Patient Information: How much information do modern patients require?

What is MR Guided Focused Ultrasound (MRgFUS) and what is its role in the management of fibroids?

The author was privileged to be invited to the first UK symposium on  MR Guided Focused Ultrasound - held in London - 26th November 2008

MR Guided Focused Ultrasound MRgFUS offers a new and exciting option for women who have symptoms attributable to fibroids, who require surgical intervention and who wish to retain their uterus. The procedure is non-invasive.

What are fibroids?

• Uterine fibroids (leiomyomas) are benign tumors that grow within the muscular wall of the uterus. 
• They are the most common pelvic tumors in women, with a prevalence of 20-40% during middle reproductive age. 
• Prevalence of 70% of all women by age 50.
• 20% of gynaecological consultations relate to fibroids.
• They are more common in women of African-Caribbean origin. 
• USA $6.5 billion for cesarean sections and $2.0 billion for fibroid surgery in 2004.

Fibroid Symptoms

Many women are unaware that they have fibroids but others have reduced quality of life because of:-

• Heavy periods
• Pelvic pain or pressure
• Pressure on the bladder leading to increased need to urinate
• Pressure on the bowel which can lead to constipation and/or bloating
• An enlarged abdomen which is sometimes mistaken for pregnancy
• Fertility Problems

Treatment options for fibroids

There are several treatment options to relieve symptoms associated with fibroids including:

• MR Guided Focused Ultrasound - NEW TREATMENT
• Medical
• Surgical

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Down Syndrome Screening

Healthcare systems appear to facilitate informed choices in the context of prenatal screening for Down syndrome screening less well for women from minority ethnic groups and those who are socioeconomically disadvantaged than for other women.^0501, While most pregnant women in England are offered prenatal screening for Down syndrome, approximately 1 in 10 is not. Asian women are less likely than White women to report being offered Down syndrome screening and are less likely to have a screening test when offered. ²⁰⁰⁸

Down syndrome (mongolism, Down's syndrome, or trisomy 21), which is associated with typical facial features and reduced mental ability, is due to an extra chromosome 21 (genes - chromosomes). The disorder was identified as a chromosome 21 trisomy in 1959. The condition is characterized by a combination of major and minor differences in structure. Often Down syndrome is associated with some impairment of mental ability and physical growth as well as facial appearance. A few have severe mental disability but the majority enjoy a good life.

Many of the common physical features of Down syndrome also appear in people with a standard set of chromosomes. They may include:-

• a single transverse palmar crease (a single instead of a double crease across one or both palms),
• an almond shape to the eyes caused by an epicanthic fold of the eyelid, upslanting palpebral fissures (the separation between the upper and lower eyelids),
• shorter limbs,
• a larger than normal space between the big and second toes,
• and protruding tongue.

Health concerns for individuals with Down syndrome include:-

• a higher risk for congenital heart defects,
• gastroesophageal reflux disease,

Is screening for abnormality in the fetus justifiable?

The question of screening for foetal abnormality is never an easy one.

Some would find the thought of caring for a handicapped child intolerable whereas others believe the practice of pregnancy termination is unacceptable.

You will also need advice on the chance of recurrence in another pregnancy.

Dysmenorrhea associated with endometriosis - Controlled trial demonstrates efficacy of combined oral contraceptive pill.

In a double-blind, randomized, placebo-controlled trial one hundred patients with Dysmenorrhoea associated with endometriosis most enrolled patients had radiologic evidence of endometriosis rather than surgical diagnosis. Patients were randomly assigned to receive either monophasic OCP (ethinylestradiol plus norethisterone) or placebo.  Total dysmenorrhea scores assessed by the verbal rating scale were significantly decreased at the end of treatment in both groups. From the first cycle through the end of treatment, dysmenorrhea in the OCP group was significantly milder than in the placebo group. The volume of endometrioma (larger than 3 cm in diameter) was significantly decreased in the OCP group, but not in the placebo group. No serious adverse events related to using OCPs occurred. This present study clearly demonstrated for the first time that OCPs could be used to effectively and safely treat pain associated with endometriosis.²⁰⁰⁸

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Cesarean Section Rate 18th November 2008

Cesarean section rates are rising and account for more than 30% of childbirths in the USA.

An article in the Daily Mail (November 2008) highlights the problem.

• Relative safety of surgery with improvement in anesthesia, availability of blood transfusion and antibiotics.
• Greater emphasis on quality of offspring rather than quantity.
• Patient preference based on claimed benefits of planned caesarean section including greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience.

The potential disadvantages, include increased risk of major morbidity or mortality for the mother, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity.

The decision on optimum mode of delivery is the most commonly encountered question in clinical practice across all medical disciplines.

The number of factors to be taken into account is greater than in any other clinical situation across all medical disciplines.

There is undoubtedly a risk of litigation issue colouring obstetric decision making. An obstetrician is more likely to be subjected to litigation because a cesarean section was not performed or was perceived to have been performed too late than for complications of surgery. In the current climate, it is likely that cesarean sections are likely to continue rising.

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Treatment For Unexplained recurrent  miscarriage

It is an understandable cry from the heart from couples who experience the devastation of recurrent miscarriage that there must be one explanation and one perfect treatment. It is only in the last ten years that we have begun to find some treatable explanations for recurrent miscarriages.

Badawy et al ²⁰⁰⁸  have reported on the efficacy of early thromboprophylaxis with low-molecular weight heparin (LMWH) in women with a history of recurrent first trimester spontaneous abortion or miscarriages without identifiable causes vs no treatment in a randomised prospective study. There was a significant difference in the incidence of both early (4.1% vs 8.8%) and late miscarriages (1.1% vs 2.3%) in heparin group. However, the mean birth weight was significantly higher in the heparin treated group. They concluded that LMWH seems to be a safe drug and effective in significantly reducing the incidence of recurrent miscarriages of unknown aetiology when given in the first trimester and continued throughout pregnancy.