Patients' Education

A high-risk pregnancy is one that threatens the health or life of the mother or her fetus.
For most women, early and regular prenatal care promotes a healthy pregnancy and delivery without complications. But some women are at an increased risk for complications even before they get pregnant for a variety of reasons.

Risk Factors for Complications During Pregnancy

RISK FACTORS INCLUDE

• Preexisting maternal disorders ( Pregnancy Complicated by Disease)
• Physical and social characteristics
• Age
• Problems in previous pregnancies (eg, spontaneous abortions
• Problems that develop during pregnancy ( Abnormalities of Pregnancy)
• Problem that develop during labor and delivery ( Abnormalities or Complications of Labor and Delivery)

HYPERTENSION

Pregnant women are considered to have chronic hypertension (CHTN) if hypertension was present before the pregnancy or if it develops before 20 wk of pregnancy. CHTN is differentiated from gestational hypertension, which develops after 20 wk of pregnancy. In either case, hypertension is defined as systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg on 2 occasions > 24 h apart. Hypertension increases risk of fetal growth restriction by decreasing uteroplacental blood flow and risk of adverse fetal and maternal outcomes. Before attempting to conceive, women with hypertension should be counselled about the risks of pregnancy. If they become pregnant, prenatal care begins as early as possible and includes measurements of baseline renal function (e.g., serum creatinine, BUN), funduscopic examination, and directed cardiovascular evaluation (auscultation and sometimes ECG, echocardiography, or both). Each trimester, 24-h urine protein, serum uric acid, serum creatinine, and Hct are measured. Ultrasonography to monitor fetal growth is done at 28 wk and every 4 wk thereafter. Delayed growth is evaluated with multivessel Doppler testing by a maternal-fetal medicine specialist for management of hypertension during pregnancy.

DIABETES

Overt diabetes mellitus occurs in ≥ 6% of pregnancies, and gestational diabetes occurs in about 8.5% of pregnancies. Incidence is increasing as the incidence of obesity increases.
If pregnant women have pre-existing insulin-dependent diabetes, risk is increased for pyelonephritis, ketoacidosis, preeclampsia, fetal death, major fetal malformations, fetal macrosomia (fetal weight > 4.5kg), and, if vasculopathy is present, fetal growth restriction. Insulin requirements usually increase during pregnancy.
If women have gestational diabetes, risk of hypertensive disorders and fetal macrosomia is increased. Gestational diabetes is routinely screened for at 24 to 28 wk and, if women have risk factors, during the 1st trimester. Risk factors include previous gestational diabetes, amacrocosmic infant in a previous pregnancy, family history of noninsulin–dependent diabetes, unexplained fetal losses, and body mass index (BMI) > 30 kg/m2. The diagnosis of gestational diabetes is made based on results of oral glucose tolerance test.
Optimal treatment of gestational diabetes (with dietary modification, exercise, and close monitoring of blood glucose levels and insulin when necessary—see Monitoring) reduces risk of adverse maternal, fetal, and neonatal outcomes.

SEXUALLY TRANSMITTED DISEASES (STDS)

Fetal syphilis in utero can cause fetal death, congenital malformations, and severe disability. Risk of transmission of HIV from woman to offspring in utero or perinatally is 30 to 50% within 6months. During pregnancy, bacterial vaginosis, gonorrhoea, and genital Chlamydia infection increase risk of preterm labour and premature rupture of the membranes. Routine prenatal care includes screening tests for these infections at the first prenatal visit. Syphilis testing is repeated during pregnancy if risk continues and at delivery for all women. Pregnant women who have any of these infections are treated with antimicrobials.
Treatment of bacterial vaginosis, gonorrhoea, or Chlamydia infection may prolong the interval from rupture of the membranes to delivery and may improve fetal outcome by decreasing fetal inflammation.Treating HIV with zidovudine SOME BRAND reduces risk of transmission by two thirds; risk is probably lower (< 2%) with a combination of 2 or 3 antivirals . These drugs are recommended despite potential toxic effects in the fetus and woman.

PYELONEPHRITIS

Pyelonephritis increases risk of premature rupture of the membranes, preterm labour, and infant respiratory distress syndrome. Pregnant women with pyelonephritis are hospitalized for evaluation and treatment, primarily with urine culture plus sensitivities, IV antibiotics , antipyretics, and hydration. Pyelonephritis is the most common nonobstetric cause of hospitalization during pregnancy. Oral antibiotics specific to the causative organism are begun 24 to 48 h after fever resolves and continued to complete the whole course of antibiotic therapy, usually 7 to 10 days. Prophylactic antibiotics with periodic urine cultures are continued for the rest of the pregnancy.

ACUTE SURGICAL PROBLEMS

Major surgery, particularly intra-abdominal, increases risk of preterm labor and fetal death. However, surgery is usually tolerated well by pregnant women and the fetus when appropriate supportive care and anesthesia (maintaining BP and oxygenation at normal levels) are provided, so physicians should not be reluctant to operate; delaying treatment of an abdominal emergency is far more dangerous. After surgery, antibiotics and tocolytic drugs are given for 12 to 24 h. If nonemergency surgery is necessary during pregnancy, it is most safely done during the 2nd trimester.

GENITAL TRACT ABNORMALITIES

Structural abnormalities of the uterus and cervix (eg, uterine septum,bicornuate uterus) make fetal malpresentation, dysfunctional labor,and the need for caesarean delivery more likely. Although unlikely, uterine fibroids can cause placental abnormalities (e.g., placenta previa), preterm labor, and recurrent spontaneous abortion. Fibroids may grow rapidly or degenerate during pregnancy; degeneration often causes severe pain and peritoneal signs. Cervical incompetence makes preterm delivery more likely. If, before pregnancy, women have had a myomectomy in which the uterine cavity was entered, caesarean delivery is required because uterine rupture is a risk during subsequent vaginal delivery. Uterine abnormalities that lead to poor obstetric outcomes often require surgical correction, which is done after delivery.

MATERNAL AGE

Teenagers, who account for 13% of all pregnancies, have an increased incidence of preeclampsia, preterm labor, and anaemia,which often leads to fetal growth restriction. The cause, at least inpart, is that teenagers tend to neglect prenatal care, frequently smoke,and have higher rates of sexually transmitted diseases.
In women > 35, the incidence of preeclampsia is increased, as is that of gestational diabetes, dysfunctional labor, abruptio placentae, stillbirth, and placenta previa. These women are also more likely to have preexisting disorders (e.g., CHTN, diabetes). Because risk of fetal chromosomal abnormalities increases as maternal age increases, genetic testing should be offered.

MATERNAL WEIGHT

Pregnant women whose BMI was < 19.8 kg/m2 before pregnancy are considered underweight, which predisposes to low birth weight (< 2.5kg) in neonates. Such women are encouraged to gain at least 12.5 kg during pregnancy.
Pregnant women whose BMI was > 29.0 kg/m2 before pregnancy are considered overweight, making maternal hypertension and diabetes, post term pregnancy, fetal macrosomia, preeclampsia, and the need for caesarean delivery more likely. Such women are encouraged to limit weight gain during pregnancy to < 11.5 kg.

MATERNAL HEIGHT

Short (about < 152 cm) women are more likely to have a small pelvis, which can lead to dystocia with fetopelvic disproportion or shoulder dystocia. For short women, preterm labor and intrauterine growth restriction are also more likely.

EXPOSURE TO TERATOGENS

Common teratogens (agents that cause fetal malformation) include infections, drugs, and physical agents. Malformations are most likely to result if exposure occurs between the 2nd and 8th wk after conception (the 4th to 10th wk after the last menstrual period), when organs are forming. Other adverse pregnancy outcomes are also more likely. Pregnant women exposed to teratogens are counseled about increased risks and referred for detailed ultrasound evaluation to detect malformations.
Common infections that may be teratogenic include herpes simplex, viral hepatitis, rubella, varicella, syphilis, toxoplasmosis, and cytomegalovirus and coxsackievirus infections.
Commonly used drugs that may be teratogenic include alcohol,tobacco, and cocaine and some prescription drugs.

PRIOR STILLBIRTH

Stillbirth is delivery of a dead fetus at > 20 wk gestation. Fetal death during late pregnancy may have maternal, placental, or fetal anatomic or genetic causes . Having had a stillbirth or late abortion (ie, at 16 to 20 wk) increases risk of fetal death in subsequent pregnancies. Degree of risk varies depending on the cause of a previous stillbirth. Fetal surveillance using antepartum testing (e.g., nonstress testing, biophysical profile) is recommended. Treatment of maternal disorders (e.g., CHTN, diabetes, infections) may lower risk of stillbirth in a current pregnancy.

PRIOR PRETERM DELIVERY

Preterm delivery is delivery before 37 wk. Previous preterm delivery due to preterm labor increases risk of future preterm deliveries; if the previous preterm neonate weighed < 1.5 kg, risk of preterm delivery in the next pregnancy is 50%. Women with prior preterm delivery due to preterm labor should be closely monitored at 2-wk intervals after 20 wk. Monitoring includes

• Ultrasound evaluation, including measurement of cervical length and shape, at 16 to 18 wk
• Uterine contraction monitoring
• Testing for bacterial vaginosis
• Measurement of fetal fibronectin

Women with prior preterm birth due to preterm labor or with shortening (< 25 mm) or funneling of the cervix should be given 17 α-OHprogesterone 250 mg IM once/wkly

PRIOR NEONATE WITH A GENETIC OR CONGENITAL DISORDER

Risk of having a fetus with a chromosomal disorder is increased for most couples who have had a fetus or neonate with a chromosomal disorder. Recurrence risk for most genetic disorders is unknown. Most congenital malformations are multifactorial; risk of having a subsequent fetus with malformations is ≤ 1%. If couples have had a neonate with a genetic or chromosomal disorder, genetic screening is recommended. If couples have had a neonate with a congenital malformation, genetic screening, high-resolution ultrasonography, and evaluation by a maternal-fetal medicine specialist is recommended.

POLYHYDRAMNIOS (HYDRAMNIOS) AND OLIGOHYDRAMNIOS

Polyhydramnios (excess amniotic fluid) can lead to severe maternal shortness of breath and preterm labor. Risk factors include uncontrolled maternal diabetes, multifetal pregnancy, isoimmunization, and fetal malformations (e.g., esophageal atresia, anencephaly, spina bifida).
Oligohydramnios (deficient amniotic fluid) often accompanies congenital malformations of the fetal urinary tract and severe fetal growth restriction (< 3rd percentile). Also, Potter syndrome with pulmonary hypoplasia or fetal surface compression abnormalities may result, usually in the 2nd trimester, and cause fetal death.
Polyhydramnios and oligohydramnios are suspected if uterine size does not correspond to gestational date or may be discovered incidentally via ultrasonography, which is diagnostic.

MULTIFETAL (MULTIPLE) PREGNANCY

Multifetal pregnancy increases risk of fetal growth restriction, preterm labor, abruptio placentae, congenital malformations, perinatal morbidity and mortality, and, after delivery, uterine atony and haemorrhage. Multifetal pregnancy is detected during routine ultrasonography at 18 to 20 wk.

PRIOR BIRTH INJURY

Most cerebral palsy and developmental delay is caused by factors unrelated to a birth injury. Injuries such as brachial plexus damage can result from procedures such as forceps or vacuum extractor delivery but often result from intrauterine forces during labor or malposition during the last weeks of pregnancy. Previous shoulder dystocia is a risk factor for future dystocia, and the delivery records should be reviewed for potentially modifiable risk factors (eg, fetal macrosomia, operative vaginal delivery) that may have predisposed to the injury.

If you have been cohabiting for more than a year or if you are more than 35 years of age and have been cohabiting for more than 6 months without contraception, you should visit an infertility clinic. Today there is hope for you in the form of improved diagnostic tools (laparoscopy, hysteroscopy, sono-hysterography and many others ), assisted reproductive techniques (IUI and test tube baby) and a better treatment options for diseases like fibroids, endometriosis and polycystic ovaries. On your first visit to our clinic, we would take your case history and examine you and carry out certain basic blood tests (usually routine tests and sometimes hormonal tests) for you and semen analysis of your husband. If all of these are within normal limits, we would carry out more advanced test to see whether your ovaries are producing eggs (ovulation) regularly and whether your fallopian tubes are open.

Infertility is a condition where a couple fails to conceive after about a year of regular unprotected intercourse.

WHAT ARE THE REASONS SOME COUPLES FIND IT DIFFICULT TO CONCEIVE?

Depending on the results of the various tests, the couple may fall into any or more of the below mentioned categories:

• Tubal factor infertility (one or both of her fallopian tubes is blocked or diseased) - This may happen in cases of pelvic infection, tuberculosis, endometriosis or adhesions due to previous surgery .
• Anovulatory infertility (failure of an egg to grow or rupture in every menstrual cycle).
• Uterine factor infertility (the uterus may have fibroids, septum, tuberculosis, adhesions)
• Multiple factor infertility -In some patients, there may be more than one cause for failure to conceive. For e.g.tuberculosis, endometriosis. Sometimes both the partners may have a problem.
• Unexplained infertility - In many cases, all tests yield normal results, yet conception does not occur in reasonable amount of time. Such couples often benefit with assisted reproductive techniques(ART).

UNDERSTANDING TESTS FOR FERTILITY:

Semen Analysis:

This is the most basic test for assessment of the male partner. Semen testing should be done preferably in a specialized lab. If the report shows any abnormality, the test should be repeated for confirmation.

Sonography:

Sonography of the female pelvis can detect any abnormality such as tumor of the uterus or ovary or hydrosalpinx (when the fallopian tube is filled with fluid).

Follicular study:

Sonography is an invaluable tool for studying ovulation. Sonography is done from the ninth day of the menstrual cycle on alternate days till ovulation is detected (on day 14th or 15th usually). Follicular study helps to detect defects in ovulation and also whether the uterine lining is ready for implantation of the fertilised egg.

Hysteroscopy:

It is a surgical procedure to be done under local or general anaesthesia. An endoscope is inserted into the uterus through the vagina and a magnified view of the inside of the uterus is seen. It helps to detect small internal fibroids,polyps, septum or adhesions (bands) and to assess the endometrium (uterine lining) and cavity. Any defects of the cavity such as double uterus, very small (hypoplastic uterus) or T-shaped uterus. The gynaecologist may combine it with a D&C (dilatation and curettage) to take biopsy of the uterine lining.

Laparoscopy:

Under general anaesthesia, an endoscope is inserted into the abdomen and a magnified view of the abdominal cavity is obtained. It is an excellent tool to evaluate the uterus, tubes and ovaries and their relationship to each other. It can diagnose tuberculosis, endometriosis, pelvic inflammatory disease, etc. and treatment may be carried out at the same sitting. In experienced hands, this is a very safe and cost-effective procedure to diagnose and treat the cause of female infertility. It is almost always combined with hysteroscopy.

