Clinical Queries

1. Post-Hysterectomy Diagnosis Of Leiomyosarcoma

2. TORCH test

3. GDM

4. Positive For HBS Ag

5. 24 Wks Pregnancy With Sudden Rise In BP 160/100

6. Hydatidiform Mole Coexisting With Fetus

7. False +Ve Pregnancy Test

8. Condylomata Acuminata

9. Very Interesting Prescription

10. Difficulties In Prescribing Calcium

11. 2nd Trimester Was Given Anti Rabies Vaccine For Dog Bite

12. Genital Herpes When She Was 8week Pregnant

13. PIH 150/110. BP Kept Rising Postoperatively

14. Mirena Be Inserted In Female 54 Years Old On Oral Hypoglycemic Agents

15. Hyperhemocystenemia

16. Significant Retroplacental Hemorrhage

17. Clomiphene Verses En-Clomiphene

18. Spinabifida With Meningocoele With Ventriculomegaly Second Trimester Abortion In A Subject With Previous Two LSCS

19. Recurrent Blighted Ovum

20. Anterior Vaginal Wall Cyst

21. Primi With Floating Head Not Given A Trial For Normal Labor

22. Galactorrhea In Otherwise Normal Pregnancy

23. HPV Vaccine

24. Using An IUCD For The Last 16 Years

25. Refractory RPL

26. Blocked fallopian tubes at the cornual ends

27. USG 10 days before shows a 6.3 week with 96 heartbeats per minute

28. Refractory Dysfunctional Uterine Bleeding

29. Prophylactic Cercalage

30. 10 Wks Live Preg With Partial Mole

31. Opinion Regarding Bed Rest

32. The Rational Of Giving Heparin Injection

33. Tranexamic Acid Be Used In Cases Of Threatened Miscarriage

34. Tuberculin Test Positive In Infertility

35. Methotrexate In Placenta Accreta

36. Paternal Lymphocyte Therapy

37. Atorvastatin In Endometriosis

38. LMWH or Standard Heparin

39. Possible Reason Of Cardiac Arrest

40. Taken I-pill and conceived in same cycle.

Q. 50 years old patient is subjected for TAH+BSO for big fibroid, mobile.(20 weeks pregnancy size).Histopathology report - degenerating fibroid, with occasional sarcomatous cells10-12 in number with hyperchromatic nuclei.------Any further management required?
A. As regards your query on a post-hysterectomy diagnosis of Leiomyosarcoma, different schools of thought but considering incomplete staging surgery in this case as the diagnosis was known only after HXP report and better survival rates of adjuvant radiotherapy in stage 1, radiation recommended.

Q. What is to be advised for a case of BOH if she is positive for IgG in the TORCH 10 test? Is Spiramycin prescribed for her if she is IgG positive for Toxoplasma? What is to be done if she is Rubella positive? Please explain.
A. Not at all. IgG is an old infection. Patient is immune. Don’t do anything. BTW there is NO INDICATION of doing TORCH in BOH

Q. I have a query on the one step diagnosis of GDM and the subset (majority) of clients with gestational glucose intolerance. We usually put the second subset on diabetic diet and follow up with FBS and PPBS. My question is, if the test at initial visit (say 8wks) suggests GGI, do I repeat a 75 Gms glucose test at 24-28wks or continue with FBS, PPBS monitoring alone throughout pregnancy?
A. I feel there is no need to repeat GTT. FBS, PP2BS should suffice. I am sure you must also be having a joint consultation with a physician for a medico-legal requirement. Glycosylated-Hb will give you a fair idea of glycemic control in last three months. It can be done accordingly.

