Comprehensive assessment of fetal wellbeing in intrauterine growth restriction: biophysical profile and doppler cerebroplacental ratio

The current routine prenatal surveillance tests such as the non-stress test and fetal biophysical profile [BPP] may not be sensitive or specific enough to detect fetuses with an early compromise. Studies suggest that the cerebroplacental ratio [CPR] may be a highly sensitive Doppler index for assessment of wellbeing and prediction of outcome in fetuses with intrauterine growth restriction [IUGR]. To evaluate [1] the screening efficiency of Doppler CPR, compared with BPP, for the prediction of IUGR and the associated perinatal complications; and [2] whether the additional use of CPR improves the prediction of such outcomes over BPP alone. A comparative cross-sectional study. Department of Obstetrics and Gynecology, Kasr El-Aini Hospital, Cairo University. Fifty singleton pregnancies at risk for IUGR. Cases were managed with weekly or twice weekly BPP, and Doppler velocimetry of the umbilical artery [UA] and middle cerebral artery [MCA] was performed when delivery is indicated. The CPR, defined as the MCA-RI divided by the UA-RI, was considered abnormal if <1.0. Adverse perinatal outcome was defined as any combination of IUGR and perinatal complications. The perinatal outcomes were correlated to the results of BPP and CPR, and the accuracy of BPP and CPR in the prediction of adverse outcome was calculated. Sixteen cases [32%] had normal outcome and 34 cases [68%] had adverse outcome. The BPP and CPR were significantly lower in cases with adverse outcome [p=0.002 and 0.001, respectively]. Cases with abnormal BPP and CPR had a very high risk of adverse outcome [27/28; 96%]. The CPR was comparable to BPP; and the correlation of BPP and CPR increased the accuracy of prediction of adverse outcome as shown by sensitivity, specificity, +ve predictive value, -ve predictive value, overall accuracy, likelihood ratio +ve, and likelihood ratio-ve of 79%, 75%, 87%, 63%, 78%, 3.16, and 0.28, respectively, for BPP alone; and 82%, 69%, 85%, 65%, 78%, 2.65, and 0.26, respectively, for CPR alone; compared to 79%, 94%, 96%, 68%, 84%, 13.17, and 0.22, respectively, for both BPP and CPR. The main finding was an increase in the perinatal risk when abnormal BPP and CPR are observed. The additional use of CPR appears to improve risk prediction over BPP alone

correlation between anthropometric measurements, insulin and reproductive hormones in Saudi females with and without polycystic ovary syndrome

The recent theories of the pathogenesis of polycystic ovary syndrome [PCOS] have focused on the role of insulin resistance and hyperinsulinemia. The insights into the role of hyperinsulinemia in the development of PCOS brought into focus the role of obesity, which magnifies hyperinsulinemia observed in PCOS patients. [1] To study the variations in the levels of insulin and reproductive hormones in lean, overweight, and obese females with and without PCOS. [2] To evaluate the relationship between anthropometric measurements, insulin, and reproductive hormones. A comparative cross-sectional study at King Faisal Specialist Hospital and Research Center [KFSH and RC], and the Department of Obstetrics and Gynecology, Umm Al-Qura University. 212 Saudi female volunteers aged 19-36 years. Cases were 90 women with PCOS. Controls were 122 volunteers representing cross section of Saudi society. The cases and controls were subdivided into six groups according to their body mass index [BMI]; lean [BMI 18.5-24], overweight [BMI 25-29], and obese [BMI >30]. Anthropometric measurements included body weight, height, BMI, and waist: Hip ratio. Hormone and metabolic assessment was made for fasting insulin, glucose, FSH, LH, oestradiol, progesterone, testosterone, androstendione, and SHBG. Main Outcome Measures: The correlation between anthropometric measurements, insulin, and reproductive hormones in females with and without PCOS. Significant positive correlation between BMI and insulin was seen in overweight and obese control women. Fasting insulin levels were significantly higher among obese control women and PCOS patients. The presence of PCOS was not associated with any differences in FSH levels, but LH levels were increased significantly. Progesterone levels were significantly lower and E[2] levels were significantly higher among the PCOS patients than their control females. Testosterone and androstenedione levels were significantly higher and SHBG significantly lower in both obese control and PCOS patients. The main finding was a significant positive correlation between BMI and insulin in overweight and obese control women. In addition, insulin levels were significantly high in obese group, which confirmed that obesity in Saudi women is associated with hyperinsulinaemia and insulin resistance. Longitudinal follow-up studies of these women are, therefore, recommended to evaluate the effects on future fertility and reproductive health

comparative study of single dose, double-dose methotrexate and surgical management of ectopic pregnancy regarding safety, efficacy and tubal patency

