Remedial O&G CT4 [note to myself]

Clinical teaching 4 with Prof Nik

Madame NH 24y/o, G1PO with a background history of subfertility for 3 years and undergone ovulation induction for 1 year (on Clomiphene ?dose) was electively admitted for management of postdate.

DOA: 6/8/2016; DOC: on the same day as admission

Last Menstrul Period: 2/12/2015; sure of date, irregular menstruation, ovulation induction

Ovulation induction(read on infertility IDA lecture) signifies there is ovulation during the LMP so LMP is trustable.

Expected date of delivery: 9/8/2016

Revised EDD(scan done around 9th week): 31/7/2016

Prof mentioned scan done around 9th week discrepancy can be up to 2-5d, find out u/s and discrepancy

the discrepancy was 1 week and so EDD counted from LMP is acceptable. (discrepancy not more than 2 weeks; find out)

currently POA: 39w 5d (if the case is presented as a Postdate case, then do not present 39w, not tally)

HOPI:

All parameters normal, excpet on ultrasound noted cord around neck and aminiotic fluid index: 1.3cm. (learn how to grade oligohydramnios, causes and management)

Beware on small AFI, usually on PE, u may find smaller fundal height

Patient is obese class I with BMI of 30.06kgm-2. (learning point: obesity cause PCOS hence irregular menstruation and subfertility?)

Subfertility, clomiphene: must ask for dosage(mg),  how many times taken a day, duration taken (clomiphene usually 1 tab 50mg OD, given at 5th to 9th or 2nd to 6th day of menstrual cycle)

noted that BMI >30, MOGTT as screening of diabetes must be done at 12-14w, 24-28w and 32-34w,
other risks factor:

1. Gestational diabetes previous pregnancy
2. Obesity (BMI >30)
3. Age > 25
4. Presence of glycosuria in >2 occasions
5. History of DM in first degree relatives
6. Previous big baby > 4.0 kg
7. Previous history of recurrent abortion or unexplained stillbirth
8. Previous congenital anomalies
9. Polyhydramnios

Physical examination:
rather than mention no resp distress, mention pt is breathing spontaneouly, well
only 5/5 palpable can be presented as balloptable fetal head (~floating)
Pt has high BP, must check CVS! check for radiofemoral delay, Coarctation of aorta! Treat pt as whole!
if not checking the breast, at least ask the pt whether there is presence of colostraum, which prepare pt for BF, student might miss pregnant mother who has breast cancer

Patient also has past medical hx of leukemia (unclear hx: so must ask what age diagnosed? completed chemotherapy? regularly follow up? whether cytotoxic drugs had caused the subfertility? and also a leukemic pt in the past need to have antenatal follow up in a tertiary centre! not district)

finally, presenter was asked to present CTG as there is cord around neck,

Prof's comment on how to present, this is a CTG of Madame NH, 24y/o Malay lady, G1PO, with a background hx of subfertility for 3 years and was on ovulation induction for 2 years, the CTG was taken on yesterday, 6/8/2016 2pm for a duration of _ hour, it shows that the baseline FHR was 140-150bpm, the beat to beat variability was 5-20bpm, there was presence of acceleration, no deceleration, the CTG taken is reactive. (any contraction? there was presence of regular uterine contraction with amplitude of?)

eventually, patient was given elective Caeserean section due to these following issue, subfertility, oligohydramnios and cord around neck. 

SO AGAIN, 
LEARNING POINT:
SUBFERTILITY CAUSES, CLOMIPHENE DOSAGE
PCOS
ULTRASOUND DISCREPANCY
OLIGOHYDRAMNIOS
CORD AROUND NECK
INDICATION FOR IOL/C-SEC (HOW TO CHOOSE)
HOW TO MANAGE POSTDATE IF NO CX ARISE?

EXTRA LEARNING POINT:
REVISE GDM
REVISE CVS, what may cause High Bp, RISK FOR pre-eclampsia

I asked a question why Prostin used in IOL is contraindicated in severe asthma/glaucoma?
Prof: only "severe" and its not absolute contraindication, if pt's asthma/glaucoma condition is well-controlled, Prostin can be used.