Q. We recently faced problems as a surgery wound took seven months to heal. We tried everything and even engaged a plastic surgeon. We later found out that the wound was infected by a strain of bacteria which is not caught in general tests. To prevent such incidents in future, we need your advice. A. Thanks for asking. This is rare. Usually such notorious strains of organisms are hospital acquired. Standard disinfection, autoclaving and fumigating need not be over stressed to someone like you. However some people recommend taking swabs from OTs at regular intervals. However I would still like to reaffirm
that rare things appear rarely and need not over bear on us
to make major policy changes.
Q. I have a patient. She is 8 weeks pregnant now. She has 2 sisters. Eldest sister had a midtrimester abortion and then 2 FTND after stitch in both pregnancies. Second sister was advised prophylactic stitch by another Obgyn and has a baby from LSCS at full term after the stitch at 14 weeks. According to patient the stitch was not preceded by any USG demonstration of cervical shortening etc. What will be prudent action in her case now? How to manage - Serial TVS for cervical shortening/ Ballooning of membranes or prophylactic stitch? A. There is no known evidence of
families having this problem. However as a generalization
they say that prophylactic encerclage is so safe a procedure
that at any instance the benefit of doubt goes in favour of
the procedure. Lest looking purely at the findings in some
other case I would not do the procedure. But this seems to
be different.
Q. I have a question. In CIN I, the basal 1/3rd of the epithelium is dyskaryotic. Superficial cells are exfoliated & pap's report says - mild dyskaryosis. Are superficial cells affected or normal here? If affected, what type of affection it is? Does CIN I mean superficial 2/3rd should be normal? A. The cells viewed on a cervical smear
have been classified using various different systems. The
older system classified the various cellular abnormalities
as mild, moderate and severe dyskaryosis and
Carcinoma-in-situ. This was replaced by the Bethesda system
of classification which classified cellular changes as
under: The precancerous changes from cervical biopsy are called cervical intraepithelial neoplasia and are categorized according to severity: CIN I, CIN II, and CIN III. While CIN is a histopathological
diagnosis based on the thickness of cells affected, it has
been practice (actually erroneous) to use CIN and Dysplasia
(dyskaryosis) and interchangeably. As regards the question, in CIN I, the
superficial cells are normal: only the basal 1/3rd of
epithelium is affected and the superficial 2/3rd is normal.
If Pap smear says mild dyskaryosis, it means it is a LGSIL.
The grade of CIN should be a histopathological diagnosis. To
avoid these confusions, it is advisable to use the Bethesda
system of classification for Pap's smear.
Q. I have a patient
21years old with 6 weeks pregnancy having big fibroid in
uterus 11cm & 9.6 cm and at present she has jaundice - 8.5
mg. Kindly suggest me whether medication abortion is safe or
not in this case
Q. I know that I am not a patient there, but I am curious to ask a GYN before I start eating bee pollen for health (I hear it’s good to help weight management and overall well being and longevity) if it will interfere with my birth control pills or render them useless? I am not trying to get pregnant at this point. Thank you so much for your time! A. I am totally unaware of any effects
of bee-pollen good or bad so i am unable to take any stand
on this
Q. A 14 years old
mildly obese girl (wt 55 kgs) is having meno-metrorrhagia
with dysmenorrhoea since her menarche at 11 yrs age. She has
to miss her school often & now stays depressed at her home
because of the said condition. She is normotensive. She was previously managed with
Norethisterone & Tranexamic acid by few other gynecologists. Her mother is obese & has NIDDM & her
father has Hypertension. She is presently having continuous
bleeding P/V since last two & half months (without any
medication). Past Investigations done: - Hb 9.8 % Her present investigation reports which
I advised are as follows : (done at SRL Ranbaxy Labs) Fasting Blood glucose – 90 mg/dl Serum Prolactin – 5.61 (normal) Testosterone Total – 65.66 (normal
range 10-40) I had initially advised the following &
waited for Investigation reports: Diet control, Exercise & Weight
reduction (1) Regestrone (5 mg) 2 tabs TDS for 5
days foll. By 1 tab TDS for next 5 days. But her bleeding is only slightly
controlled at present (1) KRIMSON 35 once daily Sir, I would like to know whether the
following would be helpful: (1) Testing for von-Willebrand’s
factor? A. In my perception this is a simple case of hormone dependence. She seems to have missed taking some hormone doses or has taken hormones improperly (not as advised) though she will not admit. I would stop ALL hormones first. Then let her bleed at the most controlling it with locally acting agents like Mefanamic acid and the like. Once this is done she will stop bleeding on her own. Then-after she can be put on cyclic hormones (COCs). This will control her cycle and her Hb will rise. Needless to say you will also add hematinics. After this I am sure she will get
controlled if not think of rare investigations.
