Questions & Answers

Questions & Answers (20)

There are many known causes of infertility. Some are more absolute than others. For example, if a woman has blocked fallopian tubes, or a man has a very low sperm count or motility, then we know the cause of the couples infertility problem (or at least one of the causes). However, there are other fertility issues that are difficult to characterize as "the problem" - but we know that often they are at least factors contributing to the infertility.

Endometriosis

What are the symptoms of endometriosis?

Pain is one of the most common symptoms of endometriosis. Usually the pain is in the abdomen, lower back, and pelvis. The amount of pain a woman feels does not depend on how much endometriosis she has. Some women have no pain, even though their disease affects large areas. Other women with endometriosis have severe pain even though they have only a few small growths.

 

Physical Care After a Cesarean

The days following the birth of your baby, which is called the postpartum period, is one of the most challenging times for moms and families. This time can be even more challenging for a mom who has undergone a cesarean delivery. After all deliveries, mom needs to take time to allow her body to rest and heal, which means no housework or running after other little ones. The maternal mortality rate is the highest in the postpartum period, so special attention needs to be given to taking care of mom. If you are a single mom or your partner has to return to work right away, try to set up a support team before the birth of your child for this postpartum period. This can be done with help from family, church members, new mom support groups or a postpartum doula.

Why and when is Ultrasound used in Pregnancy?


Ultrasound scan is currently considered to be a safe, non-invasive, accurate and cost-effective investigation in the fetus. It has progressively become an indispensible obstetric tool and plays an important role in the care of every pregnant woman.

The main use of ultrasonography are in the following areas:


1. Diagnosis and confirmation of early pregnancy.
The gestational sac can be visualized as early as four and a half weeks of gestation and the yolk sac at about five weeks. The embryo can be observed and measured by about five and a half weeks. Ultrasound can also very importantly confirm the site of the pregnancy is within the cavity of the uterus.

2. Vaginal bleeding in early pregnancy.
The viability of the fetus can be documented in the presence of vaginal bleeding in early pregnancy. A visible heartbeat could be seen and detectable by pulsed doppler ultrasound by about 6 weeks and is usually clearly depictable by 7 weeks. If this is observed, the probability of a continued pregnancy is better than 95 percent. Missed abortions and blighted ovum will usually give typical pictures of a deformed gestational sac and absence of fetal poles or heart beat.
Fetal heart rate tends to vary with gestational age in the very early parts of pregnancy. Normal heart rate at 6 weeks is around 90-110 beats per minute (bpm) and at 9 weeks is 140-170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is associated with a high risk of miscarriage.
Many women do not ovulate at around day 14, so findings after a single scan should always be interpreted with caution. The diagnosis of missed abortion is usually made by serial ultrasound scans demonstrating lack of gestational development. For example, if ultrasound scan demonstrates a 7mm embryo but cannot demonstrable a clearcut heartbeat, a missed abortion may be diagnosed. In such cases, it is reasonable to repeat the ultrasound scan in 7-10 days to avoid any error.
The timing of a positive pregnancy test may also be helpful in this regard to assess the possible dates of conception. A positive pregnancy test 3 weeks previously for example, would indicate a gestational age of at least 7 weeks. Such information would be useful against the interpretation of the scans. Please read the FAQs for more comments.
In the presence of first trimester bleeding, ultrasonography is also indispensible in the early diagnosis of ectopic pregnancies and molar pregnancies.

3. Determination of gestational age and assessment of fetal size.
Fetal body measurements reflect the gestational age of the fetus. This is particularly true in early gestation. In patients with uncertain last menstrual periods, such measurements must be made as early as possible in pregnancy to arrive at a correct dating for the patient. See FAQ. In the latter part of pregnancy measuring body parameters will allow assessment of the size and growth of the fetus and will greatly assist in the diagnosis and management of intrauterine growth retardation (IUGR).
The following measurements are usually made:
a) The Crown-rump length (CRL)
This measurement can be made between 7 to 13 weeks and gives very accurate estimation of the gestational age. Dating with the CRL can be within 3-4 days of the last menstrual period. (Table) An important point to note is that when the due date has been set by an accurately measured CRL, it should not be changed by a subsequent scan. For example, if another scan done 6 or 8 weeks later says that one should have a new due date which is further away, one should not normally change the date but should rather interpret the finding as that the baby is not growing at the expected rate.
b) The Biparietal diameter (BPD)
The diameter between the 2 sides of the head. This is measured after 13 weeks. It increases from about 2.4 cm at 13 weeks to about 9.5 cm at term. Different babies of the same weight can have different head size, therefore dating in the later part of pregnancy is generally considered unreliable. (Chart and further comments) Dating using the BPD should be done as early as is feasible.
c) The Femur length (FL)
Measures the longest bone in the body and reflects the longitudinal growth of the fetus. Its usefulness is similar to the BPD. It increases from about 1.5 cm at 14 weeks to about 7.8 cm at term. (Chart and further comments) Similar to the BPD, dating using the FL should be done as early as is feasible.
d) The Abdominal circumference (AC)
The single most important measurement to make in late pregnancy. It reflects more of fetal size and weight rather than age. Serial measurements are useful in monitoring growth of the fetus. (Chart and further comments) AC measurements should not be used for dating a fetus.

