Keywords: Fetal Distress, Cesarean Section, Artificial Rupture of Membrane, Placenta Abruption, Syphilis in Pregnancy Case Summary

STUDENT NAME : Aaron Lai Kuo Huo NAME OF SUPERVISOR: Dr Kathiravan Chinniah PATIENTS DETAILS (R/N: 1472464) I/C
NUMBER: 73112-13-5894 SEX: Female
ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010
Keywords: fetal distress, cesarean section, artificial rupture of membrane, placenta abruption, syphilis in pregnancy CASE SUMMARY Mdm. TMAL is a 37 year old Iban gravida 5 para 4 at 37 weeks and 1 day of gestation. Antenatally, the patient and her second husband was screened and confirmed for syphilis and thus, were treated accordingly. On admission, she presented with regular strong contraction pain, presence of show, an engaged fetal head and dilatation of cervical os of 3 cm which were evident of a latent phase of labour. There were no signs and symptoms of maternal syphilis. Investigations of a full blood count, transabdominal ultrasound and baseline cardiotocography (CTG) did not reveal any abnormalities. The latent phase of labour was uneventful until the active phase of labour. Following an artificial rupture of membrane, continuous CTG monitoring revealed fetal distress. Thus, an emergency lower segment caesarean section was indicated. However, en route to the operation theatre, the patient was able to spontaneously deliver vaginally a 3.2 kg baby boy with a normal Apgar score; who was later transferred to SCN in view of fetal distress and maternal syphilis. Cord blood ABG was normal with a negative VDRL status. A diagnosis of a grade II placental abruption was made, as evident by presence of a fresh retroplacental clot during delivery of the placenta, as the cause of the fetal distress. Intravenous infusion of oxytocin was given to prevent postpartum hemorrhage. The patient was initially monitored in the high dependency unit before being transferred to the ward. She recovered clinically and remained haemodynamically stable. She was thus discharged to her local clinic on day 3 of admission to be reviewed postpartumly, for counselling on long-acting reversible contraceptive techniques and to review the patient and her husbands VDRL status in 2 weeks time. Her newborn child requires to be admitted in SCN for a couple more days as he had presumed sepsis and had to complete a course of intravenous antibiotics.
STUDENT NAME : Aaron Lai Kuo Huo NAME OF SUPERVISOR: Dr Kathiravan Chinniah PATIENTS DETAILS (R/N: 1472464) I/C NUMBER: 73112-13-5894 SEX: Female
1) CLINICAL HISTORY Chief Complaint Mdm. TMAL is a 37 year old Iban housewife of G5P4 (Gravida 5, Para 4) at 37 weeks and 6 days of gestation who is antenatally known to be tested positive for syphilis. She currently presents with regular contraction pain since 2 pm on the day of admission.
History of Presenting Illness Mdm. TMAL is a 37-year-old Iban housewife of G5P4 who is currently at 37 weeks and 6 day of gestation. She presented with regular contraction pain since about 4 pm on the day of admission. Initially, the contraction pain was once in 15 to 20 minutes, with each episode lasting about 20 seconds. Later, on admission at 7pm (3 hours after onset), the contraction was progressively increasing in severity with closer intervals at once in 10 minutes, with each episode lasting 30 seconds. The contractions started in the lower back and radiated to the front of the abdomen. The contraction pain was associated with presence of show. However, there was no leaking of liquor. The patient noted that fetal movement was good. Otherwise, she did not complain of fever and change in micturition such as dysuria, hematuria and frequency.
Systemic Review She does not complain of blurring of vision, headache, stiffness of the neck, sore throat, rashes, weakness, lethargy, chest pain and shortness of breath. Otherwise, systemic review is unremarkable.
Antenatal History Presently, this is the patients second pregnancy in her second marriage. This is a planned pregnancy with her second husband. Her last menstrual period was 3rd April 2010. Her estimated date of delivery is 10th January 2011. Mdm TMAL was sure of dates of her last
menstrual period. She first found out that she was pregnant at 3 months of gestation at a private general practitioner (GP) clinic which confirmed a positive urine pregnancy test after complaining of delayed menstruation for the past 3 months. Subsequently, she did her antenatal booking at Klinik Kesihatan Yong Peng at 14 weeks of gestation. At booking, her blood pressure was 120/80 mmHg (normotensive), hemoglobin was 14.6 g/dL (normal), undetected sugar and albumin levels, weight at 61 kg and of blood group AB rhesus positive. However, her infective screening revealed a VDRL (Venereal Disease Research Laboratory test) positive (1:4 titre) but the tests were negative for HIV (Human Immunodeficiency Virus) and Hepatitis B. A diagnosis of syphilis was confirmed via TPHA (Treponema Pallidum Haemagglutination Assay) testing. Consequently, her second husband was also tested positive for VDRL (1: 32 titre). Both the patient and her husband were treated for syphilis. Previously, she did not complain of developing any form of ulceration at her genitalia; however, she noticed a non-pruritic generalised rash about a year ago in her second husband which she also, soon developed roughly 6 months ago particularly at the palms and soles along with an influenza-like illness before her current pregnancy. They did not seek medical attention for the rashes. The patient did not have a positive VDRL testing in her previous pregnancies (including with the first husband). Mdm TMAL completed two courses of antibiotic treatment for syphilis with intramuscular benzathine penicillin on booking at 14 weeks of gestation and again at 29 weeks of gestation. She did not have any notable side effects after receiving the antibiotics. She had a dating ultrasound scan one week after booking (15 weeks of gestation) which confirmed her dates and demonstrated a viable fetus with up-to-date parameters. Following that, she had another ultrasound scan at 36 weeks of gestation which revealed a singleton fetus, with parameters up-to-date with an estimated fetal weight of 2.7 kg and a normally located placenta at the anterior upper segment of the uterus. Further antenatal follow-up was uneventful until the current presentation on the day of admission.
Past Obstetric History
The patient has delivered four children whom are all currently alive and well. Her previous four pregnancies did not have a positive VDRL test on antenatal booking. Her first 3 children were conceived with her first husband (1991, 1993, 1999) whilst her fourth child was conceived with her second husband (2008). Her last child birth was in 2008.
Year
Gender Gestation Mode Weight (kg)
Location
Antenatal/ Postnatal
1991 1993 1999 2008
Male Male Female Male
Full-term Full-term Full-term Full-term
SVD SVD SVD SVD
2.9 3.0 2.9 3.1
Hospital Sri Aman Hospital Sri Aman Hospital Sri Aman Hospital Batu Pahat
Uneventful Uneventful Uneventful Uneventful
SVD = Spontaneous Vaginal Delivery. Hospital Sri Aman, Sarawak.
Gynaecology History She has used oral contraceptive pills as the form of contraception after her third child in 1999 for 1 year. She claimed that she did not develop any side effects due to the medication. She had her cervical smear screening test done after her last child birth. Her last cervical smear did not reveal any abnormal findings. She does not have any history of sexually transmitted disease prior to the current pregnancy. The patient denied having multiple sexual partners. She only had sexual intercourse with her first and second husband.
Menstrual History She attained menarche at the age of 12 years old. Her menstrual cycle was regular at 28 to 30 days per cycle. The flow usually lasts for about 5 days. She requires about 3 pads per day for the first 2 days of her menstruation and subsequently reduces after that. There was no history of dysmenorrhoea, menorrhagia, inter-menstrual bleeding or presence of blood clots. Her last menstrual period was 3rd April 2010.
Past Medical History 4
Mdm MA has no known medical illness. She does not have diabetes mellitus, hypertension or any known history of any major childhood illness. There was no prior admission for both surgical and medical problems.
Drugs History She is currently not on any medications. She has no history of using any recreational drugs.
Allergy History The patient has no known allergy to any medication or food.
Family History Her parents are still alive and well. There was no significant medical illness in the family such as hypertension or diabetes mellitus. Mdm. TMAL is the 4th of 7 siblings ranging from the age of 32 years old to 49 years old. Otherwise, her family history is unremarkable.
Social History The patient does not smoke or drink any form of alcoholic beverages. She previously worked as a clerk at a business company. She married her first husband at the age of 18 years old in 1991. Her husband is an Iban from the same village as her at Lubok Antu who works as a welder. It was a love marriage. Their marriage lasted for 9 years, before divorcing in 2000 as she could not tolerate the ex-husbands physical abuse. However, she denied that her exhusband was involved in any high risk behaviours and having multiple sexual partners. Her second union was in the year 2003 with a Bidayuh husband whom she met at Sibu. They migrated to Yong Peng after her current husband found a stable job at Yong Peng, at the recommendation of his friends. He is currently 40 years old and working as a long-distance log truck driver at Yong Peng. According to the patient, they are financially adequate and stable with an estimated family income of about RM2000 per month. Mdm TMAL has discussed with her husband in regards to the positive VDRL testing on booking; and her husband, admitted that he had other sexual partners whom were introduced by his colleagues
at his workplace. Nevertheless, the patient forgave her husbands attitude and was willing to look past it, on condition that he will change for the better. Her three children from her first marriage are currently in Kuching and Sri Aman in the care of her ex-husband. She currently stays in a rented one storey house in Yong Peng, which costs about RM170 a month. In regards to family planning, the patient noted that she wish to complete her family after this current pregnancy and will further discuss contraceptive methods with her second husband.
2) FINDINGS ON CLINICAL EXAMINATION General Examination (On Admission on 26th December 2010, 8pm) On examination, Mdm TMAL is conscious, alert and communicative. She is in labour pain. She was not in respiratory distress. She is well-hydrated. Capillary refill time was less than 2 seconds. There was no conjunctival pallor. There was also no koilonychia of the nails, bruising, angular stomatitis and atrophic glossitis. There were no rashes noted. Cervical lymph nodes were not palpable. There was mild bilateral pitting pedal edema up to the level of the ankles.
Vital signs are as followed: Temperature Blood Pressure Pulse Rate : 37oC (Afebrile) : 128/80 mm/Hg (Normotensive) : 94 beats per minute (Normal, good volume, strong, regular rhythm, symmetrical) Respiratory Rate : 20 breaths per minute (Normal)
Weight: 70 kg, Height: 1.68m
Cardiovascular Examination There were no surgical scars or deformities of the chest. There was no visible pulsation of the apex beat. The apex beat was palpable and undisplaced. It was located at the 5th intercostal space, 1 cm lateral to the mid-clavicular line. There was no presence of apex heave, left parasternal heave or thrills. There was a regular heart sound without any murmurs present.
Respiratory Examination The chest moves up and down symmetrically with respiration. There were no deformities of the chest wall. Chest expansion was normal. On percussion, it was resonant on all lung fields. On auscultation, normal vesicular breath sounds were heard with equal air entry.
