Upload
others
View
4
Download
0
Embed Size (px)
Citation preview
Message from the Organizing Committee Chairperson Dr.Deepthi Jammi (Chennai Women’s Clinic and Scan Centre)
On behalf of Chennai Women’s Clinic and Scan Centre, I thank the
panel moderators, expert panellists, sponsors and attendees who
were part of the inaugural DIALOGUE conference on April 22nd 2018.
Your presence and participation made the conference as engaging,
informative and thought-provoking as it was designed to be.
I also convey my deep appreciation to Dr.Nirmala Jayashankar and
Dr.Shanthi Sanjay for doing us the great honour of taking time from
their busy schedules to receive the first copies of the newsletter.
The primary goal of the conference was to bring together experts
across various disciplines to exchange views on the best practices of
today. As intended, what ensued was an open dialogue that delved
into the best possible approaches on the engagement of patients,
management of pregnancies and treatment of anomalous conditions.
Each of the topics chosen for discussion is vast yet the diverse and
dynamic group of moderators and panellists were able to dissect key
slivers of their area of expertise to provide thought provoking
comments and in-depth insight.
We have received very positive feedback on the discussions and
even inquiries on how to best take the said discussions forward in a
digital setting. We will work towards this and I hope that you continue
to be engaged with Chennai Women’s Clinic.
To those invitees who could not be a part of this edition, I eagerly look
forward to welcoming you personally in the next.
Stay tuned for DIALOGUE 2019. We are already working on
enhancements to the conference format and would be thrilled if it
receives the same level of acceptance and accommodation as this
inaugural edition did.
- Dr.Deepthi Jammi
This conference is useful especially because of its
format, having been structured to bring people
together and encourage discussion.
Chennai Women’s Clinic firmly believes that continual inclusive discussions bring fetal medicine
specialists and obstetricians ever closer to offer enhanced services
to the patient.
Dr.Anitha Parthasarathy welcomed the audience before Dr.Deepthi set the ball rolling.
Dr.Nanditha Thakkar deftly moderates the panel on infertility
MALE INFERTILITY
• Indications for Ultrasound scrotum / Transrectal (TRUS)
• Severe Oligoasthenoteratospermia (OATS)
• Azoospermia (to rule out obstruction. Most common cause is Tuberculosis)
• The presence of dilated seminal vesicles with normal FSH and LH levels along with Azoospermia
indicates an obstructive cause
• To rule out infection (Prostatitis / Genito Urinary Tract)
• To rule out varicocoele / undescended testis
• In suspected cases of congenital absence of Vas Deferens (bilateral)
• Morphological abnormalities of the sperm identified in semen analysis are not a routine indication for ultrasound
scrotum
• Surgical indications for varicocoele
• Only for Grade IV
• Abnormal semen analysis (motility / morphology)
• Severe pain during intercourse
• Indications for penile Doppler
• To rule out ejaculatory / erectile dysfunction
KEY TAKEAWAYS - PANEL DISCUSSION ON INFERTILITY
Female Infertility
• Why perform a baseline day 2 scan
• For ovarian reserve – antral follicular count (more than 5 to 9 mm respond better)
• Pelvic anatomy- to rule out follicular cyst
• Serum estradiol levels more than 60pg, then it is advisable to defer ovulation induction for that cycle).
• How to measure a follicle?
• If the follicle is circular - two measurements – inner wall to inner wall
• If the follicle is oval – three measurements – and take the mean value
• Is ovarian volume important for all patients?
• Yes. To rule out PCOS in reproductive age-group women
• In elderly age group patients with borderline AMH and few antral follicle count
• Why is ovarian stromal flow important?
• If the blood flow increases, the yield is better
• RI less than 0.4 and PI less than 0.7, risk of OHSS is high
• How to differentiate bicornuate and septate uterus?
• Fundal indentation is the most important differentiating factor
• What is the most desirable endometrial thickness for conception?
• 8mm to 12mm, triple line pattern has recorded the best pregnancy rate
• When does a hydrosalphinx require surgery?
• When the dilated tube is more than 3 cms
• Presence of endometrial vascularity
• More than Zone 2,3,4 – pregnancy rates more than 80% successful
It is extremely important to study the motility of the sperm -
levels A,B and C defined by the WHO
criteria.
