Diagnostic accuracy of ultrasound in the diagnosis of Placenta accreta spectrum: systematic review and meta-analysis.

OBJECTIVE: To evaluate the diagnostic accuracy of ultrasound and in the diagnosis of Placenta accreta spectrum (PAS). DATA SOURCES: Screening of MEDLINE, CENTRAL, other bases from inception to February 2022 using the keywords related to placenta accreta, increta, percreta, morbidly adherent placenta, and preoperative ultrasound diagnosis. STUDY ELIGIBILITY CRITERIA: All available studies- whether were prospective or retrospective- including cohort, case control and cross sectional that involved prenatal diagnosis of PAS using 2D or 3D ultrasound with subsequent pathological confirmation postnatal were included. Fifty-four studies included 5307 women fulfilled the inclusion criteria, PAS was confirmed in 2025 of them. STUDY APPRAISAL AND SYNTHESIS METHODS: Extracted data included settings of the study, study type, sample size, participants characteristics and their inclusion and exclusion criteria, Type and site of placenta previa, Type and timing of imaging technique (2D, and 3D), severity of PAS, sensitivity and specificity of individual ultrasound criteria and overall sensitivity and specificity. RESULTS: The overall sensitivity was 0.8703, specificity was 0.8634 with -0.2348 negative correlation between them. The estimate of Odd ratio, negative likelihood ratio and positive likelihood ratio were 34.225, 0.155 and 4.990 respectively. The overall estimates of loss of retroplacental clear zone sensitivity and specificity were 0.820 and 0.898 respectively with 0.129 negative correlation. The overall estimates of myometrial thinning, loss of retroplacental clear zone, the presence of bridging vessels, placental lacunae, bladder wall interruption, exophytic mass, and uterovesical hypervascularity sensitivities were 0.763, 0.780, 0.659, 0.785, 0.455, 0.218 and 0.513 while specificities were 0.890, 0.884, 0.928, 0.809, 0.975, 0.865 and 0.994 respectively. CONCLUSIONS: The accuracy of ultrasound in diagnosis of PAS among women with low lying or placenta previa with previous cesarean section scars is high and recommended in all suspected cases. TRIAL REGISTRATION: Number CRD42021267501.

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.

Evaluation of the adenosine deaminase (ADA) G22A gene polymorphism with recurrent spontaneous abortion among Egyptian patients.

INTRODUCTION: Adenosine and deoxyadenosine metabolism is influenced by adenosine deaminase (ADA) enzyme. ADA increases in different diseases and is considered as one of the markers for cell-mediated immunity. Pregnancy is associated with depressed cell-mediated immunity. The level of ADA expression, which seems to play a key role in maintaining pregnancy, is influenced by adenosine deaminase G22A gene polymorphism. We aimed in our study to evaluate the association of ADA G22A gene polymorphism with recurrent spontaneous abortion (RSA) in Egyptian women. MATERIAL AND METHODS: Adenosine deaminase G22A gene polymorphism was genotyped in 40 patients (age range 22-39 years) with a history of RSA, selected from those attending the Gynaecology and Obstetrics Clinic of Beni-Suef University Hospital, and 20 age-matched healthy women as a control group, using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. RESULTS: In our study, no statistically significant difference was found between RSA patients and control group as regards ADA G22A genotypes (p = 0.653) and alleles (p = 0.697). A comparison of the frequencies of ADA alleles in RSA patients as regards the below-35-years-old age group revealed that ADA 2(A) allele was associated with a low risk for RSA in patients aged 35 years old or younger (p = 0.008). CONCLUSIONS: In conclusion, our study revealed an age-dependent protective value of ADA 2(A) allele in recurrent spontaneous abortions among the Egyptian population.

Addition of sildenafil citrate for treatment of severe intrauterine growth restriction: a double blind randomized placebo controlled trial.

Background: Severe intrauterine growth restriction complicates approximately 0.4% of the pregnancies. It increases the risk of perinatal morbidity and mortality.Subjects and methods: A double blind placebo controlled trial was conducted in Beni Suef University hospitals during 2017. It included 46 pregnant women with severe intrauterine growth restriction. Women were randomly allocated into two groups each included 23 patients. Intervention group received sildenafil citrate 20 mg orally three times a day, in addition to fish oil and zinc supplementation. Control group received tablets similar to sildenafil and the same treatment as intervention group. Primary outcomes included improvement in umbilical and middle cerebral arteries pulsatility indices and abdominal circumference.Results: Umbilical and middle cerebral arteries Doppler indices showed significant difference between groups after intake of sildenafil. Umbilical artery pulsatility index decreased significantly (p value = .001) while middle cerebral artery pulsatility index increased significantly in intervention group (p value0.001). Moreover, abdominal circumference growth velocity improved after two weeks of sildenafil intake (p value = .001).Conclusions: Sildenafil citrate may improve uteroplacental and fetal cerebral perfusion in pregnancies complicated by severe intrauterine growth restriction. It also improves abdominal circumference growth velocity. A wide scale randomized trials are needed for evaluation of neonatal and long term morbidity and mortality outcomes of pregnancies treated by sildenafil citrate.

Does Adding Fluoxetine to Combined Oral Contraceptives Containing Drospirenone Improve the Management of Severe Premenstrual Syndrome? A 6-Month Randomized Double-Blind Placebo-Controlled Three-Arm Trial.

