Clotrimazole in pregnancy

Clotrimazole is antifungal drug.
Used to treat fungal infection like tenia over skin, candidiasis in mouth, vagina etc.
Trade names are Clotri -denk, lotrisone etc .

It is very poorly absorbed when used topically or vaginally.
Clotrimazole belongs to category B drug when used vaginally or topically.
Means animal studies didn't show teratogenic effect but human studies are lacking.

But when used orally, it comes under category C drug.
Means animal studies have shown some adverse effects on fetus but sufficient human studies are lacking.
In studies on rats oral usage of high dose of drug led to embryo toxicity.
In general its effect on fetus will be less in later weeks of pregnancy.
But there are no sufficient studies showing effect in early pregnancy.

So, better to be cautious when using the drug orally in early weeks of pregnancy.
And should be used only with doctor's advice and when benefits overweigh the risks.

Combined hormonal pills as emergency contraceptive pills

Many people will have doubt regarding whether combined hormonal pills can be used for emergency contraception purpose.

Yes, combined hormonal pills can be used as emergency contraceptive pills in case of non availability of emergency pill.
For that four combined hormonal pills should be taken within 72 hours of unprotected intercourse.
Next four tablets should be taken within 24 hours of first dose.
But this should be taken only in case of emergency.
Because repeated intake of high dose pills can lead to menstrual irregularities.
And also side effects like nausea, vomiting, bloating sensation etc can occur.
So, better to use contraceptive pills regularly as per as possible.

Tetracyclines in pregnancy

Nowadays the usage of tetracyclines decreased after invention of newer antibiotics.
But for some infections like,
Acne vulgaris
Lung infections like bronchitis, pneumonia, psittacosis etc
Brucellosis
Trachoma
Mycoplasma infections
Leptospirosis
Infections with Rickettsiae microorganisms like Q fever, typhus fever etc,
some doctors still prescribing these antibiotics.

But tetracycline antibiotics should not be used in pregnancy.
If the woman is having the possibility of pregnancy, better to avoid this medicines.
Tetracyclines can affect the skeletal development of unborn baby.
It can get deposited in bones.
It can lead to discoloration of unerrupted teeth in fetus.

Tetracyclines can pass through the breast milk also.
And can lead to discoloration of the unerrupted teeth.
So, better to avoid during lactation also.


(The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box. Thank you )

Foods that will help in increasing the body weight

Usually many people will think of loosing the weight.
But lower body weight is a problem to some other people.
Alteration in diet and exercise can help in increasing the weight in healthy way.
The ideal weight for the height is, height in cms - 100.
The weight should be increased gradually.
Better to increase 1 to 2 kgs of weight in a month.
For this around 250 to 500 extra calories per day should be taken.
The diet should be devided into three main meals and two snacks.
Mainly denser foods to be taken.
Like :
Proteins containing foods like chicken, fish, boiled soy beans, peanuts, boiled eggs etc.

Supplements like protenex powder etc can help.

Adding more unrefined healthy oils like olive, coconut, palm oil etc. Adding butter, toast etc to diet.

Carbohydrates in the form of whole bread with jam, honey, butter etc.

Fruits like banana, apples, pears, dry fruits etc.

Vegetables like potatoes, carrots, corns, peas etc.

Protein shakes, juices, whole milk etc.

Foods to be avoided are packed snaks, processed meat, diet sodas etc.

Exercises also play better role in increasing the body weight.

 Especially weight lifting exercises should be done. 

Postmenopausal bleeding - causes, diagnosis and treatment

Absence of periods for around one year is considered as attaining menopause.
Usually menopause occurs after 45 years in many women.
Some women may attain menopause before 40 years. This can be considered as premature menopause.
Some women may get menstrual periods till 50 years.
This can be familial, depends on general health etc.
Having menstrual cycles above 50 years should be carefully followed.
Some women may complain of bleeding per vaginum after attaining menopause.
This is called post menopausal bleeding.
The possible causes are :
- During menopause, endometrial layer gets atrophied. That can lead to exposure of underlying blood vessels and can increase their fragility, leading to bleeding.
- After menopause, vaginal mucosa will become thin and dry. Mild friction like during intercourse etc can induce bleeding.
- In case of any associated utero vaginal prolapse, decubitus ulcers etc can present and can lead to bleeding.
- Usage of vaginal pessary for utero vaginal prolapse  lead to local abrasions, ulcers etc leading to bleeding.
- Insertion of foreign objects can lead to bleeding sometimes.
- Obesity by increasing estrogen levels can cause endometrial hyperplasia and bleeding.
- Presence of cervical erosion etc can lead to bleeding sometimes.
-Uterine infections can also lead to postmenopausal bleeding.
-Usage of continuous hormone replacement therapy can lead to thickening of endometrium, polyps etc, and can lead to bleeding.
Eg : tibolone

- Cervical malignancy can lead to postmenopausal bleeding.
-Endometrial malignancy can lead to postmenopausal bleeding. Sometimes hormone replacement therapy can cause this.
-Rarely leiomyosarcoma from fibroids can cause bleeding.
-Hormone secreting ovarian tumors can lead to endometrial changes sometimes and can lead to postmenopausal bleeding.
- Usage of anticoagulants can lead to postmenopausal bleeding in some women.

Diagnosis :
Any type of postmenopausal bleeding to be considered serious and should be carefully evaluated.
Physical examination helps in ruling out local causes like cervical erosion, polyps, cervical neoplasia, ulcers, foreign objects etc.
It also helps in finding out the size of the uterus.
- Ultrasound especially transvaginal ultrasound can detect endometrial thickness, uterine size, polyps etc.
In case of suspected malignancy, MRI is more useful.
-Endometrial biopsy helps to do histopathological examination of tissue.
- Pap smear and cervical biopsy will help in ruling out the cervical neoplasia.
-Hysteroscopy helps indirect visualization of endometrial tissue,  to take biopsy and to remove polyps etc.
-Dilatation and curettage (D&C) helps to get the tissue for histopathological examination. It also helps for therapeutic purpose also.
-Coagulation profile to detect deficiency of clotting factors etc.

Treatment :
 Treatment of postmenopausal bleeding depends on cause.
- Endometrial atrophy needs hormone replacement mainly with minimal dose of estrogen.
- Minimal endometrial hyperplasia may be treated with progesterone support.
Endometrial hyperplasia with polyps can be treated with D&C followed by progesterone pills.
- Simple endometrial hyperplasia can be followed with regular checkups and ultrasound examinations.
- Infections can be treated with antibiotics.
-Cervical erosion may need cryotherapy sometimes.
- Stopping the drugs of hormone replacement therapy, anticoagulants etc can cure the problem sometimes.
- In case of early stages of cervical or endometrial neoplasia, total hysterectomy with bilateral salpingo-oopherectomy can help.
- In case of advanced malignancies radical hysterectomy with chemotherapy and radio therapy are needed.



( The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box. Thank you )

Causes of delay in periods even after taking tablets to induce withdrawal bleeding

Delay in periods can occur due to many causes.
After ruling out causes like pregnancy, thyroid hormonal abnormalities, general causes like anemia etc, doctors will prescribe progesterone tablets usually.
Progesterone tablets will help in inducing the withdrawal bleeding in many women,
As usually estrogen predominance and deficiency of progesterone will be the cause in most of the women, progesterone can cause withdrawal bleeding.
Progesterone will prime the endometrium during the period of usage.
Lead to secretory changes in it.
When the progesterone stopped, that can lead to withdrawal bleeding.
Sometimes few women will not get withdrawal bleeding even after taking progesterone pills.
The causes are :
- Insufficient dosage of pills to induce withdrawal bleeding.
- The period of onset of withdrawal bleeding can vary from 3 to 10 days. So, need to wait till that time.
-Deficiency of both estrogen and progesterone.
In this case combined hormonal pills to be used.
-Cause of the delayed periods may be something other than hormonal imbalance.
In that case detailed evaluation should be done to find out the exact cause and that to be treated.



