SIC OSPE - Obstetrics - Student's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Ms. P.C., a 23-year-old P0G1 who is 30-weeks pregnant by early ultrasound, ls referred to the
labour ward from the local antenatal clinic. She has been complaining of a headache and blurred
vision for the past 4 hours. She is a booked patient and has had an uneventful pregnancy thus
far. At the clinic her blood pressure was 170/110mmHg. Outline your management of this
patient once she arrives In labour ward. (100)

Is patient stable? (5)

• Patient is awake and orientated. Still complains of headache and blurred vision.
• BP 190/130mmHg Pulse 96bpm Urine 3+protein
• Insert ivi line - 100ml Ringer's lactate. Insert urinary catheter
• Load MgSO4 (total 149)- 4g in 200ml N/S over 20 min+ 5g MgSO4 and 1ml lignocaine imi in each buttock
• Take bloods - haematocrit, platelets, urea, creatinine, AST, LDH

History (10)
• Booked at 16 weeks. 30 weeks by early ultrasound. Uncomplicated pregnancy thus far.
• Presenting complaint: Complains that she woke up with a severe throbbing headache that did not respond to
paracetamol. She also reports blurred vision and sees flashing lights. This is the first such episode and she
does not have a history of headaches/migraines.
• Unplanned but accepted pregnancy. Unsure about infant feeding. Has not used contraception before.
• Booking bloods: HIV +ve on FDC since Nov 2017, last CD4 435; RPR neg, Hb 11 .2; Rh neg
• Medical history: HIV positive, asthma
• Surgical history: nil
• Medication/Allergies: on FDC, INH,pregnancy vitamins
• Family history: Mother is hypertensive.
• Social history: Adequate. Works as a secretary. Lives with her mother and boyfriend, who is employed. Has
adequate social amenities (water, electricity)

Examination (15)
• General appearance: Weight 63kg, Height 1.65m, MUAC 26cm.
• Vitals: repeat BP after MgSO4 160/105mmHg, Pulse 92bpm, Resp 18 breaths/min, Temp 37. 1°c
• Systems: (Student to outline a complete examination of all systems)
o CNS - GCS 15/15, Brisk patellar reflexes, No papilloedema or retinal haemorrhages.
o CVS - Normal apex beat. Normal heart sounds. No evidence of chronic hypertension.
o Respiratory - Not distressed. Sais 96%. Good breath sounds bilaterally. No crepitations/wheezes.
o Abdomen - No hepatomegaly. No hepatic tenderness. No ascites.
o Renal - 300ml clear urine drained on insertion of urinary catheter
o Immune - afebrile. No palpable lymph nodes
o Haematological - No conjunctiva! pallor. No petechiae/ecchymoses
o Musculoskeletal - Moderate pitting oedema up to the ankles. Peri-orbital oedema/puffiness.
o Endocrine - Normal breasts and thyroid.
• Obstetric exam:
o Gravid uterus - SF 31cm, longitudinal lie, Breech presentation. Head 5/5 over pelvic brim.
o Uterus non-tender, not irritable, no contractions palpable
o Fetal heart rate 150bpm
o Vaginal exam not done

What investigations will you do?

(10)
• Urine dipstick - 3+ protein
• Bloods - haematocrit, platelets, urea, creatinine, AST, LDH
• Indirect Coomb's
• Viral load
• 24h urine protein
• Sonar - EFW 1.4kg, AFI 12, RI 0.65

Ask the student for a problem list

Primigravida with breech; Rh negative; Imminent eclampsia; HIV positive (5)

1
Outline the management
(15)
• Admit to high-care. Insert ivi line and urinary catheter (if not done on admission)
• MgSO4:
o Loading dose (given on admission)
0
Maintenance _d?se - 5g MgSO4 and 1ml lignocaine imi in alternate buttocks every 4h for 6 doses.
?heck for tox1c1ty prior to each dose (deep tendon reflexes, urinary output, respiratory rate)
• Short acting ~~tihypertensive after MgSO4 and repeat if BP ~160/110mmHg - Nifedipine 10mg po
(or L~betalol 1v1 20mg, 40mg, 80mg, 80mg, 80 mg - repeat every 30min to a max of 300mg)
• Steroids - Dexamethasone 8mg 8hrly x3doses imi OR Betamethasone 12mg 24h apart x2 doses imi
• CTG once BP controlled
• Antihypertensive - start methyl dopa 500mg 8hrly po
• Monitor vitals + urine output hourly
• 6hourly bloods and CTG monitoring

