The Relevance of the Second Cesarean Delivery in the Reduction of Institutional Cesarean Delivery Rates.

OBJECTIVE: The cesarean delivery rate has increased worldwide. The aim of our study was to assess the events associated with the second cesarean deliveries in our institution. SUBJECTS AND METHODS: All cesarean deliveries at the Maternity Hospital, Kuwait, from January 1 to December 31, 2013, were identified. A comparative study was undertaken on patients having their first and second cesarean deliveries. The social and clinical characteristics of these patients were extracted from our records and the antenatal, intrapartum, and postpartum course of the pregnancies and their outcomes documented. RESULTS: During the study period, 10,586 deliveries were recorded, including 3,676 cesarean deliveries, i.e., a cesarean delivery rate of 34.7%. 840 of these patients were undergoing their first cesarean delivery (group A) and 607 patients were undergoing their second (group B); 484 patients from group A and 341 patients from group B with complete records were analyzed. Mean age (30.89 ± 4.93 vs. 29.94 ± 5.56 years, p = 0.008), parity (1.49 ± 1.22 vs. 0.98 ± 1.60, p < 0.0001), gestational age at delivery (38.12 ± 2.61 vs. 37.66 ± 3.11 weeks, p = 0.02), and fetal birth weight (3,211.60 ± 691.51 vs. 2,829.73 ± 863.26 g, p < 0.001) were significantly higher in group B than in group A. 53.2% of the patients in group B requested repeat cesarean delivery, their second cesarean. The rate of maternal morbidity was low. CONCLUSIONS: The incidence of repeat cesarean delivery in group B is high, and its reduction should contribute to a lowering of the overall cesarean delivery rate.

Consecutive successful pregnancies subsequent to intravenous immunoglobulin therapy in a patient with recurrent spontaneous miscarriage.

BACKGROUND: Recurrent spontaneous miscarriage (RSM) has a multifactorial etiology, mainly due to karyotype abnormalities including balanced translocation, anatomical uterine disorders, and immunological factors, although in 50%-60% the etiology is unexplained. The treatment of RSM remains challenging, and the role of intravenous immunoglobulin (IVIG) in RSM is controversial. CASE REPORT: Mrs HM, 37 years old, obstetric summary: P0+1+13+1, a known case of hypothyroidism/polycystic ovary syndrome, married to an unrelated 47-year-old man, presented to our RSM clinic in early January 2014 for investigation and treatment. She has had multiple failed in vitro fertilization trials and 13 first-trimester missed miscarriages terminating at 6-7 weeks, all without IVIG therapy. Her tenth pregnancy was spontaneous, managed in London, UK, with multiple supportive therapy and courses of IVIG starting from the third to the 30th week of pregnancy. The pregnancy ended at 36 weeks of gestation with a cesarean section and a live girl baby was delivered. Mrs HM had balanced translocation, 46XX t (7:11) (p10:q10). Preimplantation genetic diagnosis/intracytoplasmic sperm injection/in vitro fertilization was performed with embryo transfer on May 29, 2014, and resulted in a successful pregnancy. She was commenced immediately on metformin, luteal support, and IVIG therapy, started at 6 weeks of gestation and at monthly intervals until 30 weeks of gestation, and also received additional therapy. The pregnancy was monitored with ultrasound, progressed uneventfully until admission at 35 weeks of gestation, with mildly elevated liver enzymes and suspected fetal growth restriction. She was managed conservatively, and in the light of nonreassuring fetal status, a live female infant weighing 2.29 kg was delivered by emergency cesarean section on January 14, 2015, with an Apgar score of 8 and 9 and mild respiratory distress, and was admitted to the Special Care Baby Unit for intensive therapy. The mother and baby made satisfactory progress and were discharged on January 24, 2015. CONCLUSION: Two consecutive successful pregnancies in Mrs HM with multiple causes of RSM treated with other medications and IVIG strongly suggest that IVIG has a positive role in RSM.

Recurrent spontaneous miscarriage is still a challenging diagnostic and therapeutic quagmire.

