.: 1 in 35000 :.

subhanallah! there is no impossible things to Allah. Allah Maha Berkuasa atas segala yang berlaku.


have you ever heard about TRAP-twin reversed arterial perfusion? it is a condition occurs in twin pregnancy where one twin supplies blood and nutrition to the other twin which is already dead.
this was the first time i heard about the phenomenon.


emm...kalau dalam bahasa melayu mungkin dipanggil "kembar pengepam darah". kes ni berlaku 1 dalam 35000 pregnancies. dan yang satu tu pernah ada di wad kuning dekat sini.


kisahnya macam ni...
TRAP ni ialah satu komplikasi yang sangatlah jarang berlaku di kalangan ibu yang mengandung kembar. ia melibatkan satu kembar yang ada kecatatan dari segi struktur dan tidak boleh survive manakala kembar yang satu lagi adalah normal dan bertindak sebagai pembekal darah dan makanan kepada pasangan kembarnya tu.


nak tahu lebih lanjut, boleh la google2. macam2 ada.




Ini nak menunjukkan bagaimana TRAP terjadi. darah dan makanan dari ibu akan disalurkan ke bayi melalui umbilical vein. bahan-bahan buangan daripada bayi pula akan disalur ke ibu melalui umbilical artery. tetapi, dalam TRAP, si A punya bahan buangan disalurkan kepada si B. jadi, si B yang sepatutnya mati dapat juga merasa sisa-sisa makanan daripada si A dan menyebabkan dia membesar tanpa struktur yang sebenar. si B tiada kepala, otak, tangan, jantung. Maka, orang-orang terdahulu pun memberikan nama A sebagai "pump" atau si pengepam dan B sebagai "acardiac" atau si tiada jantung. Dapat dilihat di sini bahawasanya, si pengepam (A) berusaha keras untuk membekalkan makanan kepada kembarnya yang tiada jantung itu. Ini menyebabkan, jantung A terbeban dengan kerja tambahan dan berisiko untuk mendapat 'cardiac failure' (kegagalan jantung) semasa lahir nanti.



fenomena luar biasa ini sebenarnya telah terjadi beberapa kali di Malaysia ini. Namun, oleh sebab saya ni kurang prihatin dengan masalah-masalah seperti ini sehinggalah memasuki posting OnG baru berminat untuk tahu.


boleh la klik di bawah ini untuk 'more info':

1. http://www.sinarharian.com.my/perak/content/story6060462.asp

2. http://www.indianpediatrics.net/july2003/july-683-684.htm

3. http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-final.htm

.: Risau dan Gusar :.

yesterday, i had short case exam which i didn't feel good about it. this was my re-sit posting~obstetrics and gynecology (O&G). I really want to pass this 3rd year. Ya Allah! please help me, your weak servant.



i got this case:
35 years old chinese lady, G2P1.
LMP: 4 August 2009


1. what is her EDD (expected date of delivery) and POA (period of amenorrhea)?


2. please examine her abdomen.
(do running commentary)


3. discussion: causes? investigation? management?



from per abdomen examination, the abdomen is distended by a gravid uterus as evidenced by linea nigra. the umbilicus is centrally located and inverted. there is fetal movement noted. otherwise the abdomen looks normal. the clinical fundal height is 38 week as evidenced by 2 fingers below xyphisternum, fullness of flank and fullness of costal margin. therefore it is equal to date and measures 37 cm. there is a singleton fetus in oblique lie with head at maternal right hypochondrium and breech at maternal left iliac fossa. the fetal back is at maternal right side. the estimated fetal weight is 3.0kg. the liquor is adequate. i will finish my examination by listening to fetal heart sound at anterior shoulder which is at here (direction showed).

so, the diagnosis is 35 years old G2P1 at 37 weeks POA with oblique lie.



i did well for EDD and POA part.
my technique is also correct except I forgot to mention position of fetal back and mistaken folded cutaneous as a transverse suprapubic scar (cesarean section).



during discussion, i did not get what prof. wanted.

for causes, i answered,
laxity (not appropriate for this patient because patient is only G2), polyhydramnios (not appropriate as the liquor is adequate), concomitant mass (cannot as the uterus is equal to date) uterine abnormalities (fair enough for that answer).

the correct answer (reliable to the patient): placenta previa, prematurity and uterine abnormalities.



investigation:
ultrasound: to exclude any causes of unstable lie.
the correct answer should be to see the location of placenta.



management:
my answer: observe the lie for 24 hours
the correct answer: observe the lie for 48 hours.
(still have the subsequent management which I always forgot to mention in front of examiner)



so, the result was only borderline.
prof told me that i have to work harder for my OSCE and theory exams which will be held next Monday in order to pass my 3rd year. i want to pass! Ya Allah, please help me.