(The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box. Thank you )

Physiological leuchorrhea

Leuchorrhea is increased vaginal discharge.
It can occur physiologically sometimes.
Like :
- Before menstrual period
-At the time of ovulation
-During pregnancy etc.

Physiological leuchorrhea usually occurs due to estrogen stimulation. To:
- Maintain chemical balance at vaginal canal as natural defensive mechanism.
-To preserve the flexibility of vaginal tissue.

Increased vaginal discharge during ovulation is useful to predict the fertile period naturally.
During pregnancy increased blood flow to the vaginal tissue due to increased estrogen can lead to physiological leuchorrhea.
Sometimes because of intrauterine exposure to estrogen, female infants can show leuchorrhea for short time.


Physiological leuchorrhea will have following features:
-Color will be clear watery or white
-No foul smell
-Not associated with itching
-Usually will not stain the under garments
-Generally seen during only particular periods of time menstrual cycle or pregnancy.

No need to worry about physiological leuchorrhea. Usually that will subside without need of medication.

If vaginal discharge presents with altered color and consistency, smell, itching, increased amount etc, that can be taken as pathological leuchorrhea.
And should be evaluated and treated.

N acetylcysteine - infertility

Ferticyst, ovacare forte etc drugs contains n acetylcysteine.
It is helpful in cases of infertility especially having poly cystic ovary disease.
PCOD presents with irregular menstrual cycles, anovulation, insulin resistance etc.
 Contraceptive pills help in regularization of hormonal levels.
But they are not that much effective in correcting the insulin resistance.
 So n acetylcysteine is used for this purpose.
N acetylcysteine helps in:
- Increasing the insulin sensitivity.
Reducing fasting insulin and homocysteine levels.
-And also it enhances the effect of the ovulation induction drugs.
-Reducing the androgen levels.
- Regularizing the menstrual cycles and in optimization of reproductive health.
-Helps in treating the acne and hirsutism.

Progesterone supplementation in pregnancy

Progesterone is the main hormone in the second half of the menstrual cycle.
The levels of progesterone will be low in first half and starts to rise in the second half of the menstrual cycle.
They will increase studyly till 6 to 10 post ovulation.
And if fertilization do not occur the levels will decrease.
Values of progesterone before ovulation - < 1ng/ml
Values of progesterone in the middle of the cycle - 5 to 20ng/ml
 Ovary will produce the essential hormones for maintenance of menstrual cycle.
After ovulation, the ovarian follicle is called corpus luteum.
If a woman conceives in that menstrual cycle, then that is called corpus luteum of pregnancy.
Up to around 12 to 14 weeks, this corpus luteum of pregnancy will secrete the progesterone hormone, which is essential in pregnancy.
 Progesterone helps in preparing the endometrium to accept the zygote, that is implantation.
It also helps in maintaining the quiescence of the uterus, to prevent abortions, premature labor etc.
Normal levels of progesterone in first trimester of pregnancy - 11.2 to 90.0ng/ml
In second trimester of pregnancy - 25.6 to 89.4ng/ml
In third trimester of pregnancy - 48.4 to 42.5ng/ml
Usually corpus luteum of pregnancy and then placenta will produce the required progesterone in pregnancy.
But some women may have defective production of progesterone, that can lead to abortions, premature uterine action etc.
In these cases, supplementation of progesterone can help in preventing uterine action and in maintenance of pregnancy.
The duration of progesterone supplementation to be given depends on levels of progesterone in the woman, gestational age, previous gestational age at which abortion occurred etc.
In case of prior history of abortion, progesterone can be given two weeks more than previous gestational age when abortion occurred.
In case of anticipating preterm labor progesterone can be given upto 34 weeks of gestation.
Better to prefer natural micronized progesterone as per as possible.
Levels of progesterone will decrease after menopause to < 1ng/ml.
In males progesterone levels should be <1ng/ml.



(The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box. Thank you )

Weight reducing medicines - planning for pregnancy

Appetite suppressant drugs like phenteramine can be prescribed for weight reduction.
Trade names are duramine, metermine etc.
Along with diet management, exercise etc, these drugs can help.
But should be used only for short period like less than 12 weeks.
But these are usually prescribed to persons, in whom overweight is causing medical complications.
Obesity can lead to infertility sometimes by causing hormonal imbalance.
So women who are obese, can decrease their weight with this drug according to their doctor's advice.
After that the dailama will come regarding when to plan for pregnancy.
Usually weight changes can lead to irregularity in menstrual cycles.
So, it will take some time for regularization of hormonal levels.
Actually the half life of phenteramine is 25 hours.
So, most of the drug may get cleared from the system within one week after stopping.
But menstrual cycles may take two to three months to get regularize.
So, better to plan for pregnancy after regularization of the periods.
Intercourse should be planned around the time of ovulation, this will increase the possibility of pregnancy.
For more details regarding ovulation : http://srsree.blogspot.com/2013/10/ovulation.html

Antenatal care of pregnancy without high risk factors - Third trimester

Third trimester is from 25 weeks to 40 weeks.
The frequency of visits to be increased.
Monthly visits till 28 weeks, once in 15 days till 32 weeks, weekly visits afterwards.
 Careful watch to be kept for development of any signs of hypertension, diabetes, polyhydromnios or oligohydromnios etc.
While doing the abdominal examination the size of the uterus, position of the fetus, the presenting part, the amount of the liquor to be noted fetal heart sounds to be auscultated.
Ultrasound examination to be done as part of follow-up of the growth of the fetus and to confirm the clinical findings.
The patient should continue to take iron and folic acid prophylaxis, calcium tablets.
She should take diet adequate to met the needs of the fetus.
Routine investigations like urine microscopy and hemoglobin to be repeated.
In case of high risk  cases blood sugar, urea, serum creatinine to be done.
The weight gain in pregnancy will be normally 9 to 11 kg, it will be distributed as 1 kg in first trimester, 5 kgs in second trimester and 5 kgs in third trimester.
More than half kg in one week or more than 2kgs in month is indication of chances of developing disorders like hypertension or diabetes etc.
The preconceptional weight will decide how much a woman can gain during her pregnancy.
In the obese women with BMI more than 30, weight gain better to be restricted to 6 to 7 kgs.
In third trimester better to avoid traveling and coitus as they may provoke development of premature labor.
In 38 weeks the pelvic assessment of the woman to be done to plan for the mode of delivery.
But these estimations may change once labor starts.
The woman should be instructed to come to hospital in case of pain abdomen, bleeding per vaginum or leaking per vaginum.
If do not develop any of these she can come one week prior to expected date of delivery if everything is normal she can be advised to join at the time of expected date of delivery.
In between these time she has to  do daily fetal movement count and fetal biophysical profile should be done.
In case of prior caesarean section she has to join 1 to 2 weeks before expected date of delivery so that in that time preparations for caesarean section can be done like arranging blood, taking pre anesthetic check-up etc.
These are all the steps to be taken in antenatal care of a normal pregnancy without high risk factors.

