SAMPLE OF OBSTETRICS CASE WRITE UP

Introduction
Madam ZZ, a 36-year old Malay lady, Gravida 5 Para 3+1 currently at Period of
Amenorrhoea (POA) of 31 weeks and 5 days that was calculated based on her Last
Menstrual Period (LMP) on 26th of December 2018. She was referred from Kepala
Batas Hospital (KBH) to Seberang Jaya Hospital (SJH) on 30th of July 2019 for
expectant management of pre-eclampsia after discovery of hyperuricaemia and
persistent proteinuria of 2+ with underlying gestational hypertension on methyldopa.
Last childbirth was on 2015.

History of Presenting Complaint

She was initially normotensive since booking up until 25 weeks of POG when during
routine antenatal checkup at Klinik Kesihatan Tasek Gelugor (KKTG) her blood
pressure was noted to be 145/85 mmHg on 2 consecutive readings done 4 hours
apart. She was then diagnosed as having gestational hypertension and started on α-
Methyldopa 250 mg TDS. Since the commencement of Methyldopa, her blood
pressure dropped and controlled within range of 110 to 135 for systolic blood pressure
and within 70 to 80 mmHg for diastolic blood pressure. The frequency of her
antenatal checkup visits was also increased from once a month to biweekly after the
diagnosis.

She had no pre-eclampsia symptoms and signs since the diagnosis up until 28 weeks
of gestation when proteinuria of 2+ was detected by urinalysis at KKTG. She was then
referred from KKTG to KBH for further management of pre-eclampsia. In KBH, upon
transabdominal ultrasound, she was told that she had oligohydramnios and her baby
was Small for Gestational Age (SGA). Cardiotocography (CTG) was also done once
everyday for early detection of any fetal distress and its result was claimed to be
normal. She also had completed 2 doses of IM Dexamethasone on 27 th of July 2019.
Her proteinuria persisted with the same value of 2+. However, on 29 th of July 2019, her
serum uric acid level was noted to be high with value of 659 μmol/L. Madam ZZ was
then immediately transferred on the next day to SJH for expectant management of
severe pre-eclampsia. This was done because adequate paediatric support was not
available in KBH in the event of early delivery with extremely preterm baby.

During current admission in SJH, proteinuria level was noted to increase to 3+ and her
serum uric acid also increased to 684 μmol/L. Methyldopa admission and daily CTG
monitoring are still continued. Patient started fetal kick chart at 28 weeks and
claimed to complete the fetal kick charting usually by around 5 pm everyday. No
change in antihypertensive agent was done for her at this point. She was informed
that she needs to deliver by 34 weeks of gestation and need to stay in the ward until
then.

The patient did not have any impending eclampisa symptoms during admission to
SJH such as severe headache, visual disturbance or epigastric pain. She had no
problem with micturition and defecation. She also did not have any fever, urinary
tract infection symptoms such as frequency and dysuria. The patient is overweight
with BMI of 27.9 kg/m2 (weight: 62 kg, Height: 1.49m) and she is considered to be in
the advanced maternal age group. She had a strong family history of hypertension in
which both her parents had hypertension. She has never had any hypertension
during her previous pregnancies. She did not have any pre-existing co-morbidities
such as hypertension, diabetes mellitus or autoimmune disease. Patient’s mother also
has never had hypertension during pregnancies.
 On 6th of August 2019, which was day 7 of admission, patient complained of
epigastric pain at around 9 pm and her blood pressure was noted to be very high as
systolic blood pressure reached 175 mmHg and systolic 110 mmHg. She was then
immediately started on IV Magnesium Sulphate (MgSO4) 4g bolus and followed by
maintenance dose of 1g per hour. IV Labetalol 200 mg TDS was also administered for
the patient. She was told that she might need to deliver anytime soon after
appropriate paediatric backups such as ventilator has been prepared for her
preterm baby. While waiting for the delivery, the patient’s blood pressure was still high
despite being on Labetalol thus she was started on IV Hydralazine and it was stopped
after 30 minutes when her blood pressure was reduced. At 7.16 am the next day (7th
of August 2019), patient was sent to the Operation Theatre for Emergency Lower
Segment Caesarean Section (EMLSCS) right after the availability of ventilator was
confirmed. She safely delivered a baby boy at around 8.05 am.
Antenatal History
This was a wanted and planned pregnancy in which the patient conceived
spontaneously without any reproductive assistance. This pregnancy was known after
she got positive result for Urine Pregnancy Test (UPT) that she did herself after she
missed her monthly menses around 5 weeks of gestation.

