CPG Medical Students

8/10/2019 CPG Medical Students

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GuidelinesforMedicalStud

Gynaecological&

obstetric

history

ta

andphysicalexamination

Department of Obstetrics & GynaecologUniversity of Malta Medical School

Malta

2011


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Published byDepartment of Obstetrics & GynaecologyUniversity of Malta Medical School, Malta

Department of Obstetrics & Gynaecology, UMMS, 2011

No part of this publication may be reproduced, stored in a retrieval systemor transmitted to any form by any means, electronic, mechanical,

photocopying, recording or otherwise, without the previous permission ofthe publisher and author.


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INTRODUCTION

Female reproductive health is an important component of medical education. Regardless of the

specialitythatthemedicalstudentswillultimatelychoosetopursue,asmedicalpractitionerstheyneed

tohaveabasicknowledgeandskillspertinenttothecareofthefemalepatient.Theyneedtonotonly

needtoknowhowtoperformtheclinicalassessment,buthowtodothisinasensitive,competent,and

ethical manner. The principles of history taking and physical examination in obstetric and

gynaecologicalpatientsaresimilartothose inotherbranchesofmedicine,butthereareaspectsthat

arespecifictothespeciality.

Ingeneral,history taking andphysicalexamination shouldbe carriedout in a logical sequence. The

medicalstudentshouldunderstandthepurposeofeachposedquestionandeachobservationalaspect

oftheexamination.Whilethereismarkedoverlapbetweentheclinicalassessmentoftheobstetricand

thegynaecologicalpatient,itwillbeappreciatedthattheemphasisdiffersinthetwoclinicalsituations.

HISTORYTAKING

The scope of taking a clinical history in any situation is to identify the clinical problem and obtain

sufficientdetailtoallow forthe formulationofaprovisionaldiagnosissothatthesubsequentclinical

examinationand

investigations

are

targeted

to

narrow

down

the

diagnostic

possibilities

further.

The

eventualpresentationoftheclinicalhistory,whetherthisispresentedverballyorinthewrittenformat,

shouldfollowalogicalandchronologicalsequencepreferablyinparagraphformat[asinastory]see

example.


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Duringhistorytaking,themedicalstudentshouldatalltimesshowthepatienttherespectthatisdueto

her;while full confidentialitymustbemaintained at all timesbearing inmind that the relationship

betweentheprofessionalandhisclient isbasedonmutualtrustandrespect.Themedicalprofession

haslong

identified

the

need

for

confidentiality

with

the

classical

Hippocratic

Oath

stating:

All

that

may

cometomyknowledgeintheexerciseofmyprofessionorindailycommercewithmen,whichoughtnot

to be spread abroad, Iwill keep secret andwill never reveal. The concept of professional secrecy

relatingtothemedicalprofessionwassostronglyfeltthatitwasincorporatedwithintheCriminalCode

ofMalta[Ch.9:257].Thelawreadsasfollows:Ifanyphysician,surgeon,obstetricianorapothecaryor,

ingeneral,

any

other

person

who,

by

reason

of

his

calling

or

profession,

becomes

the

depository

of

any

secretconfidedtohim1,shall,exceptwhencompelledbylawtogiveinformationtothepublicauthority,

disclosesuchsecret,heshall,onconvictionbeliabletoafine.Furthermore,anyconvictionunderthis

headingmayalsoinvolvedisciplinaryactiononthepartoftheMedicalCouncil.

History taking should follow a logical and chronological sequence. Each clinician has his particular

preference.Ageneralusefulschemeforagynaecologicalhistoryisoutlinedbelow.

Introduce

yourself

and

obtain

consent

to

take

history

Hello.IamMr/Ms****,amedicalstudent.DoyoumindifIaskyousome

questionsaboutyourmedicalcondition?

1This

includes

the

medical

student

and

any

other

paramedical

professional.


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Personalhistory Name,age,address[ifrelevant],maritalstatus,occupation.

Presentingcomplaint

Whatistheproblemthatbroughtyoutothehospital/clinic?Besttorecordthisinthepatientsownwords.

Were you referred by your doctor or did you selfrefer yourself to the

hospital/clinic?

