VAGINAL SEEDING FOR CAESAREAN BABY!!

Vaginal seeding is a practice used for babies born by caesarean section that aims to mimic the exposure to bacteria that would have occurred during a normal vaginal delivery.  It involves rubbing vaginal fluid on the baby’s mouth, face and body, with the intention of exposing it to the “healthy” bacteria it would be exposed to in a vaginal birth.

This is not a standard practice.  It first hits the news in the United States in 2015.  It is believed that the practice of vaginal seeding improves the baby’s immunity.

The origin of this practice came from reports that found associations between being born by caesarean section and a “modest” increased risk of obesityasthma and autoimmune diseases. Other observational studies have shown associations between these conditions and changes in the different varieties of micro-organisms, such as bacteria normally present on and in the body.  These and other animal studies suggest exposure to these bacteria may play a role in developing a healthy immune system and reducing the risk of certain non-infectious diseases.

Despite the lack of studies proving cause and effect, many women in Australia and the UK are reportedly requesting the procedure after reading about it in the news.

Besides its unproven benefits, the vaginal seeding may risk the babies developing serious infections from potentially harmful bacteria (Group B Streptococcus, Chlamydia, Gonorrhea) or viruses (Hepatitis B, Genital herpes) from unaware mothers.

The current medical consensus is not to perform the procedure because there is no evidence of any benefits. The risk of harm cannot be justified. However, if the mothers have made an informed decision for vaginal seeding, their wishes should be respected.

Finally, the practice of breastfeeding and limiting exposure to antibiotics are both recommended ways to help the child obtain a wide variety of normal bacteria needed to build a strong immune system.  In summary, the practice of vaginal seeding lacks evidence to be routinely instituted on Caesarean birth babies.

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LATEST ON UTERINE TRANSPLANT- A DISAPPOINTING OUTCOME FOR THE FIRST UTERINE TRANSPLANT IN U.S.

The recent achievement of successful uterine transplant by Professor Brannstrom from Europe opens up a new excitement in the field of reproductive medicine.  This new surgical technology gives hope to women with uterine factor infertility, to conceive. Currently, the European team had reported five babies born to mothers with transplanted uteruses

On February 25th, 2016, the Cleveland Clinic in United States, similarly reported its successful uterine transplant, using a uterus from deceased donor.  However, the recipient developed complications within a week.  This had led to removal of the transplanted uterus on March 8th.  The preliminary report showed that the complication was due to infection that compromised the blood supply to the newly transplanted uterus.  The US team is actively looking into improving the protocols to reduce the risk of this complication in the future.

MRI GUIDED FOCUSED ULTRASOUND (MRIGFUS)- A NOVEL APPROACH TO THE TREATMENT OF UTERINE FIBROID?

Uterine fibroid is one of the commonest benign tumor amongst women.  It is present in 30%  of premenopausal women and is the main indication for hysterectomy.  Currently, there is no effective medical treatment available.  The uterine artery ablation has been offered as alternatives to surgical treatment (hysterectomy) but its clinical application is limited.

The MRI guided focused ultrasound is a minimally invasive fibroid treatment that uses a tightly focused ultrasound waves to deliver heat that instantaneously destroys fibroid tissue.  It is performed as an outpatient procedure with sedation.  The fibroid location is identified using T2-weighted MR imaging followed by a pretreatment planning and application of multiple therapeutic sonications to a temperature of at least 65 degree Celsius.  The heat generated basically ablates the fibroid tissue. The whole procedure takes about two to three hours.  The recovery time of about one to three days appears promising as a viable alternative to the current surgical option.

There are many reports of the experience with this treatment modality.  These reports were not from a high quality study design and occasionally sponsored by industry that are prone to bias and confounding.

There is only one randomized, placebo-controlled trial (PROMISe) to date, that assess the effectiveness of MRIgFUS therapy.  This is a high quality study and has a post treatment follow-up period of 2 years duration.  The result shows there is no diffence between MRIgFUS and placebo group, in terms of symptom improvement and quality of life at 4 to 12 weeks post procedure.  However, about a third (30%) of all women who had MRIgFUS therapy opted for hysterectomy by 2 years post treatment.

In summary, the MRIgFUS treatment for uterine seems promising and avoids the need for surgery.  Currently, the available results suggest its role as a temporary alternative treatment prior to the decision for hysterectomy, at best.

