Prevalence of metabolic syndrome in pre- and post-menopausal women: A prospective study from apex institute of North India

Background:

The metabolic syndrome (MS) (syndrome X, insulin resistance syndrome) is a constellation of metabolic abnormalities and a complex predisease state that predicts future development of type 2 diabetes mellitus and cardiovascular disease. Menopausal transition and postmenopausal state are considered as a vulnerable period for developing MS, and this increased risk has been attributed to decreasing estrogen levels with an increasing risk of insulin resistance following menopause.

Aims and Objectives:

This study aimed to determine the prevalence of MS and its components in pre- and post-menopausal women from North India.

Methodology:

This is a cross-sectional study of 350 women in the age group of 45–55 years attending gynecology clinic in a tertiary center of North India. Details of sociodemographic data, menopausal history, reproductive, and medical profile were obtained. Then, waist circumference, body mass index (BMI), and blood pressure were recorded. A venous blood sample was collected for fasting blood glucose, triglycerides, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol. MS was defined according to the modified National Cholesterol Education Program Adult Treatment Panel III criteria.

Results:

The mean age was 49.09 ± 2.2 years in premenopausal and 49.54 ± 2.8 years in postmenopausal women. The prevalence of MS in the study group was 62.6%. Occurrence of MS was higher in older and obese women. Abnormal waist circumference was the most prevalent component (87%) of MS and in terms of odd ratio, correlation was highest for BMI followed by total cholesterol and waist-hip ratio.

Conclusion:

We should target obesity and deranged lipid profile by bringing out changes in lifestyle and dietary habits to decrease the higher prevalence of MS and the risk of cardiovascular diseases.

The protective role of the -1306C>T functional polymorphism in matrix metalloproteinase-2 gene is associated with cervical cancer: implication of human papillomavirus infection

Cervical cancer is the major reproductive health problem among women caused by persistent infection of high-risk human papillomavirus (HR-HPV). Metalloproteinase-2 (MMP-2) is an endopeptidase highly expressed in cervical cancer; however, the genetic link between aberrant expression of MMP-2 and cervical carcinogenesis is not known. The genotypic distribution, expression pattern of MMP-2 and HPV infection, was analyzed in a total of 300 fresh surgically resected cervical tissue biopsies. The MMP-2 C1306T (rs243865) promoter polymorphism dominant model (CC v/s CT + CT + TT) revealed that the CC genotype had a 4.33-fold significant increased risk for development of cervical cancer (OR = 4.33; 95 % CI = 2.36-4.02, p = 0.0001) compared to those with variant genotypes (-1306 CT + TT). The C allele was associated with 3-fold significant increased risk (OR = 2.95; 95 % CI = 1.90-4.60, p = 0.0002) compared to T allele. Interestingly, a significant correlation was found between high expression of MMP-2 protein and CC genotype in cancer patients (p = 0.001) compared to normal controls (p = 0.012). Further analysis showed that the risk of cancer was extremely pronounced in HPV positive patients (OR = 9.33; 95 % CI = 2.88-30.20, p = 0.0001) compared to HPV negative ones, implicating the possible interaction between -1306CC genotype and HPV infection in increasing the cancer risk (p = 0.0001). The leads from the present study suggest the protective role of gene variant -1306C>T at the promoter region of the MMP-2 against HPV-mediated cervical cancer. These findings substantiate the functional role of MMP-2 C1306T polymorphism in a significant downregulation of MMP-2 protein in women with variant genotype (CT/TT) compared to the normal wild CC genotype.

Endometriosis presenting as carcinoma colon in a perimenopausal woman

Endometriosis is a common benign disease of reproductive age women, and can involve the intestinal tract. Inconsistent clinical presentation, similar features on radiological imaging and colonoscopy with other inflammatory and malignant lesions of the bowel makes the preoperative diagnosis of bowel endometriosis difficult. We present a case of a 42-year-old perimenopausal female clinically presented, investigated and managed in the lines of carcinoma of sigmoid colon. She underwent terminal ileac resection with end to end anastomoses, Hartmann's procedure and total hysterectomy with bilateral salpingoophorectomy. The histopathological report revealed endometriosis of small intestine, large intestine, mesentery, right ovary and adenomyoma of uterus. Thus, bowel endometriosis should also be considered as differential diagnosis in reproductive age women with gastrointestinal symptoms or intestinal mass of uncertain diagnosis.

