Gestational Diabetes (Part I)

Gestational Diabetes (GDM) ataupun masalah kecing manis sewaktu mengandung adalah salah satu masalah perubatan yang lazim ditemui di kalangan ibu mengandung. GDM berpunca dari intoleransi karbohidrat (carbohydrate intolerance) dan kadangkala disebabkan oleh kandungan itu sendiri (iaitu tiada faktor risiko yang jelas). Faktor risiko yang lazim adalah obesiti dan sejarah diabetes di kalangan ahli keluarga terdekat, Sejarah buruk kandungan lepas (Bad Obstetrics History) seperti kematian janin, peningkatan air ketuban, kecacatan kongenital dan 'big baby' adalah antara faktor pertimbangan. Untuk pesakit yang tiada sejarah seperti yang dinyatakan, kami cuba mengagak kewujudan GDM berdasarkan situasi seperti :
(a) Peningkatan berat badan secara mendadak / luarbiasa
(b) 'Glycosuria' iaitu kewujudan gula dalam kencing
(c) Janin yang membesar terlalu cepat
(d) Air ketuban meningkat terlalu cepat
(e) Ibu mengalami masalah keputihan keterlaluan ataupun berulang - tidak pulih walaupun dirawat
(f) Ibu mengalami masalah jangkitan berulang seperti bisul, kencing kotor dan sebagainya.

Nota - glycosuria memang lazim dijumpai di kalangan ibu mengandung. Glycosuria yang dikesan pertama kali TANPA kehadiran faktor risiko yang lain tidak menimbulkan sebarang syak. Tetapi glycosuria berulang (kehadiran gula dalam kencing > 1 lawatan) dianggap sebagai tidak normal.

Lazimnya, ujian saringan yang disyorkan di Malaysia adalah 'Modified Oral Glucose Test' (MGTT) di mana tahap gula dalam darah disukat dalam keadaan seseorang itu berpuasa dan 2 jam setelah mengambil minuman standard yang mengandungi 75g glukosa. Saringan ini adalah sejajar dengan syor Pertubuhan Kesihatan Sedunia (WHO). Tahap normal untuk glukosa dalam darah puasa adalah 5.5mmol/L dan setelah 2 jam minum air berglukosa dalah 7.8 mmol/L (tahap rujukan mungkin berbeza mengikut definasi pengamal kesihatan anada).

Mengapa GDM itu penting?

GDM boleh mempengaruhi kesihatan perinatal janin. Risiko kematian perinatal adalah 5 kali ganda lebih tinggi di kalangan ibu yang menghidap GDM. Ramai ibu GDM mengadu yang mereka sering ditakut-takutkan tentang risiko ini. Namun, hakikat terpaksa dinyatakan dengan telus. Malahan, janin di kalangan ibu GDM ini juga mempunyai 10 kali ganda risiko kecacatan (congenital malformation).

Ramai penghidap GDM tidak ingin mengambil berat keadaan mereka. Saya pernah juga bertemu dengan doktor yang mengaku tidak mengawal makanan seperti yang disyorkan. Lebih bahaya lagi, mereka pandai pula mengawal makanan apabila sampai masa untuk melakukan pemeriksaan BSP (Blood Sugar Profile). Tidak kurang juga yang enggan mengambil dos insulin seperti yang disyorkan.

Kecuaian seperti di atas sering menjurus ke arah komplikasi lain seperti janin terlalu besar (Large for Gestational Age fetus), shoulder dystocia dan trauma perineum disamping peningkatan kelahiran secara vakum dan forsep. Antara risiko yang dinyatakan di atas, shoulder dystocia adalah risiko yang paling signifikan. Penghidap GDM boleh mengalami shoulder dystocia walaupun berat janin mereka belum mencecah 4kg. Ini adalah kerana janin yang membesar dibawah pengaruh GDM ini mempunyai distribusi lemak yang berbeza berbanding dengan janin normal. Lemak bawah kulit berkumpul di tempat-tempat tertentu dan menyebabkan proses kelahiran biasa menjadi lebih rumit.

