Guillain-Barre Syndrome With Concomitant Severe Preeclampsia: A Case Report.

With an estimated 100,000 new cases yearly worldwide, Guillain-Barre syndrome (GBS) is the most common cause of flaccid paralysis. GBS is exceedingly rare in pregnancy and carries high maternal and fetal risk. We report a case of a 38-year-old essential primigravida who presented at 38 weeks six days gestational age with ascending paraplegia progressing to dysarthria, dysphagia, and facial weakness. A clinical diagnosis of GBS was made in an outside institution, supported by elevated protein on lumbar puncture. During the antepartum period, a diagnosis of gestational hypertension progressed to preeclampsia with severe features when a sudden rise in liver function tests occurred. The patient underwent an uneventful planned cesarean delivery but could not be extubated due to respiratory failure. After a 20-day critical care admission, she was extubated and had an improvement in neurologic status to near her baseline.

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

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

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

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

A qualitative study of women and partners from Lebanon and Quebec regarding an expanded scope of noninvasive prenatal testing.

BACKGROUND: In the near future, developments in non-invasive prenatal testing (NIPT) may offer couples the opportunity to expand the range of genetic conditions tested with this technology. This possibility raises a host of ethical and social concerns, such as the type of information (medical vs. non-medical information) that couples might be exposed to and how this might complicate their informed decision-making. Currently, only limited research, mainly carried out in western countries, was conducted on women's and partners' views regarding the potential expansion of NIPT. METHODS: This study used semi-structured interviews with pregnant women and their partners to explore their views on future potential NIPT applications such as non-medical sex selection and non-medical traits, paternity testing, and NIPT use for fetal whole genome sequencing (FWGS). It was conducted in Lebanon and Quebec, as case studies to explore the impact of cultural differences on these views. RESULTS: We found no differences and many similarities when comparing the perceptions of participants in both contexts. While couples in both settings disapproved of the use of NIPT for non-medical sex selection and non-medical traits such as physical characteristics, they were near-unanimous about their support for its use for paternity testing in specific cases, such as legal doubts or conflicts related to the identity of the father. Participants were more ambivalent about NIPT for Fetal Whole Genome Sequencing. They supported this use to detect conditions that would express at birth or early childhood, while objecting to testing for adult-onset conditions. CONCLUSIONS: These results can further inform the debate on the future uses of NIPT and future policy related its implementation.

Implementation challenges for an ethical introduction of noninvasive prenatal testing: a qualitative study of healthcare professionals' views from Lebanon and Quebec.

BACKGROUND: The clinical introduction of non-invasive prenatal testing for fetal aneuploidies is currently transforming the landscape of prenatal screening in many countries. Since it is noninvasive, safe and allows the early detection of abnormalities, NIPT expanded rapidly and the test is currently commercially available in most of the world. As NIPT is being introduced globally, its clinical implementation should consider various challenges, including the role of the surrounding social and cultural contexts. We conducted a qualitative study with healthcare professionals in Lebanon and Quebec as case studies, to highlight the relevance of cultural contexts and to explore the concerns that should be taken into account for an ethical implementation of NIPT. METHODS: We conducted semi-structured interviews with 20 healthcare professionals (HCPs), 10 from each country, practicing in the field of prenatal screening and follow up diagnostic testing, including obstetricians and gynecologists, nurses, medical geneticists and, genetic counselors. We aimed to 1) explore HCPs' perceptions and views regarding issues raised by NIPT and 2) to shed light on ways in which the introduction of the same technology (NIPT) in two different contexts (Lebanon and Quebec) raises common and different challenges that are influenced by the cultural norms and legal policies in place. RESULTS: We identified challenges to the ethical implementation of NIPT. Some are common to both contexts, including financial/economic, social, and organizational/ educational challenges. Others are specific to each context. For example, challenges for Lebanon include abortion policy and financial profit, and in Quebec challenges include lobbying by Disability rights associations and geographical access to NIPT. CONCLUSIONS: Our findings highlight the need to consider specific issues related to various cultural contexts when developing frameworks that can guide an ethically sound implementation of NIPT. Further, they show that healthcare professional education and training remain paramount in order to provide NIPT counseling in a way that supports pregnant women and couples' choice.

Splenic Artery Aneurysm (SAA) Rupture in Pregnancy: A Case Report of a Rare but Life-Threatening Obstetrical Complication.