Other important measurements are discussed here.
The weight of the fetus at any gestation can also be estimated with great accuracy using polynomial equations containing the BPD, FL, and AC. computer softwares and lookup charts are readily available. For example, a BPD of 9.0 cm and an AC of 30.0 cm will give a weight estimate of 2.85 kg. (comments)

4. Diagnosis of fetal malformation.
Many structural abnormalities in the fetus can be reliably diagnosed by an ultrasound scan, and these can usually be made before 20 weeks. Common examples include hydrocephalus, anencephaly, myelomeningocoele, achondroplasia and other dwarfism, spina bifida, exomphalos, Gastroschisis, duodenal atresia and fetal hydrops. With more recent equipment, conditions such as cleft lips/ palate and congenital cardiac abnormalities are more readily diagnosed and at an earlier gestational age. (Also see the FAQ and Anomalies pages).
First trimester ultrasonic 'soft' markers for chromosomal abnormalities such as the absence of fetal nasal bone, an increased fetal nuchal translucency (the area at the back of the neck) are now in common use to enable detection of Down syndrome fetuses.
Read also: Soft Markers - A Guide for Professionals and Ultrasonographic "soft markers" of fetal chromosomal defects.

Ultrasound can also assist in other diagnostic procedures in prenatal diagnosis such as amniocentesis, chorionic villus sampling, cordocentesis (percutaneous umbilical blood sampling) and in fetal therapy.

5. Placental localization.
Ultrasonography has become indispensible in the localization of the site of the placenta and determining its lower edges, thus making a diagnosis or an exclusion of placenta previa. Other placental abnormalities in conditions such as diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth retardation can also be assessed.

6. Multiple pregnancies.
In this situation, ultrasonography is invaluable in determining the number of fetuses, the chorionicity, fetal presentations, evidence of growth retardation and fetal anomaly, the presence of placenta previa, and any suggestion of twin-to-twin transfusion.

7. Hydramnios and Oligohydramnios.
Excessive or decreased amount of liquor (amniotic fluid) can be clearly depicted by ultrasound. Both of these conditions can have adverse effects on the fetus. In both these situations, careful ultrasound examination should be made to exclude intraulterine growth retardation and congenital malformation in the fetus such as intestinal atresia, hydrops fetalis or renal dysplasia. See also FAQ and comments.

8. Other areas.
Ultrasonography is of great value in other obstetric conditions such as:
a) confirmation of intrauterine death.
b) confirmation of fetal presentation in uncertain cases.
c) evaluating fetal movements, tone and breathing in the Biophysical Profile.
d) diagnosis of uterine and pelvic abnormalities during pregnancy e.g. fibromyomata and ovarian cyst.


What about Safety?

It has been over 40 years since ultrasound was first used on pregnant women. Unlike X-rays, ionizing irradiation is not present and embryotoxic effects associated with such irradiation should not be relevant. The use of high intensity ultrasound is associated with the effects of "cavitation" and "heating" which can be present with prolonged insonation in laboratory situations.
Although certain harmful effects in cells are observed in a laboratory setting, abnormalities in embryos and offsprings of animals and humans have not been unequivocally demonstrated in the large amount of studies that have so far appeared in the medical literature purporting to the use of diagnostic ultrasound in the clinical setting. Apparent ill-effects such as low birthweight, speech and hearing problems, brain damage and non-right-handedness reported in small studies have not been confirmed or substantiated in larger studies from Europe. The complexity of some of the studies have made the observations difficult to interpret. Every now and then ill effects of ultrasound on the fetus appears as a news item in papers and magazines. Continuous vigilance is necessary particularly in areas of concern such as the use of pulsed Doppler in the first trimester.
The greatest risks arising from the use of ultrasound are the possible over- and under- diagnosis brought about by inadequately trained staff, often working in relative isolation and using poor equipment.

