Remedial O&G Group 1 teaching with Dr. Rahimah [note to myself]

Dr. Rahimah stressed on knowing definition of gravida, parity and knowing how to count LMP and EDD. In case patient is USOD, we can give roughly estimated LMP by subtracting 40 weeks from REDD.

eg if this is patient 5th pregnancy, she had a molar, ectopic, a miscarriage and an IUD so it should be?

G5P1+3 (where there is 1 molar, 1 ectopic and 1 miscarriage)

In a case of SGA/IUGR, I put 'or' because a SGA case(suspected constitutionally small because of smaller mother's size with previous hx of small fetus) must be managed as TRO IUGR as if causes failed to be identified and patient was discharged and if a IUGR was not detected and managed, it will lead to IUD.

3 important factors lead to IUGR:
1. Placental insufficiency, which could be caused by
-pre-eclampsia (usually early onset which start to affect during formation of placenta)
-chronic medical illness which affect placenta formation
-smoking
-autoimmune disease such as SLE
-placenta previa, as placenta attach to lower segment of uterus with thinner myometrium--> less blood supply--> less nutrients--> baby smaller
(thats why we opt for lower segment c-sec as lesser blood supply there)

2. fetal infection
rule out TORCHES

3. fetal anomalies
oligohydramnios suspect renal agenesis

symmetrical IUGR: early onset, caused by Chromosomal anomalies, infection
asymmetrical IUGR, late onset, caused by placental insufficiency, thus have head-sparing

GDM will cause fetal macrosomia
however pre-existing DM in mother more likely --> congenital anomalies--> fetal microsomia

as this patient has a previous hx of small baby, ask if there is oligohydramnio in the previous pregnancy, chances are the patient has intrauterine infection in the previous pregnancy which continue to the next...

find out about percentile on growth chart for SGA, IUGR

if at district hospital, need to refer to tertiary centre if there are two abnormal plotted growth charts
usually the gap between 2 serial scans is about 1 week

however normal growth scan is 2 weeks

1 previous scar is already a criteria for admission

If Doppler U/S is abnormal, need to do CTG daily

If leaking of liquor, need to do U/S every 1w or 3d

HOPI for IUGR must rule out any CX such as
abnormal CTG, reduced fetal movement,doppler u/s findings, leking of liquor any PV discharge

Also diet hx to assess whether mother malnourish

VE assess Bishop score, if cervix favourable, deliver
if not, do induction, however previous scar, so do not do Induction as risk of uterine rupture...
if fetal distress, abnormal CTG, doppler, then c-sec
if no fetal distress, opt for vaginal delivery

Plan and management:
1. monitoring
2. timing of delivery
3. mode of delivery

investigations:
1. Blood: anemia, TWC, torches screening, group screen hold, High vaginal swab if leaking of liquor
2. U/S doppler: fetal BPP, placenta (any redding calcification), head and abd circumference, any fetal anomalies such as renal agenesis
3. CTG daily, fetal heart monitoring,

what to revise:
growth chart
causes and mx of IUGR
fetal BPP
torches
redding calcification

Remedial O&G CT3 & 6 [note to myself]

CT 6 teaching with Dr. Hoo

Pt is a 32y/o lady G2P1 came in with Placenta Previa Type III Posterior for observation at 34w + 5d.
She had previous hx of Placenta Previa Type IV in her first pregnancy and had done elective Cesarean section at 2013 which is 3 years ago. She also had a past surgical history of cystectomy at 2012 which is 4 years ago. She denied any APH such as PV bleed or abd pain. The dx was made based on ultrasound findings at 30w.

In this pt, the risk factor for her recurrent PP in second pregnancy is previous C-sec.
To clerk history of a previous C-sec, must exclude cx such as any blood transfusion? any injury to bladder, bowel, ureters? any post-partum hemorrhage? any wound infection? endometritis? UTI?
Importance is to detect any presence of placenta accreta in her next pregnancy...as C-sec is a risk.

C-sec is also planned for her second pregnancy.
Must know how to plan a C-sec,
Inform and get consent,
Large bore IV access, catheterize bladder,

Pre-op: Take blood for FBC (ensure Hb level >10g/dl), PT/PTT, GXM (4-6units of blood), urea/creatinine.
consider ECG/CHEST XRAY

Neutralize gastric contents to prevent aspiration pneumonia if GA is used.
Elective C-sec, NBM + Ranitidine

Emergency C-sec: sodium citrate and metoclopromide

Thromboprophylaxis
low-risk: early mobilization, hydration
moderate: IV heparin and TED stockings
high: IV heparin until 5-d post-op and TED stockings

Antibiotic prophylaxis
IV cefazolin. given after cord is clamped

Also don't forget to revise all the risk factors that could cause PP.

