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2016年10月13日 星期四

[醫如往常] Senior Clerkship Day 29: Ob/Gyn

柯教授
Amniocentesis 五十萬例
CVS(Chorionic Villus Sampling) 一萬例
從不開預防性抗生素,無菌操作比較重要
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前三個月死亡率最高
25% of all

Ga 16w, aminocentesis only 2% anomaly
Newborn 0.5%
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Chromosome abnormally 70%, >5 Mb
  • 50% Numerical, trisomy 16, 22 最常見
  • 50% Structural, balanced, unbalanced
Genetic, <5Mb, DiGeorge syndrome most common
Single gene, >1bp

Cytogenic
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30% pregnancy bleeding
Douglas pouch
15% vaginal bleeding
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NIPT 10% free-DNA
Screen

Nuchal translucency >3mm
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Taiwan
15%>34yo
Used to be 8% 30 years ago.
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CVS Ga>10w
Aminocentesis >16w
Fetal blood sampling >20w
CVS其實比較安全
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NIPT 0.3% 無法檢測到
Aminocentesis 0.1%, 本來就會流產
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避孕器 aminocentesis 可能感染

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大破水還是有50%沒事
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45xo with SRY translocation
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At least 100 de novo mutation
97%是突變,不是遺傳

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林助教授
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1.Goodell sing:子宮頸變軟。2.Chawuck sing: 子宮頸、陰道黏膜會陰部黏膜變紅紫或深藍色。
3.Hegar sign:子宮峽部變軟(及介於子宮頸與子宮體間部,在6~8週會變軟)。
4.Ladin sign:子宮前面正中處,有一柔軟的點出現。
5.Mc Donald sign:指屈曲子宮頸底部時沒有阻力,使子宮底易於屈曲而接觸子宮頸。
6.Braun von fernwald sign:妊娠第五週,受精卵著床處變軟,增大使子宮呈不規則球形。
7.Piskacek sign:指腹部似種瘤呈不對稱腫大。
8.Physiologic erosion:生理性糜爛、因局部血流增加,組織變軟易生糜爛屬生理變化。
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Parikh's formula is a calculation method that considers cycle duration. Naegele's rule assumes an average cycle length of 28 days, which is not true for everyone. EDD is calculated using Parikh's formula by adding nine months to the start of the last menstrual period, subtracting 21 days, then adding duration of previous cycles.

[醫如往常] Senior Clerkship Day 30: Ob/Gyn

吳助教授
新竹以南老師上課車馬費600

三人才能成立次專科
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性交疼痛治療
  • 停經藥
  • 雄性素
  • 神經切除, 副作用很多
  • 精神性
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黃達天院長選舉政見:只有15%台大老師及格,要開除85%教授
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以前學費一學期八千
住宿三千
北醫四萬
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台南一中規定至少要填一個志願:文化蠶絲系
所以填了台大醫科跟文化蠶絲
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淡水河南邊沒有醫學院
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以前把垃圾車的筆撿起來用
強力膠黏鞋子
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謝教授
Meconium peritonitis
Dry fibrosis
Wet free fluid
Associations

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以前婦幼醫院
醫師指定費
住院醫師600
主治醫師1000
繳給醫院200
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Biliary stenosis
Double bubble sign
30% Down syndrome

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Biparietal diameter
BPD*4 = GA weeks +-1 week

The calipers should be placed at the:

    outer edge of the near calvarial wall
    inner edge of the far calvarial wall

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CRL +6.5 +-3 days
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Bpd FL
10:4
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Giemsa-banding
White: gene
Black: heterochromatin
6P giant white: HLA
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Chromosome groups: Karyotyping

2016年10月5日 星期三

[醫如往常] Senior Clerkship Day 28: Ob/Gyn Management of post-partum hemorrhage; 水中分娩; Immature teratoma

    林醫師 Management of post-partum hemorrhage
    產婦死亡率7/100,000
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    >500cc, NSD
    >1000cc, cesarean
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    Primary within 24h
    Secondary within 12 days
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    Signs
    Tachycardia>120
    Hematocrit>10%
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    Etiology
    History of PPH
    Tone
    • Myoma
    • Too long
    • Too fast
    • Polyparity, macrosomia
    • Infection
    Trauma
    • Retroperitoneal bleeding
    • Uterine rupture
    • Cesarean
    • Uterine inversion
    Tissue
    • Placenta accrete
    • Placenta previa
    Thrombin
    • Severe preeclampsia
    • HEELP syndrome
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    Most mortality within 4 hours
    AMTSL, Active management of third stage labor
    • Early cord cutting
    • Uterotonic agents
      • Oxytocin, hypotension
      • Ergometrine, hypertension
      • Misoprostol, 塞anus, tremor, drug fever (pyrexia)
      • Carbetocin,  cash $2000 效果很好, hypotension


