Severe maternal outcome in Afghan immigrant women: A study in Tehran, Iran.

OBJECTIVE: To evaluate the risk factors for severe maternal outcome (SMO) in Afghan immigrant women. METHODS: Women with potentially life-threatening conditions (PLTC) were selected. Then risk factors for those PLTC which led to SMO (maternal near-miss or maternal death) were evaluated. In addition, risk factors for those SMOs occurring on hospital admission or during the first 12 hours after admission to the hospital (SMO12) were evaluated. RESULTS: Parity ≥3 (adjusted odds ratio [aOR] 3.24, 95% confidence interval [CI] 1.62-6.50, P = 0.03), low literacy level in mother (aOR 2.99, 95% CI 1.16-5.01, P = 0.03), inadequate prenatal care (aOR 2.74, 95% CI 1.2-3.87, P = 0.01), multigravidity (gravidity ≥5: aOR 2.62, 95% CI 1.31-4.53, P = 0.03), lack of health insurance (aOR 2.52, 95% CI 1.25-4.02, P = 0.01), and low literacy level in husband (aOR = 1.49, 95% CI 1.15-2.9, P = 0.02) were the risk factors for SMO in women with PLTC. Inadequate prenatal care (aOR 4.2, 95% CI 2.05-8.25, P = 0.04), low literacy level in mother (aOR 3.38, 95% CI 1.32-6.65, P = 0.04), parity ≥3 (aOR 2.69, 95% CI 1.16-4.7, P = 0.04), and lack of health insurance (aOR 2.13, 95% CI 1.25-3.67, P = 0.03) were risk factors for SMO12. CONCLUSION: There was a higher rate of SMO and SMO12 cases among Afghan immigrant women.

Efficacy of daily rectal micronized progesterone for prevention of preterm delivery: a randomized clinical trial.

INTRODUCTION: Preterm delivery is the leading cause of neonatal morbidity and mortality and its prevention is always under serious concern. OBJECTIVE: The aim of the present study was to determine the efficacy of rectal progesterone as a maintenance tocolytic after arresting preterm labor, for increasing the duration of pregnancy, and postponing preterm birth. METHOD: The study was performed as a double blind randomized clinical trial on women with preterm labor in whom contractions have been stopped. The eligible women were randomly divided into two groups. In the intervention group (progesterone group), progesterone was administered rectally as a dose of 200 mg daily until 36+6 weeks or spontaneous delivery before that time, whichever came first; and in the placebo group, placebo was administered in a similar manner. Primary outcomes were number of deliveries before 37 weeks of gestation and time to delivery interval in two groups. Secondary outcomes were neonatal Apgar score and weight, and need for NICU admission. RESULTS: 160 women finished the study (80 women in each group). The women of the two groups did not have significant difference according to the baseline characteristics. Frequency of preterm labor (earlier than 37 weeks) and mean gestational age at the time of delivery did not show significant difference in two groups. Also, neonatal outcome including Apgar score, birth weight, NICU admission and neonatal complications were not different between the two groups. The pregnancy length was longer in progesterone group (28.84 ± 3.36 VS 21.19 ± 4.62 days), [p = .001, CI 95%: 3.71-4.83]. The time-to-event (delivery) analysis showed a hazard ratio of 1.02 (95% CI 0.36-2.77). CONCLUSION: Rectal progesterone at a daily dose of 200 mg as a maintenance tocolytic agent, cannot lower the frequency of preterm delivery but was suggested to prolong pregnancy length.

Cerebroplacental ratio (CPR) and reduced fetal movement: predicting neonatal outcomes.

OBJECTIVE: The aim of this study was to evaluate the role of cerebroplacental ratio (CPR) in term pregnancies with reduced fetal movements (RFM) and appropriate for gestational age (AGA)fetuses to predict poor neonatal outcomes. METHODS: A prospective cohort study was performed on 150 singleton pregnancies with gestational age of 37-41 weeks and multiple episodes of RFM (case group) and 150 pregnancies within the same criteria only without RFM (control group). Both groups had appropriate for gestational age (AGA)fetuses. Umbilical artery (UA) and middle cerebral artery (MCA) pulsatility indices (PI) were measured, and MCA to UA ratio (CPR) was calculated. Doppler indices and neonatal outcomes were compared between the two groups. Independent prediction role of CPR MoM was evaluated through a binary logistic regression method. RESULTS: The RFM group had significantly higher UA- PI MoM (1.01 ± 0.19 versus 0.86 ± 0.05, p < .001), lower MCA MoM (1.28 ± 0.20 versus 1.40 ± 0.13, (p < .001)) and lower CPR MoM (0.98 ± 0.24 versus 1.23 ± 0.12, (p < .001)) compared to the control group. Mean umbilical artery pH was lower in the RFM group and the frequency of neonatal UA cord pH <7.2 was higher in the RFM group. In RFM group, CPR MoM showed a significant linear correlation with birth weight centiles (r = 0.244, p = .003), umbilical artery pH (r = 0.319, p < .001) and Apgar score at minute 1 (r = 0.332, p < .001). CPR MoM exhibited negative correlation with duration of NICU stay (r= -0.187, p = .022). No similar correlation was observed in the control group. In binary logistic regression analysis, CPR MoM was adjusted for the results of NST; and it was concluded that CPR MoM was the only significant predictor of Apgar score minute 1 = <7 (OR: 0.004; 95% CI: 0.0002-0.0673, p < .001), umbilical artery ph <7.2 (OR: 0.019; 95% CI: 0.00005-0.0423, p < .001) and NICU admission (OR: 0.116; 95% CI: 0.018-0.744, p = .023). In multivariate binary logistic regression analysis included parity, history of abortion and ART, AFI, BPP and CPR MoM; the AFI (OR: 0.976; 95% CI: 0.957-0.995, p = .014), BPP (OR: 0.306; 95% CI: 0.172-0.545, p < .001) and CPR MoM (OR: 0.00005 95% CI: 0.000003-0.00061, p < .001) were the significant predictor of RFM. Area under the curve in receiver operating characteristics (ROC) curve was calculated as 0.828 for CPR MoM as a predictor of RFM (SE: 0.024, p < .001), yielding sensitivity and specificity estimates of 80.0% and 65.0%, respectively, using an optimal cutoff level of = < 1.19. CONCLUSION: This study concluded that reduced fetal movement was significantly related to low CPR MOM. Also, it showed the independent role of CPR MoM for prediction of lower neonatal umbilical artery pH, lower Apgar score minute 1 and higher rate of NICU admission in AGA term fetuses without considering NST results. Also, AFI, BPP and CPR MoM are significant predictors of RFM.

