Wednesday, September 29, 2010

Maternal & Fetal Monitoring in Labour

Teaching With Dr Khaleed =) A very dedicated Obstetricians & lecturers~

Trying to recall what had been taught..lets see what I can remember..hehe
To dear groupmates, feel free to add...

1) What is normal labour?
Normal labour is from the onset of labour starts, strong regular contractions, effacement of cervix, full dilatation of cervix, expulsion of fetus until placenta delivery

2) What should be monitored during labour??
3 components - Maternal, fetal & labour progress

3)How many stages of labour? Three
Stage 1 - From onset of labour until full dilatation of cervix
subdivided into latent &active phase
Latent phase - Regular contractions to cervical effacement until 3cm dilatation of cervix
Active phase - from 3cm until full dilatation of cervix (10cm)
Stage 2 - From full dilatation until delivery of baby
Stage 3 - From delivery of baby until expulsion of placenta

4)What should be assessed for maternal while in labour??
Blood pressure - late onset of PE & also look for proteinuria
Pulse rate - infection (frequent VE introduce infection), maternal distress
Temperature - infection or maternal distress (if other causes has been excluded)
Urine - ketone (maternal dehydration), protein (especially in PE) & sugar (DM mother)

Ketones present when mother in exhaustion & distress. Body adapt produce energy by gluconeogenesis protein & later fat (cause the presence of ketones in urine)
Some maternal distress patient will have fruity odour of ketones

Monitor contraction pain.
The best is by using our own hands.
CTG can detect the presence of contraction but did not count the intensity.
So, practice to time contraction. Timing the duration of contraction in 10 minutes & intensity (mild <20secs,>40secs)
Adequate if it is 3:10 strong & 4:10 moderate
(Dr khaleed mentioned in his place, they said is adequate when contraction is 1:2. If the nurse report to him 1:1, he would ask the nurse to reduced it & achieve contraction in 1:2)

5)Fetus Monitoring??
Check for fetal heart rate using:-
Pinnard (not suitable)

when is the best time to check baby's fetal heart rate?
Before & after uterine contraction, not while contraction. To look at the baseline heart rate.

Check descent of head via:-
VE - station of fetus head in relation to ischial spine
Per abdomen - check how many fifth palpable??

Check any caput or moulding (indicates difficult labour)
bear in mind, false station could be felt due to this. Initially the head is still high but due to severe caput/moulding, we said the station is 0

Look at the liquor.
Slight, moderate or thick meconeum. If thick need to deliver immediately.
Could be via SVD, assissted delivery or CS (depends on the progress of labour&mother&fetal condition)

PH scalp sampling or FBS (fetal blood sampling)
(done when suspicion of fetal distress. Only FBS can definitely diagnose fetal hypoxia & acidosis in labour. Other modes sometimes is inaccurate. If acidemia meaning fetus in distress. Not done in Malaysia. Doing this has no risk to the baby)

If suspicious CTG / abnormal, important to rule out malpresentation or cord prolapse
If cervix fully dilated, may be possible to deliver the baby vaginally using forceps or ventouse
If cervix not fully dilated, FBS can be considered. Normal results will permit labour to continue. repeat CTG every 45 -60minutes if CTG abnormalities persist or worsen.
If there is other indication of ceaer (failure to progress), cesaer will be done despite normal FBS result, but with less urgency.

6) How to monitor labour progress??
Chart on Partogram. Watchout for abnormal delivery pattern such as:-
- Prolonged Latent Phase
- Primary Dysfunctional Labour
- Secondary Arrest

Prolong Latent Phase -
- The latent phase is longer than the arbitrary time limits
- This phase should not be worried as patient still in latent phase
- Sent patient to antenatal ward, give simple analgesics, mobilization & reassurance

Primary Dysfunctional Labour -
- poor progress in the active phase of labour where the dilatation takes >1cm/hour
- common in primid
- might be due to inefficient uterine contractions, CPD & malposition of fetus
- tx of choice in this: ARM (if not ARM yet) + oxytocin infusion-for augmentation
- great care must be exercised in the use of oxytocin if CPD, malposition / malpresentation is suspected in multiparous labour as it can cause uterine rupture in this situation
- primid with uterine rupture is a very rare event
- if suspected malposition, give further time see if the problem correct itself. But depends on the type of malposition

Secondary Arrest -
- Progress in the active phase is initially good but then slows or stops altogether, typically after 7cm dilatation
- common cause: fetal malposition, malpresentation & CPD
- eventhough the above is the common cause, but still dont forget to check the contraction, maybe due to inefficient uterine contraction (eventhough less likely)
- treatment: depends on the cause. Could end up either SVD, assissted delivery(vaccum, forcep) Or Ceaser

When the above occurs, need to evaluate 3 components:
A) Power
B) Passenger
C) Passage

- Due to incoordinate uterine contractions
- Start patient on pitocin
- Monitor the contraction progress
- 3:10 strong or 4:10 moderate
- If hyperstimulation occurs, stop pitocin. the contraction will reduce as the half life is about 5minutes

Macrosomic baby, Malposition, Malpresentation & TRO CPD

suspect contracted/small pelvis
ask about past obstetric history - any difficult labour before
assess height of mother (in old school teaching will ask about shoe size)
On VE -look any obstruction of the passage (soft tissue swelling-swelling vulva vagina & cervix)
at the same time assess pelvimetry

If you received a patient in active phase, on VE 4cm, cephalic, station -1, what should you do??
Admit patient to labour room
Do ARM -observe liquor color -slight, moderate or thick. If thick need to deliver immediately
4 hours time.
If primid, after 4 hours should at 8cm
If multip, cervix >8cm or usually will deliver within 4hours as the progress of dilatation of cervix was not necessary to be 1cm/hour
if primid/multip, after 4 hours not reaching 8cm, starts pitocin after assess the 3Ps

Do we give syntocinon in all delivery mother??yes in 2nd stage but not all in 1st stage

What else should we give&monitor during delivery??
1) Time contraction
2) BP, PR, T, urine, dextrostix (in DM mother)
3) Give analgesics
Entonox inhalation (mixture of 50% NO & 50% O2) if time of delivery is suspected to be less than 4hours (have quick onset, short duration of effect)
more effective then TENS(transcutaneous electrical nerve stimulation) or pethidine
SE - light headedness & nausea

Pethidine chosen if delivery is more than 4 hours. This drugs need 2 hours to be washed out from circulation. If given when patient was about to deliver, it will have prolong effect on the baby - cause the baby to come out flat, sleeping or with respiratory depression.
antidote - naloxone

Regional - epidural. Patient will feel very comfortable, can read news paper or watching television

SBE prophylaxis for heart disease patient
IV ampicillin in patient positive for GBS

Dr Khaleed's lectures
10 teachers Obs & Williams Obs

Tuesday, September 28, 2010

False Alarm

Perlanjutan Biasiswa. Sounds easy to be done. But trust me, its not that easy. Huhu

2nd September I submitted the Scholarship form for the second time & the next day, the OSCC dept sent the form via Pos Laju. My previous form was lost & did not received by JPA. I dont know what happenned previously & no point in pointing fingers of whom should be blame. Maafkan lebih baik daripada memendam & serahkan semuanya kepada Allah kerana Dialah Yang Maha Adil & Maha Mengetahui Segalanya.

