Archive for July, 2010

Working in Msia…procedures

Posted: July 22, 2010 by gerardloh in Uncategorized

From fb, by Thayalen Savarathanam

For all future graduates and graduates from overseas universities, I hope that this post will be of help to you.
These are the things you should do to apply for HO.

Check whether your university degree is recognized.

After graduation, apart from your basic medical degree and transcript, be sure that you have the offer letter from your university (offer letter to study), the results of exams for every semester and other relevant documents. Translate any of the above mentioned into English if it is not in English.

After my graduation convo, I applied for SPA interview online by filling in the Borang SPA 8i Online.
Use the following link:

The Borang Spa 8i Online and all the guidelines on filling in are available in the above link. Then check the status of your application after 3 days later (usually 3-7 days laters) at
After a week, my application was approved.
Then call this number 03-8885 6338 begin_of_the_skype_highlig

hting 03-8885 6338 end_of_the_skype_highlighting (Cik Zamzarina / En. Anuar) to book a date for your interview. Cik Zamzarina is a very helpful and patient lady. Thank you so much for your help n advises.

When you reach home, go to Putrajaya to collect all the application forms.
These are the government offices n departments that you need to go in Precint 1, Putrajaya:
1. MMC-Malaysian Medical Council in complex E
Malaysian Medical Council
Level 2, Block E1, Parcel E, Precinct 1,
Federal Government Administrative Centre
62590 Putrajaya.
03-88831401 begin_of_the_skype_highlighting 03-88831401 end_of_the_skype_highlighting
2. MOH-Ministry of Health in complex E
Kementerian Kesihatan Malaysia,
Bahagian Sumber Manusia, Unit Pengurusan dan Profesional,
Aras 9, Blok E7, Kompleks E,
Pusat Pentadbiran Kerajaan Persekutuan,
62590 Putrajaya.
03-8883 2805/2815 Puan Nadila/Puan Nurul
3. SPA-Suruhanjaya Perkhidmatan Awam in complex C
Suruhanjaya Perkhidmatan Awam Malaysia
Aras 6, Blok C7, Kompleks C,
Pusat Pentadbiran Kerajaan Persekutuan
03-8885 6338 begin_of_the_skype_highlighting 03-8885 6338 end_of_the_skype_highlighting (Cik Zamzarina)

Precinct 1 in Putrajaya is actually a roundabout and there are complexes in which ministries and governtment offices are located.

So, you start with MMC which is located on Level 2, Block E1 and collect the Form 4, Provisional Registration Form.
Application for Provisional Registration:
Applicants need to submit the following documents:
Form 4 of the Medical Act 1971 for Provisional Registration application form;
• 2 passport size photos;
• A Certified copy of Basic Medical Degree
• A Certified copy of your transcript encompassing the results of whole training period
• A Certified copy of ‘Bonafide Student Certificate’ – Applicable only to graduates from India, Pakistan and Bangladesh
• A Certified copy of Identity Card or passport;
• A Certified copy of birth certificate;
• A Certified copy of SPM/MCE or equivalent;
• A RM20 processing fee by money/postal order payable to The Registrar Medical Practitioner
Apart from the documents above, the following documents need to be submitted:
Local graduates:
• The original Dean’s letter
Overseas graduates:
• For graduates from Indian institutions – A Certified copy of Bonafide Student and Rotating Internship;
• For graduates from Indonesian institutions – A Certified copy of Sarjana Kedokteran and Ijazah Kedokteran;
This where you can also download the Form 4 and guidelines on filling the form.

After that proceed down the street to MOH on Level 9, Blok E7 and collect the BMD, Borang Maklumat Diri. You’ll go across the department to Bahagian Sumber Manusia, Unit Pengurusan dan Profesional. Too bad that there’s no internet link where you can download the BMD.

The next step is document verification. Open and follow the guidelines in this pdf link:
My advice is to certify 5 copies (the more the better/merrier, of course) of I/C, Surat Beranak, SPM, Basic Medical Degree, Transcript and other relevant documents. One more advice is to certify every side even though if it is not in English.

The last step is handing in the application forms.
Hand-in the application forms personally after you have certify everything. Please do not send by post because it will pass through a few departments and it will be in the destined department eg. MMC, one week later after the date of receiving.

Examination of the Cardiovascular System

Posted: July 18, 2010 by gerardloh in Medicine

by Dr James Joseph, MD, CSMU (UKRAINE) 2010]

1. Introduce yourself and ask for permission to examine the heart. This is good bedside manner and will help to establish rapport with px.

2. Make sure the patient is positioned at 450 and adequately exposed.

3. Observe carefully for tachypnea, orthopnea, cyanosis, and “spot diagnoses” that are associated with heart diseases:

•Eg: Presence of titilbation (head-nodding) and Corrigan’s sign in the neck will greatly help in the diagnosis of aortic incompetence.

Malar flush = mitral stenosis

Turner’s syndrome= coarctation and bicuspid aortic valve

Down’s syndrome = ASD, VSD and Fallot’s tetralogy

Noonan’s syndrome = pulmonary valve dysplasia and hypertrophied cardiomyopathy

Marfan’s syndrome= aortic or mitral incompetence

Myx0edema facies = pericardial effusion
Corneal Arcus

Slide 9

4. Upper limbs:

a) Palms

- moisture -> dry @ moist
- temperature -> warm @ cold – colour -> pink @ pale

b) Finger
- cyanosis -> peripheral cyanosis
- capillary filling


- stigmata of IE: Osler nodes, Janeway lesion, Splinter  hemorrhage

Splinter haemorrhage may also be seen in trauma, connective tissue diseases, and trichinella infection

Osler’s node is uncommon but important sign of infective endocarditis
Raised tender nodules on the pulp of the fingers, toes, thenar or hypothenar eminences

Janeway lesions (non-tender erythematous maculo-papular lesions containing bacteria)

- tendon xanthomas
- nicotine stain

c) Pulse

Begin by feeling the patient’s right radial pulse carefully with the index and middle fingers of the left hand (The radial pulse will be easier to feel if the wrist is slightly flexed)

Note down:
•Rate (count 60 seconds rather than 15 seconds X 4: you may miss ectopics coming later)
•Rhythm -> regular @ irregular
•Character (particularly looking for collapsing pulse)
•Radio –radial delay
•Radio – femoral delay (in coartation of aorta)

ØThe rest of the pulses are examined to determine if they are present and equal on both sides


Undergraduates are expected to detect atrial fibrillation (irregularly irregular pulse) and a collapsing pulse.

