Abnormal blood pressure in pregnancy

Blood pressure and pregnancy

During pregnancy, your body goes through numerous physical changes to accommodate fetal growth and development. Throughout these nine months, it’s ideal to have a normal blood pressure reading.

Your blood pressure is the force of your blood pushing against the walls of your arteries. Every time your heart beats, it pumps blood into the arteries, which then carry the blood to the rest of your body. The blood typically moves through the arteries at a certain rate. However, various factors can disrupt the normal rate at which blood flows through the vessels, causing an increase or decrease in pressure. Increased pressure in the arteries can result in an elevated blood pressure reading. Decreased pressure in the arteries can result in a low blood pressure reading.

Blood pressure is recorded as two types of numbers. The systolic number is the top number, which indicates the amount of pressure in the arteries when your heart beats. The diastolic number is the bottom number, which indicates the amount of pressure in the arteries between heartbeats. Your blood pressure naturally rises with each heartbeat and falls when the heart rests in between beats. However, the rapid changes your body goes through during pregnancy can greatly influence these numbers and cause a drastic change in blood pressure.

According to the American Heart Association (AHA), a normal blood pressure reading is 120/80 mm Hg and below. Readings below 90/60 mm Hg indicate low blood pressure, or hypotension. Readings above 140/90 mm Hg in pregnancy indicate high blood pressure, or hypertension. Hypertension is seen far more often in pregnancy than hypotension. About 10 percent of all pregnancies in the United States are complicated by high blood pressure issues.

An abnormal blood pressure during pregnancy is a cause for concern. Both you and your baby may be at an increased risk of health complications. However, you may be able to prevent problems by attending regular prenatal appointments so your doctor can monitor your blood pressure closely. You may also want to consider learning more about related conditions so you can help manage factors affecting your blood pressure.

How to detect abnormal blood pressure

The AHA defines abnormal blood pressure readings in non-pregnant adults as follows:

• Elevated blood pressure is a systolic number between 120 and 129 and a diastolic number lower than 80.
• In stage 1 hypertension, the systolic number is between 130 and 139 or the diastolic number is between 80 and 89.
• In stage 2 hypertension, the systolic number is 140 or higher or the diastolic number is 90 or higher.
• In a hypertensive crisis, the systolic number is higher than 180 and/or the diastolic number is higher than 120.

You may not always be able to tell whether your blood pressure is too high or too low. In fact, hypertension and hypotension may not cause noticeable symptoms. If you do experience symptoms, they may include the following:

Symptoms of hypertension

High blood pressure, or hypertension, in pregnancy is usually defined as 140/90 mm Hg or higher. It may cause:

• flushed skin
• swelling of the hands or feet
• headaches
• shortness of breath
• abdominal pain
• nausea
• vomiting
• changes in vision

Symptoms of hypotension

Low blood pressure, or hypotension, is usually defined as 90/60 mm Hg or less. It may cause:

• dizziness
• difficulty concentrating
• cold, clammy skin
• blurred vision
• rapid breathing
• depression
• sudden tiredness
• extreme fatigue

If you suspect you have symptoms of hypertension or hypotension, you should see your doctor right away to help prevent possible complications.

The symptoms of hypertension and hypotension aren’t always present. The best way to know if you have abnormal blood pressure is to take a blood pressure test. Blood pressure tests are often done at regular checkup appointments, and your doctor should perform them throughout your pregnancy.

While these tests are most commonly performed in a medical setting, they can also be done at home. Many local drug stores carry at-home blood pressure monitors that you can use to check your blood pressure. However, make sure to consult with your doctor before you try monitoring your blood pressure at home. Your doctor may have specific instructions regarding when and how often you should check your blood pressure.

Causes of abnormal blood pressure during pregnancy

The AHA estimates that 1 out of every 3 American adults has hypertension. In pregnancy, hypertension can be classified into two main categories: chronic hypertension and hypertension related to pregnancy. Chronic hypertension refers to high blood pressure that was present before pregnancy. You may also be diagnosed with this condition if you develop hypertension during the first 20 weeks of pregnancy. You may still have the condition after giving birth.

High blood pressure disorders related to pregnancy generally develop after the first 20 weeks of pregnancy. There are several types of disorders that range in severity. A 2016 review published in Integrated Blood Pressure Control Trusted Source suggests that age, obesity, and underlying health problems seem to contribute to these conditions. Though these conditions usually go away after you give birth, your risk of getting hypertension in the future is much higher if you develop any of them.

Hypotension, while much less common, can be directly related to pregnancy. Your circulatory system expands during pregnancy to accommodate your fetus. As circulation expands, you might experience a small drop in blood pressure. According to the AHA, this is most common during the first 24 weeks of pregnancy. Still, this amount is usually not significant enough to cause concern.

Hypotension may also be caused by:

• dehydration
• diabetes
• low blood sugar
• heart problems
• thyroid problems
• severe allergic reactions
• blood loss
• infection
• malnutrition, particularly a lack of folic acid, B vitamins, and vitamin D

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of Gynecological conditions and Pregnancies.

Urinary Tract infections in females

A urinary tract infection (UTI) is an infection from microbes. These are organisms that are too small to be seen without a microscope. Most UTIs are caused by bacteria, but some are caused by fungi and in rare cases by viruses. UTIs are among the most common infections in humans.

A UTI can happen anywhere in your urinary tract. Your urinary tract is made up of your kidneys, ureters, bladder, and urethra. Most UTIs only involve the urethra and bladder, in the lower tract. However, UTIs can involve the ureters and kidneys, in the upper tract. Although upper tract UTIs are more rare than lower tract UTIs, they’re also usually more severe.

UTI symptoms

Symptoms of a UTI depend on what part of the urinary tract is infected.

