ANTENATAL DISCUSSION

BOOKING DETAILS
MOTHER’S DETAIL FATHER’S DETAIL

NAME Siti Norbakyah bt Abd Hasan Bin Zakaria

Rahim
AGE 35 44
OCCUPATION Pembantu kantin Self employed

ACADEMIC SPM SPM

ACHIEVEMENT
ADDRESS Jalan Chembong Kg Bukit Senggeh

PARITY G5 P2+2
LMP
15/02/22

EDD
22/11/22

Past obstetric hx
• EMLSCS in 2009 followed by
VBAC ( fetal distress)
• H/O miscarriage x2 (2016/2021)

RISK FACTORS IDENTIFIED 1)Hypertension complicating

pregnancy
2)Goitre under SOPD( tca 25/5/22)
h/o Left thyroidectomy done in 2005
TFT normal
Planned for thyroidectomy
No obstructive sx
BOOKING - Planned pregnancy
18/4/22 - Regular menses/sure of date/Not on contraception
(8 w 6d)
Vitals: BP 114/68MMHG/PR 78
Hb 11.8
UFEME: nil

Thyroid: R thyroid enlarged

TAS: CRL 14.4mm correspond to date

Plan:
Start T. Methyldopa 250mg TDS
T.Aspirin 150mg OD
For PE Profile/TFT
Early MGTT
Repeat scan 2 weeks
27/4/22 ANC
(10 w 1d) 1)Hypertension complicating pregnancy
2)GDM on diet control ( MGTT 5.5/7.1)
BSP 5.1/5.7/4.9/4.5
3) Previous scar with 1 VBAC
4) 2 consecutive miscarriages

Vitals
BP : 118/71mmHg
PR : 75
UFEME: negative

Ix : TFT: TSH 1.51 T4 16.5

RP/LFT: Normal

TAS : CRL 32.1mm/10w 1d/FH+

no c/o
Only taking methyldopa 250mg OM as dispensed
Blood Ix (20/4/22):
RP: urea 1.59 creatinine 59 UA 229
LFT: normal ALT 12
TFT: TSH 1.51 T4 16.5

Plan:
Cont T.Methyldopa 250mg OD
T. Zincofer 1/1 od
BPM
BSP monthly
Refer O&G at 20 weeks