Q. One of my antenatal patients is 20 weeks now. Her husband is found positive for HBS Ag, when he came for blood donation. She is negative for HBS Ag. Should I recommend Hb vaccine for her? Please clarify.
A. Yes indeed

Q. A pt. had bleeding p/v in 1st trimester (8 wks.). USG showed twin gest. With 1 fetus missed n 1 live. diamniotic.( chronicity not determined) Cervix short. At 11 wks. cervical stitch applied. Now she is 24 wks pregnancy with sudden rise in BP 160/100. Albumin 1 + prothrombin time 24 sec. control 24. C/0 severe headache. Can this be attributed to her 1st missed twin? What should be the plan of action?
A. This is not likely due to the vanished twin. Plan as any other severe PIH.

Q. A patient with PCOS who has conceived following drilling. She is 13 wks pregnant and is carrying a diamniotic dichorionic twin with one showing vesicular mole and another sac showing normal gestation. Presently there is no myometrial invasion. Beta HCG is elevated but no ovarian masses seen. What to do? I would like to continue this pregnancy. Kindly give ur opinion
A. Thanks for asking. This entity is now coined as HMCF (Hydatidiform mole coexisting with fetus). I would like to reply to you in a little detail. The natural history of pregnancy affected by HMCF is still unclear. Complications particularly malignancy are poorly defined. Although HMCF detected antenatally is terminated in most cases, optimal management protocol remains controversial. Some authors recommended immediate termination of pregnancy when the HMCF has been diagnosed because HMCF carries a higher risk of severe maternal complications and post molar trophoblastic disease. However, others have suggested that, in the presence of a normal karyotype demonstrated by amniocentesis, stable clinical course, pregnancy may be continued pending fetal maturation.

It is important to distinguish between complete and partial mole when a fetus coexists because these clinical entities are different with different perinatal outcomes and complications of pregnancy. Generally, partial mole is mostly associated with triploid fetuses that tend to die before the end of the first trimester and surviving fetuses after mid pregnancy are rarely encountered. On the other hand the fetus coexisting with complete mole is usually associated with normal karyotype and has a chance of survival. It was reported that before 28 week of gestation, the chances of survival are minimal and the chance for continuation of pregnancy beyond this point is 60 %. Of pregnancies which continue beyond the 28th week, a surviving child may be expected in 70% of pregnancies.

In this present case, risks of possible fetal malformation and subsequent malignant transformation of the molar pregnancy have to be explained to parents at the time of diagnosis. It is prudent that the decision to allow such a pregnancy to continue should be taken with the couple. If fetus is chromosomally normal and clinical course of pregnancy is benign, an expectant management until infant viability must be considered. At the same time the malignant potential of disease should be taken in consideration as it had been reported that HMCF had a more aggressive post evacuation behavior with a risk of post molar disease higher than a singleton mole.

It is unclear whether the greater risk of post molar disease is associated with a more aggressive behavior of the molar tissue or with delayed delivery. Recent reports had pointed out that an advancement of gestational age did not appear to increase the risk of developing a post molar disease. No reports had demonstrated that prolonging pregnancy to term would increase the incidence of invasive mole or choriocarcinoma. Some reports showed that chemotherapy was ultimately required even when termination of pregnancy was performed during early gestation of pregnancy.

It is my opinion that patients with HMCF may be allowed to continue pregnancy, provided that the fetal karyotype is normal and maternal complications can be controlled. However, it is necessary to have detail counseling for the couples that include complete discussion of maternal and fetal risk, particularly the possible requirement of chemotherapy or even hysterectomy. However the standard textbooks still recommend a termination. In case of a Medico-legal problem at a later date the judicial authority relies on the standard text-books. However if any colleague or some academic platform asks for information than adequate references can be quoted which are readily available.

Q. Two Nulliparous patients had bilateral PCOD. Were put on 3-6moths of tab Krimson-35 & tab Metformin (1000mg) x OD. Conceived spontaneously. Were UPT good positive, done after being overdue by 7 days. Were put on Folic acid, progesterone supplementation (200mg per vaginally) & continued taking Tab Metformin. Their TSH was normal. Both of them c/o spotting after 15 days. USG pelvis (TVS), done by sonologist, showed non-gravid uterus. Repeat UPT was negative. One of the patients got a serum beta HCG done to be doubly sure that there was no extra uterine pregnancy, but they corresponded to non-pregnant levels. Sir please guide me as to 1) Why was the UPT was +ve if she was not pregnant (HCG was not given). 2) If she was pregnant then what happened as she had only slight spotting 3) What should I do if similar patients come with +ve UPT in future

A. Serial HCG may not be necessary. Only a single HCG will differentiate between ongoing pregnancies related positive UPT and a false positive UPT due to LH rise of PCOS. HCG levels to be labelled as positive for pregnancy should be more than 5 IU.

