CLINICAL CASES REPORT | TERM PREGNANCY (BIG BABY) | OBSTETRIC AND GYNAECOLOGY HISTORY

DEMOGRAPHY DATA (DD)

NAME: ZULFA YAGAWA.

AGE: 36 YEARS

SEX: FEMALE

ADDRESS: MOSHI

OCCUPATION: HOUSE WIFE

G4P3L2

LNMP: 03/04/2016.

EDD: 10/01/2017.

GA: 38wks+4 by early USS.

DATE OF ADMISSION: 28/12/2016.

 REASON FOR ADMISSION:

Term pregnancy with 1 previous scar and big baby.

She booked ANC at GA of 16wks and attended 7 times, received all supplements and she was normal tensive through are visits, PMTCT 2, VDRL non-reactive, B/G 0 RH +ve.

REVIEW OF OTHER SYSTEMS:

RESPIRATORY SYSTEM:

- No difficulty in breathing

 - No chest pain

  -No coughing

 - No chest tightness.

CARDIOVASCULAR SYSTEM:

 -No palpitation

 -No paroxysmal nocturnal dyspnea

 -No chest tightness.

MUSCULAR SKELETAL SYSTEM:

No joints pain.

No joints swelling.

OBSTETRIC HISTORY:

1^st Pregnancy delivered by SVD in 1994, 3.5kg but died after one year.

2^nd Pregnancy delivered by SVD plus vacuum in 1997, 3.5kg alive.

3^rd Pregnancy delivered by C/S in 2003, 4.2kg alive.

GYNECOLOGY HISTORY

She attained her menarche at 14 years old

Regular menstrual cycle, duration is four days, cycle is 28 days and she use two pads per day.

No history of pelvic inflammatory diseases.

PAST MEDICAL HISTORY;

-This is the fourth admission.

 -No history of history of drug allergy

- No history of blood transfusion.

FAMILY AND SOCIAL HISTORY.

-She is 36 years old female married.

-No history of alcohol consumption.

-No history of cigarette smoking

-No history of inherited diseases in the family.

ON EXAMINATION.

-Well looking afebrile, conscious, and oriented to people, place and time.

-No jaundice

-Not pale

-No lower limb edema

- Not dehydrated

- No lymph nodes enlargement.

 

VITAL SIGN

- BP is 110/70mmhg

- PR; 85b/min

- RR; 18B/min

- BT; 37 degree centigrade

 

SYSTEMIC EXAMINATION

PER ABDOMINAL EXAMINATION

- SUMI old scar seen

- Fundal height 36/40cm

- Longitudinal lie

- Cephalic presentation.

- Fetal heart rate 146B/min

CVS EXAMINATION

-no left side chest malformation or enlargement

 -No precordial hyperactivity

 - Apex beat heard at 4^th intercostal space mid clavicular left side of the chest.

- S1 and S2 sound heard clearly no added sound

 

RS. EXAMINATION

- No chest malformation

- No surgical scar on the chest

- Chest move with respiration

- Normal resonant sound heard on percussion

- Normal vesicular sound heard on auscultation.

 

 

 DIAGNOSIS: Term pregnancy with 1 previous scar and big baby.

INVESTIGATIONS

1. FBP

2. Blood grouping and cross-match.

3. Obstetric ultrasound.

PLAN: For elective C/S and patient requested for BTL.

           Patient declined trial of scar.

 INVESTIGATION RESULTS

1. Hb is 11.2g/dl.

2. Obstetric ultrasound results are GA 38wks, singleton pregnancy, BPP 8/8, EFW was 3.2kg, umbilical normal, and placental fundal not calcified.

1^st day in ward.29/12/2016.

Patient seen during ward round GA 38wks+1, for elective C/S but request to be done on 01/01/2017 as signed. BP 110/70, PR 78b/min. FHR 138b/min.

Pdx: Term Pregnancy + 1 previous scar denied a trial of scar.

2^nd day in the ward.30/12/2016.

 Patient seen during ward round GA 38wks+2, for elective C/S but request to be done on 01/01/2017 as signed. BP 120/80mmhg, PR 74b/min. FHR 136b/min.

3^rd day in the ward.31/12/2016.

Patient seen during ward round GA 38wks+2, for elective C/S tomorrow. BP 120/80mmhg, PR 74b/min. FHR 140b/min. Cancelled on danger signs, FBG 4.3mmol/L.

4^th day. 01/01/2017.

C/S Was done: Intra OP findings a male baby in breach presentation was extracted who scored 8-10 at 1 and 5 min respectively, weighing 3.35kgs, hemostasis were achieved and BTL was done. Post OP diagnosis: 1 previous scar with Breach.

Post op orders as per protocol.

1^stday post-operative.02/01/2017.

1. Patient seen during ward round no new complains, and her baby is doing fine sucking.

2. Stable vitals. BP 110/70mmhg, PR 74b/min, TEMP 36.5C.

3. Remove catheter and encourage ambulation

4. Start oral sips.

 

2^nd day post-operative.03/01/2017.

1. Patient seen during ward round no new complain.

2. Stable vitals BP 110/80mmhg, PR 72b/min, TEMP 36.5C.

3. Surgical wound is dry and clean.

4. Encourage ambulation

 

3^rd day post-operative 04/01/2017.

1. Patient seen during ward round no new complain.

2. Stable vitals. BP 120/80mmhg, PR 76b/min, TEMP 35.5C.

3. Surgical wound is dry and clean.

PLAN: Discharge home.

            To come to remove sutures on 11^th Jan 2017.

             Encourage breast feeding and feeding.