2. CASE HISTORY-PERSONAL DETAILS
NAME: Mrs. SAGARIKA NAYAK RCH NO-121011124315
AGE/SEX: 25 YEARS / FEMALE IPD-93099. Dt-06.11.23 at 10.20 PM
ADDRESS:W/O SANGRAM NAYAK
AT/PO-MUGUNIPUR PS-SORO DIST-BALASORE
OCCUPATION:HOUSE WIFE
EDUCATION-+2 ARTS
RELIGION: HINDU
SOCIO-ECONOMIC STATUS:UPPER MIDDLE CLASS
DATE & PLACE OF EXAMINATION-07/11/2023 AT 9.30 AM ,ANC
ROOM FMMCH,BALASORE
3. CHIEF COMPLAINTS:
PATIENT REFERRED FROM CHC SORO TO DEPT, O&G, FMMCH
BALASORE, HAVING MULTI GRAVIDA AT 36 WKS 6 DAYS PERIOD OF
GESTATION (POG) WITH PREVIOUSLY DIAGNOSED TWIN GESTATION
WITH CHIEF COMPLAIN OF MILD PAIN IN LOWER ABDOMEN AND
MILD LEAKING PER VAGINUM(P/V)
4. MENSTRUAL HISTORY:
MENARCHE ATTAINED AT THE AGE OF 14 YRS
PREVIOUS MENSTRUAL HISTORY: REGULAR/ CYCLIC/ NORMAL FLOW
FOR 3 -4 DAYS IN EVERY 28 -30 DAYS INTERVAL/ NO PASSAGE OF CLOTS/
MILD PAIN DURING DAY 2- DAY 3 OF CYCLE PRESENT.
LAST MENSTURAL PERIOD (LMP): 21.02.2023
5. OBSTETRIC HISTORY:
MARRIED SINCE LAST 5 YEARS.
NON CONSANGUINEOUS MARRIAGE.
SPONTANEOUS CONCEPTION
OBSTETRIC SCORE: G2P1L1A0
PREVIOUS OBSTETRIC HISTORY: NVD/ LIVE FCH /2800 GMS/ INSTITUTINOAL
DELIVERY/ DOING WELL PRESENTLY AND ATTAIND ALL DEVELOPMENTAL MILE
STONES AS PER AGE.
PRESENT OBSTETRIC HISTORY:
A BOOKED CASE WITH EARLY REGISTRATION OF PREGNANCY DONE AT NEAREST
SUB CENTER BY MPHW (FEMALE) UNDER CHC SORO, BALASORE.
UPT(URINE PREGNANCY TEST), DONE BY SELF AFTER 2 MONTHS OF AMENORRHEA
LAST MENSTURAL PERIOD (LMP): 21.02.2023
EXPECTED DATE OF DELIVERY (EDD): 28.11.2023
GESTATIONAL AGE (GA): 36 WEEKS 6 DAYS
PATIENT GIVES HISTORY OF 9 MONTHS AMENORRHEA
APPREACITING FETAL MOVEMENT WELL.
6. HISTORY OF PRESENT ILLNESS (HPI):
A 25 YRS MULTI GRAVIDA (G2P1L1A0) WITH 36 WKS 6 DAYS PERIOD
OF GESTATION WITH PREVIOUSLY DIAGNOSED TWIN PREGNANCY
PRESENTED WITH MILD PAIN IN LOWER ABDOMEN SINCE 1- 2 DAYS
WHICH IS NON RADIATING TO BACK & MILD LEAKING PER
VAGINUM SINCE LAST 12 HRS. BEING REFERRED FROM CHC SORO
TO FMMCH BALASORE ON DT. 06/11/2023 AND ADMITTED TO LR/ANC
ROOM AT 10.30 PM
7. HISTORY OF PRESENT PREGNANCY:
FIRST TRIMESTER:
CONFIRMED AFTER 1ST MISSED PERIOD, UPT- POSITIVE (DONE BY SELF);
1ST ANC VISIT DONE AT CHC SORO AND DATING SCAN DONE AND FOUND
TWIN PREGNANCY WITH CARDIAC ACTIVITY AT GA-11 WKS 4 DAYS
NO NT SCAN (NUCHAL TRANSLUCENCY) DONE.