Bagi si ibu pula, mereka menghadapi risiko 'diabetic ketoacidosis' di mana kepekatan gula dalam darah yang meruncing diikuti pula dengan asidosis (peningkatan tahap asid dalam badan) yang boleh menyebabkan renjatan (shock), jangkitan darah (septicaemia) dan pengsan (koma). Mujurnya, komplikasi 'diabetes ketoacidosis' atau DKA ini jarang-jarang berlaku dikalagan ibu mengandung kerana ramai yang tampil untuk pemeriksaan awal dan juga akses kesihatan yang mudah untuk ibu mengandung di negara ini.

Nota - tempoh perinatal merujuk kepada jangkamasa kandungan 23 minggu ke atas + jangkamasa proses kelahiran + jangkamasa neonatal awal iaitu 7 hari pertama selepas bayi dilahirkan ( sumber - WHO)

(bersambung)

You may also be interested to read the following:
1. Principles of management (DM & pregnancy)
2. Indications for MGTT

Ponggal Wishes

Happy Ponggal to all my friends, relatives, colleagues and patients.

Ponggal means many things to many people. To me, its a thanksgiving event. And it is also a day quite unlike Deepavali. The latter has grown more commercialised. Ponggal has not. You get less sms, no pressure of buying new this and new that + no pressure to visit 'sanak-saudara'. I finally spent some time with children and it was also nice to see my better half unwind and take a break from her punishing schedule (both at school as well as the homefront).

Ibu mengandung ..... Boleh Meninggal?

Proses mengandung dan melahirkan anak adalah satu transformasi yang indah. Saat terdengar sahaja tangisan si kecil, ramai ibu terlupa terus segala kesakitan, kesukaran dan penat-lelah yang diharungi. Namun, tidak semua proses bersalin berakhir dengan kesudahan manis.

"Maternal mortality" atau kematian ibu mengandung adalah perkara trajis yang boleh menimpa mana-mana wanita dari saat ia mula mengandung sehinggalah ke saat berakhirnya tempoh pantang. Dari segi perubatan, tempoh pantang adalah enam minggu atau empat puluh dua hari. Dari segi tradisi, tempoh ini berbeza-beza.

Semenjak zaman purba sehinggalah ke zaman terkini yang makin canggih, satu fakta menggerunkan masih berdiri nyata - seorang wanita boleh meninggal dunia semasa mengandung dan dalam pantang. Dengan perubahan zaman, kejadian ngeri ini telah dapat dikurangkan tetapi tidak dapat dielakkan seratus peratus.

Menurut sumber WHO (2005) (dengan kerjasama UNICEF dan Bank Dunia), nisbah kematian ibu untuk Malaysia adalah 62 per 100,000 kelahiran hidup. Angka ini dijangka lebih rendah sekiranya ditolak 'kes impot' di mana warga asing atau pendatang tanpa izin bersalin di negara ini dalam suasana tidak selamat (tiada jagaan antenatal, enggan bersalin di hospital, kelahiran disambut oleh bidan tidak terlatih, dsb). Nisbah purata MMR untuk Asia Tenggara adalah 300 per 100,000 manakala untuk benua Afrika pula adalah 820 per 100,000. Di seluruh dunia, adalah dianggarkan bahawa hampir setengah juta wanita meninggal setiap tahun akibat komplikasi yang berkait dengan proses mengandung dan kelahiran.

Punca kematian banyak bergantung kepada faktor sosioekonomi. Di negara ini, punca kematian di pusat-pusat rujukan (tertiary centres) telah menunjukkan pola perubahan yang jelas. Kematian akibat tumpah darah dan mengandung di luar rahim kini telah berkurang. Punca kematian di pusat-pusat rujukan kini menyamai situasi di negara membangun. Antara punca yang kian menarik perhatian orangramai adalah 'Amniotic Fluid Embolism' dan 'Pulmonary Embolism'.