Abdominal Examination On examination, the abdomen was distended with a gravid uterus evidenced by presence of linea nigra and striae gravidarum. The abdomen moved with respiration. The umbilicus was everted. There were no distended veins or surgical scars present. The contraction was felt with a timing of 1 in 10 minutes which was strong and regular and lasted about 30 seconds. On palpation, the abdomen was soft and non-tender. The uterus was not irritable. Fetal parts were felt. The symphysio-fundal height is 36cm which corresponds to the gestational age of the fetus at 37 weeks and 6 days of gestation. This is a singleton fetus, which is cephalic in presentation with a longitudinal lie. The fetal back present on the maternals right. The fetal head was 2/5th palpable. Clinically, the liquor was adequate. The estimated fetal weight is 3 to 3.2 kg. Fetal heart rate was 152 beats per minute which was normal.
Vaginal Examination No abnormalities were noted on the examination of the vulva and vagina. There were no ulcerations, presence of chancre, condyloma, or rashes noted. Cervical os was 3 cm of a parous cervix. It was soft in consistency, with a length of 1.5cm and in an axial position. The membrane was intact with no palpable cord pulsation. The station was at 2 and it was of a vertex presentation.
Other Examinations Neurological, thyroid and breast examination did not reveal any abnormal findings.
3) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING Provisional Diagnosis First stage of true labour in a 37 year old gravida 5 para 4, at 37 weeks and 6 days of gestation, with underlying treated early latent syphilis.
Reasoning Based on clinical findings on admission, the patient was in the first stage of labour, specifically in the latent phase of labour evidenced by sign and symptoms of labour: regular contraction pain at regular intervals and increasing in severity and strength, presence of show with cervical os dilatation of 3 cm noted in a parous cervix on examination. However, there was no leaking of liquor. This diagnosis is in line with the definition of latent phase of labour recommended by NICE (National Institute of Clinical Excellence) guidelines which states that the latent phase of labour consists of a period of time where there is regular contraction pain with a cervical dilatation of up to 4cm [1]. Apart from that, there was good fetal movement, which as one of the indicators of the fetal well-being. In regards to her underlying disease, that is syphilis; she has been tested with the disease during antenatal booking based on a screening VDRL test (1:4 titre) which yielded positive with confirmation of the disease via TPHA testing. The patients husband also was tested positive for VDRL with a higher titre of 1:32. Previously, the patient had a rash with an influenza-like illness 6 months before her current pregnancy. Otherwise, the patient did not notice any clinical features previously suggestive of other complications of syphilis such as a painless hard ulcer at the genitalia region (primary chancre), changes in micturition such as frothy urine or hematuria suggestive of glomerulonephritis, stiffness of the neck or headache suggestive of meningism and visual problems (ruling out complications of secondary syphilis such as uveitis and optic neuritis). Also, she did notice about a year ago that her husband had non-pruritic generalised rashes noted about a year ago which he did not seek medical attention for; but has soon resolved. This means that her husband most likely had a resolved secondary syphilis
infection, placing him in the latent phase of syphilis. The stage of secondary syphilis usually occurs about 6 weeks to 6 months after the infection. As for the patient, in view of the duration of the infection that the husband acquired (more than 1 year) and her previous rash 6 months before the pregnancy in addition to another 3 months before she was screened for the disease, Mdm TMAL most likely was previously diagnosed in the early latent phase of syphilis on antenatal booking before being treated accordingly twice at 14 and 29 weeks of gestation. This correlates with the diagnostic criteria of early latent syphilis: asymptomatic infection, negative physical examination, positive serology and the infection has occurred within one year of acquisition of the organism [2].
Differential Diagnosis Other differential diagnoses will not be entertained because it is rather clear-cut of a true labour as seen in the case of the patients presentation to the hospital. False labour is highly unlikely also as the patient is having regular painful contractions which is increasing in severity with closer intervals and there is dilatation of the cervical os.
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4) IDENTIFY AND PRIORITISE THE PROBLEMS 1. Labour As the patient is in the first stage of labour specifically in the latent phase of labour, characterized by the clinical features on presentation, the patient would have to be required to be admitted to the ward for further observation and monitoring before being transferred to the delivery suite. Besides that, in regards to the mode of delivery, as the patient has no obstetrics indication for an operative delivery; the patient would undergo a vaginal delivery. One of the most important principles during labour for the patient is the practice of strict and effective universal precaution, due to the underlying syphilis infection which is transmissible through blood products to the health care team. The further plan of management of the patient on admission would be discussed in the upcoming sections.
2. Syphilis in pregnancy Syphillis in pregnancy can cause harm to the fetus as the causative organism, Treponema Pallidum, may be vertically-transmitted from mother to fetus by crossing the placenta at any moment during the pregnancy and also at any phase of the disease. The risk of vertical transmission is 40% in mothers with untreated early latent syphilis. Untreated or inadequately treated syphilis infection in pregnancy may predispose to the fetus to the following complications: stillbirth, neonatal and preterm death, intrauterine growth restriction, congenital syphilis and congenital deformities [3]. A study has well demonstrated the vast difference of a higher percentage of infants (70 100%) that are born to untreated mothers have a higher risk of acquiring the congenital infection in comparison to children born to treated mothers whom have a lower risk (1 to 2%) of having the infection [4]. Fortunately, in the case of our patient, the patient has been treated twice with antibiotics of benzathine penicillin at 14 and 29 weeks of gestation without developing the side effects of the medication (particularly the Jarisch-Herxheimer reaction which may lead to uterine contractions, preterm labour and a non-reassuring fetal heart rate tracing in pregnant women [5]) during the pregnancy. Besides that, follow-up serial ultrasound scans revealed that the parameters of the fetus were corresponding to dates, thus excluding an
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intrauterine growth restriction. However, follow-up VDRL titres were not done in the patient, to evaluate the adequacy of treatment; which should show a falling trend of VDRL titres; that is seroconversion from seropositive to seronegative in 6 months [6]. Thus, this investigation should be done in the current admission for the patient. Moreover, the child has to be screened for syphilis also through VDRL testing after delivery.
3. Advanced maternal age Mdm TMAL is a 37 year old gravida 5 para 4 who is of an advanced maternal age which carries a significant risk in pregnancy. A study carried out by Hsiesh et al recently in Taiwan on a group of women giving birth at 35 years and older showed an increased risk for operative vaginal delivery, caesarean delivery, early preterm delivery (particularly before 34 weeks of gestation), low birth weight, low Apgar scores, fetal demise and neonatal death [7]. Therefore, these problems have to be well anticipated during the delivery of the older obstetric patient.
4. Completion of family After discussion with the husband, the patient has decided to complete her family after the birth of the current child. However, they have yet to decide on the contraceptive techniques which are available for the couple. The couple would be required to be counseled further on the choices of contraceptive techniques upon completion of family such as operative methods of sterilization through a bilateral tubal ligation or a vasectomy. However, if the couple does not wish for operative techniques, they should be recommended for long-acting reversible contraceptive techniques (LARC), which is a form of highly effective contraception method without the need of user action to prevent unintended pregnancies [8]. This will be further discussed in the sections ahead.
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5) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS. 1. Full Blood Count Justification: To assess for evidence of anemia in the patient through the serum haemoglobin level.
Result:
Full Blood Count Haemoglobin Mean Cell Volume Mean Cell Haemoglobin Mean Cell Haemoglobin Concentration White Blood Cell Platelet Hematocrit 9.87 180 38.9 109/L 10 /L Ratio
9
Result 13.6 90.7 29.4 324
Unit g/dL fL pg g/L
Normal Range 11.5 16.6 76 96 27 - 32 300 - 350
4 - 11 150 -400 37 - 47
Interpretation: All the parameters of the full blood count were normal. There was no evidence of anemia, leukocytosis or thrombocytopenia.
2. VDRL Testing (Quantitative Non-Treponemal Serologic Testing) Justification: To evaluate for adequacy and respond to treatment of antibiotics of benzathine penicillin in the patient against syphilis by observing for a fall in VDRL titre level in comparison to her baseline VDRL titre at 1:4 (that is a titre of 1:2, 1:1, or non-reactive). The quantitative results of the VDRL test correspond with disease activity. Seroconversion after treatment usually takes place bout 3 to 6 months [6]. Currently, the patient has been treated twice, once at 14 weeks of gestation, and another at 29 weeks; thus we expect her VDRL status to be non-reactive at this point as initial treatment was started more than 6 months ago.
Result: The investigation was not performed for the patient. 13
3. Cardiotocography (CTG) Justification: For fetal surveillance during the process of labour.
Result (Baseline CTG on admission): Fetal Heart Rate Baseline Beat-to-Beat Variability (BTBV) Accelerations Decelerations 3 accelerations in 10 minutes Negative 155 beats per minute Good variability
Interpretation: The baseline CTG was normal and reactive. There were no abnormalities detected.
4. Transabdominal ultrasound (TAS) Justification: To assess for fetal viability, physical biometry of the fetus, location of the placenta and adequacy of amniotic fluid index. To plot the latest parameters of the fetus on the fetal growth in comparison to previous fetal parameters (estimated fetal weight) to rule out intrauterine growth restriction due to the possibility of vertical transmission of syphilis from mother to fetus.
Result: TAS reported a singleton fetus with fetal parameters corresponding to the gestational age of about 38 weeks of gestation. The placenta was located at the anterior upper segment. The amniotic fluid index was 12 which were adequate. Otherwise, there was no abnormality detected. The estimated fetal weight (EFW) was 3.0 to 3.2 kg.
Interpretation: The pregnancy is viable. There were no abnormalities or deformities detected on ultrasound. There was no evidence of intrauterine growth restriction (an EFW at or below the 10th percentile) on previous and current fetal parameter based on estimated fetal weight. EFW of the fetus was in the 75th percentile. 14
6) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION Working Diagnosis First stage of true labour in a 37 year old gravida 5 para 4, at 37 weeks and 6 days of gestation, with underlying treated early latent syphilis.
Plan of Management The plan of management for the patient can be divided into the following sections (i) Acute plan of management on admission (ii) Plan of management in the labour room or delivery suite (Intrapartum Management) (iii) Postpartum plan of management (iv) Long-term plan of management
