CASE PRESENTATION

1. CASE PRESENTATION PREPARED BY: TINU VARGHESE

2. DEMOGRAPHIC DATA • CASE NO: 052125 • NAME: MS. J.J. AGE: 24 Y/O SEX: FEMALE • DIAGNOSIS: PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM) • {Primigravida 33 wks leaking since 1100H 6/1/2013}

3. GENERAL • The patient is 24 years of age, FEMALE • She is conscious, coherent, with the following Vital Signs: • BP= 110/59mmHg • PR=100 bpm • RR= 28 cpm • Temp=37. ⁰C • SPO²= 98%

4. SKIN • Fair complexion • No palpable masses or lesions, moist, with good turgor

5. HEAD • Maxillary, frontal, and ethmoid sinuses are not tender. • No palpable masses and lesions • No areas of deformity

6. LEVEL OF CONSCIOUSNESS AND ORIENTATION • Awake and alert • Oriented to persons (knows some of our name) • Place ( she can tell where she is) • Time ( knows the day, date and always asking the time)

7. EYES • Pink conjunctivae and no dryness • Pupils equally round and reactive to light

8. EARS • No usual discharges noted

9. NOSE • Pink nasal mucosa • No unusual nasal discharges • No tenderness in sinuses

10. MOUTH • Pink and moist oral mucosa and free of swelling and lesions

11. NECK AND THROAT • No palpable lymph nodes • No masses and lesions seen

12. CHEST AND LUNGS • Equal chest expansion • No retraction • Clear breath sounds

13. HEART • Regular rythm

14. ABDOMEN • Globular abdomen • Leopold’s Maneuver done: fetus in cephalic presentation, head is round and hard, fetal back is facing right side • USG report: • Pregnancy Uterine 33 weeks AOG by fetal Biometry live, Singleon in cephalic presentation, female fetus, Good cardiac and somatic activity, posterior placenta, Grade III, No previa, Adequate Amniotic Fluid Volume

15. GENITALS • Clear Watery discharge per vagina since 2 days. • No show present

16. EXREMITIES • Pulse full and equal • No lesions noted

17. PATIENT HISTORY PAST MEDICAL HISTORY • No past medical history

18. PRESENT MEDICAL HISTORY • C/O: Leaking since 1100H 6/01/2013 • MEDICAL HISTORY: Primigravida with pregnancy 33 wks by LMP, 37 wks + 1 day by USG with PROM since 1100H 06/01/2013 • ON EXAMINATION: BP=110/59 mmHg, PR=118 bpm, RR= 28 cpm, Temp=37. ⁰C, SPO²= 98%

19. PRESENT MEDICAL HISTORY INVESTIGATION:

20. PRESENT MEDICAL HISTORY Ultrasound report: • Pregnancy Uterine 37 weeks and 1 day AOG by fetal Biometry live, Singleton in cephalic presentation, female fetus, Good cardiac and somatic activity, posterior placenta, Grade III, No placenta Previa, Adequate Amniotic Fluid Volume

22. INTRODUCTION • During pregnancy, the baby is surrounded in the uterus by the amniotic sac. The sac is also called the “bag of waters.” It protects and cushions the baby. • Premature Rupture of Membranes (PROM) is defined as rupture of membranes before the onset of labor. • Preterm Premature Rupture of Membranes (PPROM), which is when the membranes rupture before 37 weeks.

23. INTRODUCTION • The sac contains amniotic fluid and the developing baby. In PPROM, the amniotic fluid inside the sac leaks or gushes out of the vagina. Before term, PPROM is often due to an infection in the uterus.

24. ANATOMY AND PHYSIOLOGY

25. ANATOMY AND PHYSIOLOGY

26. To diagnose PPROM, the doctor may do the following tests: Visual examination A nitrazine paper test Fern test Ultrasound Amnisure

27. Positive nitrazine test

28. Positive fern test

29. Amniocentesis to inject indigo carmine or evans blue dye. watch for vaginal leakage of blue fluid to assess for ruptured membranes

30. Risk factors • Lack of prenatal care • Smoking during pregnancy • Low body weight • Bleeding from the vagina during the 2nd or 3rd trimester • Having had a sexually transmitted disease (STD) • Having had certain medical procedures such as amniocentesis (a test that takes fluid from the amniotic sac) or cerclage (sewing the cervix closed during pregnancy)

