My Medical Notes

Severe Raynaud Phenomena in Patient with Scleroderma

2012-02-03T05:00:00.000-08:00

Severe form of Raynaud phenomena in patient with limited scleroderma. The above picture shows dry gangrenous changes of first till fourth toe with impending gangrene of fifth toe. vasculitis should also be suspected in this patient. Apart from typical scleroderma feature, patient also exhibit complication of pulmonary hypertension

1) What is Raynaud Phenomena?

2) Name three other rheumatic condition that can cause Raynaud phenomena other than Scleroderma?

3) What is the differences between Raynaud Phenomena and Raynaud disease

4) What is CREST syndrome

5) Do you think that it is common for the patient with Raynaud phenomena to develop gangrenous changes like this patient?

For answer to this questions, click [here]

Spot Diagnosis: Laceration Wound of Dorsum of Hand

2012-01-27T21:34:00.000-08:00

40 years old gentleman alleged cut his left hand with parang while doing some farm work. This picture of hand is taken while asking the patient to extend his fingers

1) Describe your findings

2) What is your spot diagnosis

3) Management for this patient

The anatomy of the Extensor Tendon of the hand

Answer

1) Findings

- oblique laceration wound at the dorsum of hand extending from base of ring finger to opposite of index finger

- index and middle finger in flexion position / inability to extend the index and middle finger

2) Deep laceration wound with cut of extensor digitorum of left index and middle finger

3) Management

- Wound irrigation

- Pain management (IV Tramadol/ NSAIDs-Paracetamol)

- IV Antibiotic covering gram positive, negative and anaerobs

- Anti tetanous Toxoid injection.
- Hand X Ray -Oblique and AP to exclude any bony involvement
- Full blood count for Hb level. Patient may need blood transfusion if anemia secondary to blood loss. TWBC count may be a helpful marker for infection. Coagulation profile may be helpful if suspected any clotting disorder.

- Wound exploration, debridement and tendon repair

- Thermosplint with hand in extension position for three weeks followed with hand exercise (Flexion-extension of fingers)

Treatment Option for Paediatric Femoral Shaft Fracture

2012-01-27T19:01:00.000-08:00

Complete Spiral fracture with Displacement and shortening of Left femur in 6 years old child.

While plating or Intramedullary nail being a famous and traditional treatment for femoral shaft fracture in adult, it remain controversial for the pediatric population.

For ages, conservative treatment with Pavlik harness and early or delayed cast have being implied. Study has shown that it is effective even in a severely displaced fracture or shortening up to 2.5 cm. However, it cause prolong immobilization leading to loss of school days and need of good nursing care.

Some literature may put a range of age of which treatment is the best but it remain subjective and depends on orthopaedist choice and agreement with the parent. Generally, conservative treatment is best reserved in children less than 5 years old and modality depends for children age from 6 to 13 years old. For the past few decades, the surgical management evolving very fast starting from the use of external fixator till the use of elastic platinum intramedullary nail.

After 2 weeks of skin traction, the shortening become lesser but still no callus formation seen

Various of method has being described and each of the treatment modalities has their own complication that should be discussed with parents.

Exernal fixator may cause pin tract inflammation and sepsis, malunion and refracture. But it may provide excellent result if the child being operated early within 24 hours of events even without prior traction. Usage of traction table prevent the malrotation and support the under leg and reduce the fracture before insertion of first pin.

Intramedullary nail fixation may give rise to avascular necrosis of the head of femur, coxa valga and physis disturbance

Plate and screws is a good choice to prevent rotational deformity and stabilize the fracture but it will leave a long scar, increased infection rate and require revision surgery later.

The problem with conservative treatment is the long duration of hospital stay and this will not only reduce the schooling time but also affect the working parent who needs to stay with child at wards for a long time. Besides, it may also affect the other siblings.

As a conclusion, the noble approach for modern management of paediatric fracture should shortened the hospital stay, comfortable, stabilize the fracture and less complication. This has led to many surgical approach to provide a better treatment for femoral shaft fracture in children. However, one should always bear in minds that the chosen method should spare the physis, not altering the vascularization of femoral head, as minimal invasive as possible and do not interfere with consolidation process or the fracture focus and stable enough as to not require additional casting for immobilization.[P. Gonzales-Herranz et al]

Reference:

1) Frech-Dörfler M, Hasler CC, Häcker F-M, "Immediate hip spica for unstable femoral shaft fractures in preschool children: still an efficient and effective option", Eur J Pediatr Surg 2010

2) Mukesh Kalra, Asif Mahmood & Mohit K.P, "Treatment of Pediatric Femoral Shaft Fracture with Titanium Elastic Nails- Our Experience", JCOT Vol 2, No 1, 2011

3) Peter Byass & Tedros A Ghebreyesus, "Pediatric Femoral Fracture", The Lancet, Vol 365, March 2005

4) Hanne Hedina, Sune Larsson, “Technique and considerations when using external fixation as a standard treatment of femoral fractures in children. ", Injury, Int. J. Care Injured (2004) 35, 1255—1263

