CASE PRESENTATION

1. CASE PRESENTATION

2. Mrs X, Aged 26 Years,W/O Y, an agriculturist,aged 30yrs Kollegal Housewife by Occupation Lower socioeconomic class with primary education D.O.A. : 16/5/2008 Obstetric Index : Gravida 4 Abortion 3 H/O Amenorrhoea 5 M with good perception of fetal movements with c/o watery discharge since 1 day

3. History of Present Pregnancy: I Trimester Urine pregnancy test positive at 6 weeks of gestation; first ANC at 6 weeks; 1st trimester uneventful No c/o excessive vomiting, pain abdomen or bleed P.V No h/o radiation exposure, drug intake or fever with rash Advised folate supplementation from 1st visit at 6 weeks USG at 9 weeks: Normal

4. History of Present Pregnancy: II Trimester Quickening at 4 � M ANCS once in 3 weeks at Kollegal pvt clinic Iron / calcium started from 4M 2 does of tetanus toxoid at 4th & 5th M USG at each visit in II trimester: Reported Normal

5. Patient was referred with C/o watery discharge since 1 day: present intermittently, increases on strenuous activities, decreases with rest; minimal amount, used 1 pad, not foul smelling, not blood stained No c/o bleed P.V No c/o pain abdomen Fetal movements well perceived

6. Obstetric History Gravida 4 Abortion 3 ML: 7 years Non consanguinous Marriage No h/o contraceptive use

7. History of Previous Pregnancy: I Pregnancy Conceived spontaneously 3 M after marriage; Was booked at pvt clinic in Kollegal; 1st ANC at 3 M, with Normal I trimester USG; I trimester uneventful Developed leak P.V at 5 M of amenorrhoea followed by pain abdomen Spontaneous complete abortion by 1 day at home with no complications, delivered a dead female abortus No post abortion visit to hospital

8. History of Previous Pregnancy: II Pregnancy Conceived spontaneously 1 year after last abortion Booked at Kollegal pvt clinic; first visit at 3 M, with normal I trimester USG; Developed leak P.V at 6 M of amenorrhoea followed by pain abdomen & was admitted for evaluation; reports not available Spontaneous complete abortion at hospital with no complications; Stillborn Female abortus,; no external anomalies; no karyotyping/HPE/autopsy done Patient was advised follow up after 6 weeks : noncompliant

9. History of Previous Pregnancy: III Pregnancy Spontaneous conception 2 years after last abortion Booked at Kollegal pvt clinic; first visit at 3 M, with normal I trimester USG; Developed Leak P.V at 4 � M of Amenorrhoea with no c/o pain abdomen & was admitted for evaluation; reports not available Spontaneous complete abortion at hospital with no complications Dead male abortus; no external anomalies; no karyotyping/HPE/autopsy done Patient was advised follow up after 6 weeks : Noncompliant

10. IV Pregnancy: Spontaneous conception 2 years after last abortion Present pregnancy

11. Menstrual History Menarche: 15 years Past cycle: 3-4/30 days regular, moderate flow no dysmenorrhoea / passage of clots LMP: 29/11/2007 EDD: 06/09/2008 POG: 24 weeks 2 days

12. Past History No h/o TB Asthma Hypertension Diabetes Thyroid disorders Renal diseases Jaundice Epilepsy Thormboembolic episodes Autoimmune disorders No known drug allergy; not on any medications No h/o Gynaec procedures (myomectomy, curettege /cervical lesions)

13. Family History No h/o Similar complaints in mother / siblings Congenital anomalies / multifetal gestation in family members Hypertension, diabetes, autoimmune disease Social / psychological factors: nothing contributory

14. Personal History Diet : Mixed Appetite: Good Sleep: Undisturbed Bowel Bladder habits: Regular Non smoker; no h/o alcohol consumption

15. General Physical Examination Moderate build & nourishment HT: 150 Cms; WT: 50 Kg; BMI: 22 Kg/sqm No pallor, pedal oedema, icterus Pulse: 84/M, regular; normal vol, BP: 120/60 mm Hg Thyroid, breast, spine: clinically normal

16. Systemic Examination C.V.S: First & second heart sounds heard normally; no added sounds or murmurs R.S: Normal vescicular breath sounds heard; no adventitious sounds

17. Obstetric Examination P/A: Inspection: Distension of the abdomen upto umbilicus No scars, sinuses Palpation: Fundal Height: 22 weeks SFH: 22 cms; Uterine tone: relaxed; Fetal parts made out; ext ballotment present FHR: 160 BPM P/S: No active leak P/V: Cervix uneffaced: OS closed

18. Provisional Diagnosis �26 year old Gravida 4 Abortions 3 with 24 weeks gestation with recurrent pregnancy loss�

19. Investigations HB: 9 G/DL;TC: 8,100 Cells/cu mm PCV: 31%; PLT: 2.21 Lakhs / cu mm BT, CT, PT, APTT: WNL AB Positive; Husband blood group: not known OGCT: 139 MG/DL OGTT: WNL HIV, HBSAG, VDRL: Negative

20. USG Reports 7/2/08: SLIUG 9W 5 D; EDD: 06/09/08; CRL: 33 MM; FETAL CARDIAC ACTIVITY: GOOD; CL: 4 CM; EDD: 6/9/08 11/03/08: SLIUG 15W;PLACENTA POST GR I; AF ADEQUATE; NO ANOMALIES AT THIS STAGE; NT: 2.3 MM; INT OS CLOSED; CL: 3CM; EDD: 2/9/08 11/04/08: SLIUG 19W; PLACENTA POST GR II; AF ADEQUATE;NO ANOMALIES AT THIS STAGE; INT OS CLOSED; CL: 3CM; EDD: 2/9/08 17/05/08: SLIUG 22W; GROSS OLIGOHYDROMNIOS WITH CROWDING OF FETAL PARTS; PLACENTA POST GR II; AFI: REDUCED; NO ANOMALIES; BPD: 43 MM; FL: 41 MM; EFW: 480 G; EDD: 18/9/08

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