Dr. Hakimah

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3RD CASE WRITE-UP

OBSTETRICS CASE

YEAR 3 – FIRST ROTATION

FACULTY OF MEDICINE

UNIVERSITI TEKNOLOGI MARA

OBSTETRICS AND

GYNAECOLOGY POSTING

CONFIDENTIALNAME : HAKIMAH KHANI BINTI SUHAIMI

MATRIX NO : 2008409718

YEAR OF STUDY : 3

SESSION : 2010/2011

SUPERVISOR : DR NOORNEZA ABD RAHMAN

PATIENT INITIALS: MS RNI SEX: FEMALE R/N: SB 00353955WARD: 6B

ETHNICITY: MALAY AGE: 35Y/O DATE OF BIRTH: 14th AUGUST 2010

MARITAL STATUS: MARRIED DATE OF ADMISSION: 1ST AUGUST 2010

OCCUPATION: DATE OF DISCHARGE: 4TH AUGUST 2010

ADDRESS: SUBANG 2 DATE OF CLERKING: 2ND AUGUST 2010

LMP – unsure of date

REVISED EXPECTED DATE OF DELIVERY – 11th of August 2010 – by early dating scan at 18 weeks

GRAVIDA - 2

PARA - 1

GESTATION – 38 weeks + 6 days

1. MENSTRUAL HISTORY

She attained menarche at the age of 12 years old with regular cycle of 28-30 days interval lasting for 5-7 days of bleeding. The amount was about 2-3 pads fully-soaked. No clots. No dysmenorrhea. After her first pregnancy, at the age of 21, her menses started to become irregular until now, associated with dysmenorrhea.

2. PRESENTING COMPAINT(S)

Madam RNI, 35 year-old Malay, gravida 2 para 1 at 38 weeks + 6 days period of gestation was admitted to Hospital Sungai Buloh for elective lower segment caesarean section due to macrosomic fetus.

3. HISTORY OF PRESENTING COMPLAINT

Yesterday, on the 1st of August 2010, the patient came to Hospital Sungai Buloh after being scheduled for elective lower segment caesarean section today, 2nd of August 2010, in the afternoon.

At 21 weeks period of gestation during her booking, she was diagnosed to have gestational diabetes mellitus after being tested for modified glucose

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tolerance test. She was only advised to control her diet and was not prescribed on any medications.

However, a transabdominal ultrasound done at 28 weeks period of gestation revealed macrosomic baby with estimated fetal weight of 3.2kg. Unfortunately, she was not referred to Sungai Buloh Hospital until four days ago after a significant increase of estimated fetal weight to 4.2kg based on the transabdominal ultrasound scan during her follow-up. After physical examination and transabdominal ultrasound scan was done in the hospital, she was indicated for elective lower segment caesarean section and was given the date which is on the 2nd August 2010.

Yesterday, she came to the PAC Sungai Buloh Hospital at 9am. There were no signs of labour like painful uterine contractions, leaking liquor, or ‘show’. Fetal movement was good and the CTG was reactive. A transabdominal ultrasound was done at the PAC and the estimated fetal weight was 4.2kg.

4. ANTENATAL HISTORY

Madam RNI was apparently well until 21 weeks period of gestation, when she was diagnosed of having gestational diabetes mellitus. This is her second pregnancy after 15 years of no pregnancy. She is currently at 38 weeks and 6 days of gestation. This pregnancy is unexpected but wanted. She had a period of amenorrhea for four months but she did not expect for getting pregnant because of certain reasons, 1) she had been having irregular menstruation after her first child, and 2) she is obese and she only thought of having gained weight. She only suspected that she was pregnant after she experienced some episodes of mild pain on her breasts associated with some discharge on exertion. She also noticed some fetal movements which is the quickening at the same point of time. She had history of constipation. She did not have any history of morning sickness.

She did a self urine pregnancy test brought from the pharmacy and it came out positive. Subsequently, she went to a private clinic to reconfirm and the result was consistent. Early dating ultrasound scan was also done and confirmed her pregnancy at 18 weeks period of gestation. Revised expected date of delivery is on the 11th September 2010. There were no fetal abnormalities detected.

