Q.1 I would like to know which parameters would be useful for monitoring whether beta HCG or Doppler ultrasound? (Dr Shilpa U M)

A.1 The term placenta accreta is used to describe any placental implantation in which there is abnormally firm adherence to the uterine wall. This condition complicates 1/2,500 deliveries and is rising in incidence. Abnormal placentation is associated with increased maternal morbidity and mortality from severe hemorrhage, uterine perforation, infection and loss of fertility. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Placenta Accreta should be suspected in all women with Placenta Previa.  In the majority of cases, Placenta Accreta remains asymptomatic until delivery.  Although bleeding prior to labour is not uncommon, it is more likely to be related to Placenta Previa than Accreta.  A definitive diagnosis of Accreta is not possible prior to delivery.  However, it may be possible to detect Accreta with Transvaginal ultrasound. HCG is a better marker. Inj. Methotrexate 1mg/ meter² in 4 doses alternating with Inj. Folinic and 0.1 mg/ meter²

Q. 2 I would like to know your opinion about use of aspirin, Lycopene & amino acid infusion in management of IUGR, oxygenation to mother as a part of management of IUGR. How should it be used? How often? Till what time?

(Dr Manisha Gadre)

A.2 Aspirin has lots of sense if given before IUGR sets in. You can also read about this on our website www.drpankajdesai.com. Lycopene and amino acid infusion are empirical. Oxygen is irrational

Q. 3 Unbooked, primi IUGR Rh -ve patient, came first at 32 weeks gestation. Husband B+ve, ICT –ve, Given Anti D 300 on 19/7/2008, Inj. Betamethasone given. As she had oligohydramnios, breech, low lying placenta and irregular FHS, Elective LSCS was done on 23/7/2008. Baby is Rh +.Do we need to repeat Anti D so soon after 4 days? (Dr Vibha Gupta)

A.3. We do not require repeating the Anti-D dose in this case. A repeat dose is not needed if delivery occurs within 3 weeks after administration of Rh-IG during antenatal period. Following an intramuscular injection of anti D Immunoglobulin, serologically detectable levels of anti-D are reached within minutes and peak between 72-84 hours. The half life of Anti-D immunoglobulin is 3 weeks but it may be detectable in maternal serum up-to 12 weeks, hence, it is recommended to repeat the dose-at 12 weeks.

Q. 4 I will be very glade to know your expert opinions on the following case.
Age- 32 yr. Primi USG- Single, live, intrauterine fetus of 11 weeks, Maternal- Bilateral ovarian cyst, Right possibly endometrioma 40 X 64 mm with one septum. Left possibly mucinous cyst of 102 X 117 mm, No Neovascularity at present, USG pictures are attached herewith:

My queries are:

a)     Are CA-125 & CE are of use as they may be raised with pregnancy too?

b)     Is MRI required?

c)      Does she need to undergo surgery at 16 week?

d)     If surgery mandatory, can she be taken for laparoscopy with the possibility of mucinous cyst.

e)     If surgery is deferred till parturition, then, how to follow up.

 

A. 4. Point wise reply:

a)     CA-125 AND CEA may not be of much use here as pregnancy itself may cause elevated levels.

b)     A MRI in this particular case may help in confirming diagnosis of the type of the cysts. However, it is not mandatory.

c)      This patient does require   a surgery at 16 wks as the R cyst is more than 10 cm in size. It is better to operate electively rather than in emergency situation in this case.

d)     In expert hands, she can be taken up for laparoscopic surgery. The evidence is not very clear on this issue. Cochrane review: There were no randomized controlled trials identified that compared the effects of using keyhole surgery for benign tumors of the ovary during pregnancy on maternal and fetal health. There was some evidence available from case series studies, but more research is needed on the potential benefits and harms associated with this new surgical technique in pregnancy. The practice of laparoscopic surgery for benign ovarian tumor during pregnancy is associated with benefits and harms. However, the evidence for the magnitude of these benefits and harms is drawn from case series studies, associated with potential bias. The results and conclusions of these studies must therefore be interpreted with caution. The available case series studies of laparoscopic surgery for benign ovarian tumor during pregnancy provide limited insight into the potential benefits and harms associated with this new surgical technique in pregnancy. Randomized controlled trials are required to provide the most reliable evidence regarding the benefits and harms of laparoscopic surgery for benign ovarian tumor during pregnancy.

e)     If surgery is deferred till post-partum, watch for symptoms suggestive of torsion or rupture. Carry out fortnightly USG to look for increase in size of the cysts. If symptoms appear or the cysts increase in size, a surgery is mandatory. However, I don’t think we should carry out conservative line of management for this patient. For cysts of 5-10 cm, one can follow conservative line of treatment but not for cysts larger than 10 cm.

