Impact of interval between induction of spinal anesthesia to delivery on umbilical arterial cord ph of neonates delivered by elective cesarean section.

BACKGROUND: To evaluate the impact of interval between induction of spinal anesthesia to delivery of the fetus by elective cesarean section on umbilical arterial pH and neonatal outcome. PATIENTS AND METHODS: Two hundred and twenty pregnant women who were planned for elective cesarean section at term under spinal anesthesia were recruited. Minimum systolic, diastolic and mean arterial blood pressures (SBP, DBP, MAP) and largest pressure decrease (SBP, DBP, MPA) were also recorded. Induction of spinal anesthesia to delivery interval was measured. Following delivery, umbilical arterial cord analysis for pH and base deficit were done. Apgar scores at 1 min and at 5 min, neonatal intensive care unit (NICU) admission, need for mechanical ventilation and incidence of hypoxemic-ischemic encephalopathy were recorded. RESULTS: Induction of spinal anesthesia to delivery interval was 25.7 ± 5.6 min. Lowest SBP and MAP reached during cesarean delivery were 88.9 ± 7.3 mmHg and 60.4 ± 5.6 mmHg, respectively. MAP < 65 mmHg was reached in 136 (62%) patients with a decrease of MAP of > 20% in 149 (68%) patients. Duration of the longest hypotension episode was 3.3 ± 2.2 min. All patients required ephedrine administration for hypotensive episodes with an average dosage of 11.4 ± 3.2 mg. Umbilical pH of 7.3 ± 0.1 and base deficit of 8.3 ± 4.4 mmol/l were recorded. Apgar scores at 5 min were 8.5 ± 1.2. Eight (3.6%) neonates were admitted in the NICU. One neonate needed mechanical ventilation. There were no cases of hypoxemic-ischemic encephalopathy. There were inverse correlations between induction of spinal anesthesia to delivery interval, body mass index (BMI) and duration of longest hypotension episode in relation to umbilical pH (r = -0.817, -0.395 and -0.268, respectively). Cut off value for induction of spinal anesthesia to delivery interval greater than 27 min predicted an umbilical pH of < 7.2. Cut off value for the duration of the longest hypotension episode greater than 5 min predicted an umbilical pH of < 7.2. Cut off value for BMI greater than 35 kg/m2 predicted an umbilical pH of < 7.2. CONCLUSION: Prolonged interval between induction of spinal anesthesia to delivery could be associated with neonatal acidosis. This could be aggravated by maternal obesity and prolonged duration of hypotension episodes during cesarean delivery.

The Prediction of Recurrence in Low-Risk Endometrial Cancer: Is It Time for a Paradigm Shift in Adjuvant Therapy?

Five to 10% of patients with stage IA, grade 1 or 2, endometrioid adenocarcinoma subsequently develop locoregional or distant recurrence. These patients have significantly reduced 5-year survival rates and salvage therapy success rates as low as 40%. The aim of this review is to highlight knowledge gaps that could further refine the risk categories of endometrial carcinoma (EC) and guide future randomized trials of adjuvant therapy for low-risk EC. A systematic search of the literature on PubMed and Medline was conducted using the following search terms: endometrial cancer, endometrial adenocarcinoma, endometrioid adenocarcinoma, low grade, early stage, stage IA, low risk, locoregional recurrence, and relapse. Relevant primary studies were extracted and included in this review. Risk factors for recurrence of low-risk EC were epidemiological (age, body mass index, ethnicity), molecular (DNA MMR, MSI, TP53 mutation and P53 defect, CTNNB1 mutation, PTEN and POLE mutation, L1CAM expression), pathological (positive peritoneal cytology, lymphovascular invasion, tumor size), and others like Ki67-percentage, micro-RNA expression, and hormonal receptor expression. CTNNB1 mutation, L1CAM expression, lymphovascular invasion, and tumor size were identified as significant risk factors for recurrence in low-risk EC. There are subsets of low-risk EC patients at high risk of recurrence and should be suspected when having the following risk factors: positive molecular markers, large tumor size, and lymphovascular invasion. A novel scoring system and randomized controlled trials should be conducted to identify these patients who will benefit most from adjuvant therapy to avoid recurrence.

Correlation between pre-operative diagnosis and final pathological diagnosis of endometrial malignancies; impact on primary surgical treatment.

