Dr. Rahimah stressed on knowing definition of gravida, parity and knowing how to count LMP and EDD. In case patient is USOD, we can give roughly estimated LMP by subtracting 40 weeks from REDD.
eg if this is patient 5th pregnancy, she had a molar, ectopic, a miscarriage and an IUD so it should be?
G5P1+3 (where there is 1 molar, 1 ectopic and 1 miscarriage)
In a case of SGA/IUGR, I put 'or' because a SGA case(suspected constitutionally small because of smaller mother's size with previous hx of small fetus) must be managed as TRO IUGR as if causes failed to be identified and patient was discharged and if a IUGR was not detected and managed, it will lead to IUD.
3 important factors lead to IUGR:
1. Placental insufficiency, which could be caused by
-pre-eclampsia (usually early onset which start to affect during formation of placenta)
-chronic medical illness which affect placenta formation
-smoking
-autoimmune disease such as SLE
-placenta previa, as placenta attach to lower segment of uterus with thinner myometrium--> less blood supply--> less nutrients--> baby smaller
(thats why we opt for lower segment c-sec as lesser blood supply there)
2. fetal infection
rule out TORCHES
3. fetal anomalies
oligohydramnios suspect renal agenesis
symmetrical IUGR: early onset, caused by Chromosomal anomalies, infection
asymmetrical IUGR, late onset, caused by placental insufficiency, thus have head-sparing
GDM will cause fetal macrosomia
however pre-existing DM in mother more likely --> congenital anomalies--> fetal microsomia
as this patient has a previous hx of small baby, ask if there is oligohydramnio in the previous pregnancy, chances are the patient has intrauterine infection in the previous pregnancy which continue to the next...
find out about percentile on growth chart for SGA, IUGR
if at district hospital, need to refer to tertiary centre if there are two abnormal plotted growth charts
usually the gap between 2 serial scans is about 1 week
however normal growth scan is 2 weeks
1 previous scar is already a criteria for admission
If Doppler U/S is abnormal, need to do CTG daily
If leaking of liquor, need to do U/S every 1w or 3d
HOPI for IUGR must rule out any CX such as
abnormal CTG, reduced fetal movement,doppler u/s findings, leking of liquor any PV discharge
Also diet hx to assess whether mother malnourish
VE assess Bishop score, if cervix favourable, deliver
if not, do induction, however previous scar, so do not do Induction as risk of uterine rupture...
if fetal distress, abnormal CTG, doppler, then c-sec
if no fetal distress, opt for vaginal delivery
Plan and management:
1. monitoring
2. timing of delivery
3. mode of delivery
investigations:
1. Blood: anemia, TWC, torches screening, group screen hold, High vaginal swab if leaking of liquor
2. U/S doppler: fetal BPP, placenta (any redding calcification), head and abd circumference, any fetal anomalies such as renal agenesis
3. CTG daily, fetal heart monitoring,
what to revise:
growth chart
causes and mx of IUGR
fetal BPP
torches
redding calcification
Sunday, August 14, 2016
Tuesday, August 9, 2016
Remedial O&G CT3 & 6 [note to myself]
CT 6 teaching with Dr. Hoo
Pt is a 32y/o lady G2P1 came in with Placenta Previa Type III Posterior for observation at 34w + 5d.
She had previous hx of Placenta Previa Type IV in her first pregnancy and had done elective Cesarean section at 2013 which is 3 years ago. She also had a past surgical history of cystectomy at 2012 which is 4 years ago. She denied any APH such as PV bleed or abd pain. The dx was made based on ultrasound findings at 30w.
In this pt, the risk factor for her recurrent PP in second pregnancy is previous C-sec.
To clerk history of a previous C-sec, must exclude cx such as any blood transfusion? any injury to bladder, bowel, ureters? any post-partum hemorrhage? any wound infection? endometritis? UTI?
Importance is to detect any presence of placenta accreta in her next pregnancy...as C-sec is a risk.
C-sec is also planned for her second pregnancy.
Must know how to plan a C-sec,
Inform and get consent,
Large bore IV access, catheterize bladder,
Pre-op: Take blood for FBC (ensure Hb level >10g/dl), PT/PTT, GXM (4-6units of blood), urea/creatinine.
consider ECG/CHEST XRAY
Neutralize gastric contents to prevent aspiration pneumonia if GA is used.
