CASE WRITE UP 1

(OBSTETRIC)

THREATENED PRETERM LABOUR WITH

PRETERM PREMATURE RUPTURE OF

MEMBRANE (PPROM)

FARIS MOHD NASIR

1314597

ASST. PROF. DR SALMI DARAUP

NAME : SANISAH BT BAKRI

IC NO : 720219-06-5008

AGE : 44

ETHNIC : MALAY

RELIGION : ISLAM

OCCUPATION : HOUSEWIFE

MARITAL STATUS : MARRIED

ADDRESS : KAWASAN PERUMAHAN DATO’ SYAHBANDAR,

PEKAN

STATUS : GRAVIDA 7 PARA 5 + 1

DATE OF ADMISSION : 6TH MARCH 2016

CLERKED ON : 7TH MARCH 2016

CHIEF COMPLAINT

Puan Sanisah, a 44 years old housewife, gravida 7 para 5 + 1, currently at 31 weeks 2 days

period of gestation with unsure last menstrual period date, was admitted to ward due to a

complaint of gushing of liquid and having uterine contractions 1 day prior to admission.
HISTORY OF PRESENTING ILLNESS

This is unplanned but wanted pregnancy. She was not certain of her last menstrual

period. She was also on oral contraceptive pills up until 4 months ago when she stopped. She

claimed that she has been having regular menses before and has not been lactating since 6

years ago. She first suspected to be pregnant after she missed her period for 1 month and she

experienced early symptoms of pregnancy like nausea and vomiting. She did a urine

pregnancy test (UPT) at home and the result was positive. After 8 weeks period of

amenorrhea (POA) she had it confirmed again at Klinik An-Nisa. The estimated due date

(EDD) was not made at that point because she was unsure about her LMP.

She did her first booking at Klinik Kesihatan Peramu Jaya at 12 weeks POA. Her

weight and height at that time was 66kg and 157cm making her BMI 26.77kg/m²

(overweight). She was normotensive and not anemic with Hb level of 12g/dL. Urine test also

revealed negative for glycosuria and proteinuria. Her blood group is O+ve. Blood screening

for HIV and VDRL was non-reactive. Otherwise, the routine medical examination at that

time was normal.

Her dating scan was done on the same day as the booking which is at 12 weeks POA.

The scan revealed a single viable fetus and the parameter was equal to date. From the scan,

the revised estimated due date (REDD) is 6th May 2016. The subsequent routine scan was

done during antenatal check-up and revealed a growing fetus with adequate liquor and

placenta is in normal position. She started to feel for quickening at 23 weeks POA. She

started counting fetal kick chart at 28 weeks POA and it was complete with 10 kicks/day

starting from 9am to 5pm.

MOGTT was done due to her age more than 35 years old. The fasting blood sugar

was 4.0 mmol/L which was normal but her 2 hour post-prandial reading was 8.5 mmol/L
which was high. She was then given a diet control regime by a dietician and blood sugar

profile was repeated fortnightly starting on 23 weeks POA. The reading was ranging from

3.9-5.7 which are all normal. The HbA1c level at 23 weeks POA was 5.3% which was

normal and showed that she comply with her diet control. On check-ups, she denied having

symptoms of diabetes mellitus such as polyuria, polydipsia and polyphagia and also

complications of diabetes mellitus such as diabetic neuropathy, retinopathy and nephropathy.

The pregnancy has progressed well. She had gained a total of 1.5kg throughout the

pregnancy. The estimated fetal weight is 2.8-3.0kg.

Antenatally it was uneventful until 1 day prior to admission as she had sudden

gushing of fluid from her vagina during rest. It was around 11am when she had just done with

her house chores. She noticed that her pants was completely drenched with the fluid. She

described the fluid to be clear and warm. There was no foul smelling nor bloody discharge.

Other than her doing the house chores, she denied doing any other heavy works. She also

denied any trauma, massage or sexual intercourse prior to episode.

She went to Hospital Pekan right away and at the hospital she suddenly developed

uterine contractions. The contraction was timed at 1 in 10 minutes lasting for 15 seconds. The

contraction was painful and there was a gap for about 15 minutes between each contractions.

The strength was mild. Later the intensity and frequency decreased and occur once in 30

minutes. She did not notice any reduction in fetal movement as her fetal kick chart was

completed as usual.

Otherwise, there was no history of fever, abdominal pain, per-vaginal bleed and no

abnormal vaginal discharge. There was also no UTI symptoms such as dysuria, increased

urinary frequency, urinary incontinence and nocturia. She was then referred to HTAA for

futher management. At the casualty, speculum examination was done and the fluid was
confirmed to be liquor. The os was still closed. She was then admitted to ward Kenanga 1C

for further observation and management.

PAST OBSTETRIC HISTORY

No Year Age SVD/LSCS Sex Weight POA/FT Alive Place BF

1 1987 28 SVD F 2.5 FT YES

2 1988 27 SVD M 2.8 FT YES

3 1994 22 SVD M 2.5 FT YES

4 1995 20 SVD M 2.8 FT YES

5 2000 COMPLETE MISCARRIAGE @ 12 WEEK POA, D&C DONE

6 2008 8 LSCS M 3.1 YES

She had delivered 5 children, 1 girl and 4 boys. All of them were delivered via spontaneous

vaginal delivery (SVD) except for the 5th child which was delivered via lower segment

Caesarean section due to breech presentation. The postoperative period was uneventful.

