DELH I IVF G

OLOG IS AEC YN I N F E R T I T L -

Let us giv e baby To every women who desir es

Issue - 1
January, 2014 INSIDE PAGES
Dr. Sharda Jain

RUM FO Y IT

Infertility &
E-Bulletin (Free Circulation)

Delhi Gyneacologist Forum has to think Big.. !!

Brig. R.K. Sharma

* *

Greeting & Goals for 2014 Managment of IVF Pregnancy in women with PCOS

Infertility solutions
For

Knowledge & skill are not a commodity. It is an inner energy which grows by sharing, which dies by not sharing. As a teacher . we share word of wisdom to our colleagues. The inner world of True Teacher is totally different...... You give knowledge/skill to others, you have still the same knowledge & skill or may be even better, because you grow in experience by giving & sharing your knowledge.Teacher learns a lot by her/his students too. It is like drawing water from a well: the moment you draw water, from hidden springs more water starts filling the space. If you don't draw water from the well, the water will become dirty ; it may become poisonous Delhi Gynaecologist Forum has always believed in the Dictum Many in Body, but One in Mind. This year moving ahead together, let us embrace the young gynaecologists in our fold and attempt to understand and fulfil their UNMET NEEDS. It is time that we at individual and Forum level, hold training programmes in Ultrasound, Infertility management andrology, Embryology & IVF & share in TRUE SENSE

UNIVERSAL HUNT

Happy New Year 2014

Dr Abhishek Parihar

Management of IVF pregnancy in women with PCOS

2
1. Multiple pregnancy : Miscarriage, anaemia, hypertension, vaginal bleeding, preterm delivery, low birth weight, stillbirth 2.Early

Dr. Aruna Saxena

IVF Pregnancy : Perinatal Risk

Management of IVF pregnancy in women with PCOS

3
-

pregnancy loss Birth 4.LBW & SGA 5. Congenital Anomalies 6. Vertical transmission of Genetic disease
3. Preterm ( Generally detected & avoided by PGD) 7. Perinatal mortality for twin pregnancy

: Still birth

,2.5 times higher

IVF Pregnancy : Risk Due to maternal Factors

Higher rate of LSCS, obstetric haemorrhage, preeclampsia, PIH and GDM preterm delivery, low birth weight Pre existing morbidities pregnancy loss & perinatal complications

Risk Associated with PCOS

1.Elderly primi :

2.Recipient of Donor oocytes: increased risk of early 3.PCOS 4.Antenatal screening : low PAPPA in fresh IVF cycle
false positive Double Marker

Reference : RCOG, British Fertility Society, Scientific Impact Paper no 8, May 2012

Feeling Excited But Scared ? Antenatal Care 1st Trimester

Feeling Excited But Scared ? Antenatal Care 1st Trimester

1. Bed rest after IVF doesnt help

( Reuters Health NY ,June 2013) 2. Progesterone support continued 3. PCOS is characterised by a Prothrombotic state: LMWH ?

Metformin therapy throughout pregnancy decreased the ORs of EPL,GDM, preeclampsia and preterm delivery in pregnant PCOS women with no serious detrimental side effects.( 8 studies 1106 pt) Zheng et al 2013,NICE Guidelines 2008

7 Antenatal Care 1st Trimester:Investigation

1. 2.

8 Antenatal Care 1st Trimester:Investigation

3. TVS at 5 weeks : Multiple pregnacy Ectopic pregnancy, Late OHSS (Appearing 9 days after HCG) 8 weeks : cardiac activity 12 weeks: NT/NB scan & Double Marker

Routine Antenatal screen 75 gm OGTT at 16-18 weeks single 2 hr value(NICE Guidelines 2008) Fasting,1 hr,2 hr value(International Association of Diabetes & Pregnancy study Group (IADPSG) RCOG scientific impact paper Jan2011)

Dr Abhishek Parihar

Management of IVF pregnancy in women with PCOS

10

Dr. Aruna Saxena

Management of OHSS : RCOG Guideline Sep 2006

Management of OHSS : RCOG Guideline Sep 2006

Mild & Moderate: managed on out patient basis

-Urgent review in case of abd distention, severe pain, dyspnoea, oliguria

Severe OHSS : Admission & Multidisciplinary assistance Critical OHSS : ICU admission

-Analgesia using PCM -Drink to thirst rather than to excess -Avoid strenuous exercise & sexual IC for fear of torsion -Continue Progesterone but HCG inappropriate -TVS every 2-3 days for ascites & ovarian size -Inv : Hb,haematocrit,serum creatinine and electrolytes and liver function tests.

