What is a caesarean?

A caesarean, or c-section, is an unnatural procedure for giving birth, which is performed under a regional anaesthetic, called an epidural, which numbs the lower part of the body but allows the mother to be awake during the operation. The procedure usually lasts 30-45 minutes, however an emergency caesarean can be performed in 30 minutes. The baby is delivered by making 2 main incisions; one horizontal incision in the lower abdomen and another horizontal incision in the wall of the womb. In 2 out of 100 cases, the baby’s skin is cut when the womb opening is made. Recovery after a c-section often takes longer than a natural birth, and there may be after-effects such as infection.

Currently women cannot choose to have a caesarean, but the decision is made for them by Doctors for medical reasons. Factors which effect whether a c-section is necessary include the size of the baby’s head, the shape or size of the pelvis, the positioning of the placenta, whether twins or triplets are expected, the baby’s positioning,  whether the baby becomes distressed or mother’s illness e.g. high blood pressure (1). However, this may be about to change next month in the news that NICE are making plans to make c-sections an open option available for healthy mothers at their own choice.

Arguments for the change

The change will come with great controversy. Among those for the availability of c-sections is Dr Bryan Beattie, who helped write the existing c-section guidelines. He states that the move to open c-section availability is a “huge development in terms of allowing women to make an informed choice”. Other similar arguments say that living in the 21^st century means women have the right to choose their mode of baby delivery.

Despite the caesarean being major abdominal surgery, C-sections are reported to be now safer than ever, as they are performed more commonly. Nowadays complications affect less than 20 in 10,000 babies (2).

Arguments against the change

However, there is fierce opposition from midwives and natural birth campaigners. Some people believe that the NHS should not fund the extra costs for a procedure that is medically unnecessary. Caesareans are £800 more expensive than natural births, and therefore when the demand rises, the NHS will be faced with an added financial burden which no one knows if they can actually afford. Caesareans have boomed in popularity and are now performed in just under a ¼ of deliveries, compared to 9% back in the 1970’s. It has been suggested that this could be partly due to the rising ages at which mothers give birth and rising obesity levels among pregnant women.

It has been calculated that reducing the number of caesareans a year by 1% could save the NHS £5.6 million a year. Can the NHS afford to lose this money and what will suffer in its place?

Unsurprisingly, not all Doctors will agree to performing caesareans without need, due to the problems associated with it. These include that women need to stay longer in hospital, there are higher readmission rates and more abdominal pain. Those Doctors that oppose the operation will be able to refer patients to other Doctors.

The National Institute for Health and Clinical Excellence is due to publish the new guidelines next month. Let us wait and see the controversy unfold in front of us.

1) http://www.bbc.co.uk/health/physical_health/birth/birth_caesarean.shtml

2) http://www.nhs.uk/Conditions/Caesarean-section/Pages/Risks.aspx

It has been announced this week that a new weekly injection has been approved to replace the twice daily jab which currently treats type 2 diabetes. This news comes with great elation to the 2.5 million people in the UK suffering with type 2 diabetes and a further 850,000 undiagnosed sufferers. Whilst the new injection is not curative, it is sure to improve the quality of life of diabetes patients who normally require two injections a day. Imagine the difference a weekly jab will make.

About Diabetes Type 2

Diabetes mellitus is a chronic, incurable condition which is caused by too much of the sugar glucose in the blood. As a result of the increase in sugar, sufferers of diabetes experience the following common symptoms: increased hunger (polyphagia), polydipsia (increased thirst) and polyuria (increased urination) (1).

There are two most common types of diabetes. The main differences between them are shown in the table below.

Table 1: key differences between diabetes type 1 and type 2

Treatment Now

Treatment for type 2 diabetes is aimed at managing patient’s blood glucose levels to control symptoms and reducing the risk of complications. Much of the management of diabetes involves advice on lifestyle modification including taking regular exercise, losing weight if necessary and eating healthily. Sometimes this can be enough to reduce blood sugars to a healthy level.

However, sometimes these life style changes are not enough to reduce glucose levels, and as type 2 diabetes is progressive, medicines are also required. Insulin is a hormone produced by the pancreas which aids blood cells in taking up glucose to be used as energy. Therefore when insulin is resistant, it cannot sense glucose and energy cannot be released (2).

Currently, Exenatide (marketed as Byetta) is the choice of drug is used to treat type 2 diabetes. Upon injection, exenatide increases the secretion of insulin from the pancreas, which slows the absorption of glucose, which lowers glucose sugar levels. Interestingly, exenatide is a manmade version of a hormone found in the saliva of the Gila monster which are found in Mexico, which is more effective and slows the emptying of the stomach.