To evaluate the safety, efficacy of two Meth-otrexate [MTX] regimens for treatment of ectopic pregnancy [EP] and determine the future fertility after medical and surgical management of ectopic pregnancy. 75 cases with EP, 52 were stable and eligible for medical treatment. 24 cases received MTX 50mg/m2, additional dose was given one week later if B-HCG did not decline by 15% between day 4 and 7, while 28 cases received MTX 50mg/m[2] on days 0 and 4, additional doses were given on day 7 and/or on day 11 if HCG levels did not decrease by 15% during the follow-up period. 23 cases underwent surgery. Hysterosalpingogram [HSG] was performed to assess future fertility of patients after receiving treatment for EP. Overall success rate for single-dose and double-dose protocol was 79% and 85.7% respectively. The difference in success rate between the two regimens was most evident at B-HCG concentrations between 2000-5000mIU/mL; 75% for the single dose regimen and 85.7% for the two-dose regimen which favor using the two-dose regimen in this category of patients. Treatment was well tolerated in both groups, most side effects were mild and transient. Regarding future fertility; tubal patency was 94.2% after medical treatment and 82.6% after salpingectomy. The 2-dose protocol is a hybrid between the two previously established protocols; the single dose and the multi-dose MTX. It may optimize the balance between convenience and efficacy. Single-dose regimen is most suitable for low B-HCG <2000mIU/mL mIU/mL, the 2-dose regimen is more suitable for higher B-HCG 2000-5000, while B-HCG >5000mIU/mL has a high failure rate with medical treatment. In a limted number of patients, no safety concerns were noted with either the single-dose or the 2-dose protocols. Medical treatment should be offered to stable patients whenever feasible because it preserves their future fertility meanwhile cost effective

randomized double-blind trial comparing vaginal misoprostol versus prostaglandin E2 for labour induction at term

To determine the efficacy and safety of vaginal misoprostol [50mcg] compared to vaginal prostaglandin E2 [PGE2] for induction of labour. A randomized double-blind clinical trial. Obstetric Unit, King Faisal Armed Forces Hospital, Southern Region, Khamis Mushayt, Kingdom of Saudi Arabia. Two hundred and twenty pregnant women at term requiring induction. The women were randomized to receive vaginal misoprostol 50mcg or Prostaglandin E2 3mg. The dose was repeated 6, 24 and 30 hours after the first dose if an adequate uterine response was not achieved. The primary outcome was vaginal delivery within 24 hours. Secondary outcomes were the time from induction to delivery, the need for oxytocin augmentation, the mode of delivery, the frequency of side effects, and the maternal and neonatal outcomes. There were no significant differences in maternal characteristics or indications for induction. The percentage of women who achieved vaginal delivery within 24 hours was higher in the misoprostol group compared with the PGE2 group [67% Vs. 53%, p<0.05] and fewer patients in this group needed more than 2 doses [11% Vs. 28%, p<0.05]. The time to vaginal delivery was shorter in the misoprostol group when compared with the PGE2 group [15.2 hours Vs. 20.2 hours, p<0.05]. Fewer patients in the misoprostol group required oxytocin augmentation [24% Vs. 50%, p<0.0001]. There were no significant differences between the two groups with respect to rates of caesarean section, fetal heart rate anomalies, lachysystole, hyperstimulation, meconium passage and neonatal outcome. Induction of labour with vaginal misoprostol is more effective than vaginal PGE2 with no apparent adverse effect on the mother or the fetus

association between polyhydramnios and fetal congenital anomalies: a comparative study of ultrasound techniques of amniotic fluid measurement

Objective: to determine the prevalence of polyhydramnios and its association with fetal congenital anomalies, with comparative measurements of amniotic fluid volume [AFV] using different sonographic techniques

Materials and Methods: this prospective study was done in King Faisal Armed Forces Hospital, Southern Region, Saudi Arabia. One hundred and seventeen patients between 20 and 41 weeks of singleton gestations with fetal congenital anomalies were recruited for the study. Ultrasound was solely used for the detection of fetal anomalies and measurements of AFV. The polyhydramnios was categorised into two groups; mild [>95[th] 97.5[th] percentile] from the normative scale of different techniques

