Seen at another facility for Liver and biliary tract disorders in pregnancy, unspecified trimester on 04-28-2022. Unable to see  documentation for this visit. Cholestasis and gestational diabetes noted during last pregnancy post initial series of Covid vaccination.  Presents to emergency department 05-18-22 with leaking of fluid.  History Of Present Illness:   This is a 31-year-old G4, P3 female at 34 weeks gestation by 14-week ultrasound with an EDC of June 29, 2022 that presents with leaking of fluid.  She reports that she woke up shortly after 5 AM and her underwear were wet.  She felt like she continued to leak clear fluid, so presented to the hospital.  Pregnancy has been complicated by cholestasis of pregnancy.  She developed it during her last pregnancy.  At about 31 weeks gestation she began complaining of itching during this pregnancy.  Symptoms were not as severe as last pregnancy, but we did go ahead and draw labs including CBC, CMP, and a total bile acid concentration.  It took about 9 days to get the total bile acid concentration level back, but it did come back elevated at 18.  At that point, the case was discussed with perinatologist, Dr.  She was actually scheduled to see him today.  He recommended starting ursodiol 300 mg twice daily and twice weekly nonstress tests and monitoring as an outpatient with plan for induction at 36 weeks gestation.  She has been having nonstress tests that have been reactive.  She has been doing daily fetal kick counts.  Liver enzymes were elevated but were actually trending down when last checked on May 9.  She did receive 2 doses of betamethasone on May 9 and May 10.  She reports her itching has not been too bad since starting ursodiol, currently reports her discomfort level at a 2.  Review of Systems:   Constitutional: No  fevers,  No  chills,  No  sweats  Eye:  No   recent visual problems  ENT:  No  ear pain,  No  nasal congestion,  No  sore throat  Respiratory:  No  shortness of breath,  No  cough Cardiovascular:  No  Chest pain,  No  palpitations,  No  syncope  Gastrointestinal:  No  nausea,  No  vomiting,  No  diarrhea  Genitourinary:  No  hematuria + of leaking of fluid Hema/Lymph:  No  bruising tendency,  No  swollen lymph glands  Endocrine:  No  excessive thirst,  No  excessive hunger  Musculoskeletal:  No  back pain,  No  neck pain,  No  joint pain,  No  muscle pain, No  decreased range of motion  Integumentary:  No  rash,  No  pruritus,  No  abrasions  Neurologic: Alert & oriented X 4  Psychiatric:  No  anxiety,  No  depression  Physical Exam   In general she is in no acute distress.  She is alert and oriented.  Heart regular rate and rhythm, no murmurs.  Lung sounds are clear.  Abdomen is gravid.  GU, cervix is 1 cm dilated, 50% effaced, -3 station, vertex presentation.  She does have clear fluid when checked.  Extremities, no edema.  Skin, no jaundice or rash.  Fetal heart tones are reactive with a base rate of 140 with moderate variability, positive accelerations, no decelerations.  She is having contractions every 6 to 8 minutes, but barely feeling these.  Assessment/Plan  This is a 31-year-old G4, P3 female at 34 weeks gestation with a history of cholestasis of pregnancy, on Ursodiol.  Membranes ruptured with clear fluid sometime before 5 AM this morning.  Amnisure is positive. I spoke with Dr. at facility who has accepted her for transfer.  GBS status is unknown, will give her 1 dose of penicillin G IM.  She did receive betamethasone on May 9 and 10.  Otherwise this pregnancy has been uncomplicated. She did have a history of gestational diabetes with previous pregnancies, but passed her glucose test with this pregnancy.  I do feel that she is safe for transfer at this point.  She is 1 cm dilated and having little to no discomfort with occasional contractions.  I have spoke with the patient and her husband and they are agreeable to this plan.  