5) P. Berger, J.S. De Graaf, R. Leemans, " The use of elastic intramedullaey nailing in the stabilisation of paediatric fractures", Injury, Int. J. Care Injured (2005) 36, 1217-1220, Elsevier

6) P. Gonzales-Herranz, M.L.I Rodriguez Rodriguez & M.A. Castro Torre, "Diaphyseal Femur Fractures in Children. Treatment Update", Rev esp cir ortop traumatol. 2011; 55(1): 54-66

Flying Feather: The Famous Tawau’s Street Weapon

2012-01-24T07:04:00.000-08:00

In the late 1940, Yutaka Katayama together with Ryuichi Romiya built flying feather. It is a car with good performance and economical value, yet a very light weight car that moves like a gull in flight. This can be also applied to another ‘flying feather’ which locally known as ‘pitik’ or ‘plem paddle’.This simple weapon is very light and sometimes just fly on the air and hit the victim without being realized until the adrenaline start to rush as the pain being perceived by the mind.


A young man who was accidentally shot by the arrow by unknown attacker while going out from his house.

Out of nowhere, the arrow just hit his foot. the only thing he felt was intense pain and he barely can walk.

The exact origin of this weapon is not known but with highest possibility that it is originate from Philippines. This small weapon is used in a gang fight where the purpose of this weapon is to injured the victim. Not adequate to kill the victim, but enough to bring them down so that everybody can go and beat them up with other methods. To make it more disastrous, they may put some poison at the end tip of the weapon.

A typical flying feather composed of nail with it's tip is sharpened and indented at the distal end. the other end is attached with plastic rope

Another version of flying feather without the tail.

However, most often the shot are made by a mischievous sick-minded youngster who just enjoy doing it for fun especially when there are festivities or crowds. Therefore, many patient will presented with history of walking in specific area at the town of Tawau or simply come out from their home when they get shot. The extent of injury therefore very limited and penetrate the soft tissue. However, if the attacker intended to hurt the victim by delivering a sharp and hard blow, it can even penetrate the deeper structure injuring the vessel, nerve, penetrating the abdomen or accidentally hit the eyes. The side effect of the weapon includes dirt bring by the rusted nails or used plastic rope taken from the dump side which carry hundred of bacteria hidden from the naked eye.

Another random victim of the flying feather

The weapon just fly in the air and hit the victims

This weapon is made by using simple instrument that can be found easily anywhere in the street including nail, plastic rope and rubber band. The sharp end of the nail is made flat by using a hammer first before sharpened it's tip and the distal end of it being indented to make this weapon more difficult to be taken out as the flesh will stuck in between the curvature. Then the end of the nail will be attached to the plastic rope by using a rubber band serving to increase the velocity of the weapon as it is being shot later. The plastic rope also very helpful if the attacker just blindly shot the arrow into the air and it will randomly guide the arrow to hit the target. Some attacker will not use the plastic rope if the weapon is intended to be fire at a short distance and the arrow will straightly penetrate the victim’s body.

The sharpened and indented tip of the nail which made it easily penetrate the soft tissue and make the removal challenging.

Managing the flying feather injury may look simple but not to be taken lightly. Starting with Anti tetanus toxoid jab, health care personnel should access the extend of the injury at the bedside. Routine blood investigation should be taken as patient might be needing of surgery. The coagulation profile may give a clue as rat poison use by the attacker may impair the coagulation cascade and the total white blood cell count will raise due to infection. Simple plain X- Ray will help to evaluate further the extend of the injury and rarely other modality are needed.

Deep injury with entry and exit points

If this young man is unlucky, the weapon could just penetrate his abdomen.

Irrigation with copious of normal saline will help to dilute the bacterial load and reduce the infection and inflammatory agents. Proper debridement in the OT may then be needed and the wound should be left open first with daily wound dressing before it is ready for secondary suturing. Intravenous antibiotic covering for gram positive, negative and anaerobe is the next of priority together with pain management

Ectopic Pregnancy Ultrasound

2012-01-02T05:33:00.000-08:00

Lower Limb Trauma

2012-01-01T10:23:00.000-08:00

25 years old gentleman fall from his motorbike at the speed of 70 km/hr and his left leg landed on the road divider. He sustains pain over his leg and unable to move the leg due to pain. He was fully conscious during the accidents. Below is the radiograph image of his left femur.

Questions

1) Describe the radiographic finding

2) What other injury that you are looking for

3) Complication that this patient may have

4) Management for this patient

For answer to this questions, click [here]

The Legal Aspect of Therapeutic Abortion in Malaysia

2012-01-01T06:31:00.000-08:00

A 16 weeks of gestation fetus who was terminated through cervagerm insertion due to severe uncontrolled chronic hypertension that is exacerbated by pregnancy.

As a general rule, abortion is illegal in Malaysia and both parties; the mother and the provider of the service can be charged according to penal act. Exception to this is for the medical cause in which a registered doctor formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health of the pregnant woman, greater than if the pregnancy were terminated. Apart from this cause, it remains illegal.

