Clinical Queries

  1. Hospital infection
  2. Adolescent hypermenorrhea
  3. Splenectomy and pregnancy
  4. Perimenopausal asymptomatic fibroid
  5. Vasculopathy
  6. Spontaneous closure of small nick
  7. Family H/O cervical incompetence
  8. CIN
  9. Fibroid with Jaundice for medical termination
  10. Eating bee pollen for health in pregnancy
  11. Management of monochorionic pregnancy
  12. Histopathological types of endometrial carcinoma
  13. What is obstetric village
  14. Folinic acid in gtds
  15. Adolescent hypermenorrhea
  16. Maternal thyroid peroxidase antibodies
  17. SLE in pregnancy
  18. BMI calculation and PET
  19. Transdermal patches of estradiol
  20. Heparin: When to stop
  21. Remnant of uterine tissue following hysterectomy
  22. Levels of Progesterone in saliva for pre-term labour
  23. Angular pregnancy
  24. Postpartum TL
  25. One of the twin dead
  26. Difference between meta-analysis and systematic review
  27. Diabetic pregnancy controlled on metformin
  28. Instruments Required For Lap TL
  29. Cause Of Pyrexia
  30. The Dose Of Betamethasone
  31. Quadruplets Of 17wks
  32. IgG Rubella
  33. Hyperhemocystenemia
  34. Supine Hypotension
  35. HCG For Ovulation Trigger

 

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:
• Atypical Squamous Cells: Unknown Significance (ASC-US) or Cannot exclude HSIL or high-grade changes (ASC-H)
• Low Grade Squamous Intraepithelial Lesion (LSIL)
• High Grade Squamous Intraepithelial Lesion (HSIL); one subcategory: "with features suspicious for malignancy"
• Squamous Cell Carcinoma

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.
CIN I - the affection of the basal 1/3rd of the epithelium and is also labeled as mild dysplasia. It is equivalent to a low-grade squamous intraepithelial lesion (LGSIL) identified by a Pap smear.
CIN II is affection of basal 2/3rd of the epithelium and is also called as moderate dysplasia. It is equivalent to a high-grade squamous intraepithelial lesion (HGSIL) found in a Pap test.
CIN III is affection of the entire epithelial layer and is also labeled as severe dysplasia. It is also equivalent to a high-grade squamous intraepithelial lesion.

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
A. There is no contraindication as such for use of this drug in this condition but the manual says: Women with chronic medical conditions, including hypertension, severe hepatic or renal disease, and severe anemia, should be evaluated individually. For more information please click on to this link: http://www.medicationabortion.com/mifepristone/index.html#Contraindications

 

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 %
Platelet count – 4 Lakhs/cmm
Thyroid function – Normal
USG pelvis – normal (no features of PCO) ; USG done multiple times.

Her present investigation reports which I advised are as follows : (done at SRL Ranbaxy Labs)

Fasting Blood glucose – 90 mg/dl
PP Blood glucose – 107 mg/dl
Serum Insulin – 70.84 mU/L (normal)
Insulin (Post-prandial) – 280.98 mU/L (normal 1.7-31 mU/L)

Serum Prolactin – 5.61 (normal)
Serum LH – 4.55 (normal)
Serum FSH – 5.53 (normal)

Testosterone Total – 65.66 (normal range 10-40)
Free Testosterone – 1.61 (normal)
% free testosterone – 0.25 %

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.
(2) Tranexamic acid-Mefenamic acid TDS PC
(3) Drotin DS 1 tab sos
(4) Hematinics & B-complex vitamins

But her bleeding is only slightly controlled at present
Now, I started:-

(1) KRIMSON 35 once daily
(2) Metformin 500 BD AC
(3) PYRICONTIN-F once daily

Sir, I would like to know whether the following would be helpful:

(1) Testing for von-Willebrand’s factor?
(2) Can Pyricontin benefit her?
(3) Any other investigation/drug which might help or be better to manage this unfortunate girl?

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.
Now she is at 10 weeks gestation and I was managing her with only Folic Acid and supportive therapy.
Two days ago she had slight spotting.
The US showed a viable Intrauterine Pregnancy.
All her investigations for RPL including Karyotyping are NORMAL.

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.
Sir, Am I justified in starting the same even when APLA is Negative? Please share your thoughts.

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.
It is arguable that MCMA pregnancies are ‘uncomplicated’, as most have signs of chronic cord entanglement. A retrospective study of 30 MCMA twin pairs reported a total survival of 60%.(51) Two pairs died after 32 weeks. Of the ten twin pairs that died in utero, cord entanglement was documented in eight. The authors recommended elective delivery at 32 weeks. However, it merits comment that there are no comparative data available to inform objectively the timing, or method, of delivery in such pregnancies."

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.

