April 2000
Journel of Family Medicine
An overview of Obstetric and Gynaecology (vol 1)
______________________________________________________
Expert.
Prof Dr Farrukh Zaman
MBBS,FCPS.
Special interest Infertility Disorders.
Post Graduate Medical Institute ,Services Hospital
Evening Practice at Hamid Lateef Hospital,Ferozpur Road ,Opposite Qazzafi Stadium,Lahore.From 6pm to 10 pm ,Tel no s:5862623,5882656.
______________________________________________________
Coordinator for Ob/Gyn
Dr Saadia Bakhtiar
MBBS,DGO
Gynaenacologist DHQ Hospital
Hasan Clinic (opposite DHQ Hospital).Tel no259119
Questions,Advice,comments Invited!
If you have any question or conider some aspect to be covered in next issue in May on Ob/Gyn, Please contact Dr Saadia,Dr Mehboob Ashraf or Dr Liaqat on Tel nos:259119,234836,200366.
This issue printed with courtesy of
Livial
tibolone
Meeting Women’s Specific
Needs.
From Organon.
Contents.
Subject Page no
Editorial 2
Panel interview of Prof Dr Farrukh Zaman 2
Section by Dr Sa’adia Bakhtiar.
Rational use of drugs. 8
Relevant Physiology 8
Vaginal Discharge 10
Anitnatal care 11
Pelvic Pain 12
Diabetes Mellitus in Ob/Gyn 14
Section by Dr Mehboob Ashraf
Teratology 15
Drugs in Lactation 18
Menopause 19
Internet Section.
Ectopic Pregnancy. 22
Preimplantation Genetic Diagnosis 26
Topics of next issue of May 2000.
Norms of pregnancy,High risk pregnancies.
Pregnancy with medical problems
Indications for termination of Pregnancy.
Emergencies in Ob/Gyn.,Eclampsia.,Peurperal Sepsis.
Vaginal discharge.Pelvic inflammatory disease
Pelvic tuberculosis,Low backache
Adolescent Gynacology
Contraception.
Brief review of Breast problems.
Internet section containing update on female menopause and debate on male menopause.
Chairman Board of Management
Dr Fazal Mehmood Uppal Tel no :217067
Pakistan Society of Family Physicians.
352 E Satellite Town Gujranwala
E mail:drsar@brain.net.pk
Editorial
Topic of this issue needs a different protocol for male GPs in Pakistan.Proper internal examination is missing for them.Ladies do not come out even with specific history.Physician has to confirm by direct questioning what patient means with indirect references to gynaecological problems and it needs lot of experience and verstality in our population.
After lot of discussions ,heart burn and modifying again and again,Dr Mehboob Ashraf and Dr Saadia have developed specific protocols on Vaginal discharge,pelvic pain,and contraception.This is an innovation.They must be congratulaed.This is specifically targeted to conditions in our settings.It may not be perfect but still it is practical for male family physicians.Somewhere else for some body else,something else may be needed.
Dr Mehboob Ashraf and Dr Liaqat Ali have written only those specific problems with which they have some experience.Dr Saadia was requested to write up those issues which need experience of Gynaecologist.She has made all practical arrangements for the interview ,meeting and this journel.PSFP Gujranwala is indebted to her for this.
Dr Saadia has written superbly.Her skill of writing in brief ,crisp and sharp phrases must be natural..She has very good radar to read the requirements of family physicians.She has taken lot of pains to write in present format.She is most welcome aboard.She is requested to keep on writing regularly for us.
Dr Saleem Akhtar Rana
Tel no.0431-240026.
_____________________________________
Panel Interview of
Prof. Dr. Farrukh Zaman
MBBS, FCPS
Postgraduate Medical Institute, Services Hospital, Lahore.
(Following text has been prepared from the answers given to the questions by the panel members. Panel consisted of Dr Saadia Bakhtiar, coordinator for this issue, and Dr Mehboob Ashraf, Dr Liaqat Ali Chaudhry and Dr Saleem Akhtar Rana)
Brief advice for family physicians.
Family physicians should play their primary role in motivation for family planning.
During antenatal care blood pressure should be monitored by family physicians.
Use of drugs should be monitored during pregnancy.
GPs should be watchful about problems of perimenopausal age.
Menstrual abnormalities should be interpreted according to age period of the patient.
Menstrual Disorders and Abnormal Vaginal Bleeding
During first 4-5 days there may be vaginal bleeding in the neonate. It is due to oesterogen withdrawl (of the mother) effect. It does not carry any significance or prognosis. Nothing needs to be done other than reassurance.
Foreign body should be excluded by local examination.
Sexual assault should be kept in mind.
Rarely malignancy may be the cause.
In girls of 14-16 yrs of age presenting with primary amenorrhoea, swelling in the lower abdomen and cyclic, monthly pain one should think of this condition. Sometimes these patients present with acute urinary retention. Inspection of external genitalia will show a bulging bluish membrane, which is imperforate hymen. Ultrasound confirms the diagnosis. Simple incision under general anaesthesia is good enough.
Menarche, Adolescence and Puberty
Average age for menarche is 12-14 years but it may be delayed uptil 16 years.
If there is no onset of menses even at the age of 16 years, it needs to be investigated starting with ultrasound to confirm the presence of uterus and ovaries. It should also rule out any mass.
Menstrual cycle may be irregular and the blood loss can be heavy or small in amount for the first few cycles. Nothing more than reassurance is needed.
If bleeding is heavy and prolonged then a progestogen like Tab. Primolut-N twice a day for 10 days can be given. It will stop the bleeding to be followed by withdrawal bleeding and normal pattern of menstrual cycles. In case the problem persists the cycle can be regularized with the help of contraceptive pills given cyclically for three months.
Menstrual disorders upto 20 years of age should generally be regarded as functional in the sense that the system is finding its rhythm. Therefore, conservative approach should be adopted. Ultrasound should rule out any organic lesion and then simple contraceptive pills can be given to regularize the cycle. Reservations about the use of contraceptive pills in young girls are unfounded. In about 1% of girls treated with contraceptive pill there may be post pill amenorrhoea. These girls would have had amenorrhoea anyway and it was the use of pill, which was bringing about withdrawal bleeding.
In 20-40 years age
Always rule out early pregnancy problems.
Ultrasound should always be ordered to rule out pregnancy, missed abortion, ectopic pregnancy or fibroid / polyp, etc.
Simple progesterone (like Primolut N) tid can be used to stop bleeding. Bleeding should stop within two or three days. Otherwise patient should be referred to a specilist. If bleeding stops Primolut N should be continued for 10 days and then stopped. There will be withdrawal bleeding after this. Patient should be placed on contraceptive pills to regularize the cycle.
