Effect of Sustained Uterine Compression versus Uterine Massage on Blood Loss after Vaginal Delivery: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to compare the effectiveness of sustained uterine compression versus uterine massage in reducing blood loos after a vaginal delivery. STUDY DESIGN: This was a prospective randomized trial conducted at the American University of Beirut Medical Center (AUBMC) between October 2015 and October 2017. Inclusion criteria were women with a singleton pregnancy at ≥36 weeks of gestation, with less than three previous deliveries, who were candidates for vaginal delivery. Participants were randomized into two groups, a sustained uterine compression group (group 1) and a uterine massage group (group 2). Incidence of postpartum hemorrhage (blood loss of ≥500 mL) was the primary outcome. We assumed that the incidence of postpartum hemorrhage at our institution is similar to previously published studies. A total of 545 women were required in each arm to detect a reduction from 9.6 to 4.8% in the primary outcome (50% reduction) with a one-sided α of 0.05 and a power of 80%. Factoring in a 10% dropout rate. Secondary outcomes were admission to intensive care unit (ICU), postpartum complications, drop in hemoglobin, duration of hospital stay, maternal pain, use of uterotonics, or of surgical procedure for postpartum hemorrhage. RESULTS: A total of 550 pregnant women were recruited, 273 in group 1 and 277 in group 2. There was no statistically significant difference in baseline characteristics between the two groups. Type of anesthesia, rate of episiotomy, lacerations, and mean birth weight were also equal between the groups. Incidence of the primary outcome was not different between the two groups (group 1: 15.5%, group 2: 15.4%; p = 0.98). There was no statistically significant difference in any of the secondary outcomes between the two groups, including drop in hemoglobin (p = 0.79). CONCLUSION: There was no difference in blood loss between sustained uterine compression and uterine massage after vaginal delivery. KEY POINTS: · Transabdominal uterine compression and uterine massage are appropriate to prevent postpartum hemorrhage.. · No significant difference in blood loss or maternal discomfort observed between the two techniques.. · Both methods are equally effective and either one can be used based on provider preference..

Intravenous Oxytocin Use to Decrease Blood Loss during Scheduled Cesarean Delivery: A Randomized Double-Blinded Controlled Trial (OXYTRIAL).

Objective The objective of this study was to determine the optimal dose of intravenous oxytocin administered during cesarean delivery (CD) to decrease the amount of blood loss. Methods Out of a total of 226 women presenting for CD, 189 patients were randomized into three groups by a computer-generated random number sequence table. Low-risk women with singleton term pregnancies undergoing scheduled CD were assigned to receive 20, 30, or 40 units (U) of oxytocin diluted in 500 mL of lactated Ringer solution intraoperatively. The primary outcome was the change in hemoglobin from pre-CD to post-CD. Results Overall, 63 women were assigned to each group. The primary outcome which was the drop in hemoglobin (1.4 ± 1.1 g/dL, 1.1 ± 0.8 g/dL, 1.0 ± 1.1 g/dL; p = 0.097) and the total calculated blood loss (798.6 ± 298.3 mL, 794.4 ± 313.5 mL, 820.2 ± 316.2 mL; p = 0.893) were not significantly different among the study groups. The incidence of intraoperative hypotension, postoperative systolic, and diastolic blood pressure changes was similar across the groups. Conclusion The amount of blood loss during CD was not significantly different among the three groups, thus the lowest dose of oxytocin infusion (20 U in 500 mL of lactated Ringer solution) seems to be an appropriate regimen.

Use of antenatal corticosteroids in the management of preterm delivery.

OBJECTIVE: This narrative review of the literature explores the current evidence and recommendations in favor of antenatal corticosteroids use during impending preterm deliveries as well as related issues and concerns. STUDY DESIGN: Synthesis of findings from published medical literature on antenatal corticosteroids and prematurity, retrieved from searches of computerized databases and authoritative texts. RESULTS: It is now recognized that an intramuscular course of betamethasone or dexamethasone given to a woman expected to deliver preterm not only accelerates pulmonary epithelial development but also matures other organ systems, significantly decreasing the chances of neonatal morbidities and increasing chances of survival. CONCLUSION: There remain uncertainties over the efficacy of the established protocol in populations such as the very early preterm, the late preterm, and multiple gestations. Alternative regimens remain controversial because of fear of adverse effects and doubts regarding whether benefits outweigh risks.

A clinical approach to intrahepatic cholestasis of pregnancy.

