Monday, February 28, 2011

Medical termination of Pregnancy

I miss NHS for many reasons.One of them is the freedom to choose whether you as a clinician wish to be a part of Medical termination of pregnancy or not.I have an ethical issue with termination of pregnancy and NHS gave me the freedom to say a no and all throughout my working in UK ,I was not a part of even single TOP accept if it was for a congenitally malformed baby or any such medical indication.
In Indian Practice one can choose not to do a MTP/TOP(Termination of pregnancy) ,but then that can affect your practice,as these couples come to you for a termination first and may be an year later come back for an Antenatal check up of pregnancy.So,I do perform 1st trimester terminations in India and feel guilty every time I do so.
I feel less guilty when it is a medical ( with pills) as I just prescribe the medicines.I know,still the involvement is there and am responsible for it.Medical TOP has good 30 % chance of being a faliure.There is a very clear RCOG guideline on of these 30% who would need surgical intervention ( Suction and evacuation).Those who have an endometrial thickness grater than 15 mm or the retained product of conception is approx 15 mm. There is no recommendation to prescribe a second dose of misoprost.I am very cautious in explaining the risk of failure to my patients and the aftermath but have realized that after a failure they insist on a second dose of misoprost as the 'radiologist' suggested so.That is 'quackery'.Practice of medicine without evidence is quackery and shouldn't be practiced.
So,please listen to your doctor properly during the consult,if you don't understand ,ask,ask,ask and ask before you decide any particular process.But once taken a decision don't try to influence a doctors treatment.Agreed you have a right to make a choice but the doctor has the right to say No to treat you.

Friday, February 25, 2011


In my previous post I talked of an emergency.Let's talk about that.
I am on call on Wednesdays.At 00.15 ,got a call from my attending consultant Dr Veenu Agarwal.There was young lady,all of 21 years in the triage,pouring blood vaginally.She was escorted by her boyfriend and friends of her boyfriend.They were all students of a very prestigious university of Delhi.
Apparently this girl got pregnant.Consulted some doctor at some Sharda Hospital for Termination of pregnancy.No ultrasound was conducted there to ascertain weeks of pregnancy,though her history was suggestive of about 12 weeks of pregnancy.seemed like she was advised to take the pills also in wrong manner.Who knows she had been to a local chemist and self medicated her(Very common in India).

This girl was slowly sinking with a rising pulse and dropping blood pressure.We were running short of time lest she goes in shock and DIC.Dr veenu very efficiently shifted the young lady to OR and directed the radiologist to come directly there to confirm the weeks of pregnancy.
It was a big uterus with incomplete miscarriage.She was bleeding.......It resembled spirts coming out of a fountain.
A suction and evacuation was done and as expected bleeding stopped immediately.
Her Hb had dropped to 7 gm%.But being a young patient recovery was quick.
Next day before her discharge I gave her an option of OCP and other contraceptives too.She declined flatly.
By this blog I wish to convey all young girls who behave in similar manner:please don't self medicate yourself.It might turn out to be a life threatening situation. responsible and use a regular contraceptive

Thursday, February 24, 2011

hum ko bhi stress nae mara ,tum ko bhi stress nae mara,is stress ko mar dalo........

