Management of a pregnant patient with mechanical heart valve is a complex issue for all health care providers involved in the care of such patients. Complications may arise at any stage due to the increased haemodynamic load imposed by pregnancy or because of impaired cardiac performance often seen in these patients. In addition, the use of various cardiovascular drugs in pregnancy (especially anticoagulants) may lead tofoetal loss or teratogenic complications. Additionally, the risk of thrombo-embolic complications in the mother is increased by the hypercoagulable state of pregnancy. In this review, we have attempted to draw inferences to guide management of such patients based on the available literature. It seems that in pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labour. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Unfortunately there is no consensus on such data. An overview of the available literature forms the basis of this review. In conclusion, a guideline comprising pragmatic considerations is preffered.

What is HypnoBirthing?

HypnoBirthing� - The Mongan Method is a childbirth method that focuses on preparing parents for gentle birth. In HypnoBirthing classes, birthing parents learn proven techniques in a well-thought-out program of deep relaxation, visualization, and self-hypnosis. All of these are designed to help achieve a more comfortable birth. HypnoBirthing encourages a calm, peaceful, and natural pregnancy, birth, and bonding experience for families.

HypnoBirthing is as much a philosophy as it is a technique. The concept of HypnoBirthing� is not new, but rather a "rebirth" of the philosophy of birthing as it existed thousands of years ago and as it was recaptured in the work of Dr. Grantly Dick-Read, an English obstetrician, who, in the 1920s, was one of the first to forward the concept of natural birthing. The method teaches you that, in the absence of fear and tension, or special medical circumstances, severe pain does not have to be an accompaniment of labor.

How does HypnoBirthing differ from other childbirth preparation methods?
Unlike other childbirth methods that teach you how to cope with and manage pain, HypnoBirthing is based on the premise that childbirth does not necessarily need to be painful if the mother is properly prepared and relaxed. When women understand that pain is caused by constrictor hormones, created by fear, they learn, instead, to release fear thus creating endorphins�the feel good hormones. They are then able to change their expectations of long, painful labor and are able to replace them with expectations of a more comfortable birthing. Rather than exhausting, shallow breathing and the distraction techniques of typical �prepared childbirth� programs, HypnoBirthing parents learn deep abdominal breathing and total relaxation, enabling the laboring mother to work in harmony with her body and her baby. This allows her to achieve a shorter and more comfortable labor for herself and baby.

How is the Birth Companion involved?

The Birth Companion of the mother�s choice is an integral part of the HypnoBirthing experience. He or she practices with the mother in helping to prepare for deep relaxation. During labor, the Birth Companion guides the laboring mother through hypnosis prompts, relaxation techniques, deepening methods, and visualizations, provides comfort measures, and joins in welcoming the new baby, often by receiving the baby as he emerges.


Is the mother unconscious or does she remember her birth experience?

Despite misconceptions and misinformation, you are definitely not unconscious during self-hypnosis. The HypnoBirthing mother is deeply relaxed, but she is also an active participant in the labor process. Though she is deeply relaxed, she is totally aware and may return to a conversant state or choose to become mobile whenever she desires. HypnoBirthing mothers often find that they experience time distortion and are not distracted by other people or their birthing environment, while they focus on their birthing and their baby.

METFORMIN THERAPY FOR THE MANAGEMENT OF INFERTILITY IN WOMEN WITH POLYCYSTIC OVARY SYNDROME

1. Introduction

The key clinical features of polycystic ovary syndrome (PCOS) are hyperandrogenism (hirsutism,
acne, alopecia) and menstrual irregularity with associated anovulatory infertility.1 The consensus
definition of PCOS recognises obesity as an association and not a diagnostic criterion1 as only
40�50% of women with PCOS are overweight. Ovarian hyperandrogenism is driven primarily by
luteinising hormone (LH) in slim women, while in the overweight insulin may augment the effects of LH.1 Women with polycystic ovaries are more insulin resistant than weight-matched women with normal ovaries. Insulin resistance is seen in 10�15% of slim and 20�40% of obese women with PCOS and women with PCOS are at increased risk of developing type 2 diabetes.2

