-1.6kg total in 1st trimester
-0.45kg/week in 2nd trimester
-0.4kg/week in 3rd trimester
Saturday, 7 November 2015
Maternal weight gain
Cemak Asma: Maternal weight gain in pregnancy (normal bmi):
-1.6kg total in 1st trimester
-0.45kg/week in 2nd trimester
-0.4kg/week in 3rd trimester
-1.6kg total in 1st trimester
-0.45kg/week in 2nd trimester
-0.4kg/week in 3rd trimester
Friday, 6 November 2015
Cystoscopy
Maryam: Indication of cystoscopy:
1) Hematuria
2) Recurrent UTI
3) Sterile pyuria
4) Short history of irritative symptoms
5) Suspected bladder abnormality (eg. Diverticulum, stones, fistula)
6) Assesment of bladder neck
Dr Shaiful Ehsan: Cystoscopy examination in relation to PP: suspected infiltration into bladder, clinical haematuria or persistent microscopic haematuria with PP.....
1) Hematuria
2) Recurrent UTI
3) Sterile pyuria
4) Short history of irritative symptoms
5) Suspected bladder abnormality (eg. Diverticulum, stones, fistula)
6) Assesment of bladder neck
Dr Shaiful Ehsan: Cystoscopy examination in relation to PP: suspected infiltration into bladder, clinical haematuria or persistent microscopic haematuria with PP.....
Traube's space
5. Traube's space
Traube's space:
Traube's space is a space defined superiorly by the 6th rib, laterally by mid axillary line and inferiorly by the left costal margin.
Normally, this space is resonant to percussion. In the presence of pleural effusion and splenomegaly, it becomes dull.
With the patient lying supine, abduct the patient's left arm slightly, ask the patient to breathe normally and percuss across the space from its medial to lateral margins at a couple of levels. The note should remain resonant unless the spleen is enlarged.
Traube's space:
Traube's space is a space defined superiorly by the 6th rib, laterally by mid axillary line and inferiorly by the left costal margin.
Normally, this space is resonant to percussion. In the presence of pleural effusion and splenomegaly, it becomes dull.
With the patient lying supine, abduct the patient's left arm slightly, ask the patient to breathe normally and percuss across the space from its medial to lateral margins at a couple of levels. The note should remain resonant unless the spleen is enlarged.
Gullain Barre syndrome
4. Gullain Barre syndrome
Guillain-Barre (gee-YAH-buh-RAY) syndrome is a rare disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms.
These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form Guillain-Barre syndrome is a medical emergency. Most people with the condition must be hospitalized to receive treatment.
The exact cause of Guillain-Barre syndrome is unknown. But it is often preceded by an infectious illness such as a respiratory infection or the stomach flu.
There's no known cure for Guillain-Barre syndrome, but several treatments can ease symptoms and reduce the duration of the illness. Most people recover from Guillain-Barre syndrome, though some may experience lingering effects from it, such as weakness, numbness or fatigue.
Signs and symptoms of Guillain-Barre syndrome may include:
Prickling, "pins and needles" sensations in your fingers, toes, ankles or wrists
Weakness in your legs that spreads to your upper body
Unsteady walking or inability to walk or climb stairs
Difficulty with eye or facial movements, including speaking, chewing or swallowing
Severe pain that may feel achy or cramp-like and may be worse at night
Difficulty with bladder control or bowel function
Rapid heart rate
Low or high blood pressure
Difficulty breathing
People with Guillain-Barre syndrome usually experience their most significant weakness within two to four weeks after symptoms begin. Recovery usually begins two to four weeks after weakness plateaus.
The exact cause of Guillain-Barre syndrome isn't known. The disorder usually appears days or weeks after a respiratory or digestive tract infection. Rarely, recent surgery or immunization can trigger Guillain-Barre syndrome.
In Guillain-Barre syndrome, your immune system — which usually attacks only invading organisms — begins attacking the nerves. In AIDP, the most common form of Guillain-Barre syndrome in the U.S., the nerves' protective covering (myelin sheath) is damaged. The damage prevents nerves from transmitting signals to your brain, causing weakness, numbness or paralysis.
Guillain-Barre (gee-YAH-buh-RAY) syndrome is a rare disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms.
These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form Guillain-Barre syndrome is a medical emergency. Most people with the condition must be hospitalized to receive treatment.
The exact cause of Guillain-Barre syndrome is unknown. But it is often preceded by an infectious illness such as a respiratory infection or the stomach flu.
There's no known cure for Guillain-Barre syndrome, but several treatments can ease symptoms and reduce the duration of the illness. Most people recover from Guillain-Barre syndrome, though some may experience lingering effects from it, such as weakness, numbness or fatigue.
Signs and symptoms of Guillain-Barre syndrome may include:
Prickling, "pins and needles" sensations in your fingers, toes, ankles or wrists
Weakness in your legs that spreads to your upper body
Unsteady walking or inability to walk or climb stairs
Difficulty with eye or facial movements, including speaking, chewing or swallowing
Severe pain that may feel achy or cramp-like and may be worse at night
Difficulty with bladder control or bowel function
Rapid heart rate
Low or high blood pressure
Difficulty breathing
People with Guillain-Barre syndrome usually experience their most significant weakness within two to four weeks after symptoms begin. Recovery usually begins two to four weeks after weakness plateaus.
The exact cause of Guillain-Barre syndrome isn't known. The disorder usually appears days or weeks after a respiratory or digestive tract infection. Rarely, recent surgery or immunization can trigger Guillain-Barre syndrome.
In Guillain-Barre syndrome, your immune system — which usually attacks only invading organisms — begins attacking the nerves. In AIDP, the most common form of Guillain-Barre syndrome in the U.S., the nerves' protective covering (myelin sheath) is damaged. The damage prevents nerves from transmitting signals to your brain, causing weakness, numbness or paralysis.
Wernicke's encephalopathy
3. Wernicke's encephalopathy
The three components of the classic triad of WE are encephalopathy, ataxic gait, and some variant of oculomotor dysfunction. However, a complicating factor of WE identification is that its presentation may not be associated with the classical clinical triad in up to 90% of patients.
Consideration for WE should be given to patients with any evidence of long-term alcohol abuse or malnutrition and any of the following: acute confusion, ataxia, ophthalmoplegia, memory disturbance, hypothermia with hypotension, and delirium tremens.
A high proportion of patients with acute WE who survive develop WKS, characterized by potentially irreversible retrograde amnesia (inability to recall information) and anterograde amnesia (inability to assimilate new information), with varying degrees of other cognitive deficits.
Consider WE when any patient with long-term malnutrition presents with confusion or altered metal status. Significant overlap exists between WE and Korsakoff psychosis. For this reason, the two entities are often described together as WKS.
Alcohol abuse, AIDS, malignancy, hyperemesis gravidarum, prolonged total parenteral nutrition, iatrogenic glucose loading in any predisposed patient, and other disorders associated with grossly impaired nutritional status are associated with WKS.
Bariatric surgery (there are more than 100,000 weight-loss procedures performed annually in the United States) has been associated with both malnutrition and WE. Post–bariatric surgery patients have a limited capacity for food intake during the initial weeks after a bariatric procedure and a body's reserves of thiamine can be depleted after only 20 days of inadequate supply. Post–bariatric surgery patients may still be frankly obese when presenting with WE symptoms caused by thiamine deficiency.
Presentation
History
The three components of the classic triad of WE are encephalopathy, ataxic gait, and some variant of oculomotor dysfunction. However, a complicating factor of WE identification is that its presentation may not be associated with the classical clinical triad in up to 90% of patients.
Consideration for WE should be given to patients with any evidence of long-term alcohol abuse or malnutrition and any of the following: acute confusion, ataxia, ophthalmoplegia, memory disturbance, hypothermia with hypotension, and delirium tremens.
A high proportion of patients with acute WE who survive develop WKS, characterized by potentially irreversible retrograde amnesia (inability to recall information) and anterograde amnesia (inability to assimilate new information), with varying degrees of other cognitive deficits.[13]
Consider WE when any patient with long-term malnutrition presents with confusion or altered metal status. Significant overlap exists between WE and Korsakoff psychosis. For this reason, the two entities are often described together as WKS.
Alcohol abuse, AIDS, malignancy, hyperemesis gravidarum, prolonged total parenteral nutrition, iatrogenic glucose loading in any predisposed patient, and other disorders associated with grossly impaired nutritional status are associated with WKS.
Bariatric surgery (there are more than 100,000 weight-loss procedures performed annually in the United States) has been associated with both malnutrition and WE.[9] Post–bariatric surgery patients have a limited capacity for food intake during the initial weeks after a bariatric procedure and a body's reserves of thiamine can be depleted after only 20 days of inadequate supply. Post–bariatric surgery patients may still be frankly obese when presenting with WE symptoms caused by thiamine deficiency.[9]
Physical Examination
Ocular abnormalities are the hallmarks of WE. The oculomotor manifestations are: nystagmus, bilateral lateral rectus palsies, and conjugate gaze palsies reflecting cranial nerve involvement of the oculomotor, abducens, and vestibular nuclei. Less frequently noted manifestations are: pupillary abnormalities such as sluggishly reactive pupils, ptosis, scotomata, and anisocoria. The most common ocular abnormality is nystagmus, not abducens (Cranial Nerve VI) ophthalmoplegia.
Encephalopathy is characterized by a global confusional state, disinterest, inattentiveness, or agitation. The most common presenting symptoms of WE are mental status changes. Stupor and coma are rare.
Gait ataxia is often a presenting physical examination manifestation.[8] Ataxia is likely to be a combination of polyneuropathy, cerebellar damage, and vestibular paresis. Vestibular function, usually without hearing loss, is universally impaired in the acute manifestation of WE. In less severe cases, patients walk slowly with a broad-based gait. However, gait and stance may be so impaired as to make walking impossible. Cerebellar testing in bed with finger-to-nose and heel-to-shin tests may not illicit any notable deficit; thus, it is important to test for truncal ataxia with the patient sitting or standing.
In addition to ophthalmoplegia and ataxia, 80% of adults will have some degree of peripheral neuropathy, which may include weakness, foot drop, and decreased proprioception.
Thiamine deficiency has recently been associated with a gastrointestinal syndrome of nausea, vomiting, abdominal pain, and lactic acidosis.
Other symptoms that may occur in addition to, or in place of, the classic triad include hypothermia, hypotension, and coma. Thiamine deficiency often affects the temperature-regulating center in the brainstem, which can result in hypothermia.
Hypotension can be secondary to thiamine deficiency either through cardiovascular beriberi or thiamine deficiency–induced autonomic dysfunction. Coma is rarely the sole manifestation of WE.
Of patients surviving WE, an important percentage will manifest WKS, characterized by the following: retrograde amnesia (inability to recall information), anterograde amnesia (inability to assimilate new information), decreased spontaneity and initiative, and confabulation.
Other manifestations of thiamine deficiency involve the cardiovascular system (wet beriberi) and peripheral nervous system (nutritional polyneuropathy).
Manifestations of thiamine deficiency in infants are constipation, agitation, apathy, vomiting, lack of appetite, and later, diarrhea, grunting, nystagmus, convulsions, unconsciousness, and cardiomyopathy.
The three components of the classic triad of WE are encephalopathy, ataxic gait, and some variant of oculomotor dysfunction. However, a complicating factor of WE identification is that its presentation may not be associated with the classical clinical triad in up to 90% of patients.
Consideration for WE should be given to patients with any evidence of long-term alcohol abuse or malnutrition and any of the following: acute confusion, ataxia, ophthalmoplegia, memory disturbance, hypothermia with hypotension, and delirium tremens.
A high proportion of patients with acute WE who survive develop WKS, characterized by potentially irreversible retrograde amnesia (inability to recall information) and anterograde amnesia (inability to assimilate new information), with varying degrees of other cognitive deficits.
Consider WE when any patient with long-term malnutrition presents with confusion or altered metal status. Significant overlap exists between WE and Korsakoff psychosis. For this reason, the two entities are often described together as WKS.
Alcohol abuse, AIDS, malignancy, hyperemesis gravidarum, prolonged total parenteral nutrition, iatrogenic glucose loading in any predisposed patient, and other disorders associated with grossly impaired nutritional status are associated with WKS.
Bariatric surgery (there are more than 100,000 weight-loss procedures performed annually in the United States) has been associated with both malnutrition and WE. Post–bariatric surgery patients have a limited capacity for food intake during the initial weeks after a bariatric procedure and a body's reserves of thiamine can be depleted after only 20 days of inadequate supply. Post–bariatric surgery patients may still be frankly obese when presenting with WE symptoms caused by thiamine deficiency.
Presentation
History
The three components of the classic triad of WE are encephalopathy, ataxic gait, and some variant of oculomotor dysfunction. However, a complicating factor of WE identification is that its presentation may not be associated with the classical clinical triad in up to 90% of patients.
Consideration for WE should be given to patients with any evidence of long-term alcohol abuse or malnutrition and any of the following: acute confusion, ataxia, ophthalmoplegia, memory disturbance, hypothermia with hypotension, and delirium tremens.
A high proportion of patients with acute WE who survive develop WKS, characterized by potentially irreversible retrograde amnesia (inability to recall information) and anterograde amnesia (inability to assimilate new information), with varying degrees of other cognitive deficits.[13]
Consider WE when any patient with long-term malnutrition presents with confusion or altered metal status. Significant overlap exists between WE and Korsakoff psychosis. For this reason, the two entities are often described together as WKS.
Alcohol abuse, AIDS, malignancy, hyperemesis gravidarum, prolonged total parenteral nutrition, iatrogenic glucose loading in any predisposed patient, and other disorders associated with grossly impaired nutritional status are associated with WKS.
Bariatric surgery (there are more than 100,000 weight-loss procedures performed annually in the United States) has been associated with both malnutrition and WE.[9] Post–bariatric surgery patients have a limited capacity for food intake during the initial weeks after a bariatric procedure and a body's reserves of thiamine can be depleted after only 20 days of inadequate supply. Post–bariatric surgery patients may still be frankly obese when presenting with WE symptoms caused by thiamine deficiency.[9]
Physical Examination
Ocular abnormalities are the hallmarks of WE. The oculomotor manifestations are: nystagmus, bilateral lateral rectus palsies, and conjugate gaze palsies reflecting cranial nerve involvement of the oculomotor, abducens, and vestibular nuclei. Less frequently noted manifestations are: pupillary abnormalities such as sluggishly reactive pupils, ptosis, scotomata, and anisocoria. The most common ocular abnormality is nystagmus, not abducens (Cranial Nerve VI) ophthalmoplegia.
Encephalopathy is characterized by a global confusional state, disinterest, inattentiveness, or agitation. The most common presenting symptoms of WE are mental status changes. Stupor and coma are rare.
Gait ataxia is often a presenting physical examination manifestation.[8] Ataxia is likely to be a combination of polyneuropathy, cerebellar damage, and vestibular paresis. Vestibular function, usually without hearing loss, is universally impaired in the acute manifestation of WE. In less severe cases, patients walk slowly with a broad-based gait. However, gait and stance may be so impaired as to make walking impossible. Cerebellar testing in bed with finger-to-nose and heel-to-shin tests may not illicit any notable deficit; thus, it is important to test for truncal ataxia with the patient sitting or standing.
In addition to ophthalmoplegia and ataxia, 80% of adults will have some degree of peripheral neuropathy, which may include weakness, foot drop, and decreased proprioception.
Thiamine deficiency has recently been associated with a gastrointestinal syndrome of nausea, vomiting, abdominal pain, and lactic acidosis.
Other symptoms that may occur in addition to, or in place of, the classic triad include hypothermia, hypotension, and coma. Thiamine deficiency often affects the temperature-regulating center in the brainstem, which can result in hypothermia.
Hypotension can be secondary to thiamine deficiency either through cardiovascular beriberi or thiamine deficiency–induced autonomic dysfunction. Coma is rarely the sole manifestation of WE.
Of patients surviving WE, an important percentage will manifest WKS, characterized by the following: retrograde amnesia (inability to recall information), anterograde amnesia (inability to assimilate new information), decreased spontaneity and initiative, and confabulation.
Other manifestations of thiamine deficiency involve the cardiovascular system (wet beriberi) and peripheral nervous system (nutritional polyneuropathy).
Manifestations of thiamine deficiency in infants are constipation, agitation, apathy, vomiting, lack of appetite, and later, diarrhea, grunting, nystagmus, convulsions, unconsciousness, and cardiomyopathy.
Mc Afee Regime
Mc Afee Regime
Conservative management of placenta praevia
(MCafee's regime)
- it's usually done if the fetus is preterm, patient usually has to be warded at 32 week until 38 weeks/delivery.
- if bleeding is not severe/spotting, advice for bedrest along with strict pad chart monitoring.
- monitor vital sign.
- ultrasound monitoring for placenta localization is done every 2 weeks to look for placenta migration, possible prior to 34 weeks since the lower segment formation is in the process of completion.
- fetal monitoring by ctg and biophysical profiling to ensure fetal well being.
- ask the mother to keep daily fetal kick chart.
- 2 doses of dexamethasone, 12mg administered IM 12 hours apart to enhance lung maturity and prevent interventricular hemorrhage in preterm babies.
-availability of 2 unit gsh
availability of c-sec
Conservative management of placenta praevia
(MCafee's regime)
- it's usually done if the fetus is preterm, patient usually has to be warded at 32 week until 38 weeks/delivery.
