Address of CorrespondenceDr. Fessy Louis T. Editor KFOG Journal CIMAR COCHIN, Thykavu Stop, NH 17, Cheranalloor,Edappally, Kochi -682 034, Kerala, INDIA Mob: 09846055224 E-mail: fessylouis@gmail.com

President:Dr.V.P.Paily

E-mail: vppaily@gmail.com

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 Louis

Committee Chair personsMaternal & Foetal Medicine Chair Dr.Ambujam

Academic chair Dr. V. Rajasekharan NairElect Dr. P.K.Syamala Devi

Adoloscent Chair Dr.V.K.ChellammaElect Dr.Kunjamma Roy

Reproductive Health Chair Dr.K.K.GopinathanElect Dr.Philip Abraham

Oncology Chair Dr.Sumangala DeviElect Dr.Chithra Thara

Reasearch Chair Dr.P.K.SekharanElect Dr.Nirmala .C

Laison Officer Dr. V. Rajasekharan Nair

Secretary GeneralDr. T. Jayandhi RaghavanE-mail: jayandhi@hotmail.com

KFOG

OFF

ICE

BEAR

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FOR

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YEA

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Vol: 5 No: 2 August 2011

Web:www.kfogkerala.com

Dear ColleaguesKnowledge is knowing that tomato is a fruit; Wisdom is not to include tomatoin a fruit salad. I hope that the articles in our KFOG Journal will be helpful inimproving knowledge and wisdom in your day-to-day clinical practice.I once again request all of you to contribute articles to our Journal. I also requestall of you to log on regularly to our website www..kfogkerala.comWishing you all Happy Onam and Ramzan.

Dr.Fessy Louis.TEditor

CONT

ENTS

President’s Message 02

Secretary’s Message 02

LUTEAL PHASE DEFECTS

Dr. Mala Arora 03

THROMBOPROPHYLAXIS IN

GYNAECOLOGY AND OBSTETRICS

Dr. Annie Soman 06

PRESENT STATUS OF ROBOTIC

SURGERY IN GYNAECOLOGY.

Dr. Amol Lunkad 12

MEDICAL ABORTION-

CURRENT CONCEPTS

Dr Parag Biniwale 14

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KFOG wishes a Happy and Prosperous Onam 2011!

It gives me great pleasure in addressing our esteemedmembers in this second issue of our journal for the year2011. After the hot debates and discussions about the “MassCaesarean sections”, KFOG is putting efforts to reduce theCaesarean sections and for the same purpose conductedworkshops on “Safe Obstetric Practices to promote vaginaldeliveries”. Hope these workshops will open the eyes of ourmembers and in near future the LSCS rate will stabilise oreven fall from the current level. So much so the Workshopon “Why mothers die” – case discussions and workstationswere appreciated by all the members attended and hopethere will be an improvement in the standards of care giventhe pregnant women. Thanks for the sincere and tirelesseffort by our President Prof.V.P. Paily in this aspect.

Recently a lot of articles and criticism regarding the“Unnecessary Hysterectomy” is getting news value in ourstate. Are we doing unnecessary hysterectomy? One shouldthink about the genuinenes of Indication before hysterectomy– eg: abnormal uterine bleeding, minor degrees of descentof the uterus, small fibroids etc . Think before you decideupon any procedure - whether we can avoid the surgery.We should not forget about the morbidity produced by thesesurgical procedures.

Let us think about our FOGSI president’s commentsregarding this Issue - “Presence of Pregnancy should notbe the Indication for caesarean section” and “Presence ofUterus should not be the indication for Hysterectomy”.

Let us (KFOGIANs) unite and take efforts to eradicateunethical and unscientific practices for the betterment of ourprofession and society.

Jai KFOG

Dr.Jayandhi RaghavanSecretary General

KFOG, Kerala

Secretary’s Message

President’sMessage

Dear Colleague,Greetings from the KFOG team. Karkidakam has just

started with a heavy dose of the monsoon rains. Let me remindyou to be vigilant about the infections especially H1N1, thatcome with the rains.

For KFOG the recent few months had been really busyones. We have initiated all the activities proposed in ourcalendar.

We started with a managing council meeting at Thrissuron 13th March soon to be followed by the CRMD at Calicut on20th March. Before the Vishu & Easter holidays we did thefirst workshop on safe obstetric practice at Jubilee MissionHospital, Thrissur with a view to promote vaginal deliveries.This assumed all the more importance in the few weeks thatfollowed with the media highlighting the high cesarean ratesin the State. KFOG also is very concerned about this trendand has come out with our stand. We want to promote obstetricpractices that will safeguard the health of the mother and thenewborn and keep the cesarean section rates to the lowestpossible. The support of the media, the public and thegovernment is essential for this. Thanks to the Jubilee teamfor arranging the above workshop.

The quiz for undergraduates was envisaged to instill moreinterest in the specialty among the budding doctors oftomorrow. It was not only helpful for knowledge transfer butwas good entertainment too, thanks to Aswath, Sareena andthe entire Jubilee team and management. The academiccommittee sponsored it. We hope to put in place a framework for research activities which is taking shape under theguidance of the academic and research committees.

