Monday 30 April 2012

Clinzen in pregnancy


Some people think that clinzen vaginal tablets can lead to miscarriage.
These are frequently prescribed tablets for vaginal infection especially candidiasis.
Clinzen vaginal tablets or cream contain Clindamycin phosphate which is a water soluble ester of the semi-synthetic antibiotic.
It is Category B drug in pregnancy.
There are no adequate and well controlled studies regarding its usage in first trimester of preganacy. It should be used only if clearly indicated.
In second trimester in women treated with clinzen for 7 days abnormal labor reported in 1.1% of women.
As such overall reproductive studies on humans revealed no harm to the fetus. But studies on only one mouse strain reported cleft palate with other strains being not effected.
So, this can be taken as strain specific.
In general hospital practice this is used frequently and not connected to miscarriage.

Saturday 21 April 2012

Vesicovaginal fistula(VVF) - 1


One of the most common causes of urinary incontinence in females is vesicovaginal fistula(VVF). This is most common type of genitourinary fistula.

Definition:




This is a communication between the bladder and the vagina which will lead to escape of urine into the vagina leading to true incontinence.

Etiology:
Both obstetrical and gynecological causes can lead to vesicovaginal fistula.

Obstetrical causes:
Obstetrical causes are responsible for 80 to 90% cases of vesicovaginal fistula in developing countries and 5 to 15% cases in developed countries.

1. Obstructed labor: in case of obstructed labor because of prolonged compression on the bladder base between fetal head and symphysis pubis, ischemic necrosis occurs. Because of this decreased blood supply infection super imposes which will lead to sloughing of tissue resulting in fistula. In this case fistula can develop in 3 to 5 days.

2. Difficult labor: when baby delivery becomes difficult due to big baby or contracted pelvis etc, instrumental delivery may be needed. If forceps are applied especially Kielland forceps, the chances of injury to the bladder is more. 


3. Destructive procedures: in case of difficult labors if baby dies, to take out the baby destructive procedures like craniotomy may be needed. In this case trauma may be caused by instruments used or because of bony spicules of fetal head.


4. Emergency surgeries: in cases of emergency cesarean section for prolonged or obstructed labor, as the bladder will be drawn up in these cases chances of injury is high.
In case of cesarean hysterectomy for rupture uterus the chances of bladder injury is high as here also prolonged labor may led to drawn up bladder.

5. Repeat cesarean section:  because of adhesions caused by previous cesarean section between the bladder and the lower part of uterus, the chances of bladder injury are high.



Monday 16 April 2012

Doppler in Obstetrics and Gynecology


Doppler velocimetry is a noninvasive way of assessing blood flow by characteristic downstream impedance.

Principle :
When sound waves strike a moving target, the frequency of sound waves reflected back is shifted proportionate to the velocity and direction of the moving target. As the magnitude and direction of the frequency shift depend on the relative motion of the moving target, the velocity and direction of the target can be determined.

In obstetrics :
Doppler is used to determine the volume and rate of blood flow through the maternal and fetal vessels.
Here the sound source is the ultrasound transducer, the moving target is the red blood cells flowing through the circulation. The reflected sound waves are observed by the ultrasound transducer.

Uses :
Recommended as possible adjunct to other fetal evaluation techniques.

Antepartum fetal heart rate testing :

 
In detecting the fetal heart rate patterns, accelerations or decelerations in fetal heart rate, used in nonstress test, contraction stress test, biophysical profile etc.

Doppler index:
 

 
The umbilical artery systolic/diastolic (S/D) ratio is most commonly used Doppler index.
S/D ratio = maximum(peak) systolic flow/ end diastolic flow
By this the ratio evaluates the down stream impedance of the flow. 
The resistance to umbilical artery blood flow during diastole will be initially high then decreases as the gestational age progresses.
Normal flow :
S/D ratio 4.0 at 20 weeks to 2.0 at 40 weeks.
Abnormal flow:
If elevated 95th percentile of the gestational age
If diastolic blood flow is either absent or reversed.
It indicates extreme downstream resistance, placental dysfunction and fetal compromise with chances of growth restriction.

