A comparison between induction of labor with 3 methods of titrated oral misoprostol, constant dose of oral misoprostol and Foley catheter with extra amniotic saline infusion (EASI), in women with unfavorable cervix.

Background: Different methods of cervical ripening and induction of labor have been used in the cases of unfavorable cervix with different levels of success, but no method has been found to be the best option. The purpose of the present study was to find the effects and side effects of three different methods of cervical ripening and induction of labor. These three methods were oral titrated misoprostol, constant dose of oral misoprostol and Foley catheter with extra-amniotic saline infusion. Methods: This clinical trial was performed on women with unfavorable cervix who had been admitted in Akbarabadi Teaching Hospital for induction of labor and had bishop score of less than six; between March 2014- March 2015. The eligible women were assigned into three groups. In titrated oral misoprostol group (n=33), titrated solution of misoprostol, and in oral misoprostol group (n=33), 50µg oral misoprostol every four hours and in Foley catheter group (n=50), Foley catheter with extra-amniotic saline infusion were administered. The main outcome was the number of vaginal deliveries during the first 24 hours. In addition, number of cesarean deliveries and adverse effects were compared between the three groups. The obtained data were analyzed using SPSS 18 software. Data analysis was performed according to the intention to treat principle. Chi-square test, Fisher Exact test, Student ttest, and Mann-Whitney U test, were used for comparing data. P-value≤0.05 was considered statistically significant. Results: The three groups did not have any significant difference according to maternal age, gestational age at the time of admission, gravidity, parity, and primary Bishop Score. There was no significant difference between the three groups for the main outcome, which was vaginal delivery during the first 24 hours (p=0.887). There was no significant difference between the three groups according to hypertonicity, uterine hyperstimulation, meconium passage, non-reassuring fetal heart rate, neonatal Apgar score in minutes one and 5, and mean duration of beginning the intervention up to delivery. However, uterine tachysystole and NICU admission were more in the group to whom the titrated solution of misoprostol was administered (p=0.002 and p=0.037 respectively). The number of cesarean deliveries due to failure to progress was higher in the EASI group. However, EASI group showed the least number of none-reassuring fetal heart rate between the three groups. Meconium passage was more in the titrated misoprostol group, but the difference was not significant. Conclusion: All three methods are appropriate methods for induction of labor in the cases of unfavorable cervix; and choosing each method depends on the expertise of labor staff, accessibility to the medications, cost, and taking care for monitoring the patients and adverse effects.

The effects of sequential use of oxytocin and sublingual nitroglycerin in the cases of retained placenta.

OBJECTIVES: To evaluate the effects of adding sublingual nitroglycerin to oxytocin, for delivery of retained placenta after vaginal delivery. METHOD: The study was performed as a placebo controlled clinical trial on women who did not finish delivering placenta after 30 min of active management of the third stage of labor. In case group, 1 mg nitroglycerin and in the control group, placebo was prescribed sublingually. RESULTS: In total, 80 women finished the study. The number of manual removal of placenta did not show significant difference between the two groups [25 women (62.5%) in the case and 30 women (75%) in the control group, p = 0.335]. There was no significant difference between the two groups according to duration of the third stage of labor, hemoglobin index, decline in HB index >30% and maternal vital signs after treatment. There was no significant difference between the two groups according to adverse effects [eight women (20%) in the case group and four (10%) in the control group (p = 0.348)]. CONCLUSION: The sequential use of oxytocin and sublingual nitroglycerin could not lead to delivery of more placentas and did not reduce the necessity of manual removal of placenta in comparison with placebo.

Evaluation of vaginal fluid ß-human chorionic gonadotrophin for the diagnosis of preterm premature rupture of membranes.

AIM: The purpose of the present study was to evaluate vaginal fluid ß-human chorionic gonadotrophin (ß-hCG) for the diagnosis of preterm premature rupture of membranes (PPROM). MATERIAL AND METHODS: An observational cross-sectional study was performed on 123 pregnant women who were in the third trimester of their gestation (28-37 weeks). The patients were divided into three groups: (i) PPROM group (41 cases); (ii) suspected PPROM group (42 cases); and (iii) intact membranes control group (40 cases). Five milliliters of sterile normal saline was inserted into the posterior fornix of the vagina and then vaginal fluid was aspirated and sent to the laboratory for ß-hCG measurement. Finally, the amount of ß-hCG was compared in the three groups. RESULTS: ß-hCG concentration was 7.71 ± 15.7 mIU/mL in the intact membrane control group, 468.06 ± 366.34 mIU/mL in the PPROM group and 176.43 ± 316.37 mIU/mL in the suspected PPROM group, which showed a significant difference between the three groups (P < 0.001). In order to find an optimal cut-off value for ß-hCG, the receiver-operator curve was used and a cut-off value of 79.5 mIU/mL with a sensitivity of 95% and specificity of 84% was determined to be optimal. CONCLUSION: ß-hCG was higher in the cases of PPROM and patients who were suspected to have PPROM, and may be used as a suitable, fast and reliable test for detecting rupture of membranes.

Value of serum urocortin concentration in the prediction of preterm birth.

