A) Biodata

Name:

Noor Ashikin Binti Yaakop

Age: 38 years old

Reg. Number: HRPB 681045
Address: Jelapang, Ipoh.
Parity: G7P6
LMP: 6 February 2015
Period of Gestation: 30 weeks and 4 days
EDD: 13 November 2015
Maritial status: Married (2nd union)
Date of Admission: 8 September 2015
Date of Clerking: 8 September 2015
Chief Complaint: Decrease fetal movement 6 hours prior to admission

B) History of presenting problem

Madam Ashikin started to notice that the fetus wasnt moving as usual from
9am, 8 September 2015, onwards. Usually, she feels 10 kicks every six hours,
once or twice every hour. An hour later, she still could not feel any movement.
She tried taking some light snacks and lie down for another one hour and only
then, she could feel some movement. She would then feel the fetus moved for
again 2 hours later at 1pm. At this point she was worried, and was advised by a
friend, who had the same experience and suggested her to go to the emergency.
At 2.30pm, just before she went to the hospital, she could feel another
movement. So, from 9am to 3pm the fetus only moved 3 times which was less
than usual. She was sent to the emergency by her eldest. At the emergency,
she was told that the fetal heart rate is normal and there was nothing wrong
with the fetus. However, she was admitted for monitoring since she has GDM
and is currently on diet control. Other than that, she has no leaking liquor, no
bleeding per vaginum and no contraction pain. She also had no changes in
urination frequency, no excessive thirst, and no loss of peripheral sensation, no
visual problems or any other symptoms suggesting an increase in blood sugar
level.

C) History of current pregnancy

It was an unplanned but wanted pregnancy by spontaneous conception. The
pregnancy was confirmed after 8 weeks of amenorrhea where she went to a GP
with a complaint of lower back pain. The GP did a urine pregnancy test and it
turned out to be positive. An abdominal ultrasound scan was also done at the GP
but was told by the GP that her pregnancy was not viable since theres no fetal
echo seen. She was then referred to Hospital Raja Permaisuri Bainun for
dilatation and curettage. 3 days later, she went to HRPB where an abdominal US
was done once again and she was told that fetus is normal. Later she went back,
and booked at the Maternal and Child Health Clinic in Klinik Kesihatan Jelapang.
She went for antenatal checkup once a month until the 28 th week

, and twice a

month onwards until now. She had undergone MGTT at 15 weeks of pregnancy
due to advance maternal age and strong family history of DM. She was told to
have Gestational Diabetes Mellitus. Blood sugar was 5.4mmol/L before and the 2

hour post-prandial blood sugar was 8.4mmol/L. She was on diet control and did a
blood sugar profile. The result of the blood sugar profile came out normal and so
the doctor told her to keep on diet control. Otherwise she has no other antenatal
complications. Her blood group is B+
D) Past obstetric history
She is a grand multiparous woman and is currently G7P6. No history of
preeclampsia in previous pregnancies, recurrent miscarriage, babies born with
congenital anomalies, intrauterine growth restriction and intrauterine fetal
death.
Year

Antenatal
complicati
on

Term?
(37w42w)

Normal/

Baby

Postpartu

Breastfeed

Contracepti

instrument

weight

m
complicati

ing

ve

Until

No

1995

No

Yes

al/
c-section
SVD

1998

No

Yes

SVD

No

6mths
Until

No

No

6mths
Not

No
No

Abruptio

2001

Placenta
No

Yes

SVD

3.25

No

breastfed
Until

2008

No

Yes

SVD

3.13

No

6mths
Until

No

No

6mths
Until

No

No

Yes

SVD

2.95

2000

2011

PREM

3.30

on
No

SVD

1.00

3.27

6mths
2015

GDM

No

All were term babies and was delivered through spontaneous vaginal delivery.
However, she had a preterm delivery of her 3 rd child at 30 weeks, weighing at
only 1kg. She had abruption of placenta during her 3 rd pregnancy and at 30
weeks of pregnancy; she had severe abdominal pain and was brought to the
emergency department. She was given IM Dexamethasone, tocolytic agent and
labor was induced. Baby came out still in the amniotic sac and spent 4 months
in the neonatal intensive care unit and then 6 months of recurrent admissions to
the pediatric intensive care unit. Now she is a healthy 15 years old with no
health problem and is doing well in school.

E) Past gynecological history

No history of ectopic pregnancy, miscarriage and pap smear was done every
3 years since she delivered her first child. Last pap smear was done 3 years ago
and she is going to have another one after this delivery
F) Past menstrual history
LMP: 6 February 2015 and she was very sure of the date. Regular 28 days
cycle with 5 days of menses since she had attained menarche at the age of 14.
No dysmenorrhea or menorrhagia. She was not on any form of contraception
and currently not breastfeeding.

G)

Past medical and past surgical

No past medical or surgical history and is not on medication for any chronic
illnesses.

H)

Family history
There is a strong family history of diabetes mellitus and hypertension.