Effects of tranexamic acid on the amount of bleeding following vaginal delivery and its adverse effects: a double-blind placebo controlled randomized clinical trial.

INTRODUCTION: Postpartum hemorrhage (PPH) is the most important concern after delivery. Tranexamic acid (TXA), an anti-fibrinolytic agent, has been suggested for prevention and treatment of PPH. OBJECTIVE: The purpose of the present study was to find the effects of TXA on the amount of bleeding following vaginal delivery and its adverse effects. MATERIALS AND METHODS: The study was performed as a randomized double blind placebo controlled clinical trial on low risk pregnant women who delivered vaginally. The patients were randomly assigned into two groups. Women in the intervention group received 10 mg/kg infusion of TXA in 100 mL normal saline and the control group received one vial of distilled water (as placebo) in 100 mL normal saline. The primary outcome was amount of bleeding after delivery. The secondary outcomes were decreased in hemoglobin level, need for additional uterotonic agents and need for blood transfusion. All were evaluated 6 h after delivery and compared in the two groups. Participants were followed up to six weeks after delivery for any TXA side effects. RESULTS: Two hundred and seven women finished the study. There were no significant differences between the two groups in terms of demographic data and risk factors for bleeding. Mean blood loss and need to misoprostol was more in the control group (p=.033 and p=.000, respectively). Hemoglobin level was higher in the TXA group 6 h after delivery. None of the subjects needed blood transfusion, uterine balloon tamponade or emergency hysterectomy. Adverse effects were higher in the TXA group, however, there were no side effects between weeks 3 and 6 in both groups. There were no thromboembolic events during six weeks after delivery. CONCLUSIONS: Tranexamic acid can reduce the amount of bleeding after vaginal delivery in low risk women without having serious complications. Also, it may decrease the need for additional uterotonic agents. Trial registration number and registry website: IRCT20091023002624N22.

Dexamethasone versus placebo for prevention of nausea, vomiting and pain after open total abdominal hysterectomy.

Post-operative nausea and vomiting (PONV) is a disturbing issue. Dexamethasone has been suggested for the prevention of PONV. The aim of the present study was to evaluate the efficacy of dexamethasone as an anti-emetic and analgesic following total abdominal hysterectomy. The study was performed as a double blind, placebo-controlled randomised clinical trial on 102 women undergoing an open total abdominal hysterectomy. The intervention group received 8 mg dexamethasone 1 h before surgery, and the control group received a placebo. The total number of emesis episodes during the 24 h after surgery did not show significant difference between the two groups, however, the number of emesis episodes in hours 2 and 4 after the surgery were less in the intervention group, but not in hours 0, 6, 12 and 24. The nausea severity in hours 0, 2, 4, 6 and 12 after the surgery, was less in the intervention group. The severity of pain was not different between the two groups.IMPACT STATEMENTWhat is already known on this subject? Post-operative nausea and vomiting (PONV) is an important and disturbing issue. It is one of the most common problems following gynaecological surgeries including open total abdominal hysterectomy (TAH). Dexamethasone has been suggested as a prophylaxis for the prevention of PONV.What do the results of this study add? Dexamethasone 8 mg is effective for the prevention of late onset PONV (after 2 h of surgery) in the cases of open total abdominal hysterectomy. However, it has no effect on PONV immediately following surgery (hour 0) and pain.What are the implications of these findings for clinical practice and/or further research? Dexamethasone can be considered as an effective prophylaxis for PONV for the first 24 h after an open total abdominal hysterectomy, but it has limited effects on the management of early onset of PONV; between 0 and 2 h after surgery. Since the highest rates of emesis episodes and nausea severity are at this time, it is suggested to combine another rapid onset medication with dexamethasone. Also, dexamethasone, 8 mg, cannot be considered for pain relief after an open total abdominal hysterectomy. Higher amounts of dexamethasone should be evaluated for this purpose, in order to find appropriate dosages.

Comparing the efficacy of dilapan with extra-amniotic saline infusion and oral misoprostol for cervical ripening in term pregnancies.

