Osteoporosis - Signs and symptoms

Symptoms & signs :

Back pain, decrease in height & mobility, postural deformities as kyphotic dowager's hump. Consequent pulmonary gastrointestinal and bladder dysfunction etc.

Vertebral bone:

Is especially vulnerable to fractures as bone loss begins as early as 20yrs of age.
Back ache is major clinical symptom of vertebral compression fracture.
Pain with a fracture is acute and subsides over 2 to 3 months but lingers as chronic low back pain due to increasing lumbar lardosis. The pain subsides with in 6 months unless multiple fractures produce a picture of constant pain.
App 50% of women > 65 yrs have spinal compression fractures about 2/3 are clinically unrecognized. Each complete compression fracture causes the loss of app 1 cm in ht.
The average untreated post menopausal women can expect to shrink 2.5inc .
The common sites for vertebral fractures are the 12th thorasic and the first three lumbar vertebrae. These physical changes have a negative impact on body image and self esteem.

Colle’s fracture:
There is 10 fold increase in distal forearm fracture in as the age progress from age 35 to 60 yrs. Women have a 15% lifetime risk of fore arm fractures.
Colle's fractures are the most common fractures among white women until age of 75, when hip fractures more common.

Head of femur fractures :

The incidence of hip fractures increase with age from 0.3/1000 in 45 yrs to 20/1000 in 85yrs.
White women have 14% lifetime risk and black women6%.
The fractures carries an increase risk of morbidity and mortality 25% of pts over the age of 50 yrs with hip fractures die due to fracture or its complications.
Like surgical, embolic, cardiopulmonary with in 1yr. Prevention of fractures have only minor impact on longetivity as mortality is mostly due to underlying conditions.

Toothloss :
Oral alveolar bone loss which can lead to loss of teeth strongly correlated with osteoporosis and the salutary effect of estrogen on skeletal bone mass.
Tooth loss also correlated with the use of cigarettes, a recognised contributor to bone loss. Individuals at an increased risk for fractures can be identified by a careful history.

Changes of bone remodeling
Pathophysiology
Signs and symptoms
Risk factors and investigations
Investigations
Diagnostic tests and biochemical markers
Hormonal treatment
Estrogen modulators, calcium
Vitamin D
Bisphosphonates
Calcitonin, Fluoride, Tibolone
Prevention

Osteoporosis - Pathophysiology

Pathophysiology of osteoporosis:
Low bone mass & micro architectural deterioration of bone tissue leading to increased fragility and a consequent increase in the risk of fractures even with little or no trauma.

Bone mass at the time of menopause and rate of  bone loss following it, influence subsequent risk of fractures.
Peak bone mass is influenced by heredity and endocrine factors. After 30yrs in most of people slow decrease in bone mass density occurs approximately 0.7% per year.
This decrease accelerates after menopause and upto 5% of trabicular bone and 1.5% of total bone mass decrease occur per year. Trabicular bone resorption and formation occur 4 to 8 times as fast as cortical bone.
In the first 20 yrs following menopause 50% reduction in trabicular bone and 30% reduction in cortical bone occurs.
In absence of estrogen, osteoclastic activity increases leading to increased bone resorption by classic pathway involving genomic transcription by hormone receptors and a nongenomic pathway inhibits apoptosis.
Estrogen increases the availability of vitamin D which increase the absorption of calcium.
Estrogen also modulates the production of bone resorbing cytokines such as interleukin 1&6, bone stimulating factors as insulin like growth factors 1&2, colony stimulating factors, osteoprotegerin, tranforming growth factor-beta.
Estrogen is important hormone both in males & females.
Men with mutation in estrogen receptor alpha have aromatase deficiency grow slowly and have markedly reduced bone densities. Bone mass adjusted for body size is greater in black women than whites.
But they are subject to similar risk factors as thinness, alcohol consumption etc.
Around 75% of bone loss that occurs in women during the first 15yrs after menopause is due to estrogen deficiency rather than to aging it self.
Risk of fracture depends on two factors, the bone mass achieved at maturity and the subsequent bone loss.
The bone density, which is the threshold for vertebral fracture is only slightly lower than the lower limit of normal for premenopausal women.
Changes of bone remodeling
Pathophysiology
Signs and symptoms
Risk factors and investigations
Investigations
Diagnostic tests and biochemical markers
Hormonal treatment
Estrogen modulators, calcium
Vitamin D
Bisphosphonates
Calcitonin, Fluoride, Tibolone
Prevention

Osteoporosis - Changes of bone remodelling

Osteoporosis is the most prevalent bone problem in the elderly.
This condition presents with decreased bone mass with a normal ratio of mineral to matrix leading to an increase in fractures.
It is four times more common in women than men.

Nowadays the prevalence of osteoporosis is increasing may be due to decreased physical activity & less parity.
Other factors are dietary decrease in calcium, habits like smoking etc.

Changes of bone remodelling in osteoporosis:
Bone is a very active organ, a continuous process called bone remodeling, involves constant resorption - osteoclastic activity and bone formation - osteoblastic activity.
These cells derived from bone marrow progenitors, osteoblasts from mesenchymal stem cells and osteoclasts from hematopoietic white cell lineage.
Cytokines are involved in this in development process regulated by sex steroids.
Aging and loss of estrogen both lead to excessive osteoclastic activity.
A decreased calcium intake and/or decreased absorption lowers the serum ionized calcium level which stimulates parathyroid hormone(pth), it mobilizes calcium from bone by stimulating osteoclastic activity.
Deficiency of estrogen is associated with greater responsiveness of bone to parathyroid hormone.
Pathophysiology
Signs and symptoms
Risk factors and investigations
Investigations
Diagnostic tests and biochemical markers
Hormonal treatment
Estrogen modulators, calcium
Vitamin D
Bisphosphonates
Calcitonin, Fluoride, Tibolone
Prevention

Ovarian tumors - management of malignant tumors - part 6

4.Radiotherapy:
Abdominal radiotherapy gives salvage treatment with high morbidity. Dysgerminomas
 are very sensitive to radiation, but lead to infertility.

5.Immunotherapy:
Cytokines like interferon-a, r and interleukin-2 are used.
Monoclonal antibodies are directed towards ovarian cancer associated antigens.
Others are CA125 – ovarex, HMFG – antimucin MonAb, Herceptin – breast ca.

6.Hormonal therapy:
Progestational agents : Used in the treatment of recurrent well differentiated endometrioid carcinomas.
Tamoxifen : For well differentiated ca.
Leuprolide acetate: Is a gonadotropin agonist.
Aromatase inhibitors : letrozole, anastrazole, exemestane for breast ca and relapsed ovarian ca. 

Ovarian tumors - management of malignant tumors - part 5

3.Primary chemotherapy for ovarian tumors:
For epithelial tumours : platinum based chemotherapy (cisplatin/carboplatin and paclitaxel)to be given.
For sex cord stromal tumours : platinum based chemotherapy (BEP or paclitaxel/carboplatin)can be given.
For germ cell tumour : BEP is useful.
Intraperitoneal chemotherapy: In optimally cytoreduced advanced ovarian cancer, Paclitaxel and cisplatin are administered via an intraperitoneal catheter.
Median duration of survival was more with this therapy.

Disadvantages :
Toxicity :hematologic, gastrointestinal, neurologic and metabolic complications are more. Catheter related complications can occur.
Not useful in the presence of extensive adhesions or extraperitoneal disease.
Basis: Ovarian cancer remains confined to the peritoneal cavity for a long time during its natural history.
Higher concentrations in the peritoneal cavity than anywhere else.
Higher concentrations at the tumor site and less systemic toxicity.

Ideal drug:
Neither a too  small molecule (it does not stay long in the peritoneal cavity).
Nor a too  big  molecule (it does not enter systemic circulation in adequate concentration).
Cisplatin & Carboplatin – Good intra peritoneal & systemic concentrations.
Paclitaxel – Very good intra peritoneal concentration but poor systemic concentration. (large molecule).
Most studies have used combination of cisplatin and paclitaxel.

