HISTORY

PATIENT DETAILS

Name : Puan SNS

R/N : 9251-10
Age : 21 years old
Sex : Female
Race : Malay
Occupation : Housewife
Date of admission : 8 April 2010
Date of clerking : 9 April 2010
Gravida :3
Para :0+2
Last Normal Menstrual Period (LNMP) : Unsure of the Date
Revise Expected Date of Delivery (REDD) : 26 May 2010
Period of Amenorrhoea (POA) : 33 weeks
Known case of : 2 previous miscarriages

CHIEF COMPLAINT
Admitted from O&G clinic of HoSHAS due to abnormal reduced liquo with breech
presentation.

HISTORY OF PRESENT PREGNANCY

Puan SNS noticed her pregnancy when she missed her period for 2 weeks. Then, she
went to GP to confirm it. Urine pregnancy test was done and giving positive result.
The GP did a scan and revealed it was 2 weeks pregnancy. The patient claimed that
she was prescribed by the GP a medication to control the pregnancy to prevent
another miscarriage because she had 2 histories of miscarriages of unknown cause.
Puan SNS did her booking at 12th week of POA at KK Felda Sungai Kemahan. Her
booking height was 157 cm and weighing 52 kg. While her blood group was B
positive. Her other blood test and urine test revealed normal result. Then her next
follow up were uneventful.

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However, on 28th week of POA, she had sudden increase in weight gain for 2 kg in a
month. She was adviced to do a MGTT at KK and the result was 5.8 mmol/L for
fasting blood sugar and 8.1 mmol/L for postprandial reading. The doctor adviced her
to control her diet. Puan SNS claimed that she had done 3 BSP tests and the readings
were in the range of 4 – 5.6 mmol/L which were well controlled.
She also had 5 times scan along her antenatal check up and all the findings were
normal including the parameters and AFI. However in 33nd week of POG, she was
refered to HoSHAS clinic from KK due to low AFI. The specialist repeated the scan
and it showed small parameters in the range of 29 week to 34 week and AFI was 6.8.
The specialist noted it was a breech presentation and the left kidney of the fetus was
not seen. Then she was admitted to the ward. The next day, the specialist repeated the
scan to confirm the abnormalities of renal agenesis. However, both kidney and
bladder of the fetus can be seen and normal. The fetus presentation was footling
breech.
Currently she has no abdominal contraction, leaking liquor, no show and the fetal
movement was good. Puan SNS was not in labour.

PAST OBSTETRIC HISTORY

She had 2 miscarriages in early and middle of 2009. The pregnancies only persisted
for 1 month and 2 month respectively. However no Dilation and Curettage (D & C)
were done.

PAST GYNECOLOGICAL HISTORY

Puan RAW attained her menarche at the age of 12 years old.
Her menstrual cycle is 38 to 30 days cycle. Each cycle last for about 7 to 8 days with
normal flow and no blood clots noted.
No history of dysmenorrhoea and menorrhagia during the cycle and denied history of
intermenstual bleeding and pain.
She never had pap smear done.
Patient stop taking oral contraception 6 months before current pregnancy.

PAST MEDICAL AND SURGICAL HISTORY

Puan SNS has no significant past history.

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FAMILY HISTORY
Puan SNS husband’s side has a history of twin but no congenital abnormalities runs in
the family.
Her parents have no history of having Diabetes Mellitus and Hypertension.

SOCIAL HISTORY
This is her first marriage.
She is a housewife, lives in Felda Sungai Kemahan.
She is non smoker and not alcohol drinker.
Her husband is a businessman and a smoker. He takes 7 sticks per day but non alcohol
consumer.
They earn RM 800 of total household income.

DRUG AND ALLERGY HISTORY

There was no history of drug and food allergy.

CASE SUMMARY
Puan RAW, 21 years old Malay housewife, G3 P0 +2, currently at her 33 weeks of
period of amenorrhea with two previous miscarriages, was referred from KK FSK
diagnosed of having IUGR pregnancy associated with oligohydramnios and breech
presentation. There were no history of abdominal contraction, per vaginal bleed,
leaking liquor and show. The fetal movement was good and she was not in labour.

PHYSICAL EXAMINATION
General inspection
Patient was alert and conscious lying comfortably on flat bed. She was clinically pink.
No jaundice, cyanosis and pallor noted on the patient.

Vital signs
Pulse rate : 80 bpm, regular rhythm, good volume
Blood pressure : 110/70 mmHg
Respiratory rate : 20 breaths per minute
Temperature : 37 ° C, afebrile
Pain score :0

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Height : 157 cm
Weight : 61.5 kg
BMI : 25

General examination
Hand : Both hands are warm and dry. There are no palmar erythema, peripheral
cyanosis and koilonychia.
Head : No conjunctiva pallor and jaundice. The hydration status is good and no
central cyanosis
Neck : No thyroid enlargement noted. JVP is not raised and no palpable cervical
lymph nodes.
Leg : Pedal edema bilaterally till the level of lower half of the calf.

Cardiovascular examination
First and second heart sounds can be heard. No murmurs and additional heart sounds
can be heard.

