CASE

PRESENTATION 1
GROUP A3
NUR FARAH HIDAYAH 012019040021
DANIA EDINA 012019040022
HISTORY TAKING
PATIENT DETAILS
NAME: NORLAILI BINTI MOHAMAD ALI
AGE: 36 YEARS OLD
RACE: MALAY
GENDER: FEMALE
ADDRESS: PULAU INDAH, KLANG
GRAVIDA : 2
PARA: 1
REDD: 8/9/2023
BED: 17
WARD: 5F
DATE OF ADMISSION: 6/8/2023
DATE OF CLERKING: 8/8/2023
 CHIEF COMPLAINT
Mdm Norlaili, 36 years old malay women, G2 P1
POG: 35 weeks 4 days with underlying hypertension, gestational
diabetes mellitus and anemia was presented with leaking liquor
and vaginal discharge for 1 day.
 HISTORY OF PRESENTING ILLNESS (HOPI)
My patient Madam Norlaili, a 36 years old old malay lady with 35 weeks 4 day of POG with underlying
hypertension, GDM on medication and anemia in pregnancy was admitted to HTAR O&G ward on
06/08/2023 with complains of leaking of liqour and yellow colour discharge.

1. Leaking Of Liqour
Onset: on the day of admission (6/08/2023) .
A gush of fluid 4 times (1st-0300H, 2nd-0330H, 3rd-0630H 4th-0900H) prior to admission which her
pants was fully soaked.
It was colourless. No blood present.
No increase in urine frequency, no urinary urgency and no dysuria.
2. Vaginal Discharge
The discharge is yellowish and has foul smelling with no itching sensation.
No abdominal pain, no fever, no uterine contraction with good fetal movement (strength and
frequency same as before leaking).
 No Abdominal pain

SYSTEMIC REVIEW GASTROINTESTINAL

No diarrhea
No vomiting
No difficulty in swallowing
SYSTEM
No flatulence
Fatigue is not present
No constipation
No fever
No melena
No loss of appetite
GENERAL
No loss of weight
No sleep disturbance Normal urinary output
No blurring of vision No pain during passing urine
(dysuria)
No increase/decrease in urine
frequency
No cough/sputum GENITOURINARY SYSTEM No suprapubic pain
RESPIRATORY No shortness of breath No blood in urine (hematuria)
No nocturia
SYSTEM No wheezing
No urinary incontinence
No runny nose
No frothy urine
No sandy urine

No chest pain No dizziness

No headache
No palpitation
No faint or blackouts
No edema
No visual and hearing
CARDIOVASCULAR SYSTEM No cyanosis
disturbance
No orthopnea NERVOUS SYSTEM No taste or smell changes
No paroxysmal nocturnal No memory and concentration
dyspnea change
No tingling or numbness
sensation
 HOPP
1st Trimester 2nd Trimester 3rd Trimester

Planned pregnancy Any event: Plan of Delivery: LSCS

Booking visit: 8 weeks at KK Pulau Threatened miscarriage Weight: 90kg
Indah,Klang at 13 weeks 5 days BP: 128/68 mmHg
Dating scan: 10 weeks 1 day PV Discharge - Brownish 2nd OGTT on 24 weeks 3 days
Weight: 82kg discolouration FBS: 4.5
Height: 156cm Lower Abdominal Pain 2h Post-Prandial: 7.8
BP : 133/87 mmHg She did detailed scan at 23 There were no contraction pain
BMI: 33 kg/m2 weeks 4 days Fetal Kick: more than 10 from
Urinalysis: Normal Progress of fetal growth: 9am - 2.30pm
Full Blood Count: Normal
HB: 7.5 g/dl No fetal complication
OGTT was done during booking Quickening felt at 20 weeks
visit at 12 weeks
FBS: 4.9
2h Post-Prandial: 4.4
ABO: O +
VDRL: Negative
HIV: Non-reactive
She had nausea and vomiting.
 PAST OBSTETRIC HISTORY
No Previous Placenta Previa or Placental Abruption.
She was married in 23.05.2009 with her now husband age 36 years old.