Elective C-sec, NBM + Ranitidine
Emergency C-sec: sodium citrate and metoclopromide
Thromboprophylaxis
low-risk: early mobilization, hydration
moderate: IV heparin and TED stockings
high: IV heparin until 5-d post-op and TED stockings
Antibiotic prophylaxis
IV cefazolin. given after cord is clamped
Also don't forget to revise all the risk factors that could cause PP.
Learning Point:
C-sec cx and planning
GXM and GSH difference
PP type, risk factors, mx
Rubella=german measles, effect on fetus?
ATT to prevent emergency delivery at non sterile environment
Hepatitis B vaccine? can be given during pregnancy or not?
Primary vs secondary dysmenorrhea
Pap smear done because need to remove pre-malignant lesion if there is.
Find out about Diabetic diet and ensure GDM mother follow
Results for MOGTT 5.6-7.8
CT3 with Dr. Fauziah
Know what is abnormal progress of labour, the hour...
Know partogram, and how to detect abnormal progress by partogram and how to mx to avoid fetal distress
what can a 1st U/S tell us?
-viability,
-dating
-location of gestational sac (ectopic: abdomen, cervix, broad ligament)
-fetal number, MCDA, DCDA
-Pregnancy of unknown location need beta-hCG test
-exclude uterine abnormalities
-exlude fibroid, ovarian mass
Ovarian cyst in pregnancy, cystectomy can only be done less than 18w, more than 18w might cause abortion, so planned cystectomy only after delivery
MOGTT HOW TO DO, RESULTS, WHEN TO DO, RISK FACTOR
Pt is a 32y/o lady G2P1 came in with Placenta Previa Type III Posterior for observation at 34w + 5d.
She had previous hx of Placenta Previa Type IV in her first pregnancy and had done elective Cesarean section at 2013 which is 3 years ago. She also had a past surgical history of cystectomy at 2012 which is 4 years ago. She denied any APH such as PV bleed or abd pain. The dx was made based on ultrasound findings at 30w.
In this pt, the risk factor for her recurrent PP in second pregnancy is previous C-sec.
To clerk history of a previous C-sec, must exclude cx such as any blood transfusion? any injury to bladder, bowel, ureters? any post-partum hemorrhage? any wound infection? endometritis? UTI?
Importance is to detect any presence of placenta accreta in her next pregnancy...as C-sec is a risk.
C-sec is also planned for her second pregnancy.
Must know how to plan a C-sec,
Inform and get consent,
Large bore IV access, catheterize bladder,
Pre-op: Take blood for FBC (ensure Hb level >10g/dl), PT/PTT, GXM (4-6units of blood), urea/creatinine.
consider ECG/CHEST XRAY
Neutralize gastric contents to prevent aspiration pneumonia if GA is used.
Elective C-sec, NBM + Ranitidine
Emergency C-sec: sodium citrate and metoclopromide
Thromboprophylaxis
low-risk: early mobilization, hydration
moderate: IV heparin and TED stockings
high: IV heparin until 5-d post-op and TED stockings
Antibiotic prophylaxis
IV cefazolin. given after cord is clamped
Also don't forget to revise all the risk factors that could cause PP.
Learning Point:
C-sec cx and planning
GXM and GSH difference
PP type, risk factors, mx
Rubella=german measles, effect on fetus?
ATT to prevent emergency delivery at non sterile environment
Hepatitis B vaccine? can be given during pregnancy or not?
Primary vs secondary dysmenorrhea
Pap smear done because need to remove pre-malignant lesion if there is.
Find out about Diabetic diet and ensure GDM mother follow
Results for MOGTT 5.6-7.8
CT3 with Dr. Fauziah
Know what is abnormal progress of labour, the hour...
Know partogram, and how to detect abnormal progress by partogram and how to mx to avoid fetal distress
what can a 1st U/S tell us?