This is the case of a 38 year-old Lebanese woman G2P1, history of previous cesarean section, presenting at 30+5 weeks of gestation with acute left-sided flank pain and a two-day history of chills and dysuria. In light of the clinical presentation, the patient was initially diagnosed with pyelonephritis and managed accordingly; however, her clinical status deteriorated with worsening hypotension and lethargy despite resuscitative measures and a normal abdominal ultrasound. Failure to revive the patient eventually led to a cardiac arrest for which a peri-mortem cesarean section was performed at bedside. Upon abdominal entry, an actively-bleeding ruptured splenic artery aneurysm (SAA) was identified, for which massive transfusion protocol was activated, and the patient was transferred to the operating room. The patient had a complicated postoperative course, the fetus was stillborn, and she was discharged home after 6 months of hospital stay. In view of the high mortality and morbidity associated with ruptured SAA in pregnancy, early recognition and prompt intervention are crucial for maternal and fetal benefit.

Accuracy of Pelvic Ultrasound in Diagnosing Adnexal Torsion.

Ovarian/adnexal torsion is a rather frequent occurrence in women of reproductive age group worldwide. Etiologies are quite diverse with ovarian lesions and corpus luteal cysts being the most two common. Pelvic or intravaginal ultrasound remains the first-line imaging modality used for diagnosis and evaluation of suspected ovarian/adnexal torsion. In this study, we have adopted a case-based statistical analysis to identify important sonographic markers and further evaluated their contribution in identifying ovarian torsion. Our study successfully determined the important sonographic markers. Our observation and analysis suggest that ovarian enlargement is the most sensitive marker. Ovarian edema was found to be the most specific marker to identify the ovarian torsion with higher level of accuracy and confidence. This pioneer study will provide valuable information and direction to the medical practitioners and radiologists for better diagnosis. Further studies with large sample size will help in establishing our findings universally.

Unexplained First Trimester Intrahepatic Cholestasis of Pregnancy: A Case Report and Literature Review.

Intrahepatic cholestasis of pregnancy (ICP) is a condition that usually affects the 3rd trimester-pregnant women and is associated with adverse pregnancy outcomes. We present a 31-year-old G2P1 patient with symptoms of ICP as early as 10 weeks of gestation (WG). Her pruritis was initially attributed to eczema. Due to the intensity of her discomfort and failure of topical treatment, ICP was suspected, total bile acid salt levels were taken and ursodeoxycholic acid was subsequently started at 18 WG. The patient was followed closely during her pregnancy to adjust the dose of the medication accordingly. Induction of labor was performed at 37 WG without complications. This case demonstrated the importance of clinical suspicion in the setting of such symptomatology in order not to miss or delay treatment of threatening conditions such as ICP.

Cross-cultural perspectives on decision making regarding noninvasive prenatal testing: A comparative study of Lebanon and Quebec.

Noninvasive prenatal testing (NIPT), based on the detection of cell-free fetal DNA in maternal blood, has transformed the landscape of prenatal care by offering clinical benefits (noninvasive, high specificity and sensitivity, early detection of abnormalities) compared to existing prenatal screening tests. NIPT has expanded rapidly and is currently commercially available in most of the world. As NIPT spreads globally, culturally sensitive and ethically sound implementation will require policies that take into consideration the social and cultural context of prenatal testing decisions. In a Western context, the main ethical argument for providing access and public funding of prenatal tests is the promotion of reproductive autonomy (also referred to as "procreative liberty" and "reproductive freedom"), by enabling pregnant women and couples to access information about the fetus in order to choose a certain course of action for pregnancy management (continuation of pregnancy and preparation for birth or termination). So how is the framework of reproductive autonomy operationalized in non-Western cultural contexts? We used Quebec, Canada, and Beirut, Lebanon, for case studies to explore what ethical considerations related to reproductive autonomy should guide the implementation of the test in various cultural contexts. To answer this question, we conducted a qualitative study to (1) explore the perceptions, values, and preferences of pregnant women and their partners about NIPT and (2) examine how these values and perceptions influence reproductive autonomy and decision making in relation to NIPT in these two different cultural settings, Lebanon and Quebec. Our findings may guide health care professionals in providing counseling and in helping women and their partners make better informed prenatal testing decisions. Further, at a policy level, such understanding might inform the development of local guidelines and policies that are appropriate to each context.

To ignore or not to ignore placental calcifications on prenatal ultrasound: a systematic review and meta-analysis.

