PCOS AND HYPERINSULINISM

The most common endocrine cause of anovulation is polycystic ovary syndrome (PCOS). Typically, women with this problem present with infertility associated with scanty menstrual periods and cycles of more than 35 days. Most patients have some clinical or laboratory evidence for hyperandrogenism, and polycystic ovaries appear on ultrasonography. The familial association with diabetes mellitus (DM) is quite significant. As the risk for DM amongst PCOS women is increased several-fold, many of them become diagnosed with impaired glucose tolerance or insulin resistance. This disturbance in glucose metabolism is due to elevated baseline or stimulated insulin levels and may be a consequence of a genetic predisposition. The role of insulin as a growth factor is well established. Insulin stimulates the ovarian theca cells to produced increased amounts of androgens. Considering that androgens serve as precursors for estradiol synthesis, it is therefore unsurprising that estradiol levels become elevated. Hyperandrogenism also interferes locally with the normal process of folliculogenesis thus propounding the hormonal and fertility problems. Metformin is an insulin-sensitizing drug that is commonly used in the treatment of DM and serves to reduce insulin secretion. Its use is also associated with a normalization of the intraovarian paracrine milieu and is effective in PCOS. Despite the belief that metformin may not be totally effective in the management of fertility-related issues, it is quite logically an effective form of treatment that addresses the hormonal imbalance in patients with PCOS. Having said that, lifestyle changes remain in the forefront of combating abnormalities of glucose metabolism and associated metabolic problems.
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Uterotonics and Postpartum Haemorrhage

Postpartum hemorrhage is an important cause of maternal mortality in developing countries, especially Africa and Asia. Active management of the third stage of labor consists of the use of oxytocin soon after delivery of the baby, controlled cord traction, and delayed clamping and cutting of the cord until the deliverer is ready to apply traction.

In a study published recently in The Lancet, Gulmezoglu et al showed that controlled cord traction may be omitted from the management of the third stage of labor without a significant increase in the risk for severe hemorrhage. Thus, the main component of active management is the uterotonic and it is the key intervention that will prevent excessive bleeding after childbirth.

Despite this, controlled cord traction is safe and its use can be continued in settings in which it is routinely practiced.

Hanifullah Khan

22 March 2012

Reference:

Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Gulmezoglu AM, Lumbiganon P, Landoulsi S et al. The Lancet - 6 March 2012 DOI: 10.1016/S0140-6736(12)60206-2.