A pilot study to determine whether progestogen supplementation using dydrogesterone during the first trimester will reduce the incidence of gestational hypertension in primigravidae.

BACKGROUND: Gestational hypertension (GH) remains one of the main causes of high maternal and perinatal morbidity and mortality worldwide with the highest incidence among primigravidae of about 10%-15%. However, it was noted that the incidence of GH in primigravidae who conceived following assisted reproductive technique (ART) or intrauterine insemination (IUI) supplemented with dydrogesterone during the first trimester was low. AIM: To determine whether dydrogesterone supplementation during the first trimester can reduce the incidence of GH among primigravidae. METHOD: A prospective cross-sectional comparative study was undertaken in 2010 on 116 primigravidae (study group) who conceived following ART or IUI and supplemented with dydrogesterone up to 16 weeks gestation. They were matched for age and race at 16 weeks gestation with a control patient from the early pregnancy clinic who were primigravidae (n = 116) who conceived spontaneously without dydrogesterone supplementation. FINDINGS: The incidence of GH in the study group was significantly lower than the control group (1.7% versus 12.9%, p = 0.001). The incidence of fetal distress was also significantly lower in the study group compared to the control group (4.3% versus 18.1%, p = 0.001). INTERPRETATION: Dydrogesterone supplementation during the first trimester significantly reduced the incidence of GH and fetal distress in primigravidae.

Atypical (symplastic) leiomyoma of the uterus--a case report.

A 30-year-old, nulliparous woman presented with a history of subfertility. On examination she was found to have uterine fibroid of 28 weeks size of gravid uterus and subsequently laporatomy myomectomy was performed. Multilobulated masses, with diameters ranging from 22 mm to 160 mm were found. Cut sections of the lobulated masses showed whitish whorled cut surface. One of the multilobulated masses had a cystic cavity, measuring 60x50x35 mm(3). Light microscopic findings of the mass with the cystic cavity showed a well-circumscribed cellular tumour composed of cells exhibiting moderate nuclear atypia which were enlarged, nuclei with prominent chromatin clumping and were distributed in areas. Some tumour cells showed large nuclear pseudoinclusions, multinucleated or multilobated tumour giant cells, smudging and few enlarged nucleoli. Mitotic activity was 4 MFs per 10 HPFs. Occasional cells with intracytoplasmic inclusions resembling rhabdoid - like features were seen. There were no atypical mitoses or tumour necroses were noted. Diagnosis of atypical leiomyoma or symplastic leiomyoma was made. Atypical or symplastic leiomyomas are rare in the region of Malaysia and the present case discusses its incidence in younger age, its morphological features along with diagnosis and clinical outcome.

Affordable ART for developing countries: a cost benefit comparison of low dose stimulation versus high dose GnRH antagonist protocol.

OBJECTIVE: Low dose stimulation (LS) is emerging as an alternative regime in assisted reproductive technology (ART). This study aimed to compare the cost-effectiveness of LS to the high dose GnRH antagonist (Atg) regime. METHODS: An observational prospective study conducted at an academic infertility unit from January to June 2007. Outcome measures included the numbers of follicles, oocytes and embryos, morphological quality of oocytes and embryos, clinical pregnancy (PR) and complication rate. RESULT: Ninety five first attempt ICSI cycles consisting of 54 LS and 41 Atg were analyzed. Subjects in both groups had comparable sociodemographics and reproductive characteristics. LS generated significantly fewer follicles, total oocytes, mature oocytes (all p < 0.0005) and immature oocytes (p = 0.009) than Atg but the number of excellent quality oocytes was similar. Significantly fewer embryos were available in LS although the proportion of usable embryos was higher, 83.2% vs. 67.0% for Atg. Mean embryos per transfer was 2.0 +/- 1.1 vs. 2.6 +/- 1.0 (p = 0.02) for a clinical PR per transfer of 43.2% vs. 50.0% for LS and Atg respectively. LS regime had a shorter gonadotrophin administration period with resultant COH cost one third of the Atg protocol (both, p < 0.0005). The cost per live birth per started cycle worked out to be USD 13,200 and 24,900 for LS and Atg respectively. Furthermore, LS had fewer incidences of OHSS compared to the Atg regime, 3.7% vs. 12.2%. CONCLUSION: LS cost benefits included lower amounts of gonadotrophin used and fewer injections. It is a viable alternative regime in producing comparable clinical PR at lower cost and less complication in ART.