In estimating fetal maturity:
 
Fetal maturity can be estimated by adding 30 weeks to the date of fetal heart detection by Doppler ultrasound.

In conditions like postterm pregnancy, diabetes, systemic lupus erythematosus, antipospholipid antibody syndrome or in general obstetric population Doppler is ‘not of’ much use.

In Gynecology :
In Gynecology also Doppler is used in different conditions to evaluate the blood flow pattern of different organs and the possible causes for them like,
 
  1. In ovarian and endometrial cancer,
  2.  Pelvic pain,
  3.  Benign and malignant adnexal masses,
  4.  Myometrial invasion of endometrial carcinoma,
  5.  The normal endometrium and benign endometrium disorders,
  6. Normal pelvic blood flow,
  7. Uterine sarcoma,
  8. Uterine myomas.  etc.


Sunday 15 April 2012

Hydrorrhea gravidarum


Definition:
Hydrorrhea gravidarum is defined as “the discharge of a watery fluid from the vagina during pregnancy”. It can also be called as hindwater.
 One more definition is constant or periodic flow of a serous or seropurulent liquid, resembling liquor amnii, from the vagina in pregnancy.

The causes of are:
Rupture of membranes
Hydrosalpinx
Edema of uterine walls
Inflammation of decidual glands
Placenta marginata

Pathology:
Inflammation of deciduae is not uncommon in pregnancy. It occurs usually secondary to slight degrees of endometritis. But  severe degree of endometritis leads to sterility.
The inflamed decidua will be greatly thickened either localized or diffuse and may present with polypoid growths or small cysts.
The rupture of these cystic decidual glands, with sudden gush of fluid from vagina will present as hydrorrhea gravidarum.

Quantity :
Little or more

Time :
Usually occurs after six months of pregnancy

Differential diagnosis:
Liquor amnii
Urine
Local wounds pus discharge
Secretions from local tumors

Dangers :
It can lead to preterm labour

Treatment :
No particular treatment available. Cause to be treated.


Thursday 12 April 2012

RENAL TRANSPLANTATION - PROCEDURE


        Rutherford –Morison incision
        Muscle layers divided
        Inferior epigastric vessels ligated & divided

        Iliac vessels mobilized
        Int .iliac & gluteal branches may need ligation

  Cold kidney is placed in iliac fossa



        Arterial and venous anastomosis  done

        Ureteroneocystostomy  done in extravesical fashion

POSTOPERATIVE CARE 
Foley catheter - Remove on 5th  POD, administer dose of antibiotic

Ureteral stent, if used- Remove 6–12 wk postoperatively in clinic

Drain(s)- Remove when ≤ 30 mL/24 h or in 3 wk if volume > 30 mL/24 h





    



Tuesday 10 April 2012

RENAL TRANSPLANTATION - RECIPIENT PROCEDURE


Recipient  procedure
  • Endotracheal intubation for GA
  • Establishment of arterial line & CVP monitoring access
  • Pt. is placed in supine position
  • Oblique Rutherford-Morrison incision
  • Ext.oblique, Int.oblique, Transversus abd. muscles divided
  • Inferior epigastric vessels ligated & divided
  • Spermatic cord freed & retracted (round ligament can be divided)
  • Peritoneum pushed medially& upwards
  • Common , Ext.iliac, Int.iliac arteries mobilized
  • Ext. iliac vein mobilized
  • Para psoas gutter developed for final placing of kidney
  • Vascular clamps applied  to Ext/int.iliac artery & Ext.iliac  vein 
  •     Venotomy & arterotomy are given


Back table work for vascular variations

Vascular anastomosis
Renal artery to Ext.iliac artery
                   End to side  fashion with 5-0 or 6-0 prolene
                   ( in End to End fashion if Int.iliac artery is selected )
Renal vein to Ext.iliac vein
                   side to side  fashion  with 5-0 or 6-0 prolene
Kinks and twists are avoided during vascular anastomosis

