STORY ABOUT PEMPHIGOID GESTATIONIS OR AS IT WAS KNOWN BEFORE-HERPES GESTATIONIS

This story is about Mary a young mother of 26 years of age. She had a normal first pregnancy, two years ago. There was no history of any problems associated with that pregnancy. Her current pregnancy was going well. When she presented at 32 weeks for her routine antenatal visit she complained of severe itching and puritis around the belly button.  She also had a few blisters also around the belly button. There was some redness in her thighs as well. She said she was starting to itch very severely when I looked as these blisters; I immediately thought of a condition called herpes gestations or pemphigoid gestationis (PG). This is a very rare skin disorder which occurs during pregnancy only. It has nothing to do with ordinary Herpes. It’s frequency is quoted to be 1 in 70 000, or 1 in 2 million. I had never seen a case before, or ever since, but her very intense puritis and blistering around the belly button made me think of this diagnosis.

I urgently referred her to a colleague of mine, a skin specialist. He soon confirmed the diagnosis. The diagnosis is confirmed by skin biopsy and a technique called immunoflorescence test to look for antibodies. This may be a bit technical for you, please do not worry about it. PG is an autoimmune disease of pregnancy. There are many other diseases in our body which are autoimmune. Autoimmune diseases are a range of disorders, when an individual’s immune system produces an inappropriate response to its own cells resulting in damage to the tissues for example:  Rheumatoid arthritis. In PG, antibodies form in the skin, against a protein between the epidermis (the outer layer of skin) and dermis (the inner layer of skin) and then destroy the skin. What triggers this reaction is not understood. This diagnosis was confirmed by my skin specialist colleague. He advised the usual treatment of local Corticosteroids for itching. She also had some systemic Oral cortisol. To suppress the severity of the problems, she was also given some intravenous Immunoglobulin’s. These help to make the disease a bit milder.  There are many other drugs on the market which can be used for this purpose but they were not required in her case. The other complications in this situation are; premature delivery, foetal growth restriction, secondary infection and scarring. I watched her for all these. An ultrasound was performed every two weeks to make sure that the baby was growing well. She managed well with the treatment; however she did get some rashes on her thighs. She did not have any associated disorders. The main disorder that PG is associated with is autoimmune disorders of the thyroid gland, Graves’s disease (overactive thyroid) or underactive thyroid such as Hashimotos disease. Another condition that can happen and make pregnancy difficult is pernicious anaemia. Other skin disorders are not often confused with PG as the nature of the rash is different and the symptoms are different.

An ultrasound at 36 weeks suggested that the foetal growth was being compromised as the fluid around the baby was decreased more than expected. I induced her at the first opportunity by normal induction method. Her labour was easy; a male baby weighing 2.63Kg was born in good condition. The baby had a few rashes on the abdomen. This can happen in 5-10 % of babies, as the antibodies can pass through the placenta .She did not have any trouble in the post partum period as the rash had cleared within 3 weeks. She was discharged home happily. I did advise her not to use oral contraceptives as PD can recur with oral contraceptive. It can also recur during menstrual cycle. I fitted her with an IUCD for contraception. To the best of my knowledge she never had any further problems or another baby. I was very pleased with myself for making this very rare diagnosis in a flash and had a comfortable mother and a healthy and happy baby.

STORY OF ROUND WORMS

Nina came to our hospital in June1960; I was a bit more experienced as a doctor. It had been just over a year since I graduated. She complained of a lump on the lower left side of her abdomen, with frequent abdominal pain. She was a young girl of about 20 years of age and not married. She was nonvegetarian. She looked under nourished. She had not had a menstrual period for six months her blood count showed, what we call mild eisinophilia, we did not pay much attention to this , although Ascaris can cause an eisinophilic pneumonitis. This can happen even without Ascaris her ESR was raised. Surprisingly the stool examination did not show any Ascaris ova this means that she had an infection somewhere.  Genital Tuberculosis was fairly common in India in those days. This can cause pelvic mass and absent periods. We had very basic x-ray services and ultrasound was unknown in the sixties. A clinical diagnosis of pelvic tuberculosis was entertained. She was given Anti tubercular treatment for three months but nothing changed. It was decided to do a laparatomy: guess what we found. A lump made of 16 Ascaris worms totally sealed by the peritoneum, arising from the fallopian tubes. There were sixteen worms in all. They were all removed. No holes could be seen in the bowel. The abdominal cavity was cleaned and closed. Nina made an uneventful recovery. She was subsequently given more treatment to clean her bowel of any Ascaris. It was also explained to her about personal hygiene and the meat she consumed. The cause of her not having a period was probably due to her poor nutrition. Her chest x-ray was clear 

Ascaris is one of the most common worm infections in the world. About one billion people suffer from it. It is a big fat round worm,

which can grow up to 35 cmin length. It can go round different parts of the body via the blood stream. Initially it can cause eisinophilia in the blood which we ignored, as there were no Ascaris ova in the stool.  In gynaecological literature many cases of Ascaris in the fallopian tubes have been described, and the first one was in 1926. 

TRIPLET PREGNANCY

It was November 1962; it was the second day of my new job at Benares Hindu University where; the government had just opened a new medical school. I and another doctor, from the same medical school were appointed as lecturers in obstetrics and gynaecology, after getting our masters of surgery qualifications in Obstetrics and gynaecology and under the supervision of a professor of surgery.

It was up to us to establish the department, attend to the paper work, and do whatever else was required. It was my second day in my new job. There was a registrar on duty in the department and she called me at about 5 am to come to the hospital urgently. An ambulance was sent to pick me up, which was the general rule because this way we were assured, that we would arrive very quickly. When I arrived in the labour ward, there was this woman Sitara Devi aged thirty-four in very strong labour, shouting and howling. This was her seventh pregnancy. She had six other children, all girls at home between the ages of twelve and two. She had never had any problems with any of her other pregnancies. They lived in a nearby village, her husband was a rickshaw driver, and they had decided to have a tubal ligation hoping that this baby surely would be a boy. She had never seen a doctor or a doula during this pregnancy. When I saw her she looked weak and emaciated what else could I expect. Her blood pressure was on the low side, she had an enormous belly. There was no time to measure it, we started her on an iv infusion in case she bled. In this hospital there was an x-ray department, but it was so early in the morning and there was no time for all this. I was sure that this was at least a twin Pregnancy with too much fluid; I was hoping that the babies were not abnormal. Within the next five minutes she delivered her first baby. This was a female weighing 4.6lbs. I was starting to wonder if there were three babies. I had never seen a triplet pregnancy the incidence of triplets is quoted as I in 60 000 or 1 in 200 million. They are now commoner with assisted technology. In the next ten minutes she delivered her second baby this was also a girl. I gave her an injection called syntocinon so that she will not bleed even though I was suspecting a third baby. It was very silly of me. This baby was lying with feet first which meant it was going to be a breach birth so I had to do a breech extraction. The baby came out in good condition; it was also a little girl. These babies were identical.  I felt very sad for the couple as they had wanted a boy but now had nine girls. l left the labour ward telling my registrar to deal with them Sitara did very well. She went home after 4 days with 3 new healthy girls. They did not have a tubal ligation hoping for a son in the future. Nearly 55 years down the track I still wonder about these girls. At medical school I had another Asha in my class who had 8 sisters. They came from a good family, they all became doctors. I wonder if any of these sisters made something of their lives. 

INJURY TO THE VAGINAL VAULT AFTER DELIVERY (CHILD BIRTH)

Pyarai aged 22 was discharged home on the third day after a normal child birth. This was her third child. She was sent home with her mother. She was explained about contraception. According to the latest Indian rules we were happy to do a tubal ligation as this was her third child. Her age did not matter. She did not want this, we advised her to return in 6 weeks so that we could fit an intra uterine loop, that is what we used in those days, it was 1959. However to my disgust she was brought over by her alcoholic husband to the hospital at about 2.00 AM, with a loop of bowel hanging between her legs. I was horrified; I did not know what to say or do. Obviously he came home dead drunk and forcibly raped her, the soft vaginal wall tore and a loop of bowel came down, for a change this was an easy case. I first started an intravenous drip, put her head down, and examined the bowel made sure it was not damaged. I replaced it very gently, gave her antibiotics and repaired the torn vagina. We kept her in hospital for 5 days, seeing her husband’s behavior; my boss put an intrauterine device in for her before she went home. This was not   a routine, but we had to do it for her. These days we keep talking about cruelty at home, I have been seeing this as an obstetrician, particularly in countries like India for last 60 years. Nothing has changed, cruelty towards women continues. I so much wish that organizations, like The Melinda and Bills Gates charities, governments, Millennium Development program's, prevention of domestic violence can help these women with education equality and empowerment. Happy families make happy societies’, happy nations and in the end a happy world.

MOLAR PREGNANCY (HYDATIFORM MOLE)

It was still the month, of August 1959; I am still the junior most resident posted in the septic labour ward (labour ward for neglected women who were very ill). Najma a 37 year old woman from a nearby village came in, apparently in labour, with some bleeding, This was her fourth pregnancy; she did not know how pregnant she was. She conceived while she was breast feeding the last baby who was born two years ago. She never had any problems with her previous pregnancies. She had not seen a doula or a village doctor. She was on the obese side; we could not get her weight as she was not so well. I started to examine her; she had a fast pulse and a somewhat low blood pressure. On abdominal examination I was unable to feel any baby parts, there was no foetal heart. The abdominal girth was forty two centimetres. I tested her blood on my small pocket Haemoglobinometer (HB) which we carried in our pockets for emergency. The Haemoglobin was 2.  The average HB in Indian women is often between 8 -12.  In those days we had no Ultrasound (never even heard of it). The x-ray department was about half a kilometer away. The patient could not be moved in any case. It was five AM. I was not sure what was going on. Was it a twin pregnancy with massive fluid or was it a pregnancy with massive bleeding? I sent for my registrar who was a very capable doctor. We decided to put up an IV and emergency blood, which we used to keep O, Rh-negatives. It was only two units. In emergency we had to cross match blood for our need and bleed the donor. The pathology department was also far away in the main hospital. However one of my senior colleagues went to do this cross matching and took the relatives with her .My registrar came over and very gently tried to examine her, by now she was bleeding profusely and passing out tissue which looked like bunch of grapes. Both of us immediately got the diagnosis. It was what we call a molar pregnancy. We had exhausted our emergency blood, the cross matching blood was not yet ready as it takes nearly two hours, and the same doctor had to bleed the donors. The woman was bleeding like a tap, the whole big labour ward full of blood and within two hours of admission, she passed away, as if she had come to the hospital for dying. Her relatives were very angry. They wanted to kill me, as I was their first contact my registrar advised me to hide myself in the duty doctor’s room, in the bathroom, which I did. They hung around the hospital to find me and kill me, I was so frightened. However it all settled in the end. Our professor explained to all of them, that they have to take greater care of their mothers to be. From then on we had a regular flow of pregnant women from that village.

