32 years old
G2P1 (1001)
Married
Roman Catholic
One Oasis Condo, Central (Pob), Cebu City
MEDICAL HISTORY:
(+) Hypertension: at 24 weeks AOG (Methyldopa 250 mg, if BP: ≥140/90 mmHg)
(-) Bronchial asthma
(+) Gestational Diabetes Mellitus: at 25 weeks AOG (Metformin, 250 mg/tab, BID)
(-) Dyslipidemia
(-) Food and Drug Allergies
COVID Vaccination:
1st Dose: Astrazeneca
2nd Dose: Astrazeneca
Booster Dose: none
PERSONAL AND SOCIAL HISTORY:
College graduate
Housewife
Living with husband
Non cigarette smoker
(-)alcoholic drinker
Denies illicit drug use
Diet: Rice, Meat, vegetables
No prior surgical or hospitalization
Paternal side: (+)HTN
Menarche: 12 years old
Interval: Regular
Duration: 7 days
A: 2 pads/day, fully soaked
Symptoms: (-) Dysmenorrhea
Coitarche: 20 years old
Partner: 1
Contraceptive: none
Papsmear: none
STI: none
OB Score: G2P1 (1001)
G1: 2014, Negros Occidental Hospital
Mode of delivery: NSVD
TERM, Female, 3300g (7.3 Lbs, 116 oz), No maternal complications
G2: Current pregnancy
Prenatal History:
First prenatal visit: 10 5/7 weeks AOG
Total prenatal visits: 12 visits
Last prenatal visit: 36 weeks AOG
Usual BP range: BP Systolic 110-150 mmHg, Diastolic 70-90 mmhg
Vaccines: Tdap x 1 dose
Prenatal vitamins: Folic acid, Iron, Ca, Multivitamins tab
First trimester:
Folic acid OD
Calcium tab OD
Second and third trimester
Iron 1 tab OD
Calcium + Vit D (Calciumade), 1 tab BID
HIV: Non reactive
Syphilis: Non reactive
HBsAg: non-reactive
Blood type: B positive
Papsmear: none
Test Why It's Done
To check for thrombocytopenia (Plt <100,000/µL), which is a
CBC (Complete Blood
severe feature of preeclampsia. Also evaluates hemoconcentration or
Count)
anemia.
Elevated LDH (>600 U/L) indicates hemolysis (part of HELLP
LDH (Lactate
syndrome). LDH is a marker of tissue damage and microangiopathic
Dehydrogenase)
hemolysis.
To check for transaminitis (AST or ALT >2x normal), indicating
AST/ALT (SGOT/SGPT)
liver involvement in preeclampsia.
To assess for renal impairment (Cr ≥1.1 mg/dL or doubling of
Serum Creatinine
baseline), a severe feature.
To check for proteinuria (≥1+ on dipstick) and rule out UTI or
Urinalysis
hematuria.
Urine Protein/Creatinine More accurate measure of proteinuria (significant if ≥0.3 mg/mg).
Ratio (UPCR) Confirms renal involvement.
Elevated uric acid levels are associated with endothelial
Uric Acid dysfunction in preeclampsia and may indicate disease severity. Not
diagnostic but supports clinical picture.
Peripheral Blood Smear To check for schistocytes, which suggest microangiopathic
(optional) hemolytic anemia in severe preeclampsia or HELLP.
24 weeks AOG noted elevated BP during a prenatal consult with BP
noted at 140/90.