Learning Point:
C-sec cx and planning
GXM and GSH difference
PP type, risk factors, mx
Rubella=german measles, effect on fetus?
ATT to prevent emergency delivery at non sterile environment
Hepatitis B vaccine? can be given during pregnancy or not?
Primary vs secondary dysmenorrhea
Pap smear done because need to remove pre-malignant lesion if there is.
Find out about Diabetic diet and ensure GDM mother follow
Results for MOGTT 5.6-7.8

CT3 with Dr. Fauziah

Know what is abnormal progress of labour, the hour...
Know partogram, and how to detect abnormal progress by partogram and how to mx to avoid fetal distress

what can a 1st U/S tell us?
-viability,
-dating
-location of gestational sac (ectopic: abdomen, cervix, broad ligament)
-fetal number, MCDA, DCDA
-Pregnancy of unknown location need beta-hCG test
-exclude uterine abnormalities
-exlude fibroid, ovarian mass

Ovarian cyst in pregnancy, cystectomy can only be done less than 18w, more than 18w might cause abortion, so planned cystectomy only after delivery

MOGTT HOW TO DO, RESULTS, WHEN TO DO, RISK FACTOR

Remedial O&G Fetal events during labour

AP diameter:
Suboccipitobregmatic 9.5 cephalic (well-flexed)

Transverse diameter:
Biparietal: 9.5cm
Bitemporal: 8cm



Internal rotation probably occurs as the fetal head meets the muscular sling of pelvic floor, it is often not accomplised until presenting part has reached the level of ischial spine (zero station) and is therefore engaged.

engaged= 2/5 palpable on abdomen = zero station descent at ischial spine.

OBS HX TAKING (WHY I CLERK?) [note to myself]

Obstetric hx taking learning point:

Pt identification data: to assess risk, eg age>25 must do MOGTT, eg. If you get pregnant at age 25, your risk of having a baby with Down syndrome, for example, is about 1 in 1,250, according to the National Institutes of Health. At age 40, the risk is 1 in 100. If you'll be 35 or older on your due date, you'll be offered genetic counseling.

Occupation, socioeconomic class, does the mother able to take care of the baby after C-sec at home? Does the mother BF when she needs to go to work? the home using well water? can she take water after surgery while recovering?

gravida: G, P and +
multipara will has dx of false labour if dilatation is only 1cm
if +3 indicates recurrent miscarriage, need to find out cause

LMP: naegeles rule, SOD, regular menses, no BF, no hormonal therapy
EDD, REDD, POA
(must knw how to count)
used to detect postdate and also date for IOL for cases like GDM, PIH,...
date also help to identify IUGR, SGA...
read about U/S and discrepancy

C/O what bring pt to hospital? electively admitted? referred case?
(pt came in due to contraction pain? distinguish from braxton hicks, VE see any favourable cervix using Bishop score, ask for any show/leaking of liquor)


HOPI:
must knw disease:

1. GDM/pre-existing DM, clerk MOGTT, presence of risk factors, glycosuria, sx of DM (3Ps, numbness, blurring of vision), HbA1C, family hx of GDM, any congenital anomalies in fetus, any macrosomic baby, polyhydramnios, currently admitted blood sugar profile, insulin how many unit taken, any diet control? mx: IOL? cx that may arise, macrosomic, shoulder dystocia, perineal tearing? neonatal hypoglycemia?

2. Pre-eclampsia, Bp, proteinuria, mx

3. Placenta previa, PV bleed? pain? woody hard uterus?(abruptio) grade of placenta previa, causes such as multiparity,..., mx Mcafree Regime!

4. Postdate

5. Oligohydramnios, how to see AFI

6. Abnormal lie, whether to manually betulkan lie or let it be

anemia, iron metabolism
CVD, how to terminate pregnancy

IOL indications, C-sec indication, trial of scar


HOPP
missed period? UPT? (read UPT test principle, hCG, amino acids...)
failed contraception or planned pregnancy? assess pt's desire of having baby

if not because of missed period? sx of pregnancy? vomitting, abd distension, quickening?

confirm pregnancy where?

BOOKING! READ ABOUT EACH COMPONENT OF BOOKING AND KNOW WHY WE SHOULD KNOW.

(every month till 28, every  2w  until 36, every 1w until delivery)

SUBSEQUENT FOLLOW UP? ULTRASOUND OK?

quickening? primid 18-20w, multi 16-18w

sx of pregnancy, breast engorgement, frequency, constipation, ankle edema, backache? (look for any symptomatic tx?)

