Detection of autosomal trisomies in second trimester of pregnancy

Trisomy is a type of polysomy.
In which instead of normal two instances, three instances of particular chromosome can be seen.
 The trisomies that can commonly affect the intrauterine fetus are
trisomy 21 ( Down syndrome), trisomy 18 (Edwards syndrome),
 trisomy 13 Patau syndrome.
The chances of having babies with trisomies increases with maternal age.
The possible risk of these trisomies can be detected during pregnancy by screening tests.
In second trimester:
-Quadruple test:
It is a blood test.
It should be done between 16 to 22 weeks.
In which levels of
AFP (Alfa feto protein)
hCG (Human chorionic gonadotropin)
uE3 (unconjugated estradiol)
Inhibin A are analyzed.

High HCG, inhibin A levels, low AFP and uE3 levels indicate high risk for trisomies especially Down syndrome.
Triple test measures first three and Inhibin A is not included in it.

Amniocentesis:
It is a invasive test and can be used as a diagnostic test.
Can be performed between 16 to 21 weeks.
By this amniotic fluid is collected and possible fetal cells in it are analyzed for chromosomal abnormalities.
It is having little bit higher risk for miscarriage and infections.

TIFFA scan (Targeted imaging for fetal anomalies):
It is a ultrasound examination to detect fetal anomalies.

It should be performed between 18 to 22 weeks.

By combined result of all these investigations one conclusion can be drawn regarding the possibility of trisomies.


Detection of autosomal trisomies in first trimester:
detection-of-autosomal-trisomies-in first trimester

Detection of autosomal trisomies in first trimester of pregnancy

Trisomy is a type of polysomy.
 In which instead of normal two instances, three instances of particular chromosome can be seen.
 The trisomies that can commonly affect the intrauterine fetus are
trisomy 21 ( Down syndrome),
trisomy 18 (Edwards syndrome),
trisomy 13 Patau syndrome.
The chances of having babies with trisomies increases with maternal age.

The possible risk of these trisomies can be detected during pregnancy by screening tests.
In first trimester:
-Double marker test is a blood test which is used to identify the risk of chromosomal abnormalities like trisomies.
It identifies levels of
hCG(human chorionic gonadotropin),
PAPP-A(pregnancy associated placental protein - A) in maternal blood.
In case of possible abnormality, the levels of these substances will be high.
The cutoff values may differ from lab to lab.

-Nuchal Thickness in the ultrasound. Increased nuchal thickness indicates high risk for Down syndrome.

At around 11 to 13 weeks, nuchal thickness less than 3.5 mm can be considered as within normal limits.
 To come to one conclusion combined result of blood test and nuchal thickness should be considered.

Diagnostic tests can give a clear picture.
In first trimester the diagnostic tests that can be performed are:
-CVS (chorionic villi aspiration sampling):
It can be performed between 10 to 13 weeks of gestation.
By this fetal tissue can be obtained and genetically analyzed.
It is true that chorionic villi aspiration sampling is a better test but it is having risks like chances of miscarriage, infection etc.
And it is difficult to perform in situations like low lying placenta.

-Non invasive tests like NIFTY(Non invasive fetal trisomy test).
It is a blood test.
In which maternal blood in drawn and available fetal cells in it are analyzed for chromosomal abnormalities.
As it is a non invasive test, so there is low risk for miscarriage and infection.
It is more useful in situations like low lying placenta.
According to the studies available NIFTY is also having good accuracy in detecting the abnormalities.


Detection of autosomal trisomies in second trimester:
http://srsree.blogspot.com/2014/03/detection-of-autosomal-trisomies-in_13.html

Causes of bleeding from clitoris during menstruation

Some women complain of bleeding from the clitoris during menstruation.
Though it is rare, sometimes this can be seen due to causes like:
-Most common cause is mistaking the normal menstrual flow as clitorial bleed.
Sometimes menstrual blood can get attached to clitoris and can give a picture like bleeding from clitoris.
And the women may attribute it as clitorial bleeding.
-Injuries or abrasions at clitoris. While using tampons sometimes abrasions can occur over clitoris and that can lead to spotting.
Small abrasions may go unnoticed but when spotting occurs from them, that is mistaken as clitorial bleeding.
-Vicarious bleeding.
Sometimes during menstrual flow bleeding can be seen from other parts of the body.
Like that bleeding can occur from clitoris also.
-Presence of ectopic endometrial tissue at the clitoris and that can bleed during periods.
Sometimes endometrial tissue can present outside the uterus also. That can bleeding during menstruation under hormonal influence.

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.


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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.



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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.



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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.



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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

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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.


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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.



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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.

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