Continuous electronic fetal monitoring

Continuous electronic fetal
monitoring in labour by cardio-tocography (CTG) is now the accepted standard for intra-partum fetal monitoring in women with additional risk factors.

    Compared to intermittent auscultation, CTG is associated with:

    1. A halving of the risk of neonatal seizures.
    2. A significant increase in the risk of caesarean section (relative risk 1.66; 1.30 – 2.13)
    3. A significant increase in the risk of instrumental delivery (relative risk 1.16; 1.01 – 1.32)
    4. No significant difference in overall perinatal death rate
   5. No significant difference in the risk of cerebral palsy

These results remain true for low-risk, high-risk and preterm pregnancies and were unaffected by access to fetal blood sampling.

Muscles of anterior abdominal wall (1)

Laterally the anterior abdominal wall consists of 3 separate sheet-like layers of muscles
1. External oblique muscle (outer layer)
2. Internal oblique muscle (intermediate layer)
3. Transversalis abdominis muscle (inner layer).

They become aponeurotic anteriorly, fuse and form the sheath around the rectus abdominis muscles.

Above the umbilicus, the anterior rectus sheath is formed by external oblique aponeurosis and internal oblique aponeurosis. Posterior rectus sheath is formed by aponeuroses of transversus abdominis and internal oblique muscles.

Inguinal ligament

The inguinal (Poupart's) ligament extends from the anterior superior iliac spine to pubic tubercle.
It is the free lower boder of the external oblique aponeurosis.
It is rolled inwards inferiorly into a gutter which forms the floor of the inguinal canal.

Gluteus maximus muscle

The prominent muscle of the buttock.
Is supplied by the inferior gluteal nerve.
Powerful lateral rotator and extensor at the hip joint.
Extends and stabilizes the knee joint.

Mongolian blue spot (photo)

Mongolian blue spot

Mongolian spots are flat, blue, or blue-gray skin markings near the buttocks that commonly appear at birth or shortly thereafter.
Mongolian blue spots are common among those who are of Asian, East Indian, and African descent.
Mongolian spots are not associated with disease. The markings may cover a large area of the back.

Occasionally, Mongolian blue spots are mistaken for bruises. It is important to recognize that Mongolian blue spots are birthmarks, NOT bruises.

Characteristic features are
    1.Blue or blue-gray spots on the back, buttocks, base of spine, shoulders, and other body areas
   2.Flat area with irregular shape and unclear edges
    3.Normal skin texture
    4.The spots are usually 2 - 8 centimeters wide.
No treatment is necessary or recommended.
The spots often fade in a few years and are almost always gone by adolescence.

Alternative Names
(Mongolian spots; Congenital dermal melanocytosis; Dermal melanocytosis)

Erythema toxicum

Erythema toxicum is a common rash usually seen in newborns. Usually appears on 2nd or 3rd days. It takes the form of a white pinpoint head on an oval erythematous base. Histological features show massive numbers of oesinophils. The rash rarely lasts for more than a few days and is harmless.
Erythema toxicum may appear in 50 percent or more of all normal newborn infants.
Its cause is unknown.
The condition may be present in the first few hours of life, generally appears after the first day, and may last for several days.
Alternative Names (Erythema toxicum neonatorum)

Doppler ultrasound and the prediction of adverse pregnancy outcomes

Uterine artery doppler can be done during the first and early second trimester to predict pregnancies at risk of adverse outcomes. Sixty to 70% of women with bilateral uterine artery notches at 20-24 weeks gestation will develop one or more of complications (preeclampsia, FGR, or placental abruption).

Dating the pregnancy

Setting a reliable EDD is one of the important functions in AN care.
Precise dating is important in preterm gestations, prolonged pregnancies and a number of different screening tests.
The EDD can be calculated from the first day of LMP by adding 7 days and 9 months. However, this method assumes menstrual cycle to be 28 days cycle with ovulation on day 14 and the woman must remember her LMP accurately. In reality, most women have not 28 days cycles and the timing of ovulation is variable within a cycle. Menstrual dates are not accurate in 25-40% of women.
Dating by an ultrasound scan in the first trimester must be done ideally between 10 and 14 weeks, and EDD set by this scan should be used in preference to menstrual EDD.
CRL crown rump length is used up until 13weeks+6days with accuracy ±4days.

