A FEW COMMENTS ABOUT FUNGAL INFECTIONS IN WOMEN

Candidacies or commonly called thrush is a very common infection in women. It is particularly bad during pregnancy. This

happens because women have high levels of oestrogen hormone which destroys the vaginal lining cells and besides this high levels of hormone progesterone interferes with the ability of the protective cells ( neutrophils) to fight candida. This can start fairly early during pregnancy and can go on throughout her pregnancy.  She should always see her care taker, confirm the diagnosis and make sure there are no other infections. There are two common antifungal drugs (DRUGS WHICH ACT ON CANDIDA) which are very useful and can be obtained without a prescription. These do not harm the foetus, but there are some which are not so safe. (FLUCONAZOLE). These can also be obtained easily. These can cause a miscarriage. This treatment can be in the form of vaginal suppositories or vaginal cream. In the first instant treatment is given for seven days and if it reoccurs for two weeks or more the infection can be really bad. Always have a medical input in your treatment.

Postmenopausal women

The other group of women who need attention about candidacies are, post menopausal. Postmenopausal women do not suffer candidacies as they have run out of oestrogens. They only get it if they are on HRT or are diabetic. In this situation always examine the patient, if she complains of vaginal symptoms of itching, discharge, pain on intercourse, dysurea, even bleeding.

There can be many different problems. They often get another infection called anaerobic vaginosis which causes very foul smelly discharge and itching, the discharge is predominant, as opposed to thrush where itching is maddening. I have come

across two postmenopausal women who kept on using anti thrush creams, neither they nor her primary care giver bothered to look at them. They both had a Carcinoma of the vulva which is usually occurs in menopausal women.

Other groups which suffer are Diabetics and obese women. Please do not keep focussing on one problem that is Candidacies. Do some tests, are there any other infections or any other problems. Always exclude diabetes in women with

persistent thrush.

As practitioners never order treatment without proper history and examination, if as care taker we follow this rule, we will not miss the serious issues.

MATERNAL MORTALITY IN INDIA IN 1960

These stories are from1960 when the maternal mortality rate in 

India was very high. Almost, 600 women died out of 100 000, live births. With the introduction of modern health, it has come down, one almost never sees what I am going to describe. These procedures were historically first done in the18th or 19th century.

(Warning)These stories are not to be read by the faint of heart. This day in the monsoon season was the hardest day of my 55 years of working life. The rain was nonstop, the roads? If we can call them that were flooded, Ram Devi came to our hospital in a bullock cart after being in labour for 2 days in this rain. She was 32 years of age had had 5 babies at home without any problems.  When she arrived her baby was lying across her stomach, the head was on the right side of her belly and a hand was prolapsing from the vagina. Above all this baby was dead and the mother was dying as well. She was septic, had a very high temperature and her haemoglobin was only 6. Our assessment was that her uterus was probably intact but very thin. We could not have done a Cesarean for a dead baby lying across the belly instead of lengthwise.

She was very weak; we had no trained anesthetist I was still very junior, I called my chief resident she decided to do what we called embryotomy. This means the dismembering of a dead fetus to remove it when normal birth and even Cesarean section is not safe. After this destructive procedure the woman can have a normal birth next time. My chief resident had witnessed an embryotomy but never done one herself. It required a lot of skill. Any way one of the residents went to pathology which was about half a kilometer from the hospital to cross match blood for her. I decided to help the patient to sleep after putting the woman in a comfortable operative position we started the antibiotic, gave her pethidine and Valium cleaned all the operative field put a catheter in her bladder, unfortunately the urine was blood stained. We were not sure if the uterus may have ruptured. The cervix was fully dilated, anyhow we proceeded with dismembering the baby. First the head, then the body; trying to protect the vagina all the time. At completion the uterus felt intact, we gave her the 2 units of blood. We all were happy as if we had saved the mother. We wrapped the baby parts and disposed of them. Since then I have never seen a case where this procedure has been required. I have seen a live baby with hand prolapsed on two occasions, and saved the baby and the mother both by Cesarean section.

On this occasion our mother died three hours later probably due to septicemia.

While we were still overcoming this disaster, Sitara a nineteen year primigravida came in with obstructed labour with a dead fetus. Her pelvis was very small and she had been in labour for many days. She was also septicemic and very ill. We had to do

a destructive operation for her called Craniotomy in which we crush  the head, compress it and remove it. We gave her some blood and antibiotics but could not save her.

Within 2 hours after this second maternal death, Bimla Devi aged 22 having had her second baby came in with a retained placenta. She had delivered about ten hours prior had been bleeding, but the placenta did not deliver naturally. Unfortunately

She was dead on arrival.

I was totally broken, three maternal deaths in one night.

The World Health Organisation has introduced a program called The Millennium Development Goals trying to improve maternal health and mortality rates around the world.

This includes nutrition, infectious diseases and they hope that things will improve by 2030. The most affected countries which need help are, India, Pakistan, Papua New Guinea and some African countries. 