Madam ZZ went for booking during 12 weeks of gestation at KKTG. On booking, she
was noted as normotensive, not anaemic with blood group AB and Rhesus factor
positive and non- reactive infectious screening for HIV and VDRL. No proteinuria and
no glycosuria were detected. Her Body Mass Index (BMI) at booking was 27.9 kg/m2
with weight of 62 kg and height of 1.49 m. Dating scan was done at 14 weeks of
gestation and it confirmed her Estimated Delivery Date (EDD) on 2nd of October 2019.

She went for antenatal follow-ups once every month until 25 weeks of gestation at
KKTG. She was then diagnosed with Pregnancy-Induced Hypertension (PIH) and she
went for antenatal check-ups every 2 weeks for close monitoring of her blood
pressure. Only 2 ultrasound scans were done for her in KKTG; one was the dating scan
and another one for fetal growth monitoring at 20 weeks of gestation and fetal
growth claimed to be normal. Modified Glucose Tolerance Test (MGTT) was done at
24 weeks of gestation as she only had minimal risk factors for Diabetes Mellitus (GDM)
such as advanced maternal age of 36 years old. The MGTT result turned out to be
normal and patient did not have GDM. Throughout pregnancy, she gained 8 kg with
initial weight at booking of 62 kg to 70 kg currently. No excessive weight gain was
noted.

Past Obstetrics History

Patient has 3 children. All of them were delivered via Spontaneous Vaginal delivery
(SVD) and at term. The first child is a girl with birth weight of 2.38 kg who was born in
2009. The second child was born in 2012 and the third child was born in 2015. Both of
them are boys with birth weight of 2.8 kg and 3.1 kg respectively. She never had
Pregnancy-Induced Hypertension (PIH) during her previous pregnancies. There was
no history of any other medical illness antenatally and no intrapartum and
postpartum complications as well. All her children were breastfed for 1 year. They are
all currently alive and well. She had one first trimester miscarriage in 2011 with
Dilation and Curettage (D&C) done.
Past Gynaecological History
Madam ZZ attained menarche at the age of 14 years old. She had regular periods
with 28-day cycle and 7 days of menstrual flow. She never had any dysmenorrhea or
menorrhagia. There was also no intermenstrual bleeding. She has been married since
2007. She is still sexually active during current pregnancy but the frequency reduced
since 14 weeks of gestation. There was no dyspareunia or post-coital bleeding. The
patient and her husband only practiced natural contraception method. She had 3
pap smears done; one after each delivery and the results were normal.

Past Medical History

Insignificant. No history of hospitalization.

Past Surgical History

Insignificant

Medications History
She is only taking supplements prescribed by KKTG for her pregnancy such as Vitamin
B Complex, Iron Complex, and also Folic Acid. She used to take traditional
medications after each pregnancy for 3 months.

Allergies
She has no known drug or food allergies.

Family History
Her mother who is now 60 years old has hypertension and currently on treatment.
However, her mother did not have hypertension in her previous pregnancies and the
hypertension she is having now just started since she was 55 years old. Patient’s father
had passed away at the age of 65 years old due to myocardial infarction and he
had underlying hypertension. She has 5 siblings and one of them has heart disease.

Social History
Patient is staying with her husband, children and also her mother in a double-storey
house in Butterworth. She is working as a clerk in INTEL, Kulim, Kedah. She travels
around 30 minutes back-and-forth to Kulim everyday. She does not smoke nor does
she consume alcohol. Her husband is a non-smoker. They do not have any financial
problem. She does not wish to conceive again after this.