Acute Plan of Management on Admission As the patient presented in the latent phase of the first stage of labour, as evidenced by the clinical features above (regular contraction pain, presence of show, cervical os dilated at 3cm), Mdm TMAL has to be admitted to the antenatal ward for monitoring and observation of progress of labour. She would only be required to be transferred to the labour room once she is in the active phase of labour, that is, a dilated cervical os at 4 cm or more. Apart from that, the patients vital signs has to be monitored 4 hourly (blood pressure, respiratory rate, pulse rate and temperature) and also to time her contractions hourly. The next vaginal examination to review the dilatation of the cervical os and effacement would be done once the patient has stronger contractions at 3 contractions in 10 minutes or once there is spontaneous rupture of membrane. The patient would also be started on the fetal kick chart and also labour progression chart. Otherwise, the patient should be reassured regarding the viability of the fetus and she would be required to be counseled again that there is still a possibility, though low after treatment, that the causative organism of syphilis may have been vertically-transmitted to the child leading to congenital syphilis. The mother would also have to be counseled on the need
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to transfer the newborn child to SCN (special care nursery) due to maternal syphilis infection to monitor and observe for early clinical features of congenital syphilis such as jaundice, hepatosplenomegaly, mucocutaneous rashes, rhinitis (snuffles), non-immune hydrops fetalis, pneumonitis, nephrotic syndrome, hemolytic anemia, thrombocytopenia and generalised lymphadenopathy [9] in view to treat the child early on. Clinical features of congenital syphilis such as bony deformities, dental abnormalities and neurosyphillis will only appear after 2 years old if untreated adequately [9].
Plan of Management in the Labour Room (Intrapartum Management) Once the patient is in the active phase of labour, she would be transferred to the labour room for anticipation of labour. Her vital signs would be monitored hourly and to time her contractions and monitor fetal heart rate every half an hour. The partogram would be required to be plotted (cervical os dilatation, maternal blood pressure and pulse rate, timing of contractions, fetal heart rate and medications provided) whereby the progress of labour would be monitored in the active phase of labour. Augmentation of labour, if necessary, can be done via artificial rupture of membrane (ARM) or amniotomy or an infusion of oxytocin. Once the membrane is ruptured either spontaneously or artificially, it is important to note the colour of the liquor (clear or meconium stained). Nevertheless, a continuous CTG monitoring has to be performed to monitor for signs of fetal distress at all times whereby intervention would be necessary if it were to occur. The health care team (doctors and nurses) would also be required to observe strict universal precautions at all times especially in view of the patients syphilis infection status to prevent the risk of infectious transmissible disease during the process of labour particularly during the second and third stage of labour. Universal precaution encompasses the following ideals: (i) Wear double gloves and plastic apron for protection and to handle all blood as potentially infectious (ii) Placed used syringes immediately in the impermeable container and do not recap or manipulate the needle in any way to prevent needle stick injury.
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(iii)
To wear protective mask and eyewear to prevent contact with blood or bodily fluid being splattered.
(iv)
When handling the placenta, it has to be carefully sealed in a plastic bag and discard as clinical waste with the biohazard label to be attached to the bag.
(v)
To inform the patient or their relatives that the placenta is not allowed to be taken back due to the risk of potential transmissible disease in view of the syphilis infection. After delivery of the child, the child has to be transferred in to SCN (special care
nursery) in view of the maternal syphilis status and for reasons as justified above. Apart from that, umbilical cord blood sampling is required to be sent for VDRL testing. Once the VDRL status of the child is known, the child will be treated accordingly if required. A VDRL titre fourfold higher, lesser or same as the maternal VDRL titre necessitates treatment in the newborn with benzathine penicillin whilst a non-reactive VDRL in the newborn does not require treatment [10]. Besides that, the placenta has to be carefully examined also for signs of congenital infection of syphilis such as a more larger and edematous placenta.
Postpartum Plan of Management After delivery of the child, the patient would then be transferred out to the postnatal wards for monitoring and observation of her vital signs 4-hourly. She is allowed to tolerate orally especially a high-fibre diet to prevent straining especially at the site where a perineal laceration repair is performed. She should also be encouraged to ambulate and to breastfeed the newborn once the childs condition is stabilized at SCN or through delivery of milk through pumping. She is also encouraged to pass urine frequently to prevent urinary retention and bladder over distension. The only contraindication of breastfeeding in maternal syphilis is if there is presence of syphilitic lesions on the breast. Otherwise, the patient should be advised on post-partum related care while in the ward which is as follow to minimize risk of infection, bleeding and pain [11]:
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(i)
Vaginal discharge (lochia): Use and change frequently comfortably fitting tampons to absorb the vaginal discharge which will initially be bloody before turning to pale brown to yellowish white in 2 weeks.
(ii)
Care of the perineum: The patient should prevent from douching during early puerperium, but bathing is permissible. It is important for the mother to maintain good hygiene of the perineal area particularly if an episiotomy or laceration repair was done.
(iii)
After pains: This can be treated with analgesics if required by the mother, depending on severity. This is also known as post-partum uterine contractions to prevent excessive bleeding through compression of the blood vessels of the uterus.
Long-term Plan of Management (i) The couple would be advice on options of contraception methods available in view of their wish to complete their family after the current pregnancy. However, they would need time to discuss to come to a final decision. Thus, the couple would be referred to the local clinic for further counselling and decision-making on the type of contraceptive they prefer as well (This would be discussed in further detail in the learning issue as part of communication skills in Section 11: page 29 - 31 ) (ii) To monitor adequacy of treatment of syphilis in both the patient and husband through monitoring of falling VDRL titres. This goes as well for the newborn, if the child was found to be VDRL positive and required treatment.
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7) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOME) The management plan was commenced on admission. On admission at 7 pm (26/12/2010), the patient was in the latent phase of first stage of labour with a dilated cervical os of 3cm. Mdm TMAL was further observed and monitored in the antenatal ward until she had stronger contractions of 3 in 10 minutes at 4.50am on the following day (27/12/2010). Thus, she was transferred to the labour room as she was in the active phase of labour as evident by the cervical os dilatation of 6 cm. Subsequently, an artificial rupture of membrane was performed to augment the progress of labour slightly less than an hour later at 5.40am. At 6 - 6.45 am, continuous CTG monitoring revealed fetal distress as evidenced by presence of type 1 decelerations whereby the fetal heart rate was lowered to about 60 beats per minute from the baseline fetal heart rate (FHR) of 140 beats per minute and picked up back to baseline FHR after 30 seconds. There were at least five type 1 decelerations noted in 10 minutes. The CTG also did not show presence of acceleration. Beat-to-beat variability was poor. Consequently, an internal CTG was placed which confirmed the findings of a nonreassuring fetal heart trace. Examination also revealed maternal tachycardia. Maternal per abdomen examination did not demonstrate tenderness of the abdomen or board-like rigidity. The contractions remained at 3 in 10 minutes. Further vaginal examination revealed blood-stained liquor without evidence of an umbilical cord prolapse. Henceforth, the patient was consented for an emergency lower segment caesarean section due to fetal distress and in query to rule out placental abruption as the underlying cause as an umbilical cord prolapse has been ruled out. At 7 am, en route to the operation theatre, the patient felt like bearing down. Vaginal examination noted a fully dilated cervical os and effaced cervix. The babys head descended on good maternal effort without assisted delivery after 2 minutes and was delivered at 7.02 am with an episiotomy done. There was presence of a loose cord around the neck of the baby and on indirect suction showed blood-stained liquor. Mdm TMAL delivered a 3.2 kg baby
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boy with an Apgar score of 9 in 5 minutes and 10 in 10 minutes. The baby was immediately sent to SCN. A cord arterial blood gas (ABG) and cord VDRL test was immediately sent for investigation. Cord arterial blood gas revealed the following results: pH 7.26, pcO2 49 mmHg and pO2 of 24 mmHg which is a normal umbilical cord blood acid-base state (normal umbilical cord pH > 7.10), based on data collected by Helwig et al [12]. Cord VDRL test was non-reactive. Subsequently, she was given intramuscular (IM) syntometrine and the third stage of labour was completed in 5 minutes (7.07am). There was a fresh retroplacental clot of about 100 ml delivered along with the placenta (weight: 625 grams) which had one part of the cotyledon partially separated. However, there was no short umbilical cord or velamentous cord insertion noted. The complete diagnosis, based on the Sher and Statland severity grading system [13], was a grade II placental abruption as there was fetal distress present intrapartumly with a concealed hemorrhage as noted by the presence of a retroplacental clot. The patient did not present with per vaginal bleeding as the hemorrhage was concealed and was unable to track down unlike a revealed hemorrhage. The cause of the fetal distress would be due to the placental abruption. The rupture of the maternal blood vessels in the deciduas basalis leads to accumulation of blood causing splitting of the deciduas with the placental attachment to the uterus [14]. This results in one of the detached portion of the placenta to be unable to exchange gases and nutrients, thus leading on to fetal compromise as seen in the fetal distress above. However, the only risk factors seen in this patient is an advanced maternal age and a male fetal sex [14]. There were no other associated risk factors that are suggestive in her history of placental abruption such as history of trauma, use of cigarette smoking or cocaine abuse, previous placental abruption, chorioamnionitis, prolonged rupture of membranes and pregnancy-induced hypertension [14]. Consequently, she was started on intravenous infusion of oxytocin of 40 units to prevent potential post-partum hemorrhage (PPH). Another large bore branula was inserted to anticipate the possibility of PPH in addition to a previously inserted branula. There was no further bleeding noted. A perineal repair was subsequently followed. The total estimated blood loss was about 400 mls (300 mls + 100 mls of clot). Investigations were immediately
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sent for maternal full blood count and coagulation profile which revealed the following results:
27/12/2010 (7.10am): Full Blood Count