Q. I have a patient Para1 , 30 yrs old, who had a motor vehicle accident 2 years ago wherein she had a blunt abdominal trauma and had a splenectomy done . She plans a second pregnancy. Any special precautions / care that need to be taken in such a case? A. There seems to be no additional risks however please find the indication of splenectomy and if that has a bearing on pregnancy you will have to look at that
Q. Perimenopausal asymptomatic women with fibroid uterus, fibroids of different sizes. What should we do? I mean is it worth subjecting them for hysterectomy A. This can be left alone I feel
Q. I have a patient
who is a 4th Gravida at 30 years of age with 2 IUFD at 30
weeks and a missed abortion at 18 weeks. In the last Calicut National
Conference, I got an impression that a patient with such
recurrent pregnancy loss can be started on low dose Aspirin
and Heparin. Incidentally, this patient gives a history of VSD closure at 6 years of age. And her cardiac status is within normal limits according to the Cardiologist. A. Thanks for asking. Vasculopathy
leading to such adverse obstetric outcomes are NOT
exclusively confined to APA Syndrome. It can occur in other
conditions also. This basically is due to obstetric
vasculopathy. In my opinion therefore you must start Heparin
in this patient besides aspirin. Q. When doing a vaginal hysterectomy for prolapse made a small nick just above the perineal body when doing posterior colpoperineorraphy; It was a small perforation through about 1 cm, about 1 cm above the anal verge. As I work in small settings with no surgical help around i closed it vicryl 2 layers and patient has been put on IV fluid over 2 days. Sir will this heal? Or do I do need to do anything else please advice A. Most probably it will heal. Most of
such small surgical injuries in anal canal/lower rectum heal
if sutured well in 2 layers. I would recommend that the
patient be kept nil by mouth for 3 days, 4th day just
liquids and to start solid food from 5th day. The patient
may be prescribed stool softener from 5th day onwards for
4-5 days to avoid constipation and hard stool irritating the
suture line.
Q. We had queries regarding the intrapartum management of monochorionic pregnancy. r there any specific guidelines for MCDA and MCMA PREGNANCIES for intrapartum management? A. Thank you for your enquiry. The Royal College has published a guideline on monochorionic pregnancies, which refers to monoamniotic pregnancies in paragraph 10: 10. What are the specific problems of monochorionic, monoamniotic pregnancies and how should they be managed?" Most monochorionic, monoamniotic twins
have cord entanglement and are best delivered at 32 weeks,
by caesarean section, after corticosteroids. Q. What are 2 main histopathological types of endometrial carcinoma? A. The most common histological type of
endometrial carcinoma is Endometrioid carcinoma (known as
adenocarcinoma). The next commonly occurring Carcinoma is
adenosquamous carcinoma. The less common ones are mucinous,
papillary serous, clear cell CA and squamous cell CA. A. At times, patients stay in rural
areas and the distances to be covered by these women to
reach the health facility for antenatal care may be very
large. There is a concept that low risk women may be seen
less frequently as the risk of complications with less
frequent visits in these patients is minimal. High-risk
women of course would require frequent visits to reduce
complications. This may be difficult due to large distances.
