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Fetal Foot Measurement

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801. Pre-eclampsia and Eclampsia

the presentation of the fetus and the fetal condition, together with the likelihood of success of induction of labour after assessment of the cervix. [ ] Measure blood pressure continually. The third stage should be managed with 5 units of intramuscular/slow intravenous Syntocinon®. Ergometrine and Syntometrine® should not be given for prevention of haemorrhage, as this can further increase the BP. Prophylaxis against thromboembolism should be considered. Management of eclampsia Resuscitation: The patient (...) is a relatively common condition but may become life-threatening for the mother and the fetus. It is characterised by maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. Severe pre-eclampsia is defined as diastolic blood pressure (BP) of at least 110 mm Hg or systolic BP of at least 160 mm Hg, and/or symptoms, and/or biochemical and/or haematological impairment. [ ] In severe pre-eclampsia, the fetus and/or newborn may have neurological damage induced

2008 Mentor

802. Postmaturity (Prolonged Pregnancy) Full Text available with Trip Pro

perinatal mortality. [ ] Where possible, first trimester ultrasound rather than last menstrual period (LMP) dating should be relied on to assess pregnancy duration. This should be determined using crown-rump measurement or head circumference if crown-rump length is above 84 mm. [ ] Risks associated with post-term pregnancy [ ] Fetal and neonatal risks Prolonged pregnancy is associated with an increase in perinatal morbidity and mortality. There is an increased risk of stillbirth and neonatal death (...) on research evidence, UK and European Guidelines. You may find the article more useful, or one of our other . In this article In This Article Post-term Pregnancy Prolonged Pregnancy In this article Prolonged pregnancy is defined as pregnancy which progresses beyond 42 weeks. [ ] Prolonged pregnancy is associated with fetal, neonatal and maternal complications. Risks increase after term and significantly so after 41 weeks of pregnancy. A policy of induction of labour appears to improve outcomes and reduce

2008 Mentor

803. Pernicious Anaemia and B12 Deficiency

of vibratory sense and position are early indications of central nervous system (CNS) involvement, accompanied by reflex loss and mild-to-moderate weakness. Later stages may be characterised by spasticity, Babinski's responses and ataxia. Other uncommon neurological symptoms include impairment of pain, temperature and touch sensations. The legs and feet are involved earlier and more consistently than the hands. Yellow-blue blindness may occur. Psychiatric symptoms (usually more prominent in advanced cases (...) levels should be measured to exclude deficiency, which may co-exist with B12 deficiency. Red cell folate is a better guide to deficiency than serum folate. B12 deficiency may result in increased serum folate levels but reduced red cell folate levels, because of the effect on intracellular folate metabolism. [ ] Investigations to determine the aetiology of vitamin B12 deficiency Autoantibody screen [ ] Pernicious anaemia is one of a number of autoimmune diseases, including Hashimito's disease, type 1

2008 Mentor

804. Pre-pregnancy Counselling Full Text available with Trip Pro

other smokers in the household, since smoking around a baby increases risk of sudden infant death and other respiratory diseases. Give appropriate health education regarding the effect of smoking on pregnancy and more broadly. Offer referral to a smoking cessation service. There is little information on the use of nicotine replacement therapy (NRT) in pregnancy but smoking gives a greater dose of nicotine and also exposes mother and fetus to other toxins. It is likely to be safer than smoking (...) . Where injecting drugs, or with a past history of such behaviour, offer hepatitis B and C and HIV testing. In particular: Cocaine use in pregnancy is particularly serious and has been associated with spontaneous abortion, placental abruption, premature birth, low birth weight and sudden infant death syndrome. There is conflicting evidence regarding fetal abnormalities. Opiate use is associated with increased incidence of intrauterine growth restriction and preterm delivery. This contributes

2008 Mentor

805. Prenatal Diagnosis

diagnosis but give a risk/probability of a problem with the fetus - for example, Down's syndrome. Further diagnostic tests are required to confirm and diagnose the fetal abnormality. Prenatal diagnosis is therefore offered to all pregnant women if they have positive antenatal screening results. However, some women may be offered definitive prenatal diagnosis from the outset without any preceding screening tests; for example: If there is a family history of an inherited condition. If they have had (...) is undertaken so that the probability of the fetus being affected can be assessed. [ ] If both parents are found to be carriers of a haemoglobinopathy then prenatal diagnosis will be offered. Down's syndrome screening [ ] NICE guidelines state that all pregnant women should be offered this screening. In England and Scotland this is done using the combined test (nuchal translucency measurement combined with serum markers beta-human chorionic gonadotrophin and pregnancy-associated plasma protein

