Aim: Polycystic ovarian syndrome (PCOS) is one of the most common endocrinopathies in women of reproductive age. It is associated with hyperinsulinemia and insulin resistance which is further aggravated during pregnancy. This mechanism has a pivotal role in the development of various complications during pregnancy. In the past few years, metformin, an insulin sensitizer, has been extensively evaluated for induction of ovulation. Its therapeutic use during pregnancy is, however, a recent strategy and is a debatable issue. At present, evidence is inadequate to support the long-term use of insulin-sensitizing agents during pregnancy. It is a challenge for both clinicians and researchers to provide good evidence of the safety of metformin for long-term use and during pregnancy. This study aimed to evaluate pregnancy outcomes in women with PCOS who conceived while on metformin treatment, and continued the medication for a variable length of time during pregnancy. Methods: This case-control study was conducted from January 2005 to December 2006 at the antenatal clinics of the Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan. The sample included 137 infertile women with PCOS; of these, 105 conceived while taking metformin (cases), while 32 conceived spontaneously without metformin (controls). Outcomes were measured in three groups of cases which were formed according to the duration of use of metformin during pregnancy. Comparison was made between these groups and women with PCOS who conceived spontaneously. Results: All 137 women in this study had a confirmed diagnosis of PCOS (Rotterdam criteria). These women were followed up during their course of pregnancy; data forms were completed once they had delivered. Cases were divided into three groups: group A, 40 women who stopped metformin between 4-16 weeks of pregnancy; group B, 20 women who received metformin up until 32 weeks of gestation; and group C; 45 women who continued metformin throughout pregnancy. All the groups were matched by age, height and weight. Comparison was in terms of early and late pregnancy complications, intrauterine growth restriction and live birth rates. In groups A, B and C the rate of pregnancy-induced hypertension/pre-eclampsia was 43.7%, 33% and 13.9% respectively (P < 0.020). Rates of gestational diabetes requiring insulin treatment in groups A and B were 18.7% and 33.3% compared to 2.5% in group C (P < 0.004). The rate of intrauterine growth restriction was significantly low in group C: 2.5% compared to 19.2% and 16.6% in groups A and B respectively (P < 0.046). Frequency of preterm labor and live birth rate was significantly better in group C compared to groups A and B. Overall rate of miscarriages was 7.8%. Controls were comparable to group A in terms of early and late pregnancy complications. Conclusion: In women with PCOS, continuous use of metformin during pregnancy significantly reduced the rate of miscarriage, gestational diabetes requiring insulin treatment and fetal growth restriction. No ...

Background: Polycystic ovarian syndrome (PCOS) is the most common cause of anovulatory infertility worldwide. In addition to a poor conception rate, pregnancy loss rates are significantly higher (30–50%) during the first trimester in women with PCOS. Insulin resistance (IR) in this syndrome is not only implicated toward early pregnancy loss (EPL) but also pathognomic for various obstetrical complications during pregnancy. We evaluated the role of Metformin in the reduction of EPL in women with PCOS who conceived spontaneously or after induction ovulation with or without Metformin. Objective: The primary objective was to evaluate the effectiveness of Metformin in the reduction of EPL in women with PCOS. Secondary outcomes like gestational diabetes, pregnancy-induced hypertension and intrauterine growth restriction were also analyzed at the end of the study. Material and Methods: This case-control study was conducted from March 2005 to March 2008 in the infertility and antenatal clinics of the Department of Obstetrics and Gynecology of Aga Khan University Hospital, Karachi, Pakistan. A total of 197 infertile women with PCOS were included. ‘Cases’ were women with PCOS who conceived while taking Metformin and it whom it was continued throughout pregnancy. ‘Controls’ were women in whom Metformin was either stopped in first trimester after confirmation of pregnancy (by serum βHCG or by ultrasound) or they conceived spontaneously without the use of Metformin. Results: All 197 women in this study had a confirmed diagnosis of PCOS (Rotterdam criteria). These women were followed till the final outcome of pregnancy was achieved. Both groups were compared for risk of EPL. It was found that continuation of Metformin during pregnancy reduces EPL, i.e. 8.8 vs. 29.4% in cases and controls, respectively (p < 0.001). In the subset of women with a prior history of miscarriage, the pregnancy loss rate was 12.5% in the Metformin versus 49.4% in control group (p = 0.002). Conclusion: Metformin continuation during pregnancy significantly reduces EPL in women with PCOS. IR may play a significant role in EPL.

