Monday, November 28, 2016

PCOD - Polycystic ovarian disease

Let me go through some details about PCOS or PCOD, because 'everyone seems to have it these days'. The interesting thing is, it doesn't need any medical knowledge, rather it's something that can be understood and derived as in maths.

Little bit about physiology - HPO (hypothalamus, pitutary, overy) is the collection of organs that produce the hormones that control menstruation (as well as ovum production, which is related to pregnancy). interestingly, unlike any other process in the body, uterus doesn't have a feed back to the HPO, if it has bleeding problems, HPO doesn't respond to it and correct. that's because, during evolution, our females rarely bled, they were shortlived and conceived and fed more children during which they dont bleed. As a result, evolution never got to attempt at correcting bleeding disorders.

Though HPO doesn't respond to the problems with uterus (it's target organ) and it's bleeding, HPO receives lot of feedback from the process of ovum production, it's other function. Though we like it or not, childbearing was the primary function of a living being, and the nature needed to control it finely. It makes sure the individual doesn't conceive during unfavorable circumstances, which were plenty in our wild origins. Thus it made sure HPO received feed back from every organ and process in the body, apart from the Ovum production, so that any internal or external threat or malfunction could be noted and individual's 'conceivability' averted. Thus we find the interesting thing that, the HPO is unique in the way that, it's one target organ doesnt give any feed back, where as it's other target organ as well as every other organ in the body gives feed back and controls it.

Thus HPO is an organ that's waiting to be 'tuned' to abort an attempt at pregnancy, by controlling the ovum production. Any stresses, internal or external jeopardises the HPO. The external manifestation of this HPO tuning is changes in the menstruation, because we don't see the process of ovulation, which happens inside the body. The ultrasound picks up the abnormal growth of ovulation, and due to various physiological reasons, the ovary in ultrasound appears as PCO (poly cystic ovary, which is actually a misnomer, the correct term should be 'multi follicular ovary'). Thus every female is carrying the 'tendency' to throw the process of menstruation into disarray, which is actually a normal physiological adaptation to control the timing of pregnancy.

Every female will have abnormal bleeding times, during diseases, stresses, external factors like any drug intake etc. It's common to see young girls missing their periods during exams, when they get married, when they take part in physically stressful sports activities etc. In olden times it would have been during famine, wild fires, wars etc. It's quite normal to have 'abnormal bleeding' thus, during periods of stress and diseases. During very recent times, it's actually 'obesity', which is becoming an epidemic, and the body interprets it as a 'stress to pregnancy'. (and hence the advise to lose the weight).

The 'tendency' of every female to 'tune' the HPO differs as does everything in biology. In some, their HPO becomes abnormal too easily, at slight stimulus. These females rarely get normal periods, as there's always this or that stress they face. These are the actual women who are so called afflicted with PCOD, and their numbers are not really that high. If bleeding becomes abnormal during some months and at other times it's normal, or they were normal a few years back, the woman is unlikely to be having PCOD. It's some stress, weight gain or such changes in the body that's producing the abrnomal bleeding. The ultrasound will show PCO pattern in any woman whose bleeding is abrnomal, so no need to get alarmed at ultrasound report.

Even the hardest PCOD, those who always have abnormal bleeding, whose HPO derails at slightest provocations, are amenable to treatment. This is where another interesting aspect of this disease surfaces. Because the processes inside the HPO are highly interconnected web, it's not easy to treat by exactly targetting the malfunction process. Just like in OOP (Objected Oriented Programming) in computer programming, we need not open up the HPO, rather treat it as a unit. We have drugs that completely suppress the PCO, give for a couple of months, during which the HPO remains dormant, all the processes die down inside the system, and gives the woman time to address the internal or external factors or stress that caused the malfunction. She has to try to reduce weight during the time (it she's overweight), get any disorder like thyroid problem treated, avoid stressful environment etc, and when the suppression is withdrawn and HPO bounces back to function, it'll mostly be normally functioning. These drugs are nothing special, they are just OC pills or oral contraceptive pills, which are used in contraception, because of their action of suppressing HPO and preventing ovulation. If the woman doesn't want to get pregnant, but just need normal bleeding, it's even easier to treat. The HPO in PCO will be anovulatory, producing only estrogen continuously without the progesterones, which are produced only after ovulation. Thus woman should take progesterone cyclically, to replace the progesterone, which together with the estrogen that comes from HPO will produce normal bleeding. 

