Friday, December 21, 2007


This is a rough guide. It is no doubt incomplete. Therapy is definitely individualized but for the benefit of my junior 'comrades'......

The aim of Obstetric Management in GDM is to achieve the delivery of a healthy baby at term with minimum adverse effect to the health of the mother.

'Term' here is limited to EDD (40 weeks)

Timing of delivery is an art. But in general,
GDM on diet, well controlled - delivery at 40 weeks POA
GDM on insulin - deliver at 38weeks or EARLIER

Early delivery (earlier than 38 weeks) is indicated when:
1. Maternal reasons:
Difficulty in achieving adequate glycaemic control
Signs and symptoms or complications of Diabetes predominate
2. Fetal reasons:
Severe macrosomia +/- polyhydramnios
Suspicion of a 'sick baby' based on reduced fetal movements, poor BPP

Mode of delivery is dependant entirely on the usual Obstetrics indications

When you encounter a woman (with GDM or DM complicating pregnancy) during antenatal care, the following universal steps are taken (over and above the usual care):
1. In the case of pre-existing DM,
Admit the patient at her first visit, the minute she's known to be pregnant
Do a 4-point BSP
Commence on Insulin
Refer to Diabetic team - usually comprise of Dietitian, Nurse & Dr
Dietitian emphasises need for diet control and guides the patient accordingly
Nurse teaches the patient on the technique of self-injection & home sugar
Dr co-ordinates the overall progress & decides on the following:

  • Eye assessment (if the patient haven't had any)
  • Referral to Endocrinologist, if the glycaemic control is inadequate
  • Detailed fetal anomaly scan at 18-22weeks
  • HbA1c / Serum Fructosamine
  • Fetal growth chart - monitor for macrosomia
  • Monitor for maternal complications i.e. recurrent vulvovaginal candidiasis, UTI
  • Decide timing of delivery
  • Decide mode of delivery

2. In the case of newly-diagnosed GDM, there are less concerns of long-term complications. Eye assessment and renal profile is not routinely done. The patient is usually admitted once upon diagnosis. (Even this is not mandatory but it gives us the chance to introduce the patient to the dietitian, nurse, do an ultrasound scan, get a full history, etc while the patient goes through her 4-point BSP). All other principles of management as mentioned above remains.

Take note that a detailed fetal anomaly scan is offered on a selective basis due to limitations inherent in the public healthcare system. Fetal anomaly scan should be routinely offered to ALL pregnant women at 18-22 weeks. Thats the ideal situation.

Got it?

Wednesday, December 19, 2007

Selamat Hari Raya Haji & Merry Christmas

I'd like to wish all my blog visitors "Selamat Hari Raya Aidil Adha" & Merry Christmas.

Christmas was great when I was a kid.... school holidays, TV starts at 8.00am, free Walt Disney movies.....

But you often feel a pang of guilt at the end ... wondering what on earth have you acheived after one whole year and how better you could have spent your holidays.

To my students ... drive safely. You may be young, you may have insurance but your life doesn't have AUTOMATIC PREMIUM LOAN or optional POLICY REINSTATEMENT ;-)


I think my students are probably growing tired with the above phrase....

We can practice in different parts of the world, different segments of health care but ONE thing remains common - PRINCIPLES of MANAGEMENT

Let me give you an example.

A young Engineer realizes that he is late for an important interview, held right at the heart of the city. His mobile phone is low in credit and he is 20kms away from his fateful venue. He doesn't have enough money to hire a cab. What should he do?

