Title: threatened preterm labour
Summary
26 years old Malay lady primigravida at 34th week from period of amenorrhea presented with abdominal pain, slight show, associated with history of two threatened preterm labour due to urinary tract infection and falling, two previous gynaecological surgical histories –endometriosis and ovarian polyps.
Introduction
a. Back Backgr groun ound d of of the the study study Preterm labour is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk). Risk factors for preterm birth include demographic characteristics, behavioural factors, and aspects of obstetric history such as previous preterm birth. Demographic factors for preterm labour include non-white race, extremes of maternal age (<17 y or >35 y), low socioeconomic status, and low pre-pregnancy weight. Preterm labour and birth can be associ associate ated d with with stress stressful ful life life situat situation ionss (eg, (eg, domest domestic ic violen violence; ce; close close family family death; death; insecurity over food, home, or partner; work and home environment) either indirectly by associated risk behaviours. As the cause of labor still remains elusive, the exact cause of preterm birth is also unsolved. unsolved. Labor is a complex complex process process involving involving many factors. factors. Generally, Generally, four different pathways have been identified that can result in preterm birth and have considerable eviden evidence: ce: precoci precocious ous fetal fetal endocr endocrine ine activa activatio tion, n, uterin uterinee overdis overdisten tensio sion, n, decidual decidual bleeding, and intrauterine inflammation/infection. b. Ration Rational al and signi signifi ficanc cancee of choosin choosing g the case case Threatened preterm labour is a very hard topic to be study without reference point. Therefore, this case has been selected for study of threatened preterm labour based on few actors; this is not a complicated case of threatened preterm labour, there are multiple factors that may results the threatened preterm labour presentation in this case which includes present presentation and the patient’s history. Thus Thus,, the the case case itse itself lf can can be easi easily ly said said as an exam exampl plee mult multip iple le caus causat ativ ivee case case of threatened preterm labour that is very well presented such it can help the researcher to understand and comprehend the meaning of threatened preterm labour.
History of Admission
a. Pati Patien ent’ t’ss biog biogra raph phy y Name initials Ag e Sex Religion Civil status R a ce Occupation Admission Clerking
:
:
: :
Mdm N.A : 26 : Female Islam : married : Malay : government officer 1/3/2010 2/3/2010
b. b. Chie Chieff comp compla lain intt Patient is currently G1 P0 at 34 weeks 4 days POA. She came by herself, with abdominal pain associated with slight show, no leaking. Fetal movement was present and good.
History of presenting illness
Prior to the admission, patient had history of 2 p revious threatened preterm labours due to urinary tract infection at 25+ weeks and from falling at 28 weeks, injuring her right thigh –just involving soft tissue injury. On the day of admission, patient was doing normal household chores when she suddenly feels sudden back pain similar to the previous threatened preterm labour episodes. The pain pain was associat associated ed with with per vaginal vaginal bleedi bleeding ng –noted –noted by blood blood at her sarong. sarong. She mentioned that the contraction was not n ot regular and not very consistent. Immediately, she went to the hospital and admitted into antenatal care for observation.
Review of system
system
Finding
Cardiovascular
no significant findings such as palpitation, lower limb edema, orthopnea, syncope, dizziness, etc.
Endocrine
No significant findings such as moon features, exophthalmos, tremor, acrommegaly, etc.
Gastrointestinal
No significant findings such as diarrhea, constipation, altered bowel movement, etc.
Genitourinary
No significant findings such as dysuria, oliguria, hematouria, incontinence, nocturia, etc.
Hematopoietic
No significant findings such as pallor, jaundice or bleeding tendency, etc.
Musculoskeletal
No significant findings such as myalgia, arthargia or arthritis, etc.
Neurologic
No significant findings such as recurrent headaches, fits, blurring of vision or drowsiness, etc.
