long case O&G-placenta praevia

UNIVERSITI KEBANGSAAN MALAYSIA

LONG CASE WRITE UP Module : OBSTETRICS & GYNAECOLOGY

STUDENT NAME: MUHAMMAD KHAIRI AMMAR BIN MOHD SIDEK MATRIC NO :

M000311

3

YEAR/GROUP :

4

SUPERVISOR :DR.WAGIH

ASSESSMENT OF CASE WRITE-UP: Core Clinical Component

History Physical Examination Investigation Diagnosis/ Differential Diagnosis Identify Problems, management and  progress of patient

/10 /10 /5 /5 /5

Critical Appraisal Discharge Summary Referral Letter Prescription References

/5 } } }

/5 /5

Total Score MARKS FOR CORE CLINICAL COMPONENT

/50

Professionalism Component

PART 1 : Issue on Professionalism

/10

PART 2 : Reflection & Life Long Learning

/10 Total Score

MARKS FOR PROFESSIONALISM COMPONENT

/20

Patient name

: Farah Salwani

Age

: 27 years old

I/C number

: 861108075148

Register number

: 23420/13

Gender

: Female

Race

: Malay

Date of admission

: 26  November 2011

Date of clerking

: 27  November 2011

th

th

CHIEF COMPLAINT

Puan Farah Salwani is a 27 years old Malay teacher, primid gravida,, her last menstrual th

 period (LMP) was on 10  April 2013. Currently, her period of amenorrhea is at 34 week of th

gestation, thus, her expected date of delivery is on 17  January 2014 which correspond to the date. She was admitted in the ward due to placenta previa type 4. HISTORY OF PRESENTING ILLNESS th

She was last well 1 and half month mon th ago (28  weeks of POA) when she noticed there was vaginal bleeding while getting dress. It was reddish brown in color, dribbling in nature and not associated with pain. The amount was small and it frequently occurs on that day. The Th e patient felt uncomfortable and change her pad regularly. She denied of having fever, headache, nausea, and vomiting. There was no history of urinary tract infection as the patient claimed that she did not no t has difficulty in passing urine, no nocturia, no frequency and urgency. The urine color was normal and no haematuria. However at that time the patient did not seek for any medication. Unfortunately, the amount of bleeding was increased on the next day. Hence, she went to the  private hospital in Taiping. At the casualty, CTG and ultrasound was done to monitor the baby condition, there was no abnormality abno rmality to the fetus. However, the patient was told b y a doctor that she has a low-lying placenta. So she stayed on that hospital for 2 days to monitor her condition. 2 weeks later, she was referred to Hospital Kulim and went to the clinic pakar 2. At that time,

again the scan was done, she was diagnosed to has placenta previa type 3. Her last scan was on th

28  November which is 2 days after the admission, at that time the scan shown it was placenta  previa type 4. Her current condition is well and no contraction pain indicated. There was no per vaginal bleed noted and no symptom of anemia. Her hemoglobin level was 11.8. She also was diagnosed to have gestational diabetes which in diet control, however she did not remember her  blood sugar profile result. This patient also has completed IM dexamethasone for fetus lung maturation. This is unplanned and wanted pregnancy. She knew that she was pregnant when she missed her period at 8 weeks of gestation and urine pregnancy test (UPT) was do ne by herself at home which tested positive. On the next day, she went to the private clinic and scan was done. She was told that her baby was growing well. There was a singleton fetus in longitudinal lie with cephalic presentation. The liquor was adequate and the placenta located at upper segment of the uterus. The pregnancy had progress well. 4 weeks later, she had her first booking at 12 week of gestation at the Klinik Kesihatan Tanjung Rambutan. At this visit, she was told that her hemoglobin level was low and anaemic. She was normotensive and no glycosuria or proteinuria. Her weighed was 62 kg. Her blood group is O positive and infectious screening test was n ormal. She was prescribed with haematinic Obimin and Iberet. Both medications were taken once daily. However, she has stop Obimin after 2 months. No scan was done during first booking. She had regular antenatal checkup at government clinic and no excessive weight gain was noted. After 2 weeks, she went to the same clinic for follow up of her hemoglobin level. At that time, MOGTT was done as the  patient has a strong family history with diabetes. She was also diagnosed to have gestational diabetes mellitus. Hence, she was advised by a doctor to be in diet control. She had several antenatal checkups for 4 times and her anemia was resolved after 2 months. She had several ultrasound performed and the last scan was done yesterday She had quickening at the 21 week of gestation.