By the time I am completing this saved as a draft post,I find myself quite relaxed.Its 22.17,24th of feb.But I began my day on a not so relaxed note.
It has been a one very busy month so far.But I think that's what a private practitioner wants.More work....More mullah!!!!But yes at times it makes me feel a little stressed with little time for myself.
And I think that hampers with my capacity to handle those patients who come to my OPD and are much more stressed than myself.After 15 minutes of conversation with a highly stressed person,I start feeling a surge of not so pleasant emotion within myself.
Good morning call from the same patient who likes to take pills to prepone or postpone her periods.Some very vague complaint.I hate this.Slept late in night after dealing an emergency.Will write another post on this emergency later.
Then a young lady in my clinic.She complained of blood in urine.After few questions later,it looked like a Urinary tract Infection.Told her probable diagnosis,prescribed a Routine and culture test for UTI,reassured her,instructed her about ways to prevent UTI and prescribed an antibiotic.But the lass looked irritated,stressed and depressed too.She grumbled ,but doctor why do I have blood in my urine intermittently and not everyday?Hummmm...........had to say 'I don't know, unless I have urine reports'!!She wanted an instant answer,without investigations......I felt I was loosing my cool.She wanted an instant diagnosis.Once again told her the most likely diagnosis......and when I lost my cool I did tell her a possibility of a Urinary stone and worst case scenario malignancy(which left her too scared,but then she wanted to know all the probable differential diagnosis).In midst of consultation her papaji called and I could sense an ambitious daughter and father conversation......leaving this company for that company as pay package was better ,etc ,etc.Clearly she was stressed and only half of what I said registered in her mind.And after 30 minutes I didn't feel like speaking further.
Then came two comparatively relaxed patients.And then came a lady in her mid 40s,going to USA on student visa,leaving her children behind.Wished to get all Gynaecology preventive checkups.She gave a history of untreated ovarian cyst.Ok,so I advised her a pap smear,Ultrasound pelvis and mammogram.She said I don't think there is need of these investigations.That left me irritated again.But you came to me for these investigations only...remember,I tell her.She says,oh yes I asked for it but now I don't want it.She wants to know why is she so stressed.That she replied herself,I am stressed as am leaving my children behind.
Later in the day I found myself more relaxed and to end the day came a call at 7.45pm.Need to see you today doctor at any cost.I am in Max Gurgaon till 8 pm,I replied.Can you wait till 8.15pm.Sure if it is an emergency.And then the lady informed me it was an emergency only as she was having painful periods throughout the day but now after she is free from office she wants to see me.What a paradox.An emergency which could wait in office hours and became an emergency at one's own convenient time.Advised her to come to triage,but she sounded little offended as I wasn't waiting for her.
God help me..............I find I am not as patient as I was three years back when I returned back to India and started my practice.But in the end wonder is all this stress worthwhile ,whether it is me or these stressed ladies.CERTAINLY NOT!! Then why are we all in this rat race??Any answers??

Wednesday, February 23, 2011


Being the commonest 'tumor' of uterus there are many blogs on Fibroids.For those who are new to this term ,it is a mostly non cancerous growth found in the uterus which might be asymptomatic and just an incidental finding in an ultrasound or it might be symptomatic with heavy bleeding,painful bleeding,heavyness in abdomen,bowel and bladder symptoms.
There are various ways of managing the condition from expectant to conservative to surgeries both conservative as well as removal of the uterus with fibroids.
Now what compelled me to write this blog is a surgery of a otherwise very fit and active lady for fibroids.
I was amazed to see that she was carrying multiple fibroids in her womb which measured up to 30 weeks ( 7.5 months of pregnancy).It weighed 1.53 kgs.
I was trying to understand the reason why not just her but many ladies these days keep on deferring their surgeries for very late till it becomes a challenge for the doctor as well as the patient.May be females attach too much emotional value to their uterus and loosing it means a loss ' of femininity/fertility or is it the fear of surgery?

30 weeks size,1.53 kgs uterus with multiple fibroids

My personal opinion would be manage it conservatively till advised by your doctor.After they attain the size of a 12 weeks pregnancy they start causing pressure symptoms and best removed laparoscopicaly by a Total laparoscopic hysterectomy ( Unless family isn't complete ,where laproscopic myomectomy can be done).

Monday, February 21, 2011

Ellaone ( Ulipristal)

So my European and American Blog readers might already be using this product as emergency contraceptive since October 2009.

 Levonorgestrel containing emergency contraceptives have been used as well as misused by Indian Females in last few years.Thought of shairing a new entrant to the group of post coital contraceptives:ULIPRISTAL.This is yet to reach the Indian market but when available it will be a better medicine than Levonelle,i pill etc.

This can be effectively used up to 5 days of first act of unprotected sexual intercourse in comparison to 72 hrs for current pills and the failure rate is also less than Levonorgestrel containing pills.It should not be used more than once in a cycle.