Usually unnoticed or undiagnosed incomplete abortion is the case that can be diagnosed on D & C, which proves to be therapeutic as well.
A major concern in this age group is malignancy. The physician should be alert to this possibility without arousing undue concern and alarm in the patient.
The problem usually referred to as DUB (Dysfunctional Uterine Bleeding) is the common diagnosis. But this diagnosis is reached only after excluding organic pathology by examination and relevant investigations.
At general practice level ultrasound and pap smear are the initial investigations. For further workup the patient should be referred to the specialist.
Bleeding in pregnancy is always abnormal. Use of progestogens for early pregnancy bleeding is not of much benefit. First trimester miscarriages usually are due to an abnormal conceptus and as such progestogens will not have any effect.
Oligomenorrhoea
Oligomenorrhoea is infrequent menstruation, i.e., the duration of menstrual cycle is longer than normal, which is 21 to 35 days. It may be routine matter for any single patient.
Hirsutism and obesity usually accompany oligomenorrhoea in polycystic ovaries. The condition of polycystic ovaries (PCO) is fairly common, the incidence being 22%. Ultrasound examination demonstrates the typical appearance of these ovaries.
Hyperprolactinaemia can be a cause in which case galactorrhoea may be present.
Dysmenorrhoea
Primary dysmenorrhoea is quite common. History can demonstrate that mothers, who had this problem, usually have daughters with the same complaint. Conservative approach with reassurance and explanation is all that may be needed. If pain is severe then simple NSAIDS like Ponstan or Brufen tid for 2-3 days can be good enough.
In persistent cases to rule out organic cause ultrasound as an initial investigation should be done. Endometriosis is an example of the organic causes.
Hyperemesis Gravidarum
Family physicians are often confronted with this problem. Hyperemesis gravidarum is excessive vomiting to the extent that the patient cannot retain any food or water leading to severe depletion. Nothing should be given by mouth for 2-3 days to break the cycle of vomiting. Fluids and electrolytes should be given by I/V route. One litre each of Ringer's lactate, 10 % Dextrose, Dextrose / Normal saline can roughly meet the daily needs. Hospital admission brings change of environment for the patient and should not be delayed as severe condition can affect liver function and patient may develop jaundice
For vomiting frequency of 2-3/day the patient should be reassured. She should be advised to have intervals between taking solid food and liquids. Navidoxine one tablet thrice a day half-hour before meals is quite helpful.
Air hunger / Breathlessness in late pregnancy
It is due to physical effects of pregnancy along with the effects of progesterone. Palpitation and breathlessness when only due to these factors needs only explanation and reassurance.
Hirsutism, excessive facial hair, is not an uncommon complaint. It may be familial, therefore, history of the problem in mother or sister should be elicited.
Usually hirsutism is accompanied with menstrual abnormality (oligomenorrhoea or even amenorrhoea) and weight gain. Married women may also present with infertility. As such it is part of polycystic ovarian disease (PCO) for the diagnosis of which ultrasound is quite helpful. Obesity plays an important role in the hormonal disturbance of this condition.
Young unmarried girls:
They should be emphasised the need of weight reduction by limiting caloric intake and regular physical activity, like brisk walk.
For excessive facial hair, as well as for menstrual irregularity, medical treatment in the form of Diane-35 may be prescribed. It has to be taken cyclically for around nine months to reduce the severity of hirsutism.
Additional cosmetic measures like electrolysis may also be required.
For married women:
Same general measures as for unmarried girls.
Those desirous of pregnancy should have basic workup for infertility. If other causes of infertility are ruled out induction of ovulation is carried out with clomiphene citrate. For unresponsive patients specialist referral would be needed.
Early warning for malignancy in gynaecology
Screening programme for carcinoma of cervix in western countries has considerably reduced the incidence of this malignancy. Previously this was the commonest female genital malignancy and its incidence was double that of carcinoma of body of uterus. Now ovarian cancer is number one followed by malignancy of uterus and then carcinoma cervix.
Any abnormal bleeding after 40 years of age should be viewed with suspicion. Postcoital bleeding is also an early warning sign.
D & C and cervical biopsy are general recommendations for abnormal vaginal bleeding after the age of 40.
Peak age for CA cervix is 45 - 48 years while for CA uterus it is 60 years.
Whereas malignancies of cervix and uterus announce themselves in the form of abnormal vaginal bleeding ovarian cancer remains silent for a longer time. Ovarian abnormalities picked up on ultrasound should be referred to the specialist for further management.
It should be remembered as a general rule that 45% of ovarian tumours at 45 years of age are malignant.
Ovarian Cysts
With the wider use of ultrasound examination, reporting of ovarian cysts has increased tremendously. The fact that the graffian follicle may reach a size of 2.5 cm before releasing the oocyte should be kept in mind. Criteria for management are simple. Cysts of 4-5 cm should be taken as follicles that have failed to rupture giving rise to functional cysts of the ovary. These should be monitored by repeat ultrasound examinations at monthly intervals. If they continue to grow in size, operative management would be required. Most of these gradually become smaller and disappear spontaneously. In good compliance patients, especially of younger age, cysts of even 7-8 cm size may be observed by periodic ultrasound.
Lower abdominal pain / Backache
The explanation of these common complaints in most patients is obesity and relaxed muscles of abdominal wall. This puts extra burden on back muscles. The solution is simple but difficult to practice. It requires weight management and exercise to strengthen abdominal muscles.
Vaginal discharge, weakness, backache and leg pains are frequent presentation in women. A common perception is that the vaginal discharge causes this weakness and aches and pains, whereas it is the above-mentioned mechanism that produces these complaints. If on vaginal examination uterus is not fixed and ultrasound examination is normal then the patient should be reassured.
Endometriosis and pelvic inflammatory disease are important organic causes for lower abdominal pain and backache. Their definitive diagnosis requires ultrasound and in some cases laparoscopy.
Vaginal discharge
First of all it should be decided whether it is normal or abnormal. There is some discharge (secretions) present in the vagina normally to keep it comfortably moist. Sometimes there is excess of this normal discharge and apart from its amount there is no other complaint. This happens in mid cycle, during pregnancy, with contraceptive pills or when there is cervical ectopy (previously called erosion). Cervical ectopy may require cauterisation; in all other cases reassurance is all that is needed.
Abnormal vaginal discharge is accompanied with smell and vaginal discomfort or itching. Common varieties are as follows:
Trichomoniasis
The discharge may be watery, frothy and creamy, greyish or greenish in colour and is accompanied with itching. A convenient treatment is single dose of metronidazole 2 gm each for both partners followed by abstinence for one week.