As for example, a rape case alone is not an indication for the legalization of abortion. However, if the pregnant mother of a rape case develop severe mental distress in which according to medical doctor could harm her in any aspect, therefore it is legal to perform abortion.

Another issue is whether should the abortion needs consent from the patient. As a general rule, abortion performed without consent from the mother deserves a penalty charges. However, another section (section 92) can be applied to save a doctor who performed abortion with a good intention to save the mother’s live.

The indication of legal abortion in Malaysia including 1) Any medical condition that can be worsened by pregnancy. 2) A pregnancy with fetus that is unlikely to survive like anencaphaly. This is not applied to any syndrome or congenital malformation in which the baby could survive like Down syndrome. 3) A rape case in which the pregnancy causing the mental distress to the patient.

The Malaysian Medical Council regards induced non-therapeutic abortion a serious infamous conduct and if proved to the satisfaction of the Council, a practitioner is liable to disciplinary action. A criminal conviction in Malaysia or elsewhere for the termination of pregnancy in itself affords grounds for disciplinary action. (Code of Medical Ethics, Malaysian Medical Association)

Below is some penal act regarding abortion in Malaysia.

Causing miscarriage

312. Whoever voluntarily causes a woman with child to miscarry shall be punished with imprisonment for a term which may extend to three years or with fine or with both; and if the woman is quick with child, shall be punished with imprisonment for a term which may extend to seven years, and shall also be liable to fine.

Explanation—A woman who causes herself to miscarry is within the meaning of this section.

Exception—This section does not extend to a medical practitioner registered under the Medical Act 1971 [Act 50] who terminates the pregnancy of a woman if such medical practitioner is of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health of the pregnant woman, greater than if the pregnancy were terminated

Causing miscarriage without woman’s consent

313. Whoever commits the offence defined in section 312, without the consent of the woman, whether the woman is quick with child or not, shall be punished with imprisonment for a term which may extend to twenty years, and shall also be liable to fine. Death caused by act done with intent to cause miscarriage. If act done without woman’s consent

314. Whoever, with intent to cause the miscarriage of a woman with child, does any act which causes the death of such woman, shall be punished with imprisonment for a term which may extend to ten years, and shall also be liable to fine; and if the act is done without the consent of the woman, shall be punished with imprisonment for a term which may extend to twenty years

Explanation—It is not essential to this offence that the offender should know that the act is likely to cause death

Act done with intent to prevent a child being born alive or to cause it to die after birth

315. Whoever before the birth of any child does any act with the intention of thereby preventing that child from being born alive, or causing it to die after its birth, and does by such act prevent that child from being born alive, or causes it to die after its birth, shall, if such act is not caused in good faith for the purpose of saving the life of the mother, be punished with imprisonment for a term which may extend to ten years or with fine or with both.

Act done in good faith for the benefit of a person without consent

92. Nothing is an offence by reason of any harm which it may cause to a person for whose benefit it is done in good faith, even without that person’s consent, if the circumstances are such that it is impossible for that person to signify consent, or if that personis incapable of giving consent, and has no guardian or other person in lawful charge of him from whom it is possible to obtain consent in time for the thing to be done with benefit: Provided that this exception shall not extend to—

(a) the intentional causing of death, or the attempting to cause death;

(b) the doing of anything which the person doing it knows to be likely to cause death, for any purpose other than the preventing of death or grievous hurt, or the curing of any grievous disease or infirmity;

(c) the voluntary causing of hurt, or to the attempting to cause hurt, for any purpose other than the preventing of death or hurt;

(d) the abetment of any offence, to the committing of which offence it would not extend.

ILLUSTRATIONS

(a) Z is thrown from his horse and is insensible. A, a surgeon, finds that Z requires to be trepanned. A, not intending Z’s death, but in good faith, for Z’s benefit, performs the trepan before Z recovers his power of judging for himself. A has committed no offence.

(b) Z is carried off by a tiger. A fires at the tiger, knowing it to be likely that the shot may kill Z, but not intending to kill Z, and in good faith intending Z’s benefit. A’s ball gives Z a mortal wound. A has committed no offence.

(c) A, a surgeon, sees a child suffer an accident which is likely to prove fatal unless an operation be immediately performed. There is no time to apply to the child’s guardian. A performs the operation in spite of the entreaties of the child, intending, in good faith, the child’s benefit. A has committed no offence.

(d) A is in a house which is on fire, with Z, a child. People below hold out a blanket. A drops the child from the housetop, knowing it to be likely that the fall may kill the child, but not intending to kill the child, and intending in good faith, the child’s benefit. Here, even if the child is killed by the fall, A has committed no offence.

Explanation—Mere pecuniary benefit is not benefit within the meaning of sections 88, 89 and 92.

Bone infection

2011-12-28T07:00:00.000-08:00

An 80 years old lady with history of bipolar implants of the left leg for 2 years due to fracture of the neck of femur and defaulted follow up presented with left leg pain and chronic serous discharge from the implant site. Below is the radiological image of his left femur.

