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Patients Profile

Name : Murni Bt IbrahimAge : 41Race : MalayRN : 553881L.M.P : Unsure of dateR.E.D.D : 22/03/10 (given by scan at 18 weeks)Date of admission : 22/03/10Ward : 25Bed :

Chief Complaint

Madam Murni, 41 years old malay housewife, Gravida 4 Para 3 presented with GDM on dietcontrol and had history of having big baby, a referred case from Klinik Kesihatan Tumpat forGDM on diet control and at term.

History of Present Illness

This is an unplanned but wanted pregnancy. First scan was done at 18 weeks andexpected date of delivery was 22nd March 2010 because she unsure of her last menstrualperiod. Referred to HRPZII for further management. Patient presented with GDM on dietcontrol, at term and had history of previous 2 big babies. Currently patient was not undermedication for GDM, no contraction pain, no leaking liquor, no show, fetal movementwas good and no sign and symptoms of UTI.

Antenatal History

Her antenatal booking was done at Klinik Kesihatan Tumpat when she as in her 18 weeks

of gestation. During her antenatal booking, her body weight was 52kg and her bloodpressure was 120/88 mmHg, for blood investigation, haemoglobin level was 12.4 and herblood and rhesus group is A positive. The serology test for syphilis (Venereal DiseaseResearch Laboratory) and HIV rapid test was non reactive. Her first ultrasoundexamination was done during her booking; the result showed the fetus growth andprogress was good. She was not having any vaginal bleeding and discharge duringpregnancy.

Past Obstetric History

No Year Period of gestation

Place of delivery

Mode ofdelivery

Birth weight Status

1 1995 Full term HRPZII Vacuum 4.37kg Alive and well

2 1999 Full term HRPZII SVD 4.0kg Alive and well

3 2004 Full term HRPZII SVD 3.95kg Alive and well

* The indication for assisted delivery via vacuum was big baby, macrosomic baby whichis more than 4kg. There were no complications after delivery for both maternal andbaby.

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Gynecology History

She attained her menarche at the age of 13 years old at regular interval of 28 to 30 dayswith a normal flow of 7 days. During each menstruation she does not experiencedysmenorrhea or menorrhagia. No postcoital bleed and no deep dyspareunia. She never

took any oral contraceptive in the past. She performs breast self examination however,she had never done any pap smear.

Past Medical & Surgical History

No significant past medical history and she did not underwent any surgeries.

Family history

No significant of medical problem, no history of malignancy in the family, no history ofhereditary illness or congenital defect, all the siblings are healthy.

Social history

She is a housewife and her husband work as policeman, she claimed no financialproblems and denied smoking and alcohol intake but her husband was heavy smoker, andall the children are healthy.

Allergies history

She has no known drug or food allergies

Systemic Review

Cardiovascular SystemThere is no chest pain, no palpitation, no bilateral ankle edema and orthopnea

Respiratory SystemThere is no dyspnea, no cough and no wheezing

All the system are normal

Obstetric Examination

General Examination

On examination, she was alert, conscious and lying comfortably on one pillow. Herweight is 52kg.Her vital signs were as recorded:Blood pressure: 128/70 mmHgPulse rate: 82 beat per minute, regular rhythm and good volume

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Temperature: 37CFHR: 136

She does not appear to be anaemic or jaundice and oedema of the lower limbs wereabsent. Oral hydration and hygiene was good. No goitre was noted.

Systemic Examination

All the system were found to be normal, the thyroid was not palpable, there is present ofnormal 1st and 2nd heart sound, there is also no murmur and any additional sound detected.Both lungs are clear, there is present of normal vesicular breath sound, no rhonchi, nocrepitation and no added sound detected.

Obstetric Abdominal Examination

Examination of the abdomen revealed a distended abdomen by a gravid uterus as evident

by linea nigra and striae gravidarum. Striae albicans were noted as well consistent withthe fact that this is her fourth pregnancy. No other abnormalities were observed such asdistended vein, shiny and tense abdomen. The abdomen was soft and non tender. Heruterus was of 42th week size and the symphysial-fundal height measured 42 cm whichcorresponded to her date and imply that amniotic fluid is adequate. Two foetal poles werefelt indicating singleton pregnancy in a longitudinal lie, cephalic presentation with foetalback on maternal right and the foetal head is 5/5 th palpable. There is no contraction felt in10 minute.

