Maternal, Perinatal, and Neonatal Outcomes of COVID-19 Severity in Pregnant Women: A Retrospective Study from Oman.

Objectives: To evaluate the effect of COVID-19 severity on maternal, perinatal, and neonatal outcomes in pregnant women infected with SARS-CoV-2. We also aimed to assess the effect of medical comorbidities on the severity of COVID-19. Methods: A retrospective cohort study was conducted on women who became infected with SARS-CoV-2 during pregnancy and delivered at Sultan Qaboos University Hospital, Oman, from 1 March 2020 to 31 December 2021. Results: A total of 118 pregnant women with COVID-19 and their 118 newborns were included in the study. Mean maternal age was 32.0 years, with 60.2% of women infected in the third trimester. The majority of the participants had mild symptoms. Eleven (9.3%) women had moderate infection needing inpatient care. Six (5.1%) with severe infection were admitted to intensive care unit. The chronic diseases among the participants were hypothyroidism, obesity, sickle cell disease, epilepsy, and diabetes. The mean gestational age at delivery was 37.0 weeks with 20.9% of women delivering by cesarean section out of whom 37.5% had moderate-to-severe COVID-19. The most common complications associated with COVID-19 severity were preterm labor (p =0.002), preeclampsia (p =0.002), and intrauterine fetal death (p =0.089). Of the total 118 newborns, 111 were singletons and six were twins. One fetus died and three singletons were lost to miscarriage. Placental histopathology conducted in 64 patients had no COVID-specific findings in most cases. Conclusions: Most pregnant women with COVID-19 infections had mild symptoms. The majority of women with moderate-to-severe infection were admitted for COVID-19 pneumonia. There was no direct effect of COVID-19 severity in neonatal outcomes or placental histopathology changes.

Are There Predictors of Early Diagnosis of Endometriosis Based on Clinical Profile? A Retrospective Study.

Objectives: Significant delays occur in referring cases for care of endometriosis, despite women suffering for years. This study was conducted to assess whether there is a specific symptom profile characteristic of endometriosis to alert physicians for earlier referrals. Methods: In this retrospective observational cohort study, patient data of the women who attended Sultan Qaboos University Hospital from January 2011 to December 2019 with a diagnosis of endometriosis was collected from the hospital's electronic data archive and analyzed. Results: Cases of N = 262 endometriosis patients were studied. The diagnosis was surgical in 198 (75.6%) of patients and the remaining 64 (24.4%) were diagnosed by clinical assessment and imaging. The mean age at diagnosis was 30.7±6.8 years (range = 15-51). The presence of ovarian endometrioma on ultrasound served as an alert for earlier referral. The mean age at diagnosis for those who had an endometrioma was 30.3±6.7 years and 32.4±7.1 years for those without an endometrioma without a significant difference. The mean age at diagnosis for those who did not have pain was 31.2 years and those with pain was 30.0 years (p =0.894; CI: -2.58-2.91). Among the 163 married women in the sample, 88 (54.0%) had primary infertility, and 31 (19.0%) had secondary infertility. There was no significant difference between the groups in the mean age at diagnosis (analysis of variance test; p =0.056). Over the nine-year period, diagnosis was made at progressively younger ages (p =0.047). Conclusions: Based on this study, no specific symptom profile appears to predict an early diagnosis of endometriosis. However, over the years the diagnosis of endometriosis is made earlier likely due to increasing awareness of women and their physicians about the disease.

Parental consanguinity and ovarian reserve: A retrospective cohort study.

Background: Infertility affects around 10-15% of couples worldwide and is both a social and medical problem. Parental consanguinity is considered to reduce fertility reserve. Consanguineous marriages, especially first cousin marriages, are very common in Oman according to the Oman National Health Survey data. Objective: This study aimed to determine whether women born to consanguineous parents have reduced ovarian reserve. Materials and Methods: This cohort study was conducted on 414 women aged ≤ 39, treated for infertility at Sultan Qaboos University hospital and Royal hospital, Muscat, Oman from January 2019-December 2020. Each participant was interviewed and a complete history, including parental consanguinity and physical examination, were recorded. On day 2 of the menstrual cycle, serum concentration of the following was performed: follicle-stimulating hormone (FSH), luteinizing hormone, estradiol, prolactin, thyroid stimulating hormone, and anti-Müllerian hormone (AMH). AMH was done, if necessary, on other days of the cycle. Antral follicle count (AFC) was done on day 2 and 3 of the menstrual cycle. Results: Of the 414 women, parental consanguinity was present in 40.2% of couples. In women with low AFC, parental consanguinity was present in 15.3% compared to 13.0% in the non-consanguineous group. About 15% of women with low AMH had consanguineous parents, compared to 20.2% from the non-consanguineous group. High levels of FSH were present in 6.5% and 4.2% of the consanguineous and non-consanguineous groups, respectively. No significant difference was observed in AFC with reference to body mass index. Conclusion: The results from this study showed no statistically significant difference in low ovarian reserves (AFC, AMH, and FSH) in women whose parents had a consanguineous marriage.