INTRODUCTION: Labor induction is an important issue in modern obstetrics. One of the important factors for the success of induction of labor is the Bishop score of cervix. OBJECTIVE: The purpose of the present study was to evaluate and compare the efficacy of dilapan with extra-amniotic saline infusion and oral misoprostol for cervical ripening in term pregnancies. METHODS: This clinical trial study was performed on 120 nulliparous pregnant women with the Bishop score of less than 5. Group one, group two and group three received dilapan, extra amniotic saline infusion (EASI) and misoprostol respectively. All three groups were compared for duration from beginning of the intervention up to cervical ripening and Bishop Score of ≥7, duration of active phase and the second stage of labor, number of deliveries in the first 24 h, duration from beginning of the intervention up to delivery, rout of delivery as well as neonatal weight, neonatal Apgar score; hyper- stimulation, and need for oxytocin and oxytocin doses administered after 12 h of intervention. RESULTS: The number of deliveries in the first 24 h after intervention were not significantly different between the three groups. There was no significant difference between the three groups according to duration from beginning of the intervention up to cervical ripening and Bishop Score of ≥7, duration of active phase and the second stage of labor, duration from beginning of the intervention up to delivery, rout of delivery as well as neonatal weight, neonatal Apgar score; and hyperstimulation. The Bishop Score was higher in the misoprostol group 6 h after intervention [dilapan: 4.32 ± 1.38, EASI: 5.47 ± 1.28, and misoprostol: 6.72 ± 1.61 (p = .000)], Oxytocin requirement [dilapan: 38 (95%) women, EASI: 37 (92.50%) and misoprostol: 30 (75%) women, p = .013], and required dose [dilapan: 7543 ± 2465 miu/ml, EASI: 5758 ± 1615miu/ml and misoprostol: 4930 ± 2589miu/ml, p = .000] were lower in misoprostol group. CONCLUSION: Dilapan is an effective and safe method for cervical ripening in full term gestations. In cases where misoprostol and EASI cannot be used or are not desirable, dilapan can be used as an alternative.Trial registration number and registry website: IRCT20091023002624N25.

Evaluation of placental alpha microglobulin-1(PAMG1) accuracy for prediction of preterm delivery in women with the symptoms of spontaneous preterm labor; a comparison with cervical length and number of contractions.

INTRODUCTION: Since the capacity of tertiary centers is limited, identifying women with the risk of preterm delivery is crucial amongst women who refer to hospitals with threatened preterm labor. OBJECTIVE: The purpose of the present study was to evaluate the accuracy of the placental alpha microglobulin-1 (PAMG-1) test for identifying women who referred to hospitals with signs of spontaneous preterm labor and ultimately delivered within ≤48 h and ≤7 of testing and ≤37 weeks of gestation and its comparison with cervical length of <25 mm and number of contractions. MATERIALS AND METHODS: A prospective observational study was performed on women with the signs of spontaneous preterm labor. Placental alpha microglobulin-1 (PAMG-1) was evaluated in vaginal secretion. Cervical length (CL) and number of contractions were evaluated and recorded. The test to- spontaneous- delivery interval was documented. Sensitivity (SN), specificity (SP), accuracy rate of the PAMG-1, cervical length of <25 mm and number of contractions in prediction of spontaneous preterm delivery within ≤48 h, ≤7 days and preterm delivery (≤37 weeks of gestation) were calculated. RESULTS: One hundred eighty women finished the study. 44 women had positive PAMG-1 test and 58 women had cervical length of <25 mm. Women with a positive PAMG-1 were more likely to deliver within ≤48 h (p < .0001), ≤7 days (p < .0001), and before 37 weeks (p < .0001), compared to the women who had a negative test. For delivery within ≤48 h, ≤7 days and ≤37 weeks, specificity (SP) of the PAMG-1; was statistically higher than cervical length of <25 mm and contractions of 12-17/hr but not contractions of ≥18/hr. PAMG-1 showed a higher accuracy rate than cervical length of <25 mm, contractions of 12-17/hr and contractions of ≥18/hr for deliveries within ≤48 h (78.9, 55.3, 48.9, and 69.44%, respectively) and ≤7 days (76.1, 55.32, 55, and 65.56%, respectively). For deliveries before 37 weeks; the PAMG-1 test showed higher LR + than CL of <25 mm, contractions of 12-17/hr and contractions of ≥18/hr [10.24 (2.57-40.86), 2.01 (1.24-3.23), 1.30 (1.05-1.62), and 5.12 (1.24-21.11), respectively]. PPV for deliveries within ≤48 h and ≤7 days for PAMG-1 was greater than cervical length of <25 mm and number of contractions, however, NPV did not show a significant difference. CONCLUSION: PAMG-1 test showed a higher accuracy rate for prediction of delivery within ≤48 and ≤7 days in comparison with cervical length of <25 mm and number of contractions. Also, PAMG-1 test had a higher positive likelihood ratio for deliveries at ≤37 weeks. PPV for deliveries within ≤48 h and ≤7 days for PAMG-1 was greater than cervical length of <25 mm and number of contractions, however, NPV did not show a significant difference.

Health-Care Professionals' Assessments of, and Recommendations for, Sexual-Health Education and Service Provision for Young People in Tehran.