Results: the association of polyhydramnios groups of modified amniotic fluid index [MAFI], amniotic fluid index [AFI] and maximum vertical pocket [MVP] with the fetal congenital malformations were 35 [29.9%], 29 [24.8%] and 27 [23.1%] respectively. The MAFI detected 17.1% cases of mild group and 82.9% cases of severe polyhydramnios. Twenty- nine [82.9%] patients had severe polyhydramnios with congenital defects; predominantly the central nervous system [CNS], gastrointestinal tract, multiple system defects, and others. Only CNS abnormalities had a comparatively greater prevalence [51.4%]. There were significant statistical differences between polyhydramnios and normal fluid groups [p<0.001]

Conclusion: ultrasonography accurately evaluates pregnancy complicated by polyhydramnios and has prognostic implications. Cases with congenital anomalies have higher rates of severe polyhydramnios prejudice alarming for the obstetrician for possible CNS and gastrointestinal tract abnormalities

Comparison of two- and three-dimensional ultrasonography versus diagnostic hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women

To compare two- and three-dimensional ultrasonography [2D- and 3D-US] versus diagnostic hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. A prospective observational cross-sectional study. Department of Obstetrics and Gynecology, Kasr El-Aini Hospital, Cairo University. 50 premenopausal women with abnormal uterine bleeding and suspected uterine lesions. 2D- and 3D-US followed by diagnostic hyst-eroscopy. The ultrasonographic and hysteroscopic findings were compared to the histopathological findings. Accuracy of 2D- and 3D-US versus diagnostic hysteroscopy in the diagnosis of uterine lesions. 3D-US was superior to 2D-US and hysteroscopy in the diagnosis of uterine lesions as shown by sensitivity, specificity, +ve predictive value, -ve predictive value, overall accuracy, +ve likelihood ratio and -ve likelihood ratio of 88.57%, 93.33%, 96.88%, 77.78%, 90.00%, 13.29 and 0.12 respectively for 3D-US, compared to 65.71%, 86.67%, 92.00%, 52.00%, 72.00%, 4.93 and 0.40 respectively for 2D-US, and 71.43%, 93.33%, 96.15%, 58.33%, 78.00%, 10.71 and 0.31 respectively for hysteroscopy. 3D-US can safely be used as the first line investigation for abnormal uterine bleeding in premenopausal women. Hysteroscopy can be used as a second line investigation

Placental trophoblastic apoptosis in preeclampsia and intrauterine growth retardation

To determine whether preeclampsia and intrauterine growth retardation [IUGR] are associated with an increase in placental apoptosis. A prospective observational case-control study. Departments of Obstetrics and Gynecology and Pathology, Kasr El-Aini Hospital, Cairo University. Forty pregnant women, between 37 and 40 weeks of gestation. Tissue specimens from 20 normal term placentae and each of 20 term placentae complicated by either preeclampsia [n=10] or IUGR [n=10] were analyzed after delivery. Apoptosis were quantified using light microscopy performed on hematoxylin and eosin stained placental tissue. Apoptotic index in the nuclei of cytotrophoblasts and syncytiotrophoblasts. Apoptosis was apparent in the nuclei of both cytorophoblasts and syncytiotrophoblasts. There was no significant difference in the apoptotic index in cytotrophoblast nuclei among normal term, preeclamptic term, and IUGR term placentae [p>0.05], whereas the apoptotic index of syncytiotrophoblast nuclei was significantly higher in preeclamptic term placentae [p=0.002] and IUGR term placentae [p=0.008] than that in normal term placentae. The apoptotic index of syncytiotrophoblast nuclei in preeclamptic and IUGR term placentae was significantly higher than that in normal term placentae. Further studies to determine factors responsible for regulating apoptosis of trophohlasts are recommended to provide new insight into understanding of the molecular basis of pathophysiology of the placentae complicated by either preeclampsia or IUGR

Three-dimensional sonohystersalpingography for the investigation of tubo-uterine factors of infertility

