CLINICAL CASES (OBSTETRICS)

CASE 1 – ANEMIA IN PREGNANCY

CASE 2 – PREGNANCY INDUCED HYPERTENSION (PRE-ECLAMPSIA)

CASE 3 – PREVIOUS CAESAREAN SECTION

CASE 4 – Rh NEGATIVE PREGNANCY

CASE 5 – HEART DISEASE IN PREGNANCY – 1

CASE 6 – HEART DISEASE IN PREGNANCY – 2

1. CASE OF ANAEMIA IN PREGNANCY

Name – Vasanthamma                                                                   Husband’S Name – Bailanjappa
Age – 30 years                                                                              Age – 35 years
Address – Nelamangala                                                                  Occupation – Coolie
Occupation – Housewife                                                                  Income – Rs. 3300/month
Religion – Hindu                                                                             SE Status – Upper Lower class

G₃P₂L₂ comes with 8 months of amenorrhea

PRESENTING COMPLAINTS – Easy fatigability since 2 months

HISTORY OF PRESENTING COMPLAINTS:

• Patient presents with 8 months of amenorrhea with easy fatigability since 2 months.  Previously, the patient was able to do her household work, but for the past 2 months, she gets tired even with minimal work.  On walking about 50 m, patient complains of fatigability, giddiness, blurring of vision which is relived on rest.
• No history of increased bleeding during menses prior to pregnancy.
• No history of exertional dyspnea, palpitation, PND, pedal edema or giddiness.
• No history of bleeding or leak PV.
• No history of bleeding PR or malena.
• No history of passing worms in the stools.
• No history of fever with chills and burning micturation.
• No history of cough with expectoration, hemoptysis, evening rise of temperature or contact with a known case of tuberculosis.
• No history of drug intake (anti-malarial drugs or aspirin).
• No history of any yellowish discolouration of skin and sclera.
• Not a known diabetic or hypertensive.

OBSTETRIC HISTORY:

Married Life – 13 years, Non-consanguinous
Obstetric index – G₃P₂L₂

No.	DELIVERY	BABY AT BIRTH	PRESENT AGE	COMMENTS
G1	FTND, Government Hospital	Cried soon after birth, Male, 3.2 kg, Breast fed 3 years	12 years	Booked & Immunized(Had 3 ANC visits + TT + IFA)Post partum period – normal
G2	FTND, Government Hospital	Baby cried soon after birth, Female, 3 kg, Breast fed – 2 ½ years	10 years	Booked & Immunized(Had 3 ANC visits + TT + IFA)Post partum period – normal

LMP – 02/11/2006
EDD – 09/07/2007

PRESENT PREGNANCY

T₁

• No history of nausea, vomiting or weakness.
• No urinary symptoms
• No drug intake
• No history of craving for abnormal food (pica)

T₂

• Quickening in 5^th month
• 1^st ANC visit – 20 weeks, given TT & IFA tablets (consumed)

T₃

• Fetal movements present
• No leak or bleed PV
• No h/o pain abdomen

CONTRACEPTIVE HISTORY:

No history of using any contraceptive methods.

MENSTRUAL HISTORY:

Age of Menarche – 13 years
Past Cycles – Regular 30 days cycles with flow lasting 5 days, normal quantity, no pain or passing of clots.
LMP – 02/11/2006

FAMILY HISTORY:

No history of congenital anomalies or twinning, DM, HTN

PAST HISTORTY:

No history of Tuberculosis, Epilepsy, Asthma
No history suggestive of any cardiac ailments.
No history of previous surgeries, blood transfusions.

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

DIET HISTORY:

Consumes – 2100 kcal/day
Required – 2400 kcal/day
Deficit – 300 kcal/day

GENERAL PHYSICAL EXAMINATION:

Here is a pregnant lady 30 year old, moderately built and nourished, conscious, alert & cooperative.