Hysterosalpingography (HSG):

An Xray of the uterus and tubes taken after injection of a suitable dye into the uterus . Since it is performed without anaesthesia, it may be a little painful. It gives a fairly good idea of the uterine cavity and tells us whether tubes are open. However, it may miss endometriosis and early tuberculosis and will not tell us the cause of tubal blocks.

Sonohysterosalpingography:

Saline is injected into the uterus and sonography is performed. This gives similar information as HSG, and gives better information about endometrium. However, it requires expertise and is not commonly performed.

WHAT IF ALL MY REPORTS ARE NORMAL?

We call such a situation ‘unexplained infertility’. In such cases, we induce ovulation (using medicines) and grow more than one egg (controlled ovarian hyperstimulation) to increase chances of fertilisation and then perform IUI (intrauterine insemination) in the same cycle.

WHAT IS IUI (INTRAUTERINE INSEMINATION)?

We call such a situation ‘unexplained infertility’. In such cases, we induce ovulation (using medicines) and grow more than one egg (controlled ovarian hyperstimulation) to increase chances of fertilisation and then perform IUI (intrauterine insemination) in the same cycle.

ARE THERE ANY SIDE EFFECTS TO FERTILITY TREATMENTS?

Apart from being extremely stressful, various treatments may have specific side-effects. Notable among those, is hyperstimulation of the ovaries, which may happen during ovarian stimulation especially in the course of IVF or ICSI treatment. Here the ovaries become large with multiple cysts and fluid leaks in the abdomen. It may become lifethreatening in severe cases. Fortunately, with advanced protocols of management, the incidence of this condition has become far less common. Another common problem is multiple pregnancies (twins or triplets) due to maturation of many eggs in one cycle. Surgical treatments have their independent risks as well. Counselling prior to start of treatment as well as through it, is very important to help couples understand what they are going in for, as well as supporting them emotionally.

WHEN SHOULD COUPLES OPT FOR FERTILITY TREATMENTS?

There is no hard and fast rule about when to start the process of fertility testing and treatment. It would depend on your age and your husband's and how keen you are. Medically, infertility is defined as inability to conceive after a year of regular, unprotected intercourse. However, for older couples or couples who have other associated conditions which could affect fertility, it would be wise to start early treatment, whereas for younger couples with no risk factors, we could wait a little while longer. In general, if you are anxious to conceive, we do initiate early testing.

HOW LONG SHOULD COUPLES TRY TO CONCEIVE USING THESE TREATMENTS?

Again, there is no cut-off to stop trying. It would depend on your age and your husband's, your resolve, your attitudes towards fertility and your financial and psychological state. After 40, you tend to become less fertile, and most clinics prefer to use ‘donor eggs’ for IVF or ICSI. It is interesting, however, to note that many couples conceive naturally after stopping treatment! Possibly, the sense of ‘letting go’ relieves stress and things just fall back into place naturally.

5 –25 % of all women between 15 – 65 years leak urine involuntarily. This is an extremely embarrassing problem and women are scared to venture out of the house if they are notable to control urine effectively. Some women use pads or diapers in order to hide this problem. This lack of control of urine may be Stress urinary incontinence (SUI), which is leakage of urine when the woman coughs, sneezes or laughs loudly. It may be otherwise be a condition called an unstable bladder which is characterized by an increase in frequency of urination, inability to control it and leakage of urine before reaching the bathroom, and getting up at night to go the bathroom. Many women develop these problems after vaginal delivery due to the stretching and tearing of the vagina during a difficult delivery. After menopause there is a loss of hormones which result in thinning, dryness and weakness of the bladder supports and this can result in inability to control urine.
These have different treatments and so a clear diagnosis must first be made.A urine check, sonography of the bladder and kidneys and a special test called urodynamic study will help arrive at an accurate diagnosis. Sometimes looking inside the bladder, with a telescope (cystoscopy) may be required. Wrong diagnosis may result in more problems than benefits.
The treatment of Stress incontinence is essentially surgical, though some people may benefit by pelvic floor exercises known as Kegels exercises. Surgical treatments may vary from surgery to pull up the bladder neck which can be done by open surgery or by key hole surgery (laparoscopy). The newer techniques however are easier and faster and give good results. These involve placing a tape just above the urinary opening near the vagina. These are the tension free vaginal tape (TVT) procedure or the Transobturator tape (TOT) procedure. In this there are no visible stitches on the patients abdomen and only one or two stitches near the urinary opening are required. Following these procdures,the patient can go home in one day. Few cases can be treated by injecting special material on both sides of the urinary opening.
The urge incontinence however is better managed with medicines which reduce the bladder irritability and surgery is rarely required. In menopausal women, estrogen creams or tablets may help. In some cases dilatation of the urinary opening may need to be done.

Stress Urinary Incontinence

How can I be sure this is SUI?

A simple gyneclogical examination on a full bladder , by your doctor , can clinch the diagnosis. There are specific tests, such as urodynamic study which can differentiate SUI from irritable bladder or failure of the valve mechanism of the urethra.

Do I need to undergo treatment for this?

SUI is not going to improve on its own, it will probably worsen, especially after menopause. There are conservative treatments such as physiotherapy, pelvic floor exercises (Kegels exercise), electric stimulation etc which may lead to some improvement in symptoms. However these are for mild cases only and results may not be guaranteed.

What are the surgical options for me?

There are many different types of surgeries available and the choice can be made after seeing the nature of the problem and the doctor’s preference. SUI may be accompanied by sagging of the bladder wall or cystocoele. Both these can be tackled by vaginal cystocoele repair along with the traditional kelly’s stitch, which is a vaginal approach.

Are there any newer methods of treatment available?

Nowadays the preferred surgeries are open or laparoscopic Burch colposuspension operation, sling operations or needle procedures. The latest techniques are those of TVT (tension free vaginal tape) where a tape is inserted from the vagina and fixed below the middle of the urethra. This is done under local or spinal anaesthesia. The newest modification is to pass the tape under the bladder opening and bring it out through the obturator foramen situated on the medial side of the thigh, a shorter and simpler procedure. Most of those procedures give good results and recurrence rates are low.

How risky are these surgeries?

All surgeries come with a certain amount of risk . But most of the surgeries are quick and require no prolonged hospitalization.

Dos & Donts

• Make sure your deliveries are conducted under supervision.
• Pelvic floor exercises are to be done lifelong.
• You don’t have to live with the embarassment of SUI.
• Alternate forms of treatment can be tried.
• Simple & short surgical options are available.

Menstrual cycles often bring about a wide array of uncomfortable symptoms leading up to your period. Premenstrual syndrome (PMS) encompasses the most common issues, such as mild cramping and fatigue, but the symptoms usually go away when your period begins.
However, other, more serious menstrual problems may also arise. Menstruation that is too heavy or light, or a complete absence of a cycle, all signal issues that can contribute to an abnormal menstrual cycle. It is important to stay in tune with your body and call your doctor right away if you notice any significant changes to your menstrual cycle.

Premenstrual Syndrome

PMS occurs one to two weeks before your period begins. Some women experience a range of physical and emotional symptoms. Others experience few symptoms or none at all.

PMS can cause:

• Bloating
• Backaches
• Headaches
• Breast soreness
• Acne
• Food cravings
• Excessive fatigue
• Depression
• Anxiety
• Feelings of stress
• Insomnia
• Constipation
• Diarrhea
• Mild stomach cramps

You may experience different symptoms every month, and the severity of these symptoms can also vary. PMS is uncomfortable, but it is generally not worrisome unless it interferes with your normal activities.

Heavy Periods

Another common menstrual problem is a heavy period. Also called menorrhagia, heavy periods cause you to bleed more than normal. You may also have your period for longer than the average of five to seven days.

Menorrhagia is mostly caused by imbalances in hormone levels, especially progesterone and estrogen. Other causes of heavy or irregular menstrual bleeding include:

• Puberty.
• Vaginal infections.
• Inflammation of the cervix.
• Underactive thyroid gland (hypothyroidism).
• Noncancerous uterus tumors (fibroids).
• Changes in diet or exercise.

Absent Periods

In some cases, women may not get their periods. Amenorrhea occurs when you don't get your period by the time you reach the age of 16. This may be caused by an issue with the pituitary gland, a congenital defect of the female reproductive system, or a delay in puberty.
Another common problem with teens is secondary amenorrhea. This occurs when you start your cycle, but it suddenly stops for three months or more.

Common causes of amenorrhea and secondary amenorrhea include:

• Anorexia
• Overactive thyroid gland (hyperthyroidism)
• Ovarian cysts
• Sudden weight gain or loss
• Stopping birth control
  Pregnancy

Uterine fibroids, also known as leiomyomas, are non-cancerous tumors of the womb or uterus. These tumors start in the myometrium(muscle) of the uterus. They occur in nearly half of all women over the age of 30 and this too may be underestimated as fibroids have been found in 77 per cent of uteri removed for reasons other than fibroids.

WHAT CAUSES FIBROIDS?

Fibroids only occur after puberty and shrink after menopause. The female sex hormones such as oestrogen and progesterone are most likely involved in tumour growth. However, other growth factors as well as some genetic factors may also be involved. Though the causes are not known , women who have never had children, or are obese are particularly at risk.
It is difficult to know if fibroids run in families as they are so common. Women who have used the combined oral contraceptive pill or the drug Depo-Provera as contraceptive agents are protected against developing fibroids.

ARE FIBROIDS CANCEROUS?

Fibroids are non cancerous. Cancer of fibroids (leiomyosarcoma) is very rare and begin as cancers Benign tumours do not transform to malignant ones.

• Fibroids occur in more than 25% of women over 30 years of age.
• Commonest cause for hysterectomy in women under 50 years.
• Growth of fibroids depends on oestrogen and progesterone.
• Benign fibroids do not become cancerous.

SYMPTOMS OF FIBROIDS

• Heavy Periods (Menorrhagia) -Heavy periods occur in 30 per cent of women having fibroids .Tiredness, weakness and emotional changes may occur secondary to the anaemia which results from the excessive blood loss.
• Bowel and Bladder Symptoms -Pressure caused by the fibroids may result in bowel and bladder symptoms Rarely complete blockage of urine may occur requiring a catheter to be passed.
• Lump or Bloating -Discovery of a lump in the abdomen and / or distension of the abdomen may be the fi rst change noticed. The distention may be partly due to the fibroid, which is fi rm to feel, or bowel that is pushed and distended, which feels soft.
• Sexual Discomfort or Difficulty -If the fibroid (s) expand the uterus and take up considerable space within the pelvis full vaginal penetration may be prevented. This may reduce enjoyment for the female and male.
• Pain -Menstrual. Period pain(dysmenorrhoea) may be due to stretching of the uterus, or the response of trying to expel the fibroid , creating ‘labour like’ pains.
  Pressure on neighbouring organs. Back pain, or pain in the lower abdomen, may result from pressure on the spine, pelvic bones, nerves or tissue , bowel and bladder.

COMPLICATIONS OF FIBROIDS

• Degeneration -Occasionally the blood supply to the fibroid is blocked and it undergoes degeneration resulting in swelling and release of chemicals which can cause severe pain.
• Twisting -The fibroid may grow outside the uterus and is connected to the uterus by a narrow stalk, may twist on itself and cause severe pain and tenderness.
• Infection -Rarely fibroids become infected, which usually occurs when they are protruding in the vagina or after childbirth.
• Cancer -They are very rare ,a cancerous fibroid is called ‘sarcoma’.. There may be no symptoms to distinguish a sarcoma from a simple fibroid. Sometimes a rapid increase in size may raise the suspicion of the presence of a sarcoma.

TYPES OF FIBROIDS, SYMPTOMS & PROGRESSION

Even though 25 per cent of women above the age of 30 years have fibroids, only about half experience symptoms. Fibroids may be either single or multiple and may vary from being as small as a pea to as large as a football. Their site in the womb may also vary. They may be present within the cavity of the uterus (submucosal),within the muscle of the uterus (intramural), or in the outer layer and protrude from the uterus (subserosal).

• Submucosal fibroids -Submucosal fibroids protrude inwards into the cavity of the uterus and are commonly associated with heavy bleeding and may cause infertility.
• Intramural fibroids -Intramural fibroids begin as little lumps in the muscle of the uterus that grow, making the uterus larger and distort its shape. This type of fibroid may play a role in heavy periods and pressure symptoms.
• Subserosal fibroids -Subserosal fibroids grow and protrude from the outer surface of the uterus, vary greatly in size, and may be multiple.

FIBROIDS AND INFERTILITY

Fibroids may reduce the chances of becoming pregnant in a variety of ways:

• By causing heavy periods and subsequent anaemia resulting in ill health and tiredness.
• Very large fibroids may bulge into the vagina and cause pain or discomfort during intercourse.
• Fibroids in the fundus of the uterus occasionally block the tubes preventing formation of embryos.
• Fibroids inside the cavity of the uterus may prevent implantation of the embryo.
• Multiple fibroids in the wall of the uterus reduce IVF success rates, perhaps by affecting the lining of the uterus andthe implantation of the embryo.
• Most fibroids do not need to be removed before attempting to become pregnant unless the fibroid is causing infertility.
• Fibroids in Pregnancy -Fibroids may not only make it diffi cult to get pregnant, but they may cause miscarriage, malnutrition of the foetus, abnormal position of the baby in the uterus, obstruction during labour requiring caesarean section, and bleeding after delivery of the baby.
  Most fibroids do not need to be removed before attempting pregnancy.
  Removal of fibroids before pregnancy may be required if they are large ,cause severe bleeding, grow rapidly, or protrude into the uterine cavity

DIAGNOSIS

• Detection and Diagnosis -Clinical Examination: Fibroids are often diagnosed during vaginal examination by the gynaecologist at the time of a routine Pap smear/ general health checkup . Ultrasound: The best and least expensive test to diagnose the presence of fibroids .The addition of Color Doppler measures the blood fl ow and helps to determine the diff erence between fibroids, adenomyosis (endometriosis inside the uterus) and some cancers.
• Computerised tomography -CT is another method of assessing lumps and masses in the pelvis but is not as specific as ultrasound and is inferior in its ability to diff erentiate between the uterus and ovaries.
• Magnetic Resonance Imaging (MRI) -This sophisticated X ray is most the specific imaging for the female pelvis with precision, definition and accuracy . It may be helpful in distinguishing between fibroids and adenomyosis.
• Management Strategy -Management depends upon size of the fibroid, the position of the fibroid in the uterus, the age of the women, the desire to conceive, and the attitude to surgery. Symptoms of heavy bleeding, pain during periods, or pressure on the bladder, bowel and spine usually require treatment. The anemia due to the excessive bleeding can be managed by oral iron or intravenous iron sucrose therapy if oral iron not tolerated . Fibroids which are growing in size may need treatment, as delay may increase the difficulty of surgery and lead to more extensive surgery. Most often fibroids up to 3 cm need not be treated unless they are in the cavity of the uterus.
  Management depends upon size of the fibroid, the position of the fibroid in the uterus, the age of the women, the desire to conceive, and the attitude to surgery. Symptoms of heavy bleeding, pain during periods, or pressure on the bladder, bowel and spine usually require treatment. The anemia due to the excessive bleeding can be managed by oral iron or intravenous iron sucrose therapy if oral iron not tolerated . Fibroids which are growing in size may need treatment, as delay may increase the difficulty of surgery and lead to more extensive surgery. Most often fibroids up to 3 cm need not be treated unless they are in the cavity of the uterus. In some circumstances it may be considered prudent to remove a fibroid even if it is not causing any symptoms, e.g. a symptom-free 7cm fibroid may be dealt with laparoscopically easily, whilst in a few years time if it doubles in size and causes symptoms the surgery is likely to be more complex.