Reconstruction of urinary tract
  • Orientation of renal vein, artery & pelvis is reversed antero-posteriorly  when opposite iliac fossa is selected

  • Uretero neocystostomy is done in Lich-Gregoir’s  extra vesical  technique  with 3-0 or 4-0 synthetic absorbable  suture material like polyglactide or polydioxanone

  • Placement of Double J stent is optional

  • Wound is closed in layers after fashioning  a drain

Patient in supine position
Foley’ catheter placed

Sunday 8 April 2012

RENAL TRANSPLANTATION - DONAR SCRENING AND OPEN NEPHRECTOMY


Routine live kidney donor screening

 Urinalysis –
  •  Dipstick for protein, blood & glucose
  • Microscopy & culture
  • Protein excretion rate

Assessment of renal function-
  • Estimation /measurement of GFR
Blood tests
Haemogram,coagulation profile
Haemoglobinopathies& G6PD  deficiency (when indicated)

Biochemical profile
       Blood urea, S.Creatinine, S.electrolytes, LFT, FBS, GTT(if indicated)
       Lipid profile,Thyroid profile, Pregnancy test & S.PSA

Virology& infection screen
        Hep.B, Hep.C, Toxoplasma, HIV, HTLV,CMV, EBV 

Cardio-respiratory system
       Chest X-ray, ECG, Stress test, 2D-ECHO(when indicated)

Assessment of renal anatomy& function
       KUB-IVP series, DTPA-Renogram, Renal Angiogram


  • PAC (Pre Anesthetic Checkup) and
  • Pre –Operative  Preparation
                                 ---For both donor & recipient
      
Donor Nephrectomy
  • Open              [ODN]
  • Laparoscopic   [LDN]

Open Donor Nephrectomy(ODN)
  • Endotracheal  intubation for GA
  • Kidney/flank position
  • 11th or 12th  rib incision (with rib excision when needed)
  • Ext.oblique, Int.oblique,Transversus abdominis with fascia divided
  • Retroperitoneum entered
  • Kidney mobilized all around
  • Tributaries of renal vein ligated
  • Renal vein & Renal artery are mobilized up to their origins
  • Ureter mobilized up to pelvic brim and transected
  • Brisk diuresis ensured from the cut ureter
  • Renal artery & Vein are clamped, cut and ligated
  • Kidney is handed over to perfusion team for placing in ice slush & perfusion  with chilled RL & heparin
  • Wound closed in layers with or without a drain




Friday 6 April 2012

RENAL TRANSPLANTATION - HISTORY, SELECTION OF RECIEPIENT


This is guest article by Dr.N.Anil kumar, Urologist.
History and Major landmarks
1933    - First Human Renal Allograft by Voronoy in Ukraine.
1954    - First long term Success with Human Renal   Allograft achieved in Boston.
1958    - First Histocompatibility antigen was  described.
1959    - Radiation was tried for immunosuppression.
1962    - Glucocorticoids became a part of   immunosuppression.
1962    - First use of tissue matching for selection of Donor-recipient pair.
1966  - Direct cross match between Donor  lymphocytes and  recipient serum introduced.
1970’s- Brain Death laws were passed
1978  - first clinical trials of cyclosporine were reported
1981  - Successful use of monoclonal antibodies for renal allograft rejection
1989  - Recombinant Erythropoietin  became available
1995  - Laparoscopic donor nephrectomy was introduced


Urologist’s role -recipient
Ø      Preliminary screening
Ø       Kidney disease recurrence
Ø       Infections
Ø       Active malignancy
Ø       Probable risk factors for perioperative morbidity
Ø       Non-compliance
Ø       Unsuitable conditions for technical success

