Prenatal Diagnosis of Primrose Syndrome.

Primrose syndrome is a very rare congenital malformation. Symptoms of this disorder may appear during childhood, but the diagnosis is identified in adulthood in the majority of cases. The prenatal diagnosis of Primrose syndrome is not developed in the literature. We present herein a case series of 3 cases with characteristic sonographic features. A dysmorphic metopic suture, downslanting palpebral fissures, a wide forehead, and agenesis of corpus callosum are the main signs. A missense mutation in ZBTB20 identified in whole exome sequencing can confirm the prenatal diagnosis of Primrose syndrome.

Intraoperative Ultrasound in the Management of Placenta Accreta Spectrum: Waste of Time or Valuable Step.

Placenta accreta spectrum (PAS) is increasing worldwide paralleling the rising surge of the cesarean section rate. It is well known that sonographic screening for PAS in the second trimester in high-risk patients can predict and reduce major intraoperative hemorrhage during a cesarean hysterectomy. We report the importance of intraoperative ultrasound in the management PAS disorders. It has a crucial role in the reassessment of the placenta location and invasion, reconsidering the cesarean hysterectomy, localization of the hysterotomy, the bladder dissection, and in the conservative treatment. Workshops and hands-on training in intraoperative ultrasound among surgeons must be supported.

Uterine Scar Evaluation during the Postpartum: Pleading for Extradecidual Suturing during Cesarean Section.

OBJECTIVE: Our objective is to evaluate ultrasound differences in uterine scar between techniques using extramucosal suturing and full thickness suturing of the uterine incision. STUDY DESIGN: A retrospective observational study included cases of primary cesarean section. At 6-week postpartum, we evaluated by endovaginal ultrasound two elements in the sagittal view: the thickness of the uterine scar and the surface of defect (niche). Hysterotomy sites closed using a running full-thickness technique including the uterine mucosa (group 1) were compared to hysterotomies operated by the same surgeon but with extramucosal suturing (group 2). The operator switched from the running suture technique to extramucosal in 2013. RESULTS: The study included 241 patients (115 cases in group 1 that were compared to 126 cases in group 2). There were no significant differences in age or body mass index between the two groups. Cesarean scar and niche were detectable in the entire studied population. There was a significant difference in both uterine scar thickness (5.8 vs. 6.2 mm, p = 0.02) and the presence and size of the niche (49 vs. 40 mm2, p = 0.001) in transvaginal ultrasound performed at 6-week postpartum. CONCLUSION: Extramucosal suturing of the uterine scar seems to be associated with a better outcome on the postpartum ultrasound evaluation. KEY POINTS: · The technique for suturing the hysterotomy can be the source of healing changes.. · An extramucosal suturing of the uterus seems to give a better aspect at the postpartum ultrasound.. · Decreasing the niche at cesarean scar may be beneficial for future pregnancies..

Association between Fetal Adrenal Gland Ultrasound Measurements in the 9th Month and Mode of Delivery.

OBJECTIVE: Several studies have previously assessed the value of changes in the fetal adrenal gland to predict preterm labor. The aim of this study is to evaluate the correlation between fetal adrenal gland measurements after 36 weeks and obstetrical outcomes. METHODS: Abdominal two-dimensional (2D) ultrasound is used to measure in the transversal plane the length of fetal zone (D1), the width (D2), and the length (D3) of fetal adrenal gland, and, subsequently, the fetal zone enlargement (FZE), in 98 primigravida women after 36 weeks. Labor and delivery outcomes were assessed and compared with these measurements. RESULTS: FZE changes had no association with spontaneous onset of labor. No association was found between all adrenal gland measurements and delivery onset. There was a significant relationship between D1, D2, and D3 and the delivery method. Patients delivered by cesarean section had smaller fetal adrenal gland dimensions, defining D1= 0.16 cm, D2 = 0.7 cm, and D3 = 2.37 cm as cutoff levels based on receiver operator characteristics curves. CONCLUSION: The 2D measurement of the fetal adrenal gland after 36 weeks seems to predict the delivery method in low-risk primigravida women. KEY POINTS: · We evaluate fetal adrenal gland measurements after 36 weeks versus the obstetrical outcome.. · No association was found between all adrenal gland measurements and delivery onset.. · Patients delivered by cesarean section had smaller fetal adrenal gland dimensions..