Respiratory examination
Lungs are clear and vesicular breath sounds can be heard bilaterally.

Breast examination
Both breasts are a symmetrical. The nipples are in the same line. No palpable mass
and peau de orange appearance. The axillary lymph nodes are not palpable.

Abdominal examination
Inspection :
The abdomen is distended by gravid uterus as evidenced by linea nigra and striae
gravidarum. The umbilicus is centrally located and inverted. There is no surgical scar
noted.

Palpation :
Fundal height clinically shows 28 weeks period of gestation. Symphysio fundal height
is 28 cm which is not corresponding to the dates of 33 weeks. There is singleton fetus
lying obliquely. The fetal back is on the left side of the mother. It is breech

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presentation . The estimated fetal weight is around 2 – 2.4 kg. While the liquor is
reduced.

Auscultation : The fetal heart rate was 120 beats per minute.

Central Nervous System

No hyperreflexia noted.

SUMMARY OF PHYSICAL EXAMINATION

Puan SNS is grossly normal and no other signs of anemia, UTI and URTI. Her current
pregnancy is smaller than the gestational age.

PROBLEM LIST:
1. 2 previous miscarriages; no D&C done
2. IUGR; parameters 29- 34 weeks
3. Oligohyramnios; AFI : 6.8
4. Footling Breech presentation.

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INVESTIGATION
Ultrasound result
Parameters 13th week 22nd week 29th week 33rd week
Crown-rump 12w 6d - - -
length (5.6mm)
Biparietal 12w 6d 20w 4d 27w 4d 34w 5d
diameter (2.2mm) (4.8mm) (6.8mm) (86.2mm)
Head - 20w 3d 28w 0d 33w 3d
circumference (18.0mm) (26.1mm) (301.1mm)
Abdominal - 21w 1d 27w 6d 29w 3d
circumference (16.4mm) (23.6mm) (253.0mm)
Femur length 13w1d(1.1mm) - 29w 1d 30w 0d
(5.6mm) (54.2mm)
AFI - - - 6.81

Comments:
By comparing with previous scan readings, the parameters showed decrease in growth
diagnosed at 33 week (in bold) suggestive of IUGR and supported by
oligohydramnios state.

PLAN AND MANAGEMENT

The further plan for the patient decided by HoSHAS:

1) Monitor mother’s vital sign

2) To start on IM Dexamethasone 12mg 12 hours apart
3) To repeat scan in 1 week time to monitor the growth
4) If weekly AFI >9, the patient can be allowed discharge.
5) Strict Fetal Kick Chart
6) To give a date for elective lower segment caesarian section (ELSCS) in 36th
week due to footling breech and oligohydramnios.

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DISCUSSION

Puan SNS has recently been diagnosed of having IUGR fetus with
oligohydramnios at 33rd week of POG despite having uneventful antenatal check up.
IUGR by definition is intrauterine growth restriction where the weight for the specific
age is below than the 10th percentile. At the 33rd week of POG, the specialist of
HoSHAS noted that the parameters of the growth were in the range of 29- 34 week
especially the abdominal circumference (29w 3d). By comparing with other scan
result it is suggestive that the growth suddenly smaller than expected size. The type of
IUGR is more likely asymmetrical IUGR because it occurs early in third trimester and
head parameters of the fetus still in normal pattern 1.
Intrauterine growth restriction results when a problem or abnormality prevents
cells and tissues from growing or causes cells to decrease in size. This may occur
when the fetus does not receive the necessary nutrients and oxygen needed for growth
and development of organs and tissues, or because of infection. Although some babies
are small because of genetics (their parents are small), most IUGR is due to other
causes 2. Puan SNS is normotensive through out her pregnancy. She has no significant
medical illness (renal disease, diabetes, heart or respiratory disease). Furthermore, no
blood disorder noted in this patient. She is also non smoker neither alcohol consumer.
Therefore, the IUGR state is unlikely due to maternal cause.
However Puan SNS had 2 previous histories of miscarriages. Probably the
cause come from abnormalities in the placenta. Either the blood flow or the anatomy
of the placenta is the culprit for IUGR.
According to Proctor et al, small placental size and elevated alpha-fetoprotein
(AFP) can identify women with low maternal serum pregnancy-associated plasma
protein-A (PAPP-A) who are at high risk for IUGR, preterm delivery before 32
weeks' gestation, and stillbirth. The authors noted that screening studies for trisomy
21 have demonstrated that low PAPP-A at 11-13 weeks' gestation is associated with
stillbirth, IUGR, and preeclampsia in chromosomally normal fetuses but that the
strength of these associations is too weak to justify screening for these placental
insufficiency syndromes. They therefore evaluated placental size and uterine artery
Doppler imaging as second-stage screening tests for women (90 normal singleton
pregnancies) with low PAPP-A and found that the risks of IUGR, preterm delivery
before 32 weeks' gestation, and stillbirth were significantly associated with small

