High prevalence of early (1st trimester) gestational diabetes mellitus in Polish women is accompanied by insulin resistance similar to women with polycystic ovary syndrome (PCOS)

AIMS

Both pregnancy and polycystic ovary syndrome (PCOS) constitute insulin-resistant states that are associated with an increased prevalence of glucose intolerance. Some women demonstrate significant insulin resistance (IR) and develop gestational diabetes (GDM) even in 1st trimester. We compared surrogate IR indices in 1st trimester pregnant women and in women with PCOS (Rotterdam consensus criteria).

SUBJECTS & METHODS

We performed 75 g Oral Glucose Tolerance Test (OGTT) with insulin measurements in 106 healthy 1st trimester pregnant women at 9.9±2.6 weeks of gestation and in 418 women with PCOS. We assessed IR (HOMA-IR, QUICKI, Matsuda, Belfiore and Stumvoll indices) as well as prevalence of GDM according to the IADPSG and WHO (1999) criteria.

RESULTS

Despite slightly lower BMI (p=0.027) pregnant women had either similar (QUICKI, Belfiore index, Stumvoll0-120 min) or greater IR than women with PCOS (e.g. HOMA-IR 3.85±6.11 versus 2.64±2.04, p=0.002), while only Matsuda index demonstrated less IR in pregnant women (p=0.003). Correlation between IR indices in pregnant women showed marked variability ranging from r=0.334 (HOMA-IR versus Belfiore index) to r=-1.0 (HOMA-IR versus QUICKI, p<0.001). This was accompanied by high prevalence of GDM (14.2% and 9.4%, IADPSG and WHO criteria, respectively). Women with GDM diagnosed according to IADPSG criteria demonstrated greater IR than pregnant women without GDM. In women with GDM diagnosed according to WHO (1999) criteria these differences were visible only for OGTT-derived IR indices (Belfiore, Matsuda and Stumvoll0-120 index).

CONCLUSIONS

Depending on the choice of IR indices healthy 1st trimester pregnant women demonstrate either similar, or greater IR than women with PCOS and this is accompanied by high prevalence of early GDM. It remains to be established whether GDM screening should be performed in the 1st trimester.

Subclinical thyroid dysfunction in the first trimester of pregnancy: 'Disease' versus physiological (pulsatile) variation in TSH concentrations

BACKGROUND

There is no universal consensus regarding cut-off points for TSH in pregnancy, so concentrations of 2.5 or 4.0 mIU/L were suggested for first trimester (Endocrine Society [2012] and ATA [2017] guidelines, respectively). Yet, the impact of physiological variation in TSH secretion has not been assessed.

SUBJECTS AND METHODS

We assessed baseline concentrations of free T4, free T3 and TSH at 30-minute intervals (between 7.00 and 9.00 hours) in 110 healthy pregnant women, age 30.2 ± 6.0 years, 9.9 ± 2.4 weeks of gestation, and in 19 female controls, age 28.9 ± 10.7.

RESULTS

Mean TSH concentrations in pregnant women were 1.62 ± 1.26 mIU/L and on average varied by 39.5% (dispersion between the highest and the lowest TSH), with no difference in TSH variation between pregnant women and controls. Taking into account the highest TSH out of five consecutive measurements, TSH >2.5 mIU/L and TSH above 4.0 mIU/L were found in 23 (20.9%) and 10 (9.1%) pregnant women, respectively. In contrast, when the lowest TSH value was considered, then concentrations of TSH >2.5 mIU/L and >4.0 mIU/L were found in 14 (12.7%) and 4 (3.6%) women, respectively. This discrepancy was even more pronounced in aTPO-negative subjects (21 [21.2%] vs 8 [8.1%] women, for TSH >2.5 mIU/L, and six [6.06%] vs one [1.01%], for TSH >4.0 mIU/L). Furthermore, either six (5.4%) or 10 (9.1%) women had TSH concentrations below 0.1 mIU/L.

CONCLUSIONS

In a significant number of patients, diagnosis of subclinical thyroid dysfunction could be erroneously made not as a result of 'disease', but as a result of physiological variation in TSH concentrations.

Factors influencing inguinal hernia symptoms and preoperative evaluation of symptoms by patients: results of a prospective study including 1647 patients

Background

Current recommendations for hernia treatment suggest applying techniques aimed at reducing postoperative pain in patients experiencing intense preoperative pain. However, there is still no reliable stratification method of preoperative pain, its circumstances, intensity and frequency, and the current assessments of hernia symptoms are performed by means of a subjective evaluation. The aim of this work is to discuss preoperative pain before hernia repair and determine its nature depending on the type and length of hernia persistence and the patient’s age.

