Navigating the Challenges: Thyroid Disorders and Their Impact on Pregnancy

Navigating the Challenges: Thyroid Disorders and Their Impact on Pregnancy

Pregnancy is an exciting yet emotional journey filled with anticipation and excitement, but it also comes with a myriad of physical and hormonal changes. Among the various factors influencing a smooth pregnancy, thyroid health plays a crucial role. Thyroid disorders, which affect the butterfly-shaped gland in our neck responsible for regulating metabolism, can significantly impact the well-being of the mother and the developing fetus. In such cases, it becomes important to consult high-risk pregnancy doctors in Greater Kailash.

Understanding Thyroid Disorders

Thyroid disorders encompass a spectrum of conditions, including hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), and autoimmune disorders like Hashimoto’s disease and Graves’ disease. These disorders can disrupt the delicate balance of hormones essential for maintaining a healthy pregnancy. A good Gynecologist doctor in South Delhi must be consulted in such scenarios.

Hypothyroidism and Pregnancy

Hypothyroidism is a condition where the thyroid gland doesn’t produce enough thyroid hormones. During pregnancy, this condition can lead to complications such as preeclampsia, an increased risk of miscarriage, premature birth, and developmental issues in the baby. The developing fetus depends on the mother’s thyroid hormones, particularly in the early stages when the baby’s thyroid is not yet fully functional.

Untreated hypothyroidism during pregnancy has been linked to cognitive impairments in the child, emphasizing the critical importance of identifying and managing this condition. Regular monitoring of thyroid function by high-risk pregnancy doctors in Greater Kailash through blood tests is crucial for pregnant women with hypothyroidism to ensure that hormone levels remain within the optimal range.

Hyperthyroidism and Pregnancy

Conversely, hyperthyroidism, characterized by an excess of thyroid hormones, poses its own set of challenges during pregnancy. Complications can include an increased risk of preterm birth, low birth weight, and in severe cases, preeclampsia. The autoimmune nature of conditions like Graves’ disease adds an additional layer of complexity, as the antibodies produced by the mother can potentially affect the baby’s thyroid function.

Managing hyperthyroidism during pregnancy often involves a delicate balancing act. Medications may be adjusted to maintain thyroid hormone levels within a safe range, and close monitoring is essential to address any changes that may occur as the pregnancy progresses.

Autoimmune Thyroid Disorders

Autoimmune thyroid disorders, such as Hashimoto’s disease and Graves’ disease, involve the body’s immune system mistakenly attacking the thyroid gland. These conditions can have implications for fertility and increase the risk of miscarriage. Managing autoimmune thyroid disorders during pregnancy may require a multidisciplinary approach involving endocrinologists, obstetricians, and other healthcare professionals.

Ensuring a Healthy Pregnancy

For women with pre-existing thyroid disorders or those diagnosed during pregnancy, a collaborative approach between the patient and the Gynecologist doctor in South Delhi is crucial. Regular prenatal check-ups, including thyroid function tests, help monitor hormone levels and ensure timely adjustments to medication.

A well-balanced diet rich in iodine, a vital nutrient for thyroid function, is essential for pregnant women, but supplementation should be approached with caution and under medical supervision.

Lifestyle Modifications to Reduce Fibroid Growth and Recurrence

Lifestyle Modifications to Reduce Fibroid Growth and Recurrence

Uterine fibroids are noncancerous growths that can cause significant discomfort and disrupt a woman’s quality of life. While medical interventions are available, certain lifestyle modifications can play a crucial role in reducing fibroid growth and recurrence. By making proactive changes to their daily routines, women can potentially manage fibroids more effectively. If you have been diagnosed with fibroids, you must consult the best fibroids surgeon in South Delhi.

In this blog post, we will explore lifestyle modifications that can help reduce fibroid growth and minimize the chances of recurrence.

How to Minimize the Risk and Recurrence of Fibroid Growth?

Maintain a Healthy Weight

Maintaining a healthy weight is essential for managing fibroids. Obesity and excess weight have been associated with a higher risk of fibroid development and growth. By adopting a balanced diet and engaging in regular physical activity, women can achieve and maintain a healthy weight, potentially reducing the size and growth of fibroids.

Incorporate a Nutrient-Rich Diet

A diet rich in nutrients can support overall health and potentially influence fibroid growth. Add a variety of fruits, vegetables, whole grains, lean proteins, and healthy fats to your daily diet. Emphasize foods high in antioxidants, such as berries, leafy greens, and nuts, which can help reduce inflammation and promote cellular health.