Ive been calm in settling this issue. But trust me when I said my emotion was like roller coaster while meeting & talking to the person incharged either face to face or via phone. I believe in talking nicely, smiling & negotiate with the person in charge. Discuss with them the efficacy that had happened in their department & plan for the solution. Getting angry & lashing out your emotion wont help the situation. Im human, they also a human being.

But of course, at the back of your mind, eventhough by doing the right way, your problem did not solve or the person become irresponsible of the situation, you definitely know what to do. Met Prof Nasa. Haha=P He definitely will help you. But Im glad, things went as I planned by Allah's will.

Yesterday, I called JPA. I would like to confirmed the status of my application. Based on my previous experience, its better for you to call JPA yourself rather than wait for the PA in OSCC to do it for you. You know the result faster & you can take immediate action if anything goes wrong.

I called Puan N to ask my application status as it had been sent before raya. She said this type of application will be put up in a meeting around October & I have to wait until then. Then I was told to give her the number of my mail (pos laju) & the date of post which at that time I did not have . (the form was post by OSCC. So need to get from them) She asked this detail because I asked for her help to check wether the form already received by JPA or not.

Later, I called up The OSCC Bos, to get the details. It was mailed in 3rd of sept with the no of en-blabla-my (rahsiala sgt...haha=P)

Today, again I called Pn N to check regarding the form & she connected me to another person who responsible to receive all the letters sent to JPA.

Alhamdulillah, it was received by JPA on 7th September.

Initially, when I gave my mail number, she said it was not received by JPA. She checked it from 3rd september to 23rd September but to no avail. My heart felt like being stabbed to death. Oh No, it cant be happening again. I dont want to go through the hassle of going up & down from OSCC to Office KOM again.

I said to myself, Calm down..calm down..investigate this one by one. Haha=P
(skang bole la gelak, tadi dah mengucap panjang + pucat lesi)

I asked her, how can I checked where the problem is??
(UIA had proved that they had sent the letter & JPA deny of receiving it...nak kena cari pos ofis pulakke???Tiiidaaakkk~ it cant be this difficult just to send a form )
She suggest of me checking with the post office.
(Ish, leceh nie..mesti ada cara lain..THINK..THINK)

Then I said to her politely...akak boleh tolong cek balik no yg saya bagi tue??betul ye no tue yang akak cari?? So, I gave her the number again & she kindly rechecked it.

Later she said, Sorry cik, we did received your mail on 7th September.
Alhamdulillah~ I said it loudly with sense of relieved. I called via phone at JHC. Even Akak operator smiled when seeing my response & she said, dah dapat ye~ =)

It was a FALSE ALARM atlast. My highest gratitude to Allah.

From other point of view, the person whom I called just now should double check before concluded that my mail was not received by them. If Allah havent been with me just now, lending me His strength, I dont know what the consequences will be (Taknak bayangkan...huhu.) BUt always remember, we are humans & they are humans too. Alhamdulillah, Allah telah gerakkan hati akak tue untuk cek lagi sekali.

Lesson to be learned:
Take all the precautions, check & double check, think & anticipate of the consequences before you break a bad news. You could never imagine how important the matters for certain people. Ahaks~

P/s- Tapi jangan jadikan kelemahan manusia sebagai alasan untuk sering melakukan kesilapan yang sama & tidak memperbaiki diri sendiri.

Sunday, September 26, 2010

Preterm Prelabour Rupture Of Membranes (PPROM)

Teaching with Dr Suhaiza =)

23 years old malay housewife G2P1 @ 34weeks POG, antenatally she is underweight, having asymptomatic anemia at 29 weeks, diagnosed to have bronchial asthma since childhood, on medication & partially controlled currently presented with leaking liquor with no other signs of labour & no symptoms of chorioamnitis

Suggestive history of leaking liquor:
ask the amount - in this patient 2 soaks sarong
With these kind of amount less likely due to urination

why u ask previous history of SI???
student would usually say it might be the cause of leaking
actually, it is not. We ask because sometimes in the morning upon waking up, a woman could have flowing out of semen from vagina due to previous SI. She mistakenly think it is leaking liquor.

Ask for signs of chorioamnitis. Need to highlight this in the history
mother - fever, contraction pain

Since we are 5th year, while asking about contraceptive methods, dont just ask about pills. Do ask about other methods as well (injection, implanon, IUCD, barrier method or natural contraception- safe period or coitus interruptus)
" This patient only used oral combine pills & did not use other methods as her mode of contraception"

Bronchial asthma - need to evaluate her asthma is well/partially/poorly controlled

In general, what is the risk factor that predispose pregnant women to PPROM??
Overdistension of uterus - polyhydramnios, multiple gestation
Infection - UTI/ asymptomatic bacteriuria, GBS, bacterial vaginosis
History of massage the abdomen
History of fall

In ward, what need to be asked to the patient??
Patient still leaking in ward
How many pads??
if patient, had stop leaking, need to ask why patient still in the ward.

What should be done with patient in the ward that presented with leaking??
Measure the AFI

How to objectively measure the AFI? Ultrasound

How can you asked the patient wether she knows the US result or not??
If patient said, she was not told of the result & doctor only said everything ok
meaning the liquor is normal. But if you dont wantto assume. Just said patient did not know of the result.
(This shows to the examiner that you are looking for evidence of oligohydramnios secondary to leaking liquor)

It is important to ask about the liquor because...
if patient severe oligo currently at 34 weeks & still leaking in the ward...
the doctor might consider early delivery & would not wait til 37weeks

What would you look for in this patient particularly in her case??
Physical examination
Toxic looking, anemic
Temperature - febrile
Pulse rate - tachycardia
Resp rate - tachypneic
Blood pressure - hypotension

Tender abdomen, irritable uterus - evidnce of chorioamnitis
Uterus smaller than date - evidence of oligohydramnios secondary to LL
Assess clinically, amniotic is adequate or not

Speculum examination:
Confirm the leaking, observe pooling of liquor at posterior fornix
If absent, ask patient to cough & observe flowing of liquor from os & pooling at post fornix
Litmus test - turn to blue (liquor is alkaline)
do HVS (high vaginal swab)

VE examination - check the integrity of membrane/already ruptured
assess the cervix:length, consistency, dilatation

How do you manage this patient??
FBC - evidence of infection
Urinalysis - evidence of asymptomatic UTI

Fetus: CTG (reactive/not) & US (AFI & fetal biometry - fetal parameters)

Bear in mind there are 2 possibilities patient could have uterus smaller than date
1) oligohydramnios secondary to Leaking liquor (LL)
2) TRO SGA/IUGR (as this patient has bronchial asthma & she is Orang Asli - small build mother, malnutrition,etc)

Start patient on antibiotic T.EES 400mg BD for 1week
Put patient on pad chart - to monitor progress of the leaking liquor
FKC (to monitor the progress of baby)
Labour progress chart
Watchout for sign & symptoms of chorioamnitis
IM dexamethasone 2 doses of 12mg 12 hours apart
Tocolysed patient if contraction 1:10

(generally there was no role of dexamethasone&tocolyse in 34weeks of pregnancy, but in this centree (HTAA), NICU is small & limited ventilator. So, the doctor's here will try to prolong the labour until term by using dexamethasone&tocolytics)

Tocolyse is use in 2 conditions:-
Not to STOP the labour but to DELAY the labour in order to
1) buy time to complete dexamethasone
2) while mother is transport to another hospital for delivery where there is ventilator

The best tocolyse being use (in transportation) - subcutaneous
(in this patient, its best to use sc terbutaline/salbutamol)

oral - is not appropriate to be used
IV infusion - hard to monitor in the ambulance

