Abstract Book & Souvenir

Transcription

1 North Zone Annual Conference Northern Zone AICC RCOG Multi Disciplinary Management for Best Care in Obstetrics & Gynaecology August 2014, New Delhi Abstract Book & Souvenir UROLOGY RHEUMATOLOGY ONCOLOGY ULTRASOUND ENDOCRINOLOGY GASTROENTEROLOGY RADIOLOGY NEPHROLOGY INTERNAL MEDICINE PATHOLOGY a

2 ABOUT NORTHERN ZONE AICC RCOG... Past Chairpersons Dr S K Bhandari ( ) Dr Sheila Mehra ( ) Dr Sarla Gopalan ( ) Dr Urmil Sharma ( ) Dr Urvashi Prasad Jha ( ) Chairperson Dr Sohani Verma Patrons All Past Chairpersons Dr Mohinder Kochar Dr R P Soonawala Dr Sanjeev Sharma (UK) Dr Prabha Sinha (UK) Dr Prathap C Reddy Dr Ashok Chauhan Fellow Representatives Dr Nirmala Agrawal (Vice Chairperson) Dr Mala Arora (Hon. Secretary) Dr Anita Kaul (Treasurer) Web Editors Dr Ranjana Sharma Dr Arbinder Dang Member Representatives Dr Kaberi Banerjee Dr Jasmine Chawla Dr Arbinder Dang Co-opted Members Dr Sonal Bathla Dr Anita Sabharwal Regular activities conducted by RCOG North Zone India I. Monthly Workshops/Meetings II. Twice a year courses III. Yearly activities 1. Laparoscopy Workshop 1. Enhanced Revision Program for MRCOG 1. Advanced Obstetrics Skills Workshop 2. Hysteroscopy Workshop Part II-Weekly online course over 2. High Risk Pregnancy Workshop 3. Vaginal Surgery Workshop 15 weeks period 3. Annual Conference 4. Multi Disciplinary Team 2. Written & OSCE Part II MRCOG Course Meetings (MDTM) 3. Basic Practical 4. MRCOG Part I Course For details please visit b

3 Prayer May we love ever more. May we motivate ourselves to committed love in Action. May we motivate ourselves to live the life we wish to see in the world. May we be the transformation we wish to see in the world. From the inside out... From the roots branching upwards... From the heart to thought to word to action. Through life s trials and hardships we can arise beautiful and free. 1

4 CONTENTS Invitation... 3 Annual Conference - Organising Committee... 4 Overview at a Glance... 5 Faculty... 6 Messages... 7 Pre Conference Workshops Scientific Programme Annual Report Forthcomming Events Leisure Time Our Dedicated Team List of AICC RCOG NZ Fellows & Members Scientific Session with Panel Discussion with Review of Literature, Recommendations and Guidelines List of Sponsors

5 Invitation Dear Friends, Enormous developments over the last few decades have completely transformed clinical practice, not just in Obstetrics & Gynaecology but in all medical specialties. A Multidisciplinary approach is not only recognized as the current standard of care, it is often necessary to provide the best management to the patient. However, there appears to be a lack of adequate knowledge sharing and optimum utilization of available scientific expertise. The annual conference of Northern Zone AICC RCOG (All India Coordinating Committee of the Royal College of Obstetricians & Gynaecologists UK) this year has been planned with the specific objective of addressing this very important issue. The case discussion format of the conference will provide ample scope for lively interaction among participating renowned expert faculty from several specialties. The main emphasis will be on practical and cumulative application of all modern concepts and techniques to optimize clinical management. The face to face discussion based on evidence and latest recommendations will provide an excellent opportunity to clear all doubts and reach a consensus take home message. We feel specially privileged to have Dr Philip Owen -Chair, RCOG Guidelines Committee UK, Maternal Fetal Medicine specialist join us to share his expertise and deliver key-note lectures and oration. This conference offers a unique opportunity to all family practitioners, specialists and trainees in all medical branches to share, discuss and learn about the significant transformations in conventional approach. Every medical practitioner involved in women s health care is cordially invited to participate. We have also planned four pre-conference workshops / CMEs for focused practical learning on selected topics. Each workshop will be conducted by a team of distinguished expert faculty members who are committed to provide in-depth learning and answer all your queries. The registration fee has been kept to a minimum to make it affordable for all, with a variety of options to select as per your interest. On behalf of the organizing committee, we are delighted to invite you to join us. We are sure you will find this conference extremely informative and valuable to upgrade your expertise. Looking forward to your active participation Dr Sohani Verma ORGANIZING CHAIRPERSON Dr Nirmala Agarwal CO-CHAIRPERSON Dr Mala Arora Dr Anita Kaul Dr Anjila Aneja ORGANIZING SECRETARIES 3

6 ANNUAL CONFERENCE ORGANIZING COMMITTEE ORGANIZING CHAIRPERSON Dr Sohani Verma ) VICE CHAIRPERSON Dr Nirmala Agarwal ) ORGANIZING SECRETARIES Dr Mala Arora ) Dr Anita Kaul Dr Anjila Aneja Patrons Dr S K Bhandari Dr Sheila Mehra Dr Urmil Sharma Dr Mohinder Kochar Dr R P Soonawala Dr Sanjeev Sharma (UK) Dr Prabha Sinha (UK) Dr Prathap C Reddy Dr Ashok Chauhan Executive Committee Dr Suneeta Mittal Dr Kamal Buckshee Dr S S Trivedi Dr Alka Kriplani Finance Committee Dr Nirmala Agarwal Dr Anjila Aneja Dr Mala Arora Inauguration Committee Dr Anita Kaul Dr Sweta Gupta Dr Chanchal Singh Registration Dr Chanchal Singh Dr Jasmine Chawla Dr Meena Naik Dr Jayasree Sunder Advisor Dr Urvashi P Jha (Chair AICC RCOG) Scientific Committee Dr Nirmala Agarwal Dr Mala Arora Dr Anjila Aneja Dr Anita Kaul Dr J B Sharma Dr Saritha Shamsunder Workshop Committee Dr Kaberi Banerjee Dr Sonal Bathla Dr Seema Sharma Souvenir & Abstract Book Dr Arbinder Dang Dr Sweta Gupta Hall Management Dr Arbinder Dang Dr Sweta Gupta Dr Mamta Dagar Dr Mamta Mishra Dr Jharna Behura Web Editors Dr Ranjana Sharma Dr Arbinder Dang Treasurer Dr Anita Kaul Joint Secretaries Dr Ranjana Sharma Dr J B Sharma Dr Asmita Rathore Dr Saritha Shamsunder Dr Kaberi Banerjee Dr Arbinder Dang Dr Sweta Gupta Dr Chanchal Singh Scientific Exhibition Dr Ranjana Sharma Dr Jyoti Bhaskar Dr Neema Sharma Dr Ramandeep Kaur Transport & accommodation Dr J B Sharma Dr Pakhee Agarwal Food & Beverages Dr Anita Kaul Dr Pooja Thukral Dr Anita Sabharwal 4

7 OVERVIEW AT A GLANCE Pre-Conference Workshops Date Time Venue COHS, IVF and ICSI- Conventional Protocols and Modifications in Challenging Cases Live Workshop on Pelvic Floor Dysfunctions & Management Fetal CTG, Ultrasound and Delivery Decisions 29 August, Friday 8:30am- 5:00pm Indraprastha Apollo Hospitals 30 August, Saturday 8:00am- 4:00pm Sant Parmanand Hospital 30 August, Saturday 9:00am-5:00pm Indraprastha Apollo Hospitals Male Infertility and IUI 30 August, Saturday 9:30am-5:00pm Noble Hospital Faridabad Annual Conference Date Time Venue Inauguration 30 August, Saturday 6:30pm 8:00pm Auditorium, Indraprastha Apollo Cultural Program 30 August, Saturday 8:00pm 9:00pm Hospitals, Delhi - Mathura Road New Delhi Welcome Dinner 30 August, Saturday 9:00pm onwards (Nearest Metro Station Jasola Apollo, Scientific Program 31 August, Sunday 8:30am 5:30pm on violet line) Annual Conference Northern Zone AICC RCOG Theme - Multi Disciplinary Management for Best Care in Obstetrics & Gynaecology 31 August 2014, Auditorium, Indraprastha Apollo Hospitals 08:00am Registration 08:45-09:45am Session 1 Endocrine Disorders in Obstetrics & Gynaecology 09:45-10:15 am Session 2 Oration - RCOG Guidelines development and implementation -Dr Philip Owen 10:15-11:00am Tea/Coffee Break 11:00-12:00pm Session 3 Pregnancy with Connective Tissue Disorder /Renal disease 12:00-12:50pm Session 4 Key Note Lectures Fibroids and Laparoscopy: Science Versus Sensationalisation- Dr Urvashi P Jha Prevention of Preterm Birth -Dr Philip Owen 12:50-01:50pm Session 5 Pelvic Floor Dysfunction & Urinary Incontinence 01:50-02:30pm Lunch Break 02:30-03:30pm Session 6 Vascular Malformations in Obstetrics 03:30-04:30pm Session 7 Oncology Multidisciplinary Update 04:30-05:30pm Session 8 Pregnancy with Gastrointestinal/ Hepatic disorders 05:30pm Vote of thanks General Body Meeting (GBM) North Zone AICC RCOG Members & Fellows 30 August Saturday 5:30pm - 6:30pm, Venue: Auditorium, Indraprastha Apollo Hospitals 5

8 FACULTY * DR PHILIP OWEN Chair, RCOG Guidelines Committee UK Maternal Fetal Medicine Expert Consultant Glasgow Hospital Training Program Director for OBGYN, West Scotland Deanery DR PRABHA SINHA Consultant Fetal Medicine UK DR SANJEEV SHARMA Consultant Obstetrics & Gynaecology and ART Specialist Southport and Ormskirk NHS Trust Southport, UK OBGYN Faculty Dr Anita Kaul Dr Anita Sabharwal Dr Anjila Aneja Dr Arbinder Dang Dr Archana Verma Dr Asmita Rathore Dr Brig R K Sharma Dr Chanchal Singh Dr Chandan Dubey Dr Deepika Dekka Dr Geeta Chadha Dr Gita Radhakrishnan Dr Gouri Devi Dr Harmeet Malhotra Dr Harpreet Kaur Isher Dr Ila Gupta Dr Indrani Ganguli Dr J B Sharma Dr Jasmeet Monga Dr Jasmine Chawla Dr Jayasree Sundar Dr Jharna Behura Dr Jyoti Bali Dr Jyoti Bhaskar Dr K D Nayar Dr Kaberi Banerjee Dr Kamal Buckshee Dr Kaushiki Dwivedi Dr Kiran Popli Arora Dr Kuldeep Jain Dr Lalita Badhwar Dr Leena Wadhwa Dr Madhu Roy Dr Mala Arora Dr Mamta Dagar Dr Mamta Mishra Dr Manavita Mahajan Dr Mangla Telang Dr Manju Puri Dr Manjusha Dr Meena Naik Dr Meenakshi T Sahu Dr Mohinder Kochhar Dr Monika Nagpal Dr Neelam Suri Dr Neema Sharma Dr Neena Malhotra Dr Neeta Singh Dr Nirmala Agarwal Dr P Changulani Dr Pakhee Agarwal Dr Pooja Thukral Dr Poonam Tara Thakur Dr Praveen Kumar Dr Preeti Rastogi Dr Priti Arora Dhamija Dr Priti Gupta Dr Puneet Kochhar Dr Ramandeep Kaur Dr Ranjana Sharma Dr Rashmi Sharma Dr Renu Tanwar Dr Reva Tripathi Dr Ritika Bhandari Dr Ritu Jain Dr S K Bhandari Dr S S Trivedi Dr Sandeep Talwar Dr Saritha Shamsunder Dr Seema Sharma Dr Seema Thakur Dr Shakti Bhan Khanna Dr Sheila Mehra Dr Sohani Verma Dr Sonal Bathla Dr Sonia Malik Dr Sonu Agarwal Dr Sudha Prasad Dr Suneeta Mittal Dr Surveen Ghumman Dr Sushma Sinha Dr Sweta Balani Dr Sweta Gupta Dr Tanya B Rohatgi Dr Uma Pandey Dr Uma Swain Dr Urmil Sharma Dr Urvashi P Jha Dr Usha M Kumar Dr Vijay Zutshi Non OBGYN Faculty Dr A S Arora (Invasive Radiology) Dr Ajay Kumar (Gastroenterology) Dr Amrit K Swain (Embryology) Dr Anju Virmani (Paediatric Endocrinology) Dr Anoop Gulati (Urology) Dr Arun Prasad (General, Laparoscopy & Robotic Surgery) Dr Ashok Khurana (Ultrasound) Dr C M Batra (Endocrinology) Dr Harsh Dua (Medical Oncology) Dr Manisha Chakrovorti (Paediatric Cardiology) Dr Manu Noatay (Cytopathology) Dr N Subramanian (Urology) Dr Nandini Vasudev (Pathology) Dr Narendar Pal (Urology) Dr Neeru Gera (Endocrinology) Dr Nitin Ghonge (Radiology) Dr Pinak Shrikhande (Critical care) Dr R N Makroo (Transfusion Medicine) Dr Rajiv Kumar (Urology) Dr Ramesh Sarin (Surgical Oncology) Dr Rohini Handa (Rheumatology) Dr S J Gupta (Rheumatology) Dr S K Agarwal (Internal Medicine) Dr S K Wangnoo (Endocrinology) Dr Sanjay Sikka (Gastroenterology) Dr Sanjeev Jasuja (Nephrology) Dr Saroja Balan (Neonatology) Dr Suresh Rawat (Urology) Dr Sushma Kaul (Neonatology) Dr V K Aneja (Internal Medicine) Dr V P Singh (Neurosurgery) Dr Vidya Gupta (Neonatology) Dr Vipin Arora (Urology) *There may be minor changes in the scientific program and/or faculty. Please check for regular updates. 5 6

9 Message from the Patron North Zone I write this foreword for the Annual Conference of North Zone RCOG with great sense of nostalgia, pride and pleasure. My association with RCOG goes back to more than four decades. While in UK I saw the recently set-up National Health Service in the country and its contribution to women s health from close quarters, both from the point of view of quality and uniformity of care and the results were quite obvious after few years only. I returned to India with full determination to contribute my bit towards women s health in India. Dr. Tarun Banerjee played a vital role in creation of AICC RCOG, which ensured a continuous interaction between UK and Indian members of RCOG and soon with his efforts the entire fraternity of Obstetricians & Gynaecologists and the local bodies enthusiastically joined hands. It has now become a big family. Regular academic activities carried out by RCOG North Zone for the last year mentioned in this souvenir gives an idea of the efforts put in. Annual RCOG Conference has become a pivotal link between the experts and practising doctors for dissemination of recent advances in all subspecialities in our field. All previous chairpersons with their team have done tremendous job of the conference every year, which includes Dr. Shiela Mehra, Dr. Urmil Sharma and a very dynamic Dr. Urvashi Jha and Dr. Sohani Verma, the current Chairperson. I wish this year s conference a great success and thank you all the organizers for making it possible and we all looking forward to the great academic feast. Dr S K Bhandari MBBS, FIAMS, FRCOG, FRCS Emeritus Consultant Sir Ganga Ram Hospital, New Delhi 7

10 Message from the Patron North Zone My heartiest congratulation to North Zone RCOG, at Indraprastha Apollo Hospital, New Delhi. I greatly appreciate your programme which specially emphasizes a multi-disciplinary approach. Your focus in this conferences on modern concepts and techniques is the need of the day. It is wonderful to see all the specialist of Delhi coming together and sharing experiences together. This type of knowledge is very useful to young gynaecologists and obstetricians. Delhi is hosting many conferences which is helping young obstetricians and gyanecologists to increase their knowledge, and be updated in the latest technology. I am very proud of it. I extend my heartiest congratulation to the oraganizers and the delegates. Dr Sheila Mehra, Padma Shree MD FRCOG Emeritus Obstetrician and Gynaecologist Moolchand Medcity & Indraprastha Apollo Hospital Founder and Ex-President (DGES) 8

11 Message from Chairman All India Coordinating Committee RCOG Congratulations Dr Sohani and congratulations north zone for spearheading such a useful programme in Delhi on multidisciplinary team management in obstetrics and gynaecology. Organising an entire conference on this is going to be a spectacular achievement. I wish the conference a resounding success. All those who attend will benefit greatly and so will their patients. Its always an academic delight to attend events organised by the north zone under the able leadership of Dr Sohani Verma. Good luck. Dr Urvashi Jha MBBS MD MRCOG FRCOG (UK) FICS FIMSA FICOG Director Dept of Gynaecology, Minimal & Natural Access Gynae Surgery & Gynae Cancer Surgery (MNAGCS). Fortis Hospital - Vasant Kunj, New Delhi Director Dept of Gynae-Oncology, Fortis Memorial Research Institute, President AOGD Governing Council Member of ICOG Chairperson Endoscopy Committee of AOGD Executive Committee Member of NARCHI & AOGD 9

12 Message from the Chairperson North Zone AICC RCOG Dear Friends, It is indeed a great privilege and honor for me to welcome each one of you to the Annual Conference of North Zone AICC RCOG being organized in association with Indraprastha Apollo Hospitals, New Delhi. Enormous developments over the last few decades have completely transformed clinical practice not just in Obstetrics & Gynaecology but in all medical specialties. A multidisciplinary approach is not only recognized as the current standard of care, it is often necessary to provide the best management to the patient. However, there appears to be a lack of adequate knowledgesharing and optimum utilization of the available scientific expertise. Our annual conference this year has been planned with the specific objective of addressing this very important issue. The most important aspect which makes this conference so special and unique, is the full hearted support and enthusiastic involvement of more than 30 renowned experts from various non-obgyn specialties! It is indeed a great privilege and honor to have them along with several distinguished colleagues of our specialty as faculty. I wish to convey my most sincere gratitudes to each and every faculty member for their invaluable contributions to make this multidisciplinary conference possible. We feel specially privileged to have Dr Philip Owen Chair RCOG Guidelines Committee UK with us. On behalf of the RCOG North Zone India fellows and members, I extend a very warm welcome and sincerely thank Dr Owen for sharing his views and valuable time with us. The topics he has selected for his key-note lectures and oration are extremely relevant and important and we look forward to getting an update on these. Once again Indraprasrtha Apollo Hospitals has continued its more than a decade old exemplary tradition of providing full hearted support for all RCOG activities. On behalf of the North Zone AICC RCOG, it is my privileged duty to acknowledge and convey our deep appreciation and sincere gratitudes to Dr Prathap C Reddy (Chairman Apollo Group also Patron North Zone AICC RCOG), Mr Jaideep Gupta (MD), Dr Anupam Sibal (Apollo Group- Medical Director), Maj Gen Dr L R sharma (ADMS), Mrs Raji Chandru and entire management team for their association and generous contributions towards this conference. I am most grateful to all my friends, seniors and colleagues in the organizing team, who supported & worked hard to make this event successful. A very special thank you to Dr Anita Kaul and Dr Chanchal Singh for their constant support and hard work, without which this event would not have been possible! A special note of appreciation and thanks are certainly deserved by Dr Arbinder Dang for her dedicated efforts to compile the conference souvenir and abstract book. She has worked very hard to showcase the brilliant work carried out by our members throughout the year. The inclusion of latest guidelines and recommendations on most of the topics provided by our 10

13 esteemed faculty have added a significant value, converting our souvenir into a reference book. I am sure, you would find it useful. I feel deeply indebted and immensely honored to have Ms Usha Banerjee the Nursing Director and her team of young talented nurses of Indraprastha Apollo Hospitals who accepted our invitation to perform a cultural program at the inauguration ceremony. Their unbelievable energetic dance performance will surely mesmerize you! We can not thank them enough and look forward to a brilliant show on 30 August evening. I sincerely thank each and every delegate both from OBGYN and other specialties. We appreciate the valuable time you have invested. Our team has strived hard to put together a unique scientific program. We sincerely hope, this conference will meet your expectations and further upgrade your clinical expertize. We are most grateful to all those pharma companies who have supported this academic activity. Last but not least, it is my pleasant duty to acknowledge and cordially thank our hardworking backstage team members Mr Asif (Admin Assistant North Zone), Ms Shabnam, Ms Sayeeda, Mr Issac, Ms Shweta Chauhan, Mr Ajay Bhardwaj, Ms Sarika, Ms Neha, Mr Harminder Shah & his team, Ms Mridul Arora, Ms Sonika, Ms Komal and all other support staff at Indraprastha Apollo Hospitals. Over the years Mr Rakesh Ahuja and his team members have become an extended family and I sincerely thank them for their full cooperation and excellent printing services. Your feedbacks will be eagerly awaited Best wishes & warm regards Dr Sohani Verma MRCOG, FRCOG (UK), FICOG, FIMSA, PGDMLS, PGDHHM Sr Consultant Obstetrician & Gynaecologists Infertility and ART Specialist Academic Co-ordinator Dept of Obstetrics & Gynaecology Clinical & Academic Coordinator-IVF Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India ID- drsohaniverma@gmail.com, rcog_nz2012@yahoo.com Mobile No

14 Message from the Vice Chairperson It is indeed my privilege to welcome you all to the Annual Conference of AICC RCOG-NZ 2014 as the host team has put up a unique feast for the eager learners by widening the horizon of gynaecology and obstetrics to multi-disciplinary team approach. In current day practice of evidence based medicine, one need to be abreast with knowledge of what is happening in all related field of medicine. Dr Sohani Verma has carefully chosen only clinical based multidisciplinary problems which one faces in day to day practice and has involved the best experts to guide us on the management. All cases are very interesting and interactive participation of the delegates will make this academic bonanza more meaningful. I am sure the knowledge gained would be of immense use to the current practice and will benefit your patients at large. Best Wishes Dr Nirmala Agarwal MBBS, DGO, MRCOG, FRCOG (UK) Head of Department, Obstetrics & Gynaecology Sant Parmanand Hospital, Civil Lines, Delhi Vice Chair-person, Royal College of Obstetricians & Gynaecologists-North Zone, India. 12

15 Message from Organizing Secretaries Academic Excellence is achieved by constant untiring efforts and not by chance. Care of the high risk pregnancy in patients with associated medical disorders and/or advanced maternal age can be a daunting task for the Obstetrician. RCOG AICC NZ brings to you a unique learning experience of Multi disciplinary Management for your high risk pregnancy patients. Panel discussions on Case scenarios will be discussed with a panel of experts from allied medical specialities. This will allow delegates to interact with specialists and take home clear cut messages. This souvenir brings you the cases discussed and the algorithm as well as protocols of management. It should serve as a ready reckoner for future reference. The four Pre conference workshops are on 1. IVF & ICSI at Apollo hospital 2. Pelvic Floor dysfunction at Sant Parmanand Hospital 3. Male Infertility & IUI workshop at Noble IVF Centre 4. Fetal CTG, Ultrasound & Delivery Decisions at Apollo Hospital These will be great learning opportunities. We as organisers will be keen to get your feedback on our e mails and any suggestions for improvement will go a long way in organising future academic events. Dr Mala Arora FRCOG (UK), FICOG, FICMCH Honorary Secretary AICC - RCOG NZ, India Consultant Infertility IVF Consultant Obstetrician & Gynecologist Noble IVF Centre, Faridabad Fortis La Femme, Delhi Dr Anita Kaul MBBS, MD, FRCOG (UK) Dip Advanced Obstetric Scanning Treasurer AICC - RCOG NZ, India Senior Consultant & HOD Apollo Fetal Medicine Unit Apollo Hospital, New Delhi Dr Anjila Aneja MBBS, MD, DNB, MRCOG, FRCOG, Diploma in Pelvic Laparoscopy Head Gynae Unit & Sr. Consultant Obstetrician & Gynecologist Fortis Hospitals, Gurgaon 13

16 Message from the Editor s Desk We cordially invite our privileged and honoured guests to the Annual Conference of All India Coordinating Committee of Royal College of Obstetricians and Gynaecologists of North Zone of India, with the theme topic of Multi Disciplinary Management for Best Care in Obstetrics & Gynaecology. A Multidisciplinary approach is not only recognized as the current standard of care, it is often necessary to provide the best management to the patient. Our International, National, and Guest faculty belonging to various specialities are doyens in their respective fields and will update and abreast us with current guidelines and recommendations on topics of Endocrine Disorders in Obstetrics & Gynaecology, Pregnancy with Connective Tissue Disorder and Renal disease, Pelvic Floor Dysfunction & Urinary Incontinence, Vascular Malformations in Obstetrics, Oncology Multidisciplinary Update and Pregnancy with Gastrointestinal and Hepatic disorders. The panel discussion format of the conference will provide ample scope for lively interaction among participating renowned expert faculty from several specialties. The main emphasis will be on practical and cumulative application of all modern concepts and techniques to optimize clinical management. The face to face discussion based on evidence and latest recommendations will provide an excellent opportunity to clear all doubts and reach a consensus take home message. Guidelines and recommendations provides benchmark for best quality care to patients and prevention of litigation. To provide the right guidance about this topic, we have an Oration on RCOG Guidelines development and implementation by Dr Philip Owen (Chair RCOG Guidelines Committee UK). Two Key Note Lectures on Fibroids and Laparoscopy: Science Versus Sensationalisation by Dr Urvashi P Jha (Chair AICC RCOG) and Prevention of Preterm Birth by Dr Philip Owen (Chair RCOG Guidelines Committee UK) will abreast us with latest controversies and recommendations on these topics. Four pre-conference workshops on COHS, IVF and ICSI- Conventional Protocols and Modifications in Challenging Cases, Live Workshop on Pelvic Floor Dysfunctions & Management, Male Infertility and IUI and Fetal CTG, Ultrasound and Delivery Decisions have been organized in the major hospitals in Delhi and NCR to provide unique opportunities to practising obstetricians and gynaecologists, general practitioners and budding trainees for in depth, focussed learning and interaction on a variety of current hot topics. It is that time of the year again when we have the opportunity to look into the past to help understand & plan the future , saw an exciting year full of academic activities, starting with our 28th AICC RCOG Annual National Conference on 28 August to 2 September 2013 and nine pre and post conference workshops on Colposcopy Course & Hands on, Conducting & Publishing Research, The Obstetrician s Third Eye-Enhancing Fetal Scanning Skills, Office Gynaecology, Urogynaecology & Vaginal Surgery, Ovum Pick-Up & Embryo Transfer, Advance Laparoscopy & Hysteroscopy Surgery, Labour Ward Drills & Fetal CTG and Gynae-Oncology Surgery. We also had our Monthly hands on Endoscopy courses, MRCOG Part 1 and 2 courses including OSCE course, Health camps and RCOG franchised Basic Practical skill course. There was also an inclusion of Enhanced online MRCOG part 2 revision course, members of northern zone being the pioneers in collaboration with the Royal college. A new addition to our monthly activities was introduction of Multidisciplinary team meeting (MDTM), a clinical-path-breaking initiative by RCOG north zone in association with Institute of Obstetrics & Gynaecology, at Indraprastha Apollo Hospitals, Delhi. The 14

17 RCOG world congress at Hyderabad in March 2014 had an impressive participation from fellows and members of AICC RCOG North zone and our contribution was appreciated. The editorial team takes immense pleasure in presenting the proceedings of the annual conference 2013 and Annual activities of RCOG NZ with photographs. All the above were made possible with the team effort of young, enthusiastic and dedicated fellows and members of RCOG-North zone, under the able and dynamic chairperson Dr. Sohani Verma and vice chairperson Dr. Nirmala Agarwal who has been our continuous source of encouragement. We have compiled a directory of all Fellows and Members of AICC RCOG Northern zone in alphabetical order and to express special thanks to our dedicated team, whom we cannot thank often enough. We have messages from the our Patrons, Chairman All India RCOG, Organizing chairperson, Vice Chairperson, Organizing secretaries and Editorial desk. Review of literature, guidelines and recommendations by International, National and guest faculty have been presented session wise, thereby making it a reference point for each panel discussion during scientific session and for future reference. The articles are printed as sent by authors to maintain individuality and convey the message which presenter would like to give directly. We are most grateful to all international, national faculty and contributing authors, who have put in their efforts and valuable time to share their knowledge and expertise with us. We take the opportunity to convey our most sincere thanks to all the esteemed members of the faculty, organising committee who have devoted their precious time and efforts to make this conference successful. A list of sponsors has been included, who have helped and supported us to make this event a grand success. We wish to acknowledge and thank our administrative staff, all secretaries of various hospitals across Delhi and NCR for their continuing support in our endeavour. A special thanks to Convenors and co convenors of all courses, Dr Sanjeev Sharma (UK) for his unconditional support, our web editors for keeping our website updated and working quietly behind the scenes. Heartfelt thanks to Dr Sohani Verma, our guiding light, Dr Nirmala Agarwal, Dr Anita Kaul, Dr Chanchal Singh and Dr Sweta Gupta, our positive sources of energy. Last but not the least, our special thanks to Mr. Rakesh Ahuja and his team at Process and Spot publications to prepare this souvenir and book of abstracts. We hope you would enjoy reading it and cherish it as a memento of our annual conference. Please visit our website for regular updates on our courses and other academic activities. We hope that you enjoy the scientific programme. We look forward to your participation and feedback. With warm regards and best wishes. Dr Arbinder Dang MD, DNB, MNAMS, MRCOG (UK) CERT. CLINICAL EMBRYOLOGY Senior Consultant, Sant Parmanand Hospital, Civil Lines, Delhi54 Member Representative RCOG UK North Zone India and Web Editor Editor Souvenir and Abstract Book Multi Disciplinary Management for Best Care in Obstetrics & Gynaecology Annual conference AICC RCOG NZ 2014 Live as if you were to die tomorrow. Learn as if you were to live forever. - Mahatma Gandhi 15

18 PRE-CONFERENCE WORKSHOPS Workshop 1 COHS, IVF and ICSI Conventional Protocols and Modifications in Challenging Cases Under Aegis of Indian Fertility Society In association with Apollo s Assisted Reproduction Unit (IVF Department), Indraprastha Apollo Hospitals Date: Friday, 29 August 2014 Time: 8:30 am to 5:00 pm Venue: Auditorium, Indraprastha Apollo Hospitals,Delhi - Mathura Road, New Delhi, Convener: Dr Sohani Verma (drsohaniverma@gmail.com/ ) Co-Conveners: Dr Sushma Sinha (sinha_sushma@hotmail.com / Dr Sweta Gupta (swetagupta06@yahoo.com/ ) Objective: This workshop is aimed to provide practical updates on all aspects of IVF,ICSI & COHS used for these procedures. It will be beneficial to both - the beginners as well as the seasoned infertility practitioners. There will be plenty of opportunity to clear all doubts through informal interaction with most renowned expert faculty in this subspecialty. Program: 08:30am Registration 08:45-9:00am Welcome & Introduction Session 1 Chairpersons: Dr P Changulani, Dr Archana Verma 09:00-09:15am Pre- IVF/ICSI Evaluation and Counseling of the couple- Dr Sweta Gupta 09:15-09:30am Predictors of ovarian response to COHS - Dr Sushma Sinha 09:30-09:45am Conventional COHS protocols (Agonist & Antagonist) for IVF/ICSI - Dr Rashmi Sharma 09:45-10:00am Audience Interaction Session 2 Chairpersons: Dr Sushma Sinha, Dr Neelam Suri, Dr Geeta Chadha 10:00-10:15am Luteal Support in IVF cycles - Dr Shweta Mittal 10:15-10:30am COHS Protocols in patients with Poor Ovarian Reserve -Dr K D Nayar 10:30-10:45am Protocols and coordination between Oocyte donor and recipient cycle -Dr Renu Tanwar 10:45-11:00am Audience interaction 11:00-11:30am Tea/Coffee Break Sessions 3 Chairpersons: Dr Sweta Gupta, Dr Harmeet Malhotra, Dr Rashmi Sharma 11:30-11:45am Conventional IVF: Oocyte Retrieval and Embryo Transfer procedure - Dr Puneet Kochher 11:45-12:00pm Modifications in Oocyte Retrieval and ET procedures for difficult cases - Dr Sohani Verma 12:00-12:15pm Embryology aspects of IVF, ICSI and vitrification - Dr Amrit K Swain 12:15-12:30pm Audience interaction 16

