Levonorgestrel-Releasing Intrauterine System: A Promising Choice after Uterovaginal Anastomosis in Patients with Cervical Dysgenesis.

BACKGROUND: Cervical dysgenesis is categorized into cervical fragmentation, cervical fibrous cord, and cervical obstruction. The definitive management for cervical dysgenesis is either uterovaginal anastomosis (UVA) or hysterectomy. OBJECTIVE: To compare the prevalence of dysmenorrhea, hematometra, and need for dilatation after UVA with and without postprocedural placement of a levonorgestrel intrauterine system (LNG-IUS). METHODS: This was a retrospective cohort study in which 14 patients with cervical dysgenesis were included. Patients had undergone UVA between May 2015 and January 2022 at the Department of Obstetrics and Gynecology of the Cairo University Teaching Hospital. Six patients who had an LNG-IUS inserted after UVA were included in group A, and 8 patients who had undergone UVA without LNG-IUS insertion were included in group B. Transabdominal and/or transvaginal ultrasound was performed monthly for the first 3 months after LNG-IUS insertion in group A and after UVA in group B. Thereafter, the patients were followed up every 6 months. The primary outcomes were dysmenorrhea, hematometra, and need for dilatation of the anastomosis site. RESULTS: The number of patients who developed hematometra was significantly lower in group A than in group B (0 [0%] vs 6 [75%], P = .01). The number of patients who required dilatation was significantly lower in group A than in group B (0 [0%] vs 6 [75%], P = .01). There was no significant difference in the incidence of dysmenorrhea between the 2 groups. CONCLUSION: We recommend offering LNG-IUS after UVA for adolescents who present with cervical dysgenesis. LNG-IUS decreases the recurrence of hematometra and subsequent surgical interventions.

Utero-vaginal anastomosis in cases of cervical malformations: long-term follow-up and fertility challenges.

PURPOSE: To study the long-term results of utero-vaginal anastomosis in cases of cervical malformations. METHODS: This is a retrospective cohort study. Nine patients presented with cryptomenorrhea due to cervical malformations (5 patients with cervical agenesis and vaginal aplasia, 2 patients with cervical agenesis and upper vaginal aplasia, and two patients with cervical dysgenesis in form of cervical obstruction). Five patients had utero-vaginal anastomosis (UVA) with McIndoe vaginoplasty. Four patients had UVA without vaginoplasty. Follow-up was done by transabdominal and/or transvaginal ultrasound monthly for the first 3 months then every 6 months thereafter for a duration that ranged from 15 to 82 months. The main outcome measures are achieving menstruation, dysmenorrhea, pelvic inflammatory disease (PID), needed interventions after primary surgery, infertility, and pregnancy rate. RESULTS: Nine (100%) patients achieved menstruation, one (12%) experienced severe dysmenorrhea, two (22%) had PID, seven (78%) needed dilatation of the anastomosis site, three (33%) needed reoperation, nine (100%) had primary infertility, two (28.5%) achieved clinical pregnancy, and only one (14%) ended by live birth. CONCLUSION: Conservative surgery for cervical malformation is a promising choice for relieving the obstructive symptoms. Regular dilatation is recommended. Pregnancy is a remote hope that is hindered by many challenges.

Evaluation of gastric contents using ultrasound in full-term pregnant women fasted for 8 h: a prospective observational study.

BACKGROUND: We aimed to evaluate the gastric volume and contents after an 8-h fasting period in full-term, non-laboring, pregnant women following a standardized meal. METHODS: In this prospective observational study, we included full-term pregnant women scheduled for elective cesarean delivery. The participants were instructed to fast after a standardized meal (apple juice, bread, and cheese). Participants were scanned in the semi-recumbent and right-lateral positions 8 h after the standardized meal. The primary outcome was the proportion of patients with gastric volume > 1.5 mL kg-1 calculated by two equations. Secondary outcomes included the antral cross-sectional area and gastric volume. Data are expressed as frequency (%, 95% confidence interval [CI]), mean ± standard deviation (95% CI of the mean), or median (quartiles) as appropriate. RESULTS: Forty-one women were available for the final analysis. For the primary outcome, one participant (2.4%, 95% CI of 0.06 to 12.8%) had gastric volume > 1.5 mL kg-1, and none had solids in the antrum. For the secondary outcomes, the mean (95% CI of the mean) of the antral cross-sectional area was 2.11 ± 0.72 (1.88 to 2.34) cm2 and 4.08 ± 1.80 (3.51 to 4.65) cm2 during the semi-recumbent and right-lateral position, respectively. The median (quartiles) gastric volume was 0.53 (0.32, 0.66) mL kg-1 and 0.33 (0.13, 0.52) mL kg-1 as estimated by Perlas et al. and Roukhomovsky et al. equations, respectively. CONCLUSION: After 8-h fasting following a standardized meal, full-term pregnant non-laboring women are less likely to have a high residual gastric volume.