The Success of Ovulation Induction with Letrozole and Gonadotropins in Obese and Nonobese Women: A Study from a Tertiary Center.

Background: Letrozole, an aromatase inhibitor, is suggested as a first-line drug for ovulation induction in women with polycystic ovary syndrome (PCOS) especially in obese women. Letrozole has also been used in women with unexplained infertility with similar rates of success to clomiphene. However, literature on letrozole and gonadotropins in obese and nonobese women is sparse. Hence, this study was done to assess the success of ovulation induction (OI) with letrozole plus follicle stimulating hormone (FSH) in obese (BMI ≥ 30 kg/m2) and nonobese women (BMI < 30 kg/m2). Methods: A retrospective descriptive cohort study was conducted involving 135 women who underwent OI with letrozole plus follicle stimulating hormone therapy and either timed intercourse or intrauterine insemination. The data was collected from the hospital information system, including the age, body mass index, the type of infertility, number of induction cycles with letrozole, number of gonadotropin injections, and the pregnancy occurrence following treatment. SPSS was used to analyze the data. Results: There were 135 women who used FSH injections along with letrozole. Of this, 28.5% obese women got pregnant compared to 29.2% nonobese women, but this did not attain statistical significance (P = 0.75). About 70% of obese women and 57% on nonobese women had polycystic ovarian syndrome. The median number of FSH injections was six, and the interquartile range was 3 to 11. Conclusion: Of the 135 women undergoing letrozole and FSH, there was almost an equal probability of pregnancy in the obese group (BMI ≥ 30 kg/m2) and nonobese women.

Fertility-Sparing Treatment in Young Women with Atypical Endometrial Hyperplasia and Low-Grade Endometrial Cancer: A Tertiary Center Experience.

OBJECTIVES: To evaluate the oncologic and reproductive outcomes of patients with atypical endometrial hyperplasia and low grade stage 1 endometrial cancer who received medical treatment. METHODS: We carried out a retrospective study on all patients aged 20-42 years with complex, atypical endometrial hyperplasia, and low-grade stage 1 endometrial cancer, who wished to preserve fertility and were treated at the Royal Hospital. We held this study between January 2006 and December 2016. The patients received oral megestrol acetate with or without a levonorgestrel intrauterine system. We assessed their response to progestin treatment in terms of treatment duration, time to response, pregnancy, time of surgery, and oncological outcome. We performed the statistical analysis using the SPSS 20.0 software. RESULTS: Twenty patients met the inclusion criteria, and among them 90% had complete remission. Among these 90%, 55% had complete remission within six months of treatment. The recurrence rate was recorded in 11 patients (55%) and it was more frequent in obese patients with body mass index (BMI) ≥30 (p=0.001), who had complete response in > 6 months of hormonal treatment. About 15% of the patients required hysterectomy, and 12 (60%) patients conceived after full treatment. CONCLUSIONS: Fertility-sparing treatment of atypical endometrial hyperplasia and grade 1 stage 1 endometrial cancer in reproductive-age women is feasible. However, obese patients (BMI ≥ 30) had a higher recurrence rate.

Vaginal Myomectomy for Prolapsed Submucous Fibroid: It is Not Only About Size.

Leiomyoma of the uterus, also called fibroids, are common in women. In this case report, we describe the case of a nulliparous woman with a large, prolapsed submucous uterine leiomyoma of 10 × 11 cm was vaginally impacted. The aim is to highlight the challenges in managing such uncommon clinical scenario focusing on the factors predicting the success of vaginal myomectomy including the size of the myoma but also the role of vaginal laxity to allow the steps of devascularization, detachment, and removal of the myoma. We also describe the preoperative and intraoperative methods that can be used to minimize intraoperative blood loss and enhance the safety and feasibility of the surgical procedure. Gonadotropin therapy was not applicable in our patient, and other treatments were also unavailable such as temporary ligation of uterine arteries, while others were unsuccessful like devascularization by hysteroscopy, twisting, and ligation of the pedicle. The final resort used in our case was morcellation of the myoma with intact pedicle, which should be attempted by experienced gynecologic surgeons only.

