Gestational Diabetes Mellitus (GDM) Congenital Anomalies GDM can affect fetal development that resulting in congenital anomalies.

. The exact pathophysiology behind these phenomena are unclear but it is said to be associated with the overgrowth of fetal organs in response to hyperinsulinemia in fetus (indirect response in fetus as a result from hyperglycemic and hyperinsulinemia mother). The anomalies can be presented variedly and can be multiple in a fetus. The main parts involve are heart, spinal cord and brain in addition to genitourinary, gastrointestinal and skeletal anomalies. The specific examples are neural tube defect (spina bifida), hydrocephaly, patent ductus arteriosus, orofacial clefts (cleft lips and/or palate), hydronephrosis and esophageal atresia. However, having GDM does not increase the risk for having a baby with a chromosomal problem such as Downs syndrome (that is more depending on the mothers age). References: 1. Obstetrics by Ten Teachers 18th edition 2. http://www.mfm-evms.org/dm12effectonbaby.html 3. http://emedicine.medscape.com/article/127547-overview#aw2aab6b6 4. Congenital Abnormalities And Pregestational Diabetes Mellitus In Pregnancy by Y T Chia, S Chua, A C Thai, L P Kek and S S Ratnam in Sinagapore Med J 1996; Vol 37: 380-383 5. Congenital Malformations Among Infants Whose Mothers Had Gestational Diabetes Or Preexisting Diabetes by Anders Aberg, Lena Westborn and Bengt Kallen in Early Human Development Volume 61, Issue 2, March 2001, Pages 85-95, Elsevier Science Ireland Ltd.

YEAR 3 - CSL OBSTETRIC AND GYNECOLOGY

1. Speculum - the function: inspection of cervix; any mass, bleeding, to take any specimen i.e. for pap smear - the instrument - procedure: remember the lock system, lubricate with NS/lubricant, up or down - caution/side effect: pain, - contraindication 2. Vaginal examination digital examination - the function: to feel any mass in the vagina/mass at uterus - procedure: using 2 fingers 3. Episiotomy - the function: for provide adequate space for delivery, delivery with instrument aid - the instrument: special scissor - procedure: either J shaped (mediolateral/posteriolateral) or medially - caution/side effect - contraindication 4. Suture for episiotomy - the instrument: using absorbable material

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procedure: 3 times knot caution/side effect: make sure stop all bleeding, close all spaces and suture above the apex make 2 initial knot - contraindication Mechanism of normal labor and delivery - definition of labor: regular uterine contraction lead to progressive cervical changes - 3 stages, 1st consist of latent and active, 2nd of passive and active etc. - duration: 1-3 hrs+ dont know or 1cm/1hr for primigravida to 8hrs 2-1 to 2 hrs 3-30 minutes = total is 8-12 hrs - the mechanism: engagement, descent, flexion, internal rotation, extension/crowning, restitution, external rotation, delivery of shoulder and other fetal part - then pull downward for delivery of ant shoulder, then upward for post shoulder and etc. + placenta delivery - true(regular rhythmic progressive contraction + cervix dilatation) and false labor pain Pap smear - microscopic slide and cytology - using brush (insert in the os) and spatula (at the external cervical os) - 25 years old to 65 years old - check for pre malignant cells Female urinary catheterization - 3x cleaning using iodine/the pink solution, using the gel - prepare the equipment prior to procedure - using 2 finger, left hand - the special fold for the gauze Vaginal swab - 3 tube (2 black and 1 other color) for other micro, gonorrhea and Chlamydia respectively - take swab for gonorrhea and Chlamydia at endocervical area - the other one at the vaginal fornices

