This document describes a study that compared the effectiveness of letrozole combined with misoprostol versus misoprostol alone for medical termination of first trimester delayed miscarriages. 126 women with miscarriages under 12 weeks gestation were randomly assigned to receive either letrozole followed by misoprostol (n=64) or misoprostol alone (n=62). The complete miscarriage rate was significantly higher in the letrozole/misoprostol group compared to the misoprostol alone group. The time from treatment to miscarriage was also shorter for the letrozole/misoprostol group. Fewer women in the letrozole/misopro
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Third stage complications of labour- post partum hemorrhage in obstetrics and...sreya paul
management of postpartum hemorrhage in obstetrics and gynecology,bleeding can lead to death of mother after delivery. it is a very serious problem that need immediate interventions
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Third stage complications of labour- post partum hemorrhage in obstetrics and...sreya paul
management of postpartum hemorrhage in obstetrics and gynecology,bleeding can lead to death of mother after delivery. it is a very serious problem that need immediate interventions
—In recent years, termination of pregnancy has also become more common procedure due to intensive development of medicines and increasing demand for such procedures. In previously scarred uterus the use of medical abortion regimen could avoid severe complications such as uterine perforation, cervical laceration and other physical and psychological trauma which are caused by surgical termination of pregnancy. This prospective study was conducted in Department of Obstetrics and Gynaecology, J.L.N. Medical College, Ajmer from December 2015 to November 2017 to compare the efficacy, safety and acceptability of medical abortion in previously scarred and non-scarred uterus. For this study 75 women were included of amenorrhoea < 49 days with previous one or two LSCS (Lower segment cesarean section) and 75 women with no LSCS (primi and multipara with prior normal delivery). Regime which was used in this study was tab. Mifepristone 200 mg followed by Misoprostol 600µgm were given to them. Follow up was done at day 14 using sonography. The overall success rate for complete abortion in group I was 88% and that of group II was 89.3%.Total proportion of incomplete abortion was 9.33% in group I as compared to 8% in group II and continuation of pregnancy occurred 2.67% in both the groups during the entire study period. Thus there was no significant difference in efficacy of medicines in achieving abortion in scared and non-scared uterus. So early medical abortion represents an important method in previous scarred uterus patients having unwanted pregnancy. These regimens offer the prospect of a more private, less intrusive form of abortion that is both safe and effective.
The comparison of dinoprostone and vagiprost for induction of lobar in post t...iosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Rate of Different Types of Abortion in Madinah Maternity and Children Hospita...Crimsonpublishers-IGRWH
Rate of Different Types of Abortion in Madinah Maternity and Children Hospital, Madinah, Saudi Arabia by Mohammad Othman in Investigations in Gynecology Research & Womens Health
Methods of Abortion in early weeks of PregnancyiCliniq
After conforming intrauterine pregnancy, abortion is possible in early weeks of pregnancy Abortion can be done by different methods, which includes Medical termination and Surgical evacuation with suction and evacuation.