Intrahepatic cholestasis of pregnancy (ICP) has a varying prevalence worldwide. The etiology behind this disease remains not fully understood with multiple factors influencing its development including genetic variations, dietary factors, hormonal changes, and environmental influences. Presenting mainly during the third trimester with generalized itching and resolving spontaneously postpartum, this condition is still associated with fetal morbidity and mortality. The diagnosis is based on clinical presentation in association with biochemical abnormalities. Elevation in total bile acid levels is the most frequent laboratory abnormality and seems to be the most important for gauging further management of the disease. The most appropriate gestational age for the delivery of women with ICP is yet to be determined. In this review we discuss the epidemiology, clinical features, diagnosis, etiology, and management of ICP, trying to shed light on some controversial aspects of the disease.

Vaccination in pregnancy.

The evidence indicates that pregnancy is associated with increased severity of some infectious diseases. Given the high maternal morbidity associated with influenza in pregnancy and the high neonatal morbidity and mortality associated with pertussis, the traditionally two recommended vaccines during pregnancy were those against influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccines. The recent COVID-19 pandemic introduced a third vaccine that after much debate is now recommended for all pregnant women. Other vaccines can be offered based for high-risk pregnant women, and only when the benefits of receiving them outweigh the risks. The soon expected vaccines against group B streptococcus infection and respiratory syncytial virus infection will be a breakthrough in reducing perinatal mortality. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed.

Effect of parity on maternal and neonatal outcomes in twin gestations.

OBJECTIVE: To compare maternal and neonatal outcomes of twin gestations in nulliparous and multiparous women. DESIGN: Retrospective analysis of maternal and neonatal records. SETTING: American University of Beirut Medical Center, a referral university-affiliated hospital. POPULATION: Pregnant women who delivered twin gestations beyond 24 weeks from 1990 to 2004. METHODS: The data collected were analyzed using Student's paired t-test or χ(2) test. Logistic regression analysis was used to study the effect of multiple variables on preterm delivery. MAIN OUTCOME MEASURE: Preterm birth rate. RESULTS: Nulliparas (n=333) were more likely to be younger (28.1±5.4 vs. 30.0±5.2 years; p<0.001) and the pregnancy a product of assisted reproductive technology (23.1 vs. 4.5%; p<0.001) compared with multiparas (n=508). They were at significantly increased risk of preterm delivery (54.4 vs. 45.1%; p=0.009) at lower gestational age (35.6±3.2 vs. 36.2±3.0 weeks; p=0.004). They had longer first and second stages of labor and a higher cesarean delivery rate (61.3 vs. 44.9%; p<0.001). Except for a higher intensive care nursery admission rate and longer nursery stay for twins of nulliparas, all neonatal morbidities were comparable. On multiple logistic regression analysis, multiparity (relative risk 0.70, 95% confidence interval 0.51-0.97) and growth restriction (relative risk 0.16, 95% confidence interval 0.12-0.22) were protective, while discordance (relative risk 2.24, 95% confidence interval 1.40-3.60) was a predictor of preterm delivery. CONCLUSIONS: Nulliparous women with twin gestations are at significantly higher risk for preterm delivery and cesarean delivery compared with multiparous women. Although this was not translated into higher perinatal mortality, these women should be monitored closely and counseled regarding these risks and their attendant morbidity.

Indomethacin in pregnancy: applications and safety.

Preterm labor (PTL) is a major cause of neonatal morbidity and mortality worldwide. Among the available tocolytics, indomethacin, a prostaglandin synthetase inhibitor, has been in use since the 1970s. Recent studies have suggested that prostaglandin synthetase inhibitors are superior to other tocolytics in delaying delivery for 48 hours and 7 days. However, increased neonatal complications including oligohydramnios, renal failure, necrotizing enterocolitis, intraventricular hemorrhage, and closure of the patent ductus arteriosus have been reported with the use of indomethacin. Indomethacin has been also used in women with short cervices as well as in those with idiopathic polyhydramnios. This article describes the mechanism of action of indomethacin and its clinical applications as a tocolytic agent in women with PTL and cerclage and its use in the context of polyhydramnios. The fetal and neonatal side effects of this drug are also summarized and guidelines for its use are proposed.

Effects of sildenafil in Nω-nitro-L-arginine methyl ester-induced intrauterine growth restriction in a rat model.

