FACULTY OF MEDICINE AND HEALTH SCIENCES

HM00 DOCTOR OF MEDICINE

YEAR 3 2020/2021
MM30409

OBSTETRICS & GYNAECOLOGY JUNIOR POSTING (OGJP)

CASE WRITE UP 1

NAME : SHRLEY CHEE SEE YIN

MATRIC NUMBER : BM18110019
GROUP : GROUP C
SUPERVISOR : DR DG MARSHITAH PG BAHARUDDIN
DATE OF SUBMISSION : 19TH DISEMBER 2020
Patient’s personal data

Name: Madam WM

Age: 32 years old

Adress: Kota Kinabalu

Marital status: Married

Occupation: Housewife

Gravida: 1

Parity: 0

Last menstrual period (LMP): 31st May 2020

Estimated date of delivery (EDD): 8th March 2021

Period of amenorrhea (POA): 20th weeks

Date of admission: 1st November 2020

Date of clerking: 1st November 2020

History

Chief Complaint

Madam WM, 32-year-old with a known case of Hepatitis B carrier come for routine antenatal
checkup at 20-week period of amenorrhea.

History of presenting pregnancy

Madam WM went for a check-up at Klinik Kesihatan Luyang after taking a self-urine pregnancy
test kit and the result showed as positive. She had missed her period for 2 months. She was
then diagnosed to be pregnant. The pregnancy is unexpected but wanted. She had her first
booking on the same day of the check-up. She had her weight measured, which was 51 kg at
the time. Her blood pressure was taken, 110/70mmHg and along with pulse rate
measurement,76 beats per minute. Urine sample was taken and it was normal as there was no
proteinuria, glucosuria and ketonuria. Her blood hemoglobin level was normal.

Infectious screening was done, and she had negative results for HIVand syphilis, but positive in
hepatitis B. It is later then that she informed she is a hepatitis B carrier. Scan was done on the
booking date and she was in 8 weeks of gestation. Her LMP was on 31 st May 2020 and her
estimated date of delivery is 8 th March 2021. It was a singleton pregnancy and the placenta was
normal. Ultrasound scan was done and no fetal abnormality or fetal growth restriction were
detected. The liquor was adequate.

No MGTT was done due to no family history of diabetes mellitus

Past obstetric history

Madam WM is a primigravida.

Menstrual history

Patient’s last menstrual period was 31 st May 2020. She had menarche at the age of 12-year-old
and since then having a normal menstrual period which is 1 time in every 4 weeks and last for 4
days in each menstrual period. She changed 3 pads per day and all were half soaked and there
was no blood clot. She denied on having dysmenorrhea, menorrhagia, intermenstrual bleeding,
dyspareunia and postcoital bleeding.

Past gynecological history

No previous gynecological disorder and disease.

Medical history

Patient is a hepatitis B carrier.

Surgical history

No previous surgical history.

Drug and allergic history

Patient did not take any medication, supplement or traditional remedies on daily basis. No
known drug and food allergy. No known food and drug allergic.

Family history

Patient’s parents also hepatitis B carriers. She is the only child in the family. No history of
malignancy in the family.

Social history

Patient was married at age of 29 years old. She lives with her husband. Her husband works as a
teacher and the income is stable. The family stay at single storey house with good water and
electrical supply. The distance of her house to the nearest health care provider is 10 minutes by
driving. Both the patient and her husband do not smoke and consume alcohol.

Summary of case:

Madam WM, 32-year-old woman, G1P0, currently on 20 weeks of amenorrhea, which LMP is on
31st May 2020 and her EDD will be on 8 th March 2021. She is a known case of Hepatitis B carrier
come for routine antenatal checkup.
Physical examination

General examination

Patient was lying comfortably in supine position on the bed, with the head supported with a
pillow. She was conscious, showing no sign of respiratory distress and not in pain.Upon
examination of the hands, there was no palmar pallor, palmar erythema and peripheral
cyanosis. The capillary filling time was less than 2 seconds. Pulse rate was 75 beats per minute,
regular rhythm and moderate volume. Blood pressure was 100/60 mmHg. Axillary body
temperature was 36.5 ˚C. Patient did not have conjunctiva pallor and yellow discoloration of
sclera. The tongue was moist and well-hydrated. No central cyanosis. No angular stomatitis and
glossitis. There was no thyroid and lymph node enlargement.

Systemic examination

On cardiovascular examination, the apex beat is located at the left fifth intercostal space at
midclavicular line. the first and second heart sound was heard with no murmur.

On respiratory examination, the respiratory rate was 16 breath per minute. No use of accessary
muscle and the lung expansion was bilaterally symmetrical on both sides of the lungs. On
auscultation, bilateral vesicular breath sound was heard all over the lung field with no
crepitation.

Breast examination was done with patient’s consent. There is no palpable mass on both sides of
the breast and axillary area. The nipples were symmetrical on both sides and everted. No nipple
discharge was noted. No nipple retraction or skin dimpling was noticed over the breast. No
ulceration on both breasts.

Abdominal examination

The abdomen moved with respiration. The abdomen was not distended. The umbilicus was
centrally located and inverted. No visible scar. No Cullen sign and Grey turner sign were
noticed. No dilated veins or visible pulsation was seen. The hernia orifices were intact. On
superficial palpation, the abdomen is soft and non-tender. The clinical fundal height was 20
weeks size of gestation, 1 finger under the umbilicus. On auscultation, bowel sound was heard.
Fetal heart sound was appreciated. It was strong, regular and asynchronous with maternal
pulse.

