Gravida 10 , Para 0 + 9

This is a VERY LONG complicated case- it took me 1 hour with the patient and her files - , but its really worth-discussing

Introduction

This is Mrs.Ramsi , a 31 year old employee from India , a known case of APS , who is a G10 P 0+ 9 lady at her 33 + 4 weeks of gestation with her 2nd IVF trial and her 10th pregnancy . The reason she is in hospital is for observation and fetal surviellance due to asymmetric IUGR till her planned elective C/section next week .

History of current pregnancy :

Focusing our attention on this pregnancy . Her LMP is 3rd of Nov. 2008 .She is certain of the date because she wrote it in her diary as her doctor asked her to do so for her Three Embryos transfer that was done two weeks later at 16th of november 2008 . She has regular cycle of 28 days out of which she menstruates 5-6 days .By Nagele's rule her EDD is 9th of August 2009 ..

The pregnancy was planned in Enjab center in Sharjah and she wasnt on any method of contraception prior to embryo transfer or medications except Injectable FSH analouge for 10 days started on the 3rd day of menstruation followed by Injectable Ganirelix and hCG .

Duphastone was prescribed for the first three months of her pregnancy .However , She wasnt on any preiconceptual Folic acid but she was on low dose aspirin and heparin and continued on both during pregnancy .

She had a positive pregnancy test at home after 5 weeks- 7th of Dec 2008 - of 3 embryos transfer .An TVS at Enjab clinic at the same day confirmed a single gestational sac measuring 6.25 mm and one yolk sac .On the 6th week and 1 day of gestation a fetal heart sound was heard during the scan and CRL measured 4.3 mm long .On 12th week an USS revealed a NT of 2.9 mm during the scan . However , triple test results were normal and she requested an amniocentesis which was scheduled at 15th week .

Her follow ups at Enjab hospital continued only till her 12th week of gestation after which she was transfered to Wellcare hospital for F/U in her 2nd trimester and an amniocentesis there revealed no chromosomal abnormalities . She was also found to have elevated BP ( 145/95 ) developed blood pressure at the 22nd week of gestation for which she was started on methyldopa tablets . She felt quickening at 20 th week .

On the 6th of June 2009 ( 31 weeks ) ,her husband noticed her bleeding from her nose while eating their breakfast . She bled for half an hour before reaching ER dep. in Wellcare hospital .The husband described the bleeding as bright red , not too much , and filled a small towel they used to block her nostrils till they reached wellcare hospital . Her Hb was found to be 11.1 g/dL. She received responsive management but no blood transfusion took place .She was asked to stop her aspirin and heparin pills and to double her iron tablets into two tablets per day.

An USS on 32 weeks during her regular antenatal visits detected asymmetric IUGR with decreased end-diastolic flow in MCA and Umbilical vessels and decreased AC with normal BPD ( brain sparing effect ) . The placenta was fundal anterior .The fetus recorded 6/8 Biophysical profile due to oligohydramnios . The fetal weight was 1 kg .An Elective C/S was discussed and Mrs. Ramsi was transfered to dubai hospital on her 32th week for financial issues .

She is currently being followed up here in dubai hospital and the investigation she have had have shown :

a 1.3 mg/dL serum creatinine level which is concerning her alot lately .Her coagulation profile is normal and the Epistaxsis has stopped since 2 days completely .Her anticardiolipin antibodies serum levels are still high and so is the lupus anticoagulant serum levels .No proteinuria or bacteuria and all the rest of the Ix is within normal ranges . She feels the fetal movements regularly and has no complains or disturbing symptoms except for constipation and backache . Fortunately , she is rubella immune and Rhesus positive.Her blood group is B . Moreover , she's planning to breastfeed her baby and she has recivied breastfeeding lessons in dubai hospital .She is taking Iron ( Easy-iron ) and multivitamins ( Elevit ) since the start of pregnancy .She has taken her 2 doses of IM betamethasone since the first day of admission in dubai hospital .Clexane was added recently for prevention of DVT.

P.Obs.Hx :

She has been married for 11 years and she had no history of 1ry infertility . However she was given a trial of ovulation induction on 2008 prior to her 1st IVF .Unfortunately the clomid tablets werent successful with her and it did not improve the outcome .