Like any other medicine once available it needs to be used with discretion and misuse should be avoided

Tuesday, February 15, 2011

Beware of the hands that rock the cradle

Please follow the link before you read my post.It is an interesting read.And after reading this link only my comments will make any sense.

I am a gynaecologist myself.Read your article.It made me think and then react to it as well.First of all it is not clear to me 'what the take home message is'. You do agree that you were guided properly at Sant Parmanand hospital.So that means all doctors are not 'dangerous'.What in your opinion was the reason for the sector 23 based ...Gynecologist to behave in particular manner?Money?(Probably not......coz the money a doctor gets for Termination of pregnancy is actually peanuts.It is a very small proportion of your total bill)Lack of Knowledge( may be yes....the injections must have been progesterones/HCG etc)Indian gynecologists prescribe that as a habit.And am sorry to say a lot of my patients think me 'casual' if I dismiss a finding like this as 'nothing to worry'.They are scared hasn't prescribed 'progesterone'.And I think partly patients are also responsible for the way doctors behave at times. Now.......Most important you have a suggestion for your readers how to insure to find a 'right hand to rock the cradle'?? Unless there isn't an answer to it,your article is a good sensational read but not useful for the rest.

Sunday, February 13, 2011

When 'HE'Scoffs at me!!

I am a alright gynecologist .That is a self image of me.I can handle almost all Obstetric and gynaecology cases/emergencies/complications;I believe.I am proud of myself.

See there are so many 'I's in it.I am full of myself.

And the very next moment, 'HE' (the unknown power,nature,God,energy........whatever you call it),makes me realize,I am a mear puppet.have been sent in this world to play my role and then bid  adieu!!

Am little despondent today.A Japanese couple visited me a almost a month back.Full of questions and excitement.For them they had found the best gynecologist(their Landlord holds such an impression of me and I am thankful to them).And things were going fine till 2 nights before got a call in the middle of night.her water bag had broken and she was just 19 weeks pregnant.I wished to manage her conservatively and wait and see if luck favoured us to reach around 28  to 30 weeks at least.But that could have been risky.She might have developed chorioamnionitis(maternal infection).Baby might have delivered despite our best attempt much before 28 weeks and could have suffered major health issues for life if had survived.

I asked my neonatologist friends to talk to her and help her come to a difficult decision of continuing with pregnancy knowing all the risks(I had given then a RCOG leaflet regarding the same to read,which they read and read and read and cried and cried and cried.Here was their 'adroit Gynecologist' standing helpless.Of no help to them except to help them in whatever decision they took.

And finally after talking to 3 different neonatologist they decided to terminate the pregnancy.Thats what I did today.Or was rather made to do by him.

Couldn't help but remember the very famous scene from movie Anand between Dr Bhaskar and Anand saigal where Anand Saigal says Babu Moshai, we are mere puppets in the game of life and death. Whatever happens here, we do not know for it is all in the hands of the Almighty.

Wednesday, February 9, 2011

Weight gain and nutrition during Pregnancy

We Indians are a country obsessed by food.And the first question any Pregnant woman or her partner asks is: What all she can eat?

Even if the baby is growing fine  ,if the mom doesn't gain much weight antenatally,I have realized would be dads get real panicky.

Follows the ACOG Patient information leaflet to help such anxious would be parents

A balanced diet is a basic part of good health at all times in your life. During pregnancy, your diet is even more important. The foods you eat are the main source of nutrients for your baby. Healthy eating during pregnancy may take a little effort, but it will be a major benefit for you and your baby. If you have not been eating a healthy diet, pregnancy is a great time to change old habits and start healthy new ones.

This pamphlet explains starting a healthy diet before pregnancy

basic and extra nutrients you will need

planning healthy meals

healthy weight gain

special nutrition concerns

Before You Become Pregnant

The best time to begin eating a healthy diet is before you become pregnant. Eating well before pregnancy will help you and your baby start out with the nutrients you both need.

If you are planning to become pregnant, it is a good idea to visit your health care provider. As part of your visit, you will be asked about your family life, work, and lifestyle, including your diet. You and your health care provider will discuss how to eat right before and during your pregnancy and which nutrients are especially important, such as folic acid.