Lower tract UTIs affect the urethra and bladder. Symptoms of a lower tract UTI include:

• burning with urination
• increased frequency of urination without passing much urine
• increased urgency of urination
• bloody urine
• cloudy urine
• urine that looks like cola or tea
• urine that has a strong odor
• pelvic pain in women
• rectal pain in men

Upper tract UTIs affect the kidneys. These can be potentially life threatening if bacteria move from the infected kidney into the blood. This condition, called urosepsis, can cause dangerously low blood pressure, shock, and death.

Symptoms of an upper tract UTI include:

• pain and tenderness in the upper back and sides
• chills
• fever
• nausea
• vomiting

UTI treatment

Treatment of UTIs depends on the cause. Your doctor will be able to determine which organism is causing the infection from the test results used to confirm the diagnosis.

In most cases, the cause is bacteria. UTIs caused by bacteria are treated with antibiotics.

In some cases, viruses or fungi are the causes. Viral UTIs are treated with medications called antivirals. Often, the antiviral cidofovir is the choice to treat viral UTIs. Fungal UTIs are treated with medications called antifungals.

Antibiotics for a UTI

The form of antibiotic used to treat a bacterial UTI usually depends on what part of the tract is involved. Lower tract UTIs can usually be treated with oral antibiotics. Upper tract UTIs require intravenous antibiotics. These antibiotics are put directly into your veins.

Sometimes, bacteria develop resistance to antibiotics. To reduce your risk of antibiotic resistance, your doctor will likely put you on the shortest treatment course possible. Treatment typically lasts no more than 1 week.

Results from your urine culture can help your doctor select an antibiotic treatment that will work best against the type of bacteria that’s causing your infection.

Treatments other than antibiotics for bacterial UTIs are being examined. At some point, UTI treatment without antibiotics may be an option for bacterial UTIs by using cell chemistry to change the interaction between the body and the bacteria.

UTI diagnosis

If you suspect that you have a UTI based on your symptoms, contact your doctor. Your doctor will review your symptoms and perform a physical examination. To confirm a diagnosis of a UTI, your doctor will need to test your urine for microbes.

The urine sample that you give your doctor needs to be a “clean catch” sample. This means the urine sample is collected at the middle of your urinary stream, rather than at the beginning. This helps to avoid collecting the bacteria or yeast from your skin, which can contaminate the sample. Your doctor will explain to you how to get a clean catch.

When testing the sample, your doctor will look for a large number of white blood cells in your urine. This can indicate an infection. Your doctor will also do a urine culture to test for bacteria or fungi. The culture can help identify the cause of the infection. It can also help your doctor choose which treatment is right for you.

If a virus is suspected, special testing may need to be performed. Viruses are rare causes of UTIs but can be seen in people who have had organ transplants or who have other conditions that weaken their immune system.

Upper tract UTIs

If your doctor suspects that you have an upper tract UTI, they may also need to do a complete blood count (CBC) and blood cultures, in addition to the urine test. A blood culture can make certain that your infection hasn’t spread to your blood stream.

Recurrent UTIs

If you have recurrent UTIs, your doctor may also want to check for any abnormalities or obstructions in your urinary tract. Some tests for this include:

• An ultrasound, in which a device called a transducer is passed over your abdomen. The transducer uses ultrasound waves to create an image of your urinary tract organs that are displayed on a monitor.
• An intravenous pyelogram (IVP), which involves injecting a dye into your body that travels through your urinary tract and taking an X-ray of your abdomen. The dye highlights your urinary tract on the X-ray image.
• A cystoscopy, which uses a small camera that’s inserted through your urethra and up into your bladder to see inside your bladder. During a cystoscopy, your doctor may remove a small piece of bladder tissue and test it to rule out bladder inflammation or cancer as a cause of your symptoms.
• A computerized tomography (CT) scan to get more detailed images of your urinary system.

Causes and risk factors of a UTI

Anything that reduces your bladder emptying or irritates the urinary tract can lead to UTIs. There are also many factors that can put you at an increased risk of a getting a UTI. These factors include:

• age — older adults are more likely to get UTIs
• reduced mobility after surgery or prolonged bed rest
• kidney stones
• a previous UTI
• urinary tract obstructions or blockages, such as an enlarged prostate, kidney stones, and certain forms of cancer
• prolonged use of urinary catheters, which may make it easier for bacteria to get into your bladder
• diabetes, especially if poorly controlled, which may make it more likely for you to get a UTI
• pregnancy
• abnormally developed urinary structures from birth
• a weakened immune system

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of Gynecological conditions including urinary tract infections.

Irregular periods in teenagers

Irregular periods are very common, especially in a girl’s first few years of getting her period.

What Are Regular Periods?

Most girls get their first period between the ages of 10 and 15, but some get it earlier and some later. The first period is known as menarche.

A girl’s monthly cycle is the number of days from the start of her period to the start of the next time she gets her period. You often hear this is a 28-day cycle. But 28 is just an average figure that doctors use. Cycle lengths vary — some are 24 days, some are 34 days. And a girl may notice that her cycles are different lengths each month — especially for the few years after she first starts getting her period.

Early in a girl’s cycle, her ovaries start preparing one egg. At the same time, the lining of the uterus becomes thick to prepare a nesting place for a fertilized egg in the event that the girl becomes pregnant.

About 2 weeks before a girl gets her period, the egg is released from the ovary (this is called ovulation). The egg travels through the fallopian tube into the uterus. If the egg isn’t fertilized by sperm, it starts to fall apart. Then the lining and egg leave a girl’s body as her period and the whole thing starts all over again — that’s why we use the word “cycle.” The first day a girl’s period comes is Day 1 of her cycle.

A girl’s body may not follow an exact schedule. It’s common, especially in the first 2 years after a girl starts getting her period, to skip periods or to have irregular periods. Illness, rapid weight change, or stress can also make things more unpredictable. That’s because the part of the brain that regulates periods is influenced by events like these. Going on a trip or having a major change in schedule can also make your period come at a different time than expected. All of this is perfectly normal.