OBJECTIVE: To assess the effect of sildenafil citrate in a rat model of Nω-nitro-l-arginine methyl ester (L-NAME)-induced intrauterine growth restriction (IUGR). STUDY DESIGN: An in vivo experimental study was conducted where 40 pregnant Sprague-Dawley rats were randomly assigned to receive either: (1) control, (2) L-NAME 50 mg/kg/d by gavage (days 14 to 19), (3) L-NAME and sildenafil 15 mg/kg/d by gavage, or (4) sildenafil (days 14 to 21). On day 21, a hysterotomy was performed and all fetuses (live and dead) were counted, examined, and weighed. The primary outcome measure was the difference in pup birth weight. RESULTS: The median number of live pups per dam was 11.5 (range: 1 to 15), 13.5 (2 to 17), 13.5 (7 to 16), and 11.5 (4 to 17) in controls, L-NAME, sildenafil, and combined drug groups, respectively (p = 0.02). Rats treated with L-NAME had a significantly higher number of stillbirths compared with control (p = 0.013) and sildenafil (p = 0.008) groups. L-NAME reduced pup birth weight compared with controls (4.53 ± 1.49 versus 5.65 ± 1.63 g, p < 0.001); this effect was more pronounced in the L-NAME and sildenafil groups (3.37 ± 1.25 g, p < 0.001). CONCLUSION: Our data indicate that sildenafil citrate does not ameliorate L-NAME-induced IUGR, and in the doses utilized in this study might even have a synergistic negative effect on pup birth weight.

Practice patterns of obstetric care in twin gestations: the value of MFM consultation.

OBJECTIVES: To evaluate the practice patterns among Lebanese obstetricians regarding obstetric care of twins and to compare selected practice patterns between general obstetricians and maternal fetal medicine physicians. METHODS: Questionnaires distributed during the annual meeting of the Lebanese Society of Obstetrics and Gynecology. RESULTS: Questionnaires were returned by 69.2% of the 296 physicians approached. Ten percent had fellowship training in Maternal Fetal Medicine (MFM). Thirty-nine percent perform cervical length measurement at 20-24 weeks of gestation and 34% recommend vaginal progesterone in case of a short cervix. When comparing selected practice patterns between MFM & general obstetricians, MFM specialists were less likely to perform cervical cerclage in the first trimester (5.9% versus 49%, p = .001), more likely to offer prenatal screening for aneuploidy (66.6% vs 46.4%, p = .03), less likely to use vaginal progesterone in the second trimester in the case of a short cervix (42.1% vs 61.8%, p = .04), less likely to perform serial ultrasound exam in the third trimester to assess fetal growth (50% vs 78%, p = .005) and more likely to deliver monoamniotic twins at 32-34 weeks of gestation (55% vs 37%, p = .05). CONCLUSION: Because of the different background of the Lebanese physicians, MFM specialists are more likely to follow obstetric care guidelines in twin gestation.

Oxytocin antagonists for the management of preterm birth: a review.

Preterm birth, the leading cause of neonatal morbidity and mortality, is estimated at incidence of 12.7% of all births, which has not decreased over the last four decades despite intensive antenatal care programs aimed at high-risk groups, the widespread use of tocolytics, and a series of other preventive and therapeutic interventions. Oxytocin antagonists, namely atosiban, represent an appealing choice that seems to be effective with apparently fewer side effects than the traditional tocolytics. This article reviews the available literature on the pharmacokinetics, mode of administration, and clinical utility of oxytocin antagonists for acute and maintenance tocolysis with special emphasis on its safety profile.

Calcium channel blockers for the management of preterm birth: a review.

Preterm birth continues to be the leading cause of perinatal morbidity and mortality. A wide range of tocolytics have been utilized for the management of preterm labor. Calcium channel blockers, namely nifedipine, gained popularity as tocolytics due to the oral route of administration, availability of immediate- and slow-release preparations, the low incidence of maternal adverse effects associated with their use, and the fact that they are inexpensive. This article reviews the available literature on the clinical utility of calcium channel blockers for acute and maintenance tocolysis with special emphasis on potential adverse effects, the most appropriate dose/regimen, and contemporary practice patterns among obstetricians. There are no randomized, placebo-controlled studies demonstrating the benefit of nifedipine in preterm labor. A suggested tocolytic protocol would be to start with the lowest dose of oral immediate-release nifedipine. For the first 48 hours thereafter, all attempts should be made not to exceed 60-mg daily doses.

Effect of religion on the attitude of primiparous women toward genetic testing.

