Swine flu vaccine in pregnancy

Laser for fibroid removal

LASER sound fascinating .A laser surgery sounds so exotic and as a MBBS students mention of LASER in the surgery mage it sound really impressive to my ears too.

Recently,my husband Dr Shalabh Mohan started LASER surgery for Piles and fissure and whole lot of general surgical conditions.And that made me curious as usual.Can I use it for my patients in any possible way to make the treatment better?I know vulval warts and skin tags can be removed -but I can it be for something more?

And then came A lady from Punjab.Rather her son got her to me.She had visited PGI Chandigarh and was advised removal of uterus.On examination I found a big cervical fibroid.Question was - Doctor can I avoid Hysterectomy?

I said probably yes with a cervical Myomectomy but with this big Fibroid the bleeding can be quite heavy and suddenly I remembered the friendly Diode Laser sitting next to the study table at home.Oh yes - we can.We surely can.Laser minimises the bleeding and the fibres can reach those nooks and crannies which isn't possible otherwise.So that what she wanted - a laser surgery.Getting an approval from her insurance company was a hassle.Insurance company wasn't willing to pay extra even if it meant less blood loss and early recovery.But still she wished to get the surgery done and I did perform.

With the ease of the LASER the 6cms fibroid was out and away in 1
5 to 20 minutes.The blood loss wasn't even 50 mls and the Lady had left for her home in 4 days.
How did I feel - surely ecstatic...it was a job well done.

IVF and the stimulation story

I was trying to explain a very old loyal patient of mine today.For an IUI I can't give you FSH in a dose which hyper stimulates you.And she said why?I said - see that can triplets or quadruplets which can complicate the pregnancy besides Ovarian hyper stimulation which can be dangerous for your life.And her response was -whats the harm in having triplets.In my current state I am willing to take all these possible risks.Well....her current state is a secondary sub fertility.Has a cute little child already.

So what it means is that sub fertility a 'disease' which leaves a couple so vulnerable and desperate that one is willing to take all the risks.

I have another lady under my care.Pregnant with an IVF conception.The dose at which she was stimulated was unheard of.And I had asked -so didn't you get OHSS? She said-yes I did.Was even admitted in ICU for few days,but she still had a sense of satisfaction on her face,as if to say,'' doesn't matter ,it was a small price to have baby'.

It becomes a dilemma as an infertility specialist.What is justified?Infertility treatment is nerve wrecking and costly-an emotional roller coaster too.Low dose stimulation means less eggs but then how can one be oblivious to the mothers health and life.But at the same time a low harvesting of egg means a possibility of repetition .

The evidence based and safe answer is still mild stimulation but I just wonder to a couple badly desirous of conception does this makes any sense?

Probably not for most Indian couples.

I am scared Doc!!

Not uncommonly ,couples visit me with a particular complaint after many years of suffering in silence.Health is a state of physical,mental and emotional well being.And unfortunately these co uples though physically healthy have severe emotional issues.

A typical history is where the male is a considerate person and the woman has a fear of painful sex and they are unable to consummate the marriage despite being in relationship for many years.
Most of the time the Lady doesn't have any problem locally but it is the 'fear' .

If you have tried every possible conservative method in the world and still are unable to overcome the fear,visit a Gynaecologist who has some knowledge of urogynaecology. After examination it can be ruled out if there is a local problem and that can be fixed.If there isn't any anatomical problem,then a vaginal dilatation can be performed under anaesthesia.It works as the lady knows that now the dilation has been performed and that helps them overcome the fear.

Lot many time if there is a local scarring an operation called fentons operation which widens the vagina is useful.It is a kind of vaginal reconstructive surgery .

Those who have never faced this issue might find this post surprising but for those it is a real concern,their life is muddled with a problem which they find difficult to share with anyone easily and keep on suffering.

Chronic Vaginitis

Nothing can be more frustrating that a constantly itchy vagina with a fungal or bacterial infection.What increases the frustration further is one has already visited the best of gynaecologist in the town,has had many courses of anti fungals,antibiotics,many pessaries,potassium permegnate solution and all sort of ph maintaining washes.

By now many sufferers start thinking that their martial life has gone for a toss or they themselves are mentally ill.

