Carbetocin versus oxytocin for prevention of postpartum hemorrhage in obese nulliparous women undergoing emergency cesarean delivery.

OBJECTIVE: To assess and compare the effectiveness and safety of single IV polus dose of carbetocin, versus IV oxytocin infusion in the prevention of PPH in obese nulliparous women undergoing emergency Cesarean Delivery. METHODS: A double-blinded randomized-controlled trial was conducted on 180 pregnant women with BMI >30. Women were randomized to receive either oxytocin or carbetocin during C.S. The primary outcome measure was major primary PPH >1000 ml within 24 h of delivery as per the definition of PPH by the World Health Organization Secondary outcome measures were hemoglobin and hematocrit changes pre- and post-delivery, use of further ecobolics, uterine tone 2 and 12-h postpartum and adverse effects. RESULTS: A significant difference in the amount of estimated blood loss or the incidence of primary postpartum haemorrhage (>1000 ml) in both groups. Haemoglobin levels before and 24-h postpartum was similar. None from the carbetocin group versus 71.5% in oxytocin group needed additional utrotonics (p < 0.01). The uterine contractility was better in the carbetocin group at 2, and 12-h postpartum (p < 0.05). CONCLUSIONS: A single 100-µg IV carbetocin is more effective than IV oxytocin infusion for maintaining adequate uterine tone and preventing postpartum bleeding in obese nulliparous women undergoing emergency cesarean delivery, both has similar safety profile and minor hemodynamic effect.

Levonorgestrel-releasing intrauterine device versus dydrogesterone for management of endometrial hyperplasia without atypia.

OBJECTIVE: To compare the efficacy and safety of the levonorgestrel-releasing intrauterine device (LNG-IUD) with dydrogesterone applied for the same duration in patients having endometrial hyperplasia (EH) without atypia. MATERIALS AND METHODS: One hundred thirty eight women aged between 30 and 50 years with abnormal uterine bleeding and diagnosed as EH by transvaginal ultrasound were randomized to receive either LNG-IUD or dydrogesterone for 6 months. Primary outcome measures were regression of hyperplasia after 6 months of therapy. Secondary outcome measures were occurrence of side effects during treatment or recurrence of hyperplasia during follow-up period. RESULTS: After 6 months of treatment, regression of EH occurs in 96% of women in the levonorgestrel-releasing intrauterine system (LNG-IUS) group versus 80% of women in the oral group (P < .001). Adverse effects were relatively common with minimal differences between the 2 groups. Intermenstrual vaginal spotting and amenorrhea were more common in the LNG-IUD group (P value .01 and .0001). Patient satisfaction was significantly higher in the LNG-IUS group (P value .0001). Hysterectomy rates were lower in the LNG-IUS group than in the oral group (P = .001). Recurrence rate was 0% in the LNG-IUD group compared to 12.5% in the oral group. CONCLUSION: In management of EH without atypia, LNG-IUS achieves a higher regression and a lower hysterectomy rate than oral progesterone and could be used as a first-line therapy.

HPV detection in a self-collected vaginal swab combined with VIA for cervical cancer screening with correlation to histologically confirmed CIN.

AIM: To first compare the accuracy of self-, Physician-HPV testing and VIA as standalone screening tests; and second to compare the accuracy of Self-HPV positive test triaged with VIA with the different standalone screening tests as colposcopy and histologically confirmed CIN for cervical cancer screening in low-resource settings METHODS: 1,601 women in Sharkya Governerate, Egypt concurrently received HPV DNA testing [Hybrid Capture 2 (HC2) assay] for self-collected and physician-obtained samples, and VIA. Women who tested positive for HPV DNA or VIA received colposcopy and biopsy. RESULTS: Percentage of women testing positive was 84.8 % on Self-HPV, 87.8 % on Physician-HPV, and 76.8 % on VIA. Test positivity increased in all screening methods with increasing severity of histopathologic diagnosis. Physician-HPV and HPV testing on a self-sample showed a very good agreement for HPV testing results [κ = 0.89 (95 % CI = 0.52-0.79)]; no statistically significant variation between age groups in the sensitivities of HPV testing on a self-sample, Physician-HPV testing for detecting CIN2 or CIN3 lesions. Conversely, VIA sensitivity was lower in detecting CIN2 and CIN3 than HPV testing on a self-sample and decreased significantly in the older age groups. HPV testing on a self-sample positive combined with VIA increases specificity to 98.1 % for CIN2 and 99.4 % for CIN3, and decreased colposcopy referral rate to 2.5 %. CONCLUSION: HPV testing on a self-sample is more accurate than VIA and as accurate as clinician-HPV testing for cervical cancer in low-resource settings.

