Health Guid Ind Docts KuwaitHG5

MENARCHE AND MENSTRUAL PROBLEMS IN ADOLESCENTS
Dr. RAMADEVI V WANI,

SPECIALIST, DEPT OF OBSTETRICS & GYNECOLOGY, AL-JAHRA HOSPITAL, KUWAIT
Menstruation also known as menses or periods is the periodic (approximately

monthly) shedding of the lining of the womb (uterus) in the form of blood. It is a
significant event in a girl’s life. Often girls and their parents suffer unnecessary doubts
and fears as they do not have a clear idea as to what constitutes normal menstrual
I N D I AN D O C T O R S F O R U M
cycles or patterns of bleeding. Sometimes, discussion with friends at school might
lead some girls to believe that they are going through something abnormal, but it is
not so. Here are some facts that may help you to verify your concerns regarding
menstrual cycles in adolescents.
What is menarche and why does it occur?
The first menstrual period is called menarche (said as “MEN-ar-kee”). It

heralds the onset of menstruation (menses, periods). It occurs as a part of pubertal
development. To understand menarche, we need to understand what is puberty.
Puberty is the term used to describe the changes in body, mind and emotions that
both boys and girls undergo between the ages of 10-18 years through the regulation
of numerous hormones in the body. During puberty, a child is slowly transformed
into a young adult. The most common order of physical changes in girls during
2
puberty is growth of breast and the beginning of the growth spurt to be evident first,
followed shortly afterwards by the appearance of the pubic hair, then underarm hair
0
and finally menstruation. However this pattern is followed in only 50% of girls, the
remainder showing one or more variations such as pubic hair first, or menstruation
0
prior to appearance of underarm hair. Menarche typically occurs within 2-3 years of
breast development.
When does menarche occur? 9

Menarche usually occurs sometime between ages 10 and 16. The average age
these days is 13. The age of starting menarche depends to a much larger extent on
nutrition and to some extent on race, genetics, general health and exercise. It tends
to occur when the body weight is between 42 and 52 kg. Therefore very thin girls
such as athletes, ballet dancers and malnourished girls tend to have a much later
menarche. Menarche also means that from now on if you have sex, you can get
pregnant.
During menstrual period, the lining of the womb along with some blood is
shed through the vagina. It is usually light at first and may get heavier for 2-3 days
before tapering off. The blood may be brownish color at first and then turn brighter
red. Having a period does not mean that you should stop doing any of the activities
you normally do.
What is menstrual cycle?
Length of the menstrual cycle is calculated from first day of one period (not
from the last day of the period) to the first day of the following period.
How does it work ???
You must be curious to know how you get your periods every month. Well, this
might help you understand what menstruation, or simply periods, is all about-
During each menstrual cycle the hypothalamus (a small part of the brain),
the pituitary gland (the gland located on the floor of the skull) and the ovaries
(reproductive organs inside the female body) follow a sequence of events that
prepare the womb for pregnancy. Menstrual bleeding occurs in response to the
hormones estrogen and progesterone secreted by the ovary. Normally the ovary
produces one mature egg during each menstrual cycle. This release of mature egg
by the ovary is called ovulation. This occurs two weeks before the following period.
2
This egg is capable of being fertilised by a sperm to become a baby. You may have
slight discharge from your vagina or some spotting of blood when you ovulate
0
and this is entirely normal. If egg is not fertilised, the hormone levels fall and the
lining of the womb responds by being shed, along with some blood. We call this as
0
periods. If the egg is fertilised then the hormone levels do not fall and the period
does not start, leading to pregnancy.
9
Normal menstrual cycles in adolescent girls.
Menarche 10-16years (average 13 years)

Menstrual cycle interval 21-35 days (average 28 days)
Menstrual flow length 2 - 7 days
Menstrual product use 3 - 6 pads /day
Why do I have irregular periods?
In some girls the first few periods are irregular as the relevant hormone
mechanisms have not yet attained full maturity. As a result, the ovulation is a bit
haphazard to begin with, i.e., not occurring in each menstrual cycle causing irregular
cycles. But don’t worry, periods usually become regular within two years of menarche
as ovulation becomes properly established. However, in some cases this may take up
to 5-7 years. In these first few years your cycles can range from 21-45 days, and you
may not have a period sometimes. However it is uncommon for girls and adolescents
to not have periods for more than 3 months or 90 days. Significant weight loss or
gain, heavy exercise, stresses like joining a new school or preparing for exams or
illness can all cause hormonal imbalance resulting in irregular cycles. Sometimes
irregular cycles are due to polycystic ovaries. It could also be due to thyroid or
adrenal disease. It can also be due to tumors of the ovary or adrenal or some genetic
disorder, but this is very, very rare.
Why do I have heavy menstrual bleeding?
Normally the blood loss in each menstrual cycle is 30 ml. Any bleeding more
than 80ml per cycle is abnormal and is likely to cause anemia (deficiency of iron).
It is normal to change 3-6 pads per day during periods. If you need to change pads
every 1-2 hours then it means that you have excessive menstrual bleeding. The most
common cause for excessive bleeding in adolescents is again irregularities in ovulation.
2
Occasionally it may be due to certain bleeding disorders like Von Willebrand disease
specially if you are having heavy periods since menarche. Rarely it could be due to
0
thyroid or liver disease or leukemia.
0
Period pains ( Dysmenorrhoea)
9
The first few periods are usually painless. With the establishment of regular
ovulation the periods are often accompanied by pain. It is felt as painful muscle
cramps or dull constant ache in the lower abdomen. Period pain can some times
spread to lower back or thighs. This pain which lasts 12-48 hours is usually tolerable.
However in some it may be severe and in few others it may be accompanied by
headache, nausea, vomiting and diarrhea.
In adolescents most period pain is not the result of any underlying disease.
It is only a side effect of the body’s natural menstrual process. During menses, the
hormone prostaglandin produced by the lining of the uterus causes contraction of
the uterine muscles, which is felt as pain. Simple measures like warm shower, hot
beverages are soothing during period pain. If the pain is interfering with your day
today activities, pain killers like Ponstan (mefenamic acid) 250-500mg three times
daily taken after meals are usually effective.
Rarely in adolescents, the period pain can be the result of some underlying disease
like endometriosis. Very rarely it could be due to fibroids or other malformations of
the uterus. Therefore if you have severe period pain which lasts longer than usual and
is not relieved by simple pain killers then seek your doctor’s help.
Menstrual conditions that require evaluation by doctor:

• Menstruation not established by 16 years of age.
• Menstruation not started within 3 years of breast development.
• Lack of breast development by 13 years of age.
• Menses occurring more frequently than every 21 days or less frequently
than every 45 days.
• Menses occurring 90 days apart even for one cycle.
• Menstrual flow lasting more than 7 days or requiring frequent pad change
(more than 1 pad every 1-2 hours).
KEY MESSAGES
• Menstruation is a normal and healthy physiological phenomenon. Having
2
a period does not mean that you should stop doing any of your routine
0
activities.
• Remember that the length of menstrual cycle is calculated from the first
0
day of one period to the first day of the following period.

• Irregular ovulation is the commonest cause of irregular menstrual cycles
9
and heavy menstrual flow in this age group and these correct themselves as
the hormone mechanisms mature. Worries about irregular cycles and heavy
bleeding are often due to the girl’s or her mother’s wrong interpretation of
menstrual cycles. Keeping a menstrual dairy where you record the length
of the cycle and bleeding pattern will be of great value. Often you will be
surprised to know that your menstrual cycles fall within the range of what
is considered to be a normal pattern.
If you or your parents have any doubts or fears regarding your periods, or if
you are experiencing any of the abnormal menstrual conditions given in the article
above, contact your gynecologist.
VAGINAL DISCHARGE IN CHILDHOOD
Dr. MADHU GUPTA MRCOG

SR REGISTRAR, DEPT. OF OBSTETRICS & GYNECOLOGY,
MATERNITY HOSPITAL, KUWAIT
Vaginal discharge in childhood is a common condition. It can be recurrent and

this condition can be quiet bothersome to parents and the young girl.
It is important to note that causes of vaginal discharge in childhood are quiet
different when compared to adult.
Physiological Discharge in Newborn Girl

The newborn girl often has a clear or white, non smelly vaginal discharge. It is
produced as a result of effect of mother’s hormone oestrogen still present in baby’s
blood.
2
Some times during first few months of life, discharge can be blood stained. It is
0
due to break down of lining of uterus cavity which is no longer supported by mother’s
hormone oestrogen . This condition is self limiting and not harmful in the long run.
0
Common Causes Of Vulval Irritation And Vaginal Discharge Are:
a) Bacterial infection 9
Non specific infection - Common
Specific infection - Rare
b) Fungal infection
In contrast to adult population, this is rare in adolescent group. If child is
diabetic or if her immunity is compromised, there can be fungal infection of
vulval skin only.
c) Viral
- Presence of viral infections (Herpes Simplex or Condylomata Accuminata)
raises the possibility of sexual abuse of the child..
d) Skin conditions
– Eczema
- Lichen scleroses
- Contact Dermatitis
e) Foreign body
Why young girl is prone for recurrent Vaginal Discharge
Recurrent complaint is common in girls of 2-7 years of age. Reasons are:

1) Mother ceases to supervise the perineal hygiene of her daughter as closely
because the girl is now potty trained. Young girl attempts to clean herself are
often inadequate.

2) Anatomy of perineum contributes to increased risk of infection. young girl
while sitting on ground, grass or sand has increased risk of contact with
bacteria.
2
0
3) Pre pubertal girl has an inherent susceptibility to vaginal infection as she

lacks the protective acid secretion of older women , vaginal lining is thin
0
and atrophic(due to lack of oestrogen hormone)

9
Presentation :-
The young girl presents with irritation on vulva and perineum and vaginal
discharge .
Most patients have recurrent complaints of irritation on vaginal discharge.

There may be difficulty in passing urine and an incorrect diagnosis of urinary
infection may be established.
Girl should be seen by specialist (Gynaecologist). Doctor will ask a detailed

history and perform examination. He/ She will take swab from outside the hymen as
not to affect virginity concerns.
Management:-
Recurrent Vaginal discharge is a common problem with young girls. Parents

should be assured that most of the time, condition will improve at puberty and has
no harmful effect in the long run. Condition is self limiting and each relapse is not
due to presence of continuing infection BUT is a new infection.
Many times, girl present at clinic after repeated courses of antibiotics and variety
of local creams which is not correct. Often situation is not improved with multiple
treatment.
THERE ARE SOME MEASURES THAT MOTHER CAN TAKE TO HELP THE YOUNG GIRL
2
0
1. Girl should always wear cotton pants and make sure that she changes them
at least twice a day.
0
2. Try to persuade her to avoid wearing tights and trousers especially when the
soreness is particularly bad.
9
3. Girl should (or mother should) wash the bottom with simple (non scented)
soap and water every time she goes to the toilet especially when her bowel
opens. Dry her bottom properly after washing(with clean towel). You may
find that a shower or shower attachment for taps is useful for this kind of
washing.
4. If soreness or discharge is bad, a salt bath before she goes to bed soothes
the discomfort. Easiest way to do is to put two large spoons of salt in ¾th of
medium size bucket filled with warm water. Put this solution in comfortable
basin and ask the girl to sit in the basin for ten minute.
5. Better not to wear pants in bed.
These measures will improve the symptoms
If there is no improvement to conservative management or if discharge is blood

stained or smells offensive , foreign body (eg tissue paper or pin) in vagina may be
suspected and examination of patient under anaesthesia is warranted. This is to note
that ultrasound or X Ray is not enough to diagnose foreign body.
SPECIFIC INFECTIONS :-
Specific infections are rare and need appropriate management directed to causes
of infection.
THREAD WORM (ENTEROBIUS VERMICULARIS)
It is common in young children. Eggs of thread worm are excreted in stools and
transferred digitally (by fingers) across the perineum when the child scratches. Child
has mainly vulval irritation and not the discharge. Symptoms are worse at night.
Treatment is simple with tab Mebendazole 100mg as single dose. As thread worms
are easily transferred, all members of family over 2 years of age should be treated.
10
SKIN CONDITIONS
Eczema or Psoriasis on perineal skin are rare.

2
Napkin rash
0
Is due to wetting of skin by urine and irritation from ammonia or possibly

0
washing powder. Treatment includes general advice about hygiene and use of barrier
creams to prevent further irritation.
9
Lichen sclerosus
It is a chronic skin condition of unknown cause. Perineal skin will have lesion
with irregular, shiny white bullae. Treatment is with application of potent steroid
cream locally.
So as most common cause of vulval irritation and vaginal discharge is non-

specific infection, perineal hygiene and general measures will help in majority of
cases while specific management is reserved for rest of the group.
OBESITY AND ANOREXIA IN ADOLESCENTS
A FALL OUT OF MODERN LIFESTYLE.
Dr. ANANTHAPRIYA VAIDYA

MD, MRCOG
FARWANIA HOSPITAL, KUWAIT
If you are a parent of a teenager, chances are that your child may look like one or
the other of the above photographs. Both extremes of malnutrition are unfortunately
the products of the same social environment.
Let’s begin by talking about the kid on the park bench. Just give a thought to 13
the difference in lifestyle between you and your child. You had breakfast, lunch and
dinner everyday. Snacks and sweets were reserved for holidays; your kids eat chips,
chocolates, ice-creams and super size burgers every day. You walked or cycled to
2
school, or the bus-stand, your kids get picked up and dropped back at the doorstep.
You had no option but to run over to the park in the next block and play hide-seek
0
and running & catching for entertainment, your kids have 24X7 access to T.V, internet
and the latest gaming devices. Can you imagine the positive balance of calories that
0
your kids experience? MORE FOOD+LESS WORK=EXCESS ENERGY, converted to
body fat. Can we blame the children for being overweight?
Extent of the problem. 9

There has been a drastic increase in the overweight/obese population that
began in the developed countries after the world war and has slowly spread to the
less developed countries also. “The number of children who are overweight has
doubled in the last two to three decades; currently one child in five is overweight.
The increase is in both children and adolescents, and in all age, race and gender
groups”, is the finding in one major study.
What are the consequences of this?
Apart from off course the obvious cosmetic consequences; obesity has a major
impact on all aspects of life. It leads to emotional disturbance, relationship problems,
health and financial problems.
High blood pressure, Arthritis, Diabetes, Coronary heart disease, Stroke,

Gallbladder disease, Sleep disturbance and some Cancers (endometrial, breast, and
colon) are all attributed to obesity. Some types of menstrual problems and infertility
14 are also the consequences of excess weight.
Adolescents who are obese can have low self esteem. Psychological effects of teen
obesity affect their overall health which can lead to more serious medical problems.
2
Peer pressure in teenagers is a major issue whether they have a weight problem or
not, which is why teasing obese teens can be psychologically devastating.
0
It also is a financial burden in terms of medi-care and medical insurance.

0
Scary!! Isn’t it?

9
So we as individuals and responsible parents need to be proactive. We need to

prevent our children from building up that extra fat, and if they already have it, we
have to help them lose it.
How are we going to do that??
By setting an example.
Eat regular home cooked food and do not stock junk food at home. Stock plenty
of healthy alternatives like fruits, salads or yoghurt instead of chips or frozen pizzas
for children to find when they are hungry.
Emphasise the need for regular physical activity. Allow the children to participate
in household chores where feasible. Limit TV, Internet and gaming time to a few
hours a week. Encourage them to take up at least one sport regularly, never mind
if they don’t become champions, it is enough to keep them fit! Set an example by
taking the stairs and parking far away from the destination.
For children who need to lose weight, encourage the same healthy life style, but
try not to be overly critical, because as such an overweight child suffers from low self
esteem, focus on failed weight loss attempts will only be counterproductive. Instead,
focus on the child’s strengths and make weight loss only a part of overall goals.
Get professional help from nutritionists especially in resistant cases. You don’t
want your child to diet in a wrong way and suffer from malnutrition!
Surgery in adolescents and children is a tricky issue. More is available on this

issue in the article on plastic surgery. 15
Avoid weight loss medication unless the problem is too big to tackle with simple
measures. Their safety is not proven.
2
Easier said than done! But by taking small but definite steps, we can tackle this
0
epidemic. The best time to start is now!
0
The same system that encourages obesity by promoting unhealthy food habits
and a sedentary lifestyle also gives rise to a diametrically opposite problem. Eating
9
Disorders.
Everyday children are bombarded with information about high flying lifestyles
and are exposed to images of extremely thin celebrities. Fashion, films and lifestyle
industries along with peer pressure, insensitive comments from people all result in
adolescents aspiring to acquire the “perfect body”. Women involved in fashion and
films industries and professional sportspersons are at particular risk.
Eating disorders are a group of conditions which afflict young adults, women
more than men. The common ones are, Anorexia Nervosa, Bulimia and Binge eating.
Of these Anorexia affects teenagers more often while mostly adults in their twenties
and thirties suffer from the other two. Several celebrities like the model Kate Moss
and Princess Diana are reported to have these.
The one common thread in all three is the intense desire to be thin. Teenagers
suffering from Anorexia are often obsessive about their weight, they think they are fat
in spite of being the opposite, they refuse to maintain a normal body weight and more
importantly, they hardly eat anything. They exercise to the degree of exhaustion.The
consequences can be fatal. Starvation off course is the obvious fall out; they end up
having weak, easily fractured bones (osteoporosis), their thyroid and reproductive
hormones stop functioning normally, leading to stopping of periods, and may affect
their ability to get pregnant. They also lose their ability to fight infections, and they
often come down with illnesses. In extreme cases, it may even lead to death. While
it is more prevalent in girls, it is increasingly being seen in boys also.
Bulimia is not as severe and is seen mostly in women of older age groups. In
these women, weight is usually normal. They tend to “binge eat”, i.e. eat a lot at one
go, suffer from guilt pangs and force themselves to vomit what they have eaten. They
may starve themselves or exercise in excess to compensate.
16
Binge eating is a milder form of bulimia and is more common than recognized.
These individuals are often overweight and use food as an antidote to depression or
other problems.
2
Since adolescents usually suffer more commonly from Anorexia Nervosa, let’s
0
talk about this at length.

0
If you find that your teenager is obsessive about thinness, has a distorted
perception about being “fat”, always tries to fit into smaller and smaller clothes
9
(the so called “size zero” syndrome), eats only salads and avoids all other kinds of
solid foods, exercises till he or she drops from the stress, you could be looking at an
anorexic.
The main concern again is, how do we prevent it? And secondly how do we
cure it?
The best teacher is one who teaches by example, so prevention comes by first of
all modifying our behavior in order to have an impact on our children.
How often have we ourselves reinforced the myth of “thin is beautiful-fat is
ugly”? How often are we ourselves obsessed about our weight, (regardless of how
much we weigh)? How many times have you caught yourselves saying “gosh I am so
fat and ugly”, even though you are only one size heavier than you were as a teenager
and look like a million? These are the cues which our kids pick up. We have to be
more sensitive to the signals we send to our kids.
Some small measures include the following.
Focus on the child’s strengths and don’t make yours and your child’s life
“achievement-centered”. You have to top the class, you have to win the tournament,
and you have to be a singer/dancer/painter/guitarist par excellence”. This line of
thinking should be avoided.
Avoid making unfavourable comparisons with other children particularly about

their weight.
Allow children to make healthy options rather than forcing it on them.
There should not be an over emphasis on maintaining normal body weight 17

and having a healthy lifestyle. Tactful encouragement and leading by example work
better.
2
Parents should be sensitive to their child’s behavioral changes. If they find their
child exhibiting anorexic trends, they have to act early. These children need medical
0
and psychological care along with lots of love and support from parents. Some web-
sites like “Ana” are known to promote anorexia. If you find your child visiting these
0
sites you should be careful.
9
Life in the 21st century is both easy and difficult at the same time! As we
gain control over one set of diseases, another completely baffling one emerges. It’s
the same with kids too. While raising kids in many ways has become simple, it is
complicated in so many other ways. Striking a balance between modern aspirational
lifestyles and traditional habits to derive maximum benefit from both is the way out
of the confusion.
SKIN CARE NEEDS OF THE ADOLESCENT
Dr. ASHOK KUMAR SHARMA, MD, DNB

EX PROFESSOR & HEAD, DEPARTMENT OF DERMATOLOGY,
GOVERNMENT MEDICAL COLLEGE, KANGRA (HP), INDIA
Although adolescents share skin problems with adults more so than children,
their concerns differ from those of older people and there are important issues
related to consent, self-image and self-determination that are unique to this group.
Adolescence is a time of transition from childhood to adulthood that has a legally
defined endpoint of 18 years. However, the onset of adolescence is not defined and
is perhaps best seen as a change of state of mind, which can be achieved at varying
ages depending on the individual. Adolescence is characterized by rapid physical
and psychological change.
The normal changes of adolescence and its effect on the skin, for example,
acne, striae, hair growth, sweatiness and body odor, are often of great concern to
young patients. Body image issues can also lead them to make requests for cosmetic
treatments, as well as tattoos, hair removal and piercings. Dealing with adolescents
20 with skin problems often means negotiating a path between the desires and needs of
the patient and those of the parents. This is not always straightforward.
In this article I am going to discuss in brief some common skin care concerns
2
of adolescents.
0
I would like to tell my young readers that the skin is the largest organ of our
body. It protects and covers the body, is waterproof, bacteria proof, and it self-repairs
0
when it is injured. Our skin, hair and nails are a reflection of our state of health. Skin
is repairable, but is not replaceable, so take care of the skin you’re in.
9
Acne
Acne is synonymous with adolescence and undoubtedly the most common
reason patients in this age group visit the dermatologist.
These unsightly spots on the face, back, shoulders and upper arms can be
distressing to young adults. Some lucky individuals are immune to some of these
effects, however most teenagers suffer from some degree of acne and the more
severe forms appear to run strongly in families. Acne severity varies as much as the
patient’s
perception of it. Some teenagers
see it as a normal phenomenon that
does not bother them, while others are
very troubled by minor acne.
Acne can be aggravated by greasy

skin-care products and make-up. More
importantly, synthetic sex hormones can
play a role. This is mostly encountered in
girls whose acne may worsen with use
of certain forms of the OCP, but in boys
who may be taking anabolic steroids to
enhance sporting performance acne can
also worsen, sometimes dramatically.
Although most teenagers with

acne have normal hormone levels,
associated hirsutism, obesity, menstrual
irregularity or post-pill amenorrhoea are
warning signs that the polycystic ovarian 21
syndrome may be present.
Thankfully, almost all types of acne can be treated. Treatment options depend
2
on the type of acne you have and your skin type. Most cases of acne respond to
a combination of topical therapy and oral antibiotics (doxycycline, minocycline,
0
tetracycline, erythromycin). Sometimes hormonal intervention or a medicine called
isotretinoin may be required.
0
Moles
Moles continue to appear until the mid-20s and it is quite normal for them to 9
change slowly with time. At puberty it is also normal for naevi to become larger,
darker, more raised and more numerous. Teenagers present with their moles for the
same reason as patients of any age present- either they are worried about the change
or they wish to get rid of them for cosmetic reasons. Although melanoma is rare in
prepubertal children, it becomes much more common after puberty.
Stretch marks (striae)
Striae are best known as an association of pregnancy,

but they are also common in adolescence. In girls they
occur on the breasts, buttocks and thighs. Boys may also
develop striae on the thighs, but horizontal striae on
the back only occur in boys. When striae first develop
they may be red and slightly itchy. They then flatten and
eventually become pale and atrophic. With age they
become inconspicuous but they can be a source of distress
in teenagers. Horizontal striae on the back in boys are sufficiently unusual sometimes
to raise questions about physical abuse or injury. If striae are treated early — in the
first stage when they are still raised and reddish — it is possible to improve the
appearance with topical tretinoin cream 0.05%, applied twice a day for six weeks.
Laser treatment also has its advocates. After striae have become atrophic and pale,
little can be achieved with treatment and it is best to encourage the patient to be
philosophical about their presence.
Excess body hair

22
Although excess body hair is rarely a problem, excess facial hair can be
embarrassing for teenage girls. Girls of Indian descent are the ones who usually
present. It is always important to rule out androgen excess in any young girl with
2
facial hair. It is not unreasonable to give teenage girls advice on facial hair removal.
Waxing, bleaching, depilation, shaving and plucking are all safe, but all need to be
0
repeated frequently. Laser epilation is more effective although substantially more

expensive. The new product eflornithine reduces the growth of facial hair but is also
0
expensive and has to be applied twice a day.