BIRTH
YEAR PREGNANCY LABOUR PUERPERIUM BABY
WEIGHT

2010 TERM LSCS Uneventful GIRL 3.6kg

GYNAECOLOGY HISTORY
Attained menarche at age of 11 years old
Regular 30 days menstrual cycles and period lasts for around 15 days
No dysmenorrhea.
No complaints of heavy menstrual bleeding / intermenstrual bleeding
There is history of IM Depo usage after her 1st delivery for 2 years and then stop as
she plans to be pregnant.
No history of STI or UTI
Sexually active with husband.
Pap smear was done after 1st pregnancy and 2 years before pregnancy.
No history of hormone replacement therapy.
PAST MEDICAL HISTORY DRUG HISTORY
T. Labetolol 100mg BD
Madam Norlaili have underlying
T. Aspirin 150mg ON
hypertension for 5 years and on
T. CaCo3 500mg TDS
medication.
T. Metformin 500mg BD
She has no prior hospital admissions
T. Zincofer 1/1 OD
except when she gave birth
She claims to be taking
She has never underwent any surgery
Habbatus Sauda
before.
She is allergic to meat. When
she consumes meat, her face
turns red and itchy.
 FAMILY HISTORY
She is the 1st child out of 7 siblings
Father has diabetes mellitus on insulin with
hypertension while mother is diagnosed with
hypertension on medication.
She reported her mother had a miscarriage before
but unsure when.
SOCIAL HISTORY
Lives with husbands and her
daughter in Pulau Indah in a
single story house with adequate
basic amenities
She works as a sales asisstant
while her husband is a clerk.
Taking normal Malaysian diet.
Usually cooks by herself.
Does not smoke, consume alcohol
or taking recreational drugs
PHYSICAL EXAMINATION
 GENERAL EXAMINATION
Generally, she looks well, alert, and conscious.
She is lying on a bed comfortably with support
of 1 pillow.
He looks comfortable with no signs of
respiratory distress. Anthropometric Measurement
Weight: 90kg
Vital signs: Height: 156cm
Blood pressure: 129/70 mmHg BMI: 37kg/m2
Pulse rate: 83 bpm, good volume and regular
rhythm
Respiratory rate: 16 breaths per minute
Sp02: 99% on air
Temperature: 36.7°C
 PERIPHERAL EXAMINATION
Hands & Arms:
Hands are warm and dry
Capillary refill time is less than 2 seconds
No pallor, sweating, peripheral cyanosis
Face
There is conjunctival pallor
Oral mucosa is moist with good dental hygiene
No central cyanosis or pallor
Neck
No lymphadenopathy
Legs:
No ankle edema
 OBSTETRIC ABDOMINAL
EXAMINATION
Inspection:
Abdomen is uniformly distended due to gravid uterus.
The linea nigra, striae gravidarum and striae albicans
are present.
The umbilicus is centrally located and flattened.
There is LSCS scars.
There is fetal movement.
Abdomen is move with respiration.
Palpation:
Abdomen is soft, non-tender and afebrile over 9 quadrants.
CFH: 36weeks
SFH: 35cm
The fundal heights is correspond to period of gestation.

Soft, irregular and broad structure suggests of fetal

Fundal grip
breech.

Broad, smooth, curvature structure suggests of fetal

Left maternal side
back

Right maternal side Knobby-like structure suggestive of fetal limbs

Hard, globular, regular structure suggests of fetal

Pelvic grip
head

Head is 4/5 palpable, not engaged

Estimated fetal weight: 2.0 -2.2kg
Fetal heart rate is 140bpm
Liquor volume is adequate
 SYSTEMIC EXAMINATION
Respiratory system:
Normal breath sounds, equal air entry bilaterally, no
crepitations or rhonci.
Cardiovascular system:
Normal heart sounds heard, no murmurs.
Examinations that were performed at the
hospital:
Vaginal Examination:
Normal vulva and vagina
Cervical OS is closed
Presence of liquor at the fornix
Cough test: liquor leaks
No blood seen
Yellowish and foul smelling discharge seen
High vaginal swab culture and sensitivity was taken.
 PROVISIONAL DIAGNOSIS
G2P1 @ 35 weeks of gestation with Preterm Premature Ruptured of
Membrane (PPROM)
Presence of gush of fluid before 37 weeks of gestation
During vaginal examination, there is pooling of fluid at the fornix
 DIFFERENTIAL DIAGNOSIS
1. Urinary 2. Vaginal infections 1. Leukorrhoea
incontince/Urinary (Candidiasis) Points supporting:
Tract Infections Points supporting: Normal
Points supporting: Yellowish and foul physiological
Gush of fluid at the smelling discharge changes in
fornix (mistaken VE: yellowish pregnany
with urine) discharge with foul PoInts against:
PoInts against: smelling Yellowish
Normal frequency, PoInts against: discharge with foul
no urgency and no No itchiness smelling (normal:
dysuria thin, white and
odorless)
Maternal:
INVESTIGATIONS
Full blood count (6/8/2023 @ PAC, HTAR) - Hb level, platelet count,
hematocrit, WBC, CRP
Test name Result Normal range

Haemoglobin 9.6 g/dL 12.0-15.0

Platelet 259 x 10^9/L 150-410

Hematocrit 30.3% 36-46

WBC 6.6 x 10 3.8-4.8

CRP 7.2 mg/L <5.0

Renal profile (6/8/2023 @ PAC, HTAR)

