Saturday, 30 July 2016

The four R's of working together

I have been recently reading " a toolkit 4change" by Dominique Bird and Allan Cumming and came across this interesting concept of four R's of working together.

(i)Remit- The topic that a group  is expected or authorised to do.Has this been explained to the group?
(ii)Role-Is each member is clear about the role they have to play?What is the contribution that each member is going to offer?
(iii)Relationships-Does the group members know each other?Does they know how to contact other people in the group?
(iv)Responsibility-Is  the group clear about the resposibilities?

Eventhough I work in teams on a daily basis , looking the team functioning under these headlines gives me a new perspective.

This is another four R tools that can be used in muti stakeholder pojects :

Thinking under these components helps in the efficinet running of the projects.
        more info

Sunday, 20 May 2012

Myocardial infarction(MI) in pregnancy

Ischaemic Heart Disease(IHD) in Pregnancy

Prevalence of IHD in pregnancy is 1:10,000
Incidence of Myocardial infarction  in pregnancy is 7.5:100,000
Over all mortality rate is 37%

Risk factors
Family history of myocardial infarction before age 60
History of chronic hypertension
Kawasaki disease,
Hypertrophic cardiomyopathy
Cocaine use

Atherosclerosis accounts for less than 50% of cases but dissection of coronary arteries is relatively common.

ECG changes in normal pregnancy.There could be left-axis deviation and non-specific ST and T wave
changes.Serial ECG is important in diagnosis.

Chest X ray-enlargement of the heart, straightening of the left
heart border, and increased vascular markings are features observed in myocardial infarction.

CK-MB correlates with non pregnant state but  the usage is limited in labour and postpartum period.

Troponin-I is the marker of choice as the level is not affected by pregnancy,labour or obstetric anaesthesia.

Echocardiography helps to check abnormal ventricular wall motion.

Differential diagnosis
1.Acute pulmonary embolism
2.Aortic dissection

Management of MI is similar to non pregnant patients

Setting : Coronary care unit

5.Beta blockers

Multidisciplinary care -cardiologist,obstetrician,anaesthesiologist

Primary PCI(percutaneous coronary intervention) is the treatment of choice but if it isn't feasible thrombolysis should be considered.

Anti coagulation is considered if embolus is demonstrated in angiography,otherwise risk of thrombolysis slightly outweighs the benefit.

Tissue plasminogen activator
Large molecular weight Tissue plasminogen activator wouldn't cross the placenta but there is a risk of premature labour and haemorrhage.

There is no reports linking to congenital defects.
Minimal amount crosses placenta,so no fibrinolytic effects on fetus.


It isn't teratogenic in animal studies.It isn't known whether it crosses placenta but there are proteinase inhibitors in the placenta which inactivates urokinase.

angioplasty and systemic and local thrombolytic therapy has been
described.'Fragile'nature of coronary vessels in pregnancy should be kept in mind when considering angioplasty or angiography.

Radiation exposure to fetus during cardiac catheterisation & interventional procedure is less than 0.01 Gy

Use of clopidogrel also seems to be safe.


Caesarean section is only indicated for Obstetric reasons . It doesn't improve the survival.Second can be limited with forceps.

Delivery with in the first two weeks after ischaemic heart disease should be avoided if possible.ECG monitoring should be done in labour.Epidural analgesia is recommended.

Third stage -avoid ergometrine as it can cause coronary spasm

Good outcomes have been reported from subsequent pregnancies in patients with left ventricular aneurysm and also in patients who suffered cardiac arrest during MI.

Future pregnancy

There is no evidence to suggest that pregnancy predisposes for another episode of MI but if the aetiology had been a coronary embolus the risk of recurrence should be carefully considered.

Poor prognostic features
1.Left ventricular dysfunction
2.Persistence of ischaemia

Statins should be discontinued preconception as there is a risk of fetal anomalies(CNS &Limb defects)

Useful article

1.Nelson-Piercy C. Handbook of Obstetric Medicine, Second Edition. 2nd ed. Taylor & Francis; 2001.
2.Swiet MD. Medical Disorders in Obstetric Practice. 4th ed. Wiley-Blackwell; 2002

3.Fayomi O, Nazar R. Acute myocardial infarction in pregnancy: a case report and subject review. Emerg Med J. 2007 Nov 1;24(11):800-801.