GYNAE HISTORY

She attained menarche at the age of 13. Her menses was regular in 28 days. The flow was minimal for 6-8 days and not associated with dysmenorrheal. She never had a pap smear done before. PAST OBSTETRIC HISTORY

 NIL CONTRACEPTIVE HISTORY

 NIL PAST MEDICAL AND SURGICAL HISTORY

 NIL FAMILY HISTORY

Her father died due to complication of diabetes mellitus. Her mother still alive and healthy. All of her siblings are healthy. There is n o family history of malignancy. SOCIAL HISTORY

The patient is a teacher in Ipoh and her husband is a technician. The combined income of family was RM 3000 which enough to support the family. They lived in single storey house with adequate water and electric supply. She does not smoke or consume alcohol, however her husband is a smoker since 5 years ago. SUMMARY

My patient Puan Farah Salwani 27 years old Malay teacher, primid gravida currently at 34 weeks of gestation who is electively admitted to the hospital due to placenta previa type 4. She was also diagnosed to have gestational diabetes mellitus which is currently in diet control and has a strong family history of diabetes. Other than that, she had resolved her asymptomatic anemia. She had completed IM dexamethasone for fetus lung maturation and currently she was  planning for cesarean section at 38 week of gestation.

PHYSICAL EXAMINATION GENERAL

This patient was lying comfortably on the bed in supine position. She was alert, conscious and not tachypnic. There was an iv branula on the left dorsum hand. On examine of the eye, she was not pale, not jaundice, oral hygiene was good and no central cyanosis. On examine the hands there was no sign of clubbing, the capillary filling was goo d and signs of anemia noted. Her pulse rate was 80 beat per minute, regular rhythm and good volume. On examining of the leg, there was mild ankle edema. Her weight was 159 cm and her currently weight was 69 kg. VITAL SIGN

Pulse rate

: 80 beats per min

Blood pressure

:115/70 mmHg

Respiratory rate

:18 breath per min

Temperature

: 37 C

o

NECK

Thyroid was not palpable BREAST

The breast was symmetrical and no mass was palpable RESPIRATORY

There was no scar noted on the chest. The chest moved symmetrically with respiration. The trachea was not deviated. There was no dullness on percussion. Breath sound was vesicular and normal. Air entry was equal bilaterally.

CARDIOVASCULAR th

Jugular venous pressure was not raised. Apex bea t palpable at the left 5  intercostal space, lateral to mid clavicular line. On palpation, no thrill and parasternal heave palpable. On auscultation, both first and second were hears at mitral valve,tricuspid valve,aortic valve and rd

 pulmonary valve. No murmur noted. No 3  heart sound. NERVOUS SYSTEM

Higher cortical function was intact. He was oriented to time, place and person. His  present and past memory is good. Glasgow Coma Scale was full. Cranial nerves I to XII was intact. Neurological examination of the upper and lower limbs revealed no abnormality. No hyperreflexia ABDOMINAL EXAMINATION

On inspection, the abdomen was distended with gravid uterus by evidence of cutaneous sign of pregnancy such as linea nigra and striae gravidarum. The umbilicus is centally located and it was inverted. There was no surgical scar can be noted. Otherwise, abdominal looks normal. On light palpation, the abdomen was soft and non-tender, and the uterus was not irritable. On clinical fundal high revealed it was 34 weeks and the symphysio-fundal height was 34 cm which correspond to the date. There was a singleton fetus in longitudinal lie and in cephalic  presentation. The fetal back was at right maternal side. The head was 5/5 palpable and not engaged. The liqua was clinically adequate and estimated fetal weight was 2.4 kg to 2.6 kg. VAGINAL EXAMINATION

On vaginal examination, no abnormalities detected. Cervix was firm, not effaced with os tip of finger. The os was not open.