CBC: UNremarkable
The urinalysis shows mild pyuria (WBC 44.40) and hematuria (RBC 16.65), along with
significant bacteriuria (100), strongly suggesting a urinary tract infection (UTI). The
presence of trace blood and leukocytes further supports this, while the negative
nitrites and negative protein are reassuring. The specific gravity (1.015) and pH (6.0)
are within normal limits, indicating proper hydration and kidney function, while glucose
(trace) could be linked to gestational diabetes. (Zinnat for 1 week)
at 24 weeks AOG (Methyldopa 250 mg, if BP: ≥140/90 mmHg)
CBC:
01/20/2025
WBC: 12.95
Neu: 76
Lymp: 17
Mono: 5
Eosi: 2
Baso: 0
Hgb: 13.4
Hct: 39.8
RBC : 4.4
MCV: 89.6
MCH : 30.2
MCHC : 34
RCDW : 12.5
Plt: 305
MPV: 9.9
Urinalysis:
01/0202025
Color: Yellow
Appearance: Slightly Hazy
pH: 6.0
Specific Gravity: 1.015
Leukocytes: 1+
Blood: Trace-Intact
Glucose: Trace
Nitrite: Negative
Protein:Negative
Urobilinogen: 0.2
Urinary Ketone: Negative
Bilirubin: Negative
RBC Red Cells: 16.65
WBC Pus Cells: 44.40
Epithelial Cell: 16.65
Casts: 0.00
Bacteria:100
at 25 weeks AOG (Metformin, 250 mg/tab, BID)
Clinical Chemistry:
Glucose (Fasting): 93 mg/dl
Glucose (1st hr Post 75g): 193 mg/dl
Glucose (2nd hr Post 75g): 188 mg/dl
SGPT: 44 U/L
SGOT: 24 U/L
LDH: 146 U/L
Urine total Protein: 14.30 mg/dl
Creatinine Urine Random: 75.54 mg/dl
Remarks: Urine Protein/Creatinine Ratio: 0.19
AFI Interpretation:
AFI Value Interpretation
<5 cm Oligohydramnios – low amniotic fluid
5–24 cm Normal
>24 cm Polyhydramnios – excessive amniotic fluid
Weight Classification
<1,500g to 2500 g Low Birth Weight (LBW)
Normal Birth Weight
1000–1500,000g
<1000 Extremely low birthweight
>4,000g Macrosomia (large for gestational age)
HPI:
7 hours PTA, the patient noted a sudden onset of hypogastric cramping
pain, lasting about 60 seconds, occurring every 4–5 minutes, and radiating to the
back. Pain was rated 7/10 in intensity. There was no associated watery or bloody
vaginal discharge, and fetal movements were reported to be good. Due to
persistence of symptoms, the patient consulted her private attending physician and was
subsequently advised admission to our institution.
• Timing: After meals (preferably after dinner)
• Position: Lying on the left side
• Method: Count 10 fetal movements within 2 hours
General Survey:
Awake, alert, ambulatory, coherent, responsive, not in respiratory distress
Vital Signs
BP: 150/100 mmHg -> 140/100 mmHg
HR: 96 bpm
RR: 19 cpm
Temp: 36.6 °C
O2 sat: 98% at RA
Anthropometrics
Height: 152 cm
PPW: 60 kg
PW: 75.5 kg
BMI: 32.7 kg/m2 (Obese Class II) Asia-Pacific BMI classification
Ppw BMI: 25.97 (OVERWEIGHT)
15.5 KG (34.17 LBS) is above the recommended range for an overweight individual
IDEAL: 15-25 LBS
Ideal
Skin: no lesion, (-) pallor, no jaundice, warm to touch, good turgor and mobility
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no nasal and ear discharges,
moist lips and oral mucosa, no cervical lymphadenopathies
C/L: equal chest expansion, clear breath sounds
CVS: distinct heart sounds, (-) murmurs
Abdomen: soft, nontender, NABS, gravid
FH: 33cm FHT: 140s EFW: 3255 grams (7.2lbs,115 oz)
GUT:
IE: 6cm, 70%, -3, I/C, Soft, Anterior, BS: 9
Extremities: motor strength 5/5 all extremities
Neurologic: conscious, coherent, oriented to place, person, time
FRIEDMAN: suggests progressive cervical dilatation, consistent with active labor. The cervix is
dilating steadily, approaching full dilation by hour 4.
Admitting Labs
CBC:
04/08/2025
WBC: 13.06 (H)
Neu: 79
Lymp: 15
Mono: 4
Eosi: 1
Baso: 1
Hgb: 13.5
Hct: 38.7
RBC : 4.2 (L)
MCV: 82.0
MCH : 30.2
MCHC : 37 (H)
RCDW : 9.8 (L)
Plt: 235
MPV: 6.29 (L)
UA:
04/08/2025
Color: Yellow
Appearance: Clear
pH: 6.5
Specific Gravity: 1.020
Leukocytes: Negative
Blood: Trace-Intact
Glucose: Negative
Nitrite: Negative
Protein: 3+
Urobilinogen: 0.2
Urinary Ketone: 1+
Bilirubin: Negative
RBC Red Cells: 16.65 (H)
WBC Pus Cells: 4.0
Epithelial Cell: 0.00
Casts: 1.09
Bacteria:80.00
CLINICAL CHEMISTRY
Uric acid: 7.20 mg/dl
Creatinine: 0.61 mg/dl
SGPT: 114 U/L
LDH: 143 U/L
Urine total Protein: 246.20 mg/dl
Creatinine Urine Random: 69.77 mg/dl
Remarks: Urine Protein/Creatinine Ratio: 3.528
The elevated SGPT and LDH values, along with significant proteinuria and elevated uric
acid, point to possible pre-eclampsia, hepatic involvement, or renal pathology. The
protein/creatinine ratio strongly supports the presence of proteinuria, which warrants further
evaluation and close monitoring, particularly in the context of pregnancy. Immediate follow-up
and appropriate management, including monitoring for signs of hypertensive disorders and
liver dysfunction, are recommended.