Opt for Low Glycemic Index Foods

Choosing foods with a low glycemic index (GI) can be beneficial for managing fibroids. High GI foods can lead to increased insulin levels, potentially promoting fibroid growth. Opt for complex carbohydrates like whole grains, legumes, and non-starchy vegetables, which have a lower GI and provide sustained energy while regulating insulin levels.

Reduce Stress Levels

Chronic stress can impact hormonal balance and potentially contribute to fibroid growth. Engaging in stress-reducing activities such as meditation, yoga, deep breathing exercises, and regular physical exercise can help manage stress levels. Prioritize self-care, engage in hobbies, and create a balanced work-life routine to minimize stress and its potential effects on fibroids.

Limit Alcohol Consumption

Excessive alcohol consumption has been associated with an increased risk of fibroid growth and recurrence. Limiting alcohol intake or avoiding it altogether can help reduce the chances of fibroid development and its potential complications. Alternatives such as herbal teas, infused water, or mocktails could be better and healthier options.

Seek Regular Medical Monitoring

Regular medical check-ups and monitoring are essential for managing fibroids. Consult with your healthcare provider for regular screenings and examinations. Discuss appropriate treatment options and potential interventions to manage fibroids effectively. By actively participating in your healthcare journey, you can stay informed and make informed decisions.

For proper treatment and guidance for fibroids, you can take an appointment with Dr. Ruchi Tandon, a reliable and experienced gynecologist doctor in South Delhi.

Hysteroscopy – Why and How?

Hysteroscopy is a valuable diagnostic and therapeutic procedure in the field of gynecology. It offers several benefits and is commonly performed to address various uterine issues. An experienced doctor specializing in minimally invasive surgery in South Delhi performs this technique for various purposes. Let us see why.

Why Hysteroscopy is Performed?

Here are some reasons why hysteroscopy is performed:

Diagnosis of Abnormal Uterine Bleeding

Hysteroscopy helps investigate the underlying causes of abnormal uterine bleeding, such as heavy or prolonged menstrual periods, postmenopausal bleeding, or intermenstrual bleeding. It allows doctors to visually examine the uterine lining and identify conditions such as uterine polyps, fibroids, endometrial hyperplasia, or uterine cancer.

Evaluation of Infertility

It plays a crucial role in evaluating and addressing infertility issues. It enables doctors to assess the uterine cavity for abnormalities that may hinder conception or implantation. Conditions like uterine septum, intrauterine adhesions (Asherman’s syndrome), or scar tissue can be diagnosed and treated during the procedure, improving the chances of a successful pregnancy.

Treatment of Uterine Abnormalities

In addition to diagnosis, hysteroscopy allows for therapeutic interventions. It can be used to remove uterine polyps or fibroids, resect uterine septum, and release intrauterine adhesions. By addressing these abnormalities, hysteroscopy can alleviate symptoms, improve fertility outcomes, and enhance overall uterine health.

How is Hysteroscopy Performed?

Hysteroscopy is a minimally invasive procedure that involves the use of specialized instruments to examine and treat the uterus. Here is how it is done:

Preparation

Before the procedure, the patient may receive general or local anesthesia, depending on the extent of the hysteroscopy. This ensures comfort and pain control during the procedure.

Insertion of the Hysteroscope

The hysteroscope, a thin and flexible instrument with a light source and camera, is gently inserted through the vagina and cervix, and into the uterus. Carbon dioxide gas or a saline solution may be used to expand the uterine cavity, providing a clearer view of the area.

Visual Examination

Real-time images captured by the hysteroscope’s camera are projected onto a monitor, allowing the doctor to visually examine the uterine lining. This enables the identification of any abnormalities or pathologies.

Therapeutic Interventions

If necessary, therapeutic procedures can be performed during hysteroscopy. This may include the removal of polyps or fibroids, resection of uterine septum, or lysis of adhesions. Specialized instruments are used to carry out these interventions.

Post-procedure Care

After the hysteroscopy, the patient is monitored in a recovery area until the effects of anesthesia wear off. Most hysteroscopies are performed on an outpatient basis, allowing patients to return home the same day. Mild cramping or spotting may occur, but these usually subside within a few days.

Hysteroscopy is a valuable procedure used in gynecology for diagnostic and therapeutic purposes. It provides a comprehensive examination of the uterus, allowing for the identification and treatment of various uterine abnormalities. Dr. Ruchi Tandon, an experienced Gynecologist Doctor in South Delhi is an expert in performing hysteroscopy.

What Are the Common Gynecological Problems?