 

Stages of Childbirth:

STAGE I :

Going through the birth of your child is a wonderful and unique experience. No two deliveries are alike and there is no way to tell how your delivery is going to be. What we can tell you is the stages you will go through during this process and what you can generally expect. Childbirth can be broken into three stages:
First stage: Begins from the onset of true labor and lasts until the cervix is completely dilated to 10 cm.
Second stage: Continues after the cervix is dilated to 10 cm until the delivery of your baby.
Third stage: Delivery of your placenta.

Ovarian Cysts

What are the symptoms of ovarian cysts?

Many women have ovarian cysts without having any symptoms. Sometimes, though, a cyst will cause these problems:

  • pressure, fullness, or pain in the abdomen
  • dull ache in the lower back and thighs
  • problems passing urine completely
  • pain during sexual intercourse

OPERASI MYOMA

What is a laparoscopic myomectomy?

Laparoscopic myomectomy for uterine fibroidsFibroids that are attached to the outside of the uterus by a stalk (pedunculated myomas)  are the easiest to remove laparoscopically.  Many subserous myomas (close to the outer surface) can also be removed through the laparoscope.   
Fibroids that are deep in the wall of the uterus, or submucous are most difficult to remove laparoscopically.  Although there have been successful pregnancies after laparoscopic removal of deep or multiple myomas, the real question is whether or not the uterus can be repaired as well through the laparoscope as can be done through an abdominal myomectomy.   

 

What are the advantages and disadvantages of laparoscopic myomectomy?   
The advantage of a laparoscopic myomectomy over an abdominal myomectomy is that several small incisions are used rather than one larger incision.  It is important to understand that even a laparoscopic myomectomy is real surgery, and often requires several weeks of recovery.  Another major factor in recovery time is motivation; I have found motivation can be just as important in recovery as the type of surgery.  
One concern when there are multiple fibroids is of leaving smaller myomas behind.  Often it is necessary to feel the uterus to find the smaller myomas; these likely would be left behind during a laparoscopic myomectomy.  To summarize, I think laparoscopic myomectomy is best for pedunculated and superficial myomas.  When there are deep myomas and a large number of myomas, I think that it is possible to repair the uterus better by doing an abdominal myomectomy.

A bit of editorializing...
One of my colleagues assisting me in a difficult laparoscopic surgery asked me when would I do a laparotomy (make a regular incision.)  My answer was that  I do the type of surgery that will obtain the best results.  If I can obtain just as good results through the laparoscope I will do the procedure that way.  But if I feel I can do a better job through a regular incision, then I will recommend that approach.  When someone looks back years after surgery, the quality of surgery inside will be far more important than recovering 1 or 2 weeks earlier.  Sometimes I will take a look through the laparoscope, and decide which way to approach the myomectomy at that time.  What is an "abdominal myomectomy?

An abdominal myomectomy is the removal of fibroids through an incision in the abdomen.  I usually can do this through a horizontal ("bikini") incision, even for large fibroids.  There is no limit to the size or  number of fibroids that can be removed.  Abdominal myomectomy is done in a hospital, and women usually can go home within 48 hours of surgery.  Photos below show an actual abdominal myomectomy.

Is there much blood loss with myomectomy?..
Usually there is little loss of blood when a myomectomy is done by a surgeon with extensive experience in the procedure.  There are a number of ways to reduce blood loss.  I use a laser to make the incision into the uterus, which seals blood vessels and reduces bleeding.  Before the incision, medicines are injected into the uterus to shrink blood vessels.  As a result, I find it unusual to lose an excess amount of blood during a myomectomy, even with large fibroids.There are a number of surgical techniques to reduce blood loss, so it is important to find a surgeon who is experienced in myomectomy.

What are the advantages and disadvantages of an abdominal myomectomy?
The ability to actually feel the uterus allows me to find fibroids deep inside the uterus that may not be visible just by looking.  As you can see from the photos, being able to hold the uterus allows me to accurately repair the area from which large fibroids have been removed.
The disadvantage of an abdominal myomectomy is that it requires an incision, so recovery is somewhat longer than required if an incision is avoided.  Fibroids that are on the inside of the uterus (submucous) can usually be removed with a resectoscope, without requiring any incision.  Fibroids on the outside of the uterus (subserous) can sometimes be removed through a laparoscope, through several small incisions.  I feel that this is often the method of choice for subserous or pedunculated (on a stalk) fibroids.  If there are many fibroids or fibroids that are deep I can do a better job by doing an abdominal myomectomy.  Most women feel that in the long run doing the best possible procedure to restore the health of the uterus is more important than recovering several weeks sooner.