1ST DOSE OF TT GIVEN AND ALL ROUTIN ANC :BLOOD INVESTIGATION
DONE AND FOUND: HIV, HBsAg, HCV(NON REACTIVE), VDRL, TOXO(NON
REACTIVE), BLOOD GROUP AND RH TYPING (B POSITIVE)/ Hb gm% (10.2),
FBS (90 Mg/Dl) URINE R/M (NORMAL), TSH (1.2mIU/L)
NO FOLIC ACID TABLET WHERE TAKEN PRIOR TO CONCEPTION
NO H/O FEVER OR RASH, NO H/O OF EXCESSIVE VOMITING. NO H/O OF
EASY FATIGABILITY, NO H/O PAIN ABDOMEN, NO H/O SPOTTING OR
BLEEDING PER VAGINA
NO H/O EXPOSURE TO RADIATION AND DRUG INTAKE.
8. 2ND TRIMESTER
Inj. TT 2ND DOSE GIVEN AT 16 WKS (1 MONTH AFTER 1ST DOSE)
Tab. FERROES SULPHATE(100mg) + FOLIC ACID(0.5mg) & Tab. CALCIUM
(500mg)+VIT.D3 (250 IU) TWICE DAILY STARTED 14 WKS ONWARDS AND TAKING
REGULARLY
FETAL ANOMALIES SCAN(TIFFA) DONE AT 20 WKS OF GESTATIONAL AGE AND
FOUND MONOCHORIONIC MONOAMNIOTIC TWINS HAVING NO GROSS FETAL
ANOMALIES FOUND
NO QUADRUPLE MARKER TEST {(MSAFP, Beta-hCG), Unconjugated estriol (E3), Inhibin-
A} DONE
QUICKENING FELT AT 20 -22 WKS OD GESTATION AND CONTINUED TO PERCEIVE
FETAL MOVEMENT WELL.
NO H/O B/L PEDAL EDEMA / BLOOD PRESSURE IN NORMAL RANGE/ Hb (10gm%)
NO H/O PAIN ABDOMEN , LEAKING OR BLEEDING PER VAGINA
9. 3RD TRIMESTER
FETAL MOVEMENT WELL PERCEIVED.
CONTINUING TO TAKE IFA AND CALCIUM+ VIT. D3 TABLETS.
2 ANC AND 1 USG DONE.
NO C/O ABDOMINAL PAIN
NO H/O BLEED OR LEAKING VAGINA
GROWTH SCAN REPORT (USG) AT 30 WKS SHOWING GRAVID UTERUS
WITH TWIN LIVE INTRAUTREINE FETUS MONOCHORIONIC
MONOAMNIOTIC
TWIN A: BREECH/ 29 WKS 3 DAYS/ FHR 157 BPM/ EFW 1400gms
TWIN B: CEPHALIC/ 30WKS 4 DAYS/ FHR 150 BPM/ EFW 1550gms
PLACENTA: ANTERIOR GRADE 2
AFI: 9cm
10. PAST HISTORY:
NOT A KNOWN CASE OF HYPERTENSION/ DIABETES/ ASTHMA/
EPILEPSY/ THYROID DISEASE/ TUBERCULOSIS .
NO HISTORY OF BLOOD TRANSFUSION IN THE PAST.
NO HISTORY OF ANY RECENT SURGERY.
H/O NVD 3YRS BACK WENT UNEVENTFUL
FAMILY HISTORY:
NO H/O OF HYPERTENSION, DIABETES, ASTHMA, TUBERCULOSIS IN
FAMILY MEMBERS.
