missed miscarriage management

1. Miscarriage
Suction and Curettage
for
Missed Miscarriage
Norfazalina Binti Ghazali
811108-02-5744
RN: 1439740
1/3/2021

2. Pre op diagnosis: G5P2+2 at 15weeks1days for Missed Miscarriage
Post op diagnosis: Para2+3 Post suction and curettage for Missed Miscarriage
Operation: Suction and Curettage
Norfazalina Binti Ghazali
IC: 811108-02-5744/ RN: 1439740
LMP: 14/11/20 GP2+2 @15wks +1day POA
Electively admitted for suction and curettage for Missed miscarriage
Initially p/w to KK with PV bleeding x 3/7 (soaked 3 pads) associated with Lower
abdominal pain x 1/7,
Otherwise, no passing out blood clots or POC, no fever
TAS (21/1/21) IUGS seen. No fetal heart echo
Visited EPAU on 1/2/21 with similar complaints, impression: pregnancy of
unknown viability
TAS/TVS (1/2/21): uterus 8.5x 4.9 cm, IUGS seen, 2.3cm, no CRL
Obs hx :
TAS/TVS on (10/2/21): anteverted uterus, IUGS seen 2.3cm, no CRL
TAS (24/2/21): IUGS with irregular margin 3.3cm, no fetal pole, fetal echo. uterus
anteverted 5.9 x 4.4cm
TCS: uterus anteverted, irregular IUGS 3.3cm, no fetal pole/ fetal echo. Right
ovary: corpus luteal cyst 2.5 x 1.9cm
left ovary: normal
OBS history:
2007/ SVD/ male/ BW: 2.8kg/ term
2011/ ELLSCS/ male/ BW: 3.5kg/ term
2009/ D&C for abortion
2017/ laparoscopic and salphingectomy for right ectopic pregnancy
ANC
1. 1 previous scar in 2011 ELLSCS for transverse lie, no VBAC
Upon admission, no PV bleeding, no abdominal pain, no passing out of POC, no
anemic symptoms
O/E: Alert,pink, vitlas stable
PA: soft, not tender
V/E : VVNAD , cervix: posterior tubular, os parous, uterus at 8w, adnexal free
TAS/ TVS in EPAU : uterus anteverted, 5.4 x4.7cm, empty IUGS seen, 25mm, no
fetal pole
Operative Findings:
Vulva/vagina: NAD
os: open
Cervix: Normal
Uterus : 8 weeks anteverted
Uterus sound till 8cm
Dilated with Hegar dilator 8
POD free
POC 30 cc evacuated
EBL: minimal
POC for HPE sent
Plan
1. Tab PCM 1g QID
2. TCA stat if abdominal pain /fever/increase PV bleeding
3. To call back patient if HPE abnormal

3. Evacuation of Retained
Product of Conception
For Incomplete Miscarriage
Awatif Binti Ahmad
960415-08-6028
RN: 1439711
1/3/2021