This is her first CTG. (show student CTG?) Interpret the CTG. (5)
• Name, Date, Time
• Paper speed - 1cm/min
• Contractions - no uterine activity/not recorded
• Heart rate -150bpm, decreased variability, no accelerations, no decelerations
• Categorise - suspicious

Ask possible causes for decreased fetal heart rate variability in this patient and significance thereof (when
is it suspicious, when pathological) (10)
• Decreased variability maybe due to fetal sleep, fetal acidosis, drugs (MgSO4, opiates), prematurity, congenital
heart abnormalities
• If decreased variability for 45min - suspicious; if persists for 90 min - pathological and requires delivery

Ms. P.C., is admitted to the labour ward. After 4 hours you receive her blood results from the laboratory.
(ask student to interpret results)
Hct 0.450 Pit 132 urea 4.1 creat 100 AST31 LDH 356
Student to interpret as haemoconcentration and mild thrombocytopaenia, mild renal impairment (5)

The sister calls you as the patient is now fitting. What is your management now? (10)
• Check C-A-B, Vitals - BP 155/92mmHg, Pulse 96bpm
• Administer MgSO4 2g in 200 ml N/S ivi over 20min
• Patient now has eclampsia - requires delivery.
• As breech presentation, not in labour - for emergency C/S
• Check baby's Rh after delivery- if Rh positive, Anti-D 100-300µ9 imi to mother post delivery
• Complete MgSO4 and control BP post delivery

As the patient is HIV positive, what is the plan now for her (including contraception and breastfeeding),
and her baby? (10)
• Postnatal visit for mum and baby within 1 week of discharge and again at 6 weeks
• Contraception - LARCS (IUCD, implant), condoms, injectable. Not oral contraception as hypertensive
• No mixed feeding. Exclusive breastfeeding for 6 months if AFASS criteria not met. Can consider exclusive
bottle-feeding if patient able to afford it
• Refer Ms. P.C. to the local clinic to continue on lifelong ARVs
• Baby to be discharged on NVP

What advice will you give the patient regarding her next pregnancy? (5)
• At least 2 years between pregnancies.
• Folic acid at least 3months prior to conception .
• Book early - second missed menses.
• Start aspirin 75mg once fetal heart visible on sonar. Calcium supplementation

Total 105

2
 -
~-
....

..
,.
• -
.~ . .. -·
. ' -_..., - ·- - __ _._··-· -. - ,,.. . ., ,,-::, ·-·•- - --- c_•_- - - .,_ -

' '

,~-=
j
■
_J.._2 D-
-
- I -:--
I
■
·1 2 -
- _J
--- -- --l_j ----1
-l ~
I
1
1- ,_
f-1-
--■- 2QO '
I
I

I
C--
-

1 - ' I
,_ 1 - .
- - --- 1 -
' I
I I
I I
I - '-- I
--j I
I
~~

V
A
1 -~

14 :
~, ... "' - -~ -t-
L_ 1QC ,

14 ~
I

-
-
- --
'
,_
-
,--
"
t-
-
I I 1 -
I

1 - '
I I 1 0 I ' 1 I I
I
I I
I
1 1 0 1
I I --
I ' a:; '
I
8v I BC I
;
I

\ ~
• %, ~
0- 6~ I'
I
I I I
I

"'<t- ~ I 30.05.20 18 07;50 I 1cm/min 30.05.2018 07;50

~~ ~ / min 11"1,- 1cm/ min !!(
1 .. 1
~ I 1 1 V
"1.a
12
; I
<> '2 12
lb do'i I apI I
10
I
I I I
..... ~
~ ~.

~· , ~++=J-
,
"de

Ms. P. C.

2I +I II
-,-
4v

~o
I

I
I
l t2
I
I
VIV

41p
d-',"
I

!
~6
iI
2
I
I
I
I
I

I
I
I
i
I 4_
I
I
I
'

I
I

I
I V V

kPa kPa kPa

92 Lot # 14.4 1691/10 93
91
-- --..,...- . -· --
FORM1911 A
-- --
Lot # 14.41691/10
- -~----=~-- - ·- \ · - ~ .--
FOR Ml911A
----, - - ~ -- ____
-.......
I
FOR M 191 1A Lot. # 14 .4 169 1/10

I
- - --- ----- -- ~ -.
_I