Antenatal Case Scenarios

CASE 1 – Severe PET

10/03/20:
EV, a 40-year-old iTaukei female, G 6P4A1 with gestational age of 322 came to high risk clinic with a BP of
200/120 mmHg and complaining of epigastric pain.
History of presenting complaint:
Epigastric pain started three days ago (07/03), the pain appeared to be sharp which radiated to the right
hypochondria and lower back. She had been taking paracetamol for the past 3 days which relieved her
pain. She did not take any herbal medications. Her daily activities were mildly affected.

She had no fever, no dysuria, no headaches, no visual abnormalities (scotoma, blurriness, etc.),
no nausea/vomiting, no dyspnoea or retrosternal pain and no altered mental state.
Past & current obstetric history:

She had been diagnosed with PIH during her previous pregnancy in 2016 and had been admitted
for gestational hypertension on the 2-4th of February this year. Readmitted on 11-19th of February
for the same reason. Does not have diabetes and no communicable disease noted.
Drug history:

No allergies to any medication.

Gynaecological history:

No previous pap smears done. Previously used IUCD as a family planning device. Had a
miscarriage in 1993, which was her first pregnancy. All the following pregnancies (1994, 2002,
2004 and 2016) were delivered through NVD at full term.
Family history:

Patient’s mother has HTN, otherwise no one else in the family with HTN and DM.
Social history:

Married and a maid by profession. Doesn’t smoke nor does she drink alcohol or kava. Lives in
Delainavesi in a 3-bedroom house with her husband and 4 children. Husband is an entrepreneur.
Diet dominantly consists of vegetables and fish.
Physical Examination:

Patient was sitting on the bed comfortably. Her hands are warm and capillary refill is < 2secs.
PR: 45 b/m; RR: 20 b/m; BP: 200/110 mmHg taken twice; BMI: ≥ 30
She had mild conjunctival pallor, no jaundice, no central cyanosis, pink oral mucosa and tongue.
No throat infections. More than 5 dental cavities noted and poor dental hygiene.
No neck swellings. Thyroid normal on clinical examination.
Clear lung fields, no basal crepitation. Normal S1 and S2 heart sounds heard without any
murmurs. Mild sacral edema noted.
Abdominal exam:

Single foetus, longitudinal lie, cephalic presentation, 5/5. Fundal height of 34cm.
Knee reflex: 2+ on both extremities.
Mild pedal edema noted on both extremities.
CTG: Category 1
Investigations:

10/03; 1545hrs 10/03; 1900hrs

FBC: Hb 11.7 12.9
Platelet count 57,000 40,000
MCV 93.2 91.6
PCV 33 35.9
WCC 11,270 13,800
UECr: Cr 109
Na+ 137
K+ 4.5
Cl- 109
eGFR 62
Urea 4.9
ALP 183
AST 58 80
Glb 22
TP 51
ALT 39 90
Alb
UA 488
LDH 751
Coagulation profile:
PT-----C
---------T
APTT-C
--------T
Dipstick 4+
Boiled urine loaded

Management:
The table below summarizes how the patient was managed

Date Time Management

10/03 1530hrs Admit patient
2 IV access on both hands
Administer antihypertensive – Hydralazine 5mg, IV
Repeat BP after 30mins administration of Hydralazine if diastolic BP >110mmHg;
Repeat BP after 1 hr, if diastolic BP is still >110mmHg, administer another dose of
Hydralazine and inform register
Administer Magnesium sulphate – loading dose and continue with maintenance
10mg IV
2nd regimen, 1st Administer dexamethasone 6mg IMI, BD
completed at 28wks
Paediatrics called for counselling
Insert IDC to monitor urine output
1555hrs Aldomet PO, 500mg q6hrly
1615hrs Transferred to labour ward
1630hrs Husband called in for family conference
11/03 1200hrs Emergency caesarean section done
Neonate taken to NICU for intensive care

CASE 2: TPROM
Presenting complaint
L.M, a 21-year-old G2P1 A+ seronegative with post foleys and misoprostol (2 cycle). Age of gestation 41 2
weeks of gestation by a 20 week scan. She was admitted due to fluid leakage vaginally.

History of presenting complaint

According to the patient, she noticed gush of water vaginally while she was in her bed. She tells that the
fluid ran down her thigh and wet the bed sheet. She then informed the staff in the ward who helped her
change her clothes.

Review of systems

 + headache
 - abdominal pain
 - blurry vision
 - PV bleeding
 + show
 - epigastric pain
 + FMF
 Urine output normal

Obstetrics and gynaecological history:

She had her menarche at age of 13. Her normal menstrual period was in August. According to the
patient, her menstrual cycle is regular and lasts for around 5 days. She uses around 4 pads. Her PAP
smear was done but she does not remember the date. She is a G2P1. Her first pregnancy was in 2016
which was a normal vaginal delivery of birth weight of 3.10kg. She did not have any complications during
her pregnancies. She had not been on any family planning.