Immunization
ATT (principle)
hep B (3x) last time...
Rubella secondary sch

Past OBS

consanguinous marriage?

Mode of delivery, Complication? preterm, full term? C-sec? episiotomy? poor spacing? healing scar? exclusive breastfeeding?
Recurrent miscarriage?  D&C? (uterine scar...risk of placenta previa...)

any contraception?

Menstrual hx

menorrhagia? oligomenorrhea? amenorrhea?
PCOS? subfertility?

Gynae

PCOS? Uterine fibroid? any malignancy? ectopic pregnancy? recurrent miscarriage?

Pap smear done? when? where? result?  (check how many times pap smear must be done every duration?)

PAST MEDICAL, SURGICAL, DM? HPT? HEART DISEASE? ASTHMA? TB?
uterine surgery, risk of placenta previa...

Family hx?
GDM, DM, HPT, HEART DISEASE, twins pregnancy, recurrent miscarriage, stillbirth, congenital abnormalities, gynae malignancy...

Personal and Social hx
socioeconomic status
does husband take care of family
children under care of
smoking, alcohol (husband? pt?)

Drug hx
iron, folic acid, vit b, vit c
*vit b complex contained folic acid
*obimin contain all

insulin for GDM (read back why Oral hyperglycemic Agent cannot be given)
magnesium sulphate for PIH (not sure, read back)

Prostin induction of labour, syntometrine, pitocin...(how to use)

Miseprostol, mifepristone for expulsion of POC

check for drugs use for termination of pregnancy

progesterone for maintaining pregnancy in threatened miscarriage

infection in pregnancy how to treat? common: UTI

any traditional med? any OTC drugs? any allergy?

Dietary
DM diet

Summary
AGE, GRAVIDA, PARA, POA, C/O

Remedial O&G CT1,2 [note to myself]

CT 1: GDM case teaching by Dr. Akram
Booking at least at 6w
MOGTT when, result? Insulin unit? BSP controlled? HbA1C? U/S: congenital anomalies? polyhydramnios? macrosomia?
Use SFH to compare with POG
FHR must show u're counting for 1 min
if pre-eclampsia PE must check liver tenderness, epigastric pain

CT2: Placenta Previa case teaching by Prof Adibah
quickening at 28w? impossible, check LMP wrong date/abdomen too thick

how to present:

she noticed she is pregnant when UPT is done and confirmed her pregnancy after she experienced nausea, vomitting,...

Booking was performed at....
the parameters are as followed...
u/s done at....w, and showed fetus corresponding to dates, subsequent checking was done regularly, throughout her pregnancy, there was no hypertension,...

quckening at....w

1st dose of ATT was given at....w, subsequent dose at...w

at 29w, another u/s performed as routine procedure which show placental low-lyng,...otherwise no fetal abnormalities, however, never has APH,

ask any fibroid, previous uterine surgery (risk factor)

PE for placenta previa:
1. Pain? contraction pain can cause APH in placenta previa

2. Vital signs
Bp: rule out late onset of HPT, as pt has family hx
HR: Wolff-Parkinson white syndrome...due to hyperactive thyroid

3. pallor, signs of anemia, make sure pt not in dilutional anemia, Hb enough to compensate when APH happen

4. edema, she is at risk to develop HPT, so if very gross edema, assess renal problem...

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.

Case discussion- PV leaking liqour

Discussion points:

further history of per vaginal leaking of fluid:
colour, amount, smell, blood?, pain?, mucus?
trauma/fall?, onset, after sexual intercouse?,
is it sign of labour?

is it from vagina/ urine? colour, odour

2 full term vaginal deliveries:
episiotomy, spontaneous/ induced?, complication,
any congenital abnormalities

Booking, as early as 10 weeks
how you suspect pregnancy? (UPT +ve?)
reason for late booking?
parameters?
height, weight, bp, urine protein&glucose, VDRL,
HIV, Hep B, Hb, blood group, rhesus

examples of hematinics,
Folate, Vitamin B12/B complex, Iron(Ferrous sulphate),
Vit C

Calcium

Obimine/Orbical

Slightly overweight, PR slightly increased,

Febrile(high grade):
baby temperature is 39.5
onset, pattern,
nausea, vomitting
URTI: chills, rigors, night sweat, sorethroat, cough
UTI: painful micturition, itchiness
any reduced fetal kicks?
immunization: ATT, Rubella (school times?) , Hep B
Primigravida: 2 dose ATT
Multigravida: 1 dose ATT

fever,
exo/endo pyrogens-->macrophages, T-cell produces interleukin-->
hypothalamus produces prostaglandin E2---> increase temp set point
-->muscles contract produce heat

3rd trimester: 28-40th weeks

Possible causes of leaking liquor:
UTI, sign of labour, premature rupture of membrane

earliest to detect pregnancy:22 days after LMP

when does the fetal heart started to be heard?
when mother can feel kicking?

