Archive for the ‘O & G’ Category

NEW O & G guide

Posted: June 22, 2012 by gerardloh in O & G

The O & G HO guide is now available for download!

This compilation is just a quick reference, more coverage in HOW O & G guide part 1.

Special thanks to Dr Liew Nyan Chin for helping me with this book.

Hopefully this book will help you in your early days as an O&G Houseman. Do let me know if there are any mistakes or if you have any additional input to share.  I will then upload an updated 2nd version in the near future.

Good Luck! O&G was indeed a fun posting with lots of practical work. Enjoy!

 

 

Click on image to download book.

 

 

Examination of Gynae patients

Posted: November 5, 2011 by gerardloh in Clinical Examination Workshop, O & G

Contributors
Dr. Wan Nabilah
Dr. Fatima Azmi
Dr. Nur Marini

Examination of Obstetrics patients

Posted: November 5, 2011 by gerardloh in Clinical Examination Workshop, O & G

General Examination

Contributors
Dr. Afif Omar
Dr. Liyanna Ahmad Farid

Workshop 2009/10 Handouts

HOW was established in the summer of 2009, founded by Dr. Christopher Sheng and Dr. Ng Kean Seng.

Our objectives were clear, to collect and compile as much details and experiences possible on the Housemanship service in Malaysia. Clearly, a lot of us overseas graduates are not used to the local system and methods. Terms may differ and protocols vary.

Here, you may download the guides completed by doctors of the House Officers Workshop. Please note that these guides were done by medical students and serves as a guide only. Hopefully, these materials will assist you during your Housemanship service!

1. Obstetrics and Gynaecology

2. Medicine 

3. Paediatrics

4. Orthopaedics

5. Surgery

6. Guide Medicine Workshop

7. General List of Recommended Antibiotic

8. Medical abbreviations

Menstrual disorders

Amenorrhea

–          Divided into

a)      Primary

–  Absence of menstruation by 16 years old with present of secondary sexual characteristic or absence of menstruation by 14 years old without present of secondary sexual characteristic

b)      Secondary

–   > 6 months absence of menstruation with regular menses previously or > 12 months absence of menstruation without regular menses previously (oligomenorrhea)

–          Causes

Level Primary Secondary
CNS Functionala)      Anorexic 

b)      Excessive sport

c)       Malnourished

Tumors

Kallman’s syndrome

Prolactinoma

Aneurysm

Peter-Pan’s syndrome

HyperprolactinemiaSheehans syndrome 

* NORM

Pregnant

Menopause

Periphery Testicular feminization syndrome (androgen insenxitivity syndrome) 46, XYConstitutional delay 

Chronic systemic diseases (renal, heart, TB)

Thyroid, adrenal disorders

Chemo- or radio-therapy

Surgery

Thyroid dysfunction (hypothyroidism)Drugs 

a)      Post pill (COC)

b)      Progesterone

c)       Implants

Ovary POFa)      Idiopathic 

b)      Radiation

c)       Surgery

d)      Cytotoxicity

e)      Karyotype abnormal (45, XO)

PCOS

Gonadal dysgenesis

a)      Turner’s (45, XO)

b)      Swyers (46, XY or 46, XX)

POFPCOS 

Premature menopause

Mosaic-Turner (46, XX or 45, XO)

Uterus Meyer-Rokitansky-Kuster-Hauzes syndrome Ashermann’s syndrome
Outflow tract Imperforate hymenVaginal atresia 

Transverse vaginal septum

Cervical / vaginal agenesis

–          Diagnosis

a)      Primary

–  Secondary sexual characteristic ?

–   Sexual infantilism ?

–   US, anatomy ?

–   Virilism ? PCOS

b)      Secondary

–  Pregnancy test !

–   Breast feeding ?

–   Virilism ? PCOS + US

–   Hysteroscopy

–   Colposcopy

–   Progesterone challenge

–          Treatment

a)      FSH & LH

b)      Prolactin (norm till 20ug/L)

c)       TFT (prolactin increase, due to increase TRH)

d)      Serum testosterone (+ / -) : DHEAS

Pelvic pain

classification

– divided into 3 groups

1)      Cyclical – dysmenorrheal

2)      Associated with intercourse – dyspareuria – superficial

– Deep

3)      Chronic ( more than 6 months)

– divided into:

a) gynecological – endometriosis, Uterine fibroids, adenomyosis, Uterovaginal prolapsed, ovarian mass ( especially if twisted) chronic PID, maglinancy, pelvic congestion syndrome, residual ovary syndrome ( trapped ovary syndrome), ovarian remnant syndrome

b) non-gynecological:

– urological – UTI, cystitis, malignancy, etc.

– GIT – IBS, IBD, malignancy, chronic appendicitis, adhesions in abdomen / pelvis due to    infection, perforation and surgery.

– Muscularskeletal – trauma, prolapsed iv disc, osteoarthritis, spondylodisthesis

– Psychological –  physical / sexual / emotional abuse

Investigation

– Imaging importance! Ultrasound, CT, MRI, diagnostic laparascopy, hysteroscopy, saline infusion sonohysterography.( for intrauterine mass)

* by invasive procedure for diagnostic, may try medical therapy 1st

Eg. Suspect dysmenorrheal – COC, GnRH agonist.

