Pregnancy and Exercise

Pregnancy changes

• cardiopulmonary

• anteriorly displaced centre of gravity
• hormone - jt and ligt laxity
• oedema - compression neuropathy
• bone metabolism - ?osteoporotic/osteonecrotic

Exercise benefits

• Psychological - depression, fatigue
• Biological - blood pressure (pre-eclampsia), ?gestitational DM, easier vaginal delivery (less C-section, less prolonged labour), weight (less gain, faster loss)

Guidelines:

• active - yes
• sedentary - yes
• Contraindication - (placenta previa, imcompetent cervix, preexlampsia, PPROM, antepartum haemorrhage, IUGR, abruptio, multiple gestation)

Regime: (220 - age ) x 60-80% = target heart rate

pregnancy NOT reach peak fitness
<70% maximal aerobic power
maximal exertion impairs fetal heart rate (unconfirmed relationship with fetal outcome) -  placental setal syndrome and transient fetal bradycardia

non-wt bearing sport
cycling and swimming
swimming better: hydrostatic pressure decreased oedema (increase uterine perfusion); less injury chance; diuresis decreased oedema (unknown cause)

Drugs:
NSAID - cardiac (septal defect, premature closure of ductus arterosis)
COX2 inhibitor - renal
Steroids - potential of cleft lip (relationship weak)

oral acetaminophen

Distended abdominal veins

Distended abdominal veins

Radiate out from umbilicus = caput medusae - portal hypertension
Flow upwards = inferior vena cava obstruction
Flow downwards. = superior vena cava obstruction

Dr. Samuel Ling

Ulceration

Inspection:

• site
• shape
• size
• depth - ?tendons/muscles/bone exposed
• base
• edge
• look for underlying cause: ischaemia, neuropathy
• discharge

arterial/ venous/ neuropathic

Femoral hernia

hernia exits through saphenous opening in thigh

femoral sheath border
medial = lacunar ligament
posterior =pubic rami
anterior = inguinal ligament
lateral = femoral vein

Inspection:

• bluge below and lateral to pubic tubercle
• +/- cough impulse
• look for previous scarring

Palpation:

• confirm cough impulse

Mx:
sugery suggested because of high strangulation risk


Inguinal: most used; best of both words
Low: easy, but not used if risk of strangulation
High: can proceed to gut resection

Epigastric Hernia

protrusion of extraperitoneal fat through defect in linea alba

Inspection:

• bluge in epigastric region
• may not have cough impulse
• may not be reducible
• more prominent with tensing of abd muscle (head up to see feet)

Palpation:

• delineate defect and neck
• confirm if reducible

Splenomegaly

Splenomegaly

1 x 3 x 5 - inches in size
7 - oz in weight
9 - 11 ribs

Ax:
Infective
- virus
- malaria

Haematological
- hemolytic anaemia
- leukemia
- myeloproliferative
- lymphoma

Portal hypertension

Splenectomy indications:
- trauma
- hypersplenism

Preop immunization

Dr. Samuel Ling

Hernia repair

Hernia repair

Inguinal
Tension free mesh (litchenstein)

Femoral
Low
- for elderly, and non-strangulated hernia only
High
Inguinal - most used
Intraperitoneal - if need gut resection

Dr. Samuel Ling

Cushings syndrome

excess glucocorticoids

Ax:

• iatrogenic
• adrenal tumour
• pituitary tumour

Examination:

• truncal obesity - protein catabolism
• buffalo hump - cortisol redistribution of fat
• thin skin - decreased collagen
• striae - decrease collagen in skin
• bruising - decreased collagen in vessels
• hitsuitism/acne - increased androgen
• oedema
• kyphosis - cortisol inhibits vit D, leads to osteoporosis, leads to fractures
• muscle wasting - protein catabolism

Multiple Endocrine Neoplasia

Autosomal Dominant

MEN 1:

• Pituitary adenoma
• Pancreatic Islet Cell tumour - Zollinger Ellison, Insulinoma
• Parathyroid hyperplasia 
• thyroid, carcinoid tumour

MEN 2:

• Phaeochromocytoma
• Thyroid medullary carcinoma
• Hyperparathyroidism

Stoma

Stoma

Indications:
feeding
Diversion
Exteriorisation

Examination:
Determine type of stoma
Site:
Caliber
Loop or end
Content
Sprout or not
Associated scars

Complications:
Parastomal hernia
Prolapse or retraction
Stricture
Ischaemia
Infection
Skin excoriation

Check perineum:
Is anus absent

Dr. Samuel Ling

Thyroidectomy

Preop:

• make euthyroid
• propylthiouracil/carbimazole
• beta-blocker for symptomatic
• Lugol's iodine - reduce thyroid vascularity

Intraop:

• transverse incision over skin, fascia, platysma
• preserve and retract strap muscles
• incise pretracheal fascia
• mobilise thyroid
• identify and protect recurrent laryngeal nerve
• ligate superior thyroid art - laterally to avoid RLN
• ligate inf thyroid art
• excise
• close skin in layers

Hyperthyroidism

Aetiology:
- Graves
- toxic nodule - multinudular/single adenoma
- idiopathic - overtreatment of hypothyroid (post thyroidectomy)
- carcinoma
- TSH secreting tumour

Graves disease:
eye signs
- 75% grave have eye signs
proptosis - retrorbital tissue swelling
lid retraction - thyroixine action of orbital muscles
orbital oedema

treatment
propylthiouracil, carbimazole - Pro: reversible. Con: side effect
radioactive iodine - Pro:easy, cheap. Con: social isolation
surgery - Pro:effective, Con: risks, post-op hypothyroidism

Thyrotoxic cisis
- sudden infection to thyroid causing breakdown of cells and release of thyroxine
- iatrogenic overdose

Sx: fever, tachycardia, diarrhoea, jaundice, CNS symptoms
Mx: organ support, fluid balance, propylthiouracil, lugo's iodine (decrease thyroid vascularity)

Thyroiditis

Acute - bacterial (streptococcus)
Subacute - dequervain (viral, EBV, mumps, measles)
Chronic - hashimoto (autoimmune)

Thyroid management

Conservative
- radioactive iodine
- thyroid replacement (lower TSH, prevent tumour growth stimulation)

Surgical:
- total thyroidectomy (most ideat, try to leave parathyroids)

- near total thyroidectomy
- hemi thyroidectomy (if confirned to one lobe)
- neck dissection

Thyroid nodule

Inspection:
Scar
Discolouration
Lump
Move with swallowing
Not move with tongue protrusion

Palpation:
Move with swallowing
Consistency
Solitary or multiple
Thrill
Define borders
Check cervical lymphadenopathy

Auscultate

Percussion:
Retrosternal extension