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

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NBE CME programme for DNB consultantsUterine artery embolization (UAE)-It is a minimally invasive technique for any symptomatic fibroidexcept pedunculated subserous fibroid. Other contradiction is pelvic inflammation. The disadvantageis no pathological confirmation of uterine fibroid is obtained and uterine sarcoma could be missed.UAE may be an ideal conservative treatment for leiomyoma to eliminate symptoms, reduce thesize of myoma, limit recurrence of future myoma and preserve fertility. But UAE is not withoutcomplications like pain, nausea and vomiting and general malasia, (Post embolization syndrome).Expulsion or sloughing f fibroid occur in few case particularly common in submucousfibroid.Myolysis-It can be done laparoscopically by electrosurgical heat, laser energy or cryotherapy.This procedure termed myolysis is accomplished by destruction of tumour tissue or obliteration ofvascular supply of fibroid.Other points to remember-Ascites may present along with myoma. Myoma may attach toomentum and get blood supply from omental vessels (floating myoma) , If there is torsion andobstruction of these vessels there may be transduction of fluid and development of ascites;Polycythemia may be present due to elevated level of erythropoietin; Benign metastasizing uterinemyoma characterizied by myoma like lesion in lung; Intravenous leiomyomatosis is a hormonallyresponsive disease that manisfests as vermiform extensions originating in the uterus that canextend as far as the heart; Shrinkage of myoma with GnRH against can be done before. Performingvaginal hysterectomy or LAVH; It is difficult to assess pelvis during hysterectomy for large fibroid. Itcan be made easy by prior enucleating the fibroid; Ureter may be vulnerable during operation ofbroad ligament fibroid, so their pathways may be identified; There is no contraindication to oralcontraceptive in women known to have fibroids provided uterine volume is monitored and there isno increase in size of fibroids. In women with out fibroid long term oral contraceptives may have aprotective against tumor development; Pregnancy related manifestation-Increase in size, mostly inthe early pregnancy, myoma less than in 5 cm diameter increased in size and larger myomasdecrease in size during the second trimester; Red degeneration; Miscarriage, PROM, placentalabruption , malpresentation, prolong labor, increase operative interference.Heart disease complications in pregnancyHistory- H/O -Rheumatic Fever in Childhood ; H/O Heart Disease - Surgery done for Heart Disease;Previous Pregnancy and outcome ; H/O taking anticoagulants and antibiotics; H/O CongenitalHeart disease in her motherClinical Examination -On Inspection- Dyspnoea, Orthopnoea, Neck vein pulsations, Clubbing offingers, Cynosis Edema legs; Symptoms - Progressive dyspnoea, Orthopnoea, Nocturnal cough,Hemoptysis, Syncope, Chest pain, Palpitations; Signs - Murmur, S2 Split&Other Sounds, DilatedNeck Veins, Arrythmias, Clubbing, Cyanosis, Hyper dynamic circulation of pregnancy causesalteration in CVS that mimics heart disease, Premature atrial &Ventricular ectopic beats, of peripheralpulse volume, d pulsation of neck vein, forceful apex beat due to 1"d CO suggest cardiomegaly.which occurs in normal pregnancy should be differentiated from those occuring in heart disease;Dyspnoea- Most frequent symptom; Can occur in normal pregnancy; Differentiated from heartdisease by history whether present prior to pregnancy or not Chest pain - . Occurs due to ischemicheart disease,AS,HOCM; Pulmonary hypertension MI-Arrythmias, VF-sudden death;Hemoptysis -Seen in MS; Orthopnoea & nocturnal -COUGH are other presentations of heart disease; Palpitations- Occurs commonly in pregnancy; . No correlation between dysrrythmia & symptoms; A palpitationoften short&does not necessarily requires treatment; Seen in HOCM; Syncope - Occurs in llTrimester, Peripheral resistance.,Cardiac output, Occurs in AS, HOCM, TOF, Eisenmingerssyndrome; Palpitations - Occurs commonly in pregnancy; No correlation between dysrrythmia &symptoms; . Palpitations often short&does not necessarily requires treatment ; Seen in HOCM;syncope - Occurs in ill Trimester; Peripheral resistance cardiac output~s; Occurs in AS. HOCM,TOF, Eisenmingers syndrome; edema - Non specific for heart disease; Occurs due to - Pressureof gravid uterus; in intravascular colloid osmotic pressure exacerbated injudicious use of crystalloidsolutions; dilated veins ,apex beat - Significant If heart beat is shifted >2cm outside the MCL ca ;80
