Tuesday, July 31, 2012

Fenton's Procedure

Fenton's procedure is an easy but not very commonly done procedure for superficial dysperunia (painful sex) due to scar tissue at the mouth of the introitus i.e at the mouth of the vagina.It can happen due to infected and badly scarred episiotomy wound,following labial adhesions,lichen sclerosis and Lichen Planus.I was amazed not to find a single video or picture of this operation on the whole of net.Sharing with you pictures of one of my patients who was operated about 3 years back.She attributes Fenton's surgery as her life changing surgery.

FG: Gurgaon Healing

FG: Gurgaon Healing

Sunday, July 29, 2012

It good to be informed but not good to be partially informed

This is what NICE guideline has to say on episiotomy

Episiotomy /
Carry out episiotomy only when there is:
clinical need such as instrumental birth
● suspected fetal compromise
Do not offer routinely following previous third- or fourthdegree
Use mediolateral technique (between 45° and 60° to
right side, originating at vaginal fourchette)
Use tested effective analgesia

This is what Nice Guideline has to say on Induction of labour

Induction chosen
Offer membrane sweep (check for low-lying placental site first).
Formal induction with vaginal PGE2
Inform women about the risks of uterine hyperstimulation.
Induce in the morning.
Check for low-lying placental site before induction.
Offer vaginal PGE2 as tablet, gel or controlled-release pessary:
– tablet or gel: one dose, followed by a second dose after 6 hours if labour does not
start (maximum two doses)
– pessary: one dose over 24 hours.
Reassess Bishop score 6 hours after each tablet or gel, or 24 hours after controlled-release pessary.
If woman goes home after tablet or gel, ask her to contact her obstetrician/midwife:
– when contractions begin
– if she has had no contractions after 6 hours.
Induction chosen
If labour does not start
Normal fetal heart rate
Contractions begin
Confirm fetal wellbeing with continuous electronic fetal monitoring.
Intermittent auscultation should then be used unless there are indications for continuous monitoring3.
If fetal heart rate is abnormal, refer to ‘Intrapartum care’3.
When labour is established, monitor according to ‘Intrapartum care’3.
For pain relief, see box 1.
Assess Bishop score and confirm normal fetal heart rate pattern with electronic fetal monitoring.
All stages
Provide information and support, invite questions, and allow women time for
discussion with partners and for making decisions. See also key priorities on
page 3 and guidelines on intrapartum and antenatal care3,4.
NICE clinical guideline 70 Quick reference guide

I have mentioned these two guidelines( just the relevant bit of it) because I wish to show how today's patient misinterpret these beautiful guidelines and make their management dangerous and taking patients care difficult for the concerned doctor.

1st patient.....primigravida,conceived after many years,having big fibroid and hypothyroidism,goes in spontaneos labour, has a very fast progress like a precipitate labour  and had to be given episiotomy to prevent a bad tear.Her husband questions the need for a cut as google says episiotomy should be avoided.They have coolly forgotten to read clinical need.Not that doctor has any benefit in giving a cut and repairing. It just adds on to the doctors time.Why would a doctor wish to unnecessarily add on to one's effort.The answer comes from the husband , to have a easy delivery.God easy delivery for whom?For your wife only.Why do you wish it to be difficult and traumatic?

2nd patient.....primigravida at 39 weeks goes in spontaneous labour.High risk factors----pregnancy induced hypertension controlled since 32 weeks on Methyldopa but not willing for an induction of labour as induction is associated with higher risk of caesarean section not willing to understand the risk of raised blood pressure.That lady had big blisters all over due to pregnancy hormones ,could hardly walk but the husband her gaurdian was not allowing a Induction of labour to prevent caesarean section not realizing that chronic placental insufficiency due to PIH puts one at increased risk of caesarean section.Anyways at admission she was getting mild contractions.A simple sweep  for augmenting the labour was also questioned by the husband of the patient as artifical intervention and it was too Premature to sweep her.And what was the outcome.There were type 2 dips and Lady ended with a caesarean section.