TURNERS SYNDROME

Turner’s syndrome is a condition in which a human female is missing one of her chromosomes. As I have already discussed

Humans have 46 chromosomes. They appear in pairs of 22 which are anatomical chromosomes, and 2 are the sex chromosomes, XX in female, XY in male.  If a female child is born with only one X chromosome it does not develop in to a normal female. The general characteristics of these are very variable depending on as to how many cells are missing one x chromosome. This is called  Mosaicism

Even in utero this foetus does not develop normally its tissues swell and it develops thickening round the neck called cystic hygroma, lower than normal weight, swelling of hands and toes. This diagnosis can be made from the blood test from the foetus and pregnancy can be terminated. It is not an inherited condition, it happens during the process of reproduction. At birth a baby born with turners’ syndrome shows broad neck, small weight, hands that turn out, a high narrow palate and swollen hands and feet.

It may even look like a normal female baby depending on how many cells within the body are abnormal, this is called mosaicism.  A lot of turner syndrome pregnancies are lost as miscarriages, some are terminated and some are born normally.  They can appear normal up to 3 years of age, then their growth spurts stop, they have learning difficulties and puberty does not happen. Periods do not happen. The growth problem can be helped by female hormones. In present day with the help of IVF they can even have a baby. In my time I have terminated two pregnancies, looked after a woman who had a baby with the help of IVF. I must tell you this last story Tina had 7 miscarriages under my care, other experts and I could not help her when she was having her 8 pregnancy she was 41 years of age. Investigations into the wellbeing of the foetus showed it had turner syndrome but otherwise the baby appeared normal.She decided to have this baby. The baby was born in good condition and grew nicely up to 10 years of age unfortunately I lost contact with them. I hope she is growing up nicely and normally.

GENETIC OR CHROMOSOME ABNORMALITIES

Let me focus on chromosomes, these are thread like bodies in the living cells of each living being which give us our particular characteristics, these contain our DNA and GENES. As the cells divide they must transfer the exact number of cells into the new cells. We humans have 46 chromosomes and they live in pairs. 44 of these give us our characteristics e.g. our height, our eyes, that we get from our parents. Two of these chromosomes are sex chromosomes X and Y. A human female is XX and male is XY. When reproduction takes place these can be mixed up and produce children with abnormal sexual identity. When the chromosomes in other 44 pairs are mixed up they produce children with physical abnormalities named as different syndromes. Many of these have been identified and named but we are still working on many others when we cannot give a diagnosis to an abnormal child.

In this post I am going to describe two such cases with abnormalities of sex chromosomes.

Ronald and Teresa came to see me because they had been married for four years and unable to achieve a pregnancy. Teresa was 26 years of age well built like a normal female. She has never had any problems with her menstrual cycles. It seemed that she makes an egg regularly and in fact her test for ovulation was very good. Ronald’s who was 28 years of age was normal in appearance, normally men with Klinefelter  Syndrome are taller, but he was of normal height ,5ft 7inches he had no gynaecomastia(Breasts) which they often have, although the hair on his face and hands was scanty. This is another feature of Klinefelter Syndrome. Cardiac abnormalities are also noticed with this syndrome however not in this case.

A test for semen analysis showed azoospermia. The testicular hormone was low. When his chromosomes were done they were XXY which is a predominant feature of Klinefelter Syndrome. So obviously he had Klinefelter Syndrome. Sometimes the chromosome can go haywire they can be XXXY and so on. More number of X chromosomes, more obvious the condition. This was first described by Harry Klinefelter in1940 hence the name. It occurs in one child out of 590 births .Things can be improved as regard the appearance of the adolescent if diagnosis was made early and he had been given testosterone as an adolescent. In some modern cases infertility is treated by IVF by intracytoplasmic injection. I had referred this couple to IVF.

STORIES OF THE APPENDIX

               Lisa a teenager from Fiji was visiting our country. A few days after arriving here, she came to see me complaining of pain on the right side of the lower part of her belly. Her menstrual periods were regular and her last period was ten days ago. She was not feeling sick or nauseous and had no temperature. I felt she may have a small cyst or an egg growing on the right ovary causing her pain. She had some pain (tenderness) on pressing on the right side, which we call the appendix point. So the other possibility was appendicitis. But she had no nausea or fever which often comes with appendicitis. I did an ultrasound of the pelvis myself. This was normal there was no pelvic pain and the ovarian follicle (egg) was growing on the left side.

              The egg usually grows only on one side. I gave her some pain relief, reassured her, and let her go home. The pain persisted for almost six weeks. The family were not very happy; I decided to do an appendectomy. At the time of the operation the appendix looked normal. The report on the appendix picked up two shotgun pellets at the tip of the appendix. They were about five mm each. She had a rabbit (poor rabbit) for dinner several weeks ago while she was in Fiji. She never had the pain again after appendectomy. Lesson from this story is always pay attention to patient’s symptoms

THE O     THIS STORY IS SIMILAR BUT NO PELLETS

CARCINOID TUMOUR OF THE APPENDIX

Carcinoids are rare slow growing human tumours. They rise

                from nerve cells and glands. The common sites for this are the

                Gut, even more common is the appendix. Rarely they form in the    lung as well, and not show in this diagram.

R

L

They e    They are more common in men. The case I have described here      was of a woman. About  140 cases are diagnosed each year in  Victoria.

               Tina a 36 year old healthy looking woman came to see me

               complaining of pain on the right side of her belly and this had been    going on for last two years.

               We call this appendicular point. She had seen many specialists, a    gynaecologist, a physician and a general surgeon. They could not  explain to her why she has this pain. Carcinoid can often be silent.  They can also cause pain, diarrhoea, weight loss and hot flushes as  they secrete special types of hormones for the working of the  digestive system .They occur if there is increased acidity in the gut.  She had many investigations, a FBE, electrolytes, liver function, and  an ultrasound including the pelvis and appendix. The pelvic  ultrasound showed normal ovaries and uterus no other pelvic  pathology was seen.

