Month: January 2021

Spontaneous pregnancy loss is a surprisingly common occurrence, with approximately 15% of all clinically recognized pregnancies resulting in pregnancy failure. Recurrent pregnancy loss (RPL) has been inconsistently defined. When defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period, it affects approximately 1% to 2% of women. This review highlights the current understanding of the various etiologies implicated in RPL, including factors known to be causative, as well as those implicated as possible causative agents. The appropriate diagnostic evaluation, therapy, and prognosis are also addressed.

Spontaneous pregnancy loss is a surprisingly common occurrence. Whereas approximately 15% of all clinically recognized pregnancies result in spontaneous loss, there are many more pregnancies that fail prior to being clinically recognized. Only 30% of all conceptions result in a live birth.

Spontaneous pregnancy loss can be physically and emotionally taxing for couples, especially when faced with recurrent losses. Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period. Based on the incidence of sporadic pregnancy loss, the incidence of recurrent pregnancy loss should be approximately 1 in 300 pregnancies. However, epidemiologic studies have revealed that 1% to 2% of women experience recurrent pregnancy loss.

Defining RPL as a clinical entity requiring diagnostic testing and therapeutic intervention rests on knowledge of the elevation of risk for subsequent fetal loss and the probability of finding a treatable etiology for the disorder. Although no reliable published data have estimated the probability of finding an etiology for RPL in a population with 2 versus 3 or more miscarriages, the best available data suggest that the risk of miscarriage in subsequent pregnancies is 30% after 2 losses, compared with 33% after 3 losses among patients without a history of a live birth. This strongly suggests a role for evaluation after just 2 losses in patients with no prior live births. An earlier evaluation may be further indicated if fetal cardiac activity was identified prior to a loss, the woman is older than 35 years, or the couple has had difficulty in conceiving.

The high baseline rate of spontaneous isolated and recurrent pregnancy losses in the general population, the lack of consistent definition for RPL, limited access to tissues allowing study of the disorder, and the remarkably good prognosis for live birth among patients with RPL combine to frustrate aims at diagnostic and therapeutic recommendations. At present, there exist a small number of accepted etiologies for RPL.These include parental chromosomal abnormalities, untreated hypothyroidism, uncontrolled diabetes mellitus, certain uterine anatomic abnormalities, and antiphospholipid antibody syndrome (APS). Other probable or possible etiologies include additional endocrine disorders, heritable and/or acquired thrombophilias, immunologic abnormalities, infections, and environmental factors. After evaluation for these causes , approximately half of all cases will remain unexplained.

Genetic Etiologies

Approximately 2% to 4% of RPL is associated with a parental balanced structural chromosome rearrangement, most commonly balanced reciprocal or Robertsonian translocations. Additional structural abnormalities associated with RPL include chromosomal inversions, insertions, and mosaicism. Single gene defects, such as those associated with cystic fibrosis or sickle cell anemia, are seldom associated with RPL.

Appropriate evaluation of RPL should include parental karyotyping. Genetic counseling is indicated in all cases of RPL associated with parental chromosomal abnormalities. Depending on the particular diagnosis, directed therapy may include in vitro fertilization with preimplantation genetic diagnosis. The use of donor gametes may be suggested in cases involving genetic anomalies that always result in embryonic aneuploidy (ie, Robertsonian translocations involving homologous chromosomes).

Anatomic Etiologies

Anatomic abnormalities account for 10% to 15% of cases of RPL and are generally thought to cause miscarriage by interrupting the vasculature of the endometrium, prompting abnormal and inadequate placentation. Thus, those abnormalities that might interrupt the vascular supply of the endometrium are thought to be potential causes of RPL. These include congenital uterine anomalies, intrauterine adhesions, and uterine fibroids or polyps. Although more readily associated with second trimester losses or preterm labor, congenital uterine anomalies also play a part in RPL.

The uterine septum is the congenital uterine anomaly most closely linked to RPL, with as much as a 76% risk of spontaneous pregnancy loss among affected patients. Other Müllerian anomalies, including unicornuate, didelphic, and bicornuate uteri have been associated with smaller increases in the risk for RPL. The role of the arcuate uterus in causing RPL is unclear. The presence of intrauterine adhesions, sometimes associated with Asherman syndrome, may significantly impact placentation and result in early pregnancy loss.