Neoadjuvant chemotherapy:
Few cycles of chemotherapy before debulking surgery.
May dry up the effusions, improve patient's performance, decreases postoperative morbidity. 

Ovarian tumors - management of malignant tumors - part 4

Second look laparotomy:
Is performed on a patient with no clinical evidence of persistant tumour for the purpose of determining disease status after a planned interval of treatment with chemotherapy.
It is identical to staging laparotomy. Vertical midline incision to be given.
Cytological washings can be taken. Complete abdominal inspection and palpation can be done.
Biopsy from persistant disease, peritoneal surfaces, omentum, retroperitoneal nodes, sites of previously documented tumour,adhesions can be taken.
Laparoscopy is an alternative.

Findings :
Negative : grossly and pathologically negative (30-50%). Microscopically positive : grossly negative, pathologically positive (20%).
Macroscopically positive : grossly and pathologically positive (30-50%).
Variables associated with outcome are initial stage, tumour grade,size of the residual tumour and largest metastatic tumour before treatment.
Findings correlate with subsequent outcome and survival.
Not recommended as it did not influence the survival.
Performed selectively in setting where clinical trials are going on secondary cytoreductive surgery. Cytoreductive surgery performed in patients whoare partial responders or non-responders to primary chemotherapy.
Have recurrence after primary therapy and prolonged disease free interval off therapy (> 6 months). Undergo a suboptimal debulking followed by chemotherapy.
Have persistant macroscopic tumour at second-look laparotomy. Principal setting is for platinum-sensitive recurrent disease.

Ovarian tumors - management of malignant tumors - part 3

2.Primary cytoreductive surgery or debulking:
It is a surgery done to remove the primary tumour as well as associated metastatic disease as much as possible.
Optimal debulking – minimal residual disease = 1-2cm in greatest diameter.
 It reduces the volume of ascites.
It is useful in large tumours containing poorly vascularised anoxic areas not accessible to cytotoxic agents and radiation. Removal of omental cake alleviates nausea and early satiety.
Removal of intestinal metastases restores adequate intestinal function.
Improvement of overall nutritional status and ability to tolerate chemotherapy.
Useful in larger tumours have greater proportion of cells in resting phase which are less sensitive to cytotoxic agents.
Useful in phenotypically resistant clones present in large metastatic masses.
Includes pelvic tumour resection, intestinal resection, omentectomy, resection of other metastases.
The performance of debulking operation as early as possible in the course of patient's treatment is considered the standard of care.

Interval cytoreduction:
It is true secondary cytoreduction after suboptimal primary cytoreduction and 3 cycles of chemotherapy.
 Primary cytoreductive procedure after a few cycles of chemotherapy. In patients who are poor surgical candidates because of debilitated state related to massive effusion or comorbid conditions.
Referred to oncologist after surgical or nonsurgical biopsy.
With advanced cancer predicted to be suboptimally resected.

Advantages :
To operate on a patient with an improved nutritional status, smaller tumour burden, superior perioperative risk.
Optimal debulking possible. Reduced surgical morbidity.

Ovarian tumors - management of malignant tumors-part 2

FIGO staging of ovarian tumors Stage I:
Growth limited to the ovaries.
Ia - Growth limited to one ovary, no ascites containing malignant cells. No tumor on the external surface, capsule intact.
Ib - Growth limited to both ovaries, no ascites containing malignant cells. No tumor on the  external surfaces, capsule intact.
Ic - Tumor either stage Ia or Ib but with tumor on the surface of one or both ovaries, or with capsule ruptured, or with ascites present containing malignant cells or with positive peritoneal washings.

Stage II:
Growth involving one or both ovaries with pelvic extension.
IIa - Extension and/or metastases to the uterus and/or fallopian tubes.
IIb - Extension to other pelvic tissues.
IIc - Tumor either stage IIa or IIb but with tumor on the surface of one or both ovaries or with capsule(s) ruptured or with ascites present containing malignant cells or with positive peritoneal washings.

Stage III:
Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastasis equals stage III. Tumor is limited to the true pelvis, but with histologically proven malignant extension to small bowel or omentum.
IIIa -Tumor grossly limited to the true pelvis with  negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces.
IIIb -Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Nodes negative.
IIIc -Abdominal implants >2 cm in diameter or positive retroperitoneal or inguinal nodes or both.

Stage IV:
Growth involving one or both ovaries with distant metastasis. If pleural effusion is present, there must be positive cytologic test results to allot a case to stage IV. Parenchymal liver metastasis equals stage IV. 

Ovarian tumors - management of malignant tumors -part 1

Malignant ovarian tumour: Management of malignant ovarian tumors depends on age, parity, type of tumour, stage of tumour. 1.Surgical staging
2.Definitive surgery or debulking 3.Chemotherapy
4.Radiotherapy
5.Immunotherapy
6.Hormonal therapy

1.Surgical staging of ovarian tumors:
To do the surgical staging,vertical midline or paramedian incision to be given.
It should be adequate enough to allow excision of primary tumour with its capsule intact.
It can be extended upwards.
It will give adequate access to upper abdomen.
Low transverse incision – In this rectus muscle will be divided or detached from pubic symphisis or can be converted to J shaped incision.
Evacuation of ascites or multiple cytologic washings can be done. Volume of ascitic fluid recorded and submitted (min. 25ml) for cytologic evaluation.
If no free fluid found separate saline washings (50-100ml) from a)pelvic cul-de-sac b)right paracolic space c)left paracolic space d)undersurface of each hemidiaphragm can be taken. Ovarian tumour to be inspected (papillary excrescences, rupture of capsule), removed and sent for frozen section.
Removal of opposite ovary and uterus depending on other factors. Complete abdominal inspection and palpation to be done. Peritoneal surfaces and intraabdominal viscera, the peritoneum of cul-de-sac, small bowel mesentery, ascending colon, liver, omentum, undersurface of right and left hemidiaphgram, stomach, transverse colon, spleen, descending colon, bladder peritoneumin can be examined in a systematic fashion.
All suspicious areas and adhesions to be biopsied.
If no visible disease found, biopsies from cul-de-sac peritoneum, bladder peritoneum, both lateral pelvic walls, paracolic peritoneum bilaterally, undersurface of right hemidiaphgram can be taken. Infracolic omentectomy – to be done for epithelial ovarian ca. Omental wedge biopsy – for germcell or stromal tumours. Appendicectomy - in case of mucinous epithelial ca.
Pelvic and paraaortic lymphnodes explored on both sides.
Frozen section of enlarged lymphnode, formal pelvic lymphadenectomy are to be sent. Careful documentation of the findings to be done. 

Ovarian tumors - management of ovarian cysts, benign and borderline tumors

Management of ovarian cysts and tumors:
The management depends on the age of the patient, parity, nature of the tumour, desire to retain fertility and ovarian function.

Functional ovarian cyst:
Needs sometimes only observation. Sometimes size decreases with the usage of OCP(oral contraceptive pills).
Surgery may be needed in resistant cases.
If complications like torsion, rupture,chronic pelvic pain, non regression or increasing size occurs unilateral ovariotomy or cystectomy in young women and total abdominal hysterectomy(TAH) & bilateral salpingo oopherectomy(BSO) in perimenopausal women to be done.

 Benign ovarian tumour:
In case of benign tumors unilateral ovariotomy or cystectomy in young women can be done.
TAH & BSO(total abdominal hysterectomy with bilateral salpingo oopherectomy) to be done in perimenopausal women. Laparoscopic cystectomy or ovariotomy can also be done.

Pitfalls of laparoscopy:
Potential for spillage of cyst contents or disruption of malignancy.
Potential for incomplete removal of tumour.
Increased duration and cost.