               The appendix showed an indistinct mass in the  distal part as shown in the above picture. There was some yellowish homogenous mass in the  lumen. The posterior wall component and periserosal fat was normal. The finding surely indicated an abnormal appendix probably a carcinoid. I told her to go back to the surgeon and ask him to remove her appendix if he was not happy to do this come back to me, and I will do it for her. When he did it turned out to be a Carcinoid of the appendix. I saw her twice after the operation with a one year interval.

              Repeated the ultrasound and tumour markers. Tumour markers are recent tests which indicate any tumours in the body. She has been very well and sends me her friends from far off places for correct diagnosis and Xmas cards. The lessons for me from these two cases were; listen to my patients, be attentive and think of rare  diagnosis.

FIBRIODS IN TEENAGERS

Teresa aged 16 of Italian decent came to see me in my consulting rooms with her dad, they were both very irate. Her dad was told by her GP that she may be pregnant; however she denied it with great anger.  She was well developed, very understanding and knew what he was talking about. I advised them to sit down and calm down. The only problem she had was a sizeable lump on her belly, and she had to go to the toilet frequently, which was a nuisance particularly during school. I examined her in my office. It did not take me more than a few seconds to know what it was. Besides that she had an intact hymen. So the question of pregnancy did not arise. I told them it was a uterine fibroid, which was about the size of a football. I also explained to them that although the fibroids are the commonest tumours in women between the   ages of 35 T0 50, the percentage quoted in the literature varied between 35 to 50%. I had seen one case of fibroid tumour about 5 years earlier in a girl aged 15. These tumours are very rare in teenagers; however I think Teresa had a fibroid.  Teresa’s pregnancy test was negative which reassured him. There was no ultrasound in those days. Her dad was happy that she was not pregnant and requested that I treat her. So far in the last 50 years only 19 cases of teenage girls with fibroids (they are also called myomas) are reported in English literature. I am sure there will be a few more. I did not report this case, as I did not have the facility to do so. However I never saw another case in my 55 years of practicing as a gynaecologist.

The most common treatment in those days and even now is a simple operation called myomectomy. This means removal of the fibroid or fibroids, depending on if there is more than one. This does not disturb the young girl’s reproductive function. In some cases the fibroids are reported to have reoccurred, than another myomectomy is performed. The risk of myomas being cancerous is very rare. It has been estimated to be one in 1000.No malignancy was reported in the 19 cases described in literature. I performed a myomectomy on Teresa. From then on I saw Teresa every 6 months. Later on when ultrasound became available, then I used this for Teresa on her subsequent visits. I was very lucky during my active practice years that she had two pregnancies, and I delivered two lovely boys for her by caesarean section without any trouble. It is mandatory to deliver babies by caesarean section after myomectomy. Labour can damage the uterus. 30 years down the track I still see her some times.

These days the treatment of fibroids has improved. There are many drugs we can use to decrease the size of fibroids so that myomectomy and hysterectomy become easier, there is less blood loss, recovery is easier.  The other technique is uterine artery embolization,( UAE )this means the blood to the uterus is impeded, then less blood goes to the fibroid and it dies. Both these types of treatment are not offered to teenagers although recently a 12 year old girl with fibroid and severe bleeding as well as a Bleeding Disorder had an UAE.

The latest is a new machine which uses a very high intensity focussed ultra sound in conjunction with an MRI. After detailed assessment of the women and detailed preparation it kills the fibroid. If the fibroid is a very large one it requires more than one focussed area. This has not been used in teenage woman with fibroids so far.  The Royal Women’s Hospital in Melbourne, Australia has the one and only machine for this method of treatment.

In conclusion never exclude fibroids if a young girl presents with a pelvic mass

Teresa never had any other gynaecological problems

TOXAEMIA OF PREGNANCY DUE TO VERY HIGH CHOLESTEROL LEVELS

Judi was one of my young primigravid mothers. She was 26 years of age a school teacher with a BMI of 27. Her blood pressure on her first visit was normal 120/70. At this stage she was very well, and all the routine pregnancy tests were normal. The pregnancy progressed well until 36 weeks, when her blood pressure was ,140/ 90 which meant it was elevated, the urine was clear. The toxaemia of pregnancy is usually a disease of primigravid women causing high blood pressure, it also causes kidney problems and it can progress rapidly and can be dangerous to both the mother and baby. I advised her to go home and rest. When she came next day the blood pressure was slightly elevated further to 150/90 the urine was still normal. However I decided to induce her, and deliver her as that was my gut feeling. My gut feeling played an important role in my obstetric management. The same day I admitted her to the labour ward. I started the induction by rupturing her membranes, this was OK. liquor (Fluid around the baby when in utero) was clear there were no signs of foetal distress. Luckily the induction of labour is generally easy in women with toxaemia of pregnancy.

However my joy was short lived. When I put in an intravenous needle, the fluid that came out was like milk.

