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Long case examination for phase iii medical students usmkk

This booklet in Obstetric is intended for last minute revision before taking a

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Long case examination for phase iii medical students usmkk

  1. 1. 2009/2010 2009 Long Case Examination for Phase III Medical Students (Obstetric Cases) List and Answer to Commonly Asked Questions by Lecturers Muhamad Na’im B Ab Razak University Science Malaysia
  2. 2. Open Notes to My friends In the name of Allah, The Most gracious and the Most Merciful: Assalamu’alaikum wbt, May Peace and Blessing of GOD be upon all of you Dear friends, I would like to take this opportunity to thank you for inspiring me a lot during our journey in medical school. This notes is my way of replying your kindness and favor in helping me to survive the challenging life of medical school. Lot of cry and tears, but yet we still able to laugh together! All thanks to the seniors who have been doing a great job by compiling the entire commonly asked question during an exam. I just add some spice to their effort by providing an answer to the questions through this little book. If there is any mistake in this book, do not hesitate to inform me. InsyaALLAH I will try my best to correct it and updating this book. Whatever you read in this book, please double check with current management and ask opinion from lecturers. This book mainly reserves to be used for last minutes revision and not as reference. Please keep on reading text book and enhance your knowledge through journals. It is our duty as a Muslim to keep on updating our knowledge Hopefully, all of us may become a great and outstanding Muslim doctor someday. Pray for me that I may pass my undergraduate study and successfully pursuit my dream to become an emergency specialist. Sincerely yours, Jacknaim
  3. 3. Oath Of USM Medical Student’s Graduation Day In the name of God, We seek from you: The ability to be truthful, honest modest, Merciful and objective in our dealings The fortitude to admit our mistakes, to amend our ways and to forgive The wisdom to comfort and counsel all our patients Towards well being, peace and harmony regardless of their Social status, race and religion The ability to understand that our profession is sacred, Dealing with your most precious gifts of life and intellect We promise to devote our lives in serving mankind, Poor or rich, Literate or illiterate, Irrespective of race and religion With Patience and tolerance, With virtue and reverence, With knowledge and vigilance, And with Your love in our heart
  4. 4. The Oath Of the Muslim Doctor I swear by God ...The Great To regard God in carrying out my profession To protect human life in all stages and under all circumstances, doing my utmost to rescue it from death, malady, pain and anxiety. . To keep peoples' dignity, cover their privacies and lock up their secrets... To be, all the way, an instrument of God's mercy, Extending my medical care to near and far, Virtuous and sinner and friend and enemy. To strive in the pursuit of knowledge and. harnessing it for the benefit but not the harm of Mankind. To refer my teacher, teach my junior, And be brother to members of the Medical Profession. Joined in piety and charity. To live my Faith in private and in public, Avoiding whatever blemishes me in the eyes of God, His Apostle and my fellow Faithful. And may God be witness to this Oath.
  5. 5. Long Case Examination for Phase III Medical Students University Science Malaysia Important and Common Cases Needs to be Covered in Obstetric Section. 1) Normal labour 2) False labour 3) Unsure of Date 4) Induction of Labour 5) Caesarian Section 6) Pregnancy Induce Hypertension 7) Pre eclampsia 8) Hypertension in Pregnancy 9) Diabetes Mellitus in pregnancy 10) Gestational Diabetes Mellitus 11) Oligohydramnios 12) Polyhydramnios 13) Reduced Fetal Movement 14) Threatened pre term labour 15) Premature birth. 16) Post Date 17) Post Term 18) PPROM 19) PROM 20) Placenta previa 21) Unstable lie 22) Breech presentation 23) Multiple pregnancy 24) Heart disease in pregnancy 25) Anemia in pregnancy 26) Fibroids 27) Anti phospholipids syndrome 28) Teenage pregnancy And We have enjoined on man (to be good) to his parents: in travail upon travail did his mother bear him, and in years twain was his weaning: (hear the command), "Show gratitude to Me and to thy parents: to Me is (thy final) Goal [Q31:14]]
  6. 6. Long Case Examination for Phase III Medical Students University Science Malaysia Anti tetanus toxoid Macrosomic baby (page 18) Type of immune (page 36) Management (page 16, 17) When to give (page 36) MOGTT, when to do (page 15) MOGTT, Indication (page 16) Anemia in pregnancy (page 44,45) Shoulder dystocia (page 18) Spontaneous vaginal delivery ((page 18) Breech presentation (page 36) Weight gain in pregnancy (page 15) Causes and complication Mode of delivery Heart disease in pregnancy (page 40, 41, 42, 43) Candidosis Aspirin, IV Drug (page 24) Contraindication for pregnancy (page 43) Failure (page 40) Caesarian section (page 9) Eisenmenger syndrome (page 41) Anterior abdominal wall layer (page 10) Warfarin (page 41) Impending scar rupture (page 10) Preparation pre op and post op (page 9) Episiotomy Pfannensteil scar (page 32) Definition (page 4) Trial of scar (page 9) Layer cut (page 4) Cervix Fibroids (page 46) Normal cervical length (page 3) cervical effacement (page 1) Hypothyroidism (page 50) cervical dilatation in nulli vs multiparity (page 1) Labour Bishop score (page 1, page 3) Cervical cerclage (page 26) Braxton Hicks contraction (page 2) definition of labour (page 5) Chorioamnionitis Discharging patient in latent phase of Common organism (page 8) labour (page 3) Management (page 8) engagement (page 4) Show (page 5) Diabetes Melitus in pregnancy True vs false labour (page 2) GDM (page 15) Management of active phase of labour Complication of GDM (page 16) (page 2) Diagnosis and level of sugar control (page Mechanism of labour (page 4) 15) Screening test (page 15) Induction of labour Diabetogenic hormone (page 15) definition (page 7) Hydrocephalus (page 19) Indication (page 7)
  7. 7. Long Case Examination for Phase III Medical Students University Science Malaysia Mehtod (page 7) Ultrasound placenta (page 6) Oligohydramnios (page 20) Premature labour (page 24) Parity Definition Pseudoprimid (page 5) Premature contraction (page 25) Grand multiparity (page 26) Management Great grand multiparity (page 49) Reduce fetal movement (page 22, 23) Polyhydramnios (page 21) Tocolytic Fetal kick chart Post date (page 27) Tradisional medicine (page 23) Post term (page 28, 29) PPROM (page 30) Twin pregnancy (page 37, 38, 39) Fever Classification Positive findings complication Management Physical examination Twin to twin transfusion reaction PROM (page 31) Unsure of date (page 7) Placenta Neagele's rule (page 7) seperation, sign and symptoms (page 2) Comfirmation of date Placenta previa (page 32, 33) Unstable lie (page 34, 35) Prostin Causes Complication (page 7) Complication dose (page 8) Management Instruction to patient (page 8) Mode of delivery with presence of contaction pain (page 1, page 3) Uterus Pregnancy induced hypertension support (page 4) definition (page 11) Essential hypertension (page 14) Management (page 11) Pre eclampsia (page 12) Impending eclampsia (page 13) Magnesium sulphate (page 13)
