CML Case Write Up


Patient’s Details
Name: Mr G
Age: 26
Race: Indian
Occupation: Doctor

HISTORY
G is a 26 year old Indian from India. He comes to Singapore routinely to participate in the BMS trial for his condition of chronic myeloid leukemia (CML).

Mr G was diagnosed with CML 3 years ago in India.

He presented with Melena of 5 days duration. He did not have any associated epigastric pain, and an oral gastro-duodenal scope did not show any positive findings. The melena subsequently stopped spontaneously.

Mr G also felt fullness at the left hypochondrium area and early satiety, both suggesting spleenomegaly. He was able to feel his own spleen and subsequent ultrasound revealed mild hepatomegaly and massive spleenomegaly.

Mr G also has symptoms of anemia which includes lethargy and tiredness but he did not have any breathlessness.

He had a loss of weight of 5 kg over 2 weeks with only a mild loss of appetite.

Mr G did not have any fever or other symptoms of infections. He did not have any bruises or petechiae, gum bleeding or nose bleeding.



Summary
In summary, Mdm Low a 35 yrs old lady delivered her first child prematurely at week 26+5. She was given corticosteroid and tocolysis delayed labour by 27 hours to allow time for the corticosteroid to be beneficial. Both she and her child are currently in stable condition.

PHYSICAL EXAMINATION
Mdm Low was noted to be alert and well. Her mood appeared to be good. She was not pale and she had no pallor.
Her vital signs are stable with her BP at 130/80mmHg. Pulse rate at 72 beats per minute and RR at 15 cycles per min. She was afebrile.

Examination of her thyroid and cardiorespiratory systems revealed no significant abnormailities. Breast and episotomy wound examination was not performed at the patient’s request. I would have looked for any signs of tenderness in the breast that might indicate mastitis and good healing of the episotomy wound.
Her uterus is well contracted and there are no other significant findings at the abdomen. Her calf muscles were supple.

Investigations
Full Blood Count:
A full blood count to look at the hemoglobin level is helpful as it was low after labour at 8.0g/dl. Her last hemoglobin level was on 01/11/05 (1 day before discharge) and was at 8.3g/dl. This is good as it is on an upward trend and she is currently not having any problems with anemia.
Checking the platelets and white cell count would help to check if there are any infections on going.

DISCUSSION

1) List the chief abnormalities in this case, the diagnosis and diagnostic points.

The chief abnormality in this case is preterm labour.
The Definition of preterm labour is the expulsion of a viable infant before the normal end of gestation1. Therefore a preterm delivery is when preterm labour results in delivery between the 26 to 37 weeks gestation. In clinical setting, labour is suspected when the patient suffers painful and regular contractions which lead to cervical changes. In our patient, it is possible that the bleeding per vagina she was complaining was “show” or a cause of the preterm labour. This was supported by regular painful contractions and dilatation of the cervical os that followed. I would have also checked for effacement and the engagement.
There are 3 common ways to calculate the gestation age. The Gestation age of the neonate is best calculated in a dating ultrasound scan in the 1st trimester which was the case in my patient. A dating scan in the second trimester is less accurate but nevertheless important especially when the menstrual history is unclear. Failing which it can be based from the last menstrual period from the history or by the baby’s development after birth (Dubowitz score).

2) Could any of the abnormalities have been avoided?

To consider if premature labour can be avoided, we need to look at the causes and the risk factor for premature labour.
The causes include the following:
A) Maternal Factors: Cervical incompetence, uterine abnormalities, renal diseases, malignancy, multiple pregnancy.
B) Obstetric Complications: Pre-ecalmpsis, antepartum hemorrhage, infections during pregnancy, premature rupture of membrane.
C) Fetal Factors: Fetal distress, growth retardation, fetal abnormalities.

Risk factors include:
a) pregnancy at age before 16
b) Lower socioeconomic status
c) BMI less than 19.0
d) Cigarette Smoking

However more than 50% of the patients who deliver prematurely do so spontaneously without any of the risk factors2.

Therefore, the 1st approach is to reduce the risk factors. The physician can persuade the pregnant lady to give up smoking. While we understand the possible causes in some of the preterm labour, most of them cannot be prevented. Treatments of the causes often do not change the course of preterm labour. Studies are still inconclusive on the efficacy of reducing the incidence preterm labour that results from these treatments. There have been 2 well studied treatment options which are the use of antibiotics and cervical cerclage. The use of cervical cerclage in high risk women to prevent preterm labour is controversial. Different studies have yielded different results. Treatment of bacterial vaginosis with anitibiotics may reduce the incidence of premature labour3.
Therefore, much more research has to be conducted before we can devise new and effective ways of reducing the rate of premature labour.