Pulse                – 84/min, regular, good volume
BP                    – 110/68 mm of Hg
RR                    – 14/min, regular
Temperature       – Patient is afebrile

Pallor                           – Present
Icterus                          – Absent
Cyanosis                      – Absent
Clubbing                       – Absent
Edema                         – Absent
Lymphadenopathy         – Absent

Thyroid                         – Normal
Breasts                         – Normal
Spine                            – Normal

Height                          – 146 cm
Weight                         – 56 kg
BMI                              – 26.27

SYSTEMIC EXAMINATION:

CVS –  S₁ S₂ heard, No murmurs.
RS –  NVBS heard, no basal crepts.
CNS – NAD.
PA – Normal bowel sounds heard

OBSTETRIC EXAMINATION:

INSPECTION:

• Abdomen is uniformly distended, globular in shape
• Umbilicus everted, hernial orifices normal
• Flanks do not appear to be full
• Stria gravidarum and linea nigra present
• No scars over the abdomen

PALPATION:

• Abdominal circumference – 76 cm
• Symphysio-fundal height – 28 cm (corresponds to 32 weeks)
• FUNDAL GRIP – Soft, broad & non-ballotable, suggestive of breech
• Lateral Grip –    Knob like structures on the right side suggestive of limb buds                                Uniform resistance on the left side suggestive of spine
• 1^ST PELVIC GRIP – Smooth, hard, ballotable mass suggestive of head
• 2^ND PELVIC GRIP – Fingers converge, head not engaged.
• Uterus is relaxed

• Fetal age = 28*8/7 = 32 weeks
• Fetal weight = (28-12)*155 = 2480 gm

AUSCULTATION:

• Fetal Heart sounds heard along the left spino-umbilical line
• 142/min, regular, rhythmic

DIAGNOSIS:

30 year old G₃P₂L₂A₀ with 32 weeks of gestation, moderate anemia probably due to iron deficiency, not in labour with no clinical signs of failure.

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2. CASE OF PREGNANCY INDUCED HYPERTENSION (PRE-ECLAMPSIA)

Name – Narayanamma                                                                        Husband’s Name – Chandrababu
Age – 20 years                                                                                   Age – 25 years
Occupation – House wife                                                                     Occupation – Driver
Address – Dairy Circle                                                                         Income – Rs.1700/per/month
Religion – Hindu                                                                                   SE Status – Upper Middle Class
Date of Admission – 10/07/07                                                               Date of examination – 12/07/07

G₂P₀A₁ comes with 8 months of amenorrhea.

PRESENTING COMPLAINTS: Generalized edema – since 10 days.

HISTORY OF PRESENTING COMPLAINTS:

• Patient is a gravida ₂ para₀ presents with generalized edema since 10 days, insidious in onset, initially noticed in the lower limbs which have gradually progressed to involve the upper limbs and face.  It is present throughout the day (no diurnal variation), not relieved by overnight rest nor by limb elevation in the morning.
• No history of headache, blurring of vision or syncopal attacks        
• No history of reduced urine output, hematuria.                             
• No history of chest pain, palpitations or breathlessness on exertion or history suggestive of cardiac failure.                                          
• No history of epigastric pain, nausea, vomiting.                             
• No history of DM or HTN.
• No history of jaundice, ascities before 20 weeks of gestation.                  

OBSTETRIC HISTORY:

Married Life – 2 years (non – consanguinous marriage)
Obstetric index – G₂P₀A₁

LMP – 03/11/06
EDD – 10/08/07

PREVIOUS PREGNANCY

G₁:

• Painless spontaneous abortion at 6^th month following bleeding PV.  Patient had gone for 4 ANC visits, 2 scans, booked and immunized.
• No history of excessive vomiting.                           (Rule out H. mole)
• No history of HTN during pregnancy.

PRESENT PREGNANCY

T₁

• Morning sickness for 2 months – present.
• Increased frequency of micturation – present.
• No history of easy fatiguability.
• No history of discharge or bleed PV.
• No history of drug intake or radiation exposure.
• No history of Pica.

T₂

• Quickening at 5^th month.
• No history of headache, blurred vision or sudden increase in weight.
• Booked and Immunized – 3 ANC visits, 2 TT, 100 IFA, Scan done at 20^th week.