-viability,
-dating
-location of gestational sac (ectopic: abdomen, cervix, broad ligament)
-fetal number, MCDA, DCDA
-Pregnancy of unknown location need beta-hCG test
-exclude uterine abnormalities
-exlude fibroid, ovarian mass
Ovarian cyst in pregnancy, cystectomy can only be done less than 18w, more than 18w might cause abortion, so planned cystectomy only after delivery
MOGTT HOW TO DO, RESULTS, WHEN TO DO, RISK FACTOR
Sunday, August 7, 2016
Remedial O&G Fetal events during labour
AP diameter:
Suboccipitobregmatic 9.5 cephalic (well-flexed)
Transverse diameter:
Biparietal: 9.5cm
Bitemporal: 8cm
Internal rotation probably occurs as the fetal head meets the muscular sling of pelvic floor, it is often not accomplised until presenting part has reached the level of ischial spine (zero station) and is therefore engaged.
engaged= 2/5 palpable on abdomen = zero station descent at ischial spine.
OBS HX TAKING (WHY I CLERK?) [note to myself]
Obstetric hx taking learning point:
Pt identification data: to assess risk, eg age>25 must do MOGTT, eg. If you get pregnant at age 25, your risk of having a baby with Down syndrome, for example, is about 1 in 1,250, according to the National Institutes of Health. At age 40, the risk is 1 in 100. If you'll be 35 or older on your due date, you'll be offered genetic counseling.
Occupation, socioeconomic class, does the mother able to take care of the baby after C-sec at home? Does the mother BF when she needs to go to work? the home using well water? can she take water after surgery while recovering?
gravida: G, P and +
multipara will has dx of false labour if dilatation is only 1cm
if +3 indicates recurrent miscarriage, need to find out cause
LMP: naegeles rule, SOD, regular menses, no BF, no hormonal therapy
EDD, REDD, POA
(must knw how to count)
used to detect postdate and also date for IOL for cases like GDM, PIH,...
date also help to identify IUGR, SGA...
read about U/S and discrepancy
C/O what bring pt to hospital? electively admitted? referred case?
(pt came in due to contraction pain? distinguish from braxton hicks, VE see any favourable cervix using Bishop score, ask for any show/leaking of liquor)
HOPI:
must knw disease:
1. GDM/pre-existing DM, clerk MOGTT, presence of risk factors, glycosuria, sx of DM (3Ps, numbness, blurring of vision), HbA1C, family hx of GDM, any congenital anomalies in fetus, any macrosomic baby, polyhydramnios, currently admitted blood sugar profile, insulin how many unit taken, any diet control? mx: IOL? cx that may arise, macrosomic, shoulder dystocia, perineal tearing? neonatal hypoglycemia?
2. Pre-eclampsia, Bp, proteinuria, mx
3. Placenta previa, PV bleed? pain? woody hard uterus?(abruptio) grade of placenta previa, causes such as multiparity,..., mx Mcafree Regime!
4. Postdate
5. Oligohydramnios, how to see AFI
6. Abnormal lie, whether to manually betulkan lie or let it be
anemia, iron metabolism
CVD, how to terminate pregnancy
IOL indications, C-sec indication, trial of scar
HOPP
missed period? UPT? (read UPT test principle, hCG, amino acids...)
failed contraception or planned pregnancy? assess pt's desire of having baby
if not because of missed period? sx of pregnancy? vomitting, abd distension, quickening?
confirm pregnancy where?
BOOKING! READ ABOUT EACH COMPONENT OF BOOKING AND KNOW WHY WE SHOULD KNOW.
(every month till 28, every 2w until 36, every 1w until delivery)
SUBSEQUENT FOLLOW UP? ULTRASOUND OK?
quickening? primid 18-20w, multi 16-18w
sx of pregnancy, breast engorgement, frequency, constipation, ankle edema, backache? (look for any symptomatic tx?)
Immunization
ATT (principle)
hep B (3x) last time...
Rubella secondary sch
Past OBS
consanguinous marriage?
Mode of delivery, Complication? preterm, full term? C-sec? episiotomy? poor spacing? healing scar? exclusive breastfeeding?
Recurrent miscarriage? D&C? (uterine scar...risk of placenta previa...)
any contraception?
Menstrual hx
menorrhagia? oligomenorrhea? amenorrhea?
