CLINICOSOCIAL CASE:

ANTENATAL CASE
(as taken on 18.10.2016)

By- Group 1, 2 and 3

SUBJECT PROFILE
 Name - Mrs. Manimeghalai
 Age/ Marital Status - 23years, married since
5 years
 Address – Arasampattu(District-Villupuram), 2.5 hours away from
JIPMER (by bus)
 Educational Status – 12th standard
 Occupation – Housewife
 Name of the husband – Mr. Naresh
 Monthly per capita income – Rs. 1000
 Socio-economic scale- Class III according to modified Kuppuswamy
scale
 Nearest Health facility – Govt. Hospital,
Arasampattu, 10 minutes
 Respondent – Self
 GPLA Score- G2 P1 L1
PRESENTING COMPLAINTS:
1. Easy Fatigability
2. Swelling of both legs and feet upto the knees.
3. Repeated episodes of dizziness.
4. Breathlessness on moderate to severe exertions.
5. Blisters in mouth and tongue.
6. For the past one month.
HISTORY OF PRESENTING PREGNANCY

 Easy fatigability: household activities

 Swelling :
1. acute in onset, seen in legs and feet.
2. Progressively increasing in size.
3. Relieved on rest/ after sleep.
 Dizziness : 2-3 episodes, better after rest
 Breathlessness on moderate to severe exertion.
 OBSTETRICS HISTORY

 LMP: 28/01/16; EDD:04 /11/16; POG: 37 wks+4 days

 Conception - spontaneous.
 Pregnancy confirmed after 3 months of amenorrhea at
Arasampattu Govt. hospital by Urine Pregnancy Test.
 Booked in 3rd month.
1st Trimester 2nd 3rd
Trimester Trimester
No. of ANV 1 3 3

*ANV – Antenatal Visits; LMP – Last Menstrual Period;

EDD – Expected Date of Delivery; POG – Period of Gestation
 1st Trimester

1. No H/O excessive vomiting.

2. No H/O bleeding p/v.
3. No H/O excessive vomiting during this period.
4. No folate intake, no H/O chronic drug intake
5. No H/O fever with rashes.
6. No H/O exposure to radiation.
7. No USG Scan in 1st trimester.
2nd Trimester

1. Quickening – at the end of 4th month.

2. Iron and folic acid – irregular intake due to
intolerance.
3. 7-8 hours of sleep at night.
4. Tetanus Toxoid – 4th and 5th month.
5. First USG Scan done at 4th month.
3rd Trimester

1. No pain in the abdomen.

2. Normal perception of fetal movements.
3. Iron and folic acid continued after hospital
admission.
4. No known case of diabetes / hypertension.
5. Scan at 8th month and 9th month.
6. Parenteral iron therapy also started from 9th
month of pregnancy.
TREATMENT HISTORY
She was irregular on her iron folate
medications when symptoms started 1 month
back

Went to the Govt. Hospital, arasampattu, iron

folate continued

Symptoms worsen 1 week later; referred to

Govt. Hospital, Kalakuruchi;

referred to JIPMER for evaluation of heart

disease

Admitted at JIPMER, started on medications

and the routine tests done.
MENSTRUAL and MARITAL HISTORY

 Menarche -13 years.

 Cycles – regular ,once in 30 days ,5 days of flow

 H/O of dysmenorrhea.

 Married since 5 years; non consanguineous

 No use of any contraceptive methods

PREVIOUS OBSTETRICS HISTORY

1. Type of Delivery – Spontaneous Vaginal.

2. Place ,Length of gestation-Govt. hospital
(Arasampattu) , 09 months.
3. Sex and weight : Male , 2.50 Kgs.
4. Cried immediately at birth.
5. No H/O Postnatal fever, foul smelling lochia ,
bleeding p/v.
6. Colostrum after 30 mins of delivery.
7. No prelacteal feed given. EBF for 3 months only.
8. Complementary feeding (idli, milk powder, cow’s
milk ) - after 3 months.
9. Immunized till date.
PAST HISTORY…

 No history of surgery.
 No history of co-morbidities like:
diabetes mellitus, hypertension, epilepsy,
bronchial asthma, tuberculosis, heart disease,
thyroid disorders.
 No history of allergy.
 Personal history

• No H/O addictions of alcohol/tobacco/drugs.

• Normal bowel and bladder habits.