Types of tocolyse:
1) terbutaline sulphate
2) salbutamol
3) T. nifedipine
4) IV MgSO4
5) GTN - not used in HTAA
6) Atosiban - expensive but effective
7) Ritodryl - no longer use. can cause postural hypotension

For example, patient develop fever, abdominal pain, PV discharge, Tooxic looking??
suspected chorioamnitis

what should be done??
She was already started on Tablet form antibiotics...change to IV antibiotics
Plan for delivery.
Which type pf delivery?
To determine, Bishop Score need to be done
If cervix is not favourable & by palpation, head is floating --> LSCS

If cervix is favourable & head atleast 4/5 palpable & baby stable
--> sent patient to labour room for SVD
give patient pitocin & augment the labour
start intrapartum IV ampicillin

eventhough cervix is favourable + evidence of fetal distress --> LSCS
During LSCS, after open the abdomen, pack the surrounding
then incise the uterus & take out the baby (done while sucking the amniotic fluid)
Later, clean the surrounding
(this is done to prevent infection from going to the peritoneal cavity)

If patient suspected to have GBS in pregnancy,
plan for intrapartum antibiotic during SVC
but if patient undergo LSCS - no need antibiotic (no contact of baby to the vagina)
Need to screen patient for GBS during her antenatal in her next pregnancy
(take urine, vaginal culture)

Also GBS is investigated in patient with her newly delivered baby in her previous pregnancy having pneumonia & need intubation

In treating bacterial vaginosis, there was no antenatal&intrapartum antibiotics guidelines

Saturday, September 25, 2010


Its weekend again. This weekend I decided to stay in kuantan. Next weekends, we will have wedding reception's in Sg Besar. Remember the wedding I attend in Melaka. Next week will be at our cousin's house. Next week, I also would like to see my friend's graduation day. Rindunya nak jumpa korang sume!!!

Yesterday morning, I tidied up my room. Series, its been a mess for a week!!! haha. Kalo cik fiza crite masa HO je bilik dia bersepah-sepah. Saya masa student pun dah bersepah especially bile ada banyak things to do for next days class. Ntah apela akan jadi pada bilik saya masa HO nanti. Haha. But trying to improve on that. Selalu cakap kat diri, letak barang kembali pada tempatnya. Tapi bile macam-macam kena buat, saya main letakje atas katil & nampakla tak kemas bilikku. Hoho

Then I went for breakfast & later went to ward to clerk & update few patients. Next week, 3rd years will be having their exam. So I definitely unable to go to the ward & have a look at the patients. Ruginya!!!huhu. Abis 3 hari camtue je..Isk~ So im preparing few cases in case I have a chance to have CP with our lecturers. We must be one step ahead kan kan atau pun sediakan payung sebelum hujan.

Cases that I prepared:
1) 25 yo housewife primid G1P0 @ EDD+1 day with GDM under diet control with big baby. e/a for LSCS due to big baby. Sian dia, dia tau baby dia besar & dinasihatkan undergo LSCS on her antenatal checkup 1 day before her EDD after scan by doc. Previously, nurse that check her said her baby is ok. Her last scan on her 32 weeks said her baby was about 2.6kilos. Antenatally her GDM also well control. Kelmarin dia undergo LSCS & baby dia 4.6kg. Ishh, masih xdapat pecah record baby seen by ck fiza & nadhir. 5.6kilos..hehe

2) 38 years old housewife grandmultip G9 P8 @ 36 weeks POA with anemia in pregnancy, gdm under diet control, 1 previous scar due to breech secondary to fibroid 4 years ago, history of myomectomy 1 year ago & patient is also underweight & this is the first pregnancy for her 3rd marriage. admitted due to reduce fetal movement. Oh lagi satu, she also wants to opt for BTL after this pregnancy

3)33yo housewife G4 P3 @ 25 weeks POA. Twin pregnancy - MCDA. Spontaneous conception with family history of twin (her cousin on her father's side - tapi significant if mother's side kan..Hermmm~ ) admitted due to leaking liquor but no other signs of labour & no signs of infection, UTI or chorioamnitis. This is 2nd episode of leaking. 4days before hari raya, she also admitted due to the same chief complaint. For information, this lady is a wife of one of our UIA attendant =) semoga semuanya berjalan lancar for both of them =)

4) 35years old housewife G2P1 @ 36weeks POA with 1 previous scar (EMLSCS due to fetal distress) 3 years ago. she is also underweight currently admitted due to premature contraction which she came to the clinic to rule out IUGR baby.

Later, I went to the library. However, I didnt studied much because tibe-tibe takde mood. haha. Mula la tue syndrome rindu-rindu datang.ahaks.

Later, I went back to hostel & found out dear rumets watching korean movie - my girlfriend is a gomiho. Best cite dia & klaka too!! the mean gal in da story resembles yu hi in the ANJELL series. Teacher Doong Ja resembles Taekyung (seriyes faced, control macho, kulit licin gile & rambut fesyen2.hehe) I joined them until I felt sleepy & decided to sleep for awhile before asking them to have dinner at 5.30pm together. But foundout I slept straight til 12am!!! Goshh~ teruknye saya. Rumet-rumet plak membiarkan saya tido dgn jayanye. haha Ini hanya terjadi pada waktu-waktu tertentu bile rukhsah dtg & tak perlu solat ok =P

I also found out that there was Nisa's message & miscalled in the phone. Sori Nisa. Im totally in the dream world & undisturbed!!huhu.

Teringat masa kami mengikuti cerita ANJELL. Setiap minggu anxiously waiting for new episodes & kat ward mesti akan berkumpul gosip2 pasal Go Mi Nam & Taekyung Hyungnim. Kawaayeee~ =P

Today I woke up early & had breakfast with few juniors. They were asking tips on the day of exam & how the exam will be conducted. They are very hardworking since day 1 of their posting. I know they can do it. I hope all of them can make it. I want them to stay positive & keep praying to Allah. Im very lucky to have them as my juniors.

Currently in the room, reading & do some MCQs for O&G. I also write some notes. Alhamdulillah, I really enjoy O&G posting eventhough saya terkilan O&G posting kali ini tak sediakan jadual extra classes for remedial like old times. Prof Hamizah kate Prof MUkhtar sebenarnye terlupa. Huhu. Saya teringat lagi bila dr bahiyah@dr suhaiza nak wat kelas tuk remedial, kitorang selalu nak join tapi dihalang oleh doc kerana doc mahu beri perhatian pada mereka & ini adalah special session. TAK ACI!!!!huhu.

But most important thing, berlapang dada & always pray to him.
Ya Allah, please ease my way through this 6months =)

Thursday, September 23, 2010

Updated Transfusion Medicine

Common Session with Assoc. Prof Naznin =)

1st Scenario
Trigger 1
45 yo lady was admitted for elective hysterectomy
Previously was pregnant for 4 times. No history of blood transfusion
Not on any medications
On admission, Hb=8g/dL
1 unit of packed red cells was ordered to correct anemia prior to surgery
Result from lab = Group 0 Rh D positive, cross matched done & compatible

1) what did the elective operation meant to you??
Elective means the surgery was planned & patient was not bleeding. The operation can be postponed if there is no compatible blood found for the patient & the laboratory will find what is the cause of incompatibility in the blood
If written emergency operation, the blood bank need to provide compatible blood ASAP as the patient is bleeding

2) What is the significant in stating how many times the patient had delivered & any transfusion before??
Evidence of sensitization to fetal antigen @ to the previous blood transfusion

3) Issue regarding Hb level prior to surgery.
In standard practice, we take 10g/dL prior to surgery
But there was case, patient with Hb as low as 7g/dL was allowed to go for surgery, provided the CVS was good & it also depends on what type of surgery that the patient went for.

