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Unit I |
Dr. Elsy Thomas |
General Gynaecology |
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Unit II |
Dr. Lilly Verghese |
General Gynaecology |
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Unit III |
Dr. Anuja Abraham |
General and High risk |
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Unit IV |
Dr. Manisha Beck |
General and High risk |
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Unit V |
Dr. Jiji Mathews |
General and High-risk |
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Department of |
Dr. Aleyamma T. K. |
Fertility-related |
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Department of |
Dr. Anitha Thomas |
Gynaecological Cancers |
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OG3
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Full Day |
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OG 4 |
Tuesday |
Full Day |
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Friday |
Full Day |
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The Labour Room caters to about 14,000 women a year and constitutes one of the two tertiary referral centres in the area. As such it deals with a wide variety of obstetric emergencies and is backed up by an excellent blood bank facility and laboratory services. In addition it is well supported by other clinical specialties such as neonatology, haematology, cardiology, neurology, general medicine and surgery which provide interdepartmental input and expertise as required.
Services
1. Obstetric services
1.1 Antenatal Care
Each obstetric unit has two outpatient clinics a week (Unit V on Monday and Thursday, Unit IV on Tuesday and Friday, and Unit III on Wednesday and Thursday,) and Saturdays on rotation (OG1, OG3/ OG2, OG4/ OG5 and Gyn-ONC), with ancillary services of:
a. Obstetric ultrasound: Our obstetric units offer obstetric ultrasound services which span the entire range of the radiological diagnostic spectrum from early dating scans to detailed morphological scans.
b. On-the-spot tests for glycemic control
c. Antenatal diagnosis of a wide range of conditions utilizing chorionic villus sampling, amniocentesis and cordocentesis
d. Antenatal therapy of conditions such as Rh iso-immunization with intrauterine blood transfusion.
1.2 Labour Room
The labour room in Christian Medical College provides obstetric care to patients on a round the clock basis. Included in the facilities provided to patients are labor analgesia (epidural), private rooms. Mandatory birthing attendants (patient relatives: Female in the general areas and husbands and female relatives in the private areas), immediate access to dedicated cesarean section theaters and the availability of neonatal advanced care are the notable features of the services provided here. The labor room has a consultant cover throughout the day and night.
1.3 Perinatal Clinic
The Perinatal Clinic is run with inputs from Medical Genetics, Neonatology and Obstetrics and is available on Wednesday afternoon and Saturday morning.
2. Gynaecological Oncology
2.1 Out-patient services
The Gynaecological oncology services are available on Mondays and Thursdays.
2.2 In-patient services
SURGERIES
The unit of Gynaecological Oncology provides a wide range of surgeries covering all the gynaecological malignancies. The unit performs over 200 surgeries for gynaecological malignancies exclusively. In addition to gynaecological malignancy surgeries the unit also performs surgeries for patients with general gynaecological conditions like endometriosis and fibroids of the uterus.
CHEMOTHERAPY
The unit of Gynaecological Oncology also provides chemotherapy services for gestational trophoblastic neoplasms. The unit gives chemotherapy for about 100 patients on both inpatient and outpatient basis.
MULTI-DISCIPLINARY TEAM MEETING
The multi-disciplinary team meeting is an important part of the decision making process in the management of patients with gynecological malignancies and comprises personnel from Radiotherapy, Medical oncology and Pathology in addition to members from the gynecological oncology unit.
3. Uro-gynecology and pelvic floor disorders
The Unit of uro-gynecology and pelvic floor disorders is available on Tuesdays and Fridays. In addition to general gynecological services the unit also provides advice to patients with urological complaints and provides additional investigations such as uro-flowmetry.
3.1 Female continence clinic
Gynecology – Oncology
3.1.1 WHAT IS CANCER?
Our body is made up of trillions of living cells. Normal body cells grow, divide into new cells, and die in an orderly way. During the early years of our life, normal cells divide faster to allow us to grow. After we become an adult, most cells divide only to replace worn-out, damaged, or dying cells.
Cancer begins when cells in a part of our body start to grow out of control. There are many kinds of cancer, but they all start because of this out-of-control growth of abnormal cells. Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells keep on growing and form new cancer cells. These cancer cells can grow into (invade) other tissues, something that normal cells cannot do. Being able to grow out of control and invade other tissues makes a cell a cancer cell.
