web: kfog_may_2011.pdf · vice president elect dr.ajith s joint secretary dr. sangeetha menon...

Address of CorrespondenceDr. Fessy Louis T. Editor KFOG Journal CIMAR COCHIN, Tipusulthan Road, Cheranalloor, Edappally,

Kochi -682 034, Kerala, INDIA Mob: 09846055224 E-mail: [email protected]

President:Dr.V.P.Paily

E-mail: [email protected]

Immediate Past president Dr.Narayanan T.Vice President Dr. NeenaThomas

Vice President Elect Dr.Ajith SJoint Secretary Dr. Sangeetha Menon

Treasurer Dr.Rajalakshmi JanardhananJournal Editor Dr. Fessy LouisCommittee Chair persons

Maternal & Foetal Medicine Chair Dr.AmbujamAcademic chair Dr. V. Rajasekharan Nair

Elect Dr. P.K.Syamala DeviAdoloscent Chair Dr.V.K.Chellamma

Elect Dr.Kunjamma RoyReproductive Health Chair Dr.K.K.Gopinathan

Elect Dr.Philip AbrahamOncology Chair Dr.Sumangala Devi

Elect Dr.Chithra TharaReasearch Chair Dr.P.K.Sekharan

Elect Dr.Nirmala .CLaison Officer Dr. V. Rajasekharan Nair

Secretary GeneralDr. T. Jayandhi RaghavanE-mail: [email protected]

KFOG

OFF

ICE

BEAR

ES

FOR

THE

YEAR

201

1-12

Vol: 5 No: 1 May 2011

President’s Message 02

Secretary’s Message 02

WHAT IS NEW IN ENDOMETRIALCANCERDr K Chitrathara MD 03

USE OF IV IRON SUCROSE INGESTATIONAL ANEMIADr Hema Divakar 05

MISHAPS IN OTDr Shirish Patwardhan, MD, 10

MEDICAL ABORTION CURRENTCONCEPTSDr Parag Biniwale, MD 11

MRP- TRICKS & TIPS…Dr. Alpesh Gandhi 13

KFOG ACADEMIC CALENDAR -2011 15

Web:www.kfogkerala.com

Dear ColleaguesOur journal comes this academic year with new layout. Hope that each of the articlesin this issue will be useful for all the readers. The success of this journal depends onyour response. I once again request all of you to send scientific articles and photographsof society activities to be published in the forthcoming issues.Our website has been changed to www.kfogkerala.com .Previous journals are availableonline in this website . Lot of changes had been made in this site and will be updated ona regular basis. Hope everybody will browse it as soon as possible. Please send yourvaluable ideas and suggestions to improve our journal & website . I would appreciateyour feedback. Dr.Fessy Louis.T

CONT

ENTS

2 www.kfogkerala.com

Dear colleagues and friends,Warm Festival Greetings from KFOG Secretariat! KFOG is fortunate to have a sincere and very dynamicteam of office bearers for this year also, 2011-12, and lot ofactivities are planned involving almost all the societies andclubs from Kasargode to Thiruvananthapuram. The annualcalendar is enclosed for your information and participationin the programmes. Updating and being more competentin our field is the most important thing in any professionand KFOG is trying to enrich the members with essentialknowledge and Skills. The important ones among areTraining in “Emergency Obstetric Care and Life supportskills for Obstetricians (EMOCALS)”, “Improving BasicObstetric Care at Govt hospitals in Kerala”, “More of VaginalDelivery and Less but safe Cesareans” and “CME onMaternal mortality with Important case discussions”.All of us know the Health outcomes across the country areindicated by Infant mortality and maternal mortality rates.Kerala has long been held as a model in terms of healthindices, and its IMR and MMR in many times less than theIndian average. And it is all the more creditable that itmanaged to reduce the already low MMR even further overa period. We should be proud for these achievements. But today a lot of complaints, comments and criticismregarding the practice in our specialty are seen in the frontpages of media. Recent issues in our state itself reg. the“Mass Caesarean sections” before holidays and a largenumber of Hysterectomies in a short period in two privatehospitals in another state has been criticized and isalarming. We should open our eyes to see and evaluatewhat is done in our own institution and neighboring oneand take remedial steps to avoid the allegations and try tosafeguard the medical ethics. KFOG could foresee thesetypes of situations and that is why the CMEs - More ofVaginal Delivery and Less but safe Cesareans”We KFOG ians should resist negative and unethical trendsif any, in our specialty, and nick them at the budding itself.Let us unite and change our attitude to achieve favorableGoals.

JAI KFOGWith regards

Dr.T.Jayandhi RaghavanSecretary General, KFOG

Dear Colleagues,We should congratulate Dr.Fessy Louis for bringing out

our journal on a regular basis. Its content also is gettingricher. Please do not forget that we have a website(www.kfogkerala.com) as well. The activities of ourfederation will be put up there.

Along with this issue of our journal you will see theproposed activities of KFOG for 2011. These are over andabove the regular activities of each society and club. Ours isa rapidly changing and advancing specialty. In addition ourspecialty attracts a lot of media and public attention. Thisemphasizes the need for being updated on a regular basis.I hope that the various programmes proposed for 2011 willfulfill this vital need. The workshop on promoting safeobstetric practices is indirectly to promote vaginal deliveryand reduce cesarean section. Our target should be toreduce primary cesareans as “cesarean breeds cesarean”.Offering vaginal birth after cesarean is a difficult propositionin most of the hospitals in Kerala. To reduce primarycesarean the cardinal step is to ripen the cervix beforeattempting induction of labour. The workshop emphasizesthis aspect. If we allow cesarean sections to increaseunchecked, it will be a shame on our profession.

The vaginal surgery workshop will focus on non descentvaginal hysterectomy. We have to reverse the trend towardsabdominal as well as total laparoscopic hysterectomy inevery case and promote simple non descent hysterectomy.Of course cases selected for hysterectomy should be onproper indications.

The confidential review of maternal deaths has taughtus the need for training our members in EmergencyObstetric Care and Basic Life Support especially theobstetricians in the small peripheral hospitals. The firststep towards this is to train the trainers which we are startingwith the programme on 6.7.&8th May 2011 at TOGSAcademia, Thrissur.

