Dr.Shantala
Graduated from Bangalore Medical College, and did her post-graduation from Lady Hardinge Medical College, New Delhi. She has been practicing Obs & Gyn for over a decade and a half now. In her leisure she is a published writer both in English and Kannada.








THE NORMAL MENSTRUAL CYCLE



Menstruation is a part of the female reproductive cycle that begins when a girl becomes sexually mature at puberty. It is the periodic discharge of blood and tissues from the uterus. Cyclical changes occurring from one menstruation to the next constitute a menstrual cycle. Until menopause, menstruation occurs approximately every 28 ± 4 days (excluding the period when a woman is pregnant.)

The importance of menstrual cycle:

During the menstrual cycle, an egg is released from the ovary even as the womb (uterus) prepares itself for housing and protecting the resulting embryo, if this egg were to be fertilized by a sperm. If however, the egg is not fertilized, the lining of the womb (which was prepared in anticipation) is shed from the body as periods. The menstrual blood flows out from the uterus through its mouth (the cervix) and out of the body through the vagina. The menstrual cycle is unique because it limits the fertility of a woman to the specific period of ovulation. (Production of egg) This is in contrast to a man’s physiology where significant numbers of sperms are produced during every ejaculation. The menstrual cycle is associated with not only changes in the reproductive organs but also changes in the breast, body fluids, the basal body temperature and other organs. Girls begin their first period around 12 years and this is called Menarche. Menarche occurs approximately 2 years after they begin to develop breasts (thelarche). During this interval, girls experience sudden growth spurt and other bodily changes. Menarche for some girls may be as early as at eight or as late as at 16 years. There may occur an increased amount of clear vaginal discharge a few months before their first period. The cessation of menstruation is called menopause and occurs around 50 years of age.

WHAT IS A NORMAL CYCLE?

For the ease of understanding, the normal menstrual cycle may be studied as the Menstrual Phase, Follicular (Proliferative) phase, Ovulation and the Luteal (Secretory) Phase. Refer Figures 1 and 2

1. MENSTRUAL PHASE

Tough the typical cycle length is about 28 days; it may vary between 26 to 33 days without significant alteration in function. The flow usually lasts for 3-5 days. The estimated blood loss per cycle is between 30 to 50 milliliters. During menstruation, the lining of the uterus (endometrium) shrinks as it is being partially shed due to withdrawal of hormones and hence insufficient blood supply.

2. FOLLICULAR PHASE (PROLIFERATIVE PHASE):

This is the period of menstrual cycle before ovulation. It is the duration after cessation of menses and up to the 13th day of a 28-day cycle. (Approximately 10 days)It is mainly under the influence of the Follicular Stimulating Hormone (FSH) secreted in the Pituitary Gland. It is called Follicular Phase because the follicles (tissues that house single eggs) begin to grow and develop now. It is also called proliferative because of the changes that occur in the lining of the uterus (Endometrium) Every cycle,a group of 6-10 or more follicles begin to grow during this phase, increasing in size while simultaneously producing the important female hormone, the Estrogen. However, of all the follicles developing, only one is destined to ovulate and the rests undergo atresia. (Cell death)The follicle housing the egg, which is destined to be released in that cycle, is called the dominant follicle. The dominant follicle can be imagined as a tiny (about 20-millimeter diameter) fluid filled tissue ball with an internal protrusion, where the precious egg is ensconced. The egg is seated on a mass of nutritious cells, surrounded by nourishing fluid! (Refer Figure 5) Estrogen is the main hormone of the Follicular Phase and has profound effect on the endometrium. The endometrium, which was all shed off, but for its basal layer, (during menstruation), now begins to regrow under the influence of estrogen. The blood vessels, glands and tissues of the endometrium are all influenced to grow and change favorably in preparation for a fertilized egg! Ovulation occurs at the end of the Follicular Phase.

3. OVULATION (Release of egg from the ovary)

Ovulation occurs 14 days BEFORE the next cycle is due. For example: on the 14thday of a 28-day cycle or on the 16th day of a 30-day cycle or 12th day of a 26-day cycle. It occurs within hours after a sudden surge in the release another Pituitary gland hormone, the Luteinizing Hormone (LH). The egg, which is released from the ovary, is picked up by the uterine tube. It stays within the tube for about 24 hours and is actually anticipating to be fertilized by a sperm! If fertilization does not occur during this time, the egg self-destructs! (This interesting phenomenon of programmed cell death or apoptosis, is also known as cellular suicide!)

4. LUTEAL PHASE (SECRETORY PHASE):

Immediately after Ovulation is the Luteal or Secretory Phase of the menstrual cycle. Irrespective of the initial cycle length, an ideal Luteal Phase is ALWAYS 14 days. It is called Luteal Phase because of the Corpus luteum (see below) and Secretory Phase because of an increase in the endometrial glandular secretions. With the release of the egg, the dominant follicle is now a collapsed mass of cells called the corpus luteum (Yellow body-because it looks yellow due to high lipid content). The corpus luteum begins to secrete estrogens and importantly large quantities of progesterone-which is the chief hormone of the Luteal Phase. Progesterone also acts on the uterus, continuing to modify it favorably for receiving the fertilized egg. When the egg is fertilized, the corpus luteum (Called Corpus Luteum of Pregnancy) becomes more active and is in fact responsible for sustaining the growing Embryo up to 10-12 weeks of early intrauterine life. If however there is no fertilization, the corpus luteum self-destructs by about the 21st -22nd day and sets off a cascade effect. As further production of estrogen and progesterone cease, their sustained effect on the endometrium is hampered. This disrupts the growth of the glands, tissues and blood vessels and hence the superficial layer of the endometrium, begins to peel off from the basal layer. These are shed as menses on the 28th day, thus completing the cycle; before the next one begins.


INFERTILITY-OVERVIEW


What is Infertility?

In the simplest of terms, Infertility may be described as the inability to conceive despite conscious attempts. However, as gynaecologists, we are more specific while defining Infertility. It is the inability to conceive even after two year of unprotected intercourse. It is estimated that about 84% of couple conceive spontaneously within one year of unprotected intercourse while another 7% conceive over the next 12 months, such that the cumulative pregnancy rate is about 92% at the end of 24 months. Hence, it is justified to investigate apparently healthy, young couple after 2 years of inability to conceive. However, the time frame of two years is made less stringent if the couple are elderly (the woman more than 35 years) or either of them has a pre-existing problem. Example- the woman having polycystic ovaries or endometriosis or her partner having abnormalities of the semenal parameters.

What is not infertility?

Young, healthy couple who have not been able to conceive within 12 to 18 months of staying together. Couple who are using contraceptives to avoid pregnancy, obviously! Couple who have difficulty in their sexual performance. Example-Problems of erection or ejaculation in men and sexual aversion disorders in women. Couple who are beyond the reproductive age.

Why is it important to define if a couple is or not infertile?

Without a set definition, we may unnecessarily be investigating many normal couple and of course, get credited for helping them achieve pregnancy... when in reality, they would have conceived anyway over the next few months! However, branding a couple as infertile puts them under a great deal of mental tension. We all know that the hormones secreted in the brain play an important role in maintaining normal sexual cycles and hence stress may interfere with the normal functioning of the brain and secretion of hormones. The classical example quoted is that of many childless couple who, after years of trying, finally give up and adopt a child. As the stress of trying to conceive is lifted, many of them find that the woman has conceived spontaneously over the next few months! With the advent of modern Medicine and methods, the treatment of infertility has become varied, complex and very individualistic. Treatment is often exacting in terms of money, time and interventions. Hence, it is always with great caution and consideration that a couple must be labeled as infertile. The patient load on Medical personnel is also greatly reduced with proper definition and classification of Infertility. Finally, despite all the modernization, Infertility often carries a social stigma, which is very traumatic, especially to the woman, affecting her mental well-being and curtailing her social activities.

Types of Infertility

Primary infertility is when the couple has been unable to conceive at all. Secondary infertility is when the couple, irrespective of the outcome of pregnancy, has achieved pregnancy at least once. Example: Couple not able to have another child after years of their first or couple who have had at least one miscarriage is secondarily infertile. Infertility can be also categorized as due to male factor or female factors or combined factors and finally, as unexplained Infertility (when no apparent cause can be detected in either partner) Further, female infertility can be classified as due to Ovarian Cause (problems of inappropriate ovulation-production of eggs by ovary), Tubal cause (blockage or other diseases of the uterine tubes), Uterine causes, Hormonal causes and finally as due to Endometriosis (multiple cause) Male factor infertility can be due to Semenal abnormalities (Complete absence of sperms-Azoospermia, reduction in sperm numbers-Oligospermia, insufficient motility of sperms-asthenospermia, abnormal physical characterisitics-teratospermia or a combination of these), Drugs(including tobacco, alcohol and cancer therapy), defective genes(as in Klinefelter’s syndrome or Cystic Fibrosis), Past infections of the testes(Mumps, tuberculosis), Auto immune conditions, exposure to irradiation or chemicals ;or certain medical disorders etc. Combined factor infertility is when both partners have problems pertaining to fertility. Unexplained Infertility or Idiopathic infertility is when all the tests in both the partners are apparently normal. Needless to say, with advancing investigative technologies the percentage in this category is expected to diminish. Can infertility be classified as curable or correctable? This is obviously an Ethical question. If the solution for infertility is having a child, then this can be most easily corrected by adopting a child! Only when pregnancy has been achieved after correcting the underlying medical condition, can infertility be technically termed to be ‘cured’!

Other Ethical and Social aspects in Infertility:

In India, it is very common for childless couple to resort to various religious practices in the hope of propitiating the Unknown to bless them with children. Also, a vast majority of people believe childlessness is because of a defect in the woman only. The basic knowledge that it takes a man and a woman to make children is completely lost on them! Even educated families believe so and infertility is a very easily accepted reason-by both parties and families- for the man to re-marry! I know many women who are normal but have remained childless because their husbands refuse to be examined, or even have one Semen analysis done (Which if carried out at all, always shows that it is defective). Men have re-married hoping the second wife will conceive only to find out years later that they had no sperms in their semen! Management and treatment of Infertility in the Allopathic field of Medicine scales new heights every hour! The IVF-ET (Test-tube babies) is so commonplace these days and scientists are looking at Designer babies now. Yet, even educated people resort to dangerous practices, believing it to be alternative medicine. Ethically, many issues concerned with artificial reproduction (Like Donor insemination, surrogacy, egg/embryo donation) have not been addressed at all. This could lead to serious problems in later life for all the parties concerned. In India, there is no authentic body responsible for the regulation and monitoring of the treatment of infertility and this has led to the abuse of advanced technologies by both patients and the treating doctors.

CONCLUSION:

It is therefore very important to recognize infertility, categorize it as best as possible and counsel the couple on all the possible ‘treatments’ and ‘cures’ available. Finally, treatment must be tailored to the needs of individual patient. The patients, doctors and the families must acknowledge that management and treatment of infertility is unlike that of any other disease. Because the result impacts the lifetime of two generations, the society and the profession of the treating doctor.


What is an ectopic pregnancy?


An ectopic pregnancy is when a pregnancy starts to grow outside the uterus (womb) (Ectopic-misplaced) It could occur in the uterine tube, ovary, the mouth of the uterus (cervix) and rarely, in the abdominal cavity; which is of course abnormal. Why is an ectopic pregnancy abnormal? Normally, the sperm and egg fuse in the uterine tube and after fertilization form the zygote (the fertilized egg) which moves into the uterus and implants there. The pregnancy can grow and develop as the uterus has the capacity to enlarge greatly as the pregnancy progresses. However if the egg gets implanted in other places or even stuck within the tube which has no capacity to expand as pregnancy progresses, then the tube stretched and finally ruptures resulting in a catastrophe. How is an Ectopic pregnancy diagnosed? Most often, the symptoms appear about 5-6 weeks after the last normal period. The symptoms are very varied and may vary from abnormal, irregular bleeding over several days to sudden collapse without any warning symptoms. Some women may have absolutely no symptoms and only an alert obstetrician can pick up the ectopic before any untoward event. What are the symptoms of an ectopic pregnancy?

Abnormal bleeding, pain lower abdomen and sudden collapse are the common symptoms. What is an abnormal bleeding?

The expected period may be missed or it may be light. Some women may have an almost normal period, which is then followed by bleeding after a few days. There may be spotting over several days, without missing a period at all. Women who usually have delayed cycles may be unaware that they could be pregnant, attributing the delayed period as a usual occurrence for them.

What is the nature of pain in ectopic pregnancy?

Pain may not be a feature initially. It can come on suddenly or may be present in the lower abdomen over several days. Sudden pain may be associated with giddiness. Lower abdominal pain could be one sided or generalized. Also, blood leaking from the ruptured tube into the abdomen can be an irritant and cause referred pain on the shoulder tip. This pain may worsen on lying down and may not be relieved with painkillers.

What are other symptoms of an ectopic pregnancy?

Diarrhoea or difficulty in moving bowels can occur. Nausea and vomiting can also exist. An ectopic pregnancy is a serious health risk, which must be treated as an emergency. Any of the above symptoms must prompt the woman to seek medical help immediately. Who is at an increased risk of ectopic pregnancy?

Any woman who is sexually active could have an ectopic pregnancy.

The following women are at a higher risk of ectopic: 1) Women who had a previous ectopic pregnancy 2) Women with a damaged fallopian tube which is often due to previous surgery on the fallopian tubes (includes tubectomy- sterilization operation) 3) Previous pelvic infection. 4) Pregnancy with an existing intrauterine contraceptive device (Copper-T/ IUD) 5) Patients on progesterone –only contraceptive pills (mini-pill) 6) Pregnancy after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) pregnancy (Test-tube baby) 7) Women over 40 years old or those who smoke.

How is an ectopic pregnancy diagnosed?

Though the symptoms may be vague, an alert medical person always has her/his ante up for the possibility of an ectopic pregnancy. Medical history and examination (may include internal examination) and a positive urine pregnancy test indicate a probable diagnosis of an ectopic pregnancy. A transvaginal scan (where a probe is gently inserted into vagina) to look at the uterus, ovaries and fallopian tubes often clinches the diagnosis. Sometimes, when the diagnosis is not too obvious, blood tests for human chorionic gonadotrophin hormone (hCG) and/or progesterone may be done, even serially. If the diagnosis is still unclear, an operation called a laparoscopy (button hole/key hole surgery) may be necessary. This operation is done under anaesthesia. If an ectopic pregnancy is detected, treatment may take place during the same operation. What are the options for treatment? As an ectopic pregnancy cannot result in the birth of a baby, all available options aim to end the pregnancy. The options depend on duration of pregnancy, symptoms and general condition of the woman, scan findings, hCG values and amount of bleeding inside the abdomen. Also, the preferences of the woman, her future fertility plans and an informed consent is necessary before deciding on the modalities of treatment. What are the possible treatment options for an ectopic pregnancy? The options that are available are Expectant management, medical management and surgical management.

What is Expectant management?

Expectant management implies a policy of wait and watch. If the pregnancy in tube has not ruptured it, it could simply resolve or abort completely within the abdominal cavity. Such situations are not potentially harmful. If the woman is compliant and follows her doctor’s instructions, she could be managed with watchful expectancy, with intentions to interfere only if necessary. Expectant management is not an option for all women. The attending gynaecologist must assess the patient, symptoms and reports before deciding whether the expectant management can be offered. Women undergoing expectant management may require additional medical or surgical management during their course of observation.

What is Medical management?

Again, after proper evaluation, some women may be offered medication to treat the ectopic pregnancy. Methotrexate (an anti-cancer drug) has been used to prevent the ectopic from growing and allows gradual resolution. This management also requires stringent supervision and serial evaluation with hCG and vaginal scans. Admission for a 1-3 days and regular follow up as advised thereafter is mandatory for this management to be successful.

What is the Surgical management?

The aim of surgery is to remove the ectopic pregnancy. This can be achieved by either laparoscopy (key hole surgery) or laparotomy (Open surgery through a larger cut in the lower abdomen.) Laparoscopy is done when the woman’s general condition is favourable and laparotomy when the internal bleeding is suspected to be very heavy and her condition is unstable. To have the best chance of a future pregnancy inside the uterus, and to reduce the risk of having another ectopic pregnancy, the fallopian tube removed may need removal (Salpingectomy). However, if there is only a single tube or if the other tube is unhealthy and hopelessly damaged, then the future fertility of the woman is greatly affected. In such situations, various types of operations are done to try to retain the tube. This type of operation depends on the woman’s desire for future fertility and the findings at surgery. Salpingotomy (tube conserving surgery) is done in such cases. Salpingotomy aims to remove the pregnancy within, without removing the tube. However, it carries a higher risk of a future ectopic in the same tube.

What is the risk in surgical management of ectopic?

Surgery is often done under general anaesthesia and at times under spinal anaesthesia. Apart from the risks of a ruptured ectopic itself, the anaesthetic risk is also present. The individual risks are discussed by the surgeon and the anaesthetist prior to surgery.

What about future pregnancies?

For most women, an ectopic pregnancy is an isolated chance happening and the possibility of having a successful pregnancy in future is high. There is only a small reduction in the chance of conceiving even with only one tube present. However, the chance of a repeat ectopic pregnancy is 7-10% and depends on the type of previous surgery and that of the existing tube. In a future pregnancy, an ultrasound scan at 6 to 8 weeks can confirm a healthy intrauterine pregnancy (pregnancy inside the uterus) If however, the woman does not plan for a future pregnancy, she is offered the appropriate contraception.


Painful Periods? What you need to know....


What is dysmenorrhoea? Is it common?

Dysmenorrhoea (pronounced as dis-men-or-rhea) is the scientific term for painful periods. Dysmenorrhoea is one of the commonest complaints that we come across in practice. Why are periods painful? There are many theories. Finally-as the final common pathway- it is because of the release of pain-generating chemicals called the prostaglandins (PGs) that pain is caused. As a corollary, painkillers being anti-prostaglandins help relieve pain! Is a painful period abnormal? That depends on what is the cause of pain. Dysmenorrhoea is categorized as primary when it occurs de-novo, without any underlying disease. Secondary dysmenorrhoea is when there is some disorder in the reproductive organs. Obviously, secondary dysmenorrhoea is abnormal and primary dysmenorrhoea is considered to be physiological (normal function) What is primary Dysmenorrhoea? I mentioned that primary dysmenorrhoea is physiological. It means the reproductive organs are functioning normally. Often primary dysmenorrhoea indicates that the ovaries are functioning normally and that the cycle is ovulatory! That is, as is expected, the ovaries are producing eggs and the system is normal! Does it mean that the egg is produced only those times when periods are painful? No. Though primary dysmenorrhoea is an indirect evidence of ovulation, it does not follow that all ovulatory cycles are painful.

What are the characteristics of primary dysmenorrhoea?

Most often, girls have painless periods for a few months to 1-2 years after they begin their menstrual cycle. This is because when the reproductive organs begin their function, they are still in the process of getting into the rhythm and the ovaries may not be functioning. Hence, they are anovulatory cycles-cycles occurring simply due to hormonal effects, without production of eggs. However, after a few months, as the reproductive organs mature in functions and the ovaries begin to produce eggs and the periods may become painful.

Therefore, features of primary dysmenorrhoea are:

  1. Age of onset: Adolescence
  2. Occurs a few months AFTER menarche (first period)
  3. Begins a few hours before the onset of flow and persists for a few hours and gradually abates.
  4. Is not due to any dis-order of the reproductive organs.
  5. Nature of pain- Begins from lower back and radiates to the lower abdominal region. It is described as colicky or crampy, coming on in waves. For some girls pain may radiate to inner thighs and genital region.
  6. Patient profile : Mothers of girls with severe dysmenorrhoea are often sufferers themselves. This trend is more likely to be due to the social factors rather than a strong genetic association.

What is secondary dysmenorrhoea?

Painful periods occurring secondary to an underlying disorder of the reproductive organs is secondary dysmenorrhoea.

What are the features of secondary dysmenorrhoea?

As the cause is due to an underlying pathology, dysmenorrhoea may be one of the symptoms of the disease condition. For example: Fibroids are non-cancerous lumps that may form in the uterus. Fibroids can cause heavy periods, mass in the abdomen, infertility and as another feature, there may be dysmenorrhoea too.

What are the causes of secondary dysmenorrhoea?