When cancer cells get into the bloodstream or lymph vessels, they can travel to other parts of the body. There they begin to grow and form new tumors that replace normal tissue. This process is called metastasis. No matter where a cancer spreads, it is always named for the place it started.
3.1.2 CERVICAL INTRAEPITHELIAL NEOPLASIA
Cervical intraepithelial neoplasia (CIN) is a pre-cancerous condition of the uterine cervix. CIN may be low grade or high grade. Women with low-grade CIN have minimal risk for developing cervical cancer, while those with high-grade lesions are at high risk of progression to cancer.
CIN 1 is a low-grade lesion. It refers to mildly abnormal cells
CIN 2 is considered a high-grade lesion. It refers to moderately abnormal cells
CIN 3 is a high-grade lesion. It refers to severely abnormal cells
Etiology
1. HPV(human papillomavirus) Infection of the cervix is the most important risk factor for cervical cancer .
Genital HPV is passed from one person to another during skin to skin sexual contact.
2. Early intercourse
3. Multiple sexual partners
Screening
Pap smear is the screening test done to detect abnormal cervical cells. Pap test screening for sexually active women should begin after age 25 years and needs to be repeated every three years. Women more than 65 years can stop having Pap tests if prior 3 test in the last 10 years are normal. Some centres do HPV testing which is also useful to follow up women after treatment. In rural areas, where pap smear is not available, VIA (Visual Inspection with acetic acid),VILI (Visual Inspection with Lugols Iodine) is done by nurses and referred to higher centres if abnormal.
Management
Abnormal Pap smear or HPV testing is followed by colposcopy test (look at the cervix directly with a specialized microscope). If abnormal areas are noticed in colposcopy, a biopsy is taken. Low grade lesions are kept on follow up while high grade lesions are excised or destroyed. Some women are advised hysterectomy. Vaccines against HPV are available which can be given to girls between 9 to 13 years and to older women before marriage. If cancer is found then the treatment is removal of the uterus and surrounding tissues including pelvic lymph glands. Advanced cancer is treated by chemo-radiation.
3.1.3 CARCINOMA ENDOMETRIUM
Carcinoma endometrium is cancer affecting the lining of the uterus. It is the commonest genital tract cancer in the western world. In India, there has been an increase in incidence of the disease because of the changes in lifestyle and obesity.
Who are at risk for endometrial cancer?
This cancer is usually seen in women following menopause but can be seen in younger women too. The following risk factors increase the chance of a woman having carcinoma endometrium:
1) Increasing age
2) Obesity and physical inactivity
3) Diabetes mellitus
4) Early menarche and late menopause
5) Infertility
6) Polycystic ovarian syndrome, irregular infrequent periods
7) Family history of breast, endometrial, ovarian and colorectal cancer
8) Estrogen secreting tumors,
9) Drugs like estrogen, only pills, tamoxifen
Combined oral contraception, childbearing protect against carcinoma endometrium.
How does a patient with endometrial cancer present?
Women will usually present with post-menopausal bleeding per vaginum. A lady who has not reached menopause as yet can present with irregular and increased menstrual periods. Pain and vaginal discharge are rarer symptoms and tend to be secondary to advanced cancer.
How is the diagnosis made?
Women who present with the above symptoms following gynecological examination are usually evaluated with biopsy of the endometrium. The biopsy of the endometrium can be done in the outpatient department with minimal discomfort or in theatre in case of technical difficulties. Based on the histological diagnosis, the carcinoma endometrium can be graded as high grade or low grade.
How is carcinoma endometrium managed?
Carcinoma endometrium is managed initially with surgery (open or laparoscopically) which includes removal of uterus and ovaries and lymph nodes. Based on the biopsy report following surgery, stage of the disease is determined. Requirement for post op radiotherapy or chemotherapy will be decided based on the stage of the disease and certain high risk factors. Generally patients with low grade, early disease have a good prognosis.
3.1.4 CARCINOMA OVARY
Ovarian cancer begins in the ovaries. Women have two ovaries, one on each side of the uterus in the pelvis. The ovaries produce eggs (called ova). They are also the main source of a woman’s female hormones: oestrogen and progesterone. The eggs travel through the fallopian tubes to the uterus. Here they may be fertilised and develop into a foetus.