Obstetrics and Gynaecology as a Future Career for Medical Graduates in Oman: Factors that attract and discourage graduates.

OBJECTIVES: Obstetrics and gynaecology (OBGYN) is a major speciality in the medical field that is often demanding yet rewarding; however, OBGYN receives the least number of applicants in Oman. This study aimed to determine the factors that influence graduates in choosing OBGYN as their speciality. METHODS: This cross-sectional questionnaire-based study was conducted from February to March 2017 at Sultan Qaboos University Hospital, Royal Hospital, Khoula Hospital and Al Nahdha Hospital, Muscat, Oman. The questionnaire was distributed to 150 Omani medical graduates (interns and post-intern doctors). RESULTS: A total of 145 Omani graduates took part in the study (response rate: 96.7%) and the participants' average age was 26 years. Family medicine ranked as the first choice followed by paediatrics and emergency medicine. OBGYN was the first choice for eight female graduates. The top factors attracting male graduates to the OBGYN speciality were its surgical opportunities (80.6%), intellectual content (77.4%), faculty interactions and the opportunity to care for a healthy population (54.8% each); however, the top factors attracting females were the intellectual content (88.6%), patients' desire for female physicians (85.1%), the opportunity to care for a healthy population (76.3%) and cultural expectations (69.5%). The most discouraging factors for male graduates were cultural expectations (100%), the patients' desire for a female physician (93.5%) and the level of stress (71%), while the discouraging factors for female graduates were the level of stress (82.5%), time demands (78.1%), night duties and the length of the residency (71.9% each). CONCLUSION: Most of the factors that discourage female graduates from choosing OBGYN are to some extent modifiable. These changes should be considered to encourage the selection of OBGYN as a career by medical students.

Trends of Patients' Preferences in the Management of First and Early Second Trimester Pregnancy Loss Towards the Choice of Medical or Surgical Termination of Pregnancy in a Tertiary Care Center in Oman.

BACKGROUND: This study aimed to find out the patients preference towards the management of pregnancy loss to either Misoprostol or dilatation and evacuation or curettage (D&C) in two different study periods. METHODS: Retrospective chart review study included a total of 411 patients. The first study period was January to December 2010 and the second study period was January to December 2014. All patients were managed in Sultan Qaboos University Hospital of Oman. RESULTS: Misoprostol was more preferable than dilatation and curettage D&C in both 2010 and 2014, with percentages of 79.30% and 69.57%, respectively. There was a slight increase in the preference toward D&C in 2014. There was a slight increase in the preference toward D&C with older age group as well as in patients with history of miscarriages. CONCLUSION: In comparison between 2010 and 2014 data, there was no significant change in patients' preference. There was a slight increase in the preference toward D&C in the older age group and in patients with previous history of abortion in both years.

Red Cell Alloimmunization to Rhesus Antigen Among Pregnant Women Attending a Tertiary Care Hospital in Oman.

OBJECTIVES: The detection of maternal alloimmunization against red cell antigens is vital in the management of hemolytic disease of the fetus and newborn. We sought to measure the presence of allosensitization to Rhesus D (RhD) antibodies in antenatal women attending a tertiary care hospital and assess the fetal outcome in sensitized women. METHODS: We conducted a retrospective review of pregnant Omani women who registered at the Sultan Qaboos University Hospital between June 2011 and June 2013. Pregnant women were tested for ABO blood type and were screened for RhD antigen and antibodies at their first antenatal clinic visit. In women who tested positive for the RhD antibodies, an antibody titer was performed to evaluate the severity of their case. RESULTS: Data was available on 1,251 pregnant women who were managed and delivered at Sultan Qaboos University Hospital. The prevalence of RhD negative pregnant women was 7.3%. Blood group O was the most common followed by A, B, and AB. The rate of RhD negative alloimmunization was 10%, and anti-D was the most common antibody detected. There were no stillbirths or neonatal deaths. Postnatal transfusion was necessary for only one baby. CONCLUSIONS: The prevalence of RhD negativity was comparable to other Asian countries. Previous RhD alloimmunization and history of miscarriages were the most common maternal medical history.

Alloimmunization due to red cell antibodies in Rhesus positive Omani Pregnant Women: Maternal and Perinatal outcome.