Secondary dysmenorrhoea may be caused by many disorders .It could be due to
  1. Endometriosis: Condition where menstruation occurs within the abdomen also. Associated symptoms include infertility (inability to conceive), heavy periods, constant abdominal pain, tiredness, difficulty during intercourse and painful bowel movement.
  2. PID (Pelvic inflammatory disease) Infection of the uterus and the uterine tubes may result in inflammation (swelling, increased blood supply etc.) which results in the release of prostaglandins and hence pain. Associated symptoms include fever, white discharge and painful intercourse.
  3. Adenomyosis: A condition where the menstruation occurs within the muscle of the uterus (Myometrium) resulting in an enlarged uterus. Associated symptoms include heavy periods.
  4. Fibroid uterus: Associated symptoms as above.
  5. Pelvic adhesions: Previous pelvic operations like for ectopic pregnancy, ovarian cyst, cesarean section, appendicitis may all cause the internal structures (omentum, intestines) to get stuck to the uterus or ovaries and cause pain during periods.
  6. Other conditions where surgery has been performed on the uterus or the mouth of the uterus(cervix) causing distortion of the uterine cavity (Asherman’s syndrome) and narrowing of the cervix (cervical stenosis)
  7. Malformations of the uterus (Mullerian anomalies) may cause dysmenorrhoea due to various causes (associated endometriosis, non-communicating horns etc)

What is the nature of pain in secondary dysmenorrhoea?

Onset: Any time during the reproductive life. May be having painless periods for years after menarche before any of the disorders occur. Duration of pain: Women often have progressive pelvic discomfort and heaviness several days before their periods. Pain increases during periods and persists throughout the flow, Gets relieved only by the time all the bleeding has stopped only to restart after a few days in a run up for the next cycle! Nature of pain: As for primary dysmenorrhoea. But there is also an associated dull aching pain (endometriosis, PID) or dragging pain (adhesions) constant heaviness ( Adenomyosis) and painful intercourse (PID, endometriosis)

How is the cause of dysmenorrhoea diagnosed?

History often is suggestive for primary dysmenorrhoea. Young, unmarried girls do not need to undergo an internal examination if the history and nature of pain is obvious.. However, an ultrasound scan may be necessary to rule out the possibility of endometriotic cysts of the ovary or uterine malformations. Patients suspected to be suffering from secondary dysmenorrhoea merit a detailed history, internal examination and an ultrasound to confirm the diagnosis. At times, the diagnosis of adhesions and endometriosis is made only at diagnostic laparoscopy (keyhole surgery that enables visualization of internal organs real time)

Can dysmenorrhoea be treated?

Painful periods is a part of human physiology. In addition, pain threshold (capacity to tolerate pain) may vary amongst individuals. Hence, medical help may be sought if girls feel they are unable to tolerate pain. Often, an explanation about the causation and reassurance might help the young woman to view the situation in a different perspective and help her to go through her periods without much ado. Alternatively, painkillers may be used during the period. If the pain is intolerable, we may use oral contraceptive pills that suppress ovulation and hence the period pain associated with ovulatory cycles. However, in cases of secondary dysmenorrhoea, it is the associated symptoms of heavy flow, painful intercourse or infertility that brings a woman to us and pain may be just an associated complaint. Alternatively, painful periods could be the main presenting complaint too. The treatment of secondary dysmenorrhoea hence depends on treating the underlying conditions. There exists a wide range of treatment options depending on the severity and type of disease. These include medications during periods (mefanemic acid), antibiotics (for PID), Oral contraceptives (in endometriosis) and hormone injections also. Hormone releasing intra-uterine contraceptive device (Mirena coil) is also being used with good results in selected cases. Surgical management includes laparoscopy (Keyhole surgery) which not only clinches the diagnosis but is also an operative method. Ovarian cysts may be removed during laparoscopy, adhesions released and even fibroid operated upon.

What is the last word?

If your periods become painful a few months after you have attained menarche, it is most probably a normal occurrence. However if there is a sudden onset of pain during periods with or without white discharge, fever, painful intercourse or inability to get pregnant; then probably there is an underlying disease. However, you are not to presume and make diagnosis yourself. With the help of a gynaecologist, the cause may be determined and treated, enabling you to overcome the pain and get on with your routine.


Polycystic Ovarian Syndrome (PCOS)


1. What is a polycystic ovary?

A polycystic ovary (Poly-multiple, cyst-fluid filled structure) is characterized by the presence of numerous, small (8-10mm sized) fluid filled structures all over its surface. This is in contrast to a normal ovary which may have none or 1-3 developing follicles in one menstrual cycle. Actually these fluid filled structures are immature eggs surrounded by fluid and are called follicles. Polycystic Ovarian Syndrome is also known as Stein-Levinthal Syndrome (named after its discoverers)

2. What is the cause of Polycystic Ovarian Syndrome?

The final defect in PCOS is hormonal impairment. However the cause is now regarded as multifactorial. Insulin resistance, low grade inflammation and even an impairment of genetic expression in foetal life have been attributed to cause PCOS. Genetic factors (Higher incidence amongst siblings or mother-daughter-granddaughter), environmental factors (excessive weight), metabolic derangement (obesity and impaired glucose metabolism) are all postulated to contribute to the condition.

3. Why is PCOS important?

Ovaries are the reproductive organs responsible for producing eggs and the female hormones. Hence they are important for natural conception and regularity of menstrual cycle. In PCOS there is impairment of ovarian functions. Thus it follows that in PCOS there is impaired production of eggs and hence associated menstrual and hormonal irregularities .This naturally affects not only the menstrual cycle of a woman but also her fertility. PCOS is also associated with other medical conditions and long term effects as enumerated below.

4. What is the incidence of PCOS in India?

PCOS is the most common hormonal reproductive problem in women of childbearing age. The incidence is believed to be on a rise in India. A modest estimate is that 7-10% of women in the reproductive age group (15-45 years) suffer from this condition. But in pracgice the incidence is noted to be much higher.

5. What are the features of PCOS?

Women may have varied features. These include: a) Irregularity in menstruation: Delayed cycles and/or scanty flow. Absent menstruation for several months or menstruation occurring only after hormonal therapy. Some women may have continuous flow following periods of absent menstruation. b) Excessive weight-Most PCOS patients are overweight or obese. However PCOS can occur in underweight women also. c) Facial hair, acne (pimples) and loss of hair from the temple region. These features are medically termed as hyperandrogenic features and are attributed to excess circulating male hormones. Acanthosis Nigricans is black discoloration of the nape of neck, axillae and under the breasts and is often indicative of insulin resistance. d) Inability to conceive: This results due to improper or absent production of eggs from the ovaries. e) Other hormonal impairments: PCOS patients often have impaired glucose metabolism which causes increased blood sugars. Levels of Prolactin (hormone secreted by the pituitary gland in the brain) may also be raised. LH (Luteinizing hormone, also secreted by pituitary) which is responsible for production of eggs is classically raised 3 times over its sister hormone FSH (Follicular Stimulating Hormone)-though this is no longer a required criterion for diagnosis. f) Ultrasound diagnosis: On ultrasound scan, the ovaries are classically enlarged with raised volumes and each shows over 10-12 clear follicles of 8-10mms. This is one of the latest internationally accepted criteria for diagnosis of PCOS. The other two are menstrual irregularities and features of androgenization (see c)

6. What are the long term consequences of PCOs?

Patients with PCOS have inability to conceive. This is due to absent/unhealthy egg production and also because of the multitude hormonal derangements that occur in this condition. It is now established that patients with PCOS are prone to develop diabetes (non-insulin dependent or Type II diabetes), impaired lipid metabolism (Dyslipidemia) and ischaemic heart disease (reduce blood supply to heart causing heart attacks).The associated obesity is also a contributory risk factor to these conditions. Prolonged periods of absent menstruation and hence impaired levels of the female hormone, estrogen, makes these women prone for osteoporosis (loss of calcium from bones) and its attended complications. PCOS patients are at an increased risk of developing cancers of the breast, endometrium (lining of uterus) and maybe ovary at a later stage in life. PCOS patients who conceive are believed to be at a higher risk for mis-carriages and pregnancy induced hypertension during their pregnancy. Also the psychological impact of impaired menstruation, infertility, obesity, facial hair and acne cannot be under estimated though not completely quantified.

7. Can PCOS be treated?

Yes, but not to complete satisfaction at times. It is very disappointing many a times because the patient, who got better with treatment, reverts back to impaired functioning a few months after medications have been stopped. 8. What are the modalities of treatment for PCOS? a) Lifestyle modification: As obesity is one of the features and a contributory factor to PCOS, it helps greatly if patients strive to reduce weight. Even a modest weight reduction of 4-5 kgs works wonders as patients begin to respond better to treatment. It is advisable to maintain your BMI (Body Mass Index, which is calculated based on height and weight of an individual) between 20 and 25. b) Medical treatment: Treatment of PCOS needs to be tailored to suit each patient. It depends upon the main complaint of the patient and her requirements. For a 20 year old, the problem could be of acne and irregular periods; and for a married woman it could be inability to conceive and for many others their irregular cycles or facial hair may be disconcerting. Options available are Oral contraceptive pills: A wide variety of combinations are available to suit the needs of every patient depending on her symptoms. Oral Pills regularize the cycles, correct the underlying hormonal problems to some extent and offer contraception to those not wanting to conceive. For women desiring to conceive, oral pills are offered for a few months before starting treatment. Drugs for treatment of infertility: Clomiphene citrate is a drug which induces the formation of eggs from the ovary. It may be used alone or in combination with hormonal injections like the hCG (Human Chorionic Gonadotropins) or hMG (Human Menopausal Gonadotropins) or FSH (Follicle Stimulating Hormone) or GnRH (Gonadotropin Releasing Hormone analogues) These medications are used to aid the formation and release of eggs and hence help achieve pregnancy. Metformin: This is often used in the treatment of mild diabetes. Since PCO is associated with impaired glucose metabolism, metformin helps to correct the underlying impairment. Dosage for PCOs: 1500mgs/day in divided doses. Co-therapies: Medications to reduce weight (orlistat) are used in obese patients, medications and mechanical methods (laser, electrolysis, waxing) are employed for patients with facial hair. Oral pills which contain Cyproterone Acetate help in clearing the face of acne while those with Drosperinone may reduce rate of facial hair growth. c) Surgical treatment: The multiple cysts present on the ovaries are punctured to let out the ‘unhealthy’ follicular fluid by a key-hole surgical procedure called Laparoscopic Ovarian Drilling (LOD). Around 4-6 punctures are made in each ovary. This procedure improves the internal environment of the ovaries and also makes them more responsive to drugs during the future course of treatment.

9) What is PCOS in a nutshell?

PCOS is quite a common condition with a wide variety of manifestations. The exact cause of PCOS is still not yet established. It could be familial. PCOS needs to be treated as they have current and long term consequences for a woman. The treatment of PCOS is to be tailored to an individual and may span several months. Any ovary with cysts is NOT a PCOS. It has set criteria to be satisfied and you need to consult the specialist.


Care after delivery : The Normal Puerperium


What is puerperium?

Puerperium (pronounced as pyoor-per-eum) is the name for the period after the delivery of a baby.

What is the duration of the puerperium? What does it signify?

Puerperium begins immediately after the delivery of placenta (after-birth) and lasts up to 6 weeks after delivery. It is the period during which all the organs-reproductive and other systems-which had undergone tremendous changes preparing for pregnancy and delivery, revert back to their original, non-pregnant state. Sometimes, puerperium is differentiated into Immediate (first 24 hours after delivery) early (2-7 days after delivery) and later (1-6 weeks after delivery) puerperium as the problems during each of these periods may be unique. Puerperium does not extend up to three, five or nine months post-delivery as is wrongly perceived amongst certain populations in India.

Why is the puerperium an important phase in a woman’s life?

There is no denying that this short span of periods impacts the future well-being of the woman in more ways than one. Though puerperium is a physiological condition, it is important because:
    a) Households in India often have very wrong notions and unhealthy practices during puerperium which could harm the delivered woman. b) Correct care during puerperium is important for the long term health of the mother and hence the wellbeing of the family. c) The right diet and other life-style practices are as much if not more important as during pregnancy. d) Care includes correct and healthy attention to the new-born also. e) It helps the woman to establish the initial bond with the new-born and also to consider family-planning practices.

What are the changes that occur during the puerperium?

All the systems that had undergone changes for a favorable pregnancy outcome revert back to their original functional status during this period. This process is called involution.
    a)Reproductive organs:
    Uterus which was hugely distended (abdominal organ) with the fetus, placenta and liquor (water around the baby) shrinks in size to become a pelvic organ and this is called involution of uterus. The pregnant term uterus (not including baby, placenta, fluids, etc.) weighs approximately 1000 g. In the 6 weeks following delivery, the uterus recedes to a weight of 50-100 g. The pelvic floor muscles and the ligaments of the uterus and joints which were stretched during pregnancy revert back to their original sizes. The vagina which gets lax and distended during (normal) labor, the cervix that gets dilated regain back the tone and anatomy. The sutures, if any, which were applied on the perineum after an episiotomy (an accurate cut deliberately given at the time of delivery to facilitate the birth), fall off and the wound heals with a minimal scar. The ovaries also resume their function of egg production and release by six weeks thus enabling the woman to conceive again. Lochia: Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable. The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to decrease in amount and colour and eventually changes to yellow (lochia alba). The period of time the lochia can last varies, although it averages approximately 5 weeks. The amount of flow and colour of the lochia can vary considerably. Few women continue to have lochia 6 weeks or more postpartum. Women may experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. b) Breasts:
    The breasts are the only organs that increase in size and functions during the puerperium. The preparations that began during pregnancy are completed by the time of delivery, thus enabling the breasts to become functional immediately after labor. c) Other organs:
    The heart, blood components and coagulation system, the kidneys often undergo significant changes during pregnancy and revert back to normalcy during puerperium. They are also most likely to cause problems during this period.

What is the routine procedure followed immediately after delivery?

Care of the mother:

    a) Establishing bonding: One of the most vital aspects after delivery is to help the new mother accept and welcome the challenge posed by neonatal care. The newborn is put to breast immediately after delivery as it is now established that the first baby-mother skin contact is very important and must be instituted early. Putting the baby next to the mother than in a separate crib is called rooming in. Apart from facilitating bonding it helps the newborn recognize the smell, touch and voice of her mother. (As newborn have sub-optimal vision, they rely on all these other stimuli) b) Medications to the mother:
    Instrumental deliveries (forceps or Ventouse) or cesarean delivery may merit the use of antibiotics for a few days after delivery. The choice of drug takes into consideration the fact that all drugs are secreted in the breast milk and may affect the baby. Analgesics (pain killers) may need to be given in these patients and also in women who had an episiotomy (surgical cut made on the perineum to facilitate the delivery of the baby) Rh negative mothers who have delivered Rh positive babies are given anti-D injections within the first 72 hours. c) Early ambulation:
    The new mother is encouraged to get up and out of bed as early as possible. This is within a few hours after normal delivery and after the removal of the urinary catheter in cesarean deliveries. Early ambulation helps in drainage of lochia and more importantly prevents the occurrence of deep vein thrombosis (clotting of blood in the leg) d) Diet:
    Soft diet is often advice in the early days to facilitate easy bowel movement. It is important that the nursing mother receives nutritious diet without withholding any fruits, vegetables, cereals or pulses. Water must also be given as per requirement. Baby Care:
    a) Bathing/ clothing:
    The baby may be given a bath as per the pediatrician’s instruction with special care of the umbilical cord. Babies are kept warm because the maintenance of body temperature is very important especially in preterm babies. b) Vaccinations:
    As advised by the pediatrician. Usually a card containing vaccination schedule is given. Polio vaccination and at times against hepatitis B may be given to the baby when in hospital c) Blood test:
    Babies are routinely tested for thyroid functions on the 3rd day after delivery. Some centers are also test for possible metabolic disorders in the babies, most often in high risk or suspected cases and less often routinely. d) Physiologic jaundice in the newborn:
    There are many causes for jaundice in the newborn. Physiologic jaundice refers to a relatively harmless condition which occurs because the blood groups of the mother and baby are different and there is some destruction of baby’s blood cells causing increased production of bilirubin which imparts yellow color to skin and connective tissues. Physiologic jaundice may be more prolonged and excessive in pre-term babies, babies born to diabetic mothers, after prolonged labor and many other conditions. Smearing the baby with oil and exposing the body to early morning sunrays will tackle mild degrees of jaundice. Some babies may need photo therapy if the levels of bilirubin are high.
Jaundice other than Physiologic need to be investigated and treated as per pediatrician’s advice.

What is the correct dietic advice for the new mother?

The caloric requirements during nursing are actually 300-500 calories more than during pregnancy. The following points are noteworthy: The nursing mother must not be deprived of any food. However, ghee and other fattening foods must be minimized. (some traditional households literally drown their women in ghee which is not only fattening but also a rich source of bad cholesterol) Foods rich with essential fatty acids like fresh salmon, nuts, and seeds contain omega-3 fatty acids which are essential for neuronal development of the baby. Whole foods like whole grains, fresh vegetables and fruits, unprocessed meats, nuts, and seeds provide bulk to stools and help prevent constipation. Drinking plenty of water, to keep oneself hydrated and free from constipation, is very important Fresh fruits and vegetables are rich sources of antioxidants. Drinking sufficient milk and using certain galactogogues (items that increase milk production) like garlic, alp alpha, asparagus etc. to increase production of sufficient milk. Indian households also supplement the new mother with indigenous and herbal preparations. As long as they are not harmful or intense, they may be taken in moderation.

When can a woman resume normal activities?

Though it takes up to 6 weeks for the body to recover from the changes of pregnancy, it should be borne in mind that this is a natural phenomenon and not a diseased state. Different women have different abilities to deal with their health changes. However, in most cases, after a normal vaginal delivery, daily personal care activities can be resumed within a day and the household routine within a week. It might take a little longer after a complicated delivery or a caesarean section. As this period demands maximum attention to the baby as well, it helps a great deal if there is support at home-husband, mother, mother-in-law or any other preferably female relative.

When does the menstrual function resume after delivery?

  • The ovaries may resume the function of ovulation (production of eggs) as early as 4-6 weeks.
  • The resumption of reproductive functions may be slightly delayed in women who are nursing their babies (lactating) than those who are not.
  • Timing No lactation If lactation established
  • Menstruation 6 – 12 weeks 36 weeks (average)
  • Earliest ovulation 4 weeks 12 weeks
  • Average time for ovulation. 8 – 10 weeks 17 weeks (variable)

What is the role of post-natal exercises?

Exercising the lax abdominal muscles prevents the unsightly ‘tummy’ that many women complain after the delivery. Exercises help toning the muscles and with the right diet it is possible to regain the lost shape after a few months.Similarly pelvic floor exercises help tone the muscles of the perineum and may prevent future conditions like prolapse or incontinence.

When can a woman resume sexual activities after delivery?

Sexual intercourse may resume when bright red bleeding ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready. Physical readiness usually takes about 3 weeks. Hence, sexual activity is best avoided in the early post delivery period as the perineal stitches may be raw or painful and the abdominal wound might still be healing. The genital tract is prone to infection, particularly in the 1st week as complete restoration of the lining of the uterus, including the placental site, is not complete. Hence traditional advice is abstinence till 6 weeks following delivery. However, this could be earlier if there are no problems. Some women may experience a loss of libido after delivery and is not abnormal given the demands of the new-born and the stress of being a new-mother. It calls for understanding on the part of the male partner. Until she is comfortable for actual penetrative sexual intercourse, other displays of caring and affection can suffice. Hugging, kissing, petting or touching is not forbidden at any time during pregnancy or post-delivery. Birth control is important to protect against pregnancy because the first ovulation is very unpredictable.

What are the common misconceptions held during puerperium?

Faulty practice Danger Solution
New mothers must drink  very less water 1. Dehydration
2. Blood clotting
To drink as much water as a normal person does.
New mothers must not eat pulses and vegetables and certain fruits. Nutritional deficiencies of proteins/iron/calcium/vitamins Balanced diet with good helpings of proteins, iron and calcium
Complete bed rest is a must after delivery 1.Venous thrombosis(Blood clotting)
2. Obesity
3. Lax tone of abdominal and pelvic muscles
Early ambulation. Can resume all normal duties after 6-8weeks of delivery
New mothers must always wear very warm clothes, even in summer! 1. Dehydration
2. Heat stroke
3. Electrolyte imbalance
Good protection is necessary as per the prevailing weather conditions and woman’s comfort
Breast feeding offers complete contraception Unwanted pregnancy Women must adopt contraception by 6-8 weeks even if breast feeding. If not even earlier than that!


Faulty practice Danger Solution New mothers must drink very less water
  1. Dehydration
  2. Blood clotting To drink as much water as a normal person does. New mothers must not eat pulses and vegetables and certain fruits. Nutritional deficiencies of proteins/iron/calcium/vitamins Balanced diet with good helpings of proteins, iron and calcium Complete bed rest is a must after delivery 1.Venous thrombosis(Blood clotting)
  3. Obesity
  4. Lax tone of abdominal and pelvic muscles Early ambulation. Can resume all normal duties after 6-8weeks of delivery
  5. New mothers must always wear very warm clothes, even in summer! 1. Dehydration
  6. Heat stroke
  7. Electrolyte imbalance Good protection is necessary as per the prevailing weather conditions and woman’s comfort
  8. Breast feeding offers complete contraception Unwanted pregnancy Women must adopt contraception by 6-8 weeks even if breast feeding. If not even earlier than that!