Normal values of cardiac axis (CA) measurements in healthy fetuses during the first trimester screening ultrasound.

OBJECTIVES: To report the normal fetal cardiac axis (CA) values at the time of the first trimester screening ultrasound. METHODS: Standardized images and measurement of the CA were obtained from 100 healthy fetuses between 11+0 and 13+6 weeks of gestation along with the nucal thichkness (NT), Crown-rump length (CRL) and other measurements. We excluded cases with abnormal NT, later diagnosis of abnormalities, and suspected fetal cardiopathy during the pregnancy follow-up. Data analysis was performed after all the patients delivered and cardiopathy was excluded. RESULTS: CA was measurable in all the cases. Higher CRL was associated with a decrease in the CA. The mean ± SD embryonic/fetal CA was 48±5,2°, ranging from 39 to 60°, The 2.5 percentile was defined at 40° and the 97.5 percentile at 59°. The Pearson test resulted in a significant correlation between CA and CRL with a coefficient R of 70% and p-value <0.01. CONCLUSIONS: CA tends to decrease at the 11 to 13+6 gestational ages. We defined 2.5 and 97.5% curves for the normal values of CA in our Middle Eastern population. A larger study will be required to differentiate normal and abnormal values for the early detection of heart abnormalities.

Arabic Version of Learning Organization Survey Short-Form: Hospital Pharmacy Settings.

Objective: The objective of this study was to assess the psychometric properties of a translated Arabic version of the Learning Organization Survey (LOS-27) and to use this to evaluate staff perceptions about the organizational learning process in Kuwaiti hospital pharmacies. Setting: This study adopted a cross-sectional survey of the pharmacy employees in 6 hospital pharmacies in Kuwait. Results: The results indicated that the internal consistency of all composites was more than 0.7, except for one. All item loadings for the construct measurements were above 0.7. The standardized root mean square residual (SRMR) score showed a good fit with a value of 0.08. The intercorrelation among composites ranged from 0.34 to 0.68. Conclusions: The results indicate that the Arabic translation of the LOS-27 questionnaire has adequate levels of reliability and validity in comparison with the original US survey results. The overall average positive rate of composites was 64%. Therefore, the findings suggest that the hospital pharmacy staff surveyed in Kuwait were moderately positive in their perceptions about organizational learning in their organizations.

Dynamic Asphaltene-Stearic Acid Competition at the Oil-Water Interface.

Interfacial tension (IFT) is one of the major parameters which govern the fluid flow in oil production and recovery. This paper investigates the interfacial activity of different natural surfactants found in crude oil. The main objective was to better understand the competition between carboxylic acids and asphaltenes on toluene/water interfaces. Dynamic IFT was measured for water-in-oil pendant drops contrary to most studies using oil-in-water drops. Stearic acid (SA) was used as model compound for surface-active carboxylic acids in crude. The influence of concentration of these species on dynamic IFT between model oil and deionized water was examined. The acid concentrations were of realistic values (total acid number 0.1 to 2 mg KOH/g oil) while asphaltene concentrations were low and set between 10 and 100 ppm. In mixtures, the initial surface pressure was entirely determined by the SA content while asphaltenes showed a slow initial diffusion to the interface followed by increased adsorption at longer times. The final surface pressure was higher for asphaltenes compared to SA, but for binaries, the final surface pressure was always lower than the sum of the individuals. At high SA concentration, surface pressures of mixtures were dominated entirely by the SA, although, Langmuir isotherm analysis shows that asphaltenes bind to the interface 200-250 times stronger than SA. The surface area/molecule for both SA and asphaltenes were found to be larger than the values reported in recent literature. Various approaches to dynamic surface adsorption were tested, showing that apparent diffusivity of asphaltenes is very low, in agreement with other works. Hence, the adsorption is apparently under barrier control. A possible hypothesis is that at the initial phase of the experiment and at lower concentration of asphaltenes, the interface is occupied by stearic acid molecules forming a dense layer of hydrocarbon chains that may repel the asphaltenes.

Updates on laparoscopic cervical cerclage: obstetric outcomes and surgical techniques.