Borderline ovarian tumour:
In case of borderline tumors TAH and BSO can be done.
Unilateral ovariotomy can be done. Patient needs follow up.

Ovarian tumors - Differances between benign and malignant tumors

Benign tumors:
-The onset of benign tumors can occur at young age to middle age.
-Benign tumors are slow growing.
- They are normally unilateral.
-Benign tumors are mobile.
-They will normally present with cystic consistency.
-Normally with no ascitic fluid or nodules in pouch of douglas.
-Ultrasound shows, unilocular or multilocular cyst with thin capsule, thin septum and thin papillary projections.
-Gross appearance presents with intact capsule, no adhesions, no peritoneal seedlings.

Malignant tumors:
-The onset of malignant tumors occurs at extremes of age.
-They grow rapidly.
-They present normally biilaterally. -They will be fixed to surrounding structures normally.
-They present with solid or variegated consistency.
-Normally there will be ascitic fluid and nodules in pouch of douglas.
-Ultrasound shows, solid or cystic consistency with echogenic areas, with thick capsule, thick >5mm septum and coarse papillary projections.
-Gross appearance showing intact or ruptured capsule, with adhesions,haemorrhagic fluid, with peritoneal seedlings etc. 

Ovarian tumors - investigations

Investigations to detect ovarian tumors:
Investigations are used to establish the diagnosis.
To determine the anatomic location, size, and morphology of ovarian tumour as well as possible sites of metastases.
To assess the patient's general condition and ability to undergo a major surgical procedure.
To exclude other primary cancers metastasizing to ovary.

Ultrasound :
Trans vaginal ultrasonography is more accurate for assessing ovarian tumour size and morphology.
This is used to confirm the origin of tumour.
To know the size of the tumor.
To identify the morphology of the tumor.
To differentiate between benign or malignant tumors.
To know the presence of ascites.
To esimate the metastases.

Color flow doppler :
Adds information on neovascularisation and probability of tumour being malignant.

 CT/MRI :
Used to know the extent of the spread of the tumour.
They can recognise the lymphnode involment : Pelvic and paraaortic lymphnodes > 1cm.

FNAC and ascitic fluid cytology: Used to know the type of the tumor and peritoneal spillage of the tumor. 

Chest radiograph and IVP:
Will give the extent of the tumor.

Endometrial sampling:
Is used to know the type and peritoneal spillage of the tumor leading to secondaries in ovary.

 Routine haematologic, biochemical testing, ECG:
Are done to know the general condition of the patient and during preparation for treatment procedures.

Barium meal & enema, upper GI endoscopy, colonoscopy, mammography:
Are done to know the extent of the tumor.

Tumour markers of different ovarian tumors:
These are the substances identified in higher than normal amounts in blood, urine, or body tissues of the patients with specific malignancies. They are produced directly by the tumour or as a response to the presence of cancer.
CA-125 > 35U/ml – Is the tumor marker for epithelial tumours.
CEA > 5ng/ml – Used as tumor marker for mucinous tumours.
AFP – Is the tumor marker for endodermal sinus tumour and embryonal carcinoma.
LDH - Is dysgerminoma's tumor marker.
HCG – Is the tumor marker for choriocarcinoma and embryonal cell carcinoma.
Inhibin –Is the tumor marker of granulosa cell tumour.

Ovarian tumors - Symptoms and signs

Ovarian tumors are one of the leading health problems in women.

Clinical features of different ovarian tumors:
Symptoms of ovarian tumors:
-Ovarian tumors may be asymptomatic.
-They may lead to pain abdomen.
-They may present as mass per abdomen.
- Menstrual changes may occur.
-Patients may present with respiratory distress in case of large and advanced tumors.
-They can lead to loss of weight and appetite.

Signs of ovarian tumors:
-Patient may present with pallor and/or cachexia.
-There may be pedal edema.
-Patient may present with mass per abdomen.
-Ovarian tumors may lead to development of ascites.
-They may present as pelvic mass.
-They may lead to nodularity in pouch of Douglas.

Gestational diabetes - management

Management of renal glycosuria: •Frequent urine testing to detect asymptomatic bacteriuria.
•To take several small meals per day.
•Staying alert for signs and symptoms of preterm labor. •Dietary counseling.

Management of gestational diabetes mellitus:
Diet:
Around 30-32kcal/kg per day for non obese women and 25kcal/day for obese women.
Among that 50-60% complex carbohydrates, <30% fat and proteins 25g/1000 kcal, in 3 meals & 1or2 snacks.
Should be monitored with weekly test for ketonuria.
Maintain FBS <105mg/dl and 2hrs PP value <120mg/dl.

Exercise:
Helps to improve cardio respiratory fitness and to avoid insulin therapy.
Self monitoring: Patient is instructed to self determine blood sugar levels by glucometer, 3-4 times per day both before and after meals to asses for the need of insulin therapy.

Oral hypoglycemic agents:
Should not be used in pregnant patients as they may induce severe prolonged fetal hyperinsulinemia and neonatal hypoglycemia

Management of low risk patients: Low risk GDM patients with adequate control of blood sugars and no abnormalities require no ante partum surviellance before 40 weeks.
They are monitored with kick counts and vibro acoustic stimulation at each office visit. They are allowed to develop spontaneous labor and to deliver at term.
Once the patient reaches 40 wks, evaluate the cervical ripeness, the amniotic fluid, the fetal size and wellbeing.
If normal, continue for one more week, but should be delivered once they reach 41 weeks.

In case of persistent elevation of FBS: Around 5-10 units of IAI - NPH is started at bed time and modified according to response.
Persistent elevation of PPBS:
Around 10 -15 units of IAI - NPH before breakfast or a mixture of 2/3rds IAI NPH and 1/3 rd SAI regular before breakfast or a small dose of regular insulin 10 units before meals.

Management of high risk patients: Fetal surveillance started at 34 weeks of gestation.
Weekly or biweekly non stress test(NST), biophysical profile should be done.

Patient should be delivered at 38-40 weeks.
Labor should be induced as soon as the cervix is ripe and fetal lung is mature.
No insulin is required during labor owing to the fasting status.
Blood sugar estimated every 2 hours.
Glucose levels maintained between70-120mg/dl.

Postpartum care:
Insulin requirements remain low after delivery.
Blood glucose determined 2-4 times per day.
Persistent hyperglycemia-anti diabetic therapy resumed.
FPG and PPBG are done 4-6 weeks postpartum, to be certain that the abnormality has disappeared. Repeat GTT done after delivery in GDM women who had elevated fasting glucose levels 95mg/dl or who were diagnosed with GDM before 24 wks of gestation.

Indications for elective cesarean section:
Macrosomia >4kg of expected fetal weight.
Uncontrolled diabetes.
Bad obstetric history.
Demonstrable fetal compromise as in severe IUGR, abnormal NST, biophysical profile. 

Gestational diabetes - diagnosis

Diagnosis of gestational diabetes: Screening Test:
•ACOG recommends all pregnant women be screened at 24-28 wks of pregnancy.
•If only high risk cases are screened, 35% of gestational diabetes will not be discovered. •High risk patients are screened at 18-22 wks.
If result is negative, test should be repeated between 26-30 wks.

GCT (Glucose challenge test) :
•50g of oral glucose is given at any point during the day without regard to meal ingestion.
•A plasma glucose value of >140mg/dl at one hour is considered as GDM(Gestational diabetes mellitus) & requires OGTT with 75gm of glucose for confirmation.
•Any patient whose fasting glucose is 120mg/dl or greater is diabetic & does not need 3hrs OGTT.

OGTT(Oral glucose tolerance test): Indications:
•Glycosuria on one occasion before 20 wks.
•On >2 occasions after 20 wks. •Glycosuria at any time during pregnancy with a positive family history of diabetes.
•Past history of baby weight >4kg. •FBS >90mg/dl following a positive screening test.

