Effects of insulin on placental, fetal and maternal outcomes in gestational diabetes mellitus

To observe the effects of exogenous insulin on placental, fetal and maternal outcomes in Gestational Diabetes Mellitus [GDM]. After screening and diagnoses [WHO criteria] 30 GDM patients[Group A] were kept on diet control and 39 GDM [Group B] who did not achieve glycemic targets were added subcutaneous insulin. Term placental weight, size, shape, consistency, fibrinoid necrosis, hemorrhages, cord color, length of the cord, completeness of membranes, weight and condition of baby and mode of delivery were assessed in 25 patients in each group. Placental weight, cord width and baby weight were found to be more in Group B, than Group A and were statistically significant with p value 0.005, 0.02 and 0.003 respectively. Ten patients in group A and 17 patients in group B had cesarean deliveries. Exogenous insulin produces significant effects on the placental, fetal and maternal outcomes in patients with GDM

Metformin prevents macrosomia and neonatal morbidity in gestational diabetes

To assess the clinical efficacy of Metformin in the prevention of fetal macrosomia and neonatal morbidity in gestational diabetes pregnancies compared with insulin treatment. In this interventional study, randomized clinical trial a total of 150 patients with gestational diabetes between 20-35 weeks of gestation were selected for pharmacological treatment using metformin or insulin during the study period form 20-Dec-2008 till 20-Dec-2010 from Antenatal OPD after screaning with 75 grams OGTT. The primary outcomes were fetal macrosomia and neonatal morbidity. Patients on metformin and insulin were matched in age, parity, BMI and gestational age at study entry. Mean birth weight did not differ in both groups but fetal macrosomia was less in metformin group than in insulin group 18.67% V/S 10.65% P < 0.05. Neonatal morbidity and NICU admissions were less in metformin group. Metformin is a safe and effective alternative to insulin in gestational diabetes. Metformin treatment resulted in less fetal macrosomia and fewer NICU admissions and neonatal morbidity with advantages of cheap oral therapy in our resource poor setting

Metformin therapy prevents early pregnancy loss in polycystic ovarian syndrome

The study was done to compare the early pregnancy loss rate in women with polycystic ovarian syndrome who received or did not receive metformin in pregnancy. A case control interventional study carried out at Civil Hospital Karachi, Hamdard University Hospital and Private Gynaecology clinics from January 2005 to July 2008. Eighty two non diabetic patients with polycystic ovarian syndrome who became pregnant were included in the study. A questionnaire was filled for all patients that included information on basic demography and mean age, parity, weight. Fasting blood sugar and serum insulin levels were done for all these women. Only patients with raised insulin levels [more than 10 mu/l] were included in the study and all were offered to use oral metformin throughout pregnancy as 500mg three times a day with folic acid supplements 5mg once daily. Those who agreed to take the drug throughout pregnancy and to comply with the therapy were taken as cases, while those who did not agree to take the medicine acted as controls. Patients with other causes of recurrent pregnancy loss were excluded from the study. All pregnancies were followed using serial ultrasound examination to see any pregnancy loss in the two groups. Eighty two cases of polycystic ovaries with pregnancy were seen during the study period. All cases had raised serum insulin levels. Fifty patients agreed to take metformin through out pregnancy while, 32 cases did not agree to take metformin during pregnancy and thus acted as controls. The two groups did not differ in mean age, parity, weight and mean fasting blood sugar levels. Fasting insulin levels were high in metformin group [18.40 mu/l] than in controls [12.53 mu/l]. Missed abortion rate was significantly lower [12%] in metformin group than in controls [28%] [p<0.028]. No congenital anomalies were found in both the groups on ultrasound at 16-19 weeks. Metformin treatment during pregnancy significantly reduced the rate of early pregnancy loss in women with polycystic ovarian syndrome. Metformin should be given during pregnancy in cases having polycystic ovarian syndrome with high insulin levels

