The Health | April, 2019
20
Column OBGYN
Changes in
private Obstetrics
& Gynaecology
practice
I
t has been 43 years since I left as a lecturer
in O&G from UMMC for private practice. The
practice of O&G has changed immensely in
all aspects during this period. It was a norm
during the 1960’s, 70’s and 80’s to have indi-
vidual maternity homes run by O&G specialists
all over the country. We had to work long hours and be
on call 24 hours a day. We, at that time, replaced the
maternity homes run by midwives. We had to be pre-
pared to act promptly in all emergencies. We acted as
anaesthetists, able to intubate patients while waiting
for the anaesthetist to arrive, as well as resuscitate
new-borns who were delivered with very low APGAR
scores before the paediatrician arrives.
By Datuk Dr Puraviappan
Arunasalam Pillay
Fetomaternal Medicine
Care of patients was similar to hospital practice with
routine blood tests, regular follow-ups and delivery of
the parturient at term. Vacuum and forceps deliveries
were conducted without any problems. The incidence
of LSCS in the 70’s and 80’s was only 5% going up to
30% in 20002010 for fear of medical litigation.
2D linear ultrasound was first introduced in the
early 1980’s in private practice and is still the stan-
dard practice.
Dual and triple tests along with Pregnancy Associ-
ated Plasma Protein a (PAPPa), Nuchal translucency
and HCG tests were available since 1990 and patients
were screened using these tests whenever needed.
Patients were referred to detailed ultrasound scans
centres which specialised in them. In turn, we began
using 3D scans in 1990.
Now, over the past few years, prenatal non-
invasive maternal serum screening test (NIPT) is
offered to all patients to detect early aneuploidy
and other chromosomal defects. Due to the costs, a
number of patients will opt for the dual or triple test
and detailed ultrasound scan. During the early 90’s,
amniocentesis for genetic screening was performed
in highly suspicious cases and was offered to patients
above the age of 35.
It was a routine in my practice to monitor all our
In future, I believe all Maternity houses will be
closed and O&G practice will be hospitalbased
except centres for ultrasound, infertility and office-
based gynaecological procedures. CME is a must
for all practitioners to keep abreast of changes in
the field. The clinician must be aware of all recent
advances and be adept accordingly.”
deliveries using CTG and sometimes foetal scalp
blood pH assessments. Ultrasound foetal growth
monitoring throughout the pregnancy was accom-
plished, and suspicious cases were referred for colour
doppler assessment of foetal wellbeing and timing
of delivery.
The nightmare in Obstetrics was postpartum
haemorrhage which had to be dealt with urgently by:
a) Massage
b) Compression of the aorta
c) Syntocinon and ergometrine
d) Blood transfusion and, if necessary, hysterectomy
where the incidence in my practice was 1:600
Infertility
Apart from taking a good history followed by physical
examination, the ensuing investigations were done,
namely: seminal analysis, laparoscopy, hormonal
profile and occasional HSGs before treatment.
Depending on the results, stimulation of ovulation
using Clomiphene with a maximum of 150 mg for
5 days along with the administration of HCG, when
there were sufficient mature follicles, followed by
Intrauterine insemination (IUI) for three attempts
were conducted.
Since 1986, IVF was available, and patients were
referred to centres where it was offered. GIFT, IVF,
ICSI, assessment of ovarian reserve by antral follicle
count and AMH were left to the experts.
Oncology cases
All care pertaining to this field were referred to
oncologists. Patients were requested to come for
regular, yearly follow-ups for Pap smears and blood
tests including tumour markers. Vulval, cervical and
endometrial Ca discovered after proper investigations
were referred to oncologists, including all suspicious
ovarian tumours.
Office gynaecology
All cases of vaginal infections were investigated and
treated accordingly, namely: Gardnerella vaginalis,
Trichomonas and monilial infections. PID cases were
treated as inpatients. Since 2007, HPV vaccine was
available to all patients between the age of 12-30
years. Since 2017, Gardasil 9 vaccine is available.
Colposcopy was offered to patients with suspi-
cious cervical Pap smears. Atrophic vaginitis and
evaluation of urinary symptoms were assessed and
managed.
Contraception
Counselling was routine to all patients in the repro-
ductive age group. Advice was given on the various
methods. The following contraceptive methods were
offered:
a) Hormonal – Oral contraceptives, Depo Provera,
Implanon
b) IUCD – Began with Lippies loop, Copper T, Cop-
perfix, Multiload 375 and Mirena
c) Surgery – Postpartum & elective tubal ligation were
accomplished using Pomeroy technique, Filshie
clips and Yoon rings. Vasectomies were done
for males. All benign cases of ovary and uterine
prolapse were managed by the usual conventional
methods.
Conclusion
In future, I believe all Maternity houses will be closed
and O&G practice will be hospitalbased except centres
for ultrasound, infertility and office-based gynaeco-
logical procedures. CME is a must for all practitioners
to keep abreast of changes in the field. The clinician
must be aware of all recent advances and be adept
accordingly. — Thye Health