Effect of topical oxytocin gel on vaginal mucosa in postmenopausal Egyptian women: a clinical randomized trial.

BACKGROUND: Vaginal atrophy is common after menopause and is often linked to sexual dysfunction, particularly dyspareunia. AIM: The study aimed to investigate the effect of intravaginally applied oxytocin on expressions of vaginal atrophy. METHODS: Fifty postmenopausal women aged 47 to 66 years with vaginal atrophy participated in this double-blinded placebo-controlled study. The women were randomized to intravaginal treatment with either gel with 600 IU/mL of oxytocin (oxytocin group) or gel alone (control group) once daily for 2 weeks. The gel consisted of hypromellose, pH 3.8 (Vagovital). OUTCOMES: The color of the vaginal mucosa, the vaginal pH, and the cytology of vaginal epithelial cells were investigated before and after treatment. RESULTS: The color of the vaginal mucosa shifted from pale to red in all 25 patients treated with oxytocin but only in 4 patients in the control group (P < .001). There was a significant decrease in intravaginal pH in the oxytocin group and the control group, with the delta value being significantly greater in the oxytocin group than in the control group (P < .001). The vaginal maturation index increased significantly (P < .001) in the oxytocin group but not in the control group. CLINICAL IMPLICATIONS: Topical oxytocin gel offers an effective solution to the sexual dysfunction that is related to vaginal atrophy after menopause. STRENGTHS AND LIMITATIONS: Strengths include studying different outcomes of applying the oxytocin gel for vaginal atrophy. Limitations include the small-scale population with a relatively short duration of treatment (2 weeks). CONCLUSION: Intravaginal treatment with a gel containing 600 IU/mL of oxytocin effectively counteracts physical expressions of vaginal atrophy. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05275270; https://clinicaltrials.gov/ct2/show/NCT05275270).

Hysteroscopic management versus ultrasound-guided evacuation for women with first-trimester pregnancy loss, a randomised controlled trial.

OBJECTIVE: We aimed to evaluate the hysteroscopic management of first-trimester pregnancy loss compared to surgical evacuation either blind or under ultrasonographic guidance . METHODS: This clinical trial included 315 women with first-trimester pregnancy loss, divided equally into three groups. Group 1 underwent traditional blind surgical evacuation, group 2 underwent ultrasound-guided evacuation, and group 3 underwent hysteroscopic management. All women were assessed for retained products, surgical complications, the need for further management, and pregnancy occurrence after evacuation within 2 years of follow up. RESULTS: The rate of presence of conception remnants and the need for further treatment was significantly higher in group 1 compared to groups 2 and 3 (4.8% vs. 0% vs. 0%, P = 0.012). The conception rate within 2 years was significantly lower in group 1 compared to groups 2 and 3 (57.4% vs. 73.2% vs. 82.7%, P = 0.002), and the duration needed to conceive was significantly prolonged in group 1 compared to groups 2 and 3 (9.8 vs. 8.3 vs. 6.9 months, P < 0.001). Interestingly, women who underwent hysteroscopic management needed a significantly shorter time to conceive than those who underwent ultrasound-guided evacuation (6.9 vs. 8.3 months, P = 0.006). CONCLUSIONS: Hysteroscopic management of first-trimester pregnancy loss was superior to ultrasound-guided surgical evacuation regarding the time interval to conceive. Both techniques were superior to the blind evacuation technique regarding removal of the whole conception remnants, need for further treatment and fertility outcomes. Clinical trial registration: It was first registered at ClinicalTrials.gov on 16/03/2017 with registration number NCT03081104.

Delayed versus early pushing during the second stage of labour in primigravidas under epidural anaesthesia with occipitoposterior malposition: a randomised controlled study.

