This document contains preoperative data and information for a 27-year-old pregnant patient. She presented with labor pains at 35 weeks and 6 days gestation. Examination found the fetus in cephalic presentation with adequate amniotic fluid. Ultrasound revealed persistent fetal bradycardia, cardiomegaly, and signs of multiple cardiac anomalies. The preoperative diagnosis was pregnancy at term with suspected multiple fetal cardiac anomalies. The plan was a low transverse cesarean section for the previous uterine scar and fetal indications.

1. PERTINENT DATA HPI PE DIAGNOSTICS PREOPERATIVE DIAGNOSIS
OR 27 yo
G3P2 (2002)
Prenatal check-up:
TPH 5x
Chief complaint:
Labor pains
Past Medical History:
Unremarkable
Family History:
Unremarkable
Personal and Social History:
Unremarkable
OB History:
G3P2 (2002)
G1- NSD, home delivery,
midwife assisted,
uncomplicated
G2 – LTCS I x NRFS, TPH,
2019 uncomplicated
G3 - Present pregnancy
Gynecologic History:
Unremarkable
Few hours prior to
admission, patient
complained labor
pain with bloody,
mucoid discharge.
Patient sought to
our institution for
consult hence
admission.
Weight: 69 kg
Height: 167 cm
BMI: 19.7 kg/m2
Normal
Fundic Height:
30 cm
FHT: 80s-90s via
doppler/UTZ
EFW by cupping
method: 3000 to
3300 grams
Internal
Examination:
1 cm dilated,
beginning
effacement,
cephalic, (+) BOW,
St-2
RDT: Nonreactive
HBsAg: Nonreactive
CXR: Normal chest
Ultrasound
PERSISTENT FETAL BRADYCARDIA. FHT 60s-80s
CARDIOMEGALY AND SINGLE ATRIUM, CARDIAC ARRHYTHMIA T/C DEXTROCARDIA.
Impression
PREGNANCY UTERINE 35 WEEKS 6 DAYS BY FETAL
BIOMETRY.
LIVE, SINGLETON, IN CEPHALIC PRESENTATION.
ADEQUATE AMNIOTIC FLUID VOLUME.
FUNDAL PLACENTA GRADE III, HIGH LYING.
EFW: 2962g
BIOPHYSICAL PROFILE SCORE: 10 / 10
T/C SUSPICIOUS MULTIPLE CARDIAC ANOMALY.
Congenital Anomaly Scan
Fetal anatomic survey shows no craniovertebral anomaly, normal facial features with
intact lips and palate, stomach on the left and below an intact diaphragm, normal
kidney size and echotexture with no signs of obstruction; fluid-filled bladder, 3-vessel
cord with normal insertion, complete extremities which are well-aligned: female
external genitalia. There are episodes of fetal bradycardia, going as low as 100 bpm
Comments:
Nasal bone – 0.8 cm. The normal crux of the heart is mot demonstrated. There is atrial
septal defect, ventricular septal defect, overriding of the aorta and thickening of the
right ventricular walls, suggestive of congenital cardiac anomaly.
No other obvious congenital anomaly noted
ANA: negative
G3P2 (2002) Pregnancy Uterine 38 2/7 weeks
Age of Gestation, cephalic in labor, Previous CS I
for Non reassuring fetal status(2019 TPH); t/c
Multiple Fetal Cardiac Anomaly
*Referred to Perinatologist
Plan: Low transverse Cesarean Section II for
previous uterine scar
Condition explained
Procedure: LTCS II
EBL: 300 cc
Final Diagnosis
G3P3 (3003) Pregnancy Uterine term, cephalic,
to a live baby girl AS: 9,9 BW 3 kg, Ballard Score
38 weeks AGA via LTCS II for previous uterine scar
under spinal anesthesia, Previous CS I for Non
reassuring fetal status (2019 TPH)
CBC Admission
Hemoglobin 138
Hematocrit 0.373
WBC 10.1
Platelet 292,000

2. PERTINENT DATA
HISTORY OF PRESENT
ILLNESS
PHYSICAL
EXAMINATION
DIAGNOSTICS PREOPERATIVE DIAGNOSIS
RM 27/M
G3P2 (2002)
Prenatal check-up:
Sta. Ignacia HC 3x
Chief complaint:
Labor pains
Past Medical History:
Unremarkable
Family History:
Unremarkable
Personal and Social History:
Unremarkable
OB History:
G1- NSD, live,Term, Health
center, Midwife assisted
G2- NSD, live,Term, Health
center, Midwife assisted
G3 - Present Pregnancy
Gynecologic History:
Unremarkable
13 hours prior to
admission, patient had
labor pains increasing
in intensity associated
with watery vaginal
discharge. Patient was
brought to Sta. Ignacia
health center and was
for trial of labor.
1 hour PTA, patient
insisted transfer in our
institution, hence
admission. No prior
endorsement was
made before transfer.
Patient denies
headache, difficulty of
breathing, blurring of
vision, epigastric pain,
dizziness, nausea and
vomiting.
Weight: 153 kg
Height: 58 cm
BMI: 24.8 kg/m2
Normal
Awake, conscious,
coherent
GCS 15
BP 140/100
HR 88
RR 19
T 36.8
O2 sat: 99% at room air
C/L: Clear Breath Sounds
Fundic Height: 32 cm
FHT: 120s by doppler, RLQ
EFW by cupping method:
3000-3200 grams
Internal Examination:
Cervix fully dilated, fully
effaced, cephalic St +4, (-)
BOW, Thickly meconium
stained
FBS: 5.8 mmol/L
BUN: 3.24 mmol/L
Crea: 66.9 mmol/L
SGPT: 28 U/L
SGOT: 16 U/L
Urinalysis
Pus 0-2
RBC 15-20
Protein negative
Glucose negative
RDT: Nonreactive
HBsAg: Nonreactive
No ultrasound
G3P2 (2002) Pregnancy uterine 40 3/7 weeks
Age of gestation, Cephalic in labor,
Gestational Hypertension
Plan: Assisted Vaginal Delivery
Hypertensive work up
Condition explained
Final Diagnosis
G3P3 (3003) Pregnancy Uterine delivered
term, cephalic, to a live baby boy, AS 8,9 BW
3.1kg, Ballard Score 39 weeks, AGA via
Normal Spontaneous Delivery, Thickly
meconium Stained Amniotic Fluid,
Gestational Hypertension
CBC
Hgb 123
Hct 0.353
WBC 16.85
Plt 243,000