GENERAL DATA This is a case of AB, a 28 year old primigravida who came in due to watery vaginal discharge.

HISTORY OF PRESENT ILLNESS One month prior to admission ,patient experienced urinary frequency,dysuria, flank pain and fever at 38OC . She sought consultation at her Atending physician and was diagnosed with urinary tract infection. She was prescribed with Ampicillin and Sulbactam (Urasyn), 750 mg tablet , twotimes a day for 1 week. And advised to come back for repeat urinalysis.Patient was non compliant and was lost to follow up. She was apparently well until one day prior to admission , the patient noticed a passage of painless clear, watery vaginal discharge, approximately 250 ml. She claimed to have a steady leakage of small amount of fluid but no consultation was done.It was not associated with pruritus, foul smelling discharge and dysuria. Eighteen hours prior to admission, still with vaginal discharge and a crampy lower abdominal pain radiating to the lumbosacral area with a pain scale of 5/ 10. It lasts for 5 minutes relieved by positioning and aggravated by sudden movements.Still no consultation was done until 1 hour prior to admission, she sought medical advice at her attending phisicians clinic .Internal examination was done which revealed 5 cm cervical dilatation. She was advised for admission in this institution hence admitted.

PAST MEDICAL HISTORY

The patient claimed to have complete immunization and had chickenpox,mumps and measles during her elementary years around 7 to 8 years old. She was not admitted in a hospital and was only managed at home with bed rest ,increased oral fluid intake and diet consisting of fruits and vegetables. No history of surgical operation and no reported allergy to drugs but with a known allery to chicken and seafoods.

FAMILY HISTORY There are no heredofamilial diseases on maternal and paternal side.

PERSONAL / SOCIAL HISTORY AB was born and raised in Davao City with Bachelor of Science in Management Accountancy. She works as a purchaser at Assumption College of Davao for 5 years and got married last 2010. She is in charge for placement of purchase orders and delivery of materials to meet customer order requirements and maintain stock inventory levels.She has little exercise and diet consists mainly of carbohydrates . She is non smoker and an occasional alcohol drinker. OBSTETRIC HISTORY Menarche started when she was 9 years old with regular menstrual flow of approximately 4 days duration soaking 3 pads / day ,moderate to heavy flow with dysmenorrheal. She has no history of contraceptive use and other methods of contraception. Coitarche at 18 years old with one sexual partner. She is a primigravida (G1P0). Her last menstrual period was August 22,2012 with previous menstrual period of July 2012.Expected date of confinement on May 29,2013. She had an ultrasound last October 2012 with an adjusted EDC of May 26,2013 and AOG of 38 4/7 weeks. She claimed to have pap smear last 2012 with normal findings . She had two doses of tetanus toxoid and one dose for heap B. she also took iron folic acid during her pregnancy.

REVIEW OF SYSTEMS GENERAL ENDOCRINE SYSTEM SKIN HEAD EYE EAR NOSE MOUTH THROAT NECK (+) weakness, (+) fatigue (-) thyroid problems, (-) neck surgery, (-) heat and cold intolerance (-) pruritus (+) dizziness, (+) headache (+) pain, (+) excessive lacrimation (-) tinnitus (-) persistent stuffiness, (-) nasal congestion, (-) postnasal drip (-) bleeding gums, (-) dyspnea (-) odynophagia, (-) hoarseness (-) neck surgery, (-) nuchal rigidity, (-) limited motion

BREAST CARDIAC PERIPHERAL VASCULAR GASTROINTESTINAL PULMONARY GENITO-URINARY HEMATOPOIETIC MUSCULAR NEUROLOGIC

(-) breast pain, (-) abnormal discharge (-) nocturnal dyspnea, (-) murmurs (-) claudication (-) change in bowel habits (-) hemoptysis, (-) asthma (+) dysuria, (+) flank pain (-) easy brusing (-) limited ROM (-) change in orientation

PHYSICAL EXAMINATION GENERAL The patient is seen in supine position alert, awake, not in respiratory distress. Cooperative and oriented to person, place and time.

VITAL SIGNS BP: 110/80 mmHg; PR: 91 bpm; RR: 20 bpm; temperature: 36.5 C Weight: 77kg; Height: 52

SHEENT: SKIN: I fair complexion, no lesions/scars, no palmar erythema, nails without clubbing and cyanosis PA moist and warm with good skin turgor. No palpable lesions, tenderness, lumps noted

HEAD: I hair is black in color, no lesions noted A non-palpable lymph nodes

EYES: I anicteris sclerae, pink palpebral conjunctivae

EARS: I no lumps, lesions noted PA non-tender and mobile external ear

NOSE: I symmetric, no swelling noted, nasal septum at midline PA frontal and maxillary sinuses are not tender

MOUTH: I no lesions noted, tongue and vulva at midline, no tonsilar enlargement noted -mouth ulcers

NECK: I supple, no nuchal rigidity and gross thyromegaly, trachea at midline, no lesions noted

BREAST: I no redness/discharge noted PA no mass palpated, non-tender

CHEST/LUNGS: I no scars/ lesions noted PA non-tender PE resonant A vesicular breath sounds in most areas without adventitious sounds

CARDIOVASCULAR: I adynamic precordium PA symmetric pulses, capillary refill time < 2 sec A no murmurs noted. PMI at 5th ICS, left MCL

ABDOMEN I no lesions noted A normoactive bowel sounds at 5 bowel sounds per minute PE dullness at RUQ, the rest is tympanic PA non-tender, no palpable abdominal mass

