2018 Guideline on management of Placenta Praevia by RCOG

Royal College of Obstetricians and Gynaecologists have come out with its latest 2018 Guidelines on diagnosis and management of Placenta Praevia and Placenta Accreta.

This is the fourth edition of this guideline the first one was published in 2001 and it is an update on 2011 guideline. It has appeared in British Journal of  Obstetricians and Gynaecologists. The purpose of this guideline is to describe the diagnostic modalities and review the evidence‐based approach to the clinical management of pregnancies complicated by Placenta Praevia.

Key Recommendations:

Antenatal diagnosis and care of women with placenta praevia or a low‐lying placenta

• Caesarean delivery is associated with an increased risk of placenta praevia in subsequent pregnancies. This risk rises as the number of prior caesarean sections increases.
• Assisted reproductive technology and maternal smoking increase the risk of placenta praevia.
• The mid-pregnancy routine fetal anomaly scan should include placental localisation thereby identifying women at risk of persisting placenta praevia or a low‐lying placenta.
• The term placenta praevia should be used when the placenta lies directly over the internal os. For pregnancies at more than 16 weeks of gestation, the term low‐lying placenta should be used when the placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning (TVS).
• If the placenta is thought to be low lying (less than 20 mm from the internal os) or praevia (covering the os) at the routine fetal anomaly scan, a follow‐up ultrasound examination including a TVS is recommended at 32 weeks of gestation to diagnose persistent low‐lying placenta and/or placenta praevia.
• Clinicians should be aware that TVS for the diagnosis of placenta praevia or a low‐lying placenta is superior to transabdominal and transperineal approaches, and is safe.
• In women with a persistent low‐lying placenta or placenta praevia at 32 weeks of gestation who remain asymptomatic, an additional TVS is recommended at around 36 weeks of gestation to inform discussion about the mode of delivery.
• Cervical length measurement may help facilitate management decisions in asymptomatic women with placenta praevia. A short cervical length on TVS before 34 weeks of gestation increases the risk of preterm emergency delivery and massive haemorrhage at caesarean section.
• Tailor antenatal care, including hospitalisation, to individual woman’s needs and social circumstances, e.g. distance between home and hospital and availability of transportation, previous bleeding episodes, haematology laboratory results, and acceptance of receiving donor blood or blood products.
• Where hospital admission has been decided, an assessment of risk factors for venous thromboembolism in pregnancy should be performed as outlined in the Royal College of Obstetricians and Gynaecologists Green‐top Guideline No. 37a. This will need to balance the risk of developing a venous thromboembolism against the risk of bleeding from a placenta praevia or low lying placenta
• It should be made clear to any woman being treated at home in the third trimester that she should attend the hospital immediately if she experiences any bleeding, including spotting, contractions or pain (including vague suprapubic period‐like aches).
• Women with asymptomatic placenta praevia or a low‐lying placenta in the third trimester should be counselled about the risks of preterm delivery and obstetric haemorrhage, and their care should be tailored to their individual needs.
• Women with asymptomatic placenta praevia confirmed at the 32‐week follow‐up scan and managed at home should be encouraged to ensure they have safety precautions in place, including having someone available to help them as necessary and ready access to the hospital.
• The use of cervical cerclage to reduce bleeding and prolong pregnancy is not supported by sufficient evidence to recommend its use outside of a clinical trial.
• A single course of antenatal corticosteroid therapy is recommended between 34⁺⁰ and 35⁺⁶ weeks of gestation for pregnant women with a low‐lying placenta or placenta praevia and is appropriate prior to 34⁺⁰ weeks of gestation in women at higher risk of preterm birth.
• Tocolysis for women presenting with symptomatic placenta praevia or a low‐lying placenta may be considered for 48 hours to facilitate administration of antenatal corticosteroids.
• If delivery is indicated based on maternal or fetal concerns, tocolysis should not be used in an attempt to prolong gestation.
• Late preterm (34⁺⁰ to 36⁺⁶ weeks of gestation) delivery should be considered for women presenting with placenta praevia or a low‐lying placenta and a history of vaginal bleeding or other associated risk factors for preterm delivery.
• Delivery timing should be tailored according to antenatal symptoms and, for women presenting with uncomplicated placenta praevia, delivery should be considered between 36⁺⁰ and 37⁺⁰ weeks of gestation.
• In women with a third trimester asymptomatic low‐lying placenta the mode of delivery should be based on the clinical background, the woman’s preferences, and supplemented by ultrasound findings, including the distance between the placental edge and the fetal head position relative to the leading edge of the placenta on TVS.
• Prior to delivery, all women with placenta praevia and their partners should have a discussion regarding delivery. Indications for blood transfusion and hysterectomy should be reviewed and any plans to decline blood or blood products should be discussed openly and documented.
• Placenta praevia and anterior low‐lying placenta carry a higher risk of massive obstetric haemorrhage and hysterectomy. Delivery should be arranged in a maternity unit with on‐site blood transfusion services and access to critical care.
• Women with atypical antibodies form a particularly high‐risk group and the care of these women should involve discussions with the local haematologist and blood bank.
• Prevention and treatment of anaemia during the antenatal period is recommended for women with placenta praevia or a low‐lying placenta as for any pregnant woman.

