OGTT

Normal values

75-gram 2 Hour oral glucose tolerance test

• Fasting    60 -100 mg/dL
• 1 hr:        less than 200 mg/dL
• 2 hrs:      less than 140 mg/dL. 

140 - 200 mg/dL = Impaired glucose tolerance
> 200 mg/dL = Diabetes




FOR GESTATIONAL DIABETES,
50-gram 1 hour oral glucose tolerance test

• 1 hour: < or =140 mg/dL

if >140, do
100-gram 3 hour oral glucose tolerance test

• Fasting: less than 95 mg/dL
• 1 hour: less than 180 mg/dL
• 2 hour: less than 155 mg/dL
• 3 hour: less than 140 mg/dL

2 or more abnormal values = GDM

Cervical cancer screening

Every woman, 21-65 yrs : Pap smear for cytology every 3yrs

For those above 30, alternative is Pap smear for cytology + HPV testing every 5yrs


If cytology yields abnormal results do further tests

Atypical squamous cells of unknown significance, ASC-US:
The "significance" is not clear so check for the HPV virus
If HPV +, then do colposcopy
If HPV -, then patient goes home and returns for repeat pap smear in 12 months (instead of the usual 3 yrs)


Atypical squamous cells, cannot exclude HSIL, ASC-H:
Still not clear and even more suspicious, HSIL is a possibility so go straight and do colposcopy


Low grade squamous intraepithelial lesion, LSIL:
For premenopausal women including pregnant women, do colposcopy

For postmenopausal women, 3 options:

• Do colposcopy
• Do HPV and then colposcopy if +
• Wait and repeat in 6months and 12months

High grade squamous intraepithelial lesion, HSIL:
Do colposcopy


20% of CA cervix may arise from glandular cells but the majority, 80%, are from squamous cells

Colposcopy is done for visual inspection + targeted biopsy + endocervical curretage (EC is contraindicated in pregnancy).

Findings:

If colposcopy done following abnormal cytology does not show any CIN, repeat cytology in 12 months (or 6 months if HPV+)

CIN 1: usually regresses spontaneously
CIN 2 & 3: Cautery, LEEP, Cone biopsy

Hyperprolactinemia

causes:

• Prolactinoma

woman with infertility, amenorrhoea, galactorrhoea (usually microadenomas in females so no pressure symptoms)

Man with visual field deficit, headaches etc (usually macroadenoma in males so there r pressure symptoms)

• Primary hypothyroidism

Increased TRH stimulates excess prolactin production

• Drugs:

Dopamine antagonists (antipsychotics), SSRIs, TCAs, methyldopa, metochlopromide
Dopamine inhibits prolactin secretion so its antagonists remove this inhibitory effect

Tmt:

First line for all patients: Bromocriptine

Men with prolactinomas(macroadenoma) : surgery or radio

Old women with microadenoma , not concerned about fertility, : no treatment reqrd.

Oral contraceptives and associated risks

OCPs increase risk of

cervical cancer 
breast cancer,
DVT
hypertension.


OCPs reduce risk of

ovarian cancer
endometrial cancer

Rhesus incompartibility

Every woman @ first prenatal visit, do Rh screen and Rh Ab titre.

In Rh negative woman, consider as sensitized if Ab titre is >1:4

If Ab titre> 1:16, do amniocentesis @ 16-20 wks gestation, check fetal cells for rhesus factor
If not sensitized or <1:16, repeat Ab titre @28 wks

If fetal cells r rhesus positive and mother's Ab titre >1:16 then fetus is at risk of Erythroblastosis
If fetal cells r rhesus negative, then there's no risk for the fetus even though mother is sensitized, continue usual prenatal care.

If fetus is rh + and at risk, check if fetus is already hemolysing : serial amniocetensis for amiotic fluid bilirubin
if mild, repeat in 2-3wks, if moderate, repeat in 1-2 wks, if severe consider intervention:
       Is fetus anemic?
       How low is Hct?
       umbilical cord blood hematocrit <25% ----intrauterine transfusion or deliver if >34 wks G.A

Give anti D immunoglobulin to all Rh negative pregnant women who remain unsensitized at 28 wks. Repeat after delivery if baby is rh positive.
If already sensitized, Rhogam is of no value, focus on fetal monitoring and intervene as appropriate.

After an abruptio or other events with suspected fetomaternal haemorrhage,
Do a rosette test (qualitative) to confirm fetomaternal haemorrhage.
If positive, do a kleihauer - Betke test to quantify the haemorrhage.
For every 15mls of fetal blood in maternal circulation, give 300microgram of Rhogam up to a maximum of 1500microgam.