A Malaysian solution might be:
1. Forget the komuter, stop a motorcycle and beg for a ride
2. Pay that guy some money and also get permission to use his hand phone
3. Tell some real sob story to the secretary and ask them to call your name last

But, in England,
1. You'd go to the nearest tube station
2. Use the small change (after paying fare) to make a phone call.
3. Tell the TRUTH to the secretary and tell her that you owe her a drink as long as she doesn't embarrass you by calling your name early

However, in GENERAL,
1. You would choose the fastest mode of transport, suitable for that city
2. Use your money wisely - to help you reach the destination & stay in contact
3. Relay appropriate information in order to safeguard your chances in the interview


Monday, December 10, 2007

Birth Weight - Definitions a la Malaysia

You may find the following useful:

Low Birth Weight = below 2,500g
Very Low Birth Weight = below 1,500g
Extremely low birth weight = below 1,000g
Macrosomia* = above 4,000g

*Definition of Macrosomia isn't the same throughout the world.

Maternal Mortality

In Malaysia, Maternal Mortality is quantified as a ratio (this is NOT the same as Maternal Mortality Rate).

Maternal Mortality Ratio is defined as the number of maternal deaths per 100,000 live births. The current MMR for Malaysia is in the region of 28/100,000 live births.

According to the last CEMD report (1997-2000), the 4 main causes are:
1. Associated Medical Conditions 20.6%
2. Post Partum Haemorrhage 19.1%
3. Hypertensive Disorders 14.1%
4. Obstetric Embolism 13.9%

To make a comparison with other countries, see here and here.

How can we improve the MM Ratio?

All forms of training in O&G should emphasize on the above 4 main causes. (Undergraduate training, Housemanship training, Postgraduate training). Here are some specific strategies:

Associated Medical Conditions:
a. Establishment of Combined Clinic
b. Seminars / Courses to refresh Doctors' experience in Internal Medicine - better if O&G Doctors undergo periodic attachments in specific areas of Internal Medicine.
c. The scope of premarital screening should be widened to include a medical examination OR
d. Newly married couples should be encouraged to seek pre-conceptual counseling (provide tax-breaks, dedicated clinics, etc)
e. Heavier forcus on Maternal Medicine within the branch of Maternal Fetal Medicine

Postpartum Haemorrhage

Hypertensive Disorders

Obstetric Embolism

This post will be updated soon.

Sunday, December 9, 2007

Endometriosis and Infertility

Endometriosis ..... the bane of women who seek fertility.

Well, here's a success story. Lady comes with chronic pelvic pain and primary infertility. Laparoscopy revealed Stage I endometriosis and patent fallopian tubes. The endometrial spots were ablated with diathermy.

The lady came back to see me in her next menstrual cycle, still concerned of the mild pelvic pain that she had. I reassured her and sent her back, advising her to concentrate on her fertility. This is what happened 9 months later :-)

Well, she was lucky enough that it was just stage I.

Note: Photo taken with mother's permission. DO NOT REPRODUCE.
Some notes for students / visitors:
1. About 40% of women who undergo laparoscopy for infertility are found to have endometriosis
2. Infertility afflicts only about 40% of all women with endometriosis
3. It is difficult to draw parallels between severity of endometriosis (as seen laparoscopically) and the degree of infertility
3. Do not brand ALL women with endometriosis with infertility. We, as doctors & students, are biased by the fact that we normally see the 'problematic' ones in the wards and clinic. Remember, the majority DO NOT have infertility and never come to see us save for some who have chronic pelvic pain or severe dysmenorrhoea!

Update (October 2015): the role of treatment in minimal / mild endometriosis to improve fertility remains UNCLEAR. Each case should be assessed based on its own merit. Many women with minimal / mild endometriosis do conceive without much intervention. Question is, how does one know its minimal / mild endometriosis without looking into the pelvis? Catch 22

Friday, December 7, 2007

Sodium Citrate


I have been 'bombarded' by students over this topic over the past few days. Let me clarify a few things:
1. We use sodium citrate and NOT potassium citrate.
2. The amount used is 30mL of 0.3M
3. It prevents Mendelson's Syndrome
4. It is normally used with ranitidine
5. It does increase the volume of gastric content
6. It 'elevates' the pH of stomach contents. The keyword here is 'elevate'. Bear in mind, pH2 to pH5 also means 'elevate'! Not necessarily the stomach contents turn ALKALINE!
7. The wikipedia says sodium citrate is the sodium salt of citric acid, a weak acid (based on information available when accessed on 7/12/2007)
8. I don't know the actual pH of 0.3M sodium citrate. But, it is definitely higher than 5.6
9. The pH of gastric acid is 1 to 2

From my residual knowledge of chemistry, when you neutralize acid with alkali, you will get a SALT. Perhaps we don't want that to happen and choose to 'dilute' the stomach pH but keep it acidic.