Molar pregnancy and many other complications of placental diseases, are together addressed as gestational (pregnancy) trophoblastic (arising from the placenta) diseases. Molar pregnancy is when; an abnormal fertilized egg plants itself inside the uterus and fails to grow like a normal baby. It is a disease of the placental tissue; it grows like massive tissues which look like grapes. The word mole simple denotes a mass of tissue .It is a noncancerous placental tumour, which can turn cancerous, it is then called Choriocarncinoma. Choriocarcinoma can also rarely arise after a normal miscarriage or a normal birth. There are two types of molar pregnancies, a complete mole or a partial mole; it is called a complete mole when an egg is fertilized by one sperm, all the female chromosomes die. The father’s chromosomes duplicate and make 23 pairs which is the normal chromosome number. No embryo, foetus or a normal placental tissue is formed. A partial mole is when the egg is fertilized by two sperm or one sperm duplicates, mother’s chromosomes remain, hence the embryo has 69 chromosomes. This happens if the egg has no nucleus or an inactive nucleus. Molar pregnancies are common among the Asian population say 1 in 100 as compared to western population where it happens 1 in 1000. The risk factors are, if you are of Asian descent, you are older than 40 (5times) or younger than 20 (1.5 times) you have had a previous mole (30times) and a previous miscarriage (twice as often). I have often seen molar pregnancies in young girls at the time of a miscarriage. It is a part of the same process of pregnancy failure. When a woman has a molar pregnancy she often suffers severe vomiting as compared to a normal pregnancy, intermittent vaginal bleeding and pelvic pressure pain. They can even pass grape like tissue pieces with their bleeding; they often get early rise of blood pressure or even like toxaemia of pregnancy which is a disease of late pregnancy. I have seen excessive vomiting causing liver failure in very malnourished young girls. Najma also had excessive vomiting; her blood pressure was never checked. On admission she had  low blood pressure as she had been bleeding, when a person bleeds the blood pressure goes down. A very small number of women may also develop symptoms of overactive thyroid that is they feel agitated, shaky, anxious, and cannot sleep. This happens because the very high levels chorionic gonadotrophins ( the pregnancy hormone in molar pregnancy )upset the control of thyroid  production. About one third of women with molar pregnancy also develop ovarian cysts on one or both sides because of high levels of pregnancy hormones. They almost always resolve, when the mole is gone. They are not cancerous.

In this day and age the diagnosis of molar pregnancy is easily made by ultrasound as early as eight weeks. Sometimes a vaginal ultrasound is required. The others tests that are done are to measure the blood levels of pregnancy hormones; a Thyroid function test, blood for haemoglobin and blood count, general liver and kidney function tests.

The treatment is simple under general anaesthesia in a hospital the molar pregnancy is removed by vacuum aspiration .Your clinician will explain all the details. All the tissue is sent to pathology. You will be able to go home in 4 hours. Rarely if the molar pregnancy is extensive or it is invading the uterus and you do not want any future pregnancies the uterus is removed.

After this initial treatment you require follow up regular pregnancy hormone tests and ultrasound to make sure there is no molar tissues in your body and your ovarian cysts have also resolved. Thyroid function tests and blood tests are also done to make sure that you are fully recovered. You are advised not to get pregnant for one year while the molar pregnancy is fully resolved.

In about 20 to 30 percent of Molar Pregnancies and rarely after a normal pregnancy and miscarriage a Choriocarcinoma (Cancer of the placental tissues) develops and it requires special investigation, treatment and follow up which we are not discussing in the post.

SURGICAL METHODS OF CONTRACEPTION

SURGICAL METHODS OF CONTRACEPTION

Sterilization for women and men 

What we need to understand

Sterilization with reference to family planning means permanent prevention from getting pregnant. For this to happen; the individual needs an operation. For women it is called tubal ligation or occlusion, for men it is called vasectomy. The partners need to consider it very carefully because it is permanent. Sometimes a single woman feels she never wants to have a baby and has a sterilization fairly young. I feel they need to think about it seriously. It can be reversed, however the success rate cannot be predicted. It also depends on the method of tubal ligation and what method was originally used.  If they were burned or totally removed it cannot be reversed.

pictures

Before the advent of so many methods of contraception, sterilization was very common. In countries like India, when India was trying to control its population the public was encouraged to use sterilization or vasectomy; if they did so they were given a transistor radio as a gift. It was unfortunate that many young men had a vasectomy in the greed of a transistor radio without understanding its serious consequences. Now since we have long term reversible contraceptives such as, intrauterine devices or hormone implants, the frequency of operative contraception has gone down.

VASECTOMY

It is an operative method of contraception for men. The tube called vasdeferens carrying the sperm from the testicles to the penis is cut and tied so that when ejaculation occurs, there are no sperm and the partner cannot get pregnant. This takes few months as the residual sperm will still be there. They are stored in the Epididymis as shown in the diagram below. A test is performed on your ejaculate before you are cleared for sexual relations and that there is no sperm. The sperm in your body is naturally absorbed, and there is no build up.  There may be infection or bleeding as a result of the operation but it is rare. Before you decide to have this operation performed, a man needs to think very carefully about the fact that he will no longer be able to produce any offspring however we now have the medical technology to freeze sperm should a child be desired. A vasectomy can be reversed however the results are uncertain. A vasectomy is simple and has less extra complications; it can be done under local anaesthesia.

TUBAL OCCLUSION

If you decide to have a tubal ligation, you and your partner should discuss that this is what you want. You may also discuss the alternatives with your doctor, maybe one of these appeals to you. Make sure you never want a baby or another baby. It is better if you are, older than thirty years of age. Research has shown that women often regret if they had a tubal ligation very young. The frequency of divorce also complicates matters further. In modern times the tubal occlusion is almost always performed by keyhole surgery called, laparoscopy. In developing countries where there are no surgeons who can do it or there is no equipment, as this is expensive, it is done by open surgery. Give yourself time to think about it. Keep up with your regular contraception until the very last day or to the last tablet.

There are two ways, how tubal ligation is performed.

 OPEN METHOD

This means that you belly is cut open. This is like any other surgical operation. The operation is explained to you and your partner. You have to be very sure that you want this done. In some countries they coerce to have this done by giving you money or electronic, goods. In my view it is safe if you have a good marriage, you have three children and you are above thirty years of age. After the basic things are decided, you go to the operating theatre after having given the, consent. The operation is generally done under general aesthesia by an anaesthetist. The surgeon then makes a cut near the bikini line, which is about 3-4 cms long. He then identifies the tubes and blocks them.  Different methods are used by different surgeons to block them. The urinary bladder which lies in this area is always emptied, to prevent it from being injured. The belly is then closed by sutures that do not need to be removed. Generally you can go home the same day or the next day. This operation is called mini laparatomy. It is done when you are not pregnant and using a proper contraceptive. I had an incidence when a woman who had sex the night before her operation was due, thinking this cannot do any harm, She did not turn up for her six weeks visit in spite of my requests finally when she arrived, she was twenty weeks pregnant. It was worked out that she became pregnant the night before, as she did not use the condom that night which was her normal usual contraceptive. It is best to do tubal ligation soon after a period (Proliferative phase of menstrual cycle) when the woman is not likely to get pregnant .Tubal ligation can be done at the time of caesarean section, however the failure rate of these tubal ligations are slightly higher than the ones done when you are not pregnant. Also the other problem can often be that if the baby is found to have a serious medical condition and he can die, than it can be a disaster. I am not very keen on doing tubal ligation during the time of a caesarean section or at the time of an abortion, as at that time one may not be emotionally ready.

There are several methods of Tubal ligation usually named after the Surgeon who described them. There are different parts of the tube shown in the picture below.

It is best to lift up the tube in a tissue forceps, make sure this is the part of the tube where the blood supply is least. This protects the ovaries from their blood supply being compromised. The tube is then compressed, tied and cut. About one cm loop of the tube is cut and sent to pathology. This confirms that the tube was cut. It is also very useful in any medico legal situations if they arise in case the tubal ligation fails and the cut end of the tubes are diathermied to prevent recanalisation. We make sure there is no bleeding. This is done on both sides. The tubes are put back in the abdominal cavity. When the suture material is absorbed, the cut ends of the tube separate.

This method of tubal ligation is called Pomeroy’s method. It is very simple and can be taught easily. The failure rate is 1 per 1000 at the end of one year, 7.5 per 1000 at the end of10 years. There can be deaths due to bleeding or infection although it is rare. I have seen one death after a postpartum tubal ligation probably due to deep venous thrombosis.

The Aldrige method is more temporary, where the  Fimbrial  end of the tube is tucked in . It is good for a successful reversal.

A number of surgeons remove the whole tube. This can interfere with ovarian blood supply however the recent research has shown it to be protective against ovarian cancer.

 In another method called the Madleners methods, the tube are crushed at two points and tied. No tube is removed. I have seen two cases of hydrosalpinex (swollen tubes full of fluid) following Madleners tubal ligation.

Tubal ligation can also be performed via the vagina. The vaginal tubal ligation is hardly used anywhere in the world. It also has a high risk of infection. The tubal ligation even by laparatomy can sometimes be difficult if, a woman had many pelvic surgeries or infections, as this can make difficult to identify and lift up the tubes. If following a tubal ligation, you feel you may be pregnant see your doctor urgently. If it is an early pregnancy it can be aborted if you so desire otherwise   doctors can look after your pregnancy.  Tubal ligation as such does not do any harm to your pregnancy.  Always call your doctor if you have unusual pain, fever, abnormal bleeding, pain in the calf and any other problem that is worrying you. Complications of tubal ligation are generally minor and easily managed; your surgeon always discusses these with you.

