Metformin as an Adjunct to Progestin Therapy in Endometrial Hyperplasia and Early-Stage Endometrial Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Background and Objective: Metformin has been studied for its anti-proliferative effects on endometrial cells, and it is hypothesized to have a synergistic effect with progestin therapy in suppressing endometrial cell proliferation. This systematic review and meta-analysis aimed to determine the efficacy of adjunctive metformin in the clinical regression of endometrial hyperplasia and early-stage endometrial carcinoma. There have been previous systematic reviews that investigated the role of metformin with progesterone for endometrial hyperplasia and endometrial cancer, but they have included retrospective cohorts, and are thus have higher risk of bias. Methods: This meta-analysis followed the Cochrane methodology and adhered to the PRISMA 2020 guidelines. Randomized controlled trials (RCTs) were included if they enrolled reproductive-aged women with endometrial hyperplasia (with and without atypia) and endometrial carcinoma who were treated with progestin and metformin. The primary outcome was the complete response rate at 12-16 weeks, and secondary outcomes included relapse rate, clinical pregnancy rate, and live birth rate. Subgroup analysis of endometrial hyperplasia without atypia vs hyperplasia with atypia and early endometrial cancer was also included. Odds ratios (ORs) and 95% confidence intervals (CIs) were used for dichotomous data. Results: Six RCTs were included. The addition of metformin to progestin therapy may increase the complete response rate of endometrial hyperplasia without atypia (OR 5.12, 95% CI 1.17 to 22.41; n = 102) and live birth rates (OR 2.51, 95% CI 1.34 to 4.69; n = 188) compared to progestin therapy alone, but the certainty of the evidence is low. Metformin did not have a significant effect on the clinical response of endometrial hyperplasia with atypia and endometrial carcinoma, relapse rates, and clinical pregnancy rates. Conclusion: Current evidence is uncertain on the potential benefit of metformin with progestin in endometrial hyperplasia and carcinoma. Future high-quality randomized controlled trials with larger sample sizes and longer follow-up periods are needed to support practice recommendations.

Cervical Tuberculosis Mimicking Tumor Persistence: A Case Report.

Tuberculosis can coexist with malignancy in the same organ, but cancer with TB in the cervix is rare. This is a case of cervical tuberculosis diagnosed in a cervical cancer patient after concurrent chemoradiotherapy and brachytherapy. This is the case of a 38-year-old G2P2 (2002) diagnosed with squamous cell carcinoma, large cell non-keratinizing cervix, Stage IIIB. The patient underwent concurrent chemoradiotherapy and brachytherapy. One month after the last brachytherapy dose, the attending physician noted a nodularity on the anterior lip of the cervix. A cervical punch biopsy was done to rule out tumor persistence. The histopathology revealed chronic granulomatous inflammation with Langhan's type multinucleated giant cells consistent with tuberculous infection. She was diagnosed with cervical tuberculosis, postulated to be from latent TB reactivation, and was given Anti-Koch's medication for six months. After receiving Anti-Koch's treatment, the cervical nodularity was no longer appreciated, and the rest of the cervix was smooth on palpation. Her Pap Test was negative for any intraepithelial lesion and was declared with no evidence of carcinoma. A possible latent TB infection should always be screened in cancer patients from high-burden areas or those with close contact treated for tuberculosis because immunosuppression during cancer treatment can cause the reactivation of tuberculous disease. Cervical tuberculosis complicating cervical malignancy is treatable with Anti-Koch's therapy and has not been shown to affect the course of the carcinoma.

The Efficacy and Safety of Myo-inositol Supplementation for the Prevention of Gestational Diabetes Mellitus in Overweight and Obese Pregnant Women: A Systematic Review and Meta-Analysis.

Background: Myo-inositol has emerged as one of the preventive therapies for the development of gestational diabetes mellitus in at-risk populations. This systematic review and meta-analysis was conducted to determine the efficacy and safety of myo-inositol in decreasing the incidence of gestational diabetes in overweight and obese pregnant women. Methodology: This meta-analysis was conducted using the standard Cochrane methodology and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. Inclusion criteria were randomized controlled trials (RCTs) that enrolled overweight and obese pregnant women and used myo-inositol supplementation. The primary outcome was the incidence of gestational diabetes mellitus at 24-28 weeks. Secondary outcomes included cesarean section rate, the incidence of pregnancy-induced hypertension, macrosomia and preterm delivery. Risk ratios (RRs) and 95% confidence intervals (CIs) were used for dichotomous data. Results: Six RCTs were included. Compared to standard micronutrient supplementation, standard dose of myo-inositol (4 g) may reduce the incidence of GDM (RR 0.54; CI [0.30, 0.96]; n = 887 women), but the certainty of evidence is low to very low. With low-dose myo-inositol however, evidence is uncertain about its benefit on the incidence of gestational diabetes mellitus in overweight and obese women with RR 0.71; CI [0.14, 3.50]. No adverse effects were noted. For the secondary outcomes, standard dose myo-inositol appears to reduce the incidence of pregnancy-induced hypertension and preterm delivery, but the certainty of evidence is low to very low. Conclusion: Current evidence is uncertain on the potential benefit of myo-inositol supplementation in overweight and obese pregnant women. While studies show that 4 g myo-inositol per day may decrease the incidence of GDM, pregnancy-induced hypertension and pre-term birth with no associated risk of serious adverse events, the certainty of evidence is low to very low. Future high-quality trials may provide more compelling evidence to support practice recommendations.

Obstetric management of a parturient with severe idiopathic scoliosis.

Scoliosis complicates pregnancy due to increased operative deliveries, restrictive pulmonary disease and anaesthetic difficulties. This is a case of a primigravid with severe scoliosis who underwent primary caesarean section under spinal block with isobaric anaesthetic combined with intravenous sedation postdelivery of the baby. This case highlights the importance of a multidisciplinary approach in the management of parturient with severe scoliosis, from the preconception period until the postpartum stage.