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placental size and elevated AFP but not with abnormal uterine artery Doppler indices
3
.
Melchiorre et al found that there is a significant relationship between first-
trimester uterine artery Doppler resistance indices (RI) and the subsequent delivery of
neonates who are small for gestational age (SGA) or have intrauterine growth
restriction (IUGR). They found, however, that the sensitivity of first-trimester uterine
artery Doppler is greater for SGA with preeclampsia than it is for IUGR alone and
noted that this difference could be the result of different underlying placental
abnormalities that are detected variably on first-trimester uterine artery Doppler
evaluation. In this study, the first-trimester uterine artery mean RI and prevalence of
bilateral notching were significantly higher in women who subsequently delivered
neonates with SGA than in women with normal pregnancies. The areas under the
receiver-operating characteristics curves for the prediction of SGA without
preeclampsia, IUGR, preterm IUGR, and SGA with preeclampsia were 0.602, 0.687,
0.776, and 0.708, respectively 4.
Kingdom et al demonstrated that maldevelopment of the villus tree in
pregnancies complicated by fetal growth restriction is associated with abnormal
uterine artery waveforms, which are Doppler findings indicating abnormal
uteroplacental blood flow 5. In pregnancies also complicated by absent end-diastolic
umbilical flow, the placental villi are elongated, and the capillary loops are uncoiled
and sparse. These findings are correlated with an increase in fetal-placental vascular
impedance and impair gas and nutrient exchange. An enhanced branching
angiogenesis represents an adaptive response to impaired uteroplacental blood flow.
Another problem Puan SNS had in her current pregnancy is oligohydramnios.

Oligohydramnios is a condition in which the amount of amniotic fluid is abnormally

small; when diagnosed in the second trimester of pregnancy, the fetal prognosis is

poor. The relationship between oligohydramnios and intrauterine growth retardation

(IUGR) is not clear; one possibility is that oligohydramnios occurs in association with

IUGR. It appears to develop during the third trimester of pregnancy, starting two

weeks after the first signs of IUGR are visible on ultrasound. Predictions of IUGR are

more accurate if oligohydramnios and small abdominal circumference are present;

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thus, if IUGR is suspected, determining the volume of amniotic fluid can enhance

diagnostic accuracy 6.

The specialist of HoSHAS also diagnosed the pregnancy is in footling breech

presentation. Footling breech where one or both legs are extended below the level of

the buttocks. The mode of delivery that is safer is by caesarean section. It had been

commonly believed that primigravidas with a breech presentation should have a

cesarean delivery, although no data (prospective or retrospective) support this view.

The only documented risk related to parity is cord prolapse, which is 2-fold higher in

parous women than in primigravid women 7.

In 1970, approximately 14% of breeches were delivered by cesarean delivery.

By 1986, that rate had increased to 86%. In 2003, based on data from the National

Center for Health Statistics, the rate of cesarean delivery for all breech presentations

was 87.2%. Most of the remaining breeches delivered vaginally were likely second

twins, fetal demises, and precipitous deliveries. However, the rise in cesarean

deliveries for breeches has not necessarily equated with an improvement in perinatal

outcome. Green et al compared the outcome for term breeches prior to 1975 (595

infants, 22% cesarean delivery rate for breeches) with those from 1978-1979 (164

infants, 94% cesarean delivery rate for breeches) 8.Despite the increase in rates of

cesarean delivery, the differences in rates of asphyxia, birth injury, and perinatal

deaths were not significant.

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REFERENCES

1. http://www.fetal.com/IUGR/whatisiugr.html
2. http://www.healthsystem.virginia.edu/UVAHealth/peds_hrpregnant/iugr.cfm
3. Proctor LK, Toal M, Keating S, Chitayat D, Okun N, Windrim RC, et
al. Placental size and the prediction of severe early-onset intrauterine growth
restriction in women with low pregnancy-associated plasma protein-
A. Ultrasound Obstet Gynecol. Sep 2009;34(3):274-82.
4. Melchiorre K, Leslie K, Prefumo F, Bhide A, Thilaganathan B. First-trimester
uterine artery Doppler indices in the prediction of small-for-gestational age
pregnancy and intrauterine growth restriction. Ultrasound Obstet
Gynecol. May 2009;33(5):524-9
5. Kingdom JC, Burrell SJ, Kaufmann P. Pathology and clinical implications of
abnormal umbilical artery Doppler waveforms. Ultrasound Obstet
Gynecol. Apr 1997;9(4):271-86
6. Lin, Chin-Chu, Sheikh, Zubie, Lopata, Randee. Publisher: Elsevier B.V.
Publication. Name: Obstetrics and Gynecology Subject: Health .ISSN:0029-
7844. Year: 1990
7. Richard Fischer, MD, Division Head, Maternal-Fetal Medicine, Professor,
Department of Obstetrics and Gynecology, Section of Maternal-Fetal
Medicine, Cooper University Hospital. Breech Presentation.
http://emedicine.medscape.com/article/262159-overview. Updated: Jul 7,
2009.
8. Green JE, McLean F, Smith LP, Usher R. Has an increased cesarean section
rate for term breech delivery reduced in incidence of birth asphyxia, trauma,
and death? Am J Obstet Gynecol. Mar 15 1982;142(6 Pt 1):643-8

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