2. Insulin resistance

Insulin resistance is defined as a reduced glucose response to a given amount of insulin and usually
results from faults within the insulin receptor and post-receptor signalling. As a result circulating
insulin levels rise. Insulin resistance does not affect all actions of insulin and, in the ovary, high levels
of circulating insulin are thought to contribute both to excess androgen production and to anovulation. Insulin resistance can be measured by a number of expensive and complex tests but in clinical practice it is not necessary to measure it routinely; it is more important to check for impaired glucose tolerance.2 Simple screening tests include an assessment of body mass index (BMI) and waist circumference. If the fasting blood glucose is less than 5.2 mmol/l the risk of impaired glucose tolerance is low. The 2-hour standard 75 g oral glucose tolerance test (OGTT) may be conducted in those at high risk (BMI greater than 30 kg/m2 in white women or greater than 25 kg/m2 in women from South Asia, who have a greater degree of insulin resistance at a lower body weight).1,2

3. Metformin therapy for PCOS

Obesity has a profound effect on both natural and assisted conception, influencing the chance of
becoming pregnant and the likelihood of a healthy pregnancy.3 Increasing obesity is associated with
greater insulin resistance. Metformin inhibits the production of hepatic glucose, enhances insulin
sensitivity at the cellular level and also appears to have direct effects on ovarian function. It is logical
to consider, therefore, that insulin lowering and insulin sensitising treatments such as metformin and
the thiazolidinediones (rosiglitazone, pioglitazone) should improve the symptoms and reproductive
outcome for women with PCOS.4 Most of the initial studies of metformin in the management of PCOS were observational. Initial systematic reviews, in which the majority of studies had a small sample size and did not include a power calculation for the proposed effect, suggested that metformin when compared with placebo, had a significant effect on lowering serum androgen levels and restoring menstrual cyclicity and was effective in achieving ovulation either alone or when combined with clomifene.5 Subsequent larger randomised trials, however, have not substantiated these early positive findings. Furthermore, while some studies suggested that metformin therapy may achieve weight reduction,6 the large randomized controlled trials
and systematic reviews have failed to confirm this.5,7,11

Metformin appears to be less effective in those who are significantly obese (BMI greater than 35 kg/m2),6,7
although there is no agreement on predictors for response or the appropriate dose and whether dose
should be adjusted for body weight or other factors. Doses of between 500�3000 mg/day have been used
and the most common dose regimens are 500 mg three times daily or 850 mg twice a day. Long-acting
preparations are associated with fewer gastrointestinal adverse effects. Metformin appears to be safe in pregnancy, although usual advice is to discontinue once a pregnancy occurs. There is no firm evidence that metformin reduces the risk of either miscarriage or gestational diabetes.

