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Recent Queries
1.
Colour Doppler – Endometrium – Infertility
(Reply from Dr. Pratap Kumar)
2. Missed ectopic: negligence? (Reply from
Dr. Prakash Pawar)
3. Nonoxynol and prevention of STDs (Reply
from Dr. Purvi Patel)
4. Hemiparesis in ruptured ectopic pregnancy
5. Best mode of Delivery - Induction / LSCS
and when?
6. Recurrent bouts of PPH
Previous Queries
1. Obstetric OT protocol
2. Mitral Valve Prolapse in pregnancy
3. Teratogenicity of OC pills
4. Stopping Heparin
5. Evidence Based Practice In Preterm Labour Management
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Q. While treating
infertile couples, folliculometry when added with Doppler
study of uterine arteries has confused my mind. In some
patients we find good endometrium but absent diastolic flow
in uterines while in others, the flow is good but the
endometrium is poor. What is the prognosis in these pts and
what is the remedy for such situations. Which of the two
i.e. the endometrium or the blood flow is more significant.
(Dr. Pratap Kumar)
A. Usually poor endometrium will have
poor blood flow though the other way is not true, meaning if
the endometrium is good there need not be good supply.
However if the endometrium is persistently poor (less than 8
mm) in thickness at mid-cycle or beyond we need to evaluate
the endometrium for tuberculosis by Bactec culture and PCR.
Once this is ruled we need to stimulate the endometrium with
gonadotrophins or letrozole could be tried for few cycles.
It is important to take the Doppler flow properly to avoid
wrong interpretations. I found a nice article on this:
http://humrep.oxfordjournals.org/cgi/content/full/20/2/501 |
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Q. 35 year old
lady reported to a gynecologist’s OPD with c/o amenorrhea 1
month 10 days with spotting per vaginum. Urine Pregnancy
test was done by patient at home and reported to be
positive. The doctor without doing any clinical examination
(p/s or p/v) ordered for USG examination. The transabdominal
USG pelvis read normal sized uterus, with echogenic material
in the uterine cavity suggestive of RPOC. Both adenexa were
reported to be normal. Based on this report, the doctor
concluded the diagnosis to be Incomplete Abortion and did
evacuation under GA and prescribed post procedure routine
medication. The material evacuated was not sent for
histopathology. After 7 days, the patient reported again to
doctor with c/o bleeding p/v. She was then prescribed Tab
Dynapar one TDS and sent back again without clinical
examination and any investigations. The patient in the
meanwhile continued to have spotting per vaginum and after
about 20 days she developed severe pain abdomen while on
flight to Mumbai. On reaching Mumbai, she consulted a
gynecologist and was diagnosed as right tubal ectopic
pregnancy and was operated upon in emergency. The
histopathology report showed tubal pregnancy. Now the
patient is on her way to slapping a legal notice to the
doctor in the consumer code for negligence. How right is the
patients approach and how wrong was the doctor? What can the
doctor do now in her defence?
(Dr. Prakash Pawar)
A. Pt is absolutely right in complaining to consumer forum
[both under medical negligence & deficiency of service]. If
you want to defend the doctor then it will depend upon pt’s
complaint. [Unless somebody is guiding her, pt may give
importance to something that is not important from the case
point of view & therefore line of defence will depend upon
the allegations of the pt.]
If dr. receives the notice just deny do not give detail
reply. Only
allegations should be replied in short. Let the plaint
[complaint] come & then reply in detail.
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Q. I am an intern
preparing for the All India entrance examination. I have a
doubt regarding vaginal spermicides. About vaginal
spermicides, Novac (13th edition) states that Nonoxynol 9 is
known to reduce the risk for bacterial vaginosis and other
STDs including HIV. On the other hand, current OBGY
Diagnosis and Treatment states that recent evidence
indicates that spermicides containing nonoxynol 9 is not
effective in preventing cervical gonorrhea, chlamydia and
HIV infection. In additions its frequent use has been
associated with genital lesions which may be associated with
increased HIV transmission. Shaw also states that
spermicidal agents alone can't prevent spread of HIV.