The ovaries are made of three main kinds of tissue:
• Epithelial cells cover the ovary
• Germ cells make eggs (ova) inside of the ovary
• Stromal cells hold the ovary together and make most of the female hormones
How many women get ovarian cancer?
A woman’s risk of getting invasive ovarian cancer in her lifetime is about one in 72. Her lifetime chance of dying from invasive ovarian cancer is about 1 in 100. Ovarian cancer ranks fifth as the cause of cancer death in women. (These statistics don’t count low malignant potential ovarian tumors.)
What are the risk factors for ovarian cancer?
Age:
The risk of ovarian cancer goes up with age. Half of all these cancers are found in women over the age of 63.
Obesity:
Obese women (those with a body mass index of at least 30) have a higher risk of developing ovarian cancer.
Birth control:
Women who have used birth control pills have a lower risk of ovarian cancer. The lower risk is seen after only three to six months of using the pill, and the risk is lower the longer the pills are used. This lower risk goes on for many years after the pill is stopped.
Female surgery:
Having your ‘tubes tied’ (tubal ligation) may reduce the chance of getting ovarian cancer. Removal of the uterus without removing the ovaries (a hysterectomy) also seems to reduce the risk of getting ovarian cancer.
Family history of ovarian cancer, breast cancer, or colorectal cancer:
Ovarian cancer can run in families. Your ovarian cancer risk is higher if your mother, sister, or daughter has (or had) ovarian cancer. The risk gets higher the more relatives you have with ovarian cancer. Increased risk for ovarian cancer does not have to come from your mother’s side of the family − it also can come from your father’s side. Having a family member with breast cancer can increase your risk of ovarian cancer and women who have colon cancer in their families may have a higher risk of developing ovarian cancer, too. Many cases of familial epithelial ovarian cancer are caused by inherited gene mutations that can be identified by genetic testing.
How is ovarian cancer found?
Signs and symptoms of ovarian cancer
• Pelvic or belly pain
• Swelling of the belly (abdomen) or bloating caused by a build-up of fluid or a tumour
• Feeling full quickly or trouble eating
Most of these symptoms can also be caused by problems other than cancer. Women are more likely to have symptoms if the disease has spread beyond the ovaries. Also, some types of ovarian cancer can quickly spread to the surface of nearby organs. Still, dealing with symptoms right away can improve the odds of finding the cancer early and treating it with success.
Other symptoms of ovarian cancer can include those listed below. But, again, most of these symptoms are more likely to be caused by something other than ovarian cancer.
• Tiredness
• Upset stomach
• Back pain
• Pain during sex
• Constipation
• Menstrual changes
• Abdominal swelling with weight loss
Physical exam:
Your doctor will first ask you some questions and examine you to look for signs of ovarian cancer. These signs include finding an enlarged ovary (on a pelvic exam) and signs of fluid in the abdomen (which is called ascites).
Imaging studies:
These tests can show if there is fluid or a mass in the pelvis, but they cannot tell if it is cancer.
Ultrasound:
This is often the first test done to see if there is a problem with the ovaries. This test uses sound waves to make a picture on a video screen. A small probe is placed in the woman’s vagina or on the skin over her belly (abdomen). Because tumors and normal tissue reflect sound waves differently, this test may be useful in finding tumors and in telling whether a mass is solid or a fluid-filled cyst.
CT scans (computed tomography):
A CT scan is a type of x-ray that gives a detailed picture of the inside of your body. It takes a series of pictures of the body from many angles. A computer then combines the pictures. A CT scanner has been described as a large donut around a narrow table. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken.
Also, a contrast dye may be put into your vein or you may be asked to drink a contrast fluid. The contrast dye or fluid helps better outline structures in your body. The dye can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious problems like trouble breathing and low blood pressure can happen. Medicine can be given to prevent and treat allergic reactions. But be sure to tell the doctor if you have ever had a reaction to any dye used for x-rays.
CT scans do not show small ovarian tumours well, but they can show larger tumors, and may be able to tell if the tumor is growing into nearby structures. A CT scan may also find enlarged lymph nodes, signs of cancer spread to liver or other organs, or signs that an ovarian tumor is affecting your kidneys or bladder. CT scans can also be used to guide a needle into a tumour in order to remove a sample of tissue.