For the uninitiated, sodium citrate is a common oral medication given to pregnant women before Caesarean Section.

I hope students do not forget the basic concept of preventing aspiration pneumonia that is:
1. Adequate fasting prior to a surgery
2. Avoidance of general anaesthesia unless really necessary
3. Rapid sequence induction anaesthesia (in case of GA)
4. Cricoid pressure
The administration of sodium citrate is just a minor component of the overall picture. You will learn more during your anaesth attachment in Sem9.

Monday, December 3, 2007

10 Kebaikan Pil Perancang

Ramai wanita mempunyai tanggapan yang salah mengenai pil pencegah kehamilan atau pil perancang.

Berikut adalah 10 kebaikan pil tersebut:
1. Membantu mengurangkan jerawat & muka berminyak
2. Mengurangkan masalah segugut
3. Mengurangkan masalah PMS (Pre-Menstrual Syndrome) iaitu keadaan tidak selesa yang biasa dirasai beberapa hari sebelum kedatangan haid (kemurungan, perasaan 'berat', sakit payudara dsb)
4. Menolong mengaturkan kitar haid
5. Membantu mengelakkan haid lebat, sesuai untuk wanita yang memang mengalami masalah kekurangan darah (anemia)
6. Membantu mengurangkan pertumbuhan sista (ketumbuhan berair) di dalam ovari
7. Mengurangkan risiko barah ovari
8. Mengurangkan risiko barah rahim (endometrial cancer)
9. Membantu mengelakkan sakit ovulasi (mid-cycle pain) kerana ovulasi terhalang semasa seseorang itu menggunakan pil
10. Membantu mengurangkan lebihan hormon lelaki (androgen) dan seterusnya, mengawal pertumbuhan roma tebal pada muka, perut, peha dan betis

Tetapi, pil perancang bukanlah satu kaedah yang sesuai untuk semua wanita dan semua keadaan yang dinyatakan diatas. Anda perlu berbincang dengan seorang doktor yang bertauliah sebelum mula makan pil tersebut.

Saturday, December 1, 2007

World AIDS Day

Today is World AIDS day.

The United Nations says there are more then 33million people afflicted with the Human Immunodeficiency Virus (HIV), and ultimately at risk of developing AIDS (Acquired Immuno-Deficiency Syndrome).

Many steps have been taken to curtail the spread of this virus in Malaysia. From a gynaecologist form of view, I would applaud the following steps (that are already in affect):
1. The screening of couples who intend to marry
2. Universal screening in pregnant women.
However, I also note, with certain sadness, that not all are subjected to the above 2 steps. Premarital screening is not yet mandatory for all religions and all states. But, at least we are heading in the right direction. Whereas for pregnant women, there is no law that obliges pregnant women or their caregivers to perform this screening at antenatal care.

We can also acheive much more by advocating the use of condoms. Many other diseases can be prevented by simply using the condom. Human papillomavirus (HPV), for instance, is another virus that can be prevented in the same manner. HPV is closely associated with cancer of the uterine cervix (mouth of the womb).

The battle against AIDS is an on-going one. We all have a small role to play in it. As parents, we can educate our young about AIDS. As friends, we can help spread the word to our close ones. All of us are 'arm-chair' critics in one way or the other, often leaving the authorities to fight out a lonely battle. Why don't you chip in?

Why don't you start something? A simple SMS to 5 close people perhaps....