Respiratory
Skin, hair, nails
Head and neck
Reproductive
No finger clubbing, no accessory muscle used during respiration, no shortness of breath, no noisy breathing, no hemoptysis, no night sweats. No significant findings. The skin color is normal according to his race; with hair growth distribution is normal. Nail is normal, no clubbing, koilonychia, leukonychia, etc. Normal head size, shape and symmetry; no skull enlargement, bossing, etc. no significant findings of the neck such as webbing, goiter, etc. As stated
Comprehensive health history
a. Ante Antena nata tall hist histor ory y This is an unplanned but wanted pregnancy. She noticed that she pregnant after had missed about 2 weeks of her period, confirmed by pregnancy test kit. Her L.M.P was 2.7.2009 (sure of date) and E.D.D is 9/4/2010, confirmed by scan. First scan was done at 18th week, and the latest was at 32nd week with parameters corresponds to date. She was screened for VDRL, HIV, hepatitis B and it was negative. She was normortensive, normoglycemic and no significant glycosuria was recorded. b. b. Obst Obstet etri ricc histo history ry She is primigravida c. Gyna Gynaec ecol olog ogy y hist histor ory y She attained menarche at 14 years old with regular cycle of 30 days with flow of 7 days. She does not experiencing dysmenorrhoea, menorrhagia, postcoital bleed and no deep dyspareunia. She claimed never took any contraception pill before. She had history of ovarian cyst and went for surgery at HUSM 2005, history of endometriosis and went for surgery at HKL 2006. d. Past Past medi medical cal & surg surgica icall histo history ry No significant history of medical illness or surgery. 2 previous surgical histories for endometriosis 2006 and ovarian cyst 2005 e. Fami amily hist histor ory y No family history of any medical illness except for hypertension by her mother. No history of multiple pregnancies, malformation, or mental illness in the family f.
Soci ocial his history She is working as assistant information officer at ministry of information. Her husband is entrepreneur. She does not consume alcohol and does not smoke, so does her husband. She denies of any constitutional sex. Currently, she is not experiencing any financial difficulty.
g. Allerg Allergies ies and medica medicatio tion n histo history ry No known drug or food allergies. She is taking supplements provided for her pregnancy.
Physical examination
She was alert, conscious and lying comfortable. Her height is 155 cm, with pregnant weight of 62+kg. Her body mass index is 25.8 kg/m2. Her vital signs were as recorded; Blood pressure Heart rate Respiratory rate Temperature
: : : :
103/72 mmHg 100 beat per minute, good volume, regular rhythm 17 breaths per minute 37°C
There is no sign and symptom of anaemia, by pallor or lips cracked. She was well hydrated, no sign of goitre, and there is no oedema at lower limbs. Breast examination was not demonstrated. Her heart sound S1 S2 can be heard with normal intensity, and her lungs were normal. Examination of abdomen shows distended abdomen by gravid uterus with linea nigra, striae gravidarum as evidences. There were also 2 suture scars which are midline marking for previous endometriosis on 2006 and pfannestiel marking for ovarian cyst removal on 2005 2005.. The The sutu suture re area area was was non non tend tender er,, and and soft soft at the the site site.. Ther Theree was was no othe other r abnormality. Her size is near term, SFH is 35cm. The presentation of the baby cephalic, with head engagement is 4/5. Estimated baby weight is about 2.0 – 2.2 kg. Contraction was present which is irregular with 1:10:25s. Fetal heart rate taken by the nurse was 153 beats per minute. Previous vaginal examination shows normal os, with 1cm dilatation. The cervix was 3cm thick, and the position of the head is not palpable. The membrane is still intact; therefore the the moul mould d and and caput caput cann cannot ot be asse assess ssed. ed. Ther Theree was no liqu liquor or pool poolin ing. g. Specu Speculu lum m examination reveals that the vagina and cervix to be healthy with the os is open. Show is noted, but there was no pooling of liquor, and no vaginal discharge.