T₃

• Fetal movements present.
• No history of bleeding or discharge PV.
• No history of pain abdomen.
• Generalized edema – present.
• Last abortion – 1 year back.

MENSTRUAL HISTORY:

Age of Menarche – 16 years
Past Cycles – Regular, 30 day cycle, 4 days flow, no pain or passage of clots.
LMP – 03/11/06
No history of any contraceptives used.

FAMILY HISTORY: No history of DM, HTN, asthma, twinning in family.  No history of PIH in mother or                                    sister.

PAST HISTORTY:

Medical –  No history suggestive of DM/HTN.No history of TB, epilepsy or asthma.
Surgical –  No history of blood transfusions or any previous surgical procedures.

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Here is a pregnant lady, moderately built and nourished, conscious, alert & cooperative; well oriented to time, place and person.

Pulse                – 86/min, regular, good volume
BP                    – 146/92 mm of Hg
RR                    – 18/min, regular
Temperature       – Patient is afebrile

Pallor                 – Present
Icterus               – Absent
Cyanosis            – Absent
Clubbing             – Absent
Edema (pedal)     – Present, Pitting in nature
Lymphadenopathy – Absent

Thyroid              – Normal
Breasts             – Normal
Spine                – Normal
Gait                  – Normal

Height              – 160 cm
Weight             – 70 kg
BMI                  –  27.3

SYSTEMIC EXAMINATION:

CVS – S₁ S₂ heard, no murmurs.
RS – NVBS heard, no additional sounds heard.
CNS – Knee jerk – present.  Sensory, motor and cranial nerves – normal.
PA – Normal bowel sounds heard

OBSTETRIC EXAMINATION:

INSPECTION:

• Abdomen uniformly distended.
• Flanks not full.
• Umbilicus – everted.
• Striae gravidarum, albicans & linea nigra – present.
• No scars over abdomen, no dilated veins.
• Hernial orifices – normal.

PALPATION: (Patient examined in supine position with legs semi flexed).

• Fundal height corresponds to 32 weeks gestation.
• SFH is 28 cm, abdominal circumference – 85 cm.
• Fundal grip – Smooth, broad irregular structure suggestive of breech.
• Lateral Grip – Right – Knob like structures suggestive of limb buds.                                           Left – Uniform curved resistance suggestive of spine.
• 1^st Pelvic Grip – Smooth, round, hard ballotable mass (not engaged) suggestive of head felt at lower pole

AUSCULTATION:

• FHS heard along the left spino-umbilical line, mid point.
• Rate – 146/min, regular.

DIAGNOSIS:

20 year old G₂A₁ with 32 weeks gestation, single live fetus with cephalic presentation with head not engaged and not in labour, with mild pre-eclampsia (on treatment) complicating her pregnancy.

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3. CASE OF PREVIOUS LOWER SEGMENT CAESAREAN SECTION

Name – Anita                                                                                 Husband’s Name – Venkatesh
Age – 23 years                                                                               Age – 24 years
Address – Atmajyothinagar, Kengeri                                                 Occupation – Painter
Occupation – Maid servant                                                               Income –Rs.2600/mnt
Religion – Hindu                                                                              SE Status – Lower Middle Class
Date of admission – 09/07/2007                                                        Date of examination – 10/07/2007

G₂P₁L₁ comes with 9 months of amenorrhea for safe confinement

HISTORY OF PRESENTING COMPLAINTS:

• Patient comes with 9 months amenorrhea with a history of previous LSCS and was admitted for safe confinement.  Patient had been here for regular ANC checkup on 27/07/2007 and was asked to get admitted as her EDD as per scan was 10/07/2007.
• Patient complaints of backache since today morning in the lower mid-back, non-radiating and not associated with pain abdomen.
• Patient gives history of white discharge since 1 week, non-foul smelling, not associated with fever or itching.
• No history of leak PV or bleeding PV.
• No history of hematuria.
• No history of any change in bladder habits.
• Fetal movements are well perceived.
• No history of Diabetes mellitus or Hypertension.