9
Body odor and sweating
Body odour and excessive sweating can also be a problem. In some teenagers
sweaty palms can be so severe that they interfere with holding a pen at school and
create severe embarrassment when hand to hand contact with other people is needed.
Control of excess sweating is very difficult. Antiperspirants are first line, and there are
some that are more effective than the usual over-the-counter products, for example,
those containing 20% aluminium hexahydrate. Iontophoresis is a physical
therapy in which a machine passes a low-voltage direct electric current into
the skin, using water as a conduction medium and has been used for many years to
treat hyperhidrosis. Iontophoresis with a home-use machine (which uses tap water)
can be helpful. Botox is effective, particularly in the axilla, but the patient must
be able to cope with multiple injections. Use of Botox on the hands can require a
general anaesthetic. The effect lasts 6-12 months, but the cost can be prohibitive.
Oral anticholinergics such as oxybutynin can be tried but the side effects can be
problematic. Sympathectomy is a last resort.
Greasy skin
Greasy skin and hair are a normal part of adolescence and another problem
that is difficult to treat. Often they go hand and hand with acne and are improved by
acne treatment.
If they occur on their own and are a source of major embarrassment, symptoms
can be successfully controlled with low-dose isotretinoin. However, this is an off-
label use that is not recommended unless the problem is causing severe psychological
distress.
23
Blushing
Blushing and emotional flushing can also become a problem at adolescence.
2
The patient gives a typical history of sudden redness of the face and chest when
anxious, embarrassed or overheated.
0
Although some degree of blushing is physiological, in some people it may be
0
obvious enough to cause distress and even social phobia. Teenagers who are faced with
public speaking and other high-school tasks that provoke performance anxiety can
9
find this a real trial. Blushing is also very hard to treat effectively. Systemic medications
such as clonidine and propranolol can be tried but tend to be disappointing. The
most promising treatment at the moment is Botox, but the same disadvantages apply.
Often strong reassurance that blushing is benign is all that is required, although it is
sometimes necessary to address the anxiety more than the skin problem.
Genital issues
It takes a great deal of courage for an adolescent to seek advice from a health
care professional for a problem that concerns the genital area. Some of these problems
are normal or harmless, but teenagers may be faced with a sexually transmitted
disease at a time in their lives when they are ill-equipped to deal with it and when
their parents may not know that they are sexually active.
There are several normal variants that may make adolescents worry they might
have genital warts. In boys pearly penile papules are harmless angiofibromas that
appear around the corona at adolescence. In girls the normal rugosity of the mucosal
surface of the introitus or even normal sebaceous glands may cause similar concerns.
Adolescent girls may deny sexual activity, but true genital warts and/or genital herpes
in an adolescent are sexually transmitted diseases and should raise the subject of
whether the sexual act by which they were acquired infection was consenting and
whether a complete STD screen should be performed. It also means that the girl
should be given education about safe sex, contraception and Pap smears.
Genital aphthous ulcers are harmless, but very painful. Genital skin condition
are easily confused with genital herpes. They may be frighteningly large and may
appear for the first time at adolescence. They look no different to aphthae in the
mouth. All acute painful genital ulcers should be tested for herpes simplex virus
1 and 2. However, if testing is negative and there has been no improvement with
24 an oral antiviral — particularly in the setting of previous oral aphthae — it is not
appropriate to subject a teenager to extensive testing for STDs. This situation can
be very confronting and traumatic for the family of a young teenage girl who is not
sexually active.
2
Acute candidiasis is another common vulval condition that may appear for the
0
first time at adolescence, usually presenting in the usual way with itch, pain, erythema
and a cheesy discharge. In some adolescents it may be recurrent or associated with
0
antibiotic treatment, particularly for acne. It should be remembered that vulval

dermatitis and psoriasis can first appear at adolescence and can be difficult to
9
distinguish from candidiasis without a culture. A single stat oral dose of fluconazole
150mg works well for genital candidiasis.
At the end let me just advise about 10 skin sins to my young readers:
1) Do not go to bed without first removing make-up

Girls, this is a major no-no. Leaving the accumulation of dirt, oil and makeup
on your face for more than 24 hours is just begging for acne. Use makeup
remover, wash with a mild facial cleanser, tone and moisturize.
2) Never ever leave the house without applying sunscreen.
Sun is the number one skin aging culprit. Worse still, harmful UV rays can
lead to more serious skin diseases like skin cancer.
3) Never forgo water for soda.
Drink 8 glasses (approximately 2 liters) of water per day to flush out toxins
and re-hydrate the skin.
4) Do not forego regular beauty sleep.
I know we can’t all get 8 hours a night, but 8 hours most nights of the week
will allow your body the time it needs to recuperate. You will awake refreshed
and glowing.
5) Do not allow stress to consume your life.
Sure, we all get stressed out once in a while, but a life wrought with stress is
a face wrought with wrinkles.
6) Do not sacrifice beautiful skin for junk food.
I have no doubts when I say that junk food is responsible for increasing obesity
among adolescents; it surely affects their skin also. So nix the potato chips
and French fries for some yogurt, granola and fruit. You don’t have to cut junk
food totally out of your life, just enjoy in moderation. 25
7) Do not pick and pop pimples.
Popping and picking at pimples can result in acne scarring that will stay with
you for the rest of your life.
2
8) Try not to use the same soap on your face that you use to wash your body and
hands. Shower washes, body washes and hand soaps are too harsh for your
0
face and continual use will lead to dry, flaky skin.
0
9) You shall not refrain from moisturizing just because you are a male.
That’s right men - listen up! Your skin collects oil, dirt and dries out just like
9
the rest of us. So test out your mom’s, wife’s, girlfriend’s or sister’s brand of
facial cleanser and moisturizer to see if you like it…we won’t tell.
10) Do not use heavy foundations if you’re prone to acne.
Most teenage girls cake on the foundation in the hopes that they’re covering
acne and blemishes. When in reality pancake powder and heavy foundations
just block pores and create more acne. If you have acne-prone skin, choose
a light foundation and wash your applicator sponge or brush after every
foundation application.
PAINFUL PERIODS (DYSMENORRHOEA)
Dr. RAMANI SAMUDRALA, DGO, MRCOG

Painful periods are common in teenagers and young adults. Periods tend to
become less painful as you get older. An anti-inflammatory painkiller often eases the
pain. In most cases, the cause of the pain during periods is not clear. In some cases,
usually in women in their 30’s or 40’s, a disease of the uterus (womb) causes the
pain.
Who gets painful periods?
Most women have some pain during periods. The pain is often mild, but in
about 1 in 10 women the pain is severe enough to affect day-to-day activities.
• Primary dysmenorrhoea is the common type of painful periods. This is

where there is no disease of the uterus (womb). It often occurs in teenagers
and women in their 20’s.
28
• Secondary dysmenorrhoea means that the pain is caused by a disease of
the uterus. This is less common, and is more likely to occur in women in
their 30’s and 40’s.
2
Primary dysmenorrhoea - the common type of painful periods

0
What causes the pain of primary dysmenorrhoea?

0
The cause is not clear. The uterus is normal and there is no disease of the uterus.
9
What is thought to happen is that normal body chemicals called prostaglandins build
up in the lining of the uterus. Prostaglandins help the uterus to squeeze (contract) and
shed the lining of the uterus during a period. In women with period pain there seems
to be a build up of too much prostaglandins, or the uterus may be extra sensitive to
the prostaglandins. This may cause the uterus to contract too hard, which reduces the
blood supply to the uterus. This can lead to pain.
What are the symptoms of primary dysmenorrhoea?
The main symptom is crampy pain in your lower abdomen. The pain:
• May spread to your lower back, or to the top of your legs.
• Usually starts as the bleeding starts, but it may start up to a day before.
• Usually lasts 12-24 hours, but lasts 2-3 days in some cases.
• Can vary in each period. Some periods are worse than others.
• Tends to become less severe as you get older or after having a baby.
In some women, other symptoms occur during a period in addition to pain. For
example: headaches, tiredness, fainting attacks , breast tenderness, feeling sick, and
diarrhoea.
What are the treatment options for primary dysmenorrhoea?
• Warmth. You may find it soothing to hold a hot water bottle against your
lower abdomen, or to have a hot bath. The pain often does not last long,
and this may be all that you need. (Be careful not to burn yourself with a
hot water bottle which is too hot.)
• Paracetamol usually helps if the pain is mild.
• Anti-inflammatory painkillers greatly ease the pain in about 8 in 10 cases.
Also, anti-inflammatory drugs usually reduce the amount of bleeding. 29
• The combined oral contraceptive pill (‘the pill’) is an option if you need
contraception also. Painful or heavy periods are much less likely if you
take ‘the pill’.
2
• A special intra-uterine contraceptive device called the Mirena IUS (intra-
0
uterine system) is an option if you also need long-term contraception. This
device slowly releases a progestogen hormone called levonorgestrel. This
0
‘thins’ the lining of the uterus. It is a good contraceptive, and also reduces
the amount of pain and bleeding during periods.
9
• A TENS (transcutaneous electrical nerve stimulation) machine is an option
for women who prefer not to use medication.
Secondary dysmenorrhoea - period pain due to an underlying cause
A disease of the uterus (womb) sometimes causes painful periods. For example:
endometriosis, fibroids, or infection of the uterus (pelvic infection). Symptoms tend
to start several years after your periods first began. The following may indicate an
underlying cause.
• If you have a change in your usual pattern of pain. For example, if your
periods become more painful than they used to be, or the pain lasts longer
than it used to. In some women with secondary dysmenorrhoea the pain
starts several days before the period begins, and lasts all the way through
the period. (This is uncommon with primary dysmenorrhoea.)
• If you have other symptoms, for eg, irregular periods, bleeding in between
periods, pains between periods, the bleeding becomes more heavy than
previously, vaginal discharge, or pain during sex. The treatment of secondary
dysmenorrhoea depends on the underlying cause.
Some types of intrauterine contraceptive device (IUD) make painful

periods worse in some women. The treatment for primary dysmenorrhoea
(described above) often help these women. However, some women prefer
to have their IUD removed if symptoms do not improve.
30
2
0
0
9
VAGINAL DISCHARGE
Dr. PREETI SETHI, MD

Definition: Vaginal discharge is one of the most common complaint in women

of all ages.
Normal vagina: Basic function of the vagina is to provide a route from the outside
of the body to the uterus (the womb) and rest of the internal reproductive system.
Normal acidic pH of the vagina acts to prevent infections and is maintained by the
good bacteria/germs naturally present in the vagina. This balance can be disrupted by
a number of factors interfering this natural environment of vagina.
Common questions or doubts expressed by females experiencing vaginal

discharge.
Q 1. What is normal vaginal discharge?
It is important to understand that all women experience some amount of vaginal 33

discharge a year or so before they start having their periods. A normal vaginal discharge
does not have a foul smell and usually has no colour. It often appears clear or milky
when it dries up on the clothing.
2
It is actually a fluid called mucus produced by the cervix (the lowest part of the
0
uterus ending in the vagina). This fluid is your body’s way of cleansing itself by getting
rid of dead cells, etc continually released by the uterus. You also produce vaginal
0
discharge when you are sexually excited. This is produced by tiny structures called
glands present on the walls of the vagina. This discharge acts as a lubricant to make
9
intercourse easier and also facilitates normal conception by helping sperms swim up
the vagina into the womb to meet an egg.
Certain things may cause changes in the appearance or consistency (thickness)

of your vaginal discharge.
• Your menstrual cycle

• Emotional stress
• Pregnancy
• Certain medications, including hormonal or birth control pills
• Sexual excitement
• Breast feeding
• Ovulation: production of eggs by the ovary around mid-cycle.
• Diet
• Use of vaginal douches, feminine hygiene products, perfumed or deodorant
soaps, antibiotics, pregnancy, diabetes, or presence of infections.
Q 2. What is the effect of menstrual cycles on the type of vaginal

discharge?
You are more likely to experience vaginal infections just before or during your
normal periods as the acidic environment inside the vagina which acts as a safeguard
against infections is altered toward being less acidic.
Halfway between your periods i.e. around the mid-cycle (10 days before or after
the normal menstrual bleeding), there is an increase in the vaginal discharge which
is clear, is is an indication of ovulation (laying/releasing of eggs by the ovaries). The
34 purpose of this increase in vaginal discharge is to facilitate conception if intercourse
takes place during this period.
Q 3. What is abnormal vaginal discharge?

2
Some changes that may indicate that the vaginal discharge is abnormal are as
0
follows:
0
• When you notice a change in color, consistency, or amount of the

discharge
9
• Presence of itching, burning, discomfort or any rash on the private parts

• Vaginal burning while passing urine
• Presence of blood in the vaginal discharge when it is not the expected time
of your periods
• Vaginal discharge which is thick like cottage cheese (indicates infection)
• Vaginal discharge which is yellowish, greenish, or grayish and having foul
smells
Q 4. When should I consult my doctor about my complaint of the vaginal
discharge?
You should see you doctor about your discharge being abnormal if it is
accompanied by any of the following complaints
• Anytime you detect foul odor and the discharge is yellow, green or grey
and you are also having fever at the same time.
• If you experience severe or continuous pain for more than 2 hours
accompanied by the vaginal discharge
• If vaginal/private parts appear too red, warm, sore or you notice many
draining points and fever is present
• Vaginal discharge noticed anytime during the pregnancy
• Pain during or immediately after sexual intercourse
• You experience vaginal rash or have a painful rash
Q 5. What is abnormal vaginal discharge and what are the common causes of
abnormal vaginal discharge?
Your vaginal discharge is abnormal when there is increase in its amount,

consistency, colour, smell and if it is associated with itching, or other complaints 35
mentioned above.
The most common cause of an abnormal vaginal discharge is the infection of
the vagina by germs such as bacteria, fungus or protozoa. Vaginitis is the medical
2
term used to denote inflammation (soreness) of the vagina, and it is characterized
by an increase in the quantity of the vaginal discharge, change in its consistency,
0
odor and may be accompanied by irritation, itching, discomfort or frank pain.
The most common infectious causes of abnormal vaginal discharge are bacterial
0
vaginosis, trichomoniasis, vaginal candidiasis (fungus/yeast infection). Some of these
conditions are transmitted sexually through intercourse with a person having these
9
infections while others such as candidiasis occur commonly following alteration in
the pH of the vagina, or lowering of immunity as in diabetes and during pregnancy,
or prolonged intake of oral antibiotics for other infections.
Bacterial vaginosis:
• is caused by an organism called Gardenerella vaginalis
• Is characterized by watery discharge with bad odor
Trichomoniasis:
• is caused by a protozoan organism called Trichomonas vaginalis.
• Is characterized by greenish-grey frothy discharge with very foul smell
• Genital itching is commonly complained by the patient
Candidiasis
• is caused by the fungus (yeast) Candida albicans, which is normally also
present in the vagina but causes infection and abnormal vaginal discharge
when conditions favouring or promoting overgrowth of this organism are
present in the body.
• It produces thick white curd-like vaginal discharge with itching.
• The vagina appears beefy red
Other common causes are allergic or irritation reactions to the toiletries or other
products used for the private parts.
Q 6. I commonly hear or read about a term called leucorrhea. What exactly

is leucorrhea?
Leucos (white) rrhea (discharge) is a medical term for a certain type of vaginal
36 discharge that is very common during pregnancy as well as during other time during
your reproductive years. It can vary with a woman’s menstrual cycle as the hormonal
levels change through out the cycle. It may or may not indicate the presence of
infection and is usually not accompanied by other signs of inflammation such as
2
itching, pain, burning, redness or discomfort.

0
Q 7. What can or should I do to reduce the risk of vaginal discharge?

0
Practicing these tips can significantly decrease your risks of getting vaginal
infections.
9
1) Always use cotton undergarments which are less allergic or irritant.

2) Do not use vaginal douches.
3) Never use petroleum jelly (Vaseline), or oils for lubricating the vagina as it
can create a breeding ground for germs to grow and cause infection
4) Don’t have sexual intercourse before completing treatment for any genital
infection in yourself or your partner.
5) Avoid vaginal contact with products that can irritate the lining of the vaginal
wall such as perfumes, perfumed soaps, medicated soaps such as dettol,
antiseptic lotions, powder or bubble baths.
6) Avoid prolonged wearing of tight fitting clothes like bathing/swim suits, or
slacks.
7) Use all medications upon prescription of a qualified doctor and as directed.
Always complete the full course of the treatment and do not stop treatment
earlier just because you think that the discharge has reduced or become
normal or you are feeling better.
8) Avoid scratching as much as possible as it will worsen the already present
infection or inflammation.
9) Avoid self treatment or treatments suggested by non-gynecologists/doctors,
and seek proper vaginal examination and treatment by a qualified doctor if
the complaint persists despite your self treatment.
10) Continue the medications prescribed such as vaginal creams or suppositories
prescribed by the doctor for your vaginal discharge even during your menses.
Don’t interrupt these when the menses start.
11) Avoid use of tampons, use pads instead.
12) Always use condoms for intercourse especially if either you or your partner is
not having a monogamous (single partner) relationship.
37
13) Always wipe the private parts from the front to the back after passing urine
or stool to avoid spreading of bacteria from the stool passing area to the
vagina.
2
14) Good hygiene, adequate sleep and physical rest, well balanced nutritious
diet and fluid intake are good for your general health and well being as well
0
as your vaginal health.
0
Suggested readings/some informative sites
9
1. National Institute of health
2. National Institute of Allergy and Infectious Diseases
3. Medline Plus
4. Merrian-Webster Online Medical dictionary
5. Loyola University Health System Pregnancy Glossary
CONTRACEPTION
While most accidents are caused by humans
most humans are caused by accidents ! !

SPECIALIST, DEPT OF OBSTETRICS & GYNECOLOGY, AL-JAHRA HOSPITAL, KUWAIT
Contraception or ‘birth control’ is a method of preventing pregnancy by using

hormone medications, birth control devices or agents.
The reproductive lifespan of a woman is between the ages of 15-44years,

although we know that there are exceptions with menstruation starting earlier in
some and some women get pregnant beyond 44 years. Hence, if one really wants to
avoid pregnancy, the use of contraception is recommended until the menopause.
How does contraception work?

Contraceptives act either by preventing the
occurrence of ovulation, reducing the life span of egg and
sperm, blocking the sperm from meeting the egg or by
40 making conditions in the body unsuitable for implantation
( attachment of the fertilized egg to the lining of the womb)
to occur.
2
Types of contraceptives
0
There are a lot of contraceptive methods available. Let us look into each group
briefly.
0

1. Combination contraceptives contain a combination of estrogen and
9
progesterone. They are available as

a) Combined pills (commonly called as Pills), each packet with 21 or 24 or 28
pills
b) Patches (Ortho Evra patch), to be applied weekly for 3 weeks and the fourth
week is patch free. Menstrual bleeding is expected during this patch free
week.
c) Monthly Vaginal ring (Nuva ring). It is inserted and left in the vagina for 3
weeks and then removed for one week after which a new ring is applied.
d) Monthly injection (Lunelle)
Some advantages Some disadvantages
1.Effective method not related to 1. Cannot be used in women with history
coitus of breast cancer, clot in the legs, lungs &
brain, medical disorders like migraine,
high blood pressure, heart attacks, severe
diabetes and smokers over the age of 35
years.
2.Helps ease painful and heavy 2. Small risk of clot formation in leg or
periods and regularises menstrual lungs
cycles
3.50% reduction in the risk of ovarian 3.Minute increase in the risk of cancer
and womb cancer and this protective cervix and breast which disappears in 10 41
effect continues for 15 years after years after stopping the pills
stopping the contraceptives. There is
12% overall decrease in the risk of
2
developing cancer.
0
2. Progestin only methods contain only progesterone and are available as
0
a) Pills (commonly called as mini pill)
b) Injections ( Depo Provera & NET-EN) taken every 8-12 weeks.
9
c) Implants –Small 1or 2 rod like devices placed under the skin. Insertion involves
a minor operation of 10 minutes duration under local anesthesia. Types-1)
Implanon effective for 3 years, 2) Jadelle for 18 months & 3) Uniplant for
1year.
d)Intrauterine device (IUD)
These methods are commonly used by women who cannot use combination
contraceptives mentioned above. For e.g. Breast feeding women, smokers over the
age of 35, women with history of clots in the legs, etc
Intrauterine devises (IUD) are the most commonly used reversible method of
contraception worldwide. There are two types—1.Copper containing device (Nova T,
Multiload, Paragard) -- Effective for 3-10 years depending on the amount of copper
contained in it.
2. Progesterone containing device (Mirena) effective for 5 years. It combines the

advantages of progesterone contraceptive and intra uterine device.
Both methods are very effective with little demand for time & effort from
the user. Women with copper IUD may experience heavier period. Women with
Mirena may experience irregular bleeding in the first 3-6 months. The IUDs may get
spontaneously expelled especially in the first year of use. Very rarely the womb can
be injured when IUD is being put inside.
42
Barrier methods these include male condoms, female condoms, diaphragms,
cervical caps and spermicides.
2
Natural methods—Natural signs and symptoms of fertile and infertile phases

of menstrual cycle, life span of sperm(6 days) and egg (1 day ), and duration of
0
menstrual cycle are utilised to calculate fertile period when conception is possible.
The couple need to abstain from intercourse during this fertile window.
0
Sterilization- 1.Female (Tubectomy or tubal ligation). Involves operation to

9
block both the fallopian tubes either by laparoscopy or through a small incision of
1-2 inches on the abdomen.
2. Male (Vasectomy)
Emergency contraception – It is to be used when one has had sex without using
contraception or is worried that the method used might have failed. There are two
methods
1. The emergency Progestogen pill (Plan B)—Must be taken within 72 hours

after sex. It is more effective the earlier it is taken after sex.
2. Copper IUD-Must be fitted within 5 days after sex, or within 5 days after the
earliest time of ovulation.
Breast feeding -- It is an effective natural method of contraception. If the mother

is fully or nearly fully breast feeding her child and her periods have not yet returned,
she has less then 2% chance of getting pregnant in the first 6 months after child
birth.
Choosing a method of contraception

43
Choosing a method of contraception involves a balance between its effectiveness,
possible risks and side effects, plans for future pregnancies and personal preference.
2
• Always consult your doctor before starting a contraception.
• All contraceptives are relatively safe. Definitely safer than pregnancy and
0
child birth.
• Minor side effects with contraceptives tend to settle down after first few
0
months.
• Pills are ideal for disciplined women. Ideally the pills need to be taken at
9
the same time each day. A Progesterone only pill taken 3 hours late should
be considered as missed pill. The combined pill taken 12 hours late is
considered as missed pill.
• Pills are not linked to birth defects if taken accidently through early
pregnancy.
• Remember there is 12% overall decrease in the risk of developing cancer
with combined estrogen and progesterone methods of contraception
• Progesterone only contraceptives can be used during breastfeeding.
• Implants and intrauterine devices provide “insert it forget it” contraceptive
efficacy for years.
• The so called permanent methods of contraception i.e. female and male
sterilisation need operation and also have failure rates. Implants & Mirena
the progesterone containing IUD have more efficacy than these permanent
methods (see table 1) and are easily reversible.
• Mirena combines the advantages of both copper IUD and progesterone
contraceptive. It is a fantastic device to treat heavy periods.
• The male and female condoms which are designed to prevent the greatest
amount of skin to skin contact offer the best protection against sexually
transmitted diseases. Diaphragm and cervical cap only provide partial

protection.
• Natural family planning methods suit women who are in the later part of the
reproductive life. These methods demand commitment and self control.
Are contraceptives safe?
All contraceptives are relatively safe. To put it in perspective, risk of death during
one year related to, birth control pills in a nonsmoking woman under 35 years of age
44 is 1 in 200,000, attributable to the use of an IUD is 1 in 10 million, laparoscopic
tubal sterilisation is 1 in 38,500 and due to pregnancy beyond 20 weeks is 1 in
10,000. The risk of death during one year from driving a car is worse at 1 in 5,900.
2
Thus clearly all contraceptives are definitely safer than unintended pregnancy
and child birth.
0
0
How effective are contraceptives?

