Intrapartum ultrasound measurement of the lower uterine segment thickness in parturients with previous scar in labor: a cross-sectional study.

BACKGROUND: There is a lack of reliable methods to estimate the risk of uterine rupture or dehiscence during a trial of labor in women with previous cesarean sections. This study aimed to assess the lower uterine segment and myometrial thickness by ultrasonography in women with previous cesarean sections during labor and assess their association with the uterine defect. METHODS: A cross-sectional study was conducted on 161 women in the active phase of labor having one previous cesarean section. The study was conducted et al.-Azhar University Hospital, Assiut City, Egypt, from March 2018 to March 2019. Ultrasound measurements of lower uterine segment thickness and myometrial thickness were conducted by vaginal and abdominal ultrasound by two observers. The correlation of both thicknesses with the uterine defect was analyzed. RESULTS: Uterine defects were reported in 42 women (25.9%), uterine rupture in four women (2.5%), and dehiscence in 38 women (23.5%). The uterine defects were not associated with maternal factors (maternal age, gestational age at labor, body mass index, birth weight, interpregnancy, and inter-delivery interval). Receiver operating curve analysis demonstrated that lower uterine segment thickness was linked with uterine defect, with an area under the curve of 60% (95% CI, 51-70%, P = 0.044). Myometrial thickness was also linked to the uterine defect, with an area under the curve of 61% (95% CI, 52-71%, P = 0.025). Full lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm were the cutoff value with the best combination of sensitivity and specificity for the uterine defect. Lower uterine segment thickness (OR = 0.49, 95%CI 0.24-0.96) and myometrial thickness (OR = 0.44, 95%CI 0.20-0.94) were significantly associated with the uterine defect. Lower uterine segment thickness (OR = 0.41, 95%CI 0.22-0.76) and myometrial thickness (OR = 0.33, 95%CI 0.16-0.66) were also significantly associated with cesarean section delivery. CONCLUSION: A lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm during the first stage of labor are associated with a high risk of uterine defects during a labor trial. These measurements during labor can have a practical application in deciding the mode of delivery in women with previous cesarean sections and might reduce uterine rupture.

Impact of matrix diffusion on the migration of groundwater plumes for Perfluoroalkyl acids (PFAAs) and other non-degradable compounds.

Groundwater fate and transport modeling results demonstrate that matrix diffusion plays a role in attenuating the expansion of groundwater plumes of "non-degrading" or highly recalcitrant compounds. This is especially significant for systems where preferred destructive attenuation processes, such as biological and abiotic degradation, are weak or ineffective for plume control. Under these conditions, models of nondestructive physical attenuation processes, traditionally dispersion or sorption, do not demonstrate sufficient plume control unless matrix diffusion is considered. Matrix diffusion has been shown to be a notable emergent impact of geological heterogeneity, typically associated with back diffusion and extending remediation timeframes through concentration tailing of the trailing edge of a plume. However, less attention has been placed on evaluating how matrix diffusion can serve as an attenuation mechanism for the leading edge of a plume of non-degrading compounds like perfluoroalkyl acids (PFAAs), including perfluorooctane sulfonate (PFOS). In this study, the REMChlor-MD model was parametrically applied to a generic unconsolidated and heterogeneous geologic site with a constant PFOS source and no degradation of PFOS in the downgradient edge of the plume. Low levels of mechanical dispersion and retardation were used in the model for three different geologic heterogeneity cases ranging from no matrix diffusion (e.g., sand only) to considerable matrix diffusion using low permeability ("low-k") layers/lenses and/or aquitards. Our analysis shows that, in theory, many non-degrading plumes may expand for significant time periods before dispersion alone would eventually stabilize the plume; however, matrix diffusion can significantly slow the rate and degree of this migration. For one 100-year travel time scenario, consideration of matrix diffusion results in a simulated PFOS plume length that is over 80% shorter than the plume length simulated without matrix diffusion. Although many non-degrading plumes may continue to slowly expand over time, matrix diffusion resulted in lower concentrations and smaller plume footprints. Modeling multiple hydrogeologic settings showed that the effect of matrix diffusion is more significant in transmissive zones containing multiple low-k lenses/layers than transmissive zones underlain and overlain by low-k aquitards. This study found that at sites with significant matrix diffusion, groundwater plumes will be shorter, will expand more slowly, and may be amenable to a physical, retention-based, Monitored Natural Attenuation (MNA) paradigm. In this case, a small "Plume Assimilative Capacity Zone" in front of the existing plume could be reserved for slow, de minimus, future expansion of a non-degrading plume. If potential receptors are protected in this scenario, then this approach is similar to allowances for expanding plumes under some existing environmental regulatory programs. Accounting for matrix diffusion may support new strategic approaches and alternative paradigms for remediation even for sites and conditions with "non-degrading" constituents such as PFAAs, metals/metalloids, and radionuclides.