RELEVANT INVESTIGATION AND RESULT HAEMATOLOGY

To access any feature of anaemic due to haemolysis, sign of infection and sign of pre-eclampsia such as low platelet. Full Blood count

White blood cell

: 8.68 x 10^3/uL

Red blood cell

: 3.95 x 10^6/uL

Haemoglobin

: 11.70 g/dl

Packed cell volume (HCT)

: 34.70 %

Red cell indicices (MCV)

: 87.80 fL

MCH

: 27.1 pg

Platelet count

: 222.00 x 10^3/uL

Comment: The Hb was in normal range, normal WBC which indicate no sign of infection and

 platelet level was normal COAGULATION PROFILE

To access the coagulation factor Prothrombin time (PT)

: 12.80 sec

Partial Thromboplastin Time (APTT) Comment: Both PT and APTT was normal

: 35.50 sec

BLOOD SUGAR PROFILE.

To access the venous plasma sugar level. Pre-breakfast

Pre-lunch

Pre-dinner

Before sleep

5.1mmol/l

6.7mmol/l

7.4mmol/l

7.0mmol//

Comment: The level of plasma sugar level at pre-dinner slightly high. Others are within the

normal range. Urea & Electrolyte With creatinine

In pre-eclampsia, the level of uric acid will be high Urea

: 2.6 mmol/L

Sodium

: 135 mmol/L

Potassium

: 4.1 mmol/L

Chloride

:104 mmol/L

Creatinine

:68 umol/L

Uric acid

:390 umol/L

Comment: The level of uric acid was normal. Urea and creatinine also was normal

URINALYSIS Chemical Analysis

Specific gravity

: 1.015

 pH

:6

Leucocyte

: 500 Leu/ul

 Nitrite

: Negative

Protein

: 0.25 g/L

Glucose

: Normal

Ketone

: Negative

Urobilinogen

: Normal

Bilirubin

: Negative

Blood

: Negative

Comment :  protein was negative in urine and leucocyte also normal and to detect whether is

there any sign suggestive of infection Ultrasound scan

To monitor the AFI as GDM can associate with polyhydroamnions and also to monitor the fetal development as it can cause macrosomia and also intrauterine death. The ultrasound scan of this  patient shows that the fetal is correspond to the parameter and the liqua is adequate.

Cardiotocograph (CTG)

To monitor the fetal well-being in order to ensure good fetal development. In this patient, CTG was reactive

Suggestion: Fundoscopy  –   look for any sign of involvement of the eye such as eye nipping , silver wiring

and other.

PROVISIONAL DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS Placenta Praevia

Placenta praevia exist when the placenta is inserted wholly or in part into the lower segment of the uterus. Placental migration occurs during the second and third trimesters, owing to the development

of

the

lower

uterine

segment.

It

is

hypothesized

to

be

related

to

abnormal vascularisation of the endometrium caused by scarring or  atrophy from previous trauma, surgery, or infection. Women with placenta previa often present with painless, bright red vaginal bleeding. This commonly occurs around 32 weeks of  gestation, but can be as early as late mid-trimester. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. My patient was diagnosed to have placenta praevia at 28 weeks of gestation. Within this period it is still considered as placenta praevia. Based on the history and clinical examination shown, it is  placenta praevia DIFFERENTIAL DIAGNOSIS Placenta Abruptio

Occur when there is separation of a normally situated placenta from uterine wall. It can be either revealed, concealed or mixed types. Trauma, hypertension, or  coagulopathy contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death. Usually the patient will complain of painful vaginal bleeding and the uterus is tense and tender on palpation. The patient condition also become more severe and distressed compare than  placenta praevia’s patient.

