And Women With Placental Abruption Were More Likely To Be of Higher Parity Thus Was Ruled-Out

Chief Complaint: Left Lower Abdominal Pain  Impaired liver function
Differentials:  Pulmonary edema

 Placenta abruption  Cerebral or visual symptoms
 Pre-eclampsia This was considered due to abdominal pain and since
 UTI more than half of all cases of preeclampsia occur in
 Pre-term labor first-time pregnant women. However, the patient’s
abdominal pain was on the left lower quadrant, did
Placental Abruption not experience headache, dizziness, blurring of vision,
Separation of the placenta either partially or totally nausea, vomiting, dyspnea. She is not hypertensive
from its implantation site before delivery. and is not diabetic making this diagnosis highly
unlikely.
This was considered due to the abdominal pain, and
since this usually happens in the third trimester of -Rule-in
pregnancy, thus was ruled-in. However, the patient did Abdominal pain
not present with vaginal bleeding, watery discharge, First pregnancy
uterine tenderness, history of prior trauma, she is not
hypertensive, a non-smoker, no history of cocaine use -Rule-out
and women with placental abruption were more likely Epigastric or right upper quadrant abdominal pain
to be of higher parity thus was ruled-out. No headache
No dizziness, blurring of vison
-Rule-in No nausea or vomiting
Abdominal pain No dyspnea
Third trimester of pregnancy No history of hypertension
No history of diabetes
-Rule-out
No vaginal bleeding Urinary Tract Infection
No watery discharge Pregnant women are more susceptible to urinary
No uterine tenderness infections. UTI may be asymptomatic (subclinical
No history of prior abruption infection) or symptomatic (disease). Thus, the term
No history of trauma urinary tract infection encompasses a variety of clinical
Not hypertensive entities, including asymptomatic bacteriuria (ASB),
Non-smoker cystitis, and pyelonephritis.
No history of cocaine abuse
G1P0 Ureteral dilation is seen due to compression of the
ureters from the gravid uterus. Hormonal effects of
Pre-eclampsia progesterone also may cause smooth muscle relaxation
According to the new American College of leading to dilation and urinary stasis, and vesicoureteral
Obstetricians and Gynecologists classification, reflux increases.
preeclampsia is defined as ≥140mmHg systolic or
≥90mmHg diastolic on two occasions at least 4 hours This was ruled-in since the patient is a pregnant
apart after 20 weeks AOG in a woman with a woman, had history of UTI and experienced abdominal
previously normal blood pressure or a value of pain. However, she did not have any of the following:
≥160mmHg systolic or ≥110mmHg diastolic and thus, was ruled-out.
PROTEINURIA or in the absence of proteinuria, new-
onset hypertension with the new onset of any of the -Rule-in
following: Pregnant woman
History of UTI
 Thrombocytopenia
Abdominal pain
 Renal insufficiency
-Rule-out • Diagnosis accuracy can be improved by
No dysuria, urinary frequency or urinary urgency transvaginal sonography (TVS) measurement of
No suprapubic pain and tenderness cervical length.
No flank pain, fever, chills, costovertebral angle Biochemical markers
tenderness • testing for fetal fibronectin (FFn) in cervical fluid
No malaise, anorexia, nausea, and vomiting Clinical markers for high risk imminent preterm
labor
• ruptured membranes, vaginal bleeding, and
Pre-term Labor
cervical dilatation beyond 2 cm
The American College of Obstetricians and • Among women with intact membranes, no
Gynecologists (2016b) define preterm labor to be bleeding and cervical dilatation less than 3 cm,
regular contractions before 37 weeks that are the combination of positive FFn test and a
associated with cervical change. These changes include sonographic cervical length of less than 30 mm,
effacement (the cervix thins out) and dilation of the predicted increased risk of delivery within 48
cervix (the cervix opens so that the fetus can enter the hours (26%); the risk was less than 7% if only
birth canal). one or neither test is positive.
-Rule-in MANAGEMENT
Abdominal pain Corticosteroid therapy
Cervical dilatation Magnesium sulfate
Tocolysis
Antibiotics
Etiology of preterm labor is multifactorial but the
pathophysiologic patterns (infection, fetal stress,
vascular theories) that connect them to preterm labor Cervical insufficiency
are still poorly understood. Most of the studies on the Also known as incompetent cervix, this is a discrete
etiology of preterm labor have indicated that majority obstetrical entity characterized classically by painless
of these cases have two or more possible causes. cervical dilatation in the second trimester.
Major elements in the diagnosis of preterm labor: Cervical insufficiency (cervical incompetence) is
1. gestational age defined by the American College of Obstetricians and
2. uterine activity Gynecologists (ACOG) as the inability of the uterine
3. assessment of effects of uterine activity cervix to retain a pregnancy in the second trimester, in
the absence of uterine contractions
1. GESTATIONAL AGE
Preterm labor occurs when regular contractions result Rule-in
in the opening of your cervix after week 20 and before Cervical dilatation
week 37 of pregnancy. Vaginal spotting
2. UTERINE ACTIVITY
In preterm labor, contractions are regular, frequent and Rule-out
may or may not be painful. No preterm premature rupture of membrane
The traditional criteria which is the persistent uterine Contractions every 12-15 mins. (mild-moderate)
contractions accompanied by dilatation and/or
effacement of the cervix – are reasonably accurate if the
Placenta previa
contraction frequency is 6 or more per hour and cervical
Placenta previa refers to the presence of
dilatation is 3 cm or greater and/or effacement is 80%
placental tissue that extends over the internal
or greater, or if membranes rupture or bleeding occurs.
cervical os (partially or completely).
3. ASSESSMENT OF EFFECTS OF UTERINE ACTIVITY
Cervical Evaluation
Although painless vaginal bleeding during the second
• Since digital examination of the cervix in early
labor (< 3 cm dilatation and < 80% effacement) or third trimester of pregnancy is the usual
is not highly reproducible, it is also not a reliable presentation, some women may present with
basis to diagnose early preterm labor. contractions.
Placental attachment is disrupted as this
area gradually thins in preparation for the
onset of labor; this leads to bleeding at
the implantation site, because the uterus
is unable to contract adequately and stop
the flow of blood from the open vessels.
Thrombin release from the bleeding sites
promotes uterine contractions.
This increases risk for a preterm labor.

Rule-in
Vaginal spotting
Uterine contractions

And Women With Placental Abruption Were More Likely To Be of Higher Parity Thus Was Ruled-Out

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Chief Complaint: Left Lower Abdominal Pain  Impaired liver function

Differentials:  Pulmonary edema

This increases risk for a preterm labor.

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