Transverse versus longitudinal blunt extension of the uterine incision during cesarean section in women with a uterine scar of previous cesarean delivery: A randomized controlled trial.

OBJECTIVE: To compare two different blunt extension techniques of the lower segment transverse uterine incision at cesarean delivery in women with a uterine scar of previous cesarean delivery. METHODS: Study design: Prospective single-blinded parallel multi-center randomized controlled trial involving 392 cases equally divided into two groups. Group one had their incision extended transversely, while group two had their incision extended longitudinally. OUTCOME MEASURES: The primary outcome was the unintended extension of the uterine incision, while the secondary outcomes included the need for additional stitches to achieve hemostasis, the drop in hemoglobin level, uterine vessels injury, and the need for blood transfusion. RESULTS: No significant difference between the transverse and longitudinal extension of the uterine incision during cesarean section as regards unintended uterine extension (P = 0.860), uterine vessel injury (P = 0.501), and cases requiring blood transfusion (P = 0.814). Significantly lower drop in hemoglobin level (P ≤ 0.001) and significantly less need for additional stitches (P ≤ 0.001) in cases with the longitudinal extension of uterine incision. CONCLUSION: In women with a uterine scar of previous cesarean delivery, the blunt longitudinal extension of the uterine incision in the lower segment cesarean section didn't differ from the blunt transverse extension as regards unintended uterine extension but is associated with less hemoglobin drop and less need for additional stitches as compared to transverse extension of the incision. Further studies are needed to assess the long-term complications of both techniques.

Relationship Between Ano-vaginal Distance and Bacterial Vaginosis (Cross-sectional Study).

Bacterial vaginosis is a vaginal condition caused by the overgrowth of anaerobic bacteria, owing to a shift in the vaginal microbial ecosystem. The aim of the study is to investigate the relationship between the ano-vaginal distance and the risk of developing bacterial vaginosis. In this cross-sectional study, the ano-vaginal distance was measured in 100 women participants complaining of vaginal discharge, divided into two groups. Group (1) consisted of 74 women who were negative for bacterial vaginosis, and group (2) consisted of 26 women who had bacterial vaginosis based on Amsel criteria. The negative cases for bacterial vaginosis had significantly longer ano-vaginal distance as compared with those who had bacterial vaginosis (3.85 ± 0.54 versus 3.38 ± 1.02). A positive correlation was detected between ano-vaginal distance and the risk of developing bacterial vaginosis. Further extensive studies are required to investigate this finding in different population groups.

Cesarean scar ectopic pregnancy: A cause of failed first trimester surgical termination of pregnancy (case report).

Cesarean scar (ectopic) pregnancy is due to blastocyst implantation on a Caesarean scar. The current case presented by vaginal bleeding after a failed surgical termination of pregnancy. The ultrasound scan revealed a cesarean scar ectopic pregnancy managed by surgical removal. The possibility of cesarean scar ectopic pregnancy should be considered in any case presenting with a low-lying gestational sac.

Effect of amlodipine on blood flow of preovulatory follicle in women with clomiphene resistant polycystic ovaries: a randomized controlled trial.

OBJECTIVE: To detect whether amlodipine could increase pre-ovulatory follicular blood flow, thus enhancing ovulation and creating a better chance of conception in women with PCOS. METHODS: 165 women were screened of which 124 were qualified and women were equally randomized to 62 receiving clomiphene citrate and amlodipine and 62 receiving clomiphene citrate and placebo. The primary outcome was to detect if amlodipine can improve pre-ovulatory follicle blood flow studied by colour and power Doppler Pulsatility index of ovarian arteries, with drug administration. The secondary outcomes were endometrial thickness and clinical pregnancy. RESULTS: The mean value of the ovarian arteries Pulsatility Index was significantly lower in the amlodipine group when compared to those of the placebo group (1.36 and 1.82, respectively, with P value 0.002). Mean endometrial thickness, for all women in both groups, on the day of detecting a mature follicle was significantly higher in the amlodipine group compared to the placebo group (8.99 and 7.0, respectively, with P value 0.003), and clinical pregnancy increased from 11% to 37% in the amlodipine group compared to the placebo group. CONCLUSION: Amlodipine improves ovarian blood flow and increases the chances of conception. TRIAL REGISTRATION: Pan African Clinical Trial Registry (http://www.pactr.org). Trial No: PAC TR201708002485292.

