Correlation between PAPP-A serum levels in the first trimester of pregnancy with the occurrence of gestational diabetes, a multicenter cohort study.

OBJECTIVE: This study aimed to investigate the association between first-trimester Pregnancy-associated plasma protein A (PAPP-A) levels and subsequent gestational diabetes mellitus (GDM) development. METHOD: The study was conducted on 5854 pregnant women who attended routine prenatal care. Maternal biomarkers, including PAPP-A and free beta hCG, were measured for all women in a referral laboratory and converted to MoM values. Pregnant women were divided into two groups, based on the serum concentration of PAPP-A, (PAPP-A > 0.4 (normal) and PAPP-A < 0.4 (low)). Data on the screening test for GDM and pregnancy outcomes were collected and analyzed with appropriate tests. RESULT: Of the 5854 pregnant women, 889 (15.19%) developed GDM. The maternal PAPP-A MoM concentrations were significantly lower in GDM cases compared to controls. Indeed, gestational age at delivery and birth weight were significantly lower (p < 0.001) in PAPP-A MoM < 0.4, and the rate of intrauterine growth restriction (IUGR) was significantly higher (p < 0.001). ROC analysis revealed that the sensitivity and specificity of MoM concentration for predicting GDM were 53.3% and 51.9%, respectively. CONCLUSION: Lower maternal PAPP-A in early pregnancy can lead to glucose intolerance and increase the risk of subsequent GDM development. In addition, decreased serum concentration of PAPP-A is significantly correlated to lower birth weight and IUGR.

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.

Maternal death due to COVID-19.

BACKGROUND: Despite 2.5 million infections and 169,000 deaths worldwide (as of April 20, 2020), no maternal deaths and only a few pregnant women afflicted with severe respiratory morbidity have been reported to be related to COVID-19 disease. Given the disproportionate burden of severe and fatal respiratory disease previously documented among pregnant women following other coronavirus-related outbreaks (SARS-CoV in 2003 and MERS-CoV in 2012) and influenza pandemics over the last century, the absence of reported maternal morbidity and mortality with COVID-19 disease is unexpected. OBJECTIVE: To describe maternal and perinatal outcomes and death in a case series of pregnant women with COVID-19 disease. STUDY DESIGN: We describe here a multiinstitution adjudicated case series from Iran that includes 9 pregnant women diagnosed with severe COVID-19 disease in their second or third trimester. All 9 pregnant women received a diagnosis of SARS-CoV-2 infection by reverse transcription polymerase chain reaction nucleic acid testing. Outcomes of these women were compared with their familial/household members with contact to the affected patient on or after their symptom onset. All data were reported at death or after a minimum of 14 days from date of admission with COVID-19 disease. RESULTS: Among 9 pregnant women with severe COVID-19 disease, at the time of reporting, 7 of 9 died, 1 of 9 remains critically ill and ventilator dependent, and 1 of 9 recovered after prolonged hospitalization. We obtained self-verified familial/household cohort data in all 9 cases, and in each and every instance, maternal outcomes were more severe compared with outcomes of other high- and low-risk familial/household members (n=33 members for comparison). CONCLUSION: We report herein maternal deaths owing to COVID-19 disease. Until rigorously collected surveillance data emerge, it is prudent to be aware of the potential for maternal death among pregnant women diagnosed as having COVID-19 disease in their second or third trimester.

Comparison of effacement curve with dilatation curve for prediction of labor progression.

AIM: This study was conducted to evaluate the ability of the effacement curve to predict fetal descent by comparing it to dilatation in order to improve the accuracy of the current partogram. METHOD: We conducted an observational study of women who were admitted for vaginal delivery at Mobini Hospital, Sabzevar, Iran in 2015. During labor, dilatation and effacement were plotted in different graphs and then their association with fetal descent was separately evaluated and compared. This assessment was performed in two groups: primipara and multipara. RESULTS: From 1750 individuals, 503 primiparous and 512 multiparous women were eligible for the study. An adjusted generalized estimating equations multivariable model showed both dilatation and effacement had a significant relationship with fetal descent either in primipara or multipara. In primipara, the prediction value of effacement equalled dilatation (ß,eff 0.29, P < 0.001; ß,dil 0.30, P < 0.001). In multipara, the prediction value of effacement was obviously higher than dilatation (ß,eff 0.45, P < 0.001; ß,dil 0.27, P < 0.001). The strength of effacement to predict labor in multipara was clearly greater than in primipara (ß,eff 0.45 and ß,eff 0.29, respectively). The strength of dilatation to predict labor in multipara was comparable to primipara (ß,dil 0.27 and ß,dil: 0.30, respectively). CONCLUSIONS: Regarding the acceptable predictive value of effacement, we believe considering effacement, dilatation and station curves altogether can improve the power of the existing partogram for the assessment of labor progression and detection of failure to progress.