Saya akan cuba menulis lanjut tentang kedua-dua keadaan ini bila masa mengizinkan.

Selamat Hari Raya

Dah sampai masanya untuk Raya .... terkenang zaman sekolah dulu, beraya sakan, dari pagi sampai ke senja. Ke hulu ke hilir naik bas dan berjalan kaki visit semua classmate. I learnt a lot regarding Malay customs from these visits. Enabled me to see up close (and feel) the true spirit of Raya.

Selamat Hari Raya to all my friends, colleagues, ex students, ex teachers and patients. I would also like to dedicate this post to all healthcare workers out there who have to sacrifice their Raya, providing service to the sick and needy. You, are the true heroes of Raya!

Thank me ... ?

My patients and their spouses are probably trying to be nice but God ... I feel so small when they thank me after giving birth.

I mean, here is a woman who goes through the whole pregnancy, sometimes understood, sometimes not (by her husband and colleagues) .... goes through the pain of labour ... summons up all her energy and brings out a beautiful baby..... and she thanks me for everything.

I feel that the mother deserves a whole lot more than the doctor!

Taking Vitamins during pregnancy DOES NOT make your unborn baby large

Vitamins and supplements are essential for the pregnant mother. The World Health Organization recommends routine iron supplementation in pregnant mothers. Vitamins belong to a DIFFERENT CLASS of food altogether. There are carbohydrates, fat, protein, fibre, water and there are vitamins. Vitamins do not have CALORIES!

So, the common notion that 'taking vitamins during pregnancy makes my baby large' is illogical and not supported by evidence.

You may get a large baby if its in your genes, you develop diabetes in pregnancy, develop excessive weight gain due to excessive carbohydrate intake or the baby itself is abnormal. Your baby also tends to be larger due to sedentary lifestyle during pregnancy, higher social class and increasing parity (i.e. 2nd babies are larger than 1st ones, 3rd babies larger than the 2nd and so on).

Hati Hati bila dengar Nasihat Kawan

Sila amati senario ini:

Pn M, seorang wanita berumur 48 tahun, mengadu perut semakin buncit, haid makin lewat dan sering tidur tidak lena. Setelah pemeriksaan dan kaunseling menyeluruh pada bulan Mei 2010, Pn M telah diberi Hormone Therapy (HT). Ini mengambil kira aspek-aspek seperti:
a) Dia masih aktif bekerja dan memerlukan tenaga
b) HT dapat memelihara keutuhan alat kelamin dan membantu dalam hubungan kelamin
c) Dia tiada sejarah kanser payudara
d) Dia tidak menghidap penyakit jantung, darah tinggi atau diabetes
e) Dia tidak pernah mengalami masalah hati (liver disease) atau darah tersumbat (DVT)
f) Pengambilan HT dapat memulihkan edaran haid
g) Pengambilan HT juga dapat mengelakkan masalah perut kembung yang biasanya disebabkan migrasi (pemindahan) lemak dari anggota badan ke kawasan abdomen yang disebabkan oleh kekurangan hormon
h) Puan M sangat kurus dan berisiko tinggi untuk mengalami osteoporosis

Pn M kembali berjumpa saya hari ini. Keluhannya masih sama. Darah haid tidak datang-datang .... anda tahu kenapa? Kerana ada seorang kenalan beliau yang telah menasihatkan bahawa pengambilan HT boleh menyebabkan 'pelbagai masalah' (tapi si kawan tu pun tak sure amende 'masalah' yang dimaksudkan tu) di masa hadapan. Dan si kawan yang amat prihatin ni pun tak pernah mencuba HT sebelum ini.

Ha, akhirnya siapa yang rugi? Inilah akibatnya bila meminta nasihat orang yang tidak bertauliah. Saya pun kurang faham mengapa di dunia ini ada manusia yang suka memberi nasihat di luar bidangnya. Saya yang bertaraf doktor ni pun kadang-kadang enggan memberi pendapat apabila perkara yang diajukan itu di luar bidang saya (masalah tulang, mata dsbnya).