4. Pre op diagnosis: G2P1 at 9weeks2days for Incomplete Miscarriage
Post op diagnosis: Para1+1 Post Evacuation of retained product of conception for incomplete miscarriage
Operation: Evacuation of retained product of conception
Awatif Binti Ahmad
IC: 960415-08-6028/ RN: 1439711
LMP: 25/12/20 G2P1 @9wks +1day POA
Admitted for incompete miscarriage
P/w with PV bleeding x 1/52 (soaked 3 pads/day, no blooc clots) associated with
Lower abdominal cramp x 1/7, and passing out of the POC at 12am (28/2/21) in
ED
Otherwise, no fever, no foul smelling PV discharge.
TAS (28/1/21) IUGS seen. No fetal heart echo
TCS: uterus anteverted, irregular IUGS 3.3cm, no fetal pole/ fetal echo. Right
ovary: corpus luteal cyst 2.5 x 1.9cm
OBS history:
2017/ EMLSCS for impending eclampsia
ANC
1. 1 previous scar in 2017 for impending eclampsia
2. Alpha Thalassemia intermedia, HbH disease, on monthly blood transfusion
since 6 yo. Latest Hb on 28/2/21- 8.9 (Transfused 2 pint leukodepleted
packed cell in the ward prior to op- 28/2/21, 1/3/21)
Upon admission, still having minimal PV bleeding, no abdominal pain, no anemic
symptoms, remain afebrile
O/E: Alert,pink, vitals stable
PA: soft, not tender
V/E at EPAU: VVNAD , cervix: posterior tubular, os open
Per speculum at EPAU: Cervix normal tubular, minimal oozing of blood from os,
os closed.
IM Syntometrine 1/1 stat given in EPAU
Reassessed at 28/2/21
Per speculum: Cervix normal, os open, minimal PV bleeding
VE: VVNAD , cervix: tubular, os tip of finger, uterus 8 weeks size, adnexa free
TAS: Ut anteverted, ET thick
TVS: Ut anteverted 6.6 X 4.9 cm, ET 20mm
Operative Findings: (1/3/21)
Vulva/vagina: NAD
os: open
Cervix: Normal
Uterus : 8 weeks anteverted
Uterine sound till 8cm
POD free
POC 30 cc evacuated, no vesicles seen
EBL: minimal
POC for HPE sent
Plan
1. Tab PCM 1g QID
2. TCA stat if abdominal pain /fever/increase PV bleeding
3. To call patient if HPE result abnormal

5. EMLSCS for severe pre-eclampsia
complicated with acute
pulmonary edema
Nadia Nabilah Binti Adnan
911230076068
1439841
1/3/2021

6. Patient’s details Indication and progression Outcomes
Nadia Nabilah Binti Adnan
911230076068
1439841
29 years old
G2P1 @ 34weeks6 days
Admitted on 1/03/2021 for severe pre-eclampsia
complicated with acute pulmonary edema
ANC:
1. Iron deficiency anemia
- given 1st dose of IV Sucrofer on 26/2/21
2. History admission to ACC on 25/2/21 for
symptomatic anemia and newly diagnosed
gestational hypertension and UTI,
discharged on 26/2/21
2. 1st child of second union
3. UTI
- On T Cephalexin 500mg
4. LCB 8 years ago
- on IUCD for 7 years, removed in March 2020
EMLSCS for severe pre-eclampsia complicated with acute pulmonary edema
Presented with SOB sinc discharge from ACC, worsening on the day of
admission, unsble to sleep
denies chest pain
complain of contraction pain, No PV bleeding, good fetal movement
O/e at PAC: alert, tachypneic, tachycardic
BO: 166/101
PR: 100, T: 37, SPO2: 100% under Npo2 2L/min
lungs: bilateral crepitations from LZ til MZ
CVS: murmur heard
ECG: sinus tachycardia
P/A: soft, contraction felt, uterus @ 34week size, singleton, cephalic,
VE: v/v NAD, os 2cm, cervix 1.5cm, mid, average, station -2, vertex
presentation, membrane intact, no cord, no placenta
bilateral pedal edema til knee
reflexes not brisk
TAS: singleton, cephalic, fetal heart acivity present
placenta PUS, no retroplacenta clot
urine output: 1000cc, clear urine
urine dipstick: Blood: Trace, Nitrite: neg, Leu: Neg, Protein: 1+
Reassessment, BP: 154/107, started on IVI Hydralazine and given IV Lasix
40mg stat
1/3/21
Hb: 7.7 WBC: 11.6 PLT: 381
PT: 10.3 aPTT: 31.3 INR: 0.99
Na: 136 K: 3.3 urea: 2.7 creat: 45
Alb; 20 ALT: 8 ALP: 94
Mg: 0.7 Po4: 1.12 Ca: 2.34 uric acid: 400.7
ABG under NPO2:
pH: 7.495 Pco2: 22.4 Po2: 166 Sao2: 100%, Hco3: 20.1 BE: -6
Operative Findings:
1. Peritoneal Cavity: normal
2. Lower Segment: Formed
3. Engagement: head not engaged
4. Placenta: PUS
5. Uterus: normal
6. Tube: Both normal
7. Ovary: Both normal
8. Liquor: clear, 200 cc
9. Abnormalities of other structures: none
Post-op Urine: clear
EBL: 300 cc
Baby girl delivered, Apgar 4 at 1min, 10 at 5mins, no weighing
machine available in GOT, will weigh in NNW
Admitted to NNW for post resuscitation care and respiratory
distress
ABG- pH: 7.237, PaO2:- , PaCO2:53, HCO3:18.4/ BE : -4.8
VBG- pH: 7.239, PaO2:15.9, PaCO2:50.7, HCO3:18.0/ BE : -
5.9

