Biomedical subjects
Publications and source records attributed to T R Varma.
The history, diagnosis and management of two patients with premature ovarian failure who responded to estrogen replacement therapy is presented. Both women conceived and had a live healthy baby.
Pregnancy following a period of infertility was considered to be an increased risk for the fetus. During a period of 3 years (1983-85), 748 couples were seen at this infertility clinic; 515 women (68.9%) conceived, and were followed up and studied prospectively. Fifteen of these women moved out of the area. We analysed the results of pregnancies for the remaining 500, (Group 1) and compared them with the outcome for the total obstetric population (Group 2) during the same period. Mean age at conception in the infertility group (Group 1) was 31.8 (+/- 2.7, 2 SD) years, as compared with 23.7 (+/- 2.9, 2 SD) in the total hospital obstetric population (Group 2) (p less than 0.05). The incidences of spontaneous abortion for the two groups (8 and 6.2%) did not differ (p greater than 0.05). However, the incidence of ectopic pregnancy was higher (3.0%) in Group 1 than in Group 2 (1.5%) (p less than 0.01). The incidence of pre-existing hypertensive vascular disease (7.7%) complicating pregnancy and multiple pregnancy (4.1%) was significantly higher in Group 1 than in Group 2 (1.5% and 1.4% respectively), (p less than 0.01). The incidences of induction of labor (29.5%) and elective operative delivery (10.6%) were higher in Group 1 (p less than 0.01). The incidences of infants with birth weight below the tenth centile (12.9%), of fetal distress in labor (14.6%) and a low Apgar score (0-5) (9.5%), were higher in Group 1, but there was no difference in the perinatal mortality rate between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)
For the past two decades, significant advances have been made in the treatment of anovulation. The use of therapeutic agents for induction of ovulation, however, has given rise to several adverse reactions, the most important and serious of such complications being the ovarian hyperstimulation syndrome (OHSS), which can be fatal. It is characterized by gross ovarian enlargement, ascites, pleural effusion, hemoconcentration and thromboembolic disorder, which are potentially lethal conditions. The main pathogenic mechanism is considered to be increased capillary permeability, especially of the ovarian vessels, causing acute body fluid shift from the intravascular compartment to the peritoneal and pleural cavities. An experimental model of OHSS suggests that prostaglandins mediate this increased capillary permeability and transudation. Management is based on the concept of the pathogenic mechanism and includes maintenance of intravascular volume by plasma volume expanders, reduction of capillary permeability and prevention of thromboembolic complications. Surgical intervention is indicated only in cases of ovarian torsion or rupture and should be as conservative as possible.
We studied 500 women who conceived after investigation and treatment for different infertility problems and compared the outcome of the 5 infertility groups (Group 1 to 5), the ovulatory dysfunction (Group 1), male infertility (Group 2), A.I.D. (Group 3), tubal surgery and IVF (Group 4) and no treatment (Group 5) with the outcome in the hospital group during a period of 3 years. The incidence of abortion in Group 3 is significantly higher (13.8%), the incidence of ectopic pregnancy is significantly higher in Group 4 (21.7%) as compared with the incidence in the hospital group (P less than 0.01). The rate of pre-existing hypertension and gestational diabetes is significantly higher in all the 5 infertility groups as compared with the incidence in the hospital group (P less than 0.05). The incidence of preterm labor in general is less in the infertility group as compared with the incidence in the hospital group (P greater than 0.05). The incidence of older women, multiple pregnancy, induction of labor, operative deliveries, fetal distress, low Apgar score, babies with birth weight below the tenth centile were higher in the infertility groups (P less than 0.05). But the perinatal mortality or major or minor fetal anomalies were not significantly different in the infertility groups as compared with the rate in the hospital groups (P greater than 0.05).
Combined intrauterine and extrauterine gestation is very rare. There is a higher maternal morbidity and fetal loss, due to delayed or missed diagnosis. We present a patient who was treated for primary infertility with ovulation induction agents, who presented later with combined intra- and extra-uterine gestation with successful outcome following delivery of a healthy male infant at 38 weeks gestation.
