Case Discussion on Prolonged Pregnancy by Dr. Shivani Mehta

Case Discussion On Prolonged Pregnancy By Dr Shivani Mehta

Mrs XYZ 25 yrs old resident of Tumkur She is a homemaker Studied up to PUC Husband 30 yrs old, Government teacher, did BEd Socio economic status - low middle class Primigravida LMP-25/7/2023, EDD-30/4/2024 Gestational age - 42 weeks 3 days Date of admission - 18/5/2024 at 7:30am

Chief Complaint H/o amenorrhea since 9 months Referred from CHC Tumkur as her due date of delivery has passed, perceiving good Fetal movements, no abdominal pain, no leaking or bleeding per vaginum

History of Present Pregnancy 1st trimester - pregnancy detected by UPT following 45 days of missed period. Spontaneous conception registered at CHC Tumkur H/o intake of folic acid tablets No h/o of urinary infection, hyperemesis gravidarum, fever with rash No h/o of pain in abdomen, spotting or bleeding per vaginum No h/o of radiation exposure ANC profile done (CBC, URINE RM,BLOOD SUGAR, BLOOD GROUPING, SEROLOGY) Early pregnancy scan at 7 weeks done shows SLIUG, CRL-6 weeks 6 days, EDD-29/4/2024) NT scan done at 13 weeks of gestation, NT-1.4mm, nasal bone present, uterine artery dopplers normal, cervix length 3cm

Second Trimester Quickening felt at 5 month of gestation Received 2 doses of tetanus Took IFA & Calcium supplements No h/o of increased urinary frequency, burning micturition No h/o of blurring of vision, headache, nausea, vomiting, epigastric pain, pedal edema No h/o of abdominal pain, leaking or bleeding PV Anomaly scan done at 20 weeks 6 days of gestation Shows no obvious fetal structural distress DIPSI test done at 24 weeks of gestation which was normal

Third Trimester Perceiving good fetal movement Took IFA tablet & calcium supplement No h/o of increased urinary frequency, burning micturition No h/o of blurring of vision, headache, nausea, vomiting, epigastric pain, pedal edema No h/o of abdominal pain, leaking or bleeding PV USG done on 16/05/2024 shows SLIUF 39 weeks 6 days cephalic presentation placenta posterior grade 3, EFW 3.2 kg +/- 500 gm, AFI 4 cm, SVP 2cm, Doppler normal, BPP 6/8

Menstrual History Menarche at 12 yrs of age LMP 25/07/2023 EDD 30/04/2024 By EDD gestational age 42 week 3 days PaMC 4-5 days / 35 days regular, uses 1-2 pads /day, dysmenorrhea on day 1, not associated with passage of clots. Marital history Married since 1 year, non consanguineous marriage, no h/o of contraceptive use

Past History No h/o of Thyroid disorder DM HTN TB Asthma COPD Epilepsy Jaundice blood transfusion Surgery

Family History Both parents have Diabetes Mellitus type 2 Mother has hypertension No h/o of COPD, TB, Asthma, CAD, Cancer No familial h/o of prolonged pregnancy No history of congenital anomaly in relatives either side No h/o of twining, mental retardation

Personal History Dietary habit - mixed Sedentary lifestyle Adequate sleep No h/o alcohol, smoking, drug abuse Bowel and bladder habit regular No h/o of drug allergy No h/s of contraceptive use

Dietary History Mixed diet Total Calorie 1950 kcal Protein 47 gm Total requirement 2270 kcal Calorie deficit 320 kcal

Physical Moderately built and average nourished Height 157 cm weight 64 kg BMI 25.96 kg/m2(overweight) General condition - fair, conscious, well oriented to person, time and place, No Pallor , no icterus, no cyanosis, no clubbing, no lymphadenopathy, no pedal edema Thyroid, Bilateral breast and spine normal Vitals PR - 96/min regular in rate rhythm, no radio radial or radio femoral delay, normal in volume, character and condition of vessel wall BP- 100/60 mmhg in left arm at sitting position Temperature - afebrile SpO2 98% at room air CVS - s1, s2 Heard, no murmur RS - RR 16/min, normal vesicular breath sounds heard, no added sounds

Per Abdomen Examination P/A - umbilicus central, everted, abdomen uniformly distended upto xiphisternum, linea nigra present, striae gravidarum present, no scars, no pulsation, no engorged vein seen, hernial orifice intact. On Palpation uterus corresponding to 36 weeks, cephalic, Uterus relaxed, liquor adequate, AG 84 cm at the level of umbilicus, SFH 36 weeks Obstetric grip Fundal grip - soft broad mass felt, suggestive of breech Right lateral grip - Uniform ,continues ,curved, resistance felt suggestive of back Left lateral grip - Irregular, knob like structure, suggestive of limbs. First pelvic grip - Hard non ballotable mass suggestive of fetal head. Second pelvic grip - Finger are diverging. FHR 144/min PV os posterior, medium in consistency, cervix 1 cm dilated, cervix length < 1 cm long , membrane present, presenting part vertex, vertex at -3, pelvis adequate (bishop score 5)

Provisional Diagnosis 25 years old primigravida 42 weeks 3 days of gestation with oligohydramnios

Course Of Labour Admission NST reactive Induced with dinoprostone gel 0.5 gm intracervical at 8:30 am PA- term size, cephalic, uterus contractions + 3 contractions of 25 sec in 10 min, palpable head, FHR - regular 142/min PV - cervix 5 cm dilated, cervix length <1 cm, membrane present, tense bag forming, presenting part vertex, vertex at -2 6 hour later augmented with ARM, liquor clear followed by oxytocin 5 unit in drip . At 4:00 pm PV full dilated fully effaced, membrane absent liquor clear, ppvx, vertex at +1 station Patient delivered spontaneously male baby, cried immediately after birth, delayed cord clamping done and handed over to neonatologist Uterus well contracted, no tear, no PPH, RMLE sutured in layers, hemostasis achieved DOB 18/05/2024 at 4:45 PM, sex male, birth weight 3.5 kg, APGAR 8/9.

Postnatal Period Uneventful Lactation well established Uterus well contracted Episiotomy healing Lochia healthy

Thankyou