The collapsing pulse is best elicited by grabbing the patient’s left wrist with your left hand (bottom, left). After you have detected the pulsation of his radial pulse in your palm, gradually relax the grip of your hand until the radial pulse just disappear. Then with the help of your right hand, lift the patient’s arm in the air (bottom, right) while maintaining the same grip pressure. If the pulse returns, it has become more forceful and thus deemed collapsing.
Causes of collapsing pulse:
aortic incompetence
hyperdynamic circulation: severe anaemia, thyrotoxicosis, Paget’s disease
peripheral arteriovenous fistula
Arterosclerotic aorta (in elderlies)

d ) and don’t forget to measure the patients’ BLOOD PRESSURE

5. Neck

a) Carotid pulse
- Volume
- Character
- Bruits

b) Jugular venous pressure
•Examine the internal jugular vein (JVP) in the neck carefully to determine the height (usually this will be sufficient for undergraduates)
•Turn the patient’s face slightly away and look for a pulsation in the neck . If present, determine if it is arterial or venous.
•If it is a venous, measure its height at the sternal angle with the help of 2 rulers always keeping your eyes at the level of the horizontal ruler . When the height is more than 3 cm above the sternal angle, the JVP is raised.

Causes of elevated JVP
•Right ventricular failure
•Volume overload
•SVC obstruction
•Tricuspid stenosis or regurgitation
•Pericardial effusion
•Constrictive pericarditis

6. Head

high-arched palate (Marfan’s syndrome)

- stigmata of hyperlipidemia (xanthelasma) & thyroid disease

7. Lower Limbs
a) pitting edema

b) peripheral pulses
c) cyanosis, cold limbs, trophic changes, ulceration (peripheral vascular disease)
d) clubbing of toes

Specific examination of praecordium

Every auscultation, listen for…

•1st & 2nd heart sound & their intensity
•Extra heart sound (S3 & S4)
•Additional sound ( opening snap, systolic ejection click)
•Fixed splitting  2nd heart sound (only in pulmonary area, ASD

**Auscultatory features of heart murmurs
1) When does it occur?
- Time the murmur using heart sounds, carotid pulse and the apex beat, is it systolic or diastolic?
- Does the murmur extend throughout systole or diastole or is it confined to a shorter part of the cardiac cycle?
2) How loud is it? (intensity)
- Grade 1: Very soft (only audible in ideal conditions)
- Grade 2: Soft
- Grade 3: Heard all over the precordium
- Grade 4: Loud, with palpable thrill (ie, a tremor or vibration felt on palpation)
- Grade 5: Very loud, with thrill. May be heard when stethoscope is partly off the chest
- Grade 6: Very loud, with thrill. May be heard with stethoscope entirely off the chest
3) Where is it heard best? (location)
- Listen over the apex and base of the heart, including the aortic & pulmonary areas
4) Where does it radiate?
- Evaluate radiation to the neck, axilla or back
5) What does it sound like? (pitch & quality)-> harsh/blowing/rough
- Pitch is determined by flow ( high pitch indicates high-velocity flow)
- Is the intensity constant or variable?
Heart sounds

If there is a murmur, 5 things to comment:

1) timing -> systolic/diastolic
2) area of greatest intensity
3) Radiation -> axilla? neck?
4) Grading -> 1-6
5) changes with alteration of position
( left lateral position@ sitting forward)
6) effect of dynamic maneuvers( mainly respiratory)
à ask pt to inspire, expire fully n hold

Eg: There is a pansystolic murmur best heard over the mitral area with radiation to  axilla, graded 3/6 and accentuated during inspiration and left lateral position

Site of murmur radiation
1. mitral regurgitation à left axilla
2. aortic stenosis à right side of neck
3. aortic regurgitationà left sternal bord
c) Fundus
- hypertensive retinopathy
- Roth spots (IE)
d) Abdomen
- palpate liver & spleen(enlarge?)
- percuss -> ascites (shifting    dullness)
e) Check for temperature chart , urine output , CXR (if present)
f) Take BP if forget b4 this
*** DDx of chest pain
1) Anxiety/emotion
2) Cardiac: angina, MI, myocarditis, pericarditis, mitral valve prolapse
3) Aortic: aortic dissection, aneurysm
4) Esophageal: esophagitis, esophageal spasm, Mallory-Weiss syndrome
5) Lungs/pleura: bronchospasm, pulmonary infarct, pneumonia, tracheitis, pneumothorax, pulmonary embolism
6) Musculoskeletal: osteoarthritis, rib fracture/injury, intercostal ms injury
7) Neurological: prolapsed intervertebral disk, herpes zoster

Examination of Respiratory System

Posted: July 17, 2010 by gerardloh in Medicine

Examination of Respiratory System
by Dr Chua Sook Yin, MD, CSMU (UKRAINE) 2010
Dr. Kimberly Ho,   MD, CSMU (UKRAINE) 2010

1) 5 important things before you start examining patient:
I- Introduce
P- Permission
P- Position

2) General Inspection (PCLCPRHNGMA)
 P – Position
 C- Comfort
 L- Look
 C – Consciousness
 P – Pain
 R – Respi Distress
 H – Hydration
 N – Nutrition
 G- Gross deformity
 M – Movement
 A- Attachment

3) General Examination List

A) Upper Limbs
i. Palms
ii. Finger and nails
iii. Dorsal part of hand
iv. Wrist
v. Pulse
vi. BP
vii. Flapping tremor ( asterixis)

B) Head
i. Eyes
ii. Nose and ears
iii. Mouth and tongue
iv. Character of cough

Horner’s syndrome:
1) Ipsilateral partial ptosis
2) Ipsilateral miosis
3) Ipsilateral reduced sweating
4) Enophthalmos

C) Neck
i. Jugular venous pressure
ii. Trachea deviation
iii. Tracheal tug
iv. Distance from cricoid cartillage to suprasternal notch

Causes of tracheal deviation:
a. towards the lesion
-upper lobe collapse
-upper lobe fibrosis
b. away from the lesion
-massive pleural effusion
-tension pneumothorax
-upper large mediastinal masses

D) Lower Limbs –Pitting edema

4) Specific Examination of chest

A) Inspection
i. Move symmetrically with each respiration?
ii. Chest wall deformity?
iii. Scars?
iv. Dilated Veins?
v. Skin Discoloration?
vi. Visible pulsation?
vii. Radiotherapy marking?