Cesarean Scar Pregnancy: Results of Treatment Using a Double-Balloon Cervical Ripening Catheter.

Background: Being considered a life-threatening condition, cesarean scar pregnancy (CSP) leads to loss of fertility, severe bleeding, and even maternal mortality. We intended to assess the effect of double-balloon cervical ripening catheter insertion on CSP termination before nine weeks of gestation. Method: All participants were diagnosed CSP by abdominal and transvaginal ultrasound. The cases were treated with a sterile, double-balloon cervical ripening catheter inserted with real-time transabdominal ultrasound guidance and removed three days later. The control group consisted of patients treated with systemic methotrexate with or without fetal reduction. Results: Thirty-five patients were eligible for double-balloon ripening and 32 for MTX therapy; the treatment in cases failed in five of the patients. Success rate difference between two methods was insignificant (Pearson Chi-square: 0.383, p-value: 0.536). There were significant differences regarding the time to normal menstruation (OR: 1.303) and the thickness of the myometrium after surgery (OR: 4.721), but there was no significant difference in the time resolve of either ß-HCG or residue of pregnancy. Conclusion: Double-balloon cervical ripening insertion yields acceptable results for terminating CSP. This strategy does not cause bleeding and even prevents it with its tamponade properties. Additionally, this treatment is minimally invasive simple with low morbidity.

Prediction of bleeding in placenta accrete spectrum with lacunar surface: a novel aspect.

PURPOSE: Diagnosing the placenta accreta spectrum is crucial to prevent morbidities and mortalities among women with the suspicion of this pathology. We aim to evaluate novel ultrasonography markers for these patients in diagnosing and predicting prognosis. METHODS: This cross-sectional study was performed in a referral academic hospital. The population was composed of 51 pregnant women with a suspect of placenta accreta spectrum who had scheduled C-sections. Their primary information and past medical histories were documented. Then the ultrasonography markers, including the most bulging volume behind the bladder (area, perimeter, and volume), the Lacune (diameter, length, number, and surface of the largest lacuna obtained by multiplying the length by the width), the most considerable thickness of placenta on the cervix in patients with placenta previa, the most considerable thickness of the placenta behind the bladder, the Jellyfish sign, and sponge cervix were evaluated. Their comparison to the severity of the bleeding, the rate of the hysterectomy, and the following pathology of the placenta accreta spectrum were analyzed. RESULTS: The results showed that 17 (33.3%) of patients had severe bleeding (more than 2500 cc). The diameter, length, and surface of the largest lacunae limited to women with severe bleeding were 13.50 (5.5-21) mm, 20.50 (11-56) mm, 273.00 (60-1176) mm2, and they were 11.00 (5-24) mm, 16.25 (10-39) mm, and 176.25 (50-744) mm2 for women without severe bleeding (P value = 0.039, 0.027, 0.021). 13 (76.5%) women with severe bleeding had Jellyfish signs,16 (94.2%) had bulging on the cervix, and 10(58.8%) had a sponge cervix (P value = 0.046, 0.036, 0.006). Also, 34 (66.66%) patients needed hysterectomy. The diameter, length, and surface of the largest lacunae limited to women with hysterectomy were 12.00 (5-24) mm, 18.00 (11-56) mm, 231.00 (60-1176) mm2, and they were 9.00 (5-18) mm, 15.00 (10-28) mm, and 136.00(50-504) mm2 for women without hysterectomy (P value = 0.012, 0.070, 0.021). 24(70.6%) women with hysterectomy had Jellyfish signs, 29 (85.3%) of them had bulging on the cervix, and 15 (44.1%) had sponge cervix (P value = 0.05, 0.036, 0.028). The cut-off associated with the Lacunar surface was 163.5 mm2. Its sensitivity was 80%, and its specificity was 48% (P value = 0.021). CONCLUSION: The presence of single large lacunae could be a suitable predictive factor for bleeding in the placenta accreta spectrum; Moreover, there are some other US criteria, including the presence of a sponge cervix or the Jellyfish sign that are valuable predictive factors for negative outcomes for this spectrum, including hysterectomy.

Pathologic examination of the placenta and its benefits in treatment plan or follow-up of patients: a cross-sectional study.