Delivery for women with placenta praevia or a low‐lying placenta

• As a minimum requirement for a planned caesarean section for a woman with placenta praevia, the surgical procedure should be carried out by an appropriately experienced operator.
• In cases of planned caesarean section for placenta praevia or a low‐lying placenta, a senior obstetrician (usually a consultant) and senior anaesthetist (usually a consultant) should be present within the delivery or theatre suite where the surgery is occurring.
• When an emergency arises, the senior obstetrician and senior anaesthetist should be alerted immediately and attend urgently.
• Regional anaesthesia is considered safe and is associated with lower risks of haemorrhage than general anaesthesia for caesarean delivery in women with placenta praevia or a low‐lying placenta. Women with anterior placenta praevia or a low‐lying placenta should be advised that it may be necessary to convert to general anesthesia is required and asked to consent.
• Close liaison with the hospital transfusion laboratory is essential for women presenting with placenta praevia or a low‐lying placenta.
• Rapid infusion and fluid warming devices should be immediately available.
• Cell salvage is recommended for women where the anticipated blood loss is great enough to induce anaemia, in particular, in women who would decline blood products.
• Consider vertical skin and/or uterine incisions when the fetus is in a transverse lie to avoid the placenta, particularly below 28 weeks of gestation.
• Consider using preoperative and/or intraoperative ultrasonography to precisely determine the placental location and the optimal place for uterine incision.
• If the placenta is transacted during the uterine incision, immediately clamp the umbilical cord after fetal delivery to avoid excessive fetal blood loss.
• If pharmacological measures fail to control haemorrhage, initiate intrauterine tamponade and/or surgical haemostatic techniques sooner rather than later. Interventional radiological techniques should also be urgently employed where possible.
• Early recourse to hysterectomy is recommended if conservative medical and surgical interventions prove ineffective.

Antenatal diagnosis and outcome of women with placenta accreta spectrum

• The major risk factors for placenta accreta spectrum are a history of accreta in a previous pregnancy, previous caesarean delivery and other uterine surgery, including repeated endometrial curettage. This risk rises as the number of prior caesarean sections increases.
• Women requesting elective caesarean delivery for non‐medical indications should be informed of the risk of placenta accreta spectrum and its consequences for subsequent pregnancies. Antenatal diagnosis of placenta accreta spectrum is crucial in planning its management and has been shown to reduce maternal morbidity and mortality.
• Previous caesarean delivery and the presence of an anterior low‐lying placenta or placenta praevia should alert the antenatal care team of the higher risk of placenta accreta spectrum.
• Ultrasound imaging is highly accurate when performed by a skilled operator with experience in diagnosing placenta accreta spectrum.
• Refer women with any ultrasound features suggestive of placenta accreta spectrum to a specialist unit with imaging expertise.
• Women with a history of previous caesarean section seen to have an anterior low‐lying placenta or placenta praevia at the routine fetal anomaly scan should be specifically screened for placenta accreta spectrum.
• Clinicians should be aware that the diagnostic value of MRI and ultrasound imaging in detecting placenta accreta spectrum is similar when performed by experts.
• MRI may be used to complement ultrasound imaging to assess the depth of invasion and lateral extension of myometrial invasion, especially with posterior placentation and/or in women with ultrasound signs suggesting parametrial invasion.
• Women diagnosed with placenta accreta spectrum should be cared for by a multidisciplinary team in a specialist centre with expertise in diagnosing and managing invasive placentation.
• Delivery for women diagnosed with placenta accreta spectrum should take place in a specialist centre with logistic support for immediate access to blood products, adult intensive care unit and neonatal intensive care unit by a multidisciplinary team with expertise in complex pelvic surgery.
• In the absence of risk factors for preterm delivery in women with placenta accreta spectrum, planned delivery at 35⁺⁰ to 36⁺⁶ weeks of gestation provides the best balance between fetal maturity and the risk of unscheduled delivery.