KEYHOLE SURGERY OR LAPARASCOPY

Keyhole surgery is the method used in most countries. It is often not used if the woman is obese, or is likely to have pelvic problems which can make the identification and picking up of the tubes difficult. It is usually done under a general anaesthesia in a well equipped hospital by a properly trained surgeon. The surgeon explains the procedure to you. The complications, failure rate and reversibility is also explained to you depending upon the method he uses. After general anaesthesia, he then makes two cuts one near the belly button and other at the bikini line in the middle or to one side. The belly is filled with gas, he identifies the pelvic organs, once the surgeon has access to fallopian tubes, and he usually seals them off by using, Filshie clips or rings. Sometimes they burn them and then may or may not cut them. It is harder to reverse the tube once they have been burnt.  Filshie clips are expensive and require an extra gadget, so it is not often used.

Some surgeons often prefer either to do the removal of either the tubes, or do a removal of Fimbrial ends of the tubes only. Recent research has shown that it is protective against ovarian cancer, as most of the ovarian cancers seem to arise from the Fimbrial end of the tube. One ovarian cancer is prevented after 100 such operations have been performed.

A new surgical method of achieving tubal occlusion has been added to help women. This is called hysteroscopic sterilization.It is only available in limited countries. It can be done under light sedation even in the surgeon’s office.

The surgeon inserts a small titanium coil, going through the vagina into the uterine cavity and than going through the tubal opening deposits the coil in the tube this coil is called ESSURE. At present this is the only hysteroscopic method available. After this operation you have to wait three months so that your body has created scar tissue around it totally blocking your tubes. At the end of three months a special test is performed to make sure that in fact your tubes are blocked. During this time you have to continue using your normal contraception before they confirmed that they are blocked. This was considered to be a negative factor regarding Essure. The failure rate is higher than laparoscopic sterilization. Reversibility has been tried with some success.
In recent times there has been some controversy about Essure because many women have required repeat operations. Some of these women who had this done in many situations were already compromised because of obesity, previous surgery, and co-morbidities. The repeat procedure had to be performed under a general anesthetic, which was not completely satisfactory. In view of these recent objections, please be sure that you are happy to have this procedure performed upon yourself.

HYDROCEPHALUS

STORY ABOUT HYDROCEPHALUS

This is also my story from August 1959, I was still posted in the septic labour ward, and the ward was where the women who were neglected in labour outside the hospital came in for further care and management.  Sarla a beautiful 19 year old was one such woman. She never had any care for her pregnancy. She had been in labour for two days; her waters had also broken two days ago. The baby was not coming, her Doula looking after her asked her to go to the big hospital as she was unable to do anything for her. It was early morning when she arrived, I was on duty, when I saw her, she appeared to be a fit young woman. I was unable to hear the foetal heart sounds therefore I assumed that the baby was gone. At that time we had no sonic aids, CTG, machines or any x-ray facilities.

On abdominal examination it felt like a big head when I did a pelvic examination, I felt a tense bag of fluid. I was not sure if this could be a hydrocephalic head or a bag of membranes, which may not have ruptured. (Please do not forget that I had graduated only few days ago)

I requested the nurse, for A lumber puncture needle (a long fine needle used to do a spinal puncture). With this needle I punctured the tense bag of fluid. With a great rush, lots of fluid and a baby came out hitting me on my chest. Obviously it was a hydrocephalic head.

In the human brain there are spaces which are fluid filled called the Ventricles. The spaces in the Heart are also called the ventricles.

There is a set of four ventricles in the brain, they are all connected with each other and a central canal of the spinal cord. The fluid that flows thorough these canals is called cerebrospinal fluid (for short CSF). Of these, there are two lateral ventricle right and left on each side of the front part of the brain, there is a third ventricle in the middle part of the brain which is connected to the lateral ventricles by a small opening called ,Foramen  of  Monro . The fourth ventricle lies in the posterior part of the brain. It is connected to the third ventricle by a very narrow channel called aqueduct of sylvius.

Besides these, there are other spaces called cisterns and foramens. All these together allow the free flow of CSF.

In each ventricle there is a network of specialised blood vessels with special cells called ependymal cells. It is the choroid plexus which produce two thirds of CSF the rest is produced by the lining of the ventricles and a special space around the brain called subarachnoid space.

CSF contains the same amount of sodium like blood . It has much less protein. Its osmolarity is the same as the blood. 500 ml of CSF is produced each day. It constantly moves all the time, 3.7 times each day, the resultant fluid present at any one time is 100 to 160 mls

CSF serves very important functions for the brain. It keeps the buoyancy of the brain, weight of the brain is 1400 gms, however when it floats in the CSF it records only 25 gms. It protects the brain from injury during sport and accidents. It also maintains the chemical stability of the brain and protects it from infections.

It protects the brain from ischemia, if by chance the CSF volume  drops CNS pressure drops, it then sets up a blood flow. Besides all this CSF supplies the nutrition to the brain and removes waste products and toxins. It also acts as basic immunological protector

It seems that normal head and CSF is very important for the normal human life and function. After all the brain is the band master of the body orchestra. So why we get hydrocephalus? And how do we deal with it. Again this means too much water(hydro)around the head(cephalus)

Congenital hydrocephalus means hydrocephalus present at birth. It is not an inherited disorder; it only means it is present at birth. It usually happens if the CSF cannot move normally and one of the passages is blocked. This often happens if the baby is born with other brain abnormalities. These together are called neural tube defects. One of the commonest one is spinabifida others are less common such as hydrancephaly .

This can happen if the

1) Foetus has a haemorrhage

2) Aqueductal stenosis

3) Blocking of the cisterns or foramina

4) Neural tube defects encephaocoele

5) Infections in the mother, Toxoplasmosis or syphilis

6) Tumours in the foetus or baby

7) Genetic abnormalities

So obviously the flow of the CSF is obstructed or even too much is being produced. At the time when I had a demised hydrocephalic foetus we had no tests not even a post-mortem to see if any abnormalities where present.

Now of course you can suspect a hydrocephalic head very early in pregnancy, and also look for any other abnormalities.

Now we do a chromosome analysis. These are found in 20% of cases of hydrocephalus. Further assessment can be done by MRI. If the problem is complicated a termination of pregnancy is offered. If it is isolated hydrocephalus, progress of ventricles is monitored. Delivery is done at a place where there are facilities for neonatal intensive care. Surgical drainage is generally done for the blocked ventricles. Foetal shunting has been attempted, but needs further  improvement . Mothers Needs to be advised to take 400 micrograms of folic acid when they want to get pregnant again.

The above photo is by ultrasound. It is floating choroid plexus and dilated ventricles.

PREGNANCY TEST PAST AND PRESENT

It was the first of August 1959 I had just qualified as a doctor. My life’s ambition was achieved, not only have I become a doctor, that I stood first in a class of hundred and fifty men and women. I was on cloud nine. My first day at work, as a Dr started at 7 AM, Dr E called me into her office and asked me to go to the pathology for a pregnancy test. The pregnancy test was to be done for the princess of one of the independent states. There were some states still scattered throughout India after independence. This princess had never had a baby, as it was known that the prince was azospermic.  Maybe the princess had an indiscretion, on this occasion my boss had to know what was going on.  It was a hot day, and it was raining as well, she asked me to take her car which was outside with a chauffeur. For the pregnancy test we had to go to the pathology, it was about one kilometre. The car was a green Chevrolet. I was so delighted with this permission. I forgot all about the test and became very excited about the thought of sitting in this beautiful American car.  I had never sat in a car before. My dad was a lecturer at a prestigious university and we all lived on the university campus.  There was a school for the university staff children.  We never required a car. Sitting in the car, I was not thinking about the pregnancy test which I was thinking of earlier, but now I was thinking when I will be able to have a car. After I finished my training in obstetrics and gynaecology I got married. We went to the UK. My husband was already working there. The very first day we were standing on a bus stop, my husband noticed that I was shivering , he said to me he is coming in few minutes, when he returned, he was in a beautiful  blue  Beatle(VW)  Car . He said to me “let us go”. You cannot imagine my joy.  In my excitement of the car let me not forget the pregnancy test.  My very important job on day one, as a doctor was to get this pregnancy test done. I did not even know at this stage that these tests could be done at our college.  My bosses said go and do an (A Z) test.  She called it  Aschiem-Zondek .This is described further down in the text. There was a similar test, called the toad test which was introduced by, Lancelot Hogban looking for the pregnancy hormone called human chorionic gonadotrophin (hCG ). This was discovered in 1930.  It is produced by the trophoblastic (very young placental cells) cells of the fertilized egg. The hormone is excreted in the urine of the pregnant mothers. The urine from a pregnant woman was important; some ancient Egyptians used to do a very different pregnancy test with the urine. This was in 1350.BC. A woman who was supposed to be pregnant was made to pass urine on wheat and barley seeds over several days. If the seeds grew the woman was supposed to be pregnant. Not only that they declared the sex of the baby as well., however this was disputed, if the barley grew the baby was supposed to be male, if the wheat grew the baby was thought to be female and vice versa. The urine of men, and non pregnant women did not germinate the seeds.  It was speculated that the increased levels of oestrogens in the pregnant woman’s urine may be the cause of this success. The human chorionic  gonadotrophin,  the  pregnancy  hormone  was not discovered as yet. There were many weird tests for diagnosis of pregnancy using urine.  There was the Ribbon test, the ribbon was to be dipped in the urine, if the woman gagged or vomited smelling this ribbon she was considered to be pregnant. Then in 1500AD there was an eye test described by a Dr Jacques Gulliemeau  in which a pregnant woman’s eyes get deeply set with small pupils, drooping eyelids, swollen little veins at the corner of the eyes.By 1900 the piss became an important commodity. At this time the pregnancy hormone chorionic gonadotropin(hCG) was being discovered in the blood and the urine of the mother to be. Two scientists, Selmar Aschheim and  Bernhardt Zondek  invented a test in which the urine of the woman to be tested was injected in an immature rabbit, rat ,or mouse, several doses over many days , after many days the rodent was killed to see if it had ovulated , or ovaries have grown the corpus luteum  has developed , i.e. it is gone on heat  in spite  of the rodent being immature. If this happened the woman was supposed to be pregnant; it became a cliché to say that the rabbit died, which meant that the woman was pregnant. This test was good but expensive and the animal had to be killed. A -Z test did not last for long .By 1930 hCG was studied in detail, it was certain that this hormone is produced by the placenta and can be detected after the implantation of the pregnancy.  The Americans consider the pregnancy to start with implantation.  The toad test was being performed with a vengeance, both on male toads (bufo and female frog (south African clawed toads – xenopus). The male toad laid Sunitpermatzoa and the female toads laid ova. When my boss sent for this pregnancy test it was meant to be the toad test. When I arrived at the lab there was a technician with a few toads in a tank of water, the technician injected one of female frog with some urine, just under the skin. He asked me to come the following day. When I arrived nearly 24 hours later the tanks had a lot of frog’s eggs floating in the tank. This confirmed that the woman was indeed pregnant. She had a hysterectomy performed in the name of fibroid uterus. She indeed had fibroids as well which were causing her trouble. This saved the day for everybody concerned, particularly the princess.These tests for diagnosis of pregnancy were called bioassays the immunoassay tests started instead of bioassay test. Bioassay tests were cumbersome, expensive and required special space, staff and laboratory animals. It was often a false positive because of another hormone, Luteinising hormone ,produced from the pituitary which is produced in the normal menstrual cycle. By now many Hormones were identified, it was also discovered that hCG has a beta subunit fraction which is specific to pregnancy. Special monoclonal anti bodies(proteins specific to particular proteins) were also  discovered for the  beta subunit fraction of  hCG  . Judith Vaitukailis devised the first home based pregnancy test at the national institute of health in 1970 however; she missed out on its patent. These tests are based on antigen (a protein) and antibody reaction. An identifying medium is also added. Initially it was a radioimmunoassay, then they did it with blood, called  haemagglution inhibition test and then later it was a called a latex agglutination inhibition test. A dye was also added for identification. By  1978 all these tests became commercial with an annual sale of 20 million US dollars. In 1968 Margaret Crane got the US patent for 3 million US dollars.

