Dr sangeeta's blog

Fetal Movements

2011-12-20T22:21:00.000-08:00

Fetal Movements

During pregnancy, it is a pregnant women’s ultimate joy to feel the baby’s movement. It further increases the bonding with the baby.

Fetal movements are perceived by the women as a sensation of discrete kick, flutter, swish or roll. Movements are first perceived by the mother between 18 and 20 weeks of gestation. Women in their first pregnancy may perceive movement much later than 20 weeks of pregnancy, but women who have been pregnant before may perceive fetal movements as early as 16 weeks pregnancyin the subsequent pregnancies.

Fetal movements provide an indication of the integrity of the central nervous and musculoskeletal systems. The normal fetus is active and capable of physical movement, and goes through periods of both rest and sleep.

The number of spontaneous movements tends to increase until the 32nd week of pregnancy. From this stage of gestation, the frequency of fetal movements plateaus until the onset of labor; however, the type of fetal movement may change as pregnancy advances in the third trimester. There is no reduction in the frequency of fetal movements in the late third trimester.

By term, the average number of generalised movements per hour is 31 (range 16– 45) and the longest period between movements ranging from 50 to 75 minutes. From as early as 20 weeks of gestation, fetal movements show diurnal changes. The afternoon and evening periods are periods of peak activity. Fetal movements are usually absent during fetal ‘sleep’ cycles, which occur regularly throughout the day and night and usually last for 20–40 minutes These sleep cycles rarely exceed 90 minutes in the normal, healthy fetus.

There is some evidence that women perceive most fetal movements when lying down, fewer when sitting and fewest while standing. Sedating drugs, alcohol, cigarette smoking is associated with a decrease in fetal activity.

Women are advised to be aware of their baby’s individual pattern of movements. If at any time they feel that the movements are reduced or absent then they are advised to lie on their left side and focus on fetal movements for 2 hours. If they do not feel 10 or more discrete movements in 2 hours, they should contact their doctor.

The doctor will usually do a complete assessment and may be also record the fetal heart sounds on a machine which is called as the NST. In some cases the doctor may need to assess the blood flow to the fetus via an ultrasound Doppler assessment. In case there is any compromise in the fetal wellbeing then the doctor will take an appropriate action depending on the period of gestation and various other parameters.

So enjoy the flutter of the baby in your womb - the utmost joy of life within life.

PUBERTY

2011-11-17T22:10:00.000-08:00

Puberty is the process of biologic & physical development through which sexual reproduction first becomes possible. various physical changes occur during puberty

They are

· Accelerated growth

· Breast development & growth

· Pubic & axillary hair growth

· Menarche -i.e. appearance of 1^st menses

(ovulation usually occurs 1-3years after menarche)

· Most girls get their 1^st menses between 9yrs to 16yrs. mean age is 12.8yrs

If a young girl

1. Does not have menses by age of 14yrs and also secondary sexual characteristics

2. No menses by age of 16yrs despite secondary sex characteristics

Then she would need further investigation. One should then see a gynecologist .

x-ray in pregnancy

2011-11-17T22:08:00.000-08:00

X-rays in pregnancy

Diagnostic x-ray is a frequent source of patient anxiety in pregnancy

It is important to note that

1. No single diagnostic x-ray procedure is enough to threaten the wellbeing of the embryo or fetus

2. Risk of fetal anomalies ,growth restriction spontaneous abortion are not increased at exposure level of <5 rads

3. MRI and ultrasound are safe in all stages of pregnancy

4. Radio opaque and paramagnetic contrast agents are unlikely to cause harm; but should be used only when the benefit justifies the potential risk to the fetus.

5. Use of radio-active isotopes of iodine is contraindicated in pregnancy.

Prevention of malaria

2011-11-11T01:39:00.000-08:00

Prevention of Malaria

Malaria is a very common infection and can be life-threatening but it is preventable. Malaria is caused by the bite of the female Anopheles mosquito.

Malaria infection in pregnancy carries significant risks to mother and baby. Miscarriage, stillbirth and premature labour are the main complications of malaria.