Q. This patient presented with very severe pain now in OPD with such picture. Married life of 18 days. Both partners second marriage husband asymptomatic. What cud be the possible diagnosis? VDRl negative


A. This could be condylomata acuminata

Q. A Primigravida 14 wks preg. She had conceived after 3rd time IVF was prescribed by her IVF gynecologist to give Inj. Medroxy Progesterone acetate 150 mg) 1 amp/ weekly. Pt. came & asked me what to do? He approached me because I m a local Gynecologist. Sir advise me what to do?
A. That’s a very interesting prescription. Personally I am not aware of any such prescription however the rationale behind this seems to be providing early pregnancy support. I am aware of an article that came in 2009 where medroxypregesterone acetate was used to pre-treat decidual cells in some experiments for studying Thrombin and interleukin-1beta decrease HOX gene expression in human first trimester decidual cells: implications for pregnancy loss. However I am not aware of a direct clinical study for its use in early pregnancy support. It would therefore be better if you or the patient can directly discuss the rationale with the infertility specialist.

Q. I want you to clarify difficulties in prescribing Calcium. How much is the supplementary dose of calcium after menopause in non-symptomatic patient and for how many days.-Please guide also about Vit. D and added salts of tracer elements. Is there any problem- such as atherosclerosis-- stroke, IHD etc.?

A. The National Osteoporosis Foundation recommends that women under age 50 get 1,000 mg of calcium per day and women over age 50 consume 1,200 mg of calcium per day. This is more than the average 50- to 65-year-old woman consumes in her diet — usually about 500 mg/day or less. When trying to meet the daily requirement, remember that it’s the elemental calcium that counts -- and no supplement is 100% elemental calcium. Read the labels carefully. For example, calcium carbonate contains 40% elemental calcium. That means 1,250 mg of calcium carbonate provides 500 mg of elemental calcium (1,250 mg x 40%). S0 1500 mg calcium carbonate should be adequate supplementation. (500 mg tds)

For women under age 50, a daily intake of 400-800 IU of vitamin D is recommended. For women over 50, 800-1,000 IU of vitamin D is recommended, either through 15 minutes of sun exposure daily (without a sunscreen), diet, or supplementation.

Q. Pt in 2nd trimester was given anti rabies vaccine for dog bite, should she continue s pregnancy?

A. Yes it is safe to continue the pregnancy

Q. I have query my patient had genital herpes when she was 8week pregnant now at four and half months pregnancy her torch report is as follows. Please give your opinion

A. I would like to stress and re-stress that there is NO INDICATION of doing TORCH testing in any case in obstetrics. You can therefore stop doing this test with full confidence.

Q. A primi underwent LSCS for PIH 150/110.BP kept rising postoperatively 170/120. Patient had headache. What is the drug of choice to reduce BP.? Can MGSO4 be given for imminent symptoms, at what dose? Kindly advice on proper line of management

A. Yes indeed Magsulf is the drug of choice for preventing the fit. However as she has not yet thrown a convulsion, needless to say you should give the dose as 5 gms intramuscular 6 hourly for 24 hours and avoid the loading dose of 14 grams. Also, if you are following any other regime than there too no need of giving the loading dose.
As regards immediate control of BP, IV Hydralazine is the best. If however you are not familiar with it or have availability issues then sublingual Nifedipine 5 mgs is the drug of choice immediate postpartum. Labetalol is safe in pregnancy.