Dan sekarang bila Pn M datang dengan masalahnya yang masih tak selesai, si kawan yang memberi nasihat itu:
a) Tidak menanggung / menderita seperti Pn M
b) Tidak memberi sebarang pertolongan dari segi emosi mahupun kewangan
c) Langsung tidak sedar / insaf atas kesan/akibat nasihatnya itu

Harap dapat renungkan bersama.

Selamat Hari Raya

My sincere Hari Raya Aidilfitri wishes to all my Muslim brothers, sisters and friends.

It is truly a time for reflection, forgiveness and celebration. On the topic of reflection, I cant help but compare the death toll from Ops Sikap XX versus H1N1. There was so much hoo ha regarding the latter. Everyone (almost) was scared for a moment. Sadly, the public does not exercise the same level of alertness and diligence in combating road traffic accident related deaths.

On the topic of forgiveness, allow me to use this opportunity to seek forgiveness for all those unpleasant things I may have done over the past one year.

The celebration? Well, here's one story worth celebrating .....

A 48 year old lady conceives her first child spontaneously after 8 years of marriage. She is due only in mid-October. She came to the hospital just before midnight yesterday. Examination revealed that she was in labour but the fetus was underweight (<2.5kg) and slightly premature. The conditions were favourable for a normal delivery. My midwife was not too amused. " 48 years old, got pregnant after 8 years, better C-Section", she mumbled as I left the labour room. I didn't want to hear that negative remark anymore....

I took a walk outside the hospital, reflecting on all those evidence that says 'being mature' is not an indication for a C-Section. And deep in my heart, I wanted to give her the chance to deliver vaginally.

Half an hour later, the phone rang. "Dr! You kat mana?!", the voice cracked. I rushed back in and reached just in time as she began to bear down. Alas, the first "Raya" baby was born soon after. As I reviewed the mother this morning, I realized she had been cool and composed all along. A new meaning to the word 'mature' perhaps? He He

Waktu Rawatan Pakar Wanita Suria (Consultation Hours)

Here we go again .... need to change my consultation hours again!

Effective October 1st, for SURIA, its 2pm-10pm Sunday to friday. Closed on Saturday.

For Mawar, its 9am to 1pm, Monday to Friday.

I shall be available 24hours thru Salam & Mawar.

Prefer appointments because sometimes .... I do close the clinic when there are no appointments :-)

Adoption

I received a phone call recently:

Caller: "Dr! I'm Mrs X's niece! Remember? You helped her deliver?"

Me: "Yes, go on."

Caller: "Well, we've given away the child for adoption. And the adoptive parents would like to meet you to make sure the child is completely ok"

Me: "What?!" (Not believing such people exist)

Caller: (Repeats the request)

Me: "Well, I suggest that they go see a Paediatrician"

Caller: "What?!" (Perhaps not believing that I would actually refuse)

Me: "Yes, you heard me right. Go see a paediatrician"

Well, there you are.... This is how some people view adoption - as if the baby is some 'commodity' that has to be checked for defects. Forgive me for lashing out but I suppose this is what happens when the biological parents and adoptive parents refuse to meet in person. And I sometimes doubt the sincerity of those who wish to take a child for adoption.

I have heard of couples paying thousands of ringgit to 'agents' to get a baby for adoption. And some have related how they got conned and returned home empty handed.

Hey!

You can't buy babies! You are BLESSED with them.

Even if they are not your own. Even if you pay.

Get it? Don't? I rest my case....

Back in Control .... He He

My computer got zapped by not one but two viruses: RVHost & Heap (std.txt).

They messed up my registry editor, disabling Task Manager, System Restore & REGEDIT.

For months, I kept seeing messages like "TASK MANAGER DISABLED BY ADMINSTRATOR" and multiple funny messages whenever I start up.

