Complete Androgen Insensitivity- A perfect female

 Hello everyone!

In today's post I'll try to explain you what Complete Androgen Insensitivity Syndrome (CAIS) is.

Androgens are primarily male hormones required for a normal male development. But also, these androgens are secreted in females by their adrenal glands and have some role in female body development too, e.g Growth of pubic and axillary hair.

Now imagine, a very very beautiful adolescent girl, say around 16 years of age, comes to your clinic with a history of primary amenorrhoea. She has absolutely flawless skin (No acne like other 16yr olds), breast development normally, no pubic and axillary hair and on further examination, some inguinal mass, maybe a hernia.

You ask the radiologist for an USG abdomen and pelvis. Don't be surprised to find testes as the hernia content and no uterus!!

This is a classic case of CAIS.

Karyotype analysis- 46XY

Inheritance- XL recessive, mutation in the AR (Androgen Receptor) gene

Genitalia- Female with blind vaginal pouch

Wolffian duct- Often present

Mullerian Duct- Absent

Gonads- Testes

Hormone Profile- Increased LH and Testosterone (But the receptors have resistance to it's action)

Increased Estradiol, FSH slightly raised.

For more pictographic representation, Watch HOUSE MD S02E13 "Skin deep"

That's it!

Happy Studying

Stay awesome!

Dr. ShilPill

PCOS explained

PCOS with Sherlock Holmes

Hello guys, this is my first video/podcast on Medicowesome.

Technique of Breastfeeding

Hello friends!

On International Breastfeeding Week, I am sharing the proper technique for Breastfeeding. 

Must know methods for everyone.

Techniques of Breastfeeding 

Breastfeeding is nature's precious gift for infants. Breastfeeding is advised because human milk is species-specific nourishment for the baby, produces optimum growth and development, and provides substantial protection from illness. Lactation is beneficial to the mother's health and biologically supports a special MOTHER-BABY relationship.

But most breastfeeding problems are caused by the poor attachment of the baby to the breast. Thus, it is very important to learn how to feed the baby with the correct position and attachment.

Support the mother's body as support back well and use pillow, cushion, or footstool to provide comfort. Before breastfeeding, every mother should wash their hands. 

The correct way to support baby -

1. In sitting position 

a) Cradle hold-

Hold the baby horizontally facing the mother. When nursing from the right breast, use the right arm to rest on the forearm, baby's back supports on the same forearm and holds baby's bottom with hand. Support the breast with the left hand. 

b) Transition hold (cross over hold)

When nursing from the right breast, use the left arm to hold the baby. Support baby back with the left forearm, while placing the thumb and fingers at the base of the baby's head below the ears of the baby. Support the breast with the right hand. 

c) Football hold

Hold the baby under the mother's arm and let the baby face towards the breast. Support the baby with a pillow underneath. Hold the baby close the mother with the nose pointing to the nipple, use the forearm to support baby back and neck, and the hand to hold the baby head. This position is suitable for mothers who have had a Caesarean section. Since mother does not put pressure on the abdomen. 

2.Inside lying hold 

Baby and mother lying on their sides facing each other. The mother should be relaxed. The baby needs to well supported and secure as tuck a rolled-up towel or small pillow firmly behind baby' back to keep in position. Adjust the baby's distance from the lower breast by placing a folded blanket under the baby's head. To assist with the latch on using the opposite hand to support the breast(right hand for left breast vice-versa) 

Getting baby latch on to the breast -support the base of the baby's head. Baby's head slightly extended, so that the nipple is aimed at the roof of the baby's mouth. Lightly touch the baby's lip with the nipple and wait till baby opens his/her mouth wide. Bring baby to mother's breast. Not mother breast to the baby. 

Signs of good attachment-baby open his/her mouth wide with lips flanged out, more areola is seen above the baby's lip then below baby's chin is pressed onto the breast. 

Breastfeeding should not hurt if the mother keeps a finger into the corner of baby's mouth to break the suction and gently take baby off mother's breast.

By- 

Shashikala Kumari

2nd year MBBS

GMC Bettiah

Facebook: Wolffian duct

Q1) Ejaculatory duct in males develops from 

A) Ureteric bud

B) Mesonephric duct

C) Wolffian duct

D) Paramesonephric duct

#Medicowesome

#Gynaecology

Answer to this question is Option C) Wolffian duct.

