Early diagnosis of impending rupture uterus during U/S: A case report.

INTRODUCTION AND IMPORTANCE: Uterine rupture is a rare condition that typically occurs in a scarred uterus and can happen during late pregnancy, labor, or the early postpartum period. Since most cases are seen in patients with a history of cesarean surgery, the anterior lower uterine segment is the most affected area. Most patients present with acute symptoms that compromise the fetus and the mother in a life-threatening manner. CASE PRESENTATION: We present a case of uterine rupture with subacute symptoms occurring in the second trimester, which is extremely rare. The patient was a stable second-trimester multiparous woman with chronic abdominal pain, but without any signs of peritoneal bleeding or instability. No history of previous cesarean section was present, and she had recently undergone a non-complicated hysteroscopic polypectomy. Transabdominal and transvaginal ultrasounds were performed, revealing a significant full-thickness myometrial defect in the posterior uterine lower segment. This defect allowed the amniotic sac to protrude into the posterior cul-de-sac. No abdominopelvic hematoma was detected. These findings were confirmed in an urgent MRI, and the patient underwent a laparotomy during which a significant full-thickness defect was discovered at the posterior of the uterus. As it was impossible to continue the pregnancy, the fetus was surgically removed and then prepared using multiple layers. CLINICAL DISCUSSION: The difference between our case and the previously reported one is in the aspect of gradual stable presentation and lacks of vaginal bleeding. CONCLUSION: Previous hysteroscopy carries a risk for future pregnancy complications, such as uterine rupture.

Evaluation of cardiac sphericity index among intrauterine growth restriction and normal fetuses.

Foetal growth restriction (FGR) describes the pregnancy complications of pathological reduced foetal growth, leading to significant perinatal mortality and morbidity, and subsequent long-term cardiovascular outcomes. This prospective case-control study was performed on pregnant women referred to the hospitals of Tehran University of Medical Sciences in 2017-2019. All pregnant women underwent ultrasound scan and doppler sonography. FGR was defined as a sonographic estimation of foetal weight below the tenth percentile for a given gestational age. Cardiac sphericity index, including basal-apical length (BAL), transverse length (TL), global sphericity index (GSI), umbilical artery pulsatility index (PI), middle cerebral artery (MCA) PI and cerebroplacental ratio (CPR) were assessed. Mean gestational age in FGR and control groups were 233.90 ± 22.00 days and 229.00 ± 25.02 days, respectively. Foetal size index and estimated foetal weight in FGR foetuses were significantly lower than the control group (p < .05). BAL, TL and GSI were significantly affected by FGR (p = .0001, p = .018 and p = .0001, respectively). Abnormal GSI, MCA PI, umbilical artery PI and CPR were significantly more prevalent among FGR foetuses (p = .017, p = .0001, p = .0001 and p = .0001, respectively). Cardiac sphericity index, as well as uterine PI, MCA PI and CPR, were the determinants of FGR in foetuses with normal Doppler and abnormal GSI.IMPACT STATEMENTWhat is already known on this subject? Foetal growth restriction (FGR) describes the foetus that does not grow to its expected biological potential in utero, and is a relatively common complication of pregnancy. FGR is accosted with negative birth outcomes and long-term cardiovascular outcomes. One of the indicators of FGR is cardiac sphericity.What do the results of this study add? The findings of this study revealed that the cardiac sphericity index as well as umbilical PI, MCA PI and CPR ratio change in FGR foetuses.What are the implications of these findings for clinical practice and/or further research? It is recommended that more studies be performed to follow FGR foetuses longitudinally and evaluate the long-term cardiac abnormalities in infancy and childhood and compare it between FGR foetuses and normal foetuses.

A study on sexual functioning and depression in Iranian women following cesarean hysterectomy due to placental abnormality after 3-6 months.