At 21 weeks period of gestation, she went to Klinik Komuniti Shah Alam for booking. Routine examination and screening was done. All were all within normal range and non-reactive, respectively. Ultrasound was done and her REDD was consistent.

Apart from doing the routine examination, Madam RNI was also screened for Gestational Diabetes Mellitus by testing the modified glucose tolerance test because she has first-degree-relative history of diabetes mellitus and she is 35

years old. Results were as follows:

Fasting 5.2 mmol/L

2-hour postpandrial 8.6 mmol/L

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She was diagnosed of having gestational diabetes mellitus and was advised on diet control. No hypoglycaemic medications were prescribed. Her blood sugar profile was controlled throughout the pregnancy. Her latest blood sugar profile (BSP) on admission was normal;

Fasting 4.2 mmol/L

2-hour postpandrial 4.9 mmol/L

Post lunch 5.1 mmol/L

Post dinner 3.9 mmol/L

Despite her controlled blood sugar profile, a transabdominal ultrasound done at 28 weeks period of gestation revealed macrosomic baby with estimated fetal weight of 3.2kg. Unfortunately, she was not referred to Sungai Buloh Hospital until four days ago after a significant increase of estimated fetal weight to 4.2kg based on the transabdominal ultrasound scan during her follow-up. After physical examination and transabdominal ultrasound scan was done in the hospital, she was indicated for elective lower segment caesarean section and was given the date which is on the 2nd August 2010. Her weight during the examination was 94kg. She experienced backaches and noticed increased frequency in urination.

5. PAST OBSTETRIC HISTORY

This is her second pregnancy. She has 1 teenage daughter aged 15 years old who was delivered by full term spontaneous vaginal delivery with no abnormal labor or instrumentation, weighing of 3.5kg. She breastfed her daughter for two whole years. Her daughter is now alive and well.

6. CONTRACEPTIVE HISTORY

She denied usage of any contraceptive pills or other method.

7. PAST GYNAECOLOGICAL HISTORY

She had a history of subfertility after her first child was born. She was obese at that time weighing of 98kg but was not associated with hirsutism. She went to Klang Hospital to check about her subfertility problem. Ultrasound scan was done and revealed no significant abnormalities. She was told to have hormonal imbalance and was advised to reduce her body weight.

She had pap smear being done in 1995 and 2008 and there were no abnormalities detected.

8. SEXUAL HISTORY

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No history of dyspareunia or postcoital bleeding.

9. PAST MEDICAL & SURGICAL HISTORY

She only sought treatment for her subfertility problem. No other relevant medical history.

10.DRUG HISTORY

She’s not on any medications before. She was only on obimin as prescribed by the doctor during the pregnancy

11.ALLERGIES

She has no known allergies to food, medication or vaccination.

12.FAMILY HISTORY

Both her parents are healthy. Her motherr is now 50 years old, having diabetes mellitus type 2 whereas her father has no known chronic illnesses. She is the first child out of 4, all her siblings are healthy.

No family history of hypertension, heart disease, breast tumor, endometrial, cervical, or any other tumors related to female reproductive tract.

She has second-degree relative history of twins. No family history of congenital abnormalities like Down Syndrome.

13.SOCIAL HISTORY

13.1 Occupation

She works as a team leader at a shop in Terminal II Malaysia Airlines, Subang.

13.2 Dietary History

She controls her diet by avoiding excessive food intake and high-cholesterol diet to reduce her body weight as advised by the doctor.

13.3 Smoking, alcohol and illicit drugs usage

She does not smoke cigarette, drink alcohol intake nor take illicit drugs.

13.4 Partner

Her husband is 41 years old, works as a technician. Combined together, their monthly income is about RM4000. Her husband smokes about one pack

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per day since more than 10 years ago, does not drink alcohol nor take illicit drugs.