But isn't Wolffian duct also called as Mesonephric duct ? So can you pick option B instead of option C?

Well, unless your exam allows multiple answers to be correct, do not pick 'Mesonephric duct'. Here is why?

The mesonephros gives mesonephric duct which opens in the Urogenital Sinus and forms trigone of the bladder. Mesonephric duct also gives ureteric bud to the Metanephros to form Renal system.

Now after this has happened, the Mesonephric duct will be called as Wolffian Duct which forms the internal genital organs and in females, disappears.

That's it!

Demotional bloke

MCQ mnemonics series: Genital tuberculosis most common site

#Obs_Gyn
Question:
Most common site of genital tuberculosis is?
(A) Fallopian tubes
(B) Uterus
(C) Ovary
(D) Fimbriae
________
Answer:

Age of Gestation and Estimated Date of Delivery (EDD)

Hello,

This is a nice video explanation by Jay!

Female genital tumors mnemonics

Hey everyone :) I would like to share some mnemonics that will help in remembering some facts about female genital tumors:

> Mnemonic for most deadly cancers : OUCh

Ovarian cancer> Uterine > Cervical

===
> Mnemonic for the most common female genital tumors in US:
Eradicate Ur Ovary Completely
Endometrial/Uterine > Ovarian > Cervical

===
> Effect of OCPs:

OCPs decrease the risk of cancers that start with vowels 
so ===> they decrease Endometrial cancer and Ovarian cancer
but they increase the risk of cervical cancer :O

===
> Effect of breastfeeding:
Breastfeeding decreases the risk of BOob cancer :P
so ==> it decreases the risk of Breast cancer and Ovarian cancer

And that's it :)


Written by: Murad

Oxytocin

OXYTOCIN

Hello Awesomites! Here's a collection of important facts about the love hormone oxytocin.

Oxytocin sensitivity is increased during delivery.

In lactating women genital stimulation enhances oxytocin release.

Oxytocin challenge test for assessing fetal well being is contraindicated in - Placenta previa
Previous two LSCS
Premature labour

Posterior pituitary secretes Oxytocin.

Oxytocin causes Milk ejection, Contraction of uterine muscle & Myoepithelial cell contraction.

Post partum hemorrhage, Uterine inertia & Breast engorgment due to inefficient milk ejection reflex are indication for oxytocin.

Side effect of oxytocin are Placental abruption, Fetal distress & Water intoxication.

Oxytocin is synthesized in Hypothalamus.

Oxytocin is a Polypeptide.

Oxytocin is Secreted in both sexes.

Oxytocin is an example of neurohormone.

Atosiban is an Oxytocin antagonist.

-MD Mobarak Hussain (Maahii)

Menopause

Menopause : Facts

Gonadotrophins remain elevated after menopause for rest of life.

Average age range of attaining menopause is 45 - 55 years.

A 35 years old lady is not having her menses for last 4 months. She has high serum FSH and LH level with low estradiol. The likely cause is Premature menopause.

Predisposing factors for endometrial carcinoma is late menopause.

Carcinoma vulva is seen in seen after menopause and viral predisposition.

There may be an increase in FSH secretion by the pituitary gland in menopause.

Systemic vasomotor instability may be present in menopause.

There is a decrease in skin elasticity after menopause.

The symptoms of menopause are best treated with Estrogen.

Late menopause is risk factor for breast cancer.

Osteoporosis is seen in menopause High progesterone, High estrogen & Low FSH are seen in menopause.

Menopause may cause prolapse of cervix.

-MD Mobarak Hussain (Maahii)

Kallman syndrome mnemonic

Kallman Syndrome (also known as Olfactogenital dysplasia/syndrome or anosmic idiopathic hypogonadotropic hypogonadism)

Let's​ get down with the mnemonics!

'Kallman' kinda rhymes with 'Tallman', right? Well, "man" for it's more common in boys and Tall these individuals are of normal or even increased height (Tall).

The other features are:

K - kinda looks like an X so it's X-linked
K also sounds like C for Colorblindness
A - anosmia
L - lip (cleft lip and cleft palate)
N - nerve deafness
A - ataxia (cerebellar ataxia)
M - midline defects (cleft palate, cleft lip)

Other important points are:
- The defect is in the KAL gene which codes for the protein anosmin.
- It can be due to autosomal dominant or recessive inheritance.

That's all!

Stay awesome 

This post is written by Nikhil as part of the MSGAI.