Read more to get detailed discussion by a doctor regarding abortion methods and procedure --> https://www.icliniq.com/qa/abortion/what-are-the-abortion-options-during-6-weeks-of-pregnancy
To contact an online Obstetrician And Gynaecologis --> https://www.icliniq.com/ask-a-doctor-online/obstetrician-and-gynaecologist
Evaluation of pregnancy outcomes after thyroid surgeryAI Publications
Background: According to contemporary cancer data, women account for roughly 75% of differentiated thyroid carcinoma (DTC), with the largest incidence occurring in individuals aged 50-59 years in the United States. Objective: This paper aims to evaluate of pregnancy outcomes after thyroid surgery. Patients and methods: This paper was interested to analyse and evaluate of pregnancy outcomes after thyroid surgery by radioactive iodine therapy, which includes 42 cases of pregnant women which suffered of thyroid and processes of thyroid surgery were applied in different hospitals in Iraq from 15th March 2021 to 27th July 2022. This data collected were analysed and conducted all demographic characteristics by the SPSS program. Discussion: This paper was presented different outcomes of pregnant women patients where it presented that the women have overweight were more struggled than those underweight due to a goiter which causes an overweight. In addition, the outcomes of pregnancy outcomes after surgery were got low birth weight; baby were most of the risk factors that have a high influenced on the women after pregnancy, with where it covered 7.1% of women. Furthermore, in the evaluations of blood pressure measurements post-operative of pregnant women surgery where this study diastolic blood pressure of women measurements after surgery and during surgery which found 57.14% for women have a blood pressure of <80 mm Hg and 23.81 for women have 80-89 mm Hg as well as 19.05 for women have >90 mm Hg. Conclusion: In conclusion, this study indicates that there is uncontrolled hyperthyroidism in pregnant patients, which causes many effects. In addition, this study showed that thyroidectomy surgery was successful, but our study found that there is an increased risk in the case of premature delivery before radioactive iodine treatment. After thyroid surgery, radioactive iodine therapy may be required in some thyroid cancer instances. As of currently, this paper suggests women waiting at least six months before getting pregnant after receiving radioactive iodine therapy due to worries about potential radiation impacts on the unborn child's development.
Endometrial cancer: Disease & Treatment Overview & Journal club farah al souheil
general overview of endometrial (uterine) cancer followed by treatment options followed by journal club about the possible effects of metformin on Ki-67 one of the approved prognostic factors for EC
Similar to Letrozole combined with Misoprostol for management of delayed miscarriages (20)
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. Online Journal of Gynecology, Obstetrics and Maternity Care
https://chembiopublishers.com/OJGOMC/ Submit Manuscript @ https://chembiopublishers.com/submit-manuscript.php
2
Keywords: Letrozole; Misoprostol; First trimester delayed miscarriage
Abbreviations: SD: Standard Deviation; FTDM: First
Trimester Delayed Miscarriage; NICE: National Institute
for Health and Care Excellence; SPSS: Statistical Program
for Social Science.
Introduction
(FTDM) is one type of miscarriages which defined as a
failure to expel of an embryonic gestation and embryonic
or fetal death that occurring in 10-20% of clinically
recognized pregnancies [1-3]. With around 95% success
rates, surgical evacuation is regarded as the standard
treatment for such cases, which had been widely
performed all over the world in the past 50 years [4].
However, the costs of surgery as well as the complications
associated with surgery and anesthesia are major
concerns, in addition to the increased risk of infection,
bleeding and decreased fertility caused by intrauterine
adhesions. Some studies have thus suggested that
expectant or medical management might be more suitable
instead of surgical evacuations [5,6]. Expectant
management has been reported with unpredictable
success rate ranging from 25-76% [7-9]. Waiting for
spontaneous expulsion of the products of conception
would waste much time, during which women may suffer
uncertainty and anxiety in addition to the risks of
emergency surgical treatment, bleeding and blood
transfusions [7,10].
Miso by itself is used for the medical management of
miscarriage as an alternative to surgery [11-14]. Miso is a
synthetic analogue of naturally occurring prostaglandin
E1 which induces abortion by stimulating the
myometrium and cause cervical ripening and dilatation
[15]. Compared with other type of prostaglandins, it has
the advantage of feasibility, simple and easy
administration, low price, stability at room temperature,
and fewer side effects [16,17]. The range of reported
success rate of induction of abortion with misoprostol is
quite different in several studies (between 37% and 86%)
depending on the regimen, route of administration, and
dosage used [14]. A single dose of 800 mcg of Miso by
vaginal or oral route for FTDM was recommended by
National Institute for Health and Care Excellence (NICE)
[18]. However some studies reported that, a lower dose or
different routes of Miso misoprostol may be equally
effective [19,20]. Miso has also been used in combination
with other medication such as Mifepristone to increase
the success rate of up to 95% [21-24]. The widespread
use of mifepristone is limited by the fact that it is
expensive, and is not available in many countries
[15,25,26] so, a cheaper and easily available alternative
such as LTZ has been studied.
