Role of day 4 HCG as an early predictor of success after methotrexate therapy for ectopic pregnancies.

OBJECTIVE: To validate whether change in serum HCG levels between days 0 and 4 confer any prognostic value during methotrexate therapy and to quantify its change. STUDY DESIGN: This is a retrospective study of 48 tubal ectopic pregnancies treated with single dose methotrexate protocol at University Hospital, Muscat, Oman from January 2012 to December 2013. The clinical outcome was analyzed based on the complete resolution of HCG levels or need for additional doses of methotrexate or recourse to surgery. The percentage change in HCG levels between days 0 and 4 (HCG index) of methotrexate were calculated and receiver operator characteristics curve was plotted to identify the best cutoff levels. In order to get a robust 95% confidence interval, bootstrap method using R software was done using 1000 re-sampling. ROC curve and the predictive values were estimated using MEDCALC software. RESULTS: The mean HCG level on day 4 is significantly higher in treatment failure group (4254±4095 IU/L vs. 2109±3646 IU/L, P=0.008). The HCG levels between day 0 and 4 decreased in 42.7% (21/48) of cases and 80.9% of these cases had treatment success. The HCG levels increased in 57.4% (27/48) of cases and 33.3% of these cases had treatment success. (P=0.001). A 10 percent decline in day 4 HCG levels predict the treatment success with sensitivity of 77% and Specificity 81%. The area under the ROC curve was 0.82 (95% CI: 0.67-0.92), (P<0.001). CONCLUSION: The success with single dose of methotrexate therapy for tubal ectopic pregnancies was predicted early in the course of treatment by following three key findings: the absolute mean HCG values on day 4, decrease in HCG level from day 0 to 4 and 10% or more fall in day 4 HCG levels.

Is breech presentation in nulliparous women at term an absolute indication for cesarean section?

BACKGROUND: The aim of this report was to study the perinatal outcome of singleton breech presentation in nulliparous women who delivered after 37 weeks, either vaginally or by cesarean section, and whether by elective surgery or emergency, and to identify the indications for cesarean sections. SUBJECTS AND METHODS: This is a retrospective study conducted at King Fahd Hospital of the University, AlKhobar, Saudi Arabia, to compare perinatal mortality and morbidity of singleton term breech infants delivered vaginally and by cesarean section in nulliparous women. RESULTS: There were 112 singleton term breech presentations, of which 96 (85.7%) were allowed to have a trial of labor. Of these, 67 (69.8%) had a successful vaginal delivery. Women who delivered by elective cesarean section were significantly older than those who delivered vaginally (P<0.0001), and those who delivered by emergency cesarean section (P<0.004). The infants delivered by cesarean section were heavier in weight than those delivered vaginally (P<0.0001). There were no significant differences in 5 minute Apgar scores and perinatal mortality between the groups. CONCLUSION: With proper selection of nulliparous women with breech presentation for vaginal delivery, cesarean section can be avoided in the majority of cases without compromising the perinatal outcome.

Has consanguinity any impact on occurrence of pre-eclampsia and eclampsia?

In this study we tested the hypothesis of an association between consanguinity and pre-eclampsia/eclampsia. This is a case-control study conducted at Princess Badea Teaching Hospital, Irbid-Jordan during the period May 1997-April 1998. The study population were Jordanian women delivered at Princess Badea Teaching Hospital with or without hypertensive disorders of pregnancy. The total number was 208 pre-eclamptic/eclamptic women (76 primiparous and 132 multiparous) and 618 randomly selected non-hypertensive women. In primiparous as well as multiparous women, it was evident that neither consanguinity nor the degree of the relationship to the husband in consanguineous marriages had an impact on the incidence of preeclampsia/eclampsia. However, comparing the incidence of consanguinity between pre-eclamptic/eclamptic and non-hypertensive, multiparous women married to a relative other than first cousin, the P value was 0.0248, which we explained as chance incidence. When we compared the incidence of consanguineous marriages as a whole between pre-eclamptic/eclamptic and non-hypertensive, multiparous women, there was no evidence of any impact of consanguinity on the incidence of pre-eclampsia/eclampsia.

