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Minimal Access Surgery

( Laparoscopic Surgery )

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Vaginal Aesthetics

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High Risk Obstetrics

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Pelvic Floor disorder &

Urogynecology

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Adolescent Gynaecology & Reproductive Health

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Maternal Critical care

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Gynaec Oncology

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Fertility issues

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Menopausal Health

Services Available

Minimal Access Surgery (MAS) is a modern surgical technique in which operations are performed via abdomen / tummy through small incisions (usually 0.5–1.5 cm). Minimal Access Surgery (MAS) is also known with various other names i.e. Laparoscopic surgery (Most common), Minimally Invasive surgery (MIS), Band-Aid surgery, or keyhole surgery.

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Minimal Access Surgery is performed with the use of sophisticated medical grade cameras, telescopes and surgical instruments. In another words, Minimal Access Surgery is an another way of performing surgery in which the surgical steps remain the same but it’s being performed with special instruments with least abdominal scars. With the use of specific telescopes and camera the anatomy of body organs is visualized with magnification. Magnified surgical field makes surgical steps easy.

What are the advantages of Minimal Access Surgery?

Laparoscopy has a number of advantages to the patient compared to the more common, open surgical procedure.

Smaller incisions: Incisions given for laparoscopic surgery are small (usually 0.5 cm – 1.5cm).

Lesser pain in post-operative period: Smaller incisions reduce pain after surgery.

Early Recovery: Lesser pain after surgery fastens the recovery process and faster return to everyday living.

Lesser Pain Medication: Reduced pain after surgery amount to lesser medication for pain after surgery.

Shorter hospital stays: Because of early ambulation and faster recovery average hospital stay remains 1 to 2 days for laparoscopic surgery (versus 5 to 7 days for open surgery).

Lesser wound infection and hernia formation: Smaller incisions decrease the risk of wound infection and chances of hernia formation.

Cosmetically acceptable: Smaller incisions result in less scarring and hence cosmetically acceptable scars.

Reduced chances of Infections: There is reduced exposure of internal organs to possible external contaminants which reduces the risk of acquiring infections.

Reduced hemorrhage: The amount of blood loss is lesser during laparoscopic surgeries which reduces the chance of needing a blood transfusion.

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What is the usual stay at hospital?

Usual stay at hospital varies from 24 hours to 2 days. Once planned for laparoscopic gynecologic surgical procedure it is advisable to stay in hospital one day prior to surgery. On this day a specific protocol of medicines and preparation for surgery is conducted. After surgery the sooner patient starts ambulation the sooner she gets discharge from the hospital.

 

What all diseases in Gynecology can be treated with Minimal Access Surgery?

AUB / DUB (Abnormal / Dysfunctional Uterine bleeding) which is not responding to medicinal treatment: Abnormal / Dysfunctional Uterine bleeding is due to abnormality in endometrium of uterus which usually responds to medicinal treatment. In cases where medicine is not able to control the symptoms, medicines are contra-indicated etc uterus, along with both fallopian tubes +/- ovaries, can be removed laparoscopically.

Fibroid Uterus: Uterine fibroids troubling in the form of abnormal bleeding, painful periods (dysmenorrhea), causing recurrent miscarriage / abortion, causing infertility etc. usually need surgical removal and can be removed laparoscopically.

Ovarian Cysts: Most of the ovarian cysts disappear spontaneously in 1-2 months after detection. Ovarian cysts which persist for long time, are suspicious of cancer, symptomatic can be removed laparoscopically.

Endometriosis: Endometriosis can present as ovarian endometrioma (Ovarian cyst or chocolate cyst), endometriosis implants in pelvis, Adhesions in pelvis involving uterus, fallopian tubes, ovaries, intestinal loops, rectum etc. All these entities can be treated laparoscopically.

Uterus Prolapse / Vault Prolapse / Pelvic Organ Prolapse: Uterus prolapse into vagina, vaginal vault prolapsing into vagina after hysterectomy can be treated with laparoscopic surgery.

Uterine cancer, Uterine cervix cancer: Cancers of uterus, uterine cervix, ovarian cancers after chemotherapy can be treated with laparoscopic surgery in which tumorous tissue can be removed with more precision.