4) Is 1 unit of blood is worth to transfuse to this patient??will it make any difference between Hb 8 & Hb 9 prior to the surgery???
This issue is debatable.
One school of thought, No difference, no need to transfuse
The other one, Yes, it increase the oxygen capacity & using only 1 unit, the patient will have less exposure to the donor's blood

Trigger 2
Treatment began at 1.45pm given through standard infusion set
Upon receiving 1/2 unit, she experienced chills & had a Temperature elevation to 39.4C (pre-transfusion-37.2C)
She was anxious
Transfusion was stopped & Dr in charge was notified
Transfusion reaction investigation was initiated
No ID error

1) What should you suspect in this patient??
Hemolytic transfusion reaction - ABO incompatibility

& need to look for:
any pain at infusion site @ localised to loins, abdomen chest pr head (related to rapid complement activation at the site of infusion & generation of bradykinin following complement activation)
hypotension, bradycardia or both
dark color urine (hemoglobinuria)

2) Bear in mind, this patient develop fever, what is the commonest cause of fever in transfusion??
Febrile Non-hemolytic transfusion reaction (FNHTR)
Def: febrile episodes where there is a temperature rise of 1C or more during or soon after transfusion
Occurs with red cell transfusion & platelet transfusion

3) What is the cause of FNHTR?
reaction between recipient's HLA / granulocyte-specific abs with donor leucocytes & the subsequent release of pyrogens principally IL-1, IL-6 & TNF release from leucocytes during the 5 days storage
This is happened because the patient had been sensitised in her previous pregnancy

4) How to treat patient with FNHTR??
Stop the transfusion
Administer PCM 1g orally 1 hour before transfusion
Resume SLOW transfusion, once patient stabilised

5) In future transfusion....
Give leuco-reduced products. Provided after 2 febrile reactions have been documented
The leucocyte was filtered. Can either be done prestorage filter @ bed side filter. The best would be prestorage filter. In bed side filter, there is already cytokines in the plasma, eventhough the leucocyte was filter at bed side before transfused to the patient

2nd Scenario
38 years old male admitted to surgical department from A&E
2 unit of pack red cell ordered due to bleeding with Hb of 7g/dL
2 unit of blood was crossmatched & found compatible
Transfusion of the 1st unit was initiated following ID check & documentation of Vital signs
30 minutes after the transfusion had begun,he developed urticarial rash with itching

1) What do you think happened to this patient?
Allergic reaction

2) How to treat the problems?
Discontinue transfusion
Administer Antihistamine
Once resolves, resume SLOW transfusion

3rd Scenario
45 years old male had bleeding from peptic ulcer
Patient was transfused 4 months earlier for similar problem
On admission, Hb was 7g/dL
4 unit of pack cell was ordered, crossmatched & transfused
On 5th day of admission, the patient was found to be febrile (39C) with pallor & jaundice
Hb = 5g/dL
2 unit of blood was ordered but found to be incompatible on crossmatching

1) What do you think happened to the patient?
Delayed Hemolytic transfusion reaction (DHTR)
Secondary to immune response following re-exposure to a given red cell antigen in a patient who has been sensitized

Could occur within 5-7 days up to 2-3 weeks following transfusion

sensitization occurs through pregnancy (definitely not in this pt) & result of previous blood transfusion

A few days following transfusion the antibody level rises leading to destruction of the donor's red cells beginning 2 to 10 days after transfusion
(that's why initially indirect coombs test is negative - initially the antibody is too low to be detectable & results in compatible blood result)

DHTR are much milder.
Destruction of sensitized RBCs is extravascular hemolysis (the ab involve is IgG)
Generally no symptoms
If symptomatic - fever, falling hct, jaundice & rarely renal failure

2) Why patient develop jaundice?
Red cells coated with IgG antibodies which activate complement up to C3b adhere to the C3b receptor on macrophages & monocytes & are subsequently removed through extravascular destruction
Immediate extravascular destruction of red cells will cause jaundice & accompanied by hemoglobinemia & hemoglobinuria (dt antibody dependant cytotoxicity) & fever

3) Why patient was febrile (39C)?
Due to anaphylatoxins
C3a and C5a - anaphylatoxins with potent proinflammatory effects
granule enzymes release from mast cells & granulocytes
Nitric oxide production & cytokines production (IL-1, IL-8 & TNF)

4) Why Hb patient drop???
(Prof Naznin said its out homework.Huhu.
In the handbook mentioned, due to immediate extravascular destruction of red cells cause failure to achieve the expected rise in Hb this the answer??hermmm~ )

4th Scenario
55 yo male undergo abdominal surgery due to carcinoma
Hb 10g/dL
2 units of blood was ordered
Patient blood group O Rh D positive
Crossmatched 2 units was compatible
During surgery, 1 unit was transfused following which the patient developed oozing from surgical site, BP fell from 120/70 to 80/40
Transfusion was stopped. Hypotension treated
Blood sample sent for GXM for 2 units of blood

1) What do you think happened to this patient??
Immediate hemolytic transfusion reaction

2) Why the blood oozing from surgical site?
In anaesthesized patient, the only signs maybe uncontrollable hypotension or excessive bleeding as a result of DIVC

3) How DIVC happened?
Intravascular hemolysis stimulate extrinsic coagulant cascade & cause sonsumption of platelet which leads to DIVC

- Main cause is human error (wrong blood component is transfused-involving transfusion of ABO incompatible blood group
- Main underlying pathophysiology for this is intravascular hemolysis
- Intravascular hemolysis is the most dangerous type of hemolytic transfusion reaction
- Associated with activation of full complement cascade by IgM abs & always due to A, B, anti A or anti-B
- Full activation to membrane attack complex on the red cell surface leads to lysis
- Sign & symptoms are severe & dramatic
- Apparent after receiving as little as 20ml & can occur within minutes - within 24hours of transfusion
- Most fatalities associated with transfusion more than 200ml & mortality approaches 44% for infusions exceeding 1000ml

Thats all about the scenarios =)
Later Prof Naznin shared with us cases that arised from transfusion medicine & I would like to share 3 lessons with you guys

Lesson 1: Check & double check the blood label & Patient's ID WITH THE PATIENT before transfused the blood to the patient. Do not only check the blood's label & ID with the transfusion form. The blood & form might be wrong & belong to someone else. Again CHECK WITH THE PATIENT.

Lesson 2: Do not ASSUME. Do not assume the label of blood & patient ID was checked by your colleagues. Check the label of blood and patient ID YOURSELF. Eventhough the blood was handed to you by your friends for transfusion for a particular patient. Please Check with the patient.