The vaginal surgery workshop at Kozhikode was wellappreciated, thanks to Dr.Sumangala and Dr.Beena andcolleagues at MIMS for the hard work. The programmeofficially was of Calicut Society and FOGSI, supported byJuventus. Doctors P C Mahapatra and Pattanaik took a lot oftrouble to reach Kozhikode traveling by road from Bangalore.I was honoured to represent KFOG as operating faculty. Wehave plans for two more similar workshops at Kochi andKollam.

We started the programme for training the trainers inEmergency Obstetric care and Basic Life Support at Thrissuron 6th May and hope to repeat one more such session inSeptember before starting to offer the training for the practicingobstetricians. The support of the anesthetic colleagues atThrissur is greatly appreciated.

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Luteal Phase DefectsDr. Mala Arora

DEFINITIONLuteal Phase Defects are synonomous with Corpus luteumInsufficiency, or Luteal phase insufficiency. It is definedas inadequate corpus luteal function in the latter half ofan ovulatory cycle.

PREDISPOSING FACTORSHYPERPROLACTINAEMIAHigh levels of serum prolactin cause luteolysis of thecorpus luteum and may first present as infertility orrecurrent early miscarriages due to luteal insufficiency.The entity is diagnosed by performing serum prolactinestimations. It is corrected by administration of Dopamineagonists like bromocriptine, or the long acting agonist likeCabergoline.

PATHOPHYSIOLOGYLPD may result from a host of causes, unrelated toeach other. Some of these are listed below

Poor follicular phase leading to inadequate cohort ofgranulosa cells that get luteinised to produceprogesterone in the luteal phase.Premature LH stimulation of immmature granulosacells that do not produce sufficient progesterone, asseen in Polycystic Ovarian diseaseAbnormal patterns of LH secretion in the Luteal phasecausing attenuated LH & progesterone levels as isevidenced in athletes and in women with low bodymass. There is evidence of reduced serum leptin levelsin them. This causes suppression of the GnRH pulsewhich in turn leads to low LH in the Luteal Phasecausing LPD.Endometriosis and infections like genitourinarytuberculosis may present with Luteal phase defects intheir earlier stagesDecreased endometrial nuclear progesterone receptors

Estrogen induces nuclear progesterone receptors and theprogesterone then acting through its own receptor

Auditing maternal deaths had been our priority right fromthe inception of KFOG and we experimented this time withdiscussion of the actual cases (anonymously, of course) withpracticing obstetricians of Malappuram district. Drs.Kochunarayani and Kunjumoideen and team organized thesession under the auspices of Malappuram O&G Club. Thefaculty from Thrissur loaded onto the “innova” with the teachingaids and headed for Perinthalmanna. The drive reminded us ofthe protocol workshops we did in each district few years ago.We felt that this trip was well worth it looking at the feedback.With the experience gained we then went to Kasaragod for asimilar session, thanks to the enthusiasm of Dr.Maya andcolleagues of Kasaragod O&G society. But this time the IndianRailways took us there. Last minute problems reduced thenumber of people to carry the manikins and teaching aids. I amsure Ambujam would have forgotten the inconvenience ofcarrying it through the rain because of the warm hospitality ofKasaragod and the large number of delegates who came fromMangalore and Manipal. We intend to repeat the show atPalakkad in October.

We are all gearing up for the international conference on11, 12, & 13th of November at Lulu Convention Centre, Thrissur.The faculty and the programme have been finalized. The 1st

brochure would have reached you. We are confident that thelist of eminent faculty and the relevance of the topics will drawa big crowd. Please mark the dates and book early. For achange, we don’t have parallel sessions and that limits thenumber of speaker positions. We thought of using theopportunity to hear from renowned international and nationalfaculty. The faculty for the workshops are also carefully chosen.We are introducing a new scheme of focused podiumpresentations of selected posters (3mt) and videos (7mts).Please send in your poster or video before the deadline -September 30th.

Let me sign off by soliciting your involvement in all ouractivities.

With Best Wishes and Regards,V P Paily,

President, KFOG.

Cont. from page-2

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produces a mediator protein known asProgesterone Induced Blocking factor (P1BF)(7,8)In a successful pregnancy outcome, P1BF in sufficientlevels produces Asymmetric antibodies (i.e Th2, NK cells)which offers fetus protection whereas in cases where P1BFis insufficient, symmetric antibodies are formed (Th1 cells,LAK cells) causing cytotoxic, inflammatory abortogenicreaction causing a Miscarriage. (9) (Fig. 1)

DIAGNOSTIC CRITERIAInadequate luteal function may be characterized by

Short luteal Phase of less than 13 days. This was firstdescribed by Strott. (10) It has been observed that notall short luteal phases are inadequate. However sincethis is a very objective criterion, it may the most reliablenon invasive test. It is calculated from the mid cycleLH surge to the onset of menses.Absent or Inadequate thermogenic Shift in Basal BodyTemperature (BBT )levels. There is a poor correlationbetween BBT and hormonal levels. With the advent ofultrasound follicular monitoring, the need to maintainbasal body temperature charts has dwindled.Low levels of Serum Progesterone on cycle day 21 ina 28 day cycle or 7 days post ovulation in a longercycle. For an adequate luteal phase, it should be 10ng/ml or above.