  8. 8. Long Case Examination for Phase III Medical Students University Science Malaysia 25 years old Malay lady, G1P0 at 37W+ 2/7 are admitted because of contraction pain but not associated with show or leaking. Questions 1) How do you access the favorable of cervix? 2) What is cervical effacement? 3) Are there any differences if the cervix is 1 cm dilated in primid vs. Multipara who presented with contraction pain at term? Image from: Joan Pitkin et al, Obstetrics and 4) Can we induce the labour with Prostin Gynaecology: An Illustrated colour Text with the present of recorded contraction pain? Differences if the cervix is 1 cm dilated in primid vs. Multipara who presented with Answer contraction pain at term? Cervical score In HUSM, we used Modified Bishop Score. Nulliparous women have small external os at Cervix is favorable if Bishop score > 5 cervix center. In multiparous woman, cervix is bulkier and the external os has a more slit like appearance. Therefore, dilatation of 1 cm is significant in primid and not in multigravida. In multiparous, it is usually normal if cervix dilatation is 1 cm. Diagnosis of false labour should be made if it did not progress. Role of Prostin in the presence of recorded contraction pain. Recorded contraction pain is by evidence of CTG reading plus typical history of contracting Mnemonics: DiCoLePoS (Dilatation, pain. consistency, length, Position and Station) [Credited to Dr Ramli Ibrahim, HUSM] Once it present, Prostin should never being use as it will predispose mother to uterine hyper Cervical Effacement stimulation and cause fetal distress to the baby. Cervical changes prior to onset of labour where cervix become shorter, softer and moves from its Other mode of induction of labour should be position in the posterior vaginal fornix towards considered. anterior vaginal fornix [Joan Pitkin et al, Obstetrics and Gynaecology: An Illustrated colour Text] 1
  9. 9. Long Case Examination for Phase III Medical Students University Science Malaysia Case: G1P0, Post EDD, currently in labour (VE Impression: Patient is already in active phase of 5cm) first stage of labour. Post date patient who are already in labour will Question: not change the management and spontaneous a) Patient is a primid, never experience vaginal delivery should be expected except there before, how are you going to ask her in is indication for caesarian section or Hx whether it is a true labour. instrumental deliveries. b) How to manage this patient General management Notes: A Braxton Hicks contraction is a normal 1) Transfer patient to Labour room irregular uterine contraction starts occurring 2) FBC and GSH from fourth months of pregnancy. It acts as preparation for uterus to contract properly later. First stage of labour 1) Review history and problems True vs. False Labour pain 2) Abdominal exam and VE +ARM 1) Timing of contractions 3) Starts partogram False Labor: Often are irregular and do not 4) Review patient after 4H since cervix is get closer together <6cm (if >6cm VE when full dilatation True Labor: Come at regular intervals and as is expected) time goes on, get closer together. Contractions 5) Monitor last about 30-70 seconds. a) Maternal BP, PR, Uterine contraction 2) Change with movement b) 4H temperature False Labor: contractions stop in association c) FHR auscultation/ CTG with walking or change in position. True Labor: Contractions continue, despite Second stage of labour movement or changing positions 1) Leave patient for 30 minutes if no pushing contraction. Notify MO if not 3) Strength of contractions deliver after 1H of active pushing False Labor: Contractions are usually weak 2) Episiotomy and do not get much stronger (may be strong first, then get weaker) Third stage of labour (30 Minutes) True Labor: Contractions steadily increase 1) Syntometrine (Oxytoxin 5U+ in strength ergometrine 0.5 mg) IM 2) Delivery of placenta by controlled cord 4) Pain of contractions traction False Labor: contractions are usually only 3) Repairing of episiotomy wounds felt in the front of the abdomen or pelvic region True Labor: Contractions usually start in the Signs of placenta separation lower back and move to the front of the - Uterus contract and fundus become abdomen. Referred pain from uterus felt at the globular and firm buttock. - Small gush of blood flow out - Lengthening of umbilical cord. Management of this patient 2
  10. 10. Long Case Examination for Phase III Medical Students University Science Malaysia 28 years old Malay lady, G1P0 at 38W + 5/7 Before, any decision to discharge this patient, days POA was admitted because of contraction few measures needs to be look at. pain. There is no show or leaking liquar.Below 1) If the contraction pain starts to subside is her Bishop score on admission. 2) Pre discharge vagina examination did not show any cervical progression 3) No Pre labour ruptures of membrane. 4) CTG has been performed and reactive 5) Baby is not in mal presentation. 6) Patient can easily come back to hospital if anything happen. a) Short distance b) Access to transportation c) People to take care of her. 7) With advice that patient must come to hospital if any PROM or show or if the contraction become strong and in close intervals. Questions Induction of labour 1) Comment on the Bishop score 2) What is the normal length of the cervix - Induction with prostin is not indicated as in non pregnant lady? contraction is already there. It will only 3) If this patient requested to be increase risk for uterine hyper discharged, can you allow that? Support stimulation and abruptio placenta. your answer. - ARM could be done if cervical 4) Will you induce this patient for labour? dilatation more than 3 cm. Bishop Score Based on assessment on Bishop Score, patient is already in latent phase of labour as evidence of os is dilated. However the cervix is not favorable for labour yet. Normal cervix length for non pregnant lady 3.5 CM Requested to be discharged This patient is in the latent phase of labour. In primid, the latent phase could be as short as one day but may extend up to one week. 3
  11. 11. Long Case Examination for Phase III Medical Students University Science Malaysia 23 years old Malay lady at 39W+3/7 POA Mechanism of labour was transferred into ward from labour room because of contraction pain associated with Changes in position of the fetal head during show on the day of admission. No leaking of passage through the birth canal in the vertex presentation. liquor reported and fetal movement was good. (EDFIERE!) Questions 1) Engagement 1) Types of pelvis 2) Descent 2) What is engagement 3) Flexion 3) Outline the mechanism of labour 4) Internal rotation 4) What is the layer cut during the 5) Extension episiotomy procedure? 6) External rotation 5) The structures supporting the uterus. 7) Expulsion What is episiotomy and layer cut during the procedures? Episiotomy is a surgical cut that is made to the perineum during the pushing stage of labour. Layers of cutting: 1) Skin 2) Subcutaneous tissue 3) Vaginal mucosa 4) Bulbospongiosus muscle 5) Deep and superficial transverse perineal muscle Engagement Descent of the biparietal diameter of the fetal Support of the Uterus head below the plane of the pelvic inlet. Clinically, if the lowest portion of the occiput is 1) Tone of levator ani muscle at or below the level of the maternal ischial 2) Perineal body spines (station 0), engagement has usually taken 3) Ligaments place. Engagement can occur before the onset of a. Transverse cervical or cardinal true labor, especially in nulliparous patients [The ligament John Hopkins Manual of Gynecology and b. Pubocervical Obstetrics 3rd ed.] c. Sacrocervical 4