PREVENTION OF FIBROIDS

• Weight control – reduction of obesity
• Early child-bearing
• Lactation
• Oral Contraceptive Pills

TREATMENT

No Treatment may be required

• No symptoms
• Small fibroids
• After menopause

If no treatment is given regular ultrasonography should be done to monitor the growth of fibroids.

Treatment may be required

• Symptoms – heavy bleeding, pain
• Large fibroid in young women
• Rapid growth in fibroid
• Infertility related to fibroid
• Suspicion of cancerous fibroid (sarcoma)

Drug Treatment

Gonadotrophin hormone-releasing hormone analogues (GnRHa) are the most commonly used medical treatment for shrinkage of fibroids, eg :Zoladex. .They have two major disadvantages: expense and undesirable side effects .GnRha work by decreasing the level of oestrogen, effectively causing a menopausal state and thus hot flushes, vaginal dryness and mood swings They should not be continued for longer than 6 months as constant low oestrogen levels can increase the risk of oesteoporosis and fractures.

Embolization of Fibroids

Embolization is a technique used by interventional radiologists, performed under local anaesthesia through a tiny puncture in the groin and branches of the uterine artery are blocked.
The fibroid shrinks because it is starved of blood. This may prevent it from producing growth factors which may disturb the mentstrual cycle. The shrinkage of the fibroid is slow and may take up to 3 months.

Shrinkage of fibroids before surgery

The shrinkage eff ect of GnRH analogues (e.g. Zoladex) drugs is sometimes quite dramatic but is only temporary and may not be suffi cient to overcome the ill eff ects the fibroid on fertility. They can regrow in 3 to 6 months so the drug therapy maybe useful for postponement of surgical removal.

Removal of Fibroids (Myomectomy)

Myomectomy, the surgical removal of fibroids while preserving the uterus and its child bearing function is the defi nitive treatment .

Techniques of removal

• Hysteroscopic -Telescope via birth passage
• Laparoscopic -By Small Key Hole Incisions in the abdomen
• Laparo-hysteroscopic -By a combination of Hysteroscopy & Laparoscopy
• Laparotomy -By an incision in the abdomen

INTRODUCTION :

Carcinoma of cervix is the most frequent of all the genital tract cancers, and after the breast, the second most common site of malignancy in female body. India has the highest number of cervical cancer in the world according to the international agency of research on cancer (IARC), a part of the world health organisation (WHO), Approximately, cancer cervix accounts 80%, ovary 10% and uterine body 4-5% of genital cancers in India. Every year, around 74,000 patients die in the country out of 1,32,000 women diagnosed with this deadly disease. Across the world, around 2,80,000 women die of this disease every year and 27% of these deaths occur in India only.

WHAT IS CERVICAL CANCER?

The cervix is the lower part of the uterus(womb). It is sometimes called the uterine cervix, the body of the uterus is where the baby grows, the cervix connects the body of the uterus to the vegina (birth canal). The part of the cervix closest to the body of the uterus is called the endocervix.
The part next to vagina is the ectocervix or exocervix. The 2 main types of the cells covering the cervix are squamous cells (on the ectocervix) and glandular cells (on the endocervix) the place where the two cell types meet is called the transformation zone. Most cervical cancer starts in the transformation zone. These cells do not suddenly change into cancer. Instead, the normal cells of the cervix first gradually develop precancerous changes that turn into cancer.
TYPE OF CERVICAL CANCER :

• Cervical intra epithelial neoplasia (pre cancerous changes)
• Squamous cell carcinoma 80% - 90%
• Adenocarcinoma – 20%

RISK FACTORS :

1. HPV – the virus called human papilloma virus which infects mostly women causes the disease the virus get transmitted through sexual contact and even preventive measures like contraceptive cannot prevent it from entering a women’s body from infection, the virus takes 15-20 years to develop and attack as cervical cancer in womens body.
2. High risk HPV types- 16 & 18 cause 2/3rd of cervical cancer.
3. Low risk HPV type – 6 & 11
4. Smoking
5. Immunosuppression – Hiv infection, taking immunosuppressive drugs
6. History of sexually transmitted infection
7. Diet – poor diet can lead to cervical cancer. Also overweight women are more likely to develop adenocarcinoma of the cervix
8. Oral contraceptives (birth control pills) long term use of OC pills increases the risk
9. Multiple sexual partners
10. Multiple full term pregnancies
11. Sexual activity at young age and child bearing at early age (before age 18 years)
12. Low socioeconomics group
13. Mother took DES when pregnant with the patient

CERVICAL CANCER SCREENING :

It is recommended that woman undergo periodic cancer screening based on following criteria, Sexually active woman above 18 years.

• Sexual life more than 10 years.
• More than 3 pregnancies and labour.

SCREENING METHOD USED :

1. PAP smears
2. VIA (Visual inspection of cervix with 3% or 5% acetic acid)
3. VILI (Visual inspection of cervix with lugol’s iodine)

HOW IT IS DIAGNOSED?

1. Pelvic examination – involves internal examination of the vagina and adjacent organ by the gynaecologist.
2. PAP smear – involves using a small spatula to obtain a sample of the cells from the cervix. The cells are spread into glass slides, the sample is sent to a laboratory to be examined under microscope.
3. Colposcopy – If smear test is abnormal, patient may be referred for a colposcopy in order for a biopsy to be taken. A colposcopee is like a small microscope with a light.

Vaginal discharge is any fluid or material that leaves a woman’s body through the vagina. Some vaginal discharge is normal for all women, especially those in their reproductive years (ages 15 to 44). When the amount, quality or consistency of vaginal discharge changes, it may be a sign of disease or other irritation.
The fluids, chemicals and organisms of the vagina have a natural balance. When in balance, they help to clean the vagina and protect it from outside organisms. Any change to that natural balance can affect the characteristics of vaginal discharge. Changes may originate from both internal factors (hormonal changes or stress) or from external factors (infection or poor hygiene).
Normal vaginal discharge is clear or white with no bad odor. It has regular fluctuations that result from hormonal changes occurring throughout the menstrual cycle. The normally clear and thin fluid becomes a bit thicker and heavier at the time of ovulation. Sexual excitement increases vaginal discharge. It also changes during pregnancy, at menopause and when a woman uses birth control pills.
Change in the color, odor or consistency of vaginal discharge may indicate an infection. Yeast infections, where the volume of regular vaginal yeast increases, cause a thick, white discharge that looks like cottage cheese. Other vaginal infections (sometimes grouped as vaginitis) like trichomoniasis and bacterial vaginosis can cause other changes to vaginal discharge, such as changes in amount, color and odor. Sexually transmitted diseases may also be associated with unusual vaginal discharge, but frequently have no symptoms.
In addition, altered vaginal discharge may be the result of personal behaviors or habits that can affect the vaginal environment. These include douching and wearing tight clothing that restricts air flow to the vagina.
Symptoms that may accompany vaginal discharge include painful urination, itching, pelvic pain or rash. Sudden change in vaginal discharge should be reported to a physician. If there is infection, it can be treated and the vaginal discharge should return to normal levels.
Girls may begin to notice some vaginal discharge up to a year before their first menstrual period. Those not yet nearing puberty who experience vaginal discharge should see a physician immediately, because discharge is rare in healthy prepubescent girls.

What is epidural analgesia ?

Epidural analgesia is a technique in which local anaesthetic agent is placed around the nerves supplying the uterus & birth canal. It thus stops the pain associated with contractions, dilatation of cervix and distension of birth canal. The patient is still aware of contractions of the uterus. Patient is awake & in control of labour as the drugs used for the technique has no sedating effect on the mother & baby.

Who will do it ?

A qualified anaesthetist specialized n the technique of labour analgesia will do the procedure of insertion of catheter and will be with you in the labour ward till you deliver. Pain relieving injections will be given as per your demand.

Prerequisites for Epidural analgesia

Detail history is taken & examination carried out by anaesthetist to rule out risk factors if any. Anaesthetist may ask for certain blood test if required. Consent is taken. Procedure is explained to the patient.

When can I have Epidural or Spinal Analgesia ?

You should discuss your wishes about labor analgesia with your obstetrician or anaesthetist during your prenatal care. Spinal or Epidural analgesia is easier to start before labor discomfort makes it difficult for you to discuss your situation or cooperate in analgesia administration. However, you may let the labor nurse and your physician know if you are interested in having Epidural or Spinal analgesia at any point in your labor.
When you can actually receive the analgesia depends on circumstances surrounding your labor pattern and assessment by your physician. At the appropriate time, an anesthesiologist will discuss the
techniques with you and suggest options in accordance with your wishes and those of your physician. You may have concerns unique to you that your anesthesiologist will need to discuss, and you should have an opportunity to ask questions. If you and your anesthesiologist agree after this discussion, preparations will be made to administer an analgesic. Although it is unlikely, an anesthesiologist may not be immediately available to administer the analgesia because of emergencies; or there might be a reason that makes if inadvisable for you to have Epidural or Spinal analgesia.

How is epidural catheter put in ?

Catheter insertion procedure is done in sitting position or lying down on one side. Patient is asked to remain still during the procedure so as to avoid inadvertent injury. It is easier to put in epidural catheter when the contractions are not too painful but it is never too late to ask for one.
The anaesthetist will clean your back using antiseptic solutions. Small amount of local anaesthetic agent is injected into the area where the catheter will be inserted. A special large needle will be used to determine epidural space. (It is a space above the dura, which covers the spinal cord.) A very fine polythene tube is inserted in this epidural space through the needle. The needle is then removed. The tube is left in place and firmly fixed to the back. Local anesthetic & other pain relieving drugs are given through this tube for analgesia whenever the patient demands. It takes about 15 – 30 minutes for maximum pain relief.

What can I expect from Epidural or Spinal Analgesia?

Pain relief from Epidural or Spinal analgesia is usually more complete and intense as compared to the other forms of labor analgesia. Most women notice a pressure sensation with their contractions; this pressure sensation is an important mechanism that keeps labor progressing. With the concentrations of local anesthetics and
adjuvants used for epidural analgesia labouring woman can ambulate. There is no weakness or numbness in legs.

How long will the Analgesia last ?

Continuous Epidural analgesia can usually be made to last as long as your labor lasts. Injections will be effective depending on the characteristics of the drug injected. Without the use of the catheter, they cannot be repeated without replacement of a needle. Toward the end of labor - when the birth of the baby is close at hand and discomfort is more intense - additional medication or techniques may be needed.

What happens if I need a C-Section ?

The type of anesthesia used for a C-Section will depend on the urgency and nature of the reason for the surgery. Continuous Epidural technique can be extended for use during a C-Section.

Are there any other advantages?

Apart from pain relief, epidural analgesia increases blood supply to the baby and improves its well-being. This is very important in cases where the blood supply to the baby is compromised e.g. High blood pressure in mother, Growth restricted babies etc. Epidural analgesia is known to shorten duration of labour. Studies have also shown that the caesarean delivery rate is reduced. If a patient requires emergency caesarean section, anaesthesia can be given through the same catheter without additional pricks. In case of dire emergency, the anaesthetist is always available at the very instant to undertake emergency measures.

Does the medication affect the baby ?

The doses of medication typically used in labor analgesia usually do
not cause any noticeable effect in your baby’s Apgar scores or behavior. The Spinal and Epidural techniques use very small doses of medications; the local and IV techniques use larger doses. Your body will have essentially eliminated these medications before your breasts begin producing milk for breast feeding.

Are there any complications ?

Complications with epidural analgesia technique are extremely rare. Occasionally, headache can be complained by the patient, which may require treatment. Reaction to local anaesthetic is extremely rare.

Will this injection cause backache ?

Epidural analgesia is not responsible for backache. The reason for backache in a woman after delivery is laxity of ligaments, change in the curvature of back, laxity of abdominal muscles, lack of calcium in diet / supplement. These are wrongly attributed to the injection in the back. Several studies have shown that epidural analgesia does not cause backache. Epidural anesthesia or analgesia provides relief or reduction of labor pain without affecting the mother’s mental state. It enables an exhausted mother to relax or sleep during labor and calms the woman who is anxious and tense because of pain. Once an epidural catheter is in place, additional medication can easily be administered as needed, providing prolonged and consistent pain relief.

What your body is trying to tell you

Most women experience abnormal uterine bleeding at some period in their life time &faces a dilemma regarding their visit to the gynaecologist.
The length of a menstrual cycle and amount of blood flow is unique to each woman. However, most women have a cycle that ranges from 21 to 40 days. The bleeding lasts for 4-5 days with a blood loss of about 70mls.
An irregular period is usually defined as, any bleeding of a cycle length shorter than 21 days or longer than 40 days. It includes heavy bleeding with clots or scanty bleeding. There are many causes of abnormal periods, ranging from everyday stress to more serious underlying medical conditions. In many cases, irregular periods are related to a condition called anovulation. This means that ovulation hasn’t taken place during the menstrual cycle, usually due to severe hormonal imbalances.
Anovulation is often a part of a condition called polycystic ovarian syndrome. This condition is often associated with infertility but in most cases can be addressed successfully depending on what the main concern of the person is.
Factors that can trigger irregular or missed periods are – extreme exercise or dieting, stress, polycystic ovary syndrome (PCOS), uterine polyps or fibroids, pelvic inflammatory disease, endometriosis and premature ovary failure.
70% of PCOS patients have thyroid dysfunction and abnormal prolactin levels. In some c-uses, the high prolactin levels are due to prolactinoma — a noncancerous tumor of the pituitary gland in the brain.
A woman should consult a gynaecologist under the following circumstances:

1. If she experiences severe pain during her periods or between periods.
2. Has heavy bleeding.
3. Has an abnormal or offensive vaginal discharge.
4. The period that lasts longer than 7 days.
5. Vaginal bleeding or spotting between periods.
6. Periods that become very irregular.

Here are some recommendations for self care :

• Try to maintain a healthy lifestyle by exercising moderately and eating low fat foods. If you have to lose weight, do so gradually instead of turning to diets that drastically limit your calorie and food intake.
• Make sure you get enogh rest.
• Practice stress reduction and relaxation techniques.
• If you are an athlete, cut back on prolonged or intense exercise routines, Excessive sports activities can cause irregular periods.
• Use birth control pills or other contraceptive methods as directed.
• Change your tampons or sanitary napkins at least twice each day to avoid toxic shock syndrome and prevent infections.
• See a gynaecologist for regular check-ups.