Patientmaynotfurnishsufficientdetails,inwhichcaseitwillbenecessary

toamplify

with

specific

directed

questions.

E.g.

SOCRATES

relating

to

pain:

o

Site:where,local/diffuse

o Onset:rapid/gradual,pattern,worse/bettersinceonset

o Character:sharp/dull/stabbing,burning/cramp/crushing

o

Radiation:Doesthepainaffectyouanywhereelse?[to

thigh/loin/elsewhere]

o Alleviatingfactors:Whatdoyoudotomakeyourselfcomfortable?

Isthepainbetteraftermenstruation?

o

Timecourse:Whendidthepainstart?;ifpainischronicWhat

madeyouseekattentionnow?Isthepainworseatanyparticular

timeofthecycle?

o

Exacerbatingfactors:Isthereanythingthatbringsonthepainor

makesitworse?

o

Severity&Impactonlife:Onascaleof1to10,atwhatlevelwould

youclassifythepain?"Doesitinterruptyourlife?"


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Associated

Symptoms

Systemic

enquiry

Isthereanythingelsethatyouhavenoticedrelatingtothepain?vaginal

discharge [colour, consistency, amount, smell] or bleeding [amount,

colour];weight

changes;

fever,

bowel

problems

[constipation,

diarrhoea,

etc]; urinary problems [dysuria, frequency, hesitancy, nocturia, colour

change,incontinence,feelingofincompleteemptying,etc.];etc.

Menstrual

history

Lengthandregularityofcycles

Severityofmenses lengthofmenses,heavy,flooding,presenceofclots,

numberof

tampons/pads

used

Painduringmensestimingofpaininrelationtomenses[beginning,end];

characterofpain[dullpersistent,coliky]

Lastmenstrualperiod[firstday]

Presenceofspellsofnoperiodsinabsenceofpregnancy;bleedingbetween

periods;afterintercourse.

Timeofmenarcheandmenopause.Ifmenopausal:assessforassociated

symptoms[hotflushes,nightsweats];historyofpostmenopausalbleeding.

Sexualhistory

Sexuallyactive;numberofpartners[bediscreet!].

Contraceptionbeingusedcurrentlyandanyusedpreviously.

Physicalorotherdifficultiesduringintercourseifpaincheckwhether

deep/superficial,always/

sometimes.

Papsmear:date&resultoflastsmear.


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Obstetrichistory

Anydifficultyinconceiving;Whattreatmentwasusedtoassistthe

infertility?

Possibilityof

current

pregnancy.

Numberofpreviouschildren gender,antenatalproblems,birthweights,

modeofdelivery,postpartumcomplications[bleeding,thrombosis,

infection].

Numberofmiscarriages,terminationsand/orectopicswhatmonththey

occurred,pattern

of

miscarriage

[spontaneous,

induced],

surgery

performed.

Past

medical

&

surgicalhistory

Doyoucurrentlysufferfromanyillnesseshypertension,diabetes,

epilepsy,asthma,bleedingdisorders,etc?;Haveyoueverbeenseriouslyill

beforecardiovascularepisodes,jaundice,STDPID,etc.?

Haveyouundergoneanysurgeryappendicitis,gynaecologicalsurgery

abdominalorvaginal[inclusiveD&C]?;Didyouhaveanyproblemswith

anaesthesia?;Didyourequirebloodtransfusion?

Haveyoueverseenagynaecologistbeforeforwhatreason?

Haveyoureceivedallthechildhoodvaccinationsrubella,HPV,TB?

Drug

history

Areyouonanymedicationsatpresentlist?

Areyou

allergic

to

any

medications

what

happened

when

you

took

the

medication? [ensureallergysincepatientsoftenassociatedevelopmentof

vaginalthrushasanadversereactiontoantibioticuse].


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Familyhistory

Areyourparentsstillalive?Dotheysufferfromanyillness?ifdead

Whatwasthecauseofdeath?

Doyou

have

any

brothers

or

sisters?

ifyes

What

is

their

state

of

health?

Isthereanyfamilyrelateddiseaseinyourfamilythatyouareawareof?

diabetes,hypertension,malignancy,twins

Whatisthestateofhealthofyourspouse?Yourchildren?

