Significant ACE Gene Haplotype Stipulates Development of Type 2 Diabetes in Women with Gestational Diabetes Mellitus.

Introduction: Angiotensin-converting enzyme (ACE) plays a key role in glucose and insulin regulation, and in the onset of diabetes. ACE gene polymorphisms A240T, C1237T, G2350A and I/D located in the promoter, coding and non-coding regions have been studied in both type-2 diabetes and gestational diabetes mellitus (GDM). However, their impact on the development of type-2 diabetes post GDM remains unknown, especially in under-represented population. Aim: We examined possible associations and networking between ACE gene polymorphism susceptibility / protection towards/against progression of type-2 diabetes post GDM in North Indian women. Methods: Two hundred and twenty four women (n = 224) were recruited in this study and genotyped for four ACE gene polymorphisms using polymerase chain reaction (PCR), followed by digestion through restriction endonuclease enzymes. Results: Study results suggest a significant association of ACE genes SNPs A240T, C1237T, G2350A and I/D haplotype with GDM cases progressing to type-2 diabetes later in life (P =.02). Individuals possessing haplotype “CAAI” derived from these SNPs had a 3.65 fold increased risk of type-2 diabetes development in GDM cases later in life relative to other haplotypes. Conclusion: Due to its pivotal role in the pathogenesis of both diseases, the current finding might be of future therapeutic value. Larger-scale studies are required to confirm this novel finding in multi-ethnic populations.

Intravenous iron sucrose therapy for moderate to severe anaemia in pregnancy.

Background & objectives: Iron deficiency anaemia (IDA) is the most common nutritional deficiency in pregnancy. Prophylactic oral iron is recommended during pregnancy to meet the increased requirement. In India, women become pregnant with low baseline haemoglobin level resulting in high incidence of moderate to severe anaemia in pregnancy where oral iron therapy cannot meet the requirement. Pregnant women with moderate anaemia are to be treated with parentral iron therapy. This study was undertaken to evaluate the response and effect of intravenous iron sucrose complex (ISC) given to pregnant women with IDA. Methods: A prospective study was conducted (June 2009 to June 2011) in the department of Obstetrics & Gynecology, All India Institute of Medical Sciences, New Delhi. One hundred pregnant women with haemoglobin between 5-9 g% with diagnosed iron deficiency attending antenatal clinic were given intravenous iron sucrose complex in a dose of 200 mg twice weekly schedule after calculating the dose requirement. Results: The mean haemoglobin raised from 7.63 ± 0.61 to 11.20 ± 0.73 g% (P<0.001) after eight wk of therapy. There was significant rise in serum ferritin levels (from 11.2 ± 4.7 to 69 ± 23.1 μg/l) (P<0.001). Reticulocyte count increased significantly after two wk of starting therapy (from 1.5 ± 0.6 to 4.6±0.8%).Other parameters including serum iron levels and red cell indices were also improved significantly. Only one woman was lost to follow up. No major side effects or anaphylactic reactions were noted during study period. Interpretation & conclusions: Parentral iron therapy was effective in increasing haemoglobin, serum ferritin and other haematological parameters in pregnant women with moderate anaemia. Intravenous iron sucrose can be used in hospital settings and tertiary urban hospitals where it can replace intramuscular therapy due to injection related side effects. Further, long-term comparative studies are required to recommend its use at peripheral level.

Low dose mifepristone in medical management of uterine leiomyoma - An experience from a tertiary care hospital from north India.

Background & objectives: Uterine myoma is a common indication for hysterectomy in India. An effective medical treatment option may reduce hysterectomy associated morbidity. This study was undertaken to evaluate efficacy and safety of low dose mifepristone in medical management of myoma and to compare two doses - 10 vs. 25 mg/day. Methods: In this randomized clinical trial, women with symptomatic myoma or myoma>5cm were included. Uterine size >20 wk, fibroids >15 cm were excluded. Pictorial blood loss assessment chart (PBAC) score was used to assess menstrual-blood-loss and visual analog scale (VAS) for other symptoms. Haemogram, liver function test, ultrasound with doppler and endometrial histology was performed. Patients were randomized and were given oral mifepristone as 25 mg/day in group 1 and 10 mg/day in group 2 for 3 months. Patients were followed at 1, 3 and 6 months. Results: Seventy patients in group 1 and 73 in group 2 completed treatment. Mean PBAC score reduced from 253 to 19.8 and from 289.2 to 10.4 at 1 and 3 months in groups 1 and 2, respectively. At 3 months, 67 of 70 (95.7%) patients of group 1 and 66 of 73 (90.4%) of group 2 developed amenorrhoea which reverted after median 34 (range 4-85) days. Mean myoma volume decreased by 35.7 per cent (from 176.8 to 113.7cm3) and 22.5 per cent (from 147.6 to 114.4 cm3) at 3 months in groups 1 and 2, respectively. Side effects seen were leg cramps in 7 of 70 (10%) and 5 of 73 (6.8%) and hot-flushes in 5 of 70 (7.1%) and 5 of 73 (6.8%) in groups 1 and 2, respectively. Repeat endometrial-histopathology did not reveal any complex hyperplasia or atypia in either group. Interpretation & conclusions: Mifepristone (10 and 25 mg) caused symptomatic relief with more than 90 per cent reduction in menstrual blood. Greater myoma size reduction occured with 25 mg dose. Amenorrhoea was developed in 90-95 per cent patients which was reversible. It can be a reasonable choice for management of uterine leiomyoma as it is administered orally, cost-effective and has mild side effects.