Parameters Result Normal range

Urea 2.7 mmol/L 3.2-8.2

Sodium 140 mmol/L 136-145

Potassium 3.7 mmol/L 3.5-5.1

Chloride 49umol/L 49-90

EGFR >90 >90

Liver Function
Parameters Result Normal range
Test (6/8/2023 @
PAC, HTAR) Total protein 61 g/L 57-82

Albumin 26 g/L 34-50

Globulin 35 g/L 25-39

A/G ratio 0.7 0.9-1.8

ALP 120 U/L 46-116

ALT 19 U/L 10-49

AST 20 U/L <34

Total Bilirubin 6 umol/L 3-19

UFEME
Parameters Result
(6/8/2023 @
PAC, HTAR) Glucose Negative

Ketones Negative

Nitrites Negative

Leukocytes 1+

Blood Negative

Urobilinogen Normal

Protein Negative

Urine pH 6.0
High vaginal swab (6/8/2023 @ PAC, HTAR)
Culture and sensitivity
Screen for group B streptococcus (GBS)
Result: No growth seen
 INVESTIGATIONS
Fetal:
Ultrasound - to see fetal wellbeing and liquor volume
Cardiotocogram - to see fetal heart rate
 MANAGEMENT
1. LPC/FKC/FHR 1. T. Labetolol 100mg BD
2. Strict Pad Charting 2. T. Aspirin 150mg ON
3. Daily CTG monitoring 3. T. CaCo3 500mg TDS
4. BP monitoring & inform if over 140/90mmHg 4. T. Metformin 500mg BD
5. T. EES 400mg QID x 10/7 . If labour symptoms 5. T. Zincofer 1/1 OD
appear switch to IV Benzylpenicillin
6. Daily Urine Albumin
7. IM Dexamethasone 12mg BD
8. Biweekly FBC/ CRP
DISCUSSION
 Problem List
1. Chronic Hypertension
2. 1 previous LSCS Scar
3. Anemia In Pregnancy
4. Subfertility for 13 years
5. GDM On T. Metformin 500mg BD
6. Advance Maternal Age
7. BMI : 37kg/m2
 1. PRE-EXISTING CHRONIC HYPERTENSION
Definition:
persistent elevation of systolic blood pressure (BP) Pre-eclampsia is a leading cause of maternal death
of 140 mmHg or greater and/or (Kenny, 2017)
diastolic BP of 90 mmHg or greater The World Health Organization (WHO) estimates that
taken at least twice on two separate occasions. globally between 50,000 and 75,000 women die of
this condition each year.
As written in (Kenny, 2017) the pregnant women who Furthermore, pre-eclampsia is frequently
develop or present with hypertension in pregnancy accompanied by fetal growth restriction (FGR),
have one of three conditions: which is responsible for considerable perinatal
1. Non-proteinuric pregnancy-induced hypertension. morbidity and mortality.
2. Pre-eclampsia.
3. Chronic hypertension.
MANAGEMENT RECEIVED FOR
THIS PATIENT:
Pre-Eclampsia T. Labetolol 100mg BD
T. Aspirin 150mg ON Prevent risk of
T. CaCo3 500mg TDS pre-eclampsia
Eclampsia

Maternal and Fetal mortality


2. Subfertility for 13 years
Definition:
failure to conceive after 1 year of unprotected
regular sexual intercourse.
Types:
Primary subfertility: Delay for a couple who have
had no previous pregnancies
Secondary subfertility—a delay for a couple who
have conceived previously, although the
pregnancy may not have been successful (for
example, miscarriage, ectopic pregnancy)
Some factors can affect how easily a woman ovulates, gets
pregnant, or delivers a child. These include:
Age. Women in their late 30s and older are generally less
fertile than women in their early 20s.
Chronic diseases such as diabetes, lupus, arthritis,
hypertension, and asthma
Hormone imbalance
Environmental factors (smoking,alchohol)
Too much body fat or very low body fat
(John Hopkins Medicine)
In my patient you can see that she is Secondary subfertile,
with presenting risk factors of subfertility which are :
Advance maternal Age
Chronic Hypertension
Obesity
MANAGEMENT RECEIVED FOR THIS
PATIENT:
Treat underlying disease
Refer to Reproductive Specialist
Consult lifestyle modification
 3. Anemia In Pregnancy
Definition:
Anaemia in pregnancy is defined as
first trimester haemoglobin (Hb) less than 11g/dl MANAGEMENT RECEIVED FOR THIS
second/third trimester Hb less than 10.5 g/dl PATIENT:
postpartum Hb less than 10 g/dl T. Zincofer 1/1 OD
(Sungkar & Surya, 2020)
This patient had these readings which indicates that she does
have anemia in pregnancy. The clinical consequences of anaemia : (MOH)
1st Trimester : 7.5 g/dl preterm delivery
2nd Trimester: 8.0 g/dl perinatal death
3rd Trimester : 8.6 g/dl postpartum depression.