13.5 Home circumstance

Madam RNI and her husband currently stay in their own home with adequate amenities.

14.REVIEW OF SYSTEMS

General No headache, no seizure, fever, no weight loss

CVS No chest pain, no palpitation, no pedal edema

Respiratory No dyspnea

Urinary Polyuria, no dysuria

GITPolyphagia, no constipation, no diarrhea, no abdominal pain, no nausea, no vomiting, no epigastric pain

Reproductive

No bleeding, no foul-smelling discharge, no itchiness

MSKBackache, no other joint pain or weaknesses, had pedal edema before, now not anymore

CNS No headache, no blurred vission, no numbness

Endocrine No temperature intolerance, polydipsia

15.PHYSICAL EXAMINATION

15.1 Height : - Weight: 94kg BMI: -

15.2 General condition

Miss RNI was lying flat in supine position, supported with one pillow. She was conscious, alert, cooperative, and responsive to time, place and person. There was no puffiness in her face. Her palm was warm, no pallor, no excessive sweating, no clubbing, no fungal infection between the fingers. No pedal edema. No fungal infection in the toes.

15.3 Vital Signs

a. Blood Pressure : 127/71mmHg

b. Pulse : 91 bpm

c. Respiratory Rate : 18 breaths / min

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d. Temperature : 37.3°C

Impression : Normotensive, slightly tachycardia, normal body temperature

15.4 Head & Neck

Conjuctiva : Not pale

Sclera : White and no sign of jaundice

Mouth : Lips were moist, no oral candidiasis

Thyroid : Not enlarged

Lymph node : Not palpable

13.5 Breast

Both breasts were symmetrical and nipples were normally everted. Nipples were hyperpigmented. No fungal infection beneath the breast, no masses, no retraction of the nipples, no leakage and other abnormalities were noted.

Impression: Normal

13.6 Cardiovascular System

a. Inspection : The chest was symmetrical and normal in shape. There was no scar, no precordial bulging, no visible apex beat and no prominent dilated veins.

b. Palpation : The apex beat was located in the 5th intercostal space, at the midclavicular line. There was no thrill and heave. The peripheral pulses were present with normal rhythm and volume.

c. Auscultation : The first and second heart sounds were normal. There were no murmurs heard. Increased heart rate was noted.

Impression : Physiologically normal

13.7 Respiratory System

a. Inspection : The chest moved symmetrically with respiration with no deformity seen. There was no sign of respiratory distress. There were no scar, prominent dilated.

b. Palpation : The chest expansion and vocal fremitus were equal anteriorly and posteriorly at all three zones of the lung.

c. Percussion : The lung was resonant bilaterally, anteriorly and posteriorly. There were normal liver and cardiac dullness.

d. Auscultation :  There were vesicular breath sound anteriorly and posteriorly at all three zones. No added sounds heard

Impression : Lungs clear

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13.8 Abdominal Examination

a. Inspection : On examination, the abdomen was distended by gravid uterus. There was striae gravidarum and linea nigra seen. The umbilicus was centrally located and inverted. There was no scar noted. There were superficial dilated veins. Fetal movement was seen.

b. Light palpation : The abdomen was soft and non-tender. There was singleton mass. Liver, spleen and kidney were not palpable.

c. Leopold Maneuver : Symphysio-fundal height was 40 weeks size, larger than date. The fetus was in longitudinal lie. The fetal back lies on maternal left side. Cephalic presentation which is 3/5th palpable.

d. Auscultation : Fetal heart sound was heard by using Pinnard stethoscope.