19 Pre-Conference Workshops Sessions 4 Chairpersons: Dr Sanjeev Sharma (UK), Dr Kamal Buckshee, Dr K D Nayar 12:30-12:45pm Recent advancements in embryology: IMSI, Assisted Hatching, Embryoscope Dr Brig. R K Sharma 12:45-01:00pm Modifications in COHS Protocols for PCOS/Obese patients- Dr Sonia Malik 01:00-01:15pm IVF in patients with Recurrent Endometriomas Dr Kuldeep Jain 01:15-01:30pm Audience Interaction 01:30-02:00pm Lunch Break Session 5 Chairpersons: Dr Shakti Bhan Khanna, Dr Lalita Badhwar, Dr Kiran Popli Arora 02:00-02:15pm IVF in patients with Hydrosalpinx Dr Kaberi Banerjee 02:15-02:30pm IVF in patients with large Myomas and Adenomyomas- Dr Leena Wadhwa 02:30-02:45pm Is Hysteroscopy essential before IVF?- Dr Ritu Jain 02:45-03:00pm Audience Interaction Session 6 Chairpersons: Dr Mangla Telang, Dr Mala Arora, Dr Sandeep Talwar 02:45-03:00pm ART in HIV Positive patients- Dr Ila Gupta 03:00-03:15pm IVF/ICSI in Cancer Patients - Dr Tanya B Rohatgi 03:15-03:30pm Key Points of PCPNDT Act and ICMR Recommendations governing ART- Dr Gouri Devi 03:30-03:45pm Audience Interaction Session 7 03:45-04:45pm Panel Discussion: ART Complications (OHSS, Multiple/Heterotopic pregnancy) -prediction, prevention & management Moderator: Dr Gita Radhakrishnan Panelists: Dr Mangla Telang, Dr Gouri Devi, Dr Mala Arora, Dr Sandeep Talwar, Dr Kiran Popli Arora 04:45-05:00pm Concluding remarks and vote of thanks 17

20 Pre-Conference Workshops Workshop 2 Live Workshop on Pelvic Floor Dysfunction-Evidence Based Management Date: Saturday, 30 August 2014 Time: 8:00 am to 4:00 pm Venue: Auditorium, Sant Parmanand Hospital, 18 Shamnath Marg, Civil Lines, Delhi Convener: Dr Nirmala Agarwal (n.menoky@gmail.com/ ) Co-Conveners: Dr Sonal Bathla (drsonalbathla11@gmail.com/ ) Dr Arbinder Dang (arbidang@yahoo.co.in/ ) Faculty: Dr Uma Swain, Dr Jasmine Chawla, Dr Sweta Balani, Dr Priti Arora Dhamija, Dr Praveen Kumar Introduction: The Department of Obstetrics and Gynaecology, Sant Parmanand Hospital is organizing a Comprehensive Live Workshop on Evidence Based Management of Pelvic Floor Dysfunction to enhance skills of practicing Gynaecologists, Urologists and Urogynaecologists. Expert opinions from Senior Faculty will be telecasted. Complete Lecture Notes will be provided to the registered delegates. Program: Live Surgeries/ Video 1. Surgeries for Pelvic Organ Prolapse a. Fascial Repair b. Sacrospinous fixation c. Uterosacral Suspension d. Bio-Sling 2. Surgeries for Nulliparous Prolapse a. Manchester Repair b. Hysteropexy c. Abdominal suspension 3. Surgeries for Vault Prolapse 4. Surgical Management of Incontinence a. Laparoscopic & Open Burch suspension b. Miniarc Insertion 5. Surgeries for Urogenital Fistulae Lectures 1. Anatomy of pelvic Floor & POPQ Classification 2. Medical Management of Incontinence 3. Evidence Based Surgical Management of POP 4. Urodynamics in Gynaecological Practice 5. Controversies around Mesh Usage Healing Hand 18

21 Pre-Conference Workshops Workshop 3 Male Infertility & IUI Workshop Date: Saturday, 30 August 2014 Time: 9:30 am to 5:00 pm Venue: Noble IVF Centre, Sector 14 market, Faridabad, Haryana Convener: Dr Mala Arora (narindermala@gmail.com/ ) Organising Chairperson: Dr Mala Arora Co-Conveners: Dr Sweta Gupta (swetagupta06@yahoo.com; M: ) Dr Kaberi Banerjee (banerjee.kaberi@gmail.com; M: ) 9:30 to 10:00 am Registration and Welcome Drink Session 1: Medical management of Male Infertility Co-convener -Dr Kaberi Banerjee Program: 10:00-10:30am Semen Analysis-WHO criteria and Implications -Dr Rajiv Kumar (Urologist) 10:30-11:00am Azoospermia-Workup and management -Dr Rajiv Kumar 11:00-11:30am Erectile Dysfunction and Non Consummation -Dr Subramanium (Urologist) 11:30-12:00 Ejaculatory Dysfunction-Premature & Retrograde Ejaculation -Dr Anoop Gulati (Urologist) 12:00-12:30pm Infections of the male genital Tract and Role of DNA fragmentation Index -Dr Neena Malhotra 12:30-13:15pm Panel Discussion on Medical management of male Infertility Moderators: Dr Kaberi Banerjee Panelists: Dr Abha Majumdar, Dr Mangala Talang, Dr Aanjani Agarwal, Dr Vikram Singh, Dr Anoop Gulati, Dr Neena Malhotra, Dr Jyoti Bali 13:15-14:00 Lunch Session 2 : IUI workshop & Surgical management Co-convener Dr Sweta Gupta 14:00-14:45pm Live Demonstration of semen Preparation for IUI -Brig Dr Sharma 14:45-15:15pm Surgical procedures to enhance male infertility Varicocelectomy -Dr S K Pal (Urologist) 15:15-15:45pm Indications for ICSI and video demonstration -Dr Kuldeep Jain 15:45-16:15pm IMSI and Other procedures of sperm selection -Dr Herishikesh Pai 16:15-17:00pm Panel discussion: Which treatment modality to use in patients with Oligo-astheno-teratospermia (OATS) Moderator: Dr Sweta Gupta Panelists: Dr Sushma Sinha, Dr K D Nayar, Brig Sharma, Dr Gaurav Majumdar, Dr Sandeep Talwar, Dr Seema Sharma, Dr Jharna, Dr Anita Sabrawal, 17:00pm High Tea & closing 19

22 Pre-Conference Workshops Workshop 4 Fetal CTG, Ultrasound and Delivery Decisions In association with Department of Fetal Medicine & Institute of Obstetrics & Gynaecology Indraprastha Apollo Hospitals Delhi Date: Saturday, 30 August 2014 Time: 9:00 am to 5:00 pm Venue: Auditorium, Indraprastha Apollo Hospitals, Mathura Road, New Delhi, Part A Ultrasound and Delivery Decisions Convener: Dr Anita Kaul (anita_kaul@apollohospitals.com/ ) Co-Convener: Dr Ashok Khurana (ashokkhurana@ashokkhurana.com/ ) Part B Fetal CTG Convener: Dr Chanchal Singh (chanchalsng@yahoo.com/ ) Co-Convener: Dr Ranjana Sharma (rnj_sharma@yahoo.com/ ) International faculty: Dr Philip Owen - Chair, RCOG Guidelines Committee UK,Maternal Fetal Medicine Expert Dr Prabha Sinha Consultant Fetal Medicine (UK) Program: am Registration Part A Ultrasound and Delivery Decisions Session 1 Chairpersons: Dr Vidya Gupta, Dr P Changulani, Dr Sushma Sinha, Dr Preeti Rastogi, Dr Geeta Chadha 09:00-9:20am Delivering too late risk of stillbirth in low risk pregnancy- Dr Chanchal Singh 09:20-9:40 am Delivering too early Neonatal outcomes- Dr Sushma Kaul 09:40-10:00am Audience Interaction Session 2 Chairpersons: Dr Manavita Mahajan, Dr Saroja Balan, Dr Madhu Roy, Dr Seema Thakur 10:00-10:20am Monitoring and timing of delivery in FGR - <34 weeks; >34 weeks Dr Deepika Deka 10:20-10:40am Role of ultrasound and Dopplers in pregnancy with Diabetes- Dr Ashok Khurana 10:40-11:00am Audience Interaction Session 3 Chairpersons: Dr S B Khanna, Dr Sohani Verma, Dr Witty Raina, Dr Chandan Dubey 11:00-11:20am Key Note Lecture: Prediction of Preterm labour Dr Philip Owen (UK) 11:20-11:40am PPROM role of ultrasound Dr Poonam Tara Thakur 11:40-12:00am Audience Interaction Session 4 Chairpersons: Dr Kamal Buckshee, Dr Kaushiki Dwivedi, Dr Uma Panday, Dr Manjusha, Dr Harmeet Malhotra, 12:00-12:20pm Ultrasound for previous caesarean scar Dr Anita Kaul 12:20-12:40pm Sono-partogram Role in Labour Ward management - Dr Prabha Sinha (UK) 12:40-01:00pm Audience Interaction 01:00-02:00pm Lunch Part B Fetal CTG 02:00-02:15pm Overview Dr Ranjana Sharma 02:15-02:30 Interpretation of abnormal features Dr Jyoti Bhaskar 02:30-02:45pm Pre-test Quiz Dr Chanchal Singh Breakout session CTGs will be individually discussed at the tables and there will be an overall summary and key messages after each case by Dr Chanchal Singh 03:00-04:30pm Facilitator Station 1 Dr Sonu Agarwal, Dr Astha Takkar Facilitator Station 2 Dr Poonam Tara Thakur, Dr Harpreet Kaur Isher Facilitator Station 3 Dr Mamta Mishra, Dr Jasmeet Monga Facilitator Station 4 Dr Jayasree Sundar, Dr Monika Nagpal 04:00-04:30pm Post workshop Quiz 04:30-05:00pm Discussion and Feedback 20

23 SCIENTIFIC PROGRAM Sunday, 31 August :00am Registration 08:45-09:45am Session 1: Endocrine Disorders in Obstetrics & Gynaecology Case - I A 38 year old lady with H/O primary infertility of 10 years duration on Metformin in view of FBS 115 mg /dl and HbA1C 6.7% since previous 3 months, conceived through IVF+ICSI treatment. Metformin changed to Insulin. Significant fetal growth restriction (FGR) throughout pregnancy.elective LSCS at 37 weeks gestation. Baby wt 2.2kg. Discussion issues and learning objectives - Difference between overt diabetes and GDM and impact on management - Therapeutic targets for blood glucose levels during pregnancy - Choice of therapy - Metformin or Insulin or combination - Advances in Insulin therapy Case - II A 28 year old lady attends for pre pregnancy counseling. Her serum TSH is reported as 4.2 IU (N ), Free T4 and T3 level within normal limits. Discussion issues and learning objectives - Interpretation of this report - Normal or further tests and therapy indicated - Global consensus on normal TSH levels before and during pregnancy in euthyroid and hypothyroid patients Moderators Dr Sohani Verma Dr Sweta Gupta Panelists Dr S K Wangnoo Endocrinology Dr C M Batra Endocrinology Dr S K Agarwal Internal Medicine Dr Neeru Gera Endocrinology Dr Anju Virmani Paediatric Endocrinology Dr Indrani Ganguli Dr Reva Tripathi Dr Anjila Aneja Dr Sanjeev Sharma (UK) Case - III A 49 Year old lady 1 year postmenopausal complains of hot flushes, depression, insomnia, loss of libido and low bone density. Discussion issues and learning objectives - What should be the first line therapy - SSRI (anti-depressants ) + bisphosphonates or HRT? - Latest evidence & recommendations - Which drugs, why and for how long? Case - IV A 9 year 6 months old girl had her first menstrual period recently. Anxious parents attend for counseling and request to postpone her menses for at least next 2 years. All routine investigations came as normal. Discussion issues and learning objectives - What is the normal age for menarche in Indian girls? - Implications of precocious puberty - Confirmatory tests - GnRH analogue treatment dosage, duration, side effects - Combined use of Growth Hormone Case - V The parents of a 15 year old girl attend OPD. She has not attained her menarche and there is absence of breast development and other secondary sex characteristics. Discussion issues and. learning objectives - Relevant tests to assess the pathophysiology - Induction of puberty using sex steroids Timing of the initiation of oestrogen, dosage and duration Unopposed oestrogen or combined with progesterone or sequential Maintenance therapy Growth hormone treatment 09:45-10:15am Session 2: Oration Chairpersons: Dr Urmil Sharma, Dr S K Bhandari, Dr Kamal Buckshee - RCOG Guidelines development and implementation Dr Philip Owen (Chair, RCOG Guidelines Committee UK, Maternal-Fetal Medicine Expert) 21

24 10:15-11:00am Tea /Coffee Break 11:00-12:00 pm Session 3: Connective tissue disorders and Renal disease Case - I 42 year old primigravida (IVF conception), presents at 24 weeks gestation with Proteinuria +++ on dipstick test, oedema +++, BP 120/80 Discussion issues and learning objectives - Current recommended tests to evaluate proteinuria in pregnancy - Pathophysiology of Proteinuria and difference between Albuminuria and Proteinuria - Differential diagnosis, prognosis and management Case - II 29 year old primi gravida, known case of Lupus nephritis with early onset FGR Discussion issues and learning objectives - Impact of drugs commonly used in SLE - Effect of disease on pregnancy and effect of pregnancy on disease - Monitoring - what, when and how - Pre-pregnancy counselling Case - III Sjögren s syndrome with fetal heart block 36 year old Primi gravida, Known case of Sjögren s syndrome, DCDA twin pregnancy with fetal heart block Discussion issues and learning objectives - What investigation should be done in patients with Sjögren s Syndrome? - Effect of disease on pregnancy and effect of pregnancy on Disease - Management once fetal heart block is identified - Role of fetal therapy in Fetal heart block Moderators Dr Suneeta Mittal Dr Mala Arora Panelists Dr Rohini Handa Rheumatology Dr S J Gupta Rheumatology Dr V K Aneja Internal Medicine Dr Sanjeev Jasuja Nephrology Dr Manisha Chakravarti Paediatric Cardiology Dr Chanchal Singh Dr Sonal Bathla Dr Poonam Tara 12:00-12:50pm Session 4: Key Note Lectures Chairpersons: Dr M Kochhar, Dr Sheila Mehra, Dr S B Khanna, Dr Meena Naik 12:00-12:20pm Fibroids and Laparoscopy: Science Versus Sensationalisation Dr Urvashi P Jha (Chair AICC RCOG) 12:20-12:40pm Prevention of preterm birth Dr Philip Owen (Chair, RCOG Guidelines Committee UK, Maternal -Fetal Medicine Expert) 12:40-12:50pm Audience Interaction 12:50-01:50pm Session 5: Pelvic Floor Dysfunction & Urinary Incontinence Case - I Case of procidentia with no urinary complaints Discussion issues and learning objectives - POPQ classification - Options for treatment - Preventive modalities for future Failure of surgery Case II Case of vault prolapse after abdominal hysterectomy Discussion issues and learning objectives - POPQ staging of case - Preventive surgical principles - Best options of abdominal/laparoscopic sacral colposuspension versus vaginal sacrospinous fixation - Judicious use of mesh- latest recommendations Case - III Case of detrusor instability and stress urinary incontinence with cystocele / urethral diverticulum Moderators Dr Nirmala Agarwal Dr Arbinder Dang Panelists Dr N Subramanian Urology Dr Suresh Rawat Urology Dr Rajiv Kumar Urology Dr Vipin Arora Urology Dr J B Sharma Dr Ranjana Sharma Dr Uma Swain Dr Uma Pandey 22

25 Discussion issues and learning objectives - Role of urodynamic studies - Management dilemma Case - IV Case of stress urinary incontinence Discussion issues and learning objectives - Best management options: tension free tape, colposuspension & urethal bulking agents 01:50-02:30pm Lunch Break 02:30-03:30 pm Session 6: Vascular Malformations in Obstetrics Case - I 31 year old 25 weeks of pregnancy admitted with sudden onset headache, vomiting and loss of consciousness with normal BP who then required ventilatory support. Discussion issues and learning objectives - Differentiation between severe pre-eclampsia, epilepsy, thromboembolism and cerebral haemorrhage - How to manage an unconscious pregnant patient - Basic principles of critical care management Case - II A 26 year second gravida was diagnosed with Cesarean scar pregnancy at 6 weeks and was advised termination.she declined and pregnancy continued. Later diagnosed to have placenta praevia. Elective LSCS performed at 37 weeks when found to have a morbidly adherent placenta. Had cardiac arrest on table. 40 units of blood were transfused.both mother and baby survived. Discussion issues and learning objectives - How to diagnose cesarean scar pregnancy - How to diagnose a morbidly adherent placenta - How to plan delivery in a patient with a morbidly adherent placenta versus one with a nonadherent placenta praevia - Use of different blood products Moderators Dr Anita Kaul Dr Mamta Mishra Panelists Dr R N Makroo Transfusion Medicine Dr V P Singh Neurosurgery Dr Pinak Shrikhande Critical Care Dr A S Arora Invasive Radiology Dr S S Trivedi Dr K Gujral Dr Sushma Sinha Dr Prabha Sinha (UK) Case - III 31 year old with a 29 week pregnancy with a AV malformation in the fetal brain which needed a multidisciplinary team for further management Discussion issues and learning objectives - The Law and late termination of pregnancy - Safety of Colour Doppler, Power Doppler and MRI imaging in Pregnancy - Outcomes of antenatal brain malformation in the fetus 03:30-04:30 pm Session 7: Oncology Multidisciplinary Update Case - I A 30 year old lady coming with a cervical screening report-hpv positive Discussion issues and learning objectives - Role of HPV testing for Cervical Cancer Screening - What does a positive HPV test result mean? - Step wise approach Case - II A 25 year old lady with a solid ovarian mass Discussion issues and learning objectives - D/D of an adnexal mass in a young patient - Working up a patient with a solid adnexal mass - Surgical staging-new FIGO guidelines - Fertility issues in surgery & subsequent therapy Moderators Dr Saritha Shamsunder Dr Pakhee Aggarwal Panelists Dr Ramesh Sarin Surgical Oncology Dr Harsh Dua Medical Oncology Dr Ashok Khurana Ultrasound Dr Nandini Vasdev Pathology Dr Manu Noatay Cytopathology Dr Urvashi P Jha Dr Shakti Bhan Khanna Dr Vijay Zutshi 23

26 Case - III A 32 year old lady with a breast lump detected at 10 weeks of pregnancy Discussion issues and learning objectives - Differential diagnosis of a breast lump in pregnancy - Management of a patient with a breast lump - Role of surgery, chemotherapy in pregnancy 04:30-05:30pm Session 8: Pregnancy with Gastrointestinal/Hepatic disorders Case - I A primigravida with 8 weeks intrauterine singleton pregnancy presents with c/o severe nausea, loss of appetite and vomiting 7-8 times a day Discussion issues and learning objectives - Effective and safe management of nausea and vomiting of Pregnancy (NVP) - Hyperemesis Gravidorum (HG) - Pathophysiology and principles of management Case- II 33 year old primigravida attends at 35 weeks pregnancy c/o severe itching all over body for last one month, unable to sleep. SGOT 92 U/L, SGPT 232 U/L GGTP 90, ALP 722 (N ). Patient on Tab Ursocol 300mg tds. At 36 weeks Total Bile Acid 48.16μ mol/ l (N 0 to 10.0) Discussion issues and learning objectives - Essential tests and differential diagnosis - Management of Obstetric Cholestasis Maternal monitoring and drugs for symptomatic relief Fetal monitoring - Total bile acid estimation (now available locally) - Normal range, Limitations, significance. Alternative tests - Induction of labour (IOL) - Indications & timing Moderators Dr Asmita Rathore Dr Mamta Dagar Panelists Dr Arun Prasad General, Laparoscopy & Robotic Surgery Dr Nitin Ghonge Radiology Dr Sanjay Sikka Gastroenterology Dr Ajay Kumar Gastroenterology Dr Jayasree Sundar Dr Neema Sharma Dr Ramandeep Kaur Case - III 29 year primigravida at 26 weeks pregnancy attends emergency with severe pain abdomen and vomiting since last 2 days Discussion issues and learning objectives - Non gyneacological causes of acute abdomen during pregnancy - Safety of abdominal imaging tests during pregnancy - GI Endoscopy during pregnancy - Indications & principles of benefit-to-risk ratio - Laparoscopic or open GI surgery during pregnancy - Indications, safety and special precautions Case - IV 22 year unbooked G2 P1L1 admitted at 34 weeks with H/O fever last 7 days, jaundice, anorexia, irritability, malaise, vomiting, abdominal pain, bleeding PV 6 Hours. Diagnosed as acute fulminant viral Hepatitis E Discussion issues and learning objectives - Differential diagnosis and management of Hepatitis E in Pregnancy - Maternal and fetal risks and management 05.30pm Vote of thanks (followed by Tea) 24

27 An Overview of the Activities of the AICC-RCOG Northern Zone India Committee Complied by Dr Arbinder Dang, Editor Souvenir Annual Conference Northern Zone AICC RCOG 2014 Multi Disciplinary Management for Best Care in Obstetrics & Gynaecology Teams do not seek consensus; they seek the best answer. Jon R. Katzenbach & Douglas K. Smith, from The Wisdom of Teams I am honored to write this report of the activities of the AICC-RCOG Northern Zone India Committee, an organization of academic excellence in the field of obstetrics and gynaecology, the goal being to provide quality patient care and setting standards in accordance with international standards. Over the last few years, it has grown phenomenally, thanks to the hard work and team spirit of our patrons, fellows, members and associate members. The organizing committee is grateful to all who have helped us grow leaps and bound and thankful for the continuing good work. The academic activities of the year were based on the theme of evidence based, multidisciplinary approach and highlighted the importance of team work to enhance patient care and avoid litigation. The various RCOG franchised courses were upgraded and our National Annual conference 2013 with nine workshops was an unqualified success. The RCOG world congress at Hyderabad in March 2014 had an impressive participation from fellows and members of AICC RCOG North zone and our contribution was appreciated. On philanthropic front, under the aegis of RCOG North zone, department of Obstetrics and gynaecology, Sant Parmanand hospital, Civil Lines, Delhi conducted various Gynecology surgery and screening camps all year round in Delhi and regions of Himachal Pradesh. Enhanced Revision Programmer Package for Part 2 MRCOG In , RCOG Northern Zone India was the first zone to conduct an online revision programmer package from the RCOG London with 15 weeks of online classrooms discussions & tests from February to July 2012 & September2012-March This was followed by the Part 2 Revision Course in July 2012 & January The online course was attended by 6-8 candidates with an excellent success rate. Moderators were Dr. Lisa Joels (UK), Dr. Sanjeev Sharma (UK), Enhanced Revision Programmer Package for Part 2 MRCOG Multidisciplinary team meeting (MDTM) monthly at Apollo Hospital, Delhi Annual Conference of the RCOG North Zone Bridging the Gap in Women s Healthcare 2013, inclusive of 9 workshops The Obstetrician s Third Eye-Enhancing Fetal Scanning Skills Workshop Colposcopy Course & Hands- on Workshop Advance Laparoscopy & Hysteroscopy Surgery Workshop Conducting & Publishing Research Workshop Labour Ward Drills & Fetal CTG Ovum Pick-Up & Embryo Transfer Workshop Urogynae & Vaginal Surgery Workshop Office Gynaecology Workshop Gynae-Oncology Surgery Workshop RCOG World Congress at Hyderabad in March 2014 RCOG Franchised MRCOG part 2 courses (FEB & JULY 2014) RCOG Franchised Basic Practical Skill Courses (FEB & JULY 2014) MONTHLY Hands-on gynae endoscopy and vaginal surgery workshop at Fortis Hospitals Gynecology surgery and screening camps all year round by department of Obstetrics and gynaecology, Sant Parmanand Hospital, Delhi Dr Saritha Shamsunder, Dr Arbinder Dang, Dr Meenakshi Sahu, Dr Neeta Gupta & Dr Priti Gupta. In 2014, The RCOG UK MRCOG Part II The Enhanced Revision Programme was a 15 week revision programme, started on 6 April 2014 & organized by RCOG UK, for preparation of the Part 2 MRCOG examination. This unique and rewarding programme 25

28 was mapped to the syllabus of the membership examination and its content were developed and reviewed by experienced RCOG examiners. The course was limited to 10 candidates and consisted of virtual interactive weekly classroom sessions live direct from UK and was followed by 3 days Part II written & OSCE course held on July in Delhi. Forthcoming course: For 2015, The RCOG UK MRCOG Part II Enhanced Revision Programme Package Integrated distance and classroom learning course starts on 14 September 2014 to 11 January MRCOG Part 2 Revision Course (Written and OSCE combined) will be held in January 2015 (duration 3 days) in Delhi and will include examination tips, techniques to answer exam questions, MCQs. EMQs and SAQs. women s healthcare Easy access to a team of experts from different specialties on a single platform. Face to Face discussion based on current evidence and recommendations On spot consensus opinion without any medicolegal obligations A valuable opportunity for all delegates to learn and enrich their knowledge 28 th AICC RCOG Annual National Conference with Nine Pre & Post Workshops on 28 Aug to 2 Sept, 13 was organized by the North Zone in New Delhi Theme: Bridging the Gap in Women s Healthcare UK Conveners- Dr John Duthie Dr Moshen Iskander Dr Sanjeev Sharma India Convenors- Dr Saritha Shamsunder shamsundersaritha@gmail.com Dr Sweta Gupta Dr Manjusha Dr Puneet Kochhar swetagupta06@yahoo.com manjusha9000@gmail.com drpuneet.k20@gmail.com Multidisciplinary Team Meeting (MDTM) Organizing Team Chairperson- Dr Sohani Verma Co-chairpersons- Dr Shakti Bhan Khanna & Dr Anita Kaul Secretary- Dr Chanchal Singh RCOG NZ MDTM Obs & Gynae A clinical-path-breaking initiative held on every third Saturday of month by RCOG north zone India in association with Institute of Obstetrics & Gynaecology, at Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi. A unique initiative to provide clinical decision making support to the doctors and improve Venue: India Habitat Centre, Lodhi Road, New Delhi Organizing Chairperson: Dr Sohani Verma Organizing Vice Chairperson: Dr Nirmala Agarwal Organizing Secretaries: Dr Mala Arora, Dr Anita Kaul, Dr Anjila Aneja Faculty: International: 10 (including Dr David Richmond President RCOG UK) National: 130 Total No. of Registrations 517 There were 74 Free Communications. 11 awards for the best paper in each category. A Postgraduate student s quiz was organized. Preliminary rounds were conducted by all 4 zones. The two winners from each zone participated in the final rounds in New Delhi on 1st September. A special session on Right guidance to pass MRCOG examination was conducted on 31 st August 2013 chaired by Dr David Richmond President RCOG UK, Dr. Lisa Joels, Dr. Sanjeev Sharma and team of RCOG committee fellows and members. 26

29 Inaugural ceremony with welcome dinner was held at Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi on 30th August 2013 and was attended by RCOG national and international fellows and members including Dr David Richmond President RCOG UK, dignitaries from UK, Patrons, Zonal Chairpersons, Chairman AICC RCOG Fellows and Members of our committee. Nine Pre & Post Conference Workshops were Conducted Colposcopy Course & Hands on Workshop 28 th & 29 th August 2013 Venue: Fortis Memorial Research Institute Gurgaon, Haryana Conveners: Dr Urvashi P Jha, Dr Saritha Shamsunder Total No. of Participants Conveners: Dr Meena Naik, Dr Jayasree Sundar Total No. of Participants - 77 The Obstetrician s Third Eye-Enhancing Fetal Scanning Skills Workshop 29 th August 2013 Venue: Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi Conveners: Dr Anita Kaul, Dr Prathima Radhakrishnan, Dr Chanchal Singh Total No. of Participants - 49 Conducting & Publishing Research Workshop 29 th August 2013 Venue: All India Institute of Medical Sciences, Ansari Nagar, New Delhi Conveners: Dr J B Sharma, Dr Mala Arora Total No. of Participants - 19 Office Gynaecology Workshop 29 th August 2013 Venue: Max Hospital, 1 Press Enclave Road, Saket, New Delhi 27

30 Urogynaecology & Vaginal Surgery Workshop 30 th August 2013 Venue: Sant Parmanand Hospital, 18 Sham Nath Marg, Civil Lines, New Delhi Conveners: Dr Nirmala Agarwal, Dr Ranjana Sharma, Dr Sonal Bathla, Dr Arbinder Dang Total No. of Participants 98 Labour Ward Drills & Fetal CTG Workshop 30 th August 2013 Venue: Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi Conveners: Dr Sohani Verma, Dr Asmita Rathore, Dr Chanchal Singh Total No. of Participants Ovum Pick-Up & Embryo Transfer Workshop 30 th August 2013 Venue: Adiva Hospital, 15 Anand Lok, August Kranti Marg, New Delhi Conveners: Dr Kaberi Banerjee Total No. of Participants - 66 A Live workshop on demonstration of Ovum Pick up and Embryo transfer. This was an excellent opportunity to learn the tips and tricks of egg collection and embryo transfer, optimizing the number of oocytes retrieved and doing a smooth embryo transfer which is so critical for improving the pregnancy rates. Aimed to demonstrate difficult cases of egg collection and embryo transfer. Gynae-Oncology Surgery Workshop 2 nd September 2013 Venue: Fortis Memorial Research Institute, Gurgaon, Haryana Conveners: Dr Urvashi P Jha, Dr Saritha Shamsunder Total No. of Participants 55 Advance Laparoscopy & Hysteroscopy Surgery Workshop 30 th August 2013 Venue: Max Hospital, 1 Press Enclave Road, Saket, New Delhi Conveners: Dr Anjila Aneja Total No. of Participants - 79 RCOG Franchised PART II MRCOG Revision course February 2014 & July 2014 RCOG Northern Zone centre, B 235, CR Park, N Delhi. Convenors: Dr Sanjeev Sharma (UK), Dr Saritha Shamsunder, Dr Sweta Gupta, Dr Jyoti Bhaskar. Faculty: Dr Sohani Verma, Dr Sanjeev Sharma(UK), Dr Nirmala Aggarwal, Dr Mala Arora, Dr Asmita Rathore, Dr Mamta Dagar, Dr Seema Sharma, Dr Sandhya Gupta, Dr Preeti Rastogi, Dr Jasmeet Monga, Dr Kiran Popli, Dr Preeti Gupta, Dr Poonam Tara, Dr Meenakshi Sahu, Dr Pakhee, Dr Sonu Agarwal, Dr Monica Nagpal, 28

