Perioperative nonhormonal pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy: a systematic review and network meta-analysis.

OBJECTIVE: To synthesize evidence on the most effective pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy. DESIGN: Systematic review and network meta-analysis of randomized controlled trials (RCTs). SETTING: Not applicable. PATIENTS: Trials assessing efficacy of pharmacological interventions during different types of myomectomy. INTERVENTIONS: Misoprostol, oxytocin, vasopressin, tranexamic acid (TXA), epinephrine, or ascorbic acid. MAIN OUTCOME MEASURES: Intraoperative blood loss and need for blood transfusion. RESULTS: The present review included 26 randomized control trials (RCTs) (N = 1627). For minimally invasive procedures (9 RCTs; 474 patients), network meta-analysis showed that oxytocin (mean difference [MD] -175.5 mL, 95% confidence interval [CI] -30.1.07, -49.93), ornipressin (MD -149.6 mL, 95% CI - 178.22, -120.98), misoprostol, bupivacaine plus epinephrine, and vasopressin were effective in reducing myomectomy blood loss, but the evidence is of low quality. Ranking score of treatments included in subgroup analysis of minimally invasive myomectomy showed that oxytocin ranked first in reducing blood loss, followed by ornipressin. For open myomectomy (17 RCTs; 1,153 patients), network meta-analysis showed that vasopressin plus misoprostol (MD -652.97 mL, 95% CI - 1113.69, -174.26), oxytocin, TXA, and misoprostol were effective; however, the evidence is of low quality. Vasopressin plus misoprostol ranked first in reducing blood loss during open myomectomy (P = .97). CONCLUSION: There is low-quality evidence to support uterotonics, especially oxytocin, and peripheral vasoconstrictors as effective options in reducing blood loss and need for blood transfusion during minimally invasive myomectomy. Oxytocin is the most effective intervention in minimally invasive myomectomy. For open myomectomy, a combination of uterotonics and peripheral vasoconstrictors is needed to effectively reduce blood loss.

The effect of early vs. delayed postpartum insertion of the LNG-IUS on breastfeeding continuation: a systematic review and meta-analysis of randomised controlled trials.

Objective: The aim of the study was to compare early vs. delayed postpartum insertion of the 52 mg levonorgestrel intrauterine system (LNG-IUS). Methods: The databases of PubMed, Scopus, Web of Science and CENTRAL were searched to February 2019. The search comprised randomised controlled trials (RCTs) comparing early vs. delayed postpartum insertion of the LNG-IUS. Data were extracted and combined in a meta-analysis. Pooled results were expressed as the relative risk (RR) with 95% confidence interval (CI). The main outcome measures were breastfeeding continuation, LNG-IUS expulsion, uterine perforation, LNG-IUS use, satisfaction and number of pregnancies. Results: Twelve RCTs were included, comprising 1006 women in total. Our analysis indicated no significant difference between early and delayed insertion of the LNG-IUS in terms of any breastfeeding continuation (RR 0.99; 95% CI 0.84, 1.16; p = 0.88). After removal of heterogeneity, there was a statistically significant superiority in LNG-IUS use at the endpoint in the early insertion group compared with the delayed insertion group (RR 1.27; 95% CI 1.07, 1.51; p = 0.006). LNG-IUS expulsion was significantly less in the delayed insertion group in comparison with the early insertion group (RR 5.32; 95% CI 2.68, 10.53; p = 0.00001). No significant differences were found between the groups in satisfaction, number of pregnancies and risk of uterine perforation. Conclusion: Early postpartum insertion of the LNG-IUS has no negative effects on breastfeeding continuation. Early postpartum insertion may be used as an alternative to delayed postpartum insertion.

Measurement of the fetal occiput-spine angle during the first stage of labor as predictor of the progress and outcome of labor.

BACKGROUND: Fetal head attitude has a substantial impact on labor progress and outcome. Fetal head deflexion is basically diagnosed by digital vaginal examination during labor. OBJECTIVES: To assess the effect of the fetal occiput-spine angle (OSA) measured through transabdominal ultrasound during the first stage of labor on the progress and outcome of labor. MATERIAL AND METHODS: A prospective cohort study conducted on 400 women with term uncomplicated singleton pregnancy with occipitoanterior position during active labor. The angle between two tangential lines to occipital bone and the vertebral body of the first cervical spine was measured during active labor. Follow up till delivery was done. The primary outcome parameter was the labor duration. Secondary outcomes included the mode of delivery, occurrence of maternal and fetal complications. RESULTS: There was a significant longer duration of both first and second stage of labor among women with OSA <126° when compared to those with OSA ≥126° (6.8 ± 2.1 and1.89 ± 0.85 versus 4.16 ± 1.63 and 0.92 ± 0.43, respectively). Women with OSA <126° had higher incidence of CS (46.3 versus 5.7%), perineal tears (10.4 versus 5.1%), vaginal tears (22.4 versus 6.3%), need for oxytocin augmentation (47.8 versus 21.3%) when compared to those with OSA ≥126. OSA at cutoff value of 126° had a sensitivity, specificity, and accuracy of 8264.6 and 78.4% and 93.79 and 92% in prediction of mode of delivery and overall complications, respectively. CONCLUSIONS: There was a significantly longer duration of both first and second stages of labor with higher rates of CS and maternal and fetal complications in women with OSA <126.

