Dual trigger using recombinant HCG and gonadotropin-releasing hormone agonist improve oocyte maturity and embryo grading for normal responders in GnRH antagonist cycles: Randomized controlled trial.

OBJECTIVES: To evaluate the effectiveness of dual trigger using gonadotropin-releasing hormone (GnRH) agonist and recombinant human chorionic gonadotropin (rHCG) versus rHCG alone for normal responders in GnRH antagonist intracytoplasmic sperm injection (ICSI) cycles. PATIENTS AND METHODS: The current study was a registered open-labeled randomized controlled trial (clinical trial.gov: NCT02916173) conducted in the ART Unit of a tertiary University hospital between October 2016 and October 2018. The study participants were randomized to either group I (HCG group) or group II (dual trigger group). The primary outcome was the number of mature (MII) oocytes in both groups. RESULTS: Both groups were similar regarding the baseline demographic and clinical characteristics. Women in the dual trigger group had a statistically significant higher number of retrieved oocytes (p = 0.001), MII oocytes (p = 0.01) and the number of grade one embryos (p = 0.04). Both groups were similar regarding the fertilization, implantation, clinical pregnancy and live birth rates in a fresh cycle. Dual trigger group was significantly higher in the clinical pregnancy rate and live birth rate after frozen embryo transfer (p = 0.04, 0.03, respectively). CONCLUSION: Dual trigger by GnRH agonist and rHCG improve the oocyte maturity and embryo grading for normal responders in GnRH antagonist ICSI cycles.

Effect of topical glyceryl trinitrate cream on pain perception during intrauterine device insertion in multiparous women: A randomized double-blinded placebo-controlled study.

OBJECTIVE: Intrauterine contraceptive device (IUD) insertion-related pain presents a push beyond the decline of women to use IUD for family planning. We aimed to investigate the analgesic effect of glyceryl trinitrate cream (GTN) in reducing pain during IUD insertion. MATERIALS AND METHODS: We conducted a randomized double-blinded placebo-controlled study (NCT02708251, clinicaltrials.gov) in a tertiary University hospital. Reproductive-aged women requesting Copper IUD for contraception were considered. Eligible women for IUD insertion were randomized (1:1) to glyceryl trinitrate cream (GTN arm) or Placebo. Three minutes before IUD insertion, 1 ml of GTN cream or placebo was applied to the cervical lip at the planned tenaculum site, followed by 1 ml placed in the cervical canal up to the level of the internal os using a Q-tip applicator. Our outcomes were the participant's self-rated pain perception utilizing a 10-cm Visual Analogue Scale (VAS) during cervical tenaculum placement, uterine sound and IUD insertion, then 15 min post-procedure. RESULTS: 100 women were enrolled and randomized to GTN arm (n = 50) or placebo (n = 50). Women in the GTN arm reported lower VAS scores during tenaculum placement, sound and IUD insertion (median: 2 vs. 4, p < 0.0001; 2.5 vs. 4.5, p < 0.001;3 vs. 5.5, p < 0.0001, respectively). Higher ease of insertion score was also determined among GTN arm (mean ± SD: 6.9 ± 1.15 vs. 4.7 ± 1.38, p < 0.0001). Additionally, women in the GTN arm were more satisfied by the end of the insertion (92% vs. 74%, p = 0.003). CONCLUSION: Application of cervical GTN cream before IUD insertion seems to reduce the induced pain with subsequent easy insertion.

The effect of prophylactic oral tranexamic acid plus buccal misoprostol on blood loss after vaginal delivery: a randomized controlled trial.

OBJECTIVE: The objective of this study is to evaluate the effect of prophylactic oral tranexamic acid (TA) plus buccal misoprostol on the amount of blood loss after vaginal delivery in women at low risk for post-partum hemorrhage (PPH). MATERIALS AND METHODS: The study was a randomized open label clinical trial conducted in a tertiary University Hospital between January 2016 and June 2017. We included women who delivered vaginally with a singleton pregnancy. They were randomized into three groups: group I (women received 10 IU oxytocin IV after delivery of the baby), group II (women received 600 µg buccal misoprostol after delivery of the baby), and group III (women received 1000 mg oral TA at the end of the first stage of labor plus 600 µg buccal misoprostol after delivery of the baby). In each group, pre- and post-delivery pulse rate, blood pressure, temperature, and hemoglobin level were evaluated. Additionally, the amount of blood loss, need for blood transfusion, need for additional uterotonics, and side effects of the study medications were recorded. RESULTS: There was a statistically significant lower hemoglobin level and higher blood loss in the misoprostol group compared with oxytocin group and TA plus misoprostol group (p = .0001). There was a statistically significant higher hemoglobin level and lower blood loss in the TA plus misoprostol group compared with the oxytocin group (p = .004 and .043, respectively). PPH occurred in 16.7% of women in the misoprostol group compared 1.7% in the oxytocin group and no cases of PPH in the TA plus misoprostol group (p = .0001). CONCLUSIONS: In settings like rural area or home delivery in which oxytocin is not available, alternative oral TA plus buccal misoprostol may be considered as an effective line in prevention of PPH.