Sunday, July 15, 2012

reminiscence of my internet journey

After passing my MRCOG  from London I took a conscious decision to move to India.That was Nov 2006 when I became a member of Royal college.By Feb 2007 I had been shortlisted and eventually selected to be a senior consultant at Max Hospital,Gurgaon.It was my conscious decision again to try for a job here while still in UK as it improves your market value.In August 2007 I had joined the department of Obstetrics and Gynaecology at Max hospital ,Gurgaon.There were 5 other consultants all of whom had some base in Delhi and Gurgaon since last many years.I was the new comer.No one knew Max Gurgaon and no one Knew me.First month I conducted 2 deliveries and performed one removal of uterus.OPD was negligible.It was quite demoralizing as consultants who had been practicing in Gurgaon since last 6/7 years, they had still some patients.I used to go in a situation of self doubt if the decision taken by me was right or wrong i.e to come back to India.
Then in 2008 I had plenty of time to study and then time to think about a website too.That is how I thought of my current website www.drkaushikidwivedee.com.I had no clue about how to get a domain etc.Non Medical friends helped and I was ready with a website.Slowly website helped me.Patient's used to some to me due to website but then it was up to me to retain them.And over the years it helped,many of my patients are internet savvy people,who leave good comments and that encourages others as well to visit me.In between I started this blog which again was liked immensely by readers.My another website through which I wished to show case my Laparoscopic skills was plagued with problems from the very beginning.It took me many hours to collate the material for the site edit videos etc.This site was a hot favourite with Hackers and was hacked most of the time.Though it was retrieved with great difficulty by a friend of mine it could never be what I wished it to be.
Now I think it is time to update my current website.
Two calls from educated and sensible middle aged and slightly elderly Ladies have made me think about this change.Both of them had visited my site and they thought that I most probably treated just young ladies and Pregnancies but was not treating elderly ladies and their problems.I understand that I made a website in 2008 as per my understanding which has changed  in 4 years and of course that perception needs to reflect in my website too.
I think I  am a  OBSTETRICIAN who enjoys delivering babies,but at the same time I think I am not a bad gynaecologist .I have equal interest in menopause,postmenopausal symptoms and treatment,Postmenopausal bleed,heavy bleeding,fibroids,endometriosis,Ovarian cysts ,both benign and cancerous,Vaginal prolapse,Incontinence of urine,Adolescent problems.So feel free to contact me for any women health related issue .I am not exclusive to Pregnancy ;-)

Monday, July 9, 2012

Poly cystic Ovarian Disease (PCOD)

PCOD is very common hormonal imbalance found in women of reproductive age group (14 to 40 years).In this post I will try to mention few facts about this condition as every day women young and not so young visit me and are perturbed to know that they have PCOD/PCOS.
What is PCOD : It is a hormonal imbalance and a very common one.Every 4th female has an ultrasound which suggests PCOD and every 10th female has PCOS ie associated symptoms.

Signs and Symptoms of PCOD : Irregular periods,scanty periods,out of proportion weight gain with more of fat in the mid tummy(android pattern of obesity),hair fall,increased body or facial hair,acne and difficulty in loosing weight despite exercise.

Why do the periods become irregular? : Every month after ovulation a woman gets either regular periods or gets pregnant.If due to any reason your body isn't producing egg regularily you will have irregular periods.As in PCOD body produces eggs irregularly one has irregular periods.

Do I have actual cysts ? :No you don't have actual Ovarian cysts!!Follicles the cells which are meant to be egg don't get released from the ovary causing ultrasound images which gives an appearance as if their are multiple small cysts which actually are your follicles which got arrested at the size of around 10 mm and couldn't reach upto 18 to 20 mm  or more to form egg.

Why do I have PCOD ? : Sorry !! Medical science doesn't have an answer to this.It can be Genetic,Lifestyle disorder or other reasons which we are not aware of.