Progesterone is secreted in pulses and daily progesteronelevels may vary, which can reduce the diagnostic accuracy.of this test. To reduce such variability multiple estimationsin the Luteal phase have been advised as a practicalsolution. Three estimations between 5 and 9 days postovulation can be performed and a total value of less than30 ng/ml will signify LPD

Endometrial histology lagging behind by 2 days inthe luteal phase. This is no longer performed on aroutine basis as less invasive tests can be employed.Ultrasonic evidence of poor endometrial echogenicchange. This is a subjective criteria.Ultrasonic evidence of absent corpus luteum formationin the midluteal phase, poor corpus lutealvascularisation by power Doppler and/or poor bloodflow indices in the ovarian artery on the side of thecorpus luteum are indicators of LPD. However thevalues show a lot of individual variation and thestandard cut offs are not reliably set.Promising new diagnostic techniques

1. Daily Salivary Progesterone measurementsThe total progesterone output as measured by the

area under the progesterone profile curve issignificantly lower in LPD cycles than normalcycles. In order to circumvent the need for dailyblood sampling, daily salivary measurements havebeen recommended.2. Progesterone Induced Blocking Factor Thelevels of this protein increase in the Luteal phase.(7,8) Measurement of this protein holds promisebut further studies are required to determine itsaccuracy as a diagnostic test. Progesterone inducedBlocking Factor is shown to support the Th2dominant cytokine pattern in the endometrium.

Since each of the above criteria when taken alone isnot diagnostic one has to take into account two or moreof the above criteria i.e. low progesterone levels coupledwith short luteal phaseInterestingly LPD pattern of the endometrium has been toshown to co-exist with normal serum levels ofprogesterone. Hence progesterone levels alone do notreflect endometrial histology (11,12)

Although the role of progesterone in successfulimplantation cannot be denied, yet LPD remains acontroversial entity to diagnose. The reasons being thefollowing

No correlation of endometrial histology with serumprogesterone measurementsReports of ongoing pregnancies with very low serumprogesterone levelsEndometrial biopsy is performed infrequently fordiagnosis of LPD as it is invasiveEndometrial dating when lagging by two days provesluteal insufficiency but when in phase it does notexclude it.Endometrial progesterone receptor concentration/number will help in diagnosing luteal Phase defectswith greater certainity but this test is not available.

We thus realize that the tests to diagnose LPD are at presentnot standardized.Further to this discrepancy, researchers suggest that LPDand implantation failure may not be a function ofProgesterone levels alone but may result from abnormalserum P:E2 ratio or abnormal P:E2 receptor ratios. (13,14).However some have suggested various other theories,amongst them are specific deficiencies of cytosol E2receptors at mid luteal phase.Special CircumstancesProgesterone deficiency has been documented in women

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with congenital abnormality known as‘abetalipoproteinemia”. In this disorder the cellsare unable to take up and use VLDL cholesterol forsynthesis of progesterone. These women have lowconcentrations of progesterone during pregnancy but havecarried their pregnancy to term.Fetuses that exihibit 3 beta hydroxy steroid dehydrogenasedeficiency an enzyme required for progesterone productionalso deliver at term although it is presumed that theirplacenta’s do not synthesize progesterone.

PREVELANCEIn women with RPL early in the first trimester, especiallyif associated with oligoovulation and amenorrhea, lutealphase insufficiency may play a role.

THERAPY FOR LPDThis has included the following:-

Ovulation Induction. Stimulation of ovulation willlead to a better cohort of granulosa cells which in turnwill get luteinised to theca cells to produceprogesterone. Clinical studies by Di Zerga and Hodgen (15) indicatethat LPD is secondary to aberrant folliculogenesis. Thisdisorder is said to create a cascade of deficiencies inthe preovulatory follicle, the corpus luteum and theendometrium in both the secretory and follicularphases.Insufficient luteal function is obviously a consequenceof inadequate follicular activity. For didactic or researchpurposes follicular and luteal phases may be separatedby various clinical and analytical parameters butphysiologically they must be regarded as one functionalentity. On the other hand it has also been noted that atabnormalities of the Luteal Phase may also stem fromovarian stimulation. (16). This was also observedparticularly with induction of high estradiol levels (17).Goldstein et al evaluated different P:E2 relationshipsand how they influenced endometrial development andpregnancy rates (18). They demonstrated that the mostnormal endometrium and best pregnancy rates wereassociated with high E2 levels balanced by highprogesterone levels.Supplementation of Human ChorionicGodadotropin (HCG)The supplementation of HCG stimulates the thecalutein cells to produce progesterone. Hence its action

is indirect. However it was the popular methodof luteal support prior to the advent of natural

progesterones. It has a long half life, hence can beadministered every 3-4 days. However it can only beadministered parenterally.The disadvantages of HCG are serious. HCGsupplementation increases the incidence of OHSS.HCG will also increase luteal E2 to undesirable levels,inducting an unfavourable P:E2 ratio which may behinder implantation and ongoing pregnancy rates. In amulticentered placebo controlled study Harrison RFclearly showed that hCG has no role in the managementof RSA. (19)Progesterone SupplementationProgesterone supplementation has long been practicedas the treatment of LPD. Earlier when only syntheticprogesterones were available, Medroxyprogesteroneacetate and Dydrogestone were the drugs of choicebecause of their low androgenic activity. With theadvent of natural progesterone it is the drug of choice.It may be administered by the vaginal or parenteralroute. For it to be effective it should be administeredearly in the luteal phase preferably before implantationso as to exert maximum benefit at the time ofimplantation, which is estimated to be 3-7 days postovulation. Cochrane database and other recentpublications have confirmed the benefit ofprogesterone supplementation in recurrentmiscarriages.(20,21)

