:: Reduced Fetal Movement ::

OK kali ni beralih kepada O&G (bak kata Prof Azurah, tak OK) hehe


Hari tu masa kat Slim River, ada teaching dgn specialist kat sana, iaitu Dr Ju. Beliau ni buat master o&g kat PPUKM. So aku dah kenal dia masa 3rd year lagi sebab masa tu beliau Registrar kat ward oren. Beliau baru je jadi specialist kat situ. Rajin melayan student, provided student ada eager nak stadi. Maksudnya kalau senyap je dia tak layanlah. Memang betullah kan, hidup ni kena ada give and take. Kita give dia a case utk bincang, kita take ilmu2 berkaitan dari dia. Dia take case yg kita bagi, dia bagi ilmu yg dia tahu. Fair & square rite?


Jadi kitorang cubalah cover bed (maksudnya tengok patient utk present case tersebut), mungkin nanti boleh present masa wardround. Hehe. Rasa macam menyibuk pulak kat ward round sana sebab kat sana diorang just buat 'bussiness round' (hehe) xde grand ward round macam kat sini. Pada suatu hari aku rasa terpanggil untuk present. Patient tu datang sebab dia cakap baby gerak kurang. Aku dahla duk main x sure weh korang ape cause of reduce fetal movement eh? Nak tanya apa lagi kat patient ni? 1. Eh haah la x pernah peduli pun pasal tuu 2. nanti balik kita google eh 3. erm, erm, erm.... 4. (sengih)

Hahah sume orang pun x sure jadi aku main bantai jelah present heheh. Habis present, Dr cakap history u x lengkap langsung, xpelah nanti I ajar u all pasal reduce fetal movement ni, kita arrange time nanti. :)

Ahahah as expected. Takpe2. Dr tak marah pun dan nasib baik aku brought up RFM punya isu ni. Jadi, inilah hasil teaching tersebut :)))))

(punyala panjang intro, xpe yg penting kita ceria )

HISTORY TAKING:

Dalam HOPI, inilah soalan yg kena tanya:

1. Fetal kick chart (fetal movement chart) - how, what, when

• ask patient, how she plotted the chart - buat tiap2 hari? betul tak cara plot? mula pukul brapa, biasa habis pukul brapa?
• apa yg reduce, intensity of the movement or the frequency (verify)
• when was it reduced, night or daytime - because in some working ladies, they didnt feel the fetal movement while they're working.
  

2. Any history of fall or trauma to the abdomen/pelvis?

3. Any pervaginal bleeding?

4. Any leaking liquor?

5. Antenatal history

• any medical problem in current pregnancy? (hypertension, diabetes, anemia)
• underlying illness, like Connective tissue disease?
• any ultrasound scan done? Is there any Dr say that the baby have abnormalities (fetal anomaly). Fetal growth trend.

(ni adalah key utk tanya soalan apa. Pandai2lah elaborate macam mana nak tanya lagi, contoh untuk diabetes bila diagnosed, apa result MGTT, BSP; atau utk anemia, apa latest Hb, symptoms of anemia; etc etc)

Past obstetric history:

• previous IUD, IUGR or SGA baby, macrosomic baby, congenital anomaly
• previous medical illness in pregnancy

Other history:

• Drug/ substance abuse (alcohol, smoking/ illicit drugs)

SO: causes of reduced fetal movement?
Maternal: Maternal medical condition (HPT, Anemia, DM, CTD), trauma, fall, massive antepartum hemorrage, PPROM
Fetal: Fetal anomaly, oligohydramnios, IUD, IUGR

EXAMINATION:

1. General examination:

• Is the patient is in pain?
• Signs of anemia
• stigmata for connective tissue disease
• edematous?
• Vital signs (BP, PR, RR, temperature)
  

2. Abdomen:

• Soft? tender? irritability?
  
• uterine size: smaller than date?
• adequate liquor?
• estimated fetal weight?
• daptone for fetal heart rate (reassure that baby is alive) kalau kau terror guna la PINARD utk kira fetal heart rate bahahah

3. Vaginal examination, done to:

• to look for any leaking liquor. (jangan lupa kita punya amnicator :D)
• in case patient need induction of labour, to do Bishop scoring

INVESTIGATION:

1. Full blood count
2. Renal profile
3. Coagulation profile
4. Liver function test
5. Blood glucose
investigation for CTD is not a routine

FETAL WELLBEING

1. CTG
2. USS (biometry, AFI, EFW, fetal anomaly)
3. Doppler US (resistance index)

*regarding the resistance index:

• If HIGH : no need to do anything, just continue monitoring the baby
• if REVERSE or ABSENCE : keep patient for at least 1 week, unless presence of other indication for deliver, such as severe PE

MANAGEMENT:

1. Admit patient to the ward for reassurance

• Fetal kick chart
• if in labour: labour progress chart
• Do investigation
• If really sure no underlying problem, discharge patient, TCA PRN

2. If she has medical condition, of course la kena admit

• FKC, LPC
• stabilize the medical condition (if HPT, stabilize BP, DM glycemic status)
• Then discharge patient, TCA at 38 weeks POA for induction of labour
• If need to deliver, cth in severe PE, deliver lah baby tersebut

3. If IUD baby:
Has 2 option, deliver NOW or LATER
also, SVD or LSCS

• confirm diagnosis of IUD
• tell patient (breaking bad news) - underlying medical problem or not known the cause
• do blood investigation, especially coagulation profile, because if there is DIVC, sah2 tak boleh SVD
• if no indication for LSCS (eg transverse lie, previous scar, favourable on Bishop's scoring), or in labour, try SVD
  

If delivery can be delayed, ask patient to go home. Come again when have the labour symptoms. If patient cannot tolerate olredi Dr tolonglah bagi saya bersalin sekarang saya dah x tahan nak bawak perut ni lagi so deliver lah sekarang. huhu

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If ada lagi yg lacking or ada yg salah info, seperti biasa tell me Ok. Aku just nak simplified semua benda dan nak fikir semuanya senang supaya takdelah rasa terbeban nak stadi kan. Dalam buku takde tajuk khas macam ni so kalau terjumpa bgtau aku K..