Is there anything which still remains to be tried?As a hope of relief comes Boric acid capsules which can be used vaginally for 14 days to get rid to resistant fungal of bacterial infection.Next time you have a similar condition under your Gynaecologist's supervision do try .It should be used as 600 mgs pessary.In India it isn't easily available ,so you can try this product from Amazon which I recently searched online for one of my patients.

Book to read while Pregnant

Many a times Pregnant women ask we the book or books they should read while pregnant.Those who have been my patients know that I give an elaborate handbook ( What to expect when expecting)to all the moms under my care which answers most of the FAQs.Still if you wish to read further you can read this book available on Amazon.This book is good.Also covers lots of Pregnancy complications which many a pregnant women tend to imagine themselves with all possible complication while reading this book.Avoid that and then it is a nice book to read and understand pregnancy.

Stressed ???

Stress - It isn't uncommon word or rather it is an extremely common word.
Atleast 50 % of my patients are stressed.It leads to whole load of health problems.It has contribution in infertility,metabolic syndromes like PCOD,irregularity of periods,discordance in sexual and marital life and so on and so forth.

But why are we stressed? Who is responsible?Is it us?Is it our surrounding?Is it multifactorial?
Who can help us?How can one help oneself?

I am writing this post for two reasons.One -this is a very commonly asked question.Second-I think ,I am qualified to write it now.A stage in life where I can say I have learnt to handle situations in life in a way which has reduced the stress levels to a minimum.

Not long back I was a typical type A personality who was driven on adrenaline.Even today I am a type a Personality but I have learnt to tame that type A person in me.I let it be awake when I need it but at other times I make it have good rest.Yes....thats correct you need to take good rest,detach yourself from the mad rush around you to perform more effectively and more productively .

After so many years in my profession and also my life,I realize,events are predestined.Though one should give one's best in whatever one does,nothing is in one's hand.Once I could feel this and make myself believe in this theory 70 % of my stress was relieved.Secondly ,the definition of success has changed for me.It no longer means the biggest player in the market ( number wise).I enjoy what I do.But excess of anything is bad,including enjoyment.The moment one increases one's work load beyond a certain limit the performance and productivity falls down.Recently there was a Lady admitted under surgeons for some general surgery related problem.She had an incidental ovarian cyst as well which she wished to get removed in the same sitting.Now due to whatever reason,it was convenient for the surgeon to operate the Lady late in night around 10 pm.In my opinion elective surgeries are best done in elective hours for best outcome.So what I did was I refused to operate .That lady had not come for me.For her it didn't matter who the treating gynaecologist was and thus I requested the surgeons to call some one else,which they did.

I saved myself from a stressful situation.Previously I would have operated her even at 10 pm in the night against my own wishes and belief and a tired body and mind.It would have given me 12 - 13 k but I would have lost my health and sleep and of course would have been an unsafe tired surgeon.

It is just an example .The situations are varied and you will have to find your ways to minimize your stress levels.

Another change - now when in theatre I am not worried of the waiting list in OPD.Things need to be prioritized.An emergency or on going active surgery takes priority over an OPD patient.If unhappy to wait,there are other consultants available around and am sure they can be taken care of.There is no point trying to be omnipresent. 1300 OPD fees ,isn't worth a complication in OT or a law suit in court.

INR

Now my own health is my priority.I insure to take 2 to 3 hours out for me in my 24 hours for my health and exercise.All the joys and pleasures in the world can be felt only till we have a healthy body and mind for which it should be treated as a temple and should be worshipped.

Lastly ,now i don't think any loss is irreparable accept the loss of life .So ,I don't fear the future.There is no question as what next?

These are few of the changes ,which I think has helped me immensely.Try to incorporate in your life and see if that helps an irregular period or a failing marriage or dry sex or endometriosis or makes you conceive .

I have got thyroid dddd !!!!!

Are you also worried ,you have got thyroid'? If the answer is yes then we need to know a bit more about thyroid.And what do you mean when you reach the doctor to tell'you have got a thyroid"
Thyroid is intact a gland in neck region of all of us unless surgically removed.It is present since birth.Due to various reasons it can under function when Pituitary gland ,a gland in brain starts producing more TSH and you suffer from Hypothyroidism.

On the contrary if Thyroid is overactive and produces more thyroxine,less of TSH is needed and produced by the pituitary.That is called Hyperthyroidism which is less common but more serious issue then Hypothyroidism.