Aim: Preterm birth is a worldwide health problem. After unsuccessful transvaginal cerclage, the transabdominal isthmo-cervical cerclage can be indicated. A laparoscopic approach has been described. Methods: A search was performed including the combination of: "((cerclage) AND (laparoscopy)) AND (pregnancy)". A systematic review was performed to compare indications, outcomes, techniques, and safety. Results & discussion: 42 articles were found through database search. 30 articles were included for review. By reviewing the literature, the transabdominal cervico-isthmic laparoscopic cerclage is highly effective in selected patients with a history of refractory cervical insufficiency. This technique has a high neonatal survival rate when placed in preconceptional or post conceptional patients. Moreover, laparoscopic cervical cerclage is a safe procedure when laparoscopic expertise is present.

A transvaginal cerclage is a procedure that places a stitch or tape within the cervix to mechanically close the cervix to prevent it from opening too early during pregnancy. However, if transvaginal cerclage fails, doctors may recommend a transabdominal isthmo-cervical cerclage using a laparoscopic approach. A systematic review analyzed 30 articles to compare the reasons for surgery, outcomes, techniques, and safety. The review suggests that this procedure is highly effective for certain patients with a history of refractory cervical insufficiency. It appears to be a safe technique with a high rate of survival for newborns and rare complications.

Laparoscopic sacrocolpopexy in the management of recurrent pelvic organ prolapse.

OBJECTIVES: We set out to assess long-term anatomical and functional outcomes in women after laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse. METHODS: All women with a history of pelvic organ prolapse surgery operated between 2005 and 2022 were enrolled in this retrospective observational study. The indication for recurrent POP surgery was a symptomatic stage II and above pelvic organ prolapse. The data from objective urogynecologic examination and subjective patient assessment using validated questionnaires were collected. The last follow-up information was evaluated. The outcomes were compared with preoperative state using Student t-test and Wilcoxon test, p<0.05 was considered significant. RESULTS: 39 women were enrolled in the study. The rate of perioperative complications was very low; no significant hemorrhage, ureteral damage or conversion to laparotomy were observed. The mean follow-up was 40 ± 26.8 months. The postoperative course was not complicated by bowel incarceration, pelvic infection or mesh exposure. We observed a statistically significant elevation of all POP-Q points and decrease in all mean scores of PFDI, PFIQ, Wexner and VAS prolapse bother postoperatively. Improvement in stress urinary incontinence, anal incontinence and constipation was found. CONCLUSIONS: Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse is a safe and effective surgery regardless of the type of the original repair performed. It provides good subjective and anatomical outcomes with a lasting effect on the quality of life in a long-term follow-up.

SENODAY: A New Perspective of Handling Breast Cancer.

BACKGROUND: To evaluate the feasibility of a same day breast cancer diagnosis and management protocol, consequently decreasing time to treatment and immediately reassuring patients with benign diagnosis. MATERIALS AND METHODS: A total of 60 women underwent breast exam during SENODAY in our cancer center between January 2020 and December 2022. Patients are first seen by a breast surgeon who mentions whether the patient's history and physical exam are suspicious of malignancy. Patients are then sent to the radiologist who performs a complete radiologic assessment, classifies the lesions, and performs a biopsy when necessary. The specimen is sent to the pathologist who uses the imprint cytology technique to obtain a preliminary diagnosis. Effective counseling is established in case of breast cancer diagnosis. RESULTS: Among 60 women, 25 patients were reassured by breast imaging and 35 underwent histopathological analysis (17 patients with a 1-day protocol and 18 with the standard definitive technique). Clinical examination was found to have a sensitivity of 100% and a specificity of 89.47%. The positive predictive value was 80 % and the negative predictive value was 100%. However, we did not find a strong correlation between imaging and definitive pathology. Moreover, on imprint cytology, sensitivity, specificity, PPV, and NPV were 100%. Finally, the mean time-to-treat was 28.6 days. CONCLUSIONS: SENODAY reassured 68.3% of patients. It also offered effective counseling and a treatment plan to newly diagnosed breast cancer patients within 1 day. Same day histological diagnosis by imprint cytology is effective and feasible with an excellent accuracy.

Impact of laparoscopic sacrocolpopexy (LSC) on sexual function in women with advanced stages of pelvic organ prolapse (POP): A five-year prospective study.