BACKGROUND: Factors that influence a pregnant woman's decision to accept or decline genetic tests are largely undefined. The objective of this study was to determine the acceptance rate of prenatal diagnostic testing in Lebanon according to religion. METHODS: Prenatal charts were reviewed to obtain information about prenatal genetic testing. Women were divided according to their religion and were compared regarding the acceptance of triple screen test (TST) or amniocentesis (AMN) and reasons for declining such tests. Differences between groups were examined using the student's t-test, chi(2)-test and multivariate analysis (age >or= 35 years, religion, education and class). RESULTS: The religious distribution was 73.8% Moslems, 14.0% Christians and 11.2% Druze. Utilization of TST, AMN, and either (TST/AMN) was 61.2%, 7.6% and 67.0%, respectively. Uptake of TST/AMN was highest in Christians and lowest in Moslems and that of AMN higher in Christians >or= 35 years compared with Moslems. On multivariate analysis, none of the factors studied significantly affected the utilization of TST or TST/AMN except for age >or= 35 years which was associated with a borderline decrease in the utilization of TST Odds Ratio (OR) 0.485 (95% CI 0.21-1.12). The utilization of AMN significantly increased with age >or= 35 years OR 7.19 (95% CI 2.65-19.56) and lower education. CONCLUSION: Religion does not seem to affect utilization of prenatal diagnostic tests in Lebanon.

Ectopic pregnancy in a uterine perforation site.

Uterine perforation can occur following first-trimester abortion or more commonly postpartum after evacuation of retained placental tissues. We report a case of a pregnancy at the site of a recent uterine perforation. Possible mechanisms of this rare condition and different therapeutic options are mentioned.

Advanced maternal age. Part II: long-term consequences.

In addition to the possible association between pregnancy in women with advanced maternal age and increased rates of obstetric and perinatal complications, those women and their children might suffer from long-term sequelae. In this review, the long-term consequences of delayed motherhood on the offspring and the possible association between advanced maternal age and the development of certain cancers are discussed.

A short cervical length in pregnancy: management options.

Measuring cervical length using transvaginal ultrasonography is a useful tool to predict the risk of preterm birth in low- and high-risk pregnancies. Management of a short cervix poses a significant dilemma for clinicians. Different management plans have been proposed and studied, with mixed results in different clinical settings. This article reviews the various management options in the different patient subpopulations and proposes a scheme for management once a short cervix is identified.

Two dose regimens of nifedipine for management of preterm labor: a randomized controlled trial.

We compared two dose regimens of tocolytic oral nifedipine. Women with singleton pregnancies admitted in preterm labor (24 to 34 weeks) were randomized to high-dose (HD) nifedipine ( N = 49; 20 mg loading dose, repeated in 30 minutes, daily 120 to 160 mg slow-release nifedipine for 48 hours followed by 80 to 120 mg daily until 36 weeks) or low-dose (LD) nifedipine ( N = 53; 10 mg, up to four doses every 15 minutes, daily 60 to 80 mg slow-release nifedipine for 48 hours followed by 60 mg daily until 36 weeks). Uterine quiescence at 48 hours (primary outcome); delivery at 48 hours, 34 and 37 weeks; and recurrent preterm labor were similar. Gestational age at delivery was higher in HD (36.0 +/- 2.8 versus 34.7 +/- 3.7 weeks, P = 0.049). Rescue treatment was needed more in LD (24.5 versus 50.9%, odds ratio = 0.3; 95% confidence interval 0.1 to 0.7). Maternal adverse effects, birth weight, intensive care nursery admission, and composite neonatal morbidity were similar. However, neonatal mechanical ventilation was needed less and nursery stay was shorter in HD. HD nifedipine does not seem to have an advantage over LD in achieving uterine quiescence at 48 hours. Further studies should address the optimal dose and formulation of tocolytic nifedipine.

Attitude of women with IVF and spontaneous pregnancies towards prenatal screening.

BACKGROUND: Factors influencing a pregnant woman's decision to accept prenatal testing are largely undefined. Our study aimed to compare the acceptance rate of prenatal diagnosis in women who conceived through IVF or ICSI (cases) with that of women who conceived spontaneously (controls). METHODS: Retrospective chart review in Lebanon of all primiparas carrying singletons who were offered prenatal testing (triple screen/amniocentesis) from 2004-2007. The influence of IVF/ICSI on the acceptance of prenatal screening was evaluated. RESULTS: 336 pregnant women were offered prenatal testing (120 cases and 216 controls). Cases were less likely to perform prenatal testing compared with controls (52.5 versus 72.7%; P < 0.001). The rate of utilization of prenatal testing was independent of the infertility cause. Multiple logistic regression analysis revealed that women who conceived through IVF/ICSI [odds ratio (OR) 0.427, 95% confidence interval (CI) 0.252-0.724], those >or=35 years old (OR 0.184, 95% CI 0.102-0.329) and lower socioeconomic class (OR 0.339, 95% CI 0.197-0.584) were less likely to perform triple screen test, and women who conceived through IVF/ICSI (OR 0.354, 95% CI 0.131-0.958) and those of lower socioeconomic class (OR 0.113, 95% CI 0.033-0.403) were less likely to perform amniocentesis. CONCLUSIONS: There was a significant difference in acceptance rate of prenatal diagnostic testing between women who conceived through IVF/ICSI and those who conceived spontaneously. Women who conceived through IVF/ICSI were less likely to opt for prenatal diagnosis even after controlling for confounding variables.

