Busy as Ever, Cool forever

Saturday 16 February 2013

Treat both and make them smile!

Breast feeding is a blessing for Mom and baby!

But what if it becomes a difficult one...

Mom might feel it a curse and stop the blessed act!

Gosh, the pain from sore nipples is something that is nearly ... unbearable.

Complete history taking and examination is the core for diagnosis. Cracked nipples and fungal infections are common reasons. Moms need support and empathy during cracked nipples and infected nipples. Fungal infection seems to be common but under-recognized and under-treated. Else, the baby will re-infect the mother at each feed. The amount of pain would be so bad that some discontinue feeding... Both need to be treated.

For mother:

Daktarin Cream (Miconozole) 2% is the first choice of anti-fungal cream. Quite effective. Skin Cream should be prescribed not the skin GEL for the nipples. Because, GEL doesn’t penetrate the skin of the nipple, and is unlikely to be effective.

Nyastatin cream is not as effective as Daktarin for treatment of nipple thrush, although it is safe because it doesn’t get absorbed in GIT.

If topical treatment doesn't work for mom, then we need to try oral Fluconazole, which is recognised to be compatible with breastfeeding by the World Health Organisation. But, in some countries like UK, Fluconazole is not licensed for lactating women. There is growing evidence that it is a safe and effective form of treatment and using it clears the nipple infection better and enables mom to continue breastfeeding.

A dose of 150 mg stat oral is followed by a dose of 50 mg/day for 7-10 days based on how the nipple symptoms progress. The amount of fluconazole secreted in breast milk (when mom takes oral treatment) is insufficient for baby's oral thrush. Hence, baby need to be treated as well.

For baby:

Below 4 months age babies, NY statin oral suspension and oral Fluconazole suspension are only licensed.

For babies above 4 months of age, Daktarin oral GEL is preferable to Nystatin suspension, with greater efficacy within a shorter period. Daktarin is not used in babies below 4 months age as gel is thick to cause choking.

For example if the baby is 6 weeks old, we can’t use Daktarin... So, for this baby, Oral fluconazole suspension (3 mg/kg, once a day for seven days) is be used. Oral treatment has a good cure rate - better than nystatin and miconazole.

Apart from the medications, it is essential to make sure that the mom is practising good feeding techniques and proper hygiene measures. It is essential to Change breast-pads regularly, and also ask her to hot-wash her clothes and linen. Loose clothing to expose breasts in air for few hours per day would help healing if the nipples are too sore. The regular skin advice such as not to use chemical soaps, etc should be given as verbal advice or supplemented by an information leaflet.

Most importantly, we should review every week to see how mom and baby are coping. If symptoms have not improved at all after we try the second line drugs - like a 10 day course combined with topical treatment- then it is worth to re-consider the diagnosis. We should never hesitate to re-visit the symptoms and re-examine the nipple and baby's oral mucosa appearance. We could refer to the neonatal team to review if persistent rather than continuing it for a longer time.

Hopefully most of the time, we could bring smiles to mom and the baby with the appropriate reassurance and first line medications along with the good communication and support.

Thursday 6 September 2012

Is it safe, Doctor?

A friend of mine , who is a software professional called from Germany to ask me if she could fly during pregnancy as she was concerned about radiation. A GP colleague asked whether MRI for his patient was safe. I thought it was a good idea to refresh myself with what is the latest information available on these.

Coming to the safety of radiation in pregnancy, the main questions for a Clinician are

(a) Question of necessity of investigation &

(b) Fetal effects of the investigation done.

'Is it safe, doctor?' is a common question we would face!

With regards to Question of necessity, If an intervention to save the mother or fetus could be made, by doing an MRI or X-ray or IVU, then it needs to be done, where benefits of saving the mother would outweigh the risks.

About the Fetal effects, the safety of imaging would be questioned by patients particularly, if the fetus is in embryonic stage or in first trimester. Clinicians aoften face the situation to explain if it is essential and what harm it could do to the fetus.