B) Palpation
i. Chest expansion
ii. Apex beat
iii. Vocal Fremitus
C) Percussion
i. Resonant
ii. Hyperesonant
iii. Dull
iv. Stony dull

D) Auscultation
i. Breath sound
a. Intensity ( normal, reduced, absent)
b. Nature ( vesicular, bronchial)

ii. Added sounds
a. Rhonchi
b. Crackles
c. Pleural Rub

iii. Vocal Resonance
Ask the patient to sit up, repeat the examination on the back
 While percussing, ask the patient to move the elbows forward across the front of the chest to move the scapular away from the lung field.
 While the patient is sitting, palpate for cervical lymph nodes.
 Look for vertebrae tenderness.
 Examine the heart for signs of cor pulmonale.
 Examine the sputum.

Example of conclusion: There’s pleural effusion over the left lower zone evidenced by reduced chest expansion, decreased vocal resonance and fremitus, stony dull notes and reduced breath sounds over the left lower zone.

History taking

Posted: July 17, 2010 by gerardloh in Medicine

History taking for Medicine
by Dr. Ng Kean Seng, MD, CSMU (UKRAINE) 2010

1. Age/Race/sex

Eg: 56/Malay/M

2. K/C/O ( Known case of@ co morbid)


A. DM 20 years, Currently on T Metformin 500mg bd 2) HPT Currently on? Follow up where?

B. Previously healthy

C. Refer from KK Taman Ehsan, differential diagnosis disease?

3. C/C ( Chief complaints)

A. State the MAJOR Problem in one or two of the patient’s own words. Do not use medical terminology.

For example: Chest pain for 2 hours. Ask: “Encik, saya hendak tanya, kenapa encik datang ke hospital?” “Boleh saya tahu apa yang menggangu encik” This generally tells you how to gear up your question for the ‘History of presenting illnesse’.

B. Follow sequence based on time flow:

For example : fever 2/7, cough 5/7, headache 2/52


Describe the onset, nature and course of each symptom. Important because it directs you to the system you would be concentrating during your physical examination.

A- Describe the presenting complain as completely as possible.

For example: Patient complains of pain. ‘SOCRATES drill’ S - site O - onset C - character R - radiation A - associated symptoms T - timing E - exacerbating/alleviating factor S - severity (X/10)

B- Eliminate causes that could present in a similar manner.

Keep a differential diagnosis in your mind and ask questions accordingly. Include relevant positive and relevant negative Example: Chest pain Ask symptoms associated with

  • Myocardial Infarction
  • Pericarditis
  • Aortic dissection
  • Pulmonary embolism
  • Oesophageal spasm

Example :

Relevant positive
- Typical history, pain history
- ECG – hyperacute T waves
- Cardiac enzyme – troponin

Relevant negative

- X fever
- X cough
- X risk of DVT
- X related with food / lying flat

C- Thirdly, ask about the any risk factors and relevant past history for the diagnoses you might have in mind at this point.

For example: Positive family history for ischemic heart disease, Past medical history of angina or myocardial infarction, Hypercholesterolaemia etc.


  • Further Elaborate K/C/O
  • Write in chronological order.
  • Include important negatives

Example: Patient with chest pain you should ask about previous Ml, angina, HT or DM and record whether these are present or absent.

Remember to ask about following diseases!

Respiratory: Tuberculosis, asthma, bronchitis
CVS: Hypertension, Ischemic heart disease, Rheumatic fever,
CNS: Epilepsy, Cerebral-vascular event
Liver: Jaundice Diabetes


- M yocardial infarction
–J aundice

- T uberculosis
–H ypertension
– R heumatoid Arthritis
– E pilepsy
– A sthma
– D iabetes Mellitus
– S troke


  • What operation is done and date of operation
  • GA ( General Anesthesia) / SA ( Sacral Anesthesia)

If there is local anesthesia you should ask why choose local in the last operation? Maybe there is complication of GA


  • Regular/ Irregular?
  • ? Pad (1 pad = 100ml)
  • Hx of flooding? Blood clot?
  • Intermenstrual bleeding
  • Menorrhagia? Dysmenorrhea?
  • OCP (oral Contraceptive pills)? Hormone pills?


  • Includes any family member with similar conditions; parents health,
  • If diseased then cause of and age at death
  • Health of siblings
  • Any children and their health

Example : Hypertension , hyperlipidemia, TB, DM ,Ca à Draw family tree à inherited disease / Ca


Living conditions of the patient, for example: whether living alone or not, independent or has special helper to manage care at home, income etc.

Habits that are proven risk factors for certain disease.

a. Smoking
A pack-year is smoking 20 cigarettes a day for one year.
If someone has smoked ten cigarettes a day for six years they would have a three pack-year history. Someone who has smoked forty cigarettes daily for twenty years has a forty pack-year history.

Number of Pack Years = (Packs smoked per day) x (years as a smoker)


Number of pack years = (number of cigarettes smoked per day x number of years smoked)/20 (1 pack has 20 cigarettes).

Eg:: a patient who has smoked 15 cigarettes a day for 40 years has a (15×40)/20 = 30 pack year smoking history.

b. Alcohol intake specifying ‘present or previous intake’, ‘daily intake’, ‘intake over years’.