Intramural fibroids larger than 5 cm, as well as submucosal fibroids of any size, can cause RPL. Although congenital anomalies caused by prenatal exposure to diethylstilbestrol are clearly linked to RPL, this is becoming less clinically relevant as most affected patients move beyond their reproductive years.

Diagnostic evaluation for uterine anatomic anomalies should include office hysteroscopy or hysterosalpingography (HSG). Hysteroscopic resection of intrauterine adhesions and intrauterine septa are indicated if these abnormalities are identified. Patients undergoing successful hysteroscopic septum resection seem to enjoy near normal pregnancy outcomes, with term delivery rates of approximately 75% and live birth rates approximating 85%.Myomectomy should be considered in cases of submucosal fibroids or any type fibroids larger than 5 cm. Resection has been shown to significantly improve live birth rates from 57% to 93%.Myomectomy can be performed via open laparotomy, laparoscopy, or hysteroscopy.

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 recurrent abortions.

An understanding of congenital anomalies as they are encountered in clinical practice is greatly enhanced by not only a knowledge of normal embryology and the mechanism of formation of normal infants, but also an insight into the processes that result in the development of anomalies. An awareness of malformations and a systematic examination and appraisal of every neonate will greatly increase the number of such anomalies found. In some instances, e.g., congenital adrenal hyperplasia, imperforate anus, diaphragmatic hernia, and esophageal atresia, early detection and prompt intervention may be lifesaving. In adults, amenorrhea is an important clue and may suggest an imperforate hymen, vaginal septum or absence of the uterus.

The finding of one anomaly should stimulate a careful gynecologist to carry out a complete study to detect renal and ureteral anomalies, particularly the solitary pelvic kidney which might be removed as a “pelvic mass”. Many anomalies occur infrequently so that only physicians in large medical centers may see them frequently enough to be aware of the possible anomalies and their causation, prognosis, and, in some cases, correction. The identification and interpretation of such abnormalities constitute a real challenge to the clinician. A knowledge of the problems and pitfalls in the management of these defects will benefit both the obstetrician and the gynecologic surgeon.

Causes of abnormalities

The causes of congenital malformations or abnormalities present at birth may be either environmental or genetic (chromosomal abnormalities). It is not always easy to separate the two factors; both may be at work in the same embryo or fetus. Rapidly growing embryonic organs are the most sensitive to environmental influences.

Millen has classified the mechanisms of anomaly production as follows:

1. Developmental arrest—cessation of development before completion
2. Agenesis or aplasia—failure of normal development
3. Hyperplasia or local overgrowth
4. Aberrant development
5. Failure of normal resorption (either too much or too little) or resorption in the wrong locations
6. Secondary degeneration of normally developed structures

Millen also emphasizes “that the period when environmental agents may affect the development of an embryo is very short, being nearly over by the end of the eighth week of pregnancy”. Organogenesis occurs from day 13 to day 60; teratogenic (G. teras, monster) agents are most dangerous during this period. There is a time relationship between specific organ systems and sensitivity to environmental factors as well as a relationship between specific teratogens and specific organ systems. Examples are rubella infections occurring in the first trimester, with a high incidence of cataracts, deafness, and cardiac malformations, and use of thalidomide, with varied malformations of arms and legs.

Nutgen has evaluated in detail the mechanisms of action of various environmental teratogenic factors. These include the following:

1. Ionizing radiation
2. Vital disease and related infections
3. Chemical factors
4. Immunologic disturbances
5. Hormones
6. Nutritional factors

Ionizing radiation is probably one of the best known damaging factors. Infections such as rubella virus, cytomegalovirus, and Toxoplasma gondii can cause severe damage to the eyes and central nervous system. Chemicals include aminopterin (causing skeletal defects and nervous system damage), methotrexate, and thalidomide. Immunologic disturbances include Rhesus incompatibilities. Hormone damage is particularly interesting: the administration of exogenous testosterone, synthetic progestogens, and similar preparations can cause iatrogenic deformities of the female genitalia.

Pathologic hyperandrogenemia, as seen in luteomas of pregnancy, can result in virilization in the female newborn. Environmental factors, such as exposure to diesel fumes, have also been associated with virilization due to inhibition of aromatase and accumulation of excess testosterone. Nutritional factors apparently have little direct teratogenic effect on the fetus.