First trimester
Second trimester

Antenatal care of pregnancy without high risk factors - Second trimester

Second trimester is between 13 to 24 weeks.
During the second trimester the patient should come monthly for check-up in uncomplicated cases.
 In high risk cases like with hypertension, diabetes, anemia, multiple gestation etc the visits should be more frequent.
Routine general examination, abdominal examination and investigations should be performed during each visit.
In case of high risk cases blood sugar to be tested at 24 weeks.
 Anomalies scan can be performed at 18 weeks to rule out presence of anomalies and length of the cervix to be noted by manually and also by sonographycally in case of short or incompetent cervix cervical encirclage to be planned.
The woman should take two doses of tetanus toxoid injections at fifth month and seventh month.
If her previous pregnancy is within prior three years one dose is enough.
Patient should continue the folic acid prophylaxis and she should start taking iron and calcium prophylaxis also.
She should be instructed to come to hospital if any symptoms of pain abdomen, bleeding per vaginum or leaking per vaginum develops.
She can travel to small distances either by train or other safe modes, better to avoid long drives and traveling by road.
Coitus can be practiced depending on the desire of couple but the chances of urinary tract infection, bleeding per vaginum, establishment of premature labor to be kept in mind.

First trimester
Third trimester

(The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box. Thank you )

Antenatal care of pregnancy without high risk factors - First trimester - part 2

Then general examination of the patient to be carried out like height of the patient, height below 145 cms to be considered as short stature and they may have problems during delivery.
Weight to be recorded.
Any signs of anemia to be noted and the blood pressure of the patient to be recorded.
After taking all the above history the patient to be examined.
As in first 2 to 3 months uterus cannot be felt abdominally, per vaginal examination to be done to note the signs of pregnancy, size of the uterus and to note the adnexal masses if present etc.
In case of doubt or for confirmation the woman can advised to undergo ultrasound examination.
She should be advised to undergo investigations like urine for albumin, sugar, microscopy and blood investigations like hemoglobin, blood grouping and typing, screening for retrovirus, hepatitis and VDRL etc.
After this initial visit she has to come monthly for consultation.
In case of any emergency like pain abdomen or bleeding per vaginum etc indicating impending abortion or ectopic pregnancy she has to visit the hospital immediately.
In the next visits up to 7 months she has to come monthly.
During these visits per abdominal examination to be done to note the size of the uterus and to note the progress.
In this examination the uterus will come up to the symphysis pubis and can be felt abdominally after 12 weeks.

Height of the uterus according to months

At 16 weeks it will reach four fingers above the symphysis pubis.
 It will be just below the umbilicus at 20 weeks, at the level of umbilicus at 22 weeks, just above the umbilicus at 24 weeks, four fingers above it will be 28 weeks, further four fingers above is 32 weeks at the level of xiphysternum is 36 weeks, then the uterus comedown as the head stars descending into pelvis, two fingers below xiphysternum with flanks full is 38 weeks, still two fingers below with flanks full is 40 weeks.

 First trimester is 1 to 12 weeks. Patient should be advised to take folic acid prophylaxis during the first trimester.
She should be instructed regarding the diet that it should include the cereals, vegetables, milk, fruits etc.
 Regarding coitus better to avoid in first trimester especially those with history of miscarriage.
She should better avoid long travels in first trimester.
Train journey is preferred than road journey.

Part 1: Confirmation of pregnancy, care to be taken

Antenatal care of pregnancy without high risk factors - First trimester - part 1

 If the woman gets suspicion that she might be pregnant, she can test by using urine pregnancy kit.
It is easy method can be done at home and works on basis of presence of beta hCG in the urine.
It can be done within one week of missed period.
Blood test for pregnancy gives more accurate result and can be done on the date of missed period itself.
Pregnancy can also confirmed by doing the manual examination and noting changes in the cervical mucosa, size of the uterus etc.
 Ultrasound both trans abdominal and trans vaginal can be used for confirmation of pregnancy.
After confirmation of pregnancy the patient to be carefully followed.
 She has to be instructed that she should come to hospital once in a month in the first 7 months and in the 8 month she has to come twice in the month in the 9 month till delivery she has to come weekly.

In the first trimester:
The patient should maintain a record of her visits and investigations.
In her first visit after confirmation of pregnancy her last menstrual period to be enquired.
According to it her expected date of delivery can be calculated as 9 months and 7 days from that last date.
But for it the woman should have at least 3 regular cycles before conception.
And there should be no usage of oral pills for at least 6 months before conception.
In woman who cannot remember their last menstrual period any festival related to the date or date of fruitful coitus etc can be enquired.
Ultrasound can give the expected date of delivery when performed carefully with accuracy.
The previous obstetric history of the patient to be taken like number of live children, number of abortions, number of deaths.
 History of twins, hypertension, anemia, diabetes, preterm delivery etc in the previous pregnancy to be noted.
The mode of delivery in the previous pregnancy like previous caesarean section or normal delivery or instrumental delivery to be noted as it will influence the mode of delivery in the present pregnancy.
According to above history the woman can be graded as high risk or normal pregnancy.
The marital life of the women to be enquired, history of consanguinity to be noted as some diseases are common in consanguineous marriages.
Any treatment for infertility to be noted.
Family history of twins, hypertension, diabetes, heart diseases etc to be asked as they may affect her in present pregnancy.

Part -2: Examination and investigations

Bartholin glands

Bartholin glands are compound racemose glands.
Usually they will be in pea size.
Located slightly posterior and at the left and right openings of the vagina at 4° clock and 8° clock positions.
That will come at the level of upper two thirds and lower one third of labia minora.
They will present in superficial perineal pouch.
The acini in the gland will be lined by mucinous columnar cells.
They are homologous to bulbourethral glands in males.

Duct of the Bartholin gland will be around 1.5 to 2 cms length.
opens at the fossa navicularis or fossa of vestibule of vagina.
It is the grove between vaginal opening and hymen.
The duct will be lined by transitional epithelium.

Function: Bartholin gland secretions helps in maintaining the the moisture of vaginal epithelium.
They helps for lubrication during intercourse.

Pathology :
When the duct of the gland gets blocked, it will form bartholin cyst.
When the gland gets distended that will be lined by simple columnar epithelium.
Enlarged bartholin cyst will present as swelling near the vaginal opening, sometimes involving the labia minora.

If the cyst gets infected it will form abscess.

Antibiotic course with analgesic and anti - inflammatory drugs can treat the condition.
In case of repeated bartholin abscess, marsupalization may be needed.
Sitz bath helps in relieving the symptoms.


(The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box.  Thank you)

Lochial discharge in postpartum period (puerperium)

The period after delivery is called as postpartum or postnatal period.

It can also be called puerperium. 

This extends upto 6 weeks postpartum. 

During this period, all organs in the body will start to come back to pre pregnancy state. 

Uterus will become abdominal organ in 2 weeks. 

And comes to pre pregnancy size in 6 weeks.  

During puerperal period, the woman will have lochial discharge. 

Usually this can be seen for first 4 to 5 weeks. 

There are three stages in lochial discharge. 

Lochia rubra : During first four days to one week of delivery.

It mainly contains blood. 

Excessive blood flow may indicate postpartum hemorrhage due to retained products of conception, placental bits, infection etc.

Lochia serosa : It will be thin brownish or pinkish discharge.

It mainly contains serous exudate, erythrocytes, leukocytes, cervical mucus etc.

This stage can last for 10 to 14 days after postpartum. 

If lochia rubra or serosa stages extend more than expected, that can be due to postpartum hemorrhage, retained products etc.

Lochia alba:Whitish or yellowish discharge. 

It contains epithelial cells, leukocytes, cholesterol, fat, mucus and few red blood cells etc.

This extends from 2nd week to 4 to 6 weeks after delivery. 

If this discharge extends more than expected or usual menstrual flow smell alters that can indicate infection, local lesions like cervical erosion etc. 