AIM: Preterm delivery is a serious problem during pregnancy with remarkable neonatal adverse effects. Prediction of preterm delivery in women with preterm uterine contractions or signs of preterm labor is critical because if these women are identified they can be referred to tertiary centers. The present study aimed to evaluate the value of maternal serum urocortin concentration for predicting preterm delivery in women with signs of spontaneous preterm labor. MATERIAL AND METHODS: A cohort study was conducted on pregnant women at a gestational age of 28-36 weeks who were admitted to the labor ward with spontaneous preterm labor. A blood sample was obtained from all participants to measure serum urocortin. The women were monitored up to delivery and serum urocortin was compared between women with preterm delivery and those who delivered at term (37 weeks of gestation). Receiver Operating Characteristic (ROC) curve analysis was used to determine sensitivity and specificity if applicable. RESULTS: One hundred and sixty pregnant women finished the study. One hundred and forty-eight (92.5%) of the women delivered preterm. Mean serum urocortin in the preterm delivery group was higher than in the term group, but without statistical significant difference (392.6 ± 29.23 vs 113.2 ± 11.0. pg/mL, respectively, P = 0.252). Area under the ROC curve was 0.6, which shows that this test is not appropriate for predicting preterm delivery in women with preterm labor. CONCLUSION: Serum urocortin could not predict women who delivered preterm among women with signs of preterm labor.

Risk factors for pre-eclampsia: a study in Tehran, Iran.

This study evaluated some risk factors for pre-eclampsia, which is one of the most problematic complications of pregnancy. This was a retrospective case control study conducted on 318 pre-eclamptic women (case group) and 318 women who were normotensive at the time of delivery as the control group. Evaluated factors were: maternal age, gestational age, nuliparity, mother's educational status, maternal body mass index (BMI), maternal hemoglobin and blood Rh, familial history of pre-eclampsia, history of pre-eclampsia in a previous pregnancy, marital relations, urinary infection (UTI) during the present pregnancy, season of delivery, and method of contraception. Risk factors for pre-eclampsia were: UTI (P=0.04); history of pre-eclampsia during previous pregnancy (P=0.003), and winter season (P=0.001). Maternal age of more than 20 years, high educational status of mother, parity more than one, and oral contraceptive pills were protective for pre-eclampsia. After adjusting for all possible confounding factors using multiple logistic regression, only preexisting pre-eclampsia (P=0.004) was a risk factor, whereas parity more than three (P=0.007) and anemia (P=0.01) were protective for pre-eclampsia. The rate of cesarean delivery was more common in the pre-eclamptic group (245 cases, 77%) than the control group (85 cases, 26.7%). The one minute Apgar score of neonates less than 8 was more common in the case group (28.6% vs. 47.4%, P<0.001). Gestational age at the time of delivery was lower in the case group (36.48±3.4 weeks vs. 37.12±3.3 weeks, P<0.001). Awareness of risk factors of pre-eclampsia can help to monitor patients, ensure earlier diagnosis and predict which patients are more likely to develop pre-eclampsia.

Evaluation of the effect of pelvic floor muscle training (PFMT or Kegel exercise) and assisted pelvic floor muscle training (APFMT) by a resistance device (Kegelmaster device) on the urinary incontinence in women: a randomized trial.

OBJECTIVE: To evaluate the effect of pelvic floor muscle training (PFMT) or Kegel exercise with and without assistance by a resistance device (Kegelmaster device) on the urinary incontinence in women. STUDY DESIGN: A randomized clinical trial was performed on 91 women with the complaint of urinary incontinence. In the assisted pelvic floor muscle training (APFMT) group (n=41), after complete training, Kegelmaster device were used twice daily for 15 min each session, for a total duration of 12 weeks. In the pelvic floor muscle training (PFMT) group (n=50) after complete training, kegel exercises were done (including perineal muscle contractions for 6-8s with 6s rest in between), twice daily for 15 min each session and for a total duration of 12 weeks. These two groups were then compared according to the scores of special questionnaires for quality of life, strength of pelvic floor muscles, capability to participate in social activities, severity of urinary incontinence, and the number of involuntary urine passage, taken before, and after 1 and 3 months after finishing interventions. RESULTS: 85 women out of 91 women finished the study (46 in the PFMT group and 39 in the APFMT group). Strength of pelvic floor muscles, capability to participate in social activities, score of quality of life according to three world questionnaires of IQOL (incontinence Quality Of Life), IIQ (Incontinence Impact Questionnaire), UDI (Urogenital Distress Inventory), showed no difference between the two groups 1 and 3 months after interventions. Pair t test showed a significant improvement in both groups 1 and 3 months after intervention, according to IQOL score (P=0.000), UDI score (P=0.000), IIQ score (P=0.000), strength of pelvic floor muscles, (P=0.000), capability to participate in social activities (P=0.000), severity of urinary incontinence (P=0.000) and the number of involuntary urine passage (P=0.000). CONCLUSION: Pelvic floor muscle training with or without Kegelmaster show no apparent difference to each other, however, these two methods are effective for improvement of urinary incontinence in women.

Comparison of pregnancy outcome among nulliparas with and without microalbuminuria at the end of the second trimester.