9. GYNAE-ONCO OT
4/3/21

10. Norjan Binti Abdul Majid
680119-07-5002
1440296
4/3/21

11. Pre-op diagnosis: Ovarian tumour most likely malignant RMI: 228987
Post-op diagnosis: Carcinoma of Ovary FIGO Stage 2B- pending HPE
Operation: Exploratory Laparotomy,Total Hysterectomy, Bilateral Salphingo-oophorectomy, Supracolic Omentectomy and Appendicectomy
Norjan Binti Abdul Majid, I/C: 680119-07-5002, RN: 1440296
53/ Nulliparouns/Menopause at 45 years old. BMI: 24kg/m2
E/A for exploratory laparotomy, total hysterectomy, bilateral salphingo-oopherectomy, omentectomy,
appendicectomy, Pelvic lymph node disection +- bowel resection and colostomy.
Case referred from Metro hospital on 8/2/2021
P/w abdominal distension and discomfort x 2/52
With LOW/ LOA
Ca 125 ( 31/1/21): 25443, Alpha feto protein: 2.3
CEA ( 31/1/21): 10.15
CT Abdomen pelvis on 31/2/21 in metro hospital
A well defined heterogenous enchancing custic mass in the pelvis. Predominantly on the left side ,measuring
about 10.3x 2.7x 2.3xm. Displacing uterus fundus to the right side.
Right side ovary measuring about 3.7x 2.7
No enhacing peritoneal nodules or mass seen.
Liver has smooth surface. Homogenous density. No diffuse or focal perenchyma liver parenchyma lesion.
Intrahepatic ducts are not dilated. Porta hepatis is clear for any mass or lymphadenoapthy.
Pnacrease normal. No focal lesion. Duct not dilated
Gall Bladder is well distanded with Gall stone present
Gross ascities present
Kidney normal. No hydromeorhosis. Ureters not dilated.
CT thorax 3/2/21 in metro hospital
Small areas of lung fibrosis in both a
upper lobes and medial segment of r
clear evidence of lung metastasis.
No mediastinal LN.
Gross asicties and gall stone
Done peritoneal tapping x2 in HPP (9
Peritoneal cell block for HPE (9/2/21
suspicious of adenocarcinoma
Peritomeal fluid cytology (9/2/21): o
large atypical epithelial cell
Peritoneal cell block (16/2/21): occa
cell in the background of chornic per
Peritoneal fluid cytology (16/2): A fe
background of chronic peritonitis
TAS (9/2/21): multiloculated solid cy
gross ascities
Unable to visualise ovary
TAS on (3/3/21): multuseptated tum