What Hormonal Imbalance do I have ? You have more of male hormone in your body rather than a woman who doesn't have PCOD/PCOS.You also have Insulin resistance which means that your body has to produce more Insulin to keep blood sugar levels normal.Insulin has weight gaining tendency and that explains the weight gain with PCOD.

Long term effects of PCOD : For conception you might need medicines.You are at increased risk of Diabetes,raised cholesetrol levels,increased chance of raised Blood Pressure and increased chance of uterine cancer if you miss your periods regularly.

Treatment : As of now,PCOD can be controlled but not cured.One might need OCPills,Anti male hormone medicines like aldactone ,metformin(medicines which decrease insulin resistance).It is a long term treatment...........There is no point thinking that these medicines will cure your disease.As long as you take  it your periods are normal along with other symptoms but a stoppage of medicine results in reversal of symptoms.Yes we can't cure them,so don't get disheartened when your doctor provides you this information.With medicines and healthy life style your life is as normal as that of anybody else.

Effect on Pregnancy : Conception might be difficult.Once conceived there is 3 fold increase risk of miscarriage and also there is increased risk of Diabetes of pregnancy.For both these conditions,metformin has been found to be helpful.


Monday, July 2, 2012

Is Bacterial Vaginosis ,really a Sexually transmitted disease

A young Lady came to me earlier this year with certain complains and my diagnosis was bacterial vaginosis.......which is a concern but in my opinion not such a great concern to loose sleep over it.I gave her treatment for bacterial vaginosis and her symptoms were gone.Then she went ahead with a routine PAP smear at another good gynaecologist.Her Pap smear showed clue cells.There was a huge scare,that Lady was advised 8 monthly pap smear as the gynaecologist feared that her bacterial vaginosis will repeat it again and again.She was advised Ciplox TZ,clindamycin and cotrimazole pessaries and few other medicines and HPV vaccines.This girl was alarmed.Her partner needed treatment.Too much for her to handle,I guess!!
Now I wish to write about BV as I feel not just the patients but the treating gynaecologists are not very clear on the management.Let us all revise what is BV

  • BV is overgrowth of anaerobic bacteria in vagina which outnumber the helpful Lactobacillus,because of which vaginal pH increases from 4.5 to 7. 
  • It can happen spontaneously in sexually active as well as not sexually active ladies
  • More common in blacks,smokers and with intrauterine contraceptive device.
  • It isnot a sexually transmitted disease and it's etiology is unknown.
  • It is the commonest cause of vaginal discharge in the women of child bearing age,
  • Though BV is more common in women who have pelvic inflammatory disease but at the same time there is no evidence that a Lady without any symptom needs any treatment .(Just like this girl)
  • Those who complain of BV related symptoms that are fishy smelling vaginal discharge,Vaginal itching and soreness and thin white homogenous discharge.
  • Pregnant Ladies with BV can have higher chance of preterm labour pain,miscarriages,Premature rupture of membranes.After hysterectomy one can have vaginal cuff cellulitis.
Amsel's criteria for diagnosisng BV (At least 3 out of 4 should be present)
  • thin white homogenous discharge
  • clue cells on microscopy
  • pH of vaginal>  4,5
  • Release of fishy odour on adding KOH(a;kali to the discharge
In asymptomatic women there is no need of routine Vaginal swab testing, as 50% 0f asymptomatic women will have clue cells which doesn't need any treatment at all.

Vaginal douching withantiseptic bath gels
If symptoms are present .Metronidazole tablets/Metronidazole gel/Clindamycin ointment and tablets are the treatment of choice.

Male partner shouldn't be made to have antibiotic as it never helps

Pregnant Ladies with a H/O BV shoud have her high vaginal swab more often as they are at increases risk of preterm pains,premature rupture of membranes and other complications.

The optimal management of people with recurrent symptomatic BV remains unresolved.