One hundred seventy patients were considered to be at risk of cervical incompetence from their previous history. They were scanned serially from the first trimester to 36 weeks gestation. Of the 170, 105 patients (61.8%) were found to have defective cervix (the length of cervix, width of the cervix, and cervical canal at the level of the internal cervical os, and herniation of amniotic membrane with or without fetal parts into the cervical canal). Of the 105 patients diagnosed to have defective cervix (possible cervical incompetence), 22 patients (21%) aborted, 48 patients (45.7%) had to have cervical cerclage, 26 patients (24.8%) had preterm delivery and the remaining 9 patients (8.5%) had no problems during pregnancy. The remaining 65 patients (38.2%) did not have ultrasonic evidence of cervical incompetence and 3 aborted and only 2 patients delivered between 35 and 37 weeks gestation while 60 patients delivered between 37 and 42 weeks gestation. These 65 patients would have had cervical cerclage on the basis of the clinical history alone, but in only 6, cervical cerclage was inserted.
Daily simultaneous cervical mucus evaluation and ultrasonography of the Graafian follicular growth and ovulation were studied (in the mid-cycle) in 8 infertile British women during 30 Cyclofenil-stimulated cycles, and compared with 18 non-stimulated normal ovulatory cycles in 12 subjects (controls). In the 16 Cyclofenil-induced ovulatory cycles, there was an early (5 days prior to the day of ultrasonic ovulation) Full Cervical Mucus Score (Insler) in 69% of the cycles, and the Full Cervical Mucus Score lasted for 7 days or more in 63% of the cycles. In 38%, there was persistence of the Full Cervical Mucus Score on the third day after ultrasonic ovulation. In the 14 Cyclofenil-treated anovulatory cycles, a Full Cervical Mucus Score was recorded on one or more occasions in the mid-cycle in 29% of the cycles. The classical teaching of prediction of the probable timing of ovulation by Cervical Mucus Scoring is not applicable to Cyclofenil-stimulated cycles.
Anti-thrombin III is the major inhibitor of activated blood clotting factors. We studied 320 patients with climacteric symptoms who received estrogen replacement therapy to assess the effect of hormone therapy on Anti-thrombin III (AT-III) activity). Of the 320 patients 80 patients received Prempak C (0.625 mg) for 2 years, 82 patients received Prempak C (1.25 mg) for 2 years, 78 patients received Cycloprogynova (1 mg) for 2 years and the remaining 80 patients received Cycloprogynova (2 mg) for 2 years. The mean AT-III activity before, during and 3 months after treatment showed no significant difference in all the four groups of patients. There was no incidence of myocardial infarction or stroke or thrombo-embolic disease in this group of 320 patients receiving estrogen replacement therapy.
We studied 30 normal pregnant women from the first trimester to 36 weeks. This group of women had had no previous miscarriage, termination of pregnancy, operations on the cervix, or premature labor. Fifteen were primigravidae and the remainder were multigravidae. There was no significant difference in the length of the cervix from 10 to 36 weeks of gestation (p greater than 0.05). The mean width of the cervix gradually increased from 10 to 36 weeks of gestation (p less than 0.01). The mean width of the cervical canal showed no significant change from 10 to 36 weeks of gestation (p greater than 0.05).
One hundred and fifteen women were considered to be at risk of cervical incompetence, judging from their previous history. They were scanned serially from the first trimester to 32 weeks of gestation. Of the 115, 75 women were found to have defective cervix, as assessed on the basis of its length, its overall width and the width of the cervical canal at the level of the internal cervical os, and herniation of the amniotic membrane, with or without fetal parts, into the cervical canal. Sixteen of the 75 women with ultrasonically diagnosed cervical incompetence aborted, 40 needed cervical cerclage, 24 gave birth premature (24 to 34 weeks). Of the 115 women, 40 did not have ultrasonic evidence of cervical incompetence and only one patient gave birth at 36 weeks' gestation, while 39 patients gave birth between 37 and 42 weeks. These 40 women would have had cervical cerclage on the basis of clinical history alone. Ultrasound is an objective method of diagnosing the incompetent cervix and also helps to avoid unnecessary cerclage operations on the basis of history alone.