Monilial infection
This is common in pregnancy, in diabetic women or in those who have recently taken broad spectrum antibiotics. The patient complains of itching and whitish curdy discharge. Common treatments are either single dose clotrimazole vaginal pessary or nystatin vaginal pessaries for two weeks. There are many other effective local preparations besides oral single dose preparations like fluconazole.
Bacterial vaginosis
This is a condition in which normal vagina flora is replaced by anaerobes. The resultant discharge produces a fishy smell. Treatment consists of metronidazole with doxycycline or one of the quinolones for five days.
Hormone Replacement Therapy
Hormone replacement therapy (HRT) is now widely recommended to postmenopausal women not only for alleviation of menopausal symptoms but also for other benefits. These include a general sense of wellbeing, prevention of osteoporosis and cardiovascular benefits. HRT improves quality of life. Concern regarding increased chances of CA breast with HRT use can be put into perspective by the fact that the incidence of CA breast in general population is estimated at 45/1000. After 5 years of use it rises to 47/1000, after 10 years 50/1000, and after 15 years 57/1000. Patient and physician can make an educated decision after going through these figures.
Usually HRT is started after the menopause is established, which means six months after the last periods. Some women, due to their symptoms, may require HRT in the peri-menopausal period when their menses have not stopped altogether but are infrequent. If there is any abnormal bleeding that should be investigated first.
Following workup should be done before instituting HRT:
Examination of breasts for lumps.
Lipid profile.
Mammography.
The available preparations in the market are either cyclic, three weeks on one week off (Climen, Progyluton) or continuous (Femoston, Livial). The major drawback is their cost.
In women who have had hysterectomy continuous oestrogens are given. The commonly used preparation is Tab. Premarin 0.625 mg daily.
In the presence of uterus continuous oestrogens without progestogens cause high incidence of endometrial carcinoma. In view of this the recommended preparations having oestrogens, both cyclic and continuous, have also a progestogen in them.
If there is irregular spotting during the therapy, Pap smear and specialist consult should be obtained.
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Section by Dr Saadia Bakhtiar.
Consultant Gynaecologist DHQ Hospital.Gujranwala.
Rational use of drugs.
A doctor’s job is to prescribe drugs. Rational prescriptions are expected. How it is that more and more irrational prescription are now in circulation. Quacks try to copy the routines of doctors. When doctors are not applying their knowledge or not acquiring required knowledge, how can we lament and complain incessantly about the quackery?
Following groups of drugs are being overprescribed and on many occasions without any indication.
Antibiotics.
Should not be prescribed for all sorts of vaginal discharge. These may aggravate and on some occasions cause fungal infections.
Local Steroid applications.
These are being misused to treat pruritis vulvae. Steroid applicaion augment the problem.
Dettol Wash
To treat vulvitis. This is another cause to initiate the damaged skin and worsen the damage.
Antiemetics.
In first trimester use of these must be very limited. Councilling and the modefying the diet and dieteray intake can be of more help.
Iron and Ca Supplements.
are being misused in first trimester. These are not required at this time. These may cause teratogenic effects like other drugs. Gastric irritation may be another reason to avoid.
Oral hypoglycemics.
There is no reason on the earth for these drugs during pregnancy.
Venotlin Tab.
Is being misused for abortions. They have only limited rule to delay preterm labour.
List of safe drugs during pregnancy.
Should be kept on desk for ready reference.
Progesteron
Is being misused in first trimester to treat threatened abortion. It can not prolong pregnancy, if this is going to abort.
Infertility and Empirical Use of Clomophene.
All cadres of physicians are overprescribing this drug. It is a powerful drug and should never be given without proper indications.
Uses of Clomiphene.
Induction of ovulation 50 –150 mg/day for 5 days starts on 2nd day of periods.
Some cases of Oligospermia. 50 mgs/day for 90 days with the gap of 5 days after every 25 days.
Pre requisites for use of Clomiphene.
All causes for infertility other than anovulation should be ruled out.
Liver functions must be normal.
Hypothalamic –Pituatary function should be intact.
Some degree of ovarian function should be present. It is best suited to the persons with low levels of Gonadotrophins and high levels of E.
Contraindications.
Liver impairment
Patients with ovarian cysts and masses. Drug itself has the tendency to cause cystic changes in the ovaries due to overstimulation.
Side effects.
Overstimulation of ovaries resulting into pain & enlargement, cystic changes and multiple pregnancies.
Relevant Physiology.
Estrogens.
Secreted by ovaries mainly and then by supra renal cortex.
In pregnancy by placenta.
Determines
secondary sex characters
feminine curves, soft skin,
luxuriant scalp hair, development of breast at puberty, and shyness
etc.
Development
and Stimulation of secondary sex organs.
Development
of Vulva, Vagina, glands in this area, Changing infantile Uterus to
adult form and later on proliferative activity in endometrium and
myometrium.
Development
of Breast
by icreasing vascularity, proliferation of
cells and deposition of fat. It does not cause lactation, rather it
inhibits it. That is why contraceptive pills in lactating women are
not recommended.
Acts
on Locomotor System.
Conserves Ca ++, PO4 ----, and
encourages bone formation. Growth spruts at puberty and
osteoporosis at menopause can clearly be linked to esterogens and
justifies the role of HRT (Hormone Replacement Therapy) at
menopause.
Lowers
the level of Cholesterol levels.
This may have some
bearing on relatively low incidence of coronary thrombosis before
menopause.
Progesterone.
Secreted by Corpus luteum and placenta mainly and then by suprarenal cortex.
Mainly
taken as hormone of pregnancy.
Helps in maintaining
the pregnancy and developing maternal instinct.
Acts
on secondary sex organs only if
previously primed by
estrogens. Otherwise it is practically ineffective. Brings about
glandular activity in breast, endometrium of Uterus (during second
half of Menstrual cycle), vagina etc. It is important to prepare
the breast for lactation but does not initiate the letting down of
milk. That is why injectable contraceptives can be comfortably
given to lactating mothers.
General
effects
Increases sebum production by sebaceous
glands and hence responsible for premenstrual acne and silky hair
changes during pregnancy. Relaxes smooth muscles throughout the
body. Uterus remains silent. Ligaments are relaxed. Gastric
emptying is delayed. Intestinal motility is decreased.
Menstrual cycle.
Gonadotrophin releasing hormones of hypothalamus (GnRh), Gonadotrophins (FSH, LH) in addition to estrogens and progesterone play role in cyclical changes.
Mean duration is 28 days. It can vary from 21 days to 35 days. It is most irregular 2 years before menarche and 3 years before menopause. At both times anovulation is the cause. It is usually divided in 3 phases.
Mensrual
phase: Day 1 to Day 4
Two third to four fifth of
endometrium is shed due to sudden withdrawl of E and P.Only basal
layer which is 1 mm thick, is left behind. It may last from 2nd
to 8th day.