Comparing long term impact on ovarian reserve between laparoscopic ovarian cystectomy and open laprotomy for ovarian endometrioma.

OBJECTIVE: To compare the long term impact on ovarian reserve between laparoscopic ovarian cystectomy with bipolar electrocoagulation and laparotomic cystectomy with suturing for ovarian endometrotic cyst. PATIENT AND METHOD(S): 121 patients with benign ovarian endometroitic cysts were randomised to either laparoscopic ovarian cystectomy using bipolar electrocoagulation (61 patients) or laparotomic ovarian cystectomy using sutures (60 patients). Serum follicle-stimulating hormone, Antimullerian hormon, Basal antral follicle Count, mean ovarian diameter, and ovarian stromal blood flow velocity were measured at 6, 12 and 18 months after surgery and compared in both groups. RESULT(S): A statistically significant increase of serum FSH was found in the laproscopic bipolar group at 6-, 12 and 18-month postoperativly compared to open laparotomy suture group. Also, a statistically significant decrease of the mean AMH value occurred in laproscopic bipolar group at 6-, 12 and 18-month follow- up compared to open laparotomy suture group. Basal antral follicle number, mean ovarian diameter and peak systolic velocity were significantly decreased during the 6-, 12,18 -month follow-up in laproscopic bipolar group compared to open laparotomy suture group. CONCLUSION(S): After laproscopic ovarian cystecomy for endometrioma all pareameter of ovarian reseve are significantly decreased on long term follow up as compared to open laprotomy.

Clinicopathological correlation of endocan expression and survival in epithelial ovarian cancer.

INTRODUCTION: Endothelial-cell-specific molecule-1 or endocan is a proteoglycan with tumorigenic activity through both its glycan and protein cores. Endocan mRNA is identified as one of the most significant molecular signatures defining a poor prognosis in lung, breast, kidney, and hepatocellular cancer. OBJECTIVE: To assess the clinical value of endocan expression in ovarian cancer tissues in association with other prognostic factors and its impact on overall survival. SETTING: Oncology unit of Zagazig University Hospitals, Egypt. STUDY DESIGN: Prospective observational cohort. PATIENTS AND METHODS: One hundred primary ovarian cancer patients were recruited as study group, another 100 patients undergoing hysterectomy and oophorectomy due to uterine fibroid were the control group. Angiogenesis was determined by immunohistochemical staining, using anti-endocan, and anti vascular endothelial growth factor (VEGF) monoclonal antibodies. RESULTS: Endocan was expressed in endothelium of ovarian cancer tissue specimens in all patients with no expression in endothelium of normal ovarian tissue in the control group. VEGF was also expressed in endothelium of all specimens of ovarian cancer tissue, compared with 70% expression in normal ovarian tissue specimens in the control group. A significant association was found between endocan-microvessel density (MVD) and tumor histology, tumor size, staging, and grading. No significant association was found between VEGF expression and any of the clinicopathological variables. Overall survival of patients was inversely associated with endocan-MVD (P < 0.01). Multivariate analysis showed that endocan-MVD was an independent prognostic marker for overall survival of epithelial ovarian cancer (P < 0.01). CONCLUSION: Endocan could be a reliable marker to predict the survival in epithelial ovarian cancer patients.

Reproductive performance in the next pregnancy for nulliparous women with history of first trimester spontaneous abortion.

OBJECTIVE: To determine whether interpregnancy interval after the first spontaneous abortion has an effect on reproductive performance of women in their next pregnancy. METHOD: A prospective cohort study was conducted on 4,619 women with history of spontaneous abortion in their first pregnancy. Of them 2,422 (52.4 %) conceived within 6 months of the miscarriage (group A) and 2,197 47.6 % after 12 months (group B). The primary outcome was abortion, live birth, termination, or ectopic pregnancy in the next pregnancy. Secondary outcomes were preterm delivery, low birth weight infants, caesarean section rate and occurrence of preeclampsia, placental abruption and induced labour in the second pregnancy. RESULTS: Women who conceived again within 6 months were less likely to have another abortion, termination, or ectopic pregnancy compared with women with interpregnancy interval more than 12 months. Women with an interpregnancy interval more than 12 months were less likely to have live birth in the second pregnancy and more likely to have a caesarean section, preterm delivery, or infant of low birth weight compared with women who conceived again within 6 months. CONCLUSIONS: Women who conceive within 6 months after their first spontaneous abortion have better reproductive outcomes and the lowest complication rates in their subsequent pregnancy.

