A pilot study to determine whether progestogen supplementation using dydrogesterone during the first trimester will reduce the incidence of gestational hypertension in primigravidae

BACKGROUND

Gestational hypertension (GH) remains one of the main causes of high maternal and perinatal morbidity and mortality worldwide with the highest incidence among primigravidae of about 10%-15%. However, it was noted that the incidence of GH in primigravidae who conceived following assisted reproductive technique (ART) or intrauterine insemination (IUI) supplemented with dydrogesterone during the first trimester was low.

AIM

To determine whether dydrogesterone supplementation during the first trimester can reduce the incidence of GH among primigravidae.

METHOD

A prospective cross-sectional comparative study was undertaken in 2010 on 116 primigravidae (study group) who conceived following ART or IUI and supplemented with dydrogesterone up to 16 weeks gestation. They were matched for age and race at 16 weeks gestation with a control patient from the early pregnancy clinic who were primigravidae (n = 116) who conceived spontaneously without dydrogesterone supplementation.

FINDINGS

The incidence of GH in the study group was significantly lower than the control group (1.7% versus 12.9%, p = 0.001). The incidence of fetal distress was also significantly lower in the study group compared to the control group (4.3% versus 18.1%, p = 0.001).

INTERPRETATION

Dydrogesterone supplementation during the first trimester significantly reduced the incidence of GH and fetal distress in primigravidae.

GnRH agonist and GnRH antagonist in intracytoplasmic injection cycles

The long agonistic protocol for controlled ovarian hyperstimulation (COH) is effective and used most often, thus is considered the gold standard. Therefore any new regimen has to be compared in its results with those obtained with the long protocol. This report compares the efficacy of GnRH agonist and antagonist in a retrospective study of IVF/ICSI carried out in a tertiary teaching hospital from 2003 to 2006. Only the first COH cycle followed by IVF-ICSI from 200 couples (agonist = 120 and antagonist = 80) were analysed. The end points studied included the number of oocytes recovered, number of mature (MII) oocytes, fertilization, cleavage, morphology based embryo quality, pregnancy rate, quantity and cost of gonadotrophin. The average age of female subjects was 35.1 +/- 4.7 years with 50% being 35 years and above. Major infertility factors were tubal blockage, male factor and endometriosis altogether comprising 68%. GnRH agonist and antagonist cycle parameters were comparable except lesser amount of gonadotrophin was used with lower resultant costs (both p < 0.0005) in antagonistic regime. Antagonist regime produce somewhat more good quality embryos (p = 0.065), an insignificant difference. A clinical pregnancy rate per embryo transfer of 16.3% in agonist and 20.6% in antagonist regime was achieved respectively. In conclusion, GnRH antagonist protocol produced a COH response, embryonic development and pregnancy rates on par to GnRH agonist regime. Moreover GnRH antagonist protocol required a shorter stimulation period plus fewer complications. Hence GnRH antagonist regime provided means for a friendlier, convenient and cost effective protocol for patients.

Postpartum pneumomediastinum

A 21-year-old primigravida with previous history of pulmonary tuberculosis had a normal but assisted vaginal delivery after a prolonged second stage. Within 12 hours, she complained of dyspnoea and was found to have abnormal neck and anterior chest wall swelling. A diagnosis of subcutaneous emphysema was made and this was confirmed with the chest radiograph, which also revealed pneumomediastinum. She recovered well within four days with conservative treatment.

Misoprostol (alone) in second trimester terminations of pregnancy: as effective as Gemeprost?

Gemeprost (Cervagem) has been used widely compared with Misoprostol (Cytotec) alone in second trimester pregnancy termination. This prospective randomised trial was to evaluate the efficacy of intravaginal Misoprostol (alone) and Gemeprost in second trimester termination of pregnancy. A total of 54 women with 27 on each arm were involved. A total of 25 patients (92.6%) in the Misoprostol group and 22 patients (81.5%) in the Gemeprost group delivered within 48 h. The Misoprostol group delivered earlier, although average number of tablets required were similar. The side-effects were not significant between the two groups in fact, but there was more pyrexia in the Gemeprost group (p = 0.004). Misoprostol in second trimester termination of pregnancy is clinically as effective and less costly than the standard regimen of Gemeprost.

The predictive value of the zona-free hamster egg penetration test in relation to in-vitro fertilization at various insemination concentrations

The aim of the study was to evaluate the predictive value of the zona-free hamster egg penetration test (ZHEPT) for success in in-vitro fertilization (IVF) at various insemination concentrations ranging between 0.1 and >0.6 x 10(6)/ml. The ZHEPT was assessed using sperm samples from 87 couples undergoing IVF treatment. A similar test was simultaneously performed on the same semen sample following ionophore induction of the acrosome reaction (ZHEPTii test). Both the tests were poorly correlated with the fertilization rate of IVF at all the insemination concentrations except at >0.6 x 10(6)/ml, when there was good correlation between the ZHEPTii test and the fertilization rate. Following exclusion of two cases with an oocyte problem, further statistical analysis revealed that both the ZHEPT and ZHEPTii tests were poorly correlated with fertilization rate in IVF in this treatment group. This study suggests that the ZHEPT (with and without ionophore induction of the acrosome reaction) has a poor predictive value for the success of fertilization in IVF treatment at any insemination concentration.