I rang my pathologist he said she must have very high cholesterol. I sent the fluid which was really blood to pathology; her cholesterol came out to be 58mmols/ litre. This is extremely high. Normal cholesterol levels are around 6mmol/litre. During pregnancy the cholesterol levels do rise from the start but more so in the last trimester. This can cause toxaemia of pregnancy. She later told me that her mother suffers from high cholesterol but she had had no such problems. Normally cholesterol is not tested during pregnancy, but some research is being done to see if it should be tested. I started Judi on Syntocinon drip. This is a drug used to enhance labour. Luckily for Judi and me, Judi had an easy and quick labour and delivered a healthy male baby weighing 3620 Gms within 6 hours of induction. She did not what to breast feed. Within 6 weeks of delivery her cholesterol level came down to 28mmols/L. After this experience with Judi, I tested the cholesterol levels of all my toxaemia patients, but never found a high cholesterol level. I referred Judi to a physician and he kept her on a low dosage of anti-cholesterol drugs. I advised her to use condoms for contraception as she wanted another baby.  In just under two years she got pregnant again and her cholesterol levels started to rise. The physician very carefully supervised her cholesterol levels. At about 37 seven weeks her cholesterol came up to 28.4. I induced her again; she had a successful delivery of a healthy female baby 2870 gms in weight. After this she stayed on cholesterol tablets, I wonder if she followed her mother’s pattern. She cannot be given the pill for contraception, because the pill will cause her cholesterol to go up. I fitted her with Mirena for contraception. I followed her for few years, I found her to be very happy.

POST MENOPAUSAL PREGNANCY

OLDEST MOTHER WHO I HAVE EVER DELIVERED
AGE 55; IT WAS A GREAT JOY
Sumitra came to the outpatient department of obstetrics very quietly thinking she may be pregnant. She said she can feel something moving in her belly. She had had no periods for ten years; she was now 54 years of age. This was in 1960 when I was still a junior doctor. She had 3 grown up daughters and 4 grand children. She had no sons. She was mildly obese weighing 70 kilos. Her blood pressure was normal, she had no medical problems. On my clinical examination she was surely pregnant, I could hear the foetal heart .Of course there were no ultrasounds or genetic tests. I informed my professor about her. The only important thing about her was that she was the wife of a Member of Parliament. Her pregnancy progressed like a dream and she had an easy normal vaginal birth of a male healthy baby weighing 3 kilos. There was joy all round as they had no sons. Even I got a lovely sari as a present. It was a great joy for me as well. Many cases of spontaneous births have been reported after menopause, one in 1899 and then one in 1960. Both these women were 50 years of age. In recent times many older women have given birth through I.V .F technology. Latest birth is reported from India to a 70 year woman using donor egg, and using her 72 year old husband’s sperm in 2008. How old is too old to have a baby. Who will look after this baby?

VERY YOUNG MOTHERS

I am not sure if I should call them young women or girls, so I decided to call them young mothers. There were 2 such mothers one was 13 yrs old, who I delivered in 1961, and the other was 12 years who I delivered in a western country in 1965.

The 13 year girl was a very sweet and innocent girl, who has not yet had her first period. I do not know if she knew anything about period’s and where did baby’s came from. Her Mum and Dad had to go interstate to attend a wedding so they left her alone at home with a 16 year male cousin for four days. During the time they were away, the teenagers must have explored sexual experiments. Nothing happened after that. Suddenly nine months after that she was in labour, her mother realised what was going on. On a very hot summer day they (her parents) rugged her in a big thick blanket and brought her to the hospital. I was surprised that nobody noticed anything for all these nine months. I had come across a similar incidence in Dorset, UK when two teenage sisters were trying to protect each other, the younger sister had a baby, who was flushed down the toilet, I was called on a flying squad when the placenta did not come out and the young girl was bleeding. It was in the country, they had no electricity and no running water. Will I ever forget this day? Luckily, I had water, a big light an anethesist, and blood for transfusion. I removed the placenta, gave her a blood transfusion, put a few sutures into her torn outside and saved her life. In This case her mother was never aware that all this was going on.

Now going back to my original 13 year old, I delivered her easily, with tender loving care without stressing her. She had an episiotomy which was sutured. In our college the rule was that couples who are waiting for adoption can be invited for it, after bringing to the attention of the mother, the two can meet outside the hospital gate and do the exchange. We had no legal involvement in this. I told her mother, if anybody asks her what happened to her daughter just tell them she had a cyst on the ovary.  By doing all this I hope I a saved a lot of trauma for a young innocent girl.

The second teenage mother was only 12. She was very mature looking. The school had gone on a picnic with many boys and girls. The little girl called Debbie also had never had a period as yet but she had had some sex education at the school. They played during the picnic as a group not one on one. Debbie started to be very ill after the picnic and they found out that she was four months pregnant, this fitted with the date of the picnic. Nobody could work out who the father was. Later on during pregnancy she became very ill with toxaemia of pregnancy. She had to be in hospital for a week. We successfully induced her at 37 weeks; a male baby weighing 7 pounds 2 ounces was born in good condition, both the mother and baby did well, there were as far as I know, no legal issues. Debbie was their only child and her mother was very happy to look after her grandson. 

MUCINOUS OVARIAN CYST

VERY LARGE OVARIAN CYST- FIFTYEIGHT LBS

BENIGN MUCINOUS CYSTADENOMA.