Recurrent spontaneous miscarriage (RSM), affecting 1-2% of women of reproductive age seeking pregnancy, has been a clinical quagmire and a formidable challenge for the treating physician. There are many areas of controversy in the definition, aetiology, investigations and treatment of RSM. This review will address the many factors involved in the aetiology of RSM which is multifactorial in many patients, with antiphospholipid syndrome (APS) being the most recognized aetiological factor. There is no identifiable cause in about 40-60% of these patients, in which case the condition is classified as idiopathic or unexplained RSM. The RSM investigations are extensive and should be undertaken in dedicated, specialized, well-equipped clinics/centres where services are provided by trained specialists. The challenges faced by the treating physician are even more overwhelming regarding the decision of what should be the most appropriate therapy offered to patients with RSM. Our review will cover the diverse modalities of therapy available including the role of preimplantation genetic testing using recent microarray technology, such as single nucleotide polymorphism and comparative genomic hybridization, as well as preimplantation genetic diagnosis; the greatest emphasis will be on the treatment of APS, and there will be important comments on the management of patients presenting with idiopathic RSM. The controversial areas of the role of natural killer cells in RSM, the varied modalities in the management of idiopathic RSM and the need for better-planned studies will be covered as well.

Clinical presentation and management of diabetes mellitus in pregnancy.

OBJECTIVE: To evaluate the clinical presentation, management, and the outcome of diabetes mellitus in pregnancy. METHODS: One hundred seventy-one patients with diabetes mellitus admitted between September 1, 2006, and June 30, 2008, to the labor room at Maternity Hospital in Kuwait for induction of labor made up the study population; while an equivalent number of patients without medical complications who also were admitted for induction of labor made up the control group. The patients were assessed at admission, and their medical data were extracted. The study and control patients were monitored through labor/puerperium, and the outcome was documented. RESULTS: Gestational diabetes mellitus was diagnosed in 71.9% of the study patients, a past history of diabetes mellitus was recorded in 81.34% of the study patients, and 49.2% of the patients were admitted at 8-12 weeks of gestation for diabetic control. The mean weight gained in pregnancy was significantly higher for control patients (11.52±5.643 versus [vs] 9.90±5.757 kg/m(2); P<0.009), and the body mass index of study patients was higher (32.00±6.160 vs 28.20±5.885 kg/m(2); P<0.0001). Of the study population, 64.3% of the patients were managed with diet and increased physical activity and 35.7% with insulin, diet, and increased physical activity. The incidences of maternal morbidity in both study and control groups were comparable, and the incidence of preeclampsia was low, at 2.3%. The gestational age at delivery was higher in the control group (39.02±1.834 weeks vs 38.62±1.773 weeks; P<0.0001), and the percentage of cesarean deliveries was higher in the study population (44.4% vs 33.3%; P=0.046). The Apgar scores of the both groups were comparable and in the normal range, and the incidences of fetal anomaly (1.17%), shoulder dystocia (1.8%), and Erb's palsy (1.8%) were low. CONCLUSION: Gestational diabetes mellitus was diagnosed in 71.9% of the diabetic patients studied, and dietary control and increased physical activity were the main modalities of management. There was an increased rate of cesarean section in the study population, the incidences of maternal and perinatal morbidity were low, and the perinatal outcomes were satisfactory.

Vernix caseosa peritonitis after vaginal delivery.

INTRODUCTION: Vernix caseosa peritonitis (VCP) is a very unusual complication caused by inflammatory response to amniotic fluid spilled into the maternal peritoneal cavity. Twenty-seven cases have been reported, and all occurred after cesarean section. CASE PRESENTATION: We present a case of VCP following vaginal delivery; this may be the first case reported after vaginal delivery. Mrs. A, 28 years old, gravida 3, para 2, with one previous cesarean section, was admitted at 41 weeks gestation in active labor. Vacuum extraction was performed to deliver a healthy male baby, 4.410 kg, Apgar scores 7, 8. She developed fever, acute abdominal pain, and distension about 3 hours after delivery. A diagnosis of acute abdomen was made. Laparotomy was performed and it revealed neither uterine scar rupture nor other surgical emergencies, but 500 mL of turbid fluid and some cheesy material on the serosal surface of all viscera. Biopsies were taken. She had a course of antibiotics and her recovery was complete. Histology of the peritoneal fluid and tissue biopsy resulted in a diagnosis of VCP. CONCLUSION: Clinical diagnosis of peritonitis due to vernix caseosa should be considered in patients presenting postpartum with an acute abdomen after vaginal delivery.

Computational methods are significant determinants of the associations and definitions of insulin resistance using the homeostasis model assessment in women of reproductive age.

