The relationship between visceral adiposity and cardiometabolic risk in Chinese women with polycystic ovary syndrome.

OBJECTIVE: To compare the extent to which visceral adiposity, as measured by mesenteric fat thickness, contribute to cardiometabolic risk, especially insulin resistance, in women with PCOS and healthy control. METHODS: This is a cross-sectional study with a total of 190 women with PCOS fulfilling the Rotterdam diagnostic criteria. Women without PCOS were recruited from a previous study, which comprised 416 healthy women controls with normal glucose tolerance. All subjects underwent OGTT, biochemical assessment, and sonographic assessment with measurements of mesenteric, preperitoneal and subcutaneous fat thickness. RESULTS: Mesenteric fat thickness was strongly correlated to cardiometabolic traits including blood pressure, fasting and 2-h glucose, triglycerides, HOMA-IR; and was negatively correlated to HDL-C in both cohorts (all p < 0.01). In PCOS, positive correlation was observed between mesenteric fat thickness and free androgen index (p < 0.01). Compared with controls, the regression line between mesenteric fat and HOMA-IR is much steeper in PCOS (p < 0.01). CONCLUSION: Women with PCOS remain more insulin resistant compared to controls at any given degree of visceral adiposity.

Polycystic ovary syndrome: a common reproductive syndrome with long-term metabolic consequences.

Polycystic ovary syndrome is the most common endocrine disorder among women of reproductive age. Although traditionally viewed as a reproductive disorder, there is increasing appreciation that it is associated with significantly increased risk of cardiometabolic disorders. Women with polycystic ovary syndrome may present to clinicians via a variety of different routes and symptoms. Although the impact on reproduction predominates during the reproductive years, the increased cardiometabolic problems are likely to become more important at later stages of the life course. Women with polycystic ovary syndrome have an approximately 2- to 5-fold increased risk of dysglycaemia or type 2 diabetes, and hence regular screening with oral glucose tolerance test is warranted. Although the diagnostic criteria for polycystic ovary syndrome are still evolving and are undergoing revision, the diagnosis is increasingly focused on the presence of hyperandrogenism, with the significance of polycystic ovarian morphology in the absence of associated hyperandrogenism or anovulation remaining uncertain. The management of women with polycystic ovary syndrome should focus on the specific needs of the individual, and may change according to different stages of the life course. In view of the clinical manifestations of the condition, there is recent debate about whether the current name is misleading, and whether the condition should be renamed as metabolic reproductive syndrome.

Effects of laparoscopic ovarian drilling in treating infertile anovulatory polycystic ovarian syndrome patients with and without metabolic syndrome.

OBJECTIVE: To compare the effects of laparoscopic ovarian drilling in treating infertile polycystic ovarian syndrome in patients with and without metabolic syndrome. DESIGN: Retrospective review. SETTING: A university-affiliated hospital in Hong Kong. PATIENTS: A total of 89 infertile anovulatory polycystic ovarian syndrome patients, who underwent laparoscopic ovarian drilling with completed metabolic screening and seen over a 5-year period from 2002 to 2007. MAIN OUTCOME MEASURES: The clinical, hormonal, and metabolic characteristics as well as spontaneous ovulation rates, reproductive outcomes, and diabetes risks during pregnancy observed after laparoscopic ovarian drilling. RESULTS: Approximately one fifth (21%) of polycystic ovarian syndrome patients had the metabolic syndrome. There were no differences in spontaneous ovulation rates (68% vs 61%, P=0.76), cumulative pregnancy rates (68% vs 61%, P=0.77), and diabetes risks during pregnancy (64% vs 42%, P=0.13) between patients with and without metabolic syndrome. CONCLUSION: Laparoscopic ovarian drilling was equally effective in inducing ovulation in polycystic ovarian syndrome patients with metabolic syndrome. Thus, patients with metabolic syndrome should not be precluded from laparoscopic ovarian drilling, which has the additional advantage of enabling full tubo-peritoneal assessment at the same time.

Sonographic measurement of mesenteric fat predicts presence of fatty liver among subjects with polycystic ovary syndrome.