It’s also normal for the number of days a girl has her period to vary. Sometimes a girl may bleed for 2 days, sometimes it may last a week. That’s because the level of hormones the body makes can be different from one cycle to the next, and this affects the amount and length of bleeding.

If My Period Is Irregular, How Do I Know When I Will Get It?

If your cycle is not regular, you’ll want to pay attention to the clues your body may give you that your period is coming soon. These may include:

• back cramps or stiffness
• heavier breasts or breast soreness
• headaches
• acne breakouts
• disturbed sleep patterns
• mood swings
• bloating
• loose stools

How Can I Be Prepared?

Keep some pads or tampons in your backpack or purse, just so you’ll have them handy in case your period comes when you’re not expecting it. You may even want to carry an extra pair of underwear.

What Causes Irregular Periods?

Most of the time, irregular periods are part of the normal changes that can happen when you’re a teen. As you get older, your cycle will probably settle into a recognizable pattern.

Sometimes, irregular periods can be caused by some medicines, exercising too much, having a very low or high body weight, or not eating enough calories.

Hormone imbalances can also cause irregular periods. For example, thyroid hormone levels that are too low or too high can cause problems with periods. Some girls have extra androgen, a hormone that can cause hair growth on the face, chin, chest, and abdomen. Extra androgen can also makes girls gain weight and have irregular periods.

Girls who are pregnant also will not get their periods.

Should I Worry About Irregular Periods?

Talk to your doctor if you have had sex and have missed a period because you could be pregnant. Also let the doctor know if:

• You were having regular periods that then become irregular.
• You stop getting your period.
• You have extra hair growth on the face, chin, chest, or abdomen.
• You start having periods that last longer than 7 days, are heavy, or are coming more often than every 21 days.
• Your period comes less often than every 45 days.
• You have severe cramping or abdominal pain.
• You have bleeding in between your periods.
• Your periods are irregular for 3 years or more.

The doctor may prescribe hormone pills or other medicines, or recommend lifestyle changes that can help you to have regular periods.

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of clinical experience in handling all gynecological cases including irregular periods in teenage .

Benign tumors or growth of the genitalia- vulva and vagina

Benign or malignant neoplasms of the vagina are uncommon. The frequency of benign lesions ranges from rare to very rare. Neoplasms that may develop in other locations within the genital tract may also be found in the vagina. Most vaginal tumors produce no symptoms until significant size is reached. Symptoms and signs may include a sensation of pressure, dyspareunia, obstruction of the vagina or urethra, or vaginal bleeding. However, most lesions will be detected during a routine exam in the asymptomatic patient. Vaginal neoplasms may be divided into cystic or solid lesions and a third category best described as related conditions. As is true for any neoplasm, biopsy provides a definitive diagnosis.

Gartner’s Duct Cyst

Gartner’s duct cysts develop as a result of incomplete regression of the mesonephric or wolffian duct during fetal development . In the male, these ducts form the epididymis. When present, these cysts may be multiple, and are located submucosally along the lateral aspects of the upper vagina. Histologic evaluation reveals nonsecretory, columnar epithelium. If these cysts are small, asymptomatic, and located in the lateral aspects of the upper vagina, no treatment is indicated. If the diagnosis is in question, or there is a history of antenatal exposure to synthetic hormones, adenosis of the vagina must be considered. The presence of mucosa, which stains normally with Lugol’s solution, helps to exclude the diagnosis of adenosis. Regardless of size, biopsies should be performed on symptomatic cysts or they should be excised. Larger cysts in the vaginal fornix may extend to the lateral aspects of the cervix and require excision in the operating room.

Paramesonephric Duct Cyst

In contrast to Gartner’s duct cysts, paramesonephric duct cysts are lined with secretory epithelium resembling endocervix or fallopian tube, suggesting müllerian origin. These cysts may be found anywhere in the vagina and frequently contain mucus. Vaginal adenosis is excluded by staining with Lugol’s solution. The diagnosis is established with an excisional biopsy if the cyst is large, symptomatic, or only recently identified.

Inclusion Cyst

Inclusion cysts of the vagina result from mucosa trapped in the submucosal area by surgical procedures such as episiotomy, colporrhaphy, or trauma including childbirth. As the cysts enlarge, symptoms may develop. These cysts are lined with squamous epithelium and contain keratin and squamous debris. Foreign-body reaction and inflammation surround the cyst. Treatment involves excision of the intact cyst and approximation of normal epithelium.

Endometriosis

Endometriosis in the vagina may develop at the site of a previous operation or as primary implants. Nodularity of the posterior vaginal fornix may represent endometriotic implants of the posterior cul-de-sac and may eventually erode or grow into the vaginal mucosa. When visualized colposcopically, these implants may appear dark blue or brown. If associated with fibrosis, the submucosal implants may appear white. Biopsy may yield chocolate-colored material representing old hemorrhage and dense fibrosis. Endometrial glands and stroma are usually identified histologically although the presence of both are not required to make the diagnosis. The diagnosis is made by biopsy unless endometriosis is identified in other parts of the pelvis. Small, symptomatic lesions are treated by excision or laser vaporization. Large lesions arising in the posterior cul-de-sac and extending into the posterior vaginal fornix may require laparotomy to accomplish excision. Preoperative therapy with gonadotropin releasing hormone analogs may greatly reduce the size of the implants, therefore, reducing the extent of excision or vaporization. We recommend outpatient mechanical bowel preparation prior to surgery. For the symptomatic patient who does not wish surgical excision of the lesion, gonadotropin releasing hormone analog therapy followed by suppression with oral contraceptives may be beneficial.