  12. 12. Long Case Examination for Phase III Medical Students University Science Malaysia 36 years old Malay lady, G3P0 at 37 weeks of Differential diagnosis pregnancy was admitted to ward after noticing - In labour spotting blood mixing with mucous on her - False labour underpants after waking up from sleep. The - PROM same event occurs two times in ward. However, - Bleeding from PP or Placenta abruptio. there is no recorded abdominal pain. - Discharge from urinary tract infection - Trauma to the perineal region. Question 1) What is mature pseudo primid? Management to this patient 2) What is labour 3) Terminology for blood mixing with 1) Full history and physical examination mucous a) Correct dating of pregnancy 4) Differential diagnosis b) Elicit any risky pregnancy 5) Management to this patient. c) Eliminating the differential diagnosis. Answer d) It is important to exclude PROM as patient at term and chorioamnionitis Mature pseudo primid could be disastrous for fetus. - Mature means age of mother > 35 years 2) Observation of vital sign old 3) Fetal kick chart (some doctor - Pseudo primid means patient has been recommend this) and labour progression pregnant but never deliver the baby. chart (LPC) - The term ‘mature’ should alert the 4) Speculum examination to access the doctor in carefully managing this patient cervix and excludes PROM, infection. because of many complication can occur 5) Assessment of fetal well being (CTG in this age group. Furthermore, this and ultrasound) could be her last pregnancy 6) Blood investigation (FBC to look for evidence of infection) Labour 7) Urine FEME to exclude UTI. - Process by which fetus is expelled from 8) Observe the patient in wards for 2-3 the uterus and into the outside world. days. If patient is stable and the labour - Three stages of labour does not progress, then the diagnosis is a) 1st stage- onset of contraction till false labour. Patient can be safely full dilatation of cervix discharge and ask her to come back b) 2nd stage- full dilatation of cervix till again once the sign and symptoms of delivery of fetus labor starts. c) 3rd stage- delivery of placenta 9) If patient in labour, then proceed with - Sign and symptoms of labour includes the management for labour abdominal contracting pain, show (discharging blood mixing with mucous), gushing of clear fluid (liquor) 5
  13. 13. Long Case Examination for Phase III Medical Students University Science Malaysia Notes on U/S about placenta Placental thickness judged subjectively Vascularity But if measure at midposition or cord insertion 2-4 cm = normal Very vascular – has 2 blood supplies Blood from fetus through 2 (sometimes 1) Grade 0 umbilical arteries through umbilical cord 1.Late 1st trimester-early 2nd trimester from fetal hypogastric arteries to placenta 2.Uniform moderate echogenicity 3.Smooth chorionic plate without indentations 1 umbilical vein carries blood back to fetal left portal vein Grade 1 1.Mid 2nd trimester –early 3rd trimester (~18-29 Blood from mom through branches of wks) uterine arteries through the myometrium 2.Subtle indentations of chorionic plate (arcuate arteries) through the basilar plate 3.Small, diffuse calcifications (hyperechoic) (spiral arteries) into the placenta randomly dispersed in placenta The two circulations intertwine in the Grade 2 placenta but do not mix 1.Late 3rd trimester (~30 wks to delivery) Exchange of oxygen and nutrients occurs 2.Larger indentations along chorionic plate over the large vascular surface area 3.Larger calcifications in a “dot-dash” configuration along the basilar plate Maternal venous channels in the placenta are hypoechoic or anechoic spaces called Grade 3 venous lakes (usually small, but can be 1.39 wks – post dates large) 2.Complete indentations of chorionic plate through to the basilar plate creating Anatomy on US “cotyledons” (portions of placenta separated by the indentations) Inner border of placenta against the uterine 3.More irregular calcifications with significant wall has the combined hypoechoic shadowing myometrium and interposed basilar layer = 4.May signify placental dysmaturity which can hypoechoic band called the decidua basalis cause IUGR (contains maternal blood vessels) 5.Associated with smoking, chronic hypertension, SLE, diabetes Outer surface abutting the amniotic fluid = chorionic plate (chorioamniotic membrane) Sources: = bright specular reflector s/placentapage.htm 6
  14. 14. Long Case Examination for Phase III Medical Students University Science Malaysia Case: Unsure LMP/ Unsure of Date to pregnancies at gestations greater than the legal definition of fetal viability (24 weeks). Questions a) Neagele’s rule Divided into mechanical (Sweep & scratch, b) Investigation ARM,) and pharmacological (IV Syntocinon, c) Management Prostin). d) Induction of labour e) Complication of Prostin Others; breast stimulation, relaxin, hyaluronidase, sexual intercourse, acupuncture, Neagele’s rule homeopathic method 1) Sure of date 2) Menstrual cycle is regular of 28 days (ovulation occur 14 days prior to the Indication for IOL next menses) 1) Fetal 3) Not on any form of hormonal a) IUGR contraception within 3 months b) PIH/PE 4) Not lactating within 2 months c) GDM at 38w d) Post EDD Investigation e) Twin at term 1) Cardiatocography (CTG) to access fetal f) Hx of unexplained APH well being g) Transverse oblique/unstable lie 2) Ultrasound for physical biometry of the h) Hemolytic disease baby, and amniotic fluid index i) Fetal abnormality incompatible with life (anencephaly) 2) Maternal Management a) Medical disorder aggravated by 1) Confirmation of the date of pregnancy pregnancy like DM, SLE, PE, Renal a) Early ultrasound scan (<20w) disease. b) 1st UPT positive (6-8w) b) IUD with risk of DIC c) Quickening c) Spontaneous/ PROM>24h d) Uterine size correspond to d) Abruption of placenta pregnancy e) Onset of signs and symptom of pregnancy Complication of prostin f) Conception date 1) Failed IOL (require c-sec) 2) Bishop score (>5 is favorable) 2) Uterine hyper stimulation 3) Elicit any medical problem. 3) Uterine rupture. 4) Fetal distress. Induction of labour 5) C/I in patient with asthma/glaucoma An intervention designed to artificially initiate 6) Abruptio placenta uterine contractions leading to progressive dilatation and effacement of the cervix and the birth of the baby. The term is usually restricted 7
  15. 15. Long Case Examination for Phase III Medical Students University Science Malaysia 27 years old Malay lady, G2P1 at 38 weeks of In woman whom deliver more than two babies pregnancy was admitted to ward because of (not grand Multipara) and 1 caesarean section PROM more than 24 hours. She was council for scar, the dose for each cycle is 1.5 mg. induction of labour. If labour is not progress after the second dose, Question then it is considered as failed induction [NICE 1) Common organism causing Guidelines] and emergency C-sec will be done. chorioamnionitis in PROM and how to HUSM did not follow this guidelines and IOL manage. with prostin is based on clinical experience. 2) Dose of Prostin 3) Instruction to the patient before inserting Some might consider failed induction after the the Prostin third dose, 6 hours after the second dose. (Controversy) Answer Notes: Prostin is contraindicated if presence of Common organism causing chorioamnionitis uterine contraction to avoid uterine hyper in PROM and how to manage? stimulation. 