Tuesday, May 8, 2012

An Android App for Ostetricians

This app helps keep track of patients. The patients are maintained based on an ID. Patient's details can be entered. You can have your own fields (as toggles or checkboxes). All patients can be viewed in one list, ordered by EDC. You can import and export the database, so, in case you change the phone, you continue using the software. You can also save it to a csv file, which can be viewed using programs like Excel, and may be used to prepare your statistics.


download from Android Market

Saturday, April 28, 2012

Multi-fetal Pregnancy Reduction

Carried out in a quadruplet pregnancy.

First fetus - injected amniotic fluid 5 ml intra-thoracically, but as it failed, injected 2 ml KCL intra-thoracically. It's important to verify that heart stopped for sometime, and then withdraw the needle.

Second fetus, repeated the injection of amniotic fluid, and it acted to cause a temponade on the heart, and stop it. amniotic fluid may be useful in mono-amniotic twins, in which continuation of pregnancy is very risky to both fetuses, and reduction carries risk too, due to intense vascular anastamoses.

Sunday, April 1, 2012

Day Care Delivery

An Invitation Article by -
       Dr Shruti Malvi

        KBPN Malvi Hospital
        Hoshangabad [M.P.]

Let’s Redefine Labour, with “Day-Care-Delivery” [DCD].

Advances in Medical Science all over the Globe, aim at Predictable Planned and Personally tailored Management Protocol that is least Invasive, Cost-effective and Simple…
We have succeeded too, mostly everywhere, except probably, Obstetrics, which still remains a completely unpredictable entity, bringing on helplessness in the obstetricians.
Its comparatively, the most unnoticed, unpredictable, and neglected process.

Well...maybe not anymore…
In an effort to combat this problem, we, at our hospital, started a Closely Monitored Labor management protocol which we named –The Day-Care Delivery Protocol [DCD Protocol], with subsequently Favorable Outcomes, without waiting for the Complications to actually set in.

The Concept of DCD-
Day-Care-Delivery can be defined as a planned activation and augmentation of labour at 38+ wks gestation, managed with the intention of vaginal delivery before nightfall.
It can result in a safe and predictable Feto-maternal Outcome in a manner which is very personal to the patient
The Latent Phase of Labor may extend to long and unpredictable lengths, and the active pains may start at any time which again is unpredictable and may pose problems.
Here with the DCD Protocol we aim at cutting short the latent phase ,pushing the parturient forward to enter the Active Phase, which also relieves the unnecessary stress and tension in the patient and outcome is better.

It is well known that a soft and favourable cervix becomes responsive and thereby facilitates the momentum of the ongoing labor progress
Our efforts are targeted at this Latent Phase to trigger the more predictable Active Phase in a planned way. Once achieved, the active phase will take its own natural course.

The DCD Protocol-
The dcd protocol is a comprehensive process which involves adequate counseling and informed consent with application of a dcd criteria prior to admission.
This is followed by activation of labor under close monitoring with assessment of outcomes and routine follow-up.
Patient selection begins during the 1st antenatal visit provided she’s a healthy ANC
Inclusion depends on her willingness after DCD counseling.
  • gestational age of >/= 38 wks,
  • uncomplicated pregnancy,
  • clinically adequate pelvis,
  • suitable usg findings,
  • suitability/qualifying for trial of labour,
  • informed consent form the check list prior to DCD.

