Center-by-center results of a multicenter prospective trial to determine the inter-observer correlation of the simplified POP-Q in describing pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This study was conducted to determine the differences in the inter-observer agreement of the simplified Pelvic Organ Prolapse Quantification (POP-Q) system from center to center in a large international multicenter study. METHODS: This is a secondary analysis of the results of a large prospective single blind multicenter trial studying the inter-observer agreement of a simplified POP-Q exam. Twelve centers from four continents with a total of 511 subjects were included in this study. The number of subjects recruited per center ranged from 20 to 81. Each patient was independently examined by two investigators, with examination order randomly assigned and investigators blinded to each other's result. The weighted kappa statistic was used to evaluate the inter-observer agreement. RESULTS: Good and significant associations were observed on the anterior, posterior, and apical segments. Six out of 11 sites did not provide adequate number of subjects with prior hysterectomy for weighted kappa statistics or achieve significance regarding vaginal cuff measurement. CONCLUSIONS: The simplified POP-Q demonstrated good inter-examiner agreement across multiple centers.

Gadolinium nephrotoxicity: case report of a rare entity and review of the literature.

Radiocontrast exposure has now become an important cause of iatrogenic acute kidney injury (AKI) in hospitalized patients due to an increase in the number of diagnostic and interventional procedures done. Gadolinium, a well-known paramagnetic contrast agent used primarily for magnetic resonance imaging (MRI), has attracted a lot of attention for its safety in patients at risk for AKI, namely those with chronic kidney disease (CKD) and diabetes. Since its widespread use, a few cases of gadolinium nephrotoxicity have been reported in the literature. However, this remains a largely unrecognized complication in the field of nephrology. Here we describe such a case of AKI due to gadolinium toxicity in a 65-year-old African-American man with a history of hypertension, diabetes and chronic kidney disease, who was admitted for a toe infection and consequently developed AKI from multiple imaging studies involving the use of gadolinium.

Predicting proteinuria in hypertensive pregnancies with urinary protein-creatinine or calcium-creatinine ratio.

OBJECTIVE: Evaluate the value of random urinary protein-creatinine (PrCr) and calcium-creatinine (CaCr) ratios to predict 24-h proteinuria in hypertensive pregnancies. STUDY DESIGN: Spot urine samples were collected before routine 24-h urine collections from consecutive pregnant women with hypertension (n=83). Reliability of spot urinary PrCr and CaCr to detect significant proteinuria (>or=300 mg/day) using 24-h urine protein as 'gold-standard' was assessed by receiver-operating characteristic (ROC) curve. RESULTS: Fifty-one patients (61.4%) had significant proteinuria (45 pre-eclampsia, 5 superimposed pre-eclampsia, 1 renal hypertension). Area under ROC curve to predict proteinuria was 0.82 (95% confidence interval (CI) 0.73 to 0.92, P<0.001) for PrCr and 0.55 (95% CI 0.43 to 0.68, P=0.2) for CaCr. A cutoff value of >0.19 for PrCr best predicted significant proteinuria with sensitivity, specificity, positive and negative predictive values and likelihood ratios (positive and negative), respectively, of 80.4, 68.8, 80.4, 68.8%, 2.57 and 3.51. CONCLUSION: Spot urinary PrCr predicts total urinary protein excretion in hypertensive pregnancies.

Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients.

This multicenter, randomized, double-masked, parallel-group study assessed the efficacy, safety, and tolerability of azelaic acid 20% cream compared with those of its vehicle for the treatment of facial hyperpigmentation in darker-skinned patients (phototypes IV to VI). Following a 24-week treatment period, azelaic acid produced significantly greater decreases in pigmentary intensity than did vehicle as measured by both an investigator's subjective scale (P = 0.021) and a chromometer analysis (P = 0.039). There was a significantly greater global improvement with azelaic acid than with vehicle at week 24 (P = 0.008). Azelaic acid produced a slightly but significantly greater amount of burning (weeks 4 and 12, P < or = 0.046) and stinging (week 4, P = 0.002) than did vehicle. At the end of the study, more patients treated with azelaic acid than with vehicle reported having much smoother skin and being very satisfied or satisfied with their treatment. Also, more patients treated with azelaic acid than with vehicle rated their medication as being more effective or the same as past treatments. Thus azelaic acid is an effective and well-tolerated treatment for hyperpigmentation in darker-skinned patients.