• Normal appetite.
FAMILY HISTORY…
 Type of family – Nuclear family
 Number of family members – 3
 No history of diabetes, hypertension, other chronic disease or handicaps
in family
 No H/O of consanguinity
ENVIROMENT ASSESSMENT

1. Housing - presently lives in semi pucca house with

single room and separate kitchen.
2. Toilet facility- NO. open air defeacation. WALKING
BAREFOOT.
3. Source of drinking water – household tap.(water from
municipal tanks)
4. Storage - pot , use water by dipping glass.
5. Waste disposal- proper disposal with dustbins.
Garbage trucks comes regularly.
6. Animals/pets – no pets.
7. Socio-economic scale- Class III according to Modified
Kuppuswamy scale
 SOCIO ECONOMIC HISTORY
 They actively interact in different activities and
functions in the community.no presence of any social
stigma.
 Total family income- Rs. 3000 pm
 expenses on diet and medicines- approx. Rs. 1000-
1200.
 Savings or debts- Rs. 1800- 2000.
 No family tensions due to the economic situation.
Dietary history:
Time Food Calorie(Kcal) Protein(g
)
Morning Rice(1 cup) 110 2.2
Sambar (1cup) 50 15
Vegtable curry(1 cup) 170 0
Afternoon Sambar rice ( cups) 250 15
Vegetable curry(1 cup) 170 0
Night Rice(1 cup) 110 2.2
Sambar (1 cup) 50 15
Vegetable curry(1 cup) 170
Total 1080 49.4
Calorie intake Calorie required Calorie deficit
1080 Kcals 2250 Kcals 1170 Kcals (52% )
Protein intake Protein requirement Protein deficit

49.4 gms 78 gms 28.6 gms (36.7 %)

CLINICAL EXAMINATION
•comfortable at rest
•moderately built ,adequately nourished
•Afebrile
•pulse rate 84 beats per minute.
•blood pressure 110/70mm Hg
•respiratory rate 25 breaths / min
• Spine and Gait normal.
PICCLE

 She is pale [ pallor +++]- moderate to severe.

 She is not icteric.

 There is no clubbing.

 There is no cyanosis.

 B/L Pedal Edema present.

 ANTHROPOMETRY
 Height- 147 cms.

 Weight- 47 kgs.

 Symphysio-fundal height- 34 cms.

 SYSTEMIC EXAMINATION
 Cardiovascular examination :
Normal s1 and s2 sounds are heard.
Murmur heard in the mitral area.

 Respiratory examination :
RR is elevated (25 br / min)
normal bronchial and vesicular
sounds are heard
No abnormal respiratory sounds
heard.
Abdominal examination

Inspection:
 abdomen is uniformly distended.

 All quadrants move equally with respiration.

 Umbilicus is centrally positioned, everted.

 Linea nigra and stria gravidarum are seen.

 Hernial orifices are free.

Palpation:
 Fundal height : corresponds to 37th week of
gestation
 Symphysio-fundal height is 34 cms (corresponds
to period of gestation)
1. Fundal grip reveals broad , uniform, soft mass
suggesting fetal breach.
2. Lateral grip:
–left lateral grip reveal uniform resistance
throughout curved surface suggesting of fetal
back.
- right lateral grip reveals knoblike structure
suggestive of fetal limb buds
3. 1ST Pelvic grip –it reveals hard globular mass ,
ballotable suggestive of fetal head.
4. 2nd Pelvic grip –it confirms the findings of 2nd
pelvic grip. Head is not engaged.
SYSTEMIC EXAMINATION

Auscultation – fetal heart sounds are

heard.

Estimated fetal weight: Johnson’s formula

=(fundal ht. – n )*155
(n=14) ,if vertex above ischial spine
= (34-14)*155
=3.100kg
 Investigations done
At GH:
1.pregnancy detection test : done +ve
2.hemoglobin examination : done
Hb~5.6g/dl(current levels)
3. urine test for presence of
albumin and sugar done : done
4.rapid malaria test : (not sure)
Investigations done
At JIPMER:
1. blood grouping : O+ve
2. VDRL : -ve
3. HIV test : -ve
4. rapid malaria : -ve
5. blood sugar profile : normal
6. HBs Ag for hepatitis B : -ve
 Provisional diagnosis
Based on the history, examination and lab reports , we
conclude that she is severely anaemic.

1.According to WHO expert group criterion

Cut-off point for diagnosing anaemia =11g/dl
her Hb is 5.6g/dl.
2.And she had symptoms of easy fatigue, dyspnea.
3.On examination she has moderate to severe palor.
 Management and interventions

At individual level:
1.Advised to take nutritious food. Especially about iron
rich diet
2. She is advised regarding danger signs of pregnancy.
3.Advice for institutional delivery.
4.Importance of exclusive breast feeding.
5.Importance of family planning.
Management and interventions

 At family level:
1.supportive family members
2. Provide adequate diet and rest.
3. Accompany for regular follow up visits
4.Preparation for transport to health facility.
Management and interventions

At community level:
1. Regular counselling and home visits, early
identification of anaemia and proper management
would have prevented Hb from falling to level of
severe anaemia.
 Summary

Provisional diagnosis-
23 years old, Mrs. Manimeghalai with G2P1L1 is
diagnosed to be severely anaemic and she came for
the management of anaemia and safe confinement.
Thank you 