Eman Omran

Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section. The purpose of this study was to assess the effect of rectus muscle reapproximation at cesarean delivery on the postoperative pain. This study was a prospective, double-blind, randomized controlled trial. It included 280 primigravidas, with a singleton pregnancy, who underwent elective lower segment cesarean section at term. The patients were randomly allocated into two equal groups; Group (A): undergoing rectus muscle reapproximation, and Group (B): not undergoing rectus muscle reapproximation. Postoperative pain was assessed by visual analogue scale (VAS) from 0 (no pain) to 100 (maximum pain). Postoperative analgesia, operative time, changes in hemoglobin level, length of hospital stay, and occurrence of postoperative complication were also assessed. Postoperative pain score at the end of the first 24 hours and at the end of the next 24 hours were significantly higher among the group of rectus muscle reapproximation (a difference in VAS pain score of: 5, 95% confidence interval: 0.1-11, value: .02) and (a difference of 1, 95% confidence interval: 0.1-2.9, value: .01), respectively. As regards the narcotic use in the first 24 hours after cesarean section, in the form of injections of meperidine 50 mg, it was significantly higher among the group of rectus muscle closure (a difference of 10 mg, 95% confidence interval 3-21.7 mg, value: .02). While in the next 24 hours, the NSAIDs use, in the form of diclofenac sodium injection, was significantly higher among the group of rectus muscle reapproximation (a difference of 10 mg, 95% confidence interval 3.7-31.7 mg, value: .02). Rectus muscle reapproximation among women undergoing primary caesarian section is associated with significant increase in the postoperative pain and analgesic requirements.

PURPOSE: The study aimed at assessment of the accuracy of the β-hCG test in vaginal washing fluid for diagnosis of prelabor rupture of membranes (PROM).

PATIENTS AND METHODS: Two groups of pregnant women from 17 to 38 weeks of gestation were recruited. The first group (PROM group) included 50 pregnant women with unequivocal PROM. The other group included 50 pregnant women with intact membranes. A sterile speculum examination was performed. If less than 5 cc was collected or no fluid found, 10 cc sterile saline was sprinkled on the vaginal wall and 5 cc were recollected in a sterile syringe. Two drops of collected fluid were used for qualitative testing of β-hCG. The remaining fluid was used for quantitative assessment of β-hCG.

RESULTS: The quantitative β-hCG test results were significantly higher in PROM group (median and range: 138.5 (23-475) versus 13 (1-55); the difference in medians and 95% CI: 105 (91-166); p value: <.001). The qualitative β-hCG test was positive in 42/50 (84%) of the PROM group, while it was negative in 50/50 (100%) of the intact membranes group. Areas under receiver operating characteristics (AUC) for both the quantitative and qualitative β-hCG tests were high (0.97, 95% CI: 0.91-0.99, p value: <.001 and .92, 95% CI: 0.84-0.96, p value: <.001, respectively). The suggested cut-off of β-hCG for the quantitative test was 32 mIU/ml. The sensitivity of quantitative and qualitative tests are: 94, 95% CI: 83.5-98.7% and 84, 95% CI: 70.9-92.8%, respectively. The specificity of quantitative and qualitative tests are: 94, 95% CI: 83.5-98.7% and 100, 95% CI: 92.9-100%, respectively.

CONCLUSION: β-hCG test (either quantitative or qualitative) in vaginal washing fluid can be used in the diagnosis of PROM in both preterm and term cases.

OBJECTIVE: The aim of the study was to evaluate the value of vaginal misoprostol 6 h prior to intrauterine device (IUD) insertion in women with previous Caesarean delivery.

METHODS: A double-blind randomised controlled trial was conducted in 120 women who were eligible for IUD insertion. Participants were randomly divided to receive either 600 μg vaginal misoprostol or placebo 6 h before IUD insertion. The primary outcome measure was the pain score during the procedure. Secondary outcome measures were failure of insertion, insertion difficulty score, complications of IUD insertion and side effects related to misoprostol.

RESULTS: Pain and insertion difficulty scores were significantly lower in the misoprostol group compared with the placebo group (5.7 ± 1.4 vs. 6.5 ± 0.9 and 4.1 ± 1.1 vs. 5.4 ± 2.2, respectively; p < .001). More women experienced nausea, vomiting (5 vs. 0; p = .06) and cramps (10 vs. 0; p < .001) in the misoprostol group than in the placebo group, respectively.

CONCLUSIONS: The use of misoprostol before IUD insertion is associated with less painful and easier placement.

OBJECTIVE: To determine the accuracy of the posterior cervical angle (PCA) compared with the cervical length and the Bishop score in predicting the outcome of induction of labor (IOL).

METHODS: The present prospective observational study included IOL candidates who had their PCA and cervical length assessed by transvaginal ultrasonography and the Bishop score at the Obstetrics and Gynecology Department, Kasr El-Aini Hospital, Cairo University, Cairo, Egypt, between April 1 and July 31, 2017. The accuracy of these tests in predicting successful IOL (defined as vaginal delivery) was compared.

RESULTS: The analysis included 49 women with successful IOL and 21 women with unsuccessful IOL. The suggested cutoffs for the prediction of successful IOL were a PCA of more than 99.5°, a cervical length of less than 34 mm, and a Bishop score of more than five. The areas under the receiver operating characteristics curves for these three measures were not significantly different. However, a PCA of more than 99.5° had the best sensitivity (91.84%), specificity (90.48), positive predictive value (95.7%), negative predictive value (82.6%), positive likelihood ratio (9.64), and negative likelihood ratio (0.09) compared with the other two predictors.

