ANESTHESIOLOGY

CASE PRESENTATION
KAARTHIGAN RAMAIAH
016-201204-00011
 PERSONAL DATA
• Patient’s Name : Suriah binti Sulaiman
• R/N : 48017
• Age : 32 years old
• Address : Sagil, Ledang
• Marital Status : Married
• Gravida :2
• Para :1
• LMP : 18 July 2015
• EDD : 25 April 2016
• POA : 38 weeks
• Height : 147 cm
• Weight : 94 kg
 CHIEF COMPLAINT
• Madam Suriah, 32 years old, gravida 2
para 1 at 38 weeks period of gestation
was admitted to Hospital Pakar
Sultanah Fatimah Muar for elective
lower segment caesarean section due
to macrosomia fetus.
 HISTORY OF PRESENTING
ILLNESSES
On 18th April 2016, the patient came to
hospital after being scheduled for elective
lower segment caesarean section on 20th
April 2016 in the afternoon.
At 22 weeks period of gestation during
her booking, she was diagnosed to have
gestational diabetes mellitus after being
tested for modified glucose tolerance test.
She was only advised to control her diet
and was not prescribed any medication.
• The transabdominal ultrasound
revealed a macrosomic baby with
estimated fetal weight of 4.2 kg during
her follow up. She was advised for
elective lower segment caesarean
section.
 MENSTRUAL HISTORY
• She attained menarche at the age of
12 years old with regular cycle of 28
days, lasting for 5-7 days of bleeding.
The amount was about 2-3 pads fully-
soaked. No clots. No dysmenorrhea.
 PRESENT OBSTETRICAL HISTORY
• The patient did a self-urine pregnancy
test brought from the pharmacy and it
came out positive. Subsequently, she
went to a nearest clinic to reconfirm
and the result was consistent. Early
ultrasound scan was done and
confirmed her pregnancy at 14 weeks
period of gestation.
• At 22 weeks, period of gestation, she went to
hospital for booking. Routine examination and
screening was done. All were all within normal
range. She was also screened for Gestational
Diabetes Mellitus by testing the modified glucose
tolerance test Results were as follows:

Fasting 5.1 mmol/L

2-hour
8.3 mmol/L
postpandrial
• She was diagnosed of having gestational diabetes
mellitus and was advised on diet control. No
medications were prescribed. Her blood sugar
profile was controlled throughout the pregnancy.
Her latest blood sugar profile (BSP) on admission
was normal:

Fasting 4.2 mmol/L

2-hour
4.5 mmol/L
postpandrial

Post lunch 5.1 mmol/L

Post dinner 3.4 mmol/L
• She is currently 36 weeks of gestation.
The fetal movement is more than 10
times a day. There is no any
contraction pain.
 PAST OBSTETRIC HISTORY
• She has a daughter aged 13 years old who was
delivered at full term by spontaneous vaginal
delivery, weighing of 3.2kg on year 2013. She
breastfed her daughter for six months. Her daughter
is now alive and well. There were no any
miscarriages revealed. There was no history of
gestational diabetes mellitus in the first pregnancy.

PAST GYNAECOLOGICAL
HISTORY
• She had pap smear done in 2012 and there were no
abnormalities detected.
 CONTRACEPTIVE HISTORY
• The patient denied usage of any contraceptive pills
or other method.

PAST MEDICAL HISTORY

• No relevant medical history.

PAST SURGICAL HISTORY

• No relevant medical history.
 FAMILY HISTORY
• Her mother has diabetes mellitus type
2 whereas her father has no known
chronic illnesses. She is the first child
out of 6, all her siblings are healthy.
• No family history of hypertension, heart
disease, breast tumor, endometrial,
cervical, or any other tumors related to
female reproductive tract.
 DRUG HISTORY
• She was not on any medications
before. She is now taking vitamin as
prescribed by the doctor during the
pregnancy. No drug allergics. No food
allergics.
 SOCIAL HISTORY
• She works as a teacher. She does not
smoke cigarette, consume alcohol nor
take illicit drugs. She controls her diet
by avoiding excessive food intake and
high-cholesterol diet to reduce her
body weight as advised by the doctor.
Her husband works as a teacher also.
Her husband does not smoke
cigarette, consume alcohol nor take
illicit drugs.
 SEXUAL HISTORY
• No history of dyspareunia or postcoital
bleeding.
 SUMMARY
• Madam Suriah, 32 years old, gravida 2
para 1 at 36 weeks period of gestation
was admitted to Hospital Pakar
Sultanah Fatimah Muar and scheduled
elective lower segment caesarean
section for delivery of macrosomic
fetus due to gestational diabetes
mellitus.
 PHYSICAL EXAMINATION
VITAL SIGNS :
• A. BP : 127/60 mmHg
• B. Pulse : 91 bpm
• C. Respiration rate : 18 breaths/min
• D. Temperature : 36.5 C
A) GENERAL INSPECTION

Patient lying comfortably, not dyspneic and no pallor observed.