Lochiostasis or lochioschesis is retained lochia in uterus. 

This can occur due to cervical stenosis, intrauterine adhesions etc. 

This can lead to lochiometra, distention of uterus due to lochia.

Sometimes this can get infected.

Lochiorrhea is excessive lochial discharge. 

It can occur due to infection.

After delivery generally in non lactating women menstrual flow may return around 6 weeks after delivery.
Lactating women may have amenorrhea for around 6 months after delivery also.
This period may vary from person to person.



(The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box.  Thank you )

Sitz bath

Procedure:
One tub should be taken with luke warm water.
Water should be up to the level to Immerse the required part.
Now in the water few millimeters of disinfect can be added.
Other than disinfect, salt, baking soda etc can be added as per the need.
Now the patient has to sit in that, so that water covers the required area like genital and anal region.

It is useful in relieving pain and inflammatory signs of:
-Anal fissure, hemorrhoids,
-Episiotomy, injuries or surgical wounds at the anal region,
-Folliculitis, boils etc at genital area or anal area etc.

Patient should sit in water for 10 to 15 minutes.
Taking sitz bath twice or thrice a day with give good relief.
In case of presence of infection, it acts as supportive therapy for antibiotics.

Tub fitting in toilet seat will be more convenient.

(The viewers are invited to share opinions or give suggestions or ask questions regarding the topic through comment box.  Thank you)

The possible causes for blood in saliva

The possible causes for blood in saliva are :
-Rough brushing, this can be due to hard brissels of brush, hurry while brushing etc.

-Tongue bite, some people may bite their tongue during sleeping and that can come out as bleeding in saliva in the morning.
-Injuries while cleaning the tongue, because of having long nails, hurry, using sharp tongue cleaners etc.
-Nasal bleeding, sometimes nasal bleeding can come through the mouth.
- General coagulation disorders, these can present as bleeding from gums etc.
- Vicarious bleeding, during the time of menstrual periods, some women may present with bleeding from other sites of the body.
-Injuries due to dentures, fall etc can present with bleeding from mouth.
- Bleeding from internal causes like oesophageal varices can present with bleeding.

-Carcinomas of the structures in the mouth or upper gastrointestinal track can present with bleeding in saliva.

AMH (Anti-Mullarian hormone)

AMH (Anti-Mullarian hormone) level measurement is used to estimate the ovarian reserve.
AMH is produced by the ovarian anthral follicles.
Normal AMH levels indicate good ovarian reserve.
And people with normal AMH levels will have high IVF success rate.

Normal range:
-AMH value of > 0.8 ng/ml indicates good ovarian reserve.
-AMH results between 0.7 to 3.5 can be taken as normal.
-Levels less than 0.7 indicates decreasing ovarian reserve.
-And levels above 3.5 indicates poly cystic ovary syndrome.

Doctors usually check for Anti-Mullarian hormone levels when planning for IVF.
If a woman want to postpone the pregnancy after 30 years, better to check AMH levels periodically to know their ovarian reserve.
If ovarian reserve appears as decreasing, better to plan for pregnancy early. 

Menorrhagia - definition, causes, differential diagnosis

Definition :
 Abnormally heavy or prolonged bleeding during periods is called menorrhagia.
Usually this can be taken as menstrual flow more than 80ml in a month.
Having heavy flow for more than 7days can also be considered as menorrhagia.
Passage of clots and difficulty in doing day to day activities can be seen menorrhagia.
This can occur due to many causes, like :
- Hormonal imbalance:
Imbalance between estrogen and progesterone can lead to menorrhagia.
-Dysfunction of ovaries:
Decreased production of progesterone from ovaries can lead to estrogen predominance. And that can lead to menorrhagia.
-Thyroid hormonal abnormalities
-Structural causes like adenomyosis, fibroids, endometrial polyps, cervical erosion etc.
- Pelvic inflammatory disease, endometriosis etc by increasing the local blood supply.
-Coagulation abnormalities
- Liver, kidney diseases.
-Intake of hormonal pills.
Especially repeated intake of emergency pills can lead to irregular cycles.
-Intrauterine contraceptive devices - Intake of drugs like anti inflammatory drugs, anticoagulants etc.

Around the age of menarche some amount of fluctuation in hormones is common.
That can lead to menorrhagia and that is called as puberty menorrhagia.
In perimenopausal age group also, some amount of irregularity in menstrual cycles is common due to hormonal imbalance.
But menorrhagia can occur at any age due to different causes as mentioned above.

Differential diagnosis :
°Bleeding in pregnancy, abortion. Some women may not aware of pregnancy and can interpret bleeding due to abortion, retained products etc as menorrhagia.
°Post coital bleeding.
Sometimes post coital tears can present as menorrhagia.


http://srsree.blogspot.com/2013/12/menorrhagia-diagnosis-investigations.html

General guidelines for usage of progesterone only contraceptive pills (mini pills).

Progesterone only pills are called mini pills.
-These contraceptive pills should be started on the first day of the cycle.
 -They can be started within first 5 days of the menstrual cycle.
In case of shorter menstrual cycle, if tablet started on around 5th day, better to take additional contraceptive method for first two days.
- They can be used during lactating period also.
They have to be started within 21 days after delivery.
-In case of abortion they have to be started within 7 days after abortion for better contraceptive effect.

-Pill should be taken on everyday without break, even during withdrawal bleeding.
-Pill should be taken at same time every day.
-Missing the time can lead to withdrawal bleeding and may decrease the protective effect.
-Better to prefer nights, as it is easy to remember in nights because lack of deviations.
-And better to take the pill after food to decrease side effects like nausea etc.
-If pill is missed:
• Within 3 hours, you can take that tablet.
• If 3 hours over, you can take the tablet when you remember, but should use additional contraceptive method for the next two days.
•If unprotected intercourse occurred on next two days after missing the pill, emergency contraceptive pill should be taken.
-Missing the pill can lead to withdrawal bleeding. Usually
this will subside soon.

Mini pills can present with side effects like intermenstrual spotting, break through bleeding, nausea, bloating sensation etc.
Some women may have delayed or absent periods also.
If there is any doubt regarding pregnancy, pregnancy test to be taken.
If test comes negative, pills can be continued as per the schedule irrespective of spotting.
In case of major side effects, tablets should be stopped and doctor to be consulted immediately. 

Elderly primigravidae - Care to be taken

Care to be taken during pregnancy:
- Mother should use folic acid tablets from one month before pregnancy to protect the baby from neural diseases.
-She should take protenecious diet, fruits etc.
-Carefully monitoring the blood pressure, blood sugar levels and maintaining them in optimal levels is recommended.
-Light exercises should be done to mobilize the joints and maintain weight gain and yoga can be done to overcome the tensions.
-To follow the well being of the baby ultrasound examination is recommended.
-To diagnose the Down's syndrome, nuchal translucency scan is recommended in first three months of pregnancy.
-Quadruple test, chorionic villus sampling, amniocentesis are other recommended tests.
-They have to under care of doctor through out the pregnancy and if complications occur better to be hospitalized and treated.
-Delivery to be planned carefully according to maternal and fetal condition.
In case of any expected fetal complications, neonatal unit must be nearby.

Elderly primigravidae-possible problems

Elderly primigravidae - Possible problems

Nowadays the incidence of elderly primigravidae is increasing due to change in the attitude of women towards their carrier, postponing pregnancy etc. Increasing infertility is also contributing to this.
If a woman conceives after 30yrs, she can be considered as elderly primigravidae.

