Carbetocin versus rectal misoprostol for management of third stage of labor among women with low risk of postpartum hemorrhage.

OBJECTIVE: To compare effectiveness and safety of carbetocin and misoprostol for prevention of postpartum hemorrhage (PPH) among low-risk women. METHODS: Randomized controlled trial among 150 pregnant women with low risk of PPH admitted for vaginal delivery at Kasr Al Ainy Hospital, Cairo, Egypt, between July 2018 and May 2019. Participants were assigned to two groups by a web-based randomization system ensuring allocation concealment. After neonatal delivery, the carbetocin group received one ampoule of carbetocin (100 µg/mL) intravenously and the misoprostol group received two rectal tablets of misoprostol (800 µg) for active management of the third stage. Blood pressure, blood loss, and hemoglobin levels were monitored. The primary outcome measure was need for additional uterotonic drugs. RESULTS: The carbetocin group had significantly less blood loss (P<0.001), shorter third stage (P<0.001), and less need for additional uterotonics (P=0.013) or uterine massage (P=0.007). The two drugs were hemodynamically safe. Hemoglobin levels after delivery were comparable in the two groups (P=0.475). Adverse effects were more common in the misoprostol group (P<0.001). CONCLUSION: Among low-risk women, carbetocin seems to be a better alternative to misoprostol for active management of the third stage of labor; it reduced blood loss and use of additional uterotonic drugs. CLINICALTRIALS.GOV: NCT03556852.

Prediction of metaphase II oocytes according to different levels of serum AMH in poor responders using the antagonist protocol during ICSI: a cohort study.

The aim of our study was to assess the value of serum AMH in prediction of metaphase II oocytes in poor responders. We performed a prospective cohort study included 206 poor responders candidate for ICSI using antagonist protocol. They were classified into 3 groups. Group I included 50 women with AMH < 0.3 ng/ml, group II included 85 women with AMH 0.3-0.7 ng/ml and group III included 71 women with AMH > 0.7-1.0 ng/ml. The primary outcome parameter was the number of MII oocytes. There was a highly significant difference between the study groups regarding E2 at triggering (481.41 ± 222.653, 648.17 ± 264.353 and 728.74 ± 305.412 respectively, number of oocyte retrieved (2.37 ± 1.178, 3.38 ± 1.622 and 3.80 ± 1.427 respectively), number of MII oocytes (1.66 ± 1.039, 2.35 ± 1.171 and 2.61 ± 1.080 respectively), number of fertilized oocytes (1.39 ± 0.919, 1.91 ± 0.983 and 2.21 ± 0.937 respectively), , total number of embryos (1.34 ± 0.938, 1.76 ± 0.956 and 2.09 ± 0.907 respectively), clinical pregnancy rates (4.9 vs. 7.7 and 19.7% respectively). We concluded that AMH is a good predictor for number of MII oocytes in poor responders undergoing ICSI.

Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the effectiveness of perineal massage, pelvic floor muscle training (PFMT) and a pelvic floor dysfunction (PFD) prevention educational program in pregnant women above the age of 35 years to prevent perineal tear and episiotomy. METHODS: A randomized parallel assignment study involved two groups of pregnant women at the obstetrics outpatient clinic 4 weeks prior to their due date. The first group (n = 200) was educated to do digital perineal massage and pelvic floor muscle training and received an educational PFD prevention program. The second group (n = 200) received only the prevention education program. Occurrence of perineal laceration was reported at time of delivery as a primary outcome. Statistical analysis was done using the IBM SPSS computer program (Statistical Package for the Social Sciences; IBM Corp, Armonk, NY, USA), release 22 for Microsoft Windows. RESULTS: Delivery was significantly less complicated by perineal tear, episiotomy and postnatal pain in the first than in the second group (p < 0.05). Grades of perineal tear were mostly of first and second degree in the first group compared with the second group. We found a significantly lower need for analgesia and fewer ampoules required during the hospital stay in the first group (p < 0.001, 0.002, respectively). CONCLUSIONS: Performing antenatal digital perineal massage and PFMT in addition to health education is recommended to reduce perineal complications.

Antepartum and postpartum uterine artery impedance in women with pre-eclampsia: a case control study.

This is a cohort study which included 100 cases with pre-eclampsia (PE) and 100 controls, done to compare the antepartum and postpartum uterine artery (UtA) Doppler velocimetry between them. UtA PI and RI were measured before and within 48-72 h after delivery. There was a highly significant difference between the cases and controls, regarding the UtA RI (0.70 ± 0.10 and 0.72 ± 0.10, versus 0.59 ± 0.12 and 0.60 ± 0.11) and PI (1.41 ± 0.89 and 1.45 ± 0.90 versus 0.85 ± 0.30 and 0.90 ± 0.34) measured at the antepartum and postpartum periods, respectively. Age and gestational age were significantly related to the postpartum and changes in the UtA PI. The gestational age was also correlated to UtA RI changes. Both the antepartum and postpartum mean blood pressure were correlated with postpartum UtA RI and PI and PI changes after delivery. We concluded that uterine artery Doppler indices changes are more common in women with PE, than in normotensive women with significant correlations with age and gestational age. Impact statement What is already known on this subject? After delivery, the haemodynamic changes that occurred with pregnancy reverse. Both the heart rate and the cardiac output decreased to reach the non-pregnant state. Impedance to flow in the uterine artery rises as the nutritional needs are decreased abruptly. What do the results of this study add? Both the antepartum and postpartum measurement of uterine artery Doppler indices is significantly higher in women with PE when compared to control women. The persistent uterine artery impedance is a result of inadequate trophoblastic invasion within the basal part of the decidua basalis and myometrium or persistently increased maternal vascular tone. What are the implications of these findings for clinical practice and/or further research? The uterine artery Doppler parameters return to the non-pregnant values in normal pregnancies. Knowing such information may help in understanding the haemodynamics of the uterine vasculature during puerperium in hypertensive patients.