Socialhistory

Race&

migration

ifrelevant

Presentandpastoccupations

Diet,physicalactivity

Smoking,alcohol,entertainmentdrugs

Wholiveswithyouathome?supportofotherhouseholdmembers;

Anypets?

Haveyoutravelledoverseasrecently?Where?

Atthispointoneshouldbe inapositionto identifythePRESENTINGCOMPLAINTandtoformulatea

workingprovisionaldiagnosis.


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CLINICALEXAMINATION

Thescopeoftheclinicalexaminationistogatherfurthercluestosupplementtheinformationgathered

fromthe

clinical

history

to

help

identify

the

clinical

problem

and

narrow

down

the

differential

diagnosis.

Withthisaiminmind,theexaminationshouldbeacomprehensivebuttargetedone.Alwaysobtainthe

patientconsenttoallowyoutoperformtheexaminationandexplainatalltimestothepatientwhat

youplantodo.

REMEMBERTO

ALWAYS

PUT

THE

PATIENT

AT

EASE

AND

ENSURE

COMFORT.

BESENSITIVETOTHEPATIENTSFEELINGSANDDECENCY.

Obtaining

consent

toexamine

patient

Doyou

mind

ifIexamine

you?

You

can

ask

me

to

stop

at

any

time

you

feel

uncomfortable?


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SystemicExamination

A systemic examination is always useful since it can identify conditions that may predispose or

aggravatethe

presenting

complaint.

Generalappearance Weight:anorexic,cachectic,orobese.

Hydrationlevel,Hyperventilation,Hiccupping,Twitching,spasms

Hands

&

Arms Examinenails:koilonychias,leuconychia[whitetransversebands],

Muehrcke'snails

[white

paired

lines

near

fingernail

tip];

finger

clubbing;

nicotinestains

Checkpalmsforpalmarcrease,anaemiaorerythemia

Wrists:checkpulsererate,regularity,andcharacter.

Checkforscratchmarks,injectionmarks,spidernaevi,bruising.

Checkbloodpressure

Face,

neck,

chest

Checkeyes:jaundice,anaemia,considerfundoscopywhenindicated.

Mouth:fetor.ulcers,infections,hypertrophicgums/gingivitis.

Face:cloasma,rash.

Checkheartsounds:rate,rhythm,extrasounds/murmurs

Checklungs:wheezing,bronchialsounds,crepitations[basal],etc.

Legs

Checkfor

oedema

[pitting

till

what

level:

ankle/shin];

Presenceofvaricosities+/ thrombosis[superficial/deepunilateral

swelling,tenderness]

Checkperipheralvasculature:pulses

Checktoes&foot:signsofdiscolouration,gangrene,tophi.


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AbdominalExamination

Anabdominalexaminationisanessentialpartofthegynaecologicalexaminationandshouldpreferably

precede the genital examination. The adage of INSPECTION PALPATION PERCUSSION

AUSCULTATIONshould

always

be

adhered

to.

Duringtheexamination,ensurethattheabdomen issufficientlyexposedtoallowaclearoverallview

from the symphysispubis to thecostalmargin.Aspartof theabdominalexamination, remember to

always include the supraclavicular region [check for Virchov lymph nodes]; and the inguinal region

[checkfor

lymph

nodes/hernia].

o REMEMBERTOAGAINOBTAINCONSENTTOEXAMINETHEPATIENTSABDOMEN.

o

REMEMBERTOINFORMANDEXPLAINTOTHEPATIENTWHATYOUINTENDTODOAT

ALLTIMES.

o

WARN

PATIENT

TO

INFORM

YOU

IF

THE

EXAMINATION

BECOMES

UNCOMFORTABLE

ATANYTIME.

o

ALWAYSLOOKATTHEPATIENTSFACEDURINGTHEEXAMINATIONTOIDENTIFYANY

SIGNSOFPAINORDISCOMFORTELICITEDDURINGTHEEXAMINATION.

o MAKESURETHATTHEPATIENTHASRECENTLYEMPTIEDHERBLADDER.


