FACULTY MEDICINE AND HEALTH SCIENCES YEAR 3 OBSTETRICS & GYNAECOLOGY POSTING MDP 30408 4 TH ROTATION CASE WRITE UP (OBSTETRICS PDF

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FACULTY MEDICINE AND HEALTH SCIENCES YEAR 3 OBSTETRICS & GYNAECOLOGY POSTING MDP 30408 4TH ROTATION CASE WRITE UP (OBSTETRICS) NAME : MOHAMAD ZEKRY ZUHAIRY B MOHD ATAN MATRIC NUMBER : 34937 SUPERVISOR : A/P DR SOE LWIN Patient’s Detail Madam Boon Pui Tze is a 36 year-old, Gravida 1 Parity 0, Chi...

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FACULTY MEDICINE AND HEALTH SCIENCES YEAR 3 OBSTETRICS & GYNAECOLOGY POSTING MDP 30408 4TH ROTATION

CASE WRITE UP (OBSTETRICS) NAME

: MOHAMAD ZEKRY ZUHAIRY B MOHD ATAN

MATRIC NUMBER : 34937 SUPERVISOR

: A/P DR SOE LWIN

Patient’s Detail Madam Boon Pui Tze is a 36 year-old, Gravida 1 Parity 0, Chinese at 39 weeks of POA who is admitted for elective admission for induction of labor due to high blood pressure. Her LMP was on 27th June last year. She has regular 28-30 days menstrual cycle. Therefore, her EDD is on 5th April 2014 and she is currently at 39 weeks of POA. History of Presenting Illness She is an early booker with booking blood pressure was 100/70 mmHg. On subsequent routine antenatal checkups, the blood pressures were normal except for during 38 weeks of POA where her blood pressure was found to be 142/98 mmHg. Repeated blood pressure measurement was done half hours later and it was found to be higher with measurement of 144/90 mmHg. Then, her MCHC doctor referred her to SGH for further management. In that admission, serial blood pressure and urinalysis were done. The results showed her blood pressure still high with measurement of 141/92 mmHg although there is no presence of proteinuria. No pharmacological treatment initiated, but, she was advised for bed rest throughout the admission. Then, she was discharged 3-days after without any on-discharged drugs and she was scheduled for follow up on 30th March 2015. On the next follow up, the doctor found her blood pressure to be 140/99 mmHg and she was readmitted for assessment of necessities of induction of labor. Further questioning, her high blood pressure associated with bilateral leg oedema. However, she denied facial puffiness and she still able to put on her wedding ring. On top of that, there has been no headache, visual disturbances and epigastric pain and the baby is moving well. She also denied any regular contraction pain, leaking liquor and passing show. Further questioning also revealed that she had never been hypertension prior to pregnancy and she denied any history of associated kidney disease prior to or throughout the pregnancy. History of Present Pregnancy This is planned and wanted pregnancy. She realized she is pregnant when she missed her menses for two months and it is associated with morning sickness. She did home pregnancy test and the result was positive. She confirmed her pregnancy by visiting Mother and Child Health Clinic (MCHC) during 10 weeks of POA. At the same time, booking visit was done and initial blood pressure, blood and urine investigations were normal. She also had done dating scan during that visit and her MCHC doctor decide her EDD to follow her LMP and she was scheduled for further antenatal care visits thereafter. Subsequent antenatal care visits were normal except for during 34 weeks of POA where she was indicated for MOGTT due to increasing BMI. Result of MOGTT showed, Fasting Blood Sugar was 3.53 mmol/L and 2-Hours Blood Sugar was 7.9 mmol/L. Then, she was advised by the doctor for practicing