After some serious experimentation and internet search, I have found some links to help others to solve the same problem:

http://windowsxp.mvps.org/Taskmanager_error.htm

http://www.pchell.com/support/registryeditordisabled.shtml

http://forum.lowyat.net/topic/531132

Good luck!

PCOS (Polycystic Ovarian Syndrome)

PCOS atau Sindrom Ovari Polisistik adalah satu penyakit yang telah lama diketahui oleh pakar-pakar sakitpuan. Namun, hanya dalam seabad yang lepas, penyelidikan berkaitan PCOS makin bertambah dan mula mungungkit minat pelbagai pihak.

European Society for Human Reproduction and Embryology (ESHRE) dan the American Society for Reproductive Medicine (ASRM) adalah antara organisasi yang telah lama cuba menyeragamkan diagnosa dan cuba mewujudkan garispanduan dalam perawatan wanita yang menghidap sindrom ini. Usaha mereka akhirnya berhasil di satu sidang kemuncak PCOS di Rotterdam pada tahun 2004.

Menurut 'kriteria Rotterdam' tersebut, seseorang wanita harus memiliki sekurang-kurangnya DUA dari TIGA ciri-ciri am PCOS iaitu:
1. Haid tidak teratur atau haid sering lewat (absent)
2. Hiperandrogenisma (keadaan di mana berlaku peningkatan hormon androgen, sejenis hormon kaum lelaki)
3. Ovari polisistik, iaitu, sekurang-kurangnya satu ovari mempunyai minima 12 telur (follikel) atau saiz ovari telah membesar

Namun, PCOS masih merupakan satu sindrom dan dengan itu, diagnosa PCOS tidak TERIKAT semata-mata kepada tiga kriteria yang disebut di atas.

Berikut adalah antara masalah lazim yang saya kenalpasti di kalangan wanita yang disyakki menghidap PCOS:
1. Pertambahan berat badan yang mendadak (sekurang-kurangnya 5%) .... sering berlaku walaupun wanita-wanita ini tidak mengalami pertambahan nafsu makan
2. Ahli keluarga atau diri sendiri menghidap penyakit Diabetes (kencing manis)
3. Peningkatan pertumbuhan bulu roma yang tidak menyenangkan - roma makin menebal, hitam dan menjadi kerinting. Mula tumbuh di bahagian-bahagian 'sensitif' seolah-olah ada pertumbuhan misai halus atau janggut
4. Central obesity - kaki dan tangan tampak 'slim' tetapi lemak berkumpul di kawasan dada, abdomen dan punggung maenyebabkan wanita tersebut hilang 'shape' (maaf, saya bukan menghina kaum wanita...)
5. Kurang subur. Mengandung pun, mudah gugur.

Rawatan PCOS biasanya merangkumi strategi-strategi seperti berikut:
1. Mengurangkan berat badan
2. Ubatan seperti metformin (yang sebenarnya adalah ubat kencing manis) dan pil perancang. Pelbagai jenis pil perancang boleh diguna. Ada diantaranya yang mengandungi ubat anti-androgen (anti hormon lelaki) iaitu 'cyperoterone acetate'. Contohnya adalah Diane 35 (dipasarkan oleh syarikat farmaseutikal Schering) dan Estelle (maaf, saya tidak tahu nama syarikat)
3. Rawatan kesuburan bagi wanita yang mengingingkannya
4. Rawatan jangka panjang, terutamanya dari segi risiko kencing manis, kolestrol tinggi, darah tinggi, penyakit jantung & barah rahim
5. Rawatan kosmetik - juga untuk golongan wanita yang menginginkannya

Jenis dan cara rawatan adalah bergantung kepada kehendak pesakit, indikasi perubatan dan pendapat doktor yang merawat.

