Hyperstimulation

This is an image taken from a patient who presented with left lower abdominal pain. She has a past history of surgery for endometriosis, GnRHa therapy and is currently seeking to get pregnant. She had been taking Clomiphene for the past 3 months prescribed by her gynaecologist. The ultrasound scan shows a bizarre multiloculated cyst about 9 cm in size. This looks like a hyperstimulated ovary due to clomiphene. Hyperstimulation with clomiphene is not common and usually subsides without complications. The main point here is to observe rather than to rush into any further surgery. 

Ini adalah gambaran yang diambil dari seorang pesakit yang mengadu perasaan sakit dibahagian kiri abdomen. Beliau pernah menjalani pembedahan dan rawatan ubat hormon untuk penyakit endometriosis. Buat masa kini, pesakit ini sedang melalui rawatan kesuburan dengan ubat clomiphene 3 bulan yang lepas yang diberi oleh pakar sakitpuannya. Imbasan ultrasound menampakkan sebuah sista sebesar 9 cm yang mempunyai banyak ruang dalamnya. Ini merupakan sebuah ovari yang telah terangsang berlebihan oleh ubat clomiphene. Rangsangan hiper saperti ini jarang belaku dengan ubat clomiphene dan biasa surut tanpa komplikasi. Tindakan utama ialah pemerhatian dan elak dari melakukan pembedahan tergesa-gesa.

Clear 4D Pictures

Right ear and neck/Telinga dan leher kanan

Both feet/Kedu-dua kaki

Everybody likes to see clear pictures of their baby, so it is important that a 4D scan is done at the right time. This is around 20-24 weeks of gestation, but a lot depends on the amount of liquor within the uterus. These pictures are from a pregnancy with excessive liquor, termed polyhydramnios, so the 4D scan pictures are particularly clear.

Semua ibu-bapa ingin melihat gambaran yang jelas kandungan mereka. Dari segi imbasan 4D, penting supaya ia dilakukan pada waktu yang betul, biasanya antara 20-24 minggu usia kandungan. Walaupun demikian, banyak bergantung pada jumlah air ketumban yang ada dalam rahim. Gambar-gambar ini diambil dari kandungan yang mengalami air ketumban yang berlebihan, lebih dikenali sebagai polyhydramnios, dan nyata kejelasan gambarnya.

Right thigh and knee/Peha dan lutut kanan

Funny Places for Endometriosis

The July edition of The Journal of Minimally Invasive Gynaecology (JMIG) presents 2 case reports of endometriosis occurring in abnormal places. In the first case, the patient had nose bleed and pain and was found to have growths there. The second case presented with gastric-like abdominal pain and was found to have a growth in the pancreas on scanning. Both cases were confirmed as endometriosis after surgical removal. Of note was that these patients had positive correlation with cyclical symptoms as well as previous suggestion of endometriosis. So, endometriosis in the nose and in the pancreas. Who would have thought it?

Tapak Aneh Penyakit Endometriosis 

Dalam isu bulan Julai The Journal of Minimally Invasive Gynaecology (JMIG), terpapar 2 kes penyakit endometriosis yang ditemui di kedudukan yang aneh. Pesakit kes pertama melapor pendarahan dan perasaan sakit di hidungnya serta ternampak ketumbuhan. Pesakit kes kedua pula mempunyai perasaan sakit ala gastrik dan ternampak ketumbuhan di kelenjar pankreasnya melalui imbasan. Kedua-dua kes ini dipastikan mengidap penaykit endometriosis selepas pembedahan untuk mengeluarkan ketumbuhan-ketumbuhan tersebut. Yang penting dalam kes-kes ini ialah sejarah perubatan yang mengaitkan penimbulan simptom-simptom tersebut dengan kitaran haid serta sejarah lama penyakit endometriosis. Jadi, endometriosis di hidung dan pankreas, sungguh aneh!