This study aims to investigate the prevalence of depression and impaired sexual function following the hysterectomy in Iran. This study was performed as a retrospective cohort study, from August 2017 to August 2018. Fifty-two patients with a cesarean hysterectomy and 52 with cesarean section were considered as the cases and controls, respectively. Depression and sexual function were assessed 3-6 months following the surgery in both cases and controls. Depression was evaluated by using Beck Depression Inventory (BDI) questionnaire-II-Persian. Sexual function was assessed using the Female Sexual Function Index (FSFI). The average BDI in cases was 15.37 ± 7.6 and in controls was 13.06 ± 6.7. Mild to moderate depression was detected 57.3 percent of whom with hysterectomy and 36.5 percent of whom with C/S, the BDI sum score did not differ significantly between cases and controls (p = .096). The FSFI in cases was 20.06 ± 6.96, and controls was 21.7 ± 9.83 without any significant difference (p = .364). The depression had not been significantly different between women who underwent hysterectomy and were not following 3-6 months after surgery. Furthermore, both groups had impaired sexual function after the surgery.

Umbilical Cord Diameter at Early Second Trimester: Relation to Trisomy 21.

BACKGROUND: To compare the umbilical cord diameter (UCD) at early second trimester (at 17-19 weeks of gestation) in trisomy 21 and normal fetuses and determined value of measuring UCD in screening trisomy 21. METHODS: This was a case-control study. The UCD was measured in 39 fetuses with trisomy 21 (documented by chorionic villus sampling or amniocentesis) and 39 fetuses in control group at 17-19 weeks of gestation. The control groups were low-risk fetuses for aneuploidy in routine screening and were shown not to have aneuploidy after birth. RESULTS: Mean of UCD in fetuses with trisomy 21 was lower than normal fetuses, but there were no significant differences between them (7.48 ± 0.99 mm vs. 7.66 ± 0.91 mm; P = 0.41). Mean of UCD had no significant difference between other maternal variable, for example, body mass index and obstetric history. Mean of UCD among mothers who had previous cesarean section was significantly lower than without it (7.21 ± 0.97 vs. 7.71 ± 0.97; P = 0.03). CONCLUSIONS: At 17-19 weeks of gestation, the UCD of fetuses with trisomy 21 is thinner than normal, but the importance of this difference is too small for using this measurement in screening.

Ultrasound measurement of fetal adrenal gland in fetuses with intrauterine growth restriction, an early predictive method for adverse outcomes.

OBJECTIVES: Comparing the sonographic measurements of fetal adrenal gland in pregnancies with intrauterine growth restriction (IUGR) versus healthy controls and to assess whether the changes in adrenal gland measurements could predict adverse pregnancy outcomes in IUGR fetuses. METHODS: This prospective cohort study evaluated 97 pregnant women (48 with IUGR pregnancies and 49 healthy controls) during their third gestational trimester. All mothers underwent two dimensional ultrasonography of the fetal adrenal gland, and the fetal zone in transverse, sagittal, and coronal planes. Adrenal gland volume (AGV) and fetal zone volume (FZV) were calculated and corrected (c) for fetal weight. The mothers were then followed until delivery. RESULTS: Fetuses in the IUGR group had larger corrected adrenal gland volume (c_AGV) and smaller corrected fetal zone volume (c_FZV) compared to the fetuses in the control groups (p < .001). In the IUGR group, significantly smaller c_AGV and higher fetal/adrenal were detected in IUGR fetuses who had nonreassuring fetal status before delivery, preterm birth, very low birth weight delivery, and also those who required neonatal intensive care unit admission (p < .01 for all). CONCLUSIONS: Third trimester fetal adrenal gland sonography could potentially be used as an easy noninvasive method for identifying those IUGR fetuses who might have poorer outcomes.

Predictors of Cranial Ultrasound Abnormalities in Intrauterine Growth-Restricted Fetuses Born between 28 and 34 Weeks of Gestation: A Prospective Cohort Study.