Between the years of 1960 and 1980 ,Further improvement in Immunological techniques and our knowledge on  hormones  increased the bioassay done for pregnancy tests, were totally replaced by immunoassays  for pregnancy testing. Ultrasound also started  playing its role from 1960 onwards. Immunological tests are more sensitive and easier to do. These are a type of tests that measures a protein molecule with another substance for which we are looking for.This is a part of immunology it is called antigen antibody reaction. Proteins called Monoclonal antibodies specific for a particular protein (antigen) were also identified and manufactured.   There   are several thousand types of monoclonal antibodies which react with the special antigens you want them to react with .They are used in thousands of clinical situations in medicine. In pregnancy we want them to pick up  hCG.  Initially researchers identified it as a pregnancy hormone. However they kept getting false positive results. This was due to the presence of another hormone called luteinising hormone which is produced from the Pituitary during each menstrual cycle.  By 1972 it was identified that hCG has 2 fractions alfa and beta subunits. It is the beta sub-unit where the biological and immunological specificity resides as regards pregnancy tests. After all this, different types of pregnancy tests where manufactured, by 1978 the market was full of these tests when we look for the beta sub-unit of hCG the pregnancy tests are 99% accurate. After sexual intercourse the sperm can live in the fallopian tube up to 5 days waiting for the ovulation to occur when the egg   arrives is fertilized and it takes another 10 to12 days for implantation to take place. So the best time to test for pregnancy is about 17 days after sex. These pregnancy tests looking for beta subunit of chorionic gonadotropin, either in blood or urine are highly sensitive. They can be both qualitative  or quantitative. Quantitative  tests in blood can detect beta  hCG  as low as 1mIU/mL while urine test strips can  detect as low as 10mIU/mL  to 100mIU/mL ,depending on the brand of the strip .Most pregnancy  test have a threshold of 25 mIU/ mL  These pregnancy can be false positive. This is generally due to the drugs producing hCG, in accurate testing, some common medications EG; chlorpromazine, phenothiazine and methadone give false positive results Some cancers producing beta hCG, such as liver cancer, germ cell tumours of the ovary, trobhoblastic cancers( these are cancers from the placenta) again give false positive results Treatment of infertility when hCG injection is used for treatment also can give a false positive results . This can often be distressing, you are trying for a pregnancy and you get a false positive result.

Modern pregnancy test  are all immunoassay tests.  A scientist observed that people taking insulin for Diabetes developed antibodies. With this in mind ,researcher started to develop antibodies in animal models. After this immunology progressed; exponentially.  By 1972 the problem of luteinizing hormone was also sorted out as an alpha subfraction of hCG.  Improved prenatal care and legalization of abortion both made it urgent to make diagnosis of pregnancy as early as possible. Initially the immunoassay pregnancy tests were cumbersome needed, test tubes, chemical reagents, filters and so on. But as time moved on they became very simple.

By 1978 FDA approved these tests. Initially they required the help of a doctor or a lab but later 1979 home pregnancy tests were on the market. This gave woman a new opportunity to look after their health and keep the secrecy of their life style to themselves. By now the importance of folic acid in early pregnancy was also known. Further improvement in test techniques made the home pregnancy test very simple and fool proof.  As already mentioned earlier there accuracy was 99%.  They used special monoclonal antibody which reacted with any beat subfraction hCG present in the urine. This also had an agent to cause colour change if the level of hCG  was consistent with pregnancy levels . They are best done two weeks after the missed period. However the newer tests can give a positive reading even before you have missed a period. If you are fairly certain that you may be pregnant, and the test comes negative, you can repeat in few days. These tests come on a latex-coated test strip. This has been treated with different antibodies. The antibodies are placed in three distinct zones.  The first zone contains anti-a hCG which combines with any hCG in the urine and the other is immunoglobulin G (IgG). This a control to see that the test strip is working properly. Before the the urine flows to the second zone two things have happened 1) hCG in the urine had combined with anti-ahCG antibody forms a  complex  and 2)urine suspends the IgG. The urine then flows to the second zone carrying with it the IgG and the anti-a antibody complex. This second zone is the test zone contains anti-b hCG and a dye substrate, which reacts further to create a sandwich which turns bright blue in colour. This technique is referred as Elisa sandwich technique. The IgG from the first antibody zone goes into the third zone. This zone contains another antibody which reacts with IgG and forms another coloured line. This indicates that the test was properly done. The blue line in the test zone and another fainter line in the control zone indicate that the pregnancy test is positive, and the test was properly done. There are many different types of pregnancy tests with different designs and details. These tests have been passed by FDA. These tests have now become digital. On the test kits, it reads pregnant or not pregnant. It also indicates how many days of pregnancy. It is estimated that the home pregnancy market is over 200 million in sales per year. Why do we do these pregnancy tests?  These tests can be qualitative and quantitative. Quantitative test are always on the blood in complex situations of diagnosis and progress of malignant diseases. The urine pregnancy tests are done by almost everyone, women, students, teenagers, nurses and clinicians. These tests are very useful to assess the progress of pregnancy, is it alive and well ?failure of hCG levels to rise indicates that all is not well with the pregnancy. hCG levels double in 48 hours if pregnancy is progressing well . Quantitative measurements if small may indicate an ectopic pregnancy (pregnancy outside the uterus often in the Fallopian tubes). This diagnosis is often confirmed with the help of trans-vaginal  ultrasound. Ectopic pregnancy is a life threatening  condition .This requires urgent treatment The pregnancy test is often required after medical abortion to make sure that the abortion was complete especially if the woman continues to bleed or after removal of molar pregnancy (abnormal products of pregnancy these can sometimes turn into cancer.)Ultrasound also helps .Women with a positive pregnancy test, may also need medical check up in many areas, nutrition, sexually transmitted infections, antenatal care,  termination of pregnancy, contraception and psychosocial support.

It has been 56 years since; I first did the toad test for diagnosis of pregnancy. Today a wide range of tests are available for pregnancy and infertility, with the sale of these products exceeding 200 million American dollars. We have come a long way in 35 years or should I considerate 55years saving the martyrdom to poor rabbits.

STORIES OF MY LIFE

ABOUT THROMBOEMBOLISM IN PREGNANCY

It was the month of September 1959; I was still a junior resident and only qualified two months ago. I was escorting the lovely Tara and her eight day old new baby, to her parents at the time of her discharge from hospital. This was the rule in our hospital that a resident doctor had to escort the mother and the baby to her relatives. We were happily going down the stairs, suddenly I heard a loud thud, and Tara was falling down. In the blink of an eye she was on the floor, after the last step. The professors, room was next to the staircase, she came out, looked at Tara. It was too late for Tara she was already dead. What could it be except for a Pulmonary Embolism? Pulmonary embolism has only been recently recognized (1990) as a part of, Thromboembolic disorders, after the nineties. In America more than one million people die of thromboembolic diseases each year which is more than, all the deaths put together  from breast cancer, prostate cancer and road trauma. In the developed world maternal deaths from thromboembolic disorders are still among the top four causes although with current management it is declining. In the United Kingdom there are 14 deaths per million maternities. In the developing world the percentage to maternal deaths from thrombosis related disorders is 2.2%. To make the public aware of this problem The ISTH( The International Society on Thrombosis and Haemostasis) has announced a thrombosis day, which commenced in 2014 and will be held annually on the “13th of October.” 150 years ago Virchows, triangle was described as hypercoagubility, vascular damage, and venous stasis. This still holds good as a cause of blood clotting. Many developments in the past two decades have improved our understanding of why blood clots. This can be both in our arteries or veins. These risk factors can be both inherited or acquired. We had known about the acquired factors for a long time , but a recent understanding of genetic factors has improved our management  in preventing thrombosis. In the western world it is suggested that we look for these factors in pre pregnancy and use anticoagulant treatment during pregnancy in women who have high risk factors , and use Anticoagulants in special circumstances for example after a caesarean section. This has been added to obstetric management since 1990.Tara had arrived at our hospital from a village after a five hour journey on a bullock cart. This was her third birth. The other two had been totally normal, four and two years ago. The only contraception they had used was coitus interruptus There were no significant findings in her history or clinical examination. She was a slim fit woman, the B.P., was normal. She had seen the village dula( the village midwife) a few times. She had told her that all was going well. The labour progressed nicely; she had a normal healthy male child. All went well, everybody was happy. At this time India was going through an intense family planning programme. Every couple who had a tubal ligation or a vasectomy got a transistor radio from the government. The main reason for Tara to come to the hospital was to have a tubal ligation. This was done the following day. At the time we did not have a qualified anesthetist, we did our own spinal anesthesia, and tubal ligation was done by mini laparatomy. A small longitudinal cut was made just above the bladder, both tubes were tied cut and diathermy of cut the ends was done. The abdominal cavity was closed. This was called modified Pomeroy’s method. This was usually done by a resident doctor and usually took about twenty five to thirty minutes. All this was progressing well. The women where usually discharged on the seventh day. I still have tears when I think of Tara she had three risk factors for thrombosis as we know today and these were as follows, 1) She came to hospital sitting in a bullock cart for five hours. 2) She had an operation which took about half an hour. 3) She was not mobilized quickly as we do now. We had not known about thrombosis associated with pregnancy. Hospitals where not as well equipped as they are today, as India was still very new and it had only been 12 years since independence.

