Prevention of gestational diabetes mellitus by continuing metformin therapy throughout pregnancy in women with polycystic ovary syndrome.

AIM: The aim of the present study was to assess whether continuation of metformin therapy throughout pregnancy can reduce the development of gestational diabetes in women with polycystic ovarian syndrome (PCOS). METHODS: This experimental study was conducted in a private tertiary level infertility care center between June 2002 and December 2006. Fifty-nine non-diabetic PCOS patients who conceived while taking metformin and different ovulation-inducing agents comprised the sample group. Twenty-nine of them continued metformin throughout pregnancy and 30 did not The main outcome measure was development of gestational diabetes in women with PCOS and their fetal outcome. RESULTS: Basic parameters such as age, body mass index, levels of follicle-stimulating hormone and luteinizing hormone, free testosterone, dihydroepiandrosterone sulfate, fasting sugar and fasting insulin did not differ between the two groups. Among 29 women who received metformin, gestational diabetes developed during one of 29 pregnancies (3.44%) versus nine of 30 pregnancies (30%) without metformin. The odds ratio for gestational diabetes in women without metformin versus with metformin was 12 (95% confidence interval: 6.20-18.08). All babies born in the metformin group had average birthweight and those in the control group 4 (13.33%) were large for date. CONCLUSION: In PCOS use of metformin throughout pregnancy is associated with and might be responsible for a ninefold reduction (30-3.44%) of gestational diabetes.

Comparison of efficacy of aromatase inhibitor and clomiphene citrate in induction of ovulation in polycystic ovarian syndrome.

OBJECTIVE: To compare the effectiveness of letrozole and clomiphene citrate (CC) in induction of ovulation in polycystic ovary syndrome (PCOS). DESIGN: Prospective, randomized, not blinded, controlled trial. SETTING: A tertiary level infertility care center. PATIENT(S): Sixty-four anovulatory patients with PCOS, who failed to ovulate when taking 100 mg/day CC in previous cycles. INTERVENTION(S): Patients were randomly divided into two groups by lottery and treated with either 7.5 mg/day letrozole (an aromatase inhibitor) or 150 mg/day CC for 5 days starting from day 3 of the menstrual cycle. MAIN OUTCOME MEASURE(S): Occurrence of ovulation, endometrial thickness, and pregnancy rate (PR). RESULT(S): Twenty (62.5%) patients from the letrozole group and 12 (37.50%) patients from the CC group ovulated during the observation period. Mean serum E2 level was 817.75 pg/mL and 448.03 pg/mL in the CC and letrozole groups, respectively, on the day of hCG administration. The mean endometrial thickness on the day of hCG administration was 9.03 mm and 10.37 mm in the CC and letrozole groups, respectively. The mean D21 serum P was 13.09 ng/mL and 19.09 ng/mL in the CC and letrozole groups, respectively. Thirteen patients from the letrozole group (40.63%) and six patients from the CC group (18.75%) became pregnant. CONCLUSION(S): Letrozole has better ovulation and PR in comparison to CC in patients with PCOS.

Role of aromatase inhibitor in ovulation induction in patients with poor response to clomiphene citrate.

AIM: To examine the efficacy of aromatase inhibitor in the induction of ovulation. METHODS: This prospective clinical trial in patients with infertility and poor response to clomiphene citrate (CC) was undertaken in a tertiary referral infertility clinic. Thirty-five infertile patients, who were treated by clomiphene citrate for several cycles and referred to the infertility clinic, were the target population. Initially, the response of CC was assessed by same dose of CC that the patient had in her last cycle. The patients who did not respond adequately were treated by aromatase inhibitor 2.5-5 mg/day from day 3-7 of the menstrual cycle. The main outcome measures were the number of mature follicles, ovulation rate, endometrial thickness and pregnancy rate. RESULTS: Twenty-seven (90%) patients developed mature follicles by day 12. The majority (77.77%) developed single follicle. Except for one cycle of one patient, the follicles of all patients were ruptured in all cycles and seven (25.94%) got pregnant. CONCLUSION: The aromatase inhibitor letrozole is effective for ovulation induction in anovulatory infertility in patients that failed to ovulate by CC.

Eclampsia: still a problem in Bangladesh.

This descriptive study, conducted at Dhaka Medical College and Hospital, Bangladesh, includes 2956 consecutive eclamptic patients who were admitted between 1998 and 2000 and evaluates their outcomes after treatment with magnesium sulfate. Although magnesium sulfate controls convulsion efficiently, death from eclampsia remains high in our country. Thus, a second purpose of this study was to identify additional factors responsible for death from eclampsia. Among 32,999 obstetric patients admitted to the hospital during the years 1998 to 2000, 2956 were eclamptic, yielding an incidence of 9%. The antepartum/intrapartum and postpartum incidences of eclampsia were 80% and 20%, respectively. Among the patients with eclampsia, 79% had good prognosis without any added complication except convulsion, and 21% had other complications. For the period 1998 to 2000, the rate of maternal death from eclampsia was 8.6%, which was lower than that of the immediate past year (1997) for which the mortality was 16%. Changing the protocol from diazepam to magnesium sulfate for control of convulsion significantly reduced the incidence of death. But reduction of the risk of death was difficult when patients had developed complications. Most of the patients in the group who had complications died (98%); these complications developed as a result of a delayed decision for treatment. Therefore, efforts should be directed at developing awareness to receive treatment at an appropriate time to prevent the development of eclampsia and to reduce the mortality from eclampsia and its complications.

Management of hypertensive emergencies of pregnancy by hydralazine bolus injection vs continuous drip--a comparative study.