The detection of anaemia should prompt examination of the Foetal and neonatal consequences: (MOH)
mean cell volume to identify likely iron deficiency anaemia low birth weight
(microcytic anaemia) or folate or vitamin B12 deficiency poor mental and psychomotor
(macrocytic anaemia). performance.
(Kenny, 2017)

This can be seen in patient by her results in her

MCV which is 78.1 L out of a range of 83-101 which is lesser
thus she is iron deficient.
 4. Gestational Diabetes Mellitus
GDM is diagnosed if a woman has: MANAGEMENT RECEIVED FOR THIS
fasting plasma glucose level of 5.6 mmol/l or above, PATIENT:
or a T. Metformin 500mg BD
2-hour plasma glucose level of 7.8 mmol/l or above.
it is proven that the patient is
Risk factors for the development of GDM include experiencing inflammation at the
women with : vaginal canal. The reason behind this is
previous gestational diabetes because the patient has 1+ leukocyte
previous macrosomia (≥4.5 kg) GDM
raised BMI (≥30 kg/m2)
first-degree relative with diabetes UTI
Candidiasis.
Dysfunction in immune
(Kenny, 2017) response

We can see in this patient that she has : susceptible to

FBS : 4.5 mmol/l infections
2h PP: 7.8 mmol/l fails to control the spread of
with her having positive risk factors of raised BMI 37. invading pathogens
 5. Advance Maternal Age
Definition:
women who are 35 years or older at estimated date
of delivery.
selected based on evidence of declining fertility
and concern surrounding increasing risks for
genetic abnormalities identified in the offspring of
pregnant women older than age 35 years
(ACOG)
Advance Maternal Age
1. Advanced maternal age (40 years and
over) was associated with an increased
risk of preterm birth even after
adjustment for confounders.
2. The lowest risk of prematurity was found
in mothers aged 30–34 years.
3. Preterm birth was mainly spontaneous in
younger women (20–24 years) whereas
it was more frequently of iatrogenic
origin in women over 40.
(Fuchs et al., 2018)

It is seen in our patient that she is definitely

Increase cellular inflammation
advance maternal age which is 36 years old

Uterine Dysfunction

Contractile activity reduce

 6. OBESITY ( BMI: 37)
Patient's BMI: 37 kg/m2
The risks of PPROM were higher in obese
Defintion: women (BMI > or = 30) than in normal-
maternal BMI 30kg/m2 or more at the antenatal weight women (18.5 < or = BMI < 25),
booking visit. especially before 34 completed weeks of
At risk of develop GDM, PIH and miscarriage gestation, when obese women faced twice
the risk.

Obesity
MANAGEMENT:
advice for diet control to avoid excessive
gestational weight gain which may result in
Increase cellular inflammation severe complications
monitor patient blood glucose and blood
pressure
Risk for gdm, hypertension, LGA
 7. ANTEPARTUM HAEMORRHAGE
The presence of a subchorionic haematoma in
early pregnancy increases the risk of later PPROM,
either through an effect of thrombin on membrane
strength or through the occurrence of infection in
the haematoma.
(Kenny, 2017)
Acute bleeding
Antepartum haemorrhage did occur
in the 1st trimester of the patient which
leads to Threatened Miscarriage.
Risk factors that is present in this
patient:
Hypertension
Advance Maternal Age

MANAGEMENT:
Release thrombin advice for diet control to avoid excessive
gestational weight gain which may result in
severe complications
stimulates myometrial contractions monitor patient blood glucose and blood
pressure

PPROM
 References:

Royal College of Obstetricians & Gynaecologist

Kenny, L. C. (2017). Antenatal obstetric complications. In Obstetrics: By Ten Teachers, 20th Edition.
https://doi.org/10.1201/9781315382401-6
Sungkar, A., & Surya, R. (2020). Blood Transfusion in Obstetric Cases. Indonesian Journal of Obstetrics and
Gynecology, 8(3), 197–200. https://doi.org/10.32771/inajog.v8i3.1376
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC188498/#:~:text=Table%201,have%20had%20no%20previous%20preg
nancies
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475801/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683335/
Fuchs, F., Monet, B., Ducruet, T., Chaillet, N., & Audibert, F. (2018). Effect of maternal age on the risk of preterm birth: A
large cohort study. Obstetrical and Gynecological Survey, 73(6), 340–342.
https://pubmed.ncbi.nlm.nih.gov/17239174/#:~:text=The%20crude%20risks%20of%20PPROM,women%20faced%20twic
e%20the%20risk.