One of the most common cause of dilated epididymis is
Tuberculous obstruction
To rule out vasculogenic Erectile Dysfunction, a penile Doppler is done.
Resistive index and Peak Systolic Velocity are the
important parameters assessed.
Selection of patients for varicocoelectomy is
important. It is indicated In cases of persistent Grade
IV varicocoeles with abnormal parameters in
semen analysis.
AF count -In case of round follicle, 2
measurements [inner to inner wall] are enough
while in an oval follicle, 3 are required
Some key moments during the discussion
With regard to the role of Doppler in endometrial
thickness, as an IVF professional what do you look for in an Ultrasound
report, prior to Embryo transfer ?
Average endometrial line thickness of 8–12 mm and triple line (good morphologic texture) are good
prognostic values if good quality embryos are transferred.
The endometrial blood flow beyond zone 2,3 and 4 is used as a good
predictor for successful implantation rate in IVF/ICSI cycles.
Dr.Uma Ram and the panelists drive home key messages using various case scenarios
1. IUGR – If estimated fetal weight (EFW) / abdominal circumference (AC) less than 3rd centile then the prognosis of the fetus is
worse when compared to fetuses with EFW between 3rd to 10th centile.
2. When to involve the neonatologist?
1. At the earliest, extensive counselling with the entire neonatology team
2. In fetuses with early onset growth restriction the decision of delivery before 32 weeks is based on venous Doppler i.e.
ductus venosus PI more than 95th percentile. This indicates that the fetal hypoxia has progressed to fetal acidemia.
3. In fetuses with late onset IUGR, at term beyond 36-37 weeks with absent end diastolic flow in the umbilical artery is a
better indicator for delivery than expectant management.
KEY TAKEAWAYS - PANEL DISCUSSION ON HIGH RISK OBSTETRICS
Gratacos Staging /
management protocol for
SGA / IUGR fetuses
Placental failure
Early
Nutrition affected
Long latency to demise
Time for SGA to develop
Late
?Respiration affected
Short latency to demise
No time for SGA to develop
Assessment of neurodevelopmental
outcome
Early
Check for hypoglycaemia
Rule out Retinopathy of Prematurity (ROP) at 4
to 6 weeks of birth
Auditory testing at day 7 of life
Late
4 weekly review for developmental
milestones
Review with the occupational
therapist
IUGR Fetuses with EFW or AC less than 3rd centile
have poorer prognosis when compared with fetuses
whose EFW or AC between 3rd-10th %centile
Low risk primi at 20weeks with structurally normal fetus with low profile growth –check for dating scan / parentral BMI/regularity of cycles/hyperemesis in first
trimester/ uterine artery doppler
In fetuses with early onset IUGR, the decision of
delivery before 32 weeks is based upon the venous
doppler [ DV PI> 95th%le]
The involvement of neonatologist team at the earliest is important.
Early neurodevelopmental outcome is assessed by ruling out hypoglycemia / opthal check at 4-6weeks and hearing assessment
at day 7 of life. Late neurodevelopmental outcome
is by 4 weekly check with occupational therapist
Increasing incidence of environmental pollution and
smoking also is a major cause for IUGR
Some key moments during the discussion…
Sections of the audience
Prof.Suresh
Seshadri
Dr.Indrani
Suresh
Dr.Uma
Ram
Prof.Jaya
Vijayaraghavan
Prof.Cynthia
Alexander
NEWSLETTER LAUNCH The inaugural edition of the “DIALOGUE” newsletter was launched and received much positive feedback from the audience. I sincerely
thank the authors for having put pen to paper and drafting such high-quality contributions.
Right from the ideation stage, the newsletter was conceived not just as a communication tool but as a platform for doctors across
multiple disciplines to share their thoughts and opinions on trending topics.
From the conversations I have had with doctors since the conference, I have gained deeper insights into the expectations of the
audience. I look forward to engaging with contributors and the target audience to best orient the content to satisfy those expectations.
As I had said during the conference, this initiative was made possible only by the constructive feedback of and guidance from the
editorial advisory board (below). I once again thank them deeply for their time thus far and going forward in advising me on the
nuances of stitching together various articles into a compelling reading experience.