Impression : Uterus larger than date

13.9 Pelvic Examination

Not done

13.10 Central Nervous System

a. Mental status : She was alert and conscious, orientated to time, place and person. Her memory function was intact. She was not in a state of confusion.

b. Cranial nerves : All the 12 cranial nerves were intact.c. Motor system : No abnormalities noted.d. Muscle Tone : No abnormalities noted.e. Muscle Power : Normalf. Cerebellar sign : There was no cerebellar sign present and her gait

was normal.g. Sensory system : No abnormalities noted. Her sensation toward pain,

light touch, vibration, temperature and propioception were intact and equal bilaterally.

h. Reflexes : All normal

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16.SUMMARY

Madam RNI, 35 year-old Malay, gravida 2 para 1 at 38 weeks + 6 days period of gestation was admitted to Hospital Sungai Buloh and scheduled for elective lower segment caesarean section for delivery of macrosomic fetus due to gestational diabetes mellitus

17.DIAGNOSIS

14.1 Provisional Diagnosis

Gestational Diabetes Mellitus

Points to support: The modified glucose tolerance test revealed 2-hour postprandial glucose level of 8.6mmol/L. Since the glucose intolerance was first discovered at 21 weeks period of gestation, and the patient was previously non-diabetic.

14.2 Differential Diagnosis

Previously undiagnosed Pregestational Diabetes Mellitus

Points against: No overt diabetes was known previously. If the glucose intolerance disappeared after the delivery without requiring any medications, hence pregestational diabetes mellitus is ruled out

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Distended abdomen, size of 40 weeks

gravid uterus

Linea nigra

Striae gravidarum

Hyperpigmented areolar

18.INVESTIGATIONS

Investigations upon admission to Sungai Buloh Hospital

1. Transabdominal ultrasound scan on 27th of July 2010

Estimated birth weight – 4.0-4.2kg - Macrosomia

Amniotic Fluid Index was 18 – not polyhydramnios

2. Blood Sugar Profile on 27th of July 2010

Fasting 4.2 mmol/L

2-hour postpandrial 4.9 mmol/L

Post lunch 5.1 mmol/L

Post dinner 3.9 mmol/L

Blood sugar profile was well-controlled

3. Cardiotocograph

Results: Reactive.

Interpretation: Fetal not in distress.

4. Full Blood Count on 1st of August 2010 – was ordered for pre-op assessment

Blood Group: AB+

Event Results

Ref. range Status

RBC 4.61 4.5 – 6.5 x 109/L Normal

WBC 9.09 4.0 – 11.0  x 109/L Normal

Hemoglobin 11.4 13.5 – 18.0 g/dL Low

Hematocrit 34.6 40.0 – 54.0 % Low

Mean Cell 75.2 76.0 – 96.0 fl Low

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Volume

Mean Cell Hemoglobin Concentration

32.8 31.0 – 40.0 (pg/cell) Normal

Red cell distribution width

15.1 11.5-14.5 Abnormal

Platelet count 300 150 – 450  x 109/L Normal

Automated differentials:

a) % of Neutrophil: 65.4% (40.0-80.0)

b) % of Lymphocyte: 26.4% (20.0-40.0)

c) % of Monocyte: 3.5% (2.0-10.0)

d) % of Eosinophil: 2.6% (1.0-6.0)

e) % of Basophil: 0.6% (0.0-2.0)

Results: Hemoglobin, hematocrit, mean cell volume were low.

Interpretation: Physiological hemodilution effect occurring in pregnancy.

Investigation post-operation

1. Full Blood Count on 2 nd of August

Event Result Status

WBC 13.63 (4.0 – 11.0  x 109/L)

Abnormal

RBC 4.14 (4.5 – 6.5 x 109/L) Normal

Hemoglobin 10.4 (12.0-15.0 g/dl) Abnormal

Hematocrit 31.2 (37.0-47.0%) Abnormal

MCV 75.4 (76.0 – 96.0 fl) Abnormal

MCHC 33.4 (31.0 – 40.0 pg/cell)

Normal

Red cell distribution width 15.1 (11.5-14.5) Abnormal

Platelet 273x10.e3/uL (110-450) Normal

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Interpretation:

White blood cell count was elevated post-operation probably in response to medication.

Hemoglobin, hematocrit and MCV were reduced and red cell distribution width was raised- probably due to the blood loss during the operation and uterine atony causing postpartum hemorrhage.

