CASE WRITE UP

OBSTETRICS AND GYNAECOLOGY

POSTING
Obstetric case

NAME : SANGARI A/P SARKUNA SINGAM

STUDENT ID : 1001439079
BATCH: 2012/17
Patient's Details

Name : Ros Amira Binti Mohd Yusoff

Age : 26 years old

Registration number : HSNZ 00617860

I.C. : 891031115460

Address : Cheneh ( near the hospital)

Gravida : 1

Parity : 0

LMP: 2/4/2014

EDD: 9/1/2015

POA : 40 weeks and 3 days

Race : Malay

Religion: Islam

Marital status : Married

Occupation : Civil Engineer

Date of admission : 9/1/2015

Date of clerking : 11/1/2015

HISTORY

Chief Complaint :

Pn Ros Amira, 26 year old, malay lady, a primigravida at 40 weeks and 3 days gestation got
referred from Klinik Kemaman due to post date for induction of labour.

History of current pregnancy :

This was not a planned pregnancy and the patient first suspected pregnancy when she missed
her period for 4 weeks and then took a urine pregnancy test by herself and it came out
positive although she could not remember when she did the test. She then went to klinik
Kemaman for her 1st antenatal check up at the 9th week of gestation. A blood test was done
and it was then that she got to know that she was HIV positive and her VDRL test result was
reactive. Her blood group is O positive and her hemoglobin level were in normal range. Her
urine test showed no presence of glucose or protein. Her husband after getting to know that
she was HIV positive, did a rapid HIV screening test and the result was also positive. On
further questioning, the patient revealed that she had been in a sexual relationship with her ex
boyfriend while she was married to her husband whose only sexual encounter was with her.
She was started on anti-retroviral therapy during her second trimester and was asked to come
for check up once a month. She attended all her follow up visits. During her subsequent
antenatal check up, ultrasound was done and no abnormalities were detected and the scan
showed a singleton fetus and fetal heart was present. Her viral load were continuously
monitored and it did not show any rapid increase. Her blood pressure were all under normal
range although she could not remember the exact value and her urine test was free of glucose
and protein. She did complaint of having recurrent urinary tract infection several times during
the course of her pregnancy and was given medications for it from the Klinik.

She first felt quickening at 18th week of gestation but could not remember the exact date.
Fetal movement is adequate and she feels more than 10 kicks in a 12 hour period. Patient has
experienced common pregnancy symptoms like urine frequency and ankle edema but no
vomiting and backache. She got 2 doses of immunization for tetanus on separate dates last
year and also for rubella when she was in high school.

Systemic Review

1) General: absence of fever, no loss of appetite and no loss of weight

2) Cardiovascular system: Absence chest pain, palpitations, orthopnea, and paroxysmal
nocturnal dyspnea
3) Respiratory system: absence of shortness of breath, coryzal symptoms and cough
4) Nervous system: absence of headache, syncopal attacks, blurring of vision, weakness
or numbness of the extremities, and no increased tone of muscles
5) Urinary system: absence of polyuria, nocturia, dysuria, hesitancy, poor stream of
urine, unsatisfactory voiding and no increase in frequency
6) Gastrointestinal system: presence of nausea, absence of diarrhea, constipation,
vomiting, changes in character of the stool
7) Musculoskeletal system: absence of fatigue, and no bone and joint pain

Menstrual History

She achieved menarche at the age of 13 years old. Her cycle duration is from 28 to 30 days
and each time it will last for 7 days. During menstruation, she uses 2 to 3 pads per day and it
is not a heavy flow.

Past Obstetric History

Patient got married at the age of 23 in 2012. This is her first marriage and is not a
consanguineous marriage. She has never been pregnant before and this is her first time.
Past Gynaecological History

The patient has no previous history of dysmenorrhea, heavy menstrual bleeding,

intermenstrual bleed, postcoital bleeding or dyspareunia. She has never done a pap smear
before.

Past Medical and Surgical History

She was currently diagnosed to be HIV positive during her first antenatal check up and had
recurrent urinary tract infection several times. Other than that, patient has no history of other
chronic illness such as hypertension, diabetes, hepatitis B, TB, autoimmune disease, renal
disease, heart disease and asthma. She has never undergone any kind of surgery. This is her
second hospitalization and her first was last month due to false labour.

Drug History

She was on hematinics and vitamins given by the doctor in the Klinik Kesihatan which
included vitamin C, vitamin B complex,iron supplements and folic Acid. She is also on
antiretroviral therapy for her HIV infection. She was given a shot of Zidovudine
intravenously to prevent perinatal transmission. Other than that, she does not take any over
the counter drugs, vitamins or traditional remedies. She is not allergic to any drugs. Patient
also claims that she never used any kind contraception.

Family History:

The patient's mother is a known case of hypertension and has given birth to twins. Her
husband is also born twins. Other than that, there is no family history of congenital
abnormality, multiple pregnancy or malignancy.

Social History:

Her education level is until diploma. This is her first marriage but apparently not her only
sexual relationship. Her husband is 32 years old and working offshore. Both their income is
used to sustain their cost of living. Both she and her husband does not smoke, take alcohol or
use intravenous drugs. She eats a normal balanced diet and has no food allergy. She lives in a
village house with all the necessary facilities.