- Dr.Deepthi Jammi
Editorial Advisory Board
Dr.Suresh, a member of the editorial board, presents a copy of the newsletter to Dr.Nirmala Jayashankar
Dr.Indrani Suresh and Dr.Jaya Vijayaraghavan (Left and Centre), members of the editorial board, present a copy of the newsletter to Dr.Shanthi Sanjay
Some of the members of the editorial board and honourable chief guests share their thoughts on the initiative to publish a periodical newsletter
Dr.Padmapriya Vivek fields questions on the latest development in the practice – uterine transplants
KEY TAKEAWAYS - CONVERSATION ON UTERINE TRANSPLANTS
Uterine Factor Infertility
Non-functioning Uterus
Intrauterine Adhesions
Radiation Damage
Uterine Malformations
Absent Uterus
MRKH Syndrome
Previous Hysterectomy
Obstetric Bleeding
Myoma
Uterine/Cervical Cancer
DONOR RECIPIENT
EX
CL
US
ION
CR
ITE
RIA
• Donor over the age of 60 years
• Subject with pre-existing clinical or medical condition that would
pose the subject at an increased risk
• Subject with an active infection
• Subject who is sero-positive for HIV, HBSAG, HCV
• Subject who has history of cancer in last five years
• Subject unwilling or unable to comply with study requirements
• Sex within the past 6 months with a male who is known to have
any of the risk factor listed in exclusion criteria
• Subject with DM type 1 or type 2 by medical history or elevated hba1c test
• Subject who has known hypersensitivity to tacrolimus, thymoglobulin or cellcept
• Subject with existing hypertension
• Subject who have history of solid organ or bone marrow transplant
• Subject who has history of cancer in last five years
• Subject with bmi>30
• Subject with active infection
• Subject who is sero-positive for HIV, HBSAG, HCV
• Subject not cleared for transplant
• Subject who has alcohol or drug abuse or has smoked within 12 months of
screening.
INC
LU
SIO
N C
RIT
ER
IA
• Women must be between 40-60 years of age
• Women younger than 40 years of age, who have had successful
pregnancies and have undergone permanent sterilization
• Subjects who are HPV negative or received vaccination for HPV
• Subject with h/o HPV in the past must show negative history and
test negative at screening
• A subject who is negative for gonorrhea, chlamydia and syphilis
• A subject with past h/o hsv-2 with no current symptoms
• A subject with normal uterus on sonogram and CT
• A subject who meets psychological donor criteria
• A subject who has had at least one prior full term live birth
• Women diagnosed with absolute uterine factor infertility and intact native ovaries
• Women of child bearing age
• Subjects who are HPV negative or received vaccination for HPV.
• Subject with h/o HPV in the past must show negative history and test negative at
screening
• A subject who is negative for gonorrhea, chlamydia and syphilis
• A subject with past h/o hsv-2 with no current symptoms
• Subject who have received counseling regarding infertility alternative to uterine
transplant such as adoption or surrogate pregnancy
• Subject who are willing to undergo in vitro fertilization and medically cleared for IVF
• Subject who have been evaluated by a fertility specialist and found to have good
ovarian reproductive potential
• Subject must have the ability to fund either through third party coverage or through
their own personal financing
The main contraindication for a donor is more than 2 surgeries (caesarean,
myomectomy) performed.
Apart from ruling out infection in the donor,
what are the other contraindications?
The most common indication is absolute
uterine factor infertility either due to congenital
absence of uterus or presence of a non-functioning uterus.
What are the most common
indications for uterine
transplant?
Some key moments during the discussion…
Dr.Indrani Suresh and Dr.Beena elaborate on the best practices and protocols in genetic testing.
KEY TAKEAWAYS - CONVERSATION ON THE ROLE OF GENETICS
In case of a previous child with
chromosomal abnormality
Do Karyotype (KT)
Numerical abnormality
Recurrence is low Indirect / direct
testing
Structural abnormality
Do parental KT
If parent is a carrier, then
recurrence risk is high
If parent is not a carrier than
recurrence risk is low
In case 22q microdeletion is detected in a fetus with complex
cardiac anomaly
Check parents for specific genetic mutation
If negative, recurrence risk is lower than 1%
If affected, recurrence risk is 50%
Protocols for various scenarios encountered
In case of a previous child with an Autosomal Dominant (AD)
condition
Check parents for specific genetic mutation
If negative, recurrence risk is low (<1%)
If affected, then the recurrence risk is at least 50%
In case of a previouschild with X-linked recessive
condition
Check if the mother is a carrier
Yes
50% males would be affected
50% females would be a carrier
No
Recurrence risk is low
Prenatal testing can be offered to rule out Germline Mosaicism
In case of structural chromosomal abnormality, a
parental karyotype is indicated to look for carrier status, which would determine the recurrence risk in subsequent pregnancies.