CTG & Doppler are two modalities that have becomeessential for our practice. Dr.Prasannakumari and Dr.SheelaBalakrishnan have agreed to run the sessions , the first ofwhich will be at Ernakulam on 5th June.

There are many other areas of our involvement – Quiz toenthuse undergraduates in our specialty, talent searchamong postgraduates and research and publicationactivities for all members are only some of these. In additionthe regular activities of our local societies and clubs amongthe adolescents, tribals and the elderly will continue.

Please remember unless we are dynamic and progress,we will be left behind. Let us join our efforts to providescientific and ethical practice and fulfill our commitment tosociety at large.

Dr. V P PailyPresident KFOG

Secretary’s Message

President’sMessage

2www.kfogkerala.com

WHAT IS NEW INENDOMETRIAL CANCER

Dr K Chitrathara MD(gynec) MCH(Uro)HOD & Senior Consultant in Surg & Gynec oncology

Lakeshore & Welcare Hospital, kochi

IntroductionEndometrial cancer is a highly curable disease in early

stages and even in advanced stages longterm control ispossible. Recently there is a trend on the part of manygynecologist to deviate from the traditional dictum ofgetting a pre-operative diagnosis and many ignore pre andper-operative staging. This article is written to highlightthe importance of pre-operative work up and influence ofsurgicopathologic stage on adjuvant treatment.Staging of endometrial cancer

Fractional curettage finding, pathology and examinationunder anaesthesia(EUA) were the basis of 1970 FIGOclinical staging. Because of high inaccuracies in clinicalstaging, FIGO adopted surgicopathological staging in 1988.Retroperitoneal lymph node dissection(RPLND) wasincluded as an inherent component of 1998 FIGOmodificationof surgicopathological staging.Recent modification of FIGO staging published in NCCNVersion 1.20111 is given below

Stage 1 NewA no or <50% myometrial invasionB >50% myometrial invasion

Stage11cervical stromal invasionStage 111

A Tumor invades the serosa of the corpus uteriand/or adnexaeB Vaginal and/or parametrial involvementC1 Positive pelvic nodesC2 Positive PA lymph nodes with or without positivepelvic lymph nodes

Pre-operative work up1. pap smear & biopsy of any suspicious area on cervix2. uterine curetting includes endocervical curetting3. MRI4. Ca 125, CEA,(optional)

5. P53 overexpression (optional)Accurate pre-operative work up is very crucial because of 2reasons1. In stage 2, radical hysterectomy & pelvic lymph nodedissection can be used as a monotherapy which avoidsthe morbidity of radiation following TH+BSO.2. If pathology is Uterine serous papillary carcinoma(USPC) or Clear cell carcinoma more extensive stagingprocedures are required.. Steps include. Thorough intraabdominal exploration. Peritoneal cytology collection. Inspection & palpation of omentum , liver , peritoneal

cavity, culdesac ,adnexae. Biopsy of suspicious area. Uterus evaluated for any breach in serosa. TAH& BSO,(or radical hysterectomy in stage 11). Selective pelvic & paraaortic lymphadenectomy

Probably the most controversial aspect ofsurgicopathological staging is the component oflymphadenectomy. No prospective randomized trialcompared lymphadenectomy with Lymph node sampling.Highlights of NCCN 11th annual conference (2005)showed that it stood for complete lymph node dissection.The conference was of opinion that 90% of involved nodeswere only microscopically positive and the extent ofdissection influenced the survival. However MRC ASTEC2

trial published in January 2009 concluded that in well pre-operatively staged stage 1 disease, there was no benefitin overall and relapse free survival with lymphadenectomy.This is a paradox since FIGO adopted surgicopathologicstaging because of inaccuracies in preoperative clinicalstaging eventhough MRI was not popular during that time.Now also to rely on MRI we should have sophisticated


MRI machines & reading experts.Critics saw many flaws in MRC ASTECTrial

1. The number of lymph nodes resected was insufficientin many patients.

2. The high rate of inclusion of low-risk patients arethe reasons for the low rate of involved lymph nodesseen in the lymphadenectomy group.

3. The study group did not assess the paraaorticnodes.

4. The ASTEC trial was too small to detect an overallsurvival difference because the expected proportionof isolated pelvic lymph-node recurrences is as lowas 2-3% in early endometrial carcinoma.

surgical staging will continue to be a confusing topic, withno appropriate quality control, one may have to followNCCN guidelines unless the patient is a very low risk.(endometriod carcinoma stage1, grade1 or 2 with nomyometrial invasion & tumor <2cms) . We can avoid para-aortic LN dissection in high risk surgical patients & patientswith no significant pelvic nodes.( can utilize frozen sectionfacility )3,4.

Developments in sentinel node concept, noninvasive PET-CTscan and nanopartcle enhanced MRI staging mayreplace non therapeutic surgical staging in future

Per-operative staging is also important since wellstaged stage 1 patients can be observed without anyadjuvant treatment, vaginal brachytherapy is optionalin 1B.

Pathological assessment should include ratio of depth of

myometrial invasion to myometrial thickness,tumor size, tumor location, histological subtype,

grade, lymph nodal statusand lymph-vascularinvasion(LVI).

Classification of endometrial carcinoma1. Type I endometrial carcinomas or endometroid

carcinoma :These cancers occur most commonlyin pre- and peri-menopausal women, often with ahistory of unopposed estrogen exposure and/orendometrial hyperplasia. They are often minimallyinvasive into the underlying uterine wall, are of thelow-grade endometrioid type, and carry a goodprognosis: display a high incidence of alterations inKRAS oncogene, PTEN tumor suppressor genethe -catenin gene , defects in mismatch repair thatresults in microsatellite instability.

2. Type II: These cancers occur in older, post-menopausal women, are more common in African-Americans, are not associated with increasedexposure to estrogen, and carry a poorer prognosisendometrial carcinomas. These are mainly UterineSerous Papillary carcinoma & Clear Cell Carcinoma(USPC &CCC) are more likely to be characterizedby p53 mutation and ERBB-2 (HER-2/neu)expression.