OBJECTIVES: to compare the accuracy of preoperative and postoperative endometrial sampling obtained by dilatation and curettage (D&C), Pipelle and hysteroscopy to diagnose endometrial malignancies and to evaluate the adequacy of surgical treatment for these patients. STUDY DESIGN: This retrospective record-based study was conducted at Gynecology Oncology Unit, Ain Shams University Maternity Hospital, Cairo, Egypt. Records of patients with an initial preoperative or a final postoperative pathological diagnosis of endometrial hyperplasia or endometrial malignancies were retrieved over a six year period from January 2013 until March 2019. The preoperative biopsy methods, results, postoperative pathology diagnosis and treatment received were recorded and analyzed. RESULTS: Records of 395 patients were retrieved. Rates of agreement between initial and postoperative pathology for endometrial hyperplasia (with and without atypia) were 10% by D&C, 7.8% by Pipelle and zero % by hysteroscopy; for endometrioid adenocarcinoma grade 1, they were 40.7% by D&C, 40.6% by Pipelle and 20% by hysteroscopy; for endometrioid adenocarcinoma grades 2 and 3, they were 83.7% and 84.6% by D&C, 97% and 60% by Pipelle, and 100% by hysteroscopy, respectively. For type II endometrial cancer and endometrial stromal sarcoma, agreement rates were 100% by all biopsy methods. Out of 13 cases diagnosed with atrophic endometrium preoperatively, 11 cases were diagnosed as endometrial stromal sarcoma. Comparing accuracy of the three biopsy methods, D&C had highest sensitivity of 61.9%; hysteroscopy showed 100% specificity, while Pipelle was the least accurate method. Finally, 61.4% of the patients received adequate surgical treatment. CONCLUSION: There were excellent concordance rates between initial biopsy and postoperative pathology in diagnosis of high grade endometrioid and other endometrial malignancies compared to endometrial hyperplasia and low grade endometrioid adenocarcinoma. Patients diagnosed initially with atrophic endometrium or hyperplasia warranted more surveillance before their surgical treatment. It is crucial to develop protocols for increasing accuracy of endometrial sampling such as performing molecular studies for preoperative pathology.

Bone Health Assessed by Calcaneal Quantitative Ultrasound among Cohort of Pregnant Egyptian Women.

AIM: The aim was to assess the risk of osteopenia and osteoporosis and to identify possible risk factors affecting bone density (BD) during pregnancy as parity, body mass index (BMI), Vitamin D, and calcium supplementation using quantitative ultrasound (QUS) of the calcaneus among first- and third-trimester pregnant women. METHODS: It is a case-control study conducted at Ain Shams Maternity Hospital, Egypt, from May 7 to December 14, 2015. One hundred and thirty-two women in the third trimester and 33 matched controls in the first trimester were screened for BD at the calcaneus by QUS. Stiffness index (SI), QUS-T, and Z scores were measured. RESULTS: Comparing both the groups regarding QUS-T score, Z score, and SI showed a statistically significant difference between both groups. Third-trimester participants had lower scores (-0.72 ± 1.0, -0.63 ± 0.99, and 88.53 ± 14.81, respectively) compared to their matched controls (1.05 ± 0.89, 1.16 ± 0.91, and 113.79 ± 12.49, respectively). According to QUS-T scores, 82 women (62.1%) in the third-trimester group were assessed as having normal BD, whereas 47 women (35.6%) were at risk of being osteopenic and 3 women (2.3%) were at risk of being osteoporotic. All women of the first trimester were assessed as having normal BD. Logistic regression was performed to identify possible risk factors affecting BD among third-trimester patients. BMI was the only statistically significant predictor for changes in bone health in those women (P = 0.001, odds ratio: 0.857, 95% confidence interval: 0.786-0.936). CONCLUSION: With one-unit rise in BMI, a 14% reduction in risk of decreased bone health is obtained.

Combined measurement of fetal lung volume and pulmonary artery resistance index is more accurate for prediction of neonatal respiratory distress syndrome in preterm fetuses: a pilot study.

OBJECTIVE: The objective of this study is to estimate optimal cut-off values for mean fetal lung volume (FLV) and pulmonary artery resistance index (PA-RI) as non-invasive measures to predict neonatal respiratory distress syndrome (RDS) in preterm fetuses. METHODS: A prospective study conducted at Ain Shams University Maternity Hospital, Egypt from May 2015 to July 2017: 80 eligible women diagnosed with preterm labor were recruited at 32-36 weeks' gestation. Before delivery, three-dimensional ultrasound was used to estimate FLV using virtual organ computer-aided analysis (VOCAL), while PA-RI was measured by Doppler ultrasonography. RESULTS: A total of 80 women were examined. Thirty-seven (46%) of the newborns developed neonatal RDS. FLV was significantly lower in neonates who developed RDS (p = .04), whereas PARI was significantly higher in those who did not (p = .02). Cut-off values of FLV ≤27.2 cm3 and PARI ≥0.77 predicted the subsequent development of RDS. Combining both cut-offs generated a more sensitive and specific methodical approach for the prediction of RDS (sensitivity 100%, specificity 88.5%). CONCLUSION: Measurement of FLV or PA-RI can predict RDS in preterm fetuses. Combined use of both measures bolstered their predictive significance.