The age and symptomatology of natural menopause among United Arab Emirates women.

OBJECTIVES: To determine the median age of natural menopause in United Arab Emirates women, the factors affecting that age and the prevalence of climacteric symptoms amongst those women. METHODS: A population-based survey was conducted on a community sample of United Arab Emirates women who had had natural menopause defined as cessation of menstruation for at least 6 months at the end of reproductive years. A total of 742 women aged 40 years and above were recruited from both urban and rural areas of the country using the multi-stage stratified cluster sampling technique. Data were collected using a structured questionnaire and face to face interviews and included a number of familial, reproductive and life-style variables. RESULTS: The median age of the menopause in the United Arab Emirates is 48 years (mean = 47.3 +/- 3.29, range 40-59). This is significantly lower than the median age reported from the West (50.3 years). The subject median age of the menopause was significantly related to that of the mother (P < 0.001), older sister (P < 0.001), parity (P < 0.0001) and the previous use of oral contraceptive pills for more than 1 year (P < 0.001). Hot flushes were the commonest feature of the menopause occurring in 45% of women. CONCLUSION: The age of natural menopause in United Arab Emirates women, as in other developing countries, is less than in Western women and may be influenced by genetic factors, parity and previous use of oral contraceptives. Climacteric symptomatology, however, is similar in the different patient groups.

PIP: A population-based survey of 742 United Arab Emirates women aged 40 years and over who had attained natural menopause (amenorrhea of at least 6 months' duration) investigated age at onset and the prevalence of climacteric symptoms. Women from both urban and rural areas of Al-Ain City and Abu Dhabi, Dubai, and Sharjah Emirates were recruited through use of the multi-stage stratified cluster sampling technique. The median age at menopause in this sample was 48 years (mean, 47.3 +or- 3.29 years; range, 40-59 years)--significantly lower than the 50.3 year mean recorded among Western women. Median age at menopause was significantly associated with that of the mother (p 0.001) and older sister (p 0.001), parity (p 0.0001), and a history of use of oral contraceptives for more than 1 year (p 0.001). 394 women (53%) reported at least one climacteric symptom. Most common were hot flushes, reported by 47% of women. 145 women (19.5%) were currently taking hormone replacement therapy. The relatively low age at menopause in this population could reflect additional social, economic, environmental, or genetic factors that were not explored in this study.

Cerebral mucormycosis: proton MR spectroscopy and MR imaging.

Proton magnetic resonance spectroscopy (MRS) was integrated with magnetic resonance imaging (MRI) in the evaluation of a case of cerebral mucormycosis. MRS showed markedly elevated lactate, depleted N-acetyl aspartate and metabolite resonances attributable to succinate and acetate. The spectroscopy profile is essentially similar to that of bacterial abscess but without the commonly seen resonances of the amino acids valine, leucine and isoleucine. Our extensive literature review did not yield any reports of MRS findings on cerebral mucormycosis. MRS prospectively limited the differential diagnoses given the otherwise nonspecific and complex MR imaging findings in our immunosuppressed patient.

Renal handling of endogenous human chorionic gonadotrophin in preeclampsia.

OBJECTIVE: To test the hypothesis that the elevated maternal serum concentration of human chorionic gonadotrophin (hCG) in preeclampsia is due to altered renal handling of the hormone. SETTING: Department of Obstetrics and Gynecology, Al Ain Hospital, United Arab Emirates, a tertiary center affiliated with the Faculty of Medicine and Health Sciences, UAE University. METHODS: The renal clearances and handling of endogenous creatinine and human chorionic gonadotrophin were compared in 14 normotensive volunteer and 14 preeclamptic mothers who received oral hydration at 34-37 weeks' gestation. The hCG content in the placentas was estimated immunohistochemically after delivery. RESULTS: Maternal serum concentration of hCG (p = 0.0057), the placental hCG immunopositive cell (p < 0.0001), and syncytial knot counts (p < 0.0001) were significantly higher in preeclamptic mothers. The renal clearances of endogenous creatinine and hCG and fractional hCG clearance were not significantly different in both groups. Significantly increased amounts of hCG were filtered (p = 0.007) and excreted (p = 0.007) by preeclamptic mothers. Only a small but fixed proportion of the filtered load of hCG is excreted in both groups and there was a positive correlation (r = 0.5, p = 0.005) between filtered and excreted loads of hCG. CONCLUSION: The results indicate increased placental content of hCG in preeclampsia. The resultant increased maternal serum concentration is probably sustained by the mechanism of renal handling of the hormone.