Planning delivery of women with suspected placenta accreta spectrum

• Once the diagnosis of placenta accreta spectrum is made, a contingency plan for emergency delivery should be developed in partnership with the woman, including the use of an institutional protocol for the management of maternal haemorrhage.
• Any woman giving consent for caesarean section should understand the risks associated with caesarean section in general, and the specific risks of placenta accreta spectrum in terms of massive obstetric haemorrhage, increased risk of lower urinary tract damage, the need for blood transfusion and the risk of hysterectomy.
• Additional possible interventions in the case of massive haemorrhage should also be discussed, including cell salvage and interventional radiology where available.
• The elective delivery of women with placenta accreta spectrum should be managed by a multidisciplinary team, which should include senior anaesthetists, obstetricians and gynaecologists with appropriate experience in managing the condition and other surgical specialties if indicated. In an emergency, the most senior clinicians available should be involved.
• The choice of anaesthetic technique for caesarean section for women with placenta accreta spectrum should be made by the anaesthetist conducting the procedure in consultation with the woman prior to surgery.
• The woman should be informed that the surgical procedure can be performed safely with regional anaesthesia but should be advised that it may be necessary to convert to general anaesthesia if required and asked to consent to this.
• Caesarean section hysterectomy with the placenta left in situ is preferable to attempting to separate it from the uterine wall.
• When the extent of the placenta accreta is limited in depth and surface area, and the entire placental implantation area is accessible and visualised (i.e. completely anterior, fundal or posterior without deep pelvic invasion), uterus-preserving surgery may be appropriate, including partial myometrial resection.
• Uterus preserving surgical techniques should only be attempted by surgeons working in teams with appropriate expertise to manage such cases and after appropriate counselling regarding risks and with informed consent.
• There are currently insufficient data to recommend the routine use of ureteric stents in placenta accreta spectrum. The use of stents may have a role when the urinary bladder is invaded by placental tissue (see section 8.4.2).
• There is limited evidence to support uterus-preserving surgery in placenta percreta and women should be informed of the high risk of peripartum and secondary complications, including the need for secondary hysterectomy.
• Elective peripartum hysterectomy may be unacceptable to women desiring uterine preservation or considered inappropriate by the surgical team. In such cases, leaving the placenta in situ should be considered.
• When the placenta is left in situ, local arrangements need to be made to ensure regular review, ultrasound examination and access to emergency care should the woman experience complications, such as bleeding or infection.
• Methotrexate adjuvant therapy should not be used for expectant management as it is of unproven benefit and has significant adverse effects.
• Larger studies are necessary to determine the safety and efficacy of interventional radiology before this technique can be advised in the routine management of placenta accreta spectrum.
• Women diagnosed with placenta accreta spectrum who decline donor blood transfusion should be cared for in a unit with an interventional radiology service.
• If at the time of an elective repeat caesarean section, where both mother and baby are stable, it is immediately apparent that placenta percreta is present on opening the abdomen, the caesarean section should be delayed until the appropriate staff and resources have been assembled and adequate blood products are available. This may involve the closure of the maternal abdomen and urgent transfer to a specialist unit for delivery.
• In the case of unsuspected placenta accreta spectrum diagnosed after the birth of the baby, the placenta should be left in situ and an emergency hysterectomy performed.                                

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Intermittent fasting may help fight type 2 diabetes

What is intermittent fasting?

              Intermittent fasting is a type of diet in which people cycle between periods of eating and fasting. It does not specify the foods that are allowed during the eating window.

The most common type of fasting is known as the 16:8 method, which involves fasting for 16 hours and reducing the eating window to just 8 hours. For example, a person can have dinner at approximately 7 p.m., skip breakfast the day after, and eat lunch at around 11 a.m.

Other forms involve fasting for 2 days per week, 24-hour fasting once or twice each week, and fasting every other day.

              Researchers used intermittent fasting as a method to reduce the symptoms of type 2 diabetes in a new observational study conducted in Canada and published in the journal BMJ Case Reports.

The study included three men, aged 40–67, who were taking both drugs and daily doses of insulin to manage the disease. They all had high blood pressure and high cholesterol.

"The use of a therapeutic fasting regimen for treatment of [type 2 diabetes] is virtually unheard of," the authors of the study write.