- if bleeding is not severe/spotting, advice for bedrest along with strict pad chart monitoring.
- monitor vital sign.
- ultrasound monitoring for placenta localization is done every 2 weeks to look for placenta migration, possible prior to 34 weeks since the lower segment formation is in the process of completion.
- fetal monitoring by ctg and biophysical profiling to ensure fetal well being.
- ask the mother to keep daily fetal kick chart.
- 2 doses of dexamethasone, 12mg administered IM 12 hours apart to enhance lung maturity and prevent interventricular hemorrhage in preterm babies.
-availability of 2 unit gsh
availability of c-sec
Placenta previa
Athirah Fikri: Salam dr
What is the use of MRI in investigation of placenta previa patient?
Umair: Mri is the gold standard imaging for pp as saggital images best demostrate the relationship of placenta to cervical os.
Ni yg saya baca sendiri dr. Is it correct? Sbb takde sekali dgn group yg dr mention hari tu.
Umair: But in most situation it is not required since it can be detected by ultrasound
Dr Shaiful Ehsan: Dear my BELOVED juniors...
Remember events at 34 weeks?
I did mentioned about completion of lower segment?
Placental mapping should be done for those patient with histroy of I PREVIOUS scar plus current PP or anterior placenta on top of prev scar....
Modalities of placental mapping includes ultrasound...
MRI is indicated if ultrasound is inconclusive for accreta percreta but suspicions is high......
Placental mapping is done around 32 - 34 weeks...
⏳⏳⏳⏳⏳⏳⏳⏳⏳⏳⏳
Antenatal care for asymptomatic complete PP.
https://www.google.com/url?q=http://article.sciencepublishinggroup.com/pdf/10.11648.j.cmr.20130201.11.pdf&sa=U&ved=0CDAQFjAEahUKEwjoxYuIpf3IAhUUSY4KHZB0BRQ&sig2=8xeXYVDfxV7ZKsb-9GBRQA&usg=AFQjCNF7mbx82OgO09IeS3d67e1pE9nLZQ
What is the use of MRI in investigation of placenta previa patient?
Umair: Mri is the gold standard imaging for pp as saggital images best demostrate the relationship of placenta to cervical os.
Ni yg saya baca sendiri dr. Is it correct? Sbb takde sekali dgn group yg dr mention hari tu.
Umair: But in most situation it is not required since it can be detected by ultrasound
Dr Shaiful Ehsan: Dear my BELOVED juniors...
Remember events at 34 weeks?
I did mentioned about completion of lower segment?
Placental mapping should be done for those patient with histroy of I PREVIOUS scar plus current PP or anterior placenta on top of prev scar....
Modalities of placental mapping includes ultrasound...
MRI is indicated if ultrasound is inconclusive for accreta percreta but suspicions is high......
Placental mapping is done around 32 - 34 weeks...
⏳⏳⏳⏳⏳⏳⏳⏳⏳⏳⏳
https://www.google.com/url?q=http://article.sciencepublishinggroup.com/pdf/10.11648.j.cmr.20130201.11.pdf&sa=U&ved=0CDAQFjAEahUKEwjoxYuIpf3IAhUUSY4KHZB0BRQ&sig2=8xeXYVDfxV7ZKsb-9GBRQA&usg=AFQjCNF7mbx82OgO09IeS3d67e1pE9nLZQ
Pouch of douglas
Liza: Dr, I have questions. Is cul de sac same as pouch of Douglas ? And to examine the fluid in that space, we shoud do PR Or bimanual exam ?
Dr Shaiful Ehsan: POD = cul de sac.... Bimanual for adnexal mass....
To examine the fluid....
Clinical = shifting dulness = ascites....
PR also can detect bogginess = fullness at POD...
Dr Shaiful Ehsan: POD = cul de sac.... Bimanual for adnexal mass....
To examine the fluid....
Clinical = shifting dulness = ascites....
PR also can detect bogginess = fullness at POD...
Vaginal candidiasis
Abdullah Bee: Salam dr, if a non pregnant lady comes with a complain of vaginal pain assoc with whitish dischge n itchiness,,is it most likely to be v.candidiasis?
Im asking this because to know whether v.candidiasis is also common for non pregnen lady
Tq dr
Dr Shaiful Ehsan: Waalaikumsalam....
Its common for woman to have vaginal discharges....
But what becomes pathological if it changes in color, foul smelly, increasing in amount & worsening itchiness...
So if it is pathological....u have to think of vaginitis....
There are multiple aetiological of vaginitis....
Not only candidiasis...
Candidiasis are common in pregnant lady, diabetic, poor hygiene, immunocompromised....
Normal profile without risk factor not common to have vaginal candidiasis...
Typical history of vaginal candidiasis is thick whitish discharges associated with itchiness....
Im asking this because to know whether v.candidiasis is also common for non pregnen lady
Tq dr
Dr Shaiful Ehsan: Waalaikumsalam....
Its common for woman to have vaginal discharges....
But what becomes pathological if it changes in color, foul smelly, increasing in amount & worsening itchiness...
So if it is pathological....u have to think of vaginitis....
There are multiple aetiological of vaginitis....
Not only candidiasis...
Candidiasis are common in pregnant lady, diabetic, poor hygiene, immunocompromised....
Normal profile without risk factor not common to have vaginal candidiasis...
Typical history of vaginal candidiasis is thick whitish discharges associated with itchiness....
IUGR & SGA
Abd Halim: Dr, correct me if im wrong here.
As of lately i noticed many of many collegues can't grasp the topic of FGR.
This is my summary of it.
FGR is the prevention of the fetus to grow to its maximum potential.
It can come in 2 forms. Either IUGR (Intrauterine Growth Restriction) or SGA (Small for Gestational Age).
We can differentiate IUGR from SGA based on their pattern on the growth chart & the process behind them.
In growth chart (fetal weight is used as parameter), fetuses with IUGR will have stunted growth.
I.e: The graph plateaus off. It becomes stagnant after a period of growth.
SGAs still progressively grow, but the graph will be below the 3rd centile.
(Both IUGR & SGA graph will be below the 3rd centile. What differentiates them is the pattern)
All IUGRs are SGAs, but not all SGAs are IUGRs.
Dr Shaiful Ehsan: Dear Halim, some information are corrects....some are not... What is ur reference of SGA & IUGR below 3rd centile
Safira Fyra: From ten tcers, it said some FGR fetuses may not actually be SGA..but nevertheless will hv failed to fulfill their growth potential..So tak semua fgr is sga la kan dr?
Dr Shaiful Ehsan: Yupp....👍🏻👍🏻Anyone would like to give definition of IUGR and SGA?
Safira Fyra: FGR = failure of fetus to achieve its genetic growth potential
SGA = weight of the fetus <10th centile for its gestation
Dr Shaiful Ehsan: Yupp...almost correct...I need more specific answer for iugr...
Liza: Iugr : fetus growth < 10th percentile
Cemak Asma: Rasa mcm sga fetal growth <10th percentile.. Iugr fetal growth between 50th and 10th percentile.. Correct me if i'm wrong
Azyati: Correct me if i'm wrong dr.. Iugr is when growth chart crossing less than 3 centile with oligo. Sga is when EFW + parameter less than 10th centile for that gestational age
Kak Zaim: Dr had mentioned iugr in previous cp session.. Xingat sangat tp dr mcm ada sebut its crosses 2 centiles with or without oligo.. Huhu sorry dr kalau salah
Dr Shaiful Ehsan: Okeylah....nasib baik ada yg masih ingt.... Yupp
SGA is when the fetal parameters & efwt is less than 10th centile for the gestational age....
IUGR when the parameters on plot chart crossing 2 major centiles, usually with presence of oligohydramnios.....
Dr Shaiful Ehsan: HOMEWORK: definition of oligohydramnios....
****ni homework lama ni....xde org reveal answer yet....
Cemak Asma: Oligohydramnios: amniotic fluid index <5th centile for gestation on ultrasound estimation. Tp selalunya amik masa 3rd trimester because afi alters throughout gestation
Dr Shaiful Ehsan: Asma 👍👍👍
Dr Shaiful Ehsan: Oligohyramnios is afi less than 5th centile for respective gestational age....and deepest pole less than 3cm for twin pregnancy...
As of lately i noticed many of many collegues can't grasp the topic of FGR.
This is my summary of it.
FGR is the prevention of the fetus to grow to its maximum potential.
It can come in 2 forms. Either IUGR (Intrauterine Growth Restriction) or SGA (Small for Gestational Age).
We can differentiate IUGR from SGA based on their pattern on the growth chart & the process behind them.
In growth chart (fetal weight is used as parameter), fetuses with IUGR will have stunted growth.
I.e: The graph plateaus off. It becomes stagnant after a period of growth.
SGAs still progressively grow, but the graph will be below the 3rd centile.
(Both IUGR & SGA graph will be below the 3rd centile. What differentiates them is the pattern)
All IUGRs are SGAs, but not all SGAs are IUGRs.
Dr Shaiful Ehsan: Dear Halim, some information are corrects....some are not... What is ur reference of SGA & IUGR below 3rd centile
Safira Fyra: From ten tcers, it said some FGR fetuses may not actually be SGA..but nevertheless will hv failed to fulfill their growth potential..So tak semua fgr is sga la kan dr?
Dr Shaiful Ehsan: Yupp....👍🏻👍🏻Anyone would like to give definition of IUGR and SGA?
Safira Fyra: FGR = failure of fetus to achieve its genetic growth potential
SGA = weight of the fetus <10th centile for its gestation
Dr Shaiful Ehsan: Yupp...almost correct...I need more specific answer for iugr...
Liza: Iugr : fetus growth < 10th percentile
Cemak Asma: Rasa mcm sga fetal growth <10th percentile.. Iugr fetal growth between 50th and 10th percentile.. Correct me if i'm wrong
Azyati: Correct me if i'm wrong dr.. Iugr is when growth chart crossing less than 3 centile with oligo. Sga is when EFW + parameter less than 10th centile for that gestational age
Kak Zaim: Dr had mentioned iugr in previous cp session.. Xingat sangat tp dr mcm ada sebut its crosses 2 centiles with or without oligo.. Huhu sorry dr kalau salah
Dr Shaiful Ehsan: Okeylah....nasib baik ada yg masih ingt.... Yupp
SGA is when the fetal parameters & efwt is less than 10th centile for the gestational age....
IUGR when the parameters on plot chart crossing 2 major centiles, usually with presence of oligohydramnios.....
Dr Shaiful Ehsan: HOMEWORK: definition of oligohydramnios....
****ni homework lama ni....xde org reveal answer yet....
Cemak Asma: Oligohydramnios: amniotic fluid index <5th centile for gestation on ultrasound estimation. Tp selalunya amik masa 3rd trimester because afi alters throughout gestation
Dr Shaiful Ehsan: Asma 👍👍👍
Dr Shaiful Ehsan: Oligohyramnios is afi less than 5th centile for respective gestational age....and deepest pole less than 3cm for twin pregnancy...
Bilateral ovarian cyst - tahbso/ hysteroscopy & dd&c
Syamila: Assalamualaikum Dr.I clerk this pt.initially she was electively admitted for tahbso due to bilateral ovarian cyst.however, this morning dr decided to do hysteroscopy and dd&c instead of tahbso in order to rule out any endometrial pathology. so, my questions:
1)how i want to write my chief complaint? is it still EA for tahbso...or...??
2)why dr suddenly change the operation?
Abd Halim: Sbb dalam hx die latest pipelle sampling showed benign endometrial hyperplasia instead of initial findings which were more malignant in nature.
Dr Shaiful Ehsan: Waalaikumsalam syamila...
That is why in Chief complaint i will advice u guys not to mentioned specific procedure or diagnosis in exam.....becoz it will usually changed after our preop rounds on monday & wednesday afternoon with consultants...
U can write ur CC eg like this:
38 yr old, teacher, para 3, electively admitted for further MANAGEMENT of her underlying abdominal mass for the past 1 year associated with dysmenorrhea...
She was apparently well till...bla bla2..
Dr Shaiful Ehsan: Q2: why suddenly...
Becoz usually the plan for operation is made by 1 specialist while we see this case at gynae clinic...with or without consulting the consultant (usually Dr alik / Dato Rozihan)...
During this time, patient might agree for the above operation....
However, we usually benefit our pre-op rounds....in which we will explore further patient understanding and social background profile.....in which some operation need to be change to meet patient's need...
Dr Shaiful Ehsan: Eg, if this patient is postmenopause & alreday completed family....there is NO WRONG of doing tabhso...
However, if this patient is young, you need to explain to patient that with tabhso...she will get PREMATURE menopause....in which she need to take HRT for at least her age till 50....
And she should understand her risk to develop osteoporosis and Cardiovasvular event is higher compared to those without prem menopause....
Dr Shaiful Ehsan: These are among issues we will discuss back with patients at pre op rounds...in which I DO BELIEVE SHOULD BE DISCUSSED EARLIER....
Other reason possible if the workout so far is still not clear enough....i which the mass could not arising from ovary....but actually benign from uterus.....
In which JUMP into TABHSO is totally not appropriate but hysteroscopy and biopsy is more accurate and justifiable before further surgical options can be discussed...
Thank u very much...
Oh ya...other benefits of not mentioning diagnosis and procedure in chief complaint is that:
U can have diffirential doagnosis in discussion
U can have better provisional diagnosis talley with ur patient presentation
You can vomit out ur fantastic principle of management.....rather than being rigid....tq
1)how i want to write my chief complaint? is it still EA for tahbso...or...??
2)why dr suddenly change the operation?
Abd Halim: Sbb dalam hx die latest pipelle sampling showed benign endometrial hyperplasia instead of initial findings which were more malignant in nature.
Dr Shaiful Ehsan: Waalaikumsalam syamila...
That is why in Chief complaint i will advice u guys not to mentioned specific procedure or diagnosis in exam.....becoz it will usually changed after our preop rounds on monday & wednesday afternoon with consultants...
U can write ur CC eg like this:
38 yr old, teacher, para 3, electively admitted for further MANAGEMENT of her underlying abdominal mass for the past 1 year associated with dysmenorrhea...
She was apparently well till...bla bla2..
Dr Shaiful Ehsan: Q2: why suddenly...
Becoz usually the plan for operation is made by 1 specialist while we see this case at gynae clinic...with or without consulting the consultant (usually Dr alik / Dato Rozihan)...
During this time, patient might agree for the above operation....
However, we usually benefit our pre-op rounds....in which we will explore further patient understanding and social background profile.....in which some operation need to be change to meet patient's need...
Dr Shaiful Ehsan: Eg, if this patient is postmenopause & alreday completed family....there is NO WRONG of doing tabhso...
However, if this patient is young, you need to explain to patient that with tabhso...she will get PREMATURE menopause....in which she need to take HRT for at least her age till 50....
And she should understand her risk to develop osteoporosis and Cardiovasvular event is higher compared to those without prem menopause....
Dr Shaiful Ehsan: These are among issues we will discuss back with patients at pre op rounds...in which I DO BELIEVE SHOULD BE DISCUSSED EARLIER....
Other reason possible if the workout so far is still not clear enough....i which the mass could not arising from ovary....but actually benign from uterus.....
In which JUMP into TABHSO is totally not appropriate but hysteroscopy and biopsy is more accurate and justifiable before further surgical options can be discussed...
Thank u very much...
Oh ya...other benefits of not mentioning diagnosis and procedure in chief complaint is that:
U can have diffirential doagnosis in discussion
U can have better provisional diagnosis talley with ur patient presentation
You can vomit out ur fantastic principle of management.....rather than being rigid....tq
Ectopic pregnancy & miscarriage
Cemak Asma: Salam doctor.. Me n my frens have a few questions.
1. How many weeks of gestation can we diagnose a pregnancy as ectopic? Sbb ada setengah patient tu doc suruh tunggu dulu baru confirmkan.
Dr Shaiful Ehsan: Q1: Ectopic pregnancy can be diagnosed as early as clinical suspicion is high....either in early 1st trimester till 3rd trimester....
I did mention to some of u guys that while I in H Keningau we did encounter ectopic pregnancy in ovary not detected early and that time already around 30 - 32 weeks....
If clinical suspicion is high...TVS is good enough to see free fluids and adnexal mass in which u need to do laparosopic surgery to identify and manage...
There is no point of waiting as it will rupture and leads to sepsis & death...
Usually wait is for missed miscarriage for those opt for conservative management....
Or on TVS no suspicious findings were found in which patient most probably had wrong date!!!!
2. How can molar pregnancy lead to preecplampsia? Is it because of the hyperthyroid state?
Dr Shaiful Ehsan: Q2: Molar pregnancy is associated with excessive hormones released from placenta....including anti angiogenic proteins from its trophoblast...
Antiangiogeneses = inadequate blood vessel formation = culprit for PIH and PE...
3. Regarding inevitable miscarriage.. Some books classify complete and incomplete miscarriage under inevitable but some dont.. Yg classify inevitable as it own entity, dy kata on ultrasound we can still see fetal heart activity. But this is not present if complete n incomplete miscarriage.. So kami dah pening 😅 inevitable ni nak letak bawah mana? Huhu
Dr. Shaiful Ehsan:Q3: incomplete or complete miscarriage is an outcome.....
Of any miscarriage either inevitable or missed miscarriage that treat conservatively and passed out...
Complete miscarriage means ET is already thin...no REMAINING POC....