Q. What is Obstetric Village?

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
Follows:
26/03/2011(7.00 pm) TSH 8.02 (0.4 -4.00)
29/03/2011(12 noon) TSH 5.495 (0.4 – 4.6)
FT 3 3.08 (2 – 3.8)
FT 4 1.08 (0.5 – 1.6)

Antithyroid Peroxidase antibodies 1300 (>60 positive)
Anti Thymoglobulin’s antibodies 1086.9 (>60 positive)
We have already started on Eltroxin 50/day 3 days back

We would be highly obliged if you could guide us regarding any effect on fetus
1) Of not starting Eltroxin in 1st trimester
2) Of thyroid antibodies crossing placenta affecting fetal thyroid adversely.
3) Any neurological deficit in the fetus
4) Any other abnormalities

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:
http://jcem.endojournals.org/cgi/content/abstract/80/12/3561 for reading the abstract of this article.

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
History of symptoms & Drugs: treated by Physician)
28/9/10 - Multiple small joint swelling , decreased weight approx. 7 kg in 2-3months, pain & difficulty in swelling , decrease appetite , not able to take chill food , weakness ,bleeding PR in past (July 10)

CXR shows – hilar nonspecific infiltration
Serum iron - 192 (70-180)
Ferritin - 17.4 (28 - 397)
TIBC - 272 (250-450)
Transferrin saturation - 70.5% (13 – 45 %)
ANA - 1.24 (> 1.2 - positive)
DS DNA ABS - 26.9 (>25 positive)
HIV Negative
PS for opinion - microcytosis + hypochromic + anisopoikilicytosis + macrocytosis +
TLC – WNL, Plat- adeq, Retic count - .7 %
T3 – 91 (60-200)
T4 - 7.5 (4.5 -12)
TSH - 1.22 (.30- 5.5)
Hb- 9.4
TLC – 4100
Plat - 1.93
BSL-89
Total proteins -7 (alb-3, Glb-4)
Urine - alb Trace rest WNL
Drugs received (Given by physician)
29/9/10 - Tab. Wysolone 10 mg tds for 1 month, tapered 16/10/10 - Tab . Wysolone 10 mg BD for 15 days
30/10/10 -- Tab. Wysolone 10 mg OD for 15 days
11/12/10 - pregnancy diagnosed. Wysolone 5 mg on alternate days till date
Patient is clinically stable now.
Patient reported yesterday for the opinion that whether to continue or not. What problems will come if continued? What I should advice?

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.
(Praveen Gopinath)

 

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.
Available formulations:
• Climaderm (Estradiol) ---Wyeth
• Estraderm (Estradiol)----Novartis
• Fempatch (Estradiol)---Parke Davis
• Climara (Estradiol)----3M Pharmaceuticals
• Progynova TS
These patches are available as 50 and 100 mcg patches. The dose could be 50 or 100 mcg per day as per the requirement on the same days as you would give oral Progynova.

 

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.
CA- 125 is 28 IU (Normal). My patient is expectantly waiting to see if her so called 'menses' comes again this month. What should i do if there is vaginal bleeding again this month?
I have formulated three options
- Vault biopsy followed by vault electrocauterization of raw areas/ granuloma,
- CECT / MRI ABDOMEN/ PELVIS.
- LAPAROSCOPIC OOPHORECTOMY/ ? B/L / ? CYSTECTOMY WITH VAULT INSPECTION.
Or should I do nothing and wait and watch?
Can a MICRO bit of uterine tissue be left behind? Would it survive hysterectomy? Why should it bleed at the vault?

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.

 

Q. What is angular pregnancy?

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:
1. The increased risk of malformations. This too is for mono-zygotic twin. It is attributed to the FDPs released from the dead fetus crossing over to the surviving twin through vascular communications in the placenta
2. Coagulation failure in the mother. Both of these are theoretical and on clinical practice can be safely ignored. However for medico-lea gal reasons you can get her Coagulation profile repeated say every monthly. We have handled many such cases and have encountered no such problems ever. Even literature calls these as theoretical risks

 

Q. I would like to know the difference between a meta-analyses and systematic review article
A. A systematic review is a literature review focused on a single question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine. A systematic review is a summary of research that uses explicit methods to perform a thorough literature search and critical appraisal of individual studies to identify the valid and applicable evidence while a Meta analysis is any systematic procedure for statistically combining the results of many different studies. It is an analysis resulting from combining the results of diverse statistical studies

 

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?
A. It is true that Plasminogen is converted to Plasmin which dissolves fibrin from the clot. And it is the imbalance of clotting and fibrinolytic mechanisms which is responsible in some cases of RPL. The 7th edition of Speroff mentions the same on page 1086. Then there is a table on coagulation factors and fibrinolysis factors. The table is in 2 parts: first relates to clotting and second to fibrinolysis and each part is subdivided in to 2. It appears that there is a typing error there. In the second part also they have mistakenly used the word clotting instead of fibrinolysis. So the title under which Plasminogen and PAI 1 are listed should be factors that favor FIBRINOLYSIS when increased instead of factors that favor CLOTTING when increased, The factors related to clotting have already been mentioned in the first part of the table. So it is just a typing error in the book: somebody just copied and pasted the title and did not change clotting to fibrinolysis hence, this confusion.

 

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.