31. Main symptom: Fluid leaking or gushing from the vagina It may be a sudden, large gush of fluid, or it may be a slow, constant trickle of fluid. The complications that may follow PROM include premature labor and delivery of the fetus, infections of the mother and/or the fetus, and compression of the umbilical cord (leading to oxygen deprivation in the fetus). Other symptoms: Bleeding from the vagina Other symptoms: Pain in the Lower abdomen or in the low back If you have any of these signs & symptoms, call your healthcare provider right away

32. VIII. NURSING INTERVENTION • Prevent infection and other potential complications • Make an early and accurate evaluation of membrane status, using sterile speculum examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection. • Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, an organism that increases the risk to the fetus. • Determine maternal and fetal status, including estimated gestational age. Continually assess for signs of infection. • Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapse if additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged.

33. VIII. NURSING INTERVENTION • Educate the patient to use sterile pads

34. VIII. NURSING INTERVENTION • Provide client and family education • Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent; encourage the client and partner to prepare themselves for labor and birth. • If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are likely to be needed.

35. TREATMENT • Hospitalization • Expectant management (in some cases of PPROM, the membranes may seal over and the fluid may stop leaking without treatment) • Monitoring for signs of infection such as fever, pain, increased fetal heart rate, and/or laboratory tests • Giving the mother medications called corticosteroids that may help mature the lungs of the fetus (lung immaturity is a major problem of premature babies • Antibiotics (to prevent or treat infections) • Tocolytics - medications used to stop preterm labor. • Delivery (if PROM endangers the well-being of the mother or fetus, then an early delivery may be necessary to prevent further complication

36. COMPLICATIONS OF PROM • Prolapse of the umbilical cord (the baby's cord drops down interfere with the blood supply to the baby). • Infection of the uterus and unborn child. • Placental abruption (the placenta comes away early with bleeding and loss of blood supply to the baby). • Potential increased rates cesarean delivery. • Premature Birth (PPROM) • Chorioamnionitis • Cord compression • Respiratory distress syndrome

37. PRIORITIZATION OF NURSING PROBLEMS • Risk for infection related to loss of protective barrier by the fern test. • Anxiety r/t threat to maternal or fetal well-being secondary to risk for infection or preterm birth • Risk for infection related to ascending bacteria • Risk for injury to fetus secondary to prematurity • Compromised Family coping secondary to hospitalization • Risk for infection: maternal or fetal r/t premature rupture of membranes • Risk for injury: maternal or fetal r/t tocolytic drugs used to delay birth

40. NURSING HEALTH TEACHING • Remain on modified bed rest • No sexual activity, no tub bath. • Assess for uterine contraction and fetal movement. • Assess for foul smelling vaginal discharge • Wipe front to back after urinating or having a bowel movement • Take antibiotics if prescribed.

41. CONCLUSION • This is a case of a 24 y/o Primigravida with pregnancy 33+ 1 wks by LMP, 37 wks + 1 day by USG who came in due to watery discharge, amnicator test positive. Patient was advised for expectant management. • Premature Rupture of Membranes (PROM) is defined as rupture of membranes before the onset of labor. Preterm Premature Rupture of Membranes (PPROM), which is when the membranes rupture before 37 weeks. • Premature Rupture of Membranes happens when the membranes that hold amniotic fluid (the water surrounding the baby) usually break at the end of the first stage of labor.

42. CONCLUSION • Criteria which are fulfilled by the patient, conservative management rendered such as investigations, antibiotic coverage • In cases by which this patient will undergo active labor despite tocolytic medication, there will be no objection for delivery as long as all maternal & fetal consequences are explained properly to the patient.

43. BIBLIOGRAPHY • Maternal and Child Health Nursing by Adele Pillitteri 5th edition; volume 1 page 426- 433;page 329-332 • All-in-one care planning resource page 748; by Pamela L. Swearlngen, RN • Maternal Neonatal Nursing;page 30 by Lippincott Williams and Wilkins • Luckman and Sorensen’s Medical-Surgical Nursing a Physiologic Approach 4th edition Volume 1 page 734 • Lippincot Manual of Nursing Practice 9th edition • http://www.ualberta.ca/~olsonlab/Am%20J%20Obstet%20Gynecol%201999%20180(1%20Pt%201).pdf

44. Thank you!! 