SIC OSPE – Obstetrics

Student’s Name: _________________________________________________________________________

Ms. S.T. a 32-year-old P2G3 presents for her first antenatal visit. Her last delivery was in 2013. Her LNMP
was at the end of July 2016 and she thinks that she is about 7 months pregnant. Her booking bloods
today are Rh +ve, RPR –ve, HIV –ve. Her Hb is 7.3g/dl. On examination her SFH is 35cm.
How would you manage this patient? (100)

History (15)
• 32-year-old P2G3
• LNMP – end July 2016. Irregular heavy menstrual bleed – bleeds for 10 days. She was not using any
contraception. She previously used Depo-Provera after the second pregnancy but stopped due to the
irregular heavy menses. She did not seek medical attention for the heavy menstrual bleeding.
• She did not book early as she did not have money to come to the clinic
• No problems that she knows of in this pregnancy. She feels fetal movements.
• She eats soil (Pica) in this pregnancy. Her diet consists mostly of pap and vegetables. She can only
afford to eat meat about once a month.
• Her previous pregnancies were uneventful and she had two normal vaginal deliveries. She bled
excessively after the second delivery. The PPH was medically managed and she received 2u red
packed cells before discharge
• This was an unplanned but wanted pregnancy. She is undecided about future contraception but she
plans on breastfeeding.
• She does smokes occasionally but does not drink alcohol
• She is currently unemployed and lives with her mother who is a pensioner. They have running water but
no electricity.
• No other medical, surgical or family history of note

Examination (10)
• Patient appears stable.
• BP 110/75mmHg, Pulse 102bpm, Temp 36.8°C, RR 18 breaths per minute
• She has pale conjunctiva and mucous membranes.
• BMI 35, MUAC 42
• CVS – hyperdynamic apex with an ejection systolic murmur.
• Other systems normal
• Abdomen: SF 35cm, difficult to feel fetal parts, fetal heart present

Problem list: (5)

• Late booker with unsure gestation
• Anaemia - heavy menstrual bleed, pica, previous PPH
• Increased BMI, smoker
• SFH large for dates
• Poor social circumstance

Differential for SF larger than expected (5)

• Incorrect dates or incorrect measurement
• Increased BMI
• Polyhydramnios
• Multiple pregnancies
• Fetus large for gestational age
• Uterine tumours e.g. fibroids

What investigations will you do? (10)

• FBC, peripheral smear
• Iron studies, B12, folate
• Sonar – EFW 1.1kg, AFI 27cm (polyhydramnios) à estimate gestation (about 28 weeks), ?congenital
anomalies (normal anatomy), signs of congenital infection or anaemia (nil found)

1
Outline the management (15)
• Dietary advice
• Oral iron supplements – can consider ivi iron once the iron deficiency is confirmed
• Random glucose – 5.5mmol/l
• Schedule OGTT
• TORCH screen
• Review in 1/52 with results
• Follow up at high risk clinic 2-weekly for fetal well-being

Ms. S.T. follows up at the clinic a week later. Iron deficiency anaemia is confirmed and she receives ivi
iron and oral supplements. Her OGTT and TORCH screen was normal.

She then presents at 32 weeks gestation complaining of PROM followed by severe abdominal pain. How
would you manage the patient? (15)
• Is patient stable? Vitals – BP 85/30mmHg, Pulse 120bpm
• Insert 2ivi lines and a urinary catheter. Administer ivi fluids (Ringer’s lactate bolus)
• Bloods – FBC, U/E, clotting profile
• Order 4u red packed cells and 4u FFPs
• Brief history + exam – woody hard uterus
• Fetal heart present – fhr105bpm
• PV 2cm dilated – blood stained fluid
• For emergency c/s

At C/S a 2kg baby with Apgars 6/10 and 8/10 delivered. A 40% abruptio placentae was noted. Patient
now has PPH due to an atonic uterus. How would you manage her? (15)
• Continue resuscitation. Fluids, blood products. Consider cell-saver
• Syntocinon. Can consider Syntometrine
• B-Lynch suture
• Balloon tamponade
• F2α intramyometrial
• Stepwise devascularisation
• TAH

List complications of abruptio placentae (5)

• Massive blood loss - anaemia
• Coagulation abnormalities following massive blood loss – thrombocytopaenia, DIC
• Massive blood transfusion and its complications
• Renal impairment
• Death of mother or fetus

The bleeding is controlled and the uterus was preserved. Ms. S.T.’s haemoglobin was optimised and she
is fit for discharge.
Discuss contraception options, motivating the best option in the case of Ms. S.T. (10)
• Barrier contraception – protect against STD
• Progesterone only pill – have to be taken at same time every day – needs good compliance
• Combined oral contraceptive – patient obese and smoker and breastfeeding so not indicated
• Injectable – she previously defaulted
• Copper-T IUCD – may have irregular menses so she will default
• Mirena – Will address contraception needs as well an heavy menstrual bleeding so possibly best option
Total 105