1) Risk of getting infection arises after 12 Instruction to patient before inserting the hours of PROM. Prostin 2) Antibiotic prophylaxis should be given based on common isolated organism 1) Ask the patient to urinate first because which is group B Streptococcus (IV she needs to lie on bed for one hour Penicillin) 2) Ask the patient to lie down on bed for 3) Chorioamnionitis is more dangerous to one hour fetus as compared to mother 3) Ask the patient to inform the doctor if 4) IOL should be suggested to the mother the contraction pain is strong. if PROM > 24 hours. 90% of patient 4) Do CTG after one hour to access uterine with ruptured membrane will deliver the contraction and any evidence of fetal baby within 24 hours. distress 5) If chorioamnionitis develop, patient 5) After one hour, do the VE to access the should be covered with antibiotic cervical dilatation. against GBS, gram negative and 6) If cervix is more than 3 cm, remove the anaerobes. residual Prostin and sent patient to labour room. Dose of Prostin 7) If less than that, and suspect uterine Notes: I suppositories equals to 3 mg. hyper stimulation, remove the residue Prostin as well and send patient to In primid, we can insert 1 suppository and labour room and monitor with CTG. access the Bishop score 6 hours later. If cervix is KIV tocolytic agents (salbutamol). If favorable, then we may proceed with artificial fetal distress, emergency cs. rupture of membrane. If not, second dose of 8) If CTG normal, patient can regain her Prostin may be given. activity. Recheck cervical score 6 hour later. 8
  16. 16. Long Case Examination for Phase III Medical Students University Science Malaysia Case: 3 Previous C-sec scars 3) To cover the surgery a) Consent form signed Question b) Baseline blood investigation (FBC, a) Investigation GSH, LFT, BUSE/Creat) b) Management c) Blood cross match (2U Pack cell) c) Post op-acute management d) IV ampicillin 1g stat for prophylactic Trial of Scar e) Bladder catheterization Notes: According to ACOG guidelines on f) Pre med (IV Ranitidine 50mg in 10 vaginal birth after Caeserean Section, trial of ml by slow injection, IV Maxalon scar is not recommended in patients at high risk 10 mg by slow injection, Sodium for uterine rupture. One of the contraindication citrate 30 ml orally) including this case. 4) Anesthetist with at least one year experience 1) Two prior uterine scars and no vaginal 5) Ideally use regional block except contra deliveries indicated (major placenta previa, local 2) Previous classical or T-shaped incision skin sepsis, severe heart disease, or extensive transfundal uterine surgery coagulation disorder, severe fetal 3) Previous uterine rupture distress, cord prolapsed, eclampsia) 4) Medical or obstetric complication that 6) Present of obstetrician. precludes vaginal delivery 7) Reduce risk of thromboembolic 5) Inability to perform emergency cesarean phenomenon after surgery delivery because of unavailable surgeon, a) Early ambulation anesthesia, sufficient staff, or facility b) Anti embolic stocking/Flowtron c) Anti coagulant for high risk cases. Notes: The management of this patient should [The practical Labour Suite Management- Dr Adibah Ibrahim] emphasize more on caesarean section and anticipating in possibility of uterine rupture. It Post op management also includes advice for tubal ligation. (Practice 1) Recovery area (one to one observation until in Malaysia to do BTL after 4 Caesarian patient has airway control, cardio respiratory Section) stability and can communicate) 2) In wards (1/2hly observation RR, HR, BP, Investigation pain and sedation) for 2H, then hourly if stable Fetal investigation 3) Intrathecal opiods- hourly observation for RR, - Ultrasound (AFI, Estimated fetal Sedation and pain scores for 12h for weight, exclude placenta previa, accrete diamorphines and 24h for morphines) or abruptio, biometry) 4) For epidural opiods and patient-controlled - CTG analgesia with opiods (hourly monitoring during CS, plus 2h after discontinuation) Maternal (preparation for C-sec) 5) Post natal care (analgesic, monitor wound 1) For patient in labour (fluid diet and T. healing, signs of infection) Ranitidine 150 mg q.d.s) 6) consider CS complication (endometritis, 2) Patient at high risk of anesthetic( sips of thromboembolism, UTI, urinary tract trauma) water+ IV fluid if indicated) [NICE Guidelines on Caesarian Section] 9
  17. 17. Long Case Examination for Phase III Medical Students University Science Malaysia 26 years old Malay lady, housewife, G2P1 at 38 4) Forceps application and breech extraction weeks of gestation with second husband and once full cervical dilatation achieves history of previous caesarean section was 5) Elective caesarean section admitted because of c-sec scar tenderness. 6) Explore the genital tract after difficult or instrumental delivery Questions 7) Blood FBC and GSH 1) S&S of impending scar rupture 2) Management for patient come with Once the ruptured occur impending scar rupture 3) Elicit the scar tenderness on PE 1) Secure the ABC. 02 100%, 3L/min increase 4) The anterior abdominal wall layer cut oxygenation to tissue if hemorrhage occurs. during the c-sec operation. 2) 2 large bore IV line 3) Blood transfusion and shock management Uterine scar rupture 4) Emergency laparatomy 5) Delivery of fetus and placenta A complete uterine rupture is a tear through the 6) Exploration of the rupture site thickness of the uterine wall at the site of a prior a) Try to repair the lesion cesarean incision. b) Hysterectomy of not salvageable 7) Internal iliac artery ligation in case of broad Patient might present with: ligament hematoma because uterine artery is usually retracted and difficult to be identified. 1. Fetal distress evidence by abnormalities 8) Vaginal repair if there is cervical tear in fetal heart rate 2. Vaginal bleeding Layer cut through caesarean section 3. Sharp onset of pain at the site of (Pfannenstiel approach) previous scar 4. Sharp pain between contractions 1) Curved transverse cut just below hair 5. contraction become less intense (finally border lead to atony) a) skin 6. Diminished baseline uterine pressure b) superficial fascia (Camper and 7. Abdominal tenderness Scarpa) 8. Recession of the presenting fetal part c) Rectus sheath (contains fascia of 9. Hemorrhage EO, IO and TM) 10. shock 2) Vertical incision for access into lower Management to impending scar ruptures abdomen Management a) Separation of rectus abdominis muscle in midline Prophylactic management b) Dividing of the fascia transversalis c) periperitoneal fat tissue 1) Close monitoring for woman with high risk of d) peritoneum uterine rupture 2) Early detection of causes of obstructed labour 3) Use Oxytoxin with caution 10