Lesson 3: Do not ASSUME. Do not assume that all the blood in the ice box belong to one patient. Check & double check the blood details before transfuse to the patient. There is no such thing as just take the blood and straightaway transfuse to the patient eventhough it is in emergency situation

Lastly, Prof gave us few OBA & MCQs. This is the summary of it

Patient develop hemolysis 2 hours after transfusion with 2 unit red cells.
Serology results:
A positive
Antibody screening negative
Direct Coombs test negative

Answer: Non-immune hemolysis (because the ab & direct coombs test were negative. Meaning the problem did not related to immune)
If ab & coombs test are positive meaning we are dealing with immune hemolysis

What can cause this??
Prior to blood transfusion usually we will give normal saline to patient. If prior to transfusion, th e patient was given D5, it will cause hemolysis to the patient.
Transfusion was given via small bore needle --> hemolysis
The blood was not in appropriate temperature or being heat prior to admission

TWO. Patient develop fever, need to sent for culture and sensitivity.
If patient develop reactions due to bacterial pyrogens or bacteria, patient will present with septic or endotoxic shock

THREE. Whole blood transfusion can cause dilutional thrombocytopenia especially in massive transfusion. But it would not occur if patient was only given 2 units of whole blood.

FOUR. Washed red cells only used in patient with PNH.

FIVE. if patient need transfusion but previously patient develop fever after transfusion. What blood should you opt for? Leuco-reduced blood components either leuco reduced platelet or red cells

SIX. If Patient is iron deficiency anemia & her Hb 9 g/dL & asymptomatic. Previously she developped mild fever after transfusion. Physician ask for you to transfuse the patient. What is your choice?? Inform the physician that there is no indication & need to transfuse this patient. Yes, there is mild anemia but patient is asymptomatic. Here,the risk of transfusion reaction is higher than correcting the anemia.

Thats all I could remember from the class. Hope it benefits =)

Prof Naznin's Class
Booklet : Transfusion Medicine for IIUM medical students reviewed by Assoc Prof Naznin, Dr Norlelawati, etc.

Wednesday, September 22, 2010

PIH with IUGR Baby

Teaching With Dr Bahiyah..I really enjoy teaching with Dr Bahiyah =)


35 years old, malay housewife, grandmultipara G6P5 @ 33weeks POA, with the background of low socioeconomic&low education, antenatally she was underweight, anemic which improves with hematinic & diagnosed to have Gestational hypertension at 28 weeks but not on medication. The baby is IUGR with abnormal doppler, FM good. Was admitted for delivery in view of abnormal doppler & waiting for availability of ventilator.


Since the problem is underweight, need to highlight about her weight gain throughout the pregnancy & comment wether it is normal or not

In social history, dont forget to ask how many children the patient wants, this can help in managing this patient.

In examination, you should elicit the causes of IUGR
Look for signs of anemia, connective ts ds such as SLE (malar rash, oral ulcer, alopecia,etc)
& ask for blood pressure (PIH is one of the cause & BP is one of bedside examination)

Abdomen: elicit uterus smaller than date & if could feel obviously the fetal parts - evidence of oligohydramnios. But bear in mind, IUGR can also have normal AFI

What is causes uterus smaller than date??
mother: wrong date, small build mother, malnutrition, anemia, PIH, DM cx pregnancy, Conn TS Dz
fetus: IUGR/SGA, IUD, fetal abnormality (renal agenesis/PCKD), transverse lie

What is causes of oligohydramnios??
Mother: DM cx pregnancy, PIH, drugs (NSAIDS)
Fetus: IUGR, renal agenesis, PCKD
Leaking liquor

IUGR Vs SGA. How to determine which one??
DO serial scan & plot growth of the fetus
IUGR - initially it is growing (can be normal weight initially) than the growth become plateu & cross the centiles
SGA - the growth is following the normal growth curve but below the 3rd centiles

If you only have one scan?? how to determine?
Look at HC & AC parameters. There will be head sparing effect. Ratio of HC:AC >1 with HC value could be normal or bigger than AC

If you met this patient at 28 weeks & was told this patient had IUGR. What would you do?
TRO cause of smaller than date first
Confirm the date. check LMP
Ask about maternal disease - anemia, PIH & Conn TS disease
Ask about any history of fetal anomaly before
Previous obs history - PIH, DM, small baby before, previous baby weight

Physical examination : like what have been discussed as the above

Mother: FBC - to look at the Hb (evidence of anemia) & RBS
Fetus:US - confirm date, serial scan to plot growth , AFI
Doppler if indicated (need to mention this)

Doppler is done 2weekly

if plan to scan the mother again after 2weeks, what should you advice the mother at home??

How do u advice the patient?
Councel - this is to be done to monitor the condition of the baby, there is risk baby could IUD anytime.
Start count the baby movements about 10 times starting at 9am for 12 hours. Each time baby moves, please tick. Write down at what time the baby complete 10 movements. If the baby did not complete movement about 10 times within 12 hours which is at 9pm, please come to hospital immediately.

Plan For this patient...
Monitor her blood pressure & vital signs
In view of her condition, the baby with abnormal doppler, I would like to plan for CS to this patient as soon the ventilator is available
Counsel the patient regarding the needs for CS
Inform paeds

This patient, her BP was constant at 140/90 in each follow up & dx to have Gest hypertension. WHy she was not on any hypertensive medication???
In gest hypertension, the target BP are systolic 120 - 160 & diastolic 90-100. So in this patient, her BP was in the range. Lower down the BP, the diastolic will drop & will cause reduce perfusion to placenta which cause hypoxia to the baby. Bear in mind, hypertensive mother, the placenta has high resistance. Low BP can precipitate hypoxia to the baby.
As HO please watch out the diastolic also not only the systolic reading =)

Last Qs...Regarding Doppler~
if the doppler has abnormal result??is the patient need immediate delivery???
ANswer: ???
(this is a about doppler..masih dlm proses membaca....what I know, absent diastolic flow can buy about few days but reversed flow need immediate operation...but doctor said to me to read more.Haha=P)

Tuesday, September 21, 2010

Re-Updated Heart Disease In Pregnancy

I had the oppurtunity to learn this case twice...
Yesterday :Teaching With Dr Bahiyah =)
Today (22nd Oct) : Teaching with Dr Rozihan (She's new HOD for O&G department)


27yo, Malay Housewife, G2P1 @ 37 w +4days POA with hx of corrected VSD at the age of 13 yo & 4years ago dx to have Valvular HD, NYHA class 2 under f/up & medications
admitted for further mx of her Heart Disease & plan mode of delivery. She remain asymptomatic throughout her pregnancy & her baby was found to be SGA with good fetal movement. Currently had irregular contraction with no other signs of labour.

On examination:

presence of well healed sternotomy scar, collapsing pulse, apex beat was displaced Left 6th IC space midclavicular line with MR & AR & she's not in failure

abdomen: only correspond to 34 weeks size (smaller than date), singleton fetus, longitudinal lie, fetal back at R maternal side, cephalic presentation, 5/5 palpable, not engaged yet, EFW about 2- 2.2, adequate liquor

She had no pre pregnancy counselling b4 (need to be highlighted in hx)

She was initially f/up at JB. Why now admitted to Kuantan??? (need to ask this Qs)
Following her husband or due to inadequate facilities?? for this pt its the former one

ECHO done twice in this patient. Why twice???
Patient becoming more severe??or become more symptomatic??
Doctor in HTAA just want to confirm otherwise no other indication as the patient was well

Did she attend any combine clinic??
Yes at 16 weeks

Was an detailed scan was done to her?? No.
Do u think she should have one???Yes because she has Congenital HD
VSD- 5% risk for her fetus

How to ask wether pt had done detailed scan??
Scan that need longer time to do (>30minutes) & doc mentioned to look at the fetus's fingers, face, etc

Why she was on Penicillin since her childhood??who prescribed to her??Does she need the abtc?
Pt corrected VSD no need to take life long Penicillin. This patient was given penicillin for 10 years & already stopped for 4 years ago. She was not under IJN f/up

Lasix...Y in this current pregnancy she 's on lasix???
Actually there was once during her pregnancy she developed SOB, palpitation & reduced effort tolerance. So she was started on this

Why patient was admitted??