The babies weighed between 2.5 to 3.1 kg. All children are normal, alive and healthy.

She had a history of complete miscarriage in 5th pregnancy at 12 week of POA, confirmed

with ultrasound. A dilation and curettage (D&C) was performed and there was no

complication following the procedure.

She attained menarche at 11 years old. Since then, her menses has been regular with 28 days

cycle with normal bleeding for around 7 days. She claims that she need 2-3 pads/day during

period. No history of dysmenorrhea, urinary tract infection (UTI) or sexually transmitted

diseases (STDs). She had done Pap smear multiple times since her second pregnancy and the

results were all negative. She used to take oral contraceptive pills and used intra-uterine

contraception device. She stopped consuming the OCP around 4 months ago.

PAST MEDICAL HISTORY

No history of previous hospitalization or other surgery. No known medical illness. No known

drug allergy.

FAMILY HISTORY

She is the fifth out of six siblings. No family history of malignancy, hypertension or diabetes

mellitus. Both of her parents died at 62 and 65 years old respectively. Her marriage has been

blessed with 5 children which are all alive and healthy.

SOCIAL HISTORY

She lives with her husband and 3 of her children in a house in Kawasan Perumahan Dato’

Syahbandar in Pekan. She is a housewife and her husband works as an officer at Jabatan Parit

dan Saliran (JPS). Her husband is a smoker and he smokes around 2-3 packs per day. The

nearest KK is KK Peramu Jaya which is located around 5 minutes away from her house.
PHYSICAL EXAMINATION

On general examination, my patient is lying on supine position with one pillow. She is

conscious and alert. She is not in any pain or respiratory distress. There was no

subconjunctival pallor and scleral jaundice. The oral hygiene is fair and hydration status is

good. The followings are her vital signs:

Blood pressure : 107/60 mmHg

Pulse rate : 94 beats/minute

Respiratory rate : 20 breaths/minute

Temperature : 37°C

HEAD AND NECK

There were no palpable lymph nodes, masses or thyroid enlargement. The tongue was moist

and fairly hydrated. There was no angular stomatitis or glossitis.

CARDIOVASCULAR EXAMINATION

Her apex beat was at 5th intercostal space at midclavicular line. There was no thrill or

parasternal heave palpable. Her first and second heart sound was heard.

RESPIRATORY EXAMINATION

No chest deformity or any scar observed. The chest movement was symmetrical. Chest

expansion and vocal fremitus were normal. On auscultation, vesicular breath sound was heard

and air entry was equal and normal for both lungs. No crepitation heard.

ABDOMINAL EXAMINATION

Upon abdominal examination, on inspection, the abdomen is distended by a gravid uterus.

Linea nigra and striae gravidarum can be seen. The umbilicus is centrally located and everted.
There is a well-healed transverse suprapubic scar measuring about 9cm. The scar is not

tender. On palpation, the abdomen is soft and non-tender. Symphisio-fundal height was

measured to be 28cm. Clinical fundal height corresponds to 28 week of gestation, which is

smaller than date. There is a single fetus in longitudinal lie with cephalic presentation. The

fetal back is on maternal right side. The head is 5/5 palpable, not engaged. Liquor is

inadequate in volume. The estimated fetal weight is 2.0-2.2kg. Fetal heart was heard at 160

bpm with normal rhythm.

VAGINAL EXAMINATION

No abnormality detected on the vulva and vagina. No pooling of liquor. The os appeared to

be closed.

INVESTIGATION

1. Full Blood Count : to check for any anemia and infection

Results: Hb – 11.3 g/dL (normal), TWBC – normal

2. C-Reactive protein : to check for any inflammation, not done

3. Urinalysis: to check for any UTI

Results: specific gravity – 1.017, pH – 8.0, color – pale yellow, leukocyte, nitrite,

protein, glucose, ketones not detected.

Comment: urinalysis was normal

4. High vaginal swab : to check any infection especially group B Streptococcus, not

done

5. Cardiotocography (CTG) : to check for any fetal distress.

Result: baseline fetal heart rate: 140, variability 5-15, acceleration and deceleration

present.

Comment: CTG is reactive indicating fetus in good condition.

Result: no growth abnormalities detected. Fetal heart detected. Cephalic presentation.

AFI is 17.1.

MANAGEMENT

1. For tocolysis with T. Adalat (nifedipine)

2. Watch for any scar dehiscence

3. Strict pad chart monitoring

4. T. EES 500 mg BD for 12 days.

5. To complete intra-muscular injection of dexamethasone 12-hourly X4

PROGRESS IN WARD

6/3/2016

She was conscious and alert. Currently, no more leaking, no show. Good fetal movement.