CONCLUSION: A PCA of more than 99.5° yielded the best accuracy in predicting successful IOL compared with the cervical length and the Bishop score. CLINICALTRIALS.GOV: NCT03113227.

Purpose: The aim of the study was to evaluate the effect of clomiphene citrate on uterine artery blood flow using pulsed Doppler and endometrial and subendometrial micro vascularization using 3D power Doppler in unexplained infertility.

Patients and methods: In a prospective observational study at a university teaching hospital, the mid-luteal (peri-implantation) endometrial thickness and volume, uterine artery pulsatility index (PI) and resistance index (RI), endometrial and subendometrial vascularization index (VI), flow index (FI), and vascularization flow index (VFI), and serum estradiol and progesterone levels were compared between natural and clomiphene citrate stimulated cycles in the same group of 50 patients with unexplained infertility. Statistical analysis was done using paired -test to compare different study variables.

Results: The primary outcome, which was the endometrial flow index, was significantly lower in the stimulated cycles (mean ± SD: 23.89±7.96 vs 27.49±8.73, mean difference (95% CI): -3.6 (-2, -5.9); =0.03). The mean ± SD of endometrial thickness (10.92±3.04 vs 12.46±3.08 mm; =0.01), volume (4.57±1.28 vs 5.26±1.32 cm; =0.009), endometrial VI (0.86±0.15 vs 0.95%±0.21%; =0.02), VFI (0.25±0.08 vs 0.31±0.12; =0.004), subendometrial VI (1.93±0.68 vs 2.26%±0.75%; =0.02), FI (26.81±9.16 vs 30.73±9.87; =0.04), and VFI (0.68±0.18 vs 0.79±0.21; =0.006) were significantly lower in the stimulated cycles. However, there were no significant differences in the uterine artery PI (=0.12) and RI (=0.08) or serum estradiol (=0.54) and progesterone (=0.37) levels between natural and stimulated cycles.

Conclusion: Peri-implantation endometrial perfusion is significantly lower in clomiphene citrate stimulated cycles when compared to natural ones in patients with unexplained infertility.

OBJECTIVE: To test the hypothesis that there is a higher rate of unsuccessful induction of labor (IOL) in post-term obese pregnant women compared to non-obese ones.

METHODS: In this prospective cohort study, 144 obese (BMI > 30) and 144 non-obese (BMI < 29.9) post-term (> 41 weeks) pregnant women were recruited. IOL was done by misoprostol or amniotomy and oxytocin infusion according to the Bishop score. Comparison of percentage of failed IOL in both groups (primary outcome) was performed by the Chi-test. Logistic regression and multivariable regression were performed to assess the odds ratio (OR) of cesarean section (CS) and coefficient of delay in labor till vaginal delivery (VD) in obese versus (vs) non-obese groups. Adjustment for gestational age, parity, Bishop Score, membrane rupture and amniotic fluid index was done in both regression analyses.

RESULTS: CS rate was significantly higher in obese group [26.4 vs 15.9%; difference in proportion (95% CI) 0.1 (0.01, 0.19); P value 0.02]. 106 (73.6%) obese women and 121 (84.1%) non-obese women delivered vaginally. In addition, the duration till VD was significantly higher in obese group (22 vs 19 h, P value 0.01). After adjustment for possible confounding factors, the CS was still higher in the obese group in comparison to non-obese group (OR 2.02; 95% CI 1.1, 3.7; P value 0.02). This finding suggested that obesity was an independent factor for failure of IOL. In addition, after adjustment for these confounders, obesity had the risk of increasing labor duration by 2.3 h (95% CI 0.1, 4.5) in cases that ended in VD.

CONCLUSION: Based on our results, we conclude that there is a higher risk of CS in obese postdate pregnant women undergoing IOL in comparison to non-obese counterparts. Therefore, obstetricians should pay more attention to advising pregnant women about optimal weight gain during pregnancy and counseling about the chances of VD in cases of IOL. CLINCALTRIAL.

GOV ID: NCT02788305.

Aim: The aim of our study was to compare the outcome of pregnancy in patients who became pregnant within 24 months of renal transplantation and patients who became pregnant more than 24 months after renal transplantation.

Materials and methods: The sample population of our prospective cohort study comprised of 44 patients who became pregnant following renal transplantation. In all cases, living donors were used for renal transplantation. The patients were allocated into either group A, which included 24 patients who became pregnant more than 24 months after renal transplantation, or group B, which included 20 patients who inadvertently became pregnant within 24 months of renal transplantation. Serum creatinine and 24-hour urinary protein concentration were measured each trimester. The incidences of preeclampsia and gestational diabetes, the timing and mode of delivery, the rate of preterm labor, and the mean fetal birth weight were determined.

Results: The mean gestational ages in groups A and B were 35.8±3 weeks and 34.1±2.5 weeks, respectively. The mean fetal birth weights in groups A and B were 2,480±316 g and 2,284.5±262 g, respectively. These differences were statistically significant. The incidence of preterm labor was 45.8% in group A and 55% in group B. Proteinuria was significantly higher in group B during the third trimester of pregnancy. Preeclampsia occurred in 25% of the cases in group A and 30% of the cases in group B; this difference was not statistically significant. Gestational diabetes occurred in 2 out of 24 cases in group A and 2 out of 20 cases in group B. For group A and group B, normal vaginal delivery occurred in 58.3% and 55% of cases, respectively, and cesarean section was performed in 41.6% and 45% of cases, respectively.

Conclusion: A longer interval between renal transplantation and pregnancy is associated with better pregnancy outcome.