Incomplete there is still remaining POC...
Above statement that u shared is misleading...tq
Cemak Asma: So doctor if inevitable miscarriage, will it still be possible to see fetal heart activity? I dont quite understand this part
Dr Shaiful Ehsan: The golden difference between inevitanle and threatened miscarriage is cervical os opening...
Presence or absence FH is not part of criteria for inevitable miscarriage....
Nevertheless it is more common to have absence FH in inevitable miscarriage...
Yupp...u still can have FH in inevitable miscarriage
Btw...threathened miscarriage MUST HAVE FH...tq
Cemak Asma: Ohh okay doctor.. Thank you
⛄⛄⛄⛄⛄⛄⛄⛄
Adlina: Assalamualaikum Dr. How ruptured fallopian tube due to ectopic pregnancy can cause diarrhea?
Dr Shaiful Ehsan: Waailaikumsalam adlina, ruptured ectopic pregnancy will cause intraperitoneal harmorrhage....blood is irritants in which will induce inflammatory cascade upon contact with bowel or surface...
Eg making contact with diaphgram will cause shoulder tip pain
Making contact with bowel will induce inflammation of the bowel wall, increase peristaltic movement & reduced absorption....= diarrhea
1. How many weeks of gestation can we diagnose a pregnancy as ectopic? Sbb ada setengah patient tu doc suruh tunggu dulu baru confirmkan.
Dr Shaiful Ehsan: Q1: Ectopic pregnancy can be diagnosed as early as clinical suspicion is high....either in early 1st trimester till 3rd trimester....
I did mention to some of u guys that while I in H Keningau we did encounter ectopic pregnancy in ovary not detected early and that time already around 30 - 32 weeks....
If clinical suspicion is high...TVS is good enough to see free fluids and adnexal mass in which u need to do laparosopic surgery to identify and manage...
There is no point of waiting as it will rupture and leads to sepsis & death...
Usually wait is for missed miscarriage for those opt for conservative management....
Or on TVS no suspicious findings were found in which patient most probably had wrong date!!!!
2. How can molar pregnancy lead to preecplampsia? Is it because of the hyperthyroid state?
Dr Shaiful Ehsan: Q2: Molar pregnancy is associated with excessive hormones released from placenta....including anti angiogenic proteins from its trophoblast...
Antiangiogeneses = inadequate blood vessel formation = culprit for PIH and PE...
3. Regarding inevitable miscarriage.. Some books classify complete and incomplete miscarriage under inevitable but some dont.. Yg classify inevitable as it own entity, dy kata on ultrasound we can still see fetal heart activity. But this is not present if complete n incomplete miscarriage.. So kami dah pening 😅 inevitable ni nak letak bawah mana? Huhu
Dr. Shaiful Ehsan:Q3: incomplete or complete miscarriage is an outcome.....
Of any miscarriage either inevitable or missed miscarriage that treat conservatively and passed out...
Complete miscarriage means ET is already thin...no REMAINING POC....
Incomplete there is still remaining POC...
Above statement that u shared is misleading...tq
Cemak Asma: So doctor if inevitable miscarriage, will it still be possible to see fetal heart activity? I dont quite understand this part
Dr Shaiful Ehsan: The golden difference between inevitanle and threatened miscarriage is cervical os opening...
Presence or absence FH is not part of criteria for inevitable miscarriage....
Nevertheless it is more common to have absence FH in inevitable miscarriage...
Yupp...u still can have FH in inevitable miscarriage
Btw...threathened miscarriage MUST HAVE FH...tq
Cemak Asma: Ohh okay doctor.. Thank you
⛄⛄⛄⛄⛄⛄⛄⛄
Adlina: Assalamualaikum Dr. How ruptured fallopian tube due to ectopic pregnancy can cause diarrhea?
Dr Shaiful Ehsan: Waailaikumsalam adlina, ruptured ectopic pregnancy will cause intraperitoneal harmorrhage....blood is irritants in which will induce inflammatory cascade upon contact with bowel or surface...
Eg making contact with diaphgram will cause shoulder tip pain
Making contact with bowel will induce inflammation of the bowel wall, increase peristaltic movement & reduced absorption....= diarrhea
Pprom- cord prolapsed
Izzat Mubarak: Salam Dr Shaiful...
I have a question...why do you have to exclude cord prolapse in PROM?
Is the cord prolapse due to unstable lie?? Or just because it is a possible complication of PROM??
Umair: Kalau tak silap complication of prom. Due tu sudden decrease in pressure.
Cemak Asma: Bila liquor tu leak out, cord akan ikut turun sekali sbb dy ringan
Izzat Mubarak: Thank you umair and asma
Dr Shaiful Ehsan: Waalaikumsalam....becoz in prem...head is not engaged yet....
So there is possibility of cord presentation / footling presentation and so on....
I have a question...why do you have to exclude cord prolapse in PROM?
Is the cord prolapse due to unstable lie?? Or just because it is a possible complication of PROM??
Umair: Kalau tak silap complication of prom. Due tu sudden decrease in pressure.
Cemak Asma: Bila liquor tu leak out, cord akan ikut turun sekali sbb dy ringan
Izzat Mubarak: Thank you umair and asma
Dr Shaiful Ehsan: Waalaikumsalam....becoz in prem...head is not engaged yet....
So there is possibility of cord presentation / footling presentation and so on....
Antibiotic GBS
8)how many dose of antibiotics enough to cover for the baby if the mother is GBS positive?
The mother should have receive >/=4hours of IV penicillin, ampicillin or cefazolin prior to delivery
A) penicillin : 5 million units IV initially, then 2.5-3.0 million units IV every 4 hours until delivery
B) ampicillin : 2 grams IV initially, then 1 gram IV every four hours until delivery (with the exception of women with PPROM who may have received 2 grams IV initially and followed by 1 gram IV every 6h)
C) cefazolin : first dose of 2 grams IV followed by 1 gram IV every 8 hours until delivery
Dr Shaiful Ehsan: For GBS...ampicillin is the drug of choice...before u escalate to cephalosporin...
Adequate dose is considered when mother is covered at least 2 completed doses of ampicillin intrapartum before deliver the baby....
📖📖📖📖📖📖📖📖
[04/11 1:03 pm] Dr Shaiful Ehsan: http://www.mmgazette.com/which-antibiotics-should-i-use-dr-mohd-shaiful-ehsan/
[04/11 1:04 pm] Dr Shaiful Ehsan: Purposely written for my juniors....moga bermanfaat...
The mother should have receive >/=4hours of IV penicillin, ampicillin or cefazolin prior to delivery
A) penicillin : 5 million units IV initially, then 2.5-3.0 million units IV every 4 hours until delivery
B) ampicillin : 2 grams IV initially, then 1 gram IV every four hours until delivery (with the exception of women with PPROM who may have received 2 grams IV initially and followed by 1 gram IV every 6h)
C) cefazolin : first dose of 2 grams IV followed by 1 gram IV every 8 hours until delivery
Dr Shaiful Ehsan: For GBS...ampicillin is the drug of choice...before u escalate to cephalosporin...
Adequate dose is considered when mother is covered at least 2 completed doses of ampicillin intrapartum before deliver the baby....
📖📖📖📖📖📖📖📖
[04/11 1:03 pm] Dr Shaiful Ehsan: http://www.mmgazette.com/which-antibiotics-should-i-use-dr-mohd-shaiful-ehsan/
[04/11 1:04 pm] Dr Shaiful Ehsan: Purposely written for my juniors....moga bermanfaat...
indication of MgSo4
7) indication of MgSo4
-hypomagnesemia
-toxemia of pregnancy (prevent seizures assoc. with PE and control of seizures with eclampsia)
-Torsades de Pointes (a specific form of polymorphic VT in patients with long QT interval)
-Preterm labour
-hypomagnesemia
-toxemia of pregnancy (prevent seizures assoc. with PE and control of seizures with eclampsia)
-Torsades de Pointes (a specific form of polymorphic VT in patients with long QT interval)
-Preterm labour
normal endometrium thickness under ultrasound
6) normal endometrium thickness under ultrasound
Lange current o&g dx and tx : follicular phase 4-8mm, luteal phase 7-14mm and has a uniform echogenic appearance
Lange current o&g dx and tx : follicular phase 4-8mm, luteal phase 7-14mm and has a uniform echogenic appearance
hypertensive
5) hypertensive crisis
-acute increase in BP, usually with diastolic BP over 100mmHg, with or without endorgan damage
-drugs choice in mx for hpt in pregnancy: hydralazine, labetalol, magnesium sulphate
⏬⏬⏬⏬⏬⏬⏬⏬⏬
Izzat Mubarak: Salam dr shaiful...chronic hpt is diagnosed at before 20 wks gestation...
To dx hpt its must be >140/90 on 2 ocassions 4 hrs apart
A lady at booking taken first bp, reading above 140/90...so she has to repeat 4 hrs later...and she comes back again and bp is also above normal...
But it cud be that she is anxiety, rushing from somewhere or just perform something stressful... So is the reading reliable???
Dr Shaiful Ehsan: Waalaikumsalam....any high BP at visit should be entertained....
Provided it is done appropriately....
Nevertheless, there is possibility of white coat hypertension....in which home blood pressure monitoring or ambulatory BP monitoring should be done...
These group of patient usually have normal BP at home....but high on visit with new staff or new doctors....regular doctor treating them...they will feel more comfortable...
Izzat, you can refer to our latest CPG hypertension in adult 2014....regarding appropriate measures before BP measurement and white coat hypertension...tqvm
-acute increase in BP, usually with diastolic BP over 100mmHg, with or without endorgan damage
-drugs choice in mx for hpt in pregnancy: hydralazine, labetalol, magnesium sulphate
⏬⏬⏬⏬⏬⏬⏬⏬⏬
Izzat Mubarak: Salam dr shaiful...chronic hpt is diagnosed at before 20 wks gestation...
To dx hpt its must be >140/90 on 2 ocassions 4 hrs apart
A lady at booking taken first bp, reading above 140/90...so she has to repeat 4 hrs later...and she comes back again and bp is also above normal...
But it cud be that she is anxiety, rushing from somewhere or just perform something stressful... So is the reading reliable???
Dr Shaiful Ehsan: Waalaikumsalam....any high BP at visit should be entertained....
Provided it is done appropriately....
Nevertheless, there is possibility of white coat hypertension....in which home blood pressure monitoring or ambulatory BP monitoring should be done...
These group of patient usually have normal BP at home....but high on visit with new staff or new doctors....regular doctor treating them...they will feel more comfortable...
Izzat, you can refer to our latest CPG hypertension in adult 2014....regarding appropriate measures before BP measurement and white coat hypertension...tqvm
rhogam Rh negative
4) rhogam ( yg rhesus negative tu)
As prophylaxis : 500iu at 28&34weeks @ 1500iu at 28 weeks
📃📃📃📃📃📃
Umair: And also, i have a question. For a mother who is rhesus negative, saya pernah dgr ada dr order blood dari blood bank time kat labour room. If im not mistaken, only the child who will be affected by the hemolysis, not the mother. I have read about this but still couldnt find the answer....or mungkin saya yg tak faham. 😅😅
Dr Shaiful Ehsan: Why they order blood in the 1st place? Any bleeding or anticipated caesar?
Yupp haemolysis is in the fetus...not mother...
Umair: Not sure dr, tapi ayat dr tu mcm ni
"Patient rhesus negative, dah order blood dr blood bank?"
I thought they order the blood becouse of the rhesus negative
Dr Shaiful Ehsan: They need to inform blood bank early if mother is indicated for blood transfusion....becoz quite difficult to get rhesus negative blood avaliable in blood bank...
Umair: Oh...Now it makes more sense...
Dr Shaiful Ehsan: There must be some other indications...
Anyhow....its good that every mother go into labor u anticipate bleeding....like in rhesus negative mother....u cant expect the rhesus negative blood is always available...
Thus its good u send gsh early and inform blood bank that the mother is in labor....and enquire any availability of bloods...
Just enquire shj....selalunya x guna pun darah tu...
Umair: Okay dr. Thanks a lot. 😄
As prophylaxis : 500iu at 28&34weeks @ 1500iu at 28 weeks
📃📃📃📃📃📃
Umair: And also, i have a question. For a mother who is rhesus negative, saya pernah dgr ada dr order blood dari blood bank time kat labour room. If im not mistaken, only the child who will be affected by the hemolysis, not the mother. I have read about this but still couldnt find the answer....or mungkin saya yg tak faham. 😅😅
Dr Shaiful Ehsan: Why they order blood in the 1st place? Any bleeding or anticipated caesar?
Yupp haemolysis is in the fetus...not mother...
Umair: Not sure dr, tapi ayat dr tu mcm ni
"Patient rhesus negative, dah order blood dr blood bank?"
I thought they order the blood becouse of the rhesus negative
Dr Shaiful Ehsan: They need to inform blood bank early if mother is indicated for blood transfusion....becoz quite difficult to get rhesus negative blood avaliable in blood bank...
Umair: Oh...Now it makes more sense...
Dr Shaiful Ehsan: There must be some other indications...
Anyhow....its good that every mother go into labor u anticipate bleeding....like in rhesus negative mother....u cant expect the rhesus negative blood is always available...
Thus its good u send gsh early and inform blood bank that the mother is in labor....and enquire any availability of bloods...
Just enquire shj....selalunya x guna pun darah tu...
Umair: Okay dr. Thanks a lot. 😄
3) criteria discharge NICU / ICN
3) criteria discharge NICU / ICN.
DISCHARGE CRITERIA (ICU) -
A. When a patient's physiologic status has stabilized and the need for ICU monitoring and care is no longer necessary
B. When a patient's physiological status has deteriorated and active interventions are no longer planned, discharge to a lower level of care is appropriate
ICN criteria:
For growing preterm infants, discharge can be anticipated when the infant:
•weighs ≥1,800 g
•is gaining weight steadily on nipple feedings (breast or bottle)
•can maintain body temperature in an open crib
•has had no episodes of apnea for at least 5d
•has an adequate home environment
Criteria for infants with other medical/surgical conditions vary with the clinical situation.
2) PCOS Rotterdam's criteria
2) PCOS Rotterdam's criteria
-hyperandrogenism
-oligo/anovulation
-polycystic ovaries( if she has 12 or more peripheral follicles in at least 1 ovary, measuring 2-9 mm in diameter, or a total ovarian v
⏳⏳⏳⏳⏳
Mb Umair: Dr, for pcos, must have more than 12 follicles? Sbb saya ada rujuk buku lain dia kata more than 8 pun dah kira
Dr Shaiful Ehsan: Some book even mentioned multiple follicles / polycystic ovary
But typically as details above....
It may differd according to which references u used...
-hyperandrogenism
-oligo/anovulation
-polycystic ovaries( if she has 12 or more peripheral follicles in at least 1 ovary, measuring 2-9 mm in diameter, or a total ovarian v
⏳⏳⏳⏳⏳
Mb Umair: Dr, for pcos, must have more than 12 follicles? Sbb saya ada rujuk buku lain dia kata more than 8 pun dah kira
Dr Shaiful Ehsan: Some book even mentioned multiple follicles / polycystic ovary
But typically as details above....
It may differd according to which references u used...
serum progesterone in normal pregnancy and missed miscarriage
1) value serum progesterone in normal pregnancy and missed miscarriage
-Hahlin et al: 99% of viable intrauterine pregnancy serum progesterone >30nmol/L, 75% of ectopic pregnancy and spontaneous abortion <30nmol/L
-medscape : serum progesterone level below 20nmol/L shown to have a positive predictive value greater than 95% of predicting pregnancy failure; levels >25nmol/L (likely to indicate) and >60nmol/L (strongly associated) with pregnancies subsequently demonstrated to be viable
-Hahlin et al: 99% of viable intrauterine pregnancy serum progesterone >30nmol/L, 75% of ectopic pregnancy and spontaneous abortion <30nmol/L
-medscape : serum progesterone level below 20nmol/L shown to have a positive predictive value greater than 95% of predicting pregnancy failure; levels >25nmol/L (likely to indicate) and >60nmol/L (strongly associated) with pregnancies subsequently demonstrated to be viable
Gdm on d/c -IOL & varicose vein
Cemak Asma: Salam dr. I clerk this patient 44y/o, g6p5 with gdm on d/c. She was referred from pekan because of her 19 years voluntary subfertility.. Cumanya, pekan refer because she wants to give birth svd so they send her to htaa.. If at pekan, only can do caesar for her.. But how do i phrase the chief complaint?
Dr Shaiful Ehsan: Waalaikumsalam.She's currently in labor?
Usually patient need to be referred at labor...or come at labor....
Cemak Asma: Not yet.. She was already given date by pekan to come to htaa
Dr Shaiful Ehsan: How many weeks?
Cemak Asma: Baru masuk 38 minggu
Dr Shaiful Ehsan: Plan for IOL at 38 weeks?
Cemak Asma: Yes.. She said yesterday if not in labour they will induce her today.. But just now i followed dr raja arif doing rounds and he said she's not ready for induction yet
Dr Shaiful Ehsan: So the chief complaint initially is IOL at 38 weeks..m
44, G6P5 with GDM on diet control with 19 years voluntary subfertility referred to htaa for IOL at 38 weeks...
GDM on DC usually IOL at 40 weeks...
Those with longer duration of subfertility or precious pregnancy...some specialist give IOL earlier...some give 39 weeks...
I personally prefer 39 weeks...