Questions

1) Describe the radiological findings

2) What is your provisional diagnosis

3) Investigation

4) Management for this patient.

5) What are the component of implant failure

For answer to this questions, click [here]

Radius Fracture

2011-12-27T15:17:00.000-08:00

16 years old boy fall from motorbike with his wrist landing in flexion position. He sustains pain, deformity and swelling of his right hand. Picture A is his right hand and picture B is the Right/Ulnar radius with Hand X Ry in AP and Lateral view.

Picture A

Picture B

Questions

1) Describe the radiological finding for this patient

2) What is your spot diagnosis?

3) How do you differentiate between Smith vs Barton's fracture?

4) How do you treat this fracture?

5) Complication of untreated or mis treatment of this fracture?

For answer to this question, click here

Traumatic amputation of Finger

2011-12-08T08:08:00.000-08:00

A three years old girl sustained injury after her left hand accidentally caught by the escalator. Picture shows complete amputation of the fifth finger and fingertip injury of the fourth finger. The radiology film shows open fracture of the distal phalanx and complete bone loss of distal and intermediate phalanx of the fifth finger.

Basically traumatic finger amputation may be divided into

1. Distal to DIP joint (Fingertip injury)

2. Proximal to DIP joint.

Objective to achieve in managing this injury

1. Reduce pain

2. Preserve sensation of fingertip

3. To help the wound heal with as little functional disability.

Simple concept

1. Amputation distal to DIP – Refashioning

2. Amputation proximal to DIP – Re implant the finger provided avaibality of equipment and skillful hand surgeon to perform hand microsurgery. Even so, patient should be warned of possibility of failed implantation and the finger will not fully functioning. In the absent of all these, re fashioning is the answer to help the wound heal.

Management of traumatic finger amputation.

1) Airway, breathing and circulation. Always remember that live first before the limb.

2) Adequate analgesia

3) Wound irrigation

4) compression bandage to stop bleeding

5) Immobilization of the injured part

6) Radiology investigation to look for the extent of injury

7) Further evaluation of the injury under digital ring block or in the operation theatre.

8) Wound debridement

9) Refashioning of the injury distal to DIP and nail bed injury.

Note: Study shows that if nail and surrounding nail margin intact, then no need to remove the nail.

10) Re implantation of finger proximal to DIP if possible

a. Clean wound

b. adequate tissue

c. availability of facility and skills for hand microsurgery

11) immobilization of the injured part either by using K-wire or simple splint depending on assesment to the patient.

12) Antibiotic

13) finger exercise.

14) KIV for skin graft if wound can not be closed.

Aetiology and Complication of Abnormal Lie

2011-09-30T11:02:00.001-07:00

Dun like killer examiner :

2nd question: Dothe same complications of unstable lie apply as well in transverse and obliquelie? e.g rupture of uterus and compund presentation

30 Sep 2011 5.30PM

Answer

In approachingthis question, we need some area of clarification for the usage of the term.. Basically,we refer all this problem as abnormal lie. Lie is defined as relationshipbetween longitudinal axis of fetus to the longitudinal axis of maternal uterus.

Presentation isdefined as part of fetal that presenting at the superior strait of the maternalpelvis. Simply put, it means, what part of fetus that appear at maternalpelvis.

Meanwhile, unstablelie is defined as the lie of fetus persistently changed at term because it is aphysiological act of the baby to change it’s lie and presentation before 36weeks. After 36 week, the normal lie is longitudinal.

Patient withunstable lie may have transverse or oblique lie during labour. Be it at term orduring delivery. It may also turn back to longitudinal lie.

The most commoncause for abnormal presentation is uterine laxity seen in patient withmultiparity or anything that cause distension of uterus (previous multiplepregnancy, fibroid etc). Other causes includes, multiplegestation, polyhydramnios, prematurity/ wrong dating, placenta previa, fetalanomaly, uterine anomaly, pelvic mass and contracture of the uterus.

You also need toknow the physiology of the growing fetus and the anatomy of the uterus. In earlypregnancy, all baby have unstable lie. As the uterus getting bigger and bigger,the pear shape of the uterus make the upper space being occupy the larger partof the baby (buttock) and the lower space being occupy by the head.

However, in laxuterus, the baby may settle down it position in transverse position and itbecome more comfortable with that position. As the uterus and baby grow, itjust fit in that position.

Polyhydramnios,prematurity multiple gestation will have this problem simply because there area lot / bigger space in wombs that they easily turning around. (relative liquorvolume in relation to fetal size)

Meanwhile, anyinjury/ abnormality of the uterus make the baby unable to turn into longitudinallie and remain in their position.

Using the sameprinciple, you may explain why baby with neural tube defect have unstable liewhich basically due to the polyhydramnios.

After youunderstand the physiology of the baby lie and uterus anatomy, then you canexplain easily the complication of the abnormal lie with regards to theiraetiology.

