CASE REPORT SESSION

P1A1 Spontaneous Early Term Labour

w/ Oxytocin Augmentation ec.
History of PROM + IUH + IUD insertion

Nadiya Afifah
12100117126

Preceptor:
dr. H. Dadan Susandi, Sp.OG

Obstetrics and Gynecology Department

Doctor Slamet General Hospital
Garut
2018
PATIENT’S DATA
▷ PATIENT’S IDENTITY ▷ HUSBAND’S IDENTITY

▷ Name : Mrs. F ▷ Name : Mr. A

▷ Age : 18 ▷ Age : 22
▷ Address : Sukakarya ▷ Address : Sukakarya
▷ Education : JHS ▷ Education : SHS
▷ Occupation : Housewife ▷ Occupation : Entrepreneur

▷ Date of Admission :
November 1st, 2018
▷ Time of Admission:
4.30 PM
2
CHIEF COMPLAIN

▷ Watery vaginal discharge

3
History of Present Illness

▷ Patient G2P0A1, 9 months pregnant, complains of

a watery vaginal discharge since 8 hours before
admitted to the hospital (around 9 AM).
▷ Patient noted passage of watery vaginal
discharges, colorless, unscented, in sufficient
volume.
▷ Patient denied a recent history of trauma to the
abdomen (fall) nor the birth canal (fall, coitus),
denied a recent history of infection (fever,
abnormal vaginal discharge), no history of
smoking, alcohol consumption, or drug
consumption. 4
History of Present Illness

▷ The complain associated with a bloody show and

irregular non-radiating contractions since 9 hours
ago. Three hours PTA, contractions have become
stronger and more regular, occurring every 20-30
minutes, 15-30 sec duration, sometimes radiating
to the lumbosacral area.
▷ The fetal movement began to be felt since around
4 months ago until now.

5
OB History

I 2017 Spontaneous Abortion

II 2018 Present

6
Additional Information
▷ Marital History ▷ Menstrual History

♀ 1st , 17yo Last menstrual first day: 12-

♂ 1st , 21yo 02-2018 (GA: 37-38 weeks)
EDD: 19-11-2018
Menarche – 11 years old
Menstruation: regular, 28-30
day cycle, 4-7 days duration,
normal amount with the
heaviest on the 2nd/3rd day,
consuming 2-4 pads/day, no
dysmenorrhea
Previous contraceptive
method: none
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Additional Information
Complaints during Pregnancy
▷ Nausea (-)
▷ Vomiting (-)
▷ Diarrhea (-)
▷ Constipation (-)
▷ Headache (-)
▷ Blurred vision (-)
▷ Epigastria pain (-)
▷ Seizure (-)
▷ Edema (-)
▷ Fever (-)
▷ Urinal pain (-)
▷ Vaginal discharge (-)
▷ Vaginal blood spotting (-)
Prenatal Care History
▷ Patient has done prenatal
routine check to the nearest
midwife for >9 times during
the past 9 months.
(last visit: 1 week ago)
▷ Patient has gone to the OB
for further prenatal check
and USG 2 times.
(last visit: 2 week ago)
8
Additional Information

▷ History of Past Illness

No history of neurological disease.

No history of respiratory disease.
No history of cardiovascular disease.
No history of hematologic disease.
No history of gastrointestinal disease.
No history of endocrine disease.
No history of urogenital disease.

9
Review of Systems

▷ GENERAL: (+) vaginal spotting; (+) for weakness

▷ SKIN: (-) for cold skin, rashes, itchiness and color
changes
▷ HEAD: (-) for headache, lightheadedness, dizziness
and trauma
▷ EYES: (-) for blurred vision and discharges
▷ EARS: (-) for pain, discharges and hearing loss
▷ NOSE: (-) for discharges, sinusitis, colds and
epistaxis
▷ MOUTH & THROAT: (-) for oral lesions and sore
throat
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▷ NECK: (-) for stiffness, shoulder pain
▷ RESPIRATORY: (-) for cough and difficulty of
▷ breathing
▷ CARDIOVASCULAR: (-) for chest pain and
palpitations
▷ GASTROINTESTINAL: (-) for rigidity, diarrhea,
constipation, vomiting, hematochezia, and melena
▷ URINARY: (-) for dysuria, frequency, and nocturia
▷ GENITAL: (-) for sores, itchiness