Preparation:
•Unrestricted carbohydrate intake during the previous 3 days.
•Fasting for 8 hrs & not >14 hrs. •100gm (75gm according to WHO) of glucose given orally.
•Venous blood sampled at baseline and hourly for 3 hrs while continuing the fast.

Criteria for an abnormal OGTT to the diagnosis of GDM:
O' Sullivans criteria WHO(75gm)               Whole blood         Plasma
0 hr >90mg/dl          105mg/dl
1 hr >165mg/dl        190mg/dl
2hr >145mg/dl         165mg/dl
3hr >125mg/dl         145mg/dl

-Fasting value of >140mg/dl and after 2 hours value of > 200mg/dl in plasma is confirmative of GDM.
-If 2 or more values are abnormal patient is diagnosed as GDM.
-If only 1 value is abnormal,cannot be diagnosed as GDM, but the patient is at risk for macrosomia around 20%, and for preeclampsia & eclampsia 7.9%.
Repeat testing should be done.
-With no abnormal values patients have a risk for macrosomia 6.6%, preeclampsia & eclampsia 3.3%.
-Even those with normal 3 hr GTT after an abnormal screening test are at risk for macrosomia.

•Urine glucose is not used as standard test because the renal glucose threshold decreases during normal gestation leading to glycosuria.
•HbA1c is not used as screening test because of the length of the time that is required to increase the percentage of glycosylation of the hemoglobin molecule.

Gestational diabetes - effects on fetus

Effects of diabetes on fetus:

1.Congenital abnormalities: Incidence of major congenital abnormalities is 6 to 10%.
It is 2 to 3 times more than the general population.
Around 40% perinatal deaths occur in insulin dependent diabetes mellitus.

•Possible anomalies in Central nervous system:
a)Anencephaly

b)Holoprosencephaly
c)Encephalocele d)Meningomylocele

e)Spinabifida

•Possible anomalies in Heart and great vessels:
a) Transposition of great vessels
b) Ventricular septal defect
c) Aortic coarctation
d) Atrial septal defect
e) Situs inversus
f) Single ventricle
g) Hypoplastic left ventricle

•Possible anomalies in Skeleton and spine:
 a) caudal regression syndrome

•Possible anomalies in Genitourinary system:
a) Renal agenesis
b) Ureter duplex

•Possible anomalies in Gastrointestinal system:
a) Anal and rectal atresia
b)Small left colon

•Possible anomalies in Pulmonary system:
Hypoplasia


2.During pregnancy:
- Sudden intrauterine death

3.After delivery:
-Hypoglycemia
-Hyperviscosity syndrome
-Hyaline membrane disease
-Macrosomia
-Hypocalcemia apnea and bradycardia
-Traumatic delivery -Hyperbilirubinemia

Etiological factors for diabetic embryopathy:
1.Hyperglycemia
2.Hypoglycemia
3.Hyperketonimea
4.Somatomedin inhibitors
5.Yolk sack failure
6.Reduced intracellular myoinositol 7.Arachidonic acid deficiency 8.Maternal vasculopathy 

Gestational diabetes - definition, risk factors, effects on mother

Definitions:
Gestational diabetes is defined as carbohydrate intolerance of variable severity with onset or first recognition during present pregnancy.

Renal glycosuria is appearance of simple sugar in urine despite of normal or low blood sugar levels.
In pregnancy, renal glycosuria is common due to lowering of renal threshold for glucose excretion.

Women at low risk for gestational diabetes:
•Age younger than 25 years.
•Not a member of ethnic group at high risk for development of Type II diabetes (Hispanic, African, Native American, South or East Asian, or Pacific islands ancestry)
•Body mass index of 25 or less.
•No previous history of abnormal glucose tolerance.
•No previous history of adverse obstetric outcome.
•No known diabetes in first degree relative.

Women at high risk for gestational diabetes:
•History of still birth in previous pregnancies.
•History of neonatal death.
•History of fetal macrosomia.

•Concomitant obesity and / or hypertension.
•Development of oligohydramnios, polyhydramnios, preeclampsia, or fetal macrosomia.
•Inadequate control with diet alone.

 Effects of diabetes on mother: 1.Spontaneous abortion 2.Preeclampsia
3.Infection
4.Polyhydamnios
5.Postpartum bleeding
6.Increased incidence of cesarean section etc.

Effects of pregnancy on diabetes: •More insulin is necessary to achieve metabolic control.
•Progression of diabetic retinopathy.
•Worsening of diabetic retinopathy. •Increased risk of death for patients with diabetic cardiomyopathy.

Gestational diabetes - classifications

Classifications:
National Diabetes Data Group:
1. Type I diabetes mellitus - Immune mediated Idiopathic
2. Type II diabetes mellitus 3.Gestational diabetes mellitus

Other specific types of diabetes
a) Genetic defects of beta – cell function
b) Genetic defects in insulin action c) Disease of excrocrine pancreas
d) Drug or Chemical induced
e) Infections
f) Uncommon forms of immune- mediated diabetes
g) Other genetic syndromes associated with diabetes.


Priscilla White's Classification of diabetes during pregnancy: Gestational diabetes - Discovered during pregnancy, glycemia may or may not be maintained by diet alone and insulin may be required. Class A - Discovered before pregnancy, controlled with diet alone, any duration or age of onset. Class B - Onset age 20 year or older, duration less than 10 years.
Class C - Onset age 10 -19 years, duration less than 10 -19 years. Class D - Onset age under 10 year, duration over 20 years, background retinopathy.
Class R - Proliferative retinopathy or vitreous hemorrhage.
Class F - Nephropathy with proteinuria over 500 mg/day.
Class RF - Criteria for both class R and F coexist.
Class H - Atherosclerotic heart disease clinically evident.
Class T - Prior renal transplantation.

Advantages of Priscilla White's Classification :
1.It separates patients in to groups according to age of onset, years of duration and presence or absence of micro or macrovascular change. 2.It provides a basis for comparison of many of pregnant diabetics in different institution.

Disadvantages :
•Number of groups are more and patients in same group may have different prognosis.
Thus it has a poor predictive value.

Gestational diabetes - carbohydrate metabolism in pregnancy, accelerated starvation

Gestational diabetes is a medical complication during pregnancy, which should be dealt carefully. Previously pregnancy was contraindicated in diabetes mellitus because of the increased risk of maternal and fetal morbidity and mortality.

After isolation of insulin by Banting and Best in 1921 management of pregnancy has become easy, maternal and fetal mortality and morbidity decreased.


 Incidence:
•Incidence is 3 to 5% of all pregnancies according to South Asian perspective.
•Diabetes occurs in around 3.3% of all pregnancies in United states.


Carbohydrate metabolism during pregnancy:
•During first and early parts of the mid trimester there is increased sensitivity to insulin.
•Opposite occurs in third trimester.
That is why gestational  diabetes is more common after 26 weeks.

 Diabetogenic effects of pregnancy: •Insulin resistance
•Decreased ability of insulin to act effectively on target tissues.
Due to:
- Production of human placental lactogen.
- Increased production of cortisol, estriol, and progesterone.
-Increased insulin destruction by kidney and placenta.

Acclerated starvation:
•The rapid metabolic adaptation of fat metabolism was described by frienkel as accelerated starvation. •The metabolism is to facilitate fetal utilization of protein and non lipid fuel.
•The placental hormones oestradiol, human placental lactogen, progesterone are all responsible for this accelerated starvation.

Vaginal odor

Some women may complain of abnormal vaginal odor.
This can be seen due to causes like :
-If vaginal odor is associated with symptoms like discharge, itching etc, there is possibility of infection.
Eg. Bacterial vaginosis, chlamydia, yeast infection etc.
-Poor hygiene.
-Forgotten tampons.
-Rectovaginal fistula.
-Cervical or vaginal neoplasia etc.