She had 9 misscarriages all at the gestational age of 6-7 weeks . from 2000 till 2008 in a row.

P.Gyne .Hx :

Her LMP : 3rd /11 / 08 . Her cycle 5-6/ 28 days . No mestrual irregulatries . Normal lenght , flow , frequency .No Intermenstrual bleeding or postcoital bleeding . Noclots, flooding or heaviness . No dysmenorrhea or premenstrual mood swings . Her menarche was at the age of 13 years old .

No history of contraception .

Her last pap smear was taken on 2007 in wellcare hospital and the results were normal so was all her previous smear tests .

PMH .PSH:

Mrs Ramsi was diagnosed to have APS at the time she attended Enjab center for her first IVF at 5/4/2007 that has ended with the same fate of her previous 8 pregnancies with misscarriage at the 6-7th week of gestation .She has no history of chronic hypertension prior to pregnancy or diabetes . No hemoglobinopathies or genetic thrombophilias in her personal or family history .

She had no previous history of blood transfusions or previous hospital admissions except for 4 ERPC ( Evacuation of retained products of conception ) in her last 4 misscarriages in dubai hospital with no post-op complication and a hospital stay of 1 day .

She had all her vaccinations during her childhood in India .

Drug history has been mentioned through history , and to add :
She is not known to have any drug or substance allergy.

Her father is hypertensive with renal imapirment . No twins or congenital abnormalities or handicaps in the family .No Thromboemoblic , Rhematic , Systemic , organic , or malignant diseases or any history of chronic family illnesses except for HTN .Her grandparents died at the age of 70s without complicated medical history .

Social history

With regard her social history she works as in employee in etisalat company . She is due to go on a 3 month maternity leave since 1 week . She is residing in a 2 bedroom apartment with her husband who works as an engineerer in Dubai . There is good sun exposure and no crowdiness where they live except for the noisey traffic . She doesnt smoke nor does her husband . She has stopped alcohol since her embryo transplant

Examination:

Generally , Mrs ramsi looks clinically well . Her vitals are

Temp : 36.9 Degree celsius . Her radial pulse is easily palpable and is 80 bpm , regular rythme , normal character and volume . Her blood pressure is 140/90 mmHg. Her respiratory rate is 14.

She has a canula in her right hand but she is not connected to any IV lines and no drugs or nebulizer is seen at bed side however , there is a yellowish clear urine sample on the table .

She has no evidence of conjunctival pallor , scleral discoloration , central or peripheral cyanosis . No detectable pedal , hand or face edema . Her lower deep tendon reflexes are not elevated . No skin leisons or clinical evidence of thrombocytopenia. The patient is wearing leg stockings probably to prevent DVT.

On Inspection of her abdomen there is a globular swelling consistent with the pregnancy state , a 3rd trimester pregnancy . There are cutaneous signs of pregnancy such as striae gravidarum and new pink linea nigra . There is no visible scars . However , there is visible fetal movements .

On palpation Mrs ramsi didnt complain of any pain or tenderness before touching or during palpation.
I measured the SFH on cm side and found it to be 30 cm which is small to date and not compatible with geststation probably due to oligohydramnios and asymmetric IUGR which was detected on USS.The fetal parts that I felt in the fundus were soft , irregular and non-ballotable which appears to be the breech ,hence the presentation is cephalic.The lie is longtidunal and the back would appear to be on the left as it appears to offer more resistance to palpation and Ifeel small parts on the opposite side . The head is not engaged.The fetus appears clinically small in size.The liquor volume appears clinically reduced .

On auscultation The fetal heart is best heard over the back and below the umbilicus and is 145 bpm which is normal.

I only felt 2 fetal poles . One in the fundus ( breech ) and one in lower segment ( head ) , Hence the pregnancy appears to be a singleton pregnancy on examination

Later after i took the history from the patient . she developed placenta abruptio after 5 hours and she was transfered immediately to OT for emergency C/section . She had a lovely baby girl that she will name nayla and she is doing fine now .The baby is in the NICU.

congratulations Ramsi .You are a true fighter .