The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: a randomized control trial.

Objective: To identify the role of bilateral internal iliac artery (IIA) ligation on reducing blood loss in abnormally invasive placenta (AIP) undergoing caesarean hysterectomy. Methods: In this parallel-randomized control trial, 57 pregnant females with ultrasound features suggestive of AIP were enrolled. They were randomized into two groups; IIA group (n = 29 cases) performed bilateral IIA ligation followed by caesarean hysterectomies, while Control group (n = 28 cases) underwent caesarean hysterectomy only. The main outcome was the difference in the estimated intraoperative blood loss between the two groups. Results: There was no significant difference between the two groups regarding the intraoperative estimated blood loss (1632 ± 804 versus 1698 ± 1251, p value .83). The operative procedure duration (minutes) (223 ± 66 versus 171 ± 41.4, p value .001) varied significantly between the two groups. Conclusions: Bilateral internal iliac artery ligation, in cases of AIP undergoing caesarean hysterectomy, is not recommended for routine practice to minimize blood loss intraoperatively.

The role of gene polymorphisms and AMH level in prediction of poor ovarian response in Egyptian women undergoing IVF procedure.

OBJECTIVE: The aim of this study is to assess the role of AMH in prediction of poor ovarian response as well as the relation between ESR 2 (+ 1730G>A) (rs4986938) and FSHR p.Thr307Ala (c.919A>G, rs6165) SNPs and the poor ovarian response in Egyptian women undergoing IVF procedure. Discovering the genetic variants associated with ovarian response is an important step towards individualized pharmacogenetic protocols of ovarian stimulation. METHODS: We performed a prospective study on 216 young women with unexplained infertility. Ovarian stimulation was performed according to the GnRH antagonist protocol with a fixed daily morning dose of human menopausal gonadotrophin (HMG). The estrogen receptor (ESR2) (+ 1730G>A) (rs4986938) and FSH receptor p.Thr307Ala (c.919A>G, rs6165) single nucleotide polymorphisms (SNPs) were detected by real-time polymerase chain reaction. Serum FSH, Estradiol (E2) and anti-Müllerian hormone (AMH) levels were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: This study revealed that the low AMH level was highly significantly related to the poor ovarian response (p < 0.001). Furthermore, the frequency of the ESR2 (AA) genotype and the FSHR (Ala307Ala) genotypes were highly significantly associated with the poor ovarian response (p < 0.001). CONCLUSION: The AMH level in combination with the ESR2 and the FSHR gene polymorphisms predict the poor ovarian response to COH in Egyptian women. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02640976.

Oral antioxidants supplementation for women with unexplained infertility undergoing ICSI/IVF: randomized controlled trial.

OBJECTIVE: Good oocyte quality and maturity are important prerequisites for high fertilization and implantation rates in IVF/ICSI treatment cycles. Reactive oxygen species (ROS) are produced within ovarian follicles, especially during the ovulation process, and increased ROS activity may be a cause of impaired oocyte maturation and higher rate of failure of IVF/ICSI cycles. STUDY DESIGN: RCT evaluating the effect of antioxidant supplementation on ICSI/IVF outcomes. Two hundred and eighteen women with unexplained subfertility undergoing IVF/ICSI were randomized into two groups. The study group (n = 112) received daily oral antioxidants in the form of multivitamins and minerals (amino acid chelated) while the control group (n = 106) did not. Main outcomes were number of mature metaphase II (MII) oocytes and clinical pregnancy rate. RESULTS: There were no significant changes between the groups as regards age, BMI, basal FSH, number of mature (MII) oocytes (12.7 ± 9.4 vs. 13.2 ± 8.6, P = 0.7) and clinical pregnancy rate per woman randomized (38% vs. 34%; [OR = 1.2; 95% CI, 0.70-2.11]. CONCLUSION: Oral antioxidants in the form of a combination of multivitamins and minerals (amino acid chelated) did not improve oocyte quality and pregnancy rates in women with unexplained infertility undergoing IVF/ICSI treatment.

Reproductive health and HIV awareness among newly married Egyptian couples without formal education.

OBJECTIVE: To assess awareness of several reproductive health and HIV issues and to determine the sources of reproductive health knowledge. METHODS: A cross-sectional survey of 150 randomly recruited, newly married couples without formal education attending gynecology or andrology outpatient clinics in Cairo, Egypt, was conducted from January 2012 to January 2013. Participants were interviewed separately and asked to respond to a semi-structured questionnaire on reproductive health and HIV awareness. RESULTS: Most participants had not received premarital counseling or undergone premarital testing. Awareness about HIV was relatively high: 117 (78.0%) women and 128 (85.3%) men had heard of HIV and had some awareness of the modes of HIV transmission. Only 24 (16.0%) women had ever used a condom compared with 36 (24.0%) men. Only two men out of the 150 couples questioned were aware of the free HIV hotline. Television and friends were the main sources of reproductive health knowledge. CONCLUSION: Routine premarital counseling and testing by reproductive health, gynecology, and andrology specialists need to be enforced. Mass media is an essential source of knowledge about HIV and reproductive health. Premarital, reproductive health, and HIV education programs need to be improved.