Neonatal exchange transfusion: a Jordanian experience.

The aetiology and complications of exchange transfusion (ET) were studied over a 6-year period in northern Jordan. During that time, 336 neonates (0.46% of total live births) underwent 386 ETs. There was a yearly reduction in the number of ETs, varying from 8.2% in the 1st year of the study to 2.7% in the last year. Thirty-nine (11.9%) required more than one ET. Twenty-five (7.4%) were preterm babies and the remainder full-term. The commonest cause of ET overall was G6PD deficiency, either alone or concomitant with ABO incompatibility (38.1%). ET complications occurred in 51 neonates (15.2%), the commonest being anaemia and bradycardia. Septicaemia occurred in only 3% of cases. Only one baby died. G6PD deficiency, either alone or concomitant with ABO isoimmunization, is the most common cause of ET in northern Jordan. Fewer preterm babies require ET and there is a low incidence of septicaemia following ET.

Maternal and perinatal outcome of pregnancies after the age of 45.

OBJECTIVE: To describe the maternal and perinatal outcome of pregnancies in women aged 45 years or more at the time of delivery and to compare them with pregnancies in women aged between 20 and 29 years. METHODS: A retrospective review of hospital deliveries after 28 weeks gestation was performed at the Princess Badeea Teaching Hospital in North Jordan for patients delivered between 1st April 1994 and 31st December 1997. We compared the maternal and perinatal outcome of pregnancies in women aged of 45 years or more (study group, n = 114) with women aged between 20-29 years (control group, n = 121) delivered at the same hospital during the same period. RESULTS: The incidence of pregnant women aged 45 years or more was 3.3 per 1,000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45 to 46 years old. Gravidity and parity was significantly higher in the study group (p < 0.0001), also antenatal and medical complications as pre-eclampsia and diabetes mellitus were higher in the study group. Caesarean section rate, incidences of placental abruption and placenta previa were more common in older patients compared with young patients (32.4 vs 10.7%, 6.1 vs 0.8% and 4.4 vs 1.6%, respectively). There were no differences in the incidences of neonatal deaths, lethal malformations and fetal weight between the 2 groups. CONCLUSION: Women aged 45 years or more at delivery may expect a good pregnancy outcome but should expect a higher incidences of placental abruption, placenta previa, preeclampsia and caesarean delivery.

Emergency peripartum hysterectomy at the Princess Badeea Teaching Hospital in north Jordan.

OBJECTIVE: To study the prevalence, indications and outcome of emergency peripartum hysterectomy in women delivered at the Princess Badeea Teaching Hospital in North Jordan. METHOD: This is a retrospective study of all cases of emergency peripartum hysterectomy performed between 1st of January 1994 and 31 August 1998. RESULTS: During the study period there were a total of 21 emergency peripartum hysterectomy were performed. The overall incidence was 0.5/1,000 deliveries. The mean age of patients was 34.7 +/- 3.9 years, the median parity was 6 and the mean gestational age was 36.9 +/- 2.01 weeks. There were 19 cases of caesarean hysterectomy. The leading indication for caesarean section was previous caesarean section (89.5%), placenta previa alone (10.5%). It should be noted that 7 cases with previous caesarean section also had placenta previa (41.2%). The main indications for emergency hysterectomy were, abnormally adherent placenta was the leading indication (38.1%), followed by rupture uterus (33.3%), haemorrhage and uterine atony occurred in 14.3% of cases each, maternal complications occurred in 42.9% of cases postoperatively. There were 4 cases of stillbirths and 2 cases of neonatal deaths. CONCLUSION: Peripartum hysterectomy remains a necessary procedure for life saving during abdominal and vaginal deliveries. The procedure itself is usually associated considerable perioperative morbidity. Obstetricians should identify patients at risk and anticipate the procedure and complications.

The management of unexplained infertility.

