Are you postponing pregnancy?

Because of increasing importance to studies and profession, nowadays women are postponing the pregnancy. 
So planning pregnancy in 30's is becoming common today. Compared with 20's, planning pregnancy in 30's can lead to few problems. 
With increasing age the function of ovaries will get affected, number of ovarian follicles will decrease and remaining follicles may not respond properly to hormones. 
Possibility of problems like hormonal imbalance, pelvic inflammatory disease, endometriosis etc increase with age. 
Adverse effects of using contraceptive measures for prolonged period, possible medical complications diabetes, hypertension etc will increase with age. 
Tensions at work place can also affect fertility by leading to hormonal imbalance. 
Before planning for pregnancy in 30's, the factors to be considered are: 
-Folic acid supplementation should be started around three months before pregnancy. 
It helps in neurological development of baby and helps in conditions like anencephaly. 
-If the woman is having irregular periods, menstrual irregularity should be corrected before planning for pregnancy because menstrual irregularities can lead to difficulty in planning pregnancy and also infertility. Usually menstrual cycle with length of 21 days to 35 days and menstrual flow for 2 to 7 days should be considered as normal only. Deviation from these normalcy needs evaluation.
 Physical examination to access weight, height, BMI, anemia, thyroid abnormalities and gynecological examination to access the size, shape of uterus and adenexal pathology helps in finding out the possible cause of irregular periods. 
Then depending on the findings required investigations like estimating hemoglobin, blood sugar levels, gonadal hormonal profile, thyroid hormonal profile, prolactin levels estimation, ultrasound etc can help finding out the possible cause of irregular periods and treatment can be taken accordingly. 
If decreased ovarian reserve is suspected in ultrasound due to age factor, AMH( (Anti-Mullarian hormone) levels estimation is adviced. AMH is produced by the ovarian anthral follicles. 
Normal AMH levels indicate good ovarian reserve. Women with low AMH levels should plan for pregnancy early without postponing. 
-In case of regular periods or after correction of irregularity, planning intercourse during the time of ovulation increases the possibility of pregnancy. 
Usually ovulation occurs in the middle of the cycle. In case of regular 28 to 30 days cycles, ovulation is possible between 14th to 16th day of the cycle. 
-In case of infertility not getting corrected with medicines, artificial reproductive methods may be needed depending on the problem. 
Like in case of seminal abnormalities depending on spermatozoa count artificial methods ranging from IUI (Intra uterine insemination) to ICSI (intra cytoplasmic sperms injection) may need. After becoming pregnant also elderly women are more to some problems like hyperemesis gravidarum, means excessive vomitings in the first trimester of pregnancy and also pregnancy induced stress is more in elderly pregnant ladies. 
Medical complications like pregnancy induced hypertension, gestational diabetes etc can increase with age. Already existing chronic hypertension, diabetes mellitus, thyroid abnormalities etc can aggrevate during pregnancy. Placental problems like decreased blood supply to placenta due to age related vascular changes and also placenta previa etc are more common in these elderly pregnant women. 
Incidence of operative deliveries also increase in elderly women because of uterine inertia. 
Babies of elderly pregnant women are more prone for chromosomal abnormalities like Down's syndrome, preterm or intrauterine growth retardation etc complications. 
So, better to think once again when you want to postpone the pregnancy. 

General gynaec checkup and routine investigations adviced during checkup

Nowadays because of increased awareness of gynecological problems women are approaching gynecologist early for different complaints. Tests advised during gynecological checkup depends on symptoms of the patient. For those women who come for general gynaec checkup: 
-General examination is performed to access the weight, height, BMI(Body mass index), anemia, thyroid swellings, blood pressure recording etc. 
-For women with age above 35 years or for women having problems related to breast, breast examination and mammography are adviced to rule out pathological conditions like benign or malignant lumps in the breast, fibrocystic changes etc. 
-Abdomen palpation will be done after emptying the bladder to rule out any abdominal lumps, to observe any scars over abdomen etc. 
-External genitalia is examined to find out any discoloration, ulcers, bumps, vaginal discharge etc. 
Perspeculum examination is done to observe the condition of cervix, to rule out erosion, polyps etc. 
Pap smear test is regular screening test to detect changes of cervical cancer, which is advised to all women above the age of 21 years. Yearly once examination is advised for first three years, if all three tests gives negative results, then three years once pap smear test is enough. If unhealthy cervix is noted or frank growth is noticed at the level of cervix, cervical biopsy will be taken. Depending on the reports further management can be planned. 
-Per vaginal examination will be done to observe the size of the uterus, position, mobility and to palate adnexal masses. This helps in finding out uterine pathology and adnexal pathology. 
Depending on the clinical findings if needed specific investigations like blood tests to detect hemoglobin levels, blood sugar levels, thyroid profile, gonadal hormonal profile, prolactin levels estimation, ultrasound etc are advised. 
In case of uterine tumors or ovarian cysts or tumors etc sometimes CT scan or MRI may be needed to confirm the diagnosis and plan the management. 
In case of ovarian cysts or tumors blood CA125 levels estimation is advised to find out the malignant nature of cyst or tumor. 