As u see, this is all very confusing. I searched in
E-medicine which again says that it is protective against
STDs. Please tell me what is the recent belief about
nonoxynol - whether it reduces risk or doesn't or actually
increase the risk of STDs including HIV?
(Dr. Purvi Patel)
A. The recent evidence is convincing that frequent use of
N-9 does not reduce the risk of infection by HIV and may, in
fact, increase the risk by causing disruptions and lesions
in the ano-genital mucosal lining. In the case of rectal
use, even the single use of a low dose of N-9 may increase
the risk of HIV infection by causing disruptions and lesions
in the rectal mucosal lining. N-9 should not be used
rectally. It is unclear whether N-9 products, when used
vaginally in small doses and infrequently, increase the risk
of HIV transmission and acquisition. Products containing N-9
should not be promoted as a primary means of contraception
in women with the potential for frequent usage. Products
containing N-9 should not be promoted as an effective means
for the prevention of HIV or STIs. For the prevention of
STIs, including HIV, it is best to use a condom without N-9.
However, a condom lubricated with N-9 is better than no
condom at all. The protection provided by the mechanical
barrier of the condom would appear to outweigh the potential
risk of the N-9, at least for low frequency of use and
dosage. The data on the ineffectiveness of N-9 as a
microbicide serve to further reinforce the importance and
urgency of research on the development of other possible
compounds as microbicides. Cochrane database: There is no
evidence that nonoxynol-9 protects against vaginal
acquisition of HIV infection by women from men. There is
evidence that it may do harm by increasing the frequency of
genital lesions.
There is good evidence that nonoxynol-9 does not protect
against sexually transmitted infections, and there is some
evidence that it may be harmful by increasing the rate of
genital ulceration. As such, this product cannot be
recommended for STI prevention.
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Q. MRS XYZ, age 23,
married since 4 months came with acute abdominal pain,
giddiness since 8 days & left hemiparesis since 1 day. USG &
clinical diagnosis: ruptured ectopic pregnancy on R side.
O/E: Power in both left upper & lower limbs was grade 0.
Patient was operated for ectopic pregnancy & has recovered,
but hemiparesis hasn’t improved. MRI of brain showed infarct
in the R temporal lobe. Heparin therapy was given for 5
days. What could be the cause of hemiparesis in ruptured
ectopic pregnancy & any such cases reported or any
references in this matter?
A. It is difficult to take any stand on this matter till we
get full details of this case as it is a very unusual
presentation.
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Q. G4P3+0, 25 yrs
old first and second were full term normal delivery, third a
preterm delivery at 8 months. She was admitted as 31 weeks 2
days pregnancy with PROM on 6th Sep. History of leaking
since 12 midnight. She was an unbooked case, not in Labour.
She was given injection Betamethasone 12 mg IM given 2 doses
at 24 hour interval (6 Sep - 12:30 pm, 7 Sep - 12:30 pm).
EFW was 1650g. USG reveals no congenital malformation. AFI
was 2. What is the best mode of Delivery - Induction / LSCS
and when?
A. Induction or augmentation as per the
condition of cervix - if already in labour - augment if not
induce. This should be after 24 hours of Betamethasone.
However prognosis should be guarded and explained to the
relatives. Needless to say the baby will require an NICU
care
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Q. A young primi
presented with sec PPH after 20 days of post c/s del, After
exploring uterine cavity & on USG uterus was found to be 10
wks & empty cavity except for slight blood collection was
treated conservatively &discharged after one wk. After 10-15
days she reported back with severe bout &needed 2units of
BT. After 1wk she had one more severe bout .On Colour
Doppler a highly vascular area 9.5x6.5 mm was seen on the
lower segment over the scar area S. beta HCG negative. With
provisional diagnosis of placental polyp D&C was done. Only
blood clots removed& fresh bleeding was controlled with
difficulty. Progesterone was started 2x3/day without any
gain. Bout recurred. Doppler showing the same picture. One
injection of methotrexate I.M. was given but no improvement.