EXTERNAL GENITALIA I no lesions/scars noted, no enlargement and swelling noted, with watery vaginal discharge

SPECULUM EXAM (+) pooling of clear watery discharge at the posterior vaginal wall (+) fluid per cervical os

INTERNAL EXAMINATION 6 cm dilatation; 80% effacement; station -2; RBOW, clear; soft; midpostion (BS = 10) FRIEDMANS CURVE

EXTREMITIES I no lacerations, fissures noted PA warm to touch, no edema noted

MUSCULOSKELETAL I normal muscle strength of 5/5, normal ROM, no deformities, atrophy and swelling noted MENTAL STATUS The patient is appropriately dressed. She is in supine position and with good grooming. Cooperative with the interviewer. Mood is congruent with affect and appropriate. Thought process is coherent, no suicidal ideations or plans. Memory is intact to remote, recent and immediate recall. CRANIAL NERVES I able to smell II pupils equally round and reactive to light and accommodation III exhibit normal EOM IV able to move eyeballs obliquely V blinks whenever sclera was lightly touched VI able to move eyeballs laterally VII able to perform different facial expressions VIII able to hear loud and soft spoken words IX able to elicit gag reflex X able to swallow without difficulty XI able to shrug shoulders against resistance XII able to protrude tongue at midline and move it side to side

MOTOR: Muscle strength 5/5

COORDINATION: Finger to nose test intact

SENSORY: Pinprick: intact Light touch, position and vibration: intact

REFLEX: Negative primitive reflex Corneal reflex elicited

SALIENT FEATURES History of UTI poor follow up compliance Passage of watery vaginal discharge > 18 hours PTA 38 1/7 weeks AOG Ruptured bag of water upon speculum exam for 18 hours Pooling of clear watery discharge at the posterior vaginal wall Fluid per cervical os

DIFFERENTIAL DIAGNOSIS CERVICITIS An inflammation of cervix caused by a number of factors including infections, chemical/ physical irritations and allergens Ruled in due to the presence of: History of UTI Passage of watery vaginal discharge Abdominal pain Ruled out due to the absence of: Urinary frequency Multiple sexual partners Prior diagnosis of cervicitis BACTERIAL VAGINOSIS Mild infection of the vagina caused by bacteria Ruled in due to the presence of: Watery vaginal discharge Abdominal pain Ruled out due to the absence of: Vaginal discharge with unpleasant odor (fishy odor) Pruritus Multiple partners PREMATURE RUPTURE OF MEMBRANES Breaking of amniotic sac before labor begins Ruled in due to presence of: Watery vaginal discharge Abdominal pain 38 weeks AOG Ruptured bag of water > 18 hours Pooling of clear watery discharge Fluid per cervical os

EFM

LABORATORY

URINE FLOW CYTOMETRY WBC RBC EPITHELIAL CELLS CAST BACTERIA 19/UL 133/UL 26/UL 0/UL 42/UL

PHYSICAL EXAM COLOR CLARITY REACTION SPECIFIC GRAVITY YELLOW ORANGE SLIGHTLY CLOUDY 5.0 1.030

CHEMICAL ANALYSIS

GLUCOSE PROTEIN

++ TRACE

CASE DISCUSSION Premature Rupture of Membranes This term defines spontaneous rupture of the fetal membranes before 37 completed weeks and before labor onset. Such rupture likely has a variety of causes, but many believe intrauterine infection to be a major predisposing event. Some studies suggest that the pathogenesis of preterm rupture relates to increased apoptosis of membranes cellular components and to increased levels of specific proteases in membranes and amniotic fluid. Much of the membranes tensile strength is provided by the extracellular matrix within the amnion. Interstitial amnionic collagens, primarily types I and III, are produced in mesenchymal cells and are the structural component most important for its strength. Clinical factors associated with PROM Low socioeconomic status, low body mass index, tobacco use, preterm labor history, UTI, vaginal bleeding at any time of pregnancy, cerclage, amniocentesis.

DIAGNOSIS 1. Vaginal Speculum Exam the speculum should be sterile as to not introduce microorganisms into the vaginal vault - Examine the cervical os for dilatation, free flow of fluid, and pooling of fluid in posterior fornix. Visualization of fluid coming from the cervical os is diagnostic 2. NItrazine paper testing vaginal pH is acidic, amniotic fluid pH is alkaline at 7.0-7.7 3. Fern slide must allow slide to dry thoroughly prior to examination under microscope. Assess for arbonization of fluid. Cervical mucous has broad, ferning pattern that is different than the fern of amniotic fluid 4. Ultrasonography used to measure pockets of fluid and quantitate AFV to AFI.

MANAGEMENT

GESTATIONAL AGE TERM (37 weeks)

MANAGEMENT

Proceed to delivery Group B Streptococcus prophylaxis recommended Same as above

NEAR TERM (34-36 weeks)

PRETERM (32-33 weeks)

Expectant management unless fetal pulmonary maturity is recommended Antibiotics recommended to prolong latency if no contraindications exist Costicosteroids recommended by some experts, but no consensus exists Expectant management Group B Streptococcus prophylaxis recommended Antibiotics recommended to prolong latency, if no contraindications exist Single course of corticosteroids recommended No consensus on use of tocolytics Patient counselling Expectant management/ induction of labor Group B Streptococcus prophylaxis not recommended Data incomplete on the use of antibiotics to prolong latency Corticosteroids not recommended

PRETERM (24-31 weeks)

PRETERM (24 weeks)