Care after delivery : Abnormalities in puerperium


What are the routine problems that can occur during the immediate and early puerperal period? (When the patient may still be in the hospital)

Immediate Puerperium (the first 24 hours after birth) is a critical stage. This is the time when the uterus must remain well contracted, in order to stop the bleeding. It is also the time for initiation of breastfeeding and bonding. Occasionally, this is the time that serious complications of delivery like excessive bleeding (post-partum haemorrhage), collapse of the circulation, cardiac failure, etc. may occur. The risk of death due to these is about 1 in 10,000 women. This risk may be more in women with pre-existing medical conditions like anaemia, hypertension or heart diseases and after operative deliveries (caesarean, forceps or ventouse deliveries) Early Puerperium (2-7 days post-delivery.) There are many relatively minor, yet significant bodily changes that women should be aware of. They are Lochia or Vaginal discharge: Lochia refers to the discharge from the vagina, coming mainly from shedding of the inner lining of the uterus. For the first 4 days, there is fresh bleeding, like a heavy menstrual flow (Lochia rubra) necessitating use of 2 pads at a time, changing 3 – 4 times a day. By the 5th day, the flow becomes much less, and may now be more of a blood stained yellowish-brown discharge (lochia serosa) which usually stops by the end of the second week after which it becomes a plain white discharge. Good hygiene and care of episiotomy will prevent infection. Any foul smell in the discharge should be reported to your doctor.
Urination Passing urine frequently (2 – 3 hourly) is important as the urinary bladder tends to become atonic (lax) and this may cause problems, especially infections later. Women may notice excess urination for 2-3 days after delivery and is normal.
Stools Improper and insufficient intake of fluids and pain in the stitches of the perineum (episiotomy) may result in constipation. High fibre diet and plenty of liquids can prevent hard stools. Some women may need a mild laxative for a few days
After pains: Cramping lower abdominal pain may occur off and on due to the uterus contracting in response to oxytocin. This is especially marked during breast feeding. It is less obvious after first delivery and is more in women delivering for second and third time and over.

What are the problems encountered when nursing the baby and how should they be dealt with?

Breastfeeding is neither easy nor automatic. It requires much effort on the part of the mother and her support team. It is a scientific fact that lactation (production and secretion of milk) is established only by the 3rd day after delivery. This understanding is very important as the new mother and the family members are often apprehensive that milk is not being produced. The thick and scanty yellowish secretion that precedes secretion of milk is called the colostrum. Colostrum is a rich source of antibodies (protective natural substance) and MUST be fed to the baby and not discarded.
Even if the milk production is not yet established, it is very important to suckle the baby beginning within hours after birth. This helps establish the suckling reflex and the baby learns to put its mouth to the nipples. Breastfeeding should be initiated as soon after delivery as possible. The baby must be fed every 2-3 hours (at least during the day) and on demand anytime in-between. Frequent suckling stimulates milk production. Long feedings are unnecessary, but they should be frequent. Milk production should be well established by 36-96 hours. It is essential to learn the correct technique of holding the baby while feeding. Faulty posture puts a great mental and physical strain on the new mother and may affect production of sufficient milk.
At times, there is the problem of plenty. It is wise to remember that milk gets produced as it gets emptied from the breasts. So if the breasts are full, just nurse the baby and afterwards DO NOT express the excess milk. Expressing the residual milk only provides stimulus for producing more milk and the cycle become vicious and the breasts keep getting filled frequently and become painful. Over a period of 7-10 days, the requirement by the baby and the milk production by the mother get adjusted and the problems of less or more gets sorted out by itself.
Cracked and painful nipples are another common complaint. It is advisable to keep the nipples soft and supple by using bland creams like Vaseline or petroleum jelly. The liniment must be wiped off with cotton soaked in warm water each time the baby is fed and then re-applied. Cracked nipples can become routes of infection and cause breast abscess which is characterized by fever, swelling and pain in the breasts. It must be drained surgically. Milk Fever often occurs by 3-5 days and is because of engorgement of breasts with milk secretion. It often subsides on its own or with mild painkillers but must be differentiated from a breast abscess.
Breast abscess is because of infection of the breast tissue and a cracked nipple is often the cause. It is characterized by fever; pain in the involved breast associated with redness/ heaviness and sometimes discharges of pus either from the nipple or from a surface ulcer when the abscess breaks down on its own. It requires surgical intervention at the earliest so that involvement of the whole breast by infection and pus is prevented.

What are the medical problems that can crop up after delivery? How do we recognize and tackle it?

1) Puerperal pyrexia ( Post-delivery fever)

Fever that occurs in a new mother anytime from birth up to 6 weeks is called puerperal pyrexia. There are various definitions as to what constitutes puerperal pyrexia. One spike of over 1010F or fever of over 1000 F on three consecutive days is the most accepted definition. The cause of fever may be breast fullness/abscess, urinary infections, infections like typhoid/malaria/ viral fevers or even deep vein thrombosis.
Management: Fever after delivery must not be ignored. Puerperal pyrexia needs to be fully investigated and treated. Blood and urine investigations, X-ray Chest and Ultrasound (If needed) aid in the diagnosis for the cause of fever. Treatment with medications must takes into consideration the fact that drugs pass through the breast milk and might affect the baby and also that the baby may be exposed to the maternal infection.
Breast feeds might have to be stopped or continued as per the advice of the attending doctor.

2 )Deep vein thrombosis(DVT)

This condition is characterized by sudden swelling and pain in the leg (often the left leg). It is because the blood gets clotted in the veins of the thigh or calf. DVT occurs because the changes that occur in blood during pregnancy make the blood more prone to clot. This blood clot can get dislodged from the leg and move up to and block important blood vessels in the lung and thus may cause a serious condition known as pulmonary embolism. Blood clots can also occur I the blood vessels of the brain and is known as cortical venous thrombosis. This can cause fits, paralysis and even coma. Venous thrombosis (clotting of blood) can recur in later pregnancies or after delivery or when taking oral contraceptive pills. There could be a family history also.
Risk factors for venous thrombosis include: Obesity, pre-existing hypertension (BP during pregnancy), family or past history of DVT, twin pregnancies, abdominal delivery (cesarean section) especially emergency cases, forceps or Ventouse deliveries, prolonged bed rest post-delivery. In India it is a tradition to keep the new mother in complete bed rest while severely reducing the intake of fluids, especially water. These two practices only make the woman more prone for DVT and must be avoided.
Management: Women who are likely to be at a high risk for DVT are often recognized during or even prior to pregnancy.

3) Pre-existing medical conditions:

  • Hypertension: Increased blood pressure which develops during pregnancy (pregnancy induced hypertension) reverts back to normal by the first 1-2 weeks after pregnancy. It might persist beyond 6 weeks and then needs to be re-classified as essential hypertension.
  • Eclampsia: Increased blood pressure may cause eclampsia (seizures or fits) with its attended complications. Eclampsia occurs during pregnancy or during labor or even after delivery. The probability of eclampsia occurring after delivery is maximum in the first 48-72 hours after delivery and the woman should be under observation.
  • Diabetes: Raised blood sugars that appeared for the first time during pregnancy (Gestational diabetes) comes down dramatically immediately after delivery. Most patients do may not require any further medications. If however raised sugars persist even after 6 weeks, then it is re-classified as diabetes.
  • Pre-existing cardiac (heart) diseases: Owing to the rapid changes that occur in a woman after delivery, there is an increase in the amount of fluid which the body must cope up with. This puts an extra burden on the heart and hence women with cardiac conditions like the rheumatic heart disease are at risk of congestive cardiac failure after delivery. The risk is maximum within the 48 hours to 7 days after delivery. Cardiac conditions like the rheumatic heart disease
  • Auto-immune disorders: Certain Auto-immune conditions like thyroid disorders, Ulcerative colitis, and Rheumatoid arthritis can exacerbate after delivery.
  • Psychological conditions: Post natal blues, Puerperal depression and puerperal psychosis are some of the psychological conditions and need to be differentiated from each other as the management and prognosis (future prediction) are different for each. In general the psychological conditions are characterized by feeling low (depression) and hence this is an important symptom in the new-mother which deserves immediate attention.

4) Peripartum Cardiomyopathy:

This is an infrequent condition that involves the heart in an apparently normal woman. The onset is during the last few week of pregnancy and the symptoms of breathlessness may only worsen after delivery. The heart is grossly enlarged and peripartum cardiomyopathy may be fatal despite diagnosis and treatment.

5) Nutritional deficiencies;

It is a known fact that in India most women enter the pregnancy while in sub-optimal nutritional conition. Iron deficiency anemia is rampant and may worsen during delivery because of excess demand from the growing fetus and also because of blood loss after delivery. Calcium deficiency during lactation can be exacerbated as the calcium that gets secreted in the breast milk is derived from the maternal bones. This is the reason why many women feel generalized body aches and pain along their spine and low back. Added to this, faulty dietary habits and food faddism imposed by the household further depletes the nursing mother of nutrition. The new mother should part-take a balanced diet with good helpings of fruits and vegetables. Iron supplements may be needed for 10-12 weeks post-delivery in order to correct pre-existing anemia and replenish the iron stores. For breast feeding women the need for extra calcium exists for as long as she is feeding and this may be for up to 8-9 months post-delivery.

How can one ensure a safe and healthy puerperium?

  • Be aware that puerperium is but a physiologic condition in the life of a woman and proper care during this period is beneficial both short and long term. Extended puerperium-up to even nine months post-delivery is unnecessary and has no physiologic basis.
  • Preparation for puerperium begins from the time of conceiving and continues during pregnancy also
  • .
  • It is important not to follow faulty practices which are rampant amongst some Indian households.
  • Baby care should be scientific and not follow dangerous indigenous habits.
  • Accepting a suitable method of contraception is important not only to avoid unwanted pregnancy but also to allow sometime for the new mother to recuperate nutritionally from the previous one.




ADOLESCENT HEALTH


Most young girls seek medical help only when they have irregular or heavy or painful periods and seldom approach a doctor for information and guidance about sexual well being. For this, they resort to ill-informed peers or pornographic material (books or web sites) or simply presume most things! The dangers of such behavior cannot be quantified because it impacts hugely on the mental make-up, social behavior, academic performance and finally the kind of an adult that one turns into in later life. Many a family is shaken; many girls lose their confidence, self-esteem, resort to dangerous behavior and may also become reproductively crippled for the rest of their lives only because they were not aware that the solution to the adolescent problems was only a discussion away! This article is dedicated to all those unhappy girls who may have suffered or might be suffering because they are alarmed at what is happening in their lives and are at a loss to cope up with the adolescent stress.

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What is Adolescence?

The World Health Organization defines Adolescence as the period between the ages of eleven and nineteen. The teens are adolescents.

Adolescence can further be categorized as:

  1. Early Adolescence (10 to 14 years) when children need concrete straightforward information applicable to actual life situations;
  2. Middle Adolescence (14 to 17 years) when they are testing new adult behavior and are not easy to influence.
  3. Later period between 17 and 20 years when they are capable of abstract thoughts and are able to undertake preventive safety measures which may have been difficult earlier.

Why is Adolescence the focus of so much discussion and concern?

Adolescence is a milestone period in a person’s life. It is associated with physical changes, psychological changes, sex & sexuality confusion (including fears and facts about sex abuse), relationship dilemmas and career planning. It is hence obvious that it this is a period of maximum stress from all spheres.

What are the physical changes associated with Adolescence?

Adolescence includes a very important phase in human development and that is puberty. Puberty is the period during which physical growth and sexual maturation occurs. In girls, it usually begins with breast development (thelarche) followed by appearance of axillary (underarms) and pubic hair (adrenarche). Menarche or the appearance of first menstrual period is the last in the sequence of puberty in girls. Girls have a sudden growth spurt between breast development and the first period.

What is the pattern of normal breast development?

Appearance of breast buds is often the first sign of puberty and occurs between 8-10 years usually. It presents as a small firm protuberance beneath the nipples and is often painful. However, the pain does not last long and also, it is normal to have one breast bud develop first. Mild breast asymmetry is not a matter of alarm. Breast development is under the control of the female hormone, estrogen.

What is the normal pattern of axillary and pubic hair development?

Pubic hair appears about six months after the breast buds and axillary hair about 1-2 years later. Unlike for the breasts, the hair development does not depend on estrogens, but on the proper functioning of adrenal glands. Therefore, girls without ovaries can also have normal axillary and pubic hair development.

When does the growth spurt occur?

Growth spurt occurs about two years earlier in girls than in boys. This is around 11-12 years and the growth peak is reached two years after breast budding. Girls attain menarche about a year after their growth peak. Also because of the effect of estrogen, the body begins to acquire the female contour with narrow waist and broad hips.

Is there a variation in the age of puberty?

Yes. Children closer to equator, at lower altitudes and in urban areas start puberty earlier. Obese girls and those with a family history also experience early puberty. Earlier the onset, longer is the duration of puberty. However morbidly obese girls (more than 30% over weight), diabetics and intense exercisers may have delayed menarche. Blind girls experience earlier menarche.

What should we do to ensure that the girls accept their physical changes positively?

It is natural and normal for girls to feel overwhelmed by the changes that begin to occur in her body. As development of breasts is the change most obvious externally, girls become conscious of this. Most feel shy and some may even want to hide the changes by wearing loose fitting garments or even avoid company. Some on the other hand may become overly expressive and this may lead to dangerous behavior. In order to ensure that the child accepts her bodily changes with the right attitude:
  • Keep her knowledgeable about the changes she may expect in her body during this period.
  • Select the right kind of clothes that neither accentuate nor hide her. She must develop confidence without becoming vain.
  • Shopping for undergarments could be embarrassing to the child. The mother must do this shopping until the girl feels up to it.
  • How should the girl be prepared for her first menstrual period?

    The onset of menstruation may be expected about two years after the onset of breast development and a year after the growth peak. Girls who know what to expect are not overly shocked at the sight of blood. As many girls do, it is advisable to always carry a sanitary napkin. Some girls may not get their monthly cycles regularly for a year or two after its onset. This is because of hormonal changes and the gradually maturing reproductive organs. However if the irregularity continues or if the bleeding occurs over a prolonged period or is heavy, the gynaecologist must be consulted. Many girls may experience pain during periods. The pain usually starts a few hours before the onset of periods and disappears after a few hours or after the onset of bleeding. The response to this pain varies between girls. Some may accept the pain and bear it while for others it may become unbearable and may even mean absenteeism. It is wise to consult your doctor if the pain seems abnormal.

    What are the common psychological dilemmas encountered in Adolescence?

    As if the rapidly developing physical changes are not enough, adolescents go through a tumultuous psychological phase as well. The abnormal behavior is also a cause of intense parental anxiety and may lead to disharmony at home.
    The adolescent behavioral dilemmas may be:
    1. Developing and consolidating relationships: Making friends of the same or opposite sex may be exciting, adventurous and even taxing to the adolescent. Peer pressure, loyalty and an intense desire to be accepted play a major role in adolescent behavior.
    2. Establishing the right relationship and rapport with elders at home or teachers in schools and colleges.
    3. Interest in and getting attracted to the opposite sex.
    4. Getting introduced to dangerous behavior: Smoking, alcohol consumption, drug abuse and indulging in sexual activities may begin out of curiosity and may develop into serious consequences.
    5. Unacceptable behavior: Lying, stealing and class absenteeism are some of the negative behaviors observed amongst adolescents.
    6. Threatened or attempted self-injury-slitting wrists, drug over dosage may be observed in some.
    7. As Adolescence is a transitional period, major psychiatric disorders like Maniac-Depressive psychosis and Schizophrenia may manifest for the first time during this period.
    8. Impaired body image and faulty dietary habits: Some girls may develop a pathological aversion to being obese and begin to fast, almost to death.(Anorexia nervosa) At the other end of spectrum are the depressed girls who begin to over eat and become obese. Also underlying diseases as hypothyroidism or polycystic ovaries may also contribute to obesity. Food faddism and junk food gorging are common behavioral abnormalities of adolescent girls.

    What is the right approach to deal with the adolescent behavioral problems?

    Even the best of parental-off-spring relationship might be put to test as the child passes through Adolescence. This is a passing phase and can be passed off as such without far-reaching negative consequences only with a lot of effort from the older generation. It is not unusual or wrong to seek the help of professional counselors for both the child and parents to overcome this tumultuous phase successfully. It is the duty of the parents to help young people form a strong moral identity in their early adolescent years & to empower them to contribute to the well-being of their communities.

    Adolescent health-Part II

    What are the Medical Problems of the Adolescents?

    The medical problems may be:

    1. Sex related-lack of sexual awareness, Sexual abuse, early sexual relationships and attended complications.
    2. Emotional : These arise because of the changes that occur with the transition from childhood to adulthood, being attracted to the opposite sex, fantasies, mood changes (irresponsible, stubborn) and a search for identity and sexual development that creates a sense of crisis
    3. General medical problems :Mainly dietary mal-adjustments resulting in anaemia, obesity, food-faddism and anorexia nervosa (Extreme cases of impaired body-image)

    What is sexual awareness? How does one become sexually aware?

    Sexual awareness is no way obscene or a no-no to adolescents. Sexual awareness simply means understanding the physiology of the human body with special reference to the reproductive organs. Understanding your bodily functions not only gives you a sense of being in control but also helps explain the various changes that occur in your body and which may be baffling to the un-initiated. It is desirable that the adolescents know about the medical aspects of how human life is conceived. For this, a basic understanding of the reproductive organs-namely, the production of egg from the ovary; the production and functions of the sperms and the consequences of fertilization must be understood. Nowadays this information is being imparted in schools as a part of the curriculum. However, if not, the adolescents must approach any elder in the family with whom they feel free or the counselors at school and request them to clear the doubts and mis-conceptions. This approach is far healthier and informative than resorting to pornographic web sites or reading material or even an ill-informed peer.

    What is incorrect ‘sexual awareness?’

    Information from the pornographic sites is most often incorrect, far from reality and given with an aim not to be informative but provocative. If anything, they cause more confusion than awareness! Pornographic books: Same as for the internet information. There are however a few reliable and authentic books which may be of help. Ill-informed friends- may turn out to equally dangerous, as they are poorly aware themselves! Finally, experimenting and sexual escapades are certainly not the ways for adolescents to become sexually aware! What are the actual problems related to sex in the adolescents?

    Most stem from ignorance and irresponsibility.

    1. Early sexual involvement with its attended complications of an unwanted pregnancy. This naturally leads to resorting to abortion, not to mention the attended psychological trauma.
    2. Reproductive tract infections: Infection of the reproductive organs which may cause pain, white discharge and even infertility (inability to conceive) in future.
    3. Sexually transmitted diseases: HIV, Syphilis, Gonorrhoea, Chlamydia, Hepatitis-B are some of the long-standing infections that can be contracted due to unprotected sex.
    4. Mal-adjustments to normal bodily functions: The classic example is the fear and mis-conceptions about menstrual pain.
    5. Sexual abuse

    What is the main way to avoid complications arising from sex?

    The best and the only way to avoid pregnancy, infections and psychological scarring is to keep away from sex! It is important to understand that Adolescence is a period to consolidate the overall personality of an individual and sex must not be a priority issue. However, if you have been sexually initiated, the next best advice is to maintain a monogamous relationship and remember to use protection always! Barrier contraception protects from pregnancies as well as infections and sexually transmitted diseases. It is always advisable if you could consult a gynaecologist who will help you out with more contraceptive advice.

    What must be done in the unfortunate scenario of an accidental pregancy?

    If unfortunately, pregnancy is suspected or even happens, a gynaecologist must be contacted immediately. And also remember-it is best to confide in your parents, however unpleasant and embarrassing it may be for you. DO NOT GO AT IT ON YOUR OWN. It could cost your life!

    What are STDs (Sexually Transmitted Diseases)?

    In India, STDs affect 30 lakh teenagers every year! STDs are dangerous and occur only after sexual contact with infected partner. So it is obvious that your partner is not monogamous and has in fact, contracted it from someone else! An infected person may not have visible signs and definite illness cannot be predicted. It can lead to serious consequences like pelvis infection, infection in fallopian tubes and problems in having a pregnancy in future. Curable STDs include Trichomoniasis, Chlamydia, Gonorrhoea, Syphilis whereas the least Curable / Incurable are HIV / AIDS, HPV, Hepatitis B, Herpes Common symptoms of STDs are discharge, redness, itching, ulcers, over genitals and burning while passing urine. The partner may also have similar symptoms.

    What are the safety tips to avoid STDs? Remember prevention is better than cure. Learn to Say ‘NO’. Follow your mind more than your heart. Never say YES when you actually want to say NO .Learn to politely refuse and even give a reason!

    What constitutes sexual abuse?