Summary
Patient is Madam WM, 32 years old, Gravida 1 Para 0 lady was currently at 20 weeks period of
amenorrhea. Known case of Hepatitis B carrier come for routine antenatal checkup at 20-week
POA. Fetal heart rate was strong, regular and asynchronous with maternal pulse.
Diagnosis

Provisional diagnosis:

- Normal uncomplicated pregnancy but with risk or vertical transmission of hepatitis b

Points:

- Known for case of hepatitis B carrier

- HBsAg is positive for more than 6 months.
- No sign of jaundice and inflammation of the liver.

Differential diagnosis

- Chronic hepatitis B.
- Infection of hepatitis B prior to pregnancy
Investigation

1. Full Blood Count (check if patient if anemic and confirm if there is infection)

RBC : 4.25 X 10 12 /L (normal)

WBC : 13.5 X 10 9 /L (normal)
Platelet : 240 g/dL (normal)
Comment: Patient is not anemic and not infected. Other parameters were normal.

2. Liver Function Test (check for liver damage)

Total bilirubin : 0.7 mg/dL (normal)

ALT : 18 U/L (normal)
AST : 25 U/L (normal)
ALP : 125 U/L (normal)
Comment: No indication of liver damage.

3. Quantitative measurement of HBV DNA (PCR)  to confirm the infection from previous
outcome test of HBsAg test as positive.

The result show less than 200 000 IU/ml.

Comment: Confirm of hepatitis B infection but as a hepatitis carrier and low risk of
progression to cirrhosis and HCC. No antiviral therapy needed.

4. Renal profile (to exclude secondary cause of hypertension because of renal damage and
to assess tubular dysfunction and renal failure)

Blood Urea Nitrogen : 4.2 mmol/L (normal)

Serum creatinine : 65 µmol/L (normal)
Serum uric acid : 290 µmol/L (normal)
Comment: No indication for renal damage, tubular dysfunction and renal failure.

5. Urinalysis (check for protein and glucose in urine)

Protein : Normal
Glucose : Normal
Comment: No indication to urinary tract infections, kidney disease and diabetes.
6. Ultrasound assessment (to monitor fetal complication)

Fetal size: No restricted growth

Amniotic fluid volume: adequate

7. Cardiotocography (CTG)

To monitor the heart rate and contraction of the uterus to detect abnormalities in the
pregnancy. The fetal heart rate is normal.
Management

Management of patient during prenatal care is mainly based on monitoring. First of all, steps to
prevent perinatal transmission of HBV infection require screening for HBV which had already
been done in the first prenatal visit. For HBV-positive mother like madam WM, management
during pregnancy includes HBV DNA viral load testing and referral to specialty care for
counseling and medical management of HBV infection.

Avoid intrapartum invasive procedures such as fetal electrocardiogram and scalp lactate if
possible, which may raise the risk of exposure of the child to percutaneous hepatitis B virus.
Furthermore, for the main purpose of reducing the risk of perinatal transmission of the hepatitis
B virus, a caesarean section is not recommended. When possible, spontaneous vaginal delivery
should be carried out.

Meanwhile, HBV vaccination and HBIG prophylaxis should be given within 12 hours of birth.
Plus, it should accompany with continuous series of dose by completing the vaccine series by
age 18 months, and serologic testing for infection and immunity at age 9 to 12 months of the
infant.

Apart from that, it is recommended to give a counselling session for patient, informing further
management. Additionally, encourage patient, along with the husband if available, to complete
the infant immunization series for hepatitis B virus according to local infant vaccination schedule
and obtain serological confirmation of protection after completion of hepatitis B vaccination
series, no sooner than 9 to 12 months of age. Inform the risk of transmission and the reason of
vaccination to prevent the mother to child transmission of hepatitis B.

On the other hand, breastfeeding does not show additional risk of hepatitis B virus infection,
even without neonatal vaccination. Hence, patient is encouraged to breastfeed her baby.
Literature review

The HBV virus has infected many people around the world and is a common cause of
liver disease and cancer of the liver. For the diagnosis of various types of HBV-associated
disease and for the treatment of chronic hepatitis B infections, virological and serological assays
have been developed. HBV infection leads to multiple series of liver diseases ranging from acute
to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Acute HBV infection may be either
asymptomatic, or symptomatic. Most adults infected with the virus are recovered, but about
10% are unable to eradicate the virus and become permanently infected. Many chronically
infected persons have mild liver disease with little or no long-term morbidity or mortality. Some
with chronic HBV infection develop active disease instead, leading to cirrhosis and liver
malignancy (Liang, 2010).

On the other hand, majority of the chronic HBV infected patients is inactive carriers.
According to study by Sharma, Saini, and Chwla (2005), the inactive HBsAg carrier state is
diagnosed by absence of HBeAg and presence of anti-HBe, undetectable or low levels of HBV
DNA in PCR-based assays, repeatedly normal ALT levels, and minimal or no necroinflammation,
slight fibrosis, or even normal histology on biopsy. In addition, about 30% or less of persons in
the inactive HBsAg carrier state may experience spontaneous reactivation of hepatitis B during
follow-up.

Meanwhile, it is possible to transmit the Hepatitis B virus (HBV) by blood or sexual

contact (Schillie et.al., 2018). Thus, ACIP suggests all pregnant women to be screened for
hepatitis B surface antigen (HBsAg) and HBsAg-positive pregnant women to be tested for
hepatitis B virus deoxyribonucleic acid (HBV DNA). For newborn babies by HBV-infected women,
HepB vaccine and hepatitis B immune globulin (HBIG) should be given within 12 hours of birth,
preceded by vaccine sequence completion and serologic post-vaccination testing. In addition,
vaccination of children and teens under the age of 19 years old that have not previously been
vaccinated (Schillie et.al., 2018).

Figure 1 summarizes the recommendations from AASLD, ACOG and Pan et al. (Walid S. Ayoub
and Erica Cohen, 2016)

Figure 1 Management of HBV in pregnant patients