Background: Only limited Sexual Health and Relationships Education (SHRE) is provided in Iranian schools and universities while research has highlighted demand and need for improved SHRE among young adults. We explored health-care professionals' (HCPs) assessments of, and recommendations for, SHRE and service provision for young people in Tehran. Design and Methods: Semi-structured interviews were conducted with a sample of 17 HCPs based in Tehran and verbatim transcripts were analyzed using thematic analysis. Results: Participants confirmed the need for improved SHRE and service provision for young adults. HCPs described how a lack of reliable educational resources for young adults, taboo and cultural barriers, and a lack of trust and confidentiality prevented young people from accessing information and services. They unanimously supported education and services to be augmented, and provided recommendations on how this could be achieved. Conclusions: A number of positive suggestions for the improvement of SHRE and Iranian sexual health services in Iran were identified.

A qualitative assessment of the sexual-health education, training and service needs of young adults in Tehran.

BACKGROUND: Sexual Health and Relationships Education (SHRE) provides individuals with knowledge and skills to manage risky behaviors and take informed decisions to protect themselves against STIs, and unintended pregnancy. Only minimal SHRE is provided in Iranian schools and universities and previous research has highlighted needs and demands for improved SHRE and sexual services in Iran. This study explored young, Iranian adults' experience of, and need for sexual health education, sexual skills training and sexual healthcare services, as well their views on how to augment and improve existing provision. DESIGN AND METHODS: Semi-structured interviews were conducted with a sample of 25 young adults who lived in Tehran, Iran and had volunteered to participate in the study. Transcripts were analyzed using thematic analysis. RESULTS: Participants explained their needs and demands for sexual health education and sexual healthcare. They unanimously expressed their dissatisfaction with available SHRE and sexual health care provision. They highlighted barriers to gaining sexual health information and seeking advice and healthcare, including a lack of reliable resources, taboo and cultural barriers, lack of trust and protected confidentiality. This has resulted in ambiguities and misconceptions, including those regarding the cause and transmission of STIs and correct use of contraceptives. Participants recommended improvements, including holding mixed-gender extracurricular workshops with a comprehensive approach to sexual health and relationships education. CONCLUSIONS: There is a clear need and demand for provision of relevant and reliable sexual health and relationships education for young adults in Tehran. This should be addressed to empower young people to make informed choices and avoid risky sexual behavior.

Woman's perceived stress during pregnancy; stressors and pregnancy adverse outcomes.

Background: Stress perceived by mothers during pregnancy is dependent on several factors and can lead to adverse pregnancy outcomes threatening mother and child physical and mental health.Objective: The purpose of the present study is measuring perceived stress of pregnant women by 14 items Cohen's perceived stress scale (PSS), detecting stressors surrounding pregnant women including male partner's role, intimate violence, socioeconomic situation, etc., as well as investigate the effect of perceived stress on pregnancy adverse outcomes.Method: Two hundred first gravid pregnant women between 18 and 35 years old at post labor ward entered our cross-sectional study. They were asked to fill out the PSS questionnaire and an information gatherer filled out the checklist for exposures and baseline characteristics.Result: Mean ± SD of participants' PSS was 25.5 ± 8.6. Mothers' PSS was significantly higher in group reported father's verbal aggression against mother (N = 71, 38%) (23.7 ± 9 versus 28.2 ± 7.2; p < .001) and father's physical aggression against mother (N = 28, 15%) compared to nonexposed one (24.9 ± 7.7 versus 28.4 ± 8.7; p: .04). Mothers' PSS score was significantly correlated with mothers' satisfaction from both fathers' emotional (r: -0.30, p: .001) and financial support (r: -0.34, p < .001) during pregnancy. Moreover, the mother's satisfaction from father's concomitance in prenatal care (PNC) visits was significantly correlated with the mother's perceived stress (r: 0.24, p: .001).Conclusion: Male partner's role during pregnancy directly affects the pregnant woman's perceived stress.

Evaluating the efficacy of outpatient use of isosorbide mononitrate on cervical ripening in pregnant women with unfavourable cervix.

The aim of the present study was to evaluate the efficacy of outpatient administration of nitric oxide donor isosorbide mononitrate for cervical ripening. A randomised clinical trial was performed on term pregnant women with Bishop Score < 6. In the case group, Isosorbide-5-mononitrate capsule and in the control group, placebo was inserted in the posterior vaginal fornix for two consecutive days. The main outcomes were increases in Bishop Score after 48 hours of intervention, number of vaginal deliveries and interval from intervention to delivery.There was a significant increase of the mean Bishop score in the isosorbide group [3.57 ± 1.12 VS 1.54 ± 1.42 respectively (p = .001)]. The other outcome variables did not show a significant difference between the two groups except for headache which was significantly more in the case group. No cases of tachysystole were observed in the two groups. Additionally, haemoglobin levels after delivery did not show a significant difference between the two groups.Impact statement:What is already known on this subject? Cervical ripening in women with an unfavourable cervix and having an indication for induction of labour is an important issue in modern obstetrics. Different methods have been used for cervical ripening and induction of labour including mechanical (i.e. laminaria tents, Dilapan-S, foley catheter), medical (i.e. PGs) and supportive methods. There is no consensus on the best option for cervical ripeningWhat will the results of this study add to the current knowledge of this subject? Outpatient administration of nitric oxide could affect cervical ripening without a significant improvement in the duration of different stages of labour, intervention to delivery interval and number of vaginal deliveries.What are the implications of these findings for clinical practice and/or further research? Due to the contradictory results of various studies, more studies should be performed with greater sample size to evaluate nitric oxide donor isosorbide mononitrate effect on labour duration and reducing caesarean deliveries. Additional data is needed to assess the real impact of NO donors on different stages of labour and its implications.