    Sexual abuse is most often under-reported for obvious reasons.

    The following constitute abuse:
    1. Whenever a person’s sexual privacy is not respected.
    2. Forcing sexual intercourse;
    3. Rape.
    4. Unwanted touching, fondling, watching, talking, or being forced to look at sex organs
    5. "Peeping" secretly at another individual (boy/girl) in bathroom / bedroom

    What must be done to protect one-self?

    Most often, a known person is the culprit. It could be a distant relative, a married person, a family friend or a neighbor. Whoever it is, it is important to understand that sexual abuse is a crime and must be addressed seriously. Here is what you could do:
    1. Tell a trusted adult about abuse
    2. If you have been sexually assaulted you may feel ashamed, guilty, depressed, angry,
    3. voiceless. This is natural, but silence is not a solution or even an option.
    4. Counseling & healing are important to help tend your bruised shaken self & to move on.
    5. Choose not to remain silent because harassment will not go away if you ignore it. What are the medical problems that may be associated with adolescents?
    Faulty dietary habits are common among teen-agers and it may cause anaemia, Obesity and even malnutrition (As in anorexia nervosa) Also Thyroid disorders, PCOS (poly cystic ovarian syndrome) which cause irregularity of periods, acne and certain psychiatric disorders may manifest for the first time during Adolescence and may need to be addressed. What’s the last word? Adolescence is indeed a roller-coaster ride. It has happened to all others before you and you can sail through it too-with a little awareness, some support from family and a lot of determination and positive attitude from you! d

    Dr. Anil Abraham
    is presently Professor & Head of Dermatology at the St. John’s Medical College in Bangalore. He trained at Stanford University during which he specialized in cosmetic procedures including laser surgery and went on to become a Fellow of the American Academy of Dermatology. He is the recipient of many prestigious medals and awards. A well known orator, Dr. Abraham is married to Dr. Veena Abraham, with whom he is also running a successful private practice in Bangalore.












    HAIR

    HAIR Hair is often referred to as the crowning glory and has been praised as an important attribute of beauty by poets like Kalidasa. References to the black waist length hair of Shakuntala or Damayanti are common in literature. Draupadi left her hair loose until her vow was fulfilled. Even for men hair is often considered a sign of virility and good looks. Samson even lost his hair when his hair was chopped off by Delilah. In the animal species the mane of the lion or the attractive feathers of birds like the peacock underline the fact that hair and its modifications have long been a socially accepted part of interaction between the sexes. The hair can tell you about the typeof person in front of you. A sheved head can mean a bereavement in the family or recent pilgrimage to Tirupati or Vailankanni. Uncut hair in a male wearing a turban can help to identify a person as a Sikh or may even make people the focus of unwanted attention as happened in the US after the 9/11 tragedy. A punk cut with purple or pink tints may signify trendiness or rebellion whereas a military cut just before an interview may help to convey to the interview board that you are reliable and disciplined.. The hair can be your method of making a first impression and combing the hair in a mirror is probably what every person does before leaving the house. Open any magazine or newspaper and you will invariably find advertisements of products or persons who promise to help you grow hair or improve the colour, texture or length of your hair. It is obvious that loss of hair does not mean a serious illness yet millions of people all over the world suffer from hair loss and worry about their problem. To understand why we lose hair we must first learn a little about hair.

    INTRODUCTION

    Humans have about 5 million hair follicles at birth. No follicles are formed after birth but their size and growth may vary based on hormonal influences. The hair shaft is dead protein and consists of 3 basic layers – an outer cuticle, a cortex and an inner medulla. The cuticle protects and holds the cortex cells together. Split ends results if the cuticle is damaged by vigorous brushing or cosmetic treatments. The hair bulb (Fig 1) contains the matrix with rapidly multiplying cells. The mitotic rate of the hair matrix is greater than any other organ. Systemic diseases, nutritional factors and drugs may therefore interfere with hair growth and result in hair loss.

    Fig. 1 : STRUCTURE OF HAIR

    TYPES OF HAIR

    There are three types of hair (Table 1). Thick, pigmented hairs are called terminal hairs. Terminal hairs on the top of the scalp and in the beard, axillary and pubic areas are influenced by androgens. Androgens are important in regulating hair growth. At puberty, androgens increase the size of follicles in the beard, chest and limbs and decrease the size of follicles in the bitemporal region, which reshapes the hairline in men and many women. Lanugo hairs are the fine hairs found on the fetus; similar fine hairs found on the adult face and body are called vellus hairs. Vellus hair is short, fine, relatively nonpigmented and covers much of the body. Hair on the rest of the body is independent of androgens.

    Table 1 : TYPES OF HAIR

    Clinical Presentation telogen
    Onset of shedding after insult 2-4 months
    Percent hair lost 20-50
    Type of hair lost Normal club (white bulb)
    Island Trading Helen Bennett
    Hair shaft Normal

    HAIR GROWTH CYCLE

    Each hair follicle perpetually foes through three stages in the hair growth cycle: catagen (transitional phase), telogen (resting phase), and anagen (growing phase) (Fig 2). Approximately 90% to 95% of hairs are in the anagen phase, and 5% to 10% are in the telogen phase. Up to 10 telogen hairs are lost each day from the head, and about the same number of follicles enter anagen. The duration of anagen determines the length of hair, and the volume of the hair bulb determines the diameter (Table 2).

    Fig 2 : HAIR CYCLE Table 2 : HAIR FACTS

    • Average scalp has more than 100,000 hairs
    • Scalp hair grows 0.3 to 4 mm /day
    • 90 -95 % of hair are in anagen phase
    • 5-10 % are in telogen phase
    • Upto 100 telogen hairs may be lost per day.

    EVALUATION OF HAIR LOSS

    The causes of hair loss (alopecia) are numerous. A systemic approach for evaluation of hair loss is outlined in tables 3 and 4.

    Table 3 : HAIR LOSS – CLASSIFICATION

    Diffuse Localised
    eg. Telogen effluvium eg : Alopecia areata
    Scarring Non scarring
    eg. Telogen effluvium eg : Alopecia areata

    Table 4 - SYSTEMIC APPROACH TO EVALUATION OF HAIR LOSS

    <
    History Diagnostic procedures
    eg. Telogen effluvium eg : Alopecia areata /td>
    Sudden vs. gradual loss Hair pull test
    Presence of systemic disease or high fever Daily count
    sdfjh Part width
    Recent psychological or physical stress Possible trichotillomania
    Medication or chemical exposure /td> Potassium hydroxide examination for fungi
    Examination Scalp biopsy
    Localized vs. generalized Scarring vs. nonscarring
    Inflammatory vs. noninflammatory Hormone studies
    Density: normal or decreased Presence of follicular plugging
    Skin disease in other areas

    History Diagnostic procedures eg. Telogen effluvium eg : Alopecia areata Sudden vs. gradual loss Hair pull test Presence of systemic disease or high feverDaily count sdfjhPart widthRecent psychological or physical stressPossible trichotillomania Medication or chemical exposure Potassium hydroxide examination for fungiExamination Scalp biopsyLocalized vs. generalized Scarring vs. nonscarring Inflammatory vs. noninflammatory Hormone studies Density: normal or decreasedPresence of follicular plugging Skin disease in other areas

    Generalized Hair Loss

    A number of events have been documented that prematurely terminate anagen and cause an abnormally high number of normal hairs to enter the resting, or telogen, phase. The follicle is not diseased but has had its biologic clock reset and undergoes a normal innovational process. Usually no more than 50% of the patients hair is affected. Scarring and inflammation are absent. Resting hairs on the scalp are retained for approximately 100 days before they are lost; therefore telogen hair loss should occur approximately 3 months after the event that terminated normal hair growth. High fever from any cause may result in a sudden diffuse loss of club hairs 2 to 3 months later. Hair loss begins abruptly and lasts for approximately 4 weeks. Hair pluck tests show telogen counts that vary from 30% to 60%. Full recovery can be expected. Telogen effluvium is to be differentiated from anagen effluvium (Table 5).


    Table 5 : TELOGEN EFFLUVIUM VS ANAGEN EFFLUVIUM

    Clinical presentation TelogenAnagenOnset of shedding after insult 2-4 months 1-4 weeks Percent hair lost20-50 80-90Type of hair lostNormal club (white bulb)Anagen hair (pigmented bulb)Hair shaft Normal Narrowed or fractured

    Localized Hair Loss


    Areata Alopecia

    Alopecia areata (AA) is a common asymptomatic disease characterized by the rapid onset of total hair loss in a sharply defined, usually round, area. The diagnosis is made by observation. Any hair-bearing surface may be affected. The cause is unknown. An interaction between genetic and environmental factors may trigger the disease. Alopecia areata is a partial loss of scalp hair; alopecia totalis is 100% loss of scalp hair, and alopecia universalis is 100% loss of hair on the scalp and body.

    HAIR RAISING FACTS !

    The number of patients presenting with complaints of hair loss in Bangalore city has significantly increased by more than 80% over the last 5 years. The patients include both men ( 54 % ) and women ( 46 % ) and a large proportion of children even as young as 6 months. Software professionals and call-centre employees are the largest group among the patients with hair loss. Stress is an important factor and more than 85% of these patients had significant stress levels as indicated by a questionnaire study. Poor nutrition, inadequate or altered sleep patterns and work stress were found to be primary causes. In another group, college students and housewives who indulge in crash dieting were also found to have sudden unexplained hair loss together with hormonal problems. Several of the patients complained of increased hair loss after coming to Bangalore and blamed the change in water especially from bore-wells for their loss. Typical complaints were that hair came off easily during combing, bathing or during application of oil. Many patients already had significant hair loss when they first approached their doctor and others had tried several hair oils or advertised remedies before seeking medical help. The study was carried out by Dr. Anil Abraham, Professor of Dermatology, St. John’s Medical College Hospital who has been elected as a Fellow of the International Congress of Trichology and a spokesperson for the Asia - Pacific region on Hair loss and Pigmentary Disorders based on this work. He has been invited to address several groups of international dermatologists on hair loss and pigmentation among Asian and Indian patients. Dr. Anil Abraham has trained at Stanford University in USA and presently practices from Bangalore at his clinic near Mt. Carmel College Dr. Anil Abraham, MD. FAAD (Stanford, USA) Professor and Head of Dermatology docanilabe@yahoo.co.in ,98440-66844,080-22261560

    Check List of causes for hair loss

    • Stress -domestic,work related, studies / exams / others including commuting
    • Hormonal : menses / Thyroid / Others
    • Shampoo / Oil / Dye / Others
    • Water source / Swimming / Bath / Combing
    • Recent illness / Medical problems / Anemia
    • Medication / Drugs
    • Itching / Dandruff
    • Diet / Food habits
    • Pregnancy / Child-birth / Surgery
    • Family history

    Dr. H. SUDARSHAN BALLAL, MD Professor of Clinical Medicine,

    St. Louis University School of Medicine & Manipal University.
    Director. Manipal Institute of Nephrology &
    Urology Manipal Hospital. Bangalore.

    Introduction:

    Severe chronic kidney disease (End stage renal disease/Kidney failure) afflicts about 150 - 200.000 people in our country and is a devastating problem and often means death for the patient and a major emotional and financial drain for the family. Hence it is very important that we detect kidney disease early to prevent progression to End Stage Renal Disease where dialysis or transplantation becomes inevitable.

    The Causes of kidney failure

    Kidney failure is caused by Diabetes, Hypertension, Glomerulonephritis, Interstitial Nephritis, infections, kidney stones, hereditary diseases and frequent use of drugs without proper medical advice & monitoring.

    Signs and symptoms of Kidney failure

    The signs and symptoms of Kidney Failure may be silent! They include weakness and fatigue, puffiness of face, swelling of feet, decreased urine output, shortness of breath, drowsiness, loss of appetite, nausea and vomiting, unexplained anemia, excessive, frequent urination at night.

    Simple tests to detect Kidney Disease

    Kidney Number:

    Our endeavor is to familiarize the general public about the 'kidney number' which is the function of the kidney assessed using a simple formula by knowing the serum Creatinine, weight, age and sex of the person.

    Urine Analysis for Albumin:

    The vital numbers that are important for the normal health of a person are blood sugar blood pressure, cholesterol and the kidney number. These four numbers account for most of the non-infectious diseases of mankind. Who needs screening?Everyone needs screening for kidney disease, especially those who are above the age of 40 years. And also those who have the following:
    • Diabetes
    • High blood pressure
    • History of Kidney disease

    Treatment of kidney failure:

    In the early stages of kidney failure, the treatment is conservative and consists of dietary modifications, medication to control blood pressure, tight control of diabetes, avoidance of drugs that are toxic to the kidneys, measures to reduce the risk of heart disease and lifestyle modification.Renal Replacement Therapy (late Stage/End Stage Kidney disease)
    • Dialysis
    • Transplantation
    It is important to remember that kidney disease is not only a problem in itself, but it also increases the risk of heart disease.

    The Burden of Chronic Kidney Disease:

    The cost of treatment:

    • Dialysis - 2 to 3 lakhs per year
    • Transplantation - 2 to3 lakhs initially followed by Rs. 10000 to Rs.20000 per month
    • This obviously is way beyond the means of most people in our country.
    • The solution to this is prevention, early detection and slowing of progression of chronic kidney disease.
    Kidney disease has reached epidemic proportions. The burden of severe kidney disease is something that the common man and the society cannot afford. Hence our focus should be on prevention, early recognition and slowing the progression of chronic kidney disease. An ounce of prevention is truly worth a ton of cure in Kidney disease.

    GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)


    Author : Dr.Lakshman,

    (Acid Reflux / Heartburn)

    What is gastro-oesophageal reflux disease?

    When there is reflux (back flow) of acid and other contents from the stomach into oesophagus (food pipe) it is called gastro-oesophageal reflux disease. The acid causes damage to the lining of the food pipe and hence symptoms like heartburn and belching.

    Why am I having acid reflux?

    Normally, there are mechanisms in the body which prevent reflux of acid from the stomach into the food pipe. They are the purse string or pinch cock mechanism of diaphragm (muscle between chest and abdomen), inner lining between stomach and food pipe that is thrown into folds and also a valve like mechanism at their junction (Sphincter)
    The lining of the food pipe is thinner than that of the stomach and is hence prone for damage during reflux.

    What are the symptoms of reflux?

    The important symptoms are

    Heartburn where a person feels burning in the middle of the chest. Also, occasionally the pain could be on the left side sometimes mistaken for a heart problem. However, this pain is related to food or sometimes to posture, increasing on bending or after a full meal. Reflux. Acid or food coming from the stomach into the chest can be felt, sometimes it can reach as high as the mouth and a person feels like spitting the contents of the mouth out which is sour to taste. Belching or burping, which happens because of weakness of the valve when air escapes from the stomach. Other symptoms include change in the voice due to acid affecting the vocal cords or voice box, cough or wheezing at night mimicking asthma or sometimes food getting stuck in the middle of the chest. What are the underlying causes and triggers for reflux disease? The usual underlying problem is a weak valve or a hiatus hernia where stomach is pulled into the chest. There are also some factors which weaken the valve called the lower Oesophageal sphincter. These include smoking, significant alcohol intake, more of fatty foods including chocolates and ice

    What tests are needed to confirm gastroesophageal reflux?

    Symptoms for a short duration do not need any tests. It could improve with proper life style modifications and by taking tablets called proton pump inhibitors or H2 receptor antagonist. If symptoms of reflux and heartburn persist for more than a month, perhaps it may be best to get an endoscopy, which means that a small camera fitted on a flexible tube is inserted through mouth into stomach. The doctor will do this test and uses a monitor to see the internal views. It could make out a hiatus hernia or damage caused by reflux. At the time of endoscopy, a sample (biopsy) may also be needed if the doctor feels there is something abnormal. Rarely, other tests are needed to rule out any problems with the heart or lungs.

    What lifestyle changes are needed to improve this condition?

    Stopping smoking and cutting down alcohol significantly. Small and frequent meals. Weight reduction, if obese. Avoiding anything which will bloat the stomach like a fizzy drink or a heavy meal. Not to lie down for at least three hours after last meal of the day. If resting after meals, it should be in a reclining position with a 6-9 inch raise at the head end. Do not drink lot of water immediately after food if you have this problem. You can take half a cup or one cup of water and an hour later you can take additional cups of water for digestion.

    What are the medications/treatments?


    Medications which prevent/reduce the amount of hydrochloric acid secreted in the stomach and hence the acidity and damaging capacity of contents that reflux into the food pipe. They include H2 receptor antagonists (Ranitidine, Famotidine, etc) and Proton pump inhibitors (PPIs) (omeprazole lansoprazole, pantoprazole etc.) The duration of treatment with both varies and usually for 6 to 8 weeks initially and further can be continued depending upon the response to the symptoms, recurrence of the symptoms, and the endoscopic findings.
    Antacids - Liquid or solid antacids help in neutralizing the acid as well as preventing its effect on the inner lining of the food pipe by coating it.
    Surgery - When the reflux is large and uncontrollable, an operation may be needed. Wrapping the stomach around lower food pipe increases the tone between the food pipe and stomach. This is called Nissen’s fundoplication. This also can be done laparoscopically (keyhole surgery).

    Are there any complications of reflux disease?

    Yes, there are a few complications which can happen rarely. Stricture- narrowing of the food pipe due to inflammation and scarring. When this happens there maybe difficulty to swallow food and the food will go down the food pipe slowly. This obstruction will be more to the solids but swallowing liquids also become affected at a later state. If it happens, treatment is possible endoscopically where a balloon is inserted to stretch the stricture. Barrett’s esophagus - This inner lining especially at the lower part of the food pipe becomes thicker due to constant assault and may change to cancer over years. According to many studies, the lifetime risk of this changing into cancer is about 5% and this can be diagnosed by endoscopy and biopsies and this Barrett’s mucosa can be minimized with the help of long-term proton pump inhibitors.

    Conclusion:

    Heart burn is a common symptom which can be easily diagnosed and treated. However , at times a heart attack can also mimic a heart burn and so it is prudent to see the doctor and let them make the diagnosis rather than self medicate all heart burn as ‘acidity’ or ‘gas’

    Author : Dr.Lakshman


    Screening for cancer of the Cervix


    What is the cervix?

    Why is Cancer cervix important? Cervix is the mouth of the uterus.

    One out of every five women in the world suffering from this disease belongs to India. More than three-fourths of these patients are diagnosed at advanced stages leading to poor prospects of long-term survival and cure.

    What, if any, is the silver lining in the matters of Cance rof cervix?

    Cervix is an organ which is easily visible and also accessible during routine gynaecologic examination. Hence any abnormality of cervix holds the promise of easy detection and therefore early, appropriate intervention. This means that with regular screening, it is possible to keep a track of any undesirable change that a cervix might undergo.

    What is screening for cervical cancer?

    Screening is a method by which all the population- including the healthy ones are subjected to some test or examination so that it is possible to pick up the ones which are abnormal. Screening must not be confused with a diagnostic test. A screen merely detects a possible high risk case while a diagnostic test is used to confirm the presence or absence of the disease.Screening for cervical cancer aims at recognizing women who are at high risk of and likely to develop cancer of the cervix.

    Who can get cancer of the cervix?

    Any sexually active woman can get cancer of the cervix. However there are a few women.who are at a higher risk (probability) than others in getting cancer cervix.

    Who are the high risk women for Cancer cervix?

    The following factors are well recognized risk factors for cancer cervix:a) Early age of marriage and/or early age at first intercourse.b) Early age at first child birth. Multiple pregnancies.c) Sexual promiscuity: Multiple sexual partners or sexual partner with multiple partners.d) Persistent HPV (Human Papilloma Virus) Infectione) Co-exists with other sexually transmitted diseases like HIV, syphilis and gonorrhea.f) Smokersg)

    Women receiving immune-suppressant drugsAre any women at lower risk?

    Monogamous women whose sexual partners have had circumscision or have used condoms. (The male smegma has been implicated in the causation of cancer Cervix.) may be at a lower risk.Long term efficacy of vaccination against HPV for Cervical cancer prevention is being studied.Virgins, women who have not borne children may also be at lower risk.

    What is the natural history and evolution of Cancer of the Cervix?

    As we are aware, the cells in our body are in a state of constant flux. New cells keep replacing the old ones as a part of this remodeling mechanism. Due to certain reasons, the cells of the cervix gradually transform from being normal to cancerous. This transformation does not occur overnight or over a period of days. It takes several YEARS for a normal cervix to become cancerous.Before becoming obviously cancerous, the cervix therefore has a long pre-cancerous period. Sometimes, it may take well over 15-20 years for a pre-cancerous cervix to become overtly cancerous.Hence it is possible to detect an abnormal cervix during the course of its evolution from normal to abnormal. And therefore halt the process by appropriate interventions.

    What does the screening for cervical cancer do?