FBC: check for infection(WBC count)
patient pallor in PE? check for anemia (Hb)
VDRL, Hep B,

Blood C&S, check for infection

Urine FEME, C&S

Vagina swab: source of infection

TPHA?

A+, Hep B surface antigen n antibody -ve, VDRL +ve in low dilution
HIV screening -ve, Hb 11.8, WBC: 16x10^9,

Vagina swab: beta hemolytic group B streptococcus

TPHA: Trepenoma pallidum

Learning issues:

1. causes of leaking fluid + causes of fever during pregnancy, harm to the fetus 
2. immunization during pregnancy + TORCHES( vertically transmitted infection) 
3. normal pregnancy changes? weight increased during pregnancy, guidelines?
4. reasons for smaller/larger symphysio-fundal height
5. antennetal checkup schedule, baseline
6. Iron requirement during pregnancy
7.when does the fetal heart started to be heard? + Principles of cardiotocography + when mother can feel kicking?
8. significance of screening for Hep B, HIV;
9. importance of TPHA, principle of test VDRL, Normal flora of vagina 

10. indication for dexamethasone + principle of choosing antibiotics for pregnant mother
11. Criteria & causes of fetal distress
12. Physiology of liqour, causes of poly, oligo and treatment + Amniotic fluid index, how to determine poly/ oligo

Notes on obstetrics history taking and physical examination (adapted to culture in Asia)

HISTORY

Patient identification

1.      Name

2.      Age

3.      Ethnic

4.      Lady

5.      Occupation

6.      Address

7.      Date of admission and clerking

8.      Informant

9.      Gravida

       - No. of pregnancy irrespective of the outcome

10.  Para

      - No. of delivery of ≥ 24 wks of gestation / > 500g (including stillbirth)

      - Twins are counted as 2

         e.g: never pregnant before G1P0. If she delivered twins & come back next time at

                12 wks, she will be G2P2 (twin)

      - If abortion (delivery < 24 weeks / < 500g), put ‘+ number of abortion’

         e.g: If abortion for 2 times and now she pregnant, she will be G3P0+2

*miscarriage occurred by accident, abortion occurred by planned surgery

11.  Last menstrual period (LMP)

       - 1^st day of last menses (ask hari pertama tak boleh sembayang)

       - LMP reliable must fulfil Naegele’s rule:

  * Sure of date

  * Regular menstrual cycle 28-30 days

  * Not on breastfeeding within 2 mths

            (If exclusively breastfeed, ovulation will not start in 1^st 3^rd month; if not

            exclusively, ovulation will occur at the 3^rd month)

        * Not on hormonal therapy within 3 mths

(mention the Naegele’s rule in history to see one is fulfill

       - If LMP not reliable:

  * Ask about early U/S (<20w)

            # 1^st trimester: difference 1 wk;

               2^nd trimester: difference 2 wk

               3^rd trimester: difference 3 wk

            # If the scan date is corresponding to the EDD, use EDD

            # If not corresponding, use the rEDD

            # POA that is counted from rEDD should be presented as POG (period of gestation)

Mention date for each U/S

For U/S 1^st trimester is the most accurate reading the discrepancy of rEDD compared to real date of delivery is 1 week.

For 2^nd trimester is 2 weeks discrepancy.

For 3^rd trimester is 3 weeks.

12. 

Other ways for dating: - UPT in dilution (1st positive 6-8wk) - quickening - uterine size corresponding to date - histopathology (presence of    chorionic villi- either passed out    spontaneously or from curettage    specimen)

Expected date of delivery (EDD)

- LMP + (9 moths 7days)

13.  Periods of amenorrhea (POA)

- counted from LMP to date of clerking

- present as ?weeks ?days

1 month= 4w + 2 days

2 months= 8w+ 5 days

3 months= 13w

     (prof adibah: every 3mth- add 1 week (3x4+1=13))

Comment:

The LMP is ___. It fulfils the Naegele’s rule. U/s was done at___ weeks which is corresponds to the EDD, therefore the EDD is___/ not correspond to EDD, therefore, the rEDD is___

* u/s scan: normal EFW

 - 24 wk: <1kg

 - 28 wk: 1.4-1.8kg

 - 32 wk: 2kg

 - 36 wk: 2.4kg

* normal weight gain:

 - 1^st 5mths: 0.5kg/mth

 - 2^nd 5 mths: 0.5kg/wk

Chief complaint

- Complaint + duration

History of presenting illness (HOPI)

- ask about chief complaint or any related question (associated sx/ risk factors/ cx)

- at the end of HOPI, ask about:

   * is patient in labour ?