Leiomyoma

Vaginal leiomyomas or fibromyomas are rare lesions usually located in the anterior vaginal wall . Between 250 and 300 cases have been reported in the world literature. These lesions are benign smooth muscle neoplasms, usually solitary and in many cases asymptomatic. Histologically, they resemble leiomyoma of other origins. Proposed sites of origin include vaginal smooth muscle, local arterial musculature, or smooth muscle of the bladder or urethra. As is true of uterine leiomyomata, the vaginal lesions are estrogen dependent. Malignant conversion is extremely rare. When large, symptoms can include vaginal discharge or bleeding, dyspareunia, or urinary retention. The differential diagnosis of a midline anterior vaginal mass includes urethral diverticulum, fibroepithelial polyp, cystocele, Skene duct abscess, or vaginal malignancy. Therapy involves excision in the symptomatic patient. Recurrence is uncommon but reported.

Fibroepithelial Polyp

Fibroepithelial polyps of the vagina are uncommon and usually asymptomatic. In infants and young girls, sarcoma botryoides must be ruled out. Fibroepithelial polyps of the vagina are usually small and may be multiple. During pregnancy, these lesions may become enlarged, very edematous, and bizarre in appearance. Histologically, the polyps are composed of a squamous epithelial surface with a fibrovascular stalk and edematous stroma. Proposed etiologies include stromal proliferation or granulation tissue reaction as a result of local injury. Therapy involves excision of the polyp and stalk in the symptomatic patient or the patient with a large polyp.

Condyloma Acuminatum

Condyloma acuminatum represents the clinical manifestation of human papillomavirus infection.There are currently more than 120 human papillomavirus types identified. These lesions may be associated with condylomata of the cervix and vulva or appear only as vaginal lesions. Histologic evaluation confirms the diagnosis and rules out a dysplastic lesion. The microscopic description is similar to that for condyloma in other locations. Hybridization techniques to identify high-risk DNA type are currently of little help to the clinician in the face of obvious condyloma. Clinical management includes topical therapy with carefully applied bichloroacetic or trichloroacetic acid. For large or multiple lesions, excision, cauterization, laser vaporization, or loop electrical excision may be required. Cryotherapy may be helpful for small lesions; however, depth of thermal injury may be difficult to control. The entire genital tract should be evaluated and any obvious lesions treated simultaneously. Overly aggressive treatment, especially with laser or cautery may result in significant distortion and scarring of the vagina and should be avoided.

Urethral Caruncle

Urethral caruncles present as localized, red, friable lesions at the urethral meatus . They are generally seen in the postmenopausal woman and are thought to result from a localized area of prolapse of the urethral mucosa with secondary inflammatory changes. They can be confused with acute circumferential prolapse of the urethral mucosa, a condition usually seen in young girls. Urethral carcinoma must be excluded in patients with larger urethral caruncles. There may be pain, dysuria, and bleeding. Small asymptomatic urethral caruncles may not require any treatment. Larger or symptomatic lesions can be treated by topical application of estrogen. To establish the diagnosis, small biopsies may be performed under local anesthesia. Large or persistent lesions may require excision and reapproximation with fine absorbable suture.

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of Gynecological conditions including tumors of the vagina and vulva.

Gynecology conditions and Gynecology consultation in COVID times for patients in South Delhi

The impact of the novel coronavirus disease 2019 (COVID-19) pandemic is catastrophic, with the cumulative number of confirmed worldwide cases reaching 1,610,909 by April 11, 2020. Despite the necessary reassignment of many healthcare resources to the care of patients with COVID-19, gynecologic patients must still receive a diagnosis and be treated. Therefore, guidelines for the safe management of these patients during the epidemic are needed to protect patients and the healthcare workforce.1 The Chinese Obstetricians and Gynecologists Association (COGA) organized experts from all provinces and autonomous regions in mainland China (Wuhan included) to contribute their experience in the diagnosis and treatment during the epidemic, aiming to distribute guidelines regarding the care of gynecologic patients during the COVID-19 outbreak in mainland China.

These guidelines were developed by the Department of Obstetrics and Gynecology at the Peking Union Medical College Hospital (PUMCH) and represent an effort to integrate infection control strategy and promote professionalism in medical practice. The guidelines represent collaboration with experts from 31 provinces over 2 weeks’ time. With the implementation of these guidelines, no nosocomial infections of COVID-19 have been identified at PUMCH. Given that it is not easy to anticipate when the epidemic will peak and the understanding of COVID-19 is still changing, parts of this consensus statement may become obsolete as knowledge about the epidemic evolves.

1. Outpatient

There should be triage for outpatients. Patients suspected of having COVID-19 should go to the fever clinic for further treatment. In principle, suspected cases, probable cases, or confirmed cases should not be allowed to seek medical advice in the outpatient gynecology clinic. Avoid having people gathering in the waiting area. One doctor or provider should treat 1 patient at a time in the consulting room, and the consulting room should be disinfected immediately after use. During the COVID-19 pandemic, we recommend online or remote consultation by telephone as much as practical, to minimize the risk of disease spread by close contact.

2. Operative patient

In emergency surgery with sufficient time available for screening, patients who are clinically stable should be asked the screening questions listed ,have their temperature assessed, and be checked for clinical symptoms to eliminate the possibility of COVID-19. If the possibility of a COVID-19 diagnosis cannot be completely ruled out, patients should go to the fever clinic for further screening . If the patient is clinically unstable or the patient’s condition is life-threatening, an emergency consultation with infection control experts may be useful. The decision may be made to treat the patient as a suspected case or even confirmed case .

In principle, it is recommended to reduce elective surgery during the epidemic. If the decision is made to perform elective surgery, the inquiry (screening questions) and triage protocol should be followed as for “time-limited” surgery.
Planning coordination throughout the hospital system, including the various surgical departments, anesthesia, and nursing services, is important in managing surgical services in the setting of a health emergency. Furthermore, adequacy of the blood supply must be considered when arranging operations. Autologous blood donation, acute normovolemic hemodilution, directed donation, and other methods can be considered as alternatives to allogenic blood transfusion.