diabetic diet control of 1800kcal per day without any pharmacological treatment initiated. She did monitor her glucose level by using glucometer at home and she claimed that her serial blood glucose measurements were below than 6.5 mmol/L 2-hours after she has eaten. Other subsequent antenatal care visits were normal except for during 38 weeks of POA where her blood pressure was found to be 142/98 mmHg and repeated blood pressure measurement on 4-hours later was found to be 144/90 mmHg. Her MCHC doctor referred her to the O&G Department of SGH for further assessment. Serial blood pressure and urine test were done. Although her blood pressure is high in that admission, but, there is no evidence of proteinuria on urine test. Then, she was discharged 3 days after and scheduled for readmission on 30th March 2015 for further evaluation and induction of labor if necessary. Menstrual History She had her menarche when she at the age of 12 year-old. Her menses was regular with 28 till 30 days cycles and the flow was normal with duration of 5 days and it is associated with regular period pain. She denied any usage of oral contraceptive pills. Past Gynaecological History She had not been having dyspareunia or per vaginal discharge and there is no pap smear done throughout her life. Past Obstetric History None Past Medical History None Past Surgical History None Drug History None Allergy History None Family History None of her first-degree relatives have diabetes mellitus and hypertension. Social History

She works as general clerk and her husband works as a mechanic. Their total salary is approximately RM2,500. The duration from her house to MCHC clinic is roughly around 20 minutes by car, however, the duration from her house to SGH is roughly around 1-hour. She is neither a smoker nor drinker and her husband is a smoker but she claimed that her husband smokes outside of her house. Vital signs Blood pressure

: 154/92 mmHg

Pulse rate

: 70 beats/min

Physical Examination On general examination, the patient was comfortable and not paled. On peripheral examination, the palms were not paled nor sweaty and capillary refill time less than two seconds. Her pulse rate was 70 beats per minute, regular and strong volume. The scleras were not jaundiced and the conjunctivae were no pallor. There was no enlargement of thyroid and clinically palpable cervical lymph nodes and the Troisier’s sig was a se t. There was marked pitting edema on the legs bilaterally. On systemic examination, S1 and S2 were heard with no murmurs and vesicular breath sound was heard throughout auscultation with no added sounds. On obstetric examination, On inspection, the abdomen was distended with gravid uterus with evidence of linea nigra. Umbilicus was flat, centrally located and hyperpigmented. Dilated veins were seen. However, no striae gravidarum, striae albicans and scars were seen. On palpation, abdomen was soft, non-tender and uterus was not irritable. Fundal height was at 40 weeks with evidence of subcostal fullness and symphysio-fundal height was 40cm. The fetus was lied longitudinally in cephalic presentation with the fetal head 3-feets above the pelvic brim. On auscultation, fetal heard sound cannot be heard. The amniotic fluid was adequate and EBW was 2.8 to 3.6 kg. Otherwise, there was no evidence of hyperreflexia.

Summary Madam Boon, 36 year-old primigravida at 39 weeks of POA admitted for induction of labor due to high blood pressure. Her LMP was on 27th june last year and her EDD is on 5th april 2015. She is an early booker and she denied any symptoms of impending eclampsia. Otherwise, her antenatal checkups were normal except for during 34 and 38 weeks of gestation where she were found to had GDM and hypertension respectively. On examination, pitting edema noted on her leg bilaterally and no hyperreflexia . Otherwise,her fundal and symphysio-fundal height were correspond to her gestational age. Provisional Diagnosis 36 year-old primigravida at 39th weeks of POA associated with GDM on diet control with diagnosis of PIH and currently not in labor Differential Diagnosis 1. Pre-eclampsia a. Point against i. Patient denied any proteinuria on antenatal checkups ii. Patient denied facial puffiness and hands edema 2. Eclampsia a. Point against i. Patient denied any symptoms of impending eclampsia ii. Normal reflex on examination 3. Essential hypertension a. Point against i. Blood pressure on booking visit is normal ii. No history of pre-existing hypertension before pregnancy 4. Seconday hypertension a. Point against i. Patient denied any renal diseases