Ectopic pregnancy: Extra uterine pregnancy e.g. pregnancy in fallopian tube (tubal pregnancy), pregnancy in ovaries (ovarian pregnancy), pregnancy in cervix (cervical pregnancy) can be treated with laparoscopic approach, as per the indications.

Ovarian Torsion: Due to numerous factors ovarian tissue twists around its own axis which leads to compromise in its blood supply ultimately leading to infarction of ovarian tissue. Laparoscopically ovaries can be untwisted and fixed to prevent further twisting.

Recurrent Miscarriage with incompetent cervix: With the incompetent cervix there are chances of recurrent miscarriage. Few cases of incompetent cervix need cerclage from abdomen which can be performed through laparoscopic approach.

Blocked fallopian tubes: Fallopian tubes might get blocked due to infections, adhesion or pressure from mass. In few cases there is requirement of tube opening in cases of tubal sterilization. All these fallopian tube blocks can be opened with laparoscopic surgery.

 

What Gynaecology Surgeries can be performed laparoscopically?

Total Laparoscopic Hysterectomy (commonly called as TLH): For the indications e.g. AUB / DUB, chronic cervicitis, chronic pelvic pain etc uterus along with both fallopian tubes or uteri along with both tubes and ovaries is removed with the procedure named

Laparoscopic Myomectomy: Fibroids in uterus can be removed laparoscopically. Fibroids troubling in the form of abnormal bleeding, painful periods (dysmenorrhea), causing recurrent miscarriage / abortion, causing infertility etc. usually need surgical removal.

Laparoscopic Ovarian Cystectomy: This procedure is meant for removing a symptomatic ovarian cyst. The normal ovarian tissue is preserved in this procedure.

Laparoscopic Oophorectomy: In cases of ovarian mass one or both of the ovaries are removed laparoscopically.

Laparoscopic Surgery for Endometriosis: In cases of endometriosis of ovaries, endometriosis implants in pelvis surgery can be performed to remove endometriosis.

Laparoscopic Procedures for Pelvic Organ Prolapse: Uterovaginal prolapse can be treated with laparoscopic surgery.

Laparoscopic Radical Hysterectomy with pelvic / para aortic lymph adenectomy: For cervical cancer and uterine cancer uterus surrounding tissues are also removed for proper clearance of cancerous tissue. This surgery is done for cervical cancer cases

Laparoscopic Salpingectomy: laparoscopically, Ectopic Pregnancy can be treated (surgically removed) from fallopian tube, ovary.

Laparoscopic surgery for ovarian torsion: Ovarian torsion occurs in enlarged ovary and most commonly in cases of ovarian dermoid cyst. This is an emergency and if not operated and normalized this can jeopardize the ovary.

Laparoscopic Cervical Cerclage: In cases of cervical incompetence when the vaginal cervical cerclage has failed in the previous pregnancy, Laparoscopic cervical cerclage is indicated. We prefer to do this surgery in the inter pregnancy period.

Laparoscopic Tuboplasty: In Cases of infertility with tubal pathology, block and adhesions, tuboplasty opens the fallopian tube and restores the anatomy.

Pelvic Floor medicine or Urogynaecology is a gynecology sub-specialty which deals with dysfunctions / diseases & their respective treatment for women pelvic floor.

What exactly is Pelvic Floor?

In women, inside the bony pelvis the muscles, ligaments, connective tissues and nerves that support the bladder, uterus, vagina and rectum constitutes the pelvic floor. The muscular content act as a hammock within the pelvic bone and physically supports the organs.

Are these problems serious?

Most women feel uncomfortable talking about personal problems pertaining to issues related to urinary difficulties, vaginal heaviness and symptoms such as incontinence. But these are actually very common medical problems that can be treated successfully. Millions of people have the same issues and they keep compromising their quality of life as they hesitate in seeking treatment for the same.

How do I know about pelvic floor disorder?

Pelvic floor disorders occur when the “sling” or “hammock” that supports the pelvic organs becomes weak or damaged.