Proliferation
phase: Day 5 to Day 14
Under the growing effect of
Esterogen repair endometrium starts increasing its thickness and
vascularity till it is 2-3 mms. Phase lasts till ovulation.
Secretory
Phase: Day 15 to Day 28.
After ovulation
progesterone is secreted from corpus luteum and this leads to
increase in thickness and tortousity of grandular components and at
the same time increases vascularity. Thickness becomes 5-7 mms. This
phase ends with the sudden withdrawl of E and P and consequent
shedding.
____________________________________________
A protocol for Family Physicians to deal with Vaginal Discharge.
Carefull history should decide whether it is
Recent Event ,Acute, Recurrent or Chronic event.
Character and associations Treat Husband and Look for
secondary causes.Cervical erosion,P I D UTI,Do blood sugar for DM,Do
Characteristics. U/S & Vag swab.Refer.
1) Clour Colourless ,mucoid = Leucorrhoea
White Curdy = Candida
Yellowish green = Trichomonal
Thin white,purulent = Bacterial
2) Smell Foul Smelling = Trichomonal
Fishy = Bacterial
No smell = Candida
3) Amount Excessive = Leucorrhoea,Trichomonal.
4) Consistency Thick = Candida
Thin = Leucorrhoea
5) Association with Pruritis = Trichomonal & Candida
Associations with
Local soarness and ulcers Positive in Trichomonal but more. pronounced in bacterial and candidal infections.
Relation with Menstrual cycle. Exaggerates before it Candida
. After Trichomonal
. Throughout Leucorrhoea and Bacterial.
During Pregnancy Candida
During or after Antibiotic use Candida
With contraceptive use. Candida.
All neglected discharges get bacterial infections.
___________________________________
Aims.
To warn against home deliveries.
To prepare them mentaly for lactation to educate them on norms of pregnancy and about their anxiety.
To pinpoint high-risk patients.
To find out medical ailments like DM, Anaemia, Heart problems, hypertensive, tuberculosis thyrotoxicosis etc.
Points not to be missed in antinatal care.
Pregnancy should always be documented with positive urine test.
All physicians are quite familiar with the risk of teratogenicity of most of the drugs. Still in practice this is not reflected. Only situation to take the risk is where mother’life is in real danger.
LMP should be noted on first visit. Patient has tendency to forget. All problems of maturity need accurate date.
All cases of Diabetes Mellitus must be placed on insulin immediately. No relaxation is possible here. Not to do this is worse than quackery. It is wilful neglect and physician can be prosecuted.
Oral anticoagulants are prohibited. Only injectable therapy can be given.
All cases with bad obstetric history should be under the care of specialist right from start.
All pregnant patients should have a monthly visit till 28 weeks, fortnightly till 36 weeks and weekly till delivery. More frequently if there is any problem.
All patients should be checked for BP at every visit. Anything above 140/100 should be treated or refered. Salt and fat restriction, bed rest and aldomet can be prescribed. If condition persists and/or oedema develops patient should be under specialist’s treatment.
Blood group should be checked of all patients. If Rh factor is negative then blood group of father should always be documented. Delivery must be in hospital and attending doctor must know about this.
Protein and sugar in urine should be checked at every visit or at least once in each term. Vaginal secretion contamination can give false positive result for proteins. Instructions of washing of vulva and collecting mid stream urine, keeping the containing above vagina, near urethera are essential.
Weight gain should be recorded at each visit.
Hb must be checked at each visit. Anaemic patients should be given oral iron. If Hb is below 9 gms/dl or in case patient can not tolerate oral iron then injectable iron should be given. Roughly 3 injections of Jectofer raise one gram of Hb.Amount can be calculated.
Ultrasound should be ordered in all cases. Ideally once during each term, even if pregnancy is progressing normally. Two are essential. One at 12 weeks and second at 36 weeks.
Iron can be started after 12 weeks and calcium supplements at 20 weeks when bone formation of fetus is actively in process.
Vaccination against Tetanus with 2 doses at the interval of one month anytime after 1st term.
__________________________________________
A protocol for pelvic pain in women.
History and Examination.
Acute or chronic.
Unilateral Bilateral Pregnancy or no Pregnancy.
Stable General Condition Poor General Condition
History and examination should highlight following important indicators.
Is it Acute or Chronic?
Is it associated with pregnancy or not?
Important to note is whether it is unilateral or Bilateral?
General condition must be defined as Serious,Emergency or stable.
Can you rule out urninary or intestinal causes,musculoskeletal etc?
Acute episode.
Pelvic pain associated with pregnancy.
If pain is related with pregnancy and pain is bilateral then following conditions should be kept in mind.
Mild discomfort=Reassure.
If General condition is serious and vaginal bleeding is present.Then think of
Abortion.
Ruptured Ectopic
Ruptured Uterus
If general condition is serious but no bleeding is there,Pain is unilateral then think of
Unruptured Ectopic
Salpingitis
Torsion of ovary
Ruptured Ovarian cyst.
Appendicitis.
If pain is Bilateral i.e generalized,see the pattern.
If intermittent then think of
Preterm labour
Abortion
If pain is continous then thik of
Any infection
Or an attempt to induce abortion.Signs of localized or generalized peritonitis and foul smelling discharge can help in diagnosis.U/S exam may show positve evidence.
History of recent delivery may suggest P.sepsis.
Acute Pelvic pain in non pregnant women.
Young girls,cyclical pain,no menses yet,and or urinary retension,U/S shows a cystic mass = Imperforate hymen.
Newly weds.
Any vaginal bleeding = ? Coital injury
No bleeding then take it as localized infection and treat.
Associated with urinary complaints = Honeymoon Cystitis.
In all other ladies.If pain is unilateral rule out
Salpingitis
Torsion of cyst
Appendicitis
If pain is bilateral and associated with vaginal discharge,dysparaenia, Dysmenorrhoea ,low back ache then local examination is required.
Chronic pelvic pain.
Frequently recurrs after treatment.Always look for underlying cause.
Personel hygeine ,use of dirty pads during menses.
Treat the partner also
General health should be improved.
Diabetes Mellitus should be ruled out.
Rule out other debilitating diseases like Koch’s.
Examine for UV prolapse.Even minor one can give pain.
Detailed P/V examination and P/S examination is required to rule out specific pathologies.
Differetial diagnosis is as in P I D.
Diabetes Mellitus in Ob/Gyn practice.
Paramouont problem is not lack of knowledge with the doctors. It is the communication gap with the patient and then acceptance by her. All doctors know insulin is essential for pregnant Diabetics.Still majority of these diabetics are on oral hypoglycaemics. What is the solution?
Risks to Mothers.
U T I
Candidiasis of vulva and vaginitis.
Pre eclamsia.
Hydramnias.