Blood tests:
These tests are done to make sure you have the right number of the different kinds of blood cells. The tests also measure your kidney and liver functions, and look for a protein named CA-125. CA-125 is a protein in the blood that may be higher than normal in some women with ovarian cancer. Other substances in the blood can point to different types of ovarian tumors. These substances are called tumour markers. Summary of ovarian cancer stages:
Stage I: The cancer is only in the ovary (or ovaries).
Stage II: Cancer is in one or both ovaries and has spread to other organs in the pelvis such as the bladder, colon, rectum, or uterus. It has not spread to lymph nodes, the lining of the belly (abdomen) or distant places.
Stage III: The cancer is in one or both ovaries and has spread to one or both of the following: the lining of the belly (abdomen) or the lymph nodes.
Stage IV: This is the most advanced stage. The cancer has spread from one or both ovaries to distant organs such as the liver or lungs, or there may be cancer cells in the fluid around the lungs.
Five-year survival rates
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Invasive epithelial |
Borderline / low |
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Stage I |
90% |
99% |
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Stage II |
65% |
97% |
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Stage III |
35% |
95% |
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Stage IV |
18% |
75% |
How is ovarian cancer treated?
The main treatments for ovarian cancer are:
• Surgery
• Chemotherapy
• Hormone therapy
• Targeted therapy
• Radiation therapy
Often, two or more different types of treatments are used.
Surgery for ovarian cancer:
Surgery is the main treatment for most ovarian cancers. How much and what type of surgery you have depends on how far the cancer has spread, your health (other than the cancer), and whether or not you still hope to have children.
For women of childbearing age who have certain kinds of tumours and whose cancer is in a very early stage, it may be possible to treat the disease without taking out both ovaries and the uterus. For epithelial ovarian cancer, surgery has 2 main goals: staging and debulking (these are discussed in detail further on). It is important that this surgery be done by someone who is experienced in ovarian cancer surgery. Many gynaecologists and surgeons are not trained to do the staging and debulking that are needed in treating ovarian cancer. For this reason, experts recommend that patients see a gynaecologic oncologist.
Staging:
Surgery for ovarian cancer has two main goals. The first goal is to stage the cancer, to see how far the cancer has spread from the ovary. Staging is very important because ovarian cancers at different stages are treated differently. If the staging isn’t done right, the doctor might not be able to give the right treatment.
Most often, staging means taking out the uterus, both ovaries, and both fallopian tubes. The omentum (a layer of fatty tissue that covers the stomach area like an apron) is also removed. Some lymph nodes in the pelvis and belly are taken out to see if they contain cancer. If there is fluid in the belly, it will also be removed. The surgeon may also remove tissue samples from different places inside the abdomen and pelvis. All the tissue and fluid samples taken during the operation are sent to a pathology lab to be looked at for cancer cells.
Debulking:
The other goal of surgery is to remove as much of the tumour as possible. This is called debulking. The aim of this surgery is to leave behind no tumour. Patients who have had successful debulking surgery have a better outlook than those left with large residual tumour after surgery.
In order to ‘debulk’ the cancer, the surgeon may need to remove part of the colon, bladder, stomach, liver, and/or pancreas. The spleen and/or gallbladder may also need to be removed. Sometimes when a piece of colon is removed, the two ends that remain can simply be sewn back together. In other cases, though, the ends can’t be sewn back together right away. Instead, the top end of the colon is attached to an opening (stoma) in the skin of the belly to allow body wastes to get out. This is known as a colostomy. Most often, this is only temporary, and the ends of the colon can be reattached later in another operation.
If part of the bladder needs to be removed, a catheter (to empty the bladder) will be placed during surgery. This will be left in place after surgery until the bladder recovers enough to be able to empty on its own. Then, the catheter can be removed.
Most women will stay in the hospital for three to seven days after the operation and can go back to their usual activities in 4 to 6 weeks. Taking out both ovaries and/or the uterus means that you will not be able to become pregnant. It also means that you will go into menopause if you have not done so already.