After admission, the active phase is triggered once the dcd criteria are fulfilled. This is the final check…
Which includes,
  • DCD Trigger criteria
  • Regular FHS,
  • Irritable uterus,
  • Cephalic presentation
  • Intact membranes
  • Hd at brim
  • Bishop’s 4-5

Once the trigger point is confirmed, Labour is activated with
Intracervical dinoprostone instillation under close monitoring
Oxytocin drip commenced as indicated.
ARM done at a 3 cm dilated >50% effaced soft cx.
Augmentation continued aided by Drotaverine and epidosin injections an hr apart.
All being well pt is expected to deliver by late evening

So, what are the benefits of the Day Care Delivery Option as opposed to the conventional vaginal deliveries?

*From the pt’s perspective,
-its s a planned admission
-less transportation problems
-family support available .
*From the hospital perspective,
-senior medical and nursing staff will be available when the patient arrives.
Hence the emphasis changes from Masterly Inactivity and watchful expectancy to Masterly Activity and watchful expectancy.

Such mode of delivery is cost-effective and helps the women, resume their duties faster both in personal and professional fronts. These modalities make both the Rural as well as Urban clientele more receptive to the idea.

Advantages of Day care are always there, everything is planned and help is available, for instance, the Neonatologist, Anaesthetist, Blood, Pathological Investigations etc are at hand, compared to that in the middle of the night,

So the bottom line is, DCD may prove to be a suitable option for the patient and her obstetrician ensuring quality labour and Optimal perinatal outcome in the present day, helping the Pleasant Births of both a Cute Baby and Its Mommy.

Monday, February 20, 2012

Screening for chromosomal defects- Why should we do screening? - Patient Education

Guest article by Dr Lakshmi Kiran, who is a fetal medicine expert in Hyderabad. You can contact her at :

Chromosomal abnormalities are one of the major causes for perinatal death and mental handicap in children. The only definitive way to diagnose is by invasive testing (ie, CVS/Amniocentesis). These tests are associated with
a risk of miscarriage of about 1% and therefore these tests are carried out only in pregnancies considered to be at high-risk for chromosomal defects.
So, there are various methods designed to identify the high risk population. These tests are the screening tests which, even though do not give a definitive diagnosis, will give the patient specific risk score, which determines whether the woman is screen positive or screen negative.

Who should be screened?
Every woman has a risk that her fetus/baby has a chromosomal defect. The risk for many of the chromosomal defects increases with maternal age. So, every pregnant woman is entitled to screening.

Pre-screening probability
The risk of Down's syndrome varies with maternal age:
  • 1:1,500 at 20 years
  • 1:800 at 30 years
  • 1:270 at 35 years
  • 1:100 at 40 years
  • >1:50 at 45 years and over1
The risk also increases after a previously affected pregnancy:
  • With regular trisomy 21, the recurrence risk is 0.75% more than the maternal age related risk.
  • Following trisomy due to a translocation, the recurrence risk is dependent on the type of translocation and which partner carries the translocation.

The challenge of an antenatal screening programme is to identify women in whom a risk of Down's syndrome is sufficiently high to justify such an invasive test and to minimise the risk of miscarrying a healthy baby.

So, various methods are designed to increase the detection rate with as less false positive rate as possible.

Screening Tests :

There are two methods of screening : Serum screening and ultrasound screening. The methods also vary based on the age of pregnancy.

First trimester: The serum screen measures free beta-hCG (human chorionic gonadotrophin) and Pregnancy-associated plasma protein A (PAPP-A) between 10 to 13+6 weeks.
The NT (Nuchal translucency) scan between 11 – 13+6weeks.
In this scan, on ultrasound, mainly the thickness of the nape of fetal neck, presence of nasal bone are assessed.Various other parameters like the fetal heart rate, blood flow across tricuspid valve and ductus venosus are also checked.
Both together is called the “combined screening” ,which has 90% detection rate.

Second Trimester: Quadruple test: If a woman books later in pregnancy (when NT scan is not possible) the quadruple test can be taken between 15 to 20 + 0 weeks of gestation. This measures free beta-hCG, alpha fetoprotein (AFP), inhibin-A and unconjugated estriol (uE3) . It is less accurate than the combined test.

