JC M O&G

JC M O&G

THEME CASE 1
Dr N C Poddar

O&G

Wed 23-10-02
ANTENATAL SCREENING

LMP = 1^st day of last normal MP

MCV

Cervical smear: pre-invasive lesions (CIN, abn), ca, HPV, chlamydia (not routine in HK)

Blood group

Rubella

VDRL

HbsAg: +ve ® counselling

Vitals - P, BP, RR

Urine - glucose, protein, RBC, WBC, casts

Glycosuria - DM, intake, renal disease. If trace, repeat test. If +ve 2x ® OGTT (no longer screening). If pre-existing DM noted in Hx, not screening. If previously no DM then dev DM - GDM (gestational) or IGT, OGTT 2 samples (fast + post-glucose) - wait 2h and sample blood again (N < 5). DO NOT perform OGTT < 12w (nausea) \ perform at 13-15w, then repeat at 28-30w

Protein - UTI (may be subclinical, still need to Tx), UTI can ® pyelonephritis

HIV

US dating - foetal size ® crown-rump length (CRL), LMP wrong, irregular cycles, OCP, exclude tubal pregnancies, chromosomal abn (later), to be done at 1^st visit

Note: lactational amenorrhoea (mother breast-feeding but becomes pregnancy)

Screening

ID among apparently healthy individuals, of those who are sufficiently at risk of a specific disorder to justify a subsequent diagnostic test or procedure, or in certain circumstances, direct preventative action
Journal of Medical Screening - systematic application of a test or enquiry, to ID individuals at sufficient risk of a specific disorder to benefit from further Ix or direct preventative action, among persons that have not sought medical attention on account of symptoms of that disorder
DETECTION, INDICATION, SUSPICION

Thalassaemia

One of the most common genetic diseases in HK (incidence 1/10)

Risk of thalassaemia in local population = disease/+ve + disease/-ve

TOTAL

Detection rate of test = disease/+ve / disease

Specificity of test = healthy/-ve / healthy

Positive predictive rate of test = true +ve / test +ve

Negative predictive value of test = true -ve / test -ve

If risk of thalassaemia ¯ , you would expect

No D - sensitivity, specificity

¯ PPV - b/c true +ve would ¯

NPV - b/c true -ve would

CASE STUDY

Ms Cheung - 1^st antenatal consult @ 12w gestation (primigravida)

Hb = 9.8 g/dl

MCV = 68 fl (N > 80)

VDRL -ve

HbA2 2.3% (N < 3.5)

HbF 0.51% (N < 1%)

HbH +ve (b 3 chain)

Therefore, a -thalassaemia

Action - ask husband in for screening (Hb, MCV (, if normal, no action. If abn, electrophoresis

MINOR PREGNANCY DISORDERS

Signs of pregnancy

Amenorrhoea
Pregnancy test
Morning sickness
Frequency
Distension (later)
IVF
Sexually active

28/F, primigravida, 9wk gestation, antenatal clinic

C/O nausea, vomiting 2w, 1-2x/d, usually am, contains fluid/ small amt undigested food

Healthy all along

O/E well-hydrated, no abn physical signs, same wt as before pregnancy (43 kg)

SUFFERING - morning sickness, not severe (no wt loss, no dehydration)

WHAT TO TELL PT? 90% of preg get this, keep active, will stop after 12w (¯ HCG)

Pt returns 1w later, c/o severe vomiting everytime eat/drink, lost 3kg in 1w

O/E - dehydrated, admitted to hosp for Tx

SUFFERING? Hyperemesis gravidarum

WHY THIS DX? Wt loss, hydrated, ketones in urine (Tx = IV anti-emetic b/c tab vomited up)

WHY RAPID WT GAIN AFTER ADMISSION? ¯ vomiting, IV rehydration, some solids, feeling better

AGGRAVATION OF VOMITING? Socio-economic factors (stress, psych), Multiple pregnancy, Molar pregnancy, Watery diet, Hyperthyroidism (transient common in preg), Gastroeso reflux, UTI, Hepatitis

BLOOD TESTS? RLFT, Urine, Thyroid

WHY US PELVIS NEEDED? Check Multiple, Molar, Ectopic pregnancy

FAMILY & SOCIAL RELEVANT? Hyperemesis gravidarum with stress, ¯ $, ¯ attention/ position/ food, psych problems (PROBS @ HOME IMPORTANT!)

Pt recovers from vomiting. Comes back at 20w c/o occasional retrosternal heart-burning sensation

WHY? Gastroesophageal reflux
PRECIPITATING FACTORS? Eating, Supine (eg. immediately after meal)
COMMON DURING PREGNANCY? Yes (1) Relaxation of sphincter (progesterone relaxes all SM) (2) Pressure of uterus upwards on stomach

Pt c/o constipation, occasional fresh rectal bleeding immediately after bowel motions

CONSTIPATION COMMON IN PREGNANCY? ¯ peristalsis

CAUSE OF RECTAL BLEEDING? (1) Solid stool from ¯ peristalsis (2) Haemorrhoids (either new, or engorgement of existing + weakened BV - pregnancy haematological changes)

EXAMINATION TO CONFIRM DX? Proctoscopy

Pt now at 36w gestation + c/o back pain

COMMON SITE BACK PAIN? Lumbosacral + sacroiliac jt (LBP)

WHY PAIN? progesterone + oestrogen ® laxity of ligaments (also wt in front which D 's COG, posture/ gait of pregnancy)

EXPECT NEURO DEFICIT? Mostly no, maybe some due to oedema pressing on n

Signs noticed during P/E

Striae gravidarum

Linea nigra (reasons NK)

Flattened umbilicus

Distended stomach

Pregnancy pigmentation

Previous C-section scar

Varicose veins (with/ without oedema) - uterus impedes VR thru ab great vessels (also walking, standing)

Oedema = FELT, not seen (advise put feet up)

Pruritis vulvae (candida, trichomonas, chlamydia ® mixed) - imm-comp in preg

Candidiasis (high vaginal swab ® Tx: vaginal pessaries)

Vulval varices

Leg cramp (Tx = Ca++)

Acroparaesthesia - carpal tunnel/ medial nerve (physio, elevate arm)

Urinary frequency ( in 1^st and 3^rd trimesters more)

Headache

Palpitation (tachycardia at clinic - ran to clinic, nervous, heart disease, infection/ fever, transient thyrotoxicosis, previous untreated thyroid problem, hypokalaemia)

Faintness

Subluxed pubis - separation of symphysis pubis (acute severe pain, > 36w gestation) - perform elective C-section?