    Cervical cancer screening aims to pick up abnormal cells that are developing in the cervix. As mentioned earlier, cervix is one of the organs that is easily visible to the naked eye. Hence it is possible not only to visualize the cervix but also do certain simple tests on it in order to confirm or rule out the presence of an abnormality.

    Who must undergo screening for Cancer of the cervix?

    All women who are sexually active currently or have ever been, merit screening for cancer of the cervix.A concrete screening program and follow up to identify pre-cancerous cervices has not yet been strategized in India, unlike in the UK where the organized and well documented cancer screening program has seen a dramatic reduction in cases of cervical cancer.

    What are the tests done for cervical cancer screening?

    Inspection of the cervix: Visualizing the cervix under good light and after the application of acetic acid aids in identifying suspicious areas. Pap’s Smear: This is a simple test done quite extensively all over the world for early detection of cervical cancer.Colposcopic examination: Often undertaken after an abnormal Pap’s test. A colposcope is a specialized equipment which helps to examine the cervix under magnification and through filters. This gives information about the nature and degree of cervical abnormality. Colposcopes also aid while taking biopsies and doing certain operative procedures on the cervix.HPV DNA testing: Infection with certain strains of HPV (Human Papilloma Virus) predisposes to development of cancer cervix. HPV DNA testing aims to detect the presence of such infectious strains. This test is an advanced technique and is not routinely used universally because of the cost implications.

    What is a Pap’s Test?

    Pap’s Test or Pap’s smear (named after the Greek Doctor, George Papanicolaou, who invented the test) is a very simple yet indispensible test for the detection of an abnormal cervix. It has helped save the lives of millions of women all over the world.Cells from the cervix are collected and are either smeared on a slide or transferred on to a liquid in a test tube. These cells are then studied under the microscope by the pathologist/cytologist.When seen under the microscope, cells which are cancerous and those which are pre-cancerous (destined to turn into cancer in the future) appear very different from normal cells of the cervix. The cytologist then reports it as per International Guidelines which helps the treating doctor to do the needful.

    How is a Pap’s test done?

    A Pap’s smear entails a pelvic examination. The cervix is visualized completely under good light and its surface and canal are gently swept or brushed with the help of an Ayre’s spatula and/or Cyto-brush. As the cervix is insensitive to touch, the woman will have no pain at all. So getting a Pap’s smear is as simple or as uncomfortable as a pelvic examination!

    Any precautions before undergoing a Pap smear?

    A Pap smear cannot be done during menstrual flow. It is ideally done after a week after the last menstrual period, and before the onset of the next cycle.Vaginal infections interfere with the smear report or such a smear gets simply reported as inflammation. Hence, pre-existing infections must be satisfactorily dealt with before taking a Pap’s smear.Douching the vagina must be avoided at least 24-48 hours before the smear.It would also do well to abstain from sex for 24-48 hours before a smear.No antiseptic creams are used while taking a Pap’s smear.

    What is an abnormal Pap’s Smear?

    An Abnormal Pap’s Smear DOES NOT mean Cancer! There exists an Internationally agreed classification, grading and nomenclatures which helps the clinicians to chalk out further course of action. Depending on the report, a Pap’s smear is followed up with colposcopy and/or repeat Pap’s smear after a specified time and/or cervical biopsy. However an abnormal Pap’s smear needs regular follow up until the abnormality is resolved. The treating doctor will be able to discuss with you the significance of the smear report and the future course of action. BUT AN ABNORMAL PAP’S IS NOT CANCER.

    When should Cervical cancer screening be initiated?

    It is good practice to do the first Pap’s smear on a woman at the age of 25 if she is sexually active. HPV infection often interferes with interpretation of smear reports. However, HPV infection is common in women before the age of 25 and is also often self-limiting. Hence, the rationale in not doing a Pap’s test for women below 25 years even if they are sexually active.

    How frequently must one undergo the Pap’s smear test?

    Keeping the relatively slow evolution of cancer cervix in mind, it is proposed that if a Pap’s smear is reported as normal, then the woman will need a repeat testing only after three years. However an abnormal Pap’s is dealt with according to the nature of abnormality.

    For how many years must a woman continue to get the Pap’s smear done?

    As cancer of the cervix is the disease of the reproductive age group (upto 45 years) a normal Pap’s smear must be done every three years upto the age of 50. Also, as cancer of the cervix is a slowly evolving condition, it is proposed that for a woman beyond 50 years, repeating Pap’s once every five years upto the age of 65 is a safe practice. If all smears have been normal, then, after the age of 65, the incidence of cervical cancer is remote and hence screening may be closed. In conclusion: Cancer cervix is the commonest cancer in India and can affect any sexually active woman. By a simple screening test-the Pap’s smear, it is possible to detect pre-cancerous stage in the cervix. An abnormal Pap’s smear does not mean Cancer. It is a mere alert and indication for the treating doctor to carry on further tests and treatments. It is possible to ESCAPE from Cervical cancer by undergoing regular Pap’s smear testing!!

    Genetics


    There can be no question that we are in the midst of a revolution in clinical medicine. The 21st century has already been christened “the age of molecular medicine”. The molecule in question being the DNA. The development of new technologies such as the polymerase chain reaction (PCR), automated DNA sequencing and the completion of human genome project have helped in the analysis of patient DNA in clinical medicine. Medical genetics is acquiring priority in India after achieving better health care for infections and nutritional diseases. All components of the human body are influenced by genes hence genetic disease is relevant to all medical specialities. Genetic factors are gaining importance in the management of developmental abnormalities, neurological, cardiovascular diseases and cancer. 3- 7% of the population will be diagnosed with a recognizable genetic disease with an incidence of 1 in 100. More than 10,000 human genetic disorders are known to date and the number increases every day.

    Types of genetic diseases:

    Structure and function of the human being is determined by roughly 30,000 – 40,000 genes distributed as pairs on the 46 chromosomes, 22 autosomes and one of sex chromosomes from each parent.

    Genetically caused diseases fall into 4 categories:

    Chromosomal disorders

    in which an entire chromosome or large segments of chromosome are missing, duplicated or otherwise altered affecting the gene dosage. Of these Down syndrome (Trisomy 21) is the commonest (1 in 1000 children).

    Single gene disorder

    involve actual changes in the genes themselves often termed Mendelian disorders eg. Thalasemia, spinal muscular dystrophy, sickle cell disease etc.

    Multifactorial disorders

    create a susceptibility to developmental errors that is then modified by factors in the environment eg. Cleft lip, neural tube defects, diabetes etc.

    Mitochondrial disorder a relatively small number due to alterations in cytoplasmic mitochondrial DNA of maternal egg (Ova) hence also known as maternal inheritance.Of these the single gene disorders have probably received the greatest attention and classified according to the way they are inherited:


    a) Autosomal Dominant or Recessive, and
    b) X-linked disorders. Autosomal dominant disorders have a vertical transmission where one of the parents manifests the condition.

    Most skeletal dysplasias like Marfan syndrome, Achondoplasia and Huntington’s disease are some of the examples. The risk of recurrence is 50 percent in the next offspring. Spontaneous mutations in the gene are often the cause when the in parents are normal and no other family members are affected. In such situations the risk is very low to the next offspring. X- Linked recessive disorder have mutant gene on the X chromosome. Only males will be affected as they have a single X chromosome. The females will be only carriers. Eg. Duchene Muscular Dystrophy and Fragile X syndrome.
    In Autosomal Recessive inheritance the parents are carriers of gene trait and do not show the disease. The genes occur in pairs and the baby inherits one gene of a pair from each parent (23 chromosomes). In recessive disorders one of the genes is mutated while the other is normal in the carriers. However, if both parents transmit the mutant gene, the baby is affected. In such cases if both parents are carriers there is a 25 percent chance of having one affected baby. Common eg. are Thalasemmia, albinism and metabolic disorders.


    Consanguineous marriages between close relatives often increase the risk of autosomal recessive genetic disorders. All of us carry 1-2 deleterious recessive genes. Since, the other normal gene prevents the manifestations of the disease, we are all silent carriers. The chances of marrying a person with the same recessive gene out of the 40,000 genes in the general population are very rare. In consanguineous marriages however the gene pool is common and the likelihood of the segregation or coming closer of recessive gene is higher in successive generations.
    In India, consanguineous marriages are common in South India varying from 5% to 60% depending on factors as religion, caste and socio-economic status. First cousins and uncle niece marriages are most common among the second degree relatives. Various studies done by several groups (Radha RamaDevi and Bittles, 1987; Appaji Rao, 1991, Nath and Patil, 2004) have shown an increased number of autosomal recessive disorders in children born to consanguineous couples.
    A higher incidence of miscarriages and congenital defects in second degree relatives were reported than in the distantly related couples (Muthu kumaravel and Bhat, 2005). Rare autosomal recessive neurological disorders have been observed in large consanguineous families (Nalini and Gayathri, 2008; Bindu, 2006). Consanguinity has no effect on X linked or autosomal dominant disorders. The overall increase in the incidence of recessive disorders is 5 percent higher than general population risks. A case therefore can be made out for the avoidance of consanguineous marriage. The genetic price to pay for the beneficial effects of consanguineous marriage is high.


    Prevention of genetic disorder is important through genetic counseling and prenatal diagnosis as a majority of them still do not have a cure. Accurate diagnosis with relevant investigations especially the DNA based of the affected child is very important. All pregnant mothers should undergo both biochemical and ultrasound. Genetic counseling should be sought in case an anomaly in the fetus is detected.

    The ethical issue raised by this rapid stride in technology is inevitable. A scientist and a humanist would argue that it is entirely appropriate to use these advanced tools to mitigate the human suffering that is caused both to the child and the parents. But, when sentimentality is allowed to take center stage in one’s thinking, it is the pro-life section of the population that wins the argument. This dilemma is particularly poignant in the case of diseases like Huntington’s disease which appears in the 3rd or 4th decade of the person’s life. Tormenting questions such as, should the child be informed, and should be would-be spouse be enlightened before an alliance is settled, will need to be addressed. This is one of those endless debates. Eventually, these are individual decisions.

    Consanguineous marriages are often dictated by social factors such as preservation of property within the family fold or the concept of lineage. This seeming benefit is lost by the lurking possibility of a genetically imperfect child. A couple will go to any lengths to have a normal healthy child and today’s technology allows them to do just that. A personal defining moment came when one anxious consanguineous couple underwent an overall gene testing for several diseases costing $350 in US!! Advanced genetic technologies have spawned business enterprises making access to them, easier. Overtime costs are bound to come down with demand.


    Data To Be Soon Represented


    Data To Be Soon Represented


    Data To Be Soon Represented


    LIFESTYLE AND THE EYE


    The Computer Vision Syndrome

    Author : Dr.Nagaraju G


    Introduction

    The changing scenario in recent times has made computers or visual display units (VDU) part of our routine existence. From a school going child to a corporate almost every one is using VDU either at work or at home. Numerous studies have focused upon the health hazards while working on VDUs. These have been termed as Repetitive Stress Injuries (RSI) and involve the musculoskeletal system not only due to excessive computer work but also due to faulty workstations. It has been found that almost one fourth of patients working on various forms of VDU exhibit visual complaints. It has been found to be proportional to the number of hours working in front of computers., almost 90% of patients complain of visual problems with more than 6 hours of computer work.

    Manifestations

    The usual symptoms are asthenopia or eyestrain, burning or tender eyes, redness, watering, blurred vision or difficulty in focusing, grittiness or dryness or aching sensation, double vision, feeling of heaviness, headache, tiredness, throbbing and altered color perception. Some patients feel the need to wear prescription glasses and some might require frequent change of spectacles. Systemically some patients might complain of facial rash or dermatitis, photosensitive epilepsy, fatigue, while some might complain of behavioral changes.

    The problem

    The eye symptoms associated with visual display units has been termed as Computer Vision Syndrome. (CVS). The eye consists of various parts which help in the perception of an object, and information of the same is conveyed to the brain through visual pathways. Eye functions like a dynamic camera and is balanced by its intrinsic and the extrinsic musculature. Cranial pathways coordinate information between the two eyes. CVS may be due to ocular factors, personal factors, workstation factors or environmental factors or a combination of the above.

    The cause

    Special effort is made by the eye while visualizing a VDU unlike while seeing a printed matter. The object presented to the eye itself is made up of numerous pixels which reflects upon the resolution of the monitor and by itself is not a sharp image and excess effort Asthenopia can also occur with accommodation and convergence anomalies. Hence it is more symptomatic in patients with convergence insufficiency. Since accommodative power decreases with age, appropriate modification in the workstation has to be done for persons above forty years.
    The eye front of the cornea is covered by a thin film of tears (inner mucin layer, central aqueous layer and outer lipid layer.) Blinking which normally is 15 to 20 times per minute helps in maintaining the ocular surface health and washing out the contaminants. Working on VDU is associated with a lowered blink rate and increased incidence of dryness and irritation of the eyes. Personal factors like general ill health, lack of nutritious food (food faddism), use of certain medications (antihistaminics), tendency for migraine, level of stress and variable working schedules all lead to symptomatic CVS

    The remedy

    Visual Problems

    1. The ideal distance from the eye to the monitor should be 25 inches or more.
    2. The ideal viewing area of the monitor is 6 inches (15 to 30 deg) below the horizontal eye level
    3. Keep the monitor top tilted 15 to 20 degrees away from the top
    4. Preferably work with dark letters on a light background
    5. Adjust brightness and contrast on the screen to avoid glare and flicker
    6. Attach an antiglare screen in front of the monitor as this will decrease the amount of light
    7. reflected from the screen
    8. Use a screen mounted document holder, positioned between the keyboard and minister screen almost at the same distance and height as that of the monitor.

    Workstation problems

    1. Adopt good posture, with feet resting flat on the ground
    2. Use adjustable screen and keyboards
    3. Use adjustable chairs with armrests
    4. Use table with adjustable height
    5. Use LCD( liquid crystal display ) screens than CRT (cathode ray tubes) screens
    6. Use adjustable document holder when required
    7. Adequately dimensioned workstation so that there is sufficient space for the operator to change
    8. position and vary movements

    Environmental problems

    The work station should have sufficiently large and low reflectance surface The room should have medium reflectance ( pastel color) to avoid glare Lighting should be ambient: Concealed fluorescent lamps, suspended lights and windows with blinds. Indirect lighting helps to reduce glare Low humidity in air-conditioned offices aggravates symptoms especially in contact lens wearers. Avoid direct flow of air on your eyes

    Personal factors

    Regular rest breaks away from the screen are essential : follow the 20-20-20 rule ( take short breaks every 20 minutes between work for 20 seconds and look at objects at least 20 feet away) Eye exercises : closing eyes and performing clockwise and anticlockwise movements Using lubricating eye drops Nutritious diet Regular eye examination by an eye specialist Delegate tasks to prevent stress and to evoke job satisfaction

    Conclusion

    With the changing times, there is a definite change in lifestyle. The present day competitive world requires one to adapt to the digital age. With computers being an absolute necessity in everyday life one has to adapt oneself to the modern technology in such a way our body system acclimatizes to the world of VDUs References
    Work and the Eye. Rachel V North VDU work and the hazards to health. A London Hazards Centre Handbook Author :

    Dr.Nagaraju G
    MBBS, MS (Ophth), DNB (Ophth), FGO, FCED


    Associate Professor in Minto Ophthalmic Hospital,
    Bangalore Medical College & Research Institute
    nagarajug63@gmail.com

    For the expectant mothers....


    “Before you were conceived I wanted you. Before you were born, I loved you. Before you were here an hour I would die for you. This is the miracle of Mother's Love.”
    -Maureen Hawkins
    So you are the miracle called mother, aspiring for another miracle-your baby. It is only natural that you would want only the best!
    Here is a comprehensive list you must be aware of. But it is on no way exhaustive as your needs may be a little different from the routine. I am sure your obstetrician will be able to take care of that.

    Time-When?

    What should be done?

    Why it needs to be done...

    How is it done?

    Before you get pregnant Pre-pregnancy counseling

    To assess your health status before pregnancy.

    To ensure you embark on pregnancy in optimal health.

    1) Folic acid supplements for 3 months prior.
    2) Rubella immunization
    3) Weight reduction (if obese).
    4) Optimize medical conditions (asthma, epilepsy, hypertension, diabetes, Thyroid disorders etc.) which may have been existing before
    5) Stop smoking and alcohol

    First visit:
    Immediately after a missed period. 

    Diagnosis of pregnancy Confirmation that the missed period is because of pregnancy and not just an over-due period.

    1) Urine pregnancy test
    2) Trans-vaginal ultrasound

    3) Internal examination
    First trimester (up to 13 weeks)
    • Period of formation of fetal organs.
    • Avoid medications other than those prescribed.
    • Frequency of clinical examination: Once in 4-6 weeks
    6-8 weeks History and examination

    1) Risk assessment-Categorization as high risk or low risk pregnancy.
    2) Calculating the expected date of delivery.(EDD)
    3) Preliminary examination of blood pressure, height and weight. General systemic examination.
    4)Assessment of early pregnancy

    5) Testing for HIV, hepatitis, syphilis, blood group and type, hemoglobin and blood sugars. Rubella and chicken pox susceptibility may also be tested

    1) Detailed family history of diabetes, twins, hypertension, thyroid, autoimmune and other disorders.
    2) Personal history of any pre-existing medical or surgical conditions, or allergies along with the treatment details
    3) General and Internal examination
    4) Blood and urine tests
    5) Medication: Folic acid supplementation.

    8-14 weeks Screening for abnormalities like Down Syndrome and others. This is optional. Your doctor will discuss your age related risk for Down syndrome and will offer the screening test.
    1. Trans-vaginal scan for Nuchal translucency (NT) and other subtle markers for Down Syndrome.
    2. Blood tests (free beta hCG and PAPP-A hormones)
    Second trimester (13 to 28 weeks)
    • Period when the formed organs begin to function.
    • During clinical examination, you are serially assessed for blood pressure, anemia, feet/facial swelling, and weight gain. Baby is assessed for growth, position, movement and heartbeats.
    • Frequency of examination: once in 4 weeks.
    Medications- Iron and Calcium supplements. Tetanus toxoid injection (TT)-Two shots at an interval of at least 4 weeks in-between.
    18-22 weeks

    1) Detailed look at the growing baby  to see if all organs appear normal
    2) Screening for high risk cases

    1) As all the major organs are formed now, it is possible to pick up most anomalies.
    2) Termination of pregnancy may be offered for potentially uncorrectable/ lethal deformities.

    3) In high-risk cases (hypertension in pregnancy, previous bad outcomes etc.) the blood flow pattern to the uterus and from placenta to the baby is assessed. It is of predictive value.

    1. Detailed anomaly scan.
    2. Uterine and umbilical artery Doppler studies. May be done at the same sitting as an anomaly scan.

    26-30 weeks

    To look for diabetes in pregnancy

    Some women may manifest diabetes in pregnancy for the first time now

    Oral glucose challenge test-Blood sugar estimation on empty stomach and 2 hours after drinking 75 gms of glucose mixed in water.
    Third trimester (29 to 40 weeks)
    • Period when the functioning organs continue to mature
    • During clinical examination, you are serially assessed for blood pressure, anemia, feet/facial swelling, and weight gain. Baby is assessed for growth, position, movement, descent into the pelvis (at advanced stages), heartbeats and also the amount of fluid around it.
    Frequency of examination: once in 2-3 weeks, or as per your doctor’s advice.

     

    36 weeks

    Relook at the well-being of the baby.

    Monitoring the baby’s environment in high-risk cases.

    Gastro intestinal anomalies may manifest for the first time.

    Some high risk babies need supervision frequently

    1) Abdominal Obstetric scan
    2) Bio-physical scoring-same sitting as the scan

    3) Non-stress test(NST)
    38 weeks Assessment of the birth passage, especially for the first time mothers. To evaluate if the descent of head has begun (By 36 weeks in first pregnancies) and if labor is likely to start earlier Internal examination.
    Term (40 weeks) Reassess  for delay

    Is there any harm waiting for another week?

    What tests must be done to ensure that the baby is safe inside?

    1) Clinical examination
    2) Ultrasound and biophysical score

    3)NST

    Emergency Contraception

    What is Emergency Contraception (EC)?

    Most sexually active women have had a scare of an unprotected sexual Intercourse (UPSI) at some time or the other during their lives. Emergency contraception is that ‘second chance’ to prevent an unwanted pregnancy. It offers a solution to such women by ensuring that they do not become pregnant from the UPSI episode.

    When does the need for EC arise?

    Changing norms and habits in the modern society and women empowerment have contributed greatly to the need for emergency contraception.
    1. Method failure: Failure or non-usage of regular contraception. Some women might have forgotten to take their regular dose of oral contraceptive pills, condom slippage/tear, or incorrect use of any other precaution.
    2. A chance/surprise/accidental encounter resulting in UPSI
    3. For women who have irregular cycles and those who have occasional sex.
    4. Women in the perimenopausal period (nearing menopause) who might be having irregular cycles and hence unpredictable ovulation.