The symptoms include:

Urinary problems, such as an urgent need to urinate, painful urination or incomplete emptying of their bladder

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Sense of heaviness / dragging sensation in the pelvis

Bulge in the vagina or rectum

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Feeling of mass coming out of vagina

Pain or pressure in the vagina or rectum

Constipation, straining or pain during bowel movements

Unexplained pain in the lower back, pelvis or rectum

Painful intercourse for women

How are pelvic floor disorders commonly treated?

Many women do not need specific treatment for their problems. Treatment is required when symptoms are bothersome, restrict a woman’s activities or disturbs her quality of life. In major percentage of cases women can be guided to take specific actions (which she can be trained to perform on self) to help reduce or ease symptoms.

Mainly two types of treatments are available for Pelvic floor disorders: 1. Nonsurgical treatment & 2. Surgical treatment

Nonsurgical treatments :

Pelvic floor muscle training: It is also called Kegel exercises. Pelvic floor muscle training involves squeezing and relaxing the pelvic floor muscles. If performed correctly and routinely it may improve the symptomatology.

Injections for problems with bladder control. “Bulking agents” can be injected near the bladder neck and urethra to make the tissues thicker and close the bladder opening. At times repeat injections are needed over time.

Medicine. Medicine is sometimes prescribed to treat certain bladder control problems, to prevent loose stools or frequent bowel movements.

Vaginal pessary. Vaginal pessary is a device made up of plastic, rubber or silicone. This device is used to treat some types of prolapse and improve bladder control in selected women. Pessary is inserted into the vagina to support the pelvic organs. The Urogynaecologist / gynaecologist secures the vaginal pessary according to requirement, shape and size assessed for the patient.

Surgical Treatment

In some cases, surgery is the best treatment option, especially when other treatments are not helpful. Some surgical treatments can be performed as outpatient procedures.

For prolapse. Surgery involves repairing and building back pelvic floor support. Women with uterine prolapse may also have the uterus removed (hysterectomy) in addition to pelvic floor muscle repair. Women who have surgery to repair prolapse often have surgery at the same time to prevent bladder control problems. Traditionally pelvic floor surgeries are conducted from vaginal approach. These surgeries can also be performed laparoscopically / with keyhole approach. There are various other surgical procedures which are performed according to age, associated medical co-morbidities and requirement of the patient problems.

For bladder control problems. Problems holding in urine that occur because of weakness of bladder neck and relative increase of pressure on the bladder (stress incontinence) can be treated with surgery.  Most commonly performed surgery is mid-urethral sling in which a mesh strap or “sling” is inserted to hold the bladder neck in its normal position. In other form of surgeries, the bladder neck is put back in its correct position by securing it to the vaginal wall and pelvic floor tissues.

For bowel control problems. Surgery may be needed to repair a damaged anal sphincter muscle or repair certain types of prolapse.

Combination Treatment

“Combination treatment” means a woman is getting treated for more than one type of pelvic floor disorder, such as a treatment for both uterine prolapse and urinary incontinence. Combination treatment is quite common as most of the pelvic disorders have associated problems. Usually the approach consists of different treatments together to address pelvic floor disorders, such as using  Pelvic floor muscle training and a surgical treatment to treat the symptoms.

Gynaec-Oncology is a sub-specialization dealing with female genital cancers / pre-cancerous states like cancer of cervix, cancer of uterus, cancer of ovaries, cancer of fallopian tube, cancer of trophoblastic tissues, cancer of vagina and external female genital.

How are cancers of gynecology treated?

Treatment of gynecologic cancer includes participation by three disciplines namely Gynaec-Oncosurgery, Medical Oncology and Radiation Oncology. Gynaec-oncosurgery contributes in removal of the cancerous tissue from the body. Medical oncology contributes in giving medicines (also called as Chemotherapy) for the cancerous tissue inside the body. Radiation oncology deals in irradiating the body parts (also called as Radiotherapy) where cancer tissue resides. Treatment approach towards any gynecology cancer is planned by Gynaec-oncosurgeon, Medical oncologist & Radiation oncologist. These three modalities i.e. Oncosurgery, Chemotherapy and Radiotherapy complement each other for complete cure of cancer. During cancer treatment, mostly, oncosurgery is followed by chemotherapy or radiotherapy or both (combination of chemotherapy & radiotherapy). Depending on location of cancer, type of cancer, extent of cancer these modalities are followed by others in various combination.