Q. Can Mirena be inserted in female 54 years old on oral hypoglycemic agents not attained menopause yet. Ultrasound shows submucosal fibroid of 1.4cm. Histopathology report shows disordered proliferative growth with no evidence of malignancy.

A. To your query on oral hypoglycemic agents: Levonorgestrel may affect glucose tolerance, and the blood glucose concentration should be monitored in diabetic users of Mirena.
As regards your query on submucosal fibroid: Mirena has also been shown to be effective in managing symptoms of other gynecological conditions, such as fibroids, endometriosis, adenomyosis, endometrial hyperplasia and premenstrual syndrome. However, Mirena is presently not licensed in USA to be used as a treatment for these conditions.

Q. You mention testing for Hyperhemocystenemia: How do you go about it? Isn't treating this perhaps a little easier than trying to diagnose (And do you test for any other inherited thrombophilia?) Also, with the APLA, you mention only ACA. Any reason to exclude Lupus Anticoagulant?

A. Point regarding hyperhemocystenemia, yes in clinical practice we too treat it without getting the levels done and all that is required to treat is 5 mgs of folic acid. But in this lecture there were post-graduate students also who needed to be told to complete their list in exams when enlisting investigations.

As regards LAC once you get ACA done it is not terribly important to get LAC done. I have given extensive explanation for this in both my books.

As regards the template of tests for inherited thrombophilia, no we do not get this investigated as again this is more academic. Treatment still remains the same. Therefore most critical is the history and USG of previous pregnancies.

Q. One subject of 12 weeks pregnancy had bleeding (blackish), USG: live fetus, cx length normal. She is bleeding minimal to moderate amount. Previous obst H/O similar bleeding pattern, was given aspirin, parenteral progesterone, but eventually she started bleeding profusely in 6th month of preg. And we had to terminate d preg. Her first antenatal scan also revealed bicornuate uterus with hemorrhage in 1 horn of uterus. Present scan shows significant retroplacental hemorrhage. Patient has no pain but bleeding persists.

A. In my opinion it is immunology at play in this subject of yours. I feel till that time as the fetus is thriving please do not worry. But guard the patient about the prognosis. Also please continue aspirin (and heparin) if started. I also suggest you take a good opinion of a sonologist to rule out a low-lying placenta.

Q. I am delivering a debate on clomiphene verses en-clomiphene. Can you give me some guidelines?

A. The en form is more active as we know. But the inactive form can increase reproductive toxicity of clomiphene. So it has been suggested to keep a break of one month after using clomiphene. This is because the relatively inactive form of clomiphene is said to be in circulation as it is poorly metabolized by liver. As a result of this it tends to produce reproductive toxicity. However the active en form is expected not to create this problem. As a result it is theoretically forwarded as a better form of clomiphene. However the literature is still not very clear on this as regards the evidence support.

Q. A G3P2 with previous two LSCS at 18-19 wks, on a second trimester USG has a spinabifida with meningocoele with ventriculomegaly. She wants a second trimester abortion for the same. What are the options in view of the previous two LSCS?

A. No problem. Handle it as any other II trimester termination

Q. I had a query regarding one of my patients and wanted your opinion regarding the same. I have one patient who is around 30 yrs., a doctor by profession has a history of recurrent miscarriage. She is G4P1L1A3. 1 FTND a healthy baby boy about 5 yrs. 2nd blighted ovum- D&C done. 3rd blighted ovum
4th blighted ovum - D&C done. Her investigations showed CBC, RBS, TSH, TORCH, Homocysteine, - all this normal. USG pelvis- normal. VIT D levels- slightly on lower side and started on cholicalceferol sachet weekly. Karyotyping - patient – normal. Husband balanced translocation of chromosome 1,4. Reports attached herewith. Could you suggest what is the best line of treatment for her so as to have a good outcome of pregnancy? Sir I am here in Saudi Arabia and the patient who is also practicing in Saudi Arabia would like to go to India if any interventional treatment needed.