August Case - Twin Fibroids

Sorry, I have been meaning to write but have been swamped with other things. This was a 51 year old lady who had never conceived in 30 years and presented with abnormal and heavy menstrual bleeding. There was a mass felt in the abdomen, about 6 months pregnancy size. Ultrasound scan showed multiple uterine masses suggestive of fibroids. This was the view on laparoscopy - twin, large fibroids. I had counselled hysterectomy, but it was difficult due to the restricted view. I had to remove the fibroids from the uterus first (myomectomy) before proceeding to hysterectomy. As usual, everything was done laparoscopically. 

Fibroid Kembar

Maaf atas kelewatan menulis. Kes ini adalah seorang wanita berumur 51 tahun yang tidak pernah mengandung walaupun kahwin selama 30 tahun. Beliau mengalami pendarahan haid yang berpanjangan dan lebat, dan setelah diperiksa, didapati mempunyai ketulan di perut sebesar kandungan berusia 6 bulan. Imbasan ultrasound telah menampakkan banyak ketumbuhan di rahim yang berciri fibroid. Gambaran ini dilihat melalui laparoskop - fibroid-fibroid besar dan berkembar. Pembuangan rahim menjadi rumit apabila penglihatan terhad kerana ketumbuhan-ketumbuhan tersebut. Akhirnya, fibroid-fibroid ini dipisahkan dahulu dari rahim sebelum histerektomi dilaksanakan. Saperti biasa, semua prosedur dilakukan dengan melalui pembedahan laparoskopi.

Facts About Menopausal Hormonal Therapy

10 years after the seminal publication of the Women’s Health Initiative trials data¹, certain facts and data have emerged that can help guide us in this so controversial an issue of Menopausal Hormonal Therapy (MHT). The following is a summary of a review published lately in the journal Menopause².

It has always been a truth that MHT is an acceptable option for treating severe early menopausal symptoms. As is the wont of these symptoms, they disappear within 10 years of menopause, thus this treatment is prudent and applicable within this time frame. Such therapy must of course be precluded in the presence of medical problems, foremost of which are blood clots, heart disease, stroke and cancer.

Estrogen replacement alone suffices for a woman who has lost her uterus, whereas progesterone therapy needs to be added for the sole purpose of prevention of endometrial cancer in those who retain theirs. If the symptoms are limited to the vulva, vagina and the bladder, topical estrogen therapy to the affected parts might be enough to soothe the symptoms.

So much is so true, and we must keep in mind that the whole controversy arose not because of questionable beneficial effects, rather, the serious consequences of MHT. Foremost in the mind of most women is the occurrence of breast cancer. The WHI trials demonstrated an increased risk of breast cancer with more than 5 years continued use of the estrogen-progesterone combination therapy. This increased risk was not present in users of estrogen-only preparations, thus suggesting a causal link of breast cancer with progesterone. The data shows that the risk is not that great and decreases after discontinuation of said replacement therapy. Estrogen, whether given alone or together with progesterone, increases the risk of thromboembolic events (TE) such as deep vein thrombosis, pulmonary embolism and stroke, but these occurrences are rare before the age of 59 years.

Thus we have come to accept that combination estrogen-progesterone MHT is proven effective in the management of early menopausal symptoms only (and not for other indications) but should be used for the shortest duration and with the lowest possible dosage. More flexibility is accorded to estrogen only therapy but similar caveats should apply whenever possible.

Fakta Berkenaan Rawatan Hormon Menopause

10 tahun selepas maklumat daripada kajian unggul berkenaan rawatan menopause diketengahkan¹, situasi berkenaan rawatan ini semakin jelas, saperti dipaparkan dalam jurnal Menopause baru-baru ini². Berikut adalah ringkasan tajuk utama.

Terapi hormon untuk menopause (MHT) sungguh berkesan mengatasi gejala awal menopause dan boleh diteruskan selama 10 tahun, iaitu, sehingga simptom-simptom keadaan ini hilang. Rawatan ini tidak boleh digunakan jikalau seseorang wanita mengalami beberapa masalah perubatan, terutama sekali ketulan dalam saluran darah, serangan angina ahmar, sakit jantung dan kanser.

