Evaluación de la dilatación cervical en simuladores comparada con una herramienta visual: estudio aleatorizado / Cervical dilation assessment in simulators compared to a visual tool: A randomized study / Avaliação da dilatação cervical em simuladores comparada a uma ferramenta visual: estudo randomizado

Objetivo: comprobar la tasa de evaluación correcta mediante la comparación visual directa de las medidas de dilatación cervical en modelos de cuello uterino de consistencia dura. Método: estudio aleatorizado abierto con 63 estudiantes de obstetricia a los que se les asignó usar o no la comparación visual directa con una guía de dilatación. Los estudiantes estimaron de forma ciega la dilatación cervical en simuladores con diferentes dilataciones. El resultado primario fue la tasa de evaluación correcta. Resultados: los estudiantes realizaron 441 pruebas. Se observó una mayor tasa de evaluación correcta en el grupo experimental que en el grupo control (47,3% versus 27,2%; p < 0,001; Odds Ratio = 2,41; intervalo de confianza del 95% = 1,62-3, 58). Conclusión: la comparación visual directa aumentó la precisión de la evaluación de la dilatación cervical en modelos de simulación de cuello, lo que podría ser beneficioso en el entrenamiento de laboratorio. Registro Brasileño de Ensayos Clínicos n.º U1111-1210-2389.

Objective: to verify the correct assessment rate when using direct visual comparison in the cervical dilation measures in hard-consistency cervix simulation models. Method: an open-label and randomized study conducted with 63 Obstetrics students that were designated either to use direct visual comparison in a dilation guide or not. The students estimated cervical dilation blindly in simulators with different dilations. The primary outcome was the correct assessment rate. Results: the students performed 141 tests. A higher correct assessment rate was found in the Experimental Group than in the Control Group (47.3% versus 27.2%; p<0.001; Odds Ratio = 2.41; 95% Confidence Interval = 1.62-3.58). Conclusion: the direct visual comparison increased precision of the cervical dilation assessment in cervix simulation models, with the possibility of being beneficial in laboratory training. Brazilian Registry of Clinical Trials No. U1111-1210-2389.

Objetivo: verificar a taxa de avaliação correta com o uso da comparação visual direta nas medidas de dilatação cervical em modelos de simulação de colo com consistência dura. Método: estudo randomizado aberto com 63 estudantes de obstetrícia que foram designados para usar comparação visual direta em um guia de dilatação ou não. Os estudantes estimaram cegamente a dilatação cervical em simuladores com diferentes dilatações. O desfecho primário foi a taxa de avaliação correta. Resultados: os estudantes realizaram 441 testes. Foi encontrada maior taxa de avaliação correta no grupo experimental do que no grupo controle (47,3% versus 27,2%; p <0,001; Odds Ratio = 2,41; intervalo de confiança de 95% = 1,62-3,58). Conclusão: a comparação visual direta aumentou a precisão da avaliação da dilatação cervical em modelos de simulação de colo, podendo ser benéfica no treinamento em laboratório. Registro Brasileiro de Ensaios Clínicos nº U1111-1210-2389.

Risk Factors for Intrapartum Cesarean Section Delivery in Low-risk Multiparous Women Following at Least a Prior Vaginal Birth (Robson Classification 3 and 4)

Abstract Objective The aim of the present study was to evaluate the risk factors for cesarean section (C-section) in low-risk multiparous women with a history of vaginal birth. Methods The present retrospective study included low-risk multiparous women with a history of vaginal birth who gave birth at between 37 and 42 gestational weeks. The subjects were divided into 2 groups according to the mode of delivery, as C-section Group and vaginal delivery Group. Risk factors for C-section such as demographic characteristics, ultrasonographic measurements, smoking, weight gain during pregnancy (WGDP), interval time between prior birth, history of macrosomic birth, and cervical dilatation at the admission to the hospital were obtained fromthe charts of the patients. Obstetric and neonatal outcomes were compared between groups. Results The most common C-section indications were fetal distress and macrosomia (33.9% [n=77 and 20.7% [n=47] respectively). A bivariate correlation analysis demonstrated that mothers aged>30 years old (odds ratio [OR]: 2.09; 95% confidence interval [CI]: 1.30-3.34; p=0.002), parity >1 (OR: 1.81; 95%CI: 1.18-2.71; p=0.006), fetal abdominal circumference (FAC) measurement>360mm (OR: 34.20; 95%CI: 8.04 -145.56; p<0.001)) and<345mm (OR: 3.06; 95%CI: 1.88-5; p<0.001), presence of large for gestational age (LGA) fetus (OR: 5.09; 95%CI: 1.35-19.21; p=0.016), premature rupture of membranes (PROM) (OR: 1.52; 95%CI: 1-2.33; p=0.041), and cervical dilatation<5cm at admission (OR: 2.12; 95%CI: 1.34-3.34; p=0.001) were associated with the group requiring a C-section. Conclusion This is the first study evaluating the risk factors for C-section in low-risk multiparous women with a history of vaginal birth according to the Robson classification 3 and 4. Fetal distress and suspected fetal macrosomia constituted most of the Csection indications.