A. Blighted ova are usually a sign of gem cell defect. Parental karyotyping may not yield any result as these are more likely to be normal. In such cases you have to wait for a spontaneous resolution. Just as their first child is normal and all well the next can be so. However early pregnancy support can help albeit marginally,

Q. I am having a patient with 6-8 cms huge anterior vaginal wall cyst. Please guide.

A. You need to rule out two points:
1. Is this part of a larger para-ovarian cyst which is seen below? Ultrasound abdomen pelvis will rule it out
2. Is it connected in any way to the bladder like a diverticulum? Urinary complains and gentle bladder sounding will rule it out.
Once this is done all that is required is vaginal excision

Q. Should primi with floating head not given a trial for normal labor. R there studies as to know the percentages?

A. Yes. One can give trial if the pelvis is adequate. All primis with floating head may not require a CS. I am not sure of percentages as statistics from published data show a wide variation.

Q. Does galactorrhea in otherwise normal pregnancy pose any problem to the fetus at term? Is there any indication for elective LSCS? What are the precautions to be taken?

A. Galactorrhea in pregnancy is normal. It is the preparations being made by mother- nature for the arriving new-born. No precautions are needed for a normal physiological event. It has no bearing on the route of delivery.

Q. In India -what ages in our family ladies should take HPV vaccine? 35 yrs. old ok? At what age to start-if at all?

A. It is not the is before first intercourse. As per Indian culture first intercourse occurs usually after marriage so it is thus advised - before marriage. Ideally as a broad policy it is advised to young adolescents who by-and-large are sexually not expected to be active in India.

Q. I have a subject 43 years old and using an IUCD for the last 16 years. She is gravida two and on inspection of cervix shows hypertrophy and gross erosion. A pap reveals an inflammatory smear. Lot of thick discharge, can she change and continue or it should be discontinued. How long can one use IUCD?

A. Please treat the infection energetically and completely. Please keep her on a follow-up of pap as is recommended at and after this age. There is no limit as such as to how long can one use IUD. It depends on the subject herself. But infections can be a bug-bear.

Q. I wonder if you can help me in managing a 5th gr, 1st preg conceived and progressed to full term, after those 3 losses between 6 and 8 weeks. All reports, including chromosome analysis of POC and that of both parents are normal. Last preg at 6 weeks we even started LMWH daily and aspirin, but could not continue. This time its 6 weeks and all well in US but had one spot once. Any suggestions? Patient is on folic acid with Vit B12, aspirin 50mg and Progesterone. She is reluctant to take daily LMWH, which is anyways not ethically indicated.

A. I agree. A refractory one on hand! 6 weeks losses are usually not-immunological and so Heparin and even aspirin are best empirical. I am sure you must have ruled out thyroid and insulin resistance.
In these subjects you have to wait for a spontaneous resolution continuing the current treatment as chances of spontaneous resolution is more than 70%. Coming to spotting of-course you must have ruled out a low lying placenta. So now the explanation to this: it is just an interaction between the protective cytokines and destructive cytokines. They fight at the level of vascular channels and so result in spotting. If the protective ones win, the bleeding will stop. If not the bleeding will continue for some time till whatever be the end-point. So, if the baby is thriving and there is no fetal bradycardia prognosis is unaffected by bleeding, irrespective of the amount of bleeding. You are just a witness in the war and can’t do anything more except weekly monitoring.

Q. I am 29 years of age and my wife is same age also. She has blocked fallopian tubes at the cornual ends and we were wondering if you could outline and tell us of any treatment for this and the potential costing. We have been married 10 years and have one son who will be 9 years old in April. My sperm count is normal and all other tests for my wife have proved normal just the tubes are blocked.

A. Thanks for asking. In my opinion ART (Commonly known as Test-tube baby) will be best for her. I am not into ART so will not be able to tell you about the costing involved.