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Inspection Assessthegeneralappearanceoftheabdomendistended[fat,foetus,

faeces,flatus,fluid,fullsizedtumours],umbilicus[flattened,possible

presenceof

hernae,

Sister

Joseph

nodule,

Cullens

discolouration],

superficialveinprominence,telangectasia/caputmedusae,

discolouration,pigmentation,scars[onemayneedtorollthepatientto

theside],striae,presenceofstoma,anyobviouslyvisible

masses/peristalsis/movements/pulsations.

Palpation

ensurewarmcleanhands;

ensurerelaxationof

abdominal

muscles.

Startwith

light

palpation

first

and

go

systematically

through

all

the

six

divisionsoftheabdomenRIF,rightHypochondrium,epigastrium,left

hypochondrium,LIF,hypogastrium.[Startfromnontenderlocationfirst]

o Lookforanymasses,tendernesswith/outguarding

Proceedwithdeeperpalpation,warningthepatientthatthismaybe

uncomfortableinwhichcaseistotellyouandyouwillstopthe

examination.Keepavisuallookoutforandfacialgrimacethatreflectdiscomfort.Gothroughthesixdivisionsoftheabdomen.

o Lookforanymasses,tendernesswith/outguarding

o Ifanytendernesscheckforthepresenceofrebound

tendernesswarningthepatientfirst.Also,assessforany

referredpain

during

palpation.

o Ifamassispalpable,assesssize[measurediameterin

centimetreorgestationalageequivalence],form

[regular/irregular],consistency[hard,soft,cystic],mobility,

tenderness,relationshiptoabdominalwall[superficial,intra

abdominal],etc.


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Proceedtoexaminespecificallyforanenlargedortenderliver[check

Murphyssign],spleenandkidneys.Remembertoalsocheckthebackfor

tendernessoverbaseofspineoroverloin[kidneypunch],sacral

oedema.

Percussion PercussforthetopborderofliverdownRightmidclavicularline[normally

at5th

rib]andcontinuedowntoabdominaledgecalculatingspan

[generally12.5

cm].

Percussion

of

liver

border

for

loss

of

dullness

in

presenceofairinabdomen.

Percussspleentoassesssizewhensplenomegalysuspect.

Percussforkidneysizeestimationwhenenlarged;toassessanenlarged

bladderorextentofabdominalmass.

Checkforthepresenceofascites

o

Shiftingdullnessthedoctorspercussingfingerisplacedvertically

sothatfingertipispointingtowardsthepatientslegs;start

percussingatmidlineandcontinueleftlaterallyuntildullness

noted.Levelmarkedandpatientrolledovertorightforafew

minutes,thenrepercuss.Ascitespresentifthedullnessmoves

mediallyand

previous

point

of

dullness

is

now

resonant.

o

Fluidthrilldoctorplaceshandsoneachofthepatientsflanks,

whilethepatientisaskedtoplaceherleftlateraledgeofthehand

verticallyonthemidlineattheumbilicus;doctorflickshandon

rightflank,acorrespondingthrillisfeltbythecontralateralhand.


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Auscultation

Belowumbilicustoassessbowelsoundsfor:

o

Rushingsoundcalled"borborygmi";

o Nosoundfor3minutes;

o

"Tinkling"sound.

Aboveumbilicusfor:AAAbruit;Venushum.

RightandLeftaboveumbilicusforrenalarterystenosis.

Overliverfor:Frictionrub[gratingduringbreathing];Bruit.

Overspleenforsplenicrub.


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ObstetricExamination

Theobstetricexaminationcanbeconsideredaspecialisedadditiontotheexaminationoftheabdomen,

itsscopebeingtoassessthepregnancycharacteristics. Examinationoftheabdomen isaccomplished

withthe

patient

supine.

Late

in

pregnancy,

care

must

be

taken

to

have

the

patient

lie

slightly

to

one

side,lestthepregnantuterusimpedevenacava bloodflow,leadingtosyncope.

Inspection Assessthegeneralappearanceoftheabdomen

o

Distendedconsistentwithpregnancy;flatteningoreversionof

umbilicus;presence

of

striae

gravidarum;

presence

of

linea

nigra;

presenceofscars[notegynaecological/obstetricsurgeryscars,

laparoscopy,etc].

o

Observeregularityofuterineshape[maybepartiallyrotatedtoone

sideortheother];lookforpresenceoffoetalmovements.

Palpation

ensure

warmcleanhands;

ensurerelaxationof

abdominalmuscles.