Letrozole vs. Placebo Pretreatment in the Medical Management of First Trimester Missed Miscarriage: a Randomized Controlled Trial.

INTRODUCTION: Misoprostol is used for the medical management of miscarriage as it is more effective in the early stages of pregnancy. Letrozole has an anti-estrogen effect and is used for the pretreatment of miscarriage with misoprostol. AIM: The aim of this study was compare the efficacy and safety of letrozole with placebo pretreatment in the medical management of first trimester missed miscarriage. DESIGN: This was a prospective randomized case-control study. PATIENTS AND METHODS: Four hundred and thirty-eight women were randomly divided into two groups of 219; the placebo group received placebo tablets twice daily for 3 days, followed by 800 micrograms of misoprostol vaginally on the fourth day of enrolment, while the letrozole group received letrozole 10 mg twice daily for three days followed by 800 micrograms misoprostol administered vaginally. Symptoms and side effects were recorded, and the women advised to return to hospital if they experienced severe pain or bleeding or intolerable side effects and to report to hospital for a check-up one week after misoprostol administration. Ultrasound was done seven days after misoprostol administration to monitor outcomes. Surgical evacuation was carried out if medical management failed. RESULTS: There were significant differences between the two groups, with better outcomes found for the letrozole group in terms of rates of complete miscarriage, onset of vaginal bleeding, and interval between induction and onset of expulsion (p < 0.001). A higher rate of nausea and vomiting was reported for the letrozole group (p = 0.002). Differences between groups with regard to pre- and post-termination hemoglobin levels, fever, severe pain and severe bleeding needing evacuation were not statistically significant. CONCLUSION: Adding letrozole to misoprostol improves the success rate and decreases the interval between induction and expulsion in cases of first trimester miscarriage; however, nausea and vomiting is higher with letrozole.

Evaluation of Serum Nidogen-2 as a Screening and Diagnostic Tool for Ovarian Cancer.

INTRODUCTION: Ovarian cancer is a relatively common occurrence with the formation of a tumour in the ovaries and is the leading cause of death in the gynecological field. Despite enormous efforts, there are no successful screening methods developed until now to decrease mortality in this regard. AIM: To evaluate nidogen-2 as a new tumour marker combined with higher sensitivity, specificity and accuracy than carbohydrate antigen (CA-125) and Doppler ultrasound to improve early diagnosis of ovarian cancer. PATIENTS AND METHODS: One hundred and forty-four qualified women with a preliminary diagnosis of adnexal mass were subjected to history, examination, transvaginal Doppler ultrasound and Quantitative assessment of serum level of CA-125 and nidogen-2 followed by the resection of the masses, which were sent for histopathological examination. RESULTS: One-hundred and sixteen cases were benign and 28 cases were malignant. The surgical procedures ranged from limited resection to radical hysterectomy. There was a highly significant correlation between both serum nidogen-2 and CA-125 and the results of histopathological examination (p = 0.0001). Serum nidogen-2 had 91.6% sensitivity, 62% specificity, 37.1% positive predictive value, 97.9% negative predictive value and 68% accuracy (p < 0.05). CONCLUSION: Nidogen-2 is a new promising ovarian malignancy biomarker that correlates closely with ultrasound and CA125. It did improve the accuracy of diagnosis, but further studies are needed.

Correction: Letrozole vs. Placebo Pretreatment in the Medical Management of First Trimester Missed Miscarriage: a Randomized Controlled Trial.

[This corrects the article DOI: 10.1055/s-0043-122499.].

Effect of female genital cutting performed by health care professionals on labor complications in Egyptian women: a prospective cohort study.

