long case O&G-placenta praevia

UNIVERSITI KEBANGSAAN MALAYSIA

LONG CASE WRITE UPModule : OBSTETRICS & GYNAECOLOGY

M00031134STUDENT NAME: MUHAMMAD KHAIRI AMMAR BIN MOHD SIDEKMATRIC NO : YEAR/GROUP : SUPERVISOR :DR.WAGIH

ASSESSMENT OF CASE WRITE-UP:Core Clinical ComponentHistory/10Critical Appraisal/5

Physical Examination/10Discharge Summary }

Investigation/5Referral Letter } /5

Diagnosis/ Differential Diagnosis/5Prescription }

Identify Problems, management and progress of patient/5References/5

Total Score

/50 MARKS FOR CORE CLINICAL COMPONENT Professionalism ComponentPART 1 : Issue on Professionalism/10

PART 2 : Reflection & Life Long Learning/10

Total Score

/20 MARKS FOR PROFESSIONALISM COMPONENT

Patient name : Farah Salwani Age: 27 years oldI/C number: 861108075148Register number: 23420/13Gender: FemaleRace: MalayDate of admission: 26th November 2011Date of clerking: 27th November 2011

CHIEF COMPLAINTPuan Farah Salwani is a 27 years old Malay teacher, primid gravida,, her last menstrual period (LMP) was on 10th April 2013. Currently, her period of amenorrhea is at 34 week of gestation, thus, her expected date of delivery is on 17th January 2014 which correspond to the date. She was admitted in the ward due to placenta previa type 4. HISTORY OF PRESENTING ILLNESSShe was last well 1 and half month ago (28th weeks of POA) when she noticed there was vaginal bleeding while getting dress. It was reddish brown in color, dribbling in nature and not associated with pain. The amount was small and it frequently occurs on that day. The patient felt uncomfortable and change her pad regularly. She denied of having fever, headache, nausea, and vomiting. There was no history of urinary tract infection as the patient claimed that she did not has difficulty in passing urine, no nocturia, no frequency and urgency. The urine color was normal and no haematuria. However at that time the patient did not seek for any medication. Unfortunately, the amount of bleeding was increased on the next day. Hence, she went to the private hospital in Taiping. At the casualty, CTG and ultrasound was done to monitor the baby condition, there was no abnormality to the fetus. However, the patient was told by a doctor that she has a low-lying placenta. So she stayed on that hospital for 2 days to monitor her condition. 2 weeks later, she was referred to Hospital Kulim and went to the clinic pakar 2. At that time, again the scan was done, she was diagnosed to has placenta previa type 3. Her last scan was on 28th November which is 2 days after the admission, at that time the scan shown it was placenta previa type 4. Her current condition is well and no contraction pain indicated. There was no per vaginal bleed noted and no symptom of anemia. Her hemoglobin level was 11.8. She also was diagnosed to have gestational diabetes which in diet control, however she did not remember her blood sugar profile result. This patient also has completed IM dexamethasone for fetus lung maturation. This is unplanned and wanted pregnancy. She knew that she was pregnant when she missed her period at 8 weeks of gestation and urine pregnancy test (UPT) was done by herself at home which tested positive. On the next day, she went to the private clinic and scan was done. She was told that her baby was growing well. There was a singleton fetus in longitudinal lie with cephalic presentation. The liquor was adequate and the placenta located at upper segment of the uterus. The pregnancy had progress well.4 weeks later, she had her first booking at 12 week of gestation at the Klinik Kesihatan Tanjung Rambutan. At this visit, she was told that her hemoglobin level was low and anaemic. She was normotensive and no glycosuria or proteinuria. Her weighed was 62 kg. Her blood group is O positive and infectious screening test was normal. She was prescribed with haematinic Obimin and Iberet. Both medications were taken once daily. However, she has stop Obimin after 2 months. No scan was done during first booking. She had regular antenatal checkup at government clinic and no excessive weight gain was noted. After 2 weeks, she went to the same clinic for follow up of her hemoglobin level. At that time, MOGTT was done as the patient has a strong family history with diabetes. She was also diagnosed to have gestational diabetes mellitus. Hence, she was advised by a doctor to be in diet control. She had several antenatal checkups for 4 times and her anemia was resolved after 2 months. She had several ultrasound performed and the last scan was done yesterday She had quickening at the 21 week of gestation.