Current status of successful treatment of Gynaec cancers?

With the advent of development of diagnostic tests and modalities, newer chemotherapy medicines, radiotherapy techniques and surgical instruments the prognosis has improved over past decades. Most importantly “the participation of patients” themselves, in terms of being aware of alarming signs for the cancer.

How do I know if I have cancer in my reproductive organs?

There are early indicators which give suspicion of / early indication of harboring cancer in body

Suspected Uterine or Endometrial cancer

Bleeding in a woman who has gone through menopause

Irregular vaginal bleeding in a woman before menopause

Suspected Ovarian Cancer

The initial symptoms of ovarian cancer are common complaints of women. This is why it may not be detected early. These symptoms include:

Bleeding in a woman who has gone through menopause

Irregular vaginal bleeding in a woman before menopause

Changes in your normal bowel or bladder patterns

Suspected Cervical Cancer

Abnormal bleeding between periods

Bleeding after sexual intercourse

Vaginal discharge that has a foul smell, unusual color, or is more than usual

Suspected Vulvar Cancer

The most common symptom of vulvar cancer is itching of the vulva.

Vulvar burning, pain, or other discomfort

A sore on the vulva

Changes in skin color

How diagnosis of Cancer is confirmed?

Definite diagnosis of cancer is made by examining the suspected cancer tissue under microscopy (Histopathology) & performing specific cancer tests on that tissue. For suspected uterine / endometrial cancer, tissue is obtained from uterine cavity with an instrument on daycare / OPD basis. For suspected cervical cancer a piece of cervix is obtained in the form of biopsy which is mostly performed on daycare / OPD basis. Similarly, suspected area on vulvar region is biopsied on daycare / OPD basis. In cases of suspected ovarian cancer, the diagnosis is made ‘provisionally’ which is supported by blood tests (CA 125 etc) along with imaging of pelvic organs by either Ultrasound, CT Scan or MRI.

Vaginal Aesthetics sub specialty Also known as female genital plastic surgery or aesthetic vaginal surgery deals with cosmetic surgery of private parts of a female. Invariably it includes hymenoplasty, labiaplasty, vaginoplasty etc. It includes various other procedures as well. The vaginal canal, mucous membrane and the vulvo-vagina structure is repaired with the help of Vaginal Rejuvenation Surgery, also known as Vaginoplasty.

Why Important?

Vaginal Aesthetics is a perspective of health as well as image – it’s about confidence, more fulfilling sex, improved self-esteem.

Aesthetic vaginal treatments can help restore their self-esteem and confidence and assist them in recreating sexual excitement and rejuvenation of their love lives.

Who is it for?

Women who are not fully satisfied with how their intimate area looks (e.g. large labia or shape of their labia)

Women who experienced childbirth and have lax vagina

Women who want more fulfilling sex life

Women who have distorted genitalia since birth (congenital) or damaged in later life by diseases or injuries.

Women who desire re contouring after significant weight loss, aging or injury to genital structures

What all problems can be treated with Aesthetic Vaginal Surgeries?

There are multiple abnormalities of female genital area which need surgical treatment :

Torn Hymen: The hymen is a small mucosal fold that partially covers the entrance of the vagina. Though it does not entirely cover the opening due to common incidences e.g. after child birth, pelvic exercises, masturbation, trauma etc. it gets torn along its circumference. Torn hymen can be repaired with a procedure named as Hymenoplasty.

 Abnormal shaped Labia Majora or outer vaginal lips / Labia Minora / inner vaginal lips:Larger folds of skin that are present on both sides of vaginal opening are called as labia Majora or outer vaginal lips. External genital structures which are closest to the vaginal opening just inside the larger labia majora structures that surround and protect the vaginal and urethral openings, are called as labia minora or Vaginal inner lips.  In some cases, labia majora become hypertrophic because of childbirth and/or weight gain. Similarly, labia minora / vaginal inner lips develop an abnormal morphology or abnormal appearance e.g. the large protuberant appearance, asymmetrical (different size or shape from each other), thickening, developing dark edges, or large in size etc. The change in size (increase, hypertrophy) of labia minora can result in constant irritation in tight wears. Also changes in shape and appearance may cause embarrassment with a sexual partner. Surgery for these issue can greatly improve the aesthetic appearance and function of abnormally enlarged labia. This surgery of labia (majora or minora) reduction is called as Labiaplasty.

Clitoral hood abnormalities: —Clitoris is a small, knob like, structure composed of erectile tissues located at the apex of the labia majora, superior to the urethra. It is covered by the prepuce tissue—the surrounding “hood” that sheaths the clitoral node on three sides. The clitoris is one of the structures that are important for female sexual response & orgasm. Some women have thickened skin over the clitoris. This can interfere with stimulation and decrease sensitivity. The surgery for removing the hood surgically is called as Un-hooding of the Clitoris or Clitoral Unhooding . After surgery woman may enjoy greater and more intense stimulation often leading to more intense orgasms. In few women, the lateral clitoral hood merges with enlarged labia minora. In those cases, in order to get a truly improved aesthetic result, reduction of this lateral clitoral hood is done surgically which is called as Lateral clitoral hood reduction.

 Dyspareunia—Commonly defined as pain in the pelvic region of women, the vagina or labial structures, during or after sexual encounters. The causes can be infection, inadequate vaginal lubrication, atrophy of vaginal mucosa caused by rejection of surgical mesh, and others.

 Decreased orgasm

Adolescent gynaecology sub specialty specifically deals with gynecologic health problems encountered during the phase of “Adolescence” i.e.  is a transitional stage of physical and psychological development that generally occurs during the period from puberty to legal adulthood.  

Reproductive health implies that people are able to have a responsible, satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.

What is adolescence period / adolescent age?

Adolescence is the period of physical psychological and social maturation from childhood to an adult. The term adolescent refers to individuals between the age of 10-19 years which make up about 1/5th of Indian population.

adolescence can be defined biologically, as the physical transition marked by the onset of puberty and the termination of physical growth; cognitively, as changes in the ability to think abstractly and multi-dimensionally; or socially, as a period of preparation for adult roles.

Why gynaecologic problems in adolescent age are important?

Gynecological problems of adolescents occupy a special space in the spectrum of gynecological disorders of all ages. In this age physical nature of problems is unique; and emotional and psychological factors are also associated. The gynaecological problems in adolescence are different from that of adults and these conditions may be caused by other disease conditions or hormonal imbalance.

What are the common problems during adolescent age?

Most commonly faced problems during this age group are:

  • Menstrual irregularities: Heavy periods / Painful periods / No periods
  • Sex and sexuality:
  • Pregnancy:
  • Sexually transmitted infections: They are also at increased risk of STDs including HIV and Hep B,C because of unprotected sexual practices. So, awareness about STDs is essential as it can later on cause pelvic inflammatory disease (PID) and infertility in girls.
  • Cervical cancer (HPV) vaccinations
  • Irregular breast development
  • Genital anomalies
  • Sports effects on the reproductive system

What an adolescent should know during this age?

Adolescents complete their physical psychological and emotional journey to adulthood in a world that contains both opportunities and dangers. By educating and helping adolescents to break the myths can solve the problems.

• Sex education is important during adolescent period. Knowledge of contraceptives to avoid teenage pregnancies is very important. Adolescents are at risk of early and unwanted pregnancy because of poor understanding of their sexuality and sometimes the only information sources available to them are media and peers. They are not aware of contraceptive measures and teenage pregnancy results in increased morbidity and mortality.

• Genital & perineal hygiene is important. In this age group it is a healthy practice to learn genital and hygiene.

• Knowledge of menstrual cycles and management of self during periods. An adolescent girl should learn how to manage hygiene during periods and managing heavy flow or pain during periods.

• Adequate nutritional health is important during adolescent period to prevent future health problems like anemia, osteoporosis. Balanced diet containing adequate amount of milk and leafy vegetables should be given to the teenagers to avoid nutritional deficiencies.

• Outdoor sports and exercise is important for adolescent to maintain a healthy lifestyle. Exercise and physical activity increase self-esteem and confidence and also decrease anxiety and stress

• Lots of emotional changes occur during this period like mood changes (irresponsibility, stubbornness) attraction to opposite sex and search for identity etc. Adolescents need to learn how to adjust and learn to deal with these.

• Vaccination of teenage girls against Rubella, cancer cervix (Gardasil, Cervarix) is advised. Hepatitis B, Chicken pox vaccination should be offered to both boys and girls.

• Adolescents have significant needs for health services. Adequate care and support should be given to them so that they enter into their adulthood in good mental and physical health.

What all an adolescent should avoid?

• In this age group there is an inclination towards junk food e.g. pizza, burgers, soft drinks etc. Regular consumption of junk food devoid adolescents to have healthy & nutritious diet. Consumption of junk food can lead to obesity, medical problems like hypertension, cardiac disease in adulthood.

• Adolescents are at risk for smoking, alcohol intake and drug abuse. Smoking, alcohol intake and drug abuse cause addiction and use of these should be avoided. Smoking can cause cancers, infertility, hypertension, heart disease and premature death. Drugs are like poisons for everyone and must be avoided.

Infertility ( now commonly called as SUBFERTILITY ) is a condition of the reproductive system often diagnosed after a couple has had one year of unprotected, well-timed intercourse (in women under 35, after six months in women over 35) or if the woman has been unable to carry a pregnancy that results in a live birth.

How common is infertility?

One in every eight couples of childbearing age has an infertility problem. There is a female problem in 35% of the cases, a male problem in 35% of the cases, and a combined problem of the couple in 20% of cases. Therefore, it is essential that both the man and the woman be evaluated during an infertility work-up. In 10% of cases, the problem is “unexplained”, meaning that all testing yielded normal results.

When should one seek help for infertility evaluation & treatment?

If a female partner’s age is less than 35 years and after one year of intercourse she is not able carry a pregnancy or If a female partner’s age is more than or equal to 35 years and after six months of intercourse she is not able carry a pregnancy then the couple should seek expert medical advice for evaluation of cause and treatment of infertility.

If the male partner has a known or suspected low sperm count or the female partner has a history of pelvic inflammatory disease, prior ectopic pregnancy, painful periods, recurrent miscarriage, or irregular periods, it is advisable to start treatment soon as the couple decides to plan baby.

What are “primary” and “secondary infertility”?

Primary infertility is infertility without ever conceiving or successfully carrying a pregnancy to a live birth. Secondary infertility is the inability to conceive again after one or more successful pregnancies.

How infertility is diagnosed in females ?

Blood investigations and ultrasound / imaging of pelvic organs in females are conducted to find out the cause of infertility in women.

Is infertility exclusively a “women’s problem?”

Infertility is a medical problem. Approximately 35% of infertility is due to a female factor and 35% is due to a male factor. In the rest of cases the cause of the infertility cannot be explained.

How is infertility treated?

Currently there are many treatment options available which help the couple to conceive a baby. Treatment options include hormonal treatments, ovulation induction, Intrauterine insemination, in vitro fertilization (IVF), ICSI, surrogacy, egg/sperm donation and even embryo donation.

What are the risk factors for infertility?

There are risk factors for both, men and women.

Women’s factors include:

  • Age
  • Smoking
  • Excess alcohol use
  • Stress
  • Poor diet
  • Athletic training
  • Being overweight or underweight
  • Sexually transmitted infections (STIs)
  • Health problems that cause hormonal changes, such as polycystic ovarian syndrome (PCOS)
  • Radiation treatment and chemotherapy for cancer

Male factors include:

  • Heavy alcohol use
  • Drugs
  • Smoking
  • Age
  • Environmental toxins, including pesticides and lead
  • Health problems such as mumps, serious conditions like kidney disease, or hormone problems
  • Medicines
  • Radiation treatment and chemotherapy for cancer
  • Varicocele

What causes infertility in Women?

Most cases of female infertility are caused by problems with ovulation. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.