BACKGROUND: The placental examination provides important information about the effect of maternal abnormalities on the placenta or the cause of preterm delivery, fetal growth restriction, or fetal neurodevelopmental damage. In this study, the frequency of placental pathologies of patients in a tertiary hospital was investigated. METHODS: In this longitudinal and cross-sectional study, all removed placentas after any type of pregnancy termination referred to a pathological examination, within 1 year (2019-2020). All placentas were examined macroscopically and microscopically by two pathologists. RESULTS: Unfortunately, because of the COVID-19 pandemic, the number of pregnant women in our hospital declined. A total of 258 placentas were examined. The type of delivery in 193 cases (79.4%) was cesarean section and 50 cases (20.6%) had a vaginal delivery. In the pathological assessment of placentas, 238 (92.2%) cases were normal and 20 cases (7.8%) were abnormal. Infarct and chorioamnionitis were the pathologies with higher frequencies (4.3% and 2.7%, respectively). Intra-uterine fetal death (p = 0.701), preeclampsia (p = 0.51) had no significant difference was seen in normal and abnormal placentas. Maternal age (p = 0.83), gestational age based on the last menstrual period (p = 0.38), and gestational age based on the first ultrasound (p = 0.78) did not show a significant relationship with any of the pathological complications categories. CONCLUSIONS: Pathological examination of the placenta from all live-birth deliveries is not worthwhile, and it's recommended to modify the guidelines as to when the placenta is submitted for pathological evaluation.

Duodenal Obstruction during Pregnancy.

Intractable vomiting and elevated liver enzymes during pregnancy seem to be associated to the obstetric etiologies; however, other causes such as acute surgical emergencies should be considered. The patient was a 26-year-old woman at 18 weeks of gestation with intractable vomiting, intolerability of oral intake, weight loss, and absence of abdominal pain. Her physical examinations and laboratory tests had no remarkable findings except elevated liver function test (LFT) and hypokalemia. Considering the lab data and normal abdominopelvic ultrasound, magnetic resonance imaging was performed which revealed dilation of the D1-3 and collapse the D4 sections of duodenum. She underwent exploratory laparotomy which confirmed duodenal obstruction caused by Ladd's band. After the Ladd's operation, the patient started oral intake of nutritious, and her LFT decreased to normal ranges. After the last follow-up, she has had gained 18 kg and gave birth at 36 weeks of gestation due to the premature rapture of membranes and delivered a 2 kg small for gestational age otherwise healthy infant. The experience gained from this case was to consider all possibilities (such as small bowel obstruction) and evaluate them in a pregnant patient to consider other causes of nausea, vomiting, and abnormal LFTs in a pregnant patient.

Measuring fetal thymus size: a new method for diabetes screening in pregnancy.

Objective: To investigate the correlation between fetal thymus size and diabetes in pregnancy.Method: Fetal thymus size was assessed in 160 pregnant women with gestational age of 19-39 weeks. They included 80 diabetic (investigation group) and 80 nondiabetic (control group) women. Fetal thymus size was measured by thymic-thoracic ratio. We did this with dividing the thymus' anteroposterior diameter by anteroposterior of mediastinum.Results: Thymic-thoracic ratio was significantly smaller in fetuses of diabetic mothers compared to the nondiabetic group (p = .001). It remained significant after subgrouping diabetic mothers into overt diabetes, insulin-dependent gestational diabetes, and noninsulin-dependent gestational diabetes.Conclusion: Although thymus size was smaller in fetuses of diabetic pregnant women compared to nondiabetic pregnant women, it seems that thymic-thoracic ratio can be a predictor of diabetes and its other related adverse effects during pregnancy.

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.

Mid-trimester amniotic fluid C-reactive protein, ferritin and lactate dehydrogenase concentrations and subsequent risk of spontaneous preterm labour.

BACKGROUND: Preterm delivery is a serious problem in obstetrics. A pre-existing inflammation in the first half of gestation has been proposed as a possible condition that leads to preterm delivery. AIM: Our aim was to compare C-reactive protein (CRP), ferritin and lactate dehydrogenase (LDH) concentrations in mid-trimester amniotic fluid of patients with preterm and term deliveries and to found out their predictive values for preterm delivery. METHODS: The study was conducted on 90 pregnant women who underwent genetic amniocentesis between the 15th and the 20th weeks of gestation. The samples were carried immediately to the laboratory for cytogenetic and biochemical examination. Non-parametric tests and receiver-operating characteristic curve analysis were used for statistical purpose. RESULTS: This study showed women with preterm delivery at < 37 weeks (n = 17) had a higher median of amniotic fluid LDH concentration than those women who delivered at term (n = 73) (P = 0.003). Amniotic fluid LDH concentration of > 120 IU/L had a sensitivity of 59% and a specificity of 81% in the prediction of spontaneous preterm delivery at < 37 weeks. Maternal serum alpha-fetoprotein levels were higher in patients delivered preterm compared with term deliveries (P = 0.036). CONCLUSION: Mid-trimester LDH is found to be quite effective in the prediction of preterm delivery. Pre-existing intrauterine inflammatory process early in gestation may be an important risk factor for preterm delivery.