Uterine abnormalities

The most frequent uterine anomalies (Fig. 3) are those resulting from varying degrees of failure of fusion of the müllerian ducts. This variability makes classification difficult and determination of the true incidence uncertain. Many of these malformations are detected by radiologic or sonographic studies. Estimates of incidence vary from 0.13% to 4.0%. The incidence of müllerian anomalies in patients with infertility has been reported to be as high as 6.3%.Pregnancy occurs in many women despite these anomalies. The complication rates with pregnancy are considerably increased; complications include abortion, prematurity, postpartum hemorrhage, retained placenta, and breech presentation. Not surprisingly, the rate of cesarean delivery is markedly higher.

Uterus duplex, or the bicornuate uterus, is the most frequent uterine anomaly. The unicollis type in which there is a single cervix with a septum that does not reach the cervix is the most frequent type, occurring in over one third of all patients with uterine anomalies.

Uterus duplex bicollis, in which two cervices are present, is less frequent. Obstetric complications are frequent, but live births do occur.

Uterus didelphys, with completely separate uterine cavities, is also frequent. The cervices are externally united and the uterine fundi are externally separate. In most patients the vagina is septate, causing a double vagina. The halves of such a uterus are often of different sizes. If there is an asymmetric vaginal septum which occludes one vagina, mucocolpos or hematocolpos may result. Communicating uteri, involving an incomplete uterine septum with part of the fetus in each uterine cavity, occasionally occur.

Uterus septus is an essentially normal uterus with a septum reaching to the cervix.

Uterus subseptus involves a partial septum that does not reach the cervix. Twins apparently occur approximately three times more often in women with this condition than in women with normal uteri; the cause is not clear.
Uterus arcuatus is a normal uterus without a septum. The fundus, however, is notched or flattened. There is usually no interference with normal pregnancy.
Uterus unicornis is a uterus with a single horn. A normal vagina and a single normal tube are usually present. The other half of the uterus is usually absent or rudimentary. In most patients the kidney is missing on the side of the missing uterus. Successful pregnancy can occur.

Separate hemiuteri with separate vaginas is a rare condition that is usually associated with duplications of urethra and bladder or of the colon and anus. Pregnancy in each of the two hemiuteri in the same woman at different times has been reported.

These anomalies result from failure of fusion of the paired müllerian ducts, but in some instances there is a true duplication of the ducts on one or both sides. Such duplications result from splitting of the müllerian duct during the seventh week of development. Accessory tubes or ovaries may be present.

Semmens extensively reviewed the literature on genital tract anomalies and evaluated 56 personal patients as well as 500 cases from the literature. He employed a simplified classification, based entirely on the functional capacity of the uterine cavity, which divided genital tract anomalies into two groups: group I—hemiuterus of single müllerian origin, paired or otherwise, and group II—uterus of dual müllerian origin, associated with varying degrees of absorption. He concluded that if the entire functional component has been derived from a single müllerian duct and its vaginal outlet is a cervical canal of similar origin its capacity is smaller than that of the uterus resulting from fusion of bilateral ducts.

By contrast, if the uterus is derived from two müllerian ducts, its capacity is larger. Semmens concluded that the space available for the developing fetus as well as the variations in uterine circulation had a direct effect on the length of gestation, onset and behavior of labor, and overall fetal salvage. The diagnosis of uterine anomalies during pregnancy is always difficult. The most important factor is awareness of their existence and frequency and of the problems that frequently develop. Findings such as a floating head at term without apparent cause, notching and broadening of the uterine fundus, abnormal lie, recurrent breech presentations, prolonged third stage of labor, and trapped or retained placenta indicate the possibility of an anomaly. In abnormal uteri, triangular spasm and cornual pocketing of the placenta may occur and necessitate manual removal of the placenta.

The administration of oxytocin under these circumstances usually increases the degree of pocketing in an abnormal uterus. Among antepartum patients, pyelitis (often associated with a urologic anomaly), passage of a decidual cast, hemorrhage, and premature rupture of the membranes are the most common complications. Intrapartum complications include septal dystocia, incarcerated nongravid horn, uterine inertia, and retained placenta. Fetal dystocia is considerably increased. Postpartum complications are few and include hemorrhage, retained placenta, and failure of uterine involution. Most complications of uterine anomalies in the pregnant woman can be anticipated and managed successfully if the clinician is alert to the possibility of anomalies and if the nature of the anomaly is known.