Obstetric outcome of teenage pregnancies compared with adult pregnancies.

BACKGROUND: To compare the obstetric outcome of teenage pregnancies with that of older women. METHODS: Retrospective chart review of singleton births > or =24 weeks' gestational age at the American University of Beirut from 1994 to 2003. Adolescents (<20 years) were compared to subsequently delivered women aged 25-30 years (controls), n=486 each. RESULTS: Only 131 (27.0%) adolescents were <18 years. More adolescents were nulliparous (79.8 versus 17.9%; p<0.0001). Preterm delivery <37 but not <34 weeks occurred more frequently in cases (11.1 versus 5.8%, p=0.004). Pre-eclampsia was more commonly encountered (2.9 versus 0.6%; p=0.012) and mean predelivery haematocrit was lower in cases (30.6+/-3.3 versus 33.8+/-4.3%, p<0.001), but the incidence of gestational diabetes, placenta previa, abruptio placentae, breech presentation, or meconium-stained amniotic fluid were similar. Caesarean delivery was performed less frequently in cases (9.2 versus 14.0%; p=0.028), but primary caesarean and operative vaginal delivery rates were similar though vacuum was used more frequently in multiparous controls (0.2 versus 2.7%, p=0.011). Nulliparous cases had shorter first and second stages of labour (384+/-304 versus 524+/-339 min, p<0.0001 and 47+/-36 versus 63+/-50 min, p=0.002), respectively. Mean birth weight was higher in controls (3177+/-567 versus 3284+/-511 g, p<0.001), but intrauterine growth restriction, birth weight <2500 g, low Apgar scores, intrauterine fetal death, and stillbirths were similar in both groups. CONCLUSIONS: Adolescents are more likely to deliver preterm than older women, and are more likely to suffer from anaemia and pre-eclampsia. Nulliparous adolescents have a quicker progress of labour while multiparous adolescents require vacuum less frequently compared to their older counterparts. In most other respects, they have comparable maternal and perinatal morbidity.

Shoulder dystocia: what is the risk of recurrence?

OBJECTIVE: To study the recurrence risk of shoulder dystocia in women who have previously experienced at least once shoulder dystocia. DESIGN: A retrospective study of vaginal deliveries complicated by shoulder dystocia. Setting. American University of Beirut Medical Center - Lebanon. SAMPLE: Vaginal deliveries complicated by shoulder dystocia over a 15-year period who had subsequent vaginal delivery. Methods. Charts of index and subsequent deliveries beyond 24 weeks' gestation were reviewed for demographics and intrapartum events. Women were divided into those with recurrent shoulder dystocia (group I) and those with uncomplicated subsequent delivery (group II) and compared. MAIN OUTCOME MEASURES: Recurrent shoulder dystocia and characteristics of women with recurrence. RESULTS: The incidence of shoulder dystocia was 0.9% of all vaginal deliveries. Of 193 shoulder dystocia cases, 48 women had a subsequent delivery. After excluding cesarean deliveries (n=4), 44 women were analyzed. Eleven had recurrent shoulder dystocia (25.0%). Mean birthweight was larger (4,019+/-430 vs. 3,599+/-398 g, p=0.005) with a higher rate of macrosomia > or =4,000 g (63.6 vs. 15.2%, p=0.004) and the birthweight in the subsequent pregnancy was larger than the index pregnancy in a significantly larger proportion of women in group I compared with group II (72.7% vs. 33.3%, p=0.035). Otherwise, maternal age, gestational age at delivery, parity, duration of labor, gender, history of macrosomia, and interval between pregnancies were similar. CONCLUSIONS: The risk of recurrence of shoulder dystocia is around 25%. When counseling women about recurrence risk, the absence of macrosomia and a smaller birthweight than the previous pregnancy could be reassuring.

Advanced maternal age. Part I: obstetric complications.

More women are postponing pregnancy into the fourth and fifth decades of life for a variety of reasons. Advanced maternal age, traditionally defined as age more than 35 years, has been associated with increased obstetric morbidity and interventions. In addition, perinatal complications are reported to be higher in this patient population, although recent data point to a more favorable outcome. This article reviews the available literature with special emphasis on antepartum, intrapartum, and postpartum complications and perinatal outcome.