NBE CME programme for DNB consultants - National Board Of ...

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NBE CME programme for DNB consultantsPersonal history - Addiction to drugs, alcohol, cigarette smoking, Socioeconomic status, Nutritionaladequacy; Family History - H/o DES exposure in the mother of the patient, H/o DM/HT/thyroiddisorder, H/o recurrent preterm births in family, H/o of GCA in the baby in the family.Examination - Height, Weight, BMI, Pulse, BP, Thyroid examination, Breast (pregnancy change ofbreast), Per Abdomen - Uterine fundal height, whether corresponding to gestational age or not, Anyuterine activity ( whether any contractions present or not ), Presentation of the fetus, Estimatedbaby weight, Liquor volume, Fetal heart rate auscultation, Per speculum - Any discharge P/V,Leaking and bleeding P/V, Cervical os dilation/funneling of the cervix, Per vaginum, Cervical length,dilatation of os, funneling of the cervixInvestigations - BG, RH typing, Complete blood count (TLC, DLC), Sugar – fasting and post prandial,Urine – routine and microscopy + culture, HVS-C/S or cervical smear – culture and sensitivity; USG- Fetal maturity, viability and fetal growth biometric parameters, To rule out GCA, Liquor volume,Placental localization and grading, Uterine congenital anomaly, Cervical parameters- length,dilatation or funneling of the cervixManagement of preterm labour- Management of patient with warning symptom of preterm labour,Management of patients in established preterm labourManagement of patient with warning symptoms- Bed rest, Reassurance, Treatment of any riskfactors for preterm labour – treatment of vaginal infection, urinary tract infection, fever or medicaldisorder like PIH, renal disease; Sedation may be considered; Glucorticoids may be considered;Role of tocolysis in inhibiting preterm labour – only when uterine contraction are present andassociated cervical dilation is there, under 2 conditions-For the effect of – gluocorticoids can set in24 hours, tocolysis can be given, For the transfer to a tertiary care unit, where good nursery carefacilities are available; Identification of patient in whom the preterm labour need not be inhibited -Advanced preterm labour, Choriomnionitis, Fetal congeniatl anomaly, Severe fetal growth restriction,Disease detrimental to meternal health - Uncontrolled DM, Severe preeclampsia, eclampsia.Management of established preterm labour - Glucorticoids (inj. Betamethasone 12mg I/M repeat12mg after 24 hrs.); Tocolysis may be considered if no contraindication to its use are present andtill the time glucorticoids action sets in - Beta-adrenrgic agents, Isoxurpine, Ritodrine, Terbutaline,Calcium channel blockers, Magnesium sulpate, Indomethacin; Nursery and pediatrician to beinformed; Intensive labour monitoring and aseptic precautions at the time of delivery.Abnormal uterine bleedingHistory-age;Obstetric history pertaining to abortions, ectopic, gestational trophoblastic disease,last child birth, any complication causing endometritis;Menstrual history – excessive bleeding,content (clots or POCs), amount, cydical / acyclical, post – coital or intermenstrual; H/O D&C orinstrumentation; H/O Hormonal Contraception or irregular use of hormonal preparations, IUCDs;H/O sexually transmitted diseases;disorders, aspirin or any anticoagulant use; H/O abnormalweight gain, cold or heat intolerance, S&S of diabetes, hirsutism (excessive hair growth),glactorrhoeaExamination- Appearance, obese/excessively cachetic, weight, height; Enlargement of thyroid,petechiae or ecchymosis on skin ; Discharge from breasts, hair distribution; Secondary sexualcharacterstics; Any mass or lump in abdomen, hepatosplenomegaly; Any abnormal discharge,growth or ulcer in per speculum examinationInvestigations-CBC with differential count and platelet count; Coagulation profile, APTT whererequired; Blood Grouping and RH typing; Urine albumin, sugar and microscopy; Blood sugar –fasting and psot-prandial; Liver function tests; Pap’s smear; Endomaterial sampling orHysteroscopy (particularly in > 40 year age group); Thyroid profile, prolocation (wherever indicated);Ultrasonography – transvaginal76