3. Nonoperative inpatient

The triage protocol for a newly admitted patient is provided. Recommendations for ward management include the following: First, review the screening questions and take the temperature of patients, visitors, and accompanying persons; any patient with an elective admission or any nonpatient suspected of infection should be refused entry into the hospital.

Second, visiting rules can be modified according to local preference. It is recommended to prohibit visiting, and if visitors cannot be avoided, the number of visitors should be no more than 1. Visitors must be screened. Third, if a patient develops fever that cannot be explained by the primary disease (requires judgment by the attending doctor or professor), a consultation with infectious disease specialists is recommended. Fourth, if a patient is identified to have COVID-19, the patient should be transferred to a facility that can provide an airborne infection isolation room. At the same time, everyone who has had close contact with the patient should be isolated (This is a recommendation from our experience in mainland China. If there is a shortage of local medical staff, the strategy can be modified according to the actual situation.). Fifth, rooms should be reserved for emergency use for patients with infections during the outbreak (for emergency operations and for emergency isolations). Sixth, provide education for patients and close contacts.

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of Gynecological conditions and is available in COVID free clinic.

Dermoid cyst of the ovary

A dermoid cyst (also called as “mature teratoma”) is a sac-like growth that may be present at birth. It contains structures such as hair, fluid, teeth or skin glands that can be found on or in the skin. In some cases, especially when in the ovary, it also contains thyroid or brain tissue. Ovarian dermoid cysts, which not uncommonly are found in both ovaries, can develop in a woman during her reproductive years. The word “teratoma” is derived from Greek work “teraton” meaning monster. It was initially used by Virchow in 1863. The term “dermoid cyst” was coined by Leblanc in 1831.

Keywords: Bilateral ovaries, dermoid cyst, asymptomatic condition

Introduction

Mature cystic teratomas account for 10-20% of all ovarian neoplasms and are the most common neoplasm in patients of reproductive age group. Mature teratomas are usually benign, but in 0.1-0.2% of cases, it may undergo malignant transformation. They may remain asymptomatic or may present with acute abdomen due to torsion, infection, or rupture. Spontaneous rupture of the teratoma is rare and has been occasionally reported. Here we present a case of deroid cyst of ovary, which is bilateral and which is a rare presentation.

Discussion

Cystic teratomas make up approximately 15-25% of ovarian neoplasms. Almost 10-15% is bilateral. They are composed of well-differentiated derivatives of three germ layers-ectoderm, mesoderm and endoderm. Mature cystic teratomas, often referred to as dermoid cysts, are the most common germ cell tumors of the ovary in women of reproductive age and are usually asymptomatic until they reach considerable size. Though they are common in reproductive age, but they can occur at any age including the post-menopausal woman. Most are 5-10 cm in diameter when diagnosed and on sectioning they usually contain thick sebaceous material, tangled hair and various dermal structures. One of the major complications seen in cystic teratomas is torsion, a partial or complete twisting of the ovarian suspensory pedicle causing severe pain, nausea and tissue necrosis. Malignant transformation is uncommon, occurring in approximately 0.1-0.2% of cases usually in older women. Ovarian teratomas have a predisposition to right lateral side.

Endometriosis co-existing with bilateral dermoid cysts of the ovaries is a rare occurrence although both benign conditions are said to be common in women in reproductive age group. This association has a clinical relevance because an endometriotic pathology can reveal a silent teratoma with bilateral ovarian localization.

In general, removing a dermoid cyst is not an emergency procedure. If a dermoid cyst ruptures, becomes inflamed, or causes pain or fever, a person should seek immediate medical advice. Treatment depends also upon the patients age. In younger woman, it may be possible to remove the dermoid cyst while still leaving behind normal ovary tissue for needed hormone benefits or future pregnancy. Autoimmune hemolytic anemia has been noted occasionally in patients with teratoma of the ovary, especially mature cystic teratoma.

Ovarian teratoma commonly has an indolent course and presents with abdominal pain due to complications such as torsion, hemorrhage, or infection. Spontaneous rupture of teratoma is rare due to its thick wall and it usually occurs in the peritoneal cavity. Rupture into a hollow viscus due to adhesions is extremely rare complication, which may present as perforation peritonitis.
Although ovarian teratomas are common day, we present this case because of its bilateral presentation, which is rare and the mode of treatment and the complications if not treated properly.

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max e Apollo hospitals with over 14 years of experience in handling all kinds of Gynecological conditions including dermoid cysts of ovary.

Big and plenty of fibroids

Uterine fibroids are tumors that grow in a woman’s womb (uterus). These growths are typically not cancerous (benign)

Causes

Uterine fibroids are common. As many as one in five women may have fibroids during their childbearing years. Half of all women have fibroids by age 50.

Fibroids are rare in women under age 20. They are more common in African Americans than White, Hispanic, or Asian women.

No one knows exactly what causes fibroids. They are thought to be caused by:

• Hormones in the body
• Genes (may run in families)

Fibroids can be so tiny that you need a microscope to see them. They can also grow very large. They may fill the entire uterus and may weigh several pounds or kilograms. Although it is possible for just one fibroid to develop, most often there is more than one.

Fibroids can grow:

• In the muscle wall of the uterus (myometrial)
• Just under the surface of the uterine lining (submucosal)
• Just under the outside lining of the uterus (subserosal)
• On a long stalk on the outside the uterus or inside the uterus (pedunculated)

Symptoms

Common symptoms of uterine fibroids are:

• Bleeding between periods
• Heavy bleeding during your period, sometimes with blood clots
• Periods that may last longer than normal
• Needing to urinate more often
• Pelvic cramping or pain with periods
• Feeling fullness or pressure in your lower belly
• Pain during intercourse

Often, you can have fibroids and not have any symptoms. Your health care provider may find them during a physical exam or other test. Fibroids often shrink and cause no symptoms in women who have gone through menopause. A recent study also showed that some small fibroids shrink in premenopausal women.

