Nota Perubatan

Author: notaperubatan

  • Angiotensin-Converting Enzyme Inhibitor (ACEI) & Angiotensin Receptor Blocker (ARB)

    How to initiate and monitor ACEi / ARB?

    🍊Repeat RP (potassium, creatinine) within 2 – 4 weeks of

    • Initiation of ACEi / ARB, OR
    • Increase / change in dose of ACEi / ARB

    🍊Continue ACEi / ARB if serum creatinine rises by less than 30% & normal serum potassium within 4 weeks following initiation of treatment / increase in dose

    🍊Stop / Reduce ACEi / ARB if

    • Pregnant women / Women plan for pregnancy
    • Serum creatinine rises more than 30% or persistent hyperkalaemia within 4 weeks following initiation or increased dose of ACEi / ARB, if mitigation strategies (as mentioned above) failed

    🍊If serum creatinine >30% after 2 – 4 weeks of initiation of therapy:
    Review for causes of AKI

    • Review concurrent medications (e.g. NSAIDs, diuretics)
    • History of taking supplements concurrently
    • Acute illness / Fever
    • Possible renal arterial stenosis

    Medical treatment (wherever indicated):

    • Correct dehydration / volume depletion

    🍊If hyperkalaemia after 2 – 4 weeks of initiation of therapy:

    • Review concurrent drugs
    • Advise for moderate / Low potassium diet
    • Consider adding other medical treatment e.g. diuretics, sodium bicarbonate, potassium binder

    =====

    • If worried, continue more frequent monitoring, until renal function and/or potassium level stabilised
    • Raised creatinine ≠ immediate discontinuation of ACEi or ARB

  • Prolonged Neonatal Jaundice (NNJ)

    Introduction

    The main aim of management / monitoring of prolonged NNJ is exclusion of conjugated hyperbilirubinaemia, especially biliary atresia (early diagnosis & biliary drainage will give successful long-term good bile flow in >80% of children; good bile flow is achieved only achieved in 20 – 30% children if surgery is late)

    Definition

    Very important to know the definition to avoid wrong treatment to patients with NNJ

    Prolonged NNJ

    Prolonged NNJ = Visible jaundice (serum bilirubin >85 µmol/L) that persists beyond 14 days of life in term baby (≥37 weeks) or 21 days in a preterm baby (≥35 to <37 weeks)

    Conjugated hyperbilirubinaemia

    Conjugated hyperbilirubinaemia = Conjugated bilirubin >34 µmol/L or more than 15% of total bilirubin
    Note: Conjugated hyperbilirubinaemia is NEVER normal / physiologic

    Causes of Prolonged NNJ

    Unconjugated hyperbilirubinaemia

    • Septicaemia, UTI, breast milk jaundice, hypothyroidism
    • Haemolysis (e.g. G6PD deficiency, congenital spherocytosis)
    • Galactosaemia
    • Gilbert syndrome

    Conjugated hyperbilirubinaemia

    • BIliary tract abnormalities: biliary atresia, choledochal cyst, paucity of biliary ducts, Alagille syndrome
    • Idiopathic neonatal hepatitis
    • Septicaemia
    • UTI
    • Congenital infection: TORCHES
    • Metabolic disorders e.g. citrin deficiency, galactosaemia, alpha-1-antitrypsin deficiency
    • Total parenteral nutrition – induced cholestasis

    Monitoring / Management of Prolonged NNJ

    Important history

    • Any pale stool / dark urine?
    • Feeding: Breastfeeding / Bottle feeding / Mixed?
    • Any poor feeding?
    • Any fever / rapid breathing at home?

    Examination

    • Septic or ill looking? Lethargy?
    • Signs of respiratory distress? (e.g. tachypnoeic, chest recession, desaturation)
    • Perfusion: good / poor?
    • Weight monitoring (good / poor weight gain)
    • Any hepato / splenomegaly?
    • Diapers inspection (dark yellow urine, pale stool)

    Laboratory tests

    • Cord TSH (should have been done at birth)
    • G6PD (should have been done at birth)
    • FBC, reticulocytes
    • UFEME
    • Serum bilirubin — direct, indirect
    • Thyroid function test (FT4, TSH)
    • Certain centers will also send FBP (full blood picture) to look for haemolysis as well as LFT + AST

    Other tests (if indicated)