      # contraction pain (how many times in 10mins? each contraction last for how long?

         regular? ↑ frequency and intensity?)

      # show- blood stained mucus passed PV

      # leaking liquor

   * fetal movement (good or ↓?)

     (ask the patient to count how long for fetal kicks for 10x, look  for the pattern of time

      completion- see the FKC)

FKC is a chart given at 3^rd trimester. Counted everyday from 9am-9pm. 1 KICK= 1 kick, or multiple kicks at one time, or 1 rolling. When mother sensed there are 10 kicks in total, she will made a tick at the time of completion of 10kicks(eg. Usually 1pm) at the chart. Another version is fast Fetal Kick Chart which only required counting 10 kicks in 2 hours, for busy mother. If kicks is less than 10 in a day(from 9am-9pm) indicative of reduced fetal movement.

London used Cardiff county method.

Fetal movement reduced, possible causes:

1.      Mother is fatigue, (involved in strenuous activity), less energy provided to baby

2.      Infection, if mother is having fever, fetal temperature is 1 degree Celsius more than the mother

3.      Trauma, in kampong, mother rode motorcycle or multigravida mother, the abdomen was kicked by her naughty children in fight

4.      Mother took sedatives

5.      Mother is malnourished, can be due to taboo(wrong thoughts about some food could cause harm to baby), nausea and vomiting(cannot eat much)

6.      Mother went for lenggang perut, reposition of baby by traditional healer causing cord around neck

7.      Baby is hypoxic, placenta insufficiency

8.      Increased in amniotic fluid or uterine contraction (cannot sense the kicks)

9.      Sometimes can be just due to mother too busy and not correctly count or too worried as she had experienced miscarriage or similar experience in previous pregnancy

10.  IUD is usually dued to abruption placenta, no kick at all.

Hx should mention –ve trauma, -ve sx of infection(eg. UTI sx), -ve goin to traditional healer, and diet balance.

**no need systemic review if all +ve n –ve sx had been illicited

- briefly about what is done in hospital

	Comment: She missed the period for __weeks. She did the UPT and was found to be +ve

 

Systemic review

History of presented pregnancy

Present HOPP in sequence, 1^st, 2^nd, then 3^rd trimester

- suspect pregnancy

  * why- missed period? Quickening? Abdominal distension?

  * when?

Missed period state when, at 6^th week since last period? Did she do UPT herself? When UPT is +ve, did she go to the clinic immediately, if no state why?

*UPT can only be positive at 2 w after ovulation which means 1 mth after the last period

- confirm pregnancy

  * when? where? who?

  * u/s?

Which clinic?

- booking= 1^st antenatal check-up

  * when? where? (bila ambil kad merah?)

  * physical examination

ANC: - Monthly till 28 weeks - Fortnightly till 36 weeks - Weekly till delivery

     # height, weight, BP, fundal height

  * investigations

     # blood test- blood group, rhesus, Hb

Comment: - blood and urine test were done    and were normal - screening test were not reactive - mOGTT was done at __wk with    reading __/__ - BP, height and weight were   normal - For the subsequent ANC, u/s    scan and fundal assessment    show fetal growth correspond to    gestational age and amniotic    fluid is adequate, no congenital    abnormality detected

    # Urine test- glucose, protein

    # VDRL (reactive/non-reactive), HIV

- mOGTT done? Indication? When? Result?

- subsequent antennal check-up

  * when- patient attend all ANC follow schedule?

  * parameter- normal?

  * weight gain 

  * BP

  * Uterine size

  * Hb

  * Urine glucose and protein

  * U/S done?

     - When?

     - Any abnormalities

Things to be stated from booking: Height, weight, bp, urine protein n glucose, hb, blood group, rhesus, VDRL, Hep B, HIV

(try use clerkin in osce/long case, ask the patient whether she remembered the parameters instead of copy from the redbook, if she cant remember, ask if doc comment anythg, any abnormalities)

Antenatal checkup is done every 4w in 1^st tri, every 2 w in 2^nd tri and every week in 3^rd tri

10-12w  : correct dating (dating scan) 20-22w  : to detect any congenital abnormality 28w        : to detect location of placenta 32w        : to final confirm the location of placenta

 

Quickening: - Primigravida= 18-20w (5 months) - Multigravida= 16-18w (4 months)

- Quickening- 1^st fetal movement

  * When?- bila berasa bayi pertama kali bergerak?

  * ↑ intensity and frequency?