Problems during pregnancy:
- Compared with youngsters, elderly pregnant women are more prone for hyperemesis gravidarum, means excessive vomitings in the first trimester of pregnancy and also pregnancy induced stress is more in them.
-Chances of getting pregnancy induced hypertension, gestational diabetes are also more.
-If they are already having hypertension or diabetes because of increasing age these may become aggravated during pregnancy.
-Chances of having preterm or intrauterine growth retarded babies are also more comparatively.
-Placental problems like decreased blood supply to placenta due to age related vascular changes can occur and also placenta previa is more common in these women compared with youngsters.
-Because of uterine inertia or because of other complicated factors chances of instrumental delivery or cesarean section are more in elderly women.

Problems to baby:
- The babies of elderly pregnant women may have chromosomes related problems. Like Down's syndrome which occurs due to trisomy of chromosome 21, means they will have three no.21 chromosomes instead of two.
This will affect the baby both mentally and physically.
The chances of having this syndrome increases with increasing age of the mother.
-Chances of having intrauterine growth retarded babies is more common due to placental insufficiency or maternal medical problems.
-Preterm babies are also more common to elderly women.
-In case of placenta previa, excessive bleeding will affect the baby also.
-Instrumental delivery or cesarean section will increase fetal morbidity also.

Elderly women -problems in fertility
Care to be taken in elderly primigravidae

Elderly women - Problems in fertility

Normally pregnancy is recommended between 20 to 30 years.
Usually after 30 years, the women can be considered as elderly women.
Generally after 30 years fertility decreases in women.
This can occur because of many things like,
-As age increases the function of ovaries, which are the organs which release ovum, will decrease.
- The number of ovarian follicles will decrease as age increases.
-And the remaining follicles also will not respond properly to the hormonal influence.
-Hormonal imbalance may also occur with increasing age.
-Comparatively increased possibility of problems like:
○ Infections  can occur to reproductive organs like ovaries, fallopian tubes etc called pelvic inflammatory disease. ○Endometriosis is another problem in which endometrium will grow on ovaries or fallopian tubes or on other organs which can affect reproduction ability.
- If the women uses some contraceptives like oral contraceptive pills for postponement of pregnancy after their stoppage regaining regular cycles will take some time and also drug related complications can occur.
- Possibility of occurrence of medical complications like diabetes, hypertention etc increase with age.
-The work tensions will also affect the women psychologically which may cause hormonal imbalance by affecting hypothalamic function. It will further increase the problem.
-Spouse factors can add to these.

Recommendations to overcome the problems:
- As per as possible better to plan pregnancy between 20 to 30 years.
-If not possible they have to plan their pregnancy and continue it under obstetrician guidance.
-They have to plan unprotected intercourse around the time of ovulation to increase the possibility of pregnant.

Investigations:
- Ultrasound examination is recommended to verify the status of uterus, ovaries, fallopian tubes and other surrounding organs.
-To know the functioning of the ovaries, on third day of the periods estimation of FSH (Follicular stimulating hormone) and LH( Lutenising hormone) should be done in women who are not conceived after one year of unprotected intercourse.
-Ovulation stimulating drugs are recommended in women having anovulatory cycles.
-If they do not succeed in natural way, artificial reproductive methods like IUI(Intra uterine insemination), IVF( In vitro fertilization), Surrogacy etc can be employed.

Possible problems in elderly pregnant woman
Care to be taken for elderly pregnant woman

Prostaglandins - in uterine atony, postpartum hemorrhage

Prostaglandins for uterine atony: PGF2 alfa- corboprost tromethamine can be used in case of uterine atony in injection form 250 micro g, intramuscularly.

Can be repeated if needed at 15 to 90 min period, with maximum of 8 doses.
Side effects:
diarrhea, hypertention, vomiting, fever, flushing, tachycardia, pulmonary airway and vascular constriction etc.

Other alternatives are:
- Rectally administered PGE2 20 mg suppositories.
-Misoprostol, 1000 micro g per rectally, with mean response time 1 to 4 min.


Prostaglandins for late PPH :
Late PPH (post partum hemorrhage) is a serious uterine hemorrhage developing 1 to 2 weeks in puerperium.
The causes may be abnormal involution of placental site, placental polyp etc.
PGE1 (misoprostol) can be used in this condition to stop hemorrhage along with curettage.

Other uses are like maintaining patency of ductus arteriosus and for healing of peptic ulcers etc.

Prostaglandins-types
Prostaglandin-routes of administration
Prostaglandins- in inducing abortions
Prostaglandins-induction of labor
Cervidril, misoprostol

Prostaglandins - in inducing labor- cervidil, misoprostol

Cervidil:
It is a device containing dinoprostone, with a small amount of water- miscible lubricant, should be placed in the post fornix of vagina.

The devise absorbs moisture and swells, releases dinoprostone at a rate of 0.3 mg per hour for 12hrs.
FHR(fetal heart rate) monitoring should be done from 15 to 30 min before placement to 15 min after removal.
Patient should remain recumbent for 2 hrs after keeping the device in place to prevent falling of device.
 The device can be removed by pulling the cord attached to it after 12 hrs or when active labor begins, or if uterine hyperstimulation occurs.

Misoprostol :
Misoprostol is a synthetic PGE1 analog.

Can be used as:
- 25 micrograms tablet form intravaginally, repeated every 4 to 6 hrs
- or orally 50 – 100 micro g tablet , to be repeated every 4 hrs.
During induction of labor misoprostol can be placed as 25 micro g tablet, intravaginally without the use of any gel.
Patient should remain in recumbent position for 30 min to prevent falling of tablet.
FHR monitoring should be done for 3 hrs.
Oxytocin augmentation can be done after 3 hrs if needed.
Side effects:
Hyper stimulation syndrome:
contraction for 90 sec or more and 5 contractions or more in 10 min.
 Tachysystole :
Six or more uterine contractions in 10 min for two consecutive 10 min period.
Hypersystole:
a single contraction of at least two minutes duration.
Misoprostol should not be used in women with uterine scars, as chances of rupture of uterus are there.

Prostaglandins-types
Prostaglandin-routes of administration
Prostaglandins-in inducing abortions
Prostaglandins-induction of labor
Prostaglandins- in PPH, uterine atony

Prostaglandins - in induction of labor

Prostaglandins for induction of labor :
Prostaglandins act on cervix to enable ripening there by initiating labor.
This can be caused by dilatating of smooth vessels in cervix, increasing collagen degradation, increasing hyaluronic acid, elastase, glycosaminoglycons.
And also by increasing chemotaxis for leukocytes, stimulation of IL- 8 and increasing the intracellular cal levels.
Different forms of prostaglandins can be used for induction of labor like,
Dinoprostone gel:

For placement of dinoprostone gel for induction of labor, patient should be selected carefully.
Patient should be afebrile with no active vaginal bleeding.
And FHR tracing should be reassuring.
Informed written consent should be given by the patient.
Bishop score(a score which indicates the status of cervical ripening) should be < 4.
We have to bring the gel to room temperature before insertion.
FHR monitoring and uterine activity should be monitored continuously from 15 to 30 min before insertion to 30 to 120 min after gel insertion.
For uneffaced cervix, 20 mm endocervical catheter should be used to introduce the gel into endocervix just below the level of the internal os.
In case of 50% effaced cervix, 10 mm endocervical catheter can be used.
Patient should remain in recumbent position for 30 min to prevent spillage of gel.
Dose may be repeated every 6 hrs, up to 3 doses in 24 hrs.
End point for ripening is, establishment of strong uterine contractions, or achieving Bishop score >/ 8, or change in maternal or fetal status.
Maximum dose of dinoprostone gel is 1.5 mg in 24 hrs.
After gel insertion should not start oxytocin for 6 to 12 hrs to protect from overstimulation.
Side effects: hyper stimulation, nausea, vomiting, diarrhea, fever etc.