The Identification of Immune-Related Plasma Proteins Associated with Spontaneous Preterm Delivery and Intra-Amniotic Infection in Women with Premature Cervical Dilation or an Asymptomatic Short Cervix

BACKGROUND: We aimed to investigate whether various immune-related plasma proteins, alone or in combination with conventional clinical risk factors, can predict spontaneous preterm delivery (SPTD) and intra-amniotic infection in women with premature cervical dilation or a short cervix (≤ 25 mm).METHODS: This retrospective study included 80 asymptomatic women with premature cervical dilation (n = 50) or a short cervix (n = 30), who underwent amniocentesis at 17–29 weeks. Amniotic fluid (AF) was cultured, and maternal plasma was assayed for interleukin (IL)-6, matrix metalloproteinase (MMP)-9, tissue inhibitor of metalloproteinases (TIMP)-1, and complements C3a and C5a, using enzyme-linked immunosorbent assay (ELISA) kits. The primary outcome measures were SPTD at < 32 weeks and positive AF cultures.RESULTS: The plasma levels of IL-6, C3a, and C5a, but not of MMP-9 and TIMP-1, were significantly higher in women with SPTD at < 32 weeks than in those who delivered at ≥ 32 weeks. The women who delivered at < 32 weeks had more advanced cervical dilatation, and higher rates of antibiotic and tocolytic administration and were less likely to be given vaginal progesterone than those who delivered at ≥ 32 weeks. Using a stepwise regression analysis, a combined prediction model was developed, which included the plasma IL-6 and C3a levels, and cervical dilatation (area under the curve [AUC], 0.901). The AUC for this model was significantly greater than that for any single variable included in the predictive model. In the univariate analysis, plasma IL-6 level was the only significant predictor of intra-amniotic infection.CONCLUSION: In women with premature cervical dilation or a short cervix, maternal plasma IL-6, C3a, and C5a levels could be useful non-invasive predictors of SPTD at < 32 weeks. A combination of these biomarkers and conventional clinical factors may clearly improve the predictability for SPTD, as compared with the biomarkers alone. An increased plasma level of IL-6 predicted intra-amniotic infection.

Avaliação do impacto de um protocolo fisioterapêutico na diminuição do quadro álgico durante a primeira fase do trabalho de parto vaginal / Evaluation of the impact of a physiotherapeutic protocol on the reduction of pain during the first phase of vaginal labor

O objetivo deste estudo foi avaliar a eficiência de um protocolo fisioterapêutico, aplicado em gestantes atendidas na Santa Casa de Misericórdia de Sobral/CE voltado para a redução do quadro álgico na primeira fase do trabalho de parto e na humanização do parto vaginal. Participaram grávidas com idade gestacional entre 37-42 semanas de gestação com feto único, vivo em apresentação cefálica e que estivessem na primeira fase do trabalho de parto, atuando de forma ativa e com dilatação cervical mí­nima de 3 centí­metros e sem uso de medicação após entrada no hospital. As participantes do grupo controle (GC; N=25) receberam orientações sobre relaxamento, respiração, dor e parto vaginal como placebo. As parturientes do grupo de intervenção (GI; N = 25), além das orientações, realizaram exercí­cios de respiração, liberação miofascial, alongamento, exercí­cios cinético-funcionais e massagem. Observou-se que as intervenções realizadas no GI proporcionaram diminuição da dor relatada (p = 0,0001), tendência não observada no GC. Foi observado aumento da dilatação vaginal e saturação de O2 em ambos os grupos, entretanto a média foi maior entre as pacientes do GI (p = 0,0001). Infere-se que o protocolo utilizado diminui a dor da gestante na primeira etapa do parto genital, além de estar associado ao relaxamento das pacientes. (AU)