PCOS? subfertility?
Gynae
PCOS? Uterine fibroid? any malignancy? ectopic pregnancy? recurrent miscarriage?
Pap smear done? when? where? result? (check how many times pap smear must be done every duration?)
PAST MEDICAL, SURGICAL, DM? HPT? HEART DISEASE? ASTHMA? TB?
uterine surgery, risk of placenta previa...
Family hx?
GDM, DM, HPT, HEART DISEASE, twins pregnancy, recurrent miscarriage, stillbirth, congenital abnormalities, gynae malignancy...
Personal and Social hx
socioeconomic status
does husband take care of family
children under care of
smoking, alcohol (husband? pt?)
Drug hx
iron, folic acid, vit b, vit c
*vit b complex contained folic acid
*obimin contain all
insulin for GDM (read back why Oral hyperglycemic Agent cannot be given)
magnesium sulphate for PIH (not sure, read back)
Prostin induction of labour, syntometrine, pitocin...(how to use)
Miseprostol, mifepristone for expulsion of POC
check for drugs use for termination of pregnancy
progesterone for maintaining pregnancy in threatened miscarriage
infection in pregnancy how to treat? common: UTI
any traditional med? any OTC drugs? any allergy?
Dietary
DM diet
Summary
AGE, GRAVIDA, PARA, POA, C/O
Pt identification data: to assess risk, eg age>25 must do MOGTT, eg. If you get pregnant at age 25, your risk of having a baby with Down syndrome, for example, is about 1 in 1,250, according to the National Institutes of Health. At age 40, the risk is 1 in 100. If you'll be 35 or older on your due date, you'll be offered genetic counseling.
Occupation, socioeconomic class, does the mother able to take care of the baby after C-sec at home? Does the mother BF when she needs to go to work? the home using well water? can she take water after surgery while recovering?
gravida: G, P and +
multipara will has dx of false labour if dilatation is only 1cm
if +3 indicates recurrent miscarriage, need to find out cause
LMP: naegeles rule, SOD, regular menses, no BF, no hormonal therapy
EDD, REDD, POA
(must knw how to count)
used to detect postdate and also date for IOL for cases like GDM, PIH,...
date also help to identify IUGR, SGA...
read about U/S and discrepancy
C/O what bring pt to hospital? electively admitted? referred case?
(pt came in due to contraction pain? distinguish from braxton hicks, VE see any favourable cervix using Bishop score, ask for any show/leaking of liquor)
HOPI:
must knw disease:
1. GDM/pre-existing DM, clerk MOGTT, presence of risk factors, glycosuria, sx of DM (3Ps, numbness, blurring of vision), HbA1C, family hx of GDM, any congenital anomalies in fetus, any macrosomic baby, polyhydramnios, currently admitted blood sugar profile, insulin how many unit taken, any diet control? mx: IOL? cx that may arise, macrosomic, shoulder dystocia, perineal tearing? neonatal hypoglycemia?
2. Pre-eclampsia, Bp, proteinuria, mx
3. Placenta previa, PV bleed? pain? woody hard uterus?(abruptio) grade of placenta previa, causes such as multiparity,..., mx Mcafree Regime!
4. Postdate
5. Oligohydramnios, how to see AFI
6. Abnormal lie, whether to manually betulkan lie or let it be
anemia, iron metabolism
CVD, how to terminate pregnancy
IOL indications, C-sec indication, trial of scar
HOPP
missed period? UPT? (read UPT test principle, hCG, amino acids...)
failed contraception or planned pregnancy? assess pt's desire of having baby
if not because of missed period? sx of pregnancy? vomitting, abd distension, quickening?
confirm pregnancy where?
BOOKING! READ ABOUT EACH COMPONENT OF BOOKING AND KNOW WHY WE SHOULD KNOW.
(every month till 28, every 2w until 36, every 1w until delivery)
SUBSEQUENT FOLLOW UP? ULTRASOUND OK?
quickening? primid 18-20w, multi 16-18w
sx of pregnancy, breast engorgement, frequency, constipation, ankle edema, backache? (look for any symptomatic tx?)
Immunization
ATT (principle)
hep B (3x) last time...