Ketoacidosis.
So patients (Pregnant or non-pregnant) with symptoms related to any of above conditions should be routinely screened for DM.
Risks to Foetus.
Icreased Risk of congenital anomalies such as
Neural tube defects like hydrocephalus, anencephaly, Mirocephaly.
VSD, Coartation of Aorta, Cardiomegaly etc,Renal agenesis.
Duedenal and anorectal atresia.
Macrosomia.Leading to difficult deliveries and truama.
Risks to Neonates.
Hypoglycaemia
Respiratory Distress Syndrome.
Neonatal jaundice.
All deliveries must be in the hospitals.
Varieties of DM in Pregnancy.
Division between Type 1 or 2 i.e. IDDM or NIDDM is insignificant and immaterial, as all patients need insulin. Following division is more practical.
Pregestational DM
Disease is present before pregnancy. So risks can be conveyed to her before pregnancy. Chances of transmitting to siblings can be explained. Here genetics of Type 1 and 2 are different.
Gestational DM
Disease developes only during pregnancy. It disappears after the delivery. They have very high incidence of disease in later life.
Antinatal care in diabetics.
All pregnant patients should be screened for diabetes at earliest occasion.
If readings are borderline than glucose tolerence curve should be ordered.
Once labelled as Diabetic, then eduction about use of Insulin, self-monitoring by urine and blood glucose initially daily and later on twice weekly is essential.
Dose of insulin needs adjustment as pregnancy advances.
Risk of hypertension is greater in these patients. It should be always looked for.
Have a high risk for U T I and vulvovaginal candidiasis. Use of local clotrimazole is safe and should be encouraged if there is any indication.
Ultrasound at 16-20 weeks is mandatory to localize any defect in the foetus.
Early induction at 37-38 weeks should be the aim to avoid risks to the baby and mother.
_______________________________
Teratology.
Definition: of a teratogenic agent: Any chemical (Drug), infection, physical agent, defeciency state after exposure to foetus alters morphology or function. Period of exposure is determining factor whether malformation is going to be there or not.
Three important periods
Resistant Period: From day 0 to day 11 of gestation, post ovulation. This is the period when it will either be killed by any specific insult or it will survive without any negative effect of the same insult.
Maximum Susceptibility: From day 11 to day 57.Foetus is undergoing differentiation. This the period where chances of tertogenicity are maximum.
Lower Susceptibility: After 57 days (8 weeks gestation) differentiation is completer. Organs have formed. Teratogenic agent at this stage may cause reduction in cell size and number. Following may manifest this
Growth Retardation.
Reduction in organ size.
Fuctional derangement of organ.
Incidence of congential anomalies ascribed due to different tertogenic agents in England.
Multifactorial or unknown. 65 % -75 %.
Genetic 20 % -25 %
Environmental
Intrauterine infections 3 %
Maternal metabolic
disorders 4 %
Environmental pollutant chemicals 4 %
Drugs
<1 %
Ionizing Radiation 1-2 %
Route and length of administeration.
Frequency and severity are related with blood levels of different agents. If these can be kept low, then, tertogenicity becomes less omnious.
Relevant timing and specific pathology.
23 days to 36 days:Facial defects,Encephaly,Meningocele,Cleft lip,Aplasia of Radius
6 weeks to 12 weeks:Rectal atresia,with fistula.VSD,Separation of digital rays.Omphalocele.Duedenal atresia,Brachial sinus cyst,Early mandibular hypoplasia,
7 months to 9 months: Hypospadias, Cryptorchidism.
From 9 months onwards:PDA,
Teratogenic Agents.
Radiation
Dose and time of exposure are predictive of microcephaly, mental retardation, and growth retardation. Retrospective studies have demonstrated following relationship.
2-4 weeks: Spontaneous abortion or normal foetus.
4-12 weeks: Microcephaly, Menatal retardation, Cataracts, Growth retardation, Microphalanxia.
6-12 weeks: Mental and or growth retardation.
After 20 weeks effects are same as in postnatal exposures. Such as Hair loss, Skin lesions, bone marrow suppression.
Infections
Infections in first trimester have proven record of causing congenital malformations. Rubella, cytomegalovirus, Herpez Simplex, Herpez Zoster, Mumps and syphililus need proper evaluation of foetus and newborns for congenital abnormalities.
Hyperthermia
Studies suggest that sustained temperatures rather than spiking fevers, above 38.9 C (103 F) between 4-14 weeks of Gestation are teratogenic. Malformations should be scanned in first trimester.
Maternal medical disorders.
Diabetes in the mother is associated with risks of cardiac abnormalities, GI malformations and neural tube defects. Skeletal malformations can also occur.
Glycoselated Haemoglobins more than 8 % are teratogenic. Alpha-fetoprotein screening should be done at 16 weeks.
Extensive anatomic survey should be carried at 18-22 weeks to map possible malformations.
Mothers on epileptic drugs are prone to have congenital malformed foetus.
Drugs.
Drugs are divided into many categories.
Starting with drugs which are absolutely safe. Vitamins and Iron.
Which have produced negative effects in animals but not in humans. Penicillin, Digoxin, Epinepherine, terbutaline.
Teratogenic effects in animals but no studies carried out in humans, e.g., Frusamide, Calcium blockers, Beta-Blockers.
Teratogenic effects in humans but drug has to be used, e.g Phenytoin.
Then lastly those drugs which have definite tetartogenic effects in humans and can be avoided certainly.like Vit A,Alcohal,Caffiene,sex steroids,
Dose threshhold: It is a theoretical dose for each teratogenic agent, below, which it is supposed to be safe.
Teratogenic table of Drugs.
Type of drugs Safe Relative safe Risk associated Avoid
Analgesics Paracetamol Hydromorphine Salicylates
Codiene Ibuprofen
Mophine Indomethacin
Antibiotics. Amoxicillin Amikacin Streptomycin Ciprofloxacin
Ampicillin Sulbactum Sulphonamide Norfloxacin
Erythrocin Chloroquin Rifampicin Tetracycline
Penicillin INH Trimethoprim
Carbenicillin Metronidazole Kanamycin
Nitrofurantoin Miconazole Clavulanate
Ethembutal Aztreonam Tobramycin
Ticracillin Chloramphenicol
Cephalosporin
Clindamycin
Genamycin
Antiemetics Meclizine Prochlorperazine Triethylperazine
Metoclopramide
Scopolmine
Antihistamines Tripelonamine Brompheneramine Astemizole
Chloram- Diphenhydramine
Phenaramine Hydroxyzine
Antihypertensive Atenolol Timolal
Methyldopa Nadolal
Metoprolol Prozasin Ace-
Labetolol Clonidine Inhibitors
Propranolol Diazoxide Reserpine
Nitropruside.