Hence, was the origin of the concept of obstetric village.
Obstetric village is a waiting area, where cheap
accommodation is available for patients, which provides an
ideal solution for some intermediate risk patients,
high-risk patients and the some primigravida, so that they
can be seen more regularly. Q. For trophoblastic disease, along with methotrexate folinic acid is used. I would like to know in what form is available & also can folic acid be used instead. What is the difference? A. Folinic acid has to be used and not
folic acid. You can get its info about availability etc from
MIMS Q. A fifteen year old girl has presented to me with BPV for 2 days. She is soaking almost 7-8 napkins per day. LMP 15 days back. That time she bled for almost 20 days off and on. her haemogram, thyroid profile is WNL. Ultrasound Pelvis showed normal uterus size, ET=12mm, adnexa normal. Previous cycle managed with Texid-MF tds and Daflon-BD. Right now same medicines being given. How to proceed further? Management? A. This is adolescent hypermenorrhea.
If all other causes have been ruled out her parents and she
can be reassured that this will soon set to its normal
rhythm. Also she may require Iron supplementation. However
if there is no clinical response and/or if parents are very
apprehensive then as a last resort you can put her on
hormones for treatment of this condition. Q. Mrugaya is 29yrs.
old and is a primigravida – 14 weeks pregnant. Her Thyroid
profile done is as Antithyroid Peroxidase antibodies 1300
(>60 positive) We would be highly obliged if you could
guide us regarding any effect on fetus A. Your apprehension is quite
understandable. However I feel you need not panic. By and
large untreated and severe hypothyroidism only causes
clinical problems. Your daughter’s case doesn’t fit into
this area. She has already been diagnosed and has been put
on treatment. Therefore I feel this may not be a case of
termination of pregnancy. However the matter of concern is
maternal thyroid peroxidase antibodies. There is one study
that says maternal thyroid peroxidase antibodies during
pregnancy may be a marker of impaired child development. The
authors mention that After correction for possibly
confounding variables, maternal TPO-Ab during gestation was
found to be the most important factor related to the scores
on the General Cognitive Scale (odds ratio = 10.5; 95%
confidence interval = 3-34; P = 0.003). We conclude that
children of pregnant women who had elevated titers of TPO-Ab
but normal thyroid function are at risk for impaired
development (Journal of Clinical Endocrinology & Metabolism,
Vol 80, 3561-3566, Copyright © 1995 by Endocrine Society).
You can click on: As regards other complications
hypothyroidism affects about 1% of pregnancies. Clinical
presentation includes weight gain, fatigue, lethargy,
constipation and hoarseness of voice, thyromegaly and
delayed deep tendon reflexes. Untreated hypothyroidism
during pregnancy has been reported to cause miscarriages,
congenital anomalies and intellectual impairment in the
fetus and hypertensive complications in the mother.
Stillbirth, growth restriction and the Parkland hospital
investigators have reported maternal complications such as
anemia, preeclampsia, abruption and cardiac dysfunction.
These are usually problems of untreated hypothyroidism which
may not apply to your daughter’s case. Therefore the only matter of a little
concern is maternal thyroid peroxidase antibodies. I leave
it to you and your family to decide regarding decisions for
termination etc as this is where my limitations come. Q. I had a patient 28
year old G2P1L1 - 16 -18 weeks with previous LSCS (Breech
presentation) with Diagnosed SLE 6 months back CXR shows – hilar nonspecific
infiltration A. In this case, pregnancy may be
continued as the patient is clinically stable. Renal
function tests are advisable. The pregnancy should be
considered high risk and will require close observation for
possible complications. The literature mentions that currently, more than 50% of all pregnancies in women with lupus have a normal outcome. Outcome is best for mother and child when SLE has been controlled for at least 6 months prior to pregnancy. 7-33% of women with SLE have flares during pregnancy. Preeclampsia is a frequent complication of pregnancy in SLE, occurring in approximately 13% of patients. Preeclampsia is most likely in patients with antiphospholipid antibodies, diabetes mellitus, pre-existing hypertension or nephritis or a previous episode of preeclampsia. About 25% of women with lupus deliver healthy babies prematurely. Fetal loss (early and late) occurs in less than 20.