In Pregnancy the cut off for TSH is 2.5 If the concerned Lady has anti thyroid antibody and TSH level is between 2.5 to 10 mu,even then thyroxine supplement is needed to prevent potential complications like mental retardation ,miscarriage ,if Anti thyroid antibody is negative,no supplement is needed between TSH values 2.5 to 10.Any value measuring 10 and above needs thyroxine supplement.

( Based on American Thyroid society guidelines 2017)

Normal Delivery or caesarean ??

You are Pregnant.Are you ?Most likely you are if you are reading my post or are planning it real soon.Or may be you are not.Pregnancy and delivery are facts of life which most of the women go through with great apprehension,enjoyment ,doubts and at times confusion.

It is a quite frequent question - Doctor ,which one is better -normal or Caesarean section ?Well well,may be few years back my answer would have been 'of course vaginal delivery if you can manage it safely'.Still my answer is more or less the same but my attitude to it has changed slightly.I don't know whether it is right or wrong but it is changed for sure.I will share my thoughts and the reason behind it.

Before I write what I feel,let me tell my interpretation of high Caesarean section rate in corporate hospitals.It isn't certainly not for money making.No doctor is paid more for doing Caesarean vs normal delivery.Hospital probably gains marginally from caesarean section but atlas I haven't been told my anyone and I mean no one in either of the the two hospitals I have worked to perform a single un indicated surgery.The most common reason is a scared doctor,scared of things going wrong during the long process of labour and at times not to wait the long hours of labour and get tied leaving rest of the chores and social life and responsibilities and at times a busy OPD.

Now coming back on track,Vaginal delivery is good.Caesarean is good too.Vaginal birth after caesarean section is no less good.But what is bad then ?Bad is when a procedure is done against the wishes of the Lady and if it is unindicated. Now a caesarean on demand of a lady without any Obstetric indication isn't unindicated. The Lady needs to know pros and cons of all the three methods and after that whatever she decides is a correct decision.

Not many of us give a unbiased we including me.Vaginal delivery is the normal process which nature wanted.But has caesarean got certain advantages over it ? Probably yes.With vaginal delivery there is for sure more chances of weakness of the pelvic floor in long run with an increased chances of urinary leakage,pelvic organ prolapse.It is not to be mistaken with me saying ,women who delivered by caesarean won't or can't have these problems.If the baby size is too big and if it is a traumatic delivery it can have long lasting impact on your pelvic wall as well as the baby.Again i am not saying ,it is rule of thumb but it can happen.

Now caesarean - well it has many disadvantages too.Recovery is longer than vaginal delivery for sure but it isn't a long long process but there is increased risk of adhesions,injury to bowel and bladder,infection,ectopic pregnancy,placenta praaevia and increased possibility of caesarean section in future pregnancy.

Vaginal birth after caesarean section can be achieved in 60 to 80 % of women who had previous caesarean section.But if any female decides an elective caesarean after a previous caesarean is also not an insane decision.VBAC has a risk (1%) of previous scar giving way during labour and that risk increases if we need to use any drip -syntocinon or Prostaglandin gel either for induction or augmentation.The lady needs to take an informed decision whether is wishes to take the risk of repeat major surgery or the scar giving way.

Now you know,when I see dispassionately which I wasn't able to do before due to my NHS training which  then recommended -Normal delivery rate of 80%,I don't think either of the mode of delivery is bad.It is all about choices.But what I do disapprove is ,if the woman wants a vaginal delivery and can achieve one safely to convert it into a caesarean.


If any one of you wish me to write any further posts on this issue or any other please do write back .

Genital Warts

Genital warts aren't uncommon.I am frequented by Ladies who have developed warts and aren't sure what it is or they have done so much internet surfing that the are too stressed by the time they visit a specialist.
Genital warts are caused by Human Papilloma Virus,the same virus type which causes cervical cancer but having said that Vulvar warts aren't equal to cervical cancer and thus detection of a wart shouldn't be a cause of panic.It is one of the sexually transmitted disease but it doesn't mean that your partner is cheating on you.Actually most of the women develop these warts many months or years after acquiring the HPV infection.HPV can be transmitted by skin to skin contact and need not be through penetrative sex.Condoms are the most effective way of preventing HPV transmission but condoms don't give 100% protection.Even for oral sex it is advisable to put condom over the penis and sharing of sex toys should be avoided.
Warts in general don't cause massive symptoms or cause major damage.They can look unsightly and if not removed can be a source of spreading the infection to your partner.For very small warts some chemicals can be used but it takes a lot of time for them to get cleared with the chemicals .
Surgically it can be removed using electrocautery or laser.It is important to seek specialist help.HPV infection and warts can get cleared off the body completely or it can be recurrent.There is no medicine to prevent the recurrence and depends on the immunity of the lady.If smoker,stopping smoking can be helpful in making the treatment more effective.

