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.

Thursday, June 2, 2011

Growth Restricted Baby - patient education

These babies (IUGR - Intrauterine Growth restricted baby) fail to attain their normal growth and, as a result, they are either small and weak at birth, or their growth severely affects and they succumb in mother's womb itself.

The common cause of growth restriction is reduction in blood supply to the baby through mother's placenta. Though exact cause of this reduction is not known yet, it's thought to be because of complex interplay between immune and tissue factors which lead to defect in the normal formation of the placenta. This formation of placenta occurs early in the gestation, in the first-third month itself, so, the growth restriction is already destined at that early in pregnancy.

So, growth restriction is not due to poor nutrition of the mother or her exertion. 

Babies grow slowly till 6 months, during which their organs are formed and shaped. The growth spurt occurs in the last 3 months of pregnancy, so, a restricted baby deviates in growth from a normal baby, after 6 months of gestation. Before this period, the growth restricted (destined to be growth restricted) baby may be differentiated from a normal baby, by doppler ultrasound. But often such diagnosis is not possible, and usually, growth restriction is diagnosed, after it has set in, at 7th or later months.

As the growth restriction is due to supply system of the baby, that's placenta, overloading the mother with nutrients or other things is not going to change the scenario. Placenta is an organ, which sucks in mother's nutrients even across a gradient, to keep the baby nourished at the expense of mother. So, making the mother over-eat is like trying to raise the water level in the upper tank, by raising the level in lower tank, when the motor which pumps it uphill is damaged. It doesn't work.

In fact none of the treatment strategies increase the baby's growth, as seen in rigorous studies.

So, only treatment to be offered to the patient is, continuous monitoring of the baby, and when it's survival in the mother's womb is in danger, to deliver it outside, and treat it after birth.

Totally restricting mother's activities, and confining her to strict bed rest, doesn't help the baby either.  Still, the mother may restrain from doing heavy work, and she can do some light routine work.

The mother may keep a watch on her fetal-kicks. Various strategies were devised in measuring these kicks, like count to ten, or count for one hour thrice a day, but these strategies were not proved to be any better than, just casually keeping a note on one's kicks. The mother need not count them. (I personally advise them also, not to compare one's kicks with her neighbour's. Kicks of different women vary, and they vary even in different pregnancies of the same woman, and also in, different months of the same pregnancy.)

Maternal weight measurement have not been proved to be of much benefit. Now we have measures to directly assess fetal weight, health, and blood supply. So, indirectly assessing fetal weight, by weighing mother is not necessary.

In the end, I would like to stress that, babies are normal, only that their nutrition is affected. Once delivered, they grow normally, catch up with rest of the babies, and live like them. Sir Isaac Newton weighed only 2 kgs at birth (normal is 2.5 kgs at the least) and he's considered greatest scientist ever.

Friday, May 20, 2011

Hypertension in pregnancy - Patient Education

Hypertension (high BP) is a common complication of pregnancy. It occurs in later months of pregnancy. It's progressive, albeit the rate of progress varies. 

The cause of hypertension is inherent in pregnancy itself, due to variation in mother's immunological reaction to the pregnancy. Mother's immunological status changes in pregnancy, in order not to reject the fetus, and to facilitate it's growth. In pregnancies with hypertension, this immune modulation is abnormal, causing widespread immunological changes in mother, which in turn causes systemic changes in maternal body. The obvious changes are hypertension, leaky capillaries, activation of coagulation system. They cause tissue edema (not just in legs, but all tissues are edematous), albuminuria, tissue hypoxia, and organ dysfunction. It affects all organs, including kidney, liver, lungs and brain.

Hypertension is associated with restriction of baby's growth, to some degree. Mother may have swelling in her legs.

If severe, hypertension can affect mother's kidney, liver, lung and brain. It can cause these organs to fail, and mother may throw up convulsions. Her coagulation (blood clotting) is affected and she may bleed profusely. Baby's growth, if severely affected, may cause it's death. Needless to say, hypertension is a dangerous conditions, if not properly followed up, and actions taken in due time.