Key pointsLuteal phase deficiency can best be regarded as a subtleform of ovulation dysfunction that should be treatedwith optimizing ovulation.The diagnostic criteria are not properly validated asserum progesterone levels fluctuate in a cycle and asingle measurement may not be representativeThe short length of luteal phase of less than 13 days isdiagnosticHistological Endometrial dating is no longer requiredfor diagnosisSearch is on for new markers like Progesterone inducedprotein e.g. PIBF

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THROMBOPROPHYLAXIS INGYNAECOLOGY AND OBSTETRICS

Dr. Annie SomanAssociate Professor

Mosc Medical College, Kolenchery

INTRODUCTIONVenous Thromboembolism (VTE) was considerd as adisease of western population earlier. Now we are comingacross more and more cases of VTE among our patients.The following is the list of few cases of VTE which Iencountered within a short span of 6 months whichprompted me to write this article. This shows that venousthrombosis is not an uncommon entity even among ourpopulation. So it is important to identify these cases andto administer appropriatriate prophylaxis

CASE STUDY1. A 40 year old multiparous lady underwent LAVH foradenomyosis. No associated risk factors. Her post-operative period was uneventful for 3 days. On the 4thday she developed pain and swelling of left lower limb.Doppler showed acute DVT with partial occlusion ofexternal iliac and popliteal vein2. Aprimigravida had termination of pregnancy for severepre eclampsia and IUGR at 20 weeks of gestation. After 2weeks she reported with severe head ache and seizures.CT showed cerebral venous thrombosis. Her APLA testingcame as positive.3. Mrs A G2P1L1, a case of previous LSCS for severe preeclampsia is now admitted with gestational hypertensionat 32 weeks. After 3 days she developed swelling, painand tenderness in the right thigh. Doppler showed partialthrombosis involving distal superficial femoral vein andthrombosis of great saphenous vein. Diagnosed as DVTR leg and her APLA testing was negative.4. A 48 year old obese lady had TAH for fibroid uterus.No other comorbidities. She had an uneventful postoperative period in the hospital. On the 6th day shereported to the casualty with breathlessness,tachypnoea,cyanosis and tachycardia.O/E- swelling of Rlower limb.She had O2 desaturation and expired after 2hrs.Diagnosis –Pulmonary Embolism

THROMBOPROPHYLAXIS IN GYNAECOLOGYThe major factors contributing to venous thrombosiswere described by Virchow more than 125 years ago.They are

increased blood coagulabilty Venous stasis Trauma to vessel wall

Many high risk factors have been described for VTE ingynaec surgeries.

FACTOR CONDITIONAGE >40 yrs in major surgery

>60 yrs in a non-major surgeryObesity Moderate >75 to 90 kgMorbid >115 kgImmobility pre operatively – prolonged hospitalization

Intra operatively – prolonged operation timePost operatively - prolonged bed confinement

Trauma Damage to walls of pelvic vesselRadical surgery Skeletonisation of vesselsMalignancy Release of tissue thromboplastinRadiation Prior radiation therapyMedical disease Diabetes, Cardiac disease,

C/c pulmonary ds, severevaricose veinsPrevious VTE

Deficiency /dysfunction Protein C, Protein S, Antithrombin, factor V Leiden

Prothrombinvariant 20210 A, APLAHyper homocystenemia, Dysfibrinogenemia

Post opinfection and tissue thromoplastinPelvic cellulitis

The main changes occurring in surgery are grouped intothree.1. Tissue injury – produces thromboplastin activation by

both intrinsic and extrinsic pathways leading toformation of fibrin.

2. Increase in circulating platelets, platelet aggregationand adhesiveness increase for 72 to 96 hrs following asurgery.

3. Venous stasis – prolonged anaesthesia and generalisedmuscle relaxation leads to venous stasis and increase inincidence of VTE.

Prophylaxis of Venous ThrombosisThe most effective treatment of venous thrombosis is its

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PREVENTION.

How to Prevent VTE?1. Weight Reduction – Grossly overweight patients should

reduce weight before an elective surgery.2. Those on OC pills should stop it one month prior to

surgery.3. Reduce post-operative hospitalisation – Those who are

hospitalised for investigation or some other treatmentshould be discharged and it is ideal to have an ambulantperiod of 2-3 weeks at home before readmitting forsurgery.

4. During surgery, avoid pressure on the calf muscles sothat venous return should not be impeded in any way.This can be done by elevating the leg by a sand bag orsorbo rubber pad. At the end of surgery it is a good planto elevate and massage the legs.