NBE CME programme for DNB consultantsNYHA classificationCLASS - I - No limitation of physical activities,Ordinary physical activities does not cause palpitations,dyspnoea or anginal pain.CLASS - ll-Slight limitation of physical activity. Pt is Comfortable at rest.CLASS - ill - Marked limitation of physical activity ,less than ordinary activity causes fati gue, pal pitation, dyspnoea&anginaCLASS - IV - Inability to cany out any physical activity with out discomfort,syrnptoms of cardiacinsufficiency or of anginal syndrome may be present even at rest. Any physical activity causesdiscomfortMurmurs-Can occur in normal pregnancy ; Early to midsystolic murmur which is soft & of grade I &II is normal; ESM heard over Rt & Lt II ICS about 2cm from steral edge systolic or continuousmodified by pressure of stethoscope occurs due to ot flow in mammary vessels; Venous hum,Murmurs should be attached clinical significance if systolic murmur is loud or long like;PSM(VSD,MR, TR); Late SM (MR,MVP); ESM louder than Gr3/6(AS)or that varying with respiration(PS);. Or associated with other abnormalities like ejection click (pSorAS) . Munnur associated withthrill, Diastolic murmurMURMUR -Mid to late systolic murmur associated with or without mid systolic click - MVP Posturalmaneuvers are used to aid in As.; ctivities that Lt ventricular volume degree of MVP;Arrhythmias-Sinus bradycardia, tachycardia, atrial&ventIjcular premature contractions,SVT occursIn pregnancy ; VT ,multiform premature ventricular ; complexes are less common in normal pregnancy.AF suggests heart disease; ASD can present with supra ventriculararrhythmias;Cyanosis,clubbing,pulse deficit peripheral signs of endocarditic are other signsInvestigations- Chest X-Ray - Radiation to abdomen &fetus is minimal; Use of pelvic & abdominalshield is mandatory. CXR is not specific ; Pulmonary venous congestion,cardiomegaly, valvecalcifications can be made out ECG - ST depression,flattening ofT wave in It side precordicalleadsoccurs in 14o/00fnorrnal pregnancy ;T wave inversion,Q wave in L III in seen in healthy pregnantwomen; ECG is used in diagnosing dysrrythmias &rare causes of cardiomyopathy than indemonstrating structural abnormalities of heart; Ischemic changes in ECG is important if associatedwith biochemical changes; Blood Chemistry -. Haemoglobin , TC, ESR,& LDH occurs even innormal pregnancy; serum glutamic acid transarninases & CPKwith appropriate clinical setting isused in diagnosing MI; During puerperium interpretation of enzyme should be cautious becausethey are liberated in tissue destruction of involuting uterus; MB isoenzyme of CPK is specific tocardiac muscle;ECHO -. Used to demonstrate structural changes in heart ; Bacterial vegetations.prosthetic valwlar dysfunction can be made out better by Transesophageal echo.done by attachingthe transducer to a flexible endoscope. In Marfan’ s echo showing significant aortic rootdilatation.pregnancy should be discouraged; DOPPLER -Used to study flow patterns. But prevalenceof regurgitant flow across Rt sided valve is significantly greater in nonnal pregnant woman than innon pregnant state. Hence it should be considered;USG - Important in establishing gestationalage early ; Early obstetrical scan is important for confirmation of due date; Diagnosing multiplepregnancies or fetal anomalies; USG done in 16-20 wks is used to study fetal heart & majorvessels; Those at risk for intrauterine growth retardation occurring in Eisenminger’s should besubjected to serial USG every 2-4 wks in III TrimesterDifferential Diagnosis - Normal Physiological changes during pregnancy; Anaemia ;HypoproteinemiaNon - Surgical Management - Class I & II ,Admission 2 weeks earlier to EDD; Class Ill&IV -Immediate Hospitalization, AN Care; Prevent Anemia, Prevent Infections - RI . UTI. Limitation ofactivities; JP Care - Hospitalization in tertiary care centreStage 1 - Propped up position, oxygen, sedation.81
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