Assess

fundal

height

starting

from

the

xiphisterum

and

working

ones

way

downwardsuntilfundusispalpated.Measuresymphysisfundalheightin

cmequivalenttogestationalageinweeks.

Bylateralpalpationusingbothhandoneithersideoftheabdomen,

assessthelieofthefoetus[longitudinal/transverse/oblique],thelocality

oftheback[right/left]andthepresentation [cephalic/breech].

Iflongitudinal,

assess

the

degree

of

the

descent

of

the

presenting

part

throughthepelvicbrimassessedinthenumberoffingersonecanplace

overfoetalheadsuprapubically[infifths2/5th

isconsideredengaged;

3/5th

unengaged].

Auscultation Listenoverthefoetalheartwherethescapulaislocated.Assessheart

rateto

maternal

pulse


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Assessingengagementofhead


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GynaecologicalExamination

Thepelvicexaminationisanintegralcomponentofanygynaecologicalconsultationandfundamentalto

planninganygynaecologicalintervention.Inallsettings,thepatientsconsentmustalwaysbeobtained

beforeapelvic

examination

is

undertaken.

BLADDERMUSTBEEMPTIEDPRIORTOEXAMINATION

PERFORMED IN LITHOTOMY POSITION [on back, legs apart, knees bent], OR LEFT LATERAL

POSITION

INFORMTHE

PATIENT

OF

WHAT

YOU

PLAN

TO

DO

AND

INFORM

HER

OF

YOUR

OBSERVATIONS.

Inspection Examinetheexternalgenitalianotingandrashes,swellings,ulcerations,

lesions.

Separate

labia

with

forefinger

and

thumb

and

examine

clitoris.

Lookforanydischargeandnotecharacteristics[purulent/clear/blood

stained]

Tellpatienttobeardownandcoughlookforanyvaginalwallor

introitalbulges[prolapsedvaginalwallsoruterinedescent] orpassage

ofurine[stressincontinenceideallyherebladderwouldbefull]


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Speculuminspection. InsertCuscos[bivalve]speculumlubricate,insertinupwards

directionwithbladesclosedusingonehandwhilelabiaareseparated

withother

hand;

open

blades

gently

to

visualise

cervix

and

vaginal

walls.Closebladesslowingduringwithdrawal.

o

Lookforanycervicallesions[ectopy,polyps,cysts,tears,etc],

vaginaldischarge[purulent/clear/bloodstained];cervical

inflammation;etc.

o

Perform

a

Cervical

smear

using

spatula

and/or

brush

rotaing

both

through360o andsmearingsampleslightlyonasmear.

o

Mayperformhighvaginalswab,cervicalswabs,wetslidesfor

infection.


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Bimanualpalpation. PalpateBartholin'sglands[posterioroflabiamajor].

Lubricateindexandmiddlefingerifnecessary.Whiletheleftindex

fingerand

thumb

separate

labia,

the

right

index

and

middle

finger

areInsertintovagina.Thecervixislocated[assess:size,shape,

position,tenderness,mobility].

Thenperformabimanualexamination:keepingthevaginal

finderspushingupwardsandbackwards,pushthelefthanddown

back

onto

the

symphysis

pubis.

o

Palpatetheuterus[assesspositionantevertedorretroverted;

size;consistency;mobility;tenderness,cervicalexcitation.

oPalpatetheforniceswhileusingthelefthandtopushdownfrom

theiliacfossaetothesuprapubicregion[assessovariansize;

adnexialmasses,tenderness].


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In the obstetric patient, a pelvic examination can help assess progress of labour by assess certain

specificcriteriarelatedtothestateofthecervix.AlltheseparametersareincludedinBishopScoreto

giveanoverallnumericalscoreofthestateofthecervix.

Score 0 1 2 3

Dilatation 0 12 34 >5

Effacement 80%

Consistency Firm Moderate Soft

Position

Posterior

Middle

AnteriorStation 3 3 1,0 +1,+2

BishopScoreCriteria

Effacement Descentofhead[station]inpelvis


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EXAMPLEPRESENTATIONOFANANTENATALHISTORY&EXAMINATION

Seehttp://www.clinicalexam.com/pda/o_obs_antenatal_history_exam.htm

PresentationoftheHistory

Introduction

This is , a

baby.