5. Avoid dehydration – 200-300ml of fluid per hour shouldbe infused during surgery.

6. Leg movements should be encouraged while the patientis on bed post operatively.

7. Early ambulation following surgery is advisable.

Agents used for thromboprophlyaxisThe main methods of thromboprophylaxis are anticoagulantsand compression modalities.Low dose heparinLow dose heparin with DHE Dextran 70/40Low molecular weight heparin WarfarinHeparinoids Compression modalities

Low dose heparinHeparin combines with antithrombin III and neutralisesactivated factor II (IIa). It also inhibits coagulation factorsXIIa, XIa, Xa and thrombin. Low dose heparin interfereswith early stages of coagulation without significantlyaltering the clotting factors in plasma.

5000 units 2 hours prior to surgery and every 12 hourspost op for 5 days.5000 units 8th hourly in high risk patients.

The main side effects of heparin are :ThrombocytopeniaAllergic reactionsOsteoporosis – if used for long term

Low dose heparin with DHEDihydroergotaminemesylate0.5mg exerts a selectiveconstrictive effect on veins and venules with minimaleffect on arteries and arterioles. Hence it decreases venousstasis and accelerates venous return. It is contraindicatedin patients with hypertension, vascular disease or impairedliver or kidney function.

Low molecular weight heparin (LMWH)It potentiates inhibition of factor Xa and has less

effect on prolonging aPTT; once daily dosage is enough;The main preparations available are:

Fragmin 5000 units s/c ODEnoxaparin 40MG s/c OD

HeparinoidSame as LMWH. Used when there is heparin inducedthrombocytopenia.

Direct thrombin inhibitors (Hirudin)Inhibits thrombin activity and may be used in heparininduced thrombocytopenia.

Dextran 40/70Dextran decreases platelet function and coagulation factorV and VII and accelerates fibrinolysis. Infusion of 1 L ofDextran 70 over 6-8 hours during surgery or immediatelyafter provides protection for 5 days. Dextran 40 is clearedrapidly and should be administered at continuous infusionat the rate of 20ml/hr or 500ml over 4-6hrs daily.

WarfarinOral anticoagulant inhibits the synthesis of vitamin Kdependant coagulation factors. It is used in long termtreatment and prevention of VTE. It has high risk ofbleeding, requires anticoagulation monitoring. Numerousdrug interactions are there. It is contra indicated inpregnancy.

Compression modalitites (TED stockings)TED stockings decrease the luminal diameter andincrease the blood flow velocity, thereby decreasingvenous stasis.1. Graduated elastic compression stockings causes 20%increase in flow velocity. TED pressures- 18, 14, 8, 10,8mmHg from ankle to upper thigh are used.2. Intermittent sequential pneumatic compressiondecreases venous stasis and stimulates fibrinolysis. In thismethod there is a 200% increase in flow velocity. Pressuresof 35, 30, and 20 mmHg are used sequentially for 12 secondsat ankle calf and thigh.

THROMBOPROPHYLAXIS IN PREGNANCYPregnancy is a Hyper-coagulable state. There is a 4 – 5 foldIncrease in the risk for VTE in pregnancy. It is still higher inpuerperium. Overall risk is 1 – 2 per 1000 deliveries.

The various risk factors of VTE in pregnancy are grouped asfollows.

Preexisting causes Newer onset or transient causes

Previous VTE Surgical procedure

Thrombophilia Hyperemesis gravidarum

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Dr.Kadeeja Mumtaz being felicitated on her acheivement ofKerala Sahitya Academy Award

Full site sensitization programme on HIV jointly organized byTrivandrum Society & KSACS.

FOGSI President Dr. P.C. Mahapatra and KFOG Office Bearersduring the Vaginal Hysterectomy Workshop at Calicut

Darsan Annual CME inauguration at Kottayam.

November 11-13 , 2011Lulu Convention Centre Thrissur

International Conference on

CURRENT TRENDS INOBSTETRICS AND GYNECOLOGY 2011

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

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

WORKSHOPS 2. Infertility

1.Urodynamics and Pelvic Floor 3. Fetal Medicine For detailed programme log on

www. togsicon2011.com

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Age >35 years OHSS

Obesity (BMI >30) Immobility after delivery

Parity e” 3 Systemic infection

Smoking Post partum wound infection

Varicose veins Long distance travel

Paraplegia

Medical co-morbidities

Obstetrics causes

Multiple pregnancy

Pre Ecclampsia

Caesarian section

PPH

Previous VTEWomen with previous VTE have an increased risk ofrecurrence in pregnancy and post-partum. The risk is moreif the woman had thrombophilia or VTE in an unusualsite or an unprovoked one.Take a detailed history to assess whether the previous VTEwas a single one or a recurrent VTE. If it was a singleVTE see whether it is an unprovoked, estrogen provoked,thrombophilia associated or associated with temporary riskfactors like surgery or trauma.In single previous VTE, if it is an unprovoked one, orprovoked by estrogen (OC pills, pregnancy) or associatedwith thrombophilia are considered in the high risk group.They require both antenatal and postnatalthromboprophylaxis. But those associated with surgery ortrauma is grouped as low risk cases and require onlypostnatal thromboprophylaxis.In recurrent VTE, many of them are on warfarin. If so,stop warfarin and change to LMWH as soon as pregnancyis confirmed (before 6 weeks of pregnancy). If the patientis not on warfarin, start LMWH as soon as pregnancy isconfirmed.