Rawatan ini boleh dibahagikan kepada 3 – hormon estrogen sahaja untuk wanita yang tidak mempunyai rahim, kombinasi hormon estrogen-progesteron bagi mereka yang ada rahim dan krim estrogen setempat jikalau gangguan terhad kepada kemaluan, faraj atau pundi kencing.

Risiko penggunaan MHT ialah kejadian saperti kanser payudara dan kejadian tromboembolik (TE) saperti angina ahmar, ketulan darah dan embolasi paru-paru. Tidak dinafikan yang MHT meningkatkan risiko mengalami kanser payudara, tetapi jumlah kejadian ini kecil dan risiko tersebut hilang selepas rawatan diberhentikan. Lagipun, risiko berlakunya kanser payudara hanya meningkat jika digunakan terapi kombinasi estrogen-progesteron dan bukan estrogen bersendirian. Kejadian TE lebih berkemungkinan berlaku dengan kesemua jenis rawatan oral tetapi jarang dialami sebelum umur 59 tahun.

Dengan ini, MHT didapati sesuai untuk rawatan simptom-simptom awal menopause sahaja tetapi perlu digunakan dalam dos yang paling rendah dan dalam jangkamasa yang paling pendek. Pengawasan untuk gejala kanser payudara dan kejadian TE mesti berterusan.

1. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA 2002;288(3):321-333.

2. Stuenkel CA, Gass MLS, Manson J et al. A Decade After the Women’s Health    Initiative – The Experts Do Agree. Menopause 2012;19(8):846-847.

Increased Risk of Type 2 Diabetes With Polycystic Ovary Syndrome

Peningkatan risiko mengidap penyakit kencing manis untuk wanita PCOS

It has been known for some time that a woman with PCOS has an increased risk of getting Diabetes mellitus (DM) has been known for some time. Adding to this knowledge is a new study from Cardiff that examined a very large number of patients (more than 20000) to confirm this point. The data taken from the UK's General Practice Research Database showed a 2-3-fold increase of DM among PCOS women when compared with controls.

Telah lama diketahui bahawa seseorang wanita yang mengalami PCOS berisiko lebih tinggi mengidap penyakit kencing manis (DM). Kini, kenyataan ini menjadi lebih kukuh berdasarkan satu kajian dari Cardiff, United Kingdom yang melibatkan lebih dari 20 000 orang wanita. Maklumat daripada kajian ini mendapati wanita PCOS berkemungkinan mengidapi DM 2-3 kali ganda lebih berbanding dengan wanita tanpa PCOS.

Christopher L. Morgan, Sara Jenkins-Jones, Craig J. Currie, and D. Aled Rees. Evaluation of Adverse Outcome in Young Women with Polycystic Ovary Syndrome Versus Matched, Reference Controls: A Retrospective, Observational Study. JCEM jc.2012-1690; doi:10.1210/jc.2012-1690

Upside Down Baby

This baby at around 25 weeks gestational age was captured on a 4D scan in a na upside down position because of its transverse lie in the uterus. A fatal lie like this may be considered normal at this gestational age, and most babies stabilise into a normal lie between 28-32 weeks gestation. this baby's hand can also be viewed in the gallery.

Bayi Tertungging

Gambaran 4D seorang bayi (perempuan) dengan kepala tertungging didapati apabila bayi beruisa   kandungan lingkugan 25 minggu berkedudukan melintang dalam rahim. Kedudukan saperti ini adalah biasa dalam usia ini dan kebanyakan bayi akan membetulkan diri selepas 28-32 minggu usia kandungan. Tangan kanan bayi ini boleh juga dilihat dalam galeri.