Accuracy of noninvasive blood pressure measured at the ankle during cesarean delivery under spinal anesthesia.

In this study, we evaluated the accuracy of oscillometric noninvasive blood pressure (NIBP) measured at the ankle in detecting low arm NIBP during cesarean delivery under spinal anesthesia. In this prospective observational study, a cohort of full-term mothers undergoing elective cesarean delivery under spinal anesthesia was examined. Simultaneous NIBP measurements were obtained from the arm and the ankle. The primary outcome was the accuracy of the ankle NIBP in detecting arm systolic blood pressure (SBP) < 90 mmHg. Other outcomes included the accuracy of ankle NIBP in detecting SBP < 80% of the baseline value. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the accuracy of ankle NIBP in detecting low arm NIBP. The Bland-Altman analysis was conducted to evaluate the agreement between values. We analyzed 1729 pairs of readings obtained from 97 mothers. Ankle SBP showed good accuracy in detecting SBP < 90 mmHg, with an AUC (95% confidence interval [CI]) of 0.90 (0.89-0.91) and a negative predictive value (NPV) of 99 (98-99%) at a cutoff value of ≤ 103 mmHg. Furthermore, ankle SBP showed good accuracy in detecting SBP < 80% of the baseline value, with an AUC (95% CI) of 0.84 (0.82-0.89) and an NPV of 95 (93-96%) at a cutoff value of ≤ 76% of the ankle baseline SBP. The mean bias between the two sites of measurement was - 5.4 ± 15.5, - 2.0 ± 11, and 0.5 ± 12.1 mmHg for SBP, diastolic blood pressure, and mean arterial pressure, respectively. In conclusion, ankle NIBP measurement is not interchangeable with arm NIBP measurement. However, ankle NIBP measurement showed good accuracy for ruling out low arm NIBP during a cesarean delivery.Clinical trial rejistration: NCT04199156.

Hemodynamic effects of lateral tilt before and after spinal anesthesia during cesarean delivery: an observational study.

BACKGROUND: Post-spinal hypotension is a common maternal complication during cesarean delivery. Aortocaval compression by the gravid uterus has been assumed as a precipitating factor for post-spinal hypotension. The role of left lateral tilting position in improving maternal cardiac output after subarachnoid block (SAB) is unclear. The aim of this work is to investigate the effect of left lateral tilting on maternal hemodynamics after SAB. METHODS: A prospective observational study was conducted including 105 full term pregnant women scheduled for cesarean delivery. Mean arterial pressure, heart rate, cardiac output (measured by electrical cardiometry), stroke volume, and systemic vascular resistance were recorded in three positions (supine, 150, and 300 left lateral positions) before SAB, after SAB, and after delivery of the fetus. RESULTS: Before SAB, no significant hemodynamic changes were reported with left lateral tilting. A significant decrease was reported in mean arterial pressure, cardiac output, stroke volume, and systemic vascular resistance after SAB (in supine position). When performing left lateral tilting, there was an increase in cardiac output, heart rate, and mean arterial pressure. No difference was reported between the two tilt angles (150 and 300). CONCLUSIONS: Changing position of full term pregnant woman after SAB from supine to left lateral tilted position results increased cardiac output and mean arterial pressure. There is no difference between the two tilt angles (150 and 300). TRIAL REGISTRATION: clinicaltrials.gov ( NCT02828176 ) retrospectively registered.

Leg elevation decreases the incidence of post-spinal hypotension in cesarean section: a randomized controlled trial.

