STUDENT PROBLEM-BASED LEARNING SESSION

Prematurity

Clinical Problem Basis:  

Immediately upon completion of your residency in Obstetrics and Gynecology you are employed by a Suburban Branch of the County Health Department. Though technically suburban, this area is part of a larger urban community and has a significant indigent and uninsured population. As part of your new job you will be:

1. Developing a prenatal screening and data collection form. This device will be used by all types of health care providers. It will not replace the currently used prenatal forms, but instead will be used to identify patients at risk for prematurity so that efforts can be made to improve the outcome of these pregnancies. (Resources are such that not all patients can receive these interventions - so low socioeconomic status alone is not the issue.) Bring your screening sheets with you to class. They will be DISCUSSED.
2. Asked to list at least 5, preferably 10, interventions based on information collected from your prenatal screening and data collection form.
3. Provide prenatal care for high risk women including this patient:

Clinical Case:

She is a 28 year old Hispanic gravida 3, para 1101 whose last menstrual period was 24 weeks ago. She has had no contact with any health care provider prior to you. Since she has been aware of her pregnancy, she has felt tired, noticed increased pelvic pressure, had heavy vaginal discharge and experienced nausea with vomiting 3 to 4 times per week.

She has never been hospitalized except for the delivery of her two previous pregnancies. As a child she experienced frequent coughs.

Her first pregnancy was two years ago. She began prenatal care in Mexico in the "third month". In the last month of her pregnancy, she presented to the emergency room with headaches and swelling. She states that she was "toxic" and that the baby had died because it was too small. She was given a medicine that made her hot and another that made her have "hard labor". She states she started to bleed and then delivered the baby right away. It was a stillborn baby boy weighing 1580 grams with creases on the infant's sole all the way to the heel.

Her second pregnancy was delivered 12 months ago. She became pregnant as soon as her periods returned, on the advice of her family. She felt fine and was planning to go back to the doctors who delivered her first baby. She experienced a blood tinged discharge at approximately 27 weeks and went to the emergency room. She was told she was dilated and if she stood up the water bag would fall out. She was admitted to the hospital and given the medicine that made her hot again. She says two days later they stopped the "hot" medicine and gave her pills that made her heart pound. She described rupture of the membranes three days later. One week later she developed chills, fever and labor pains. The same day she delivered a 1100 gram female infant by cesarean section ("the baby was coming backwards"). The baby remained hospitalized for 3 months but is now at home and reportedly doing well.

The patient does not smoke. She drinks 3 beers after work each day. She is employed cleaning houses and works as needed by a service run out of her boss's house. She smokes marijuana when the baby's father brings it home.

Physical exam: Height 5'2", weight 101 pounds, blood pressure 120/80, P 99, R 18, T 99.0.

Discussion questions:  

1. Identify this patient's risk factors for recurrent preterm birth from the information given above.
2. List at least one intervention for each risk factor to improve this patients outcome.
   
   

   Risk Factor

   Intervention

   
   
   
3. For each part of the patient's physical exam, list items which need specific mention because of the patient's history and current risk of preterm birth.
4. List any abnormal findings in these areas which you might expect to find in this patient.

5. List the management for all abnormal findings listed above.
6. Identify other pregnancy risks.
7. Develop a schedule of laboratory tests, ultrasounds, tests of antenatal wellbeing and office visits for this patient.

References:

1. Premature Rupture of Membranes and Preterm Labor and Preterm Birth, Chapters 22 & 23 in Obstetrics and Gynecology, 5 th Edition , Beckmann, 2006

2. View: Radiology Curriculum
   http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric_f.htm

The APGO Educational Objectives related to this topic are the following:

Prematurity is the most common cause of neonatal mortality and morbidity. The reduction of preterm birth remains a goal of quality obstetric care. Understanding of the causes of preterm labor provides a basis for management decisions. Rupture of membranes prior to labor is a problem for preterm gestations. Careful evaluation and understanding of the implications of this complication may improve fetal outcome.

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