JULY CASE

This 37 year old lady with 3 children was diagnosed with a missed abortion. She was planned for Dilatation and Curettage (D&C) but also expressed the desire for tubal ligation (TL) as permanent contraception. Over the years she had developed mild period pain but was otherwise well. Under general anaesthesia, D&C was carried out followed by laparoscopy for the TL. Incidental endometriosis was then discovered on inspection of the pelvis. This picture shows some classical lesions. Firstly, the uterus was mildly enlarged but this could have been due to the pregnancy. There was a left ovarian cyst and the enlarged ovary was stuck to the back of the uterus. At the point of adhesion, a flame shaped endometriotic lesion was observed. This case demonstrates again the discrepancy between symptoms and the extent of the disease in endometriosise, as despite having severe endometriosis, she was relatively well apart from mild dysmenorrhoea.

Wanita berumur 37 tahun dan beranak 3 mengalami keguguran dan bersedia melalui prosedur cuci (D&C). Sambil itu, memandangkan usia meningkat serta ketidakrelaan mengandung lagi, dia juga ingin melalui prosedur ikat tiub (TL) sekali harung. Selain dari mengalami perasaan sakit senggugut sedikit, beliau sihat walafiat. Selepas dibius penuh, kandungan yang gugur telah dicuci dan laparoskop di masukkan melalui pusatnya untuk prosedur TL. Selepas diteliti, pesakit ini didapati mengalami penyakit endometriosis yang agak teruk dengan serba jenis lesi. Rahimnya bengkak sedikit tetapi ini mungkin disebabkan mengandung. Ovari kiri bengkak juga kerana kehadiran sista, dan ovari ini terlekat pula ke bahagian belakang rahim. Ditempat lekatan ini berlaku, terdapat satu lesi "flame". Kes ini memberi pengajaran lagi yang simptom atau tanda penyakit endometriosis tidak semestinya secocok dengan keterukan penyakit itu.

Pembedahan Laparoskopi

Pembedahan laparoskopi adalah suatu jenis pembedahan moden yang melibatkan belahan-belahan kecil dan proses penyembuhan yang cepat. Perasaan sakit yang dialami sangat sedikit berbanding dengan pembedahan tradisional dan pada kebiasaannya, seseorang pesakit hanya perlu tinggal di wad kurang dari 24 jam. Untuk keterangan yang lebih lanjut berkenaan pembedahan yang mempunyai banyak kelebihan ini, layarilah mukasurat "Pembedahan Laparoskopi".

Apakah dia 4D Scan? Jika anda berminat untuk mendapat maklumat lebih, layari muka terbaru blog ini.

KES BULAN MEI

Susah Mengandung

Puan SI, seorang perempuan Melayu berumur 32 tahun yang telah berkahwin selama 4 tahun mengalami masalah susah mengandung. Dia telah membuat penelitian dan rawatan di hospital kerajaan tanpa jaya sebelum ini. Beliau tidak pernah mengalami apa-apa masalah lain dan mempunyai perjalanan haid yang sempurna tanpa sakit senggugut. Air mani suaminya didapati normal. Pemeriksaan fizikal tidak menampilkan keganjilan, cuma pesakit ini sedikit obese. Scan ultrasound menunjukkan rahim dan persekitarannya yang normal. 

Gambar ini mempamerkan sebeuah rahim yang mempunyai banyak saluran darah halus dipermukaannya yang digelar "Vascular Patterns" seakan ia meradang. Kedua-dua saluran Falope tersumbat yang disebabkan oleh benjolan hasil dari penyakit endometriosis. Ovari-ovari normal kelihatan warna putih.

Puan SI telah menjalani pembedahan laparoskopi di mana nyata kelihatan sebuah rahim yang meradang (lihat gambar) dan saluran Falope yang tersumbat kedua belah. Ini disebabkan oleh penyakit endometriosis dan rawatan hormon kini sedang dilaksanakan untuk mengatasi masalahnya.