To monitor any risk of failure (anemia, any infection-UTI/resp infxn & hypertension)

Anemia - monitor Hb. Gives pt hematinic

Iron tablets was given to all pregnant mummies. Iron tablet has prophylaxis dose & treatment dose. This patient need to be given treatment dose. Not prophylaxis dose which given to normal pregnant mummy. Tapi dose nya...saya xcek lagi...muahahaha (HELP...HELP...)

Regarding infection: each antenatal check up all pregnant mummies need to do urinalysis in order to catch mummies with asymptomatic bacteriuria. If this problem is not detected&treated, about 20%-25% mummies can get pyelonephritis. Kesian kan. (Dr Rozihan-HOD O&G)

How do you manage this patient if u see her for the 1st time???
I would like to confirmed her history 1st
Would like to ask any symptoms of heart failure & any risk factors that could precipitate heart failure such as anemia & any infection (UTI, respiratory infection) or any symptoms of hypertension

Do physical examination (PE)
Abdomen: (like what mentioned earlier)
VE: because patient complained of irregular contraction. Look at vulva vagina,etc2. Do bishop score, if favourable, sent pt to labour room
CVS: check wether patient in failure or not, any evidence of pulmonary hypertension & Infective endocarditis
Fetus: check for fetal well being - do CTG - check reactive or not

Do investigation such as
FBC - to check her HB level. Anemia can precipitate / worsen her heart dz & she might go for CS
US - confirm the fetal well being, AFI, continue plot the graph either baby IUGR/SGA (pt was on f/up b4, there must be graph plotted to check for this)

Refer to cardiologist for ECHO (to check for EF, severity of regurge & any evidence of pulm hypertension) & to optimise her condition & consult regarding her mode of delivery (wether she can withstand the stress of labour or plan for elective CS)

What is your mode of delivery???I would choose SVD if there is no obstetric indication or heart complication. Wait for spontaneous labour. Not allow post date & can induce her but with precaution. Prostin is only relative contraindication to heart disease. Why?? cause vasoconstriction & can cause increase venous return & overload the heart

If there is obstetric complication or she has severe heart disease - LSCS

If allow SVD what should you do??
1st phase of labour:
Patient was prop up, given oxygen, analgesia - epidural (inform anaest), if infused patient, avoid fluid overload
what is standard heart dz regime given to patient?? (yang nie tak jumpa lagi. Hoho =( )
SBE antibiotic prophylaxis - ampicillin & gentamycin

Regarding epidural analgesia.

Contraindication-patient on anticoagulant & aortic stenosis

advantage - can top up & heart disease pt is high risk case, so they have high chance to go for operative delivery (either ceaser@assissted delivery). so if she were put on epidural, no need to give extra analgesia & epidural also do not have effect on the baby

But Im query, pt heart disease in labour, kite put her on cardiac monitor ke???xpenah nampak ponggg~ ( need help regarding this)

2nd phase of labour:
Shortened the 2nd stage, assisst the delivery - vacuum

3rd phase of labour:
Avoid Ergometrine


Observed patient for 5 days
w/o fr PPH, anemia, thromboembolism
Adviced patient for contraception, how many children patient wants, adviced good spacing & what type suits the patient.
If patient compliance can give pills, if not injection or implanon, if patient already completed family @ fatal for her to get pregnant - BTL should be done but consult cardiologist first

OCP is not suitable for heart disease - estrogen can cause thrombosis in patient with heart dz

IUCD & barrier method also can be given to the patient. Books saying that IUCD can cause infection to the patient is an old school taught. Skang tidak lagi, dgn teknologi yg ada.Hehe

Barrier method is an option if both patient & husband are highly motivated & educated. Cannot say, due to less effectiveness ( low pearl index) is not suitable for the couple to opt this method

If she allows to get pregnant later, adviced for prepregnancy counselling & plan her pregnancy well

Last but not least, refer her to cardiologist for her heart disease follow up

Monday, September 20, 2010

Yang Bermain-main Di Fikiran....

Waaa, tak sangka hampir 2 minggu tak mencoret apa-apa di sini. Haha. I missed my blog very much.

Kali terakhir adalah, 6 jam sebelum bertolak pulang ke pangkuan keluarga di Sg Buloh. Coretan terakhir tu, agak emosi. Muahaha.

Sori ye pada kawan-kawan yang membaca. Abaikan sahaja entry itu. Hampir nak delete entry tersebut, tapi saya telah berjanji pada diri sendiri. Blog ini adalah tempat untuk saya luahkan jatuh dan bangun saya, jadinya saya batalkan hasrat untuk menghapuskan entry tersebut.

RAYA 2010 (10 Sept - 16 Sept )
Raya tahun ini sangat-sangat berlainan daripada tahun-tahun sebelumnya

Beraya tanpa mak,ayah,angah,ahmad & yam disisi kerana mereka jauh diperantauan
Beraya bersama suami yang tersayang
Beraya di rumah mentua pada raya pertama di Sg Besar
Memandu bersama suami ke kampung halaman di Kuala Lipis pada Raya Ketiga
Meneruskan tradisi beraya ke rumah sanak saudara di Mela, Sega, Taman Sri Selasih,etc2 yang dipupuk oleh mak ayah sedari saya kecil (tak sempat nak pegi Kerdau & Telang.Huhu)
Menjadi wakil keluarga Haji Khairuddin di rumah sanak saudara & sampaikan salam mak ayah kepada mereka

Raya...mmg macam2 pengalaman baru. Jadinya perlu satu entry lain untuk ceritakan pengalaman raya tahun 2010...hehe =P

Paling best. Saya masih dapat duit raya. Alhamdulillah. Rezeki masih ada lagi.

Ayah di Saudi tak semena-mena menyuntikkan a very handsome amount of money to my bank. huhu. Thank you daddy. NIe memang duit raya paling banyak along penah dapat

Abah juga memberi duit raya tak semena-mena. Huhu
Tidak lupa juga kepada keluarga belah suami; Bikza & Along (abg ipar)

Mereka menghulurkan sampul duit raya kepada saya dgn alasan, saya masih pelajar. Ouhh, tak kusangka. Ingatkan dah kawennie, memang takde harapan dah. haha. Segan jugak nak menerima kerana sudah terasa diri besar panjang. Tapi orang kata rezeki jangan ditolak.

Terima kasih semua. Semoga kalian dimurahkan rezeki =)

Balik ke rumah macam-macam azam yang diletakkan. Nak menghabiskan membaca topik-topik O&G yang terbengkalai pada minggu ke2 raya. Bukan main banyak buku yang dibawa balik. Alih-alih, buku-buku tersebut + Williams Obs tue dibawa kulu kilir&belek-belek sahaja tanpa dapat difahami isinya.

Nak tau kenapa???Beraya sakanlaaa. Ape lagi. haha. Ada sahaja rancangan setiap hari. Sampai keletihan berjalan seharian.

2ND PROFESSIONAL EXAM (14 & 15 Dis 2010)
Waaa, pejam celik pejam celik. Lagi 2 bulan sahaja lagi. Sekejapkan. Tak sangka!!!

