Nutan Agarwal

Cardiac disease in pregnancy

Objectives: To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country. Methods: A retrospective analysis was carried out of 207 pregnancies in women with cardiac disease who delivered at ≥28 weeks of gestation from June 1994 through December 2000 at a tertiary care center. Results: Rheumatic heart disease (n=183, 88%) with isolated mitral stenosis (n=71) was the predominant cardiac problem. Septal defects were the most common form of congenital heart disease (n=24). In 28 (13.52%) women, the diagnosis of cardiac disease was made during pregnancy. Cardiac complications were noted in 62 (29.95%) and fetal complications in 42 (20.28%) pregnancies. Patients in NYHA class I/II (n=175, 84.54%) had fewer maternal complications and their babies had a higher birth weight than those in NYHA class III/IV (n=32, 15.45%). Cardiac intervention was performed prior to pregnancy in 111 (60.65%) patients with rheumatic heart disease: PTMC/CMV in 73 and valve replacement (VR) in 38. Maternal and fetal outcome was better in patients with prosthetic valves (n=38) and the majority (97.4%) of them remained in NYHA class I/II. Cardiac intervention was safely carried out during pregnancy in 10 women (PTMC in 7, CMV in l, and VR in 2). One of them developed congestive cardiac failure during labor. None of the newborns of the 41women who had received anticoagulants had any congenital malformation. Conclusions: Rheumatic heart disease was the predominant type. Patients in NYHA class I/II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. Pregnant women with prosthetic valves tolerated pregnancy well.

Effect of oral contraceptive containing ethinyl estradiol combined with drospirenone vs. desogestrel on clinical and biochemical parameters in patients with polycystic ovary syndrome.

BACKGROUND A prospective randomized trial was conducted to compare efficacy of a drospirenone-containing combined oral contraceptives (COC) with desogestrel-containing COC in women with polycystic ovary-syndrome (PCOS) not desirous of child-bearing. STUDY DESIGN Sixty women were randomized into study group [ethinylestradiol (EE) 30 mcg+drospirenone 3 mg] and control group (EE 30 mcg+desogestrel 150 mcg), treated for 6 months and followed up at 1 month, 3 months, 6 months, during treatment and 3 and 6 months post-treatment. Acne and hirsutism scoring, bodyweight, body mass index (BMI), blood pressure (BP), ultrasound parameters, lipid profile, glycemic profile and hormonal profile were compared. RESULTS Cycles were regular in both groups during treatment. Effect of regular cycles persisted in 44.83% (13/30) vs. 17.24% (5/30) in study vs. control group at 6 months post-treatment with 33.3% decreased hirsutism score in the study group (versus no change in control group) even at 6 months after stopping treatment. With treatment, BMI fell by 0.52 kg/m(2) in the study group; systolic and diastolic BP fell in the study group while it rose in the control group. Low-density lipoprotein significantly decreased and high-density lipoprotein was elevated in the study group (p<.05). The study group showed a significant fall in fasting/postprandial blood sugar and insulin and total testosterone against a rise in the control group. CONCLUSION In women with PCOS, a drospirenone containing COC has better outcome in terms of persistent regular cycles, antiandrogenic effect, fall in BMI and BP, better lipid profile, favorable glycemic and hormonal profile than desogestrel-containing COC.

Efficacy, acceptability and side effects of the levonorgestrel intrauterine system for menorrhagia.

Objective: To evaluate the efficacy, acceptability, and possible side effects of a levonorgestrel‐releasing intrauterine system for menorrhagia. Methods: Sixty‐three women with menorrhagia but without uterine enlargement, endometrial hyperplasia with atypia, or endometrial carcinoma were enrolled in this prospective, open, nonrandomized clinical trial. An intrauterine system releasing 20 μg/day of levonorgestrel (LNG‐IUS; Mirena, Shering, Finland) was inserted in the postmenstrual phase. Menstrual pattern, number of bleeding days, and subjective and objective estimation of menstrual blood loss using a pictorial blood loss assessment chart (PBAC) were recorded before insertion and at specific intervals for 4 years. Hemoglobin levels and endometrial thickness were evaluated at baseline and at 12 months. Treatment continuation and hysterectomy rates were noted as well as side effects. Results: The device was expelled spontaneously in 6 patients (9.52%) and removed prematurely in 9 patients (14.3%); 3 patients (4.8%) were lost to follow‐up; and 45 patients (71.4%) continued with the LNG‐IUS. Menorrhagia was cured in 35 (77.7%) of these 45 patients at 3 months and in all patients at 36 months. There was a significant decrease in the mean number of bleeding days (P = 0.01) and PBAC score (P = 0.00) at 1 month, and the decrease continued with treatment duration. The subjective blood loss reduction was considerable as well, and at 12 months the mean ± SD rise in hemoglobin concentration was 1.06 ± 1.7 g/dL (P = 0.000). Endometrial thickness was decreased by 3.4 ± 3.53 mm (P = 0.0001) at 12 months. The most common side effect was intermenstrual spotting during the first 6 months, and 18 patients (28.57%) developed amenorrhea. Conclusion: Using the LNG‐IUS is an effective and well‐accepted option overall for the medical management of menorrhagia.