Why did uterinerupture occur? Basically it is due to the obstructed labour in over distendeduterus.

Abnormal presentationbe it compound, cord, face, brow can also due to the complication of unstablelie. Because, as i mentioned earlier, presentation simply means relation offetal part with maternal pelvis. So anything can happen but there will becertain condition that will have abnormal presentation as complication. Forexample, cord prolapse more common in footling breech, compound presentationmore commonly occur in transverse lie and many more.

Evidence Based Approach for The Management of Asthma in Pregnancy

2011-09-24T08:15:00.000-07:00


Picture of a pregnant woman using an inhaler taken from science library photo taken at this link [here]

Asthma is anincreasingly common chronic illness in pregnancy with the prevalence may reachup to 8%. [Holland & Thomson, 2006]. Pregnancy is characterized by aphysiological immunosuppression, an immunological tolerance that protects thefetus from maternal immune response against paternal antigens expressed by thefetus. [Lilla Tamasi et al, 2011]

Physiologicalpregnancy has been described as a Th2-dominated state, and current studies showthat a trimester dependent, pregnancy-induced increase in regulatory T cell(Tregs) number has a key role in the maintenance of maternal tolerance topaternal antigens during pregnancy, exerting an inhibition on the activation ofeffector T lymphocytes and NK cells. [LillaTamasi et al, 2011] Absence of trimester dependent regulatory T cellelevation in asthmatic pregnancy leads to impaired inhibition of T lymphocyteand NK cell activation and proliferation. Elevated numbers of activatedeffector T lymphocytes and NK cells may cause immune mediated alteration offetal growth and enhancement of allergic/asthmatic response. [Lilla Tamasi et al, 2011]

Pregnancy may alterthe natural course of asthma. Asthma improves during pregnancy in aboutone-third, remains the same in another one-third, and worsens in one-third of pregnantwomen. More severe asthma before pregnancy increases the risk of worseningduring pregnancy, and there is a concordance between the courses of asthmaduring subsequent pregnancies [LillaTamasi et al, 2011]. Lung inflammation, smoking, obesity , alteredplacental function [Ross E. Rocklin, 2011] and female fetuses are alsorecognized risk factor for asthma exacerbation. [Lilla Tamasi et al, 2011] and poor pregnancy outcomes.

Patient may alsosuffers from co- morbid condition such as obesity, pregnancy-inducedhypertension and gastro-oesophageal reflux. [Holland& Thomson, 2006] Asthma represents a risk factor for several maternaland fetal complications, such as asthma exacerbations, use of oral corticosteroids,hospitalizations due to asthma attacks, preeclampsia, gestational hypertension,preterm delivery, cesarean delivery, low birth weight, intrauterine growth restriction,and fetal death [Lilla Tamasi et al,2011].

Most of theasthma exacerbation are usually mild and self limiting and rarely causingsevere attack. However, if severe exacerbation occur, it will cause significantmorbidity and mortality to the patient as well as the fetus. Major risk of asthma to the mother and fetusare due to under treatment or poorly controlled disease and may be compoundedby poor maternal compliance with treatment due to fears of side-effects on theunborn child [Holland & Thomson,2006] Apart from that, Jennifer W. Mc Callister et al, has found out thatthere is a disparities of treatment for acute exacerbation of asthma in emergencydepartment especially in term of systemic steroid administration. This should not happen and pregnancy shouldbe considered an indication for maximizing therapy during an exacerbation,rather than withholding it.

Congenitalmalformation may complicate maternal asthmatic exacerbation in early trimester asmaternal hypoxia together with respiratory alkalosis may decrease the placentalblood flow. Decreased fetal blood oxygen could result in abnormal growth anddevelopment of the fetus. Furthermore, maternal hypoxia has been found to beassociated with an increased risk of cleft lip and palate in mice.[ LucieBlais & Amelie Forget, 2008]

Short actingbeta 2 agonist (SABA) is safe eventhough it is previously being said that theusage of this agent will increase the risk of developing pregnancy inducedhypertension. The explaination laid behind this hypothesis was that the inhaledSABA will enter the systemic circulation and cause vasodilation of the bloodvessel. This will then cause reduction in diastolic blood pressure and causereflex tachycardia. Study by Marie-Jose´eMartel et al however shows that inhaled SABA actually reduced the risk ofPIH and the use of this medication is safe throughout pregnancy. The reasonsfor the previous hypothesis of relation between SABA-PIH could be due to somereason including smoking and maskingeffect of SABA that reduce the diastolic blood pressure, hence lead to underdiagnosed of PIH. The usage of SABA alone is safe, however, it should bepointed out that all patients with persistent asthma require a controllermedication such as an inhaled steroid [R.E.Rocklin et al, 2011]

Long-acting Beta2 agonists are now recommended to be used in conjunction with inhaled steroids.The use of these long-acting bronchodilators as monotherapy was reported in onestudy that did not find any evidence of an effect on fetal growth in humans [R.E. Rocklin et al, 2011]