This prospective study was conducted at Dhaka Medical College and Hospital, Bangladesh. The objective was to identify the time required to control high blood pressure levels in obstetric patients by injection of hydralazine in a bolus intravenous dose vs continuous drip. Seventy-seven patients with eclampsia and hypertensive emergencies comprised the target population. Patients were managed either by hydralazine drip in normal saline (existing official protocol, n = 33) or hydralazine bolus injection (as experiment, n = 44) until diastolic blood pressure fell to 90-95 mmHg. Results were compared. Student's t-test was done for statistical significance, and a P value of <.05 was considered as significant. The groups were similar with respect to maternal age and their mean systolic and diastolic blood pressure at the time of enrollment. Patients who received bolus injection required less time to achieve the therapeutic goal (65.23 +/- 23.38 minutes) than continuous drip (186.36 +/- 79.77 minutes; P <.001). The experimental group also required significantly lower doses (6.68 +/- 1.66 mg) in comparison to that required by control group (20.07 +/- 11.38 mg; P <.001). There was no overshoot hypotension in either group. The data suggest that hydralazine bolus dose is equally safe and more effective than continuous drip in the management of hypertensive emergencies in pregnancy.

Loading dose versus standard regime of magnesium sulfate in the management of eclampsia: a randomized trial.

OBJECTIVE: To determine whether only loading dose of magnesium sulfate is effective in controlling convulsion in eclampsia. STUDY METHODS: This prospective study was conducted in Dhaka Medical College and Hospital, Bangladesh between July and November 1999. Eclamptic patients who were eligible for magnesium sulfate (MgSO4) therapy were randomly assigned by lottery to receive either only loading dose (n = 202) or standard regime (n = 199) of MgSO4. Besides the anticonvulsant, patients of both the groups were managed by same protocol for eclampsia management prepared by Eclampsia Working Group, Bangladesh. Efficacy of both the regimes was assessed by measuring the rate of recurrent convulsion. Results were expressed as mean +/- SD and a proportion. Statistical analysis was done using unpaired t-test, Z-test and chi2 test as appropriate. A P-value of < 0.05 was considered significant. RESULTS: At the time of randomization there were no significant differences between the two groups in terms of age (22.40 +/- 4.21 vs 22.49 +/- 4.67 years), parity (72.77% vs 70.35% primi), type of eclampsia (84.65% vs 85.42% antepartum eclampsia), number of convulsions (5.30 +/- 3.26 vs 5.48 +/- 3.32 times), gestational age (35.65 +/- 3.37 vs 35.13 +/- 3.26 weeks), systolic blood pressure (153.19 +/- 20.19 vs 154.17 +/- 22.32 mmHg), diastolic blood pressure (106.23 +/- 13.84 vs 105.60 +/- 12.88 mmHg), proteinuria (70.80% vs 72.36% had > + proteinuria) and Glasgow Coma Scale (GCS) (73.26% vs 75.88% > 8) for the loading and standard regime groups. There were also no differences between the two groups in mean fit and treatment interval (6.88 +/- 5.26 vs 7.12 +/- 4.29h), fit and delivery interval (11.35 +/- 10.22 vs 11 +/- 6.69h) and return of consciousness (10.94 +/- 8.29 vs 11.24 +/- 8.37h). The recurrent convulsion rate was almost the same in both the groups (3.96% in loading vs 3.51% in standard regime, P > 0.05). Case fatality rate was 4.45% and 5.02% in loading and standard regime groups, respectively (P > 0.05). CONCLUSION: Only loading dose of MgSO4 can control convulsion in eclampsia and it is as effective as standard regime.

Conservative management of eclampsia and severe pre-eclampsia--A Bangladesh experience.

OBJECTIVE: To observe whether the pregnancy can be safely continued for a reasonable period to gain fetal maturity in cases of eclampsia and severe pre-eclampsia. METHODS: Fifty-one patients were followed up in a specialized care (eclampsia) unit in Dhaka Medical College and Hospital between January 1998 and October 2000. Twenty-one patients with complaints of headache and blurred vision, and 30 patients with history of convulsion, all at gestational age < 36 weeks, were enrolled for this study. Magnesium sulfate was used to prevent convulsion in severe pre-eclampsia and to control convulsion in eclampsia. After conducting a baseline assessment, pregnancy was continued to gain fetal maturity. Patients were monitored closely. Diastolic blood pressure, 24-hour urinary total protein (UTP), and serum uric acid were chosen as the main parameters to detect the deterioration of a patient's condition. Pregnancy was terminated when deterioration occurred, as determined clinically or by 1 or more of the above parameters. Dexamethasone was used during the waiting period for fetal lung maturity. Patient outcomes were analyzed. RESULTS: At admission, the patients' mean gestational age ( SD) was 30.65 2.38 weeks, and the range was 24-34 weeks. Mean diastolic blood pressure was 109.06 11.61 mm Hg, 24-hour UTP was 2.25 1.73 g/24 h, and serum uric acid level was 5.5 1.12 mg/dL. Pregnancy was continued for a mean of 13.27 8.26 days (range, 3-35 days). Thirty-two babies (62.75%) with birth weight 1.0-2.5 kg (2.02 0.45) were born alive. Six of them (18.75%) weighing between 1.0 and 1.5 kg at birth were referred to the intensive care unit, and 1 (3.13%) weighing 1 kg at birth died within 5 minutes after birth. Among live-born babies, 93.75% were in good condition at the time of discharge from the hospital. Intrauterine death occurred in 19 (37.25%).cases. Twelve of them delivered spontaneously within 7 days of death and 7 required induction. In all cases, maternal condition was satisfactory. CONCLUSION: In carefully selected cases and with close supervision, pregnancy may be continued in women with eclampsia and severe pre-eclampsia to increase fetal maturity without increasing the risk to the mother.