- Signs and symptoms of pregnancy

  * nausea and vomiting

  * breast discomfort/engorgement

  * frequency of urination

  * constipation

  * ankle edema

  * backache

- immunization:

  * anti-tetanus toxoid (ATT) - IM 0.5mL

    # Primigravida

       - 1^st dose after quickening (20-24w)

       - 2^nd dose - 4-6 weeks after 1^st dose (24-28w)

       - latest 4 wks before delivery

    # Multigravida

       - One dose only after quickening (usually at 32-36w)

  * Hepatitis B (3X)

  * Rubella (usually during school times)

Past obstetric history (POH) – no need present if primigravida- only marital status

- Marital status

  * When married?

  * Married at age?

  * 1^st married? the only married? (related with pregnancy induced hypertension)

  * Consanguineous married? (related with chance of genetic disease transmission)

- no of children? How many boy and girl?

- for each pregnancy:

  * age

  * sex

  * where deliver- hospital? Clinic?

  * when- full term? POG if preterm?

  * method of delivery

     # spontaneous vaginal delivery

     # induced vaginal delivery: Postdate, PIH, GDM, heart disease etc

     # assisted vaginal delivery- forceps? Vacuum? Why? Prolonged labour, heart dz etc

     # lower segment caesarean section- elective/emergency?

  (a) why? where? POG?

  (b) duration of staying in wad- 5 days if no Cx

  (c) cx- PPH, blood transfusion, fever, scar pain

  (d) any VBAC after the caesarean section?

  * ask the indication except SVD

  * birth weight

     # low birth weight < 2.5kg

if all deliveries are normal, summarize ‘no AP,IP,PP Cx’ at the end of presentation of POH

     # big baby > 4.0kg

  * antepartum Cx- APH, placenta praevia,

  * intrapartum Cx- poor progress, fetal distress

  * postpartum Cx- PPH, lochia changes, fever

  * breastfed till when?

     # normally for 2 yrs (exclusive 6 months)

     # if stop early/bottled feeding-why?

- if abortion

  * POG?

  * why?- spontaneous? Trauma?

  * signs and symptoms before abortion.

  * dilatation and curettage (D&C) done?

# D&C- incomplete abortion

# no D&C- complete abortion

- if >5 children

  * Summarize all the uneventful deliveries (FTSVD with no Cx)

  * eldest what age? youngest what age? birth spacing?

  * all born through FTSVD with no AP, IP, PP Cx

  * BW range

  * breastfeeding

  * developmental growth

  * Mention the abnormal deliveries separately

- spacing

  * good spacing- 2 years apart

  * abnormal-> 6 years, why? contraception? Subfertility?

- contraceptive method:

  * OCP/ injection/ implantation

  * IUCD

  * condom

For complication of C-sec,

1.      Anesthesia, half or full

2.      Bleeding? Any blood transfusion

3.      Injury to organ, bladder? Rectum?

4.      Post-op, well?

Csec: indication to do, complication, venue which hospital

Past Gynaecology History (*combined together and state gynae hx)

- menstrual history

  * when attain menarche (1^st menstrual period)? Normal 9-16 y/o

  * menstrual cycle

Written as: Age of menarche    flow                                   cycle

     # regular/irregular

     # cycle- normal 21-35 days

     # flow- normal 2-8 days

     # heavy flow- normal 1^st-3^rd day

     # pad used-average blood loss 30ml

     # problems

 (a) dysmenorrhoea- painful menstruation

 (b) menorrhagia- prolonged and increased menstrual flow (blood loss>80ml)

 (c) intermentrual bleeding

 (d) postcoital bleeding

 (e) dyspareunia- painful coital

- pap smear history

  * how many times?

  * when was the last one?

  * result normal?

Past medical and surgical history

- hx of chronic illnesses: HPT, DM, heart disease, asthma, TB

- any surgery procedure done before?

Family history

- siblings and parents- health problem

- family hx of HPT, DM

- Family hx of twins preg or congenital abnormality

Personal and social history

- education level

- husband’s age, occupation (type, work place, daily come back), income

- house condition: stair, toilet and etc

- how frequent husband visit her?

- who take care of her children during admission?

- how does she contact her children?

- smoking? alcohol?- both husband and pt

Transportation at home, some pregnant lady ride motorcycle

Nearest clinic from home? Convenient to checkup?

Drug history

- hematinics

  * iron- besi (T. ferrous fumarate 200mg contain 60mg iron)

  * folate- ubat kuning kecil (5mg/tablet)

  * vitamin B12 &C

- over counter drugs: Obimin (contain iron, folate, Vit B12 and etc)

- traditional medication

- allergy/ side effect

Obimin contained all four, iron(ferrous fumarate, folic acid, B12 and Vit C)

Obical include obimin plus calcium

The all four are enough for what required for mother

Dietary history

- normal balance adult diet

- allergy

- if patient is diabetic, details diet history are needed, including dishes for every meals,

  who give the advice? was pt understand, give eg of food?