Cemak Asma: Oh.. Okay.. Pastu doctor, i noticed varicose veins in her legs.. She said it is only painful when pressed very hard.. Otherwise no ulcers, bleeding, cramps.. Cuma sakit bila diri lama.. Are there any other important questions that i should ask the patient regarding this?
Dr Shaiful Ehsan: Started noticed since when? Any skin changes / swelling / fever?
Cemak Asma: Since her 2nd childbirth
[30/10 9:13 am] M Cemak Asma: If skin i didnt notice any.. But the veins were discoloured and bumpy bumpy.. No fever
Dr Shaiful Ehsan: History...means u ask pts...
Cemak Asma: Ohh.. Fever no.. But skin changes i didnt ask.. Also for her first three children she gave birth at home dengan bidan kampung.. Ada relation ke doctor?
Dr Shaiful Ehsan: Nope...
Dr Shaiful Ehsan: Please read further in white tagging, green, yellow, red....
Cemak Asma: Okay.. Thank you doctor
Dr Shaiful Ehsan: Waalaikumsalam.She's currently in labor?
Usually patient need to be referred at labor...or come at labor....
Cemak Asma: Not yet.. She was already given date by pekan to come to htaa
Dr Shaiful Ehsan: How many weeks?
Cemak Asma: Baru masuk 38 minggu
Dr Shaiful Ehsan: Plan for IOL at 38 weeks?
Cemak Asma: Yes.. She said yesterday if not in labour they will induce her today.. But just now i followed dr raja arif doing rounds and he said she's not ready for induction yet
Dr Shaiful Ehsan: So the chief complaint initially is IOL at 38 weeks..m
44, G6P5 with GDM on diet control with 19 years voluntary subfertility referred to htaa for IOL at 38 weeks...
GDM on DC usually IOL at 40 weeks...
Those with longer duration of subfertility or precious pregnancy...some specialist give IOL earlier...some give 39 weeks...
I personally prefer 39 weeks...
Cemak Asma: Oh.. Okay.. Pastu doctor, i noticed varicose veins in her legs.. She said it is only painful when pressed very hard.. Otherwise no ulcers, bleeding, cramps.. Cuma sakit bila diri lama.. Are there any other important questions that i should ask the patient regarding this?
Dr Shaiful Ehsan: Started noticed since when? Any skin changes / swelling / fever?
Cemak Asma: Since her 2nd childbirth
[30/10 9:13 am] M Cemak Asma: If skin i didnt notice any.. But the veins were discoloured and bumpy bumpy.. No fever
Dr Shaiful Ehsan: History...means u ask pts...
Cemak Asma: Ohh.. Fever no.. But skin changes i didnt ask.. Also for her first three children she gave birth at home dengan bidan kampung.. Ada relation ke doctor?
Dr Shaiful Ehsan: Nope...
Dr Shaiful Ehsan: Please read further in white tagging, green, yellow, red....
Cemak Asma: Okay.. Thank you doctor
Pre-eclampsia
Faizah -
Q : how to determine severity of pre-eclampsia?
A : The source for my answer before is from medscape.
This is from CPG/H015: Hypertension in Pregnancy – Hypertensive Disorders (2011)
Pre-eclampsia (PE) : is a multisystem disorder arising after 20 weeks gestation. The usual manifestation is hypertension and protienuria, although proteinuria is not mandatory in order to confirm the diagnosis. 📎Classification
🌀Mild to moderate : Defined as systolic blood pressure of 140mmHg and/or diastolic blood pressure of 90 mmHg or higher measured on at least two occasions over 4 hours, combined with protienuria >300 mg total protein in a 24 hour urine collection, or ratio or protein to creatinine >30 mg/mmol)
🌀Severe pre-eclampsia : Defined as a systolic blood pressure of 160 mmHg and/or diastolic blood pressure or 110mmHg or higher measured on at least two occasions over 4 hours, combined with protienuria >300mg total protein in a 24 hour urine collection, or ratio of protein to creatinine >30mg mmol and usually accompanied by other haematological, neurological, hepatic or renal derangement. The diagnosis may also be considered with lesser degrees of hypertension in women who have clinical features and/or haematological derangement.
Q : how to determine severity of pre-eclampsia?
A : The source for my answer before is from medscape.
This is from CPG/H015: Hypertension in Pregnancy – Hypertensive Disorders (2011)
Pre-eclampsia (PE) : is a multisystem disorder arising after 20 weeks gestation. The usual manifestation is hypertension and protienuria, although proteinuria is not mandatory in order to confirm the diagnosis. 📎Classification
🌀Mild to moderate : Defined as systolic blood pressure of 140mmHg and/or diastolic blood pressure of 90 mmHg or higher measured on at least two occasions over 4 hours, combined with protienuria >300 mg total protein in a 24 hour urine collection, or ratio or protein to creatinine >30 mg/mmol)
🌀Severe pre-eclampsia : Defined as a systolic blood pressure of 160 mmHg and/or diastolic blood pressure or 110mmHg or higher measured on at least two occasions over 4 hours, combined with protienuria >300mg total protein in a 24 hour urine collection, or ratio of protein to creatinine >30mg mmol and usually accompanied by other haematological, neurological, hepatic or renal derangement. The diagnosis may also be considered with lesser degrees of hypertension in women who have clinical features and/or haematological derangement.
GSH & GXM
Hanim -
Q : what is gsh & gxm?
A : 🎁GSH
🍭Group screen and hold
🍭A test which patient's blood sample will be typed for ABO & Rh grouping and screened for unexpected antibody (by indirect antiglobulin test)
🍭The serum/ plasma is retained for 48 hrs in blood bank in the event that cross matched is required within this period.
🍭Gsh is used with maximum surgical blood ordering schedule (MSBOS)
🍭Bcoz to avoid the units of blood being reserved unnecessarily, create artificial shortage as well as prolonging shelf life of units
🍭MSBOS : list of effective surgical procedure together with no of blood units needed.
🍭Not practiced in :
-pt with abnormal red cell antibodies detected
-emergency cases
-paed pt
-transfusion dependent pt
🎁GXM :
🍭Group cross match
🍭Usually for transfusion such as thalassemia, anemia, pt undergo surgery, pregnant lady in labour
🍭Must be careful to handle this as not will cause transfusion reaction
🍭Is performed to test donor red cell against recipient serum as to detect any potential incompatibility which antibody in recipient cause hemolysis to donors cell
🍭The antibody would be against other than ABO system.
🍭Cross matched donor's unit will be retained for particular pt for 48 hrs b4 the unit is returned to pool of donors blood to be cross matched for other pts
Q : what is gsh & gxm?
A : 🎁GSH
🍭Group screen and hold
🍭A test which patient's blood sample will be typed for ABO & Rh grouping and screened for unexpected antibody (by indirect antiglobulin test)
🍭The serum/ plasma is retained for 48 hrs in blood bank in the event that cross matched is required within this period.
🍭Gsh is used with maximum surgical blood ordering schedule (MSBOS)
🍭Bcoz to avoid the units of blood being reserved unnecessarily, create artificial shortage as well as prolonging shelf life of units
🍭MSBOS : list of effective surgical procedure together with no of blood units needed.
🍭Not practiced in :
-pt with abnormal red cell antibodies detected
-emergency cases
-paed pt
-transfusion dependent pt
🎁GXM :
🍭Group cross match
🍭Usually for transfusion such as thalassemia, anemia, pt undergo surgery, pregnant lady in labour
🍭Must be careful to handle this as not will cause transfusion reaction
🍭Is performed to test donor red cell against recipient serum as to detect any potential incompatibility which antibody in recipient cause hemolysis to donors cell
🍭The antibody would be against other than ABO system.
🍭Cross matched donor's unit will be retained for particular pt for 48 hrs b4 the unit is returned to pool of donors blood to be cross matched for other pts
Management in molar pregnancy and Management for miscarriage.
Safira -
Q : Management in molar pregnancy and Management for miscarriage.
A : -The uterus shud be evacuated asap.
-missed abortion, th WHO suggest misoprostol 800mcg vaginally/sublingual dosw of 600mcg.
-This dose may be repeated twice at 3 hour intervals if needed.
If uterus is
<12w gestation, suction evavuation with prior priming with PGE1 tablet can be attempted.
>12w PGE1 tablet(misporostol/gemeprost) is used to induce expulsion.
-Can be augmented with Oxytocin drip.
-Surgical of theres retained of POC
Summary
Threatened abortion
-Conservative
Inevitable abortion
-D&C
Complete abortion
-Wait and watch
Incomplete
-D&C
Missed
-D&C
Septic miscarriage
-Broad spectrum of antibiotics
(Patient is stabilized first if shock)
Source: obstoday
[10/27, 7:11 AM] Safira: From jibah
General management
*Resuscitation*
EXPECTANT MANAGEMENT
MEDICAL MANAGEMENT
-Gemeprost n misoprostol(PG analogues)
-Mifepristone: anti progesterone
SURGICAL MANAGEMENT
-D&C
-Cervical prep first to reduce complication
-Antibiotic prophylaxis
Athirah - 7)How to monitor pt after induce with PGE1?
-ctg because uterine hyperstimulation can cause bradycardia
-monitor uterine contraction
Q : Management in molar pregnancy and Management for miscarriage.
A : -The uterus shud be evacuated asap.
-missed abortion, th WHO suggest misoprostol 800mcg vaginally/sublingual dosw of 600mcg.
-This dose may be repeated twice at 3 hour intervals if needed.
If uterus is
<12w gestation, suction evavuation with prior priming with PGE1 tablet can be attempted.
>12w PGE1 tablet(misporostol/gemeprost) is used to induce expulsion.
-Can be augmented with Oxytocin drip.
-Surgical of theres retained of POC
Summary
Threatened abortion
-Conservative
Inevitable abortion
-D&C
Complete abortion
-Wait and watch
Incomplete
-D&C
Missed
-D&C
Septic miscarriage
-Broad spectrum of antibiotics
(Patient is stabilized first if shock)
Source: obstoday
[10/27, 7:11 AM] Safira: From jibah
General management
*Resuscitation*
EXPECTANT MANAGEMENT
MEDICAL MANAGEMENT
-Gemeprost n misoprostol(PG analogues)
-Mifepristone: anti progesterone
SURGICAL MANAGEMENT
-D&C
-Cervical prep first to reduce complication
-Antibiotic prophylaxis
Athirah - 7)How to monitor pt after induce with PGE1?
-ctg because uterine hyperstimulation can cause bradycardia
-monitor uterine contraction
Risk factors of penicillin in leptospirosis
Aini -
Q : Risk factors of penicillin in leptospirosis?
A : mild leptospirosis is treated with doxycyline,ampicillin or amoxicillin.for severe lepto,iv penicillin G is drug of choice
Iv penicillin is effective but may not prevent the development of renal failure.parenteral ceftriaxone is as effective as penicillin.Jarish-Herxheimer reaction may occur during treatment but usually mild..
following penicillin treatment spirochetal diseases, a substantial proportion of patients may develop Jarisch-Herxheimer (JH) reaction, a syndrome composed of some of the following features: abrupt onset of fever, chills, myalgias, tachycardia, vasodilatation with flushing, exacerbated skin rash, or mild hypertension
[definition of jarisch-herxheimer rxn]
🐀 a transient, short term immunologic reaction commonly seen following antibiotic treatment of early and late stage of syphilis and less often in other disease, such as borreliosis, thypoid fever. 🐀manifestation include fever, chills, headache, myalgia, and exacerbation of cutaneous lesions.
🐀attributed to liberation of endotoxin-like substance or antigen from killed or dying microorganism, but its exact pathogenesis is unclear..
Q : Risk factors of penicillin in leptospirosis?
A : mild leptospirosis is treated with doxycyline,ampicillin or amoxicillin.for severe lepto,iv penicillin G is drug of choice
Iv penicillin is effective but may not prevent the development of renal failure.parenteral ceftriaxone is as effective as penicillin.Jarish-Herxheimer reaction may occur during treatment but usually mild..
following penicillin treatment spirochetal diseases, a substantial proportion of patients may develop Jarisch-Herxheimer (JH) reaction, a syndrome composed of some of the following features: abrupt onset of fever, chills, myalgias, tachycardia, vasodilatation with flushing, exacerbated skin rash, or mild hypertension
[definition of jarisch-herxheimer rxn]
🐀 a transient, short term immunologic reaction commonly seen following antibiotic treatment of early and late stage of syphilis and less often in other disease, such as borreliosis, thypoid fever. 🐀manifestation include fever, chills, headache, myalgia, and exacerbation of cutaneous lesions.
🐀attributed to liberation of endotoxin-like substance or antigen from killed or dying microorganism, but its exact pathogenesis is unclear..
Iron load effect
Mila -
Q : Iron load effect?
A : Effects of iron overload
🔸Liver disease
-seen in >95% pt
-accompanied by abdominal pain, cutaneous stigmata of liver disease (palmar erythema etc..), liver failure (ascites or encephalopathy), spleonmegaly, hepatomegaly
🔸Skin bronzing/hyperpigmentation
-cause by iron deposition+melanin
-🔺of cirrhosis, DM, skin pigmentation occur late in ds
🔸DM
-progressive iron accumulate in pancrease ➡ pancreatic beta cells damage
-so pt can present with polyuria, polydypsia, ⬆ blood & urine glucose
🔸Arthropathy
-when iron accumulate in joint tissue
-most affected joint like knees, feey, wrist, MCP joint...
🔸Amenorrhea, impotence, hypogonadism
-due to pituitary iron deposition
🔸Cardiomyopathy
-cardiac enlargement (with or w/o heart failure or conduction defect)
-dilated cardiomyopathy (characterized by dev of heary failure & cardiac diaturbances)
🔸Others
-osteopenia
-osteoporosis
-hair loss (commonly affect pubic area)
-koilonychia (usually thumb, index & middle finger)
Q : Iron load effect?
A : Effects of iron overload
🔸Liver disease
-seen in >95% pt
-accompanied by abdominal pain, cutaneous stigmata of liver disease (palmar erythema etc..), liver failure (ascites or encephalopathy), spleonmegaly, hepatomegaly
🔸Skin bronzing/hyperpigmentation
-cause by iron deposition+melanin
-🔺of cirrhosis, DM, skin pigmentation occur late in ds
🔸DM
-progressive iron accumulate in pancrease ➡ pancreatic beta cells damage
-so pt can present with polyuria, polydypsia, ⬆ blood & urine glucose
🔸Arthropathy
-when iron accumulate in joint tissue
-most affected joint like knees, feey, wrist, MCP joint...
🔸Amenorrhea, impotence, hypogonadism
-due to pituitary iron deposition
🔸Cardiomyopathy
-cardiac enlargement (with or w/o heart failure or conduction defect)
-dilated cardiomyopathy (characterized by dev of heary failure & cardiac diaturbances)
🔸Others
-osteopenia
-osteoporosis
-hair loss (commonly affect pubic area)
-koilonychia (usually thumb, index & middle finger)
Asherman syndrome
[28/10 8:31 pm] Arif Pauzi: Homework:
Arif -
Q : What is Asherman syndrome?
A : ➡Ashermans syndrome or intrauterine adhesions (synechiae) means the scarring of uterus. It is the commonest condition seen in uterine disorders. The endometrial cavity is obliterated by intrauterine fibrosis and adhesions. The commonest cause is overzealous DnC procedure. Other cause can be inflammation or infection. It can cause amenorrhea to the patient because of the abnormal uterine wall.
Arif -
Q : What is Asherman syndrome?
A : ➡Ashermans syndrome or intrauterine adhesions (synechiae) means the scarring of uterus. It is the commonest condition seen in uterine disorders. The endometrial cavity is obliterated by intrauterine fibrosis and adhesions. The commonest cause is overzealous DnC procedure. Other cause can be inflammation or infection. It can cause amenorrhea to the patient because of the abnormal uterine wall.
D & C
Arif Pauzi: Homework:
Alif -
Q : Preparation before D n C procedure?
A : 1.Some pt will need to have blood testing before D and C ( such as blood count or tests of clotting factor), although this is not always necessary. Pt should not eat or drink anything starting the night before the procedure. Pt will need someone to accompany they home because it is not safe to drive after receiving anesthesia, which cause sedation.
2. Know the contraindication for D n C.
Absolute contraindications to dilation and curettage include the following:
-Viable desired intrauterine pregnancy
-Inability to visualize the cervical os
-Obstructed vagina
Relative contraindications to dilation and curettage include the following:
-Severe cervical stenosis
-Cervical/uterine anomalies
-Prior endometrial ablation
-Bleeding disorder
-Acute pelvic infection (except to remove infected endometrial contents)
-Obstructing cervical lesion
3. Equipment
-A Graves speculum may be used to visualize the cervix. Alternatively, a weighted speculum with one or more vaginal retractors in the anterior and lateral vaginal fornices may be used.
-Several types of cervical dilators are commonly used. A dilator has a tapered end. Common dilator types include the Pratt, Hegar, and Hank dilators.
-currete and forceps(ring, Randall or packing forceps)
Patient preparation
Anesthesia
Office procedures may require no formal preoperative preparation if a need for cervical dilation is absent or minimal and a small-caliber endometrial sampling device or suction device is employed.
Some providers suggest patients undergoing cervical or paracervical instillation of local anesthetic be instructed to have an empty stomach. Manipulation of the cervix and placement of the curette may induce a vasovagal response with secondary nausea and vomiting.