Comparative study between VEGF-A and CA-125 in diagnosis and follow-up of advanced endometriosis after conservative laparoscopic surgery.

OBJECTIVE: To evaluate the role of serum level of VEGF-A in comparison to CA-125 in diagnosis and follow-up of patients with advanced endometriosis after conservative laparoscopic surgery. METHODS: A prospective randomized case-control study was performed on patients referred for laparoscopy complaining of unexplained primary infertility with or without chronic pelvic pain. Thirty patients with advanced endometriosis; stage III-IV were included (study group), another 30 women without endometriosis or any other medical conditions were settled as a control group. Pre-operative blood samples were collected from study and control cases. Post-operative blood samples were collected from 25 treated patients in the follicular phase of the third menstrual cycle; 5 cases were drop-outs. Serum level of cancer antigen-125 (CA-125) and vascular endothelial growth factor (VEGF-A) were assayed by using enzyme linked immunosorbent assay (ELISA) kit. RESULTS: There was a statistically significant difference in serum CA-125 and VEGF-A level in patients with advanced endometriosis before conservative laparoscopic surgery and those without endometriosis (p < 0.001) and after conservative laparoscopic surgery (p < 0.001). High sensitivity (93.3 %), specificity (96.7 %) and accuracy (95.0 %) of VEGF-A assay than in CA-125 distinguishing between patients with endometriosis from those without endometriosis; CA-125 has 70.0 %sensitivity, 90.0 % specificity and 85.0 % accuracy. Percentage of decrease of VEGF-A level after operation was higher than that of CA-125 (45.9 vs. 25.8 %) p < 0.001, respectively. CONCLUSION: The use of VEGF-A for diagnosis of advanced endometriosis at cut-off 680 pg/ml and for follow-up is better than CA-125.

Effect on ovarian reserve of laparoscopic bipolar electrocoagulation versus laparotomic hemostatic sutures during unilateral ovarian cystectomy.

OBJECTIVE: To compare the effects of laparoscopic bipolar electrocoagulation with laparotomic hemostatic suturing during unilateral ovarian cystectomy on the ovarian reserve. METHODS: A prospective randomized trial was conducted on 59 women with unilateral benign ovarian cysts who underwent laparoscopic ovarian cystectomy by a stripping technique (n = 30) or open laparotomy with hemostatic suturing (n = 29). Serum anti-Müllerian hormone (AMH), antral follicle count (AFC), and ovarian stromal peak systolic velocity (PSV) at the 1st, 3rd, and 6th postoperative cycle were used to assess the ovarian reserve. RESULTS: Preoperative AMH levels did not differ significantly (P = 0.18) between the laparoscopy and laparotomy groups. In the laparoscopy group, there was a significant decrease in AMH levels, AFC, and PSV at the 3rd and 6th postoperative cycles compared with the 1st postoperative cycle, with an insignificant decrease between the 3rd and 6th cycles. In the laparotomy group, nonsignificant decreases in AMH levels, AFC, and PSV were detected at the 1st, 3rd, and 6th postoperative cycle and between the 3rd and 6th cycles. CONCLUSION: Laparoscopic ovarian cystectomy is associated with a significant reduction in ovarian reserve. This is a consequence of damage to the ovarian vascularity and the removal of an increased amount of ovarian tissue.

Association between circulating interleukin-1 beta (IL-1ß) levels and IL-1ß C-511T polymorphism with cervical cancer risk in Egyptian women.