Q. I went through the invitation article at your site which mentions various recommendations. It says Body weight of a pregnant lady is important only for BMI calculation at first visit it is of no use thereafter but I feel PET shows excess weight gain and weight gain of more than half kilo in a week after 28 weeks may be an early indicator of PET. It also mentions improvement of cerclage is seen after 3 pre term deliveries but with the advent of higher end sonography machines and knowledge of predicting preterm labor by measuring cervical length is it justifiable to wait for 3 pre term deliveries. It also mentions that amniotomy should be reserved for cases where progress of labor is abnormal and simultaneously also mentions early amniotomy shows low LSCS rates if it is so why don't we use it in all cases and curtail the risks associated with LSCS? (Manisha Jhawar) A. I am quite happy that my article has evoked a few questions. I would like to make the following clarification in this regard. The article is about evidence based medicine in Obstetrics and Gynecology. The very basis of our endeavour of doing scientific medicine is to practice scientifically valid medicine, wherever available. In any disease, we first arrive at a few conclusions about diagnosis and treatment, based mainly on our intuition. Human mind has great ability to discern pattern out of nature, which it does very accurately most of the time. Also, at times, we draw incorrect conclusions, nonexistent relations etc, which is the reason why, human perception about an incidence may not be totally reliable, and should be verified in controlled settings, ruling out biased opinion of a human mind. When we started treating a given condition, many things were done which were correct, or probably correct according to the experts of the field. As our experience increased, many of these methods had to be changed or even abandoned. Many of our procedures, which may appear very logical, effective and the best to us now, may have to be changed in future. Then it's our duty to subject all our methods to strict objective scrutiny, however obvious they may seem now. Consider body weight measurement in antenatal visits. We regard increasing body weight as a good sign, and any deviation from accepted range of body weight increase as abnormal. We have been doing this, actually without checking. It has been shown that, despite normal body weight gain, pregnancies are at no less risk of complications, than a woman, without normal body weight gain. Similarly, the validity of cervical length measurements, and utility of Cervical encerclage has been revised in many studies. I recently read an article saying that, a good history is better than TVS in assessing the probability of a preterm birth. Many studies have shown futility of cervical cerclage in suspected or proven cases of cervical incompetence. We do so many cerclages, that our confidence in them has increased, (and our confidence without them has decreased.) Early amniotomy has been a part of O'Driscoll's active management of labor protocol, who thought, racing all the laboring women against each other is better for them than the traditional obstetric policy of 'watchful expectancy'. Their team has shown remarkable reduction in LSCS rate, which was not reproduced in subsequent attempts. So gradually, this strict timing of labor has again given way to milder, more patient approach, even in UK practice. I hope I am clear in answering the
doubts.
Q. I have read that when oral Progynova, even in higher doses fails to achieve a satisfactory endometrial growth, one can use estrogen patch. What is the trade name and dose schedule? A. Some patients who may not respond
well to oral estrogen may respond to transdermal patches of
estradiol.
Q. Ms X, 2nd gravida, has 14 weeks gestation has no complaints but has RBCs in urine [microscopic hematuria] at 8 wks she had RBCs in urine but her culture was sterile. She was advised alkasol, which she did not take. At 12 weeks her USG showed bilateral enlarged kidney [122mm length] and she had 6-9 RBCs and 2-3 pus cells, no cast no crystal. Consultation with nephrologist was done. He advised S. Calcium & 24 hr urine calcium --both were normal. Her S. Creatinine is normal, BP is normal and she is asymptomatic. What should be done further? Should she be given antibiotics or what else? A. This requires a proper work-up. It will be difficult to take a stand without actually examining the patient and reviewing the reports. I would like to get Koch's ruled out on the face of it. Please take some more opinions
Q. My two Patients Are on Inj. Heparin 5000 daily IV. Out of them one patient reaches pregnancy upto 20 weeks. What next? Stop heparin by which criteria? A. Please get uterine artery Doppler done at 22 weeks. If the diastolic notch has disappeared, you can stop. If not please continue till 36 weeks or till one week before intervention is planned.