Systemic Review
Insignificant

Summary
Madam ZZ, a 36-year old Malay clerk, G5 P3+1, was referred from Kepala Batas
Hospital at 31 weeks and 5 days of gestation for expectant management of pre-
eclampsia. Patient has underlying Pregnancy-Induced Hypertension (PIH) on
methyldopa with proteinuria 3+ and hyperuricaemia. Fetal movement was normal
but evidence of oligohydramnios and Small for Gestational Age (SGA) were found on
transabdominal ultrasound scan.

Physical Examination (Done on 5th of August 2019)

General Examination
Madam ZZ was lying comfortably flat on the bed with no respiratory distress. Her
colour appears normal and her abdomen appears to be distended.

Vital signs
 Blood pressure: 147/85 mmHg
 Pulse rate: 74 beats per minute
 Respiratory rate: 18 breaths per minute
 Temperature: 37 degree Celcius
 Pain score: 0

Hand Examination
No pallor of palmar creases, capillary refill time was less than 2 seconds, no
koilonychia or leukonychia and no clubbing.

Face Examination
On eyes examination, no conjunctival pallor and no leukonychia were appreciated.
Upon mouth examination, dentition was good, no central cyanosis, no glossitis and
no angular stomatitis present.

Neck Examination
No neck swelling and no cervical lymphadenopathy.

Breasts Examination
Bilateral breasts were non-tender and soft with no palpable mass. The nipples on
both sides were everted.

Cardiovascular Examination
Patient’s apex beat was at the normal site which was at 5th intercostal space, mid-
clavicular line. No thrills or heaves was palpable. Heart sounds S1 & S2 were present
upon auscultation with no murmurs.

Respiratory Examination
Both lungs move symmetrically upon breathing. Trachea was at the center, not
displaced. Lungs expansion was symmetrical. Percussion note was resonant for both
lungs. Upon auscultation of lungs, vesicular breath sound with normal air entry and no
added sounds such as crepitations were appreciated.

Lower Limbs Examination

Pedal oedema was appreciated up until mid-shin levels bilaterally. No calf
tenderness or erythema was present. Patellar reflex was not brisk.
Abdominal Examination

Inspection

The abdomen was distended corresponding to a gravid uterus as evidenced by

cutaneous signs of pregnancy such as linea nigra and striae gravidarum. The
umbilicus was at the centre of abdomen and not everted. The abdomen was
moving with respiration. There were no scars and no dilated vessels.

Palpation

The abdomen was soft and non-tender. Symphysial Fundal Height (SFH) was 28 cm
which did not correspond to the gestational week of the fetus. A singleton fetus with
transverse lie and breech presentation was appreciated. The fetal back was on the
left side of the mother. Presenting part of the fetus was 5-fifths palpable and not
engaged. Liquor volume was reduced and estimated fetal weight was 2.0-2.2 kg.

Auscultation

Daptone was used to auscultate the fetal heart and get the fetal heart rate. It was
heard over the anterior shoulder of the fetus; which was found in between fetal head
and the umbilicus of the mother on the maternal left side. Fetal heart rate was 148
beats per minute.

Vaginal Examination

No vaginal examination was done by any housemen/medical officers/specialists on

this patient throughout her admission in the ward.
Management (Investigation)
Investigation Significance Result
Laboratory tests
Full Blood Counts To determine the baseline level of platelets Plt: 317.0 x103/μL
(Plt) and determine if patient has Hb: 12.1 g/dL
thrombocytopenia. Used also to monitor
progress of the disease hence can be used Both results were normal-
to assess the severity of pre-eclampsia (eg; no thrombocytopenia
HELLP syndrome) and no anaemia
Also to check for haemoglobin (Hb) levels to
look for anaemia.
Serum Uric Acid To assess whether there is any renal 637.0 μmol/L
impairment secondary to pre-eclampsia. High level of uric acid in
Increase in serum uric acid is the earliest sign serum (normal level:
that suggests reduced kidney function as 142.8-339.2 μmol/L)
uric acid is excreted through kidneys.
Renal Profile To serve as baseline values. Na+: 138 mmol/L
K+: 4.4 mmol/L
Urea: 4.9 mmol/L
Creatinine: 6.1 μmol/L
Urinalysis FEME (Full To detect any derangement in the kidney 2+ (in KBH)  3+ (in SJH)
Examination and function especially proteinuria level. Patient has increased
Microscopic level of proteinuria which
Examination) suggests that pre-
eclampsia is getting
worse.