How is an abdominal myomectomy done?

Here are photographs of an actual abdominal myomectomy. 

Uterine myomectomy - before surgery

Here is the abdomen before surgery.  The uterus is the size of a 5 month pregnancy.  It can be seen to protrude up to the belly button.

 

Uterine myomectomy - beginning of incision with laser

The uterus, which, is greatly enlarged by the fibroid, is lifted through the incision.  A laser is being used to make an incision into the uterus so the fibroid can be removed.

 

Uterine myomectomy - fibroid beeing freed from uterus

The fibroid is being separated from the wall of the uterus (myometrium).  It is very important to do this in the exact location between the fibroid and the myometrium in order to prevent excess bleeding.

 

Uterine myomectomy - fibroid being freed from uterus

This shows the fibroid almost completely free from the uterus.  It is attached only at the base.  The blood vessels at the base are being sealed with an electrosurgical device.

 

Uterine myomectomy - reconstruction of uterus

The uterus is being reconstructed by suturing the walls together with dissolving suture.  This is being done in multiple layers to ensure a precise repair.

 

Uterine myomectomy - reconstruction of uterus complete

The last layer of sutures is placed, and the uterus is completely restored.  A barrier to prevent adhesions will be placed before the uterus is replaced into the abdomen and the abdomen closed.

 

What is the recovery time for an abdominal myomectomy?

Recovery varies tremendously from person to person.  Most women can return to work that does not require heavy lifting in 4 weeks.  Many women can return in 2 weeks, and some women take 6 weeks. 

Molar Pregnancy

What is a complete molar pregnancy?
Complete molar pregnancies have only placental parts (there is no baby), and form when the sperm fertilizes an empty egg. Because the egg is empty, no baby is formed. The placenta grows and produces the pregnancy hormone, hCG. Unfortunately, an ultrasound will show that there is no fetus, only a placenta.
What is a partial molar pregnancy?

  • Partial Mole occurs when the mass contains both the abnormal cells and an embryo that has severe defects. In this case the fetus will be overcome by the growing abnormal mass rather quickly.
  • An extremely rare version of a partial mole is when twins are conceived but one embryo begins to develop normally while the other is a mole. In these cases, the healthy embryo will very quickly be consumed by the abnormal growth.

What are the symptoms of a molar pregnancy?

How do I know if I have a molar pregnancy?

  • A pelvic exam may reveal a larger or smaller uterus, enlarged ovaries, and abnormally high amounts of the pregnancy hormone hCG.
  • A sonogram will often show a “cluster of grapes” appearance, signifying an abnormal placenta.

How is a molar pregnancy treated?

  • Most molar pregnancies will spontaneously end and the expelled tissue will appear grape-like.
  • Molar pregnancies are removed by suction curettage, dilation and evacuation (D & C), or sometimes through medication. General anesthetic is normally used during these procedures.
  • Approximately 90% of women who have a mole removed require no further treatment.
  • Follow-up procedures that monitor the hCG levels can occur monthly for six months or as your physician prescribes.
  • Follow-up is done to ensure that the mole has been removed completely. Traces of the mole can begin to grow again and may possess a cancerous-type threat to other parts of the body.
  • Pregnancy should be avoided for one year after a molar pregnancy.
  • Any birth control method is acceptable with the exception of an intrauterine device.

How will I feel emotionally after a molar pregnancy?
Although the removal of a molar pregnancy is not the termination of a developing child, it is still a loss. Even when an embryo is present, it does not have the opportunity to develop into a child. Most women discover that they are dealing with a molar pregnancy after the discovery and anticipation of being pregnant. Dreams, plans and hopes are cancelled all at once; it is still a significant loss.

  • There will have to be healing time for all involved, and grief will be experienced.
  • Recognize that people may try to console you with statements like, “Well at least it wasn't a baby.” This doesn't help, but at least know that they are trying. Let them know what you need.
  • What makes this type of loss further different from a “normal miscarriage” or loss is the continued concern of the mother's health. Make sure that you stick with your follow-up appointments.
  • Support groups and counseling may prove beneficial.

Can I have another molar pregnancy?

  • If you had a molar pregnancy without complications, your risk of having another molar pregnancy is about 1-2%.
  • Genetic counseling prior to conceiving again is helpful for some couples.