Gynecological problems are common as almost every woman experiences one or the other issues in her lifetime. However, in most cases, the conditions are mild and easily treatable. While on the other hand, some issues are severe enough to need surgical intervention. It is always better to consult an experienced Gynecologist doctor in South Delhi to address these issues timely and get the best treatment.

In this blog, we will have a quick look at some of the commonly reported gynecological problems.

Common Gynecological Problems

There are several common gynecological problems that women may experience at some point in their lives. Some of these problems include:

Menstrual disorders: Menstrual disorders refer to a range of conditions that affect a woman’s menstrual cycle, including the length of her cycle, the amount of bleeding, and the regularity of her periods. These include irregular periods, heavy periods, painful periods, and the absence of periods.

Pelvic pain: Pelvic pain refers to discomfort or pain in the lower abdominal area, below the belly button, and between the hips. It can affect both men and women. However, women are commonly affected. This can be caused by various factors such as endometriosis, pelvic inflammatory disease, ovarian cysts, and fibroids.

Vaginal infections: These can be caused by yeast, bacteria, or viruses and may cause symptoms such as itching, discharge, and pain during intercourse.

Polycystic Ovary Syndrome (PCOS): Polycystic ovary syndrome (PCOS) is a hormonal disorder that affects women. It is characterized by the presence of multiple cysts on the ovaries, which can cause irregular periods, infertility, weight gain, and other symptoms.

Menopause and perimenopause: These are natural stages in a woman’s life when the ovaries stop producing eggs and the levels of estrogen and progesterone decline, leading to symptoms such as hot flashes, mood changes, and vaginal dryness.

Sexually Transmitted Infections (STIs): Sexually transmitted infections (STIs), also known as sexually transmitted diseases (STDs), are infections that are spread through sexual contact, including vaginal, anal, and oral sex. These infections can be caused by bacteria, viruses, or parasites and may cause symptoms such as itching, burning, discharge, and pain during intercourse.

Pelvic organ prolapse: Pelvic organ prolapse is a medical condition in which one or more organs in the pelvic region, such as the uterus, bladder, or rectum, slip or protrude into the vaginal wall or outside the vaginal opening. This condition is more common in women and is caused by weakened pelvic floor muscles or damaged connective tissues that support the pelvic organs.

It is important to seek medical attention if you experience any symptoms or have concerns about your gynecological health. Consult Dr. Ruchi Tandon, an experienced Gynecologist doctor in South Delhi.

Cervical infection in women

Cervicitis

Cervicitis is an inflammation of the cervix (the end of the uterus). Cervicitis often does not cause symptoms, but if they do happen, they may include abnormal vaginal discharge, painful intercourse, or vulvar or vaginal irritation. Antibiotics successfully treat cervicitis in most cases. For other cases, laser therapy or surgery may be required.

What is cervicitis?

Cervicitis is an inflammation of the cervix (the end of the uterus). This inflammation may be acute or chronic in nature. Cervicitis might not have symptoms, or a woman with cervicitis may have abnormal vaginal discharge.

Who gets cervicitis?

Cervicitis is very common. It has been projected that more than half of all adult women will have cervicitis at some point. Women who engage in high-risk sexual behaviors and have multiple partners are at a higher risk for cervicitis. Women who have had sexually transmitted diseases, or who have partners who have had sexually transmitted diseases, are also at a higher risk for cervicitis. Sexual practices are far from the only cause of the condition, however.

What are the causes of cervicitis?

There are many causes of cervicitis. Acute cervicitis is usually caused by an infection. Chronic cervicitis is more likely from a noninfectious cause.
Infections can result from the introduction of staphylococcus or streptococcus bacteria into the uterus. The sexually transmitted diseases chlamydia and gonorrhea are also significant causes of cervicitis. It has been estimated as much as 40 percent of cases of cervicitis are related to chlamydia. Herpes simplex virus, trichomonas and mycoplasma genitalium are also sometimes a cause.

Noninfectious causes of cervicitis include exposure to chemicals or

mechanical irritation. These include:

• Chemical irritation from spermicides or douches or the latex used in condoms
• Reaction to diaphragms, cervical caps, tampons or pessaries inserted
• Radiation therapy or systemic inflammatory diseases

What are the symptoms of cervicitis?

Symptoms of cervicitis can include:

• Abnormal vaginal discharge that may be yellow, white, or gray and have an unpleasant odor. This may persist for a long period of time.
• Sexual intercourse may become painful.
• Vulvar or vaginal irritation.

Cervicitis often does not have any symptoms, however. This is one reason why women should have regular gynecological appointments. It is especially important to seek an exam if you notice any of the above symptoms and/or have had chlamydia or another sexually transmitted disease in the past.