USMLE Step 3 CCS: Rape

Hello!

These are my CCS steps for a case of rape. Lemme know if I missed out on anything!

Consent
Rape evidence kit

Complete physical examination

CBC
BMP
Vaginal fluid analysis
Vaginal, cervical, rectal cultures
BHCG
UA
Urine culture
HIV test, P24 antigen
VDRL
HbSAg
Gonococcal tests
Chlamydial tests

Emergency contraception (ulipristal / levonogestrol)
Ceftriaxone
Azithromycin
Metronidazole
Tenofovoir + emtricitabine + raltegravir
HBIG (if unvaccinated)

Psych consult
Drug screen
Colposcopy (for injuries)

That's all!
-IkaN

Puerperal sepsis

PUERPERAL SEPSIS

Puerperal sepsis is any bacterial infection of the genital tract which occurs after the birth of a baby. It is usually more than 24 hours after delivery before the symptoms and signs appear.

Some of the most common bacteria are:
Streptococci
Staphylococci
Escherichia coli (E.coli)
Clostridium tetani
Clostridium welchii
Chlamydia
Gonococci

SYMPTOMS AND SIGNS 
Fever (temperature of 38°C or more)  Chills and general malaise
Lower abdominal pain
Tender uterus
Subinvolution of the uterus
Purulent, foul-smelling lochia.
Slight vaginal bleeding
Shock.

RISK FACTORS
Some women are more vulnerable to puerperal sepsis, including anaemia and/or malnourished, protracted labour, prolonged rupture of the membranes, frequent vaginal examinations, a traumatic delivery, caesarean section and retained placental fragments, PPH, diabetes all predispose to puerperal infection.

SITES
The most common site of infection in puerperal sepsis is the placental site.
Other sites of infection are abdominal and perineal wounds following surgery and lacerations of the genital tract, e.g. cervix, vagina and perineum.

Following delivery, puerperal sepsis may be localized in the perineum, vagina, cervix or uterus.
Infection of the uterus can spread rapidly if due to virulent organisms, or if the mother’s resistance is impaired.
It can extend beyond the uterus to involve the fallopian tubes and ovaries, to the pelvic cellular tissue causing parametritis , to the pelvic peritoneum, causing peritonitis , and into the blood stream causing septicaemia

DIFFERENTIAL DIAGNOSIS
Fever  in the puerperium can also be caused by:  urinary tract infection (acute pyelonephritis)  wound infection (e.g. scar of caesarean section)  mastitis or breast abscess  thrombo-embolic disorders, e.g. thrombophlebitis or deep vein thrombosis  respiratory tract infections.

-Md Mobarak Hussain (Maahii)

Fact of the day : Easier approach shot to the pouch of Douglas

Hey Awesomites

The posterior fornix of the vagina is separated from the peritoneal cavity by a single layer of peritoneum and the posterior vaginal wall. Therefore, vaginal approach from its posterior aspect for evacuation of pus in the pouch of Douglas can be done without much difficulty.

On the other hand, approach to uterovesical pouch ( anterior relation ) is much more difficult from the vaginal route and consists of a series of steps :
- Incise the vagina
- separate bladder from cervix
- Traverse the vesicocervical space ( till the uterovesical fold of peritoneum is reached )

This difference is due to the normal physiological position of the uterus that is anteverted and anteflexed; the direction of external os being downwards and backwards.


That's all
- Jaskunwar Singh

Basic modalities of Transitional Zone

Hey Awesomites

Squamocolumnar junction ( the transitional zone ) is a junction formed by merging of squamous epithelium of the vagina with the columnar epithelium of endocervix.

Squamous non keratinized epithelium lining the vaginal mucosa has three distinct layers -
- Basal layer of cuboidal cells
- Middle layer of prickle cells
- Superficial layer of cornified cells

Embryologically, the junction consists of columnar epithelium that spreads over the external os and only the basal and middle layer of squamous epithelium lining the vaginal mucosa.

After attaining puberty, hormonal effects of oestrogen and progesterone induce metaplastic changes in columnar epithelium. Therefore, the squamous epithelium comes in close vicinity to the external os.

During reproductive age, growth of uterus, hypertrophy of cervical cells and associated hormonal changes and in females exposed to DES in utero, the transitional zone extrudes well out of the external os.