1. Preliminary  screening :
  • Drug / substance abuse
  • Morbid  obesity
  • Compliance issues
  • Heart disease

2. Kidney disease recurrence
High Risk of Graft Failure
  • FSGS
  • HUS
  • Oxalosis

Potentially treatable
  • Renal Amyloidosis
  • Cystinosis
  • Fabry’s Disease

Graft failure  is rare
  • DM
  • IgA nephropathy

Do not recur in transplanted kidney
  • ADPKD
  • Renal  dysplasia
  • Alport’s without anti BM antibodies

3. Infections
  • Dental sepsis
  • Infection of dialysis access sites
  • Pulm.infections & Tuberculin test
  • Symptomatic cholelithiasis & cholecystitis
  • Recurrent diverticulitis
  • Diabetic foot ulcers
  • UTI
  • CMV, HSV, EBV,  Hep.B, Hep.C, HIV

4. Active  malignancy
  • Invasive cancers- 2-5 yrs of waiting time after last treatment recommended
  • Low grade / Non-invasive cancers-  shorter intervals may be accepted
  • GB-Polyps of >1cm in diameter- cholecystectomy is recommended

5.Probable risk factors for perioperative morbidity & mortality
  • Cardiac risk factors
  • Peptic ulcer disease
  • Significant pulmonary  disease
  • Smoking

6. Unsuitable conditions for technical success
  • Signs& Symptoms of  lower extremity arterial disease
  • H/O abdominal or pelvic vascular surgeries
  • H/O previous vascular thrombosis, antiphospholipid antibodies,  previous transplant renal vein thrombosis
  • Diseases & operations on urinary tract            











Sunday 1 April 2012

Chyluria: introduction, etiology, diagnosis and treatment


Chylous urine
Introduction:

  Chyluria  -  Milky urine

         Defined as leakage of lymphatic fluid in urine.

         An infrequently discussed problem which is not uncommon in our area.

         Described by CHARAK in 300B.C. as ‘ SHUKLAMEHA’

         Prevalent in African countries and Indian Subcontinent.

         Seen in rural and economically weaker population

Etiopathogenesis:

Chyluria is a state of chronic lymphourinary reflux caused by obstruction to the lymphatic flow.

         Parasitic
         Non – Parasitic

            Parasitic infestation
                         /
            Obliterative lymphangitis
                         \
            Lymphatic hypertension
                          /
            Varicosity and collateral formation
                           \
            Failure of valvular system
                           /
            Back flow
                        \
            Rupture of varicosities into renal calyces and pelvis.
 
PARASITIC (Primary, Tropical)

         Wuchereria  bancrofti (most important and most common)
         Eustrongilus gigas
         Taenia echinococcus
         Taenia nana
         Malarial parasites
         Cereonomas nominitis


NON – PARASITIC (Secondary, Non – Tropical)
         Congenital
         Lymphangiomas of urinary tract
         Megalymphatics with ureteral or vesical fistulae
         Stenosis of thoracic duct
         Retroperitoneal lymphangiectasia.
         Traumatic lymphangio urinary fistulae
         Obstruction of lymphatics due to
        thoracic duct obstruction by tumor
        granuloma glands, aortic aneurysm

Other causes
         Pregnancy
         Diabetes
         Pernicious  Anemia

Clinical features:
  1. Monosyptomatic
  2.  Polysymptomatic
         nutritional deficiencies
         recurrent clot colic
         urinary retention
          UTI
          Hematuria
          Immunosuppression (loss of Ig A and Ig G cause lymphopenia leading to                                                               promotion of opportunistic fungal infections, malignant tumors.)

Diagnosis:
1 .Confirm chyluria
2. Ruleout other causes of milky urine(pyuria, phosphaturia, caseousuria)
3. Confirm the cause of chyluria (99% is failarial)
4. Exclude secondary causes like tuberculosis, tumour by ultrasound abdomen or CT scan.