Pregnancy with Irreducible Utero-Vaginal Prolapse

Pregnancy with uterine prolapse is a relatively rare condition. Irreducible prolapse occurring during pregnancy is even rarer. There is still a need for obstetricians to be aware about the management of uterine prolapse which allows for an uneventful pregnancy, labour and delivery. Here we present a case of a woman who developed irreducible uterine prolapse during pregnancy and the issues surrounding its management. We had to abort her pregnancy to reduce her prolapse which could otherwise have been life threatening.

Distinguishing Myasthenia Exacerbation from Severe Preeclampsia: A Diagnostic and Therapeutic Challenge

Myasthenia gravis is an acquired, autoimmune neuromuscular disorder characterized by voluntary muscle weakness. Pregnant patients may have disease exacerbation, respiratory failure, crisis, adverse drug reaction, surprisingly enough remission at any trimester or postnatal period. Concurrence of myasthenia gravis with severe preeclampsia is a dreadful condition raising diagnostic and management issues. We hereby discuss a case of myasthenic woman who developed severe preeclampsia during pregnancy and presented in last trimester with clinical features mimicking signs of impending eclampsia. Keeping in mind the history of myasthenia gravis, urgent neurology review taken and diagnosis of myasthenic exacerbation was entertained. She responded well to injection neostigmine and in this way inadvertent use of magnesium sulphate was avoided.

Liquid-based cytology versus conventional cytology for evaluation of cervical Pap smears: experience from the first 1000 split samples

CONTEXT AND AIM

Screening programs using conventional cytology conventional Pap smear (CPS) have successfully reduced cervical cancer, but newer tests like liquid-based cytology (LBC) and human papillomavirus testing might enhance screening. The main aim of the present study was to assess the diagnostic accuracy of LBC versus CPS using "split samples."

MATERIALS AND METHODS

This was a prospective study comprising of 1000 consecutive cervical "split samples" over a period of 1 year. Split sample was obtained using cervex-brush. CPS was prepared from the brush and the brush head was suspended in the LBC vial and processed by SurePath™ LBC.

RESULTS

There were 4.3% unsatisfactory (U/S) cases in CPS and 1.7% in LBC; the main cause is insufficient cells, and excess of blood in CPS. About 25/100 (2.5%) split samples had epithelial abnormalities both in CPS and LBC (1.2%-atypical squamous cells of undetermined significance; 0.4%-low grade squamous intraepithelial lesion; 0.2%-high grade squamous intraepithelial lesion; 0.5%-squamous cell carcinoma; 0.1%-atypical glandular cells favouring neoplasia; 0.2%-adenocarcinoma). Inflammatory organisms were almost equally identified in both techniques but were better seen in LBC samples.

CONCLUSIONS

LBC technique leads to significant reduction of U/S rate. LBC samples offered better clarity, uniform spread of smears, less time for screening and better handling of hemorrhagic and inflammatory samples. LBC had equivalent sensitivity and specificity to CPS.

Involvement of the family members in caring of patients an acute care setting

BACKGROUND

Family members are critical partners in the plan of care for patients both in the hospital and at home. Involving the members of the family in acute care can help the nursing staff in emergency. The present study was aimed to find out the role of the family members while caring for the patients admitted in emergency unit of a tertiary care hospital.

MATERIALS AND METHODS

A total of 400 family members of the patients were conveniently selected. Only one member per family was interviewed and their role in taking care of the patient in acute care setting was evaluated.

RESULTS

The mean age of patients admitted in acute care setting was 46.6 yrs ± 18.8 with the age range of 18-84 years. Majority (39%) of the patients were in the age group of 31-60 years. More than half of the caregivers of patients were males and 88% of them were first-degree relatives. The major tasks performed by the caregivers during the patient care was communicating with doctors/ nursing staff (98%), cleaning and dressing the patient (94%), feeding the patient (90%), procuring medication and other supplies (88%), administering oral medications (74%), changing position and helping for back care (65%), shifting the patients for investigations (60%), collecting reports (35%) and providing physiotherapy (25%).