Thyroid function in pregnancy

Human chorionic gonadotrophin (hCG) has the same alpha subunit as thyroid stimulating hormone (TSH). Maternal TSH production is suppressed during the first trimester, when hCG levels are the highest. The TSH response to TRH (thyrotrophin releasing hormone) is reduced during the first trimester then returns to normal after this. Total T3 and T4 production increase because of the increased production of thyroid binding globulin (TBG) which starts in the first 2 weeks and reaches plateau by 20 weeks. Thyroid hormone reference ranges for nonpregnant women are not appropriate in pregnancy. Trimester specific range of free T4, free T3 and TSH should be analysed. There is a fall in TSH and a rise free T4 concentrations in 1st trimester followed by fall in fT4 concentration with advancing gestation. Iodine is essential for thyroid hormone synthesis. There is increased renal loss of iodide in pregnancy. The thyroid compensates by increasing uptake of iodide from circulation. Thyroid gland becomes enlarged where there is background iodine deficiency.

Ventilation in pregnancy

Ventilation begins to increase significantly around 8 weeks of gestation.
Mechanical aspects of ventilation alter significantly in pregnancy.
Tidal volume increases about 40% (from 500ml to 700ml). The respiratory rate remains unchanged. Therefore the minute ventilation (the amount of air in and out of the lungs within one minute) increases. That minute volume is the product of tidal volume and the respiratory rate. It increases by approximately 30-50% with pregnancy.
Pregnant women perceive this increase in minute volume as shortness of breath, which affects 60-70% of pregnant population.
Expiratory reserved volume and residual volume both decrease in pregnancy. The sum of these two, the functional residual capacity, decreases about 10-25%. FRC is further reduced in supine position.
Forced expiratory volume in one second FEV1 and peak expiratory flow rate remain unchanged.

Haemostasis and coagulation in pregnancy

Pregnancy is a hypercoagulable state.
Almost all procoagulant factors, including factors VII, VIII, IX, X, XII, and fibrinogen, are increased.
Fibrinogen is increased by 50% (from 300mg/dL to 450mg/dL).
Von Willebrand factor also increased.
Protein S activity decreases.
Activated protein C resistence increased.
Antithrombin III levels remain  unchanged.
Plasma homocystiene concentration are lower in normal pregnancies.
Maternal plasma D dimer concentration increases progressively from conception until delivery.
Incidence of venous thromboembolic complications is five time greater during pregnancy.

CTG (variable deceleration)

Typical variable deceleration has the following characteristics

1. Shouldering
Accelertion before and after deceleration

2. Sharp drop and sharp rise back to the baseline- v sign

3. Continued variability in the trough

4. Usually but not necessarily coinciding with contraction.

Screening for trisomy 21 (Down's syndrome )

Natural birth prevalence of Down's syndrome increased with Maternal age;
Under  25- 1 in 1500
At 30- 1 in 1000
At 40- 1 in 100.

Second trimester screening
( between 15 and 22 weeks )

1. Double test
Total hCG or free beta hCG + MSAFP ( Maternal serum alpha fetoprotein) + Maternal age
Detection rate 60%
False positive rate 5%

2. Triple test
Double test + uE3 (unconjugated estriol)
Detection rate 68%
False positive rate 5%

3. Quadruple test
Triple test + inhibin A
Detection rate 76%
False positive rate 5%

First trimester screening
(8-14 weeks)

1. Biochemical
beta hCG + PAPP-A + Maternal age
Detection rate 62%
False positive rate 5%

2. USG + Maternal age
NT (nuchal translucency )
Detection rate 77%
False positive rate 5%

3. BC + USG + Maternal age
Detection rate 90%
False positive rate 5%

Integrated test
( First trimester NT, PAPPA + Second trimester beta hCG, uE3, MSAFP)
Detection rate 95%
False positive rate 5%

Treatment modalities for cervical intraepithelial neoplasia; excisonal techniques

1. LLETZ
Remove the transformation zone using an electrodiathermy loop
Require LA or GA

2. Laser cone
Removal of transformation zone using the Laser
Require LA or GA

3. Knife cone biopsy
Taking a cone with Knife
require GA

4. Hysterectomy 

Treatment modalities for cervical intraepithelial neoplasia (CIN); Ablative techniques

Ablative techniques

1. Radical electrodiathermy- burning the transformation zone; Usually requires GA

2. Cold coagulation- destroying the transformation zone by applying a probe heated up to 100-120 degree celcius; Usually require LA