Full Blood Count Haemoglobin Mean Cell Volume Mean Cell Haemoglobin Mean Cell Haemoglobin Concentration White Blood Cell Platelet Hematocrit 16.43 160 40 109/L 10 /L Ratio
9
Result 12.9 89.9 29.2 324
Unit g/dL fL pg g/L
Normal Range 11.5 16.6 76 96 27 - 32 300 - 350
4 - 11 150 -400 37 - 47
27/12/2010 (7.10am): Coagulation Profile Coagulation Profile Prothrombin Time (PT) aPTT INR 30.6 1.5 Seconds 30.6 43.8 Result 13.2 Unit Seconds 11.8 13.7 Normal Range
1.0 - 2.5 (Prop. VT Surgery) 2.0 3.0 (DVT, TIA, AF, VHD, AMI) 3.0 4.5 (Recur. DVT, PE)
Both investigations above did not revealed normal parameters. There was no evidence of anemia due to the blood loss, leukocytosis or thrombocytopenia due to blood loss. Furthermore, coagulation profile was normal in the patients case, ruling out the possibility of disseminated intravascular coagulation (DIC), due to a placental abruption. DIC may occur due to a sudden influx of tissue factors (TF) in the blood stream activating the coagulation pathway causing a consumptive coagulopathy [15]. Consequently this causes a systemic bleeding diathesis. Fortunately, this did not occur in the patient after further monitoring. 21
Following delivery, the patient was transferred to the High Dependency Unit (HDU) in the labour room for further observation in view of potential post-partum hemorrhage and disseminated intravascular coagulation. She was started on intravenous fluid therapy of 1 liter of normal saline over 24 hours with vital signs monitoring every half-hourly and strict pad charting. At 10.35am, the patient had one further episode of 50 mls of bleeding per vaginally. After stabilization of vital signs, she was transferred to the post-natal wards on the following morning (28/12/2010). She had minimal per vaginal bleeding while she was managed and observed in wards. The patient was clinically and haemodynamically stable on examination. Examination showed a soft, non-tender abdomen with uterus contracted well to 20 weeks and sutures were intact at the site of perineal repair. After discussion with her husband on options in regards to contraceptive methods available, as they wish to complete their family, her husband declined for surgical sterilization (bilateral tubal ligation, vasectomy), however the couple were more interested in long-acting reversible contraceptive (LARC) methods. Therefore, they would be referred downstream to their local clinic for further counselling on LARC methods available (LARC would be discussed in further detail in the learning issue as part of communication skills in Section 11: page 29 - 31). The patient remained clinical stable and well, thus, she was discharged on day 3 of admission (29/12/2010); with the discharge plan as below. As for her newborn child, on the day of discharge of the mother, she was informed that he would be required to be kept in SCN for a couple of days more as he had presumed sepsis and would required intravenous antibiotics (IV C-Penicillin and Gentamycin). However, as mentioned above, the babys VDRL testing was non-reactive, means that the syphilis infection was not verticallytransmitted to the fetus and most-likely the mother has been adequately treated for the infection.
22
8) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION Discharge plan and counselling 1. For downstream referral and appointment at the her local clinic (Klinik Kesihatan Yong Peng) after two weeks of discharge for: (i) Post-partum and post-natal follow-up (ii) Counselling on long-acting reversible contraceptive methods as the couple has wished to complete their family and were not interested in surgical sterilization. (iii) To review the patient and her husbands VDRL status again, with the aim to ensure that adequate treatment was given for the treatment of the syphilis infection. (iv) For further counselling and patient education for behavioural counselling in regards to preventing sexually transmitted disease for the patient and her husband by avoiding high risk behaviours and activities [16]. 2. To advise the patient to come back to the hospital immediately if she notice that there is abnormal or continuously excessive bleeding particularly after discharge to 12 weeks postnatally as she could be at risk of secondary post-partum hemorrhage. 3. To continue post-natal nursing care plan through the home visit nurses, once the newborn child is being discharged from SCN. 4. To further counsel and educate the patient on the importance of breastfeeding in her child 5. To counsel on postpartum care particularly on proper wound care and importance of maintaining proper perineal hygiene (as discussed above in page 17 -18) 6. To advice for cervical smear in her local clinic as her last cervical smear was done after her last child birth in 2008. 7. No medications are required for the patient on discharge.
23
9) REFERRAL LETTER Medical Officer, Klinik Kesihatan Yong Peng, Jalan Muar, 83700 Yong Peng, Batu Pahat. 29th December 2010
Dear doctor, Patient Name: Mdm. TMAL IC Number: 73112-13-5894 Registration Number: 1472464 Age: 37 years old Phone Number: 013-765 4321 Date of Admission: 26th December 2010 Date of Discharge: 29th December 2010
Problems: (i) Post spontaneous vaginal delivery complicated intrapartumly with a grade II placental abruption (ii) Underlying treated syphilis infection during pregnancy at 14 and 29 weeks of gestation (iii) Completion of family
Thank you for seeing the above patient, Mdm. TMAL, a 37 year old Iban of parity 5 with the above problems. She was recently admitted to Hospital Batu Pahat on 26th December 2010 and delivered a baby boy weighing 3.2 kg. The delivery was complicated intrapartumly with a grade II placental abruption evidenced by fetal distress and fresh retroplacental clot noted on delivery of the placenta. The baby boy required to be admitted to special care nursery (SCN) for further observation and monitoring and also, in view of potential maternal syphilis. The newborn later was tested negative for VDRL. Intravenous oxytocin was given to prevent a
24
potential postpartum hemorrhage. The patient, however, recovered clinically and was haemodynamically stable throughout the stay in the ward and was discharged well on 29th December 2010. We are referring and discharging the patient to Klinik Kesihatan Yong Peng to manage her problems above, as follow: (i) For post-partum review and follow-up (to ensure intact perineal repair and good perineal hygiene and to inquire whether there is continuously abnormal or excessive bleeding after discharge) (ii) To counsel on long-acting reversible contraceptive (LARC) methods available as the couple has wished to complete their family and were not interested in surgical sterilization. (iii) To review the patient and her husbands VDRL status again, with the aim to ensure that adequate treatment was given for the treatment of the syphilis infection Baseline VDRL titre on June 2010: Mdm TMAL (1:4), Husband (1:32). (iv) For further counselling and patient education for behavioural counselling in regards to preventing sexually transmitted disease for the patient and her husband by avoiding high risk behaviours and activities. Ive also hereby, enclosed the patients relevant laboratory investigations and documents for your references. Thank you very much for your kind assistance. Please do not hesitate to contact us for further queries or clarification. Thank you.
Yours sincerely,
__________________________ (DR. AARON LAI KUO HUO) House Officer, Obstetrics and Gynaecology Department, Hospital Batu Pahat.
25
10) LEARNING ISSUES IN THE 8 IMU OUTCOMES 1. Clinical Skills (Management) Anticipation, Prevention and Management of Postpartum Hemorrhage Mdm TMALs delivery was complicated intrapartumly with a grade II placental abruption evidenced by fetal distress and presence of a fresh retroplacental clot on delivery of the placenta. Placental abruption is one of the risk factors for potential post-partum hemorrhage. The following learning issue explores on clinical skills of anticipating, preventing and managing a potential post-partum hemorrhage, if it were to occur in the patient above. As of 2008, the maternal mortality rate in Malaysia is estimated at 31 per 100,000 with postpartum hemorrhage as one of the leading cause of maternal death in our country [17]. Therefore, it is important for us as junior doctors to anticipate, prevent and effectively manage mothers presenting with postpartum hemorrhage. Based on the Royal College of Obstetricians and Gynaecologists (RCOG), primary postpartum hemorrhage (PPH) is defined as the loss of 500 ml or more blood within the genital tract within 24 hours (which is further divided to minor, moderate or severe PPH) whilst secondary postpartum haemorrhage is defined as an excessive or abnormal bleeding from the birth canal between 24 hours and 12 weeks postnatally [18]. The role of active management (early clamping, administration of IM syntometrine and Brandt-Andrew controlled cord traction) in the third stage of labour has reduced the risk and rate of PPH [19]. In cases of potential PPH, this can be anticipated by estimating the severity of blood loss in the mother which can be judged clinically via signs and symptoms of shock such as maternal tachycardia, hypotension, tachypnoea and delayed capillary refill time and also via visual blood loss estimation which is used in our clinical setting (for example: gauze = 50 ml, tampon = 80 ml, abdominal pack =250 ml, sarong = 500 ml, kidney dish: 700 ml). Once a diagnosis of a massive obstetric collapse has been made, the general management consists of four vital components, based on the updated Green-top guideline [17]: (i) Communication: Activation of red alert to call on assistance from a multidisciplinary team (consultant obstetrician, anaesthetist, pediatrician, hematologist, theater staff, nursing staff and support staff).
26
(ii)
Resuscitation: This is then followed by the ABCs of resuscitation by ensuring adequate airway, breathing ( a high concentration of oxygen of 10 to 15 litres per minute via face mask) and circulation (establishing intravenous line with wide bore cannula of 14/16G whilst retrieving 20 ml of blood for investigations: full blood count, group cross match 4 to 6 units, coagulation profile, blood urea and electrolytes, and transfuse blood as soon as it is available or infuse Hartmanns solution of 2 litres with or without addition of colloids of 1 to 2 litres, depending on clinical severity. Besides anemia, it is also important to correct thrombocytopenia and coagulation profile with the use of fresh frozen plasma, platelet concentrates and cryoprecipitates)
(iii)
Monitoring and Investigation: Subsequently, once the patient is stabilized. It is important to monitor her vital signs (blood pressure, pulse rate, respiratory rate, and oxygen saturation) for every 15 mins, catheterizing the bladder to monitor urine output, repeat investigations and consider transferring to an intensive care unit for further monitoring.
(iv)
Arrest of bleeding: Following that, the four Ts of PPH should be ruled out cautiously as the cause of the hemorrhage: Trauma (Caesarean section, mediolateral episiotomy, operative vaginal delivery, ruptured uterus), Tissue (Retained placenta), Tone (Uterine atony due to prolonged labour, anemia, advanced age, multiple pregnancy causing over distension of uterus, and placenta praevia), Thrombin (preeclampsia, placental abruption). Uterine atony remains as the leading cause (80%) of PPH [17]. Secondary PPH encompasses causes such as retained products of conception, infection and breakdown of uterine wound.
When uterine atony is found to be the cause of the PPH, the following measures are required to be done in a stepwise approach [17]: PHARMACOLOGICAL Bimanual uterine compression and massage (To encourage contractions) Ensuring an empty bladder (A full bladder displaces the uterus, preventing contractions) Examination of the placenta again (To rule out retained placenta) Slow IV Syntocinon 5 units 27
Slow IV or IM Ergometrine 0.5 mg or IM Syntometrine (Contraindicated in hypertension) IV Syntocinon infusion (40 units in 500 ml Hartmanns solution at 125 mls/hour) IM Carboprost 0.25 mg (15 Methyl-PGF2) (Repeated at intervals more than 15 minutes for a maximum of 8 doses). Contraindicated in asthma. Misoprostol 1000 gm rectally If persistent bleeding, re-check cervical or vaginal tear If there is torrential haemorrhage, immediate bimanual compression of uterus or aortic compression, and transfer to operation theatre SURGICAL Further examination under anaesthesia (to rule out vagina, cervix, endocervix tears; retained products of conception, and ruling out coagulopathy before surgical intervention) Balloon tamponade Uterine compression sutures (B-lynch suture or haemostatic suturing technique) Devascularization procedures (Bilateral uterine artery ligation, bilateral internal iliac artery ligation, uterine artery embolisation) Hysterectomy
Comment: In the case of Mdm TMAL, placental abruption was not detected earlier even with imaging of ultrasound on admission, as studies have noted that ultrasound has a poor sensitivity in detecting placental abruption (positive findings in only 25% at delivery) [14], however, another cause could be due to user-dependent. This is true as on imaging, both placenta and acute hemorrhage would be hyperechoic [14]. The hemorrhage would only be hypoechoic after a week. This means that most likely, Mdm TMAL recently had an undetected placental abruption at any period at the week before her delivery. It was only diagnosed after delivery of the placenta. Therefore, as junior doctors, we must be vigilant at all times while anticipating the possibility of a post-partum hemorrhage clinically likewise in the patient above and furthermore, with careful monitoring and observation particularly in the first 24 hours.
28
2. Communication Skills Counselling on Long-acting Reversible Contraceptive (LARC) Techniques The patient and her second husband wish to complete their family after the birth of their current child, thus, they were keen on knowing the contraceptive techniques available. The patients second husband was not interested in surgical sterilization of either bilateral tubal ligation for his wife or a vasectomy. However, the couple agreed for additional counselling on LARC methods available in our clinical setting as their choice of contraception. LARC is defined as contraceptive techniques that require administration less than once per cycle or month [8]. The aim of counselling of LARC methods in our patient is to prevent unintended pregnancies (as they wish to complete their family) which may lead on to potentially negative consequences like decisions on abortions and relationship instabilities [20] and to provide information on types of LARC which are available to allow the couple to choose a method and use it effectively. According to studies done on LARC, it has a proven record of higher efficacy, convenience, cost-effectiveness and higher user satisfaction in comparison to a higher failure rate in traditional contraceptive methods (like oral contraceptive pills and the use of condom)
[20]
. In the United Kingdom, this form of contraceptive has been actively promoted to the
public instead of traditional contraceptive methods since 2008 [21]. First and foremost, the couple has to be educated on the purpose of counselling on LARC that is to prevent unintended pregnancies upon completion of family. Following that, the patient will then be introduced the types of LARC methods available which are as follow: copper intrauterine devices (IUD), progestogen-only intrauterine systems (IUS), progestogenonly injectable contraceptives and progestogen-only subdermal implants. It is important also to let the couple to be aware that these LARC methods available are more cost-effective than the combined contraceptive oral contraceptive pills (that she has taken before), even at 1 year of use. In accordance, the patient should receive detailed information on the above four methods available in the context of mode of action, contraceptive efficacy, duration of use, risk and side effects, non-contraceptive benefits and the procedure for insertion and removal; which is summarized in the table below, based on NICE guidelines on LARC [8].
29
Summary of Long-Acting Reversible Contraceptive (LARC) Techniques

