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ObGyn Watch October 2004

ObGyn Watch October 2004. R Narayanan. OCTOBER 2004. Nitric Acid (N.O) in Female Reproduction. Menstruation Ovulation Endometrial receptivity Implantation. Maintenance of Pregnancy Cervical Ripening Tocolysis Labour Pains. N.O - Major Paracrine Mediator & Regulatory Agent.

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ObGyn Watch October 2004

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  1. ObGyn WatchOctober 2004 R Narayanan OCTOBER 2004

  2. Nitric Acid (N.O)inFemale Reproduction

  3. Menstruation Ovulation Endometrial receptivity Implantation Maintenance of Pregnancy Cervical Ripening Tocolysis Labour Pains N.O - Major Paracrine Mediator & Regulatory Agent N.O Donors promote Fertility & Inhibitors facilitate Contraception Maul H et al Curr Pharm Design Feb 2003

  4. 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

  5. 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

  6. 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

  7. Oral 0.1G/Kg/Day X 2 weeks From 10th Gestational Week

  8. Coffee & Abortion Moderate intake of Coffee has No effect on Abortion -Coll PN Project 1956-66 - -Klebenoff et al NEng 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

  9. Recommendations During Pregnancy It is safe to consume Less than 150G Coffee/Day Which is equal to: 1 cup of Brewed 2 cups of Instant 3-4 cups of Tea 2-3 Soft Drinks

  10. 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

  11. Polycystic Ovaries • Incidence of Abortion in PCOS: 30-50% • Causes: • Elevated LH • Hyper insulinemic Insulin Resistance • Elevated Androgens • CL Deficiency following Dysovulation

  12. Metformin • Insulin Resistance • Serum Androgen • Improves Ovulation • Abortion • Obesity

  13. 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

  14. 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

  15. 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

  16. L'scopic Drilling of Ovaries for Ovulation in PCO • 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 Farquhar C et al Cochrane Library Issue 3, 2004

  17. X ray of Man shaving -Westinghouse 1941 American Men shave 48 sq inches 24 times/month Women, 412 sq inches 11 times/month -Gillette

  18. Dysmenorrhoea

  19. Dysmenorrhoea • Pain Relief: Naproxen 59% Ibuprofen 70% Mefanemic Acid 69% Aspirin 29% • Ibuprofen drug of choice • Coxibs=Naproxen Metanalysis: Double Blind RCTs Zhang WY et al Br J Ob G 1998

  20. We have heard of Alternative Medicine & Evidence-Based Medicine But, what are the Alternatives to EBM? Source BMJ 1999

  21. 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’

  22. Vehemence-Based Medicine ‘Substitution of volume For Evidence!’

  23. Eloquence-Based Medicine ‘Smooth tongue, Sartorial elegance And Verbal eloquence are Powerful Substitutes’

  24. Providence-Based Medicine ‘Decision may best be left In the hands of Almighty!’

  25. Diffidence-Based Medicine ‘A sense of Despair Makes the physician feel helpless And do nothing!’

  26. Nervousness-Based Medicine ‘Fear of Litigation Leads to over investigate And over treat!’

  27. Confidence-Based Medicine (Restricted to Surgeons) ‘He will let his scalpel speak!’

  28. One-day old TAMARA – 3.75 Kg With Mother 32 year old Quarda Touriat at Brussels On 24 Sep ‘04 Stop Press! Prof Donnez froze Touriat’s ovaries in 1997 before Chemo/Radio Rx for Stage IV Hodgkins Lymphoma. Laparoscopic Ovarian Transplant in 2003 Menstruation returned 4 months later. Conceived naturally -Lancet Sept’04

  29. Thank you!

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