3. Cryocautery-freezing the tissue; does not require any anaesthesia

4. Laser- vaporizing the tissue; require LA or GA

Screening for cervical cancer:The current indications for colposcopy are

1. Three smears showing boderline nuclear changes in squamous cells

2. One smear showing boderline nuclear changes in endocervical cells

3. One or two smears showing mild dyskaryosis

4. One smear showing moderate or severe dyskaryosis

5. One smear showing Possible invasion

6. One smear showing glandular neoplasia

7. Three consecutive inadequate smears

8.  Any grade of dyskaryosis following treatment for CIN before return to routine recall

9.  There abnormal smears of any grade over a 10 year period

10. Suspicious symptom and abnormal cervix

Findings suggestive of a placenta accreta in antenatal ultrasound scan

1. Loss of normal hypoechoic rim of myometrial tissue beneath the placenta

2. Loss of normal hyperechoic uterine serosa-bladder wall interface

3. Presence of tissue of placenta echotexture extending beyond the uterine serosa, sometimes seen within the lumen of bladder

4. Sometimes multiple or large placental venous lakes are seen, giving the placenta moth-eaten appearance

What is the sinusoidal pattern (CTG)?

Regular oscillation of the baseline Heart rate (long term variability) resembling a sine wave.

Smooth undulating pattern lasting at least 10 minutes.

Relatively fixed period of 3-5 cycles per minutes.

Amplitude 5-15 bpm above and below the baseline.

Baseline variability absent.

CTG (baseline heart rate)

     Fetal heart rate is controlled by the rhythmicity of the fetal heart, the central nervous system, and the autonomic nervous system.

FHR is increased in sympathetic response and decreased by para sympathetic response.

Usually there is a balanced increase of sympathetic and para sympathetic response occured during contraction with no observable change in baseline.

Baseline HR is reassuring at 110-160 bpm, non-reassuring at 100-109 and 161-180. It becomes abnormal when the rate is less than 100 bpm, greater than 180 bpm and sinusoidal pattern >=10 minutes.

CTG (fetal heart rate)

Possible causes of baseline bradycardia

Late fetal hypoxemia
Adrenergic blocking drugs such as propanolol
Prolonged umbilical cord compression
Maternal hypotension
Maternal hypothermia
Prolonged Maternal hypoglycaemia

Possible causes of baseline tachycardia

Early fetal hypoxemia
parasympatholytic drugs such as atropine
sympatho mimetic drugs such as ritodrine
chorioamnionitis
Fetal anaemia, heart failure and cardiac dysrhythmia
Maternal fever
Maternal hyperthyroidism
Maternal use of recreational drugs such as cocaine and methamphetamine

Femoral triangle

It is located anteromedially in upper part of thigh.
Boundaries are
inguinal ligament superiorly,
medial border of sartorious laterally,
lateral border of adductor longus medially.
The apex continues into adductor canal.
The base is formed by the adductor longus, pectineus and iliopsoas.
The floor is formed by fascia lata pierced in the region of saphenous opening to form cribiform fascia.

Femoral canal

In the human anatomy of the leg, the femoral sheath has three compartments.
The lateral compartment contains the femoral artery, the intermediate  femoral vein and the medial the femoral canal.
The femoral canal contains efferent lymphatic vessels and a lymph node ( Cloquet).
It is 2 cm long. Its shape is conical.
Its opening is femoral ring.
The boundaries are
inguinal ligament anteriorly,
the pectial ligament posteriorly,
the lacunar ligament medially,
the femoral vein laterally.

Cephalhaematoma versus subgaleal haemorrhage

Cephalhaematoma is a subperiosteal haemorrhage secondary to the
rupture of blood vessels. Its boundaries are limited by the individual
bones. In most cases, there is probably a hairline fracture of the
underlying cranial bone, which may be difficult to demonstrate but is
unimportant since it affects only the outer table of the skull. There
is usually no brain damage. A large amount of blood may be accumulated
and blood transfusion may be required. A large cephalhaematoma may be
associated with neonatal jaundice and anaemia.
The usual cause of cephalhaematoma are prolonged second stage of
labour or instrumental delivery particularly ventouse.
During resolution, there may be a hard swelling which takes several
months to disappear. In some cases, calcification of the swelling
leaving a relatively softer centre mimic depressed fractures.
Cephalhaematoma can be differentiated from the caput succedaneum ,
which is a soft swelling due to the edema of the skin presenting at
the cervix and it crosses the suture line. Caphelhaematoma is limited
to the one side of suture line.
Cephalhaematoma must also be distinguished from another scalp bleeding
called subaponeurotic haemorrhage (also called subgaleal haemorrhage),
which is bleeding between the scalp and skull bone (above the
periosteum).
Subgaleal haemorrhage is rare after normal vertex vaginal. It can be
found one in 1000 babies delivered by ventouse. The baby can become
shocked and mortality rate can be as high as 20%. The clue to the
diagnosis is a boggy swelling of the scalp that crosses the suture
line.