Q. Post-operative Ca Endometrium (R.V. Bhatt Baroda)

 A female aged 37 years presented with DUB.She was non-hypertensive, non -diabetic and not obese. There was no family history of cancer. USG showed slightly bulky uterus. She did not respond to progesterone. She had two previous C-sections. Both children alive. Laparoscopic TL was performed. D&C was not done. She was taken for abdominal hysterectomy. Right ovary had 2-3 small cysts so uterus and right ovary were removed. Left ovary was preserved. Unfortunately, the histology showed endometrial carcinoma not penetrating into myometrium. She had a smooth post-operative recovery. 

Now the question is 

1 Should other ovary be removed?

2 Should she be left alone and observed?

3 Would chemotherapy /radiation helpful ? 

This question was sent to may authorities in the subject in the country and the consensus answer received was: 

We need to know the exact histopathological report of the specimen; especially the grade of the tumor.  If there is no evidence of myometrial invasion and the lesion is a well-differentiated, grade I tumor, the residual ovary need not be removed and no further treatment is required. However, the patient should be put on a close follow-up. If the uterine disease is grade II (moderately differentiated tumor) or grade III (poorly differentiated tumor), or there is myometrial invasion, the residual ovary can be removed surgically, not only to exclude a potential site of tumor metastasis but also to decrease the serum estrogen level and to restage the disease.  

            At re-laparotomy, pelvic lymphadenectomy and omentectomy with peritoneal sampling is recommended. Some oncologists, however, also think of post-operative radiotherapy as a good alternative to a repeat surgery. Any of the two options would be good enough. 

Other relevant opinions received were: 

·         If there is no myometrial invasion and grade of the tumor is of grade I, no further treatment is required. If the grade is III, the options are (a) Post operative irradiation (b) Laparoscopic staging, Node sampling and removal of the ovary and irradiation. (Sekharan – Calicut)

·         The pathologist should be asked for some more details. Even though the malignancy is limited to the endometrium only, the histological type, grade and area of involvement are important in our decision and follow up. If the lesion is papillary or clear cell type, of grade 3 or with area of involvement more than 2 cm , the patient should have lymphadenectomy. Otherwise I would do a laparoscopy, peritoneal cytology and omental biopsy and resection of remaining ovary and tube. In any case she should get the remaining ovary and tube removed to complete the primary treatment of ca endometrium. (Paily - Thrissur)

·         Unfortunate but happens. If possible please get ER & PR studies. Receptors will help deciding treatment. If positive an oopherectomy is essential. Also the grade of tumor is helpful. (Kurian – Chennai)

·         I would like to add the following points to the consensus opinion. (1) Since the risk of local recurrence ( vaginal vault) is more in endometrial CA, we should take vaginal smear from the vault at the end of 6 months and then every year. (2) We must do CA-125 estimation now and then repeat after 6 months and then every year for 5 years.

Q. Date of manufacture and expiry date is mentioned on all intra-uterine devices. (R. V. Bhatt – Baroda and Rupam Singh – Bokaro) 

I wish to know that after the expiry date of copper IUDs, does it affect its efficacy. Does the copper content of unopened IUD get less with the passage of time? OR the copper content of IUD gets reduced when it comes in contact with organic material 

The life span of an IUCD means the period of its maximum efficacy which is approved by a regulatory body like FDA. Regulatory approvals are generally based on effectiveness demonstrated in clinical trials but must await the sponsor's application and often lag behind the latest clinical findings. The effectiveness is based on the failure rate (pregnancy rate while using IUD). This is compared with the pregnancy rate of more established methods of contraception like implants (LNG-IUD) or surgical sterilization. The time span before which the difference in the pregnancy rate becomes significantly less as compared to these established methods is the life-span of IUD. 