9
Table 1 shows how effective contraceptives are. It shows for every 100 women
who use a particular method how many get pregnant within the first year of use with
‘typical use’ and ‘perfect use’.
Typical use means that the method was not always used correctly or was not
used with every act of sexual intercourse (e.g., sometimes forgot to take the pill).
Perfect use means that the method was always used correctly and consistently
with every act of sexual intercourse but the method still failed.
Table1
Method % of women experiencing

pregnancy within the first year of use
Typical use Perfect use
No method 85 85
Spermicides 29 18
Fertility awareness method 25
Diaphragm 16 6
Condom, female 21 5
Condom, male 15 2
All Combined Contraceptives & mini pill 8 0.3
Depo-Provera 3 0.3
Implanon 0.05 0.05
Cu- T IUD 0.8 0.6
Mirena Intra uterine system 0.2 0.2
45
Female sterilisation 0.5 0.5
Male sterilisation 0.15 0.10
2
The only 100% effective and risk free contraceptive method is Abstinence i.e.,
not having sex!!
0
Choose contraception under doctor’s guidance and have secure marital life.
0
9
CHRONIC PELVIC PAIN
Dr. ANNIE ROY CHERIAN

(DGO, MD, DNB, MRCOG) FARWANIA HOSPITAL, KUWAIT
What is chronic(long term) pelvic pain?
Pelvic pain is any pain in the lower abdomen or pelvis,which is the area below
your belly button and above your hips.Long term pelvic pain is pain that persists
for atleast six months.The pain may be steady ,or it may come and go.It may be a
constant dull ache or sharp at times. It happens at times other than when you have
your period or sexual intercourse.The pain may be bad enough to interfere with your
daily activities.
It affects approximately one in six women.Long term pelvic pain is not a diagnosis
in itself but a description of a symptom.
What causes long term pelvic pain?
48 Long term pelvic pain is often caused by a combination of physical,psychological

and /or social factors,rather than a single condition.
Possible causes include,

2
Endometriosis: Here the tissue lining the womb is found elsewhere in the pelvis.
0
When you have periods ,this tissue swells and bleeds just like the lining of your
womb.This is often painful and scar tissue can form in your pelvic area.
0
Adenomyosis: A condition where the endometrium(tissue lining the womb) is in

9
pockets within muscle wall of the womb.
Pelvic Inflammatory Disease(PID):It is an infection of the womb ,fallopian tubes

or ovaries.
Interstitial Cystitis:Bladder inflammation.
Musculoskeletal pain:Pain in your joints,muscles,ligaments or bones.
Irritable Bowel Syndrome

Depression
Adhesions:Areas of scar tissue that may be the result of a previous

infection,endometriosis or surgery.
Traumatic experiences such as sexual abuse
Trapped or damaged nerves in the pelvic area.
What happens when I first see the doctor?
At your first appointment you should have the chance to tell your story,describe
the pain you experienced and discuss your anxieties.By working in partnership with
you, he or she will aim to identify the causes of your pain.You may be asked to
describe the kind of pain you have,where it is and how strong it is,aspects of your
everyday life including your sleep patterns,appetite and general well-being.Your
doctor will probably ask you questions like;
- Is the pain related to periods?

49
- Is it related to bowel movements?
- Does it hurt during urination or sexual activity?
- Have you had an infection?
2
- Have you had surgery in your pelvic area?
0
What types of tests might be offered?
0
Your own history and the way you describe the pattern of your pain can provide
valuable clues to diagnosis.For this reason you may be asked to keep a pain diary.
9
This involves noting when your pain occurs,how severe it is,how long it lasts and the
things that seem to affect it.
You may be offered any of the following types of tests:
- You will probably be offered a pelvic scan.

- You may be offered screening tests for sexually transmitted infections.
- If your pain is related to bladder or bowel symptoms you may be referred
to a specialist.
-You may be offered a diagnostic laparoscopy.
Diagnostic laparoscopy is a surgical procedure done as a day case surgery.Most

women are given anaesthetic to induce sleep and prevent pain. A thin telescope with a
camera is introduced through an incision just below the belly button.Through the telescope
the surgeon visualises the reproductive organs clearly.As with any surgical procedure there
are risks and benefits and these will be explained fully to you when you are offered the
test.
-If your pain occurs on a regular basis at a specific time of your menstrual cycle,then
you may be offered drugs to suppress your periods for a few months.This may help your
doctor to make a diagnosis.
How is chronic pelvic pain treated?
Treatment depends on your individual problem.Your doctor will help you determine
which form of treatment is right for you.You should be offered treatment and advice if;
-your pain is related to the menstrual cycle and you have heavy periods.
-you may have symptoms and signs suggestive of sexually transmitted infection
50
or PID.
-you have symptoms suggestive of irritable bowel syndrome.
-your pain varies with movement.
2
Some treatment options include,

0
- Stopping ovulation with birth control pills (especially if the pain is related
0
to periods)
9
- Use of pain killers.

- Relaxation exercises,biofeedback(treatment to control emotional states using
electronic devices)
- Antibiotics like doxycycline to treat infections.
- Medications like GnRh analogues used to treat endometriosis.
- Surgical treatment is usually reserved for intractable and debilitating pelvic
pain.
If the standard treatments do not help to control your pain you may be referred to a
pain management team or a specialist pelvic pain clinic.
Your doctor will provide you with full information of all treatment options.
Are there any risks?
Your doctor should give you detailed information about the risks and benefits of
any investigation,surgical procedure and treatment suggested.
What does long term pelvic pain mean for me?
How each woman perceives pain is an individual matter and depends on many
factors.Long term pain may be difficult to live with ,causing emotional ,social and
even economic problems.You may fear that people do not understand the full extent
of your misery and dismiss it as ‘all in the mind’.
The reasons for long term pelvic pain are not always easy to diagnose. It is not
always possible to treat.Women may need support in coping with their pain.
Even if no reason can be found for the pain ,many women may find that
the quality of their lives improve when they get a better understanding of what is 51
involved.
Is there anything else that I should know?
2
You should visit your doctor if you experience any of the following;
0
- bleeding from the rectum.
0
- a change in your bowel habits which lasted more than 6 weeks
- new pain after menopause.
9
- any unusual swelling in your tummy.
- suicidal thoughts.
- excessive weight loss.
- irregular vaginal bleeding.
INFERTILITY- an issue of the unknown
Dr. CHRISTINA JAMES

KOC HOSPITAL, KUWAIT
Trying to get pregnant and haven’t been successful, when should you think
about seeing your doctor , to rule out a problem with fertility.
Most women wait a year before going to see the doctor , because infertility
is defined as the inability to conceive a pregnancy after 12 months of unprotected
sexual intercourse. But if you are older than 35 years, have irregular periods or any
medical problems that could make it difficult for you to get pregnant , you should go
sooner .
To achieve a successful pregnancy several prerequisites are required ,good

quality eggs and sperm , an open fallopian tube and a receptive lining of the womb.
Finally for the pregnancy to continue full term, the embryo must be healthy and
woman’s hormonal environment adequate for its development. When just one of
these factors is impaired infertility can result.
54
The chance of getting pregnant in one month is 25 % at the age of 25 and
decreases with increasing female age, particularly after the age of 35.
2
What causes infertility?

0
One third of the infertility cases can be attributed to male factors and about one
third to factors that affect women. For the remaining one third it is a combination
0
of factors in both partners. In 20 % of cases it is unexplained infertility, where both

partners are apparently normal.
9
The most common male infertility factors include azoospermia (no sperms are
produced) and oligospermia (only few sperms are produced). Sperms with abnormal
motility or morphology can also contribute towards male infertility.
The most common female infertility factor is anovulation disorder ( eg. Polycystic
ovarian disease- PCOD) Being overweight or extremely under weight can be a cause
of anovulation ( BMI > 25 or < 19). Other causes of female infertility include blocked
fallopian tubes, which can occur when a women has had pelvic inflammatory disease
or endometriosis (Painful condition causing adhesions or cysts).
How is fertility diagnosed?
Initially your doctor will take your medical and sexual history followed by a
physical examination on both partners to determine the general state of health and to
exclude physical disorders .History of tuberculosis have to be ruled out . If no cause
can be determined at this point, more specific tests may be recommended.
For men initial tests focus on semen analysis, which is conducted after an
abstinence period of 3 days at least. Normal total count is at least 20 million with a
motility of 50% and 80% of sperms with normal morphology. (WHO – criteria)
For women tests of ovulation followed by fallopian tube testing is the next
step.
Tests of ovulation include
Basal body temperature check- your body temperature rises after ovulation.
Measuring hormone progesterone – on Day 21 of the cycle, which rises after
ovulation.
Growth of a follicle in the ovary can be measured by an ultrasound which can 55
predict the time of ovulation.
Fallopian tube testing
2
After you ovulate an egg travels from the ovary to the uterus through one of
0
the fallopian tubes. For the eggs to make the trip, the tubes need to be clear of any
blockages. To make sure that one or both tubes are not blocked, your doctor can
0
perform one of the two different procedures.
9
Hysterosalpingogram (HSG)
During this Xray procedure ,a radio opaque liquid is injected through the mouth
of the uterus, so that it flows into the uterus .If the dye comes out through one or both
of your tubes into the abdominal cavity, then it is determined that the tubes are open.
If the dye does not enter or flow completely through the tubes then the affected tube
is considered blocked.
Laparoscopy is a minimally invasive procedure where a laparoscope is introduced

into the abdominal cavity under anesthesia below your belly button. The surgeon
directly visualizes the intrabdominal structures such as the uterus, ovaries, fallopian
tubes, adhesions or endometriosis which could cause infertility. Tubal patency is
checked by injecting dye into the uterus and following the spill through the tubes.
Hormone testing
Too much or not enough of important chemicals called hormones can cause
ovulation problems. Some of the hormones include -Day 2 FSH, LH prolactin and
thyroid hormones.
Congenital malformations (birth defects), fibroids and polyps are rare causes of
infertility.
How is infertility treated?
85% to 90 % are treated with conventional therapies, such as drug treatment or

surgical repair of reproductive organs.
Treatment include
Ovulation induction – medications (oral or by injection) - Clomiphene Citrate,
56 Letrazol HMG and pure FSH are used to stimulate egg production and often used with
timed intercourse or insemination. Weight loss of 5-10% may dramatically improve
ovulation and pregnancy rates.
2
Intrauterine Insemination: with this technique prepared sperm is inserted into

the female’s uterus at the most fertile time. This technique uses the male partner’s
0
sperm or if required donor sperms.

0
Fertility surgery - This includes the treatment of endometriosis, tubal microsurgery,

the removal of fibroids and the correction of uterine anomalies and laparoscopic
9
drilling for PCO.
Assisted Reproductive Technology

In Vitro Fertilization - IVF
Gamete Intra Fallopian Tube Transfer - GIFT
Zygote Intra Fallopian Tube Transfer - ZIFT
Intra Cytoplasmic Sperm Injection - ICSI
Indications for ART 57
Failed ovulation induction treatment in anovulation
Failed drug therapy in unexplained infertility / endometriosis
Fallopian tubal block
2
Moderate to severe male factor
0
IVF - generally start with stimulating
the ovaries with drugs to increase egg
0
production, the eggs are collected from
the ovaries using ultrasound guided
9
transvaginal needle aspiration. These eggs
are placed in a dish with a large number of
sperms allowing fertilization to occur and
some of these eggs go on to form embryo.
These embryos are transferred back into the
uterus using a small plastic tube and some
can be frozen and stored for later use.
ICSI – this is a different more complicated form of IVF where the scientist injects
a single sperm into the egg under a microscope.Embryos formed are transferred into
the uterus.
Preimplantation Genetic Diagnosis – (PGD) in this procedure a cell from the

embryo can be tested for chromosomal and genetic abnormalities prior to placement
into the uterus.
Cryopreservation – Freezing of embryos and sperm are possible for patients with
excessive embryos or for those men about to have cancer treatment or a vasectomy.
Egg freezing is technically less successful. Frozen embryos can be used after any
number of years for the next pregnancy.
Egg, Sperm and Embryo Donation: These options are available in certain IVF
centres in the West and in India.
Is IVF expensive?
The average cost of IVF cycle in the United States is 12,400 $.In India it is around
1.2 -2 lacs per cycle. IVF involves highly trained professionals with sophisticated
laboratory equipment and the cycle may need to be repeated to be successful.
58
Does IVF work?
Yes, success rates vary and depend on many factors especially age of the female
2
partner and the cause of infertility. However the experience of the IVF centre with
excellent laboratory facilities where good embryos are generated is also a key factor.
0
Success rates range from 30-35% per retrieval. Take home baby rates can be lower.
0
Does IVF have risks or complications?

9
As with any form of treatment, certain complications are associated with

infertility treatment.
Multiple pregnancies are the most common complication of ART treatment.
In ovarian hyper stimulation syndrome, a

woman’s ovaries may enlarge and have pain and bloating. Mild to moderate
symptoms often resolve without treatment. Severe form of OHSS may require
hospitalization, close monitoring and treatment.
Low birth weights and increased rate of miscarriages are associated with IVF
treatment.
Birth defects: There is some concern about the possible relationship between
ART and birth defects. However more research is necessary to confirm this possible
connection.
Counseling
Coping with infertility can be difficult as it is an issue of the unknown. You can’t
predict how long it will last or what the outcome will be. Infertility causes enormous
psychological pressure on the couple.Those undergoing IVF cycle face considerable
stress. They must seek professional counselors. Counseling is a part of treatment for
infertile couples in many IVF centers.
Take home message
Seek medical assistance after 1 year of infertility.

If age more than 35 years, seek help earlier.
Success rate of all forms of infertility
treatment declines after the age of 35. 59
Infertility investigation to be directed at the
couple not the female partner alone.
ART - IVF is the treatment of choice for
2
tubal block
ART - ICSI for severe male factor infertility.
0
ART is expensive and may require multiple
attempts for success.
0
Success rate of IVF –also depends on the
experience of the IVF centre.
The desire to have children and be a parent 9

is one of the most fundamental aspects of being
a human. Infertility at times can be a monster,
therefore seek help early at an appropriate
infertility centre.
HORMONE REPLACEMENT THERAPY
Dr. GANGA DEVI M.D, DNB, MRCOG

CONSULTANT, ALORF HOSPITAL, JAHRA, KUWAIT
INTRODUCTION
Hormone Replacement Therapy (HRT) is a system of medical treatment for

surgically menopausal, perimenopausal and to a lesser extent postmenopausal
women, based on the assumption that the treatment may prevent discomfort caused
by diminished circulating oestrogen and progesterone hormones.
Female hormones, oestrogen and progesterone are produced mainly from the
ovaries.Oestrogen is responsible for the development and maintenance of female sex
organs and breasts. It also helps to maintain the lining of the vagina and to keep other
body tissues moist and flexible. Oestrogen is also needed to protect the bones from
osteoporosis. Progesterone is another hormone which helps to bring about menstrual
periods, prepares the womb (uterus) to receive a fertilized egg, maintain pregnancy
and also helps in the development of breast.
62
Menopause is the state of absence of menstruation for at least 6 months and
surgical menopause is due to the removal ovaries for any reason or along with
removal of uterus (hysterectomy).The average age of menopause is 51 yrs.
2
Oestrogen production from the ovaries falls at the time of menopause or following
0
removal of or damage to, the ovaries. But, fatty tissues and adrenal glands in our body
continue to make oestrogen from other hormones. As the oestrogen from the ovaries
0
fluctuates and declines during and just before menopause, the body goes through a
period of readjustment. This is manifested in the form of menopausal symptoms like
9
hot flushes, night sweats, fatigue, panic, disturbed sleep, irritability,vaginal dryness,
loss of sex drive. Seventy five percent experience these symptoms for more than one
year of menopause and 25% for more than 5 years.There is rapid bone loss for a few
years after menopause and osteoporosis (loss of bone strength) may result.
So oestrogens are used in HRT mainly to stabilize oestrogen levels and relieve
menopausal symptoms. It may be used to prevent osteoporosis.
Oestrogen on its own can cause the lining of the womb ( uterus ) to build up
in thickness and so increase the risk of cancer. Progestogens prevent this build up
by causing the lining to be lost each month in the form of bleed.So progestogens are
added to HRT to prevent cancer of uterine lining.
Sometimes testosterone (male hormone) is also added to HRT. In females

testosterone is produced by the ovaries and in women who have had their ovaries
removed may notice a loss of sex drive. So testosterone supplements may be given.
But they cause side effects like increase in body hair.
There is another drug, tibolone, which combines the properties of oestrogen,
progesterone and male sex hormone. Tibolone (Livial) can be started one year after
stoppage of periods.
USE OF HRT
HRT can be used as a short term treatment to relieve menopausal symptoms.

HRT is acknowledged as a beneficial treatment for hot flushes, night sweats and
vaginal dryness. They generally feel much better after using HRT. But the current
safety advice is to use HRT for the shortest time possible ,at the lowest effective dose
and followed up regularly by the doctor.
63
HRT is no longer recommended as the first choice of treatment for the prevention
of osteoporosis. Dietary and lifestyle measures, and non hormonal drugs are tried
first. But in women who have menopause before the age of 45, HRT can be given
2
until the age of 50 to counter menopausal symptoms and to prevent osteoporosis.
The risks of taking HRT are very less before the age of 50.
0
HOW TO TAKE HRT ?
0
HRT is not appropriate for all women.It should be taken only after consulting a
9
doctor and after doing a number of initial tests like
- breast examination including mammogram ( modified x-ray of breast tissue)

- internal pelvic examination and pelvic ultrasound
- PAP smear (a test done to detect cancer of the mouth of uterus)
- Thyroid function tests
- Blood pressure
There are many ways to take HRT and many different combinations and dosages.
Also there are different routes of taking HRT. It is available as tablets,transdermal
patches, implants, daily nasal sprays, skin cream and 3 monthly vaginal rings.
Regardless of the route of administration, women who have not undergone
hysterectomy (removal of uterus)should take a progestogen to reduce the risk of
endometrial (lining of uterus) cancer.
Tablets
* Cyclical combined preparation - Here progestogen is taken with the oestrogen
on a cyclical basis ( for 10-14 days of each oestrogen treatment cycle).So most women
will have a monthly bleed like period. Women who are still having periods but are
experiencing menopausal symptoms are prescribed cyclical HRT.
* Bleed free HRT – Here oestrogen and progestogen are combined in a continuous
dose and there is no monthly bleed. They are an option from more than 1-2 years
after the last menstrual period. But any erratic bleeding after 6-12 months of therapy
needs further investigation.
*Another option is to take oestrogen continuously for 3 months and then take
progestogen for 14 days. This creates a withdrawal bleed every three months.
64 Disadvantage
- should remember to take the tablets correctly.

- higher dosage must be taken to compensate for the loss as the drug pass
2
through the digestive system.So side effects like nausea ,gallstones and liver
damage are more.
0
0
MIRENA
9
This is an intrauterine system (a type of IUD) which contains a small amount of

progestogen that thins the womb lining.It is a contraceptive which is also used for
the relief of heavy bleeding.It can provide another way of getting the progestogen
part of HRT.
PATCHES
These are small plasters which are applied to the skin. They are available as
single patches which contain oestrogen alone and double patch which has both
oestrogen and progestogen.The patch has to be changed once or twice weekly and
a new one applied to clean, dry, hairless skin (buttocks, abdomen).patches have less
side effects as dose is less but can cause skin irritation, swelling and blisters.
IMPLANTS
These are small pellets containing oestrogen which are inserted under skin.They
usually contain a 6 month supply of hormone and are inserted into the fatty layers
of abdomen,buttocks or thighs under a localanesthetic.Implants can result in higher
oestrogen levels than patches or tablets and if due to side effects removal is needed,
locating it may be difficult and removal painful.
NASAL SPRAY
It does not provide a constant dose of oestrogen, but is effective and easy to
use.
CREAMS
Oestrogen cream is put directly into the vagina in a measured dose with an
applicator.It has a local effect and also absorbed into blood stream. If they are used 65
longer than 3-6 months, women who have not had hysterectomy ,should use a
progestogen.The effect of cream will take some days to appear.
2
GEL
0
Oestrogen in gel form can be spread over the skin daily and acts in the same
way as the patch.Here, skin irritation is less but unlike patch it has to be applied
0
daily.
9
VAGINAL RINGS
Ring containing oestrogen is inserted into vagina and should be changed every
3 months.It does not interfere with sex.It treats hot flushes and local dryness.
STOPPING HRT
HRT should be stopped gradually to avoid recurrence of menopausal symptoms,

especially hot flushes. For instance, dose can be reduced by taking half tablet and
introducing pill free days. Stopping HRT should be done in consultation with your
doctor.
SIDE EFFECTS OF HRT
As with any medication, some women experience unpleasant side effects from
HRT. Common side effects include breast tenderness, nausea, headaches, leg cramps,
irregular bleeding, weight gain and bloating.If unwanted side effects persists after 6-8
weeks of starting HRT, altering the dosage or changing the product, eg from tablets
to patches may bring relief.
Inflammation and itching may occur with patches. But less of a problem with
the newer matrix patch.
Gallstones can enlarge with HRT tablets and it can also increase the likelihood
of women developing gall stones.
Progestogens can cause swollen feet and ankles, premenstrual tension,

breakthrough bleeding, depression and jaundice. These should be discussed with
your doctor.
Women with high blood pressure which is being monitored and treated should
66 be able to take HRT.
Fibroids ( non cancerous growth in the uterus) sometimes shrink after menopause
but oestrogen therapy may cause them to enlarge. So they should be monitored with
regular ultrasound scans.
2
Circulatory diseases - oestrogen can affect liver dependant blood clotting

factors and platelets, so can aggravate existing disease.
0
Endometriosis - tissues from the lining of the uterus growing elsewhere in the
pelvic area is stimulated by oestrogen. So HRT should be given with caution in such
0
people.
Heart Disease – HRT is not recommended for women who have heart disease
9
or have had a heart attack.
HRT RISKS
The committee on Safety of Medicines no longer recommends HRT as safe

to use for a long term treatment because of safety concerns. The increased risks of
taking HRT are small. Women who do not take HRT can also develop these. Any
risk assessment needs to take into account a range of factors including life style and
family history.
Breast Cancer
• In women who do not take HRT, about 32 in every 1000 women aged 50
will get breast cancer by the time they reach 65.
• In women aged 50 who take oestrogen only HRT for 5 years, about 33.5
in every 1000 will get breast cancer.
• In those taking combined HRT at the age of 50, the number of cases
diagnosed by 65 would be 38 cases in a 1000 after 5 years.
• Tibolone risks are between those for oestrogen only and combined HRT.
Cancer of Uterine Lining
Oestrogen only HRT increases the risk of endometrial cancer.
Venous Thrombolism (VTE)
Harmful clots can develop in the veins and if a part of the clot breaks off and
moves into the lungs it can cause a potential life threatening obstruction called
pulmonary embolism. For women in their 50’s who do not use HRT, about 3 in a
1000 will have VTE over 5 years compared to 7 in a 1000 women of the same age 67
who use HRT for 5 years.
STROKE
2
HRT slightly increases stroke. For women in their 50’s who do not take HRT
0
about 3 in every 1000 will have a stroke in any 5 year period compared to about 4 in
1000 of the same age who take HRT for 5 years. Stroke increases with age.
0
9
Conclusion
Despite the current safety recommendations, it is important to emphasise that

the increase in risks identified is small. Each woman needs to discuss the pros and
cons of HRT with their doctor to see if it is suitable for them. HRT can be taken for
longer duration if the benefits of HRT outweigh the risks.
ALTERNATIVES TO HRT
Drugs
Raloxifene, a synthetic selective oestrogen receptor modulator ( SERM), has
oestrogenic effects on bone but has a minimal effect on uterine and breast tissue.It is
not effective in controlling menopausal symptoms but has a role in protecting against
osteoporosis.
Preventing Osteoporosis
• regular weight bearing exercises like brisk walking, dancing etc

• maintaining weight
• eating calcium rich diet like milk, dairy products, almonds,leafy vegetables
like broccoli etc
• avoid alcohol, caffeine and smoking all of which reduce calcium.
Nutritional Approaches
68
Menopausal symptoms are relieved by taking oestrogen like substances in
plants known as phyto- oestrogens. Soya foods, linseed, mung beans all contain
phyto oestrogens and they have shown to reduce hot flushes.
2
0
0
9
OSTEOPOROSIS
Dr. JAITHA A JOHN MD., MRCOG

AL-ADAN HOSPITAL, KUWAIT
Osteoporosis, which means «porous bones», causes bones to become weak and
brittle – so brittle that even mild stresses like bending over, lifting a vacuum cleaner
or coughing can cause a fracture. It’s never too late- too early- to do something about
osteoporosis. You can take steps to keep bones strong and healthy throughout life.
73
2
0
0
In the early stages of bone loss, you usually have no pain or other symptoms.
Once weakened by osteoporosis, symptoms include: back pain, loss of height over
9
time, with an accompanying stooped posture, fracture of the vertebrae, wrists, hips
or other bones.
Risk factors:
Non-modifiable risk factors include the female gender, older age, smaller body
size, family history, Caucasian or Asian ethnicity (especially women). Modifiable
risk factors include abnormal absence of menstrual periods, low estrogen level
(menopause in women), and low testosterone level in men, a life time diet low in
calcium and or vitamin D.; inactive life style or extended bed rest; cigarette smoking;
drinking alcohol; or using steroid medications, Selective serotonin reuptake inhibitors
(SSRIs) or treatment of breast cancer using aromatase inhibitors like letrozole.
Tests and diagnosis:
Osteopenia refers to mild bone loss that increases your risk of osteoporosis.
Doctors can detect osteopenia or early signs of osteoporosis using a variety of devices
to measure bone density. The best screening test is dual energy X-ray absorptiometry
(DEXA). Other tests that can accurately measure bone density include: Ultrasound,
Quantitative CT. If you are a woman, the National Osteoporosis Foundation

recommends that you have a bone density test if you aren’t taking estrogen and any
of the following conditions apply to you: (1) you are older than age 65. (2) You’re
postmenopausal and have at least one risk factor for osteoporosis, including having
fractured a bone, (3) You have a vertebral abnormality, (4) You use medications, such
as prednisone, that can cause osteoporosis, (5) You have type I diabetes, liver disease,
kidney disease, thyroid disease or a family history of osteoporosis. (6) You experienced
early menopause. (Doctor’s don’t generally recommend osteoporosis screening for
men because the disease is less common in men than it is in women).
74 Treatment:
Hormone therapy (HT) was once the main stay of treatment for osteoporosis.
But, because of concerns about its safety and because other treatments are available,
2
the role of hormone therapy is changing.