Antiasthmatics Beclomethasone
Aminophylline
Cromolyn Glycolate
Terbutaline
Ipratropium
Cardiac Digoxin Procainamide Calcium Blockers
Atropine
Quinidine
Lidocaine
Disopyramide
Cough Terpin hydrate
Guifenesin
Diuretics Frusemide Hydrochlorthiazide
Mannitol Spironolactone
Acetazolamide
Ethacrynic acid
Bumetamide
Antidiabetics Insulin Chlor-
Propamide
Tolbutamide
Laxatives Milk of magesia Ducosate
Thyroid Thyroxine Iodide
Methemazole
Propyl-
Thiouracil
Sedatives Benzpdiazepine
Barbiturates.
Antiepileptics Ethosuximide Phenytoin Trimethadione
Clonazepam Valproic Acid
Phenobarbitone
Primidone
Other drugs.
Safe
in pregnancy
FeSO4, Kaopectate, Probenicid, Antacids.
Relatively safe (limited information
availabe)
Allopurinol,Clofibrate,H2
Antagonists,Vaccines,Bromocryptine,Epinepherine,
Definite History of risks.
Glucorticoids, G.Anaesthetics,
Haloperidol, Penicillamine, Phenothiazines, Tricyclic
Antidepressants, EDTA, Amphetamines.Androgens.
Must be avoided
Antineoplastics,Lithium,Disulfiram,Estrogens,Vit
A,Quinine,Alcohal,Warfarin,
Drugs and Lactation.
Contraindicated in lactating mothers
Aspirin
Gold salts
Penicillamin
Chloramphenicol
Clindamycin
Tetracycline
Atropine
Amiadrone
Cyprolerone iodides
Estrogens.
Lithium
Doxepin
Vit A Vit D
Special Precautions needed. May be used at low or below normal dose levels. In premature babies with extreme care. Mother and baby have to be monitored for specific side effects.
Dextroproxyphene
Benzodiazepines.
Carbamazepine
Ethosuximide
Phenobarbitone
Primidone
Aminoglycosides.
Antimalarials.
Cotrimoxazole.
Ethambutol
Metronidazole
Nalidixic acid
Piperazine
Trimethoprim
Sulphonamides.
Aminophylline.
Antihistamines
Ephedrine
Theophylline
Betablockers.
Ace inhibitors.
Thiazides.
Frusamide.
Spironolactone.
Cimetadine
Ranitidine
Sulphasalazine
Carbimazol
Combined Contraceptive pills
Glibenclamide
Metformin
Estrogens
Thiouracil
Thyroxine
Tolbutamide.
Antidepressants.
Barbiturates
Benzodiazepines
Phenothiazines.
Can be used.
Paracetamol
Codiene
Iboprofen
Ketoprofen
Mefanamic Acid
Naproxen
Sodium Valproate
Cephalosporins
Erythrocin
Ketoconazole
Metronidazole
Nitrofurantoin
Nystatin
Rifampicin.
Beclomethasone
Salbutamol
Sodium Cromoglycate
Terbutaline
Digoxin
Heparin
Hydralazine
Methyldopa
Tranexamic Acid
Warfarin
Antacids.
Bisacodyl
Bulk laxatives
Metocloperamide
Sucraflate
Pregesterone pills
Corticosteroids
Insulin
Folic acid
Iron
Vit A in low doses
Vit B
Vit C
Vit D in low dose
______________________________________________
Menopause.
Defenition: Amenorrhoea for 6-12 months in women of 45 years and elderly.
Changes in menstrual cycle occur as women progress through their forties.The remaining follicles in both ovaries become less sensitive to gonadotrophins resulting into
Increase in the FSH.
Reduction in estrogen levels.
The limited follicle maturation leads to either a decreased cycle interval or lapses of cycles with oligomenorrhoea.
Menses usually cease between age of 50 –52 years in majority of patients. Estorgenic acitivity is evident for many years after the menopause at reduced levels. Adrenal gland is the source.
Any bleeding after this kind of amenorrhoea is usually due to some kind of pathology. Usually Polyps or Neoplasia.
Premature Menopause: Permanent amenorrhoea before 35 years of age. Causes may be
Genetic
Autoimmune disease.
Inflammatory reaction.
Clinical manifestations of Menopause.
These are usually multiple, affecting many systems at one time,vague ,ill defined.Can be broadly classified into
Vasomotor Symptoms.
Mood Swings.(in menopauasal Syndrome)
Altered menstrual functions.
G I T symptoms.
Atrophic changes.
Osteoporosis.
Vasomotor Symptoms.
Episodes of hot flushes and sweating lasting for few seconds to few minutes. Feeling of heat on face or/and neck once or more frequently daily. After the attack patient can become pale and sweating on the forehead may be there. These flushes may start when periods are still regular. These usually improve gradually over few months. May last for more than 5 years. Flushes appear more severe and frequent at night or at times of stress.
Mood swings.
Menopausal syndrome includes a variety of symptoms such as fatigue, headache, nervousness, loss of libido, insomnia, depression, irritability, palpitation and joint and muscle pains.
Altered menstrual functions.
Any kind of bleeding irregularity may be present. But any bleeding after amenorrhoea of 12 months must be investigated. This is very very suspect.
GIT symptoms.
Icreased or decreased appetite leading to weight changes. Indigestion and constipation are regular complaints. Retrosternal and epigastric burning can be present.
Atrophic changes.
Atrophy of vaginal mucosa leads to atrophic vaginitis, pruritis of vulvovaginal area, dysparenia.
Uretheral changes with mucosal lining lead to dysuria, urinary frequency, urgency and incontinence.
Increased frequency of cystitis.
Vaginal Uretheral and bladder changes improve with esterogen therapy.
Osteoporosis
Primary Oteoporosis is most common variety. It can be further classified as postmenopausal and senile Osteoporosis.
Defined as low bone mass with ratio of mineral to osteod tissue. It is an abnormal decrease in bone mass. But Bone is of normal structure.
Osteoporosis affects about one third of postmenopausal women. Imagine the total number in your practice.
In the absence of estrogen bone resorption takes place. Predominently trabecular bone is last. In contrast to this in senile Osteoporosis both cortical and trabecular bone is lost with increased risk of hip and vertebral fracture.
Becomes clinically manifest 10 years after menopause. Peak incidence is in 60s and early 70s.
Followoing Secondary Causes should be kept in mind
Steroid induced or Cushing syndrome.
Hypogonadism
Hyperthyroidism
Immobilization.
Chronic heparin administeration.
Osteogenic imperfacta
Primary Hyperparathyroidism.
Osteomalacia
Renal Osteodystrophy.
Clinical manifestation of Osteoporosis.