Patients may be instructed to abstain from oral intake of solid foods for 6–8 hours and oral intake of clear liquids for 2 or more hours, even in the office setting. A preoperative over-the-counter pain medication, such as a nonsteroidal anti-inflammatory medication, may be taken with a sip of water at home prior to the procedure to assist with comfort during and after the dilation and curettage.
Procedures involving conscious sedation or regional or general anesthesia should follow the American Society of Anesthesiology guidelines for abstaining from clear liquids and oral consumption prior to surgical procedures. The current recommendations are no solid food for 8 hours preprocedure and no clear liquids for 4 hours preprocedure.
Positioning
The procedure is typically performed in the dorsal lithotomy position. Care should be taken to prevent pressure injuries and excess abduction of the hip joint. Patients with orthopedic limitations may need to be positioned before sedation or general anesthesia is employed.
Dr Shaiful Ehsan: Additional info for D&C...
Consent and explanation...
Explain risk of procedures including early (eg uterine perforation) & late complications
Insert CBD / to empty bladder...
The rest are acceptable...tq
🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃
Ili Dalia: Salam doctor, if patient missed misscarriage admitted to the ward for d&c or erpoc whar was the suitable chief complaint.. if i just said puan j, 23 yrs old malay lady g3p2 at 10 week poa admitted to htaa for surgical intervention in view of her misscarrige. Boleh ke?
Dr Shaiful Ehsan: Waalaikumsalam Ili, 23, G3P2 at 10 weeks poa, electiveley admietted for further management of her absence progress of pregnancy / no progress of gestational sac / fetus parameters on scan....tq
Alif -
Q : Preparation before D n C procedure?
A : 1.Some pt will need to have blood testing before D and C ( such as blood count or tests of clotting factor), although this is not always necessary. Pt should not eat or drink anything starting the night before the procedure. Pt will need someone to accompany they home because it is not safe to drive after receiving anesthesia, which cause sedation.
2. Know the contraindication for D n C.
Absolute contraindications to dilation and curettage include the following:
-Viable desired intrauterine pregnancy
-Inability to visualize the cervical os
-Obstructed vagina
Relative contraindications to dilation and curettage include the following:
-Severe cervical stenosis
-Cervical/uterine anomalies
-Prior endometrial ablation
-Bleeding disorder
-Acute pelvic infection (except to remove infected endometrial contents)
-Obstructing cervical lesion
3. Equipment
-A Graves speculum may be used to visualize the cervix. Alternatively, a weighted speculum with one or more vaginal retractors in the anterior and lateral vaginal fornices may be used.
-Several types of cervical dilators are commonly used. A dilator has a tapered end. Common dilator types include the Pratt, Hegar, and Hank dilators.
-currete and forceps(ring, Randall or packing forceps)
Patient preparation
Anesthesia
Office procedures may require no formal preoperative preparation if a need for cervical dilation is absent or minimal and a small-caliber endometrial sampling device or suction device is employed.
Some providers suggest patients undergoing cervical or paracervical instillation of local anesthetic be instructed to have an empty stomach. Manipulation of the cervix and placement of the curette may induce a vasovagal response with secondary nausea and vomiting.
Patients may be instructed to abstain from oral intake of solid foods for 6–8 hours and oral intake of clear liquids for 2 or more hours, even in the office setting. A preoperative over-the-counter pain medication, such as a nonsteroidal anti-inflammatory medication, may be taken with a sip of water at home prior to the procedure to assist with comfort during and after the dilation and curettage.
Procedures involving conscious sedation or regional or general anesthesia should follow the American Society of Anesthesiology guidelines for abstaining from clear liquids and oral consumption prior to surgical procedures. The current recommendations are no solid food for 8 hours preprocedure and no clear liquids for 4 hours preprocedure.
Positioning
The procedure is typically performed in the dorsal lithotomy position. Care should be taken to prevent pressure injuries and excess abduction of the hip joint. Patients with orthopedic limitations may need to be positioned before sedation or general anesthesia is employed.
Dr Shaiful Ehsan: Additional info for D&C...
Consent and explanation...
Explain risk of procedures including early (eg uterine perforation) & late complications
Insert CBD / to empty bladder...
The rest are acceptable...tq
🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃🎃
Ili Dalia: Salam doctor, if patient missed misscarriage admitted to the ward for d&c or erpoc whar was the suitable chief complaint.. if i just said puan j, 23 yrs old malay lady g3p2 at 10 week poa admitted to htaa for surgical intervention in view of her misscarrige. Boleh ke?
Dr Shaiful Ehsan: Waalaikumsalam Ili, 23, G3P2 at 10 weeks poa, electiveley admietted for further management of her absence progress of pregnancy / no progress of gestational sac / fetus parameters on scan....tq
Cleft palate -ultrasound?
Alif Hussaini: Dr, salam, can cleft palate be detected thru ultrasound
Dr Shaiful Ehsan: Waalaikumsalam...our US at htaa and KK still 2D....so we cant...
Unless you go for US 4D at certain GP...
Dr Shaiful Ehsan: Waalaikumsalam...our US at htaa and KK still 2D....so we cant...
Unless you go for US 4D at certain GP...
Abnormal lie & breech presentation
Afif -
Q : What is definition of 'lie' & presentation?
A : 🐥lie is the relation between the long axis of fetus to the long axis of the gravid uterus
🐥presentation is the pole of the fetus which lies over the pelvic inlet
😀😀😀😀😀😀😀😀😀😀😀😀
Azei Sam 2: Homework. Maaf lambat. Reference Obs Today and senior notes.
ABNORMAL LIE
What is lie?
- relationship between longitudinal axis of fetus ti longitudinal axis of maternal uterus
Type of abnormal lie
- tranverse
- oblique
- unstable lie (lie of fetus change after 37 weeks of pog)
Causes
a) maternal causes
- multiparity (due to laxity of uterine musculature with each pregnancy)
- polyhydroamnios (greater freedom of movement)
- uterine septa
- placenta previa (physical obstruction to fetal engagement)
- obstruction suh as fibroid or ovarian cyst
- transient factor (full bladder)
b) fetal causes
- prematurity
- multiple pregnancy
- hydrocephaly
- tumor of neck and sacrum
- fetal neuromuscular dysfunction (impede engagemnet due to reduce fetal movement)
Complication
- obstructed labor
- uterine rupture
- cord prolapse
Management
- admission to hosp from 37 weeks if in labor or ROM LSCS is carried out
- if remain unstable, remain in the hosp observe for 24hours, if stable observe another 3 days
- if the lie is not stabilize do LSCS
- stabilizing induction
(> Involve stabilizing the lie
> Oxytocin infusion for uterine contraction
> Controlled amniotomy)
Azei Sam 2: BREECH PRESENTATION
Introduction
- 3-4% occurs in deliveries
- decreases with advancing gestational age
Predisposing factor
- prematurity
- uterine abnormalities (malformation, fibroids)
- fetal abnirmalities (CNS malformation, neck masses, aneuploidy)
- amniotic fluid abnormality
- abnormal placentation (placenta previa)
- pelvic tumor
Types of breech
- frank breech
- complete breech
- footling or incomplete
Management
Options available:
a) ECV
- manipulation of fetus through maternal abdomen to a cephaluc presentation
- contraindication to ECV
> indication for CS
> antepartum haemorrhages within the last 7 days
> abnormal CTG
> major uterine anomaly
> ruptured membranes
> multiple pregnancy
> small for gestational age fetus
> proteinuric pre eclampsia
> oligohydroamnios
> major fetal anomalies
> scarred uterus
> unstable lie
b) vaginal breech delivery
- Factors that increase successful vaginal delivery
> normal size baby
> flexed neck
> mental attitude
> breech deeply engaged
> adequate pelvis
> multiparous
- Complications
> placenta abruption
> fetomaternal hemorrhage
> transplacental hemorrhagr
> PPROM
> pain precipitation of labor
> cord prolapsed
> fetal bradycardia
c) Cesearean section
- indication
> large or small fetus (>3.5kg and <2.5kg)
> extended neck
> small pelvis
> primigravida
> previous c section
😊😊😊😊😊😊😊😊😊😊😊😊
Dr Shaiful Ehsan: Assalam arif...
I have already ask 2 O&G specialists , 4 registrars ...
All are frens of mine...
NO such thing as breech engagement on palpation....
Similar as what I told you guys just now...
Only fetal head engagement is present...
Thank you...
Arif Pauzi: Orait tq dr.
Dr Shaiful Ehsan: Guys any doubts....please ask...please do not hesitate to ask...
Tq
Nevertheless.....in certain setting for example before do ECV.......we try to palpate either the breech is totally on lower part or not....as its important to give a PROGNOSTIC factor for succsssful ECV or not...
In this situation....not using the term how many fifth palpable......some said just mentioned breech engaged or not....but NEVER EVER TELL how many fifth palpable....
Tq.
Overall, it is not something common to be mentioned. Tq.
Alif Hussaini: Oblique also never tell how many fifth palpable 😅
Dr Shaiful Ehsan: 👍🏻👍🏻
Liza: Jadinya doktor, kalau breech, tak perlu buat VE lah ye ?
Alif Hussaini: Hari tu nampak mo buat sebab ho tu tertakut masuk dalam anus fetus
Alif Hussaini: Takut jari masuk anus
Dr Shaiful Ehsan: Sama mcm cephalic...kalau ada leaking buat speculum....
Takut2 cord prolapse...
Kalau contraction pain kena buat VE....in order to expect time of delivery and expedite your EMLSCS if pt in labour...
But jgn buat ARM....unless mother opt for vaginal delivery...
Liza: Owh macam tu. Thank you dr
Q : What is definition of 'lie' & presentation?
A : 🐥lie is the relation between the long axis of fetus to the long axis of the gravid uterus
🐥presentation is the pole of the fetus which lies over the pelvic inlet
😀😀😀😀😀😀😀😀😀😀😀😀
Azei Sam 2: Homework. Maaf lambat. Reference Obs Today and senior notes.
ABNORMAL LIE
What is lie?
- relationship between longitudinal axis of fetus ti longitudinal axis of maternal uterus
Type of abnormal lie
- tranverse
- oblique
- unstable lie (lie of fetus change after 37 weeks of pog)
Causes
a) maternal causes
- multiparity (due to laxity of uterine musculature with each pregnancy)
- polyhydroamnios (greater freedom of movement)
- uterine septa
- placenta previa (physical obstruction to fetal engagement)
- obstruction suh as fibroid or ovarian cyst
- transient factor (full bladder)
b) fetal causes
- prematurity
- multiple pregnancy
- hydrocephaly
- tumor of neck and sacrum
- fetal neuromuscular dysfunction (impede engagemnet due to reduce fetal movement)
Complication
- obstructed labor
- uterine rupture
- cord prolapse
Management
- admission to hosp from 37 weeks if in labor or ROM LSCS is carried out
- if remain unstable, remain in the hosp observe for 24hours, if stable observe another 3 days
- if the lie is not stabilize do LSCS
- stabilizing induction
(> Involve stabilizing the lie
> Oxytocin infusion for uterine contraction
> Controlled amniotomy)
Azei Sam 2: BREECH PRESENTATION
Introduction
- 3-4% occurs in deliveries
- decreases with advancing gestational age
Predisposing factor
- prematurity
- uterine abnormalities (malformation, fibroids)
- fetal abnirmalities (CNS malformation, neck masses, aneuploidy)
- amniotic fluid abnormality
- abnormal placentation (placenta previa)
- pelvic tumor
Types of breech
- frank breech
- complete breech
- footling or incomplete
Management
Options available:
a) ECV
- manipulation of fetus through maternal abdomen to a cephaluc presentation
- contraindication to ECV
> indication for CS
> antepartum haemorrhages within the last 7 days
> abnormal CTG
> major uterine anomaly
> ruptured membranes
> multiple pregnancy
> small for gestational age fetus
> proteinuric pre eclampsia
> oligohydroamnios
> major fetal anomalies
> scarred uterus
> unstable lie
b) vaginal breech delivery
- Factors that increase successful vaginal delivery
> normal size baby
> flexed neck
> mental attitude
> breech deeply engaged
> adequate pelvis
> multiparous
- Complications
> placenta abruption
> fetomaternal hemorrhage
> transplacental hemorrhagr
> PPROM
> pain precipitation of labor
> cord prolapsed
> fetal bradycardia
c) Cesearean section
- indication
> large or small fetus (>3.5kg and <2.5kg)
> extended neck
> small pelvis
> primigravida
> previous c section
😊😊😊😊😊😊😊😊😊😊😊😊
Dr Shaiful Ehsan: Assalam arif...
I have already ask 2 O&G specialists , 4 registrars ...
All are frens of mine...
NO such thing as breech engagement on palpation....
Similar as what I told you guys just now...
Only fetal head engagement is present...
Thank you...
Arif Pauzi: Orait tq dr.
Dr Shaiful Ehsan: Guys any doubts....please ask...please do not hesitate to ask...
Tq
Nevertheless.....in certain setting for example before do ECV.......we try to palpate either the breech is totally on lower part or not....as its important to give a PROGNOSTIC factor for succsssful ECV or not...
In this situation....not using the term how many fifth palpable......some said just mentioned breech engaged or not....but NEVER EVER TELL how many fifth palpable....
Tq.
Overall, it is not something common to be mentioned. Tq.
Alif Hussaini: Oblique also never tell how many fifth palpable 😅
Dr Shaiful Ehsan: 👍🏻👍🏻
Liza: Jadinya doktor, kalau breech, tak perlu buat VE lah ye ?
Alif Hussaini: Hari tu nampak mo buat sebab ho tu tertakut masuk dalam anus fetus
Alif Hussaini: Takut jari masuk anus
Dr Shaiful Ehsan: Sama mcm cephalic...kalau ada leaking buat speculum....
Takut2 cord prolapse...
Kalau contraction pain kena buat VE....in order to expect time of delivery and expedite your EMLSCS if pt in labour...
But jgn buat ARM....unless mother opt for vaginal delivery...
Liza: Owh macam tu. Thank you dr
PV bleed (PALM COIEN)
Mnemonics utk PV bleed (PALM COIEN)
Polyps
Adenomysis
Leiomyoma
Malignancy
Coagulopathy
Ovulatory dysfunction
Iatrogenic
Endometrial disorder
Non identified/Neoplasm
Polyps
Adenomysis
Leiomyoma
Malignancy
Coagulopathy
Ovulatory dysfunction
Iatrogenic
Endometrial disorder
Non identified/Neoplasm
By Wana
Polyps
Adenomysis
Leiomyoma
Malignancy
Coagulopathy
Ovulatory dysfunction
Iatrogenic
Endometrial disorder
Non identified/Neoplasm
Polyps
Adenomysis
Leiomyoma
Malignancy
Coagulopathy
Ovulatory dysfunction
Iatrogenic
Endometrial disorder
Non identified/Neoplasm
By Wana
GDM
Syamila: Salam Dr..if the patient's BSP is well controlled, then why the baby is still big?
Dr Shaiful Ehsan: Waalaikumsalam...
What is the HBA1c, mothers OGTT, diagnosed since when, BMI and family history of DM?
All these have factors...which I will explain later...
Please reply...tq
Syamila: HBA1c-6.5%
MOGTT-5.5 and 8.9 mmol/L
Diagnosed at 24w POA
BMI-25.6 kg/m2
No family history of DM..
Liza: Nurse ada kata sebab ibu minum susu yg manis boleh dpt big baby. Eg Anmum. Huhu
Dr Shaiful Ehsan: What is the risk factors for her ogtt indications?
M Syamila: Increse weight gain. Dr..actually, suspicious big baby..so they plan for ELSCS.. why not they try svd first?
Liza: Ada kaitan tak dr susu yg ibu minum dengan saiz baby ?
Dr Shaiful Ehsan: From her biodatas...I can tell that she is true GDM...not overt DM...
Thus the target HBA1c should be lower...even less than 5.8..
The higher the HBA1c...the higher the risk....
Her HBA1c is 6.5...which means not parallel with her BSP....
BSP patient can lie...as they need to come to KK or KD...and they can prepare few days before BSP done...
Abd Halim: Which means... shes just not compliant to medication or something went wrong before the BSP.
Dr Shaiful Ehsan: But HBA1c cant lie... She is not compliance to her diet....
Bila lepas BSP buat dah happy...makan tak control....
Sehari sebelum BSP cepat2 tahan makan balik....mcm tu lah...
Most patients try to cheat us..
Thats why we rely on HBA1c...
Another factors include earlier GDM diagnosis, level OGTT more than 7/11, strong family history of DM and obesity (metabolic syndrome)...
All these factors favors overt DM which will give risk of big baby if not controlled enough with diet or medications...
Dr Shaiful Ehsan: Regarding issue...WHY not SVD 1st? I need to know what is the estimated fetal weight on palpation and TAS?
Dr Shaiful Ehsan: Nurliza, regarding minum susu =
Most mother tend to drink susu during pregnancy...if it is consume excessively....the CHO will be excessive and leads to excess sugar and fat...
Actually, it is okey for the mother not to take milk powder...as long as she take good calcium intake from daily foods.....
That is why dietitian referral and education is important at point of diagnosis GDM...
Dr Shaiful Ehsan: Syamila, EFWT??
Syamila: sorry dr..based on my palpation i think 3.4-3.6kg.. i forget to see the bht of the pt..i just ask her regarding her baby weight, which she just mention "baby saya besar..'
