Pudendal Nerve Block

Recent changes in diagnosis, management of preeclampsia by ACOG

Recently ACOG has made the following observations as regards diagnosis, management of preeclampsia

• First and foremost observation made by ACOG is that proteinuria should no longer be considered the signature criterion in diagnosing preeclampsia. How things have changed over the years. When we were students preeclampsia was considered a TRIAD of three signs: Hypertension, Edema and Proteinuria. Later Edena as a criteria for diagnosis was dropped as it came to be realised that edema is an incidental finding in preeclamsia and has no bearing on severity or prognosis. And now in 2014, ACOG says: “Proteinuria, in addition to being downgraded as the signature diagnostic finding in preeclampsia, should no longer be considered as useful in classifying preeclampsia as severe or in deciding whether to induce, the guidelines say, because the amount of protein in the urine has not been shown to predict either maternal or fetal outcomes.”
• ACOG says that equal weight should be given to reduced platelet counts, renal insufficiency, severe headache, heart-lung compromise, and impaired liver function. Any one of these concurrent with new-onset hypertension at 20 weeks of pregnancy or beyond is enough to establish preeclampsia, even in the absence of proteinuria. I feel vindicated about this because I have already said in II edition of my textbook, Modern Obstetrics, that significant hypertension with any organ damage such as kidneys, liver, lung, heart, brain etc. should be called preeclampsia. As I have said in my book “nonproteinuric preeclampsia is now a diagnostic entity”
• Another important change is that preeclamsia is no longer considered as Mild and Severe. Now ACOG guidelines distinguish extensively between preeclampsia with and without severe features, but discourage the use of the phrase "mild preeclampsia," considering it misleading. "Preeclampsia in any form should never be minimized as ‘mild.’
• Fetal growth restriction (FGR), once considered a major criterion to make the diagnosis of severe preeclampsia, is now to be used not for diagnosis of preeclampsia, but for indicated delivery in a patient with preeclampsia who also has an extremely small fetus (< 5th centile) that is associated with abnormal blood flow findings in the umbilical cord connecting the fetus to the placenta.
• The guidelines emphasize that preeclampsia can appear for the first time following delivery, or worsen rather than improve during in the postnatal period.
• As regards prevention, ACOG has this to say: The use of vitamins C and E is not advised in preventing preeclampsia. Low-dose aspirin, however, is recommended starting late in the first trimester for patients who experience preterm severe preeclampsia.
• Delivery at 37 weeks is advised for women with preeclampsia without severe features.

NACO Kits for Treatment of Sexually Transmitted Infections

The other day my DNB students were asking me about various color kits that are available for syndromic management of vaginal discharge. I said I will tell you provided you answer one question. They said shoot! 

My question: 

Q.: What is the difference, if any, between sexually transmitted disease (STD) and venereal disease (VD)?

Needless to say, nobody could give the correct answer.

Answer: Venereal diseases are those sexually transmitted diseases that have lesions on the genital tract whereas other diseases that transmitted sexually but do not have pathological manifestations on the female genital tract should be called only sexually transmitted diseases. Thus all venereal diseases are sexually transmitted diseases but all sexually transmitted diseases are not venereal diseases. Examples: gonorrhea, syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale are venereal diseases; on the other hand HIV and hepatitis B are sexually transmitted infections but they are not venereal diseases.

Reference: Modern Gynecology, II edition, Ch. 06, Page 57, Ajit Virkud, APC Publishers.

Now back to syndromic management of vaginal discharge using different NACO kits.

In low resource settings e.g. developing countries like India, WHO advocates prescribing a single day course of multiple drugs for syndromic management of vaginal discharge. To avoid costs, no diagnostic tests are done before starting treatment. The treatment should be given to both the partners. National Aids Control Organization (NACO) of India has also adopted these guidelines and added a few extra measures to simultaneously control HIV in this high risk group. With this aim, they have developed different colour kits for syndromic management of symptomatic patients are shown in the table below.