BACKGROUND: Doppler parameters have been commonly used for the prediction of neonatal outcomes. However, controversies exist with regard to the value of Doppler parameters in predicting the risk of neurological outcomes among neonates. OBJECTIVE: This prospective cohort study attempted to assess the value of Doppler parameters in predict ing cranial ultrasound abnormalities (CUAs) in intrauterine growth restriction (IUGR) among fetuses at 28-34 weeks of gestation. METHODS: This was a prospective cohort study of 83 delivered IUGR fetuses and 75 control fetuses matched for gestational age (GA). The value of mentioned Doppler parameters and GA in predicting the risk of CUAs, including periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH), and basal ganglia lesions (BGLs), was analyzed. RESULTS: The incidence of CUAs among IUGR fetuses (66.3%) was significantly higher (p < 0.001) than in the control group (40%). The incidence of neonatal mortality among IUGR fetuses was significantly higher (p < 0.001) than in the control group. Absent or reversed end-diastolic velocity (AREDV) in the umbilical artery (UA) and the ductus venosus (DV) after adjustment for GA was associated with increased odds of IVH, PVL, BGLs, and any CUA. CONCLUSIONS: GA at birth and AREDV in the UA and the DV within 1 week before childbirth were reliable predictors of CUAs during the neonatal period.

Pre-induction translabial ultrasound measurements in predicting mode of delivery compared to bishop score: a cross-sectional study.

BACKGROUND: By increased concerns about the accuracy of the traditional methods to predict outcomes after induction of labor, developing new standards has a great clinical importance. Here, we compared the predictive value of translabial ultrasound measurements with Bishop Score to determine the suitability of induction of labor. METHODS: A homogenous population of primigravid women was recruited. Induction of labor was performed with low-dose infusion of oxytocin. Translabial ultrasound and assessment of Bishop Score were performed by two different obstetricians. Receiver-operating characteristics curves were obtained to measure area under curve and subsequently, test sensitivity of each method. RESULTS: One hundred women entered the investigation. Maternal body mass index was significantly higher among candidates of Cesarean section (P: 0.02). Maternal age and fetus weight, gender and occiput position were not determinants of outcomes of induction of labor. Cervical length and fetal head-pubis symphysis distance measured by translabial ultrasound had a test sensitivity of 90 and 88 %, respectively which were slightly higher than sensitivity of Bishop score (84 %). CONCLUSION: This study demonstrates that translabial measurements can be a suitable alternative method to monitor labor progress with an admissible predictive value compared with Bishop Score. It is a non-invasive method which provides valuable objective measurements and can be better accepted by women when considering the painful process which is required in evaluating Bishop Score.

Induction of Labor Using Native (OXYTIP) in Comparison to Foreign Oxytocin (SYNTOCINON).

OBJECTIVE: This study was conducted with the aim to investigate and compare Iranian produced and foreign oxytocin for use in induction of labor. MATERIALS AND METHODS: This random clinical trial was conducted on a population of 198 pregnant women with live fetus and cephalic presentation and conditions conducive to induction of labor, monitored by obstetricians and gynecologists. They were randomly divided into group A (n = 99) received 10 units of Syntocinon (Novartis Pharma Canada) in 500 cc Ringer lactate, and group B (n = 99) received 10 units of Oxytip (Caspian Tamin Company Iran) in 500 cc serum, who entered the study to commence induction, by signing written consent. Study variables such as induction indications (post-term, ruptured membranes, diabetes, and..), induction duration, duration of the 1(st) and the 2(nd) stages of labor, and delivery method; as well as labor outcomes like hyper-stimulation of uterine, postpartum bleeding, 5-minute Apgar score, and infant's birth weight; and neonatal outcomes (admission to NICU, oxygen and intubation) were assessed for the two groups by a trained midwife and registered in the patient's questionnaire. Data were analyzed in SPSS software using statistical tests: t-test, Chi-square, and Mann-Whitney. RESULTS: Two groups were similar in demographic variables such as; age, BMI, parity, education. There was no significant difference regarding to obstetric and gynecologic characteristics such as: gestational age, dilatation, effacement, and fetal positioning, as well as the indication for labor induction when the study began. After intervention, variables including: induction duration, duration of the 1(st) and the 2(nd) stages of labor, delivery method; and labor outcomes such as: hyper-stimulation of uterine, postpartum bleeding, 5-minute Apgar score, and infant's birth weight; and neonatal outcomes (admission to NICU, oxygen and intubation), in the two groups, were found to be the same (P < 0.05). Mean oxytip dosage needed was less than that of oxytocin to reach for appropriate pain (P = 0.042). CONCLUSION: The two drugs in terms of labor induction and neonatal complications had similar outcomes and the locally made drug with a lower dosage appears to produce the desired outcome.