Q. I have a patient overt diabetic controlled on metformin preconceptionally. Now she is 14 weeks pregnant. Sugars are well controlled. How do we go about in 3rd trimester? Can she be allowed to continue metformin during labour/LSCS? A. Traditionally Metformin is not used in pregnancy for tighter control is achieved with insulin. But Metformin being a group B drug it can be used in pregnancy if the situation so demands. However this decision should be jointly taken with the physician as diabetes management in pregnancy is always a team work
Q. I performed NDVH (bisection + morcellation) on a 48 Yr old obese P2L2 (No previous surgeries) non menopausal lady for likely adenomyosis. (Metromenorrhagia). Pre op uterine size ~12 wk. Pre op USS showed adenomyosis with normal adnexa. During the procedure, I did not suspend the vault to either uterosacral pedicle. I do not reperitonealize prior to vault closure. Four months have passed. She claims she
has had cyclical bleeding (menses - although only one pad
stained, for only one day) every month despite the
hysterectomy! HPE - confirms adenomyosis with chronic
cervictis. During first post op visit at 21 days, when she
claimed bleeding, no bleeding was found only healing vault
with vicryl remnants. She came next at exactly four months
after the operation with the same complaint of 'one day
spotting/staining'. I examined and found minimal bleeding at
the vault with a granuloma. I also advised a post op USS and
CA - 125. USS shows, absent uterus, with a right ovarian
cyst 5x3x3 cm with no internal echoes and no increase in
vascularity on Doppler. A. A remnant of uterine tissue following hysterectomy is a possibility. There have been some case reports suggesting this. However, in this particular case, it seems less likely to be the cause of the so called menstrual period which the patient is complaining of. Such a remnant should not cause this type of bleeding. If at all, a small part of cornu of the uterus has been left behind, it might just stay there. Very rarely, it can lead to a small swelling at one of the lateral angles of the vault, which may be palpable or seen on USG. It may cause some pain to the patient. I recently operated on such a patient who had a 3 cm swelling at the right angle of the vault. It could be removed laparoscopically; seemed like a fibroid arising from a uterine remnant. She presented with pain and the lesion was visible on USG. I feel, in this case, the bleeding is most likely, due to the vault granuloma. I suggest waiting for 2 months and if still she complains of bleeding then consider going for electro-cauterization of the vault granuloma.
Q. Could u tell me the levels of progesterone in saliva which is the cut off for risk of preterm labour? A. Salivary progesterone level assessment is NOT a good predictor of preterm labour as of now. However, the proposed use of salivary estriol measurements in detecting preterm labor was based on the belief that the adrenal gland production of dehydroepiandrosterone increases before the onset of labor, which results in an increase of maternal estriol. Unfortunately, maternal estriol levels show diurnal variation, peaking at night, and are suppressed by betamethasone administration, thereby decreasing the predictive value of salivary estriol in the detection of preterm delivery risk.
A. Angular pregnancy, a type of cornual pregnancy, is a rare obstetric complication that can be life-threatening. In this situation, the embryo is implanted in the lateral angle of the uterine cavity, medial to the uterotubal junction and round ligament. Angular pregnancy must be distinguished from interstitial pregnancy, in which the embryo is implanted lateral to the round ligament.
