HISTORY

Personal Details
Name: Intan Sunarti Binti Sidik
Age: 25 years
Parity: Primigravida
Gender: Female
Ethnicity: Malay
Occupation: Clerk
Address: Setapak
Hospital Registration No.: 2154189
Date of Admission: 17 December 2015

Menstrual history:
The first day of last menstrual period was 24 September 2015. Her period of amenorrhea is
12 weeks. Intan Sunarti attained menarche at the age of 12 years. Her menses are of regular
cycles of 28 days with 7 days of menstruation. The flow is normal and she used 2 pads per
day. No flooding. No clots were present. No dysmenorrhea. No intermenstrual bleeding. No
postcoital bleeding.

Presenting Complaint:
Per vaginal bleeding for a duration of 1 day.

History of Presenting Illness:

It all began this morning when Intan Sunarti noticed her garments were wet with blood on
waking up in the morning. She then used one pad that was fully soaked before she was
brought to the hospital in about two hours later. The bleeding was of fresh blood. There was
no clots passed. This is the first episode of the kind. There was no abdominal pain. No fever.
No symptoms of urinary tract infections or upper respiratory tract infections. No history of
trauma. No symptoms of anaemia such as shortness of breath, palpitations or effort
intolerance.

Intan Sunarti was brought to the Emergency Department at Hospital Kuala Lumpur by her
husband. She was ambulating. Triaging was done and Intan Sunarti was sent to the Green
Zone. She was clerked at the Green Zone and referred to the gynaecology ward with the
impression of miscarriage.
Intan Sunarti was received at Ward 15 in about an hour after she arrived at the hospital. She
walked to the ward. In the ward, Intan Sunarti was clerked again. An intravaneous line was
set. Blood was withdrawn for investigations and she was ran on fluid. A transabdominal
ultrasound was done. She was also kept by nil by mouth.

History of Present Pregnancy

This is a planned pregnancy. A urinary pregnancy test was done at home after a weeks delay
in menstruation to confirm the pregnancy. Booking was done at 8 weeks of amenorrhea at
KK1A Bukit Bangsar. At the time of booking, Intans height was 160cm, weight was 52kg,
her vital signs were normal, her blood group was found to be O+, her haemoglobin level was
12.5g/dL. Her urine albumin and glucose were negative and infectious screening was
unreactive.

Gynaecological history
Intan Sunarti had no previous gynaecological problems. She had not been on any forms of
contraception. No Pap smears were done previously.

Past obstetrics history

Nil of note.

Past medical/surgical history:

Nil of note.

Drug history:

Tablet folic acid once daily

Tablet obimin

Review of System
General: there was no complaints of fever, malaise/lethargy/fatigue & loss of appetite

or loss of weight.
Gastrointestinal: No abdominal pain, nausea & vomiting, diarrhoea/constipation
Genitourinary: No urinary incontinence, dysuria, haematuria, nocturia & polyuria.
Cardiovascular: no chest pain, shortness of breath, exercise intolerance, PND,
orthopnoea, palpitations, fainting, loss of consciousness & claudication.
Respiratory: no cough, wheeze or haemoptysis.

Family history
Intans parents are alive. Her father is hypertensive and her mother is diabetic. She has four
siblings and they are all alive and well. No history of miscarriages in the family. There is no
history of multiple pregnancy or malignancy in the family.

Social history
Intan works as a clerk at Sams Groceria. Her husband is a journalist at a local press. She
lives in Setapak in a double-storey link house in a household of two. Her husband is a smoker
but does not smoke in the house or in close proximity of her. Intan does not smoke. They are
both teetotallers. Their household income is about MYR5000.