Effect of aspirin in prevention of adverse pregnancy outcome in women with elevated alpha-fetoprotein.

BACKGROUND: To evaluate the effect of low-dose aspirin in prevention of adverse pregnancy outcomes (APO) in women with second trimester alpha-fetoprotein (AFP) >2.5 multiple of median (MOM) and to compare aspirin effect on women with normal and abnormal uterine artery (UtA) Doppler. The primary outcome was the adverse pregnancy outcome. METHODS: This randomized controlled trial was conducted in singleton pregnant women, who had unexplained AFP >2.5 MOM and gestational age between 15 and 18 weeks of gestation. They were assigned randomly to receive either aspirin (N = 65) or control (N = 68). UtA Doppler velocimetry studies were performed at the time of targeted ultrasonographic exam. RESULTS: Two groups were comparable regarding the maternal characteristics. The frequency of APO in aspirin and control groups were 26.1% versus 44.1% (p = 0.045), the frequency of preterm delivery before 34 weeks were 3.2% versus 22.0% in aspirin and control group, p = 0.001. Other outcomes were similar in both groups. The frequency of adverse outcomes in women with abnormal UtA Doppler was 39.1% in aspirin and 60.0% in control group, p = 0.556. CONCLUSION: Low-dose aspirin reduces APO and delivery before 34 weeks of gestation in pregnant women with unexplained elevated AFP.

Comparative efficacy of probiotic yoghurt and clindamycin in treatment of bacterial vaginosis in pregnant women: a randomized clinical trial.

OBJECTIVE: This study was performed to determine the comparative efficacy of probiotic yoghurt and clindamycin in the treatment of bacterial vaginosis in pregnant women in the third trimester. METHODS AND MATERIALS: This randomized clinical trial was performed as an open-label study. 310 symptomatic patients with BV were recruited. Diagnosis of BV was through Amsel criteria. The patients were randomly assigned to receive either probiotic yoghurt (100 g twice a day/week) or orally administered clindamycin (300 mg twice a day/week). RESULTS: Ten patients in probiotic group and 9 subjects in clindamycin group had symptom recurrence (p > 0.05). 132 patients in probiotic group and 105 subjects in clindamycin group had pH decrease (p < 0.0001). 140 patients in probiotic group and 141 subjects in clindamycin group had complete symptomatic cure (p > 0.05). Twelve patients in probiotic group and seven subjects in clindamycin group had preterm birth. Nine women in probiotic group and five subjects in clindamycin group had PROM (p > 0.05). CONCLUSIONS: According to the obtained results, it may be concluded that probiotics would have a good efficacy in the treatment of bacterial vaginosis in pregnancy leading to decreased burden of subsequent preterm birth.

Comparison of 8-h urine protein and random urinary protein-to-creatinine ratio with 24-h urine protein in pregnancy.

OBJECTIVE: To evaluate the relationship between 24-h and 8-h urinary protein excretion and protein-to-ceratinine (p:c) ratio in random urine sample. As well as determining a best cutoff for p:c ratio for accurately diagnose significant proteinuria. METHODS: Fifty hospitalized pregnant women who need 24 h urine collection for medical complications were studied. At first for each patient protein-to-createnin ratio in random urine sample was done. Then 8- and 24-h urinary protein estimation was performed. The 24-h and 8-h urinary protein were compared to urinary p:c ratio in random urine sample. RESULTS: There were significant correlations (p < 0.001) between protein levels of 24-h and 8-h urine collections (r = 0.75), 24-h and random urine p:c ratio (r = 0.97) as well as 8-h and random urine p:c ratio (r = 0.79). Mean protein levels were significantly higher in group with proteinuria ≥ 300 mg/24 h in these three types of urine samples (p < 0.001). We found cutoff levels of 105 mg for 8-h urine sample and of 0.18 for p:c ratio. CONCLUSIONS: This study showed that 8-h urine protein or random p:c ratio in a single-voided urine can be appropriate methods for detection of proteinuria in the shorter period than 24-h urine protein.

