OVARIAN CYST IN PREGNANCY

The incident of ovarian cyst is about 1 in 100- 10000 pregnancies. Most are diagnosed incidentally, during a routine obstetric scan. The majority of these masses resolve by the second trimester, allowing a conservative management. Is there a cause for concern?

The ovarian cyst is broadly classified into functional (luteal cyst) and pathological groups (endometriosis, cystadenoma, dermoid cyst, malignancy). Most pregnancy related ovarian cyst, are of corpus luteal and follicular cyst origin. By 16-20 weeks, up to 96% of masses resolve spontaneously.

The persistent ovarian cyst in pregnancy is associated with significant sequelae such as torsion, leaking, rupture, infection and malignancy (1-8%). The common presentation is pain and occasionally obstructed labor. These complications may result in the need for emergency surgical intervention and increased risk of adverse outcome.

Masses that persist longer may warrant further work-up for potential neoplastic disease . Surgery may be indicated when cyst cause pain and discomfort, or with rapid growth on serial scan. Other factors that influence this decision include the size of the cyst, gestational age, available resource and patient preference.

If surgery is indicated, it is generally done in the second trimester, usually 16-20weeks. However, this surgery is associated with a 22% risk of preterm labor. The fetal outcome is closely related to the fetal weight and gestational age.

 

WOMAN WITH SEVERE MENSTRUAL CRAMPS (DYSMENORRHEA)

Menstrual cramps (dysmenorrhea) are used to describe pain over the lower abdomen during menstrual period. It is a common condition affecting most women. This symptom varied in severity. It can be just a mild discomfort or an excruciating experience. The debilitating effect of this menstrual cramps results in absenteeism and loss of productivity.

Menstrual cramps can be broadly classified into primary and secondary dysmenorrhea. This allows differentiation between a ‘physiological cause’ from one that needs further investigations.

Primary dysmenorrhea results from the uterus (womb) trying to expel the menstrual blood. This symptom is common among women who has not conceived before. The strong uterine contractions resulted in release of pain substance. The pain is felt during the day of heaviest flow, usually on second day of menses. This symptom is observed to improve following childbirth.

Secondary dysmenorrhea refers to menstrual cramps that occur before and may last until after menses. It usually indicates the presence of underlying pelvic disease that needs further investigations.

This above differentiation generally allows doctors to make clinical decision whether to proceed with other investigations. However, there are certain exceptions which your doctor may want to exclude pelvic diseases even though the symptom is mild or of primary dysmenorrhea. Therefore, it is important to consult your doctor.

Among the common causes are endometriosis, chronic pelvic inflammatory disease, adenomyosis and uterine fibroid. The pelvic ultrasound scan and laparoscopy are useful tools to investigate this condition.

Doctors often use painkiller and advise hot compress to relieve the painful symptom. The definitive treatment will depends on cause of dysmenorrhea.

(See also Endometriosis)  Link below:

https://womenshealthtoday.wordpress.com/womens-health/endometriosis/

Vaginal bleeding in early pregnancy- Part I

This is one of the commoner presentation to my clinic besides the general antenatal workload.

The euphoria of early pregnancy(first trimester) is sometimes interrupted by symptom of vaginal bleeding.  There is usually high anxiety level, which is only natural.   This bleeding varies from brownish discharge to fresh red bleeding. This symptom can be associated with lower abdominal cramps.  Most couple come early for consultation.  My assessment during this consultation is to attempt to ascertain the cause of vaginal bleeding and demonstrate pregnancy viability.

It is understandable that couple would want to know if  ‘the pregnancy or fetus is alright’.  However, there is no single clinical assessment, blood test or ultrasound features that provides a reliable prediction of the pregnancy outcome following such event.  The current treatment this condition remains empirical.  Most doctors advocate bedrest and hormonal support, although the evidence is lacking.

On the contrary, it is not uncommon to find a cervical polyp as the source of vaginal bleeding.  This condition can be treated with removal of the polyp to relieve the symptom. The pregnancy is usually left undisturbed.

Our clinical experience has shown that about half of the early pregnancies with complication of vaginal bleeding is associated with good prognosis.  In these cases, the vaginal bleeding stop gradually over time and the pregnancy continues to term.

Early pregnancy vaginal bleeding is common and requires immediate medical attention

See also “Pregnancy and Baby” section for Early pregnancy bleeding or  click here.