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    Uterine artery, IIA ligation
    • 先放ureter catheter, 確定位置
    B lynch suture
    Square suture
    • 1,0 absorbable line
    Hymen suture
    Trans arterial embolization
    Rupture repair
    pRBC, FFP, Platelets
    Cryoprecipitate, vWF; Von Willebrand factor
    Subtotal hysrectomy
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    En caul delivery

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    Sheehan's syndrome

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    水中分娩
    黃醫師 惠欣婦幼診所

    樂得兒產房LDR 一天約五千多元
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    不要用按摩浴缸
    水質要控制
     1960 Dr. Igor Charkovsky
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    Dive reflex

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    產球
    繩子可以拉
    護理找沒生過的

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    嬰兒按摩
    嬰兒游泳

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    防水胎心音監視器

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    R1 張/ Attending 陳醫師
    Immature teratoma

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    Pregnancy ovarian immature teratoma
    0.7%

    Grade 1 不太會復發,不用做化療
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    第二孕期做化療相對安全
    第一孕期會有10%異常
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    Pubmed發表bias
    週數大, 第二孕期
    治療相對積極

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    ACGME 六大核心能力
    1. 病人照護 (Patient care)
    2. 醫學知識 (Medical knowledge)
    3. 從工作中學習及成長 (Practice-based learning and improving)
    4. 人際及溝通技能 (Interpersonal and communication skills)
    5. 制度下的臨床工作 (System-based practice)
    6. 專業素養 (Professionalism)
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    Dysgerminoma
    Grade 1: 15%復發
    復發後再化療, 可治療90%病人

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2016年10月4日 星期二

[醫如往常] Senior Clerkship Day 27: Ob/Gyn 產科麻醉 梁醫師

產科麻醉 梁醫師
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Maternal factor
  • Respiration
  • RBC
  • CV

Placenta factor
  • Perfusion
  • Drug diffusion

Fetus factor
  • RBC
  • CV

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CO=HR*SV
HR
  • ANS

SV:
Myocardial contractility*Venous return
  • Volume
  • Vassal tone (ANS, 彈性襪)
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GA; general anesthesia
  • Pain
  • Consciousness 最重要
  • Reflex
  • IV or inhalation
  • ETGA or IVGA
Muscle relaxant 作用在NMJ, 不會穿過BBB, plancenta
其他都會穿過BBB, plancenta

RA; regional anesthesia (nerve fiber)
SA; spinal
EA; epidural
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EA怕intoxication
Proximal最深度
藥效過之後
腳先有感覺之後肚子才痛
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SA下面麻最深
藥效過之後
先痛之後腳才有感覺
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Cesarean
肚皮切在Pubic bone 上兩指

太下面的話(Bikini cut), 毛長出來很癢
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Accessory fiber (2-4 levelS)
所以要麻到T4-T6
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Local anesthetics complications
  • Brain
  • Heart T1-4
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Thoracolumbar sympathetic chain T1-L2

Vagus nerve, S2-4
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IV 1500cc
麻黃素ephedrine,可用來預防腰椎麻醉時可能引發的低血壓症狀
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RA半身麻醉風險比較多
但是比較便宜
VIP都是用GA
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用酒精棉測試麻醉深度
先測臉頰確認有感覺
再測其他地方

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Active phase 最痛
Uterus (T10-L2)
Fundus T10

Primiparous
Cervix 2 fts 開始止痛
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常見轉Cesarean時機
Prolonged latency phase
Protractive active phase
Early deceleration

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[醫如往常] Senior Clerkship Day 26: Ob/Gyn Grand Round: Cases

Grand Round: Cases
懷疑ectopic Pregnancy
D&C七次
沒送病理,沒刮到東西
病人很生氣要提告
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IUD for 40 years
Actinomycosis
Radiology, GS都不想處理
送給ID收住院
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Gastroschisis VS Omphalocele

Gastroschisis
Omphalocele
Defect
Open
Membrane covered
Defect size
2-5 cm
2-15 cm
Umbilical cord
Left of defect
Center of membrane
Bowel
Inflamed
Normal
Alimentation
Delayed
Normal
Anomalies
10%
60%

Associations
Omphalocele
Gastroschisis
Cardiac
Chromosomal
Down’s syndrome
Macrosomia
GERD
Cryptorchidism
Musculoskeletal
Neural tube defects
Intestinal atresia
Small for gestational age
Prematurity
GERD
Cryptorchidism

Ref.