Anti-hypertensive (tablets for BP) are only temporarily effective, the underlying disease progresses despite treatment. As the condition is caused by the pregnancy itself, the ultimate treatment is it's removal, that's baby's delivery. The obstetrician may wait as much as possible, to allow the baby time to mature, but not allow it to go to full nine months.

Restricting salt intake or fluid intake is not the treatment of the condition. Though absolute rest is not required, some restriction of activity may help. The mother can lie down in any position, not necessarily, in later position. She has to note her baby's movements, though she need not count them exactly. The obstetrician will call her frequently, to check her BP, to carry out urine and blood investigations, to do baby's ultrasound to note it's growth and detect it's restriction.With such due treatment, complications are rare and to a great extent avoidable.

Saturday, May 7, 2011

Low BP - Patient Education

A large percentage of people consider themselves 'suffering' from 'low BP' (Blood Pressure). The symptoms of the conditions include a fainting attack or tiredness, and is often diagnosed by paramedical people or 'expert' layman. The treatment even includes excessive salt intake!

I devout consider amount of my consulting time, telling people that 'low BP' doesn't exist as a chronic disease. The BP  of a person can fall suddenly, even to dangerous levels, due to various reasons such as bleeding, dehydration, or allergic reaction. But the body takes adequate measures immediately, to maintain the Blood Pressure.

The body is capable of adjusting and maintaining the required blood pressure on second to second basis, otherwise, a sitting person won't be able to stand. The body should immediately raise the pressure, or the blood won't reach adequately to his brain, and he'll have a black out.

Body is not that much concerned with high blood pressure, because no sudden adverse events will occur due to it. So, while high blood pressure can occur as a chronic disease, not low blood pressure.

BP is variable between the patients. Normal blood pressure is considered as 120/80, but there are large number of people, whose normal is at 90/60. It's their normal blood pressure, not that they are hypotensive (low BP).

finally, I have a doubt, why no one complains of Low Temperature?

Friday, May 6, 2011

Abortion - Patient Education

Abortion early in pregnancy is very common. About 10% of diagnosed pregnancies end up in abortions (and many more pregnancies abort before they are diagnosed).

The main cause for early abortion (not late abortions, which occur after the first 3 months) is defective embryo. The formation of embryo, by fusion of male and female gametes, and the formation of the gametes themselves are delicate processes, and are prone to end up in chromosomally defective embryos. It's natures way to discard these defective embryos by means of abortion.

So, it's not the woman's defect, any problem with her uterus, any hormonal deficiencies (often cited cause), or any food or physical strain which causes the abortion. That means, the woman is not at risk of abortion, and if she aborts, it 's just a chance event. She is not at increased risk of abortion in her subsequent pregnancies.

Not knowing these people often unnecessarily get worried, and take a lot of precautions, which wont help, if the pregnancy is destined to abort.

Why  abortion is not caused by other causes

The early development of an embryo is a delicate process, with formation of all parts like brain, heart etc. After the initial few weeks, the embryo only gains in size, it's parts have been fully formed. At these delicate time, nature will present it with ideal controlled conditions. It leaves it least to the external factors, and it's mainly directed by it's internal processes themselves. So, maternal physical environment has least effect on embryo, and if the pregnancy fails, it's embryo's own fault. A pregnancy can be compared to a rocket. It's launch is a very delicate process, and the control of launch is mainly by internal arrangement. The base station takes over only after the rocket has managed to scale some to some altitude on it's own. If something goes wrong at the launch, they are not correctable, and the mission simply aborts.

Friday, April 22, 2011

Patient Education: Fibroids in Uterus

Uterine fibroids ( ഗര്‍ഭപാത്രത്തിലെ  മുഴ) are very common in women. They are benign masses, and rarely cause cancer, and they are not cancer. They don't spread or infiltrate other tissues. They occur in upto 25% of women and are often harmless. Fibroids grow only till menopause, and regress after that. 

They are often incidentally diagnosed, when the patient visits the doctor with some abdominal or menstrual symptoms. A Pelvic Ultrasonogram (Ultrasound scan) reveals the fibroid. It's often better to do by vaginal route. 

 They can occur at different locations in uterus : submucous, subserous or intramural.