OBSTETRIC HISTORY:

Married Life – 4 years (non – consanguineous marriage)
Parity  index – G₂P₁L₁

LMP – 01/11/06
EDD – 08/08/07

PREVIOUS PREGNANCY:

T₁

• History of increased vomiting – present.
• History of easy fatigability.
• No history of urinary symptoms.
• No history of drug intake or radiation exposure.
• No history of pica.

T₂

• Quickening at 20^th week.
• History of generalized edema – present.
• No history of headache or blurring of vision.
• Patient was booked and immunized – 6 ANC checkups, 2 USG scans, 2 TT & 100 IFA.

T₃

• Fetal movements present.
• Uneventful.

• Delivered by Lower Segment Caesarean Section probably due to obstructed labour or non-progression of labour.
• Patient was initially put n trial of labour by administering injections, but since labour pains were not adequate, she was posted for emergency LSCS, after infusing 1 unit of blood.
• Outcome was a live male fetus, 3.7 kg at birth, was immunized and exclusively breast fed for 1 year.
• Mother had no fever or wound discharge in the post-op period.
• Sutures were removed on the 7^th day but had to stay in the hospital for 16 days as the baby had jaundice.
• Last C-section – 3 years back (April 25^th, 2004)

PRESENT PREGNANCY: T₁, T₂ and T₃ uneventful. EDD-08/08/07

CONTRACEPTIVE HISTORY:

No history of using any contraceptive methods.

MENSTRUAL HISTORY:

Age of Menarche – 12 years
Past Cycles – Regular, 50-70 day cycle, 8-9 days flow, no pain or passage of clots.
LMP – 01/11/06
No history of any contraceptives used.

FAMILY HISTORY: No history of DM, HTN.

PAST HISTORTY:

Medical – No history suggestive of DM/HTN.  No history of TB, epilepsy or asthma.
Surgical – No history of blood transfusions or any previous surgical procedures.

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Mother is a young lady, moderately built and nourished, conscious, alert & cooperative; well oriented to time, place and person.

Pulse                – 78/min, regular, good volume
BP                    – 116/82 mm of Hg
RR                    – 18/min, regular
Temperature      – Patient is afebrile

Pallor                – Present
Icterus               – Absent
Cyanosis           – Absent
Clubbing            – Absent
Edema              – Absent
Lymphadenopathy – Absent

Thyroid              – Normal
Breasts             – Normal
Spine                – Normal
Gait                  – Normal

Height                         – 158 cm
Weight                         – 51 kg

SYSTEMIC EXAMINATION:

CVS – S₁ S₂ heard, No murmurs.
RS – NVBS heard, no basal crepts.
CNS – NAD.
PA – NAD

OBSTETRIC EXAMINATION:

INSPECTION:

• Distended and flanks are full.
• Umbilicus – normal.
• Striae gravidarum, albicans & linea nigra – present.
• No dilated veins.
• Hernial orifices – normal.
• A vertical right paramedian incision, 14 cm long is seen in the infra-umbilical region, healed by primary intention – no hypertrophy or keiloid formation, no supra-pubic bulge.

PALPATION: (Patient examined in supine position with legs semi flexed).

• Fundal height corresponds to 32 weeks with flanks full – corresponding to 40 weeks of gestation.
• SFH is 32cm.
• Fundal grip – Broad, soft irregular structure suggestive of breech.
• Lateral Grip – Right – Knob like structures suggestive of Limb buds.                                          Left – Uniform curved resistance suggestive of spine.
• 1^st Pelvic Grip – Smooth, hard ballotable mass.
• 2^nd Pelvic Grip – Fingers diverge.
• Abdominal girth – 95 cm.
• Weight of the fetus (Johnson’s formula) = 3260 gm.
• Age of fetus (Mc Donald’s formula) = 40 weeks.
• No scar tenderness.
• No supra-pubic bulge felt.

AUSCULTATION:

• FHS heard along the left spinoumbilical line, mid point.
• Rate – 140/min, regular.