Effect of tetracyclines on contraceptive pills

What is the effect of tetracyclines on combined oral contraceptive pills?

Tetracyclines like doxycycline, mini cycling etc can affect the function of combined oral contraceptive pills by affecting the absorption of hormones especially oestogen component.
So, during the usage of tetracyclines, additional contraceptive measures like condoms are advised.
Take care.

Galactorrhea with oc pills

Can oral contraceptive pills can lead to Galactorrhea?

Yes. Sometimes combined oral contraceptive pills can lead to galactorrhea(milk secretion from breast) in non pregnant women due to the estrogen component in them.
Estrogen can suppress the prolactin inhibitory factor from hypothalamus and also can stimulate pituitary lactotrophs leading to galactorrhea. Sometimes estrogen withdrawal can also lead to galactorrhea. Because lack of estrogen leads to absence of the inhibitory effect on prolactin hormone at the breast and can cause galactorrhea. 

Emergency pill while on IUCD

Is emergency pill intake is required after intercourse while being on IUCD?

Usually intrauterine contraceptive device is inserted around 5th or 6th day of menstrual cycle.
So, if IUCD is inserted during the end of  menstrual period, it will start giving protection from that month itself and protection will be continued till the period mentioned on IUCD like 3 years, 5years etc depending on the hormone content in it.
So, additional protection like emergency pill is not required while using IUCD.

Treatment options for endometriosis

 The treatment options of endometriosis depends on the severity of the symptoms and the extent of the tissue involvement.
Hysterectomy is not the treatment of choice in all the cases.
If endometriosis involvement is minimal with mild symptoms, that can be dealt with analgesics to relieve the pain and hormonal therapy to shrink the tissue.
In severe cases only surgery may be needed, in that also laparoscopic surgery can be done to remove the endometriotic tissue.
In extreme cases and in women who have completed their family, hysterectomy may be attempted.
Ultrasound helps in identifying the extent of the tissue. Sometimes diagnostic laparoscopy may be needed to identify the endometriosis and its extent. 

Continuous bleeding after emergency contraceptive pill

Emergency contraceptive pill should be used for emergency purpose only.
Because repeated and frequent intake of emergency contraceptive pills can lead to menstrual irregularities.
There should be at least two months gap between two pills.
Frequent intake of emergency pills can cause prolonged bleeding in some women as a side effect.
If bleeding doesn't get controlled even after one week, better to consult gynecologist once and get examined.
Antifibrinolytic drugs can help in controlling the bleeding to some extent.
If bleeding is doesn't get controlled with them, hormone pills may be needed.
To prevent these side effects regular contraceptive methods are advisable to couple with history of frequent intercourse. 

Causes of secondary infertility

If couple who are fertile once
(having first child or children or with previous miscarriage), not able to conceive again for one year with regular unprotected intercourse history, that is called secondary infertility.

The possible causes of secondary infertility are:
Gonadal hormonal imbalance which can cause irregular menstrual cycles, anovulation etc
Fallopian tubal block
Uterine causes like endometrial abnormalities, fibroids, adhesions etc.
Thyroid hormonal or prolactin level abnormalities giving rise to irregular periods etc.

Male factors can also lead to secondary infertility like:
Abnormal seminal parameters like low sperm count, decreased motility etc.
Genital abnormalities like varicocele, ejaculatory duct obstruction etc.
 By examination and by investigations like ultrasound, hysterosalpingography, gonadal hormonal analysis, thyroid profile, prolactin levels estimation for female partner and by physical examination and semen  analysis for male partner the possible cause of the problem can be identified and treated. 

Feeling periods as burden?