Basic Nutrients

Every diet should include proteins, carbohydrates, vitamins, minerals, and fat. Dietary reference intakes (DRIs) are recommended amounts an individual should consume daily of certain nutrients, vitamins, and minerals. During pregnancy, the DRIs are higher for many nutrients (Table 1).

Table 1. Key Nutrients for You and Your Baby During Pregnancy

Nutrient (Dietary Reference Intake [DRI] Why You and Your Baby Need It Best Sources

Calcium (1,000 milligrams) Helps build strong bones and teeth. Milk, cheese, yogurt, sardines

Iron (27 milligrams) Helps red blood cells deliver oxygen to your baby. Lean red meat, dried beans and peas, iron-fortified cereals, prune juice

Vitamin A (770 micrograms) Forms healthy skin and helps eyesight. Helps with bone growth. Carrots; dark, leafy greens; sweet potatoes

Vitamin C (85 milligrams) Promotes healthy gums, teeth, and bones. Helps your body absorb iron. Citrus fruit, broccoli, tomatoes, strawberries

Vitamin D (200 international units; some experts recommend 400 international units during pregnancy) Helps build your baby’s bones and teeth. Sunlight exposure; vitamin D fortified milk; fatty fish such as salmon

Vitamin B6 (1.9 milligrams) Helps form red blood cells. Helps body use protein, fat, and carbohydrates. Beef, liver, pork, ham; whole-grain cereals; bananas

Vitamin B12 (2.6 micrograms) Maintains nervous system. Needed to form red blood cells. Liver, meat, fish, poultry, milk (found only in animal foods—vegetarians who do not eat any animal foods should take a supplement)

Folate (600 micrograms) Needed to produce blood and protein. Helps some enzymes function. Green, leafy vegetables; liver; orange juice; legumes and nuts

You do not have to eat the DRI for each nutrient every day. Try to eat a variety of foods and eat the recommended amounts from the basic food groups. If you do, chances are good that you and your baby are getting the right amounts of nutrients (see box “How Much Should You Eat?”).

Extra Nutrients

Pregnant women need extra iron and folic acid. To get these extra nutrients, a prenatal vitamin supplement is recommended for most women. These supplements contain all the recommended daily vitamins and minerals you will need during your pregnancy, such as vitamins A, C, and D; folic acid; and minerals, such as zinc and copper. Talk to your health care provider about the vitamins that you are already taking before taking a prenatal vitamin supplement. Excess amounts of some vitamins or minerals during pregnancy can be harmful.

Extra Nutrients

Folic Acid

How Much Should You Eat?

How much you eat is just as important as what you eat. If you are a normal weight before pregnancy, you need only an average of 300 extra calories per day to fuel your baby’s growth and keep you healthy during pregnancy—the amount in a glass of skim milk and half a sandwich. During the first trimester, you need less than 300 extra calories per day. During the third trimester, you will need slightly more.

Having healthy snacks that you can eat during the day is a good way to get the nutrients and extra calories you need. You may find it easier to eat snacks and small meals throughout the day rather than three big meals a day.

If you are overweight or obese, you will need to pay close attention to how much you eat during pregnancy. Smaller amounts of weight gain or even a small weight loss may be recommended to ensure a safe pregnancy and a healthy baby (see “Pregnancy and Weight Gain”).

Folic acid is a B vitamin that is also known as folate. Before pregnancy and during the first 12 weeks of pregnancy, you need 0.4 milligrams (or 400 micrograms) of folic acid daily in order to reduce the risk of neural tube defects. Folic acid is added to certain foods (breads, cereal, pasta, rice, and flour) and is found in leafy dark-green vegetables, citrus fruits, and beans. However, it may be hard to get all of the folic acid you need from food sources alone. For this reason, all women of childbearing age should take a multivitamin supplement containing 0.4 milligrams of folic acid a day.

Women who have had a child with a neural tube defect or who are taking certain drugs need much higher doses of folic acid—4 milligrams daily. Women who need 4 milligrams should take folic acid as a separate supplement, not as part of a multivitamin.


