Tuesday, January 26, 2016

Are all IUGR babies Small for gestation?

While going through a chapter on IUGR, I came over an interesting fact. All time long, we have been thinking ' All IUGR babies are SGA but All SGA babies are not IUGR" . It is a common dictum we learn in medical schools, but the fact speaks something else. In a chapter written by Kara Calkins and Sherin Devaskar , the fact was very much well explained.

The fact is " All SGAs are not IUGR neither all IUGR are SGAs". An intrauterine growth restricted baby need not always be small for gestation but can be appropriate for gestation.

About the Basics,

SGA - Small for gestation age babies- babies whose birth weight is below the expected weight (< 10th centile) for gestation and sex.

AGA Appropriate for Gestation - Babies weighing between 10th to 90th Centile for expected gestation age at birth. 

Intrauterine Growth restriction or IUGR are babies who fail to grow as per their growth potential due to intrauterine insults and can be SGA or AGA. Detection of IUGR relies on symphysis-fundal height measurements as part of routine prenatal care. Ultrasound is used to confirm IUGR based on estimated fetal weight and measurements of head & abdominal circumference.

Terminology : by ACOG : Defined as per pathology and Doppler changes

1. “SGA” refers to small fetuses with no discernible pathology and with normal umbilical artery and middle cerebral artery Doppler results.
2. “Growth restricted” refers to small fetuses with recognizable pathology and abnormal Doppler studies.
3. “Idiopathic growth restricted” applies to small fetuses with no discernable pathology or abnormal Doppler studies.

IUGR is basically a pathophysiological state where the fetus fail to reach their inutero growth potential. They must not be confused with SGA babies which can be constitutional, genetic or ethnicity related. More than babies born below 10 th centile in curves are constitutional and racial and do not pose added risk of further complications.  

On the other hand , Intrauterine growth restricted babies who are born Appropriate for gestation age may have suffered intrauterine growth deceleration as a result of maternal or fetal factors. Even if these patient are mis-classified as AGA , they are not exempted from the complications that they are to face. Due to intrauterine survival mechanism, the natural response of the body is to preserve the brain and heart while rest of the organism gets compromised. Due to these intrauterine metabolic and physiological changes the infants are at risk of later diseases during infancy, pediatric period and adulthood.
The Careful attention, identification and follow-up of such babies become important.
Discussing the IUGR in details is beyond the scope of my discussion. A good short review of IUGR is given Here


1. Fanaroff and Martin's Neonatal perinatal medicine.
2. http://www.utmb.edu/pedi_ed/CORE/Neonatology/page_06.htm

Monday, January 18, 2016

CNS examination long case: How to prepare

Central nervous system examination is the most difficult thing to complete within a time limit during final exam and the dilemma is that, most of time the CNS is what is kept as a long case. Examiners love judging you on the basis of CNS case because-

1. CNS is maths and science- it needs a lot of logics and understanding
2. CNS is the most methodological system
3. CNS is the most length and only organized students can complete examination in time.

Ideal neurokit structure

Now , without a proper planning and preparation for CNS case, you will seldom be able to complete it in time. And incomplete examination is most common cause of failure in PG, MBBS though can be excused sometimes. I will not try to be a Guru, rather I will only share our experience, how we practiced and complete the examination 1 minutes before 20 minutes in the final, thus assuring a fair results.

Which Book to Refer?

Standard Standard Standard! Always the books should be standard.
We did not prefer Hutchinson, despite of the Hype it has had all the time. Macleod is much better tool and with videos available on youtube, it is the key.

Being a Pediatrician, you must also review the Books- Meherban Singh and Piyush Gupta Bedside books.

What you need?

1. 3 friends minimum, maximum 4.
2. Each must be ready to volunteer.
3. Each must be ready to be the Judge or critic
4. A neurological Kit- complete.
5. Watch the Macleod videos and read the book
6. A pattern in mind or written on a paper.

How to proceed?

1.Before exam , going to bedside and doing it was neither time friendly nor easy. It only caused us to lose time and get more anxious. So we decided to practice at hostel.
2. Discuss and create a pattern or sequence to follow, which will be the protocol you all will follow till exam.
A- appearance
B- behaviour
C- conscousness
I- Intelligence
J- Judgement
L- Learning
S- Speech

What questions you will ask to assess? For judgement- Fire in the house, Post a letter ( Read Hutchison for these questions once - Standard questions)

3. One volunteers as patient

4. Other examines
5. The Onlooker and critic sets time - initially 20 minutes of just cranial nerves, Higher mental functions each
6. Start practising, you may make a lot of mistakes. 
7. In the end, the critic tells you all you have done wrongly. This way both will remember the mistakes and will not repeat it.
8. With practice , your speed will boost on each another time. And as you do, your spine picks the pattern and you will get fluency with steps.

Try to completely learn Normal examination first then you can move to Diseases and deficits.

The Normal Pattern is

1 Higher Mental Function
2. Cranial Nerves Examination
3.Motor system examination
4. Sensory System examination
5. Cerebellar signs examination
6. Gait
7. Abnormal movements
8.Skull and spine
9. Autonomic nervous system.

Repeating all the theory is out of scope, as books are always best for learners.

Hope it would be of help in a way for medical students.
The Formula is - Practice , Practice and Practice : keep examination videos in cellphones

Friday, January 8, 2016

Fenton Fetal-infant growth chart 2013

The main difficulty in designing a preterm standard charts is that it is difficult to define an ideal healthy preterm.
2013 Fenton chart is upgraded form of Fenton 2003 fetal infant growth chart.  The new charts have specific curves for male and female and have been tuned to match WHO growth charts after 50 weeks. Other specialty is the charts are design to allow plotting between the weeks rather than completed weeks and intervals have also divided in between 500 gram intervals.