 For e.g.:

Copper T 380 A, the intrauterine device (IUD), has now been clinically approved by the US Food and Drug Administration (FDA) to have a longer lifespan. Previously approved only for 3 years, the Cu-T 380-A is now approved for 10 years use. Throughout the T 380A IUD's 10-year life span, annual pregnancy rates are less than 1 woman per 100. The cumulative 10-year rate is 2.1 per 100 women at 10 years; no pregnancies were reported after year 8. This is comparable to the cumulative 10-year pregnancy rate seen overall with surgical sterilization -- 1.9 per 100 women. 

There is  some more information on this: 

The expiry date indicated on IUCD package indicates the date when the sterile packaging expires, not the date when the IUCD's effectiveness expires. IUCD should not be inserted after the expiry date is over, purely for sterilization purpose. It can be inserted even one day before the expiry date.
As long as the sterile package is intact, even tarnished or discolored IUD's are safe and effective. The copper IUD's may get oxidized while in package causing the surface to appear less shiny or discolored. This is not a problem as long as the sterile package is intact. 

Q. Is ARV Teratogenic? (Dr. Meenambal – Madurai) 

Q. What is POPQ classification of prolapse? (Jigar Mehta)

A. POPQ classification

Q.  High Uric acid and pregnancy complication (Roopam Singh – Bokaro) 

I had a patient with 34 weeks pregnancy with normal blood pressure but edema leg .On investigation she was found to have raised uric acid & urine alb 1+ ,with reactive fetus on NST. I called her with all fresh reports after one week . But one day before her appointment she had less fetal movement .On admission her blood pressure was 130/100 mm of Hg & urine alb was ++.For that Emergency Lscs was done & approximately 200 cc of retroplacental clots were found . My questions are as follows -

1.       Where did I fail in managing this case?

2.       What should be proper protocol for managing such cases of raised uric acid to avoid such emergency at odd hours?  

A. 

The rise in uric acid should not be seen in isolation. It is in fact a reflection of uncontrolled oxidative stress in this mother. Uric acid is the strongest reducing system in our body.  We all know that the entire genesis of PIH has a strong association with oxidative stress. As a result of this stress the mother produces different reducing systems so as to combat it. Thus uric acid is like a combat army that tries to protect the mother from the ill effects of the oxidative stress in this case resulting in PIH. Thus an increased level of uric acid means the maternal system is unable to control the oxidative stress therefore it produces more of protective system. Any where an increase in combative force is a sign of war. This increase in Uric Acid is a sign of a war in which the mother is producing more and more of protective substances (Uric acid in this case) 

                Therefore you have not gone wrong anywhere. This entire case is a result of a fulminant under-running PIH.  Her BP being 130/90 and not of severe levels could be explained by two possibilities:  

1)            Her accidental hemorrhage process was pulling the BP down and /or

2)            The protective mechanisms in the mother were keeping the BP low but were failing to prevent other complications like abruption.

                 Thus this case is a simple case of accidental hemorrhage following P.I.H. and in no way have you missed or are mistaken.

ARV AND TERATOGENICITY

I have a patient who had ARV(antirabic vaccine)around 8-9 weeks of pregnancy, following stray dog bite.

Baby was born with absent corpus callosum, retarded growth, and congenital heart disease. Girl is 4yrs old, no other abnormality in family h/o, drug intake, fever.

Could ARV cause this neurological defect?

I am not able to get any reference Expecting your opinion.

DR.MEENAMBAL Madurai.

REPLY:
 

Pregnancy and infancy are never contraindications to post-exposure rabies vaccination. Now more convenient and painless tissue culture vaccines are available, which can easily be administered in the deltoid region. It must be remembered that the anti-rabies immunization takes preference over any other consideration since it is a life saving procedure. The anti-rabies vaccines and the inactivated rabies virus do not have any teratogenic properties. These do not induce abortion and have no influence on the progress of pregnancy, mother-to-be or the fetus.