Rubella secondary sch
Past OBS
consanguinous marriage?
Mode of delivery, Complication? preterm, full term? C-sec? episiotomy? poor spacing? healing scar? exclusive breastfeeding?
Recurrent miscarriage? D&C? (uterine scar...risk of placenta previa...)
any contraception?
Menstrual hx
menorrhagia? oligomenorrhea? amenorrhea?
PCOS? subfertility?
Gynae
PCOS? Uterine fibroid? any malignancy? ectopic pregnancy? recurrent miscarriage?
Pap smear done? when? where? result? (check how many times pap smear must be done every duration?)
PAST MEDICAL, SURGICAL, DM? HPT? HEART DISEASE? ASTHMA? TB?
uterine surgery, risk of placenta previa...
Family hx?
GDM, DM, HPT, HEART DISEASE, twins pregnancy, recurrent miscarriage, stillbirth, congenital abnormalities, gynae malignancy...
Personal and Social hx
socioeconomic status
does husband take care of family
children under care of
smoking, alcohol (husband? pt?)
Drug hx
iron, folic acid, vit b, vit c
*vit b complex contained folic acid
*obimin contain all
insulin for GDM (read back why Oral hyperglycemic Agent cannot be given)
magnesium sulphate for PIH (not sure, read back)
Prostin induction of labour, syntometrine, pitocin...(how to use)
Miseprostol, mifepristone for expulsion of POC
check for drugs use for termination of pregnancy
progesterone for maintaining pregnancy in threatened miscarriage
infection in pregnancy how to treat? common: UTI
any traditional med? any OTC drugs? any allergy?
Dietary
DM diet
Summary
AGE, GRAVIDA, PARA, POA, C/O
Remedial O&G CT1,2 [note to myself]
CT 1: GDM case teaching by Dr. Akram
Booking at least at 6w
MOGTT when, result? Insulin unit? BSP controlled? HbA1C? U/S: congenital anomalies? polyhydramnios? macrosomia?
Use SFH to compare with POG
FHR must show u're counting for 1 min
if pre-eclampsia PE must check liver tenderness, epigastric pain
CT2: Placenta Previa case teaching by Prof Adibah
quickening at 28w? impossible, check LMP wrong date/abdomen too thick
how to present:
she noticed she is pregnant when UPT is done and confirmed her pregnancy after she experienced nausea, vomitting,...
Booking was performed at....
the parameters are as followed...
u/s done at....w, and showed fetus corresponding to dates, subsequent checking was done regularly, throughout her pregnancy, there was no hypertension,...
quckening at....w
1st dose of ATT was given at....w, subsequent dose at...w
at 29w, another u/s performed as routine procedure which show placental low-lyng,...otherwise no fetal abnormalities, however, never has APH,
ask any fibroid, previous uterine surgery (risk factor)
PE for placenta previa:
1. Pain? contraction pain can cause APH in placenta previa
2. Vital signs
Bp: rule out late onset of HPT, as pt has family hx
HR: Wolff-Parkinson white syndrome...due to hyperactive thyroid
3. pallor, signs of anemia, make sure pt not in dilutional anemia, Hb enough to compensate when APH happen
4. edema, she is at risk to develop HPT, so if very gross edema, assess renal problem...
Booking at least at 6w
MOGTT when, result? Insulin unit? BSP controlled? HbA1C? U/S: congenital anomalies? polyhydramnios? macrosomia?
Use SFH to compare with POG
FHR must show u're counting for 1 min
if pre-eclampsia PE must check liver tenderness, epigastric pain
CT2: Placenta Previa case teaching by Prof Adibah
quickening at 28w? impossible, check LMP wrong date/abdomen too thick
how to present:
she noticed she is pregnant when UPT is done and confirmed her pregnancy after she experienced nausea, vomitting,...