Cases diagnosed with Down syndrome need complete evaluation of Karyotype to ascertain whether it is pure Trisomy or translocation type of Down syndrome. In case of
translocation type, parental karyotyping must be offered.
Some key moments during the discussion…
Dr.Suresh raises thought provoking questions on prenatal testing during the panel discussion
KEY TAKEAWAYS – PANEL DISCUSSION ON FETAL MEDICINE
PRENATAL SCREENING
• It was pointed out that while prenatal screening should be offered to all patients, there is no written rule to do so. A
majority of the patients are not offered prenatal screening at all.
• All the panelists agreed that the screening should be offered as a mandatory procedure accompanied by pre- and
post-test counseling.
• Recently there has been considerable thought given to non-invasive testing that provides a higher predictive value vis-
à-vis combined first-trimester screening. This eliminates the risks of miscarriage brought about by invasive testing.
Combined First-Trimester Screening Non-Invasive Prenatal Screening
Methodology
Brings together maternal serum screening
and a measurement of the nuchal
translucency to give a risk score for trisomy
21.
Uses a simple draw of the mother’s blood to
measure the risk.
Detection Rate
Lower compared to NIPT which might prompt
a need for invasive testing.
Very high which is sometimes taken as
confirmatory thereby eliminating the need for
invasive testing.
Chance of miscarriage Higher incase of an invasive procedure done
to rule out a false positive.
Nil as the test is confirmatory.
Specificity for Trisomy 21 ~90% ~99.9%
CONGENITAL HEART DEFECTS
• There was an energetic discussion about cardiac anomalies and the appropriate course of management.
• The Paediatric Cardiologist and the Neonatologist on the panel provided a lot of experts comments.
• Congenital Heart Defects is much more common than chromosomal anomalies and neural tube defects.
• It is key that antenatal detection of CHD is done at the right stage so that,
• Adequate counseling may be provided to the parents
• Screening for other malformations is conducted
• Preparation for post-delivery procedures are done as required
• Routine cardiac evaluation followed by a Fetal Echo (if required) helps reduce the post-delivery mortality rates.
• However, it is important to note that the ideal gestational age for a Fetal Echo is before 20 weeks of gestation.
• If this protocol is adhered to, outcomes relate to cardiac anomalies can be optimized.
What is the goal of prenatal screening?
Should it be offered to all pregnant mothers?
Ideally screening should be offered to all pregnant mothers with pre & post-test
counseling.
The ideal time for a fetal echo is between 18 to 20 weeks of
gestation. Effective communication between the
paediatric cardiologist, obstetrician and fetal medicine
consultant is essential to manage cardiac anomalies.
The goal of any prenatal screening test is to achieve
highest detection rate with the least false
positive rate possible.
The most common cardiac anomalies identified at birth
for a baby with normal prenatal ultrasound are
Ventriculoseptal defects. Rarely TAPVC (Total Anamolous Pulmonary Venous Connection).
Some key moments during the discussion…
Trade Marks
Chennai Women’s Clinic and Scan Centre, DIALOGUE and their respective logos are trademarks of Chennai
Women’s Clinic and Scan Centre used under licence.
Copyright
Materials available in the DIALOGUE 2018 post-event summary is owned by Chennai Women’s Clinic and Scan
Centre. No part of the said materials available may be copied, photocopied, reproduced, translated or reduced
to any electronic medium or machine-readable form, in whole or in part, without the prior written consent of the
author. Any other reproduction in any form without the permission of Chennai Women’s clinic and Scan Centre
is prohibited.
CHENNAI WOMEN’S CLINIC AND SCAN CENTRE
Address: No.13, Soundarajan Street, T Nagar, Chennai-17.
Mobile : +91 733 8771 733
Landline: +44 4359 4620
E-mail: [email protected]
Web: www.ChennaiWomensClinic.com
Appointments based on patients request and convenience. Appointments available on Sundays on prior notification