OBJECTIVE: To evaluate the rate of poor pregnancy outcome among nulliparas who had microalbuminuria at the end of the second trimester of their pregnancy. METHODS: A prospective cohort study was performed on 490 nulliparous women who were at the end of the second trimester of pregnancy. Urine tests for albuminuria and creatinine measurements were performed in all women and the albumin to creatinine ratio (ACR) was calculated. The women with microalbuminuria (exposed group) and those without microalbuminuria (nonexposed group) were monitored until the end of their pregnancy and compared for pregnancy outcome. RESULTS: Preterm labor (57.9% versus 13.5%), preeclampsia (50.0% versus 8.6%), intrauterine growth restriction (42.1% versus 6.4%), and preterm premature rupture of membranes (31.6% versus 10.2%) were significantly more common in the exposed group. The rates of gestational diabetes did not differ significantly between the 2 groups. In multivariate logistic regression analyses, microalbuminuria increased the risks for preterm labor (adjusted OR 2.4; 95% CI 1.1-5.5, P=0.03) and preeclampsia (adjusted OR 9.5; 95% CI 4.6-19.3, P<0.001). CONCLUSION: Microalbuminuria at the end of the second trimester of pregnancy might increase the risks of preterm labor, preeclampsia, intrauterine growth restriction, and preterm premature rupture of membranes.

Comparison of the efficacy and adverse effects of nifedipine and indomethacin for the treatment of preterm labor.

OBJECTIVE: To compare the effectiveness and adverse effects of nifedipine versus indomethacin in the treatment of preterm labor. METHODS: In a randomized clinical trial, 79 women with labor pain at 26-33 weeks of gestation were treated with either oral nifedipine (n=40) or rectal indomethacin (n=39). RESULTS: Twenty-three (59%) women in the indomethacin group, and 10 (25%) in the nifedipine group did not respond to treatment (P=0.002). None of the 16 and 30 women remaining in the indomethacin and nifedipine groups, respectively, delivered during the subsequent 48 hours. Of these remaining women, 1 (6.25%) in the indomethacin group and 4 (13.3%) in the nifedipine group delivered between 48 hours and 7 days (P=0.162). For the women who responded to treatment, the mean gestational age at time of delivery was 238.5±19.4 days and 246.4±15.4 days in the nifedipine and indomethacin groups, respectively (P=0.182). Seventeen (42.5%) women in the nifedipine group, and 11 (28.2%) in the indomethacin group showed adverse effects (P=0.184). CONCLUSION: Indomethacin was less effective than nifedipine for the fast treatment of preterm labor. For women who responded to treatment within 2 hours, however, the delaying of delivery by indomethacin was similar to that by nifedipine.

Subcutaneous sterile water injection for labour pain: a randomised controlled trial.

BACKGROUND: About 30% of women experience severe continuous low-back pain in labour, but limited options are available to reduce this pain especially in developing countries and remote areas. AIMS: To evaluate the efficacy of subcutaneous sterile water injection in reduction of labour pain compared with placebo. METHODS: One hundred (100) consecutive patients were enrolled in a double-blind randomised controlled trial. During the first stage of labour with planned normal vaginal delivery, the intervention group (n = 50) received 0.5 mL sterile water injected subcutaneously and the control group (n = 50) received normal saline as a placebo. Pain score was measured before and 10 and 45 min after the injection, using the faces rating scale. MAIN OUTCOME MEASURE: Low-back labour pain. RESULTS: The two groups were not significantly different regarding maternal age and weight, gestational age, parity and gravidity and degree of effacement. The median pain score was equal in both groups prior to the injection. Pain severity was reduced in both groups after the injection. However, the median pain score in the sterile water group was significantly lower than the placebo group 10 min (P < 0.01), as well as 45 min, after the injection (P < 0.01). CONCLUSION: Administering one subcutaneous injection of sterile water in a painful point of the lumbosacral area is effective in reducing low-back pain during labour.

Association between lamellar body count and respiratory distress in neonates.

OBJECTIVE: Assessment of fetal lung maturity by a simple and rapid test has a pivotal role in obstetric managements. Lack of modern laboratory techniques in our country made us investigate whether lamellar body count (LBC) can be applied efficiently in the evaluation of fetal lung maturity. METHODS: Lamellar body count was assessed in 104 unspun amniotic fluid samples taken from pregnant women admitted at Akbar Abadi Hospital, Tehran, Iran between May 2003 and November 2003 whose fetuses were at risk for respiratory distress syndrome (RDS). Cut-off points for LBC were determined to evaluate the risk of RDS. Standard clinical and radiographic criteria were used to diagnose RDS. RESULTS: An LBC of less than 10,000 was 99.1% specific for lung immaturity (positive predictive value = 99.1%, negative predictive value = 83.5%). The LBCs of greater than 45,000 eliminates RDS (negative predictive value = 98.9%). CONCLUSION: Lamellar body count is an easy, rapid and cost-effective test to assess fetal lung maturity in high-risk fetuses. Using the cut-off points of 10,000 and 45,000, LBC can serve as the first screening test of fetal lung maturity.