The risk of central nervous system effects is greatest with exposure at 8–15 weeks of gestation, with no proven risk at less than 8 weeks of gestation or at greater than 25 weeks of gestation. Thus, at 8–15 weeks of gestation, the foetus is at greatest risk for radiation-induced mental retardation, and the risk appears to be a "no threshold linear function of dose" at doses of at least 20 rad.

It is important to understand what rad is to gray. The following is commonly used.

· 1 rad = 0.01 Gy = 1 rem

· 1 mrad = 0.01 mGy

Xray : Women should be counselled that X-ray exposure from a single diagnostic procedure does not result in harmful foetal effects. Specifically, exposure to less than 5 rad has not been associated with an increase in foetal anomalies or pregnancy loss.

The estiamted exposure for common procedures are as follows:

chest Xray has 0.02 mrad ,

CT head has < 1 rad and

Mammography has <20 mrad.

IVU has > 1 rad and CT abdomena dn lumbar spine has 3.5 rad.

Ultrasound : safe in pregnancy.

MRI is considered safer in pregnancy than CT imaging. The two important effects concerned theoretically, would be teratogenicity and acoustic damage to fetus due to MRI.
Although, No damage to the developing human fetus caused by MRI has been documented, all guidelines seem to say that caution is advised, and risks and benefits must always be considered before evaluating a pregnant patient with MR imaging.
The 2009 Health Protection Agency, Royal College of Radiologists and College of Radiographers (RCR) echo the same as the 2007 Medicines and Healthcare products Regulatory Agency (MHRA). Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use.
"The MHRA recommends that, where possible, the decision to scan
should be made at the time by the referring clinician, an MR radiologist and the patient, based on the information above about risks weighed against the clinical benefit to the patient."

With regards to radiation exposure with flying during pregnancy,

The Airport Security Scanners & Ionising Radiation, a working group of The Royal College of radiologists (RCR) and British Institute of Radiology (BIR) have released a report in 2011 stating that ‘Airport body scanners are safe’. The average dose form a single scan is 100000 times lower than the average annual dose of radiation a person receives from natural background radiation and medical resources.

HPS, a society for Radiation safety states that the radiation exposures while flying are not considered high exposures. For example, in a 10-hour flight, the exposure would be less than 1 milliard, which would bring the exposure in the range of a low-level exposure from many diagnostic radiological procedures. This exposure would not increase the risk for birth defects or miscarriage.

So, a summary of most guidelines would be the following:

1. The standard dose of radiation associated with a diagnostic x-ray produces a minuscule risk to the foetus. However, all women of childbearing age are asked if they are pregnant before any exposure to radiation.

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. During pregnancy, other imaging procedures not associated with ionizing radiation (e.g., ultrasonography, MRI) should be considered instead of X-rays when appropriate. Ultrasonography and MRI are not associated with known adverse foetal effects.

4. The use of radioactive isotopes of iodine is contraindicated for therapeutic use during pregnancy.

5. 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 the foetus.

6. Airport scanners are safe and have miniscule radiation exposure,

7. During pregnancy, a woman and her foetus will receive about 300 milliard of background radiation (which of course no-one can avoid). The background risk is 3% for birth defects and 15% for miscarriage for all healthy women when they begin their pregnancy. This is not increased due to flying during pregnancy.

Useful information can be found on these links:

http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Guidelines_for_Diagnostic_Imaging_During_Pregnancy

http://hps.org/documents/Medical_Exposures_Fact_Sheet.pdf

http://hps.org/publicinformation/ate/faqs/pregnancyandflying.html

http://www.uptodate.com/contents/diagnostic-imaging-procedures-during-pregnancy

http://www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON2033018

http://www.rcr.ac.uk/docs/radiology/pdf/Pregnancy_Work_Diagnostic_Imaging_2nd.pdf

Friday 8 June 2012

Pregnant Woman and the blues

Depression is so common now-a-days, given the stress in fast-tracked life. Nuclear families, pressure to work & earn for living, travel, stress of job appraisal, career growth and effects of maternity break on career have caused immense stress in a Woman’s mid-year life.

