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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..