CONCLUSIONS

The results of the study concluded that family involvement in acute care setting can help the nursing staff in taking care of the patient in acute care setting and it also provides the opportunity for preparing them for after care of the patients at home following discharge.

Characterization of Toll-like receptor transcriptome in squamous cell carcinoma of cervix: A case-control study

OBJECTIVE

Human papillomavirus (HPV) is a proven etiological agent for cervical cancer However, not all HPV infections result in cervical cancer. The mechanisms of host immune system to prevent/control HPV infection remain poorly understood. Toll-like receptors (TLRs) are a system of innate immune defense. HPV has been demonstrated to modulate TLR expression and interfere in TLR signaling pathways, leading to persistent viral infection and carcinogenesis. The aim was to study the relative gene expression of TLRs in cervical squamous cell carcinoma (SCC).

METHODS

Gene expression profile of TLRs 1 to 9 was examined in 30 cervical SCCs and an equal number of normal cervical tissue samples using a PCR array platform. Gene expression studies for TLRs 3 and 7 were validated by western blotting.

RESULTS

HPV was detected in all cases and in none of the controls (p<0.0001). HPV16 was the preponderant (83.3%) subtype. A significant downregulation in the relative gene expression of TLR3 (p<0.0001), TLR4 (p<0.0005) and TLR5 (p<0.0001) was observed in cases. A significant upregulation for TLR1 was observed (p=0.006). Although TLRs 2, 7, 8 and 9 were upregulated and TLR6 was downregulated, it was not significant. The western blot performed with antibodies against TLRs 3 and 7 confirmed the findings of the gene expression studies.

CONCLUSIONS

A significant downregulation in the gene expression of TLRs 3, 4 and 5 and upregulation of TLR1 was observed in cervical SCC as compared to controls. Study results evoke the proposition for investigating TLRs 3, 4 and 5 agonists for therapeutic exploration.

Management of Endometrial Cancer: A Review

Endometrial cancer is the most common malignancy of the female genital tract in developed countries and second to cervical cancer in India. Endometrial cancer predominately affects post menopausal women; however 15-25% of cases are diagnosed before menopause. Endometrial cancer is not amenable to screening, hence needs to be managed effectively as soon as diagnosis is made. Though quite a lot of studies have been conducted in this area, still there are controversies regarding few issues in its management. We decided to review the current literature on use of imaging techniques in diagnosing and assessing loco regional spread, mode of surgery, role of lymphadenectomy in early stage disease including sentinel lymph node status, adjuvant treatment and fertility preservation in women with endometrial cancer. Transvaginal ultrasound and MRI help in diagnosing the disease as well as locoregional spread of the tumor. Laparoscopy is replacing the conventional laparotomy without any increase in complication rate. Robotic technology being new has not been critically evaluated. Role of lymphadenectomy in early disease is still controversial. Only few studies have assessed the place of sentinel lymph node biopsy in the management of endometrial cancer. Fertility preservation in young women is the need of the hour and has been used with successful pregnancy outcome. There is need for more randomized controlled trials to clarify certain issues regarding management of endometrial cancer and on-going trials such as PORTEC3 and LACE may answer these queries.

Direct sampling of metastatic ovarian carcinoma masquerading as endocervical adenocarcinoma in liquid-based cytology cervical sample

Cervical sample is routinely taken to identify squamous dysplastic lesions of the cervix. Glandular lesions are far less commonly reported on cervical samples. The most common glandular lesion reported on cervical smear is endocervical adenocarcinoma, followed by endometrial adenocarcinoma. Direct sampling by Cervex brush is possible even in endometrial adenocarcinoma, if the tumor directly involves lower uterine segment/endocervical canal. Metastases to cervix are rare but have occasionally been reported in previous reports. We wish to highlight in this case, metastatic ovarian carcinoma directly sampled in cervical liquid-based cytology (LBC) sample, which mimicked cytomorphologically a well-differentiated endocervical adenocarcinoma. To the best of our knowledge, a similar case has not been previously published in SurePath LBC sample.