Evaluating Uterine Fibroid Size for Removal

Women with large or symptom-producing fibroids may need to have an imaging study done to evaluate uterine fibroid size to determine whether it needs to be removed. The risk of not getting treatment is that fibroids sometimes grow to a size that often leads to significant symptoms, eventually requiring removal.

Larger fibroids or those that continue to grow may lead to complications.

• If submucosal fibroids are found on the inside of the uterus and are large enough to misshape the uterine lining, they should be removed to prevent reproductive problems. (iii)
• If fibroids are larger than a 12- to 14-week pregnancy (about the size of a large grapefruit), the risk of complications during surgery, such as injury to the ureter or bladder, increases. (i)
• Left untreated, very large fibroids can begin to degenerate or burst, even if they aren’t causing any symptoms. (i) Degeneration occurs when the growing fibroid outgrows its blood supply, causing the cells of the fibroid to die. This typically causes abrupt, severe pain and tenderness.
• When fibroids reach the size of a grapefruit (4 – 6 inches), there is a rare association with blood clots in the lungs, which can be deadly. (i)
• Rapidly growing large fibroids may be a sign of a rare cancerous form of fibroid, called a leiomyosarcoma. This type of tumor can’t be differentiated from a non-cancerous (benign) fibroid using ultrasound, MRI, or other imaging studies. However, this type of fibroid only occurs in less than 1percent of uterine fibroids, and these cancerous tumors are not believed to grow from a benign fibroid. (ii)

Treatment Options for Uterine Fibroids

There are several uterine fibroid treatment options:

• Uterine fibroid embolization (UFE) uses tiny particles about the size of sugar crystals that are injected into the blood vessels that lead to the uterus. The particles block the flow of blood to the fibroid, causing it to shrink and die. This minimally invasive procedure can be performed by an interventional radiologist on an outpatient basis. It doesn’t require open surgery and offers relief of symptoms with fewer risks, less pain, and a faster recovery compared to surgical procedures.
• Magnetic resonance imaging-guided (MRI) ultrasound surgery uses ultrasound waves to destroy fibroids. Waves are directed at the fibroids through the skin with the help of magnetic resonance imaging.
• Endometrial ablation destroys the lining of the uterus. This procedure is best for small fibroids that are less than 3 centimeters in diameter. (v)
• Hysterectomy is the surgical removal of the uterus. Because this surgery removes the fibroids along with the uterus, there is no chance of becoming pregnant after undergoing a hysterectomy.
• Myomectomy is another surgical option to remove all types of fibroids. There are three approaches to performing a myomectomy: hysteroscopy, laparotomy, and laparoscopy.

How large do uterine fibroids need to be before being surgically removed?

The normal uterine size is the size of a lemon or 8 cm. There isn’t a definitive size of a fibroid that would automatically mandate removal. Your healthcare provider will determine the symptoms that are causing the problem. Fibroids the size of a marble for instance, if located within the uterine cavity, may be associated with profound bleeding. Fibroids the size of a grapefruit or larger may cause you to experience pelvic pressure, as well as make you look pregnant and see increased abdominal growth that can make the abdomen enlarged.

It’s important for the healthcare provider and patient to discuss symptoms which might require surgical intervention.

Dr. Ruchi Tandon is a Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of Gynecological conditions including Fibroids. She is one of the best fibroids surgeon in south delhi.

Antenatal care or pregnancy care in the COVID pandemic

The COVID-19 pandemic has everyone anxious and in fear. If you are pregnant, undoubtedly you have a lot of queries about whether coronavirus poses a threat to you and your baby. The answers are not crystal clear yet, due to the evolving nature of the disease. Knowledge from past epidemics due to similar respiratory illnesses help understand and manage viral infections during pregnancy. Here are the common queries among pregnant women answered.

What effect does coronavirus have on pregnant women?

Generally, pregnant women do not appear to be more risky than healthy adults to develop a more serious disease or any complications if affected by coronavirus. Mostly, they will only experience mild to moderate flu-like symptoms.

If you are pregnant and your flu-like symptoms are getting worse, it could mean that your chest infection is getting more severe, and you may require hospitalization. If you develop more severe symptoms or your recovery is getting delayed, contact a first response hospital near you immediately.

What effect will coronavirus have on my baby if I test positive for COVID-19?

As this is a very new virus, all the information and evidence is still not available to us. There is no evidence to suggest an increased risk of miscarriage if exposed to COVID-19. There is also no evidence of vertical transmission, which refers to the ability of the virus to pass to your unborn baby during pregnancy.
In a study of nine pregnant women in China who tested positive for COVID-19, all nine babies tested negative for the virus and were healthy overall. One pregnant lady in London tested positive for coronavirus and later her newborn also tested positive. However, it is unclear whether the baby contracted the viral infection in utero or shortly after birth. Expert opinion is that the baby is unlikely to be exposed during pregnancy, and it is unlikely for the baby to have any defects in development as a result. As of now, there isn’t any new evidence that says otherwise.

What are the effects of Coronavirus in the first trimester?

Pregnant women who were part of The Lancet study were all in their second or third trimesters. There is still no data on pregnant women who tested positive for the virus in their first trimester. Patients who may get infected with symptoms like high fever may increase the risk of birth defects, though there is no evidence for this yet.

Are pregnant women a vulnerable group for Coronavirus?

It is not yet known if pregnant women are more susceptible to be infected by COVID-19 when compared to the normal population. Despite this, pregnant women are advised to reduce social contact by social distancing. It is an established fact that in some women, pregnancy alters how the body fights some viral infections. Though evidence for coronavirus is still insufficient, it is for this reason that pregnant women are advised to be extra cautious during this pandemic.

Will I be able to breastfeed my baby if I have suspected or confirmed coronavirus?