GYNAE HISTORY She attained menarche at the age of 13. Her menses was regular in 28 days. The flow was minimal for 6-8 days and not associated with dysmenorrheal. She never had a pap smear done before.PAST OBSTETRIC HISTORY NILCONTRACEPTIVE HISTORYNILPAST MEDICAL AND SURGICAL HISTORYNILFAMILY HISTORYHer father died due to complication of diabetes mellitus. Her mother still alive and healthy. All of her siblings are healthy. There is no family history of malignancy.SOCIAL HISTORYThe patient is a teacher in Ipoh and her husband is a technician. The combined income of family was RM 3000 which enough to support the family. They lived in single storey house with adequate water and electric supply. She does not smoke or consume alcohol, however her husband is a smoker since 5 years ago.SUMMARYMy patient Puan Farah Salwani 27 years old Malay teacher, primid gravida currently at 34 weeks of gestation who is electively admitted to the hospital due to placenta previa type 4. She was also diagnosed to have gestational diabetes mellitus which is currently in diet control and has a strong family history of diabetes. Other than that, she had resolved her asymptomatic anemia. She had completed IM dexamethasone for fetus lung maturation and currently she was planning for cesarean section at 38 week of gestation. PHYSICAL EXAMINATIONGENERALThis patient was lying comfortably on the bed in supine position. She was alert, conscious and not tachypnic. There was an iv branula on the left dorsum hand. On examine of the eye, she was not pale, not jaundice, oral hygiene was good and no central cyanosis. On examine the hands there was no sign of clubbing, the capillary filling was good and signs of anemia noted. Her pulse rate was 80 beat per minute, regular rhythm and good volume. On examining of the leg, there was mild ankle edema. Her weight was 159 cm and her currently weight was 69 kg. VITAL SIGNPulse rate : 80 beats per minBlood pressure:115/70 mmHgRespiratory rate:18 breath per minTemperature: 37 oCNECKThyroid was not palpableBREASTThe breast was symmetrical and no mass was palpableRESPIRATORYThere was no scar noted on the chest. The chest moved symmetrically with respiration. The trachea was not deviated. There was no dullness on percussion. Breath sound was vesicular and normal. Air entry was equal bilaterally.

CARDIOVASCULARJugular venous pressure was not raised. Apex beat palpable at the left 5th intercostal space, lateral to mid clavicular line. On palpation, no thrill and parasternal heave palpable. On auscultation, both first and second were hears at mitral valve,tricuspid valve,aortic valve and pulmonary valve. No murmur noted. No 3rd heart sound.NERVOUS SYSTEMHigher cortical function was intact. He was oriented to time, place and person. His present and past memory is good. Glasgow Coma Scale was full. Cranial nerves I to XII was intact. Neurological examination of the upper and lower limbs revealed no abnormality. No hyperreflexia ABDOMINAL EXAMINATIONOn inspection, the abdomen was distended with gravid uterus by evidence of cutaneous sign of pregnancy such as linea nigra and striae gravidarum. The umbilicus is centally located and it was inverted. There was no surgical scar can be noted. Otherwise, abdominal looks normal.On light palpation, the abdomen was soft and non-tender, and the uterus was not irritable. On clinical fundal high revealed it was 34 weeks and the symphysio-fundal height was 34 cm which correspond to the date. There was a singleton fetus in longitudinal lie and in cephalic presentation. The fetal back was at right maternal side. The head was 5/5 palpable and not engaged. The liqua was clinically adequate and estimated fetal weight was 2.4 kg to 2.6 kg. VAGINAL EXAMINATIONOn vaginal examination, no abnormalities detected. Cervix was firm, not effaced with os tip of finger. The os was not open.

