With the use of Doppler in the clinical practice our focus on
the subject of IUGR has currently been shifted from fetal growth
assessment to the study of deep rooted functional
obstruction in the tertiary placental villous complex.
Increasing obstruction progressively increases the circulatory
resistance in the umbilical artery and decreases pO2 level in
umbilical vein. Both these events set into motion, a phenomenon
of a circulatory re-distribution, principally characterized by
reopening of ductus venosus sphincter and centralization of
blood flow modulated by chemoreceptors. The better oxygenated
blood goes towards the most vital organs brain, heart & adrenal;
while vasoconstriction limits the blood arrival at the organs
considered less indispensable like liver, kidney, lower
extremities, muscle and skin.
Recent studies in clinical and animal experiment
The redistribution of blood flow was extensively
studied in fetal sheep and primates by injecting radioactively
labeled micro-spheres. Hypoxemia and acidosis was induced by
different procedures, such as maternal breathing of
a mixture low in oxygen, hypotension, partial umbilical
compression using clamps and by micro-embolisation of umbilical
arteries.
Animation of
Umbilical Embolisation (Click to Advance)
In all cases, the pattern of redistribution of blood flow was
confirmed
and
two types of fetal deterioration were identified.
1.
When fetal hypoxia was caused by
maternal internal medium without placental lesionlike
cardio-respiratory pathology, acute deficit of specific
nutrients, severe anemia, altered maternal hemodynamic due
to hypertensive crisis of renal or endocrinal origin not
only was there an increase in cardiac and cerebral perfusion but there was no change in umbilical blood
flow.
2.But this was
not the case when the fetal hypoxia originated from
microembolisation of the umbilical arteries thus creating
conditions similar to those of a human
fetus
with a placental lesion. A
progressive decrease in the
umbilical blood flow was evident with the increasing
obstruction in terminal villous arterioles.
Fetal hypoxemia in IUGR is thus a result of functional
obstruction of terminal villous complex and not the cause of
altered hemodynamic in umbilical artery. So centralization
of blood flow may develop independently of umbilical wave form.
Using Color
Doppler since 1997 in more than 7500 cases (nearly 30% high risk
pregnancies) we now can confidently quantify placental deficit
better, and identify different stages of fetal ill health, as
below:
A.
Stage I sub-clinical or silent phase:
From animal experiment, we know there is no clinical reflection
in the Doppler analysis of the feto-placental circulation up to
50% of placental obstruction. Fetal growth, BPP, Liquor volume
remains normal. Clinician can not detect this theoretical
placental deficit which is made up by the remaining 50%
placental function. This is called ‘Placental Reserve’
B.
Stage II or Pre centralization:
Beyond 50% placental obstruction, the umbilical artery displayed
progressive loss of end diastolic flow (EDF) with intermittent
opening up of Ductus venous floodgate and delay the onset of
centralization of blood flow. AFI, BPP score and NST
tracings still remain normal. The Increasing number of SGA babies
are delivered in stage II with nearly 25-30%
increase in C-Section rate, due to display of early fetal
distress in CST. This is the clinical significance of Stage II.
C.
Stage III or Centralization of blood flow
a.
Stage III A or initial phase: Umbilical
artery EDF continues to decrease but still showing forward
flow during the whole cardiac cycle. When compared to Middle
cerebral artery , Cerebro-placental ratio (CPR) becomes
equal or less than one. Most of the clinician believes that
This is the best fluxo-metric index
for early diagnosis of IUGR to warn the clinician well in
advance about the prospective risk from chronic vascular
changes. BPP and AFI often found normal or equivocal
having normal NST tracing.
b. Stage
III B or advanced phase:
When 80 % blockage reaches in villous circulation advance
phase starts, displaying
absent end diastolic flow (AEDF) in umbilical artery and
aorta. BPP and NST may still
show normal tracing.
c.Stage III C or terminal phase:
In addition to AEDF umbilical artery (and aorta) may now
show REDF. Ductus Venosus shows reversed blood
flow at atrial contractions suggest central venous stasis
due to right heart failure with possible display of
umbilical venous pulsations. IVC also shows increasing
reversed blood flow during atrial contraction, reaches up to
30% (normal up to 10 %). Ventricular Ejection Force (VEF)
reduced to 5th
percentile. The CST now registers late deceleration and loss
of reactivity due to loss of cardiac automatism.Fetus is very critical but still the
fetus can be salvaged, if delivered promptly with good NICU
support.
d.