2016年10月2日 星期日

[醫如往常] Senior Clerkship Day 20: Ob/Gyn 施醫師; 華醫師FXS, SMA; 黃醫師 多胞胎妊娠

施醫師
  • Compound B mode
  • 2D mode
  • 3D mode
Probe 100萬
0-256 level
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Situs inversus
Dextrocardia, L loop

Primary ciliary dyskinesia (PCD), also immotile ciliary syndrome or Kartagener syndrome
is a rare, ciliopathic, autosomal recessive genetic disorder that causes defects in the action of cilia lining the respiratory tract (lower and upper, sinuses, Eustachian tube, middle ear) and fallopian tube, as well as in the flagella of sperm cells. The phrase "immotile ciliary syndrome" is no longer favored as the cilia do have movement, but may be inefficient or unsynchronized.
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Irregular lacuna
前置胎盤v.s.植入性胎盤
植入性胎盤 3d mode:異常血管增生、血管融合
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華醫師
FXS, Fragile X syndrome
  • Xq27.1 FMR1
  • Male 1/4000, female 1/8000
  • CGG repeat 
  • AD
Repeat > 40 permutation: carrier
Repeat > 55 2%
Repeat > 200 100% full methylation
父親遺傳 長度不會增加
母親遺傳會anticipation

FXPOI
  • Primary ovary insufficiency
  • Average Age 28 開始排卵異常
  • 20% permutation woman would have FXPOI
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FXTAS
  • Tremor Ataxia
  • Age related
  • Male>female
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CGG Repeated primed PCR
台大3350
外面檢驗收兩千多不過是傳統PCR
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AGGs增加精確度
降低full mutation發生率
可以偵測高達1300 CGGs
Homozygous or heterozygous
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Carrier
Israel 1 in 158
Taiwan 1 in 333
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Early treatment
  • Drug clinical trial
  • Occupation therapy
Prevent next sibling
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SMA; Spinal Muscular Atrophy
  • Anterior horn cells, bilateral, Proximal lower limbs
  • 5q13 AR
  • SMN1 Gene 8 exons
  • SMN2 exon 7 沒有表現

95% SNM1 Homozygous mutation
2% point mutation
Carrier: 1/40
Taiwan: 2.04% only has one SMA1

Tx:
  • Valproic acid 蔡力凱醫師發表
  • Gene therapy 效果不好
  • Antisense oligonucleotide
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MLPA Gold standard
37 target regions
跟housekeeping gene 比較
Chromosome 13, 18, 21做比較

台大MLPA一次2500
外面用傳統方式1500
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Multiplex Ligation-dependent Probe Amplification

Stuffer sequence(填充序列) 增加跑膠的鑑別性

"The stuffer sequences are varied in length so that a range of up to 50 targets can be amplified and separated in a single experiment."
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ISIS Cop.
Q PCR
Then drug Clinical trial
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胡教授實驗室每年做十萬個血片
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黃醫師 多胞胎妊娠
"珺"要念四聲

<20 weeks chronic hypertension
>20 weeks PIH
PIH with others: preeclampsia
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GDM
75g OGTT Diagnosis 空腹
50g OGTT screen 不用空腹
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超音波
fetus在上下兩周可接受

Placenta: Hyperechoic

Lambda sign, beak sign
DC twin

T sign
MC twin
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Painless antepartum hemorrhage
  • Anterior placenta implantation
Twins high risk
  • Cervical incompetence

Painful antepartum hemorrhage
  • Placenta abruption
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Cervical incompetence
  • painless
  • Cervical length shortening <2.5cm
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Cervical length shortening with Pain
  • Preterm labor
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常常來不及Cesarean Delivery
直接NSD
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Day 4-8: MCDA Twins
Day 8-13: MCMA twins
Day 14: Conjoined twins
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Twins Prevalence 3%
Twins Risk factor
  • Maternal weight and height: Obese (BMI 30 kg/m2) and tall women (≥65 inches [164 cm])
  • Family history
  • Increasing parity
  • Race/geographic area
  • Age: Naturally conceived dizygotic twinning increases four-fold between age 15 and age 35
  • fertility stimulating drugs
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CD indication
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Presentation twin
決定於第一個twin 胎位
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Slective reduction
  • KCl
  • Cord occlusion
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Steroid stimulate lung maturation
2 dose 間距24小時
Week 23-34
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TTTS
Disconcordent + 羊水量不一樣
10-15% mc twin

TAPS; TWIN anemia polycythemia sequence
MCA PSV; Pulse systolic velocity >1.5x

TRAP; twin reversed arterial perfusion

法國前五次IVF 免費