LTZ is a non-steroidal, third generation aromatase
inhibitor. It reversibly and competitively bonds with the
iron in cytochrome P450 and prevents the production of
estrogen by the enzyme aromatase which is secreted from
the placenta, ovarian granulosa cells, and other tissues,
such as fat, muscle, brain and breast tissue [27]. LTZ is
widely used in the treatment of hormonally-responsive
breast cancer after surgery [28,29]. And other
gynecological conditions which are hormonal dependent
such as management of subfertility, endometriosis and
uterine fibroids in combination with Cabergoline [30]. It
has been shown that the use of LTZ combined with
vaginal misoprostol was more effective than misoprostol
alone in termination of pregnancy [31,35,36,37].
Previous studies explored the mechanism of LTZ in
medical abortion. One study concluded that, the
expression of progesterone and estrogen receptor
transcripts and estrogen receptor-alpha protein were all
suppressed by LTZ in the placentas of women receiving
LTZ; however, their study only examined second
trimester terminations and not terminations in the first
trimester of pregnancy [38]. Another study evaluated the
effect of LTZ-induced estradiol suppression on the
reduction of progesterone receptor expression and
apoptosis in the first trimester pregnancies and found no
difference in the expression of progesterone receptors
and apoptotic markers in decidual tissue after
pretreatment with LTZ for 7 days before first trimester
abortion [39]. Also, another study measured the effect of
LTZ on uterine artery Doppler indices prior to surgical
termination of first trimester pregnancy and found
significant decreases in both pulsatility and resistance
index in the LTZ group, which suggests that blood flow
changes might play a role in the mechanism of action of
LTZ [41]. However, recent study has shown that LTZ has
no effect on uterine contractions [42]. In our study, we
aimed to compare the success rate (The rate of complete
miscarriage) & safety of LTZ combined with Miso versus
Miso alone for medical termination of FTDM.
Patients and Methods
A hospital based clinical trial was conducted at Obstetrics
& Gynecology departments, Al-Amal hospital & Misurata
Medical Centre, during a period of 15 months from first
3. Online Journal of Gynecology, Obstetrics and Maternity Care
https://chembiopublishers.com/OJGOMC/ Submit Manuscript @ https://chembiopublishers.com/submit-manuscript.php
3
January 2017 to 31st March 2018. Patients were recruited
from outpatient antenatal clinics with inclusion criteria:
gestation age up to 12 weeks based on LMP with no fetal
cardiac activity diagnosed by ultrasound scan, age
between 20- 33 years old, pre-treatment hemoglobin
concentration (Hb) ≥ 10 gr/dL with no coagulopathy,
agreement by the woman to undergo surgical termination
if treatment fails; willing and able to participate after the
study had been explained; Exclusion criteria: presence of
fibroid or uterine anomalies, having intrauterine device,
coagulopathy, and any other medical conditions
contradicted with induction of abortion. A detailed
medical history was taken and physical examination was
performed including local examination to assess the
cervix, investigations were performed including complete
blood count, blood group and Rh typing, screening for
thrombophilia. A total of 126 patients with FTDM were
randomly divided into 2 groups; (LTZ/Miso group) in
which 64 patients received LTZ 2.5mg every 8 hours for
three days followed by vaginal Miso 800mcg on 4th day
which is the day of admission and (Miso group) in which
62 patients were admitted to receive only Miso tablet of
800 mcg given as a single PV dose.
Patients stayed in the hospital after the administration of
Miso for 4 hours. Time of expulsion of product of
conceptions, side effects if any including (nausea,
vomiting, diarrhea, headache, fever, skin rash or
abdominal pain) and PV bleeding were recorded. They
were discharged after the 4-hrs observation period if the
PV bleeding was not heavy and abdominal pain was not
severe. A follow-up visit was arranged on day 7 during
which a transvaginal ultrasound was performed and
blood sample was taken for Hb level. Patients who did not
abort till 7 days were considered failure to induce
complete miscarriage and surgical evacuation was
performed under general anesthesia. Surgical evacuation
was performed at any time over the 7 days follow up
period if there was heavy bleeding. If no surgical
evacuation was necessary over the 7 days, the outcome of
treatment was labeled as complete miscarriage.