OBJECTIVE: Visceral fat is believed to be important in the pathogenesis of metabolic syndrome and fatty liver. In this study, we examined the relationship between mesenteric fat thickness and other sonographic indices of adiposity and the presence of fatty liver among subjects with polycystic ovary syndrome (PCOS). SUBJECTS AND METHODS: A total of 117 Chinese subjects with PCOS were evaluated (mean age, 28.6 ± 6.5 yr; mean body mass index, 24.3 ± 5.3 kg/m(2)). Anthropometric measurements and metabolic risk profile, including a standard oral glucose tolerance test, were assessed in all subjects. All subjects underwent an ultrasound examination for measurement of thickness of mesenteric, preperitoneal, and sc fat as well as evaluation for fatty liver. RESULTS: Forty-six (39.3%) of the subjects had fatty liver. PCOS subjects with fatty liver had higher body mass index, waist circumference, waist-hip ratio, and systolic blood pressure; a more unfavorable lipid profile with higher triglyceride; lower high-density lipoprotein cholesterol; higher fasting glucose and insulin; higher 2-h glucose during oral glucose tolerance test; lower SHBG; and higher alanine aminotransferase. Subjects with fatty liver had increased thickness of preperitoneal, mesenteric, and sc fat, as well as increased carotid intima-media thickness. Abdominal fat thickness showed moderate correlation to alanine aminotransferase as well as fasting insulin. On multivariate logistic regression, fasting insulin and mesenteric fat thickness were identified as independent predictors of fatty liver among subjects with PCOS. CONCLUSION: Fatty liver is present in a significant proportion of Chinese patients with PCOS. Sonographic measurement of mesenteric fat is an independent determinant of fatty liver among subjects with PCOS and identifies subjects at increased cardiovascular risk.

Cardiovascular risks and metabolic syndrome in Hong Kong Chinese women with polycystic ovary syndrome.

BACKGROUND: Women with polycystic ovary syndrome (PCOS) frequently exhibit central obesity, glucose intolerance, atherogenic dyslipidaemia and hypertension which are characteristic features of the metabolic syndrome (MetS). METHODS: A total of 295 premenopausal Chinese women with PCOS diagnosed by the Rotterdam criteria (mean age: 30.2 +/- 6.4 years) and 98 control subjects without PCOS were evaluated for prevalence of MetS and cardiovascular risk factors, including dyslipidaemia and dysglycaemia. RESULTS: Using the 2005 modified Adult Treatment Panel III criteria, MetS (presence of three or more risk factors) was found in 24.9% of PCOS women compared to 3.1% of controls. The prevalence of MetS in PCOS women increased from 16.7% at under 30 years of age to 53.3% at over 40 years. MetS was also more prevalent in overweight and obese (41.3%) than normal-weight PCOS women (0.9%). However, multivariate regression analysis showed that women with PCOS had a 5-fold increase in risk of MetS (odds ratio 4.90; 95% confidence interval: 1.35-17.84) compared with women without PCOS even after controlling for age and BMI, suggesting PCOS alone is an independent risk factor for MetS. CONCLUSIONS: There is high prevalence of MetS in Hong Kong Chinese women with PCOS despite their relatively young age. Recognition of these cardiometabolic risk factors requires a high level of awareness in conjunction with early and regular screening.

Polycystic ovarian syndrome in Hong Kong Chinese women: patient characteristics and diagnostic criteria.