The iron in red blood cells helps carry oxygen to your organs, tissues, and baby. Women need more iron in their diets during pregnancy to support the growth of the baby and to produce extra blood. The recommended daily amount of iron you should consume while pregnant is 27 milligrams, which can be found in most prenatal vitamin supplements. Women who do not have enough iron stored in their bodies before pregnancy may develop anemia. Some women may need extra iron in the form of an iron supplement. Taking an iron supplement on an empty stomach or with a source of vitamin C (such as a glass of fruit juice) helps the body absorb iron. Be sure to tell your health care provider if you are taking any other medications because some drugs should not be taken with iron.

Planning Healthy Meals

The U. S. Department of Agriculture has designed an online interactive diet-planning program called “My Pyramid Plan for Moms” specifically for women who are pregnant or breastfeeding ( This program gives you a personalized plan that includes the kinds of foods in the amounts that you need to eat for each trimester of pregnancy.

My Pyramid Plan for Moms is based on specific food groups. These groups are the best sources of some of the nutrients that are needed during pregnancy and breastfeeding:



Milk and dairy foods


Meat, beans, and eggs

Fats and oils

Also included is a group of foods that do not fall into any of these groups, such as high-fat or sugary foods, or extra amounts of the foods in the other food groups.

The amount of food that you need to eat each day is calculated according to your height, prepregnancy weight, due date, and how much you exercise during the week. The amounts of food are given in standard sizes that most people are familiar with, such as cups and ounces (Table 2 on the reverse side).

Pregnancy and Weight Gain

How much weight you gain during pregnancy depends on your weight before pregnancy (see box “How Much Weight Should You Gain During Pregnancy?”). Body mass index (BMI) is a measure of body fat based on height and weight. Women with a normal BMI before pregnancy should gain between 25 and 35 pounds during pregnancy. The box “Where Does the Weight Go?” shows where all of the extra weight goes during pregnancy.

How Much Weight Should You Gain During Pregnancy?


Weight Status Body Mass

Index (BMI)* Weight Gain


Underweight Less than 18.5 28–40

Normal weight 18.5–24.9 25–35

Overweight 25.0–29.9 15–25

Obese 30 or more 11–20

*You can find out your BMI by going to

Data from Institute of Medicine (US). Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academies Press; 2009.

Overweight and obese women are at increased risk for several pregnancy problems. These problems include gestational diabetes, high blood pressure, preeclampsia, and cesarean delivery. Babies of overweight and obese mothers also are at greater risk for certain problems, such as congenital abnormalities, macrosomia with possible birth injury, and childhood obesity. For women with a BMI of 30 or greater, a weight gain of between 11 pounds and 20 pounds is recommended during pregnancy. For women with a BMI of 40 or greater, a modest weight loss during pregnancy may be recommended. The weight loss should not be drastic, should be individualized for each woman, and should be done only under a health care provider’s close supervision.

Where Does the Weight Go?

Here is how much weight an average woman gains in parts of her body during pregnancy:

Baby 7 ½ pounds

Your breast growth 2 pounds

Maternal stores (your

body’s protein and fat) 7 pounds

Placenta 1 ½ pound

Your uterus growth 2 pounds

Amniotic fluid (the

water around the baby) 2 pounds

Your blood 4 pounds

Your body fluids 4 pounds

Special Concerns

As you plan your pregnancy diet and make decisions about what to eat, there are a few special issues to keep in mind.


Studies about caffeine consumption and miscarriage risk are conflicting. Because of these conflicting results, it is not possible to say whether high caffeine intake leads to miscarriage. Moderate caffeine intake (200 milligrams a day—the amount in approximately two 8-ounce cups of brewed coffee) does not appear to lead to miscarriage or preterm birth. It is not clear whether caffeine increases the risk of having a low birth weight baby.

It may be a good idea to limit your caffeine intake during pregnancy for other reasons. Excess caffeine can interfere with sleep and contribute to nausea and light-headedness. It also can increase urination and lead to dehydration.

Table 2. Daily Food Choices

These guidelines are for a pregnant woman who is a normal weight and who gets less than 30 minutes of exercise a week. They show the recommended daily food intake.