RELEVANT INVESTIGATION AND RESULTHAEMATOLOGYTo access any feature of anaemic due to haemolysis, sign of infection and sign of pre-eclampsia such as low platelet. Full Blood countWhite blood cell: 8.68 x 10^3/uL Red blood cell: 3.95 x 10^6/uLHaemoglobin: 11.70 g/dlPacked cell volume (HCT): 34.70 %Red cell indicices (MCV): 87.80 fLMCH: 27.1 pgPlatelet count: 222.00 x 10^3/uLComment: The Hb was in normal range, normal WBC which indicate no sign of infection and platelet level was normalCOAGULATION PROFILETo access the coagulation factorProthrombin time (PT): 12.80 secPartial Thromboplastin Time (APTT): 35.50 secComment: Both PT and APTT was normal

BLOOD SUGAR PROFILE.To access the venous plasma sugar level.Pre-breakfastPre-lunchPre-dinnerBefore sleep

5.1mmol/l6.7mmol/l7.4mmol/l7.0mmol//

Comment: The level of plasma sugar level at pre-dinner slightly high. Others are within the normal range. Urea & Electrolyte With creatinineIn pre-eclampsia, the level of uric acid will be highUrea : 2.6 mmol/LSodium: 135 mmol/LPotassium: 4.1 mmol/LChloride:104 mmol/LCreatinine:68 umol/LUric acid:390 umol/LComment: The level of uric acid was normal. Urea and creatinine also was normal

URINALYSISChemical AnalysisSpecific gravity: 1.015pH: 6Leucocyte: 500 Leu/ulNitrite: NegativeProtein : 0.25 g/LGlucose: NormalKetone: NegativeUrobilinogen: NormalBilirubin: NegativeBlood: NegativeComment : protein was negative in urine and leucocyte also normal and to detect whether is there any sign suggestive of infectionUltrasound scanTo monitor the AFI as GDM can associate with polyhydroamnions and also to monitor the fetal development as it can cause macrosomia and also intrauterine death. The ultrasound scan of this patient shows that the fetal is correspond to the parameter and the liqua is adequate.

Cardiotocograph (CTG)To monitor the fetal well-being in order to ensure good fetal development. In this patient, CTG was reactive

Suggestion:Fundoscopy look for any sign of involvement of the eye such as eye nipping , silver wiring and other.

PROVISIONAL DIAGNOSIS AND DIFFERENTIAL DIAGNOSISPlacenta PraeviaPlacenta praevia exist when the placenta is inserted wholly or in part into the lower segment of the uterus. Placental migration occurs during the second and third trimesters, owing to the development of the lower uterine segment. It is hypothesized to be related to abnormalvascularisationof theendometriumcaused by scarring oratrophyfrom previous trauma, surgery, or infection. Women with placenta previa often present with painless, bright red vaginal bleeding. This commonly occurs around 32 weeks ofgestation, but can be as early as late mid-trimester.This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. My patient was diagnosed to have placenta praevia at 28 weeks of gestation. Within this period it is still considered as placenta praevia. Based on the history and clinical examination shown, it is placenta praeviaDIFFERENTIAL DIAGNOSISPlacenta AbruptioOccur when there is separation of a normally situated placenta from uterine wall. It can be either revealed, concealed or mixed types. Trauma,hypertension, orcoagulopathycontributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into thedecidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption.Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions,fetal distressor death. Usually the patient will complain of painful vaginal bleeding and the uterus is tense and tender on palpation. The patient condition also become more severe and distressed compare than placenta praevias patient. Vasa praeviaThere is rupture of fetal vessels that run in membrane below fetal presenting part which unsupported by placenta/ umbilical cord. Vasa previa is seen more commonly with velamentous insertion of the umbilical cord, accessory placental lobes (succenturiate or bilobate placenta), multiple gestation, IVF pregnancy. In IVF pregnancies incidences as high as one in 300 have been reported. The reasons for this association are not clear, but disturbed orientation of the blastocyst at implantation, vanishing embryos and the increased frequency of placental morphological variations in in vitro fertilisation pregnancies have all been postulated.Fetal vessels may rupture at spontaneous rupture of membranes (SRM) or be damaged at artificial rupture of membrane (ARM). Fetal tachycardia may develops followed by deep decelerations.IDENTIFY PROBLEMS IN TERMS OF PRIORITY1. Vaginal bleedingAs we know, placenta praevia continues to be an important association with maternal and fetal morbidity and mortality if there is uncontrolled maternal hemorrhage and fetal hypoxia. In such cases, we should manage the patient according to the type of placenta praevia either minor or major. Puan Farah Salwani which is currently at 34 weeks of gestation was diagnosed to have placenta praevia type 4 which is major. Usually, elective caesarean section should deferred to 38 weeks to minimize neonatal morbidity. Hysterectomy should be mentioned as possibility if placental percreta happen or overlies a previous scar which can lead to infertility in the future. However, good news for this patient because she does not has previous scar.2. High blood glucose level.She was also diagnosed to has gestational diabetes mellitus. Luckily, this patient has a good progress for maintaining her blood glucose level. She used to be in diet control. There was no severe complication to the fetal such as macrosomia or polyhyromnions which may lead to birth asyphyxia during birth.

IMMEDIATE, SUBSEQUENT MANAGEMENT AND PROGRESSIONThe aim of management is to prevent any complication such as fetal distress and maternal vaginal bleeding Besides that, we want to deliver healthy neonate with minimal maternal morbidity. Firstly, a complete history taking must be taken and followed by doing physical examination before admitting the patient into the ward. For this patient, she was admitted to the ward because she had previous bleeding and the clinician want to manage as inpatient since the patient current gestation of this patient is at 34 weeks. She was given prophylactic thromboembolic stocking to decrease the risk of thromboembolism. The doctor also encouraged her to gentle mobility regularly. She was also subjected to daily CTG in order to ensure fetus heart rate. On admission, fetal movement was good, ultrasound shows singleton fetus in longitudinal lie with cephalic presentation. CTG was also appearing to be normal and it was reactive. 1 large IV line was set up on her left dorsum hand. Blood was taken to check for full blood count, group screen hold 2 units, blood urea nitrogen. Monitor her vital signs such as blood pressure, pulse rate, and temperature 4 hourly. Pad chart is used to look for amount if the patient is bleeding again. Other than that, fetal kick chart is used also to monitor the fetal well-being. The patient was diagnosed with GDM. Hence, blood sugar profile was done to check her venous plasma sugar level. BSP was taken at pre-breakfast, pre-lunch, pre-dinner and before sleep. However the result was not really significant thus, the patient was given an advice to on diet control. For fetal, ultrasound was done to look for any fetal abnormalities such as big baby, polyhydroamnions and IUD. Corticosteroid was given to enhance the lung maturation by stimulate surfactant production. IM dexamethasone 12mg stat and the second dose were repeated after 12 hours. It is important to prevent respiratory distress syndrome if the patient is in process of labor which can lead to preterm labor. She was planned for elective caesarean section at 38 weeks to minimize neonatal morbidity. Hysterectomy also was mentioned as possibility to happen during the operation if the placenta accrete occur. During pre-operation, again investigation was done; FBC to check for Hemoglobin and platelet level. BUSE, GSH 2 unit and GXM 4 unit for preparation of blood transfusion if there is severe bleeding during the operation. The procedure of operation was explained to get consent from her. The patient was advice to nil by mouth by 12 midnight. Subcutaneous heparin and cefuroxime were given as a thromboprophylaxis and prophylactic antibiotic. Indwelling bladder catheter and IV line was set up. The patient was transferred to operation theater in left lateral position to prevent supine hypotension or fetal distress.In performing cesarean delivery, low transverse uterine incision is used. Luckily this patient did not have invasive placentation (accrete, increta, or percreta). A baby girl was delivered on 2nd January 2014 at 8.47 am weighing 2.71 kg via LSCS. Her apgar score was 9/10. The head circumference was 31 cm and the length of the baby was 50 cm. She was given 1 mg vitamin k and 0.5 ml Hepatitis B injection. Cord blood was collected to test G6PD and it was negative.At 9 am, the placenta and the membrane were completely delivered via control cord traction and no retained placenta. The estimated blood loss was 300cc. The placental weight was 600g.Postpartum, she was comfortable and not tachypnic with blood pressure 130/75 mmHg and the pulse was 72bpm. There were no vaginal bleeding and she was not fever. The uterus size was 18 weeks of gestation and well contract. There were no sign of infection. She was prescribing with Haematinics once daily, subcutaneous heparin 5000U, Synflex tablet and Syrup Lactulose 15mg were given 3 times daily .