Alcoholism screening test TWEAK
Have u increased Tolerance of alcohol? 2pts
Have close friends or relatives Worried or complained about your drinking in the past year? 2pts
Do you sometimes take a drink in the morning when you first get up? (Eye opener) 1pt
Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? (Amnesia) 1pt
Do you sometimes feel the need to c(K)ut down on your drinking? 1pt

> 3 points = alcoholism

c. If appropriate also ask about illicit drug use, sexual history, occupation and pets.

recent travel (chest pain might be the hidden pulmonary embolism due to deep venous thrombosis developed during long flights).

10. Allergy Hx

  • Ask for any allergies that the patient might have.
  • Drugs (penicilin), food (seafood, shellfish), environment (pollen, fur)
  • Traditional medicine ( can promote renal and liver failure)

11. Provisional Diagnosis or Impression

= (most likely diagnosis)

Most likely diagnoses In patients with multiple pathology make a problem list so the key issues are seen immediately

12. DD (Differential Diagnosis)

  • at least 2-3 similar diseases
  • to rule out

eg: Myocardial infarction ? To rule out PE /pericarditis

13. Plan

  • List the investigations required.
  • When a result is already available, for example of an ECG, record it.
  • If uncertain about an investigation or treatment, precede with a “?” and discuss with a more senior member of staff

E.g. 1) Fluids – 1 pint D5% over 24h
2) Investigation: FBC/ RP/ LFT/ CXR/ECG
3) Medication: IV Ranitidine 50Mg
4) Other – refer Palliative – VS monitor every 4 hours – I/O chart – To D/W Mr. Ng for further man

14. Management

Record any immediate management instigated

Clerked By:

Presenting Summary:

  • 56/Malay/Male
  • K/C/O
  • Presented with the CC of
  • Relevant HOPI
  • @ this stage my provisional diagnosis is
  • With the differential diagnosis of

Example: 56 years old Malay gentlemen, refered from ED, with known case of DM for 20 years currently on Metformin 500mg bd, HPT for 10 years, patient is not sure of the name of the medication for HPT. Currently patient is on follow up at KK Taman Ehsan for HPT.

Patient complaints of acute central pain which radiate to the left arm and neck, associated with dyspnea and palpitation, pain last more than 1 hour and intensity is 8/10 according to the patient. GTN doesn’t help.

Patient smokes 10 packs per year. Patient’s father passed away on 2003 due to AMI. Patient has past medical history of MI for 2 times, which is on 2005 and 2007.

At this stage my provisional diagnosis is Acute Myocardium Infraction with ddx of Pulmonary Embolism and Pericarditis.


On admission

 Physical appearance e.g. alert, drowsy, unconscious

 Skin color: pink, cyanosis, pallor, jaundice

  • Ankle edema
  • Clubbing
  • Bp
  • Pulse
  • Temp
  • RR

16. Systemic Review:

 CVS: Peripheral Pulse: Good volume, regular rhythm

Heart: DRNM

  • Respi: Lungs: Clear, A/E equal
  • Abdomen/GU System: P/A:
  • CNS: Cranial Nerves

Peripheral Nerves

  • PR: Inspection/ palpable mass/ color of stool

If it is revision of patient:

  • I/O: 1500cc/1520cc
  • -20cc
  • RT / tapping : Volume/ color- 70cc (Greenish)
  • Urine Output: 50-75cc/ hr


Posted: July 15, 2010 by gerardloh in Uncategorized

Just posted the topics for Ob Gyn! More to follow. Enjoy your elective posting and don’t forget your HOW handbooks!


Posted: July 15, 2010 by gerardloh in O & G


A metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbance of carbohydrate, fat and protein metabolism resulting from defects of insulin secretion, action or both


*Gestational diabetes mellitus is any degree of glucose intolerance during pregnancy

raised blood glucose level >7.8 mmol/L or not >11.1 mmol/L 2 hours post-prandial OGTT


  1. Gestational diabetes previous pregnancy
  2. Obesity (BMI >30)
  3. Age > 35
  4. Presence of glycosuria in >2 occasions
  5. History of DM in first degree relatives
  6. Previous big baby > 4.0 kg
  7. Previous history of recurrent abortion or unexplained stillbirth
  8. Previous congenital anomalies
  9. Polyhydramnios

Complication in GDM


  • Nephropathy
  • Retinopathy
  • Coronary artery diseases
  • Hyperglycemia / hypoglycemia /ketoacidosis
  • Pre-eclampsia
  • Infection
  • TE


  • Congenital abnormalities:  cardia and neural tube defect
  • Macrosomia
  • RDS
  • Hypoglycemia
  • Polycythemia
  • Hyperbilirubinemia

Management of diabetes in pregnancy !!!

v      Prepregnancy counselling.

v      Combined diabetic-antenatal clinic.

v      Dietary advice.

v      Routine antenatal care.

v      Ultrasound            : early for dating

v                                                      : detailed TRO fetal                                                                                              abnormality

v      Insulin therapy.

v      Monitoring.


After 12-14 weeks gestations as soon as the risk factors are identified.

In women whose GTT is normal but have significant risk factors, a repeat test must be perform at 24-28 weeks gestation and again at 32-34 weeks gestation.


  1. Fasting from 12am till the next morning
  2. Take blood.
  3. Give patient to drink 75g glucose+ 250ml water ,drink in 10-15min.
  4. After 2 hrs,take blood again.


Normal (mmol/L Impaired glucose tolerance (mmol/L) Diabetes (mmol/L)
Fasting < 6.0 6.0 – 7.9 > 8.0
Or And And/or
2 hours < 8.0 8.0 – 10.9 > 11.0

Antenatal care

Aim: to maintain blood glucose level

at 4-6mmol/L

Glucose control

¡         Dietary Control (D/C)- by dietitian

(Requirement: 30 – 35 kcal/kg per day for non-obese and 25kcal/kg per day for obese patient)

OHA is not recommended due to:

v      possible teratogenic effect

v      difficult to establish tight control

  • Insulin Therapy
    1. FBS > 5.8mmol/L
    2. 2 hour post-prandial >7 mmol/L
    3. failed D/C (start insulin after 2 weeks on diet control(IV) )
    4. fetal macrosomia (AC > 95th centile) between 29 – 33 week gestation despite good glycaemic control

¡         require 3 or 4 daily doses of insulin.

