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.