It is the support from Parents and Siblings which seems to be the protective factor to avoid the stress going overboard for many decades for the birthing woman. Not to mention, the in-laws in most (not all) Asian families where the support mostly is minimal to a woman during pregnancy and postpartum. Given the rituals during pregnancy and post-delivery in Asian families, the clash between the families could damage the morale of the woman, who loses the love and affection of husband and parents at the same time, caught between the sleeplessness and the duties of a new mom. However, the term depression does not go well with men partly, as they might feel guilty for having been a part of that diagnosis in their wives!

On the other side of it, there needs to be more awareness amongst women that depression can occur during pregnancy and in post-partum period. The responsibility falls on the shoulders of the clinicians to make the families understand better about the support that needs to be provided to the pregnant woman. It is better to enquire how they feel within themselves during every antenatal check-up so that it remains a screening method. Probably, leaflet about depression and antidepressants could be placed in the clinics so that they could become aware of warning signs when they have to seek help. Women could open up to doctors particularly when husband or in-laws are not present during consultations. When found in low mood, we could probably start on low dose of antidepressants or give advice about CBT or counselling.

As doctors, we could face a patient on antidepressants trying to become pregnant or a pregnant woman presenting in low mood. I had a general discussion with colleagues about which antidepressant is safe in pregnancy and breastfeeding.

If a woman on antidepressant intends to become pregnant, the best thing is to provide the information about safety of the medications. If on paroxetine, it needs to be changed. However, if she is stable for a while on a safe SSRI or TCA, it is best to continue the same. The question arises, which is safe, if we were to start one in a woman who is depressed after becoming pregnant or in postpartum.

Pregnancy:

TCA s and some SSRIs are safe in pregnancy. Tricyclic antidepressants, such as amitriptyline and imipramine, have lower known risks in pregnancy than other antidepressants. The risk of adverse events during pregnancy, in case of overdose is higher than with SSRIs. Hence SSRIs are preferred during pregnancy in women who are at risk of overdose.

Fluoxetine is the best-documented selective serotonin re-uptake inhibitor (SSRI) used in pregnancy.

Information on the safety of other SSRIs in pregnancy is limited. The use of fluoxetine in the first trimester of pregnancy is not associated with teratogenicity effects. There is small risk of neonatal withdrawal syndrome characterised by convulsions, irritability and feeding problems when used in last trimester. We also need to inform patients that there is a small risk of cardiac defects in babies,

born to mothers on other SSRIs. Use of SSRIs may be associated with Persistent Pulmonary hypertension in the new-born and hence, paediatric assessment after delivery is advised. However, this is not a common side-effect that needs to scare a woman to deny a worthy medication that could improve her quality of life. The benefits obviously should outweigh the risks during prescription.

Breast feeding:

The selective serotonin reuptake inhibitors (SSRIs) sertraline can safely be given to a woman who is

breastfeeding provided the infant is healthy and baby's progress is monitored. Citalopram and fluoxetine are less preferred as they are secreted more in breast milk than sertraline; but these could be considered if the woman has been successfully treated with one of these drugs during pregnancy.

So, Summarising, Fluoxetine is preferred during pregnancy and sertraline during breastfeeding.

It is better to use the lowest possible (maintenance) dose and monitor effects (adverse) carefully.

All the more, the clinical care does not end with prescribing medications. It is best to ensure that the family around helps the woman to combat the mood and stress. It is the moral, psycho-social support network that really helps to overcome the stressful period of pregnancy and delivery.

Reference for MRCOG exams about Depression in Pregnancy and Breastfeeding:

1. Moses-Kolko EL et al. Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications. JAMA 2005;293:2372-83.

2. NICE (February 2007). Antenatal and postnatal mental health.

3. Chambers CD et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 2006 Feb 9;354(6):579-87

4. http://depression-in-pregnancy.org/

5. http://www.rcpsych.ac.uk/mentalhealthinfo/problems/mentalhealthinpregnancy.aspx

Tuesday 15 May 2012

Vit D in pregnancy - Looking for Consensus view

I was recently discussing with my friends about Vitamin D deficiency in Asian population in UK, when we realised that we were not disucussing this as much in pregnant population as we do in general population. I was more interested in this topic after I read the BJOG article recently on Vit D.