CRITICAL APPRAISAL.By completing this case write up, which is about placenta praevia, I have learnt a lot about it started from definition until the management.Placenta praevia is one of the most common causes of antepartum hemorrhage. Usually, the patient will presented to you with painless per vaginal bleeding which occur spontaneously. However, we should elicit any history of trauma, hard exercise and postcoital which can lead to the vaginal bleeding. It happened when there is tearing of placental attachment and less muscle to suppress bleeding in lower segment. There are 4 type of placenta praevia. Type 1 occurred lateral less than 5cm from the os. Type 2 is marginal which can occur either anterior or posterior part. Type 3 is also known when placenta partially covering the os. Lastly, type 4 is completely fulling overlying os. Different type of placenta praevia has its own management. Usually, in minor case such as type 1 and 2, the patient will recommended to undergo spontaneous vaginal delivery (SVD). While on the other types which is considered a major case, elective caesarean section is usually done to them. For this case, this patient started to has placenta praevia at 28 weeks of gestation without significant per vaginal bleeding. So, we can say that this patient has antepartum haemorrhage since from definition APH occur after 24 weeks of gestation. Apart from that, the patient also was diagnosed to has GDM with onset or first recognition during pregnancy. Increased estrogen and progesterone, degradation of insulin by placenta and increase cortisol and hPL can lead to hyperglycemia in maternal body ultimately it will promote carbohydrate intolerance in pregnancy. So, it is important to monitor the patient condition, sign and symptoms and complication of placenta praevia and GDM.The safest, simplest, and most precise method of placental localization is by using transabdominal sonography or transvaginal sonography. All patients with minor placenta praevia can be manage conservatively and treat as outpatient. In patient with major placenta praevia, if no previous bleeding, careful counselling should be made before contempting outpatient care. If patient had previous bleeding, they should be admitted and managed as inpatients form 34 weeks of gestation. However, prolong inpatient care can be associated with thromboembolism. Thus, gently mobility should be encouraged together with the use of prophylactic thromboembolic stockings. Prophylactic anticoagulation should be reserved for those at high risk of thromboembolism. We also can educate the patients to not having abdomen massage, no coital and immediate admit if there is contraction feel. Monitor the patient blood pressure, pulse rate and pad chart. Correct the anaemia until the haemoglobin level reach at least 11g/dL. We should also monitor the fetal well-being by using fetal-kick chart, CTG, and serial scan for growth because there is high chance for the baby to has hypoxia and IUGR. Other than that, we can give 2 dose IM dexamethasone 12mg stat 12 hours apart for fetal lung maturation. Immediate caesarean section is indicated if gestational age is more than 36 weeks of gestation, profuse bleeding and fetal distress. All minor case can proceed with spontaneous vaginal delivery while all major case elective caesarean section should be considered at 38 weeks of gestation. There are several complications of GDM that can happen to the fetal and maternal. During 1st trimester, there will be congenital abnormalities occur to the fetal such as VSD, ASD, neural tube defect and sacral agenesis. While during 2nd trimester macrosomia and polyhydoamnions much more indicated which may lead to birth asphyxia and shoulder dystocia. After the delivery, baby may suffer respiratory distress syndrome, hypoglycemia and hypomagnesaemia. Maternal may suffered microangiopathy, ketoacidosis, hyperglycaemia and prone to have infection. For reason my patient has a strong family history with diabetes mellitus. Her father was dead due to complication of DM. Hence, a 2 hour 75g glucose 250ml, oral glucose tolerance test (OGTT) at 16-18 weeks to test for gestational diabetes was indicated for this woman. Normally at 0-hour plasma glucose value should be less than 5.6 mmol/L. At 2-hour plasma glucose value should be less than 7.8mmol/L. If the level of plasma glucose value high than these it is considered as GDM. After diagnosed, consult them lifestyle and diet changes. Blood sugar profile is done after 1-2 weeks. Venous plasma sugar level was taken at pre-breakfast, pre-lunch, pre-dinner, and before sleep. If range between 4-7 mmol/l, consider diet therapy. If more than 7mmol/l or types 1 diabetes or ultrasound show fetal macrosomia, start insulin (actrapid 4-6 unit tds) admit patient for education of therapy. HbA1c should be check for every trimester (especially 1st trimester) and maintain between 4-7% to check risk of fetal malformation. Full term SVD delivery may be the choices of delivery if no other obstetrics complications. If the patient on insulin we can deliver at 38-40 weeks. But, if DM uncontrolled with fetal compromised should electively deliver the baby as soon as possible. Elective c-sec is indicated if the patiet has big baby, poor DM control, vascular complication, history of subfertility, and bad obstetric history. For my patient, she does not have any complication of GDM because she has a good and well controlled performance for her blood glucose profile. However, since she had a placenta praevia major, she underwent LSCS.