Summary

Name/ age/ race/ gravida/ para/ POA/ chief complaint/ complication/risk factor/ management that been given/ in labour or not/ fetal movement

lightening: primigravida at 34 wk when head enter the pelvic brim (mother will felt sudden relief of SOB or breathing discomfort)

PHYSICAL EXAMINATION

Before start

- introduce pt to dr

- introduce dr to pt

- ask permission from pt and ask for chaperone

- position: Lying flat

- pt comfortable? With both hands at the side of body

- pt can sit upright if she had sign of cardiac disease or grossly enlarged uterus (cause

  splitting of diaphragm)

General examination

- Inspection:

v  Comfortable, lying flat/ propped up supported with one pillow

v  Alert and conscious

v  Well orientated to time, place and person

v  In pain, in respiratory distress

v  Hydrational and nutritional status

v  Gross deformity

v  Abnormal movement

v  Attachment

v  Height : <148cm and small shoe size→ smaller pelvic capacity→ CPD

v  Weight

v  Hand:

·         Warm/cold, dry/sweat

·        

* Mother with HPT is not advice to wear ring (edema)

Pale

·         Palmar erythema (↑ estrogen level)

·         Koilonychias (iron deficiency)

·         Peripheral cyanosis

·         Clubbing

·         Capillary refilling

·         Collapsing pulse (pathological/physiological d/t hyperdynamic circulation)

v  Vital sign:

·         Pulse rate, volume and rhythm

·         BP (sitting position or prop up 45 degree) pregnancy induced HPT dx after 20 w with measurement of high bp in 2 occasions

·         RR

·         Temperature

v  Neck:

·         JVP- if indicated

·         Thyroid swelling (normal for pregnant mother as they usually experience iodine deficiency)

v  Face and eyes:

·         Jaundice in sclera

·         Pallor on conjunctiva

·         Mouth, lips and tongue:

- Tongue: Moist/ Coated

      - Oral hygiene

      - Central cyanosis

      - Glossitis- nutritional deficiency

      - Angular stomatitis- nutritional deficiency

      - Oral thrust- candidiasis

v  Leg:

·         Pitting edema

·         Dilated vein

v  Examine reflex and fundoscopy for hypertensive patient

Specific examination

(a)  Before start:

v  Ask permission

v  Exposure- xyphisternum to symphysis pubic (not nipple line to mid-thigh!)

Prof Nora- expose from lower border of bra to pubic symphysis (ask chaperone or examiner to expose the patient)

(b) Inspection:

v  Abdomen is distended with gravid uterus evidenced by

·         Linea nigra

·         Striae gravidarum-red, present stretch mark

·         Visible fetal movement

(Prof Nora- show the findings by pointing it with thumb)

v  Striae albicans- white, previous stretch mark

v  Move symmetrically with respiration

v  Umbilical: Centrally located and Inverted/flat/everted

v  Dilated vein

v  Surgical scar

·         Laparoscopy: Umbilical; Small, easy to miss

·         LSCS: Transverse suprapubic/ pfennential scar

·         Upper segment caesarean section: Paramedian

     * If there is scar

        - site, size, shape

        - well heal/infected/keloid

        - surrounding skin- pigmentation, redness, swelling, ulceration, discharge

        - look for scar tenderness during palpation. (palpate around the scar to look for

          uterus tenderness)

v  Inguinal cough impulse

(c)  Palpation: (examiner sit down n patient lie flat!!!!)

v  Superficial palpation: Soft, tenderness

     (comment- the abdomen is soft and not tender)

v  Deep palpation: Contractile uterus

     (comment- the uterus is soft, not tender and not irritable)

     (if present of contraction- palpate at the fundus and time the contraction)

    (don’t perform deep palpation for Prof Nik Haslina)

v  Fundal height

·         Symphysiofundal height

- Palpate the fundus using ulnar border of left hand from xiphisternum

12w- just above suprapubic 22w- umbilicus 36w- xyphisternum

- Put the tape with inch scale on top

- Palpate for symphysis pubic (midline, 1^st bony prominent)

- Measures in cm (1w= 1cm)

·         Clinical fundal height (some dr no need present this…)

- Estimate how many finger breadth the fundal palpable below xyphisternum/above

  umbilical

  (don’t use finger to count- Prof Nik Haslina)

- Count fundal height (1w=1cm)

     * After 36w- below xyphisternum (less 1cm for every week) but there is fullness of  

        flank and cannot get below the costal margin)

     * Mention as ‘’fundal height is __ weight’’

     * Fundal height corresponding to POA?- allow +/- 2cm

Example 1: pt in 38w POA

The symphysiofundal height was 33cm. The fundus was palpable one finger breath below xyphisternum. There was fullness of flank and I could not get below the costal margin. The clinical fundal height was 38w which was corresponding to the POA.