The objective of this study was to evaluate the physiotherapeutic practice on the impact of pain during the first phase of vaginal labor in pregnant women attended at Santa Casa de Misericórdia of Sobral/CE. Pregnant women of gestational age between 37-42 weeks with a single fetus, alive in cephalic presentation and in the first phase of labor, active and with cervical dilatation of at least 3 cm, without use of medication after hospital admission, participated in this study. Participants in the control group (CG; N = 25) received guidance on relaxation, breathing, pain and vaginal delivery as placebo. In the intervention group (GI; N = 25), the patients received physical therapy, breathing, myofascial release, stretching, kinetic-functional exercises and massage. We observed that the interventions performed in the GI provided a decrease in the pain reported by the patients (p = 0.0001), a tendency not observed in the CG. Increased vaginal dilation and O2 saturation were observed in both groups, however, the mean was higher among GI patients (p = 0.0001). It is inferred that the protocol used reduces the pain of the pregnant woman in the first stage of genital delivery, besides being associated with the relaxation of the patients. (AU)

Emergency cerclage: gestational and neonatal outcomes

SUMMARY BACKGROUND: The gestational and neonatal outcomes of women with early cervical dilatation undergoing emergency cerclage were evaluated and compared with women treated with expectant management and bed rest. METHODS: Retrospective analysis of pregnant women admitted between 2001 and 2017 with a diagnosis of early cervical dilatation and/or bulging membranes. Patients with a singleton pregnancy of a fetus without malformations, between 16 and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included; patients who delivered or miscarried within 2 days after admission were excluded. RESULTS: The study enrolled 30 patients: 19 in the cerclage group and 11 in the rest group. There was a significant difference, with the cerclage group showing better results concerning gestational age at delivery (28.7 vs. 23.3 weeks; p=0.031) and latency between hospital admission and delivery (48.6 vs. 16 days; p=0.016). The fetal death rate was lower in the cerclage group (5.3% vs. 54.5%, p=0.004). Considering gestational age at delivery of live newborns, no difference was observed between the cerclage and rest groups (29.13 vs. 27.4 weeks; p=0.857). CONCLUSIONS: Emergency cerclage was associated with longer latency, a significant impact on gestational age at delivery and reduction in the fetal death rate.

RESUMO OBJETIVO: Os resultados gestacionais e neonatais de mulheres com cervicodilatação precoce submetidas à cerclagem de emergência foram avaliados e comparados com mulheres tratadas com manejo expectante com repouso no leito. MÉTODOS: Análise retrospectiva de gestantes admitidas entre 2001 e 2017 com diagnóstico de cervicodilatação precoce e/ou membranas protrusas. Foram incluídas pacientes com gestação única de feto sem malformações, entre 16 semanas e 25 semanas e 6 dias, com dilatação cervical de 1 a 3 cm; as pacientes que tiveram parto ou aborto dentro de 2 dias após admissão foram excluídas. RESULTADOS: O estudo envolveu 30 pacientes: 19 no grupo cerclagem e 11 no grupo repouso. Houve diferença significativa, com o grupo cerclagem apresentando melhores resultados em relação à idade gestacional no parto (28,7 vs. 23,3 semanas; p=0,031) e à latência entre a admissão hospitalar e o parto (48,6 vs. 16 dias; p=0,016). A taxa de mortalidade fetal foi menor no grupo cerclagem (5,3% vs. 54,5%, p=0,004). Considerando a idade gestacional no nascimento dos recém-nascidos vivos, não houve diferença entre os grupos cerclagem e expectante (29,13 vs. 27,4 semanas; p=0,857). CONCLUSÕES: A cerclagem de emergência foi associada a maior período de latência com impacto significativo na idade gestacional do parto e à redução da taxa de mortalidade fetal.

Terapias complementares no trabalho de parto: ensaio clínico randomizado / Terapias complementarias en el trabajo de parto: ensayo clínico randomizado / Complementary therapies in labor: randomized clinical trial

Resumo OBJETIVO: Avaliar o efeito do banho quente de chuveiro e exercício perineal com bola suíça isolados e de forma combinada, sobre a percepção da dor, ansiedade e progressão do trabalho de parto. MÉTODO: Ensaio clínico randomizado e controlado com 128 parturientes alocadas em três grupos de terapias, banho, bola, isolados e combinados. A percepção da dor e ansiedade foi avaliada antes e trinta minutos após a intervenção terapêutica por meio de escala visual analógica (EVA). RESULTADOS: Houve aumento no escore de dor e redução da ansiedade em todos os grupos, sobretudo quando utilizaram banho de chuveiro. A dilatação cervical, aumentou em todos os grupos de intervenção (p<,001) bem como o número de contrações uterinas, principalmente quem utilizou banho e bola associados como também mostrou menor duração do tempo de trabalho de parto. CONCLUSÃO: As terapias estudadas contribuem para adaptação e bem-estar materno e favorecem a evolução do trabalho de parto.