BACKGROUND: Insulin resistance (IR) plays an important role in the pathogenesis of polycystic ovary syndrome (PCOS), but identification of insulin-resistant individuals is difficult. The homeostasis model assessment (HOMA), a surrogate marker of IR, is available in 2 computational models: HOMA1-IR (formula) and HOMA2-IR (computer program), which differ in incorporated physiological assumptions. This study evaluates the associations of the 2 models as markers of IR, the metabolic syndrome (MS), and PCOS. METHODS: Anthropometric, hormonal, and biochemical parameters were measured in 92 PCOS women and 110 controls. HOMA1 and HOMA2 were used to assess IR. Regression analyses were used to find the associations of the 2 models with different variables, MS, and PCOS. RESULTS: The cutoff levels for definition of IR were HOMA1-IR ≥2.9 and HOMA2-IR ≥1.7. Mean HOMA1-IR (2.79) and HOMA2-IR (1.42) differed substantially. The difference (HOMA1-IR - HOMA2-IR) was significantly correlated with insulin, fasting plasma glucose, triglycerides, HDL cholesterol, waist circumference, leptin, and adiponectin (all P < 0.05). HOMA1-IR and HOMA2-IR were significantly associated with MS (odds ratio 5.7 and 4.2, respectively) and PCOS (odds ratio 3.7 and 3.5, respectively). CONCLUSIONS: HOMA computational methods significantly affect the associations and cutoff values used for definition of IR. The correlations of the difference in the computational methods corroborate differences in captured physiological mechanisms. As precise identification of IR in PCOS patients is of practical importance, practitioners and researchers should be aware of these differences in the HOMA computational methods.

The scope of pediatric and adolescent gynecological problems in Kuwait.

OBJECTIVE: To establish an insight into pediatric and adolescent gynecological disorders encountered in a tertiary care center in Kuwait. SUBJECTS AND METHODS: A retrospective case cohort review of 89 case records of patients under the age of 19 years who were admitted to the Maternity Hospital, Kuwait, from October 2002 through September 2003 was undertaken. For a variety of reasons, 35 patients were excluded and the remaining 54 patients constituted the study population. The patients were divided into 5 groups (A-E): group A = ovarian cysts, group B = disorders of pregnancy, group C = menstrual disorders, group D = gynecological infections and group E = miscellaneous. The clinical presentation and management of patients were analyzed. RESULTS: The following spectrum of gynecological disorders was obtained: 13 ovarian cysts (24.1%), 28 disorders of pregnancy (51.8%), 4 menstrual disorders (7.4%), 2 infections (3.7%) and 7 miscellaneous cases (13.9%). Of the 54 patients, 36 (66.7%) were Kuwaitis and the remaining 18 (33.3%) were non-Kuwaitis. The mean age of the study population was 15.16 years, the median was 15.5 years, and the range was 8-19 years. The mean age of the patients with disorders of pregnancy was 17.52 +/- 1.16 years, which is significantly higher than that of groups A, C and E (p = 0.007, 0.0001 and 0.05). The main presenting symptoms at admission were vaginal bleeding: 31 (57.4%), abdominal pain: 17 (31.5%), abdominal mass: 10 (18.5%), and vomiting: 10 (18.5%). Ultrasonography revealed that dermoid cysts were the most frequently encountered ovarian cysts. Patients were hospitalized for 1-7 days. CONCLUSION: Disorders of pregnancy and ovarian cysts were the most frequently encountered pediatric/adolescent gynecological disorders. It is recommended that there should be a dedicated specialized clinic to guarantee privacy and centralized discreet care for these patients.

Intrapartum performance of patients presenting with diabetes mellitus in pregnancy.

OBJECTIVE: To investigate the intrapartum performance of pregnancies complicated by diabetes mellitus (DM). SUBJECTS AND METHODS: A pilot study (April-June 2005) of medical records of patients with DM admitted into the labour wards of the Maternity Hospital, Kuwait, was undertaken. Consecutive patients, matched for age and parity with the study group and with no medical complications, admitted for induction of labour during the study period served as the control. The ethnicity, obstetric/medical history and antenatal course of the index pregnancy were extracted. The intrapartum, postpartum and the neonatal outcome were documented. Statistical analysis was performed using chi(2) and alternative Welch t tests. RESULTS: During the study period, 3,005 patients were delivered at the hospital, and 177 of these (the study population) presented with DM, an incidence of 5.9%. Another 177 patients admitted for induction of labour served as the control. Of the 177 study patients, 86 (48.6%) were Kuwaitis, and the remaining 91 (51.4%) were non-Kuwaitis, of whom 41 were Arabs (23.2%), 34 Indians (19.2%), and 16 Asians (9%). Of the controls, 65 (36.7%) and 112 (63.3%) were Kuwaitis and non-Kuwaitis, respectively. Of the 177 study patients, 128 (72.3%) presented with gestational DM. The significant complications were pregnancy-induced hypertension (13, 7.3%) and premature rupture of membranes (14, 7.9%). The incidence of caesarean section in the study population (58, 32.8%) was significantly higher than that of the controls (35, 19.8%; p = 0.008). Although the mean gestational ages at delivery in both groups were comparable (p = 0.669), the mean birth weight in the study group was significantly higher, 3.315 +/- 0.605 vs. 3.160 +/- 0.594 kg (p = 0.012). The neonatal complications in the diabetic patients were shoulder dystocia (4, 2.3%) and Erb's palsy (12, 1.1%); there were more perinatal deaths (3) in the control group. CONCLUSION: The incidence of DM was high, and the rate of caesarean section significant. The maternal and neonatal morbidity were high. A prospective study is recommended for enhanced management guidelines.

