A FEW COMMENTS ABOUT FUNGAL INFECTIONS IN WOMEN

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

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

Postmenopausal women

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

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

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

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

persistent thrush.

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

MATERNAL MORTALITY IN INDIA IN 1960

These stories are from1960 when the maternal mortality rate in 

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

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

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

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

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

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

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

She was dead on arrival.

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

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

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

TURNERS SYNDROME

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

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

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

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

GENETIC OR CHROMOSOME ABNORMALITIES

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

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

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

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

STORIES OF THE APPENDIX

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

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

THE O     THIS STORY IS SIMILAR BUT NO PELLETS

CARCINOID TUMOUR OF THE APPENDIX

Carcinoids are rare slow growing human tumours. They rise

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

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

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

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

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

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

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

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

FIBRIODS IN TEENAGERS

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

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

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

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

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

Teresa never had any other gynaecological problems

TOXAEMIA OF PREGNANCY DUE TO VERY HIGH CHOLESTEROL LEVELS

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

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

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