Dari segi rawatan kesuburan, tidak semua wanita yang perlu rawatan secara ubat. Ada wanita yang bijak mengurus berat badan dan ini dengan sendirinya merangsang kesuburan. Dari segi perubatan, bantuan boleh diberi dari segi:
1. Ubat metformin
2. Pil subur (clomiphene citrate) atau Suntikan harian hormon (FSH)
3. Suntikan hCG untuk menggalakkan ovulasi
4. Kaedah laparoskopik (ovarian drilling) - untuk memperbetul ketidakseimbangan hormon di dalam ovari

Ada juga doktor yang menggunakan kaedah tambahan seperti pemanian beradas (IUI) atau persenyawaan tabung uji (IVF).

Namun, kejayaan rawatan tidak boleh diukur dari segi kadar kehamilan sahaja. Ini adalah kerana kadar KELAHIRAN adalah kurang dari kadar KEHAMILAN. Bukan semua janin dapat bertahan sehingga tempoh matang. Ada yang gugur. Ada yang lahir terlalu pramatang. Ini adalah suatu kelemahan semulajadi dalam kes-kes rawatan kesuburan, apakan lagi kes PCOS di mana telur (ovum) yang terhasil kadangkala tidak sihat dan tidak stabil.

Semasa menjalan rawatan kesuburan, doktor biasanya akan memanggil wanita itu untuk datang pada hari ke 9 atau ke 10 untuk 'follicle tracking'. Ini adalah satu proses pengesanan tumbesaran telur (ovum) dengan bantuan alat skan melalui faraj. Skan ini terpaksa dilakukan berulang-kali (biasanya 3 hingga 4 kali) untuk memahami kadar tumbesaran ovum. Apabila ovum telah mencapai peringkat matang, satu suntikan penggalak ovulasi (hCG) akan diberi.

Tidak semua wanita yang memerlukan skan sehingga 3 atau 4 kali. Ada kes di mana telur matang dengan cepat.

Begitu juga dengan suntikan hCG: doktor kadangkala membuat keputusan untuk tidak memberi suntikan ini, terutamanya dalam kes respons terlalu lemah ATAU respons terlalu kuat (terlalu banyak telur yang matang sekaligus)

Kemaskini Sept 2009: Suatu kertas kerja jawatankuasa saintifik RCOG telah menyarankan bahawa metformin BUKANlah suatu rawatan 'first-line' yang disyorkan untuk PCOS. Sila ambil perhatian dan jangan ambil ubat ini tanpa arahan doktor. Untuk maklumat lanjut, layari: http://www.rcog.org.uk/files/rcog-corp/uploaded-files/SAC13metformin-minorrevision.pdf

Indications for MGTT

For the benefit of my students and those who seek knowledge:

Malaysia practices SELECTIVE screening for gestational diabetes. Not all women are screened for the disease. Here are a few indications:

1. Maternal obesity - em..... a bit tricky here.... i'm not sure whether we should follow BMI or maternal weight. Maternal weight > 80 is practical in the sense of a busy set-up such as Klinik Kesihatan. Can follow this simple rule of thumb so long you don't miss obese mothers who are short but weigh > 80 kgs

2. Excessive weight gain in pregnancy

3. Glycosuria on 2 or more occasions

4. Symptoms of frank diabetes

5. Recurrent infections, such as vulvovaginal candidiasis

6. Previous intrauterine death

7. Previous fetal anomaly

8. Previous macrosomia

9. Polyhydramnios

10. Underlying Polycystic Ovarian Disease

11. Family history of diabetes

12. GDM in previous pregnancy

I'm sure the above list is incomplete. If you think we should add more, leave me a note :-)

Biochemical Pregnancy

Have you heard of this term?

I didn't like it from the first time I heard. I mean, the term is both demeaning and confusing.

Demeaning because the affected woman feels like she's being treated like an experimental subject. Confusing because we are neither confirming or denying that she is pregnant.

Ok, background info. Decades ago, our grandmas realized they were pregnant when they began to experience 'morning sickness'. A doctor would then look for Hegar's sign and confirm the pregnancy. Then came in the urine pregnancy tests. Then, these tests became more sensitive. And we are now finally in an era where serum beta-hCG assay is easily available. To that, you add an anxious lady with fertility problems and an equally anxious doctor who wants to see the success of his/her fertility treatment.