Isolated complex limb reduction abnormality diagnosed antenatally.

Congenital limb reduction defects are rare lesions that are usually associated with other anomalies. Terminal defects are the commonest reduction defects. The aetiology seems to be multifactorial. We present a case of congenital terminal deficiency of the same side of the upper and lower limbs diagnosed by ultrasound scanning during the second trimester. The fetus had an absent right fibula and right foot, a hypoplastic right hand and left talipes equinovarus. The pregnancy was terminated. Micrognathia was the only associated anomaly found on postmortem examination. The cause of this isolated anomaly is unknown but, because of the very variable presentation of limb reduction defects, could possibly fit into the categories so far described in the literature.

Consanguinity and the age of menopause in the United Arab Emirates.

OBJECTIVE: The study examined the association between some biosocial factors, consanguinity and age at natural menopause in the United Arab Emirates (UAE). METHOD: A cross-sectional population-based study using a multi-stage sampling design and face-to-face interview. RESULTS: In a sample of 800 UAE females aged 40 years and above, there were 742 (85.8%) respondents. The median age of natural menopause was 48 years. The bodyweight, parity number, occupation, smoking habits and consanguinity in marriage were the significant variables associated with the age at natural menopause. There were statistically significant differences between women in consanguineous and non-consanguineous marriages with regard to BMI (P < 0.002), occupation (P < 0.008), weight (P < 0.0001), age (P < 0.03), age of menopause (P < 0.005), parity (P < 0.0001), mother's age at menopause (P < 0.007) and sister's age at menopause (P < 0.002). CONCLUSION: The study showed that among UAE women, consanguinity of marriage, maternal and sister's age at menopause, BMI, parity number and smoking habits significantly influence the natural age of menopause.

Systemic antibiotic prophylaxis in elective cesarean delivery.

OBJECTIVE: To test the value of using prophylactic antibiotics at elective cesarean delivery. METHOD: One-hundred and twenty women delivered by elective cesarean in the absence of labor and before the rupture of membranes were randomized to receive either 1.5 g of cefuroxime intravenously at cord clamping (n = 59) or no prophylaxis (control group, n = 61). RESULTS: Twelve women developed febrile morbidity (six study, six control, P = 0.09). Of these, five had endometritis (two study, three control, P = 0.09) and two had wound infection (one study, one control, P = 0.09). Ten more women had microbiological evidence of endometritis and wound infection (six study, four control, P = 0.08). There was no significant difference in the hospital stay (6.5 days study, 6.8 days control, P = 0.06). Staphylococcus aureus was the commonest pathogen accounting for 14 infection episodes. Amniotic fluid culture could not predict the development of infection. CONCLUSION: Administration of prophylactic antibiotics at elective cesarean deliveries was not associated with decreased postoperative morbidity.

Factors influencing the quality of life of infertile women in United Arab Emirates.

OBJECTIVES: To measure the quality of life in a representative sample of infertile women and evaluate their sociocultural attitude to this condition. METHODS: Two hundred sixty-nine infertile women attending the Assisted Reproduction clinic, Tawam Hospital were consecutively selected. They were interviewed about the effect of infertility on their quality of life using a structured, measurement-specific and pre-tested questionnaire. RESULTS: Parameters mostly affected were mood-related mainly in women above 30 years, with primary and female factor infertility and those in polygamous marriages. Quality of life did not affect sexual performance and was not affected by duration of infertility or cost of treatment. CONCLUSION: The results highlight the importance of bearing children and the stresses exerted on infertile women in Eastern societies. Thorough counseling and continuing support of infertile women is therefore indicated to improve their quality of life.

Subdermal levonorgestrel implants. Three years' experience in Cairo, Egypt.