Investigations (Done in Hospital) Full blood count Hb 11.9 x 106/μL WBC 6.93 x 103/μL PLT 181 Interpretation: Platelet count and Hb value are normal. Thus, there are no evidence of hemolysis and thyrombocytopenia (a sign of pre-eclampsia and HELLP Syndrome). Urinalysis pH 5 Ketone Negative Protein Negative Nitrate Negative Hematocyte Negative Interpretation: There is no proteinuria (a sign of late manifestation of pre-eclampsia). Blood Urea and Serum Electrolytes plus Creatinine and Serum Uric Acid Sodium 137 mmol/L Potassium 3.7 mmol/L Chloride 105 mmol/L Urea 1.5 mmol/L Creatinine 43 μ ol/L Uric acid 230 mmol/L Interpretation: BUSE plus serum creatinine and serum uric acid are within normal range, therefore, the kidney function is not compromised. Liver Function Test Total Bilirubin 4 μ ol/L Direct Bilirubin μ ol/L AST 14 U/L ALT 8 U/L Total Protein 56 g/L Albumin 31 g/L Globulin 25 g/L ALP 137 U/L Interpretation: Liver is not damaged in term of its excretory and synthesizes function as well as its hepatocytes integrity. However, there is evidence of damage over the common bile duct with ALP value over 137 U/L.

In Hospital Management During 39th weeks of POG, Madam Boon was admitted to maternity ward for IOL. Followings are initial management plan done for her during antenatal period: 1. 2. 3. 4. 5. 6.

She is being monitored for blood pressure and vital signs for 4-hourly Her fetus is being monitored by CTG and fetal kick chart Blood sample was taken for PE Profile PET Chart and labor progression chart were started She was assessed for Bishop’s s ore The doctors were noticed if her blood pressure exceed >150/100 mmHg or any symptoms of impending eclampsia

In the day of admission, the doctors were alerted by the nurses for two episodes of high blood pressure exceeding 150/100 mmHg. However, PE profile and urinalysis were returned to be normal without any signs suggestive of pre-eclampsia. Furthermore, her fetal movement was good and CTG was reactive Next morning, due to previously two episodes of high blood pressure exceeding 150/100 mmHg, the do tor started her with T. La etolol g TDS a d Bishop’s s ori g was do e. i utes later, after the doctor found out that her cervix was not favorable, the doctor inserted 3mg prostin in her posterior fornix of vagina at 7.45 am and proceed with prostin protocol. Followings are outcomes after first prostin was inserted:

Time inserted CTG 1 hour post prostin Time contraction at 3 hours CTG 5 hours post prostin Review at 6 hours Time contraction at 8 hours Time contraction at 10 hours

Time 7.45 am 8.45 am 10.45 am 12.45 pm 1.45 pm 3.45 pm 5.45 pm

Comments 3mg prostin inserted CTG reactive TCM 0:10 TCM 0:10 CTG reactive TCM 0:10 Os closed TCM 0:10 TCM 0:10

Despite she completed her first prostin protocol, her cervical os still closed and no signs of labor yet. Therefore, her doctor scheduled her for se o d Bishop’s s ore assess e t for the e t da . Next day, Madam Boon complained of lower abdominal pain associated with per vaginal bleeding. Initially, the doctor thought they were uterine contraction and passing show. However, further assessment revealed, they were not contraction pain and passing show. Therefore, Bishop’s s ori g was done late and it was found out that her cervix was not favorable yet. Thus, second 3mg prostin was inserted in her posterior fornix of vagina at 9.20 am and continue with prostin protocol. Following are outcomes after second prostin was inserted:

Time inserted

Time 9.20 am

Comments 3mg prostin inserted

CTG 1 hour post prostin Time contraction at 3 hours CTG 5 hours post prostin Review at 6 hours Time contraction at 8 hours Time contraction at 10 hours