  18. 18. Long Case Examination for Phase III Medical Students University Science Malaysia Case: PIH being, abnormal surveillance basic blood test (BP and urine dipstick at least Questions 3X per week, weekly PE profile and a) Differential diagnosis CTG.) b) Management 6) Starts anti hypertensive when diastolic c) Drugs (SE&MOA) BP > 90 mmHg d) Drugs contraindicated in PIH a) T. Methyldopa 250 mg tds to max dose of 3g/day or Definition b) T. labetolol 100 mg tds to max 300 BP more than or equal to 140/90 mmHg in mg tds previously normotensive patient, @ A rise in 7) IM dexamethasone 12 MG 12 hourly for systolic BP of > 30 mmHg or diastolic BP > 15 two doses for expectant prem delivery. mmHg compared with pre-conception or first trimester value in two recording of at least 4H In case of severe PE apart 1) Manage in hospitals 2) Close monitor BP 4Hly, reflex, clonus Differential diagnosis 3) Check fundus - Chronic hypertension (long or before 20w) 4) Twice weekly(or more based on - Pre eclampsia (>20W+new onset proteinuria) severity) PE, CTG, biophysical profile - PE with superimposed chronic HPT and doppler New onset or A) acutely worsen proteinuria, B) 5) Anti-hypertensive but aim for 20-25 sudden increase in BP, C) thrombocytopenia or reduction only and not normal by using D) elevated liver enzymes after 20 week hydrallazine or labetolol gestation in women with pre existing HPT - Gestational HPT (after 20w without In labour proteinuria) 1) BP stabilization 2) Watch for fluid overload (monitor UO) Management 3) Seizure prophylaxis in severe PE 1) if detected <20W, must exclude molar 4) Epidural analgesic is the best pregnancy by US and after exclusion, 5) Oxytoxin only to augment labour. being investigate for primary or 6) Never allow woman with severe PE to secondary HPT push excessively. If BP high, consider 2) If pre existing HPT during Booking, instrumental delivery. should be managed by obs+internist 7) C/I to ergometrine/syntometrine in third 3) Every other day BP check at local clinic stage due to hypertensive effect. if BP is first high during any ante natal check up. 4) Investigation for PE profile (platelet Drugs contraindicated for PIH includes ACE count, uric acid, serum creatinine level, inhibitor and ARB as it can cause renal AST, urine albumin). If PE is diagnosed, dysgenesis of the baby. then it should be repeated once a week 5) If BP sustained at >100mg/ >25 increment mmHg or clinical suspicious of IUGR, poor maternal-feternal well 11
  19. 19. Long Case Examination for Phase III Medical Students University Science Malaysia Case: 41/M/F, G1P0 at 29W+2d POA 5) PE profile twice a week (severe PE) or High blood pressure and proteinuria 3+ once a week(mild PE) compose of a) Platelet count (decrease) Question b) Uric acid (1st indication of renal a) Investigation and reason impairment) b) Treatment plan c) Sr Creatinine level (renal function) c) Time of delivery and why? d) Liver enzyme, AST (liver damage) e) Urine albumin as mention in above. My impression: High blood pressure with 6) Clotting study if platelet < 100 x 106/l proteinuria could lead to Pre eclampsia which is 7) Input/output Fluid Chart. worrisome due to serious complication. 8) CTG for fetal well being. Therefore, PE should be ruled out first before 9) Serial ultrasound measurements of fetal considering other condition that may falsely give size, umbilical artery Doppler and liquor positive result to proteinuria like UTI volume PE is defined as: Treatment plan Hypertension unique to pregnancy, diagnosed after 20W of gestation and associated with new Mild PE onset proteinuria; Eclampsia if seizure occurs. T. Methyldopa 250mg tds, max 3g/day or T. Labetolol 100 mg tds, max 300mg tds If woman already having pre existing HPT but Or, Tab. Nifedipine 10 mg tds stat dose after 20W she develops new onset proteinuria, sudden increase in BP, thrombocytopenia or Severe PE elevated liver enzymes, then PE with IV hydrallazine start 5mg, double if no effect superimposed on chronic hypertension must until 35mg. change drug if fails or be suspected. IV Labetolol start 10 mg, double if no effect until max 300mg/day) HELLP (Hemolysis, Elevated liver enzyme, low platelet) is a variant of PE with involvement of ** MgSo4 slow infusion 4g 10-15 minutes. liver giving rise to tender epigastric pain, and Maintenance dose IV ig/hour finally DIC. When to Deliver Investigation 1. Delivery is definitive treatment if mother life 1) Repeat Dipstick testing within 6H is compromised. (Very high uncontrolled BP, PE shows by urinary albumin platelet <100, AST>150 iU/L >300mg/24 hour@ >1g/l in 2 random 2. Can wait until term if well controlled and fetal urine 6 hour a part. is not compromised. 1+ = 0.3 g/l, 2+ = 1 g/l and 3+ = 3 g/l. 3. If gestation >34W, then delivery after 2) 24 Hour proteinuria to see severity of stabilization is recommended PE. Severe PE >5000mg/24 hr. 4. In this case, prolong delivery for 24 Hr to give 3) BP should be checked every 15 minutes steroid injection for lung maturity until women are stable. Then, [RCOG Guideline No. 10(A) March 06] 4) Close monitoring of BP (at least 4Hourly) + reflex, clonus. 12
  20. 20. Long Case Examination for Phase III Medical Students University Science Malaysia Case: 19/M/F, G1P0 at 32W of pregnancy 1g/h for at least 24h after last seizure or delivery diagnosed with pre eclampsia at 28W of Add 4 vials (10g) to 50cc of normal saline & run gestation. at 5cc/h Question If further fits occur give a further slow IV dose furth a) Signs and symptoms of impending of 2g & continue the maintenance infusion eclampsia b) Magnesium sulphate Contraindications for Magnesium Sulfate: Cardiac failure Signs and symptoms of impending eclampsia Acute renal failure 1) Headache 2) N & V Drug monitoring: 3) Visual Disturbances Clinical 4) Right upper quadrant pain 1) Patellar reflex: 5) Progressively oedema (non dependant) - After completion of loading dose 6) Frothy urine (proteinuria - Half hourly whilst on maintenance infusion maintenanc - use elbow reflex if epidural in situ Magnesium sulphate 2) Respiratory rate: should be >16/min Magnesium sulfate is superior to other AED 3) Hourly urine output: should be >25ml/h (phenytoin, diazepam). (urine output is critical as serum Mg level depends on renal excretion) Indications: 1) Eclampsia 4) Pulse Oximetry : must remain >90% 2) Fulminating severe PE either: a) Severe hypertension (MAP: >125 Serum Mg level should be checked when: mmHg, SBP: >170 mmHg, DBP: >110 Oliguria (<25ml/h) mmHg); OR Respiratory rate <16/min b) Hypertension with proteinuria (BP: Pulse oximetry <90% >180/90 mmHg, proteinuria: Continuing fit >0.3g/24h), AND one of the following: i. Clonus (>3 beats) Toxicity (therapeutic range: 2-4 mmol/l @ 4-8 2 ii. Severe persistent headache mg/dl) iii. Visual disturbance Loss of patella reflex iv. Epigastric pain Weakness v. Platelet count <100 x 103/dL Nausea Feeling of warmth 5mmol/l Protocol for use of Magnesium Sulfate: Flushing (5ml vial contain 2.5g MgSO4 ~0.5g/ml) Double vision Slurred speech Loading Dose – 4g Magnesium Sulfate Muscle paralysis 6-7 mmo/l 8ml (4g) + 12ml 0.9% saline IV over minimum Respiratory arrest of 10 - 15 minutes Cardiac arrest >12 mmol/l [Labor suite Management by Dr Adibah Ibrahim] Maintenance Dose 13
  21. 21. Long Case Examination for Phase III Medical Students University Science Malaysia Case: 34/M/L, G2P1 C/C-High blood pressure Investigation Dx- Essential hypertension. 1) ECG 2) Urine dipstick test Question: Hx and Pe only 3) Fasting Lipid profile 4) BUSE and creatinine, Essential hypertension -Primary elevation of blood pressure without Management known causes which can be ameliorated only by lifelong pharmacological therapy [Kumar& Non pharmacological Clark 6th edition] 1. Lifestyle medication with light exercise. 2. Reduce the intake of salt and fat. Risk factor - Genetic Pharmacological - Low birth weight 1. Stop ACE inhibitor and ARBs. Atenolol - Environmental factor can cause IUGR and Labetolol is a) Obesity relatively contraindicated in Asthmatic b) Alcohol intake patient. c) Sodium intake 2. T. Methyldopa 250mg tds, max 3g/day d) Stress or e) Smoking 3. T. Labetolol 100 mg tds, max 300mg tds - Humoral mechanism (insulin resistance) or 4. Tab. Nifedipine 10 mg tds stat dose Cardiac output rises in pregnancy, however there ** Do not give Methyl dopa together is relative greater fall in peripheral resistance, with Nifedipine. therefore BP in pregnant woman is usually low 5. High calcium supplementation of 1.5 than those not pregnant [Kumar& Clark 6th g/day to prevent PE edition] 6. Avoid Combined vitamins C and E (in the form of tocopherol from soybean) as Important history to be elicited it may cause IUGR 1) Risk factor to develop pre eclampsia Others measurement 1. Routine ante natal check up. a. existing chronic medical disorders such 2. Advise patient to come immediately to as obesity, hypertension, diabetes hospital if develop signs and symptoms mellitus, renal disease, connective tissue of impending PE. disease and thrombophilia, 3. Urinary Dipstick to screen new onset of b. Previous history of preeclampsia or proteinuria. eclampsia or IUGR or unexplained 4. CTG and ultrasound to monitor fetal stillbirth well being. c. Family history of preeclampsia or 5. Re assurance to the patient. eclampsia, and 6. Can allow delivering via SVD unless d. Extremes of reproductive age (below 20 there is indication for C-Sec. or above 40 years old) 14