The other sad day I had was when Gita left us. It was august 1961 She was also a young, first mother, nineteen years of age. Like a lot of the women she came from a village. She had not seen a care giver during pregnancy however when she went into labour they had doctor, a new young doctor. Her husband called him.  When, the doctor came over ,he found her blood pressure to be high 150/90, luckily he advised them to take her to the medical college. It was not very far from her village. He brought her to the hospital, sitting on the back of his scooter. She was not over weight. She was in good labour. The scooter ride did not put her blood pressure up; there was some protein in her urine. I started the treatment for toxaemia of pregnancy. Her membranes were ruptured. There was a touch of muconium (baby’s poo) in the liquor that came out suggesting, that the baby was distressed. In those days we did not have  CTG (foetal heart recording) machines. We depended on our hearing using a foetascope. Soon after (3hours) she was ready for delivery. In view of raised blood pressure and mild foetal distress I lifted the baby out easily with forceps. All was well, her urine was clearing, the blood pressure was stable. I left her room for some lunch, a midwife was with her. When I came back in 20 minutes the midwife was trying to suck her secretions from her mouth, but she was dead. I tried a cardiac massage, but no luck. My chief resident and professor came over, a diagnosis of amniotic fluid embolism (AFE) was made. AFE means some amniotic fluid goes in the circulation. It is suggested that, amniotic fluid enters through, endocervical veins, placental site and uterine trauma. It is believed that substances in amniotic fluid set up vasodilatation, interfere with coagulation, and set up an immune mediated response. Decades ago the mortality from AFE was as high as 85 %. Now with better understanding multi-specialist, resuscitators things have improved. AFE cannot be predicted or prevented. It has a higher risk with advanced maternal age, placenta praevia, induction of labour and operative delivery. I wonder if I can apply the last two to this case after having done thousands of inductions, and operative deliveries and never seen another AFE.

My third case after 15years of peace and quiet, happened in another country, the United Kingdom. It was in July 1975. I had done a repeat number 2 caesarean section on a slim healthy young woman very active.  Rita who was 28 years old and her first child was three years old with no history of any thrombosis.  By now it was not routine to use prophylactic anticoagulants after cesarean section, although the patients were mobilised earlier. Prophylactic anticoagulant routines were only started in 1990. When Rita was getting ready to go home on day 7, very early in the morning she collapsed in the bath room, a colleague of mine happened to be in the hospital, he attended to her but with no luck. She had already died. Things have changed in 50 years, we know a lot about thrombosis, do prophylactic testing and use prophylactic anticoagulants, and there is multidisciplinary help, Interventionists and resuscitators. I have never experienced a maternal death after Rita. I must add after 1971 I have always practiced in the western world.

CONTRACEPTION CONTINUED

LONG ACTING REVERSIBLE CONTRACEPTIVES (LARC)

I will discuss, what is called long acting reversible contraceptives.

What is LARC; these are long acting   reversible contraceptives. They can last anything from 1 to 15 years or forever you do not have to worry about contraception every day or every time you have sex. Have it done or fitted and forget about it. Fertility returns when it is removed.  It is as safe as sterilization, but much better than sterilization, as it is not surgical and not permanent. LARCs are inexpensive in the long term, although upfront cost in some countries seems to be high. Other contraceptives are dependent on the couple to remember every time, they have sex therefore their failure rate is high, between 25 % to 50%particularly among the teenagers.

About 3 million unplanned pregnancies occur in America alone. Nearly 30% of pregnancies around the world are unplanned, 25% to 30% of these are aborted. It is estimated that 35 of every 1000 women have had an induced abortion in their life time. The World Health Organisation’s quoted statistics are 1.6 million unsafe abortions took place in 2008. 1 in 10 pregnancies will end in an unsafe abortion. In 2008, 47,000 women died of unsafe abortions; this is 13% of all maternal deaths. Besides these deaths many women (8.5 million) get temporary or permanent disability as a result of these botched procedures. Almost one third of these women have no access to any medical help. This is well known to many of us.

Forced sex, domestic violence, no access to   contraception, poor quality of contraceptives, incorrect use and finally no empowerment or education for women.  Globally, in the developing world 215 million women, have a need for contraception which they are unable to get. These figures show that effective contraception is an important issue for women’s health. Contraceptive methods discussed so far depend on the user compliance. As already mentioned LARC methods are independent of user compliance, they are very private (your partner or his relatives as in some cultures cannot interfere). Failure rates are low when used correctly, like in perfect use. Long term these are very cost effective from the cost of contraception itself, reduction in abortions in general, reduction of septic abortions and compromised women’s health, and maternal death.

Around the world there is a movement to promote  LARC methods  among women of all age groups and we should take this as international priority.

There are four methods;

1) Intrauterine devices (IUD)

2) Intrauterine systems (IUS)

3) Subcutaneous implants

4) Hormone injections

LARC can be used for

1) Women of any age

2) Nullpariae (meaning a woman whose has never given birth) is no

 longer an objection to these contraceptive particularly IUD OR IUS.

3) Women who cannot take hormone contraceptive particularly oestrogen

4) Have nausea, breast tenderness, and migraine headaches.

5) Who are breast feeding or recently had a baby.

6) Have or had a hormone dependent breast cancer,

7) Who have had an STI including  HIV

8) Have epilepsy

9) Have Diabetes or high BP, inflammatory bowel disease or are smokers

10) Have recently had an abortion. In fact Copper IUD is used as an emergency contraceptive and can be continued as a contraceptive.

Let us talk about these LARC Methods

The intrauterine device for contraception was first invented by a gynaecologist, Jack lippes. He started working on it in the 1950’s. Initially he was discouraged about it, however he continued to work on it and he released it in1962. It is an S or different   shaped plastic with a string attached to its tail end, so that it can be easily removed. It works by making the bizarre changes in lining of the uterus, this, also realises white blood cells and an hormone called prostaglandins. These are hostile to the fertilized eggs, preventing implantation.  After its release in the sixties, it became the most popular IUD. From memory I can remember that I used to put in a few IUD’s for women who went home after child birth. We were sure we will never see them again until they were pregnant. It was 99% safe as regards failure, expulsion, perforation of the uterus and infection .In some women the loop remained there for their life time. It’s now off the market as; no inert IUD’s are   approved in USA, UK and CHINA.  Now is the era of copper IUD’s which came in the market in 1969. Slowly different designs were made and sold globally. A new IUD called a DALKON shield came on the market in the seventies (1971-1976) it caused a lot of pelvic infections even deaths with lots of legal issues.  The company went bankrupt, and Dalkon shield was withdrawn.  Its design was   faulty. It had a multi filament at the end for withdrawal. This caused infections. This episode with  the  Dalkon  shield gave women a worrying time. Confidence in using IUD’s was very low.  The newer IUD and IUS are both safe. One of the IUD’s is a Copper IUD called  Paragard . It came on the market in 1984, and was made in the USA. It is the only copper IUCD you can get in USA.

It is a T shaped polyethylene frame wrapped with 380 mm of copper wire and it is called a T380A.
The following photograph shows Paragard with Mirena

Copper is wrapped around the arms and stem of the T shape IUD.  They have two monofilamentous strings attached to its tail end which helps to pull it out when it needs to be removed. There are only two different types of IUCD available now. These are called IUCS (intra uterine contraceptive system) .They contain hormones and not copper. The two IUCS are called MIRENA and SKYLA or JAYDEN.  Both  of the IUD and IUCS work by damaging or even killing sperm. Copper is toxic to the sperm, it makes the uterus and the fallopian tubes produce a fluid containing copper ions, white blood cells, prostaglandins(Hormones) and enzymes, that kills the sperm; this also causes a kind of inflammatory reaction in the uterine cavity . Some women have an ethical objection to it, thinking it is an abortion. This is not so. According to the latest American laws, a pregnancy is a pregnancy only after implantation.

Your care giver should be trained, as to when to and how to insert an IUD and IUCS. You will be required to attend the clinic twice, once to get your medical, social, sexual and family history, and make sure you are suitable for a particular contraceptive and second to have it fitted. All the methods are discussed with you in detail. After this you can go home and think about it.

May be if you wish or need to discuss this

with your partner. After this you can go   back  to  you care  giver  at the appropriate time. The best time is with in the first 5 days of your periods. If this clashes with your commitments it can be done at any time if pregnancy is excluded. It is easier if you have had a vaginal delivery. Any current STI’s should be excluded. If you are at risk for an STI and HIV, these tests are performed at the same time.  Many clinicians like to give a prophylactic (preventative) antibiotic as well. It is ideal if you have only one sexual partner.  It helps a woman if you explain to her how and what you are going to do. It is very useful if the woman takes a couple of Paracetamol and one Neurofen(ibuprofen 200mgms) 250 mgm half an hour before the time of insertion.    you will feel more relaxed and will not feel the pain so much. Many clinicians like to give 400 micrograms of a prostaglandin tablet either Misoprostil or Cytotec. This ideally should be taken 4 hours or the night before insertion of the IUD either orally or vaginally, to nulliparae women or in women who are expected to have a scarred cervix, (previous, caesarean section,) or cervical operation. Sometimes a local anaesthetic or mild sedation is required. It is best to go for the procedure with someone, so that you can come home easily if you feel somewhat unwell e.g.  Faint or Nauseous, or wait in the doctor’s office until you feel better.

A follow up visit is required in 4-5 weeks.  This is to make sure you are well, IUCD is in place, and you know how to feel the string.

If your partner can feel the string, it can be trimmed.