The usage ofhigh dose ICS may increase the risk of congenital malformation if use in thefirst trimester. Lucie Blais et al inher study observed that women who took high doses of ICSs during the firsttrimester of pregnancy were 63% more likely to have a baby with a congenitalmalformation than women taking low to moderate doses of ICSs. However, low tomoderate dose of ICS is safe. Furthermore, current asthma guidelines recommendICSs for the management of all levels of persistent asthma during pregnancy andrecommend that pregnant women be treated as aggressively as nonpregnant womento achieve and maintain control of asthma. [Marie-Claude Breton et al, 2010] Therisk of perinatal mortality was not found to be significantly associated withICS use during pregnancy. The result associated with higher doses of ICSs islimited due to a lack of statistical power and a possibility of residualconfounding by asthma severity and control. [Marie-Claude Breton etal, 2010] Furthermore, a trend towards higher Treg cell prevalence wasobserved compared to those with inadequate adherence to ICS treatment. [Lilla Tamasi et al, 2011] Therefore,asthmatic pregnant women should be managed with the minimum effective ICS dose.But if higher doses of ICSs are needed to control asthma, their benefitsoutweigh their risks. [Marie-ClaudeBreton et al, 2010]

The usage oforal corticosteroid previously being said to be associated with increase riskof congenital malformation particularly cleft lip, cleft palate or both.However, observation by Lucie Blais &Amelie Forget in their study shows that women who had an asthmaexacerbation but who did not fill a prescription for oral corticosteroids were2 times more likely to have a baby with a major congenital malformation thanwomen who did not have an exacerbation. It is found that the hypothesis thatlink between the usage of oral corticosteroid and congenital malformation areweak. Study by Ludmila N.Bakhireva et al, demonstrate that the usage of systemic corticosteroid mayresulting in deficit of about 200 g in birthweight compared with controls andexclusive B2-agonist users. However, the result is not significant to suggestthat the usage of this agent impair fetal growth and it use should be weighedagainst the necessity to control severe asthma.

Chromones suchas cromolyn and nedocromil have an anti inflammatory activity but due to theirrelatively limited efficacy, it should only be used in mild persistent asthmaand recommended as alternative medication only.

Leukotrianemodifiers such as leukotriene receptor antagonists (montelukast andzirfirlukast) and 5-lipoxygenase pathway inhibitors (zileuton) are notpreferred as treatment option in mild persistent asthma in pregnancy.

Theophyllinethat has bronchodilating activity and mild anti inflammatory properties are safeto be used in pregnancy but it is considered as alternative treatment and notthe preferred therapy

In managingsevere acute asthma, Oral corticosteroid should not be witheld. The BritishThoracic society guidelines has clearly stated that the medical management ofasthma in pregnant and non pregnant mother are same. Volume resuscitationshould be considered as there would be a volume deplition due to combination ofhyperventilation and intercurrent sepsis despite of difficulty in accessing thefluid balance. Central venous access is impractical and potentially dangerousin severe asthmatic. Regional anesthesia especially epidural is more preferredthan general anesthesia if patientrequired operative delivery or as pain management as it reduce hyperventilationand stress response to the pain. However, judgement should be made clearly asregional anesthesia would be impractical in patient who are severely breathlessand precipitate deterioration of lung function due to loss of intercostalmuscle function

Apart from that,education about asthma, life style modification and smoking cessation should beencourage to the patient. Main educationtopic should includes information about the disease, use of inhaler devices,adherence to treatment and importance of regular visit, environmental controlmeasure to reduce exposure to allergens and irritants and self treatment actionplan. [Lilla Tamasi et al, 2011].

Reference:

1) FaranakFiroozi, Catherine Lemiere, Francine M. Ducharme et al, "Effect ofmaternal moderate to severe asthma on perinatal outcomes", RespiratoryMedicine (2010) 104, 1278- 1287

2) JenniferW. McCallister, Cathy G. Benninger, Heather A. Frey, et al, "Pregnancyrelated treatment disparities of acute asthma exacerbations in the emergencydepartment", Respiratory Medicine (2011) 105, 1434-1440

3) LillaTamasi, Ildiko´ Horvath, Aniko Bohacs et al, " Asthma in pregnancy eImmunological changes and clinical management", Respiratory Medicine(2011) 105, 159-164, Elsevier

4) LucieBlais & Amelie Forget, "Asthma exacerbations during the firsttrimester of pregnancy and the risk of congenital malformations among asthmaticwomen", J Allergy Clin Immunol 2008;121:1379-84

5) LucieBlais, Marie-France Beauchesne, Catherine Lemie` & Naoual Elftouh,"High doses of inhaled corticosteroids during the first trimester ofpregnancy and congenital malformations", J Allergy Clin Immunol2009;124:1229-34.

6) LudmilaN. Bakhireva, Kenneth Lyons Jones, Michael Schatz et al, "Asthmamedication use in pregnancy and fetal growth", J Allergy Clin Immunol2005;116:503-9.)