UNLABELLED: Unexplained infertility is a diagnosis made by exclusion after all of the standard investigations have revealed no abnormality (1). The range of the prevalence is from 6 to 60 percent (23), depending on the diagnostic criteria. This article reviews the literature in the management of unexplained infertility; published data suggest no benefit of danazol or bromocriptine. The empirical use of clomiphene citrate suggests that ovarian stimulation using clomiphene citrate can double the spontaneous pregnancy rate (52, 58, 59). Induction of ovulation with human menopausal gonadotrophin (hMG) yields an overall pregnancy rate between 2 and 26 percent per cycle (68, 74). These results seem to be lower than those reported for in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) procedures in similar patients (25-30 percent (92, 95)). Based on the literature, a rational treatment plan for treating infertility in couples with unexplained infertility includes up to four cycles of clomiphene citrate with or without intrauterine insemination (IUI). Superovulation with hMG and IUI or stimulated intrauterine insemination (SIUI) is the next step for three-cycle treatments and if unsuccessful, one of the variants of assisted reproductive techniques (ART) should be considered. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will understand the appropriate tests and work up for unexplained infertility, the various treatment options for the unexplained infertility couple including which drugs are effective and not effective, and to be able to outline an appropriate treatment plan for such patients.

Placenta previa: effect of age, gravidity, parity and previous caesarean section.

OBJECTIVE: To study the effect of maternal age, gravidity, parity, previous abortion and previous caesarean section on placenta previa. METHODS: We reviewed records of 95 women with placenta previa and compared with 190 women delivered during the same period, all delivering between 16 April 1994 and 15 May 1997. We compared maternal age, parity, gravidity, previous abortion, and previous caesarean section. RESULTS: Placenta previa is higher among women gravida > 4 (p < 0.002), para > 3 (p < 0.01) and previous caesarean section (p < 0.02). There is no increase in the incidence of placenta previa with increasing maternal age and previous abortion. CONCLUSION: The risk of placenta previa is increased with higher gravidity, higher parity, previous lower segment caesarean section, while increasing maternal age and previous abortion had no significant effect.

A comparison between ultrasound and clinical methods for predicting fetal weight.

Fetal weight prediction by different methods were compared. Those methods were ultrasound fetal weight estimations using Campbell, Warsof and Hadlock equations, and clinical subjective estimation by experienced obstetricians, as well as clinical objective studies (Zayed's equation). We evaluated 523 Jordanian (Arabic) patients in labour. Our results shows that ultrasound equation provides the highest accuracy in predicting fetal weight. In this study Hadlock's equation was more precise than the other equations. There is still a place for clinical fetal weight estimation, especially if objection methods are used.

Meconium-stained amniotic fluid in term pregnancies-a clinical view.

The objective of this study was to explore details of the clinical relationship between meconium-stained amniotic fluid (MSAF) in labour, abnormal fetal heart pattern and meconium aspiration (MA). This was a prospective study carried out in Princess Badeea Teaching hospital during a 6-month period from March to September 1997. During the study period 344 (8.5%) of the deliveries had MSAF (344 women). Continuous fetal heart monitoring was routinely used and 36 women with MSAF (10.5%) needed to be delivered by caesarean section because of fetal distress (diagnosed by abnormal fetal heart pattern) in early labour, compared with 0.95% in those with clear amniotic fluid (CAF), (P <0.00001). Many infants in the MSAF group had a low Apgar score and required ventilation at birth. Nineteen infants (5.5%) developed MA, three of whom (15.8%) died. We conclude that there is an association between MSAF, abnormal fetal heart pattern in labour and a low Apgar score and that it should be considered a high risk situation. MA a problem that occurs with particulate meconium was significantly related to abnormal fetal heart pattern and longer length of labour.

Obstetrics and perinatal outcome of pregnancies after the age of 45.

We set out to describe the maternal and perinatal outcome of pregnancies in women >/= 45 years old at the time of delivery. A retrospective review of hospital deliveries after 28 weeks of pregnancy was performed at the Princess Badeea Teaching Hospital (PBTH) in North Jordan for patients delivered between 1 April 1994 and 31 December 1997. During the study period, there were 114 women aged >/= 45 years at delivery at the PBTH. The incidence was 3.3 per 1000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45-46 years old. Maternal ages were 45 (n =64), 46 (n =29), 47 (n =9), 48 (n =8), 49 (n =2) and 50 (n =2) years. Median gravidity was 10, median parity was seven. Forty-four (38.6%) patients had obstetric complications. The most frequent complication was diabetes mellitus (9.6%), followed by hypertension (4.4%). Caesarean section was performed in 32.5%. There were nine stillbirths and four early neonatal deaths, the perinatal mortality rate was 114/1000 births. We conclude that women >/= 45 years old at delivery have high perinatal mortality rate and we also noted a higher incidence of placental abruption, placenta praevia and caesarean delivery, compared with a younger group of women.

