PMTCT MEETING

1/2022
PKD KUALA MUDA
RVD CASE 1 - PUAN NA
KK MERBOK
A. BIODATA
PATIENT PARTNER
Name Madam NA Mr MA
Age 27yo 31yo
Ethnic/Nationality Malay/ Malaysian Malay/ Malaysian
Gravida/Parity G2P1 -
Occupation Housewife Operator @ factory

LMP/EDD LMP: 1.10.2021 -

EDD: 8.7.2022

Date of marriage 30.5.2015 (1st marriage - 14.3.2020 (1st marriage)

Divorced)
14.3.2020 (2nd marriage)
A. BIODATA
PATIENT PARTNER
Date of HIV rapid test Diagnosed RVD +ve on HAART Premarital HIV screening in
since 9/1/2020 during 2020 - NR
premarital screening for 2nd
marriage 1.12.2021 - NR
Date of confirmatory HIV test Jan 2022 - old case (exact date December 2021 - NR
sent (ELISA) not documented inside ANC
book)
Date of confirmatory HIV test 9.1.2020 - old case (taken from -
received referral letter from KK Pendang
inside her previous ANC book)

Risk factor 1st husband - substance Deny high risk behaviour

abuse ?status
Heterosexual - h/o SI once with
friend before her 2nd marriage
Notification date -
B. HISTORY OF CURRENT PREGNANCY
DATE POA NOTES
Booking 28.11.2021 8w Seen by MO on 1.12.2021 (at 8w1d) for RME 1
-continue HAART (T.Ten-Em 1/1 od, T.Efavirenz
600mg on)
-Blood ix (viral load, cd4 count, toxoplasma IgG,
LFT, RP, OGTT, FBC)
-STI workout (in view of patient having pv
discharged)
-Refer FMS
-T.obimim 1/1 od

Rawatan ARV 28.11.2021 (cont. 8w T.Tenofovir 300mg + T.Emtricitabine 200mg 1/1

HAART) od (Ten-Em 1/1 od)
-started on HAART T.Efavirenz 600mg on
since 3.2.2020 by KK
Pendang
CD4 COUNT 6.12.2022 9w 610 cells/uL

VIRAL LOAD 8.12.2021 9w2d Not detected

7.4.2022 26w5d Not detected
B. ANTENATAL CARE PLAN
PLAN DATE POA NOTES

1. Referral 21.12.21 12w -cont Ten-Em 1/1 od, Efavirenz 600mg on

to FMS -T.Metformin 500mg bd
-Refer ID/O+G
-cont HAART & Metformin

21.2.2021 20w -T.Metformin 1g bd, cont HAART

-for viral load & Hb Analysis

7.6.2021 35w3d -T.Maltofer 1/1 tds

B. ANTENATAL CARE PLAN
PLAN DATE POA NOTES
2. Referral 5.1.2022 14w -explaine to couple regarding currently risk of vertical transmission is low in
to O&G view of undetectable viral load and normal cd4 count.

9.2.2022 18w -cont current mx

-cont ID and ANC f/up

2.3.2022 21w 5d -discharged combine clinic

(combine
clinic)

11.5.2022 32w tca 1/12 to review viral load & decide MOD

25.5.2022 34w 2d Admitted from 25-28.5.2022 for maternal tachycardia secondary to

dehydration, discharged well.

22.6.2022 37w 6d -referred for maternal and fetal tachycardia

-EmLSCS on 23.6.2022 due to mother refused vaginal delivery.
 B. ANTENATAL CARE PLAN
3. Referral to 5.1.2022 14w -case d/w Dr Guan ID Physician by Dr
ID Peacchaima Physician.
-to repeat viral load at 30-32w

8.5.2022 33w -case d/w Dr Guan ID Physician

-cont HAART
-TCA ID clinic 6w postnatal
B. ANTENATAL CARE PLAN
PLAN DATE POA NOTES
4. Compliance to Compliance to HAART and follow up
treatment and follow up
5. Counselling safe sex, Given
condom

6. Problems identified -After delivery of first child, she was immediately

put on implanol but then pregnant again with
implanol in situ. May need to consider another
method of contraception for her.

**Currently she keen for double protection -

condom and IM depo.
C. MANAGEMENT FOR PARTNER

DATE PROBLEM IDENTIFICATION PROBLEM SOLUTION

Repeated offer for HAART as
prophylaxis for serodiscordant
couple - Not agree.

Counselling for safe sex.

 D. OTHER TESTS
TEST DATE PATIENT HUSBAND NOTES

Hepatitis B 28.12.2021 NR -

Hepatitis C 28.12.2021 NR -

HVS C&S 1.12.2021 No growth -

GC smear 1.12.2021 NR -

VDRL/TPHA 6.12.2021 NR -

TOXOPLASMA IgG 8.12.2021 NR -

Se Ferritin 12.4.2022 8.66ng/mL -

FBP 13.4.2022 IDA, suggest Hb Analysis -

OGTT 5.12.2021 6.0/6.8 - on T.MTF 1g
bd
TEST DATE PATIENT HUSBAND NOTES

Hb Analysis 25.5.2022 Suggest DNA Analysis -

LFT 5.12.2021 Albumin 37.6 g/L -

ALP 123.7 U/L
ALT 8.8 U/L
TB 4.6 U/L
RP 5.12.2021 2.7/135.9/4.3/102.3/48.3 -
E. BABY’s BIODATA
Name

MyKid/ sex/ BW Not registered yet/ Boy/ 3.57kg

Mode of delivery EmLSCS on 23.6.2022 at 19:37hr

Place of birth HSAH

AZT intrapartum Given

Plan of care

→ ARV tx at discharge Syrup Zidovudine 15 mg BD till 4/52

(from 23.6.22 till 21.7.2022)
→ feeding replacement Formula milk given
F. BIRTH AND MANAGEMENT FOR BABY
BABY NOTES
HIV STATUS
→ PCR 1 Taken 27.6.2022, result pending
TCA peads ID clinic on 10.8.2022
→ PCR 2

→ PCR 3

Date of immunization 24.6.2022 - BCG & Hep B (1st dose)

Bactrim prophylaxis Not given
Health status Healthy
G. POST NATAL CARE FOR MOTHER
Referral to ID clinic Discharged ID follow up
TCA FMS KK Merbok on 22.8.2022
Status of ARV treatment Continue HAART

Contraceptive IM depo and condom

Social support Good social support from husband and in laws.