Deena a thirty two year old very emaciated women came to our medical college from another state about 400 hundred miles away by train and then the three wheeler from the station. She was unable to get any treatment in her state. I wonder how she travelled. She was told that this tumour had become too big, and if they did anything she would die. Her family had heard of this new medical school. Therefore   she was brought to our very new medical college. This was in 1962, the college was very new. There were two lecturers, myself, who had just done her master of surgery after three years of graduation, which we could do after 3years, in those days, and another lecturer who was two years senior to me.

Deena came on my outpatient’s day so I took charge of her. Deena was young, skin and bones except for this very large ovarian cyst. It had been growing for the last six years. First the family thought that she was pregnant. She had had a baby six years ago when no baby arrived they started to get concerned.  There was no one to take her to the hospital.  Her husband was in the army and could not get leave. Any way when she saw me, she begged me to save her life for her son.

She had this very large ovarian cyst, and her total weight was 86kg I believe the cyst was about 50kgms. Her breathing was very shallow. A chest x-ray showed small lung capacity but, they were clear. Her Haemoglobin was 8 which was not too bad and her urine was clear. Ultrasound was not known in those days. I decided to operate on her.  I had to take consent from her and her family that if she died during the operation I would not be held responsible. I spoke the same language as Deena so I was able to explain everything to her in detail and reassure her.  My anaesthetist refused to anesthetise her, but he promised to be in theatre with me. It was difficult to put her straight on the table . We kept her upper body slightly raised. I gave her a local anaesthesia along the length of the cyst about 6cm long and made a tiny cut. It was great to notice that the cyst was multi loculated. Extremely carefully I aspirated hundreds of cysts so that they did not leak .After I had removed about thirty pounds of fluid from her cyst my anaesthetist was happy to anaesthetise her and relax her. I was able to put my hand in and feel around the cyst .The cyst was arising from the left ovary and was mobile. The ovary was totally gone the left tube was also destroyed. I put a catheter in her urinary bladder to protect it, and  extended the incision from just above the umbilicus to the pubic bone,  sealed or closed all the punctures I had made, and then very carefully removed the tumour with the tube ,of course the ovary was all incorporated in it. The right ovary and tube was normal. I made sure there was no spill. The weight of the remaining cyst was 28 ILBS. So the total weight of this cyst was 58 LBS. This meant that Deena weight was only 26 LBS, as the total weight preoperatively 86 LBS. I was very happy that the operation went very well. But then I had a big problem, how to close the belly. I had such large amount of Skin freely floating after being stretched for so long. I double breasted the muscles and the sheaths, cut the superfluous skin and stitched it in two layers. The sutures were removed after ten days. I kept the patient in hospital for two weeks to nourish her. The biopsy on the cyst confirmed it to be gigantic cyst adenoma without any evidence of malignancy.  Deena came to see me at three and six months. She was very well happy and grateful.

I earned a big name in town .Our photos were in the local papers.

Benign mucinous cyst adenomas of the ovary are common. They make up for 20 -25 % of all benign ovarian tumours occurring in 30 - 50 year old age group and they can, often be cancerous. Mucin is a protein produced by the epithelial cells of the baby, other organs such as pancreas; appendix and fingers can have this type of cyst. If ovarian mucinous cyst rupture they can cause mucinous deposits which can become a major problem .I have removed 100’s of mucinous ovarian cysts but never as big as this one.I have also seen an ovarian tumour in 1961 when a mucinous ovarian cyst must have ruptured, her abdominal cavity was full of mucinous cysts. We could not do anything for her. I wondered if they were cancerous as well.  My professor closed her without doing anything; she passed away a few days later.

BENIGN DYSGERMINOMA

UNPLANNED PREGNANCY WITH LEFT OVARIAN
TUMOUR - DYSGERMINOMA.

One of my regular patients called Wendy aged 26 years came to see me one morning in September 1982 requesting a termination of her pregnancy. At this stage she was 8 weeks pregnant. I had delivered her previous two babies who were aged 4 and 2 without any problems. I am not keen on terminations but I agreed to do this as she was finding it difficult to manage two infants without adding another one. Incidentally and luckily, I had a new Ultrasound machine brought to my office for demonstration. I thought it will be good to use this machine on Wendy. She agreed to it. It confirmed an 8 week pregnancy. I tried not to show her the foetus. But what I saw was a bit worrying. She had a 6 centimetre left ovarian tumour, both solid in some areas and cystic (filled with fluid) in others. It was knobby in appearance on the surface.

A Diagnosis of ovarian Dysgerminoma was made. Dysgerminoma is a germ cell tumour (primitive cells in the ovary from which all parts of the body grow) of the ovary. It accounts for 1 % of all ovarian cancer. It is common in children, adolescent and young women. It seldom occurs after 50 years of age. It seldom produces symptoms in early stage, as in our present case. The diagnosis is often made fortuitously on routine pelvic examination or ultrasound done during pregnancy. They produce certain substances in the body which can be useful in the diagnosis. These are called tumour markers. These would not have been useful in this case as she was already pregnant. The next important step is to know the staging of the tumour. A simple way to understand this is, if it is confined to one ovary or both ovaries, or it has spread to the surface of the ovary peritoneum and distant organs. Like this they are divided into four stages. By ultrasound I could make out that Wendy’s tumour was very early. The other ovary and the uterus were normal there was no fluid in the abdominal cavity. With this in mind I explained the situation to Wendy. I proceeded to operate on her. I terminated her pregnancy and proceeded to a laparatomy. The ovarian tumour was soft and solid. Peritoneum was clean and I washed the peritoneum and collected this fluid for pathology to look for any malignant cells, no lymph nodes were felt and the liver felt normal. Dysgerminoma can be malignant, but in early stages a simple removal of the ovary with the fallopian tube gives excellent results. This procedure is called unilateral salpingo-oophorectomy. The patient was discharged on day 5. The pathology reported it to be Dysgerminoma without any features of concern. The oncologist was of the opinion that no further therapy was required. Her pregnancy test became negative after four weeks. I took her under my care for the next 5 years. In the first year I did an ultrasound every 3 months then every 6 months and then every year. I saw her after 20 years; she was divorced from her first husband and had had 2 more children in the new marriage. Wendy was very lucky that her unplanned pregnancy became a life saver for her.