OBJECTIVE: The human placenta is known to calcify with advancing gestational age, and, in fact, the presence of significant calcifications is one of the components of grade III placenta, typical of late gestation. As such, the presence of significant placental calcifications often prompts obstetric providers to expedite delivery. This practice has been attributed, in part, to the presumed association between grade III placenta and adverse pregnancy outcomes. Such approach, however, can be the source of major anxiety and may lead to unnecessary induction of labor, with its associated predisposition to cesarean delivery as well as a myriad of maternal and neonatal morbidities. The objective of this study was to examine the association between grade III placental calcifications and pregnancy outcomes. MATERIALS AND METHODS: A systematic review of the literature was performed for studies evaluating the association between grade III placenta and a number of pregnancy outcomes, including labor induction, fetal distress (abnormal fetal heart tracing), low Apgar score (less than 7 at 5 min), need for neonatal resuscitation, admission to the Neonatal Intensive Care Unit, perinatal death, meconium liquor, and low birth weight. RESULTS: There was a five-fold increase in risk of labor induction with the presence of grade III placenta (OR 5.41; 95% CI 2.98-9.82). There was no association between grade III placenta and the incidence of abnormal fetal heart tracing (OR 1.62; 95% CI 0.94-2.78), low Apgar score of less than 7 at 5 min (OR 1.68; 95% CI 0.84-3.36), need for neonatal resuscitation (OR 1.08; 95% CI 0.67-1.75), and admission to the Neonatal Intensive Care Unit (OR 0.90; 95% CI 0.21-3.74). In turn, the incidence of meconium liquor was higher in the setting of grade III placentae (OR 1.68; 95% CI 1.17-2.39). Similarly, a positive association between grade III placental calcifications and low birth weight (OR 1.63; 95% CI 1.19-2.22) and perinatal death (OR 7.41; 95% CI 4.94-11.09) was identified. CONCLUSION: The study alerts us to a significant association between grade 3 placental calcifications and labor induction, although it demonstrates that these sonographic findings do not appear to predispose to fetal distress, low Apgar score, need for neonatal resuscitation, or admission to the NICU.

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

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

Effect of the Mode of Application of Cryopreserved Human Amniotic Membrane on Adhesion Formation after Abdomino-Pelvic Surgery in a Mouse Model.

Adhesions after abdomino-pelvic surgery are a cause of morbidity and reoperations. The use of human amniotic membrane (HAM) for adhesion prevention has given controversial results. The mode of administration of the amniotic membrane has not been well studied. This study assessed the efficacy of two modes of application of cryopreserved HAM, patch or fragmented in Lactated Ringer (LR) solution, for the prevention of pelvic adhesion formation postabdomino-pelvic surgery in a mice model. After a midline laparotomy incision, a small cautery lesion was done on each side of the abdominal wall peritoneum in mice. In Group A (control; n = 42), the abdomen was closed directly, Group B (n = 42) received 2.5 ml of LR prior to closure. In Groups C (n = 42) and D (n = 42), a 2 cm × 2 cm patch of HAM and another one fragmented and dispersed in 2.5 ml of LR were applied prior to closure, respectively. Two weeks later, a laparotomy was performed, and gross and pathological evaluation of adhesions, fibrosis, angiogenesis, and inflammation were conducted. Group D exhibited a significantly lower rate of gross adhesion formation. Fibrosis was significantly lowest in Group C as compared to the control. Group B had the lowest vascular formation in the adhesions. The use of HAM fragmented in LR solution is associated with a significantly lower incidence of postoperative adhesions in mice when compared to LR alone, HAM patch, or control. The mechanism of action of this reduction needs to be elucidated by future studies.

Echogenic intracardiac focus on second trimester ultrasound: prevalence and significance in a Middle Eastern population.

OBJECTIVE: The association between echogenic intracardiac focus (EIF) and trisomy 21 is well established, with a recognized ethnic variation. Our study aimed to determine the prevalence of EIF in a Middle Eastern population and to examine its association with trisomy 21 and other adverse pregnancy outcomes. METHODS: Retrospective case-control study of second-trimester obstetric sonograms (16-28 weeks) performed at a tertiary care center over a 5-year period. Cases with EIF were retrieved, and a matched control group with no EIF was identified. The incidence of trisomy 21 and other adverse pregnancy outcomes was compared. RESULTS: A total of 9270 obstetric sonograms were examined, with an EIF prevalence of 2.5% (95% CI: 2.2-2.8%). Of patients with available outcome data, EIF was not associated with trisomy 21 (0/163 versus 1/163; p value = 1.00). Additionally, EIF was not associated with trisomy 18, trisomy 13, small for gestational age, preterm birth, fetal demise, cesarean delivery, operative vaginal delivery, or admission to the neonatal intensive care unit. CONCLUSION: In a contemporary Middle Eastern population, EIF is a rare occurrence. As an isolated finding, it is not associated with aneuploidy or other adverse pregnancy outcomes. EIF appears to be incidental with no impact on clinical practice.

Recurrent twin pregnancy, with the second a heterotopic pregnancy, following clomiphene citrate stimulation: an unusual case and a review of the literature.

Multiple gestations are on the rise with the advent of artificial reproductive technologies. Even with ovulation induction using clomiphene citrate alone, the twinning rate can reach up to 9 percent. We report a case of recurrent twin gestation after treatment with clomiphene citrate, with the second pregnancy being heterotopic. We also review, using Medline and PubMed, previously reported cases of recurrent twin gestation after treatment with clomiphene citrate published before June 2014. Patients undergoing ovulation induction for oligoovulation, anovulation, or unexplained infertility should always be counseled about the possibility of multiple gestation prior to the treatment including the probability, although low, of a heterotopic pregnancy.

