Dear
Colleagues
Hello
Premature
rupture of membrane is one of the very important issue in
obstetrics, esp. when it is remote from term (PPROM).
Rupture of membrane takes away the shield for the fetus and
exposes it or vaginal flora and infection.
Infection
is the most clearly recognized and more widely studied cause
of preterm birth. Infection is responsible for between
20-40% of all cases of preterm birth, and this variation
depends on the criteria used for the diagnosis of infection.
The most rigorous criteria are positive cultures or
demonstration of bacterial fingerprints by polymerase chain
reaction in the amniotic fluid. The less stringent criterion
is the presence of leukocytic infiltration in the placenta.
The evidence demonstrating that intrauterine infection is a
cause of preterm birth is overwhelming and involves positive
cultures indicating bacterial colonization and invasion of
the chorioamnion, the amniotic fluid , and the fetus;
histological demonstration of infection in the placenta,
membranes and umbilical cord; and hematological and
biochemical findings consistent with infection..
Color
Doppler is one the finest tool in the assessment of growth
retarded fetus. Evaluation of systolic and diastolic blood
flow and their ratio in umbilical artery and the middle
cerebral artery gives us a great idea about the fetal
compromise and the risks.
There is a
topic on CA-125 by one of our colleague Dr.Sarika Sharma .I
welcome it .
Hope you
will enjoy the literature of this news letter, I eagerly
wait for the responses.
With warm
regards
Sincerely
yours
Dr.D’Pankar
Banerji
-
Identifying Chorioamnionitis
There are
mainly three criteria, which tell that there is infection
and there are chances of premature labor, or should we do
conservative treatment in cases of PROM.
-
WBC count
-
C-reactive protein estimation
-
Fetal biophysical profile, esp. fetal
breathing movements
Laboratory
and biophysical tests are widely used to predict the
development of infection in women with PPROM. A commonly
used test is the maternal leukocyte count (WBC) at the time
of admission to the hospital.WBC greater than 12,000/cmm had
a 67% sensitive the and 82 % positive predictive value for
the disgonsi of amniotic infections. But is confusing as
more than 12,000 WBC with neutophila may be normal, and
injection of steroids for fetal pulmonary maturity causes an
immediate increrase in WBC count.
A useful
blood test is the determination of C-Reactive Protein (CRP),
a substance that increases markedly in patients with
infection and inflammation. The upper limit of normal CRP
concentration during pregnancy is 0.9 mg/dl with no
variation due to gestational age. Women with acure
chorioamnionitis usually have CRP values above 3.0 or 4.0
mg/dl and women with subclinical infection or inflammation
exhibit values between 0.9 and 3.0 mg/dl. But the CRP has
some limitations too. CRP is highly specific for the
diagnosis of intrauterine infection, with CRP elevation
usually occurring 1-3 days before the development of
clinical signs. CRP concentration is not altered by
administration of steroids. CRP is much better predictor of
infection than the WBC. However it is prudent not to make
the diagnosis of chorioamnionitis infection on the basis of
CRP concentration alone by rather the diagnosis of acute
infection requires the presence of fever and diagnosis of
subclinical infection requires amniocentesis.
Fetal
biophysical activities help a lot to identify the presence
of intrauterine infection. The absence of fetal breathing
and gross body movements during a 30 minutes period of
observation was associated with chorioamnionitis in almost
100 % of the cases. When fetal breathing movements were
present for at least one episode lasting 30 or more seconds
during a 30 minutes periods the possibility of infection was
less than 5 %. First manifestations of the impending fetal
infection may be nonreactive NST and the absence of fetal
breathing movements. Even the efficacy of amniotic fluid
gram staining may be inferior to daily BPP in predicting the
development of amnionitis.
-
Relation ship between Systolic /Diastolic(s/d)
ratio of Umbilical artery and middle cerebral artery in
late pregnancy
-
UA Doppler indicates presence or
absence of placental resistance to the blood flow from the
fetus to the placenta and has a strong correlation with
the acid/base balance of the fetus.
-
Measurement of interest is UA s/d
ratio.
-
Simple rule to remember is that the UA
s/d ratio should be under 3.0 after 30 weeks of gestation.
-
Evidence supporting a role for UA
Doppler in surveillance of high risk pregnancy is robust.
-
Middle cerebral artery Doppler shows
minimal or absent diastolic flow showing high resistance
to flow.
-
During the initial stage of placental
insufficiency UA diastolic flow decreases and s/d ratio
increases while the compensatory increase of the brain
circulation causes increase in diastolic flow with
resulting decrease in the MCA S/D ratio.
-
When MCA s/d ratio decreases than the
UA s/d ratio then it is called brain sparing effect or
centralization of flow.
-
Centralization of the flow is not an
indicator of fetal hypoxemia or acidosis, but a
compensatory state of appreciable placental blood flow
resistance.
-
Fetal anemia can be measured by Peak
systolic blood flow in middle cerebral artery in Rh
negative sensitized pregnancy
3.Capsule on CA-125
Dr.Sarika
Sharma MS (ObGy)
-
CA 125 is a high molecular weight
surface glycoprotein
-
It is an antigenic determinant derived
from coelomic epithelium and mullerian duct
-
Its normal level is < 35 U / ml
-
Mainly used to differentiate between a
benign ovarian mass and a malignant epithelial ovarian
mass
-
It is elevated in 80% of patients with
epithelial ovarian cancers particularly non mucinous
tumours
-
But unfortunately, this antigen is also
detectable in a variety of benign conditions like fibroid,
endometriosis, pregnancy, pelvic inflammatory disease,
ectopic pregnancy, adenomyosis, ovarian cyst adenomas,
liver disease, pancreatitis, peritonitis, renal failure,
luteal phase of menstrual cycle and even in 1% of normal
individuals!
-
Serum CA 125 levels can be used during
chemotherapy to follow these patients whose level were
positive at the initiation of therapy. The change in level
correlates with response
-
the levels frequently become
undetectable after the initial surgical resection and one
or two cycles of chemotherapy
-
Positive levels are useful in
predicting the presence of disease, but negative levels
are an insensitive determinant of the absence of disease
-
The predictive value of the positive
test was 100% during follow up
-
But if the level was less than 35 U/ml
during follow up, 44% of patients had disease at 2nd look
surgery
-
If levels are persistently elevated
after 3 cycles of chemotherapy, they most likely have
resistant clones and if level rise after treatment, the
disease has comeback and the treatment has failed
4.
Fellowship course in Reproductive endocrinology and
Infertility
Program :
Day
1 :Theory : Basic
reproductive endocrinology of female, Understanding of
Hypothalamo-pituitary-gonadal axis
Practical : Microscopy,
stereozoom, trinocular, micro-photography and documentation
,inverted microscope and micromanipulator introduction
Day
2:Theory :
Introduction to cell biology and cell division and cell
culture, Meiosis and Gametogenesis, Culture media
preparation
Practical : Tissue culture
media preparation for IUI
Day
3:Theory
: Basic endocrinology of Male, Hormonal
control of Spermatogenesis
Practical : Routine semen
analysis, sperm preparation methods for IUI, hands on
Day
4 :Theory :
Anovulation and Polycystic ovaries ,Hirsutism
Practical : Preparation of
culture dishes and droplet making under oil
Day5 :Theory
: Amenorrhoea ,How to deal with it.
Practical : Hands-on retrieval
of mammalian eggs and their in vitro maturation
Day6 :Theory :
Induction of Ovulation for IUI and IVF
Practical : Observation and
demonstration of Cryo preservation techniques
-
Theory classes will be from 9.30am to
11.00am.
-
Candidates can repeat their practical,
if they wish
-
Candidates will be involved in daily
OPD infertility counseling and treatment approach from
11-4 . They will see and do transvaginal sonography (as
patients allow).
-
They will be allowed to observe IVF and
ICSI procedures done during their stay. They will have
access in embryology laboratory to see the lab set up and
equipments and exposure to embryology ( observation),
fertilization to blastocyst stage and embryo
transfer.*
-
Fees
: Rs .25,000 per candidate. Students** : Rs.15,000
-
One or Two candidates are allowed in
one batch
-
Course will be from Monday to Saturday
of a week.
-
Certificate of attendance will be given
at the end of the course
-
Prior registration is must with full
payment( demand draft in the name of Dr.D'Pankar
Banerji,payable at Jabalpur)
-
Stay and food is extra. Stay @ Rs.
500-1500/day can be arranged in nearby hotels within one
kilometer of the venue
Faculty :
1.
Dr.D'Pankar Banerji, Consulting Gynecologist and Infertility
specialist
2. Dr. Mrs.
Rinku Banerji ,Consulting Pathologist and Embryologist
Venue : Ideal
Fertility, ICSI,IVF and Genetic center, Jabalpur
*Depending
on the availability of cases.
**Student,
applies to undergraduate medical students and residents. A
letter from the Head of the Department proving the
participant’s student status must accompany each student
registration
Sale :
1. CO2
Incubator Minicellmate,GenX USA,6yrs old Rs. 1,00,000(
working condition)
2.
Logiq XP ,Color Doppler,2005 with three probes ( TV/TR,
Abdominal Sector,and Linear) in excellent condition at Rs.
7,00,000( owner going for 4-D machine)