IBS – antispasmodic, diet changes

* but if chronic pain – directly diagnostic laparascopy.

Dysmenorrhea

– lower abdomen / pelvic pain associated with menstruation. Onset may be prior, during or continue after cessation of menses.

– may be headache, nausea, vomiting, backache, diarrhea

a) Primary

– no obvious cause

– onset < 20% usually. Decreased with age.

– begins within a day of onset of flow, lasts 24-72hours, crampy

– Improves after childbirth.

b) secondary

– associated with pelvic pathology.

– onset > 20%. Increased with age.

– begins several days by menses, gradually increase in severity as menses approach.

– endometriosis, adenomyosis, polyps, fibroids, PID, IUD, obstructions, ovarian cysts, cancer.

– may be other symptoms associated with primary disease

history: past menstrual history

Investigation:

– ultrasound, MRI pelvis, diagnostic laparascopy( gold standard), diagnostic hysteroscopy, saline infusion sonohysterography.

– Final diagnostic: laparascopic uterine nerve ablation (LUNA)

Treatment

– Medical – paracetamol, NSAIDs, COX-2 inhibitor (mefenemic acid 0.5 TDS, naproxen 0.55 BD, ibuprofen 0.4 BD/TDS, diclofenac natrium 0.05 BD), buscopan 10mg TDS.

– COCs

– Depot MPA ( Depo Provera 3 mths)

– Laparoscopy

– presacral neurectomy, LUNA

– hysterectomy may be with BSO

ENDOMETRIOSIS

– presence of ectopic endometrial tissue outside the uterus.

History: chronic pelvic pain

Dysmenorrhea

Dyspareunia (due to rectovaginal / uterosacral involvement)

Intermenstrual bleeding may be premenstrual spotting

Infertility

Abdominal swelling(endometrioma)

If invasion GIT/ urology –present symptom of them

Common sites: ovaries, pelvic peritoneum, uterosacral ligaments, fallopian tubes, rectovaginal septum( can cause rectal/ vaginal bleeding cyclically), vagina(etc- urinary tract( ureter, bladder), GIT, abdomen, abdomen/ episotomy scar, abdominal organs, lungs.

Physical exam: pelvic mass & tenderness on bimanual & rectoveginal exam.

Lab test not helpful!

Gold standard – direct visualization via laparatomy/ laparascopy

US, MRI only useful in presence of mass. Ovary “ chocolate cyst”

Treatment

– NSAIDs

– induce pseudopregnancy/ pseudomenopause – progesterone

– surgery – destroy foci

Radical TAH +/ – BSO

* High recurrence rates

classification of endometriosis

Stage I (score 1-5) minimal

– isolated implants & no significant adhesions

Stage II (score 6 -15) mild

– shallow implants on the pelvic lining & 1 ovary; with filmy adhesion in the other ovary

Stage III (score 16-40) moderate

– deep implants on the pelvic lining & 1 ovary; dense adhesions in the other ovary

Stage IV ( score >40) severe

– deep implants on the ovaries, fallopian tube & pelvic lining

* stage – poor correlation with degree of symptom & fertility prognosis

GESTATIONAL DIABETES MELLITUS

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

DIABETES MELLITUS

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

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

raised blood glucose level >7.8 mmol/L  2 hours post-prandial OGTT

RISK FACTORS

  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

Maternal

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

Fetal

  • 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.

SCREENING FOR DIABETIC IN PREGNANCY…

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.

MOGTT PROCEDURE

  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.

DIAGNOSIS OF DM IN PREGNANCY

Normal (mmol/L Diabetes (mmol/L)
Fasting < 5.6 > 5.6
And/or
2 hours PP
< 7.8
> 7.8

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

Maternal-

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

Fetal

–          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

HbA1c

    • 3 month control
    • level < 7%

Timing for delivery

¡         If on insulin- terminate by 38th week

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

DO NOT EXCEED DUE DATE!!!

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

DEXTROSTIX INSULIN INFUSION
< 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.

Post-partum..

¡         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

HYPERTENSIVE DISEASE IN PREGNANCY

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


HYPERTENSIVE DISEASE IN PREGNANCY

Definition:

  • 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.

1) GESTATIONAL HYPERTENSION

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

2) PRE- ECLAMPSIA


3) CHRONIC HYPERTENSION

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

4) CHRONIC HYPERTENSION WITH SUPERIMPOSED PRE-ECLAMPSIA

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

–        worsening of hypertension

–        proteinuria

Management:

Antenatal:

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

Inpatient/Admission:

  • 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

ANTI-HYPERTENSIVE MEDICATION

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


ECLAMPSIA

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

–        Control convulsion

–        Control blood pressure

–        Stabilize patient

–           Delivery

Management

  • 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)

OR

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)

OR

* 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:

1.Investigations-

  • BUSE,FBC
  • Serum Ca2+,Mg
  • Renal function test (urea,uric acid,creatinine)
  • Coagulation profile
  • UFEME
  • 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!!!