Dr.

Hakimah
[Pick the date]

YEAR 5 – FACULTY OF MEDICINE

OBSTETRICS AND
GYNAECOLOGY POSTING

NAME :
 PATIENT INITIALS: MS RANI SEX: FEMALE R/N: 00353955 WARD: wing A

ETHNICITY: INDIAN AGE: 35Y/O

MARITAL STATUS: MARRIED DATE OF ADMISSION:

OCCUPATION:housewife DATE OF DISCHARGE:

ADDRESS: kamunting DATE OF CLERKING: 12 july 2020

LMP – 13 october 2019

EXPECTED DATE OF DELIVERY – 20 july 2020 , G2P1

GESTATION – 38 weeks 6 days

1. PRESENTING COMPAINT(S)

Madam Rani, 35 year-old , gravida 2 para 1 at 38 weeks + 6 days period of

amenorrhoea with underlying gestational diabetes meelitus was admitted to Hospital
Taiping for elective lower segment caesarean section due to macrosomic fetus.

2. HISTORY OF PRESENTING COMPLAINT

At 21 weeks period of gestation during her booking, she was diagnosed to have
gestational diabetes mellitus after being tested for modified glucose tolerance test. She
was only advised to control her diet and was not prescribed on any medications.

However, a transabdominal ultrasound done at 28 weeks POA revealed macrosomic

baby with estimated fetal weight of 3.4kg. Unfortunately, she defauted her follow up at
Hospital taiping until 38 weeks POA after a significant increase of estimated fetal weight to
4.0kg based on the transabdominal ultrasound scan during her follow-up. After physical
examination and transabdominal ultrasound scan was done in the hospital, she was
indicated for elective lower segment caesarean section and was given the date which is on
the 13 july 2020.

There were no signs of labour like painful uterine contractions, leaking liquor, or
‘show’. Fetal movement was good and the CTG was reactive

3. ANTENATAL HISTORY

Madam RANI was apparently well until 21 weeks period of gestation, when she was
diagnosed of having gestational diabetes mellitus. This is her second pregnancy after 15
years of no pregnancy. She is currently at 38 weeks and 6 days of gestation. This pregnancy
is unexpected but wanted. She only suspected that she was pregnant after she experienced

2
 some episodes of mild pain on her breasts . She also noticed some fetal movements which is
the quickening at the same point of time. She did not have any history of morning sickness.

She missed her period for 8 weeks and did a self urine pregnancy test brought from
the pharmacy and it came out positive. Subsequently, she went to a private clinic to
reconfirm and the result was consistent. Early dating ultrasound scan was also done and
confirmed her pregnancy at 10 weeks period of gestation. This confirms a intrauterine
pregnancy.

At 12 weeks period of gestation, she went to Klinik Komuniti Shah Alam for booking.
Routine examination and screening was done. All were all within normal range and non-
reactive, respectively. Ultrasound was done . Apart from doing the routine examination,at
20 weeks , Madam RaNI was also screened for Gestational Diabetes Mellitus by testing the
modified glucose tolerance test because she has first-degree-relative history of diabetes
mellitus and she is 35 years old. And she had BMI of 29. Results were as follows:

Fasting 5.2 mmol/L

2-hour postpandrial 8.6 mmol/L

She was diagnosed of having gestational diabetes mellitus and was advised on diet
control. No hypoglycaemic medications were prescribed. Her blood sugar profile was
controlled throughout the pregnancy. Her latest blood sugar profile (BSP) on admission was
normal;

Fasting 4.2 mmol/L

2-hour postpandrial 4.9 mmol/L

Post lunch 5.1 mmol/L

Post dinner 3.9 mmol/L

Despite her controlled blood sugar profile, a transabdominal ultrasound done at 28

weeks period of gestation revealed macrosomic baby with estimated fetal weight of 3. 4kg.
Unfortunately, she defaulted her follow up due to transport related issues and there was
significant increase of estimated fetal weight to 4.0kg based on the transabdominal
ultrasound scan during her follow-up. After physical examination and transabdominal
ultrasound scan was done in the hospital, she was indicated for elective lower segment
caesarean section and was given the date which is on the 13 july 2020. Her weight during
the examination was 80kg, height is 166 cm. She experienced backaches and noticed
increased frequency in urination.For infective screening (HIV.VDRL) was not reactive.her
blood group is A+ and her husband blood group is also A+ .she had total of 6 scans
throughout her pregnancy.Anti-tetanus toxoid was given during quickening 24 weeks.
Patient had gained 8 kg throughout her pregnancy.