To compare three-dimensional sonohystersalpingography [3D-SHSG] and X-ray hystersalpingography [XHSG] versus the 'gold standard' diagnostic laparoscopy and hysteroscopy [DL/DH] for the investigation of tubo-uterine factors of infertility. A prospective observational cross-sectional study. Department of Obstetrics and Gynecology, Kasr El-Aini Hospital, Cairo University. Fifty women, with suspected tubo-uterine factors of infertility, scheduled for DL/DH. Tubal patency and uterine cavity were investigated by saline infusion 3D-SHSG and XHSG. The sonographic and radiological findings were compared to the endoscopic findings as the 'gold standard'. The accuracy of 3D-SHSG and XHSG versus DL/DH in the diagnosis of tubo-uterine factors of infertility. 3D-SHSG was superior to XHSG and comparable to DL/DH in the diagnosis of tubo-uterine factors of infertility as shown by sensitivity, specificity, +ve predictive value, -ve predictive value, overall accuracy, +ve likelihood ratio and -ve likelihood ratio of 93.75%, 94.12%, 88.24%, 96.97%, 94.00%, 15.94 and 0.07 respectively for 3D-SHSG compared to 87.50%, 76.47%, 63.64%, 92.86%, 80.00%, 3.72 and 0.16 respectively for XHSG in the diagnosis of tubal patency, and of 80.00%, 94.29%, 85.71%, 91.67%, 90.00%, 14.00 and 0.21 respectively for 3D-SHSG compared to 46.67%, 91.43%, 70.00%, 80.00%, 78.00%, 5.44 and 0.58 respectively for XHSG in the diagnosis of uterine abnormalities. Compared with DL, the efficacy of 3D-SHSG to assess tubal patency was acceptable. 3D-SHSG also provided advantages of better assessment of uterine cavity over XHSG. Thus, 3D-SHSG with saline contrast is feasible and may be recommended for the initial investigation of infertile women

comparison of supracervical foley catheter, prostaglandin E2 tablet and combination of foley catheter and prostaglandin E2 tablet for cervical ripening and labor induction

The purpose of this study is to compare the efficacy and safety of supra-cervical Foley Catheter and vaginal prostaglandin E[2] [PGE[2]] tablet and combination of supracervical Foley Catheter and PGE[2] tablet for cervical ripening and labor induction. 90 patients admitted for induction of labor with a Bishop score

Maternal serum leptin in pregnancy induced hypertension

To investigate maternal serum leptin levels in pregnancy induced hypertension, subdivided into preeclampsia and gestational hypertension, compared with uncomplicated pregnancies. A prospective observational case-control study. Department of Obstetrics and Gynecology. Kasr El-Aini Hospital, Cairo University. Forty cases in the third trimester of pregnancy with either preeclampsia [n=20] or gestational hypertension [n=20] and 20 normotensive pregnant controls. The control and study groups were matched for maternal age [ +/- two years], pre-pregnancy body mass index [ +/- 10%] and gestational age [ +/- one week]. Fasting blood samples were collected from cases and controls. Glucose was measured using the glucose oxidase method and leptin was measured using enzyme-linked immunosorbent assay [ELISA]. Glucose and leptin levels were compared based on serological data. The demographic and clinical characteristics, which might influence leptin levels, were comparable [p>0.05]. The mean glucose levels were not significantly different in the control and study groups [p>0.05]. However, mean leptin levels were significantly higher in the women with preeclampsia compared with the normotensive group [16.9 +/- 7.0ng/mL vs. 9.8 +/- 4.8ng/mL, p=0.001]. Similarly, mean leptin levels were significantly higher in the women with gestational hypertension compared with their normotensive counterparts [15.1 +/- 5.9ng/mL vs. 9.8 +/- 4.8ng/mL, P=0.003]. Preeclampsia and gestational hypertension ire is associated with elevated maternal serum leptin. Leptin may play a role in the pathogenesis of these disorders. Further longitudinal studies are recommended to investigate the possible value of leptin as a second trimester predictor of pregnancy induced hypertension