  22. 22. Long Case Examination for Phase III Medical Students University Science Malaysia 25 Years Old Malay lady, Nurse, G1P0 at date b) 2 hour post glucose load: 7-8 + 5/7 was admitted to wards because of mmol/L contraction pain and URTI. Patient also was 2) Level of blood glucose control: Blood investigated for GDM because of excessive Sugar Profile (4-6 mmol/L) and Serum weight gain during 21 week of pregnancy. HBA1c concentration (< 6.5%) Questions Screening test for GDM before performing the 1) What Is GDM? MOGTT 2) How do you diagnose GDM 3) Screening test for GDM a) Random blood sugar (> 11.1 mmol/L) 4) When to do MOGTT b) Urinary glucose level (≥ 1+ on more 5) Name the diabetogenic hormone in than one occasion or ≥ 2+ on one pregnancy occasion) 6) What is normal weight gain in c) Mini Glucose Tolerance Test (> 7.8 pregnancy? mmol/L) Answer When to do MOGTT What is GDM? 1) Candidates for MOGTT is offered for this test at 16-18 weeks of pregnancy A syndrome of glucose intolerance appears 2) If normal, then repeat at 26-28 weeks of during pregnancy and usually disappears after pregnancy. If it negative, then no need pregnancy is terminated. It affects 7% of all to re-do it as HPL diabetogenic effect pregnancy. starts to plateau even though it’s serum level continue to increase It is a metabolic disorder of multiple aetiology proportionally. characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein Diabetogenic hormone in pregnancy metabolism resulting from defects in insulin secretion, insulin action, or both. a) Human Chorionic Somatomammotropin (HCS) or formerly known as Human Previously, it is categorized into impaired Placental Lactogen (HPL) glucose tolerance test and GDM based on fasting b) Estrogen (stimulate production of and 2 hour post glucose load in MOGTT. prolactin) However, current guidelines stated that GDM c) Progesterone includes impaired glucose tolerance test. d) Cortisol Notes: In GDM, besides of anti-diabetogenic Diagnosing Diabetes Mellitus and the level of hormone, there will be increased in insulin blood sugar control degradation by placental enzymes 1) Diagnose: Based on MOGTT Normal weight gain in pregnancy Normal level of MOGTT is a) Fasting: 5-6 mmol/L 1) First 5 months: 0.5 kg/months 2) Followed with: 0.5 kg/ week. 15
  23. 23. Long Case Examination for Phase III Medical Students University Science Malaysia Case: 28/M/F, G3P2 at 28W P.O.A admitted in Neonate view of uncontrolled blood sugar level. a) Congenital abnormalities Diagnosed as GDM at 26W P.O.A. Previous b) Shoulder dystocia, birth asphyxia & traumatic pregnancy also complicated with GDM and birth macrosomic baby requiring LSCS. Positive c) Hypoglycemia – fetal islet cell hyperplasia family history of DM on maternal side. d) Jaundice e)Respiratory distress syndrome – Questions hyperinsulinaemia diminished surfactant a) Complication of GDM production b) Indication for MOGTT f) Hypocalcaemia and hypomagnesaemia c) Management to this patient Indication for MOGTT Complication of GDM 1) Significant glycosuria on 2 or more Maternal occasions during pregnancy a) Hypertension, ↑ incidence of pre- 2) Maternal obesity (i.e. maternal weight eclampsia (if a/w nephropathy) >80 kg or BMI >27 at booking) b) ↑ incidence of infection – UTI, 3) Family history of diabetes in first-degree vulvovaginitis etc relatives c) Polyhydramnios 4) Previous big baby (weighing >4 kg) d) Pre-term labour 5) Women >35 years old e) Coronary artery disease 6) Previous unexplained stillbirths, f) Thromboembolic disease recurrent abortions, birth defects g) Risk of caesarean delivery 7) Previous history of gestational diabetes 8) Polyhydramnios in current pregnancy Fetus 9) Big baby in current pregnancy 1. Early pregnancy 10) Congenital abnormality a) Spontaneous abortion b) Congenital anomalies → 40% of perinatal Management for this patient death in diabetic pregnancies My point of view: This patient was diagnosed as c) Cardiac defects GDM at 26W of pregnancy. Now is her 28W of d) Neural tube defects pregnancy and her blood sugar level is e) Renal anomalies uncontrolled. Obviously DM diet is not working. f) Caudalregression synd (rare) Therefore, I see the role of giving insulin injection to her. 2. Later pregnancy a) Macrosomia Therefore for this current admission, BSP should b) Polyhydramnios be done after giving insulin injection to look for c) IUGR (intrauterine growth restriction) the blood sugar level and further adjustment of d) Unexplained intrauterine death. May be insulin dosage. secondary to: Chronic hypoxia Pregnancy shouldn’t be allowed beyond 38W Polycythemia due to risk of unexplained IUD. Lactic acidemia Ketoacidosis 16
  24. 24. Long Case Examination for Phase III Medical Students University Science Malaysia 36 years old Malay lady, teacher, G4P3 at 37W Caesarean section + 6/7 was admitted to wards for further 1) This is possibly a best option but this management in view of will put patient in high risk category for next pregnancy which is 2 caesarean 1) Establish DM for three years. scars with no successful VBAC. Previously on OHA but now changed to 2) If patient wish to pregnant again, she insulin. However, blood sugar is will require caesarean section for the uncontrolled. Currently there is no following pregnancy. complication of DM develops. 2) Last pregnancy is by caesarian section Management for this patient because of transverse lie. Antenatal 1) Fetal surveillance with ultrasound for Questions biophysical profile and CTG. 1) Option of mode of delivery and pre 2) Blood sugar profile with adjustment of requisite for it. insulin dosage. 2) Management for this patient. 3) Diabetic diet Answer Intrapartum 1) Management based upon modes of Patient with uncontrolled diabetes mellitus delivery either chooses induction of should not be allowed to proceed with labour with spontaneous vaginal pregnancy beyond 38 weeks of pregnancy. delivery or caesarean section. 2) Patient should be started on DKI Therefore, it is crucial to determine the correct regimes (5% dextrose solution with 1 date of pregnancy to avoid pre term delivery. gram KCL) together with sliding scale Furthermore, fetus of diabetic mother is insulin infusion. If patient go for c-sec, associated with delay lung maturity. morning dose of insulin should be omitted. Mode of delivery 3) Presence of senior obstetrician to In this patient, mode of delivery should be standby in case any complication occur. balanced between benefit and risk. The decision 4) Pediatrician needs to be informed should always be discussed with the patient. regarding this case. Spontaneous vaginal delivery with induction of Post partum labour. 1) Baby should be observed in NICU for 1) Should be done carefully if using 24 hours before discharged. Prostin because of history of c-sec with 2) After the delivery, insulin can be stop no successful VBAC. Dosage is 1.5 mg and patient may continue taking OHA. for each cycle. Membrane sweeping 3) Referral to internal medicine team for could be considered. further management 2) Need to elicit the lie of the fetus in 4) Advise for contraception. cephalic presentation. 5) Counseling on blood sugar control if 3) Excludes macrosomic baby. patient wish to get pregnant again 17