OBJECTIVES: To identify the characteristics of Hong Kong Chinese women with polycystic ovarian syndrome and to compare different diagnostic criteria. DESIGN: Retrospective study. SETTING: Gynae-endocrinology Clinics in the Prince of Wales Hospital, Hong Kong. PATIENTS: Ninety Hong Kong Chinese women with polycystic ovarian syndrome who were diagnosed according to the hospital's criteria. MAIN OUTCOME MEASURES: Prevalence of typical features of polycystic ovarian syndrome, including anovulation and hyperandrogenism (with other endocrine causes excluded), polycystic ovarian features on ultrasonography, luteinising hormone predominance, obesity, and insulin resistance. RESULTS: Almost all (98.9%) patients with polycystic ovarian syndrome presented with anovulation, only 48.9% of them had clinical or biochemical evidence of hyperandrogenism. Typical ultrasound appearances of polycystic ovaries were observed in 86.7% of patients. Luteinising hormone predominance and insulin resistance were demonstrated in 67.8% and 40.7% of the cohort, respectively. Eight-six (95.6%) patients should have also been diagnosed with polycystic ovarian syndrome based on the 2003 Rotterdam new criteria. About 60% of patients who screened positive for insulin resistance had normal fasting serum glucose levels. The same proportion who had full screening for insulin resistance by oral glucose tolerance tests and fasting serum glucose to insulin ratios had discordant results of these two tests. CONCLUSIONS: The 2003 Rotterdam new diagnostic criteria for polycystic ovarian syndrome are generally applicable to the Hong Kong Chinese population. Early detection of insulin resistance in patients with polycystic ovarian syndrome can be ensured by performing an oral glucose tolerance test combined with measurement of fasting serum glucose to insulin ratio.

Revisit of metformin treatment in polycystic ovarian syndrome.

Polycystic ovary syndrome (PCOS) is a common endocrinopathy in women; its traditional pharmacological therapy mainly addresses short-term symptom control and does not correct the associated long-term metabolic risks. Recently, there has been increasing evidence that insulin resistance has an important implication in the pathogenesis of PCOS and that insulin-sensitizing drugs are a useful therapeutic approach. Therefore this review aims to discuss the current evidence on the use of metformin, a commonly used insulin-sensitizing agent, in treating both the short-term and the long-term problems of women with PCOS.

Follicular fluid and serum concentrations of myo-inositol in patients undergoing IVF: relationship with oocyte quality.

BACKGROUND: The follicular microenvironment is an important determinant of oocyte development. The aim of this study was to examine whether the myo-inositol (MI) content in human follicular fluid (FF) was associated with better oocyte quality. METHODS: A total of 53 patients treated with IVF was recruited to a prospective observational study. FF and serum samples collected were divided into two groups: group A consisted of FF associated with matured and fertilized oocytes, whilst group B was from follicles with immature and unfertilized oocytes. RESULTS: Patient's age, total ampoules of HMG used, days of stimulation, basal levels of FSH, estradiol (E(2)) levels on the day of HCG, and serum MI content were not significantly different between the two groups. FF volume and its MI content were significantly higher in group A compared with group B (P < 0.05). The levels of MI in FF were positively correlated with the amount of E(2) in their corresponding FF samples and also correlated with embryo quality. CONCLUSIONS: We propose that higher concentrations of MI and E(2) in human FF appear to play a role in follicular maturity and provide a marker of good quality oocytes.

Effects of the intensity of downregulation on outcome of in vitro fertilization and embryo transfer.

Gonadotropin releasing hormone agonists (GnRHa) are commonly used during in vitro fertilization and embryo transfer (IVF/ET) treatment cycles to downregulate the hypothalamic-pituitary-ovarian axis prior to ovarian stimulation with gonadotropins. It has been suggested that profound downregulation may have an adverse effect on IVF/ET outcome. The aim of this study was to examine the relationship between the degree of downregulation and IVF/ET outcome. A retrospective analysis was performed on 151 IVF/ET cycles conducted over a six month period. Intensity of downregulation was assessed using measurements of serum concentrations of luteinizing hormone (LH) and estradiol (E2) made at the end of a two week downregulation period. There was no correlation between serum concentration of LH (whether used alone or in combination with E2) and IVF/ET pregnancy rates. However, those subjects who were more suppressed according to the E2 concentration (< 148 pmol/l, [median]) required significantly more gonadotropins (3306 IU versus 2863 IU, p < 0.05) and took longer for follicles to reach maturity (10.9 days versus 9.7 days, p < 0.05). They also had a lower pregnancy rate per embryo transfer (10.4% versus 28.6%, p < 0.05) compared with those having a higher basal E2 concentration. We conclude from this study that the basal serum E2 concentration rather than the LH concentration is a more sensitive indicator of the intensity of downregulation by GnRHa and it may be a better predictor of IVF outcome.