Copper IUD (Paragard) Mode of Action Preventing fertilization and implantation Duration of Use Failure Rate Less than 2 in 100 women Less than 1 in 100 women 5 to 10 years Progestogen-only IUS (Mirena) Preventing fertilization and implantation 5 years DMPA+: 12 weeks NET-EN : 8 weeks Less than 0.4 in 100 women Less than 0.1 in 100 women
^
Progestogen-only Injection Preventing ovulation
Progestogen only Implants (Implanon) Preventing ovulation
3 years
Expulsion: 1 in 20 women Side Effects Heavier bleeding/ dysmenorrhea during periods Irregular bleeding, spotting, oligomenorrhoea/ amenorrhea Vaginal pain, ectopic pregnancy, PID (less than 1%), Uterine Perforation (1:1000), change in mood or libido, No effect on weight gain Contrain dications Current STIs*/Risk of high exposure, PID , Endometrial/ cervical cancers, puerperal sepsis, postpartum 48 hours to 4 weeks, Malignant trophoblastic disease
# #
Amenorrhea, Altered bleeding pattern, weight gain, small loss in bone mineral density. No effect on depression, acne, headaches
Altered bleeding pattern, Acne. No effect on weight, mood, libido, headaches, bone density.
Pregnancy, enzyme-inducing drugs, liver disease, venous thromboembolism, deep venous thrombosis, pulmonary embolism, breast cancer, stroke, immobilization, smoking, diabetes
Wilsons disease, Copper/nickel allergy Insertion
Breast cancer
Osteoporosis
Anytime during menstrual cycle or 4 weeks post-partum
Any time post-partum, anytime during menstrual cycle Delay up to 1 year in return of fertility after stopping No evidence of delay of fertility after removal
Removal
No delay in return of fertility after removal
+ Depot medroxyprogesterone acetate, ^ Norethisterone oenanthate, # Pelvic inflammatory disease, *Sexually transmitted infections: Chlamydia Trachomatis, Neisseria Gonorrhoeae, syphilis
30
Otherwise, LARC is safe for women who are nulliparous, breastfeeding, body mass index more than 30, underlying diabetes, migraine or HIV (human immunodeficiency virus) infection. After the couple has been informed in detailed about the choices available with their queries answered as well; the couple would then be allowed time to discuss and choose the preferential choice of LARC method which will then be provided by their local clinic and general physician. In view of the unknown status of both the couples VDRL status currently, it is best for the patient to either opt for a progestogen-only injection or subdermal implants as current and active STIs are contraindicated in both IUD and IUS. At the end of the counselling session, the couple should also be advised on safer sex and to avoid high risk behaviours and activities to prevent sexually transmitted infections which could have possibility occurred in this pregnancy through vertical transmission if an infective screening was not done during antenatal booking.
3. Professionalism, Ethics and Personal Development Medical and legal obligation of the doctor in Prevention & Control of Infectious Diseases Both the patient and her husband were diagnosed and confirmed to have syphilis during the time of the patients antenatal booking. Therefore, they were treated immediately with a course of antibiotics (benzathine penicillin) at Klinik Kesihatan Yong Peng. The doctor at their local clinic fulfilled his medical obligations as a duty of a doctor towards the community to immediately treat the patient and her second husband. Furthermore, as syphilis is a mandatory notifiable sexually transmitted infection, as required under the laws of Malaysia (Act 342: Prevention and Control of Infectious Diseases Act 1988 [22]), the doctor at KK Yong Peng has also performed his duties by reporting the infectious disease to the relevant authorities. The doctor should be acknowledged for his professionalism in handling the situation. Under part IV Section 10(2) (Control of the spread of infectious disease) of Act 342, every medical practitioner who diagnoses any sexually transmitted diseases (STD) cases
31
(syphilis, chancroid, gonococcal, HIV as noted in Part I and II of the First Schedule) is required to notify to the nearest medical officer of health via the disease notification form [22]. The infectious disease surveillance system in Malaysia will then require this report to be passed on to the State Health Office and followed through to the Communicable Disease Control Section of the Public Health Department, Ministry of Health Malaysia [23]. This existing system of mandatory notifiable infectious disease surveillance is represented as follow:
Besides that, the medical officer who has seen the case initially would be required to carry out the Partner Notification, as done by the medical officer above at KK Yong Peng. Partner Notification resembles a form of contact tracing. The importance of partner notification would be to take early precautions to prevent further spread of the STD, access to early treatment and counselling to avoid future risky behaviours and activities [23]. Partner notification requires the patient to persuade and encourage their contact/(s) who has been exposed to the disease to come to the clinic for counselling, investigation and treatment [23]. If the contact is non-contactable or the patient is not willing to bring him or her in to the clinic, the medical officer has to inform the District Health Officer who will undertake necessary action (under Part IV Section 15) [23]. Failure for the individual to adhere to this mandatory notifiable disease surveillance would be liable on conviction as accorded by Act 342, whereby the person found guilty under this act would be either imprisoned or fined. In conclusion, the purpose of surveillance of notifiable diseases would be to ensure adequate and effective treatment to help increase patient compliance and to prevent further spread of infectious disease to the community. It is both the medical and legal obligation of the doctor to report notifiable diseases to the relevant authorities and to treat and counsel the patients and their partner/(s). 32
4. Critical Review Question: What is the most effective choice of antibiotic in the treatment of syphilis in pregnancy? Before the advent of penicillin, arsenic therapy has been the choice of treatment for pregnant women with syphilis in the 1930s [24]. Since the early 1940s, treatment of syphilis with the use of penicillin has been largely successful whereby it has remained as the choice of antibiotic till this day, even in pregnancy [24]. Unfortunately, it is still filled with uncertainty in regards to the optimal treatment regimen of penicillin. In the case of our patient above, Mdm TMAL, she has been treated for syphilis with a depot preparation of penicillin (IM benzathine penicillin G of 2.4 million units) twice during her pregnancy: on booking at 14 weeks of gestation and another at 29 weeks. However, it is unknown whether treatment was adequate as there was no follow-up of VDRL titres level documented to indicate success and adequacy of treatment. Therefore, a traditional narrative review from the Cochrane Database of Systematic Reviews was identified to review the most effective choice of antibiotic regimen (inclusive of dose, duration of course and mode of administration) in the treatment of syphilis in pregnancy. Twenty nine studies over the course of 50 years (1946 to 2005) met the criteria for review of which information was extracted via a data sheet [24]. Unfortunately, none of these studies fulfilled the pre-determined criteria for comparative groups. Also, none of these studies included comparisons between randomly allocated groups of pregnant women. Thus, no randomised controlled trials were identifiable in these studies. In regards to other antibiotics besides penicillin been reviewed in this 29 studies, there seem to be limited experience with the use of other type of antibiotics to concur to a fitting conclusion [24]. The antibiotics which have been tried are: amoxycillin, erythromycin, azithromycin and cephalosporins [24]. Out of all these antibiotics, erythromycin has been noted to have the highest failure rate when used to treat pregnant women (as agreed by 6 of the studies) [24]. Azithromycin, however, has found more success, in a 2005 study done by Riedner in Tanzania, who concluded in a randomised controlled trial that showed a single
33
dose of oral 2g azithromycin is as effective as IM benzathine penicillin G 2.4 million units