The reproductive performance of women at 40 years and over.

OBJECTIVE: Adverse pregnancy outcome and increased operative deliveries have been reported in women of advanced maternal age. The objective of our study was to evaluate the reproductive performance of our women 40 years and over, and assess if they were at increased risk for adverse pregnancy outcome compared to younger women. STUDY DESIGN: A retrospective study of all women 40 years and over who delivered singleton pregnancies at Maternity Hospital, Kuwait, from 1 January 2000 through 30 June 2002, was undertaken. One-hundred and sixty-eight women formed the study group while 160 women aged 25-30 years served as the control group. The antenatal records, the intrapartum and postpartum events, and the perinatal outcome were extracted and analysed. Statistical analysis was done by Chi-square test, Fisher exact two-tailed test and the Welch t-test. RESULTS: The mean age of the study and control groups were 41.46+/-1.38 (range 40-47) and 27.40+/-1.67 (range 25-30) years, respectively. The mean parity of the study group, 4.24+/-2.35 was statistically higher than for the control group, 1.69+/-1.39, P < 0.0001. The past history of previous preterm delivery (10.1% versus 4.4%) and previous caesarean section (24.4% versus 11.9%) were more significant in the study group, P = 0.0562 and 0.0053, respectively. Women of 40 years and over presented significantly more medical complications. The incidence of caesarean section in the study group was significantly higher (31.0% versus 16.3%), P = 0.0027, OR 2.310, CI 1.356-3.935. The overall maternal and perinatal outcomes in both groups were comparable and satisfactory. CONCLUSION: Advanced maternal age of 40 years and over was not associated with adverse maternal and perinatal outcome, although the incidence of caesarean section was significantly increased in these women.

Nitric oxide metabolites in preterm and induced labor.

BACKGROUND: Nitric oxide has potent relaxant effects on the pregnant uterus and has been associated with a quiescent uterus in animal and human studies. Nitric oxide donors have been used to arrest preterm labor and a reduction in nitric oxide production has been reported before the onset of labor. OBJECTIVE: The aim of the study was to estimate the serum levels of nitrate and nitrite in women undergoing spontaneous preterm labor and induced labor. MATERIALS AND METHOD: Venous blood was drawn from 39 patients before the onset of labor (control) and also from 17 patients undergoing induction of labor who were in active labor (study group A), and 24 patients in spontaneous preterm labor (study group B). Serum concentrations of nitrate and nitrite were estimated in the samples using the HPLC method. RESULTS: The maternal age of the patients was similar in all the groups. There was no significant difference in the mean gestational age at delivery between the control and group-A patients (38.86 vs. 38.29 weeks); however, there was a significant difference between the control and group-B patients (38.86 vs. 30.92; p < 0.0001), and between study groups A and B (38.29 vs. 30.92 weeks; p < 0.0001). The mean serum levels of nitrite in groups A and B (0.563 +/- 0.15 and 0.512 +/- 0.13, respectively) were significantly lower than the level in the control group (0.915 +/- 0.13; p < 0.0001). Although the serum nitrate levels in study groups A and B were lower than in the control group, this difference was not significant. The maternal outcome was satisfactory but, as expected, the mean birth weight of the babies in group B (1,665.73 +/- 863.84 g) was significantly lower than the birth weights in the control and group-A patients (p < 0.0001). CONCLUSION: There is a drop in nitric oxide production in active preterm labor and induced labor. These findings need to be confirmed in larger studies to establish the role of nitric oxide in the initiation of labor.