.:rheumatoid arthritis:.

discussion in rheumatology tutorial was different from other tutorial. conducted by Prof Shahrir, as usual he did not directly ask what was written in question paper that we got. he has his own way to make our adrenaline peaked. each students had 'opportunity' to answer his question.


we were asked about the rhematoid arthritis (RA) criteria. we answered:


1.rheumatoid factor (+)
2.finger/hands joints 6w or more
3.rheumatoid nodules present
4.involve 3 or more joints
5.morning stiffness more than 1h for more than 6w
6.erosions on xray
7.symmetrical arthritis for 6w or more

he did not approve our answer. then he told us the new criteria:


it has 4 domain:

1.joint distribution (joint pain)
0- no pain
1- 1 medium joint
2- 2-3 medium joints
3- 1-3 small joints
4- 4-10 small joints
5- more than 10 joints

2.serology (Rheumatoid factor, anti CCP)
0- RhF (-) or anti CCP (-)
1- RhF (+) +/- anti CCP (+) less than 3times upper limit (low titer)
2- RhF (+) +/- anti CCP (+) more than 3times upper limit (high titer)

3.duration of synovitis
0- less than 6w
1- more than 6w

4.acute phase reactant (ESR, CRP)
0- ESR, CRP normal
1- ESR high or CRP high


4-5: probable RA
>6: classical


at that time, this criteria had just came out. amazingly, prof shahrir had remembered it well.~the only doctor in rheumatology department PPUKM.


i don't know how wide is this criteria being used. ~~~ask rheumatologist, surely he will know.hahaha.


~ade org tnye prof. mana satu nak guna. prof kata guna criteria yang lama.

.: I am a Muslim doctor :.

born not to be an ordinary doctor. born to be a Muslim doctor.


muslim doctor is different from other doctor. he not only treat patient physically but also spiritually. muslim doctor always remind his patients about purpose of living in this world. i also would like to be one.


arixtra vs heparin vs clexane


one of patient that i attended has DVT. she is a pregnant woman in 17 weeks of pregnancy. she presented with unilateral right leg swelling upto thigh at 9 weeks of pregnancy and was diagnosed to have DVT. she was treated with clexane.


i flash backed meeting with another patient about 3 months ago. he also got clexane for his heart problem. that was the first time i heard about that medication. he told me that he was informed by the nurse about ingredients of clexane. there is pig enzyme in clexane. he cannot refuse clexane as he was told that clexane is the best drug for him. i paused, not knowing what to say and not knowing about alternative drug.


now, the similar case comes back to me. it urged me to find the answer. what drug can substitute clexane (which is 'halal')? is clexane better than heparin? why not give heparin?


now i know that:
heparin is derived from porcine or bovine.
clexane is low molecular weight heparin, is derived from intestinal mucosa of pigs.

"Muzakarah berpandangan bahawa Islam menegah penggunaan ubat dari sumber yang haram bagi mengubati sesuatu penyakit, kecuali dalam keadaan di mana tiada ubat dari sumber yang halal ditemui dan bagi menghindari kemudharatan mengikut kadar yang diperlukan sahaja sehingga ubat dari sumber yang halal ditemui.

Oleh itu, berhubung dengan penggunaan ubat Clexane dan Fraxiparine yang dianggap darurat kepada para pesakit bagi mencegah formulasi pembekuan darah secara serta-merta ketika pesakit berada pada tahap kronik, Muzakarah bersetuju memutuskan bahawa penggunaan kedua-dua jenis ubat ini adalah ditegah kerana ia dihasilkan dari sumber yang diharamkan oleh Islam, memandangkan pada masa ini telah terdapat alternatif ubat iaitu Arixtra yang dihasilkan daripada sumber halal dan mempunyai fungsi serta keberkesanan yang sama dengan Clexane dan Fraxiparine."

http://e-fatwa.intranetportal.my/fatwa-kebangsaan/hukum-penggunaan-ubat-clexane-dan-fraxiparine



also, i've found an article written in NST (new straits times) about arixtra. so, we should have no doubt not to use clexane as first choice. we should first choose arixtra. go!go!arixtra!

http://www.myhealth.gov.my/myhealth/eng/template.jsp?showMe=31&storyid=1256026385822



however, the problem is 'is arixtra widely used in Malaysia?', 'is every hospital in malaysia has arixtra?'


this is not a joke. this is not something that we can play2. if not us, muslim doctors, who else would stand, backing up our muslim patients?


patients are innocent. they don't know options they have. they put their trust on doctors.
so we, muslim doctors should not disappoint them. give the best for patients' benefits. to gain not only medical knowledge but also 'medical fiqh' is essential for us, muslim doctors.