How is cervicitis diagnosed?

If you have any of the above symptoms, or if you have engaged in high-risk sexual practices, you should see your Gynecologist for a full pelvic exam. At this exam, your Gynecologist may perform tests including a Pap smear. In this test, a swab is used to collect cells from the cervix and uterus to look for abnormalities.

Your Gynecologist will also take a sample of any vaginal discharge to test for bacteria, such as bacterial vaginosis under a microscope. Tests for the sexually transmitted diseases gonorrhea and chlamydia will also be done.

Your Gynecologist also perform a full manual pelvic exam, looking for:

• Any redness on the cervix
• Discharge
• Blood on the vagina or cervix
• Inflammation of the vaginal walls
You will lay down on an examination table with your feet in stirrups for these tests.

How is cervicitis treated?

If your Gynecologist determines that you have cervicitis, you will usually be prescribed an antibiotic to treat any bacterial infections that may be causing the condition. Women under age 25 or who engage in high-risk behaviors may be treated with antibiotics even if bacteria are not detected in the diagnosis. Some bacteria can be hard to detect but may still be present. You should abstain from intercourse until treatment is done.

Antibiotics successfully treat cervicitis in most cases. If cervicitis is not successfully treated by antibiotics, laser therapy or surgery may be required. Your Gynecologist can best determine the treatment for your cervicitis based on your age, habits, diagnostic tests, and the length of the condition.

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 cervical and vaginal infections .

Can Pelvic or uterine adhesions cause infertility?

Pelvic adhesions, sometimes referred to as “scar tissue”, are a common cause of both infertility and pelvic pain.

Pelvic adhesions can occur as a result of a variety of different conditions including endometriosis, pelvic infection, and previous abdominal or pelvic surgery. It is well known that pelvic adhesions develop over 90% of the time following major abdominal surgery. The most common types of surgery that predispose to the development of pelvic adhesions include the removal of uterine fibroids (myomectomy), treatment of endometriosis, removal of ovarian cysts, and the repair of obstructed fallopian tubes.

Many complications can occur as a result of pelvic adhesions. For example, it is thought that adhesions may be a significant factor in as much as 40% of cases of infertility. They are also thought to be responsible for up to 50% of cases of chronic pelvic pain. In addition, adhesions are typically responsible for 50-75% of cases of bowel obstruction. Although more recent data are lacking, the treatment of pelvic adhesions accounted for 3% of all surgical procedures performed in the United States in 1998, as well as 1% of all hospital admissions and 2% of all patients admitted for surgeries around that time.

How do pelvic adhesions occur?

Adhesions typically develop in response to injury, as part of the normal healing process. Immediately following injury, cells that cause healing (inflammatory cells) migrate to the site of the injury. Within seven days following injury, the scaffold for healing or adhesion formation has already developed. As a result, it appears that no new adhesions form more than seven days after an injury. Rather, the character of the adhesion changes, progressing from thin, filmy adhesions to more dense, vascular adhesions. The earlier in this process that adhesions can be removed, the less likely it is that they will recur and cause long-term problems.

Adhesion formation that occurs following surgery can be of two types; de novo adhesion formation or adhesion reformation. De novo adhesion formation means the formation of adhesions at a site that did not have any adhesions affecting it prior to surgery. This would include the formation of adhesions around the uterus following the removal of a fibroid tumor or the formation of adhesions around an ovary following removal of an ovarian cyst.

Adhesion reformation refers to the recurrence of adhesions following a procedure designed to remove pre-existing pelvic adhesions. This difference is important, as the techniques described below may be very effective at preventing de novo adhesion formation, while they appear to be somewhat less effective at preventing adhesion reformation

What types of surgeries can increase my risk of adhesions?

In most cases of adhesions, they form in the majority of women after gynaecologic pelvic surgery. Studies have shown that adhesions formed in 55-100% of patients who had reproductive pelvic surgery, whether open or laparoscopic.

For example:

• myomectomy (surgery to remove fibroids)
• tubal surgery (to remove an ectopic pregnancy)
• surgery on the ovary (to remove cysts)
• surgery for endometriosis
Even surgery to remove adhesions can lead to new adhesions. It can be a vicious cycle.
• Laparoscopic surgery (surgery done through several small incisions using a camera) has been known to cause less adhesion formation than laparotomy (surgery through one larger incision without use of a camera).
• Microsurgery (surgery using a microscope or magnifying glass, and special surgical technique) leads to less tissue damage and has a lower incidence of adhesion development than the traditional approach.
• Diagnostic procedures, which only involve a visual inspection of the organ(s), such as a diagnostic hysteroscopy or diagnostic laparoscopy, rarely lead to adhesions.