Dr Shaiful Ehsan: If 3.4 to 3.6 i would agree for SVD trial 1st with close monitoring in labor room...
Any delay in progress...definitely caesar...
Nevertheless...what is the mother's HT?Height?
Syamila: 145cm..
Dr Shaiful Ehsan: Oops...definitely caeasar my dear...she had risk of cephalopelvic disproportion CPD...
CPD + Suspicious big baby = preferably caesar
What is the HT level suspicious for CPD?
Syamila: dr..what is the indication for earlier GDM diagnosis? is it in the 1st trimester?
Dr Shaiful Ehsan: Q:What is the HT level suspicious for CPD? I need answer....
Syamila: tak ingat dr.....
Dr Shaiful Ehsan: 145 and less...
Dr Shaiful Ehsan: If she had normal estimated fetal weight can proceed with SVD ( but risk of CPD already there)...
But suspected big baby & short stature / CPD is = caesar...
Indication for early OGTT are those risk factors for GDM except age...
Need to done earlier eg at 12 -14 weeks...
Early diagnosis = earlier control & treatment...
Syamila: okay..thank you dr..
🎑🎑🎑🎑🎑🎑🎑🎑🎑
Alif Hussaini: Salam dr, is it typical for women with DM complicating pregnancy to be warded during the first trimester? Tq
Dr Shaiful Ehsan: Waalaikumsalam alif, DM complicating pregnancy usually NOT require admission unless she need to be taught and start insulin which she had no experience and we need to adjsut the dose by monitoring her dxt closely in ward....
Dr Shaiful Ehsan: Waalaikumsalam...
What is the HBA1c, mothers OGTT, diagnosed since when, BMI and family history of DM?
All these have factors...which I will explain later...
Please reply...tq
Syamila: HBA1c-6.5%
MOGTT-5.5 and 8.9 mmol/L
Diagnosed at 24w POA
BMI-25.6 kg/m2
No family history of DM..
Liza: Nurse ada kata sebab ibu minum susu yg manis boleh dpt big baby. Eg Anmum. Huhu
Dr Shaiful Ehsan: What is the risk factors for her ogtt indications?
M Syamila: Increse weight gain. Dr..actually, suspicious big baby..so they plan for ELSCS.. why not they try svd first?
Liza: Ada kaitan tak dr susu yg ibu minum dengan saiz baby ?
Dr Shaiful Ehsan: From her biodatas...I can tell that she is true GDM...not overt DM...
Thus the target HBA1c should be lower...even less than 5.8..
The higher the HBA1c...the higher the risk....
Her HBA1c is 6.5...which means not parallel with her BSP....
BSP patient can lie...as they need to come to KK or KD...and they can prepare few days before BSP done...
Abd Halim: Which means... shes just not compliant to medication or something went wrong before the BSP.
Dr Shaiful Ehsan: But HBA1c cant lie... She is not compliance to her diet....
Bila lepas BSP buat dah happy...makan tak control....
Sehari sebelum BSP cepat2 tahan makan balik....mcm tu lah...
Most patients try to cheat us..
Thats why we rely on HBA1c...
Another factors include earlier GDM diagnosis, level OGTT more than 7/11, strong family history of DM and obesity (metabolic syndrome)...
All these factors favors overt DM which will give risk of big baby if not controlled enough with diet or medications...
Dr Shaiful Ehsan: Regarding issue...WHY not SVD 1st? I need to know what is the estimated fetal weight on palpation and TAS?
Dr Shaiful Ehsan: Nurliza, regarding minum susu =
Most mother tend to drink susu during pregnancy...if it is consume excessively....the CHO will be excessive and leads to excess sugar and fat...
Actually, it is okey for the mother not to take milk powder...as long as she take good calcium intake from daily foods.....
That is why dietitian referral and education is important at point of diagnosis GDM...
Dr Shaiful Ehsan: Syamila, EFWT??
Syamila: sorry dr..based on my palpation i think 3.4-3.6kg.. i forget to see the bht of the pt..i just ask her regarding her baby weight, which she just mention "baby saya besar..'
Dr Shaiful Ehsan: If 3.4 to 3.6 i would agree for SVD trial 1st with close monitoring in labor room...
Any delay in progress...definitely caesar...
Nevertheless...what is the mother's HT?Height?
Syamila: 145cm..
Dr Shaiful Ehsan: Oops...definitely caeasar my dear...she had risk of cephalopelvic disproportion CPD...
CPD + Suspicious big baby = preferably caesar
What is the HT level suspicious for CPD?
Syamila: dr..what is the indication for earlier GDM diagnosis? is it in the 1st trimester?
Dr Shaiful Ehsan: Q:What is the HT level suspicious for CPD? I need answer....
Syamila: tak ingat dr.....
Dr Shaiful Ehsan: 145 and less...
Dr Shaiful Ehsan: If she had normal estimated fetal weight can proceed with SVD ( but risk of CPD already there)...
But suspected big baby & short stature / CPD is = caesar...
Indication for early OGTT are those risk factors for GDM except age...
Need to done earlier eg at 12 -14 weeks...
Early diagnosis = earlier control & treatment...
Syamila: okay..thank you dr..
🎑🎑🎑🎑🎑🎑🎑🎑🎑
Alif Hussaini: Salam dr, is it typical for women with DM complicating pregnancy to be warded during the first trimester? Tq
Dr Shaiful Ehsan: Waalaikumsalam alif, DM complicating pregnancy usually NOT require admission unless she need to be taught and start insulin which she had no experience and we need to adjsut the dose by monitoring her dxt closely in ward....
ARM in Active Phase of Labour
Abd Halim: Dr Saiful, in malaysia ARM is indicated for patients who are in Active Phase of Labour ke?
Dr Shaiful Ehsan: Assalamualaikum halim
ARM is indicated for augmentation in patient come with favourable bishop score or those already established in active phase of labor..
It is STATED in most labor room protocol....
Kenapa ya?
Atiqah ZB: So dr, it is not considered as induction of labour right?
Dr Shaiful Ehsan: It is considered as augmentation....which means bishops score more than 7.....
Induction is indicated for unvavourable bishops score....
However...some books do mentioned amniotomy, pitocin & ect as part of induction modalities...tq
Mb Abd Halim: Something just crossed my mind, is it done with the intent of making labour quicker in view of not enough labour rooms to accomodate patients
Or
For reasons of morbidity.
Dr Shaiful Ehsan: The reasons you augment the labor is to reduce the morbidity.....
Lets say u just let the labor progress without doing ARM....patient might end up with prolonged active phase of labor in which it is PAINFUL experience....
Late ARM....late in detection of meconium stained liquor....in which child may end up with HIE and lifelong palsy....
No IT IS TOTALLY not becoz not enough labor rooms bed...
Mb Abd Halim: Owh. Makes more sense.
Mb Abd Halim: Kalau doula tanye:
"Izinkanlah labour berlaku sepertimana semula jadi"
Kita ade hujjah based on clinical evidence.
Dr Shaiful Ehsan: Yupp....doula is not clinical practitioners....they are just normal public personnel....
However they demand high amount of fee for their so call "labor advice"...
But if anything bad happen to patients, they not gonna be sued, becoz they are not medical personnel and no licensed....they are just giving opinions (BUT GETTING FEE FOR THAT)...
Therefore dear my future doctors....please EDUCATE your patients well....who are this doula is....
And EDUCATE your patient how important they follow the DOCTOR advice...not doula...tq
Adlina: 👍🏼👍🏼👍🏼
Dr Shaiful Ehsan: Assalamualaikum halim
ARM is indicated for augmentation in patient come with favourable bishop score or those already established in active phase of labor..
It is STATED in most labor room protocol....
Kenapa ya?
Atiqah ZB: So dr, it is not considered as induction of labour right?
Dr Shaiful Ehsan: It is considered as augmentation....which means bishops score more than 7.....
Induction is indicated for unvavourable bishops score....
However...some books do mentioned amniotomy, pitocin & ect as part of induction modalities...tq
Mb Abd Halim: Something just crossed my mind, is it done with the intent of making labour quicker in view of not enough labour rooms to accomodate patients
Or
For reasons of morbidity.
Dr Shaiful Ehsan: The reasons you augment the labor is to reduce the morbidity.....
Lets say u just let the labor progress without doing ARM....patient might end up with prolonged active phase of labor in which it is PAINFUL experience....
Late ARM....late in detection of meconium stained liquor....in which child may end up with HIE and lifelong palsy....
No IT IS TOTALLY not becoz not enough labor rooms bed...
Mb Abd Halim: Owh. Makes more sense.
Mb Abd Halim: Kalau doula tanye:
"Izinkanlah labour berlaku sepertimana semula jadi"
Kita ade hujjah based on clinical evidence.
Dr Shaiful Ehsan: Yupp....doula is not clinical practitioners....they are just normal public personnel....
However they demand high amount of fee for their so call "labor advice"...
But if anything bad happen to patients, they not gonna be sued, becoz they are not medical personnel and no licensed....they are just giving opinions (BUT GETTING FEE FOR THAT)...
Therefore dear my future doctors....please EDUCATE your patients well....who are this doula is....
And EDUCATE your patient how important they follow the DOCTOR advice...not doula...tq
Adlina: 👍🏼👍🏼👍🏼
UTI in pregnancy
Atiqah ZB: Dr. Nk tnye...why pregnant women prone to get uti?
Dr Shaiful Ehsan: Pregnant woman is considered on low immune state...
Plus woman is easier to get uti due to anatomical ascending infection....
Plus stasis of urinary tract pathway...
Therefore they common develop ASYMPTOMATIC bacteriuria...
Asymptomatic bacteriuria in pregnancy need to be treated....
But if not pregnant...no need to treat asymptomatic bacteriuria...
📐📐📐📐📐📐📐📐📐📐
Afif: Causal microbs of uti:
(KEEPS)
Klebsiella
E. Coli
Enterococcus
Proteus
S.saprophyticus
Dr Shaiful Ehsan: 👏🏻👏🏻👏🏻
S. saprophyticus especially in newly married couple...
Dr Shaiful Ehsan: Pregnant woman is considered on low immune state...
Plus woman is easier to get uti due to anatomical ascending infection....
Plus stasis of urinary tract pathway...
Therefore they common develop ASYMPTOMATIC bacteriuria...
Asymptomatic bacteriuria in pregnancy need to be treated....
But if not pregnant...no need to treat asymptomatic bacteriuria...
📐📐📐📐📐📐📐📐📐📐
Afif: Causal microbs of uti:
(KEEPS)
Klebsiella
E. Coli
Enterococcus
Proteus
S.saprophyticus
Dr Shaiful Ehsan: 👏🏻👏🏻👏🏻
S. saprophyticus especially in newly married couple...
Detailed scan is done for detecting fetal anomaly
Wana: Salam Dr,
My friends and I have encountered a 26-year-old patient, G2P1,came for IOL in view of GDM on DC, at 40 weeks POG with a history of the first child having Edward Syndrome.
What I want to clarify from you , is it true that for her current pregnancy, she would undergo this process:
-the early pregnancy scan would identify an increase in nuchal translucency
-due to her history of having Trisomy 18 baby and increase NT detected, she was thus justified to undergo the detailed scan (detection of Choroid plexus cyst and renal pelvis dilatation) & amniocentesis in midpregnancy
Or
Having the history of trisomy 18 baby alone is enough to justify her for the detailed scan?
Abd Halim: Edward syndrome is characterized by hypercalcemia right? With morphological features such as heart valve abnormalities.
On other that comes to mind, thus hx of Trisomy 18 increases the risk of developing Trisomy 21?
Isn't nuchal translucency indicative of Trisomy 21.
Wana: From what ive read, nuchal translucency is not specific for Trisomy 21 only, but also indicative of Trisomy 13 & 18
Abd Halim: Ok. Jzkl
Wana: it's true that baby with Edward syndrome will have cardiac malformations. So maksudnya masa detailed scan bole detect jugak heart defects tu sume kan?
[20/10 7:01 am] Mb Abd Halim: Not sure. What i stated above was clinical manisfestation.
Abd Halim: We ascultate the baby. Not sure if detailed scan can find that much.
Wana: Ok tq 👌🏻
Dr Shaiful Ehsan: Waalaikumsalam syazwanamira,
Detailed scan is done for detecting fetal anomaly....
It is done at 18 to 22 weeks...
As at this point of time, most internal organs already WELL seen on US and fetus already show movements good enough for examining all angles of view as the fetus move...
Nuchal traslucency is done around 11 to 13 weeks POG...to identify the nuchal thickness...
It is not specific only for Down syndrome nor for any chomosomal.anomaly...
It is still detected in gastroschisis, fetal anaemia, duodenal atresia or others...
It just tell you that there is a likelihood of having abnormal baby either struturally or chomosomally.....
Therefore, to increase the likelihood of measuring probability of having down syndrome...
Nuchal translucencny must be done together with maternal triple test which is serum AFP, bhcg & estriol...
Nevertheles...the value combinations just tell you either it fall on the high risk or normal risk to have fetal anomaly....still not confirmative...
In Msia, any history of having baby with IUD or fetal anomaly before is indicated to be seen by O&G team at least one....
For them to assess risk and the need for detailed scan...
If indicated eg having fetal anomaly before...detailed scan can be done...
Nevertheless, having prenatal diagnosis of having fetal anomaly noted upon scan is not indicated for abortion under malaysia regulations....
Thus eventhough detailed scan or NT or tripple test been done and show more likelihood for DS....patient is not allowed to undergone abortion as it is not indicated under Malaysia laws...
Thus it is more of mentally preparation of the mother regarding the poor prognosis of edward & patau...which usually died upon birth....
And further long term plan of DS which is not related with mortality but morbidity and delayed development...
Dr Shaiful Ehsan: Abd halim, history of trisomy 18 wont increase the risk of having trisomy 21...
Nevertheless latest worldwide guideline (RCOG)...no specific indicator for determining risk...
But previous history of downs baby plus age is definitely a strong one...
Amniocentesis is another modalities to determine type of chromosomal.anomaly...
Can be done by Dr Anna...then send to private lab...or HKL...
Result would be available if im not mistaken in 2 weeks time...(but usually patient have to pay)
I hope I have answered all ur guys doubt...
Tq.
C u guys later...
Wana: Tq dr, it does help a whole lot! 🌟 btw, amniocentesis is optional right? Relying on the detailed scan alone is enough for the diagnosis of fetal anomaly?
Dr Shaiful Ehsan: Relying on detailed scan alone is NOT enough to identify the karyotype...
For example it can tell you ur fetus had heart anomaly but cant tell you either it is Down syndrome or not......
So to know the karyotype...amniocentesis can be advised if patient keen....
Nevertheless advantage of doing detailed scan is that preparation can be made before & during delivery....
Eg we have send patient to IJN when we detect fetal cardiac.anomaly....during that time we suspect ASD plus VSD...on the same week fetal.echo was done by cardiologist of IJN and detailed plan had been made by cardiologist to parents including cardiac standby if needed....tq...
Wana: Okayy thx a lot dr! 👍🏻👍🏻👍🏻
My friends and I have encountered a 26-year-old patient, G2P1,came for IOL in view of GDM on DC, at 40 weeks POG with a history of the first child having Edward Syndrome.
What I want to clarify from you , is it true that for her current pregnancy, she would undergo this process:
-the early pregnancy scan would identify an increase in nuchal translucency
-due to her history of having Trisomy 18 baby and increase NT detected, she was thus justified to undergo the detailed scan (detection of Choroid plexus cyst and renal pelvis dilatation) & amniocentesis in midpregnancy
Or
Having the history of trisomy 18 baby alone is enough to justify her for the detailed scan?
Abd Halim: Edward syndrome is characterized by hypercalcemia right? With morphological features such as heart valve abnormalities.
On other that comes to mind, thus hx of Trisomy 18 increases the risk of developing Trisomy 21?
Isn't nuchal translucency indicative of Trisomy 21.
Wana: From what ive read, nuchal translucency is not specific for Trisomy 21 only, but also indicative of Trisomy 13 & 18
Abd Halim: Ok. Jzkl
Wana: it's true that baby with Edward syndrome will have cardiac malformations. So maksudnya masa detailed scan bole detect jugak heart defects tu sume kan?
[20/10 7:01 am] Mb Abd Halim: Not sure. What i stated above was clinical manisfestation.
Abd Halim: We ascultate the baby. Not sure if detailed scan can find that much.
Wana: Ok tq 👌🏻
Dr Shaiful Ehsan: Waalaikumsalam syazwanamira,
Detailed scan is done for detecting fetal anomaly....
It is done at 18 to 22 weeks...
As at this point of time, most internal organs already WELL seen on US and fetus already show movements good enough for examining all angles of view as the fetus move...
Nuchal traslucency is done around 11 to 13 weeks POG...to identify the nuchal thickness...
It is not specific only for Down syndrome nor for any chomosomal.anomaly...
It is still detected in gastroschisis, fetal anaemia, duodenal atresia or others...
It just tell you that there is a likelihood of having abnormal baby either struturally or chomosomally.....
Therefore, to increase the likelihood of measuring probability of having down syndrome...
Nuchal translucencny must be done together with maternal triple test which is serum AFP, bhcg & estriol...
Nevertheles...the value combinations just tell you either it fall on the high risk or normal risk to have fetal anomaly....still not confirmative...
In Msia, any history of having baby with IUD or fetal anomaly before is indicated to be seen by O&G team at least one....