Yes. The benefits of breastfeeding your infant far outweigh the risk of transmission of coronavirus through breastmilk. The main risk of breastfeeding is due to the close contact between you and your baby which can pose a risk of droplet infection that can spread to the baby while breathing. Discuss the risks and benefits with your treating doctor and family before you make a decision.

Here are some steps to follow to minimize the risk of transmission:

• Wash your hands before feeding or touching the baby, breast pump or bottles
• Try to avoid coughing or sneezing while you feed
• Wear a face mask while feeding, if available.
• If you are using a breast pump, follow instructions for cleaning and sterilizing properly.
• Consider asking one of your healthy family members to feed your baby if you are expressing milk.

Precautions for pregnant women against Coronavirus

Here are some actions you can take to prevent getting the disease during pregnancy:

• Wash your hands frequently. Hand hygiene can really protect you from exposure to COVID-19. You may hear this over and over but with good reason.
• Practice social distancing. Always maintain a distance of at least 2 metres or 6 feet from others when you are in a public place. Avoid contact with others as much as possible.
• Get your flu vaccination on time. Though the flu vaccine does not protect you from exposure to COVID-19, it does make you less susceptible to influenza, which can cause complications during pregnancy.
• Use a tissue when you cough or sneeze, throw the tissue in the dustbin. Wash your hands right after.
• Do not ignore any respiratory symptoms. If you develop a cough or any respiratory distress, do not hesitate to call your doctor. After taking a detailed history, your doctor will decide if you need to get tested for COVID-19.
• Go virtual. As much as possible, consider virtual consultations instead of prenatal visits to your gynecologist. Try to minimize or altogether avoid spending time in the doctors waiting room or in the hospital. However, some tests will require you to be there in person such as the ultrasound, blood tests and fetal testing.
• Work from home whenever possible.
• Stay safe. Symptoms such as high fever with or without continuous cough may indicate a possible coronavirus infection. Avoid coming in close contact with anyone showing these symptoms & take the time to look for support from your family and friends. Keep in touch via emails, messages or video chats. Consider taking up a new hobby or acquiring a new skill. Do things that make you happy and put your mind at ease such as taking a long shower, meditating or reading a book. Exercise as per your doctor’s advice and regularly do your Kegels and squats as recommended.

Do not stress too much if your due date is nearing, as hospitals have a system in place for safe deliveries and to ensure minimal risk of exposure for newborns.

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of pregnancies. She is known for her bedside manners and etiquette towards pregnant women.

Safe medical abortion in early pregnancy for unwanted pregnancy

Medical abortion, also known as non-surgical abortion, is one way to terminate an early pregnancy using medications. Medical abortion is provided by trained health care providers in private office settings, family planning clinics and hospitals.

A medical abortion can be performed from the time a woman suspects and confirms she is pregnant up until nine weeks from her last menstrual period. However, some insurance companies limit medical abortion to pregnancies of seven weeks or less.
In clinical practice, medical abortion is about 95 percent to 98 percent effective, causing a woman to completely pass the pregnancy without the use of surgery. In comparison, early surgical abortion is effective 98 percent of the time.

Medication abortion procedure

Medication abortion involves using the medications mifepristone and misoprostol instead of surgery to end a pregnancy. It can be done as soon as a pregnancy can be seen in an ultrasound. In India, medication abortion is performed up to five weeks of pregnancy.

A pregnancy needs high levels of the hormone progesterone to continue. Mifepristone works by blocking the action of progesterone to cause the pregnancy to stop progressing. Misoprostol causes the cervix to soften and the uterus to contract to allow the pregnancy to be expelled from the uterus.

The process and number of appointments for having a medication abortion varies depending on the type of clinic setting you attend, and whether certain tests you need (such as ultrasound and blood tests) are available on site or require separate appointments. A number of clinics are able to offer necessary tests and medication abortion in a single initial appointment.

The process of having a medication abortion generally involves the following steps:

• You will have a medical consultation with a Gynecologist and often a nurse as well, which involves a clinical assessment of medical and other relevant information, and arrangements for you to have an ultrasound and blood tests.
• You will be given information about the methods of abortion to help you to make an informed decision about the best method for you.
• If you decide to have a medication abortion, you will be asked to sign a consent form and will be given all the relevant information about what to expect, the steps you will need to take, and about pre- and post-abortion care.
• You will discuss what sort of pain relief, and any other appropriate medication you may require, and how to obtain it, in preparation for the abortion.
• If you have an intrauterine device, it will need to be removed before you take the first medication (mifepristone).
• You will take a tablet of mifepristone either at the clinic or at home and obtain the other appropriate medications.
• You will take a tablet of misoprostol 24 to 48 hours later. This softens the cervix and helps the uterus push out the pregnancy. This stage nearly always occurs at home. (If you need to travel after taking misoprostol and before the abortion is complete, it is recommended that you have a responsible adult who can drive you.)
• The abortion is usually completed some hours later, although it may take longer. You will usually need a day or two of rest or reduced activity.
• You will be encouraged to have telephone contact with the clinic you attended or another source of expert support in case you have any questions or concerns at any time during and after the procedure.

What to expect during and after a medication abortion

After taking the second medication abortion tablet at home, you may experience the following:

• nausea, vomiting, diarrhoea, dizziness, headache and fever
• pain – usually within half an hour and generally much stronger than period pain
• bleeding one to four hours later – heavier than a period and there may be large clots
• after two to six hours the bleeding usually settles to the level of your normal period
• bleeding is usually similar to a normal period for another three to seven days
• unpredictable, irregular or prolonged bleeding can last for up to four weeks after a medication abortion.

Note: The timing of the pain and bleeding is unpredictable. It occasionally starts before taking the second medication, but may take up to 24 hours to start.

Follow-up after a medication abortion

It is important to have a follow-up appointment to make sure the procedure is complete and the pregnancy has ended. Many doctors order a blood test to check that the pregnancy hormone level has dropped. You will be given an appointment for review in two weeks’ time.
Medication abortion does not work in around one percent of cases. Around two to five per cent of women will have some pregnancy tissue remaining in the uterus (womb) and will need further treatment such as additional tablets or a small surgical procedure to complete the abortion. Your Gynecologist will discuss this with you.