0
Prescription medications include:

0
Biphosphonates: Side effects, which can be severe, include nausea, abdominal

pain, and the risk of an inflamed esophagus or esophageal ulcers, especially if you’ve
9
had acid reflux or ulcers in the past. Biphosphonates that can be taken once a week
or once a month may cause fewer stomach problems. In 2007, the Food and Drug
Association (FDA) approved the first once-yearly drug for postmenopausal women
with osteoporosis. The medication, zoledronic acid (Reclast) is given intravenously.
It takes about 15 minutes to get your annual dose. A small number of cases of
osteonecrosis of the jaw which primarily occurred after trauma to the jaw, such as a
tooth extraction, or cancer treatment have been reported.
Raloxifene (Evista): This medication belongs to a class of drugs called selective

estrogen receptor modulators (SERMs). Raloxifene mimics estrogen’s beneficial effects
on bone density in postmenopausal women, without some of the risks associated
with estrogen, such as increased risk of uterine cancer and, possibly breast cancer.
Hot flushes are a common side effect of raloxifene, and you should not use this
drug if you have a history of blood clots. This drug is approved only for women with
osteoporosis.
Calcitonin: A hormone produced by your thyroid gland, usually administered

as a nasal spray and causes nasal irritation in some people who use it, but it’s also
available as an injection. It is normally reserved for people who can’t take other
drugs.
Teriparatide (Forteo): Unlike other available therapies for osteoporosis, it

works by stimulating new bone growth, as opposed to preventing further bone loss.
Teriparatide is given once a day by injection under the skin on the thigh or abdomen.
FDA recommends restricting therapy to two years or less.
Tamoxifen: Possible side effects of tamoxifen include hot flushes, stomach upset,
and vaginal dryness or discharge.
Emerging Therapies: A new physical therapy program has been shown to 75

significantly reduce back pain, improve posture and reduce the risk of falls in women
with osteoporosis who also have curvature of the spine. The program combines the
use of a device called a spinal weighted kypho-orthosis (WKO)- a harness with a light
2
weight attached and specific back extension exercises.
0
Prevention: 800 IU of vitamin D also may improve muscle strength in addition
to improving bone density. Scientists are continuing to study vitamin D – which
0
may also protect against certain types of cancer, to determine the optimal daily
dose, but it’s safe to take up to 2.000 IU a day. Although many people get adequate
9
amounts of vitamin D from sunlight, this may not be a good source if you live in high
latitudes, if you’re housebound, or if you regularly use sunscreen or you avoid the
sun entirely because of the risk of skin cancer. Although vitamin D is present in oily
fish such as tuna and sardines and in egg yolks, you probably don’t eat these on a
daily basis. Calcium supplements with added vitamin D are a good alternative. As for
calcium, dairy products, almonds, broccoli, canned salmon with the bones, oats and
soy products also are rich in calcium. Sometimes, calcium supplements can cause
constipation. Calcium phosphate and calcium citrate tend to be less constipating.
Calcium and vitamin D supplements are most effective taken together in divided
doses with food.
Exercise may help you prevent bone loss. Combine strength training exercises
with weight-bearing exercises. Strength training helps strengthen muscles and bones
in your arms and upper spine, and weight- bearing exercises- such as walking,
jogging, running, stair climbing, skipping rope, skating and impact-producing sports
– mainly affect the bones in your legs, hips and lower spine.
76
These suggestions may help relieve symptoms and maintain your independence
if you have osteoporosis:
2
Maintain good posture. Good posture-which involves keeping your head held
high, chin in, shoulders back, upper back flat and lower spine arched – helps you
0
avoid stress on your spine. When you sit or drive, place a rolled towel in the small of
your back. Don’t lean over while reading or doing handwork. When lifting, bend at
0
your knees, not your waist, and lift with your legs, keeping your
upper back straight.
9
Prevent falls. Wear low-heeled shoes with nonslip soles

and check your house for electrical cords, area rugs and slippery
surfaces that might cause you to trip or fall. Keep rooms brightly
lit, install grab bars just inside and outside your shower door, and
make sure you can get in and out of your bed easily.
These recommendations if followed ensure that your family is protected against

osteoporosis.
SCREENING FOR GYNAECOLOGICAL CANCER
Dr. RAGHUNANDINI KORATKAR

LONDON HOSPITAL, KUWAIT
What is screening?
Screening is detection of any disease before a person has any symptoms.

Screening for cancer helps it in an early stage when it is treatable.
MOST COMMON GYNAECOLOGICAL CANCERS
• Cervical Cancer
• Uterine/Endometrial Cancer ( Lining of the uterus)
• Ovarian Cancer
Let us discuss about the screening tests for each type of cancer in women.
Screening for cancer of cervix

81
Worldwide, cervical cancer (neck of the womb) is the third most common type
of cancer in women.
2
The development of cervical cancer is usually very slow. It starts as a pre-
0
cancerous condition called dysplasia. This pre-cancerous condition can be detected
by a Pap smear and is 100% treatable.
0
Undetected, pre-cancerous changes can develop into cervical cancer and
9
spread to the bladder, intestines, lungs, and liver. It can take years for pre-cancerous
changes to turn into cervical cancer. Patients with cervical cancer do not usually
have problems until the cancer is advanced and has spread.
Almost all cervical cancers are caused by HPV (human papilloma virus). HPV
is a common virus that is spread through sexual intercourse. There are many different
types of HPV. However, only certain strains of HPV actually lead to cervical cancer.
(Other strains may cause genital warts.)
PEOPLE AT RISK FOR CANCER OF THE CERVIX
• Early age at first sexual intercourse
• Multiple sexual partners especially when the partners have multiple
contacts
• Weakened immune system, eg in HIV infection, leukemia.
• Infections with Genital herpes
• Poor economic status (may not be able to afford regular Pap smears)
Screening tests include

Pap smear
• It is recommended to start undergoing this

test from 25 years of age or earlier in the presence
of risk factors.
• If the test is normal, it is repeated once every
three years usually. However each country has its
its own protocol based on local logistics.
82
• Usually, it can be discontinued after 65 years
of ge.
• If an abnormal test is reported, further tests are done to decide the kind of
2
treatment needed.
0
HPV-DNA tests
0
• Detects the presence of HPV virus responsible for the cancer.

• The process of collecting the sample is similar to the Pap smear.
9
• It is especially useful when deciding on further treatment when an abnormal

smear is detected.
Colposcopy-
A microscope called colposcope is used to visualise the cervix.
The physician applies a mild vinegar solution to the cervix which makes
abnormal cells appear more white than pink. A sample of tissue can be taken from
these abnormal areas called a biopsy.
Cervical biopsy
In a cervical punch biopsy, the cervix may be stained with iodine solution in order
to see abnormalities better. These areas of tissue are then sampled and examined.
Screening for ovarian cancer
Ovarian cancer is the fifth most common cancer among women, and it causes
more deaths than any other type of female reproductive cancer. The cause is unknown
which makes early detection difficult.
People at risk of developing ovarian cancer
• Older age poses the greatest risk. About two-thirds of the deaths from
ovarian cancer occur in women age 55 and older. About 25% of ovarian
cancer deaths occur in women between 35 and 54 years of age.
• More number of children and early age of first pregnancy birth lowers risk
of ovarian cancer.
• Certain genes (BRCA1 and BRCA2) are responsible for a small number of
ovarian cancer cases. Women with a personal history of breast cancer or a
83
family history of breast or ovarian cancer have an increased risk for ovarian
cancer.
• The use of fertility drugs may be associated with an increased chance of
2
developing ovarian cancer, although this is a subject of ongoing debate.
• The links between ovarian cancer and talc use, asbestos exposure, a high-
0
fat diet, and childhood mumps infection are controversial and have not
been definitively proven.
0
Ovarian cancer dangers
Ovarian cancer is particularly dangerous 9

because its presence is difficult to detect until it
has spread beyond the ovaries.
By the time the cancer is diagnosed, the
tumor has often spread beyond the ovaries.
Tests that may detect ovarian cancer are

• Routine gynaecological examination:
It is not really very good at detecting erly
cancer.
• Transvaginal ultrasound involving insertion of ultrasound probe into
the vagina. The Ovaries can be seen as image and any cancer growth
detected.
• CA-125 is a chemical found in the blood. In certain cancers including
ovarian, the blood levels of this substance is high. It involves a simple
blood test and is especially useful to determine if a mass found in the ovary
is cancer or not.
However most methods of screening are not very good at detecting early Ovarian
Cancer.
Screening of endometrial carcinoma
Endometrial cancer involving the lining of the uterus is the most common type
of uterine cancer.
Most cases of endometrial cancer occur between the ages of 60 and 70 years,
but a few cases may occur before age 40.
84
This cancer is usually detected early since it comes with abnormal vaginal
bleeding.
People at risk of developing endometrial cancer.

2
0
• Women having diabetes and high blood pressure.

• Hormone replacement at menopause, especially if only oestrogen without
0
progesterone is used.
• Use of Tamoxifen, a drug for breast cancer treatment
9
• A condition called Polycystic Ovarian Disease which causes irregular

periods, acne, excessive hair growth and infertility.
• Older age at first pregnancy and fewer numbers of pregnancies.
• Obesity
• Starting menstruation at an early age (before age 12)
• Stopping periods, (Menopause) late, after 50 years.
• Family history of breast, ovarian and colon cancer.
Common screening methods for endometrial cancer.
• Unlike cancer of the cervix, there is no worldwide accepted programme

for early detection of endometrial cancer.
• Usually women at risk are older women. Especially women with abnormal
vaginal bleeding after menopause are screened for this.
• A trans-vaginal ultrasound is especially useful in detecting the thickness of
the lining of the uterus, and also the presence of any abnormal projections
(polyps).
• Some centres may inject some saline inside the uterus before ultrasound
(sono-hystrography) to improve the detection of polyps.
Office (out-patient) methods
Hysteroscopy
This involves the use of a slim flexible telescope like device, into the uterus,
to have a look at the endometrium and remove any suspicious looking tissue for
pathological examination (biopsy). This does not need any anaesthesia or admission 85
to the hospital.
Pipelle or Vabra sampling
2
This can also be done in the out-patient where a thin wire like device is
0
introduced into the uterus and a random sample of the lining is taken for pathological
examination.
0
Dilation and curettage (D and C) usually along with hysteroscopy
This usually involves hospital admission and anaesthesia. 9

Pap smear at times may raise a suspicion for
endometrial cancer, but does not diagnose it.
Symptoms suspicious of cancer: when to ask

for help.
• Abnormal vaginal bleeding or discharge

• Bleeding after intercourse
• Painful intercourse
• Pain in the pelvis, back or legs severe enough to interfere with routine
activities.
• Change in bowel or bladder habits
• Weight loss.
• Increased abdominal girth
Cancer in other parts of the genital tract like vagina, vulva and fallopian tubes
is very rare and do not need routine screening.
If a screening test result is abnormal you may need to have more tests done to
find out if you have cancer called diagnostic tests.
A majority of the times, these symptoms are innocent and do not mean that
you have cancer! Just consult your doctor to be 100% sure.
86
2
0
0
9
BREAST SELF EXAMINATION
Dr. RAGHUBIR PRASAD GUPTA

SURGICAL CASUALTY, AL SABAH HOSPITAL, KUWAIT
Breast Self Examination (BSE) is examining her own breast by woman. at monthly
interval with the idea of finding out any abnormality of breast, especially any nodule
or lump, at the earliest.
Why it is needed?
Breast cancer is a devastating disease with incidence growing rapidly in all
population. Nearly one million new cases are reported every year in the world. It
is the commonest malignancy in woman, comprising one-fifth (18%) of all female
cancers.
In UK, nearly 14,000 deaths occur each year with increasing incidence among
women aged 50-64 years.
In USA, it is second most common cancer in women and accounts for one in 89
three deaths in female due to cancer.
So, still the mortality and morbidity from breast cancer remains very high and
2
the best factor for reducing it remains early detection and its management.
0
Techniques for early detection
1. Breast self examination monthly for woman 20 years of age & older
0
2. Clinical Breast examination yearly
9
3. Mammography, Ultrasonography, MRI
4. Biopsy
Breast self examination (BSE)
BSE is a cost free health service, under woman’s control and often leads to
detection of breast abnormality and breast cancer at the earliest and thus improves
the survival of patient with breast cancer. Although young women have low incidence
of Breast cancer, it is important to teach BSE to young women so that it becomes a
habit when they are old.
Frequency of BSE
The Premenopausal woman should start BSE monthly in first week after menses
on fixed dates as breast remains least tender and swollen (nodular) at this time of
menstrual cycle.
The postmenopausal woman or those above 40 yrs can do it on first day or last
day of each calendar month, but fixed dates.
80 % of all breast cancers are first palpated by the patient rather than
physician. Over 80% of breast lumps are not cancers but it has to be proved by the
doctor.
Techniques of BSE
1. Inspection ( to look )
2. Palpation ( to feel )
INSPECTION
Undress from waist up and view yourself in front of mirror. Familiarize yourself
90 with boundaries of your breasts. They are regular, clearly recognisable below the
nipple and on the inner side, but the upper and outer parts fade away into the skin
of upper and side part of chest. Breast is not round but has a tail like part which
stretches towards and may extend into the armpit. Surface is smooth. It has a darker
2
areola and projecting nipple.

0
It is normal for one breast to be larger than other & for one to be higher than
other on the chest wall.
0
In case of large or pendulous breast, lift the breast with opposite hand to see
9
underneath the breast and turn from side to side to visualize all breast tissue.
Abnormalities to be looked for (Be aware of):
1. Any change in color, size, shape, symmetry or texture of skin. Any dimpling
or puckering of skin.
2. In areola, any swelling, tense skin or discharging sinuses
3. In nipple, scaling, soreness, pulling to one side (retraction) or turning in
(inversion)
Different positions for inspection:
1. Start with hands at the sides, relaxed.
2. Place your hands on your waist and press hands inwards and roll your
shoulders forwards & see.
3. Keeping your hands on waist, lean forwards allowing your breasts to fall
away from your body. See any change in contour of your breasts.
4. Place your hands behind your head and press, and observe.
5. Stretch your arms high above your head and see the difference.
PALPATION
It needs applying three different degrees of pressure from mild soft touch for 91
skin, medium pressure to feel deeper breast tissue and then firm pressure to feel deep
breast tissue & chest wall. Then squeeze the nipple and areola.
2
Again it is done in different positions and by different techniques.
0
Positions
0
9
1. Standing under shower: while taking bath, wet skin remains smooth and
hands glide easily over it.
2. Standing with breast hanging.
3. Lying down position. Put a small pillow under your back, directly beneath
your right breast. Raise your right arm and place your right hand behind your
head. In this position, breast tissue is evenly distributed over the chest wall
and as thin as possible-making it much easier to feel.
While palpating, use the flat portion of your three middle fingers and keep
your fingers flat on breast tissue all the time and move with wriggling movement in
continuity. Do not lift your fingers off the breast and do not use finger tips or poke or
pinch the breast tissue.
How to palpate?
Palpation is done in 3 different patterns. Idea is to palpate whole of breast tissue

and lymph nodes, from side to middle of chest, armpits and above and below the
collar bones (both sides).
Both breasts are palpated one by one .Right breast by left hand & left breast with
right hand.
What to feel?

1. Confirm first the aspects of boundary and surface seen while inspection.
92
2. Feel normal texture and smoothness of skin. Look for any abnormality such
as thickening, roughness, tender area ,prominence or scaling.
3. Normal nodularity of breast tissue to be felt. A firm ridge in lower part of both
2
breasts is normal. Note any thickening or swelling, soft, firm or hard nodule
or lump within the breast, whether slippery or fixed and painful or not .
0
4. Any abnormality as thickening, roughness or scaling over nipple. Any tender

area or prominence is noted.
0
5 . Squeeze the nipple and see if there is any discharge, its color and amount.
Whether it is white (milky), yellowish (purulent), reddish (bloody) or mixed
9
appearance.
Techniques of palpation
1. Up and down pattern - vertical sweeping

2. Overlapping concentric pattern
3. wedge pattern ( from periphery towards nipple )
Vertical sweeping is considered best and most comfortable. Start by smoothly

palpating your right breast for any lump or thickening different from your normal
state. Sweeping is done by moving inch by inch starting from upper point at side of
chest along an imaginary line – down to rib cage and moving across the breast to
the middle of chest bone ( sternum ).
In Concentric or clockwise pattern, starting from upper outer quadrant at

12 O’clock, move your flat fingers in a clockwise direction back to 12 O’clock
position. Repeat concentrically a bit down (overlapping) spiralling inwards towards
nipple.
In wedge pattern visualise your breast as a circle divided

into wedges like pieces of a pie. Start at the top of your breast
93
one cm below the collar bone and slide your fingers towards
nipple. Examine entire wedge, piece by piece, in a clockwise
fashion moving in the next wedge.
2
Finish checking the breast by squeezing behind the nipple and areola with
0
fingers at 12 and 6 O’clock along and then at 9 and 3 O’clock across.
0
Feel the tissue and see the discharge from nipple. Also examine the softness
of nipple by pushing the nipple inwards when it sinks inwards into a little well
9
normally.
Palpate above and below the collar bones and both armpits.
Repeat the same steps on other breast.

WARNING SIGNS
On Inspection
1. Unusual difference in size or shape of breast.

2. Alteration in the position of either nipple (retraction).
3. Turning in (inversion) of either nipple.
4. Dimpling or puckering of the skin surface.
5. Unusual rash or scaling on the breast or nipple.
94 6. Unusual prominence of the veins over either breast.
7. Unusual discharge from nipple.
On Palpation
2
0
Unusual discrete lump or nodule felt during the BSE in any part of either
breast.
0
WHAT TO DO?
9
If you find any warning sign, report to the Doctor. Remember BSE is not a
replacement for examination and investigation by a Doctor.
Do not panic. 80% of lumps found are not cancerous.
Breast cancer can develop at any age. Risk increases with age. More than 70%
of women with breast cancer have no risk factors including family history.
Early diagnosis of Breast cancer means better survival. Mammography, ultrasound
and MRI are safe and effective screening methods.
THE ROLE OF MAMMOGRAPHY
Dr. ASHIM KUMAR LAHIRI - CONSULTANT

DEPARTMENT OF RADIOLOGY - FARWANIA HOSPITAL, KUWAIT
Mammography is a special X-ray imaging technique to examine breasts.

Screening mammography plays a key role in early detection of breast cancers using
low-dose X-ray. The goal of screening mammography is to detect breast cancer before
a patient or a physician can feel them. Moreover, when
the cancers are detected at an early stage, they can be
successfully cured and breast conservation therapies are
also possible.
Diagnostic mammography is an X-ray examination

of breasts when the patient is symptomatic: patient feels
a lump or presents with symptoms like, blood-stained
nipple discharge, skin thickening, nipple retraction or
change in breast size or shape.
Mammogram images
When women are recommended screening mammograms? The National Cancer 99
Institute of USA recommends that women in their forties should get mammogram
every one to two years and after the age of 50, mammography should be performed
every year. In many western countries, the protocol of screening mammogram is once
2
every two years after 40 years of age. The overall aim is that women in the age group
of 40-60 years should have regular mammograms and physical breast examination
0
by the gynecologists or the surgeons.
0
However, those women with greater risks of breast cancer, must start the screening
at the earlier age (after 30 years). The risk of developing breast cancer is not the same
9
for all women. The most important risk factors include: positive family history of
breast cancer (mother, sister and daughter), genetic changes (specific alterations in
certain genes), women who use hormone replacement therapy for post-menopausal
symptoms for more than five years and women who had radiation therapy to chest
before 30 years of age. Research studies have shown that there are also some other
risk factors for developing breast cancer: women who start menstruating before 12
years of age and attain menopause after 50 years of age, higher alcohol intake and
physical inactivity throughout life.
Women with breast implants should also have regular mammograms like other
women. However, the patients must inform at the mammography center so that the
technologists take special care.
Mammogram is performed on out patient basis. This procedure is performed by the
specially trained radiology technologists. In the beginning, the procedure is explained
to the patient. The breast is placed on a special platform and then compressed with a
paddle. The compression is applied slowly. The compression technique is extremely
important to get high quality mammograms and to reduce
the X-ray exposure. However, the patients may experience
some discomfort or pain during the breast compression. Patient
is advised to stand still and to stop breath for few second during
the exposure. Two X-ray images are obtained for each breast.
One X-ray is taken in upward-downward direction and the
other from side to side. The entire procedure may take 20-30
minutes. Once the examination is over, you will be advised
to wait till the doctor (radiologist) decides that the images are
satisfactory. Mammogram (X-ray) Machine
Nowadays, many centers have replaced the traditional mammogram units with
the digital mammogram units. The basic principle of the digital machines is same as
10 0 the conventional ones. But, with the digital mammography, accuracy of detecting the
abnormal findings is higher because the digital images have much better contrast .
Moreover, the digital images can be stored and retrieved electronically for comparison
in future.
2
Interpretation and subsequent course: A radiologist specifically trained to

0
interpret the mammograms, reports these cases. The normal cases are not called back
for any further investigations. However, in some cases, patient may require additional
0
X-rays (specific mammogram views) to rule out or confirm the abnormality. If a

suspicious area shows presence of suspicious tiny calcifications (microcalcifications)
9
which favor early cancerous growths, patient is advised mammogram-guided biopsy.