A comparative study on the efficacy of nifedipine and indomethacin for prevention of preterm birth as monotherapy and combination therapy: a randomized clinical trial.

Introduction: Preterm delivery is an important issue in obstetrics, which is the most common cause of neonatal mortality and morbidity. Therefore, finding a way to prevent it is always under serious concern.Objective: The study aimed to compare the efficacy of two tocolytic agents, nifedipine and indomethacin, for inhibiting preterm uterine contractions as monotherapy and combination therapy.Materials and methods: A double-blind randomized clinical trial was performed on pregnant women with gestational age of 26-34 weeks of pregnancy who referred to hospital for preterm labor. They were randomly assigned to three groups. Indomethacin plus placebo, nifedipine plus placebo, and a combination of indomethacin and nifedipine were administered to the three groups. Inhibiting contractions for 2 hours and prevention of delivery for 48 hours and 7 days were evaluated. Also, duration of pregnancy, the number of preterm births, and the interval between entering the study and delivery were compared between three groups.Results: One hundred fifty women were eligible for the study. Two women in the nifedipine group and one woman in the combined group were excluded from the study because of hypotension. The women of the three groups did not have significant difference according to age, BMI, gravidity, parity, Bishop score, gestational age, and the number of contractions at entering the study. Thirty-six women (72%) in the indomethacin group, 36 women (72%) in the nifedipine group, and 41 women (89.4%) in the combination group had stopped contractions within the first 2 hours of intervention (p = .002). Inhibiting contractions for 48 hours (p = .003), inhibiting contractions for 7 days (p = .021), gestational age at birth (p = .001), number of pregnancies more than 37 weeks (p = .007), and neonatal weight (p = .020) were significantly more in the combination group.Conclusion: Combination therapy with nifedipine and indomethacin was more effective than monotherapy with either of these two medications for inhibiting preterm labor, delaying delivery, and prolongation of the duration of pregnancy.

Evaluation of the relationship between serum anti TPO antibody levels and mood disorders in euthyroid pregnant women.

Introduction: Depression and anxiety during pregnancy have a negative impact on prenatal health and reduces mother's child care capability. Up to 20% of the pregnant women experience mood disorders.Objective: The aim of this study was evaluating the relationship between serum anti-TPO antibody levels and mood disorders in pregnant euthyroid women.Materials and methods: Serum anti-TPO antibody levels were measured in the first trimester of gestation in euthyroid pregnant women. Then, the women were divided into two groups of positive and negative anti-TPO antibody. Depression and anxiety were evaluated by Hamilton depression rating scale (HAM-D) and Hamilton anxiety rating scale (HAM-A) during the first, second, and third trimester of pregnancy (all women had three assessments during pregnancy).Results: Thirty women with high serum anti-TPO antibody levels (case group) and 32 women with normal serum anti-TPO antibody levels (control group) were compared. Mean anti-TPO levels were 105.63 ± 54.17 and 5.57 ± 1.80 IU/mL in case and control groups, respectively (p = .000). The baseline characteristics and initial HAM-A and HAM-D scores were not significantly different in the two groups except for anti-TPO. Pair t-test showed that the level of anxiety and depression has increased significantly during pregnancy in both groups. Comparison of anxiety and depression level in both groups showed that in anti-TPO antibody positive group, anxiety, and depression levels were significantly higher than the anti-TPO antibody negative group.Conclusion: Depression and anxiety of euthyroid pregnant women in the second and third trimester of pregnancy have a significant correlation with serum anti-TPO antibody levels of the first trimester of pregnancy.

Efficacy comparison of titrated oral solution of misoprostol and intravenous oxytocin on labour induction in women with full-term pregnancy.

A double-blind randomised trial was conducted on women with gestational age of 40-42 weeks of pregnancy and Bishop score of more than 5. The first group received oxytocin infusion and the second group received a titrated oral solution of misoprostol. Then, the two groups were compared by the primary outcome (the number of deliveries in the first 24 hours of intervention). The two groups did not have any significant difference in maternal and gestational age at the time of intervention, primary Bishop score, parity and neonatal weight. The number of deliveries in the first 24 hours was greater in the misoprostol group. Duration of onset of intervention to proper contractions was longer in the misoprostol group. However, the number of deliveries between 6-12 hours, 12-18 hours and 18-24 hours after induction was greater in the misoprostol group. The incidence of tachysystole and meconium was greater in the misoprostol group.Impact statementWhat is already known on this subject? Labour induction is widely used where the continuation of pregnancy might be dangerous for the mother or the baby. Of the various methods used for induction, misoprostol which is a prostaglandin E1 analogue has been reviewed more in recent years. Misoprostol has various routes of administration but in most studies only vaginal administration has been evaluated, leaving us with limited data about oral administration.What do the results of this study add? Oral misoprostol is a suitable method for labour induction and can be used as an alternative to oxytocin.What are the implications of these findings for clinical practice and/or further research? Misoprostol is not expensive, has a long shelf life, accessible in underdeveloped countries and rural areas and has several routes of administrations such as oral, sublingual and vaginal. Despite the fact that the oral route of misoprostol has a fast absorption and easier administration, there are relatively few studies assessing the the use of the oral route of misoprostol. Misoprostol is a suitable method for Labour induction and it has the potentials of being used as an alternative for oxytocin, however, the optimum dosages, the preferred route of administration, the maximum dose, the maximum time for administration, and maternal and neonatal safety should be studied more.