  25. 25. Long Case Examination for Phase III Medical Students University Science Malaysia 35 Years old Malay lady, G1P0 at 37W + 5/7 b) > 4,250 g = elective caesarean section with gestational Diabetes Mellitus was admitted Notes: Ultrasound is specific for determination of for review for intrapartum management estimated fetal weight but only with sensitivity of 60- 70% at term. There will be a + of 500 mg Questions discrepancy of estimated and real fetal weight. 1) What should you elicit before allowing Macrosomic baby of diabetic vs. non diabetic patient to deliver by vagina delivery? mother 2) What is macrosomic baby? 3) Are there any differences between Macrosomic baby of non diabetic mother is at macrosomic baby who is belonging to low risk for developing shoulder dystocia as diabetic mother and non diabetic compared to baby of diabetic mother. This is due mother? to present of excessive fat tissue growth at 4) If this patient keen on SVD even though shoulder region in baby of diabetic mother. The the estimated fetal weight is 4 Kg and disproportionate excessive growth of the the labour is complicated with shoulder shoulder will predispose them to the risk of dystocia, what would be your shoulder dystocia during SVD. management? Steps in managing Shoulder dystocia Answer 1) Call for help, inform senior obstetrician and pediatric colleague Before allowing diabetic mother deliver via 2) Experienced obstetrician should be SVD, few thing needs to be excluded first. present during second stage of labour 1) The size of baby is not macrosomic 3) Mc Roberts’ maneuvers (Flexion and 2) Cephalic presentation abduction of the maternal hips, 3) Longitudinal lie positioning the maternal thighs on her 4) Not a candidate for Caesarean section abdomen) a) Major placenta previa 4) If not successful, apply suprapubic b) Footling or flexion breech pressure together with Mc Roberts c) 2 previous c-sec scar without prior (External suprapubic pressure is applied normal delivery in a downward and lateral direction to d) Unstable lie push the posterior aspect of the anterior e) Any obstruction to descending of shoulder towards the fetal chest ) fetus (fibroid, ovarian cyst, 5) If fail, proceed with Wood-Corkscrew Cephalopelvic disproportion) Maneuvers (The hand is placed behind the posterior shoulder of the fetus. The shoulder is rotated progressively 180° in Macrosomic Baby a corkscrew manner so that the impacted For undergraduate level, macrosomic is the anterior shoulder is released. estimated weight of fetus > 4 kg. However, it is 6) If still fail, then deliver the posterior arm further classified into categories first. a) 4,000 - 4,250 g (discuss with patient 7) If fail, do Zavanelli maneuvered (push regarding mode of delivery) the baby back) and prep for emergency C-sec 18
  26. 26. Long Case Examination for Phase III Medical Students University Science Malaysia Case: DM with hydrocephalus baby 2) Observation of fetal condition through serial ultrasound. Check for any Question abnormality like spina bifida (associated a) H(x) and P(e) with hydrocephalus) b) Investigation and management 3) 30 minutes CTG monitoring for fetal condition. History 4) FBC and GSH for the mother 1) Regarding DM 5) Blood sugar profile, Hba1c level of the a) Since when? Pre existing or during mother. this pregnancy 6) Check for any complication of diabetes b) Any history of macrosomic baby, mellitus. Polyhydramnios or unexplained IUD during previous pregnancy? Management c) Are there family risk factor? d) Is MOGTT done? (normally early 1) Prenatal pregnancy and repeated at24-28w in a) Pre term delivery is unlikely in this case; high risk group in which initial test therefore corticosteroid injection is not is negative) needed. e) Now on diabetic diet, OHA, or b) Admit the patient at obstetric wards to insulin. observe the blood sugar level. Starts f) Ever being admitted due to DM with diabetic diet. If fails, starts insulin. complication like hypoglycaemia, c) Inform the pediatrician and neonatal diabetic foot. neurosurgeon regarding delivery of baby g) Any complaint of DM complication and next intervention. (most likely like heart disease, peripheral caesarian section at 38-39w to prevent vascular disease, diabetic head entrapment) nephropathy, diabetic retinopathy. d) Counseling to the patient regarding the baby condition. Congenital abnormality 2) Regarding hydrocephalus in DM is low. On next pregnancy should a) How did the patient know that? take folic acid to reduce risk of Through US (usually diagnosed hydrocephalus. after >24w)? Who confirmed it? e) Termination of pregnancy is against b) Did mother took/compliance to folic medical ethics and Islamic law. Only acid? fetus which is dead in vitro or no chance c) Did previous baby having of living can be terminated. congenital anomaly? 2) Intrapartum d) The weight of the baby? a) Prep for C-sec e) P(e) for unstable lie. 3) Post natal 1) Check CBS of the baby and mother Investigation 2) Admit baby to the NICU for further 1) Find the causes of hydrocephalus. management. TORCHES? Bleeding? Edward 3) Counsel mother to control diabetes and took syndrome? folic acid before next pregnancy 19
  27. 27. Long Case Examination for Phase III Medical Students University Science Malaysia Case: Oligohydramnios In the term or post-term gestation, oligohydramnios is frequently associated with Question thick meconium (a/w Meconium Aspiration), a) Complication of oligohydramnios deep decelerations in the fetal heart rate, and b) How to detect the dysmaturity syndrome. One team reported c) Management a 13-fold increase in perinatal mortality rate (to 57/1,000) when the sonogram showed Definition amniotic fluid volume to be marginal, and a 47- Reduce in AFI <5 based on ultrasound fold increase (to 188/1,000) with severe [additional of vertical amniotic fluid pocket oligohydramnios. depths volume in four quadrant.] Some specialist may consider AFI <8 as oligohydramnios (AP In 62 cases of second-trimester Dr Nik Hasliza). oligohydramnios, another team reported a 43% perinatal mortality rate, with lethal pulmonary Amniotic fluid production hypoplasia complicating 33% of cases. If A) Production of amniotic fluid is from amniotic fluid was essentially absent 1. Inward transfer of solute across the ("anhydramnios"), 88% had lethal outcomes, amnion with water following passively in compared with 11% of those with moderate fluid early gestation. reductions. 2. Water transport across the highly permeable skin of the fetus during the first Diagnosis half of gestation (keratinization of skin at - Via ultrasound 22-25W) 3. Baby's urination (first starts at 8-11W Management and is major source of production. it is Other Investigation recycled when baby swallows it) 1) intrauterine instillation of dye to 4. Secretion of large volumes of fluid each diagnose PROM [confirm if the dye is day by the fetal lungs after second half of found in the vagina]-not practically done gestation (2nd source) 2) Furosemide test to visualize fetal B) Increase amniotic fluid from 8-43W bladder gestation linearly until 32W (700-800 mL- Both test not practically done constant until term) Others -C) After 40W, declines at rate 8% per 1) Amnioinfusion of 200 ml Normal saline week until 300ml at 42W (not practically done) 2) Maternal rehydration.(controversial) Causes 3) frequent fetal biophysical testing and 1) PROM or PPROM appropriately timed delivery 2) fetal urinary tract anatomy (renal and 4) Rule out fetal structural and ureter most common) chromosomal anomalies 3) Uteroplacental insufficiency 5) Earlier delivery in baby incompatible 4) Pulmonary hypoplasia with life. Complication Notes: risk of fetal asphyxia and death is high in IUGR 20