Fortunately I had a trial Ultrasound Machine which made the early diagnosis of her stage one Dysgerminoma Tumour possible. A simple unilateral salpingo-oophorectomy saved her fertility and her life.

In adults 3 percent of these can be malignant but they respond well to chemotherapy and radiotherapy. 

SPLENIC PREGNANCY

A TYPE OF ECTOPIC PREGNANCY

An ectopic pregnancy is a pregnancy which takes place outside the uterus. The incidence of ectopic pregnancy is about 20%.  The fertilized egg usually implants itself in different parts of the fallopian tube, sometimes on the ovaries and rarely on other abdominal organs. The tube and the abdominal organs cannot sustain this pregnancy, this can rupture or burst and cause intractable haemorrhage, which becomes life threatening and requires urgent treatment. When the fertilised egg implants to start with on other abdominal organs it is called primary abdominal pregnancy, rarely the pregnancy is expelled from the fallopian tube and settles down on abdominal organs. Such as, Omentum (It is a sheet of fatty tissue with the abdominal lining called the peritoneum that insulates the abdominal organs, Latin for apron) intestines or liver and continues to grow into a baby, the placenta also forms. This is called a secondary abdominal pregnancy. About 1.3% of ectopic pregnancies are abdominal pregnancies many cases of abdominal pregnancy are reported, few above the age of viability,   some even at full term. The ectopic pregnancy at any time is a life threatening problem. In recent decades it has become very much easier to make a diagnosis with the advent of pregnancy tests, very high quality Ultrasounds and MRI’s. Treatments have simplified as well. An operation can be avoided if the diagnosis is made in time. I always remember when a few friends had gone for a picnic about thirty kilometres from our medical school. One of my friends, whose husband was with us, started to feel severe abdominal pain and felt faint, we rushed back to the hospital having immediately made the diagnosis of an ectopic pregnancy, but we could not save her. This was in 1960.The pregnancy I am talking today about was a primary abdominal pregnancy on the spleen. This is one of the rarest sites for an abdominal ectopic pregnancy. So far, only nine such cases have been recorded in English literature to date. I found another case described from India in 2011 bring the total to 10 and I wonder if I can count my case as number eleven, as we never published this. This was in early1960 when I was an intern.

A woman called Katori aged 18 years was rushed to our emergency room, I was on duty. She was thought to be pregnant. Her period was 6 weeks late. It was about 6 AM. She was extremely; restless I was unable to record her blood pressure. I thought that I could feel a very feeble pulse in the neck. There was no time to do too much. Toad pregnancy which was the only pregnancy test available at this time in the world was not possible because it takes a day to get the results. There was no ultrasound in those days. There is a test called shifting dullness, which was positive, which meant that her belly was full of blood. A diagnosis of ruptured (bleeding ectopic) pregnancy was made. I put her on two intravenous drips, one was a dextran drip which was to improve the blood volume and the other was  called a noradrenalin drip to improve her bold pressure. I got her to the operating theatre quickly which was only a few feet away. I sent for my chief resident and my Professor who happened to be a general surgeon as well. The theatre was ready for the patient to be operated on, all the staff we had were there within fifteen minutes.  We had two units of O negative blood (universal donor) which was also started. We had no proper anaesthetist or a person trained in resuscitation. In those days, one of the resident doctors had to give open ether for anaesthesia. I had to do that on the day. One other resident had gone to the pathology laboratory with three of Katori’s relatives to cross match the blood. In those times we had to cross match the blood ourselves. My heart was in my mouth when I started the open ether, it was not difficult as she was very flat any way.  Katori’s  belly was opened it was full with almost  two litres of blood. This blood was filtered in a very simple way and transfused back to her. She was found to have a ruptured pregnancy on the lower pole of the spleen.  A spleenectomy was performed, which did not take much time. The abdomen was closed. For a few moments the woman seemed to have improved. We could record her blood pressure as 60/40.  One further unit of blood was being cross matched from one of her relatives. I was able to wake her up from the anaesthesia, which was such a relief. I could breathe again.  The ectopic pregnancy was confirmed on histology as few chorionic villi were seen.

She continued to show ups and downs in her condition with noradrenalin dextran glucose and saline drips, but she was not conscious or passing much urine. She finally passed away after twenty four hours probably due to kidney failure. We could not save her. There are many cases from my first two years as resident which I will never forget. This was one of them. It was like a war zone, no equipment, no highly trained personal and only the Professor.