Regulation of human oviductin mRNA expression in vivo.

OBJECTIVE: To examine changes in oviductin mRNA expression in oviductal mucosal tissue from fertile women throughout an ovulatory cycle. DESIGN: Semiquantitative reverse-transcriptase-polymerase chain reaction (RT-PCR) analysis of oviductin mRNA. SETTING: University-based obstetrics and gynecology department. SUBJECT(S): Twenty women undergoing laparoscopy for tubal sterilization or hysterectomy for uterine fibroids. INTERVENTION(S): The mucosal layer was isolated from the oviduct tissue, and semiquantitative RT-PCR was performed. MAIN OUTCOME MEASURE(S): The relationship between serum estradiol, luteinizing hormone, and progesterone concentrations and the expression of oviductin mRNA. RESULT(S): There was a significant positive correlation between serum estradiol and luteinizing hormone concentrations and oviductin mRNA expression. There was a significant inverse correlation between serum progesterone concentrations and oviductin mRNA expression. CONCLUSION(S): Little is known about the regulation of human oviductin. This study was the first to examine the relationship between oviductin mRNA expression and serum estradiol and luteinizing hormone and progesterone concentrations in fertile women. Estradiol and luteinizing hormone both have a stimulatory effect on oviductin mRNA in humans, however, it is difficult to determine whether the effects are independent of one another, as the luteinizing hormone surge is dependent on the estradiol increase. Progesterone shows a clear inhibitory effect on oviductin mRNA.

Dose-finding study for the use of long-acting gonadotrophin-releasing hormone analogues prior to ovarian stimulation for IVF.

Gonadotrophin-releasing hormone (GnRH) analogues improve the outcome of treatment with IVF by increasing the number and quality of oocytes retrieved and by reducing cycle cancellation rates. Whilst short-acting GnRH analogues are most commonly used, depot preparations are now available that are more convenient for patient use. Some studies have reported that pregnancy rates with depot GnRH analogues are similar to those of short-acting preparations, but others have suggested that the more profound down-regulation seen with depot GnRH analogues results in inferior embryo quality. The purpose of this study was to determine whether a lower than conventional dose of a depot GnRH analogue may be more appropriate for use in ovarian stimulation prior to IVF. Sixty patients were randomized to receive either 3.75 mg (conventional dose) or 1.87 mg (low dose) triptorelin prior to ovarian stimulation for IVF. Suppression was measured using serum concentrations of LH measured 2 and 3 weeks after the administration of the GnRH analogues, the dose of gonadotrophin used and the time to resumption of menses. Mean concentrations of LH were 2.2 +/- 1.0 and 1.1 +/- 0.6 IU/l in the conventional dose group and 3.5 +/- 5.5 and 2.7 +/- 1.9 IU/l in the low dose group (P < 0.05 at 2 and 3 weeks). There were no significant differences between the doses of gonadotrophins used, the number of oocytes and embryos available and the time to resumption of menses, nor in the pregnancy rates. Although the degree of suppression as measured biochemically was more profound with the conventional dose, this did not affect the IVF outcome. The use of a lower dose therefore appears to be equally effective and could contribute to a reduction in the cost of treatment.

Anterior cruciate ligament injury: fast spin-echo MR imaging with arthroscopic correlation in 217 examinations.

OBJECTIVE: Our objective was to evaluate the accuracy of MR imaging strategy that uses primarily fast spin-echo sequences for the diagnosis of anterior cruciate ligament tears. MATERIALS AND METHODS: The original clinical interpretations of MR images of 217 examinations of the knee joint were correlated with subsequent arthroscopic results. Each MR examination included a double-echo fast spin-echo sequence as the only imaging sequence in the sagittal plane. Subsequent discordant MR and arthroscopic examinations were then subjected to reanalysis by two observers who were unaware of arthroscopic results to determine if misinterpretations were observer or image dependent. Two hundred sixteen patients who underwent MR imaging for suspected internal derangement of the knee subsequently underwent arthroscopic surgery. Two patients had both knees evaluated. One patient was excluded because he was referred for evaluation for osteomyelitis, not internal derangement. This yielded a total number of 217 MR examinations for suspected internal derangement of the knee. RESULTS: For 56 arthroscopically proven tears, the sensitivity of MR imaging was 96%. The specificity was 98%, yielding an overall accuracy rate of 98%. The positive and negative predictive values were 95% and 99%, respectively. These values are within the ranges of previously reported MR imaging strategies using conventional spin-echo sequences. CONCLUSION: Fast spin-echo MR imaging of the knee can be an alternative to conventional spin-echo imaging for the detection of anterior cruciate ligament tears.