ThrombophiliaThrombophilia is broadly divided into inherited andacquired.Women should be stratified according to the level of riskassociated with their condition.

InheritedAsymptomatic inherited thrombophilia without any riskfactors requires LMWH for 7 days post-partumThose with Antithrombin deficiency or more than onethromboplilic defect and those with additional factorsrequire both antenatal and postnatal prophylaxis.

Acquired – APLAWomen with Antiphospholipid syndrome and

previousVTE, require both antenatal and post-partum prophylaxis. Women with persistent

antiphospholipid antibodies, with no previous VTE, andno other risk factors, need only close surveillanceantenatally and LMWH for 7 days postpartum.

Other risk factors

Age > 35ObesityParity e” 3Varicose veinsCurrent systemic infectionsImmobilityLong haul travelPre ecclampsiaDehydration/Hyperemesis/OHSSMultiple Pregnancy

If three or more risk factors are there, they are consideredas intermediate risk group and they require both antenataland postnatal thromboprophylaxis. If only less than threefactors are present they are considered in the low risk groupand require only mobilization and avoidance ofdehydration.

Initiation of ThromboprophylaxisAntenatal thromboprophylaxis should be begun as earlyas possible in pregnancy. Postpartum prophylaxis shouldbe begun as soon as possible after delivery, after observingthe precautions for regional anesthesia.

Interruption of Thromboprophylaxis before delivery

Discontinue thromoboprophylaxisAt the onset of labourOne day prior to a planned deliveryOne day prior to a planned CSWhen there is bleeding

Regional anesthesia must not be given until at least 12hours after the previous prophylactic dose and until at least24 hours after the previous therapeutic dose of LMWH. Itshould be restarted only after 4 hours of spinal or removalof epidural catheter. High dose prophylactic or treatment,only 24 hours after regional anesthesia.

After Delivery (postpartum)The greatest risk of VTE associated with pregnancy is inthe early puerperium.Previous VTE and all cases requiring antenatal LMWHare high risk cases.Thromoboprophylaxis for 6 weeks is required in thesecases.

Agents used for Thromboprophylaxis in ObstetricsLMWH

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It is the drug of choice for antenatalthromboprophylaxis. The risk of heparin.induced thrombocytopenia is less

Unfractionated heparinIt has a shorter half-life.In cases with high risk of coagulopathy unfractionatedheparin or graduatedcompression stockings are the methods of choice to beused.

CS in Labour

Thrombophilia

BMI >40

Prolonged Hospitaladmission

Medical Comorbidities

Intermediate risk 7

days posnatal

thromboprophylaxis}Age>35yrsObesityParity>3Elective CSAny surgicalprocedures in thepureperiumVaricose veinsCurrent systemicinfectionImmobilityPre-ecclampaiaForceps deliveryProlonged labourPPH

Intermediate Risk7 days posntnatal

Lower RiskMobilization &

avidance ofdehydration

< 2 factors

> 2 factors

Weight(kg) Enoxaparin Dalteparin Tinzaparin

<50 20 mg OD 2500U OD 3500 U OD

50-90 40 mg OD 50000 U OD 4500 U OD

91-130 60 mg OD 7500 U OD 7000 U OD

131-170 80 mg OD 10,000 U OD 9000 U OD

>170 0.6 mg/kg/day 75 U/kg OD 75 U/kg OD

HIGHPROPHYLACTIC 40 mg BD 5000 U BD 4500 U BDDOSE (50-90KG)

TREATMENTDOSE1 mg/kg BD 100 U/kg BD or 175 U/kg/ OD

antenatal 200 U/kg OD (antenatal &1.5mg/kg OD postnatal postnatal)postnatal

DOSAGE of LMWHDrugs like Donoparoid, Fondaparinux are used only inthose intolerant to heparin. Lepirudin, a thrombininhibitor is best avoided in pregnancy. Low dose aspirinis used only in those with APLA syndrome. No controlledtrials of it for thromboprophylaxis in pregnancy.

WarfarinIt is better avoided in pregnancy. It is used in those withmechanical heart valves. In patients with prosthetic valvesthere are about 45% thrombotic episodes with a morbidity

of 1-4%. Substitute LMWH for warfarin during 6-12weeks of gestation and restart warfarin after 12 weeks ofgestation and is continued till 38 weeks of gestation. At38 weeks of gestation, stop warfarin and switch over toLMWH and terminate pregnancy.

DextranIt is avoided in antepartum and intrapartum period. Itcauses anaphylactoid reaction and uterine hypertonicityleading to fetal distress and fetal death. Fetal neurologicalabnormalities are also reported.

TED stockingsIt is advised in all cases of VTE detected during pregnancyand for 6 -12 weeks postpartum. It is useful in cases whenanticoagulation is contraindicated. It is used as an adjuvantto anticoagulation in hospitalized patients and useful forwomen travelling for long hours. Thigh length stockingsare better.

Conclusion

* VTE is not an uncommon entity

* Timely and effective thromboprophylaxis candecrease the morbidity and mortality

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Present status of Robotic surgeryin Gynaecology.

