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  1. PREPARED BY: DIANA KATHERINE MALINAO LR/DR

  2. DEMOGRAPHIC DATA

  3. CASE NO: 181*** NAME: MS. PTL 40/F Dx: PRETERM LABOR G2P1 Pregnancy Uterine 31 3/7 Weeks, Cephalic, PROM, Previous LSCS, GDM on diet, Vaginal Candidiasis

  4. PHYSICAL ASSESSMENT

  5. GENERAL The patient is 40 y/o, FEMALE, weighs 65 kg. She is conscious, coherent • Vital Signs: • BP= 120/70 mmHg • PR=80 bpm RR= 20 /mt • Temp=36.9⁰C O²Sat= 98%

  6. SKIN •  Pallor of skin and nails  No palpable masses or lesions

  7. HEAD •  Maxillary, frontal, and ethmoid sinuses are not tender.  No palpable masses and lesions •  No areas of deformity

  8. LOC & ORIENTATION  Awake and alert •  Oriented to Persons, Place, Time

  9. EYES  Pale conjunctivae and no dryness •  Pupils equally round and reactive to light

  10. EARS  No unusual discharges noted

  11. NOSE • Pink nasal mucosa • No unusual nasal discharge • No tenderness in sinuses

  12. MOUTH •  Dry mouth and lips • Free of swelling and lesions

  13. NECK AND THROAT No palpable lymph nodes No masses and lesions seen

  14. CHEST AND LUNGS ৣEqual chest expansion ৣNo retraction ৣClear breath sounds

  15. HEART Regular rhythm

  16. ABDOMEN ৩Globular abdomen ৩Abdominal scars from previous LSCS ৩The patient complained of mild hypogastric pain

  17. ABDOMEN • ৩Leopold’s Maneuver done: Cephalic presentation ৩FHR: 152bpm

  18. GENITALS • েWatery discharge since 1000H 13/08/12 েThick, yellow patchy, cheese like particles adhere to vaginal walls

  19. GENITALS েPatient claimed pain and burning on urination েCervix: 1cm dilation, 50% Effacement, Station -3 Cephalic, Clear AF

  20. EXTREMITIES • ৫Pulse full and equal • ৫No lesions noted

  21. PATIENT HISTORY

  22. PAST MEDICAL HISTORY  On her 1st pregnancy cardiac consultation was done all normal including 2D echo. Prenatal Care: Previous Prenatal in Pakistan and a clinic in Riyadh.

  23. PAST MEDICAL HISTORY Patient on Iron and Prenatal Vitamins. No known allergies. No history of Asthma, Hypertension, Renal disease and Thyroid problem.

  24. PAST SURGICAL HISTORY 1993 Arterial Ligation (Heart) No report

  25. PAST SURGICAL HISTORY • 2008 Low Segment Cesarean Section due to cord coil under General Anesthesia without complication

  26. PRESENT MEDICAL HISTORY • 12/08/12. 1 day prior to admission patient came to our OPD for prenatal check up. Patient claimed that 2 days ago • 1. she has a reddish-brown in character and minimal vaginal discharge • 2. mild hypogastric pain • 3. dysuria.

  27. PRESENT MEDICAL HISTORY • Ob/Gyne History: • Gravida: 2 • Para: 1 • Gestational Age: 31 3/7 Weeks • LMP: not sure • LMP by early UTZ: 06-01-12 • EDD: 13-10-2012

  28. PRESENT MEDICAL HISTORY • On Examination: • Vital signs: BP: 120/70mmHg, PR: 85 bpm, RR: 20 cpm, Temp. 37◦C, 02 Sat 96%, • FHR: 138bpm • IE: PV parous, closed. • Cardiotocogram: shows reassuring no contraction. • Investigation: • Amnisure ROM test: Negative

  29. PRESENT MEDICAL HISTORY • 13/08/12 Patient came to ER with chief complained of: • watery discharged since 1000H 13/08/12 • labor pains started since 2400H 12/08/12. •  According to the patient she took Aspirin 81mg OD 4 days ago

  30. PRESENT MEDICAL HISTORY •  Sugar monitoring at home are not well controlled •  No cardiac consultation on present pregnancy. • On Examination: • IE:PV 1cm dilated, 50%effaced, station -3, clear amniotic fluid.

  31. INVESTIGATION • Amnisure ROM test:Positive

  32. CTG or Cardiotocogram CTG TRACING

  33. BLOOD GLUCOSE MONITORING A fasting blood glucose level below 95 to 100 mg/dL and 2 hour postprandial level below 120mg/dL *Maternal & Child Health Nursing – Lippincot, 2007.

  34. Internal Medicine CONSULTATION • Patient has mild fluctuation in blood sugar level. • Patient does not need insulin; just diet control. • Plan: BSR x 8hourly, HBaIC, TSH

  35. MEDICATION

  36. Anesthesia CONSULTATION • Pre-Anesthetic Visit done. • For cardiac consultation.

  37. Cardiac CONSULTATION • PLAN • No specific intervention right now from cardiology side. • Low risk for cardiac arrest, no objection for operation if you need to do. • If you can decrease dose of Nifedipine to decrease tachycardia

  38. COLLABORATION • Neonatologist & Neonatal Intensive Care Unit Staff for Neonatal care/resuscitation.

  39. TOPIC PRESENTATION

  40.  Preterm Labor (PTL) is defined as regular contractions associated with cervical changes after 20 weeks’ gestation and prior to 37 completed weeks of gestation. •  It is the second, only to birth defects, as the leading cause of neonatal mortality.  It occurs in up to 12 % of all pregnancies and is the most frustrating clinical dilemmas in obstetrics.

  41. Molecular Mechanism of PTL 1. Premature activation of the maternal or fetal HPA axis 2. Decidual and amniochorionic inflammation 3. Decidual hemorrhage 4. Pathologic uterine distention

  42. ANATOMY & PHYSIOLOGY

  43. Hypothalamic-Pituitary-Adrenal Axis Stress

  44. ADRENAL HORMONES Cortisol Aldosterone Sex hormone & DHEA Adrenaline Noradrenaline

  45. MATERNAL SYSTEMIC DISEASE Heart Gestational Diabetes Current Pregnancy complications Fetal anomaly • Hydramnios • Abdominal surgery Previous LSCS • Infection • PROM • UTI • DEMOGRAPHIC DATA: • MATERNAL AGE • < 17 & > 35 PRETERM LABOR OTHER: • Stress • Occupational factors • BEHAVIORAL & ENVIRONMENT: • Poor Nutrition • Late Prenatal care UNKNOWN CAUSES RISK FACTOR OF PTL

  46. MATERNAL STRESS (Genital infections, Maternal factors/ Systemic Disease) FETAL STRESS (Uteroplacental insufficiency) Activation of maternal HPA axis Activation of fetal HPA axis ACTH Adrenocorticotropichormone  CORTISOL ADRENAL DECIDUA PLACENTA MEMBRANES COX-2 IN PGDH IN AMNION CHORION DHEAS  PLACENTA MEMBRANES CRH ESTROGEN   PROSTAGLANDINS MYOMETRIAL Oxytocin Receptors, Prostaglandins, Myosin Light Chain Kinase, calmodulin, gap junctions CERVICAL CHANGE CONTRACTIONS RUPTURE OF MEMBRANCES