Urine sample:
Naked eye examination: Urine settles down into 3 layers-fat  on the top,clots in the middle and debris in the bottom
Ether test: Milky urine becomes transperant on adding Ether
Biochemical examination: For Triglycerides
Microscopy: Chylomicrons,  RBC’s,Lymphocytes
TREATMENT
         Disease of unknown natural history
         It is a self limiting disorder with intermittent remissions and exacerbations.
        
Man of them require:
Reassurance
Antifilarial treatment
Dietary modifications
Correction of anemia
 Bed rest                                           Abdominal Binders          

DIETARY  MODIFICATIONS:
         Minimal oil in diet
         Use nonstick pans to minimize the amount of oil
         Avoid ghee
         Use coconut oil as cooking medium
         Skimmed milk is better
         Cow milk is better than buffalo `
         (Boil, cool, refrigerate for 12hrs and strain top cream layer          before use)
         Avoid fried foods like poori, cream biscuits, parantha, chat, pastry
         Avoid dry fruits
          Restrict sweets
          Avoid mutton
          Fish and chicken are better ;roast or boil instead of   fry
          Boiled egg is better than having it as fried or omlette  (Not more than 1-2 whole eggs/ week)
          Routine diet should include roti, broken wheat,rice, corn flakes,dals,fruits and vegetables               

Indications for Intervention  : 
         Weight Loss
         Hypoproteinemia
         Recurrent clots
         Anaemia due to haematochyluria
         Refractory chyluria
         Psychological disturbance

Interventional therapy
          Cystoscopy &sclerosant instillation(RPIS)
          Surgical –open / laparoscopic
           Nephrolympholysis
          Microsurgery  

RPIS  (Retrograde pelvic instillation of sclerosants)
      Agents:
           Silver Nitrate 1%
           Povidone Iodine 0.2%
           Dextrose 50%
           Hypertonic saline 3%
           Urograffin 

Mechanism:
Installation of agent – reaches lymphatics through fistulae – chemical lymphangitis – blockade of lymphatics due to edema – immediate relief.
Healing by fibrosis – permanent relief.

Procedure :
              High fat diet evening before sclerotherapy
              NBM for 5hrs
                      Anesthesia – local, caudal
              IV – antibiotics + Lasix (steroids – sos)
              Cystoscopy to identify the side (85% unilateral, 15% Bilateral)
              RGP – 6Fr ureteric catheter
              Size of pelvis estimated injecting water till pain develops ( 7 – 10ml)
              Only one side at a time
              Contralateral side planned after 6 weeks.
Preparation and schedule
         AgNO3 – 1gr in 100ml
         Povidone – 1:50 dilation of 10% W/v in water
         Povidone Iodine  + 50% dextrose
              8th hrly instillation for 3 days
              12th hrly instillation for 2 days
              ½  hrly  instillation  for  2hrs.
Response
         70% - permanent remission with single course
         30% - recurrence
         2nd course of RPIS -   50% remission
                                                       50% need surgery
         Late failure is due to recanalization of lymphatics – better response with 2nd RPIS.

SURGERY:

Indications:
         Failure of instillation therapy 
    Techniques:
      Lympho-urinary disconnection (open / retroperitoneoscopy)
                       
         High fat diet 24 – 36hrs prior surgery
         Kidney is freed all around
     NEPHROLYMPHOLYSIS HILAR STRIPPING -    Renal hilar lymphatics are cleared
  URETEROLYMPHOLYSIS -   Downward mobilization of ureter up to pelvic brim                                                                                    
         Nephropexy , fasciectomy – optional
     Lymphangio – venous anastomosis
    Men – Inguinal region
         Women – dorsum of foot, leg, thigh
  Renal autotransplantation

To  summarise :
Ø      Chyluria – an alarming symptom with benign course
Ø      Can be diagnosed by simple urinary tests
Ø      Rare secondary causes should be ruled out
Ø      Most of them do not need any intervention except for reassurance
Ø      70-80% can be cured with RPIS
Dietary modifications may help preventing recurrence.