CONCLUSIONProper pre-operative evaluation and meticulous

surgicopathological staging are crucial in the managementof endometrial cancer. The good prognostic type 1 diseasehas to be differentiated from aggressive type 11 cancer.Staging and classification profoundly influence adjuvanttreatment

Dear Colleagues,I recieved a letter from Dr.Amar Fettle, State Nodal Officer-H1N1. As explained in the letter, we have to be on ourguard in the forthcoming rainy season against H1N1. Youmay recall that H1N1 was the single most common nonobstetric cause of maternal death last year. We don’twant to lose any mother due to H1N1 this year.Please remember that even in suspected cases ofrespiratory viral infection in pregnancy oseltamivir is tobe given early. Late administration may not give thedesired effect. As per present knowledge there is noanxiety about congenital malformation of the fetus as aresult of oseltamivir (tamiflu).

H1N1 ALERT

The government is prepared to give it free to allpregnant women even in private hospitals. So pleasemake sure that your hospital stocks it before actualcases arrive.It is not mandatory to test and confirm the H1N1 infectionfor starting the treatment.For any further assistance you can contact Dr. Amar Fettle, State Nodal Officer- H1N1 State H1 N1 Control Room Directorate of Health Services Trivandram, Kerala.

With regards,Dr.V P Paily

4www.kfogkerala.com

USE OF IV IRON SUCROSE INGESTATIONAL ANEMIA

Dr Hema DivakarBengaluru

John Lawson, in his classic annual report in 1954,concluded that it was hoped that maternal (and fetal) lossfrom anemia would show a steady decline in the future.In his view, the declining level of Hb, in some patients,meant that they reached a point of no return and woulddie;. Fifty years later, maternal and fetal losses are stillunacceptably high, although today we have better waysof preventing women from reaching that point of noreturn.The article takes you through the ground realitiesin the Indian context, right from the rising prevalence ofiron-deficiency anemia through the perils of failure ofprograms to control this and the fresh thinking and newfrontiers of the use of parenteral iron to combat thisproblem.Priorities for policymakers can save lives,improvehealth, increase productivity and make maternal anemiacontrol a reality.

However beautiful the strategy, you shouldoccasionally look at the results.

Winston Churchill

Looking at the rising trends , it is clear that the IFA programhas largely failed to meet its primary objectives. Thereasons often cited are partial coverage of the population,inadequate dosing of the iron supplement, short supplies,defective absorption due to intestinal infestations, dietscontaining high levels of iron chealators, problems withformulation, inadequate consumption or poor complianceby the beneficiaries, failure to replenish the stocks at thebeneficiary level, and lack of effective health educationand supervision3.

It has become evident that cosmetic initiatives willnot overcome the failings of the IFA program, andfresh thinking is required. So, we plunge intothinking about Specific recommendations forimplementation

The challenges posed by attempts to use iron sucrose asa vehicle for the mass eradication of IDA in resource-poor areas include the cost of the drug and the method ofits administration, the sheer logistics of administeringseveral infusions of the drug to women who need it most,

compromising compliance, and potential concerns aboutadverse reactions and how they might be handled in suchsettings. We have sought to evaluate ways in which theseimpediments might be overcome. If iron sucrose could beused on a mass scale, this would eventually drive downthe cost of the drug, especially if generic formulations couldbe developed. This is a challenge for governments andthe pharmaceutical industry.

1. Rendering intravenous iron AVAILABLE to thepopulace

Intravenous iron is easily and widely available for use inthe private sector in all the pharmaceutical outletsthroughout India. However, the vast majority of women inIndia have no access to private medical care, and thereforeno easy access to this vital drug. There is an urgent needto render this drug “ALWAYS AVAILABLE”: if womenattend a health centre needing intravenous iron but areasked to return due to lack of availability, research hasshown that less 20% would come back – a real lostopportunity, for most of the rest of the women would thenonly present in labour, often with very low haemoglobinand therefore at major risks from all the complications ofsevere anaemia.

A number of measures can be implemented to renderintravenous iron more available to every one woman whoneeds it in India.

- If intravenous iron is designated an “emergency drug”,by law this renders the drug always available

- A collaborative effort between obstetricians,government and the pharmaceutical industry would helppromote policies that will render the drug available

India does not suffer the problems of accessibility withthe exception of very few remote and inaccessible areas,but these areas are not heavily populated. In essencetherefore there is no significant problem of transportationof the drug to where it is required.


2. Challenges posed by STORAGE

In reality storage, from the point of view ofstability of the drug, is not a problem since iron sucrose isa stable compound with a long shelf life. No refrigerationis required and the drug can be stored at room temperature:thus there are no additional logistic problems such as theneed for refrigeration, and of course the need for a reliablesource of electricity. However, there may beinfrastructural problems of space for the actual physicalstorage of the drug – this, however, should not be a realisticproblem for a people with sufficient ingenuity to drive theeconomy of their country the way India’s is going!

3. Equipment requirements and expertise inadministration

The intravenous equipment (cannulae, syringes, infusionssets) required for the administration of intravenous ironare no different from those required for any otherintravenous drug. Thus no special equipment nortechnology is needed, and the actual technique ofadministration is similar to that of any other intravenousinjection , and therefore no special training and expertiseis required.

However, of course some basic minimum training isrequired with respect to building the confidence level ofproviders , including specialists, medical officers and staffnurses. This is especially with regard to awareness ofpotential anaphylaxis and how to deal with it: while everyhealthcare provider administering iron sucrose should befamiliar with how to manage anaphylaxis, it should bestressed that most adverse reactions are minor andanaphylaxis very rare indeed (refer to chapter on SafetyAspects of iron sucrose). No test dose is required, and nodeaths have been reported in over 50 million women onwhom this drug was used.

4.Dose calculation:

Conventionally, the dose of iron infusion required iscalculated by the following formula:

(Body weight (kg) x Hb deficit x 0.3) + (body weight x10) mg.