The largest prospective randomised, double blind, placebo-controlled study trial to evaluate the combined effects of lifestyle modification and metformin (850 mg twice daily) studied 143 anovulatory women in the UK with a mean BMI of 38 kg/m.27 All subjects had an individualised assessment by a dietician in order to set a realistic goal that could be sustained with an average reduction of energy intake of 500 kcal per
day. As a result, both the metformin-treated and placebo groups managed to lose weight but the amount of weight reduction did not differ between the two groups. An increase in menstrual cyclicity was observed in those who lost weight, but again did not differ between the two arms of the study.7
In a Dutch trial, 228 women with PCOS were treated either with clomifene citrate (CC) plus metformin
or CC plus placebo.8 There were no significant differences in either rates of ovulation (64% versus
72%), continuing pregnancy (40% versus 46%) or rate of spontaneous miscarriage (12% versus 11%).
A significantly larger proportion of women in the metformin group discontinued treatment because of
adverse effects (16% versus 5%). The US Pregnancy in Polycystic Ovary Syndrome (PPCOS) trial9 enrolled 676 women for six cycles or 30 weeks, randomised to three treatment arms (metformin 1000 mg twice daily plus placebo, clomifene citrate plus placebo or metformin plus clomifene citrate). Overall, live birth rates were 7% (5/208), 23% (47/209) and 27% (56/209), respectively, with the metformin alone group being significantly lower than the other two groups. Miscarriage rates tended to be higher in the metformin alone group (40% versus 23% and 26%, respectively). Thus, it was concluded that as
first-line therapy for the treatment of women who are anovulatory and infertile with PCOS, metformin
alone was significantly less effective than clomifene citrate alone and that the addition of metformin to
clomifene citrate produced no significant benefit.9 Subgroup analysis of women with a BMI greater than
35 kg/m2 and in those with clomifene resistance did, however, suggest a potential benefit from the
combined use of metformin with clomifene citrate.9
It has been suggested that co-treatment with metformin may improve the response to exogenous
gonadotropins or the outcome of assisted reproduction therapy. Indeed, the largest study to date has shown an increase in continuing pregnancy rates in women with polycystic ovaries and a mean BMI of 28 kg/m2 treated with metformin (850 mg twice daily) for only 4 weeks during an IVF cycle.10 In this study, 101 women were randomised to receive metformin or placebo. Both the clinical pregnancy rates beyond 12 weeks of gestation per cycle started (39% versus 16%; P = 0.023) and per embryo transfer (44% versus 19%; P = 0.022) were significantly higher in those treated with metformin. Furthermore, a significant decrease in the incidence of severe ovarian hyperstimulation syndrome was observed (4% versus 20%; p=0.023) despite the higher pregnancy rate in the metformin arm of the study.10 These results are promising but further studies are required to confirm these observations before the place of metformin in assisted reproductive techniques can be clearly assessed.
The updated Cochrane review concluded that the benefit of using therapy to lower insulin levels such as metformin is limited in terms of improvement in reproductive outcome and metabolic parameters.11 In
SAC Opinion Paper 13 2 of 4 particular, the use of metformin either alone or in combination with drugs to induce ovulation such as clomifene citrate did not increase the chance of having a livebirth. Furthermore, despite evidence of a reduction in development of diabetes in a high risk non-PCOS population12 the long-term use of metformin in reducing the risk of developing metabolic syndrome is questionable.11 Lifestyle advice with
appropriate attention to diet and exercise has to be the mainstay for young women with PCOS.

4. Opinion

While initial studies appeared to be promising, more recent large randomised controlled trials have not
observed beneficial effects of metformin either as first-line therapy or combined with clomifene citrate
for the treatment of the anovulatory woman with PCOS. Most work has been undertaken in the
management of anovulatory infertility and there are no good data from randomised controlled trials on
the use of metformin in the management of other manifestations of PCOS. It is clear that the first aim
for women with PCOS who are overweight is to make lifestyle changes with a combination of diet and
exercise in order to lose weight and improve ovarian function. The European Society for Human
Reproduction and Embryology and American Society for Reproductive Medicine consensus on infertility
treatment for PCOS concluded that there is no clear role for insulin sensitising and insulin lowering drugs
in the management of PCOS, and should be restricted to those patients with glucose intolerance or type
2 diabetes rather than those with just insulin resistance.13 Therefore, on current evidence metformin is not a first line treatment of choice in the management of PCOS.

References

1. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003
consensus on diagnostic criteria and long-term health risks related to polycystic ovary
syndrome (PCOS). Hum Reprod 2004;19:41�7.

2. Legro RS, Castracane VD, Kauffman RP. Detecting insulin resistance in polycystic ovary syndrome: purposes and pitfalls. Obstet Gynecol Surv 2004;59:141�54.

3. Balen AH, Anderson R. Impact of obesity on female reproductive health: British Fertility
Society, Policy and Practice Guidelines. Hum Fertil 2007;10:195�206.

4. Kayshap S, Wells GA, Rosenwaks Z. Insulin-sensitizing agents as primary therapy for patients
with polycystic ovary syndrome. Hum Reprod 2004;11:2474�83.

5. Lord JM, Flight IH, Norman RJ. Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, d-chiro-inositol) for polycystic ovary syndrome. Cochrane Database Syst Rev 2003;(2):CD003053 [DOI:10.1002/14651858. CD003053].

6. Fleming R, Hopkinson Z, Wallace A, Greer I, Sattar N. Ovarian function and metabolic factors in women with oligomenorrhoea treated with metformin in a randomized double blind placebo-controlled trial. J Clin Endocrinol Metabol 2002;87:569�74.

7. Tang T, Glanville J, Hayden CJ, White D, Barth JH, Balen AH. Combined life-style modification and metformin in obese patients with polycystic ovary syndrome (PCOS). A randomised, placebo-controlled, double-blind multi-centre study. Hum Reprod 2006;21:80�9.