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General Examination

▷ General Survey: ambulatory, conscious, coherent,

not in pain, not in respiratory
▷ Vital Sign:
○ Temp: 36.9C
○ Pulse rate: 88 bpm
○ Respiratory rate: 24 cpm
○ BP: 120/80 mmHg
○ distress, in labor
▷ Anthropometric Measurement:
○ Height: 158 cm
○ Weight: 62 kg (Pre-pregnancy weight = 50kg)

12
Physical Examination

▷ Skin: warm, good turgor, no jaundice

▷ HEENT: mildly pale palpebral conjunctivae, anicteric
sclerae, pupils equally reactive to light, no nasal
discharges, moist pale lips, moist oral mucosa, no
tonsillopharyngeal congestion
▷ Neck: supple, no lymphadenopathies, no jugular vein
distention
▷ Chest/Lungs: equal chest expansion, no intercostal
and supraclavicular retractions, equal tactile fremitus,
resonant lung fields, bronchovesicular
breathsounds all

13
Physical Examination

▷ Heart: PMI at 5th intercostal space, left midclavicular

line. No heaves, no thrills, cardiac area of dullness not
enlarged. Normal rate and regular rhythm. No murmurs.
▷ Abdomen: Ovoid with striae gravidarum
○ L1 palpated breech, L2 feta back on right, L3
cephalic, L4 cephalic prominence
▷ Extremities: equal, strong palpable radial and dorsalis
pedis pulses, CRT <2s, no edema

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Obstetrics Examination

▷ FHt = 34 cm / 99 cm
▷ Fetal Presentation = head, right-fetal back, 2/5
▷ Fetal Weight = 3.105 gram
▷ Uterine contractions = 2 contractions in 10 minutes,
for 35 seconds
▷ FHB = 148x/ min., regular
▷ Internal Exam:
○ Vulva: Normal
○ Vagina: Normal
○ Cervix: thick, soft, medial, 4-5 cm dilated,
○ Amniotic membrane: not intact, clear amniotic fluid
○ Lowest part: cephalic, station +1
○ Smallest crown: right anterior 15
V
V
V
V
V
10

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Laboratory Examination
▷ Hematology: ▷ Immunoserology
▷ Hemoglobin :12,3g/dl ▷ HIV : Non Reaktif
▷ Hematokrit : 35% ▷ HBsAg: Non Reaktif
▷ Leukosit : 8,330 /mm3 ▷ Kimia Klinik
▷ Trombosit : 327,000 /mm3 ○ AST (SGOT): 20 U/L
○ ALT (SGPT): 9 U/L
▷ Eritrosit : 3.88 juta/mm3

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Diagnosis

▷ G2P0A1 37-38 weeks active phase

parturien w/ history of premature
rupture of membrane

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Management Plan

▷ R/ vaginal delivery
▷ Oxytocin drip: 5 IU in 500c D5% 20
dpm for the first 15 min., increased 5
drops every 15 minutes (max. 60 dpm)
▷ Observe general condition, vital sign,
fetal heart rate, uterine contraction, and
progress of labor.
▷ Family planning motivation.

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 Follow up
Tanggal Catatan

02/11/2018 S/ Nyeri pada jalan lahir Mata: Ca -/- Si -/-

PP day 1 O/ Ku: CM ASI : -/-
(01/11 18:40) TD: 120/80 mmHg Abd: datar lembut, NT-
♂, alive N: 76x/menit regular TFU: 2 jari dibawah pusat
BW 2860 g R: 20x/ menit BAB/BAK: -/+ (spontan)
BL 47 cm S: Afebris Lokhia : + rubra
AS 5-7 Kontrasepsi: IUD
A/ P1A1 Spontaneous Early Term Labour w/ Oxytocin Augmentation ec.
IUH + IUD insertion
P/ Observasi KU, TTV, Perdarahan
Cefadroxil 2x500 mg PO
Asam Mefenamat 3x500 mg PO
SF 1x1
Vaginal hygiene
Breast care
 Final Diagnosis

▷ P1A1 Spontaneous Early Term

Labour w/ Oxytocin Augmentation
ec. History of PROM + IUH + IUD
insertion

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Prognosis

▷ quo ad vitam
○ Mother: ad bonam
○ Child: dubia ad malam
▷ quo ad functionam
○ Mother: ad bonam (no risk of reproductive organ
damage unless there’s another underlying
reproductive organs’ disease/trauma)
○ Child: dubia (high risk of recurrency in next
pregnancies)
▷ quo ad sanantionam : dubia ad bonam

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Premature Rupture of
Membrane (PROM)

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Fetal membranes consist of 2 layers:
1. Chorion (outer).
2. Amnion (inner).