The main treatment outcome evaluated was the success
rate of this protocol, represented by patients achieving a
complete miscarriage with the medical treatment and the
induction-to-miscarriage time in each group. Also the
presence of side effects was analyzed.
Statistical Analysis
Data were analyzed using the Statistical Program for
Social Science (SPSS) version 20.0. Quantitative data were
expressed as mean±standard deviation (SD). Qualitative
data were expressed as frequency and percentage.
Independent t-test of significance was used to compare 2
means. Chi-square (χ2) test was used to compare
proportions of 2 qualitative parameters. Probability (p-
value): p>0.05 was considered insignificant, p≤0.05 was
considered significant, and p<0.001 was considered
highly significant.
Results
A total of 126 patients diagnosed with FTDM met the
inclusion criteria and were elected to enroll on this study.
During follow up period, 4 patients in LTZ/ Miso group,
and 6 patients in Miso group did not return for the follow-
up visit and were excluded. Finally, 60 patients in
LTZ/Miso group and 56 patients in Miso group completed
the study and analyzed (Figure 1). The mean age of
patients in the LTZ/ Miso group and Miso group was
28.3±3.4 and 29.8±4.5 years respectively. Mean GA was
9.2 ±3.4 and 10.9±1.8 respectively. The number of
previous miscarriages was 21 (35%) and 18 (32.14%)
respectively which showed no significant difference
between the groups. The rate of recurrent miscarriages
was high in both groups; the difference was not significant
(Table 1). The rate of complete abortion was (48/60,
80%) in LTZ/Miso group and (29/56, 51.8%) in Miso
group, the differences was statistically significant (P
<0.0001) (Figure 2). Surgical treatment was performed in
the remaining (39/126, 30.95%), representing the total
failure of medical treatment. The mean duration time
from Miso administration to expulsion of product of
conception (induction-to-miscarriage time) was shorter
(6.1±1.6 hrs) in LTZ/Miso group compared with (9.4±2.2
hrs) in Miso group. The difference was also statistically
significant (<0.003) (Table 2). The mean hemoglobin
before treatment was (10.90 g/d, ranging 9-11g/d) and
(10.82 g/dl ranging 9-12) in LTZ/Miso group and Miso
group respectively, the difference was not significant
(P=0.654). After treatment, the mean hemoglobin was
(10.40 g/d, ranging 9-11g/d) and (10.24 g/dl ranging 8.5-
11.10) in LTZ/Miso group and Miso group respectively,
the difference was not significant (P=0.428).
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Figure 1: Flow-chart of the patients involved in the study.
Variables
LTZ/Miso group
(n=60)
Miso group
(n=56)
P value
Age (years) 28.3±3.4 29.8±4.5 0.14
BMI 23.4±1 22.9±2 0.09
Gestational age (weeks) 9.2 ± 3.4 10.9±1.8 0.17
Gravidity
1
2
≥3
14 (23.3%)
13 (22.6%)
32 (53.3%)
10 (17.8%)
8 (14.2%)
33 (58.9%)
Previous miscarriage 21 (35.0%) 18 (32.1%)
Table 1: Comparison of demographic data.
The recorded side effects after LTZ/Miso treatment were
Nausea & vomiting (16.7%), abdominal pain (10.0%),
fever (8.3%) and sever bleeding needing evacuation
(6.7%), and diarrhea (5%) whereas after Miso only
administration, sever bleeding needing
evacuation(14.3%), nausea & vomiting (10.7%),
abdominal pain (7.1%), fever (7.1%) and diarrhea (3.6%).
The difference between groups was not significant; almost
all side effects subside on follow up visit (Table 2).
Figure 2: Comparison of the success rate (complete miscarriage rate) between the groups.
P <0.0001.
