10th Batch MBBS IIUM Blog

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A 38 y.o, Malay lady, from Felda Panching, G5 P1+3, a k/c/o PCOS with 14 yrs hx of subfertility, recurrent abortions dx with anti-phospholipid syndrome(APS) and valvular heart dx with LNMP 15/6/10 SOD, no contraception but irregular menses with benefit of early scan 10/52 confirm her EDD at 22/3/11 making current px at 37/52 presents 3 days ago for 3 days history of reduced fetal movement.

Dr: so in conclusion u have a very complicated case *smiles*
Me: Yes..huhu... but i will try my best Dr

HOPI

This is a very precious pregnancy.
Suspected when missed period, UPT done positive.
1st trimester symptoms = only breast engorgement.
No episodes of PV bleeding or abd pain during 1st trimester

Booking at 8/52 POA
-Obese = BMI 35
-normotensive, blood group cant remember, rheses +ve
-blood test = nonanaemic, VDRL, HIV. Hep B non-reactive
-urine = no glycosuria or proteinuria

Due to her dx of APS, given aspirin 75mg from 10/52-37/52. Self-administered s/c clexane given from 28/52.
Due to heart dx, visit MOPD and was told can cont with pregnancy and does not need combine care.
Due to obesity, MOGTT indicated, done 3 times @ 15, 24, 34 weeks.. all normal.

So far 13 followups(biweekly) at HTAA due to her probs, all uneventful.
Scans done on every visit – singleton, healthy, no congenital abnormality, normal growth, AFI good, placentation normal with no obvious calcification.

Quickening felt at 16/52. ATT completed.
Started on FKC at 34/52.
3 days ago, reduced fetal movement(do not complete 10 in 12 hrs), did not seek medical attention because of an upcoming followup. On followup, fetal movement returned normal but warded just to make sure.

Currently no sign and symptoms of labour, no PV bleeding, FM good.

On further questioning, denied rashes of face or anywhere else, no joint pain, no easy bleeding, no jaundice, no SOB, no calf tenderness.

Past Gyn + Obs (I decided to just combine the both to have smoother chronological flow)

Attained menarche at 12, regular till age 21 when turned irregular (every 1-3 months around 3-5 days) nor dysmenorrhea.

Was married for 14 yrs however conceived first child after 6 years of trying in which she got help of two cycles of clomiphine citrate (without any complication of OHSS) and an ovarian drilling. Dx with PCOS, other than the subfertility and irregular menses does have hirsutism(moustache), was on metformin.

Her first child was born full term 9 yrs ago with weight of 2.3 kg via elective LSCS due to oligohydramnios. On further questioning, no cause was found, she denied LL, GDM, PIH or congenital abnormality. No other cx antenat,intra,post-partum. Breast fed for only a week due to migraine.

Subsequently 3 miscarriage (2006(required D+C), 2008, 2009), investigated, dx with APS.
None of the pregnancy after the first was helped with induction.
Last papsmear 3 yrs ago – normal

Medical/surgical Hx
No significant hx

Family Hx
3/8 siblings. Both parents alive and healthy. Two other sisters have similar problems of subfertility.

No other significant drug hx. No allergy

Social Hx
Housewife, SPM holder. Live with hsband and daughter. Husband mechanic making RM1500.No high risk behavior.

PE

VS BP = 130/75 mmHg, PR=80bpm, RR=18bpm, T= 36.7oC
BMI= 42
Not pale, not jaundice, hydrational fair, No pedal oedema
Respi, thyroid normal.. denied breast examination
Heart = systolic murmur of the mitral region, radiating to the axilla, grade 3… no raised JVP.

Abd : distended due to gravid uterus. Pfannenstiel scar 20 cm, no scar tenderness, SFH 37cm, singleton, longitudinal lie, fetal back on maternal right, cephalic presentation , 4/5th palpable, adequate liquor with EFW of 2.8-3.0 kg. Can’t hear fetal heart due to thick abd.

Would like to complete with VE and bishop scoring…



Discussions

List the patients problems…

What is your concern now ?
Fetal wellbeing

How do you check for fetal well-being now?
Hx-FKC, PE-serial SFH(not relevant in this case), Ix- US and CTG.

Tell me bout FKC…

Tell me bout CTG and inteprete the pt's CTG….

What is APS? korang baca la ye sendiri pasal APS

How does it cause recurrent abortions?

What is done to this patient to maintain the px? How does it help?
Aspirin n clexane..bla2 ets

How wud u manage this patient?
-Seeing that the FM carry on till 38 weeks

Y c-sec? – very precious, dun wanna take the risk of vaginal delivery.

What risk? – untried scar, risk of rupture, no previous SVD before, so there is probability of CPD… again I stress it’s a precious pregnancy.

But is she contraindicated for SVD? No

How wud u monitor if pt keen on SVD?... S+Sx of impending rupture, prolonged active/2nd stage…

How wud you prepare this patient for C-sec: Ix : FBC, GXM, PT/APTT….Make sure anaes team comes… fasting… stop clexane on the morning of surgery.. bla2 ak goreng lagi ;P

What is the cx of the c-sec? anaes[mendelson(px)? Diff intubation(obese+px)? Difficult epidural(obese)], Hge, injury to other organs, bla2 etc….

After delivery, does she still need the anticoagulant? Yes, eventhough if the delivery is successful, she is still at risk of thromboembolism due to her obesity and APS…

So when do u wanna start? 6 hrs post-surgery..bolus 5000u and maintenance 1500u

What if tomorrow she complains of reduced FM? Put on cont CTG and if there is any sign of fetal distress EmLSCS..

thank you, u can go now