In cases where, a mass lesion is seen, radiologist may advise ultrasound examination
to assess the characteristics of the tumor; whether benign or malignant. Finally, all
the tumors which do not show definite features of benign nature, are subjected to
biopsy for confirmation.
Benefits and accuracy of screening mammograms: Screening mammograms can

detect breast cancer at very early stage when the cancerous growth is confined to the
milk ducts of breast, called ductal carcinoma in-situ (DCIS). Screening mammogram
can detect about 85% of breast cancers. At this stage tumors can be easily removed
with complete cure. Several studies done worldwide have shown that screening
mammograms significantly reduce deaths from breast cancer.
The other benefits include: no radiation remains in a patient’s body after X-ray
examination and the diagnostic range of X-rays do not cause any side effects.
Limitations of screening mammogram: False negatives are the cases when the
patient has breast cancer and the radiologist reports the mammogram as normal.
Screening mammograms can miss about 15% of cancers. These false negative cases
mainly occur in younger women with dense breasts than the older women.
False positive cases are those where the radiologists reports the mammogram as
abnormal and actually there is no abnormality and patient might have to undergo a
biopsy for this reason. This error is also seen in the younger women.
To conclude, screening mammogram is an excellent technique for early detection

of breast cancer in asymptomatic women, particularly over forty years of age.
10 1
2
0
0
9
LIPOSUCTION
PROFESSOR (Dr.) RAMESHWAR L. BANG

DEPARTMENT OF SURGERY, FACULTY OF MEDICINE &
AL-BABTAIN CENTRE FOR PLASTIC SURGERY & BURN, KUWAIT
Fat Cells:
Fat cells (adipocytes) in the body have a specific function that is vital to the
body’s overall health. The fat cells provide ready form of energy, insulation, and shock
absorption (cushion effect). The excess unused energy from the food we eat is stored
as fat cells. In adult life most of the fat is stored in the white adipose tissue, whereas
the brown adipose tissues largely occur in new born. The pattern of fat distribution in
the human body depends on inheritance, gender, age and race where the inheritance
plays a predominant role. Body Mass Index (BMI = Body Weight in kilograms/Height
in meters2) is indicative of obese or non-obese personality. If BMI is more than 25 it
is indicative of obesity. The gynaecoid obesity is the predominant form of obesity in
women with excessive fat accumulation around hips, thighs, and buttocks, whereas
android is the predominant form of obesity in men generally involves the abdomen,
10 4 flanks, torso and nape. Women usually have a higher percentage total body fat and
thicker adipose layer. Age is also a significant factor in determining the regional
distribution of fat. With aging the fat tissues in abdomen significantly increases and
arm and legs decreases in both men and women.
2
What is Liposuction?
0
Liposuction is the surgical removal of excess fat deposition in the body, through
0
a cannula attached to suction device. It is designed to remove pockets of extra fat

from specific areas of the body and in present days it is quite in vogue amongst
9
contour conscious people.
The patient’s selection and consideration for Liposuction:
The suitability and success of liposuction depend on number of factors, such

as age, skin elasticity, body weight, and overall health. Young to middle age, close
to ideal weight for height or stable body, good general health, good to excellent skin
tone, having specific “trouble areas” such as the tummy, thighs, and buttocks that
will not respond to changes in diet and exercise are good candidate for liposuction.
Liposuction is appropriate for women with macromastia, looking for breast reduction,
and for men who suffer from gynaecomastia (male breast development). Liposuction
is not appropriate for people with a weakened immune system, diabetes, heart or
artery problems, or a history of blood clots or restricted blood flow. It is important
that you should have realistic expectations and limitations of the procedure. It should
be emphasized that liposuction is good for removal of localized accumulation of
fat from any part of the body which is resistant to overall weight loss, dieting and
exercises. It must be made clear that Liposuction is Not meant for treating Generalized
Obesity. The measure for generalized obesity is directed toward the dietary regimen
and exercises. Some form of gastric by-pass surgery should be considered in Gross
Obesity.
The Liposuction Procedure:
The concept of the liposuction

surgery may seem simple – the fat is
vacuumed out, and you are good to go-
but it is actually a complex process just
like any other surgical operation. It can be
performed under either local or IV sedation
or general anesthesia (the term anesthesia 10 5
simply means without pain) depending on
how many areas are to be treated in one
sitting.
2
Liposuction procedure involves
insertion of a small, tube-like instrument
0
called cannula through tiny skin incisions
and to suck away (either by syringe or
0
vacuum pump) the fat deposits. The fat cells
break up by back and forth movements
9
of the cannula. The broken fat cells are
removed by vacuum suction device. The
procedure is good for the removal of the
cellulite (Cellulite is caused by fat cells pushing through the collagen connective tissue
directly beneath the skin’s surface, causing a dimpled appearance). The appearance
of cellulite is not related to the amount of body fat but it may be prevalent even
in healthy and underweight people. Cellulite is more common in women because
men have a tighter collagen mesh pattern beneath their skin. Liposuction can help
cellulite removal in both men and women, but it is important to remember that there
is no permanent «cure» for cellulite. The skin incisions can either be closed with a
few stitches or left open to drain at the end of the procedure. In one sitting up to 4
to 5 kilograms of fat can be removed safely. A significant amount of blood and other
bodily fluids are removed; therefore, patients need intravenous fluids replacement
during and after the liposuction procedure. It is important to carefully monitor the
patient for any excessive fluid loss. If left untreated, fluid loss may lead to shock.
Types of various Liposuction Procedures:

There are several types of liposuction procedures available:
Dry Liposuction: - The fat is sucked out without any injection or infiltration of
fluids the area to be treated.
Tumescent liposuction: - It involves injection or infiltration of large amount

of fluid (a mixture of salt solution, lidocaine, and epinephrine) into the area to be
treated. It allows for easier removal of the fat and reduces blood loss. The wet and
super-wet techniques are variations of this type of liposuction.
Ultrasonic assisted liposuction (UAL): - In this procedure a special ultrasonic

cannula is used to liquefy the fat cells and remove it without the traditional
10 6 suctioning.
Power assisted liposuction (PAL): - It uses a motor-powered cannula, which

produces tiny, rapid vibrations to break up fat cells. This allows gentler removal of fat
2
cells, resulting in less pain during surgery and less bruising afterward.
0
Preparation Prior and During Procedure:

0
Two weeks prior to the surgery patient should stop all forms of aspirin medication
and vitamins that interfere with blood clotting mechanism. The smoker should
9
attempt to stop for at least two weeks before liposuction. A general medical check
up is carried out prior to surgery. The consent ensures that you understand about the
procedure, possible benefit, the risks and final outcomes.
After Care:
After liposuction surgery, there is always some amount of fluid collect beneath
the skin. If the incisions are stitched shut, the fluid drains less easily and can lead to
bruising or swelling. The current “open drainage” technique allows the incisions to
stay open after liposuction surgery, and the fluid continues to drain from the area for
several days. However, in both cases the patients need to wear an elastic compression
garment post-operatively for up to 3 months. The post-operative swelling and bruising
may last for several weeks but it will not interfere with your everyday life. The scar
that will result from liposuction surgery is typically only a quarter of an inch long
and will begin to fade only a few weeks after the operation. Most of the side effects
of liposuction are so minor that, within a week of surgery, most patients are able to
go back to work and resume their day-to-day activities.
Will Liposuction get rid of cellulite?
Liposuction for cellulite removal is not completely effective, though it can

diminish the appearance of cellulite. Cellulite is caused by many factors e.g. age,
genetics, gender, and the thickness of skin. Liposuction can minimize the appearance of
cellulite through fat removal, but cannot be expected to eliminate cellulite entirely.
Will the fat come back after Liposuction?
Liposuction removes the fat cells from specific areas of the body. These fat cells
will not return; however, if the patient does not follow a healthy diet and exercise 10 7
routine, the remaining fat cells could expand and lead to weight gain across all
areas of the body. However, the areas that were contoured with liposuction will have
a reduced capacity for fat production. With a post- liposuction exercise and diet
2
regimen, patients can maintain their slimmer figures.
0
When should I expect to see positive results following the Liposuction
Procedure?
0
You will most likely notice some improvement after your liposuction surgery, but
9
it will take four to six weeks for most of the swelling to subside. Optimal liposuction
results should be visible in three to six months.
Liposuction Recovery & Typical Liposuction Recovery Time
After liposuction, recovery time can last from days to months depending on
the size of the treated area. In the majority of liposuction cases, recovery progresses
to the point where the patient can continue with their normal life after one to two
weeks, and a full recovery is made within a few months. In less than a week after
liposuction, most patients are able to move normally and even return to work with
minimal discomfort. After a few weeks, most feel comfortable enough to remove
their compression garment and begin their new lives with more contoured, appealing
figures.
Liposuction Complications:
Liposuction complications may include:
Allergic reaction to medication or anesthesia,

Excessive fluid loss - fluid loss can lead to shock
and, in some cause death, Infection, Friction burns,

Skin necrosis, Fluid accumulation (Seroma or
Hematoma), Fat or blood clots - clots can migrate
to the lungs and lead to death, Damage to vital
organs, Damage to nerves, Delayed wound healing,
Bruises and Scars, Numbness of the skin, Sagging
or discolored skin, Lumpy appearance may be due to excessive removal of fat
Conclusion:
Liposuction can eliminate deposits of fat from stubborn areas unresponsive to
10 8 diet and exercise. It provides a way to override genetics and take control of the shape
of your body. The re-contouring effects of the procedure are often so dramatic that it
looks as though more weight has been lost. Liposuction benefits are often more than
aesthetic. Many patients are able to partake in activities they had previously avoided
2
because of their appearance, and most report an increase in their confidence. The body
smoothing and contouring available with liposuction can make an individual look and
0
feel better by simple virtue of the fact that their clothes fit better. Fat removal, whether
through dieting or liposuction, can have beneficial effects on your overall health
0
and well-being. The weight loss is the best way to reduce your risk of heart disease,
diabetes, and even certain types of cancer. Liposuction also benefits those in need of
9
breast reduction where disproportionately large breasts cause health problems such
as back pain, neck pain, and headaches, including migraines. Although liposuction
does remove a number of existing fat cells, it does not guarantee that you won’t
regain some fat. The importance of post- liposuction healthy lifestyle choices should
be stressed enough; you should stick to a moderate diet and be sure to exercise for
at least thirty minutes three to five times per week to maintain your figure. If you are
going to treat yourself to liposuction, be sure to treat your body well afterward
PRE CONCEPTION COUNSELLING.
CARING FOR YOUR BABY BEFORE IT COMES INTO YOUR WOMB.
Dr. ANANTHAPRIYA VAIDYA MD MRCOG

Pregnancy and child-birth are meant to be natural events that all women can
take for granted. There are however a few women who have problems during this life
changing event. These women can be helped from the period prior to conception by
preparing them and optimizing their health to carry the pregnancy safely. This is ‘Pre-
conception counselling’. The aim of this is to reduce the risk of harm to the unborn
baby, and to reduce the risk of pregnancy complications.
Who needs ‘Pre-conception counselling’? If you think about it, almost every
mother feels under prepared to face pregnancy regardless of how many she’s faced
before! So every future mother can benefit from this. However, most women need
just general advice which can be dispensed as leaflets, or found in magazines or
the internet. Some women however need extra care owing to concerns about their
own health or the health of the child particularly if they have had previous bad
experiences in pregnancies. 111
There are certain issues which are universal to all women. These mainly concern
nutrition.
2
Folic acid supplements
0
Folic acid is a vitamin which is normally found in food derived
0
from plants. It is essential for the normal development of the babies’
brain and spinal cord. All women benefit by taking supplements of this
9
vitamin. They should ideally take 400 micrograms of folic acid at least
three months before they plan a pregnancy and continue for the first
three months of their pregnancy. Some women like those who have had
a baby with a birth defect, those taking epilepsy medication or diabetics need extra
folic acid and should take 5 mg instead of 400 micrograms.
Smoking is harmful for the baby. It can cause a variety of problems ranging from
miscarriage, birth defects, and prematurity to small babies and death during delivery
and early infancy. Women who smoke should try to quit smoking before planning on
a pregnancy and those who continue to smoke when pregnant should try to stop or
cut down. Even smoking spouses can affect the baby, and fathers-to-be should also
take the opportunity to tackle their own smoking problems. It’s off course easier said
than done! Trying to get a professional to help you succeed is a good idea.
Alcohol in moderation is not known to cause any bad effect but addictive habits
and especially binge drinking are harmful. «How much is ok?» is the moot question
for which there are no clear cut answers.
A ‘healthy diet’ is off course what is recommended

for everyone, pregnant or not! It’s almost impossible to
determine what is the ideal food, however, in general,

the bulk of most meals should be starch-based foods
(such as bread, cereals, potatoes, rice, and pasta), with
fruits and vegetables. Eat protein foods such as meat,
fish, pulses, chicken, etc, in moderation.
It’s a common misconception that pregnant women should <eat for two’! That
certainly isn’t so! If you double your intake you are likely to become overweight
which in turn increases your risk of developing problems later in the pregnancy. Also,
extra weight is difficult to lose after the birth. If you are already obese or overweight,
11 2 try to lose some weight before becoming pregnant to reduce the risk of pregnancy
complications.
Include foods with plenty of iron, calcium and folic acid

2
These are required for the growing baby. Iron is found in red meat. Pulses, dry
0
fruits green vegetables like spinach and fortified food like wheat flour. Calcium is
found in dairy products, fish, fruits like banana and custard apple. Folic acid is found
0
in green leafy vegetables

9
Foods and drinks to avoid -This is discussed in the article ‘Care of the pregnant
mother’
Medications
Some commonly used drugs like paracetamol at normal dose are safe in
pregnancy while a lot of others are unsafe or their effects are unknown. These are
discussed in detail in the article pertaining to drugs in pregnancy.
Infections
German measles if contracted early in pregnancy can cause birth defects. Taking
a vaccine at least a month before you plan a pregnancy can prevent this disease. It
should not be taken if you are pregnant. Chicken-pox, Toxoplasma, Parvovirus and
Herpes are some of the viruses that can cause problems in pregnancy. More information
about this can be found in the article about viral infections in pregnancy.
Working environment
Certain types of work for example, those involving with chemicals, fumes,
solvents, etc, and working with animals such as cats or sheep may pose risks in
pregnancy. Alternative arrangements should be made if possible during pregnancy to
avoid exposure to these risks.
Women requiring special care pre-conceptually
Women with long standing medical conditions. Women who suffer from certain
conditions like asthma, clotting problems, diabetes, epilepsy, heart disease, high
Blood pressure, kidney or liver disease should consult their doctors at least three
months before planning on a pregnancy. They should make sure that they are healthy
enough to go through the pregnancy with minimal risks to themselves and the baby. 113
They should discuss potential hazards of medication and discuss safer alternatives.
They should ideally be taken care of by a team comprising of their obstetrician as
well as the doctor caring for their medical condition.
2
Women with genetic disorders. Those who suffer from or belong to families
known to carry familial conditions like haemophilia, sickle cell anaemia, thallassemia
0
or G6PD deficiency will benefit by preconceptual testing of themselves and their
spouse to determine the risk of having an affected child and plan for methods of
0
testing in early pregnancy. Certain state of art procedures like Pre-implantation
genetic diagnosis, where diseases are diagnosed in a baby which is conceived in
9
a test tube before being placed back in the mother’s womb are also available for
women at risk.
Pregnancy and child birth are life defining experiences for any woman. A
little bit of planning and preparation can help you have a safe and memorable one.
Given below are some web addresses if you want more information. Don’t hesitate
to seek more information from your doctor if you need to clarify anything. Happy
motherhood!
Web site addresses
www.cks.library.nhs.uk/patient_information_leaflet/preconception
http://74.6.146.244/search/cache?ei=UTF-8&p=preconception+care+patient
+information&fr=moz2&u=www.cdc.gov/ncbddd/preconception/QandA.htm&w=
preconception+care+patient+patients+information&d=SreUakLURpML&icp=1&.
intl=uk
http://www.acog.org/publications/patient_education/bp056.cfm
114
2
0
0
9
NURTURE WITH CARE!!!
CARE OF THE PREGNANT MOTHER

SPECIALIST, DEPT OF OBSTETRICS & GYNECOLOGY, AL-JAHRA HOSPITAL , KUWAIT
Pregnancy is a beautiful phase in the life of a couple. It is amazing to see the

miracle of life unfolding before our eyes. All the prospective moms and dads nurture
the dream of a healthy pregnancy and a healthy baby. Antenatal (ante-before, natal-
birth) care helps in making this dream a reality.
Antenatal care monitors your health, as well as the health and development of
your baby. It can help predict and detect possible problems with your pregnancy or
during childbirth, so action can be taken to avoid or treat them.
The routine antenatal care of ‘healthy pregnant woman” is briefed here. The
special antenatal care of high risk pregnancies (presence of a condition that puts the
mother or baby or both at higher than normal risk for complications during or after
the pregnancy and child birth) (Table 1) is not discussed.
117
Table 1. Few examples of high risk pregnancies
Personal factors Age of mother < 18 yrs or ‘35yrs. smoking, alcohol, drugs
2
Obstetric factors > 5 children, ≥3 abortion, previous 2nd trimester abortion
0
or preterm birth
previous still birth or baby with birth defect, previous
0
cesarean birth
Medical history Presence of diabetes, heart disease, kidney disease, high
9
blood pressure, epilepsy
Family history Birth defects or inherited disorders
Current Physical Mother’s weight > 90kg or <45kg, bleeding per vagina,
Profiles multiple pregnancy, anemia, jaundice, diabetes, high blood
pressure.
First visit - Your first visit to the doctor should be during the first 6 to 8 weeks
of your pregnancy i.e. when your menstrual period is 2-4 weeks late. During this
visit a detailed history including age, occupation, the date of last menstrual period,
previous pregnancies, previous surgeries, any previous allergies, physical or mental
illness that you may have had is noted. If you are on any medications, discuss with
your doctor as some medications are not safe during pregnancy and need to be
replaced. Your weight, blood pressure, heart and lungs are examined. This detailed
evaluation in the first visit helps the doctor to decide whether you need extra special
care (high risk pregnancy).
The following investigations are done to check whether you have any conditions
or infections that could affect you or your baby’s health.
1. Blood tests to check for anemia, blood group, rhesus status, immunity to
rubella, evidence of diabetes and hepatitis and HIV. Based on your family
history or family origin you may be tested for conditions like thalassemia and
sickle cell disease.
2. Urine test for evidence of kidney disease, diabetes and infection. Sometimes
there can be urine infection without symptoms (asymptomatic bacteriruria).
Identifying and treating it can reduce the risk of preterm delivery.
3. You may have screening tests for Downs’s syndrome if you wish.
118
Do you know this?
Average duration of 280 days or 40 weeks

2
pregnancy
0
Full term baby baby born between 37 and 42 completed weeks

Preterm baby baby born between 22 to ≤37 weeks
0
Average weight gain ± 12 kg. 1-2 kg during first three months and about 1-2
during pregnancy kg per month after that
9
Follow up visits
• Every 4 weeks until 28 weeks pregnancy

• Then every 2 weeks until 36 weeks
• Then once a week until delivery. If you have not delivered by 41 weeks,
your doctor will discuss with you about starting labor using medications as
it is safer to deliver by 41 weeks.
During these visits your weight and blood pressure are usually recorded. Swelling
in your legs, arms or face if any is noted. The doctor notes the size of your womb and
listens to your baby’s heart. At 28 weeks of pregnancy your blood is again checked
for evidence of anemia, diabetes and red blood cell antibodies.
Use these appointments to share any concerns that you may have even if you
presume them to be silly. Do not feel embarrassed.
The ultrasound examination of your baby
• The first ultrasound scan is preferably done around 10-13 weeks to calculate
your date of delivery and to check whether you are expecting more than
one baby. Usually an external
ultrasound is done placing the
ultrasound device on your tummy.
Sometimes your doctor may perform
vaginal (internal) ultrasound. This is
not harmful to your baby.
• Between 18 and 20 weeks of
pregnancy you should be offered
11 9
another scan to check for physical
abnormalities if any in your baby.
You may not need any further scans if your pregnancy is progressing normally.
2
Food & Diet
0
You should take folic acid tablets (400micrograms daily) when you are planning
0
to have a baby and for the first 12 weeks of your pregnancy. It reduces the risk of
having a baby with birth defects in the brain and spinal cord.
Plan your daily diet to include foods from each of these groups 9
1. Fresh fruits, vegetables and green leafy vegetables
2. Carbohydrates such as bread, cereals, grains, pasta
3. Milk & other dairy produce like yoghurt, cheese etc
4. Pulses, eggs, lean meat and fish.
You don’t need to eat for two. Some extra servings of

fruits, vegetbles and healthy snacks should be enough.
If you are a vegetarian and not taking enough dairy products you may need
extra vitamins, for example B12.
If you have anemia with hemoglobin < 11 gm/dl you need to take iron
supplements. If you are not taking 3-4 servings of dairy products, then you need to
take calcium supplements (1 serving = 1 cup full fat , low fat or skimmed milk or 2
slices of cheese or 200 grams yoghurt).
Don’t eat these foods !! Why??

Liver or anything made of liver Contain high levels of vitamin A

( can cause abnormalities in the unborn
baby)
Raw or soft boiled eggs, May contain Listeria (can cause
unpasteurized dairy products, mould miscarriage, preterm delivery or fetal
ripened soft cheese death)
(cheddar, cottage & processed cheese
are safe)
12 0 Undercooked or uncooked meat May cause Toxoplasmosis (can cause
blindness & brain damage in the unborn
baby)
Shark(flake), broadbill, marlin, Contain high levels of mercury ( may
2
swordfish cause brain damage in the baby)

Avoid excess caffeine. Not more than May cause miscarriage
0
3 cups of instant coffee or 6 cups of

tea. Chocolate and cola also contain
0
caffeine - Watch out for them too!!

9
Lifestyle advice
• Eat healthy food and have enough rest.

• Don’t smoke, drink alcohol or take ‘drugs’.
• Do not use over the counter medications without discussing with your
doctor.
• Exercise- discussed separately in this health guide.
• Having sex is safe in normal pregnancy.
• Travel-safest time to travel is between 18- 24 weeks. You must wear seat
belts above and below the bump and not over it both in aircraft and car.
• While traveling to reduce the chance of developing a blood clot, drink
plenty of water. Move around as much as possible at least for 15 minutes
every hour, stretch your legs and wiggle your toes and wear compression
stockings to promote blood flow from your ankles to heart.
Some concerns during pregnancy
Concerns Advice Action
Constipation Regular exercise Laxatives like Normocol can
Plenty of fluids and fiber rich be prescribed until diet and
food. exercise take effect
May need to change Iron
preparation.
Varicose veins Avoid tight underpants or Surgical treatment is not advised
anything that fits tightly as condition improves after
around top of the leg. Avoid delivery.
standing for long periods of 12 1
time. While sitting elevate
your legs on a stool. Wear
elastic stockings.
2
H e m o r r h o i d s Avoid constipation or Application of analgesic
(Piles) diarrhoea. ointment
0
Muscle cramps Rub calf muscle firmly. Walk Magnesium silicate 300mg per
0
around. Flex your legs at day may help.
knee while lifting your toes Not enough evidence that
9
towards knee. calcium may help.
Back pain Regular exercise including
walking. Avoid wearing high
heels. Hot packs to the back.
Stretch marks Fade with time after delivery Massaging the skin with oils and
ointments won’t prevent stretch
marks but keeps the skin in good
condition
VOMITING IN PREGNANCY
Dr. LALITHA UMESH

GYNAECOLOGIST & OBSTETRICIAN
AL-JAHRA HOSPITAL, KUWAIT
Most pregnant women feel sick or vomit during early pregnancy. This is usually
a part of a healthy pregnancy and is commonly seen in 50-90% of women .
Nausea and vomiting of pregnancy usually begins by 9-10 weeks of pregnancy,

peaks at 11-13 weeks, and resolves in most cases by 15 weeks. But in upto 10% of
pregnancies, symptoms may continue even beyond 20 weeks.
AETIOLOGY
Although several theories and factors like hormonal, endocrinal, immunological,

psychological have been proposed but none have been definitively proven.
Occurrence is more common in first pregnancy, multiple pregnancies (twins),

12 6 Hydatidiform mole, unplanned pregnancy, women more than 35 years age, overweight
women and those with history of infertility and motion sickness.
Depending upon the severity it is classified as-

2
• Simple vomiting
• Hyperemesis Gravidarum or severe vomiting
0
0
Simple Vomiting (also called morning sickness):

9
• This is mild and self limiting, and may resolve itself.

