Case summary and examination of Obstetrics Posting

Case abridgment and examination of Obstetrics Posting brothel keeper NTR is a 34 long time old Malay lady with gravida 4 and parity 3, currently at 37 weeks of gestations. She was admitted on 21st Nov 2010 at gestational age of 30 weeks and 1 sidereal day, due to referral from Health Clinic Sendayan in view of placenta previa based on ultrasound findings during a r out(p)ine antenatal visit. Her estimated date of delivery was on 20th Jan 2011. She was asymptomatic with no complaints of per vaginal eject, compressing pain, leaking liquor or show. Fetal movements were felt and were non reduced. She has no history of placenta previa in her anterior pregnancies.The offshoot day of her last normal menstrual period was on 15th Apr 2010. This was an unexpected maternal quality but both her and her maintain valued it. She suspected she was pregnant when she missed her menses for 4 weeks. She confirmed her gestation after urine pregnancy test done in a private clinic yielded positi ve result. Booking was done in Maternal and babe Health Clinic Gadong at 16 weeks of gestation and the dating scan at 16 weeks revealed parameters corresponding to date. However, placenta was noted to be low lying during that scan. throughout her routine antenatal visits, she was normotensive, not anaemic and did not have diabetes mellitus. human immunodeficiency virus and VDRL test were negative. Her blood group type is O Rh Dpositive.This is her fourth pregnancy. Her third pregnancy was in the year of 2007. She delivered a adept term mollycoddle male child with birth weight of 2.6 kg via ces theatren section delivery due to breech presentation in Hospital Tuanku Jaafar Seremban. She delivered her first two children who are both males in the year of 2004 and 2005 via spontaneous vaginal delivery, with birth weight of 4.26kg and 2.6kg respectively. thither was no history of shoulder dystocia. either her children were born alive and s intumesce up. Antenatal, natal and postna tal for all previous pregnancies were un even outtful.She attain menarche at the age of 12. It is regular at 28 to 30 eld cycle with duration of 5 to 7 days. There was neither dysmenorrhea nor menorrhagia. She skilled coitus interuptus as contraceptive measure. She never had any PAP bemire done previously.Past surgical, medical exam and drug history were unremark competent. Family history was unremarkable. She and her husband are married for 7 years. They are staying together with their three children in Gadong Jaya Village. She is a housewife. She neither smokes nor drinks alcohol. On the other hand, her husband works as a construction worker. He is a smoker but not alcoholic. Family income is approximately RM2000 per month which is barely adequate for their living.Physical examination noble fair sex NTR was alert, conscious and communicative. She was not in pain or respiratory distress. Her natural elevation and weight are 165cm and 76kg respectively. Her blood pressure was 110/80 mmHg thump rate was 86 beats per minute of regular rhythm and unfluctuating volume temperature was 37 C respiratory rate was 19 breaths per minute. every vital signs were within normal range. Upon general examination, there was no conjunctival pallor, sclera jaundice, palmar erythema or peripheral cyanosis. Thyroid glands were not plain and breast examination was unremarkable. There was bilateral pedal edema up to mid-shin. Cardiopulmonary examination was unremarkable.Upon examination of the abdomen, it was distended with a gravid womb. Linea nigra and striae gravidarum were visible. There was a tranverse scar, measuring 12cm, located above pubic symphysis. Distension appeared to be corresponding to gestational age. The umbilicus was flattened. On light palpation, the abdomen was fragile and non-tender. Uterus was not irritable. Symphysiofundal height was 38 cm which was corresponding to gestational age. It was a singleton pregnancy with transverse dissimulation and ce phalic presentation. The liquor was adequate. Estimated fetal weight was 3.0-3.2kg. Fetal heart sound was 160 beats per minute.Investigations climb moon Blood Count revealed normal haemoglobin take (10.9g/dL).Transabdominal Sonography(TAS) revealed transverse lie foetus with the presence of fetal activity, estimated fetal weight of 3.19kg at 37 weeks of gestation, anterior placenta previa type 3 (placenta previa major) with evidence of placenta accreta at one area over bladder base. The images besides demonstrated placental lacunae, gross amplification in vascularity of cervix which is suggestive of placenta accreta.DiagnosisAnterior placenta previa type 3 with possible placenta accreta.ManagementUpon admission, brothel keeper NTRs vital signs were taken. Cannula was inserted and blood was taken for respectable blood look at investigation and blood group cross-matching. Madam NTR was as considerably as given the explanation to keep her in ward until delivery and the take a im of her pregnancy. She was encouraged to