  28. 28. Long Case Examination for Phase III Medical Students University Science Malaysia 35 years old Malay lady, G3P2 at 26W POA moderate (AFI 30.1-35) and severe (AFI >35) was admitted for further management after she [Naser Omar et al] persistently worried about her current pregnancy because her belly was too big Causes of polyhydramnios compared to previous pregnancy 1) 60% is idiopathic Questions 2) Maternal causes 1) What is polyhydramnios and how do a) Gestational diabetes mellitus you grade them? 3) placental abnormalities (placental 2) What is the causes of polyhydramnios abruption, placenta accreta) 3) How do you manage this patient? 4) Fetal factor a) congenital anomalies ( anencephaly, Answer hydrocephalus, spina bifida, tracheoesophageal fistula, duodenal atresia, hydrops fetalis and many more) b) Multiple pregnancy 95th percentile c) chromosomal abnormalities such as Down's syndrome and Edwards Mean value syndrome 5) Skeletal dysplasia and syndrome. 5th percentile 6) others like chorioangioma of the placenta Management to this patient Source: 6-overview 1) Reassure the mother 2) Excludes the causes of polyhydramnios a) This patient should be offered to do MOGTT Polyhydramnios b) Ultrasound examination and proceed to Doppler and full scan if Polyhydramnios may be defined as an amniotic necessary fluid index above the 95th centile for gestational 3) Assessment of fetal well being age [Moore& Cayle]. a) Access while doing ultrasound + CTG. Previously, it is defined when the deepest 4) Treat the underlying causes vertical pool is more than 8 cm, but currently 5) Treat the hydramnios based on measurement on 4 quadrant > 25. a) Mild & Moderate: Indomethacin or (Based on ultrasound) sulindac b) Severe: Amnioreduction It complicates approximately 0.4-3.5 % of 6) Corticosteroid if anticipating pre term pregnancies and it can be divided into three delivery. groups: mild (amniotic fluid index 25-30), 21
  29. 29. Long Case Examination for Phase III Medical Students University Science Malaysia Case: 32/M/F, G2P1, decreased fetal movement Tocolysis has also been advocated for the management of intrapartum fetal distress, Question impaired fetal growth, pre term labour and to 1) H(x) and P(e) facilitate external cephalic version at term 2) Management of decrease fetal movement MgSO4 3) Use of tocolytic (function/type) 1. works as membrane stabilizer, 4) Fetal kick chart (indication and competitive inhibition of Ca; therapeutic component) at 4-7 mEq/L 2. SE: flushing, nausea, lethargy, pulm Reduce fetal movement? Baby goes through edema normal sleep cycle. As long as baby moves 3. Toxicity: cardiac arrest (tx: calcium every couple of hour, then it’s fine. gluconate), slurred speech, loss of patellar reflex (@ 7 -10), resp problems History (@15-17), flushed/warm (@9-12), Exclude Abruptio placenta muscle paralysis (@15-17), hypotonia -Decreased fetal movement, abdominal pain, (@10-12) bleeding after 22w -shocks, tender uterus, fetal distress/absent fetal Nifedipine heart sound 1) calcium channel blocker: 10 mg q 6 h; se: nausea and flushing Exclude fetal distress -Decreased/absent fetal movement, abnormal B2 agonist fetal heart rate 1. ritodrine/ terbutaline - Thick meconium stained fluid 2. dec. uterine stimulation; may cause DKA in hyperglycemia, pulm edema, Other history n/v, palpitations (avoid with h/o cardiac - What did patient do? Working mother seems to disease or if vaginal bleeding) 0.25 mg perceive less fetal movement. sq q 20-30 min x 3 then 5 mg q 4 po - Any history of trauma? - Elicit maternal medical illness Indomethacin/prostaglandin synthesis inhibitor 1. 50 mg po/100 mg pr SE: premature PE and investigation closure of PDA in an 1) Auscultation of fetal heart rate and hour,oligohydramnios confirmation with ultrasound. 2) CTG monitoring for ½ hour. Fetal kick chart 3) Umbilical artery Doppler ultrasound in 1) Screening by caregivers to alert them about high risk cases. their fetal condition which might compromised. This will aid early intervention to reduce Tocolysis perinatal mortality. The administration of medications to stop 2) Routine or done in women with increased risk uterine contractions during premature labor of complication in baby 3) Decision of management shouldn’t be made based on fetal kick chart. 22
  30. 30. Long Case Examination for Phase III Medical Students University Science Malaysia Case: Reduce fetal movement about decrease in fetal movement as compared with multi para. Question 2) Identification of maternal risk factor a) Regarding traditional medicine, how to which might contribute to perinatal advice patient mortality. b) Line of thinking to get diagnosis - age, smoking, overweight/obesity, c) Management. previous stillbirth or neonatal death Traditional medicine 3) What actually the causes of reduce or A doctor has no right to order patient to stop absent fetal movement? taking traditional medicine. However, lack of a) Placenta Abruptio study and information between interaction of b) Intra uterine growth restriction traditional medicine and modern medicine may c) Syndromic baby cause few un-expected side effect. d) Placenta insufficiency. e) Mother’s perception. Furthermore, few manufacturers being dishonest by adding some ‘hidden’ ingredient inside their 4) Investigation to support diagnosis product which may cause serious side effect in reaction to certain drugs. Therefore, as a doctor Management we can advise patient to 1. Choose either taking only traditional or 1) Take full history and elicit risk factor modern medicine or not combining that might compromise fetal condition. them. 2) Fetal well being assessment 2. Suggest to them to stop traditional (recommended by NICE guideline) medicine while pregnant because afraid CTG, Ultrasound. of unexpected side effect with 3) Fetal kick chart (not recommended by prescribed medicine. NICE and others as it will cause more 3. Avoid herbal base traditional medicine. anxiety to the mother.) however, some 4. Use alternative traditional medicine that says it is better than doing nothing. known scientifically not harmful like 4) If CTG or ultrasound shows fetal honey. compromise, admit patient to the wards and do serial monitoring of fetal Line of thinking to get the diagnosis condition 1) Is mother really paying full attention 5) Re assures the mother. about fetal movement 6) Patient can be safely discharge after a) Fetal movement is rather perception fetal monitoring shows normal result in of woman. Busy mother tends to three consecutive days. Discharge feel less fetal movement. patient with b) Working in busy environment may a) TCA at antenatal wards weekly or cause less perception of fetal twice weekly movement. b) To come again to ward if reduce c) A woman which is first time fetal movement pregnant may become too anxious c) Instruction to use fetal kick chart. about fetal condition and notice 23