The Accuracy of Integrated [(18)F] Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography in Detection of Pelvic and Para-aortic Nodal Metastasis in Patients with High Risk Endometrial Cancer

Lymph nodal (LN) metastasis is the most important prognostic factor in high-risk endometrial cancer. However, the benefit of routine lymphadenectomy in endometrial cancer is controversial. This study was conducted to assess the accuracy of [¹⁸F] fluorodeoxyglucose-positron emission tomography/computed tomography ([¹⁸F] FDG-PET/CT) in detection of pelvic and para-aortic nodal metastases in high-risk endometrial cancer. 20 patients with high-risk endometrial carcinoma underwent [¹⁸F] FDG-PET/CT followed by total abdominal hysterectomy, bilateral salpingo-oophorectomy and systematic pelvic lymphadenectomy with or without para-aortic lymphadenectomy. The findings on histopathology were compared with [¹⁸F] FDG-PET/CT findings to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of [¹⁸F] FDG-PET/CT. The pelvic nodal findings were analyzed on a patient and nodal chain based criteria. The para-aortic nodal findings were reported separately. Histopathology documented nodal involvement in two patients (10%). For detection of pelvic nodes, on a patient based analysis, [¹⁸F] FDG-PET/CT had a sensitivity of 100%, specificity of 61.11%, PPV of 22.22%, NPV of 100% and accuracy of 65% and on a nodal chain based analysis, [¹⁸F] FDG-PET/CT had a sensitivity of 100%, specificity of 80%, PPV of 20%, NPV of 100%, and accuracy of 80.95%. For detection of para-aortic nodes, [¹⁸F] FDG-PET/CT had sensitivity of 100%, specificity of 66.67%, PPV of 20%, NPV of 100%, and accuracy of 69.23%. Although [¹⁸F] FDG-PET/CT has high sensitivity for detection of LN metastasis in endometrial carcinoma, it had moderate accuracy and high false positivity. However, the high NPV is important in selecting patients in whom lymphadenectomy may be omitted.

Menopause and oral health

Different phases of a woman's life: Puberty, menses, pregnancy, and menopause have varied influence on her oral health. During the menopause, women go through biological and endocrine changes, particularly in their sex steroid hormone production, affecting their health. Because the oral mucosa contains estrogen receptors, variations in hormone levels directly affect the oral cavity. A few oral conditions and or diseases are seen more frequently during post menopausal years. Role of hormones affecting the health of oro-dental tissues, as well as treatment by HRT in ameliorating these conditions is not clear. There is paucity of randomized controlled trials in this field and more data is needed, before the recommendations for oral health care in post menopausal women can be made. A gynecologist sitting in menopausal clinic should be aware of oral changes happening during this period, and dental needs of these women and should refer them to the dental specialists accordingly. On the other hand, a dentist should also be sensitized about the menopausal status of the woman, her HRT status and special preventive and treatment needs.

Are we missing hypertrophic cardiomyopathy in pregnancy? Experience of a tertiary care hospital

BACKGROUND

Controversies persist regarding risks associated with pregnancy and delivery in women with hypertrophic cardiomyopathy (HCM). To date, pregnancy outcome data for these patients is scarce. We report the experience of pregnancies with HCM in a tertiary care hospital.

MATERIALS AND METHODS

Data regarding cardiac illness and obstetric profile of all women attending the cardio-obstetrics clinic from January 1990 to December 2012 were studied. The records of cardiac illness of all women were checked and all patients with HCM were included in the study.

RESULTS

Out of total 2016 patients booked in the cardio-obstetrics clinic between 1990 and 2012, only 4 women were found to have a diagnosis of HCM (0.2%). Of these, 2 women with left ventricular outflow tract obstruction and one with non-obstructive HCM had only mild symptoms and tolerated pregnancy and labour well. One patient had HCM with restrictive physiology developed heart failure and intra-uterine fetal death.

CONCLUSION

HCM is underdiagnosed and rarely identified in pregnancy. Most patients with HCM tolerated pregnancy well, howeverone patient with restrictive physiology developed heart failure during her first pregnancy.