Compliance with hormone replacement therapy in Chinese women in Hong Kong.

Compliance with hormone replacement therapy (HRT) has been extensively studied in western countries. However, there is little data concerning women in Asian countries. A retrospective study was performed to determine compliance in a group of Hong Kong Chinese women who commenced HRT over a 2 year period. Two years after the commencement of HRT, 68.3% were still taking HRT, although not always in the original formulation. The highest drop out rate occurred during the first 6 months. Factors which were associated with a higher degree of compliance were young age at menopause and at the time of initial consultation and the use of unopposed HRT. A number of significant medical problems were identified during the 2 years of follow up which may have remained otherwise undetected. Compliance with HRT appears to be comparable to that reported in other western specialist centres. Nearly 9% of women who stopped HRT did so because other doctors told them that they did need the treatment and another 6.5% because of the fear of breast cancer.

Acute effects of a surgical menopause on serum concentrations of lipoprotein(a).

OBJECTIVE: The aim of this study was to investigate acute changes in serum concentrations of lipoprotein(a) and other atherogenic lipids and lipoproteins after a surgical menopause. METHODS: A total of 100 premenopausal Chinese women who were booked for hysterectomy for benign gynecological disorders were recruited. They study group comprised 40 subjects undergoing hysterectomy as well as bilateral oophorectomy. The control group consisted of 60 subjects undergoing hysterectomy with conservation of the ovaries. Complete data were available from 30 of the 40 subjects in the study group and from 44 of the 60 controls. Serum concentrations of lipoprotein(a) and other atherogenic lipids and lipoproteins were measured before surgery and these measurements were repeated 3 days, 8 weeks and 6 months postoperatively. Those study patients who received hormone replacement therapy and control patients who became menopausal, according to biochemical criteria, during the study period were excluded from analysis. RESULTS: Three days after surgery, there was a significant increase in the mean lipoprotein(a) concentration in the control group from 19.1 to 23.0 mg/dl (p < 0.01), but there was no significant change in the study group. There were no significant changes from baseline in the mean lipoprotein(a) concentration in either group 8 weeks or 6 months after surgery. There was a significant increase in the mean concentration of total cholesterol in the study group 8 weeks after surgery from 5.08 to 5.45 mmol/l (p < 0.01), in low density lipoprotein cholesterol from 3.22 to 3.49 mmol/l (p < 0.01), and in apolipoprotein B from 95.6 to 103.0 mg/dl (p < 0.05). However, the mean concentrations 6 months after surgery were not significantly different from baseline levels. The mean concentrations of high density lipoprotein cholesterol, apolipoprotein A-1 and triglycerides also did not differ significantly from baseline in the study group, either 8 weeks or 6 months after surgery. CONCLUSIONS: These results suggest that any increase in concentrations of lipoprotein(a), and other atherogenic lipids and lipoproteins which occur after the menopause, develops relatively slowly. The changes in concentrations which occurred within 8 weeks of surgery were probably an acute-phase reaction after surgery rather than a response to a decreasing estradiol concentration.

Changes in atherogenic lipids and lipoproteins during natural and hyperstimulated cycles in healthy women.