Objectives: To determine the prevalence of abnormal Papanicolaou (Pap) smears in patients visiting the gynecologic outpatient department at Aga Khan University Hospital, Karachi (AKUH) and their cytohistologic correlation. This data was also compared with other international institutions. Methods: A database search of all abnormal cervical cytological cases diagnosed in the gynecologic outpatient department at Aga Khan University Hospital in the last 10 years (i.e. from 1994 to 2004), as well as their follow-up biopsies, was carried out. The data was then analyzed. Results: Of the 66 617 Pap smears reviewed, 95% of cases had a diagnosis of ‘negative’, 2% of smears were labeled as ‘inadequate’, 0.54% Pap smears showed dysplastic changes, and 0.14% were labeled as ‘malignant’. These numbers are less than figures in Western countires, but are comparable with Asian figures. The pick-up rate for abnormal Pap smears was 8/1000, while the overall concordance rate was 74%; positive predictive values for high-grade cervical lesions and for carcinomas was high 92–100%, respectively; while for ASCUS and low-grade cervical lesion was 35% and 67%, respectively. A total number of 8 cases were identified where there was a discrepancy between cytological and histological diagnosis, they were reviewed critically. Conclusion: In most of the developing countries effective Pap screening faces certain barriers. This includes limited or poor quality of cytology services. In a low-resource country like Pakistan there is a subset of patients (those with atypical cellular abnormalities) who may benefit from repeat smears instead of early cervical biopsies. In order to improve the efficacy of our cytology services, we need to develop specific clinical protocols for subsequent management of abnormal smears

Previous studies have found a significantly increased risk of preterm delivery and low birth weight after cervical conization. Most of these studies were case-control studies or were small, hampering the ability to detect significant differences between gestational age groups. This population-based cohort study evaluated the adverse consequences of cervical conization on subsequent pregnancies. The investigators linked data from the Medical Birth Registry of Norway and the Cancer Registry of Norway for the years 1967 to 2003 on 15,108 births occurring in women who had previously had cervical conization and 57,136 who subsequently had the procedure. The 2,164,006 births during the study period by women who had never had cervical conization served as controls.The proportion of preterm birth (delivery before 37 weeks of gestation) was 17.2% [95% confidence interval (CI); 16.6%-17.8%] among women who gave birth after cervical conization; 6.7% (95% CI, 6.5%-6.9%) in women who gave birth before cervical conization; and 6.2% (95% CI, 6.2%-6.3%) in women who never had the procedure. The relative risk (RR) of premature delivery after cervical conization compared with women who never had cervical conization increased with decreasing gestational age: RR 2.5 (95% CI, 2.4-2.6) at 33 to 36 weeks; RR 3.4 (95% CI, 3.1-3.7) at 28 to 32 weeks; and RR 4.4 (95% CI, 3.8-5.0) at 24 to 27 weeks. The risk of a late abortion (Ͻ24 weeks of gestation) was higher after cervical conization compared with no conization; the RR was 4.0 with a 95% CI of 3.3 to 4.8. During the study period, the RR of preterm delivery declined, particularly for delivery before 28 weeks of gestation. These findings show that cervical conization increases the risk of preterm delivery in subsequent pregnancies, especially early in pregnancy when the clinical significance is highest. EDITORIAL COMMENT(As one would expect, the data that we have relating ablative and excisional procedures for cervical dysplasia to late abortion and prematurity were not derived from randomized studies. That is to say, reproductive age women with cervical dysplasia deemed to require cervical ablation or excision have not been randomized to therapy or to expectant management for the purposes of evaluating their subsequent preg-nancy performance. Nor has a study been done wherein women have been randomized to different methods of cervical ablation or excision for the purposes of comparing subsequent pregnancy outcomes. Clearly, randomized trials of this nature would be logistically extremely difficult to do, and, in some situations, ethically problematic. But they would be the best way to overcome the major problem in evaluating the OBSTETRICS Volume 64 Number 2 OBSTETRICAL AND GYNECOLOGICAL SURVEY ABSTRACTPrevious studies have shown that during cesarean section, the concentration of lactate in myometrial capillary blood is higher among women with dysfunctional labor compared with normal labor. Small increases in lactate concentrations have been associated with impairment in the strength an...

Objective: To determine the prevalence of urinary tract injuries, identification of risk factors and methods employed for repair and their outcomes. Study Design: Cross-sectional study of patients who had urinary tract injuries during major obstetric and gynaecological surgeries at the Aga Khan University Hospital (AKUH) from 1985 to 2004. Material and Methods: Computer-generated discharge summaries of patients who underwent major obstetric and gynaecological procedures during the 20 years of study period were retrieved. Information was collected on data collection form, and entered in SPSS version 13 and analysed. Results: During the study period 12,567 obstetrics and 5,966 gynaecological procedures were performed. There were 3,910 abdominal hysterectomies, 984 myomectomies, 591 ovarian/ adenexal surgeries and 481 vaginal hysterectomies. Out of these 110 urinary tract injuries were identified, 71 (64.5%) were of the urinary bladder and 39 (35.5%) were ureteric in origin, 31 (43.6%) bladder injuries were sustained during caesarean sections while 40 (56.3%) were during gynaecological procedures. In obstetric cases there were two ureteric injuries, the other ureteric injuries were sustained during surgeries for benign gynaecological conditions. The prevalence of bladder and ureteric injuries in obstetric surgeries was 0.25 and 0.02%, respectively, whereas in gynaecological surgeries the prevalence was 0.7 and 0.6% for urinary bladder and ureteric injuries. These figures compare well with other published series. Conclusion: Urinary tract injuries are an uncommon occurrence but when they occur they have serious implications in terms of morbidity and litigation. The prevalence of urinary bladder and ureteric injuries observed in our review is comparable to previous reported international series. Of concern is the fact that most of the ureteric injuries were diagnosed post operatively which means that further vigilance and preventive strategies need to be designed.