The finding of an asymmetrically located cervix in the vaginal fornix, an excessively large cervix whether or not a septum is present, or a duplicated cervix suggests uterine abnormality. Abnormal configurations of the fundus of the uterus in the third trimester should suggest abnormalities to the clinician, as should abnormal presentations and failure of the presenting part to engage without apparent reason. An obstetric history of successive abortions, recurrent breech presentations, or recurrent pyelitis should alert the obstetrician to the possibility of anomalies and, in nonpregnant women, to the need for hysterosalpingogram, saline sonography, magnetic resonance imaging, and renal imaging.

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 uterine abnormalities.

Laparoscopy overview

• Laparoscopy for infertility is a minimally invasive surgical procedure in which a telescope-like instrument (laparoscope) with light and small camera allows the surgeon to examine the pelvic anatomy for causes of female infertility.
• Laparoscopy can be diagnostic, assessing for causes of infertility in the uterus, fallopian tubes and ovaries.
• An operative laparoscopy involves surgical treatment for problems found during a diagnostic laparoscopy procedure, utilizing small surgical tools passed through the laparoscope.
• Laparoscopic surgery can also be used to remove scar tissue or endometriosis.

When is laparoscopy used for treating infertility?

Laparoscopy for infertility is generally only performed after other fertility tests have not resulted in a conclusive diagnosis. For this reason, laparoscopy is often performed on women with unexplained infertility.

Laparoscopy also allows for biopsy of suspect growths and cysts that may be hampering fertility. Laparoscopy may be recommended for women experiencing pelvic pain, which is a potential symptom of endometriosis. Laparoscopy can also remove scar tissue that can be a cause of pelvic or abdominal pain.

Why It’s Needed

Some causes of infertility can only be diagnosed through laparoscopy.

(Endometriosis, for example.) Laparoscopy allows your doctor to not only see what’s inside your abdomen but also biopsy suspicious growths or cysts.

Also, laparoscopic surgery can treat some causes of infertility, allowing you a better chance at getting pregnant either naturally or with fertility treatments.

How Is It Done?

Laparoscopy is performed in a hospital under general anesthesia. While it is sometimes possible to conduct a diagnostic laparoscopy in a fertility clinic office, this is not recommended. In the office setting, if something is found during the procedure, you will need to have the procedure again in a hospital setting for the repair.

Your doctor will give you instructions on how to prepare for surgery beforehand. You will probably be told not to eat or drink for 8 or more hours before your scheduled surgery, and you may be instructed to take antibiotics.

When you get to the hospital, you’ll receive an IV, through which fluids and medication to help you relax will be delivered. The anesthesiologist will place a mask over your face, and after breathing a sweet-smelling gas for a few minutes, you’ll fall asleep.

Once the anesthesia has taken effect, the doctor will make a small cut around your belly button. Through this cut, a needle will be used to fill your abdomen with carbon dioxide gas. This provides room for your doctor to see the organs and move the surgical instruments.

Once your abdomen is filled with gas, the surgeon will then place the laparoscope through the cut to look around at your pelvic organs. The surgeon may also biopsy tissue for testing.

The surgeon will visually evaluate the pelvic organs and the surrounding abdominal organs. He or she will look for the presence of cysts, fibroids, scar tissue or adhesions, and endometrial growths. He or she will also look at the shape, color, and size of the reproductive organs.

A dye may be injected through the cervix, so the surgeon can evaluate if the fallopian tubes are open.

Even if no signs of endometriosis or other problems are found, the surgeon may remove a sample of tissue to be tested. Sometimes, very mild endometriosis is microscopic and cannot be seen by the naked eye with the laparoscopic camera.

If an ectopic pregnancy is suspected, the surgeon will evaluate the fallopian tubes for abnormal pregnancy.

How Will It Feel?

During laparoscopic surgery, you’ll be under the effects of general anesthesia, so you should not feel any pain, nor remember the procedure.

When you wake up, you may have a sore throat. This is caused by the tube placed down your throat to help you breathe during surgery. (This tube is removed before you wake-up).

It’s normal for the area around the cuts to feel sore, and your abdomen may feel tender, especially if your doctor removes a lot of scar tissue. You may feel bloated from the carbon dioxide gas, and you may experience sharp pains in your shoulder. This should go away in a few days.

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 infertility.