12. Pre-op diagnosis: Ovarian tumour most likely malignant RMI: 228987
Post-op diagnosis: Carcinoma of Ovary FIGO Stage 2B- pending HPE
Operation: Exploratory Laparotomy,Total Hysterectomy, Bilateral Salphingo-oophorectomy, Supracolic Omentectomy and Appendicectomy
Operative Findings:
Peritoneal Cavity : Hemorrhagic ascitic fluid about 1500 mls
Left adnexal mass measuring 20x20x22cm most likely arising from the
left ovary with extensive adhesion to the left pelvic side wall and
rectosigmoid colon- ruptured during manipulation releasing
hemorrhagic fluid
Also noted solid component in the cyst highly suggestive of malignant
tumour
Uterus and right ovary embedded in the mass
POD completely obliterated
Noted extensive thickening of the pelvic peritoneum most likely due to
tumour involvement
Uterus normal size - cut opened post-operatively --> no obvious
tumour seen
Cervix normal
Both fallopian tubes not identified most likely embedded by the
tumour
No enlarged pelvic or paraortic lymph nodes
Small and large bowel, omentum normal
Appendix normal
Liver and subdiaphragmatic area smooth
Total Estimated Blood Loss: 1000 mls
Transfused 3 pints WB and 1 pint PC
Specimens Sent:
(1) Cytopathology/cell block: Peritoneal Washing
(2) Histopathology: 1)Uterus with left ovarian
tumour ? right ovary and ?both fallopian tubes and
ovaries
2)Omentum
3)Appendix
Discharge plan:
TCA gycae-onco on 30/3/21.

14. Neoh Chai Hoon
490630-07-5504
1440280
4/3/21

15. e-op diagnosis: Advanced primary peritoneal/ovarian malignancy (RMI 15867)
ost-op diagnosis: Carcinoma of Ovary FIGO Stage 4B (Metastatic nodule at umbilicus)
peration: Interval Debulking, Exploratory Laparotomy, Total Hysterectomy and Bilateral Salphingo-oophorectomy and Omentectomy
eoh Chai Hoon, I/C: 490630-07-5504, RN: 1440280
2yo, Para 2, BMI 18.31kg/m2, Menopause at 50 y/o
nderlying:
Hypertension
- On T Perindopril 8mg OD, T Amlodipine 10mg OD, T Bisoprolol 5mg OD
esented with abdominal mass for 2 months associated with bilateral lower limb swelling
therwise, no abdominal pain, no constitutional symptoms, no SOB/ chest pain, menses
gular previously
ECT TAP (13/11/20):
Multiple intraabdominal and pelvic masses involving peritoneum may represent ovarian
alignancy with peritoneal metastases. Differential diagnosis is primary peritoneal
alignancy.
Splenic lesions likely to represent metastases
Cervical, mediastinal, abdominal and pelvic lymphadenopathy suggestive of metastases.
Left pleural effusion.
A: soft, mass felt up to 18 weeks size more towards right side
gital examination: procidentia, noted cervical growth: removed for HPE using punch biopsy
rceps.
lateral lower limb: Pitting oedema
Cervical mass for HPE (25/11/20) :
Pseudoepitheliomatous hyperplasia with mild acute
on chronic cervicitis, negative for malignancy
Peritoneal fluid cell block (30/11/20) :
Moderately differentiated carcinoma
Suggestive of serous carcinoma of female genital
tract, favouring ovarian in origin
Referred to urology for mass protruding from
urethra.
Flexible cysto-endoscopy (24/11/2020): Bladder
trabeculated, no tumour seen, prolapse posterior
urethral mucosa, no tumour along urethra
CEA (1/12--17/12/20--12/1/21): 1.2/1.2/3.0
CA125 (1/12--17/12/20--12/1/21): 2616/ 1733/ 401
CECT TAP (21/1/21):
Known case of advanced primary peritoneal/
ovarian malignancy post chemotherapy with:

16. Pre-op diagnosis: Advanced primary peritoneal/ovarian malignancy (RMI 15867)
Post-op diagnosis: Carcinoma of Ovary FIGO Stage 4B (Metastatic nodule at umbilicus)
Operation: Interval Debulking, Exploratory Laparotomy, Total Hysterectomy and Bilateral Salphingo-ophorectomy, Omentectomy
Operative Findings:
Peritoneal Cavity : No ascites, no adhesion
Uterus normal size - cut opened post-operatively --> no obvious tumour
seen
Cervix normal but edematous due to prolonged prolapsed
Bilateral residual ovarian tumour- right side measuring 5x5 cm, left side
6x5 cm
Both fallopian tubes normal
Also noted residual omental caking with extension to the umbilicus
measuring 4x4cm
Multiple small nodules (< 1cm) over the mesentery of small and large
bowel
Appendix not visualized
Multiple nodules (<1cm) over under surfaces of both diaphragm
Liver surface smooth
Total Estimated Blood Loss: 200mls
Intra-op transfused 2 pints of pack cells
Post-op Urine: 700 mls
Clear Urine
Specimens Sent:
(1) Cytopathology/cell block: Peritoneal Washing
(2) Histopathology: 1)Uterus, cervix, bilateral
ovarian tumors and both fallopian tubes
2)Omentum
Discharge plan
TCA Gynaeonco clinic on 7/4/21. (KIV for
chemotherapy)

17. Pre-op diagnosis: Ovarian Tumour most likely malignant (RMI 7113)
Post-op diagnosis: Carcinoma of Ovary FIGO Stage 2B (Pending Final HPE)
Operation: Exploratory Laparotomy, Total Hysterectomy and Bilateral Salphingo-oophorectomy, Supracolic Omentectomy and Appendicectomy
Operative Findings:
Peritoneal Cavity : No ascites
Uterus normal size - cut opened post-operatively --> normal looking
endometrial cavity
Cervix normal
Bilateral ovarian tumour highly suggestive of malignancy
right side measuring 20x20x22cm, biloculated, mainly cystic with some
solid component. Noted tumour deposit at its surface measuring
1x1cm.
left side measuring 5x5cm, cystic component.
Both fallopian tubes normal
No enlarged pelvic or paraaortic lymph nodes
Small and large bowel, appendix, omentum normal
Liver and subdiaphragmatic area smooth
Total Estimated Blood Loss:500 mls
Post-op Urine:150 mls
Clear Urine
Specimens Sent:
(1) Cytopathology/cell block: Peritoneal Washing
(2) Histopathology:
1)Uterus, cervix, bilateral ovarian tumours and both
fallopian tubes
2)Omentum
3)Appendix
Discharge plan:
TCA gynae-onco on 29/3/21

18. Nor Faiza Bt Osman
820711-08-5826
1440292
4/3/21

19. Pre-op diagnosis: Ovarian Tumour most likely malignant (RMI 7113)
Post-op diagnosis: Carcinoma of Ovary FIGO Stage 2B (Pending Final HPE)
Operation: Exploratory Laparotomy, Total Hysterectomy and Bilateral Salphingo-oophorectomy, Supracolic Omentectomy and Appendicectomy
Nor Faiza Bt Osman, I/C: 820711-08-5826, RN: 1440292
38yo, Para 3, BMI 22.27kg/m2, LMP: 20/2/21
Underlying: NKMI
1. H/O LSCS x2
- 2016: PP Major
- 2007: Breech presentation
Presented with abdominal distension x1/12, Alternate constipation with
diarrhoea x 1/12
Otherwise, no abdominal pain, no constitutional symptoms, no SOB/
chest pain, menses regular
Pap smear (13/1/21): Negative for intraepithelial lesion of malignancy
Pipelle Sampling (13/1/21): Mid secretory endometrium
CECT TAP (27/1/21):
- Large heterogeneously cystic pelvic mass with fatty component, Ddx:
ovarian teratoma/ immature ovarian teratoma/ malignancy
- Right non obstructive nephrolithiasis
Tumour marker (13/1/21): CA-125 2371, CEA 3.7, AFP 1.7
TAS (15/2/21): Uterus 6.8x4.7cm, ET: 21mm, Right multi-septated cyst
with solid area 9.2x8cm, Left ovarian cyst 3x4.3cm, no ascites
Repeated TAS (3/3/21):
Uterus 6.1x4.3cm, ET 5mm, Multiloculated ovarian tumour with solid
cystic area measuring 10.5x10.1cm and 8.1x7.9cm, no ascites