Common forms of Birth trauma to the baby

1. caput succedaneum
2. cephalhaematoma
3. chignon from vacuum extraction
4. brachial plexus injury (Erb's palsy)
5. facial palsy
6. subconjunctival haemorrhage
7. subgeleal (subapponeurotic haemorrhage)

MIN(Multicentric intraepithelial neoplasia)

Intraepithelial neoplastic changes seen at more than one site in lower
genital tract.
The sites involve are the cervix, vagina, vulva, perineum, and anal canal.
The aetiology of MIN is the combination of HPV Infection and host immune
suppression of varying degrees.
MIN may be detected in a woman who has repeated abnormal smear despite
treatment for CIN, in a woman being examined for VIN, or an HIV positive
woman.
There are no guidelines for treating this disease. MIN must be treated in
large centres to concentrate experience and expertise.
Cases are complex and chronic. Some women have already undergone repeated
surgery over years.
Investigations must be individualized and may include multiple colposcopic
directed biopsies, HPV typing, HIV testing and test of T cell function.
Management aims to exclude invasive cancer, to control symptoms, and to
preserve anatomy and functional integrity where possible.
New immunomodulating therapies currently under investigations such as
therapeutic vaccination and imiquimod.

Polymorphic eruption of pregnancy

The commonest pregnancy specific dermatosis. Incidence is about 1 in 200-250 ie about 0.5%.

Occured in 3rd trimester, usually after 35 week's gestation.

More common in primiparous and multiple pregnancies.

Distributed over the abdomen along the striae (with umbilical sparing), with spread to thigh, buttock, under the breast and upper arms.

Pruritic, urticarial, plaques, rarely vesicles and target lesions

Histology shows epidermal/dermal oedema, perivascular infiltration, and patchy parakeratosis.

Resolve usually 2 weeks after delivery.

No effect on fetus.

Treatments include 1% menthol in acqueos cream, 1% hydrocortisone cream or oinment, sedative antihistamine. Systemic steroids are only occationally required for intractable cases.

Recurrence is uncommon.

Fwd: Dermatological Conditions in pregnancy: treatments to be avoided

Acitretin and terzarotene (retinoids used in Psoriasis)

Isotretinoin (retinoid used to treat severe acne)

Griseofulvin (antifungal)

Methotrexate (antimetabolites used in treatment of Psoriasis)

Tetracycline

Thalidomide (leprosy treatment)

Source: An evidence based text for MRCOG

Fitz-Hugh-Curits Syndrome

A rare complication of pelvic inflammatory disease.
Named after the two physicians, Thomas Fitz-Hugh, Jr and Arthur Hale Curtis.
Occur almost exclusively in female.
The major symptom, following an episode of PID, is an acute onset,
right upper quadrant abdominal pain aggravated by breathing, coughing
or movement.
The pain may be referred to right shoulder.
Violin string(adhesions between parietal peritoneum to liver) may be
seen by laparoscopy.
Treatment involves diagnosing and treating the underlying cause correctly.
The adhesiolysis may be performed laparoscopically.

Norplant: levonogestrel implants

Norplant system kits contain levonogestrel implants, a set of six flexible
closed capsules made of silicone rubber tubing. Each contains 36mg of
levonogestrel. Each capsule is 2.4 mm in diameters and 34mm in length.
Efficacy is 5 years.

The system releases 85mcg per day of levonogestrel, followed by 50mcg per
day by 9 month, 35mcg per day by 18 months and then further decline to
about 30 mcg per day.

Contraindications are
1. active thrombophlebitis or thromboembolic disorders
2. undiagnosed abnormal bleeding pre vagina
3. suspected pregnancy
4. active liver disease, benign or malignant liver tumour
5. known or suspected carcinoma of breast
6. history of idiopathic intracranial hypertension
7. hypersensitivity to levonogestrel or any other components of Norplant

Side effects are prolonged menstruation, irregular menstruation,
spotting, amenorrhoea, pain or itching near the implant site,
infection at implant site, difficulties in removal

Renal disease in pregnancy: chronic renal disease

Chronic renal disease is classifed as CKD 1-5 according to the severity.