Resumen OBJETIVO: Evaluar el efecto de la ducha caliente y del ejercicio perineal con pelota suiza, separadamente y de forma combinada, sobre la percepción del dolor, la ansiedad y la progresión del trabajo de parto. MÉTODO: Ensayo clínico aleatorizado y controlado junto a 128 parturientes asignadas en tres grupos de terapias, ducha caliente, pelota suiza separadamente y de forma combinada. La percepción de dolor y de ansiedad se evaluó antes y treinta minutos después de la intervención terapéutica por medio de escala visual analógica. RESULTADOS: Hubo un incremento en la puntuación de dolor y una reducción de la ansiedad en todos los grupos, sobre todo cuando se utilizó la ducha. La dilatación cervical aumentó en todos los grupos de intervención (p<,001) así como el número de contracciones uterinas, principalmente en el grupo que utilizó las dos terapias combinadas, ducha caliente con pelota suiza. Asimismo se constató menor duración del tiempo de trabajo de parto. CONCLUSIÓN: Las terapias estudiadas contribuyen a la adaptación y el bienestar materno y favorecen la evolución del trabajo de parto.

Abstract OBJECTIVE: To evaluate the effect of isolated and combined warm shower bath and perineal exercise with Swiss ball, on perception of pain, anxiety and labor progression. METHOD: Randomized, controlled clinical trial with 128 patients allocated into three groups of therapies: isolated and combined bath and ball. Pain and anxiety perception was evaluated before and thirty minutes after therapeutic intervention through visual analogic scales (VAS). RESULTS: Pain perception score increased, and anxiety decreased in all groups, mainly when using a shower bath. The cervical dilation increased in all groups (p<.001), as well as the number of uterine contractions increased, mainly in the group that used combined bath and ball and also showed shorter labor time. CONCLUSION: The studied therapies contribute to maternal adaptation and well-being and favor labor's evolution.

Evaluation of isosorbide-5-mononitrate as a cervical ripening agent prior to induced abortion in contrast to misoprostol- a randomized controlled trial

OBJECTIVE: To determine whether vaginal application of 40 mg isosorbide-5-mononitrate (ISMN) has a comparable cervical ripening efficacy to and lesser side effects than 400 µg misoprostol in women scheduled for the first trimester induced abortion using a manual vacuum aspirator (MVA). METHODS: We conducted a prospective randomized open- label study in 70 women at 6–12 weeks of pregnancy at the R G Kar Medical College and Hospital, Kolkata, India, over a period of two years from 2015 to 2017. Forty milligrams of ISMN and 400 µg misoprostol were vaginally applied for cervical priming. The primary outcome measure was the cervical response assessed by the passage of the appropriate and largest sized MVA cannula through the internal os without resistance, at the beginning of the procedure. RESULTS: The base line cervical dilatation was found to be significantly higher in the misoprostol group than in the ISMN group (7.65±1.38 vs. 6.9±1.26 mm; P=0.025, 95% confidence interval, −1.4046 to −0.953). However, when the women were sub-analyzed based on parity, there was no statistically significant difference in the same parameters among the multigravid women. The need for further cervical dilatation was significantly higher in the ISMN group when the primigravid women were compared, although the multigravid women responded favorably to ISMN. CONCLUSION: In the primigravid women, misoprostol appears to exert a higher efficacy as a cervical ripening agent in contrast to ISMN. However, ISMN can be used in multigravid women for the same purpose as in this group, misoprostol did not show any significant improvement in efficacy over ISMN.

Comparison of Caesarean sections and instrumental deliveries at full cervical dilatation: a retrospective review

INTRODUCTION@#This study aimed to compare instrumental vaginal deliveries (IDs) and Caesarean sections (CSs) performed at full cervical dilatation, including factors influencing delivery and differences in maternal and neonatal outcomes.@*METHODS@#A retrospective review was conducted of patients who experienced a prolonged second stage of labour at Singapore General Hospital from 2010 to 2012. A comparison between CS and ID was made through analysis of maternal/neonatal characteristics and peripartum outcomes.@*RESULTS@#Of 253 patients who required intervention for a prolonged second stage of labour, 71 (28.1%) underwent CS and 182 (71.9%) underwent ID. 5 (2.0%) of the patients who underwent CS had failed ID. Of the maternal characteristics considered, ethnicity was significantly different. Induction of labour and intrapartum epidural did not influence delivery type. 70.4% of CSs occurred outside office hours, compared with 52.7% of IDs (p = 0.011). CS patients experienced a longer second stage of labour (p < 0.001). Babies born via CS were heavier (p < 0.001), while the ID group had a higher proportion of occipitoanterior presentations (p < 0.001). Estimated maternal blood loss was higher with CSs (p < 0.001), but neonatal outcomes were similar.@*CONCLUSION@#More than one in four parturients requiring intervention for a prolonged second stage of labour underwent emergency CS. Low failed instrumentation rates and larger babies in the CS group suggest accurate diagnoses of cephalopelvic disproportion. The higher incidence of CS after hours suggests trainee reluctance to attempt ID. There were no clinically significant differences in maternal and neonatal morbidity.