OBJECTIVE: To compare patients undergoing laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse (POP), in terms of sexual function and surgical anatomical outcomes more than 5-years follow up period. STUDY DESIGN: This is a cohort study of prospectively collected data that includes all women who underwent LSC between July 2005 and December 2021 at a tertiary care center. A total of 228 women were enrolled in this study. Patients completed a validated quality of life questionnaires and were evaluated using the POP-Q, the PFDI-20, PFIQ-7 and the PISQ-12 scores. Patients were divided preoperatively if they are sexually active or not and postoperatively according to the sexual improvement after POP surgery. RESULTS: There was a statistically significant improvement in the PFDI, PFIQ and POPQ score. There was no significant improvement in the PISQ-12 score with more than 5 years follow-up. 76.1 % of patients who were not sexually active preoperatively resumed their sexual activity after the surgery. CONCLUSION: The anatomical correction of a pelvic organ prolapse and pelvic floor disorders by laparoscopic sacrocolpopexy allowed a significant proportion (over ¾) of the women to resume sexual activity whom had not previously been sexually active. However, PISQ 12 scores did not alter significantly in those who were sexually active prior to surgery. Sexual function is a very complex issue affected by multitude of factors among which prolapse seems to be less important.

The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon.

OBJECTIVE: To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. METHODS: A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. RESULTS: The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P = 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P = 0.02 and 0.01, respectively). CONCLUSION: The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.

Outcome of prenatal diagnosis of clubfoot: a single institution experience.

AIM: To assess the accuracy of antenatal diagnosis of clubfoot (CF), risk factors and outcomes in postnatal. PATIENTS & METHODS: Maternal characteristics, sonographic signs and postnatal outcomes were evaluated in 60 patients with a prenatal diagnosis of CF between 2007 and 2020. RESULTS: The rate of antenatal diagnosis of CF was 3.72/1000 live births. The false-positive rate was 6.67%. 66.7% of fetuses had bilateral CF and 33.3% had unilateral CF; 58.3% were isolated and 41.7% were complex; 58.3% were males and 41.7% were female; 16.7% were multiple pregnancies and 10% were cases of consanguinity. CONCLUSION: The accuracy of the diagnosis of CF depends on the operator's skills. A significant relationship is demonstrated between the interruption of pregnancy, consanguinity, laterality and complexity.

Fetal supraventricular tachycardia and maternal COVID-19 vaccination: is there any relationship?

Fetal supraventricular tachycardia accounts for 60-80% of the fetal tachyarrhythmias with prevalence ranging from 1/1000 to 1/25 000 pregnancies. It may be secondary to fetal anomalies or maternal factors. By reviewing the literature, there is no previous article that reports fetal arrhythmia after maternal vaccination. We present herein two cases of fetal supraventricular tachycardia following the administration of the Pfizer-BioNTech COVID-19 vaccine during pregnancy. Continued safety monitoring and more longitudinal follow-up are needed to evaluate the fetal impact after maternal COVID-19 vaccination.

COVID-19 mRNA vaccine in pregnancy and newborn passive immunization: a case report.

AIM: Evaluating the newborn passive immunization after maternal vaccination against SARS-COV-2. CASE PRESENTATION: We present the case of a pregnant woman, with no prior history of COVID-19 infection, who got her second dose of mRNA vaccine against SARS-COV-2, 3 days before the start of her spontaneous labor. She was delivered by cesarean section after dynamical dystocia. Placental cord blood was retrieved immediately and sent to evaluate the titers of COVID-19 antibodies. Vaccine-generated antibodies were present in the umbilical cord with IgG spike >100 AU/ml. CONCLUSION: By reviewing the literature, vaccination seems to give hope about the potential protective effect of the maternal vaccination on her baby. Thus, pregnant women deserve a priority in the COVID-19 vaccination program.

Expression of epithelial-mesenchymal transition biomarkers: Discoidin domain receptor 2, Snail-1, and Ovol-2 as predictors of clinical outcome in patients with epithelial ovarian carcinoma.