Repeatedly she needed BT after a gap of 1mnth with
persistent bleeding tab Methotrexate 2.5 mg 1x3x7days was
given. Now she is still bleeding after 4 months of delivery
the patient and her relatives are requesting for
hysterectomy. Should I go ahead? Or would local resection
help?
A. A similar case took place at Bhilai
some time back. I am sending you the details and that will
solve your query:
Smt. S.S. Aged 26 years Unbooked primipara was admitted to
Jawaharlal Nehru hospital & research centre, Bhilai, on
9/7/1997 for repeated bouts of fresh bleeding per vaginum on
and off of 3 months duration, Following lower segment
caesarean section done for prolonged second stage of labour
at a private nursing home. She had her second bleeding
episode (approximate blood loss 600 ml.) within 6 weeks of
LSCS, after uneventful post-operative stay for 8 days. She
received one unit of compatible blood along with other
conservative measures at the same hospital. Third and fourth
bleeding episodes were more sudden and severe (total blood
loss 800 ml.). Patient received two units of compatible
blood and underwent dilatation and curettage at the same
hospital. The tissue obtained for histopathological
examination was not significant. Hence she was referred to
this hospital for further investigations and treatment, when
she had another bout of fresh bleeding.
On examination Patient was anemic, Pulse rate 130min., Bp
110/80 mm of mercury, CVS examination: tachycardia and
haemic murmur over pulmonary area Respiratory system normal.
Per abdomen examination: transverse healthy scar of lscs
present, Ps examination: cervix and vagina normal, clots
were removed from vagina, Uterus appeared bulky, well
involuted, mobile. Both fornices were free
Laboratory investigations Hb 5gm/dl, Blood group 'O' rh +ve,
Bleeding time, clotting time, prothrombin time normal,
Platelet count 2,40,000/- cmm. Serum total protein 5.9
gm/dl. (Albumin 4.4 gms/dl), Blood urea, creatinine,
glucose, serum electrolytes normal. Fibrin degradation
products 10 microgram/ml. Urine analysis normal, culture
sterile. ECG showed sinus tachycardia, ski gram chest showed
globular heart, Serum chorionic gonadotropin normal 7.8 miu/
ml, Urine for gravindex test negative, Pelvic USG showed
normal findings, no focal lesion in uterus seen.
She received total 8 units of blood, supportive therapy and
put on progesterone, hematinics, and antibiotics. Packing
was done as temporary measure with roller gauze during
bleeding episodes. In spite of the above measures, patient
went into severe oligaemic shock following sudden bout of
torrential bleeding. She was resuscitated and decision was
taken for abdominal hysterectomy. Under GA, abdominal
hysterectomy was done. Cut section of the uterus showed
small polyp arising from the fundus of the uterus.
Histopathology confirmed fibromyomatous polyp, patient had
speedy uneventful post-operative recovery and was discharged
on the 8th day after surgery. On follow-up after one month
she was well.
I am sure this experience will help you solve your problem
case.
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Q. I would like to know whether any
Obstetric OT protocol is there which states all facilities
that should be present where LUCS is to be performed. I am
worried that if any mishap occurs I'll be left out alone to
face the consequences.
(Dr. Montila
Ghosh)
A. Please
click on the following link:
http://www.iimahd.ernet.in/faculty/Tool%20No.3%20Data%20collection%20format%20for%20public%20sector%20CEOC%20facilities.pdf
I am sure this will help you
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Q. I had my first delivery a caesarian
section on March 13th 2007 but the baby died due to Total
Anomalous Pulmonary Venous Return (TAPVR) on 80th day. I
have mild MVP (Mitral Valve Prolapse). Immediately I
conceived and give birth to a healthy male child on March
5th 2008. He is quiet fine and healthy and now in 18th
month. Now I am in 2nd month pregnancy (17th July 2009 LMP).