Stage IV decentralization of B/F or irreversible hemodynamic
changes: Lastly
if the fetus is not rescued from the extreme hostile
intra-uterine environment; in a day or two, an irreversible
state of generalized vascular paralysis sets in with 95%
blockage. Brain edema and rise of intracranial pressure
hinder cerebral blood perfusion à alter
cell membrane permeability à
increased intra-cellular osmotic pressureà tissue
necrosis. CTG display flat heart rate tracing even
with good uterine contractions. Such neonates often die
due to brain death in spite of best neonatal care.
KEY POINTS TO CLINICIAN
:
CTG AND DOPPLER
1.Doppler sonogram is an outstanding “early warning device“
for a slowly developing threat to fetal well-being from
chronically impaired nutritional supply and offers advance
warning several days before the CTG. It can lead to a
significant reduction in the incidence of acidosis if the
Doppler findings are analyzed correctly for the optimum time and
type of delivery. A normal Doppler finding reflects
normal circulation in the vascular region where as abnormal
Doppler in umbilical artery, reflects deep rooted placental
pathology, thus a chronic parameter but can not indicate acute
hypoxic changes that commonly supervene at term or during
labour.
2.A normal CTG reflects only normal cerebral
function of fetus; where as a highly abnormal CTG
expresses depression in cerebral function
3.However we wish to point out again, the threat to the
fetus arising acutely, such as acute placental insufficiency in
a previously normal pregnancy can not be detected by Doppler
examination especially after 38 weeks gestation. In such
situation CTG is clearly superior.
When comparing the validity of these two methods the differences
between them must be borne in mind. Seeing is believing.
We documented two IUGR case reports managed more than eight
years back during our initial learning phase.
Conclusion:
Study of feto placental hemodynamic using Color Doppler and CTG
is considered indispensable in the hands of a modern clinician
managing high risk pregnancies. However, it is essential to
understand the natural history of fetal deterioration to obtain
significant fetal outcome.
In my then new job in an industrial
hospital, in the antenatal clinic, at the time of
clinical interview, as I used to (still do) ask
patients, like any other obstetrician, whether she was
feeling her fetal movements alright or not. Strikingly,
I often used to notice that before the woman answered
the husband used to come out with some candid comment
about it like – ‘Yes doctor it moves alright’,
‘Oh, it moves such a lot’, ‘It has slowed down a bit’,
‘Some nights it almost revolts to be released from that
cramped place.’, ‘It is going to be either a footballer
or a break dancer’ etc. These rather smart couples
invariably were all educated and were primiparae
carrying late pregnancy. It is this that turned on my
mind and made me think – how can he tell ! and so
precisely, so confidently !.
It is the year 1976 and Telco (now
called Tata Motors) Hospital that I am talking about.
In this hospital a large majority
of my patients were wives of young brilliant (Tata
worthy !) engineers and many were engineers themselves
married to an engineer boy of her college because by
that era in India the engineering colleges had started
looking colourful like the medical colleges.
A light probing
One day I decided that I have to
clear this soft mystery and directly asked one husband
about it – as to how does he know it so well and this
was the answer I got :“Every night before we actually
fall asleep we chat for a little while in bed lying on
our sides face to face lightly embraced. It is then that
I can feel occasional movement of the baby on the
surface of my tummy transmitted through the wall of my
wife’s protruding tummy which somewhat bulges into my
tummy” (Please see the sketch).
This immediately reminded of my own
experience while my wife was carrying our first child
and so I decided to do a small study of such
couples/husbands. I inter-viewed total 30 husbands and
each admitted of perceiving the occasional fetal
movement on their tummy.
Implementation of the finding
into practice
Based on the above experience I
decided to use this everyday routine of the young
couples as an additional means of checking the status of
movement of theirfetuses.