3) Was the treatment given the best possible

She was well investigated for the episode of bacterial vaginosis and was given appropriate treatment.
The current treatment for premature labour is mainly based on delaying the delivery through tocolysis. This is to prolong the labour for at least 24 to 48 hours so that the corticosteroid can be beneficial.
. Therefore, my patient has received good treatment and care for her premature labour.
In this episode, my patient was given Salbutamol as tocolysis. While Salbutamol has been proven to be efficacious as tocolytic agent5, the use of nifepedine (Adalac) as a tocolysis has been preferred by some specialists. They stated the reduced side effect profile of nifepedine as the reason. A meta-analysis comparing studies involving beta adrenergic agonist and nifedipine showed reduced interrupted treatment due to side effects in using nifedipine6. However, it should be noted that occurence of pulmonary edema with salbutamol only about 1 in 400.


Antibiotics were given to treat any possible subclinical infections of the genitals and the urinary tract. While the use of antibiotics is controversial in preterm labour(see below), it is appropriate in this patient since she has a history of bacterial vaginosis in the 1st trimester.
There are currently no guidelines on whether preterm babies should be delivered via normal vagina delivery or via a caesarian section, although most specialists would agree that it should follow the normal indications of term babies.

4) What were the reasons for adopting such a line of treatment

She received flagyl for bacterial vaginosis in the 1st trimester. Reviews have suggested that abnormal changes in the normal flora of a pregnant lady are a risk factor for premature labour. Treatment should begin as early as possible before the inflammatory response leading to irreversible tissue damage has occurred so as to effectively reduce the chances of preterm labour6. This is because studies have suggests that it is the inflammatory response rather then the infection itself that might be the cause of premature labour.

Data from the KK hospital shows a 75 percent survival rate in preterm babies at gestational age of 26 weeks and discussions with the neonatlogist suggest that 26 weeks is the common cut of age in which the neonatal team would prefer to resususitate the baby as the survival rate of a 25 week neonate falls to 56 percent.
Also, the fetal weight is estimated through ultrasound as the survival rate of an infant more than 750g would be more than 70 percent.
These predictive values help the team and the parents come to a decision on the resuscitation plan for the neonate and their prognosis.

The use of antibiotics in preterm labour is not a currently recommended treatment. When it is done, it is often because of the suspicion that a sub-clinical infection may be present. Studies until now have conflicting results in the use of antibtiotics in preterm labour. Some have reported a prolongation of gestational age7 while others showing no similar effects8.
The administration of corticosteroid has been shown to promote lung maturity in the neonate and reduces the severity and incidence of respiratory distress syndrome in the neonate. It has also been shown to reduce the incidence of Necrotising enterocolitis. The use of tocolysis in this context is to allow the corticosteroid to have at least 24 hours so that the corticosteroids can work optimally9.

5) Were there other ways of treatment which might have been considered? Why were they not used?

There have been recommendations to use fetal fibronectin as a predictor of premature labour and thus allowing the team to better prepare for preventive and treatment options. However, there have been doubts regarding its widespread use due to its low specificity10. A recent New Zealand study also concluded that although the use fibronectin assays have allowed shorter hospital stays, less use of tocolysis and corticosteroid, the neonatal outcome and the total hospital expenditure remains approximately the same as without the assays11. Therefore, the use of fetal fibronectin is not routinely recommended in most cases.

6) Give a brief comment on the case. What lessons did you learn in the management of this case?

Although the main abnormality in this case is premature labour, there are many issues to grabble with in normal obstetrics practice which includes subfertility and the use of IVF.

This case has also clearly illustrated the importance of early and continuous antenatal care so that any pathology or abnormalities can be picked up early. This would allow early commencement of treatment for best results and also allows time for teams to be assembled and plans to be made.

I have learnt the normal pathway of management for preterm labour and the indications and side effects of tocolysis. The importance of a team approach to such a patient is emphasized in my study of this case.

Although it was not discussed in this write up, counseling and patient education is particularly important in the case of premature labour. Predelivery high risk consults are available in all obstetrics hospital in Singapore to discuss the risk and causes associated with preterm labour to high risk patients. This not only allows the patient to understand the actions of the team and therefore puts their mind at ease, but will also ensure that they do not put the blame of the preterm labour on themselves.

Post delivery counseling is equally essential to help educate the parents of the care for their babies. This also helps them understand the risks of having another preterm baby and thereby helping them in future family planning. It should be conveyed to parents that although preterm labour is associated with subsequent preterm birth, this is an insensitive markers for recurrences12.
There are many complex issues regarding the management of preterm labour that are still being debated by the specialist at this point Despite this, a clear guideline is necessary in the management of preterm labours to ensure a good outcome. This was learnt through the study of this case. The learning issues that were taught, read and learnt during this case also provided a good footing to approaching all other kinds of obstetrics and medical cases with a logical, evidenced based and holistic care for my patients.