Various measures can be taken to prevent malaria

The ‘ABCD’ of malaria prevention is as follows:

● Awareness of risk

● Bite prevention

● Chemoprophylaxis

● Diagnosis and treatment which must be prompt

Education about the cause and symptoms of malaria (such as a fever with chills) is useful.

Bite Prevention measures include

· skin repellents

· knock-down mosquito spray

· insecticide-treated bed nets

· clothing and room protection

The anopheline mosquito has different preferred biting times in different parts of the world. But the maximum risk period is from dawn to dusk.Therefore the mosquito bite prevention measures need to be applied 24 hours a day.

Skin repellents containing 20% DEET

Have been used and there are no apparent adverse effects

Knock-down mosquito sprays:

Permethrin and Pyrethroids sprays kill resting and flying mosquitoes. A can of insect spray active against mosquitoes is useful to help clear the room of mosquitoes. Pyrethroids will quickly kill mosquitoes and are the preferred ingredient in sprays, while permethrin will both repel and kill mosquitoes when used regularly in the same room.

Insecticide treated bed net

Long lasting pyrethroid-impregnated bed nets offer significant protection.Nets are now recommended by the World Health Organization for all pregnant women

Clothing that covers the body and forms a barrier from biting mosquitoes will also reduce the risk of malaria.

After sunset, long sleeves, long trousers, loose-fitting clothing and socks, regardless of colour, are recommended. Clothes can be impregnated with permethrin or permethrin or DEET can be spayed on to the clothes.

Drugs for malaria prevention

it is important to note that there is no drug that is 100% protective in preventing malaria. The choice of drug depends on various factors.

Women planning pregnancy and travelling to a destination where there is a risk of contracting malaria should note that

1. Malaria can cause harm to the pregnancy. Malaria is associated with increased risk of miscarriage.

2. Prophylaxis is not 100% effective

3. Women should try and avoid travel to endemic places or choose an alternative destination. If it not possible to delay either the pregnancy or the travel plan, then they should take prophylaxis.

4. They are also advised that they should avoid getting pregnant till the drug is completely excreted from the body. Thus they can avoid any inadvertent exposure of the fetus to the drug in the first trimester.

5. Nevertheless, if there is an unplanned conception while taking malaria prophylaxis, it is not necessary to do termination of pregnancy, as the risk to the fetus is low.

6. Mefloquine is essentially the only drug considered safe for prophylaxis in pregnant travellers in the second and third trimesters. The use of mefloquine in the first trimester may still be justified in areas of high risk of acquiring falciparum malaria.

This article is meant only to provide information and not be a substitute for medical opinion.

2011-11-02T01:09:00.001-07:00

IT IS WITH GREAT PLEASURE THAT I INFORM ALL MY FOLLOWERS THAT I HAVE NOW ATTAINED THE TITLE OF

THE 'FRCOG'

AFTER 12 YEARS OF MRCOG THE ROYAL COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS.... IN THE UK, DOES AN ASSESSMENT OF YOUR PERFORMANCE AND THEN CONFERS ON YOU THE TITLE OF FRCOG ...... I.E. FELLOW OF THE ROYAL COLLEGE

THE CONVOCATION FOR THE SAME WAS CONDUCTED IN LONDON AT THE ROYAL COLLEGE ON THE 23RD SEPT 2011.

HERE I WANT TO THANK MY PARENTS FOR ALWAYS BEING THERE FOR ME , ENCOURAGING ME AND SUPPORTING ME ALL THE WAY THRU. NONE OF THIS WOULD BE POSSIBLE WITHOUT THEIR SUPPORT.

I ALSO THANK ALL MY FAMILY MEMBERS, FRIENDS WELL WISHERS AND PATIENTS WHO HAVE SUPPORTED ME ALWAYS.

Cervical Cancer - Role of HPV Vaccine

2010-09-24T00:52:00.000-07:00

Cervical Cancer – Role of HPV vaccine

Article contributed By
Dr Sangeeta Agrawal
Consultant Obstetrician and Gynecologist.