DISCHARGE SUMMARYPuan Farah Salwani is a 27 years old Malay Primid gravida with 4 day post LSCS delivery at 38 weeks period of gestation. VITAL SIGNPulse rate : 80 beats per minBlood pressure:118/75 mmHgRespiratory rate:18 breath per minTemperature: 37 oC

Problems:1. Placenta Praevia type 4 She underwent LSCS on 38 weeks period of gestation with no severe complications. Given birth to baby girl: Birth weight 2.71 kg Apgar score is 9 G6PD: negative Active, pink, Currently, patient is: Comfortable, afebrile The blood pressure is in normal range Tolerating orally On examination, Alert, comfortable Pink Vital sign stable, afebrile The abdomen is soft and non-tender Uterus well contracted at 18 weeks sizePlan:1. Allow discharge today2. TCA 2 weeks later for blood pressure monitoring3. Discharged medication: T.Ponstant and T.Gelusil 11/11 tds T.Haematinics 1/1 od Syrup lactulose 15ml tds

( DR MUHAMMAD KHAIRI AMMAR )Medical officerO&G DepartmentHospital Kulim

REFERRAL LATER

HOSPITAL KULIMJalan Mahang, 09000 Kulim.Kedah. Tel: 04 4903333. Fax: 04 4900760. URL: http://hkulim.moh.gov.my

To : House Officer/ Medical Officer/ Specialist Patient Name: FARAH SALWANIDear doctor,Thank you for seeing this patient and for your concern. We would like you to facilitate this patient follow up visits in your health clinic.This is Puan Farah Salwani is a 27 years old Primid gravida, currently 4 day post vaginal delivery after underwent LSCSProblems:1. She was diagnosed to have placenta praevia type 4. She has undergone for LSCS was done. The labour was progress well with no other complication.Upon discharged, both mother and baby was healthy. Maternal blood pressure was 118/75 and other vital sign was normal. She was afebrile and can tolerate orally.Patient was prescribed with: T.Ponstant and T.Gelusil 11/11 tds T.Haematinics 1/1 od Syrup lactulose 15ml tdsKindly please see this patient for:1. Family planning consultation2. Explain the complications for next pregnancy

( DR MUHAMMAD KHAIRI AMMAR )Medical officerO&G DepartmentHospital Kulim

PRESCRIPTION

HOSPITAL KULIMJalan Mahang, 09000 Kulim.Kedah. Tel: 04 4903333. Fax: 04 4900760.