Q. A colleague of mine intends to perform tubal ligation on a patient who is 20 days postpartum. Is this technically as well as legally correct?? This is not the recommended time for postpartum TL neither does this fall into interval TL. Is it advisable to do this surgery? Please throw some light on this issue and oblige us. A. Postpartum TL is perfectly legal and indicated. However Postpartum Lap TL is not encouraged because of a high chance of failure and vascularity. Therefore it should not be done. But modified Pomeroy's method has no reason not to be done
Q. I’ve a case of twin pregnancy of 14 weeks gestation in which one twin has died at 11 weeks. She presented with bleeding PV now stabilized. She has two previous LSCS. Is it safe to take this pregnancy to term if possible? What would be the management and investigations needed to be done on a repetitive basis to know of impending DIC. NOW FDP IS normal. I ask this as i recently read in literature that when one twin dies early there are higher chances of abnormalities in the live twin. A. There is hardly any additional risk
to the surviving fetus if it is a dizygotic twin. If it is a
mono-zygotic twin then the surviving twin has a risk to its
own life, maximum in first 48 hours, after which the risk is
negligible. There are two other theoretical risks:
Q. I would like to
know the difference between a meta-analyses and systematic
review article
Q. I was reviewing the
topic of RPL. While reading the same topic from Speroff, I
came across following observations page 1086 of 7th edition
there is a table on Coagulation factors and fibrinolytic
factors. Of the factors that favour clotting when increased,
Plasminogen and PAI1 are the factors mentioned. Normally
Plasminogen is converted to Plasmin which dissolves fibrin
from the clot. PAI1 inhibit this conversion. I do not
understand how and why increase in levels of plasminogen
favour clotting?
Q. A local NGO wants to buy a lap TT set for holding Lap TT camp. There is no fixed Surgeon. They will be using volunteer from various hospitals. The set is meant for Lap TT only and for NO OTHER SURGERY. May I request you to suggest how to go for it?
Q. My patient has a
quadruplets of 17wks, she wants an assurance from me for at
least one live baby otherwise she wants these to be aborted.
What do I do? A. For the first patient offer a feto-reduction
explaining its complications. For the second - Just don’t worry IgG
has no meaning. It means she is immune.
Q. Mrs. x, primigravida
had oligoamnios at 26 wks gestation. Her IgG Rubella was 31.
She was lost to follow up. She underwent C. section at 37
weeks gestation at another place and the baby had cataract,
limbs attached ,no genitalia could be made out and baby did
not survive .This happened in April. She conceived in august
again. Her IgG titers were repeated and it was 62. What
should be done? A. IgG raised is an old infection. This
patient is immune from Rubella now. You need not worry or
bother about a high IgG. Just ignore it. Q. I have a 26 yr. old female with prior 3 first trimester losses. During workup only positive findings are raised homocysteine levels & MTHFR- positive heterozygous mutation. S.TNF-alpha levels rose (37.7; ref.=upto8.2pg/ml).I got her TNF-alpha done on suggestion of a senior who has benefitted by using LIT in these pts. Despite various references on the contrary. I have already put her on 5 mg. Folic acid O.D. How do I proceed further?
Q. When does supine hypotension come up in pregnancy, and what exactly is the mechanism? One source from RCOG (Teaching module) says 20 weeks, but I cannot understand how aorto-caval compression can come with a uterus that is still below the level of the aorta. Could you please clarify? A. You are absolutely right in your
perception. It has to be after 28 weeks and not earlier. Of
course it also depends on the stature and built of the
subject. In smaller ones it appears earlier BUT NEVER before
28 weeks.
Q. Mrs. Archana 25yrs
old G 3 P2 A 0 with LMP -1/9/08 EDD -8/6/09 A. There is no indication of doing
TORCH testing in this patient. Repeating it still more
irrational. Please ignore the TORCH results.
Q. I have a query
regarding the dose of hCG for ovulation trigger. On what
basis the dose is decided? A. I have myself tried to search answer to this many times. But have not been able to get a good response from my resources. One explanation which impressed me was if the dose of the primary ovulogen that you use is high, it is possible that the concentration of granulosa cells increase. This leads to increase in the release of inhibin causing a stunting of LH surge. In such situations to combat this dwarfed LH surge higher HCG may be required. This is the only explanation which made sense to me. Lest all others are speculative explanations. |
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