How far it is suggestible to continue my pregnancy?
A. Mitral valve prolapse is a relatively common
condition affecting females. Usually women with MVP
tolerate the physiological changes of pregnancy well. In
fact, some women feel symptomatically better during
pregnancy due to the hormonal changes of the pregnancy.
You can very well continue this pregnancy. However, in
view of the first child being affected by TAPVR, it
would be advisable to undergo fetal echocardiography at
22 weeks. Other than that, the pregnancy should be
managed as per routine.
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1) A
patient has irregular periods, she came with history of 5
month amenorrhea, on exam she is 5month pregnant, but she
has taken oral contraceptive pills at 13-14 weeks of
pregnancy. She has 2 children last one is 8 yrs old. Please
suggest whether she can continue this pregnancy if she
wishes, whether fetus has any bad effect due to OCP.
2) One of
my patients, Mahua has 32weeks pregnancy she is on Aspirin
(75mg) at bed time, along with heparin (5000unit) sc
biweekly. Sir now please suggest what to continue and when
to stop these two. How to manage further? I want to do
elective LSCS at 37 or 38 weeks.
A)
1. There
are NO side effects or teratogenicity of OCPs so you need
not worry. For this you can also refer to our website where
we have latest article on Progestrone in Pregnancy uploaded
in I Have Recently Read section.
2. Please get her color Doppler done. If in the uterine
artery there is no diastolic notch, you can stop Heparin
right away. In case diastolic notch persists, please
continue Heparin till one week before you are planning
an intervention. As regards Aspirin you can stop like
heparin just one week before the LSCS (intervention) is
planned.
(Dr. Anju Parira)
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Q. Can you please give me your insights in
the recent advances in Preterm Labour Management?
A. I am
including herewith a series of current global thinking on
Preterm Labour management. I have also labeled the quality
of evidence on which these are based on. I am sure this will
answer your query:
·
C Advice on bed rest and abstinence from sexual
intercourse should be given to the high risk patient. In
selected patients, prophylactic cervical cerclage and
antibiotic treatment of women with bacterial vaginosis may
be associated with a reduction in preterm delivery. Grade
C, Level IV
C
Inhibition of preterm labour is contraindicated if delivery
is in the best interest of the mother and/or the baby.
Medical therapy used to inhibit labour should be
discontinued if labour progresses. Grade C, Level IV
A
Intravenous beta-agonists administered between 20 and 36
weeks of gestation are useful in achieving uterine tocolysis
in premature labour. Grade A, Level Ia
C To
reduce the risk of pulmonary edema, beta-agonists should be
administered intravenously with the minimum volume of fluid.
Beta agonists should also be used with caution in a woman
with multiple pregnancies. Grade C, Level IV
C
Beta-agonists should be administered via a controlled
infusion device. The infusion rate should be increased at
regular intervals until contractions have ceased or until
the maternal pulse reaches 130-140 per minute.
Oxytocin
antagonists may also be useful in inhibiting preterm labour
with potentially fewer maternal side-effects than beta
agonists. Grade A Level Ib
A
Maternal corticosteroid administration is beneficial in the
preterm patient to reduce the incidence of Respiratory
Distress Syndrome in the newborn. Grade A, Level Ia
A
Beta-agonists should be used to delay delivery for 24 to 48
hours in order to administer corticosteroids to promote
fetal lung maturity. Grade A, Level Ia
A
Maternal corticosteroid administration should be given using
two doses of 12 mg of Betamethasone/dexamethasone
intramuscularly 12 to 24 hours apart. Grade A, Level Ia
C
During intravenous administration of beta-agonists, maternal
pulse and blood pressure should be monitored at regular
intervals. A record of fluid balance should also be kept.
Grade C, Level IV
C
Delivery of the preterm fetus should be in an obstetric unit
with neonatal intensive care facilities. Fetal monitoring
during labour is important to ensure fetal well-being.
Grade C, Level IV
(Dr. Ameet Dhurandhar) |
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