31 Dr Jyoti Bhaskar, Dr Ausha(UK), Dr Saritha Shamsunder, Dr Jayashree Sundar, Dr Mina Naik, Dr Sweta Gupta, Dr Puneet Kochhar, Dr. Praveena Pai, Dr Neelam Vinay, Dr Anita Kaul, Dr. Jharna, Dr. Arbinder Dang This course has gained popularity among candidates appearing for MRCOG examination part II. It is three days course consisting of lectures, discussions, MCQs, SAQs, EMQs and OSCE circuits practice. It covers topics like clinical governance, audit, NHS healthcare which are extremely helpful for overseas candidates for better understanding of UK based exam. Faculty is Consultants both from UK and Indian with UK experience. It has received excellent feedback from candidates and runs fully booked in the recent years. Skills in Obstetrics and Gynecology. This course is held twice a year at Ethicon Institute, Kirti Nagar and is run by eminent faculty from RCOG North Zone and UK. It was initiated in 2009 by Dr UP Jha, to improve the basic surgical skills of the trainees and practioners. The Course has gained popularity as evident by the increasing number of national and international candidates attending it. The Course information is available at and RCOG Franchised Basic Practical Skills Course February 2014 & July 2014 Ethicon Institute of Surgical Education, Johnson and Johnson, Kirti Nagar, Delhi. Conveners: Dr Mamta Dagar, Dr Sanjeev Sharma (U.K), Dr Arbinder Dang, Dr Jasmine Chawla, Dr Sohani Verma Faculty : Dr Sohani Verma,Dr Nirmala Agarwal,Dr Sanjeev Sharma(UK),Dr Mamta Dagar, Dr Jasmine Chawla, Dr Arbinder Dang, Dr. Poonam Tara, Dr. Sandhya Gupta, Dr. Kiran Popli, Dr. Ausha De Silva(UK), Dr. Jasmeet Monga, Dr. Neema Sharma, Dr. Meena Naik, Dr. Jharna Behura, Dr. Jyoti Bhaskar, Dr. Vinita Kumar, Dr. Sweta Gupta, Dr. Mamta Mishra, Dr. Pakhee Agarwal, Dr. Sonu Agarwal, Dr. Chanchal Singh, Dr. Aastha, Dr. Vanita Mittal, Dr.Saritha Shamsundar, Dr Jayshreesundar, Dr. Pakhee Agarwal, Dr Seema Sharma, Dr. Puneet Kochhar BPS Course is a RCOG Franchised Course which aims at enhancing Basic Surgical, Endoscopic and Obstetric 29

32 Monthly Hands-On Gynae Endoscopy workshop and Vaginal surgeries NDVH workshops Monthly hysteroscopy and laparoscopy workshop, organized since May 2011 by the under aegis of RCOG NZ and AOGD Endoscopic committee. Vaginal surgeries workshop is a new addition since Hands on laparoscopy and hysteroscopy workshop is a two days endoscopy course certified independently by Ethicon and AICC RCOG and AOGD. First day is in the Ethicon Institute Kirti Nagar where delegates do supervised hands on training on the pig and laparo trainers and second day is at Fortis Vasant Kunj where they assist in 2-3 endoscopy cases. Three workshops with 15 delegates in each workshop. Conveners: Dr Urvashi Prasad Jha, Dr Neema Sharma, Dr Ramandeep Kaur Department of Minimal and Natural Access Gynae & Gynae Cancer Surgery, Fortis Flt Lt Rajan Dhall Vasant Kunj, New Delhi Part I & Part II MRCOG Examinations Delhi, India Part I & Part II MRCOG Examinations were conducted on 2 nd & 3 rd September 2013 by RCOG UK with help of Dr JB Sharma and Dr Sohani Verma at Indraprastha Apollo Hospitals, New Delhi. RCOG world congress at Hyderabad in March 2014 Organising Committee UK RCOG Congress Committee: Chair/RCOG Honorary Treasurer : Dr Paul Fogarty Local Congress Organising Committee: Chair: Mr Pramathes Das Mahapatra Free Communications and eposters: Dr Sohani Verma (Chair) North zone faculty members Dr Sohani Verma lecture on Management options for patients with Poor Ovarian Reserve. Dr Nirmala Agarwal Debate: Ovaries should always be preserved at hysterectomy for benign disease. Debater for: Paul Fogarty; Debater against: Nirmala Agarwal. Dr Urvashi Jha Free Communications: Experience with a novel primary port site described as Jha s left subxiphisternal incision. Panel Moderator in Challenges in Operative Endoscopy Sponsored by Stryker. Dr Mala Arora Lecture on Protocols for Luteal Phase support. Dr Anita Kaul Pre Congress Workshop on The Foetus at Risk. Lecture on Ultrasound & Doppler identification of fetal anemia. Dr Anjila Aneja as panelist in Challenges in Operative Endoscopy Dr S N Basu as a panelist in Uterine and cervical factors in infertility. Dr Saritha Shamsundar Panelist in Abnormal cervical smears cases and management. As a faculty in Pre Congress Workshop on Live Operative Pelvic Endoscopy. Dr J B Sharma panelist in Panel: Managing Ovarian Cysts case discussions. Dr Ranjana Sharma panelist in Amenorrhea : Case Discussions. Dr Ritika Bhandari Faculty in Pre Congress Workshop on The Foetus at Risk. Lecture on Identifying the fetus at risk for hypoxia. As a panelist in Discussion -Clinical scenarios Dr S Suresh Dr Arbinder Dang Coordinator E poster committee Faculty in Pre Congress Workshop on Practical Obstetric Skills. Presented two E posters on: To compare Obstetric and perinatal outcomes in Oocyte recipients and in-vitro fertilization pregnancies and Retrospective Audit of Obstetric Critical Care and assessment of Severe maternal morbidity in a tertiary hospital. Abstract on To compare Obstetric and perinatal outcomes in Oocyte recipients and in-vitro fertilization pregnancies, published in BJOG special edition for top 500 abstracts. 30

33 Dr Neema Sharma Chaired a session on Free Communications: Gynae Endoscopy & Robotic Surgery. Participated as moderator in Endoscopy: Robotic Surgery has limited utility in Endoscopy. As a faculty in Pre Congress Workshop on Live Operative Pelvic Endoscopy. Dr Sweta Gupta faculty in Pre Congress Workshop on Practical Obstetric Skills. Dr.Kaberi Bannerji faculty in Pre Congress Workshop on Trouble Shooting in Infertility. Dr. Mamta Dagar: faculty and hall management committee. Dr. Chanchal Singh: faculty and hall management committee. Abstract Reviewers for free communications and E posters: Dr Anita Kaul, Dr Anjila Aneja, Dr Arbinder Dang, Dr Chanchal Singh, Dr J B Sharma, Dr Jyoti Bhaskar, Dr Mala Arora, Dr Mamta Dagar, Dr Nirmala Agarwal, Dr Puja Dewan, Dr Ranjana Sharma, Dr Saritha Shamsunder, Dr Seema Sharma, Dr Shishta Nadda Basu, Dr Sweta Gupta, Dr Urvashi Prasad Jha 15 patients of prolapse and urinary incontinence were operated. Mobile Surgical Camp at Rekong Peo under aegis of IMS & RCOG in collaboration with NRHM in Nov eye, 22 Gynae and 32 General surgeries. Organized Free Surgical Camp at Herbertpur in association with ONGC under aegis of IMS & RCOG from Jan 4 to major surgeries were done. Gynaecology surgery and screening camps Conducted all year round by department of Obstetrics and gynaecology, Sant Parmanand hospital, Delhi under aegis of AICC RCOG North zone. Organized Free Surgical camp for prolapse patients at Sant Parmanand Hospital on 30 th August 2013 in collaboration with inner wheel under aegis of IMS & RCOG. Delhi Institute of Trauma & Orthopedics at Sant Parmanand Hospital, in collaboration with RCOG North Zone and IMS conducted a camp at Roshanara Club on 16th Feb 2014 in Delhi. 31

34 Bone densitometry and Vitamin D3 estimation was done in 74 volunteers.. The RCOG North Zone India Centre whilst being a temple of academic activities continues to bond us, the RCOG North Zone fraternity. On occasion of World Women s day on 02/03/14 a Health Check Camp and Public Awareness Programme was organized by Department of Obstetrics & Gynaecology at Sant Parmanand Hospital in association with Friends of Sant Parmanand Hospital Welfare Association under aegis of Royal College of Obstetricians and Gynaecologists, North Zone and IMS in Delhi. 37 patients belonging to poor socio- economic strata attended the camp. Health check up of the patients was done by a team of consultants. Investigations including transvaginal sonography, pap smear, basic blood investigations & serum vitamin D3 levels were done. Free medicines were distributed to the patients according to their complaints. Health awareness lectures were given to the patients by the Consultants of Department of Obstetrics & Gynaecology, Sant Parmanant Hospital on Cervical cancer, Osteoporosis and Breast Cancer. Free Surgical Camp at Manali in association with Sree Cement under aegis of IMS & RCOG from 10 to 11 th June major surgeries were done. The RCOG North Zone India Centre With the capable Chairperson Dr. Sohani Verma and vice chairperson Dr. Nirmala Agarwal and their team, Asif (administrative assistant) who has to multitask many times, we are keeping our flag flying. We profusely thank our course convenors and convenors of various workshops for their diligent work and continuous support given to our organization. Our web editors, Dr. Ranjana Sharma and Dr. Arbinder Dang are doing an excellent work in keeping our website updated and we are thankful for their brilliant work. It has been the vision and determined motivation by all our patrons and our dear past Chairperson presently AICC RCOG Chairman Dr Urvashi Jha and now are present Chairperson Dr. Sohani Verma to develop the various courses to an excellent standard and persue academic excellence. Synergy - the bonus that is achieved when things work together harmoniously. Mark Twain Arbinder Dang MBBS, MD DNB MNAMS, MRCOG (UK) Member Representative North Zone rcog uk Editor Souvenir Annual Conference AICC RCOG Northern Zone 2014 Multi Disciplinary Management for Best Care in Obstetrics & Gynaecology. Dated: A workshop on Family & Togetherness was organized by Department of Obstetrics and Gynaecology, Sant Parmanand Hospital under aegis of Indian Menopause Society and RCOG at Kalingcha Homestay, Manali from 13 th to 15 th June

35 Royal College of Obstetricians & Gynaecologists -AICC- Northern Zone India Website: North Zone Announces Upcoming Courses / Meetings / Workshops These courses are invaluable not only for MRCOG aspirants, but also for all postgraduates (DNB, MD students) and Obstetrics & Gynaecology practitioners to refresh their skills Details on website Limited seats in each course Registration strictly on first-come-first-served basis S No Dates Course Venue Contacts Course Fee 1 Starts 14 The RCOG UK MRCOG Part II Enhanced Online Course shamsundersaritha@gmail.com Rs 60,000:00 Sept Revision Programme (ERP) Package x 15 weeks Written & OSCE (1/3 of UK Fee) Integrated distance and classroom learning Course at swetagupta06@yahoo.com course. Interactive weekly classroom Only 15 Seats sessions live direct from UK to your home RCOG NZ over 15 weeks with focus on NHS practice. Academic Centre, drpuneetkochhar.art@gmail.com, Package includes 3 days Part II written & B-235,C R Park, drpuneet.k20@gmail.com OSCE course on January 2015 in New Delhi Delhi 2 15,16, & 17 January, & 19 January, Sept. 18 Oct. 15 Nov. 20 Dec Sept. 8 Nov. 13 Dec 6 24 Sept. 26 Nov. 31 Dec 8 27 Sept. 29 Nov. 27 Dec RCOG UK Franchise Part II MRCOG Revision Course - written and OSCE Combined Course Content : Extensive revision session in SAQs, MCQ, EMQs, Demonstration OSCE & OSCE circuits RCOG UK Franchise Basic Practical Skills Course in Obstetrics & Gynaecology (Hands on refresher course for trainees & practicing gynaecologists. Certified by RCOG London. Essential for aspirants of MRCOG Exam. Principles of and hands on practice on mannequins for safe and effective general gynae Lap and Hystero surgery and all obstetric drills, Fetal CTG interpretation Monthly MultiDisciplinary Team Meeting (MDTM) - (Third Saturday of the month) A unique initiative by RCOG NZ to provide clinical decision making support to OBGY practitioners. Delegates are invited to present their current or recent problem cases. The MD experts will provide answers on the spot. Monthly Laparoscopy Workshop* (Every Second Saturday of the month) Monthly Hysteroscopy Workshop* (Every Last Wednesday of the month) Vaginal Surgeries Workshops* (Last Saturday of month) RCOG NZ Academic Centre, B-235,C R Park, New Delhi Ethicon Institute of Surgical Education, Kirti Nagar, New Delhi Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi Timing- 2:30-4:30 PM (preceded by lunch 1:30-2:30 PM) Fortis Flt Lt Ranjan Dhall Hospital, Vasant Kunj, New Delhi swetagupta06@yahoo.com drpuneetkochhar.art@gmail.com, drpuneet.k20@gmail.com mamtadagar2004@yahoo.co.in arbidang@yahoo.co.in rcog_nz2012@yahoo.com / drsohaniverma@gmail.com / urvashipjhaclinic@gmail.com , nimavijay@yahoo.co.in , Same as above + dr.ramandeep@ymail.com / Rs. 35, (1/3 rd UK Fee) Only 5 Seats Rs. 8, course fee + Rs for RCOG Manual = Total Rs 10, (1/3 rd UK Fee) Only 20 Seats Rs till one week before the meeting date Rs within 6 days & Spot registration Limited seats Rs (Total seats 4-5 each workshop) Same as above Rs (Total seats 4-5 each workshop) Same as above Same as above Rs (Total seats 3-4 each workshop) *Hysteroscopy, Laparoscopy and Vaginal skills enhancing workshops are organized by the department of Minimal and Natural Access Gynae & Gynae Cancer Surgery, Fortis Flt Lt Ranjan Dhall Hospital under the aegis of RCOG NZ and AOGD Endoscopy Committee. Please confirm the dates prior to booking from contacts. Registration Guidelines (Online registration available on website) Bank Transfer or Demand Draft must be made in favour of RCOG NZ 2012 Plus payable at New Delhi. (cheques not accepted for MRCOG & BPS Courses). There will be no refunds on cancelation Registration request along with Demand Draft to be posted to the Secretariat mailing address as given below:- Mailing Address: RCOG North Zone Secretariat Hostel Complex- Basement, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi Tel No /2146/2199, / / rcog_nz2012@yahoo.com/drsohaniverma@gmail.com 33

36 Funny facts The good always defeats the bad. That means that the one, who wins is always the good one. Over a lifetime a woman eats about 20 kg of lipstick. The world s oldest piece of chewing gum is 9000 years old.. Fingernails grow four times faster than leg nails. The strongest muscle in the body is the tongue. Physically it is impossible to sneeze with opened eyes. People talk in average speed of 120 words per minute. Electric chair was invented by a dentist. Months, starting on Sunday, will always have a Friday the 13th. Only 55% of Americans know that the sun is a star. Los Angeles has more cars than people. Just like people, dogs and cats can be left-handed or right-handed. A pig has no physical possibilities to look at the sky. Only China and India have more people than there are on Facebook. More than 50% of the people in the world have never made or received a telephone call. Eskimo has 20 different words to say snow. Elephants - the only animals that cannot jump. The sales of vodka in Russia brings its Government 10 percent of income. Women purchases 85% of all Valentine s day greeting cards. A sneeze can reach a speed of 100 miles per hour. 5% of Microsoft Word users do not know how to change the font style. One liners Q Where does Thursday come before Wednesday? A In the dictionary. Q What do you call 2 orthopedic doctors reading an EKG? A double blind study! Q What is the difference between God and an orthopedic surgeon A God dosn t think he is an orthopedic surgeon. Q Did you hear about the baby born in the high tech delivery room? A It was cordless! Q Did you hear about the optometrist that fell into his lens grinding machine? A He made a spectacle of himself. Q What do you call a doctor that fixes websites? A URLologist Hard Sudoku Puzzles

37 Coming together is a beginning. Keeping together is progress. Working together is success. -Henry Ford Our Dedicated Team Complied by Arbinder Dang, Editor Souvenir AICC RCOG Annual conference Name Designation Hospital / Phone Number Course Photograph Anita Kaul MBBS, MD, FRCOG (UK) Dip Advanced Obstetric Scanning anitagkaul@gmail.com M: Senior Consultant & Head of Department Apollo Fetal Medicine Unit, Apollo Hospital, New Delhi Treasurer AICC - RCOG NZ, India Faculty RCOG Basic Practical Skill Part II MRCOG Course Anjila aneja Arbinder Dang Arun Prasad Asmita Rathore MBBS, MD, DNB, MRCOG, FRCOG, Diploma in Pelvic Laparoscopy MBBS, MD DNB MNAMS, MRCOG (UK) Member Representative North Zone rcog uk FRCS, FRCSEd, MS (MAMC) MBBS (AFMC) MBBS, MD, FRCOG (UK) Head Gynae Unit & Sr. Consultant Obstetrician & Gynecologist Fortis Hospitals, Gurgaon Senior Consultant, Sant Parmanand Hospital, Delhi Senior Consultant Surgeon - Minimal Access Surgery (Gastro Intestinal, Robotic, Bariatric & Thoracoscopy) Apollo Hospital, New Delhi, India Director Professor Maulana Azad Medical College, New Delhi anjilaaneja1966@gmail. com M: arbidang@yahoo.co.in; arbidang@gmail.com M: surgerytimes@gmail.com Tel office: M: , asmita.rathore@yahoo.com M: Convenor Advanced Obstetric Skill Faculty RCOG Basic Practical Skill Part II MRCOG Course Editor Souvenir Web Editor Co Convenor RCOG Basic Practical Skill Faculty Part II MRCOG Course Advanced Obstetric Skill Faculty RCOG Basic Practical Skill Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course Astha (Takkar) Dayal Mbbs, md, mrcog(uk), fmas, dmas(wals) Consultant, Panacea Newrise Hospital, Gurgaon asthatakkar@gmail.com M: Faculty Part II MRCOG Course Faculty RCOG Basic Practical Skill Chanchal Singh MBBS, MD, MRCOG (UK) Associate Consultant, Apollo Centre for Fetal Medicine Apollo Hospital, Delhi chanchalsingh@yahoo.com M: Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course J.B. Sharma MD, FRCOG (London), FAMS, FICOG, MFFP, DNB, FIMSA Additional Professor Deptt. of Obstetrics & Gynaecology AIIMS, New Delhi jbsharma2000@gmail.com M: Office Coordinator Part1& II MRCOG Exams 35

38 Jasmeet K Monga MD, DNB, MRCOG(UK), PGA(ART)(UK) Consultant Obstetrics & Gynaecology, Paras Hospital Sushant Lok Gurgaon jasmeetmonga@gmail.com M: Faculty RCOG Basic Practical Skill Part II MRCOG Course Jasmine Chawla Jayasree Sundar MD, MRCOG (UK) MD, MRCOG (UK) Senior Consultant, Hindu Rao Hospital Senior Consultant, Max Medcentre, Panchsheel Park drjasminechawla@gmail.com M: jayasreesundar@yahoo.co.in M: Member Representative North Zone rcog uk Co Convenor RCOG Basic practical Skill Faculty Part II MRCOG Course Faculty Part II MRCOG Course Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Jharna Behura MD, MRCOG (UK) Senior Gynaecologist Kasturba Hospital jharnabehura@yahoo.co.in M: Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course Jyoti Bhaskar MD, MRCOG Consultant & Director Pushpanjali Crosslay Hospital jytbhaskar@yahoo.com M: Faculty RCOG Basic Practical Skill Part II MRCOG Course Kaberi Banerjee MD, MRCOG Senior Infertility and IVF Specialist banerjee.kaberi@gmail.com M: Member Representative North Zone rcog uk Faculty Part II MRCOG Course Kiran Arora MD, MRCOG IVF Specialist, Gurgaon IVF Clinic kiran_popli@hotmail.com M: Faculty RCOG Basic Practical Skill Part II MRCOG Course Mala Arora Mamta Dagar Mamta Mishra FRCOG (UK), FICOG, FICMCH MBBS, MD, MRCOG, FICOG, FICMCH MBBS, MD, MRCOG Consultant Infertility IVF Noble IVF Centre, Sector 14 Market, Faridabad, Consultant Obstetrician & Gynecologist, Fortis La Femme. S 549 Greater Kailash -2, New Delhi Associate Professor GRIPMER Consultant Gynaecologist & Obstetrician Gynae Endoscopic & Robotic Surgeon, Sir Ganga Ram Hospital, New Delhi Senior Consultant Obstetrics & Gynecology Fortis Hospital, Vasant Kunj, Delhi narindermala@gmail.com M: mamtadagar2004@yahoo. co.in M: drmmishra12@gmail.com, shreeja11@yahoo.co.in M: Honorary Secretary AICC- RCOG NZ, INDIA Faculty Advanced Obstetric Skill Part II MRCOG Course Faculty RCOG Basic Practical Skill Convenor RCOG Basic Practical Skill Faculty Advanced Obstetric Skill Part II MRCOG Course Faculty RCOG Basic Practical Skill 36

39 Manavita Mahajan Meena Naik Meenakshi Sahu Monika B Nagpal MBBS, MD, MRCOG Senior Consultant Obstetrics & Gynecology Fortis Memorial Research Institute Gurgaon MD, MRCOG Senior Consultant Diploma in Gynaecologist & Gyn Advanced. Gynae laparoscopic Surgeon Endoscopy (France) Max Super Speciality Diploma in Advanced Hospital, Saket, New Laparoscopic Delhi Surgery (Germany) MD, DNB, MRCOG (UK) MBBS, DCH, MS, DNB, MRCOG Sr. Consultant, Department of Obstetrics & Gynecology, Fortis la Femme, ADIVA and Institute of Liver and Biliary Sciences, New Delhi Assistant Professor LHMC & SSKH, New Delhi manavitamahajan@ hotmail.com M: m.naik1971@yahoo.com, meena.naik@ maxhealthcare.com M: meenakshi_sahu@ rediffmail.com M: drmonikanagpal@gmail. com M: Faculty Advanced Obstetric Skill Part II MRCOG Course Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course Faculty Part II MRCOG Course Faculty RCOG Basic Practical Skill Part II MRCOG Course Neema Sharma MBBS, MD, MRCOG (London) Senior Consultant, Department of Minimal & Natural Access Gynae & Gynae Cancer Surgery Gynae Onco Unit, Fortis Flt Lt Rajan Dhall Hospital & Fortis Memorial Research Institute Neena Bahl MD Obst. & Gynae Senior Consultant & Advanced Laparoscopic Surgeon, Max Healthcare, New Delhi drneemasharma@yahoo. com M: Co Convenor Part I MRCOG Course Hysteroscopy, Laparoscopy Workshops at Fortis, Vasant Kunj. Faculty RCOG Basic Practical Skill Part II MRCOG Course Faculty Advanced Obstetric Skill Special field of Interest - Advance Laparoscopic & Hysteroscopic Surgery Neeta Gupta MD, MRCOG Consultant Obs & Gynae Fellowship in Infertility Medicine (CIMAR,EDAPPAL Nirmala Agarwal DGO, FRCOG (UK) Head of Department, Obstetrics & Gynaecology, Sant Parmanand Hospital, Delhi Nivedita MBBS, MD, MRCOG Consultant, Fortis Hospital, Delhi drneetagupta@hotmail. com M: , n.menoky@gmail.com M: drniveditakaul@gmail. com M: Faculty RCOG Basic Practical Skill Part II MRCOG Course Vice Chairperson, AICC RCOG-NZ Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course Faculty RCOG Basic Practical Skill Pakhee Aggarwal MBBS, MD, MRCOG Pool Officer Safdarjang Hospital & VMMC pakh_ag@yahoo.com M: Faculty RCOG Basic Practical Skill Part II MRCOG Course 37

40 Parul Chopra MBBS, MD, MRCOG Faculty RCOG Basic Practical Skill Part II MRCOG Course Pooja Thukral MD, DNB, MRCOG Consultant Obs & Gynae Asian Institute of Medical Sciences Faridabad M: Faculty Advanced Obstetric Skill Part II MRCOG Course Poonam Tara MD, MRCOG, CCT (UK) Diploma in Advanced Obs Scan (UK) Accredited in Fetal Med (UK) Senior Consultant, Max Saket & Panchsheel, New Delhi com M: Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course Priti Gupta Faculty RCOG Basic Practical Skill Part II MRCOG Course Puneet Kaur Kochhar Ramandeep Kaur Ranjana Sharma Sandhya Gupta MBBS, MD (Obst & Gyne), DNB, MRCOG, MICOG, Diploma Reproductive Medicine (Germany), FMAS MBBS, MD MBBS, MS, MRCOG, FRCOG, MFFP MBBS, DGO, MRCOG, Dip Endoscopy (Germany) Elixir Fertility Center Plot no.6, Vardhman Royal Plaza, LSC, Gujranwala town, New Delhi Consultant, Department of Minimal & Natural Gynae and Gynae Cancer Unit, Fortis Flt LT Rajan Dhall Hospital, Vasant Kunj & Fortis Memorial Research Institute, Gurgaon Senior Consultant Obstetrician, Gynaecologist, Urogynaecologist, Indraprastha Apollo Hospitals, Delhi Director & Sr Consultant Deptt of Obs. & Gynae Niramaya Hospital Vis. Consultant Apollo Hospital drpuneetkochhar. drpuneet. Mobile: M: M: M: Co Convenor The RCOG UK MRCOG Part II Enhanced Revision Programme (ERP) Package Hysteroscopy, Laparoscopy Workshops at Fortis, Vasant Kunj, New Delhi Web Editor AICC - RCOG NZ, India Faculty Part II MRCOG Course Advanced Obstetric Skill RCOG Basic Practical Skill Co Convenor Part I MRCOG Course Faculty RCOG Basic Practical Skill Part II MRCOG Course Sanjeev Sharma (UK) Saritha Shamsunder MRCOG, FRCOG (UK) MRCOG, FRCOG (UK), Consultant, Gynaecologist Director of Medical Education, Southport & Ormskirk NHS Trust Southport, UK Specialist Gynaecologist, Vardhmaan Mahaveer Medical College & Safdarjung Hospital, New Delhi sdsharma@gmail.com sdsharma49@hotmail.com shamsundersaritha@ gmail.com M: Chief Co-ordinator Part I MRCOG Course Part II MRCOG Course Advanced Obstetric Skill RCOG Basic Practical Skill Convenor The RCOG UK MRCOG Part II Enhanced Revision Programme (ERP) Package Faculty RCOG Basic Practical Skill 38

41 Seema Sharma MD, dgo, mrcog Director Srishti Clinic, HOD, Apollo Clinic Rajouri Garden, Delhi M: Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course Shweta Gupta S N Basu MBBS, MD, MRCOG (UK), DFSRH (UK) MSc (Reproduction and Develpoment, UK) MBBS, MS, MRCOG (UK), FRCOG (UK) Sr Consultant Reproductive Medicine and IVF Moolchand Medcity, Delhi Senior consultant and HOD, Max Hospital, Delhi swetagupta06@yahoo.com M: ssndbasu@yahoo.com M: Convenor The RCOG UK MRCOG Part II Enhanced Revision Programme (ERP) Package, Co Convenor Part II MRCOG Course, Faculty RCOG Basic Practical Skill Convenor Part I MRCOG Course Sohani Verma Sonal Bathla MRCOG, FRCOG (UK), FICOG, FIMSA, PGDMLS, PGDHHM MD, FICOG, FICMCH, FIMSA Incharge-IVF Lab, Senior Consultant Obstetrician & Gynaecologist and IVF Specialist, Academic Coordinator Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi Senior Consultant, Department of Obstetrics & Gynaecology, Sant Parmanand Hospital. rcog_nz2012@yahoo.com drsohaniverma@gmail. com M: tcsharma@hotmail.com M: Chairperson - NZ AICC RCOG (UK) Faculty RCOG Basic Practical Skill Advanced Obstetric Skill Part II MRCOG Course Faculty Advanced Obstetric Skill Sonu Agarwal Tanya Buckshee Rohatgi Urvashi Prasad Jha Vinita Jaggi Kumar DGO, FRCOG (UK) MD DNB MNAMS MRCOG (London, UK) DFFP (London, UK), Fellowship IVF & Reproductive Surgery (London and Singapore) Laparoscopy Fellowship (AIIMS) MRCOG, FRCOG (UK), AICC (Chair) MD (Gynae), FICMCH, MRCOG (UK) Fellow Gynecological Oncology (Accredited to RANZCOG) K K Hospital, Singapore Senior Consultant Obstetrician & Gynaecologist Fortis La Femme Hospital, Max Super Specialty Hospital Senior Consultant Reproductive Medicine, Surgery & Assisted Reproductive Techniques (Ivf), Max Super Specialty Hospitals, Saket, Panchsheel, and Noida sonuagarwal393@ hotmail.com M: tanyabrohatgi@gmail. com M: Senior Consultant, urvashipjhaclinic@gmail. Head of Department com Department of Minimal M: and Natural Access Gynae & Gynae Cancer Surgery Gynae Onco Unit. Fortis Flt Lt Rajan Dhall Hospital & Fortis Memorial Research Institute Assistant Professor Oncosurgery (Gynecological Oncology) Delhi State Cancer Institute Govt of NCT of Delhi, Dilshad Garden, Delhi drvinitakumar@yahoo. co.in M: Faculty RCOG Basic Practical Skill Part II MRCOG Course Faculty Mrcog Part II Course Immediate Past Chairperson AICC- RCOG NZ, India Chief Cordinator Hysteroscopy, Laparoscopy and Vaginal Surgery Workshops at Fortis, Vasant Kunj. Faculty RCOG Basic Practical Skill Part II MRCOG Course Faculty RCOG Basic Practical Skill Part II MRCOG Course 39

42 Current Office Bearers May 2012-Present Fellows and Members R No E Mail Telephone City/ State/Country Patron & Past Chairperson Dr S K Ghai Bhandari ( ) FRCOG 4306 drskbhandari@rediffmail.com / Delhi Dr Sheila Mehra ( ) FRCOG 4964 drmehra@hotmail.com Delhi Dr Urmil Sharma ( ) FRCOG 5497 sharmaurmil33@gmail.com Delhi Patron Dr M Kochhar FRCOG 1429 drmkochhar@yahoo.com Delhi Dr Prabha Sinha FRCOG agynaecologist@gmail.com UK Dr Sanjeev Sharma FRCOG sdsharma@gmail.com UK Dr R P Soonawala Dr Prathap C Reddy Dr Ashok Chauhan Past Chairperson and Current Chairman, All India Co-ordinating Committee (AICC) Dr Urvashi P Jha FRCOG urvashipjhaclinic@gmail.com Delhi Chairperson Dr Sohani Verma FRCOG drsohaniverma@gmail.com Delhi Vice Chairperson Dr Nirmala Agarwal FRCOG n.menoky@gmail.com Delhi Secretary Dr Mala Arora FRCOG narindermala@gmail.com Faridabad Treasurer Dr Anita Ganju-Kaul FRCOG anita_kaul@apollohospitals.com Ghaziabad Web Editor Dr Ranjana Sharma FRCOG rnj_sharma@yahoo.com Delhi Member Representative & Web Editor Dr Arbinder Dang MRCOG arbidang@yahoo.co.in, Delhi arbidang@gmail.com Member Representative Dr Jasmine Chawla MRCOG drjasminechawla@gmail.com Delhi Dr Kaberi Banerjee MRCOG banerjee.kaberi@gmail.com Delhi 40