• Can occur at any time, not just in the morning, may come and go. Does
not restrict the normal activities of the woman.
• Patient looks well. Blood and urine test reveal no abnormalities.
Many women, especially those with mild to moderate nausea and vomiting do
not need to see a healthcare provider for treatment of their symptoms. Although there
are no known ways to completely prevent sever vomiting, the following measures
might help to keep morning sickness from becoming severe:
A. Emotional Support from family members
B. Simple diet changes
Plenty of fluid intake including glucose or fruit juices,
Eating small, frequent meals every couple of hours,
Eating bland foods, which is high in carbohydrates and low in fat,
Eating dry food like toast or biscuit or Salty foods (e.g., salted crackers) before
getting out of bed,
Avoid drinking fluids during meals and immediately before or after meal,
Get up slowly and not to lie down right after eating,
Sniffing lemons or ginger,
Eating cold food instead of hot,
Waiting until nausea has improved before taking iron supplements
C. Triggers
If possible, avoid anything that may trigger your symptoms. like stuffy rooms,
odors, perfume, chemicals, coffee,etc 12 7
D. Ginger
2
Consuming small amounts of ginger in the form of ginger ale,tea,cookies or
candies may be helpful.
0
Acupressure and Acupuncture
0
Applying pressure to point three fingerbreadths above volar (inner) surface of
9
the wrists has been shown to relieve nausea in some women. Women can do this
with their fingertips or purchase special bands (e.g. Sea-Band, Relief Band). Look for
an experienced and licensed acupuncturist for acupuncture.
HYPEREMESIS GRAVIDARUM
It is the term used to describe severe nausea and intractable vomiting during
pregnancy. This can lead to fluid, electrolyte and acid base imbalance, nutritional
deficiency and weight loss.
Investigation:
Your doctor may do blood and urine tests to investigate the cause and determine
the severity of vomiting.
Remember, not all severe vomiting is due to the pregnancy.
Once pathologic causes such as gastrointestinal, genitourinary, metabolic and

neurological disorders have been ruled out, then the management is as follows:
Hospitalization of the woman

Emotional support by family friends and medical staff.
12 8 Correcting fluid imbalance by intravenous fluids
Antihistaminic and anti emetic drugs can be used, such as Chlorpromazine

(Largactil®), Promethazine, Metoclopramide and Ondansetron (Zofran). These
2
medications are safe during pregnancy.

0
Vitamin B6 and B1 suppliments have been found to reduce symptoms of mild

to moderate nausea.
0
If symptoms persist: Corticosteroid are given

9
Enteral or Parenteral Nutrition.
Women who fail to respond and continue to vomit and lose weight despite
aggressive treatment with any or all of the previously discussed modalities, should
be assessed for enteral feeding using an 8-French nasogastric tube (which is inserted
through the nose into the stomach). Parenteral is administered through a central
venous catheter.
OUTCOME — Most women with pregnancy-related nausea and vomiting recover

completely without any complications. Mild to moderate nausea and vomiting may
make you feel awful but effort of retching and vomiting does not harm your baby.
Interestingly these women experience fewer miscarriages and stillbirths then women
without these symptoms.
Severe pregnancy-related nausea and vomiting is likely to recur in subsequent

pregnancies. The risk has been estimated to be between 15 and 20 percent. In women
who are hospitalized multiple times are who do not gain weight normally during
pregnancy, and there is a small risk that the baby will be underweight or small.
12 9
2
0
0
9
BLEEDING IN PRENANCY
Dr. ANANTHAPRIYA VAIDYA MD, MRCOG

Your pregnancy test has come positive! Your doctor has told you that you are 8
weeks pregnant. You are elated and want to share the news with the whole world.
You then notice that you have some bleeding.
1 in 4 pregnant women are faced with the situation just mentioned and most of
them react with alarm and panic. The good news is that most of the times, this kind
of bleeding is innocuous and does not affect the baby in any way. That however does
not mean that you ignore all bleeding in pregnancy! A small percentage of them
can be life threatening. So, never ignore bleeding in pregnancy. Consult your GP/
mid-wife/specialist immediately! You may have to undergo an internal examination,
blood tests and ultrasound to find out the reason.
This leads to the most obvious questions. “What causes the bleeding”? “When
is it dangerous”?
134
The causes of bleeding differ in various stages of pregnancy. The first 20 weeks
of pregnancy is “early pregnancy” and the rest is “late pregnancy”. We’ll talk about
them one by one.
2
EARLY PREGNANCY BLEEDING

0
Most of these are, like I said before, innocent. The commonest causes are
0
implantation bleeding (bleedig occuring because of your baby getting embedded in

your womb), infection and post-coital bleeding following intercourse. Your doctor
9
will be able to reassure you after examining you and performing some tests and
ultrasound.
We will now talk about the more worrying causes for bleeding.
Threatened miscarriage
• Bleeding is usually light.
• There is no cramping pain.
• If your ultrasound shows your baby’s heart beat, the pregnancy has an 8
out of 10 chance of continuing.
• However, 2 out of 10 times, it may result in a
miscarriage.
Actual miscarriage.
• Usually the bleeding is heavy. Ultrasound image of a 9 weeks
pregnancy showing the fetal heart
• There can be cramping pain.
• You may pass tissues through the vagina.
• In rare cases you may faint, if you lose too much blood
• A complete miscarriage means that the entire pregnancy has been expelled.
This would normally require no further treatment.
• An incomplete miscarriage means that some parts of the pregnancy still
remain in your womb and may have to be removed surgically by D&C. In
other parts of the world, there are medicines which can be used in place
of surgery. This facility is not available in this country.
Most miscarriages are not preventable. They are often nature’s way of dealing 135
with an unhealthy pregnancy. A miscarriage does not mean that you can never have
a baby or that you yourself are not healthy.
2
Ectopic pregnancy
0
• It is a pregnancy growing outside the womb, usually in the tube.
• They can present with cramping pain and slight bleeding.
0
• At times the pain can be severe and lead to
fainting.
9
• If not dealt with in time, ectopic pregnancies
can rupture and cause life threatening internal
bleeding.
• Very early ectopic pregnancies can be treated
with medicines.
• Others need surgery.
• Those which are undisturbed may be managed by laparoscopy (“key-hole”
surgery).
• The larger, disturbed ones may need an open cut on the tummy.
Molar pregnancy
• This is a rare condition where pregnancy involves the growth of abnormal
tissue instead of an embryo. It is also referred to as gestational trophoblastic
disease (GTD).
• When an ultrasound is done, there is no baby in the womb, instead there
is a cluster of grape like tissues.
• This needs to be treated surgically by Dilatation and Evacuation.
• A small minority of these can persist or become cancerous because of
which follow up with blood tests for pregnancy hormones is needed for a
few months.
LATE PREGNANCY BLEEDING
Infection and post-coital bleeding following intercourse are common to both

early and late pregnancy bleeding
Some common causes of bleeding after 20 weeks are as follows.
136
Threatened Preterm labour
• This is labour which occurs before 37 weeks of pregnancy.
• It is associated with crampy pains and contractions of the womb, similar to
labour pains.
2
• There may be a pinkish or bloody discharge.

• The doctor may be able to tell you if you are likely to progress and deliver
0
your baby by examining you and determining if your womb is opening

up.
0
9
Low lying placenta

• When the placenta lies too low in the womb (uterus) after 20 weeks of
pregnancy, this is known as placenta praevia.
• A low-lying placenta is often diagnosed on ultrasound scan before 20
weeks.
• As the baby grows, the placenta is carried upwards.
• For some women, the placenta continues to lie in the lower part of the
womb into the last months of pregnancy.
• Only around one in ten women (or 10%) who have a low-lying placenta
in early pregnancy will go on to have placenta praevia.
• A low-lying placenta after 20 weeks of pregnancy can be very serious as
there is a risk of severe bleeding and this may threaten the health and life
of the mother and baby.
• If the placenta covers the entrance to the womb (cervix) entirely after 20
weeks, this is known as major placenta praevia.
• Persisting placenta previa at the end of pregnancy will require delivery by
Caesarian Section.
Position of the placenta
in placenta previa
Placental abruption
• Normally the placenta seperates from the uterus and follows the baby after
delivery.
• In some women, this can separate before the baby is delivered or sometimes
even before labour starts, this is known as placental abruption. Some
137
women like those having high blood pressure or clotting disorders are
more prone to this condition.
• This may present with bleeding, commonly after 28 weeks of pregnancy.
2
• It is often associated with severe pain.
• The bleeding can at times be very heavy and life-threatening.
0
• In rare instances it may affect clotting of blood or kidney functions.
0
While most cases of bleeding in late pregnancy can be managed without
interfering with the pregnancy, some of them may require hospital admission, blood
9
transfusion, and immediate delivery vaginally or by caesarian-section.
Some points to remember about bleeding in pregnancy.

• A small percentage of conditions that cause bleeding may be serious, so
contact your health care provider immediately.
• Avoid inter-course, douching or tampons till a diagnosis has been made, in
order not to introduce further infection.
• Don’t panic. Remember! Most cases of bleeding in pregnancy are
harmless!
DRUGS IN PREGNANCY
Dr. MARIAM CHISTI

SENIOR CONSULTANT
OBSTETRICS / GYNAECOLOGY
AL SALAM INTERNATIONAL HOSPITAL
KUWAIT
Drug administration in pregnancy is

unique for two reasons, first, the physiological
changes associated with pregnancy affect

drug metabolism, and second, the presence
of the fetus has a significant bearing on the
type of drugs that can be prescribed.
This is largely because some of these

drugs may cross the placenta and affect the
fetus in several ways, depending on the drug and the gestational age.
14 0 Teratogenicity:
The fetus is vulnerable during the embryonic period which is between the 2nd
and the 8th week post conception.
2
Organogenesis which occurs at this time may result in fetal abnormality or

0
death.
0
The drugs that affect organogenesis are described as teratogenic and should be
avoided in the first three months of conception.
9
Anticonvulsants (drugs used in epilepsy)
Unfortunately most of the antiepileptic drugs are teratogenic.
The most commonly used drugs are Tegretol (Carbamazepine) Epanutin

(Phenytoin). Preferably single drug therapy is safer than a combination of drugs.
Anti Coagulants:( blood thinning agents)
Commonly used to prevent the clot formation in the blood, Heparin , an injectable
drug is very safe through out the pregnancy. Warfarin is an oral preparation not
advisable in pregnancy, specially in the first trimester. Fetal anomalies are reported in
15 – 25 % of cases, which is a very high figure.
Psychotropic drugs:
These are sedatives and tranquilizers and are not safe in pregnancy.
Anti-fungal agents:
The most common indication for prescribing anti fungal agent in pregnancy is
vaginal candidiasis. Most of them are applied locally. Commonly used drugs are
Clotrimazole, Nystatin, Canesten, Lotrimin etc. There is no evidence to link these
agents with teratogenecity or fetal abnormality.
Anti-viral agents:
141
The most commonly prescribed antiviral agents in pregnancy are Acyclovir and
Zidovudine (AZT). Acyclovir is the drug of choice in Herpes and Varicella infections
and is administered systemically. AZT is the safe choice for treatment of H.I.V.
2
infection in pregnancy.
0
Anti-bacterial agents(drugs used in infections)
0
Urinary tract infections are most common in pregnancy. Fortunately, most
antibacterial agents are not teratogenic. Nitrofurantoin is safe in pregnancy.
Commonly used antimicrobials are Penicillin, Ampicillin, Amoxicillin, 9

Augmentin, Dalacin, Erythomycin, Cephlosporin group of drugs like keflex, Ceclor,&.
Zenat. All these drugs are considered fairly safe, which means that there are no
known association with birth defects or other pregnancy related complications.
Flagyl (Metronidazole) and Sulfa drugs are avoided in first trimester. Tetracycline,
Streptomycin, Chloramphenicol are not advised at all during pregnancy. Tetracyclin
is associated with discoloration of teeth. Streptomycin causes nerve deafness.
Chloramphenicol is associated with “grey baby syndrome”.
Analgesics:
Analgesiscs are used to relieve pain. Paracetamol is

considered the analgesic of choice in pregnancy being associated
with no risk of malformation or fetal defects. Low dose Aspirin is
also considered safe in pregnancy. Other NSAIDS, which include
Indomethacin, Ibuprofen (Brufen) and Naproxen should not be
taken during pregnancy.
Anti-diarrhoeal
Kopectate and Imodium are safe in pregnancy after the first

trimester.
Antacids:
Malox, Mylanta, Tums, Gaviscon are safe in pregnancy.
Anti-emetics (used fot vomiting)

14 2
Primperan, Navidoxine, Phenergan and Vit – B6 tablets are safe in
pregnancy. Thalidomide tragedy is still fresh in our minds.
2
For relief of constipation:

0
Fibercon, Colace, Normacol, Senakol are all safe in pregnancy.

0
Respiratory Drugs:
9
The most common respiratory problem requiring medication during pregnancy

is bronchial asthma. Bronchodilators such as Thepophyllin, Aminophyllin and
Salbutamol are not associated with any adverse effect on pregnancy.
Endocrine medication:
Thyroid dysfunction and diabetes mellitus are most common disorders of

pregnancy.
At present oral anti-diabetic agents should preferably be avoided during

pregnancy. Hypothyroidism is treated with thyroxine, and is not associated with any
malformation and does not cross the placenta. In Thryrotoxicosis, carbimazole and
Propylthiouracil should be used in lowest doses. Radio active Iodine is avoided.
Cardiovascular Drugs:
These drugs should be taken under close supervision of a physician.
Please note: No drug can be considered 100% safe to be used in pregnancy.
143
2
0
0
9
VIRAL INFECTIONS IN PREGNANCY
CHICKEN POX AND RUBELLA
Dr. AMBILY,T,K
MD, MRCOG
Chicken pox (medical name VARICELLA) is a highly infectious disease and this
is caused by Varicella Zoster Virus. The disease is transmitted by respiratory droplets
and by direct contact with the fluid in the skin lesions or indirectly through the things
which are being used by the patients. You can have chicken pox by being in the same
room with the infected person for at least 15 minutes or being face to face with them
for at least 5 minutes. You can have Chicken pox virus for 10 days to 3 weeks before
any symptoms appear & you can spread the disease 48 hours before the skin rash
appears & till the skin lesions crust over. The signs and symptoms are fever, feeling
unwell, itchy rash of watery blisters, which may burst after few days and form a crust
and finally heal over.
After healing, the chickenpox virus can stay in the body and can become
148 active later causing SHINGLES or HERPES ZOSTER. This appears as patchy areas of
itchy blisters in contrast to the involvement of the whole body which dry out and
crust over after a few days. This can be painful. The risk of acquiring infection from an
individual with shingles from non exposed area like back of your chest or abdomen is
2
remote. However shingles in vast areas or in exposed areas like face can be infective
to others who have not had Chicken pox.
0
Antibodies which are protective against Chicken pox, IgG, (IMMUNOGLOBULIN)

0
can be checked before attempting pregnancy. Those who are negative for antibodies
can be advised to take Chicken pox vaccine which can give protection from chicken
9
pox even upto 20 years. Women who received vaccine against chicken pox should
be advised to avoid pregnancy for 3 months. Vaccination taken unknowingly during
pregnancy has not been shown to produce any abnormality to the foetus.
A previous history of Chicken pox infection is 97 to 99 % predictive of presence

of antibodies against chicken pox .If a pregnant women gives history of contact and
if she had already chicken pox before, she is immune & there is nothing to worry
about. If she never had chickenpox or not aware of if she had Chicken pox before,
she should have a blood test to confirm the presence of antibodies (Ig G) which can
fight against the virus. If antibodies are present there is no need for any treatment.
If antibodies are absent, she should be given IMMUNOGLOBULIN (IgG)
vaccination which is effective even if given 10 days after the contact. If vaccination
is given after 10 days, it will not prevent chicken pox but it can reduce the symptoms
and the disease will last less than the normal time. Patients can still spread the disease
to others for 8 to 21 days if vaccination is given .A second dose of vaccination is
given if further exposure to chicken pox is noted and 3 weeks have elapsed since
the last dose.
If a pregnant lady develops chicken pox, she should avoid contact with other
ladies and babies until the skin lesions are crusted over. Tablets against the virus
(ACYCLOVIR) can be prescribed if they present within first 48 hours of onset of the
rash and if they are more than 20 weeks pregnant. This can reduce the fever and
symptoms. IgG injection has no role once the chickenpox develops.
Risks to the mother includes Pneumonia, infection

to liver, and brain, bleeding tendency, etc. Pneumonia
can cause death in 1% which is 5 times more than in
non pregnant women. Pregnant women are more at risk
if they are smokers, have lung disease such as bronchitis,
or taking steroids, or in second half of pregnancy. 14 9
Risk of spontaneous abortion is not increased if

chicken pox appears in the first 3 months. If a pregnant
2
woman develops chickenpox in the first 28 weeks of
pregnancy, she has a 2% risk of getting fetal varicella
0
syndrome to the baby which means damage to the head,
eyes, legs, arms, bladder and bowel. So if she plans to
0
continue with the pregnancy she should be advised to
have a detailed scan for the baby at 16 to 20 weeks of pregnancy or 5 weeks after the
9
infection. The baby should have an eye check up after the delivery.
If chicken pox occurs between 28 to 36 weeks of pregnancy the baby will not
have any problems in the uterus but may show SHINGLES in the first few years. If
the infection occurs 1 to 4 weeks before delivery up to 50% of babies are infected
and approximately 23%of these will develop clinical picture of chicken pox .Severe
chicken pox is most likely to occur if the baby is born within 7 days of the onset of
appearance of mothers rash and some babies may die as a result of this. To prevent
this Varicilla Zoster Immunoglobulin(ZIG) should be given to such babies.
If the mother develops SHINGLES during pregnancy it is usually mild and there
is no risk to the baby.
RUBELLA ( GERMAN MEASLES) IN PREGNANCY

Rubella is a viral infection which is
spread by respiratory droplet exposure
and the period from exposure to
development of symptoms usually lasts
for 2-3 weeks. Symptoms are fever, rash

all over the body, joint pains and gland
enlargement especially behind the ears
and head. Vaccination results in long
term (not life long) protection in 95%of
those vaccinated. Rubella produces
only mild or subclinical illness to the
mother in contrast to the adverse effect to the fetus. The clinical diagnosis of Rubella
infection is extremely difficult as a large proportion of infection is not evident clinically
and the rash if present at all may not be specific to Rubella as these rashes can appear
15 0 in other different infections. Confirmation of the disease is either by the isolation of
virus from blood or throat or by detecting the Rubella Immunoglobulin IgM (not IgG
which denotes protection from Rubella).
2
The risk of fetal infection and abnormalities to the fetus may be over 80% if the
infection occurs in the first 12 weeks of pregnancy and reduces to 25% if the infection
0
occurs after 12 weeks. No fetus will be affected if the infection occurs after 20 weeks
of pregnancy. Rubella can cause damage to the eyes, heart, ear, liver, spleen. This
0
can cause diabetes, thyroid disease and growth retardation to the fetus. There is no
treatment for the fetus once it is infected. If fetal infection is suspected fetal blood
9
can be taken from the umbilical cord of the fetus (inside the uterus itself) to detect
the virus as well as IgM. This test is being done only in few specialized hospitals .So
usually termination of pregnancy is advised especially if Rubella occurs in the first 3
months of pregnancy.
Rubella vaccination cannot be given to pregnant female as it is a live vaccine

(means it contains live Rubella virus but its virulence is reduced so that it will not
produce clinical illness). The ideal management is universal vaccination of all children.
But patients accidentally vaccinated during pregnancy or becoming pregnant shortly
after vaccination should be reassured that the risk to the fetus is negligible.
HIV IN PREGNANCY
Dr. AMBILY T.K, MD,MRCOG

HIV stands for Human Immunodeficiency Virus. This virus prevents bodies
immune system from working properly and makes it hard to fight for infections.
Effective treatment with a combination of 3 or more anti-retroviral drugs (drugs against
HIV), known as Highly Active Anti Retroviral Therapy (HAART) has the capacity to
prolong greatly the quality and length of life. The infection can be passed from one
person to another through body fluids, which are blood, semen, vaginal fluid and
breast milk.
The risk of Mother to Child Transmission (MTCT) of HIV varies from 25 to

30%. Baby can be infected through Placenta, during birth & through breast milk.
Over 80% of the HIV transmission from mother to child occur from 36 weeks (9th
month) of pregnancy, during labour and delivery. Fewer than 2% transmission occur
during the first 28 weeks of pregnancy. Breast feeding is associated with two fold
increase in rate of HIV transmission. The rate of transmission can be reduced to less
then 2% by using interventions like a combination of antiretroviral drugs, planned 153
caesarean section and avoiding breast feeding.Pregnant women with HIV now have
hope of their babies be free from getting the infection.
2
Pregnant women should be offered screening for HIV in early pregnancy. If the
patient is having Sexually Transmitted Infections (like Gonnorhoea or Syphylis) or
0
Hepatitis B or C which has not been diagnosed or treated it may affect the baby or
affect the pregnancy or increase the rate of transmission of HIV to the baby. So all
0
pregnant women should be offered screening for these infections in early pregnancy
as well as at 28 weeks of pregnancy. If these are found to be positive husband should
9
be advised to check for these infections.
There are 19 antiretroviral drugs (Drugs against HIV) currently licensed for
the treatment of HIV. Zidovudine is the only drug specifically indicated for use in
pregnancy for the prevention of MTCT. This is the only drug available for intravenous
administration. However it is found that this drug alone cannot suppress viral load
to undetectable level in the blood. This may allow the emergence of resistant virus.
So potent combination of 3 or more drugs known as HAART has now become the
standard care for all the HIV positive individuals requiring treatment for their own
health.
Patients who are not taking antiretroviral drugs, who do not need HIV treatment
for themselves should still be offered treatment to prevent MTCT. This can be by single
agent Zidovudine or HAART starting from 28 to 32 weeks of pregnancy and continue
until the baby is born. If a patient becomes pregnant while taking the drugs it is better
to continue with the treatment. Patients who are already having advanced HIV need
treatment for themselves as well as to prevent MTCT, should start taking HAART from
13 weeks and should continue till the baby is born and thereafter. Patients who are
diagnosed with HIV late in pregnancy or in labour should be offered treatment with
HAART including Zidovudine.
Planned Caesarean is better at 38 weeks to reduce MTCT. Infusion of Zidovudine

is started 4 hours before Caesarean and should be continued till the baby is born and
the umbilical cord has been clamped and cut. Cord should be clamped immediately
to reduce the transmission and the baby should be bathed immediately. However
whether elective Caesarean is of benefit in female taking HAART and who have an
undetectable plasma viral load in the blood at the time of delivery is uncertain; they
could deliver normally.
Patient who opts for vaginal delivery should have their membranes left intact
154 (Avoid rupturing of membranes to hasten the delivery), avoid using electrodes which
are fixed to the baby’s head to monitor the heart beat. Zidovudine should be started
at the onset of labour and continued till the delivery and the cord is cut. Baby should
be given prophylactic drugs like Zidovudine upto 4 to 6 weeks and breast feeding
2
should be avoided to reduce MTCT.

0
Virus can be checked in the blood of the baby by special tests at birth, 3 weeks,
6 weeks and at 6 months. A negative antibody test at 18 months of age conforms that
0
the child is not infected.