NO H/O OF TWINNING IN MOTHERS OR SISTERS
11. PERSONAL HISTORY:
MIXED INDIAN DIET.
SLEEP UNDISTURBED 6-8 HRS PER DAY ( LACKING OF
SLEEP/REST DURING DAY TIME)
APPETITE-NORMAL
BOWEL & BLADDER HABBITS-REGULAR
NO H/O DRUG INTAKE, ALCOHOL CONSUPTION, SMOKING.
H/O CONTRACEPTIVE (Cu 380A) PRESENT FOLLOWED BY OC
PILLS(MALA-N) FOR LAST 1YEAR PRESENT
12. GENERAL PHYSICAL EXAMITATION-
PATIENT WAS CONSCIOUS, COOPERATIVE WELL ORIENTED TO TIME, PLACE,
PERSON
AVERAGELY BODY BUILR AND NOURISHED
HT:152CM, WT: 65Kgs, BMI:29.1Kg/m2
PALLOR- MILD PALLOR PRESENT, MILD B/L PEDAL EDEMA PRESENT , NO
ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
VITALS:
TEMPERATURE- AFEBRILE(98.2F)
BLOOD PRESSURE- 124/76mm Hg IN RIGHT ARM SUPINE POSITION(RASP)
PULSE- 98 BPM, REGULAR IN RHYTHM, B/L SYMMETRICAL, GOOD VOLUME,
NORMAL IN CHARACTER, ALL PERIPHERAL PULSES ARE FELT WELL.
RESPIRATORY RATE- 18 CYCLES/MIN
BREASTS : B/L NORMAL
NO THYROMEGALY
13. SYSTEMIC EXAMINATION :
CNS: NO FOCAL NEUROLOGICAL DEFICIT.
CVS: S1,S2 NORMAL , NO MURMUR.
RESPIRATORY SYSTEM(RS): NORMAL VESICULAR BREATH SOUND(VBS)
PRESENT, B/L CHEST CLEAR , NO ADDED SOUNDS
PER ABDOMEN EXAMINATION:
INSPECTION:
ABDOMEN APPEARS GROSSLY ENLARGED
FLANKS FULL
UMBILICUS CENTRAL AND EVERTED
LINEA NIGRAE AND STRIAE GRAVIDARUM PRESENT
NO OTHER VISIBLE SCARS, ENGORGED VEINS, SINUSES PRESENT
14. PALPATION:
NO LOCAL RISE OF TEMPERATURE OR TENDERNESS
SFH: 34CM, ABDOMINAL GIRTH- 36 INCHES
UTERUS : OVER DISTENDED FOR GESTATIONAL AGE, RELAXED.
MULTIPLE FETAL PARTS FELT.
1ST TWIN IN BREECH PRESENTATION, 2ND TWIN IN CEPHALIC PRESENTATION
LIQUOR: CLINICALLY APPEARS REDUCED.
FUNDAL GRIP: BROAD, SOFT, IRREGULAR STRUCTURE FELT SUGGESTIVE OF
BREECH
LATERAL GRIP: RIGHT- MULTIPLE FETAL PARTS FELT
LEFT – MULTIPLE FETAL PARTS FELT
1ST PELVIC/PAWLIK GRIP: BROAD, SOFT, IRREGULAR STRUCTURE FELT
SUGGESTIVE OF BREECH
2ND PELVIC GRIP: PRESENTING PART BREECH NOT ENGAGED
15. AUSCULTATION:
2 FETAL HEART SOUNDS HEARD
ONE IN RIGHT SPINO-UMBLICAL LINE, REGULAR,138BPM AND 2ND JUST
ABOVE UMBLICUS TOWARDS LEFT SIDE, REGULAR 150 BP
INSPECTION OF VULVA: (IOV)
VULVA APPEARS NORMAL, NO EDEMA
MILD LEAKING +
ON SPECULUM EXAMINATION:
CERVIX AND VAGINA HEALTHY
MILD LEAKING THROUGH OS PRESENT
ON COUGHING REFLEX LEAKING PRESENT THROUGH OS
PER VAGINAL EXAMINATION:
CERVIX SHORT , SOFT.