Vaginal reconstruction,Vaginal rejuvenation,tightening of Vagina

Does these name vaginal rejuvenation,Vaginal reconstruction,Vaginal resurfacing,Hymen repair sound familiar.have you heard it recently more often than before



With changing society the current day health requirements are not just about how one feels but also how one looks inside out,top to bottom( literally)





A lot of attention is paid to the genitalia by females as well as males to get aesthetic surgery for private parts.





Though I don't see a compulsion when a lady about to get married comes to me to repair the hymen,but I do understand her judgement and that needs to be respected.A neo hymen needs to be made and yes,it is refreshed and made.



Then comes a Lady with multiple Vaginal births with a vagina and perineum which has naturally gone lax.She feels embarrassed while her husband feels unsatisfied.A minor issue but a major one for the Lady and her husband.Can the vagina be tightened,refreshed where the couple can get for pleasure out of sex to keep a harmonious marital life.Yes surely it can be done. If you feel the need to visit our centre at Clinic nirvana ,I would feel happy to explain you the procedure and how simply it can be done.



At time women have body dimorphism and the go for aesthetic surgeries and private part is no different and have seen many young ladies who didn't like their Labial size or shape.Can we help them.Sure we can





Urinary Leakage ...well mesh surgery as well as  minimal incontinence can be dealt with laser surgery too.



Menopausal lady whose vagina is hormone depleted,gone dry and thinned out and has uneasy buning sensation,she can be helped with laser surgery too by generating new collagen



With many years of  experience in urogynaecology,I find aesthetic gynaecology an interesting part of health care.With new techniques and modalities it is possible to give as much efficacy in vaginal tightening or rejuvenation as one would do after a big surgery  by just a half day or maximum 24 hours or at times 45 minutes of non knife surgery.-Lasers to be precise.



Considering that anything to do with aesthetic surgery or repairs,doesn't come cheap including the Laser machines used.



We also perform hymenectomy in couples who have not been able to consummate marriage due to any reason.

Cervical Cancer and Pap smear

So, January being cervical cancer awareness month,I thought of getting repetitive  and talk about Pap smears and vaccines once again.

Cervical cancer - Cervical cancer is the cancer of mouth of the womb and is the commonest cancer in Indian women.Unlike other cancers cervical cancer doesn't surprise you by it's sudden occurrence.It goes through various stages of cell abnormality before getting pre cancerous or even cancerous.


High Risk Factors-Promiscus behaviour and multiple sexual partners,usage of Oral contraceptive pills,smoking,multiple child birth to mention a few.It is caused by a virus called Human papilloma virus,which is mostly transferred during sexual encounter.


Screening- Pap smear is a preventive test which doesn't  take more than 5-7minutes to perform.A brush is used to gently take the cells from the cervix.At worst this test can be called mildly uncomfortable but not painful.A laboratory examination screens out any abnormal cells.

Pap smear should be done every 1 to 3 years till the age of 64years.

What if Pap smear is abnormal-Incase of an abnormal report,another test colposcopy is done where the cervix is visualised under a magnifying lens after applying a vinegar like solution or iodine or both and if any area looks suspicious,small piece s taken and sent for pathological confirmation.Again,this procedure can be done without Anaesthesia.


What if Biopsy also comes abnormal.If it is till precancerous stage,a procedure called LETTZ is performed where the abnormal area of cervix is 'shaved of' using electric current.A cancer obviously would need removing major chunk of cervix if family isn't complete or a hysterectomy if the family is complete.

HPV vaccine- It covers only 4 out of 100 strains of HPV and thus the maximal protection offered is 72 % and not 100 percent.Maximal benefit derived is before the girl became sexually active.Recommended age group is 9 years to 26 years.After that one would get some protection but difficult to say how much protection.

So a few minutes spared every year can save many lives.If you haven't had a screening so far,it is never too late to begin something as beneficial as this.