First Trimester Second Trimester Third Trimester Comments

Total calories per day 1,800 2,200 2,400

Grains* 6 ounces 7 ounces 8 ounces 1 ounce is 1 slice of bread, ½ cup of cooked rice, ½ cup of cooked pasta, 3 cups of popped popcorn, or 5 whole wheat crackers

Vegetables† 2 ½ cups 3 cups 3 cups 2 cups of raw leafy vegetables count as 1 cup

Fruits 1 ½ cup 2 cups 2 cups One large orange, 1 large peach, 1 small apple, 8 large strawberries, or ½ cup of dried fruit count as 1 cup of fresh fruit

Milk 3 cups 3 cups 3 cups Two small slices of swiss cheese or 1/3 cup of shredded cheese count as 1 cup

Meat and beans 5 ounces 6 ounces 6 ½ ounces 1 ½ cup of cooked beans, 25 almonds, 13 cashews, or 9 walnuts count as 2 ounces

Extras 290 calories 360 calories 410 calories These extra calories come from high-fat and high-sugar foods, or higher amounts of foods from the five food groups

Fats and oils 6 teaspoons 7 teaspoons 8 teaspoons Some foods are naturally high in fats and oils, such as olives, some fish, avocados, and nuts

*Make one half whole grain.

†Make sure that you get a mixture of dark green, orange, starchy, and other vegetables, including dry beans and peas.

Vegetarian Diets

If you are a vegetarian, you can continue your diet during your pregnancy. However, you will need to plan your meals with care to ensure you get the nutrients you and your baby need. Be sure you are getting enough protein. You will probably need to take supplements, especially iron, vitamin B12, and vitamin D.


Fish and shellfish are good sources of protein, omega-3 fatty acids, and other nutrients. However, pregnant women should not eat certain kinds of fish because they contain high levels of a form of mercury that can be harmful to the developing fetus.

You should avoid eating shark, swordfish, king mackerel, or tilefish during pregnancy. These large fish contain high levels of mercury. Common types of fish that are low in mercury are shrimp, canned light tuna (not albacore, which has a higher mercury content), salmon, pollock, and catfish. You can safely eat up to 12 ounces (about two meals) of these fish per week while you are pregnant. If you want to include albacore tuna as part of your two fish meals one week, limit your intake of albacore tuna to no more than 6 ounces for that week.

Check local advisories about fish caught in local rivers and streams. If there is no advice about them, it may be safe to eat up to 6 ounces (one meal) per week of fish from local waters. During that week, do not eat any other fish.


Listeriosis is an illness caused by bacteria that can occur in unpasteurized milk and soft cheese and prepared and uncooked meats, poultry, and shellfish. It can be particularly harmful to pregnant women and their babies.

Symptoms occur several weeks after you eat the food. They can include fever, chills, muscle aches, and back pain. In some cases, there may be no symptoms at all. When a pregnant woman is infected, the disease can cause miscarriage or stillbirth.

Because the symptoms of listeriosis are like the flu, it can be difficult to diagnose. If you have a fever or flu-like illness, check with your doctor who may take samples from your vagina, cervix, and blood. If the bacteria are found, you and your baby can be treated with antibiotics. If there is a chance that a newborn is infected, he or she also can be tested and treated.

To prevent listeriosis, wash all fresh fruits and vegetables before using them. While you are pregnant, do not eat the following foods:

Unpasteurized milk or soft cheeses

Raw or undercooked meat, poultry, or shellfish

Prepared meats, such as hot dogs or deli meats, unless they are heated until steaming hot

Always be sure to wash your hands and any utensils, countertops, or cutting boards that have been in contact with uncooked meats.


During pregnancy, some women feel strong urges to eat nonfood items such as clay, ice, laundry starch, or cornstarch. This condition is called pica. Pica can be harmful to your pregnancy. It can affect your intake of nutrients and can lead to constipation and anemia. Talk with your health care provider if you have any of these urges.