DIAGNOSIS:

23 year old G₂P₁L₁ with full term single intrauterine pregnancy with previous LSCS with longitudinal lie with cephalic presentation not in labour.

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4. CASE OF Rh NEGATIVE PREGNANCY

Name – Savita                                                                                   Husband’s Name – Satishchandra
Age – 24 years                                                                                  Age – 28 years
Occupation – House wife                                                                    Occupation – Clerk
Address – Chamrajpet                                                                        Income – Rs. 1000/person/month
SE Status – Lower Middle Class
Date of Admission – 07/07/07                                                             Date of examination – 11/07/07

G₂P₁L_o comes with 7 months of amenorrhea for safe confinement.

HISTORY OF PRESENTING COMPLAINTS:

• Patient comes with 7 months amenorrhea for safe confinement.  Patient had been here for regular ANC checkup on 5^th July and was advised to get admitted telling her that her blood group does not match with that of her baby (told to her by a private practitioner).
• No history of generalized weakness and giddiness
• No history of headache, blurred vision or decreased micturition
• No history of edema and pruritis.
• No other systemic complaints.

OBSTETRIC HISTORY:

Married Life – 4 years (non – consanguineous marriage)
Obstetric index – G₂P₁L₀A₀D₁

LMP – 04/12/06
EDD – 11/08/07

PREVIOUS PREGNANCY:

• FTD at home, cried soon after birth, weight not measured.
• Booked & Immunized, 5 ANC visits, 2 TT & 100 IFA.
• The baby died 2 days after birth due to unknown reasons.

PRESENT PREGNANCY

T₁

• Morning sickness for 2 months.
• No history of Urinary symptoms.
• No history of Drug intake.
• No history of Pica.

T₂

• Quickening at 20^th week.
• No history of headache, blurred vision.
• 2 ANC visits, 2 TT, 100 IFA, 2 scans.

T₃

• Fetal movements present.
• No bleeding/leak PV.
• In this pregnancy, she was evaluated & her blood group turned out to be B –ve while that of the fetus was O +ve
• No Anti – D injection given.
• No history of abortion, LSCS or IUFD or invasive fetal procedure.
• Previous baby blood group not known.
• Last delivery – 2 years back.

CONTRACEPTIVE HISTORY:

No history of using any contraceptive methods.

MENSTRUAL HISTORY:

Age of Menarche – 15 years
Past Cycles – Regular, 30 day cycle, 4 days flow, no pain or passage of clots.
LMP – 04/12/06

FAMILY HISTORY: No history of DM, HTN.

PAST HISTORTY:

Medical – No history suggestive of DM/HTN.  No history of TB, epilepsy or asthma.
Surgical – No history of blood transfusions or any previous surgical procedures.

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Mother is a 24 year old lady, moderately built and nourished, conscious, alert & cooperative.

Pulse                – 82/min, regular, good volume
BP                    – 120/50 mm of Hg
RR                    – 18/min, regular
Temperature       – Afebrile

Pallor                           – Absent
Icterus                          – Absent
Cyanosis                      – Absent
Clubbing                       – Absent
Edema                         – Absent
Lymphadenopathy         – Absent

Thyroid              – Normal
Breasts             – Normal
Spine                – Normal
Gait                  – Normal

Height              – 156 cm
Weight             – 60 kg

SYSTEMIC EXAMINATION:

CVS – S₁ S₂ heard, No murmurs.
RS – NVBS heard, no basal crepts.
CNS – NAD.
PA – NAD

OBSTETRIC EXAMINATION:

INSPECTION:

• Abdomen uniformly distended.
• Flanks not full.
• Umbilicus – normal.
• Striae gravidarum, albicans & linea nigra – present.
• No scars over abdomen, no dilated veins.
• Hernial orifices – normal.

PALPATION: (Patient examined in supine position with legs semi flexed).