10.20 am 12.20 pm 2.20 pm 3.20 pm Not documented Not documented

CTG reactive TCM 0:10 CTG reactive Os : 2 cm Not documented Not documented

In the night at 10.40 pm, she was brought to labor ward due to TCM 3 in 10 minutes lasting for 25 seconds. However, during that time, she encountered a third episode of high blood pressure exceeding >150/100 mmHg. Therefore, she was immediately brought to labor ward for further management there. In labor ward, partogram was started and her blood pressure was reassessed, it was found out that her blood pressure measurement was 180/98 mmHg by sphygmomanometer, however, there are no symptoms of impending eclampsia. Then, branula was set up and T. Labetolal dosage was increase from 200 mg to 400 mg TDS. Her blood was taken again for reassessment of PE profile. The result showed her PE profile was normal except for high blood pressure. In the next morning at 1.15 am, Madam Boon was complained of sudden gush of clear fluid which proven to be leaking liquor by speculum examination. Vaginal examination was done and the cervical os still opened only at 1cm. Upon leaking, followings management was planned: 1. 2. 3. 4.

To do vaginal examination on 4-hours later and keep in view for pitocin augmentation Nurse should informed the doctor if there is changes of liquor color TCM to do regularly Watchout for symptoms of chorioamnionitis

Next blood pressure measurement was done at 2.00 am and it was found out that her blood pressure was exceeding 187/102 mmHg, however, she was free from impending eclampsia symptoms. Therefore, her doctor infused her IV Labetolol bolus (25mg in 5ml) add in with 15ml normal saline given over 20 minutes. Then, blood pressure was measured again 30 minutes later. 30 minutes later, her blood pressure was found to be 158/85 mmHg and she was counseled regarding analgesia during that time also. On 3.45am (2/4/2015), her doctor ordered to withhold T. Labetolol, instead commencing parenteral labetol regime. Following is the parenteral labetol regime that was carried out: Rapid control Maintenance dose

Bolus IV Labetolol 5ml/25mg + 15ml Normal saline IV Labetolol 50ml/250mg

Given for 20 minutes Infusion at 4ml/hour = 20mg/hour

On 5.30am (2/4/2015), IV pitocin 10units in 500ml normal saline was given by infusion which running at 3ml/hour. At 6.00am (2/4/2015), manual blood pressure measurement was done and it ranges from 121 – 126/79 – 85mmHg. Then, she was off from IV Labetolol infusion and changed back to T. Labetol 400mg TDS. However, previous IV pitocin infusion still continued and together she was infused with IV fluid at a rate of 83mls/hour. On 6.40am (2/4/2015), all the vital signs were stabilized and patient was offered analgesia to reduce her contraction pain. IM Pethidine 75mg combined with IM promethazine 4mg were successfully given to her at 7.20am. Meanwhile, IV pitocin was increase to 36ml/hour. On 10.00am (2/4/2015), her CTG showed Type I Deceleration and immediately her IV pitocin was reduced to 24ml/hour. On 11.00am (2/4/2015), her subsequent CTG monitoring was found to be reactive. Vaginal examination was done and the result was as followed; cervical os opened for 1cm, cervical dilatation was 2 cm and its consistency was soft and subsequent blood pressure measurement was stabilized at 145/95 mmHg. On 2.00pm (2/4/2015), she still not delivered yet, then, she was given IV ampicillin 2gm for prophylaxis against chorioamnionitis. Meanwhile, previous pitocin and normal saline infusion still continued at a rate of 12mL/hour and 62mL/hour respectively. All other vital signs are normal and cervical os still opened only at 1cm. On 2.50pm (2/4/2015), she was in labour for 8 hours but the contractions were not optimum despite induction and augmentation of labor. Meanwhile, her cervical os still opened at 1cm. Therefore, the doctor concludes her as failed IOL and she was scheduled for emergency LCSC thereafter. On 3.00 pm (2/4/2015), consent was taken and she was kept NPO. Next, CBD was inserted and shaving was done. Then, she was immediately brought to OT for emergency LSCS. On 3.35 pm (2/4/2015), she was given IV cefuroxime 1.5g stat prior to operation. LSCS was done and baby was successfully delivered via forceps and fundal aid with no complications noted. Baby was handed over to paediatric team and placenta was delivered by CCT. She was transfer to puerperium ward thereafter. Urine output, protein and ketone as well as vital signs and pad chart were monitored throughout. On 6.45 pm (2/4/2015), her blood pressure was found to be 188/96 mmHg, however, urine protein was negative. Then, she was prescribed with T. Labetolol 400mg stat. On 7.30 pm (2/4/2015), she complaint of frontal headache. On top of that, she denied blurring of vision and epigastric pain. Thus, she was developed hypertension crisis. Then, the doctor prescribed her with T. Nifedipine 10mg stat. Her blood pressure was checked again at 8.15 pm and was found to be 165/93 mmHg.