Ovulation problems are often caused by polycystic ovarian syndrome (PCOS). PCOS is a hormone imbalance problem which can interfere with normal ovulation. PCOS is the most common cause of female infertility.

Other causes of fertility problems in women include:

Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy

Physical problems with the uterus

Uterine fibroids, which are non-cancerous tumors of muscle tissue within the walls of the uterus

What all is done in evaluation of cause of infertility ?

Basic infertility work-up includes only a few tests. Commonly the following 4 factors are helpful in providing the correct diagnosis

  • Detailed Patient History and Examination
  • Ovarian Function Testing
  • HSG ( Hysterosalpingography )
  • Partner Semen Analysis

What are the treatments for infertility?

Treatment of infertility is according to the cause of infertility. For example, in cases of hormonal imbalance treatment is conducted with medicines.  Depending on the diagnosis, in specific conditions,  the assisted conception (in vitro fertilisation – also called IVF or ICSI ) is performed.

What is in vitro fertilization?

In vitro fertilization (IVF) is a technique used to treat more difficult forms of infertility and is effective because it bypasses some of the most common causes of infertility such as damaged tubes or poor sperm function. It is normally reserved for cases in which more conservative and less invasive methods have failed.

In vitro fertilization (IVF) means that the oocyte or egg is fertilized in a laboratory dish under highly controlled circumstances. The woman must first inject drugs to cause her body to produce and mature multiple oocytes. Approximately 36 hours after a trigger injection to complete the maturational steps, a doctor inserts a slender needle through the woman’s vagina to remove the mature oocytes from her ovary. A laboratory specialist then exposes the oocytes to her partner’s sperm cells, fertilizing the eggs to create embryos and leaving them to grow for three to five days. In cases where sperm are defective or few in number, or there are difficulties with the fertilization process, the sperm cells may be injected directly into the oocytes using a process called intracytoplasmic sperm injection (ICSI).

The resulting embryos are placed into the woman’s uterus through the vagina using a small catheter. For the following three to five days, the embryos float freely in the uterus and then implant onto the uterine walls. The pregnancy hormone human chorionic gonadotropin (HCG) is first detectable in a woman’s blood about 10 days after fertilization and three to five days before the first missed menstrual cycle. Pregnancy testing will usually take place two weeks after the trigger injection.

High risk obstetrics domain deals with women in which some condition puts the mother or the developing fetus (or both) at an increased risk for complications during or after pregnancy and birth.

How High Risk Pregnancy is different from normal pregnancy in terms of physician care?

Obstetricians treating high risk pregnancy help women who have /may have an increased risk for complications during their pregnancy. These pregnancies require advanced ultrasound exams and enhanced obstetrician expertise in diagnosing and treating problems related to high risk pregnancy. In comparison to normal pregnancy these patients require multi-disciplinary approach, frequent obstetric check-ups & expert neonatal care.

What are high-risk factors in pregnancy?