The

reason

she

is

in

hospital

is

.

CurrentPregnancy

Focusingourattentiononthispregnancy,thefirstdayof. The current pregnancy was

and

taking

periconceptual

folic

acid.

She had a positive pregnancy test at weeks. She visited her doctor at .Duringthefirsttrimesterofpregnancy,she

. She booked into hospital at


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alcohol||hasrestrictedherselfto...unitsofalcoholperweek>sincefindingoutshewaspregnant.She

takingironandfolicacidsupplements.

Summaryof

history

In summary, therefore, this is , a baby. Thereasonshe is inhospital is. isbeingkeptin

thehospital.

PresentationoftheExamination

General

looks . Her temperature is . Her pulse is

. Her blood pressure is .

Herrespiratoryrateis.Herurinesampleis


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Onpalpation,Imeasuredthesymphysiofundalheightontheinchessidetoreduceobservererror,and

foundittobe,whichcompatiblewithgestation.ThefoetalpartsthatI

feelinthefundusappeartobetheastheyare.Thelieis

and

the

back

would

appear

to

be

on

the

as

it

offers more resistance to palpation and I feel small parts on the opposite side. The presentation

appearstobe.Theheadengaged.The foetusappears

clinicallyinsize.Theliquorvolumeappearsclinically.Thefoetalheartisbestheardovertheandoftheumbilicus,andis

.

SummaryofExamination

This is apregnancy, lie,presentation,thehead,thefoetusisclinically

insize,theliquorvolumeisclinically,andthefoetalheartis.


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EXAMPLEANTENATALCASEWRITEUP

CaseSummary

Ms.Xis

a28

year

old

secondagravida

Rhesus

negative

woman

who

presented

to

the

emergency

departmentwithpainlessmoderatevaginalbleedingat34weeksofgestation.

HistoryofPresentPregnancy

Mrs.Xhadherlastmenstrualperiodonthe14th

January2008,computingherexpecteddateofdelivery

tothe

21

st

October

2008;

her

cycles

having

been

previously

normal

and

regular

every

28

30

days.

She

didnotgiveahistoryofanymenstrualproblems.

Mrs.Xhadnoproblemsduringthefirsttrimesterotherthanslightnauseaandoccasionalvomiting.This

sheacceptedasnormal,since itdidnotparticularlydistressher.Thepregnancywasplannedandshe

hadstartedfolicacidtwomonthsprevioustoconception.Shecontinuedtotakefolicacidthroughout

the first trimester. Shedidnot giveanyhistoryof vaginalbleedingduring the first threemonthsof

pregnancy.Sheattendedher familydoctorateightweeksofpregnancy,whenaclinicalexamination

wasreportedasnormal.

SheattendedtheantenatalclinicandbookedherconfinementatMaterDeiHospitalduringthesecond

trimesterat

14

weeks

of

gestation.

All

routine

investigations

taken

[complete

blood

count;

TORCH

SyphilisHepatitisCHIVscreen;bloodglucose]atthatvisitwerenormal.HerbloodgroupwasARhesus

negative;antibodytitreforantiDwasnegative.Ageneralclinicalexaminationwasnormal.Uterinesize

corresponded to dates; foetal heart was audible using a doptone stethoscope. She had her first

ultrasoundscanat18weeksofgestation.Shewastoldthatwhilethefoetuswasnormal,theplacenta

waslow

lying

and

that

she

will

need

afurther

scan

in

the

third

trimester

to

correctly

assess

the


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29

significance of this. She had no problems during the second trimester and gave no history of any

episodesofvaginalbleeding.Shewasstartedonhaematinicsat14weeksofgestation.

Mrs.Xhad

no

problems

during

the

early

part

of

the

third

trimester

until

32

weeks

of

pregnancy.

All

routineantenatalvisitswerereportedlynormalwithadequatefoetalgrowthandbloodpressure.She

wasgivenaprophylacticantiDinjection[500IU]at28weeksofpregnancy.Ultrasoundscandoneat32

weeksofgestationconfirmedthepersistenceofalowplacentation;foetalgrowthandwellbeingwas

normal; foetalpresentationwastransverse. Inretrospectshementionedthatatabout31weeks,she

hadanepisodeofmildvaginalspottingthemorningafterhavinghadsexualintercourse.Thebleeding

was slight lasting only onemorning and she did not particularly alarm herself. She was advised to

refrainfromhavingsexualintercourse.