Hysteroscopic myomectomy without anesthesia

OBJECTIVE: Scarce literature about myoma removal without anesthesia has been published. The aim of this paper is to evaluate the feasibility of a new alternative for a hysteroscopic myomectomy in a conventional office setting, without need for anesthesia. METHODS: Step-by-step description of the surgical technique has been provided, based on video images. An office hysteroscopy was performed in a Gynecological Endoscopy Department of a tertiary European hospital. RESULTS: A 49-year-old woman was referred for management of severe hypermenorrhea. Consent and approval were received from the patient and the institutional review board, respectively. The introduction of a Truclear® hysteroscopic polyp morcellator of 5.5 mm with optic of 0 degrees into the uterine cavity did not require any kind of anesthesia or cervical dilatation. The use of saline flow helped distend the cavity and identify a submucosal myoma. Under direct vision, a full myomectomy was performed via mechanical energy with continuous cutting movements, without any complication. After the procedure was completed, the excised material was aspirated through the device into a collecting pouch. A successful complete morcellation of a Type-0 submucosal leiomyoma with a polyp morcellator device was performed in an outpatient setting. Good medical results, good tolerance by the patient besides lower surgical risks due to mechanical instead of electrical energy are shown. CONCLUSION: In conclusion, this video demonstrates that a hysteroscopic myomectomy can be performed successfully in office with lower risk of complications from the procedure and without use of general anesthesia besides good tolerance by the patient.

Vía de finalización en pacientes con segunda inducción al trabajo de parto en el Hospital Nacional prof. A. Posadas / Postterm pregnancy in patients with second labour induction - Author's experience

The labour induction is an intervention to initiate artificially the uterine contractions to produce the effacement and dilatation of the uterine cervix until the child-birth is achieved. It is indicated when the benefit of the termination of the pregnancy for the mother and the child is greater than its continuation. It is perfored in more or less the 20 % of the women. In our institution the rate oscillates in around the 9 % of the cases. It is understand as an successful induction the termination of the labour through the vaginal delivery. The methods for labour induction more commonly used at present are mechanical and pharmacological. Between the first group we can find the Hamilton maneuver and the amniotomy. And between the pharmacologicals we find the oxytocine. These elements are considered in the article

Anaphylactic shock to vaginal misoprostol: a rare adverse reaction to a frequently used drug

Misoprostol is widely used in daily practice for induction of labor and cervical dilatation prior to intrauterine procedures, including dilatation and curettage or hysteroscopy. Anaphylactic shock to intravaginal misoprostol can occur not only in pregnant women, as reported in 2 previous cases, but also in a non-pregnant, perimenopausal woman, as in the case described herein. A 49-year-old woman received vaginal misoprostol for cervical ripening prior to hysteroscopic myomectomy and experienced anaphylactic shock. Two 400 μg doses of misoprostol 6 hours apart caused uncontrolled shaking and high fever followed by shock. In conclusion, the possibility of anaphylactic shock should be considered in patients with sudden hypotension following misoprostol administration. Prompt identification and management are crucial to prevent morbidity and mortality following an anaphylactic shock to misoprostol.

Elastografía: una nueva herramienta en obstetricia / ELASTOGRAPHY: A NEW TOOL IN OBSTETRICS

Elastography is a new method which is innovating its use in obstetrics. Elastography has been employed in different fields as a complement of the bidimensional sonography and has been widely studied. However, guidelines for the employement of elastography of the uterine cervix are not available at present. The limitations consist in that there is not a reference of the normel tissue, and of the pathological elasticity of the preterm labor delivery, and besides it is necessary in some types of elastographies an external force which is dependant operator for which the performance of elastographies with cut waves or quantitatives seems to be the most promising method for the evaluation of the elasticity of the cervix. The present utility, current status and future challenges are well docummented in the article. The diagnostic accuracy of cervical elastography in predicting labor induction success is reviewed. The wave elastography of placenta for in vivo quantation of placental elasticity is also considered.