43 Team AICC RCOG North Zone (Delhi & NCR) Fellows and Members R No E Mail Telephone City/ State/Country Dr Anjila Aneja Wig FRCOG anjilaaneja1966@gmail.com Delhi Dr Asmita Rathore FRCOG asmita.rathore@yahoo.com Delhi Dr Astha Takkar MRCOG asthatakkar@gmail.com Gurgaon Dr Chandan Dubey MRCOG chandandubey15@gmail.com Delhi Dr Deepti Goswami MRCOG drdeeptigoswami@hotmail.com Delhi Dr Deepti Goswami MRCOG gosdeepti@hotmail.com Delhi Dr J B Sharma FRCOG jbsharma2000@gmail.com Delhi Dr Jasmeet Kaur MRCOG jasmeetmonga@gmail.com Gurgaon Dr Jayasree Sundar MRCOG jayasreesundar@yahoo.co.in Delhi Dr Jharna Behura MRCOG jharnabehura@yahoo.co.in Delhi Dr Jyoti Bhaskar MRCOG jytbhaskar@yahoo.com Delhi Dr Kiran Popli MRCOG kiran_popli@hotmail.com Gurgaon Dr Mamta Dagar MRCOG mamtadagar2004@yahoo.co.in Delhi Dr Mamta Mishra MRCOG drmmishra12@gmail.com, / Delhi shreeja11@yahoo.co.in Dr Manavita Mahajan FRCOG manavitamahajan@hotmail.com Delhi Dr Meena Naik MRCOG m.naik1971@yahoo.com Delhi Dr Meenakshi T Sahu MRCOG meenakshi_sahu@rediffmail.com Ghaziabad Dr Monika Nagpal MRCOG drmonikanagpal@gmail.com Delhi Dr Neema Sharma MRCOG drneemasharma@yahoo.com Delhi Dr Neena Malhotra MRCOG malhotraneena@yahoo.com Delhi Dr Neeta Gupta MRCOG drneetagupta@hotmail.com Delhi Dr Nivedita M N Kaul MRCOG drniveditakaul@gmail.com Delhi Dr Pakhee Agarwal MRCOG pakh_ag@yahoo.com Delhi Dr Parul Chopra MRCOG drparulchopra@gmail.com Gurgaon Dr Pooja C Thukral MRCOG poojacthukral@gmail.com Haryana Dr Poonam Tara Neeti FRCOG poonamtara@hotmail.com Delhi Dr Preeti Rastogi MRCOG preeti818@icloud.com Gurgaon Dr Priti Gupta MRCOG priti.krish@yahoo.co.in Delhi Dr Puja Dewan MRCOG pujadewan2006@yahoo.com Noida Dr Puneet Kaur Kochhar MRCOG drpuneetkochhar.art@gmail.com Delhi drpuneet.k20@gmail.com Dr Ritika Bhandari MRCOG bhandariritika@yahoo.co.in Delhi Dr S N Basu FRCOG ssndbasu@yahoo.com Delhi Dr Sandhya Gupta MRCOG sums.sandhya@gmail.com Delhi Dr Sangeeta MRCOG drsangeetamamc@gmail.com / Ghaziabad Dr Sangeeta Sabherwal FRCOG sangeetadhawan3@gmail.com / Delhi Dr Seema Sharma MRCOG drseemagyn@hotmail.com Delhi Dr Shikha Pasrija Chadha MRCOG shikhapasrija@gmail.com Delhi Dr Sonu Agarwal FRCOG sonuagarwal393@hotmail.com Delhi Dr Sushma P Sinha FRCOG sinha_sushma@hotmail.com Delhi Dr Sweta Gupta MRCOG swetagupta06@yahoo.com Delhi Dr Tanya B Rohatgi MRCOG niteshrohatgi@yahoo.com Delhi Dr Tripti Madan MRCOG triptimadan@yahoo.co.in Delhi Dr Usha M Kumar MRCOG dr_usha_mkumar@hotmail.com Delhi Dr Vinita Jaggi Kumar MRCOG drvinitakumar@yahoo.co.in / Delhi Dr Saritha S Kale FRCOG shamsundersaritha@gmail.com / Delhi 41

44 AICC RCOG North Zone (Alphabetical Order) Fellows and Members R No E Mail Telephone City/ State/Country Dr A Sharma MRCOG archana_doc05@yahoo.com Kanpur Dr A Gauba Singh FRCOG 4294 Delhi Dr A K Kanwar FRCOG 4582 Delhi Dr A Raman MRCOG anusri@gmail.com Chennai Dr A Sanadaya MRCOG gouranita@gmail.com Jaipur Dr A Singh MRCOG anubha_singh167@hotmail.com Delhi Dr B Ganjoo FRCOG basantiganjoo@gmail.com Srinagar Dr B K Dhaliwal FRCOG 4098 drmp007@yahoo.co.in Moga Dr Chetna Jain MRCOG jainchetna@gmail.com Dr D M Thaker MRCOG darshanapawar2003@yahoo.com Nagpur Dr G I Dhall FRCOG 1183 dhallgi@yahoo.com Panchkula Dr G Rai Chowdhuri FRCOG 5384 Delhi Dr G S Tomar MRCOG drgtomar@gmail.com Indore Dr G V Padubidri FRCOG 5171 Delhi Dr Gunjan Gupta MRCOG Gunjan21sep@gmail.com Ghaziabad Dr H K Narang MRCOG hrkng@hotmail.com Delhi Dr I M James MRCOG 4526 irismanjula@hotmail.com Delhi Dr J A Naqshbandi MRCOG 5064 Srinagar Dr J Sidhu FRCOG 3290 drjasusidhu@gmail.com Bathinda Dr K Dua MRCOG drdua@msn.com Delhi Dr K Dwivedee MRCOG kaushikid@yahoo.com Gurgaon Dr K Gupta MRCOG sg2710@gmail.com Varanasi Dr L Mehta FRCOG 4962 Lucknow Dr M Jindal FRCOG 4540 Meerut Dr M Karna MRCOG 4590 Delhi Dr M L Aggarwal FRCOG 3598 Shashi_aggarwal@ rediffmail.com Delhi Dr M M Dass FRCOG 4058 mohinidass@gmail.com Lucknow Dr M R Dutta FRCOG 4160 Delhi Dr M Sahai FRCOG 5414 Jaipur Dr M Singhal FRCOG 5551 msinghal07@yahoo.co.in Muzaffarnagar Dr M Srivastava MRCOG drmadhusrivastava@gmail.com Noida Dr Madhu Ahuja MRCOG madhu_ahuja@hotmail.com Delhi Dr Manjusha MRCOG manjusha9000@gmail.com Lucknow Dr Mrs S K Vohra FRCOG 5773 docvohra@gmail.com Delhi Dr N Bhan MRCOG neerabhan@yahoo.com Ghaziabad Dr N Metre Singh FRCOG 5537 Himachal Pradesh Dr N V Baheti FRCOG nvbaheti@gmail.com Rajasthan Dr Neelamvinay Singh MRCOG neelamvinay@gmail.com Lucknow Dr P Gupta MRCOG prerna12in@yahoo.co.in Jaipur Dr P Gupta FRCOG 4377 Gurgaon Dr Puneet R Arora MRCOG indianfertility@gmail.com, parora@doctors.org.uk Dr Renu Mittal Lakhatia MRCOG devishiv2001@yahoo.com Lucknow Dr S Aggarwal FRCOG ashim14@gmail.com Delhi Dr S Bahl-Dhall FRCOG 3718 Noida Dr S Bhalgotra FRCOG Delhi Dr S C Kohli FRCOG 4672 rsck19@gmail.com Delhi Dr S C Saha MRCOG drscsaha@sify.com Chandigarh 42

45 Dr S G Singh MRCOG 5552 Patiala Dr S Jindal MRCOG shobakapil@rediffmail.com Rajasthan Dr S K Mangat FRCOG drsmangat@yahoo.com Jalandhar City Dr S Kamra FRCOG 4569 shailakamra@gmail.com Delhi Dr S Kataria MRCOG savysab15@yahoo.com Delhi Dr S Patodi MRCOG sweetynsoni@yahoo.com Jaipur Dr S Patra MRCOG sukanya.97@hotmail.com Delhi Dr S Rakheja MRCOG anilrakheja@hotmail.com Delhi Dr S V Sachdev MRCOG sachdevshivani@yahoo.co.in Noida Dr Suman Bansal MRCOG drsumanbansal@gmail.com Ambala Dr Sumita Prabhakar MRCOG sumitaprabhakar@hotmail.com Dehradun Dr Sushma Dikhit MRCOG sushmadikhit@hotmail.com Ghaziabad Dr T M Malik FRCOG tahirmalik235@yahoo.com Srinagar Dr U Sharma FRCOG 5443 Ghaziabad Dr Uma Pandey MRCOG uma.pandey2006@yahoo.com Varanasi Dr V B Arora MRCOG vbbarora@yahoo.com Ghaziabad Dr V K Garg FRCOG vibha_garg@hotmail.com Jaipur Dr Witty Raina MRCOG wittysumbli@yahoo.co.in Haryana 43

46 Annual Conference Northern Zone AICC RCOG North Zone Multi Disciplinary Management for Best Care in Obstetrics & Gynaecology SCIENTIFIC PROGRAM Review of literature with Recommendations and Guidelines (Contributions by Moderators and Panelists) 44

47 Session 1 Endocrine Disorders in Obstetrics & Gynaecology 45

48 Endocrine Disorders in Obstetrics & Gynaecology Moderators Dr Sohani Verma Academic Coordinator & Sr Consultant, Dept. of Obs & Gynae, Incharge IVF Unit Indraprastha Apollo Hospitals, New Delhi Dr Sweta Gupta Consultant IVF, Moolchand Hospital New Delhi Panelists Dr S K Wangnoo (Endocrinology) subhaashwang@hotmail.com Senior Consultant Endocrinologist and Diabetologist Apollo Centre for Obesity, Diabetes and Endocrinology (ACODE) Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road New Delhi Dr C M Batra (Endocrinology) chandarbatra@yahoo.com Senior Consultant Endocrinology Indraprastha Apollo Hospitals, New Delhi Dr S K Agarwal (Internal Medicine) drsatish_a@apollohospitals.com Senior Consultant Internal Medicine Academic Advisor & DNB Coordinator Indraprastha Apollo Hospitals Sarita Vihar, New Delhi Dr Neeru Gera (Endocrinology) ngera@maxhealthcare.com Consultant, Endocrinology, Fortis Hospital, New Delhi Dr Anju Virmani (Paediatric Endocrinology) virmani.anju@gmail.com Senior Consultant Diabetologist & Endocrinologist Apollo, Max, Pentamed & SL Jain Hospitals, Delhi Dr Indrani Ganguli indrani.ganguli@gmail.com Senior Consultant & HOD Deprtment of Obs & Gynae Sir Ganga Ram Hospital, New Delhi Dr Reva Tripathi revatripathi@gmail.com HOD Dept. of Obs & Gynae, Safdarjung Hospital, New Delhi Dr Anjila Aneja anjilaaneja@yahoo.co.in Head - Gynae Unit & Sr. Consultant, Fortis Hospitals, Gurgaon Dr Sanjeev Sharma (UK) sdsharma@gmail.com Consultant Gynaecologist, Director of Medical Education Southport & Ormskirk NHS Trust, Southport, UK Case - I A 38 year old lady with H/O primary infertility of 10 years duration on Metformin in view of FBS 115 mg /dl and HbA1C 6.7% since previous 3 months, conceived through IVF+ICSI treatment. Metformin changed to Insulin. Significant fetal growth restriction (FGR) throughout pregnancy. Elective LSCS at 37 weeks gestation. Baby wt 2.2kg. Discussion issues and learning objectives Difference between overt diabetes and GDM and impact on management Therapeutic targets for blood glucose levels during pregnancy Choice of therapy -Metformin or Insulin or combination Advances in Insulin therapy Case - II A 28 year old lady attends for pre pregnancy counseling. Her serum TSH is reported as 4.2 IU (N ), Free T4 and T3 level within normal limits. Discussion issues and learning objectives Interpretation of this report -Normal or further tests and therapy indicated Global consensus on normal TSH levels before and during pregnancy in euthyroid and hypothyroid patients Case III A 49 Year old lady 1 year postmenopausal complains of hot flushes, depression, insomnia, loss of libido and low bone density. Discussion issues and learning objectives What should be the first line therapy -SSRI (anti-depressants) bisphosphonates or HRT? Latest evidence & recommendations Which drugs, why and for how long? Case IV A 9 year 6 months old girl had her first menstrual period recently. Anxious parents attend for counselling and request to postpone her menses for at least next 2 years. All routine investigations came as normal. Discussion issues and learning objectives What is the normal age for menarche in Indian girls? Implications of precocious puberty Confirmatory tests GnRH analogue treatment - dosage, duration, side effects Combined use of Growth Hormone Case V The parents of a 15 year old girl attend OPD. She has not attained her menarche and there is absence of breast development and other secondary sex characteristics. Discussion issues and. learning objectives Relevant tests to assess the pathophysiology Induction of puberty using sex steroids Timing of the initiation of oestrogen, dosage and duration Unopposed oestrogen or combined with progesterone or sequential Maintenance therapy Growth hormone treatment 46

49 Diabetes and Pregnancy Recommendations Dr Sohani Verma MD FRCOG Academic Coordinator & Sr Consultant Dept. of Obs & Gynae, Incharge IVF Unit Indraprastha Apollo Hospitals, New Delhi International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy International association of diabetes and pregnancy study groups consensus panel Diabetes Care, volume 33, number 3, March 2010: Gestational diabetes mellitus (GDM), a common medical complication of pregnancy, is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. There is consensus that overt diabetes during pregnancy, whether symptomatic or not, is associated with significant risk of adverse perinatal outcome. The risk of adverse perinatal outcome associated with degrees of hyperglycemia less severe than overt diabetes is controversial. Several factors contribute to this longstanding controversy. Table 1: Threshold values for diagnosis of GDM or overt diabetes in pregnancy To diagnose GDM and cumulative proportion of HAPO cohort equaling or exceeding those thresholds Glucose measure Glucose concentration threshold* Above threshold (%) mmol/l mg/dl Cumulative FPG h plasma glucose h plasma glucose To diagnose overt diabetes in pregnancy Measure of glycemia Consensus threshold FPG 7.0 mmol/l (126 mg/dl) A1C 6.5% (DCCT/UKPDS standardized) Random plasma glucose 11.1 mmol/l (200 mg/dl) + confirmation One or more of these values from a 75-g OGTT must be equaled or exceeded for the diagnosis of GDM. In addition, 1.7% of participants in the initial cohort were unblinded because of FPG_5.8 mmol/l (105 mg/dl) or 2-h OGTT values _11.1 mmol/l (200 mg/dl), bringing the total to 17.8%. One of these must be met to identify the patient as having overt diabetes in pregnancy. If a random plasma glucose is the initial measure, the tentative diagnosis of overt diabetes in pregnancy should be confirmed by FPG or A1C using a DCCT/ UKPDS-standardized assay. Table 2: Strategy for the detection and diagnosis of hyperglycemic disorders in pregnancy First prenatal visit Measure FPG, A1C, or random plasma glucose on all or only high-risk women If results indicate overt diabetes as per Table 1 Treatment and follow-up as for preexisting diabetes If results not diagnostic of overt diabetes and fasting plasma glucose 5.1 mmol/l (92 mg/dl) but <7.0 mmol/l (126 mg/dl), diagnose as GDM and fasting plasma glucose <5.1 mmol/l (92 mg/dl), test for GDM from 24 to 28 weeks gestation with a 75-g OGTT weeks gestation: diagnosis of GDM 2-h 75-g OGTT: perform after overnight fast on all women not previously found to have overt diabetes or GDM during testing earlier in this pregnancy Overt diabetes if fasting plasma glucose 7.0 mmol/l (126 mg/dl) GDM if one or more values equals or exceeds thresholds indicated in Table 1 Normal if all values on OGTT less than thresholds indicated in Table 1 To be applied to women without known diabetes antedating pregnancy. Postpartum glucose testing should be performed for all women diagnosed with overt diabetes during pregnancy or GDM. Decision to perform blood testing for evaluation of glycemia on all pregnant women or only on women with characteristics indicating a high risk for diabetes is to be made on the basis of the background frequency of abnormal glucose metabolism in the population and on local circumstances. The panel concluded that there have been insufficient studies performed to know whether there is a benefit of generalized testing to diagnose and treat GDM before the usual window of weeks gestation. Conclusions There is high prevalence of obesity and disorders of glucose metabolism in the general population of young adults and with recent reports of a rising prevalence of GDM and preexisting overt diabetes in pregnant women. Glucose testing early in pregnancy to detect overt diabetes and again with a 75-g OGTT at weeks of gestation in all pregnancies not already diagnosed with overt diabetes or GDM by early testing represents fundamental changes in strategies for detection and diagnosis of hyperglycemia in pregnancy. 47

50 Thyroid Dysfunction During Pregnancy and Postpartum Dr Sohani Verma MD FRCOG Academic Coordinator & Sr Consultant, Dept. of Obs & Gynae, Incharge IVF Unit Indraprastha Apollo Hospitals, New Delhi Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline Leslie De Groot, Marcos Abalovich, Erik K. Alexander, Nobuyuki Amino, Linda Barbour, Rhoda H. Cobin, Creswell J. Eastman, John H. Lazarus, Dominique Luton, Susan J. Mandel, Jorge Mestman, Joanne Rovet, and Scott Sullivan J Clin Endocrinol Metab, August 2012, 97(8): Summary of Recommendations Management of hypothyroidism: maternal and fetal aspects We recommend caution in the interpretation of serum free T4 levels during pregnancy and that each laboratory establish trimester-specific reference ranges for pregnant women if using a free T4 assay. The nonpregnant total T4 range (5 12 _g/dl or nmol/ liter) can be adapted in the second and third trimesters by multiplying this range by 1.5-fold. Alternatively, the free T4 index ( adjusted T4 ) appears to be a reliable assay during pregnancy. (U.S. Preventive Service Task Force (USPSTF) recommendation level: B; evidence, fair GRADE 2). Overt maternal hypothyroidism is known to have serious adverse effects on the fetus. Therefore, maternal hypothyroidism should be avoided. (For overt hypothyroidism: USPSTF recommendation level: A; evidence, good). Subclinical hypothyroidism (SCH; serum TSH concentration above the upper limit of the trimesterspecific reference range with a normal free T4) may be associated with an adverse outcome for both the mother and offspring, as documented in antibodypositive women. In retrospective studies, T4 treatment improved obstetrical outcome, but it has not been proved to modify long-term neurological development in the offspring. However, given that the potential benefits outweigh the potential risks, the panel recommends T4 replacement in women with SCH who are thyroid peroxidase antibody positive (TPO-Ab+). (For obstetrical outcome: USPSTF recommendation level, B; evidence, fair for neurological outcome, USPSTF recommendation level, I; evidence, poor). The panel also recommends T4 replacement in women with SCH who are TPO-Ab negative (TPO-Ab-). (For obstetrical outcome: USPSTF recommendation level, C; evidence, fair; for neurological outcome: USPSTF recommendation level, I; evidence, poor (2). If hypothyroidism has been diagnosed before pregnancy, we recommend adjustment of the preconception T4 dose to reach before pregnancy a TSH level not higher than 2.5 miu/liter. (USPSTF recommendation level:c; evidence, poor (2). The T4 dose usually needs to be incremented by 4 to 6 wk gestation and may require a 30% or more increase in dosage. (USPSTF recommendation level: A; evidence, good (1). If overt hypothyroidism is diagnosed during pregnancy, thyroid function tests should be normalized as rapidly as possible. T4 dosage should be titrated to rapidly reach and thereafter maintain serum TSH concentrationsof less than 2.5 miu/liter (in an assay using the International Standard) in the first trimester (or 3 miu/liter in second and third trimesters) or to trimester-specific TSH ranges. Thyroid function tests should be remeasured within d and then every 4 6 wk. (USPSTF recommendation level: A; evidence, good (1). Women with thyroid autoimmunity who are euthyroid in the early stages of pregnancy are at risk of developing hypothyroidism and should be monitored every 4 6 wk for elevation of TSH above the normal range for pregnancy. (USPSTF recommendation level: A; evidence, fair (1). After delivery, most hypothyroid women need to decrease the T4 dosage they received during pregnancy to the prepregnancy dose. (USPSTF recommendation level: A; evidence, good (1). Always continue to grow. It is possible to achieve what you wish, If you take the time to learn who you are, and willing to be who you were meant to be... - Embellished minds 48

51 Menopausal Hormone Therapy Dr Sohani Verma MD FRCOG Academic Coordinator & Sr Consultant, Dept. of Obs & Gynae, Incharge IVF Unit Indraprastha Apollo Hospitals, New Delhi Global Consensus Statement on Menopausal Hormone Therapy T. J. de Villiers, M. L. S. Gass, C. J. Haines, J. E. Hall, R. A. Lobo, D. D. Pierroz and M. Rees Climacteric 2013:16: The following Consensus Statement is endorsed by The American Society for Reproductive Medicine, The Asia Pacifi c Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society. MHT is the most effective treatment for vasomotor symptoms associated with menopause at any age, but benefits are more likely to outweigh risks for symptomatic women before the age of 60 years or within 10 years after menopause. MHT is effective and appropriate for the prevention of osteoporosis-related fractures in at-risk women before age 60 years or within 10 years after menopause. Randomized clinical trials and observational data as well as meta-analyses provide evidence that standarddose estrogen-alone MHT may decrease coronary heart disease and all-cause mortality in women younger than 60 years of age and within 10 years of menopause. Data on estrogen plus progestogen MHT in this population show a similar trend for mortality but in most randomized clinical trials no significant increase or decrease in coronary heart disease has been found. Local low-dose estrogen therapy is preferred for women whose symptoms are limited to vaginal dryness or associated discomfort with intercourse. Estrogen as a single systemic agent is appropriate in women after hysterectomy but additional progestogen is required in the presence of a uterus. The option of MHT is an individual decision in terms of quality of life and health priorities as well as personal risk factors such as age, time since menopause and the risk of venous thromboembolism, stroke, ischemic heart disease and breast cancer. The risk of venous thromboembolism and ischemic stroke increases with oral MHT but the absolute risk is rare below age 60 years. Observational studies point to a lower risk with transdermal therapy. The risk of breast cancer in women over 50 years associated with MHT is a complex issue. The increased risk of breast cancer is primarily associated with the addition of a progestogen to estrogen therapy and related to the duration of use. The risk of breast cancer attributable to MHT is small and the risk decreases after treatment is stopped. The dose and duration of MHT should be consistent with treatment goals and safety issues and should be individualized. In women with premature ovarian insufficiency, systemic MHT is recommended at least until the average age of the natural menopause. The use of custom-compounded bioidentical hormone therapy is not recommended. Current safety data do not support the use of MHT in breast cancer survivors. These core recommendations will be reviewed in the future as new evidence becomes available. Let your imagination run free Tear down the walls so you can soo Throw off the chains that lock your mind There s so much to be had, so much to find 49

52 Delayed Puberty Dr Sohani Verma MD FRCOG Academic Coordinator & Sr Consultant Dept. of Obs & Gynae, Incharge IVF Unit Indraprastha Apollo Hospitals, New Delhi Sex Steroid Treatment for Pubertal Induction and Replacement in the Adolescent Girl Delayed Puberty Scientific Impact Paper No. 40 June 2013 Royal College of Obstetricians and Gynaecologists Normal pubertal development The overall aim of induction of puberty in girls with hypogonadism is to achieve timely secondary sex characteristics including breast and uterine development. This leads to menses, generation of the pubertal growth spurt and finally, acquisition of peak bone mass which continues to approximately the age of 30.2 The first oestrogen effects to show will be breast budding which will have occurred in 50% of girls by the age of 11.3 years. Breast development continues to breast stage four (near full development with elevated areola) by the age of 13.3 in 50% of girls. The average age of menarche in the UK is 13. With respect to bone development there are the competing effects of low dose oestrogen which increases height velocity and higher dose oestrogen that results in closure of the epiphyseal growth plates. The majority of breast development therefore occurs over the two years prior to menarche. In treatment terms, this would be the equivalent of two years of unopposed oestrogen. Definition of delayed puberty Delayed puberty can be defined by the ages at which 95% of girls achieve breast stage 2 (clear elevation of the breast mound and enlargement of the areola as breast budding), which is 13 years of age. Menarche will have occurred in 95% of girls by age Therefore; girls with complete absence of breast development should be referred for full evaluation from the age of 13 and those with primary amenorrhoea, but normal breast development, by the age of 15. The latter presentation implies no deficiency of oestrogen and includes anatomical causes such as Rokitansky syndrome and also euoestrogenaemic causes of amenorrhoea such as PCOS. Late presentations are common. A list of common conditions resulting in oestrogen deficiency in adolescents is shown in the Table. Of the few trials in this area, the majority focus on either Turner syndrome, because it forms a relatively homogeneous population, or those receiving growth hormone because of the complex effects of oestrogen on growth. Constitutional delay of puberty Gonadal dysgenesis 45X, 46XX, 46 XY Premature ovarian insufficiency Surgical hypogonadism Hypopituitarism Hypogonadotrophic hypogonadism Hypothalamic amenorrhoea Disorders of sexual development For all girls presenting with primary amenorrhoea, it is mandatory to assess potential for growth with involvement of a paediatric endocrinologist before starting oestrogen. In adolescent girls with delayed puberty, the introduction of oestrogen should be initiated using fractions of a transdermal matrix oestradiol patch with the aim of achieving some months of unopposed oestrogen administration. The dose of oestrogen is then increased until breakthrough bleeding occurs or is expected, after which cyclical progestins are introduced. Combined oral contraceptive pills containing ethinylestradiol, being unphysiological in their formulation, do not provide optimal oestrogen replacement in young women and should only be used if contraception is required such as in girls with ovarian failure, hypothalamic amenorrhoea or hypogonadotrophic hypogonadism in whom a return of normal ovarian function is a possibility. In summary, current opinion favours induction of puberty with transdermal oestradiol patches starting at a dose of 6.25 mcg in the younger age groups and 12.5 mcg in older age group. The timing of dose escalation should be individualised taking into account the potential for further growth potential. This treatment should only be initiated with input from a paediatric endocrinologist. 50

53 Precocious Puberty Dr Sohani Verma MD FRCOG Academic Coordinator & Sr Consultant, Dept. of Obs & Gynae, Incharge IVF Unit Indraprastha Apollo Hospitals, New Delhi Understanding precocious puberty in girls Sakunthala Sahithi Tirumuru MRCOG, Pratibha Arya FRCOG, Pallavi Latthe MD MRCOG, Jeremy Kirk MD FRCPCHd The Obstetrician & Gynaecologist 2012; 14: Key content Precocious puberty is defined as the development of secondary sexual characteristics before the age of 8 years in girls. It is divided into central (gonadotrophindependent) precocious puberty and peripheral (gonadotrophin-independent) precocious puberty. Variants of premature sexual development include isolated premature thelarche, premature pubarche and isolated premature menarche (menstruation without other signs of puberty). Possible consequences of precocious puberty include short adult stature due to premature epiphyseal closure and psychosocial problems. Gonadotrophin-releasing hormone analogues are the mainstay of treatment for central precocious puberty. Treatment options vary for peripheral precocious puberty, depending on the underlying aetiology. These include aromatase inhibitors, anti-estrogens, antiandrogens and tumour resection. Combined consultation with or referral to a paediatric endocrinologist is indicated in all cases. Adversity causes some men to break, Others to break records. William A, Ward 51

54 Endocrine Disorders in Obstetrics & Gynaecology: Pediatric problems Dr Anju Virmani MD, DNB Endocrinology Senior Consultant Endocrinologist/ Diabetologist Apollo, Max, Pentamed & Sunderlal Jain Hospitals, New Delhi CASE IV A 9 year 6 months old girl had her first menstrual period recently. Anxious parents attend for counseling and request to postpone her menses for at least next 2 years. All routine investigations came as normal. Discussion issues and learning objectives. What is the normal age for menarche in Indian girls? The average age of menarche is about years in different populations; including India. From the 17 th to early 19 th century, there was a drastic decrease in age at menarche from 17years to 13 years in Europe and the US: this trend has now levelled off. In India, there is insufficient historical data. Precocious puberty is defined as breast budding before age 8y, or menarche before age 10y. About 90% of puberty is central PP, and 90% of these are idiopathic ie no underlying pathology is found. Secular trend in age at menarche according to the first year of data collection. Inset shows the past 50 years in which the secular trend in age at menarche seems to have ceased. Horm Res Pediatr2012: Recent secular trends in pubertal timing: implications for evaluation and diagnosis of precocious puberty. Sorensen et al. Implications of precocious puberty: Early development of breasts and pubic hair is associated with rapid height gain and advanced skeletal maturation ( bone age ). This often results in short final height. The mood swings and other emotional changes seen in normal puberty are also seen. The child often feels isolated since her peers are not experiencing these changes; she may also be more at risk for sexual abuse. In very young girls (not our present case), it may indicate serious intracranial pathology. Confirmatory tests: Baseline (sample should be a pooled one) and if necessary, GnRH stimulated gonadotropins and estradiol should be measured by suitable assays with sensitivity in the lower range. Even then, assay variability makes interpretation difficult, and there are no clear diagnostic cut-offs. LH < 0.1 IU/L is prepubertal, but half the girls with Tanner 2 breasts may have prepubertal LH levels. LH can be measured min after a dose of GnRH or 60 min after a 100 mcg subcut or intramuscular dose of leuprolide: a level > 6 IU/L is considered suspicious. A stimulated LH/ FSH ratio > 1 may also help differentiate progressive from non-progressive CPP. With very sensitive assays, prepubertally estradiol is < 1 pg/ml; more conventional assays usually cannot detect estradiol in this range. Measurable E2 is usually suggestive. A pelvic ultrasound is useful to measure ovarian size (prepubertal < 1 cc), uterine length (< 3-4 cm) and morphology, and rule out ovarian cysts or other pathology. In girls older than 6y, with breast development, intracranial pathology is seen in < 2%, so MRI head including pituitary is not advocated routinely. In this girl, a local examination to look for injuries (sexual abuse causing vaginal bleeding), careful auxology and x-ray of the left hand for bone age, and a pelvic ultrasound may be all that is necessary at baseline. GnRH analogue treatment dosage, duration, side effects: GnRH agonist depot preparations are useful to safely postpone further periods. Triptorelin and leuprolide are easily available, and may be given for 1-2 years. I prefer the mg 12 weekly depot preparation. Since it is basically stimulatory, one period may occur after the initial dose, so family should be explained this might happen. Monitoring can be done be carefully monitoring height velocity, measuring serum LH 60 min after the GnRHa injection, and pelvic ultrasound. If the dose is inadequate, the gap can be reduced. Apart from local allergies, prolonged use can increase the risk of osteoporosis. After stopping GnRH agonists, pubertal changes resume within 3 to 12 months. Combined use of Growth Hormone: may be considered if the predicted adult height is very short, keeping mid-parental height in mind, but results are usually unsatisfactory, and the cost is very high. CASE V The parents of a 15 year old girl attend OPD. She has not attained her menarche and there is absence of breast development and other secondary sex characteristics. Discussion issues and learning objectives Relevant tests to assess the pathophysiology: Since the secondary sexual characteristics are also absent, the most important question is whether the hypogonadism is hypogonadotrophic or hypergonadotrophic. In hypogonadotrophic hypogonadism, LH and FSH levels are raised, and karyotype is needed. This is usually due to gonadal dysgenesis, the commonest cause being 52