Historyofpresentingcomplaint

Shepresentedat34weeksofgestationwithpainlessvaginalbleedingof suddenonset.Thepresent

episodeof

bleeding

was

sudden

in

onset

and

severe

enough

for

the

blood

to

trickle

down

her

thighs.

Therewerenoassociatedfeaturessuchaspainoranydiscomfort.

Onadmission, thebleedinghad settled toonlya slight vaginal loss. The foetuswaseasilypalpable;

presentationwascephalicobliquewiththebacktotheleft.Foetalheartwasaudibleandofnormalrate.

Symphysealfundal

height

was

about

34

cm

corresponding

to

the

gestational

age.

There

was

no

tendernessovertheuterus.Therewerenosignsofmaternalcardiovascularshock;thepatientspulse

was 80 beats perminute, blood pressure 110/70mmHg.An ultrasound scan confirmed the clinical

findings;theplacentawaspraevia,apparentlymarginalandposterior(Type2placentapraevia).Foetal

growthcorrespondedtogestation.


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Anintravenousinfusionwassetup,whilebloodwastakenforhaemoglobinestimationandcrossmatch.

An antiD injection was administered. Regular monitoring of vaginal blood loss, pulse and blood

pressurewerecarriedout;while foetalheartratemonitoringwasalsocarriedout intermittently.The

motheralso

received

two

doses

of

dexamethasone

[12

mg

every

12

hours]

to

assist

foetal

lung

maturity.

Thepatientwas reviewedafter24hours.Thevaginalbleedinghad stopped completely, therebeing

only a slight browning staining on the vaginal pad. All parameters had remained normal. The

intravenousinfusionwasstopped.ShewastransferredtotheAntenatalWardandtoldthatsheneeded

to remain inhospital throughout the remainingantenatalperiod.Shehada repeatepisodeof slight

bleeding at 35 weeks of gestation, which was managed conservatively. Foetal monitoring with

cardiotocographyandultrasoundshowednoabnormality.AnantiDimmunoglobulindose[500IU]was

repeated.

PastObstetricHistory

Thepatient

had

had

aprevious

pregnancy

four

years

earlier.

The

antenatal

period

had

run

anormal

course.Onsetof labourwas induced since thepatientspregnancyhad run tooveraweekpasther

estimateddates.Labourhadprogressedeffectively,but foetaldistresswasdiagnosedatabout5cm

cervical dilatation. An Emergency Caesarean section was thus performed. A live born male infant,

weighing3400gmwasdelivered.Shegavenohistoryofmiscarriages.

PastMedical&SurgicalHistory

Thepatientgavenohistoryofanysignificantmedicalevents.Shehadhadanappendectomyperformed

attheageof15years.


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PastGynaecologicalHistory

Thepatienthadnorelevantgynaecologicalevents.Hermenarcheoccurredaroundtheageof10years;

hercyclesstabilisingwithinaboutayear.Shehadhadregularsmeartestsaftershebecamesexually

active;these

having

been

always

normal.

Her

last

smear

test

was

performed

about

six

months

before

embarking on this current pregnancy. During the interpregnancy period she used the oral

contraceptivepill[Yasmine]forcontraception.

DrugHistory

Thepatientwasonnolongtermmedication,exceptforthehaematinicsreceivedduringherpregnancy.

Shedidnot reportanydrugallergies.Shedidnotsmokecigarettesanddidnotabusealcoholatany

timeduringherpregnancy.

SocialHistory

Thepatientwasinastablerelationship.Shemarriedattheageof20years;andlivedwithherhusband

andchild.

She

worked

as

aclerk

in

an

industrial

manufacturing

setting.

She

intended

to

apply

for

parentalleavetocareforherchildren.

Examinationat36weeksofpregnancy

Thepatientwasexaminedat36weeksofpregnancy.Atthispointintime,shewasaninpatientinthe

hospital.There

were

no

acute

symptoms.