    5. Victim of sexual assault What are the dangers of UPSI?
    1. Pregnancy, of course
    2. Sexually transmitted diseases (STDs) especially with a new partner and without barrier contraceptives. However, ECs offer protection only against pregnancy and not against STDs.

    What is the scientific basis of Emergency contraception?

    After its release from the ovary, the unfertilized egg can live in the woman’s body (in the Fallopian tube) for 24-36 hours. The human sperm which enters the female body after UPSI, has the capacity to stay alive for 2-3 days. This means that having an UPSI 2-3 days before or after ovulation (release of egg) can potentially cause fertilization. Even after fertilization, it takes another 2-3 days for the fertilized product (zygote) to attach itself to the uterus and begin to grow. (implantation) What are the available emergency contraceptives? Currently, oral pills (LNG or Ulipristal containing medicines) and Intra Uterine Contraceptive Devices (IUCD) are the methods being offered for EC. What are the LNG oral pills? And how should they be used? Often referred to as the ‘morning-after pills’ All of them contain the ingredient Levo Norgestrel (LNG).LNG causes alteration in the secretions of the cervix (Entry point to the uterus), impairs sperm transport and hence prevents fertilization. The total dose needed for emergency contraception is 1.5 milligrams. The medication must be taken immediately after the act and within 72 hours to be effective at all. If the formulation contains two tablets of 0.75 milligrams, then the woman may take one tablet immediately followed by another 12 hours later. However taking the entire dose (two tablets of 0.75 milligrams=1.5 mgms) at one go is slightly more effective than splitting the dose. What is an Ulipristal containing EC pill? At the time of writing (December 2012) Ulipristal containing medications are not available in India. Ulipristal not only makes the environment hostile for sperm entry but also inhibits ovulation. These EC pills contain 30 milligrams of Ulipristal and one tablet offers protection if taken within 120 hours (5 days!) of the UPSI, and irrespective of the number of exposure.

    What is IUCD? How are they useful as emergency contraceptives?

    The IUCD is more popularly known as Copper-T today. (The olden day Lippes’ Loupe and the current LNG-containing IUCD is not being referred to in this section) Actually the Copper-T is classified as a LARC (Long acting Reversible contraceptive) It may be used for a fairly long time contraception (3 or 5 or even 8-10 years). The copper it contains is capable of killing the sperms (spermicidal) and the fertilized zygote (blastocidal) function. Its physical presence inside the uterus may also prevent the implantation of the zygote. Copper-T inserted within 5 days after UPSI acts as an effective emergency contraceptive.
    Are there any other methods than LNG/Ulipristal or Copper-T? Yes. In case of a REAL emergency when LNG/Ulipristal pills are not available or Copper-t is unwanted, you could take the usual contraceptive pill that contain LNG (Total dose How successful are the emergency contraceptive methods? LNG containing pills prevent 95% of pregnancies if taken within24 hours of UPSI (84% if within35-48 hours and 58% if within 48-72 hours) Randomized control trials have shown that Ulipristal is as effective, Copper-T has the lowest failure rates, less than 1% and also the advantage that it can be continued as a LARC.

    What are the side-effects, contraindications and precautions?

    Though the ECs are relatively safe and are promoted as over the counter drugs (OTCs) it is always safe and sane to consult medical care givers before you use them, at least for the first time.Nausea and vomiting can occur. If vomiting occurs within 2-3 hours then you may need to repeat the dose for efficacy. As Yuzpe’s regime has high doses of estrogen, it is more likely thereMenstrual irregularity-Most women may have a normal period around the expected date. Some may experience prior spotting (LNG pills) and some may have an early period (Yuzpe’s) Ectopic pregnancy rates because of method failure may be slightly more than observed in the general population.
    If pregnancy occurs, then there are no documented fetal effects.There are conflicting reports of Ulipristal usage for more than once during a menstrual cycleThere are claims that no drug overdose or dependency (in the sense of drug dependency!) has been reported with LNG pills. The World Health Organization (WHO) says that the “repeated use [of EC] poses no known health risks,”The contraindications for EC are; pregnancy, geriatric age group (over 65 years). It must not be used as a routine contraceptive! Women are advised to adopt more comprehensive methods after the first EC itself! Follow up after using the emergency contraception.
    1. Remember that one dose of emergency contraception does not provide protection for the complete cycle.
    2. For victims of sexual assaults or UPSI with an unknown partner, it is important to undergo tests for sexually transmitted diseases (STDs) like HIV, Syphilis and hepatitis etc.
    3. Report to the doctor if you do not get your expected period eve by the end of a week.
    4. Report to the doctor in case of pain abdomen, spotting and giddiness-It could be symptoms of ectopic pregnancy.
    5. Do not forget to consult your doctor for detailed information about future contraception as emergency contraceptives are meant for emergencies only and not for routine use….!

    GENERAL ADVICE IN PREGNANCY-Working during pregnancy- It is safe to continue working during pregnancy.Standing for long hours and work involving heavy physical activity must be avoided Diet in Pregnancy

    1) reduce the risk of listeriosis by:

    a) Drinking only pasteurised or UHT milk
    b) Do not eating ripened soft cheese such as Camembert, Brie and blue-veined cheese. (No risk with hard cheeses, such as Cheddar, or cottage cheese and processed cheese)
    c) Do not eat pâté (of any sort, including vegetable Not eating uncooked or undercooked ready-prepared meals

    2) Reduce the risk of Salmonella:

    a) avoiding raw or partially cooked eggs or food that may contain them (such as mayonnaise)
    b) Avoiding raw or partially cooked meat, especially poultry. Exercise in pregnancyBeginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes. There are potential dangers in certain activities during pregnancy, for example, contact sports, high-impact sports and vigorous racquet sports that may involve the risk of abdominal trauma, falls or excessive joint stress, and scuba diving, which may result in fetal birth defects and fetal decompression disease. Sexual intercourse in pregnancySexual intercourse in pregnancy is not known to be associated with any adverse outcomes.

    Alcohol consumption in pregnancy

    1) women planning a pregnancy are advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage
    2) Getting drunk or binge drinking during pregnancy (more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.
    3) If women choose to drink alcohol during it must not be more than 1 to 2 UK units once or twice a week (1 unit= half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine= 1 to 1.5 UK units). Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.Smoking in pregnancyDiscouraged completely. Even Second hand smoking.Air travel during pregnancyLong-haul air travel is associated with an increased risk of venous thrombosis, although whether or not there is additional risk during pregnancy is unclearCar travel during pregnancyThe correct use of seatbelts (that is,three-point seatbelts 'above and below the bump, not over it').Travelling abroad during pregnancyIf you are planning to travel abroad, discuss considerations such as flying, vaccinations and travel insurance with your doctor. Nutritional supplements
    1. dietary supplementation with folic acid, before conception and
    a. throughout the first 12 weeks, reduces the risk of having a baby with a neural
    b. Tube defect (for example, anencephaly or spina bifida). The recommended
    c. dose is 400 micrograms per day
    2. vitamin A supplementation (intake above 700 micrograms) might be teratogenic and should therefore be avoided.Pregnant women should be informed that liver and liver products may also contain high levels of vitamin A, and therefore consumption of these products should also be avoided3. It is important to ensure adequate vitamin D stores during pregnancy and whilst breastfeeding.

    Medication:


    1) Few medicines have been established as safe to use in pregnancy. Prescription medicines should be used as little as possible during pregnancy and should be limited to circumstances in which the benefit outweighs the risk.
    2) Few complementary therapies have been established as being safe and effective during pregnancy and they should be used as little as possible during pregnancy.

    Pet care and Gardening:

    1) Avoid handling cat litter.
    2) Use gloves when gardeningHandling Babies/ ChildrenThe body fluid of babies and children below 5 years (saliva, nasal discharge, urine) are sources of cytomegalovirus. So be careful while handling them.

    Data To Be Soon Represented


    Dr. VasudevAnanthram - MD
    FACC is the Physician Practice Director and Attending Cardiologist at Caediovascular Health, Riverside Medical Group in Williamsburg, Virginia. His Practice includes invasive cardiology, Cardiac device therapy, nuclear Cardiology, echocardiography, Cardiac CT and vascular medicine. His passion is preventive cardiology and patient safety. Dr. Ananthram is also an expert contribuior to health tap which is a leading physician patient interface.











    ALL YOU WANTED TO KNOW ABOUT BLOOD PRESSURE


    What is blood pressure?

    Blood pressure, as most of us know, is designated by two numbers. Example as-120/80 The top number (120) or the systolic blood pressure (SBP) is the pressure in the blood vessels while the main pumping chamber of the heart is squeezing. This is dependent upon the volume of blood being ejected, the diameter of the blood vessels, the elasticity (or stiffness) of these blood vessels. The bottom number(80) or the diastolic blood pressure (DBP) is the pressure in these blood vessels while the pumping chamber of the heart is relaxing and is mainly dependent on the elasticity (or resilience) of the blood vessels. This seemingly simple explanation is however dependent on a complex interplay of a variety of chemicals in the body known in medical jargon as neurohumoral mechanism.

    Why should there be blood pressure?

    While pressure in the blood vessels is vital to bring blood to the various organs of the body, high blood pressure (hypertension) can cause over the course of time, damage to both the blood vessels and the various organs. This leads to premature aging of the blood vessels and organs leading to heart attack, stroke, kidney failure and poor circulation. Unfortunately most cases of hypertension are without symptoms and hence may be unrecognized and untreated thus lurking as a silent killer.

    How is Hypertension classified?

    Present guidelines classify blood pressure as noted below. The higher the blood pressure is over the normal limits, the greater is the risk of disease resulting from it. Normal blood pressure: SBP < 120 and DBP< 80 Prehypertension: SBP 120 to 139 and/ or DBP 80 to 89 Hypertension: SBP > 140 and/ or DBP > 90

    What are the implications of hypertension?

    Hypertension is a very preventable and treatable disease. Treatment of hypertension has enormous implications in decreasing the incidence of heart attack, congestive heart failure, atrial fibrillation (irregular heart rhythm), disabling stroke and kidney failure requiring dialysis. Hence the urgent need to increase public awareness.

    Why does one get hypertension?

    To answer this, one has to consider two types of hypertension.

    Primary Hypertension.-

    .Commoner type This is essentially due to a combination of genetic, environmental (unhealthy eating, lack of adequate exercise, high stress, obesity, excess alcohol intake, smoking) and age related factors which cause a lot of changes in the body. These changes include increase in the blood volume, hardening of the blood vessels, increase in the resistance of the blood vessels due to an excess of certain chemicals and a lack of others, and damage to the kidneys; all of which contribute to the development of hypertension. While there is not one correctable cause, a healthy life style has a favorable effect on these changes and helps improve blood pressure.

    Secondary Hypertension:

    It is less common and noted more in adolescents and young adults. There is usually one identifiable cause which when dealt with can result in curing the problem. Examples include primary hyperaldosteronism and pheochromocytoma (resulting from tumors and hyperactivity of adrenal glands); hyperthyroidism and hypothyroidism (over and under activity of the thyroid gland), hyperparathyroidism (over activity of the parathyroid glands), Cushing’s syndrome (overproduction of steroids in the body), coarctation of the aorta (narrowing of the main blood vessel leaving the heart) and renal artery stenosis (narrowing of one of the blood vessels of the kidneys). Infrequently these factors may also contribute to difficulty in controlling hypertension in the elderly.

    How is hypertension diagnosed?

    Blood pressure is a dynamic entity varying by as much as 25 points or greater between different measurements. Hanging the hat on one or two readings will either lead to over or under diagnosing the problem! Diagnosing hypertension in the doctor’s office usually requires several readings at different times. For instance, if a blood pressure of 140-159/ 90 to 99 is noted for the first time, the doctor will generally advice life style modifications and check the blood pressure several times over six months before starting medications. The situation however becomes more urgent if there are other significant risks for heart disease or if there is evidence of organ damage in which case the decision will be made much sooner. Blood pressures of 160-179/ 100 to 109 will be followed up sooner and decision about medical treatment will be made by the third visit (or immediately if other risk factors or organ damage is present) Blood pressure over 180/ 110 usually warrant starting treatment right away upon conformation of the reading over 30 minutes Similarly normal or pre-hypertension should be confirmed by periodic readings. Prehypertension requires effective life style modification and reassessment in 6 months to a year.
    Every year 10 percent of patients with prehypertension will convert to hypertension!
    White coat hypertension is a well recognized entity where in the blood pressure is abnormally high only in the doctor’s office and not elsewhere! This usually carries a good prognosis. In making this diagnosis your doctor will confirm the absence of any organ damage from high blood pressure such as kinking of arteries in your retina, absence of abnormal thickening of your heart muscle which is evident by an ECG and absence of any protein in the urine in addition to reviewing several out of office blood pressure readings. Masked Hypertension- Quite the opposite of white coat hypertension! It is encountered by solely relying on an office blood pressure reading. This simply means that the blood pressure reading in the doctor’s office was normal but other daytime readings are consistently higher. Thus the diagnosis of hypertension can actually be missed.

    What is home self blood pressure monitoring?

    To circumvent problems of blood pressure measurements in the doctor’s office, self blood pressure monitoring at home has comes very handy. In fact, it is well established that self- blood pressure measurements have a much better correlation with outcomes than office measurements. [Note: In doing self blood pressure monitoring, one should procure an instrument that is validated by AAMI (American Association for the Advancement of Medical Instrumentation). An apparatus which has memory makes it easier to track readings over time and obtain an average. One should be seated relaxed with adequate back support, feet planted on the ground and supporting arms at the level of the heart.
    The cuff should be properly applied following the manufacturer’s instructions. During the initial evaluation blood pressures should be checked twice a day for seven days. Day 1 which is usually higher should be discarded and the other blood pressure readings should be averaged. If the average reading by such measurements is greater than 135/ 85, aggressive life style modification and/ or medical treatment is generally warranted. If it is less than 135/ 85, a healthy life style and periodic assessment is generally sufficient in the absence of other compelling conditions. Similarly such average blood pressure readings by self monitoring can also help to check the efficacy of treatment. Please do not drink caffeine or smoke for half hour prior to the blood pressure measurement (better still do not smoke ever!)]

    What are the life style changes to be adopted?

    1. Positive life style changes are very much important in not only controlling blood pressure but also a host of other risk factors such as high cholesterol, diabetes and obesity.
    2. A diet emphasizing plenty of fruits and vegetables, whole grain, low fat dairy, low sodium (decreasing salt intake in half) was studied under the acronym DASH (Dietary Approaches to Stop Hypertension) and had positive effects in controlling blood pressure. Minerals such as calcium, potassium and magnesium are important in achieving good blood pressure control. However the results are forthcoming only when these nutrients were obtained thorough a wholesome diet rich in nutrients rather than concentrating on individual components. The sum of the whole is greater than its parts!
    3. Weight loss has been shown to substantially reduce blood pressure in overweight patients. Attaining an ideal body weight may be far fetched and disheartening for some obese patients. However studies have shown that maximal benefits can be obtained by shedding as little as 10 to 12 percent of one’s body weight. For instance a 300 pound individual can obtain maximal benefit by loosing 30 to 36 pounds which is very attainable by sustained effort. The benefits are far greater and longer lasting when this is achieved by healthy diet and exercise.
    4. Aerobic exercise for as little as 60 to 90 minutes a week at a comfortable level has been shown to lower blood pressure by an average of 12/ 8 points. This is easily done even by those hard pressed for time
    5. While alcohol in moderation (such as one drink a day for women and one to two drinks a day for men) may have beneficial effects, excessive alcohol intake is counterproductive and results in difficult to control hypertension, high triglycerides and obesity. Hence excessive alcohol intake should be avoided. Needless to say, smoking should be entirely discarded (decreasing rather than giving up smoking entirely has not shown to reduce the risk of heart disease or stroke).
    6. Sleep apnea characterized by disturbed sleep, excessive snoring, day time sleepiness and fatigue can result in resistant hypertension. It is important that this is recognized and treated not only to improve blood pressure control but also to avoid a host of other complications. It is important to inform the doctor about any of these symptoms.
    7. Ultimately, in order to achieve good blood pressure control it is important to take the prescribed medications properly and persistently. Discussion with the doctor about any problems causing nonadherence to treatment either due to cost, complexity or side effects is important. There is quite an array of medications available to allow tailoring appropriate regimen for most patients.

    IS MY CHEST PAIN SERIOUS?

    Q: How do you tell the difference of chest pain between a heart attack and other causes?

    Chest pain due to heart problem is called Cardiac pain and that not due to the heart is non-cardiac pain. There is no fool proof way to distinguish between these two conditions by symptoms (Patient’s complaints) alone. It merits evaluation by a health care provider and even further diagnostic testing in order to rule out the life threatening causes of chest pain. Angina: Chest pain of cardiac origin is most frequently a result of an interruption of blood flow to the heart due to a partial or complete blockage of the coronary arteries (blood vessels that supply blood and hence nutrients and oxygen) This type of chest pain is called Angina. If the interruption of blood supply is gradual and partial, it results in a less threatening condition called stable angina. If on the other hand the interruption is sudden and near complete or complete, it results in a life threatening condition called unstable angina or a heart attack.
    Anginal pain is usually described as chest heaviness, pressure, tightness, constriction, burning or an ache. It is usually diffuse and hard to pin point one area as the site of pain and is typically provoked by physical exertion, emotional stress, or cold exposure. It may commonly radiate to the neck, jaw, back, shoulder and arms. In stable angina, paint is commonly relieved within 2 to 5 minutes of resting. However if the pain is gradual in onset but worsens progressively to a point of being relentless may be associated with symptoms such as profuse sweating, cold clammy sensation, shortness of breath, nausea, vomiting and a sense of doom. This may be life threatening unstable angina or heart attack.

    What are other life threatening causes of chest pain?

    1. Aortic dissection:

    Aorta is a major, large blood vessel that arises from the heart.Aortic dissection means a progressive tear in the aorta. Aortic dissection is usually associated with an intensely severe chest and/ or back pain of sudden onset often described as a tearing or ripping sensation.

    2. Pulmonary embolism

    In Pulmonary Embolism, a blood clot lodges in the lungs causing sudden shortness of breath and chest pain on either side of the chest which may worsen on breathing. The life threatening causes of chest pain require immediate medical attention. Hence any acute and previously undiagnosed chest pain lasting greater than 5 minutes calls for emergency medical attention to rule out these conditions. Non-Life threatening, non-cardiac chest pain Acid reflux Known in medical jargon Gastro-Oesophageal Reflux Disease (GORD) is the most common non cardiac cause for chest pain. It is important to exclude cardiac and other life threatening causes while making this diagnosis. Symptoms can be hard to differentiate from cardiac chest pain since the heart and the esophagus share common nerve supply and hence can produce similar symptoms. Pain can last from a few minutes to a few hours, usually intense at onset and easing gradually, may occur after eating or when lying down. It might even waken someone from sleep! It may or may not be related to exertion, may be provoked by bending or stooping. It causes regurgitation of stomach contents and a burning sensation in the middle of the chest. It may be associated with difficulty swallowing and may be relieved with antacids.
    Once cardiac condition is excluded it may be treated with a high dose of acid suppression medications for 6 to 8 weeks. Relief of symptoms commonly confirms the diagnosis. If still unrelieved other tests may be required such as ambulatory esophageal pH monitoring to evaluate the acidity of the esophagus, manometry to look for abnormal esophageal contraction and endoscopy to rule out conditions such as ulcers, infections or tumors. There are still umpteen other less common causes for chest pain. But the most immediate concern is to rule out the life threatening conditions which require prompt medical evaluation. In conclusion, though all cheat pain may not be cardiac pain, no chest pain is trivial enough to be ignored!!.

    Author : Dr. Vasudev Ananthram - MD, FACC


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    INTRODUCING PLASTIC SURGERY


    Author : Dr Satish H V,

    Plastic Surgery is always a mystery to the public.

    The word plastic denotes the ability of the plastic surgeon to mould tissues the way plastic can be moulded to various shapes. There is no better word for this and therefore the name. Plastic Surgeons use many of the ‘normal’ surgery instruments. The difference however, is in the planning of the steps, the meticulous care and utmost skill in execution of the surgical procedure and the patience and perseverance to try and achieve perfection each and every time. Unlike public perception, Plastic surgery is more than skin surgery. Plastic surgeons deal with skin, fat, muscles, arteries, nerves and a few bones too. And with all parts of the human body! There is no regional limitation (head/ chest/hand etc.) unlike other branches eg. ENT, Eye surgeon, Head and neck, Gyneacology etc As our understanding has increased and diagnostic modalities have become more accurate and sophisticated; plastic surgery today is vastly different from what it was earlier. Using knowledge and technology, the scope of Plastic surgery is truly varied and wide.