Psychosocial and biological paternal role in pregnancy outcomes.

Background: Pregnancy outcomes are affected by many different factors. One of the influential factors on pregnancy outcomes is the male partner as an important person to mother's wellbeing.Objective: The aim of the present study was to investigate the effects of male partner's role including socioeconomic support, emotional support, accompanying pregnant women during prenatal care visits (PNC) and labor, and the level of pregnant women's satisfaction from their partners' support and involvement during pregnancy on pregnancy outcomes.Method: Two hundred first gravid pregnant women with mean age of 23.2 ± 4.3 were studied. Primary outcomes were total maternal and neonatal adverse outcome (TMNAO), total maternal adverse end result (TMAE), and total neonatal adverse outcome (TNAO), regardless of the type of outcomes. Preterm labor and delivery; premature rupture of membrane (PROM) and preterm premature rupture of membrane (PPROM); preeclampsia and eclampsia; placental abruption; chorioamnionitis; stillbirth; meconium passage; maternal death; postpartum hemorrhage; poor progression labor; abnormal vaginal bleeding in third trimester of pregnancy; low birth weight and neonatal need for CPR or intubation, neonatal anomaly, NICU admission, and neonatal mortality were also analyzed as subgroup outcomes.Results: One hundred twenty-seven (63.5%) participants showed a kind of total maternal and neonatal adverse outcome (TMNAO), 72 (36%) deliveries resulted in a kind of neonatal adverse outcome (TNAO), and 104 (52%) of participants had a kind of maternal adverse end result (TMAE). Iranian fathers showed a significantly higher rate of TMNAO than Afghan fathers did (82 versus 69%, odds ratio: 2.9, 95% CI 1.0-7.8, p: .01). Mother's nationality showed the same result (82 versus 64%, odds ratio: 2.6, 95% CI 0.9-6.8, p: .03). Iranian fathers showed a significantly higher rate of TMAE than Afghan fathers did (79 versus 58%, odds ratio: 2.7, 95% CI 1.1-6.3, p: .01). Mother's nationality showed the same result (78 versus 60%, odds ratio: 2.4, 95% CI 1.0-5.6, p: 0.02). Neonates with Iranian fathers showed significantly more TNAO than those with Afghan fathers (50 versus 31%, odds ratio: 2.21, 95% CI 0.9-5.5, p: .04). The same trend was observed among Iranian mothers in comparison to Afghan mothers (50 versus 32%, odds ratio: 2.11, 95% CI 0.9-4.6, p: .06). Of mother's age, mother's BMI, father's age, father's BMI, and mother's nationality, only father's BMI contributed significantly to the binary logistic regression model (n = 116, R2: 9%, p: .028). It was found that for each decreased unit in BMI, the risk of TNAO was increased by 16%, p: .03. Moreover, Father's family history of preeclampsia resulted in a higher prevalence of total neonatal adverse outcome (TNAO) in comparison with lack of such family history (87 versus 43%, odds ratio: 8.9, 95% CI 1.1-74.5, p: .02). Besides, mothers' participation in prenatal care (PNC) visits, assessed by caregivers, was significantly more satisfactory in neonates without any adverse outcome than those with neonatal adverse outcomes (median (IQR) = 2 (1-2) versus 2 (2-3), p: .04). PROM, pre-eclampsia, NICU admission, neonatal intubation, low Apgar score minute 0, and low Apgar score minute 5 were significantly more prevalent in participants revealing positive father's family history of pre-eclampsia. Regarding psychosocial exposures, placental abruption was more prevalent in mothers with exposure to verbal aggression versus non-exposed ones (9 versus 2%, odds ratio: 4.0, 95% CI 0.9-24.6, p: .04). Moreover, a weak positive association between neonatal gestational age at birth and quality of mother's participation in PNC visits (r: +0.3, p: .01) as well as mother's satisfaction from father's commitment to PNC visits was found (r: +0.1, p: .03).Conclusion: Male partners may play a key role in pregnant women and fetus's heath.

Evaluation the relationship between serum progesterone level and pain perception after cesarean delivery.