Stage 1- GFR (ml/min/1.73m2) >90

Stage 2- GFR (ml/min/1.73m2) 60-80

Stage 3- GFR (ml/min/1.73m2) 30-59

Stage 4- GFR (ml/min/1.73m2) 15-29

Stage 5- GFR (ml/min/1.73m2) <15

Howevever, estimated GFR is not validated to use in pregnancy.

Source: An evidence based text for MRCOG

Inheritable skin disorders

1. Autosomal dominant
Ichthyosis hystrix and vulgaris
Palmoplantar hyperkeratosis (tylosis)
Epidermolysis bullosa simplex
Ectodermal dysplasia (some form)

2. X-linked recessive
X-linked Icthyosis
Hypohidrotic Ectodermal dysplasia

3. Multifactorial
Atopic eczema
Psoriasis

Source: An evidence based text for MRCOG

Contraceptive ring: NuvaRing

NuvaRing is a trade name of a combined hormonal contraceptive vagnial
ring. It is a flexible plastic (ethylene-vinyl acetate copolymer) ring
that releases a low dose of a progestin and estrogen over three weeks.
The ring works primarily by inhibition of ovulation. The other effects
are inhibition of sperm penetration by changes in cervical mucus and
possible thinning of endometrium inhibiting implantation.
The ring delivers 15mcg of ethinyl estradiol and 120mcg etonogestral
each day of use.
The ring must be inserted into the vagina for a 3-week period, and no
ring for one week period. The break week of NuvaRing is comparable to
the placebo week for the COC pills. In case of accidental expulsion,
the ring must be rinsed with cool water and reinserted immediately.
There is increased risk of pregnancy if the ring is removed,
accidentally expelled or left outside the vagina for more than three
hours. If these happened, the ring must be reinserted immediately and
additional methods of contraception must be used for one week.
The ring must not be used while breastfeeding.
The benefits of the ring include:
1. once a month self administered use offers convenience, east of use
and privacy
2. lower estrogen exposure than with COCpills and patch
3. low incidence of estrogenic side effect
4. low incidence of irregular bleeding

Pemphigoid gestationis

It is also called herpes gestationis. One of the pregnancy specific dermatoses and incidence is 1 in 3000 to 1 in 60000. Commonly occur in 2nd and 3rd trimester. Howevever can appear in 1st trimester and even in puerperium. It may resolve spontaneously within weeks or may prolonged up to year.
Started to occur in periumbilical area and spread the trunk and limbs.Erythematous urticarial plaques appear. Vesicles and bullae are seen at the centre or periphery of plaques. Microscopically, perivascular inflammation and subepidermal blisters  are
seen.
May be associated with other autoimmune disease such as Grave's disease.
Can be treated with moderate/ strong topical steroid, systemic steroids and antihistamine.
There may be possible increase in IUGR and preterm labour.

Pregnancy specific dermatoses

Pregnancy Specific Dermatoses

1. Polymorphic eruption of pregnancy

2. Pamphigoid gestationis (herpes gestationis)

3. Prurigo of pregnancy

4. Pruritic folliculitis of pregnancy

What is Persona?

Persona
This is a method of contraception works by monitoring changes in hormones (LH and oestrogen) and identifies the day when the user is at significant risk of becoming pregnant. It consists of test sticks and a hand-held Monitor. The test sticks collect the hormone from the first urine of the day and process them into information that the monitor can read. The monitor shows "Red Day" (days at which the user has risk of becoming pregnant) or "Green day" (days at which the user can have sex). Persona is 94% reliable when correctly used.
        Contraindications are
Cycle length less than 23 days or greater than 35 days
experiencing menopausal symptoms
Breast feeding
Using hormonal treatment (hormonal contraception, fertility treatments, HRT)
Tetracycline
Liver impairment
Renal impairment
Polycystic ovarian syndrome.