Perineal tears These are classified into 4 degrees: . 1st-degree tears are where the fourchette and vaginal mucosa are damaged and the underlying muscles are exposed, but not torn. . 2nd-degree tears are to the posterior vaginal walls and perennial muscles, but the anal sphincter is intact. . 3rd-degree tears extend to the anal sphincter that is torn, but the rectal mucosa is intact. . 4th-degree tears are where the anal canal is opened, and the tear may spread to the rectum. Thyroid hormone changes in early pregnancy -beta hCG, increase T3 and T4, however, TBG also increase thus balance the free T3 and T4 -total TH will increase and lower TSH -no symptoms of hyper/hypothyroidism -active form is free T3

In hyperthyroidism, free T3 and T4 level may be normal or increase and TSH will further suppress throughout the pregnancy compared to normal physiological changes in pregnancy. Monitor the T3 and T4. Mechanism of action for PTU is inhibiting T4 production process and inhibits the conversion of T4 to T3. FIGO classification A. Cervical ca 0. cervix I. upper 1/3rd vagina II. lower 1/3rd vagina+pelvis III. bladder and rectum IV. distant B. Endometrial ca I. corpus II. cervix III. pelvis IV. bladder and rectum C. Ovarian ca I. Ovary/ovaries II. pelvis III. peritoneal implant IV. distant e.g. liver 9th may 2011 1. CP with Dr. Mini - pih and pp; treatment for chronic hpt is not the same as pih in term of the medication bcoz in chronic hpt, it is more towards maintaining the renal function - PCOS - pylonephritis - DVT - Uterine fibroid; its changes include calcification, necrosis, cystic, degeneration and malignant change 2. Bedside with Dr. Neza - pregnant mother is uncomfortable lying supine flat because they will experience breathlessness due to the gravid uterus that will pressing the diaphragm upwards and also uncomfortable due to acid reflux (hypotonia) - constipation in pregnancy is also due to hypotonia - pyrexia, exclude any possible causes of fever including DVT, dengue, malaria - fever is more prominent at night in malaria, the intermittent fever as the plasmodium will multiply cause hemolysis of red blood cells at night, thus releasing the organism into the blood - per vaginal bleeding; the menorrhagia can be described as flooding, changing pads after sleeping at night and associated with clots. It is cyclical heavy bleeding and may be prolonged; uterine fibroid, endometriosis, adeno and also endometrioma - PID, endometritis (due to inflammation causing erosion of blood vessels) and polyps, may cause pv bleeding

- uterine contraction; weak<20s moderate<30s and strong<45s. brixston hicks<15s 3. CP with Dr. Syam - pv bleeding, menorrhagia 4. Tutorial with Dr. Syam - menopause and its sequelae - menopause defined as the termination of reproductive age of a woman in absence of menstruation for 12 months consistently, ranging from 47 to 52 years old. - premature ovarian failure and premature menopause (before the age of 40 years old) - due to physiological ovarian failure leads to less production of estrogen. Also may due to any surgical intervention like oophorectomy, any intake of GnRH analogue, radiation, toxic medication etc. - the main consequences are towards CVS, bone, vasomotor, genitourinary system and psychological impact. - vasomotor include hot flush, night sweat, palpitation, irritability and insomnia - ix and rx (include HRT, herbs etc) Autosomal dominant; marfans and Huntington, vonWillebrand disease Autosomal recessive; thalassemia and cystic fibrosis, CAH X linked dominant; X linked recessive; hemophilia, G6PD and color blindness PCOS - multiple ovarian cyst produce estrogen, causing high LH and low FSH -rx aim is to treat the symptoms including infertility, virilism, amenorrhea and menorrhagia and/or diabetes, obesity - drug that promote ovulation is clomid/clomiphene, OCP (reduce LH, thus reduce production of progesterone and androgen) Lie; the relation between the long axis of mothers uterus and the long axis of fetus Station; the relation between bony prominence of the presenting part and ischial spine Normal labor; progressive painful rhythmic and regular uterine contractions that lead to cervical effacement and dilation and resulting in the expulsion product of conception. Pp; placenta is at abnormal position at lower segment of uterus after 28 weeks of gestation. Engagement; the widest part of presenting part passing though pelvic inlet Crowning: when the head has passed though pelvic outlet and does not recede between contractions.