OBJECTIVE: To compare changes in the concentrations of Lp(a) lipoprotein and other atherogenic lipids and lipoproteins in natural and hyperstimulated ovarian cycles. DESIGN: Open, prospective study. SETTING: Academic department in a teaching hospital. PATIENT(S): Normal ovulatory women served as controls and the treatment group consisted of women undergoing ovarian hyperstimulation. INTERVENTION(S): The treatment group received hMG on a fixed regimen. MAIN OUTCOME MEASURE(S): Measurements of serum lipids and lipoproteins were made in both natural and hyperstimulated cycles. RESULT(S): There was a significant increase in the median concentration of Lp(a) lipoprotein from 10.1 to 10.7 mg/dL in the luteal compared with the proliferative phase of unstimulated cycles. In hyperstimulated cycles, there was a significant increase in the median concentration of Lp(a) lipoprotein from 9.7 mg/dL in the proliferative phase to 11.3 mg/dL in the luteal phase. Reductions in concentrations of total cholesterol and low-density lipoprotein cholesterol were found in the luteal phase of hyperstimulated cycles. CONCLUSION: Concentrations of Lp(a) lipoprotein increase during the luteal phase of both natural and hyperstimulated ovarian cycles.

Meniscal tears of the knee: accuracy of detection with fast spin-echo MR imaging and arthroscopic correlation in 293 patients.

PURPOSE: To evaluate the accuracy of a magnetic resonance (MR) imaging strategy that uses primarily fast spin-echo (SE) sequences for the diagnosis of meniscal tears. MATERIALS AND METHODS: The original clinical interpretations of MR images in 293 patients who underwent imaging for suspected internal derangement of a knee joint were correlated with results from subsequent arthroscopy. MR examination included a double-echo fast SE sequence as the only imaging in the sagittal plane. RESULTS: The sensitivity and specificity for 143 confirmed tears of the medial meniscus were 89% and 84%, respectively, while the values for 96 confirmed tears of the lateral meniscus were 72% and 93%. These values are within the ranges of values recently reported for imaging strategies relying predominantly on conventional SE sequences. CONCLUSION: Fast SE imaging of the knee can be an alternative to conventional SE imaging for the detection of meniscal tears.

The treatment of cervical intra-epithelial neoplasia: when could we 'see and loop'.

OBJECTIVE: To determine the possible role of the selective 'see and loop' approach with a loop electrosurgical excision procedure (LEEP) for high grade cervical intra-epithelial neoplasia (CIN). DESIGN: Comparison of the colposcopic and histological diagnosis in patients who received LEEP treatment. SUBJECTS: Subjects included 95 patients from May to October 1994. SETTING: Department of Obstetrics and Gynaecology, the Prince of Wales Hospital, the Chinese University of Hong Kong. MAIN OUTCOME MEASURES: Agreement between colposcopic and histological diagnosis and between histological diagnosis by biopsy and by LEEP. Sensitivity and false positive rate of colposcopic diagnosis in different classifications of high grade CIN lesions. Decision analysis on the cost of three proposed strategies based on the study results. RESULTS: The colposcopic diagnosis was correct in 58% of cases with 31% overall and 11% undercall rates. The false positive rate of colposcopic examination was 11.4% in the diagnosis of CIN III or more advanced lesions and 36.8% if CIN II lesions are also classified as high grade. Decision analysis showed a saving of: (i) US$53,000: or (ii) US$73,000 per annum if 'see and loop' was performed on all cases where colposcopic diagnosis is: (i) CIN III or more; or (ii) CIN II or more. If the cost of inappropriate surgery by LEEP is estimated to be more than US$550 per person over-treated (i) becomes the preferred strategy. CONCLUSIONS: Selective 'see and loop' approach for high grade CIN III lesions suspected on colposcopy will not over-treat significantly but will reduce the number of colposcopy appointments, waiting list for colposcopy and subsequent expenses.

Screening psychiatric morbidity after miscarriage: application of the 30-item General Health Questionnaire and the Edinburgh Postnatal Depression Scale.

