Subjective:
CC: Referred from antepartum testing 3rd trimester pregnancy with IUGR
HPI: 35 y/o Asian female G1P0 @ 36w 3 d gestational age with estimated date of delivery of 3/15/21, dated by LMP 36 weeks. Patient confirms LMP is correct. Patient sent from ATU after NST with ctx q 1.5-3 minutes. Patient states she had tightening cramping in abdomen since last night, intermittent, approximately 1-2 per hour at most. She states the tightening isn’t alleviated or worsened by anything. Denies headache, blurry vision cramping, pain, discharge, bleeding, or leaking fluid. Patient reports good fetal movement.
Problem List:
1) Advanced maternal age
2) Late registrant @ 22 wks
3) non-compliance with prenatal recommendations to get prenatal ultrasounds
Anatomy sonogram 2/18/21:
GA 36 W 3 D. Late registrant. Arithmetic ultrasound age 32 W 4 D. EFW 1890 g < 1%. Mean Umbillical artery Doppler 2.91. Transverse lie. Normal anatomy limited by advanced GA. Suboptimal facial anatomy., LVOT, DA, Right leg, Right arm, hands, feet. Patient was referred to NST. Pt not compliant with follow up BPP, doppler and targeted anatomy.
Obstetrics/Gynecology history:
Gravida: 1 Para: 0
LMP: 6/8/2020
Past medical history:
HPV infection
Past Surgical history:
none
Social history:
Marital status: married
lives with: unknown
Sexual history: sexually active with one male partner
smoking status: never smoked
Drug use: none
Family history:
unknown
Medications:
Prenatal vitamins
Ferrous Sulfate 325 mg 1 tablet PO daily
Allergies:
no known drug or environmental allergies
Review of systems:
General: Denies fever, chills
HEENT: denies vertigo, rhinorrhea
Pulmonary: Admits to shortness of breath associated with pregnancy. Denies cough, wheezing, dyspnea.
Cardiovascular: Denies Diaphoresis, syncope, angina, palpitations.
Gastrointestinal: Denies changes in appetite, nausea, vomiting, diarrhea, constipation.
Musculoskeletal: Denies joint pain, swelling, erythema.
Neuro: Denies dizziness.
Dermatologic: Denies rash, moles, itching, hair loss
Psychological: Denies depression, anxiety or changes in sleep.
Breast: Denies masses, discharge, pain, or history of breast cancer.
Genital: Admits to normal vaginal discharge. Denies dryness, abnormal bleeding, pruritis, sexual dysfunction or lesions.
Urinary: Denies dysuria, urgency, flank pain, hematuria or urinary incontinence.
Objective:
Physical Exam:
Vitals:
BP: 103/61
HR: 80
RR: 17
Temperature: 98.2 F (oral)
O2 sat: 97 in room air
Ht: 149.9 cm (4 ft 11 in)
Wt: 50.3 kg (111 lb)
BMI: 22.42 kg/m2
General: Alert, awake and oriented to person, place and time. Not in acute distress.
Heart: S1 and S2 present, regular rate and rhythm, no murmurs noted.
Lungs: Clear breath sounds present in all lung fields. No adventitious breath sounds.
Abdominal: Abdominal sounds present in all four quadrants. Soft, non-tender abdomen. No CVA tenderness. Gravid uterus.
Uterine size: size less than dates
Estimated fetal weight: 1890 g (<1%)
Vaginal exam: closed/long/posterior. No signs of rupture of membrane.
Extremities: lower extremities symmetrical and non-tender bilaterally
DVT evaluation: no evidence of DVT on physical exam
Bedside Abdominal Ultrasound:
Presentation: Transverse
Placenta Location: posterior
AFI: 13
POC Urine: Trace leukocytes, trace ketones
Assessment/Plan:
Assessment:
35 y/o G1P0000 with EGA of 36 weeks 3 days admitted for preterm labor management and monitoring for intrauterine growth restriction, estimated fetal weight 1,890 g (<1%).
Electronic fetal heart rate monitoring:
Category 1 tracing.
Fetal baseline heart rate: 150
Decelerations/acceleration: moderate variability with accelerations. No decelerations.
Toco: Contraction q3-5 minutes
Plan:
1. Admit
2. Labs CBC, Type and Screen, Syphilis, GBS
3. Administer Ampicillin 2 g IVPB for GBS unknown x 1
4. Betamethasone 12 mg IM q24h x 2
5. Terbutaline SQ injection 0.25 mg x 1
6. IV fluids Lactate Ringers 1000 mL
7. Fetal heart rate monitoring
8. Analgesic as needed