OS CLOSED
16. PROVISIONAL DIAGNOSIS:
A 25 YRS OLD MULTI GRAVIDA(G2P1L1A0), PREVIOUS NVD AT
36WKS 6DAYS PERIOD OF GESTATION(POG) WITH TWIN LIVE
PREGNANCY 1ST TWIN BREECH AND 2ND TWIN CEPHALIC WITH
PPROM IN PRE-LABOUR.
17. INVESTIGATION:
CBC: Hb(10gm%), WBC COUNT(10500), PLATELET(2.5lakh)
URINE R/M: PUS CELL (10-12), PROTEIN (ABSENT)
REST ALL PARAMETER WITHIN NORMAL LIMITS
USG: DONE ON 07.11.2023 AT FMMCH BALASORE
TWIN A: BREECH/ 36 WKS 3 DAYS/ FHR 142 BPM/ EFW
2100gms
TWIN B: CEPHALIC/ 37WKS 4 DAYS/ FHR 150 BPM/ EFW
2300gms
PLACENTA: ANTERIOR GRADE 3
AFI: 5cm
18. DIAGNOSIS:
A 25 YRS OLD MULTI GRAVIDA(G2P1L1A0), PREVIOUS
NVD AT 36WKS 6DAYS PERIOD OF GESTATION(POG)
WITH MCMA TWIN LIVE PREGNANCY 1ST TWIN
BREECH AND 2ND TWIN CEPHALIC WITH PPROM
WITH OLIGOHYDROAMNIOUS WITH MILD ANEMIA
WITH UNFAVUORABLE CERVIX IN PRE-TERM
LABOUR.
19. MANAGEMENT PLAN:
Dt: 06.11.2023(10:30pm)
Inj. DEXAMETHASONE 6mg IM 12 hourly 4 doses to be given
Inj. Ceftriaxone 1gm iv 12 hourly to be given
Monitor FHR
Bed rest and use sterile pad
Patient councelled about fetal prognosis.
NICU consultation to be done
LSCS to be done after USG report and Dexona completion
20. COURSE IN HOSPITAL:
Patient complaining of pain lower abdomen which
increasing intensity and radiating to back with blood mixed
mucoid discharge since 2:30 pm
Patient received 2nd dose of dexona at 11am dt 07.11.2023
and antibiotic 2nd dose
on examination: P/A uterus irritable, FHS 146, 158
P/V Cx 50%effaced, OS admitting 1cm, presenting part
breech
Patient prepared for emergency LSCS
21. EMERGENCY LSCS NOTE:
Emergency LSCS done under spinal anesthesia
INDICATION multi with twin with 1st twin breech with pprom with
oligohydroamnious
Delivered twin male child having
Twin 1: MCH, 2000gms, 04:04PM BY BREECH EXTRACTION
APGAR 10/10
Twin2: MCH, 2100gms, 04.06PM BY CEPHALIC DELIVERY
APGAR 10/10
No intraop complications
Both babies send to SNCU for LBW
22. POST OP FOLLOW UP:
Rx
1. NPO for 24 hours.
2. IVF 2 pnt RL, 2pnt D5, 2 pnt NS
3. Inj. Oxytocin 10 unit in 1st 3pnt IVF 30-40 drops per minute
4. Inj. Tranexa 500mg IV TDS for 24 hours
5. Inj. Ondansatron 1 amp IV TDS for 24hours
6. Inj. Ceftriaxone+ sulbactum 1.5gm IV BD FOR 5 days
7. Inj. Metronidazole 1 bottle IV TDS for 5 days
8. Inj. Amikacin 500mg IV BD for 5 days
9. Inj. Diclofenac 1amp IM BD for 5 day
10. Inj. Pantoprazole 40IV OD for 5 days