Elective Repeat Caesarean Section

Elective repeat caesarean section
Maternal benefits
Caesarean section avoids labour with its risks of
perineal trauma (urinary and faecal problems)
the need for emergency caesarean section
scar dehiscence or rupture with subsequent morbidity and mortality
advantages of allowing a planned delivery
Fetal benefit
        no risk from intrapartum scar rupture
Maternal risks
prolonged recovery
future pregnancies would probably require caesarean delivery
increased risk of placenta praevia and accrete in subsequent pregnancies.
Fetal risks
        Increased risk of transient tachypnoea/respiratory distress syndrome (6% at 38weeks, 1-3% at 39weeks)

source: An evidence based text book for MRCOG

Contraceptive patch

Contraceptive patch

A contraceptive patch is a transdermal patch applied to the skin that releases synthetic estrogen and progestogen hormone. They have been shown to be as effective as combined oral contraceptive pills with perfect use ( failure rate approximately 1% first year). The currently available patches are Ortho Evra and Evra. The patch can be applied to upper outer arm, buttocks, abdomen or thigh. Seven days later, the patch is removed and another new patch is applied. After using 3 patch (3 weeks), there is a patch free week.
        The patch should be applied to the skin that is clean, dry and intact. Lotions, powder or makeup must be avoided around the area where the patch is applied. The patch works primarily by prevention of ovulation. A secondary mechanism of action is inhibition of sperm penetration by changes in cervical mucous. There may also be prevention of implantation.
        A 20cm2 Ortho Evra patch contains 750mcg ethinyl estradiol and 6000mcg norelgestromin. Twenty microgram of ethinyl estradiol and 150mcg of norelgestromin per day are relased into the circulation. These patches have similar benefits to the combined oral contraceptive pills. Risks are also similar.

GyneFix: frameless copper IUCD

GyneFix

Contraception: Persona

Persona

Heart disease in pregnancy: maternal mortality rates

Heart disease in pregnancy: Maternal mortality rates
Low Risk: Maternal mortality rate less than one percent
1. septal defect
2. NYHA functional class 1
3. NYHA functional class 2
4. patent ductus arteriosus
5. pulmonary/ tricuspid lesions
Moderate risk: Maternal mortality rate 5-15%
1. NYHA functional class 3
2. NYHA functional class 4
3. mitral stenosis
4. Marfan's syndrome with normal aorta
5. Uncomplicated coarctation of aorta
6. past history of myocardial infarct
High risk: Maternal mortality rate 25-50%
1. Essimenger's syndrome
2. pulmonary hypertension from any cause
3. Marfan's syndrome with abnormal aortic root
4. peripartum cardiomyopathy
source; http://onyeije.net/present

Liquor volume-gestational age

Amount of Liquor in each gestational age.

Causes of Polyhydramnios

Causes of polyhydramnios
(source: Obstetrics and Gynaecology, An evidence based text for MRCOG)
1. idiopathic
2. maternal diabetes mellitus
3. intestinal obstruction (oesophageal or duodenal atresia)
4. impaired fetal swallowing (anencephaly, aneuploidy, muscular dystrophy)
5. fetal polyuria (twin-twin transfusion syndrome, Barter syndrome)
6. cardiac failure secondary to significantly lowered fetal vascular
resistance or fetal anaemia
7. fetal infection

Malignant melanoma of the Vulva

Malignant melanoma of the vulva
Malignant melanoma of the vulva is the second most common cancer of
the vulva, but is very rare. It accounts for 5% of all vulva
malignancy. Only 0.1% of all nevi in women are on vulvar skin, the
disproportionate frequency of occurrence of melanoma in this area may
be a result of the fact that nearly all vulvar nevi are of the
junctional variety. These tumours most commonly arise in the region of
labia minora and clitoris. There is a tendency of superficial spread
towards urethra and vagina. A darkly pigmented raised lesion at
mucocutaneous junction is a characteristics finding. However,
non-pigmented lesion may closely resembled to the squamous cell
carcinoma on inspection. The lesion primarily spreads through
lymphatic channels and tends to metastasize early in the course of
disease. It should be managed by wide local excision. Outcomes are not
influenced by inguinal lymph nodes dissection. The management should
be considered as for criteria for other sites of cutaneous melanoma.
Ref: Health.am>Health Centers>Cancer Health Center>Cancer of the Vulva

Indomethacin in the treatment of polyhydramnios

Indomethacin can be used as a medical management for polyhydramnios. It is a prostaglandin synthetase inhibitor. The optimal dose of indomethacin is unknown. A 25mg oral dose can be given 6 hourly.
Fetal echocardiography should be started in the 24hr after the start of the indomethacin and then weekly. Discontinue the drug when there is severe constriction of ductus arteriosus or tricuspid regurgitation. Decrease the dose when there is lesser degree of constriction of ductus arteriosus. Amniotic fluid assessment should be done with USG once or twice weekly. Known side effects of drug are renal failure in neonates, premature ductus arteriosus, increased in perinatal mortality, necrotizing enterocolitis and intracranial haemorrhage.