Immediate dilation of a tight or stenotic cervix by intra-procedural administration of hyoscine butylbromide: A clinical trial.

BACKGROUND: Cervical dilation is indicated prior to performing various gynecological procedures. However, gynecologists are at times confronted with a stenotic or tight cervix, resistant to dilation. This can be problematic particularly when cervical ripening has not been attempted hours before the start of the procedure. OBJECTIVE: The objective of this study is to investigate the efficacy of administration of hyoscine butylbromide for cervical dilation for immediate dilation of the tight or stenotic cervix. MATERIALS AND METHODS: In this clinical trial study, a population of 40 women, aged 20-70 yr with stenotic cervix, evidenced by resistance to pass dilator #2 through their cervical canal were compared. Cervical patency was assessed 10 min following intra-cervical canal instillation of hyoscine butylbromide. RESULTS: Cervical width of 57.5% of patients became wider, as evidenced by passage of the number 4 Hegar dilator through the cervical canal without resistance. Independent T-tests did not reveal any statistically significant difference between the two groups based on their age. Fisher Exact test revealed a statistically significant difference between the two groups based on the prior route of delivery, with a more statistically significant response in patients who had vaginal deliveries. CONCLUSION: Intra-cervical canal instillation of hyoscine butylbromide is effective in immediate dilation of the tight or stenotic cervix during intra-uterine procedures.

Auditing the appropriateness of cesarean delivery using the Robson classification among women experiencing a maternal near miss.

OBJECTIVE: To evaluate appropriateness of cesarean delivery and cesarean delivery-related morbidity among maternal near misses (MNMs) using the Robson ten-group classification system. METHODS: In the present audit study, medical records were assessed for women who experienced MNM and underwent cesarean delivery at three university hospitals in Tehran, Iran, between March 1, 2012, and May 1, 2014. Local auditors assessed cesarean delivery indications and morbidity experienced. All records were re-assessed using Swedish obstetric guidelines. Findings were reported using the Robson ten-group classification system. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS: Of the 61 women included, cesarean deliveries were more likely to be considered appropriate by local auditors compared with Swedish ones (OR 2.7, 95% CI 1.3-5.7). Cesarean delivery-related morbidity was attributed to near-miss events for 10 (16%) MNMs and was found to have aggravated 25 (41%). Of 16 women classified as Robson group 1-4, cesarean delivery-related MNM was identified in 15 (94%), compared with 13 (43%) of 30 women in group 10. Cesarean delivery with appropriate indication was associated with very low likelihood of cesarean delivery-related MNM (OR 0.2, 95% CI 0.1-0.6). CONCLUSION: Cesarean delivery in the absence of appropriate indication could be an unsafe delivery choice. Audits using the Robson classification system facilitate understanding inappropriate cesarean delivery and its impact on maternal health.

Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran.

BACKGROUND: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. METHODS: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. RESULTS: Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. CONCLUSIONS: Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.

Assessing the efficacy of vaginal hyoscine butyl bromide on cervical ripening prior to intrauterine procedures: A double-blinded clinical trial.

BACKGROUND: Unripe cervix prevents entering the endometrial cavity during intrauterine procedures. Mechanical dilatation of cervical canal might cause undesirable complications. OBJECTIVE: To investigate the substitute of mechanical intervention with chemical treatment by administering hyoscine to patients. MATERIALS AND METHODS: Sixty non-pregnant women, 20-70 years of age, with a closed cervix who were scheduled for an intrauterine procedure, were randomly divided into two groups. Group A as experimental (received two doses of hyoscine) and group B, as control group (received two doses of vitamin B6) in the vagina (8 hrs and 2 hrs before procedure) and the effect of these two drugs on dilatation and consistency of cervix were studied. RESULTS: Statistics resulted from Mann-Whitney U test (p=0.027) and 2(p=0.002) indicated that in premenopausal women, the priming effect of hyoscine on dilatation and consistency of uterine cervix was significant, but there were no significant benefits from giving vaginal hyoscine to menopausal women preoperatively (p=0.603). CONCLUSION: Hyoscine proved a good choice for inducing cervical priming before intrauterine procedures in premenopausal women.

Maternal near-miss at university hospitals with cesarean overuse: an incident case-control study.