[24]
. This is clearly advantageous for resource poor countries or also for individuals with
penicillin allergy [24]. On the same note, patients with penicillin allergy can be desensitized under close supervision with increasing oral doses of penicillin over 4 to 6 hours or also, with a slowly increasing infusion of penicillin G and then with the administration of penicillin [24]. The only worrying problem with the use of azithromycin is the possible emergence of azithromycin-resistant Treponema Pallidum [24]. So far, syphilis is still very much sensitive to penicillin until this day [25]. The reasons behind this constant susceptibility of syphilis to penicillin, without the development of penicillin-resistant syphilis, are still not completely understood [25]. Thus, the author concluded that, without a doubt based on these 29 studies, that penicillin still remains as the most effective antibiotic in the treatment of syphilis in pregnancy evident from 50 years of studies and experience and also the limited-effectiveness of other antibiotics besides a high dose of oral azithromycin [24]. However, it is unbeknownst still of the optimal treatment dosage. Nevertheless, it would be timely to follow the standard regimen and dosages set out by the CDC guidelines on the treatment of syphilis in pregnancy, as also noted and observed in the Cochrane review as above, which states that the choice of antibiotics is presently IM benzathine penicillin G of 2.4 million units in a single dose for primary, secondary and early latent syphilis while a higher dose of 7.2 million units total is administered as 3 doses each at one week intervals for late latent syphilis [10].
34
EVIDENCE BASED MEDICINE WORKSHEET FOR REVIEW OF THERAPY STUDIES