To illustrate this with a woman starting with an Hb of 8g/dl, who weighs 45kg and where the target Hb is 11g/dl,the dose required is:

(45 x 3 x 0.3) + (45 x 10) = 815mg

Clearly the above dose calculation is cumbersome.

We would suggest a user-friendly dose calculation whichassumes that

(i) all anaemic women have depleted iron stores whichcan be adequately replenished with 500mg of iron, and

(ii) (ii) that 100mg of intravenous iron willraise the Hb by 1g/dl. Thus for a woman whostarts with an Hb of 8g/dl where the target Hb

is 11g/dl, the calculation becomes VERY simple sincethe dose requirement is calculated as follows:

Dose required = 500 + 300 = 800mg.

The 500mg is to replenish the stores, and the 300mg is toraise the Hb by 3 units from 8 to 11g/dl. This requires 4visits if the iron sucrose is to be administered at 200mgper visit.

5.Reducing the costs and inconvenience of slowintravenous infusions:

By conventional 200 mg elemental iron diluted in 100 ml0.9% normal saline and infused over 30 minutes every 3-7 days up to the total calculated dose – for eg - threevisits for a patient needing 600mg as total dose with 200mgadministered at each visit.

This approach requires a temporary bed, as wellintravenous infusion giving sets – with obvious costimplications. Research has now shown that iron sucrosecan in fact be administered a “rapid push” over 2-5 minutesin an outpatient setting, without the requirement of a bed.When it is considered that in busy institutions as many as50 women per day may need iron sucrose, the advantagesof the rapid push technique become immediately obvious.

6. The COST of intravenous iron sucrose

There can be no argument that intravenous iron sucroseis vastly more expensive than the oral preparations. Equally,there can be no justification for perpetuating a treatment(routine oral supplementation) that has failed to eradicatethe problem. Although vastly cheaper per unit cost, thetotal sums of money spent on free oral iron supplementsrepresent a colossal waste of money due to lack ofefficacy

What is the solution to this conundrum? Perhaps anotherway of asking the same question is “what value is placedon a woman’s life in India”? If IDA in pregnancy couldbe eradicated this would make a major dent in theembarrassing maternal mortality rates in India, which arehigher than those of Sri Lanka in the Indian sub-continentand Botswana in southern-central Africa!

It is clearly a challenge for government and thepharmaceutical industry. Government needs to place valueon women’s lives and provide the necessary resources.The pharmaceutical industry needs to make profits, butthey could make profits while at the same time providinga drug at an affordable cost. The authors of this articleare neither economists / politicians nor industrialists, but itseems quite obvious that a meeting of minds between

6www.kfogkerala.com

government and the pharmaceutical industry couldgo a long way towards resolving the problems.India is one of the most populous countries in theworld – the sheer numbers of women needing iron therapymean that pharmaceutical companies could cut the costof the drug and yet realize their profits through bulk sales.If there were the political will an understanding could bereached where government would be able to makeavailable iron sucrose to all women who need it. In thisregard the challenge for the obstetrician is to work withboth government and the pharmaceutical industry to bringabout change.

The increased use of iron sucrose in a variety ofsettings might drive down costs, and such situationsinclude the following:

- in every situation where the desired response tooral iron is not obtained

- using IV iron sucrose as the first line therapy inall cases of moderate and severe anaemia

- using IV iron sucrose more frequently in thepostpartum anaemia

COST of blood transfusion compared to currentcost of intravenous iron:

In a typical rural setting, when a woman with moderatelysevere anaemia in goes into labour, she is at significantrisk of postpartum haemorrhage. A requisition is made fora couple of units of blood or blood products, but these arenot easily available. The hazards of blood transfusions areonly too well known. The alternative would have been forthis woman to have entered labour with a normalhaemoglobin, her anaemia have been effectively treatedin the antenatal period with intravenous iron. Even atcurrent costs, intravenous iron sucrose is cheaper thanemergency blood transfusion. Thus it is false economy towith hold IV iron sucrose due to cost – the expenseincurred for 4 to 5 pints of blood/blood product transfusionis much more than what the IV sucrose administration inthe antenatal period would cost – and the expense mayalso include the young woman’s life!

So here is an issue government should consider: ifgovernment wishes to save women’s lives, one option withregard to anaemia and peripartum blood loss would be toset up several thousands of blood banks or blood storageunits in peripheries. This is a pipe dream, both in terms ofcost and in terms of logistics. A cheaper, achievable andmore realistic option is to invest in making IV iron sucroseavailable. Many district hospitals and large governmentinstitutions where IV sucrose has been used on a widescale have documented a steep decline in the need forblood transfusion. The lower cost of decreasing the number

and severity of cases of obstetric haemorrhage,and thereby saving lives, surely makes acompelling case for government to invest in making

IV iron sucrose more readily available rather than tryingto manage the complications of peripartum haemorrhageto the mother and the child.

5. The challenge of the need for repeatedinfusions

With the current iron sucrose, the maximum permissibledose to be administered at one sitting is 200mg, and then aminimum 24 hours must elapse before the next dose canbe given. Thus a woman who presents with anhaemoglobin of 6 g/dl would need 5 visits over a minimum10 days to achieve a target haemoglobin of 11 g/dl.

A number of challenges immediately arise:

- very few women will complete the 5 visits, eitherbecause it is just too inconvenient on their time, tooexpensive to travel that many times to the healthcentre, or the idea of 5 separate intravenousinjections is daunting, or a combination of these andother factors.

- many women present late in pregnancy: thewoman who presents at 38 weeks gestation isunlikely to have the time required to complete thetreatment course before she goes into labour, evenif she were compliant.

The potential solution lies in the use of intravenous ironavailable as a total dose infusion. Ferric carboxymaltoseis an effective option in the treatment of iron-deficiencyanaemia in patients for whom repeated visits can be anissue..There are discussions and arguments over relativecosts, but the avoidance of several visits may in the longterm mean that Ferrinject may turn out to be cheaper. ForIndia, this is a potential solution that would overcome mostof the difficulties discussed above – Ferrinject has yet tobe licensed and marketed in India.

The partial solution in the meantime is educate andencourage women to attend for antenatal care early inthe second trimester so that any anaemia can be diagnosedand treatment commenced early.