PROM is spontaneous rupture of

membrane any time beyond 22nd week
of pregnancy but before onset of labor.
Incidence: 10% of all pregnancies.
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Incidence of PROM

▷ PROM in 5-10 % of all term pregnancy

70% of all PROM begin in term
pregnancies, p-PROM in 1% of all
pregnancies.
▷ PROM is accelerator of 1/3 of preterm
pregnancies
▷ In gravid with history of PPROM the
incidence of recurrence is 32%

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Types of PROM

1. Term: is rupture of membranes beyond

37th weeks of gestation but before the
onset of labour.
Incidence is: 8% of all pregnancies.
2. Preterm: rupture of membranes before
37 completed weeks of gestation.
Incidence is: 2-3% of all pregnancies.

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Etiology of PROM
▷ In majority, causes not known.
▷ Possible causes:
○ increases friability of the membranes.
○ Decreased tensile strength of membranes.
○ Cute inflammation of placenta
○ Polyhydramnios.
○ Cervical incompetence.
○ Multiple pregnancies.
○ Infections: e.g. chorioamnionitis, UTI and lower genital
tract infections.
■ sub clinical infection: maybe one reason for prom ,
the relatinship between bacterial vaginosis and pre
term labor or pprom show this fact
○ Cervical length <2.5 cm.
○ Prior preterm labour.
○ Low BMI (<19 kg/m2). 27
Risk Factors of PROM

▷ Cervical insufficiency: less than

25mm in 23 week
▷ Polyhydramnious
▷ History of p-PROM
▷ PROM fibronectin positive in week
of 23

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Patho-
genesis

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Diagnosis of PROM

▷ History.
○ Patient complains of discharge of clear fluid
(liquor) vaginally.
▷ Examination:
○ Speculum: shows liquor draining through
cervical os.
○ Examination of collected fluid from posterior
fornix:
■ Fern test, crystallization of liquor when
dried on a slide.
■ Litmus test or Nitrazine paper test for
detection of pH (6 to 6.2) 30
Differential Diagnosis

▷ Hydrorrhoea gravidarum: a state

where periodic watery discharge
occurs probably due to successive
decidual glandular secretion.
▷ incontinence of urine.
▷ P-PROM.

31
Complications of PROM

▷ Maternal hazards:
○ Preterm labor.
○ Increased risk of infection.
▷ Fetal:
○ Cord prolapse.
○ Intrauterine infection.
○ Fetal pulmonary hypoplasia.
○ Neonatal sepsis.
○ Respiratory distress syndrome.
○ Intraventricular hemorrhage.
○ Necrotizing enterocolitis. (NEC).
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Management of PROM

▷ Depends on:
1. Gestational age of the fetus.
2. whether the patient is in labour or not.
3. Any evidence of sepsis.
4. Prospect of fetal survival in that institution, if delivery
occurs.
▷ If there is: amnionitis, placental abruption, fetal
death or distress, labour process then a prompt
effective delivery should be done with broad
spectrum intrapartum antibiotics and admit the
baby to the nursery intensive care unit if needed.

33
Management
Term (37 weeks or Preterm (32 to 33 completed
more) or Near term (34 weeks) :
weeks to 36 completed ▷ Expectant management, unless
weeks) : fetal pulmonary maturity is
documented. Management aims
▷ Wait for spontaneous to continue for fetal maturity so
onset of labor for 24- transfer the patient with the
48h. fetus in utero to a center
equipped with NICU.
▷ If fails then induction
▷ Group B streptococcal
of labor with oxytocin prophylaxis recommended
or C/S (for obstetric ▷ Corticosteroids—no consensus,
reasons). but some experts recommend
▷ Group B streptococcal ▷ Antibiotics recommended to
prophylaxis prolong latency if there are no
contraindications
recommended. 34
Preterm (24 weeks to 31
completed weeks) :
▷ Expectant management
▷ Group B streptococcal
prophylaxis recommended
▷ Single-course
corticosteroid use
recommended
▷ Tocolytics—no consensus
▷ Antibiotics recommended
to prolong latency if there
are no contraindications
Less than 24 weeks:
▷ Expectant Management
or induction of labor
▷ Group B streptococcal
prophylaxis is not
recommended
▷ Corticosteroids are not
recommended
▷ Antibiotics—there are
incomplete data on use
in prolonging latency
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