Since then I have been advising
selected patients carrying uncomplicated pregnancy of 37
plus weeks of gestation to do this additional
pleasurable exercise in additionto the two one hourly
session of the usual solo Fetal movement count during
the dayby the wife on her own.
Possible advantages of
husband monitoring fetal movement
It guarantees that the fetus
has actually moved because even another external
individual has been able to feel it. This can do
away with the odd incidence of mother going on
counting fetal movement even three days after
intrauterine fetal death.
It also certifies that the
movement was strong – strong enough for an external
individual to feel it – such babies are expected to
be a vigorous baby. Sick fetuses (e g fetuses with
gross IUGR) on the other hand may be expected to
move feebly – which may not be perceivable by the
husband.
For mothers who are somewhat
poorly sensitive to recognition of their fetal
movement, their husbands can guide them as to when
the fetus moved and what is a real fetal movement by
trying for joint perception of the movements.
No additional expense is
involved.
Daily and domestic fetal
monitoring is possible
It promotes BONDING of the
fetus with its Father
Three unique advantages of
using the husband for fetal monitoring
· He is readily available
· He is naturally keenly
interested because it is his child
· He, a valuable human resource,
remains totally unutilized during the whole antenatal
period like a bystander, why not use him?
Disadvantage
Chance of husband/the father
falling asleep.
It slightly increases the frequency of coitus !
This has also been the finding of Dr. Pratap Kumar
of Manipal (personal communication). But, let us
rethink, could it constitute an advantage rather
than a disadvantage for
the 37 plus weeks gravidae carrying normal
pregnancy. Of course, it naturally occurred from the
posterior which the couple instinctively arranged as
I found out.
The method is of course not applicable if the wife
is sent to her mother’s place for delivery which has
been customary in India.However, nowadays, since
most organizations give free medical facility as
perks of the husbands job, the old trend has
significantly reversed and now usually the mothers
go to their daughter’s house to take care of her
rather than daughter going to their mother’s place.
This is happening more frequently amongst the
working couples.
Published record
The method has been published in
the International Journal of Obst & Gyne, September
1991, FIGO Supplement, Elsevier, p-47.:
A striking feedback on the
method
Of the many feedbacks that I have
received the following are worth mentioning which I got
from the obstetricians of the developed world -
“It can be a powerful tool to
promote bonding”, “It can generate a special kind of
‘Triple bonding’ – a composite bond between the mother
and the fetus and the father altogether and all at the
same time – a FAMILY BOND !.
Our immediate past President of
FOGSI, Dr. Pankaj Desai, as long as 20 years ago
enthusiastically commented about it during the
Pre-congress workshop at AICOG
Nagpur in 1988..
Anyway, if
nothing else, this practice makes the pregnancy perhaps
little more enjoyable specially for the enlightened
couple.______________________________________________
Inability
to conceive is one of the common problems among the many
conditions bringing a woman to a gynecologist for
treatment. In daily practice I have observed that often
the lady may come for the first consultation with
another female relative often her mother, sister,
mother-in-law, sister-in-law etc. In such cases, the
husband is often unavailable during this initial
consultation. I strongly feel that social problems often
need to be tackled in such cases as many a male partner
refuses to acknowledge his potential role in the
situation. With all this in mind, I give much importance
to husband’s presence in all first visits.
Whenever
the couple are available together for consultation, I
take detailed history regarding complaints,
menstrual pattern, relevant occupational details,
previous unsuccessful pregnancies which they may have
discounted, history of any instrumentation such as D&C
for diagnostic or therapeutic purpose, medical history
regarding tuberculosis, diabetes etc.
Sexual
history gives me important additional information in
such couples to pinpoint problems such as infrequent or
irregular intercourse, premature ejaculation,
dyspareunia etc which can have a direct bearing on
fertility potentialSince some times
questions are difficult to ask from the couples in our
busy practice when in OPD as either the staff is moving
around or the patients may come with their other
relatives, hence, I have started giving them a form with
questions like private coital history in detail to be
filled up by the husband and wife together at home which
they return to me on the next day.This I
feel gives freedom to the couple to explain their
problems in detail.After reading their
form I write down the positive points in their case
paper and tear down their form in order to keep their
privacy.
