Polycystic Ovarian Syndrome ??

I've gotten a couple questions about this one topic of polycystic ovarian syndrome (PCOS) and decided to blog on the topic.

PCOS is a grouping of problems under one name. The average patient with PCOS usually presents to the doc with the c/o infertility. The (textbook) patient is usually overweight (BMI >30), hairy (in the sense that she has more male pattern hair distribution (see woman on

the left), has an ultrasound showing polycystic ovaries (see the image)

and the hallmark is the fact that she has very irregular periods. The irregularity of the cycles is what is the central visible problem that the patient notices. She will have complaints that she misses several monthly cycles at a time.

Behind the scenes the patient has the following problems

• Borderline diabetic state (if not fully diabetic): high insulin levels
• Increased levels of male hormones (i.e. Testosterone and it precursors)
• And the possibility of leading to other health issues: increased cholesterol and hypertension (take a look at Metabolic syndrome)

Now although the goal of most of the patients is either to: get pregnant or have a regular cycle there are several goals that the gynecologist would have.

1. Weight loss (obesity is the cornerstone of several preventable diseases)
2. Diagnosis and then the subsequent control of diabetes
3. Blood pressure control if it has become a problem
4. Monitoring of lipids
5. Testing for pre-cancerous (hyperplasia) endometrium (the lining on the inside of the uterus, this is what sloughs off each month and becomes the menstrual cycle) because the patient can have several months of anovulatory bleeding (basically bleeding that is not controlled by a normal cycle: these patients are not releasing an egg each month and will subsequently have an overgrowth of the endometrium) that can lead to endometrial cancer.

PCOS is a complex but yet conquerable disease process that you and your GYN should talk about if you feel I'm describing you.

Induction of Labor

Induction of Labor (IOL)

Many times I have heard and seen my birthing community cringe at the mention of the IOL as if it is some type of @#!@# word. Induction of labor is a very useful tool in the hands of the gentle OB. I will admit that the use of IOL has definitely gotten OB's in trouble several times but I want to give my guidelines for the usuage.

Indications: simply put, a solid medical reason. Whether my mom has Pre-Eclampsia, the scare of it via elevated BP's (150's+ SBP or 100+ DBP), uncontrolled diabetes (gestational or pre-exsiting), cardiac disease, IUGR, oligohydramnios, too mention a few off the top of my head. I feel as though under circumstances where the potential is harm to mom and/or baby this is a no-brainer. As with the process of Pre-E the outcome can be so devastating (Hypertensive disease is the #1 cause of maternal mortality) that anything less than delivery would constitute mal practice.

Now where the argument arises in the community is the idea of elective IOL. Here is where I will expose myself (cover your eyes :). I have yielded to the crying, sobbing, and pitful mom who is begging to be done with the pregnancy. The times when I have done so the following criteria have been met:

1. 39+ wks gestation by solid dating (LMP c/w a 1st trimester sono)
2. Favorable cvx (as determined by a Bishop score of >8)
3. Vertex fetus
4. Counselled mom explaining that she will be at an increased risk of c-section

My method of induction will fluctuate.

Unfavorable, Medically indicated IOL:
I have used cytotec before in the past but prefer cervidil (can pull the medication if any signs of tachysystole or hyperstimulation). Most times I will place a foley bulb. The foley bulb is almost always very effective and by the time it comes out the patient is usually around 4 cm dilated so pitocin can be increased. Will use 2-4 mu of pitocin with the foley bulb to provide the starter contractions (the pitocin is not increased until the foley bulb comes out).

Elective, Favorable cvx IOL
Because I have gotten away from doing these types of inductions on a regular basis I will mostly perform a membrane stripping for patients who are anxious to get started and don't want to wait and let their body do what it should naturally. I usually will strip a cervix that is 3-4 cm dilated and > 50% effaced. If the patient's cervix is very favorable and she is not in active labor I have found the membrane stripping to be very effective in starting the laboring process. Most of these moms will not need a milliunit of pitocin.

The patients that I am particularly hands off with are my first time moms. I explain to them that they should be given every opportunity to go into labor on their own. Some are crying to me by 41 weeks. My postdates cut off is 41 1/2 wks to 42 wks. I will intervene and do an IOL by that point. I'm sure that I will hear plenty on that point but that is what I do.

As always I love the discussion. Fire away.