Cholestasis of pregnancy in third trimester O26.613   Pregnancy Z34.90   Premature rupture of membranes O42.90   Orders:   Lactated Ringers Injection 1,000 mL, 1,000, mL, IV, Routine, Start date 05/18/22 6:59:00 CDT, 100 mL/hr, 10, hr, Total volume (mL): 1,000, 85.73 kg, 1.89, m2, 05/18/22 6:59:00 CDT  Comprehensive Metabolic Panel Standard, Blood, Stat collect, 05/18/22 6:48:00 CDT, Once, Stop date 05/18/22 6:48:00 CDT, Lab Collect  Patient Discharge Condition  Guarded but Stable  Follow Up  No qualifying data available  Medication Reconciliation   Unchanged  multivitamin, prenatal (Prenatal 1 oral capsule)1 cap Oral Daily.    ursodiol (ursodiol 300 mg oral capsule)1 cap Oral 2 times a day.   Problem List/Past Medical History   Ongoing  Pregnant  Historical  Pregnant  Pregnant  Pregnant  First pregnancy was a vaginal delivery without complication at 36 weeks gestation.  Male infant weighing 6 pounds 5 ounces.   Second pregnancy was a vaginal delivery without complication at 36 weeks gestation  Female infant weighing 7 pounds 12 ounces.   Third pregnancy was a vaginal delivery at 36 weeks gestation.  Pregnancy was complicated by cholestasis of pregnancy and gestational diabetes.  She was induced at 36 weeks and delivered a female infant weighing 6 pounds 1 ounce.  Procedure/Surgical History  ?Cholecystectomy ?None ?Tonsils and adenoids  Allergies   No Known Medication Allergies  Social History   Alcohol  Past, Alcohol use interferes with work or home: No. Drinks more than intended: No. Others hurt by drinking: No. Household alcohol concerns: No.  Electronic Cigarette/Vaping  Electronic Cigarette Use: Never.  Employment/School  Unemployed  Home/Environment  Lives with Children, Spouse. Living situation: Home/Independent. Alcohol abuse in household: No. Substance abuse in household: No. Smoker in household: No. Injuries/Abuse/Neglect in household: No. Feels unsafe at home: No. Family/Friends available for support: Yes. Concern for family members at home: No. Major illness in household: No. Financial concerns: No.   Substance Abuse  Never  Tobacco   Never (less than 100 in lifetime) Tobacco Use:.  Lab Results   Last 1 Month   Chemistry      Event Name  Event Result  Date/Time   Sodium Level 135 mEq/L 05/09/22 17:03:00  Potassium Level 3.4 mEq/L Low 05/09/22 17:03:00  Chloride Level 102 mEq/L 05/09/22 17:03:00  CO2 22 mmol/L Low 05/09/22 17:03:00  Glucose Level 97 mg/dL 05/09/22 17:03:00  BUN 5 mg/dL Low 05/09/22 17:03:00  Creatinine Level 0.6 mg/dL 05/09/22 17:03:00  BUN/Creat Ratio 8 05/09/22 17:03:00  GFR AA 162 05/09/22 17:03:00  GFR Non AA 134 05/09/22 17:03:00  Calcium Level 8.7 mg/dL 05/09/22 17:03:00  Bili Total 0.3 mg/dL 05/09/22 17:03:00  Alk Phos 255 unit/L High 05/09/22 17:03:00  AST/SGOT 61 unit/L High 05/09/22 17:03:00  ALT/SGPT 113 unit/L High 05/09/22 17:03:00  Protein Total 6.7 g/dL (%) 05/09/22 17:03:00  Albumin Level 2.2 g/dL (%) Low 05/09/22 17:03:00  Globulin 4.4 gm/dL High 05/09/22 17:03:00  A/G Ratio 0 05/09/22 17:03:00   Hematology      Event Name  Event Result  Date/Time   WBC 8.6 x10^3/mcL 05/18/22 06:53:00  RBC 4.52 x10^6/mcL 05/18/22 06:53:00  Hgb 12.4 g/dL (%) 05/18/22 06:53:00  Hct 37 % 05/18/22 06:53:00  MCV 82 fL 05/18/22 06:53:00  MCH 27 pg 05/18/22 06:53:00  MCHC 33 g/dL (%) 05/18/22 06:53:00  RDW 12.8 % 05/18/22 06:53:00  Platelet 282 x10^3/mcL 05/18/22 06:53:00  Auto Lymph % 23 % High 05/18/22 06:53:00  Auto Neut % 68 % 05/18/22 06:53:00  Auto Mono % 6 % 05/18/22 06:53:00  Auto Eos % 2 % 05/18/22 06:53:00  Auto Baso % 0 % 05/18/22 06:53:00  Neut Abs# 5.9 x10^3/mcL 05/18/22 06:53:00   All Other Results      Event Name  Event Result  Date/Time   Premature Rupture of Membranes Positive 05/18/22 06:38:00  Professional Services/Counseling  Level 5 Outpatient OB Signature Line [Electronically Signed by: 05/18/2022 07:17 CDT] ________________________________________  DO     [Verified on: 05/18/2022 07:17 CDT] ________________________________________ DO DO