Blocked fallopian tubes are one possible cause of female infertility. There are usually no symptoms, but there are some risk factors that can increase the chance of developing the condition. The medical term for a blocked fallopian tube is tubal occlusion.

The fallopian tubes are muscular tubes that are lined with delicate hair-like structures. These “hairs” work in both directions; helping an egg to travel from the ovaries down to the womb (uterus) and helping sperm travel up from the womb.

Each fallopian tube ends in fimbriae, which are finger-like structures. The fimbriae catch and guide an egg when the ovary releases it.

The fallopian tubes play an important role in conception because they are where most eggs are fertilized.

If any part of the fallopian tube is damaged, for example by surgery or an infection, they can become blocked by scar tissue.

Symptoms

Blocked fallopian tubes do not often present symptoms other than difficulty conceiving. Doctors typically class this as having tried to conceive for 1 year without success.

A blocked fallopian tube may cause some women to experience symptoms such as pain in the pelvis or belly. This pain might happen regularly, such as around the time of their period, or be constant.

Sometimes, a blockage in a fallopian tube can cause a fertilized egg to get stuck. This is known as an ectopic pregnancy.

An ectopic pregnancy may not always cause symptoms and is usually detected during a scan. However, some woman may experience signs of pregnancy, such as stomach pain on one side of the body, or vaginal bleeding. Any woman who suspects she has an ectopic pregnancy should seek immediate medical attention.

Causes

Fallopian tubes can become blocked for a range of reasons, which include:
• a history of pelvic infection
• a previous burst appendix
• having had a sexually transmitted disease, such as gonorrhea or chlamydia
• endometriosis, a condition that causes the lining of the womb to grow outside of the uterus
• history of abdominal surgery
• hydrosalpinx, which is swelling and fluid at the end of a fallopian tube Effects on fertility

All of these conditions can affect the fallopian tubes directly or this area of the body. In most cases, these conditions or procedures create scar tissue that can block the tubes.

The female reproductive system is made up of the ovaries, uterus, and fallopian tubes.

If a medical problem has affected any of these three areas, it may make getting pregnant more difficult.

Each of the two ovaries is connected to the uterus by a fallopian tube. The ovaries store eggs and release them randomly, with one ovary releasing an egg each month.

For example, the right ovary might release an egg for 3 months in a row, and then the left ovary might release an egg the following month.

If one fallopian tube is blocked, it may still be possible for an egg to be fertilized. If both are blocked, this is less likely.

Diagnosis

Blocked fallopian tubes can be difficult to identify. The tubes can open and close, so it is not always easy to tell if they are blocked or just closed.

There are three key tests to diagnose blocked fallopian tubes:

• An X-ray test, known as a hysterosalpingogram or HSG. A doctor injects a harmless dye into the womb, which should flow into the fallopian tubes. The stain is visible on an X-ray. If the fluid does not flow into the fallopian tubes, they may have a blockage.
• An ultrasound test, known as a sonohysterogram. This is very similar to the HSG test but uses sound waves to build up a picture of the fallopian tubes.
• Keyhole surgery, known as a laparoscopy. A surgeon makes a small cut in the body and inserts a tiny camera to take pictures of the fallopian tubes from inside.

A laparoscopy is the most accurate test for blocked tubes. However, doctors may not recommend this test as an early diagnosis because it is invasive and cannot treat the issue.

A doctor may be able to suggest a possible diagnosis based on medical history. For example, a woman may have had a burst appendix in the past. If the woman has had difficulty conceiving, this could suggest blocked fallopian tubes as a likely cause.

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 high risk Pregnancies and blocked fallopian tubes.

Immunization during pregnancy is a simple and effective way to protect the mother and child from certain infections. The immunological changes occur during pregnancy which may be responsible for the susceptibility of certain infectious diseases that increases the risk of more serious outcomes. Vaccination of pregnant women can protect to mother against vaccine-preventable infections, and in so doing potentially protect the fetus. Immunization during pregnancy can also directly protect the fetus and infant via transferred of antibodies from the mother to the fetus.

This is why vaccinations during pregnancy are so important. Vaccination during pregnancy is a cost-effective strategy to improve pregnancy outcomes in India. Globally, no scientific study exist which shows the risk of fetus after vaccination of pregnant women with inactivated vaccines or bacterial vaccines or toxoids. Even live vaccines causing risk to fetus is theoretical. Vaccination with inactivated virus, bacterial or toxoid in pregnancy is risk to a developing fetus during pregnancy is theoretical. But definitely the live vaccine poses a theoretical risk to a developing fetus. Therefore, all live vaccines should be avoided during pregnancy. The developing country like India where the people can’t afford these vaccines, the government should be included these vaccines in routine immunization program.

