5th year medical student _ Tabuk University

1. OB&GYN
Case presentation
Done by :
Afrah Dhaifallah
Elaf Ibrahim
Norah Abdurrahman

2. Personal Hx:
Maram, 34 years old Saudi housewife who lives in Tabuk.
Married for 6 years. G3P2002, her LMP was 16 of April 2016,
EDD is 23 of January 2017 and GA is 32 weeks.
Her husband’s name is Muhammad, a 41 years old Soldier.
Both she and her husband have no medically significant
habits.

3. C/O:
She came to ER complaining of:
Leakage of fluid from her
vagina for 1 hour.

4. HPI:
Patient was well until her 32 week when fluids started gushing suddenly from her
vagina.
The fluids were clear, serous in consistency, odorless, and about two cups in amount.
She was diagnosed with bacterial vaginosis one week ago and got treatment.
She feels good fetal movements. No lower abdominal pain nor back pain. No vaginal
bleeding. No current vaginal itching or smelly discharge.
No GIT nor Urinary symptoms. No fever. No recent abdominal trauma. No previous
similar episode.

5. Current obs Hx
Her current pregnancy was spontaneous, not planned. She perceived
her pregnancy by 2ry amenorrhea 2 weeks after her usual menstrual
time then she did a pregnancy test at home which was positive. She
confirmed the pregnancy by serum HCG.
She had vomiting, nausea in her 1st trimester. She follows up regularly
at Military hospital. She underwent US in the 8th week and the GA was
confirmed. She did U/S , Blood and urine tests in her 2nd trimester and
the results were normal. She felt the fetal movement at week 18 of
gestation. She takes folic acid and vitamins. No chronic illnesses, no
other pregnancy complications. No prior use of contraception.

6. Past obs Hx:
All Her past pregnancies were spontaneous, not planned, no use of
contraception, free of complications.
Her 1st baby * his age now 5 years old *
was delivered at full-term, vaginally , episiotomy was done , no intra or post-
partum complications. She doesn’t remember the length of her labor. The
baby was a boy, 3 kg. She breast-fed him for 9 months.
Her 2nd baby * her age now 2 years old *
was delivered at full-term, vaginally , episiotomy was done , no intra or post-
partum complications. She doesn’t remember the length of her labor. The
baby was a girl, 1.8 kg. She breast-fed her for 7 months.

7. Menstrual Hx:
 LMP: 2nd of May of this year.
 She had her menarche when she was 11 years old.
 Regular length and frequency, 7/30.
 Moderate flow.
 No dysmenorrhea.
 No intermenstrual bleeding.
 Premenstrual symptoms ( breast pain & lower abdominal pain 4 days before her
period )
 No Midcyclic pain.
 No post-coital pain nor bleeding.

8. Past medical and surgical Hx:
No chronic illness, no previous surgeries, no
blood transfusion, no allergies.

9. Drug Hx:
No use of other drugs nor herbs.

10. Family Hx:
Both of her parents has type 2 Diabetes.
No Hx of similar condition, genetic
diseases, twins, or tumors.

11. Social Hx:
Unhealthy diet.
No exercise.
No smoking.
No alcohol consumption.
No Animal contact.
No recent traveling.

12. Systemic review was insignificant.

13. Summary
 Maram, 34 years old, G3P2002,
 present at 32 weeks gestation to ER complaining of sudden gush of clear odorless fluids
from her vagina for 1 hour.
 Positive history of bacterial vaginosis one week ago which was treated.

15. ∆D:
P-PROM.
Urinary incontinence.
Vaginal infection.

16. EXAMINATION
General:
Patient is alert, conscious,
oriented and lying
comfortably on the bed.
BMI: 23.
Vital signs:
Pulse: 83 bpm
BP: 94/53 mmHg
TMP: 36°
RR: 20.
O2 saturation: 100%
Abdominal:
Abdomen is Soft, lax and not
tender.
Fundal height: 32 cm.
Single fetus, longitudinal lie,
breech presentation.
Positive fetal movement.
Pelvic:
Sterile Speculum
Examination: Os is
closed. fluid is leaking
from the cervical
opening when the
patient coughs and
there's fluid pooling in
the posterior fornix.

17. Investigation: CBC
Values Normal
WBCs 8.27 4-11 x103
RBCs 4.27 3.8-4.8 x106
HB 9.8 12-16 g/dl
HCT 32.1 36-45
MCV 75.2 82.7-89.4

18. Investigation:
Normal rangeValuesTest
2.12 – 2.522.04Calcium
All within normalElectrolyte
All within normalCoagulation
profile
34-50 g/l
30-65 U/l
All within normal except :
Albumin = 28
ALT = 15
Liver
function test

19. US Report:
Single viable fetus.
breech presentation.
Posterior placenta.
AFI = 1.8 cm. (Liquor is markedly decreased)
BPD = 31 weeks .
FL= 31weeks + 6 days.

20. Urine analysis was normal. No
bacteriuria.

21. Nitrazin and Fern test weren’t
available at the hospital.

24. What’s your first step in
management?

25. •Admission.
•Continuous maternal and fetal monitoring.
•Dexamethasone: 6 mg every 12 hours for 48 hours.
•7 days course of Antibiotics:
oAmpicillin 2g IV every 6h for 48 hours.
oAmoxicillin 500 mg for 5 days.
•Delivery at 34 weeks of gestation.