Nur Syaheeda Binti Narudin BMS13091290

Obstetric Case

Identification Detail

Name: Noorain Binti Ahmad G & P: G4P3

Age: 33 years old LMP: 23rd February 2015

Registration Number: SB00191045 EDD: 30th November 2015

Race: Malay Gestational period: 38 weeks and 1 day

Job: Clerk (Assistant Logistic) Date of admission: 16th November 2015

Address: Ground floor Klang Apartment Date of clerking: 17th November 2015

Marital Status: Married for 9 years

Chief Complaint

Madam Noorain was referred from the Sungai Buloh Hospital O&G clinic to Sungai

Buloh Hospital because of elevated blood sugar level on insulin and schedule for

induction of labour.

History of Presenting Pregnancy

It is an unplanned but welcomed pregnancy. She missed her menses for one month

and did urine pregnancy test twice but she was still not convince. She claimed that the

result was not clear. She confirmed her pregnant during her first ultrasound at Clinic

Puteri and the pregnancy is 14 weeks period of gestation. But at the same time a 5cm

fibroid was seen in the ultrasound image. She did booking at Klang Hospital and the

colour code was green. She went for antenatal check up once a month. She did

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experienced morning sickness in early pregnancy. The blood count is normal, her

blood group is B+. No albumin and sugar in urine. Hep B, HIV, VDRL Syphilis result

is non reactive and she has rubella antibody. On the 18 weeks of pregnancy, during

her antenatal check up, modified glucose tolerant test (MGTT) was done and the

result revealed that the result is abnormal she was diagnosed with gestational diabetes

mellitus (GDM). It is not a pre-existing diabetes. The fasting blood glucose was

6.4mmol/L and the two hours postprandial result was 9.5mmol/L. She was referred to

Sungai Buloh Hospital and the colour coding was changed from green to yellow. At

first she was on diet control but starting in her 28 weeks period of gestation she

started using insulin. Up to 26 weeks she did the antenatal check up once a month.

But starting 27 weeks period of gestation, she was asked to come for antenatal check

up twice a month. In the 31 weeks period of gestation during her 7th ultrasound scan,

she was said to have type 1 placenta previa. But during her last ultrasound, which was

in the 36 weeks period of gestation she was informed that, the placenta already go up

back to the original position. She felt quickening in the 5th month period of gestation.

She was easily tired at the last trimester of pregnancy. She also loss her appetite. She

gains 6kg throughout this pregnancy. During her last antenatal check up in the 36

weeks period of gestation her urine colour was dark brown. Her hemoglobin (Hb)

level was low; 8g/dL and she did experienced palpation. She was prescribed Iberet

once oral daily. She felt a bit of contraction and was schedule for induction on the 17th

November.

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Past Obstetric History

Madam Noorain is a G4P3 had her first child in 2007 at Metro Maternity Hospital.

There is no antepartum complication for the first child. It is a full term baby boy with

2.2kg of weight, by spontaneous vaginal delivery with normal Apgar score. There is

no intrapartum and postpartum complication. The baby had jaundice for a week. The

baby was breastfed for two years and follows the Ministry of Health vaccination

program. The second child was born in 2009 at Sungai Buloh Hospital. There is no

antepartum complication. It is a full term baby girl with 2.8kg. The baby was in

unstable lie and delivered by normal vaginal delivery in breech position with normal

Apgar score. After delivery, she claimed had to undergo minor surgery to remove

hematoma left in her uterus. The baby was breastfed for 3 years and follows the

Ministry of Health vaccination program. Her third child was born in 2013 at Sungai

Buloh Hospital. At the labour room, the baby changed position to transverse which

made her to undergo emergency low section caesarean section (EMLSCS). She told

by the doctor that the baby changed position due to increase in liquor

(polyhydramnios). It is a full term baby boy with 3.13kg of weight with normal Apgar

score. The baby has jaundice for a month. The baby was breastfed one and a half year

and follows the Ministry of Health vaccination program.