Second Trimester Ultrasound(Anomaly scan +Genetic Sonogram):
In this scan we not only look for major structural defects in the baby, which is mandatory in every pregnancy, but also look for certain soft markers which suggest the increased likelihood of chromosomal abnormalities.
The first and second trimester tests could all be done and interpreted together and that is called Integrated test”
The risk assessment should be done individually for every woman after taking into consideration, the various factors like maternal weight, ethnic group, assisted conception, whether previous pregnancy was affected, bleeding in pregnancy, Insulin dependent diabetes, smoking, gestational age of the pregnancy, singleton or multiple pregnancy. The patient specific risk is arrived at by considering all above parameters and the screening tests.
  • The integrated test offers the most effective and safe method of screening for women who attend in the first trimester.
  • The quadruple test is the best test for women who first present in the second trimester.

The parents are counselled in detail about this in detail based on which they can make a decision whether they would want to opt for a diagnostic test or not.
Women found to be carrying a baby with Down's syndrome will be offered expert counselling and support, they may be offered a termination of pregnancy or they may choose to continue with the affected pregnancy with support.

Screening for Down's syndrome in multiple pregnancy:
Around 2% of pregnancies affected by Down's syndrome are twins. The screening is mainly by NT scan. Combined screening may be beneficial. The risk assessment and interpretation and management depends on whether the twins are dichorionic or monochorionic.

For further information, i suggest visiting the websites: and

Wednesday, August 24, 2011

Should pregnant women sleep on left lateral position?

It was long believed that pregnant women should lie on their left side. They thought it improved the feto placental circulation by reducing aorto-caval compression by gravid uterus.
But the truth was that this remained unproven. counter arguments can be:
  • woman whose circulation is affected will feel uncomfortable and dizzy. She will spontaneously turn, without any instructions to do so.
  • the circulatory effects were demonstrated in test conditions, like in anaesthesia, which may not be the case in normally sleeping woman
  • if the sleeping position improved the pregnancy outcome, natural selection would have favoured laterally sleeping women, or at least those who turn to side in pregnancy.
But recently they have come up with a study which shows 2 fold rise in still birth in women lying in other than left lateral position.
the original article

All media highlightened this.
But the recommendation is still that, pregnant need not be adviced to lie in any particular position.

The above study is a retrospective poorly controlled study.
Suggested reading:
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Tuesday, August 16, 2011

Weight gain in Pregnancy

All pregnant ladies and their attendants are usually very anxious about her weight gain. A pregnancy lady gains about 10-12 kgs, only about one or two kgs in first 3 months, and rest of it after that.

None of the antenatal check up guidelines recommend regular check of female's weight (except at booking visit). Still it continues to be in the minds of our people, and is taught to ANMs and midwives.

Why we need not check the lady's weight routinely?

  1. Though the woman gains weight naturally, any deviations in it, doesn't correlate well on the adverse pregnancy outcomes like pre-eclampsia, diabetes, macrosomia, or IUGR. 
  2. We can better directly assess these pregnancy- deviations by clinical examination and ultrasound, than indirectly from the patient's weight gain. 
  3. A normal weight gain may falsely reassure us that pregnancy is proceeding normally, where, actually it may not be. 
  4. Abnormal weight gain in a normally proceeding pregnancy may cause unnecessary anxiety to the patient. 

(Mums-to-be used to be weighed every time they went for an antenatal check. Then doctors realised that this made many women anxious. It wasn't a useful way of assessing how well their pregnancies were going.)

Nice guidelines: Maternal weight and height should be measured at the first
antenatal appointment, and the woman’s BMI calculated
(weight [kg]/height[m]2). Repeated weighing during pregnancy should be confined to
circumstances where clinical management is likely to be
US guidelines:
 Maternal weight and height should be measured at the first antenatal appointment, and the woman's body mass index calculated (weight [kg]/height[m]2).Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced.