cp primary care antenatal

8/3/2019 CP Primary Care Antenatal

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Mohd Helmy B Abu Bakar

012010050487


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Patients Profile

Name : Malani A/P SinappanAge : 31

Race : Indian

Gravida : G2P1

RN : A480/2011

L.M.P : 9/06/11 (sure of date,regular menstrual period,not on OCP, non lactating)

E.D.D : 23/11/11 (verified by scanat 9 weeks 1 days)

Date of clerking : 13/12/11


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Chief Complaint

Madam Malani, G2P1 at 26 weeks 5 days POA

with history of low Hb level coming for regular

antenatal check up.


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History ofPresent Illness

This is planned and wanted pregnancy

Patient had monthly antenatal check up whichis uneventful until on 15/11/11 at 22 weeks 5days POA she noted to have low Hb levelwhich is 10.3g/dL.

Then patient repeat the Hb level at 13/12/11

and the result was 10.1g/dL. There is no palpitation, no SOB, no complain

of weakness, no headache, no dizziness


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There is no history of exertional dyspnea, no

hematemesis or malena.

No per vaginal bleeding and no history oftrauma.


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Antenatal History

Antenatal booking was done at KK Taman

Botanic on 12/8/11 at 9 weeks 1 day POA.

Weight 50.2kg, height 1.56m BP: 120/80, Hb: 13.3g/dL

Blood group: B, Rhesus: positive

HIV rapid test: Non reactive

VDRL: Reactive (1:8) repeat at 13/9/11 (non

reactive)


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First scan was done during booking, FH seen

and present of gestational sac. CRL at 8 weeks5 days.

Patient had serial monthly antenatal check up

and subsequent scan which is uneventful. Patient had normotensive throughout

pregnancy with blood pressure range 110-120for systolic blood pressure and 70-80 for

diastolic blood pressure. Latest hemoglobin level on 13/12/11was

10.1g/dL.


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Past Obstetric History

No Year Period of

gestation

Place of

delivery

Mode of

delivery

Birth

weight

Status Breast

feeding

1 2009 Full term Hospital

Seremban

SVD 3.0kg Alive and

well

8 month

2 2011 Current pregnancy


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Gynecology History

She attained her menarche at the age of 12

years old at regular interval of 26 to 28 days

with a normal flow of 3-4 days.

No history of menorrhagia or intermenstrual

bleeding.

No pap smear done.

She never took any oral contraceptive in the

past


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Past Medical & Surgical History

No significant past medical history and she

had lumpectomy at Hospital Seremban in

2001.


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Social History

She is housewife, and her husband working astechnician at west port.

Total family income: RM2500

Patient denied smoking, alcohol and drugintake.

Passive smoker, husband smoke about 20

cigarette per day, socially alcohol drinker. Live in single storey terrace house with basic

emenities.


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Allergies History

She has no known drug or food allergies


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Systemic Review

All system found to be normal, no active

complain.


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Obstetric Examination

On examination, she was alert, conscious and

lying comfortably on one pillow.

Her vital signs were as recorded: Blood pressure: 110/76 mmHg

Pulse rate: 78 beat per minute, regular rhythm

and good volume Temperature: 37C


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She does not appear to be anemic or jaundice

Oral hydration and hygiene was good, no

bleeding from the gum

No puffiness of the face

No finger clubbing, no koilonychia and nosplinter hemorrhage. Conjunctiva slightly pale.

Mild pitting edema


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Systemic Examination

CVS: no added heart sound.

Respiratory: vesicular breath sound.


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Abdominal Examination

Inspection

Mildly distended abdomen by a gravid uterus asevident by linea nigra and striae albicans but no

striae gravidarum. Umbilicus was centrally located and inverted.

The abdomen is move asymmetrically with therespiration.

There is no surgical scar. No other abnormalitieswere observed such as distended vein, visiblepulsation or visible peristalsis.


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Palpation

The abdomen was soft and non tender. Heruterus was at 26th week size and the

symphysial-fundal height measured 26 cm .

Singleton fetus There is no contraction felt in 10 minute.

Auscultation Unable to listen for the fetal heart rate


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Summary

Madam Malani, a 31 year old indian, Gravida

2 Para 1 at 26 weeks 5 days POA with history

of low Hb level presented to us for routine

antenatal check up. She had no underlying

medical illness and symptoms of chronic

anemia. On physical examination, all system

found to be normal except slightly conjunctivapallor and mild pitting edema.


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Provisional Diagnosis

Physiological anemia in pregnancy


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Discussion

Topic: Anemia in pregnancy

Definition:Hb level


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Concept ofPhysiologic Anemia

Disproportionate increase in plasma volume,

RBC volume and hemoglobin mass during

pregnancy

Marked demand of extra iron during

pregnancy especially in second trimester


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Significance of Hypervolemia

1. To meet the demands of the enlarged uterus withits greatly hypertrophied vascular system.

2. To protect the mother, and in turn the fetus,against the deleterious effects of impaired venousreturn in the supine and erect positions.

3. To safeguard the mother against the adverseeffects of blood loss associated with parturition.


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Causes

1. Iron deficiency anemia Poor diet

Poor spacing (good spacing > 2 years)

Chronic blood loss (UTI, worm, menorrhagia)

2. Thalassemia

Autosomal recessive

3. Folic acid deficiency anemia

Decrease diet Impaired absorption

Increase demand


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Complications

Maternal1. Inability to withstand hemorrhage (PPH)

2. Risk of infection

3. Risk of cardiac failure4. Risk ofPPH

Fetal

1. Hypoxia

2. IUGR(iron deficiency)

3. Spontaneous abortion (Thalassemia)


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Clinical Approach

History1. Diagnosis

When, where, how, Hb reading?

Symptoms

- SOB- Weak and lethargy

- Palpitation

- Headache

- Symptom of CCF

- Blurring of vision

Treatment? Compliance?


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2. Determine cause

Bleeding history?

History of anemia in family that require

frequent transfusion?

Diet history

Compliance to hematinics

Obstetric history (APH, multiple pregnancy,

PPH, poor spacing)


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Physical Examination

1. Pallor

2. Angular stomatitis, glossitis, koilonychia

3. CVS

CCF (ankle edema, crepitation)

Murmur (hyperdynamic blood flow)


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Management

Investigation1. Hb screening- booking, 32w and 36 week

(WHO recommended screen at booking, 28w)

2. MCV: If 76fl, cause IDA

If lower and other sign of anemia and RBC count

raised, B2 thalassemia Normal MCV with low Hb, typical of pregnancy

3. Full blood picture

4. Hb electrophoresis


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Treatment

If Hb level


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2. Moderate anemia (6-8g/dL)

Can consider double hematinic (give 400mg daily) Transfuse only aim for fast correction(when

prepare for delivery or c-sec)

3. Severe anemia (8g/dL before discharge Oral iron and folate continue

Follow up regularly


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Routine hematinics:

1. Given when >20 weeks

2. Ferrous fumerate 200mg daily

3. Folate 5mg daily

4. Vitamin B

5. Diet advise


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Thank You..

cp primary care antenatal

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