Advantages and disadvantages of medication abortion

Advantages of medication abortion include:

• For around 95 to 98 per cent of pregnancies up to five weeks, no further treatment is needed after taking the two doses of abortion medication.
• Unlike surgical abortion, medication abortion does not need to take place in a hospital or day surgery unit as it does not require a surgeon, anaesthetist or other medical staff to be present during the later stage of the procedure. This makes it a suitable alternative for those living in remote areas provided they have access to emergency care.
• It is a less clinical and non-surgical procedure, which some women may prefer.
• Some women feel it is a more natural process.
• It happens in a home environment.

Disadvantages of medication abortion include:

• Medication abortions are generally more time consuming than surgical abortions, and there may be more doctor visits and tests.
• In a small percentage of cases the medication needs to be repeated, and sometimes a surgical procedure is needed.
• Pain and bleeding generally last longer than following a surgical abortion.
• It is difficult to predict the time it will take for a medication abortion to complete – it may take longer than the expected four to eight hours, after taking the second medication.
• A separate appointment is needed if you would like an IUD inserted.
• Mifepristone is not suitable for some women.

Mifepristone may not be recommended for you if you:

• have certain medical conditions such as bleeding problems, adrenal failure or high blood pressure
• are taking long-term steroid or blood-thinning medication
• have had allergic reactions to medication containing mifepristone.

Dr.Ruchi Tandon is a Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of abortions.

Fibroids – Do’s and don’ts

What Are Fibroids?

Fibroids, or leiomyomata (myomas), are common noncancerous growths that usually occur in or on the muscle walls of the uterus. One cell divides repeatedly and grows into a firm, rubbery mass separate from the rest of the uterine wall. Almost half of women older than 50 have these growths. They’re more common in African American women than in Caucasian women. They can grow as a single mass or more often as a number of masses of different sizes.

What Causes Fibroids?

The cause isn’t clear. Several factors probably work together to produce fibroids. These factors may be hormones such as estrogen, genetics (runs in families), and environmental. Being overweight, never having had a child, and getting periods before age 10 also may have an effect. The fibroids usually, but not always, shrink after menopause (change of life).

What Are the Symptoms of Fibroids?

Most fibroids (30% to 50%) cause no symptoms. Problems, when they occur, are related to the size and location of the fibroids. Fibroids may grow to be quite large so that a woman may look pregnant and have symptoms of pregnancy: pressure in the pelvic area (lower belly), heaviness, and need to go to the bathroom often to urinate. Fibroids in the uterine wall or in the cavity of the uterus may cause bleeding between periods or heavier and more painful periods. Constipation, backache, pain during sex, and lower belly pains may occur. Rarely, fibroids cause sudden pain or bleeding.

How Are Fibroids Diagnosed?

The health care provider will do an examination of the pelvic area. Ultrasound or x-rays may be used but aren’t always needed for diagnosis. The doctor may do a special procedure (hysteroscopy) for women with bleeding symptoms. This simple procedure lets the doctor look into the uterus to find the cause of the bleeding or to plan or carry out therapy.

How Are Fibroids Treated?

Most fibroids need no treatment and only regular checks to be sure that they’re not growing too large or causing problems. Medicines including hormones and drugs that act against hormones can be tried. If fibroids continue to be a problem, hysterectomy (surgery to remove the uterus) is an option. Sometimes, fibroids alone may be surgically removed (myomectomy), which saves the uterus if children are wanted. Another newer method is uterine artery embolization. In this method, arteries to the uterus are blocked so they don’t feed the fibroids. Myolysis (electric current destroys fibroids and shrinks blood vessels feeding them) and cryomyolysis (liquid nitrogen is used instead of electric current) are other methods. However, fibroids can return and mean more surgery later. Newer medicines may shrink fibroids, but this change is only temporary.

DOs and DON’Ts in Managing Fibroids:

• DO get regular health care provider checkups.
• DO tell your health care provider your concerns and describe your symptoms.
• DON’T delay having children just because you have fibroids. They usually won’t get in the way of pregnancy. If you do need treatment for fibroids, some treatments can temporarily or permanently prevent you from becoming pregnant.
• DON’T worry about getting cancer from fibroids. Typical fibroids are not cancerous.

Surgery for uterine fibroids

Medication to treat fibroid symptoms usually only works while you are taking it. Many women who have severe pain and heavy menstrual bleeding end up considering surgery as an option. There are a number of different types of surgical treatments, each with its own pros and cons.

• Surgery is done in the hope that it can permanently stop the symptoms of uterine fibroids. Some women do, in fact, experience long-term relief. But surgery always carries risks too. Whether or not surgery is an option – and, if so, what kind of surgery – will depend on how the woman feels about the different advantages and disadvantages. The size, number and location of the fibroids will also influence the choice of treatment. Not all types of surgery are suitable for women who still want to have children.

Your doctor may recommend taking hormones such as GnRH analogues several weeks before having surgery. These kinds of artificial hormones are used to shrink the fibroids. Doctors can then make smaller cuts during surgery, allowing the womb (uterus) to recover more quickly. The drug ulipristal acetate is sometimes used for this purpose too.

• But removing individual fibroids isn’t a good idea if it might cause too much scarring in the womb, or if the risk of bleeding during or after surgery is too high. Plus, it isn’t always absolutely certain that the symptoms will improve after surgery. Hysterectomy (surgical removal of the womb) is then an option – or possibly another non-surgical treatment approach such as uterine artery embolization (UAE, sometimes also called uterine artery embolization, or UFE). Uterine artery embolization cuts off the blood supply to the fibroid.

Dr.Ruchi Tandon is a Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years experience in handling all kinds of Gynecological conditions including Fibroids.