Below are the Charts published in BMC 2013 by T Fenton.

Special tool is available at http://peditools.org/fenton2013/

These growth charts are not standard or a prescription to how infant should grow but they are rather a descriptive approach of how preterm infants grow.
Fenton 2013 have vastly replaced the old charts like Lubchenco, Babson Benda, Erenkranz and other charts for preterm infants.

Sunday, December 13, 2015

Partial Exchange transfusion for Neonate with Polycythemia

A Late preterm 36 weeks by gestation baby who was small for gestation age was delivered via Cesarean section for Oligohydramnios. At birth the Apgar was 9/10, 9/10 and baby was shifted to mother side and was planned for Sugar monitoring . Hemoglobin and Pack cell volume was sent at 2 hours.
Baby was active and accepting feed well.

Hemoglobin was 20mg/dl and PCV was 64.
Baby was observed and adequate feeding was ensured.

On Day 2 of life, baby developed jaundice with TcB of 11 mg/dl. Baby also appeared suffused and red. Blood sugar done was 40mg/dl. Feeding was given and Repeat PCV/Hb/Serum Bilirubin was sent. Baby was started on phototherapy. As Hb report came 25mg/dl and PCV was 71, baby was shifted to NICU.

At NICU, baby was alert, icteric and tachypneic with respiratory rate of 68/min. Baby also had repeated episodes of hypoglycemia.

A plan for Partial exchange transfusion was done.

Baby was taken under radiant warmer in NICU.
Feeds were given.

Calculation for partial exchange was done as per: Weight X 80ml X ( Observed Hematocrit - Desired Hct)/ Observed Hct [ Cloherty manual ] 
A target of 60 hematocrit was chosen.
= 2 X 80 X (71-60)/71 = 24 ml was volume planned for exchange.

In our unit, we prefer Peripheral vessels for partial exchange in term babies as it has shown to be associated to lesser infections. [Comparison of 2 methods of partial exchange transfusion in newborns with polycythemia: peripheral-peripheral and central-peripheral, http://www.ncbi.nlm.nih.gov/pubmed/8373543 ]

A Peripheral IV assesses was made with 24 Guage IV cannula.
An Arterial access was done with cannula of 24 G.

Blood was drawn out of arterial line and Normal saline equal volume was infused via venous line. Normal saline in Partial exchange. Symptomatic neonatal polycythemia: comparison of partial exchange transfusion with saline versus plasma., http://www.ncbi.nlm.nih.gov/pubmed/8772864 ]

Post procedural PCV was sent, which came 62.
Baby remained stable , was on full feeds and was discharge next day with advice to follow up.

Here is a good article given in AIIMS protocol 2014 regarding Neonatal Polycythemia.

Friday, November 6, 2015

10 Problems of Doctors : Society does not Understand

1. Hectic Schedule: Lack of time for Socials
Most fields in Medicine are hectic as we are dealing with patient's life or are on cover on duties. So naturally time for Social activities are compromised. This will gradually affect the social standings and relationships unless you are a great diplomat. People rarely accept the lack of time and assume it as not being given a priority, Be it at Home or Parties.

2. Doctors are not God
If I say this, people will readily say Yes they aren't who said so. But the expectation doesn't tell us that. Society doesn't understand that everything is not in our hand and we can not know everything every time. Sometimes expectations are so much, when they can;t be fulfilled are turned into rage. Doctors aren't god and cannot be expected to be like God. Even a doctor who assumes himself God is ignorant.

3. All Doctors don't earn Millions
We'll like in every field the successful, clever and the best people make it, not all get opportunity and space to make millions. However, still it is one of the best paid occupations. 

4. Doctors Get Ill too
Once there was a consensus among people that Doctors don't get ill because they have all the medicines and even though they get ill , should be fine by evening. I am sure the thinking process has changed a lot by now.

5. All Doctors Don't Have Bad Handwriting
The most common thinking is doctors handwriting are bad, but the fact is most doctors write beautiful handwriting and next time try to take a notice. 

6. All Doctors don't look after all symptoms
The modern society is changing on it, but the convention is still prevalent. I have heard patient saying that "This doctor knows only about Bone and Joint problems, What sort of a doctor is he?" It may not be that the doctor cannot but ethically he isn't looking at all your problems.

7. Anesthesists only makes people Sleep
But the fact is, he/she makes the modern medicine possible. There are lot of things to do to maintain a life while the patient is at sleep painlessly. They are even involved in most complicated procedures and critical care as well.

8. Doctor couldn't Diagnose my problem
Even modern medicine cannot diagnose all the problem, or while approaching a disease, it may take sometime before reaching a diagnosis.

9. Doctors Charge too much- They loot
While all over the world, Medical and health care industry is the most expensive because it is the field requiring the most Investment for education, most skilled man power and requiring most sacrifices.

10. Even Doctors Smoke and consume Alcohol
Though you are advised by doctors not to some or drink, they are as human as you are and they do smoke and often more than the general population. To curb stress of studies, work and life, doctors get into smoking habit, despite  knowing every pathology it causes.

So the Doctor is a bit different that you think, He is no different than you. Respect your doctor and know his limitations, obligations. Next time you visit a doctor, share a smile of warmth and I am sure you'll get the best courtesy in return.