PATIENT NAME : FARAH SALWANI Patient is prescribed with,1. T.Ponstant 11/11 tds2. T.Gelusil 11/11 tds3. T.Haematinics 1/1 od4. Syrup lactulose 15ml tds

( DR MUHAMMAD KHAIRI AMMAR )Medical officerO&G DepartmentHospital Kulim

PROFESSIONAL COMPONENTPART I: ISSUE ON PROFESSIONALISMProfessional etiquette is one of the most important factors contributing to a successful healthcare career. Healthcare involves many personal interactions with a variety of people. Etiquette in healthcare is more than just good manners; it is about establishing respectable relationships with patients, colleagues, and supervisors. I learnt that I need to be brave and confident when communicating with the patients. I tried my best to use simple questions so that my patients would understand my questions easily and would not feel burden to answer them. I felt comfortable to talk with her as she was always smiling and cooperative with me. She gave me permission to do physical examination on her and she even asked me about the Leopard Maneuvar as she found that it is very interesting. I palpated her abdomen as gentle as possible while explaining to her and she was very amazed. I was very happy that I can palpate the fetal parts and at the same time share my experiences with the patient. This is a very precious experience as I cannot easily get the opportunity to approach someone who I did not know about her whereabouts before, and try to convince her to believe in me.At the beginning, of and throughout the patient and doctor relationship, the physician must work toward an understanding of patients health problem. After the patient agree on the problem and the goals of therapy, the physician must be professionally competent, act responsibly and treat the patient with compassion and respect. In the care, including giving informed consent or refusal to care as the case might be.The physicians primary commitment must always to the patients welfare and best interests, whether in preventing or treating illness or helping patient to cope with illness disability and death. The physician must respect the dignity of all persons and respect their uniqueness. The interest of patient should always be promoted regardless of financial arrangements, decision making capacity, behavior and social status.

PART II: REFLECTION & LIFE LONG LEARNING:

The patient has the right to expect good quality in healthcare. Patient must be treated in such way that their beliefs and privacy are respected and their dignity remains unoffended. In my case, my patient was diagnosed to have placenta praevia type 4 which is major. As we all known that placenta previa can create a lot of complications especially to the mother. In severe case, we should not forget to mention hysterectomy to the patient. Since this is the 1st pregnancy of my patient, we should also taking care of her emotions as there is chance for to not get pregnant anymore. Luckily, this patient did not have any severe complication during the operation and her uterus is still intact. Unfortunately, she might has problem which can affect for the next pregnancy as she had a scar. So, I learned that we should always explain and educate the patient regarding her condition so that she will be more caution in the future. As a medical student, I need to practice more on communication skill. I learnt how to become more alert and sensitive towards patients and be more considerate in getting information. From the practice, I got a lot of advantages that can help me to improve my skills to understand the patients conditions and needs.

The patient-physician relationship entails special obligations for the physician to serve the patients interest because of the specialized knowledge that physician possess. Effective communication is critical to a strong patient- physician relationship. At that time, I learned that it is important to gain trust and having a good communication between a doctor and the patient. The efforts and commitments from the doctor also give me inspiration to do my very best in treating my patient. I believe that I should take an initiative to not only treating my patient, I also need to respect and take care of them earnestly.

REFERENCES.

Redman C W G 1989. Hypertension in pregnancy. Medical disorder in obstetric practise. Blackwell scientific oxford Fenakel et al : nifedipine versus hydralazine in the management of preeclampsia , obstetric and gynaecology 77 : 731 1991 Repke JT, Villar J : Pregnancy induced hypertension and low birth weight : the role of calcium 1991 Labib M. Ghulmiyyah and Baha m. Sibai, gestational hypertension-preeclampsia and eclampsia ,management of high risk pregnancy : an evidence based approached Pipkin FB,Risk factor for pre-eclampsia,2001 Berkowitz KM,Insulin resitance and preelampsia,1998 Ten Teachers. 2011. Obstetrics 19th edition. Edited by Philip N Baker and Louise C Kenny. Published by Hodder and Stoughton Ltd. Kevin P.Hanretty. 2010. Obstetrics Illustrated 7th edition. Published by Churchill Livingstone Elsevier.