Menstrual History

Madam Noorain attained her menarche at the age of 14 years old. The period is

regular with 5 to 7 days flow in a 30 days cycle. She bleed more on the 1st to 3rd days

and using 7 pads. She experienced mild pain during menses with some clot. The clot

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comes out on the 1st and 2nd day. Her first day of the last normal menstrual period was

on the 23rd February 2015 and she was expected to due on the 30th November 2015.

Gynaecology History

During her first ultrasound in the 14 weeks, a 5cm fibroid was seen in the ultrasound

image. But during her antenatal check up in 16 weeks period of gestation, the fibroid

shrunk to 3cm. She did both the ultrasound at Clinic Puteri. In 18 weeks period of

gestation, the ultrasound done at Klang Hospital revealed no fibroid. She never do pap

smear. Never take HPV vaccine. She never takes any contraceptive.

Medical & Surgical History

There is no significant medical history. No preexisting diabetes, no hypertension, no

thyroid problem. She never been admitted for any other reason. She had a minor

surgery to remove hematoma after her 2nd delivery in 2009 and an emergency

caesarean section for her 3rd child in 2013.

Medication and Allergy History

Currently she only takes Iberet once daily orally. Hematinic and also Insulin for her

gestational diabetes mellitus (GDM) 10cc on night. She has no allergy to any

medication or food.

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Family History

No consanguinity between Madam Noorain and her husband. There is no twin in her

family. No family member with disable child. No cancer runs in her family. Her

mother and brother have diabetes mellitus and hypertension. Her father has

hypertension.

Social History

She lives at ground floor of Klang Apartment. She never takes alcohol or smoke. Her

husband works at the same company as supervisor. He is not a smoker and never take

alcohol. She used to go jogged before pregnant but now she only went for a walk at

park. She eat a normal malay diet but due to GDM she on diet control.

Summary

Madam Noorain is a 33 years old Malay lady, work as clerk, G4P3 who is in 38

weeks and 1 day period of gestation referred from Sungai Buloh Hospital O&G clinic

with GDM on insulin. She was admitted on the 16th November and scheduled for

induction of labour on the 17th November. She had one normal vagina breech delivery

with 2nd baby and emergency low section caesarean section with her 3rd baby due to

transverse lie. After her 2nd delivery she had a minor surgery to remove hematoma.

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General examination

Madam Noorain is awake, alert, conscious and responds well to the surrounding. She

lying supine comfortably with brannula at the dorsal side of right hand and nametag is

attached to her left side. The hand were warm, pink and moist. The capillary refilling

time is normal. No jaundice or pallor noted on sclera and conjunctiva. No facial

puffiness noted. No central cyanosis. The oral mucosa is well hydrated. No presence

of neck swelling. There is no sign of edema at legs.

Her current body weight is 56kg with height of 1.53m. Her calculated BMI is

23.9kg/m2. Her recorded blood pressure is 124/60 mmHg and her pulse is 79 beats per

minute (bpm). Her pulse is regular with good volume. Her respiratory rate is 20

breaths per minute.

Upon palpation her liver and spleen in non palpable. The s1 and s2 heart sound heard.

There is no cardiac murmur . The lung sound is clear.

Obstetric Abdominal Examination

On inspection, the abdomen is distended by gravid uterus with evidence of linea nigra

and striae gravidarum. The umbilicus is slightly flat and in midline position. There is

one caesarean scar with 5 cm measurement 4 cm above the pubic symphysis. Fetal

movement seen upon inspection. There were prominent superficial vein seen. The

abdomen moves symmetrically with respiration.

On superficial palpation, the abdomen is soft and non-tender. No abdominal guarding

seen. The symphysiofundal height is 39 weeks, which is one week bigger than the

gestational age of fetus. The fetus is in longitudinal lie with cephalic presentation. The
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head is 5/5th palpable. The fetal back is felt to maternal left while limb at the maternal

right side. The fetal heart beat sound is heard below the umbilicus at the lower left

quadrant using stethoscope. The liquor is adequate.