Face
No pallor, no cyanosis, no jaundice

Mouth
Oral hygiene is good, no sublingual jaundice, no central cyanosis

Neck
No visible enlargement of thyroid, no visible enlargement of lymph
node

Hand
No koilonychia, no leuconychia, no peripheral cyanosis, no pallor, no
finger clubbing. Pulse is 86 bpm, BP is 128/56 mmHg
Chest
Both breasts were symmetrical, nipples were everted, no
visible discharge from the nipples, no ulcers around the
breast region and no visible enlargement of axillary lymph
node.

Abdomen
Abdomen is distended, linea nigra seen, striae gravidarum
seen, umbilicus is everted, no previous surgery scars.

Legs
No swelling, no varicosity, No bilateral pitting ankle edema
B) PALPATION

• Face : Eye show no sign of anemia and

jaundice
• Neck : No mass, no swelling of lymph node
• Hand : Pulse is 91 bpm, BP is 127/60 mmHg
• Breast : No mass or tenderness, no
enlargement of axillary lymph node
• Abdomen : Fundus felt, pubic
symphysis felt, fundal
height is 38 weeks, fetal lie
is longitudinal, fetal
presentation is cephalic
• Legs : No bilateral pitting ankle
edema.
D) AUSCULTATION

• Normal heart and lung sound heard

with no added sound.
• Fetal heart rate was 138 bpm.
 PROVISIONAL DIAGNOSIS
Gestational Diabetes Mellitus
• Points to support: The modified glucose
tolerance test revealed 2-hour
postprandial glucose level of
8.6mmol/L. Since the glucose
intolerance was first discovered at 21
weeks period of gestation and the
patient was previously non-diabetic.
 DIFFERENTIAL DIAGNOSIS
Previously undiagnosed Pregestational
Diabetes Mellitus
• Points against: No diabetes was known
previously. If the glucose intolerance
disappeared after the delivery without
requiring any medications, hence
pregestational diabetes mellitus is
ruled out.
1. Transabdominal ultrasound scan

• Estimated birth weight – 4.2kg -

Macrosomia
• Amniotic Fluid Index was 18 – not
polyhydramnios
2. Blood Sugar Profile

Fasting 4.2 mmol/L

2-hour postpandrial 4.9 mmol/L

Post lunch 5.1 mmol/L

Post dinner 3.9 mmol/L

Blood sugar profile was well-controlled

3. Cardiotocograph

• Results: Reactive.
• Interpretation: Fetal not in distress.
4. Full Blood Count
Component Results Ref. range Status

RBC 4.61 4.5 – 6.5 x 109/L Normal

WBC 9.09 4.0 – 11.0 x 109/L Normal

Hemoglobin 15.4 13.5 – 18.0 g/dL Normal

Hematocrit 43.4 40.0 – 54.0 % Normal

Mean Cell Volume 78.2 76.0 – 96.0 fl Normal

Mean Cell 32.8 31.0 – 40.0 (pg/cell) Normal

Hemoglobin
Concentration

Red cell distribution 13.1 11.5-14.5 Normal

width

Platelet count 300 150 – 450 x 109/L Normal

 LEARNING ISSUES
A) PRE-OPERATIVE DETAILS
History As Stated Above

Physical Examination As Stated Above

Laboratory investigation As Stated Above

B) INTRA OPERATIVE DETAILS
Type of block Subarachnoid block
Position of patient Sitting
Needle type and gauge Pencun needle 27G
Approach Midline
Level/site of inserted L3/L4
Distance Skin to space : 5cm
Length of catheter in space : 5cm
Level of anaesthesia T10 and below
Comment CSF clear
No blood stain
Drug & Amount used IV Fentanyl 20mg
Heavy Marcaine 0.5%
Monitoring ECG
NIBP/IABP
Drugs Administered IV Fentanyl 20mg
Heavy Marcaine 0.5%
IV Pitocin 40 unit
C) POST OPERATIVE DETAILS

Recovery Room Order

BP 124/72 mmHg
Pulse Rate 92/min
Respiratory Rate 18 breaths/min
SpO2 99%
• Bromage Score

0 No residual motor block

Full flexion of knee and feet

• Pain Score

0/10
• Post Anaesthesia Recovery Score

NO PARAMETER SIGNS SCORE

1 ACTIVITY Able to lift head/ has a good hand grip 1

2 RESPIRATION Able to breath and cough easily 1
3 CIRCULATION BP and pulse regular within 20% of 1
preoperative level

4 CONCIOUSNESS Arousable 1
5 COLOUR Pink 1
Total 6/6
• Acute pain Survey (APS)
Operation Lower Section Caesarean Section
Anaesthesia Epidural
Epidural Catheter inserted Skin to space : 5cm
In space : 5cm

MANAGEMENT
 IV Augmentin 1.2g TDS
 Analgesia as per APS round
 Heavy Marcaine 0.5%
 Strict pad chart
 Strict I/O chart