I)

Allergies
No drug or food allergy

J)

Social history
This is her 1st pregnancy from her 2nd union. Husband is 33 years old and is
contractor. She runs a frozen food and scarf business. Family income is good.
From the business alone she earns around RM4000 per month. Ex-husband also
gives money for other children monthly. No consanguinity.

General Examination :
Patient alert and conscious, wearing hospital attire with medium-sized body
build lying supine on hospital bed. She has long hair with fair skin colour. She was
well not in any distress. She was cooperative throughout history taking and
examination.
Vital signs:
BP

125/80 mmHG

PR

80 beats per minute

RR

20 breath per minute

Temp :

37 degree celcius

Hand Palm was pink and warm, no koilonychias, no clubbing, no bruises.

Eyes - Conjunctiva was pink. No scleral jaundice.
Mouth Mucosal was moist. No angular stomatitis and no angular cheilitis.
Neck Diffuse thyroid enlargement. No nodular tissues and non-tender.
Feet No pedal edema. No ulceration on pressured dependent area.

Obstetric Examination (Abdominal)

Inspection
Uterus is distended with the presence of linea nigra and striae
gravidarum. There are no dilated veins or any surgical scars. Umbilicus is
centrally located and is inverted. No fetal movement can be seen during
inspection.
Symphysiofundal measurement:
Symphysio-fundal height is 31cm which is equal to date.
Palpation
No tenderness on superficial palpation.
Leopolds maneuver:
There is a singleton fetus in longitudinal lie with breech presentation. Fetal
back is on the maternal right. The liquor is clinically adequate. Estimated
fetal weight is 3.0 kg.
Auscultation:
Fetal heart rate is 140 beats per minute.

Differential Diagnoses:

Gestational Diabetes Mellitus on diet control

Fetal sleep cycle
Oligohydramnios
Fetal effects of maternal drug use (Opiates, steroids)
Fetal distress

Investigation and Management:

Fetal Kick Chart

Non-stress CTG for Fetal Heart Rate
Transabdominal ultrasonography
Biophysical Profile (AFI, fetal movement)
Blood Sugar Profile

Discussion

Normal fetal movements can be defined as 10 or more fetal movements in 2

hours, felt by a woman when she is lying on her side and focusing on the
movement, which may be perceived as any discrete kick, flutter, swish or roll. Fetal
movements provide reassurance of the integrity of the central nervous and
musculoskeletal systems. The majority of pregnant women report fetal movements
by 20 weeks of gestation.
The average number of movements perceived at term is 31 per hour, ranging
from 1645, the longest period between movements being 5075 minutes. Sleep
cycles, in which fetal movements can be absent, usually last 2040 minutes and
rarely exceed 90 minutes. As the fetus matures, the amount of movement and the
nature of movement will change.
Fetal movement is a subjective measure, mainly assessed by maternal
perception. Research has shown that there is a correlation of 3788% between
maternal perception and ultrasound. Multiple factors can decrease perception of
movement, including early gestation, a reduced volume of amniotic fluid, fetal sleep
state, obesity, anterior placenta (up to 28 weeks gestation), smoking and nulliparity.
Various drugs, including alcohol, benzodiazepines, methadone and other opioids,
and cigarette smoking, can cause transient suppression of fetal movement. A simple
explanation provided by some women presenting with decrease fetal movement
(DFM) is that they have been too busy to feel fetal movements. It is known that
fewer movements are perceived when women are standing or sitting, compared
with lying down or concentrating on movements. It is commonly thought that having
a cold drink or eating something sugary will stimulate fetal movements but there is
no evidence to suggest either of these will affect movement.
Kick charts, which have been historically used to monitor fetal movement, are
not currently recommended. In fact, significant maternal anxiety and unnecessary
intervention (i.e. induction of labor and caesarean section) have been attributed to
the use of kick charts. If there is uncertainty surrounding perceived DFM after 28
weeks gestation, women should be advised to lie on their left side and focus on fetal
movements for 2 hours. If they do not feel 10 or more discrete movements in 2
hours they should seek for professional help immediately. Nevertheless, maternal

concern about decreased fetal movement warrants assessment even if the situation
does not comply with the previously stated definition of DFM.
If there is a history of DFM and viability is confirmed on Doppler auscultation,
a CTG should be performed and referral to hospital is indicated if patient came from
a primary care setting and immediate admission to ward if they came to a hospital.
If CTG is not available in the primary care setting, a woman with a history consistent
with DFM should be referred to hospital for a CTG. If the fetal heart is not heard on
Doppler auscultation, an urgent hospital referral and ultrasound should take priority.
70% of pregnancies with a single episode of DFM go on to be healthy
pregnancies. Women who have normal investigations and resumed movements
following a presentation and history suspicious for DFM should always be
reassessed if they experience repeat episodes. Representation for DFM should
prompt review for predisposing factors, examination, CTG and an ultrasound. Early
delivery is an option for DFM that may be considered in particular situations, when
the risks to the mother and baby have been weighed up appropriately