20. Nurul Syakila Binti Hamezah
IC: 900222-02-5988
RN: 1440313
4/3/21

21. Pre op diagnosis: G3P0+2 at 12 weeks for Missed Miscarriage
Post op diagnosis: Para 0+3 post suction and curettage for missed miscarriage
Operation: Suction and curettage
Nurul Syakila Binti Hamezah
IC: 900222-02-5988 RN: 1440313
LMP: 9/12/20 G3P0+2 @12 weeks POA
Electively admitted for suction and curretage for missed miscarriage
Initially referred by KD Teluk Kumbar to HPP for overt diabetes and for insulin
commencement on 25/1/21. Warded in C13 from 26/1/21-1/2/21 for optimization
of blood sugar.
Otherwise,
Afebrile
No abdominal pain
No PV bleeding
No passing out POC
TVS (26/1/21): IUGS seen. No fetal pole seen.
TVS (11/2/21): IUGS seen. No fetal pole seen.
TAS (18/2/21): Uterus anteverted. IUGS seen 4.8cm. No fetal pole seen.
TVS (18/2/21): Uterus anteverted. CRL seen 12.5mm. No fetal echo seen.
No cyst/fibroid.
Obstetric history:
2018/Complete abortion @ 6/52 / D&C not done
2019/Missed miscarriage@ 13/52 / D&C done at HPP
ANC
1.Maternal obesity
3.History of 2 previous miscarriage
-2018/Complete abortion @ 6/52 / D&C not done
-2019/Missed miscarriage@ 13/52 / D&C done at HPP
4. Pseudoprimigravida
5. Hypochromic microcytic RBC (Hb:13.1) TRO Thalasemia
-Mentzer index:12.575
-Not investigated before
Upon admission, no PV bleeding, no passing out POC, no abdominal pain, no
anemic symptoms, no fever
O/E: Alert, not pale, vitals stable
PA: soft, not tender, uterus not palpable
Reassessed on 3/3/21
VE: VVNAD , Os Closed, Cx tubular , uterus 8 week
TAS/TVS: IUGS seen 44.7mm. CRL 10.3mm (7week 1 day). No fetal heart seen.
Operative Findings: (4/3/21)
Vulva/vagina: Normal
os: open
Cervix: Normal
Uterus : 10 weeks anteverted
Uterine sound up to 10cm
POD free
POC 100 cc evacuated, no vesicles structures seen

22. Census 05/03/21
Hartini Binti Abdul Hadi @ Paulus
Incision and Drainage for Left Labia Majora Abscess

23. Pre operative diagnosis: Left Labia Majora Abscess
Post operative diagnosis: Left Labia Majora Abscess
Operation: Incision & Drainage of Left Labia Majora Abscess
Name : Hartini Binti Abdul Hadi @ Paulus
Passport : 831230-02-5420 / RN: 1440543
Para 1+2
U/L:
1. Diabetes mellitus (diagnosed in 2018)- on T. Metformin 1g BD
2. Morbid obesity- BMI: 64
3. Bronchial asthma- on MDI Salbutamol & MDI Budesonide
4. Polycystic ovarian syndrome
5. H/o admission to H. Melaka for prolonged menses in 2011
Initially p/w swelling & pain over left labia majora for 1/52
- Progressively increasing in size, no PV discharge/ bleeding, no
fever, no itchiness, no h/o trauma to labia.
On inspection of left labia majora:
- Swelling 5x4cm, tender on palpation, no punctum, no redness/
not erythematous, indurated surface, no fungal infection
surrounding perineum.
Operative findings:
- Left labial swelling around 5x4cm
- no punctum
- Pus drained : 10cc
Specimen sent : Pus and swab for culture and sensitivity
Pre-Hb: 10.5
TEBL : Minimal
Discharge plan:
- Memo to KK Bayan Baru for optimization of blood glucose
- For KK to trace pus and swab culture and sensitivity.