AIM: To examine the effect of the degree of female genital cutting (FGC) performed by health-care professionals on perineal scarring; delivery mode; duration of second stage of labor; incidence of perineal tears and episiotomy in a cohort of uncircumcised versus circumcised (types I and II) women. METHODS: A prospective cohort study included 450 primigravida women in active labor attending the Faculty of Medicine Cairo University Hospital between January 2013 and August 2014. Women were divided into three groups based on medical examination upon admission. Group I (Control) included 150 uncut women, Group II included 150 women with type I FGC and Group III included 150 women with type II FGC. A structured questionnaire elicited the information on women's socio-demographic characteristics including age, residence, occupation, educational level, age of marriage and FGC circumstances. Association between FGC and labor complications was examined. MAIN OUTCOMES: risk of perineal scarring; delivery mode; duration of second stage of labor; incidence of perineal tears and episiotomy. RESULTS: Family history of genitally cut mother/sister was the most significant socio-demographic factor associated with FGC. FGC especially type II was associated with significantly higher incidence of vulvar scar (P<0.0002), perineal tears (P<0.0001) and increased likelihood of additional vaginal and perineal trauma [odds ratio (OR): 1.85, 95% CI: 0.60-5.65. P≤0.001]. There was insignificant difference in risks of cesarean section (CS), instrumental delivery, episiotomy and short-term neonatal outcomes. CONCLUSION: The study strengthens the evidence that FGC increases the risk of tears in spite of medicalization of the practice.

Pregnancy in a non-communicating rudimentary horn: a cause of failed medical and surgical management of second trimester pregnancy loss.

OBJECTIVES: We present the management of a case of failed medical and surgical management of second trimester pregnancy loss due to pregnancy in a non-communicating rudimentary horn. CASE: A 16-week intrauterine fetal death singleton pregnancy was referred to us after failed medical and surgical termination of pregnancy. Ultrasound confirmed the diagnosis and showed minimal blood clots and fluid in the pouch of Douglas. Laparoscopy showed a soft, enlarged right uterine horn not communicating with the cervix and containing the pregnancy, and a left uterine horn communicating with the cervix and showing a posterior wall perforation. The procedure was converted to laparotomy, and the right uterine horn and adjacent tube were excised. The patient made an uneventful recovery and was discharged after 3 days. CONCLUSION: Pregnancy in a non-communicating horn is rare and usually presents with serious complications. Any case of failed medical termination of pregnancy after repeated doses of misoprostol should be carefully assessed to exclude the possibility of uterine anomalies (especially in a primigravida), before proceeding with dilatation and evacuation to minimise the risk of complications.

Three-dimensional ultrasound first trimester fetal volume measurement and its relation to pregnancy outcome.

AIM OF WORK: To determine whether fetal volume (FV) measured by three-dimensional (3D) ultrasound was able to detect fetuses at risk of low birth weight (primary outcome) and/or preterm labor (secondary outcome). METHODS: One hundred pregnant women carrying a singleton living pregnancy who were sure of dates, and had a dating scan, with gestational age between 11 weeks and 13 weeks+6 days coming for routine first trimester nuchal translucency (NT) were examined by both two-dimensional (2D) and 3D ultrasound (Vocal System) for crown-rump length (CRL) and FV then followed up regularly every 4 weeks until 28 weeks then biweekly until 36 weeks then weekly until delivery both clinically and by ultrasound biometry. FINDINGS: Eighty-seven cases had a normal outcome, while the remaining 13 cases had either preterm labor (four cases) or low-birth weight (nine cases). FV positively correlated with CRL (P=0.026), gestational age in weeks (P=0.002), neonatal body weight in grams (P=0.018) and neonatal body length at birth (P=0.04). A mean FV of 8.3 mm3 was association with neonatal complications (P=0.045). A cut-off point of 9 mm3 for FV was associated with 100% sensitivity for detection of the date of birth, while a cut-off point of 9.15 mm3 for FV was associated 100% sensitivity for detection of neonatal birth weight. CONCLUSION: 3D assessment of FV in the first trimester provides an accurate method for predicting pregnancy outcome namely low birth weight and neonatal complications, however, it is a better positive predictor than a negative one.