Backache
Fractures with minimum trauma.(Femur neck,Colles,Crush vertebral fracture)
Bone pains.
Investigations.
Plain xray changes (Characteristic wedge and crush fractures in spine) become evident only when upto 40 % of bone mass resorbed. Dual or Single photon absorptiometry, and quantitative CT scan can be ordered. Bone Biopsy can finalize the diagnosis in difficult cases.
Serum calcium, Phosphate and alkaline phosphate can be measured. These ar normal in primary (menopausal and senile) osteoporosis. Abnormal in secondary types.
Prevention of posts menopausal Osteoporosis.
No therapy fully restores the lost bone. So prevention is essential. Estrogen replacement therapy is the only choice. All patients with premature menopause (idiopathic and oopherectomy etc) must receive estrogen. In other women risks and benefits should be weighed. Benefits far outweigh the risks.
Patient should be educated to correct the possible risk factors for Osteoporosis.These are excerise, withdrawal of steriods, and improved diet.
Treatment of Established Osteoporosis.
Effective treatment in patientsn, whose bone mass has fallen down than threshold of fractures, is very very difficult. Prevention is the only answer.
Estrogen replacement therapy is very effective in reducing the bone density loss per month.
Calcium carbonate 1000mgs –1500 mgs /day alone is effective to reduce bone resorbtion, but not as effective as estrogen. Combination of Cacium and Estrogen is very effective in treatment.
Vit D icreases calcium resorption from intestine so has a homeostatic effect on plasma calcium levels.
Calcitonin is strong in preventing the resoption of bone.
So Calcium + Estrogen + Calcitonin are effective to prevent further resorption of bone.
Estrogen therapy should be continued for 5-10 after menopause. Prolonged use of estrgen use induces compensatory increase in parathormone production. If estrogen is suddenly stopped there is a period (upto 3 years) of enhanced bone loss, due to this effect.
HRT (Hormone replacement therapy)
Prof Dr Furrukh Zaman stressed in his interview that HRT is being grossly underused even in developed counteries. Only 12 % of women who need HRT are using it. Situation in Pakistan is certainly worse than this.
Benefits of HRT.
Relieves all symptoms and alleviates negative risk factors (due to estrogen deficiency states) described above under different subheads.
In Osteoporosis this is the only effective preventive therapy. It has beneficial effect on bone mass at least uptill 75 years.
Impoves the life overall. Quality of life is tremendously improved.
Lower death rate from all causes.
Risk of Myocardial Infarction, and stroke is reduced.
It keeps skin young looking.
Contraindications of HRT.
History of Breast or endometrial cancer.
Recurrent thromboembolic disease.
Acute liver disease.
Unexplained vaginal bleeding.
Recent M I
Stroke and T I A.
Relative Contraindications.
Seizural disorders.
Uterine Liomyomas.
Familial Hyperlipidemia
Migrains
Deep thrombophlebitis.
Endometriosiss
Gall Bladder disease.
Hypertension.
Side Effects of estrogen replacement.
Breast tenderness.
Bloating.
All above ones are amenable to dose adjustment.
Headache
Menstrual bleeding.
Periodic monitoring for women on HRT.
Breast examinaion yearly.
Pelvic examination/1-3 years.
Blood Pressure /yearly
Mammography if indicated.
Preparations for HRT Dose
Conjugated equine Estrogen 0.625 mgs-1.25 mgs OD
Ethinyl Estradiol 0.025 mgs-0.05 mgs.od.
Estrone Sulfate 1-2 mgs OD
Transdermal Estradiol 0.05 mgs bid
Estrogen + Cyclical Progesteron 0.625 mgs OD continously and . Medroxyprogesteron 5-10 mgs OD for 10-14 days.each month.
Estrogen and continous Progesteron 0.625 mgs OD and medroxyprogesteron 2.5 mgs OD continously.This regime is less likely to cause withdrawl bleeding so it is usually prefered by patients.
Internet Section.
Following
articles have appeared in bmj of Aprill 1 2000.Original articles
have been abridged to smaller size.Full articles and reference are
availabe in our library.
Ectopic pregnancy
J I Tay, lecturer, J Moore, research fellow, J J Walker, professor. Division of Obstetrics and Gynaecology, St James's University Hospital, Leeds LS9 7TF
Ectopic pregnancy causes major maternal morbidity and mortality, with pregnancy loss, and its incidence is increasing worldwide. In northern Europe between 1976 and 1993 the incidence increased from 11.2 to 18.8 per 1000 pregnancies. In 1989 in the United States admissions to hospital for ectopic pregnancy increased from 17 800 in 1970 to 88 400.These changes were greatest in women over 35 years of age. In the United Kingdom there are around 11 000 cases of ectopic pregnancy per year (incidence 11.5 per 1000 pregnancies), with four deaths (a rate of 0.4 per 1000 ectopic pregnancies).
The incidence of ectopic pregnancy is increasing, mainly due to the increased incidence of pelvic inflammatory disease caused by Chlamydia trachomatis
Ectopic pregnancy must be excluded in a sexually active woman with a positive pregnancy test, abdominal pain, and vaginal bleeding
Early ultrasonography should be available in subsequent pregnancies for women who have had an ectopic pregnancy
Diagnosis cannot be made clinically or in the community
Treatment should be tailored to individual needs; in selected cases medical management can be as effective as laparoscopic salpingostomy
Conservative surgery results in slightly higher rates of intrauterine pregnancy and higher recurrent ectopic pregnancies
We review the incidence, causes, diagnosis, and management of ectopic pregnancy. The evidence presented is from a combination of selected published papers identified from Medline and a reflection of clinical practice in our unit. Medline was searched with the term "ectopic pregnancy" and combined with terms such as incidence, risk factors, methotrexate, salpingectomy, salpingostomy, etc.
Although a proportion of women with ectopic pregnancy have no identifiable causal factors, the risk is increased by several factors: If there is previous ectopic pregnancy, tubal damage from infection or surgery, a history of infertility, treatment for in vitro fertilisation, increased age, and smoking.
A history of pelvic inflammatory disease is particularly important and has been implicated in the increased incidence of ectopic pregnancy. After acute salpingitis, the risk of an ectopic pregnancy is increased sevenfold. This is particularly true of Chlamydia trachomatis, the main cause of pelvic inflammatory disease in the United Kingdom.Comprehensive programmes to prevent chlamydia not only decrease the incidence of C trachomatis infections but also the rate of ectopic pregnancies.
Previous female sterilisation and current use of an intrauterine contraceptive device are only risk factors when patients with ectopic pregnancy are compared with pregnant controls and not with non-pregnant women. This is because overall the risk of pregnancy in these situations is low, but if pregnancy does occur an ectopic pregnancy is more likely. The risk of ectopic pregnancy after sterilisation is only 7.3 per 1000 within 10 years.