9
If the female is HIV negative and the husband is HIV positive the risk of
transmission to the female is estimated to be approximately 1 in 500 per sexual act.
Couple who are HIV positive can still consider a pregnancy by artificial insemination
(Injecting washed semen which contains mainly sperms to the uterus) or IVF (In Virto
Fertilization commonly known as Test Tube Baby) or by sperm washing to reduce the
transmission to the baby.
RH NEGATIVE MOTHER
Dr. RITA THUSSU

OBSTETRICIAN & GYNECOLOGIST
What is Rhesus-Negative?
There are differences in human blood known as blood groups. There are four
main blood groups: A, B, AB, and O. Each of these blood groups can either be rhesus-
positive or rhesus-negative. Around 85% of the UK population is rhesus-positive.
Blood Groups are identified by the presence of molecules called antigens

on the red blood cells. People with rhesus-positive blood have D antigens in their
blood, while people who are rhesus-negative do not have D antigens. To be rhesus-
positive, an individual may have inherited either a single copy of D antigen (called
heterozygote Dd) or two copies (called homozygote DD).
If a person who is rhesus-negative comes in contact with rhesus-positive blood,

the rhesus-negative blood will produce antibodies that attack the D antigens in the 155
rhesus-positive blood. If the antibodies reach a sufficient level, they start to destroy
the red blood cells in rhesus-positive blood. These antibodies can cross the placenta
from the mother’s circulation into the baby’s.
2
What are the causes of rhesus disease?
0
A woman who is rhesus-negative and has a rhesus-positive partner, there is a
0
chance that their baby will be rhesus-positive. If male partner of a rhesus-negative
woman has two copies of the D antigens (homozygote DD), the baby will definitely
9
inherit one copy of the D antigen (Dd), and all the babies will be rhesus - positive.
If male partner of a rhesus - negative has a single copy of the D antigen (hetrozygote
Dd) then there is 50% chance that it will be rhesus-positive, and 50% chance that
the baby will be rhesus-negative. A rhesus-negative baby will not get rhesus disease.
However, if the baby is rhesus-positive, there is a chance that rhesus disease can
occur.
Rhesus disease can occur if blood from a rhesus-positive baby come into contact
with the blood of rhesus-negative mother, the mother will develop antibodies that
fight the baby’s rhesus-positive red blood cells. This is called sensitisation.
The most likely time for mother’s and baby’s blood to come into contact is
during delivery. When this happens in the first delivery, the mother’s body will not
have time to produce enough antibodies to affect the baby’s red blood cells before
the baby is delivered. However, if sensitisation has happened earlier, or in a previous
pregnancy, then subsequent rhesus-positive babies are at risk.
Sensitisation can also occur during pregnancy such as:
• Following bleeding in pregnancy-for example during a threatened

miscarriage,
• Following an invasive procedure during pregnancy, such as amniocentesis
or chorionic villus sampling (CVS), or
• Following abdominal injury-for example a road traffic accident.
Sensitisation can also occur following a previous miscarriage or ectopic

pregnancy, or if a rhesus-negative woman has received a transfusion of rhesus-positive
blood.
After sensitisation, the antibodies will continue to be present in the mother’s

156
blood. If more rhesus-positive cells enter the mother’s circulation, for example during
a future pregnancy, she will make more antibodies, which may be sufficient to cross
the placenta and destroy her baby’s red blood cells in the womb. This will then cause
2
rhesus disease.
0
What are the symptoms of rhesus disease?

0
Rhesus disease is also known as haemolytic disease of the newborn.

The two main signs of rhesus disease in the newborn baby are:
9
i. Haemolytic anaemia
ii. Jaundice
If a baby has rhesus disease, the symptoms of anaemia and jaundice are not
always present at birth. They can develop up to eight weeks afterwards.
Haemolytic Anaemia develops when red blood cells (the cells in your blood
that transport oxygen) are destroyed. Symptoms are:
• Breathlessness
• Palpitations (rapid or irregular heartbeats), and
• Jaundice
Jaundice develops as a result of haemolytic anaemia. It is caused by a build up

of a chemical called bilirubin in the blood, which is made naturally in the body when
red blood cells are broken down. Bilirubin is broken down by the liver. In rhesus
disease, more red blood cells than normal blood cells are destroyed, and so the
amount of bilirubin, and the bilirubin levels in the baby’s blood remain high leading
to jaundice. Jaundice will make the baby’s skin and whites of eyes turn yellow .
How to diagnose rhesus disease?
During pregnancy, several routine screening tests are done. A sample of blood
is taken in early pregnancy to be tested for anaemia, rubella, hepatitis B, and blood
sugar. Blood is also tested to check for blood group and also tested to check whether
you are rhesus-positive or rhesus-negative. If you are rhesus-negative, a test will also
be carried out to make sure that your blood is not producing antibodies (known as
Anti-D antibodies). your blood will also be checked again at 28 and 36 weeks of
pregnancy. If anti-D antibodies are present in blood, it is possible that your baby
could develop rhesus disease. 157
Diagnosis in a new born baby
2
If the mother is rhesus-negative, blood will be taken from the baby’s umblical
cord after birth to check the baby’s blood group and to see if there is any evidence
0
that the anti-D antibodies have crossed the placenta (called a Coombs test). If you
are known to have anti-D antibodies, the baby’s blood will also be tested for anaemia
0
and jaundice.
Diagnosis in an unborn baby

9
If you develop anti-D antibodies during pregnancy, or if you have antibodies
present from a previous pregnancy, there is a risk that your baby will be affected and
become anaemic before the baby is born. For this reason, you and your baby will
be monitored more frequently than in an uncomplicated pregnancy. Your blood will
be tested for anti-D antibodies titres (levels) and if the antibodies are above a certain
level than you and your baby will be monitored by further tests.
Your baby will be monitored by measuring the blood flow in their brain. If your
baby is anaemic, their blood will be thinner and it flows faster. Your baby’s blood
flow can be measured using a type of ultrasound scan called a Doppler ultrasound.
If a Doppler ultrasound shows that your baby’s blood is flowing at a higher speed
than normal, a procedure called foetal blood sampling (FBS) can be used to check
whether your baby is anaemic. In FBS, a needle is inserted through your abdomen
and used to take a small sample of blood for testing, either from your baby’s umbical
cord, or from the umbilical vein as it passes through their liver. The procedure is
performed under local anaesthetic, usually as an outpatient procedure. If your baby
is found to be anaemic, they can be given a transfusion of blood through the same
needle. This is known as an intrauterine transfusion (IUT). After a transfusion, you

may need to stay overnight in the hospital.
Foetal blood sampling and intrauterine blood transfusion are only available in
some hospitals, so if you need to have one of these procedures it may be necessary
for your doctors to send you to a hospital where these facilities are available.
What is the treatment of rhesus disease?
Rhesus-negative pregnant women who have no anti-D antibodies in their blood

158 can have routine antenatal check-up as in an uncomplicated pregnancy, but the
pregnancy should not be allowed to go beyond the due date of delivery.
Mild rhesus disease requires no treatment but after birth your baby will need
2
to be monitored on a regular basis, as symptoms can get worse within the first six
to eight weeks. If your baby has moderate rhesus disease, they can be treated with
0
phototherapy (treatment with light), which speeds up the removal of bilirubin from
the body.
0
More severe rhesus disease requires a blood transfusion. This is when blood of
9
the same blood group is taken from a donor and given to your baby through a vein. It
will replace the red blood cells that have been destroyed. Your baby may need more
than one blood transfusion, depending on how severe their jaundice and anaemia
is.
If your baby develops rhesus disease while still in the womb, they can be given
an intrauterine foetal blood transfusion (IUT). Your baby may require more than one
IUT, depending on how severely they are affected by rhesus disease. Transfusions
can be repeated every two to four weeks until your baby is mature enough to be
delivered (usually 34 weeks). Even if the disease is not sufficient to cause anaemia
before birth, it is likely that your baby will be delivered a little earlier than your due
date.
How to prevent rhesus disease?
If you are rhesus-negative and routine tests during your pregnancy show
that sensitisation has not happened, you will be offered an injection of anti-D
immunoglobulin at 28 and 34 weeks of pregnancy. This helps to prevent sensitisation
by destroying any rhesus-positive cells in your blood stream before you can develop
antibodies. You will also be offered this injection if you experience any bleeding
during pregnancy, have an invasive procedure, or experience any abdominal injury
during pregnancy.
After birth, a sample of your baby’s blood will be taken from umblical cord.
If your baby is rhesus-positive, you will be offered an injection of anti-D within 72
hours of giving birth. This injection destroys the rhesus-positive blood cells that may
have crossed over into your blood stream before your blood has a chance to produce
antibodies. This will significantly lower the risk of your next baby having rhesus
disease.
15 9
Some women may develop a slight short-term allergic reaction to anti-D
immunoglobulin, which may include a rash or flu- like symptoms.
2
However, if test during pregnancy show that you are already sensitised and
producing antibodies to rhesus-positive blood, you will not be offered injections of
0
anti-D as they do not work in already sensitised women. You will be monitored with
regular blood tests and scans.
0
9
HIGH BLOOD PRESSURE IN PREGNANCY
Dr. RINA DIAS

AL ADAN HOSPITAL, KUWAIT
What is pregnancy-induced hypertension (PIH)?
Pregnancy-induced hypertension (PIH) is a form of high blood pressure in

pregnancy. It occurs in about 5 to 10 % of all pregnancies.
There are three primary characteristics of this condition, which are;

- high blood pressure (a blood pressure reading higher than 140/90 mm Hg, or
a significant increase in one or both pressures)
- protein in the urine
- edema (swelling)
Eclampsia is a severe form of pregnancy-induced hypertension. Women with

eclampsia have seizures (convulsions) resulting from the condition. In most cases
Eclampsia develops towards the end of pregnancy.
16 0
HELLP syndrome is a complication of severe preeclampsia or eclampsia. HELLP
syndrome is a group of physical changes including the breakdown of red blood cells,
changes in the liver and low platelets (cells found in the blood that are needed to
2
help the blood to clot in order to control bleeding).

0
What causes pregnancy-induced hypertension (PIH)?

0
The exact cause of PIH is not known. Some conditions may increase the risk of
developing PIH, including the following:
9
- pre-existing hypertension (high blood pressure)

- kidney disease
- diabetes
- PIH with a previous pregnancy
- Mother’s age younger than 20 or older than 40 years
- Multiple foetuses (twins, triplets)
What are the symptoms of pregnancy-induced hypertension (PIH)?
The most common symptoms of pregnancy-induced hypertension are:

- increased blood pressure
- protein in the urine
- edema (swelling)
- sudden weight gain
- visual changes such as blurred or double vision
- nausea, vomiting
- right-sided upper abdominal pain or pain around the stomach
- urinating small amounts
- changes in liver or kidney function tests
How is pregnancy-induced hypertension diagnosed?
Diagnosis is often based on the increase in blood pressure levels, but other
symptoms may help establish PIH as the diagnosis. Tests for PIH include:
- blood pressure measurement 161
- urine testing
- assessment of edema
- frequent weight measurements
2
- eye examination to check for retinal changes
0
- liver and kidney function tests
- blood clotting tests
0
Why is pregnancy-induced hypertension a concern?
With high blood pressure, there is an increase in the resistance of blood vessels. 9
This may hinder flow in many different organ systems in the expectant mother
including the liver, kidneys, brain, uterus, and placenta.
There are other problems that may develop as a result of PIH. Placental
abruption (premature detachment of the placenta from the uterus) may occur in some
pregnancies. PIH can also lead to foetal problems including intrauterine growth
restriction (poor foetal growth) and stillbirth.
If untreated, severe PIH may cause dangerous seizures and even death of the
mother and the foetus. Because of these risks, it may be necessary for the baby to be
delivered early, before 37 weeks gestation.
Treatment for pregnancy-induced hypertension:
Specific treatment for PIH will be determined based on the extent of the disease,
overall health, and medical history
The goal of treatment is to prevent the condition from becoming worse and to
prevent it from causing other complications. Treatment for PIH may include:
- bed rest (either at home or in the hospital)

- hospitalisation (as specialized personnel and equipment may be
necessary)
- magnesium sulphate and other anti-hypertensive medications for PIH
- fetal monitoring (to check the health of the foetus when the mother has
PIH) may include
• fetal movement counting – keeping track of fetal kicks & movements
16 2 • nonstress test – a test that measures the fetal heart rate in response to
the featl movements
• Biophysical profile – a test that combines nonstress test with ultrasound
to observe the foetus and Doppler flow studies – type of ultrasound
2
that uses sound waves to measure the flow of blood through a blood
0
vessel
- medications called corticosteroids that may help mature lungs of the
0
foetus
- delivery of the baby (if treatments do not control PIH or if the foetus or
9
mother is in danger). Caesarean delivery may be recommended, in some

cases
Prevention of pregnancy-induced hypertension
Early identification of women at risk for pregnancy-induced hypertension

may help prevent some complications of the disease. Education about the warning
symptoms is also important because early recognition may help women receive
treatment and prevent worsening of the disease.
WOMEN WITH DIABETES AND PREGNANCY
Dr. LAKSHMI BASAVARAJ – GYNECOLOGIST

NEW DAR AL SHIFA HOSPITAL, KUWAIT
Introduction:-
Pregnancy and new motherhood are times of great excitement ,worry and
change for any women. If you have diabetes and are pregnant your pregnancy is
automatically considered a high risk pregnancy. High risk means you need to pay
special attention to your health with specialized doctor. Pregnancy is considered
risky for women with diabetes because of the increased risk of miscarriages, stillbirth
and birth defects in their babies.
Keeping your blood glucose as close to normal as possible before you get
pregnant and during your pregnancy is most important thing for you to stay healthy
and have a healthy baby. The team needs to give the best care includes –
a) Medical doctors specialized in diabetes care for continuous monitoring and
advise a glucose control throughout pregnancy is required.
b) An obstetrician who has experience with women with diabetes and its
complications during pregnancy and delivery. 165
c) A pediatrician to take care of the new borns.
Effects of Diabetes on Mother
2
0
a) Pre eclampsia- affects 10% to 30%
b) Infections - high incidence of chorioamnionitis and postpartum
0
endometritis.
c) Postpartum bleeding.
d) Caesarean infection
9
Effects of Diabetes on Fetus
a) Congenital Anomalies (defects)

b) Hypoglycemia , Hypocalcaemia
c) Macrosomia (big babies)
d) I U F D (unexplained fetal death)
e) Traumatic delivery
Effects of Pregnancy on Diabetes
a) more insulin is necessary to achieve metabolic control

b) progression of diabetic Retinopathy
c) worsening of diabetic Nephropathy
d) High risk of death with cardiac myopathy.
Gestational Diabetes
Patient with gestational diabetes

are those where first recognition occurs
during the pregnancy. Some of these
patients may have type II diabetes that was
asymptomatic before pregnancy, some
other may have preclinical type I or type
II diabetes that became apparent under
the metabolic demands of pregnancy
and a few may have type I or type II
166
diabetes coincident with pregnancy,
Gestational diabetes affects 1% to 2% of
all pregnancies.
2
Gestational diabetes may recur in a future pregnancy. They are at high risk for
developing type II diabetes later in their lives. Roughly 40% to 60% will develop
0
overt diabetes later in life. Obviously weight loss, dietary control and exercise will
help prevent overt diabetes in later life.
0
Ultrasound :- Ultrasound can tell about the age of pregnancy ,position of the
9
baby ,size & the weight of the baby.Birth defects can also be diagnosed by U/S.
Kick count :- Counting kicks is an easy way to keep track of

baby’s activity and health.
Nonstress Test (NST) A fetal monitor checks whether baby’s heart rate
increases as it should when baby is active.
Biophysical Profile Ultrasound checks your baby’s muscle tone, breathing

and movement to obtain a biophysical profile.
Management
Screening for Diabetes in Pregnancy
The best screening test for gestational diabetes is the measurement of plasma
glucose 1hr. after ingesting 50grams of glucose. It has excellent sensitivity and
specificity.
The best time to screen is between 24 & 30 weeks of Pregnancy .Patients at high
risk may have the test earlier. (18-22 weeks) but if it is negative it should be repeated
between 26 – 30 weeks.
Patient with an abnormal screening test should be given a 3hrs glucose tolerance
test (GTT)
Upper limits of Normal for the 3 hours glucose tolerance test during
Pregnancy.
Fasting 96mg/d1 5.3 mmo/L

One hour 172mg/d1 9.6 mmo/L 167
Two hour 156mg/d1 8.4 mmo/L
Three hour 131mg/d 7.3mmo/L
2
Blood Glucose Monitoring
0
Blood checks will help you keep your blood glucose under control. It is
recommended testing at least four times a day. Write down the results every time in
0
daily blood glucose record. The diabetologist can keep track of blood sugar levels
using this record. It can help the doctor to decide whether the treatment plan is
9
working or it needs to be changed Patient can make note of her insulin dose and
urine for ketones.
The daily goals recommended by the American diabetes association for most
pregnant women are as follows
Times of testing blood glucose plasma blood glucose (mg/dl)

Before meals and when you wake up 80 to 110 or <6mmol/L
Two hours after the start of meal below 155 or <8mmol/L
* 1 mmol = 18 mg%
TREATMENT WITH INSULIN
The dose and administration of insulin depends upon the severity and
characteristics of metabolic problem .Controlled blood sugar seems the fundamental
in the prevention of fetal macrosomia.
During pregnancy the safest diabetic medicine is insulin. The oral medicine
have undesirable effects on fetus. If patient is already on injection insulin there is
need to change the type and dose of insulin according to the blood sugars & the
follow up with the blood sugars is very important throughout the pregnancy.
Timing of Delivery
To prevent antepartum deaths and foetal distress patients, need some methods
of foetal surveillance during last 6 to 10 weeks of pregnancy. They depend upon the
severity and stability of maternal diabetes like NST, BPP or OCT.
All pregnant diabetic patients should have ultrasound examination of the foetus
every 4 weeks to monitor growth. The macrosomic fetus at time will be above 95%
168 for one or more variable (Abdominal Circumference)
The mode of delivery depends upon baby’s size and position ,baby’s lung
maturity, baby’s heart rate, amount of amniotic fluid ,patients blood glucose and
2
blood pressure levels.

0
Doctors prefer to deliver babies of women with diabetes 1 or 2 weeks before

their due dates to lower the risk of problems. Most women with diabetes have the
0
option of delivering vaginally .

9
Primary caesarean section is justified if the estimated fetal weight at the end
of pregnancy is 4500gm or above. If the babies weight is between 4 to 4.5 kg they
should go in spontaneous labor and deliver vaginally. No vacuum or forceps should
be tried in these patients.
EXERCISE IN PREGNANCY & AFTER DELIVERY
Dr KIRAN SHARMA
Exercise during pregnancy is an issue of concern & thought.

It is generally found that if correct exercise is done, both expectant
mother & the unborn baby can be benefited.
Until recently, even the medical community was ambivalent about prenatal
exercise, citing concerns that it could cause miscarriage, poor fetal growth, or injury
to Mom. But for normal, low-risk pregnancies, these apprehensions are off base.
New research shows that regular exercise will improve your health, stabilize weight
gain without affecting the baby’s development, help prevent gestational diabetes,
allow you to bounce back better post-delivery, and improve your psyche.
Benefits of exercises:
- Exercise helps minimize back pain because 171

it helps strengthen back muscles.
- Exercise helps combat fatigue.
2
- Exercise can help promote a smaller amount
of fat gain during pregnancy.
0
- Exercise provides an exceptional form of
stress relief.
0
- Women who exercise during pregnancy are
more likely to return to their pre-pregnancy
9
weight faster & recover more quickly after
delivery.
If you were physically active before your pregnancy, you should be able to
continue your activity in moderation. Don’t try to exercise at your former level;
instead, do what’s most comfortable for you now. If you have never exercised regularly
before, you can safely begin an exercise program during pregnancy after consulting
with your health care provider, but do not try a new, strenuous activity. Walking is
considered safe to initiate when pregnant.
WHO SHOULD NOT EXERCISE DURING PREGNANCY
Women with a medical problem, such as asthma, heart disease, or diabetes,

exercise may not be advisable. Exercise may also be harmful if one has pregnancy-
related condition such as:
1 Bleeding or spotting
2 Low lying placenta
3 Threatened or recurrent miscarriage
4 Previous premature births or history of early labor

5 Weak cervix
EXERCISES THAT ARE SAFE DURING PREGNANCY
The best exercises for pregnant women, that can help promote physical fitness
& are less likely to result in injury are
1 Walking
2 Swimming
17 2 3 Stretching
4 Yoga
5 Pilates
2
6 Dancing
7 Stationary cycling
0
8 Low impact prenatal aerobics

0
EXERCISES THAT SHOULD BE AVOIDED DURING PREGNANCY

9
There are certain exercises and activities that can be harmful if performed during
pregnancy. They include:
• Holding your breath during any activity.
• Activities where falling is likely (such as skiing and horseback riding).
• Contact sports such as softball, football, basketball, and volleyball.
• Any exercise that may cause even mild abdominal trauma such as activities
that include jarring motions or rapid changes in direction.
• Activities that require extensive jumping, hopping, skipping, bouncing,
or running.
• Deep knee bends, full sit-ups, double leg raises, and straight-leg toe
touches.
• Bouncing while stretching.
• Waist-twisting movements while standing.
• Heavy exercise spurts followed by long periods of no activity.
• Exercise in hot, humid weather.
WHAT SHOULD A PREGNANCY EXERCISE PROGRAME CONSISTS OF ?
Always begin by warming up for five minutes and stretching for five minutes.
Include at least fifteen minutes of cardiovascular activity. Measure your heart rate at
the time of peak activity. Follow aerobic activity with five to ten minutes of gradually
slower exercise that ends with gentle stretching.
Here are some basic exercise guidelines for pregnant women:
1 Wear loose fitting, comfortable clothes as well as a good support bra.

2 Choose shoes that are designed for the type of exercise you do. Proper shoes
are your best protection against injury. 173
3 Exercise on a flat, level surface to prevent
injury.
4 Consume enough calories to meet the needs
2
of your pregnancy (300 more calories per
0
day than before you were pregnant) as well
as your exercise program.
0
5 Finish eating at least one hour before
exercising.
9
6 Drink water before, during, and after your
workout.
7 After doing floor exercises, get up slowly and gradually to prevent dizziness.
8 Never exercise to the point of exhaustion. If you cannot talk normally while
exercising, you are probably over-exerting yourself and should slow down
your activity.
WHAT PREGNANCY CHANGES MAY AFFECT EXERCISE?
Physical changes during pregnancy create extra demands on your body. Keeping
in mind the changes listed below, remember that you need to listen to your body and
adjust your activities or exercise routine as necessary.
1 Your developing baby and other internal

changes require more oxygen and energy.
2 Hormones produced during pregnancy cause
the ligaments that support your joints to
stretch, increasing the risk of injury.
3 The extra weight and the uneven distribution
of your weight shift your center of gravity. The extra weight also puts stress on
joints and muscles in the lower back and pelvic area and makes it easier for
you to lose your balance.
WARNING FOR PREGNANT WOMEN
Stop exercising and consult your health care provider if you:
1 Feel chest pain.

174 2 Have abdominal pain, pelvic pain, or persistent contractions.
3 Have a headache.
4 Notice an absence or decrease in fetal movement.
5 Feel faint, dizzy, nauseous, or light-headed. Feel cold or clammy.
2
6 Have vaginal bleeding.

0
7 Have a sudden gush of fluid from the vagina or a trickle of fluid that leaks
steadily.
0
8 Notice an irregular or rapid heartbeat.

9 Have sudden swelling in your ankles, hands, face, or calf pain.
9
10 Are short of breath.

11 Have difficulty in walking.
12 Have muscle weakness.
HOW SOON CAN ONE EXERCISE AFTER DELIVERY ?
Being healthy & loosing weight after pregnancy is one of the major concerns for
mothers who have delivered the baby.
It’s a question of When, How, and Should she exercise, if she has recently
delivered the baby.
Most women recovering from a C- Section will be able to exercise after their
incision has healed. A low-impact activity can safely be performed one to two weeks
after a vaginal birth and three to four weeks after a cesarean birth. Do about half of
your normal floor exercises and don’t try to overdo it. Each & every individual is
unique & different, thus their ability to return to a regular exercise routine will vary
after delivery.
It is important to listen to your body.
175
2
0
0
9
CESAREAN ON DEMAND
Dr. RAJNI GUPTA

MBBS, MD (OBSTETRICS & GYNEC), MRCOG ( U.K)
SPECIALIST OBSTETRICIAN & GYNECOLOGIST
DAR AL SHIFA HOSPITAL, HAWALLY, KUWAIT
With the increasing rate of cesarean section all over the world it has been
observed that one of the important reason for this is cesarean at the request of
patient. This has been a long debated topic with the controversy whether it is really
helpful for the mother and baby.
There are many organizations which have been laying emphasis on women’s
rights to make informed choice about the way in which they make their birth plans
according to their birth experience or apprehensions.
Celebrities like Britney Spears, Madonna, Celine Dion and others had their
choice of Cesarean on demand and are strongly advocating this. Before undergoing
for it without any medical indication one should be fully informed about its pros and
178 cons so decision by the couple can be made without prejudice.
COMMON REASONS FOR CESAREAN ON DEMAND BY THE MOTHER :

2
1. Psychological fear of child birth or Tokophobia.

2. Anxiety and lack of support during labor.
0
3 Control over date and convenience (social reason)

0
4 Previous bad experience of vaginal delivery.