8. Moll E, Bossuyt PM, Korevaar JC, Lambalk CB, van der Veen F. Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of ovulation in women with newly diagnosed polycystic ovary syndrome: randomised double blind clinical trial. BMJ 2006;24:332(7556):1485.

9. Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, et al. Cooperative
Multicenter Reproductive Medicine Network. Clomiphene, metformin, or both for infertility
in the polycystic ovary syndrome. N Engl J Med. 2007;356:551�66.

10. Tang T, Glanville J, Orsi N, Barth JH, Balen AH. The use of metformin for women with PCOS undergoing IVF treatment. Hum Reprod 2006; 21:1416�25.

11. Lord JM, Flight IHK, Norman RJ. Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, D-chiro-inositol) for polycystic ovary syndrome. Cochrane Database Syst Rev 2008;(4):CD003053. SAC Opinion Paper 13 3 of 4

12. Diabetes Prevention Program Research Group. Reduction in the incidence of Type 2 diabetes
with lifestyle intervention or metformin. N Engl J Med 2002;346:393�403.

13. Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on
infertility treatment related to polycystic ovary syndrome. Hum Reprod 2008; 23:462�77.

Breathing Techniques: How to Practice


Throughout all practice, remember these points:
1. There is no required breathing strategy for each
phase of labor.
2. Slow-paced breathing is best for mother and baby.
Return to it whenever possible.
3. Use relaxation skills with all breathing techniques.



Phase I--Developing Breathing Awareness

� During relaxation practice, feel your breath in your
nose, mouth, throat' then shoulders, chest, abdomen,
and back.
� Note rise and fall of chest.
� Feel the pressure of your body against a chair, bed,
pillows, and other contact areas.
� Listen to the sounds made by your breath.
� Notice changes in your breathing as you vary
positions and activities.



Phase II--Mastering Slow-Paced Breathing

� Practice with the strategy most comfortable for you.
For example, "In, 2,3,4,5, out 2,3,4,5" or listen to your
breath go in and out.
� Mentally link the ideas "release tension" and "focus"
with the initial cleansing breath.
� Practice slow-paced breathing in different positions.

Note the different sensations as you vary your position.


Phase III--Developing Strategies for Slow-Paced Breathing;

Mastering Modified-Pace Breathing
Practice slow-paced breathing by yourself using different strategies. Examples:
� Visualize breathing in a continuous circle.
� Picture energy entering your body as you breathe in
and tension leaving as you breathe out.
� As you inhale and exhale, say phrases such as "I
can give birth," "energy in, pain out," "My breath is
calm."
� Rock or walk in rhythm to your breathing.
Practice slow-paced breathing with your partner's help. Examples:
� Imagine breathing into the parts of your body where
your partner places his hands.
� Have your partner stroke down your arms or legs as
you exhale.
� Begin to practice modified-paced breathing as taught
in class, using a strategy most comfortable for you.
Vary positions and note differences in sensations.


Phase IV--Developing Strategies for Modified-Paced Breathing
Experiment with one or two strategies using modified-paced breathing. Examples:
� Breathe quietly, listen to your breath move in and out.
� Say words in rhythm, like "health-y ba-by," "be calm,"
"in, 2,3, out, 2,3."
� Use music our counting while you breathe.
� Practice patterned-paced variation as learned in
class.
� Practice with your partner, using gentle pressure
contractions rather than verbal cues.



Phase V--Mastering All Techniques
� Practice switching from one paced breathing
technique to another within the same pretend
contraction.
� Vary the length and intensity of practice
contractions.
� Practice for an early urge to push. Use a series of
light blows or a pattern of one breathe, one blow.

Introduction

Primary infertility is the term used to describe a couple that has never been able to conceive a pregnancy, after at least 1 year of unprotected intercourse.
We present a case study in which PCOS (diagnosed by USG) and unovulation were thought to be the cause of primary infertility. After taking the conventional treatment for about 1 � year the patient was unable to conceive. The conventional treatment was discontinued and ayurvedic treatment was given. The patient conceived in 7 months and delivered a healthy child.
The Case Report

Mrs. V. N, a 24 year old women, software engineer, married for 3 � years, approached for the treatment of primary infertility. Since their marriage Mrs. V. N and her husband were staying together and were sharing a healthy sexual relationship. After one year of normal married life, as Mrs. V. N was unable to conceive, she consulted a gynecologist for advice.