    Sub specialties of Plastic Surgery are:

    1. Reconstructive surgery:

    This deals with replacement of lost tissue or function, often by using body parts for overcoming the problem. Loss of tissue may occur following trauma (injury) or cancer etc. The challenge is to tailor the treatment and surgery to suit the need of the patient – restore shape, restore movement etc. It can range from repairing a damaged fingertip to restoring its form, repairing a badly injured hand and replacing skin, tendon etc; repairing blood vessels, nerves etc . Diabetic wounds leading to loss of tissue may also be corrected in this way. This constitutes 40% of a plastic surgeon’s work.

    2. Paediatric plastic surgery:

    Deals with correction of defects that a new born may be born with. The commonest is cleft of the lip and palate. Abnormalities in the hand (fused or extra fingers etc), blood vessel tumours in the face, birth marks, large swellings, deformed ears etc can all be corrected.

    3. Cosmetic surgery:

    Deals with a voluntary need for a change in external appearance in a healthy patient. Most people believe plastic surgery means only this! But this makes up for only 20% of a plastic surgeon’s practice. It might be the navel, breast, nose…and any other part of the body that catches the fancy of people who think they want it changed! This is hence an expanding branch which moves forward with public imagination!

    4. Burns :

    When a patient who has suffered burns escapes out of the horror alive, his/her skin is as scarred as the psyche! One of the main problem in burns is loss of skin with subsequent scarring . Correcting this and replacing the skin (skin grafting) is the solution.

    5. Microvascular surgery:

    Many a times, we get patients who have had an accident and a finger or even a limb has been cut off. Attempting to suture the severed organs is a challenging and time consuming surgery, not to mention the technical finesses involved in it. Small blood vessels of 1-2 mm and small nerves must be aligned and sutured together so that life and function is restored to the severed organ. These are repaired using a microscope. Tissues in our body can also be shifted from place to place using this technique.

    You need to know that: Plastic surgeons do not use ‘plastic’ during surgery as some people imagine! We try to use the body’s own tissues as much as possible as we believe nothing can replace the natural tissues in our body! Sometimes we may use ‘implants’ which are made of different materials. Plastic surgeons cannot perform scar less surgeries. Nobody can. Scars will always occur when skin is cut. It is nature’s way of healing a wound. Plastic surgeons can only try to hide it or make it as inconspicuous as possible so that the scar does not look ugly. The final results of such also depends on the ability of the body to heal normally and hence may vary from person to person. Plastic surgeons cannot and have never ‘changed faces’ by putting skin from the thighs! The skin on the thigh is dark, grows hair and has different patterns as compared to facial skin. How could an aesthetic surgeon imagine such a blatant disregard of tissue nature? In fact, even on the face the nature of skin differs from forehead to nose to cheek to chin! Skin graft to the face is a last choice, if at all! Plastic surgeons even stitch the skin with utmost care and love! We use fine suture materials that will not leave any mark. We also sometimes use ‘gum’ or ‘tapes’ Plastic surgery is not always expensive. The experience, skill, duration and the special materials contribute to the cost. Some surgeries take 8- 10 hours to perform. They require a high amount of skill. Patients expect only the best results from us and will not accept any problems easily. All these are needed to meet the expectations of the patient! There are 2100 plastic surgeons in India. Compared to the need for this speciality, there is a severe shortage of Plastic surgeons especially in all non tier 1 cities.

    What you need to ask when you meet a plastic surgeon

    • What is the diagnosis or the problem in this person?
    • What is your solution for this?
    • What are the alternatives to this?
    How do the results of different methods compare in terms of Time for healing/ Final outcome/ Cost In which method are you most sure that the result will be good? Can you show me photographs of similar problems and their outcomes? What if the outcome is not as expected? Are there any ways to salvage the situation? These are exactly the same issues that we focus our modalities of treatment on. P.S: A plastic surgeon is a super-specialist. His basic training of MBBS is followed with specialization in General Surgery (MS) and then the super-specialization in Plastic surgery (M Ch) Thus the plastic surgeon may have trained for 12 years before acquiring a Plastic surgery degree. Author : Dr Satish H V - MS. DNB, M Ch, DNB. Nose reconstruction following a injury using a ‘Indian forehead flap’

    This is the first plastic surgery procedure described in the world. It was described more than 2000 years ago by Sushrutha, the eminent surgeon. Ptosis – sleepy eye - correction
    Some people have weak muscles in their upper lids and their lids droop. This can be corrected by a surgery. Filling up depressions with fat.
    When there are depressions in the face, such as in this lady who had it from birth, her own fat was used to fill it up. The color too improved, bringing a smile in addition! Cleft lip –before and after…
    A common birth defect that leaves the parents in shock. Surgery can restore a ‘normal’ appearance to these kids. Correction of prominent ears
    When the ears are more prominent, it attract comments . This can be easily corrected and a better position achieved. Surgical Management of Facial lesions

    Case 5: Digital nerve neuroma


    This vendor has severe pain in his palm and had eaten tablets for months. He had a old nerve injury that had healed badly leading to severe apin whenever he gripped any object. Using microsurgical techniques, this nerve was identified, trimmed and repaired. This not only treated his pain, but partly restored his sensation also. Doctor can you change my face? Every Plastic surgeon has faced this query. The answer is yes and no! What makes people happy/unhappy about their face? Is it the color, the shape or glow etc? A major factor is the symmetry of the face. Facial proportions play a large role in making a face acceptable. In a crowd we always tend to glance a second time at people with blemishes. A prominent jaw, unequal eyes, large nose are instant magnets for the eyes. This manifests itself as ‘something is wrong, your lips are big, you don’t have a nose’ comments. We also have what is called a ‘body image’. The mental image is the picture of our face we see, when we close our eyes. If the mirror does not show our ‘mental image’ we feel uncomfortable. Sometimes other problems (career or relationship failures) get linked to this perception and dissatisfaction multiplies. What does the Plastic surgeon see? We look for overall proportion of the face first. We look for structural problems like large bones, bones that are not in place or bones that are displaced. We then look for the covering tissue – muscle/ fat and skin. We then have to decide which of these may be causing the dissatisfaction and then offer solutions.

    Can we actually change the full face?

    Technically-NO. The face has a combination of tissues which are themselves different. Such as: skin of different textures/ characters – forehead : horizontal lines; nose: thick and oily; eyes : thin and fine lines, differing fat content - lots on the cheek , less elsewhere, nil in lids Muscles (thick on the jaw and thin elsewhere). These are not replaceable with tissues from elsewhere in the body. Bones which are multiple pieces that are linked to each other -The eyes are supported by the bones; the nose shape is largely dependent on this; the teeth are fixed to bone and any change in bone will have an impact on chewing. Any surgery will have to take all this into consideration.

    What can be changed?

    The nose: its height, projection and the shape of the tip can be changed. Changes to the width of the lower part of the nose are more difficult in the typical Indian skin that is thick and oily. The ears – projection can be decreased if prominent. The eyes – wrinkles can be removed, sleepy eyes can be corrected, bulges reduced. The lips – can be made thicker or thinner The jaw and chin - can be made more or less prominent by moving the bones. They can also be changed by adding tissues or implants. The lower half of the face can also be changed by reducing muscle thickness. Forehead wrinkles, age relate wrinkles, skin sagging and drooping eyebrows can be corrected Dimples can be created on the cheeks, moles removed and scars reduced. Thus many changes are possible and a combination of these will change the face! Psychological issues Any facial surgery carries the risk of long term psychological problems. If the request for change is made by a person on whims, that person is likely to be unhappy after the change. In case a Plastic surgeon feels that the request is not rational, he/she may ask for a psychiatric evaluation. None of these surgeries are instant magic. After every surgery, we have to wait for a minimum of 3 months for the results as the swelling reduces, scars become softer and skin shrinkage occurs. Poor results Not every surgery will lead to full patient satisfaction. Studies in USA have shown that 25% of those who undergo nose surgery are unhappy with the results. A patient must be mentally prepared for this. Also, some people are unhappy even with a good result, because their colleagues/friends did not approve of the result (you were better before!)

    What you need to clarify before surgery?

    Write down your desires/ requests and make sure the surgeon has understood them. Poor communication can lead to unwanted changes! Ask for results of similar procedures. Remember that you may not get the same results as shown to you. Make sure you have discussed all alternatives and risks. This will help you prepare for the surgery What of the result is not good? What will the surgeon plan then? Remember, every surgeon tries 100%, but the result may not always be perfect. Repeat surgery cannot be free and you must be aware of this. What is the recovery period? Some operations will lead to more swelling/black eye and may take a month to resolve. FINALLY Cosmetic surgery is a fine balance between changing what should/can be changed and what should be left alone. The surgeon’s skills, the reaction of the body and the perception of the patient should all synchronize for a good result. That’s the art and science of Cosmetic surgery Author : Dr Satish H V
    Scar that was deforming the eyes was revised and reduced . The eyes are back in position . Scar remov l operations donotexist . We can reduce and manipulate scars for betterresults The nose shape has been changed from a low and depressed to a prominent one with a shaper tip . This adds a new dimension to the face and loads of confidence too ! When the ear projection is reduced the face seems more harmonious . The lips thickness can bevaried . In this person , who felt the upper lip was too thick it was reduced . If it i stoothin , then it can be made thicker with injections of fat or of other safe material . Hand surgery Our hands are our source of daily bread. Yet they do not get the recognition of the heart, the brain or the kidney. They are marvels of engineering and as of today no one has been able to replicate even a part of the functions we effortlessly perform. When we pick up food with our hands,we are actually doing a complex job. As we touch the food, we are assessing temperature and softness. As we tear a piece of chapatti, we are stabilizing one side, and pulling on another side( opposite movements) in a controlled way, with one hand. As we gather it we are squeezing the fingers depending on the amount of liquidity. As we lift up the hand we don’t ‘see’ our mouth, but our hand heads straight for it. 30 bones, more than 20 joints, 50 muscles and 3 nerves work in seamless harmony to provide a movement in multiple axis. What a wonderful symphony!
    The part of the hand beyond our wrist, is the most complex area. The skin is thick on the front, and yet is among the most sensitive in the body. It has separate sensors for heat, touch, vibration and pain. It has sweat glands but does not have oil glands. It has special layer to keep it firmly anchored so that we can grip well. As we move to the tip, the number of sensors ,increase, especially in the thumb.+ The bones in the hand are narrow and are meant for mobility and suppleness. The joints are strong and allow movements easily. Take a look at your thumb. It can move in 3 different axis – in and out, up and down and rotate to face the fingers. Yet it is strong enough to resist pull and delicate enough to pick up a hair! There are 12 long muscles to fold your fingers, 11 long muscles to straighten them. In addition there are 4 short muscles for your thumb, 3 for the little finger and 12 for the 4 fingers. The total is an amazing 42 muscles. Yet they are superbly co ordinated. When you fold your fingers , the straightening muscles relax synchronously . Signals at the speed of light fly back and forth controlling the muscles and providing feedback. And yet we do it ‘effortlessly’!
    When we have such a complex structure, leading our effort to work, they are more prone to injuries and disease than most other parts of the body. They actually contribute to 40 % of all injuries to the human body. Yet, many people are not sure whom to approach when they have a hand injury. Orthopedic surgeons are often a natural choice. By nature a majority of them are focused on the bony part and may not focus adequately on the other structures. Thus was born HAND SURGERY.
    A hand surgeon , in India , is more likely to be a Plastic Surgeon. Equipped to deal with all challenges a Hand surgeon can with equal ease fix the small bones, re align joints, repair nerves and arteries using a microscope, stitch cut tendons and ensure good function, stitch or replace lost skin to allow for fast healing and achieve the goal of ‘ functional restoration’. Finger tips are often injured in a closing door or with a running motor. Skin is lost, bone may be crushed and the nail may be ripped off. Dressings are only occasionally the answer. A precise repositioning of the nail tissue, shifting skin from a less important part or from an adjacent fingers , may be needed. The goal is to enable a finger tip that can painlessly grip objects. Industrial injuries and sharp objects damage multiple structures at the same time. It is easiest to repair them the first time. Knowledge and experience will ensure that this happens. The complex repair is however only the beginning of the journey. Often, the repaired fingers are stiff and immobile. A good surgeon will guide the patient in physiotherapy. The result is gauged more by the function and less by appearance.
    Replantation is another area of great importance. When a part of the limb is cut off, it can be re attached. This depends on the level of the injury , the amount of damage to the part and the time interval. There is no universal rule and this is a judgment of the surgeon involved. Return of function can take time, but this procedure is undoubtedly a revolution in managing amputations. Even ‘small’ problems in the hand can cause major inconvenience. A swelling can be attached to an important nerve. It is then important to separate the two and not damage the nerve. Numbness in the hand in software companies, stiffness in elderly people, deformity with arthritis, disability in children with spasticity are all areas that can be improved with surgery. Hand surgery is a growing speciality and one with practical application to the society. Restoring a working hand is an invaluable contribution to the family of these bread winners. This is a role not commonly associated with Plastic surgeons!
  • Patient experience is a priority..
  • Complexities of finger injuries.

  • This is an injury caused during sports – Mallet finger. Unable to straighten the tip of the finger, but can fold with pain
  • Result of an accurate repair of this tendon showing ‘normal’ movement.
  • Nerve repair needs high magnification for accurate repair. Only the outer covering layer of the nerve can be held or stitched. The stitches are much thinner than human hair. This is a nerve in the wrist area – Median Nerve.
  • A combination of extra fingers and fused fingers. The surgery is ideally done before 1 year of age, so that the child can use the hands ‘normally’ from 1 year of age. It is more than just splitting the fingers. Often structures are missing/ fused and blood supply may be insufficient. Yet it is an ‘essential ‘ surgery. This is a child with polysyndactyly. The child 6 years later. She can separate all fingers and write well too…

    Dr.Roopa
    Professor & Head Dept. of oral pathology
    M.S.Ramaiah Dental college & Hospital










    EAT YOUR WAY TO A SPARKLING SMILE…..!

    A million dollar smile doesn’t cost much…not until you take care. It comes with healthy food and a few good habits. Although there is a lot of awareness on good habits for general hygiene, little is known on how food habits affect your smile!

    How does food affect my teeth? What food is good for my teeth?

    Foods that protect and strengthen the enamel (outer layer) on your teeth and foods that check the release of acid in the mouth are obviously helpful.

    What foods are harmful to my teeth?

    All your favorite fast foods - pizzas, sweets, chocolates, soft drinks, canned foods fare badly when it comes to building your oral hygiene. All these cause release of acid by bacteria in the plaque causing gradual wearing of the enamel, cavities & tooth decay. It also leads to increase in intestinal secretions leading to a craving for more.

    How do I make my teeth healthy?

    1. Check your consumption pattern. Are you eating burgers, pizzas or chocolates too often ? Is your favorite celebrity’s soft drink eating away your teeth ? Are my habits for smoking & alcohol to be ‘IN’ with my peers is making the way ‘OUT’ for my teeth?!!!
    2. Replace your fast foods gradually with more healthy foods like fruits and fruit juices.
    3. Alcohol and Cigarettes are a strict ‘No’.
    4. Try these on your own for 3 weeks. Good habits are said to be built in 21 days if you focus on it.
    5. If you do not see improvement in your oral hygiene, it is time to see your dentist.
    6. If you still sense a strong craving for candies & burgers, check the ingredients in your foods for any inactive ingredients which makes you addictive to it. For example people who love coffee; though milk is a nutritious food, caffeine act as an addictive.
    7. Craving for salty foods like pickles, chips and chats indicates altered functioning of certain glands and deficiency in iodine or potassium or even fluid imbalance.

    Ageing gracefully !!!

    As you grow older, your teeth grow old too…so age gracefully !!! The elderly face challenges with their teeth: Staining, tooth sensitivity, gum disease and bone recession(shrinkage), to name a few. Proper and timely care can check common problems faced by them. A strong set of teeth is essential to maintain our general health and for a confident & graceful ageing.

    Staining

    Teeth darken in color as a result of staining. The stains are usually brown, yellow and orange, or combinations of these colors. Pigments in food, tea, coffee & smoking causes staining. In cases of extensive staining, nerves and blood vessels of the teeth die, making teeth grey or black. Some antibiotics taken over long periods can also stain teeth grey.

    Tooth sensitivity

    Teeth become sensitive to hot, cold and sweet foods and drinks which then causes pain.- This can be caused by teeth wearing down as a result of old age, due to faulty tooth brushing & loss of tooth structure due to exposure of tooth to acids like carbonated soft drinks & vinegar used as preservative in pickles.

    Gum disease

    Gum disease causes gum recession or shrinkage which results in its loosening its original attachment to the tooth. The gum then re-attaches itself to the tooth at a lower level making the tooth look longer. The gums will now bleed easily, and the teeth will become loose.

    Bone recession (shrinkage)

    Gum disease, if left untreated, will lead to bone loss around the teeth. The tooth loses its supporting bone, and becomes loose. This will lead to a condition called periodontitis.

    What can you do to ensure a healthy mouth and teeth as you get older?

    1. Chew your food well to ensure a healthy flow of saliva.
    2. Good oral hygiene and regular visits to your dentist should allow you to keep your teeth and gums in good condition.
    3. Make sure that you continue to eat a balanced diet.
    4. Cosmetic dentistry can provide older people with attractive and natural-looking tooth replacements.
    5. What if you wear dentures? Here are some tips on dentures:

      Dentures should be taken out of the mouth every night, and cleaned with a soft brush or a denture brush. Full dentures will benefit from being left overnight in a soaking solution. Soaking solutions can remove plaque, tartar and stains. Dentures must not be left to dry out. With time, the gums and bone shrink, and dentures may loosen. Denture fixatives or adhesives can help to improve the firmness of dentures. Fixatives help the wearer to adjust to new dentures. Do not use denture fixatives to keep old, ill-fitting dentures in place. This can cause injury to the gums.
      Dentures can be relined or rebased to improve the fit. New dentures need to be made when the changes in the gums and bone make the dentures too loose. This is done by any dentist. Never self adjust the dentures on your own.

      Expecting mother?-Watch your gums and teeth!

      Pregnancy is a period which instills a sense of responsibility in women. It makes her feel complete as a woman as she prepares herself for the new motherhood. During this period there are certain hormonal changes in her body which can be reflected in her mouth. It is easy and commonplace to take your oral health for granted during pregnancy but taking good care of your mouth can prevent disease in them and through out the body.

      What are the commonly noticed changes during pregnancy?

      • Bleeding from gums during brushing—gingivitis
      • Presence of lump or growth over the gums—Pregnancy tumor
      • Increased incidence of tooth decay.
      • Wearing out of tooth surface due to repeated vomiting—Erosion of teeth
      • Dryness of mouth and bad breath.

      Changes in gums during pregnancy

      During the second and eighth month of pregnancy the gums can be affected because of variation in hormonal levels. It can range from simple reddened gums to severe swelling and bleeding. When you notice a glistening red colored lump which bleeds or causes discomfort while eating or speaking it can be a pregnancy related growth known as “Pregnancy tumor” which may occur anytime during pregnancy but most likely seen between fourth to sixth month.

      Tooth decay and pregnancy

      Due to craving for sweet and certain unusual changes in diet, pregnant women are more likely to suffer from tooth decay if the oral hygiene is neglected. Wearing out of tooth surface Suppose you notice loss of tooth surface usually in the inner side of the teeth it is because of increased vomiting during pregnancy. The acid released from the stomach leads to wearing away of tooth surfaces, thus increasing tooth sensitivity. Dryness of mouth and bad breath The infection in gums, decreased quantity of saliva and poor oral hygiene might make you prone to bad breath. Decrease in saliva content can also increase the risk of tooth decay. How to get rid of these problems?
      Practicing strict oral hygiene methods is the key to prevent most of these changes which include:-
      • Brushing twice a day.
      • Use of floss which is an inter-dental aid to remove deposits in-between the teeth.
      • Using antimicrobial mouth rinse regularly.
      • Cut down on sweets and other sugary snacks.
      • Regular dental check up.
      • Pregnancy tumor usually disappears on its own after the baby’s birth, however if the lump interferes while eating, your dentist might choose to remove it. Remember!! Never do anything on your own to get rid of it.!

      When is the right time to visit your dentist?


      Try to have complete dental check up prior to or very early, during pregnancy. Treatments are most dangerous during the first three months of pregnancy as it can affect the development of the baby. The dental chair position may be uncomfortable if treatment is done during the last three months of pregnancy. Therefore all needed dental work should be done before pregnancy or between the fourth and sixth month. If you haven’t already, start practicing good oral hygiene and eating a healthy diet. “Visit your dentist regularly and welcome the new born with a bright smile” NURSING BOTTLE CARIES The cavities baby!!