Uterine contraction timed 1 in 10 minutes lasting for 15 sec. no signs and symptoms of

chorioamnionitis. T. EES, T. Adalat and IM Dexamethasone were given.

7/3/2016

The patient can sleep well last night with no contraction pain. Uterine contraction is now nil.

Pad chart also nil. To complete IM Dexamethasone, if contraction remain nil allow patient to

be discharged.
CASE SUMMARY

Puan Sanisah, 44 years old, Gravida 7 Para 5 + 1, at 31 weeks 2 days period of gestation

presented to HTAA with a complaint of leaking of liquor with clear fluid discharge

associated with uterine contractions. There was no signs and symptoms of chorioamnionitis.

Examination showed her uterus to be smaller than date with fundal height of 28cm at 31

weeks POG and estimated fetal weight of 2.0-2.2kg.

PROVISIONAL DIAGNOSIS

Threatened preterm labour with preterm premature rupture of membrane (PPROM).

DIFFERENTIAL DIAGNOSIS

1. Urinary incontinence:

 The discharge usually smells like urine.

 Should have occurred more frequently.

2. Vaginal discharge

 Normal vaginal discharge may occur during pregnancy.

Preterm labour is defined as the presence of uterine contractions of sufficient

frequency and intensity to effect progressive effacement and dilation of the cervix prior to

term gestation. As the name implies, preterm labour occur at 20-37 weeks of gestation. It is

usually characterised by regular and often painful uterine contractions. In some cases, the

cervix may even start to open. Preterm birth occurs in 12% of total pregnancies and currently

the leading cause of neonatal death in the United States.

Even though the exact mechanism of preterm labour remain unknown, but there are

several risk factors that are known to increase a woman’s risk. The strongest risk factor is

history of previous preterm birth. Other risk factors include:

●Being pregnant with twins, triplets, or more

●A history of cervical surgery (eg: conisation or cone biopsy) for abnormal Pap

smears, if the amount of the cervix removed is large

●Abnormalities of the uterus

●Uterine bleeding, especially in the second or third trimester

●Use of certain illicit drugs, such as cocaine

●Cigarette smoking

●Some infections

●Low pre-pregnancy weight and low weight gain during pregnancy

●Excessive amniotic fluid

●Moderate to severe anaemia early in the pregnancy

●A short interval (less than 12 to 18 months) between pregnancies (deliveries)

●Abdominal surgery during pregnancy

There will be contractions, show and rupture of membranes. Preterm labour is also highly

associated with preterm premature rupture of membrane (PPROM). PPROM refers to a

patient presented with rupture of membrane prior to 37 week of gestation. Another condition

that closely related to this is premature rupture of membrane (PROM) which occur after 37

weeks of gestation. If the fluid continue to leak for more than 18 hours, it is categorised as

prolonged PPROM.

Ruptured membrane maybe be due to programmed cell death and activation of

catabolic enzymes such as collagenase and mechanical forces. Premature activation of these

pathway or trauma and vigorous activities may cause the membrane to rupture prematurely.

Patients usually some with the complaint of gushing of fluid per vaginally. The fluid must be

differentiated with urine because urinary incontinence is a common occurrence in pregnancy.

The vast majority of patient with PPROM proceed to active labour and deliver a while

after PPROM. However, with adequate therapy and conservative management, the delivery

can be delayed up to several weeks especially if the gestational age is less than 24 weeks. In

less than 10% of the cases, spontaneous sealing of the membranes may occur. This might be

the case in this patient.

There are multiple risk and complications of PPROM. Maternal risk include

chorioamnionitis, postpartum infection, risk of having caesarean section and placental

abruption. On the other hand, complication of PPROM to the fetus may include

oligohydramnions, neonatal infection, abnormal lie, preterm labour, fetal death and even cord

prolapse.

There are several investigation may be performed to confirm the diagnosis and to rule

the differential diagnosis:

2. Full blood count. High total white may indicate chorioamnionitis.

3. C - reactive protein to check for any inflammation.

4. High vaginal swab in patients suspected with infection in order for specific

antibiotic therapy.

5. UFEME to exclude urinary tract infection.

6. Ultrasound to detect viability, AFI, lie of fetus, to rule out any cord presentation

and placenta previa.

In this patient, the complaint was leaking of liquor and having multiple uterine

contractions prior to admission. The gushing of fluid was only in one episode and it stopped

in less than 18 hours. So, this is not a case of prolonged PPROM. She also did not develop

any signs and symptoms of chorioamnionitis. Since that the patient is still less than 37

gestational weeks, induction of labour is not indicated. She was given T. EES in order to

prolong the labour. She was also given IM injection of Dexamethasone 12-hourly for 4 doses.

The use of corticosteroids to accelerate lung maturity should be considered in all patients

with PPROM with a risk of infant prematurity from 24-34 weeks' gestation. She was also

given tocolytic agent, T. Adalat, and her uterine contractions goes away completely on the

next day.

REFERENCES

1. Baker and Kenny, Obstetrics by Ten Teachers 19th edition

2. Obstetric Today, 1st edition

3. http://www.emedicine.medscape.com

4. http://www.uptodate.com