2008 Mentor

806. Premature Labour Full Text available with Trip Pro

membranes who are >30 +0 weeks of gestation: Transvaginal ultrasound measurement of cervical length is used to estimate likelihood of delivery within the following 48 hours: If the cervix is >15 mm it is unlikely she is in preterm labour. Fetal fibronectin is a quick, simple test that may be used as an alternative when transvaginal ultrasound measurement of cervical length is unavailable or unacceptable: It requires that an internal examination has not been undertaken first. If fibronectin concentration (...) and previous preterm delivery. Worldwide, the greatest risk factor is infection, mainly from , HIV and mycoplasma. Around 25% of preterm deliveries are elective due to either maternal factors such as or fetal factors such as . [ ] Diagnosis Pregnant women may present with a history of painful contractions and assume that they are in a premature labour. Many of these women are experiencing Braxton Hicks contractions and over 60% will not have delivered within 48 hours of presentation, many going on to full

2008 Mentor

807. Placenta and Placental Problems

and European Guidelines. You may find one of our more useful. In this article In This Article Placenta and Placental Problems In this article The normal placenta [ , ] The placenta provides for exchange of nutrients, oxygen and waste products between the mother and fetus, as well as being an endocrine organ for the synthesis of hormones and neurotransmitters and a barrier to toxins and infection. It is derived from both maternal and fetal tissue, with approximately one fifth derived from fetal tissue (...) crystalloid Hartmann's solution and/or 1-2 litres of colloid as rapidly as required. With continuing massive haemorrhage and whilst awaiting coagulation studies and haematology advice, up to 4 units of fresh frozen plasma (FFP) and 10 units of cryoprecipitate may be given empirically. Ideally, measure central venous pressure (CVP) and adjust transfusion accordingly. Assess fetus and D ecide on D elivery: If the fetus is alive, perform either caesarean section or artificial rupture of the amniotic

2008 Mentor

808. Lumps

with the patient. Management may range from explanation and reassurance to urgent referral for surgery. Aetiology Generally, lumps fall into one of the following aetiological categories: Congenital or acquired. Traumatic. Inflammatory (acute or chronic). Neoplastic (benign or malignant, primary or secondary). Other (degenerative, metabolic, parasitic, hormonal disorder). History Where was the lump found? Common sites are: Neck Breast Groin Axilla Wrist, hands and feet Scrotum Perianal area Scalp Skin Chest (...) . It may be easy to define (as with lumps in the breast, thyroid or parotid) or more difficult (as, for example, with abdominal masses). Where it is difficult to ascribe an anatomical origin, other features should then be described. Size This should be measured and recorded, with a diagram showing dimensions, position and shape. It can be misleading to describe size by comparisons with other things, familiar or otherwise. For example, 'It is about the size of a quail's egg, sir'! Shape Some swellings

2008 Mentor

809. Multiple Pregnancy

triplet pregnancies. Monochorionic diamniotic triplet pregnancies. Dichorionic diamniotic triplet pregnancies. Pregnancies complicated by any of the following: Asymmetrical fetal growth. Fetal anomaly. Death of one fetus. Twin-twin transfusion syndrome (TTTS). Scanning Women with multiple pregnancies should be offered a first-trimester ultrasound scan when approximately 11 weeks 0 days to 13 weeks 6 days: This is to estimate gestational age, determine chorionicity and screen for Down's syndrome (...) . Intrapartum management On admission in labour: Obtain intravenous (IV) access. Blood should be taken for group and save, as significant blood loss is more likely in multiple pregnancy. Monitor fetal heart rates separately and continuously. Fetal scalp electrodes are used where there is concern about the quality of the trace of twin 1. Check the position of the lead fetus: This is usually confirmed by ultrasound. Both fetuses may present as cephalic. The first twin may be cephalic, with the second breech

2008 Mentor

810. Maple Syrup Urine Disease

-mass spectrometry: for the detection of alpha-hydroxyisovalerate, lactate, pyruvate and alpha-ketoglutarate. Enzyme activity can be measured in lymphocytes and/or cultured fibroblasts, although this test is not necessary for diagnosis. Management [ ] Treatment includes dietary leucine restriction, high-calorie BCAA-free formulas, careful supplementation with isoleucine and valine, and frequent clinical and biochemical monitoring. [ ] Dietary therapy must be lifelong (proprietary products (...) who have MSUD, frequent monitoring of plasma amino acid concentrations and fetal growth is necessary to avoid the opposing risks of leucine teratogenicity and essential amino acid deficiencies. [ ] Complications Patients are at risk of metabolic decompensation during periods of intercurrent illness - eg, infection, trauma, surgery. Dietary compliance is necessary to prevent developmental delay and neurological symptoms. Adolescents and adults with MSUD are at increased risk for , and disorders