Lagi 3 posting yang menanti. Paeds, Ortho & Psy. Fuuhhhhh~

Doakan saya. Semoga kite semua dimudahkan

p/s-Kena kurangkan balik rumah sekarang nie. Huhu

Tak sabar mahu melihat mereka dgn jubah konvo.
Harap saya boleh join bergambar bersama mereka selepas mereka selesai menerima ijazah.
Harapnya weekend itu saya bisa turun ke GOMBAK =)

They deserves it. This 2 months they trying their very best to serve da ummah.

May Allah always give them the strength

p/s- paling tak tahan, surat konvo pun sampai pada saya. Tahniah Dr Nur Liyana atas bla bla
hahaha. Siap suruh reply jawapan kehadiran. Haissshhhh~ nie memang kena pegi ofis for me to clarify to them my status. If tak buat, takut next year takde nama pulak. Hoho

MELAKA (17 & 18 September 2010)
Berlangsung kenduri kawen belah perempuan kazen pada Encik Suami.
Felda .....ermmm, isk2...tak ingat pulak apa nama tempatnya. Haduiiii~
Meriah but penat!!!

Bertolak seawal 8.30 pagi dari Sg Buloh. Berkumpul Di Kajang (Rumah Paman Amin) dan berkonvoi bersama-sama ke Melaka dengan membawa hantaran.

Akad diadakan selepas solat Asar di masjid di sana
Malamnya diadakan perarakan & menepung tawar
Sabtu pula diadakan majlis resepsi

Tentang ini juga perlu another entry. hehe.

Banyak pengalaman menarik sepanjang menyertai rombongan lelaki keluarga mentua nie. Sebelum ini, mereka semua adalah orang yang menjadi rombongan lelaki ke rumah saya. Tapi pada kali ini, saya menyertai mereka menjadi rombongan lelaki & siap tolong angkat dulang hantaran lagi. Ahaks =P

KUANTAN (19 September)
Arrived at kuantan yesterday at 7pm. Encik Suami menemankan saya drive ke Kuantan. Saya drive separuh bermula dari Temerloh. Sian Encik Suami. 3 hari drive berturut-turut.

Encik Suami berjumpa kawan-kawannya yang bekerja sebagai HO di HTAA
Mereka berkongsi&meluahkan tentang pengalaman kerja mereka to Encik suami
Katanye jadi doktor nie, bukan setakat dgn burden kerja je..tapi tiap2 hari bermain dgn ethics

Paling penting, rawatla setiap pesakit seperti mana kite merawat ahli keluarga kite sendiri
FIkirlah pesakit ini adalah ibu bapa kepada seseorang diluar sana
Jgn sambil lewa @ hanya mengikut ape yang di order oleh MO@specialist & langsung tidak berfikir

Doktor kadang kala boleh melakukan kesilapan & menyebabkan kematian pesakitnya
Jika ini berlaku, ponderlah kembali kesilapan tersebut & stadi kes tersebut kembali & jgn ulanginya

Lengkapkan diri dgn skil memasang line dgn pantas & belajarlah cara2 resus patient & jgn lupe mempelajari cara2 menggunakan de-fibb kerana anda mungkin merupakan da only doktor disitu ketika patient kena heart attack @ collapse.

Mulanya saya xphm apa ethics yang dimaksudkan mereka di atas. Setelah mendengar, dapatla memahaminya sikit-sikit. Tapi saya yakin kawan-kawan saya yang sudah menjadi doktor & membaca entry ini akan lebih memahami tentang apa yang dimaksudkan oleh kawan-kawan kami ini kan kan =)

Alhamdulillah wahid sudah pulih sepenunya.

Im waiting for her to continue her study here.

I will always support her. Tahniah wahid kerana berjaya mengharungi perit & getir dugaan dgn tabah & berani =)

Im grateful for what I have. Thank You Allah

Tuesday, September 7, 2010

The Video

Watching the video tag by Dr Aizat...really touched me...
It reminds me of every minute that happenned to me after the result was announced....
It reminds of the tears I shed, the rationality & the strength that I need to pull out of me..
& at the same time, to pushed away all the emotional that fighting to rise inside of me...

After Dr Azarisman, held the list name up & said "this is the name of all the students"....

I straightaway...broke down,cover my face & cries uncontrollably on my seat...w/o a sound~
still remember, my right side was nazu (during the names being called out, we were holding hands) & on my left side - wahida...they did notice & was no what to do...

Afterwards, I straightaway went out from back doors & in my mind at that time was...
"I need to breath fresh air from outside"......still in denial that all this happened to me...

I walked very the same time, I put up a smile on my face & congratulate everybody that I passed by...because I know they didnt know yet who was among them that couldnt make it....
& some of them even congratulate back to me...oh, I just smiled~

I walk faster & faster...I would just want to fine a place that nobody knows & I can cry my heart out...without seeing by anybody....."yes, in my big car -nazaria'... that I parked in hospital....So thats where im heading to...

without noticing that nazu was following right behind me...

I just noticed when she called my name.. But I just cant say 'go away' to her...
at that very instant minute that I realised I do need company, a shoulder to cry on & somebody that could hear what I wanna say without saying back anything to me...just listens~

We got into the car & cries. Nazu hugged me & she cries even worse than me...haha =P (she's goin to kill me if she knows i said this. I always luv u nazu)
& I still remember she said " Yana, ure the strongest person I have ever seen~

I told her, right now, i dont know what to do, I dont know what to expect, I dont know how to response, I felt sooo numb, everything becomes so unexpected & I need to plan everything up again - my study, my career & my family life.

And I said to her' U need to pass this exam & go home & take care of your dad. nazu's dad is not well right now. My prayer is always with them

Most important is, I dont know what to say to my family that raised me by their own hands & with the same hands they always pray for my success all this years....
Nazu just nodded her head...

And I told her, dont worry, I wont do stupid things & we laughed..haha
(thats the points where I realised the role of Iman & how easily we could glitch away from the straight path. Please protect me, my husband, my family, my lecturers & friends Ya Allah)

After everything cooled down, I called Prof Hamizah. She already expecting my calls.
There's inside of me, keep telling that. Stop crying. Tak guna nangis-nangis & lets plan for your 6months extension &held your head high~ Allah is always with you....

Me: Prof what should I do???
Prof: Where are you?? Please come to my room...

After that, I drove the car to JHC..bumped into few friends but thats where I put up back my smile, waved at them & head to Prof hamizah's room...

I told nazu, Its ok, she can go back to hostel. I promised to update her what Im doing. So we go separate ways after she sent me in front of Prof's room..Thank You nazu. I dont know what to do if you are not there....may Allah ease your life along the way till the end...

With prof....We discussed few things. I could tell by her face, Prof was in shocked. haha.
Later, prof zalina joined us. She hugged me. She was also speechless...
& said, ' kamu repeat bukan sbb tak pandai but the luck is not on your side'

But I still remember. I dont shed even a tear in front of Profs & when I met her. The first things I said was 'please help me to pass in 6 months time' with confidence & a smile....
At that time, I said to myself, I can take & face all this...

Allah only delay my success BUT He did not take away all the person I love in this world =)

That what makes me move forward...