Prevention and treatment:
-In case of having symptoms of infection better to consult gynecologist once and get examined.
Vaginal swab for culture and sensitivity may be needed. According to the report, treatment can be planned.
-If only odor is the problem without symptoms of infection, following measures may help:
- Taking bath twice a day and changing the inner wear twice a day.
- Using cotton inner wear as per as possible.
- Changing the sanitary pads or tampons in every 6 to 8 hrs during periods.
- Cleaning the genital area with few milliters of mild disinfectant added luke warm water.
-Adding rose water etc in the water before bath.
-Keeping the genital area dry as per as possible etc.

In case of rare causes like fistula or neoplasia, treatment should be planned accordingly. 

Chronic uterine inversion

Occasionally uterus undergoes incomplete inversion which is often over looked.
May be due to:
 Pedunculated tumor.

Senile inversion because of atonicity of cervix.

Clinical features:
Vaginal discharge
Irregular bleeding
Low backache
Chronic pelvic pain etc.

On examination:
Infected hemorrhagic mass in the vagina.

Differential diagnosis:
Sloughing polyp
Retained portion of placenta.

Management:
1) Clear up the infection by antiseptic packing of the vagina.
2) If prolapsed fundus is clean then replacement can be tried with special repositor- aveling's repositor.
Surgical procedures:
Vaginal – Spinelli procedure Abdominal – Huntinton's procedure, Haultain's procedure and Ocejo procedure.
In multiparous – Vaginal or abdominal hysterectomy

Acute uterine inversion - part 2

Prevention:
1) Donot employ any method to expel the placenta out when the uterus is relaxed.
2) Pulling the cord simultaneous with fundal pressure should be avoided.

Management:
Immediate replacement without attempting to remove the placenta from the inverted fundus.

Indications for removing the placenta before replacement of the uterus:
If placenta got separated already.
If very big size placenta obstructing the replacement.

Principle steps in manual replacement:

1)Replace that part which is inverted last.
2) Apply counter support.
3) After replacement the hand should remain  inside the uterus until uterus becomes contracted by iv oxytocin or PGF2a.

If shock developes:
1) Immediate resuscitation must be started with IV fluids and cross matched blood.
2) On no account should ergometrine or oxytocins be given before replacement as these will only aggravate matters and make reduction or replacement of uterus more difficult.

Replacement of Uterus:
The longer the time the more difficult is to replacement because of constriction of cervical ring.
1) Manual reposition
2) Hydrostatic reduction or Osullivan's method, if the above method fails because of too tight cervical ring, need to be relaxed by tocolytics or general anesthesia.

Acute uterine inversion -1

Uterine Inversion definition: Uterine inversion is a rare life threatening complication occurring in the third stage of labor in which the uterus turns inside out, the fundus prolapsing through the cervix.

There are three degrees of uterine inversion.
First degree – Dimpling of the fundus which still remains above the level of Internal OS.
Second degree – Fundus passes through cervix and lie inside the vagina.
Third degree – Entire Uterus turns inside out and  hang out side the vagina.

Uterine inversion seen in two forms:
1. Acute
2. Chronic

1. Acute Inversion:
Extremely rare, Life threatening complication of third stage of labor in which uterus turns inside out either partially or completely.

Incidence 1 in 2,500 deliveries. Causes :
Around 80% cases occur due to faulty management of third stage of labor and 20% cases are spontaneous.
Predisposing factors are
(a) Incompletely separated placenta.
(b) Atonic Uterus
(C) Short Cord
(d) Fundal fibroid
(e) Precipitate labor.
 (f) Associated with fundal attachment of placenta.
(g) Placenta accreta etc.

 Risks of Inversion:
- Post partum hemorrhage – especially after detachment of the placenta.
-Shock – is disproportionate to the blood loss.
Is of neurogenic in origin due to traction on the infundibulo pelvic ligament, peritonium and broad ligament, stimulating the parasympathetic system & cervical distention.
-Puerperal sepsis – Various therapeutic measures adopted to reduce the inversion may aggravate the sepsis.
-Anuria and sheehan's syndrome – associated with shock.

 Diagnosis:
Symptoms: Severe lower abdominal pain with bearing down sensation. Signs :
1) Varying degrees of Shock.
2) Abdominal examination shows cupping or dimpling of fundal surface.
3) Bimanual examination: to confirm the diagnosis & degree of inversion.

Prognosis: Prognosis is poor if not replaced immediately, death may occur due to shock, hemorrhage and pulmonary embolism.
Even if the patient survives, infection, sloughing of the uterus etc may lead to chronic inversion. 

Risk factors of having child with autism

Children with autism will have abnormalities in brain development and behavior.
This can be seen before the child attains three years, it will have steady course without remission.
These children will present with symptoms like :
-Impairment in social interaction and communication
-Restricted interests
-Streriotyped behavior etc.

The theory of causation of autism is incomplete.
The possibility of autism depends on many risk factors like :
- Maternal diabetes.
-Increased paternal and maternal age.
-Genetic factors. But it is not established which gene is responsible to cause autism.
-Autoimmune diseases to mother.
-Exposure to teratogenic agents.
- Intrauterine infections.
-Stress and strain pre conceptionally can lead to autism by gene-environment interaction.
-Hypothyroidism in mother etc.
-High levels of testosterone in amniotic fluid.
This can be diagnosed by amniocentesis.
- Nutritional deficiency, especially folic acid deficiency.
- Intake of drugs like antidepressants during pregnancy.


The possible steps that can be taken to avoid autism to some extent are :
- Maintaining strict normal blood sugar levels for at least 3 months before planning for pregnancy.
-Staring folic acid supplementation 2 to 3 months prior to pregnancy.
-Regular antenatal checkups and ultrasound examinations during pregnancy.
-Some studies recommend estimation of testosterone levels in the amniotic fluid by amniocentesis. But its role is somewhat doubtful.
-Avoiding the risk factors like nutritional deficiency, teratogens etc.

Investigations needed in case of repeated abortions

Most of  the abortions in the early gestational age can be seen as part of avoiding abnormal embryos due to defective germ plasm by the nature.
This can occur due to defective sperm or defective ovum or both.
Usually 50% of the abortions will occur before diagnosing the pregnancy.
Other possible causes are :
Infections,
trauma,
hormonal,
General conditions like thyroid abnormalities, clotting disorders, increased blood sugar levels etc.
Usually abortions due to defective embryo won't repeat in future pregnancies.
Because normally in semen around 30% abnormal forms can be seen and the remaining will be normal forms.
And only few ova can be abnormal.
So, possibility to have the normal embryo is more.
In cases of two to three continuous abortions, following tests are needed to find out the cause:
For the wife:
-General physical and local examination
-Ultrasound
-Hemoglobin
-Blood sugar levels
-TORCH panel
-VDRL
-Thyroid profile
-Antiphospholipid antibodies etc.

For the husband:
Blood sugar levels
VDRL

In case of consaguinous marriage, both should undergo genetic profile.
After undergoing these investigations, one conclusion can be drawn regarding the possible cause for abortion and depending on that treatment can be planned.

Advantages and disadvantages of IUCDs

Advantages of IUCD'S:
Only one time motivation is enough for a long time protection.
There will be no problem of disposal privacy.
As there is no interference with sexual act, so acceptable to many people.
There are no much of systemic side effects.
Return of fertility is immediate, so better choice as a temporary contraceptive method.
No effect on breast milk, so can be used by the lactating mothers.
No drug interactions and also some devices helps in preventing ectopics.

Disadvantages of IUCD'S:
High initial cost compared with other cheap alternatives.
Trained personnel needed for the insertion of the device.
Insertion is sometimes painful and some patients may bleed.
Expulsion may occur unknowingly if the patient is not cautious about the device, leading to failure. IUCD'S offer no protection against STD/HIV.