Vasa praevia

There is rupture of fetal vessels that run in membrane below fetal presenting part which unsupported by placenta/ umbilical cord. Vasa previa is seen more commonly with velamentous insertion of the umbilical cord, accessory placental lobes (succenturiate or bilobate placenta), multiple gestation, IVF pregnancy. In IVF pregnancies incidences as high as one in 300 have  been reported. The reasons for this association are not clear, but disturbed orientation of the  blastocyst at implantation, vanishing embryos and the increased frequency of placental morphological variations in in vitro fertilisation pregnancies have all been postulated. Fetal vessels may rupture at spontaneous rupture of membranes (SRM) or be damaged at artificial rupture of membrane (ARM). Fetal tachycardia may develops followed by deep decelerations. IDENTIFY PROBLEMS IN TERMS OF PRIORITY 1. Vaginal bleeding

As we know, placenta praevia continues to be an important association with maternal and fetal morbidity and mortality if there is uncontrolled maternal hemorrhage and fetal h ypoxia. In such cases, we should manage the patient according to the type of placenta praevia either minor or major. Puan Farah Salwani which is currently at 34 weeks of gestation was diagnosed to have  placenta praevia type 4 which is major. Usually, elective caesarean section should deferred to 38 weeks to minimize neonatal morbidity. Hysterectomy should be mentioned as possibility if  placental percreta happen or overlies a previous scar which can lead to infertility in the future. However, good news for this patient because she does not has previous scar. 2. High blood glucose level.

She was also diagnosed to has gestational diabetes mellitus. Luckily, this patient has a good  progress for maintaining her blood glucose level. She used to be in diet control. There was no severe complication to the fetal such as macrosomia or polyhyromnions which may lead to birth asyphyxia during birth.

IMMEDIATE, SUBSEQUENT MANAGEMENT AND PROGRESSION

The aim of management is to prevent any complication such as fetal distress and maternal vaginal bleeding Besides that, we want to deliver healthy neonate with minimal maternal morbidity. Firstly, a complete history taking must be taken and followed by doing physical examination before admitting the patient into the ward. For this patient, she was admitted to the ward because she had previous bleeding and the clinician want to manage as inpatient since the  patient current gestation of this patient is at 34 weeks.

She was given prophylactic

thromboembolic stocking to decrease the risk of thromboembolism. The doctor also encouraged her to gentle mobility regularly. She was also subjected to daily CTG in order to ensure fetus heart rate. On admission, fetal movement was good, ultrasound shows singleton fetus in longitudinal lie with cephalic  presentation. CTG was also appearing to be normal and it was reactive. 1 large IV line was set up on her left dorsum hand. Blood was taken to check for full blood count, group screen hold 2 units, blood urea nitrogen. Monitor her vital signs such as blood pressure, pulse rate, and temperature 4 hourly. Pad chart is used to look for amount if the patient is bleeding again. Other than that, fetal kick chart is used also to monitor the fetal well-being. The patient was diagnosed with GDM. Hence, blood sugar profile was done to check her venous plasma sugar level. BSP was taken at pre-breakfast, pre-lunch, pre-dinner and before sleep. However the result was not really significant thus, the patient was given an advice to on diet control. For fetal, ultrasound was done to look for any fetal abnormalities such as big baby,  polyhydroamnions and IUD. Corticosteroid was given to enhance the lung maturation by stimulate surfactant  production. IM dexamethasone 12mg stat and the second dose were repeated after 12 hours. It is important to prevent respiratory distress syndrome if the patient is in process of labor which can lead to preterm labor. She was planned for elective caesarean section at 38 weeks to minimize neonatal morbidity. Hysterectomy also was mentioned as possibility to happen during the operation if the  placenta accrete occur.

During pre-operation, again investigation was done; FBC to check for Hemoglobin and  platelet level. BUSE, GSH 2 unit and GXM 4 unit for preparation of blood transfusion if there is severe bleeding during the operation. The procedure of operation was explained to get consent from her. The patient was advice to nil by mouth by 12 midnight. Subcutaneous heparin and cefuroxime were given as a thromboprophylaxis and prophylactic antibiotic. Indwelling bladder catheter and IV line was set up. The patient was transferred to operation theater in left lateral  position to prevent supine hypotension or fetal distress. In performing cesarean delivery, low transverse uterine incision is used. Luckily this  patient did not have invasive placentation (accrete, increta, or percreta). nd