Hyperemesis gravidarum- Oh,Oh!! Nothing seems to stay in my tummy

The joy of knowing that one is pregnant, is often interrupted by feeling of bloatedness, poor appetite and nausea. Most women (50-90%) will have these symptoms during their early stage of pregnancy but gradually subside by the 14-16th weeks.  Morning sickness, another name for this condition is coined due to the belief that these symptoms are commonly experience by pregnant mothers in the morning.

Hyperemesis gravidarum is associated with the rising pregnancy hormone (HCG, human chorionic gonadotrophin).  Once the placenta is fully functional, the HCG hormone declines and hyperemesis improved. It does not affect the fetus but can be a challenging experience for most pregnant mothers.  Besides the discomfort of nausea and bloated, medication is usually not necessary for most cases.  Very rarely, severe hyperemesis is associated with liver (Wernicke’s encephalopathy) or kidneys (acute renal failure) complications.  Looking at the bright side, hyperemesis indirectly indicates a healthy ongoing pregnancy.  Only in a normal pregnancy, the HCG hormone will rise accordingly.  On the contrary, women with missed abortion or failed pregnancy will not have a decline in the serum HCG level, which clinically manifest as regression of symptom.

I do not often prescribe anti-emetic drugs for my patients except if the hyperemesis is severe.  I generally advise them to choose their food carefully, identify symptom triggers to avoid them, and take frequent but small snacks.  There are also other alternative methods such as acupressure, acupuncture, taking ginger drinks and hypnosis but their effectiveness remains to be proven.

Embrace and welcome your pregnancy symptoms.  They are challenging but mostly transient

See also “Pregnancy and Baby” section for Coping with hyperemesis gravidarum or  click here.

Doctor, I missed my period!!!

This is a common presentation to my clinic.  My response will depend on the age of my patient and her intention.  She is most probably pregnant or one who is approaching menopause. It could also be some drug (medication) side-effect.  There are also other gynae causes for ‘missed period’, which I will write some time later.

Working as an O&G specialist in Puchong, with a relatively young and growing population, pregnancy is still the commonest diagnosis for “missed period”.  For this group of women, they come to confirm their pregnancy. Many have come with prior positive test on the urine pregnancy kit. A pelvic ultrasound scan will normally bring glow and joy to these mothers to be.

Most women will come with their spouse, especially if this is their first child.  The concerned husband will listen attentively as the excited mom shares her early pregnancy symptoms.  I usually let them to clear their doubts, proceed to discuss the 9- month  journey towards becoming  the super “Mom & Dad” and not forgetting  the long list of do’s and don’ts during this critical time.

My most important message is that during the first 3 months (first trimester), the fetus develops rapidly. It is the most vulnerable period as it is proned to malformation caused by teratogen (factors that derail fetal development).  Although most women will sail through this period without any untowards incident, some may encounter vaginal bleeding.  The first three months is a critical time to determine if the pregnancy will continue or otherwise.   The would be “Mom and Dad” leave my clinic with feelings of joy, and ready to brave through the sea of  uncertainty.

Early Pregnancy, a time of sheer joy & uncertainty

See also “Pregnancy and Baby” section for diagnosis of pregnancy, how to calculate your due date. importance of ultrasound scan. Or click here

Couples with difficulty to conceive

Doctor, is it true that subfertility is more common nowadays?

This question is commonly pose to me during my consultation with couples seeking treatment for fertility.  The figure quoted for prevalence of this problem is 1 in every 7 married couple.  However, there is no local data available (at least that I can recall).  Doctors are seeing more subfertility cases because (1) Better access to fertility treatment, (2) Increased patient awareness, (3) Couple delaying childbirth and (4) Higher prevalance of lifestyle disease.

When to seek treatment?

The probability of pregnancy for a healthy couple is 30% per month. This is known as fecundity rate.  This low figure is just to show that Man are poor reproducer. Despite this low pregnancy rate, most couple with regular unprotected sexual intercourse (2-3 times a week), should be able to conceive within a year.  Fertility is influenced by age, duration of subfertility, presence of poor sperm count and past history of pregnancy. It is important for couple to seek treatment after 1 year of trying to conceive but sooner if they have the following problem.

  1. Women aged more than 35years.
  2. Irregular menstrual cycle.
  3. Previous history of Endometriosis,  pelvic infection.
  4. Poor sperm count.

Difficulty to conceive- seek treatment early

See also “Women Health” section for couples with difficulty to conceive or  click here.