0%
10%
20%
30%
40%
50%
60%
70%
80%
LTZ/Miso groupMiso group
success rate
failure rate
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P value
Group A
LTZ/Miso
Group B
Miso
Variables
Induction to miscarriage time (h) 6.1±1.6 9.4±2.2 <0.003
Side effects
• Nausea & vomiting
• Abdominal pain
• Diarrhea
• Fever
Sever bleeding needing evacuation
28 (46.6%)
10 (16.7%)
6 (10.0%)
3 (5.00%)
5 (8.30%)
4 (6.70%)
24 (42.8%)
6 (10.7%)
4 (7.1%)
2 (3.6% )
4 (7.1%)
8 (14.3%)
>0.05
Table 2: Comparison of induction-to-miscarriage interval and side effects of medication.
Discussion
The present study is aimed to assess the effects of
sequential LTZ/Miso protocol compared with Miso alone
for the induction of FTDM. Based on our observations,
there was a higher rate of complete miscarriages in the
group received LTZ/Miso (80%) compared to the Miso
group (51.8%) which was statistically highly significant.
The induction-to-miscarriage time was significantly
shorter in LTZ/Miso group compared to the Miso group.
Previous studies also reported a significant difference in
favour of the LTZ/Miso group. In Lee et al. study, after use
of LTZ (10 mg for 3 days) combined with a single dose of
vaginal Miso (800mcg), complete abortion rate was 93%
up to 49 days gestation [31]. A study by Torky HAet al.
who used LTZ 10 mg twice daily for 3 days followed by
800mcg administered vaginally, showed a complete
miscarriage rate of 78% compared to 39% in group
received placebo prior to Miso administration [34].
Another study explored the regimen of sublingual Miso
following pretreatment with LTZ 10 mg for 3 days in
women with gestational age less than 17 weeks and
showed a complete abortion rate of 76.7% [33]. In a pilot
study, by Yeung et al. tested a longer protocol of 7-days
course of LTZ followed by vaginal Miso and showed a very
high complete abortion rate about 95% [39].
Javanmanesh F et al. found a significantly higher rate of
complete abortions (78.3%) in those who received 10mg
daily Letrozole for 3 days followed by oral Misoprostol
with mean induction- tobo nbi ni noitr ba 22.61±7.721
hours [40].
A possible explanations for the different results could be
the different treatment regimens and differences in
gestational age, in addition, differences in studied
populations, genetic diversity and distribution of
receptors, PH of the vagina, drug manufacturers were
confounding factors that must be considered. However
like previous studies, LTZ/Miso combination is more
effective than Miso alone or with placebo. Our study also
showed that the mean induction-to-miscarriage time in
LTZ/Miso group was significantly shorter than the time in
Miso group (6.1±1.6 hrs). Our result was within the range
of time reported by other studies, after the addition of
LTZ pretreatment of Miso [31,38,39,29].
Regarding the side effects, the regimen used was well
tolerated with no major side effects and was comparable
between the groups. Our study was similar to some
previous studies that show similar side effects [43]. The
proportion of women who complained of nausea,
vomiting and abdominal pain was higher in LTZ/Miso
group and that may be related to the use of two
medications. In addition, the proportion of women with
severe bleeding who needed surgical evacuation was
lower in the LTZ group, none of the women had a marked
drop in hemoglobin level or required blood transfusion.
Based on the success of management of first trimester
delayed miscarriages, Letrozole might be considered as
medical treatment of ectopic pregnancy as estradiol
suppression facilitate the abortion process and leads to
cease development of this condition.
Conflicts Of Interest
The authors declare that they have no conflicts of interest
related to the subject matter or materials discussed in this
article.
Financial Disclosure
he authors declare that this study has received no
financial support.
Conclusion
Our results showed that a 3-day course of Letrozole
(2.5mg every 8hrs) followed by vaginal Misoprostol 800
mcg on the 4th day was associated with a higher complete
miscarriage rate and decreased the interval between
induction and expulsion in women with FTDM. However,
further studies using different regimens and different
indications may be warranted.
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Author Contributions
AME-designed the study, data collection, conducted the
clinical work and writing manuscript. FME- conducted the
literature search, statistical analyses/interpretation, and
critical review. All authors approved the final manuscript.
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