Prostaglandins-types
Prostaglandin-routes of administration
Prostaglandins-in inducing abortions
Cervidril, misoprostol
Prostaglandins- in PPH, uterine atony

Prostaglandins - in inducing abortions

Uses of prostaglandins:
For first trimester(upto 12 weeks) abortions:
For first trimester abortion prostaglandins can be used in combination.
That is with mifepristone.
-Mifepristone 600mg orally, followed by a misoprostol 800 micro g vaginally a day later. Or mifepristone 600 mg followed by 400 micro g of misoprostol orally can be used. Or lower dose mifepristone 200 mg followed by 800micro g of misoprostol , 24 to 72 hrs later vaginally can also be used.
 -Repeated doses of misoprostol can be used for delayed expulsions.
 -Other regimes are Tomoxifen 20 mg daily for 4 days followed by misoprostol 800 micro g vaginally, second dose 24 hrs later if needed.
-Or Methotrexate 25 to 50 mg orally or 75 mg IM, followed by 800 micro g vaginally after a week.
-Misoprostol 800 micro g daily for 3 days can be used in late first trimester.
-In very early gestation single vaginal dose of 800 micro g, or multiple doses within 24 hrs are enough.
Infants born to mothers exposed to misoprostol, may have abnormal vascular development, mobius's syndrome, congenital facial paralysis with or without limb defects, equinovarus, arthogryposis etc.
Women with medical abortions experience more bleeding and cramping than spontaneous abortions.


For second trimister(12 to 20 weeks) abortions:
PGE2 (dinoprostone) can be used in the form of 20 mg suppositories kept in the post vaginal fornix.
Side effects:
nausea, vomiting, fever, diarrhea etc. Or PGE1 ( misoprostol) can be used 600 micro g vaginally followed by 400 micro g every 4 hrly.
But even after usage of prostaglandins, 2% of women may require curettage for retained placenta.

Prostaglandins-types
Prostaglandin-routes of administration
Prostaglandins-induction of labor
Cervidril, misoprostol
Prostaglandins- in PPH, uterine atony

Prostaglandins - Administration routes, Commercially available prostaglandins

Administration routes of prostaglandins:
By the mid 1980s prostaglandins had become established as the most effective pharmacological agents for inducing abortions and labor when the cervix is unripe.
A variety of administration routes had been employed during the preceding years, including oral, intravenous, sublingual, rectal, intra amniotic, extra amniotic, intra cervical, and vaginal administration.
The vaginal route is found to be the most acceptable, providing good efficacy and acceptability for the parturient and is now the preferred method of choice.


Types of prostaglandins commercially available:
Two forms of PGE2 are available commercially.
The first is Prostaglandin E2 (dinoprostone) formulated as gel and is placed inside the cervix but not above the internal os.
Prostaglandin E2 (dinoprostone) is licensed for the use of labour induction in the cases of viable pregnancies.
The application ( 3g gel / 0.5 mg dinoprostone) can be repeated in 6 hrs, not to exceed 3 doses in 24 hrs.
The second form is 10 mg of dinoprostone embedded in a mesh and is placed in the posterior fornix of vagina, this allows for control release of dinoprostone over 12 hrs, after which it is removed.

 Prostaglandin E1 analog (misoprostol) available in tablet form for induction of labor was described recently in a series of articles.
This is a synthetic prostaglandin, which is marketed as an antinuclear agent under the trade name cytotec.
Generally 25 or 50 micro g placed in the posterior fornix, has been shown in several studies to be quite effective in inducing cervical ripening and initiation of abortion or labor.
The application of medication can be repeated every 4 -6 hrs up to 5 doses.
The major risk of above prostaglandin preparation is uterine polysystoly, hyper stimulation, meconium stained liquor and fetal distress.
The women and fetus must be monitored for contractions, fetal wellbeing and changes in Bishop score.

Prostaglandins-types
Prostaglandin-routes of administration
Prostaglandins- in inducing abortions
Prostaglandins-induction of labor
Cervidril, misoprostol
Prostaglandins- in PPH, uterine atony

Prostaglandins - types

Prostaglandins:
Prostaglandins are derivatives of prostanoic acid.
With the property of acting as local hormones.
They are most effective pharmacological agents for inducing abortions and labor when the cervix is unripe.
Prostaglandins act through G-protein coupled receptors. PGD2- DP, PGI2 - IP, PEP2, PEP4 act by increasing intracellular C AMP.
PGF2 alfa - FP, PGE2- EP1, EP3 act by increasing intracellular calcium.

PGF2 alfa:
PGF2 alfa is responsible for initiation of menstruation.
It causes vasoconstrictor of endometrial spiral arteries.
It is luteolytic in women causes loss of luteal cells by increasing apoptotic cell death.
And signal endometrium to initiate molecular events leading to menstruation.
Side effects:
Symptoms mimic dysmenorrhea because of myometrial contraction & uterine ischemia.

PGI2:
PGI2 is the principal prostaglandin of endometrium.
Increases in late pregnancy.
It functions in regulation of blood pressure and coagulation.
Needed for the angiotensin resistance of normal pregnancy.

PGE2 & PGI2 :
PGE2 & PGI2 maintain uterine quiescence by increasing C AMP signaling.
They stimulate adenylcyclase activity in myometrium at 32 to 35wks leading to relaxation of vascular smooth muscle, vasodilatation.
At 39 to 40 wks, regional myometrial contractions in fundus occurs after initiation of parturition.
PGE2 synthesis in renal medulla is markedly increased in late pregnancy and it acts as natriuretic.

Prostaglandin-routes of administration
Prostaglandins- in inducing abortions
Prostaglandins-induction of labor
Cervidril, misoprostol
Prostaglandins- in PPH, uterine atony

Preterm labor with premature rupture of membranes(PROM)

 The time period from PROM to delivery is inversely proportional to the gestational age when the membranes ruptured.
PROM between 24-34 wks is identified in 1.7% of pregnancies it contributed to 20% of perinatal deaths.
In one study, by that time they presented 75% of women were already in labor and 5% delivered for other complications another 10% delivered within 48 hrs.
Only 7% delivered in 48 hrs or more, appear to benefited from delayed delivery with no neonatal deaths.

Diagnosis of preterm PROM:
Is usually obvious when there is history of sudden escape of watery amniotic fluid.
To be differentiated with urinary incontinence, intermittent normal vaginal discharge which is mucoid and thick in consistency, infected vaginal discharge which is foul smelling and associated with itching.
In clinical examination amniotic fluid pools in to vagina, when patient coughs gush of fluid comes out from vagina.
Sterile speculum examination confirms the fluid coming through the os.

Other tests to diagnose preterm PROM:
Measurement of phosphotidyl glycerol, nitrazine test, fern test or to detect alfafetoprotien in the fluid.
Ultrasound examination showing oligohydromnios may contribute to diagnosis.
Some other tests like injecting indigo caramine or fluorescein into amniotic cavity or immunochromatographic method to detect placental microglobulin 1 can be used.

Complications of premature PROM: Most common complication is preterm delivery.
Other maternal complications : Chorioamnionitis, placental abruption , retained placenta , PPH(post partum haemorrhage) and endometritis.
Fetal complications :
Infection leading to sepsis, oligohydromnios leading to pulmonary hypoplasia and hospitalization.
Most women enter in labor within a week or less after membranes rupture.

Intentional delivery :
Prior to mid 1970s labor was usually induced in women with PROM because of fear of infection.
Neonatal mortality is seen in both intentional delivery and in expectant management.