Cancer cervix is one of the leading causes of cancer-related mortality among women worldwide. It is believed that the host genetic factors such as inflammation-induced cytokines may play a role in cervical carcinogenesis. The interleukin-1ß (IL-1ß) gene contains several single nucleotide polymorphisms. One of them, C-511T, which in the promoter region has been associated with increased IL-1ß production and with increased risk of developing cancers. We assessed the association between the IL-1ß C-511T polymorphism and cervical cancer risk in a case-control study among 100 histopathologically confirmed Egyptian women with cervical cancer and 50 age-matched, cervical cytology negative, healthy controls by polymerase chain reaction-restriction fragment length polymorphism. Plasma levels of IL-1ß were assayed by enzyme-linked immunosorbent assay. There was significant increase in the mean plasma IL-1ß level in cervical cancer cases (43.40 ± 25.95 pg/ml) when compared with controls (30.51 ± 18.28 pg/ml, P = 0.002). The plasma levels above the 75th percentile of controls (IL-1ß ≥ 45.74 pg/ml) were significantly associated with a 2.49-fold increased risk of cervical cancer. The significant increase in IL-1ß concentration in cervical cancer cases was observed only among cervical cancer cases carrying C-511T variant genotypes. T/T genotype of IL-1ß polymorphism was significantly higher in cervical cancer cases compared with controls (57 vs. 38%; OR = 2.16; P = 0.028) and the T allele carriage was significantly associated with cervical cancer risk (OR = 2.00, 95% CI = 1.19-3.38, and P = 0.008). In conclusion, plasma IL-1ß level and IL-1ß C-511T polymorphism may be considered as candidate biomarkers for cervical cancer in Egyptian women.

Three-dimensional power Doppler study of changes in uterine vascularity after absorbable cervical tourniquet during open myomectomy.

OBJECTIVE: To evaluate the effect of an absorbable polyglactin tie (i.e., cervical tourniquet) on postoperative uterine artery blood flow using three-dimensional (3D) power Doppler. PATIENTS AND METHODS: Forty-four patients with symptomatic uterine myomas warranting surgical treatment were randomized to either receive absorbable cervical tourniquets group 1 or not group 2. Resistance index, pulsatility index, and peak systolic velocity of the uterine artery as well as 3D power Doppler study of uterine vascularity in terms of VI, FI, vascularization flow index (VFI) were performed preoperatively and at 1 and 3 months, postoperatively. Estimated myoma and uterine volume, operative time were compared in both groups. RESULTS: No significant difference in the characteristics of myomas, regarding number, size, and location of the largest myoma, between the two studied groups. No significant differences between the two groups for uterine artery RIs, PIs, and PSV at 1 and 3 months, postoperatively. The myometrial VI, FI and VFI in the study group were comparable to those in the control group. No sequential change in FI was noted in either group. CONCLUSION: Absorbable cervical tourniquet during open myomectomy did not compromise uterine perfusion as evaluated by 3D power Doppler study.

Effect of umbilical vein blood flow on perinatal outcome of fetuses with lean and/or hypo-coiled umbilical cord.

OBJECTIVE: To evaluate the effect of umbilical vein (UV) blood flow measured by color-directed pulsed-wave Doppler on perinatal outcome of fetuses with lean and/or hypocoiled umbilical cord after 24 weeks of gestation. METHODS: Two hundred and forty-four women with singleton fetus after 24 weeks of gestation were studied. Umbilical cord area, umbilical vessel cross-sectional area and antenatal umbilical coiling index (UCI) were calculated and compared with Doppler parameters including UV blood flow volume in ml/min/kg, UV peak systolic velocity in cm/s, and umbilical artery pulsatility index. RESULTS: Thirty-eight (15.5%) fetuses had lean umbilical cord (area < 10th percentile). A significant difference between fetuses with and those without lean cord was found in terms of: UCI (0.17 ± 0.06 vs. 0.35 ± 0.08, P < 0.001), cord cross-sectional area (89.6 ± 11.7 vs. 198.7 ± 33.7 mm(2), P < 0.001), Wharton's jelly amount (36.5 ± 11.2 vs. 125.2 ± 34.1 mm(2), P < 0.001), UV blood flow (83.4 ± 15.8 vs. 131.0 ± 19.8 ml/min/kg, P < 0.001), and UV blood flow mean velocity (8.6 ± 3.7 vs. 12.1 ± 2.8 cm/s, P < 0.05). A significant positive correlation was found between antenatal UCI and UV blood flow (r = 0.73, P < 0.001). CONCLUSION: Fetuses with lean and/or hypo-coiled umbilical cord showed a noticeable decrease in UV blood flow of sufficient magnitude that could affect fetal growth, and this could explain the higher prevalence of fetal intrapartum complications in growth-restricted fetuses.