INTRODUCTION: Cesarean section carries a substantial risk of maternal near-miss morbidity. The aim of this study was to determine the frequency, causes, risk factors, and perinatal outcomes of maternal near-miss at three university hospitals with a high rate of cesarean section in Tehran, Iran. MATERIAL AND METHODS: An incident case-control study was conducted from March 2012 to May 2014. The modified WHO near-miss criteria were used to identify cases. A control sample of 1024 women delivering at the study hospitals was recruited to represent the source population. Near-miss ratio, crude and adjusted odds ratios with confidence intervals were assessed. RESULTS: Among 12 965 live births, 82 mothers developed near-miss morbidities and 12 died. The maternal near-miss ratio was 6.3/1000 live births. Severe postpartum hemorrhage (35%, 29/82), severe preeclampsia (32%, 26/82), and placenta previa/abnormally invasive placenta (10%, 8/82) were the most frequent causes of maternal near-miss. Women with antepartum cesarean section (adjusted odds ratio 7.4, 95% confidence interval 3.7-15.1) and co-morbidity (adjusted odds ratio 2.3, 95% confidence interval 1.4-3.8), uninsured Iranians (adjusted odds ratio 3.4, 95% confidence interval 1.7-7.1) and uninsured Afghans (adjusted odds ratio 4.7, 95% confidence interval 2.4-9.2) had increased risks of near-miss morbidity. Stillbirth and extremely preterm birth were the most prominent adverse perinatal outcomes associated with maternal near-miss. CONCLUSIONS: Overutilization of cesarean section clearly influenced the causes of maternal near-miss. A lack of health insurance had a measurable impact on near-miss morbidity. Tailored interventions for reducing unnecessary cesarean section and unrestricted insurance cover for emergency obstetric care can potentially improve maternal and perinatal outcomes.

Cervical Priming by Misoprostol before Diagnostic Dilatation and Curettage: A Randomized Clinical Trial.

BACKGROUND: Difficulty in cervical dilatation is a hard situation during the procedure of diagnostic dilatation and curettage in some cases. This study was performed to evaluate the effect of vaginal misoprostol for cervical priming before diagnostic dilatation and curettage. METHODS: In this study 56 women were selected as the candidates for dilatation and curettage. The study was double blind and was performed for two parallel groups. One misoprostol tablet (200 µg) was administered in posterior fornix of vagina 2-4 hr before operation in 28 patients whereas in other 28 patients, placebo (VitB6) was used. Then, the two groups were compared according to the patency of the cervix measured by No. 5 Hegar dilators and the duration of dilatation and curettage procedure as well. Chi-square test, t-test, and Mann-Whitney U test were used for comparing two groups, and a p-value less than 0.05 was considered as statistically significant. RESULTS: Before the procedure of dilatation and curettage, the patency of the cervix was measured by passing Hegar dilator number 5 through the cervical canal in fifteen (53.6%) patients in the misoprostol group and 8 patients (28.6%) in the placebo group (p=0.05) which their difference was statistically significant. The effect of misoprostol was not significant in nulliparous women and postmenopausal period either. CONCLUSION: Vaginal misoprostol is a useful drug for ripening and dilating the cervix. It also facilitates the procedure of dilatation and curettage in premenopausal and multiparous women. Misoprostol was less effective in nulliparous women and in postmenopausal period.

The effect of progesterone suppositories on threatened abortion: a randomized clinical trial.

BACKGROUND: Threatened abortion is a common complication of pregnancy. In order to prevent miscarriage in the cases with threatened abortion, this study was conducted to determine whether progesterone suppository is effective in allowing pregnancy to proceed beyond week 20 in women with threatened abortion. METHODS: This single-blind clinical trial study was done on 60 pregnant women with threatened abortion. Pregnant women, who had vaginal bleeding until 20 weeks of their pregnancy, were assessed for inclusion. Participants were divided into two groups by random allocation; the control group, which did not undergo any treatment and the case group. The case group was given 400 mg of vaginal progesterone suppository (Cyclogest) each day until their bleeding stopped in less than one week. Participants were followed up until the end of their pregnancy. The treatment was considered successful if pregnancy continued beyond 20 weeks of gestation. Qualitative and quantitative variables were analyzed statistically by Chi Square and T- test respectively. The p-values of less than 0.05 were considered significant. RESULTS: There was no statistically significant difference between the case and the control groups in terms of background variables. The number of abortions in the case group (6 cases, 20%) was lower than the control group which had 10 abortions (33.3%). CONCLUSION: The study demonstrated that the rate of abortion was reduced in women treated with progesterone suppositories. However, the difference was not statistically significant.

Diagnosis of premature rupture of membranes by assessment of urea and creatinine in vaginal washing fluid.