Next I
try to evaluate all previous reports of investigations
as well as the treatment details if available, which the
couple has got done earlier during the course of
undergoing treatment
After
history and a detailed clinical examination of the
couple, I always explain in simple terms, the normal
process of reproduction utilizing visual aids such as
simple diagrams or pictures of the reproductive system.
A visual impression accompanied by a short description
of the various factors which can be responsible for
difficulty in conception helps to motivate the couple to
cooperate in treatment. A basic understanding of the
reproductive process also explains the need for
investigations as indicated by history and clinical
examination.
I usually
give baseline investigations to the couple when they
first approach me for the treatment of sub-fertility. I
feel that simply making a long list of investigations
without adequate explanation of the role of such
investigations is not helpful in their management. I
strongly feel that, individualizing the approach to
management of the couple goes a long way in arriving at
a diagnosis and also helps in reducing the financial
burden they have to bear. I even tell them about the
limits of various treatment modalities and discuss the
optimum number of trials of a particular drug or
intervention, keeping guidelines for the patient’s
safety in mind.
I usually
give folic acid supplementation (if not advised earlier
or stopped by the couple) in such women trying for
conception with a simple explanation of its utility in
healthy child-bearing.On the very first visit, I
emphasize on the importance of regular follow up and a
dedicated, timely approach to following instructions
given to them.
I my
experience I realized that using such an approach while
treating couples with the problem of sub-fertility helps
to develop confidence in them as well as clear any
doubts or misconceptions they may have harbored.
Often I
find that these couples are frustrated and tired after
long drawn-out treatment, I have experienced that a
patient hearing and a sympathetic, yet systematic
approach can go a long way in helping them tackle their
situation more optimistically with better chances of a
favorable outcome.
One
of the most dramatic change in the route of removal
of the uterus during the last few years is switching
over from Abdominal to Vaginal irrespective of the
decent of the uterus, volume (fibroids, Adenomyosis)
or previous surgeries on it. While doing Non Descent
Vaginal Hysterectomy, apart from opening Anterior
and Posterior pouch most challenging and time
consuming step is transfixation of Uterosacral ,
Mackenrodts ligaments and ligation of Uterine
Pedicle with available 40 mm half circle needle as
the space is narrow and pedicle is deep in Vagina.
With
40 mm Half Circle Needle the problem starts from
(1) Where to catch the needle in the Needle holder.
(2) At which angle needle is to be inserted in to
the pedicle
(3) Some time tip of needle is lost and can not
found on the other side of clamp
Repetitive unsuccessful attempt causes distressing
and disturbing expressions on Surgeon and more so on
Assistants.
To
overcome this disturbing situation I thought of
trying short straight needle instead of half circle.
I designed new 15 mm short straight needle to make
these steps comfortable and easy.
Technique After cutting the pedicle the SRS needle
is inserted from below upwards, as shown in the
image, so the tip of the needle emerges anteriorly
in vision and it can be very easily caught and
handled. It can also be inserted from above and to
catch from below. Since last 4 years we are using
this needle in NDVH. We have done last 1000 Vaginal
Hysterectomy with this types of straight needle and
was found convenient, easy, time savings and with
least wrist joint movement
The SRS needle in now available in market by
Dolphine Sutures as PETCRYL* SRS FS 2545.
Comparision of Short Straight Needle –SRS Needle
with 40 mm half circle Needle .
40 mm Half Circle Needle
15 mm SRS Needle
Technically Difficult
Technically Very Easy
Movement Difficult
Movement Easy
Surrounding structures may injured
Surrounding structures not injured
Difficult in transfix Pedicle
Easy in transfix Pedicle
More space required to handle the needle
Less space required to handle the needle
Since the incidence of Vaginal hysterectomy is
increasing day by day and more and more gynec
surgeons are adopting this route for the removal of
uterus we have to find out more and more easy and
safe steps for the surgery. This new technique is
very easy for ligating pedicles apart from its high
safety.