Is genetic polymorphism of ER-α, CYP1A1, and CYP1B1 a risk factor for uterine leiomyoma?

INTRODUCTION: Uterine leiomyoma is the most common benign smooth muscle tumor. OBJECTIVE: This study was carried out to evaluate the association of ER-α, CYP1A1, and CYP1B1 polymorphisms with uterine leiomyoma in Egyptian women. METHODS: The study population consisted of 160 patients with uterine leiomyoma and 100 healthy women as control. The genetic polymorphisms for ER-α MSP1 exon 1, CYP1B1 Leu432Val, and CYP1A1 Ile462Val were analyzed by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) and DNA sequencing methods. RESULTS: There were no statistically significant differences in the overall associations between the ER-α exon I CT genotypes and uterine leiomyoma (P = 0.47). However, an elevated risk of uterine leiomyoma was observed among women with the CYP1A1 Ile462Val AG genotype (P = 0.07) and CYP1B1 Leu 432Val C/C genotype (P = 0.08). CONCLUSION: We concluded that the carriage of CYP1A1 Ile462Val AG and CYP1B1 Leu 432Val CC genotypes predict the susceptibility to leiomyoma in Egyptian women and they are likely to contribute in the pathogenesis of leiomyoma.

Effect of laparoscopic ovarian drilling on vascular endothelial growth factor and ovarian stromal blood flow using 3-dimensional power Doppler.

OBJECTIVE: To determine, by using 3-dimensional power Doppler ultrasonography, the effect of laparoscopic ovarian drilling (LOD) on the serum level of vascular endothelial growth factor (VEGF) and ovarian stromal blood flow changes in polycystic ovary syndrome (PCOS). METHODS: A prospective controlled clinical study was conducted on 26 clomiphene-resistant women with PCOS who were scheduled for LOD and a control group of 22 fertile regularly menstruating women. VEGF and 3 ovarian Doppler indices-vascularization index, flow index, and vascularization flow index-were measured and compared between the 2 groups, and before and after LOD in the PCOS group. RESULTS: Serum VEGF and the Doppler indices of ovarian stromal blood flow were significantly higher in the PCOS group than in the control group. Serum VEGF and the ovarian stromal blood flow Doppler indices were significantly reduced in the PCOS group after LOD. CONCLUSION: Increased vascularity in PCOS demonstrated by Doppler blood flow measurements might be explained by the high level of VEGF. LOD reduced ovarian vascularization and serum VEGF.

Does cervical length and the lower placental edge thickness measurement correlates with clinical outcome in cases of complete placenta previa?

OBJECTIVES: To evaluate the effectiveness of cervical length and the lower placental edge thickness measurement in predicting the risk of antepartum hemorrhage (APH) and emergency preterm cesarean delivery in women with complete placenta previa. METHODS: Fifty-four cases with confirmed diagnosis of complete placenta previa in third-trimester were subjected to transvaginal sonographic measurement of cervical length and lower placental edge thickness and correlated this to clinical outcome with regards to gestational age at delivery, ante partum hemorrhage, emergency cesarean section before 36 weeks due to massive hemorrhage and neonatal birth weight. RESULTS: Antepartum bleeding and emergency cesarean section rate before 36 weeks due to massive bleeding were significantly higher in cases with thick lower placental edge or central placenta than cases with thin lower placental edge [16 cases (53.3%) vs. 5 cases (20.8%)] for the former and [14 cases (46.6%) vs. 4 cases (16.6%) for the later]. Antepartum bleeding was observed in 18 cases (51.4%) when cervical length measurements ≤30 mm of whom 16 cases (88.9%) had showed severe attack necessitated emergency cesarean delivery before 36 weeks versus 4 cases (21.1%) with cervical length ≥30 mm. By combining cervical length with lower placental edge thickness measurement sensitivity, specificity, positive predictive value (PPV) negative predictive value (NPV) and accuracy increased to 83.3, 78.4, 53.4, 79.8 and 89.7%, respectively for the prediction of antepartum bleeding and emergency cesarean section <36 weeks using receiver-operating characteristics curve with area under the curve 0.882. CONCLUSION: Short cervical length at cut-off value ≤30 mm and increased lower placental edge thickness measurements may predict with high accuracy the risk of APH and emergency preterm cesarean delivery in patients with complete placenta previa.