rest in bed and decrease activity train to avoid expel. Ultrasound was performed to confirm the diagnosis of placenta previa.She was then monitored for any contractions or bleeding. Madam NTRs pad chart, fetal kick chart and labour pregnancy chart were strictly monitored. Fetal heart rate was assessed 4 hourly with Daptone. Cardiotocography was done regularly and it was normal. She was given a course of IM dexamethasone 12mg BD of 1 day duration at 30 weeks of gestation. Full blood count investigation was performed once weekly and transabdominal sonography was carried out once in every 2 weeks throughout admission. Anemia should be corrected if present.Madam NTR was withal prescribed ferrous fumarate, folic acid, vitamin B complex as well as ascorbic acid. She was eventually planned for an elective caesarean delivery on 5th Jan 2011 at 37 weeks of gestational age. Prior to that, she was counseled about find of haemorrhage and orifice o f hysterectomy to be done during physical attend to as well as option of hidebound management etc. Written informed harmonize was taken from both her husband and her.ProgressionThroughout the admission, she was homey and her vital signs were all normal. She had no any episodes of vaginal bleed, leaking liquor, show, uterine contraction and pain. She was not anaemic as evidenced by normal value of her haemoglobin levels. The intimately recent haemoglobin value was 10.9g/dl. Fetal upbeat was assured as evidenced by normal CTG results. She and her fetus remained horse barn until the scheduled operation date.A day prior to that, she was kept postcode by mouth. Packed cell blood was ready for transfusion if needed. after(prenominal) delivery of the fetus, manual removal of the placenta was done and placenta accreta was free-base to be at the anterior bed of lower segment of the uterus. She developed a colossal uterine haemorrhage and a hysterectomy was performed. 3 units of packed cells (1 litre in arrive) were transfused intraoperatively. The operation lasted for 1 hour and 15 minutes.She delivered a baby boy weighs 3.2kg with Apgar s onus of 6 at first minute and 9 at fifth minute of life. After being assessed by paediatrician, he was execute to the mother. Estimated blood loss was 2.8 litres. Explanation about intraoperative findings and the decision of be sterilise to proceed to hysterectomy was given to Madam NTR. Postoperatively, she remained hemodynamically stable. Post operative haemoglobin level was 12g/dl. She was able to ambulate and tolerate orally on third day after operation despite minimal pain over operation site. She did not complain of shortness of breath, palpitation, chest pain or sura pain.Baby was pink, active and well with no jaundice. Breastfeeding was established. Both of the mother and baby were discharged on 7th Jan 2011and subsequent follow-up was scheduled to be 2 months later. She should be arranged for mental review and management as termination of fertility can sometimes cause withering psychological impact to women.DiscussionWhat other alternatives that Madam NTR has other than hysterectomy in the sheath of placenta accreta? Is hysterectomy absolutely indicated in Madam NTR?Mainstay traditional management has centred upon hysterectomy which has a mettlesome complication rate and terminates fertility of a woman. It can also cause devastating psychological consequences. While in vast mass of teddys hysterectomy will remain appropriate, there are other management options visible(prenominal) involving ultraconservative greetes. The main nonsurgical conservative management would be to retract the placenta undisturbed in situ for it to be resorbed or to be passed spontaneously. It is expected that bleeding will remain minimal with this approach. This enables fertility to be preserved even though leaving the placenta in situ has implications for infection and recurrence.Loc Sentilhes et al. (1) concludes thatsuccessful conservative management for placenta accreta does not compromise the patients subsequent fertility or obstetrical outcome but there is a high lay on the line that placenta accreta whitethorn recur during future pregnancies. FlorenceBretelle et al.(2) conducted a retrospective study in which 50 cases of placenta accreta were studied and 26 patients (52%) were treated conservatively. 