2. Patient Profile
• Name : Pn. Syahirah Zainudin
• Age : 25 yrs old
• Parity : G2P0+1
• Last Menstrual Period: 15/09/2010
• Estimated Date of Delivery: 22 /06/2011
• Period of Gestation: 37weeks 5 days
• Date of Admission: 11/05/2011
• Date of examination: 06/06/2011
3. Chief Concern
Patient was admitted into ward for bed rest
following an episode of bleeding per vagina
4. History of Presenting Illness
On 11th May 2011 at 8am, she was awaken by a
sudden mild cramp-like pain below the umbilicus
with pain score of 2/10. Pain was continuous and did
not increase in intensity nor it radiated. She noticed
her half of her pad was stained with fresh blood.
She immediately came to Melaka Hospital and
was admitted. There was no signs and symptoms of
labour. Fetal movement was perceived at that time
and USG was done. Scan had shown a low lying
placenta. CTG was also done and patient was told
that her baby is in a good condition.
5. She was monitored with pad chart; 3 pads were
changed during that episode. Then the bleeding and
pain stopped at noon. She was advised to take bed
rest and was monitored in ward.
Second episode of bleeding occurred at 8pm on
the same day with the similar type of pain and
bleeding per vagina but only one and half pad was
soaked with fresh blood before it stopped
spontaneously. Fetal movement was perceived at
that time.
6. She was told by doctor that she has a low lying
placenta but it did not obstruct the internal os as it
was a type 2.She was given dexamethasone injection
12mg b.d. She will be scheduled for LSCS and was
informed of the risk of the operation.
Currently, patient feels worried about the
complication of the operation and the wellbeing of
baby once delivered. She wants to stay in hospital till
date of operation because she fears she will lose her
baby.
7. History of Presenting Pregnancy
Pregnancy was planned and confirmed by urine
pregnancy test at 1 month of period of gestation.
Booking was done immediately at Klinik Desa Bukit Katil.
She was given hematinics which she was compliant to.
She goes for regular antenatal check up. Anomaly scan
was done at 20 weeks and fetus is normal. Up till 5th
month, her pregnancy was uneventful.
At 5th month of pregnancy, she was told that she has
gestational diabetes mellitus. Her fasting blood glucose
level was initially 7.8mmol/L and was advised to control
her diet and it dropped to 6.9mmol/L. No history
suggestive of hypoglygemic episodes. Currently, her
fasting blood glucose level is 7.0mmol/L and well
controlled with diet restriction.
8. Obstetric History
Patient is married for 2 years. She has a
history of miscarriage in 2010. She was 3rd
month into her pregnancy and it was an
incomplete miscarriage. Dilatation and
curettage operation was done then.
9. Menstrual History
Patient attained menarche at 11 years old.
She has regular cycles with no dysmenorrhea.
No oral contraceptive taken. Pap smear was
done last year and results was normal.
10. Past History
There is no significant medical history.
No history of previous surgeries.
No known drug allergy.
11. Family History
Patient’s father and mother is both living
and healthy. No history of diabetes,
hypertension, heart disease or genetic
disorders.
12. Personal History
Sleep, appetite, bowel and bladder habits are
normal. She is a non-smoker, non-drinker and
no illicit drug abuse. Husband is a smoker and
smokes near patient at times.
13. Social History
Patient lives with her husband in Bukit Katil
about 20 minutes from hospital. Her husband
is a factory worker and she is a housewife.
Total family income is about RM1500.
14. SUMMARY
25 years old, G2P0+1 ,currently 37 weeks and 5 days
of gestation with known gestational diabetis
mellitus presented with bleeding per vagina and
ultrasound scan shows placenta praevia type 2.
Currently, mother and fetus is in good condition,
blood sugar level is well controlled and awaiting
LSCS to be scheduled.
15. General Physical Examination
• Alert, conscious,pink
• No pallor, oral hygiene good, no lymphadenopathy
• Mild bilateral pedal oedema present.
• No lumps palpable in both breast, both nipples
normal ( no inverted or cracked nipple)
• Pulse is 80bpm, regular rhythm, normal volume, no
special character
• BP is 120/70 mmHg
• Temperature is 37o
C (afebrile)
16. Obstetric Examination
On inspection, abdominal is
uniformly distended, both flanks are
full, umbilicus central and flat,linea
nigra and striae gravidarum present. All
quadrants move with respiration.No
dilated veins and scar seen. Fetal
movement is seen.Both hernial orifice
intact.
17. On palpation, fundal height is 34 weeks,
symphysiofundal height is 38cm. Fundal grip
revealed a soft, broad, non-ballotable mass
suggestive of breech. Lateral grip revealed a
curved,smooth, continous feeling on the
maternal right suggestive of the back and
irregular knob like structures were felt on
maternal left suggestive of the limbs. Pelvic grip
revealed a hard, round,non-ballotable structure
which is the head, 4/5th palpable.The
presentation is cephalic and liquor is adequate.
On auscultation,fetal heart rate was 150bpm.
18. In summary, a singleton pregnancy,
longitudinal lie with cephalic presentation and
head 4/5th palpable.
