ObGyn Watch October 2004

R Narayanan

OCTOBER 2004

Nitric Acid (N.O)in

Female Reproduction

N.O - Major Paracrine Mediator & Regulatory Agent

Menstruation Ovulation Endometrial

receptivity Implantation

Maintenance of Pregnancy

Cervical Ripening

Tocolysis Labour Pains

N.O Donors promote Fertility & Inhibitors facilitate Contraception

Maul H et al Curr Pharm Design Feb 2003

Effect of N.O on Vasculature N.O Promotes Vasodilatation &

inhibits Platelet Aggregation Low N.O in early II Trimester

impairs vascular formation leading to Placental insufficiency & FGR

High N.O in III Trimester represents compensated Pl perfusion in IUGR

PE develops due to dysfunction of L-arginine – N.O pathway

Tranquilli AL et al J Mat Fet NN Med

Effect of L-arginine L-arginine infusion decreases BP in

Normo as well as Hypertensive mothers

Reduces BP through release of N.O Improves endothelial function Inhibits Platelet aggregation Prevents Pre eclampsia Potent relaxant - Prolongs pregnancy Better Perinatal outcome

Alfredo et al Rev Chil Ultrasono 2001

Doppler – USG Evaluation

Lowers Uterine artery vascular resistance

Pathological Doppler waveforms paralleled with N.O production

Accelerated fetal Growth in Rx Group Birth weight improved

Sieroszewski P et al J Mat Fet NN Med June 2004

Oral0.1G/Kg/Day

X 2 weeksFrom 10th

GestationalWeek

Moderate intake of Coffee has No effect on Abortion -Coll PN Project 1956-66 - -Klebenoff et al N Eng J Med 1988

Coffee >150G/day increases RR Spontaneous Abortion to 1.36

& LBW to 1.5 Meta analysis of 32 studies

High Coffee intake increases Sudden Infant Death Syndrome

Ob Gyn Surv 1999

Retrospective study 562 Spont Aborters compared with 953 matched controls: Increased coffee consumption increases abortion risk – Coffee not Mutagenic

-Cnattingius S Sweden N Eng J Med 2000

During PregnancyIt is safe to consume

Less than 150G Coffee/Day

Which is equal to:

1 cup of Brewed2 cups of Instant3-4 cups of Tea2-3 Soft Drinks

How about Tea?

Study of>1000 women 30 & Older in Taiwan

•Average of 2 cups of Tea >10 years•6.2% greater Bone Density Fluorides,Flavonoids & Phytoestrogens responsible•Tea has >4000 Health-affecting Compounds

Polycystic Ovaries

Incidence of Abortion in PCOS: 30-50%

Causes:1. Elevated LH2. Hyper insulinemic

Insulin Resistance3. Elevated Androgens4. CL Deficiency

following Dysovulation

Metformin Insulin Resistance Serum Androgen

Improves Ovulation

Abortion Obesity

Retrospective Study of Metforminin Pregnancy

Metformin 1-2 G / day throughout Pregnancy

Abortion Rate : 9% in study group

(42% in controls) Lower Free Testosterone levels No IUGR No Fetal Anomalies

Daniela DJ et al J Endocrin Metabol 2002

Metformin & GDM

Prospective & retrospective Study Incidence of GDM: 3% in Study group (23% in Controls) Safe in Pregnancy Probably acts by decreasing secretory

demands on Pancreatic beta cells

Glueck et al 2001

L’scopic Ovarian Drilling In CC Resistant PCO: Spont Ovulation 57% Conception 50% Reg Cycles >1 yr 50% Poor Responders: BMI >35Kg/m2 Testosterone >4.5 nMol/L Infertility >3 yrs

Hum Repr 2004

Farquhar C et al Cochrane Library Issue 3, 2004

•15 Trials of L’scopic Drilling Vs GTH Induction:•Compared 6-12 mths following Drilling with 3-6 cycles of GTH•Cumulative Pregnancy Rate Same•Miscarriage rate same •Multiple pregnancy less with Drilling

American Men shave 48 sq inches

24 times/monthWomen, 412 sq inches

11 times/month-Gillette

-Westinghouse 1941

Dysmenorrhoea Pain Relief: Naproxen 59%

Ibuprofen 70% Mefanemic Acid 69% Aspirin 29%

Ibuprofen drug of choice

Coxibs=Naproxen

Metanalysis: Double Blind RCTsZhang WY et al Br J Ob G 1998

Source BMJ 1999

Eminence-Based Medicine

‘The more senior the physician, the less important the evidence!’

“Clinical Experience” is defined as ‘Making the same mistakes With increasing confidence

over an impressive number of years’

Vehemence-Based Medicine

‘Substitution of volumeFor Evidence!’

Eloquence-Based Medicine

‘Smooth tongue, Sartorial elegance And Verbal eloquence are

Powerful Substitutes’

Providence-Based Medicine

‘Decision may best be leftIn the hands of Almighty!’

Diffidence-Based Medicine

‘A sense of DespairMakes the physician feel

helplessAnd do nothing!’

Nervousness-Based Medicine

‘Fear of Litigation Leads to over investigate

And over treat!’

Confidence-Based Medicine

(Restricted to Surgeons)

‘He will let his scalpel speak!’

One-day old TAMARA – 3.75 KgWith Mother 32 year old

Quarda Touriat at BrusselsOn 24 Sep ‘04

Prof Donnez froze Touriat’s ovaries in 1997 before Chemo/Radio Rx for Stage IV Hodgkins Lymphoma.Laparoscopic Ovarian Transplant in 2003Menstruation returned 4 months later.Conceived naturally -Lancet Sept’04

Stop Press!