A baby girl was delivered on 2  January 2014 at 8.47 am weighing 2.71 kg via LSCS. Her apgar score was 9/10. The head circumference was 31 cm and the length of the baby was 50 cm. She was given 1 mg vitamin k and 0.5 ml Hepatitis B injection. Cord blood was collected to test G6PD and it was negative.At 9 am, the placenta and the membrane were completely delivered via control cord traction and no retained placenta. The estimated blood loss was 300cc. The placental weight was 600g. Postpartum, she was comfortable and not tachypnic with blood pressure 130/75 mmHg and the  pulse was 72bpm. There were no vaginal bleeding and she was not fever. The uterus size was 18 weeks of gestation and well contract. There were no sign of infection. She was prescribing with Haematinics once daily, subcutaneous heparin 5000U, Synflex tablet and Syrup Lactulose 15mg were given 3 times daily .

CRITICAL APPRAISAL.

By completing this case write up, which is about placenta praevia, I have learnt a lot about it started from definition until the management. Placenta praevia is one of the most common causes of antepartum hemorrhage. Usually, the patient will presented to you with painless per vaginal bleeding which occur spontaneously. However, we should elicit any history of trauma, hard exercise and postcoital which can lead to the vaginal bleeding. It happened when there is tearing of placental attachment and less muscle to suppress bleeding in lower segment. There are 4 type of placenta praevia. Type 1 occurred lateral less than 5cm from the os. Type 2 is marginal which can occur either anterior or posterior part. Type 3 is also known when  placenta partially covering the os. Lastly, type 4 is completely fulling overlying os. Different type of placenta praevia has its own management. Usually, in minor case such as type 1 and 2, the patient will recommended to undergo spontaneous vaginal delivery (SVD). While on the other types which is considered a major case, elective caesarean section is usually done to them. For this case, this patient started to has placenta praevia at 28 weeks of gestation without significant per vaginal bleeding. So, we can say that this patient has antepartum haemorrhage since from definition APH occur after 24 weeks of gestation. Apart from that, the patient also was diagnosed to has GDM with onset or first recognition during pregnancy. Increased estrogen and progesterone, degradation of insulin by placenta and increase cortisol and hPL can lead to hyperglycemia in maternal body ultimately it will promote carbohydrate intolerance in  pregnancy. So, it is important to monitor the patient condition, sign and symptoms and complication of placenta praevia and GDM. The safest, simplest, and most precise method of placental localization is by using transabdominal sonography or transvaginal sonography. All patients with minor placenta praevia can be manage conservatively and treat as outpatient. In patient with major placenta praevia, if no previous bleeding, careful counselling should be made before contempting outpatient care. If  patient had previous bleeding, they should be admitted and managed as inpatients form 34 weeks

of gestation. However, prolong inpatient care can be associated with thromboembolism. Thus, gently mobility should be encouraged together with the use of prophylactic thromboembolic stockings. Prophylactic anticoagulation should be reserved for those at high risk of thromboembolism. We also can educate the patients to not having abdomen massage, no coital and immediate admit if there is contraction feel. Monitor the patient blood pressure, pulse rate and pad chart. Correct the anaemia until the haemoglobin level reach at least 11g/dL. We should also monitor the fetal well-being by using fetal-kick chart, CTG, and serial scan for growth because there is high chance for the baby to has hypoxia and IUGR. Other than that, we can give 2 dose IM dexamethasone 12mg stat 12 hours apart for fetal lung maturation. Immediate caesarean section is indicated if gestational age is more than 36 weeks of gestation, profuse bleeding and fetal distress. All minor case can proceed with spontaneous vaginal delivery while all major case elective caesarean section should be considered at 38 weeks of gestation. st