Pelajaran yang boleh didapati dari kes ini ialah penyakit endometriosis kerap kali wujud tanpa tanda dan simptom utamanya mungkin hanya kesukaran mengandung. Tiada keganjilan yang kelihatan menerusi penelitian biasa, dan diagnosa hanya dapat dilakukan melalui pembedahan laparoskopi. Oleh itu, seseorang pesakit yang mengalami kesukaran mengandung tanpa sebab yang nyata berkemungkinan mengalami penyakit endometriosis.

Surgery for diabetes?

Recently, two studies were published in the New England Journal of Medicine (NEMJ) providing compelling evidence that surgical methods of achieving weight loss can lead to better control of Type 1 diabetes mellitus (T1DM). It is well established that weight loss in an obese person can show marked improvement in the control of their DM.

As we are well aware, while T1DM results from the body’s failure to produce adequate amounts of the hormone insulin, Type 2 DM (T2DM) is a consequence of improper utilization of this hormone. Regardless of the type, DM becomes more difficult to manage as it progresses and ultimately leads to serious and severe complications such as heart disease, kidney failure, blindness and stroke.

Crucial to proper management of this disease is the adequate control of blood sugar centered upon lifestyle measures that encourage weight loss and physical activity. The weight loss regimen involving diet and exercise can be a mentally and physically painful process with often a less than desirable outcome. Many patients are unable to achieve good glycemic control, leading to the addition of medications, frequently with increasing number and dosage, and ultimately the addition of insulin therapy. Counter to the aim of the therapy, one of the side effects of insulin therapy is weight gain, thus rendering management more difficult.

It is no surprise then that more patients are starting to resort to surgery to decrease the size of their stomach. This type of weight loss surgery is termed bariatric surgery and involves gastrectomy (removal of part of the stomach), stapling or banding of the stomach. Although having been around for some time now, an upsurge in cases of bariatric surgery for the management of DM has been reported, mainly due to recent information from clinical studies that showed significant weight loss and subsequent improvement in diabetic control. These recent studies provide more dependable information because of their random and rigorous comparison between medical and surgical forms of treatment. There is now better proof that weight loss operations seem to work much better than standard medical management. 

Nevertheless, caution must be employed and it may be wise to examine the studies in depth and note their deficiencies. They involved only a small number of patients (150) and were of a short duration. As well as not being able to prove long-term benefits, it is also questionable if the results of bariatric surgery will be as good in routine clinical practice, or for that matter, in patients who are not as heavy as those in the studies. Since highly skilled surgeons performed the operations in these studies, results by others may not be as good. Surgical complications can range from infections, mineral and bone deficiencies and other injuries. Furthermore, these studies compared bariatric surgery with standard medical care involving medications, when in actual fact, the comparison should have been with medical weight loss therapy (diet, exercise, behavior change and other appropriate medical interventions). Patients succeeding with medical treatment would then have no necessity to undergo surgery at all.

To be fair though, bariatric surgery has been recognized as appropriate treatment, but only for those obese patients with Type 2 DM who are unable to reach their glycaemic targets with the prescribed medical therapies.

In conclusion, we should not rush to embrace bariatric surgery as a standard treatment alternative for DM despite the strong evidence suggesting so. Due recognition has to be given for the hard work put in by the researchers, but benefit must be shown in a larger numbers of patients, and over a longer period of time before we can determine the place of bariatric surgery in the management of Type 2 DM.

References:

Schauer PR et al. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. March 26, 2012 (10.1056/NEJMoa1200225)

Mingrone G et al. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes. March 26, 2012 (10.1056/NEJMoa1200111)

Zimmet P, George K, Alberti MM. Surgery or Medical Therapy for Obese Patients with Type 2 Diabetes? March 26, 2012 (10.1056/NEJMe1202443)

Kes Bulan April 2012

PENDARAHAN YANG LEBAT DALAM USIA MATANG

Puan S, seorang ibu berusia 46 tahun dan beranak 3 telah mengadu pendarahan haid yang lebat sejak 3 tahun yang lepas. Walaupun pendarahan haidnya lebat, tetapi kitarannya tetap sama saperti masa-masa dahulu. Yang menyebabkan Puan S mencari rawatan selepas kian lama mengalami pendarahan ini ialah penimbulan simptom baru, iaitu, perasaan sakit senggugut.