Copper IUD’s tend to cause painful and heavy periods.  They should not be used if a women already has heavy or painful periods, if she is anaemic, if she has abnormal bleeding without a diagnosis, if she has an abnormal cervical smear or cervical cancer, recent or current pelvic infection, abnormal shaped uterus or has  a uterine fibroid distorting the shape of the uterus and is suspected to be pregnant. Woman with congenital or valvular heart disease should not use IUD’s because of the risk of infection to the heart valve.

The above mentioned problems  can be diagnosed by a pregnancy test , blood tests and ultrasound . An experienced clinician can make these diagnoses by clinical examination alone.

The big benefits of IUD are fit and forget. It is very private and very effective (99%)

Long term it is not expensive.

It is immediately reversible.

An IUD can be inserted after an unprotected sex or accident at the time up to 5 days, to protect you from getting pregnant and then it can continue for future contraception.

The side effects of Copper IUD’S As already mentioned are heavy and painful periods, but they often settles down in 3-4 months. The newer IUD’s cause problems less often. For these problems women are prescribed special drugs (NSAID, e.g Nurofen, and antifibrinolytics called tranexamic acid). Both these are very   effective.

As already mentioned some situations make it more difficult to insert an IUD such as a previous caesarean section.

There is a  small chance of getting a pelvic infection (1in500). It is more likely to happen within 21 days of insertion or if you have more than one sexual partner always practice safe sex to protect yourself.

LARC’s do not protect you from STI’s. This is one very big disadvantage of LARC’s

At the time of insertion the IUD can be pushed out of the uterus. It happens in 1 in 1000 insertions. If this happens it may need to be removed laprascopically.

Sometimes it falls out spontaneously outside the uterus (5 in 100) without a woman knowing it. That is why it is important to feel the thread. Sometimes the thread withdraws in the uterine cavity. An ultrasound is the best way to look for a missing IUD. If a woman gets pregnant with an IUD (1 in 100), most often it can be easily removed; and it should be removed as soon as possible. There is a small risk of miscarriage.  In situations like this it ideal to do an ultrasound to make sure that the pregnancy is alive and it is in the uterus, because sometimes these pregnancies can be ectopic meaning outside the uterus.

Always remember to feel the thread of the IUD after a heavy period.

Report to your doctor if you do not feel well, you have pain, discharge, irregular bleeding, pain on passing urine, or you have any symptoms of pregnancy or if your period is more than a week overdue.

If you have casual sex or sex with a new partner always use condoms.

Remember the date when you need to change your IUD. It can be removed easily by pulling the string without causing too much discomfort. A new IUD can be fitted at the same time if you so desire.  Most of the IUD’s can stay 5-10 years.  Multiload, an Australian IUD needs to be changed after 3 years.

NEWER COPPER IUD

In China family planning is a big issue. It is only in the last six months that they have relaxed their one child policy, so over the years many different types of IUD were invented and used. It was always a challenge to find and remove a Chinese IUD.  Now with ultrasound it has become a game instead of a challenge. It always intrigues you what you might find. One of the most commonly used IUD was a stainless steel ring (SSR). This had a high failure rate, and higher expulsion rate which was worry some. Slowly copper IUD’s replaced SSR by 1989.

In China 60% of the female population (about 114 million women in 2007) uses IUD after first child birth, until now they were allowed only one child. One serious problem with copper IUD is heavy and painful periods. This causes anaemia and poor health. To overcome this problem  Chinese developed a copper IUD with INDOMETHACIN ( a nonsteroidal anti inflammatory drug)  in 1986.

This decreases the amount of bleeding and  cramps. It is composed of three layers. An inner layer of y shaped stainless steel the middle layer is wound with about 200 to 300 mm of copper wire, the outer layer is again stainless steel. A total of 25 mgm of indomethacin is welded to both ends of the horizontal arms and in the centre by silastic beads. Few studies compared both medicated –Y IUD VS TCU380A(a type of copper IUD).That medicated IUD’s better than other copper IUD’s , blood loss was  less , less removal rate for medical reasons, higher continuation rates, and similar low pregnancy rate. Some of these studies continued up to 5 years, more trials will be needed before we make this a standard method. It is very reassuring and comforting for women.

GYNEFIX STANDRED AND MINI

Gynefix   standard  has 6 copper rings(5MM diameter) where as gynefix mini has 4 copper rings hence it is better for nulliparous teenagers.

Due to continuing side effects of copper IUDS and a large number teen age pregnancies research for better copper IUCD continued. People measured the sizes and shapes of nulliparous uterine cavity and decided they were different.  A Belgian gynaecologist decided to make a frameless copper IUCD. He used a polypropylene string with a naught at the top to anchor it to uterine muscle in the front wall of the uterus. There were 6 or 4 copper rings on this string. The one with 4 rings was smaller and is called mini. They have 200mm square of copper on the smaller one 330mm square of copper in the larger one. The first and the last copper ring is crimped to the thread to stop it from falling out. They work the same way as any copper IUCD. Any copper IUCD which has more than300mm of copper is spermicidal.  This proved to be excellent as the egg could not be fertilized and therefore no ectopic  pregnancy has ever been reported in women using  gynefix . It needs special equipment and trained personnel to put it in. It is less painful for nulliparous teenagers. It has to be watched carefully so that the copper rings do not get uncrimped and fall out. Some authorities recommend a six monthly ultrasound. Gynefix is available in Europe only. Research continues on copper IUCD there are about about 9 already, in diffrent parts of the world.

 The above image is of GYNEFIX within the uterine cavity.

MIRENA ,SKYLA (OR JAYDEN)

Since contraception is so important in some parts of the world researchers are working on better and better methods.

Although newer, inventions in the shape and sizes of many IUCD have improved the spatial and pain problems with copper IUCDS, the main problem with menorrhagia( heavy Periods and also painful periods )remained.

This led to a new generation of hormone releasing IUCD. This is called Mirena, all over the world.  Since we emphasised using IUD for younger women a smaller version of Mirena is produced called Skyla in Australia it is called Jayden. This is also a hormone releasing IUD in a smaller size releasing smaller dose of the hormone (LNG-IUS;mirena). Mirena has a plastic T shaped frame of 32 by 32 mm, it contains a small size reservoir which stores,  52 mgm  of  Levonorgestrel  (a Progesterone hormone) Mirena is fitted inside the uterine cavity. It remain there for 5 year doing its job of contraception and preventing excessive bleeding  unless it needs to be removed for some medical reasons or woman’s wishes .It has a mechanism which helps it to release 20 micrograms of  levonorgestral per day . Skyla on the other hand is Smaller, 28 by 28 mm in size; 13.5mg of levenorgestrel is stored. It releases 12 micrograms of levonorgestral per day. Diameter of the inserter in skyla is also smaller preventing pain at the time of insertion. (Mirena 4.75   skyla3.8) Mirena works for 5 years skyla works for 3yrs .there efficiency is comparable. If the women’s uterus is small skyla is preferred as it will not cause pain.                    

Mirena was invented and released in 1976 in Finland. Like it is said while discussing copper IUD it is always best to give IUCS women two sessions, unless it is impossible for them to attend twice. The insertion is always done by a trained person. A follow up appointment is also very important.

Some Women cannot have an, IUCS these include

1)          Undiagnosed abnormal vaginal bleeding

2)          Current or recent pelvic infection

3)          Abnormal cervical cytology

4)          Present or past breast cancer

5)           Compromised immune system

6)          Abnormal uterine cavity shape  either due to congenital abnormality or fibroid uterus

7)          Serious liver disease

8)          Allergy  to levonorgestral and chemicals used to make the device, silica, silver ,barium iron oxide ,and polyethylene

9)           Make sure definitely not pregnant

10)  Not keen to get pregnant in a hurry.

11)   If  the woman suffer  from congenital heart disease , do not use IUCD or IUCS ,as these can cause infection in the heart valve

HOW DOES IUCS WORK

There is no single explanation how Mirena   works. It thickens the cervical mucus plug   so that the sperm cannot penetrate the cervical canal and enter the uterine   cavity.  The sperm becomes sluggish and cannot reach the egg to fertilize it .The lining of the uterus thins out, even if there is a fertilized egg it cannot implant itself.  Mirena works well, only 2 out of 1000 women become pregnant in the first year of use. This can often happens if, IUCS was not properly positioned to start with

or it was pushed out unnoticed often during a very  heavy  period .     

OTHER BENEFITS OF IUCS

Very heavy periods in women are   decreased almost by 90 % after few months of use. Cramps also stop, menstrual periods stop all together in almost 20% women it works like a hysterectomy. Unlike hysterectomy, the periods and fertility returns to normal after Mirena is removed in premenopausal women. It is not harmful, not to have periods when you are using the Mirena, If you are in the older age group say, 38 onwards, if you have perimenopausal symptoms you can use oestrogens. You do not need progesterone as you already have a progesterone IUD. TheyL together work like HRT. Mirena greatly helps the woman with endometriosis particularly in teenagers. High doses of progesterone for the treatment of endometriosis cause too many side effects, where as Mirena does not. Lessening of back flow  of the blood  because of the very heavy periods from the uterus via the fallopian tubes into the belly also helps to improve endometriosis, as with Mirena there is very little bleeding or no bleeding. It also prevents Endometrial thickening (HYPERPLASIA) and cancer. Reduces  the risk of Ectopic pregnancy; as the eggs do not get fertilized. It is useful to decrease bleeding in bleeders suffering from inherited bleeding disorders. Mirena can be used to decrease bleeding with fibroids.

No harmful effects have been noted in obese women on serum lipids (cholesterol and triglycerides), carbohydrates, Coagulation profile and liver enzymes. Although there are no publication on the use of IUCS with history of DVT many studies found it to be safe hence a history of DVT or  Thrombophilia , it is considered appropriate to use progesterone alone contraceptive. It should be used with caution.

IUCS, did not show any effect on High blood pressure or weight gain even in women with type 1 diabetes. It can be used in women with type 2 diabetes as long as their vascular (blood) system is normal

It can be used 4 weeks after child birth.  I preferred it to be 6-8 weeks so that the risk of expulsion, bleeding and infection is minimised. WHO and  The  American college of O and G also recommend 6 weeks. Anyway there is no need for contraception in the first 3 post natal weeks.

Levonorgestral does not have any adverse effects on breast feeding or on the growth and development of the breast fed infants.

