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

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NBE CME programme for DNB consultantsVaginal examination-Bishop’s score - value span- 0 – 13; bishop’s score increased by one pointfor each previous vaginal delivery, at the initiation of labour, in pre-eclampsia ; Bishop’s scoredecreased by one point in post dated pregnancy, premature rupture of membranes, primigravidae(reference- Nisswander . Cervical scoring systems in Danforths Obstetrics, 2002)Investigations- Ultrasonography- Confinnation of date- BPD, FL; Growth - HC / AC; Liquor – AFI;Fetal well-being - biophysical score, components, fetal tone(1imb movement), trunk movement,breathing movement, FHR, amniotic fluid volume (at least one pocket> lcm); Cardiotocography - 2x wkly / daily ; Pre-induction scoring- cervical scoring systemsDifferential diagnosis - Mistaken dates; IUGR - SGA, Preterm; Oligohydramnios Management -Placental ageing leads to impaired gas transfer - fetal hypoxia & distress. Hypoxic state isaggravated in elderely clients, hypertensive disorders, bleeding during pregnancy.During labour,there is increased incidence of asphyxia and intracranial damage due to Aggravation of preexistinghypoxia, Increased incidence of difficult labour due to big size baby, non moulding of head,Shoulder dystocia, Increased incidence of cord compression. After birth, greater chance of meconiumaspiration syndrome and atelectasis, hypoglycaemia, Polycythaemia,Perinatal mortality increasedx 1.5 at 42 wks, x 2 at 43 wks, x 4 at 44 wks Therefore IOL at 10 days past expected date; 25 - 30%clients start on their own by 10 daysNon-surgical management - Cervical ripening methods and agents- Prostaglandin E2 gel, PGE2pessary, misoprostol 25~g, foley’s catheter; Stripping of membranes digitallySurgical management - ARM; Planned Caesarean section - post-caesarean pregnancy,malpresentation, elderely primi;Any other Accoucher should be conversant with management of shoulder dystocia.Jaundice in pregnancyHistory- Period of ammenorrhoea; Duration of Jaundice; Pruritis/Itching; Abdominal pain/distension;Pale/clay wloured stools; History of Blood transfusion, I/V drugs, fluids, hepatoxtoxic drug, needleprick; Nausea(mild/moderate/severe); History of malaise, anorexia, weight loss; H/o fever, rash;Any History suggestive of — coagnlopathy(bleeding diathesis),encephalopathy(altered sensorium,conrulsions),nephropathy(renal failure); Family H/o Jaundice; H/o Jaundice in previouspregananciesClinical examintation- Weight of the patient; Icterus-eyes, palm, oral mucosa & skin; Signs ofpruritis(scratch marks); Bleeding spots(if any); Oedema; Sensorium; Temperature; Blood Pressure;Liver- Surface, span, margin, consistency, tenderness; Spleen; Ascites; Any evidence of dhydration;Obstertrical examination- Height of uterus Presentation Fetal Heart; Any evidence of IUGR< Fetaldistress; Patients of Pre-eclampsia with HELLP syndicrome are vry ill with hypertension, protecnuria,hemolysis,Jaundice, hemoglobinopathies, thrombocytopenia with activation of coagulation cascadeInvestigation - Complete hemogram including ESR; Serum Bilirubin – Total Direct, Indirect; SGOT,SGPT; Serum alhaline phosphalase; Urine-Bile salts, bile pcpinen ts, urobilingogen, ketone; Serumproteins- Total Differential(A/G Ratio); PTI, PTTK; Viral markers.hepatitis serology; Blood sugar;Serum creatinine; Ultrasound of abdomen for - Liver echotexture, Splenoportal axis, Collaterals inportal hypertension, Ascites, Space occupying lesion, Biliary stone, Fetus & placenta, IUGR/IUDDifferential diagnosis- Causes not specific to pregnancy - Viral hepatitis, Cholelithiasis, Autoimmunehepatitis, Neoplasia, Gilberts syndromeSpecific to pregnancy- Hyperemesis gravidarum ( Ist trimester), Severe pre-eclampsia/HELLP(2nd half of pregnancy), Acute fatty liver of pregnancy (2nd half of pregnancy), Intrahepatic cholestasis(2nd half of pregnancy)Management -Management will be as per aetiological causeHepatitis- Antenatal(Prenatal) - Supportive care, Dietary advice, Monitor liver function tests, Testing84