Single visit approach for management of cervical intraepithelial neoplasia by visual inspection & loop electrosurgical excision procedure.

Background & objectives: Developing a feasible and sustainable model of cervical cancer screening in developing countries continues to be a challenge because of lack of facilities and awareness in the population and poor compliance with screening and treatment. This study was aimed to evaluate a single visit approach (SVA) for the management of cervical intraepithelial neoplasia (CIN) using visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) along with loop electrosurgical excision procedure (LEEP) in women attending Gynaecology OPD in a tertiary care hospital in north India. Methods: In this hospital-based study, 450 women receiving opportunistic screening by conventional Pap cytology were also screened by VIA and VILI. VIA/VILI positive cases underwent same-day colposcopy and biopsy of all lesions. If the modified Reid score was >3, the patient underwent LEEP at the same visit. Results: Of the 450 women screened, 86 (19.1%) and 92 (20.5%) women were VIA and VILI positive, respectively. Detection rates of VIA, VILI and cytology findings at ASCUS threshold were 33.3, 35.5 and 24.4 per 1000, women, respectively to detect a lesion >CIN1. For detection of CIN2+ lesion, detection rates of VIA, VILI and cytology were 20, 22.2 and 22.2 per 1000 women, respectively. Sixteen patients with Reid score >3 underwent the See-and-treat protocol. The overtreatment rate was 12.5 per cent and the efficacy of LEEP was 81.3 per cent. There were no major complications. Interpretation & conclusions: The sensitivity of VIA/VILI was comparable to cytology. A single visit approach using visual screening methods at community level by trained paramedical personnel followed by a combination of ablative and excisional therapy can help to decrease the incidence of cervical neoplasia.

Utility of pH test & Whiff test in syndromic approach of abnormal vaginal discharge.

Background & objective: In India, National AIDS Control Organization (NACO) introduced syndromic approach to treat patients with abnormal vaginal discharge without a need for laboratory tests. Simple tools like pH test and Whiff test can be done without high expertise, microscope and even speculum. This can improve diagnostic value of syndromic approach of abnormal vaginal discharge. The present study was conducted to evaluate sensitivity and specificity of pH test and Whiff test in diagnosis of abnormal vaginal discharge, considering microscopic diagnosis as gold standard. Methods: This prospective hospital-based study included 564 women with abnormal vaginal discharge. All women were subjected to gynaecological examination, pH test and Whiff test. The findings were compared with microscopic examination. Statistical analysis was done by calculating proportions, percentage, sensitivity and specificity. Results: Vaginitis was diagnosed in 301 (53.37%) women. Bacterial vaginosis (BV) was the commonest type of vaginitis (39.01%). Cervical erosion was the second most common cause (17.91%) and physiological discharge was the third (14.36%). pH > 4.5 and positive Whiff test had sensitivity of 94.09 per cent and specificity 87.5 per cent in diagnosing BV. Similarly pH < 4.5 and positive or negative Whiff test had sensitivity of 83.72 per cent in diagnosing candidiasis. Interpretation &conclusion: pH test and Whiff test can improve diagnostic value of speculum examination where microscope facilities are not available.

Aetiology & risk factors of recurrent vaginitis & its association with various contraceptive methods.

Background & objectives: Women who do not seek treatment for recurrent vaginitis have risk to acquire other sexually transmitted infections. Besides proper antibiotic treatment, male condom acts as a barrier to various infections. Present study was done to assess type of vaginitis, its association with various contraceptive methods and need of male condom in prevention of recurrent vaginitis. Methods: Prospective hospital based cohort study with a total of 400 women with recurrent vaginitis was done. Wet mount and Gram’s staining examination were done to diagnose type of vaginitis. After treatment, proper counselling about good hygiene and use of male condom for 4 months in addition to their contraceptive method was advised. Patients were called after four months or when they developed symptoms of vaginitis. Results: Tubal ligation (38.8%) and non contraceptives (34.0%) were the most common methods used by recurrent vaginitis patients. Bacterial vaginosis (BV, 53.8%) and mixed infection (36.8%) were commonly seen infections. BV was not observed in OC pill users. Overall post-treatment cure was 89.1 per cent. Interpretation & conclusions: Our findings showed that male condom use provided protection against recurrent vaginitis and its use should be promoted with other contraceptive methods in high risk cases. Female condom may be another option.

Erythrocyte indices in pregnancy: effect of intermittent iron supplementation.

BACKGROUND: Erythrocyte indices change in pregnancy, mainly due to physiological haemodilution and iron-deficient erythropoiesis. The present study was undertaken to determine the haematological indices during different periods of gestation in women receiving daily iron supplements and compare them with those in women receiving weekly iron supplements. METHODS: Pregnant women < 20 weeks of gestation attending the antenatal clinic at the All India Institute of Medical Sciences were randomized to receive either 100 mg elemental iron daily or 200 mg elemental iron weekly. The haemoglobin, haematocrit, mean corpuscular volume, mean corpuscular haemoglobin and mean corpuscular haemoglobin concentration were estimated at baseline, after 1 month, 3 months and at 34 weeks of gestation. RESULTS: Changes consistent with physiological haemodilution in mid-term pregnancy were noted and the values at 34 weeks of gestation were not significantly different between the two groups. CONCLUSION: The effects of intermittent iron supplementation on the erythrocyte indices in pregnancy are comparable with those observed with daily supplementation.