When to remove IUCD & what to do in case of missed IUCD

When to remove the IUCD:
After expiry of the effective life span of the device we have to remove it.
If pelvic pain and cramping or abnormal or excessive bleeding troubling the patient the device should be removed.
In patient having acute pelvic inflammation the  device should be removed.
In case of Displacement of the IUD, it should be removed.
When the woman is pregnant the device should be removed.
In case of uterine or cervical malignancy the device should be removed.
When the woman attains menopause – after one year the device should be removed.
In case of non-physical reasons – like patient is having desire of pregnancy, husband's death, or at request the device can be removed.

 Technique of removal of IUCD, eg.Cu T:
Threads are held by artery forceps and steady traction applied to bring it out.


Missed IUCD eg.Cu T:
To diagnose the missed IUCD, pregnancy should be excluded first. Then sounding of the uterine cavity should be done to feel the missed device in the cavity.
Straight X-ray with radio-opaque sound can detect missed device and its position.
Hysteroscopy can be done for direct visualization.
If tail is not seen, cervix is cleaned, cavity probed with sound, cervix steadied with vulsellum, dilated and vaccum curette applied.
If it fails, general anaesthesia given and IUD is curetted, with long Spencer Wells forceps.
If probing can not detect the device there are two possibilities:
1. IUCD is expelled.
2. Has perforated the uterus.
IUCD can be removed by culdoscopy, colpotomy, laproscopy or laprotomy depending on the position.
Hysteroscopic guided removal is the best procedure.

IUCDs- When to consult doctor & complications

When to visit a doctor after insertion of IUCD:
When the patient is having missed menstrual period.
When she got exposed to STDs. When the strings are missing or the strings seeming shorter or longer than before.
Increased pain and bleeding bothering the patient.
When she wants removal of the device at any time.
When she wants go for other method of family planning.

Complications of IUCD'S:
Increased bleeding is seen in – 50% of cases.
Pain: is the one of the most common cause of IUCD removal. Expulsion is seen in – 2-8% of cases in the first year.
Vaginal discharge: sometimes foul smelling troublesome vaginal discharge can occur. A cute
 and chronic salpingo-oophoritis noted in – 1% of cases.
Perforation seen in – 1.2/1000 insertions.
Infections like – actinomycosis, endometritis etc can occur. Pregnancy rate is – 2% in 1st year, but later it can increase.
Ectopic pregnancy(ovarian ) seen in – 0.25-1.5/1000 women years.

Counseling for insertion of IUCD and procedure of insertion

Counseling the woman before insertion of IUCD:
Before insertion of IUCD the woman should empty the bladder, perineum should be draped.
Per speculum examination done by the medical person to note any infection or local lesions or menstrual flow.
Pap smear taken to rule out any premalignant conditions.
Per vaginal examination done to know the position of cervix, position and size of uterus, to know the mobility of uterus and to make out any adnexal masses.
Then the anterior lip of the cervix held with vulsellum and the uterus is sounded to know the length and version.

Procedure for loading the IUCD eg. Cu-t:
IUCD should be loaded not more than five minutes before insertion. Have to bend the arms of the Cu-t between thumb & index finger and push the insertion tube to pick up the folded arms.
Check the position of the plastic adjustable collar accordingly.

Then we have to gently introduce the inserter until the adjustable collar snugly fits the external os. Then hold the plunger firmly with left hand and outer inserter tube is retracted over the plunger with right hand for about 2 cms , withdraw the plunger and inserter tube.
Then cut the threads.


Instructions after the procedure: Patient should be informed that she can have cramping pain, vaginal discharge, heavier menstrual periods and bleeding between the periods.
But all this will settle down normally.
Checking the IUD should be done, once a week in the 1st month then after each menstrual period.
The woman should not pull the strings.

When to insert IUCDs

Preinsertion clinical management Personnale: have to select the person according the categories as mentioned in    http://srsree.blogspot.in/2013/11/eligibility-criteria-to-use-iucds.html

Timing :
The best time for IUCD insertion will be during the time of menstrual period, because it is dangerous to insert an IUD into a pregnant woman.
Inserting the IUCD during menstruation eliminates the possibility of pregnancy and also cervix is slightly dilated during your period, so insertion will be easier.
In non pregnant women IUCD may be inserted at any time during the menstrual cycle, provided the woman is using another effective birth control method consistently, or have had a negative pregnancy test.
IUCD can be inserted at any time during the menstrual cycle, if the woman haven't had sex since her last period.
IUCD can be inserted within six days of unprotected sex, as a post -intercourse (emergency) contraceptive.
If the woman is just been pregnant, she can have an IUCD inserted. Woman can use IUCD immediately after or within 3 weeks of an uncomplicated first trimester miscarriage or immediately (within 10 minutes) following childbirth—by either vaginal or cesarean delivery .
IUCD can be used six weeks after giving birth if the woman is breastfeeding.
IUCD can also be used six weeks postpartum, if the woman haven't had a period return, is not breast feeding, and has had a negative pregnancy test. 

Mechanism of action of IUCDs & Possible pregnancy rates

Mechanism of action of Intrauterine contraceptive devices: IUCDs act by inducing biochemical and histological changes in the endometrium there by preventing implantation.
They also prevent implantation through enzymatic reaction, by increasing tubal motility and by impairing sperm motility. Hormonal IUCDs : they act by forming thick cervical mucus, there by preventing entry of sperms.
By creating anovulation and by leading to insufficient luteal phase.

Division of IUCDs according to pregnancy rates(failure of contraception) (WHO-1987):
Group I : pregnancy rate > 2/100 women years, Eg. lippes loop, Cu 7, Cu T 200.
Group II : pregnancy rate <2 & >1/100 women years, Eg. Nova T, ML Cu 250, CuT220.
Group III : pregnancy rate <1/100 women years, Eg. Cu T380A, Cu T380S, ML Cu 375, LNG 20.

Eligibility criteria to use IUCDs according to WHO

Category 1: No restriction on use Category 2: Advantages overweigh risks
Category 3: Risks overweigh advantages
Category 4: Do not use.

Category 1:
Women coming into this category are not having any restriction in usage of IUCD's .
These are women with age >20 yrs, parous ladies, obese ladies, with history of headaches, with cardiovascular complications, with chronic diseases – thyroid, epilepsy, DM(diabetes mellitus), jaundice, hepatitis, malaria, non pelvic TB, cirrhosis etc.
Women with Gynaecological/Obstetrical conditions like – breast feeding women, women delivered 4wks back, with benign breast disease, CIN(Cervical intraepithelial neoplasia), cervical ectropion, prior pelvic surgery etc all can use.

Category 2:
Women coming into this category can use IUCD's as advantages overweigh risks.
These are women with age < 20 yrs, with Gynaecological/Obstetrical conditions like nulliparity, menorrhagia/dysmenorrhea, endometriosis, past PID(pelvic inflammatory disease), fibroids, post partum < 48 hrs, post abortal. Also women chronic diseases like : thalassemias,  iron deficiency anemia, sickle cell disease.
Women with STD/HIV : (advice condom use) vaginitis without cervical pus/discharge.

Category 3:
Women coming into this category should use IUCD's with caution as risks overweigh advantages. Women in post partum period between 48 hrs to 4 wks, with benign gestational trophoblastic diseases, HIV positive or AIDS pts or women with increased risk of HIV / AIDS.

Category 4:
Women coming into this category should not use IUCD's.
These are women with pregnancy, puerperal and post abortal sepsis, active PID, malignant GTD's(gestational trophoblastic diseases), unexplained vaginal bleeding, cervical, ovarian and endometrial cancer.
 And also women with chronic diseases like : known pelvic TB, current STD or within 3 months.

IUCDs - Hormone releasing intrauterine contraceptive devices

C. Hormone releasing intra-uterine contraceptive devices:
In 1973, hormonal IUDs with effective life span and lower failure rate (eg. Progestasert and LN 20) were invented.