Heart rate variability - a review

Heart rate variability [HRV] is a measure of the balance between sympathetic mediators of heart rate that is the effect of epinephrine and norepinephrine released from sympathetic nerve fibres acting on the sino-atrial and atrio-ventricular nodes which increase the rate of cardiac contraction and facilitate conduction at the atrio-ventricular node and parasympathetic mediators of heart rate that is the influence of acetylcholine released by the parasympathetic nerve fibres acting on the sino-atrial and atrio-ventricular nodes leading to a decrease in the heart rate and a slowing of conduction at the atrio-ventricular node. Sympathetic mediators appear to exert their influence over longer time periods and are reflected in the low frequency power[LFP] of the HRV spectrum [between 0.04Hz and 0.15 Hz].Vagal mediators exert their influence more quickly on the heart and principally affect the high frequency power [HFP] of the HRV spectrum [between 0.15Hz and 0.4 Hz]. Thus at any point in time the LFP:HFP ratio is a proxy for the sympatho- vagal balance. Thus HRV is a valuable tool to investigate the sympathetic and parasympathetic function of the autonomic nervous system. Study of HRV enhance our understanding of physiological phenomenon, the actions of medications and disease mechanisms but large scale prospective studies are needed to determine the sensitivity, specificity and predictive values of heart rate variability regarding death or morbidity in cardiac and non-cardiac patients

Effect of metformin on ovulation in PCOS

To evaluate the effect of metformin on ovulation in patients having Polycystic Ovarian Syndrome [PCOS]. This clinical trial was carried out in a private infertility clinic of Karachi on fifty infertile PCOS females with individual study period of 3 months. A total of 57 infertile PCOS females with ages between 20-40 years were enrolled after a written consent. Only 50 subjects completed the study. Metformin HC1 thrice daily was given to fifty infertile PCOS females with ages between 20-40 years for three months. Plasma progesterone level was done at day-0 and day-90, besides fasting serum glucose, insulin, follicle stimulating hormone, luteinizing hormone, prolactin and testosterone at day- 0 as per requirement for the diagnosis of PCOS. 33 [66%] patients developed regular cycles and 11 [22%] patients showed improvement in their cycles at day-90. Serum progesterone level showed an increase from a mean +/- SD of 1.3 +/- 0.3 to 9.5 +/- 5.1 at day-0 to day-90. On statistical evaluation it was found to be significant with P-value of 0.001. Metformin promotes ovulation in PCOS patients

Management and maternal outcome in morbidly adherent placenta

To describe the management and maternal outcome in diagnosed cases of morbidly adherent placenta. Descriptive case series. Hamdard University Hospital and Two private hospitals, from May 2005 to June 2009. All diagnosed cases of morbidly adherent placenta were analyzed. The cases were managed by elective caesarean hysterectomy and non separation of placenta at delivery. Amount of blood loss, blood transfused, ICU admission, postnatal complications and hospital stay were recorded. Thirty cases of morbidly adherent placenta diagnosed on doppler ultrasound scan were identified. Scheduled caesarean hysterectomy without attempting placenta removal, was done. Sub total hysterectomy was performed in 26 cases and total hysterectomy in remaining 4 cases. Two patients sustained urinary bladder injury and two went into DIC. One needed ventilatory support. No patient died in this series. Significantly reduced maternal morbidity was observed. In diagnosed cases of morbidly adherent placenta, antenatal diagnosis and avoidance of placental separation and caesarean hysterectomy results in better maternal outcome

Use of recombinant factor VII for massive posrtpartum haemhorrage: Case serie and review of literature

Recombinant activated factor VII is indicated mainly for the treatment of patients with haemophilia inhibitors. It has also been found successful in the treatment of platelet disorder Glanzmann's thrombasthenia. Recently, its use in trauma patients and in patients with intracereberal haemorrhage has become well established. We present three cases of massive post partum haemorrhage treated with rFVIIa, following caesarean section. The response of these three patients is discussed along with review of literature

Rupture of gravid uterus

To study the maternal morbidity and mortality and fetal outcome in cases of rupture of gravid uterus. Design: Descriptive study. Place and Duration: July 2001-June 2004 at Civil Hospital Karachi. Subject And Seventy two women with uterine rupture diagnosed on history, examination and ultrasound scan were included in the study. Outcome measures recorded included parity, gestational age, previous caesarean delivery and its indication, previous evacuation of uterus and nay other uterine surgery induction or augmentation of labour, duration of labour mal presentations, type of delivery and birth weight of baby. 4800 deliveries were conducted over a period of three years. out of which 72 patients had uterine rupture with a prevalence of 1.5%. 46 patients [63.8%] were grand multigravidae and 61 [84.7%] were non booked referrals. Previous caesarean scar was found in 44.5% of patients. 52 patients had a peripartum hysterectomy complication like hypovoemic shock [66.7%], hemorrhage [69.4%] and disseminated intravascular coagulation [25%]. Four maternal deaths occurred Perinatal mortality was 72.2%. Maternal and fetal complications can be avoided and outcome improved by early diagnosis, intensive perioperative monitoring, immediate laparotomy and proper post operative care and management of complications