For them to assess risk and the need for detailed scan...
If indicated eg having fetal anomaly before...detailed scan can be done...
Nevertheless, having prenatal diagnosis of having fetal anomaly noted upon scan is not indicated for abortion under malaysia regulations....
Thus eventhough detailed scan or NT or tripple test been done and show more likelihood for DS....patient is not allowed to undergone abortion as it is not indicated under Malaysia laws...
Thus it is more of mentally preparation of the mother regarding the poor prognosis of edward & patau...which usually died upon birth....
And further long term plan of DS which is not related with mortality but morbidity and delayed development...
Dr Shaiful Ehsan: Abd halim, history of trisomy 18 wont increase the risk of having trisomy 21...
Nevertheless latest worldwide guideline (RCOG)...no specific indicator for determining risk...
But previous history of downs baby plus age is definitely a strong one...
Amniocentesis is another modalities to determine type of chromosomal.anomaly...
Can be done by Dr Anna...then send to private lab...or HKL...
Result would be available if im not mistaken in 2 weeks time...(but usually patient have to pay)
I hope I have answered all ur guys doubt...
Tq.
C u guys later...
Wana: Tq dr, it does help a whole lot! 🌟 btw, amniocentesis is optional right? Relying on the detailed scan alone is enough for the diagnosis of fetal anomaly?
Dr Shaiful Ehsan: Relying on detailed scan alone is NOT enough to identify the karyotype...
For example it can tell you ur fetus had heart anomaly but cant tell you either it is Down syndrome or not......
So to know the karyotype...amniocentesis can be advised if patient keen....
Nevertheless advantage of doing detailed scan is that preparation can be made before & during delivery....
Eg we have send patient to IJN when we detect fetal cardiac.anomaly....during that time we suspect ASD plus VSD...on the same week fetal.echo was done by cardiologist of IJN and detailed plan had been made by cardiologist to parents including cardiac standby if needed....tq...
Wana: Okayy thx a lot dr! 👍🏻👍🏻👍🏻
VTE DVT
Dr Shaiful Ehsan: http://medwebapp.com/nsbapp/vte/
Dr Shaiful Ehsan: The apps...for mobile...
Dr Shaiful Ehsan: Message from Dr Jamilah (haemato) & Dr Carol (o&g)...
VTE in pregnancy is indeed common in Msia.....and among the 1st contributing factor for maternal death...
**world thrombosis week
🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙
6. Venous thromboembolism
Venouse thromboembolism in pregnancy:
- occur due to hypercoagulable state in pregnancy and venouse stasis due to compression of ivc by gravid uterus.
- can cause direct maternal death.
- can have DVT( unilateral pain in calf, redness and swelling ) and pulmonary embolism (mild dyspnea, inspiratory chest pain, tachycardic and milg pyrexia).
- treated with LMWH
7. Homans sign
A positive sign is present when there is pain in the calf on forceful and abrupt dorsiflexion of the patient's foot at the ankle while the knee is extended 👆🏻.
treatment dvt:
1) unfractionated heparin - initial treatment in non pregnant
2) warfarin - contraindicated in pregnant woman becoz can cross placenta nd cause fetal defect and intracerebral haemorrhage
3) LMWH(such as clexane)- for pregnant woman
4) graduated elastic compression stockings
Dr Shaiful Ehsan: The apps...for mobile...
Dr Shaiful Ehsan: Message from Dr Jamilah (haemato) & Dr Carol (o&g)...
VTE in pregnancy is indeed common in Msia.....and among the 1st contributing factor for maternal death...
**world thrombosis week
🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙🍙
6. Venous thromboembolism
Venouse thromboembolism in pregnancy:
- occur due to hypercoagulable state in pregnancy and venouse stasis due to compression of ivc by gravid uterus.
- can cause direct maternal death.
- can have DVT( unilateral pain in calf, redness and swelling ) and pulmonary embolism (mild dyspnea, inspiratory chest pain, tachycardic and milg pyrexia).
- treated with LMWH
7. Homans sign
treatment dvt:
1) unfractionated heparin - initial treatment in non pregnant
2) warfarin - contraindicated in pregnant woman becoz can cross placenta nd cause fetal defect and intracerebral haemorrhage
3) LMWH(such as clexane)- for pregnant woman
4) graduated elastic compression stockings
Ovarian cancer - vaginal bleeding
Azrul Aziz: Salam dr shaiful, what is the common ovarian cancer that present with with vaginal bleeding?
Dr Shaiful Ehsan: Waalaikumsalam....
Ovarain ca can be divided histopathologically....either arising from epithelial, germ cells or stromal....
Generally any ovarian cancer may cause bleeding...
But those mostly related with estrogen / hormonal changes / abnormal uterine bleeding are stromal type...
Dr Shaiful Ehsan: Waalaikumsalam....
Ovarain ca can be divided histopathologically....either arising from epithelial, germ cells or stromal....
Generally any ovarian cancer may cause bleeding...
But those mostly related with estrogen / hormonal changes / abnormal uterine bleeding are stromal type...
LPC & investigation for GDM on diet come with LPOL
Izzat Mubarak: Aslmkm Dr Shaiful...
Is there any particular graph or table or chart plotted/drawn for the "Labour Progression Chart"??
Or is it just an imaginary chart in the minds of medical personals to follow the progress of pregnant mothers??
Azrul Aziz: Kt ward ade la zat
Azrul Aziz: Monitor contraction pain, fhr
Izzat Mubarak: Another question....
39 weeks Poa mother with GDM on diet control admitted to Htaa due to leaking liquor and contraction pain.
So this patient is already in labour.
As for the investigation, do we still need to perform blood test, and ultrasound??
Because we already know that she has been following up in the klinik kesihatan (after 36 weeks it is a weekly check up).
Dr Shaiful Ehsan: Waalaikumsalam...dear izzat & others
The partogram is in the bedticket of patient (postpartum) and in labor room....
We start plot it once we do ARM / enter labor room.....
Usually we repeat VE in 4 hrs if its early and may done earlier upon stronger contraction or other indications...
U can see it in labor room....
The reason to do the chart is to detect any poor progress of labor and any other abnormality in which intervention need to be done....
We expect 1cm opening progress per hr....it may be longer for primig....shorter for multigravida
Btw...u should be able to see the chart throughout the posting..its UNUSUAL if cant find it...please dont make me WORRY guys....
Dr Shaiful Ehsan: Dear izzat for ur 2nd question:
39 weeks POA with GDM on diet come with LPOL...
If the TAS done 2 weeks ago...we may repeat depends on our suspicion....
Eg if u palpate it is larger or head not engaged....or any informations not complete on previous scan....
UFEME is a must as asymptomatic bacteriuria is common in GDM or DM and Pregnancy...
Review the latest HB, BSP and Hba1c for that patient from her red book....
If any abnormality....need to repeat the fbc...
Dxt obviously need to be monitor during labor...
Tq.
Izzat Mubarak: Ah i see dr...yes, i have seen the partogram in the labour room...
In the ward i do see Houseman writing in the bed ticket to monitor labour progress chart...so i began to wonder where is the "LPC"...
If you mean the LPC as the Partogram then alhamdulillah i have seen...otherwise, i have to work even harder...
Thank you Dr for the time and effort and help offered
Is there any particular graph or table or chart plotted/drawn for the "Labour Progression Chart"??
Or is it just an imaginary chart in the minds of medical personals to follow the progress of pregnant mothers??
Azrul Aziz: Kt ward ade la zat
Azrul Aziz: Monitor contraction pain, fhr
Izzat Mubarak: Another question....
39 weeks Poa mother with GDM on diet control admitted to Htaa due to leaking liquor and contraction pain.
So this patient is already in labour.
As for the investigation, do we still need to perform blood test, and ultrasound??
Because we already know that she has been following up in the klinik kesihatan (after 36 weeks it is a weekly check up).
Dr Shaiful Ehsan: Waalaikumsalam...dear izzat & others
The partogram is in the bedticket of patient (postpartum) and in labor room....
We start plot it once we do ARM / enter labor room.....
Usually we repeat VE in 4 hrs if its early and may done earlier upon stronger contraction or other indications...
U can see it in labor room....
The reason to do the chart is to detect any poor progress of labor and any other abnormality in which intervention need to be done....
We expect 1cm opening progress per hr....it may be longer for primig....shorter for multigravida
Btw...u should be able to see the chart throughout the posting..its UNUSUAL if cant find it...please dont make me WORRY guys....
Dr Shaiful Ehsan: Dear izzat for ur 2nd question:
39 weeks POA with GDM on diet come with LPOL...
If the TAS done 2 weeks ago...we may repeat depends on our suspicion....
Eg if u palpate it is larger or head not engaged....or any informations not complete on previous scan....
UFEME is a must as asymptomatic bacteriuria is common in GDM or DM and Pregnancy...
Review the latest HB, BSP and Hba1c for that patient from her red book....
If any abnormality....need to repeat the fbc...
Dxt obviously need to be monitor during labor...
Tq.
Izzat Mubarak: Ah i see dr...yes, i have seen the partogram in the labour room...
In the ward i do see Houseman writing in the bed ticket to monitor labour progress chart...so i began to wonder where is the "LPC"...
If you mean the LPC as the Partogram then alhamdulillah i have seen...otherwise, i have to work even harder...
Thank you Dr for the time and effort and help offered
Clinical fundal height
Izzat Mubarak: Dr Shaiful, if my patient is 39 weeks POA. And clinical fundal height is 36 weeks (i am not sure if i have estimated it well). Is the clinical fundal height corresponding to the POA??
Or the clinical fundal height should be 38 weeks??
Alif Hussaini: Baby dah descend
Alif Hussaini: Normal
Dr Shaiful Ehsan: Waalaikumsalam izzat....what is the patient gravida?
And how many head fifth palpable?
Izzat Mubarak: Gravida 4 para 2+1
3/5 palpable
Dr Shaiful Ehsan: Dear izzat and others...
As a general rules....discrepancies of SFH from POA is as follows:
2nd trimester = can not be more than 2cm
3rd trimester can not be more than 3 weeks...
And you can see further about the head engagement....
Like in ur case, the head is not engaged yet but 3/5th palpable...which may lead to the loss of about 1cm on SFH....
So overall I can tell that ur patent SFH is following POA...tq
Dr Shaiful Ehsan: Homework, primigravida engaged when?
Dr Shaiful Ehsan: Gravida 2 and above fetal head engaged when?
Mb Izzat Mubarak: Tq dr
Or the clinical fundal height should be 38 weeks??
Alif Hussaini: Baby dah descend
Alif Hussaini: Normal
Dr Shaiful Ehsan: Waalaikumsalam izzat....what is the patient gravida?
And how many head fifth palpable?
Izzat Mubarak: Gravida 4 para 2+1
3/5 palpable
Dr Shaiful Ehsan: Dear izzat and others...
As a general rules....discrepancies of SFH from POA is as follows:
2nd trimester = can not be more than 2cm
3rd trimester can not be more than 3 weeks...
And you can see further about the head engagement....
Like in ur case, the head is not engaged yet but 3/5th palpable...which may lead to the loss of about 1cm on SFH....
So overall I can tell that ur patent SFH is following POA...tq
Dr Shaiful Ehsan: Homework, primigravida engaged when?
Dr Shaiful Ehsan: Gravida 2 and above fetal head engaged when?
Mb Izzat Mubarak: Tq dr
Mogtt
Izzat Mubarak: Dr Shaiful why is ogtt repeated at 3rd trimester(late pregnancy) at 30 wks when at that time we already know that blood glucose will be high at that time?? Simply said it is non informative.
In the words of Dr Muna "it is a malpractice performing mogtt at 3rd trimester"
P/S: Im sorry that it is already resting time
Dr Shaiful Ehsan: Assalam izzat....
It is NOT A MALPRACTICE performing OGTT at 3rd trimester...
IT IS IN OUR GUIDELINE AND UNIVERSAL GUIDELINE....
I am not sure why she said like this...
But try to look at guidelines and facts rather than someone's opinion only....
If u really wanna follow someone's opinion....then u can quote those expert in O&G (preferably local o&g which PRACTICE clinical in Msia)...
I would like to quote Dr Rachel's O&G consultant HOSHAS....
"OGTT can be repeat at any weeks if new indication arise....eg polyhydramnios, excessive wt gain & suspected big baby durinh scan & ect...)
If there is RIsk factors for GDM, need to be done early for the 1st time (preferably around 12 weeks) and repeat 2nd time at 28 - 30 weeks...
Bear in mind...that's already a 3rd trimester....
Nevertheless, we already understand that GDM is related with hormonal changes in pregnancy which is diabetogenic....
Normal pregnancy would be able to adapt to this changes without expressing hyperglycaemia in blood....
But those GDM mother, they unable to adapt and exhibit intolerance / GDM.....
Izzat Mubarak: Wasalam...thank you dr shaiful.👍
Yupp the more weeks of pregnancy, the more diabetogenic hormone there is....
And once the risk factor and indicator is there.....They need to be detected....
What's the point of doing ogtt at the point of most would able to adapt....we definitely do not want to miss the critical point as well....
Tq
🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓
Liza: Dr, for mogtt, if fbg 6.2 then 2hpp 6.2 as well, pts diagnosed as gdm or not ?
Dr Shaiful Ehsan: Fasting more than 5.6....we need only one reading to be high...so it is GDM...
Kalau mcm ni....most likely yg glucose water tu dia tak minum betul....sebab tu tak berapa naik....
Sorry pt memang mcm tu....sometimes...
In the words of Dr Muna "it is a malpractice performing mogtt at 3rd trimester"
P/S: Im sorry that it is already resting time
Dr Shaiful Ehsan: Assalam izzat....
It is NOT A MALPRACTICE performing OGTT at 3rd trimester...
IT IS IN OUR GUIDELINE AND UNIVERSAL GUIDELINE....
I am not sure why she said like this...
But try to look at guidelines and facts rather than someone's opinion only....
If u really wanna follow someone's opinion....then u can quote those expert in O&G (preferably local o&g which PRACTICE clinical in Msia)...
I would like to quote Dr Rachel's O&G consultant HOSHAS....
"OGTT can be repeat at any weeks if new indication arise....eg polyhydramnios, excessive wt gain & suspected big baby durinh scan & ect...)
If there is RIsk factors for GDM, need to be done early for the 1st time (preferably around 12 weeks) and repeat 2nd time at 28 - 30 weeks...
Bear in mind...that's already a 3rd trimester....
Nevertheless, we already understand that GDM is related with hormonal changes in pregnancy which is diabetogenic....
Normal pregnancy would be able to adapt to this changes without expressing hyperglycaemia in blood....
But those GDM mother, they unable to adapt and exhibit intolerance / GDM.....
Izzat Mubarak: Wasalam...thank you dr shaiful.👍
Yupp the more weeks of pregnancy, the more diabetogenic hormone there is....
And once the risk factor and indicator is there.....They need to be detected....
What's the point of doing ogtt at the point of most would able to adapt....we definitely do not want to miss the critical point as well....
Tq
🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓🍓
Liza: Dr, for mogtt, if fbg 6.2 then 2hpp 6.2 as well, pts diagnosed as gdm or not ?
Dr Shaiful Ehsan: Fasting more than 5.6....we need only one reading to be high...so it is GDM...
Kalau mcm ni....most likely yg glucose water tu dia tak minum betul....sebab tu tak berapa naik....
Sorry pt memang mcm tu....sometimes...
primary & secondary dysmenorrhea from history
Dr Shaiful Ehsan: Homework for u guys:
How do u differentiate between primary & secondary dysmenorrhea from history?
Tq.
Wana: Primary dysmenorrhea:
-Onset shortly after menarche (≤6 months)
-Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow)
-Cramping or laborlike pain
-Background of constant lower abdominal pain, radiating to the back or thigh
secondary dysmenorrhea:
-Dysmenorrhea beginning in the 20s or 30s, after previous relatively painless cycles
-Heavy menstrual flow or irregular bleeding
-Dysmenorrhea occurring during the first or second cycles after menarche
-Infertility
- deep dyspareunia
-Vaginal discharge
How do u differentiate between primary & secondary dysmenorrhea from history?
Tq.
Wana: Primary dysmenorrhea:
-Onset shortly after menarche (≤6 months)
-Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow)
-Cramping or laborlike pain
-Background of constant lower abdominal pain, radiating to the back or thigh
secondary dysmenorrhea:
-Dysmenorrhea beginning in the 20s or 30s, after previous relatively painless cycles
-Heavy menstrual flow or irregular bleeding
-Dysmenorrhea occurring during the first or second cycles after menarche
-Infertility
- deep dyspareunia
-Vaginal discharge
Endometritis and endometriosis
Arif Pauzi: Dr, about endometritis and endometriosis, the sign and symptoms, is there any differences between both of it?
Dr Shaiful Ehsan: Assalam arif,
Endometritis and endometriosis are 2 different pathological disorder..
In fact both occur at totally different site...
Endometritis is inflammation or infection of the endometrial lining of UTERUS....which may spread even further to myomterium or ascending or descending to other organs...
Whereby endometriosis is presence of ECTOPIC endometrial tissues OUTSIDE of uterus...
Therefore S&S would be different..
Endometriosis typically presented with secondary dysmenorrhea, dyspareunia, infertility or subfertility and +/- abdominal mass if involving the ovary (endometrioma)
Whereby endometritis patient present with fever, PV discharge or continuous foul smelling PV bleeding...