The effect of rectus muscle re-approximation at cesarean delivery on pain perceived after operation: a randomized control trial.

Background: Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section. Objective: The purpose of this study was to assess the effect of rectus muscle reapproximation at cesarean delivery on the postoperative pain. Methods: 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. Results: 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, p value: .02) and (a difference of 1, 95% confidence interval: 0.1-2.9, p 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, p 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, p value: .02). Conclusions: Rectus muscle reapproximation among women undergoing primary caesarian section is associated with significant increase in the postoperative pain and analgesic requirements.

Evaluation of foetal neurological behaviour in hypothyroid pregnant females - a pilot study.

OBJECTIVES: Maternal hypothyroidism is known for its possible deleterious effect on the neurocognitive function of the offspring. The aim of the current study is to investigate if maternal hypothyroidism also affects foetal neurological behaviour. METHODS: Fifty foetuses were examined for abnormal neurological behaviour from 25 euthyroid and 25 hypothyroid age matched pregnant females, between 28 and 38 weeks gestation. The hypothyroid group was further subdivided into controlled (n = 5) and uncontrolled (n = 20) groups. Evaluation of foetal neurological behaviour using Kurjak's antenatal neurodevelopmental test (KANET) test was performed. RESULTS: Mean total KANET score was significantly lower for foetuses in the hypothyroid group compared to the euthyroid (p < .001, 95% CI: 2-6). The number of foetuses showing pathological scores was significantly higher in the hypothyroid group (9, 36%) compared to euthyroid (1, 4%) (p < .005). The distribution of total KANET score was significantly different between the two groups (p = .017). Foetuses in the uncontrolled hypothyroid group showed lower mean KANET scores (9.650 ± 2.907 versus 10.80 ± 3.03) and higher frequency of pathological scores compared to controlled (8 = 40% versus 1 = 20%) although without statistical significance. The distribution of total KANET score was not statistically significant between the two groups (p = .893). CONCLUSIONS: Overt maternal hypothyroidism may adversely affect foetal neurological behaviour. Correlation of prenatal findings with postnatal long-term neurological development is recommended in such cases.

Prevalence of sexual dysfunction in infertile versus fertile couples.

OBJECTIVES: The primary aim of this study was to test the hypothesis that sexual dysfunction is higher in infertile females in relation to normal healthy women through comparing total and sexual domains scores in both groups. The secondary objectives were: to determine factors affecting occurrence of female sexual dysfunction (FSD) in all sample and to determine factors affecting the different sexual domain scores within the infertile group. STUDY DESIGN: This cross sectional study was done at Cairo University Hospital. 200 infertile and 200 control females were evaluated using the Female Sexual Function Index (FSFI) questionnaire. Total score less than 26.55 signified sexual dysfunction. Husbands were evaluated by Sexual Health Inventory for Men (SHIM) questionnaire. A score less than 22 signified erectile dysfunction (ED). RESULTS: Proportion of females with sexual dysfunction was higher in the infertile versus control group (47% versus 30%, 95%CI for the difference: 8%, 26%, p-value:<0.001). Total, orgasm, satisfaction and pain scores were significantly lower in infertile versus control group (mean±SD: 26.8±3.8 versus 27.9±3.5, p-value: 0.003; 4.2±0.7 versus 4.6±0.6, p-value: 0.01; 4.9±0.5 versus 5.2±0.5, p-value: 0.004 and 3.9±0.9 versus 4.4±0.7, p-value:<0.001 respectively). Husband SHIM erectile score was significantly lower in the infertile group (median score (range): 19 (5, 25) versus 22 (12, 25), p-value: 0.001). After adjustment for 15factors by logistic regression, the odds ratio of having FSD was 2.6 (95%CI: 1.5, 4.5, p-value: 0.001) in the infertile relative to control females. Secondary (versus primary) infertility was negatively correlated with arousal score (B (95%CI): -0.6 (-0.02, -1.2), p-value: 0.003) while duration of infertility was negatively correlated with arousal, satisfaction and pain domains scores (B (95%CI): -0.2 (-0.08, -0.32), p-value: 0.04; -0.2 (-0.1, -0.3), p-value: 0.005; -0.2 (-0.06, -0.34), p-value: 0.03 respectively). CONCLUSION: sexual dysfunction is more prevalent in infertile versus control group. Infertility clinicians should be aware of this problem to assess and treat their patients to improve their quality of life.