7) Marie-ClaudeBreton,, Marie-France Beauchesne, Catherine Lemie, et al, "Risk ofperinatal mortality associated with inhaled corticosteroid use for thetreatment of asthma during pregnancy", J Allergy Clin Immunol 2010;126:772-7.

8) Marie-Jose´eMartel, E´ velyne Rey, Marie-France Beauchesne, et al "Use of short-actingb2-agonists during pregnancy and the risk of pregnancy-inducedhypertension", J Allergy Clin Immunol 2007;119:576-82

9) RossE. Rocklin, "Asthma, asthma medications and their effects onmaternal/fetal outcomes during pregnancy", Reproductive Toxicology 32(2011) 189–197

10) S. M.Holland, K. D. Thomson, "Acute severe asthma presenting in latepregnancy", International Journal of Obstetric Anesthesia (2006) 15, 75–78

to download pdf version of this paper, please click [here]

Physiological Immunosuppression in Pregnancy

2011-09-24T07:21:00.001-07:00

Diclaimer: This is not written by blog author butrather taken from: Lilla Tamasi, Ildiko´ Horvath, Aniko Bohacs et al, " Asthma inpregnancy e Immunological changes and clinical management", RespiratoryMedicine (2011) 105, 159-164, Elsevier. This note is not for the commercialuse and mainly for educational purposes.

Pregnancy is characterized by a physiologicalimmunosuppression, an immunological tolerance that protects the fetus frommaternal immune response against paternal antigens expressed by the fetus.

Diminished numbers of Tregs in pregnancy wereassociated with immunological rejection of the fetus as well as preeclampsiaand low fetal birth weight.

Of note, Tregs exert inhibitory effects on naturalkiller lymphocytes responsible for protection against viruses that maycontribute to increased susceptibility to viral infections (e.g. influenza)during pregnancy.

False vs. True Umbilical Cord Knot

2011-09-14T01:14:00.000-07:00

Introduction

1.Umbilical cord length varies from achordia to 300cm, diameters up to 3cm.

2.Helical in nature with as many as 380 helices.

4.Avarage umbilical cord is 55cm, 1-2cm in diameter and 11 helices.

5.Most cord coils to left with unknown reason

6.5% of cord shorter than 35 cm and 5% longer than 80 cm.

7.Short cord a/w fetal movent disorder, intrauterine constrain, placentalabruptio and cord rupture.

8.Long cord a/w fetal entanglement, true knot and thrombi.

True knots


©1993 – 2010 by The University of Utah • Spencer S. Eccles Health Sciences Library, image taken from this [link]

1.Complicates 1% of pregnancy with highest rate occuring in monoamniotic twin.

2.Arise from fetal movement and more likely to develop during early pregnancy(more amniotic fluid and greater fetal movement)

3.Also could associated with abnormally long umbilical cord, advanced maternalage and multiparity.

4.May lead to up to a 4 fold increase of fetal loss (about 10% of fetalmortality)

5.Umbilical cord is tied in a true knot

6.May be loose or thight

7.Loose knot did not affect circulation (no color changes or swellings)

8)Thight knot (affect circulation, lead to hemorrhage on the fetal side of knotand edema on the placental site). It also can cause compression of Wharton'sjelly and mural thrombosis in umbilical vessel

False knot

1.Of no clinical importance and it is actually kinks in the cord due to tortuousaggregation of dilated ectatic vessel with less covering of Wharton's jelly.

Image taken from this [link]

Notes:

1.Wharton's jelly (substantia gelatinea funiculi umbilicalis) is a gelatinous substancewithin the umbilical cord, largely made up of mucopolysaccharides (hyaluronicacid and chondroitin sulfate). It also contains some fibroblasts andmacrophages. It is derived from extra-embryonic mesoderm.[Wikipedia]

2.Ectasia is a pathologically explaination for distension or dilation of a duct,vessel, or hollow viscus

Reference

1.Linda Ernst, "Umbilical Cord Knot",http://radiology.uchc.edu/eAtlas/GYN/405.htm

2.Marie Helen Beall, "Umbilical Cord Complications"http://emedicine.medscape.com/article/262470

Maternal Obesity and Postpartum Hemorrhage

2011-09-13T00:52:00.000-07:00

Image taken from this [link]

Disclaimers The Points are not written by the blogauthor but extracted from article for continuous medical education; Emma Hitt," Maternal Obesity Increases Riskfor Postpartum Hemorrhage", http://www.medscape.org/viewarticle/748707based on study by Blomberg, Marie, "MaternalObesity and Risk of Postpartum Hemorrhage", Obstetric &Gynecology, September 2011 - Volume 118 - Issue 3 - p 561–568

1. Maternalobesity seems to be associated with an overall increased risk of postpartumhemorrhage, but risk estimates vary from 7% to 70%

2. The risk foratonic hemorrhage appears to increase rapidly with increasing body mass index(BMI)

Study by , Dr.Blomberg:

1) Data wasanalyzed rom the population-based Swedish Medical Birth Registry, whichincludes 1,114,071 women who gave birth to 1 child in Sweden from January 1,1997, through December 31, 2008.