Typically in postpartum (retained POC) or after septic abortion or IUD...
Endometritis can cause maternal shock and death (due to element of infection / sepsis)
Whereby pure endometriosis not gonna cause death...
Dr Shaiful Ehsan: Assalam arif,
Endometritis and endometriosis are 2 different pathological disorder..
In fact both occur at totally different site...
Endometritis is inflammation or infection of the endometrial lining of UTERUS....which may spread even further to myomterium or ascending or descending to other organs...
Whereby endometriosis is presence of ECTOPIC endometrial tissues OUTSIDE of uterus...
Therefore S&S would be different..
Endometriosis typically presented with secondary dysmenorrhea, dyspareunia, infertility or subfertility and +/- abdominal mass if involving the ovary (endometrioma)
Whereby endometritis patient present with fever, PV discharge or continuous foul smelling PV bleeding...
Typically in postpartum (retained POC) or after septic abortion or IUD...
Endometritis can cause maternal shock and death (due to element of infection / sepsis)
Whereby pure endometriosis not gonna cause death...
Lnmp: irregular menses
Azei Sam 2: Dr.. my patient claimed that she's having menses 3 times a month since menarche. She claimed it is always like that. For the first time she's having it, it wil be about 4-5 days, then the second time will be about 3-4 days and the third time in a month it will be about 3-4 days too. She said the pad will be fully soaked everytime she's bleed. About 2 pads each day.
Is it considered regular menses? And does this means menorrhagea? She doesn't have any sign symptoms of anaemia. And for this type of patient is it possible to calculate her LMNP. Because she gets her EDD through calculation.
Dr Shaiful Ehsan: Frankly speaking...I have encounter only those pts with twice menstrual cycles per month...
Never encounter up to 3 times per month...
About the 1st question: is that regular menses?....nope...it is not..as it is not fulfill the 28 to 30 days cycle...
2nd Q: is it menorrhagia?
Theoretically menorrhagia is define as those with prolonged menses or several consecutive cycles per month or more than 80ml per cycle (can use pictorial picture chart...try look for it - useful for quantify amount of bleeding).
For ur patient, she falls on 2nd point. Nevertheless, to support for points towards menorrhagia...u should ask other features such as presence of blood clots & flooding, plus symptoms of anaemia...
Dr Shaiful Ehsan: LNMP only can be calculate if:
Sure of date
Regular menses
Not taking OCP or other hormonal contraceptives methods or brestfedding at least 3 months prior to her lmp...
Thus in your case, can not use her LMP as LNMP....
Dr Shaiful Ehsan: What we can do is do earliest TAS...and repeat 2 weeks later...if subsequent scan follow the 1st scan...then REDD is taken from the 1st scan....and POG can be calculated...
Hopefully she BENEFITED early scan less than 12 weeks POG.
Dr Shaiful Ehsan: Tq.
Azei Sam 2: Thank you Dr. 👍🏻
Is it considered regular menses? And does this means menorrhagea? She doesn't have any sign symptoms of anaemia. And for this type of patient is it possible to calculate her LMNP. Because she gets her EDD through calculation.
Dr Shaiful Ehsan: Frankly speaking...I have encounter only those pts with twice menstrual cycles per month...
Never encounter up to 3 times per month...
About the 1st question: is that regular menses?....nope...it is not..as it is not fulfill the 28 to 30 days cycle...
2nd Q: is it menorrhagia?
Theoretically menorrhagia is define as those with prolonged menses or several consecutive cycles per month or more than 80ml per cycle (can use pictorial picture chart...try look for it - useful for quantify amount of bleeding).
For ur patient, she falls on 2nd point. Nevertheless, to support for points towards menorrhagia...u should ask other features such as presence of blood clots & flooding, plus symptoms of anaemia...
Dr Shaiful Ehsan: LNMP only can be calculate if:
Sure of date
Regular menses
Not taking OCP or other hormonal contraceptives methods or brestfedding at least 3 months prior to her lmp...
Thus in your case, can not use her LMP as LNMP....
Dr Shaiful Ehsan: What we can do is do earliest TAS...and repeat 2 weeks later...if subsequent scan follow the 1st scan...then REDD is taken from the 1st scan....and POG can be calculated...
Hopefully she BENEFITED early scan less than 12 weeks POG.
Dr Shaiful Ehsan: Tq.
Azei Sam 2: Thank you Dr. 👍🏻
monitor the fetal development for these pregnancies
Abd Halim: Dr Shaiful, i have 2 cases of Monochorionic Diamniotic Twins.
I just wanna ask how to we monitor the fetal development for these pregnancies.
Cos my patient stated that:
"Satu baby kecik, satu besar."
Faiz Johari: patient ad HT ke hazwan?
Faiz Johari: guna Ultrasound?
Abd Halim: PIH. 32 weeks POA ade elevated BP.
Abd Halim: Ultrasound tu betul, tp how can we describe the finding? What i got was:
✅ Fetal growth (how do we compare?)
✅ Fetal lie (when do we start measuring)
✅ Fetal movement (how can we know?)
✅ Amniotic fluid index (If diamniotic)
Jeng jeng jeng.
Dr Shaiful Ehsan: Assalam halim, thanks for asking, I will reply later in afternoon after work...tq.
Btw...good observation....
Abd Halim: Geng2 ni pon byk soklan dr, cuma x tahu nk start tanye dr mana.
Dr Shaiful Ehsan: Keep on asking guys...InsyaAllah the more u ask...the more brighten ur future is...
Dr Shaiful Ehsan: Halim:
In monochorionic twins (MCDA), the monitoring should begins since the 1st time patient suspected prenancy,
Early booking should be done and early confirmation of the chorionicity should be done....as early as before 14 weeks to see the lambda sign or T sign (MCDA)
Monitoring and follow up of twins pregnancy should be done by primary care (FMS) together with O&G team at tertiary center...
Aims of monitoring is for fetal monitoring and maternal monitoring..., to detect early complications to mother (eg anaemia in pregnancy, hypertension, DM)
Dr Shaiful Ehsan: And to detect complications to fetus eg discordance growth, Twin to twin tranfusion syndrome and others...
Dr Shaiful Ehsan: So usually TAS is 2 weekly to 4 weekly...
Dr Shaiful Ehsan: If more than 26 weeks....usually we do every 2 weeks..
Dr Shaiful Ehsan: Aim for delivery is around 34-36 weeks for MCDA......
Dr Shaiful Ehsan: If MCMA around 32-34 weeks by ELLSCS....risk of IUD and cord entaglement is higher in MCMA...
Dr Shaiful Ehsan: For fetal growth....we measure by clinical SFH and TAS for BPD , HC , FL and AC...any SGA or IUGR is depends on centile per gestational age....need to plot the chart...
Dr Shaiful Ehsan: Any lie is considered normal unless at term...completed 37 weeks...abnormal lie is by definition at 37 weeks..
Dr Shaiful Ehsan: Fetal movement patient need to count since 28 weeks....that is universal rule...
By fetal quickeming usually felt at 16-20 weeks...
Dr Shaiful Ehsan: AFI is important in any pregnancy...in twin we cant measure the total AFI....but the deepest pole...
Abd Halim: Cop dr saiful. 4 weekly maksudnye once every 4 weeks kan? 2 weekly one every 2 weeks kan?
Dr Shaiful Ehsan: Yupp...TAS after 26 - 28 weeks is done 2 weekly for monochorionic....for DCDA can done 4 weekly...
I just wanna ask how to we monitor the fetal development for these pregnancies.
Cos my patient stated that:
"Satu baby kecik, satu besar."
Faiz Johari: patient ad HT ke hazwan?
Faiz Johari: guna Ultrasound?
Abd Halim: PIH. 32 weeks POA ade elevated BP.
Abd Halim: Ultrasound tu betul, tp how can we describe the finding? What i got was:
✅ Fetal growth (how do we compare?)
✅ Fetal lie (when do we start measuring)
✅ Fetal movement (how can we know?)
✅ Amniotic fluid index (If diamniotic)
Jeng jeng jeng.
Dr Shaiful Ehsan: Assalam halim, thanks for asking, I will reply later in afternoon after work...tq.
Btw...good observation....
Abd Halim: Geng2 ni pon byk soklan dr, cuma x tahu nk start tanye dr mana.
Dr Shaiful Ehsan: Keep on asking guys...InsyaAllah the more u ask...the more brighten ur future is...
Dr Shaiful Ehsan: Halim:
In monochorionic twins (MCDA), the monitoring should begins since the 1st time patient suspected prenancy,
Early booking should be done and early confirmation of the chorionicity should be done....as early as before 14 weeks to see the lambda sign or T sign (MCDA)
Monitoring and follow up of twins pregnancy should be done by primary care (FMS) together with O&G team at tertiary center...
Aims of monitoring is for fetal monitoring and maternal monitoring..., to detect early complications to mother (eg anaemia in pregnancy, hypertension, DM)
Dr Shaiful Ehsan: And to detect complications to fetus eg discordance growth, Twin to twin tranfusion syndrome and others...
Dr Shaiful Ehsan: So usually TAS is 2 weekly to 4 weekly...
Dr Shaiful Ehsan: If more than 26 weeks....usually we do every 2 weeks..
Dr Shaiful Ehsan: Aim for delivery is around 34-36 weeks for MCDA......
Dr Shaiful Ehsan: If MCMA around 32-34 weeks by ELLSCS....risk of IUD and cord entaglement is higher in MCMA...
Dr Shaiful Ehsan: For fetal growth....we measure by clinical SFH and TAS for BPD , HC , FL and AC...any SGA or IUGR is depends on centile per gestational age....need to plot the chart...
Dr Shaiful Ehsan: Any lie is considered normal unless at term...completed 37 weeks...abnormal lie is by definition at 37 weeks..
Dr Shaiful Ehsan: Fetal movement patient need to count since 28 weeks....that is universal rule...
By fetal quickeming usually felt at 16-20 weeks...
Dr Shaiful Ehsan: AFI is important in any pregnancy...in twin we cant measure the total AFI....but the deepest pole...
Abd Halim: Cop dr saiful. 4 weekly maksudnye once every 4 weeks kan? 2 weekly one every 2 weeks kan?
Dr Shaiful Ehsan: Yupp...TAS after 26 - 28 weeks is done 2 weekly for monochorionic....for DCDA can done 4 weekly...
estimate the fetal weight
Izzat Mubarak: Dr Shaiful, how to clinically estimate the fetal weight?
Thank you
Dr Shaiful Ehsan: Assalam izzat, overall u need to remember 3 commons SFH and mean fetal weight:
These are the golden rules:
At pog 28 weeks = 1kg
At Pog 32 weeks = 1.7kg
At 36 weeks 2.4 - 2.6kg
Then the rest is based on palpation and adjust accordingly....
Nevertheless, it depends on ur experience as well...
If u guys palpate a lot enough...u can appreciate and just +/- the golden rule estimation
In presenting estimated fetal weight...please present in estimation of 0.2kg...
Eg estimated fetal weight is 2.6 to 2.8kg...
Thanks
Dr Shaiful Ehsan: Based on golden rules...lets say u palpate a patient's abdomen sfh is 38 weeks and its follow date...no other abnormalities u suspected on palpation...and its size appropriate....
U can tell EFW is aroun 3.0 to 3.2kg....
If u palpate it is quite small...u can roughly say 2.8 to 3.0kg...
Something like that...tq
[08/10 9:06 am]
Thank you
Dr Shaiful Ehsan: Assalam izzat, overall u need to remember 3 commons SFH and mean fetal weight:
These are the golden rules:
At pog 28 weeks = 1kg
At Pog 32 weeks = 1.7kg
At 36 weeks 2.4 - 2.6kg
Then the rest is based on palpation and adjust accordingly....
Nevertheless, it depends on ur experience as well...
If u guys palpate a lot enough...u can appreciate and just +/- the golden rule estimation
In presenting estimated fetal weight...please present in estimation of 0.2kg...
Eg estimated fetal weight is 2.6 to 2.8kg...
Thanks
Dr Shaiful Ehsan: Based on golden rules...lets say u palpate a patient's abdomen sfh is 38 weeks and its follow date...no other abnormalities u suspected on palpation...and its size appropriate....
U can tell EFW is aroun 3.0 to 3.2kg....
If u palpate it is quite small...u can roughly say 2.8 to 3.0kg...
Something like that...tq
[08/10 9:06 am]
sexual intercourse during pregnancy
Aiman Fauzi: Thank you doctor.. Doctor my patient ask me whether is it okay to have sexual intercourse during pregnancy? And she also inquire if 'pancut dalam' can cause any harmful effects on pregnancy?
Cc: faiz ros malu bertanya
Azrul Aziz: Sperm ade prostaglandin kan?
Azrul Aziz: Takut effect pada cervix
Dr Shaiful Ehsan: Waalaikumsalam for those who did ask the questions...
SI in pregnancy is indeed safe, though theoretically it may cause premature contraction due to presence of prostaglandin in semen....but it is still in grey area...
Even in placenta praevia, though painless bleeding may occur after SI....but no guidelines suggest avoidance of SI...
So, generally you can tell ur patients that there is no contraindications for performing SI during pregnancy...tq.
Dr Shaiful Ehsan: But for those presented with prem contraction...SI should be included under your history taking..
Can refer to my 6th note for juniors....got previous script with Dr Sudesan on prem contraction....tq.
[07/10 6:06 pm]
Cc: faiz ros malu bertanya
Azrul Aziz: Sperm ade prostaglandin kan?
Azrul Aziz: Takut effect pada cervix
Dr Shaiful Ehsan: Waalaikumsalam for those who did ask the questions...
SI in pregnancy is indeed safe, though theoretically it may cause premature contraction due to presence of prostaglandin in semen....but it is still in grey area...
Even in placenta praevia, though painless bleeding may occur after SI....but no guidelines suggest avoidance of SI...
So, generally you can tell ur patients that there is no contraindications for performing SI during pregnancy...tq.
Dr Shaiful Ehsan: But for those presented with prem contraction...SI should be included under your history taking..
Can refer to my 6th note for juniors....got previous script with Dr Sudesan on prem contraction....tq.
[07/10 6:06 pm]
management cor IUD of one fetus in twin pregnancies
Dr shaiful: Assalamualaikum, 5th month of pregnancy...so it would be after age of viability...which means more than 24 weeks gestations...which we called intrauterine death (IUD) or fetal demise...
For fetal demise of one fetus in twin pregnancy, mx depends on type of chorionicity, gestation and causes of fetal demise...
Dr. Shaiful: But for monochorionic twins (shared placenta) the risk of IUD of the paired twin is there...can be as high as 20%...even if survive...there is still risk of neurological damage to the surviving fetus...
I have encounter certain hospital giving MgSo4 (not for PE) but for cerebral protection in potential severe prem baby (eg htaa) which can be applied as well in this case of reducing risk of morbidity of surviving 2nd fetus...
Time of delivery is basically still grey area in monochorionic twins...and opinions from fetomaternal specialist (eg Dr Anna) is really required...
If conservative is choosed, some suggest delivery as early as 28 weeks for MCMA, and up to 34 weeks for MCDA...
Dr. Shaiful: Lets begin with DCDA twin (2 sacs 2 placentas = 2 different sets of rooms). If one fetus IUD, and the causes is not related to systemic or uteroplacental insufficieny, and most likely not gonna cause another IUD to the surviving fetus...conservative managememt can be done and wait for delivery at least till 34 weeks (most studies showed that 90% of preterm baby salvageable at 34 weeks)
Dr. Shaiful: Im forwarding my answers to ur fren in other posting asking about management cor IUD of one fetus in twin pregnancies....
Above are the answers...
Hope its useful...
Dr. Shaiful:My homework for u guys are events occur at 34 weeks...
Tq.
Faiz Roslan: Dr, one of the events occur during 34 weeks is that the amniotic fluid is at its max. Betul ke dr?
6oct2015
For fetal demise of one fetus in twin pregnancy, mx depends on type of chorionicity, gestation and causes of fetal demise...
Dr. Shaiful: But for monochorionic twins (shared placenta) the risk of IUD of the paired twin is there...can be as high as 20%...even if survive...there is still risk of neurological damage to the surviving fetus...
I have encounter certain hospital giving MgSo4 (not for PE) but for cerebral protection in potential severe prem baby (eg htaa) which can be applied as well in this case of reducing risk of morbidity of surviving 2nd fetus...
Time of delivery is basically still grey area in monochorionic twins...and opinions from fetomaternal specialist (eg Dr Anna) is really required...
If conservative is choosed, some suggest delivery as early as 28 weeks for MCMA, and up to 34 weeks for MCDA...
Dr. Shaiful: Lets begin with DCDA twin (2 sacs 2 placentas = 2 different sets of rooms). If one fetus IUD, and the causes is not related to systemic or uteroplacental insufficieny, and most likely not gonna cause another IUD to the surviving fetus...conservative managememt can be done and wait for delivery at least till 34 weeks (most studies showed that 90% of preterm baby salvageable at 34 weeks)
Dr. Shaiful: Im forwarding my answers to ur fren in other posting asking about management cor IUD of one fetus in twin pregnancies....
Above are the answers...
Hope its useful...
Dr. Shaiful:My homework for u guys are events occur at 34 weeks...
Tq.
Faiz Roslan: Dr, one of the events occur during 34 weeks is that the amniotic fluid is at its max. Betul ke dr?
6oct2015
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