The effectiveness of evening primrose oil gel capsule as a cervical ripening agent during labor induction as measured by bishop score on term singleton pregnant patients / Philippine Journal of Obstetrics and Gynecology

BACKGROUND: Pre-induction of labor cervical ripening increases success of labor induction when there is unfavorable cervix. Evening primrose oil soft gel capsule contains linoleic and gamma-linolenic acid, which are precursors of prostaglandins E1 andE2.OBJECTIVE: To measure the effectiveness of evening primrose oil capsule as a cervical ripening agent by measuring the Bishop score before and 4 hours after intravaginal insertion of six capsules.METHODS: A quasi-experimental cross-sectional study was conducted from the period of May to July 2016 involving labor induction patients with a Bishop score ?4, an intact amniotic sac and a Biophysical profile score of 10/10 or 8/8.RESULTS: Thirteen patients had an average age of 27±6 years, and a mean age of gestation of 40±1 weeks. Seven patients (54%) were nulliparous, 2 (15%) were primiparous and 4 (31%) were multiparous. Seven patients (54%) had hypertension, 1 (8%) had diabetes mellitus, 5 (38%) had post-term pregnancies. A paired t-test was done to check for statistically significant changes in the Bishop score. Change in the Bishop score from baseline to 4 hours after insertion of evening primrose oil capsules was statistically significant (p=0.001). Eleven patients (85%) had improvement in the Bishop score after 4 hours, 4 (31%) of which had a clinically significant change in the Bishop score (?4). Specifically, there were statistically significant changes in the dilatation (p=0.027), effacement (p=0.006) and consistency (p=0.002). The mean birth weight of deliveries was 3192±351 grams. Nine patients (69%) underwent primary low segment cesarean section, six (46%) of which for nonreassuring fetal status, 2 (15%) for arrest in cervical dilatation, and 1 (8%) for intraamnionic infection. Four patients (31%) successfully delivered vaginally.CONCLUSION: Results showed a positive effect on the Bishop score during cervical ripening although further studies are needed to establish direct correlation.

The effectiveness of evening primrose oil gel capsule as a cervical ripening agent during labor induction as measured by bishop score on term singleton pregnant patients / Philippine Journal of Obstetrics and Gynecology

@#<p style="text-align: justify;"><strong>BACKGROUND</strong>: Pre-induction of labor cervical ripening increases success of labor induction when there is unfavorable cervix. Evening primrose oil soft gel capsule contains linoleic and gamma-linolenic acid, which are precursors of prostaglandins E1 andE2.<br /><strong>OBJECTIVE:</strong> To measure the effectiveness of evening primrose oil capsule as a cervical ripening agent by measuring the Bishop score before and 4 hours after intravaginal insertion of six capsules.<br />METHODS: A quasi-experimental cross-sectional study was conducted from the period of May to July 2016 involving labor induction patients with a Bishop score ?4, an intact amniotic sac and a Biophysical profile score of 10/10 or 8/8.<br /><strong>RESULTS:</strong> Thirteen patients had an average age of 27±6 years, and a mean age of gestation of 40±1 weeks. Seven patients (54%) were nulliparous, 2 (15%) were primiparous and 4 (31%) were multiparous. Seven patients (54%) had hypertension, 1 (8%) had diabetes mellitus, 5 (38%) had post-term pregnancies. A paired t-test was done to check for statistically significant changes in the Bishop score. Change in the Bishop score from baseline to 4 hours after insertion of evening primrose oil capsules was statistically significant (p=0.001). Eleven patients (85%) had improvement in the Bishop score after 4 hours, 4 (31%) of which had a clinically significant change in the Bishop score (?4). Specifically, there were statistically significant changes in the dilatation (p=0.027), effacement (p=0.006) and consistency (p=0.002). The mean birth weight of deliveries was 3192±351 grams. Nine patients (69%) underwent primary low segment cesarean section, six (46%) of which for nonreassuring fetal status, 2 (15%) for arrest in cervical dilatation, and 1 (8%) for intraamnionic infection. Four patients (31%) successfully delivered vaginally.<br /><strong>CONCLUSION:</strong> Results showed a positive effect on the Bishop score during cervical ripening although further studies are needed to establish direct correlation.</p>

Effect of pre-pregnancy maternal body mass index on pregnancy outcomes in nulliparous women in the Islamic Republic of Iran

This study was conducted to evaluate the effect of pre-pregnancy BMI on pregnancy outcomes. BMI was calculated measured in 360 nulliparous women. According to BMI, pregnant women were placed into three groups: group I [lean group BMI . 19.8], group II [normal weight group BMI = 19.9.24.9], and group III [obese group BMI . 25]. Data were analyzed using SPSS 16. The mean duration of the first and the second stage of labour were significantly different between three groups [P < 0.001]. Cesarean section ratio in group I was lower than group II [OR = 0.15; P = 0.013]. Instrumental delivery in group III was more than group II [OR=4.6; P = 0.002]. Risk of nonreactive non-stress test [NST] was significantly different between groups II and III [OR = 5.7; P = 0.009]. Induction ratio in group I was lower than group II [OR=0.43; P = 0.002]. Deviation of BMI from the normal level is associated with adverse outcomes of pregnancy and delivery