Eating right during your pregnancy is one of the best things you can do for yourself and your baby. Finding a balance between getting enough nutrients while maintaining a healthy weight is important for you and your baby’s future health.


Anemia: Abnormally low levels of blood or red blood cells in the bloodstream. Most cases are caused by iron deficiency, or lack of iron.

Congenital: Refers to a condition that is present in a baby when it is born.

Gestational Diabetes: Diabetes that arises during pregnancy.

Macrosomia: A condition in which a fetus grows very large.

Miscarriage: Early pregnancy loss.

Neural Tube Defect: A birth defect that results from incomplete development of the brain, spinal cord, or their coverings.

Pica: The urge to eat nonfood items.

Preeclampsia: A condition of pregnancy in which there is high blood pressure and protein in the urine.

Stillbirth: Delivery of a baby that shows no sign of life.

This Patient Education Pamphlet was developed by the American College of Obstetricians and Gynecologists. Designed as an aid to patients, it sets forth current information and opinions on subjects related to women’s health. The average readability level of the series, based on the Fry formula, is grade 6–8. The Suitability Assessment of Materials (SAM) instrument rates the pamphlets as “superior.” To ensure the information is current and accurate, the pamphlets are reviewed every 18 months. The information in this pamphlet does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations, taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice, may be appropriate.

Copyright © August 2010 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

ISSN 1074-8601

Requests for authorization to make photocopies should be directed to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923.

To reorder Patient Education Pamphlets in packs of 50, please call 800-762-2264 or order online at

The American College of Obstetricians and Gynecologists

409 12th Street, SW

PO Box 96920

Washington, DC 20090-6920


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Saturday, February 5, 2011

A Pregnant Lady who had a big Ovarian Cyst

If only life had readymade answers to all the questions.If only there was no shade called grey.....and there were just blacks and whites.If only..........But unfortunately life quite often gives us situations where we have to exercise our brain and heart to come to a gray decision.
About 2 weeks back a 28 year old female trying to conceive since last year came for her routine early pregnancy check up.On her Ultrasound it was found that she had 6 weeks pregnancy with a 15 cms x 15cms (Which is quite big) ovarian cyst ( A dermoid).She had heaviness on that side of her abdomen but yes there was no evidence of any torsion yet.Now what do I do?She looked quite expectantly at me to say 'all is well'.
My mind was ticking fast.....I have to break this bad news to her and I am not yet ready as to how to make the impact of the report less traumatic.Then I gathered all my skills learnt at various breaking bad news sessions in UK and also my clinical practice and told her so.She was in tears.Actually howling.
Now how do I manage her?Do I leave her for a torsion to develop or do I operate her now if she agrees.Situation had started taking a grey turn.I recalled the sages guidelines on laparoscopy in pregnancy.

It clearly said Laparoscopy is safe in all trimesters of pregnancy.But then old school of thought says defer surgery till second trimester or defer it till she delivers.But then when her uterus will grow bigger,the cyst which is already so big is bound to complicate the pregnancy and then may be with a big vascular uterus and a torsion I might end up opening her than perform a minimally invasive laparoscopy.
Then I also remembered a lady who had been operated upon by some doctor for torsion of dermoid with early pregnancy.She had come to meet me as she was suffering from post traumatic stress following a termination of pregnancy along with cyst removal.She wasn't happy at all with the doctors involved.

What Do I do Know.As usual,I told them the evidences,ref of Pubmed and Sages guidelines and left the decision on her.She and her husband wanted to get it removed laparoscopically at around 7 weeks.I was questioned by our anaesthesia chief about a possible side effect of anaesthetic drugs on fetus but in the times of evidence based medicine can't tell the patient my gut feeling.Every gut feeling needs evidence in support.And I had none to suggest a Termination of pregnancy to her or even to tell her laparoscopy increases the chances of miscarriage.Even one of my gynaecologist colleague didn't seem to like the collective decision which we ( My patient and myself had taken).

Anyways.....She was operated last week.Both mother and fetus stood the surgery well and were discharged the very next day.An ultrasound done post surgery confirmed an ongoing viable pregnancy.
Will keep on updating as we move further in her journry of becoming a mom.