Q. My wife has 2 month amenorrhea. USG 10 days before shows a 6.3 week with 96 heartbeats. After 10 days on today USG shows 6.3 weeks only with 66 heartbeats with regular g-sac and regular y-sac without complain of spotting PV. Now what treatment I do to save this pregnancy? I know chances of miscarriage are high but still what treatment? She is on tab. aspirin 50mg Spiramycin, Progesterone and HCG.

A. Thanks for asking. My full feelings are with both of you. As you have rightly said bradycardia is not a good prognosis. Among all the treatment she is on Spiramycin is most irrational and should be immediately discontinued. However beyond this you have very little that you can do. Continue weekly monitoring. If the conceptus is inherently not sick or is able to protect itself from the rejection process it would survive on its own. So for you and me at this stage regular monitoring is the most we can do. Rest all other is supportive.

Q. It might be weird of me to write to you, but I have found your write-up about Dysfunctional Uterine Bleeding and it was very interesting for me. I am located in Poland and my fiancé has a gynecological problem that is baffling doctors around here and no one was able to provide a conclusive diagnosis. Therefore I am looking for sources of knowledge outside.

A. Thank you very much for asking. It seems your fiancée may need a thorough clinical and endoscopic workup. I suggest you to contact good doctors at some advanced center there itself. It should solve the problem.

Q. About a month ago I had posted a query about a woman with recurrent pregnancy loss. The recent developments are that she has high TPO ab level, CT is negative. She has been put on thyroxin. Presently she is 17 weeks gestation. As of now there is no e/o cervical incompetence. I would like to know whether to go ahead with prophylactic cercalage. Is there need for quadruple screen?

A. I feel Thyroid peroxidase test does not help much. We clinicians are giving over importance to Thyroid in recurrent pregnancy loss.

As regards encerclage I feel it will help only if these were live disasters lest it won’t. However if you feel prophylactic encerclage will give you a peace of mind then there are some schools of thought who believe that the disadvantages of such encerclage is so less that they can be taken even if not fully indicated. In my clinical practice over a period of years cervical encerclage have reduced to a meager 20% from what I was doing before twenty years.

Q. Pt with 10 wks live preg with partial mole (increased vascularity and a mass adjusted to sac on USG). Surprisingly her β-HCG is only 10000! What should be the next step? Can the diagnosis be wrong or her β-HCG report is wrong? Is there a role of methotrexate prior to suction evacuation?

A. The β-HCG report may not be wrong. In case of a partial mole, the level of β-HCG is often within the wide range associated with normal pregnancy and the symptoms are usually less pronounced. For these reasons the diagnosis of a partial mole is often missed clinically and made from subsequent histologic assessment of the abortive material.

The outcome of a partial hydatidiform mole after uterine evacuation is almost always benign. Persistent disease occurs in 1.2% to 4% of cases; metastasis occurs only in 0.1% of cases. Therefore there is no reason to give methotrexate.

Q. If you remember when my daughter had her first missed abortion & her CMV IgM was + & avidity was high I had asked your advice about Tt but your suggestion was not to give any medication. I followed your advice. This was on 1-6-2013 and her LMP is now 22/10/13 & pregnancy test is positive.
For the last 3 months I have kept her on combination of L-methyl folate, Pyridoxine and Methylcobalamine. She is still taking the same. What is your opinion regarding Bed rest. She is office going 5 days a week. No strenuous work but continuous sitting is needed. Her husband drives her to office. Role of Aspirin, Should I give her? Role of NMP and HCG injection, If so in what dose?

A. As per my opinion in a subject with one anecdotal miscarriage all that is required is a 5 mgs of folic acid daily. This is not a case to start any extra treatment. However in recurrent miscarriages one may give treatment as per the cause.

I would appreciate if you can email me her current USG report so that I can know exactly what is happening and be of best use to you.

Hormones like HCG and progesterone in this case are empirical. If you are very tense you may give for your peace and satisfaction. How much are they of benefit is difficult to say. Aspirin likewise is also not indicated in this subject nor is Heparin.