Dr. Amol Lunkad, MD; DNB; MICOG; MNMAS - Senior Registrar

Deptt. of Obstetrics & Gynaecology,All India Institute of Medical Sciences, New-Delhi.

Laparoscopy first started mainly in Gynaecologyand than was picked up in general surgery and othersurgical fraternities. Still majority of gynaecologicalsurgeries are done by the open technique due to the steeplearning curve of gynae endoscopy, availability ofinfrastructure, lack of proper training etc. Now acompletely new dimension of gynae. endoscopy has comeup that is robotic assisted surgery. Let us review the presentstatus of robotic surgery in gynaecology.

A robotic device is, technically, a “powered,computer controlled manipulator with artificial sensingthat can be reprogrammed to move and position tools tocarry out a wide range of tasks”. Robotic systems used insurgery today are computer assisted devices and are nottrue robots, because they lack independent motions orpreprogrammed actions.

Historical background - The term robot was firstintroduced in 1921 by Czech writer Karel Capek in hisplay. In 1994 the first U.S FDA approved robotic surgicaldevice called AESOP (Automatic endoscopic system foroptimal positioning) was introduced in which the surgeoncould control the orientation of the laparoscope throughvoice commands2. The da Vinci surgical system being usedtoday was developed by Intuitive Surgical, USA and thefirst successful surgery using it was performed in Belgiumin 1997. In April 2005, Da Vinci® was FDA cleared forgynecologic procedures. The upgraded version of da Vinciwith a high definition vision 4-arm “S” system waslaunched in 2006.

Da Vinci robotic system – It has 3 majorcomponents: vision system, surgeon console, and roboticplatform (as shown in figure 1). After creating pneumo-peritoneum, placing abdominal ports, and “docking” therobot, the surgeon sits at console and views through athree-dimensional, high-definition vision system. Therobotic central arm contains the optic system consistingof an endoscope with 2 optical channels and two three-chip cameras. Three of lateral arms hold surgicalinstrument. The surgeon manipulates cabled EndoWrist

instruments which has seven degrees of freedom bymanipulating specially designed joysticks. The surgeoncontrols the camera with clutch maneuvers, and activatesenergy sources via foot pedals at the console.

The advantages of robotic assisted surgery over theconventional laparoscopic surgery are –

Three dimensional operating viewIncreased operating accuracy, increased precision

Fig.1) The Da Vinci robot with 4 arms and thesurgeon console

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thus reduced number of errorsAbsence of tremors, down scaling ofmovements with superior instrument articulationEase in sututring and knotting and comfort for theoperating surgeonTeleoperating possibleFaster and less steeper learning curve for thesurgeonBetter and finer dissection possible with evenlesser blood loss

The disadvantages of robotic assisted laparoscopicsurgery are –

Absence of tactile feedback and absence of tissuefeel or tactile sensationHigh cost of the setup and instruments,instruments have to be disposed after 10 usesBulky robotic arms can collideIncreased operative timeRestrain due to availability of robot, higheroperative skill required and technical

knowledge requiredInability to move the surgical table once robotarms are attached.

Robotic surgery in gynaecology –a) Robotic assisted laparoscopic hysterectomy (RALH)- The first series of robotic hysterectomy were performedby Diaz-Arrastia etal in 2002. Beste etal in 2005 reporteda 11 case-series of RALH, with one conversion tolaparotomy and one cystotomy 3. Fiorentino etal published20 RALH cases with 2 conversions and one cuff bleedingcomplication4. Payne and Dauterive did a comparativeretrospective study of robotic (100 cases) and laparoscopichysterectomy (100 cases) for benign disease. They reportedsimilar uterine weights, operative times, and blood loss,but significantly higher conversion rate with standardlaparoscopy. They noted that the last 25 robotic cases hadsignificantly lower operative time than laparoscopy cohortand concluded that robotic hysterectomy was quicker andwith less risk for abdominal conversion5.b) Robotic assisted laparoscopic Myomectomy(RALM) – Advincula etal introduced RALM in 2004 asa safe and reproducible surgical approach to uterinefibroids6. In 2007, the same group compared short-termsurgical outcomes and costs of RALM and openmyomectomy, in 58 patients with symptomatic fibroids.Patients who underwent RALM had significantlydecreased estimated blood loss, decreased complicationrates, less post operative adhesion formation andsignificantly lesser length of stay7. The role of RALM is

to guarantee a procedure that is as effective as aclassic open myomectomy, but is as safe and