How can I reduce my risk of adhesions?

It starts with talking to your doctor and explaining your concerns about adhesions. There are techniques which can be used at the time of surgery to reduce the risk of developing adhesions. In addition to using microsurgery or laparoscopic techniques, prevention of infection is essential.

During surgery, various products are used to inhibit adhesion formation, known as adhesion barriers. These include gauze-like materials placed over the tissue which dissolve to become a gelatinous layer to reduce the incidence of post-operative adhesions. This material is eventually absorbed by the body.

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 and high risk Pregnancies.

COVID vaccine in women healthcare

Who should be vaccinated first?

As with all COVID-19 vaccines, health workers at high risk of exposure and older people should be prioritized for vaccination.

As more vaccine becomes available, additional priority groups should be vaccinated, with attention to people disproportionately affected by COVID-19 or who face health inequities.

Who else can take the vaccine?

The vaccine is safe and effective in people with known medical conditions associated with increased risk of severe disease, such as hypertension, diabetes, asthma, pulmonary, liver or kidney disease, as well as chronic infections that are stable and controlled.

Although further studies are required for immunocompromised persons, people in this category who are part of a group recommended for vaccination may be vaccinated after receiving information and counselling.

Persons living with HIV are at higher risk of severe COVID-19 disease. Known HIV-positive vaccine recipients should be provided with information and counselling.

Vaccination can be offered to people who have had COVID-19 in the past. But individuals may wish to defer their own COVID-19 vaccination for up to six months from the time of SARS-CoV-2 infection.

The vaccine can be offered to a breastfeeding woman who is part of a group recommended for vaccination (e.g. health workers); discontinuing breastfeeding after vaccination is currently not recommended.

Should pregnant women be vaccinated?

While pregnancy puts women at higher risk of severe COVID-19, very little data are available to assess vaccine safety in pregnancy.

Nevertheless, based on what we know about this kind of vaccine, we don’t have any specific reason to believe there will be specific risks that would outweigh the benefits of vaccination for pregnant women.

For this reason, those pregnant women at high risk of exposure to SARS-CoV-2 (e.g. health workers) or who have comorbidities which add to their risk of severe disease, may be vaccinated in consultation with their health care provider.

Who should not take the vaccine?

Individuals with a history of severe allergic reaction to any component of the vaccine should not take this or any other mRNA vaccine.

While vaccination is recommended for older persons due to the high risk of severe COVID-19 and death, very frail older persons with an anticipated life expectancy of less than 3 months should be individually assessed.

The vaccine should not be administered to persons younger than 18 years of age pending the results of further studies.

What’s the recommended dosage?

SAGE recommends the use of the Moderna mRNA-1273 vaccine at a schedule of two doses (100 µg, 0.5 ml each) 28 days apart. If necessary, the interval between the doses may be extended to 42 days.

Compliance with the full schedule is recommended and the same product should be used for both doses.

Is it safe?

While this vaccine has yet to be approved by WHO for an Emergency Use Listing, it has undergone review by the European Medicines Agency (EMA) and consequently meets WHO’s criteria for SAGE consideration.

The EMA has thoroughly assessed the data on the quality, safety and efficacy of the Moderna COVID-19 vaccine and authorized its use across the European Union.

SAGE recommends that all vaccinees be observed for at least 15 minutes after vaccination. Those who experience an immediate severe allergic reaction to the first dose should not receive additional doses.

Longer-term safety assessment involves continued follow up of clinical trial participants, as well as specific studies and continued surveillance of secondary effects or adverse events of those being vaccinated in the roll out.
The Global Advisory Committee on Vaccine Safety, a group of experts that provides independent and authoritative guidance to the WHO on the topic of safe vaccine use, receives and assesses reports of suspected safety events of potentially international impact.

How efficacious is the vaccine?

The Moderna vaccine has been shown to have an efficacy of approximately 92 per cent in protecting against COVID-19, starting 14 days after the first dose.

Does it work against new variants?

Based on the evidence so far, the new variants of SARS-CoV-2, including the B.1.1.7 and the 501Y.V2, do not alter the effectiveness of the Moderna mRNA vaccine. The monitoring, collection and analysis of data on new variants and their impact on the effectiveness of COVID-19 diagnostics, treatments and vaccines continues.

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.

ecurrent miscarriage or recurrent Pregnancy loss

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.

Abnormalities in uterus or reproductive organs

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.

Diagnostic Laparoscopy for infertility

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.