24- hour Urine To reconfirm the proteinuria found on Uric protein level:
Protein urinalysis 1.68 g/24 h

Liver Function Test To assess for hepatocellular damage and Alanine transaminase
reduced liver function. This can happen due (ALT): 38 U/L (High)
to ischaemia of the liver secondary to
systemic vasoconstriction that happens in Albumin: 21 g/L (Low) –
pre-eclampsia. this result may suggest
chronic damage of liver.

Imaging/Scanning/Others
Transabdominal To determine the Amniotic Fluid index (AFI). Oligohydroamnios &
Ultrasound To assess the growth parameters of the fetus Small for Gestational Age
to plot on a growth chart to determine if (SGA) fetus
there is any Intrauterine Growth restriction
(IUGR)

Cardiotocography Done daily to assess fetal heart rate for fetal Ranged from 120 to 150
(CTG) distress anticipation beats per minute.

Fetal Kick Chart To monitor the activity of the fetus that might Completed 10 kicks
suggest any deteriorating condition of the everyday at around 5
fetus. pm.

Impending Daily pre-eclampsia charting done to Proteinuria raised to 3+ in

Eclampsia monitor signs and symptoms of impending SJH. Patient had
eclampsia including blood pressure, epigastric pain that was
proteinuria levels, epigastric pain and attended to immediately
headache. and patient was sent for
EMLSCS.
Management (Treatment plan)

Issues Intervention Done

Maternal
High blood  Since first discovery  Epigastric pain (impending eclampsia
pressure symptom):
Alpha-methyldopa 250 mg PO TDS
 Since occurrence of epigastric pain  Delivery:
Labetalol 200 mg PO TDS + Hydralazine IV (for 30 minutes only
after no drop in blood pressure after labetalol administration)
 Delivery  Current:
Labetalol 200 mg PO TDS
Eclampsia After occurrence of imminent eclampsia symptom (epigastric pain):
Prophylaxis IV MgSO4 4g bolus and followed by maintenance dose of 1g per
hour.
MgSO4 toxicity MgSO4 toxicity charting was done for this patient after the
administration of MgSO4 as eclampsia prophylaxis. This charting
focused on signs that suggest MgSO4 toxicity such as reduced
patellar reflex, reduced respiratory rate and reduced urine output.
Delivery She was scheduled for delivery at 34 weeks of gestation because of
her severe pre-eclampsia. The mode of delivery was via Elective
Lower Segment Caesarean Section (ELSCS) indicated by preterm
delivery.
However, as the patient experienced symptom of impending
eclampsia which was epigastric pain, she was sent for Emergency
Lower Segment Caesarean Section (EMLSCS) at 32 weeks and 6
days of gestation.
Fetal
Intrauterine Fetal growth chart was plotted to monitor the fetal growth to
Growth determine the presence of IUGR.
Restriction
(IUGR)
Neonatal In reference to early delivery that was scheduled for this patient, 2
Respiratory doses of IM Dexamethasone was given for acceleration of fetal lung
Distress maturity.
Syndrome
Discussion

2% to 7% of pregnant women worldwide develop Pregnancy-Induced Hypertension

(PIH) and it can cause significant morbidity and mortality for both mother and child1.
Hypertensive Disorders in Pregnancy (HDP) is defined as development of systolic
blood pressure (BP) of more than 140 mmHg or diastolic BP of more than 90 mmHg in
pregnant women who were previously normotensive with both readings taken at
least 4 hours apart. HDP is classified according to its severity and in this patient it falls
under the category of pre-eclampsia. Pre-eclampsia (PE) in this patient is diagnosed
after she was discovered to develop proteinuria of 2+ on urinalysis with underlying
PIH.