Introduction: Cesarean delivery is the most common surgery in obstetrics, and pain relief after cesarean section is an important concern for obstetricians and their patients. Objective: The aim of this study was to evaluate the relationship between serum progesterone level and pain perception after cesarean delivery. Method: The study was performed as a prospective cohort study on 166 pregnant women who were candidates for elective cesarean delivery due to previous cesarean section. Before surgery, serum progesterone level was measured. Pain score of women was evaluated 4, 8, 12, and 24 h after surgery using visual analog scale (VAS) score, and correlation between progesterone level and pain was evaluated. Results: The median value of serum progesterone was 119.45 ng/ml. Mean pain score in hours 4, 8, 12, and 24 were 6.80 ± 2.11, 5.31 ± 1.48, 3.89 ± 1.68, and 2.30 ± 1.26, respectively. The women were divided according to mean progesterone level of 119.45 ng/ml into two groups of high progesterone level (≥119.45) and low progesterone level (<119.45), and the pain score was evaluated in different times (hour 4, 8, 12, and 24) for both levels of progesterone. The mean pain score in the 4, 8, 12, and 24 h were significantly lower in high progesterone group (progesterone level ≥119.45). The number of women with low pain score (less than five) in hours 12 and 24 was significantly higher in high progesterone level group. With increasing BMI, progesterone level was lower and women with higher BMI, had a higher pain score in hours 4, 8, 12, and 24, while women with lower BMI had a lower pain score during the same hours. (p = .004, r = 0.223; p = .004, r = 0.223; p = .039, r = 0.160; and p = .007, r = 0.207). Progesterone level and BMI (p = .025, r = - 0.174), and progesterone level and pain score in hours 4, 8, 12, and 24 (p = .000, r = - 0.324; p = .000, r = - 0.474; p = .000, r = - 0.329; and p = .000, r = - 0.417, respectively) showed a negative significant correlation. Putting three variables of age, gestational age, and BMI in a multiple regression model, progesterone level showed significant negative correlation with the pain score in hour 4 (p = .000, r = - 0.305), hour 8 (p = .000, r = - 0.461), hour 12 (p = .000, r = - 0.328), and hour 24 (p = .000, r = - 0.409). Conclusions: Serum progesterone level showed a negative correlation with the pain score after cesarean section.

A comparison between induction of labor with 3 methods of titrated oral misoprostol, constant dose of oral misoprostol and Foley catheter with extra amniotic saline infusion (EASI), in women with unfavorable cervix.

Background: Different methods of cervical ripening and induction of labor have been used in the cases of unfavorable cervix with different levels of success, but no method has been found to be the best option. The purpose of the present study was to find the effects and side effects of three different methods of cervical ripening and induction of labor. These three methods were oral titrated misoprostol, constant dose of oral misoprostol and Foley catheter with extra-amniotic saline infusion. Methods: This clinical trial was performed on women with unfavorable cervix who had been admitted in Akbarabadi Teaching Hospital for induction of labor and had bishop score of less than six; between March 2014- March 2015. The eligible women were assigned into three groups. In titrated oral misoprostol group (n=33), titrated solution of misoprostol, and in oral misoprostol group (n=33), 50µg oral misoprostol every four hours and in Foley catheter group (n=50), Foley catheter with extra-amniotic saline infusion were administered. The main outcome was the number of vaginal deliveries during the first 24 hours. In addition, number of cesarean deliveries and adverse effects were compared between the three groups. The obtained data were analyzed using SPSS 18 software. Data analysis was performed according to the intention to treat principle. Chi-square test, Fisher Exact test, Student ttest, and Mann-Whitney U test, were used for comparing data. P-value≤0.05 was considered statistically significant. Results: The three groups did not have any significant difference according to maternal age, gestational age at the time of admission, gravidity, parity, and primary Bishop Score. There was no significant difference between the three groups for the main outcome, which was vaginal delivery during the first 24 hours (p=0.887). There was no significant difference between the three groups according to hypertonicity, uterine hyperstimulation, meconium passage, non-reassuring fetal heart rate, neonatal Apgar score in minutes one and 5, and mean duration of beginning the intervention up to delivery. However, uterine tachysystole and NICU admission were more in the group to whom the titrated solution of misoprostol was administered (p=0.002 and p=0.037 respectively). The number of cesarean deliveries due to failure to progress was higher in the EASI group. However, EASI group showed the least number of none-reassuring fetal heart rate between the three groups. Meconium passage was more in the titrated misoprostol group, but the difference was not significant. Conclusion: All three methods are appropriate methods for induction of labor in the cases of unfavorable cervix; and choosing each method depends on the expertise of labor staff, accessibility to the medications, cost, and taking care for monitoring the patients and adverse effects.

Comparison between two doses of betamethasone administration with 12 hours vs. 24 hours intervals on prevention of respiratory distress syndrome: a randomised trial.

The purpose of the present study was to compare the effect of a two-dose administration of betamethasone with 12 hours interval vs. 24 hours interval on neonatal respiratory distress syndrome (RDS). The study was performed as a randomised clinical trial on 201 pregnant women with a gestational age of 26-34 weeks. In one group 12 mg of betamethasone every 12 hours for two doses and in the other group 12 mg of betamethasone every 24 hours for two doses were prescribed intramuscularly. There were no significant differences between the two groups according to maternal age, parity, gravidity, BMI, neonatal sex, need to surfactant, NICU admission, NICU stay, neonatal death, neonatal sepsis and Apgar score at minutes 1 and 5, but the gestational age at the beginning of the study and delivery receiving complete course of betamethasone and neonatal weight were lower in 24 hours group. RDS, necrotising enterocolitis, intra-ventricular haemorrhage and chorioamnionitis were more in the 24 hours' group. Multiple regression analysis showed that RDS and IVH (p = .022, RR = 0.07, CI95% 0.006-0.96 and p = .013; RR = 0.9, CI95% 0.1-0.89, respectively) were more in the 24 hours group and neonatal death (p = .034, RR = 4.7, CI95% 1.07-16.2) and NEC (p = 0.038, RR = 2.5, CI95% 1.7-3.7), were more in the 12 hours group. In conclusion, it seems that 12 hours interval betamethasone therapy may be considered as an alternative treatment in the case of preterm labour for acceleration of lung maturity; however, it is suggested that more studies should be performed on this issue and various morbidities. IMPACT STATEMENT What is already known on this subject: Administration of a single course of corticosteroids in all women with a gestational age of 24-34 weeks of pregnancy who are at risk for preterm labour and delivery has been recommended. The accepted regimen by National Institutes of Health (NIH) is an injection of betamethasone for two doses with 24 hours interval. What do the results of this study add: Twelve hours interval betamethasone therapy may be considered as an alternative treatment in the cases of preterm labour for acceleration of lung maturity. What are the implications of these findings for clinical practice and/or further research: Prescription of two doses (complete regimen) is more important than the interval between two doses for obtaining the maximum effect in a preterm birth.