The gynecologist advised routine investigations and sonography of the abdomen and ovulation study. On sonography, the ovaries were found to be polycystic and a diagnosis of PCOS was made. On ovulation study, it was observed that the ovarian follicles were not maturing, resulting into un-ovulatory cycle.

She was advised a course of Human Chorionic Gonadotrophin (HCG) 5000 i.u., i.m. in mid cycle, which she took for 12 cycles. However, even after a year of treatment, she was unable to conceive.

The gynecologist then advised her to undergo exploratory laparoscopy, which she was unwilling to undergo. At this stage she thought of �trying� ayurvedic treatment.

Complaints of: Inability to conceive after 2 � years of marriage

On examination: G.C - fair, Temp / Pulse / Respiration / Blood Pressure - Normal. R.S, C.V.S - Normal, Weight 51 Kg.

No history of consuming oral contraceptives or the use of any IUCD.

Menstrual history- Regular, moderate, painless

Menarche- at age 12 years

Past history of illness- Insignificant
Family history- Insignificant
No menstrual complaints of mother and elder sister

Investigations:
CBC, Blood sugar- Normal
Hystero salpingography - Normal, both tubes patent
Husband�s Semen - Normal

Treatment:

The following medicines were advised:
1.Syrup Dashmularishta1 20 ml two times a day before meals
2.Tablet Rajapravartini vati2 500 mg twice a day before lunch and dinner from day 1 to day 13 of the cycle.
3.Phala ghruta3 10 gm twice a day after breakfast and after dinner from day 14 till the next cycle.
4.Tab. Garbhapal Rasa4 250 mg twice a day after breakfast and after dinner from day 14 till the next cycle. (And throughout pregnancy)
5.Tablet Laghumalini Vasanta rasa5 250 mg twice a day after breakfast and after dinner from day 14 till the next cycle. (And throughout pregnancy)

The same treatment was continued for 7 months. No other modern medicines were given.

Result:
After about 7 months of treatment, Mrs. V.N. conceived. During the treatment period her menstrual cycles were normal. There were no other complaints. She delivered a healthy male child, weighing 2.5 kg,

Discussion:

According to ayurved, akin to the germination of a plant seed, the four most important factors for conception are 1) Rutu (season), 2) Kshetra (the field- uterus), 3) Ambu (water - nourishment) and 4) Beeja6 (seed - ovum and sperm).The probability of conception increases if all these factors are in perfect condition and in harmony with each other.

�Rutu�, in this context, refers to the most fertile days of the menstrual cycle and the fertile age of women. �Kshetra� refers to the cyclical conditioning of the uterus for making the uterine cavity most suitable for implantation of the fertilized ovum. As both these factors are associated with rhythmicity / periodicity, it is under the control of vata dosha. Also, the process of ovulation, maintaining the pregnancy till its full term and parturition are controlled by �apana vayu�7. Diminution of vata dosha also results in unovulation7b. Therefore, procedures (ahyanga, basti) and medicines beneficial in balancing of vata dosha, would be useful in ovulation, maintenance of pregnancy and in normal childbirth.

Nourishment of the fetus is carried out by �rasa�. Rasa dhatu in a pregnant women is split into three parts one nourishes the mother herself, second part is utilized to nourish the fetus and the third to produce milk8. Therefore, the medicines acting on rasa dhatu would benefit the nutrition of the fetus.

�Beeja� refers to both ovum and sperm. Both need to be in perfect condition for conception. The ovum is �agneya�9 (�agni mahabhoota� predominant) and shukra is �soumya� (jala mahabhoota predominant). Therefore the �rasayana� medicines predominant in agni mahabhoota and jala mahabhoota are beneficial for producing best quality of �beeja� - ovum and sperm.

During the follicular and ovulatory phase of menstrual cycle, Rajapravartani vati, which contains �hinga� (asafetida) as one of its ingredient was given to induce ovulation. As hing is �ati ushna veerya� (very hot in potency, it helps the maturation and release of ovum, which is also �agneya� (hot) in nature.