Chlamydia trachomatis infection in primary fallopian tube and high-grade serous ovarian cancers: a pilot study.

BACKGROUND: The aim of this study was to evaluate the association of Chlamydia trachomatis (CT) infection with primary tubal and high-grade serous ovarian cancers. METHODS: This is a cross-sectional, retrospective study conducted at Ain Shams University Maternity Hospital, Egypt, from February 2008 to October 2017. Sixty-seven paraffin archival blocks specimens were retrieved from cases who underwent staging laparotomy due to high-grade serous ovarian cancer (30 cases), primary tubal serous cancer (25 cases), and control specimens of (12) tubal specimens from cases of benign gynecological conditions. All samples were examined for CT DNA using semiquantitative qRT-PCR. RESULTS: CT DNA was detected in 84% of high-grade tubal serous cancer, 16.7% of high-grade serous ovarian cancer, and 13.3% in controls (P<0.0005). Mean CT DNA relative quantity was significantly high (256) in tubal carcinoma, in comparison to that in high-grade serous ovarian cancer and controls (13.5 and 0.28, respectively; P<0.0005). CONCLUSION: To the best of our knowledge, this is the first report on relation of CT to the tubal serous cancer, so the responsibility of CT tubal infection in the pathogenesis of primary tubal cancer needs to be considered.

Intravenous carbetocin shot is superior to oxytocin infusion for placental delivery in second trimester abortion: a pilot randomized controlled trial.

OBJECTIVE: To study the efficacy of 100 µg intravenous shot of carbetocin compared to 20 IU oxytocin intravenous infusion to prevent placental retention in second trimester medical termination of pregnancy. METHODS: A double-blinded randomized controlled trial was conducted at Ain Shams University Maternity Hospital from 1 April 2013 to 30 November 2013. A total of 132 women between 14 and 24 weeks gestation indicated for termination were randomized to receive either 20 IU oxytocin infusion (n = 66) or 100 µg carbetocin shot (n = 66) after fetal expulsion. Patients were observed for time elapsed between fetal and placental expulsion, presence of placental retention and blood loss. RESULTS: Third stage was 33.4 ± 20.4 min in oxytocin group & 23.1 ± 16.8 min in carbetocin group (p = 0.002). Eight patients (12.1%) in oxytocin group had complete placental retention versus two patients (3.0%) in carbetocin group (p = 0.05). Eight patients (13.8%) received oxytocin had remnants of placenta compared to four patients (6.2%) received carbetocin (p = 0.04). Sixteen patients (24.2%) received oxytocin and six patients (9%) received carbetocin needed surgical curettage (p = 0.04). Third stage blood loss was 87.2 ± 33.7 ml in carbetocin and 206.9 ± 35.2 ml in oxytocin groups (p = 0.001). CONCLUSION: Carbetocin is superior to oxytocin infusion for management of placental delivery in second trimester abortion.

Percentage of CD3-CD56+dim and of CD3-CD56+dimCD69+ Natural Killer Cells in the Peripheral Blood of Women with In Vitro Fertilization (IVF) Failure.

CD56dim cells, potent mediators of natural cytotoxicity, have direct contact with chorionic villi at the intervillous space. The manner the developing fetus evades NK cytotoxicity from these cells may determine the pregnancy outcome. CD69 is one of the earliest cell surface activation markers expressed by NK cells. In vitro models demonstrated that activated CD69+ NK cells are capable of lysing trophoblasts. This study aimed to investigate the relation between the percentage of these NK cells in peripheral blood and infertility. The study included two groups, each of 30 women, one with previous implantation failure and a fertile matching control group. CD3-CD56+dim and CD3-CD56+dimCD69+ NK were analyzed by flow cytometry. A higher percentage of CD3-CD56+dim and CD3-CD56+dimCD69+ in the study group than the control group was observed (P=0.0001 and P=0.003, respectively). Fair predictive values were evidenced by ROC curve analysis. We conclude that increase in CD56+dim NK and CD56+dim CD69+ NK cell percentages may be related to infertility problems.