¡         2 forms of insulin used in combination:

short acting : actrapid, humulin R

given before meals

Long acting : Monotard, humulin L

given before bed

*educate the pt about correct way of insulin injection.

¡         fetal supervision with ultrasound for growth and well being – usually every trimester.

Assessment for GDM patient


  • BSP
    • HbA1c
    • Renal profile (pre-existing)
    • Home monitoring
    • Early detection of complication.


-          Ultrasound

-          Biophysical profile

-          CTG

-          Fetal kick chart

Blood Sugar Profile

¡         BSP- Blood Sugar Profile

¡         Do before starting and also  to monitor insulin therapy

¡         4 times

-          pre-breakfast

-          pre-lunch

-          Pre-dinner

-          Pre-bed time

Normal range- 4-6 mmol/L

Monitoring of glycaemic control

BSP (blood sugar profile)

If on Insulin therapy: BSP every 2 weeks

If on D/C: BSP every 4 weeks

    • fasting < 5.5 mmol
    • pre-meals level of 4-6mmol/L
    • 2-hour postprandial capillary level < 7.0 mmol/L


    • 3 month control
    • level < 7%

Timing for delivery

¡         If on insulin- terminate by 38th week

¡         If on D/C – can prolonged till 40th weeks


Mode of Delivery

¡         Aim for SVD !!

¡         C-Section if:

▪           Macrosomia

▪          Suspicion of cephalo-pelvic disproportion

▪          A previous caesarean section

▪          Malpresentation

▪          Polyhydramnion

▪          Evidence of fetal compromise

▪          Bad obstetric history

▪          Poor diabetic control

Management in labour

¡         Mother admited to LR  NBM

¡         Omit morning dose of insulin injection.

¡         GSH, 2 units

¡         Hrly glucometer monitoring

¡         4 hrly BUSE, RBS

¡         pain relief – epidural is ideal

¡         monitor fetal heart closely, CTG

¡         Capillary blood sugar on admission and follow sliding scale:

Sliding scale regime

< 4 mmol/L To inform registrar start (IV bolus 10ml dextrose 50% if <2mmol/L)
4-6.9mmol/L Omit insulin
7-9.9mmol/L 1 unit/hour
10-12mmol/L 2 unit/hour
>12mmol/L Inform registrar (change to Hartmann with 3 unit/hour & ½ hourly dextrostix monitoring untill 11 mmol/L is achieved, then change back to standard regime).

Preparation of glucose-insulin-kalium regime. (GIK)

- A constant infusion of 500ml of 5% dextrose water 100ml/hour

  1. Baseline BUSE should be traced within ½ hour admission to labour room. K+ level should be checked prior to commencing KCl infusion.
  2. KCl is added into dextrose sol(13mmol,1 ampule of KCl
  3. Separate infusion insulin such as 50 units actrapid in 49.5ml normal saline is maintain
  4. Important to ensure infusion is separated from syntocinon infusion. Do not override with syntocinon infusion.


¡         If GDM, off all insulin and repeat MOGTT at 6 weeks following delivery

¡         If known diabetic, on insulin or oral hypoglycemic, start back their pre-pregnancy dose the next day when taking normal diet


Posted: July 15, 2010 by gerardloh in O & G



  • BP of 140/90 mmHg or more taken on 2 occasion at least 4 hour apart; OR
  • An increase in systolic BP of 30 mmHg or/and diastolic BP of 15 mmHg compared to pre-pregnancy level
  • Single reader of Diastolic BP more than 110mmHG.


  • Is hypertension after 20th week of gestation in a previously normotensive woman
  • x proteinuria
  • Condition return to norm within 6 weeks after labour



  • Presence of hypertension of at least 140/90 mmHg before 20th week of pregnancy or beyond 6 weeks postpartum.
  • Includes essential & secondary hypertension.


  • Development of pre-eclampsia in patient with pre-existing hypertension
  • Criteria used should include:

–        worsening of hypertension

–        proteinuria



1. Identify risk factor and observe BP:

  • -primigravida
  • -40yo
  • -chronic hypertension
  • -chronic renal disease
  • -multiple pregnancy
  • -past history or family history of pre eclampsia or eclampsia
  • -excessive weight gain

2. Physical examination,urinanlysis,BP

3. Confirm Diagnosis:

Mild PIH Outpatient

Severe PIH,PE Admission

Outpatient management:

  • Antenatal clinic visit:

– every 4 weeks        if x on treatment,norm biophysical profile,good fetal growth

– every 2 weeks       if on treatment

  • Tests:

– urinalysis (protein)

– BP

– SFH and liquor vol.

– BUSE,FBC,Serum uric acid

  • Fetal surveillance: US monthly,FKC


  • BP every 4 hrs
  • SFH and liquor vol.
  • Daily PE chart,urine protein
  • FBC,BUSE,serum uric acid
  • LFT,Coagulation profile(if suspected HELLP)
  • I/O chart
  • Fetal surveillance: – FKC,CTG,US

v     Antihypertensive agents only used if DBP>100mmHg.(aim: maintain 90-100mmHg)

v     Dexamethasone if early delivery expected (<34weeks)

Intrapartum management:

  • BP/ pulse rate half hourly
  • To continue oral antihypertensive treatment
  • Strict I/O chart
  • Adequate analgesia(preferable epidural analgesia)
  • CTG monitoring
  • Shortened 2nd stage- assisted delivery,episiotomy
  • X syntometrime/ergometrine!
  • Use Syntocinon 10 units

Postpartum management

  • Beware of Sx of IE and pulmonary oedema
  • BP monitoring

–        1/2hourly monitoring for at least 2 – 4hours before sending to postnatal ward

–        4 hourly monitoring in the ward for 24 – 48hours before discharge

  • Antihypertensive should be continued and stopped later on postnatal review. (methydopa discontinueà can cz postpartum depression)
  • I/O chart
  • Daily urine albumin,PE chart

Criteria for discharge:

  • Asymptomatic
  • BP< 140/90mmHg
  • Reflexes not brisk
  • Urine albumin- nil
  • Mono-antihypertensive therapy

v     Review patient in 2 weeks and 6 weeks


AIM: to keep diastolic BP  between  90-100mmHg!