Progestasert :
Progestasert contains 38mg of progesterone dispensed in silicone oil.
And delivers 65 micrograms/day. Reduces the menstrual flow.
Needs to be replaced every year. Can increase the risk of ectopic pregnancy.

Levonorgestrel IUD 20 (LNG20, MIRENA, LEVONOVA): Levonorgestrel IUD 20 is a longer acting harmone releasing device.
Vertical arm has steroid capsule with 40-60mg of levonorgestrel , releasing 20 micrograms/day. Mirena has 52mg of LNG, with this stable plasma level of 150-200pg/mg can be attained.
Failure rate is – 0.09/100 women years.

IUCDS - Copper releasing intra uterine contraceptive devices- part 2

Multiload Mark II :
It is the updated version of original multiload 375, developed in Netherlands, having 375 mm2 copper as the original ML-375.
But shorter, more flexible with less expulsion rate than original multiload  375.
Having three improvements than original multiload 375 : prevents IUD being pushed beyond the inserter, functions as a uterine sound and one handed expulsion action.
These innovations decrease the uterine perforation.
Life span of multiload mark II is 5 yrs.

GyneFix (Cu fix 390):
It is frameless IUD with Six 5mm copper sleeves and proximal end with a knot, which is pierced 1cm into the fundal myometrium of the uterus.

ICFD (Intra cervical fixing device): It is 4cm copper coated polyethylene frame with 5mm projection at the distal end anchored to the inner cervical wall with modified tenaculum.
It can be removed by sponge forceps but some difficulty in disengaging may occur.

IUCDs- Copper releasing intra uterine contraceptive devices - part 1

B.Copper releasing intra-uterine contraceptive devices:
By 1970's bioactive devices or first generation devices were developed. With plastic frames which were carriers of either metals, hormones or anti bleeding agents.
Jaime Zipper and Howard Tatum, in 1969 deviced first Cu T & Cu 7 with 200 sq mm of copper.
To improve the life span and effectiveness, second generation Cu releasing IUDs were invented in 1974.
The higher doses of copper with silver or copper sleeves, reduce the chance of fragmentation of copper.

Cu Safe 300:

Cu safe 300 is a T-shaped copper containing IUD with flexible, uniquely shaped arms, transverse arms curve inward to reduce uterine tissue irritation.
Flexible design facilitate easier and less painful insertion and removal, but the curved, "fundal-seeking" arms also resist expulsion.
Life span of CuSafe 300 is 5 yrs.


Fincoid-350:

 Fincoid-350 is devised in Finland, it is designed to resist accidental expulsion.
It is having two parts:
curved horizontal arms, and a copper coated vertical stem.
The horizontal arms lock into a groove on the vertical stem.
The resultant movable joint easily constricts and expands with uterine contractions, adjusting to variations in uterine size and shape.


Sof-T:

The Sof-T, which is manufactured in Switzerland, has soft, flexible knobs, occlusion bodies, on each end of its flexible transverse arms. These knobs theoretically block the entrances into the fallopian tubes. Failure rate is 0 to 1.3/ 100 women years.

IUCDs - Inert intra-uterine contraceptive devices

A.Inert intra-uterine contraceptive devices:
Lippes loop:

It is a double 'S' shaped polyethylene loop impregnated with barium sulfate (for radiopacity) and the tail is made of fine nylon.
Lippes loop was available in four sizes – A,B,C,D.
 Push out method was used for the insertion of the lippes loop.


Dalkon shield:

In 1967, Lernes and Davis designed dalkon shield with larger area of contact with the endometrium.
 But later withdrawn due to its severe infection rate.

Intrauterine contraceptive devices (IUCDs)- history and categories

Intrauterine device is a small, flexible plastic frame which is effective, safe, convenient method of temporary sterilization.
It is inserted into the uterus through the vagina.
IUDs also called IUCDs in general are called the loops (after Lippes loop which is no longer used).
 Their usage started in ancient times where Arabs and Turks used to insert pebbles into the uteri of camels in caravan.
In 11th century Islamic scientists first reported intra uterine pessaries for humans.
Richard Richter (1909), German physician introduced first ring shaped IUD made of silk worm gut. Ota in 1934 in Japan, made a ring with small disc in the centre with 3 spokes.
Jack Lippe, from Buffalo, NewYork in 1962, designed the first ever plastic IUD, which was used widely further added barium sulphate to make it radio-opaque so that it can be detected in X-rays.

The criteria of choice:
Every Couple needs to consider what issues are important to them in making a wise contraceptive choice.
Six steps in counseling are:
-Greet the person
-Ask them about themselves
- Tell them about choices
- Help them to make an informed choice
- Explain fully how to use the chosen method
- Return visits should be welcomed.



Categories of IUD's(intra-uterine contraceptive devices):

A. Inert intra-uterine contraceptive devices
Eg: Lippes loop, Saft coil, Chinese single coil ring, Mahua ring, Ota ring etc.

B. Copper releasing intra-uterine contraceptive devices
Eg: Cu 7, Cu T200, Multiload copper 250, MLCu 375, Cu T 380A, Cu T380S, Nova T and Cu T220C.

C.Harmone releasing intra-uterine contraceptive devices
Eg: Progesterone IUD(Progestasert) and Levonorgestrel IUD (Mirena, LNG 20)

D.Newer intra-uterine contraceptive devices.

Recent interventions in barrier contraceptive methods

Male condoms made up of polyurethane (plastic), new
designs as looking fitting with a possible longer shelf life and improved sensation and compatibility with oil based lubricants.

New types of diaphragm made up of silicon are also coming into market.
The diaphragm used without spermicide and worn continuously removed only for washing is under study.

'Lea's shield', a new cup shaped barrier that covers cervix with valve that allows the draining of cervical secretions and menstrual flow , has a 'u' shaped loop for easy removal. Made of silicon rubber it can be worn up to 48 hrs.

The gynaeseal diaphragm tampon, available in Australia, has as inner chamber and an outer pouch.
The inner chamber has a one-way valve that allows menstrual fluids to pass through and cervical secretions are collected in outer pouch.

Barrier contraceptives - Female condoms

E. Female condoms:

The female condom is a thin, soft, loose fitting polyurethane plastic pouch that lines the vagina.
It has two flexible rings, one inner ring at the closed end used to insert the device inside the vagina and to hold it in place and outer ring which remains outside the vagina and covers the external genitalia. Because the device is made from polyurethane, the female condom can be used with any type of lubricant without compromising the integrity of the device.
Women tended to accept the device more favorably than did men.
But overall difficulties of insertion decreased as experience with device increased , and use became more comfortable and acceptable in practice.

Advantages:
Female controlled, more comfortable to women, less decrease in sensation than with the male latex condom.
Female condom offers greater protection as it  covers both internal and external genitalia. More convenient than male latex condom that it can be inserted pre-coitus.
Stronger than the male latex condom, as polyurethane is 40% stronger than latex.

Disadvantages:
Female condom is not aesthetically pleasing.
The coverage of external genitalia had a decidedly negative impact on the device's aesthetics and acceptance.
Some people dislike of the appearance of the device, noise associated with use and size of the device.
Partner resistance may be seen in some cases.
Difficulties in insertion and removal can occur.
There are few cases of slipping of the penis between the device and woman's body or slippage and breakage of device itself.
It is relatively expensive than other methods.

Effectiveness:
Typical failure rate is 21% as commonly used.
But only 5% when used correctly and consistently.

Barrier contraceptives - Spermicides

D. Spermicides

Spermicides are chemical barriers that consists of two components: a spermicidal chemical, most commonly nonoxynol-9 and a delivery base.
Spermicides can be delivered through foam, cream, jelly, film, suppositories or tablets.
They can be used either alone or with another contraceptive method.