There are several complications of GDM that can happen to the fetal and maternal. During 1

trimester, there will be congenital abnormalities occur to the fetal such as VSD, ASD, neural nd

tube defect and sacral agenesis. While during 2   trimester macrosomia and polyhydoamnions much more indicated which may lead to birth asphyxia and shoulder dystocia. After the delivery,  baby may suffer respiratory distress syndrome, hypoglycemia and hypomagnesaemia. Maternal may suffered microangiopathy, ketoacidosis, hyperglycaemia and prone to have infection. For reason my patient has a strong family history with diabetes mellitus. Her father was dead due to complication of DM. Hence, a 2 hour 75g glucose 250ml, oral glucose tolerance test (OGTT) at 16-18 weeks to test for gestational diabetes was indicated for this woman. Normally at 0-hour plasma glucose value should be less than 5.6 mmol/L. At 2-hour plasma glucose value should be less than 7.8mmol/L. If the level of plasma glucose value high than these it is considered as GDM. After diagnosed, consult them lifestyle and diet changes. Blood sugar profile is done after 1-2 weeks. Venous plasma sugar level was taken at pre-breakfast, pre-lunch, pre-dinner, and before sleep. If range between 4-7 mmol/l, consider diet therapy. If more than 7mmol/l or types 1 diabetes or ultrasound show fetal macrosomia, start insulin (actrapid 4-6 unit tds) admit patient

st

for education of therapy. HbA1c should be check for every trimester (especially 1   trimester) and maintain between 4-7% to check risk of fetal malformation. Full term SVD delivery may be the choices of delivery if no other obstetrics complications. If the patient on insulin we can deliver at 38-40 weeks. But, if DM uncontrolled with fetal compromised should electively deliver the baby as soon as possible. Elective c-sec is indicated if the patiet has big baby, poor DM control, vascular complication, history of subfertility, and bad obstetric history. For my patient, she does not have any complication of GDM because she has a good and well controlled performance for her blood glucose profile. However, since she had a placenta praevia major, she underwent LSCS.

DISCHARGE SUMMARY

Puan Farah Salwani is a 27 years old Malay Primid gravida with 4 day post LSCS delivery at 38 weeks period of gestation. VITAL SIGN

Pulse rate

: 80 beats per min

Blood pressure

:118/75 mmHg

Respiratory rate

:18 breath per min

Temperature

: 37 C

o

Problems: 1. Placenta Praevia type 4 She underwent LSCS on 38 weeks period of gestation with no severe complications. Given birth to baby girl: Birth weight 2.71 kg Apgar score is 9 G6PD: negative Active, pink, Currently, patient is: Comfortable, afebrile The blood pressure is in normal range Tolerating orally On examination, Alert, comfortable Pink Vital sign stable, afebrile The abdomen is soft and non-tender

Uterus well contracted at 18 weeks size Plan: 1. Allow discharge today 2. TCA 2 weeks later for blood pressure monitoring 3. Discharged medication: T.Ponstant and T.Gelusil 11/11 tds T.Haematinics 1/1 od Syrup lactulose 15ml tds

( DR MUHAMMAD KHAIRI AMMAR ) Medical officer O&G Department Hospital Kulim

REFERRAL LATER

HOSPITAL KULIM Jalan Mahang, 09000 Kulim.Kedah. Tel: 04 4903333. Fax: 04 4900760. URL: http://hkulim.moh.gov.my

To : House Officer/ Medical Officer/ Specialist Patient Name: FARAH SALWANI

Dear doctor, Thank you for seeing this patient and for your concern. We would like you to facilitate this  patient follow up visits in your health clinic. This is Puan Farah Salwani is a 27 years old Primid gravida, currently 4 day post vaginal delivery after underwent LSCS Problems: 1. She was diagnosed to have placenta praevia type 4. She has undergone for LSCS was done. The labour was progress well with no other complication. Upon discharged, both mother and baby was healthy. Maternal blood pressure was 118/75 and other vital sign was normal. She was afebrile and can tolerate orally. Patient was prescribed with: T.Ponstant and T.Gelusil 11/11 tds T.Haematinics 1/1 od Syrup lactulose 15ml tds Kindly please see this patient for: 1. Family planning consultation 2. Explain the complications for next pregnancy

( DR MUHAMMAD KHAIRI AMMAR ) Medical officer O&G Department Hospital Kulim

PRESCRIPTION

HOSPITAL KULIM

Jalan Mahang, 09000 Kulim.Kedah. Tel: 04 4903333. Fax: 04 4900760.