  • Pregnancy induced hypertension with generalized tonic clonic fits
  • Aim of management:

–        Control convulsion

–        Control blood pressure

–        Stabilize patient

-           Delivery


  • 4 subsections:

1) Resuscitation and general management

2) Anticonvulsive therapy

3) Antihypertensive therapy

4) Delivery

(A) Resuscitation and General

1. Left lateral position,2 IV lines

2. Maintain airway,O2 mask

3. Abort fit by- MgSO4 loading dose= 4g IV bolus over 10-15 min

= 5g IM each buttock(10g)

* (1 amp:5ml – 2.5g MgSO4)

* 8ml- 4g (dilute in 12ml Nacl waterà 20ml)


Diazepam IV 10mg bolus (1-2min)

4. After fit aborted- GXM,Coagualtion profile,renal profile,platlet count.

5. Asses level of consciousness & neurological status

6. Closely monitor V/S- BP,PR,SPO2,RR,I/O chart

(B) Anticonvulsive therapy

  1. MgSO4 à Maintainance dose:

*IV infusion of 1g/hour

* 5ml MgSO4 + 45ml 5%Dextrose sol.

à Infuse at 20ml/hour( syringe pump)


* 10ml MgSO4 in 500ml D5% at 33 dpm (drips)

ü       Duration: – continue for 24hours after last fit or after delivery

ü      Monitoring for MgSO4 therapy:


  • Serum Ca2+,Mg
  • Renal function test (urea,uric acid,creatinine)
  • Coagulation profile
  • ECG
  • GXM

2. STOP !!! If present signs of Mg toxicity:

à(a) RR < 16/min

(b) Urine output < 25ml/hr

(c) patellar reflex absent

(d) Serum Mg > 3.5mmol/L (therapeutic range: 1.7-3.5)

(e) BP < 90/60 mmHg

3. Antidote: Ca gluconate 10%-10ml

(C) Antihypertensive therapy

  • initiatiate parenterally if BP> 160/110mmHg

(D) Delivery:

v     Definite treatment

v      within 6hrs after mother is stabilised

à if cervix favourable,cephalic: assisted SVD

à if cervix not favaurable: LSCS

v     Pediatrician informed n present at delivery

v      Syntocinon!!!

Postpartum Hemorrhage

Posted: July 15, 2010 by gerardloh in O & G
Estimation of blood lost:

  • Tampon: 80 ml
  • Sarong: 500 ml
  • Abdominal pack: 250 ml
  • Gauze: 30 – 50 ml
  • Pad: 100 ml
  • Linen: 300 – 5—ml
  • Kidney dish: (portex) 700 ml

( plastic) 300 ml – small

500 ml – big

  • Gully pot – 100 ml

Postpartum Hemorrhage

Postpartum Hemorrhage – >500ml blood lost

Early ( 1°) PPH  – in 1st 24 hours

Late ( 2°) PPH – up to 6 m.o

Risk factor:



Patients on coagulation therapy

Multiple gestation

Multiple parity

Obese patients

Patients with anemia


1° PPH – uterine atony (90%), genital tract trauma, coagulopathy, uterine rupture, uterine inversion

2° PPH – retained product of conception, uterine infection

Clinical signs of PPH

  • External hemarhage – visible vaginal bleeding  + anemic syndrome, severe → HYPOVOLEMIC SHOCK!!
  • Internal hemorrhage – x visible bllod lost, but present signs and symptoms of anemia
Genital tract trauma

Perineum tear

1° – perineal skin and mucosa

2° – 1° + muscles

3° – 2° + external anal sphincter

4° – 3° + rectal wall

Paravaginal hematoma

Supralevator – spreads upwards and outwards beneath the broad ligament or partly downwards to bulge into the walls of the upper vagina. Not visible externally, only can be detected by digital examination and laparotomy.

Infralevator – includes those of vulva and perineum, as well as those occurring in ischiorectal fossa. Massive swelling and ecchymosis of the labia, perineum and lower vagina on the affected side, and may extend to the buttock. Anorectal tenesmus may result from extension into ischiorectal fossa, and urinary retention may succeed spread ventrally into the paravesical fossa.


Determine the cause and treat it!!

  1. FBC + cross matching of blood group
  2. Massage the uterus
  3. Set 2 lines (large gauge – 14 – 16 Fr) on both wrist
  4. Ergometrine
  5. Empty bladder
  6. Check for trauma of the genital tract

According to cause:

  • Genital tract trauma
  1. Cervical tear – stitch from apex
  2. Vaginal tear – s/f tear: stitch  from the apex

Deep tear – EUA, packed –remove after 24 hours and stitching is done

  1. Paravaginal hematoma –

supralevator: laparotomy, CT, TAH (total abdominal hysterectomy)

infralevator: if <5cm and is not expanding → ice packed, vaginal packing and analgesics,

If >5cm and is expanding → xplore and evacuate hematoma, ligate vessels,

drain, packed and CBD for 24hours.

  • Coagulopathy – correction by transfusion with O- blood, FFP,  and anticoagulant therapy should be reversed: aspirin with platlets, LMW heparin with protamine and warfarin with vit K or FFP. In DIC – 6 cryopercipitate + 4 FFP + 2 platlet
  • Uterine rupture – incomplete type: repair;  complete type: TAH
  • Uterine inversion – immediately replace the uterus through the cervix by manual compression using as much of the hand as possible and maintain uterine contraction with an oxytocin.
  • Retained product of conception – early: manual extraction of the placenta under anaesthesia; late – blunt curettage
  • Uterine infection – antibiotics, uterotonics and antipyretics.