A case of an intracerebral aerocele as a complication of an osteoma in the frontal sinus is reported. The patient had been investigated 7 years earlier for three episodes of idiopathic nocturnal epilepsy. Roentgenograms of the skull at that time showed the presence of a small osteoma within the frontal sinus. Removal of the osteoma was undertaken via a bifrontal approach and repair to the dural defect was made with a temporalis fascia graft. Postoperatively, the patient made a good recovery but developed frequent focal left hemisphere epilepsy. It is our view that sinus osteomas that are incidentally found should be removed before complications arise.
We studied a group of 398 patients who had been receiving estrogen replacement therapy since 1976. Group I consisted of 138 patients who received Premarin (conjugated equine estrogen, Ayerst) in two different dosages (0.625; 1.25 mg) and progestational agents such as Neogest (Norgestrel, Schering), Duphaston (Dydrogesterone, Duphar) 5 mg and Primolut N (Norethisterone, Schering) 5 mg, for a period ranging between 7 and 21 days. Group II consisted of 106 patients who received Harmogen (Piperazine Oestrone Sulphate, Abbott) in two different dosages (1.5 mg; 2.25 mg) with the above-mentioned progestational agents for a period ranging between 7 and 21 days. Group III consisted of 154 patients who received Progynova (Oestradiol Valerate, Schering) in two different dosages (1 mg; 2 mg) with the above-mentioned progestational agents for a period ranging between 7 and 21 days. When increasing dosages of estrogen with progestational agents were added for 7 days, this produced cystic hyperplasia of the endometrium. When the duration of progestational agents was increased to 10 days or more, a more atrophic and secretory endometrium resulted and there was no incidence of cystic hyperplasia.
Serum FSH, estradiol and estrone levels were assayed in 35 post-menopausal women who received the three commonly available estrogen preparations Premarin, Progynova and Harmogen. The results were compared with the levels during treatment with Dixarit. Hormone levels did not change when Dixarit was used. The levels of estrone and estradiol increased significantly (p less than 0.01) when estrogen preparations were used. There was no abnormality in the endometrium at the end of the treatment period.
We studied 3002 antenatal patients to assess the relationship between maternal weight at booking in the first trimester and the total weight gain during the pregnancy and the birth weight of infants, pregnancy complications and mode of delivery. We found if the weight of the mother in the first trimester was lower or higher by 20% as compared with the standard weight, and the weight gain was more than 16 kg and less than 2.5 kg, there was higher incidences of maternal and fetal morbidity (P less than 0.01).
We studied 10 normal and asymptomatic patients with ovulatory cycles and measured serum sodium, potassium, FSH, LH, prolactin, estradiol, progesterone and cortisol. The findings were compared with the levels in 25 patients with ovulatory cycles with premenstrual symptoms (PMS) lasting for 7-14 days prior to the onset of menstrual flow. We found no significant difference in serum sodium and potassium levels between the asymptomatic (control) group and the PMS group, or between the follicular and luteal phases of the menstrual cycle. We found no difference in hormone levels other than an altered estrogen/progesterone ratio in the second half of the luteal phase in seven out of 12 PMS patients with severe symptoms and a higher level of cortisol in the luteal phase in six out of 12 patients with severe PMS symptoms. However, the level of serum cortisol was still within the normal range. There was no significant alteration in the levels of electrolytes or hormones during treatment with Navidrex K (cyclopenthiazide, diuretic) pyridoxine (Vitamin B-6), dydrogesterone ( Duphaston ) alone, or all the three drugs combined.
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A study of antenatal cardiotocographs (CTG) in 250 patients with fetal growth retardation showed that nonreactive tracings were associated with a significant increase in operative deliveries for fetal distress in labour, a high perinatal mortality rate, and fetal anomalies, and a low Apgar score of the infant, both at one and five minutes after delivery. A "ten-point" scoring system was used to evaluate the CTG tracing. A score of 6 or less was associated with a significantly higher perinatal morbidity and mortality rate compared with those who had a score of 7 or more (p less than 0.01).