55 Turner syndrome (karyotype XO or mosaic); androgen insensitivity (karyotype XY), or other causes of primary ovarian failure (resection, radiation, trauma, infections, idiopathic). Hypogonadotrophic hypogonadism could be due to constitutional delay (this is a diagnosis of exclusion), general or systemic illnesses (eg hypothyroidism, celiac disease, malnutrition, eating disorders, excess exercise). Along with careful clinical examination to look for any systemic illness or syndromes, the initial tests to be done include hemogram, albumin, globulin, SGOT, calcium, phosphorus, alkaline phosphatase, creatinine, T4 and TSH, transglutaminase (total IgA must also be done), in addition to LH, FSH, and prolactin (in a pooled sample). An Xray left hand for bone age, and pelvic ultrasound by an ultrasonologist experienced in pediatrics, are also needed. If necessary, a GnRH stimulation test can be done (as above) to distinguish constitutional delay from hypogonadotrophic hypogonadism. MRI head may be indicated if pituitary abnormality is suspected (e.g. panhypopituitrism or galactorrhea: for tumors like craniopharyngiomas, prolactinomas). Induction of puberty using sex steroids Timing of the initiation of oestrogen, dosage and duration. Estrogen should be started in very low doses: 1-2 ug/ day (1/5 tablet of 0.1 mg ethinyl estradiol), and slowly increased over 1-2y. Once a dose of 20ug is reached, or breakthrough bleeding occurs, progesterone should be added. After 2y, when the routine has settled down, E+P can be replaced by oral contraceptives for maintenance. With OCPs, it must be kept in mind that for one week out of 4 (25% time), there would be no estrogen supply. To avoid this, during this week, low dose estrogen (e.g. 5 mcg, i.e. half tablet of 0.1 mg ethinyl estradiol) can be given for 3-7 days. Over-rapid correction with estrogen reduces the final height since it gives little time for the growth spurt, causes development of odd breast shape, and causes significant psychological distress. In girls with Turner syndrome, growth hormone treatment should be offered if the epiphyses are open, and the family can afford it. Unfortunately, high doses are needed, increasing the already high cost. GH therapy must be accompanied by low dose estrogen therapy. Streak gonads should be removed, especially in 45,XO/46,XY mosaics. Turner girls should also be screened for associated problems e.g. cardiac and renovascular malformations, deafness, insulin resistance. If the diagnosis is a condition like celiac disease or hypothyroidism, it should be treated accordingly. Results are often gratifying. If other pituitary hormones are deficient, they must also be replaced. Hypogonadism also affects bone density. In addition to the therapy above, adequate supplements of Vitamin D, enough dietary calcium and regular exercise must be emphasized. Psychological support may be necessary if there is low self-esteem, or in eating disorders. References 1. Sorensen et al. Recent secular trends in pubertal timing: implications for evaluation and diagnosis of precocious puberty. Horm Res Pediatr2012, 77(3): Carel et al. ESPE-LWPES GnRH Analogs Consensus Conference Group. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics 2009 Apr; 123(4):e Write from your heart Write from your soul... Make the best of your talent And don t ever let it go Not for anything... 53

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57 Session 2 Oration 55

58 RCOG Guidelines development and implementation Guideline Development; Everything you wanted to know but were afraid to ask. Evidence based guidelines have become an integral part of modern medicine. This presentation describes how the RCOG Green Top Guidelines are produced and how they can be adapted to accommodate local needs and resources. Dr Philip Owen Chair, RCOG Guidelines Committee UK, Maternal-Fetal Medicine Expert MB BCh, MRCOG, MD, Diploma in Fetal Medicine (Fetal Medicine Foundation) Present Consultant Obstetrician and Gynaecologist at the Princess Royal Maternity, Glasgow, Scotland : Medicine from University of Wales. MD thesis Longitudinal Ultrasound Studies in Human Pregnancy. 1990: MRCOG Fellows representative for Scotland on the Council of the RCOG Chairs the Scottish Committee of the RCOG Immediate past chair of the Guideline Committee of the RCOG Training Program Director for the West of Scotland Examiner of the MRCOG. Specialty editor of the European Journal of Obstetrics and Gynaecology Everyone wants Happiness, No one wants Pain. But you cant have a Rainbow, Without a little Rain. 56

59 Session 3 Connective tissue disorders and Renal disease 57

60 Connective Tissue Disorders and Renal Disease Moderators Dr Suneeta Mittal Senior Consultant and HOD Dept of Obs & Gynae Fortis Hospital Gurgaon Dr Mala Arora Director, Nobel Hospital & IVF Centre, Fardiabaad Panelists Dr Rohini Handa (Rheumatology) Sr Consultant Rheumatology Indraprastha Apollo Hospitals, New Delhi Dr S J Gupta (Rheumatology) sirindergupta@gmail.com Sr Consultant Rheumatology Indraprastha Apollo Hospitals, New Delhi Dr V K Aneja (Internal Medicine) dr.vkaneja@gmail.com Sr. Consultant, Dept. of Internal Medicine Indraprastha Apollo Hospitals, New Delhi Dr Sanjeev Jasuja (Nephrology) sanjivjasuja@yahoo.com Sr Consultant Nephrology Indraprastha Apollo Hospitals, New Delhi Dr Manisha Chakravarti (Paediatric Cardiology) manishamukh@hotmail.com Senior Consultant paediatric Cardiology, Indraprastha Apollo Hospitals, New Delhi Dr Chanchal Singh chanchalsngh@yahoo.com Consultant Fetal Medicine Indraprastha Apollo Hospitals, New Delhi Dr Sonal Bathla drsonalbathla11@gmail.com Sr.Consultant Obs & Gynecologist Sant Parmanand Hospital, Delhi Dr Poonam Tara poonamtara@hotmail.com Consultant Obs & Gynecologist Max Hospitals, New Delhi Case - I 42 year old primigravida (IVF conception), presents at 24 weeks gestation with Proteinuria +++ on dipstick test, oedema +++, BP 120/80 Discussion issues and learning objectives Current recommended tests to evaluate proteinuria in pregnancy Pathophysiology of Proteinuria and difference between Albuminuria and Proteinuria Differential diagnosis, prognosis and management Case - II 29 year old primi gravida, known case of Lupus nephritis with early onset FGR Discussion issues and learning objectives Impact of drugs commonly used in SLE Effect of disease on pregnancy and effect of pregnancy on disease Monitoring what, when and how Pre-pregnancy counselling Case - III Sjögren s syndrome with fetal heart block - 36 year old Primi gravida, Known case of Sjögren s syndrome, DCDA twin pregnancy with fetal heart block Discussion issues and learning objectives What investigation should be done in patients with Sjögren s Syndrome? Effect of disease on pregnancy and effect of pregnancy on Disease Management once fetal heart block is identified Role of fetal therapy in Fetal heart block Forget what hurt you but never forget what it taught you 58

61 Proteinuria with Normal Blood Pressure in Pregnancy Dr Suneeta Mittal MD FRCOG Senior Consultant and HOD Dept of Obs & Gynae, Fortis Hospital Gurgaon Dr Chanchal Singh MD MRCOG Consultant Fetal Medicine Indraprastha Apollo Hospitals, New Delhi Urine dipstick > 2+ Check BP normal Check for glycosuria Check for conditions that can cause false positive results: Concentrated urine Highly alkaline urine (ph>7) Gross hematuria Mucus, leukocytes, semen Iodinated contrast agent Contamination with chlorhexidine Present Absent Reassure patient Repeat dipstick with catheter sample Persistent Non-persistent 24-hour urine protein or spot urine protein-creatinine ratio Reassure patient <300 mg/24 hours BP monitoring LFT Observe >300 mg but less than 3.5 gram/ 24 hours (non-nephrotic range) These women are more likely to develop preeclampsia despite normal BP Close monitoring - LFT, KFT, platelet count Gestational proteinuria (retrospective diagnosis) >3.5 gram/24 hours (nephrotic range) Renal biopsy Love is not a thing to understand, Love is not a thing to feel. Love is not a thing to give and receive, Love is a thing only to become And eternally be. -Sri Chinny 59

62 Lupus Nephritis in Pregnancy Dr Suneeta Mittal MD FRCOG Senior Consultant and HOD Dept of Obs & Gynae Fortis Hospital Gurgaon Dr Chanchal Singh MD MRCOG Consultant Fetal Medicine Indraprastha Apollo Hospitals, New Delhi Pre-pregnancy counselling: Patients should be strongly discouraged from pregnancy during a lupus flare or persistently active disease - pregnancy should be avoided for at least 6 months after renal disease has been brought under control Drug regime: Mycophenolate mofetil (MMF) should be switched over to safer drugs like Azathioprine and pregnancy to be planned only if patient remains in remission after the switchover Unsafe drugs in pregnancy like ACE inhibitors and angiotensin receptor blockers should be discontinued Corticosteroids, Azathioprine, hydroxychloroquine and cyclosporine are acceptably safe in pregnancy Antenatal care of pregnant patient with Lupus nephritis: Multidisciplinary management - Obstetrician, Fetal Medicine specialist and Rheumatologist Screen for thrombophilias and lupus anticoagulant, anti- Ro and anti-la antibodies Continue pre-pregnancy medications safe in pregnancy, ie lowest possible dose of steroids, hydroxychloroquine, azathiprine, cyclosporine Low does aspirin (75 mg OD) LMWH if thrombophilias screen positive or other factors warranting antenatal thromboprophylaxis High risk for pre-eclampsia, fetal growth restriction, preterm labour, intrauterine fetal demise Antenatal monitoring (table below) Plan delivery at 37 to 38 weeks tertiary care centre with NICU facilities Induction of labour and caesarean reserved for obstetric indications although both will have higher rates in view of increased incidence of pre-eclampsia and fetal growth restriction Antenatal monitoring in patients with Lupus nephritis Antenatal visits High risk pregnancy clinic Monthly till 20 weeks, 2 weekly till 28 weeks and weekly thereafter Check BP, urine dipstick, symphysiofundal height (SFH) at each visit Rheumatologist - 4 to 6 weekly; more frequent in case of disease flare Investigations (at each visit) Complete blood count Kidney function tests, Liver function tests, Spot urine/creatinine ratio Complement levels, dsdna antibodies Ultrasound: Combined first trimester screen with uterine artery PI Fetal anomaly scan 18 to 20 weeks TVS for cervical length at 22 to 24 weeks risk of premature labour (?) 4 weekly growth scans with fetal Dopplers after 24 weeks Specific monitoring Pre-eclampsia IUGR - 2 weekly ultrasound for fetal growth, amniotic fluid and fetal Dopplers; CTG Anti Ro, anti La positive - Fetal echocardiogram weekly from 16 weeks until delivery Even when it s hard to move, take small steps forward. Because every step will lead you, farther away from where you, were yesterday. 60

63 Sjogren s Syndrome with Fetal Heart Block Dr Suneeta Mittal MD FRCOG Senior Consultant and HOD, Dept of Obs & Gynae Fortis Hospital Gurgaon suneeta.mittal@gmail.com Dr Chanchal Singh MD MRCOG Consultant Fetal Medicine Indraprastha Apollo Hospitals, New Delhi chanchalsngh@yahoo.com Diagnosis Medical therapy Follow up Labour and delivery Postnatal Confirm congenital heart block (CHB) is isolated Detailed anomaly scan Fetal echocardiogram No role of routine invasive testing Heart rate > 55 beats/min and normal ventricular function Consider maternal oral dexamethasone 4-8 mg/d Heart rate > 55 beats/min and abnormal ventricular function Dexamethasone 4-8 mg/d + beta sympathomimetic Weekly - biweekly obstetric assessment Weekly - biweekly fetal echocardiogram Delivery at tertiary care center Uneventful course - C section at 37 weeks (anticipated difficulty in fetal heart rate monitoring during labour) Progressive hydrops - C section and immediate pacing Decision regarding indication and timing of pacing If symptomatic, immediate pacing Outcome good When obstacles arise, you change your direction to reach your goal; you do not change your decision to get there. -Zig Ziglar 61

64 Sjögren s Syndrome and Pregnancy Dr S J Gupta, FRCP (Glas), FRCP (Edin), FICP. Senior Consultant Rheumatologist, Apollo Indraprastha and Sant Parmanand Hospitals, Delhi. sirindergupta@gmail.com Systemic rheumatic diseases (connective tissue diseases -CTDs) may occasionally coexist with pregnancy. The conditions seen, include- systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome (APS), rheumatoid arthritis (RA), scleroderma (SSc), and spondyloarthropathy (SpA). Both SLE and APS have a female to male ratio of about 7:1 and though RA is more common (female to male ratio about 3:1), it often occurs after the child-bearing age. Therefore, the auto-immune illnesses most often associated with pregnancy, are SLE and APS 1. Sjögren s Syndrome (SS) is another systemic rheumatic disease and may occasionally be seen in association with pregnancy. SS is usually characterised by dryness of eyes, mouth and mucous membranes- kerato-conjunctivitis sicca (KCS). SS may- be a) primary (PSS) or b) secondary (SSS) when the KCS features are seen in association with another systemic CTD such as RA or SLE. Arthritis may be seen with PSS, though this tends to be not a dominant feature and the effect of pregnancy on SS (and SS on pregnancy) is less clear. The diagnosis of systemic CTDs, rests essentially on clinical grounds, SS being no exception and rests on recognising the significant clinical features and relevant investigations - (see table 1) 2. The clinical significance of SS in association with pregnancy is, that the children are at risk of Neonatal Lupus Syndrome as about 80% patients with SS demonstrate anti- Ro/SSA and/or anti- La/SSB antibodies 2. Though Anti-Ro/Anti-La antibodies are seen in about 80% of mothers of children who have conduction abnormalities or congenital heart block (CHB) at birth, the risk for a mother with positive antibodies delivering a child with CHB is only about 1 in Management of patients with SS in pregnancy, depends upon the clinical features. Musculo skeletal and joint symptoms are managed very much similar to the management for rheumatoid arthritis. KCS symptoms are managed more symptomatically with artificial tear drops; however the effects of parasympathomimetics (Pilocarpine) on the foetus are less established and therefore best avoided. Table 1: Revised International Classification Criteria for Sjögren s Syndrome I. OCULAR SYMPTOMS: a positive response to at least one of the following: 1. Have you had daily, persistent, troublesome dry eyes, for more than 3 months? 2. Do you have a recurrent sensation of sand or gravel in the eyes? 3. Do you use tear substitutes more than 3 times a day? II. ORAL SYMPTOMS: a positive response to at least one of the following: 1. Have you had a daily feeling of dry mouth for more than 3 months? 2. Have you had recurrently or persistently swollen salivary glands as an adult? 3. Do you frequently drink liquids to aid in swallowing dry food? III: OCULAR SIGNS: that is, objective evidence of ocular involvement defined as a positive result for at least one of the following 2 tests: 1. Schirmer s test: performed without anaesthesia ( 5mm wetness in 5 minutes) 2. Rose Bengal Score or other ocular dye score ( 4 according to van Bijsterveld s scoring system IV: HISTOPATHOLOGY: in minor salivary glands (obtained through normal appearing mucosa): Focal lymphocytic sialadenitis, evaluated by an expert histopathologist, with a focus score 1, defined as a number of lymphocytic foci (which are adjacent to normal appearing mucous acini and contain more than 50 lymphocytes) per 4 mm 2 of glandular tissue V. SALIVARY GLAND INVOLVEMENT: objective evidence of salivary gland involvement defined by a positive result for at least one of the following diagnostic tests: 1. Unstimulated whole salivary flow ( 1.5ml is 15 minutes 2. Parotid sialography showing the presence of diffuse sialectasias (punctate, cavitary or destructive pattern), without evidence of obstruction in the major ducts 3. Salivary scintigraphy showing delayed uptake, reduced concentration and/or delayed excretion of tracer VI. AUTOANTIBODIES: presence in the serum of the following autoantibodies: 1. Antibodies to Ro (SSA) or La (SSB) antigens, OR both References 1. Lockshin MD, et al: Pregnancy and Rheumatic Diseases: in EULAR Text Book of Rheumatic Diseases 2012: Ed: Bijlsma, Johannes WG. 2. Vitali C,et al and the European Study Group on Classification Criteria for Sjögren s Syndrome: Classification criteria for Sjögren s syndrome: a revised version of the European Criteria Proposed by the American- European Consensus Group: Ann Rheum Dis 2002; 61: Buyon JP, Clancy RM. Neonatal Lupus Syndromes: Curr Opin Rheumatol 2003; 15:

65 Session 4 Key Note Lectures 63

66 Prevention of Preterm Birth Dr Philip Owen MB BCh, MRCOG, MD Diploma in Fetal Medicine (Fetal Medicine Foundation) Chair, RCOG Guidelines Committee UK Maternal -Fetal Medicine Expert Strategies to prevent preterm birth include modification of socio-economic and lifestyle factors, progesterone supplementation, cervical cerclage, and most recently the use of a cervical pessary. Tocolysis has a limited role in the management of women with preterm uterine activity and the consequences of preterm birth can be reduced with the antenatal administration of corticosteroids and magnesium sulphate. This presentation will provide an overview of current strategies aimed at the prevention of preterm birth and its consequences. Imagination is more important than knowledge. -Albert Einstein 64

67 Fibroids and Laparoscopy: Science Versus Sensationalisation Is uterine morcellation on its way out? Dr Urvashi P Jha (Chair AICC RCOG) MBBS MD MRCOG FRCOG (UK) FICS FIMSA FICOG Director Dept of Gynaecology, Minimal & Natural Access Gynae Surgery & Gynae Cancer Surgery (MNAGCS) Fortis Hospital - Vasant Kunj, New Delhi Director Dept of Gynae-Oncology Fortis Memorial Research Institute, President AOGD Governing Council Member of ICOG Chairperson Endoscopy Committee of AOGD Executive Committee Member of NARCHI & AOGD Morcellation in the news A raving debate has been initiated worldwide following Dr Amy Reed s unexpected detection of uterine sarcoma in her hysterectomy specimen and her death within a year of her surgery which had involved open power uterine morcellation in USA in march Amy Reed and her husband, Hooman Noorchashm from Pennsylvania resorted to legal action. The lawyers are having a field day seeking more such cases. The print media made mince meat of the news. Uterine morcellation has made it to international headlines. The stock market world also knows since stocks and shares have also been affected of Johnson and Johnson, the popular makers of a slick laparoscopic morcellator. What gynecologists do in the operating room is in the limelight today. Questions are being asked about surgical techniques, patient choices and informed consent issues. We are going to be even more answerable to the public. Here are some examples of what hit the medical and lay press: Philadelphia hospital restricts morcellation procedure Wall Street Journal, February 20, 2014 Society of Gynecologic Surgeons releases position statement on morcellation Uterine surgical technique is linked to abnormal growths and cancer spread New York Times, February 6, 2014 Evaluating the risks of electric uterine morcellation JAMA, February 6, doi: /jama Critics of fibroid removal procedure question risks it may pose for women with undetected uterine cancer JAMA, February 6, doi: /jama Implications What will be the implications of stopping the use of uterine power morcellation to thousands of women who would normally undergo minimally invasive laparoscopic surgery for fibroids - whether myomectomy or hysterectomy, and who do not actually have leiomyosarcoma or sarcoma? Is the current tide going to force gynecologists to stop performing laparoscopies for middle and large sized fibroids? With this medicolegal sword of Damocles dangling over our heads are we going to persist with laparoscopic myomectomies and laparoscopic hysterectomies even after detailed counseling and consenting of patients? Worst of all, are the patients going to be influenced to opt for laparotomies based on cancer phobias and a looming threat of imminent death? Or are they going to avoid hysterectomies and myomectomies altogether- rather not facing a diagnosis, or, rather not having a painful open surgery with its prolonged recovery. Sequence of events The domino effect resulted in the FDA issuing warning recommendations, J and J withdrawing and withholding production of its morcellators and lead hospitals in the USA banning the use of morcellators - a knee jerk response to self preservation. Following are self explanatory excerpts: The knowledge effect of the cancer risk leads FDA to discourage use of morcellators in hysterectomies say Westlaw Journal Medical Devices. They further go on to quote that The Food and Drug Administration has issued an advisory recommending that surgeons avoid the use of surgical morcellators in performing hysterectomies to prevent the spread of undiagnosed cancer cells. The FDA said on April 17 that morcellation performed on a woman with undiagnosed uterine cancer can spread cancerous tissue throughout the pelvic area and greatly lower the patient s chances of survival. The agency reviewed 18 published and unpublished scientific studies to try to determine the prevalence of unsuspected uterine sarcoma among women undergoing gynecological surgeries from 1980 to Uterine sarcoma can include uterine leiomyosarcoma, malignancy of the fibroid tissue. The studies looked at more than 38,000 patients in eight countries. According to the FDA advisory, the review showed that one in 352 patients had an unsuspected sarcoma and one in 498 patients had an unsuspected leiomyosarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen. 65

68 If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma in the pelvis, it results in significantly worsening the patient s likelihood of long-term survival, the advisory said. For this reason, and because there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids, it said. Recommendations of the FDA: The FDA advised physicians and patients to discuss alternatives to laparoscopic power morcellation for gynecological surgeries, and it directed device manufacturers to review and, if necessary, revise the warnings on their labels. The advisory noted that vaginal hysterectomy, which is performed without morcellation, usually yields comparable or better results and fewer complications than laparoscopic or abdominal hysterectomy. Other alternatives for women experiencing symptoms due to fibroid growth include mini-laparotomy using a smaller incision, high-intensity focused ultrasound and drug therapy, the agency said. J & J halts production and sales of morcellator following FDA investigation Johnson and Johnson, has suspended worldwide sales, promotion and distribution of its morcellators. Johnson and Johnson has followed the FDA warning with this statement, We believe that suspending the commercialization of these products until their role is better understood and redefined by the medical community is the appropriate course of action at this time Worrisome sequelae of open power morcellation Open power morcellation of uterine tissue usually results in small bits of tissue to spill inside the peritoneal cavity. The enhanced growth potential of the uterine tumor (fibroid) cells may result in the postoperative growth of this tissue scattered by morcellation in the abdominopelvic and the laparoscopic ports. These nodules of tissue result in disseminated leiomyomatosis. Investigators have called these disseminated nodules of fibroid tumor, morcellomas. New terminology coined Our first and only brush with this complication was a decade ago when, unfortunately, this condition was not well known or understood. It had resulted in great embarrassment to us. An extremely difficult explanation was offered to the patient of incomplete evacuation of dispersed fibroid remnants in order to go back in and remove all the nodules that had grown since. Needless to add that, thereafter, all patients, on whom we have had to perform a laparoscopic myomectomy, have been subjected to a thorough peritoneal lavage in an obsessive manner! Morcellation of occult uterine leiomyosarcomas also called morcelloma cancers Arnold P. Advincula and Bich-Van Tran have very aptly summarized the concern regarding occult leiomyosarcoma in Surgical Technique, August 2013 as In some cases, a uterine tumor thought to be a fibroid is surgically excised, but histologic analysis shows that the tumor is actually a uterine leiomyosarcoma. Most leiomyosarcomas are Stage I, but if the sarcoma tissue is open power morcellated in the peritoneal cavity, bits of tissue can be spread, upstaging the tumor and worsening the prognosis. In one retrospective study of women with leiomyosarcoma, the 5-year estimated survival was 73% if the tumor was removed without morcellation and 46% if the tumor was removed using morcellation. Many experts recommend a standardized preoperative evaluation of all cases of presumed uterine fibroid tumors where open power morcellation of tissue is planned. Recommended preoperative studies include: imaging studies such as MRI or sonography, endometrial biopsy in cases with abnormal uterine bleeding cervical cytology. There are currently no established imaging studies that can reliably detect a uterine sarcoma preoperatively,and endometrial biopsy has a low sensitivity for detecting leiomyosarcoma. Why do morcellomas form in some patients and not in others? According to Amy Garcia (April 2012(1) in Update: Minimally invasive surgery Uterine fibroids are clonal tumors that arise from a somatic mutation in a precursor cell. Tumors with clonal somatic mutations have enhanced growth potential because normal mechanisms that control cell growth have been disrupted at the level of cell DNA. Many uterine fibroids demonstrate an abnormal karyotype. Fibroids with a karyotype showing an exchange of genetic material between chromosomes 12 and 14 (t(12;14) (q13-15, q23-24)) are often large. The t(12;14) (q13-15, q23-24) translocation is associated with an increased expression of HMGIC, a gene that stimulates cell growth. Open morcellation of uterine fibroids may result in the dispersion of bits of tissue around the peritoneal cavity and surgical ports. If the fibroid contains genetic mutations that significantly increase the growth potential of fibroid cells, fibroid nodules may grow postoperatively in the pelvis, abdomen, and surgical ports. The Society of Gynecologic Oncology (SGO) position statement on morcellation, December 2013 Excerpts: Power morcellation or other techniques that cut up the uterus in the abdomen have the potential 66

69 to disseminate an otherwise contained malignancy throughout the abdominal cavity. For this reason, the Society of Gynecologic Oncology (SGO) asserts that it is generally contraindicated in the presence of documented or highly suspected malignancy, and may be inadvisable in premalignant conditions or risk-reducing surgery. Patients being considered for minimally invasive surgery performed by laparoscopic or robotic techniques who might require intracorporeal morcellation should be appropriately evaluated for the possibility of coexisting uterine or cervical malignancy. Other options to intracorporeal morcellation include removing the uterus through a mini-laparotomy or morcellating the uterus inside a laparoscopic bag. The SGO recognizes that currently there is no reliable method to differentiate benign from malignant leiomyomas (leiomyosarcomas or endometrial stromal sarcomas) before they are removed. Furthermore, these diseases offer an extremely poor prognosis even when specimens are removed intact. Patients and doctors should communicate about the risks, benefits and alternatives of all procedures so that a patient is able to make an informed and voluntary decision about accepting or declining medical care (ACOG Committee Opinion 439 Informed Consent). Alternative options to open power mocellation in surgery for fibroids One approach to reducing the pitfall of open power morcellation is to place the uterine tumor in a bag, hand morcellate the tissue within the bag, and remove the bag and tissue through an abdominal incision (minilaparotomy) or a colpotomy. If transabdominal removal of the tumor tissue is planned, the surgical port incision typically would need to be enlarged to permit hand morcellation and removal of the tissue. If a supracervical hysterectomy is planned, it may be difficult to remove a very large tumor through a small colpotomy. An advance would be to develop power morcellation technology that occurs within a bag, with the removal of the bag and the enclosed morcellated tumor through a laparoscopy port. Morcellation of tissue within a bag would reduce the risk of spreading bits of tumor tissue around the peritoneal cavity. Laparoscopic assisted myomectomy (LAM): Nezhat et al developed laparoscopic-assisted myomectomy (LAM) and reported on it in Laparoscopic myomectomy is performed followed by a minilaparotomy to suture the uterus and remove the fibroid without the need for power morcellation. Nezhat advocated it as a technique that may lessen the concerns regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery, namely, short hospital stay, lower costs, and rapid recovery. By decreasing the technical demands, and thereby the operative time, LAM may be more widely offered to patients. He adds LAM allows easier repair of the uterus and rapid morcellation of the myomas. In women who desire a future pregnancy, LAM may be a better approach because it allows meticulous suturing of the uterine defect in layers and thereby eliminates excessive electrocoagulation. According to Nezhat The criteria for LAM are myomas larger than 10 to 12 cm or numerous and deep myomas requiring extensive morcellation and necessitating uterine repair with sutures. A similar approach, combined laparoscopic and vaginal myomectomy, has also been suggested for treating extensive and deeply infiltrating fundal and posterior wall leiomyomata. The posterior colpotomy permits delivery of the myomas and allows uterine reconstruction by conventional suturing performed transvaginally. This approach also permits layered traditional uterine reconstruction of deep myometrial defects Development of new technology A major advance in gynecology would be the development of imaging studies that would permit the identification of uterine leiomyosarcomas prior to hysterectomy using open power morcellation. A preliminary study reported that diffusion-weighted imaging may be capable of differentiating leiomyosarcomas and leiomyomas but this study would require replication in multiple centers before it could be reliably utilized in surgical planning. ACOG Special Report s findings include the following Minimally invasive surgery, including gynecologic power morcellation, continues to be an option for some patients undergoing hysterectomy or myomectomy; In women with strongly suspected or known uterine cancer, power morcellation should not be used; Preoperative evaluation and diagnosis play an important role when power morcellation is being considered; and Patient counseling and the informed consent process also play an important role. Physicians and patients considering power morcellation as an option during gynecologic surgery should discuss the risks, benefits, and alternatives. Please also see Succinct updates on page 36 for recomendation of AAGL. So what do we do? Arnold P. Advincula and Bich-Van Tran go on to quote in Surgical Technique, August 2013 that During the surgical consent process the issue of power morcellating an occult leiomyosarcoma and the consequences of causing the spread of cancer cells should be discussed 67

70 with the patient. The patient may decide that the small risk of power morcellating an occult leiomyosarcoma is sufficiently worrisome that she would prefer an alternative procedure. These alternatives include abdominal hysterectomy, vaginal hysterectomy, or a hybrid operation involving removal of the uterine tissue through a mini-laparotomy or colpotomy incision. And what would we do? Continue as we do now, which is to leave the decision to the patient offering her all the feasible routes for a hysterectomy or a myomectomy as appropriare to her case. But she would need to leave the feasibility options to us to be decided after an examination under anaesthesia having indicated her preference to me preoperatively. However one more detail would now be discussed in the informed consent and that would be the risks of an undiagnosed preexisting malignancy and disseminated leiomyomatosis. If pressed for our recommendation, it would still be a laparoscopic procedure - myomectomy with morcellation in a bag, In situ morcellation would only be possible after a frozen section of a piece of wedge obtained at laparoscopy. For a hysterectomy for fibroids it would continue to be in order of preference, a vaginal followed by laparoscopy followed by abdominal hysterectomy. Would we morcellate? Yes, but with a fully informed consent, in a bag and after a frozen section. We guess uterine morcellation is not on its way out if we can adopt careful techniques of morcellating in a bag and counsel appropriately! The achievement of one goal should be the staring point of another -Alexander Graham Bell 68