Example 2: pt is in 34w POA

The symphysiofundal height was 34cm. The fundus was palpable 1 finger breath below xiphisternum. There was no fullness of flank and I was able to get below the costal margin. The clinical fundal height was 34w which was corresponding to the POA.

Notes:

- symphysiofundal height is not very reliable in assessing the uterus size if you only see your patient for the 1^st time because it is influenced  by other factors, e.g. obese and thin, amount of amniotic fluid, fetal weight.

- symphysiofundal height is useful when you f/u the patient during antenatal visit. You can assess the ↑ in symphysiofundal height compared to last visit.

Pawlick grip: - can not performed by medical student - using thumb and pointing finger to grip at   the fetal head

(d) Grips (Leopard’s)

- Fundal grip

·         face patient

·         feel the fundus using both hand

- lateral grip

·         face patient

·        

* causes of head not engaged: - placenta praevia - polyhydramnios - pelvic mass/ uterus mass (fibroid) - CPD

fix one hand and palpate with another hand

- pelvic grip

·         face patient’s leg

·         feel with both hands

·         feel for engagement

- comment on:

- singleton/ twins

- Lie- relation of long axis of fetus to the long axis of uterus

  * longitudinal (normal), transverse, oblique

- Presentation- pole of fetus that presents on pelvic brim

  * cephalic (normal), breech

- Engagement (for cephalic presenting)- the largest presenting part enter the pelvic brim

·         If ballotable= not engaged

·         use 5 fingers to measure

·         if 3 fingers palpable per abdomen= 3/5th palpable

·         2/5th palpable per abdomen= engaged

- liquor volume- clinically adequate?

- fluid thrill if excessive liquor

- estimated fetal weight

Polyhydramnio: when palpate hand need to go deep more than 8cm to feel fetal

Oligo: hand less than 2cam

·         Head- round, hard, ballotable ·         Buttock- broad, firm, not ballotable ·         Fetal back- smooth, firm, continuous ·         Fetal parts- bulging ·         Excessive liquor (large fundus, can’t feel fetal parts, + fluid thrill) ·         Reduced liquor (tense abdomen, easy to feel fetal parts, small fundus)

Reason oligo: HPT, placenta insufficient

(e) Auscultation:

·         For fetal heart sound-present/ not present

·         Use pinard (don’t stress on look at patient face,as long as

·         Comfortable n hands off pinard)

·         Listen at anterior shoulder

·         Dont press too hard and both hands off when listen!!

·         Must count HR (normal 120-160)

(f) Complete examination with:

·         Per vaginal examination (C/I- in PV bleeding/ leaking liquor)

·         Breast examination: important for breastfeeding

·         l/n examination

·         Others systems if relevant

Present:

- From inspection, the abdomen was distended with gravid uterus evidenced by presence of linea nigra, striae gravidarum, visible dilated vein and fetal movement. There were __    striae albican and ___ scar (type, length, well healed/not, sign of inflammation, tenderness). The umbilicus is centrally located and ___

- On superficial palpation, the abdomen is soft and not tender.

- On deep palpation, the uterus is soft, not tender and not irritable.

- The SFH was ___ cm correspond to POA/POG. The fundus is palpable __FB below xiphesternum. __ fullness of flank and ___ get below costal margin. The clinical fundus height is ___wk

- There is ___ fetus with ___ presentation, ___ lie. The fetal back is at maternal __side and fetal part at maternal __ side. Fetal head is __/5^th palpable, __ engaged. Fetal movement __ felt and __ uterus contraction. Liquor is clinically __. FW is __kg (range with interval 0.2)

- Fetal heart was heard at __ quadrant using  Pinard and heart rate is __ bpm

# Prof Adibah: evidence of gravid unterus: only fetal movement and fetal heart

Investigate

U/S
: check anencephaly, cord around neck, growth restriction

CTG: Fetal distress: check whether HR normal, whether there is acceleration (normal)

Urine FEME: check UTI

FBC: ANEMIA, INFECTION

Placenta blood flow, check using doppler ultrasound,

Normal position of placenta, upper segment

Mx for reduced fetal mov:

Admission, bedrest, fetal kick chart, CTG daily