Role of tranexamic acid in management of dysfunctional uterine bleeding in comparison with medroxyprogesterone acetate.

Summary Currently, tranexamic acid (TXA) is used as 4 g/day in menorrhagia This prospective randomised study included 100 cases to assess efficacy and safety of 2 g/day TXA in dysfunctional uterine bleeding (DUB) vs cyclical 10 mg twice-daily medroxyprogesterone acetate (MPA) for 3 cycles. Follow-ups were made monthly for 3 months during therapy, then 3 months after. Mean pictorial blood loss assessment chart (PBAC) score decreased from 356.9 to 141.6 in the TXA group and from the pre-treatment 370.9 to 156.6 with MPA and mean reduction of blood loss was 60.3% with TXA and 57.7% with MPA after 3 months (p < 0.005 in both groups). Lack of response during treatment was seen in three patients (6.1%) TXA and in 13 patients (28.9%) with MPA (p = 0.003). In patients who reported 3 months after stopping the treatment, 66.7% in TXA group and 50% in MPA had recurrence of menorrhagia, (p = 0.155). During the 6 months study period more hysterectomies were performed in the MPA than in the TXA group (17.8% vs 4%; p = 0.002). We conclude that TXA in 2 g/day dosage is an effective and safe option in DUB.

Laparoscopic Ovarian Drilling in Clomiphene Citrate-Resistant Women with Polycystic Ovary Syndrome

STUDY OBJECTIVE To analyze the efficacy of laparoscopic ovarian drilling using monopolar diathermy in women with anovulatory infertility with clomiphene-resistant polycystic ovary syndrome (PCOS), and to determine factors influencing pregnancy rate and pregnancy outcomes. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING Infertility clinic in a tertiary referral teaching hospital. PATIENTS Seventy women with clomiphene-resistant PCOS. INTERVENTION Laparoscopic ovarian drilling, with follow-up for 4.5 years. MEASUREMENTS AND MAIN RESULTS Follow-up data, which were available for 66 patients, showed a spontaneous ovulation rate of 81.8%, cumulative ovulation rate of 93.9%, and pregnancy rate of 54.5%. Successful pregnancies were commonly complicated by gestational diabetes mellitus and pregnancy-induced hypertension. Pregnancy rates (23.5%) were low in women with tuboperitoneal disease and those whose partners had subfertile male factors. Statistical evaluation using a proportion test (Z test) and multivariable logistical regression analysis showed that elevated luteinizing hormone levels (>10 IU/L), short duration of infertility (<3 yrs), and absence of preexisting tubal disease were associated with better outcomes. CONCLUSION Laparoscopic ovarian drilling is an effective surgical procedure in women with clomiphene-resistant PCOS.

Genital tuberculosis among infertile women and fertility outcome after antitubercular therapy.

To compare modalities for diagnosing genital tuberculosis (GTB) and to assess fertility outcome after antitubercular therapy (ATT).

Efficacy of the levonorgestrel-releasing intrauterine system in uterine leiomyoma

To evaluate the efficacy of the levonorgestrel‐releasing intrauterine system (LNG‐IUS) in reducing menstrual blood loss (MBL) in myoma‐related menorrhagia and to assess the effect of the LNG‐IUS on uterine and leiomyoma volume.

Fetal foot length ― a new parameter for assessment of gestational age

Ultrasonographic measurement of fetal foot length, a new parameter, was correlated with the gestation age. One hundred and five ultrasonographic measurement of fetal foot length was performed between 13 and 42 weeks gestation. Comparison of linear regression of foot length versus gestational age demonstrated a strong correlation with an r2 value of 0.84 (P < 0.001). Ninety‐five percent confidence intervals at each week compared favorably with both biparietal diameter and femur length data. Mean foot lengths at each week of gestation compared favorably with data based on pathological specimens described in 1920 (Streeter GL: Weight, sitting height, head size, foot length and menstrual age of the human embryo. Contrib Embryol Carnegie Inst. 11: 143, 1920). Measurement of fetal foot length is of particular use when other parameters do not accurately predict gestational age, e.g. hydrocephalus, anencephaly, short limb dysplasia. It can also be used in conjunction with biparietal diameter and femur length in the management of patients with premature labor in order to accurately predict gestational age. Hence the present study demonstrates that the ultrasonographic measurement of foot length is a reliable indicator of gestational age.

In vitro sperm phagocytosis by human peritoneal macrophages in endometriosis-associated infertility

PROBLEM: The mechanism of infertility in women with endometriosis remains obscure. In this context the role of peritoneal macrophages sperm phagocytic ability in infertile women with and without endometriosis was investigated.

Six hourly vaginal misoprostol versus intracervical dinoprostone for cervical ripening and labor induction

Aim:  Prospective clinical trials were conducted to assess the safety and efficacy of 6‐hourly vaginal misoprostol versus intracervical dinoprostone for induction of labor.