ASKING QUESTION Patient (P): Pregnant women with syphilis infection Intervention (I): Any type of antibiotics Comparison (C): Versus placebo Outcome (O): To determine the most effective antibiotic treatment regimen (dose, duration of course, and mode of administration) for syphilis in pregnant women. ACESSING EVIDENCE: THE SEARCH PATH How was the article identified: OVID Technologies Search Keywords: syphilis, pregnant, antibiotics, therapy, vertical transmission Citation: Walker GJA. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No: CD001143. DOI: 10.1002/14651858. CD001143. Is this a systematic review (or a traditional narrative review)? This is a traditional narrative review. Results What is the main result To determine the most effective antibiotic treatment regimen inclusive of dose, duration of that I am interested in course and mode of administration for syphilis in pregnant women. 29 studies over the course (.i.e. that answers my of 50 years (1946 to 2005) met the criteria for review of which information was extracted via a question)? data sheet. Unfortunately, none of these studies fulfilled the pre-determined criteria for comparative groups. Also, none of these studies included comparisons between randomly allocated groups of pregnant women. Thus, no randomised controlled trials were identifiable in these studies. The author concluded without a doubt, based on these 29 studies, that penicillin is still the most effective antibiotic in the treatment of syphilis in pregnancy evident from 50 years of studies and experience and limited-effectiveness of other antibiotics besides a high dose of oral azithromycin. However, it is unbeknownst still the optimal treatment dosage. Nevertheless, the author also noted on current CDC guidelines on treatment of syphilis in pregnancy, that the choice of antibiotics is presently IM benzathine penicillin G of 2.4 million units in a single dose for primary, secondary and early latent syphilis, while a higher dose of 7.2 million units total is administered as 3 doses each at one week intervals for late latent syphilis. Was there a big enough Unclear. difference between the intervention and control groups in terms of this result? Application i. My patient is similar to the study Yes Patient is a pregnant woman who was screened and confirmed with participants (i.e. not within the syphilis on antenatal booking with a VDRL titre of 1:4. She is not exclusion criteria) within the exclusion criteria ii. The treatment is available and Yes IM Benzathine penicillin G is widely available in the clinical setting. feasible in my setting iii. The treatment is likely to be Yes It requires a single dose via intramuscular administration only. The acceptable for my patient and patient is not allergic to penicillin. hisher family. My Conclusions Having read and appraised this article, I would recommend the use of intramuscular benzathine penicillin G for pregnant women with syphilis, as there is convincing evidence of its benefits as applicable to my setting. In regards to the optimal dosage, it would be timely to follow the standard dosages set out by the CDC guidelines on the treatment of syphilis in pregnancy.
35
References 1. National Institute of Clinical Excellence (NICE). Clinical Guidelines 55: Intrapartum Care: Management and delivery of care to women in labour (Online). September 2007. [Cited on 29th December 2010] Available from: URL: http://www.nice.org.uk/CG55 2. Fiebach NH, Barker LR, Burton JR, Zieve PD. Principles of Ambulatory Medicine p.553. 2nd Edition. 2007. Lippincott Williams and Wilkins, PA, Pennsylvania, USA. 3. Ray JG. Lues-Lues: Maternal and fetal considerations of syphilis. Obstet Gynecol Surv 1995; 50:845. 4. Sheffield JS, Sanchez PJ, Morris G, et al. Congenital syphilis after maternal treatment for syphilis during pregnancy. Am J Obstet Gynecol 2002; 186:569. 5. Myles TD, Elam G, Park-Hwang E, Nguyen T. The Jarisch-Herxheimer reaction and fetal monitoring changes in pregnant women treated for syphilis. Obstet Gynecol 1998; 92:859. 6. Talwar S, Tutakne MA, Tiwari VD. VDRL titres in early syphilis before and after treatment. Genitourin Med 1992; 120 122. 7. Hsieh TT, Liou JD, Hsu JJ, Lo LM, Chen SF, et al. Advanced maternal age and adverse perinatal outcomes in an Asian population. Eur J Obstet Gynecol Reprod Biol. 2010 Jan; 148(1): 21 6. 8. National Institute of Clinical Excellence (NICE). Clinical Guidelines 30: Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception (Online). October 2005. [Cited on 30th December 2010] Available from: URL: http://www.nice.org.uk/CG030 9. Remington JS, Klein JO, Wilson CB, et al. Infectious Diseases of the Fetus and Newborn Infant p. 556. 6th Edition. Elsevier Saunders, PA, Pennsylvania, USA. 10. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases: Treatment Guidelines 2006: Congenital Syphilis (Online). 2006. [Cited on 30th December 2010]. Available from: URL: http://www.cdc.gov/std/treatment/2006/congenitalsyphilis.htm
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11. The Merck Manuals Online Medical Library. Postpartum Care (Online). 2010. [Cited on 30th December 2010]. Available from: URL: http://www.merckmanuals.com/professional/sec18/ch265/ch265a.html 12. Helwig JT, Parer JT, Kilpatrick SJ, Laros RK. Umbilical cord blood acid-base state: What is normal? Am J Obstet Gynecol 1996;174:1807-14 13. Calleja-Agius J, Custo R, Brincat MP, Calleja N. Placental abruption and placenta praevia. European Clinics in Obstetrics and Gynaecology. 2006;2(3): 121 7. 14. Deering SH. E-Medicine: Abruptio Placentae (Online). 2008 Dec 22. [Cited on 30th December 2010] Available from: URL: http://emedicine.medscape.com/article/252810overview 15. Levi MM. E-Medicine: Disseminated Intravascular Coagulation (Online). 2009 October 4. [Cited on 30th December 2010] Available from: URL: http://emedicine.medscape.com/article/199627-overview 16. US Preventive Services Task Force. Clinical Practice Guidelines: Behavioural Counselling to Prevent Sexually Transmitted Infections: US Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2008 Oct; 149(7): 491496. 17. United Nations Childrens Education Fund (UNICEF). Maternal Health Malaysia (Online). 2010. [Cited on 31st December 2010] Available from: URL: http://www.unicef.org/malaysia/children_maternal-health.html 18. Royal College of Obstetricians and Gynaecologists. Prevention and Management of Postpartum Haemorrhage (Green-top 52) (Online). November 2009. [Cited on 31st December 2010] Available from: URL: http://www.rcog.org.uk/files/rcog-corp/Greentop52PostpartumHaemorrhage.pdf 19. Murray E, Marc JNC, Neilson J, et al. A guide to effective care in pregnancy and childbirth: The third stage of labour p300 - 309. 3rd Edition. 2000. Oxford University Press, Oxford, UK.
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20. Speidel JJ, Harper CC, Shields WC. Contraception Editorial: The Potential of Longacting Reversible Contraception to Decrease Unintended Pregnancy. Association of Reproductive Health Professionals. 2008 Sept. 21. Hairon N. Increasing use of long-acting reversible contraception. Nursing Times. 2008; 104(42): 23 4. 22. Attorney Generals Chamber (AGC). Laws of Malaysia. Act 342: Prevention and Control of Infectious Diseases Act 1988 (Online). 2006. [Cited on 31st December 2010] Available from: URL: http://www.agc.gov.my/Akta/Vol.%207/Act%20342.pdf 23. Ministry of Health Malaysia. STD Series 4: Surveillance for Sexually Transmitted Diseases (Online). 2010. [Cited on 31st December 2010] Available from: URL: http://www.infosihat.gov.my/media/bahanPameran/Pam%20SURVEILLANCE/PDF/SU RVEILLANCE%2002.pdf 24. Walker GJA. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No: CD001143. DOI: 10.1002/14651858. CD001143. 25. Rougas S. Clinical Correlations, New York University: Why is Syphilis still sensitive to Penicillin? (Online) 2009 Jul. [Cited on 31st December 2010] Available from: URL: http://www.clinicalcorrelations.org/?p=1657
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Keywords: Fetal Distress, Cesarean Section, Artificial Rupture of Membrane, Placenta Abruption, Syphilis in Pregnancy Case Summary