• Fundal height corresponds to 28 weeks gestation.
• SFH is 25 cm.
• Fundal grip – Smooth, broad irregular structure suggestive of breech.
• Lateral Grip – Right – Knob like structures suggestive of Limb buds.                                           Left – Uniform curved resistance suggestive of spine.
• 1^st Pelvic Grip – Smooth, round, hard ballot able mass (not engaged) suggestive of Head felt at lower pole.

AUSCULTATION:

• FHS heard along the left spinoumbilical line, mid point.
• Rate – 140/min, regular.

DIAGNOSIS:

22 year old G₂P₁L_o with 7 months amenorrhea, single live fetus, not in labour with Rh –ve pregnancy.

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5. CASE OF HEART DISEASE IN PREGNANCY – 1

Name – Chandrakala                                                                           Husband’s Name – Manjunath
Age – 32 years                                                                                   Age – 35 years
Address – Chikaballapur                                                                      Occupation – Cloth merchant
Occupation – Housewife                                                                       Income–Rs.2000/month
Religion – Hindu                                                                                  SE Status – Upper Middle
Date admission – 12/07/2007                                                               Date of examination– 12/07/2007

G₃P₁L₁A₁ comes with 9 months of amenorrhea for safe confinement of delivery.

HISTORY OF PRESENTING COMPLAINTS:

• Patient comes with 9 months amenorrhea for safe confinement with a history of cardiac surgery.
• No history of breathlessness on exertion, palpitations, chest pain, PND, orthopnea, edema of feet.
• No history of any congenital heart disease.
• No history suggestive of CCF, infective endocarditis in the past or present pregnancy.

OBSTETRIC HISTORY:

Married Life – 16 years (non – consanguineous marriage)
Obstetric index – G₃P₁L₁A₁

LMP – 15/10/06
EDD – 22/07/07

PREVIOUS PREGNANCY:

G₁ – FTND, Government Hospital, Now 11 years, Cried soon after birth, Weighed 3 kg, Post partum period normal, Booked and immunized, 3 ANC visits, 2TT & 100 IFA received.

G₂ – Aborted at 1½ months gestation (MTP) 6 years ago.

PRESENT PREGNANCY:

T₁

• History of nausea and vomiting.
• No history of urinary symptoms.
• No history of drug intake or radiation exposure.
• No history of pica.

T₂

• Quickening at 18^th week.
• No history of headache or blurring of vision or edema.
• Patient was booked and immunized – 4 ANC checkups, 2 TT & 100 IFA.

T₃

• Increased frequency of micturItion – present.
• Fetal movements present.
• Uneventful.

CONTRACEPTIVE HISTORY:

No history of using any contraceptive methods.

MENSTRUAL HISTORY:

Age of Menarche – 15 years
Past Cycles – Regular, 30 day cycle, 3 days flow, no pain or passage of clots.
LMP – 15/10/06

FAMILY HISTORY: No history of DM, HTN.  No history of any congenital heart disease among relatives.

PAST HISTORTY:

• Patient underwent a cardiac surgery 2 years back when she developed sudden onset of breathlessness though she was on medical treatment for some cardiac ailment for 5 years.  Her previous reports revealed that she was diagnosed to have RSOV with VSD.  She underwent the operation in a government hospital in Putbarti.
• No history of fleeting joint pains or fever in the childhood and patient not on penidure prophylaxis.
• No history of any post-op complications.
• No history suggestive of DM or HTN.
• No history of TB, epilepsy or asthma.

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Here is a pregnant lady, moderately built and nourished, conscious, alert & cooperative; well oriented to time, place and person.

Pulse                – 90/min, regular, good volume, normal character, all PP felt.  JVP – normal
BP                    – 130/70 mm of Hg
RR                    – 18/min, regular, TA
Temperature       – Afebrile

Pallor               – Absent
Icterus              – Absent
Cyanosis          – Absent
Clubbing           – Absent
Edema              – Absent
Lymphadenopathy – Absent

Thyroid              – Normal
Breasts             – Normal
Spine                – Normal
Gait                  – Normal

Height              – 160 cm
Weight             – 60 kg

SYSTEMIC EXAMINATION:

CARDIO-VASCULAR SYSTEM:

INSPECTION

• No precordial bulge.
• Apical impulse – left 4^th inter-costal space, 2 cm lateral to Mid-cavicular line.
• No other abnormal pulsations.
• A linear scar seen over the mid-sternum 15 cm × 2 cm.
• No dilated veins over the chest wall.