BACKGROUND: Rupture of fetal membranes can occur at any gestational age. Premature rupture of membranes (PROM) means rupture of fetal membranes before the onset of labor. OBJECTIVE: The purpose of this study was to evaluate and compare the reliability of the vaginal washing fluid urea and creatinine for the diagnosis of PROM and to determine cut-off values. MATERIALS AND METHODS: A total of 179 pregnant women were recruited. All patients underwent different examinations. These included nitrazine paper test, fern test, amniotic fluid pooling, vaginal washing fluid urea and creatinine sampling. The one group consisted of 126 pregnant women between 14 and 41 weeks of gestation with the complaint of vaginal fluid leakage. Patients who had positive pooling, nitrazine paper test and fern test were considered as confirmed PROM group (group 1). On the other side, patients with pooling (-) and/or nitrazine paper test (-) and/or fern test (-) were taken as suspected unconfirmed PROM cases (group 2). The control group consisted of 53 pregnant women between 14 and 41 weeks of gestation without any complaint or complication. Weconducted one-way ANOVA test on the urea and creatinine measures and post-hoc comparison test. Cut-off value was determined by receiver operating characteristic (ROC) curve. RESULTS: Vaginal fluid concentrations of urea and creatinine were significantly different between the three groups (p<0.001). The sensitivity, specificity, positive and negative predictive values and accuracy were all 100% in detecting premature rupture of membranes by evaluation of vaginal fluid creatinine concentration with a cut-off value of 0.45 mg/dl, respectively. CONCLUSION: This study demonstrates that of two markers investigated creatinine has the higher diagnostic power.

Outcome of subsequent pregnancies in familial molar pregnancy.

Familial recurrent molar pregnancy is an exceedingly rare condition, in which complete hydatidiform moles are mostly diploid but biparental in origin and the outcome of subsequent pregnancies is likely to be a hydatidiform mole or other type of reproductive loss. We previously reported a case of familial molar pregnancy (family K) comprising five affected members (four sisters and one of their cousins) each with at least one hydatidiform mole (HM). In addition to the molar pregnancies, these patients have a total of three miscarriages and 8 normal pregnancies leading to healthy children; but the youngest member of this family has given birth to a boy with Down syndrome. Our second family (case S) includes two sisters with diploid biparental complete moles. They have a total of six molar pregnancies with no living child. Recently the younger sister had a partial molar pregnancy with apparently normal XX fetus accompanying diffuse molar changes of the placenta that led to preeclampsia and preterm delivery. Overall, these families have had 26 pregnancies including 12 molar pregnancies (complete or partial) and three abortions. We concluded that these families are predisposed to various genetic mutations, chromosomal abnormalities and clinical manifestations, which affect their offspring. Further studies of patients are needed to determine any relationship between a history of familial molar pregnancy and trisomy or other chromosomal abnormalities in offspring and genetic mutations in the products of conception to complete the puzzle and manage familial molar pregnancy.

Mutations in NLRP7 and KHDC3L confer a complete hydatidiform mole phenotype on digynic triploid conceptions.

Digynic triploidy is classically associated with a severely growth restricted fetus and a small nonmolar placenta. However, in genotyping hydatidiform moles as part of clinical practice, we identified two digynic triploid conceptions presenting with histopathological features of classical complete hydatidiform mole (CHM). Both cases occurred in women with a history of previous molar pregnancies and no normal pregnancies. Pathological review and genotyping of other molar pregnancies in these cases showed them to be typical CHM with negative p57(KIP2) immunostaining of the cytotrophoblast cells and villous stroma and to be diploid but biparental, confirming a diagnosis of familial recurrent hydatidiform mole (FRHM). Mutation screening of NLRP7 had identified a homozygous duplication, leading to a truncated protein, in case 1 whereas mutation screening of KHDC3L (C6orf221) in case 2 showed both the proband and her sister to be compound heterozygotes for mutations in KHDC3L. The observation of a single digynic, triploid conception presenting as a CHM in women with FRHM, where other pregnancies are diploid and biparental, supports the hypothesis that the role of both NLRP7 and KHDC3L in pregnancy is in setting and/or maintaining the maternal imprint. Clinically, a diagnosis of FRHM should be considered in women with genetically unusual conceptions that are phenotypically CHM.

Maternal and neonatal complications of substance abuse in Iranian pregnant women.