Mechanism of action:
They will inactivate or kill sperm, making fertilization unlikely and also act as mechanical barriers. Should be introduced ½ hour before the sexual act, including 10 minutes time to allow the tablet to melt.
No douching is permitted with in 8 hrs.
Can be used by:
Women who cannot or do not want to use hormonal methods.
Couples who have sexual intercourse infrequently.
Women wanting a method that they control.
Breast feeding women who need contraception.

Should not be used by:
Women having cervical cancer (awaiting treatment)
High risk of HIV.

Advantages:
Spermicides are effective at preventing pregnancy when used consistently and correctly.
They are safe, with no systemic side effects.
Easy to initiate and discontinue with immediate return to fertility. Do not require clinical visit while starting or partner co-operation while using.

Disadvantages:
Spermicides are not effective as other methods in typical use.
Side effects like local irritation can occur, especially if used several times a day.
May interrupt sexual activity. Usage can be messy.
Can make yeast infection or urinary tract infections more common because of repeated use and local aberrations.
Formally thought to reduce the risk of STDs but research found no protection against them.

Effectiveness:
The failure rate of spermicides when commonly used is 21%.
That can be decreased to 6% when used correctly and consistently. 

Barrier contraceptives - Vaginal sponges

C. Vaginal sponges:

Currently two contraceptive sponges called protectaid and pharmatex are available primarily in Canada and Europe.
A third, today sponge, was introduced to the U.S. market in 1983, was removed in 1995, but in expected to return.
Fourth one called Avert, is on clinical trials for contraceptive efficacy.
All four types are manufactured in one size, allowing women to buy them over the counter without the help of a provider.
Common qualities are blocking the cervix, trapping sperm and releasing the spermicides.
Effective for many hours, same as long as 24 hrs, regardless of number of sexual intercourse during this period.
Being able to insert them hours in advance but should be left in place at least six hours after last intercourse.
But should not leave them in place beyond the maximum recommended time.
The 'pharmatex sponge', marketed in Europe contains 60 mg of spermicide benzalkanium chloride(BZK).
The 'today sponge', contains 1000mg of spermicide nonoxynol-9(N-9).
Though spermicides kill pathogens, they can irritate vaginal lining developing vaginal abrasions that could facilitate HIV transmission. The 'protectaid sponge', marketed in Canada, contains three spermicides N-9, BZK & sodium cholate in relatively small concentrations.
The 'Avert sponge' is expected to have 100mg of N-9. The protectaid and Avert sponges have the advantages of being wet.
Water is not needed before they are used.
Some studies are showing that using N-9 containing today sponge are less likely to have contracting chlamydial infection and gonorrhea.
But women using N-9 sponge developed genital ulcers important risk factor for HIV infection.

 Effectiveness:
Failure rate of N-9 impregnated Today sponge is 17 %.
That is on average 14% for nulliparous and 27% for parous women.
For protectaid sponge it is 23 %for typical use. 

Barrier contraceptives - Occlusive caps part - 2

2.Cervical cap:

The cervical cap is a thimble or dome shaped rubber appliance designed to cover the cervix, they remain in place by suction. Conventional caps can be worn up to 48 hrs.
They are usually made of latex, must be fitted by a provider at first time and can be difficult to insert or remove.
Cervical caps are available in four sizes between 22mm to 31mm.

Two new cervical caps are under development.
Female cap:

The first one is called fem cap, made of silicone, worn up to 48 hrs. Shaped like a hat with an upturned brim that lies against the vaginal walls around the cervix.
It is easier to insert than conventional caps.
And there will be no pressure on urethra, unlike conventional diaphragms.
A strap is added to facilitate removal.
And uses less spermicidal jelly, so less irritation.
But it is less effective than conventional cap with failure rate of 23 %, whereas conventional cap failure rate is 18 %.

Oves cap:
Second new cervical cap is oves cap, made of silicone, can be left in place for three consecutive days. Equipped with removal loop and it is disposable after one use.


3.Vault cap:
It is a hemispherical, dome shaped rubber or plastic cap.
Which fits into vaginal vault covering the cervix.
Rim will be thick but have no metal spring.
The sizes ranges from 50 to 75 mm in 5 mm steps.
Correct size for a particular woman is smallest one which fits evenly into the vaginal vault.
Eg: Dumas cap, Plastic dumas cap.

 4.Vinule cap:
It is a cervical cap made up of rubber, with fairly rigid flanged base to increase the degree of suction, when cap is put in place. String will be attached for easy removal.
It is useful in case of cystocele & mild prolapse cases when diaphragm can't be retained.
This is a good advantage of vinule cap.
Vinule cap sizes from 45 to 55 mm in 3 mm steps.

Barrier contraceptives - Occlusive caps part-1

Occlusive caps are used as means to retain spermicides in contact with cervical os.
Spermicides must be used along with devices.
Women need to be instructed to use of the device by a doctor.
Usually manufactured from latex rubber and have got a storage and usage life.
They are of four types:
1.Vaginal diaphragm
2.Cervical cap or check pessary
 3.Vault cap
4.Vinule cap


1.VaginalDiaphragms:

These are the most common form of occlusive caps.
Easiest to fit & use.
The diaphragm is a soft latex rubber cup that should be used with spermicidal jelly or cream. Available in sizes from 45 mm diameter to 105 mm.
Most commonly used are 60, 65, 70, 75, 80 mm sizes, height varies from maker to maker.
The length from posterior vaginal fornix to symphysis pubis in cms minus one cm is the size of diaphragm generally suitable.
The women inserts a diaphragm into her vagina, fitting it over the cervix, shortly before the sexual intercourse and leaves it in place for at least 6 to 8  hrs after intercourse.
If sexual act vaginally is delayed more than two hours or intercourse is repeated after a few hours, an applicator full of spermicidal by cream or jelly should be introduced earlier as it takes time to dissolve.

Mechanism of action:
Diaphragm blocks sperm from entering the uterine cavity. Spermicides provide additional protection by damaging the sperms. Can be used by women of any reproductive age group and parity who want to use this method of contraception.

Contraindications:
It can't be used within 6 wks after delivery because of chances of infection and as there will be laxity of tissues it will not stay in place. Also in those people who are having allergy to latex it can't be used.
In women with history of toxic shock syndrome, better to avoid using diaphragm because if it retained in vagina precipitation of syndrome can occur.
And in certain anatomical abnormalities of cervix and vagina, where diaphragm cannot be retained in position it can't be used.

 Advantages:
Diaphragm is a woman controlled method and possible to use without male partner's co-operation.
Offers contraception only when needed.
So useful for irregular and unplanned sexual intercourse. Effective if used correctly with every act of sexual intercourse.
It is having no systemic side effects. And has no impact on lactation.
Can be stopped at any time and can be inserted before sex to avoid interrupting of sex.
Provides some protection from STDs.
And also reduces the risk of neoplasia.
Contains menstrual flow when used during menses.

Disadvantages:
Initially the diaphragm requires fitting by a family planning provider, involving a pelvic examination.
A woman may need a different size diaphragm after the child birth. Requires having the method on hand and taking  correct action before each act of sexual intercourse.
Less effective contraceptive method than IUDs(intra uterine contraceptive devices) or systemic methods.
Interrupts sex if not inserted before hand.
And may be messy to use. The possible side effects usually are local irritation or allergic reaction to latex.
It should be washed with soap and clean water after every use.
And needs careful storage to avoid developing of holes.
Requires a steady supply of spermicide, without it the diaphragm is not very much useful. AIDS and other sexually transmitted diseases are not effectively prevented by this method.
Repeated usage and pressure on urethra while using increases the risk of urinary tract infections.

Effectiveness:
The failure rates of the diaphragm are 18 to 28% as commonly used and 6% when used consistently and properly with spermicide. Diaphragms should be replaced anytime between 6 months to 2 yrs depending on its use.

Spermicides