Selepas diteliti, didapati Puan S adalah seorang wanita yang obes dan bertekanan darah tinggi serta pucat akibat kekurangan darah. Dibahagian bawah perutnya terasa satu ketulan keras sebesar kandungan 4-5 bulan.

Ultrasound scan telah menampakkan sekurang-kurangnya 3 fibroid dalam rahim, yang paling besar berukuran 9 cm.

Beliau telah menjalani pembedahan laparoskopi dan pembuangan rahim (kedua-dua ovarinya dipelihara kerana masih menghasilkan hormon estrogen). Pembedahan yang agak rumit ini mengambil masa 3 jam dan memerlukan pemotongan fibroid dari rahim untuk menyenangkan pembedahan.

Puan S telah bergerak dan makan saperti biasa pada keesokan hari dan balik rumah dengan hanya mengadu perasaan sakit sedikit saja.

Gambaran ini mempernampakkan rahim yang besar hasil dari fibroid dikelilingi usus sebelum pemotongan dimulakan. Ovari kanan kelihatan di celah tiub kanan dan berwarna putih. 

PCOS AND HYPERINSULINISM

The most common endocrine cause of anovulation is polycystic ovary syndrome (PCOS). Typically, women with this problem present with infertility associated with scanty menstrual periods and cycles of more than 35 days. Most patients have some clinical or laboratory evidence for hyperandrogenism, and polycystic ovaries appear on ultrasonography. The familial association with diabetes mellitus (DM) is quite significant. As the risk for DM amongst PCOS women is increased several-fold, many of them become diagnosed with impaired glucose tolerance or insulin resistance. This disturbance in glucose metabolism is due to elevated baseline or stimulated insulin levels and may be a consequence of a genetic predisposition. The role of insulin as a growth factor is well established. Insulin stimulates the ovarian theca cells to produced increased amounts of androgens. Considering that androgens serve as precursors for estradiol synthesis, it is therefore unsurprising that estradiol levels become elevated. Hyperandrogenism also interferes locally with the normal process of folliculogenesis thus propounding the hormonal and fertility problems. Metformin is an insulin-sensitizing drug that is commonly used in the treatment of DM and serves to reduce insulin secretion. Its use is also associated with a normalization of the intraovarian paracrine milieu and is effective in PCOS. Despite the belief that metformin may not be totally effective in the management of fertility-related issues, it is quite logically an effective form of treatment that addresses the hormonal imbalance in patients with PCOS. Having said that, lifestyle changes remain in the forefront of combating abnormalities of glucose metabolism and associated metabolic problems.
http://www.blogger.com/blogger.g?blogID=6093017718873746713#editor/target=page;pageID=8001467461256480910

Uterotonics and Postpartum Haemorrhage

Postpartum hemorrhage is an important cause of maternal mortality in developing countries, especially Africa and Asia. Active management of the third stage of labor consists of the use of oxytocin soon after delivery of the baby, controlled cord traction, and delayed clamping and cutting of the cord until the deliverer is ready to apply traction.

In a study published recently in The Lancet, Gulmezoglu et al showed that controlled cord traction may be omitted from the management of the third stage of labor without a significant increase in the risk for severe hemorrhage. Thus, the main component of active management is the uterotonic and it is the key intervention that will prevent excessive bleeding after childbirth.

Despite this, controlled cord traction is safe and its use can be continued in settings in which it is routinely practiced.

Hanifullah Khan

22 March 2012

Reference:

Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Gulmezoglu AM, Lumbiganon P, Landoulsi S et al. The Lancet - 6 March 2012 DOI: 10.1016/S0140-6736(12)60206-2.