The global consensus is available for routine supplementation in Pregnancy, which is 10 mcg (400 IU) of Vit D in all pregnant women. NICE mentions that it is offered to all pregnant women. But, the most important part is screening for deficiency in pregnancy and the treatment in deficient women, where there seems to be no consensus. However, The ACOG offers clarity in their statement regarding Vit D screening & supplementation.

Screening :

Is it universal or high risk screening? As like in Gestational Dibates (GDM), this confusion still exists. ACOG says that there is no need to screen all pregnant women with a blood test to find out Vit D deficiency. However women at greater risk should be offered a bllood test.

Who are at high risk?

Risk finding is from history and examination of BMI.
Greatest risk is seen in those with
(a) darker skin such as South asian, African, Caribbean, Middle Eastern women
(b) those women with limited exposure to sunlight like housebound and
(c) those with BMI>30.

Defining deficiency :

In nonpregnant, there is a cut-off. However, there is no consensus on an optimal level to maintain overall health in pregnant women.

Most agree that a serum level of at least 20 ng/mL(50 nmol/L) is needed to avoid bone problems. In a Scandinavian Obs & Gyn journal, it was mentioned that Institute of Medicine advises the following serum concentrations of 25-OH-D for defining deficiency: <12 ng/mL (vitamin D deficient), 12–20 ng/mL (vitamin D insufficient), ≥20 ng/mL (vit D sufficient).

When do you test it ? When do you repeat it in pregnancy?

Again there is no consensus. The test is offered mostly in first trimester beacuse the treatment could be started early , once the teratogenic phase (earlyweeks of pregnancy) has passed. The Vit D levels are tested again at 28 weeks gestation.

Much is talked about Vit D deficiency linked to Pre-eclampsia. The recent issue of BJOG (2012) has a RCT with evidence that Vit D levles at mid-trimester is associated with high risk of pre-eclampsia. Hence, in future, we might expect the blood testing in mid-trimester.

What is tested?

For the individual pregnant woman thought to be at increased risk of vitamin D deficiency, the serum concentration of 25-OH-D can be used as an indicator of nutritional vitamin D status.

How and when would you treat it?

The Australian/NZ practice are different to US/Europe. In some aprts of Australia & NZ, the treatmetn for pregnant women with levels 25–50 nmol/L would be to commence 1,000 IU daily and Pregnant women with levels < 25 nmol/L should be commenced 2,000 IU daily. Such consensus is not availble in UK.
When vitamin D deficiency is identified during pregnancy, most experts agree that 1,000–2,000 international units per day of vitamin D is safe. Higher dose regimens used for the treatment of vitamin D deficiency have not been studied during pregnancy.
1 mcg vitamin D (cholecalciferol) = 40 IU

Why is there no rush globally to treat Vit D deficiency in pregnancy unlike in neonates of breastfeeding mothers?

In adults , the calcium metabolism is much dependent on 25-OH levels. So, we would expect that the vit-D defficieny to have impact on foetus.However,
The Calcium and Vit D homeostasis / metabolism in pregnancy is much differnt such that irrespective of maternal Vit D levels, the calcium reaches the foetus due to maternal adaptations during pregnancy. It is only the NEONATE (not the foetus) that becomes calcium-deficient. So, the treatment is always aimed at provisding the neonate with sufficent calcium. hence a nominal Vit-D dosage is chosen instead of intensive treatment in pregnant women - this could be to balance the risk of hypervitaminosis of a fat soluble vitamin.

What about breastfeeding women?