Expectant management:
Remote from term conservative management is advisable, provided acute cord complications like prolapse and compression , placental abruption and fetal distress are excluded.

Between 20 – 24wks:
The volume of amniotic fluid remaining after rupture of membranes appears to have prognostic importance.
Women developing oligohydromnios should be delivered before 25wks.
Women with adequate amniotic fluid can be delivered in 3rd trimester.

Between 24-34wks:
If conservative management is to be done, digital vaginal examination must be avoided as it increases the risk of infection and reduces the latent period for labor.
Antibiotics should be administered as they help to prolong the latency and improve perinatal outcomes.
 Corticosteroids should be given, but multiple courses may increase the risk of infection.
Short term tocolytics may be consider for administration of steroids and antibiotics and also to facilitate maternal transport.
Long term tocolytics do not have a role.
On conservative management we have to look for the features of chorioamnionitis, with signs like tachycardia, leukocytosis, fever, uterine tenderness, foul smelling liquor etc.
Delivery must be planed when there is any evidence of clinical infection.
Chorioamnionitis is a known risk factor for cerebral palsy in new borns can also develop sepsis , respiratory distress syndrome, intra ventricular hemorrhage, periventricular leukomalacia.
Fetal surveillance by NST(non stress test) and biophysical profile are to be done daily.
Other indications for terminating conservative management are non reassuring fetal monitoring, pregnancy reaching 34wks.

Between 34-36wks:
Management is controversial between 34-36wks.
Advantages of gaining fetal maturity to be balanced against chorioamnionitis.
It may be preferable to induce labor unless the fetal lung maturity or gestational age is doubtful.
Fetal membranes have very limited ability to heel spontaneously.
 Fibrin glue intra cervical instillation, gelatin sponge or maternal platelets and cryoprecipitates intra amniotic instillation and endoscopic placement of collagen graft over fetal membrane defect have been tried but safety and efficacy of these methods remain unproven.

Intra partum management:
The more immature the fetus the greater the risks of labor and delivery.
 Labor either induced or spontaneous, abnormalities of FHS(feta heart sounds) and uterine contractions should be sort.
Continuous electronic monitoring is preferred.
In case of ruptured membranes patient and fetal tachycardia suggest sepsis.
Umbilical artery blood PH < 7 suggest neonatal complications like respiratory distress syndrome.
 Antibiotics intravenously every 6th hrly to be given until delivery.

 Delivery:
Episiotomy can be given if vaginal out let is not relaxed.
Routine forceps are not recommended as pre term fetal head is fragile and can lead to intracranial hemorrhage.
If specialized personale and facilities are available the survival of preterm neonates will be good.

The problems of premature neonates:
As the body systems are functionally immature, decreased physical activities, poor suckling, swallowing and sluggish reflexes will be present.
Resuscitation is difficult because of small size and stiff lungs.
Other problems like sepsis, necrotising enterocolitis, retinopathy of prematurity and germinal matrix hemorrhage, respiratory complications like inadequate expansion of lungs , respiratory distress syndrome, hypoglycemia, hypothermia, nutritional deficiency etc may occur.


Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes

Preterm labor - Tocolytics

There are many groups of tocolytics, like:
1.Beta adrenergic receptor agonists: React with beta adrenergic receptors to reduce intracellular ionized calcium and prevent activation of myometrial contractile proteins.
Ritodrine and terbutaline has been used but only ritodrine has been approved.
a.Ritodrine:
 Neonates whose mothers were treated with ritodrine had less mortality and respiratory distress, they achieved a gestational age of 36wks or birth wt of 2500g or more.
 The tocolytic effects of ritodrine may be transient due to beta adrenergic receptor desensitization.
Ritodrine infusion is started at a dose of 50 micrograms/ min and increased in every 20 min until uterus is quiescent or side effects limit escalation of dose.
The maximum recommended infusion rate is 350 micrograms/ min.
If pulse rate is more than 120/min infusion rate should not be increased.
Potential side effects of beta agonists are palpitations, tremors.
Serious complications are pulmonary edema, hyperglycemia, hypokalemia, hypotension, arrhythmias, myocardial ischemia.
 Tocolytics are the third most common cause of acute respiratory distress and death of pregnant women.
Beta agonists cause retention of sodium and water with time usually 24hrs to 48hrs, they can lead to volume overload.
Increased capillary permeability, disturbance of cardiac rhythm and myocardial ischemia can occur.
 Myocardial sepsis appreciably increases this risk.
Ritodrine was withdrawn voluntarily in 2003 from US.
Contraindications for the use of Ritodrine: diabetes  mellitus, cardiac disease, digitalis use, severe anemia, hyperthyroidism and hypertension.

b.Terbutaline:
It is not been used as much as ritodrine, but is effective in temporarily arresting contractions when given parenterally.
Dose is 5 to 10 micrograms/min, increased every 10 to 15 min to a maximum of 80 micrograms/min.
Can cause hyperglycaemia and side effects are similar to ritodrine.

2 . Magnesium sulphate :
Ionic magnesium in a sufficiently high concentration can alter myometrial contractility by acting as a calcium antagonists.
Following a loading dose of 4g, infusion is started at 2g/hr and infusion rate carefully titrated according to uterine response and toxicity.
Once uterus is relaxed, the infusion rate is maintained at its lowest effective rate for 12 to 24 hrs and then weaned off.
Monitor for evidence of hypermagnesemia, which may present as flushing, nausea, headache, drowsiness, blurred vision, respiratory depression, weakness diplopia, muscular paralysis or cardiac arrest.
Contraindications :
myasthenia gravis, heart block, renal disease, recent myocardial infarction.

3.Prostaglandin inhibitors:
Prostaglandins are involved in the establishment of contractions of normal labor.
Group of enzymes collectively termed PG synthase is responsible for the conversion of free arachidonic acid to PGs.
Antagonists act by blocking this system.
Eg.Indomethasin: Oral loading dose 50 to 100 mg, rectal loading dose100 to 200mg.
Followed by 25 to 50 mg every 4 to 6 hrs.
Serum concentration usually peaks 1 to 2hrs after oral administration.
 Rectal administration peaks sightly sooner.
Oligohydramnios can develop if used for more than 24 to 48 hrs .
If detected early have to discontinue.
Fetal complications:
Premature closure of patent ductus arterioses, oligohydromnios, necrotising enterocolitis etc.
 To mother:
Headache, dizziness, gastritis, vomiting, diarrhea etc. Contraindications:
Allergy, drug induced asthma, peptic ulcer, hepatic and renal dysfunction.

4.Calcium channel blockers:
Myometrial activity is directly related to cytoplasmic free calcium, and a reduction in its concentration inhibits contraction.
These are safer and more effective tocolytics than beta mimetics.
 Nifedipine is the most commonly used .
Nifedipine: Dosage 20 mg followed by 10 to 20 mg every 6 to 8 hr.
Nifedipine does not significantly prolong pregnancy if treated with IV Mg so4 for pre term labor initially.
Nifedipine enhances the neuromuscular blocking effects of Mg that can interfere with pulmonary and cardiac function.
 Side effects – dizziness, flushing, headache, peripheral edema.
It decreases vascular resistance leading to hypotention and decrease in uteroplacental  perfusion.
Fetus can have hypercapnea, acidosis, hypothermia etc.
 Contraindications :
 CCF(congestive cardiac failure), aortic stenosis.

5.Atosiban:
This nona peptide oxytocine analogue is a competitive antagonist of oxytocin, decreases oxytocin induced contractions.
Dose – 6.75 mg bolus over 1min followed by infusion at 18mg per hr for 3hrs and then 6mg per hr for up to 45 hrs.
Side effects:
Nausea, chest pain, vomiting, dyspnoea.