Once upon a time ectopic pregnancies were a major cause of maternal death. 1n 1980-2007 as many as 56.5% per 100,000 live births and has been come down slowly to 0.50% of maternal deaths out of 100,000 live births, in 1980-1984. It was estimated that with current improvements this can decline further to 0.36 % of 100,000 live births. Unfortunately the racial and age disparities, persist. In countries with poor facilities, the deaths will continue. It was very reassuring that out of  the ten Splenic pregnancies reported in English literature there were no deaths. The main reasons are awareness, very early and very reliable pregnancy tests (we have come a long way from the toad test) very good ultrasounds and MRI. 

OBSTRUCTED LABOUR

This is a sad story about the failure of a labour to progress. It is not for those, who are faint hearted. Why does the progress of a normal labour get blocked? It is if the baby is too big for the size of the mother, or is it lying in a funny abnormal position; however the most common cause in the developing world is a distorted or small pelvis. This often happens because of poor nutrition from child hood causing problems such as rickets or in adolescent girls resulting in bone deformities called Osteomalacia. This causes not only a deformed pelvis, but deformed bodies. Often culturally more attention is placed to the nutrition of boys than the girls, and if there is not enough to feed everybody the girls suffer. Sometimes the mother is too young and not fully developed. In spite of many efforts by WHO, in some countries the maternal mortality remains as high as 410 deaths per 100,000 births due to obstructed labour and besides maternal deaths this causes long term severe maternal morbidity by way of vesico vaginal fistulas. There are half a million women in the world with fistulas, mainly in Africa and India. The college of obstetricians and gynaecologists is working very hard to prevent them happening by preventing   obstructed labour, better maternal care during labour, and also curing the fistulas in large numbers. The story I am going to tell you in this post is of one such girl.  I will have more stories about obstructed labour in some of my future posts.

This was in 1968, a very young girl named Renu aged 17 was brought to the hospital by her husband and brother on a home bed (CHARPAI).

She was in strong labour for some hours. She had not been able to walk for two years. Her thighs and legs were totally folded over her abdomen. She obviously was pregnant; and according to her mother in law almost full term. She had never seen a doctor or even a midwife. I wondered how the groom married her. He seemed a bit simple, or had she become disabled recently. Her pelvis was so narrow I was unable to insert even one finger and even the rectal examination was not of much help. I wondered how she had even become pregnant. She had to have a caesarean section (C.S) to have this baby delivered. 

There are two types of C.S, a lower uterine section, when a transverse cut is made on the lower part of the uterus, this is a safer C.S, as it is less likely to be torn or as we call it ruptured in the next labour. The other C.S. is called a classical C.S, this is a long cut made in the upper part of the uterus. This is a more risky procedure as it is likely to rupture more often ( 4% to 9% as compared to lower uterine scar which is less than 1%). Once a woman has had a classical scar, she must always have a hospital delivery by C.S.  In this case I had to do to a classical C.S.as I could not reach the lower part of the uterus due to the extremely narrowed pelvis. To add to my sadness when I pulled out the baby it was grossly abnormal weighing only 2.2lbs. It was what we call an anencephaly, this means that a part of the babies brain and skull failed to develop.

This is incompatible with life, so we did not revive the baby. There are many stories for anencephalic babies living for a while. The longest reported baby lived for 3 years. I once worked in an hospital in the UK, the sister in charge of the maternity ward did not allow us to let an anencephalic baby to be treated how we normally would have treated them. This one particular baby lived for 11 days. These days diagnosis of an anencephaly is made early on with an ultrasound, all women are offered an abortion, which most of them have. In 2012 about 208 terminations were performed in England and Wales.  Neural tube defects occur 1 in 1000, in the western world, were as it can be 5 in 1000 in developing worlds. The recurrence rate can be 4-5%, if there is a previous history of having had two such babies the risk raises to 13%.

Main reason for this to happen is poor nutrition and folic acid deficiency. In the western world this had been prevented by generous use of folic acid. In this case we could see the poor nutritional effect on the mother as well as the baby. We had lots of instructions for the family before they went home. Firstly we advised contraception for at least, 5 years. Regular visits to the village health centre, vitamin D, calcium, milk, eggs, and a high protein diet, regular physiotherapy, massage and plenty of sunshine. The next pregnancy must be supervised, and must be by C.S. in a hospital. Renu’s health could be improved if she was taken care of seriously. I found out that all this happened because of ignorance and carelessness rather than poverty. Unfortunately   I was unable to follow her case as I had to leave the country.

BIG BABIES

These are the stories of some of the big babies that I have delivered over my career. One of these was in India in 1960. Usmana a Muslim woman aged 38 years came into the labour ward and she was well established in labour, she was obese weighing 96 kgs. This was her 7th baby she never had any antenatal care (ANC), never had any problems with any of her pregnancies or childbirth. She came to the hospital as she wanted a tubal ligation so that she can also get a transistor radio which the Indian government was offering to all those couples who had a tubal ligation. This was to promote family planning in India. This was an enormous size baby lying as breech (bottom first). Her blood pressure was mildly elevated 146/90; her urine was loaded with sugar (Probably gestational diabetes). She was well advanced in labour her cervix was 8 cms (almost fully dilated). Luckily the presenting part was well down. I was very worried about the delivery, particularly the after coming head and post partum bleeding. Luckily she delivered so fast, I did not have to do anything. I gave syntocinon for the placenta which followed soon after.  There were no tears or bleeding. A glucose tolerance test which we did within 24 hours of delivery,(as is advised) confirmed gestational Diabetes. It was a male infant weighing 7.2 kgs’, it required care and treatment because of mothers gestational diabetes. I had to start believing in GOD even if I never did before this incidence; there were many situations that happen during obstetric practice that takes your faith to GOD.