Physical Examination

General Examination

Patient was lying comfortably on the bed propped up with one pillow. Patient was alert and
conscious and well orientated to time, place and person. She was not cyanosed, in pain or
respiratory distress. She appears to have good hydration and nutritional status. There were no
drip lines, branula or any medical apparatus attached to her.

Vital Signs
Blood pressure : 120/70 mmHg

Pulse: 92 beats per minute(normal volume and regular rhythm, collapsing pulse not present)

Respiratory rate : 21 breaths per minute

Body Temperature : 37c

Pain Score : 1 out of 10.

On examination of the hands, her hands were warm and dry. There was no pallor of the nail
beds, peripheral cyanosis, clubbing, koilonychia or palmar erythema. Capillary refill time
was less than 2 seconds. On examination of the face, her conjunctiva was pink and her sclera
was white. No xanthelasma, and no corneal arcus can be observed. . The mucous membrane
of the oral cavity was moist and no central cyanosis, glossitis, angular stomatitis and oral
thrust. As for the examination of the neck, there were no raised JVP or swelling of the thyroid
and lymph nodes that could be felt on palpation. On examination of the lower limbs, there
was mild pitting edema at her legs, calf tenderness was not present and no dilated veins can
be seen.

On cardiovascular examination, first and second heart sounds (S1 and S2) were heard, apex is
located at the left 5th ICS, midclavicular line, no murmurs or other abnormalities detected. No
heaving, thrills or thrusting.
For respiratory examination, patient had the normal vesicular breath sounds, air entry was
equal on both sides with no added sounds such as crackles and no sign of pleuaral effusion.
Upon percussion there was no difference on both signs. Vocal fremitus and vocal resonance
are equal on both sides.

Upon asking if she had any breast tenderness, lumps, nipple discharge or any relating to her
breasts, she denied of having any.

Abdominal examination

Upon inspection, the abdomen is distended by a gravid uterus evidenced by the presence of
linea nigra and striae gravidarum. The umbilicus is centrally located and inverted. The
abdomen moves symmetrically with respiration and there are no dilated veins or surgical scar
evident. There were no visible fetal movement as well. On light palpation, the abdomen was
soft and non-tender. The clinical fundal height corresponds to 34 weeks of gestation and the
symphysiofundal height was 43 cm. On palpating the fetal parts, there is a single fetus in
longitudinal lie with cephalic presentation. The fetal back was facing the maternal's right
side. The head is 3/5 palpable and thus not engaged. The liquor volume is adequate. I
estimate the fetal weight to be around 3. 2 to 3.4 kg. On auscultation using a pinard
stethoscope, the fetal heart beat was 120bpm. Uterine contractions were not felt.
Provisional Diagnosis

Pn. Ros Amira, 26 year old malay lady, primigravida, a HIV positive came in due to post date
for induction of labour and possible emergency caesarean section .

Investigations

Maternal :

1) Full blood count : To detect increases in WBC which indicates infection and also to
monitor the hemoglobin level.
2) C-Reactive protein : Can indicate infection.
3) High and low vaginal swab- To rule out any urinary tract infection.
4) Enzyme-linked immunosorbent assay (ELISA) : which looks for the presence of antibodies
against HIV.
5) Western blot to confirm the diagnosis.
6) Determine maternal plasma viral load and CD4+ T-cell count
7) Lipid profile- To determine cholesterol level of the patient.
8) Tuberculosis skin testing
9) Hepatitis B testing
10) Opportunistic infection assessment- To determine the need for prophylactic drugs.

Fetal :

1) Ultrasound: To determine the fetal biophysical profile and detect any abnormalities.
2) CTG monitoring : to identify if the fetus is under any distress (presence of decelerations)
complicated by the condition.

Management

Maternal :

- Pre- pregnancy counseling should be given to the couples who are planning to have a baby
regarding the risk and safer options that are available to prevent mother-to-child transmission.
-Counseling should be given to every HIV positive pregnant women regarding optimizing
their health status. This includes encouraging compliance to medication regimens, cessation
of smoking, and updating immunizations.
- Anti-retroviral therapy should be given antenatally and intrapartum to the mother. It usually
commenced in the second trimester and is discontinued soon after delivery
- An elective vaginal delivery is an option for women taking triple drug antiretroviral therapy
who have viral load below 50 copies/mL at the time of delivery.
-A caesarean section is recommended if a woman is taking azidothymine monotherapy or if
the viral load is above 50 copies/mL at the time of delivery.
Fetal :
-The cord is clamped as early as possible and the bay is bathed immediately after the birth.
- The mother is advised not to breastfeed her baby as it increases the risk of mother-to-child
transmission.
- The baby will be treated with antiretroviral therapy from birth. Zidovudine is usually
administered orally to the neonate for 4-6 weeks.
- If the mother started antiretroviral therapy late in pregnancy, highly active antiretroviral
therapy (HAART) is considered.
- PCR is carried out to diagnose infant infection.
- Advice regarding protection for partners and contraception to avoid further pregnancy.
- Partner notification.