Past medical history

She was admitted in 2016 during her delivery

Drug history and allergies:

She is not on any medications. She has no allergies

Social history

She lives with her husband and daughter. She does domestic duties. She is a non-smoker and doesn’t
drink alcohol.

Physical examination

O/E : comfortable, alert and well oriented

Vitals: BP: 107/54 mmHg RR: 21 b/m PR: 63 b/m Temp.: 36.4 0C

HEENT: no conjunctival pallor

Chest: lungs field clear. Good air entry.

Normal heart sounds. No murmur.

Abdomen: soft and non-tender. FH: 39cm, cephalic presentation of baby, 4/5 of the foetal head was
palpable above maternal symphysis pubis.

Extremities: warm and well perfused. CR< 2 sec. No edema was noted.

Speculum: pooling of light greenish liquor in the vaginal vault. Swab was taken.

VE: 4cm dilated, soft and well effaced. Vertex presentation. Station at -1. Light meconium. Absent caput
and moulding.

Investigation: FBC (10/5/18)

Hb: 12.2 WCC: 7000 Plts.: 184000 MCV: 98 Hct: 38

Assessment:

 Post dates
 Post misoprostol – 2 cycle
 Term prelabour rupture of membrane
 Light meconium stained amniotic fluid

Plans:

 Full blood count, X-match and HVS

 Ampicillin 1g IV every 6 hourly
 Counselled about risk of meconium aspiration syndrome and informed about the risks during
normal vaginal delivery vs cesarean section. Patient wanted normal vaginal delivery.
 CTG monitoring hourly
 Start syntocinon augmentation and transfer to first stage of labour. But there were no beds in 1 st
stage for the next 6 hours and patient waited in ante-natal ward.

Case 3 GDM

35-year-old iTaukei female, G4P3 O+ve, Sero-ve with age of gestation of 35 6 weeks of gestation who was
called in for admission for glycemic control.
FBS was 10.2 on the 1st of March.
She has defaulted about 3 ANC visits and doesn’t want any medication.

She was admitted in the first week of March as she had high 4 points. On discharge, she was prescribed
insulin 20 units subcutaneous TDS and Isophane 20 units nocte. Her previous 4 points was 8.6, 10, 8.2
and 8.7. She’s not allergic to any medications and denies that she had HTN and DM.

She had 3 pregnancies in which she had gestational diabetes and was on diet control. She had her first
pregnancy in 2013, second pregnancy in 2015 and then in 2017. She had normal vaginal delivery in all
her pregnancy and they were all term. Her 3 rd child was born with a weight of 4.okg.

She had menarche at the age of 13 and her menses has always been regular which usually lasts for four
to five days. She used 3 pads per day. She had a pap smear 3 years ago which was normal. She denies
any history of STI and never opted for family planning.

Her dad had diabetes mellitus type 2. No one in the family has hypertension. She lives with her husband
and children in Kinoya. She doesn’t smoke or drink alcohol.

Examination:

An obese, iTaukei female lying on bed comfortably without any distress.

Her vitals were as follows:

Examination Findings
PR 92 b/m
BP 110/72 mmHg
RR 20 b/m
Temp. Afebrile
CBG 14

Her conjunctiva were pink and sclera was clear without any yellow discoloration. Her oral mucosa was
moist.

On chest examination: vesicular breath sounds without any crepitations. Dual heart sounds were heard.

Her abdomen was non-tender with fundal height of 35cm. It was a longitudinal lie with cephalic
presentation and head was engaged with 5/5. Fetal movement were felt.

She didn’t have edema and pulse was regular with good volume. The capillary refill was less than 3
seconds.

Assessment:

1. Default clinic
2. Gestational diabetes mellitus A2

Plan:
 1. Admit pt. to antenatal ward
2. Do FBC and renal function test
3. For 4 points tomorrow
4. For trans-abdominal scan tomorrow for fetal assessment and AFI.
5. Continue with the current insulin dose and metformin 500g PO OD
6. CTG to be done per shift

Below are his investigation results:

Investigations Results
RCC 4.9x10^6
WCC 5.5x10^3
PLT 236x10^3
Hb 12.5
Na 135
K 4.3
U 29
Cr 73
eGFR 100
4 points 10.9, 12.6, 7.3, 5.7
Scan Single viable fetus, vertex
AFI: 10.8, EFW: 2632g
MG: 351, AC: 31.4, HC: 31.1, BPD: 8.6

Further Management:

1. Supervised insulin administration

2. Increase insulin nocte – 25 units
3. Metformin 500mg PO BD
4. Do 4 points
5. Assess for delivery at 37 weeks and aim for NVD, Cesarean-section if indicated.