Multiple intracranial space-occupying lesions in a renal transplant recipient from an area endemic for tuberculosis (TB): TB vs. toxoplasmosis

Renal transplant recipients may present with intracranial space-occupying lesions (SOLs) due to infections as well as a post-transplant lymphoproliferative disorder (PTLD). Here, we discuss a renal transplant recipient who presented with neurologic symptoms and magnetic resonance imaging (MRI) of the brain showed multiple focal SOLs. Tuberculosis (TB), toxoplasmosis, nocardiosis, fungal infections, and PTLD were considered in the differential diagnosis. MRI spectroscopy was suggestive of an infectious cause, such as toxoplasmosis or TB. Serologic tests using Toxoplasma were negative. A brain biopsy followed by immunohistochemical staining using Toxoplasma antibody demonstrated multiple intravascular cysts of toxoplasma. This case highlights the diagnostic dilemma in an immunocompromised patient with multiple focal brain lesions, especially in areas where TB is endemic.

Antioxidant effect of isoflavones: A randomized, double-blind, placebo controlled study in oophorectomized women

Background:

One of the postulated mechanism for cardioprotective potential of isoflavones is their ability to exert antioxidant action. However, various reports give conflicting results in this area.

Aim:

The present study was conducted with an objective to probe into the cardioprotective mechanism of isoflavones by evaluating their antioxidant potential in oophorectomized women.

Materials and Methods:

This was a randomized, double-blind, parallel, placebo controlled study. A total of 43 women were randomized to receive 75 mg/day isoflavones tablet or placebo for 12 weeks. Red blood cell antioxidant parameters including lipid peroxidation, superoxide dismutase (SOD), catalase and glutathione peroxidase (GSH-Px) were determined at baseline and at the end of the study.

Results:

After 12 weeks of administration of isoflavones, there was no statistically significant difference in lipid peroxidation (P value for isoflavones: 0.37; for placebo: 0.37), catalase (P value for isoflavones: 0.35; for placebo: 0.84), SOD (P value for isoflavones: 0.41; for placebo: 0.28) and GSH-Px (P value for isoflavones: 0.92; for placebo: 0.29). There was no statistically significant difference in the proportion of patients experiencing adverse events in the two groups (P -1.00).

Conclusion:

The study strengthens the concept that the cardioprotective mechanism of isoflavones might be due to some other reason apart from the antioxidant pathway.

Pregnancy outcome in hyperthyroidism: a case control study

BACKGROUND

Data comparing pregnancy outcome in hyperthyroid women with euthyroid women are scarce. Hence, this study was carried out to assess the maternal and fetal outcome in pregnant women with hyperthyroidism to ascertain the effect of disease on pregnancy.

METHODOLOGY

This retrospective study was conducted over a period of 28 years. We compared the maternal and fetal outcomes of 208 hyperthyroid women with 403 healthy controls, between women with well-controlled and uncontrolled disease and amongst women diagnosed with hyperthyroidism before and during pregnancy.

RESULTS

Maternal outcome: women with hyperthyroidism were at increased risk for preeclampsia (OR = 3.94), intrauterine growth restriction (OR = 2.16), spontaneous preterm labor (OR = 1.73), preterm birth (OR = 1.7), gestational diabetes mellitus (OR = 1.8), and cesarean delivery (OR = 1.47). Hyperthyroid women required induction of labor more frequently (OR = 3.61). Fetal outcome: newborns of hyperthyroid mothers had lower birth weight than normal ones (p = 0.0001). Women with uncontrolled disease had higher odds for still birth (OR = 8.42; 95% CI: 2.01-35.2) and lower birth weight (p = 0.0001).

CONCLUSIONS

Obstetrical complications were higher in women with hyperthyroidism than normal women. Outcome was worsened by uncontrolled disease. Women with pregestational hyperthyroidism had better outcomes than those diagnosed with it during pregnancy.

Familial dermal eccrine cylindromatosis with emphasis on histology and genetic mapping

Familial cylindromatosis (FC) is an autosomal dominant disorder with apparently complete penetrance, but variable expression. There is an increasing evidence that FC is clinically, genetically, and histologically heterogeneous disorder as the simultaneous occurrence of cylindromas and other tumors of skin appendages within the affected individuals and families. The presence of multiple scalp cylindromas is often associated with autosomal dominant Brooke-Spielger syndrome, a condition in which there are co-existent facial trichoepitheliomas and spiradenomas. We present here a case of multiple cylindromatosis in a family affecting many members successively.