Endometrial Volume Measured by VOCAL Compared to Office Hysteroscopy for Diagnosis of Endometrial Polyps in Premenopausal Women with Abnormal Uterine Bleeding.

The aim is to compare hysteroscopy, two-dimensional transvaginal ultrasound (2D TVUS), and three-dimensional (3D) Virtual Organ Computer-aided AnaLysis™ (VOCAL) to detect endometrial polyps (EPs) in premenopausal women with abnormal uterine bleeding (AUB). This prospective study was done at Ain Shams Maternity Hospital, Egypt, from March 5, 2015, to December 30, 2015, enrolling 118 premenopausal women with AUB. 2D TVUS, 3D VOCAL, and hysteroscopy were done. 109 patients reached final analysis. 36 women (33%) were diagnosed with EP by 2D TVUS. 50 (45.9%) had EP by hysteroscopy. Endometrial thickness was 10.1 mm by 2D TVUS and endometrial volume was 4.92 mL by VOCAL in women with EP by hysteroscopy compared to 9.9 mm and 3.50 mL in women with no EP, respectively (P = 0.223; P = 0.06). 2D TVUS has sensitivity, specificity, and positive and negative predictive values of 54%, 84.7%, 75%, and 68.5%, respectively. Endometrial thickness of >7.5 mm has sensitivity, specificity, positive and negative predictive values, and overall accuracy of 82%, 37.3%, 52.6%, 71%, and 57.8%, respectively. Endometrial volume of >1.2 mL has sensitivity, specificity, positive and negative predictive values, and overall accuracy of 90%, 42.4%, 57%, 83.3%, and 64.2%, respectively. 3D VOCAL may be used as a noninvasive method for the diagnosis of EP in premenopausal women with AUB.

Endometrial Injury May Increase the Pregnancy Rate in Patients Undergoing Intrauterine Insemination: An Interventional Randomized Clinical Trial.

OBJECTIVE: This study aimed to investigate the effect of endometrial injury using Pipelle catheter in the follicular phase (cycle day 5, 6, or 7) of the stimulation cycle on pregnancy rates in patients undergoing intrauterine insemination. METHODS: This prospective randomized controlled study was carried out in the Assisted Reproductive Technology Unit of Ain Shams University Maternity Hospital, Cairo, Egypt, from July 1, 2013 to August 31, 2015. Three hundred sixty women, 20 to 35 years of age, with patent fallopian tubes, mild male factor infertility, or unexplained infertility were recruited. Participants were allocated randomly into 2 groups: experimental arm and control arm. Women in the experimental arm underwent endometrial biopsy using a Pipelle catheter on day 5, 6, or 7 of the stimulation cycle combined with intrauterine insemination. Women in the control group underwent intrauterine insemination with no endometrial biopsy done. The primary outcomes were the clinical and chemical pregnancy rates. RESULTS: Data of 344 participants were statistically analyzed. The chemical pregnancy rate was 23.66% in the experimental arm and 10.85% in the control arm (P = .002). The clinical pregnancy rate was 18.93% in the experimental arm and 7.42% in the control arm (P = .003). CONCLUSION: Endometrial injury using a Pipelle catheter in the stimulation cycle may improve pregnancy rates in women undergoing intrauterine insemination.

Prediction of neonatal respiratory distress syndrome in term pregnancies by assessment of fetal lung volume and pulmonary artery resistance index.

OBJECTIVE: To develop reference cutoff values for mean fetal lung volume (FLV) and pulmonary artery resistance index (PA-RI) for prediction of neonatal respiratory distress syndrome (RDS) in low-risk term pregnancies. METHODS: As part of a cross-sectional study, women aged 20-35 years were enrolled and admitted to a tertiary hospital in Cairo, Egypt, for elective repeat cesarean at 37-40 weeks of pregnancy between January 1, 2012, and July 31, 2013. FLV was calculated by virtual organ computer-aided analysis, and PA-RI was measured by Doppler ultrasonography before delivery. RESULTS: A total of 80 women were enrolled. Neonatal RDS developed in 11 (13.8%) of the 80 newborns. Compared with neonates with RDS, healthy neonates had significantly higher FLVs (P<0.001) and lower PA-RIs (P<0.001). Neonatal RDS is less likely with FLV of at least 32 cm(3) or PA-RI less than or equal to 0.74. Combining these two measures improved the accuracy of prediction. CONCLUSION: The use of either FLV or PA-RI predicted neonatal RDS. The predictive value increased when these two measures were combined.