There is an increased prevalence of maternal substance abuse during pregnancy in younger women in all socioeconomic classes and races. Our aim was to determine the prevalence and correlates of self-reported substance abuse among pregnant women and obstetric complications or neonatal outcomes in Iran. This retrospective cohort study is covering a five year period on medical records of pregnant women attending the maternity unit of four major hospitals (Mahdieh, Taleghani, Imam Hossein and Akbarabadi Hospitals). Women who reported using opium, heroin, crack, cannabis or methamphetamine were compared with women with no reported history of drug abuse for obstetric complications and prenatal morbidity and neonatal mortality. From 100,620 deliveries substance abuse was recorded for 519 women giving a prevalence of 0.5%. Opium was the most prevalent substance abused followed by crack (a mix of heroin and amphetamines). The exposed group had significantly more obstetric complications including preterm low birth weight and postpartum hemorrhage than the non-exposed group. The exposed group had significantly worse prenatal outcomes including more admissions to intensive care unit and higher infant mortality than the non-exposed group. None of the women in the exposed group was on methadone treatment at time of delivery. Risks of maternal and neonatal complications were increased in substance using pregnant women, especially preterm birth and low birth weight. We recommend a multidisciplinary team to provide methadone maintenance therapy for substance using pregnant women and urinary screen of all pregnant women presenting to hospital.

Mutations causing familial biparental hydatidiform mole implicate c6orf221 as a possible regulator of genomic imprinting in the human oocyte.

Familial biparental hydatidiform mole (FBHM) is the only known pure maternal-effect recessive inherited disorder in humans. Affected women, although developmentally normal themselves, suffer repeated pregnancy loss because of the development of the conceptus into a complete hydatidiform mole in which extraembryonic trophoblastic tissue develops but the embryo itself suffers early demise. This developmental phenotype results from a genome-wide failure to correctly specify or maintain a maternal epigenotype at imprinted loci. Most cases of FBHM result from mutations of NLRP7, but genetic heterogeneity has been demonstrated. Here, we report biallelic mutations of C6orf221 in three families with FBHM. The previously described biological properties of their respective gene families suggest that NLRP7 and C6orf221 may interact as components of an oocyte complex that is directly or indirectly required for determination of epigenetic status on the oocyte genome.

Evaluation of bone mineral density in premature ovarian failure.

This study was performed to evaluate whether or not early menopause and premature ovarian failure can cause an increased risk of osteoporosis. The bone mineral density (BMD) of the 2nd and 4th lumbar spine as well as femoral neck in 29 cases with secondary amenorrhea were compared with a reference data using a dual-energy X-ray absorptiometry on a bone densitometer: Serum levels of luteinizing hormone, follicular stimulating hormone, calcium and phosphorus were also measured. Both in 20-29 years and in 30-39 years, BMD were significantly lower than their normal range as compared with a reference data from a large study of the same population (P value<0.05). At lumbar vertebrae, 2 cases had osteopenia and 17 had osteoporosis while at the femoral neck, 17 cases had osteopenia and 4 osteoporosis. Only serum levels of phosphorus had positive relationship with femoral neck BMD (P value<0.05). It may be possible to decrease fracture incidence through the early diagnosis of individuals at risk by BMD. In conclusion, our study indicates that females with early onset of menopause and premature ovarian failure had lower value of BMD in both femoral neck and lumbar vertebrae implying the need for more bone health measures.

A survey of sued physicians' self-reported reactions to malpractice litigation in Iran.

OBJECTIVE: To illustrate the psychological effect of grievances and negligence litigation on doctors sued by Legal Medicine Organization Complaints Commissions. METHODS: Retrospective survey regarding the views of a large sample of Iranian sued physicians by using a piloted anonymous questionnaire. RESULTS: The answer rate was 77.5%. Seventy-six per cent of participants encountered monitoring criteria for psychiatric disturbance. Rate of psychological morbidity in between study cluster was much higher than Iranian general population, Iranian non-sued general practitioners, interns and medical students. There was, however, minimal dysfunction of work, public or family life. The survey form to estimate the doctor's realization of lawful risk displayed that doctors yet misconceive medico-legal risk. Doctors being sued or having legal protests against them depict the process as an exceedingly demanding event. CONCLUSIONS: Grievance or legal action is unusual in the daily practice of doctors, but in today's medico-legal domain they face a continuous possible threat. The threat of, or real, legal process can cause psychological, corporeal and behavioral practice changes.

Menstrual disorders in nongenital tuberculosis.