Q. I wanted to know what is the rational of giving heparin injection in 1st trimester abortions and in what dose should it be administered s/c. Doctors are giving it daily s/c for 3 months continuously in 1st trimester abortions,

A. I am indeed thankful to you for asking this query. If they are late first trimester missed abortions then these could be immunological. In that case heparin has a role. For how long and all is in itself a full lecture but only for three months needs colour Doppler report for backup. In some of these cases where at 12 weeks there is no diastolic notch and PI is < 1.7 I do stop heparin. So if that is being followed then the practitioners are justified.

Q. My query is can tranexamic acid be used in cases of threatened miscarriage and antepartum hemorrhage? I have encountered a couple of patients for whom this was used to stop the bleeding for threatened miscarriage. Is there any evidence for its use??

A. Thanks for asking. No there is no evidence of efficacy of tranexamic acid in threatened miscarriage. In fact if you go into the etiopathology of these two conditions you too will be convinced of the fact that there can be no rational for its use too. However I am not discounting the results that you have achieved. This could be more coincidental.

Q. If Tuberculin test positive and patient is labelled at latent TB also has moth eaten appearance of uterine cavity in HSG , is a case of Primary sterility 4yrs. Our Government policy says not to treat. Whereas every other foreign website mentions latent tuberculosis as seen by Tuberculin test if positive should be treated by the regime advised on these sites for t/t of latent TB. What is your opinion?

A. Though the appearance described by you is rare to find and in combination with tuberculin test nearly clinches the diagnosis. But this too is circumstantial. If your patient load is very high and unable to wait for the confirmatory evidence one can start treating. But still I would consider this as by and large empirical

Q. is there a real benefit of keeping methotrexate in placenta accreta? If so what is the dosage schedule. What is the best time to do hysterectomy in placenta accreta: At the time of LSCS or after waiting for some time thinking in a view to reduce its vascularity?

A. The folate antagonist methotrexate has been proposed as an adjunctive treatment for placenta accreta. Some have opined that after delivery, the trophoblasts are no longer dividing, thereby rendering methotrexate ineffective. Small studies have reported mixed results. Although uterine conservation was achieved in one study, most of the patients subsequently developed postpartum hemorrhage that required hysterectomy. Other reports documented failure of treatment with methotrexate. Thus, there are no convincing data for the use of methotrexate for postpartum management of placenta accreta.

Generally, the recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ because removal of the placenta is associated with significant hemorrhagic morbidity. However, this approach might not be considered first-line treatment for women who have a strong desire for future fertility. Therefore, surgical management of placenta accreta may be individualized.

There are reports of an alternative approach to the management of placenta accreta that includes ligating the cord close to the fetal surface, removing the cord, and leaving the placenta in situ, potentially with partial placental resection to minimize its size. However, this approach should be considered only when the patient has a strong desire for future fertility as well as hemodynamic stability, normal coagulation status, and is willing to accept the risks involved in this conservative approach. The patient should be counseled that the outcome of this approach is unpredictable and that there is an increased risk of significant complications as well as the need for later hysterectomy. Reported cases of subsequent successful pregnancy in patients treated with this approach are rare. This approach should be abandoned and hysterectomy performed if excessive bleeding is noted.

Q. My question is about role of Paternal Lymphocyte Therapy. What is its role in treatment of RPL And also the evidence (or lack of) behind it.

A. Right from first I said nearly two decades ago and I was proved right that paternal Leukocyte Antigen therapy was not only irrational but downright dangerous. Please don't use

Q. I have been using atorvastatin 20mg per day in all degrees of endometriosis with 70% relief in dysmenorrhea and infertility i.e.70% % patients were relieved. I started using after I read the good results on mouse trials. How should we carry this forward?

A. What exactly is your end-point to be achieved? Do you want to publish your data? Do you want to share your data? Do you want the world to know about your work? All of these or none of these? My answer will depend on your reply. You can start documenting your results right away statistically as well as through visuals as the original paper that you have sent me have done. The direction can be given as per your desire what you want to do with the data.

