my patient is at 38+ weeks of pregnancy comes term prom without labour pain. As it was more than 12 hours of term PROM , Portable USG and Clinical examination was consistent with severe oligohydramnios and we planned for emergency CS
2. Particulars of the patient
Name: Mrs. Sharmin Aktar
Age: 28 years
Occupation: Housewife
Religion: Islam
Address: Ashokola, Bogura Sadar, Bogura
Date and Time of Admission: 07-03-
2023@04:55PM
Date and time examination:07-03-2023@5:00PM
Bed No.:D-3
Ward No.: D/W
Reg. No.: 230307028
3. Chief complaints
History of amenorrhoea for 38 weeks
A sudden gush of watery vaginal discharge 12 hours
back.
4. History of present illness
According to the statement of the patient, she is
amenorrhoeic for about 38 weeks. She had a regular
antenatal checkup and her antenatal period was
uneventful. Her LMP was 04/06/2022 and her EDD was
dated according to her early USG report which was
17/03/2023. she noticed a sudden gush of watery discharge
per vagina 12 hours back. Persistence per vaginal watery
discharge for the last 12 hours, which is spontaneous more
during coughing, colorless, odorless. Fetal movement is
good. She has no history of abdominal pain, fever, foul
smelling vaginal discharge. Her bowel habit is normal. She
has no burning sensation of micturition, increased
frequency, or urgency of micturition. With this complaints
she is admitted to TMC & RCH for better management.
5. Obstetric History:
Married for 2 years
Para:0+0 years
Gravida: prmigravida
Menstrual History:
Age of Menarche: 13 years
MP/MC: 5 / 28 (±2) days Menstrual flow: Average
1st day of LMP:4/6/22
EDD:17/3/23
6. History of past illness:
She has no history of
-DM
-HTN
-Rhematic heart disease
Renal disease
Thyroid disorder
Any Chronic illness.
7. Family History:
All members of her family are enjoying healthy life
Personal History: Non, Smoker, non-alcholic
Immunization History: She is immunized according
to EPI schedule and has got TT vaccine in full dose.
She also took booster dose of COVID- 19.
Socio-economic history: Middle class
8. GENERAL EXAMINATION:
(With due consent and maintaining the adequate
privacy I examined her on well lit room. she is co-
operative but anxious but well oriented to time place
and person.)
Body built: Average
Nutritional status: Average
Anaemia: +
Jaundice: Absent
Skin condition: Normal
9. `
Oedema: Absent
Cyanosis: Absent
Pulse: 80/min
BP: 120/80 min RR: 16/ min
Temperature: 990F
Dehydration:- absent
Breast examination: Not done
Thyroid gland: Not enlarged
11. Palpation:
Symphysiofundal height: 32 weeks
Abdominal girth: 86cm
Fundal grip: Rounded smooth, hard , globular
ballotable structure seemed to be fetal head.
Lateral grip: Irregular knob like limbs on right side
and smooth, curved, resistant back on its left side.
Pelvic grip: Broad, soft, irregular structure seemed to
buttock which was not engaged
12. Auscultation: Foetal heart rate 140/min and regular
Per speculum examination: Sterile speculum
examination on labour table was done , which shows
watery fluid discharge which is colourless, odouless.
There is no cord prolapse or any other pathological
finding or disease condition.
Other system examination: NAD
13. Salient feature:
Mrs. Sharmin Aktar, 22 years of age primi gravida,
muslim housewife, normotensive, non-diabetic, non-
smoker, non-alcoholic hailing from Bogura Sadar,
Bogra admitted to TMC & RCH with the complaints of
amenorrhoiec for 38+ weeks and a sudden gush of
watery discharge per vagina 12 hours back, which is
spontaneous more during coughing, colorless,
odorless and profuse in amount.
14. Fetal movement is good. She had no history of any
pain, fever or foul smelling vaginal discharge. On
general examination, she is mildly anaemic, pulse
80/min, BP 120/80 mm of Hg, RR 16/min, temperature
990F, no dehydration, no ankle oedema. No history of
any bowel-bladder abnormality.
15. On examination, per abdomen SFH is 32 weeks, with
breech in presentation. Sterile speculum examination
on labour table was done , which shows watery fluid
discharge which is colourless, odourless.
So from meticulous history taking and clinical
examination, our provisional diagnosis is
18. Investigations:
S.NO. INVESTIGATIONS FINDINGS
1 Hb 10.70g/dL
2 Plasma glucose,
Random
5.50mmol/L
3 Blood grouing (ABO)
& Rh Factor (D)
A positive
4 Ultrasonogram of
Pregnancy Profile
Single live pregnancy of about 37 weeks 05 days in
breech presentation at present ( 26.02.023)
5 Urine R/E Pus cell: 2-3/HPF
Epithelial cell : 1-2/HPF
RBC : Nil
Portable Ultrasonography shows A single live fetus showing severe
oligohydramnios with breech presentation
21. Ultrasonogram of Pregnancy profile
on 24/12/2022
Which shows single live pregnancy
at about 28 weeks 06 days in
cephalic presentation at present
22.
23. Confirm Diagnosis: Primigravida 38+ Weeks of
Pregnancy with breech presentation with severe
oligohydramnios with term PROM.
24. Treatment
On admission :
Complete Bed rest with left lateral position with bathroom
previllage
Sterile vulval Pad
INf. Hartman solution 1L
INJ. Antibiotics
Continious cathetrization was done.
Decision for LUCS was taken and done after pre-operative order.
(Male alive baby of 3.2kg with A/S of 7/10, and 8/10 at 1 and 5
minutes respectively ).
25. Per-operative finding
During LUCS , there was less amount of fluid that
suggesting oligohydramnios.
Bleeding was minimal and controlled by diathermy.
Placenta was separated by CCT.