71 Session 5 Pelvic Floor Dysfunction & Urinary Incontinence 69

72 Pelvic Floor Dysfunction & Urinary Incontinence Moderators Dr Nirmala Agarwal HOD & Senior Consultant Department of Obs & Gynae Sant Parmanand Hospital, Delhi Dr Arbinder Dang Senior consultant Department of OBG, Sant Parmanand hospital, Delhi, India Panelists Dr N Subramanian (Urology) drnsubra@yahoo.co.in Senior Consultant Urology, Indraprastha Apollo Hospitals, New Delhi Dr Suresh Rawat (Urology) docskrawat@gmail.com Sr Consultant Urology Indraprastha Apollo Hospitals, New Delhi Dr Rajiv Kumar (Urology) Professor, Dept. of Urology AIIMS, New Delhi Dr Vipin Arora (Urology) arora@cheerful.com Sr. Consultant, Dept. of Urology Indraprastha Apollo Hospitals, New Delhi Dr J B Sharma jbsharma2000@gmail.com Professor, Dept. of Obs & Gynae AIIMS, New Delhi Dr Ranjana Sharma rnj_sharma@yahoo.com Sr Consultant Obs & Gynecologist Indraprastha Apollo Hospitals, New Delhi Dr Uma Swain urswain@indiatimes.com Senior Consultant Shri Balaji Action Medical Institute & Sunder Lal Jain Hospital, New Delhi Dr Uma Pandey uma.pandey2006@yahoo.com Asstt Professor, Dept of Obs & Gynae, IMS Banaras Hindu University Varanasi Case - I Case of procidentia with no urinary complaints Discussion issues and learning objectives POPQ classification Options for treatment Preventive modalities for future Failure of surgery Case II Case of vault prolapse after abdominal hysterectomy Discussion issues and learning objectives POPQ staging of case Preventive surgical principles Best options of abdominal/laparoscopic sacral colposuspension versus vaginal sacrospinous fixation Judicious use of mesh- latest recommendations Case III Case of detrusor instability and stress urinary incontinence with cystocele / urethral diverticulum Discussion issues and learning objectives Role of urodynamic studies Management dilemma Case - IV Case of stress urinary incontinence Discussion issues and learning objectives Best management options: tension free tape, colposuspension & urethal bulking agents The secret to success is consistency of purpose -Benjamin Disraeli 70

73 Pelvic-Support Defects: Anatomy and assessment Dr Arbinder Dang MBBS, MD, DNB, MNAMS, MRCOG (UK), CERTFICATE CLINICAL EMBRYOLOGY Senior consultant, Department of OBG, Sant Parmanand hospital, Delhi, India Member Representative (U K ) AICC RCOG North Zone India. Anatomy Pelvic organ prolapse (POP) is a distressingly common condition and 11% of women have a lifetime risk of surgery for this condition. It is the descent of one or more of anterior vaginal wall, posterior vaginal wall, and apex of the vagina (cervix / uterus) or vault (cuff) after hysterectomy.anterior vaginal wall prolapsed (previously termed a cystocoele ) is descent of the anterior vagina so the urethra vesical junction (a point 3cm proximal to the external urinary meatus) or any anterior point proximal to this, is less than 3cm above the plane of the hymen. Prolapse of the apical segment of the vagina (previously termed vault prolapse ) is any descent of the vaginal cuff scar (after hysterectomy) or cervix, below a point which is 2cm less than the total vaginal length above the plane of the hymen. Posterior vaginal wall prolapse (previously known as a rectocoele ) is any descent of the posterior vaginal wall so that a midline point on the posterior vaginal wall 3cm above the level of the hymen or any posterior point proximal to this is, less than 3cm above the plane of the hymen. Anatomic support mechanisms The bony pelvis (Bony Scaffolding) The bony pelvis consists of the 2 innominate bones, or hip bones, which are fused to the sacrum posteriorly and to each other anteriorly at the pubic symphysis... Muscular Supports of the Pelvic Floor The bony structures fuse to the pelvic organs through a contiguous network of connective tissue that surrounds the obturator and levator muscles. The obturator muscle is in contact with the lateral pelvic wall. The bowl-shaped levator muscle is joined to the obturator muscle at the arcus tendineus fascia or white line of the pelvis and consists of 3 parts: iliococcygeus, pubococcygeus, and puborectalis. Within the levator muscle sit the urethra, bladder base, vaginal tube, and anorectum. The levator complex of muscles and the surrounding connective tissue, vessels, and nerves are often referred to as the pelvic floor. Pelvic Diaphragm The levator ani and coccygeus muscles that are attached to the inner surface of the minor pelvis form the muscular floor of the pelvis. With their corresponding muscles from the opposite side, they form the pelvic diaphragm. The levator ani is composed of 2 major muscles from medial to lateral: the pubococcygeus and iliococcygeus muscles. The arcus tendineus of the levator ani is a dense connective tissue structure that runs from the pubic ramus to the ischial spine and courses along the surface of the obturator internus muscle. Various muscle subdivisions have been assigned to the medial portions of the pubococcygeus to reflect the attachments of the muscle to the urethra, vagina, anus, and rectum- pubourethralis, pubovaginalis, puboanalis, and puborectalis- or collectively as the pubovisceralis. The thin lateral part of the levator ani is the iliococcygeus muscle, which arises from the arcus tendineus of the levator ani to the ischial spine. The fibers from both sides also fuse to form a raphe and contribute to the anococcygeal ligament. This median raphe between the anus and the coccyx is called the levator plate. It is formed by the fusion of the iliococcygeus and the posterior fibers of the pubococcygeus muscles. The coccygeus muscle that extends from the ischial spine to the coccyx and lower sacrum forms the posterior part of the pelvic diaphragm. It sits on the anterior surface of the sacrospinous ligament. Direct innervation of the levator ani muscle on its cranial surface is primarily from the third and fourth sacral nerve roots via the pudendal nerve. Majority of the muscle fibers in the levator ani are slowtwitch fibers that maintain constant tone (type I), with an increased density of fast twitch (type II) fibers distributed in the periurethral and perianal areas. Urogenital Diaphragm (Perineal Membrane) Musculofascial structure, present over the anterior pelvic outlet below the pelvic diaphragm. It contains deep transverse perinei muscle, compressor urethrae, sphincter urethrae, and urethrovaginalis and an inferior fascial layer called the perineal membrane. The more superficial ischiocavernosus and bulbocavernosus muscles, as well as the thin slips of the superficial transverse perinei, complete the inferior aspect of the urogenital diaphragm Perineal Body The perineal body is a pyramidal fibromuscular structure in the midline between the anus and vagina with the rectovaginal septum at its cephalad apex. Acquired weakness of the perineal body gives rise to elongation and predisposes to defects such as rectocele and enterocele. Connective tissue of the pelvis: Endopelvic Fascia and Connective Tissue Supports Organs are surrounded by endopelvic fascia consisting of largely smooth muscle, elastin, collagen and fibromuscular connective tissue. This structure lies immediately beneath the peritoneum and is one continuous unit with various thickenings or condensations in specific areas. Anterior Supports Connective tissue supports of the urethra, bladder, and vagina extend to the arcus tendineus of the pelvic fascia on the pelvic diaphragm. The pubourethral ligaments are connective tissue structures that extend from the 71

74 urethra to the pubic bone. At the level of the bladder base,the support comes from the lateral attachment of the vagina to the arcus tendineus of the pelvic fascia. The pubocervical fascia has been described as extending from the symphysis along the anterior vaginal wall to blend with the fascia that surrounds the cervix. It is continuous laterally with the pubococcygeus and also suspended to the arcus tendineus of the pelvic fascia. Middle Supports The paracolpium and parametrium are the connective tissues surrounding the vagina and the uterus, respectively. In the midvagina, the paracolpium fuses with the pelvic wall and fascia laterally. The cardinal ligaments (also called the transverse cervical ligaments of Mackenrodt) extend from the lateral margins of the cervix and upper vagina to the lateral pelvic walls and are condensations of the lowermost parts of the broad ligaments. The uterosacral ligaments are attached to the cervix and upper vaginal fornices posterolaterally. Posteriorly, they attach to the presacral fascia in front of the sacroiliac joint. The cardinal and uterosacral ligaments hold the uterus and upper vagina in their proper place over the levator plate. Posterior Supports The posterior vaginal wall, below the cardinals, is supported from the sides by the paracolpium, which is attached to the endopelvic fascia referred to as rectovaginal fascia and pelvic diaphragm.this fascia forms the anterior margin of another potential space, the rectovaginal space. A unifying theory of the anatomic vaginal support. According to DeLancey, the normal anatomic position of the distal vagina in the standing female is a vertical ascent of 1 to 3 cm. From the midvagina to the vaginal apex, the axis of the vagina is more horizontal, forming an approximately 120 angle. DeLancey Level I The vaginal apex and cervix are held by the surrounding endopelvic connective tissue-mainly the thickened lateral and posterior portions referred to as the cardinal and uterosacral ligaments. DeLancey Level II The midvagina is supported by the connective-tissue sheath that surrounds it and its lateral connectivetissue attachments to the levator muscle. DeLancey Level III The connective-tissue attachment of the urethra to the pubic bone and laterally to the levator muscle supports the distal vagina. Physiologic support mechanisms The muscles, vessels, and nerves of the pelvic floor function interactively as a compression mechanism in a manner similar to a valve, maintaining positioning of the viscera. The resting tone of the pelvic floor provides a valve like closure surrounding the urethra, vagina, and rectum.. The pelvic axis. The connective-tissue supports of the vagina anchor it to the pelvic skeleton and hold the vagina in the previously described semihorizontal axis. When this axis is maintained, increased abdominal pressure pushes the vaginal tube into the hollow of the sacrum, maintaining an intra-abdominal position. When the connective-tissue supports of the vagina and uterus are broken, the pelvic organs align in a more vertical axis. Increased intraabdominal pressure causes the pelvic organs to descend through the natural openings in the pelvic floor (genital hiatus). How symptoms relate to the level of support failure Pelvic floor disorders become symptomatic through either of two mechanisms: 1. Mechanical difficulties produced by the actual prolapse, 2. Bladder or bowel dysfunction, disrupting either storage or emptying. Level 1 symptoms The main presentations of Level 1 prolapse are pelvic heaviness, pressure, a feeling of something falling, a bulge at the entrance or a sense of sitting on something. Typical symptoms include hesitancy, straining to void, slow stream, stop and start flow, post-void dribbling and a need to lean forward or digitally elevate the bladder base. Level 2 symptoms Level 2 support failure, either anterior or posterior, produces eversion of the vaginal walls rather than inversion of the vaginal apex. Although mid vaginal weakness can present because of a vaginal bulge (cystocele or rectocele), symptoms relating the visceral dysfunction, stress incontinence, voiding difficulty, faecal soiling or incomplete rectal evacuation are more typical. Midvaginal prolapse can also cause sexual difficulties Level 3 symptoms Distal vaginal defects create introital gaping and rolling out of the lower vagina. Such patients often complain of dryness or chronic vaginitis secondary to passage of air into the vaginal lumen. 72

75 Assessment Pelvic Organ Prolapse Quantification System (POP-Q) - A pelvic prolapse staging Introduction Pelvic Organ Prolapse Quantification system (POP-Q) refers to an objective, site-specific system for describing, quantifying, and staging pelvic support in women. It provides a standardized tool for documenting, comparing, and communicating clinical findings with proven interobserver and intraobserver reliability. The POP-Q system, is approved by the International Continence Society (ICS), the American Urogynecologic Society (AUGS), and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse. Pelvic organ prolapsed is not life threatening,but often associated with deterioration in quality of life and may contribute to bladder, bowel and sexual dysfunction. The system describes quantitatively the position of 6 vaginal points (two anteriorly, two posteriorly, and two apically) and the length of the genital hiatus, perineal body, and vagina and is referred to as the POP-Q exam (pelvic organ prolapse Ð quantified). The measurements are taken using a marked Pap smear spatula. Six specific vaginal sites (points Aa, Ba, C, D, Bp and Ap) and the vaginal length (TVL) are assessed using centimeters of measurement from the introitus. The length of the genital hiatus (GH) and perineal body (PB) are measured. The clinical examination is performed and the measurements recorded on the POPQ grid. It is based on measurements that are taken using the introitis as reference. Any measurement above this is negative and anything below this is positive Measurement D is not taken in the absence of a cervix. Staging of the grade of pelvic support is objectively done on a five stage system. The POP-Q system has been criticized for being cumbersome and difficult to learn and does not include findings such as vaginal caliber, status of paravaginal sulci, pelvic muscle strength, or the presence of symptoms. Physical Examination and the POP-Q General The women s mobility and general condition noted. Neurological examination The spinal segments S2,3.4 should be assessed by testing the tone, strength and sensation in the lower limbs. The anal sphincter tone should be tested. Gynaecological Examination Urogynaecological examination using a Sims speculum. The examination begins with the woman in the dorsal position. The vulva and vagina are inspected for any lesions, atrophy or excoriation. The woman is then asked to cough or valsalva to observes for any stress incontinence. She is then asked to turn onto her left side and the Sims speculum is used to inspect the anterior and posterior vaginal walls for prolapse. If the women s symptoms are not adequately explained by the findings at examination, it may be useful to perform an additional assessment with her standing. 73

76 REFERENCES 1. Baden WF, Walker T. Surgical Repair of Vaginal Defects. Philadelphia:Lippincott; Berglas B, Rubin IC. Histologic study of pelvic connective tissue. Surg Gynecol Obstet. 1953;97: Brubaker L, Norton P. Current clinical nomenclature for description of prolapse. J Pelvic Surg, 1996;7: Bump RC, Mattiasson A,Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Smith ARB. The standardisation of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175: DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166: Emge LA, Durfee RB. Pelvic organ prolapse: four thousand years of treatment. Clin Obstet Gynecol 1966; 9: Herschorn S. Female Pelvic Floor Anatomy: The Pelvic Floor, Supporting Structures, and Pelvic Organs. Rev Urol. 2004;6 (suppl 5):S2-S Julian T. Pelvic support defects. In: Precis: An Update in Obstetrics and Gynecology. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists;2001: Julian T. Physical examination and pretreatment testing of incontinent women. Clin Obstet Gynecol. 1998;41(3): Julian TM. The efficacy of Marlex mesh in the repair of severe, recurrent vaginal prolapse of the anterior midvaginal wall. Am J Obstet Gynecol. 1996;175(6): Persu C, Chapple CR,Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) a new era in pelvic prolapse staging. Journal of Medicine and Life Vol. 4, No.1, January March 2011, pp Porges RF, Porges JC, Blinick G. Mechanism of uterine support. Obstet Gynecol. 1960;15: Ricci JV, Thom CH. The myth of a surgically useful fascia in vaginal plastic reconstruction. Q Rev Surg. 1954;(Dec): Richardson AC, Lyons JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976;126: Uhlenhuth E, Nolley GW. Vaginal fascia, a myth? Obstet Gynecol. 1957;10: Perseverance is a great element of success. If you knock long enough and loud enough at the gate, you are sure to wake up somebody. Henry Wadsworth Longfellow 74

77 Management of Urinary Incontinence Dr Sweta Balani, MD Consultant, Department of OBG Sant Parmanand Hospital, Delhi, India Dr Nirmala Agarwal FRCOG Senior consultant & HOD, Department of OBG Sant Parmanand hospital, Delhi, India Vice Chairperson. AICC RCOG North Zone India Dr Arbinder Dang MBBS, MD, DNB, MNAMS, MRCOG (UK) CERTF. CLINICAL EMBRYOLOGY Senior consultant, Department of OBG Sant Parmanand hospital, Delhi, India Member Representative AICC RCOG North Zone India INTRODUCTION: Urinary incontinence (UI) is a common symptom that can affect women of all ages, with a wide range of severity and nature. Incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals. The impact on the families and care givers of women with UI may be profound, and the resource required from the health services considerable. UI is defined by the International Continence Society as the complaint of any involuntary leakage of urine. Worldwide, several studies report prevalence of UI in the range of 25 to 45 percent [1]. Types of Urinary incontinence Stress UI (SUI) is involuntary urine leakage on effort or exertion or on sneezing or coughing. Urgency UI is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden compelling desire to urinate that is difficult to delay). This is due to detrusor overactivity (previously called instability, which may be idiopathic or secondary to neurogenic or nonneurogenic causes. Mixed UI is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing. Overactive bladder (OAB) is defined as urgency that occurs with or without urgency UI and usually with frequency and nocturia. OAB that occurs with incontinence is known as OAB wet. OAB that occurs without incontinence is known as OAB dry. These combinations of symptoms are suggestive of the urodynamic finding of detrusor overactivity (DO), but can be the result of other forms of urethrovesical dysfunction. Stress urinary incontinence (SUI) is estimated to be the commonest type of incontinence accounting for 41% of cases, followed by mixed urinary incontinence in 34% of cases, urge urinary incontinence account for 16% of cases. [2] Stress incontinence is more prevalent in young age group & urge incontinence is more common in elderly. Urinary Incontinence is a common symptom that can affect women of all ages, with wide range of severity & nature. Hence extent & interpretation of its evaluation must be tailored to the individual need. PATIENT-CENTRED CARE History-taking and physical examination: At the initial clinical assessment, categorise the woman s urinary incontinence (UI) as stress UI (SUI), mixed UI, or urgency UI/overactive bladder (OAB). Start initial treatment on this basis. In mixed UI, direct treatment towards the predominant symptom. If predominant symptom is SUI, explain importance of treating OAB first before considering surgical options of SUI. Also look for precipitating factors and other systemic diseases which may need attention by other specialties. 3 Assessment of pelvic floor muscle and detailed pelvic examinations: Undertake routine digital assessment to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of UI. Pelvic examination may reveal any abnormality like prolapse uterus or pelvic mass which may the main contributing factor for the symptoms. Take opportunity to do a Pap smear if recently not done. Urine testing All women presenting with UI, routine urine dipstick test is done for blood, glucose, protein, leucocytes and nitrites. If nitrites or leucocytes are positive or she is symptomatic for UTI, send mid stream urine (MSU) for culture and sensitivity and treat accordingly. In asymptomatic women when dipstick is negative, do not send MSU for culture as she is unlikely to have UTI. 3 Assessment of residual urine Residual urine is measured by a catheter or by ultrasound which is non-invasive. A palpable bladder or haematuria even microscopic, persistent bladder pain, pelvic mass, associated fetal incontinence, symptoms of voiding difficulty, suspected urogenital fistula, previous continence surgery or suspected neurological disease need urgent referral to specialist. 3 Bladder diaries Use bladder diaries in the initial assessment of women with UI or OAB. Encourage women to complete a minimum of 3 days of the diary covering variations in their usual activities, such as both working and leisure days. 3 Urodynamic testing: If a detailed history and examination clearly indicate OAB or SUI do not perform a urodynamic study. Perform multichannel filling and voiding cystometry before surgery in women who have: symptoms of OAB leading to a clinical suspicion of detrusor overactivity, or symptoms suggestive of voiding dysfunction or anterior compartment prolapse, or had previous surgery for stress incontinence. Consider ambulatory urodynamics or videourodynamics if the diagnosis is unclear after conventional urodynamics. Do not use the Q-tip or Bonney, Marshall and Fluid-Bridge tests 75

78 in the assessment of women with UI. Cystoscopy is also not recommended in initial stages. Ultrasound may be used for residual volume of urine. 3 Llifestyle interventions and Bladder training should be offered as first-line treatments for OAB Lifestyle interventions: Try reducing intake of caffeine in women with OAB. Restrict fluid intake in women who have high intake of fluid. Weight reduction in women with BMI.30 is advised. 3 Physical therapies Pelvic floor muscle training Offer a trial of supervised pelvic floor muscle training of at least 3 months duration as first-line treatment to women with stress or mixed UI. Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day. Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training. Continue an exercise program if pelvic floor muscle training is beneficial. 3 Therapeutic stimulation Do not routinely use electrical stimulation alone or in combination with pelvic floor muscle training. in the treatment of women with OAB. Electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy. 3 Behavioural therapies Bladder training: Offer bladder training lasting for a minimum of 6 weeks as first-line treatment to women with urgency or mixed UI. Medical Management for OAB: Before OAB drug treatment starts, discuss with women: the likelihood of success and associated common adverse effects, and the frequency and route of administration, and that some adverse effects such as dry mouth and constipation may indicate that treatment is starting to have an effect, and that they may not see the full benefits until they have been taking the treatment for 4 weeks. Choosing OAB drugs Offer one of the following choices first to women with OAB or mixed UI: Oxybutynin (immediate release), Tropan 2.5 mg or 5 mg Tolterodine (immediate release), Roliten OD 4 mg Darifenacin (once daily preparation), Dariten OD 7.5mg or 15 mg tablets Offer a transdermal OAB drug to women unable to tolerate oral medication. Side effects include dry mouth and eyes and constipation. Mirabegron, a beta-3-adrenoceptor agonist is recommended as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects. (FDA approved in 2013 & NICE guidelines 2013) Myrdetriq, 25mg / 50 mg OD. Nausea, dizziness, fast heartbeat, or headache may occur. Allergic reaction and difficulty in breathing are other side effects. Desmopressin may be used in women with troublesome nocturia. Caution in cases of cystic fibrosis and women more than 65 years with heart disease. Offer intra-vaginal oestrogens for the treatment of OAB symptoms in postmenopausal women with vaginal atrophy. If the first treatment for OAB or mixed UI is not effective or well-tolerated, offer another drug with the lowest acquisition cost. Oestrogens: Do not offer systemic hormone replacement therapy for the treatment of UI. Offer intra-vaginal oestrogens for the treatment of OAB symptoms in postmenopausal women with vaginal atrophy. 3 Medical management in stress Incontinence Imipramine, serotonin noradrenalin re-uptake inhibitor, increases outlet resistance by directly acting on external sphincter, dose mg /day. Side effects: CNS & cardiac, postural hypotension, fatigue. It is not recommended for long term use. Duloxetine increases urethral rhabdosphinter activity, dose is 40 mg BD. Onset of action starts in 1 to 2 weeks, side effects are nausea, dry mouth, constipation, decreased appetite, somnolence, fatigue, increased sweating and sometime suicidal tendency. It is not FDA approved for usage in SUI. 3 Do not offer duloxetine routinely as a first or second-line treatment for women with predominant stress UI. Although it may be offered as second-line therapy when women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects. 3 The multidisciplinary team (MDT) Offer invasive therapy for OAB and/or SUI symptoms only after an MDT review. Invasive procedures for OAB: Botulinum toxin A Discuss the risks and benefits of treatment with botulinum toxin A with women before the therapy and informed consent need to be taken including the following points: There is a likelihood of being symptom free or having a large reduction in symptoms. She needs to be aware of the risk of clean intermittent catheterisation and the potential for it to be needed for variable lengths of time after the effect of the injections has worn off. There is an absence of evidence on duration of effect between treatments and the long-term efficacy and risks. She has added risk of adverse effects, including an increased risk of urinary tract infection. Start treatment with botulinum toxin A only if woman has been trained in clean intermittent catheterisation and has performed the technique successfully, and is able and willing to perform clean intermittent catheterisation on a regular basis for as long as needed. Use 200 units when offering botulinum toxin A. Consider 100 units of botulinum toxin A for women who would prefer a dose 76

79 with a lower chance of catheterisation and accept a reduced chance of success. If the first botulinum toxin A treatment has no effect discuss with the MDT. If botulinum toxin A treatment is effective, offer followup at 6 months or sooner if symptoms return for repeat treatment without an MDT referral. Tell women how to self-refer for prompt specialist review if symptoms return following a botulinum toxin A procedure. Offer repeat treatment as necessary. Do not offer botulinum toxin B to women with proven detrusor overactivity. Percutaneous sacral nerve stimulation If conservative management including OAB drug treatment has not worked adequately and they are unable to perform clean intermittent catheterisation and or botulinum toxin A has not worked, review the patient with MDT. If MDT advise, offer percutaneous sacral nerve stimulation. Discuss the long-term implications of percutaneous sacral nerve stimulation with women including the need for test stimulation and probability of the test s success, the risk of failure, the long-term commitment, the need for surgical revision, and the adverse effects. Tell women how to self-refer for prompt specialist review if symptoms return following a percutaneous sacral nerve stimulation procedure. Augmentation cystoplasty Restrict augmentation cystoplasty for the management of idiopathic detrusor overactivity to women whose condition has not responded to conservative management and who are willing and able to self-catheterise. Preoperative counseling for the woman or her care giver should include common and serious complications: bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder, UTI and urinary retention. Discuss the small risk of malignancy occurring in the augmented bladder. Provide life-long follow-up. Urinary diversion Urinary diversion should be considered for a woman with OAB only when conservative management has failed, and if botulinum toxin A, percutaneous sacral nerve stimulation and augmentation cystoplasty are not appropriate or are unacceptable to her. Provide life-long follow-up. SURGICAL APPROACHES TO SUI When offering a surgical procedure discuss with the woman the risks and benefits of the different treatment options for SUI using the information in Information to facilitate discussion of risks and benefits of treatments for women with stress urinary incontinence. If conservative management for SUI has failed, do not use duloxetine as a first-line treatment for women with predominant stress UI, instead, offer synthetic midurethral tape or open colposuspension or autologous rectus fascial sling (New in NICE 2013). 3 Offer a follow-up appointment (including vaginal examination to exclude erosion) within 6 months to all women who have had continence surgery. Colposuspension: Do not offer laparoscopic colposuspension as a routine procedure for the treatment of stress UI in women. Only an experienced laparoscopic surgeon working in an MDT with expertise in the assessment and treatment of UI should perform the procedure. 3 Biological slings: Do not offer anterior colporrhaphy, needle suspensions, paravaginal defect repair and the Marshall Marchetti Krantz procedure for the treatment of stress UI. 3 Intramural bulking agents: Consider intramural bulking agents (silicone, carbon-coated zirconium beads or hyaluronic acid/dextran copolymer) for the management of stress UI if conservative management has failed. Women should be made aware that repeat injections may be needed to achieve efficacy, efficacy diminishes with time, efficacy is inferior to that of synthetic tapes or autologous rectus fascial slings. Artificial urinary sphincter is offered only if previous surgery has failed. Life-long follow-up is recommended. Considerations following unsuccessful invasive SUI procedures or recurrence of symptoms: Women whose primary surgical procedure for SUI has failed (including women whose symptoms have returned) should be referred to tertiary care for assessment (such as repeat urodynamic testing including additional tests such as imaging and urethral function studies) and discussion of treatment options by the MDT, or offered advice about managing urinary symptoms. Multi Disciplinary Team (MDT) for urinary incontinence should include a urogynaecologist, a urologist with a subspecialist interest in female urology, a specialist nurse, a specialist physiotherapist, a colorectal surgeon with a sub-specialist interest in functional bowel problems, for women with coexisting bowel problems, a member of the care of the elderly team and/or occupational therapist, for women with functional impairment. MDTs should work within an established regional clinical network to ensure all women are offered the appropriate treatment options and high quality care. 3 Reference 1. Abrams P, Cardozo L, Fall M, et al. The Standardization of terminology of lower urinary tract function: report from the standardization subcommittee of the international continence society. Neurourology Urodyn.2002; 21: National Collaborating Centre for Women s and Children s Health Urinary incontinence in women. 2006, London: RCOG Press 3. (NICE Clinical guideline 171, 2013). 77

80 Pelvic Organ Prolapse- Mesh controversy Dr Nirmala Agarwal, FRCOG Senior consultant & HOD Department of OBG Sant Parmanand hospital, Delhi, India Vice chairperson. AICC RCOG North Zone India. Dr Sonal Bathla, MD Senior consultant, Department of OBG Sant Parmanand hospital, Delhi, India Pelvic organ prolapse is the descent of one or more of the pelvic organs (uterus, vagina, bladder or bowel). The different types of prolapse include: upper vaginal prolapse i.e. uterus, vaginal vault (after hysterectomy when the top of the vagina drops down); anterior vaginal wall prolapse i.e. cystocele (bladder descends), urethrocele (urethra descends), paravaginal defect (pelvic fascia defect); posterior vaginal wall prolapse i.e. enterocele (small bowel descends), rectocele (rectum descends), perineal deficiency. 1 A woman can present with prolapse of one or more of these sites. Incidence of pelvic organ prolapse in parous women is 40-60%. Risk factors are pregnancy, childbirth, congenital or acquired connective tissue abnormalities, denervation or weakness of pelvic floor, ageing, hysterectomy, menopause and factors associated with chronically raised intraabdominal pressure. Women with prolapse commonly have a variety of pelvic floor symptoms only some of which are directly related to the prolapse. Generalised symptoms of prolapse include pelvic heaviness; bulge, lump or protrusion coming down from the vagina; a dragging sensation in the vagina; or backache. Symptoms of bladder, bowel or sexual dysfunction are frequently present. For example, women may need to reduce the prolapse by using their fingers to push the prolapse up to aid urinary voiding or defaecation. These symptoms may be directly related to the prolapsed organ, for example poor urinary stream when a cystocele is present or obstructed defaecation when a rectocele is present. They may also be independent of the prolapse, for example symptoms of overactive bladder when a cystocele is present. Many women with POP report concomitant stress urinary incontinence (SUI); in women with stage II POP, about 55% also have stress urinary incontinence. However, this prevalence decreases with increasing prolapse, and possibly obstruction of the urethra due to the prolapse, to 33% in women with stage IV POP. The term de novo SUI is used to describe stress incontinence that develops following surgical correction of the prolapse amongst women who were symptomatically continent prior to surgery. Types of prolapse are upper, anterior and posterior vaginal prolapse. Only 2% of these patients are symptomatic, hence, careful patient selection is a must. Apical prolapse The International Continence Society defines posthysterectomy (apical) vaginal prolapse as descent of the vaginal cuff scar below a point that is 2 cm less than the total vaginal length above the plane of the hymen. 2 The abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse, (0-6%) (Level I evidence), reduced grade of residual prolapse (3-31%), greater length of time taken to recurrence of prolapse and less dyspareunia as compared to vaginal sacrospinous colpopexy. Superior anatomic results were seen with abdominal route despite it being more expensive and having longer operating and recovery time. Some studies showed increased pain, blood loss and febrile morbidity in the open route but these were reduced with laparoscopic approach. Mesh erosion was 0-12% but higher when hysterectomy was done or combined abdomino-vaginal approach was used. 3 Sacrospinous ligament suspension: Incidence of recurrent cystocele after sacrospinous ligament suspension is 8-30 % presumably due to posterior orientation and fixation of upper vagina which predisposes the anterior compartment to excess intraabdominal pressure. According to Cochrane Review, the total reoperation rate for prolapse, stress urinary incontinence, or mesh complications after the combined mesh repair was 10 % as compared to 3.4% after native tissue repair. Long term follow up showed higher recurrence rates where uterus is preserved in addition to risk of future uterine pathology. Reducing the risk of recurrence or de novo prolapse requires adequate apical support at the time of initial reconstructive surgery, extension of mesh down on to the anterior or posterior wall during sacral colpopexy and simultaneous correction of anterior / posterior wall defects. Recurrence is associated with poor tissue quality, factors predisposing to poor wound healing,(diabetes, urogenital atrophy, smoking, vaginal infection) and surgical factors (surgeons experience, tension in the arms) etc. Anterior vaginal wall prolapse Surgeries carried out for anterior wall prolapse are anterior colporrhaphy (native tissue or mesh augmented), paravaginal repair, obliterative procedure or anterior wall mesh repair. Cochrane review in 2010 showed that mesh repairs improved anterior anatomy more (higher objective cure rate) than native tissue repairs, however, there was a higher rate of complications (1-15%) associated with vaginal mesh even though functional and subjective cure rates were similar. Complications of mesh: Range from transient pain and small mesh erosions to large mesh exposures / extrusions or perforations into the bladder or bowel. Mesh erosion through the vagina was the most common and consistently reported mesh related complication 78