Cell-free placental mRNA in maternal plasma to predict placental invasion in patients with placenta accreta.

OBJECTIVE: To evaluate whether measuring cell-free placental mRNA in maternal plasma improves the diagnostic accuracy of ultrasound and color Doppler in detecting placental invasion in patients at risk for placenta accreta. METHODS: Thirty-five singleton pregnant women of more than 28 weeks of gestation and at risk for placenta accreta underwent ultrasound and color Doppler assessment. Cell-free placental mRNA in maternal plasma was measured using real-time reverse-transcription polymerase chain reaction. Patients were classified into 2 groups based on the findings at cesarean delivery and histological examination: women with placenta accreta (n=7) and women without placenta accreta (n=28). RESULTS: The median MoM (multiples of the median) value of cell-free placental mRNA was significantly higher in patients with placenta accreta than in those without placenta accreta (6.50 vs 2.60; P<0.001. Moreover, cell-free placental mRNA was significantly elevated in patients with placenta increta and percreta than in those with simple accreta. Six false-positive results were found on ultrasound, all from patients without placenta accreta and an insignificant rise in cell-free placental mRNA levels. CONCLUSION: Measuring cell-free placental mRNA in maternal plasma may increase the accuracy of ultrasound and color Doppler in prenatal prediction of placental invasion in patients with suspected placenta accreta.

Diagnostic accuracy of uterine fluid lactate dehydrogenase isoenzyme activity profile and vaginal ultrasound in detecting endometrial cancer in women with postmenopausal bleeding.

OBJECTIVE: To evaluate the diagnostic accuracy of lactate dehydrogenase (LD) isoenzyme activity profile in uterine fluid and transvaginal ultrasound (TVS) in detection of endometrial cancer in women with postmenopausal bleeding. STUDY DESIGN: Prospective controlled clinical study. METHODS: One hundred twenty postmenopausal women with one or more episode of vaginal bleeding were studied. Endometrial thickness was classified as >5 mm or <5 mm on TVS. LD isoenzyme activity profile was described as normal or abnormal. LD isoenzyme profile was subsequently related to histopathological diagnosis. RESULTS: Endometrial carcinoma was found in 10 out of 120 patients (8.3%). Sixty-seven patients (56%) were found to have endometrium >5-mm thickness on TVS. LD isoenzyme activity profile was abnormal in 22 (18.3%) cases. Histopathological diagnosis in these cases revealed 10 endometrial cancer and 12 benign endometrium. LD isoenzyme activity profile has 100% sensitivity, 90.1% specificity, 45.4% positive predictive value, 100% negative predictive value, and 88.6% accuracy. CONCLUSION: LD isoenzyme profile of uterine fluid could be added as a marker for endometrial cancer in postmenopausal women with vaginal bleeding and endometrial thickness >5 mm on transvaginal ultrasound. Uterine fluid sampling is easy, highly reliable, minimally invasive, with high patient compliance, and can be performed as an office procedure. Furthermore, this method is insensitive to endometrial thickness, amount of sample, sampling device, and dilution.

Angiogenic factors for the prediction of pre-eclampsia in women with abnormal midtrimester uterine artery Doppler velocimetry.

OBJECTIVE: To determine whether assessing uterine perfusion and angiogenic factors concurrently in the second trimester improves the prediction of pre-eclampsia and intrauterine growth restriction (IUGR). METHOD: Plasma levels of soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) were measured for 108 women with abnormal uterine perfusion on Doppler velocimetry in the 23rd week. Later, 33 cases of pre-eclampsia and 9 of IUGR developed. RESULTS: Compared with the plasma levels of the women whose pregnancies remained normal, sFlt-1 levels were significantly higher and PlGF levels significantly lower in the women whose pregnancies became complicated by pre-eclampsia and/or IUGR (P<0.001). The alterations were more pronounced in cases of early-onset pre-eclampsia and in cases of IUGR that necessitated delivery before 34 weeks. Using the sFlt-1/PlGF ratio, these complications could be predicted with 98% sensitivity, 95% specificity, and 93% positive predictive value. CONCLUSION: Measuring uterine perfusion and angiogenic factors concurrently in the second trimester improved the prediction of pre-eclampsia and IUGR.