NACO KITS

For more information on this topic refer to my textbook: Modern Gynecology, II Edition, APC Publishers

FIGO Cancer Staging Systems

Very often students appearing for exams are asked about FIGO cancer staging of various gynecological malignancies. In this blog I want to put to pen my views on the same. What students need to know and are not always taught is why do we need to have a staging system in the first place? The primary objectives of any good staging system are:

• To help the clinician in planning treatment
• To provide indication of prognosis
• To assist the physician in evaluating the results of treatment
•  To facilitate the exchange of information between treatment centers (to correctly compare their success/failure rates)
• To provide an evidence-based approach to cancer

A good staging system must have 3 basic characteristics:

• It must be valid,
• It should be reliable, and
• Most importantly it should be practical

Historically the first staging system for gynecological cancers appeared around the turn of the 20^th century; it was applied to the carcinoma of the cervix- the most common cancer affecting women at that time. Professor J. Heyman (the Radiumhemmet, Stockholm, Sweden), Dr A. Lacassagne (Radium Institute of the University of Paris, France) and Professor F. Voltz (Munich, Germany), appointed by the Radiological Sub-Commission of the Cancer Commission of the Health Organization of the League of Nations, recommended a  staging classification designed to mimic the natural history of the disease, i.e., the different stages representing the progressive growth of the tumor. These recommendations – adopted by the Sub-Commission with minor modifications – were published in 1929 and became known as the League of Nations Classification for Cervical Cancer. To cut the long history short, this classification underwent many changes and ultimately after FIGO and the FIGO Committee on Gynecologic Oncology were officially formed, it became known as FIGO staging system.

I want to draw the students’ attention to the following facts about FIGO cancer staging system

• Although FIGO is an acronym for International Federation of Gynecology and Obstetrics it is written as FIGO based on the same phrase in French language: students get confused because they are unaware of this. Currently it has member societies in 125 countries or territories. The current president for the period 2012-2015 is Professor Sir Sabaratnam Arulkumaran from United Kingdom.
• Over the years, all staging systems for gynecological malignancies with the exception of cervical cancer and gestational trophoblastic neoplasia – have shifted from a clinical to a surgical–pathological basis.
• When asked students always mention the FIGO nomenclature Montreal, 1994 for carcinoma cervix and FIGO nomenclature, Rio de Janeiro, 1988 for carcinoma of endometrium. But they should be aware that things have changed: FIGO staging systems for cervix, endometrium, sarcomas, ovary and vulva have been revised for the first time in over a decade. Remember “change is the most constant thing in life” and FIGO staging is no exception.
• As regards carcinoma of endometrium, the FIGO staging system was revised in 2009; changes include the classification for disease stages I through III. In the revised staging system, pelvic cytology results are excluded from changing the disease stage and should be reported separately. In the 2009 FIGO staging system, stage I is divided into 2 categories, with stage IA denoting less than 50% myometrial invasion, and stage IB denoting greater than or equal to 50% myometrial invasion. Uterine serosal disease, which was formerly categorized as stage IC in previous FIGO staging systems, is now categorized as stage IIIA. Cases of endocervical glandular involvement are considered stage I. In addition, stage IIIC is further subdivided into stage IIIC1 (metastases to pelvic lymph nodes only); and stage IIIC2 (metastases to para-aortic lymph nodes). See table I.
• The new FIGO nomenclatures are shown in tables below.

Table I: FIGO staging of Carcinoma of the Cervix
IA1	Confined to the cervix, diagnosed only by microscopy with invasion of < 3 mm in depth and lateral spread < 7 mm
IA2	Confined to the cervix, diagnosed with microscopy with invasion of > 3 mm and < 5 mm with lateral spread < 7mm
IB1	Clinically visible lesion or greater than A2, < 4 cm in greatest dimension
IB2	Clinically visible lesion, > 4 cm in greatest dimension
IIA1	Involvement of the upper two-thirds of the vagina, without parametrial invasion, < 4 cm in greatest dimension
IIA2	> 4 cm in greatest dimension
IIB	With parametrial involvement
IIIA/B	Unchanged
IVA/B	Unchanged