Insulin resistance in pregnancy induced hypertension

Pregnancy induced hypertension continues to be a major of pregnancy associated morbidity and mortality. Yet, its exact pathophy sinology remains obscure. There is a growing body of evidence linking insulin resistance and pregnancy induced hypertension. To investigate the association between insulin resistance and pregnancy induced hypertension, subdivided into preeclampsia and gestational hypertension, compared with uncomplicated pregnancies. A prospective observational case-control study. Setting: Obstetric Unit of Cairo University Hospital [Kasr EL-Aini]. Participants: Forty cases in the third trimester of pregnancy with either preeclampsia [n=20] or gestational hypertension [n=20], and 20 normotensive pregnant control. The control and study groups were matched for maternal age [ +/- two years], pre-pregnancy body mass index [ +/- 10%] and gestational age [ +/- one week]. Fasting blood samples were collected from cases and controls. Glucose was using the glucose oxidase method and insulin was measured using radioimmunoassay. Main Outcome Measure: Fasting glucose and insulin levels were compared based on serological data and fasting insulin levels were used as a marker of insulin resistance. The demographic and clinical characteristics, which might influence insulin resistance, were comparable [p>0.05]. The mean fasting glucose levels were not significantly different in the control and study groups [p>0.05]. However, mean fasting insulin levels were significantly lower in the women with preeclampsia compared with the normotensive group [p<0.001]. Conversely, mean fasting insulin levels were significantly higher in the women with gestational hypertension compared with their normotensive counterparts [p<0.001]. As with other forms of secondary hypertension, preeclampsia is not associated with insulin resistance, and like essenential hypertension, gestational hypertension is associated with insulin resistance. Insulin resistance may play a role in the pathogenesis of gestational hypertension, but not preeclampsia

Comparative study of spontaneous vaginal delivery and elective caesarean section as obstetric risk factors for urinary and anal incontinence

The aim of this study was to evaluate the contribution of the mode of delivery to the occurrence of stress, urge and mixed urinary incontinence, overactive bladder, anal incontinence and combined incontinence. The study involved 900 women satisfying the selection criteria seen for counseling and/or treatment of urinary and/or anal incontinence or observed for routine gynecological examination or minor gynecological complaints without any symptoms related to these disorders. Six hundred women with previous 1-3 deliveries were included in this study and classified into 2 groups [each comprising 300 women]. Group I included women with only spontaneous vaginal deliveries and group II included women with only elective caesarean section deliveries. In addition, 300 nulliparous women observed during the study period in the same gynecology clinic. Urinary and anal incontinence symptoms were measured using questions from the urogenital distress inventory and Manchester health questionnaire. The main outcome measures included spontaneous vaginal delivery and elective caesarean section delivery as obstetric determinants of stress, urge and mixed urinary incontinence, overactive bladder, anal incontinence and combined incontinence. The results showed that in comparison with women reporting 1-3 elective caesarean section deliveries [group II], a history of 1-3 spontaneous vaginal deliveries [group I] was associated with the risk of stress, mixed and overall urinary incontinence and increased the risk of urge urinary incontinence, overactive bladder, anal incontinence and combined urinary and anal incontinence

randomised controlled trial of orally and rectally administered prostaglandin E1 analogue misoprostol and standard management of the third stage of labour in the prevention of postpartum haemorrhage

Misoprostol may have the potential to prevent atonic postpartum haemorrhage, when administered orally or rectally, and may be an alternative to conventional standard oxytocic regimens for the active management of third stage of labour. To examine the efficacy and side effects of oral versus rectal misoprostol compared to standard oxytocics for the prevention of postpartum haemorrhage. A prospective randomised controlled trial. Obstetric Unit of Cairo University Hospital [Kasr El-Aini]. Five hundred low risk women with anticipated vaginal delivery. In the third stage of labour, the women were randomised to 600 micro g misoprostol given orally [Group I; n=150] rectally [Group II; n= 150] after clamping and division of the cord, or to standard oxytocic regimens of syntometrine or syntocinon [Group III; n=200] after the delivery of the anterior shoulder. The main primary outcomes were changes in haemoglobin concentration and haematocrit from before delivery to 12 hours postpartum. Secondary outcomes were the side effects of drug regimens, including, nausea, vomiting, diarrhoea, shivering and elevated temperature. The baseline demographic characteristics and labour variables were similar. There were no statistically significant differences [P>0.05] between the groups in the changes of haemoglobin concentrations and haematocrit [the main primary outcomes], the estimated blood loss, the incidence of postpartum haemorrhage, the incidence of severe postpartum haemorrhage, the proportions of women requiring blood transfusion, the length of the third stage, the incidence of prolonged third stage, the need for manual removal of the placenta, the percentage of women requiring additional oxytocic administration and the incidence of delayed haemorrhage in post natal ward. The main side effects were shivering and a rise in temperature, which occurred more frequently in the oral misoprostol group [P-overall <0.001 and 0.012 respectively]. Other side effects were mild with no differences between the groups. Oral and rectal misoprostol were comparable to standard oxytocics for the prevention of postpartum haemorrhage. Shivering and pyrexia were the main side effects of oral misoprostol. Of importance is the apparent lack of these side effects with the rectal route. Further randomised controlled trials are required to identify the best drug combinations, route, and dose for the prevention of postpartum hemorrhage