Q. 27yr old lady presented with 6wks pregnancy. H/o 3 missed abortions between 6to12wks. No live issues. Investigations show:
B group: A+
TSH: normal
PROLACTIN: normal RBS normal
TORCH: normal
VDRL: normal
LAC: normal
ACA: normal
APA: normal
She is very anxious and doesn’t want to miss this pregnancy. May I start LMWH or STANDARD HEPARIN? At what dose? Kindly guide me.
A. Heparin LMWH has no advantage over regular Heparin except the latter being much cheaper. The dose is 5000 IU of heparin daily from diagnosis of pregnancy subcutaneously till 36 weeks.

Q. I did LSCS of primi with normal antenatal history on 4th Nov she was 2 days postdated and developed spontaneous labour pains .I admitted her and watched for POL. HER Hb and blood sugar at the admission was normal, cx was not favorable, FHS was 150/minute regular. After 4 hours of good uterine contractions cx findings was almost same and FHS became irregular. I talked to the relatives and advised them for LSCS after half an hour they gave consent add we went for LSCS with qualified team of surgeon, anesthetist, pediatrician and gynecologist under SA. Everything was well till baby came out, as soon as baby delivered she went into cardiac arrest, immediately we gave CPR and she was intubated and IPPR was given her heart came back but respiration was gasping so we talked to the relatives and arranged for shifting to tertiary care center which is hardly 300 meters away from my center. As soon as I closed the abdomen ambulance came. I accompanied the patient in ambulance with ambu bag in 5-10 min after surgery she was on ventilator. I remained there for 3-4 hours and regularly visited 3-4 times a day and whenever they called, phoned to ICU and consultants every 2-3 hours. She had normal echo but x ray chest after 4 hours showed pulmonary edema which cleared after 2 days but she developed hypoxic brain injury remained unconscious on tracheostomy. They took away the patient and kept her at home after that I do not know the progress of patient now they complained in state medical council and I have to present in front of council on 12th July now I want your help and expert advice as what could be the possible reason of cardiac arrest.

A. Thanks for asking.

In this case what will be critical will be your records.

It would be excellent if your records show that there was irregularity in FHS and the relatives took time in consenting for the LSCS.

I feel if your records should show a noting every time you visited the NICU or talked with the doctor on duty telephonically. This will be important as it will show that you did not leave the baby just like that.

Further to this if you have an Fetal CTG or Colour Doppler record that would further fortify your case.

I would like to bring to your kind notice that if you do not have these notings or recordings please do not try to insert anything now or delete anything. If a copy has already been given to the patient or the Council of your records please do not make any changes. If not you can attach a separate paper which gives the details of your visit to the NICU and phone calls made there. If your records are already submitted you can prepare a separate paper and carry it with you to the council and request them to take a cognizance. Even the NICU doctor can be requested to corroborate your contention.

Now the most important point comes with text-book references. They will be considered most valid. You require finding relevant references from standard text-books showing that such eventualities can occur and these are known complications. FHS irregularity and asphyxiated baby is what you will have to work on. Also delay in giving consent and its effects on an asphyxiated baby is also to be shown on reference. Best would be text book references. If not, you can Google this or get it through (PubMed). This you will have to do on your own as you only now the details of the case thread-bare. Once fortified with all these documents I think you can face the inquiry without difficulty.

Now on a side matter but still very important. Please do not be afraid. Fear is our biggest bug-bear. Face the council and patients boldly. At the same time please also accept that in a democracy they have a right to complaint and we have a right to reply. This is important as it will break you anger and bitterness towards the patients and relatives and so can handle the inquiry more dispassionately and objectively.

Q. if a patient has taken I-pill (morning after pill: levenogesterol75) and conceived in same cycle. Should she continue d pregnancy? What are the chances of effect to fetus?

A. Theoretically there is a risk of virilization of the female fetus with progesterone. But the androgenic activity of this compound is very feeble. In clinical practice too there is no adverse effects seen. i therefore in my personal opinion feel that there is no need to panic and pregnancy should be allowed to continue