In India cervical cancer is the commonest cancer to affect women, there are various factors that increase the risk of cervical cancer; such as malnutrition, low socio-economic status, multiple sexual partners, smoking etc.
Human papilloma virus infection is also an important cause of cervical cancer there are many types of HPV. They are classified as High risk and Low risk.
High risk types cause genital cancer and the low risk types cause genital warts.
HPV can spread due to skin-to-skin contact. It does not require penetrative intercourse.

One can acquire the virus at any time and then it may persist in the cells for a long time. It will then induce changes in the cells that over a long period of time lead to precancerous and then cancerous changes.

The HPV infection may not produce any symptoms. Taking vaccination against HPV can prevent cervical cancer. The vaccines contain some strains of the virus in the antigen form. These then help one to develop antibodies to the viral antigen.

All women can take the vaccine. It is particularly meant for young girls who have started sexual activity. It is not recommended for girls below age of 10 years. It should be avoided during pregnancy.
The dose is as follows 3 doses to be given intramuscularly in the deltoid muscle At 0, 1 month and 6 months interval.
It is imperative to remember that this vaccination does not take away the need to do regular screening for cervical cancer i.e. Pap smear.

exercise in pregnancy

2010-09-24T00:45:00.000-07:00

Exercise in pregnancy
Contributed by Dr Sangeeta Agrawal
Consultant Gynecologist and Obstetrician.
E mail. sangeetaagrawal@yahoo.com

Exercise should form an important part of our daily lives. Exercise promotes a sense of well-being. Daily routine activity such as climbing stairs, walking to the train or bus stop, shopping for groceries, all involve some form of exercise. But yet it is important to do exercise in an organized manner for a fixed period of time. Further it is important to do exercise in pregnancy.

The aim of exercise during pregnancy is to stay fit. Exercise improves muscle tone and strength. It makes it easier to carry the weight one gains during pregnancy. It helps relieve generalized aches and pains, lower back pain and reduce varicose veins and swelling of the feet and ankles.

Exercise during pregnancy may help to prevent development or worsening of medical problems such as diabetes and blood pressure in pregnancy.

Exercise during pregnancy helps to prepare for the physical challenge of labor. Appropriate exercise can help women to breathe well during contractions, stretch the perineum muscles and have toned abdominal muscles. This may help reduce the duration of labor.

Exercise may be of two types.
Aerobic exercise: - such as swimming, running, fast walking, aqua aerobics and dancing.
Muscle strengthening exercise. This involves slow, controlled movements that help build strength of certain muscle groups and weight bearing exercises.

During exercise it is advisable to
Drink lots of water before and during exercise
Avoid over-exerting yourself
Avoid exercising in a very hot and humid climate
Avoid exercises which involve lying flat on the back
Do warm-up and cool-down exercises
Consider wearing pelvic support belts during exercise
Avoid exercise at altitudes over 2500 metres
Avoid sports where there is a risk of being hit in the abdomen, such as kickboxing, or falling due to running such as football, horse riding and cycling.
Avoid scuba diving for entire pregnancy because the baby has no protection against decompression sickness and gas embolism under water.
Exercise for 45 minutes at a time. Do not over exert.
After delivery one can start walking and simple stretches immediately, and then gradually progress in intensity and duration. Pelvic floor exercises are particularly useful to tone the perineum.

When one is exercising then one should look out for the following symptoms. And if any of this happens then one should stop exercise

· feeling faint/ giddy
· pain or palpitations in your chest
· pain in your abdomen, back or pubic area
breathlessness
· weakness in your muscles
· painful uterine contractions or preterm labour
· fewer movements from baby
· leakage of ‘waters' (amniotic fluid)
· bleeding.
Under these circumstances one must seek the opinion of the doctor.

cord blood banking

2010-06-15T23:14:00.000-07:00

Cord blood banking:

Cord blood is the baby's blood that remains in the placenta and umbilical cord after birth. Cord blood can be collected and stored for future use. Cord blood is not collected as a routine.
Cord blood contains stem cells. Stem cells can grow into different kinds of cells in the body.
The stem cells from the cord blood can be used for treatment of various conditions (blood diseases, leukaemia, sickle cell anaemia and thalassaemia, immune diseases and metabolic diseases.) Research is on to see if stem cells can be used to cure diabetes. In cord blood transplant, stem cells replace diseased cells and grow to form the mature healthy cells that are required in the body.
Cord blood transplants can be used as an alternative to bone marrow transplants to treat some disorders. This has mainly been successful in treating young patients for leukaemia. Cord blood transplant has some advantages over that of a bone marrow transplant. There are fewer complications with a cord blood transplant and it is easier to find a match from stem cells than from bone marrow. There are certain drawbacks too. Sometimes the cord blood may be insufficient and enough cells may not be obtained for the transplant.