PHYSICAL EXAMINATION
General/ On Examination (OE)
Intan was lying comfortably in supine position propped up to approximately 45. She looked
fairly well and not in pain. She was conscious and oriented to time, place and person. Her
hydration status was normal. The patient was attached to an IV cannula on her right wrist. No
gross deformity or abnormal/involuntary movement.
Vital Signs
Body Temperature

37.2C

Pulse Rate

100 beats per minute

Blood Pressure

110/60 mmHg

Respiratory Rate

14 breaths per minute

Intan measures 160cm in height and weighs 55kg. Her BMI is 20.
Upper limbs: The palms were warm and pink in colour. No clubbing of the fingers. Capillary
refill time < 2 seconds. No peripheral cyanosis. The radial pulse was 100 beats per minute
and was of regular rhythm, moderate volume and of normal character.
Face: No conjunctival pallor, no jaundice. Dental/oral hygiene was good and the tongue was
moist and pink. No central cyanosis.
Neck: Jugular venous pressure (JVP) is not elevated. No lymph node enlargement. No
midline neck swelling.
Breasts: The breasts were soft and non-tender. The nipples were everted. There was no nipple
discharge.
Lower limbs: Bilateral pedal oedema is present. No clubbing, no peripheral cyanosis.

Abdomen

Inspection: The abdomen is not distended. It moves freely with each respiration. The
umbilicus was centrally located and inverted. No surgical scars were seen. There was
no dilated veins, skin discoloration and visible peristalsis.
Palpation: On superficial palpation, the abdomen was soft and non-tender. On deep
palpation, no mass was felt. The liver and spleen were not palpable.
Auscultation: The bowel sounds were present and were of normal intensity. There
were no renal bruits.

Respiratory System:
On observation, the abdomen and chest move symmetrically with respiration. There were no
suprasternal notch. There was no noisy breathing. On palpation, the chest expansion was
normal. On auscultation, the air entry in the lungs were symmetrical. The breathing pattern
was vesicular. There were no added sounds.
Cardiovascular System:
On observation, the chest wall was symmetrical. On palpation, the apex beat was felt at the
intersection of the left fifth intercostal space and midclavicular line. On auscultation, the
heart rate was 88 beats per minute. The rhythm was regular. There were no added sounds.

Pelvic examination
The vulva and vagina looked normal. No discharge or swelling seen. The os was closed. The
cervix was tubular in shape. Uterus was of 12 weeks size and was anteverted. No adnexal
mass was felt. The pouch of Douglas was free.

INVESTIGATIONS
Urine analysis
Reagent Strip

Result

Normal

Urine colour

Straw

Straw

Urine appearance

Clear

Blood

Negative

Negative

Bilirubin

Negative

Negative

Urobilinogen

Normal

Normal

Ketone

Negative

Negative

Protein

Negative

Negative

Nitrite

Negative

Negative

Glucose

Negative

Negative

pH

8.0

5.0-8.0

Specific Gravity

1.008

1.000-1.030

Leucocytes

Negative

Negative

Free T4

19.5

Reference range: 12.0-22.0

TSH

1.94

Reference range: 0.27-4.20

WBC

7.5

4.00-10.00

HGB

13.5

12.0-15.0

PLT

235

150-410

RBC

4.7

3.80-4.80

MCV

85

83.0-101.0

Thyroid function test

Complete Blood Count

MCH

29.0

27.0-32.0

MCHC

34.2

31.5-34.5

RDW-CV

12.8

11.6-14.0

MPV

10.9

9.0-13.0

Neutrophil count

3.82

2.00-7.00

Neutrophil percentage

60.1

40.0-80.0

Lymphocyte count

2.01

1.00-3.00

Lymphocyte percentage

31.6

20.0-40.0

Monocyte count

0.39

0.20-1.00

Monocyte percentage

6.1

2.0-10.0

Eosinophil count

0.13

0.02-0.50

Eosinophil percentage

2.0

1.0-6.0

Basophil count

0.02

0.02-0.10

Basophil percentage

0.2

<2.0

Result

Normal

Prothrombin Time

11.9 sec

9.3-12.1

INR

1.06

APTT

31.8 sec

APTT Ratio

0.9

White Cell Differentials

PT/INR/APTT

26.5-39.8

Ultrasound
Transabdominal sonography

Product of conception measuring 4.8cm x 4cm is seen.

DIAGNOSIS
Threatened miscarriage. Differential diagnoses: missed miscarriage, molar pregnancy.
MANAGEMENT
On admission, Intan was kept nil by mouth. Urine sample was collected for routine urine
analysis. Blood was withdrawn for full blood count, coagulation profile, group, screen & hold
(GSH), beta hCG. A transabdominal sonography was done. A chest x-ray was taken. Intan
was also started on intravenous fluid of 3 pints of normal saline and 2 pints of Hartmanns
solution of 24 hours. Four pints of packed cells were grouped and cross-matched. Vital signs
monitoring was done.