4. PAST OBSTETRIC HISTORY

3
2015 5 years old female Spontanous 3.50 kg at term
vaginal delivery

This is her second pregnancy. She has 1 daughter aged 5 years old who was delivered by full
term spontaneous vaginal delivery with no abnormal labor or instrumentation, weighing of
3.5kg.She breastfed her daughter for two whole years. Her daughter is now alive and well.

There was no complication thrught her pregnancy, both antenatal and post natal was
ueventfull.

5. CONTRACEPTIVE HISTORY

She denied usage of any contraceptive pills or other method.

6. PAST GYNAECOLOGICAL HISTORY

.She attained her menarche at age of 12 years old, she has dysmenorrhea but does not
require medication for the pain.She had a history of subfertility after her first child was
born. She was obese at that time weighing of 98kg but was not associated with hirsutism.
She went to Hospital Ipoh to check about her subfertility problem. Ultrasound scan was
done and revealed no significant abnormalities. She was told to have hormonal imbalance
and was advised to reduce her body weight. She had pap smear being done in 2010 and
2018 and there were no abnormalities detected.No history of dyspareunia or postcoital
bleeding.Patient states she is sexually active and staying with her husband.

7. PAST MEDICAL & SURGICAL HISTORY

She only sought treatment for her subfertility problem. No other relevant medical history.

8. DRUG HISTORY

She’s not on any medications before. She was only on obimin as prescribed by the
doctor during the pregnancy

9. ALLERGIES

She has no known allergies to food, medication or vaccination.

10. FAMILY HISTORY

4
 Both her parents are healthy. Her mother is now 50 years old, having diabetes mellitus
type 2 whereas her father has no known chronic illnesses. She is the first child out of 4, all
her siblings are healthy.

No family history of hypertension, heart disease, breast tumor, endometrial, cervical,

or any other tumors related to female reproductive tract.

She has second-degree relative history of twins. No family history of congenital

abnormalities like Down Syndrome.

11. SOCIAL HISTORY

-Occupation

She is a housewife.

-Dietary History

She controls her diet by avoiding excessive food intake and high-cholesterol diet to
reduce her body weight as advised by the doctor.

-Smoking, alcohol and illicit drugs usage

She does not smoke cigarette, drink alcohol intake nor take illicit drugs.

-Partner

Her husband is 41 years old, works as a technician. Combined together, their monthly
income is about RM4000. Her husband smokes about one pack per day since more
than 10 years ago, does not drink alcohol nor take illicit drugs.

-Home circumstance

Madam RNI and her husband currently stay in their own home with adequate
amenities.

12. REVIEW OF SYSTEMS

General No headache, no seizure, fever, no weight loss

CVS No chest pain, no palpitation, no pedal edema

Respiratory No dyspnea

Urinary Polyuria, no dysuria

Polyphagia, no constipation, no diarrhea, no abdominal pain, no nausea,

GIT
no vomiting, no epigastric pain

Reproductive No bleeding, no foul-smelling discharge, no itchiness

Backache, no other joint pain or weaknesses, had pedal edema before,

MSK
now not anymore

CNS No headache, no blurred vission, no numbness

5
 Endocrine No temperature intolerance, polydipsia

13. PHYSICAL EXAMINATION

15.1 Height :166 Weight: 80kg BMI: -24

15.2 General condition

Miss RANI was lying flat in supine position, supported with one pillow. She was
conscious, alert, cooperative, and responsive to time, place and person. There was no
puffiness in her face. Her palm was warm, no pallor, no excessive sweating, no clubbing, no
fungal infection between the fingers. No pedal edema. No fungal infection in the toes.

15.3 Vital Signs

a. Blood Pressure : 127/71mmHg

b. Pulse : 91 bpm

c. Respiratory Rate : 18 breaths / min

d. Temperature : 37.3°C

Impression : Normotensive, slightly tachycardia, normal body temperature

15.4 Head & Neck

Conjuctiva : Not pale

Sclera : White and no sign of jaundice

Mouth : Lips were moist, no oral candidiasis

Thyroid : Not enlarged

Lymph node : Not palpable

Abdominal Examination

a. Inspection : On examination, the abdomen was distended by gravid uterus.