Chemotherapy for ovarian cancer:
Chemotherapy (chemo) is the use of drugs to kill cancer cells or shrink tumours. Most often the drugs are given into a vein (IV) or by mouth. Once the drugs enter the bloodstream, they spread throughout the body. This treatment is especially useful when cancer has spread beyond the ovaries. The drugs can also be given right into the belly (abdomen). This puts the drugs in contact with the cancer cells yet still allows them to be absorbed to reach the rest of the body. This works well, but does have more severe side effects. This is called intraperitoneal (IP) chemotherapy.
Chemo is often a combination two or more drugs, given in a cycle every three to four weeks. A cycle is a schedule where doses of a drug are followed by a rest period. Different drugs have different cycles. Your cancer doctor (oncologist) will prescribe the right cycle for your chemo.
Approach to treatment of ovarian cancer
The first step in treating most stages of ovarian cancer is surgery to remove and stage the cancer. Debulking is also done as needed. Chemotherapy (chemo) is often given after surgery. Patients who are too weak to have full staging and debulking surgery are sometimes treated with chemo first. If the chemo works and the patient becomes stronger, surgery to debulk the cancer may be done. This is often followed by more chemo. After treatment, blood tests will be done to see if your CA-125 tumor marker levels are normal.
For some patients, the doctor will recommend giving more chemo after the first treatment even if the cancer appears to be gone. This is called maintenance or consolidation therapy. It is aimed at killing any cancer cells that were left behind after treatment but are too small to be found with medical tests.
The goal of consolidation therapy is to keep the cancer from coming back after treatment. It is not clear how helpful this treatment is. If the cancer has spread to distant sites, like the liver, the lungs, or bone, then it can’t be cured with current treatment. But it can still be treated.
The goals of treatment are to help patients feel better and live longer. Surgery may be done to remove the tumor and debulk the cancer, followed by chemo. Or chemo may be given first; then, if the tumors shrink from the chemo, surgery may be done. This is often followed by more chemo. Another option is to limit treatments to those aimed at helping the patient feel better. This type of treatment is called palliative.
URO-GYNAECOLOGY
3.2 Pelvic organ prolapse:
Weakness of the supporting structure of (womb) uterus, pelvic floor and vagina is called as prolapse. Uterine prolapse often affects postmenopausal women who’ve had at least one vaginal delivery of a baby. Damage to supportive tissues during pregnancy and child birth, loss of oestrogen and repeated straining and lifting of heavy objects over the years can weaken your pelvic floor and lead to uterine prolapse.
Symptoms of uterine prolapse:
1. Bulging and heaviness in vagina
2. Low backache
3. Frequent urination
4. A flow of urine that stops and starts a feeling that your bladder has not emptied properly and the need to pass urine again soon afterwards.
5. Difficult or painful intercourse
6 Difficulty passing stools and having to strain to pass stools
Treatments for uterine prolapse:
If you have mild uterine prolapse, treatment usually is not needed. But if prolapse is painful, uncomfortable, or disrupting your normal activities such as social life, sports activities or sex life, then check out some of the very effective treatment options.
1) Life style changes:
i. Weight reduction
ii. Coughing can make prolapse worse.
iii. Receiving adequate treatment for constipation.
2) Pelvic floor exercises / Physiotherapy
The exercises may stop mild degrees of prolapse from getting any worse. They may also relieve symptoms such as backache and abdominal discomfort.
3) Vaginal ring pessary
Women who are waiting for surgery or women who do not wish to have , pessaries are ring shaped, inserted into vagina. It is left in place helps to lift up the walls of your vagina
4) Surgery
i. Removal of uterus is common treatment for uterine prolapse.
ii Vaginal repair operation: In this procedure, the walls of vagina are reinforced, and tightened up.
What is the outlook for genital prolapse?
Left untreated, prolapse usually gets worse. The outlook is worst for older women, those in poor physical health and those who are overweight.
Prolapse can return after surgery over 10 years.
How long will the hospital admission require?
Two to four days depending on the type and extent of surgery involved long term results are usually very good the tissues in the area that are being operated on, are not as strong as they used to be otherwise prolapse would not have occurred. Therefore there is still a slight risk of re occurrence of prolapse.
3.3 ENDOMETRIOSIS:
This is a condition where the tissue, similar to the inner lining of the uterus (endometrium) is found outside the uterus (endometriosis). This tissue can respond to hormonal changes and can bleed and cause symptoms. This is a common condition that is seen in approximately 5-20% of the women in reproductive age group. This abnormally placed tissue can be seen often in the ovary, fallopian tubes and other part of the pelvis. Most often, it is a progressive disease.