Transabdominal ultrasound was repeated:

Intrauterine vesicle-like seen. Snow storm appearance. Uterus measures 6.8cm x 7.7cm. A
molar pregnancy was then suspected.
An endovaginal ultrasound was done. Findings: there is a presence of product of conception
as abnormal hyperechoic material within the uterine cavity and an irregular gestational sac.
The crown-rump length was 4.3mm. The heart beat was absent.
Beta hCG was assessed was found in the normal range.
A diagnosis of missed miscarriage was made.
Intan was planned for suction and curettage on the next day. She was explained of the risks of
the procedure which include uterine perforation, haemorrhage and the risk of hysterectomy.
The operation was an emergency suction and curettage. The preoperative diagnosis was
molar pregnancy. The postoperative diagnosis was missed miscarriage (to be confirmed by
histopathology). The operation was done under general anaesthesia. Intan was put in a
lithotomy position. She was then cleaned and draped. Bladder catheterization was done. The
cervical os was dilated with Hagers dilaters of the size 5, 6 and 7. Karman suction cannula of
size 9 was used. 400cc of product of conception was evacuated. No active bleeding from the
os postoperatively. The product of conception was sent for histopathology examination.

The plan after the operation was vital sign monitoring half-hourly for the first two hours and
hourly for the subsequent four hours, intravenous fluid (2 pints of normal saline & 2 pints of
dextrose 5% solution over 24 hours), to allow orally once fully conscious, pad charting, to
trace the admission beta hCG and post-operative beta-hCG and if the latter is found to be
high, urgent histopathology examination was to be done.
Post-operative transabdominal sonography showed empty uterus. Histopathology
examination confirmed a missed miascarriage.
Post-eperatively, Intan was stable. No per vaginal bleeding. Post-operative plan and
observation was continued till the next day. Intan was then tolerating orally, ambulating, had
no per vaginal bleeding, no abdominal pain. She was comfortable. Her temperature was
37C, blood pressure was 119/61mmHg and pulse rate was 61.
Intan was discharged a day later and was told to come again in 6 weeks to be reviewed. A
memo on the current condition was given.

SUMMARY
Intan Sunarti Binti Sidik, 25 years of age, Malay, primigravida, at 12 weeks of amenorrhea,
who works as a clerk and lives in Setapak was brought to Hospital Kuala Lumpur following
an episode of painless per vaginal bleeding of fresh blood that soaked a pad and her
garments. On physical examinations, her vital signs were stable. Her abdomen was soft and
non tender. On pelvic examination, her os was closed. Following an endovaginal sonography
that showed a crown-rump length of 4.3mm and the absence of fetal heart rate, a diagnosis of
missed miscarriage was made. A suction and curettage was done and 400cc of product of
conception was evacuated. The product of conception was sent for histopathology
examination for the confirmation of the diagnosis. There was no operative complications.
Post operatively, Intan was closely monitored on her vital signs and pad charting. Her vital
signs were stable and there was no per vaginal bleeding. She was also orally tolerating and
ambulating. Intan was allowed to be discharged and was told to come again in 6 weeks time
to be reviewed.

DISCUSSIONS
Snowstorm sign in obstetric imaging is classically seen in complete hydatiform mole. It is
characterised by the presence of multiple hydropic villi which gives the ultrasonographic
appearance of a central heterogeneous mass having a solid, hyper echoic area and
interspersed with multitude of cystic areas and filling the entire uterine cavity (Nucci &
Oliva, 2009).
The snowstorm sign usually dates back to earlier ultrasound equipment with inferior
resolution and is therefore no longer a valid sign in aid of the diagnosis of molar pregnancy
and could have mislead in the making of diagnosis in the ward.
Intans preoperative beta hCG levels was 117501mIU/ml. The reference range for a 12 week
pregnancy is 25,700 288,000 mIU/ml. Low levels of beta hCG is suggestive of miscarriage
whereas high levels of the same hormone indicates the molar pregnancy. The beta hCG of
normal level in the case of Intan is again unfavourable of a molar pregnancy.

REFERENCES
1. Nucci MR, Oliva E. Gynecologic Pathology. Churchill Livingstone. (2009).