21 of them (80.7%) did not undergo hysterectomy and 3 women had successful pregnancy during follow-up. This further proves that treated patient with placenta accreta selectively with conservative approach enables fertility to be preserved without increasing morbidity.However, conservative approach is usually considered only when bleeding is minimal. In this case of Madam NTR, there was severe haemorrhage encountered after delivery of fetus. Conservative management such(prenominal) as leaving the placenta in situ will lead to severe postnatal hemorrhage or even maternal death . Uterine compression suture to stop the bleeding was not able to be performed as her uterus was too fragile to hold the sutures. Therefore, hysterectomy is absolutely indicated in the case of Madam NTR for her safety. This is her fourth pregnancy therefore termination of fertility is not a major concern in her as discussed previously prior to obtaining her consent.As Madam NTR was planned for a high risk surgery with possibility of hysterectomy, counseling and obtaining written informed consent prior to surgery lick a vital role. After being counseled, Madam NTR stated that she had minute understanding about her situation and the surgery but not to the full understanding due to inability to fully comprehend medical terminologies used. The research here would be Has the tending doctor done his duties well plentiful and is patients autonomy protected in this context?Informed consent is the core principle of modern medical practice. The primary aim of the consent process is to pr otect patients autonomy. Patients have the right to refuse medical care, even when it message they will die. This surgery is associated with high complication rate, termination of fertility and devastating psychological consequences to patient. Therefore, educating and informing her about her healthcare options, advantages and disadvantages associated with recommended management as well as other alternatives are very crucial.The point is not barely to disclose information, but to ensure patients comprehension of relevant information. Unfortunately, very a good deal that doctor are disclosing information presuming that patients with different level of maturity, education level, heathenish background and native language will be able to comprehend. On top of that, doctors are so used to medical terminologies and it is often found difficult to disclose medical information in laymans terminologies. Majority of patients whom I encounter were not aggressive in seeking opportunities to raise questions to attending doctors, especially during ward round whereby patient will be ring by specialist accompanied by medical officers, housemen and medical students. altogether these further jeopardize patients autonomy to exercise personal choice with total comprehension of relevant medical issues.In the case of Madam NTR, she and her husband should first of all be told what a placenta is before explaining to them about placenta praevia. Subsequently, attending doctor should explain to her the reason vaginal delivery was not able to be carried out as the placenta covers the entrance to the womb (cervix) entirely, which is known as major placenta praevia. Therefore, caesarean delivery is absolutely indicated and it will be conducted by experienced obstetrician and anaesthetist on duty. If an emergency arises, a adviser will be present.Risk of severe bleeding from placenta praevia which can empower the life of the mother and baby in danger should be show therefore explai ning the purpose of blood group cross- matching for blood transfusion. She should also be informed that rarely, placenta praevia may be complicated by a problem known as placenta accreta, when the placenta is abnormally attached to the womb, making disengagement at the time of birth difficult. Most of the time, it will pass out spontaneously. However, if the bleeding continues and cannot be controlled, removing the womb has to be done to control the bleeding after consideration of conservative approaches such as leaving it in situ with possibility of recurrence or infection fails.She has to be told to fast prior to operation. Choices of analgesia should be discussed with anesthesiologist in relation to risks and advantages for each option. Lastly and most importantly is to assure her that the healthcare team will recommend the beat out way for both her and her baby and at the same time, she has the right to be fully informed about her health care and to share in making decisions a bout it.Under the law, the doctor has a duty of medical care to give adequate information about the proposed medical treatment. The bump of informed consent in todays legal setting is more normally interpreted as negligence when the doctor has not disclosed the risk of procedure and when the risk occurs, causing harm to patient. In the English case of Wells v Surrey Area Health Authority (3), a 36-year-old woman with 2 children, was advised to proceed to caesarean delivery after elongated labour. She was in exhausted state when she was suggested to be sterilized during the surgery and consent was signed and sterilization was done. When she recovered, she complained that consent was invalid as it was taken when she was mentally confused. She sued the doctor for assault and battery for operation was done without consent as well as for negligence as information regarding sterilization was not given at all.In conclusion, informed consent should be salutary in the correct way, especia lly in obstetrics and gynaecology, an area with high risk of medico-legal perspectives, to provide best treatment and management to patient and fetus as well as protecting doctors from being sued for negligence.