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Risk management Risk Management
Ectopic pregnancy Ectopic pregnancy


MACROCYTOSIS

Bone marrow is megaloblastic

Deficiency, or rarely abnormalities of the metabolism, of:
(a) Vitamin B12 /cobalamin (pernicious anaemia ~ 80% all cases)
(b) Folate

Bone marrow is usually normoblastic
(a) Alcohol & (b) Liver disease
(c) Hypothyroidism
(d) Reticulocytosis
(e) Aplastic anaemia
(f) Red cell aplasia
(g) Myelodysplasia
(h) Cytotoxic drugs Paraproteinaemia (such as myeloma)
(i) Pregnancy

Causes of megaloblastic anaemia

Diet
Vitamin B12 deficiency (veganism, poor quality diet)
Folate deficiency (poor quality diet, old age, poverty, synthetic diet without added folic acid)

Malabsorption
Gastric causes of vitamin B12 deficiency (pernicious anaemia, congenital intrinsic factor deficiency, gastrectomy)
Intestinal causes of vitamin B12 deficiency (stagnant loop, congenital selective malabsorption, ileal resection)
Intestinal causes of folate deficiency (gluten induced enteropathy, tropical sprue)

Increased cell turnover
Folate deficiency (pregnancy, prematurity, chronic haemolytic anaemia, inflammatory and malignant diseases)

Renal loss
Folate deficiency (congestive cardiac failure, dialysis)

Drugs
Folate deficiency (anticonvulsants, sulphasalazine)

Defects of
Vitamin B12 metabolism (e.g. transcobalamin II deficiency, nitrous oxide anaesthesia)
Folate metabolism (such as methotrexate treatment)
DNA synthesis

NON-IMMUNE HYDROPS FETALIS

1. Rhesus hemolytic anemia / Alpha thalassemia / Fetal erythro-leukemia
2. Toxoplasmosis / CMV / Parvovirus / Syphilis
3. Angioma of placenta or fetus / Renal or umbilical vein thrombosis / Cardiovascular malformation / Fetal tachycardia / Cardiac rhabdomyoma (Tuberous sclerosis)
4. Fetal haemorrhage / Twin to twin tranfussion syndrome
5. Fetal red cell enzyme defects / Lysosomal enzyme defects
6. Cystic adenomatoid malformation of the lung / Extralobar pulmonary sequestration / Pulmonary hypoplasia / Pulmonary lymphangiectasia / Tracheal atresia / Diaphragmatic hernia
7. Hepatitis or hepatic necrosis / Cirrhosis
8. Lower urinary tract abnormalities
9. Congenital neuroblastoma , teratoma, glioma
10. Some types of short limbed dwarfism
11. Noonan / Nuchal bleb / Optiz frias / Turner / Edward / Patau syndromes
12. Triploidy
13. Maternal nephrotic syndrome

POLYHYDRAMNIOS

Twin gestation with / without twin-to-twin transfusion (7.5%)
Fetal anomalies, including gastrointestinal (40%: oesophageal atresia, usually associated with a tracheoesophageal fistula, duodenal and oesophageal atresia, gastroschisis, imperforate anus), genitourinary (13%), cardiorespiratory (22%: tracheal agenesis, narrow thoracic cage (due to skeletal dysplasias such achondroplasia) and compressive pulmonary disorders (pleural effusions, diaphragmatic hernia or cystic adenomatoid malformation of the lungs)
CNS abnormalities (26% of anomalies) and neuromuscular diseases that cause swallowing dysfunction including anencephaly, iniencephaly, facial tumours and defects, fetal akinesia syndrome, Beckwith-Wiedemann syndrome, and Pena-Shokeir syndrome, craniofacial syndromes (Pierre-Robin, Crouzon, Treacher Collins, Goldenhar, agnathia-holoprosencephaly, agnathia-microstomia-melotia)
Increased fetal urination maternal type 2 diabetes mellitus (5%) and maternal uremia
Fetal and placental tumours or cutaneous arteriovenous malformations (such as sacrococcygeal teratoma, placental chorioangioma)
Congenital cardiac-rhythm anomalies and hyperdynamic fetal circulation associated with hydrops, fetal-to-maternal haemorrhage and viral infection (parvovirus, rubella, CMV and rubella, Listeria)
Chromosomal abnormalities, most commonly trisomy 21, then trisomy 18 and 13
Others include myotonic dystrophy, alpha-thalassemia, lithium