The efficacy of etoricoxib vs mefenamic acid in the treatment of primary dysmenorrhoea: a randomised comparative trial.

Dysmenorrhoea is painful menstruation that occurs in 45-72% of all women. This was a prospective randomised study of the efficacy of etoricoxib (Arcoxia) compared with mefenamic acid (Ponstan) in treating primary dysmenorrhoea. All single, sexually inactive women with primary dysmenorrhoea were randomised into two groups (mefenamic acid and etoricoxib) of pain relief and underwent a cross-over study. The success of treatment as evidenced by pain relief, the side-effects and complications were observed and analysed. Some 80% (20 women) had significantly better pain relief with etoricoxib, compared with only 20 per cent in the mefenamic acid group (p = 0.007). Etoricoxib has significantly fewer side-effects compared with mefenamic acid (p = 0.005) with significantly reduced menstrual blood loss (p = 0.025). In conclusion, etoricoxib is a better treatment for primary dysmenorrhoea with better pain relief, less menstrual blood loss and fewer side-effects compared with mefenamic acid.

Postpartum pneumomediastinum.

A 21-year-old primigravida with previous history of pulmonary tuberculosis had a normal but assisted vaginal delivery after a prolonged second stage. Within 12 hours, she complained of dyspnoea and was found to have abnormal neck and anterior chest wall swelling. A diagnosis of subcutaneous emphysema was made and this was confirmed with the chest radiograph, which also revealed pneumomediastinum. She recovered well within four days with conservative treatment.

Misoprostol (alone) in second trimester terminations of pregnancy: as effective as Gemeprost?

Gemeprost (Cervagem) has been used widely compared with Misoprostol (Cytotec) alone in second trimester pregnancy termination. This prospective randomised trial was to evaluate the efficacy of intravaginal Misoprostol (alone) and Gemeprost in second trimester termination of pregnancy. A total of 54 women with 27 on each arm were involved. A total of 25 patients (92.6%) in the Misoprostol group and 22 patients (81.5%) in the Gemeprost group delivered within 48 h. The Misoprostol group delivered earlier, although average number of tablets required were similar. The side-effects were not significant between the two groups in fact, but there was more pyrexia in the Gemeprost group (p = 0.004). Misoprostol in second trimester termination of pregnancy is clinically as effective and less costly than the standard regimen of Gemeprost.

The predictive value of the zona-free hamster egg penetration test in relation to in-vitro fertilization at various insemination concentrations.

The aim of the study was to evaluate the predictive value of the zona-free hamster egg penetration test (ZHEPT) for success in in-vitro fertilization (IVF) at various insemination concentrations ranging between 0.1 and >0.6 x 10(6)/ml. The ZHEPT was assessed using sperm samples from 87 couples undergoing IVF treatment. A similar test was simultaneously performed on the same semen sample following ionophore induction of the acrosome reaction (ZHEPTii test). Both the tests were poorly correlated with the fertilization rate of IVF at all the insemination concentrations except at >0.6 x 10(6)/ml, when there was good correlation between the ZHEPTii test and the fertilization rate. Following exclusion of two cases with an oocyte problem, further statistical analysis revealed that both the ZHEPT and ZHEPTii tests were poorly correlated with fertilization rate in IVF in this treatment group. This study suggests that the ZHEPT (with and without ionophore induction of the acrosome reaction) has a poor predictive value for the success of fertilization in IVF treatment at any insemination concentration.