Due to high cellular activity and sensitivity to certain irritants and mutagens, there is high risk of dysplastic changes in the squamocolumnar epithelium and eventually carcinoma cervix. So, scrapings for PAP smear are done without difficulty from this exposed area to screen the patients.

In menopausal women, the atrophy of cervix leads to in drawing of SCJ into the canal. Hence the junction is not easily accessible and this ill exposure is the reason for high rates of false negative findings in PAP smear in older women! Hormonal therapy in such patients improves the positivity of results.


That's all
Jaskunwar Singh

SERM for vulvovaginal atrophy mnemonic

Which of the following is a selective estrogen receptor modulator (SERM) that is prescribed mainly for treatment of genitourinary syndrome of menopause (vulvovaginal atrophy)?

A.) Bazedoxifene
B.) Raloxifene
C.) Phentermine
D.) Lasofoxifene
E.) Ospemifene

Image Based MCQ on Twin Pregnancy

Hello awesomites! 

Yesterday we posted an Image based MCQ on Twin Pregnancy. Here's the answer for it. 

#Radiology
#Obs_Gynae
Q. What is the diagnosis of the given USG image? 

A. Polyhydramnios 

B. Diamniotic Monochorionic twins 

C. Diamniotic dichorionic twins

D. Monoamniotic Monochorionic twins. 

The correct answer is C. Diamniotic dichorionic twins. 

The twin peak sign (also known as the lambda (λ) sign) is a triangular appearance of the chorion insinuating between the layers of the inter twin membrane  and strongly suggests a dichorionic pregnancy.  It is best seen in the first trimester (between 10-14 weeks). While the presence of a twin peak sign is a useful indicator of dichorionicity its absence, however, is not that useful in confidently excluding it.

It should be noted that the 'twin' in 'twin-peak' refers not to the presence of two peaks, but that it relates to twins. In pregnancies with more than two fetuses, the chorionicity and amnionicity of the each fetus may be different, and therefore this sign only aids in determining chorionicity of adjacent twins.

That's all! 

Thank you 

MD Mobarak Hussain (Maahii) 

Image Based MCQ on Shoulder Dystocia

Hello awesomites!
Yesterday we posted an Image based MCQ on Shoulder Dystocia.
And as promised here is the answer.

#Obs_Gynae
Q. The image given below represents:

A. Mc Roberts maneuver
B. Woods corkscrew maneuver
C. Cleidotomy
D. Zavanelli maneuver

The correct answer is A.

The given image shows Mc Roberts maneuver.

All of the above mentioned maneuvers are used for management of shoulder dystocia.

Mc Roberts maneuver:
In this maneuver, legs of the mother will be abducted and flexed against the abdomen. It causes cephalic rotation of the pelvis. Along with this gentle suprapubic pressure is applied by the assistant.

MD Mobarak Hussain  (Maahii)

Fact of the day: Gonorrhea and vulvovaginitis

Gonorrheal infection is generally limited to superficial mucosal surfaces lined with columnar epithelium. The areas most frequently involved are the cervix, urethra, rectum, pharynx, and conjunctiva. 

Treponemal and nontreponemal tests for syphilis (notes + mnemonic)

Nontreponemal tests include:

Rapid plasma reagin (RPR)
Venereal Disease Research Laboratory (VDRL)
Toluidine Red Unheated Serum Test (TRUST) 

Mnemonic:
Do not trust VDRL rapidly.

Features of non treponemal tests:

They are based upon the reactivity of serum from infected patients to a cardiolipin-cholesterol-lecithin antigen. 

Used for initial syphilis screening due to their relatively low cost, ease of performance, and ability to be quantified for the purpose of following response to therapy.

Specific treponemal tests include:

Fluorescent treponemal antibody absorption (FTA-ABS)
Microhemagglutination test for antibodies to T. pallidum (MHA-TP)
T. pallidum particle agglutination assay (TPPA)
T. pallidum enzyme immunoassay (TP-EIA)
Chemiluminescence immunoassay (CIA)

Features of treponemal tests:

Treponemal tests have been more complex and expensive to perform than nontreponemal tests. Thus, they have traditionally been used as confirmatory tests for syphilis when the nontreponemal tests are reactive.

Treponemal tests are qualitative only and are reported as "reactive" or "nonreactive" 

Once a patient has a positive treponemal test, this test usually remains positive for life. Thus, these tests are generally not useful for confirming a diagnosis of syphilis in a patient with prior treated disease.

That's all!
-IkaN