Umbilical vein injection of 400 versus 800 µg misoprostol for the treatment of retained placenta: A multicenter, randomized double-blind controlled trial.

AIMS: This trial was conducted to determine the efficacy of umbilical vein injection of 400 versus 800 µg misoprostol to deliver retained placenta and to compare both regimens regarding the time of placental delivery and amount of vaginal blood loss. METHODS: A double-blind, multicenter randomized clinical trial was undertaken in four teaching hospitals in the North of Iraq and Al-Azhar University Hospital in Egypt, from March 2016 to May 2019. Group I (274 women) received 400 µg misoprostol and group II (249 women) received 800 µg misoprostol. Data regarding the time of placental separation and amount of vaginal blood loss were analyzed and proportions were compared between groups using Chi-squared test. Mean values were compared using the Student's t-test. The Mann-Whitney test was used to determine the median of vaginal blood loss. RESULTS: The proportion of placental separation was 84.3% among women in group I and 86.7% of women in group II. The mean time of placental separation was 18.86 ± 234.2 and 17.86 ± 213.09 min in groups I and II, respectively (P < 0.05).The mean hemoglobin levels on admission and 24 h after placental deliveries were significantly higher in group I than group II. CONCLUSIONS: Intra-umbilical injection of 400 and 800 µg misoprostol were both safe and effective methods for delivery of retained placenta.

Preoperative assessment of ovarian tumors using a modified multivariate index assay.

BACKGROUND: Preoperative differentiation between benign and malignant masses can be challenging. The aim of this research was to evaluate the performance of a modified multivariate index assay (MIA) in detecting ovarian cancer and to compare the effectiveness of gynecologist assessment, cancer antigen (CA) 125, and MIA for identifying ovarian masses with high suspicion of malignancy. RESULTS: This prospective observational study included 150 women with ovarian masses who underwent surgery in the Maternity Teaching Hospital from December 2014 to May 2016. Preoperative estimation of modified MIA, assessment by a gynecologist, and CA 125 level correlated with the surgical histopathology. A modified MIA was implemented because of lack of access to the software typically used. Among 150 enrolled women there were 30 cases of malignancy, including 8 cases (26%) of early-stage ovarian cancer and 22 cases (74%) of late-stage cancer. MIA showed high specificity (96.7%) in detecting cancer and a sensitivity of 70%, with a positive predictive value of 84% and a negative predictive value of 92.8%. No significant differences were detected between the MIA results and the histopathology results (P = 0.267). For early-stage ovarian cancer, the sensitivity of MIA was 100% compared with 75% for CA 125 alone. CONCLUSION: MIA seems to be effective for evaluation of ovarian tumors with higher specificity and positive predictive value than CA 125 while maintaining high negative predictive value and with only a slightly lower overall sensitivity. For evaluation of early-stage ovarian cancer, MIA showed a much higher sensitivity that markedly outperformed CA 125 alone. This modified MIA strategy may be particularly useful in low resource setting.

Improvement in pregnancy outcomes in couples with immunologically male infertility undergoing prednisolone treatment and conventional in vitro fertilization preceded by sperm penetration assay: a randomized controlled trial.