19.PROGRESS DURING HOSPITALIZATION

DAY 1 post operation (2 nd August 2010)

The operation was uneventful. Baby boy with birth weight of 4.88kg was delivered at 1640H, with Apgar score 9 in 1 min and 10 in 10 mins. Estimated blood loss was 500ml. Liquor was clear.

After the operation, she has been keeping well,

BP – 108/70mmHg

Pulse Rate – 71/min, regular

spO2 – 100%

She was pale but alert, complaining of nausea, no vomiting, no shortness of breath or palpitation. She was on strict pad chart. Since the operation, she has been using 3 pads full-soaked

On abdomen examination, the uterus was not well-contracted at 22-week size of a gravid uterus

She given IV oxytocin 40 units over 6 hours

DAY 3 post operation (4 th August 2010)

Uterus was soft, non-tender, well-contracted at 20 weeks size of a gravid uterus, no active bleeding at the site of operation. No longer has per vaginal bleeding.

She was due for discharge and was told to repeat modified glucose tolerance test 6 weeks later.

20.DISCUSSIONS

Madam RNI has a firfamily history of DM so she was indicated for Modified Glucose Tolerance Test (MGTT) as she was considered as a high risk groups.

There are other indications for MGTT which are;

1. Two or more episodes of glycosuria on routine testing

2. Diabetes in a 1st degree relative

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3. Maternal weight greater than 85 kg

4. Maternal age greater than 30 yrs old

5. Previous hx of Gestational Diabetes Mellitus

6. Previous baby of 4.0 kg or more (macrosomia)

7. Previous unexplained perinatal death

8. Previous congenital anomelies

9. Polyhydramnions

10. Women from an ethnic group with a high prevalence of type II DM (Hispanic, Native American, African-American)

Definition of Gestational Diabetes Mellitus

The WHO has defined Diabetes Mellitus as either a raised fasting blood glucose level of > 7.8 mmol/L or a level of > 11.0 mmol/L 2 hours following a 75 g oral glucose load.

Pathogenesis of Gestational Diabetes Mellitus

Placenta secretes anti-insulin substances; such as human placental lactogen (HPL), hCG, estriol, cortisol and progesterone

Presence of these substances in the maternal blood

Glucose intolerance develops in the mother; mainly if maternal β cells are unable to produce additional insulin which is required to counteract this antagonism

Maternal Gestational Diabetes Mellitus

Maternal nutrients mainly glucose can readily crosses placenta but not maternal insulin

As the mother develops hyperglycemia due to Gestational Diabetes Mellitus hence fetal pancreas will secrete additional insulin to cope with the fetal hyperglycemia

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Fetal β cells hyperplasia

Fetal hyperinsulinemia

Effects of Fetal Hyperinsulinemia

1. Reduced lung surfactant RDS

2. Increased erythropoiesis can leads to jaundice or hyperviscosity syndrome. Hyperviscosity syndrome will later develops into necrotizing colitis or renal vein thrombosis.

3. Increased fetal metabolism which will increases O2 demand. Low O2 supply from the mother can leads to intrauterine death.

4. Macrosomia shoulder dystocia

5. Hypoglycemia

6. Hypertrophic myocardiopathy

Effects of Diabetes on Pregnancy

1. Increased miscarriage rate

2. Increased perinatal loss due to intrauterine death (IUD)

3. Macrosomic baby hence is at risk of dystocia

4. Fetal lung maturation may be delayed; if the fetus was delivered prematurely then the risk of getting RDS is increased

5. Risk of pre eclampsia

6. Risk of polyhydramnions

7. Susceptible to infections; mainly UTI and candida vaginitis

Management of Diabetes

A. Pre pregnancy

The women who are known to be diabetic and women who have had gestational diabetes should seek medical attention before they get pregnant. This consultation offers opportunities in explaining to them about;

1. The reason for meticulously maintaining her blood glucose at normal level before conception

2. The need of taking folic acid to reduce the risk of neural tube defects

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This consultation can also be used as an assessment for the presence of any Cx related to diabetes, such as diabetic retinopathy and nephropathy.