Colloid cohydration and variable rate phenylephrine infusion effectively prevents postspinal hypotension in elective Cesarean deliveries

Background:

Prevention of post-spinal hypotension in obstetric patients can be accomplished using intravenous fluid expansion and prophylactic use of sympathomimetic drugs. The affect of combination of colloids and phenylephrine infusion on maternal hemodynamics has not been widely studied and there is no consensus about the dosage required and time of starting its administration.

Materials and Methods:

This prospective, randomized, double-blind study enrolled 90 healthy term parturients undergoing elective Cesarean delivery under lumbar subarachnoid block (0.5% hyperbaric bupivacaine 10 mg with fentanyl 25 μg). Patients in Group A received prophylactic intravenous phenylephrine infusion (60 μg/minute) along with hydroxyl-ethyl-starch cohydration (6% HES 130/0.42;15 ml/kg) immediately after subarachnoid block. In Group B, patients received 6% HES cohydration and intermittent intravenous 50 μg boluses of phenylephrine. The efficacy of these in maintaining maternal SBP at 90-110% of baseline and neonatal well-being was evaluated.

Results:

In Group B, 75.5% of patients required rescue phenylephrine boluses to maintain SBP while maternal hemodynamics were well maintained in Group A and rescue drug was not needed. Reactive hypertension occurred in one patient (2.2%) and bradycardia in two patients (4.4%) in Group A. Six patients complained of nausea in Group B (13.3%) compared to one in Group A. All the newborns had normal Apgar scores and Umbilical arterial pH > 7.2.

Conclusion:

A combination of colloid cohydration and prophylactic phenylephrine infusion initiated at 60 μg/minute maintained maternal hemodynamics and neonatal well-being during Cesarean deliveries requiring minimum interventions by the anesthesiologist.

Thrombotic thrombocytopenic purpura in the first trimester of pregnancy

Thrombotic thrombocytopenic purpura (TTP) occurs more commonly in women and so can be associated with pregnancy. The time during pregnancy with greatest risk for development of TTP is near term and during the post partum period. TTP occurring in early trimester is uncommon and is also associated with great maternal and fetal mortality. We report a successful outcome of pregnancy in a woman with TTP in early first trimester who was treated with therapeutic plasma exchange.

Obstetric cholestasis: outcome with active management

AIM

To study the nature and clinical outcome of pregnancies with obstetric cholestasis on active management and to correlate perinatal outcome to gestational age at delivery.

MATERIAL AND METHODS

This prospective randomized study included 69 women with obstetric cholestasis. Fetal surveillance began at 34 weeks or later at diagnosis and included daily maternal record of fetal movements, and biophysical profile (i.e. non stress test, the four quadrant amniotic fluid index). Fetal monitoring was conducted weekly before 36 weeks and biweekly after that. Randomization into two groups was done where one group was planned for delivery at 37 weeks whereas in the other group, pregnancy was carried to 38 weeks under surveillance. The primary outcome variable was correlation of fetal and neonatal complication rates to gestational age at delivery.

RESULTS

There were no stillbirths in the study. No episode of fetal asphyxia or bradycardia was observed. The overall rate of meconium passage was 7.46% (5/67). However, there was no case of meconium aspiration syndrome. Women delivering at or after 38 weeks had a lower incidence of cesarean section (17.85% vs 25.8%), neonatal nursery admission (17.85% vs 22.5%), and neonatal jaundice (17.85% vs 19.35%) compared to those delivering at 37 weeks. The differences between the two groups were, however, not found to be statistically significant.

CONCLUSION

The current study demonstrates that with active intervention, pregnancies with obstetric cholestasis can be carried to a later gestation under surveillance.