Endometriosis can be asymptomatic in some women. Otherwise, most of the women present with:
1. Pain during periods which may start even before the periods.
2. Pain during intercourse.
3. Pain while passing urine or motion (especially during periods)
4. Continuous pain in the lower part of the tummy, low back.
5. Infertility (difficulty in conceiving)
Endometriosis can be suspected by the symptoms you have and by examination. Ultrasound scan may help in the diagnosis. The definitive diagnosis is surgery. Endometriosis can be of varying severity. Endometriosis when untreated can lead to worsening of symptoms. They are at risk of developing complications including blockage of ureters (tube connecting kidney and bladder) and damage to kidneys.
The available treatment options include;
1. Pain medications: These tablets given during periods help in reducing the pain associated with endometriosis.
2. Combined hormonal pill / progesterone pill: These medications help by reducing the pain and bleeding. These pills taken continuously results in fewer periods and hence less bleeding and pain.
3. Injectable forms of hormones are also available. A device with hormones that can be placed inside the uterus like a coil/copper T can also be used. Hormones containing preparations cannot be used in women planning on pregnancy.
4. Other options including gonadotrophin releasing hormone agonist can used occasionally.
5. Surgery: Some women may need surgery for treatment for endometriosis. It can be done laparoscopically or by open surgery. This surgery may involve removal of the affected tissues including ovary, tubes and uterus.
Endometriosis with infertility can be managed by varied treatment options including IVF.
4. Reproductive Medicine
5. Menopause Clinic
The menopause clinic provides specialised advice and evaluation to post-menopausal women. The notable feature of this clinic that women attending this clinic are seen in conjunction with the endocrinology department which allows for holistic care to women as the women in this group are at risk of many problems specific to them such as osteoporosis, dyslipidemia, diabetes and other disorders.
6. Fetal Medicine Unit
Fetal medicine unit provides comprehensive prenatal care in a medical college setting. The unit provides care for women with a wide range of fetal conditions. Our services include obstetric ultrasound, diagnostic testing, genetic counseling and treatment. We work closely with the obstetric team to provide a holistic care to pregnant women with empathy and concern.
Services:
Clinics: The Fetal medicine Unit runs 6 clinics in a week (Mon- Sat) and provide various services including specialized antenatal scans and fetal procedures.
Obstetric scans: We provide high quality scan services in pregnancy which includes nuchal scan, anomaly scan, Fetal echo and multiple pregnancy scan along with counseling.
Fetal procedures: Antenatal diagnosis for various conditions through procedures including chorionic Villus Sampling, Amniocentesis, Cordocentesis, Multifetal reduction, Fetal shunt placement and non- invasive prenatal testing (NIPT) are provided. Intrauterine transfusion services are provided for fetuses affected by Rh iso-immunization.
Counselling services: Prenatal counselling services are also provided in the fetal medicine clinics along with the medical genetics, neonatology and pediatric surgery team.
Fetal medicine unit services are focused for women with the following conditions.
1. Pregnant women whose baby is detected /suspected to have abnormality
2. Women whose previous baby had structural /genetic /developmental problems and currently pregnant /planning for future pregnancy
3. Pregnant women with high risk for Down syndrome/screening for Trisomy
4. Pregnant women with Rh iso-immunisation
5. Triplet/higher order pregnancy
6. Twin pregnancy with complication in the baby
7. Prenatal counselling
Day Time:
Monday 10 am – 2 pm
Tuesday 10 am – 2 pm
Wednesday 10 am – 2 pm
Thursday 9 am – 1 pm
Friday 10am – 2 pm
Saturday 10 am – 12 pm
Faculty list:
Dr. Manisha Madhai Beck – Professor and Head of the unit
Dr. Preethi. R.N – Associate Professor
The Head
Department of Obstetrics and Gynaecology
ISSCC Building 7th Floor
Christian Medical College Vellore
Ida Scudder Road, Vellore – 632004
Tamil Nadu, India
Email us :
ogone@cmcvellore.ac.in
04162283399
Mon-Fri: 8 am to 4.30 pm
( Sat : 8 am to 12:30 pm)