Placental praevia and accreta: an analysis of two-years' experience.

This retrospective review of the case records was designed to determine the relationship between previous caesarean section and subsequent development of placenta praevia and placenta praevia with accreta. All women delivered with the diagnosis of placenta praevia at Princess Badeea Teaching Hospital from 1 January 1995 to 31 December 1996 were analysed. There were 18 651 deliveries in the study period. Sixty-five had placenta praevia, 21 of whom had a history of previous caesarean. The incidence of placenta praevia was significantly increased in those with a previous caesarean section (1.87%) compared with those with an unscarred uterus (0.25%) (P<0.0001). The risk increased as the number of previous caesarean sections increased. We also conclude that there is a high association between anterior placenta praevia, placenta accreta and previous caesarean section. This was enhanced with the increasing number of previous caesarean sections.

Neural tube defects in newborns.

Full text is available as a scanned copy of the original print version.

Ectopic pregnancy in North Jordan.

Full text is available as a scanned copy of the original print version.

Effect of age and parity on primary caesarean section rates.

OBJECTIVE: To study the effect of maternal age and parity on the rates of primary caesarean section. METHOD: We reviewed all patients who delivered at the Princess Badeea Teaching Hospital between 1 January, 1995 and 26 November, 1995. RESULTS: There were 8,732 deliveries included in this study. The primary caesarean section rates in primiparous women less than 25, 25 to 34 and over 34 years of age were 6.1%, 11.1% and 22.2%, respectively. A similarly dramatic rise with advancing maternal age was seen in multiparous women with rates of 3.1%, 6.4% and 9.5%, respectively, in the three age groups. A strong association between maternal age and primary caesarean section exists (p < 0.05). Caesarean section rates in the primiparous women were higher in all age groups when compared with multiparous women (p < 0.0001). CONCLUSIONS: Increasing maternal age and parity are factors strongly associated with increased primary caesarean section rates.

Dystocia: is it a major indication for caesarean section?

OBJECTIVE: To find out the indications for caesarean sections, the contribution of "dystocia" to the overall caesarean section rates, and to find ways to reduce dystocia-induced caesarean sections. METHOD: This was a retrospective study where all caesarean sections performed in 1995 at the Princess Badeea Teaching Hospital in North Jordan (the main teaching and referral hospital in the area) were reviewed. RESULTS: The caesarean section rate for 1995 was 8.4%. Dystocia was the main indication in 13.4% of all caesarean sections in that year. In 80.2% of patients who delivered because of dystocia labour started spontaneously. Thus if we advocate active management of labour, especially in nulliparous women who start labour spontaneously due to dystocia, we may reduce caesarean section and many repeat caesarean sections could be avoided. CONCLUSIONS: Applying a policy of active management of labour in nulliparous women may be the most useful approach to reduce caesarean section rates in modern obstetric practice.

Can we reduce repeat caesarean delivery at the Princess Badeea Teaching Hospital in north Jordan?

OBJECTIVE: Our aim was to describe the indications of repeat caesarean delivery and to determine modifiable practice patterns that might lead to fewer repeat caesarean deliveries. METHOD: Hospital records of all women with previous caesarean sections who delivered between 15 April, 1994-31 December, 1994 at the Princess Badeea Teaching Hospital in North Jordan were reviewed. Three groups were identified: 1) elective repeat caesarean 2) vaginal birth after caesarean 3) failed vaginal birth after caesarean. RESULTS: In this study there were 388 patients. Of these, 208 had a repeat caesarean delivery for the following reasons: failed vaginal birth after caesarean (39, 10.1%) and repeat elective caesarean section (169, 43.5%). The remaining (180, 46.4%) patients had a vaginal birth after caesarean. CONCLUSIONS: Our vaginal birth rate after one previous caesarean section was 82.2%. If this rate can be maintained in patients with 2 or 3 previous caesarean deliveries, we can reduce repeat caesarean rates by at least 14% by allowing more patients with 2 or even 3 previous caesarean deliveries to have a trial of labour under appropriate conditions and also proper management of dystocia.