Placenta percreta: rare presentation of haemorrhage in the second trimester

A 25-year-old woman, third gravid, with previous two miscarriages presented to the emergency at 17 weeks 2 days of gestation with complaints of pain in the abdomen for 1 day and decreased urine output for 2 days. She was in shock. There was no history of bleeding per vaginum, trauma, surgical procedure or medical illness. Her obstetrical history was marked by a spontaneous second trimester miscarriage at 24 weeks that was followed by fever for 1 week. Ultrasound revealed an extra uterine fetus with sac en caul secondary to uterine rupture. She was resuscitated and taken up for emergency salvage laparotomy. The ragged fundal rent was excised and uterine reconstruction was performed. Histology revealed placenta percreta. The patient had a rapid recovery.

Usefulness of fetal monitoring in intrahepatic cholestasis of pregnancy: a prospective study

AIM

To study the role of fetal surveillance in intrahepatic cholestasis of pregnancy.

MATERIALS AND METHODS

A total of 69 women with obstetric cholestasis were included. Fetal surveillance began at 34 weeks or later at diagnosis and included daily maternal record of fetal movements, biophysical profile (i.e., non-stress test, amniotic fluid volume assessment using the four quadrant amniotic fluid index), and Doppler flow velocimetry. Fetal monitoring was done weekly before 36 weeks and biweekly after that.

RESULTS

There were no abnormal non-stress test readings and all pregnancies had good biophysical profile. One hundred and sixty Doppler measurements [Systolic-Diastolic (S/D ratio) and Pourcelot index (PR)] were taken from 67 patients at scheduled intervals during the study period. Findings were compared to gestation matched reference values of Doppler flow velocities of umbilical artery of normal pregnant population. Fifty-six out of 160 PR indices and 33 out of 162 S/D ratio readings were above 2 SD and these results were found to be statistically significant. However, there was no significant correlation with the serum levels of alanine transaminase (r=-0.071) or with aspartate transaminase (r=0.058). Further, there was no correlation of Doppler with rates of preterm delivery or meconium-stained liquor.

CONCLUSION

Doppler investigation of the umbilical artery might be of some value in recognition of the specific risk of fetal compromise in pregnancies complicated by intrahepatic cholestasis.

A new objective scoring system for the prediction of successful induction of labour

A prospective study was done in 311 women undergoing induction of labour for the formulation of a new score, which will be more objective than the conventional Bishop's score. Pre-induction cervical assessment was done by the transvaginal sonographic parameters followed by the digital examination. Labour induction was successful in 79.09%. A new score was formulated using the parameters having independent association and weighting of individual components was given according to its regression coefficients. A new score with a maximum value of 13 was proposed. The best cut-off point for the new score in receiver operating characteristics curve was six with a sensitivity of 95.5% and specificity of 84.6%. The new score was found to have a better area under the curve than the conventional score.

Tamoxifen: An alternative to clomiphene in women with polycystic ovary syndrome

BACKGROUND:

Clomiphene citrate is commonly used for ovulation induction in women with anovulatory infertility. However, pregnancy rates with this drug are not as good as ovulation rates. Tamoxifen may be a better choice in some patients who fail to either ovulate or conceive with clomiphene due to its favorable effect on the cervical mucus and endometrium. This study was conducted to evaluate the role of tamoxifen in women with anovulatory infertility and find out the optimum dose needed for achieving the best outcome.

MATERIALS AND METHODS:

160 women attending the infertility clinic and suffering from anovulatory infertility were recruited for the study. Tamoxifen was administered in the dose of 40 mg daily and ovulation monitored. In case of anovulation, the dose was increased to 80 mg daily. Ovulation and pregnancy rates were calculated.

RESULTS:

Twenty-three out of 160 women who received 40 mg of tamoxifen conceived, giving a pregnancy rate of 14.38% and pregnancy rate per ovulatory cycle as 14.94%. 32 out of 80 women who received 80 mg of tamoxifen conceived, giving a pregnancy rate of 40% and pregnancy rate per cycle as 33.68%. This difference in the pregnancy rate between the two groups was statistically significant. 35 women out of 90 with polycystic ovary syndrome (PCOS) became pregnant with a pregnancy rate of 38.8% and 20 out of 70 women with clomiphene citrate failure conceived, giving a pregnancy rate of 28.5%.

CONCLUSIONS:

Tamoxifen is a good alternative to clomiphene in women with PCOS and clomiphene-resistant cases.