List of drugs available for hamostasis in PPH

  1. Syntometrine (i/m) : oxytocin 5 units + ergometrine 0.5 mg (long acting)

c/i: HPT and cardiopathy

  1. Syntocinon (i/v) : oxytocin 10 units (short acting)

40 units in 1 pint over 4 hours, 125 ml/hr

  1. Hemabate (i/m) : PGF2α

If 3 times syntometrine (fail) → give hemabate up to max 8 times, every 15 min (fail) → tamponade or balckmore tube/rusch catheter (fail) → hysterectomy


Active 3rd stage management to prevent PPH

  1. Indentify risk factors.
  2. Early cord clamping.
  3. Control cord traction.
  4. Administration of syntometrine (i/m)
  5. i/v syntocinon.
  6. Massage uterus.
  7. Set 2 lines (large bore).


Posted: July 15, 2010 by gerardloh in O & G



n      Bleeding from the genital tract in pregnancy before the onset of labour at gestations of 22 weeks or beyond


n      Placenta causes: Placenta Praevia, Placenta Abruption, Vasa Praevia

n      Local causes: cervical polyps, cervicitis, vaginitis, cervical cancer

Placenta Praevia

n      Definition :- Placenta that is implanted partly or entirely in the lower uterine segment.


n      Type I : Low placental implantation but the lower edge does not reach the internal cervical os.

n      Type II : The lower placental edge reaches the internal cervical os but does not cover it.

n      Type III : The placenta completely covers the internal os     when the cervix is closed, but only partially covers when the cervix is dilated.

n      Type IV : The placenta covers the internal os when the cervix is either closed or dilated.

Grades:Minor I –II a-anterior

Major IIb-posterior, III, IV

Risk Factors

Previous placenta praevia,caesarean section or abortion.

Previous pregnancies, esp. a large number of closely spaced pregnancies, are at higher risk.

Women younger than 20 & women older than 30 are at increasing risk as they get older.

Women with a large placentae from twins or erythroblastosis

Smoking or cocaine usage

Placenta accreta (adhere), increta (invade), percreta( penetrate through myometrium)

Assisted conception

Uterine structure abnormality

Placenta Abruption

Definition :- Premature separation of normally situated placenta from its uterine attachment prior to 3rd stage of labor.

Risk Factors

q     Pre-eclampsia

q     Abdominal trauma

q     Abruptio in previous pregnancy (10 fold increased risk)

q     Multiparity

q     multiple gestation (over distention of uterus)

q     Cord traction

q     Smoking

q     Sudden decompression of the uterus

q     Maternal Substance Abuse (Cocaine, alcohol)

q     Maternal Tobacco abuse (2 fold increased risk)

q     Polyhydramnios

Differences between placenta praevia and placenta abruptio

placenta praevia placenta abruptio
Pain painless painful
Uterus Soft, non tender Tense, tender, irritable,

hard ly palpate fetal parts

Fetal position Not engagement, malpresentation Normal, head maybe engaged
Fetal heart Usually normal Absent or abnormal
A/w pre-eclampsia N0 Yes
Haemodynamic signs Proportional Signs of hypovolaemic shock with increase pulse rate, hypotension, and peripheral vasoconstriction.

To access the patient-History and General Examination


n      Severity of the bleeding

n      Time of onset

n      Any provoking factors

n      Associated with pain/uterine activity

n      H(x) of ruptured membranes

n      Previous episodes

n      Fetal movement

n      Cervical smear h(x)

n      Review of previous ultrasound report

2.Resuscitation Measures

n      2 IV access

n      Crystalloid / Colloid

n      CBD

n      IO chart

n      GXM

Parameter Explanation & reason
1 Quick but thorough history
2 Vital signs Estimate blood loss (BP,Pulse)
3 Palpate abdomen uterine size, activity, tenderness, presenting, part, lie
4 Ultrasonograpy -fetus viability

-fetus abnormality

-location of placenta

-adequacy of the liquor

-growth parameters

5 CTG and fetal heart monitoring Determines fetal well-being.
6 No Vaginal examination ONLY After exclude placenta Praevia first by US !!!


  • FBC- Check haemoglobin level to rule out anaemia and maintain haemoglobin level above 10g/dL
  • Coagulation Profile :APTT,Serum fibrinogen,PT

Check for any bleeding tendency in this patient due impaired coagulation.

  • BUSE

Conservative Management

Admit ( according to RCOG is 28weeks)

Monitor BP & Pulse rate

Pad chart

Minimise abdominal examination

Appropriate investigations are done – FBC & GXM/GSH ( 2units)

Monitor fetal well being

- Fetal kick chart(daily)

- CTG (weekly)

- U/S ( forthnightly)

Steroid injection(> 24w, <36w)- IM dexamethasone12mg stat and repeat the second dose after 12 hours.

Any symptoms or signs of labour

  • * Placenta Praevia – must deliver by 38 weeks. If baby is dead, do not perform Caesarean section, instead induce & augment labour
  • Placenta abruptio- must deliver  as soon as possible (within 2 hour)

In severe AP or when got DIVC, transfuse DIVC regime

DIVC regime:       4 units FFP

6 units cryoprecipitate

2 units platelet concentrate

Management (PA)

1.Resuscitation Measures

Complications on the Mother

q     hypovolaemic shock

q     disseminated intravascular coagulation(DIC)

q     Acute renal failure

q     Postpartum hemorrhage

- Couvelaire uterus

-Bleeding into myometrium results in hypotonic wall

-Risk of Postpartum Hemorrhage

q     Feto-maternal hemorrhage

q     Maternal mortality

q     Recurrence risk higher

q     Amniotic fluid embolism

Complications on the Fetus

q     Perinatal mortality-influenced by size of abruption, interval to delivery, gestational age at which the abruption and delivery have occurred, others factors (growth retardation related to poor placentation)

q     Intrauterine growth restriction

q     Preterm birth

q     Low birth weight

Vasa praevia

-In a normal gestational sac, the umbilical cord is inserted into the middle of the placenta and entirely enclosed in the amniotic sac.

-Velamentous insertion means that the cord is inserted on the amniotic membrane rather than on the placenta with blood vessels stretching along the membrane between the insertion point and the placenta.