PATIENT NAME : FARAH SALWANI Patient is prescribed with, 1. T.Ponstant 11/11 tds 2. T.Gelusil 11/11 tds 3. T.Haematinics 1/1 od 4. Syrup lactulose 15ml tds

( DR MUHAMMAD KHAIRI AMMAR ) Medical officer O&G Department Hospital Kulim

PROFESSIONAL COMPONENT PART I: ISSUE ON PROFESSIONALISM

Professional etiquette is one of the most important factors contributing to a successful healthcare career. Healthcare involves many personal interactions with a variety of people. Etiquette in healthcare is more than just good manners; it is about establishing respectable relationships with patients, colleagues, and supervisors. I learnt that I need to be brave and confident when communicating with the patients. I tried my best to use simple questions so that my patients would understand my questions easily and would not feel burden to answer them. I felt comfortable to talk with he r as she was always smiling and cooperative with me. She gave me permission to do physical examination on her and she even asked me about the Leopard Maneuvar as she found that it is very interesting. I palpated her abdomen as gentle as possible while explaining to her and she was very amazed. I was very happy that I can palpate the fetal parts and at the same time share my experiences with the  patient. This is a very precious experience as I cannot easily get the opportunity to approach someone who I did not know about her whereabouts before, and try to convince her to believe in me. At the beginning, of and throughout the patient and doctor relationship, the physician must work toward an understanding of patient’s health problem. After the patient agree on the  problem and the goals of therapy, the physician must be professionally competent, act responsibly and treat the patient with compassion and respect. In the care, including giving informed consent or refusal to care as the case might be. The physician’s primary commitment must always to the patient’s welfare and best interests, whether in preventing or treating illness or helping patient to cope with illness disability and death. The physician must respect the dignity of all persons and respect their uniqueness. The interest of patient should always be promoted regardless of financial arrangements, decision making capacity, behavior and social status.

PART II: REFLECTION & LIFE LONG LEARNING:

The patient has the right to expect good quality in healthcare. Patient must be treated in such way that their beliefs and privacy are respected and their dignity remains unoffended. In my case, my patient was diagnosed to have placenta praevia type 4 which is major. As we all known that placenta previa can create a lot of complications especially to the mother. In severe case, we should not forget to mention hysterectomy to the patient. S ince this is st

the 1  pregnancy of my patient, we should also taking care of her emotions as there is chance for to not get pregnant anymore. Luckily, this patient did not have any severe complication during the operation and her uterus is still intact. Unfortunately, she might ha s problem which can affect for the next pregnancy as she had a scar. So, I learned that we should always explain and educate the patient regarding her condition so that she will be more caution in the future. As a medical student, I need to practice more on communication skill. I learnt how to  become more alert and sensitive towards patients and be more considerate in getting information. From the practice, I got a lot of advantages that can help me to improve my skills to understand the patient’s conditions and needs.

The patient-physician relationship entails special obligations for the physician to serve the patient’s interest because of the specialized knowledge that physician possess. Effective communication is critical to a strong patient- physician relationship. At that time, I learned that it is important to gain trust and having a good communication between a doctor and the patient. The efforts and commitments from the doctor also give me inspiration to do my very best in treating my patient. I believe that I should take an initiative to not only treating my patient, I also need to respect and take care of them earnestly.

REFERENCES.

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Redman C W G 1989. Hypertension in pregnancy. Medical disorder in obstetric practise. Blackwell scientific oxford Fenakel et al : nifedipine versus hydralazine in the management of preeclampsia , obstetric and gynaecology 77 : 731 1991 Repke JT, Villar J : Pregnancy induced hypertension and low birth weight : the role of calcium 1991 Labib M. Ghulmiyyah and Baha m. Sibai, gestational hypertension-preeclampsia and eclampsia ,management of high risk pregnancy : an evidence based approached Pipkin FB,Risk factor for pre-eclampsia,2001 Berkowitz KM,Insulin resitance and preelampsia,1998 th  Ten Teachers. 2011. Obstetr i cs 19  . Edited by Philip N Baker and Louise C  editi on  Kenny. Published by Hodder and Stoughton Ltd. th  Kevin P.Hanretty. 2010. Obstetr ics I ll ustrated 7  . Published by Churchill  editi on  Livingstone Elsevier.