Fertility management in Kallmann syndrome: a step towards optimization

Kallmann syndrome (KS) is a genetic disorder with an incidence of one per 50,000 women. It is associated with hypogonadotropic hypogonadism and anosmia/hyposmia. An important aspect of managing KS is to achieve successful pregnancy. We hereby present a case series of three patients with KS who successfully conceived with human menopausal gonadotropin (HMG) induction. One patient achieved pregnancy with ovulation induction, second with fresh embryo transfer and the third with frozen embryo transfer. Two of these three women delivered at term and both babies were doing well at one year of follow up. Both received cyclical hormone therapy (HT) since adolescence. The third patient received HT only for six months before starting ovulation induction. She conceived twice but miscarried at both occasions. At times, it may be challenging to attain fertility in Kallmann syndrome but with persistent efforts results are usually rewarding. It is important to diagnose KS and start hormone therapy at appropriate time so that satisfactory fertility outcome can be achieved

Unraveling Prostaglandin and NLRP3 Inflammasomemediated Pathways of Primary Dysmenorrhea and the Role of Mefenamic Acid and Its Combinations

Painful menstrual cramps during or around the time of the monthly cycle are known as dysmenorrhea. The estimated global prevalence in women of reproductive age ranges from 45% to 95%. It has a significant negative impact on regular activities and productivity at work. However, despite the severe consequences on quality of life, primary dysmenorrhea (PD) is underdiagnosed. Dysmenorrhea has complex pathogenesis. It involves the release of prostaglandins and activation of the nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) inflammasome and also includes the involvement of other mediators such as bradykinin, histamine and acetylcholine. Even though nonsteroidal anti-inflammatory drugs (NSAIDs) remain the most common type of pain medication, the question of which one should be the most preferred is still open to debate. The current review examines the existing evidence for the pathogenesis of PD and makes evidence based and clinical experience based recommendations for the use of mefenamic acid and its combination in the treatment of dysmenorrhea. Mefenamic acid alleviates PD by inhibiting endometrial prostaglandin formation, restoring normal uterine activity, and reducing the inflammatory response by inhibiting the NLRP3 inflammasome and reducing the release of cytokines such as interleukin (IL)-1β. It is also known to have bradykinin antagonist activity. Dicyclomine has a dual action of blocking the muscarinic action of acetylcholine in postganglionic parasympathetic effect or regions and acting directly on uterine smooth muscle by blocking bradykinin and histamine receptors to relieve spasms. According to the experts, mefenamic acid and dicyclomine act synergistically by acting on the different pathways of dysmenorrhea by blocking multifactorial agents attributed to the cause of dysmenorrhea. Hence, the combination of mefenamic acid and dicyclomine should be the preferred treatment option for dysmenorrhea

Large-volume paracentesis, up to 27 L, with adjuvant vaginal cabergoline in the case of severe ovarian hyperstimulation syndrome with successful pregnancy outcome: A case report

Severe ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of assisted reproductive technology. Herein, we report the case of an infertile couple, with the husband being azoospermic, who underwent in-vitro fertilisation and intracytoplasmic sperm injection at our institute. The woman presented with late OHSS 7 days after embryo transfer. Inpatient management was performed with intensive surveillance. Oral cabergoline was started prophylactically but was replaced by the vaginal route due to intolerance. Transvaginal paracentesis was performed five times over 20 days, and a total of 27 L of ascitic fluid was drained. The patient improved substantially and had a further uneventful pregnancy course. This case report helped us theorise that large-volume paracentesis is safe and efficacious in the management of severe OHSS. In addition, the vaginal route of cabergoline administration is more favourable than the oral route in view of lesser side effects and better patient compliance

Comparison of the effect of positive end expiratory pressure on respiratory mechanics and arterial oxygenation in laproscopic cholecystectomy

Objective: To study and compare the effects of PEEP on Respiratory Mechanics, Oxygenation Index and Heamodynamic changes at different intervals. Methods :This prospective study was done to evaluate the effects of extrinsic PEEP on respiratory mechanics, haemodynamics and arterial blood gases during laproscopic cholecystectomy in obese patients. Results: Primary outcome variable was ratio of arterial oxygen partial pressure to inspiratory oxygen concentration Pa02/Fi02 and other variables related to gas exchange, oxygenation, ventilation, respiratory mechanics and haemodynamics were reported separately for patients randomized to PEEP application as well as control group.  All continuous data are expressed as mean ± SD.  Comparison of two groups were done by using student's test. ConclusionPEEP improves oxygenation in morbidly obese patients without causing hemodynamic instability. This improved oxygenation persists throughout the surgery but it promptly dissipates after tracheal extubation. Keywords:Positive End Expiratory Pressure ,Respiratory Mechanics ,Arterial Oxygenation , Laproscopic Cholecystectomy

Comparison of Bupivacaine 0.5% and Bupivacaine + Clonidine Intrathecally for intraoperative and Postoperative analgesia in Lower Limb Orthopaedic Surgeries

Background: A randomized controlled study was designed to investigate the effects of addition of clonidine to hyperbaric bupivacaine 0.5% for spinal anaesthesia in patients undergoing lower limb orthopaedic surgeries, in terms of vital parameters, onset and duration of sensory and motor block, intra and post operative pain and adverse effects. Methods: Sixty adult ASA Grade I and II patients of either sex posted for lower limb orthopedic surgeries were randomly divided equally in to clonidine or control group. Control group received intrathecal 3.0 ml of 0.5% hyperbaric bupivacaine with 0.5 ml of normal saline and Clonidine group received identical volume of intrathecal clonidine with hyperbaric bupivacaine. Results: Mean time for post operative analgesia was significantly longer in clonidine group (9.6 hours) than in the control group (3.55 hours). (p-value<0.01). Heart rate and blood pressure compared at 30 minute and 45 minute intervals were significantly less in clonidine group. ( p-value < 0.05). Bradycardia and hypotension did not require any therapeutic intervention. Clonidine group patients were found to be more sedated than control group. Conclusion: Adding clonidine 75 μg to intrathecal bupivacaine prolongs the duration of spinal anaesthesia and analgesia. It is safe and is likely to be as effective as higher doses of bupivacaine without severe adverse effects