Laparoscopy

What is laparoscopy used for in women ?
This procedure allows us to determine whether there are any defects such as scar tissue, endometriosis, fibroid tumors and other abnormalities of the uterus, fallopian tubes and ovaries.
If any defects are found then we can often be corrected with operative laparoscopy which involves placing instruments through ports in the scope and through additional, narrow (5 mm) ports which are usually inserted at the top of the pubic hair line in the lower abdomen.

Is it a big procedure? How much work would I miss?
In this country laparoscopy is usually done with general anesthesia (you go to sleep) although it can be done with local anesthesia and in many parts of the world local is the preferred technique.
The procedure usually takes between 20 minutes to 2 hours depending upon how much operative corrective work is required. A complicated case could take up to 4 hours or more.

What is the Complications
Complications associated with laparoscopy include the possibility of damage to other structures in the pelvis such as the bladder, ureter, bowel and blood vessels. Unexpected open surgery (larger incision) is always a possibility, but is very uncommon.
Any surgery can have an anesthesia-related complication or be associated with post-operative infection, such as a skin infection at an incision site.
Fortunately, all of these complications are very unusual when laparoscopy is expertly performed on young, healthy women.

Ectopic Pregnancy

What causes an ectopic pregnancy?

Ectopic pregnancies are caused by one or more of the following:

  • An infection or inflammation of the fallopian tube can cause it to become partially or entirely blocked.
  • Scar tissue left behind from a previous infection or an operation on the tube may also impede the egg's movement.
  • Previous surgery in the pelvic area or on the tubes can cause adhesions.
  • An abnormality in the tube's shape can be caused by abnormal growths or a birth defect.

Who is at risk for having an ectopic pregnancy?
Women who are more at risk for having an ectopic pregnancy include the following:

  • Are 35-44 years of age
  • Have had a previous ectopic pregnancy
  • Have had pelvic or abdominal surgery
  • Have Pelvic Inflammatory Disease (PID)
  • Have had several induced abortions
  • Women who get pregnant after having a tubal ligation or while an IUD is in place

What are the symptoms of an ectopic pregnancy?
The following symptoms may be used to help recognize a potential ectopic pregnancy:

  • Sharp or stabbing pain that may come and go and vary in intensity. The pain may be in the pelvis, abdomen or even the shoulder and neck (due to blood from a ruptured ectopic pregnancy gathering up under the diaphragm).
  • Vaginal bleeding, heavier or lighter than your normal period
  • Gastrointestinal symptoms
  • Weakness, dizziness, or fainting

It is important for you to seek emergency care if you are experiencing sharp pain or have bleeding.

How is an ectopic pregnancy diagnosed?
Ectopic pregnancies are diagnosed by your physician who will probably first perform a pelvic exam to locate pain, tenderness or a mass in the abdomen. Your physician will also use an ultrasound to determine whether the uterus contains a developing fetus.
The measurement of hCG levels is also important. An hCG level that is lower than what would be expected is one reason to suspect an ectopic pregnancy. Low levels of progesterone may also indicate that a pregnancy is abnormal.
Your physician may do a Culdocentesis, which is a procedure that involves inserting a needle into the space at the very top of the vagina, behind the uterus and in front of the rectum. The presence of blood in this area may indicate bleeding from a ruptured fallopian tube.

How is an ectopic pregnancy treated?
An ectopic pregnancy may be treated in any of the following ways:

  • Methotrexate may be given, which allows the body to absorb the pregnancy tissue and may save the fallopian tube, depending on how far the pregnancy has developed.
  • If the tube has become stretched or it has ruptured and started bleeding, all or part of the fallopian tube may have to be removed. Bleeding needs to be stopped promptly, and emergency surgery is needed.
  • Laparoscopic surgery under general anesthesia may be performed. This procedure involves a surgeon using a laparoscope to remove the ectopic pregnancy and repair or remove the affected fallopian tube. If the ectopic cannot be removed by a laparoscope procedure, then another surgical procedure called a laparotomy may be done.

What about my future?
Your hCG level will need to be rechecked on a regular basis until it reaches zero if you did not have your entire fallopian tube removed. An hCG level that remains high could indicate that the ectopic tissue was not entirely removed, which would require surgery or medical management with methotrexate.
The chances of having a successful pregnancy after an ectopic pregnancy may be lower than normal, but this will depend on why the pregnancy was ectopic and your medical history. If the fallopian tubes have been left in place, you have approximately a 60% chance of having a successful pregnancy in the future.

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