PURPOSE: Anti-sperm antibodies (ASA) in men impair not only sperm motility but also fertilization and conception. However, utilization of corticosteroids to suppress ASA has shown variable pregnancy outcomes. This controversy is also extended to include the usefulness of conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in treatments of men with ASA. This study was therefore designed to define factors contributing to these inconsistent results. METHODS: Infertile men having ASA (n = 241) were randomly assigned for treatment with or without prednisolone for three cycles each of 21 days of their partner's menstrual cycles. Control and treated men underwent then human sperm penetration assay (SPA), of hamster oocytes, to diagnose men with impaired sperm fusogenic capacity. Men with positive or negative SPA results were admitted to conventional IVF or ICSI programs, respectively. RESULTS: Treated patients had improved sperm motility and progressive motility when compared to control patients (P < 0.001). Fertilization (P = 0.04), embryo cleavage (P = 0.01), and chemical (P = 0.02) and clinical (P = 0.04) pregnancy rates were higher in treated patients than in control patients undergoing conventional IVF but not ICSI cycles. CONCLUSIONS: Men with ASA may also have compromised sperm fusogenic capacity, which can mask the clinical significance of corticosteroids. Corticosteroid administration in men with ASA, but without compromised sperm fusogenic capacity, improves conventional IVF but not ICSI outcomes; the reason being that ICSI bypasses issues of compromised fusogenic capacity. Inclusion of SPA in infertility clinics that offer both conventional IVF and ICSI services may be useful to identify which patients with ASA benefit from corticosteroid treatments.

Implications of matrix diffusion on 1,4-dioxane persistence at contaminated groundwater sites.

Management of groundwater sites impacted by 1,4-dioxane can be challenging due to its migration potential and perceived recalcitrance. This study examined the extent to which 1,4-dioxane's persistence was subject to diffusion of mass into and out of lower-permeability zones relative to co-released chlorinated solvents. Two different release scenarios were evaluated within a two-layer aquifer system using an analytical modeling approach. The first scenario simulated a 1,4-dioxane and 1,1,1-TCA source zone where spent solvent was released. The period when 1,4-dioxane was actively loading the low-permeability layer within the source zone was estimated to be <3years due to its high effective solubility. While this was approximately an order-of-magnitude shorter than the loading period for 1,1,1-TCA, the mass of 1,4-dioxane stored within the low-permeability zone at the end of the simulation period (26kg) was larger than that predicted for 1,1,1-TCA (17kg). Even 80years after release, the aqueous 1,4-dioxane concentration was still several orders-of-magnitude higher than potentially-applicable criteria. Within the downgradient plume, diffusion contributed to higher concentrations and enhanced penetration of 1,4-dioxane into the low-permeability zones relative to 1,1,1-TCA. In the second scenario, elevated 1,4-dioxane concentrations were predicted at a site impacted by migration of a weak source from an upgradient site. Plume cutoff was beneficial because it could be implemented in time to prevent further loading of the low-permeability zone at the downgradient site. Overall, this study documented that 1,4-dioxane within transmissive portions of the source zone is quickly depleted due to characteristics that favor both diffusion-based storage and groundwater transport, leaving little mass to treat using conventional means. Furthermore, the results highlight the differences between 1,4-dioxane and chlorinated solvent source zones, suggesting that back diffusion of 1,4-dioxane mass may be serving as the dominant long-term "secondary source" at many contaminated sites that must be managed using alternative approaches.

Comparison of clinical and hormonal characteristics among four phenotypes of polycystic ovary syndrome based on the Rotterdam criteria.

PURPOSE: Polycystic Ovary Syndrome (PCOS) is the most common endocrine disturbances in women and is divided into different phenotypes. The aim of study is to compare the clinical and hormonal parameters among the four phenotypes of PCOS based on the Rotterdam criteria and with control group. METHODS: Women with PCOS (n = 263) confirmed based on the Rotterdam criteria and 263 women with no evidence of PCOS were recruited as controls using observational case-control study. Evaluation of clinical and hormonal parameters, and differences in anti-Mullerian hormone (AMH) were compared between four phenotypes of PCOS and controls. RESULTS: Women with phenotype A (olig-anovulation (O) + hyperandrogenism (H) + polycystic ovary morphology (P)) had significantly larger waist than phenotype D (O + P) and higher body mass index than phenotype C (H + P). The LH/FSH ratio was significantly higher in phenotype A than phenotype D and controls along with significantly higher serum total testosterone levels in phenotype A compared to the phenotype B (O + H), C, D, and controls. AMH was significantly higher with phenotype A, C, and D than in women phenotype B and controls. CONCLUSIONS: The highest AMH levels were found in phenotype A. Phenotype B similar to controls had significantly low AMH compared to other three PCOS phenotypes. Women in the phenotypes D and controls showed significantly lower levels of LH/FSH ratio, total testosterone, and free androgen index, and higher levels of FSH and SHBG compared with phenotype A (P < 0.001). In logistic regression analysis, AMH and LH were predictors for PCOS.