OBJECTIVE: Psychiatric morbidity affects 48% to 51% of women who have miscarried. This study evaluated the utility of two sample and brief self-report questionnaires in screening psychiatric morbidity after miscarriage. METHOD: One hundred fifty-six subjects completed the 30-item General Health Questionnaire (GHQ), the Edinburgh Postnatal Depression Scale (EPDS), and the Beck Depression Inventory (BDI) 6 weeks after miscarriage. Then there was a blind assessment using the Structured Clinical Interview for DSM-III-R (SCID) to establish psychiatric diagnosis. The criterion validity of GHQ and EPDS were tested against this yardstick diagnosis and the concurrent validity against the BDI scores. The internal consistency of the scales was measured by Cronbach's alpha-coefficient. RESULTS: Both GHQ and EPDS had good sensitivity and specificity in screening for psychiatric morbidity after miscarriage. The concurrent validity and the internal consistency of both scales were satisfactory. The EPDS could only identify those subjects with major depression. The GHQ was longer to perform, but was able to detect both anxiety and depressive disorders. Furthermore, the GHQ had better psychometric properties when compared with the EPDS. CONCLUSIONS: These scales will be particularly useful for nonpsychiatric medical personnel. We recommend routine application of the GHQ 6 to 8 weeks after miscarriage to identify women who may require psychiatric management.

A medical approach to management of spontaneous abortion using misoprostol. Extending misoprostol treatment to a maximum of 48 hours can further improve evacuation of retained products of conception in spontaneous abortion.

BACKGROUND: To compare a 48 hour non surgical policy in the management of spontaneous abortion with a policy of routine, universal uterine curettage. METHODS: A prospective, observational study on 354 women admitted to hospital with spontaneous abortion. Of these, 225 who had retained products of conception were treated with misoprostol for up to 48 hours after 101 were excluded because they had an empty uterus on transvaginal scan (TVS) and another 28 women because they were unsuitable for conservative management. Follow-up was conducted over a 3 week period to assess morbidity. A reference group of 137 women, all of whom had an evacuation of retained products of conception (ERPC) as a routine after they had a TVS documenting retained products of conception (POCs), was used for comparison. RESULTS: Evacuation of the uterus occurred within 24 hours in 107 women and in 148 at 48 hours after misoprostol treatment was started. There were three uterine curettages up to 14 days after discharge from hospital for persistent bleeding and two cases of pelvic infection. An ectopic pregnancy was diagnosed at follow-up in one woman. In the reference group, there were nine women who had complications, four requiring another ERPC and five had infection, an overall complication rate of 6.6% in the reference group and 1.7% in the protocol treatment group. CONCLUSION: A 48 hour regimen using transvaginal ultrasound and misoprostol for the management of spontaneous abortion was successful in avoiding surgery in 249 out of a possible 354 (70.6%) women with spontaneous abortion, with a low rate of subsequent morbidity.

PIP: A prospective, observational study of 354 women admitted to a Hong Kong hospital with a confirmed diagnosis of spontaneous abortion confirmed the effectiveness of a non-surgical 48-hour regimen using transvaginal ultrasound and misoprostol administration. 101 women were excluded because they had an empty uterus on transvaginal scan and another 28 were considered unsuitable for conservative management. The 225 remaining women were treated with up to 1200 mcgs of misoprostol administered orally in 3 divided doses per day for up to 48 hours; a comparison group of 137 women underwent surgical evacuation of retained products of conception. Evacuation of the uterus occurred within 24 hours of misoprostol administration in 107 women and by 48 hours after misoprostol administration in 148 women. The cumulative success rate was 69.6%. There were 3 uterine curettages for persistent bleeding up to 14 days after discharge, 2 cases of pelvic infection, and 1 ectopic pregnancy. In the reference group, 4 women required a repeat evacuation and 5 had infection. The overall complication rate in up to 3 weeks of follow-up was 6.6% in the surgical reference group and 1.7% in the medical treatment group.

Inappropriate ADH secretion due to immature ovarian teratoma.

Inappropriate antidiuretic hormone secretion syndrome (IADHS) is usually associated with postoperative pain, stress, chest infection, drugs or carcinoma. It is rarely found in patients with gynaecological malignancy. IADHS was found in a 17-year-old girl with an immature ovarian teratoma. Hyponatraemia was persistent and did not respond to fluid restriction therapy before the operation. The plasma sodium level however returned to normal after the removal of the tumour. This is the first reported case of IADHS due to an immature ovarian teratoma or germ cell tumour.