Menstrual patterns differ even in nongenital tuberculosis. Our objective is to determine whether nongenital tuberculosis makes menstrual dysfunction, before and sustain after treatment. Menstrual patterns were compared in women with pulmonary or extrapulmonary but nongenital tuberculosis with healthy nursing students and also with themselves, before and after treatment in a retrospective cohort study. Subjects were selected by convenient nonrandomized sampling but control groups were selected by random allocation among volunteers of nursing students. Case and control subjects were matched in age group. Menstrual patterns including amount, duration, interval, cessation of period, any menstrual irregularity, and pelvic pain were evaluated. Among 100 cases of proven tuberculosis, 90 patients had pulmonary and 10 cases had extrapulmonary tuberculosis. Secondary amenorrhea (P < or = .001, RR: 22), spotting during menstrual period (P < or = .0001, RR: 4.5), decreasing in amount (P < or = .001, RR: 7.8), shorter duration of menstrual period (P < or = .001, RR: 12), and pelvic pain (P < or = .001, RR: 8.6) were more prevalent and significantly different in the cases compared to control subjects (with CI:95% and P < .001), but excessive or prolong vaginal bleeding was not observed. Menstrual disorders occur even in nongenital tuberculosis, but it is manifested with cessation or decrease in menstrual bleeding flow and period.

Asymptomatic bacteriuria in users of intrauterine devices.

INTRODUCTION: The aim of this study was to compare the frequency of asymptomatic bacteriuria in women who use intrauterine devices (IUDs) as a contraceptive method with subjects who use tubal ligation (TL). MATERIALS AND METHODS: A cohort study was conducted on women who were candidates for IUD insertion or TL (control). The patients were followed for 3 months, and urine cultures were assessed for bacteriuria at the end of the study. RESULTS: Overall, 131 women (mean age, 31.9 +/- 4.25 years) in the IUD group and 78 (mean age, 32.1 +/- 4.0 years) in the control group were studied. The parity score was 2 or more in 72% of the women in the IUD group and in 74% of the controls. The average intercourse frequency was twice per week in 82% of IUD users and 80% of controls. Fifty-seven percent of the women in the IUD group and 55% of the women in the control group had graduated secondary school (high school). Asymptomatic bacteriuria was detected in 13 IUD users (9.9%) and in 1 woman (1.3%) in the control group (risk ratio = 7.74, confidence interval: 1.03 to 58.03; P = .019). The detected microorganism in the urine culture was Escherichia coli in 12 IUD users and in 1 patient in control group. Klebsiella was found in 1 IUD user. CONCLUSION: Use of an IUD is a risk factor for urinary tract infection and should be considered, especially in women with recurrent urinary tract infections.

Intrauterine diagnosis and management of fetal goitrous hypothyroidism: a report of an Iranian family with three consecutive pregnancies complicated by fetal goiter.

The diagnosis and treatment of hypothyroidism during the fetal period may decrease perinatal morbidity and are believed to be important to optimize growth and intellectual development. Herewith a case report of fetal goitrous hypothyroidism is presented in a euthyroid mother, detected at 34 weeks' gestation by ultrasonography, and treated with intra-amniotic levothyroxine injections. The mother had two previous consecutive pregnancies (13 and 8 years ago), also complicated by the occurrence of fetal goiter, resulting in tracheal compression, asphyxia, and early neonatal death in the first and in an emergency cesarean section delivery, because of fetal malpresentation, in the second neonate affected by congenital hypothyroidism (CH). The present male newborn, although born without observable goiter, had a large thyroid on ultrasonography and an early rise of his peripheral venous blood thyrotropin confirmed the diagnosis of CH. Low serum thyroglobulin in the proband and his older brother and parental consanguinity was mostly compatible with a thyroglobulin defective synthesis and secretion as the cause of CH and fetal goiter. Despite apparently sufficient dose of intraamniotic levothyroxine injections repeated weekly from 34-37 weeks' gestation (i.e., four injections of 500 microg levothyroxine), neonatal bone age on the second day of life showed delayed skeletal maturation.

Postmenopausal bleeding resulting from placental site trophoblastic tumor of the uterus: a case report.

BACKGROUND: Placental site trophoblastic tumor (PSTT) is the least common form of gestational trophoblastic disease. Occurrence of PSTT after menopause is extremely rare. CASE: A 53-year-old woman complained of postmenopausal bleeding 6 years after cessation of her menstrual periods. On dilatation and curettage and on hysterectomy and bilateral salpingo-oophorectomy later, PSTT was found in the uterus with myometrial invasion and no metastasis. Serum human chorionic gonadotropin levels before and after the operation were 15 and < 1 IU/mL, respectively. Hysterectomy was performed. CONCLUSION: Because of PSTT's rarity, limited information is known about its natural history, and there is no reliable means to predict clinical outcome. Thus, patients must be evaluated on a case-by-case basis.