There was striae gravidarum and linea nigra seen. The umbilicus was centrally

6
 located and inverted. There was no scar noted. There were superficial dilated
veins. Fetal movement was seen.

b. Light palpation : The abdomen was soft and non-tender. Uterus not irrtable.
Liver, spleen and kidney were not palpable.

c. Leopold Maneuver : clinical fundal height was 42 cm,Symphysio-fundal height

was 42 weeks size, larger than date. There is a singleton fetus was in
longitudinal lie. The fetal back lies on maternal left side. Cephalic presentation
which is 3/5th palpable.Liver, spleen and kidney were not palpable.Fluid thrill is
was positive.

d. Auscultation : Fetal heart sound was heard by using Pinnard stethoscope.

Impression : Uterus larger than date

Breast

Both breasts were symmetrical and nipples were normally everted. Nipples were
hyperpigmented. No fungal infection beneath the breast, no masses, no retraction of
the nipples, no leakage and other abnormalities were noted.

Impression: Normal

Cardiovascular System

a. Inspection : The chest was symmetrical and normal in shape. There was no
scar, no precordial bulging, no visible apex beat and no prominent dilated veins.

b. Palpation : The apex beat was located in the 5 th intercostal space, at the
midclavicular line. There was no thrill and heave. The peripheral pulses were
present with normal rhythm and volume.

c. Auscultation : The first and second heart sounds were normal. There were no
murmurs heard. Increased heart rate was noted.

Impression : Physiologically normal

13.7 Respiratory System

a. Inspection : The chest moved symmetrically with respiration with no

deformity seen. There was no sign of respiratory distress. There were no scar,
prominent dilated.

b. Palpation : The chest expansion and vocal fremitus were equal anteriorly
and posteriorly at all three zones of the lung.

c. Percussion : The lung was resonant bilaterally, anteriorly and posteriorly.

There were normal liver and cardiac dullness.

d. Auscultation :  There were vesicular breath sound anteriorly and posteriorly at

all three zones. No added sounds heard

7
 Impression : Lungs clear

Pelvic Examination

Not done

Central Nervous System

a. Mental status : She was alert and conscious, orientated to time, place and
person. Her memory function was intact. She was not in a state of confusion.
b. Cranial nerves : All the 12 cranial nerves were intact.
c. Motor system : No abnormalities noted.
d. Muscle Tone : No abnormalities noted.
e. Muscle Power : Normal
f. Cerebellar sign : There was no cerebellar sign present and her gait was normal.
g. Sensory system : No abnormalities noted. Her sensation toward pain, light touch,
vibration, temperature and propioception were intact and equal bilaterally.
h. Reflexes : All normal

Hyperpigmented
areolar

Distended abdomen,
size of 42 weeks
gravid uterus

Linea nigra

Striae gravidarum

14. SUMMARY

8
 Madam RNI, 35 year-old Malay, gravida 2 para 1 at 38 weeks + 6 days period of gestation
was admitted to Hospital Sungai Buloh and scheduled for elective lower segment caesarean
section for delivery of macrosomic fetus due to gestational diabetes mellitus

15. DIAGNOSIS

14.1 Provisional Diagnosis

Polyhydraminos with underlying gestation diabetes mellitus

Points to support: The modified glucose tolerance test revealed 2-hour

postprandial glucose level of 8.6mmol/L. Since the glucose intolerance was first
discovered at 21 weeks period of gestation, and the patient was previously non-
diabetic.

14.2 Differential Diagnosis

16. INVESTIGATIONS

Investigations upon admission to

1. Transabdominal ultrasound scan

Estimated birth weight – 4.0-4.2kg - Macrosomia

Amniotic Fluid Index was 22 – polyhydramnios

2. Blood Sugar Profile

Fasting 4.2 mmol/L

2-hour postpandrial 4.9 mmol/L

Post lunch 5.1 mmol/L

Post dinner 3.9 mmol/L

Blood sugar profile was well-controlled

3. Cardiotocograph

Results: Reactive.

Interpretation: Fetal not in distress.