Reference

PROMISe trial (Pilot Randomized trial of MRIgFUS for symptomatic fibroid) trial. Fert Steril 2016

Alternative therapies in management of leiomyomas. Fert Steril 2014

Clinical improvement and shrinkage of uterine fibroids after thermal ablation by magnetic resonance-guided focused ultrasound surgery. Ultrasound Obstet Gynecol 2007.

Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids.  Fert Steril 2006

 

 

 

THE LATEST SCARE – ZIKA VIRUS AND PREGNANCY

For the last two months, the world is shocked by news of microcephalic babies born after suspected Zika virus infected mothers in South America. These babies have smaller than normal head circumference, with high probability of brain damage, blindness or even deafness. It affects more than 2000 pregnant mothers in South America and the government has advised women to postpone pregnancy for six to eight months in order to avoid potential infection.

Zika virus, is a member of the family Flaviviridae, together with dengue and chikungunya viruses. The main transmission is via mosquito bites, mainly the Aedes Aegypti and A. Albopictus. Majority of patient infected with Zika virus are asymptomatic while others presented with mild rash, fever, muscle pain and conjunctivitis. All these symptoms last for about one week. Only a few cases need hospitalization while Gullain- Barrre syndrome has been associated with this infection.

Testing of Zika virus infection in symptomatic pregnant mother can done using immunoglobulin M and neutralizing antibody. When congenital infection is suspected, an amniocentesis can be used to look for Zika virus RT-PCR.

Currently, there is no specific antiviral treatment available for Zika virus disease. The current treatment is generally supportive, including hydration, analgesia and anti-pyrexia.

 Recommendation for pregnant mothers

The CDC recommends that all pregnant mothers should consider avoiding areas where Zika virus transmission is ongoing. For those who have to travel to these endemic areas, a strict adherence to prevention from mosquito bite must be followed. This includes wearing long sleeved shirts and long pants, using insect repellent and staying in screened-in or air-conditioned rooms.

The viremia period for Zika infection is about one week. This virus will have been removed from the body’s circulation after this short period. Any pregnancy after this interval is unlikely to be harmed by Zika virus.

PELVIC FLOOR INJURY – A PRICE TO PAY FOR VAGINAL BIRTH?

Pelvic floor (Levator ani) injury occurs in 3 of 10 vaginal deliveries and often results in pelvic floor dysfunction including pelvic organ prolapse and incontinence.

The pelvic floor muscles is consist of three main muscle groups: the puborectal, the pubococcygeal, and the iliococcygeal. The main function is to support the vagina and pelvic organs, and maintenance of urinary and fecal continence.

During vaginal childbirth, the opening of the genital hiatus distends substantially to allow the passage of the fetus. This stretches the pelvic floor muscle greater than 3 times their original length, thereby putting strain on the muscles and can result in damage.

In addition, during the second stage of labor as the fetal head descends, excess stretch and distention of the muscles result in stretch and distention of the nerve to the levator ani. Prolonged stretching of this motor nerve has the potential to permanently damage the nerve, leading to laxity or sagging of one or both sides of the Iliococcygeus muscle.

 The above two labor related mechanisms have the potential to cause significant injury to the pevic floor muscle attachments and nerve supply, leading to an increase risk of urinary and fecal incontinence and future development of pelvic organ prolapse (POP).

 The prevention for pelvic floor dysfunction may be reduced by pelvic floor education and exercises during and after pregnancy. In one study, women who received pelvic floor therapy from 20 weeks’ gestation were less likely to report urinary incontinence in late pregnancy, at 3 months and 6 months postpartum. It appears that routine pelvic floor education or referral to pelvic floor physical therapy during the intrapartum and postpartum period may be beneficial, especially in high-risk patients.

 

Reference

  1. Dietz HP. Pelvic Floor trauma in childbirth. Aust N Z J Obstet Gynaecol. 2013;53:220-230.
  2.  Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106:707–712.

RECURRENCE OF ENDOMETRIOSIS – HOW TO PREVENT IT

Endometriosis is a common, benign gynecological disorder and a leading cause of disability in women of reproductive age, responsible for dysmenorrhea, pelvic pain and subfertility.  It is a debilitating and costly disease. Surgery is the treatment of choice for its management since the efficacy of medical treatment alone is often inadequate or of limited efficacy.  Surgical excision of lesions (conservative surgery) has been shown to both improve pain and enhance fertility. This is preferred over radical surgery because most women with endometriosis are of reproductive age.