Let us hope that the fresh thinking and bold and safeinitiatives would lead the way to better the healthcare ofwomen in India.


Organised by Thrissur O&G Society, KFOGSponsored by South Zone AICC RCOG

November 11-13 , 2011Lulu Convention Centre Thrissur

International Conference onCURRENT TRENDS IN

OBSTETRICS AND GYNECOLOGY 2011

www.togsicon 2011.com

SPECIAL FOCUS ONMedical disorders in pregnancy

Urogynecology, EndoscopyGyn Oncology, Repro. Medicine

Labour and delivery

PROPOSED INTERNATIONAL FACULTYDR HENRY MURRAY — AustraliaDR JUSTUS HOFMEYR – South AfricaDR TRABUCO – Mayo Clinic USA

A CONFERENCE WITH A DIFFERENCENo parallel sessions, Maximised audienceparticipation, Eminent and eloquent faculty

WORKSHOPS1.Urodynamics and Pelvic Floor

2. Infertility 3. Fetal Medicine

Inauguration by Former Minister and Cine Artiste Mr. K.B Ganeshkumar Cochin Society Receiving the Best Society Award

KFOG President Dr. V.P. Paily addressing the Managing Committee meeting Cultural Programme

33 rd AKCOG 2011 KANHANGAD

8www.kfogkerala.com


Of all the mishaps in OT cardiac problems are theworst. They are traumatic for the doctors as well as thestaff. The family members of the affected person are of-course aghast. The reactions of the affected are manytimes violent. In this article we will discuss how to preventcardiac mishaps exclusively. The other complications likeperforations – haemorrhage – organ injury and the likecan be managed and are excluded from the purview ofthis article.

It is presumed that all the necessary care in pre-operative assessment and investigations has been taken.Having done that what are the preventive measures thatone can take? When do the chances of a cardiac problemincrease?

Watch Out: Be sure to check availability of oxygencylinder availability. Making it a subconscious habit ofobserving the patient’s face whenever feasible andpossible. It is mandatory to do this while administering LAafter you have ensured that the tip of the needle is not ina vessel by aspiration. Keep an eye on sudden foreheadsweating or yawning. Treat every moment / gesture ofthe client/ patient in the OT with due diligence. Theseprecautions are essential even when all the gadgets arepresent.

Back out: On a rare occasion it so happens that theclient / patient at the last moment decides not to undergothat particular surgery. This puts the operating team in fixspecially if they have gone to ‘outside’ nursing home. It ismore distressing if the team has traveled a considerabledistance. Under such circumstances it is best to back outrather than coax the client / patient to revise her decision.In a state of refusal the internal environment undergoeschanges which are unsafe for surgery.

In the unlikely event of encountering a situation wherea surgery cannot be completed safely, be ‘brave’ and learnto retreat. A client / patient with the pathology is a muchbetter situation to deal with than an OT death. With moderndiagnostic technique such a situation should not arise.

Do not get carried away by technique or by pre-decidedroute of surgery. Be open to change / reconsider yourchosen technique or route in good time.

Expected Time of Completion (ETC): Just as wehave expected time of delivery (ETD) in normal labour,set up a likely time for finishing the surgery. This is doneby the surgeon himself knowing his own speed and thenature of the case. Should the case take longer than theallotted time, think of calling for help in good time. It is farbetter to do this sooner than later. Respect yourAnaesthesiologist judgment in this matter. Having seenyou operate/worked with you for a sufficiently long time,he would know your strengths and weaknesses.

Maximize use of LA: The chances of a cardiac eventwould go down drastically provided we avoid GA in asmany cases as possible. Cardiac events in Tubectomy andMTP bring in media Govt attention along with everythingelse. Performing Laparoscopic Tubectomy and/or MTPis eminently feasible under LA. By no stretch ofimagination I am suggesting that we compromise on thestandards of OT. All the necessary monitoring gadgetsshould be in place. Anaesthesiologist is present as a stand-by with everything in place to administer GA if requestedby the client/patient at the last moment. Is this possible inPrivate Practice? Do clients / patients accept this? Will Ilose my Client / Patient if this does not succeed or causespain? Counseling plays a crucial role in performingsurgeries under LA or regional anesthesia. We have toexplain the difference between touch sensation and pain.Clarify to the patient that she would know / feel /understand / sense what is happening. However therewould be no pain. Analogy of a dental extraction ortreatment helps in counseling. Explain the risk of GA.Counsel the patient of the fact that anaesthisiologist wouldbe in attendance & would administer GA should the patientfeel it is not possible for her to undergo the procedureunder LA without any discussion at that time. Her decisionwould be respected and implemented. Let her knowemphatically that she is not being subjected to anexperiment nor is this (GA Vs LA) a prestige issue. It isin her own interest. I have been training doctors in the artof Laparoscopic Tubectomy since last 20 years exclusivelyunder LA and performing all my Lap TL &/or MTP cases

Dr Shirish Patwardhan, MD, Pune

Mishaps in OT

Contd. page-11

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MEDICAL ABORTIONCURRENT CONCEPTS

Induced abortion is an important aspect of woman’ssexual & reproductive life. Woman’s right activists believethat it is the woman who should decide whether she wouldlike to continue pregnancy. But, in reality, all other factorsare involved in our country except the woman’s wish. Thismay even result in an unsafe abortion. In India, 12000-18000 women are dying to complications of unsafeabortions. And there are thousands who suffer silentlymorbidity associated with it.

Amendment of MTP act 2003The Drug Controller of India approved marketing of

mifepristone in April 2002 for termination of earlypregnancy. The use of drug was recommended forpregnancy up to 7 weeks i.e. 49 days from last menstrualperiod.

The judiciary amended the MTP act by addingMifepristone followed by Misoprostol for termination ofearly pregnancy. This was also called as Medical Abortion.The drugs were considered very safe when used undermedical supervision & after proper counselling. The basicprerequisites of MTP act remained the same.

Further to this Drug Controller of India in 2009 hasapproved use of medical abortion up to 63 days or 9 weeksof pregnancy. Though, the MTP act is not yet amended onthis point.Who is the right candidate to have medicalabortion?