Sunday, 13 May 2012

USS in Ectopic Pregnancy

EMQ's for the MRCOG Part 2 in Gynaecology

Thursday, 10 November 2011

Doctor Patient Relationship

Two simple models on doctor patient relationship.One is doctor as an expert adviser and  the other is doctor in partnership.

Doctor as an expert adviser  
  • Docotor defines the patient's needs
  • Doctor advises the patient what to do
  • Doctor solves problems for the patient
  • Doctor decide how much information to be given to the patient

Doctor  in  partnership
  • Doctor elicit the patient's problems & needs
  • Doctor explains the options to the patient
  • Doctor and the patient explore the solutions to gether
  • Doctor ask what information the patient wants
What is your style ?

 Emanuel and Emanuel ( JAMA. 1992 Apr 22-29;267(16):2221-6.) elaborated four models of doctor patient relationships:
  1. Paternalistic: physician makes decisions for the patient’s benefit independent of the patients values or desires
  2. Informative: physician provides information, patient applies values and decides.
  3. Interpretive: patient is uncertain about values, physician, as counselor, assists the patient in elucidating his or her values.
  4. Deliberative: Patient is open to development, physician teaches desirable values
Interestingly another article,Physician-Patient Relations: No More Models, argues that one model doesn't fit all.Based on my experience,I agree with this article.What do you think?

Friday, 1 July 2011

Postpartum thyroiditis

(i)It is an autoimmune disorder

(ii)It is chracterised by lymphocyte infiltrate of thyroid gland

(iii)There is transient hyperthyroidism followed by hypothyroidism or one or other

(iv)It occurs  in the first year of delivery.

The condition is more common on patients with family history of hypothyroidism, those with thyroid peroxidase antibodies and patients with type 1 DM.

3 phases of classical postpartum thyroiditis




1/3 of patients develop permanent hypothyroidism

Clinical features

presentation is usually between 3 to 4 months after delivery

(I)classical features of hyper or hypothyroidism is rarely observed

(II)painless enlargement of the gland



(I)thyroid function tests

(II)thyroid peroxidase antibodies.

(III) radioactive iodine uptake test may be necessary to differentiate from Graves' disease but this test can't be done in breast feeding mothers.

(*Thyroid receptor antibodies are present in Graves' disease)


Most patients recover spontaneously.
Treatment should be determined by symptoms rather than biochemistry.

hyperthyroid phase needs treatment beta blockers but not with antithyroid drugs.

hypothyroidism needs with treatment thyroxine. Only 3-4 % of women remain permanently hypothyroid.


(i)Post-partum thyroiditis – a clinical updateElio Roti and Ettore degli Uberti.European Journal of Endocrinology (2002) 146 275–279
(ii)Nelson-Piercy C. Handbook of obstetric medicine. Taylor & Francis; 2002.

(iii)Swiet MD. Medical disorders in obstetric practice. Wiley-Blackwell; 2002.

Sunday, 6 March 2011

Uterine rupture

2 types
(I) Uterine dehisence-separation of a preexisting scar without the disruption of parietal peritoneum.
(II)uterine rupture-full thickness disruption of uterine wall.

Risk factors

(I)previous caesarean section(Classical &Lower segment)
(II)Previous uterine surgery-myomectomy
(III)Grand multi parity

Clinical features

Uterine dehisence could be asymptomatic
(I)continuous lower abdominal pain
(II)fetal distress
(III)receding presenting part in labour
(IV)loss of uterine contractility during labour
(V) Haematuria/Bleeding per vaginum
(VI)Maternal tachycardia & hypo tension are late signs

Stair case sign-stepwise gradual decrease in contraction amplitude has been reported in uterine rupture.


This is an Obstetrics emergency

resuscitation & surgery should go hand in hand.
call for Senior help(Obstetrician & Anaesthetist)
IV access
Arrange Cross matching of Blood(6-10 units)
Allocate one person to scribe the events
Keep the family informed during the procedure
Debrief at the end of procedure

If uterine rupture occurs prior to delivery emergency caesarean section should be done.
The following options can be selected according type of tear,state of the patient and  ongoing blood loss.
(I)uterine repair
(III)Internal artery ligation

Powerpoint on uterine rupture
(I)E Medicine
(II)Successful management of gravid uterine rupture.Taiwan J Obstet Gynecol. 2009 Sep;48(3):319-20.Authors: Fu PT Chen CH Wu GJ Yu MH.PMID: 19797032 [PubMed - indexed for MEDLINE]
(III)Spontaneous uterine rupture-Case report and  review