2) Participantswere separated out based on weight, with obesity being classed from I to III.

3) Hemorrhagewas defined as loss of more than 1000 mL of blood

4) Type ofhemorrhage; retained placenta, uterine atony, laceration in birth canal

Result

1. Prevalence ofpostpartum hemorrhage increased over the study period

2. There was anincreased risk for postpartum hemorrhage for women with a BMI of at least 40kg/m2 after normal delivery compared with normal-weight women (5.2% vs 4.4%;odds ratio [OR], 1.23; 95% confidence interval [CI]

3. Theassociation was even greater after instrumental delivery for obese vs normal-weightwomen (13.6% vs 8.8%; OR, 1.69; 95% CI, 1.22 - 2.34).

risk for atonicuterine hemorrhage increased directly with increasing BMI, with a 2-foldincreased risk in the heaviest obese group

4. Noassociation was found between maternal obesity and other types of hemorrhage.

5. Maternalobesity also increased the likelihood of heparin-like drug use (OR, 2.86; 95%CI, 2.22 - 3.68).

6. Risk forpostpartum hemorrhage after induction of labor was not affected by BMI,regardless of delivery mode.

Study limitation

1. Reliance onInternational Classification of Diseases codes to define various types ofpostpartum hemorrhage,

2. Variation incriteria for diagnosis and in method of estimating blood loss,

3. Failure toinclude oxytocin use and epidural anesthesia as possible confounders.

Conclusion:

1. This newknowledge emphasizes the need for active management after delivery of theplacenta

2. Considerationto use prophylactic postpartum uterotonic drug

Preparation for Emergency Cesarean section

2011-08-31T16:25:00.000-07:00

1) Explain briefly and meaningfully to the patient regarding indication for emergency cesarean

2) Informed consent

3) Consent for blood transfusion

4) Paediatric referral to standby for delivery

5) Prophylactic antibiotic (IV cefoperazone 1 g+ IV metronidazole 500 mg stat)

• Some place may use IV ampicillin 1g +IV metronidazole 500mg stat

6) Prophylactic for acid aspiration (assume all patient take orally)

- IV ranitidine 50 mg stat

- IV maxalon 10 mg stat

- Oral citrate solution, 30 ml (0.3 molar)

7) Fill up the Emergency OT list. Crucial investigation are FBC+ BUSE and PT/aPTT if result already available.

8) Make sure that GXM of 2 unit whole blood readily available. Depending on pre op Hb, the total number of GXM may be increased.

9) Insert the CBD.

Post op plan for patient post Cesarean Section

2011-08-31T16:10:00.000-07:00

For spinal analgesia

1) Keep patient lie flat till next review

2) V/S ½ hourly for 2H, then hourly till stable. After than 4 hourly.

3) Keep patient nil by mouth till next review

4) IV fluid maintenance 5 pints (2 pints D5%, 3 pints NS) / 24H

5) I/O chart

6) Pad chart

7) Keep CBD X 1/7

8) Wound inspection D2 (*some place, D3)

9) STO D7

10) S/C heparin 5000U B.D (6 hour post op till patient ambulate)

11) S/C Morphine 5 mg 4 hourly (*Some place may use suppositories voltaren)

12) IV antibiotic

- IV cefoperazone 1g BD

- IV metronidazole 500 mg t.d.s

13) Post op Hb (6 hour post op)

If patient under intra thecal analgesia

- Omit S/C morphine 5mg 4-Hrly

- Add IV piriton 10 mg t.d.s

- Add IV maxalon 10 mg t.d.s

If patient having blood loss more than 1000cc

- Withold S/C heparin until the result PT/aPTT come back and normal.

- FBC stat. To transfuse whole blood if Hb less than 8 or patient symptomatic.

- Double hematinic once patient tolerating orally

Diabetic foot ulcer

2011-07-01T06:13:00.000-07:00

This man has Diabetes Mellitus

Questions

1)Describes the abnormal findings
2)What is your diagnosis?
3)Give two investigations

For answer to this question, click [here]

Complication of fracture

2011-06-29T07:09:00.000-07:00

This man has history of MVA 6 months prior to admission

Questions

1)Describes the abnormal findings
2)What is your diagnosis?
3)Give two further investigations to support your diagnosis

For answer to this question, click [here]

OSCE pro III series 25

2011-06-29T06:52:00.000-07:00

OSCE Pro III 2003 Station 4

Questions

1)Name the device
2)Name two indications
3)Name four complications
4)Mark the site of insertion in the picture

For answer to this question, click [here]

OSCE pro III series 24

2011-06-28T00:05:00.000-07:00

Image source [link]
Provider: CDC/Dr. Lucille K. Georg

Questions
1)Describes the abnormal findings
2)Diagnosis
3)Name one investigation to confirm the diagnosis
4)Treatment

For answer to this question, click [here]