Some women think that having periods monthly is a burden to their life.
As they have completed their families or they don't want pregnancy, they want to get rid of periods either by hysterectomy or by other methods.
But this is not correct.
Because the gonadal hormones which are responsible for regular menstrual cycles, also help in many other functions of the body like cardiac function, bone health, neurological function etc.
Having uterus is important for gonadal function. Because if end organ is lost, ovaries function will get affected.
So having menstrual cycles is important for general health also.

Subchorinic hematoma

Live fetus with subchorionic hematoma

Subchorionic hematoma is collection of blood between chorion and uterus.
This is a common ultrasound finding in early pregnancy.
 The possible causes of subchorionic hematoma are   damage of the surrounding blood vessels by growing  gestational sac, during the process of abortion separation of gestational sac can lead to collection of blood etc.
Usually small subchorionic hematomas will get absorb soon.
But if pain abdomen, bleeding per vaginum etc occurs there is possibility of miscarriage and needs evaluation.
 Ultrasound should be repeated after two to three weeks, which can help in finding out whether hematoma got absorbed or not. 

Fimbrial cyst

This is a case of 38yrs old female patient  presenting with pain abdomen. 

Ultrasound diagnosis was ovarian cyst. During surgery that was found out to be large fimbrial cyst and removed.

Vulval leukoplakia - definition, causes, pathogenesis, symptoms and signs, diagnosis, prevention, treatment, differential diagnosis

 Definition:

Generally benign keratotic white lesions on the vulva are called as vulval leukoplakia or precancerous disease or white spot disease.

In these more are benign or pre-cancerous lesions. Only 4 to 6% can be cancerous.

Nowadays instead of using the general term leukoplakia, one standard nomenclature has developed based on the histopathological findings of the vulval lesions.

And these lesions are called non-neoplastic epithelial disorders in general. And these are subdivided into:

-Squamous cell hyperplasia.

-Lichen sclerosus.

-And other dermatoses.

Causes of leukoplakia:

Exact etiology is not clear. But the possible factors are:

-Systemic factors like:  

    Diabetes

    Endocrine disorders

    Malnutrition

   Vitamin deficiency

   Pituitary-ovarian dysfunction

-EB virus infection

-Candida albicans infection

-HPV infection seen in around 22% of the patients.

-Can be seen in patients with oral leukoplakia.

-P 53 gene mutation leading to cell proliferation.

-Local factors like:

   Genital partial wetness

   Heat stimulation

   Rubbing

  Age related atrophy

-Previous similar lesions

-The skin graft to vulva can also get the lesions.

Pathogenesis:

It is a mucosal or epidermal epithelial proliferative lesion.

In leukoplakia mucosal epithelium becomes keratinized ranging from granular layer thickness.

Histopathological features:

-Significant hyperkeratosis

-Granular layer thickening

-Mucosal or skin epithelial hyperplasia

-Acanthosis thickening

-Epithelial crest

-Infiltration of dermal lymphocytes and plasma cells

-Appearance of prickle cell layer

-Cells with irregular shape and mitotic figures

Symptoms and signs:

-Patient will usually present with irregular milky white shiny patches or plaques with slightly elevated mucosal surface, well defined borders and state clearly.

These lesions can be seen on genital organs like vaginal mucosa, urethral mucosa, clitoris, labia majora, labia minora etc.

Itching is one more common feature.

Itching can lead scratching, rubbing which can in turn lead to flushing, edema, erosion, ulcers or liquenification.

With progression of time some lesions can become:

-Uplifted, state unclearly

-Surface becomes more keratinized, rough and hard to touch.

-Bleeding from the erosion or ulcers can be seen.

Diagnosis:

Histopathological examination and clinical features collectively help in diagnosis.

Prevention:

-Pertinacious diet containing vitamins, minerals etc. should  include milk, eggs etc.

-Treating provoking factors like diabetes, endocrine diseases etc.

-Treating EB virus, candidial infections etc.

-Maintaining vulval local health like reducing the moisture, friction, heat production etc.

Treatment:

-With appropriate and early intervention around 96 to 97% cases can be prevented from becoming worse.

-Local treatment – to keep the vulva clean and dry.

-Using mild soaps and avoiding soap over scrub etc.

-For itching local corticosteroids can be used.

-For keratosis proliferative lesions topical 0.025% to 0.05% Vitamin-A acid ointment or 2.5% fluorouracil ointment can be used.