  • occur when the fetal vessels run in the membranes below the presenting fetal part, unsupported by placental tissue or umbilical cord at the cervical opening
  • Spontaneous or artificial rupture of membranes often leads rupture of these vessels with likely resultant fetal exsanguination (reported fetal mortality 33-100%).
  • -Must be suspected when APH occurs in a woman especially if,bleed is a bright red trickle .
    -fetal heart shows sudden tachycardia or sudden deceleration (even persistent bradycardia!) and the fetal distress appears disproportionate to the relatively ‘little’ bleed
    -occurs just after ARM
  • Antenatal diagnosis can be made using transvaginal sonography in combination with color Doppler.

Indeterminate APH-diagnosis by exclusion of PP, PA, lesion and trauma of genital tract.

Normal Labour

Posted: July 15, 2010 by gerardloh in O & G

Normal Labour


the process whereby there is a spontaneous onset of painful, regular contractions at term which followed by effacement and dilatation of cervix and descent of the presenting part which resulted in birth of a normal fetus and expulsion of the placenta

—        3 stages

1st : cervical dilation fr 0-10cm

> Latent phase (0-3cm)

> Active phase (3-10cm)

2nd : fr full dilation to delivery of fetus

3rd : fr delivery of fetus to delivery of


1st stage ( Latent phase)


—        Regular  painful contractions

—        Significant cervical effacement

—        Cervical dilation up to 3cm


PRIMI: 20 hrs(mean 8 hrs)

MULTIPARA: 14 hrs ( mean 6 hrs)


ü      Contractions – irregular and intensity varies

ü      Contractions may be painless

ü      If painful, intensity  same

ü      Painful contractions are relieved by sedation

ü      No progression in cervical effacement and dilatation

ü      No evidence of fetal compromise

ü      Patient should be reassured that she is not in labour and allowed discharge.


—        V/s (BP,PR,T) monitoring of the maternal condition 4Hourly

—        Fetal monitoring 4H ~ CTG or pinard

—        Abdomen examination, time contraction within 10min

—        R/v VE on strong and regular contractions

—        Consider pain relief as required by patient

Active phase


  1. R/V History and problem
  2. V/S monitoring
  3. Abd examination,time contraction (aim contraction for 3-4:10min)
  4. VE (on strong n regular contraction)
  5. ARM
  6. Start partogram
  7. CTG monitoring  2hr-ly  for  20min( if normal CTG+good contraction,consider IM Pethidine 75mg +IM Phenergen 25mg)
  8. Time for next R/V

<6cm at 1ST VE-next 4 hrs

>6cm next VE when full dilation is expected


  1. FBC
  2. UFEME
  3. GSH (for all in labour)

GXM (for high risk labour)


—        Catetherise patient

—        Check position of patient

—        Continuous monitoring of uterine contraction

—        Encourage pt to push with each contraction (chin to chest,look to abd,take deep breath n push)

—        When no contraction,ask pt to stop pushing. Monitor FHR

—        Sweep vulva gently

—        Perineal guarding n push head down

—        Usually episiotomy at ‘crowning’

—        Delivery of head

—        Check for any cord around neck⃰

—        Fetus head pull biparietally downward with mother’s effort

—        Delivery of ant. Shoulder and then post. shoulder

—        Delivery of whole baby.

—        Clamping and cutting of cord*

—        Wipe and suction of newborn

—        Cord blood- TSH,G6PD*

—        Syntometrine/syntocinon IM on maternal thigh

—        1st touch btw mother n child


—        Interval between period after delivery of fetus and complete delivery of placenta

—        Ask mother to relax and don’t try to push during this stage!!!


  1. Gushing of blood
  2. lengthening of cord
  3. elevation of fundus as the uterus contracts(globulation)

ACTIVE MANAGEMENT- Syntometrine/Syntocinon


—        give 1ml syntometrine IM (syntocinon + ergometrine) the patient’s thigh for healthy patient.

—        Patient with PIH & heart problem only can be given 10 units syntocinon IM


—        Left hand is placed suprapubically over uterus Press uterus backwards towards the mother.

—        Grasp cord  by clamp with right hand and apply gentle traction  (1st slightly downwards,then upwards)

—        When placenta is seen,deliver it with both hands in rotation movement

—        Clamp the coming membrane n remove slowly in rotation movement too.

—        massage of fundus of uterus

—        Remove blood clot by right hand (position of hand- VE position)

—        Use cotton to clean up the vaginal area

—        Check if present tears???

v      If after ½ hour (30 minutes) the placenta still not delivered, inform specialist. Usually will do MRP(manual removal of placenta)



—        Antibiotic cover (see Antibiotic guidelines)

—        Adequate analgesia, preferably under GA or regional anaesthesia, if patient is already on epidural, procedure can be carried out in the LR

—        Put patient in lithotomy position and apply perineal sheet (sterile)

—        The operator should be scrubbed and gowned with MRP gloves.

  1. 1. Introducing one hand into vagina along the cord
  2. 2. Grasping fundus with other hand,while detaching the placenta with sideways slicing movement of the fingers
  3. 3. Grasp placenta in the palm of hand
  4. 4. Examination of placenta for completeness

—        It is important to re-explore the uterine cavity to make sure no placental tissue is left behind.

—        Once the uterus is confirmed empty:

ü      intravenous infusion of  oxytocin 40units at 60-80mls/ hour.

ü      Uterine massage

ü      manual compression


1.Check the umbilical cord

—        2 arteries & 1 vein

—        Measure length of cord (normally 40-60cm) –use finger to estimate, end of middle finger till end of thumb à15cm

—        Colour of cord

—        Where the cord planted on placenta – center or lateral

—        Present of knot or not. If yes, distinguish either true or false knot

2. Check the placenta

  • Opening of membrane (normally 1)

If > than 1 – may be because of tear of  the membrane, may be some part of                                                     membrane left inside

  • Cotiledon   - colour

- lobes (norm:18-20 )

INFARCT -dead of tissues (caused by decrease O2

supplyàdecrease fx of placenta)

-common in post-date delivery

how to know?

-feel it by hand – sandy-like

-white spot on cotiledon

(use cotton to clean up the


—        Membrane layers

1) amnion layer (fetus’ side-inner)



-high in tensile  strength

2) chorion layer (mother’s side-outer)  -easy to break,shaggy

—        3. Measure blood loss volume

-include the blood clots

- < 500ml