New concerns in the management of the disease with the Covid 19 pandemic have created a state of anxiety amongst expectant mothers.

New Delhi: The rising incidence of gestational diabetes in India and globally is a cause for global concern amongst clinicians and obstetricians. Prevalence of the condition is higher in the urban than the rural population in India. Established risk factors for GDM are a family history of diabetes, obesity, advancing maternal age, reduced physical activity, desk jobs, sedentary lifestyle, unhealthy eating habits, smoking and alcohol consumption, history of PCOD and associated factors such as hypertension.

Due to compromised fetal outcomes in the form of higher incidence of miscarriages, congenital birth defects, higher risk of preterm deliveries, acute respiratory distress and hyaline membrane disease, heart disease, complicated labour due to the large size of the foetus leading to a higher incidence of shoulder dystocia and a higher risk of caesarean sections, hypoglycaemia in the newborn, obesity and a higher incidence of diabetes in the newborn, prevention and active management of altered blood sugars imperative.

How COVID-19 pandemic has changed consultation, diagnosis of gestational diabetes

New concerns in the management of the disease with the COVID-19 pandemic have created a state of anxiety amongst expectant mothers.

The standard glucose tolerance test which was previously held as the gold standard for monitoring women with altered blood sugars has now taken the backseat. Prioritising on social distancing, reducing frequent visits to labs, now monitoring expectant mothers with fasting blood glucose and HbA1c (of 5.7) are now accepted contrary to the glucose tolerance test. Altered routine prenatal visits, lack of personal consultation with the obstetrician and a phobia to visit labs has modified the management criteria. Lifestyle management comprising healthy dietary habits and increased physical activity, regular home monitoring (self) of blood sugars and fortnightly video consultation, routine antenatal tests for maternal well-being with a proper genetic history of any congenital defects or history of consanguinity, an early ultrasound helps rule out the possibility of an extrauterine pregnancy (ectopic) and confirms a healthy heart activity by 5.5 weeks thus ruling out chances of a missed aborption. All expectant mothers are offered the option of prenatal screening for Down’s syndrome (blood tests like the NIPT and dual markers) at 12 weeks, quadruple markers at 14 to 16 weeks, an anomaly scan at 19 weeks and most importantly a fetal cardiac anomaly scan at 23 weeks. Patients prefer to visit stand-alone ultrasound clinics with prior appointments following all the Covid-19 precautions. A repeat ultrasound Doppler at 28 to 30 weeks to check for the interim growth possibility of fetal macrosomia is advisable. At 32 weeks again an HbA1c to monitor blood sugars is advisable with home charting. Known diabetics in pregnancy have to follow up closely with the diabetologist to adjust the dose of insulin. In case of preterm labour, a hospitalization with tocolytics and antenatal betamethasone injection to promote lung maturity is advisable, and should such patients progress to irreversible preterm labour then drugs such as magnesium sulphate are offered as an option after counselling the expectant mother for neuroprotection for the foetus. Delivering such patients is preferred in tertiary care centres where all facilities for neonatal care are available owing to the high incidence of hyaline membrane disease and acute respiratory distress syndrome. COVID-19 evaluation is mandatory for patients prior to admission. Each index case if affected with COVID-19 behaves differently and needs individually tailored treatment for her symptoms. Vertical transmission is not a reason to fear as it is seldom encountered. Commonly encountered heart defects are usually diagnosed early in pregnancy during the anomaly scans. Late-onset issues in infants of diabetic mothers could be macrosomia, fetal cardiomyopathy, cardiomegaly, acute respiratory distress with fetal hypoglycaemia which warrant intensive care.

Maternal issues such as a higher incidence of prolonged labour, obstructed labour, higher incidence of caesarean sections, the associated risk of hypertension, are observed. To avoid these, prevention is better than cure, and hence expectant mothers with a high risk of gestational diabetes with obesity or PCOD are advised monitored weight gain of not more than 7-8 kg. Close monitoring of blood sugars from the first trimester helps reduce the chances of fetal and maternal complications. The TDAP vaccine is offered to all mothers at 32 weeks.

In conclusion, we as physicians have to constantly tailor monitoring techniques, counsel expectant couples with close follow-ups to monitor fetal and maternal well-being. The COVID-19 precautions are here to stay till we see the end of the tunnel in this global pandemic.

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Living with my diagnosis since the age of 15

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Self-Management of hypertension

Hypertension, which is among the most common chronic diseases in adults, is a major cause of stroke, heart disease, and renal failure. About one billion people live with hypertension worldwide, many of whom do not control their blood pressure well, despite the fact that lowering BP lessens the risk of renal and cardiovascular disease. One of the most effective ways of coping with hypertension is through self-management, making patients more responsible for their own care. 

