INVESTIGATIONS OF INFECTIVE SYMPTOMS IN PREGNANCY

Clinical presentation Possible diagnosis Investigations

Maculopapular rash Rubella IgM and IgG*
Parvovirus IgM and IgG*
Enterovirus Throat or faecal culture


Vesicular rash Varicella Rash IgM and IgG* if uncertain
Enterovirus Throat or faecal culture


Flu-like symptoms CMV IgM and IgG*
(fever, myalgia, malaise, LFTs, FBC
+/- lymphadenopathy) Toxoplasmosis IgM and IgG*
Listeriosis Blood and faecal culture
Other viral infections Serology or culture as required


*In parallel with previous
antenatal serum and 2-4 weeks later if required

PREPREGNANCY COUNSELLING.

GPs should encourage couples who are planning
to conceive to have counselling and
testing before conception.
Tests for infection should include:
• rubella IgG
• syphilis serology – TPHA or RPR
• hepatitis B serology – hepatitis B
surface antigen
• hepatitis C serology – hepatitis C antibody
• HIV
• varicella – IgG
• CMV IgG (in high-risk patients)
Women who have negative rubella serology
should be offered MMR vaccine and
retested for rubella seroconversion eight
weeks later. About 5% will need revaccination.
A very small number of women will
remain rubella seronegative despite two successive
MMR vaccinations.
It is unlikely that further vaccination will
lead to seroconversion. In these cases it is
best to counsel the woman to avoid rubella
contact in her subsequent pregnancy.
Women found negative to varicella IgG
should be offered varicella vaccine with two
doses, eight weeks apart. Pregnancy should
be delayed until eight weeks after vaccination
for rubella or varicella.
In those at high risk of CMV infection
(carers of young children), CMV IgG should
also be measured.
Seronegative women should be counselled
to practise thorough hygiene when in
contact with secretions of newborn infants
and toddlers.
A pre-pregnancy session will also allow
the GP to provide nutritional advice and
instructions on ways to minimise risks of
infection with toxoplasmosis, listeria and
other infections.

SIGNS OF A PERFORATED EYE

■ an irregular or peaked pupil
■ a shallow anterior chamber
compared to the other eye
■ absent or diminished red
reflex
■ a boggy haemorrhagic
swelling over the sclera
■ uveal tissue, which is dark,
lying external to the globe
Note: not all these signs need
be present.

EYE EXAMINATIO TOOLS

■ a vision chart
■ a light source with a cobalt
blue filter
■ a means of magnification such
as loupes (or a pair of +3.0
“chemist’s glasses”)
■ amethocaine drops to
anaesthetise the ocular surface
■ fluorescein drops to stain any
epithelial defects
■ cycloplegic drops to dilate the
pupil
■ an ophthalmoscope to visualise
the red reflex and/or posterior
segment of the eye
■ cotton buds to wipe up any
secretions and help evert the
upper lid.

Diagnosis of metabolic Syndrome

The size of the waistline is the key
to selecting patients to investigate.
People who are genetically predisposed
and who take in an excessive
amount of calories are most
likely to develop this condition.
The lean man with a pot belly, a
shape seen commonly in general
practice, could be considered the
most toxic shape of all.
Objective assessment of known
risk factors (cholesterol, fasting
lipids, blood glucose level, blood
pressure, smoking, obesity and
sedentariness) is also necessary.
Risk factors for metabolic syndrome
often cluster together and have
a multiplicative rather than an additive
effect. In women, it is the level
of fasting triglycerides, rather than
cholesterol, that predicts subsequent
cardiovascular disease and death.
Waist target parameters have
tightened over time and vary according
to genetic polymorphism (see
table below).
If BMI is >30kg/m2, central
obesity can be assumed and waist
circumference does not need to be
measured. Abnormal blood glucose
should be investigated with a
glucose tolerance test.
About a third of patients with diabetes
will be picked up by the
glucose tolerance test compared with
just focusing on the fasting glucose.
Obesity and central adiposity
seem to co-segregate, not only with
cardiovascular and diabetes risk, but
also with an increased risk of certain
types of malignancy, such as breast
and endometrial cancer.

METABOLIC SYNDROME

the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose

METABOLIC SYNDROME

the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose

METABOLIC SYNDROME

the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised fasting plasma glucose

CASE STUDY

CASE ONE

A mother brings her six-year-old
son to your emergency department.
He was practising his “Power
Ranger” moves in the family’s
split-level living room and leapt
from the upper to the lower level,
landing heavily on his feet. He
complains of neck pain but no
other symptoms.
What features are present on
inspection?
He has a torticollis, and is in some
degree of pain.
What immobilisation is
indicated?
This child would not fit into a collar.
Forcing the issue would create further
pain and distress and may exacerbate
an injury. He should be allowed to
adopt a position of comfort, with
padded support if necessary, and
given simple analgesia as required.
What imaging is indicated?
X-rays are indicated as an initial investigation,
but should be interpreted
with care, with recognition that in
this age-group plain X-rays are
known to be poorly sensitive.
What is the injury?
X-rays showed an anterior subluxation
of C2 on C3. In this particular
case, injury was missed on two presentations,
as the treating doctor interpreted
the X-rays as normal and
assumed a “muscular strain”. Relying
on negative X-rays in this age
group is a classical error – the
history and examination (inspection)
give the diagnosis.
Neck pain after play mishap
X-rays are indicated for the boy but
should be interpreted with care.

CERVICAL SPINE CLEARING

1. The awake, alert patient, with no other
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.

2. The mentally obtunded patient.

Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.

This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.

Non-ulcer dyspepsia

Functional or non-ulcer dyspepsia is defined as at least three
months of dyspepsia in which no definite biochemical or
structural cause can be found to explain symptoms. There
is no confirmatory test and the diagnosis can only be made
after exclusion of the aforementioned structural causes.
A diagnosis of non-NSAID, non-H pylori ulcer should
only be entertained after:
■ exclusion of surreptitious NSAID use
■ careful exclusion of H pylori infection by several
biopsies
■ use of more than one H pylori diagnostic test
■ exclusion of confounders that would alter the sensitivity
of these tests, such as concurrent proton pump inhibitor
(PPI) use, recent antibiotic therapy or gastrointestinal
bleed.
Management involves 4-8 weeks of PPI therapy.
Although rare, exclusion of gastric carcinoma and other
upper gastrointestinal malignancies is important in those
with “alarm symptoms”, which the American Gastroenterological
Association guidelines summarise as:
■ age older than 55 years with new-onset dyspepsia
■ family history of upper gastrointestinal cancer
■ unintended weight loss
■ gastrointestinal bleeding
■ progressive dysphagia
■ odynophagia
■ unexplained iron-deficiency anemia
■ persistent vomiting
■ palpable lymphadenopathy
■ jaundice.
However, the presence of alarm symptoms has been
found to have poor predictive value for malignancy – rather
they alert the practitioner to the need for early endoscopy
to avoid the risk of missing a neoplastic process.
Functional dyspepsia can be difficult to manage. There
is evidence showing a small benefit with H pylori eradication
and PPI therapy. Although impaired gastric emptying
is noted in 25-40% of patients with functional dyspepsia,
there is inadequate evidence for the efficacy of
prokinetic therapy.
Despite its similarities to irritable bowel syndrome in
pathophysiology, there is also inadequate evidence to support
routine use of anti-depressants and psychological
therapies, although these should be considered as alternatives
for refractory patients. Counselling and reassurance
is essential.