5 Better for baby
9
6 Fear of Pelvic floor damage.
OBSTETRICIAN’S REASON FOR ENCOURAGING CESAREAN ON DEMAND :

1 Convenience.
2 To avoid stress and difficult delivery.
3 For financial gain.
Before a decision is made a careful analysis of the benefits and risks has to be
seriously considered.
BENEFITS - TO THE MOTHER :
1. No labor pain.
2. Decreased fear and anxiety related to childbirth and health of the baby
3. Avoiding emergency LSCS (going for Cesarean after going through
labor)
4. Conveniently planning the date and circumstances of delivery.
5. Protection of pelvic floor including reduced risk of prolapse - dropped
bladder, bulging rectum and fallen uterus which can result in involuntary
passing of urine and stool.
6. Decreased chance of genital prolapse in old age - after multiple child
birth and difficult delivery chance of loosening of support of uterus is
more common and it may come out through vagina in old age.
BENEFITS - TO THE BABY:

1 . Reduced chances of unexplained death of the baby in late pregnancy and
during labor. (100 planned cesarean saves one baby)
2. Decrease infections for baby (especially if mother has HIV or primary
17 9
Herpes infection).
3. Decrease in number of sick babies due to meconium aspiration, severe
oxygen depletion, cerebral palsy.
2
4. Decrease in incidence of fracture and nerve injury due to difficult
delivery
0
RISKS - TO THE MOTHER
0
1. Risk of death (Anesthesia and cesarean section increases the chance of
9
death 5 times more than normal delivery).
2. Complication of Operation – infection, bladder and bowel injury.
3. Blood loss is 3-5 times more in Cesarean with increase risk of anemia ,
and blood transfusion and its associated risk.
4. Longer recovery time . More pain and decrease in activity for up to one
month and some pain remains up to 6 month after surgery.
5. Readmission to the hospital - few cases may have readmission due to
infection, bleeding and blood clotting (thrombosis) .
6. In future pregnancies more chance of going for Cesarean again.
7. Risk of abnormal placement of placenta like placenta previa, placenta
acereta and uterine rupture. Out of 1000, 4-6 cases may have life
threatening complication in next pregnancy after previous cesarean.
RISK – TO BABY :
1. More chance of breathing problems requiring oxygen therapy in babies
with Cesarean section.
2. Removes the benefit of vaginal delivery in which the fluid in the
lungs of babies are squeezed out as the infant passes through the birth
canal.
3. Chances of low APGAR score which indicates lack of breathing or
activity at birth due to effect of anesthesia or lack of stimulation.
4. More chance of acidosis due to anesthetic drug.
5. More chance of death for future baby during pregnancy (4 out of 1000)
FACTS AND RECOMMENDATION ABOUT CESAREAN ON DEMAND
18 0 The number of cesarean delivery on maternal request is increasing tremendously.

There is insufficient evidence to evaluate fully the benefits and risk for such a
request.
2
So discuss with your doctor about your chance of delivering normally. Take 2nd
opinion if necessary . Avoid cesarean just for you or your doctors convenience.
0
If you have good chance of delivering normally and risk is low for the baby then
0
best is to try first for normal labor and delivery

9
For an obstetrician any decision to perform a Cesarean delivery on maternal

request should be carefully individualized according to safety and consistent with
ethical principles which is best for the mother and baby.
PAINLESS CHILDBIRTH – YOUR RIGHT, YOUR CHOICE
Dr. ABHAY PATWARI, CONSULTANT,

DEPARTMENT OF ANESTHESIA AND INTENSIVE CARE,
A letter from the Indian Doctors Forum, Kuwait
Dear Mothers and Expectant Mothers,
We bring you greetings from the Anesthesia department of Farwania hospital.
Do you know that pregnancy is the only physiological condition requiring

hospital admission and we along with the Maternity department welcome you to our
labor rooms.
The process of childbirth is associated with severe and excruciating pain over
a long period of time. It is no longer necessary to suffer from pain during childbirth
and the whole experience can become a pleasant one if you choose one of the 183
various pain-relief options available.
The following information will help you to make an intelligent and informed
2
choice and we will be happy to provide you this service if you so desire.
0
During the ante-natal visits, please discuss with the obstetrician your options for
pain-relief during labor. You could enquire about ante-natal classes where you will be
0
told what to expect during labor. You will also be taught various breathing, relaxing
and positioning techniques to help you cope with the painful uterine contractions.
9
This can also reduce injury to the back and joints after pregnancy and labor. You
could request a meeting with the anaesthesiologist for more clarifications about the
best options and the required preparation.
Labor pain is mild at the beginning but gradually increases in intensity and
frequency.
It is most severe during the first stage of labor, which can last anywhere from
4 – 12 hours.
Common methods of relieving pain are inhalation or breathing in of a gas (a
mixture of oxygen and nitrous oxide called Entonox) from time to time or intra-
muscular / intravenous injections of pain relieving medication (opiate analgesics –
most commonly pethidine). The relief provided by these
methods is inadequate (50%) and these drugs can affect
the baby’s breathing after birth in addition to causing
nausea and vomiting in the mother
The best and most effective method of pain relief

during childbirth is Lumbar Epidural Analgesia (LEA).

This is the gold standard against which all other methods
are compared. Millions of epidurals are given worldwide
and the method is well-established in practice. Any fear
of the procedure is unwarranted and is usually based
on inaccurate information. If properly conducted, it can Fig.1
provide you with a most pleasant experience during
labor.
You should have decided about this option during

184 the antenatal period so that you can ask for it as soon as
the labor begins. If you have not decided earlier, you can
also request an epidural after coming to the labor room.
2
LEA involves giving a small injection in the lower

back while you are either sitting or lying on your side
0
(Fig. 1). A fine plastic tube is introduced through this Fig.2

needle into the space through which the pain-carrying nerves pass. When a local
0
anaesthetic solution along with a very small dose of narcotic analgesic is introduced
into this space (epidural space –see Fig. 2), the transmission of pain sensation from
9
the birth canal to the brain is blocked. The process of childbirth continues but you
do not feel the pain. The injection is given intermittently or as a continuous infusion.
Sometimes, we can give a button (like a TV remote control) in your hand. You can
press this button if you feel any pain. Thus you can control your own pain. Fig 1
Should you unfortunately need an operation to deliver your baby, the anaesthesia
can be managed by the same epidural catheter and you can avoid the risks and
dangers of general anaesthesia (mainly inhalation of your stomach contents into your
breathing tube – which can be life-threatening). This complication known as ‘acid
aspiration syndrome or Mendelson syndrome’ is the most important preventable
cause of death under anaesthesia in the mother.
During the first stage of labor, it may be

possible for you to walk or go to the bathroom
with the epidural catheter.
Should you need an episiotomy (a small cut

that is made to enlarge the birth passage) or a
forceps delivery, both can be managed painlessly
under epidural analgesia.
At the end of the whole process, the plastic tube is removed and a small dressing
is applied.
On the whole, LEA is safe and effective, keeps the mother alert while relieving
her pain, has minimum ill-effect on the baby and allows earlier feeding and contact
with the baby.
Most hospitals in UK, USA and Europe offer epidural service to all their patients
and almost 70% opt for this method of pain relief. Millions of epidurals are given 185
safely all over the world each year.
Over the past 4-5 years, some ministry hospitals and most private hospitals in
2
Kuwait are offering this service to their patients.
0
Are there any problems or difficulties associated with LEA?
0
If you are obese or there is any deformity of the back, there may be technical
difficulty and failure to insert the epidural catheter. In this case, you can always go
9
back to the other less-efficient methods.
Occasionally (less than 1-2%), the sheath covering the spinal cord may be
punctured unintentionally leading to leaking of spinal fluid (CSF) and headache. But
this can be managed easily by simple methods.
You may experience some nausea, vomiting or a fall in your blood pressure. All
these problems can be easily corrected by the doctors.
Sometimes the pain-relief obtained may be inadequate or patchy. This can be

corrected by adjusting the dosage and concentration of the drugs.
You may require the assistance of forceps for delivery of the baby if you are
unable to push during the 2nd stage. This problem has been minimized by using a
lower concentration of the local anaesthetic drug.
There may be some soreness or backache, which usually disappears within a

week or two.
Very rarely, there may be some infection, or temporary weakness in one of the
legs which will recover over a period of time. We would like to assure you that we
have not seen many.
On extremely rare occasions, a small amount of blood may collect in the epidural
space leading to some compression of the spinal cord. This may need emergency
surgery to evacuate the blood clot.
We wish you a very happy and pleasant stay in our labor rooms.
186
2
0
0
9
CARE OF THE MOTHER DURING PUERPERIUM
Dr. ROOBA MOSES

GERMAN MEDICAL CENTER, KUWAIT
Puerperium covers the six week period following birth during which time various
changes that occurred during pregnancy revert back to non-pregnant state.
PHYSIOLOGICAL CHANGES
Heart. The extra load on the heart due to the extra volume of blood during
pregnancy disappears by the second week.
Vagina. Post delivery vaginal wall is swollen, bluish and pouting .It remains
fragile for 1-2weeks and gradually regains its tone.
Uterus The uterus reduces in size on abdominal examination by 1 finger breadth

each day from the original size of 20 week pregnancy which it takes after the delivery
of the placenta. After the 12th day it cannot be palpated. By the end of puerperium it 187
is only slightly larger than pre pregnancy
Lochia Lochia is the vaginal discharge during the first few days after delivery.
2
From days 3-4 the lochia comprises of blood and bits of decidual tissue. During the
next few days the colour changes from reddish brown to yellow.
0
CARE IN HOSPITAL
0
Common puerperal problems
Perineum (The area around the vagina) 9

Sometimes there may be a cut on the perineum which is stitched after delivery.
This may cause considerable pain requiring pain-killers. An ice bag applied to the
perineum may help to reduce the swelling and discomfort. Warm water bath is also
helpful.
Urination
Some women may have difficulty in passing urine and need catheterization at
times especially if epidural analgesia has been used.
Bowel problems
Constipation is a common problem. Being active and consuming food with

high fiber is helpful. Stool softners are helpful.
EARLY AMBULATION REDUCES BLADDER COMPLICATIONS AND

CONSTIPATION
Breast problems.
It may be due to failure to express milk from one part of the breast. This can be
treated by ensuring that all milk is expressed and cold compresses are given to the
breast.
Sometimes complications such as infection and abscess formation occur

requiring incision and drainage.
Back ache
188 This may persist after delivery and affects approximately a quarter of all women.
50% of women suffered from backache before pregnancy. Pain may be considerable
and last for several months.
2
Psychological problems
0
‘Third day blues’ or post partum blues can occur 3-5

days after delivery. A large proportion of women become
0
temporarily sad and emotional. Hormonal changes,

excitement of child birth, and fear of inability to rear the child
9
can be the cause of this temporary depression.
Effective treatment need to be nothing more than anticipation,

recognition and reassurance.
Tummy flab
Abdominal binder is unnecessary. It does not help to restore the mother’s figure. If tummy is
unusually flabby or pendulous an ordinary girdle is often satisfactory. Exercises to restore
abdominal wall tone may be started any time after vaginal delivery and as soon as abdominal
soreness diminishes after caesarean delivery.
Diet
There need to be no dietary restriction for women who have delivered vaginally.
Breast-feeding mothers need about 500 extra calories per day.
Serious puerperal problems
Puerperal psychosis
It is a serious mental disorder and may require hospital admission sometimes
along with the baby. It generally occurs in women with a previous history of psychiatric
disorder.
Post partum haemorrage(bleeding following delivery)
Early or Primary haemorrage:
This usually happens immediately after delivery. The cause is usually failure of
the uterus to contract and stop the bleeding. At times, retained placenta or tears in
the vagina or cervix can cause bleeding. Bleeding may be stopped by massaging the
uterus and giving some medicines. Tears may need to be stitched under anaesthesia. 18 9
Retained placenta or placental tissue are removed under anaesthesia. When the
haemorrhage is severe blood transfusion may be needed.
2
Late or Secondary haemorrage
0
It is defined as abnormal bleeding after 24hr and up to 6 wks post partum.
Usually causes are
0
• retained placental fragment or blood clot
• Infection
• If you have heavy fever, foul smelling discharge or extreme pain in the
lower abdomen, contact your doctor.
9
Puerperal pyrexia
It is defined as temperature 38˚C or above during the first 14 days after delivery.
Presence of fever is not normal in puerperium.
Infection anywhere in the body is usually responsible for fever. Common sites
of infection are:
• Birth tract
• Breasts
• Lungs
• Urinary tract.
• Clots in the leg veins or lungs.
This may appear as cough, burning in the urine, pain and swelling in the breast,
smelly discharge and lower abdominal pain. Contact your doctor immediately as
this can be serious.
CARE AT HOME
Coitus
There is no definite time after delivery when coitus should be resumed. Difficulty
frequently cited for not resuming intercourse included concern about perineal pain,
bleeding and fatigue. After about 2 weeks coitus may be resumed BASED UPON
19 0 PATIENT’S DESIRE AND COMFORT. Breast feeding and combined oral contraceptive
pills may cause vaginal dryness. A lubricant may have to be used.
Return of menstruation and ovulation

2
Risk of pregnancy in breastfeeding women is approximately 4% per year. If

0
the women does not nurse her child, menses usually returns within 6-8 weeks. In
breastfeeding woman the first period may occur as early as the second or as late as
0
the 18th month after delivery. Pregnancy can occur even with breastfeeding. Hence
it is necessary to use contraception to avoid pregnancy.
9
Contraception
Contraception is not necessary in the first 21 days after delivery. Methods

such as barrier methods (condoms), intrauterine devices, the progestogen-only pill,
injectable progesterone contraceptives, the etonogestrel implant and sterilization
are suitable choices for breast feeding women. The combined oral contraceptive pill
may interfere with lactation and hence it is not recommended. In non breast feeding
women combined oral contraceptives can be used along with all the other above
mentioned methods.
Breast and bottle feeding
Breast feeding is the best feeding. The advantages of breast feeding to the
baby are
• Boosting of baby’s immune system
• Decreasing autoimmune disorders later in life
• Decreasing gastrointestinal problems
• Reducing risk of cot death.
• Promoting bonding between mother and child
• A good bra support and analgesia will relieve a lot of discomfort caused by
breast engorgement
Activity in new mothers
New mothers should be encouraged to start walking and go

to toilet as soon as possible. They should be encouraged to take
care of their babies as soon as possible. Some mothers may suffer
from after pains especially when they are breast feeding because
of uterine contractions that continue after birth and these can be 19 1
treated with analgesics.
2
References:
0
1) Gary Cunningham, Norman F Gant, Kenneth J Leveno, et al : The Puerperium.
0
Williams Obstetrics 21st edition Mc Graw Hill: Chapter 17,pp 415-419
2001
9
2) Nielsen-Forman D, Videbech P, Hadegaard M: Postpartum depression :
identification of women at risk. BJOG 107: 1210,2000
3) Barret G, Pendry E, Peacock J: Women’s sexual health after child birth. BJOG
107:186,2000
4) Post natal care: Routine postnatal care of women and their babies. NICE
2006
5) Contraception, Clinical Knowledge Summaries 2007
POSTNATAL DEPRESSION
Dr. SADHNA NARANG

AL JAHRA POLYCLINIC, KUWAIT
What is postnatal depression?
The birth of a baby can often trigger a jumble of powerful emotions, from
excitement and joy to fear and anxiety. But it can also result in something unexpected
– mood swings and depression, in which feeling of sadness, loss, anger, or frustration
interfere with everyday life for an extended time.
The illness has its onset within weeks of childbirth and can be of 3 forms
depending on the severity-
(1) Baby blues or mild form.

(2) Postnatal depression or moderate form.
(3) Postnatal psychosis or severe form.
19 4
What is the difference between Baby blues, postnatal depression and postnatal
psychosis?
Baby blues can happen in the days right after childbirth and normally resolves
2
within few days to a week. A new mother can have sudden mood swings, sadness,
0
crying spells, loss of apetite, sleeping problems, irritability, restlessness, feeling of

loneliness and of being a ‘bad’ mother. Symptoms are not so severe and subside with
0
counseling and lifestyle changes like adequate rest, help from family and friends and
reassurance.
9
Postnatal depression may appear to be baby blues at first but symptoms are
more intense and longer lasting, eventually severe enough to interfere with your
ability to care for your baby and handle daily tasks, and requiring you seek medical
help like counseling, support groups and medications.
Postnatal psychosis is rare and usually develops within the first 2 weeks after
delivery. It generally occurs in women with a previous history of psychiatric disorder.
The symptoms are severe enough to need hospitalization and include confusion,
delusion, disorientation, paranoia, and attempts to harm yourself or the baby.
What causes postnatal depression?
There are a number of reasons why women get depressed.

• Sudden drop of hormones, changes in immune system
and metabolism can all lead to mood swings.
• Irregular sleep patterns without enough rest.
• Feeling overwhelmed with a new or another baby
to take care of and doubting the ability to be a good
mother
• Feeling of loss- loss of identity, loss of control, loss of your own pre-
pregnancy figure and feeling of being less attractive.
• Having less free time, having to stay indoor, and having less time to spend
with your partner and loved ones.
• Marital and financial problems
• Young age of motherhood or unplanned pregnancy.
• Problems with previous pregnancies or birth of a handicapped child.
• Major life changes like moving house or a death in the family.
• Previous history of depression. 19 5
What are the symptoms of postnatal depression?
2
If you suffer from 3-4 of the following, you may be suffering from Baby blues. If
you suffer from 6-8 of these, you may be suffering from postnatal depression. If you
0
are suffering from almost all of these, you may be having postpartum psychosis.
• Constantly feeling tired, having no energy or motivation.
0
• Sleeping problems- disturbed sleep, difficulty waking up and getting back
to sleep.
• Crying a lot, often over small things for no reasons.
• Can not eat or overeating.
9
• Overanxious or overprotective for the baby.
• Lack of interest in anything, for example household activities, dressing up
etc.
• Feeling sad, lonely and isolated, feeling rejected by friends, family, partner
and your baby.
• Feeling overwhelmed, hopeless, and unable to cope.
• A constant underlying sense of anxiety-
escalating into panic attacks. Easily ‘set off’
and difficulty in calming down.
• Difficulty in concentrating, say on a book, a
film, a conversation or difficulty in decision
making and forgetfulness.
• Putting on a front, trying hard to be a
supermom.
• No interest in sex.
• Feeling guilty about everything- especially

about being a bad mother.
• Strange, frightening thoughts about harming yourself or your baby.
• Having physical aches and pains, such as headaches, stomach pains,
blurred vision, palpitations, hyperventilation (fast and shallow breathing)
and worrying that it is something serious or terminal.
10 steps to recovery
19 6 (1) Could you have postnatal depression?

If you feel something is not right, be prepared to admit the possibility of
suffering from postnatal depression. There are no prizes for suffering.
2
(2) See your doctor or health care provider

0
If you are feeling depressed, don not hesitate to confide in your doctor
especially if the symptoms interfere with your ability to do everyday task.
0
Remember , early intervention speeds recovery.

9
(3) Medication? What will the doctor do?

Your doctor may ask you to complete a depression screening questionnaire to
assess the severity of illness. He will do the blood test to assess blood counts
and thyroid hormones, check blood pressure and do general examination.
He may suggest anti-depressant drugs, don’t be afraid. If you are breast
feeding, tell your doctor, as there are drugs that will not harm your baby.
Thyroid hormones may be given for under active thyroid. In severe case, ECT
(shock) may be recommended.
(4) Talk to your family and close friends. You need to talk your heart out to them,
and seek their help.
(5) Counseling
Many new moms find counseling helpful. It helps allay your fears, cope up
with your feelings, solve problems and set realistic goals.
(6) Little things you can do yourself

The best way is to take care of yourself, as it helps in speedy recovery.
Take enough rest – nap when the baby naps, take plenty of fresh fruits, veggies,
milk, whole grains and avoid alcohol. Make time for yourself dress up, go
out, watch a film, read a book, take a walk, spend time with your partner, visit
a friend etc.
(7) Find like-minded friends and avoid isolation

Someone to go for a walk with, have coffee and chat.
(8) Get local help and support

Get help in the house and stop pushing yourself to do everything. It helps 19 7
ease your pressure.
2
(9) Find out more.
Read books on the subject, on how to look after your baby, surf the net,
0
discuss with other new moms. It will help you to realize that this is common
and curable and you are not the only one going mad.
0
(10) Remember 3 things everyday
- Postnatal depression is an illness

9
- You will get better soon
- You are doing a great job ….., and you are a good mom.
Alternative remedies-
o Acupuncture – it helps promote deep relaxation and sometimes even sleep.

It may relieve fatigue.
o Omega-3-fatty acids – may help.
o Massage therapy – may help to relieve stress and fatigue
o Herbal therapy – the herb St. Johns wart, known as ‘natures Prozac’ may
help, but should not be given if you are breast feeding.
o Yoga, meditation, physical exercise – all help in relaxing the mind and
body, improves circulation and give a sense of well being.
o Creative arts – art, music, drama, can be possible ways to relax the mind
and encourage positive behavior.
o Laughter therapy – can help you de- stress and elevates the mood.
Postnatal depression in fathers
Some fathers can suffer the same symptoms. Watch out if you are a new dad and
seek help if you think you are suffering.
19 8
2
0
0
9

Health Guid Ind Docts KuwaitHG5

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Health Guid Ind Docts KuwaitHG5

Uploaded by

Copyright:

Available Formats

MENARCHE AND MENSTRUAL PROBLEMS IN ADOLESCENTS

Dr. RAMADEVI V WANI,

Menstruation also known as menses or periods is the periodic (approximately

What is menarche and why does it occur?

The first menstrual period is called menarche (said as “MEN-ar-kee”). It

When does menarche occur? 9

What is menstrual cycle?

How does it work ???

Normal menstrual cycles in adolescent girls.

Menarche 10-16years (average 13 years)

Why do I have heavy menstrual bleeding?

Menstrual conditions that require evaluation by doctor:

day of one period to the first day of the following period.

Dr. MADHU GUPTA MRCOG

Vaginal discharge in childhood is a common condition. It can be recurrent and

It is important to note that causes of vaginal discharge in childhood are quiet

Physiological Discharge in Newborn Girl

Why young girl is prone for recurrent Vaginal Discharge

Recurrent complaint is common in girls of 2-7 years of age. Reasons are:

3) Pre pubertal girl has an inherent susceptibility to vaginal infection as she

and atrophic(due to lack of oestrogen hormone)

Most patients have recurrent complaints of irritation on vaginal discharge.

Girl should be seen by specialist (Gynaecologist). Doctor will ask a detailed

Recurrent Vaginal discharge is a common problem with young girls. Parents

If there is no improvement to conservative management or if discharge is blood

THREAD WORM (ENTEROBIUS VERMICULARIS)

Eczema or Psoriasis on perineal skin are rare.

Is due to wetting of skin by urine and irritation from ammonia or possibly

So as most common cause of vulval irritation and vaginal discharge is non-

Dr. ANANTHAPRIYA VAIDYA

Extent of the problem. 9

What are the consequences of this?

High blood pressure, Arthritis, Diabetes, Coronary heart disease, Stroke,

It also is a financial burden in terms of medi-care and medical insurance.

Scary!! Isn’t it?

So we as individuals and responsible parents need to be proactive. We need to

How are we going to do that??

Surgery in adolescents and children is a tricky issue. More is available on this

talk about this at length.

Some small measures include the following.

Avoid making unfavourable comparisons with other children particularly about

Allow children to make healthy options rather than forcing it on them.

There should not be an over emphasis on maintaining normal body weight 17

Dr. ASHOK KUMAR SHARMA, MD, DNB

Acne can be aggravated by greasy

Although most teenagers with

Striae are best known as an association of pregnancy,

Excess body hair

repeated frequently. Laser epilation is more effective although substantially more

expensive and has to be applied twice a day.

Body odor and sweating

Blushing and emotional flushing can also become a problem at adolescence.

antibiotic treatment, particularly for acne. It should be remembered that vulval

1) Do not go to bed without first removing make-up

Dr. RAMANI SAMUDRALA, DGO, MRCOG

Who gets painful periods?

• Primary dysmenorrhoea is the common type of painful periods. This is

Primary dysmenorrhoea - the common type of painful periods

What causes the pain of primary dysmenorrhoea?

What are the symptoms of primary dysmenorrhoea?

Secondary dysmenorrhoea - period pain due to an underlying cause

Some types of intrauterine contraceptive device (IUD) make painful

Dr. PREETI SETHI, MD

Definition: Vaginal discharge is one of the most common complaint in women