The Future

However, on 18^th October, the National Institute for Health and Clinical Excellence (NICE), the instituton which provides guidance on medication choices for diseases, recommended an exenatide based prolonged release suspension injection for type 2 diabetes. This new injection named Bydureon is manufactured by the pharmaceutical company Eli Lilly. So far however, it’s recommendation has not been finalised, this is due in February 2012. Until then the weekly injection will only be available in surgeries in which local NHS bodies have agreed to distribute Bydureon (3).

Let’s hope that NICE approve Bydureon as soon as possible so that diabetes sufferers all over the world can manage this ruthless disease in a slightly easier way. Watch this space for updates on this story.

(1)   http://www.nhs.uk/Conditions/Diabetes-type2

(2)   http://www.diabetes.org.uk/Guide-to-diabetes/Treatments/Insulin/

(3)   http://www.fiercepharma.com/press_releases/nice-recommends-long-acting-exenatide-type-2-diabetes-draft-guidance

The next medical news story will be posted tomorrow morning. This weeks post is one of celebration concerning the announcement of a new therapy that will improve the lives of 2.5 million people in the UK. Read more about this tomorrow!

About Gonorrhoea 

Gonorrhoea, also known as the clap, is a sexually acquired infection caused by transmission of the bacterium Neisseria gonorrhoeae. Gonorrhoea is the 2^nd most common bacterial STI in the UK after chlamydia (1). Whilst gonorrhoea cases in England and Wales were declining at the beginning of the decade, unfortunately despite the improved accessibility of STI clinics, since 2008 cases are now rising. According to the Health Protection Agency, in 2010 there were 16,145 new diagnoses of gonorrhoea, a 3% increase on 2009 when there were 15,606, as shown in the graph below.

Gonorrhoea is transmitted during unprotected sexual intercourse. Diagnosis of the infection is often delayed as symptoms are often mild or there are none. In both young men and women, the first sign of infection are a burning sensation when passing urine which can occur as late as 10 days after infection. If left untreated, gonorrhoea can have serious long term effects especially for women. Pelvic inflammatory disease (PID) is caused when the bacteria spread up the vagina and cervix into the reproductive tubes towards the ovaries. Here the bacteria can cause chronic abdominal pain and pain during intercourse. PID can cause ectopic pregnancies, infertility and even death. A further complication of gonorrhoea occurs when an infected woman passes the bacteria to her baby during delivery causing neonatal conjunctivitis. This can be an easily treatable infection if the mothers’ infection is detected. In few cases however, the infection can cause the babies blindness.

The Treatment

Since the first discovery of penicillin, gonorrhoea was considered an easy infection to treat. But like any bacteria, with rapid reproduction leading to evolution, gonorrhoea soon became resistant to penicillin. Since then the bacteria has gained resistance against other antibiotics such as the tetracyclines and ciprofloxacin.

The World Health Organisation recommends that the first line antibiotic used to treat the STI is changed to an alternative when resistance among gonococcal isolates reaches 5%. To determine this level, a national surveillance programme called GRASP was set up in 2000 (2). The programme collects bacteria samples from patients attending 26 different STI clinics over England and Wales. As a result of findings in 2002, GRASP ordered a change in the choice of antibiotic for gonorrhoea treatment from ciprofloxacin, to the 3^rd generation cephalospotins, cefixime and ceftriaxone. These two antibiotics were used without worry until 2009 when GRASP acknowledged a decreased susceptibility to these antibiotic, but especially cefixime the most widely used agent. In the GRASP report this year, laboratory rests on samples taken in clinics showed 17.4% of bacteria had a reduced susceptibility to cefixime compared to 10.6% the year before. It has now been released that the first cases of treatment failures have been discovered.

The Future

Doctors are now being advised to treat the infection with a combination of two drugs; azithromycin which is given orally, and ceftriazone, a more powerful antibiotic than cefixime which is given by injection. This is almost certainly a worry as treatment via injection requires more assistance and is likely to put a lot of patients off. Professor Cathy Ison from the Health Protection Agency has said on the subject;

“many patients may feel anxious about having an injection, but this is now the best way of avoiding treatment failure.” (1)

The search for new antibiotics is a lengthy and ongoing process that requires copious amounts of time and effort. We must hope that scientists can continue their research and efforts into finding new antibiotics so we may treat gonorrhoea. Until then, the importance of wearing a condom during sexual intercourse must be stressed.

(1)   http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Gonorrhoea/

(2)   http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1316016752917

Here at Medicine Weekly my aim is to provide my readers with a current and topical medical story every week. I believe that everybody should keep in touch with the latest news from the medical world as ultimately it could affect us all. My aim is to keep my readers up to date with the latest medical discoveries or controversies through a short, comprehensible article. New articles will be published every week and I look forward to any comments and feedback.