On 9.20 pm (2/4/2015), her latest blood pressure measurement was 151/85 mmHg and she noticed that her frontal headache was decreased in intensity. PE profile was normal. However, she was continued with her previous hypertensive medications, T. Labetolol 400mg TDS and T. Nifidepine 10g TDS. Continuous PET charting and daily urine albumin were commenced and S/C Clexane 40mg OD was started. On 12.40 am (3/4/2015), she was sleeping comfortably and her blood pressure was steadily decreased. Currently, her blood pressure was 145/81 mmHg. On 6.20 am (3/4/2015), she was well with no signs and symptoms of impending eclampsia. Currently, her blood pressure was 134/84. On top of that, the dressing was intact and not soaked. CBD was taken off. On 9.50 am (3/4/2015), T. Nifidepine was withdrawn. However, she was still on T. Labetolol and oral analgesia and she was scheduled to discharge on tomorrow if there was not complication. Subsequent follow-up was unremarkable. Her blood pressure was decreasing steadily to the normal range and he was discharge on 4th April 2015 with T. Labetolol 400mg TDS, S/C Clexane 40mg OD and oral analgesia and was scheduled to attend post-natal visit to her MCHC nearby.

Discussions Madam Boon is a 36 year-old, Gravida 1 Parity 0, who was at 39th weeks of POA. Following table shows the point in the history which suggests she had pregnancy induced hypertension and it also shows points in the history which rule out other differential diagnoses: Differential Diagnoses Pregnancy induced hypertension

Pre-eclampsia

Eclampsia

Essential hypertension

Seconday hypertension

Supportive Points  Normal booking blood pressure  Onset of hypertension at 38th weeks of POA (Beyond 20th weeks of POA)  Normal antenatal urinalysis  No evidence of gross edema  No signs of impending eclampsia  No history of pre-existing hypertension  No history of renal disease  Normal booking blood pressure  Onset of hypertension at 38th weeks of POA (Beyond 20th weeks of POA)  Normal booking blood pressure  Onset of hypertension at 38th weeks of POA (Beyond 20th weeks of POA)  None

Points Against None





None

  









Normal antenatal urinalysis No evidence of gross edema

No signs of impending eclampsia

Normal booking blood pressure No history of pre-existing hypertension Normal booking blood pressure No history of pre-existing hypertension No history of renal disease

Therefore, by history alone essential hypertension, secondary hypertension and eclampsia can be ruled out. However, in the history, other possible complications for pregnancy induced hypertension have been ruled out such as pre-eclampsia and eclampsia. The evidences are there are no symptoms of impending eclampsia and the antetenal urine test was normal.

Following table shows points which supporting the diagnosis of pregnancy induced hypertension rather than pre-eclampsia in term of physical examination. Differential Diagnoses Pregnancy induced hypertension

Pre-eclampsia

Supportive Points  Blood pressure 154/92 mmHg  Mild pitting edema (normal for pregnancy)  Normal reflex  Clear lung field on auscultation  Blood pressure 154/92 mmHg

Points Against  None

  

Normal reflex Mild pitting edema (should be generalized involving facial and hand) Clear lung field (should be reduced breath sound in lower zone of the lung bilaterally due to pleural effusion)

With evidences li...