OBJECTIVE: This study is aimed to determine the prevalence of alloimmunization due to antibodies to red blood cell (RBC) antigens (other than rhesus [Rh] antigen) and report the maternal, perinatal, and neonatal outcomes. MATERIALS AND METHODS: A retrospective review of medical records of all patients with minor RBCs antibodies alloimmunization who were followed and delivered at Sultan Qaboos University Hospital, Oman from June 2011 to June 2013. Maternal characteristics, antibody type, antibody titer in addition to perinatal and neonatal outcomes were reviewed. RESULTS: There were 1160 patients with Rh positive status in the study. The most common ABO blood group was O, followed by A, B, and AB. We found 33 out of 1160 Rh positive women alloimmunized with minor RBCs antibodies that gave a prevalence of minor RBCs alloimmunization of 2.7%. The most frequent antibody was anti-E 38%, followed by anti-c 17% and anti-kell 17%. 6 of these 33 patients were identified to have significant antibody titer, and two cases showed evidence of fetal anemia. Only one case required an intrauterine blood transfusion. The most common neonatal complication was jaundice in 53%, followed by respiratory distress syndrome in 28%. Two cases complicated by neonatal anemia required a postnatal blood transfusion. CONCLUSION: Alloimmunization with anti-E, anti-c, and anti-kell were the most common antibodies among the study group. Minor RBCs alloimmunization was an important cause of neonatal morbidity.

Antenatal prevalence of fear associated with childbirth and depressed mood in primigravid women.

AIM: To investigate the antenatal prevalence of fear of childbirth and its association with depressed mood in low-risk primigravidae in a referral teaching hospital. SETTINGS AND DESIGN: The study was conducted in a tertiary referral center catering to three districts in the state of Kerala. This was a cross-sectional study with internal comparison of associated factors. MATERIALS AND METHODS: Malayalam translation (translation back translation) of Edinburgh Postnatal Depression Scale (EPDS) was self-administered by the participants. It was followed by a structured interview based on the International Classification of Diseases 10 (ICD 10) after which the EPDS scale was scored. STATISTICAL ANALYSIS: Chi-square test was used to compare the presence of fear in women with a EPDS of ≥ 12 and the association of fear and depression. RESULTS: Fear associated with childbirth was expressed by 17.7% women. The prevalence of depressed mood based on the EPDS (score > 12) was 9.8% but based on the ICD 10 criteria, the prevalence of depression was 8.7%. A significant number of women with depressed mood and clinical depression had fear of childbirth of some sort. CONCLUSIONS: A significant number of primigravid women with depressed mood and clinical depression had fear of childbirth of some sort.

Aetiological profile of women presenting with premature ovarian failure to a single tertiary care center in Oman.

BACKGROUND: Premature ovarian failure is estimated to affect at least 1%-3% of adult women. There are several aetio-pathogenic factors that may cause premature ovarian failure including iatrogenic causes, genetic, autoimmune, infectious and idiopathic. The aim of this study was to identify the aetiological profile of women with premature ovarian failure presenting to Sultan Qaboos University hospital. METHOD: A retrospective medical record review was conducted from June 2006 to October 2012. All women diagnosed with symptoms and/or laboratory evidence of premature ovarian failure (follicle stimulating hormone ≥40 UI/L and less than 40 years of age) were enrolled in this study. Possible causes of premature ovarian failure were obtained and classified into main aetiological factors. RESULTS: There were 90 patients during the study period, of which, 39 (43%) were following chemotherapy and bone marrow transplant. The second most common reason was idiopathic (n = 29; 31%) followed by autoimmune diseases (n = 8; 9%) and genetic disorders (n = 7; 8%). Most chemotherapy cases (69%) were among the young age group, while in the older age group idiopathic was the commonest (48%). CONCLUSION: Compared to the world literature, the most common cause of premature ovarian failure in this study was chemotherapy induced, especially in young girls undergoing bone marrow transplantation. This is due to high prevalence of transplantable hereditary haematological disorders like thalassemia and sickle-cell disease in this part of the world. Current standard of care recommends cryopreservation of ovarian tissue to preserve ovarian function in young girls undergoing bone marrow transplantation for such disorders.

Etiological profile of Omani women with recurrent pregnancy loss.