Prediction of Fetal Hypertrophic Cardiomyopathy in Diabetic Pregnancies Compared with Postnatal Outcome.

OBJECTIVE: The aim of this study was to estimate the accuracy of prenatal assessment of interventricular septum (IVS) thickness, right myocardial wall thickness (RMWT), and left myocardial wall thickness (LMWT) by two-dimensional (2D) ultrasound for the prediction of perinatal mortality and postnatal diagnosis of hypertrophic cardiomyopathy (HCM) among diabetic pregnant women. SUBJECTS AND METHODS: A total of 120 diabetic pregnant women at 35 weeks or more were enrolled in this study from January 1, 2012, to June 30, 2014, at Ain Shams Maternity Hospital, Cairo, Egypt. The 2D ultrasound was done once for all the participants at the time of recruitment; IVS thickness, RMWT, and LMWT were measured. The glycosylated hemoglobin (HbA1c) levels of the participants were recorded. Neonatal assessment including postnatal echocardiography was done after 48 hours. Postnatal results were compared with the prenatal predictive results. RESULTS: Higher thickness values for IVS, RMW, and LMW were obtained in the uncontrolled diabetic cases (HbA1c > 6.5%) than in the controlled diabetic cases (HbA1c < 6.5%; P < 0.01). Of the included 120 neonates, 10 (8.3%) were stillborn, 99 (82.5%) had a five-minute Apgar score ≥7, and 4 (3.3%) had a five-minute Apgar score ≤3. The four neonates with severe neonatal distress died after admission to neonatal intensive care unit within one week after delivery. Out of 110 live-born neonates, 4 (3.6%) neonates had a low ejection fraction (EF) (<50%) due to HCM; of them 2 (1.8%) died within one week after delivery, while 2 (1.8%) survived. Another two (1.8%) neonates died from severe respiratory distress syndrome. A cutoff value of ≥4.5 mm for prenatal IVS thickness was predictive of neonatal distress due to HCM with a sensitivity of 82%, specificity of 68%, and diagnostic accuracy of 72%. A cutoff value of <1.18 for the ratio of IVS thickness to LMWT had a sensitivity of 82%, specificity of 72%, and diagnostic accuracy of 74% for the prediction of neonatal distress due to HCM. In this study, 8 of the 10 fetuses with intrauterine demise and the 2 neonates who died within one week after delivery due to heart failure had a prenatal IVS thickness of ≥4.5 mm, while 7 of the 10 fetuses with intrauterine demise and the 2 neonates who died postnatal from heart failure had a prenatal IVS thickness to LMWT ratio of ≤1.18. CONCLUSION: A prenatal IVS thickness of ≥4.5 mm or an IVS/LMWT ratio of ≤1.18 seems to be predictive of HCM and is associated with almost twofold higher risk of intrauterine fetal death and almost threefold higher risk of possibly relevant perinatal mortality.

Placenta accreta is associated with decreased decidual natural killer (dNK) cells population: a comparative pilot study.

OBJECTIVE: Placenta accreta is a general term describes abnormal adherent placenta to the uterine wall. When the chorionic villi invade the myometrium, the term placenta increta is appropriate. Nowadays, it is one of the increasing causes of materno-fetal morbidities and mortality. The aim of this research was to evaluate density of decidual natural killer cells (dNK, CD56+(bright)) in decidua basalis in patients with placenta accreta. STUDY DESIGN: We recruited 76 patients from Ain Shams Maternity Hospital between June 2012 to August 2013, they were divided into study subgroup (A) which included 10 patients who underwent cesarean hysterectomy due to unseparated placenta accreta, study subgroup (B) included 16 patients with separated placenta accreta, a comparison group included 25 patients with placenta previa and a control group included 25 patients with normally situated placenta. All patients underwent elective cesarean delivery. Decidual biopsies were taken during the operation. An immunohistochemical staining for (dNK, CD56+(bright)) and a semi quantitative scoring were done. One-way ANOVA and Fisher Exact tests were used for statistical correlation. RESULTS: The mean dNK cells scores were (0.4±0.5, 1.9±1, 3.3±0.5 and 3.5±0.5) for study subgroups (A), (B) comparison and control groups respectively) with a highly significant statistical difference (P<0.001). There was a significant statistical difference between study subgroups (A) and (B) P=0.002 .There was an insignificant statistical correlation between dNK scores and number of previous uterine scars (P=0.46). CONCLUSION: These findings suggest that low dNK score was associated with cases of morbidly adherent placenta accreta.