2008 Mentor

811. Neonatal Examination

and incorporate [ ] : A review of parental concerns and the baby's medical history. Family, maternal, antenatal and perinatal history. Fetal, neonatal and infant history, including any previously plotted birth weight and head circumference. Whether the baby has passed meconium and urine (and urinary stream in a boy). Other tests as recommended by the UK National Screening Committee. These should also be carried out or arranged at this time. The examination is best conducted in a well-lit, warm, private room (...) . Listen to the baby's cry and note its sound. Weigh the baby and plot this reading on its growth chart. Perform a systematic 'head to toes' examination This should be done carefully and in good light to detect abnormalities: Head : Shape, presence of fontanelle and whether normal, sunken or bulging. Measure and record head circumference on the growth chart. Assess facial appearance and eye position. Look for any asymmetry or abnormality of facial form. Eyes : Establish that they are of normal shape

2008 Mentor

812. Turner's Syndrome

of the remaining karyotypes show a mosaic pattern - eg, 45,X/46,XX, 45,X/46,XiXq, 45,X/46,XY, 45,X/46,XrX. NB : advanced maternal age is not a risk factor for Turner syndrome. Clinical features [ , ] Clinical features by age include: Newborn infants: may be recognised because they are often borderline small for dates, have lymphoedema of the hands and feet and excessive skin at the nape of the neck, and cardiac abnormalities (eg, coarctation of aorta, pulmonary stenosis, aortic stenosis, bicuspid aortic valve (...) , specific learning difficulties, social vulnerability (social problems, immaturity, less social activity), foot problems (eg, toenail involution, cellulitis), renal anomalies. Adolescence: impaired pubertal growth spurt (even with oestrogen induction), ovarian failure (absent/incomplete puberty), obesity, hypertension, increased prevalence of immune disorders (eg, autoimmune thyroiditis, coeliac disease, inflammatory bowel disease), specific learning difficulties, social vulnerability, foot problems

2008 Mentor

813. Subfertility Investigations and Management

. Women should be advised that when pregnant, drinking alcohol is not advised due to the potential risk to the developing fetus. Smoking: advise women that smoking can harm a developing baby; offer those who smoke support and referral to help them quit. Advise men that smoking affects semen quality (although it is not known if this adversely affects fertility) and discuss the benefits of quitting smoking to their general health and discuss risks of passive smoking to partner and potential baby. Weight (...) . Timed intercourse: there are insufficient data to draw conclusions about effectiveness of methods to predict ovulation so that intercourse can be concentrated in the right time of the cycle. [ ] Methods used include measuring basal temperature and urinary hormones, monitoring cervical mucus and using ultrasound scans. There may be a slight improvement in pregnancy rates but concerns remain about the side-effects of stress and the detrimental effect on relationships and sexual spontaneity. Treatments

2008 Mentor

814. Thallium Poisoning

admission Measure thallium levels in blood and urine three times per week to confirm a decreasing trend. Although not well studied, case reports suggest that Prussian blue treatment can be discontinued when spot urine thallium levels fall to less than 100 mcg/L. [ ] Physiotherapy may reduce or prevent muscle contractures. Prognosis Of those who survive poisoning, about a third to a half have residual neurological or visual disability. Exposure during pregnancy can lead to fetal abnormalities. Chronic (...) with marked leg and foot tenderness and paraesthesia. Weakness may be difficult to elicit because of pain and it tends to be mild. With severe neurological involvement, respiratory paralysis can be fatal at the end of a week. Examination of the eyes and face may show loss of the lateral half of the eyebrows, drooping eyelids, facial nerve palsy, ophthalmoplegia and nystagmus. Specialist examination is required with slit-lamp assessment and documentation of colour vision. Keratitis and corneal opacities

2008 Mentor

815. Syringomyelia and Syringobulbia

of a Chiari malformation. This is a developmental abnormality occurring in the fetus, causing the cerebellum to protrude from its normal position through the foramen magnum and into the cervical portion of the spinal canal. There are two main types of Chiari malformation - type I and type II. Type I has no other associated cause, whereas type II is associated with spina bifida. Causes of disruption/blockage of CSF circulation include: Arachnoiditis following infection, inflammation, irradiation (...) than the other. Classically, the sensation loss is experienced in a shawl-like distribution over the arms, shoulders and upper body. Dysaesthesia (pain experienced when the skin is touched) is common. Light touch, vibration and position senses in the feet are affected as the syrinx enlarges into the dorsal columns. Motor features These begin to occur as the syrinx extends and damages the lower motor neurons of the anterior horn cells. Muscle wasting and weakness begins in the hands and then affects