Effective self-management of hypertension consists of self-monitoring blood pressure; identifying the warning signs, initiating lifestyle changes; maintaining regular contact with the health care provider. Studies suggest that self-management of hypertension in nonclinical settings is superior to traditional in-clinic hypertension management, and can improve medication adherence, self-efficacy, self-rated health, cognitive symptom management, frequency of aerobic exercise, and depression. Collaboration with the healthcare provider can improve the patient’s ability and confidence for self-management, to yield even greater improvements in BP control.

The burden of undiagnosed hypertension

As per reports from the World Health Organization, hypertension is the third biggest risk factor for heart disease in India. Data from National Family Health Survey suggest that in India about 9 per cent women and 14 per cent men falling in the age bracket of 15-49 years suffer from hypertension. Despite the identified burden of hypertension, majority of hypertensive patients still remain undetected. Reportedly, for every known person with hypertension there are two persons with either undiagnosed hypertension or prehypertension. Though, an individual with hypertension remains unaware until the condition is diagnosed, he/she will be posed to increasing risk of the complications. If left untreated, hypertension can cause damage to the cardiovascular system and other internal organs. Thus, it is of utmost importance that the factors that predispose to the risk of hypertension be controlled. Sedentary lifestyle, wrong food choices and lack of physical activity along with persistent exposure to stress are the major factors that increase the vulnerability to hypertension and thus need to be improved.Being attentive towards certain symptoms associated with high blood pressure, including sweating, anxiety, sleeping problems and blushing can also be helpful. It is imperative that once the diagnosis of hypertension has been made, the antihypertensive therapy be started at the earliest to prevent any further complications.

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Following findings from a British Broadcasting Corporation (BBC) study outlining the wide-ranging toll of endometriosis, supporters — including Endometriosis UK — are calling for stakeholders from government, healthcare, and business to step up efforts to improve the lives of the 1.5 million women in the U.K. who have the chronic and debilitating disease.

Nearly all of the study’s 13,500 participants said endometriosis has badly affected their career, sex life, and mental health. In addition, most said the disease has adversely impacted their education, and that they rely on prescription painkillers, including opioids, for ongoing treatment. About half of the women respondents said they have experienced suicidal thoughts.

“This shocking new research is a stark reminder that both society and the NHS (National Health Service) need to wake up and accept that endometriosis is a chronic condition that cannot be brushed under the carpet,” Emma Cox, Endometriosis UK CEO, said in a press release. “The impact it can have on all aspects of a person’s life — both physically and mentally — must be recognized.”

The study, a survey said to be the largest of its kind, questioned women in the U.K. about how endometriosis has affected them. Endometriosis UK assisted the BBC in collecting survey answers.

Cox called for efforts to reduce the time to diagnosis — currently 7.5 years on average — for women with the disorder. Pelvic pain associated with endometriosis is typically indistinguishable from other causes, including menstruation, urinary tract infections, pelvic inflammatory disease, and irritable bowel syndrome. That makes rendering a diagnosis difficult.

“Without investment in research, a reduction in diagnosis time and better access to pain management, women will continue to face huge barriers in accessing the right treatment at the right time,” she said.

Saying that endometriosis costs the UK £8.2 billion (about $9.1 billion) annually, Endometriosis UK is urging the government to fully implement the National Institute for Health and Care Excellence (NICE) guidelines. Those guidelines, set forth in 2017 in “Endometriosis: Diagnosis and Management,” established minimum care to which patients should have access.

For her part, Caroline Dinenage, Minister of State at the Department of Health and Social Care, said that while endometriosis awareness is increasing, more work is needed.

“Too often across society, women’s bodies are seen as an inconvenience, with their symptoms and health concerns not taken seriously enough,” she said.

By adhering to the NICE guidelines, clinicians can help erode stigmas around the disease, Dinenage said. She also called for employers to create supportive and flexible ways to help those living with the disorder.

As a result of the study, Members of Parliament are expected to launch their own inquiry into the disease’s effects.

Other advocacy groups also are calling for change.

“Health services need to wake up to the hidden and unspoken emotional pain too many women experience without the help they need to manage such a poorly understood and distressing condition,” said Sarah Hughes, CEO of the UK’s Centre for Mental Health.

Study participant Bethany Willis, 19, of the county of Essex in southeast England, said in an article on the BBC’s website that she started experiencing symptoms at age 9. However, despite having a mother and grandmother with the same disorder, she was not diagnosed with endometriosis until this summer.