To compare efficacy of combined use of fluoxetine and combined oral contraceptives (COC) versus COC alone in treating severe premenstrual syndrome (PMS), a randomized double-blind placebo-controlled three-arm trial was conducted at Cairo and Beni-Suef University Hospitals. PMS was diagnosed prospectively using the Daily Record of Severity of Problems (DRSP). Three hundred women with severe PMS were randomly divided into three equal groups. Group 1 received oral fluoxetine 20 mg daily in addition to COC containing drospirenone daily for 21 days. Group 2 received COC containing drospirenone daily for 21 days in addition to daily oral placebo. Group 3 received placebo similar to COC and oral placebo similar to fluoxetine. Drug duration was 6 months, and women kept daily records of their symptoms using the Daily Record of Severity of Problems (DSRP) form. The main outcome was the number of women with improved PMS in the final cycle of treatment. Women with improved PMS decreased progressively between groups during last treatment month (65% vs. 50% and 2% respectively; p < 0.0001). Combined use of fluoxetine and COC containing drospirenone is superior to COC in severe PMS.

Randomized controlled trial of the effect of endometrial injury on implantation and clinical pregnancy rates during the first ICSI cycle.

OBJECTIVE: To assess whether endometrial injury in the cycle preceding controlled ovarian hyperstimulation during intracytoplasmic sperm injection (ICSI) improves the implantation and pregnancy rates. METHODS: Between January 1, 2016, and March 31, 2017, a randomized controlled trial was conducted at a center in Egypt among 300 women who met inclusion criteria (first ICSI cycle, aged <40 years, day-3 follicle-stimulating hormone <10 IU/L, normal serum prolactin, no uterine cavity abnormality). The women were randomly allocated using a web-based system to undergo endometrial scratch in the cycle preceding controlled ovarian hyperstimulation (n=150) or to a control group (n=150). Only data analysts were masked to group assignment. The primary outcomes were the implantation and clinical pregnancy rates at 14 days and 4 weeks after embryo transfer, respectively. Analyses were by intention to treat. RESULTS: The implantation rate was significantly higher in the endometrial scratch group (41.3% [90/218]) than in the control group (30.0% [63/210]; P<0.001). The clinical pregnancy rate was also significantly higher in the endometrial scratch group (44.2% [61/138]) than in the control group (30.4% [41/135]; P<0.001). CONCLUSION: Endometrial injury in the cycle preceding the stimulation cycle improved implantation and pregnancy rates during ICSI. CLINICALTRIALS.GOV: NCT02660125.

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.

Doppler and biochemical assessment for the prediction of early pregnancy outcome in patients experiencing threatened spontaneous abortion.

OBJECTIVE: To evaluate the usefulness of Doppler indices of the corpus luteum and uterine artery in combination with serum progesterone and cancer antigen 125 (CA125) as prognostic tools in first-trimester threatened spontaneous abortion. METHODS: Pregnant women with threatened spontaneous abortion at a pregnancy duration 8-10 weeks were enrolled into an observational prospective clinical trial at a university hospital in Egypt during 2015. Doppler indices (uterine artery/corpus luteum resistance index and pulsatility index) and biochemical markers (CA125, progesterone) were determined and compared by pregnancy outcome (spontaneous abortion vs continuing pregnancy at 20 weeks). RESULTS: Of 100 women included, 16 had a spontaneous abortion. These women had a higher CA125 value than did women without an abortion (P<0.001), whereas the progesterone level among women with an abortion was lower (P<0.001). The Doppler indices were not significantly different between the groups, but calculation of the uterine artery resistance index as a percentage of the normal standard value at a given pregnancy duration revealed significant differences (P<0.001) between the two groups. CONCLUSION: Serum progesterone and CA125 are useful provisional predictors of spontaneous abortion, whereas the Doppler indices are not. The two biomarkers could be used as a basis to counsel anxious couples. CLINICALTRIALS.GOV: NCT02420769.

Diagnostic accuracy of serum miR-122 and miR-199a in women with endometriosis.

OBJECTIVE: To evaluate the value of serum microRNA-122 (miR-122) and miR-199a as reliable noninvasive biomarkers in the diagnosis of endometriosis. METHODS: During 2015-2016, at a teaching hospital in Egypt, a prospective cohort study was conducted on 45 women with pelvic endometriosis and 35 women who underwent laparoscopy for pelvic pain but were not diagnosed with endometriosis. Blood and peritoneal fluid (PF) samples were collected; interleukin-6 (IL-6) was detected by enzyme-linked immunosorbent assay and miR-122 and miR-199a expression was measured by quantitative real-time polymerase chain reaction. RESULTS: The serum and PF levels of IL-6, miR-122, and miR-199a were significantly higher in women with endometriosis than in controls (P<0.001 for all comparisons). Serum miR-122 expression was positively correlated with serum IL-6 (r=0.597), PF IL-6 (r=0.603), PF miR-122 (r=0.934), serum miR-199a (r=0.727), and PF miR-199a (r=0.653). Serum miR-199a expression was positively correlated with serum IL-6 (r=0.677), PF IL-6 (r=0.678), PF miR-122 (r=0.744), and PF miR-199a (r=0.932). Serum miR-122 and miR-199a had a sensitivity of 95.6% and 100.0%, and a specificity of 91.4% and 100%, respectively, for the detection of endometriosis. CONCLUSION: Serum miR-122 and miR-199a were significantly increased in endometriosis, indicating that these microRNAs might serve as biomarkers for the diagnosis of endometriosis.