OBSTETRICS HISTORY

GENERAL DATA
E.R., 36 years old, G2P0 (0010), married, Filipino, Christian, born on December 28, 1978 at Villasis,
Pangasinan and is currently residing at GMA, Cavite consulted for the 12th time on July 12, 2016 at
around 9:30am.
CHIEF COMPLAINT
Prenatal check-up
PAST MEDICAL/SURGICAL HISTORY
The patient has no history of Hypertension, Diabetes, exposure to Rubella, hepatitis, cardiorespiratory disease, epilepsy, gonorrhea, renal disease nor tuberculosis. Patient has no allergies to food
or medication. She has complete immunization records and has no history of previous hospitalizations or
surgery. Patient was not in any form of accident.
FAMILY HISTORY
The patients mother was diagnosed with hypertension and her father had asthma. The child of the
patients sister has Autism. No other diseases like cardiac disease, diabetes mellitus, cancer, hepatitis,
tuberculosis were noted in the family. No family history of multiple pregnancies or births with congenital
anomalies.
PERSONAL AND SOCIAL HISTORY
The patient is a highschool graduate and is currently working in a sari-sari store owned by her
sister. This is her only source of income. Patient is married to her husband for 2 years already, who is 40
years old, a highschool graduate, and also works at the small store of the patients sister. Patient has no
history of smoking cigarettes, intake of alcoholic beverages and illicit drugs. The patient lives with her
husband and mother in a bungalow, concrete house with a water source from the water district and
mineral water as their drinking water. Garbage is being segregated and collected once a week. Patient
has no hobbies or interests during her extra time.

MENSTRUAL HISTORY
Patients menarche was during her 6th grade in Elementary School, around the age of 12. Patients
first day of last normal menstrual period was unrecalled and has irregular mentrual cycle with 1 and a half
month to 2 months of interval every after each cycle. Patient usually experiences 4 days of duration of
menstrual period, with 2 pads used, moderately soaked, per day. Patient feels pruritus in the chest and
breast area whenever her menstrual period is coming. Patient does not have headache, hypogastric pain,
swelling of the hands and feet, leg cramps, nor dysmenorrhea. Patient does not take any form of
medication when she is on her menstrual period.
OBSTETRICAL HISTORY :
Patient is G2P0 (0010)
G1 = Early, spontaneous abortion. Patient was given a medication, unrecalled name, once at the
Fabella Lying In and patient was asked to lie down. This was done on an outpatient basis. No
complications were noted.

GYNECOLOGICAL HISTORY
Patient has no history of infections, diseases, or surgery pertaining to the female reproductive tract.
SEXUAL HISTORY
Patient's coitarche was 33 years old. She has only 1 sexual partner, her husband, and has sex
once a week when the husband worked in tagaytay and 3 times a week. She is sexually satisfied and has
no associated signs and symptoms, and no post coital bleeding was noted. no other associated
symptoms like pain upon sexual intercourse, abdominal cramps, post-coital bleeding and foul vaginal
discharges. Last sexual contact was around December 2015.
CONTRACEPTIVE HISTORY
Patient has no history of using any contraceptive method.
HISTORY OF PRESENT PREGNANCY
LNMP: unrecalled
PMP: unrecalled
EDC: August 5, 2016
AOG: 36 weeks, 5/7 days
Quickening: 5th month (1st week of March) 18 weeks AOG
Eight months prior to consult (2 Weeks AOG), patient took a urine pregnancy test due to still not
having her menstrual period. Pregnancy test was positive. Patient sought consult in UMC, for her first
prenatal checkup and was prescribed with folic acid and kalvin, unrecalled dosage. Patient did not
experience vomiting, bleeding, headaches, fever nor any of the danger signs of pregnancy and other
associated symptoms like cough and colds.
Seven months prior to consult (5 weeks 1/7 AOG), patient sought consult at UMC and underwent
her first ultrasound on December 1, 2015. Results included the AOG of 5 weeks 1/7 and no fetal heart
tone detected. Patient was advised to come back after 3 weeks. Patient still did not experience vomiting,
bleeding, headaches, fever nor any of the danger signs of pregnancy and other associated symptoms like
cough and colds. 3 weeks later, patient returned and underwent her 2 nd ultrasound on December 28, 2015
and results included her AOG of 8 weeks 4/7 and presence of fetal heart tone.
Six months prior to consult (10 weeks AOG), patient experienced vomiting of previously ingested
food without blood or any type of secretions, almost everyday with moderate amount per vomitus. Patient
sought consult at UMC and underwent Fasting Blood Glucose testing, unrecalled date. Results were
unremarkable. No other signs and symptoms associated were noted.
Five months prior to consult (14 weeks AOG), patient sought consult for her routine prenatal
check up. Patient did not experience vomiting, bleeding, headaches, fever nor any of the danger signs of
pregnancy and other associated symptoms like cough and colds.
Four months prior to consult (16 weeks AOG), patient sought consult at the health center and was
given Tetanus Toxoid vaccine. No other signs and symptoms were experienced by the patient.
Three months prior to consult (22 weeks AOG), patient returned to the health center for her follow
up vaccination, of unrecalled vaccine. Patient underwent her 3 rd ultrasound on April 5, 2016 for monitoring
of any congenital anomaly occuring, results were unremarkable. Patient underwent her 2 nd Fasting Blood
Glucose Testing, and results indicated an inrease from her previous blood sugar level but is still within
normal limits.
Two months prior to consult (26 weeks AOG), patient suddenly experienced productive cough, 2
weeks in duration with colds. Patient sought consult at UMC, and was prescribed with antibiotics, to be

taken two times a day for seven days. Patient was not compliant and just took one capsule a day for four
days. No other associated symptoms like headache, vomiting nor any of the danger signs noted.
One month prior to consult (30 weeks AOG), patients cough and colds eventually was relieved.
No other associated symptoms were noted.
Eight days prior to consult (35 weeks AOG), patient consult with complaints of tolarable low back
pain. No medication was prescribed. Patient underwent her 3 rd ultrasound on July 4, 2016 for biophysical
scoring.
Day of consult (36 5/7 weeks AOG), patient sought consult with complaints of severe low back
pain with pain scale rate of 8/10. Internal Examination was done and showed closed cervix. Patient was
advised to continue monitor for danger signs and asked to return on the 21 st of July. No other associated
symptoms were noted.
REVIEW OF SYSTEMS
General
Skin
Head & Neck
Eyes
Ears
Nose & Sinus
Mouth & Throat
Respiratory
Cardiovascular
GIT
GUT
Hematologic
Endocrine
MSS/Extremities
Nervous System

(+) weight gain (-) weakness (-) loss of appetite (+) easy fatigability
(+) mild pruritus on the periumbilical region (-) rashes (-) wounds
(-) stiffness (-) lymphadenopathy (-) mass (-) swelling
(+) farsightedness (-) discharge (-) pain
(-) masses
(-) discharge (-) tinnitus
(-) watery discharge
(-) obstruction
(-) mass
(-) lymphadenopathy (+) dentures
(-) dyspnea (-) cough (-) phlegm
(-) cyanosis (-) palpitations
(-) angina
(-) jaundice (-) nausea (-) vomit (-) diarrhea
(-) polyuria (-) discharge (-) edema
(-) pallor (-) easy bruising (-)
(-) polyuria (-) dysuria
(-) fractures (-) edema
(-) seizures (-) slurring in speech (-) headache

TEN DANGER SIGNALS OF PREGNANCY

(-) 1. Any vaginal bleeding
(-) 2. Swelling of the face and/or fingers
(-) 3. Severe or continuous headache
(-) 4. Dimness or blurring of vision
(-) 5. Abdominal pain
(-) 6. Persistent vomiting
(-) 7. Chills or fever
(-) 8. Dysuria
(-) 9. Escape of fluid from the vagina
(-) 10. Marked change in frequency or intensity of fetal movements

PHYSICAL EXAMINATION
GENERAL SURVEY
Patient is well developed, well nourished, conscious, coherent, ambulatory, oriented to time,
place and person, not in cardio-respiratory distress and appears her chronological age of 36.
VITAL SIGNS:
BP = 120/78 mmHg (left arm, sitting position) Pre-pregnancy weight = unrecalled
HR = 84 bpm
Present weight = 75 kg
PR = 83 bpm
Height =149.86 cm

RR = 20 cpm
Temp = 36.4 C

BMI= 33.4

HEENT
Patient has hyperpigmentation on the neck. Patient has pinkish conjunctiva. Patient has no visible
chloasma on her face and no epulis on her oral cavity. Patient has pearly gray tympanic membrane with
visible cone of light.