Booking was performed at....
the parameters are as followed...
u/s done at....w, and showed fetus corresponding to dates, subsequent checking was done regularly, throughout her pregnancy, there was no hypertension,...
quckening at....w
1st dose of ATT was given at....w, subsequent dose at...w
at 29w, another u/s performed as routine procedure which show placental low-lyng,...otherwise no fetal abnormalities, however, never has APH,
ask any fibroid, previous uterine surgery (risk factor)
PE for placenta previa:
1. Pain? contraction pain can cause APH in placenta previa
2. Vital signs
Bp: rule out late onset of HPT, as pt has family hx
HR: Wolff-Parkinson white syndrome...due to hyperactive thyroid
3. pallor, signs of anemia, make sure pt not in dilutional anemia, Hb enough to compensate when APH happen
4. edema, she is at risk to develop HPT, so if very gross edema, assess renal problem...
Remedial O&G CT4 [note to myself]
Clinical teaching 4 with Prof Nik
Madame NH 24y/o, G1PO with a background history of subfertility for 3 years and undergone ovulation induction for 1 year (on Clomiphene ?dose) was electively admitted for management of postdate.
DOA: 6/8/2016; DOC: on the same day as admission
Last Menstrul Period: 2/12/2015; sure of date, irregular menstruation, ovulation induction
Ovulation induction(read on infertility IDA lecture) signifies there is ovulation during the LMP so LMP is trustable.
Expected date of delivery: 9/8/2016
Revised EDD(scan done around 9th week): 31/7/2016
Prof mentioned scan done around 9th week discrepancy can be up to 2-5d, find out u/s and discrepancy
the discrepancy was 1 week and so EDD counted from LMP is acceptable. (discrepancy not more than 2 weeks; find out)
currently POA: 39w 5d (if the case is presented as a Postdate case, then do not present 39w, not tally)
HOPI:
All parameters normal, excpet on ultrasound noted cord around neck and aminiotic fluid index: 1.3cm. (learn how to grade oligohydramnios, causes and management)
Beware on small AFI, usually on PE, u may find smaller fundal height
Patient is obese class I with BMI of 30.06kgm-2. (learning point: obesity cause PCOS hence irregular menstruation and subfertility?)
Subfertility, clomiphene: must ask for dosage(mg), how many times taken a day, duration taken (clomiphene usually 1 tab 50mg OD, given at 5th to 9th or 2nd to 6th day of menstrual cycle)
noted that BMI >30, MOGTT as screening of diabetes must be done at 12-14w, 24-28w and 32-34w,
other risks factor:
Physical examination:
rather than mention no resp distress, mention pt is breathing spontaneouly, well
only 5/5 palpable can be presented as balloptable fetal head (~floating)
Pt has high BP, must check CVS! check for radiofemoral delay, Coarctation of aorta! Treat pt as whole!
if not checking the breast, at least ask the pt whether there is presence of colostraum, which prepare pt for BF, student might miss pregnant mother who has breast cancer
Patient also has past medical hx of leukemia (unclear hx: so must ask what age diagnosed? completed chemotherapy? regularly follow up? whether cytotoxic drugs had caused the subfertility? and also a leukemic pt in the past need to have antenatal follow up in a tertiary centre! not district)
finally, presenter was asked to present CTG as there is cord around neck,
Prof's comment on how to present, this is a CTG of Madame NH, 24y/o Malay lady, G1PO, with a background hx of subfertility for 3 years and was on ovulation induction for 2 years, the CTG was taken on yesterday, 6/8/2016 2pm for a duration of _ hour, it shows that the baseline FHR was 140-150bpm, the beat to beat variability was 5-20bpm, there was presence of acceleration, no deceleration, the CTG taken is reactive. (any contraction? there was presence of regular uterine contraction with amplitude of?)
eventually, patient was given elective Caeserean section due to these following issue, subfertility, oligohydramnios and cord around neck.
SO AGAIN,
LEARNING POINT:
SUBFERTILITY CAUSES, CLOMIPHENE DOSAGE
PCOS
ULTRASOUND DISCREPANCY
OLIGOHYDRAMNIOS
CORD AROUND NECK
INDICATION FOR IOL/C-SEC (HOW TO CHOOSE)
HOW TO MANAGE POSTDATE IF NO CX ARISE?
EXTRA LEARNING POINT:
REVISE GDM
REVISE CVS, what may cause High Bp, RISK FOR pre-eclampsia
I asked a question why Prostin used in IOL is contraindicated in severe asthma/glaucoma?