      “Why fill up baby teeth? Aren’t they going to fall off anyway?” It is a common misconception among some parents that their child’s “milk teeth” aren’t important because they do not last forever. The fact is that children use milk teeth for more than just chewing. They play an important role in the proper development and alignment of permanent teeth and to the development of speech and self esteem.
      About 5% to 10% of young children have early childhood caries also known as ‘baby bottle tooth decay’ or ‘nursing bottle caries.’ It is the presence of one or more decayed surface in a baby tooth in children under three years of age. Symptoms are white spots or early development of cavities (brown areas on teeth). This is a very devastating type of tooth decay for the young patients, their parents, and the pediatric dentist.
      The milk teeth are softer than permanent teeth because of which they decay more easily. This being not so attractive a condition, is also painful and may be one of the reasons why your baby won’t stop crying. The teeth most prone are the upper front teeth. Lower teeth are in general less affected since they are covered by the tongue.

      What causes Nursing bottle caries?

      Nursing bottle caries is caused in bottle fed infants due to prolonged & frequent exposure of teeth to sweetened liquids (milk with sugar or honey ) which combine with normal bacteria (germs) to produce acids and dissolve the hard protective coating of the tooth. The worst damage occurs when a child is given a bottle at bed time as there is lesser saliva produced at night. Many sweetened medications are capable of producing tooth decay.A favorite trick among parents is to thicken vitamin syrups with honey or other sugar syrup to ensure long feeding. The pacifier dipped in honey is another bad habit. Honey needs to be avoided in the first year of life.

      How can you prevent nursing bottle tooth decay?

      Do not put your baby to bed with the bottle filled with anything but water or preferably a clean pacifier. Wipe the gum pads with a damp cloth after each feeding. When the first teeth appear; begin good early mouth care with a soft baby brush or a finger tip. Examine their teeth by lifting their lip to look for decay on the outer and inner surface of the upper front teeth once a month. Wean your child from the bottle in a timely manner. Reduce frequent sugar consumption. If the drinking water does not have fluoride, supplement with fluoride as recommended by a child’s physician or dentist. Have early dental visits for your child. Early childhood caries, if left unchecked, can lead to infection of the underlying bone and early tooth loss leading to long term dental problems, not to forget the extensive and expensive dental treatment which may be required later on. So take care of your baby’s milk teeth.

      Author : Dr Roopa S. Rao

      Professor & Head
      Dept. of oral pathology

      M.S.Ramaiah Dental college & Hospital
      New Bel Road, Bangalore
      E-Mail Id:drroopasrao1971@gmail.com
      Mobile- 0888583689
      .

    BRAIN FACTS



    Statistics:

    • The modern human brain weighs 3 pounds (1.36 kilograms)
    • However, 5,000 years ago humans had brains that were even larger! Maybe it evolved and got slimmer to be more efficient or maybe our skulls are getting smaller because our diets include more easily chewable foods and so large, strong jaws are no longer required.
    • Whatever the reason; thankfully, the brain size doesn't directly correlate with intellect! The weight of Albert Einstein’s brain was 1,230 grams and that is less than an average weight of the human brain!

    Anatomy

    • The human brain boasts of 100 billion neurons (nerve cells) and 100,000 miles of blood vessels! The number of neurons is maximum at six years of age though everyone has almost the same number at birth. Brain develops from ectoderm (outermost covering of a developing embryo) this makes skin, hair and lens its siblings!!
    • The brain surface is wrinkled into folds (gyri and sulci) and these increase the surface area and thus, more processing power gets packed into the limited confines of the skull. The Cerebro Spinal fluid (CSF) surrounds and bathes the brain while coverings called the Dura, Pia and Arachnoid Mater ensheath it.
    • The brain is actually a fatty organ because it is rich in lipids! The living brain is so soft you could cut it with a knife. Some compare the consistency to toothpaste but I guess the ‘tofu-like’ comparison is the nearest!
    • The brain is a recluse! There exists a BBB (blood-brain barrier) which bars any and every molecule from having a free entry into the brain tissues! The capillaries that feed the brain are lined with tightly bound cells, which keep out large molecules. This is at once protective and inconvenient because for any drug to reach the brain, it must have the capacity to cross the BBB!

    Physiology

    Brain hogs energy! 20% of oxygen and 25% glucose in the circulating blood go to the brain! It is so sensitive that it cannot survive for more than 4-6 minutes without oxygen/blood supply. Most times death of a brain cell is permanent. For all its sensations, the brain is pain insensitive! However the coverings (Dura, Pia, arachnoid) have pain sensors and are capable of pain!

    Functions

    • It is a myth that humans only use 10% of their brains. Each part of the brain has a function. However all the functions of the Frontal lobe (the foremost part of brain) have not yet been completely charted.
    • The brain is much more active at night than during the day!
    • The brain operates on the same amount of power as 10-watt light bulb!
    • Generally, the left half of your brain (left hemisphere) controls the right side of your body; and, the right half (right hemisphere) controls the left side of your body. Processing of information in the brain depends on the type of neuron. It can be processed as slowly as 0.5 meters/sec or as fast as 120 meters/sec!
    • The average number of thoughts that humans are believed to experience each day is 70,000. The Hypothalamus in the brain is the thermostat for our body which keeps us at 98.6 Fahrenheit (37 degree Celsius). Shivering and sweating are the mechanisms through which this is maintained!!
    • Brains never stop changing! It is now a myth that once you are an adult, the brain stops making new connections! Aren’t you glad? Keep exercising your brain, because mental activity stimulates the creation of new neurons throughout your whole life. New connections are created each and every time you remember something or have a new thought.
    • The human brain can hold 5times as much information as the Encyclopaedia Britannica! Scientists have yet to settle on a definitive amount, but the storage capacity of the brain in electronic terms is thought to be between 3 or even 1,000 terabytes!!!Remember that!

    HEART FACTS

    Anatomy:

    The human heart weighs less than a pound. It is about the size as two fists for an adult and one for a child. Most people think the heart is located on the left side of the chest while in reality, it is placed exactly in the centre just behind the breast bone (sternum) However, it is so tipped that a part of it (apex) taps on the left side of the chest. Owing to the placement of the heart, the left lung is smaller than the right. The heart begins beating at four weeks after conception and does not stop until death! The human heart is four chambered. It has 2 atria (Atrium-singular) which are smaller chambers and which communicate with corresponding 2 ventricles, which are larger chambers. The right half (Atrium and Ventricle) carries impure blood (De-oxygenated) and the left half (Atrium and ventrilce0 carries pure (Oxygenated) blood.
    The SVC (Superior Vena Cava) and IVC (Inferior Vena Cava) collect impure blood from the body and drain it to the heart. (to Right Atrium) The aorta and the Pulmonary artery are two major vessels that lead off from the heart from the left ventricle and the right ventricle respectively. The aorta is the largest artery in the body, is almost the diameter of a garden hose and carries pure blood to the whole body. The Pulmonary artery carries impure blood from the right ventricle to the lungs and the Pulmonary veins transport the purified (Oxygenated) blood from lungs to the heart (to Left Atrium) The capillaries are the most distant, end-vessels from the heart and are so small that it takes ten of them to equal the thickness of a human hair. The human heart is actually a very clever and efficiently designed bundle of specialised smooth muscle fibres (Cardiac smooth muscles) .Even at rest, the muscles of the heart work hard—twice as hard as the leg muscles

    Statistics:

    The average adult heart beats 72 times a minute; 100,000 times a day; 35 million times a year; and 2.5 billion times during a lifetime. The fetal heart rate is approximately twice as fast as an adult’s, at about 150 beats per minute. A woman’s heart typically beats faster than a man’s. (78 beats per minute versus 70) In a lifetime, the heart pumps about one million barrels of blood which means 2,000 gallons of blood through 60,000 miles of blood vessels each day. This supplies 75 trillions of body cells! By the time a fetus is 12 weeks old, its heart pumps an amazing 60 pints of blood a day.
    The cornea is the only organ in the body that does not receive any blood supply. The volume of blood pumped by the heart varies from 5-30 litres/minute. The speed of blood at the aorta is 1.6kms/hour and in the capillaries, 109cms/hour. Five percent of blood supplies the heart, 15-20% goes to the brain and central nervous system, and 22% goes to the kidneys. Human body has about 5.6 litres which circulates through the body three times every minute. In one day, the blood travels a total of 19,000 km!

    Functions

    The heart generates its own impulse form the SA node (Sino-atrial node ).Because the heart has its own electrical impulse, it can continue to beat even when separated from the body, as long as it has an adequate supply of oxygen. The lub-dub of a heartbeat is the sound made by the four valves of the heart closing. The heart does the most physical work of any muscle during a lifetime. The power output of the heart ranges from 1-5 watts.
    An adult has 4.5-5.5 litres of blood in circulation while a newborn baby has about one cup of blood. Blood is actually a tissue. When the body is at rest, it takes only six seconds for the blood to go from the heart to the lungs and back, only eight seconds for it to go the brain and back, and only 16 seconds for it to reach the toes and travel all the way back to the heart.!

    Diseases of the heart

    Congenital heart diseases are those where the defect of the heart is present from birth. It could be a hole in the heart (ASD-atrial Septal Defect/VSD Ventricular Septal defect), Abnormal connection (PDA-Patent Ductus Arteriosus) or abnormal anatomy (TOF-Tetralogy of Fallot/TOGV-Transposition of Great vessels), Valve malformations( Bicuspid valve/ Prolapse) etc. Acquired heart diseases are those that develop during the course of our lives. Eg.Valvular heart diseases (Mitral/Aortic stenosis), Coronary heart disease, CCF (Congestive Cardiac Failure), Infections (Pericarditis/Endocarditis) etc.
    Coronary artery disease is due to atherosclerosis, or hardening of the arteries that supply blood to the heart. A progressive build-up of cholesterol plaque in the arteries might completely block them one day.
    There is a 1 in 3 chance that your first heart attack will also be the last! 35% of all acute heart attacks are fatal. Half of these deaths are SUDDEN and will occur within one hour after the onset of chest pains. But contrary to popular belief, there may be no warning signs weeks before a heart attack occurs. 70% of heart attacks have NO warning Symptoms.

    Classic warning signals of a heart attack

    Uncomfortable pressure, fullness, squeezing or pain in the centre of the chest that lasts more than a few minutes, coming on after exercise/ physical work and often relieved by rest. Pain that spreads to the shoulders, neck or arms. Chest discomfort with light-headedness, fainting, sweating, nausea or shortness of breath

    Helps to know:

    Obesity, smoking, high levels of cholesterol, High blood pressure, Diabetes and ethnicity (Being Asian/Indian) are risk factors for Coronary artery disease. Olive oil can help in lowering cholesterol levels and decreasing the risk of heart complications. People that suffer from gum disease are twice as likely to have a stroke or heart attack. Prolonged lack of sleep can cause irregular jumping heartbeats called premature ventricular contractions (PVCs).
    Some heavy snorers may have a condition called Obtrusive Sleep Apnoea (OSA), which can negatively affect the heart Cocaine affects the heart’s electrical activity and causes spasm of the arteries, which can lead to a heart attack or stroke, even in healthy people. Evaluation of the heart
    • Pulse and Blood pressure measurement
    • Auscultation (The doctor listens with stethoscope)
    • ECG-Electro Cardiogram
    • ECHO-Scan of the heart
    • Stress test or Tread Mill test
    • Coronary Angiogram
    • Cardiac CT (Computerised Tomogram of the heart)
    • Amusing Historical background
    • The Greeks believed the heart was the seat of the spirit, the Chinese associated it with the centre for happiness and the Egyptians thought the emotions and intellect arose from the heart.
    • No one is sure the exact origin of the love association, however. The heart might have got its "love mark" in the ancient Greek city of Cyrene (now in modern Libya). The plant Silphium, found there, had heart-shaped seed pods.
    • Aristotle (384 BC – 322 BC) believed that the heart was the body’s source of heat, a type of “lamp” fuelled by blood from the liver and fanned into spirituous flame by air from the lungs. The brain merely served to cool the blood.
    • Physician Erasistratus of Chios (304-250 B.C.) was the first to discover that the heart functioned as a natural pump.
    • Galen of Pergamum (AD 129–c.?200/c.?216), a prominent surgeon to Roman gladiators, demonstrated that blood, not air, filled arteries, as Hippocrates had concluded.
    • Andreas Vesalius (1514-1564), the father of modern anatomy, argued that the blood seeped from one ventricle to another through mysterious pores!
    • In 1929, German surgeon Werner Forssmann examined the inside of his own heart by threading a catheter into his arm vein and pushing it 20 inches and into his heart, inventing cardiac catheterization, a now common procedure.!

    Milestones:

    • 1628 William Harvey (English Physician) - First describes blood circulation.
    • 1706 Raymond de Vieussens (a French anatomy professor) - First describes the structure of the heart's chambers and vessels.
    • 1733 Stephen Hales (English clergyman and scientist) - First measures blood pressure.
    • 1816 Rene T. H. Laennec (French physician) - Invents the stethoscope.
    • 1903 Willem Einthoven (Dutch physiologist) - Develops the electrocardiograph.
    • 1912 James B. Herrick (American physician) - First describes heart disease resulting from hardening of the arteries.
    • 1938 Robert E. Gross (American surgeon) - Performs first heart surgery.
    • 1951 Charles Hufnagel (American surgeon) -Develops a plastic valve to repair an aortic valve.
    • 1952 F. John Lewis (American surgeon) - Performs first successful open heart surgery.
    • 1953 John H. Gibbon (American surgeon) - First uses a mechanical heart and blood purifier.
    • 1961 J. R. Jude (American cardiologist) - leads a team performing the first external cardiac
    • massage to restart a heart.
    • 1965 Michael DeBakey and Adrian Kantrowitz (American surgeons) -Implant mechanical devices to help a diseased heart.

    Dr.Pramod Pandurang
    ENT consultant
    Yashaswini ENT clinic
    2nd cross, Durgaparameshwari layout, Bangalore
    E-mail Id: pramodpandurang@yahoo.com
    pramodent@gmail.com










    ENT

    LIFESTYLE AND THE EYE

    Nose bleeds: What you should know and do.

    A vast majority of the population across the globe have had this problem at least once in their life time.. Nose bleeds known in medical parlance as epistaxis can have varied causes, as do their management. It can range from a simple case such as nose picking to life threatening aneurysmal bleed. Nose bleeds can occur in both the sexes as well as in all age group.

    Childhood causes of nose bleeds:

    1. nose picking
    2. foreign bodies that children insert in.
    3. trauma to the nose,
    4. infection in the sinuses and adenoids.
    While these are tackled easily as out-patients, more serious bleeding resulting from bleeding disorders, growth in the nose such as angiofibroma require specialized care.
    In the older population malignant (Cancerous) as well as non malignant growth and infections are the main reasons for nose bleed apart from the causes enumerated above. Uncontrolled blood pressure is often associated with nose bleed though it is not the cause thereof.
    The first aid to these sufferers is most importantly, creating a calm and reassuring atmosphere; taking precautions to prevent aspiration of blood into air way and application of icepack to the nasal bridge. Arrangements are then made to transport the patient to the nearest medical facility. Ideal position is that the child should be sitting with head bent on the knees. For those who can’t maintain this position, lie them down on their side. The third first aid would consist of application of nose drops after consultation with ER personnel.
    In the majority of cases, bleeding stops with the above steps. When it doesn’t, these steps at least constitute appropriate first line management after which the patient eventually receives treatment in the ER.

    Author : Dr. Radhika Raghupathi,

    MBBS, MD (Microbiology)

    Recent Advances Future Watch...

    Robotic SurgeryIn the coming future, there shall be a revolution in the medical field. Soon, precise, complicated surgery which is currently being done by humans will be taken over by highly intelligent robotic machines!Imagine being operated upon by not a person but a machine! Doctors around the world are using sophisticated robots to perform surgical procedures on patients.
    In today's operating rooms, you'll find two or three surgeons, an anesthesiologist and several nurses, all needed for even the simplest of surgeries. Most surgeries require nearly a dozen people in the room. Surgical robots will eventually eliminate the need for some personnel. In the near future, surgery may require only a single surgeon who is controlling a marvelous machine completing a task with ease which once took a crowd to achieve!

    Not all surgical robots are equal. There are three different kinds of robotic surgery systems:

    1. Supervisory-controlled systems,
    2. Telesurgical systems
    3. Shared-control systems.

    The main difference between each system is how involved a human surgeon must be when performing a surgical procedure. On one end of the spectrum, robots perform surgical techniques without the direct intervention of a surgeon. On the other end, doctors perform surgery with the assistance of a robot, but the doctor is doing most of the work
    Advantages of Robotic Surgery:Robotic surgery has several advantages over conventional surgery, including enhanced precision and reduced trauma to the patient. For instance, traditional heart bypass surgery requires that the patient's chest be "cracked" open by way of a 1-foot (30.48-cm) long incision.
    However, with robotic surgery, it's possible to operate on the heart by making three or four small incisions in the chest, each only about 1 centimeter in length. Because the surgeon would make these smaller incisions instead of one long one down the length of the chest, the patient would experience less pain, trauma and bleeding, which means a faster recovery.The use of robotics would also prevent surgeon fatigue. Surgeons can become exhausted during those long surgeries, and can experience hand tremors as a result.
    Even the steadiest of human hands cannot match those of a surgical robotWhile robotic surgery systems are still relatively uncommon, several hospitals around the world have bought robotic surgical systems. These systems have the potential to improve the safety and effectiveness of surgeries. But the systems also have some drawbacks. It's still a relatively young science and it's very expensive. Some hospitals may be holding back on adopting the technology.

    Contributed by: Dr. Radhika Raghupathi
    MBBS, MD (Microbiology)


    Dr. Radhika Raghupathi graduated from Bangalore Medical College in the year 1989.
    She did her post graduation in medical microbiology from Chennai.
    Her interests include infectious diseases, anaerobic cultures, and pathogenesis of infections.
    She has taught a number of students including nursing students during her tenure at St John’s Medical College Bangalore.

    LABORATORY TESTS


    Author : Dr. Radhika Raghupathi,

    MBBS, MD (Microbiology)

    Know your Lab tests:

    Culture and Sensitivity Tests What is a Culture and Sensitivity test?When a disease is suspected to be due to an infection, it is important to know which antibiotics (drugs that kill the disease causing organisms) will be effective against the particular pathogen (i.e., disease-causing agent).

    For this:

    The species (and strain) of bacteria (or other pathogen) must be identified The drugs most effective at inhibiting their growth must be determined. The only reliable way this can be done is a culture and sensitivity test. What is the basis of the test?The test examines for the presence of bacteria, in the hope of identifying it and also attempts to point out to the drugs which are likely to be effective against the infection in life.From where can the material for culture & sensitivity be taken?Cultures may be taken from any infected (or potentially infected) tissue or fluid,

    for example:

    Urine Sputum Blood Wound fluid or pus Body fluids-CSF (cerebrospinal fluid from spinal cord), Peritoneal fluid (from abdomen), pleural effusion (chest fluid) etc.How the test is performed? A cotton-wool swab, which is like an ear-bud, is used to collect a small amount of fluid from a wound or surface. The swab is transported in a special medium that encourages growth of bacteria.At the bed side, some of this sample may also be transferred onto a glass slide for microscopy and for a preliminary look at the offending organism.For culture, the swab is smeared on a culture medium filled glass plate systematically.
    The glass dish may have to be incubated for body temperature conditions. The bacteria begin to grow on the culture plates as small colonies which have different appearances and characteristics based on their species. For the (antibiotic) sensitivity test, small round pieces of special tissue paper containing various antibiotics is placed in another glass dish and the bacteria are inoculated on the dish. Those antibiotics that can kill the bacteria will not allow growth around them in the culture medium.
    This way, effective drugs can be identified.It may take 2 to 3 days to actually grow the relevant bacterium in the laboratoryHow long does it take for a culture sensitivity report?About 48-72 hours. What are the precautions to be taken? Avoiding contamination-The specimens must be collected with appropriate precautions in order to avoid contaminating the specimen with other organisms present in atmosphere, on body surface etc.

    Proper transport of the specimen Ideally the patient should have a culture sensitivity done before starting any antibiotic therapy in order to avoid interference with results.





    1) Petri dish with medium and bacterial colony growth




    2) Culture and sensitivity plate: Note halos of various diameters around the antibiotic strip dots. The halos are areas wher bacterial growth is inhibited by the antibiotic.Larger tha halo, more effective is the drug against bacteria. No halo means that the bacteria are resistant to that drug.Contributed by: Dr. Radhika Raghupathi MBBS, MD (Microbiology)

    Dr. Radhika Raghupathi graduated from Bangalore Medical College in the year 1989.


    She did her post graduation in medical microbiology from Chennai.
    Her interests include infectious diseases, anaerobic cultures, and pathogenesis of infections.
    She has taught a number of students including nursing students during her tenure at St John’s Medical College Bangalore.