Summary
26 years old Malay lady primigravida at 34th week from period of amenorrhea presented with abdominal pain, slight show and; 1) Histor History y of 2 threat threatene ened d preterm preterm labou labour r 2) Histor History y of endome endometri triosi osiss 2006 2006 3) Histor History y of of ovari ovarian an cyst cyst 2005 2005 4) Hist Histor ory y of UTI UTI 5) Hist Histor ory y of of fal falll Diagnosis
Patien Patientt is primig primigrav ravida ida curren currentl tly y at 34th week 4 days POA diagnosed as threatened preterm labour. Due to; 1) Irregul Irregular ar contra contracti ction on with with <2:10 <2:10 2) No cer cervi vical cal dil dilat atat atio ion n 3) No pooli pooling ng of of liq liquor uor
Investigation
Investigation
Full blood count
Grou Groupi ping ng,, Scr Screeni eening ng,, Hol Hold d (GS (GSH) Urine FEME
High vaginal swab C&S
Reason to support To look for haemoglobin, white blood cell and platelet leve levells. To ensu ensurre she is stabl tablee enou enough gh for any any emergency surgery, to rule out any ongoing infection, anaemia that may cause poor tolerance of blood loss during delivery. Pat Patient ent mi might ght need need trans ansfusi fusion on Basically, to assess renal function in general. Glucose will be significantly high in EDM, GDM. Blood may present in renal tract trauma, inflammation, tumour or even vaginal vaginal bleeding contamination as well. If ther theree is any any infe infect ctio ion, n, espe especi cial ally ly for for grou group p B stre strept ptoco ococc ccal al,, Tric Tricho homo mona nass vagi vagina nali lis, s, Chlam Chlamyd ydia ia trac tracho homa mati tis, s, neis neisse seri riaa gono gonorr rrho hoea ea.. Impo Import rtan antt in determining management of patient
Full blood count investigation
Wbc Rb c Hgb Hct Mcv Mch Mchc Rdw-cv Plt Neutrophil Lymphocyte Monocyte Eosinophil Basophil
12.1 4.16 124 37.1 89.2 29.8 33.4 13.7 237
% 71 19.6 7. 5 1. 7 0. 2
unit
reference
109/L 1012/L g/L
4-10 3.8-4.8 120-150 36-46 77-97 27-32 315-345 11.6-14.0 150-400 109/L 2-7 1.0-3.0 0.2-1.0 0.02-0.10 0.9-12
fL Pg g/dL % 109/L 109/L 8.59 2.37 0.91 0.20 0.04
Comment During pregnancy there is also an increase in white cells from about 7 x 10^9 to 15 x 10^9 per litre solely due to a neutrophilia. This was noted in her CBC & differential blood result. In spite of this, note that other causes of a raised neutrophil count must be excluded. In her case, clinically she is well with no sign or symptoms suggesting active infection. Urine FEME
investigation Specific gravity pH Leukocyte Nitrate Protein Glucose Ketone Bilirubin Erythrocyte
1.020 6 .5 2+ -ve 1+ 3+ -ve 1+ -ve
Comment No remarkable findings
HVS C&S culture Smear White cell Epithelial cell + cocci - cocci + bacilli - bacilli other
No culture/ colony Occasionally Occasionally nil few nil few nil
Comment One-t One-thi hird rd of the the preg pregna nant nt wome women n yiel yielded ded potential pathogenic organisms in their HVSs. Among these organisms 87% were Monilia and Streptococcus, whil whilee the the rest rest were were E. coli, Proteus, Klebsiella and Neisseria. and Neisseria. Lactobacilli are regarded as a normal flora. Staphylococcus Staphylococcus epidermidis epidermidis and Diphteroids have also been found in significant
percentages (30-60%) in pregnant women.
Plan and management
1) Admi Admitt ante antena nata tall ward ward 2) CTG in ward, IM nubain 10mg 1 0mg per 6 hourly if reactive 3) Time Time cont contra ract ctio ion n 4) Stri Strict ct FKC FKC mon monit itor orin ing g 5) To book book vent ventil ilat ator or 6) Tocolysis 7) IM Dexamethasone 12 mg bd 8) Pad chart chart –to inform inform if if increase increase in per per vaginal vaginal bleeding bleeding
Discussion
Preterm labour is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation (between 20 and 37 wk). The exact mechanism(s) of preterm labour is largely unknown but is believed to include decidual haemorrhage, (eg, abruption, mechanical factors such as uterine overdistension from multiple gestation or polyhydramnios), cervical incompetence (eg, trauma, cone biopsy), biopsy), uterine uterine distortio distortion n (eg, müllerian müllerian duct abnormalit abnormalities, ies, fibroid fibroid uterus), uterus), cervical cervical inflam inflammat mation ion (eg, (eg, result resulting ing from from bacter bacterial ial vaginos vaginosis is [BV], [BV], trich trichomo omonas nas), ), matern maternal al inflammati inflammation/fev on/fever er (eg, urinary tract tract infection) infection),, hormonal hormonal changes changes (eg, mediated mediated by maternal maternal