ADVANCED MATERNAL AGE

Perinatal and maternal death
Hypertension
Medical disorders including DM
Thromboembolism
Fibroids and associated complications
Fetal chromosomal abnormalities
Miscarriage
Dizygotic twins
Operative delivery (5-fold increase in caesarean rate)
Preterm delivery (4-fold increase)
Abruption
Amniotic fluid embolus
Trophoblastic disease

ABRUPTION

chronic or pregnancy-induced hypertension (> 140/90 mmHg or higher) *
previous placental abruption (4% to 17% recurrence after one and 25% after two)
smoking (20% ? risk per 10 cigarettes per day: 15% to 25% caused by smoking)
cocaine
physical injury to the uterus (RTA, direct blow)
PPROM > 24 hours (3% to 5%)1
uterine leiomyoma
multiparity
advanced age (3 in 1,000 aged 20 to 24, increasing to 7 in 1,000 in women over 35)
multiple pregnancy
low levels of folate (linked to high levels of homocysteine)
black ethnic origin
some uterine and fetal malformations
thrombophilia

HYPERPROLACTINAEMIA

Anti-depressants / anxiolytics: MAOI (phenelzine, isocarboxazid), tricyclic antidepressants (amitryptiline, imipramine), meprobamate
Dopamine receptor antagonists: phenothiazines, butyrophenones (haloperidol), thioxanthenes (flupentixol), atypical (risperidone), substitued benzamides (sulpiride), diphenylbutylpiperadines (pimozide)
Dopamine-depleting agents: methyldopa, reserpine
Anti-emetics: metoclopramide (phenothiazine-like), domperidone
Hormones: oestrogens (high dosage), TRH
Others: isoniazid, danazol,, monoamine antihypertensives, verapamil, cocaine, antiandrogens, cyproheptadine, opiates, cimetidine, omeprazole,

CHORIOCARCINOMA

Derived from intermediate trophoblastic cells 2ry to a prior pregnancy (normal or abnormal)
1 per 40 moles (usually complete), 1 per 150,000 normal pregnancies vs 1 per 2,500 in Nigeria
Risk factors: blood type A women and blood type A men (RR: 10.4:1)
50% prior moles, 25% prior abortions, 22% normal pregnancies, 3% ectopics or teratomas
Metastases to lungs, vagina, brain, liver, kidney, bowel; may resemble clear cell carcinoma
Serum hCG ~ 18,000, causes endocervical glandular hyperplasia, decidual reaction, Arias-Stella, bilateral enlargement of ovaries by theca-lutein cysts, breast epithelial ductal hyperplasia
Poor prognosis: age > 39, term pregnancy, long interval to diagnosis, high hCG, blood groups B or AB, large tumor, metastases to brain, GI, liver, >8 metastases, prior multiagent chemotherapy
Better prognosis if intense inflammatory infiltrate at interface between tumor and stroma
Surgery occasionally needed for hemorrhage
Monitor via serum hCG and chest Xrays


DOWN SYNDROME

Decreased muscle tone at birth
Small skull (microcephaly)
Asymmetrical or odd-shaped skull
Broad short hands
Single crease on the palm
Round head with flat area at the back of the head (occiput)
Upward slanting eyes, unusual for ethnic group
Small mouth with protruding tongue (see tongue problems)
Retarded growth and development
Delayed mental and social skills (mental retardation)
Iris lesion (Brushfield spots)