Placenta praevia and accreta: analysis of a two-year experience.

OBJECTIVE: Our purpose was to determine the relationship between previous caesarean section and subsequent development of placenta praevia and placenta praevia with accreta. METHOD: A retrospective review of the case records of all women delivered with the diagnosis of placenta praevia during the 2-year period from January 1, 1995, to December 31, 1996, at the tertiary referral centre, Princess Badeea Teaching Hospital, in north Jordan. RESULTS: There were 18, 651 deliveries in the study period. 65 (0.35%) had placenta praevia, 21 (32.3%) of whom had a history of previous caesarean section. The incidence of placenta praevia was significantly increased in those with a previous caesarean section (1.87%) compared with those with an unscarred uterus (0.25%); p < 0.0001). This risk increased as the number of previous caesarean sections increased: 1.78% for one previous section; 2.4% for two, and 2.8% for three or more. The incidence of anterior placenta praevia and placenta accreta was significantly increased in those with previous caesarean scars. In the group without antecedent of caesarean section, accretism risk was 9%, with one section or more 40.8% (p < 0.005). CONCLUSION: There is a high association between anterior placenta praevia, placenta accreta and previous caesarean section. This was enhanced with the increasing number of previous caesarean sections. Patients with an antepartum diagnosis of placenta praevia who have had a previous caesarean section should be considered at high risk of developing placenta praevia and accreta.

PIP: The association between previous cesarean section delivery and subsequent development of placenta praevia and placenta praevia with accreta was investigated in a retrospective review of the records of all women delivered at Princess Badeea Teaching Hospital (Irbid, Jordan) in 1995-96 with a diagnosis of placenta praevia. The 65 women with placenta praevia represented 0.35% of total deliveries during the 2-year study period; 21 of these women (32.3%) had a history of previous cesarean section. The incidence of placenta praevia was significantly greater in women with a history of cesarean section than in those without such a history (1.87% and 0.25%, respectively; p 0.0001). This risk increased with increases in the number of previous surgical deliveries: 1.78% for 1, 2.4% for 2, and 2.8% for 3 or more. The incidence of placenta accreta also was significantly increased in women with previous cesarean section compared to those without a prior surgical delivery (40.8% and 9.0%, respectively; p 0.005).

Abruptio placentae: risk factors and perinatal outcome.

OBJECTIVE: It is a case control study, conducted in order to determine the risk factors, and to find out the perinatal outcome of abruptio placentae in women delivered at the Princess Badeea Teaching Hospital in North Jordan. METHODS: We reviewed all cases of placental abruption delivered between 15th April 1994 till 26 November 1995 and to compare that with pregnancies and deliveries not complicated by abruptio placentae. RESULTS: During the study period there were 108 cases of abruptio placentae and 108 cases of the control group. The total number of women delivered were 18,256, so the incidence of abruptio placentae was 5.9 per 1000 births. When compared to the control group, abruptio placentae occurred more in parous women (para > or = 5) (p < 0.0005), more preterm deliveries (p < 0.0001) with more birth weight < 2,500 g (p < 0.0001). Preeclampsia and pregnancy induced hypertension, intrauterine growth retardation, caesarean delivery, and intrauterine fetal death occurred more in patients with abruptio placentae. CONCLUSION: High parity, preeclampsia and hypertension are significant etiological determinants of abruptio placentae.

Retrospective study of outcome on vaginal and abdominal delivery in twin pregnancy in which twin 1 is presenting by the breech.

We retrospectively reviewed the perinatal outcome of twin pregnancies cohere the first baby was presenting by the breech. 21 were delivered vaginally and 37 abdominally. Differences in perinatal outcome, as measured by Apgar score and mortality, were not apparently different.