Mirena is useful in women with heavy   bleeding with fibroids.  Before it is inserted in uterine cavity, the care giver has to make sure the fibroid is away from the Path of the IUCS. This can be done by ultrasound, and also make sure there is no other serious cause for excessive bleeding eg cancer of the uterus.

RISKS AND SIDE EFFECTS OF MIRENA

Menstrual problems;

Hormones IUCS on one hand is supposed to help with menstrual problems on the other hand this causes initial irregular bleeding. This may be due to the fact that it interferes with the normal hormone cycles, incomplete suppression of ovarian

activity and oestrogen deficiency The bleeding is treated by estrogens , oral contraceptive for few weeks, non-steroidal anti -inflammatory drugs such as Neurofen  with which most of us are familiar . Another group of drugs with which many of you may not be familiar

are very useful. They are called antifibrinolytic agents (TRANEXAMIC ACID). They are very useful in all kinds of uterine bleeding .Finally progesterone receptor modulators called  Mifepristone is also very useful as they decrease the progesterone activity and increase the oestrogen activity. This is also used if there is irregular bleeding with other progesterone only contraceptive. So please do not worry there are many ways to stop this intermittent unscheduled bleeding. Very Often some care givers give Mifepristone   (100mgm) at the time and then once a month for 3 months. It has proved to be useful and can be repeated.  Once the   uterine lining thins out this settles down, as mentioned earlier the periods usually stop for the remaining time.

Perforation of the Uterus

This is rare. It usually happens at the time of insertion, the frequency being 1 in 1000. If the uterus is perforated IUCS should be removed.

Expulsion of the IUCS

This means that the IUCS is expelled out of the uterus. It usually happens in about 5% of women in the first few months. It happens often, if it was inserted too soon after child birth or in nulliparous women.

Once it is expelled  the woman is no longer protected.

Mirena  never protects  you from STI’s. If you are at risk make sure you use a condom as well. It can be used if you are HIV positive, as it has not shown to cause viral multiplication.

 It seems to be protective against infection due to the thickened cervical mucus. The other problems Mirena can cause are headache, vaginitis

Pelvic pain, pain during bleeding, breast tenderness, hair loss, and ovarian cysts. These ovarian cysts are harmless and go away on their own.  Mirena has been reported to cause stroke like symptoms, I have seen one case amongst my own patients. I had her checked over by a neurologist, he said he cannot find anything wrong however she settled after   Mirena was removed. I have also come across intermittent anaphylactic reaction, swelling of tongue or lips, difficulty in breathing, on and off until I removed the Mirena as matter of urgency. These can be   due to Nickel allergy.                                                     

THE NEXT LARC WHICH I WILL TALK ABOUT IS A PROGESTERONE IMPLANT

Implanon, I am sure, thousands of you have heard about it. It is now used by 11 million women around the world in 60 countries. This technique uses a single rod of 4cms by 2 mm sealed on both sides.

The  possibility of subdermal(under the skin )contraceptive was discovered after Silicone was discovered in 1940 ,not only that it was found to be compatible with the human body. It was felt that these silicone rods can be filled with drugs which can then be slowly released and act as contraceptives.

Slowly different types of implants were made. They are filled with progesterone only. The implant which was first marketed was called Implanon. It was first marketed in Indonesia in 1998. It

contains 68mgm of progesterone called Etonogestrel. It is inserted into the non dominent upper arm of a woman just under the skin .This releases about 30 to 40 ug to progesterone per day. It gradually decreases in amount, in the 3rd year it releases 25 -30 ug per day, however this enough to act as a contraceptive.

The commonest implant used in the world was Implanon. However in recent times it has been modified so that it has become easier to locate it by x-ray when it is lost. Now it contains 15 mgm of barium dispersed in it, it is called

IMPLANON NXT. There are many different types of progesterone implants available in different countries sold under different names(NORPLANT, NEXPLANON SINOPLANT11).The techniques of their making  differs . They work similarly and have same problems. They can last from 3 to 5 years.

Like any contraceptive advice, your care giver will take your history, do an examination, and relevant tests ie: Pregnancy test and an Ultrasound. This has been discussed in detail earlier.

Progesterone Implants can be used in women of all ages. However there are some situations when it should not be used and in some it should be used with caution.

Contraindication to use Implanon

1) Make sure you are not pregnant. A negative pregnancy test excludes pregnancy only if it is more than 3weeks

2) You are not allergic to progesterone (Etonogestrol) or any substances contained in the applicator or used at time of application.

3) You have or had no jaundice, liver disease, liver tumours, and gall stones.

4) You have no history or presence of breast cancer, ovarian cancer, uterine cancer or cervical cancer.

5) If you want to breast feed, make sure baby is at least 6 weeks old.

6) You do not have unexplained, undiagnosed vaginal bleeding

7) Current or past history of thrombosis, heart disease and any other vascular disorders.

8) If you have diseases such as porphyria, epilepsy, tuberculosis, lupus and if you are on any drugs please inform your care giver so that he/she can make sure it does not interfere with Etonorgestero or vice versa. He/She will explain all this to you.

9) Diseases such as high blood pressure, severe diabetes, obesity, restricted mobility, high cholesterol and triglycerides other metabolic conditions require special care when you use ImplanonNXT

10) Previous history of ovarian cyst or ectopic pregnancy also requires special attention.

11) Any vascular diseases of the eye

12) There is some difference of opinion, if it is safe to use, Implanon, in women who are HIV positive or have AIDS.

HOW DOES IT WORK

Like all other hormone contraceptives it works in 3 ways

1) It inhibits ovulation, no eggs no pregnancy.

2) It increases the thickness of cervical mucus hence the Sperm cannot penetrate it.

3) It thins out the lining of the uterus (Endometrium) as a result the fertilized egg cannot stick to it (Implant).

This is why some people have a moral objection to it considering it to be an abortion.  However as we have already mentioned American law only considers it to be a pregnancy after the egg has implanted.

EFFECTIVENESS

Nexplanon , ImplanonNXT ( Implanon)and Sinoplast 11, are all long acting subcutaneous reversible contaceptives. They have been shown to be the most effective contraceptives in the current world. We wish we could spread them like sunshine on the grass; as this then could save millions of women and millions in terms of money. Their failure rate is .o5% . They are almost 10 times more effective than, tubal Sterilization. Not only that, they are reversible. The failure is often due to wrong placement, wrong timing of placement, and prexisting pregnancy.

It should be inserted  within the first 5 days of menstrual cycle, on the day when the previous one is removed, on the first day  after  Depo-Provera is due, within 5 days of first trimester abortion or miscarriage, within 21 -28 days of 2 trimester. If all these instructions are followed it is 99% safe.

INSERTION AND REMOVAL

An insertion is done only after the woman has been informed all about the implant and other contraceptives, and she wishes to use the sub dermal implant .Make sure she is not pregnant, has no STI, no absolute contraindications; it is inserted by a trained clinician on the inner side of the non dominant arm.(ie: If right handed then implant goes in the left arm) The rod comes in a pre packed container with an applicator.

It is inserted in an aseptic manner.  The clinician and the woman have to make sure that the Implanon has gone in the arm by feeling it under the skin.

Removal of the device is also done by a trained clinician. A small cut is made; the device is picked with a small forceps and gently pulled out. Sometimes the   Implanon migrates and is lost; this often requires a high resolution ultrasound or an x-ray, CT or MRI.

Most women begin to ovulate within 6 weeks of removal. Fertility levels return to pre Implanon levels within 3months.

Implants require changing every 3 years.

Sometimes they require removing for medical reasons for example, thrombosis, persistent high blood pressure, ovarian cysts, and reaction with other drugs. Like all drugs; Implanon can have side effects, some of these are serious, tell your care giver if you don’t feel well after the implant of Implanon.

SIDE EFFECTS OFSUBDERMAL IMPLANTS

1) Insertion and removal complications

They can  cause  pain , infection , bruising and scarring . Many pregnancies have been reported when the rod was not checked and it was left in the inserter. Newer applicators are much better and easier.

2) Irregular bleeding pattern is the most annoying problem .Sometimes, on and off or else prolonged. They do not hurt in any way but they are bothersome, and often one of the reasons to have it removed. The same treatment is offered as with Mirena . Generally it settles down in 3 to 6months

3) Many other side effects are similar to  Mirena ; Acne , Decreased libido , Hair loss, pigmentation of the skin and face ; Cloasma ( yellowish butterfly pigmentation of the face),Hives, Breast tenderness, Depression, nervousness, Mood  swings, Dizziness

Nausea, Vomiting, and Abdominal pain. Besides these progesterone like symptoms more serious ones are increase of Blood Pressure, poor control of diabetes, chest pain, pain in the  legs  suggesting thrombosis, swollen face or tongue , trouble swallowing, breathing problems, sudden collapse, loss  of vision and sudden feeling of weakness in your body you need urgent medical attention. These symptoms are indicative of thrombosis phenomenon in the body.
ADVANTAGES OF IMPLANTS AS CONTRACEPTIVES

1) Most women of any age group can use it

2) Most effective form of birth control and does not require women’s compliance or daily attention.

3) It can be confidential, you do not have

to involve your partner, does not require

interruption of foreplay or intercourse.

4) Fit it and forget about it for 3 years. In   some special cases you may require regular   checkups e.g. if you smoke, you have high blood pressure you have any conditions already discussed before.    

5) You can use this if you cannot use oestrogens

5) Women who want to breast feed can use it after baby is 6 weeks old. Very small quantities of progesterone are seen in the breast milk but this does not alter the quality of milk or in any way interfere with

the babies’ growth and development.

6) You can use it if you are a smoker and over 35.

7) It takes only 1- 2 minutes to insert it and remove it, if inserted at the correct time, it starts working soon after.

8) Fertility returns within months of

 Removal.

9) You cannot use it if you have an abnormal shaped uterus or if you have a fibroid distorting the uterine shape.

10) Medical benefits, it reduces menstrual bleeding and pain in women with fibroids or endometriosis

11) Helps with Premenstrual symptoms

12) Although in some women it causes acne in others it prevents it.

13) There is initial expense in some parts of the world, but long term it works out very economically.

DISADVANTAGES

1) The biggest risk is of STI, Including HIV. Anyone who feels that they are at risk for STI, they must use condoms along with Implants.

2) Other risks have already been discussed with side effect.

