DETAILED HISTORY FOR EXAMINATION

PNC (Postnatal Care) Case - AIIMS Gorakhpur

PATIENT IDENTIFICATION

CHIEF COMPLAINTS

1. Abdominal pain - 1 am
2. Decreased fetal movement - 1 am
3. Associated symptoms as below

HISTORY OF PRESENT ILLNESS

• She was not perceiving fetal movements appropriately.
• She also had features of decreased amniotic fluid (oligohydramnios suspected) and complaints related to cephalic presentation.
• She also received treatment including:
  • Tab. Salcium tablets and
  • Vitamin D / calcium supplementation
• She has fetal heartbeat concerns (bilateral, documented on examination).
• Features suggestive of pelvic cellulitis were also noted on presentation.

OBSTETRIC HISTORY

• Patient was receiving Tab. Folic acid / Iron-folic acid medications
• Receiving B12 / NV12 / NutriMed/Nutrolin B syrup for ~2 years (ongoing)
• Receiving Tab. Thyronorm (levothyroxine) - documented under ongoing medications, suggesting hypothyroidism in pregnancy

PAST HISTORY

ONGOING MEDICATIONS (at the time of presentation)

1. Tab. Thyronorm (Levothyroxine) - for hypothyroidism
2. Tab. IFA (Iron-Folic Acid)
3. B12 / NV12 / NutriMed syrup - ~2 years
4. Tab. Salcium / Calcium + Vitamin D supplementation
5. Tab. Lupihance / Lupicor (possibly oral iron / micronutrient supplement)
6. Note: Tab. Thyronorm and endocrine medications strongly suggest pre-existing or gestational hypothyroidism

PERSONAL HISTORY

FAMILY HISTORY

• No significant family history documented on the sheet.

IMMUNIZATION HISTORY

GENERAL EXAMINATION (from Examination Sheet)

General Physical Examination:

SYSTEMIC EXAMINATION

Respiratory System:

• Bilateral air entry present
• No added sounds documented

Central Nervous System (CNS):

• Patient is conscious and oriented to time, place, and person

Cardiovascular System (CVS):

• S1, S2 heard
• No murmur documented

Per Abdomen (P/A):

• FHS (Fetal Heart Sounds) present at 34 weeks cephalic presentation
• Uterine size: ~34 weeks
• Fetus in cephalic presentation
• Fetal Heart Sounds present (documented)
• Findings suggestive of blood-stained liquor / meconium-stained liquor noted

Gynaecology / Obstetrics (Gyn/Obs):

• VIA = uterus 34 weeks, cephalic presentation
• Evidence of blood-stained / meconium-stained liquor noted
• OS 2 cm soft - cervical assessment documented
• Further findings consistent with acute fetal distress

PROVISIONAL DIAGNOSIS

G2P1L1A0 with ~34 weeks pregnancy in cephalic presentation with FHS, OS 2 cm soft - Meconium-stained / Blood-stained Liquor with Acute Fetal Distress

INVESTIGATIONS ADVISED

Routine / Bedside:

Special / Inflammatory Markers:

Microbiology / Culture:

COVID-19:

PREVIOUS INVESTIGATIONS

• Records of previous investigations were present but specific values not fully legible from the sheet.

SUMMARY FOR VIVA / EXAMINATION

Note: Some handwritten entries on the original sheet were partially legible. The above history has been constructed as accurately as possible from the available clinical information. Any values in parentheses are interpretations based on standard obstetric documentation practice.

DIFFERENTIAL DIAGNOSIS

PNC Case - Suman, 27F, G2P1L1A0, ~34 Weeks

PRIMARY / MOST LIKELY DIAGNOSIS

1. Abruptio Placentae (Placental Abruption)

• For: Abdominal pain + decreased fetal movements + blood-stained liquor + acute fetal distress at 34 weeks
• Premature separation of normally situated placenta
• Can present with concealed or revealed bleeding
• Causes fetal hypoxia - explains decreased FM and acute fetal distress
• Key features matching: Pain, blood-stained liquor, FD

DIFFERENTIAL DIAGNOSES

2. Meconium-Stained Amniotic Fluid (MSAF) with Fetal Distress

• For: Documented meconium/blood-stained liquor on per vaginal examination
• Indicates fetal hypoxia - fetus passes meconium in utero
• Associated with decreased fetal movements
• Common at or near term, especially with uteroplacental insufficiency
• Grade 1 / 2 / 3 meconium staining needs grading

3. Preterm Labour with Fetal Distress (PTL)

• For: 34 weeks gestation (preterm), OS 2 cm dilated, soft cervix, abdominal pain (uterine contractions)
• Cervix 2 cm dilated = early active labour / latent phase
• Preterm uterine contractions can compromise fetal oxygenation
• Meconium staining at 34 weeks is always pathological - increases suspicion of underlying fetal compromise

4. Intrauterine Fetal Growth Restriction (IUGR) / Placental Insufficiency

• For: Decreased fetal movements + 34 weeks + hypothyroid mother
• Hypothyroidism is a known risk factor for IUGR and placental dysfunction
• Oligohydramnios (suspected clinically) further supports placental insufficiency
• Would explain chronic fetal compromise culminating in acute presentation

5. Chorioamnionitis (Intrauterine Infection)

• For: Blood-stained/turbid liquor + inflammatory markers ordered (Procalcitonin, CRP, IL-6, D-Dimer, Blood Culture)
• Infection of fetal membranes causes fetal tachycardia, decreased movements, preterm labour
• Treating team ordering extensive culture workup (blood, urine, sputum) - suggests high clinical suspicion of infection
• Can coexist with MSAF and fetal distress

6. Umbilical Cord Complications (Cord Prolapse / Cord Compression)

• For: Acute onset fetal distress + decreased FM + cephalic presentation + OS 2 cm
• With partially dilated cervix, cord prolapse or cord around neck can cause acute FHR decelerations
• Less likely but must be ruled out on USG / auscultation

7. Placenta Praevia (Lower Segment)

• For: Painless bleeding (partial) - though pain is present here, making this less likely
• Against: Pain + contractions usually suggest abruption rather than praevia
• Still consider: If USG shows low-lying placenta

8. Hypothyroidism-related Obstetric Complication

• Patient is on Tab. Thyronorm - documented hypothyroidism
• Uncontrolled/undertreated hypothyroidism in pregnancy is associated with:
  • Placental abruption
  • Stillbirth
  • IUGR
  • Pre-eclampsia
  • Preterm labour
• Should always be mentioned as a contributing/predisposing factor

9. Pre-eclampsia / HELLP Syndrome

• For: Ordering LFT, KFT, coagulation (PT/INR, APTT), D-Dimer, LDH, Ferritin
• BP was 112/64 on admission - currently not hypertensive, but ruling out is warranted
• HELLP can present with epigastric/abdominal pain + fetal distress
• Less likely given BP, but cannot be excluded without full labs

10. Sepsis with Fetal Compromise

• For: Extensive infectious workup ordered (procalcitonin, cultures, CRP, IL-6)
• Maternal sepsis from any source (pelvic cellulitis mentioned in notes) can cause uteroplacental insufficiency
• Explains ordering of Sputum MTB GeneXpert - possible TB co-infection screening

SUMMARY TABLE

INVESTIGATIONS TO CLINCH DIAGNOSIS

Bottom Line for Exam: This is most likely Abruptio Placentae at 34 weeks with Acute Fetal Distress and Meconium-Stained Liquor in a Hypothyroid Mother who has gone into Preterm Labour, requiring urgent obstetric intervention (likely emergency LSCS).