This randomised controlled trial aimed to compare the effect of early and delayed pushing during the second stage of labour in women with occipitoposterior (OP) malposition. It included 184 nulliparous women with OP position randomised to early pushing in which women were allowed to push within one hour after full cervical dilatation or delayed pushing in which women were asked not to push for maximum of three hours or start pushing when the vertex was visible. The primary outcome was successful vaginal delivery. The rate of spontaneous vaginal delivery was significantly higher in the early pushing group (80.4 vs. 60.9%, p=.004) while the rate of instrumental vaginal delivery (30.4 vs. 15.4%) and CS (8.7 vs. 4.3%) was significantly higher in the delayed pushing group. Women in the delayed pushing group showed a significantly longer duration of the second stage (129.4 ± 7.5 vs. 61.6 ± 15.3 minutes, p<.001) and shorter duration of pushing (219.8 ± 74.8 vs. 693.9 ± 145.2 seconds, p<.001) .The rate of 2nd and 3rd degree perineal lacerations (19.6 and 13% vs. 5.4 and 8.7% respectively, p=.013) and vaginal tears (41.3 vs. 8.7%, p<.001) was significantly higher in the early pushing group. We concluded that early pushing during the second stage of labour is associated with higher rates of spontaneous vaginal delivery and vaginal and perineal lacerations.Clinical trial registration NCT03121274.Impact StatementWhat is already known on this subject? Occipitoposterior malposition is common during delivery especially in primigravida and is associated with higher rates of instrumental delivery and caesarean section. It can be managed through early or delayed pushing.What the results of this study add? Early pushing is associated with higher rates of spontaneous vaginal delivery, perineal and vaginal tears, shorter duration of second stage of labour, shorter duration of pushing, lower rates of both instrumental vaginal delivery and caesarean section.What the implications are of these findings for clinical practice and/or further research? Early pushing during the second stage of labour is associated with higher rates of spontaneous vaginal delivery and vaginal and perineal lacerations in women with OP malposition and should be tried and not delaying the pushing.

The effect of rectus muscle re-approximation at cesarean delivery on pain perceived after operation: a randomized control trial.

Background: Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section. Objective: The purpose of this study was to assess the effect of rectus muscle reapproximation at cesarean delivery on the postoperative pain. Methods: This study was a prospective, double-blind, randomized controlled trial. It included 280 primigravidas, with a singleton pregnancy, who underwent elective lower segment cesarean section at term. The patients were randomly allocated into two equal groups; Group (A): undergoing rectus muscle reapproximation, and Group (B): not undergoing rectus muscle reapproximation. Postoperative pain was assessed by visual analogue scale (VAS) from 0 (no pain) to 100 (maximum pain). Postoperative analgesia, operative time, changes in hemoglobin level, length of hospital stay, and occurrence of postoperative complication were also assessed. Results: Postoperative pain score at the end of the first 24 hours and at the end of the next 24 hours were significantly higher among the group of rectus muscle reapproximation (a difference in VAS pain score of: 5, 95% confidence interval: 0.1-11, p value: .02) and (a difference of 1, 95% confidence interval: 0.1-2.9, p value: .01), respectively. As regards the narcotic use in the first 24 hours after cesarean section, in the form of injections of meperidine 50 mg, it was significantly higher among the group of rectus muscle closure (a difference of 10 mg, 95% confidence interval 3-21.7 mg, p value: .02). While in the next 24 hours, the NSAIDs use, in the form of diclofenac sodium injection, was significantly higher among the group of rectus muscle reapproximation (a difference of 10 mg, 95% confidence interval 3.7-31.7 mg, p value: .02). Conclusions: Rectus muscle reapproximation among women undergoing primary caesarian section is associated with significant increase in the postoperative pain and analgesic requirements.

Urine test for HPV genotypes as a predictor of precancerous cervical lesions and for cervical cancer screening.

OBJECTIVE: To assess the sensitivity of a urine test for high-risk HPV DNA genotypes in the detection of high-grade squamous intra-epithelial lesion (HSIL) and its correlation with pathologic precancerous lesions. METHODS: The present prospective cross-sectional study included women referred to Kasr AlAiny Medical School, Cairo, Egypt, for cervical smear anomalies, a history of cervical smear anomalies, or for suspicious cervix between May 1, 2015, and April 30, 2017. Paired urine tests and cervical smears were performed. HPV DNA was detected in urine using polymerase chain reaction and cervical smears were performed with a cervical spatula and a cytobrush. Agreement between urine test results and pathology was examined. RESULTS: In total, 1375 women were included. Urine test for high-risk HPV DNA demonstrated 97.8% (95% confidence interval [CI] 92.1%-99.7%) sensitivity and 100% (95% CI 99.7%-100.0%) specificity for HSIL. Overall, 87 women had a positive urine test for high-risk HPV; of these, 82 (94.3%, 95% CI 87.1%-98.1%) had pathologic findings of cervical intra-epithelial neoplasia 2 or 3 (CIN2/3). Similarly, 89 women had HSIL cytology; again, 82 had CIN2/3 (92.1%; 95% CI, 84.3%-96.4%). CONCLUSION: There was good agreement between a positive urine test for high-risk HPV DNA genotypes and pathologic findings of CIN2/3.

Prevalence and diagnostic accuracy of Doppler ultrasound of placenta accreta in Egypt.