Vaginal Examination

Vagina: No abnormalityCervix: position is posterior, consistency is firm and length is 2cmOS: 1cmStation: -1Liquor: not seenCaput and moulding: not felt

Summary

Madam Murni, 41 years old malay housewife, Gravida 4 Para 3 currently at term, presented withGDM on diet control, estimated big baby and history of 2 previous big baby.

Investigation

1. Full blood count (FBC)

Reason of doing:The main reason is to look at the haemoglobin, white cell and platelet levels. This is toensure she is stable haemodynamically and there is no ongoing infection. Anaemic

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patients have poor tolerance for potential blood loss during delivery. However in this caseI failed to trace the FBC result.

2. GSH

3. TASThe ultrasound examination of the fetus was done by medical officer doctor Siti Wira, theresult was as the follow: all the parameters corresponded to the date which was at term,the lie of the fetus was longitudinal, singleton and the presentation of fetus was cephalic.Amniotic fluid index (AFI) was 21.2 and was normal and the placenta was in posteriorupper segment.

Management Plan

On admission, Madam Murni was examined, the temperature and pulse rate was taken asa baseline and both were 37C and 82 beat per minute, the size of uterus, the lie and the

presentation were examined. The daily monitoring to both patient and fetal was carriedout until labor such as 4 times record of vital signs, timed contractions, pad charts, CTG,for TAS, fetal heart rate and FKC monitoring and review by medical officer for startinduction of labor (IOL).

After ultrasound examination was done, they found out the size of baby was big andexplanation was given to patient about mode of delivery, for spontaneous vaginaldelivery (SVD), the risk is injury to the baby, nerve injury and asphyxia, risk for themother was extended tear up to 3 and 4 degree of tear. Other than SVD was LCSC, therisk was injury to adjacent organ and excessive bleeding. The patient was understoodupon explanation.

Patients progress

Post Operation Review

Post EMLSCS for one and half hour at 1109H + BTL

1. Acute fetal distress2. Estimated big baby (complicated with primary postpartum hemorrhage secondary

to transient uterine atony)

After EMLSCS, the patient was delivered 4.1 kg baby, estimated blood lost was 2300ccand placenta was complete.

Intra-operatively

Bleeding profusely from left angle, during that time the blood lost was 800cc and bleeding secured. For the bleeding from bladder, sutured with multiple figure andestimated blood lost was 1900cc, uterine not well contracted and uterine massage was

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done approximately in 20 minutes. IV pitocin 10mg is given twice, IM Hemabate 250mgwas injected and surgical applied.

Currently patient was comfortable, no shortness of breath and no palpitation. Onexamination patient was alert, conscious and slightly pallor, the blood pressure was

115/70 mmHg, heart rate is 92 beat per minute and temperature is 37C. On abdominalpalpation, uterus was in 20 weeks, abdomen is soft and non tender.

Investigation

1. Blood Urea Serum Electrolyte (BUSE)Objective: To access the renal function and electrolyte imbalance

2. PT/APTTObjective: To determine any coagulative problem in this patient and to monitor thenormal level coagulative factors

3. FBCObjective: The main reason is to look at the haemoglobin, white cell and platelet levels.This is to ensure she is stable haemodynamically and there is no ongoing infection.

Review by Dr Aziz

Day 2 post EMLSCS under spinal anesthesia for acute fetal distress. Currently patient iscomfortable, alert and conscious. The blood pressure was 123/75, pulse rate is 119 andtemperature is 37C.

Medication

1. T. augmentin 625mg bd2. SC heparin 5000 bd3. IM nubain 10mg PRN

CommentThe patient claimed no more bleeding and felt comfortable, no headache or dizziness. Ifthere are no bleeding or other complications, this patient can be discharge after day 3 ofEMLSCS.

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Discussion