(Fluorouracil helps in blocking the conversion of uracil into thymidine. Thereby it inhibits DNA synthesis, which prevents tumor cell proliferation and differentiation. It can be used in precancerous skin lesions and also in malignant skin lesions.)

-Leukoplakia with mild dysplasia can be treated with this combination therapy and long term follow-up.

-In case of leukoplakia lesions with atypical cellular features with possibility of development of carcinoma in situ needs surgery.

Differential diagnosis of leukoplakia :

Keratosis:

-White skin cells due to hypopigmented keratosis with out heteromorphism.

-Appear as ill-defined white spots with no or mild infiltration.

-If the keratosis prolongs for long term it can turn into leukoplakia etc lesions.

Oral lichen planus in combination with genital lichen planus

-Can appear on genital skin or at mucocutaneous junction.

-Usually appears as polygonal flat purple or dark red papules with glossy surface.

-HPE: colloid bodies, basal liquefaction, degeneration, dermal infiltration of lymphocytes etc.

 

Atrophic lichen sclerosis:

-Often occurs on labia.

-It is atrophic vulvar dystrophy.

-Appear as blue and white papules, integrated pale hypo pigmented spots can be seen.

-Can involve anus and vagina to form a dumble – shaped lesions.

-Itching will be minimal usually.

Vulval vitiligo:

-Depigmented spots with clear boundaries can be seen.

-No keratosis or infiltration or itching.

-Same type of lesions can be on other parts of the body.

-HPE: complete lack of dopamine stained melanocytes in the basal layer.

-Easy to differentiate with leukoplakia.

Vulval neurodermatitis:

-Usually distributed on both sides of the outer labia.

-Conscious itching sensation will be present.

-Skin lesions can develop due to continuous scratching.

-HPE: changes of chronic dermatitis, thickening of skin layers can be seen. There will be no spindle shaped cells which will help in differentiating with leukoplakia.

Types of anemia according to RBC indices and causes

 RBC(Red blood cells) indices are part of complete blood picture examination.

Usually measured RBC indices are:
-Number of RBC.
Normal values:
Male: 4.7 to 6.1 million cells /mcL
Female: 4.2 to 5.4 million cells/mcL
Decreased number of RBC indicate anemia.

-MCV (mean corpuscular volume) - the average red blood cell size.
Normal value:  80 to 100 femtoliter

-MCH (mean corpuscular hemoglobin) -the amount of hemoglobin per red blood cell.
Normal value: 27 to 31 picograms/cell

-MCHC (mean corpuscular hemoglobin concentration)- the amount of hemoglobin relative to the size of the cell or hemoglobin concentration per red blood cell.
Normal value: 32 to 36 grams/deciliter

Depending on these indices anemias can be classified as:
-Normocytic and normochromic anemia:
• decreased number of RBC with normal hemoglobin content, MCV and MCHC.
•Causes:
Sudden and significant blood loss Prosthetic heart valve
Tumors
Any chronic disease
Aplastic anemia etc.

-Microcytic and hypochromic anemia:
•decreased number of RBC with low MCV and MCHC.
•causes:
iron deficiency
lead poisoning
thalassemia etc.

-Macrocytic and normochromic anemia:
•decreased number of RBC with high MCV and normal MCHC.
•Causes:
B-12 and/or folate deficiency
Pernicious anemia
Chemotherapy etc.

-Macrocytic and hyperchromic anemia:
•decreased number of RBC with high MCV and MCHC.
•Causes:
Folic acid deficiency
Chronic alcoholism
Using drugs which are having antagonistic activity to folic acid like cotrimoxacol  and triamteren etc.

Weight losing drugs - infertility

Obesity sometimes can lead to infertility by leading to hormonal imbalance.
Obese women are prone for poly cystic ovary disease.
It can also lead to other medical complications like diabetes, hypertension etc, and these can also affect the fertility.
So weight loss can improve the fertility.
But using drugs to loose weight while trying for pregnancy is not advisable.
Because some of these drugs can lead to side effects according to studies.
And they can affect the baby if pregnancy occurs.
Physical exercise and dietary management are the best ways to loose weight.
Any drug should be used only with doctor's prescription and after verifying FDA approval.
Sometimes FDA can recall some drugs after patients reporting side effects.
Example: http://www.fda.gov/forconsumers/consumerupdates/ucm374742.htm
So full information should be gathered before starting any drug. Take care.


(The viewers are invited to ask questions or share opinions related to obstetrics and gynecology through the comment box. Thank you)

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.


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