Review article: late post-hysterectomy ectopic pregnancy.

Ectopic pregnancy after hysterectomy is a rare but potentially life-threatening condition requiring prompt diagnosis to prevent the increased mortality associated with rupture. Twenty-seven cases of late post-hysterectomy ectopic pregnancy reported in the English literature since 1918 were reviewed and analysed for presenting symptoms, missed diagnosis rate at initial presentation, location of ectopic and rupture rate at diagnosis. The presenting symptoms were found to be non-specific. The diagnosis in this population is twice more likely to be missed than in women with intact uteri. The rupture rate is 63%, compared with 37% in women with intact uteri. The majority of late post-hysterectomy ectopic pregnancies (62%) were located in the fallopian tubes. Because of the potential risk of mortality, emergency physicians should always consider the possibility of ectopic pregnancy in childbearing women whose surgical history includes hysterectomy without oophorectomy. Evaluation of abdominal pain in this population should include a pregnancy test to ensure prompt diagnosis when the possibility of pregnancy exists clinically.

Maternal mortality from preeclampsia/eclampsia.

Preeclampsia/eclampsia is one of the 3 leading causes of maternal morbidity and mortality worldwide. During the past 50 years, there has been a significant reduction in the rates of eclampsia, maternal mortality, and maternal morbidity in the developed countries. In contrast, the rates of eclampsia, maternal complications, and maternal mortality remain high in the developing countries. These differences are mainly due to universal access to prenatal care, access to timely care, and proper management of patients with preeclampsia-eclampsia in the developed countries. In contrast, most of maternal deaths and complications are due to lack of prenatal care, lack of access to hospital care, lack of resources, and inappropriate diagnosis and management of patients with preeclampsia-eclampsia in the developing countries. Preeclampsia/eclampsia is associated with substantial maternal complications, both acute and long-term. Clear protocols for early detection and management of hypertension in pregnancy at all levels of health care are required for better maternal as well as perinatal outcome. This is especially important in the developing countries.

Vaginoscopic resection of vaginal septum.

We report the resection of a vaginal septum while preserving the virginity of a 12-year-old girl with Herlyn-Werner-Wunderlich Syndrome (HWWS) having a didelphys uterus, obstructed hemivagina, and an ipsilateral renal agenesis with follow-up at 18 months. Successful resection of the vaginal septum with conservation of the hymenal ring and complete drainage of both the hematocolpos and the hematometra were achieved. Cyclic dysmenorrhea and pelvic pain were completely resolved on follow-up visits at 4, 6, and 18 months. Office hysteroscopy performed during the last follow-up visit revealed a patent vaginal vault without evidence of adenosis or recurrence of the vaginal septum. Vaginoscopy is a safe, convenient, and efficient diagnostic and therapeutic modality that can be used in the management of patients with an obstructed hemivagina. It maintains the patient's virginity and it is useful in patients with a restrictive vaginal opening or narrow vaginal canal. Furthermore, the hysteroscopic excision of the vaginal septum offers minimal risk of recurrence of the septal defect.

The role of oxidative stress in the developmental origin of adult hypertension.

OBJECTIVE: To determine whether oxidative stress plays a role in the development of hypertension using a mouse model of fetal programming induced by endothelial nitric oxide synthase deficiency. STUDY DESIGN: Homozygous nitric oxide synthase knockout and wild type mice were cross-bred producing maternal (endothelial nitric oxide synthase+pat/-mat) and paternal (endothelial nitric oxide synthase+mat/-pat) heterozygous offspring. RNA from liver and kidney tissues of female pups were obtained at 14 weeks of age. Relative expression of the heat shock protein-B6, peroxiredoxin-3, superoxide dismutase-1, peroxisome proliferator-activated receptor gamma, nitric oxide synthase-1 and -2 were determined. RESULTS: In the kidneys, expression of nitric oxide synthase-2, peroxiredoxin-3, heat shock protein-B6, and superoxide dismutase-1 was up-regulated in endothelial nitric oxide synthase+pat/-mat but not in endothelial nitric oxide synthase+mat/-pat compared with wild type offspring. In the liver, there were no significant differences in the expression of nitric oxide synthase-1, nitric oxide synthase-2, peroxiredoxin, superoxide dismutase-1, or peroxisome proliferator-activated receptor gamma; however, heat shock protein-B6 was down-regulated in both heterozygotes offspring compared with wild type. CONCLUSION: The intrauterine environment alters oxidative pathways gene expression in the kidneys of offspring, which may be a mechanism in the development of adult hypertension.

Ectopic pregnancy in a uterine perforation site.

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