or fetal stress), stress), and uteroplacen uteroplacental tal insuffici insufficiency ency (eg, hypertensi hypertension, on, insulininsulin1,2 dependent diabetes, drug abuse, smoking, alcohol consumption). In this case, the patient presented with abdominal pain associated slight show. Patient has stro strong ng hist histor ory y sugge suggest stin ing g thre threat atene ened d pret preter erm m labo labour ur with with two two previ previou ouss event event of threat threatene ened d preter preterm m labour labour –histo –history ry of urinar urinary y tract tract infect infection ion in 25th week, history of falling in 28th week. Patient also had history of two gynaecology surgical history – endometriosis on 2006 and ovarian cyst on 2005. Usually, based on the patient’s presentation, contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix at 24-37 weeks’ gestation are indicative of active preterm labour. However, the patient in this case was not indicative for preterm labour as the contraction c ontraction was not consistent and not sufficient. Accord According ing to the histor history, y, patien patientt had histor history y of urinar urinary y tract tract infect infection ion that that leads leads to previous threatened preterm labour in 25+ week of pregnancy. Due to pregnancy, several phy physi siol olog ogic ic chan change gess that that occu occurr can can caus causee othe otherw rwis isee heal health thy y wome women n to be more more susceptible to serious sequelae from urinary tract infections. These effects have been showed in study done by Duarte et al3 in 2008. Remarkable changes occur in the structure and and funct functio ion n of the the urin urinar ary y trac tractt durin during g pregn pregnan ancy cy.. Bloo Bloodd-vo volu lume me expan expansi sion on is accompanied by increases in the glomerular filtration rate (GFR) and urinary output. The ureters undergo tonic relaxation because of the mass production of hormones, particularly progesterone. This loss in tone, along with the increased urinary tract volume, results in urinary stasis that in time promotes bacterial infestation.
Preterm labour may be difficult to diagnose and a potential exists for overtreatment of uterine irritability. Tocolytic agents, while generally safe in appropriate dosages with prope properr clinic clinical al monit monitori oring, ng, have have potent potential ial morbid morbidit ity y and should should only only be used used after after consideration of the risks and benefits of such use. Neonatal morbidity and mortality are greatly affected by gestational age, especially when the pregnancy is less than 28 weeks’ gestation. Tocolytic is the standard management for threatened preterm labour to reduce irregular contraction. Usually, prophylaxis antibiotic will be given to the mother and in case of previous urinary tract infection, antibiotic will be given specifically according to the causative agent.
Conclusion
Threatened preterm labour is defined as sign and symptoms that lead to the risk of preterm labour to occur. It is usually presented with irregular contraction and associated with show or liquor, depending on the patient itself. Even though the mechanism is not clearly clearly understand understand by physician physician,, patient patient threatened threatened preterm preterm labour usually associated associated with with histor history y of cervic cervical al incomp incompete etence nce –traum –trauma, a, cervic cervical al inflam inflammat mation ion –previ –previous ous infection, infection, hormonal changes –maternal –maternal or fetal stress, or uteroplacent uteroplacental al insufficie insufficiency ncy – hypertension, diabetes, etc.
References 1. Ameri American can Colleg Collegee of Obstet Obstetri ricia cians ns and Gyneco Gynecolog logist ists. s. ACOG ACOG Pract Practice ice Bullet Bulletin. in.
Assessment of risk factors for preterm birth. Clinical management guidelines for obstetrician-gynecologists. Number 31, October 2001. (Replaces Technical Bulletin number 206, June 1995; Committee Opinion number 172, May 1996; Committee Opinion number 187, September 1997; Committee Opinion number 198, February 1998; and Committee Opinion number 251, January 2001). Obstet Gynecol. Oct 2001;98(4):709-16 2. ACOG practice bulletin. Management of preterm labor. Number 43, May 2003. Int J Gynaecol Obstet. Jul 2003;82(1):127-35. 3. Duarte Duarte G, Marcol Marcolin in AC, Quinta Quintana na SM, Cavall Cavallii RC. [Urina [Urinary ry tract tract infect infection ion in pregnancy]. Rev pregnancy]. Rev Bras Ginecol Obstet . Feb 2008;30(2):93-100.