NBE CME programme for DNB consultantsDifferential diagnosis-Pregnancy complications; Anovulation associated; Submucous fibroids;Endometrial Polyps; Medication related; Endometrial hyperplasia; Endometrial cancer; Infectionassociated; Coagulation abnormalities; Mullerian abnormalities; IUD complications; AdenomyosisManagement-Hormonal – Combined pills, progestogens, danazol, GnRH Agonists, Mirena;Tranexamic acid, mefenamic acid; D & C, Hysteroscopy; Conservative Surgery – TCRE, Endometrialablation by Various methods ( LASER, thermal, radiofrequency); Hysteroscopy – abdominal, nondescentvaginal, laparoscopic; Treatment of basic pathology.Pruritus vulvaeHistory-Mode of onset, its duration, intensity, relation to menstruation; Associated gynecologicalsymptoms like type of white discharge- Mucoid, Frothy,curdy white, etc.; Associated abnormal vaginalbleeding; Any urinary or fecal incontinence, history of passing worms in stool; Any vulval sore orgrowth; Contraceptive history- use of any spermicides, condoms, etc.; Generalized skin diseases-Eczema, psoriasis, etc.; Any allergy to medications, soaps, deodorants; History of diabetes mellitus;History of dyspareuniaClinical examination- Look for evidence of dermatological, metabolic or deficiency diseases;Condition of vulva, vagina, urethra, anus; Type of dischargeInvestigations -Haemogram; Urine for sugar to exclude glycosuria; Urine for C/S to exclude urinarytract infection; Blood sugar to exclude Diabetes Mellitus; Wet saline vaginal smear to look forTrichomonas vaginalis; KOH smear to diagnose Moniliasis; Stools for ova and cyst; Biopsy of vulvallesion-to confirm the diagnosis and to exclude carcinoma in-situ.Diifferential diagnosis- Eczema, psoriasis; Various types of vulval dystrophies; Contact Dermatitis;Allergic dermatitis; Diabetic Vulvitis; Monilial & Trichomonas vaginitis and vulvitisManagement- Treatment of specific cause if found; Control of diabetes; Control of Trichomonalinfection and monilial infection with specific drugs. Treatment of husband also to prevent re-infection;If Vulval dystrophy is localizied, local excision/partial vulvectomy; If extensive and atypical epithelialactivity present advise simple vulvectomy and follow up; Apart from specific measures generalmeasures like cleanliness, antihistamines, sedatives and hydrocortisone ointments prevent itchingand provides adequate night sleep. Avoidance of allergens and antigens.Fibroid utreusHistory-age (peak between 35-45 years);patients are usually nulliparous or history of longperiod of secondary infertility; menstrual irregularities- menorrhagia or hypermenorrhoeacommonest. Metrorrhagia can be due to ulceration of submucous fibroid or fibroid polyp;symptoms of anaemia like shortness of breath, palpitation may be present; Heaviness orlower abdominal lump. Progress of the Lump(static, slowly increasing, rapidly increasing orinitially slowly increasing but later rapidly.); pain is not a common symptom.It may be due tocervical dilation induced by submucosal myoma, torsion of a pedunculated myoma or reddegenration associated with pregnancy. Congestive variety of dysmenorrhoea may be presentdue to associated endometriosis or adenomyosis; Pressure symptoms- More common withcervical fibroids. When the uterine size is increased, pressure is exerted on adjacent organs.Urinary manifestations include frequency, urinary incontinence or difficulty in urination.Posterior wall myoma exerting pressure on the rectosigmoid may cause constipation ortenesmus. Rectal pressure can occur due to incarceration of the myoma in the culde-sac;infertilityClinical examination-General examination-Usually various degrees of pallor; Abdominalexamination- Inspections- number, site, size, shape, surface, margin, Consistency, mobility,temperature, tenderness; Fibroid uterus is usually firm to hard in consistency, maybe cystic incystic degeneration. Margins are well-defined except the lower pole which cannot be reached.Surface nodular or uniformly enlarged. Mobile from side to side but not from above downwards;Rising test to confirm intra-abdominal or parietal swelling. Knee-elbow position and examination77
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