All pregnant women should be assessed at booking to determine those with risk
factors of developing pre-eclampsia. This includes patient who is nulliparous, age
more than 35 years old, has had PIH in previous pregnancy, has pre-existing co-
morbidities such as hypertension, diabetes mellitus or autoimmune disease and family
history of hypertension including pre-eclampsia. As for Madam ZZ, her risk factors for
developing PE are her age (she is 36 years old) and strong family history of
hypertension as both her parents have hypertension. She is also considered as
overweight with BMI of 27.9 kg/m2. Women with high risk factors should be started on
low-dose aspirin prophylaxis with 150 mg daily since 12 weeks of gestation until
delivery2. This prophylaxis can decrease risk of developing pre-eclampsia by 17%, risk
of neonatal deaths by 14% and relative risk of preterm births by 8%3.

These risk factors were overlooked in this patient hence no aspirin prophylaxis was
given for her during the early stage of pregnancy. Medical officers at primary point of
care such as at District Health Clinics should be more vigilant in detecting pregnant
women who have risk factors for pre eclampsia. This step is vital in ensuring
appropriate management including aspirin prophylaxis to be given to this group of
pregnant ladies. By doing this, it is not only beneficial to the patient as it can reduce
the development of pre-eclampsia and morbidities that are associated with it but
can also lessen the financial burden of public health sector in treating pre-eclampsia
patients who require continuous supply of anti-hypertensive agents that can cost a
substantial amount of money.

Obstetric teams in both hospitals; KBH and SJH have done an excellent job in
managing this patient. Rigorous monitoring, investigations and treatment have been
carried out for this patient. One of the events that show their high competency in
managing this patient is that they acted very quickly when the patient complained
about having epigastric pain. They tried to contact all the nearest hospitals such as
Penang General Hospital, Kulim Hospital and Taiping Hospital to get a ventilator for
the preterm baby since no ventilator was available at that time in SJH. Unfortunately,
these hospitals did not have any ventilator available at that moment. As soon as a
ventilator was obtained from SJH itself, they did an EMLSCS for the patient without
any delay. The patient safely delivered a preterm baby boy with birth weight of 1.5
kg that was then taken and managed by the paediatric team. This event truly
reflects the real situation that happens in government hospitals where inadequate
facilities can impede proper management of patients.
The administration of MgSO4 as prophylaxis against eclampsia in women with
impending eclampsia signs or symptoms is proven to be useful in reducing the
incident of eclampsia by more than 50% hence preventing maternal death4. This
medication was given to the patient right after she developed one of the impending
signs of eclampsia which was epigastric pain. MgSO4 charting was also successfully
started for this patient to monitor the possibility of development of MgSO4 toxicity as it
has a narrow therapeutic range of 2-4 mmol/L. This practice again showed that the
patient was well-managed during her hospitalization.
References

1. Yelumalai S, Muniandy S, Zawiah Omar S, Qvist R. Pregnancy-Induced

Hypertension and Preeclampsia: Levels of Angiogenic Factors in Malaysian
Women. Journal of Clinical Biochemistry and Nutrition [Internet]. 2010 [cited 8
August 2019];47(3):191-197. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966928/

2. Penang State Health Department. Penang State Obstetrics Protocol. Penang;

2018 p. 86.

3. Brown C, Garovic V. Drug Treatment of Hypertension in Pregnancy. Drugs

[Internet]. 2014 [cited 7 August 2019];74(3):283-296. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558097/

4. Duley L, Gülmezoglu A, Henderson-Smart D, Chou D. Magnesium sulphate and

other anticonvulsants for women with pre-eclampsia. Cochrane Database of
Systematic Reviews [Internet]. 2010 [cited 7 August 2019];. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/21069663