CHEST AND LUNGS

Patient has symmetrical chest expansions, no use of accessory muscles and no deformities were
noted. On palpation, patient has equal tactile fremitus. On auscultation, patient has normal breath sounds,
vesicular over most of the lungs, no adventitious sounds were heard. Percussion was not done.
BREASTS
Not done.
HEART:
Patients heart rate is normal, with a rate of 84 beats per minute, with regular rhythm, best heard on
the apex (S1), and absence of S3 and S4 murmurs. On inspection, there was no precordial bulge.
ABDOMEN
Inspection: striae on abdomen was brown in color, extends across the midline from the top of the
abdomen to the pubis.
Palpation:

FH= 33cm
EFW= 3.26 kg
LM1: large nodular body
LM2: Fetal back on maternal right
LM3: head is not engaged, cephalic presentation
LM4: not done

Auscultation: FHT= 140 bpm located on the right lower quadrant of the mothers abdomen
GENITALIA (not done)
EXTREMITIES
No edema on both feet and hands
NEUROLOGIC:
Patients general behavior is normal. She is dressed appropriately according to age of 36 years old
and occasion. Her stream of talk is normal. Mood and contents of thought are appropriate. Intellectual
capacity is average. Patient is awake, with normal attention span and orientation. Patients remote
memory is poor, recent memory is fair, immediate memory is good. Patient is well-informed.
IMPRESSION
36 years old, G2P0(0010), Pregnancy, uterine, 36 5/7 weeks AOG, cephalic presentation, not in
labor, high risk with age of 36, height of 149.86 cm and BMI of 33.4
Basis:

Patient is a high risk pregnancy: age is >35 years old, height is <153 cm, weight (increased BMI)
Patient is a multigravid
Diagnosis of pregnancy is based on amenorrhea, positive pregnancy test and confirmation by
ultrasonography accompanied by anatomical changes and fetal heart tone
Age of gestation is based on the patient's ultrasound results
Presentation is based on performing Leopold's maneuver
There were no contractions noted during the evaluation

Discussion:
This is the case of ER, 36 years old, G2P1 (0010), consulted for the 12th prenatal check-up in
DLSU-UMC. Her LNMP was unrecalled, age of gestation of 36 weeks and 5/7 days and expected date of
delivery is August 5, 2016 based on her ultrasound results. Quickening was on the 5th month, 1 st week of
March at 18 weeks AOG. Her last prenatal check-up was on July 4, 2016, no complications were noted.
Pregnancy is considered to be high-risk if these factors are seen: maternal factors include age
<18 years old or >35 years old, height of less than 5 feet (153cm), obesity, hypertension and/or other
medical conditions; Social factors include smoking, illicit drug use, alcohol intake; poor obstetric history;
PROM; fetal growth disorders, amniotic fluid abnormalities; post term pregnancy. Based on the criteria of
having high risk pregancy, the patient has 3 risk factors, including age of 36 years old, height of almost
150 cm and a BMI of 33 which suggest obesity. Patient does not smoke cigarettes, drink alcoholic
beverage nor take illegal drugs. Patient has been compliant with the intake of multivitamins and
medications of folic acid, as well as ferrosulfate and calcium. These are very important supplements in
order to prevent or decrease the risk of the fetus having congenital defects, iron deficiency anemia as well
as preeclampsia.
Prenatal visits are important and should be done once pregnancy is suspected. This is to
adequately assess the status of the mother and the fetus, estimate the age of gestation and to gradually
and adequately plan obstetrical care and even postpartum care. The patient was compliant to seek
consult and go to prenatal check-ups every month since she suspected the possibility of pregnancy.
Prenatal visits are scheduled at 4 week intervals until 28 AOG, followed by 2 week intervals until 36 AOG
and 1 week intervals until delivery. She noted that she consulted at DLSU-UMC every month for her
prenatal check up.
Diagnostics:

Amniocentesis can be done to identify certain genetic conditions, as well as neural tube defects
affecting the brain or spinal cord.
Cervical length measurement can be done to assess risk of having preterm labor

Management

Continue prenatal visits every week until time of delivery

Advise to notice any danger signs of pregnancy and if any signs are present, consult obstetrician
immediately.
Advise mother to eat healthy food, espcially those rich in folic acid, iron, calcium and other
essential nutrients.
Advise mother to monitor weight gain to provide the proper support for the baby
Advise mother to avoid exposure to toxic substances like cigarettes, alcoholic beverages and
illegal drugs.
Advise mother to do simple, tolerable physical activity to promote blood circulation
Educate the patient on the signs of labor and how to prepare for when time of delivery comes

References:
Cunningham. (2014). Williams Obstetrics, 24e. McGraw-Hill.
http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/high-risk-pregnancy/art-

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