The incidence of ectopic pregnancy after assisted reproductive techniques is 4%, which is 2-3 times greater than the background incidence. The main risk factor in this group is tubal infertility. The incidence of heterotopic pregnancy (an ectopic pregnancy together with an intrauterine pregnancy) is also increased after assisted reproductive techniques.
Ectopic pregnancies usually present after seven (SD two) weeks of amenorrhoea. The diagnosis can be difficult unless the condition is suspected and can be confused with miscarriage, an ovarian accident, or pelvic inflammatory disease. The abdominal pain is usually lateral. However, history and physical examination alone do not reliably diagnose or exclude ectopic pregnancy, as up to 9% of women report no pain and 36% lack adnexal tenderness. The presence of known risk factors can increase suspicion, but any sexually active woman presenting with abdominal pain and vaginal bleeding after an interval of amenorrhoea has an ectopic pregnancy until proved otherwise. Women who present in a collapsed state usually have had prodromal symptoms that have been overlooked. Tubal rupture is rarely sudden since it is due to invasion by the trophoblast. Therefore, if there is any suspicion, hospital referral for investigation is mandatory.
Percentage occurrence of history and presenting signs with ectopic
Abdominal pain (97%)
Vaginal bleeding (79%)
Abdominal tenderness (91%)
Adnexal tenderness (54%)
History of infertility (15%)
Use of an intrauterine contraceptive device (14%)
Previous ectopic pregnancy (11%)
Referral should preferably be to a unit dedicated to managing problems early in pregnancy as this allows ease of investigations and continuity of outpatient care. The initial investigations are a sensitive pregnancy test and ultrasonography. The presence of an intrauterine pregnancy generally excludes ectopic pregnancy, although other ultrasound findings have to be considered, especially if symptoms are atypical, severe, or persistent. The use of quantitative measurement of serum concentrations of beta human chorionic gonadotrophin together with transvaginal ultrasonography has improved the diagnosis. There is, however, controversy about the concentration of serum human chorionic gonadotrophin that is diagnostic. In the presence of an ectopic mass or fluid in the pouch of Douglas, a cut off point for a serum concentration of human chorionic gonadotrophin of 1500 IU/l is recommended, but in the absence of any ultrasound signs the higher concentration of 2000 IU/l should be the cut off point before an ectopic pregnancy is diagnosed. Ectopic pregnancies produce lower concentrations of human chorionic gonadotrophin than normal pregnancies, but the change in concentrations provides more information. In a normal pregnancy, serum concentrations of human chorionic gonadotrophin double every 2-3.5 days in the fourth to eighth week of gestation reaching a peak around the eighth to 12th week, as calculated from the last menstrual period .A failure of this increase is suggestive of an ectopic pregnancy although it is also associated with early pregnancy failure. A two-day sampling interval has been recommended if paired serum samples be being tested. The accurate diagnosis of ectopic pregnancy can be life saving, reduce invasive investigations, and allow conservative treatment.
Expectant and medical management is possible, and should be considered in selected cases, but they are not widely practised in the United Kingdom. Surgery remains the mainstay of treatment, possibly overtreating a number of cases.
Expectant Management.
Some ectopic pregnancies resolve spontaneously, and expectant management is possible in selected cases. This is not related to the size of the ectopic pregnancy on an ultrasonogram but the initial serum titre of human chorionic gonadotrophin and the trend in titres are independent predictors of success. It is important, therefore, to serially monitor serum titres of human chorionic gonadotrophin in-patients who are being managed expectantly. The higher the serum concentration the more likely expectant management will fail. Overall, if the initial serum concentration of human chorionic gonadotrophin is less than 1000 IU/l, expectant management is successful in up to 88% of patients.
Medical Management.
Methotrexate, a folic acid antagonist, is used for medical management in-patients before rupture who are haemodynamically stable. It can be given intramuscularly or injected into the ectopic pregnancy, a route that delivers high concentrations locally with smaller systemic distribution. However, rates of successful treatment are lower than with systemic methotrexate, and it requires a laparoscopic or ultrasound guided needle procedure. Methotrexate in a single dose is more convenient than the variable dose regimen but may carry a higher risk of persistent ectopic pregnancy. Close follow up with serial measurements of serum concentrations of human chorionic gonadotrophin is required. A second course of treatment may be necessary, and some patients may require surgical intervention. Methotrexate treatment may produce significant side effects.
Surgical Management.
Surgical treatments may be radical (salpingectomy) or conservative (usually salpingostomy), and laparoscopy or laparotomy may perform them. Salpingectomy is the treatment of choice if the fallopian tube is extensively diseased or damaged as there is a high risk of recurrent ectopic pregnancy in that tube.
Generally, hospital stay (1.3 days) and convalescence (2.4 weeks) are shorter after laparoscopy than with laparotomy (3.1 days and 4.6 weeks respectively). Both techniques produce similar rates of complications and persistent trophoblast. If there is a risk of persistent trophoblast, follow up with serial measurements of serum concentrations of human chorionic gonadotrophin is necessary. Since no single postoperative concentration of human chorionic gonadotrophin is predictive, follow up until complete resolution is necessary. The need for a second laparoscopy should be based on symptoms rather than changes in concentrations of human chorionic gonadotrophin. In a randomised controlled trial, methotrexate and laparoscopic salpingostomy were equally effective.
The cost of salpingostomy is slightly more than salpingectomy in the short termed. Both treatments are equally effective initially, but additional treatment for persistent ectopic pregnancies is occasionally required after salpingostomy. Although it is comparatively simple to cost the acute episode, calculating the long term costs of subsequent infertility treatment and treatment for recurrent ectopic pregnancy is more difficult.
The psychological cost is often overlooked, as it is not generally viewed in the same way as other pregnancy loss. It would seem that the women have similar grief reactions to those with miscarriages but have the additional trauma of the potential reduction in fertility. Support networks such as the Miscarriage Association are recommended to women after miscarriage but, until recently, there has been no specific support group for woman after ectopic pregnancy. The recently formed Ectopic Pregnancy Trust evolved out of this need and provides both information and support.
Rates of intrauterine pregnancy after expectant management are comparable to those achieved after medical or surgical management, varying between 80% and 88%, and rates for recurrent ectopic pregnancy vary between 4.2% and 5%.
A population based cohort study reported a pregnancy rate of 66% regardless of whether treatment was surgical or medical.33 of those who conceived, 90% achieved an intrauterine pregnancy and 10% had recurrent ectopic pregnancy. The risk factors for recurrent ectopic pregnancy are previous spontaneous miscarriage, tubal damage, and age greater than 30.25 after methotrexate, between 62% and 70% of women had a subsequent intrauterine pregnancy and around 8%