Typically, even in severe OHSS with a developing pregnancy, the duration does not exceed the first trimester. Women should be reassured that pregnancy may continue normally despite OHSS, and there is no evidence of an increased risk of congenital abnormalities.

11 Antenatal Management 2nd &3rd Trimester

Monitoring of pregnancy as High Risk Pregnancy: Frequent surveillance To prevent PIH 75 mg Aspirin daily from 12 weeks till birth of the baby for pre vention of

12 Antenatal Management 2nd &3rd Trimester

Use of Progesterone to prevent preterm delivery: Not recommended by

Preeclampsia, salt restriction not recommended (NICE Guidelines 2011) Encourage women with chronic hypertension to keep their dietary sodium intake low, either by reducing or substituting sodium salt, because this can reduce blood pressure For early diagnosis of GDM:75 gm OGTT at 24-28 weeks (NICE Guidelines 2008)

RCOG , should be restricted to clinical trials only Cerclage if cervical length < 25 mm before 24 weeks in Women with a hist ory of one or more spontaneous mid-trimester losses or preterm births (RCOG Guidelines May 2011) Prevention of IUGR : Two weekly check & Colour Doppler if IUGR diagnosed Every 4 week USG monitoring of Foetal growth & AFI from 28- 36 weeks ,in case of GDM

13

Nice Guidelines for elective Birth in multiple pregnancy

14
504

Outcome of IVF pregnancy At ARMY Hospital R&R ( Feb 2007- Jan 2009)

Uncomplicated

monochorionic twin pregnancies : 36 weeks Dichorionic twin pregnancies : 37 weeks

higher fetal death rate in monochorionic twin pregnancies than in dichorionic twin pregnancies.

Total live birth following IVF of delivery : Vaginal delivery 37.7% Elective LSCS 30.9% Emergency LSCS 25.1% Preterm birth 47.4% Singleton pregnancy 51.2% Multiple pregnancy 48.8% SGA 22.6% Congenital Malform 3.9% NICU admission 25 %
Mode
Conclusion: In our setting, neonates born followin IVF appeared to be at increased risk of prematurity, multiple births and low birth weight. Proper obstetric and neonatal management can result in good neonatal outcomes

Uncomplicated

triplet pregnancies:35 weeks.

15

Summery

16

Summery

While it is clear that IVF pregnancies are at increased risk of adverse

perinatal outcomes, majority of the children born following IVF will have a good outcome. 1st trimester care with IVF specialist 2ND&3rd trimester: Risk assessment & appropriate referral.

Elective single embryo transfer long-term follow-up studies on children born following IVF are

largely reassuring once the confounding factors of prematurity and multiple gestation are removed. However continued surveillance is a prerequisite.

Lifecare IVF Experience

1

Lifecare IVF Experience

On

Our Team

Outcome of IVF Pregnancies in PCOS Patients

3

PCOS Patients
- Patients of PCOS with ovulation & without ovulation who do not get pregnant & need IVF - are not easy patients to achieve pregnancy - To achieve a pregnancy is a realtreat to our IVF Team

---------------------------------Multiple Pregnancy 6 (Quadraplets 1)

6

, Pregnancies following IVF in PCOS patients Total No. 28

Pregnancy Outcome
-Mild OHSS with Pregnancy - 3/28 - Chemical Preg. 3/28
- Blighted Ovum - 1 - Missed Abortion - 1 (11 weeks) - 2nd Trimester abortion -1 (22 weeks Twins) - Congenital Malformation - Nil

Pregnancy Outcome
- Preterm Delivery - 21.43%
- Hypertension/PIH - 40.9% - Gestational DM - 27.27%

Gestation at Preterm Delivery (6/28)

- < 28 wks - 1 twins (Both Alive) - < 34 wks - 4 - < 37 - wks - 1

NICU admission 39.28%

No stillbirths No Perinatal Deaths

-------------------------------------------------------------------

-------------------------------------------------------------------

------------------------------------------------------------------! ! <1 kg - 2 (saved Twins) ! <2.5 kg

Baby Weight

www.lifecareivf.com

Head Office :
35, Defence Enclave, Opp. Preet Vihar Petrol Pump, Delhi-110092 Phone-22414049, 43015662 Email:delhi.gynaecologistforum@gmail.com Website:www.delhigynaecologistforum.com