OBJECTIVE: The objective of this study is to assess the prevalence of placenta accrete (PA) among those with placenta implanted over cesarean section (CS) scar and to evaluate the accuracy of Doppler ultrasound in diagnosis. METHODS: A cross-sectional study included 100 patients with placenta previa (PP) anterior with at least one previous CS. Ultrasound and color Doppler were done to all participants and correlated with operative findings. RESULTS: There was a significant difference between accrete and non-accrete group regarding maternal age (32.6 ± 5.01 versus 29.14 ± 4.89), and a highly significant difference regarding the postoperative hemoglobin (6.71 ± 1.156 versus 8.41 ± 1.257) and the number of previous CSs (p <.001). The abnormal Doppler findings showed a highly significant difference between the two groups as loss of retroplacental clear zone (87.3% versus 10.8%), intraplacental lacunae (93.7% versus 37.8%), hypervascularity in uterine bladder interface (47.6% versus 5.4%), and blood vessels invading myometrium (82.5% versus 18.9%) (p < .001). The sensitivity, specificity, PPV, NPV, and accuracy of loss of retroplacental clear were 87.3%, 89.19%, 93.2%, 80.49%, and 88%; intraplacental lacunae were 93.65%, 62.16%, 80.82%, 85.19%, and 82%; hypervascularity in uterine bladder interface were 47.62%, 94.59%, 93.75%, 51.47%, and 65%; dilated vessels over peripheral subplacental zone were 82.54%, 81.08%, 88.14%, 73.17%, and 82%, respectively. There was a highly significant difference between the two groups regarding surgical management with cesarean hysterectomy, occurrence of bladder injury, the need for intraoperative, and postoperative blood transfusion, ICU admission (p < .001). CONCLUSION: The use of ultrasound together with the color Doppler allowed for better prediction of placental invasion of the myometrium prior to obstetrical intervention to improve the maternal and the fetal outcome.

Effect of oral contraceptives on balance in women: A randomized controlled trial.

OBJECTIVE: To detect the effect of combined oral contraceptive pills (COC) on dynamic postural balance in healthy middle aged women. MATERIALS AND METHODS: A prospective randomized controlled study included 200 patients classified into two groups. Group I received COC containing 30 µg of EE and 3 mg of drospirenone for 12 consecutive cycles and Group II received no treatment. Overall, medio-lateral and antero-posterior stability were measured using Biodex system after 12 months. RESULTS: There was a highly statistically significant difference between the 2 study groups regarding estradiol level (12.84 ± 1.96 vs. 38.86 ± 3.99, P value < 0.001) and progesterone level (0.52 ± 0.25 vs. 11.64 ± 4.53, P value < 0.001). There was a highly statistically significant difference between the 2 study groups regarding mediolateral stability (1.84 ± 0.23 vs. 2.40 ± 0.56, P value < 0.001), antereoposterior stability (1.91 ± 0.29 vs. 2.33 ± 0.61, P value < 0.001) or overall stability (2.42 ± 0.29 vs. 2.95 ± 0.53, P value < 0.001). CONCLUSION: COC are effective method of contraception to improve postural balance and decrease risk of injury in normal and athletic women. NCT02855294.

Maternal serum homocysteine and uterine artery Doppler as predictors of preeclampsia and poor placentation.

PURPOSE: The aim of this study was to evaluate the role of maternal serum total Homocysteine (tHcy) and uterine artery (Ut-A) Doppler as predictors of preeclampsia (PE), intrauterine growth restriction (IUGR), and other complications related to poor placentation. PATIENTS AND METHODS: A prospective cohort study was conducted on 500 women with spontaneous pregnancies. tHcy was measured at 15-19 weeks, and then, Ut-A Doppler was performed at 18-22 weeks of pregnancy. RESULTS: 453 pregnant women completed the follow-up of the study. The tHcy and Ut-A resistance index were significantly higher in women who developed PE, IUGR, and other complications when compared to controls (tHcy: 7.033 ± 2.744, 6.321 ± 3.645, and 6.602 ± 2.469 vs 4.701 ± 2.082 µmol/L, respectively, p value <0.001 and Ut-A resistance index: 0.587 ± 0.072, 0.587 ± 0.053, and 0.597 ± 0.069 vs 0.524 ± 0.025, respectively, p value <0.001). The use of both tHcy assessment and Ut-A Doppler improved the sensitivity of prediction of PE relative to the use of each one alone (85.2 relative to 73.33 and 60%, respectively). CONCLUSION: The use of elevated homocysteine and uterine artery Doppler screening are valuable in prediction of preeclampsia, IUGR, and poor placentation disorders. CLINCALTRIAL. GOV ID: NCT02854501.