On examination the patientwas in good general health. She did not appear anaemic and was not

distressed inanyway.Cardiovascularsystemwasnormal;herbloodpressureandpulsebeing110/60

mmHg and 70 beats/min respectively. There was no lower limb oedema. Abdominal examination

conformedtoa36weeksofpregnancy.Onvisualexaminationtherewasadistendedabdomenwitha

f i li i d i id O l i h h i f d l h i h d 37


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faint lineanigraandsomestriaegravidarum.Onpalpation,thesymphysisfundalheightmeasured37

cm;thefoetallieappearedtobeobliquewithacephalicpresentationandthebacktotheleftside.The

foetalheartwasaudibleontheleftlowerquadrant.

Followupofthispregnancy

At37weeksofpregnancy,thepatientsufferedasuddenonsetofseverevaginalbleedingwhilehaving

a shower. She was transferred to the Central Delivery Suite. Assessment at this stage, showed a

persistingunstablelieofthefoetus.Inviewoftheseverityofbleedingandthematurityoftheinfant,a

decisionwasmadetoundertakedeliverybyurgentCaesareansection.Thiswascarriedoutunderspinal

anaesthesia.Atsurgery,theplacentawasconfirmedtobeaposteriorType2placentapraevia.Afemaleinfant,weighing 3540 gm,was bornwith anApgar score of 8 at 1minute. The infant required no

resuscitation.TheCaesareansectionproceededwithoutanycomplications.

Thepatientwas treatedwithasyntocinon infusion (40units in500mls infusion)during the first24

hourspost

operatively.

She

also

received

intra

operative

prophylactic

antibiotics

three

eight

hourly

dosesofintravenousAugmentin(amoxycillin250mgandclavulanicacid125mg)oninductionhasbeen

comparedwiththree8hourlydosesin900patients.ThefoetusbloodgroupwasreportedasGroupO

Rhesus negative; Coombs test was negative. No antiD prophylaxis was thus administered to the

mother.Shewasdischargedwithherchildfourdaysaftersurgerywithapostoperativehaemoglobin

levelof

10.5

g/dl;

she

was

advised

to

continue

her

haematinics

for

afurther

six

weeks.

CaseDiscussion

Thiscase involvedapregnancy ina secondagravidawomancomplicatedbyType2Placentapraevia.

ThesituationwasfurthercomplicatedbyaRhesusnegativebloodgroup.

Th ti t t d t h ibl b l l t ti t h fi t lt d t 18


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The patientwas noted to have a possible abnormal placentation at her first ultrasound scan at 18

weeksofgestationwhentheplacentawasnotedtobelowlying.Whilethisobservationissuggestiveof

an eventualplacentapraevia at term,not all casesof lowlyingplacentaediscovered in the second

trimesterremain

so

in

the

third

trimester

when

the

lower

segment

actually

develops.

The

patient,

by

virtueofherpreviouscaesareansection,wasathighriskofabnormalplacentation.

The clinical course was typical of the condition with warning bleeding occurring at 32 weeks of

gestation[aftersexual intercourse],followedbymoreseverebleedingat34weeksandsubsequently.

Theinitialmanagementfollowedinthiscaseincludedanexpectantregimenawaitingfoetalmaturity.In

anticipationof thepossibleneed foraprematurebirth, foetal lungmaturitywasaugmentedby theadministration of dexamethasone. Blood was crossmatched and kept in reserve to enable timely

transfusionshouldtheneedarise.At37weeksofgestation,thebleedingincreasedsignificantly,andin

viewofthedegreeoffoetalmaturity,adecisiontoterminatethepregnancywastaken.Becauseofthe

persistingunstablelie,aCaesareansectionwasdecidedupon.

ThecasewasfurthercomplicatedbyamaternalRhesusnegativebloodgroup.Toobviatethepossibility

of subsequent immunization, aprophylacticdoseof antiD immunoglobulinwas administered at 28

weeks is linewith currentguidelines. Inanticipationofpossible fetomaternal transfusion, a further

dosewasgivenwheneverthepatientexperiencedepisodesofbleeding.Theseprophylacticmeasures

provedneedless

since

the

foetus

was

eventually

found

to

have

been

Rhesus

negative.

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