acceptable as a laparoscopic operation. RALM may havea role where large amount of suturing is required, wheredense adhesions are present, where extensive dissectionis required.c) Robotic assisted tubal anastomosis – Tubalanastomosis is lesser done nowdays due to wideavailability of In-vitro fertilization with better results.Laparoscopic tubal anastomosis requires precision,extensive suturing and microsurgery, it has a steep learningcurve and requires higher skills so here use of roboticassistance may help. Rodger et al did a retrospective case-control study of tubal reversal performed through roboticassistance compared to minilaparotomy. Althoughoperative times were lengthened in the cohort undergoingrobotic surgery, there was a decreased convalescencecompared to the minilaparotomy cohort and similarconception rates8.d) Robotic assisted Pelvic reconstructive surgery –Sacrocolpopexy, sacrocervicopexy and vesico-vaginalrepair all seem particularly suited for robotic surgery giventhe necessity large amount of intracorporeal suturing, finerdissection of spaces required and important structuresinvolved. Geller etal compared 73 robotic and 105 openabdominal sacrocolpopexy cases9. The robotic group hadsignificantly increased operative time, but decreased bloodloss and length of stay. The patient postoperative prolapseassessment was comparable over most parameters in bothgroups. Initial studies concerning the role of robotics inpelvic reconstructive surgery are encouraging, and thetechniques appear to enhance conventional laparoscopicprocedures9.e) Robotic application in Gynaecologic oncology – Sertetal in 2006 where the first to do robotic radicalhysterectomy, since than several case series have beenpublished to show the role of robotic assistance inendometrial, cervical and vaginal cancers10. Pelvic andaortic lymphadenectomy done in these cancers is muchmore precise with better lymph node yield when done withrobotic assistance. For technically challenging operationslike radical trachelectomy, radical parametrectomy, pelvicexentration robotic technology facilitates the surgicalapproach better in comparison to laparoscopy due to itssteady 3-dimensional visualization, instrumentation witharticulating tips, and an adaptive downscaling of thesurgeons movements without tremor. Although patientadvantages are similar or slightly improved with robotics,there are multiple advantages for the surgeons as comparedto conventional laparoscopy.11

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f) Other Gynae surgeries done with robotic assistanceor where robotic assistance helps are:- Severeendometriosis, presacral neurectomy, ovariantransposition, and severe adenomyosis. Thus roboticassistance is being used in more and more surgeries whereextensive dissection or suturing or precise handling isrequired.

Medical Abortion- current concepts

Induced abortion is an important aspect of woman’s sexual& reproductive life. Woman’s right activists believe thatit 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 ofmifepristone 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 medical abortion?Any woman can be offered to any woman up to 9 wksFrame of the mind of patient: she should accept that

she should come back for minimum 3 follow up visits& can understand the instructionsShe should be ready for surgical procedure if failureor excessive bleeding occursThere should be good Family supportShe should have easy access to appropriate healthcarefacility in case of emergency.Permission of guardian in case of minor is mandatoryas per MTP Act 1971.

Who can provide medical abortion services?Only Registered Medical Practitioner (RMP) asdescribed 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 proceedDetermine gestational age by LMP & MenstrualHistoryEctopic pregnancy must be excludedIf IUD in situà should be removedIf client is taking OC Pills previously à R/O post-pillamenorrhoeaAdminister with caution in women with Previous

Thus to conclude, robotic surgery is now anestablished thing in gynaecology and larger randomizedtrials are required comparing it with open and conventionallaparoscopic gynae. surgery to exactly know its advantage.Robotic surgery in gynaecology offers the opportunity tobridge the gap between the advantages of laparotomy &laparoscopy. It brings to the patient all the advantages ofminimal invasive surgery with more surgeon comfort, withmore precision and accuracy.

Dr Parag BiniwaleMD, FICOG, FICMCH, Dip in Pelviscopy (Germany) Consultant Ob –Gyn, Pune

Postgraduate Teacher, Dr Patankar Medical FoundationNational Website Editor, FOGSI (2011-13)

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

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scarred uterus (myomectomy, CS &hysterotomy), fibroidStop breast-feeding for 6 hours on takingmisoprostolTreat active vaginal infection if present.

Medical abortion is not recommended inChronic adrenal failureUncontrolled hypertensionCardiovascular diseaseAnaemia (Hb < 8 gm %)Severe liver, renal or respiratory diseaseKnown coagulopathy / on anticoagulantsDrugs (aspirin, steroids, antidepressants)Uncontrolled seizure disorderPsychiatric disorder

Following investigations are mandatoryHaemoglobin: should be at least 8 gm%Urine for albumin & sugarBlood group

Pregnancy test & ultrasound ARE NOT mandatory. Theyshould be used on individual case basis as deemednecessary by Gynaecologist.

Pre-abortion counselingPre-abortion counseling is important & it should includefollowing points

Possibility of continuation of pregnancyOptions available for terminationDetail procedure, associated risks / complicationsNeed for surgical termination in cases of failure(continuation / incomplete / missed)Discuss methods of contraceptionAdvantages (no risk of surgery or anaesthesia, futurefertility 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 care

ConsentThe consent of the client must be taken in prescribed formC as in MTP act. In case of minor, signature of guardian isnecessary.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/

ultrasound assessment for completionB] 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/ ultrasound

assessment

Post abortion careAfter administration of misoprostol, client may beobserved for 4 hours. Her vitals are monitored.Antibiotics are not universally recommended but mustbe given to women taking medical abortion at home.The drug would include Doxycycline100 mg OD for7 days 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 abortionCombined Oral Contraceptive can be started on theday of misoprostolSterilization, IUD, Progesterone only method must beoffered only after completion of abortionCondoms, Vaginal tablets should be advised afterbleeding stopsNatural methods should be advocated only after nextmenses

Key points for successful medical abortion

Proper selection- < 63 DaysThorough Counseling must be doneregarding method & failureStress should be given on proper follow up toensure completeness Management of complications should bedone promptly.Contraceptive counseling is a must during.Constant Medical Supervision is a must!!