|
1.
Instruments Required For Lap TL
2. Cause Of Pyrexia
3. The Dose Of Betamethasone
4. Quadruplets Of 17wks
5. IgG Rubella
6. Hyperhemocystenemia
7. Supine Hypotension
8. HCG For Ovulation Trigger
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?
A. Instruments required for Lap TL
Item Number
1) 10 mm telescope with ring applicator (Either Karl Storz
or KLI) 1 or 2
2) 10 mm trocar with cannula 2
3) Veress needle
4) CO2 insufflators with CO2 gas cylinders 1
5) Light source for laparoscope with a spare bulb 1
6) Fiber-optic cable 1
7) Falope rings
8) Sim’s vaginal speculum 2
9) Anterior vaginal wall retractor 2
10) Valsellum 2
11) Uterine manipulator 2
12) Scalpel with Surgical blades 2
13) Sponge holding forceps 2
14) Bowls for antiseptic solutions 3
15) Needle holder 2
16) Curved Cutting needles 4
17) Tooth forceps 2
18) Mayo Scissors 2
19) Chromic Catgut no 1-0
20) Stainless steel trays to hold these instruments and for
rinsing in-between 2 surgeries
21) Plastic Cidex container with cover
22) 5 and 10 cc disposable syringes and 22 G needles
23) Gauze pieces
24) Sticking plaster/ leucoplast
25) Drugs- for pre-anesthetic medication( Atropine,
Phenargan, Fortwin), Lignocaine (for local anesthesia) and
emergency drugs and Antiseptic solutions( Betadine, Spirit,
Savlon)
Q. (1) Often, the eclamptic patients have
Hyperpyrexia which have poor prognosis. Sir, what is the
exact cause of this Pyrexia/ hyperpyrexia?
(2) Sir, presently Betamethasone is the preferred drug (RCOG)
for inducing Fetal Lung maturity. Sir, is there any change
of dose (higher doses) for the same cause?
A. 1. Hyperpyrexia in eclamptic women is a result of pontine
hemorrhage (other causes ruled out of course!). This is the
reason of pin-point pupils in such a complication and poor
prognosis too
2. As of now there is no change in the dose of Betamethasone.
I am aware of some discussion on this matter. However the
standard recommendation has not yet been changed
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?
2. The other patient primi with 12 wk pregnancy came for the
1st time with mild fever with rashes on face, neck and back
but not on abdomen & extremities. Her Rubella IgM was
negative but IgG is raised. 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?
A. If you have reasons to believe that these are autoimmune
losses then low dose aspirin and heparin combination will
help her. As regards hyper-homocysteine levels there is
nothing more that can be done. B12 addition can help but no
consistent results can be found. However we have reasons to
believe that even hyper-homocysteine acts through immune
channel, in that case, if you too agree, aspirin plus
heparin may help
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
OB/H 1st, (Nursing home) Normal delivery, of term male
child, who cried immediately after birth but within one &
half hours of delivery died. (Cause?) No hospital records
available, from, where delivery took place.
2nd again normal delivery, at term in the same hospital,
baby cried immediately, apparently normal, died within an
hour of delivery. Cause? (No hospital records)
She was seen for the first time by me in Feb. at about 26wks
of pregnancy. BP normal fundal height corresponding, fetal
movements & heart rate normal. All routine blood work up
within normal limits.
USG on first visit showed single fetus about 26wks size with
normal cardiac activity & movements, BPS10/10 but lateral
ventricle mildly dilated. blood flow studies normal.
Repeat USG on 18/3/09 -31 wks, oblique lie, lateral
ventricle which was reported dilated in earlier USG is
normal in this USG with normal blood flow.
TORCH Profile )On - (From her records)
On 7/1/09 ON 16/feb/09
TOXO _ IgM - 0.52 (<0.8) 0.5 (<0.9)
IgG - 4.32IU/ml (<6Neg) 2.29 (<27)
Rubella IgM -0.27 (<0.8Neg) 0.8 (<0.9Neg)
IgG - 56.76 ((<7-10/LNeg) 58.8 (<9)
CMV IgM - 0.45 (<0.8) 10.7 (<0.9)
IgG - 13.78(<0.8) 11.71 IU/ml(<0.45)
HSV IgM - 0.33 (<0.8) Combined 6.23 (<0.9)
IgG - 1- 0.19 (<0.8) 6.62 (<4.4)
2 -0.4 (<0.8)
A. There is no indication of doing
TORCH testing in this patient. Repeating it still more
irrational. Please ignore the TORCH results.
Also, Please let me know the exact dimension of lateral
ventricle
Q. I have a query
regarding the dose of hCG for ovulation trigger. On what
basis the dose is decided?
• Pts basic LH, No of follicles, Age of the pt, E2 levels,
BMI
What is the serum level achieved with 5000 IU of hCG ?
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. |