NBE CME programme for DNB consultantsfor HbsAƒ, Asess fetal growth & health, Vigilance for uterine activity, Infection control measuresLabor/delivery and postnatal - Infection control measure; Watch for PPH; In HbsAƒ positive cases,newborn should receive passive(HBIG) and active immunization;Intrahepatic-Cholestasis of Pregnancy-Prenatal- Local antipruritic measures; Considercholestyramine, ursodeoxycholic acid; Vit K supplement; Monitor fetal well being; Consider electivedeliver; Biliary tract ultrasonographyLabor/delivery-Anticipate preterm delivery; Increased risk of PPHPostnatal— Monitor biochemical resolution; Vit K supplement for baby“Acute Fatty Liver of Pregnancy” Prenatal- Estabilish diagnosis, resuscilate; Intensive care;Supportive therapy; Plan delivery; Labor/Delivery - Maternal resuscitation by correction of –Hypoglycemia, Fluid imabalance, Coagulopathy; Treatment of liver failure; Intensive fetal monitoring;Urgent delivery when maternal condition is stabilized, vaginal delivery preferable for mother;Meticulous hemostasis, including adequate wound drainage;Postnatal-Continue intensive caremanagement; Watch for postpartum wound hematoma formation and spses, PPH; Supportivecontraceptive measure“Severe Pre eclampsea-Prenatal & Labor - Control of hypertension; Control coagulation disturbance;Consider anticonvulasant prophylaxis; Close fetal monitoring; Watch for fall in hemoglobing fromhemolysis; Fluid and electrolyte management; Initiate deliver process;Postnatal - Anticipate delayedpostnatal recovery; Continue monitoring plalelets and renal function; Monitor for hemolysis; Controlsevere hypertension“Hyperemesis Gravidarum”-Intravenous fluid and electrolyte therapy; Diet-Discuss with dietitian;Antremetic regimen; Nutrient and Vitamin supplement; Antressphageal reflerex measures;Psychological and social support; Steroids-controversialSurgical Management-No role of surgeryUrinary fistulaHistory-Details of Incontinence - true or false, associated presence of urinary stream Previousobstretric history including-details of labour; mode of delivery; interval between delivery and leakagePrevious gynae operative history Type of surgery performed; Interval between surgery and leakageClinical examination-Inspection of Vulva with special reference to excoriation; PIS to demonstratesite and size of Fistula; PN to confirm above and to comment on extent of scaring I fibrosis; Furtherinformation on PN to assess regarding uterine and adnexal pathology ; Urinary examination formicroscopy and culture Methylene blue test Cystoscopy; IVP in selected cases; Examination underanaesthesia especially if clinical examination is not infonnative enough; Must distinguish betweenureterovaginal and vesicovaginal fistulaeManagement-Non - Surgical management - Role of prolonged catheterization Pre Operativemanagement - Elimination of urinary tract infection; Treatment of external excoriations; Surgicalmanagement -Various techniques of repair; Special reference to postoperative management -Prophylactic measures for both obstetric and gynae urinary fistulaeFaecal fistulaeHistroy- Similar to urinary fistulae. Special importance to intermittent incontinence with reference toconsistency of faecal matterVulval examination- PIS and P/V to determine details of fistula and especially to assess distanceof fistula from anal verge and introitus; Tone of external anal sphincter;Investigations – Routine; Special - proctoscopy I sigmoidoscopy ; Examination under anesthesiaif required - FistulogramDifferential diagnosis- Distinguish between RVF and 3 rd degree perineal tearManagement-- Local hygiene; Various kinds of repair and their approaches; Prophylactic measuresduring episiotomy, Perineorrhaphy suturing and hysterectomy.85
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