Intrauterine insemination (IUI) is a fertility treatment that involves placing processed semen sample inside a woman’s uterus to facilitate fertilization. The goal of IUI is to increase the number of sperms that reach the fallopian tubes and subsequently increase the chance of fertilization
IUI provides the sperm an advantage by giving it a head start, but still requires a sperm to reach and fertilize the egg on its own. It is a less invasive and less expensive option compared to in vitro fertilization.

When is IUI used?

The most common reasons for IUI are a low sperm count or decreased sperm mobility.

However, IUI may be selected as a fertility treatment for any of the following conditions as well:

• Unexplained infertility.
• A hostile cervical condition, including cervical mucus problems.
• Cervical scar tissue from past procedures which may hinder the sperms’ ability to enter the uterus.
• Ejaculation dysfunction.

IUI is not recommended for the following patients:

• Women who have severe disease of the fallopian tubes
• Women with a history of pelvic infections.
• Women with moderate to severe endometriosis.

How does IUI work?

Before intrauterine insemination, ovulation stimulating medications may be used, in which case careful monitoring will be necessary to determine when the eggs are mature. The IUI procedure will then be
performed around the time of ovulation, typically about 24-36 hours after the surge in LH hormone that indicates ovulation will occur soon.
A semen sample will be washed by the lab to separate the semen from the seminal fluid. A catheter will then be used to insert the sperm directly into the uterus. This process maximizes the number of sperm cells that are placed in the uterus, thus increasing the possibility of conception. The IUI procedure takes only a few minutes and involves minimal discomfort. The next step is to watch for signs and symptoms of pregnancy.

What are the risks of IUI?

The chances of becoming pregnant with multiples is increased if you take fertility medication when having IUI. There is also a small risk of infection after IUI.

How successful is IUI?

The success of IUI depends on several factors. If a couple has the IUI procedure performed each month, success rates may reach as high as 20% per cycle depending on variables such as female age, the reason for infertility, and whether fertility drugs were used, among other variables.
While IUI is a less invasive and less expensive option, pregnancy rates from IUI are lower than those from IVF.

Cervical cancer (cancer of the lowermost part of the uterus) is a leading cause of deaths in the Indian subcontinent and it is the number one cause of cancer-related deaths in India. Globally, each year, 500,000 women are diagnosed with cervical cancer and 270,000 women die from it. In India itself, each year, 1,32,000 women are diagnosed with cervical cancer and 74,000 women die from it! The irony is that the western world, which has fewer cases, is far more active in taking preventive steps like early screening (PAP Smears) and vaccination, while the developing world which as got most of the cases of cervical cancer, is still struggling to educate its masses to undergo screening and vaccination

What is screening?

As we all know, most cancers do not cause symptoms until it is too late. Hence, screening for cancer is the single most important step in cancer prevention. Screening is looking for cancer before a person has any symptoms. This can help detect cancer at an early stage, when it may be curable. By the time symptoms appear, cancer is likely to have begun to spread. Cervical cancer usually develops slowly over time (over many years). Before cancer appears, the cells of the cervix go through changes known as dysplasia, which can be detected by screening.

What is the PAP test?

The PAP test is a simple and routine test to detect cell changes which occur before cancer develops. The PAP test can be performed in any clinic, is painless and does not require anaesthesia. The report is available in about a week’s time.

Do I need to prepare for a PAP test?

You do not need any special preparation. However, you should avoid intercourse and not use any vaginal creams, tablets or insert a tampon for 48 hours before the test. Also, remember to not take the test during your monthly period.

When should I have a PAP test?

Have your first Pap test about 3 years after the first time you have sex, or when you reach age 21 (whichever comes first). Keep getting Pap tests every 1 to 3 years. Your gynaecologist will advise you on this, depending on your risk profile. If you are 30 or older, an HPV test may be done along with the Pap test. A PAP test is a part of annual gynaecological check-up. Regular use of the Pap test has greatly reduced the number of cases of cervical cancer in the United States and other developed countries. Indians should follow the example.

What does an abnormal PAP report mean?

Abnormal cell changes which occur due to HPV infection can be identified by a PAP test. These abnormal cells show early precancer changes called dysplasia or cervical epithelial neoplasia (CIN ). Dysplasia/CIN are graded as mild, moderate, or severe. Mild dysplasia (CIN 1) usually goes away on its own. Moderate (CIN 2) and severe (CIN 3) dysplasia indicate more serious changes and need further testing and counselling. The PAP is not a diagnostic test and any abnormal report has to be confirmed by a biopsy. Conversely, abnormal cell changes may be missed by a routine PAP test. Hence, a normal PAP test does not always exclude cancerous or pre-cancerous changes.

What has HPV infection to do with cervical cancer?

HPV or the Human Papilloma Virus infection is a sexually transmitted viral infection which may lead to cancer development. The HPV can infect many organs in the human body, of which one is the cervix. The infection may cause no symptoms or harm at all or it may cause the development of warts and in an occasional case, it may lead to abnormal cell changes leading to cancer.

How does the cervix get infected with HPV?

HPV infection of the cervix is mainly sexually transmitted. It can spread by skin to skin genital contact and does not necessarily require sexual intercourse for transmission. The use of condoms reduces but does not eliminate the risk of cervical cancer. Worldwide, HPV infection is the commonest sexually transmitted disease.

What is liquid cytology and how is it different from a PAP test?

Liquid cytology is a relatively new technique for screening for cellular changes and offers some advantage over the PAP test that it is more accurate and also that the same sample can be used to test for HPV DNA testing (infection with HPV). It has been approved by the FDA and has replaced the PAP test in many developed countries for cervical cancer screening. Of course, it costs a little more than the PAP alone.

How do you know that you are pregnant ?

You may have symptoms like.

1. Sudden cessation of otherwise normally occurring periods
2. Nausea, vomiting
3. Frequency of urination
4. Heaviness in breasts
5. Excessive fatigue

You can confirm pregnancy by pathologically testing the morning sample of urine about one week after missing your periods.
Pregnancy lasts for about 40 weeks or 9 months and 9 days from the first day of fast menstrual period. Development of the different organs of the baby occurs in the first three months. Hence you should avoid taking any sort of medicines during this period without consulting your doctor.
You will start feeling your baby’s movements by about fifth month. You will gain about 10-12 kgs during your pregnancy.
As pregnancy advances due to the growing size of the uterus you may feel breathless, tired, swelling of feet or burning in chest. Please consult your doctor anytime you face these problems. It is advisable to consult the doctor soon after missing the menstrual period.

Some common problems in pregnancy and their solutions.

1. Nausea, Vomiting
   This mainly occurs in the first 3 months of pregnancy. Eat small frequent meals Avoid oily spicy foods Drink lot of water. You may take medicines which your doctor prescribes for you. These are safe in pregnancy.
2. Frequency of urination.
   This is common in the first three months and the last month of pregnancy. It is due to altered physiology in the body. Make a habit of passing urine every two hours. Drink less water before bedtime.
3. Constipation
   Drink plenty of water Increase roughage and green leafy vegetables in your diet. Have regular light exercise.
4. Burning in chest
   Eat small frequent meals, avoid oily spicy foods. Drink cold milk before bedtime.
5. Bleeding piles
   Avoid constipation. Have daily light exercise Consult your doctor.
6. Swelling of feet
   Some amount of swelling of feet in last few months of pregnancy is due to pressure of enlarged uterus. But it could also be a sign of increasing blood pressure. Sleep on one side of body. Keep a pillow under your feet while sleeping. Do not stand at one place for a long time .
7. Backache & leg - cramps
   Adequate rest & calcium can alleviate these symptoms. If unbearable please consult your doctor for medication.

Pregnancy and medical check up

Medical check ups are essential to ensure that pregnancy is proceeding smoothly and to diagnose any complications at the earliest.
Please consult your doctor as soon as you realize you are pregnant.You must visit your doctor at least monthly for first 6 months, fortnightly for next 2 months and weekly during last month.
The frequency of these visits may change at the discretion of your doctor if there are any complications.

Consult your doctor immediately if you have any time

• Bleeding
• Fever
• Pain in abdomen
• Watery discharge per vaginum
• Decrease in movements of your baby.

At every visit your doctor will check

• your blood pressure.
• your weight.
• any swelling of feet
• if your baby is growing well

Your doctor will check your blood and urine.
Your doctor will do your sonography by fourth or fifth month to see if your baby is completely normal & to rule our certain abnormalities.
Your doctor will start you on iron, folic acid and calcium tablets.
You will be given two injections of tetanus toxoid during your check-ups . Keep all your reports and records carefully and take them with you when you go for delivery.

Diet and care in Pregnancy

Your baby is totally dependant on you for its growth. Hence you must eat well in pregnancy.
Your diet should be complete and wholesome in carbohydrates, proteins, fats, minerals and vitamins.
You should also take iron and calcium tablets after three months and continue upto 3 months after delivery.
You should drink a glass of milk daily to increase your calcium intake. There are no specific dietary restrictions in pregnancy. Home cooked food is safer.
One should preferably avoid sexual intercourse during first 3 months of pregnancy and also after seventh month to avoid risk of abortion and preterm labour.
A pregnant woman should have minimum two hours rest in the afternoon and 8 hours sleep at night. Avoid long journey in pregnancy. While travelling try and avoid rough and bumpy roads.

Pregnancy and exercise-Do only light exercise while pregnant. This helps prevent constipation, keeps body supple and also helps easy delivery. Avoid exercise during first 3 months of pregnancy. Always assume correct posture while standing or sitting. The safest & the best exercise in pregnancy is walking. You can consult your doctor about light exercises that can be done in pregnancy. Also continue exercising after delivery to regain your shape and improve the tone of your muscles.

Delivery
How to know the date of your delivery ?

If a woman is having regular periods, the date of delivery is calculated by adding 7 days and giving forward nine months from the date of last M. C.
Delivery usually occurs around two weeks before or after this expected date.

How to know that your labour has started ?

1. Pain in abdomen and / or back.
   The pain keeps coming and going.
   The intensity & duration of pain increases.
   If initially pain comes every 10-15 minutes, later they come earlier and earlier.
2. Discharge per vaginum.
   It is slight and usually blood stained. This occurs from the mouth of the uterus which must have started opening.
   

Before going to hospital, take care of the following precautions.

• Do not eat or drink anything once you suspect the beginning of delivery process.
• Always have a relative accompany you.
• Take all your reports with you. Your doctor will examine your thoroughly and decide whether you can deliver normally or you will need a caesarean section. Even if your pregnancy has proceeded smoothly and everything is normal, there are some situations where your doctor will have to do a caesarean section to deliver you.
• The first delivery usually takes 12-14 hours while later deliveries occur faster. Remove all your fears and worries and co-operate with your doctor. This will allow you to have a safe and easy delivery . Occasionally during the course of your delivery you may require a caesarean section due to some unforeseen events. You must exclusively breast feed your baby upto four months of age. Weaning should be started from fourth month. Before going home consult your doctor about different methods of family planning to protect you from having another baby soon.

Some commonly asked questions in pregnancy.

Q 1. What restrictions should be applied to diet ?

There are no special restrictions to be followed. During first 3 months if there is nausea and vomiting one should have small frequent feeds and eat dry foods like bread, biscuits in the morning. In last few months due to burning in chest avoid only spicy food.

Q 2. Does eating papaya, jackfruit cause harm ?

There is no harm if one eats such fruits in moderation.

Q. 3 Are medicines safe in pregnancy?

As the baby is developing in the first 3 months, one should take medicines only after consulting one’s doctor. There is no harm with sonography. One should avoid X-rays in pregnancy and if absolutely essential, one should take out X-ray with abdominal shield.

Q. 4 Why should sleep on one side ?

It helps to increase blood supply to the uterus and baby by removing pressure of uterus on the large blood vessels.

Q. 5 Should one abstain from inter course in pregnancy ?

If one had any problems in previous pregnancy one should refrain from sexual intercourse. Otherwise one should abstain during first 3 months and after the seventh month.

Q. 6 Is eclipse harmful to the baby.

No. There is absolutely no scientific basis for this.

Q. 7 If the liquor amnii gets less then does drinking lot of water help?

Drinking water will not help to increase the liquor in the uterus.

Q. 8 Can one work on the computer when pregnant?

There is no harm, in working on the computer.

Q. 9 Can one undergo dental treatments during pregnancy?

If one informs the dentist that one is pregnant then he will take adequate precautions during treatment.

Q. 10 Will eating iron and calcium tables make the baby big and cause difficult delivery?

No. These tablets will not make your baby big as wrongly supposed.

Q. 11 Will salt restriction help if there is swelling of feet?

Salt restriction or diuretics do not help to decrease swelling of feet.

Q. 12 It is said that excess rest is not good during pregnancy?

A pregnant woman must take 2 hours rest in the afternoon and 8 hours sleep at night. This helps the baby’s growth. If a lady is feeling excess tired and sleepy one should rule out any medical problem like anaemia.

Q. 13 Should one avoid scooter driving, travelling in autorickshaw in pregnancy?

Till 7 months, there in no problem in driving scooter or going in autorickshaw if you have no medical problem. Drive slowly. Be careful while kickstarting or pulling scooter on stand, avoid rough roads. Travelling in bus is safer than travelling in autorickshaw.

Q. 14 Should one avoid journey in pregnancy?

Avoid long journeys and travelling in first 3 months. If one has to travel to maternal home for delivery then one should do so by 32-34 weeks. Travelling by aeroplane is not allowed after 32 weeks.

Q. 15 Should one take any special care of breasts in pregnancy?

One should keep breast and nipples clean during bath if nipples are retracted, daily one should pull them out. There will be some watery secretions from nipple. This is normal and no cause for concern.

What exactly is Hyperemesis Gravidarum?
Hyperemesis gravidarum is a medical term for excessive vomiting during pregnancy, especially in the first trimester. It is an exaggerated form of morning sickness, to the extent that, you as a mother-to-be may experience significant weight loss and vomiting. You may be unable to eat, or even tolerate the smell or sight of food. You may throw up every time you eat anything at all. Prolonged periods of going without food or water cause acidity which worsens nausea and vomiting. This causes a vicious cycle and you may go for days without much food.
The condition is particularly distressing because of the severe retching and inability to eat, even though you may be very hungry!

How many women does it affect?

Most women (70-80%) experience varying degrees of nausea and vomiting in early pregnancy. Hyperemesis gravidarum affects about 1% pregnant women.
It is commoner if you have a multiple pregnancy (twins or triplets) and in a condition called vesicular mole (a type of abnormal pregnancy).
The condition usually begins in the second month of pregnancy (5th to 6th week) and usually subsides by the end of the third month although it may continue till even the fifth month in some cases.
The condition also tends to recur in future pregnancies, although it is impossible to predict for whom it will.