Bemiparin versus enoxaparin as thromboprophylaxis following vaginal and abdominal deliveries: a prospective clinical trial.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of maternal mortality and morbidity, with the highest incidence occurring during the postpartum period. This study compared the ability of two types of low-molecular-weight heparin, enoxaparin and bemiparin, to decrease the incidence of VTE following elective caesarean section, emergency caesarean section, and vaginal delivery in women who had risk factors for thromboembolism. METHODS: In this prospective clinical trial using a sequential group allocation method, 7020 haemodynamically stable women delivered vaginally or abdominally at the Maternity Teaching Hospital, Kurdistan region, Erbil, Iraq, between May 1, 2012, and November 1, 2013. These women had risk factors for VTE and were allocated to the following groups: treatment with 3500 IU/day of bemiparin, 4000 IU/day of enoxaparin, or no intervention (control). The first dose was administered 6 hours after vaginal or abdominal delivery, or 8 hours after delivery in women receiving spinal anaesthesia. Subsequent doses were administered daily for up to 6 days. The incidence of VTE was assessed for up to 40 days postpartum. Data were analyzed using the Statistical Package for Social Sciences version 19. Proportions were compared using the chi square test of association or Fisher's exact test. Binary logistic regression analysis was used with VTE as the dependent variable. RESULTS: VTE occurred in 1 (0.042%) woman in the bemiparin group, two (0.085%) women in the enoxaparin group, and nine (0.384%) women in the control group (P = 0.017). Regression analysis showed that women on bemiparin (OR = 0.106; 95% CI = 0.013-0.838) and enoxaparin (OR = 0.226; 95% CI = 0.049-1.049) were at lower risk of developing VTE than control women. Adverse events in the enoxaparin group included wound dehiscence, haematoma, and separation. None of these occurred in the bemiparin group. CONCLUSIONS: Postpartum bemiparin is significantly effective as a prophylaxis for VTE. Wound complications develop after use of enoxaparin, but not after bemiparin. TRIAL REGISTRATION: ClinicalTrials.gov; Identifier: NCT01588171 ; date: April 26, 2012.

A case-control observational study of insulin resistance and metabolic syndrome among the four phenotypes of polycystic ovary syndrome based on Rotterdam criteria.

BACKGROUND: Polycystic ovary syndrome (PCOS) is associated with an increased risk of insulin resistance (IR), metabolic syndrome (MetS), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM). Metabolic aspects of the four PCOS phenotypes remain to be fully defined. The aim of this study was to compare metabolic parameters and insulin resistance among the four PCOS phenotypes defined according to the Rotterdam criteria and to determine predictors of these complications. METHODS: A total of 526 reproductive-aged women were included in this observational case-control study. Of these, 263 were diagnosed as a PCOS based on Rotterdam criteria and 263 infertile women with no evidence of PCOS were recruited as controls. Biochemical, metabolic and insulin resistance parameters were compared in the two groups and the frequency of MetS and IR were compared among the four phenotypes. Data were analyzed for statistical significance using Student's t-test and one way analysis of variance followed by a post-hoc test (least significant difference). Chi-square tests were used to compare proportions. Univariate and multivariate logistic regression analyses were also applied. RESULTS: IR was identified in 112 (42.6%) of the PCOS women and 45 (17.1%) of the control (P <0.001). There were no significant differences in the frequency of IR and MetS between the four PCOS phenotypes. Homeostatic model assessment for IR (HOMA-IR) ≥3.8 was the most common IR parameter in PCOS and control groups. Women with oligo-anovulation (O) and PCO morphology (P) had a significantly lower level of 2-h postprandial insulin compared to women with O, P and hyperandrogenism (H) phenotypes. Logistic regression analysis showed that body mass index, waist circumference, triglyceride/high-density lipoprotein ratio (cardiovascular risk), HOMA-IR and glucose abnormalities (T2DM) were associated with increased risk of having MetS (P < 0.05). CONCLUSIONS: PCOS women with (O + P) show milder endocrine and metabolic abnormalities. Although, there were no significant differences in IR, MetS and glucose intolerance between the four PCOS phenotypes, women with PCOS are at higher risk of impaired glucose tolerance and undiagnosed diabetes.