81 from trans-vaginal POP surgeries using mesh. Mesh erosion can require multiple surgeries to repair and can be debilitating for some women. In some cases, even multiple surgeries will not resolve the complication. Mesh contraction (shrinkage) was a previously unidentified risk of trans-vaginal POP repair with mesh that has been reported in literature and in adverse reported events to FDA. Mesh contraction is associated with vaginal shortening, vaginal tightening and vaginal pain. Both mesh erosion and mesh contraction can lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion. FDA notification basis In the light of complications, FDA conducted systematic reviews of literature from on use of mesh in POP. Mesh used in trans-vaginal POP repair introduces risks not present in traditional non -mesh surgery for POP repair. Abdominally placed mesh for POP repair appears to lower rates of mesh complications compared to transvaginal POP surgery with mesh. There is no evidence that trans-vaginal apical or posterior repair with mesh provides any added benefit compared to traditional surgery without mesh. While trans-vaginal anterior repair with mesh augmentation may provide an anatomic benefit compared to traditional POP repair without mesh, this anatomic benefit may not result in better symptomatic results. 3 Recommendations Health care providers should recognize that most cases of POP can be treated successfully without mesh. One should obtain specialized training for each mesh placement technique, and be aware of its risks. Choose mesh surgery only after weighing its risks and benefits versus all surgical and non-surgical alternatives. Be vigilant for potential intra-operative and post-operative adverse events of mesh placement. Inform patients about non-surgical options, non-mesh surgery, mesh placed abdominally and the likely success of these alternatives compared to trans-vaginal surgery using mesh. Notify patients that mesh implantation is permanent and make them aware of its complications including risk of reoperation and impact on quality of life (pain and sexual dysfunction); make sure she understands them. Provide patient with information regarding the specific product used. 4 Management of mesh complications Management of graft erosion depends on the material involved and on the location and area of exposure. Proposed risk factors for mesh extrusion or erosion include estrogen deficiency, improper dissection planes, poor tissue integrity, subclinical or frank infection, hematoma formation, increased mesh area, and lack of integration of the mesh into the host due to any of the above or related to a variety of mesh characteristics. Choice of observation with local hormone replacement therapy vs. formal excision of the exposed graft should be given to the patient who presents with vaginal extrusion of the mesh. In patients in whom the mesh is being removed for pain, the question of how much mesh to remove arises. This is not universally established. The undermining of the vaginal flaps is also important in facilitating a tension-free re-approximation of the vaginal tissue edges. With bladder involvement, a trans-abdominal, trans-vesical approach is typically preferred with clean edges of bladder closed to itself. Careful bladder drainage should be accomplished via catheter for 7 10 days (typically both a urethral foley and a suprapubic tube), and catheter removal should be preceded by a cystogram with drainage film that confirms the absence of extravasation of contrast material. Posterior vaginal wall prolapse Posterior vaginal wall repair performed better than the trans-anal repair of rectocele in terms of significantly lower recurrence rate of posterior vaginal wall prolapse. Posterior compartment prolapse is often associated with loss of apical support necessitating a combined procedure with apical repair. Traditional surgical treatment for rectocele and enterocele (posterior colporrhaphy and site specific repair) generally result in 85-95% anatomic cure rates and patient satisfaction. Addition of synthetic graft material offers no further advantages, only mesh associated complications. Conclusion With the current widespread use of graft materials to reinforce pelvic floor reconstructive techniques, it is imperative for surgeons to be familiar with potential complications related to the materials and proper management of these complications. Although it is beginning to appear that the benefit of using some synthetic materials may outweigh the risks, proper management and understanding of the risks is important in order to counsel our patients appropriately and responsibly prior to their surgeries. Macroporous monofilament synthetic grafts and non-cross-linked biologic grafts appear to have the best integration into native tissues. Solvent dehydration and irradiation of biologic grafts may weaken the integrity of the material and may prevent proper tissue integration. Technical factors related to surgical technique may impact success rates, such as tension on suture line or failure to use vaginal packing. The perfect graft material has not yet been created. References 1. Maher C et al. Surgical management of pelvic organ prolapse in women (Review). The Cochrane Library 2013, Issue Abrams P et al. Report from the standardization sub-committee of the International Continence Society. Neurourol Urodyn 2002;21: Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse. FDA, 2011 & Updated in The management of post hysterectomy vaginal vault prolapse. Green-top guideline no. 46 October

82 Genital Prolapse in Young Woman: Case discussion Dr Nirmala Agarwal, FRCOG Senior consultant & HOD, Department of OBG Sant Parmanand hospital, Delhi, India Vice chairperson. AICC RCOG North Zone India. Dr Arbinder Dang MBBS, MD, DNB, MNAMS, MRCOG (UK) CERTF. CLINICAL EMBRYOLOGY Senior consultant, Department of OBG Sant Parmanand hospital, Delhi, India Member Representative AICC RCOG North Zone India. A 26yrs old woman with one child presents with genital prolapse. Critically appraise your management of this patient. In this young patient the difficulties arise if she had not completed her family. The fact that she has developed genital prolapse at such a young age indicates that the support of her pelvic organs is weak. However, trauma from childbirth must not be discounted. The first important step is therefore to obtain an adequate history about the onset of the prolapse and the precipitating factors. A recent traumatic delivery will be suggestive of a possible cause. However it is unlikely to be the main reason for the prolapse. Further questioning may reveal a history of prolapse in other members of the family, suggesting a familial tendency. However the absence of any precipitating factor or an affected family member does not exclude congenital weakness of the pelvic muscles. Other aggravating symptoms, such as chronic cough, constipation, abdominal swelling and an at-risk occupation, must be excluded. A thorough general examination will exclude chest infection, hypertension and abdominal masses or ascites. During a pelvic examination, the perineum and its tone will be assessed as well the type of prolapse (cystocele and rectocele or enterocele). These will determine to a large extent the management the patient will be offered it is very likely that in this young woman the perineum will be demonstrated to be deficient. Definitive management will depend on the examination findings. Management will be tailored to the patient s need. Where her family is incomplete, surgery may have to be deferred until she has completed it. In that case, a pessary may be inserted after the pelvic examination as an interim measure. Retention of pessaries depends on a relatively intact perineum and pelvic muscle tone. If she has a defective perineum but the pelvic muscles are a relatively good tone, a right pessary may be retained. Once the patient has completed her family, definitive corrective surgery should be offered. In some cases she may have to complete her family early to enable corrective surgery to be offered and in the long term this may result in regret if she later felt than her family was incomplete. Another option is to offer the patient corrective surgery in the form of a Manchester operation. The operation consists of amputation of the cervix, shortening of the transverse cervical ligament, anterior colporrhaphy and a colpoperineorrhaphy depending on the type of prolapse. This procedure must only be undertaken after adequate counseling as its complications, such as cervical stenosis, infertility and cervical weakness (incompetence) may affect the patient s ability to have children. The long term management of this young woman is extremely important. It is most likely that she will become symptomatic in her later years even of corrective surgery is offered now or at a later date. An important part of her management should therefore include counseling about the prognosis and chances of success after corrective surgery and physiotherapy. Persistent people begin their success where others end in failure. -Edward Eggleston 80

83 Session 6 Vascular Malformations in Obstetrics 81

84 Vascular Malformations in Obstetrics Moderators Dr Anita Kaul Academic & Clinical Coordinator Sr Consultant, Dept. of Fetal Medicine Dr Mamta Mishra Department of Obs and Gynae, Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, New Delhi Panelists Dr R N Makroo (Transfusion Medicine) makroo@apollohospitals.com raj_makroo@hotmail.com Sr Consultant Transfusion Medicine Indraprastha Apollo Hospitals, New Delhi Dr V P Singh (Neurosurgery) vpsingh1958@yahoo.com Sr. Consultant, Dept. of Neurosurgery Indraprastha Apollo Hospitals, New Delhi Dr Pinak Shrikhande (Critical Care) pinak.shrikhande@fortishealthcare.com Consultant Department of Critical Care, Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, New Delhi Dr A S Arora (Invasive Radiology) asarora54@yahoo.com Senior Consultant Radiology, Indraprastha Apollo Hospitals, New Delhi Dr S S Trivedi drsstrivedi@gmail.com Professor, & HOD Dept. of Obs & Gynae LHMC New Delhi Dr K Gujral kgg_in@yahoo.com Senior Consultant Deprtment of Obs & Gynae, Sir Ganga Ram Hospital New Delhi Dr Sushma Sinha drsinha_sushma@hotmail.com Sr. Consultant Obs & Gynecologist, Infertility & ART Specialist Indraprastha Apollo Hospitals, New Delhi Dr Prabha Sinha (UK) agynaecologist@gmail.com Sr. Consultant Obs & Gynecologist. UK Case - I 31 year old 25 weeks of pregnancy admitted with sudden onset headache, vomiting and loss of consciousness with normal BP who then required ventilatory support. Discussion issues and learning objectives Differentiation between severe pre-eclampsia, epilepsy, thromboembolism and cerebral haemorrhage How to manage an unconscious pregnant patient Basic principles of critical care management Case II A 26 year second gravida was diagnosed with Cesarean scar pregnancy at 6 weeks and was advised termination. She declined and pregnancy continued. Later diagnosed to have placenta praevia. Elective LSCS performed at 37 weeks when found to have a morbidly adherent placenta. Had cardiac arrest on table. 40 units of blood were transfused.both mother and baby survived. Discussion issues and learning objectives How to diagnose cesarean scar pregnancy How to diagnose a morbidly adherent placenta How to plan delivery in a patient with a morbidly adherent placenta versus one with a non adherent placenta praevia Use of different blood products Case - III 31 year old with a 29 week pregnancy with a AV malformation in the fetal brain which needed a multidisciplinary team for further management Discussion issues and learning objectives The Law and late termination of pregnancy Safety of Colour Doppler,Power Doppler and MRI imaging in Pregnancy Outcomes of antenatal brain malformation in the fetus Persistent people begin their success where others end in failure. -Edward Eggleston 82

85 Algorithm for the Management of Unconscious Pregnant Patient Dr Anita Kaul, MD, FRCOG Senior consultant & HOD Department of Apollo Centre For Fetal Medicine, New Delhi Dr Neha Gupta Clinical Fellow, Apollo Centre For Fetal Medicine, New Delhi Figure 1 BASIC LIFE SUPPORT (BLS) Specific Difficulties in a Pregnant Patient Assessment and initial management of an unconscious pregnant patient P-pulse, BP-blood pressure, FH- fetal heart rate, CPR-cardiopulmonary resuscitation, AED- automated electrical defibrillator, ALS- Advanced life support Automated Electrical Defibrillator AED- automated electrical defibrillator, CPR-cardiopulmonary resuscitation Cpr-Cardipulmonary Resuscitation, Gcs Glasgow Coma Scale 83

86 Perimortem Caesarean Section Why needed- Gravid uterus > 20 weeks- makes CPR difficult 1. At term- vena cava occlusion is 90% by gravid uterusstroke volume only 30% 2. 20% decrease in fuctional residual capacity + 20% increase in oxygen demand due to fetus-hypoxia ensues quickly 3. Effectiveness of ventilation breaths decreases- due to increased weight of abdominal contents and the breasts Initiate- 4minute rule initiate within 4 mins of cardiac arrest and deliver within 5 mins Where to consider Moving the mother to an operating theatre (e.g. from a labour room or accident and emergency department) is not necessary If the mother is successfully resuscitated, she can be moved to theatre to complete the operation Make decision to abandon CPR if unsuccessful Do not abandon CPR if rhythm continues as Ventricular fibrillation/ ventricular tachycardia. A decision to abandon CPR should only be made after discussion with the consultant obstetrician and senior clinicians. Emergency numbers to contact operational in 18 states- Andhra Pradesh, Telangana, Gujarat, Uttarakhand,Goa, Tamil Nadu, Karnataka, Assam, Meghalaya, Madhya Pradesh, Maharashtra, Himachal Pradesh, Chhattisgarh, Uttar Pradesh, Rajasthan, Kerala, Odisha, Daman & Diu and Dadra & Nagar Haveli 102- ambulance services (all over INDIA) Each failure to sell will increase your chances for success at your next attempt -Og Mandino 84

87 Safety of Imaging in Pregnancy Dr Anita Kaul, MD, FRCOG Senior consultant & HOD Department of Apollo Centre For Fetal Medicine, New Delhi Dr Nupur Shah Clinical Fellow, Apollo Centre For Fetal Medicine, New Delhi Ultrasound: Though USG is considered safe in pregnancy, as low as reasonably achievable (ALARA) principle must be followed Experimental studies suggest that biological effects on the fetus/embryo from ultrasound can result due to thermal and mechanical mechanisms. All diagnostic ultrasound machines should comply with output standards and display the thermal and mechanical indexes on the screen,particularly if the values are 1.0; TVS: With the use of transvaginal ultrasound, there may be higher exposure of the embryo at early stages of development during organogenesis,with more thermal effect and radiation stress which could theoretically affect cell migration so scanning must be kept to a minimum Dopplers: The colour flow and pulsed wave Doppler have powerful acoustic output and high intensity pulses. When the beam is held in a fixed position during spectral pulsed Doppler measurements, the temporal average intensity is increased relative to that when moving probes are used, so constanly moving the probe is important. Thermal effects are of particular concern with the use of Doppler ultrasound in the second and third trimesters, particularly in the soft tissues adjacent to fetal bones Mechanical effect on the other hand may be more hazardous in the first trimester, at which time the embryonic tissues are more sensitive and relatively loosely tethered It is therefore recommended,that the use of Doppler ultrasound in the first trimester should be restricted to medically indicated diagnostic purposes with the shortest possible exposure duration performed by competent personnel who are trained because first trimester is the most vulnerable period in context to organogenesis. Safety of MRI in Pregnancy: Present data have not conclusively documented any deleterious effects of MR imaging at 1.5 T on the developing fetus. The use of MRI is not generally advisable during the first trimester of pregnancy due to potential hazards of hyperthermia and acoustic noise. Nevertheless, it is still preferable to any imaging involving ionising radiation. MRI contrast agents should not be routinely administered to pregnant patients. Gadolinium is a pregnancy class C drug, meaning that the safety in humans has not been proven. Human studies assessing the variability of the fetal heart rate during the scan, the effect of MRI regarding intrauterine fetal growth and a 9-month and 3-year follow-up study of children imaged in utero, showed no significant statistical difference between the study and control groups. References 1. ACR SPR practice guideline for the safe and optimal performance of fetal magnetic resonance imaging, AIUM, ACOG Clements H et al. Infants exposed to MRI in utero have a normal paediatric assessment at 9 months of age. Br J Radio 2000;73: TOAG All of our dreams can come true if we have the courage to pursue them. -Walt Disney 85

88 Critical Care Issues During Pregnancy Dr Pinak Shrikhande, MD, DNB, FNB Addl. Director and HOD Critical Care Medicine Fortis Hospital, Shalimar Bagh, Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, New Delhi % of obstetrical admissions require transfer to an intensive care unit. One-third are admitted to ICU antepartum. Mortality among obstetric patients admitted to ICU is 5-6%. (Overall maternal mortality <1 per 10,000). Mortality among obstetric patients admitted to ICU is relatively low, but given maternal mortality ratios in the developed world of about 10 per maternity admissions, this represents a 500-fold increase in mortality Common Reasons for ICU Transfer The two biggest contributors are hypertension and hemorrhage. Respiratory, cardiac, neurologic, endocrinologic, poisonings/overdose, and trauma admissions also play a role. Sepsis in Obstetrics patients Basic Principles in Obstetrics Critical Care Two patients rather than one Interests may not coincide exactly, but maternal needs take precedence Fetal health, as a rule, is maximized when maternal medical condition is optimized Changes in maternal physiology; therefore, changes in normal values Obstetrics patients with clinical evidence of local infection have 8-10% risk bacteremia which rarely progresses to sepsis (4%) and in patients with septic shock, mortality is <20%. The epidemiology of septic shock in pregnancy is not clear. It has been reported to affect only 1 in 8000 pregnancies. The overall low mortality in obstetric septic shock probably relates to a number of factors: the patients tend to be young with less co morbidity than other ICU patients, bacteremia is frequently transient, and the primary site is frequently the pelvis, which is accessible to both medical and surgical intervention. Infections Associated with Septic Shock in Pregnancy Chorioamnionitis % PP endometritis: SVD <10% PP endometritis: CS 12-50% Urinary 1-3% Septic abortion 1-2% Necrotizing fasciitis <1% Rates of postpartum infection are higher among women after cesarean compared to vaginal birth, but all estimates vary widely. Rates of septic abortion are inversely proportional to population access to safe abortion. Not all infection in pregnant or postpartum women, however, derives from a pelvic source. Management of severe Sepsis in Obstetric patient Initial Resuscitation (First 6 hrs) Begin resuscitation immediately in patients with hypotension, or serum lactate > 4 mmol/l; do not delay pending ICU admission. Resuscitation goals are: CVP 8 12 mm Hg MAP 65 mm Hg Urine output 0.5 ml. kg -1.hr -1 Central venous O 2 saturation 70%, or mixed venous 65% If venous O 2 saturation target not achieved: Consider further fluid Transfuse prbc to Hct 30% and/or Dobutamine infusion max 20 μg.kg -1.min -1 Fluid Therapy Fluid-resuscitate using crystalloids. Target CVP 8 mmhg ( 12 mmhg if mechanically ventilated) Give fluid challenges of 30ml/kg of crystalloids and 5% Albumin. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B). Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B). Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C). Vasopressors Maintain MAP 65 mm Hg. Norepinephrine should be used as the first agent of choice over dopamine as decreased mortality in patients on Norepinephrine. Need to be administered through a central line, hence arterial catheter should be inserted. Inotropic Therapy: In patients with low cardiac output despite adequate fluid resuscitation, dobutamine should be started in combination with a vasopressor. ScVo2 of >70% is the goal. Blood Product Administration Give RBC when Hb < 7.0 g/dl to target HB g/dl in adults. Administer platelets when: platelet counts are < 10,000/mm 3 regardless of bleeding. 86

89 platelet counts 20,000/mm 3 and there is significant bleeding risk. platelet counts 50,000/mm 3 are required for surgery or invasive procedures. No basis of correcting sepsis induced coagulation abnormlities. Diagnosis Obtain appropriate cultures before starting antibiotics. Minimum two blood cultures: one percutaneous and one from each vascular access ³ 48 hours Perform imaging studies promptly in order to confirm and sample any source of infection. Correct antibiotic prescribing saves more lives than the following Activated Protein C Tight glucose control Low volume ventilation Low dose steroids in sepsis Mixed venous O 2 monitoring Antibiotic Therapy Begin intravenous antibiotics within first hour of recognition of severe sepsis. One or more drugs active against likely bacterial or fungal pathogens. Consider microorganism susceptibility patterns in the community and hospital. Each hour off delay of appropriate antibiotic carries 7.6% reduction in survival. Source Control Antibiotics don t replace source control Steroids IV corticosteroids (hydrocortisone mg/day for 7 days by continuous infusion) are recommended in patients in septic shock who, despite adequate fluid replacement, and vasopressor therapy to maintain an adequate blood pressure Airway and Ventilatory Management in Pregnancy Higher risk of failed intubation in pregnancy (even for the professionals) Fetal well-being depends on maternal well-being Assess airway even in urgent intubations Avoid aspiration: elevate head of bed, cricoid pressure, sod citrate, smaller ETT in size Need of Lower dose of sedatives/anesthetics Pre-oxygenation risk of aspiration by manual ventilation Faster occurrence of Hypoxia and hypercapnia in response to apnea Left lateral decubitus to relieve IVC obstruction Ready availability of Difficult intubation cart Intubation by the most experienced CXR to confirm ETT placement Use sedation/paralysis as appropriate; fetus is not a consideration Opioids, benzodiazepines, propofol are all acceptable in pregnancy, although all do cross placenta and will also sedate the fetus. Muscle relaxants (pancuronium, vecuronium etc) do not cross placenta. Pregnancy and ARDS Incidence low (1/6,000-10,000 deliveries). Maternal mortality ~30% Aside from usual causes ARDS, consider preeclampsiaeclampsia-hellp, AFLP, anaphylactoid syndrome of pregnancy, tocolytic therapy Specific OB causes (preeclampsia, amnionitis/ endometritis, OB hemorrhage, etc) can be identified in about 40% of ARDS in pregnancy; another 20% are related pyelonephritis & varicella pneumonia which rarely trigger ARDS in immunocompetent adults. However, cell-mediated immunity is known to be depressed in pregnancy. Antepartum: Infectious causes 66% (8% PIH, 8% aspiration); Mortality 25% Postpartum: Infection 35%, PIH 29%, shock 18%; Mortality 50% Obstetric Hemorrhage Control of Hemorrhage ~ SURGICAL. FFP = ml/kg Platelet transfusion <50,000. Cryoprecipitate if fibrinogen con.<100 mg/dl rfviia ~ microg/kg Prompt correction of hypothermia, acidosis, coagulopathy Resuscitation endpoints: Euthermia, ph > 7.2, PTT, PT > 1.25 times control levels, Platelet count > 100,000/ mm3, fibrinogen> 100 mg/dl. CPR in Pregnancy : Key Interventions to Prevent Arrest Place the patient in the full left-lateral position to relieve possible compression of the IVC. Uterine obstruction of venous return can produce hypotension and may precipitate arrest in the critically ill patient. Give 100% oxygen. Establish intravenous (IV) access above the diaphragm. Assess for hypotension; maternal hypotension that warrants therapy has been defined as a SBP of 100 mm Hg or 80% of baseline. Maternal hypotension can result in reduced placental perfusion. In the patient who is not in arrest, both crystalloid and colloid solutions have been shown to increase preload. Consider reversible causes of critical illness and treat conditions that may contribute to clinical deterioration as early as possible 87

90 Refrences 1. Kumar et al. Crit Care Med 2006; 34: Surviving Sepsis Campaign: International guidelines for Management of severe sepsis and septic shock: Critical Care Medicine Feb; 41(2): The SAFE Study Investigators A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. N Engl J Med 2004; 350: All of our dreams can come true if we have the courage to pursue them. -Walt Disney 88

91 Cesarean Scar Pregnancy Dr Mamta Mishra MD MRCOG Senior Consultant. Fortis Hospital, Vasant Kunj, Delhi Ultrasound is the first-line diagnostic tool for CSP. By far, the majority of the CSPs have been diagnosed by transvaginal scan (TVS) in the early weeks of pregnancy. A sagittal view along the long axis of the uterus through the gestation sac can localise a CSP with confidence. The following ultrasound criteria have been put forward for the diagnosis of a CSP an empty uterine cavity, without contact with the sac a clearly visible empty cervical canal, without contact with the sac presence of the gestation sac with or without a fetal pole with or without fetal cardiac activity (depending on the gestation age) in the anterior part of the uterine isthmus, and absence of or a defect in the myometrial tissue between the bladder and the sacn addition, there should be no adnexal mass or free fluid in the pouch of Douglas, unless the CSP has ruptured. The thickness of the intervening myometrium between the gestation sac and the bladder has been shown to be less than 5 mm in two-thirds of the case Jurkovic et al have described a negative sliding organ sign, defined as inability to displace the gestational sac from its position at the level of the internal os by gentle pressure applied by the transabdominal probe, as diagnostic Additional diagnostic information can be obtained by colour flow Doppler to show distinct circular peritrophoblastic perfusion surrounding the gestation sac. Treatment No consensus on the preferred mode of treatment. Generally, termination of pregnancy (TOP) in the first trimester is strongly recommended, as there is a high risk of subsequent uterine rupture, massive bleeding and life-threatening complications Treatment objectives should be to perform feticide prior to rupture, to remove the gestation sac and to retain patient s future fertility. Conservative medical treatment is appropriate for a woman who is pain free and haemodynamically stable with an unruptured CSP of <8 weeks of gestation and a myometrial thickness < 2 mm between the CSP and the bladder All women considered suitable for MTX treatment(dose of 50 mg/m 2 )should have prior baseline full blood count and liver and renal function tests performed. They must be agreeable to surgery if medical treatment fails or if the CSP rupture 1) Medical treatment combined with surgical sac aspiration Various sequences of combination have been described: local potassium chloride TVS-guided sac aspiration local MTX injection intramuscular MTX injection systemic MTX TVS-guided sac aspiration sac aspiration (transvaginal or transabdominal) local MTX injection sac aspiration under ultrasound guidance systemic MTX \systemic MTX sac aspiration by vaginal route local MTX A supportive, secondary, salvage treatment, e.g. hysteroscopic or laparoscopic resection of the CSP under direct vision, has been indicated in some cases. 2) Hysteroscopic evacuation 3) Operative laparoscopy Operative laparoscopy should be performed only after a prior TVS confirms the diagnosis. Laparoscopic findings as described above must corroborate with the features of a CSP. The CSP mass is incised and the pregnancy tissue removed in an endobag 4) Laparotomy Laparotomy followed by wedge resection of the lesion (hysterotomy) should be considered in women who do not respond to conservative medical and/or surgical treatments, present too late or if facilities and expertise for operative endoscopy are not available. Laparotomy is mandatory when uterine rupture is confirmed or strongly suspected. This conventional low-tech surgery, which is available in all hospitals, has the advantage of complete removal of the CSP and simultaneous repair of the scar, followed by a quick return of the β-hcg to normal level within 1 2 weeks. 5) Hysterectomy Follow-up of Therapy Most uterine scar pregnancies managed medically resolved within 3 9 months Continuation of cardiac activity or growth of the sac indicated failure. weekly [beta]-hcg measurements until undetected and monthly ultrasound evaluations until no products of conception are visualized Future Fertility Uneventful viable intrauterine pregnancies have been reported after all modalities of conservative management of a CSP 89

92 Screening and Diagnosis for Placenta Praevia/Accrete Dr Mamta Mishra, MD MRCOG Senior Consultant. Fortis Hospital, Vasant Kunj, Delhi Clinical suspicion should be raised in all women with vaginal bleeding after 20 weeks of gestation. A high presenting part, an abnormal lie and painless or provoked bleeding, irrespective of previousimaging results, are more suggestive of a low-lying placenta but may not be present, and the definitive diagnosis usually relies on ultrasound imaging. Routine ultrasound scanning at 20 weeks of gestation should include placental localisation. Transvaginal scans improve the accuracy of placental localisation and are safe, so the diagnosis of placenta praevia at 20 weeks of gestation by abdominal scan should be confirmed by transvaginal scan. All women require follow-up imaging if the placenta covers or overlaps the cervical os at 20 weeks of gestation. Women with a previous caesarean section require a higher index of suspicion as there are two problemsto exclude: placenta praevia and placenta accreta. If the placenta lies anteriorly and reaches the cervical os at 20 weeks, a followup scan can help identify if it is implanted into the caesarean section scar. Women who bleed should be managed individually according to their needs. In cases of asymptomatic women with suspected minor praevia, follow-up imaging can be left until 36 weeks of gestation. In cases with asymptomatic suspected major placenta praevia or a question of placenta accrete,imaging should be performed at around 32 weeks of gestation to clarify the diagnosis and allowplanning for third-trimester management, further imaging and delivery Women who have had a previous caesarean section who also have either placenta praevia or an anteriorplacenta underlying the old caesarean section scar at 32 weeks of gestation are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparations for surgery made. Antenatal sonographic imaging can be complemented by magnetic resonance imaging in equivocal cases to distinguish those women at special risk of placenta accreta. Ultrasound criteria for diagnosis are as follows: Greyscale: loss of the retroplacental sonolucent zone irregular retroplacental sonolucent zone thinning or disruption of the hyperechoic serosa bladder interface presence of focal exophytic masses invading the urinary bladder abnormal placental lacunae. Colour Doppler: diffuse or focal lacunar flow vascular lakes with turbulent flow (peak systolic velocity over 15 cm/s) hypervascularity of serosa bladder interface markedly dilated vessels over peripheral subplacental zone. Three-dimensional power Doppler: numerous coherent vessels involving the whole uterine serosa bladder junction (basal view) hypervascularity (lateral view) inseparable cotyledonal and intervillous circulations, chaotic branching, detour vessels (lateral view). The main MRI features of placenta accreta include: uterine bulging heterogeneous signal intensity within the placenta dark intraplacental bands on T2-weighted imaging Elective delivery by caesarean section in asymptomatic women is not recommended before 38 weeks of gestation for placenta praevia, or before weeks of gestation for suspected placenta accreta. Interventional radiology can be life saving for the treatment of massive postpartum haemorrhage, and therefore having this facility available locally is desirable. If a woman is suspected of having placenta accreta and she refuses donor blood, it is recommended that she be transferred to a unit with an interventional radiology service. Management of patients with diagnosed or suspected placenta accreta Multidisciplinary approach. The timing of delivery must be individualized; Timing of delivery in cases of placenta accreta is controversial and depends on specific clinical circumstances and the extent of placental invasion Patient counseling should include discussion of the potential for hysterectomy, risks of profuse bleeding, and possible maternal death. A planned delivery is optimal but a plan for emergency delivery should also be created for each patient The use of antenatal corticosteroids if preterm delivery is likely should be individualized. Any delivery should be performed in a facility with an operating room with the personnel and support services required to handle the potential complications. Use of pneumatic compression stockings, prophylactic antibiotics, preoperative cystoscopy, and availability of a blood bank capable of supporting care in patients with massive hemorrhage should be considered. Planned preterm cesarean hysterectomy with the placenta left in situ is the recommended surgical approach unless the woman wants to maintain future fertility. In that case, an approach that includes ligating the cord close to the fetal surface, removing the cord, and leaving the placenta in situ is possible. However, the patient must be hemodynamically stable, have normal coagulation status, and be willing to accept the risks inherent in this approach. If excessive bleeding occurs, hysterectomy should be performed. Use of balloon catheter occlusion or embolization to reduce blood loss and improve outcomes does not yet have sufficient evidence to allow a recommendation as to the advisability of its use. No convincing data are available for the use of methotrexate to hasten placental absorption in the postpartum management of placenta accreta. If the diagnosis of placenta accreta is unsuspected before delivery but is suspected after vaginal delivery, options for management include intrauterine balloon tamponade, selective pelvic embolization, and emergency surgery. 90

93 Session 7 Oncology Multidisciplinary Update 91

94 Oncology Multidisciplinary Update Moderators Dr Saritha Shamsunder Consultant Dept. of Obs & Gynae Safdarjung Hospital New Delhi Dr Pakhee Aggarwal Consultant Obs & Gynae Fortis Hospital New Delhi Panelists Dr Ramesh Sarin (Surgical Oncology) Sr Consultant Surgical Oncology Indraprastha Apollo Hospitals, New Delhi Dr Harsh Dua (Medical Oncology) Consultant Medical Oncology, Indraprastha Apollo Hospitals, New Delhi Dr Ashok Khurana (Ultrasound) Consultant Ultrasound, Defence Colony New Delhi Dr Nandini Vasdev (Pathology) Consultant Pathology Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, New Delhi Case - I A 30 year old lady coming with a cervical screening report-hpv positive Discussion issues and learning objectives Role of HPV testing for Cervical Cancer Screening What does a positive HPV test result mean? Step wise approach Case - II A 25 year old lady with a solid ovarian mass Discussion issues and learning objectives D/D of an adnexal mass in a young patient Working up a patient with a solid adnexal mass Surgical staging-new FIGO guidelines Fertility issues in surgery & subsequent therapy Case - III A 32 year old lady with a breast lump detected at 10 weeks of pregnancy Discussion issues and learning objectives Differential diagnosis of a breast lump in pregnancy Management of a patient with a breast lump Role of surgery, chemotherapy in pregnancy Dr Manu Noatay (Cytopathology) manu@ntlabs.in Laboratory Director and Principal Consultant, Niche Theranostics New Delhi Dr Urvashi P Jha urvashipjha@yahoo.com, urvashipjhaclinic@gmail.com HOD Department of Minimal & Natural Access Gynae and Gynae Cancer Surgery, Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, New Delhi Dr Shakti Bhan Khanna sbkhanna@yahoo.com Sr Consultant Deprt. Of Obs & Gynae Indraprastha Apollo Hospitals, New Delhi Dr Vijay Zutshi drvzutshi@gmail.com Prof. & HOD Deprt. Of Obs & Gynae GTB Hospital New Delhi Successful people see alternatives and are willing to try different ways. People who only see failure are unable to see another way and give up to easily. -Catherine Pulsifer 92

95 Management of HPV Positive Women (ASCCP Guidelines) Dr Saritha Shamsunder, MD FRCOG Consultant Dept. of Obs & Gynae Safdarjung Hospital New Delhi Dr Pakhee Aggarwal, MD MRCOG Consultant Obs & Gynae Fortis Hospital, New Delhi If you don t accept failure as a possibility, you don t set high goals, you don t branch out, you don t try - you don t take the risk. -Rosalynn Carter 93

96 Revised Figo Ovarian Cancer Staging (effective 1 st jan 2014) Dr Saritha Shamsunder, MD FRCOG Consultant Dept. of Obs & Gynae Safdarjung Hospital New Delhi shamsundersaritha@gmail.com Dr Pakhee Aggarwal, MD MRCOG Consultant Obs & Gynae Fortis Hospital New Delhi pakh_ag@yahoo.com IA IB IC STAGE I: Tumor confined to ovaries OLD NEW IA Tumor limited to 1 ovary, capsule intact, no tumor on surface, negative washings/ascites. Tumor involves both IB ovaries otherwise like IA. Tumor involves 1 or both IC ovaries with any of the following: capsule rupture, IC1 tumor on surface, positive washings/ascites. IC2 IC3 Tumor limited to 1 ovary, capsule intact, no tumor on surface, negative washings. Tumor involves both ovaries otherwise like IA. Tumor limited to 1 or both ovaries Surgical spill Capsule rupture before surgery or tumor on ovarian surface. Malignant cells in the ascites or peritoneal STAGE II: Tumor involves 1 or both ovaries with pelvic extension (below the pelvic brim) or primary peritoneal cancer OLD NEW IIA Extension and/or implant on uterus and/or Fallopian tubes IIA IIB IIC Extension to other pelvic intraperitoneal tissues IIA or IIB with positive washings/ascites. IIB Extension to other pelvic intraperitoneal tissues STAGE III: Tumor involves 1 or both ovaries with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes OLD NEW IIIA Microscopic metastasis beyond the pelvis. IIIA1 IIIA (Positive retroperitoneal lymph nodes and /or microscopic metastasis beyond the pelvis) Positive retroperitoneal lymph nodes only IIIA1(i) Metastasis 10 mm IIIA1(ii) Metastasis > 10 mm IIIB IIIC Macroscopic, extrapelvic, peritoneal metastasis 2 cm in greatest dimension. Macroscopic, extrapelvic, peritoneal metastasis > 2 cm in greatest dimension and/or regional lymph node metastasis. IIIA2 IIIB IIIC Microscopic, extrapelvic (above the brim) peritoneal involvement ± Macroscopic, extrapelvic, peritoneal metastasis 2 cm ± positive retroperitoneal lymph nodes. Includes Macroscopic, extrapelvic, peritoneal metastasis > 2 cm ± positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen. STAGE IV: Distant metastasis excluding peritoneal metastasis OLD NEW IV Distant metastasis IVA Pleural effusion with excluding positive cytology peritoneal metastasis. IVB Hepatic and/or splenic Includes hepatic parenchymal parenchymal metastasis. metastasis, metastasis to extra- abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity) **Old stage IIC has been eliminated** changes in italics Other major recommendations are as follows: Histologic type including grading should be designated at staging Primary site (ovary, Fallopian tube or peritoneum) should be designated where possible Tumors that may otherwise qualify for stage I but involved with dense adhesions justify upgrading to stage II if tumor cells are histologically proven to be present in the adhesions 94

97 RCOG Guidelines on Breast Cancer in Pregnancy Dr Saritha Shamsunder, MD FRCOG Consultant Dept. of Obs & Gynae, Safdarjung Hospital, New Delhi Dr Pakhee Aggarwal, MD MRCOG Consultant Obs & Gynae Fortis Hospital New Delhi Women presenting with a breast lump during pregnancy should be referred to abreast specialist team and any imaging or further tests should be conducted in conjunction with the multidisciplinary team Bone scanning and pelvic X-ray computed tomography are not recommended because of the possible effect of irradiation on the fetus The decision to continue the pregnancy should be based on careful discussion of the cancer prognosis, treatment and future fertility with the woman and her partner and multidisciplinary team The multidisciplinary team review outcome should be forwarded to the obstetric team and family doctor Tamoxifen and trastuzumab are contraindicated in pregnancy and should not be used The birth of the baby should be timed after discussion with the woman and the multidisciplinary team. Women should not breastfeed when taking trastuzumab (Herceptin, Roche) or tamoxifen, as it is unknown whether these drugs are transmitted in breast milk Non-hormonal contraceptive methods are recommended Women planning a pregnancy after treatment for breast cancer should consult their clinical oncologist, breast surgeon and obstetrician Women can be reassured that long-term survival after breast cancer is not adversely affected by pregnancy. Advice on postponement of pregnancy should be individualised and based on treatment needs and prognosis over time. Most women should wait at least 2 years after treatment, which is when the risk of cancer recurrence is highest Women can be reassured concerning the risk of malformation in children conceived after treatment for breast cancer Pregnancy following breast cancer should be jointly supervised by the obstetrician, oncologist and breast surgeon. Echocardiography should be performed in pregnancy Women can be reassured that they can breastfeed from the unaffected breast There are insufficient level 1 data to support the routine use of GnRH analogues for ovarian protection in estrogen receptor positive breast cancer Ovarian stimulation for egg or embryo freezing requires careful discussion in light of unknown long-term risks. Modified stimulation regimes should be considered for women with estrogen-sensitive breast cancer There are insufficient data to support ovarian tissue storage for fertility preservation in women with breast cancer; this should be offered only in the context of a research trial. Every breast oncology service should have a designated pathway for prompt referral to a fertility specialist able to offer assisted conception; service provision should not be dependent on local in vitro fertilistion funding arrangements. The only limit to our realization of tomorrow will be our doubts of today; Let us move forward with strong and active faith. -Franklin D. Roosevelt 95

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99 Session 8 Pregnancy with Gastrointestinal/ Hepatic disorders 97

100 Pregnancy with Gastrointestinal/ Hepatic Disorders Moderators Dr Asmita Rathore Professor, Dept. of Obs & Gynae MAMC, New Delhi Dr Mamta Dagar Consultant Deprtment of Obs & Gynae, Sir Ganga Ram Hospital New Delhi Panelists Dr Arun Prasad (General, Laparoscopy & Robotic Surgery) Senior Consultant General, Laparoscopy & Robotic Surgery, Indraprastha Apollo Hospitals, New Delhi Dr Nitin Ghonge (Radiology) Consultant Radiologist, Indraprastha Apollo Hospital, New Delhi-76 Dr Sanjay Sikka (Gastroenterology) Sr Consultant Gastroenterology Indraprastha Apollo Hospitals Delhi Dr Ajay Kumar (Gastroenterology) Senior Consultant Gastroenterology Indraprastha Apollo Hospitals, New Delhi Dr Jayasree Sundar Senior Consultant Obs & Gynae, Max Superspeciality Hospital Saket New Delhi Dr Neema Sharma Consultant Department of Minimal & Natural Access Gynae and Gynae Cancer Surgery, Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, New Delhi Dr Ramandeep Kaur Consultant Department of Minimal & Natural Access Gynae and Gynae Cancer Surgery, Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, New Delhi Case - I A primigravida with 8 weeks intrauterine singleton pregnancy presents with c/o severe nausea, loss of appetite and vomiting 7-8 times a day Discussion issues and learning objectives Effective and safe management of nausea and vomiting of Pregnancy (NVP) Hyperemesis Gravidorum (HG) Pathophysiology and principles of management Case- II 33 year old primigravida attends at 35 weeks pregnancy c/o severe itching all over body for last one month, unable to sleep. SGOT 92 U/L, SGPT 232 U/L GGTP 90, ALP 722 (N ). Patient on Tab Ursocol 300mg tds. At 36 weeks Total Bile Acid 48.16μ mol/ l (N 0 to 10.0) Discussion issues and learning objectives Essential tests and differential diagnosis Management of Obstetric Cholestasis Maternal monitoring and drugs for symptomatic relief Fetal monitoring Total bile acid estimation (now available locally) Normal range, Limitations, significance. Alternative tests Induction of labour (IOL) Indications & timing Case - III 29 year primigravida at 26 weeks pregnancy attends emergency with severe pain abdomen and vomiting since last 2 days Discussion issues and learning objectives Non gyneacological causes of acute abdomen during pregnancy Safety of abdominal imaging tests during pregnancy GI Endoscopy during pregnancy Indications & principles of benefit-to-risk ratio Laparoscopic or open GI surgery during pregnancy Indications, safety and special precautions Case - IV 22 year unbooked G2 P1L1 admitted at 34 weeks with H/O fever last 7 days, jaundice, anorexia, irritability, malaise, vomiting, abdominal pain, bleeding PV 6 Hours. Diagnosed as acute fulminant viral Hepatitis E Discussion issues and learning objectives Differential diagnosis and management of Hepatitis E in Pregnancy Maternal and fetal risks and management 98

101 Safety of Gastro-Intestinal Imaging Studies During Pregnancy Dr. Nitin P. Ghonge, MD, DNB, FICR, FIMSA. Consultant Radiologist, Indraprastha Apollo Hospital, New Delhi Consultant to Chief Editor, Radiology [Radiological Society of North America] Associate Editor, British Journal of Radiology. ID: Amid imaging innovations, the antenatal care has certainly changed for the better in last few decades. Diagnostic imaging performed during pregnancy, involving the use of ionizing radiation (during radiography or CT or radionuclide studies), can be a source of great anxiety for both clinicians and patients. Ultrasound and MRI are safe during pregnancy and should always be first-line imaging options. However, no examination should be withheld when a critical clinical diagnosis is under consideration. Radiation exposure to a pregnant or potentially pregnant patient from diagnostic imaging and subsequent clinical management of such patients involves complex issues. Clinician-Radiologist interaction is certainly the key to effective and efficient use of imaging technology in these settings. It is important that the risk burden of radiation exposure to the fetus is carefully weighed against the benefits of obtaining a critical diagnosis using an imaging study in these circumstances. Stochastic effects are the result of cellular damage, causing cancer or germ cell mutation. The probability is considered to be directly proportional to radiation dose and is now believed to be independent of gestational age after first 4 weeks of gestation [1]. Non-stochastic effects (threshold effects or deterministic effects) are caused by exposure to radiation at high doses. These effects are predictable and involve multi-cellular injury, which can include chromosome aberrations. The average fetus is exposed to less than 50 mgy (5 rad) from a single study. The theoretical risks are not likely at doses less than 100 mgy [2,3]. It is still a good practice to adopt the 10 days rule, whereby all forms of nonemergency diagnostic medical exposure to a female in her reproductive period should be confined to the ten days following the first day of last menstrual period, on the assumption that ovulation occurs at mid-cycle. With inadvertent radiographic exposure, the overall risk to fetus and the on-going pregnancy depends on several issues including the exact gestation age and type of radiographic examination. It is advisable to consult a Radiologist in such circumstances to decide the further course of management. If the risk-benefit analysis is favourable and diagnostic imaging study involving an ionising radiation is required for a pregnant patient, it should be performed in consultation with Radiologist. The ALARA (as low as reasonably achievable) principle must be followed, during scanning. In general, there is lower than expected awareness of radiation risks to the fetus and the imaging algorithm to be followed in these patients. It is important to understand the basic radiation principles, radiation risks and diagnostic imaging protocols during pregnancy. Accordingly, American College of Obstetrics and Gynecology (ACOG) suggested the following guidelines related to diagnostic imaging during pregnancy [4]: 1. X-ray exposure from a single diagnostic procedure does not result in harmful fetal effects. Specifically, exposure to less than 5 rad has not been associated with an increase in fetal anomalies or pregnancy loss. 2. Concern about possible effects of high-dose ionizing radiation exposure should not prevent medically indicated diagnostic X-ray procedures from being performed on a pregnant woman. 3. Ultrasound and MRI are not associated with known adverse fetal effects. 4. Consultation with an expert in dosimetry calculation may be helpful in calculating estimated fetal dose when multiple diagnostic X-rays are performed on a pregnant patient. 5. The use of radioactive isotopes of iodine is contraindicated for therapeutic use during pregnancy. 6. Radiopaque and paramagnetic contrast agents are unlikely to cause harm and may be of diagnostic benefit, but these agents should be used during pregnancy only if the potential benefit justifies the potential risk to fetus. As far as possible, imaging during pregnancy are performed without any use of oral or intravenous contrast. Oral contrast agents are however, considered to be safe and barium is also recommended as a measure of internal shielding. Iodinated contrast media and gadoliniumbased contrast agents are known to cross the placenta with clinical use but have not shown any adverse effects over the fetus [5]. It is not uncommon to encounter a patient presenting with acute abdomen during pregnancy in routine obstetric practice. Appendicitis is the most common cause of surgical abdomen in pregnancy. Bowel obstruction or acute inflammatory bowel disease may manifest during pregnancy. Apart from gastro-intestinal causes, diseases of gall bladder, liver, pancreas, urinary tract and ovarian origin may also manifest during pregnancy and need to be diagnosed and managed. Flowcharts The following flowcharts are suggested, when the 99

102 pregnant patients with acute abdomen need imaging studies to establish the diagnosis [5,6]. Figure 1. Recommended algorithm for imaging evaluation of patient with acute abdomen during pregnancy. Figure 2. Recommended algorithm for imaging evaluation of patient with acute abdomen during pregnancy, when acute appendicitis is mainly suspected. References: 1. Protection of Pregnant patients during diagnostic medical exposures to ionizing radiation. Advice from health protection agency, The Royal College of Radiologist (RCR) and the College of Radiographers, RCE 9, March American College of Radiology. ACR practice guideline for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. Reston, Va: American College of Radiology, Streffer C; International Commission on Radiation Protection. The ICRP 2007 recommendations. Radiat Prot Dosimetry 2007;127(1-4): American College of Obstetrician and Gynecology guidelines; Committee opinion, no. 529, July Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. RadioGraphics 2007;27(6): Imaging in Pregnant Patients: Examination appropriateness. Wieseler KM, Bhargava P; Kanal KM, Vaidya S, Stewart Management is efficiency in climbing the ladder of success; leadership determines whether the ladder is leaning against the right wall. -Stephen Covey 100

103 Nausea and Vomiting in Pregnancy (Nvp) Dr Asmita Rathore, MD FRCOG Professor, Dept. of Obs & Gynae MAMC, New Delhi Dr Mamta Dagar, MD MRCOG Consultant, Deprtment of Obs & Gynae, Sir Ganga Ram Hospital New Delhi Severe NVP affects approximately 30% of pregnant women while hyperemises gravidarum (HG), the extreme spectrum of NVP, occurs in % of pregnancies. Pathogenesis: The pathogenesis of NVP is unknown. The predominant factors include. Psychologic factors Hormonal changes: elevated serum HCG, estrogen, progesterone - no consistent relationship documented Abnormal gastrointestinal motility Helicobacter pylori infection Other specific nutritional deficiencies, alternation in lipid levels, changes in autonomic nervous system, associated genetic factors, immunologic dysregulation. Principles of management A step-wise approach to treatment of nausea and vomiting of pregnancy is provided in the algorithm 1. The steps are based on evidence of efficacy and safety profiles. The goal is to reduce symptoms through changes in diet/ environment and by medication, correct consequences or complications of nausea and vomiting, and minimize the fetal effects of maternal nausea and vomiting and its treatment. 101

104 Recommendations Major Recommendations (Level A): Taking a multivitamin at the time of conception may decrease the severity of nausea and vomiting of pregnancy. Treatment of nausea and vomiting of pregnancy with vitamin B6 or vitamin B6 plus doxylamine is safe and effective and should be considered first-line pharmacotherapy. In patients with hyperemesis gravidarum who also have suppressed thyroid-stimulating hormone levels, treatment of hyperthyroidism should not be undertaken without evidence of intrinsic thyroid disease (including goiter and/or thyroid autoantibodies). (Level B): Treatment of nausea and vomiting of pregnancy with ginger has shown beneficial effects and can be considered as a nonpharmacologic option. In refractory cases of nausea and vomiting of pregnancy, the following medications have been shown to be safe and efficacious in pregnancy: antihistamine H1 receptor blockers, phenothiazines, and benzamides. Early treatment of nausea and vomiting of pregnancy is recommended to prevent progression to hyperemesis gravidarum. Treatment of severe nausea and vomiting of pregnancy or hyperemesis gravidarum with methylprednisolone may be efficacious in refractory cases; however, the risk profile of methylprednisolone suggests it should be a treatment of last resort. (Level C): Intravenous hydration should be used for the patient who cannot tolerate oral liquids for a prolonged period or if clinical signs of dehydration are present. Correction of ketosis and vitamin deficiency should be strongly considered. Dextrose and vitamins, especially thiamine, should be included in the therapy when prolonged vomiting is present. Enteral or parenteral nutrition should be initiated for any patient who cannot maintain her weight because of vomiting. Potential Harms Phenothiazines identified as a possible cause of malformations. Doses of droperidol greater than 25 mg associated with a prolonged Q-T interval - fatal arrhythmia. An association between oral clefts and methylprednisolone use in the first trimester, teratogenic effect is weak. Because life-threatening complications of parenteral nutrition have been described, it is reasonable to attempt enteral tube feeding initially. For women who need longer-term support and who cannot tolerate enteral tube feedings, the use of total parenteral nutrition has been described for hyperemesis gravidarum. Source: American College of Obstetricians and Gynecologists (ACOG) 2004 Apr 13p. ACOG practice bulletin no 52 Between you and every goal that you wish to achieve, there is a series of obstacles, and the bigger the goal, the bigger the obstacles. Your decision to be, have and do something out of the ordinary entails facing difficulties and challenges that are out of the ordinary as well. Sometimes your greatest asset is simply your ability to stay with it longer than anyone else. Brian Tracy 102

105 Obstetric Cholestasis Dr Asmita Rathore, MD FRCOG Professor, Dept. of Obs & Gynae MAMC, New Delhi Dr Mamta Dagar, MD MRCOG Consultant, Deprtment of Obs & Gynae, Sir Ganga Ram Hospital New Delhi Obstetric cholestasis is multifactorial condition of pregnancy, affects 0.7% of pregnancies in multiethnic and % of women of Indo Asian origin. Obstetric cholestasis is diagnosed when otherwise unexplained pruritus occurs in pregnancy and abnormal liver function tests (LFTs) and/or raised bile acids occur in the pregnant woman and both resolve after delivery. Pruritus that involves the palms and soles of the feet is particularly suggestive. Pregnancy-specific reference ranges for LFTs should be used. Diagnosis Diagnosis of cholestasis in pregnancy is confirmed by: clinical features exclusion of other forms of liver disease or cholestasis laboratory findings Clinical features Pruritis without a rash itching is classically on the palms and soles of the feet, pruritis is worst at night, skin excoriations from scratching. malaise steatorrhea with fat malabsorption Jaundice - uncommon, but can occur in 10-15% of cases Exclude other causes Autoimmune hepatitis Hepatitis A,B, C or E Epstein Barr Cytomegalovirus Gall bladder disease Liver disease e.g. cirrhosis, acute fatty liver Early HELLP syndrome or preeclampsia Skin conditions e.g. eczema, pruritic eruption of pregnancy, scabies Laboratory tests Bile Acids levels greater than 10μmol/L common diagnostic marker Liver Function Tests (LFTs) Management of Obstetric Cholestasis Women with obstetric cholestasis should be booked in under consultant-led, team based care and give birth in a hospital unit. Obstetricians should be aware (and should advise women) that the incidence of premature birth, especially iatrogenic, is increased. Women should be advised of the increased likelihood of meconium passage in pregnancies affected by obstetric cholestasis. Once obstetric cholestasis is diagnosed, it is reasonable to measure LFTs weekly until delivery. Postnatally, LFTs should be deferred for at least 10 days. Poor outcome cannot currently be predicted by biochemical results and delivery decisions should not be based on results alone. No specific method of antenatal fetal monitoring for the prediction of fetal death can be recommended. Ultrasound and cardiotocography are not reliable methods for preventing fetal death in obstetric cholestasis. Continuous fetal monitoring in labour should be offered. Treatment There is no evidence that any specific treatment improves fetal or neonatal out comes. Topical emollients (Diprobase, Calamine lotion) Topical emollients are safe but their efficacy is unknown. Systemic treatment Systemic treatments aimed at relieving pruritus include colestyramine, a poorly tolerated bile acidchelating agent, which may improve pruritus in some women but may also exacerbate vitamin K deficiency (which has been associated with fetal intracranial haemorrhage). Antihistamines such as chlorphenamine may provide sedation but do not have a significant impact on pruritus. S-adenosyl methionine Insufficient evidence to demonstrate whether S-adenosylmethionine (SAMe) is effective for either control of maternal symptoms or for improving fetal outcome, and it is not recommended. Ursodeoxycholic acid Ursodeoxycholic acid (UDCA) improves pruritus and liver function in women with obstetric cholestasis. Women should be informed of the lack of robust data concerning protection against stillbirth and safety to the fetus or neonate. Dexamethasone Dexamethasone should not be first-line therapy for treatment of obstetric cholestasis, nor should it be used outside of a randomised controlled trial without a thorough consultation with the woman. 103

106 Role of vitamin K Women should be advised that where the prothrombin time is prolonged, the use of water-soluble vitamin K (menadiol sodium phosphate) in doses of 5 10 mg daily is indicated. Women should be advised that when prothrombin time is normal, water-soluble vitamin K (menadiol sodium phosphate) in low doses should be used only after careful counselling about the likely benefits but small theoretical risk. Bile acid estimation Normal range, Limitations, significance Fasting serum bile acid concentration 10 µ mol / L is most commonly used diagnostic test. Meconium passage may be more common in those with severe cholestasis (defined as bile acids over 40 micromoles/ litre) compared with mild cholestasis (bile acids under 20 micromoles/litre). Risk of meconium passage increases linearly with a 19.7% increase for each 10 micromoles/ litre increase in total bile acid concentration (P = 0.001). Fasting bile acid concentrations 10 micromoles/litre demonstrated that fetal compromise (preterm delivery, asphyxial events, meconium staining of amniotic fluid and membranes) increased by 1 2% for each additional micromole/litre of bile acid concentration; these rates increased significantly at bile acid levels 40 micromoles/ litre, which was defined as four times the upper limit of normal. Timing of delivery A discussion should take place with women regarding induction of labour after 37+0 weeks of gestation. Women should be informed of the increased risk of perinatal morbidity from early intervention (after 37+0 weeks of gestation). Women should be informed that the case for intervention (after 37+0 weeks of gestation) may be stronger in those with more severe biochemical abnormality (transaminases and bile acids). Women should be informed of the inability to predict stillbirth if the pregnancy continues. Source: RCOG,Green-top Guidelines No. 43, If you think you are beaten, you are. If you think you dare not, you don t. If you like to win but think you can t, It s almost a cinch you won t. If you think you ll lose, you re lost. For out in the world we find Success begins with a fellow s will. It s all in the state of mind. If you think you are out classed, you are. You ve got to think high to rise. You ve got to be sure of your-self before You can ever win the prize. Life s battles don t always go To the stronger or faster man. But sooner or later, the man who wins Is the man who thinks he can. The Victor by: C. W. Longenecker 104

107 Acute Pain Abdomen in Pregnancy Dr Asmita Rathore, MD FRCOG Professor, Dept. of Obs & Gynae MAMC, New Delhi Dr Mamta Dagar, MD MRCOG Consultant, Deprtment of Obs & Gynae, Sir Ganga Ram Hospital New Delhi Non pregnancy-related causes Pain in the upper abdomen Gastroesophageal reflux Gallbladder disease Acute hepatitis Pancreatic diseases Pneumonia Bowel obstruction Perforated ulcer Disorders of the spleen Hiatal hernia Rectus sheath hematoma Adrenal hemorrhage Pain in the lower abdomen Acute appendicitis Nephrolithiasis Inflammatory bowel disease Diverticulitis Diffuse abdominal pain or pain in variable locations Sickle cell crisis Trauma Gastroenteritis Mesenteric venous thrombosis Iliopsoas abscess Abdominal wall pain Abdominal wall hernia Hereditary angioedema Safety of abdominal imaging tests during pregnancy Ultrasound is the first-line modality for diagnostic imaging of the abdomen in pregnant women widely available, portable, nonionizing, diagnostic performance often adequate. When ultrasound findings are equivocal or uncertain, then the choice of the second-line modality depends on the differential diagnosis and should take into account availability, diagnostic performance, and fetal radiation exposure. When indicated, use of magnetic resonance (MR) imaging is preferable to computed tomography (CT) because it avoids ionizing radiation and, for diagnosis of many disorders, performs as well as, or better than, CT Ionizing radiation Almost all diagnostic radiological procedures are associated with exposures that are below the threshold for congenital malformations, growth restriction, or developmental delay. Chest and abdominal radiographs estimated fetal absorption per chest X-ray is <0.01 mgy (<0.001 rad); this dose is well below doses that have been associated with any short- or long-term adverse effects. The estimated fetal absorption for abdominal X-rays is 1 to 4.2 mgy (0.1 to 0.42 rad), which is also below doses that have been associated with short- or long-term adverse effects. GI Endoscopy during pregnancy Indications & principles of benefit-to-risk ratio Laparoscopy-Laparoscopy is sometimes indicated in the evaluation of acute pelvic or abdominal pain, especially when the diagnosis is not clear after less invasive evaluations and the differential diagnoses include potentially life-threatening or organ-threatening disorders. It is usually performed in the first, second, and early third trimester. Based on retrospective evaluation and survey data, laparoscopic surgery for evaluation of pelvic or abdominal pain in pregnancy appears to be as safe as laparotomy. When surgery is planned, the appropriate services (Obstetrics, General Surgery, Anesthesia, Pediatrics) should be consulted. Management of pregnant women undergoing surgery may require modifications to the general approach used in nonpregnant women. Benefits The benefits of laparoscopy during pregnancy are similar to those in nonpregnant patients: less postoperative pain, less postoperative ileus, reduction in adhesion formation, shorter hospital stay, and faster return to usual activities. There may also be specific benefits during pregnancyless uterine manipulation intraoperatively during laparoscopic procedures than during laparotomy, avoidance of a large abdominal scar while the uterus is enlarging results in a better cosmetic outcome and less postoperative discomfort (lower narcotic requirements, better respiratory effort). The laparoscopic approach may provide better exposure than laparotomy because of optical magnification, lighting, and other technical factors. Indication for laparotomy- Hemodynamic instability is a contraindication to using a laparoscopic approach. Laparotomy is often preferred to laparoscopy in the presence of a large solid ovarian mass on preoperative ultrasonography, and when the patient has had multiple prior surgeries and/or a history of adhesive disease Recommendations Laparoscopic surgery can be performed safely and 105

108 effectively in pregnant women. The procedure has been performed as late as 34 weeks of gestation, but the optimal time is the early second trimester. Pregnant women are placed in the left lateral recumbent position to minimize uterine compression of the vena cava and the aorta. Use of pneumatic compression devices for low-risk pregnant women undergoing short laparoscopic procedures for surgical problems, and low molecular weight heparin for procedures >45 minutes duration (Grade 2C) There is no evidence that open procedures are safer than blind procedures. Modification of port sides is necessary when the uterus is significantly enlarged. Intraabdominal pressure be maintained between 8 to 12 mm Hg and not exceed 15 mmhg (Grade 2C). Maintaining intra abdominal pressure at this level helps to avoid a decrease in placental blood flow. Keep the end-tidal carbon dioxide at 32 to 34 mmhg, as respiratory acidosis is unlikely at this level (Grade 2C). Source: Approach to abdominal pain and acute abdomen in pregnant women. UpToDate2014 Laparoscopic Surgery in Pregnancy. UpToDate A thing of beauty is a joy for ever: Its lovliness increases; it will never Pass into nothingness; but still will keep A bower quiet for us, and a sleep Full of sweet dreams, and health, and quiet breathing. Therefore, on every morrow, are we wreathing A flowery band to bind us to the earth, Spite of despondence, of the inhuman dearth Of noble natures, of the gloomy days, Of all the unhealthy and o er-darkn d ways Made for our searching: yes, in spite of all, Some shape of beauty moves away the pall From our dark spirits. Such the sun, the moon, Trees old and young, sprouting a shady boon For simple sheep; and such are daffodils With the green world they live in; and clear rills That for themselves a cooling covert make Gainst the hot season; the mid-forest brake, Rich with a sprinkling of fair musk-rose blooms: And such too is the grandeur of the dooms We have imagined for the mighty dead; An endless fountain of immortal drink, Pouring unto us from the heaven s brink. -John Keats 106

109 Hepatitis E in Pregnancy Dr Asmita Rathore, MD FRCOG Professor, Dept. of Obs & Gynae MAMC, New Delhi asmita.rathore@yahoo.com Dr Mamta Dagar, MD MRCOG Consultant, Deprtment of Obs & Gynae, Sir Ganga Ram Hospital New Delhi mamtadagar2004@yahoo.co.in Women in their third trimester of pregnancy are predisposed to severe clinical disease and may develop fulminant hepatitis with a case fatality as high as 20 %. Pregnant women with jaundice and acute viral hepatitis caused by HEV infection appear to have worse obstetric and fetal outcomes compared to pregnant women with jaundice and acute viral hepatitis due to other causes. Differential diagnosis Acute viral hepatitis HELLP Syndrome Acute fatty liver pregnancy Drug induced liver injury Maternal risks Encephalopathy Cerebral edema Renal failure Hypoglycemia Metabolic acidosis Sepsis Coagulopathy Fetal risks Spontaneous abortion, intrauterine death and preterm labour Vertical transmission and viral hepatitis in new born Management of Hepatitis E in Pregnancy Treatment remains supportive, as the disease appears to be self limiting in non immunocompromised patients. Treat complications of ALF Ribavirin have been used for severe acute hepatitis E with promising results Liver transplantation Efficacy of HEV vaccine in pregnant women has not been studied yet. There is at present no proof that immune globulin confers protection against hepatitis E. Source: Hepatitis E virus infection. UpToDate

110 Acknowledgement and sincere thanks Indraprastha Apollo Hospitals Delhi Sant Parmanand Hospital Delhi Noble Hospital Faridabad Merck Serono Pvt. Ltd. Jagsonpal Pharmaceuticals Abbott India Ltd Emcure Xennea Bharat Serum and Vaccinations Ltd. Roche Pharma Ltd Bayer Zydus pharma Akumentis healthcare Ltd- Elitis Division Pharmed 108

111 For the Use of a Registered Medical Practitioner or a Hospital or a Laboratory Only. With Best Compliments From For Healthy Pregnancy & Lactation Tablets Calcium Citrate 1000 mg, Vitamin D 200 IU, Magnesium 100 mg & Zinc 4 mg 3 In igh- emand Pregnancies Tablets Calcium Citrate 1000 mg, Vitamin D 500 IU, Magnesium 100 mg & Zinc 4 mg 3 Right from Preconception to Pregnancy and Through to Lactation Capsules Folic Acid 5 mg, Cyanocobalamin (Vit B12) 1 mcg & Docosahexaenoic Acid (DHA) 200 mg 109

112 110 Notes

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