Is there any way apart from hospitalisation to treat/ avoid it?

Unfortunately, there is no known way to prevent the condition. However, one can definitely manage it well.
If you are dehydrated, you may need to be hospitalised and given IV fluids, anti-vomiting medication and antacids. Your obstetrician may also perform tests for liver or gastrointestinal condition.
In rare cases, if things do not get better, you may need to be fed through a tube passed into your stomach.

What should a woman who suffers from it do and not do during pregnancy?

Do –

• Seek medical help early
• Confirm whether you have twins or vesicular mole (sonography)
• Eat small but frequent meals
• Eat dry snacks such as crackers or biscuits first thing in the morning
• Keep yourself distracted. Watch movies, read and carry on with your routine activities as far as possible.
• Eat raw, bland and minimally seasoned foods
• Drink plenty of fluids (in various forms)
• Suck on a ginger drop/ peppermint or drink ginger ale
• Go out for fresh air as much as possible
• Seek emotional support from spouse, family, friends

Don’t –

• Lose heart. It is only a matter of time and your condition can be easily tided over with some medical help.
• Eat spicy, junk or fried foods
• Cook, if you cannot tolerate strong smells or fumes
• Self-medicate. Contact your obstetrician for medicines which are safe for your baby
• Go without food or liquids for prolonged periods (it increases acidity)
• Feel guilty. It is not your fault.
• Worry. Babies’ requirements are low in the first trimester. You may actually lose weight, but that won’t harm the baby’s growth.

The concept that a pregnant woman should ‘eat for two’ is long out-dated. What she needs is a well-balanced diet with a few extra ingredients to meet the unborn baby’s needs.

Calories:

This means about 300 extra calories per day which translates into 1 extra meal per day.Remember: Consuming too many calories can make you prone to obesity, diabetes and high blood pressure in pregnancy and give you a very large baby too!Other than added calories, you would also need more proteins, vitamins, calcium, iron and essential fatty acids. An average Indian diet cannot meet these requirements and hence, you would need to focus on adding the extra proteins, iron and calcium to your existing diet.

Proteins

Make sure you include plenty of dals, pulses, sprouts, milk and milk products to boost your protein intake. Non-vegetarians can benefit from egg, meats and fish. Animal proteins have a high biological value, meaning they are better absorbed and utilised.

Carbohydrates:

These provide the much needed energy and fiber. Avoid refined sugar and refined flour, as these can cause your sugar levels to fluctuate. Stick to whole wheat (brown bread and flour), whole fruits and add lots of salads and veggies to increase roughage in your diet. That would help you avoid constipation too.

Fats:

The role of DHA and other essential fatty acids in the development of the fetal brain is now clear. These are essential for ideal development of intelligence, learning and vision. Add flax seeds, walnuts, beans and tofu to your diet. Olive oil and soyabean oil are also good sources of essential fatty acids. Non-vegetarians can benefit from fish intake or cod liver oil capsules.Saturated fats such as ghee, butter, cheese and hydrogenated fats should be consumed in limited quantities.

Iron:

Your unborn needs iron for his/her needs and the requirements increase with advancing pregnancy. So do you. To meet your own expanded blood volume and increased oxygen requirements. Green leafy vegetables, beans and pulses, fruits such as pomegranate, cherries and berries, lychee, pineapple, dry fruits such as raisins, dates and figs and animal foods contain a good amount of iron.
Vitamin C is essential for the absorption of iron, hence, squeeze in a lemon into your meal for good measure.

Calcium

Calcium requirement in pregnancy doubles to help your baby’s developing bones, teeth as well as his/her essential bodily functions. Adequate calcium would also help prevent backaches and prepare you for breastfeeding as well. For calcium, consume milk and milk products in various forms, nuts, seeds, beans, green leafy vegetables and seafood.

General tips:

• Consume relatively small frequent meals to prevent bloating, heartburn and indigestion.
• Drink plenty of water to flush the toxins and to avoid constipation.
• Avoid excess salt (fast foods and preserved foods), refined sugars and fats.

EXERCISE DURING PREGNANCY

The more active and fit you are during pregnancy, the easier it will be for you to adapt to your changing shape and weight gain. It will also help you to cope with labour and get back into shape after the birth.
Keep up your normal daily physical activity or exercise (sport, running, yoga, dancing, or even walking to the shops and back) for as long as you feel comfortable. Exercise is not dangerous for your baby – there is some evidence that active women are less likely to experience problems in later pregnancy and labour.

EXERCISE TIPS FOR PREGNANCY

Don’t exhaust yourself. You may need to slow down as your pregnancy progresses or if your maternity team advises you to. If in doubt, consult your maternity team. As a general rule, you should be able to hold a conversation as you exercise when pregnant. If you become breathless as you talk, then you're probably exercising too strenuously.
If you weren't active before you got pregnant, don’t suddenly take up strenuous exercise. If you start an aerobic exercise programme (such as running, swimming, cycling, walking or aerobics classes), tell the instructor that you're pregnant and begin with no more than 15 minutes of continuous exercise, three times a week. Increase this gradually to at least four 30-minute sessions a week.
Remember that exercise doesn't have to be strenuous to be beneficial.

Exercise tips when you're pregnant:

• Always warm up before exercising, and cool down afterwards
• Try to keep active on a daily basis: half an hour of walking each day can be enough, but if you can't manage that, any amount is better than nothing
• Avoid any strenuous exercise in hot weather
• Drink plenty of water and other fluids
• If you go to exercise classes, make sure your teacher is properly qualified, and knows that you’re pregnant as well as how many weeks pregnant you are
• You might like to try swimming because the water will support your increased weight. Some local swimming pools provide aquanatal classes with qualified instructors.
• Exercises that have a risk of falling, such as horse riding, downhill skiing, ice hockey, gymnastics and cycling, should only be done with caution. Falls may risk damage to the baby

EXERCISES TO AVOID IN PREGNANCY

• Don't lie flat on your back, particularly after 16 weeks, because the weight of your bump presses on the main blood vessel bringing blood back to your heart and this can make you feel faint
• Don't take part in contact sports where there's a risk of being hit, such as kickboxing, judo or squash
• Don't go scuba diving, because the baby has no protection against decompression sickness and gas embolism (gas bubbles in the bloodstream)
• Don't exercise at heights over 2,500m above sea level until you have acclimatised: this is because you and your baby are at risk of altitude sickness

EXERCISES FOR A FITTER PREGNANCY

If you are pregnant, try to fit the exercises listed below into your daily routine. They will strengthen your muscles so that you can carry the extra weight of pregnancy. They'll also make your joints stronger, improve circulation, ease backache, and generally help you feel well.

Stomach-strengthening exercises

As your baby gets bigger, you may find that the hollow in your lower back increases and this can give you backache. These exercises strengthen stomach (abdominal) muscles and may ease backache, which can be a problem in pregnancy:

• Start in a box position (on all fours) with knees under hips, hands under shoulders, with fingers facing forward and abdominals lifted to keep your back straight
• Pull in your stomach muscles and raise your back up towards the ceiling, curling the trunk and allowing your head to relax gently forward. Don't let your elbows lock
• Hold for a few seconds then slowly return to the box position
• Take care not to hollow your back: it should always return to a straight/neutral position
• Do this slowly and rhythmically 10 times, making your muscles work hard and moving your back carefully
• Only move your back as far as you can comfortably

Pelvic tilt exercises

• Stand with your shoulders and bottom against a wall
• Keep your knees soft
• Pull your tummy button towards your spine, so that your back flattens against the wall: hold for four seconds and release
• Repeat up to 10 times

Pelvic floor exercises

Pelvic floor exercises help to strengthen the muscles of the pelvic floor, which come under great strain in pregnancy and childbirth. The pelvic floor consists of layers of muscles that stretch like a supportive hammock from the pubic bone (in front) to the end of the backbone. If your pelvic floor muscles are weak, you may find that you leak urine when you cough, sneeze or strain. This is quite common and you needn’t feel embarrassed. It's known as stress incontinence and it can continue after pregnancy.
By performing pelvic floor exercises, you can strengthen the muscles. This helps to reduce or avoid stress incontinence after pregnancy. All pregnant women should do pelvic floor exercises, even if you're young and not suffering from stress incontinence now.

How to do pelvic floor exercises:

• close up your anus as if you're trying to prevent a bowel movement
• at the same time, draw in your vagina as if you're gripping a tampon, and your urethra as if to stop the flow of urine
• at first, do this exercise quickly, tightening and releasing the muscles immediately
• then do it slowly, holding the contractions for as long as you can before you relax: try to count to 10
• try to do three sets of eight squeezes every day: to help you remember, you could do a set at each meal

As well as these exercises, practise tightening up the pelvic floor muscles before and during coughing and sneezing.

Bleeding can be a sign of miscarriage, but does not mean that miscarriage is imminent. Studies show that anywhere from 20-30% of women experience some degree of bleeding in early pregnancy. Approximately half of pregnant women who bleed do not have miscarriages. Approximately 15-20% of all pregnancies result in a miscarriage, and the majority occur during the first 12 weeks.

Signs of Miscarriage include:

• Vaginal bleeding
• Cramping pain felt low in the stomach (stronger than menstrual cramps)
• Tissue passing through the vagina

Most miscarriages cannot be prevented. They are often the body’s way of dealing with an unhealthy pregnancy that was not developing. A miscarriage does not mean that you cannot have a future healthy pregnancy or that you yourself are not healthy.

What exactly is a miscarriage?

Miscarriage means the spontaneous loss of embryo or foetus before 20 weeks of gestation or when the foetus is less than 500 g weight.

What signs and tests can help me?

Your doctor is the best judge of that. An ultrasound is the best tool to know the status of your pregnancy. A transvaginal ultrasound (meaning an internal ultrasound) can detect fetal heart rate as early as 5.5 weeks (about 12 days after a missed period). It may be noted that a gentle internal sonography is not harmful to the pregnancy. On the contrary, it is a valuable source of information, especially to rule out a tubal (ectopic) pregnancy.
Serial blood testing of the hormone Beta HCG can tell you whether your pregnancy is growing at a normal rate or not.
Your doctor may recommend many more tests to rule out infections, autoantibodies and certain hormonal deficiencies including diabetes and thyroid condition.

When it occurs, what is the treatment for it?

In most cases of bleeding, supporting the pregnancy with the hormone ‘progesterone’ helps to a certain degree.
In specific medical conditions where the woman is at risk (such as PCOS or previous miscarriages), the doctor would prescribe certain medications (such as hormones or blood thinners) and these decisions are best left to the obstetrician.
Most obstetricians and family members prescribe “bed rest”, but the benefit of bed rest in preventing miscarriage is as yet unproven and at best remains a ‘placebo’ therapy.
Since a majority of miscarriages are unexplained or due to a genetic cause, there are no guarantees of a successful pregnancy outcome. This is a perfect example of one of those medical conditions where “Man proposes, God disposes.”

Can complications occur? What are they?

A miscarriage can occasionally cause heavy bleeding which may threaten the life of the patient and may require immediate hospitalisation and D&C (surgical evacuation or ‘cleaning’ of the uterus). In neglected cases, the womb may get infected. These cases are fortunately relatively rare.
A miscarriage can leave you scarred for a long time, so please do not hesitate to ask for family and medical support and guidance.

How can I prevent a future miscarriage from occurring?

Unfortunately, there is no definite way to prevent an abortion before or during the pregnancy.

However, certain precautions may help:

• Visit a gynaecologist for pre-pregnancy counselling to prepare you mentally and physically for pregnancy
• Ingest folic acid daily, starting before pregnancy
• Eat healthy, wholesome, home food
• Avoid emotional and physical stress
• Do not delay pregnancy till a very late age

If you have had a miscarriage before, please visit your doctor before planning the next pregnancy so that he/she may initiate treatment before the pregnancy.

A normal pregnancy grows inside the uterus. If the embryo implants outside the uterus, the pregnancy is known as ‘ectopic pregnancy’. The incidence of ectopic pregnancy is about 1-2% of all pregnancies.

Where exactly does an ectopic pregnancy occur outside the uterus?

The pregnancy may implant at any of the following sites:

• Inside the fallopian tube (tubal ectopic pregnancy)- commonest (98% cases)
• Inside the ovary (ovarian ectopic pregnancy)
• Inside the cervix (cervical ectopic pregnancy)
• Inside the abdominal cavity (abdominal ectopic pregnancy)

What happens if I have a ectopic pregnancy? What happens to my baby? Will it be fine?

Unfortunately, the fetus cannot survive outside the uterus as it cannot get the nourishment and space to grow. Normally, the baby’s blood vessels grow deep into the muscles of the mother’s uterus to form the placenta which gives it blood supply. However, when the pregnancy is in the fallopian tube, the muscles of the tube are very thin and the blood vessels erode the wall of the tube, leading to bleeding, causing an emergency situation. In an emergency situation, doctors have to operate and remove the pregnancy surgically.

Will I get any symptoms if I have ectopic pregnancy?

If you have ectopic pregnancy, you may experience the following symptoms:

• Missed periods
• Bleeding from vagina (mild, moderate or severe)
• Lower abdominal pain (usually on one side or in the centre- may be mild, moderate or severe
• Giddiness
• Fainting (usually indicates internal bleeding)

Since most women undergo an early sonography in pregnancy, ectopic pregnancies are getting diagnosed very early before symptoms can develop.

Can ultrasound diagnose ectopic pregnancy?

Since the incidence of ectopic pregnancy is on the rise, it is advisable to undergo an early ultrasound examination (baseline check) at about 6 weeks pregnancy (2 weeks after a missed period) to confirm that the pregnancy is within the uterus. Transvaginal ultrasound (internal ultrasound) is the preferred method as it gives much better information at an early stage of pregnancy.
If the sonologist does not find the pregnancy inside the uterus, he/she will look for it in the tubes. It looks like an abnormal mass outside the uterus in the region of the tubes. But ectopic pregnancy may not always show up on sonography, especially in the early stages. In such cases, doctors will look for other signs suggestive of ectopic pregnancy such as free fluid inside the pelvis and abdomen (suggestive of internal bleeding). In very early cases, there may be no indication even on sonography.

What if ultrasonography does not diagnose ectopic pregnancy? Is there any other way?

If your gynaeocologist is suspicious, he/she will advise a blood test – beta HCG level. This level is higher in normal pregnancies than in ectopic pregnancy. Also, if you do HCG level twice (at 48-72 hours interval), the rate of rise of HCG hormone gives us a clue whether the pregnancy is ectopic or not.

So how can I be sure whether it is ectopic or not?

If sonography can clearly see the ectopic pregnancy, the diagnosis is easy. Otherwise, a simple indicator is this: If the beta HCG value is more than 1500 and no pregnancy is seen inside the uterus on INTERNAL sonography, it is diagnostic of an ectopic pregnancy. Sometimes you may need to undergo serial (repeated) beta HCG levels and sonographies to arrive at a diagnosis.

I have been bleeding heavily since 2 days. Does that mean that the ectopic pregnancy has been thrown out of my system? Or that it has ruptured?

No. The ectopic pregnancy is located inside the abdominal cavity. It cannot bleed outside. If you are having vaginal bleeding, it means that the inner lining of the uterus is shedding. That can happen due to low hormonal levels.

If I have a tubal ectopic pregnancy, is it necessary that I have to undergo surgery? Can I take medicine to dissolve the pregnancy?

Fortunately, there are treatments available which can avoid surgery.The commonest and time-tested treatment is giving Inj Methotrexate (an anti-cancer drug) to dissolve the pregnancy. It is given in a small dose and thus, it harms only the growing embryo and is quite safe for the mother. This regimen is about 80% effective for well-selected cases.

How can I decide whether to undergo surgery or to take the injection? What would be best for me?

This is a technical issue and should be decided by your doctor. However, there are certain indicators which can guide you. Inj Methotrexate should be used under the following conditions:

• You are not bleeding internally
• Your tube has not ruptured
• Your ectopic pregnancy is less than 3 cm in size and the embryo does not show heart beat
• Your beta HCG level is low (preferably less than 5000 IU/ml)

If the mass is big or HCG is high or you have begun to bleed internally, the risk of rupture of the fallopian tube is high. Therefore it is better to undergo surgery.

If I am given injections, am I assured that the ectopic pregnancy will dissolve? And I will be cured?

If you are given Inj Methotrexate (single dose in the muscle), you would need to be under observation, preferably in the hospital. You may experience the following symptoms: Abdominal pain (mostly cramp-like) usually happens about 3 days after the injection; occasionally, you may get nausea, vomiting, loose motions or ulcers in the mouth. The doctor will do your beta HCG on the 4th and 7th day after the injection. The levels should drop by 15% of the initial value on 7th day. That indicates good response to the injection. The fourth day Beta HCG may rise. Do not panic. There is a chance that your tube might rupture inspite of Methotrexate injection and that would require immediate surgery.

How do I know if my tube has ruptured? Is it dangerous?

When your tube ruptures, you get intense pain in the lower abdomen. You may even faint or feel giddy or may vomit. This happens because of sudden bleeding inside the abdomen. This is a critical situation because blood loss may be sudden and massive. If your tube has ruptured and you are bleeding profusely, you may need to undergo emergency laparotomy (open surgery). You may need blood transfusions to save your life (depending on the amount of blood loss).

Why does one get ectopic pregnancy?

Ectopic pregnancy occurs more commonly in the following group of women:

• Women with diseased fallopian tubes. This may be due to infection (pelvic inflammatory disease) endometriosis or post-operative adhesions.
• Women undergoing fertility treatments
• Women who have had ectopic pregnancy in the past
• Women with IUD in place and women who have undergone tubal sterilisation or tubal repair surgery may rarely find themselves with pregnant inside the tubes
• Smokers may have a slightly increased risk depending on the number of cigarettes per day smoked

I have had ectopic pregnancy in the past. Will I get it again?

The risk of getting a repeat ectopic pregnancy on the same side or the opposite side is 15% after one episode of ectopic pregnancy and 30% after two episodes of ectopic pregnancy.

Planning our families is absolutely essential in today's day. With abortion laws becoming more stringent, women have fewer choices after getting pregnant. It is obvious that there is no perfect or best method for anyone. In order to be able to select the best option for contraception for us, we need to know a few facts about each method.We list out to you the options available and a few details of each method so you can find your pick :

THE CONDOM :

• Easily available, does not need doctor's assistance
• Has to be used with every act of intercourse
• Have to rely on male partner
• Failure possible due to user errors
• Protects from sexually transmitted diseases
• No side-effects except occasional allergy
• Failure rate (about 15%)

Every man must know the technique of using condoms correctly. Incorrect usage is the commonest reason for an unintended pregnancy. Make sure you apply the condom BEFORE the first penetration and NOT just before you ejaculate. Also, take care that you hold the condom tightly all around at the base while removing it, so that there is no spillage at the time of removal. Please use the condom for EVERY act of intercourse. Many couples use it only during the fertile period and that is the commonest reason for an unwanted pregnancy.

INTRAUTERINE CONTRACEPTIVE DEVICE (IUD) ALSO KNOWN AS COPPER T:

A small plastic device containing copper which can be inserted into the uterine cavity where it prevents implantation of the forming embryo.

• Time tested, but associated with menstrual irregularities, heavy periods and pain in many cases
• Effective for 3, 5 or 10 years depending on brand
• Not suitable for women who have yet to have a baby or those who have pelvic infections
• Needs medical assistance to insert, insertion mildly painful
• Failures rate (0.8%)
• Needs to be checked every month by the user (a simple task)
• Does not protect from ectopic pregnancy

This method is very useful for women who cannot remember to take the pill or whose partners would not want to use the condom. It certainly gives you a sense of freedom from having to remember to use protection always. The Mirena is a special type of IUD which releases the hormone progesterone within the uterus. Mirena users experience less flow during their periods compared to other IUD users and it is therefore more acceptable than the routine copper devices. It is also used to treat heavy periods. It is, however, much more expensive (about 7500 Indian rupees) and it reduces the flow during periods over time. In fact, most women stop getting periiods about 6 months after Mirena insertion. It is not harmful though,in fact, a welcome side-effect for many women. Periods resume after a while once the Mirena is removed. In fact, the Mirena is used to treat certain conditions which cause heavy periods such as endometriosis, adenomyosis and uterine hyperplasia.

THE CONTRACEPTIVE PILL:

With the market being flooded with newer contraceptive pills, there is a lot of confusion in the minds of women today about which pill to take for which situation. Whereas the doctor is the best judge of which pill is best for you, every woman must know the basics.Broadly, one may categorize pills as :

• Birth control pills ( e.g. Mala-D or any of the 21 tab or 24 tab packet tablets) which contain two hormones, Estrogen and Progesterone or Progesterone alone.
• The emergency contraceptive pill ( e.g. I pill , Unwanted 72, Pill 72 among others )
• The Abortion pill

The birth control pill is the true contraceptive pills as it prevents pregnancy. It needs to be taken daily as per instructions and is more than 99% effective if taken correctly. Today various pills are available in the market and women need to consult their gynaecologist to find out which works best for them. In olden days, the pill was not considered safe as the dosage of hormones used was high and hence the risk of stroke and breast cancer was high, especially in older women and smokers. Today's pills use better hormones in lower quantity which makes the pill a safe option for long term birth control as well

There are different ways of taking the pill:

1. For 21 tablet strip. Start a new pack within 5 days of onset of menses. Take it daily at around the same time till the pack is over. If the pack shows arrows, follow the arrows in taking the tablets. Once the pack is over, wait for your period. Start a new pack in the same manner (as above).
   OR
   Once the pack is over, wait for 7 days. Start a new pack on the 8th day irrespective of the day of menses.
2. For 24 tablet strip - Start a new pack within 3 days of onset of menses. Take one tablet daily at around the same time. After 24 days, wait for the period. Restart a new strip as above.
   OR
   Once the strip is over, wait for 4 days and restart new pack on the 5th day irrespective of the day of menses. This method works very well for women with premenstrual syndrome, premenstrual breast pain and depression.
   

Forgot a pill?

Take the pill as soon as you remember and take the next dose at the regular scheduled time. If you remember the next day at the scheduled next dose, you may take two pills together.

Forgot two pills?

Use the condom for the next 7 days.Be prepared to bleed or spot in the next few days. If you have just a few tablets left in your pack (you are nearing the end of your cycle), stop the tablet and await menses (withdrawal). If you have many tablets left, take 2 tablets immediately today and tomorrow and resume the pack as before. If the bleeding persists or becomes heavy, you may have to give a break and start a new cycle.
A special progesterone only pill (Tab Cerazette/Zerogen) is available for use by breastfeeding mothers. It does not harm the milk and does not cause any significant side-effects. It has to be taken daily continuously at around the same time, without break during menses also. Please do not forget to take a single tablet. If you forget to take a single tablet, you might get spotting or bleeding and pregnancy might become possible. The emergency pill (I pill/ Unwanted 72/ Option7/ Pill 72/ Norlevo) is to be used only in case of an emergency i.e. rape or when an unexpected unprotected act of intercourse has taken place. It needs to be taken within 72 hours, preferably 12 hours of intercourse... the sooner the better. It is about 90% effective within the first 48 hours and more you delay, less effective it becomes. The abortion pill is to be taken after you become pregnant. It is most effective for pregnancies less than 7 weeks. The success rate is about 90%. In case of failure, a surgical abortion must be carried out. Medical abortion is a legal matter and comes under the purview of the MTP Act, 1971. It must be carried out under the guidance of a registered medical practitioner as per the guidelines of the Act.

CONTRACEPTIVE INJECTIONS:

These injections are to be given every 3 months (90 days) and they release the hormone progesterone within the body which prevents pregnancy.

These injections have the following features:

• Highly effective if taken correctly
• Can cause some weight gain esp. in the first year of use
• Menstrual irregularities are very common and the main reason for discontinuation in most cases
• Return of fertility is delayed (you may take some time before you can conceive again after stopping
• Some metabolic problems are possible making you more prone to developing diabetes mellitus or high blood pressure
• Bone loss may occur with Inj DMPA and you need to take calcium and vitamin D supplements and also consult your gynaecologist about it.

They are not very popular mainly because of the disturbance caused to the menstrual cycle.

VAGINAL SPERMICIDAL:

These are chemicals applied locally in the vagina to destroy the sperms or to make them immotile thereby preventing pregnancy.

NUVARING:

This is one of the latest advances in the world of contraception. It is a vaginal ring which releases the hormones estrogen and progesterone and works just like the birth control pill.
The ring has to be inserted into the vagina by the woman within the first five days of her period (she need not wait for the period to get over) and left in place for three weeks and reinserted after an interval of one week, during which she would get her next monthly cycle.
The side effects and mode of action are the same as that of the birth control pill, except that a few women may experience problems of expulsion or vaginal irritation or discharge.

The main advantages the ring would offer would be:

• Freedom from having to remember to pop the pill everyday
• Regular menstrual cycles
• Highly effective (failure rate very low) Since Nuvaring is new in the market, it is yet to become more popular.

Do you have an unwanted pregnancy? Looking for a safe abortion? Indian abortion laws permit abortion (surgical or using pills) only in legalised abortion centres by a registered qualified gynaecologist.

Q. I have missed my period. I am worried that I may be pregnant. Can I take the abortion pill to get my period?

No. You have to first get a pregnancy test done to confirm that you are pregnant. The abortion pill does not work if you are not pregnant and have missed your period due to any other cause.

Q. I am 6 weeks pregnant and I don’t want the pregnancy. How do I get rid of it?

For early pregnancy (first trimester) up to 7 weeks (49 days from the date of the last menstrual period), the abortion pill is quite effective with a success rate of about 95%. Or you may choose to undergo a surgical abortion (D&C).

Q. Up to what weeks of pregnancy can I take the abortion pill?

The abortion pill is now permitted for use up to 9 weeks (63 days from the date of the last menstrual period). However, the success rate drops after 7 weeks. Also, the risk of heavy bleeding increases as pregnancy advances.

Q. Is it necessary to do an ultrasound before taking the abortion pill?

It is better to confirm the size of pregnancy and also make sure that you do not have an ‘ectopic’ pregnancy (pregnancy outside the uterus - usually in the fallopian tube), before prescribing the abortion pill.

Q. Where and how do I get the abortion pill? How to take it? What should I expect after taking the pills? Am I going to get pain?

The abortion pill has to be dispensed by or prescribed by a gynaecologist. It is given as two courses – one pill to be taken orally immediately and the other 4 pills about 48 hours later orally or vaginally. After the course of medication, you would start to bleed within about 24-72 hours. The bleeding may last from 3-10 days for most women. The flow could be medium to heavy, and may rarely become severe. Pain is usually quite bearable. Ask your gynaecologist to prescribe a pain-killer or you could take any OTC brand that agrees with you.

Q. How do I know that the abortion process is complete? That my uterus is completely clean?

You need to do ultrasound of the pelvis after about 2 weeks of taking the abortion pill to make sure that the abortion is complete.

Q. I have had heavy bleeding with clots after taking the abortion pill. I know that everything has come out. Do I still need to do ultrasound pelvis?

Yes, you do. Even if you have had heavy bleeding, that does not ensure that the abortion is complete. Ultrasound can pick up very small retained bits of tissue that may cause infection or bleeding if left behind.

Q. What if the abortion is not complete? Do I need to get a surgical abortion? I am very afraid.

If the abortion pill has failed (no bleeding or incomplete abortion), your gynaecologist would advise you to get a D&C done or give you another course of the abortion pill. That decision would be your doctor’s only.

Q. What are the possible complications of the abortion pill?

The abortion pill is generally very safe. Very rare cases of allergy can happen as with any other drug. You may feel giddy or nauseated after taking the first or second course of the abortion pills. Some of you may get acidity or loose motions. Heavy bleeding is somewhat common. Be prepared in case you are going to be at work. Rarely, the bleeding may be severe enough to rush you to the hospital. Infection is possible, but is again rare. Your gynaecologist would decide if you need antibiotics along with the abortion pill, or later.

Q. Will the abortion pill harm my future pregnancy?

No. If taken as prescribed, and under supervision of a gynaecologist, you are very safe. Make sure you do your ultrasound after 2 weeks to confirm an empty uterus.

Q. Can I have sex after taking the abortion pill? And how soon can I resume sex after the abortion?

It is best if you do not indulge in intercourse after taking the abortion pill, till the abortion process is complete. There is a small risk of infection. After you have stopped bleeding and the gynaecologist has confirmed on ultrasound that your uterus is empty, you may resume your sexual life with proper birth control!

Q. When can I start the birth control pill after the abortion ?

You may start the birth control pill pack immediately after the abortion process is confirmed complete.

is one of the most difficult to understand gynaecologicaldisorders.It affects millions of women today.It is also one of the leading causes of infertility among urban women. It is now considered a lifestyle disease though the exact cause is not known.

WHAT DO YOU MEAN BY ENDOMETRIOSIS?

Endometriosis actually means that endometrial tissue (the inner lining of the uterus) is present outside the uterus at various sites inside the abdominal cavity. Just as the uterine lining bleeds and is shed every month, this tissue (known as endometriotic implants) responds to the female hormones estrogen and progesterone and also bleeds every month, inside the abdomen. Because of this bleeding, there are various effects. Bands or rope like structures known as adhesions form between various organs For example, the fallopian tubes may get stuck to the back of the uterus or get pulled towards the ovary or the intestines to the uterus, etc. This causes a pull between the various organs involved and pain. Thus periods may become painful and heavy and also intercourse may become painful.

HOW DOES ENDOMETRIOSIS AFFECT FERTILITY?

Infertility may result from adhesions, inflammation in the pelvis, blocked fallopian tubes and chocolate cysts. Over a period of time, chocolate cysts can decrease the ovary's capacity to produce eggs. In endometriosis, antibodies may be produced within the pelvis, which may harm the partner's sperm or the corpus luteum (an organ which maintains early pregnancy).These antibodies may cause miscarriage. Hence, miscarriages are commoner in women with endometriosis.

WHAT IS A CHOCOLATE CYST?

A chocolate cyst is a blood filled cyst in the ovary.Just as bleeding occurs anywhere in the pelvis, it may happen within a space in the ovary, which gets filled with blood (chocolate like old blood). This may interfere with egg formation(ovulation).

ARE CHOCOLATE CYSTS CANCEROUS?

NO

DO I NEED TO UNDERGO SURGERY FOR THE CHOCOLATE CYST?

That would depend on your symptoms, size of the cyst and whether you want children. Cysts larger than 4 cm usually require surgery. If you are in pain or are undergoing treatment for fertility, you may undergo laparoscopy to perform adhesiolysis (removal or cutting of adhesion bands) and cauterisation of endometriotic implants as well as check the condition of your fallopian tubes.

IS ENDOMETRIOSIS CURABLE?

Endometriosis tends to recur throughout your reproductive life and although not life-threatening, it may cause a lot of distress due to pain. We have yet to find a "cure" for this condition. Remissions and relapses form the pattern of the disease till you reach menopause. Fortunately, it improves remarkably during pregnancy and resolves almost completely after menopause. Since the implants thrive on hormones, they grow actively only during her reproductive life (till menopause).

WHAT IS THE TREATMENT OF ENDOMETRIOSIS?

Treatment of endometriosis is based on the stage (severity) of the disease, the age of the patient, whether she wants to have children and her symptoms (pelvic pain or heavy periods). Now days, various medical and surgical options are available to women. Medications are effective to a large extent and work mainly to suppress pain and symptoms. Tablets and injections to the effect are available and they suppress periods for many months so that the implants do not grow or bleed. Recurrence after treatment is common. Laparoscopic surgery remains an important treatment tool for most patients, mainly to treat chocolate cysts, remove adhesions and destroy endometriotic implants and restore fertility. However, many women would need more than one procedure during their lifetime. The woman should be counselled thoroughly about her condition and the treatment plan should take into account her treatment goals and expectations. She should follow up regularly throughout her life till menopause in order to maintain optimum health and avoid complications. For very severe cases, it may be wise to remove the uterus and both ovaries to cut off the hormonal supply to endometriotic implants.

WHAT ARE MY TREATMENT OPTIONS IF I WISH TO GET PREGNANT?

Regular treatment (in mild cases) Laparoscopic surgery (as mentioned above) Test tube baby (it is better to opt for test tube baby early before endometriosis becomes severe) Each case has to be personalised depending on various factors such as your age, severity of disease, financial constraints, condition of fallopian tubes and ovarian reserve.

Menopause is the last period in a women’ s life. It is the phase when the reproductive life of the women is coming to an end. The hormonal changes which lead to this may start as early as five years prior to this. Derived from a Greek term, it actually means ‘ ‘cessation of periods’.
It is not a disease, it is a transitional phase of life. However, it carries with it a different internal hormonal milieu which may in fact be detrimental to the female body in the long run. Just as puberty is a transitional phase where a girl steps into womanhood, menopause is the transitional phase when a women steps out into a phase of coalescence and senescence. The ovaries (the female counter part to the testes in men) pack up. The quantity of female hormones produced by them decreases significantly. Drastic as it may sound, a gradual process of natural castration begins.
In some women, menopause may be marked by changes and drama. In others, it may be quiet and go unnoticed. It may have a positive impact on her life style or may create havoc. To some extent her basic personality and socio-cultural background may colour her attitudes, reactions and behavior at this time. Either way, it is imperative for women, men and children to understand the changes wrought in a women at this stage of her life. It eventually concerns everyones lives. So even if you are not menopausal or not a woman, do not stop reading this. You need to know, too.

What are the problems (the symptoms) faced by women at menopause?

Until quite recently many doctors believed that women going through the menopause did not require treatment and those who complained of symptoms were making much ado about nothing, Lamentalbly, few doctors were well informed about menopause. Today more gynaecologists and doctors in our country are aware. The public is also more educated about menopause and Hormone Therapy (HT). Ignorance about menopause, shrouded in myth and folklore, is being shed. It is time a fresh look is taken at the hard scientific evidence available about menopause, its associated problems and their management.
The symptoms at menopause which women may experience may be short term that may only last for a few months, or could extend to a few years. These eventually disappear on their own when the body has adjusted to the new low levels of the hormones. If distressing to the women, these symptoms should and may safely be treated to make the transition easier.

Some of the common symptoms at menopause:

Vasomotor symptoms

• Episodes of hot flushes. In India, many women just say they feel feverish.
• Episodes of sudden sweating and night sweats
• Palpitations
• Bouts of feeling, excessively cold

Muscle & joint symptoms

• Muscle, joint and bone pains

Genito urinary symptoms

• Irregularity in periods that get less and further apart
• Dry vagina
• Painful intercourse
• Decrease in libido
• Recurrent vaginal infections
• Worsening or onset of vaginal prolapse urinary symptoms
• Urinary incontinence and inability to hold urine
• Recurrent bouts of urinary infections
• Worsening episodes of sudden urinary leaks

Symptoms related to the brain

• Emotional and psychological symptoms
• Depression and irritability
• Tiredness and lethargy
• Sleeplessness
• Forgetfulness
• Forgetfulness and impaired memory
• Loss of concentration
• Thin, dry skin

What are the long term problems that may arise as a result of menopause?

When there is no oestrogen for over 2 years or more the bones may get brittle, the risk of heart disease goes up, the vagina becomes less moist, the skin becomes dry and the lining of the passage from the urinary bladder (called the urethra) becomes thin and more prone to infections. These are real problems which may or may not result in symptoms. Even worse is that sometimes even doctors may be unable to disentangle the web of these symptoms and trace them back to menopause

The problems that may result in varying degrees in different women from the long term deficiency of oestrogens may be :

• Osteoporosis, brittle bones and multiple fractures with gradual development of that often seen Dowager’s hump’ or bent spine.
• Heart attacks and coronary artery disease
• Stroke
• Urinary and genital tract atrophy with resultant infections
• Emotional and psychological problems
• Skin thinning, wrinkling and brittleness

Upto their reproductive years, women unlike men are relatively protected against most of these problems because of the natural female hormones-oestrogens and progestrones-circulating in their body. These provide a balanced internal hormonal environment. However, with the advent of menopause these hormones decrease and degenerative processes may get accelerated in almost all parts of the body. Women, who are relatively more protected against most physical ailments compared to men of the same age group, lose this protection after menopause.

Do all women suffer from problems at menopause ?

Menopause is extremely idiosyncratic. Just as every one is different as they enter puberty, the change of life as they leave the reproductive phase is even more individual. Yet, just as it is easy to spot a pubertal girl, it is easy enough for a discerning eye to spot the mature woman undergoing the change of life! Those woman with the genetic good fortune of making oestrogen from sources other that ovaries such as body fat, are lucky and may make enough to keep themselves healthier for a longer period. The need and the fitness to receive HT should be assessed by people with experience in this aspect of health care.

Can these problems arising from menopause be tackled?

Yes. Each complaint or symptom that a women experiences can be helped individually. However, the root cause of the various symptoms and the long term problems that arise is a result of estrogen lack at menopause. It can be definitely corrected if the deficiency of the female hormones in a women body is made up by replacing them by using the same or similar hormones. This is known as ‘Hormone Therapy’ or HT. Change in life- style with adequate and appropriate exercise and diet alterations go a long way in helping

Awareness

It is important for all women to be well informed about menopause. It happens to every woman. It is her right to go into this stage of life knowing as much as she can. Women must become informed and active consumers of good health care. Most important the fear of the unknown is taken away.

What is Hormone Therapy or HT?

Gynaecologists all over the world now agree that replacing these hormones in the form of giving hormone therapy (HT) provide the most effective form of treatment of menopausal symptoms. HT gives dramatic relief of symptoms as well as protects against osteoporosis. It must be understood that the associated changes from aging, of course would be unaffected by giving hormone therapy.
Most of the hormones used are ‘natural’ hormones. It must be clearly understood that these are quite different from those used in the oral contraceptive pill. Just because women are unable to take the pill, it does not mean that they cannot have hormone therapy of menopause. However, hormone therapy needs careful monitoring the current recommendation is that it should be used for symptom control.
Hormone therapy is designed to provide the necessary hormones to top up the body’s waning natural supply. These may be taken either in the form of tablets or applied as patches on the skin or even used vaginally. All these forms are now available in India.

What is the role of Hormone Therapy (HT)?

Long years of experience and research in medical science has eventually lead to better understanding of differences in the various forms of hormone therapy and the problems with each of these. The unfortunate experiences of the past with oral contraceptive and synthetic hormones had been and continues to be the basis of bias against natural hormone replacement therapy. It should be clearly understood that the two are totally different forms of therapies. The acceptable established forms of hormone therapy use natural oestrogens and progestogens or other similar products . These hormones are not given in pharmacological abnormally high doses
To enable women to get maximum benefit from this acceptable form of therapy and to prevent hormone therapy from getting into disrepute, It should be ensured and stressed that hormone therapy should be started only after careful and thorough evaluation of women. However, not all women are fit or suitable to receive. This treatment and consultation with a specialist will exclude those who simply cannot be prescribed this treatment. It is mandatory that the presence of oestrogen dependent tumors and cancers is ruled out prior to starting hormone replacement therapy. Equally important is the monitoring only by specialists. Though hormone therapy certainly is not a cure all, elexir of life, it has a distinct role in tackling the short term problems arising from lack of hormones. Medical literature has established the improvement in quality of lives of millions of women for symptom relief with these.

SOMES DOS AND DON’Ts at Menopause
If you get ‘hot flushes’:

• Wear cotton clothes rather than those made of synthetic fibres like polyester
• Wear clothes in layers, so you can drop outer layers one by one as temperature rises.
• Take as many cool showers as possible. And apply anti-perspirant.
• Avoid hot drinks and spicy food, especially at night
• Avoid smoking and alcohol since it may make the symptoms worse.

If you have painful periods

• Use a lubricant K-Y jelly which is easily available at most chemists. In an emergency, any oil or cream or even saliva is better than nothing.
• Avoid intercourse when you have active vaginal infection or your partner has penile infection
• Have regular intercourse. Long periods of abstinence can result in painful sex again. Certain chemicals are released in the brain during intercourse which can relieve tensions, elevate the mood and be good physically for the body.
• Use good quality condoms to avoid sexually transmitted diseases and allergies
• Avoid vaginal douches. They do not really cure the source of any infections and may actually lead to further problems
• Check with your doctor if you have vaginal thrush or your partner any penile infection. If you do, exclude diabetes in yourself and your partner.

If you are prone to getting urinary infection:

• Drink plenty of fluids all through the year – about 10 glasses a day! In summer, particularly if you perspire, double this intake. Not only will this prevent urinary infections but also prevent constipation and do wonders for you skin.
• Have at least 2 glasses if fresh, pure orange or Mosambi’ juice or Nimbu-paani’ (fresh lime juice). One gram of vitamin C is good substitute for those who can not take ethier.
• If you have excessive and dirty vaginal discharge, get it treated. Sometimes it can be the source of recurrent urinary infections.

If you have period problems

• If your periods are getting heavier or occurring more frequently do get yourself checked out by a gynaecologist. Though heavier frequent or delayed periods can also happen from hormone imbalances these are also signs of pre cancerous changes in a perimenopausal women. So have yourself seen.
• If you continue to have bleeding or spotting, you will again need a gynaecological consult.
• Bleeding after intercourse is not normal either. Ensure you have a pap smear check and rule out an infection.

If you get body aches, bone and joint pains

• Ensure you are getting adequate calcium in your diet (milk, milk products, pulses and vegetables). See diet chart or check with you doctor if you need calcium supplementation
• If you are overweight, try to loose weight by exercising and dieting. Dieting alone is not advisable or helpful. Remember thinning bones cannot easily take increasing weight without complaining
• Instead of resting, increase physical activity. Take a pain killer and regularly undertake physical exercises and go for walks. If possible join exercise classes. If you enjoy dancing, dance. After the intial week of pain, it should settle down and get much better. Keeping physically fit will improve your agility and also help prevent fractures by improving your responses when and if you fall.
• If you have backache, before embarking on an exercise programme, check with a orthopedic specialist whether you ca gohead.

If you are feeling low:

• Talk to someone who is willing to listen. Airing feelings can be an antidote in itself.
• Reflect on your daily activates and check if you are keeping aside at least half an hour totally for yourself. Reserve sometime of the day for yourself. Switch off from the household chores, responsibilities, work and social commitments to either just rest or do anything which you enjoy.
• Are you dressing well? Have you groomed yourself with age and menopause as physical assets decrease, self confidence may begin to drop. It is important to improve your physical self image and pep yourself.
• If you get mood swings explain to your family that these may be related to menopause and will pass. Enrol their support and understanding.
• Develop a hobby, start something creative or just take time off to entertain yourself at least once in a fortnight. If you can involve your partner, there is nothing like enjoying things together but if you cannot, better flavour it alone than not at all.
• If there are any relationship or other problem in the household discuss them frankly. However, try to resolve them without confrontation and aggression. If you are getting nowhere with this approach, drop the issue. Your own peace of mind is most important. Petty problems are sometimes best ignored in such situations.
• Daily physical exercise and brisk walking can be invigorating. Exercise also results in secretion of mood elevating chemicals in the brain and improves a sense of well being.
• Avoid tranquilisers. They do not solve problems, but mask them. A sympathetic doctor and supportive husband, family or friend are far more helpful. A short course of antidepressants rather than tranquilisers may be more appropriate but must be prescribed by an expert. So see a psychiatrist, it will help

IF you are on Hormone Therapy (HT)

• You should be clear in your mind as to the reason why you are talking HT. Is it for symptomatic relief ? If you are taking it for purely cosmetic reasons, you should think again
• Are you aware of the slightly increased risk of breast cancer with prolonged (10-15 years) use of HT?
• Do you appreciate the benefits?
• Before starting HT did you have a complete gynaecological check? Was your blood pressure, blood sugar, blood cholesterol and triglycerides checked? Did you have mammorgraphy and ultrasound of the pelvis? If not, go back and discuss it with your doctor.
• Self examine your breasts once a month
• Maintain regular annual follow-ups with your doctor
• Report any irregular or unusual vaginal bleeding or a lump or pain in the breast to your doctor
• If you read or hear anything new, alarming or disconcerting about HT, discuss it with your doctor, who will be able to check and put things in perspective. Your doctor will give you balanced answers based on scientific rather than sensational facts
• Age in itself increases the chances of developing certain age related diseases like diabetes, hypertension, heart disease, arthritis, hypothyroid or certain cancers. You should be aware that these can develop despite HT.

Prior to considering taking HRT purely as a prophylactic measure to prevent long term problems like brittle bones completion of the two attached questionnaires would be helpful. This would identify those patients at real risk and could be used whilst considering and discussing risk-benefits ratio before starting on HT. Women at Cardiac risk should only take hormone therapy after proper assessment.

With the advancement of technology and with discoveries of pioneering magnitude, it is now possible to glance at the innards of human abdomens and even perform various surgeries on it without visible incisions and technical cuts.
With these innovations paving the way for advancements, surgeries that are deemed traditional will now be performed by us with techniques that will be least invasive. Under the field of gynecology, the two main types of surgery are: Laparoscopy and Hysteroscopy.

Laparoscopy

Laparoscopy constitutes as the procedure that looks inside the abdomen and the pelvis with the help of laparoscope. Laparoscope efficiently enables images of ovaries, outside of the tubes and other organs inside the abdomen. The laparoscope is a special telescope which is attached with a camera topped with a light source. The length of the laparoscope is 12cm long and the thickness of the tool is exact to that of a normal pen.

Laparoscopy is commonly used to:

• Find the cause of symptoms such as abdominal pain, pelvic pain
• As part of investigation of infertility

Not only can a doctor take a glance inside the abdomen with the help of laparoscope, he/she can efficiently perform a surgery inside the abdomen also. The laparoscopic surgery is also known as 'Key-hole Surgery' or 'Minimal Invasive Surgery' and now-a-daysHysterectomy (removal of uterus), myomectomy (fibroid excision), ovarian cystectomy, endometriosis surgery, PCOS drilling, diagnostic laparoscopy to detect the cause of infertility as well as tubal reconstructive surgery for damaged or blocked tubes are some of the surgeries which are routinely advocated laparoscopically.

When compared with traditional surgery, laparoscopic surgery usually renders the patient with:

• Less pain following the procedure.
• A shorter duration at the hospital.
• A faster recovery.
• A smaller scar.

Hysteroscopy

Hysteroscopy involves the delicate procedure of putting in a telescope to view the inside of the womb.

Prior to Surgery

Prior to the surgery, the patient will be required to fast for six hours availed with only the consumption of water. Instructions will be given to the patient pertaining to the initiation of the fasting procedure and the time that they should come to the hospital.

Bowel Preparation

If required, the Surgeon will instruct the patient about bowel preparation beforehand. This will entail drinking a purgative the evening before surgery and taking light (eg soup) diet the night before surgery. In most common cases, the patient will have diarrhea. Though unpleasant, this arduous procedure will ensure that the patient doesn't suffer any bowel injuries during the procession of the surgery.

In the Operating Theatre

The nurse anesthetist or anesthesiologist will place four adhesive tabs on your chest to monitor your heart rate. To keep intact the patient's need for fluid and medications, an intravenous drip will be properly set up. The anesthetist will provide the patient with a mask to breathe into and will also provide the patient with some medications that will render them to sleep. The surgeons will make a small about 1-1.5 cm cut inside the patient's navel and through this the laparoscope will be introduced. Carbon dioxide gas (CO2) will be put into the abdomen through a special instrument inserted into the navel. This gas will help to distend the abdomen, making it easier for the surgeon to see the internal organs during laparoscopy. The gas will be removed at the end of the procedure. Two or three small ½ cm cuts will be made on the lower abdomen to put in the other instruments to be able to perform the surgery. At the conclusion of the surgery, these will be appropriately repaired with the assistance of dissolvable materials.

After Surgery

After the surgery has been done, the patient will be put to rest in the recovery room. The patient will be then be transferred to the ward from the Recovery Room once the clock signals an hour after procedure. The patient will be having an intravenous drip running after the operation till they are able to tolerate feeds. If needed, injectibles material will be issued for pain or nausea. If the patient feels uncomfortable and acute pain is suffered by the patient, the nurses will provide medication to ease the patient. At first the patient may experience a sore throat. This is caused by irritation from a tube placed through the patient's throat into the windpipe (trachea) during anesthesia. It usually lasts for just a few days and can sometimes be helped by throat lozenges. It is likely that the patient may have a tube draining urine after the operation and the surgeon will decide conclusively whether it is to be removed. If there is no tube draining urine, the patient can ask for a bedpan to empty the bladder. These maybe 4 or 6 hours after surgery at the earliest.
Hysteroscopy is a minor surgical procedure utilizing a thin fiberoptic tube or hysteroscope to see the inside of the uterus (endometrial cavity). Hysteroscopy allows the doctor to diagnose and treat a variety of uterine abnormalities which may cause infertility, recurrent miscarriages, abnormal bleeding and pain.
Hysteroscopy is an outpatient procedure which can be performed in the operating room of a hospital, surgical center or at a doctor’s office.
Before the surgery, you will be given a hospital gown and asked to empty your bladder. You will be given medicine to help you relax and then local or general anesthesia depending on the type of hysteroscopy (diagnostic or operative) planned for you.
The hysteroscopy is performed with you lying on your back while your feet are supported by footrests (stirrups). A speculum will be inserted into the vagina so your doctor can see the cervix. The vagina is cleaned with a special antiseptic solution and the hysteroscope is gently inserted through the cervix and advanced into the uterus. A liquid will be injected through the hysteroscope into your uterus to help your doctor see the uterine cavity clearly. A camera attached to the hysteroscope will project a magnified view of the uterine cavity on a video monitor. Your doctor will be able to see if there is any abnormality in the uterine cavity and to look at the opening of the tubes.
The hysteroscopy takes only 10-15 minutes to complete unless other procedures are planned to remove fibroids, polyps , uterine adhesions or unblock your tubes.

Preparing for Hysteroscopy

• Hysteroscopy is best performed during the first week after your period (day 5-12 of cycle).
• If you are scheduled to have a fibroid removed, you may be treated with Lupron for several weeks before surgery, to shrink the size of the fibroid
• Tell the doctor if you are or might be pregnant, if you are allergic to any medicines or if you take blood-thinning medications, such as aspirin or Coumadin.
• Talk with your doctor about the risks of hysteroscopy. Have the doctor explain how the procedure is performed and what the results will mean.
• You will be asked to sign a consent form giving the doctor permission to perform the surgery.You should not eat or drink after midnight the day before your scheduled surgery

WHAT DO YOU MEAN BY POLYCYSTIC OVARIES?

Every month the ovary produces and releases one egg which is responsible for regular menstrual cycles. In the polycystic ovary, the follicles that contain eggs do not mature and hence are not released from the ovaries. Instead, the follicles accumulate as cysts in the ovary, thus the term polycystic ovaries. These collecting cysts in the ovaries lead to hormonal changes in the woman’s body and also may be the cause for infertility. Insulin resistance is an important aspect of this condition.

HOW DO YOU KNOW YOU HAVE THIS CONDITION?

Patients may present with various symptoms... the commonest being delayed and infrequent periods, acne or excess facial and body hair (male pattern) along with obesity. Some women have difficulty in getting pregnant .A large proportion do not show any symptoms and may be accidentally diagnosed on sonography.

HOW DO YOU DIAGNOSE POLYCYSTIC OVARIES?

The gynaecologist may suspect this condition based on the symptoms and then advise sonography and blood tests. All polycystic appearing ovaries are not PCOS. This condition is diagnosed based on a combination of symptoms, signs and blood reports.

ARE THERE ANY LONG TERM HEALTH PROBLEMS ASSOCIATED WITH THIS CONDITION?

Unfortunately, yes. The body fat and carbohydrate metabolism are adversely affected, leading to increased risk of Type II diabetes, high cholesterol and heart disease. Obesity, of course increases the risk. She is more prone to developing uterine cancer at a later age.

HOW DO YOU TREAT IT?

The "treatment" depends on the symptoms of the patient. We treat irregular periods with hormones, those with excess hair growth may need to go for various hair removal treatments along with hormones to prevent regrowth.
Drugs like metformin and myoinositol help reduce insulin resistance. Infertile women need to seek treatment from a specialist who would give medication and injections to cause growth and release of eggs from the ovaries. Laparoscopic ovarian drilling is another option which can give good results in selected cases Some women may even need IVF (test tube baby) treatment. In all cases, treatment is incomplete and ineffective without lifestyle modifications such as diet, regular exercise and stress management.

IS THIS CONDITION CURABLE?

There is no definitive cure for this condition, however lifestyle modification, especially dietary and exercise with maintenance of ideal weight is the most effective remedy. Due to the diverse clinical presentations, each patient needs an individualised and holistic approach to treatment in order to improve the quality of life and prevent long-term complications.

Ovarian cysts are one of the most common gynaecological problems that can be a cause for worry. If you have an ovarian cyst, you should have a basic understanding of this condition.

Q. What is an ovarian cyst?

An ovarian cyst is a fluid filled sac inside the ovary. It may be a follicle (egg) which has overgrown (hormonal or physiological cyst) or bled inside (haemorrhagic cyst) or it may be a benign or cancerous tumor.

Q. My doctor has told me that I have a physiological cyst? And that I should do nothing about it?

What does it mean? Every month, many eggs (follicles) grow in the ovary. The normal follicle is thus a fluid filled sac which also contains a premature egg. Out of many growing follicles, one becomes the largest (between 18-15 mm) and is known as the ‘dominant follicle’. This dominant follicle ruptures to release the egg. After rupture, the dominant follicle forms a structure known as the ‘corpus luteum’ which contains fluid which contains hormones for implantation. This corpus luteum disintegrates 2 days before expected menses.
If the follicle, instead of rupturing, grows further and persists, it is known as a ‘follicular cyst’.If the corpus luteum persists or grows, it is known as a ‘luteal cyst’.At any point of time, if there is bleeding in the follicle, the follicle enlarges and gets filled with blood, known as a ‘hemorrhagic cyst’.
The above three types of cysts are hormonal and not tumors. These are therefore known as ‘physiological cysts’. This type of cysts are usually not more than 3-4 cm in size, filled with clear fluid (simple cysts), painless, are accidentally found on a routine sonography and most often require no treatment. They shrink and dissolve on their own in the coming months, or may require some minor hormonal treatment.
PCOS (polycystic ovaries) is a special condition wherein the ovary is filled with multiple small immature follicles and thus the ovary appears cystic. Please refer to article on PCOS for more details.

Q. How do I know that I have an ovarian cyst?

Ultrasound is the best way to diagnose an ovarian cyst. It can also tell us whether the cyst is filled with clear fluid (simple cyst), blood (hemorrhagic cyst) or has solid material or septations (tumor). Ultrasound can also give some indications about whether the tumor is likely to be benign or cancerous.

Q. Do all ovarian cysts require surgery?

Not all ovarian cysts require surgery. Whether surgery is needed or not depends on the size and type of the cyst. Simple and hemorrhagic cysts may dissolve with time whereas a tumor needs to be removed surgically. Occasionally a very large simple cyst which does not resolve naturally over time, may have to be operated upon. A ‘chocolate cyst’ is a special type of hemorrhagic cyst which is found in a condition called ‘endometriosis’ (its management is discussed in the section on Endometriosis).

Q. What complications can happen with an ovarian cyst?

An ovarian cyst can cause the following complications:

1. The cyst can get twisted (torsion) which can cause severe pain and inflammation and may damage the ovary.
2. The cyst may rupture causing severe pain and internal bleeding.
3. Hemorrhage in the cyst (bleeding into the cyst) causing severe pain.

How do I know that my ovarian cyst is not cancerous?

Ultrasound (sonography) features can tell us a lot about the cyst. If the cyst is filled with clear fluid (simple cyst), it is almost certainly benign. A vast majority of the hemorrhagic cysts (blood filled cysts) are also benign.

Features suggestive of cancerous cyst are:

• Solid areas/nodule or papillary(finger like) growths in a cyst
• Thick septations in a cyst
• Thick walls
• Increased blood flow on doppler
• Free fluid in the pelvis
• Raised tumor markers in blood (e.g. CA-125. AFP, HCG, LDH)

Please note that these features are only suggestive of cancer. All tumors with one or more of these tumors are NOT cancer. In fact, only a small proportion of them are cancer, but all of them need to be operated upon to remove them and confirm the same.

Q. How do I confirm that the cyst is cancer or not?

MRI or CT Scan can give us a better understanding of the tumor features. If the tumor shows one or more of the above features, CT/MRI will tell us also tell us whether the tumor is infiltrating into the surrounding organs (uterus, pelvic wall, blood vessels, ureters or opposite ovary) and whether lymph nodes, liver, kidneys or spleen are involved, which may mean cancer. If there is free fluid in the abdomen, your doctor may test the fluid which would confirm cancer.

Q. My CA-125 is 92, which is high. Does that mean I have cancer? Please help.

CA-125 is one of the tumor markers for a certain type of ovarian cancer (epithelial tumors). It is only indicative of cancer if very high. CA-125 may also be raised in pelvic infections, endometriosis, tuberculosis and peritonitis (inflammation of the peritoneum). Conversely, CA-125 may be quite normal in ovarian cancer too.

Q. Which surgery is best for ovarian cyst?

There are certain rules of thumb in the treatment of ovarian cysts.

1. Simple cysts – Observation. Should disappear in three months. If does not shrink or disappear, or it grows, consider further evaluation (CT/MRI) or hormonal treatment. If the cyst is very large (more than 6 cm) or undergoes torsion (twisting), it may have to be operated upon.
2. . Hemorrhagic cysts – Observation. Should disappear in three months. If it does not shrink or disappear or it grows or is associated with painful periods, painful sex or pelvic pain, it may be a ‘chocolate cyst’. Please refer to the section onEndometriosis for management of chocolate cysts.
3. . Suspicious ovarian cysts – Cysts with features suggestive of malignancy should be removed at laparoscopy or open surgery.

If you are young (less than 40) and premenopausal, your gynaecologist may prefer to remove only the cyst and not the ovary. He/she would do a ‘frozen section’ (testing of the tumor in the operation theatre). If the tumor is benign, your ovary need not be removed. Some ovarian tumors have a tendency to recur and the gynaecologist may decide to remove the ovary also, after discussion with you. On the other hand, if the verdict is cancer, it is better to remove your uterus and opposite ovary too along with sampling of lymph nodes and peritoneal fluid. For all postmenopausal women with ovarian tumors, it is best to remove the uterus and opposite ovary at the same sitting. Most gynaecologists today prefer the laparoscopic route of surgery due to its various advantages. But in cases strongly suspicious of cancer or confirmed cancer, open surgery may be preferable as it allows for better lymph node sampling and testing of the internal organs. However, today, there are a few experienced oncosurgeons who perform laparoscopic cancer surgery. But these are relatively few experts in the field.