Ovarian reserve markers and assisted reproductive technique (ART) outcomes in women with advanced endometriosis.

BACKGROUND: The role of ovarian reserve markers as predictors of the controlled ovarian stimulation (COS) response in intracytoplasmic sperm injection (ICSI) cycles in women with endometriosis has been much debated. The aim of the present study is to assess the predictability of ovarian reserve markers for the number of mature oocytes (MII) retrieved and to assess the pregnancy rate and live birth rate in women with advanced endometriosis. METHODS: Two hundred eighty-five infertile women who had laparoscopy followed by a first ICSI cycle were recruited in this prospective study. One hundred ten patients were diagnosed with endometriosis stage III-IV (group 1), and 175 patients had no endometriosis (group II). Sixty-three patients in group 1 had no history of previous endometrioma surgery (group Ia), and 47 patients had a history of previous endometrioma surgery (group Ib). RESULTS: The number of mature oocytes retrieved was significantly lower in women with advanced endometriosis than in women with no endometriosis. The number of mature oocytes retrieved in women with and without endometriosis was best predicted by antral follicle count (AFC) and age, whereas only AFC was a predictor in women with previous endometrioma surgery (odds ratio: 0.49; 95% confidence interval: 0.13-0.60). Women with endometriosis had a lower rate of live births than the control group, but this difference was not statistically significant; the number of live births was significantly lower in those with previous endometrioma surgery. CONCLUSIONS: The best predictor of the COS response in ICSI was AFC, followed by age. Women receiving ICSI following surgery for ovarian endometrioma had a poorer clinical outcome and lower rate of live births compared with those with endometriosis but no previous surgery and the control group.

Umbilical vein injection of misoprostol versus normal saline for the treatment of retained placenta: intrapartum placebo-controlled trial.

BACKGROUND: The third stage of labour may be complicated by retained placenta, which should be managed promptly because it may cause severe bleeding and infection, with a potentially fatal outcome. This study evaluated the effectiveness of umbilical vein injection of misoprostol for the treatment of retained placenta in a hospital setting. METHODS: This hospital-based placebo-controlled trial was conducted at the Maternity Teaching Hospital, Erbil City, Kurdistan region, Northern Iraq from April 2011 to February 2012. The inclusion criteria were: gestational age of at least 28 weeks, vaginal delivery, and failure of the placenta to separate within 30 minutes after delivery of the infant despite active management of the third stage of labour. Forty-six women with retained placentas were eligible for inclusion. After informed consent was obtained, the women were alternately allocated to receive umbilical vein injection of either 800 mcg misoprostol dissolved in 20 mL of normal saline (misoprostol group) or 20 mL of normal saline only (saline group). The women were blinded to the group allocation, but the investigator who administered the injection was not. The trial was registered by the Research Ethics Committee of Hawler Medical University. RESULTS: After umbilical vein injection, delivery of the placenta occurred in 91.3% of women in the misoprostol group and 69.5% of women in the saline group, which was not a significant difference between the two groups. The median vaginal blood loss from the time of injection until delivery of the placenta was significantly less in the misoprostol group (100 mL) than in the saline group (210 mL) (p value < 0.001). CONCLUSION: Umbilical vein injection of misoprostol is an effective treatment for retained placenta, and reduces the volume of vaginal blood loss with few adverse effects. CLINICAL TRIAL REGISTRATION: Current Controlled Trial HMU: N252.1.2011.

Prevalence of urinary incontinence and probable risk factors in a sample of kurdish women.