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STUDENT NAME : Aaron Lai Kuo Huo NAME OF SUPERVISOR: Dr Kathiravan Chinniah PATIENTS DETAILS (R/N: 1472464) I/C

NUMBER: 73112-13-5894 SEX: Female

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

Past Obstetric History

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

Gender Gestation Mode Weight (kg)

1991 1993 1999 2008

Male Male Female Male

Full-term Full-term Full-term Full-term

SVD SVD SVD SVD

2.9 3.0 2.9 3.1

Uneventful Uneventful Uneventful Uneventful

SVD = Spontaneous Vaginal Delivery. Hospital Sri Aman, Sarawak.

Past Medical History 4

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

Weight: 70 kg, Height: 1.68m

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

Result 13.6 90.7 29.4 324

Unit g/dL fL pg g/L

Normal Range 11.5 16.6 76 96 27 - 32 300 - 350

Result: The investigation was not performed for the patient. 13

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

27/12/2010 (7.10am): Full Blood Count

Result 12.9 89.9 29.2 324

Unit g/dL fL pg g/L

Normal Range 11.5 16.6 76 96 27 - 32 300 - 350

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

Summary of Long-Acting Reversible Contraceptive (LARC) Techniques

Progestogen-only Injection Preventing ovulation

Progestogen only Implants (Implanon) Preventing ovulation

Wilsons disease, Copper/nickel allergy Insertion

Anytime during menstrual cycle or 4 weeks post-partum

No delay in return of fertility after removal

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010

dose of oral 2g azithromycin is as effective as IM benzathine penicillin G 2.4 million units

ID NO : M0602001 ROTATION: Obstetrics AGE: 37 years old DATE OF ADMISSION: 26/12/2010