INJECTABLE LARC

In this paragraph I will talk about the injectable larcs. They are progesterone injections;

1) Depot medroxyprogesterone,(DMPA) it is also called Ralovera or in simple English depo-provera.It was first introduced in 1967. It has a maximum action of 12 weeks. It is best to repeat after 11 weeks, it takes one week to be active. Woman must wait for one week after the first injection. With perfect use the failure rate is .02%.

It can be used if you are breast feeding. I found it to be very popular in Indian villages, as village health care provider gave the injection every 12 weeks.

Other injectable long acting progesterone is called NET-EN. This contains only 200 mgm 0f a progesterone called Norethistirone.

 It needs to be given every 2 months and is not popular.

Advantages and Disadvantages

1) Safe in women who cannot take estrogens or the pill

2) Can be used in women who suffer from migraine.

3) Can be given any time postpartum, or soon after first or second trimester abortion.

4) Women with liver enzyme inducing medication can use it without the dose interval being reduced. Some of these drugs are, drugs for epilepsy, Tuberculosis, antibiotics and antifungal

They should be used with great care.

5) Safe in women who have HIV, AIDS,

And STI’s.

6) Useful for women with endometriosis and unexplained bleeding problems and painful period. Endomeriosis symptoms are well controlled.

7) Usually does not cause headaches depression and acne.

8)  No increased risk of DVT, pulmonary embolism   stroke and myocardial infraction

9) Decreased risk of endometrial cancer, pelvic inflammatory disease (PID), fibroids, endometriosis and functional ovarian cyst, Iron deficiency anaemia, ectopic pregnancy.

10) Minimal drug interactions compared with other hormonal contraceptives.

11) It is useful for women who are obese i.e Body mass index of 30 or more.

 12) It is good for women who suffer from bowel diseases.

Disadvantages of injectable contraceptives

1)          World health organization has reported no increased risk of breast cancer or any other cancer. In fact it decreases the risk of the cancer of the lining of the uterus (Endometrium )

2)           Irregular bleeding is the most annoying side effect. However it settles down after 2-3months. 50% women have no period after 1 year of use they are generally happy about this. The treatment for irregular bleeding can be by Oestrogens or Neurofen . There is no real dander in this bleeding, it happens because of the thinning of the uterine lining.

3)          Weight gain is another annoying side effect especially in women who were already obese. The weight gain can be as much as 5 lbs in 1 year or 8 pounds at 2 years. One of the problems is that once the injection is in it is in. 

4)          The side effects are headaches, depression, poor sex drive, breast tenderness, nervousness, dry vagina, and tiredness.

5)          The other important side effect is loss of bone density. It has been shown that some teenagers can lose as much as 2-3 % in bone density. Because of this many clinicians recommend a evaluation if  Depo- Provera is to be continued  for more than 2 years. To keeps your bones healthy, you need to take about a 1000 mg of calcium daily .  Regular exercises, sports, vitamin D, and magnesium. Your GP will be able to give you detailed information on life style, particularly in teenagers.

6)          It takes longer for a woman to get pregnant after she stopped DEPO –PROVERA. It depends on the age  weight and any other problems, a woman had before she went on DEPO- PROVERA

7)          One of the most important risk factor is exposure to STI’s, HIV. This does not protect you from any form of infections from the genital tract. If think you are at risk tell  your care giver to test for these .You should all ways use condoms when making love either ,vaginal oral or anal to protect you from STI’s.

8)          Your clinicians will always take a detailed history and examination, before you are told you are fit to have the injection.

9)          It can interfere with few Diseases. Thyroid is one such problem. It can become under active when you are on depo- provera , so if you are putting too much  weight or too tired have it checked. It is generally contraindicated in women with liver disease, severe depression.  It may have  some degree of effect on blood coagulation system

10)  You can stop It any time you like, but side effect will last for the duration of 12 weeks. Always have regular checkups. Report to your doctor if you have yellow colour urine, severe abdominal pain, prolonged painful, vaginal bleeding, headache, risk of exposure to STI, severe depression and painful legs.

 KEY POINTS ABOUT LARC

1) Larc means long acting reversible contraceptives for extended period without requiring user action. Currently a lot of attention is being paid on these methods, due to high rates of teenage pregnancies, high typical failure rate compared to perfect failure rate . This is because user is not involved, therefore compliance is not required. High failure rates of other methods leads to increased abortion rates and consequently high maternal deaths          

2) These can last anything from 2month, (There is only one such injection that has to be repeated every 2 month), 5years, 10 years and even life long.

There are 4 such methods;

A) IUD

B) IUS OR IUCS

C) Implants, It used to be called, Implanon

 now it is  ImplanonNXT , it has been modified by adding Barium to it so that it can be detected by x-ray. It is a progesterone hormone implant

 D) Progesterone injections

There are two such injections1) depo –provera, NET-NE. Depo-provera is commonly used. It starts acting after 1 week after the injection and lasts for 12 weeks. Main drawback is while using depo-provera you tend to loose, bone density. It is especially important for teenagers as this is the time for them to build their bone density. It is suggested that it should not be used for more than 2 years as a contraceptive unless there are very pressing reason to use it.

2) Larc methods are 20 times more effective than birth control pill.

There typical failure rate means the rules are not rigorously followed and every now and then the user becomes casual. Where as in perfect use all rules are strictly followed and there are no casual lapses. In larcs methods typical and perfect failure rate is the same, as you do not need to worry every time you have sex. It works on the principal, fit and forget. Failure rate of LARC methods varies between .02 % to 1 in 100 women in  one year This is even better than sterilization and it is reversible.

3) IUD and IUS are devices that live inside the uterus after being inserted. They are inserted by special tools by specially trained clinicians.  This can cause some discomfort, but it is taken care of by pre insertion pain relief, local anaesthesia or in difficult cases sedation. This settles down in a day or so. Most women do not feel anything. IUD’s are, copper IUD’s. They can last for many years, 5-10 or even forever. They used to cause heavy bleeding and pain, however newer IUD’s have been improved.  Women are given anti bleeding and anti pain medication.  The chinese have invented a new copper IUD which contains a drug called Indomethacin, it takes the pain away and decreases excessive bleeding. It is not available to the rest of world, but is becoming popular in china. This does not contain any hormones.

ICS is a hormone containing IUD. Recently it has been produced in two sizes. These have been discussed in the main text Mirena and skyla (Jayden). There contraindications and side effect are also discussed. There medical benefits are many. Decreased period pain, bleeding, less symptoms of endometriosis, less anaemia and better general health.   I frequently used Mirena in later years of my practice. I found it to be Magical. It hardly takes 5 minutes to put it in and 30 seconds to remove it . However it takes at least a one hour session to explain benefits and risk of LARCS to the clients. Mirena is permitted to be used for 5 years and skyla for three.  The biggest drawback of these IUCD and IUCS is that they cannot protect you from STI’S. Copper IUD can also be used as emergency contraceptive.

4) IUD, IUCS, both work by thickening the, cervical mucus so that the sperm cannot enter the uterine cavity, copper IUD are also spermicidal so that the sperm cannot move around and die. They both cause the failure of fertilization. Beside this copper IUD causes inflammatory reaction in the uterine cavity, IUCS thins out the uterine cavity, hence in either case even if the egg is fertilised it cannot implant. These should be considered as contraceptives not as abortificants.

The injectable contraceptives also thicken the cervical mucus, so that the sperms cannot enter the uterine cavity, stops the ovary to produce an egg, this results in a thin uterine lining so the fertilized egg cannot implant, if there is any by chance.

 5) The side effects of IUD AND IUCS, ImplanonNXT and Depo-provera are irregular bleeding, they happen more often initially and settle down in3-4 months. The treatment has already been discussed. It is generally by, nurofen, anti bleeding drugs and sometimes by oestrogens. Other side effects are headaches, depression, and a risk of weight gain with Depo-vera.  Rarely (1in 1000) IUD can perforate the uterus, it generally happens at the time of insertion. It can get expelled by itself especially with a very heavy period, and then you are not protected. This happens in, about 5% in the first year. That’s why it is important to feel for the thread after each period. There is some misconception that you get PID and STI after using IUD. If your clinician  has taken due care at the time of insertion it can happen only in the first 3 weeks . If you are at risk of STI please always use condoms, for Vaginal rectal and oral sex.

6) Rarely pregnancy can occur. There is a higher chance that his could be an ectopic pregnancy ( pregnancy outside the uterus) or you may miscarry. In this case the IUD or IUCS should be removed. If the pregnancy continues this does not cause any foetal abnormalities.

7) Over all benefits of LARC

A) Fit and forget , once it is in place you do not have to do anything to prevent pregnancy.

B) No one can guess that you are using any birth control. Does not interfere with

Sex, or any daily activities.

C) It can be inserted soon after an early abortion, 3 weeks after late abortion, 6 weeks after a baby is born and you can breast feed if you wish.

D) Any time if you wish to get pregnant or you are not happy with it. It can be easily removed.

E) Copper IUCD is an effective ,emergency contraceptive.

F) Hormone IUCS is effective with many medical problems, heavy bleeding, pain, Endometriosis, Fibroids

G) Long term works out to be cheap

H) Problems with cooper IUD’S are being resolved with newer inventions , Indomethacid, copper  IUD,and  Gynefix

I) Hormone IUCS is also improved With invention of skyla.

J) It can be used in women with HIV, History of PID, High blood pressure, Diabetes, can be used in women on liver enzyme inducing medications without changing the dose interval. These are medication used for epilepsy, tuberculosis

and other complex medical diseases. Copper IUCD can be used in women with thrombophilic disorders. In all these situations they require special care.

 K) Myths about LARC should be removed from, care givers and public by better education information and training. This is happening. This does not have an increased risk of PID, or infertility, unless your sexual habits are compromising.

It can be used in nulliparous women or after caesarean section. These can be easily inserted and removed by trained personals’ with proper equipment. I hope once this happens we can save lots of money and lots of women. At present Russians use the highest number of LARCS  33%, as compared to Australia about 10%.

Possible rare risks are with insertion and removal they occur in only 2 % of cases. You often need a clinician if there are any problems .The most important problem is you are not protected from STI’s. 

I hope this gives you a very good prospective on LARC’s methods of contraception which in most people’s opinion are one of the best methods, but unfortunately least used so far. We need a lot of education, training, publicity, and initially some government finances to start the method. Fortunately all this is being done.