2008 Mentor

816. Coxsackie Virus Infection

and European Guidelines. You may find the article more useful, or one of our other . In this article In This Article Coxsackievirus Infection In this article The Coxsackieviruses are common pathogens causing a number of diseases, of which the most common is hand, foot and mouth disease (HFMD). Virology The Coxsackieviruses are RNA viruses of the Picornaviridae family, Enterovirus genus which includes echoviruses and polioviruses. Infections are often asymptomatic. They are divided into groups A and B (...) with other group A or B viruses. [ , ] Usually a mild illness with a prodromal phase, followed by tender oral ulcerative lesions and then usually maculopapular lesions on the hands and feet. Rarely there are neurological or other complications which can be very severe. See the separate article for more information. Herpangina [ ] Incubation period of about four days. Affects mainly children up to the age of 10. Mild pyrexia, headache, sore throat, dysphagia, loss of appetite and sometimes vomiting

2008 Mentor

817. Diving Accidents

be transported at below 1,000 feet or the cabin should be pressurised to sea level pressure. 100% oxygen should also be given during transport. Keep all of the diving equipment with the diver as this may give an idea of what caused the problem. Obtain expert opinion from either the British Hyperbaric Association or the Institute of Naval Medicine. Please refer to the links under 'Internet and further reading' below for contact details. The foramen ovale is the link between the atria in the fetal circulation (...) . [ ] Accidents on entering the water Accidents may occur due to hyperextension of the spine, especially the neck. If it is necessary to enter the water from a great height (eg abandoning a sinking ship), it is much safer to enter the water feet first than head first. When people take their own life by jumping from a very high bridge, it is often the force of the impact with the water that is fatal. However, many accidents related to entering the water also occur when diving into shallow water. Nocturnal

2008 Mentor

818. Diabetes in Pregnancy

and the prevalence of type 2 diabetes amongst women of child-bearing age are increasing. Pregnancies of women with diabetes are regarded as high-risk for both the woman and the baby [ ] . Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes, 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes [ ] . Possible complications Diabetes in pregnancy is associated with risks to the woman and to the developing fetus [ ] . Miscarriage, pre (...) of hypertension during pregnancy [ ] . rates are higher. : babies are five times more likely to be delivered before 37 weeks. rates are higher in women with pre-gestational diabetes. : associated with increased risk of macrosomia and shoulder dystocia [ , ] . is more common in pregnancies where the woman has pre-existing diabetes. Maternal infection is more likely to occur. [ ] . Increased risk of fetal and neonatal complications : the Confidential Enquiry into Maternal and Child Health showed a five-fold

2008 Mentor

819. Electrical Injuries and Lightning Strikes

electricity may cause significantly more harm. Indeed, an amount enough to cause minimal injury to the mother may be lethal to the fetus. Furthermore, the path of transmission becomes important here: the current path may completely bypass the maternal heart but, if it travels through the uterus, the fetus may be seriously injured. Fetal harm : other than cardiac arrest, fetal complications include intrauterine growth restriction, oligohydramnios, fetal movement reduction and spontaneous abortion (...) significant electrical injury - this occurs days to years later. Psychological sequelae: the degree is not necessarily related to the amount of physical injury and problems may last for years. Electrical shock in pregnancy [ ] General points : there is little information available about electric shocks during pregnancy and the accepted high rate of mortality may be due to publication bias. However, it is well documented that fetal skin is 200 times less resistant than the skin postnatally, so less

2008 Mentor

820. Edward's Syndrome

posture: clenched hands with index finger overriding middle finger and fifth finger overriding fourth finger. Thumb aplasia. Radial hypoplasia or aplasia. Short sternum. Hypoplastic nails. Short, dorsiflexed hallux. Prominent calcaneus (rocker bottom feet). Congenital heart defects: >90% have these - eg, atrial septal defect, ventricular septal defect, patent ductus arteriosus, coarctation of aorta. Gastrointestinal abnormalities: eg, omphalocele, oesophageal atresia ± tracheo-oesophageal fistula (...) defined and rarely misdiagnosed. There are some overlapping features with , Pena-Shokeir syndrome type 1 or syndromes with fetal akinesia sequence, and with CHARGE syndrome: C oloboma, H eart defects, A tresia of the choanae, R estriction of growth and developmental delay, G enitourinary abnormalities and E ar anomalies. Investigations and management Cytogenetic studies and chromosomal analysis will confirm the diagnosis. Organ systems will need specific investigation depending on the abnormality - eg

2008 Mentor

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