Materials and methods

The data from 1647 patients before inguinal hernia repairs (2010–2017) were registered prospectively in the National Hernia Repair Register (demographic data, pain score and influence on everyday activities).

Results

The most common symptom upon admission was pain (949 patients at rest; 57.6% and 1561 at physical activity; 94.8%). A significant influence of hernia persistence on the pain occurrence and intensity was not observed between patients with hernia < 12-months (60.8%;VAS5.0) and > 5-years (58.3%;VAS5.4) (p = 0.068). The occurrence and intensity of pain was significantly higher patients < 40-years (63.7%;VAS5.4) than patients > 60-years (54.3%;VAS4.8) (p = 0.008).

Conclusions

While pain at rest is not a significant problem, undertaking physical activities may intensify pain and increase the number of patients suffering from it. Preoperative assessment of pain may help determine the group of younger patients who could benefit the most from inguinal hernia repair. New indications for prompter admission for treatment should be planned in future studies of patients showing pain at rest for possible prevention of postoperative neuropathy.

The change in groin pain perception after transabdominal preperitoneal inguinal hernia repair with glue fixation: a prospective trial of a single surgeon's experience

Background

Although inguinal hernia is one of the most common conditions requiring surgical treatment, no reliable information is available on the quality of life of patients with inguinal hernias before surgery. Additionally, patients with intense inguinal pain prior to surgery are more susceptible to postoperative chronic pain. In such cases, less invasive laparoscopic techniques can be used, allowing atraumatic mesh fixation to reduce postoperative pain. The aim of the study was to determine, whether these treatments for patients with preoperative pain would minimize upsetting experiences after surgery.

Materials and methods

Data were gathered prospectively from the National Hernia Repair Register for 146 patients who underwent TAPP repairs in the general surgery department (2013–2016). The demographic data were recorded, the pain intensity was determined and patients described the occurrence of pain during ten everyday activities.

Results

The average surgery time was 56.4 min. The follow-up was 23.4 months. The pain before surgery was 4.28 and 12 months after surgery 0.38 (p < 0.001). Pain intensity before surgery was scored as 4.1, 4.3, and 4.9 among patients who had a hernia < 12 months, > 1 year, and > 5 years, respectively (p = 0.028). Twelve months after surgery, the pain was 0.26, 0.34, and 0.40 (p = 0.037), respectively. Patients < 40 years experienced pain before the surgery more often. The intensity of pre-/postoperative pain was significantly higher < 40 years (4.9/0.63) than > 60 years (3.8/0.29).

Conclusions

TAPP inguinal hernia repair with glue fixation significantly decreased the frequency and intensity of the pain compared to that experienced preoperatively. After TAPP repair, the influence of pain on basic everyday activities is substantially lower. Patients under 40 years of age experience frequent and intense pre- and postoperative pain. A longer hernia duration prior to surgery causes increased pre- and postoperative pain.

Outcomes of bridging versus mesh augmentation in laparoscopic repair of small and medium midline ventral hernias

BACKGROUND

Bridging of the hernia defect in laparoscopic repair (sIPOM) technique does not fully restore the abdominal wall function. Closure of hernia defect in IPOM-plus technique leads to the restoration of abdominal wall function and improved long-term treatment outcomes. Against the expectations, the studies confirm the formation of intraabdominal adhesions to the mesh. Regardless of the above, the search of the proper technique for mesh implantation and fixation is still ongoing. There have also been attempts to identify groups of patients who may still benefit from IPOM procedure.

MATERIALS AND METHODS

Patients with midline abdominal wall hernias up to 10 cm wide were enrolled in the study except for subxiphoid and suprapubic hernias. Between 2011 and 2014 we performed 82 hernia repairs using the laparoscopic technique with Physiomesh. Patients were divided into sIPOM and IPOM-plus groups. The study included 44M and 38F patients aged 27-84 years. After 12-months and again in August 2015 a survey was posted to all patients with questions regarding potential recurrence.

RESULTS

After 12 months, eight patients (20 %) in sIPOM group reported subjectively perceived recurrence and none in IPOM-plus group (p = 0.002). Six patients (14.3 %) in sIPOM group reported suspected recurrence, as compared to three patients (7.1 %) in IPOM-plus group (p = 0.13). These patients were invited for a follow-up physical examination and sonography. Eventually, four cases of hernia recurrence were confirmed in sIPOM group (10 %) and none in IPOM-plus group (p = 0.018). Other patients presented with mesh bulging.

CONCLUSIONS

Laparoscopic ventral hernia repair is generally safe and is associated with the low recurrence rate. Closure of fascial defects before mesh insertion offers better treatment outcomes. Non-closure of fascial defects with only bridging of the hernia defect (sIPOM) causes more frequent recurrence and bulging. As a result, patient satisfaction with treatment is lower, and they are concerned about hernia recurrence.