The next case that happened was in 1978. This was a normal twin pregnancy which had regular ANC, but the babies were enormously big for twins. It was my practice to rest twin pregnancies in hospital from 28 weeks to 34 weeks in the hope of preventing premature labour which I did in this case as well. The babies were growing bigger every day; I decided to do an elective Caesarian Section (CS) at 38 weeks. Both babies were happily delivered; they were both females and weighed 7.5 pounds each. I felt safer in delivering them by CS, being such big babies the mother was 36 years of age and a primigravida. I followed these girls for many years I was advised that they were growing well and doing well at school.

The next woman I delivered was in Australia in 1986. By now I was an expereriened senior obstetrician. This woman was a recent migrant from Lebanon. She was aged about 37. She was not sure about her age, but this was the age in her passport.

She had had 12 children in Lebanon without any ANC or care during labour. All the children were alive and well. A very lucky family. She arrived in Melbourne about 30 weeks of pregnancy. When I saw her she was about 32 weeks pregnant. All her blood tests were normal. It is a routine in Melbourne to test all pregnant women for diabetes. This was very important in this case as she was obese weighing110 kgs, her B.P was normal. She had had 12 children ( the risk of gestational diabetes was very high in this woman because of her parity, age,obesity and this baby being very large) luckily for her she had a normal glucose test and no gestational diabetes. On Ultrasound it was estimated that the baby’s birth weight will be about 12 lbs. She did not know the weights of her previous babies, she thought they were average. This baby was almost always lying in different positions (Unstable lie) this is a serious complication of later stages of pregnancy. They baby can have a cord prolapse or even a hand prolapse then it can become very difficult to save the baby, and even the mother. I suggested to her and the family that we should deliver this by caesarean section, I had great difficulty in convincing the mother. I finally called her Priest who convinced her. A male baby was delivered by caesarean section and even this was difficult due to the position that the baby was lying in. The baby weighed 13.3 lbs and he did well.

I was greatly delighted when I was invited to his 21 birthday party and his mother was telling me he is the best of her 13 children. He had grown up into a handsome boy who was a charted accountant and played in a band.

The next biggest babies were born to a German couple. They were both about 6 feet tall, well built, very healthy with a good life style and they came to me for their first pregnancy at ten weeks. The pregnancy progressed well. They had told me that they were themselves big babies when they were born and weighed about 8 to 9 lbs. This labour started well, she required an epidural for pain  relief and normal labour progressed. She had a normal vaginal delivery of a male baby weighing nine lbs and two ozs in good condition with a good *apgar, with an episiotomy.

*(APGAR- measures the following in a baby-Activity (Muscle Tone), Pulse, Grimace (Reflex Irritability), Appearance (Skin Colour), Respiration).

No dramas, no Post partum haemorrhage. All went well. Two and half years later she came back to me for her second pregnancy. This time the pregnancy progressed well. She had no Gestational diabetes. This baby was also a big one, the ultrasound estimate of the foetal weight was ten and half lbs, I felt a bit anxious, but I knew that she had a well shaped big pelvis, and we would manage. This time she had a very quick and easy labour, she did not require even pain relief, however I repeated the episiotomy. He was born with good apgar weighing ten lbs four ozs. I felt happy.

Three years later I saw her for her third pregnancy. Now she was 34 years of age still well, she had not put on any weight, her blood pressure was normal, her glucose tolerance test was normal. Towards the end of the pregnancy I realised that this baby was really big. Estimated foetal weight was twelve lbs. I discussed caesarean section with her. Finally we agreed to give a trial of vaginal birth and if at anytime I felt that there was a problem I would do a caesarean section. Luckily she agreed. Labour progressed slowly with the help of an epidural. Towards the end the second stage was slow, that is, that it was longer than average for the baby to be born after full dilatation of the cervix. I delivered the baby by forceps, with a good apgar. Again it was a male baby, weighing 12lbs and 9 oz. There was some excess bleeding but not amounting to Post partum haemorrhage, which is when the bleeding is more than 500 mls.

I was in touch with the family for a long time; all the boys became involved in sports.

This story is of a big mother (Very Obese) who had a very big baby. This also showed me how I would get some sort of sixth sense about my patients .Christine was admitted to the hospital at 38 weeks of pregnancy as she was not feeling well.  At 9 pm I saw her and she was not too bad, her blood pressure was border line high 140/90, the urine was clear foetal heart monitoring was normal. I advised some sedation for her with a view to review her in the morning. In the middle of the night I felt like that I should go and see her now. When I got there the baby was very restless, the foetal heart sounds were non reassuring, I decided to do a caesarean section immediately. It was not an easy task because of the mother’s weight; the baby proved to be very big, with the cord round the neck (I wonder if that caused foetal distress), the baby’s extraction from the uterine cavity was not easy. It weighed 15 lbs and 6 ozs. It was the biggest baby I have ever delivered. The baby’s apgar was 7, it did well. There was a paediatrician present at delivery. The mother did not have gestational diabetes.

I understand that this baby remained big for many years. Maybe this was due to poor life style factors of the family.