Cord blood banks are organizations, which store cord blood. In India the choice of storing cord blood lies with the would-be parents of the child. There are many cord blood banks in India. The parents can decide to store the cord blood of their child. This blood is then available to the family in case they have a person in the family who at a later date needs the cord blood to treat a disorder that is treatable by stem cells. There is a possibility that the cord blood is never used. The would-be parents can choose the company with which they want to store the cord blood. The terms and conditions of the contract are between the patient and the company. The doctor is not a party to the contract.
Parents-to-be are advised to understand all the terms and conditions and review all current literature and then make their own decision regarding cord blood banking.
___________________________

endometriosis

2010-06-14T22:37:00.000-07:00

Endometriosis is a condition where cells of the lining of the uterus (the endometrium) are found in places outside the uterine cavity.
The uterus is made of three layers and the innermost layer that lines the cavity is called the endometrium. In some women the cells of the endometrium may be found in the pelvis and around the uterus, ovaries and fallopian tubes.
Endometriosis can happen to any women in the reproductive years i.e. 15 to 45 years of age.
Women who have endometriosis may complain of pain in the lower abdomen and pelvic region, pain during or after sex (dyspareunia), painful and/or heavy periods (dysmenorrhoea) and, sometimes difficulty in getting pregnant ( infertility). These symptoms may affect the quality of her life significantly. The pain during sex/periods and the chronic pain may be very distressing. It is also possible that the woman has endometriosis but may have no symptoms at all.
We still do not know why endometriosis occurs but there are various theories that explain the pathology. The most commonly accepted theory is that, during a period, small amount of menstrual blood flows from the uterus into the pelvic area via the fallopian tubes. This is called ‘retrograde menstruation’. This tissue then implants inside the pelvis. During the cycle it responds to the hormones (estrogen and progesterone) just as the uterine lining does.
This tissue will also grow in response to them and then break down and bleed in the same way as the normal lining. This bleeding inside the pelvis remains inside and then causes inflammation, pain and finally leads to adhesions.
Endometriosis on the ovaries can lead to cysts i.e. collection of dark brown chocolate colored fluid in and around the ovary. Occasionally endometriosis may occur on the bowel and bladder, or deep within the muscle wall of the uterus (adenomyosis) and in scars especially the caesarean.

Diagnosis is difficult as there is no definitive symptom. And there is no definitive test. The same set of symptoms may happen even in other conditions such as pelvic infections.

Sonography can be done but it has its limitations. It may show the presence of cysts if any. But it may not necessarily tell the nature of cysts. Small endometriotic spots will not be seen on sonography.

Laparoscopy is the only way to get a definite diagnosis. I.e. we look inside the abdomen with a camera. This procedure is an operative procedure and has to be done under anesthesia. If endometriosis is found on laparoscopy we will do therapeutic procedures at the same time; such as burning of the spots, cutting of adhesions and removal of chocolate cysts.
Normally before proceeding to laparoscopy one would have already tried painkillers and hormonal medication (Combined oral contraceptives, progesterone only drugs, the LNG – IUS GnRH agonists). Some of these may be used even after the laparoscopy once the diagnosis is clear.
Women who have difficulty in conceiving may require assisted reproductive techniques to conceive. Finally some women may even require to remove the uterus tubes and ovaries if the pain is very distressing.
the most important take home message is that
- endometriosis can be verty distressing and can affect quality of life.
- but in present times no women needs to suffer it. there is lots of medical help available to treat it.