They can cause heavy menstrual bleeding or severe pain during menstrual bleeding. But it should be remembered that, not all menstrual problems even in women with fibroids are not due to the fibroids at all, and menstrual problems occur in women without fibroids too. Fibroids rarely cause non-menstrual pain, back ache, urinary or bowel symptoms, leg swelling or pain. They are often wrongly attributed to fibroids. 

The nearer the fibroid to the endometrium, (or deeper the fibroid in the uterus is) the more the symptoms. A small fibroid deep in the uterus can cause more symptoms than a large fibroid on the surface. 

Deeper fibroids can also cause infertility, and may require removal. A surface fibroid may not be the cause of infertility, and if removed by surgery, may lead to infertility due to adhesions of surgery.

There's no medicines to treat fibroids. Often people go for alternate medicines which claim to have treatments for it, and are relieved of symptoms which were wrongly attributed to fibroids in the first place.

Surgery for fibroid can be: myomectomy (removal of fibroid alone) or hysterectomy. Both can be done by laparoscopy or laparotomy (conventional surgery). Myomectomy can also be done by Hysteroscopy. Actually Hysteroscopy is better, since it doesnt cause a scar on the uterus, and often the fibroids which cause the symptoms can be better removed by hysteroscopy, since they are deep in the uterus. But hysteroscopy is risky procedure and requires advanced skills at surgery. 

Recently other less invasive modalities like myolysis, uterine artery embolisation, have been available, but they have not yet come to India. 

Wednesday, March 30, 2011

Endometrial thickness and DUB

DUB is irregular uterine bleeding due to hormonal imbalance in pre-menopausal women.  Ultrasound is used routinely as a diagnostic modality in DUB. On ultrasound, endometrial thickness is measured, and an increased thickness is quoted regularly as an indication for endometrial biopsy. It 's helpful to evaluate the actual premises of endometrial thickness studies in bleeding disorders.

Endometrial thickness of less than 4 mm in post-menopausal women is very unlikely to be carrying carcinoma, and such a patient, even if she has a few episodes of post-menopausal bleeding, can be safely followed up, without carrying out a D&C. An increased thickness in these women, increases the risk of malignancy upto 10%, and warrants D&C (in post-menopausal woman).

No studies are done which show a correlation between endometrial thickness and carcinoma, in pre-menopausal women, with bleeding disorders. This fact is often forgotten, and increased thickness in women with DUB is used to advice endometrial biopsy. We often forget that in women with infertility, we try to achieve much higher endometrial thickness often giving them estrogens (though benefits of this is not proved). This confusion has gone deep into medical practice and even found its way into literature (unfortunately), like in this site. (The site also mentions PCOD as a cause for ovulatory DUB!)

So, let me make it clear, Ultrasound of endometrial thickness alone, in pre-menopausal women with DUB is not an indication for endometrial evaluation by D&C. 

Then, what's the indication?
As continous estrogen stimulation is the cause for endometrial malignancy, period of DUB (anovulatory, irregular bleeding) more than 6 months can be one. grossly thickened endometrium in ultrasound (not 4 mm but something like 25 mm), irregular endometrium etc are also indication.

Tuesday, February 15, 2011

28 week ultrasound

28 week ultrasound.

This is rather inappropriate (too late) period for an anomaly scan, but detailed anatomy can be viewed at this gestation. And it's too early for a growth and biophysical profile scan, but we may need it at times in early growth restriction.

Anatomy viewed in this scan:
intracranium : BPD plane, lateral ventricles, cerebellum, cysterna magna
thorax: heart 4chamber view, outlet view, venacave.
kidneyes, intra abdomen
limbs including digits

About biophysical profile:
No doppler done. (not necessary in a normal pregnancy.) . I would include doppler with BPP. Manning and others didnt do so, because doppler was late comer in the scene. doppler also tells us about the biophysical well being of the pregnancy.

In growth restricted baby, BPP as important as doppler. there's a tendency to make decisions solely based on doppler. the baby may be thriving even with a compromised placental flow, or it may be suffering because of it's size, even with a good blood flow. Biophysical activity tells us if the baby's blood supply is enough to keep it 'active' in addition to it's basal body function. If the baby is active, we can give it more time in utero.