  • Maternal Age : One of the most common risk factors for a high-risk pregnancy is the age of the mother-to-be. Women under age 17 or over age 35, when their baby is due, are at greater risk of complications than those between their late teens and early 30s. The risk of miscarriage and genetic defects in babies further increases after age 40.
  • Medical conditions that exist before pregnancy : Conditions such as high blood pressure; breathing difficulties, kidney diseases, heart problems; diabetes, autoimmune disease; sexually transmitted diseases (STDs); or chronic infections such as human immunodeficiency virus (HIV) can present risks for the mother and/or her unborn baby. A history of miscarriage, problems with a previous pregnancy or pregnancies, or a family history of genetic disorders are also risk factors for a high-risk pregnancy.
  • Medical conditions that occur during pregnancy : It is possible to develop or be diagnosed with problems during pregnancy that can affect a normal woman and her baby. Two of the more common pregnancy-related problems are:
  • Preeclampsia is a syndrome in which there is a tendency to develop high blood pressure with swelling in body. In this condition urine examination starts showing This condition can be dangerous or even fatal for the mother or baby if not treated. With proper management, however, most women who develop preeclampsia have healthy babies.
  • Gestational diabetes is a type of diabetes which develops during pregnancy. This condition stays till the pregnancy lasts. Usually the diabetes resolves after the gestational event. Women with gestational diabetes may have healthy pregnancies and babies if they follow the treatment plan from their health-care provider.
  • Pregnancy-related issues : Often a pregnancy is classified as high risk because of issues that arise due to the pregnant state. These conditions are not related to mother’s health. These include:
  • Premature labor / birth is developing labor pains with expected premature birth that begins before 37 weeks of pregnancy. Although there is no way to know which women will experience preterm labor or birth, there are factors that place women at higher risk, such as certain infections, a shortened cervix, or previous preterm birth.
  • Multiple births mean a pregnant woman is carrying more than one baby (twins, triplets, quadruplets, etc.). Multiple pregnancies, which are more common as women are using more infertility treatments, increase the risk of premature labor, gestational diabetes, and pregnancy-induced high blood pressure.
  • Placenta Previa is a condition in which the placenta covers the cervix. The condition can cause bleeding, especially if a woman has contractions. If the placenta still covers the cervix close to delivery, the obstetrician may schedule a cesarean section to reduce bleeding risks to the mother and baby.
  • Fetal problems : Fetal problems can sometimes be seen on ultrasound. Approximately 2% to 3% of all babies have a minor or major structural problem in development. Sometimes there may be a family history of fetal problems, but other times these problems are completely unexpected.

Maternal critical care is a specialty division of a hospital or health care facility that provides intensive treatment to women during pregnancy, child birth and after child birth.

Maternal critical care units (MCCU) cater to patients with severe and life-threatening illnesses developed during pregnancy, child birth or after child birth, which require constant, close monitoring and support from specialist equipment and medications in order to ensure normal bodily functions.

Why Maternal critical care unit?

Maternal critical care need a special emphasis as health condition of a female may need intensive treatment when she is pregnant, during child birth or even after the baby is born. In all these conditions there is an extra concern for the baby in womb (in cases of pregnancy or during childbirth) or the baby as new born (in cases of after child birth). Due to complexity of these facts a multidisciplinary teamwork is required. Multidisciplinary team mostly involves intensivist, anaesthetist, psychologist, neonatologist and obstetrician. These units are staffed by highly trained nurses who specialize in caring for critically ill patients. MCCUs are also distinguished from normal hospital wards by a higher staff-to-patient ratio and access to advanced medical resources and equipment that is not routinely available elsewhere.

 

In which conditions critical care for mother is required?

There are few obstetric conditions in which critical care is required:

  • Ruptured ectopic pregnancy
  • Septic abortion
  • Hyperemesis (intractable / severe vomiting during pregnancy)
  • Severe pre-eclampsia
  • Eclampsia
  • Antepartum hemorrhage
  • Severe anemia in failure
  • Heart (Cardiac) failure in pregnancy
  • Epilepsy in pregnancy
  • Bleeding tendencies (Coagulation failure) in pregnancy
  • Pregnancy with valve replacement
  • Pregnancy with vascular thrombosis
  • ARDS
  • Multiple organ failure
  • Sepsis

 

How are patients admitted in MCCU?

Patients may be transferred directly to an intensive care unit from an emergency department if required, or from a ward if they rapidly deteriorate, or immediately after surgery if the surgery is very invasive and the patient is at high risk of complications

High dependency unit (HDU): (also known as “step down unit or progressive care unit” or “transitional high dependency unit”) for patients who require close observation, treatment and nursing care that cannot be provided on a general ward, but whose care is not at a critical enough level to warrant an ICU bed. These units are also called step-down, progressive and intensive recovery units and are utilized until a patient’s condition stabilizes enough to qualify them for discharge to a general ward.

 

What all is done in MCCU?

MCCU is equipped with all the equipments of intensive care unit. Continuous recording of Heart rate, Blood pressure, respiration rate, central venous pressure, temperature is monitored in MCCU. In addition to monitoring of these vital functions critical monitoring of intravenous fluids intake and output is monitored. All required blood parameters analysis e.g. ABG (Arterial blood gas) analysis, other blood parameters like hemoglobin, liver function tests, renal function tests etc are performed within MCCU.

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