- Any woman can be offered to any woman up to 9wks

- Frame of the mind of patient: she should accept thatshe should come back for minimum 3 follow upvisits & can understand the instructions

- She should be ready for surgical procedure if failureor excessive bleeding occurs

- There should be good Family support- She should have easy access to appropriate

healthcare facility in case of emergency.- Permission of guardian in case of minor is mandatory

as per MTP Act 1971.

Who can provide medical abortion services?- Only Registered Medical Practitioner (RMP) as

described by the MTP Act should prescribemifepristone with misoprostol. Over the counter useof drug is not permitted.

- RMP should have post graduate qualification in ObGyn.

- Any doctor with MBBS qualification with anexperience of 25 MTP s under supervision &independently at recognized training centre.

How to proceed- Determine gestational age by LMP & Menstrual

History

Dr Parag Biniwale, MD, FICOG, FICMCH, Dip in Pelviscopy (Germany),Consultant Ob –Gyn, Pune. Postgraduate Teacher, Dr Patankar Medical Foundation

National Website Editor, FOGSI (2011-13)

Chairman, Young Talent Promotion Committee, FOGSI (2008-10)

under LA to a large extent. Remember that a surgeonrequires extra ordinary skill to harm a patient under LA.Know one is endowed with those kinds of skills. UnderLA one has to be gentle. All the reflexes of the patient areintact and it is that much safer.

Change of Anaesthesia: Whenever there is a needto switch from one type of anaesthesia to another, thechances of a cardiac event increase during the changeover. Utmost care needs to be taken at this juncture.

Anaesthesiologist is a key person in the operatingteam! Respect his opinion and abide by it. Be sure towork with your usual Anaesthesiologist for difficult cases.When you venture out for surgery, make sure the placewhere you are operating is properly equipped

Finally an acronym to take care of tricky situations inthe OT. It is ‘STOP.’ S stands for ‘step back,’ T standsfor ‘think,’ O stands for ‘organize,’ and P stands for‘proceed.’ In almost all situations this would be oftremendous help and se you and the patient / clientthrough. Wishing you a Mishap Free Life in the OT!

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- Ectopic pregnancy must be excluded- If IUD in situà should be removed- If client is taking OC Pills previously à R/O

post-pill amenorrhoea- Administer with caution in women with Previous

scarred uterus (myomectomy, CS & hysterotomy),fibroid

- Stop breast-feeding for 6 hours on taking misoprostol- Treat active vaginal infection if present.

Medical abortion is not recommended in- Chronic adrenal failure- Uncontrolled hypertension- Cardiovascular disease- Anaemia (Hb < 8 gm %)- Severe liver, renal or respiratory disease- Known coagulopathy / on anticoagulants- Drugs (aspirin, steroids, antidepressants)- Uncontrolled seizure disorder- Psychiatric disorder

Following investigations are mandatory- Haemoglobin: should be at least 8 gm%- Urine for albumin & sugar- Blood group, Pregnancy test & ultrasound ARE

NOT mandatory. They should be used on individualcase basis as deemed necessary by Gynaecologist.

Pre-abortion counselingPre-abortion counseling is important & it shouldinclude following points

- Possibility of continuation of pregnancy- Options available for termination- Detail procedure, associated risks / complications- Need for surgical termination in cases of failure

(continuation / incomplete / missed)- Discuss methods of contraception- Advantages (no risk of surgery or anaesthesia,

future fertility not affected)- Disadvantages (prolonged bleeding, chances of

failure, teratogenesis & minimum 3 clinic visits)- When she will be able to resume her daily activities.- Follow-up careConsentThe consent of the client must be taken in prescribed formC as in MTP act. In case of minor, signature of guardianis necessary.It is not mandatory to take husband’s consent but it maybe taken to avoid issues arising between the couple.

Drug protocolA] Up to 49 daysDay 1: 200 mg Mifepristone (Orally)

Inj. Anti-D if Rh -veDay 3: 400 mcg Misoprostol (Vaginal/sublingual/buccal)Day 15: Follow-up visit – Clinical/ ultrasoundassessment for completion

B] Between 49 -63 daysDay 1: 200 mg Mifepristone. Inj. Anti-D if Rh -veDay 3: 800 mcg of Misoprostol Vaginal preferred /sublingual / buccalDay 15: Follow-up visit – Clinical/ ultrasoundassessmentPost abortion care- After administration of misoprostol, client may be

observed for 4 hours. Her vitals are monitored.- Antibiotics are not universally recommended but must

be given to women taking medical abortion at home.The drug would include Doxycycline100 mg OD for 7days or Tab. Azithromycin 500 mg OD for 3 days.

- Pain relief may be offered with paracetamol, NSAIDsmay interfere in prostaglandin action & hence to beavoided.

- Third follow up visit is important to ensurecompleteness of abortion by clinical examination orultrasound. The opportunity must be utilized to counselclient for contraceptive counselling.

Contraception after medical abortion- Combined Oral Contraceptive can be started on the

day of misoprostol- Sterilization, IUD, Progesterone only method must be

offered only after completion of abortion- Condoms, Vaginal tablets should be advised after

bleeding stops- Natural methods should be advocated only after next

menses

Key points for successful medical abortion

- Proper selection- < 63 Days- Thorough Counseling must be done regarding

method & failure- Stress should be given on proper follow up to ensure

completeness- Management of complications should be done

promptly.- Contraceptive counseling is a must during.- Constant Medical Supervision is a must!!


� Tip No. 1 Always Anticipate it. Be ready for it.It is now not a rare entity.

� The incidence of placenta accreta has increased10-fold in the past 50 yrs, to a current frequency of1 / 1000 deliveries.

� Largely as a result of the increase in the number ofCS.

� In less developed countries, it affects about 1% ofdeliveries, but carries a case fatality rate of 10%. Indeveloped countries, it affects 2-3 % of deliveries,but is rarely associated with fatality.

