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2016年9月29日 星期四

[醫如往常] Senior Clerkship Day 16: Ob/Gyn Cases

戴總醫師
Gelform 38000
Endocatch 8000
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45歲以前拿子宮有傷殘補助沿用35年的勞保生育失能給付（包括切除子宮），將有重大修正。鑑於各界質疑女性切除子宮訂定45歲給付門檻是歧視女性，勞動部正規畫以大幅放寬條件、但分級給付金額的方式處理；也就是取消女性切除子宮年齡限制，但分三級給付，其中男性切除陰莖、女性切除子宮，給付標準由160天的投保薪資降為100天。
勞保失能給付中所指的「喪失生育能力」，女性係指包括「切除子宮」、「切除兩側卵巢」及「因為化療或放療致喪失生育能力」。自68年以來，由於考慮女性大都45歲以後就不生育，因此以45歲做為給付門檻，女性45歲以下切除子宮者才可請領給付，但此舉引發各方爭議。婦科醫師更發現很多女性為了經濟因素，搶在45歲之前切除子宮，造成台灣45歲以下「無子宮」切除率太高；但婦女團體則認為，男性因生殖器官切除喪失生育能力，並無年齡限制，獨對女性設限，明顯歧視。
勞保局統計，自97年以來，失能給付案每年有2.9萬至3.3萬件，其中「喪失生育能力」案件從97年7萬多件降到101年的6萬多件，件數逐年降低，但比率都在20%-22% 。
勞保局統計，目前每年3萬多件失能給付個案中，2成（6700件）是生育失能給付，政府支付近9億元，除了個位數的男性切除睪丸之外，絕大多數都是女性切除子宮、卵巢。 來自 <http://health.udn.com/health/story/5999/474610>
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鄭教授必考
Round lig.到Major labium
The round ligament of the uterus originates at the uterine horns, in the parametrium. The round ligament enters the pelvis via the deep inguinal ring,[2] passes through the inguinal canal and continues on to the labia majora[3] where its fibers spread and mix with the tissue of the mons pubis.
The round ligament is supplied by the artery of the round ligament, otherwise known as "Sampson's artery."
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Afternoon meeting
PGD
Epidermolytic ichthyosis (EI); Epidermolytic hyperkeratosis (EHK)
(also known as Bullous congenital ichthyosiform erythroderma(CIE),[1] Bullous ichthyosiform erythroderma,[2]:482 or bullous congenital ichthyosiform erythroderma Brocq[3])來自 <https://en.wikipedia.org/wiki/Epidermolytic_hyperkeratosis>

AD
keratin 1 (KRT1) and keratin 10 (KRT10)
Incidence  1 in 200,000-300,000
紅孩兒，穿山甲人
Some patients may experience amelioration of symptoms as they age. Risk for morbidity and mortality is highest in the neonatal period, where infants are at increased risk for complications such as sepsis and dehydration because of impaired barrier function. Later in life, affected patients may experience recurrent skin infections.
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Mosaic tuner syndrome 1/3000

Low grade 45xo 身高正常

Only 2-10% spontaneous conceiving and they are mosaic.
Only 5.7% live birth.

Amniocentesis mosaic, normal
可能拿到的是placental cell
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Irregular menstrual cycle
Bleeding

Left lower limb swelling and pain
DVT
EkoS catheter; The EkoSonic™ Endovascular System

Endometrial adenocarcinoma

Trousseau syndrome
May be double cancer
The Trousseau sign of malignancy or Trousseau's Syndrome is a medical sign involving episodes of vessel inflammation due to blood clot (thrombophlebitis) which are recurrent or appearing in different locations over time (thrombophlebitis migrans or migratory thrombophlebitis). The location of the clot is tender and the clot can be felt as a nodule under the skin.[1] Trousseau's syndrome is a rare variant of venous thromboembolism (VTE) that is characterized by recurrent, migratory thrombosis in superficial veins and in uncommon sites, such as the chest wall and arms. This syndrome is particularly associated with pancreatic and lung cancer.[2]
Trousseau's Syndrome can be an early sign of gastric or pancreatic cancer,[3] typically appearing months to years before the tumor would be otherwise detected.[4] Heparin therapy is recommended to prevent future clots.[5] The Trousseau sign of malignancy should not be confused with the Trousseau sign of latent tetany caused by hypocalcemia.
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Discordant MCDA twins
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Ritscher-Schinzel cranio-cerebello-cardiac (3C) syndrome
3C syndrome, also known as CCC dysplasia, Craniocerebellocardiac dysplasia[1] or Ritscher–Schinzel syndrome,is a rare condition, whose symptoms include heart defects, cerebellar hypoplasia, and cranial dysmorphism. It was first described in the medical literature in 1987 by Ritscher and Schinzel, for whom the disorder is sometimes named.
3C syndrome is an autosomal recessive disease, caused by a mutation on the long arm of chromosome 8 at 8q24.13, the locus for KIAA0196,
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Cleft palate
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Multicystic tumor at right neck
Cystic hygroma, lymphatic malformation

Risk
  • Aneuploidy
  • Trisomy 21
  • Turner syndrome
  • Noonan syndrome
  • Fryns syndrome
  • Multiple pterygium syndrome
  • Fetal alcohol syndrome
  • Cardiac and skeletal

Poor outcome
  • Nuchal thickness > 6 mm
  • Karyotype anomaly
  • Ultrasonography anomaly

Ddx
  • Increased nuchal translucency
  • Neural tube defect
  • Cystic teratoma
  • Hemangioma

Medication not good
Surgery May recur
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IUFD
Cord accident
Week 22
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ER
UTI
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ROV tumor

RLQ tenderness
Immature teratoma
Chemotherapy相當有效
也可能是良性的，只是因為懷孕影響morphology

Ddx
Dysgerminoma
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Uterine inversion
Atony
Vaginal laceration
Gauze packing
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Uterine carcinosarcoma
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