacterial etiology is
E. coli. When the diseases is left untreated or if the infection becomes chronic, complications
may arise that are harmful to both the mother and the fetus.
Asymptomatic bacteriuria refers to persistent, actively multiplying bacteria within the
urinary tract in asymptomatic women. Since it is asymptomatic, it is often an incidental finding
during a routine urinalysis in prenatal check-ups. The absence of symptoms may also be a
factor for possible delays in the initiation of treatment. If asymptomatic bacteriuria is not treated,
approximately 25% of infected women will develop symptomatic infection during pregnancy
(Cunningham et al, 2010). The infection may also ascend towards the kidneys and result to
pyelonephritis which is the leading cause of septic shock during pregnancy (Cunningham et al,
2010). Other reported maternal complications are increased risks of pregnancy-associated
hypertension and anemia.
In infants, covert bacteriuria has been associated with preterm delivery or low-
birthweight (Cunningham et al, 2010). It is even more controversial whether eradication of
bacteriuria decreases these complications. There is also concern that urosepsis may be related
to an increased incidence of cerebral palsy in preterm infants (Cunningham et al, 2010). On the
other hand, bacteriuria that persists or recurs after delivery has been associated with
pyelographic evidence of chronic infection, obstructive lesions, and congenital abnormalities
(Cunningham et al, 2010).
7. What fetal problems must be anticipated if this mother delivers now? What is the ideal
management of this case? Discuss this fully.

After assessment of the patient’s symptoms, history and physical exam, determine
whether the patient has preterm contractions, preterm labor, premature rupture of membranes,
or other diagnosis. Preterm labor diagnosis is often difficult but generally requires: Uterine
contractions: 4 in 20 mins or 8 in 60 mins plus any one of the following (a) Progressive change
in cervix
 , (b) Cervical dilatation of >1cm
 or (c). Cervical effacement of 80% or greater. On
the given case, the patient manifested with uterine contraction every 3 minutes and cervical
dilatation of 2 cm fulfilling the criteria for preterm labor.
According to the patient data, she is currently at 30 weeks age of gestation. Should the
patient deliver her babies now, she would be giving birth to premature babies as term infants
are those born at greater than or equal to 37 completed weeks age of gestation. Preterm
delivery remains to be the major cause of increased perinatal mortality rates—necessitating
proper measures to halt preterm deliveries if possible without compromising the well-being of
both the mother and the fetuses.
In infants born before 37 weeks of gestation, there exists a myriad of morbidities
associated with it—and these morbidities are primarily due to organ system immaturity. One of
the most apparent consequences of preterm delivery is giving birth to very low birth weight or
extremely low birth weight infants. The risk for developing complications due to preterm births
increase with decreasing gestational age and birth weight. There are a number of problems that
may be encountered should one give birth to premature infants—the most important being
respiratory distress syndrome secondary to decreased production and secretion of surfactant in
the lungs of premature infants. Below is a table summarizing the short-term and long-term
problems associated with preterm births.

Premature infants are susceptible to hypothermia due to their relatively large body
surface area and inability to produce enough heat and hypothermia may subsequently lead to
hypoglycemia or acidosis. Respiratory abnormalities are the most common complications of
preterm births which include respiratory distress syndrome, bronchopulmonary dysplasia and
apnea of prematurity. Cardiovascular abnormalities may include patent ductus arteriosus and
systemic hypotension. Incidence of intraventrcular hemorrhage increases in very low birth
weight infants, and glucose abnormalities either hypoglycemia or hyperglycemia may occur.
Gastrointestinal abnormalities—most importantly necrotizing enterocolitis, is one of the most
emergent problem of premature infants and is associated with an increase in infant mortality.
Another common complication in premature infants is late-onset sepsis and fungal infection.
Retinopathy of prematurity—a developmental vascular disorder may also occur in premature
infants.
Ideally, in women at risk for preterm delivery, tocolysis should be initiated with the goal
of preventing imminent preterm birth to allow time for corticosteroid treatment, transport of
mother and fetus to a center with the appropriate level of care, antibiotic prophylaxis for GBS,
and magnesium sulfate administration for fetal neuroprotection.
 Evidence is lacking on beneficial effect of tocolytics beyond the time for corticosteroid
administration and there are no convincing data demonstrating greater efficacy of one agent
over another. Tocolytics are recommended in women less than 34 weeks pregnant because
there is increased risk for complications of premature birth and labor may only proceed if there
is maternall or fetal compromise. A woman in preterm labor should be ideally admitted at the
hospital for close monitoring while tocolytics are administered. An IV line will be inserted to allow
administration of medications and fluids and a fetal monitor be used to measure uterine
contractions and fetal heart rate.
Tocolytics that may be used to stop labor include terbutaline, magnesium sulphate,
nifedipine and indomethacin among others. Some of these may be given intravenously or via
injection while others may be taken orally. It is important to monitor the mother for medication
side effects during tocolytic administration. Once labor stops, the women is kept in the hospital
for further monitoring and may be discharged if allowed. If a patient is sent home, it is important
to remind her to limit her activities and contact her physician immediately if signs of labor are
present.
For preterm with 23-31 weeks AOG, Alabama Perinatal Excellence Collaborative
Guidelines 2015 recommends Magnesium sulfate infusion for fetal neuroprotection. Magnesium
sulfate reduces the severity and risk of cerebral palsy in surviving infants if administered when
birth is anticipated before 32 weeks GA.
 The most beneficial intervention for improvement of neonatal outcomes among patients
who give birth preterm is the administration of antenatal corticosteroids (ANCS). ANCS have
been found to reduce the risk of neonatal death, intraventricular hemorrhage, and respiratory
distress syndrome in the preterm neonate. A single course is recommended for women at risk
for preterm birth that is between 24 and 34 weeks gestation. Betamethasone and
dexamethasone are the most widely studied and preferred ANCS; either is acceptable
treatment. Data on treatment of women with intact membranes support the use of ANCS up to
34 weeks. However, in the subset of women with PROM at 32-33 weeks, the benefit is less
clear. Based on this, the NIH Consensus conference felt there was insufficient evidence to
recommend routine corticosteroid administration to women with PROM at 32-33 weeks. Given
the potential benefit and minimal risk in the absence of a contraindication, justification can be
made for a uniform upper GA threshold of 34 weeks regardless of membrane status for
corticosteroid administration which would be easier to implement and ensure that all patients
who could benefit are receiving treatment. Given the increasing survival of 23-24 week infants,
many neonatologists advocate extending the window for corticosteroid administration to 23
weeks. In the absence of maternal contraindications, this should be considered.
REFERENCES

APEC Guidelines for Preterm Labor (2015).

Cunningham FG, et. al. eds. (2014). William’s Obstetrics. 24th ed.USA: McGraw Hill Education

Funai, Edmund F. (2015). Preterm labor. UpToDate.com. Retrieved 11 January 2016 from <
http://www.uptodate.com/contents/preterm-labor-beyond-the-basics#H13>
Mandy GT. (2015). Short-term complications of the premature infant. UpToDate.com. Retrieved
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