� Increases with prematurity.� Rate varies with expectant & active Mx of 3rd

stage.� Need of MRP is more in actively managed 3rd stage

group compared to expectant management.� Ergometrine is associated with more manual

removal of placenta.� Tip No. 2 Identify the risk factors. Predict it.� Because of the fact that many of these cases

become evident only at the first attempt to separatethe placenta at delivery, it is essential to attempt toidentify antenatally its risk factors, the mostcommon is…. In about 50%, it is associated withplacenta previa & pervious CS.

� Any intrauterine infection (postpartum/postabortal),Traumatic curettage - Asherman’s syndrome,Uterine scars due to myomectomy, C.S., orhysterotomy, Submucous fibroids that lead toatrophy of overlying endo., Multi parity and Past H/ O manual removal of placenta

� Tip No. 3 Suspect it. Diagnose it.� It should be suspected in women with placenta

previa and in women having pain in abdomen inpregnancies with H/O previous cesarean section.

� Establishing antenatal diagnosis helps in proper andplanned management which in turn helps todecrease morbidity and mortality.

� Ultrasound and MRI are commonly used forantenatal diagnosis of adherent placenta.

� NORMAL PLACENTA – USG FEATURES1. The normal placenta has a homogenous appearance.2. Echogenecity of placenta is > Myometrium3. Characterized by a hypoechoic boundary between the

placenta and the urinary bladder that represents the

myometrium & normal retroplacental myometrialvasculature

� In case of adherent placenta,1. There is disappearance of retroplacental

anechogenic zone2. Vessels are seen bridging placenta and uterine margin3. Myometrial thickness is < 1 mm4. Presence of multiple placental lakes (“Swiss cheese”

appearance)5. Thinning of the uterine serosa-bladder wall complex

& Elevation of tissue beyond the uterine serosa(percreta)

6. It is important to diagnose certain conditions earlierlike Placenta Succenturiate & Bilobate

7.With colour Doppler,� Dilated vascular channels with diffuse lacunar flow.� Irregular vascular lakes with focal lacunar flow.� Hypervascularity linking placenta to bladder.� Multiple layers of vascular channels can be seen.� Tip No. 4 Keep LR / OT Ready on Admission� Mention the diagnosis & possibility on the file.� Keep your LR / OT ready to tackle it.� On admission of such patient, Insert large bore IV

(18g) cannula.� Inform anaesthetist well in advance.� Keep cross- matched blood ready.� Keep or bring sonography machine in the LR.� KEEP COOL & CALM AT THE TIME OF

DELIVERY.� Tip No. 5 Before doing anything hurriedly

Identify the Type – Do D/D� It can be - TRAPPED PLACENTA, PLACENTA

ADHERENS, PATHOLOGICALLY INVADINGMYOMETRIUM – Placenta Accreta, PlacentaIncreta, Placenta Percreta

� D/D - Clinical findings� In trapped placenta- fundus feels smaller &

contractedP/V exam- edge of the placenta is palpable throughtight cervical os.

� In placenta adherence - the fundus is broad &boogy, bleeding may be excessive or not.

� Hour glass contraction may be present.� Labor Room USG is very much helpful in D/D.� Trapped placenta- myometrium is thickened all

Dr. Alpesh Gandhi.

Chairman, Practical Obstetric Committee, FOGSI.

MRP- TRICKS & TIPS…


around uterus & a clear demarcation isseen between placenta & myometrium

� Adherent Placenta- myometrium will bethickened in all areas except where the placenta isattached, where it will be very thin even invisible &Color Doppler study confirm continued blood flowthro‘ the myometrium to placenta irrespective of thecause.

� TIP No. 6 If bleeding is not there…..� Insert urinary catheter, Emptying bladder� Breast feeding or nipple stimulation can be

encouraged.� Change of position - encourage an upright position.� TIP NO. 7 If still placenta is retained or if

bleeding starts.� Immediately - CALL FOR HELP� Call Anaesthetist.� Commence/continue oxytocin infusion 20 units in

1litre at rate of 60 drops /min.� Measure and record blood loss accurately.� Keep Blood ready / Send request for it.� Prepare and transfer patient to operation theatre for

MRP.� TRAPPED PLACENTA� TOCOLYTICS - I / V bolus, or sublingual tabs can

be given.� Sedation or Short G /A can be given if needed.� If NTG is used as tocolytics, close observation is

must, as it may cause uterine relaxation &hemorrhage. Also transient but sudden fall in BPshould be watched for.

� PLACENTA WHICH IS NOT TRAPPED…..

� Pipingas Technique - UMBILICAL VEININJECTION- which reduces need for MRP by20%.

� Umbilical vein injection of oxytocin, prostaglandinsF2 Alpha or Misoprostol diluted in NS.( 30-40 IU oxytocin or 600-800 mcg misoprostol in30 ml of NS)

� Sulprostone- PGE2 Analogue- I / V can be tried,but not easily available.

� Umbilical vein injection of saline solution plusoxytocin appears to be effective in the managementof retained placenta. Saline solution alone does notappear be more effective than expectantmanagement. (The WHO Reproductive Health

Library, No 8, Oxford, 2005 and TheCochrane Database of Systematic Reviews2006 Issue 4)

� MRP - PROCEDURE - TRICKS� 1. Take all precautions for proper sterilization.2. Wash - scrub your hands.3. Put on gloves with elbow length.4. Introduce one hand covered with gloves & antiseptic

cream into the vagina along the cord. 5.Identify the margin of placenta & find the cleavage.

6. Support the fundus while detaching the placenta.Abdo. Hand presses fundus firmly. 7.Grasp the placenta & withdraw the hand fromuterus gradually.

8. Never grasp the placenta till it is separated.9. Never try to remove placenta in piecemeal &

packing.10. Always examine the placenta after removal.

11. Examine the pt. for genital tract injuries.� Tip No. 8 Real Time Sonography.Use of USG during procedure of MRP is very helpful.

Real time USG during the procedure increasesconfidence of the surgeon.

� Tip No. 9 Placenta during CS� At CS, the placenta should be removed by using

controlled cord traction, By Keeping gentle tractionon the cord and massage (rub) the uterus throughabdomen.

� Don’t remove it routinely by MRP as this increasesthe risk of postoperative endometritis.

