Mohd Helmy B Abu Bakar

012010050487

Patient s Profile
Name Age Race Gravida RN L.M.P E.D.D Date of clerking : Malani A/P Sinappan : 31 : Indian : G2P1 : A480/2011 : 9/06/11 (sure of date, regular menstrual period, not on OCP, non lactating) : 23/11/11 (verified by scan at 9 weeks 1 days) : 13/12/11

Chief Complaint
Madam Malani, G2P1 at 26 weeks 5 days POA with history of low Hb level coming for regular antenatal check up.

History of Present Illness

This is planned and wanted pregnancy Patient had monthly antenatal check up which is uneventful until on 15/11/11 at 22 weeks 5 days POA she noted to have low Hb level which is 10.3g/dL. Then patient repeat the Hb level at 13/12/11 and the result was 10.1g/dL. There is no palpitation, no SOB, no complain of weakness, no headache, no dizziness

 There is no history of exertional dyspnea, no hematemesis or malena. No per vaginal bleeding and no history of trauma.

Antenatal History
Antenatal booking was done at KK Taman Botanic on 12/8/11 at 9 weeks 1 day POA. Weight 50.2kg, height 1.56m BP: 120/80, Hb: 13.3g/dL Blood group: B, Rhesus: positive HIV rapid test: Non reactive VDRL: Reactive (1:8) repeat at 13/9/11 (non reactive)

 First scan was done during booking, FH seen and present of gestational sac. CRL at 8 weeks 5 days. Patient had serial monthly antenatal check up and subsequent scan which is uneventful. Patient had normotensive throughout pregnancy with blood pressure range 110-120 for systolic blood pressure and 70-80 for diastolic blood pressure. Latest hemoglobin level on 13/12/11was 10.1g/dL.

Past Obstetric History

No Year Period of gestation Full term Place of delivery Hospital Seremban Mode of delivery SVD Birth weight 3.0kg Status Breast feeding 1 2 2009 2011 Alive and 8 month well

Current pregnancy

Gynecology History
She attained her menarche at the age of 12 years old at regular interval of 26 to 28 days with a normal flow of 3-4 days. No history of menorrhagia or intermenstrual bleeding. No pap smear done. She never took any oral contraceptive in the past

Past Medical & Surgical History

No significant past medical history and she had lumpectomy at Hospital Seremban in 2001.

Family History
Father passed away, unknown causes. Mother had DM and hypertension, on medication No other medical illness in the family

Social History
She is housewife, and her husband working as technician at west port. Total family income: RM2500 Patient denied smoking, alcohol and drug intake. Passive smoker, husband smoke about 20 cigarette per day, socially alcohol drinker. Live in single storey terrace house with basic emenities.

Allergies History
She has no known drug or food allergies

Systemic Review
All system found to be normal, no active complain.

Obstetric Examination
On examination, she was alert, conscious and lying comfortably on one pillow. Her vital signs were as recorded: Blood pressure: 110/76 mmHg Pulse rate: 78 beat per minute, regular rhythm and good volume Temperature: 37C

 She does not appear to be anemic or jaundice Oral hydration and hygiene was good, no bleeding from the gum No puffiness of the face No finger clubbing, no koilonychia and no splinter hemorrhage. Conjunctiva slightly pale. Mild pitting edema

Systemic Examination
CVS: no added heart sound. Respiratory: vesicular breath sound.

Abdominal Examination
Inspection Mildly distended abdomen by a gravid uterus as evident by linea nigra and striae albicans but no striae gravidarum. Umbilicus was centrally located and inverted. The abdomen is move asymmetrically with the respiration. There is no surgical scar. No other abnormalities were observed such as distended vein, visible pulsation or visible peristalsis.

Palpation The abdomen was soft and non tender. Her uterus was at 26th week size and the symphysial-fundal height measured 26 cm . Singleton fetus There is no contraction felt in 10 minute. Auscultation Unable to listen for the fetal heart rate

Summary
Madam Malani, a 31 year old indian, Gravida 2 Para 1 at 26 weeks 5 days POA with history of low Hb level presented to us for routine antenatal check up. She had no underlying medical illness and symptoms of chronic anemia. On physical examination, all system found to be normal except slightly conjunctiva pallor and mild pitting edema.

Provisional Diagnosis
Physiological anemia in pregnancy

Investigation
1. FBC 2. Ultrasound

Discussion
Topic: Anemia in pregnancy Definition: Hb level <10.5g/dL in pregnancy (RCOG) Hb level <11.0g/dL in pregnancy (WHO)

Concept of Physiologic Anemia

Disproportionate increase in plasma volume, RBC volume and hemoglobin mass during pregnancy Marked demand of extra iron during pregnancy especially in second trimester

Significance of Hypervolemia
1. To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system. 2. To protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions. 3. To safeguard the mother against the adverse effects of blood loss associated with parturition.

Causes
1. Iron deficiency anemia Poor diet Poor spacing (good spacing > 2 years) Chronic blood loss (UTI, worm, menorrhagia) 2. Thalassemia Autosomal recessive 3. Folic acid deficiency anemia Decrease diet Impaired absorption Increase demand

Complications
Maternal 1. Inability to withstand hemorrhage (PPH) 2. Risk of infection 3. Risk of cardiac failure 4. Risk of PPH Fetal 1. Hypoxia 2. IUGR(iron deficiency) 3. Spontaneous abortion (Thalassemia)

Clinical Approach
History 1. Diagnosis When, where, how, Hb reading? Symptoms - SOB - Weak and lethargy - Palpitation - Headache - Symptom of CCF - Blurring of vision Treatment? Compliance?

2. Determine cause Bleeding history? History of anemia in family that require frequent transfusion? Diet history Compliance to hematinics Obstetric history (APH, multiple pregnancy, PPH, poor spacing)

Physical Examination
1. 2. 3. Pallor Angular stomatitis, glossitis, koilonychia CVS CCF (ankle edema, crepitation) Murmur (hyperdynamic blood flow)

Management
Investigation 1. Hb screening- booking, 32w and 36 week (WHO recommended screen at booking, 28w) 2. MCV: If 76fl, cause IDA If lower and other sign of anemia and RBC count raised, B2 thalassemia Normal MCV with low Hb, typical of pregnancy 3. Full blood picture 4. Hb electrophoresis

Treatment
If Hb level <10.5g/dL and exclude hemoglobinopathies, consider hematinic deficiency and start iron tablet 1. Mild anemia (8-10g/dL) Ferrous fumerate 200mg daily Folic acid 5mg daily Diet consultation

2. Moderate anemia (6-8g/dL) Can consider double hematinic (give 400mg daily) Transfuse only aim for fast correction(when prepare for delivery or c-sec) 3. Severe anemia (<6g/dL) Admit the patient Transfuse 2 unit of packed RBC Aim>8g/dL before discharge Oral iron and folate continue Follow up regularly

Routine hematinics: 1. Given when >20 weeks 2. Ferrous fumerate 200mg daily 3. Folate 5mg daily 4. Vitamin B 5. Diet advise

Thank You ..