OBJECTIVES: The most common manifestation of pelvic floor dysfunction is urinary incontinence (UI) which affects 15-50% of adult women depending on the age and risk factors of the population studied. The aim of this study was to determine the probable risk factors associated with UI; the characteristics of women with UI; describe the types of UI, and determine its prevalence. METHODS: A cross-sectional study was conducted between February and August 2011, in the Maternity Teaching Hospital of the Erbil Governorate, Kurdistan Region, northern Iraq. It included 1,107 women who were accompanying patients admitted to the hospital. A questionnaire designed by the researchers was used for data collection. A chi-square test was used to test the significance of the association between UI and different risk factors. Binary logistic regression was used, considering UI as the dependent variable. RESULTS: The overall prevalence of UI was 51.7%. The prevalence of stress, urgency, and mixed UI was 5.4%, 13.3% and 33%, respectively. There was a significant positive association between UI and menopause, multiparity, diabetes mellitus (DM), chronic cough, constipation, and a history of gynaecological surgery, while a significant negative association was detected between UI and a history of delivery by both vaginal delivery and Caesarean section. CONCLUSION: A high prevalence of UI was detected in the studied sample, and the most probable risk factors were multiparity, menopausal status, constipation, chronic cough, and DM.

Evaluation of methane sources in groundwater in northeastern Pennsylvania.

Testing of 1701 water wells in northeastern Pennsylvania shows that methane is ubiquitous in groundwater, with higher concentrations observed in valleys vs. upland areas and in association with calcium-sodium-bicarbonate, sodium-bicarbonate, and sodium-chloride rich waters--indicating that, on a regional scale, methane concentrations are best correlated to topographic and hydrogeologic features, rather than shale-gas extraction. In addition, our assessment of isotopic and molecular analyses of hydrocarbon gases in the Dimock Township suggest that gases present in local water wells are most consistent with Middle and Upper Devonian gases sampled in the annular spaces of local gas wells, as opposed to Marcellus Production gas. Combined, these findings suggest that the methane concentrations in Susquehanna County water wells can be explained without the migration of Marcellus shale gas through fractures, an observation that has important implications for understanding the nature of risks associated with shale-gas extraction.

Contaminant plume classification system based on mass discharge.

Estimation of mass discharge has become an increasingly valuable analysis technique at sites with contaminated groundwater plumes. We propose a simple plume magnitude classification system based on mass discharge comprised of 10 separate magnitude categories, such as a "Mag 7 plume." This system can be a useful tool for scientists, engineers, regulators, and stakeholders to better communicate site conceptual models, prioritize sites, evaluate plumes both spatially and temporally, and determine potential impacts.

Assessment of renal insufficiency in gestational proteinuric hypertension in third trimester pregnancy.

This prospective study on assessment of renal insufficiency in pregnancy induced proteinuric hypertension was carried out on 104 cases, in Bangabandhu Sheikh Mujib Medical University (former IPGM&R), Dhaka during period of August 1997 to September 1998. The objective of this study, to find out the impairment of renal function in mild (<110 mmHg) and severe (>110 mmHg) hypertension. The frequency of mild hypertension was 96.29% and severe hypertension was 3.71% in third trimester of pregnancy. In this study mean age of the patient was 26.53+/-3.9 years, mean gestional age was 36.46+/-1.93 weeks and mean diastolic BP was 99.07 mmHg. The prevalence of hypertension was more in primigravida which was (72.23%) than multigravida (27.77%). Proteinuria was diagnosed as quantitative measurement of 24 hour urinary protein in photometric colorometer. The mean value of total urinary protein was 335+/-74.14 mg/24 hour (range 280-800 mg/24) hour). 1+Oedema was present in 48.14%, 2+ was 12.96% and 3+ was 14.81% of cases. There is a correlation of proteinuric hypertension with renal function which was done on the basis of laboratory investigations. Findings of parameters of renal function found to declined: Serum creatinine mean value 1.0+/-0.14 (P<0.001) (normal range 0.6-0.8 mg/dl.), Urinary creatinine mean 57.69+/-12 mg/dl., Creatinine clearance mean 53.72+/-11.63 ml/min, Total urinary protein mean 335.52+/-74.14 mg/24 hour. Total urinary volume mean 2985+/-49 ml/24 hr. All the patients and their babies were followed up till discharge from hospital. Cesarean section was done in 76% of cases and vaginal delivery was done in 24% cases. Mean hospital stay was prolonged in proteinuric hypertension 7+/-1 days than non proteinuric normotensive goup 3+/-1 days. All of those were average socio-economic status. Extreme low birth weight was 14.81% in 50% of IUGR cases.