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 lacking...so 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

HOPI
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.

Discussion:

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)
MRI

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