4. Full Blood Count on 12 july 2020– was ordered for pre-op assessment

9
 Blood Group: AB+

Event Results Ref. range Status

RBC 4.61 4.5 – 6.5 x 109/L Normal

WBC 9.09 4.0 – 11.0  x 109/L Normal

Hemoglobin 11.4 13.5 – 18.0 g/dL Low

Hematocrit 34.6 40.0 – 54.0 % Low

Mean Cell Volume 75.2 76.0 – 96.0 fl Low

Mean Cell 32.8 31.0 – 40.0 (pg/cell) Normal

Hemoglobin
Concentration

Red cell 15.1 11.5-14.5 Abnormal

distribution width

Platelet count 300 150 – 450  x 109/L Normal

Automated differentials:

a) % of Neutrophil: 65.4% (40.0-80.0)

b) % of Lymphocyte: 26.4% (20.0-40.0)

c) % of Monocyte: 3.5% (2.0-10.0)

d) % of Eosinophil: 2.6% (1.0-6.0)

e) % of Basophil: 0.6% (0.0-2.0)

Results: Hemoglobin, hematocrit, mean cell volume were low.

Interpretation: Physiological hemodilution effect occurring in pregnancy.

Investigation post-operation

1. Full Blood Count on 14 july 2020

Event Result Status

WBC 13.63 (4.0 – 11.0  x 109/L) Abnormal

RBC 4.14 (4.5 – 6.5 x 109/L) Normal

Hemoglobin 10.4 (12.0-15.0 g/dl) Abnormal

Hematocrit 31.2 (37.0-47.0%) Abnormal

MCV 75.4 (76.0 – 96.0 fl) Abnormal

MCHC 33.4 (31.0 – 40.0 pg/cell) Normal

10
 Red cell distribution width
Interpretation: 15.1 (11.5-14.5) Abnormal

Platelet
White 273x10.e3/uL
blood cell count was elevated post-operation (110-450)
probably Normal
in response to medication.

Hemoglobin, hematocrit and MCV were reduced and red cell distribution width was raised-
probably due to the blood loss during the operation and uterine atony causing postpartum
hemorrhage.

17. PROGRESS DURING HOSPITALIZATION

DAY 1 post operation (13 july 2010)

The operation was uneventful. Baby boy with birth weight of 4.20kg was delivered at
1640H, with Apgar score 9 in 1 min and 10 in 10 mins. Estimated blood loss was 1000ml.
Liquor was clear.

After the operation, she has been keeping well,

BP – 108/70mmHg

Pulse Rate – 71/min, regular

spO2 – 100%

She was pale but alert, complaining of nausea, no vomiting, no shortness of breath or
palpitation. She was on strict pad chart. Since the operation, she has been using 3 pads
full-soaked

On abdomen examination, the uterus was not well-contracted at 22-week size of a gravid
uterus

She given IV oxytocin 40 units over 6 hours

DAY 3 post operation (15 july 2020)

Uterus was soft, non-tender, well-contracted at 20 weeks size of a gravid uterus, no active
bleeding at the site of operation. No longer has per vaginal bleeding.

She was due for discharge and was told to repeat modified glucose tolerance test 6 weeks
later.

18. DISCUSSIONS

Madam RANI has a firfamily history of DM so she was indicated for Modified Glucose Tolerance Test
(MGTT) as she was considered as a high risk groups.

There are other indications for MGTT which are;

1. Two or more episodes of glycosuria on routine testing

2. Diabetes in a 1st degree relative

3. Maternal weight greater than 85 kg

11
4. Maternal age greater than 30 yrs old

5. Previous hx of Gestational Diabetes Mellitus

6. Previous baby of 4.0 kg or more (macrosomia)

7. Previous unexplained perinatal death

8. Previous congenital anomelies

9. Polyhydramnions

NFollow Up of Women Who Have Had Gestational Diabetes Mellitus

Follow up is important as up to 50% of women with Gestational Diabetes Mellitus may develop
overt diabetes; mainly Type II.

At the follow up visits, we should encourage her to follow a diet which is appropriate for a diabetic.
She should also be advised to take these following measures;

1. Avoid becoming obese

2. Take regular exercises

3. Avoid cigarette smoking

4. checked annually for hypertension

These women have a 50% chance of developing Gestational Diabetes Mellitus in the future
pregnancy. If she intend to become pregnant again, testing for hyperglycemia before conception or
in early pregnancy is recommended.

Poor management in Klinik Komuniti

She has 15 years history of subfertility because

Iol?

Urine feme

Indication: Fetal, maternal, placental.

NAME OF STUDENT : HAKIMAH KHANI BINTI SUHAIMI

MATRIX NO : QIUP-201509-001712

DATE : 28 JULY 2020

COMMENTS ON WRITE-UP

............................................................................................................

12
............................................................................................................

............................................................................................................

............................................................................................................

............................................................................................................

............................................................................................................

............................................................................................................

GRADE : ..........................

NAME OF SUPERVISOR : DR GOH

13