Table II: FIGO staging of Carcinoma of the Endometrium
IA	Tumor confined to the uterus, no or < ½ myometrial invasion
IB	Tumor confined to the uterus, > ½ myometrial invasion
II	Cervical stromal invasion, but not beyond uterus
IIIA	Tumor invades serosa or adnexa
IIIB	Vaginal and/or parametrial involvement
IIIC1	Pelvic node involvement
IIIC2	Para-aortic involvement
IVA	Tumor invasion bladder and/or bowel mucosa
IVB	Distant metastases including abdominal metastases and/or inguinal lymph nodes

Table III: FIGO staging of Carcinoma of the Vulva
IA	Tumor confined to the vulva or perineum, ≤ 2cm in size with stromal invasion ≤ 1mm, negative nodes
IB	Tumor confined to the vulva or perineum, > 2cm in size or with stromal invasion > 1mm, negative nodes
II	Tumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodes
IIIA	Tumor of any size with positive inguino-femoral lymph nodes (i) 1 lymph node metastasis greater than or equal to 5 mm (ii) 1-2 lymph node metastasis(es) of less than 5 mm
IIIB	(i) 2 or more lymph nodes metastases greater than or equal to 5 mm (ii) 3 or more lymph nodes metastases less than 5 mm
IIIC	Positive node(s) with extracapsular spread
IVA	(i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone (ii) Fixed or ulcerated inguino-femoral lymph nodes
IVB	Any distant metastasis including pelvic lymph nodes

I have not come across changes in FIGO nomenclature for cancer of ovary as yet; as soon as I do, I will post it.
Reference: Mutch DG: The New FIGO staging system for cancers of the vulva, cervix, endometrium, and sarcomas. Gynecol Oncol 115:325-328, 2009
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Guidelines in Obstetrics and Gynaecology

In the modern era, in every specialty of medicine, there are guidelines issued by various medical bodies/colleges which practicing doctors have to follow. Obstetrics & Gynaecology, my field of expertise, is no exception. We have following bodies whose guidelines we follow:

• American College of Obstetricians & Gynecologists (ACOG)
• Royal College of Obstetricians & Gynecologists (RCOG)
• Society of Obstetricians & Gynecologists of Canada (SPGC)
• Royal Australian and New Zealand College of Obstetricians & Gynecologists (RANZCOG): incidentally the current vice president of this college is Indian: Prof. Ajay Rane
• National Institute for Health and Clinical Excellence (NICE)

Many examiners at various postgraduate examinations are fond of asking guidelines for management of a certain disease; the most commonly asked guidelines are those by RCOG. I think this is unfair and unnecessary for various reasons:

1. These guidelines are based on evidenced based studies in the country where these guidelines originate. Thus RCOG guidelines are not suitable and cannot be applied to Indian women who are ethnically different.
2. The guidelines given for a particular disease condition are very extensive and run into many pages: it is impossible for a student to learn and know them verbatim. My clinician friends from abroad have confessed to me that they do not remember every single point in detail.
3. There are so many different guidelines that students are confused about which ones they must know.

My take on clinical guidelines is as follows:

• Clinical guidelines are recommendations by colleges or associations on the appropriate treatment and care of people with specific diseases and conditions within the country. They are based on the best available evidence. While clinical guidelines help health professionals in their work, they do not replace their knowledge and skills.
• Guidelines are just that: Guidelines! One has to follow them in spirit and not to the letter. In a given exceptional case one should have the freedom to deviate from them in the interest of the patient.
• We do not have any worthwhile guidelines for Obstetrics & Gynaecology in India. They should be formulated by clinicians who are experts in their respective specialities; and not by doctors who are Professors/HOD in medical colleges or Office bearers of the Federation/College or their friends.
• They should be based on evidence based studies/ RCTs: this is where the main problem lies. We do not have enough evidence in Indian literature yet on which to base these guidelines.