2010-06-11T02:20:00.000-07:00

Ovarian cysts

Dr Sangeeta Agrawal
MD MRCOG DNB

Consultant Obstetrician and Gynecologist
Bombay hospital
Email: sangeetaagrawal@yahoo.com
Website: gynecdoctor.com

The word cyst is very commonly and loosely used. There can be cysts in various organs of the body and in this article I aim to address the issue of ovarian cysts.
Every woman has two ovaries- one on either side of the uterus. He ovary is the size and shape of and almond.
Every month a follicle grows in the ovary.
Each follicle gets the stimulus to grow from hormones that are produced by the pituitary organ. The follicle produces the hormones, estrogen and progesterone, and releases an egg every month. But sometimes there may be a disturbance in the hormonal balance and the follicle doesn't rupture or release its egg. Instead it grows and turns into a cyst
This cyst is commonly called a functional cyst. Follicular cysts are usually harmless, rarely cause pain and often disappear on their own within two or three menstrual cycles
Sometimes the cyst may form after the egg is released from the follicle. Once the egg is released the follicle is called corpus luteum. The corpus luteum can get filled with fluid and form a cyst. This cyst usually disappears on its own in a few weeks, but it can grow to 4- 5 inches in diameter and has the potential to bleed into itself or twist the ovary, causing pelvic or abdominal pain. If it fills with blood, the cyst may rupture, causing internal bleeding and sudden, sharp pain.

There are many more types of cysts that are not physiological.
Dermoid cysts. These cysts may contain tissue such as hair, skin or teeth because they form from cells that produce human eggs. They are not cancerous, but they can become large and cause pain. They have to be removed.

Endometriomas. These cysts develop as a result of endometriosis, a condition in which uterine cells grow outside the uterus – the ovary and the back of the uterus (also called pouch of Douglas )being the commonest sites. These cells respond to the cyclic hormones and therefore may result in bleeding every month. This blood eventually can form cysts the ovary being the favorite site. The condition per se can cause severe pain during menstruation, sex and affect the fertility adversely.

Cystadenomas. These cysts develop from ovarian cells per se and may be filled with a watery liquid or a mucous material. They can become large — 12 inches or more in diameter. They usually will present as lump in the lower abdomen, pain or they may be incidently discovered during a routine screening investigation.

Many women have ovarian cysts at some time during their lives. Most cysts present little or no discomfort and are harmless. The majority of cysts disappear without treatment within a few months. However, sometimes cysts can rupture and produce serious symptoms that on rare occasions can be life threatening.

When women complain of
Menstrual irregularities,
pelvic pain (a constant or intermittent dull ache that may radiate to the lower back and thighs. The pelvic pain may start shortly before the period begins or just before it ends),
Pelvic pain during intercourse (dyspareunia),
Nausea, vomiting
Fullness or heaviness in the abdomen,
Severe sharp pain in lower abdomen
Difficulty in emptying the bladder completely.
Regular constipation
Then one must consider the possibility of ovarian cyst. None of these are very specific for ovarian cyst and therefore the doctor will consider various other conditions also in the diagnosis.
Ultrasonography is very useful test to identify the cyst, its size, and location and to determine whether it's solid or fluid-filled.
Treatment depends on various factors such as the age, the type and size of the cyst, and the symptoms.
If there are no symptoms and an ultrasound shows a simple, fluid-filled cyst then one can wait and review in one or two cycles. Follow-up sonography is done to confirm that it has resolved.
Birth control pills may be given to reduce the chance of new cysts developing in future menstrual cycles. Oral contraceptives offer the added benefit of significantly reducing the risk of ovarian cancer.

If the cyst is large, continues to grow or persists and causes pain then it may be removed. The cysts can be removed and the ovary does not need to be removed. However in some cases the ovary will have to be removed. As long as there is at least one functioning ovary, the fertility is not affected and the hormones are also produced. If the cystic mass is cancerous, then both the ovaries and the uterus may need to be removed.
After menopause the occurrence of ovarian cysts will always raise the suspicion of cancer. Regular ultrasound screening of the ovaries after menopause is useful to detect these cysts so that timely action can be taken.