Comparison between maternal and neonatal outcome of PPROM in the cases of amniotic fluid index (AFI) of more and less than 5 cm.

The study was performed on pregnant women with a gestational age of 26-32 weeks of pregnancy, who had been admitted to the hospital with a confirmed diagnosis of premature rupture of membranes. In all eligible women, ultrasounds were performed for the evaluation of amniotic fluid index. Then, the women were divided into two groups according to amniotic fluid index of ≥5 cm and <5 cm. These women were followed and monitored up to delivery. The women of the two groups did not have significant difference between them according to age, gestational age at the time of ruptured membrane, body mass index, gravidity, parity, gestational age at delivery and route of delivery. Maternal morbidities including chorioamnionitis, placental abruption, uterine atony after delivery and retention of placenta did not show significant difference between the two groups. There was no significant difference between the two groups' amniotic fluid index <5 cm and amniotic fluid index ≥5 cm, regarding neonatal morbidities, except for neonatal sepsis and neonatal death, which were higher in the amniotic fluid index <5 cm group [7(14.6%) versus 1(2.3%), p = .039, RR = 7.7 (95%CI 0.04-0.06) and 11(30.9%) versus 2(4.7%), p = .013, RR = 6.095 (95%CI = 1.26-29.31)]. In the subgroups of two categories of gestational ages of 260-296 and 300-346, neonatal morbidities were higher in the amniotic fluid index <5 cm group. The results suggest that amniotic fluid index <5 cm should be considered as a warning sign for predicting poor prognosis of pregnancy complicated by preterm premature rupture of membranes. Impact statement What is already known on this subject? In a retrospective study in 1993, the relationship between oligohydramnios (which was defined as the largest single packet of fluid less than 2 × 2 cm) at the time of hospital admission, and the outcome of mother, foetus and neonates in a gestational age of less than 35 weeks of pregnancy was evaluated. In the oligohydramnios group, chorioamnionitis and funistis were more common. Also, the mean gestational age at the time of delivery and neonatal weight was less than that of the normal amniotic fluid group. According to these results, it was concluded that a low amniotic fluid volume in the women with preterm premature rupture of membranes (PPROM) can be considered as a prognostic factor in the cases of conservative management of PPROM. In contrast, the other study, which was performed on a larger sample size (290 patients), could not show more cases of amnionitis in the cases of amniotic fluid index (AFI) of less than 5 cm; however, the latency period was shorter in comparison with AFI of more than 5 cm. What do the results of this study add? Chorioamnionitis, placental abruption and uterine atony after delivery, retention of placenta and route of delivery did not show a significant difference between the two groups. Respiratory distress syndrome (RDS), need of surfactant and intubation, intra ventricular haemorrhage (IVH) and duration of neonatal intensive care unit (NICU) admission did not show a significant difference between the two groups; however, the rate of neonatal sepsis and neonatal death were higher in the AFI <5 cm group. What are the implications of these findings for clinical practice and/or further research? The results suggest that AFI <5 cm should be considered as a warning sign for predicting poor prognosis of pregnancy complicated by PPROM.

Evening primrose oil and labour, is it effective? A randomised clinical trial.

The purpose of the present study was to evaluate the effects of evening primrose oil (EvPO) on the duration of pregnancy and labour. The study was performed as a triple blind placebo controlled randomised clinical trial on nulliparous low-risk women with a certain gestational age of 40 weeks of pregnancy and a Bishop score of less than 4. In the case group (EvPO group), EvPO capsules were administered, 1000 mg, twice daily, for 7 days, and in the control group, placebo was administered similarly. The women of the two groups were followed up to delivery. In total, 80 women finished the study (40 in each group). The women of the two groups did not have significant differences according to age, BMI, Bishop Score at the beginning of the study, gestational age at entering the study, employment status and education level, the number of capsules used and duration of using medications. There was no significant difference between the two groups according to gestational age at delivery, need for induction or augmentation of labour, duration of different stages of labour, neonatal weight and Apgar scores, and the indications for hospital admission. Impact statement What is already known on this subject? Evening primrose oil has been used for the treatment of systemic disorders, which are accompanied with chronic inflammation such as atopic dermatitis, rheumatoid arthritis and psoriasis. Also, it has been proposed for some women's health conditions including breast pain (mastalgia), symptoms of premenstrual syndrome and menopausal symptoms, cervical ripening and induction or augmentation of labour. What do the results of this study add? Evening primrose oil does not have any impact on Bishop Score and the duration of different stages of labour. What are the implications of these findings for clinical practice and/or further research? According to the present study and the other performed studies, there is not enough evidence confirming effectiveness of Evening primrose oil for cervical ripening and duration of labour. It is suggested that pending further data its usage should be limited to experimental RCTs and its use in clinical practice should be prevented. Also, different routes of administration and different dosages should be investigated.