6.Nitric oxide donors:
Example: Nitroglycerine.
Though these potent smooth muscle relaxants affect the vasculature of gut and uterus are not showed to be superior to other tocolytics.
If tocolytics are given they should be given concomitantly with corticosteroids.
As perinatal outcomes in preterm neonates are generally good after 34wks, most practitioners do not recommend tocolytics at or after 34wks.


Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes

Preterm labor -Management

Treatment requires correct diagnosis of establishment of preterm labor.
Corner stone of management of preterm labor is to avoid delivery prior to 34 weeks if possible.
Tocolytics can be used to halt uterine contractions and steroids to reduce perinatal morbidity.
 Amniocentesis can be done to diagnose intra amniotic infection , but it has not been shown to be associated with improved pregnancy outcomes in women with or without membrane rupture.

Glucocorticoid therapy to enhance fetal lung maturity: Steroids, betamethasone and dexamethasone are effective in preventing respiratory distress and neonatal mortality if birth was delayed for at least 24 hrs after initiation of therapy.
 Its effect persisted for upto 7 days after completion of steroid therapy.

 Recommended regimens :
A single course of two doses 12 mg of betamethasone given intramuscularly 24 hrs apart or 4 doses of 6 mg dexamethasone given intramuscularly 12 hours apart.
Steroids also decrease the risk of intra ventricular hemorrhage and neonatal mortality.
Multiple maternal doses of dexamethasone is associated with increased risk of leucomalacia and neurodevelopmental abnormalities.
Though betamethasone is better than dexamethasone, multiple doses are associated with early onset neonatal sepsis, chorioamnionitis, neonatal death, IUGR.
Short term maternal adverse effects include pulmonary edema, infection and more difficult glucose control in diabetic women.
No longterm adverse effects reported.

Thyrotropin releasing hormone for fetal lung maturity:
T3 enhances surfactant synthesis. But TRH(thyrotropin releasing hormone) administration unchanged the neonatal lung synthesis.
Phenobarbital and vit-k may reduce neonatal intracranial hemorrhage but it is not proved.

Tocolytics:
These are the drugs used to prevent premature births and to prolong pregnancy.
But the overall incidence of preterm labor before 34 wks has not been found to be reduced with the use of tocolytics.
The end points of various studies has taken as cessation of contractions for 24hrs, 48hrs and 7days.
Meta analysis of randomized trials have shown that tocolytics reduce the risk of delivery within 24hrs and 48hrs.
The major advantages of tocolytics are possibility of administering steroid therapy.
And in utero transfer for better neonatal outcome.


Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes

Preterm labor - Cervical circlage

Provides a mechanical barrier to prevent untimely cervical dilatation, but decreasing of preterm labor is uncertain.
In high risk women serial cervical length measurements by TVS are performed between 12 to 24weeks and circlage is undertaken if indicated (cervix < 25mm).
Doing this can significantly reduce the need for circlage without having any adverse effect on perinatal outcome.
Women with encirclage in situ must be counseled to report if pain abdomen occurs, which may be due to premature uterine contractions or rupture of membranes.
In case of foul smelling vaginal discharge or vaginal bleeding also they have to report.
Circlage may need to be removed if the uterine contractions cannot be arrested with tocolytics, to prevent tearing and damage to the cervix.
 With preterm PROM also conservative management can be done, if there are no uterine contractions and no evidence of infection.
The circlage to be removed routinely around 37 weeks.

Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes

Preterm labor - Progesterone

Progesterone in maintenance of pregnancy:
In animal studies, medroxy progesterone treatment prevented labor and possessed anti-inflammatory property in vivo.
As medroxy progesterone suppresses the activation of both TH1 & TH2 cytokine pathways in the uterus and cervix.
These cytokines thought to play a role in maintenance of pregnancy and later in initiation of parturition.
Progesterone also responsible for tightening of cervix.
Most commonly used progestin in human clinical trials is 17 alfa hydroxy progesterone caproate. Intramuscular once a week, to women at risk for preterm labor.
And 100mg of vaginal suppository of natural progesterone can also be used.
One concept is that progesterone withdrawal does not precede the initiation of parturition.
So the use of progesterone to maintain uterine quiescence and to block labor initiation deserves continued evaluation.


Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes

Preterm labor - Bacterial vaginosis

Bacterial vaginosis:
Bacterial vaginosis is associated with excess rates of preterm birth.
 Oral metronidazole found to resolve bacterial vaginosis for at least 10 wks in 78% of treated pregnant women.
Metronidazole plus erythromycin or metronidazole plus azithromycin can also be used.
 Studies in which earlier treatment was initiated are more promising.
 Oral clindamycin 300mg twice daily for 5 days associated with fewer pregnancy losses between 13 to 24 weeks and fewer spontaneous preterm births.
If women with bacterial vaginosis underwent in vitro fertilization, rate of conception is similar but an increased risk of first trimester loss compared with that of uninfected women.
Group B streptococcus(GBS) can cause clinical infections in pregnant women, but most women are asymptomatic.
Presence of GBS colonization in pregnancy has not been found to increase rates of preterm delivery.

Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes

Preterm labor - Prevention

Prevention of preterm labor:
By reducing the background risk factors.
By screening symptomatic and asymptomatic women with the risk of preterm delivery.
Treating the women with threatened and established preterm labor.
Improving the nutrition, providing rest, increasing hydration.
Giving psychological support.
Have to screen for risk factors, monitor the uterine activity.
 Assessing the markers of preterm labour, eg. Fibronectin, ultrasonographic changes.
By detecting and treating infections.
In selected patients, we can go for cervical circlage, progestin therapy or tocolytics.

Antenatal care:
Prenatal visits to be increased. Home visits should include in prenatal visits.
Social and psychological support needed.
Nutritional counseling to be done.

 Nutritional intervention:
Women with low pre-pregnancy BMI and poor weight gain during pregnancy have a high risk for preterm labor.
Zinc, Mg and fish oil supplementation show promising results in decreasing preterm labor.
 Iron supplementation have not shown reduction in the incidence of preterm labor.
Calcium supplementation reduced preterm labour in women who were at high risk of developing hypertension during pregnancy.
 Vit-C supplementation found to increase the risk of preterm labor.

 Bed rest: There is no conclusive evidence that bed rest prevents preterm labor. Bed rest for 3 days or more may increase thrombo embolic complications.

Hydration and sedation: Hydration with 500ml of crystalloid over 30 min and 8 to 12 mg intramuscular morphine sulphate had outcomes similar to those with best rest.
 In some women contractions treated with 0.25mg subcutaneous terbutaline ceased quickly.

HUAM: Home uterine activity monitoring(HUAM) with a device which consists of a tocodynamometer worn as a belt, a data recorder and transmitter. Uterine activity is monitored for two to one hour periods in a day and analyzed for evidence of onset of preterm labor. But its utility failed to show better outcome in preventing preterm labor.

Anti microbials: Antimicrobial treatment of women with preterm labor for the sole purpose of preventing delivery is generally not recommended.
As primary outcomes of neonatal death, chronic lung disease and major cerebral abnormality are similar in both antimicrobial or placebo therapy groups.


Preterm labor-etiologicalfactors
Preterm labor-pathogenesis and diagnosis
Preterm labor-investigations
Preterm labor-prediction
Preterm labor-complications
Preterm labor -prevention
Preterm labor-bacterialvaginosis
Preterm labor-progesterone.html
Preterm labor-cervical circlage
Pretem labor-management
Preterm labor-tocolytics
Preterm labor-with premature rupture of membranes