“The pain is like barbed wire wrapped around your insides and someone’s pulling it away while at the same time an animal is trying to eat its way through you,” she said.

Willis said the pain was so severe that it caused her to take an overdose of medication. While recent surgery has helped her cope with the condition, she laments having dropped out of veterinary school and giving up her “dream career.”

According to the Endometriosis Foundation of America, roughly 200 million women globally are affected by the disease, which occurs when bits of uterus tissue lining grow on other pelvic organs.

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The American Nurses Foundation has awarded a $9,999 grant to Martha Grace Cromeens, a nurse at the University of North Carolina Hospital, to explore new pathways for diagnosing endometriosis among diverse groups of women.

The grant, supported by the Virginia Kelley Fund, will back Cromeens’ yearlong study, “Qualitative Inquiry into the Pathways to Diagnosis of Endometriosis Across a Diverse Sample of Women.” The study is expected to be concluded in August 2020.

Endometriosis can be a difficult-to-diagnose disease, often requiring invasive surgery to achieve a final diagnosis. For many women, that leads to years of struggling with chronic pelvic pain, menstrual irregularity, painful intercourse, and infertility, often without access to proper care.

In addition to its severe physical manifestations, endometriosis can represent a heavy economic burden for women and substantially diminish their quality of life. In many women, endometriosis significantly affects their work productivity, causes anxiety and depression, and results in high medical costs.

The scientific community has been working to find strategies that could prevent such delays in endometriosis diagnosis.

Cromeens, also a Hillman Scholar in Nursing Innovation, is joining this effort to better understand endometriosis and help all women affected by it.

She and her colleagues at the University of North Carolina will start by mapping the pathways for endometriosis diagnosis, according to a university press release. They will conduct qualitative interviews to acknowledge the experiences of women affected by the disorder, including detailed pathways for their symptom recognition, appraisal, and management.

Next, they will explore potential differences in these diagnosis pathways and experiences among a socioeconomically and racially diverse group of women.

As Cromeens noted in the project’s abstract, “women of lower socioeconomic status (SES) and minority races have been underrepresented in endometriosis research.”  Despite efforts made to overcome this problem, “there is a large gap in the literature regarding the diagnostic pathways women travel and the pre-diagnostic period especially among lower SES and non-white women.”

Cromeens also plans to determine what factors and symptoms are shared among women who perceive their endometriosis diagnosis as timely, and among those who have experience a delayed diagnosis.

This analysis may help better identify patterns of endometriosis symptoms and manifestations that could be useful for clinicians to expedite endometriosis diagnosis.

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32 year old woman in Hanoi with the weigh of nearly 90 kilogram admitted that she bumped into difficulties and was ashamed of her weight.
Therefore, she went to the infirmary for treatment of obesity where physicians decided to conduct the bariatric surgery after examination and diagnosis. Military surgeons and their Korean peers performed the difficult surgery because positions of the woman’s organs were reversible; for instance spleen is normally in one’s left but the woman’s spleen in the right whereas liver in the opposite side. Nevertheless, the operation was a success; two months after the operation, she lost 19 kilogram feeling better than before. Surgery Department Deputy President Colonel Nguyen Anh Tuan said that the Department has carried out such kinds of surgeries on six obese patients from March, 2019; one of them weighing 130 kilograms and they were all in good condition after the operation. According to the Ministry of Health, the number of obese people in Vietnam increased substantially in adults and children. As per the National Nutritional Institute’s report, obese people aged from 25 to 64 account for 16.3 percent of the whole country’s population. Worse, the rate of obese people has gone up by ages and more female become fat than male and city dwellers are fatter than their peers in countryside. Factors are attributable to obesity are high-fat diet, eating in fast food, less exercise and alcohol abuse. The obesity epidemic is driving up the burden of several non-communicable diseases (NCDs) such as cancers, heart disease and diabetes. Fat people should take regular exercise and take heed of their diet. In cases that exercise and less fat diet prove no effectiveness, bariatric surgery can help very overweight people who have tried but failed to lose weight and face serious medical problems. Patients undertaking the surgery will be under physicians’ monitor. Globally, obesity is increasing quickly. Statistically, around 1.9 billion overweight people in the world and 609 obese people. It is estimated that 57.8 percent of the world population will be obese by 2030 leading to high medical cost.

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Nelson’s Emma Weiland has suffered the severe pain of endometriosis since she was 12. But it took until she was 18 to get a diagnosis, despite many visits to many doctors and emergency rooms.