PALPATION

• Inspectory findings were confirmed.
• Apex beat – left 4^th inter-costal space, 2 cm lateral to Mid-cavicular line.
• No parasternal heave.
• No thrill felt.
• No abnormal pulsations.

AUSCULTATION

CVS

Aortic area	S1S2 heard, no murmurs.
Pulmonary area
Mitral area
Tricuspid area

RS – NVBS heard, no basal crepts.
CNS – NAD.
PA – NAD

OBSTETRIC EXAMINATION:

INSPECTION:

• Abdomen is distended, flanks are full.
• Umbilicus – normal.
• Striae gravidarum, albicans & linea nigra – present.
• No dilated veins or scars or sinuses.
• Hernial orifices – normal.

PALPATION: (Patient examined in supine position with legs semi flexed).

• Fundal height corresponds to 32 weeks with flanks full – corresponding to 40 weeks of gestation.
• Shelving Sign – positive.
• Symphysis – fundal height is 30 cm.
• Fundal grip – Broad, soft, non-ballotable, relatively large irregular structure suggestive of breech.
• Lateral Grip – Right – Knob like structures suggestive of Limb buds.                                           Left – Uniform curved resistance suggestive of spine.
• 1^st Pelvic Grip – Smooth, hard ballotable mass relatively small felt suggestive of head.
• Abdominal girth – 104 cm.
• Weight of fetus (Johnson’s formula) – 2800 gm.
• Age of fetus (Mc Donald’s formula) – 40 weeks.

AUSCULTATION:

• FHS heard along the left spinoumbilical line, mid point.
• Rate – 140/min, regular.

DIAGNOSIS:

32 year old G₃P₁L₁A₁ with full term pregnancy with cephalic presentation, not in labour with a previous history of cardiac surgery.

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6. CASE OF HEART DISEASE IN PREGNANCY – 2

Name – Farida Taj                                                                                  Husband’s Name – Rehman
Age – 25 years                                                                                       Age – 30 years
Address – Chikaballapur                                                                         Occupation – Plastic Items seller
Occupation – Worker in Agarbatti factory                                                  Income–Rs.3000/month
Religion – Hindu                                                                                     SE Status – Upper Middle Class
Date of admission – 08/11/2007                                                               Date of examination – 21/11/2007

Primigravida comes with 9 months of amenorrhea

PRESENTING COMPLAINTS:

• Pain abdomen                                           – 13 days.
• Swelling of both lower limbs                       – 13 days.
• Chest pain and breathlessness                   – 8 days.

HISTORY OF PRESENTING COMPLAINTS:

• Patient gives history of pain abdomen for the past 13 days, over the lower part of the abdomen, moderate intensity, intermittent in nature, each episode lasting about 2 hours and approximately 2-3 episodes per day, relived on medication.
• Patient also complaints of swelling of both the lower limbs since 13 days, insidious in onset, initially present over the feet and has gradually progressed to the knee, present throughout the day, increases on walking and relived on taking rest.  No diurnal variation.  No history of distention of abdomen or puffiness of face.
• Patient also gives a history of chest pain since last 8 days, sudden in onset, over the retrosternal region, progressive, constricting type, non-radiation, moderate severity, aggravated on exertion and relieved on rest.  It is associated with breathlessness, insidious in onset, progressive in nature, initially patient was able to do her routine activities but now she gets breathless after walking a few meters.  It is relieved on rest.
• History of palpitations present.
• No history of bleeding or discharge per vagina.
• No history of orthopnea, PND.
• No history suggestive of CCF, Infective endocarditis.
• No history of fever.
• No history suggestive of thyroid disease.
• No history of any cardiac disease
• Not a known case of DM or HTN.