              Researchers used intermittent fasting as a method to reduce the symptoms of type 2 diabetes in a new observational study conducted in Canada and published in the journal BMJ Case Reports.

The study included three men, aged 40–67, who were taking both drugs and daily doses of insulin to manage the disease. They all had high blood pressure and high cholesterol.

"The use of a therapeutic fasting regimen for treatment of [type 2 diabetes] is virtually unheard of," the authors of the study write.

"Intermittent fasting''s effects on diabetes

             Before the study, the men attended nutrition seminars, which gave them information regarding the development of the condition, its effects on the body, and how to use diet to manage diabetes.

Then, scientists asked two of them to fast for 24 hours every other day, while the third fasted for 3 days each week. During fasting days, the men could drink low-calorie beverages such as water, tea, or coffee. In addition, they could eat a low-calorie meal in the evening.

The trial lasted 10 months in total, and the three men stuck to their schedule without encountering any difficulties. After the fasting period, the team measured their weight and blood glucose.

The results revealed significant improvement: all three lost weight, blood glucose was lower, and they were able to stop using insulin after a month from the beginning of the trial. In one case, the person stopped after only 5 days.

Two of the men also discontinued all diabetic drugs, while the third participant stopped 3 out of 4 drugs.

The authors concluded that intermittent fasting may help people with diabetes, but the study was limited to three participants. More research is needed to confirm these findings, but they are encouraging.

"This present case series showed that 24-hour fasting regimens can significantly reverse or eliminate the need for diabetic medication," conclude the authors.

 

 

Published Saturday 13 October 2018 

By Chiara Townley     Fact checked by Jasmin Collier

SC stays NCDRC order to bring govt hospital’s free medical services under consumer law ambit.

NEW DELHI: The Supreme Court has stayed National Consumer Disputes Redressal Commission’s order bringing free medical services provided by government hospitals within the ambit of Consumer Protection Act to make doctors and hospital liable to pay compensation for any kind of negligence.
A bench of Justices Madan B Lokur and Deepak Gupta agreed to examine Centre’s plea who rushed to the apex court challenging NCDRC’s order to bring all government hospitals providing free treatment to patients under consumer protection law. The centre contended that the free services provided by government authorities could not be brought within the domain of consumer law.
Making government hospitals liable for medical negligence, the apex consumer court had last year directed Delhi’s Safdarjung Hospital to pay compensation of Rs two lakh to a parents for not treating their born baby properly leading to her death one and half months after being admitted in the hospital. The consumer court held that the hospital was negligent in not admitting the baby in the nursery ICU where she could have been given proper medical care. The hospital had treated the baby in general ward and had refused to admit her in nursery on the ground that it was their policy not to admit out born baby to nursery as there was chance that it could cause infection to other babies.

“Safdarjung hospital should have provided nursery facilities to the infant who was in critical condition. The facility was not made available arbitrarily and arrogantly on flimsy ground. A badly needed facility was denied on the basis of arbitrary and discriminatory policy of the hospital which is totally unacceptable,” the consumer court had said.
The court also refused to accept plea of the hospital that it was providing free treatment to patients and it could be made liable under consumer law. “Free services would also be a service and the recipient a consumer under the Act,” the court had said. 

As NCDRC’s will have a wider ramification, bringing all government hospital within the ambit of consumer law, the Centre filed appeal in the apex court challenging the verdict. Referring to SC’s 1995 verdict, additional solicitor general Pinky Anand and advocate Rajesh Ranjan, appearing for the government, said that doctors and hospitals who render free services to every person were not covered under the Act.
Agreeing with the Centre’s submission, the bench said that the issue needed to be adjudicates and issued notice on government’s petition..” In the meanwhile, there shall be a stay of operation of the impugned judgment and order passed by the National Consumer Disputes Redressal Commission.
                                                ”Amit Anand Choudhary | TNN | Oct 17, 2017, 18:40 IST

services under consumer law ambit

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Suffering of ailment by the patient after surgery does not simply mean medical negligence

In the matter titled as “Dr. S. K. Jhunjhunwala versus Mrs. Dhanwanti Kumar & Anr., the Hon’ble Supreme Court of India vide judgement dated 01.10.2018 has held that simply proving the suffering of ailment by the patient after the surgery does not amount to medical negligence. The doctor can be held for medical negligence only if the suffering of any such ailment is because of improper performance of the surgery and that too with the degree of negligence on the part of the doctor.

