FIBRIODS IN TEENAGERS

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

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

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

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

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

Teresa never had any other gynaecological problems

TOXAEMIA OF PREGNANCY DUE TO VERY HIGH CHOLESTEROL LEVELS

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

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

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

POST MENOPAUSAL PREGNANCY

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

VERY YOUNG MOTHERS

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

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

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

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

MUCINOUS OVARIAN CYST

VERY LARGE OVARIAN CYST- FIFTYEIGHT LBS

BENIGN MUCINOUS CYSTADENOMA.

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

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

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

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

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

BENIGN DYSGERMINOMA

UNPLANNED PREGNANCY WITH LEFT OVARIAN
TUMOUR - DYSGERMINOMA.

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

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

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

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

SPLENIC PREGNANCY

A TYPE OF ECTOPIC PREGNANCY

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

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

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

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