OBJECTIVE: To define the different causes of recurrent pregnancy loss (RPL) among Omani women. METHODS: This retrospective study included all women with RPL seen between June 2006 and March 2012 in the RPL outpatient clinic in Sultan Qaboos University hospital, Muscat, Oman. The data were collected from the Hospital Information System by screening the electronic records of these patients. The sample size gathered during the study period was 290 women. RESULTS: One hundred and forty (48%) of the examined patients had an identifiable cause for RPL, while in 150 (52%), no cause was identified. The most common causes were immunological factors (35.4%) and the least common were environmental factors (1.7%). Other causes implicated included: chromosomal abnormalities (8%), anatomical factors (9.4%), endocrine disorders (29.8%), infectious causes (3%), and thrombotic causes (12.7%). CONCLUSION: Recurrent pregnancy loss is prevalent among Omani women. The etiological profile of RPL in Omani women is consistent with that reported elsewhere according to previously published studies, with minor variations.

Clinical and histological profile of surgically managed benign adnexal masses.

OBJECTIVE: To study the clinical and histological nature of benign adnexal masses managed surgically. METHODS: A retrospective descriptive study in a teaching hospital in Oman of all the women who had surgical management of benign adnexal masses from January 2008 to May 2012. Data pertaining to age, parity, presenting symptoms, imaging and tumor markers performed and the surgical intervention done on those women with benign adnexal masses was collected from the electronic health records of the patients. RESULTS: There were 198 women during this period operated for benign adnexal masses. The most common benign neoplasm was mature teratoma of the ovary followed by endometriosis. Conservative surgery in the form of ovarian cystectomy was necessary in three fourths of women and in about just less than 50% of women, the procedure was completed laparoscopically. CONCLUSION: The most common benign tumor was teratoma but laparoscopic approach, which is the standard of care in these women, was possible only in just about 50% of the women.

Maternal and fetal outcomes of triplet gestation in a tertiary hospital in oman.

OBJECTIVES: The aim of this study was to describe the fetal and maternal outcomes of triplet gestation and to report on the maternal characteristics of those pregnancies in a tertiary care centre in Oman. METHODS: A retrospective study was undertaken of all triplet pregnancies delivered at Sultan Qaboos University Hospital, Muscat, Oman, between January 2009 and December 2011. RESULTS: Over the three-year study period, there were 9,140 deliveries. Of these, there were 18 triplet pregnancies, giving a frequency of 0.2%. The mean gestational age at delivery was 31.0 ± 3.0 weeks, and the mean birth weight was 1,594 ± 460 g. The most common maternal complications were preterm labour in 13 pregnancies (72.2%), gestational diabetes in 7 (39%) and gestational hypertension in 5 (28%). Of the total deliveries, there were 54 neonates. Neonatal complications among these included hyaline membrane disease in 25 neonates (46%), hyperbilirubinaemia in 24 (43%), sepsis in 18 (33%) and anaemia in 8 (15%). The perinatal mortality rate was 55 per 1,000 births. CONCLUSION: The maternal and neonatal outcomes of triplet pregnancies were similar to those reported in other studies.

A stormy and rare presentation: Eclampsia at 18 weeks of gestation.

Eclampsia is an Obstetric emergency. It is uncommon in early second trimester and an early diagnosis will aid in preventing complications. We report an unusual case of eclampsia at an 18 weeks gestation with a good maternal outcome.

Effects of Pre-Pregnancy Body Mass Index and Gestational Weight Gain on Low Birth Weight in Omani Infants: A case-control study.

OBJECTIVES: This study aimed to investigate the association between pre-pregnancy maternal body mass index (BMI), gestational weight gain and low birth weight (LBW) in babies born to a sample population of Omani women. METHODS: A case-control study was carried out among deliveries registered between 1(st) May 2010 and 30(th) April 2011 at Sultan Qaboos University Hospital, Muscat, Oman. A case was defined as a woman who delivered a low birth weight baby (<2,500 g); a control was a woman delivering a baby weighing between 2,500 and 4,000 g. A random selection of 150 cases and 300 controls was carried out using the hospital information system. Maternal, pre-natal, and delivery data were extracted from the mothers' follow-up cards. Bivariate and multivariate logistic regression analyses were executed to examine the association between pre-pregnancy maternal BMI and LBW. RESULTS: The percentage of underweight mothers (BMI <18.5) was higher among the cases compared to the controls (17.3% versus 6%; P <0.001). The proportion of mothers with less-than-recommended weight gain was also higher among the cases compared to the controls (57.7% versus 33%; P <0.001). After adjustment for potential confounders, infants of underweight mothers had more than twice the risk of LBW compared to those of mothers with normal weight (odds ratio = 2.27; 95% confidence interval 1.09-4.71). CONCLUSION: Underweight Omani women as well as women with less-than-recommended gestational weight gain were at higher risk of delivering LBW babies. Maternal health promotion programmes should be directed towards improving mothers' nutrition before and during pregnancies.