� Tip No. 10 Follow up MX- ACCRETA1. Watch for Bleeding.2. Look for Temp, Other Signs &Symptoms of

infection.3. Coagulation profile4. Do Ultrasound /doppler : To see Vascularity / and

confirm involution.5. HCG titers (If plateau� consider Mathotraxate).6. Oxytocics & prophylactic antibiotics: Benefit &

duration not universal.� Tip No. 11 Conservative MX in Accreta.1. Leave placenta in situ undisturbed.2. Keep cord as short as possible.3. Methotraxate is given.4. Trials with Mifepristone – 50 mcg daily are

encouraging.� OUTCOME WHEN LEFT IN SITU1. Spontaneous expulsion or Complete resorption occurs

or2. Interval intervention –placental removal may be

required if Heavy Bleeding, Infection, DIC.Always watch for the 4th stage of labor & post-partum

period.� NEVER try to do MRP in HURRY, it will give

you all the WORRIES & will not let you to eatCURRIES.


12 “Why Mothers die” case discussion withwork station organized by Kasaragod societyKasaragod

July3 CTG & Doppler workshop organized by

Kottayam society Kottayam24 CRMD Quarterly meeting, TCR TOGS

Academia, TCR August

5,6,7 Dakshin Kanyakumari, co-sponsored by KFOGKanyakumari

22,23,24, 25,26FOCUS- PG Training programme organizedby JMMC &RC sponsored by KFOG JMMC, TCR

28 Work shop on Safe Obstetric Practices topromote vaginal deliveries organized byKannur society Kannur

September16,17,18 Training the Trainers EMOCALS

TOGS Academia, TCR

October9 Managing committee of KFOG; Workshop

CTG + Doppler Alleppy16 Work shop on Safe Obstetric Practices to

promote vaginal deliveries organized byCochin society Ernakulam

20 Talent search among postgraduates –sponsored by KFOG Academic committee and Deptof O&G, JMMC&RC Jubilee Medical College,TCR

20 Joint meeting on research andpublication TCR

23 “Why Mothers die” – Case discussion &work stations organized by Palakkad clubPalakkad

November6 Vaginal surgery workshop organized by

Kollam society Quilon11,12,13 International conference on Current

trends in Obst & Gyne organized by TOGSon behalf of KFOG, sponsored by AICCRCOG south zone.

20 CRMD Quarterly meeting Trivandrum December

4 Vaginal surgery workshop organized byCochin society Ernakulam

9,10,11 Emergency Obstetric Care & Life support(EMOCALS) Training programme Thrissur

January16-Jan Nursing assistants Training

TOGS Academia, TCR23-Jan Research methodology organised by Health

University JMMC &RC, TCR30-Jan Vaginal surgery workshop

Mother hosp. Thrissur

February5-Feb Nursing assistants training

TOGS Academia, TCR11,12,13 AKCOG Kanjangad17-Feb Nursing assistants trainingThycaud

Trivandrum20-Feb Promoting vaginal delivery,

UNICEF supported, Palakkad26-Feb Nursing assistants training IMA Hall Calicut26-Feb Nursing assistants training IMA Hall Kottayam

March3 EMOC Review meeting of FOGSI New Delhi5 Nursing assistants training Kannur10 Nursing assistants training

TOGS Academia, TCR13 KFOG Managing committee

TOGS Academia, TCR20 CRMD Calicut

April10 Work shop on Safe Obstetric Practices to

Promote vaginal delivery organised by TOGSJMMC & RC, TCR

May6,7,8 EMOC –Training the trainer

TOGS Academia, TCR

22 “Why Mothers die” case discussion withwork stations organized by Malappuram clubMalappuram

26 Quiz for undergraduates- KFOG Academiccommittee and Dept of O&G , JMMC &RCJubilee Medical College, TCR

26 Joint meeting on research andpublicationThrissur

29 Vaginal surgery workshop organized by Calicut society. Sponsors – FOGSI, Calicut

June5 KFOG Managing council & workshop on

CTG & Doppler organized by Cochin societyErnakulam

KFOG Academic Calendar -2011

“Do we Care”

The key to High Risk Pregnancy Management is early detection andtimely intervention and hence the pertinent question “Do we Care”. TheFetomaternal Unit at CIMAR along with noted experts in the field ofObstetrics, Radiology and Paediatrics come-together for PERICON-2011on 17th July 2011 to attempt to answer the queries and dilemmas of HighRisk Pregnancy Care.

Bored with routine conferences where experts come and air their views:then this is the CME for you. This year, at Pericon, we are focusing oninteractive sessions where each and every one of your questions will beheard. Do come knowing that your questions will be answered.

Date : 17th July 2011Venue : IMA Hall, Kaloor, Kochi.

TOPICS:Congenital heart disease – ‘what next’

IUGR-Timely DeliveryFetal Infection – false alarm

PIH – New TrendsFetal therapy & Laser

CIMAR COCHINUnit of Edappal Hospitals P. Ltd.,Tipu Sulthan Road, Off NH-17

Cheranallore, Edappally,Kochi 682 034, Kerala. India

Tel. 0484-4134444Fax. 0484-4134455

Email: [email protected]

For more details, please contact:- 1. Dr. Meenu Parasuram Mob. 9947013900

2. Dr. Bijoy K. Balakrishnan - Mob. 944630228

3. Mr. Atmajan Pallipad Mob. 9847013901

Dr. Suresh S.Dr. V.P. PailyDr. RamamurthyDr. PalaniappanDr. Naveen JainDr. Sheela Nampoothiri

Dr. RiyasDr. Teena KoshyDr. Prashant AcharyaDr. Prathima RadhakrishnanDr. Balu V.Dr. Rijo

FACULTY

Delegates Post Graduates

Before 10th

July 2011 Rs. 1000/- Rs. 500/-

After 10th /

Spot Rs. 1300/- Rs. 800/-

Regn. Details

Kindly send us a demand draft in favourof “PERICON 2011” payable at Cochin

at the address mentioned below:-

web: kfog_may_2011.pdf · vice president elect dr.ajith s joint secretary dr. sangeetha menon...

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