The recurrence rate

Recent reviews had estimated the recurrence rate of endometriosis to be 21.5% at 2 years and 40-50% at 5 years (Guo SW 2009), which is more frequent than previously believed.  It seems that the recurrence rate for pain or dysmenorrhea is higher than that for the clinical recurrence as defined by presence of ovarian endometrioma on pelvic ultrasound scan.  These recurrences, which lead to repeat surgeries can further reduce fertility, exacerbate pain and complications of operation, which in turn affects quality of life, and increases social costs.

How recurrences happen?

There are two main explanations leading to the recurrence of endometriosis, namely re-growth of residue lesion and de novo lesion formation.

Vignali et al. observed that during a repeat surgery, most endometriosis recurrence occurred at the same area.  Similar observation was found in cases of ovarian endometrioma, where majority (88.7%) of the recurrences was from the previously treated ovary (Guo SW 2009). Conservative surgery is sometimes insufficient to remove these lesions completely, allowing it to re-develop after operation.  The de novo endometriosis lesion occurs via the monthly retrograde menstrual blood flow into the abdominal cavity, allowing the endometrial tissue to implant.

Prevention of Recurrence

Pain symptoms

The pain symptoms of endometriosis include non-cyclical pelvic pain (chronic pelvic pain), painful menses and intercourse. The use of oral contraceptives (OC) for a period of six month or more is found to be effective in reducing endometriosis associated pain symptom recurrence.   The continuous OC regime has an advantage over the cyclical OCs, with lower recurrence and earlier benefits (Seracchioli 2010; Vlahos 2013).  Medication should be given for at least 18-24 months as the recurrence occur rapidly when medication is stopped.

 

Ovarian endometriosis (endometrioma)

Postoperative OC conveys a protective effect against recurrence.  Again, the continuous regime has an edge over the cyclical OC regime.  This benefit is conferred as long as the woman is on OC treatment but vanished rapidly upon discontinuation (Kaori K 2015).

Recommendations

All women with endometriosis, following a conservative surgery (for pain symptoms or endometrioma), should be on medication (continuous OC) as long as possible until she is ready to conceive (Dunselman GA 2014). This will effectively reduce endometriosis recurrence and need for repeat surgery, which carries its own complications.

References

  1. Dunselman GA et al., Hum Reprod 2014
  2. Guo SW. Hum Reprod Update 2009
  3. Kaori K et al., Fert Steril 2015
  4. Seracchioli R et al., Fert Steril 2010
  5. Vlahos N et al., Fert Steril 2013
  6. Vignali M et al., J Minimal Invasive Gynecol 2005

CERVICAL MUCUS MONITORING- A SIMPLE WAY TO ENHANCE PREGNANCY CHANCE

The fertile window period is defined as the 6-day period ending on the day of ovulation (Brosens 2006). Intercourse is mostly likely to result in pregnancy when it occurs within this period.  The peak fecundability was observed when intercourse occured within 2 days prior to ovulation (Wilcox 1995).  It is desirable to predict the fertile window period and ovulation, to optimize conception rate but can be challenging with the available methods.  Amongst the methods available, include calendar method, basal body temperature (BBT), urinary LH detection, cervical mucus monitor, urinary estrogen metabolites and transvaginal ultrasound scan for follicle tracking.

Cervical mucus monitoring (CMM) is a prospective and inexpensive method to detect fertile window.  It was found to be as good as or better than BBT or urinary LH monitoring to predict the day-specific probabilities of conception (Bigelow 2004).  The cervical mucus is observed at the vulvar for its appearance and sensation.  Type 1 and 2 are typically present at the beginning of menstrual cycle.  They are associated with a dry (type 1) or damp (type 2) sensations at the vulva.  Type 3 is typically thick, creamy and whitish or yellowish mucus with damp sensation.  The type 4 cervical mucus is transparent, stretchy or elastic (raw egg white) with wet or slippery sensation.  Intercourse at this period is associated with a high conception rate.

Hoeker et al., observed that CMM when applied consistently resulted in increased fecundability. It is more effective for timing of intercourse than the calendar method, as it allows identification of onset and duration of fertile window to be determined prospectively.  It reduces the overall time to pregnancy.

CMM is a free, self-directed method used to detect fertile window prospectively.  When applied consistently, it reduces the interval to conception and enhances fecundity.

Note:

Fecundity : Ability to conceive or to produce offspring

Reference:

  1. Bigelow JL et al., Human Reprod 2004
  2. Brosens I et al., Sex Reprod Menopause 2006
  3. Evans-Hoeker E et al., Fert Steril 2013
  4. Wilcox AJ BMJ 1995