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OBSTETRICS CASE
Dr. Hakimah
[Pick the date]
OBSTETRICS AND
GYNAECOLOGY POSTING
CONFIDENTIAL
MATRIX NO : 2008409718
YEAR OF STUDY :3
SESSION : 2010/2011
REVISED EXPECTED DATE OF DELIVERY – 11th of August 2010 – by early dating scan at 18
weeks
GRAVIDA - 2
PARA - 1
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)
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 tolerance test. She
was only advised to control her diet and was not prescribed on any medications.
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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:
2-hour
8.6 mmol/L
postpandrial
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;
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postpandrial
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 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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She only sought treatment for her subfertility problem. No other relevant medical
history.
She’s not on any medications before. She was only on obimin as prescribed by the
doctor during the pregnancy
11. ALLERGIES
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.
13.1 Occupation
She controls her diet by avoiding excessive food intake and high-cholesterol diet to
reduce her body weight as advised by the doctor.
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 per day since more
than 10 years ago, does not drink alcohol nor take illicit drugs.
Madam RNI and her husband currently stay in their own home with adequate
amenities.
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14. REVIEW OF SYSTEMS
Respiratory No dyspnea
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.
b. Pulse : 91 bpm
d. Temperature : 37.3°C
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Thyroid : Not enlarged
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
b. Light palpation : The abdomen was soft and non-tender. There was
singleton mass. Liver, spleen and kidney were not palpable.
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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.
Not done
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 : Normal
f. 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
Hyperpigment
ed areolar
Distended
abdomen, size of
40 weeks gravid
uterus
Linea nigra
Striae
gravidarum
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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
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
18. INVESTIGATIONS
2-hour
4.9 mmol/L
postpandrial
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3. Cardiotocograph
Results: Reactive.
4. Full Blood Count on 1st of August 2010 – was ordered for pre-op assessment
Automated differentials:
Investigation post-operation
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Event Result Status
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.
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.
BP – 108/70mmHg
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
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.
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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.
9. Polyhydramnions
10. Women from an ethnic group with a high prevalence of type II DM (Hispanic,
Native American, African-American)
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.
Glucose intolerance develops in the mother; mainly if maternal β cells are unable
to produce additional insulin which is required to counteract this antagonism
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Maternal Gestational Diabetes Mellitus
Maternal nutrients mainly glucose can readily crosses placenta but not maternal
insulin
Fetal hyperinsulinemia
5. Hypoglycemia
6. Hypertrophic myocardiopathy
4. Fetal lung maturation may be delayed; if the fetus was delivered prematurely
then the risk of getting RDS is increased
6. Risk of polyhydramnions
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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
This consultation can also be used as an assessment for the presence of any Cx
related to diabetes, such as diabetic retinopathy and nephropathy.
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.
Timing of Delivery
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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
Iol?
Urine feme
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Absolute indication for lower segment caesarean section
Relative indication
Vital signs
Fever
Uterine involution
Discharging
Advice
- Walk
- Contraceptive for two years – injectible, oral POP, IUCD (cannot give COCP;
breastfeeding(
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NAME OF STUDENT : HAKIMAH KHANI BINTI SUHAIMI
MATRIX NO : 2008409718
COMMENTS ON WRITE-UP
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