Context: Discoidin domain receptor 2 (DDR-2), which belongs to the receptor tyrosine kinase family, Snail-1, which is a member of zinc-finger transcription factor family, and Ovol-2, which is a member of Ovol family, are incriminated in epithelial-mesenchymal transition (EMT) during cancer progression. Aim: In the current study, we aim to clarify the extent to which EMT biomarkers, DDR-2, Snail-1, and Ovol-2 expression, are involved in the progression of EOC aiming at identification of novel markers for predicting the prognosis of EOC patients. Settings and Design: This was a prospective cohort that was performed in the Faculty of Medicine, Zagazig University. Materials and Methods: We evaluated DDR-2, Snail-1, and Ovol-2 expression in 60 patients of EOC using immunohistochemistry. We followed our patients for about 36 months and analyzed the relationship between markers expression and the prognosis of patients. Statistical Analysis Used: SPSS program (Statistical Package for the Social Sciences). Results: High expression of both DDR-2 and Snail-1 was related to higher grade (P = 0.006) and advanced FIGO stage of the tumor (P < 0.001). Ovol-2 high expression was associated with lower grade of the tumor (P = 0.002) and early stage of the tumor (P < 0.001). High Ovol-2 and low DDR2 and Snail-1 expression were strongly correlated with better response to therapy (P = 0.003 and 0.005, respectively) and increased 3-year survival rates (P < 0.001). Conclusion: DDR-2 and Snail-1 are markers of poor prognosis in EOC while Ovol-2 is a marker of good prognosis.

Cesarean section rates in a tertiary referral hospital in Beirut from 2018 to 2020: Our experience using the Robson Classification.

OBJECTIVE: To evaluate the cesarean section rate using the Robson Classification for the first time in Lebanon, at Hôtel-Dieu de France University Hospital, a tertiary referral center in Beirut. METHODS: Routine medical record data that included all live births from January 1, 2018 to September 30, 2020 was investigated. The overall cesarean section rate was recorded, and the size, cesarean section rate, and absolute and relative contributions were calculated within each group. RESULTS: The overall cesarean section rate was 56.8%. The highest relative contribution to this rate came from Robson groups 5, 2 and 10, respectively. A decrease in cesarean section rate was noted in 2020 among women admitted for induction of labor (groups 2 and 4) following the implementation of new department policies and the restrictions caused by the coronavirus disease 2019 pandemic. CONCLUSION: More than 50% of the deliveries in our department were by cesarean sections (CS). Strategies to reduce this rate should include stricter departmental policies for avoidance of unindicated primary CS and raising practitioners' and patients' awareness about trial of labor after cesarean section.

Brucella pelvic tubo-ovarian abscess with a history of chronic brucellosis.

Brucellosis is a zoonotic disease located especially in Central and South America, India, the Mediterranean and the Middle East. Human brucellosis occurs as a systemic infectious disease with various clinical manifestations. We present a case of 45-year-old female patient, nulliparous, not sexually active, with a previous medical history of a treated brucellosis, and no surgical or gynecological history. The patient presented with a history of fever for 7 days of 39 degrees Celsius, chills and acute abdominal pain. She was diagnosed with diffuse peritonitis with left tubo-ovarian abscess and was admitted for an urgent diagnostic laparoscopy. A left adnexectomy was performed. The diagnosis of genital brucellosis was made. This case report discusses an unusual complication of brucellosis represented by a tubo-ovarian abscess associated with acute peritonitis, treated by a laparoscopic adnexectomy and antimicrobials. Acute peritonitis associated with a tubo-ovarian abscess is an unusual complication of brucellosis.

Splenic rupture after sexual intercourse in a pregnant woman: an extremely rare case.

A 33-year-old pregnant woman presented at 36 weeks gestation to the emergency with acute abdominal pain that started after vaginal intercourse. No bruising was present on the abdominal examination. An emergent cesarean delivery was performed for resistant hypotension and collapse. A fetus with cardiac arrest was delivered, and active spleen bleeding was identified at the splenocolic and gastrosplenic ligament insertion. The patient had a conservative treatment of the spleen and an uncomplicated postoperative course. The infant was resuscitated and discharged after 18 days. In conclusion, traumatic spleen rupture is an etiology to consider in pregnant women presenting with acute abdominal pain following sexual intercourse. Early suspicion and emergent cesarean delivery are the keys to optimize maternal and perinatal outcomes.

A case of pelvic actinomycosis affecting genital, urinary and digestive tracts: a rare misleading diagnosis.

Pelvic actinomycosis is an uncommon chronic invasive disease caused by a bacteria of the Actinomyces spp. Its diagnosis constitutes a clinical challenge and is usually reached in the postoperative period after resecting a pelvic mass that usually mimics advanced ovarian cancer. Although pelvic actinomyocosis involving the digestive and genital tract has been commonly described, very few reports have described cases involving both ovaries and requiring partial cystectomy for bladder involvement. Herein, we illustrate a case of pelvic actinomycosis with extensive involvement of multiple pelvic organs, misleading the surgeon into undergoing a complete clearance of the wrongfully thought adnexal malignancy.