OBSTETRIC HISTORY:

Married Life – 1 years (non – consanguineous marriage)
Parity index – primigravida

LMP – 03/03/07
EDD – 10/12/07

PRESENT PREGNANCY:

T₁

• History of nausea and vomiting.
• History of urinary symptoms – present.
• No history of drug intake or radiation exposure.
• No history of pica, Booked and Immunized.

T₂

• Quickening at 5^th month.
• No history of headache or blurring of vision or edema.

T₃

• Fetal movements present.
• Developed swelling of both lower limbs, chest pain and breathlessness as mentioned previously.

CONTRACEPTIVE HISTORY:

No history of using any contraceptive methods.

MENSTRUAL HISTORY:

Age of Menarche – 15 years
Past Cycles – Regular, 30 day cycle, 3 days flow, no pain or passage of clots.
LMP – 03/03/07

FAMILY HISTORY: No history of DM, HTN.  No history of any congenital heart disease among relatives.

PAST HISTORTY:

• No history of fleeting joint pains or fever in the childhood and patient not on penidure prophylaxis.
• No history suggestive of any other congenital heart disease.
• No history of heart surgery.
• No history suggestive of DM or HTN.
• No history of TB, epilepsy or asthma.
• No history of previous hospitalization or treatment for heart ailments.

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Mother is a young lady, moderately built and nourished, conscious, alert & cooperative; well oriented to time, place and person.

Pulse                – 99/min, regular, good volume, normal character, all PP felt.  JVP– raised (6 cm).
BP                    – 126/90 mm of Hg in left upper limb in supine position.
RR                    – 18/min, regular, TA
Temperature       – Patient is afebrile

Pallor                – Absent
Icterus              – Absent
Cyanosis           – Absent
Clubbing            – Absent
Edema                 – Absent
Lymphadenopathy – Absent

Thyroid              – Normal
Breasts             – Normal
Spine                – Normal
Gait                  – Normal

Height             – 160 cm
Weight             – 60 kg

SYSTEMIC EXAMINATION:

CARDIO-VASCULAR SYSTEM:

INSPECTION

• No precordial bulge.
• Apical impulse – left 4^th inter-costal space, 2 cm lateral to Mid-cavicular line.
• No other abnormal pulsations.
• No dilated veins over the chest wall, no scars.

PALPATION

• Inspectory findings were confirmed.
• Apex beat – left 4^th inter-costal space, 2 cm lateral to Mid-cavicular line.
• Parasternal heave – present.
• No thrill felt.
• No abnormal pulsations.

AUSCULTATION

CVS

Aortic area	S1 loud,  S2 heard , No murmurs
Pulmonary area	ESM – present
Mitral area	MDM – present
Tricuspid area	S1S2 heard, No murmurs

RS – NVBS heard, no basal crepts.
CNS – NAD.
PA – NAD

OBSTETRIC EXAMINATION:

INSPECTION:

• Abdomen is distended, flanks are full.
• Umbilicus – normal.
• Striae gravidarum, albicans & linea nigra – present.
• No dilated veins or scars or sinuses.
• Hernial orifices – normal.

PALPATION:

• Abdominal circumference – 76 cm
• Symphysio-fundal height – 28 cm (corresponds to 32 weeks)
• FUNDAL GRIP – Soft, broad & non-ballotable, suggestive of Breech
• Lateral Grip – Knob like structures on the right side suggestive of limb buds                         Uniform resistance on the left side suggestive of spine
• 1^ST PELVIC GRIP – Smooth, hard, ballotable mass suggestive of head
• 2^ND PELVIC GRIP – Fingers converge, head not engaged.
• Uterus is relaxed

AUSCULTATION:

• FHS heard along the left spinoumbilical line, mid point.
• Rate – 140/min, regular.

DIAGNOSIS:

25 year old primi with full term pregnancy with cephalic presentation not in labour with cardiac disease (valvular lesion), probably RHD, MS in sinus rhythm, not in failure with no evidence of infective endocarditis.