Betamethasone effects on the endocervical inflammatory cytokines in preterm labor: a randomized clinical trial.

OBJECTIVE: This study aimed to investigate the effect of betamethasone treatment on the endocervical concentration of IL-1ß, IL-4, IL-6, and TNF-α in preterm labor patients. STUDY DESIGN: We studied 68 prime-gravid women in preterm labor between 34 and 37 weeks of gestation without clinical infection. Endocervical concentrations of inflammatory cytokines were assessed; immediately on admission and 48 h after administration of two doses of intramuscular betamethasone (12 mg/kg). Wilcoxon and Mann-Whitney tests along with χ(2) and Student's t tests were utilized for statistical analysis. RESULTS: In the betamethasone group IL-1ß and TNF-α significantly decreased (P<0.001), and IL-6 and IL-4 increased (P: NS). Among patients delivered before or on the 7th day of admission IL-6 and TNF-α were higher at the most significant levels (P<0.001) compared to IL-1ß and IL-4 (P: 0.001, 0.002 in respect). CONCLUSION: Betamethasone can help induce the down regulation of endocervical inflammatory cytokines in patients with preterm labor.

Middle cerebral artery peak systolic velocity and ductus venosus velocity in the investigation of nonimmune hydrops.

PURPOSE: This study was performed to investigate the cause of nonimmune hydrops fetalis by measuring the peak systolic velocity (PSV) in the middle cerebral artery (MCA) and velocity waveforms of the ductus venosus (DV) with Doppler. METHODS: This cross-sectional study was done on 19 pregnancies referred to three university teaching hospitals for further investigation of nonimmune hydrops fetalis in 2007 and 2008. The MCA-PSV and DV velocity waveforms were recorded in all fetuses. Anemia was investigated in cases with MCA-PSV values greater than 1.50 MoM (multiple of the median). Cardiovascular causes and chromosomal abnormalities were investigated in fetuses with abnormal DV velocity. RESULTS: Four of 19 fetuses had MCA-PSV values greater than 1.50 MoM. The causes of anemia were cytomegalovirus, parvovirus B19 infections, congenital heart disease, and Turner syndrome. Four cases had reversed flow in the DV; three of them had congenital heart disease on echocardiography; and one had a normal echocardiogram, but an abnormal karyotype was detected. CONCLUSION: Assessment of the MCA-PSV and DV velocity waveforms during sonographic examination of fetuses with nonimmune hydrops fetalis may improve our knowledge about the etiology of this condition.

Caesarean or normal vaginal delivery: overview of physicians' self-preference and suggestion to patients.

PURPOSE: Caesarean delivery in the absence of any medical indications has become a major issue of concern among the women's health professionals. The patients' choice of caesarean is influenced by several factors predominating by their physicians' suggestion. Our objective was to examine factors that may affect the physicians' responses to patients consulting the mode of delivery. METHODS: Questionnaires were posted to 1,000 female obstetricians and gynaecologists practicing in Tehran in winter 2007. Questionnaires included demographic information of physicians and their history of pregnancy and delivery. Finally, they were asked their preferred mode of delivery and the mode they suggest when being consulted by parturient. RESULTS: From 1,000 physicians, 785 cases (78.5%) responded to the survey. The rate of responses in favour of suggesting normal vaginal delivery, Caesarean Section and painless vaginal delivery was 60.8, 25.6 and 13.6%, respectively. There was a correlation between the suggested and the preferred mode of delivery, it means that the physicians mostly suggested their self-preferred mode of delivery to their patients. CONCLUSIONS: Physicians normally suggest to their patients as the safe mode of delivery what they prefer for themselves. This preference and subsequent suggestion is influenced by different factors including their age, marital status, and previous modes of delivery. As conclusion, it is inferred that informing a physician to choose the right mode of delivery for herself leads to better suggestions to the patients.