Management of Spontaneous Labor in Primigravidae: Labor Scale versus WHO Partograph (SLiP Trial) Randomized Controlled Trial.

OBJECTIVE: We aimed to compare maternal and neonatal outcomes of spontaneous term labor among primigravidae who were monitored by the novel labor scale versus the World Health Organization (WHO) partograph. STUDY DESIGN: A single center, double-blinded randomized trial had been conducted between July 2015 and June 2016. Nulliparous women in spontaneous labor with singleton term pregnancies were randomized to either labor scale or the WHO partograph for management of labor. Primary outcome was successful vaginal delivery. Secondary outcome included low APGAR scores, birth injuries, postpartum hemorrhage, and infection. RESULTS: One hundred ten patients were randomized (55 in each arm). Women managed with labor scale had significantly lower rate of cesarean deliveries than women managed with the partograph arm (3.6% versus 18.2%, P=0.03). There was a significant reduction in the rate and duration of oxytocin administration for augmentation of labor (21.8% versus 69.1%, P < 0.0001) and a significant increase in average 1-minute APGAR score in the labor scale group. CONCLUSION: Labor monitoring with the labor scale is associated with lower rate of cesarean section, less and shorter use of oxytocin for augmentation of labor. Monitoring of labor progress starting at 5 cm or more is also associated with lower rate of cesarean delivery.

Integrative mid-trimester anomaly (IMTA) chart: a novel sonographic approach for syndromatic challenges (pilot study).

OBJECTIVE: To validate the use of the integrative mid-trimester anomaly (IMTA) chart, a novel chart that aims to increase sonographers' ability to diagnose fetal syndromes and complex anomalies. METHODS: This study was conducted between September 2014 and January 2015. Pregnant women who attended our hospital for fetal medicine consultation during the second trimester were recruited. The diagnosis was assigned by a qualified consultant. The research coordinator randomized women between two groups (each consisted of two sonographers with comparable experience) and each was then examined twice (once with and once without the chart). Supposed diagnosis, patient and sonographer satisfactions were reported. RESULTS: Twenty five women were recruited. Their average age was 26.48 ± 4.49 years and gestational age at examination was 24.39 ± 6.39. There were 17 (68%) fetuses that had multiple anomalies. The duration of examination was comparable. However, patient and sonographer satisfactions were higher when the same women were examined with the chart (p < 0.0001). The accuracy of diagnosis was also significantly higher (p = 0.03). CONCLUSION: The IMTA chart seems to be a useful tool for novice sonographers that could increase their diagnostic accuracy and improve their patient and their own satisfaction.

The labour scale--assessment of the validity of a novel labour chart: a pilot study.

BACKGROUND: Labour dystocia is the most common indication for caesarean section (CS). This study assessed the validity of the labour scale (WHO partograph modification) as an intrapartum management tool to minimise over-diagnosis of labour dystocia. MATERIALS AND METHODS: The study included 77 women in the early active phase of labour using the scale. This scale covers the same titles as the partograph with the cervico-graph modified using National Institute of Clinical Excellence (NICE) recommendations that adjust interference according to clinical circumstances. Labour progress was plotted on the labour scale then on the partograph to compare outcomes. Maternal and fetal outcomes were compared with international and local reports. RESULTS: Only 21 (27.3%) women crossed the 'membrane line', which promotes amniotomy, and 35 women (45.5%) crossed the 'augmentation line' and received oxytocin. Four women were delivered by CS for failure to progress. When the same data were re-plotted on the partograph, twenty-eight women were diagnosed with failure to progress. The outcome difference between the 'labour scale' and the partograph was significant (P < 0.0001). Maternal and neonatal outcomes were excellent. CONCLUSIONS: We suggest that the 'labour scale' is a promising tool for labour management that minimises labour dystocia without additional maternal or fetal risk.