Prof: only "severe" and its not absolute contraindication, if pt's asthma/glaucoma condition is well-controlled, Prostin can be used.
Madame NH 24y/o, G1PO with a background history of subfertility for 3 years and undergone ovulation induction for 1 year (on Clomiphene ?dose) was electively admitted for management of postdate.
DOA: 6/8/2016; DOC: on the same day as admission
Last Menstrul Period: 2/12/2015; sure of date, irregular menstruation, ovulation induction
Ovulation induction(read on infertility IDA lecture) signifies there is ovulation during the LMP so LMP is trustable.
Expected date of delivery: 9/8/2016
Revised EDD(scan done around 9th week): 31/7/2016
Prof mentioned scan done around 9th week discrepancy can be up to 2-5d, find out u/s and discrepancy
the discrepancy was 1 week and so EDD counted from LMP is acceptable. (discrepancy not more than 2 weeks; find out)
currently POA: 39w 5d (if the case is presented as a Postdate case, then do not present 39w, not tally)
HOPI:
All parameters normal, excpet on ultrasound noted cord around neck and aminiotic fluid index: 1.3cm. (learn how to grade oligohydramnios, causes and management)
Beware on small AFI, usually on PE, u may find smaller fundal height
Patient is obese class I with BMI of 30.06kgm-2. (learning point: obesity cause PCOS hence irregular menstruation and subfertility?)
Subfertility, clomiphene: must ask for dosage(mg), how many times taken a day, duration taken (clomiphene usually 1 tab 50mg OD, given at 5th to 9th or 2nd to 6th day of menstrual cycle)
noted that BMI >30, MOGTT as screening of diabetes must be done at 12-14w, 24-28w and 32-34w,
other risks factor:
- Gestational diabetes previous pregnancy
- Obesity (BMI >30)
- Age > 25
- Presence of glycosuria in >2 occasions
- History of DM in first degree relatives
- Previous big baby > 4.0 kg
- Previous history of recurrent abortion or unexplained stillbirth
- Previous congenital anomalies
- Polyhydramnios
Physical examination:
rather than mention no resp distress, mention pt is breathing spontaneouly, well
only 5/5 palpable can be presented as balloptable fetal head (~floating)
Pt has high BP, must check CVS! check for radiofemoral delay, Coarctation of aorta! Treat pt as whole!
if not checking the breast, at least ask the pt whether there is presence of colostraum, which prepare pt for BF, student might miss pregnant mother who has breast cancer
Patient also has past medical hx of leukemia (unclear hx: so must ask what age diagnosed? completed chemotherapy? regularly follow up? whether cytotoxic drugs had caused the subfertility? and also a leukemic pt in the past need to have antenatal follow up in a tertiary centre! not district)
finally, presenter was asked to present CTG as there is cord around neck,
Prof's comment on how to present, this is a CTG of Madame NH, 24y/o Malay lady, G1PO, with a background hx of subfertility for 3 years and was on ovulation induction for 2 years, the CTG was taken on yesterday, 6/8/2016 2pm for a duration of _ hour, it shows that the baseline FHR was 140-150bpm, the beat to beat variability was 5-20bpm, there was presence of acceleration, no deceleration, the CTG taken is reactive. (any contraction? there was presence of regular uterine contraction with amplitude of?)
eventually, patient was given elective Caeserean section due to these following issue, subfertility, oligohydramnios and cord around neck.
SO AGAIN,
LEARNING POINT:
SUBFERTILITY CAUSES, CLOMIPHENE DOSAGE
PCOS
ULTRASOUND DISCREPANCY
OLIGOHYDRAMNIOS
CORD AROUND NECK
INDICATION FOR IOL/C-SEC (HOW TO CHOOSE)
HOW TO MANAGE POSTDATE IF NO CX ARISE?
EXTRA LEARNING POINT:
REVISE GDM
REVISE CVS, what may cause High Bp, RISK FOR pre-eclampsia
I asked a question why Prostin used in IOL is contraindicated in severe asthma/glaucoma?
Prof: only "severe" and its not absolute contraindication, if pt's asthma/glaucoma condition is well-controlled, Prostin can be used.
Subscribe to:
Posts (Atom)