For breastfeeding women, aim for normal levels during pregnancy, then continue on 1,000 IU daily during breastfeeding. We should Consider neonatal supplements in babies with risk factors for low vitamin D.1 mcg vitamin D (cholecalciferol) = 40 IU.
This is my personal review from the data I have read until now on Vit D in pregnancy. If there is any thing changed or to be added , please post in the comment section.

Tuesday 20 March 2012

PCOS and Insulin resistance

PCOS and Insulin resistance

Vit D hypo-vitaminosis is now being researched with its link to PCOS and insulin resistance.
Two are the following articles, My cousin, a Geneticist, provided me as interesting ones.

Taking into account their involvement in obesity and
apoptosis, the studies are done to investigate the
balance between circulating levels of 25-hydroxy vitamin
D (25(OH)D), leptin, and adiponectin, and PED/PEA-15
protein abundance, in both lean and overweight/obese PCOS.

Hope you like the links.

Following are the links:

http://www.docstoc.com/docs/116767307/Gene_vitd_pcos_IR1

http://www.docstoc.com/docs/116767290/PCOS

please post your comments on your thoughts about this topic.

Monday 20 February 2012

MRCOG part 1

Preparing for MRCOG part 1 is like preparing for a long journey as it does not stop here..It takes throguh to MRCOG part 2 theory and then to the OSCE!

So, having decided that you are traveling, it is essential that we are prepared for the tour.

'Being prepared is equivalent to Success'.

How & What do you prepare? I have written this , from my experience of the exam a decade ago and from friends who wrote it recently. (If anyone has more details, please add to the comment boxes below this post).

The clinch is this is an exclusive MCQ exam rather than a clinical exam like MRCOG part 2. So, it is essential you go through as many MCQs as possible, read only sufficient theory (not extensive), grasp necessary MCQ points... and then come back to working out MCQs .

Practice the MCQS in MCQ books and in websites like

www.busyspr. com

http://www.examdoctor.co.uk/exam/mrcog-part-1/

http://www.onexamination.com/obs-and-gynae/mrcog-part-1

I have seen many brilliant candidates failing in MRCOG part 1 exam and some average students clearing it. The reason is that they have not changed their focus to this Exam. It is purely testing your knowledge of basics RELEVANT to Obs & Gyn, but NOT all of the books in undergraduation.

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Mostly the questions are from the following 12 subjects :

Anatomy- Anatomy of female genital tract, Abdomen, Breast, Thyroid, Pituitary & Hypothalamus

Embryology- Some topics would be covered from reproductive medicine books. But it would be wise to read and cover most topics from a embryology book like Inderbir Singh(It is a nice and simple book). If you have access to library, you can go through books like langman or Larson’s embryology.

Physiology- don’t read CVS/CNS deeply…..

Read relevant topics like Muscle, Nerve, Cell membrane function, Circulation, o”& CO2 transport, Foetal circulation, Physiology of respiration at birth.

Reproductive Endocrinology- This is an important part of the exam.You need to be thorough with this. Preferred book would be Spheroff endocrinology first 9 chapters. And you could go through relevant topics from The Recent advances in Obs & Gyn(John Bonnar).

Pharmacology- This is one subject where they can ask you anything from first to last. Particularly be thorough with . Any book like Katzung or whichever standard book you have got would be sufficient. Cover the topics of Contraceptive pills, treatment of STI, drugs related to Nutrition.

Biochem- Be thorough with Metabolism of Carbohydrates, Protein, Fat and Nucleic acids, O2-Co2 transport. You can go through Lippincott’s Illustrated book of Biochemistry. It would be easier.

Pathology- Pathology of female genital tract is something you can cover from a standard Gynaecology book like SHAW which you must have read from undergraduation. Particularly, Cover the topics of gynae oncology (pathology of cancers of female genital tract).

Immunology- Be thorough with topics like agammaglobulinemia. ..etc..,. Topics can be covered with Immunology topics in Microbiology book like Panicker and Medicine book like Davidson.

Genetics- The chapters extensively covered in Robin’s pathology and Davidson are sufficient. If you have access to library, get sometime reading ABC genetics.