Maternal immunization provides important health benefits to both pregnant women and to their fetus. Vaccine-preventable diseases cause significant morbidity and mortality among maternal, neonatal, and young infant. Some infections are so serious even they can waste pregnancy, harm her baby during pregnancy or after delivery. These complications can be protected with vaccination. This is why vaccinations are so important for pregnant mothers. Vaccines strengthen the immune systems of body that can fight off serious infectious diseases.

A vaccine can help in protection of the mother’s body from infections and this immunity passes to her baby during pregnancy. This immunity keeps the child safe during the first few months of life until baby gets his own vaccination. Vaccination also protects mothers from getting a serious disease that could affect future pregnancies. Fetus getting any risk after vaccination of the mother during pregnancy primarily is theoretical. Globally, no scientific study exist which shows the risk of fetus after vaccination of pregnant women with inactivated vaccines or bacterial vaccines or toxoids.

Even live vaccines causing risk to fetus is theoretical. Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm. Not all vaccinations are safe during pregnancy but some of inactivated vaccines are considered safe which can be give to pregnant women who might be at risk of infection.

Tetanus vaccine

Tetanus can cause severe morbidity in the mother and mortality in the neonate. Tetanus is a life-threatening bacterial disease that is caused by the toxin of a bacterium called Clostridium tetani which is often found in soil. Tetanus bacteria enter the body through an open wound. It could well be a tiny prick or scratch on the skin, although Tetanus infection is more common when there is a deep puncture wound such as a bite, cut, burn or an ulcer.

Tetanus affects a person’s nervous system and can be fatal if left untreated. Neonatal tetanus usually occurs in newborns through infection of the unhealed umbilical stump, especially when the stump is cut with a non-sterile instrument. Tetaus is prevented only through vaccination. The tetanus vaccine contains noninfectious toxoids. Tetanus toxoids appear safe during pregnancy and are administered in many countries of the world to prevent neonatal tetanus.

The World Health Organization (WHO) reported that neonatal tetanus kills over 200,000 newborns each year; almost all these deaths occur in developing countries while it is very rare in developed nations.

To maximize the maternal antibody response and passive antibody transfer to the infant, the national immunization schedule in India recommends the 2 doses of tetanus toxoid (TT) for unknown immunization status of pregnant women i.e the first dose of tetanus toxoid should be administered as soon as pregnancy is detected, second dose of tetanus toxoid is administered after 4 weeks and if a mother received 2 TT doses in the last pregnancy and mother gets again pregnant with in 3 y than only one dose of TT is recommended and that dose is called booster dose. Some experts recommend that the second dose of the vaccine should be given 4 weeks prior to the expected date of delivery.

The WHO also recommends that a third vaccine be given 6 months after the second one to provide protection for at least 5 y After TT vaccination, the antibodies formed in mother are transferred to baby and protect baby for a few months after birth. TT vaccination also helps to prevent premature birth or delivery. The American Congress of Obstetricians and Gynecologists recommends use of tetanus immune globulin, as there is no evidence of any adverse effects to the fetus from the tetanus immunoglobin.

Influenza vaccine

Influenza can cause severe illness in pregnant women than non pregnant women. During pregnancy, there is a change in the immune system, heart and lungs which makes pregnant women more prone to severe illness as well as hospitalizations and even death from influenza. Influenza infection during pregnancy also has a greater chance for serious problems for their unborn babies, including premature labor and delivery.

Women in the second and third trimesters of pregnancy are at increased risk for hospitalization from influenza. Therefore, routine inactivated influenza vaccine is recommended for all women who will be pregnant (in any trimester) during influenza season. The available inactivated influenza vaccines for the control of seasonal influenza are safe and efficacious and have the potential to prevent significant morbidity and mortality in pregnant women.

Live attenuated influenza vaccine is available in form of an intranasal spray and that is not recommended for pregnant women. Maternal influenza immunization offers demonstrated disease prevention benefits for women and their newborns and is a critically important component during pregnancy. Pregnant women should be counseled about the benefits of the influenza vaccine for themselves and their unborn baby.

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 high risk pregnancy .