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Discussion

Gestational diabetes mellitus (GDM) is defined as any degree of glucose

intolerance with onset or first recognition during pregnancy. The definition applies

whether insulin or only diet modification is used for treatment and whether or not the

condition persists after pregnancy. The HbA1c level in early pregnancy can correlate

well with the risk of early fetal loss and congenital abnormality. Even increase in

more than 10 percent of HbA1c level can increase the risk fetal dead. Diabetes

therapy should be intensified and adequate contraceptive used until the glucose level

is good. In pre-pregnancy the HbA1c level should be maintain at 6.5% and pre-meal

glucose level of 4 to 7mmol/L or postprandial more than 7.8mmol/L.

Screening for GDM in early stage is important so that prevention can be done

before it becoming worst. To do MGTT, first asked the patient to fast from midnight

(12 am) till the next morning. The patient should also be told to bring her breakfast

during the check up. Then, the next morning during check up, a venous blood was

taken to check for fasting blood glucose. Then tell the patient to drink 75g glucose

solution with 250ml water. Patient should drink it within 10 to 15 minute. Wait for 2

hours and later a postprandial blood glucose level was taken. Patient also should be

told to sit and rest after the procedure and asked to take her breakfast that she bring

from home . The MGTT post prandial blood glucose more than 11.1 mmol/L is

considered diabetic.

There are a few risk factors of women which can be screen for GDM. Firstly,

pregnant mother with BMI above 30kg/m2. Second, previous baby weighing 4.5kg or

above. Third, have previous gestational diabetes. Next, first-degree relative with

diabetes. Next, two or more episodes of glycosuria on routine testing. Previous

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unexplained perinatal death, polyhydramnios and lastly, family origin from high

prevalence area (South Asian, black Caribbean and Middle Eastern).

GDM can affect both the mother and fetus. Fetus is prone to get congenital

abnormality. Apart from structural malformations, fetal macrosomia is the most

common problem associated with traumatic birth, shoulder dystocia and possible

hypoxic damage. Hyperglycaemia in fetus results in the stimulation of insulin, insulin

like growth factors, growth hormone and other growth factor which in turn stimulate

fetal growth and deposition of fat and glycogen. Macrosomia may be associated with

birth trauma for the neonate and birth canal laceration. In diabetic pregnancies,

sudden, unexplained late stillbirth usually occurs. Maternal morbidity in pregnancies

are related to cardiac diseases such as coronary artery disease. There is also high risk

of pre-eclampsia in women with diabetes particularly in women with coexisting

microalbuminuria or frank nephropathy. Diabetic retinopathy can also progress. There

is also high incidence of infection, severe hyperglycaemia or hypoglycaemia, diabetic

ketoacidosis and complication that may arises from operative delivery rate.

For management, patient should be monitor and managed in a combined clinic

with an obstetrician and physician. Dietitian input is also important for patient to

control her diet to prevent the using of insulin. If the women come with history of pre-

existing diabetes, she should be referred directly to hospital at booking. Plan should

be set out earlier to control the glycaemic, renal and retinal, screening, fetal

surveillance and plan for delivery.

For this patient, she was at 38 weeks and 1 day period of gestation. She was

admitted in ward and schedule for induction of labour. The fetal heart rate (FHR) is

monitored twice a day using cardiotocograph (CTG) and the nurse in charge should

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inform if there is anything suspicious with the FHR result. Patient also given a fetal

kick chart (FKC) and asked to monitor the baby movement within 12 hours. Once the

fetus kick for 10 time minimums, even if it is not 12 hours yet, patient can stop

monitor. She should inform if there is reduce in fetal movement. She also continues

taking her subcutaneous insulin 10cc at night.

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