Women who are on oral hypoglycemic drugs should preferably be changed to insulin therapy.

We should check for her glycosylated Hemoglobin, HbA1c that reflects her glucose control over the previous 10 weeks. High levels of HbA1c are associated with an increased rate of fetal abnormality.

B. Pregnancy

Euglycemic state should be maintained; with fasting glucose less than 5.3 mmol/L and 2 hour post prandial blood glucose should be less than 6.7 mmol/L.

Blood sugar profile should be checked before or after each meal; preprandial or postprandial glucose level and the result should be less than 6 mmol/L or 6.7 mmol/L, respectively.

Normal blood glucose level should be maintained with a mixture of short and medium-acting insulin.

But Mrs Frh was prescribed with Monotard (long acting) 6 unit that has to be taken once daily, at 2240 H.

Ultrasound scan that was done during the first 12 weeks of pregnancy provides accurate estimation of the period of gestation. Meanwhile, scanning between 18 – 20 weeks of gestation allows exclusion of any major malformations and around 34 weeks of gestation, it permits assessment of fetal growth.

Regular assessment of fetal growth and wellbeing should be performed.

Timing of Delivery

Delivery at up to 40 weeks of gestation is possible if the sugar control is good. But if there is inadequate blood glucose control, or the presence of polyhydramnions, fetal macrosomia or maternal obesity delivery at 38 weeks of gestation is indicated. Delivery at earlier than 38 weeks is not really indicated to prevent Respiratory Distress Syndrome in the premature baby.

Management of Labour

The intention is to achieve vaginal delivery. Labour can be induced by doses of oxytocin. An artificial rupture of membrane (ARM) should be performed. Blood glucose level needs to be monitored at frequent intervals; mostly done at 2 hourly. The fetus should be monitored throughout labour and during vaginal delivery shoulder dystocia should be anticipated. On the other hand, a caesarean section may be performed if there is significant petal macrosomia or poor fetal status (CTG), or if labour fails to progress satisfactorily. Uncomplicated diabetes is not an indication for operative delivery.

Follow Up of Women Who Have Had Gestational Diabetes Mellitus

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Follow up is important as up to 50% of women with Gestational Diabetes Mellitus may develop overt diabetes; mainly Type II.

At the follow up visits, we should encourage her to follow a diet which is appropriate for a diabetic. She should also be advised to take these following measures;

1. Avoid becoming obese

2. Take regular exercises

3. Avoid cigarette smoking

4. checked annually for hypertension

These women have a 50% chance of developing Gestational Diabetes Mellitus in the future pregnancy. If she intend to become pregnant again, testing for hyperglycemia before conception or in early pregnancy is recommended.

Poor management in Klinik Komuniti

She has 15 years history of subfertility because

Iol?

Urine feme

Indication: Fetal, maternal, placental.

Absolute indication for lower segment caesarean section

Breech, transverse, contracted pelvis, placenta previa, preeclampsia, severe preeclampsia, fibroid, cervical carcinoma

Relative indication

Fetal distress, poor progress, macrosomia, pregnancy-induced hypertension, HIV, multiple pregnancy, intrauterine growth restriction, premature, uterine atony (secondary LSCS)

Managmement for post LSCS

Vital signs

Fever

Uterine involution

Uterus – firm, hard, well-contracted?

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Scars – dry no redness, no swelling, no discharge, no active bleeding

Discharging

Advice

- Avoid heavy work

- Walk

- Sleep when the baby sleeps

- Separate from husband for six weeks

- Contraceptive for two years – injectible, oral POP, IUCD (cannot give COCP; breastfeeding(

- Complication of diabetes mellitus

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NAME OF STUDENT : HAKIMAH KHANI BINTI SUHAIMI

MATRIX NO : 2008409718

DATE : 30TH JULY 2010

COMMENTS ON WRITE-UP

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GRADE : ..........................

NAME OF SUPERVISOR : DR NOORNEZA ABD RAHMAN

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