Pyometra in Elderly Patients and Its Clinical Characteristics

BACKGROUND: Pyometra should be treated with caution in elderly patients because it may indicate a malignancy in the post-menopausal period and can result in life-threatening complications such as septicemia or pan-peritonitis. METHODS: We retrospectively analyzed the clinical features of 30 patients aged ≥65 years who received treatment for pyometra between January 2010 and December 2014. RESULTS: The 30 patients (age: median, 74 years; range, 66-88 years) were evaluated. They presented with vaginal discharge (n=17), vaginal bleeding (n=8), abdominal pain (n=6), or fever (n=3). The most common accompanying systemic disease was hypertension (n=15), followed by diabetes mellitus (n=10). Of the 30 cases, seven were associ- ated with gynecologic malignancy (cervical cancers, n=3; endometrial cancers, n=3; and ovarian cancer, n=1); and 14, with gynecologic benign diseases (uterine myoma, n=5; cervical intraepithelial neoplasia, n=4; tubo-ovarian abscess, n=3; endometrial polyp, n=1; uterine prolapse, n=1). All the patients were treated with cervical dilatation and drainage. Fifteen patients underwent gynecologic surgery with antibiotic therapy, and 15 received empirical antibiotic treatment alone. Two women experienced spontaneous perforation of pyometra. Pyometra is considered a complication of benign and malignant gynecologic disease, until proven otherwise. CONCLUSION: In elderly patients with comorbidities, pyometra might induce severe complications such as pan-peritonitis or sepsis. Early accurate diagnosis is important to determine an appropriate individualized treatment to reduce morbidity and mortality.

Role of vaginal estradiol pretreatment combined with vaginal misoprostol for cervical ripening before operative hysteroscopy in postmenopausal women

OBJECTIVE: To assess the efficacy and safety of vaginal misoprostol after a pretreatment with vaginal estradiol to facilitate the hysteroscopic surgery in postmenopausal women. METHODS: In this observational comparative study, 35 control women (group A) did not receive any pharmacological treatment,26 women (group B) received 25 µg of vaginal estradiol daily for 14 days and 400 µg of vaginal misoprostol 12 hours before hysteroscopic surgery, 32 women (group C) received 400 µg of vaginal misoprostol 12 hours before surgery. RESULTS: Demographic data were well balanced and all variables were not significantly different among the three groups. The study showed a significant difference in the preoperative cervical dilatation among the group B (7.09±1.87 mm), the group A (5.82±1.85 mm; B vs. A, P=0.040) and the group C (5.46±2.07 mm; B vs. C, P=0.007). The dilatation was very easy in 73% of women in group B. The pain scoring post surgery was lower in the group B (B vs. A, P=0.001; B vs. C, P=0.077). In a small subgroup of women with suspected cervical stenosis, there were no statistically significant differences among the three groups considered. No complications during and post hysteroscopy were observed. CONCLUSION: In postmenopausal women the pretreatment with oestrogen appears to have a crucial role in allowing the effect of misoprostol on cervical ripening. The combination of vaginal estradiol and vaginal misoprostol presents minor side effects and has proved to be effective in obtaining satisfying cervical dilatation thus significantly reducing discomfort for the patient.

The relationship of preoperative anxiety with failure of extension of epidural analgesia for cesarean section

BACKGROUND: Patients anesthetized by extension of epidural analgesia during labor frequently experience intraoperative visceral pain during cesarean section. Visceral pain is known to be related to anxiety. We evaluated pain and preoperative anxiety using the numeric rating scale (NRS-11), and examined the relationship of anxiety with failure of extension of epidural analgesia due to intraoperative pain. METHODS: Patients received continuous epidural infusion at a rate of 10 ml/h for labor pain. Two percent lidocaine mixed with 100 microg fentanyl, 1:200,000 epinephrine, and 2 mEq bicarbonate was injected through the epidural catheter for cesarean section. Failure of epidural anesthesia was defined as the need for conversion to general anesthesia or supplementation with opioids, sedatives, or inhalants after epidural anesthesia for cesarean section. We investigated the relationship of preoperative factors including preoperative anxiety with failure of epidural anesthesia. RESULTS: Heavier weight of parturients, more cervical dilatation at the time of epidural analgesia administration, higher pain NRS score after epidural analgesia, higher pain NRS score before epidural analgesia for cesarean section, and lower rate of iv pethidine due to shivering were associated with a higher failure rate of epidural anesthesia. The failure rate of epidural anesthesia was comparable between the high anxiety group (NRS > 4) and the low anxiety group (NRS < or = 4). CONCLUSIONS: Preoperative anxiety evaluated by NRS may not be associated with failure of extension of epidural analgesia due to visceral pain during intrapartum cesarean section.