AMNIOCENTESIS

preterm delivery
very low birth-weight
intrauterine death
inner ear problems
orthopaedic abnormalities including talipes
pneumonia and the need for intubation
treatment with antibiotics

CYTOMEGALOVIRUS

Growth restriction
Microcephaly
Intracerebral calcification
Cerbreal atrophy
Seizures
Psychomotor delay
Learning disorders
Expressive language delay
Dental abnormalities
Long bone radiolucencies
Chorioretinitis
Optic atrophy
Cataract
Deafness
Pneumonitis
Hepatosplenomegaly
Thrombocytopaenia
Haemolytic anaemia
Jaundice
Purpuric rash


RUBELLA

Meningoencephalitis
Microcephaly
Mental retardation
Hepatosplenomegaly
Thrombocytopaenia
Purpura
Jaundice
Cataract
Pigmentary retinopathy
Glaucoma
Heart disease (PDA, peripheral pulmonary artery stenosis )
Radiolucent bone disease

Late Sequelae:

Diabetes
Thyroid disease
Progressive pan-encephalitis Precocious puberty


TRANSVERSE LIE

Prematurity
multiple pregnancy
multiparity
intrauterine death
polyhydramnios
fundal placenta
arcuate uterus
contracted pelvis
pelvic tumour (including fibroids)
placental haemangioma


FACE PRESENTATION

iniencephaly
multiple pregnancy
placenta praevia
advanced maternal age
multiparity
polyhydramnios
bicornuate uterus
branchial cyst
pelvic tumour
fetal goitre
large thorax
nuchal cord


KLINEFELTER SYNDROME

hypogonadism (small testes, azoospermia / oligospermia)
gynaecomastia at late puberty
psychosocial problems (academic difficulty, poor self-esteem, behaviour problems)
hyalinization and fibrosis of the seminiferous tubules
erectile dysfunction and subnormal libido
fatigue, weakness
osteoporosis
language impairment


BRACHIAL PLEXUS INJURIES

brachial plexus injuries have an incidence of 2-3/1000 births
usually discovered at birth or shortly after by an inequality of upper arm movement, an unequal Moro reflex, or suspicion because of the type of delivery
risk factors include being a large for dates infant, prolonged labour, or breech delivery.
about 45% are associated with shoulder dystocia
non- dystocia group associated with primagravidas, small infants, and mothers < 20 years

Erb-Duchenne (Erb's) palsy, the most common type, refers to paralysis of the upper brachial plexus and involves injury to C5 and C6. There is an inability to abduct the shoulder, externally rotate the arm, and supinate the forearm. The hand and wrist are spared and there is a normal grasp. DTRs are absent. Rarely, the fibres to the diaphragm are involved and there is paralysis on the ipsilateral side.

Dejerine-Klumpke (Klumpke's) palsy refers to paralysis of the lower brachial plexus and involves C8-T1. Inability to flex wrist or grasp and if sympathetic fibres of T1 are involved, there may be an ipsilateral ptosis and meiosis (Horner's syndrome). It is much less common than Erb's and has a poorer prognosis.

MALE SUBFERTILITY & DRUGS

anabolic steroids
cannabis
cimetidine
sulfasalazine
salazopyrine
colchicine
methadone
methotrexate
phenytoin
corticosteroids
spironolactone
thioridazine
calcium channel blockers.

PHAEOCHROMOCYTOMA

A few facts:

rare catecholamine secreting tumours of chromaffin cells.
may arise from any tissue of neuroectodermal origin.
0.75% of cases of secondary hypertension.
10% are outside the adrenal glands
10% are bilateral
10% are malignant

Clinical Features (all the Ps)

Pain in the chest & abdomen
Pallor
Perspiration
Polyuria (from glycosuria)
hyPertension ± diastolic / postural hyPotension
Prostration
Paroxysmal episodes of hypertension, headache, sweating, palpitations.

Other features:

Cardiovascular findings: tachycardia, hypertension, congestive cardiac failure, angina, myocardial infarction and stroke.
General: weight loss, anorexia and constipation.


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