Facts of the case: Mrs. Dhanwanti Kumar (patient) had filed the consumer complaint case claiming compensation for the loss, mental suffering and pain suffered by her throughout after the surgery on account of negligence of the appellant in performing the surgery of her Gall Bladder on 08.08.1996.
She complained that firstly she had never given her consent for performing general Surgery of her Gall Bladder rather she had given consent for performing laparoscopy Surgery only but the doctor performed general surgery of her Gall Bladder which resulted in putting several stitches and scars on her body.
Secondly, even the surgery performed was not successful inasmuch as the patient thereafter suffered for several days with various ailments, such as dysentery, loss of appetite, reduction of weight, jaundice etc.,
Thirdly, in June 1997, she was, therefore, required to undergo another Surgery in Ganga Ram Hospital, Delhi for removal of stones which had slipped in CBD. It was alleged that all these ailments were incurred due to the negligence of the doctor, who did not perform the surgery properly and rather performed the surgery carelessly leaving behind for the patient only mental agony, pain, harassment and money loss and hence she filed a complaint to claim the reasonable amount of compensation under various heads as mentioned above.
Doctor filed his reply and stated in his reply that he, after examining the patient No.1, advised her to go for surgery of Gall Bladder, which may even include removal of Gall Bladder. It was stated that consent of patient for performing the laparoscopic cholecystectomy was duly obtained before performing the surgery.
Doctor stated that after starting laparoscopic surgery, he noticed swelling, inflammation and adhesion on her Gall Bladder and, therefore, he came out of the Operation Theater and disclosed these facts to patients husband and told him that in such a situation it would not be possible to perform laparoscopic surgery and only conventional procedure of surgery is the option to remove the malady. The husband of patient agreed for the option suggested by the doctor and the doctor accordingly performed conventional surgery. The patient was discharged after spending few days in the Hospital for postoperative care.
Doctor, therefore, denied any kind of negligence or carelessness or inefficiency on his part in performing the surgery on the patient and stated that all kinds of precautions to the best of his ability and capacity, which were necessary to perform the surgery were taken by him and by the team of doctors that worked with him in all such operational cases.
Judgment of the Court

44. In our opinion, there has to be a direct nexus with these two factors to sue a doctor for his negligence. Suffering of ailment by the patient after surgery is one thing. It may be due to myriad reasons known in medical jurisprudence. Whereas suffering of any such ailment as a result of improper performance of the surgery and that too with the degree of negligence on the part of Doctor is another thing. To prove the case of negligence of a doctor, the medical evidence of experts in field to prove the latter is required. Simply proving the former is not sufficient.

45. In our considered opinion, respondent No. 1was not able to prove that the ailments which she suffered after she returned home from the Hospital on 08.08.1996 were as a result of faulty surgery performed by the appellant.

48. In the light of the detailed discussion made above on the issues arising in the case including the issue of grant of consent, we are unable to accept the aforesaid submissions of learned counsel for respondent No.1.

49. It is apt to remember the words of the then Chief Justice of India when he said in Jacob Mathew’s case (supra) which reads as under:

“The subject of negligence in the context of medical profession necessarily calls for treatment with a difference. There is a marked tendency to look for a human actor to blame for an untoward event, a tendency that is closely linked with a desire to punish. Things have gone wrong and therefore somebody must be found to answer for it. An empirical study reveals that background to a mishap is frequently far more complex than may generally be assumed. It can be demonstrated that actual blame for the outcome has to be attributed with great caution. For a medical accident or failure, the responsibility may lie with the medical practitioner, and equally it may not. The inadequacies of the system, the specific circumstances of the case, the nature of human psychology itself and sheer chance may have combined to produce a result in which the doctor’s contribution is either relatively or completely blameless. The human body and its working is nothing less than a highly complex machine. Coupled with the complexities of medical science, the scope for mis-impressions, misgivings and misplaced allegations against eh operator i.e. the doctor, cannot be ruled out. One may have notions of best or ideal practice which are different from the reality of how medical practice is carried on or how the doctor functions in real life. The factors of pressing need and limited resources cannot be ruled out from consideration. Dealing with a case of medical negligence needs a deeper understanding of the practical side of medicine. The purpose of holding a professional liable for his act or omission, if negligent, is to make life safer and to eliminate the possibility of recurrence of negligence in future. The human body and medical science, both are too complex to be easily understood. To hold in favour of existence of negligence, associated with the action or inaction of a medical professional, requires an in-depth understanding of the working of a professional as also the nature of the job and of errors committed by chance, which do not necessarily involve the element of culpability.”