Clinical factors affecting the timing of delivery in twin pregnancies

OBJECTIVE: To investigate clinical factors affecting the timing of delivery in twin pregnancies in order to minimize perinatal complications. METHODS: A retrospective study involved 163 twin pregnancies delivered from January 2006 to September 2011 at Gachon University Gil Medical Center. These cases were divided into three groups based on the delivery timing: less than 32 weeks' gestation (group A), between 32 and 35+6 weeks' gestation (group B), and over 36 weeks' gestation (group C). Clinical factors including maternal age, parity, presence of premature uterine contraction, presence of premature rupture of membrane, white blood cell, high sensitive C-reactive protein level, cervical dilatation, maternal complication, chorionicity, twin specific complication, and perinatal complication were analyzed for each group. RESULTS: In group B, the timing of delivery was postponed for 14 days or more from the time of admission, and there were fewer numbers of babies with low Apgar score at birth compared with other groups. The frequency of uterine contraction (P<0.001), presence of premature rupture of membranes (P=0.017), dilatation of cervix (P<0.001), increased white blood cell and high sensitive C-reactive protein levels (P=0.002, P<0.001) were important clinical factors during decision making process of delivery timing in twin pregnancies. Twin specific fetal conditions, such as twin-twin transfusion syndrome and discordant growth (over 25% or more) were shown more frequently in group A. However, there were no significant statistical differences among three groups (P=0.06, P=0.14). CONCLUSION: Proper management for preventing premature contraction and inflammation can be essential in twin pregnancies until 32 weeks' gestation, and may decrease maternal and perinatal complications.

Efectividad del tratamiento médico con misoprostol según dosis administrada en aborto retenido menor de 12 semanas / Effectiveness of medical treatment with misoprostol as abortion retained dose administered in less than 12 weeks

Antecedentes: El manejo terapéutico del aborto retenido consiste en evacuar la cavidad uterina espontáneamente o utilizando misoprostol previo al legrado quirúrgico. Objetivo: Evaluar la necesidad de dilatación mecánica post maduración cervical con misoprostol y la tasa de perforación uterina post legrado, utilizando diferentes dosis de misoprostol en pacientes con diagnóstico de aborto retenido menor a 12 semanas. Métodos: Se registraron datos demográficos y ginecológicos de una cohorte retrospectiva de pacientes con diagnóstico de aborto retenido menor a 12 semanas, entre enero de 2008 y diciembre de 2010. Se establecieron 3 grupos de trabajo según la dosis de misoprostol administrada vía vaginal, siendo de 100 (n=131), 200 (n=231) y 400 micrones (n=230), y se observaron las complicaciones asociadas al procedimiento. Resultados: La necesidad de dilatación mecánica fue significativamente mayor en el grupo que recibió 100 micrones de misoprostol al compararlo con el de 200 micrones y 400 micrones (p<0,01). No hubo diferencias estadísticamente significativas entre las que recibieron 200 versus 400 micrones de misoprostol. No hubo diferencias significativas respecto a perforación uterina. Conclusión: En el aborto retenido menor a 12 semanas, la necesidad de dilatación mecánica post maduración cervical, es menor si se utiliza 200 o 400 micrones de misoprostol, sin diferencias en la tasa de perforación uterina.

Background: The therapeutic management of missed abortion consists on evacuating the uterine cavity, spontaneously or by administration of misoprostol previous to curettage. Objectives: Evaluate the need of mechanical dilatation after cervical maturation with misoprostol and the rate of uterine perforation before curettage, using different doses of misoprostol in patients with diagnosis of missed abortion before 12 weeks. Methods: Demographic and gynecologic data were registered of a retrospective cohort of patients with the diagnosis of missed abortion before 12 weeks, between January 2008 and December 2010. Three groups were established according to the dose of misoprostol: 100 (n=131), 200 (n=231) and 400 microns (n=230). Complications associated to the procedure were observed. Results: The need of mechanical dilatation was significant higher for the group with 100 microns of misoprostol in comparison with 200 and 400 microns (p<0.001). There was no statistical significance among who received 200 versus 400 microns of misoprostol. No statistical significance was found for uterine perforation. Conclusion: In the missed abortion before 12 week, the need of mechanical dilatation is lower with 200 or 400 microns of misoprostol, without difference in uterine perforation rate.