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.

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.

A rare presentation of pheochromocytoma in pregnancy: a case report.

BACKGROUND: Early diagnosis of pheochromocytoma and its proper management can lessen its mortality and morbidity. This case report describes a 24-year-old pregnant woman with an unusual presentation of pheochromocytoma. CASE PRESENTATION: An Iranian 24-year-old primigravid woman from Kordistan province was referred to our center with left flank pain at 37 weeks of gestation. She had a history of gestational diabetes mellitus since the 12th week of gestation which was managed by insulin administration. She also had a history of pulsatile bi-temporal headache for 2 years prior to her referral to us. She underwent complete abdominal and pelvic ultrasound imaging for her flank pain. This examination revealed a heterogeneous mass of 119 × 87 × 79 mm above her left kidney, highly suspicious of being an adrenal-originating tumor. Subsequently, we consulted an endocrinologist. She underwent abdominopelvic magnetic resonance imaging and her 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid were assessed. Finally, the diagnosis of pheochromocytoma was confirmed. She underwent a cesarean section and adrenal mass excision at the 40th week of gestation. This timely diagnosis resulted in her proper management and good maternal and neonatal treatment outcomes. CONCLUSIONS: Our patient had pheochromocytoma during pregnancy. She had no complaints about hypertension before or during pregnancy until giving birth to her child; her only symptoms were a vague left flank pain, gestational diabetes, and headaches for the past 2 years. The unusual symptom of flank pain led to timely diagnosis and a good treatment outcome.

Association between Thrombophilic Genes Polymorphisms and Recurrent Pregnancy Loss Susceptibility in the Iranian Population: a Systematic Review and Meta-Analysis

Background: Studies have indicated that thrombophilic genes polymorphisms are associated with recurrent pregnancy loss (RPL) in the Iranian population. However, the results from these studies remained inconsistent and inconclusive. The aim of this systematic review and meta-analysis was to evaluate the precise association between thrombophilic genes polymorphisms (MTHFR C677T, MTHFR A1298C, Prothrombin G20210A, FVL G1691A, and PAI-1 4G/5G) and RPL risk in the Iranian population. Method: Electronic databases of PubMed, Web of Science, Google Scholar, and ISC were searched for eligible articles published up to April 1, 2017. The association between genetic polymorphisms and RPL risk was measured by ORs with 95% CI. Results: A total of 37 case-control studies in 18 relevant publications were selected in the final meta-analysis, including 1,199 RPL cases and 1,079 controls for MTHFR C677T, 1,194 RPL cases and 1079 controls for MTHFR A1298C, 630 RPL cases and 594 controls for Prothrombin G20210A, 830 RPL cases and 794 controls for FVL G1691A, and 955 RPL cases and 499 controls for PAI-1 4G/5G. When all the eligible studies were pooled into the meta-analysis of MTHFR C677T and A1298C polymorphisms, a significant increased risk of RPL was observed in all genetic models in the population. In addition, Prothrombin G20210A (in allelic and dominant models), FVL G1691A (in allelic and dominant model), and PAI-1 4G/5G (in allelic, homozygote, dominant and recessive genetic models) polymorphisms were associated with RPL risk in the Iranian population. Conclusion: The findings suggest that the thrombophilic genes polymorphisms are associated with an increased RPL risk in the Iranian population.

Acquired hemophilia as a cause of primary postpartum hemorrhage.

A 32-year-old primigravid woman developed acquired factor VIII inhibitor after delivery. She presented with postpartum hemorrhage and large hematoma in episiotomy site. Laboratory examinations showed markedly prolonged activated partial thromboplastin time, low levels of factor VIII (8%), and factor VIII inhibitor (2 Bethesda units). The bleeding was controlled successfully using combined treatment with factor VIII, intravenous immunoglobulin, steroids, and recombinant factor VIIa. Six months after delivery, factor VIII inhibitor was not present and factor VIII concentration increased to normal range. Acquired hemophilia is a life-threatening disorder. Precise screening of coagulation factors is essential for diagnosis of persisting postpartum hemorrhage.

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.