BACKGROUND: Maternal hypotension is a common complication after spinal anesthesia for cesarean section (CS). In this study we investigated the role of leg elevation (LE) as a method for prevention of post-spinal hypotension (PSH) for cesarean section. METHODS: One hundred and fifty full term parturients scheduled for CS were included in the study. Patients were randomized into two groups: Group LE (leg elevation group, n = 75) and group C (Control group, n = 75). Spinal block was performed in sitting position after administration of 10 mL/Kg Ringer's lactate as fluid preload. After successful intrathecal injection of local anesthetic, Patients were positioned in the supine position. Leg elevation was performed for LE group directly after spinal anesthesia and maintained till skin incision. Intraoperative hemodynamic parameters (Arterial blood pressure and heart rate), intra-operative ephedrine consumption, incidence of PSH, and incidence of nausea and vomiting were reported. RESULTS: LE group showed lower incidence of PSH (34.7% Vs 58.7%, P = 0.005) compared to the control group. Arterial blood pressure was higher in the LE group compared to the control group in the first two readings after spinal block. Other readings showed comparable arterial blood pressure and heart rate values between both study groups; however, LE showed less ephedrine consumption (4.9 ± 7.8 mg Vs 10 ± 11 mg, P = 0.001). CONCLUSION: LE performed immediately after spinal block reduced the incidence of PSH in parturients undergoing CS. TRIAL REGISTRATION: The study was registered at Pan African Clinical Trials Registry system on 5/10/2015 with trial number PACTR201510001295348 .

Uroflowmetric changes, success rate and complications following Tension-free Vaginal Tape Obturator (TVT-O) operation in obese females.

OBJECTIVE: The goal of this study was to evaluate the outcome of Tension-free Vaginal Tape Obturator (TVT-O) operation in the treatment of urodynamic stress incontinence (USI) in obese females, with respect to uroflowmetric changes, success rate and postoperative complications. METHODS: This prospective observational study included 26 patients with USI at the Obstetrics & Gynecology department-Cairo University hospital during the year 2015. The participants had body mass index (BMI)≥30. Patients underwent TVT-O operation. Follow up of the patients was performed by cough test and uroflowmetry after one week, one month, three months and six months. Postoperative complications such as groin pain, sense of incomplete emptying, need to strain to complete micturition and urinary tract infection were recorded. Comparisons between groups were done using Chi square, Phi-Cramer test for categorical variables. RESULTS: The mean age for the subjects was 43.58±9.01years. The mean BMI was 33.4±2.1. The success rate of TVT-O operation was 21 out of 26 patients (≈81%). Normal maximum flow rate was in 88% of patients at week one and was normal in 100% of patients at months three and six (p=0.101 & 0.101). Postoperative groin pain was the main complaint during the first week after operation and decreased significantly from week one to the 1st month postoperative (84.62% & 65.38%, P=0.041). CONCLUSION: TVT-O operation showed a high success rate in treatment of USI in obese patients without affecting the voiding function of the bladder as proven by the uroflowmetry. The main postoperative complaint was the groin pain which significantly improved after one month.

Amino acid chelated iron versus an iron salt in the treatment of iron deficiency anemia with pregnancy: A randomized controlled study.

OBJECTIVE: The aim of this study was to compare the efficacy and tolerability of iron amino acid chelate (IAAC) and ferrous fumarate (FF) in treatment of iron deficiency anemia (IDA) with pregnancy. STUDY DESIGN: A total of 150 pregnant women having iron deficiency anemia (IDA) were randomized to receive either IAAC or FF for 12 weeks. Hemoglobin, red cell indices, serum iron, and serum ferritin were measured at baseline and then 4, 8, and 12 weeks after treatment. Adverse effects were questioned in both groups. RESULTS: The mean values of hemoglobin, red cell indices, serum iron, and serum ferritin were not significantly different between both groups after 12 weeks of treatment. However, the rise in hemoglobin level after 4, 8, and 12 weeks of treatment was significantly faster in the IAAC group (p=<0.001). Constipation and abdominal colicky pain were significantly more common in the FF group (p=0.022 and 0.031 respectively). CONCLUSION: IAAC and FF are comparable in curing IDA with pregnancy; however, IAAC has the advantage of providing a faster rate of improvement of hemoglobin level and is better tolerated by the patients.

Caesarean scar pregnancy: hysterotomy is rapid and safe management option.

Caesarean scar pregnancy (CSP) is implantation of the gestational sac within the hysterotomy scar. Ultrasound is the main diagnostic tool. Early diagnosis and termination of pregnancy is crucial to avoid the risk of uterine rupture. The termination modalities available are dilatation and curettage, methotrexate therapy, hysteroscopy, uterine artery embolization and laparotomy. We present a case of undisturbed CSP which presented at 6 weeks + 6 days gestation. Our management was termination of pregnancy by exploratory laparotomy and hysterotomy for excision of the mass. The postoperative period was uneventful and there was rapid decline of beta human chorionic gonadotrophin to the normal level.