Lack of diagnosis, misdiagnosis, not being taken seriously, multiple surgeries — these are common experiences of women with the disease.

All through high school this athletic and academically gifted young woman suffered monthly debilitating pain.

“At every dance competition, every soccer competition, finals, it was always there, all that pain,” she says. “I continued to accept it.

“I went to dozens of hospital visits before I was taken seriously, because ultrasounds and other tests came back with nothing abnormal. They finally did a CT scan. In June of last year I went in for emergency surgery because they thought I had ovarian torsion.”

This turned out not to be the case, but during the surgery they found she had endometriosis. “We had never heard the word before,” she says. “We had never had any information about it.”

That surgery supplied a diagnosis but not a cure. There is no cure.

One in 10

Endometriosis affects one in 10 women, according to the U.S. Department of Health. That’s a shocking number for a disease most people have never heard of.

Tissue similar to the lining of the uterus grows in other parts of the body, most commonly in the pelvic area, causing pain, infertility and organ dysfunction. Its cause is unknown and research has been limited.

Endometriosis was found on Emma’s bowels, Fallopian tubes, appendix, bladder, uterus, and cul-de-sac.

During recovery over the summer she enrolled in business courses at the University of Victoria, but things did not go well there.

“I came back for Thanksgiving and Mom took one look at me and said something is wrong. I had lost about 15 pounds and I was falling apart physically. I was lucky if I could make it from my room in the basement up to the kitchen. Some days I would go the whole day without eating because I could not get up.”

She was spending much of her time in a wheelchair.

Weiland withdrew from school and put herself on a waiting list for excision surgery at B.C. Women’s Hospital. Excision surgery (more advanced than the surgery she received in the summer) is considered the gold standard treatment (but necessarily not a cure) for endometriosis. Weiland says there are fewer than five doctors in Canada who perform it.

“I was told I would have to wait up to a year. At this point I still have not received an initial call about an appointment.”

‘Doctors who don’t believe you’

Frustrated by the wait time, her family took her to a specialist, Dr. Ken Sinervo in Atlanta, who performed the surgery in January with a month’s notice.

Without excision surgery, sufferers are traditionally given drugs, hormones, ablation therapy, or a hysterectomy. Those are considered palliative management.

“If we had followed what was recommended as a treatment plan she would still be very sick,” says Emma’s mother, Deborah Weiland.

Emma says it would be worse than that.

“I would not be here today,” she says. “I would have committed suicide. This disease not only affects you physically but when you are in the hospital and talking to these doctors who don’t believe you and don’t recognize your illness or know how to treat it, it becomes so exhausting that you cannot imagine living it any more, it is not worth it. So without my parents and especially my mother advocating for me and travelling and finding someone to do proper surgery, I would not be here.”

Mental health effects

Deborah, who has done thorough research on endometriosis while her daughter has been coping with it, says the disease doesn’t just affect the body.

“It affects your hormones, which affects your mental state. So many women are battling mental illness created by this disease.”

Emma says she’s feeling well now, six months after the excision surgery. The surgeon told her the recurrence rate is 10 per cent.

“As far as I am concerned, I have a brand new life. I can’t do a work shift of eight hours but can work up to four hours. I still definitely still have surgical pains and cycle pains, but it is not even comparable

Every day is better.

“I have to pace myself right now. My new body is trying to catch up with my personality because I do need to take breaks. I am at about 50 per cent of what I would usually be able to to do. But I was at two per cent before my surgery.”

Not taken seriously

Emma plans to devote herself full time, in collaboration with her mother, to form and run the Endometriosis Organization of Canada.

Their first project is Demystifying Endometriosis at the Capitol Theatre on Saturday, an event that will include a screening of the documentary Endo What? and a discussion with Emma about her experience.

Emma says the message of the video aligns with her own opinion: that misogyny plays a big part in the lack of research, scarce resources and scant medical knowledge related to endometriosis. It’s a women’s disease, so it has not been taken seriously, she says.

There are already a few support organizations in Canada, Emma says, but their new group will take support further by focusing on education and advocacy.

“We want to bring advocacy and education into schools and colleges so people can become their own advocates.”

‘A very lucky person’

Emma wants to do this because she’s privileged to have been able to travel for her surgery.

“Most women spend all their money on painkillers and appointments. So I am very lucky to be only 19 and to have had excision surgery and to be able to advocate for myself and others. That is only a dream for so many women I have met.

“So many women reach out, but in a week’s time they are in a flare or in the hospital or getting another surgery. It is heartbreaking to watch. It is too debilitating to be human. You lose your humanity. You lose who you are.”

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