That night, I made a decision to stay at prof's house because I know, If I stay in my room...
i could not move forward. I will stay in the bubbles of sadness as I could see my friends & I bet they will be lots of friends already waiting for me in my room..thank you sume =)

Sorry rumets & friends...I stay out from hostel because I want to be stronger & I dont want to show to u guys.. how weak&fragile I can be....
I received lots of SMS & doa...thank you to all~

I still remember, how I called my mom & break the news. And I said to them I really ok & will face the challenges that lies ahead of me...
I called my mother in law & my husband & said the same thing...
Because I know...If I can take this..All my family will be ok because they always support me =)

after 1month of holiday...

I still remember the first day I step back into UIA, when back into the same room...

I still remember, the next day, I went to see Dr Azarisman & reassured him Im ok & take things very well & eager to start my postings & graduate from UIA (not because I dislike UIA but I want to join my dear friends out there. Serve the ummah & be professional muslim doctors)

The very 1st step meeting the HODs
The very 1st step to HTAA & all the wards
The very 1st day I met back all the lecturers & show them everything was fine & I want to move forward...

Everything I did this 3 months is with positivities & always remember Allah is always with me. Alhamdulillah. Ya Allah, lend me your strength~

Teringat kisah di zaman nabi bagaimana mereka bersusah payah membangunkan Islam & setiap hari tidak pernah putus asa& tidak putus2 berdoa pada Allah...Again, please lend me your strength Ya Allah~

There is the ups & downs during past 3 months but its all come back how you perceived it...
Quote from cik fiza "life's tough, but im tougher"

In 5 years of medical school, I always support all the activities held by my batch & become the committees...So this is the very first, that I was left out & unable to join them. Only Allah knows how I felt....& even sad when their convocation around the corner...But Im always hepy for them. Yakinlah Allah sudah letakkan ganjaran masing2 pada tempatnye. My time will come. Please be patient. Live the best of what you have & say gratitude to Allah~

My very first step..really gives me the impact that I could never imagine before
& most important is....

This what makes who I am today~

But today, I cried effortlessly......
Ampunkan Aku Ya Allah tangisan ini bukan kerana tidak bersyukur padaMu, tetapi menangisi kelemahan diri~

Teaching with Prof Zalina

I joined 5th year's teaching with Prof Zalina
i would like to share wut I learn & hope u guys also can share ur knowledge about this case=)
The hx presented was a bit i rearrange&add more points...

42 years old lady, a housewife G5P3+1 @ 33weeks 4days POA

with hx of 1 untried CS scar due to PP in her 4th pregnancy ? years ago
LCB 11 years ago
Hx of miscarriage with no ERPOC done
k/c/o DM since 2 years ago

currently e/a for expectant mx of mccafee regime

LMP: 8th jan 2010-SOD making the EDD: 15th october 2010.
Earliest scan done ? weeks & it is correspond to date

Brief Hx of DM
She was dx 2 years ago with the symptoms of ? / or is it incidental finding when she went for other check up??
She was started on OHA ? medication & non-compliance to medication
& under ? follow up
this unplanned but wanted pregnancy
No screening for her DM done
No episode of hospitalization
No pre-pregnancy counselling done
Her medication was changed to insulin

Booking was done at 12 weeks
No specific complaint
Wt 87 kg & she stood at ? cm making her BMI ?
She is normotensive
Not anemic - Hb 11
No proteinuria / glycosuria
Blood gp ? Rh positive
All screening test were normal
All other examination was normal

She was subjected to BSP about ? times in ? week & the result was normal, range about ?
Her blood sugar control was optimal, no episodes of increase insulin dosage, currently is about ? unit

No symptoms of hyperglycemia / hypoglycemia
No symptoms of UTI, skin infection, vaginal discharge, other DM cx (neuropathy,nephropathy,retinopathy)
Patient was educated on insulin injection, the storage & site of injection
she was referred to dietician & combine clinic
HbA1c is <6.5% Detailed scan was done at ? weeks of pregnancy - told to be normal (no fetal anomaly) Serial scan was done - normal (no macrosomia, polyhydramnios,IUGR) fetal movement was good She remains normotensive throughout her pegnancy

At 28 weeks of pregnancy, she was told to have low lying placenta
No pervagina bleeding & her baby was told to be cephalic with gud liquor
She was adviced on possible complication during her pregnancy of her problem such as
  • possible of per vagina bleeding
  • to avoid heavy works (good rest), SI, fall, trauma, massage to abdomen
  • any presence of contraction pain if occurs need to be some to hosp ASAP
  • need to deliver at hospital & delivered via CS
At 32 weeks another scan was done to confirm the localization of placenta & she was told to have type 3 PP (covering partial of her os) < dis patient was very educated
Currently she was admitted for mccafee regime.

On her admission, she was stable & remain asymptomatic.
Her VS was monitored every 4 hours, no episode of bleeding, fetal movement was good.
Her blood was taken.
She was given IM dexa & completed.
She also was advice to inform if there is bleeding or if has contraction pain.

Her BSP also optimally control.
If everything remain asymptomatic, she is planned to delivered by CS at 38 weeks.


What is the risk factor for PP in this patient??
1 previous scar & hx of PP

What is the problem in this patient??
1 prev scar
hx of PP PP type 3 (major)
DM cx pregnancy
LCB 11 years ago --> dont forget this

if patient has anterior PP need TRO any accreta

So How can u diagnosed placenta accreta???
Doppler US (wether there is blood flow to the bladder)

if patient has accreta this will affect management - hysterectomy

How do u manage this patient??
I wud like to know her BSP & HbA1c result - if abnormal, i wud like to optimise this patients blood sugar
I wud like to review the result of detailed scan as DM cx pregnancy associated with fetal anomaly

Management of PP
I wud like to admit her for mccafee regime
Check her Hb (anticipate she can bleed at anytime)
If there is bleeding, put her on pad chart
Plan for delivery at 38 weeks (38 weeks is chose bcz not allow pt go into labour)
- provided she does not have any life threatening bleeding as to allow her baby go to term

when we opt for mccafee regime??
bleeding is not lifethreatening & baby is still premature
components :
1) admit pt to the ward
2) close observation for any further bleeding
3)availability of atleast 2 units of GXM
4) availability of the OT

Monitor the baby - US & CTG

when we do biophysical profile??any situation of fetal compromise i.e IUGR
what are the components (1) US (fetal breathing,tome,movement, AFI) (2) CTG
  • Each are given score of 2 if normal & 0 if abnormal
  • Highest possible score is 10
  • Score 0 – significant fetal academia
  • Score 4 or less - Abnormal
  • Score 6 – equivocal
  • Normal score – 8 – 10 – normal pH

BPP takes long time to do...

So what is modified Biophysical profile?? (postgraduate level)

components : CTG & AFI

  • Require less time
  • Normal - nonstress test is reactive and the amniotic fluid index is greater than 5
  • Abnormal - nonstress test is nonreactive or the amniotic fluid index is 5 cm or less

Can patient go home??
if she has minor PP
her house is 15 minutes from home
She is educated & know how to take care of herself
rest & no heavy work
Avoid SI - orgasm can cause uterine contraction leads to bleeding & semen contains prostaglandin wic can induce labour

Now is 38 weeks& patient admitted for elective LSCS, How do u prepare this patient???
Consent (operation, blood transfusion & risk for hystercetomy)
FBC - check for Hb
GXM 4 pints
CBD should be done in OT, risk for bleeding

Mode of anaesthesia in this patient??? GA
Not spinal because spinal can cause hypotension
in PP surgery, there will be lots of blood loss & patient kan go further hypotensive
GA - is easy to control the circulation in case the surgery went complicated