And you get biochemical pregnancy.

These pregnancies are real, except when you have choriocarcinoma or hCG-secreting ovarian tumour. The more commoner culprit is hCG injections that are sometimes given to aid ovulation and / or provide hCG support for the early pregnancy.

If we take all the above factors away, then it has to be a pregnancy and nothing else (I stand corrected).

Most (up to 60%?) of pregnancies 'fade away' before most women realize them. These destined-to-fail pregnancies are being increasingly picked up due to heightened surveilance following fertility therapy.

For the benefit of students, a biochemical pregnancy is a pregnancy that fails before the beta-hCG levels enter the 'discriminatory zone'.

And you are what? No. 2 at home? Or is it No.3. Sure? Not 63?

I dedicate this article to all my biochemical brothers and sisters 'born' before me. :-)

Farewell Sir!

After months of persistent rumours, it is now confirmed and it is happening. Dato' Dr Ravindran, my boss, is finally leaving to KL.

Technically, he's my ex-boss. But, some figures remain 'boss' to us no matter how far we progress in life.

I were there at his farewell dinner. It was nice listening to all those parting words from my fellow colleagues. Though there was some amount of sadness, I was not emotional. You come to expect these things in government service. If I had been emotional, I would never have left my Alma mater, my favourite Hospital Tawau or even my memorable University Hospital. I felt a little guilty for not speaking out during his farewell but there was simply nothing much to be said. I have said it all in my Masters thesis. He is definitely one of the 'Giants' of O&G in Malaysia, who cared to lend me his shoulder during my uphill climb into this complex world of O&G!

I know there are many who despise him for one reason or another. But, as I sat there last night, trying to dig into my heart for some residual hatred, I found none. It is not that I have never incurred his wrath. There were awkward moments in the past......

In life, the best lessons are learnt when one is emotionally stirred. 'Boss' did stir up my emotions on many occasions! Alas, it was always attached with good lessons.

When you look back at your childhood, you only remember beatings that were meaningless .... without reason. Well deserved spankings are usually forgotten because the joy of realization overshadows the transient pain of torture.

Adios my boss!

Shoulder Dystocia

I really enjoyed the 'intellectual discourse' I had with the Sem 7 students yesterday. Left the discussion room with much contentment.

To my beloved students, I encourage you to visit this link (American Association of Family Practitioners):
http://www.aafp.org/afp/20040401/1707.html

Just to make sure you don't lose focus in Malaysian context:
1. You must be familiar with McRoberts manoeuvre + administration of suprapubic pressure
2. It is sufficient for you to be aware of the name & correct order of other manoeuvres but we will seldom ask HOW those things are done. Thats postgraduate stuff.

Remember, SHOULDER DYSTOCIA IS A HIGHLY UNPREDICTABLE OBSTETRIC EVENT. This underscores the need for ALL caregivers in the labour room to be ready / on their toes at ALL times. Labour room personnel should be ready to spring into action whenever this condotion is diagnosed. Frequent Shoulder Dystocia drills should be the norm and such events should be recorded and kept in a log by the Labour Ward Manager.

And for the benefit of those who missed my definition yesterday, here it is:

Shoulder Dystocia is defined as difficulty in delivery of the anterior shoulder with NORMAL traction with subsequent need for ancillary obstetric manoeuvres.

Nasopharyngeal Suctioning

I'm afraid I gave incorrect information to my students this morning.

I'm coming out 'naked' :-)

Its oral first, then nasal. But as I said, the usefulness of this procedure is controversial.

Visit this link:

http://www.obgynhealth.net/womens-health/obstetrics-gynecology/oropharyngeal-nasopharyngeal-suctioning-meconium-stained-neonate

PRINCIPLES OF MANAGMENT(2) .... DM

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
monitoring
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?

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 ;-)

PRINCIPLES OF MANAGEMENT......

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

That is PRICNCIPLE of MANAGMENT