OBJECTIVE: To assess the efficacy, safety and acceptability of the subdermal levonorgestrel implant (SLI), a new, long-acting, low-dose, progestin-only contraceptive method for women. STUDY DESIGN: A prospective, observational study conducted in the family planning clinic, Department of Obstetrics and Gynecology, Ain Shams University Hospital, Cairo, Egypt, as an advanced phase III clinical trial. RESULTS: This paper describes three years' experience with the SLI in 350 women. The net three-year cumulative pregnancy rate was 0.98%. Menstrual disturbances, ranging from amenorrhea to menorrhagia, were the major side effects and were present in 25% of women during the third year. These disturbances resulted in 28 removals, 19 of which were because of amenorrhea. Medical complications, including headache, hypertension and non-insulin dependent diabetes; desire for pregnancy; and complications at the insertion site (such as infection, spontaneous expulsion of the capsules and arm pain) were the principal reasons for another 57 implant removals. So far, no gynecologic or breast lesions have developed, and weight changes were not noted. The continuation rate after three years was 65.5%. CONCLUSION: The efficacy, safety and acceptability of the implant suggest that it will provide an important addition to the contraceptive armamentarium.

Beta-thalassemia major and successful pregnancy.

OBJECTIVE: To conduct a study of maternal and fetal outcome in pregnant women with transfusion-dependent beta-thalassemia major. STUDY DESIGN: The course and outcome of pregnancy were studied prospectively in 32 pregnant women with transfusion-dependent beta-thalassemia major, of which 10 were HIV 1 positive, at Sanjay Gandhi Hospital, Manipur, India, from January 1990 to July 1996. RESULTS: Over a period of six years, 32 women with transfusion-dependent beta-thalassemia major conceived. Twenty conceptions were spontaneous (63%), and 12 (37%) followed induction of ovulation. There were 24 (75%) singleton vaginal deliveries, all of which were term. At term, eight (25%) women delivered by elective cesarean section due to cephalopelvic disproportion. All the women remained well throughout pregnancy. Despite increased blood transfusion requirements during pregnancy to maintain the hemoglobin level > 10 g/dL, serum ferritin levels remained stable in all patients. CONCLUSION: Successful outcomes of pregnancy occurred in some women with transfusion-dependent beta-thalassemia major.

Knowledge and practice of contraception in United Arab Emirates women.

OBJECTIVE: To determine the knowledge and practice of contraception among United Arab Emirates (UAE) women. METHOD: Four hundred and fifty UAE women at risk of pregnancy were randomly selected from the community and primary health care centres and interviewed about knowledge and practice of contraception using a structured questionnaire. RESULTS: Four hundred women (89%) gave consent to participate in the study. One hundred and sixty-six participants (41.5%) were using contraception. All used natural methods backed with other methods. There were significant associations between using contraception and each of age, high level of education and low family income (p < 0.0001 for the three variables). Religious beliefs and low expectation of success of birth control were the reasons given for non-use. Eighty-five percent of subjects did not accept sterilisation without medical indications, nor using contraception before the first pregnancy. Of the women, 42.5% believed that contraceptive methods should not be used after the age of 40, and 78% were unaware that they could be used for treatment of gynaecological diseases. Disturbed bleeding patterns occurred in 48.7% of users, and these were most bothered by the inability to pray (100%) and to have sexual intercourse (97.5%). CONCLUSION: Contraception is not commonly used by UAE women because of sociocultural traditions, religious beliefs and poor knowledge.

Abnormal vascular coiling of the umbilical cord in gestational diabetes mellitus.

The objective of this study was to identify abnormal vascular coiling of the umbilical cord in neonates of mothers with gestational diabetes mellitus. The umbilical cords of 57 neonates of gestational diabetic mothers were examined and the coiling index determined by dividing the total number of complete vascular coils by the length of the cord in centimeters. Obstetric history, delivery data and neonatal outcome were also evaluated. These variables were compared with those obtained for 389 normal pregnancies. The frequency distribution of umbilical coiling index in the control population and gestational diabetic mothers were normal (10th and 90th percentiles = 0.17 and 0.37; mean +/- SD = 0.26 +/- 0.09 and 0.24 +/- 0.12 coils/cm, respectively). Non-coiling and hyper-coiling were significantly more frequent with diabetic than with normal pregnancy (p = 0.004; p = 0.008, respectively). Both abnormalities of umbilical vascular coiling were also significantly associated with adverse perinatal outcome (p = 0.04) and emergency cesarean delivery (p < 0.0001) in the diabetic and control (p = 0.03; p < 0.0001, respectively) groups. Neonates of gestational diabetic mothers are therefore more likely to have hyper-coiled or non-coiled umbilical blood vessels. Perinatal morbidity and emergency cesarean delivery are increased in this subgroup.