A randomised trial of two regimens of vaginal misoprostol to manage termination of pregnancy of up to 16 weeks.

OBJECTIVE: The purpose of this study was to compare the efficacy and side-effects of two regimens of vaginal misoprostol for pregnancy termination of up to 16 weeks. METHODS: A randomised clinical trial of medical pregnancy termination of up to 16 weeks was conducted. A hundred pregnant women requesting legal termination of pregnancy were randomised into two groups to receive either 200 microg (50 women) or 400 microg (50 women)--vaginal misoprostol every six hours up to four doses. Outcome of abortion and side-effects were assessed. RESULTS: The groups were similar in maternal age, gestational age, parity and indication for pregnancy termination. There were no statistically significant differences between the two groups in abortion (P = 0.084) and mean induction to abortion time (P = 0.35). However, the side-effects in the 400 microg group were significantly higher than in the 200 microg group (P = 0.000). CONCLUSION: In pregnancy termination of up to 16 weeks, 200 microg vaginal misoprostol every six hours up to four doses was as effective as 400 microg, but side-effects were more common in 400 microg regimen.

Maternal and neonatal outcomes in pregnant women with immune thrombocytopenic purpura.

BACKGROUND: The aim of this study was to evaluate the outcome of pregnancies in Iranian women with immune thrombocytopenic purpura (ITP). METHODS: In a historical cohort study, maternal and neonatal outcomes were studied in 30 pregnant women with ITP at a hospital in Tehran, from January 1994 through November 2003. RESULTS: Twenty-two cases were diagnosed as ITP before and 8 during pregnancy. Thrombocytopenia (platelet count <150 x 10(9)/L) occurred in 22 pregnancies. Eleven (37%) had vaginal delivery and 19 (63%) underwent elective cesarean section. Eight women had severe postpartum hemorrhage. All live-born neonates were delivered in good condition at term. Neonatal thrombocytopenia occurred in 20 (67%) neonates. No bleeding complications occurred in any of the neonates. CONCLUSION: The outcome of pregnancy in pregnant women with ITP is generally good. Cesarean section should only be performed for obstetric indications. Postpartum hemorrhage is common in these women. Postpartum hemorrhage is unrelated to the mode of delivery. Severe thrombocytopenia and bleeding in the offspring are uncommon.

'Perinatal outcome in preterm premature rupture of membranes with Amniotic fluid index < 5 (AFI < 5).

BACKGROUND: Our purpose was to determine whether AFI<5 cm after preterm premature rupture of the membranes (PPROM) is associated with an increased risk of perinatal morbidity. METHODS: We performed a prospective cohort study of 95 singleton pregnancies complicated by preterm premature rupture of the membranes (PPROM) with delivery between 26 and 34 weeks gestation.Patients were categorized in two groups on the basis of amniotic fluid index<5, (AFI<5 cm)(n = 26) or AFI >/= 5 cm (n = 69). Categorical data were tested for significance with the chi2 and Fisher exact tests. Continuous data were evaluated for normal distribution and tested for significance with the student t test.All 2-sided p values < 0.05 were considered significant. RESULTS: Both groups were similar with respect to selected demographics, gestational age at rupture of the membranes, gestational age at the delivery, birth weight. Both groups were similar with respect to selected variable, latency until delivery, early onset neonatal sepsis, RDS and neonatal death. Patients with AFI<5 cm demonstrated greater frequency of C/S delivery for non reassuring fetal tests (23%vs 2.8%) (p = 0.001). Our study demonstrated that patients in group I had a significant increase in the frequency of clinical chorioamnionitis (P < 0/001). Post partum infections were not seen in 2 groups. CONCLUSIONS: An AFI<5 cm after PPROM between 26 and 34 weeks gestation is associated with an increased risk of maternal infections and frequency of C/S.