    • Serum gamma glutamyl transpeptidase (GGT), to differentiate obstructive VS non-obstructive causes of neonatal hepatitis. Significantly elevated GGT (few hundred) with pale stool strongly suggest biliary obstruction
    • Ultrasound hepatobiliary system (HBS)

    Appendices

    Flow Chart Management of Prolonged NNJ in Babies ≥35 Weeks
    Workups for conjugated hyperbilirubinaemia

    Important Messages

    • Conjugated hyperbilirubinaemia is NOT normal
    • Refer Paediatrician if high or moderate risk prolonged NNJ / conjugated hyperbilirubinaemia / jaundice more than 2 months / SB >300 µmol/L or other abnormal lab result

    References

    1. Paediatric protocol 4th ED (2019)
    2. Integrated Plan For Detection & Management of Neonatal Jaundice 2nd ED (2017) [Download]

  • Type 2 Diabetes Mellitus Complicating Pregnancy

    Miscellaneous

    DM is one of the HIGH risk factors for pre-eclampsia. Therefore, DM pregnant women should be started with Aspirin 150 mg OD once fetus is viable, about 12 weeks or before 16 weeks of gestation. This is for pre-eclampsia prophylaxis. At 20 weeks, pregnant women should also be started with calcium carbonate 1g BD + Vitamin D

  • Induction of Labour (IOL)

    Prior to IOL

    • Indication (and the plan should have been decided by specialist)
    • FBC: Hb, platelet count
    • GSH availability
    • Presence of previous scar (note: 1 previous LSCS scar is not an absolute contraindication, but Prostin dose is halved, i.e. 1.5 mg / Foley catheter insertion is more preferable)
    • Latest CTG result – CTG must be normal prior to IOL
    • Latest vital signs of mother

  • Terminology in O&G

    TermDescription

    First trimester

    1st day of LMP to 13w6d

    Second trimester

    14w0d to 27w6d

    Third trimester

    28w0d to 40w6d

    Post-term pregnancy

    42 weeks of gestation or more

    Post-dated pregnancy

    Period of gestation beyond 40 weeks

    Term pregnancy

    37w0d onwards

  • Abbreviations

    Search Commonly Used Abbreviations:

    AbbreviationTerm

    AGA

    Appropriate for gestational age (i.e. not SGA / LGA / IUGR)

    BTL

    Bilateral tubal ligation

    Cx

    Cervix

    EDD

    Estimated delivery date

    ELLSCS

    Elective lower segment Caesarean section

    EMLSCS

    Emergency lower segment Caesarean section

    ERCS

    Elective repeated Caesarean section

    GBS

    Group B Streptococcus

    Guillain-Barré syndrome

    GDM

    Gestational diabetes mellitus

    Hb

    Haemoglobin

    IE

    Impending eclampsia (usually in O&G doesn’t mean infective endocarditis)

    IOL

    Induction of labout

    IUGR

    Intrauterine growth restriction

    KKIA

    Klinik kesihatan ibu dan anak (antenatal clinic)

    LGA

    Large for gestational age

    LMP

    (first day of) Last menstrual period

    MA

    Membrane absent

    MGTT //  MOGTT

    Modified glucose tolerance test

    MI

    Membrane intact

    MOC

    Mode of contraception

    PE

    Pre-eclampsia

    Pulmonary embolism

    PI

    Perineal inspection

    PP

    Placenta praevia

    PPROM

    Preterm prelabour rupture of membrane

    PROM

    Prelabour rupture of membrane

    REDD

    Revised EDD (determined from scan)

    SGA

    Small for gestational age

    SROM

    Spontaneous rupture of membrane

    St

    Station

    SVD

    Sponteneous vaginal delivery

    USOD

    Unsure of date

    VAD

    Vacuum assisted delivery

    VE

    Vaginal examination

    WI

    Wound inspection

    Tips

    • Each department / hospital is supposed to have an approved abbreviations for routine use. Refer to that document if available.
    • Do not use uncommon abbreviations to avoid medical error

  • Pregnancy & Puerperium  VTE Risk Assessment

  • Management of Labour

    Q&A

  • Miscellaneous – O&G

    Commonest direct causes of maternal death in Malaysia

    1. PPH
    2. Pregnancy induced hypertension
    3. Pulmonary embolism

  • External Cephalic Version (ECV)

    Q&A

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