Microbiology- Be thorough with relevant topics like STI, trichomonas vaginalis, Candida, Bacterial vaginoses. parasites causing anaemia may surprise you at exam as anaemia in pregnancy is a topic in obstetrics though not common in UK. A basic book like Panicker or similar one you studied during undergraduation is sufficient.

Biophysics- Read about USG, Doppler, CT scan, MRI. USG and Doppler physics are very essential in Obs & Gyn. Any radiology book in the library will give you the necessary articles. Ultraosund in Obs & Gyn by Callen will give you a good idea about the physics

Statistics- Parker is a book you must have read for community medicine in India. It contains an elaborative chapter on Biostatistics.

If you go through Google, you find articles on Biostatistics like t test, probability, etc... As well.

http://www.bmj. com/cgi/content/ full/315/ 7104/364

This is an article of how to read a paper; statistics for a non-statistician.

Try to work out some sums similar to those from MCQ books. You have five questions, i.e. 25 stems in total on statistics.

See sample MCQs in the following link:

http://www.medstats aag.com/mcqs. asp

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The above list is not exhaustive. The real touch is how you pick up the relevant topics from each subject. For example, an anatomy of ureter , physiology of pituitary, biochem of lipid/steroid metabolism are relevant to Obs&Gyn.. So, the timesaving tactic is to read the relevant topics in the subjects..

This is just few tips for MRCOG part1.

Try to complete the following from the books you already have studied during your undergraduation. You Dont have to buy new text books for this exam.

However, You may need to go through some MRCOG part 1 books like

i) MCQ books for Part 1 from RCOG bookshop and

ii) Books like Tim chard

iii) Basics for MRCOG part 1 by Michael De Swiet.

There is a reading list in the RCOG website : http://www.rcog.org.uk/catalog/mrcog-part-1-reading-list

Anyone, after having faced undergraduation exams or All India Entrance, can somehow attend the questions on usual topics from Microbiology, Pathology, anatomy, Pharm, etc…as these are common subjects for exam preparation. However, (a bit dry) subjects like Biophysics, Biostatistics need preparation. .and these are treasures, where you score more than others...! Likewise you can score more than others if you prepare the Immunology and genetics very well.

From September 2007 the MRCOG Part 1 Exam also has EMQs.

Try to go through EMQs for the MRCOG Part 1 by John Duthie.

Ask those collegues who wrote the exam recently, about the topics covered in EMQs.

As new patterns of exams could come out, always keep updated with RCOG website and with those who have written the exam recently..

Time management during exam is essential. As you need to complete 300 stems (60 questions with five stems each) in 2 hours, you need to practice. You need to be faster than in All India Entrance exams where it is 300 questions in 3 hours. ( So, Practice as much as MCQS possible and during your revision, try to do them quickly).

Then, MY MANTRA for any exam, particularly a MCQ based exam is DAY-PERFORMANCE. The Day performance on examday depends on how much you slept the nights before, the relaxed mind, the proper intake of food/fluids on the day, well-prepared travel, avoidance of tension-creating atmospheres,etc.

It is essential we dont read on the day of exam! Keeping cool is an art.

This is from my experience of MRCOG part1 exam.

Best of Luck!

Wednesday 15 February 2012

Are you preparing for PLAB?

My Cousin, Nila (meaning Beautiful Moon) had asked how to prepare for IELTS and PLAB. It is more than a decade I had prepared. hence , had to gather new information from recent takers of the exam. While doing so, thought I will post the same here for others to benefit.

Please find the links of IELTS and PLAB.

IELTS:

http://www.britishcouncil.org/india-exams-ielts-home.htm

British council website offers all details abut the exam.

Books:

http://www.amazon.co.uk/Cambridge-IELTS-Students-Book-Answers/dp/0521173787

Cambridge materials are one of the best materials for IELTS

You can get them in Higginbothams bookstore or order it online.

You can take IELTS in British council or Australian council. Both are valid.

Preparation time : 2 weeks

Worth getting score >8.0 in all components.

PLAB: