Role of tranexamic acid-soaked gelatin sponge in minimizing rectus sheath hematoma after cesarean section in women treated with warfarin, a simple tool for high-risk cases, a randomized controlled trial.

BACKGROUND: This study aims to illustrate the impact of applying the tranexamic acid impregnated in a gelatin sponge between the anterior rectus sheath and the Rectus Abdominis muscle during Cesarean section (CS) in minimizing rectus sheath hematoma (RHS) in women treated with Warfarin. METHODS: A clinical trial was carried out on 63 pregnant women attended for elective CS, who on antenatal warfarin anticoagulation started from 13 weeks gestation to 36 weeks then shifted to low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH), and with an indication for postnatal warfarin anticoagulation. They were randomly assigned on the day of the scheduled CS into three equal groups (21 women for each). Group 1 had two pieces of gelatin sponges soaked with one ampoule of tranexamic acid. Group 2 had two pieces of gelatin sponges not soaked with tranexamic acid. Group 3 (control group) had no gelatin sponge applied. All patients underwent postoperative assessment done for hemoglobin (Hb), hematocrit (HCT), estimated blood loss (EBL), amount and nature of discharge collected from the sub-rectus drain, complications (RHS, wound infection, thromboembolism), need for re-operation, and need for blood transfusion. RESULTS: Statistically significant differences were found between Group 1 and Group 2 regarding the postoperative Hb (10.66 ± 1.13 vs. 9.77 ± 0.69, P = 0.009), between Group 1 and Group 2 regarding the postoperative HCT (31.87 ± 3.59 vs. 28.54 ± 1.85, P = 0.001), between Group 1 and Group 2 regarding EBL (442.19 ± 244.46 vs. 744.38 ± 267.05, P = 0.003), between Group 1 and Group 3 regarding EBL (442.19 ± 244.46 vs. 664.29 ± 343.97, P = 0.040), and between Group 1 and Group 3 regarding the discharge amount from the sub rectus drain (190.48 ± 100.77 vs. 307.14 ± 127.76, P = 0.004). CONCLUSION: Tranexamic acid-soaked gelatin sponges are safe and effective in reducing postoperative drainage and EBL. CLINICAL TRIAL REGISTRATION: At ClinicalTrials.gov in June 2022 (NCT05439694).

Screening for maternal cytomegalovirus infection during pregnancy and pregnancy outcome in patients with liver disease: an observational study.

BACKGROUND: Cytomegalovirus (CMV) infection among pregnant females could induce CMV hepatitis with possible changes in liver stiffness measurement (LSM) which could be reversibly increased during normal pregnancies, particularly in the third trimester. This study aimed to detect the prevalence of CMV infection among pregnant females with and without chronic liver disease and to evaluate the effects of CMV infection on LSM and pregnancy outcomes in comparison to non-CMV-infected pregnant females. METHODS: This is an observational prospective study that included 201 pregnant ladies presented to the liver disease with pregnancy clinic, Cairo University from March 2018 to April 2019. We assessed the laboratory results, abdominal ultrasonography, LSM using ARFI elastography, and pregnancy outcomes. RESULTS: Two hundred and one pregnant ladies were divided into ; group 1: pregnant ladies with normal pregnancy (n = 128), group 2: pregnant ladies with chronic liver diseases not related to pregnancy (n = 35), and group 3: pregnant ladies with pregnancy-related liver diseases (n = 38). Positive CMV serology (either/or, +ve CMV-IgM, IgG) was detected in 106/201 patients (52.74%), and fifteen of them had an active infection (IgG +, IgM+, PCR+). Pregnant females with chronic liver diseases not related to pregnancy had significantly higher serum levels of CMV IgM, IgG, and PCR. Moreover, LSM had a significant correlation with CMV IgG and CM_PCR in normal pregnant ladies. Maternal mortality occurred only in pregnant females with chronic liver diseases in 5.7% (2/35). CONCLUSION: Maternal CMV infection carries a significant risk to pregnant females with chronic liver disease. Routine CMV screening for women planning to be pregnant, especially those with chronic liver disease could help to avoid bad maternal and fetal outcomes.

Risk factors of congenital hydrocephalus: a case-control study in a lower-middle-income country (Egypt).

OBJECTIVE: Hydrocephalus is the most common brain disorder in children and is more common in low- and middle-income countries. Research output on hydrocephalus remains sparse and of lower quality in low- and middle-income countries compared with high-income countries. Most studies addressing hydrocephalus epidemiology are retrospective registry studies entailing their inherent limitations and biases. This study aimed to investigate child-related, parental, and socioeconomic risk factors of congenital hydrocephalus (CH) in a lower-middle-income country. METHODS: An investigator-administered questionnaire was used to query parents of patients with CH and controls who visited the authors' institution from 2017 until 2021. Patients with secondary hydrocephalus and children older than 2 years of age at diagnosis were excluded. Uni- and multivariable logistic regression was performed to identify the factors affecting CH development. RESULTS: Seven hundred forty-one respondents (312 cases and 429 controls) were included in this study. The authors showed that maternal diseases during pregnancy (OR 3.12, 95% CI 1.96-5.03), a lack of periconceptional folic acid intake (OR 1.92, 95% CI 1.32-2.81), being a housewife (OR 2.66, 95% CI 1.51-4.87), paternal illiteracy (OR 1.65, 95% CI 1.02-2.69), parental consanguinity (OR 3.67, 95% CI 2.40-5.69), a history of other CNS conditions in the family (OR 2.93, 95% CI 1.24-7.34), conceiving a child via assisted fertilization techniques (OR 3.93, 95% CI 1.57-10.52), and the presence of other congenital anomalies (OR 2.57, 95% CI 1.38-4.87) were associated with an independent higher odds of a child having CH. Conversely, maternal hypertension (OR 0.22, 95% CI 0.09-0.48), older maternal age at delivery (OR 0.93, 95% CI 0.89-0.97), and having more abortions (OR 0.80, 95% CI 0.67-0.95) were negatively correlated with CH. CONCLUSIONS: Multiple parental, socioeconomic, and child-related factors were associated with higher odds for developing CH. These results can be utilized to guide parental counseling and management, and direct social education and prevention programs.

Acoustic radiation force impulse to measure liver stiffness and predict hepatic decompensation in pregnancy with cirrhosis: A cohort study.

BACKGROUND AND STUDY AIMS: Pregnancy in association with cirrhosis is a rather uncommon and highly risky situation for both mother and child. We aim to study all factors and the utility of liver stiffness (LS) measurement by Acoustic Radiation Force Impulse elastography (ARFI) to predict hepatic decompensation in pregnant cirrhotic patients. PATIENTS AND METHODS: We prospectively recruited 224 pregnant women at the multidisciplinary clinic of liver disease with pregnancy, Cairo University. LS was measured using ARFI (Siemens ACUSON S3000 ultrasound system) during the second trimester and 8-12 weeks post-delivery. The outcome of pregnancy and the incidence of hepatic decompensation were assessed. RESULTS: Our cohort comprised 128 normal pregnancies, 37 patients with pregnancy-related liver disease (Intrahepatic cholestasis (n = 6), preeclampsia (n = 23), and hyperemesis gravidarum (n = 8)) and 59 patients with an established chronic liver disease not related to pregnancy. In all patients, LS significantly decreased after delivery from 1.19 m/s to 0.94 m/s (P < 0.001). In multivariate analysis, LS was an independent predictor for the outcome of pregnancy in all patients (odds ratio (OR) = 5.442 (3.01-6.82), cut-off = 1.21 m/s). Patients with cirrhosis, mean LS was 1.57 ± 0.66 m/s and 26 (44%) patients had hepatic decompensation (hepatocellular jaundice (n = 8), ascites (n = 9) and variceal bleeding (n = 6)). In multivariate analysis; LS, platelets, albumin, and bilirubin were independent predictors of decompensation post-delivery and the OR for LS was 6.141(4.32-7.98). The optimal cut off value of LS to predict decompensation was 1.46 m/s (8.4 kPa) with AUROC of 0.827. CONCLUSION: LS can be used to predict hepatic decompensation after delivery in pregnant women with manifest cirrhosis.

Comparative study between single versus dual trigger for poor responders in GnRH-antagonist ICSI cycles: A randomized controlled study.

OBJECTIVE: To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the number of retrieved oocytes and clinical pregnancy rate in poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles using a GnRH-antagonist protocol. METHODS: A randomized controlled trial included poor ovarian responders indicated for ICSI using a GnRH-antagonist protocol. They were divided equally into two groups: group I received 10 000 units of hCG plus 0.2 mg of triptorelin while group II received 10 000 units of hCG only for triggering of ovulation. The primary outcome parameter was the number of oocytes retrieved. Secondary outcomes included metaphase II oocytes number, cancellation rate, number of obtained embryos, chemical and clinical pregnancy rates. RESULTS: One hundred and sixty women were included in the study, with 80 women in each treatment group. Dual triggering was associated with higher number of retrieved oocytes (5.3 ± 1.9 vs 4.5 ± 2.4, P=0.014), metaphase II oocytes (3.8 ± 1.4 vs 3.1 ± 1.7, P=0.004), total and grade 1 embryos (2.7 ± 1.1 and 2.3 ± 1.0 vs 1.9 ± 1.2 and 1.1 ± 0.2, P=0.001 and 0.021 respectively), and transferred embryos (2.2 ± 0.9 vs 1.6 ± 0.9, P=0.043, and lower cancellation rate (7.5% vs 20%, P=0.037) compared with single triggering. There were significantly higher chemical (25% vs 11.3%, P=0.039) and clinical (22.5% vs 8.8%, P=0.028) pregnancy rates in women with dual triggering compared with those with single triggering. CONCLUSION: Dual triggering is associated with better IVF outcome in poor responders compared with single trigger. Clinical trial registration NCT04008966.

Physical endometrial manipulation and its impact on success rate and live birth rate in ICSI in patients with unexplained infertility after recurrent ICSI failure, a double blinded randomized controlled trial.

Background: Unexplained infertility is a rising problem and endometrial manipulation could be one of the solutions for enhancing the pregnancy rate and live birth rate in such circumstances.Aims: To evaluate the influence of local endometrial physical manipulation with specializd method for endometrial and tubal hydration (Elgazzar and Alalfy technique) on ICSI outcome and in increasing chemical, clinical, and live birth rate in ICSI after previous recurrent ICSI failure in patients with unexplained infertility.Results: When comparing group 1 (hydrotubation group) and group 2 (the control group with no intervention) with regards to the biochemical, clinical, and live birth rate, the hydrotubation group revealed higher rates and a better ICSI outcome.Conclusion: Hydrotubation is useful in increasing biochemical, clinical, and live birth rates after recurrent failed ICSI trials with a specialized method for hydration of endometrium and tubes (Elgazzar and Alalfy technique).

Effect of body mass index on the outcome of IVF cycles among patients with poor ovarian response.

OBJECTIVE: To assess the effects of body mass index (BMI) on the outcome of IVF cycles among poor responders. METHODS: A prospective cohort study in Egypt enrolled 185 poor responders who underwent intracytoplasmic sperm injection via an antagonist protocol between 2012 and 2017. Participants were classified into three groups by BMI (calculated as weight in kilograms divided by the square of height in meters): 18.5-24.9 (normal, n=48); 25-29.9 (overweight, n=54); 30 or higher (obese, n=83). Outcomes were clinical pregnancy rate, implantation rate, chemical pregnancy rate, gonadotropin dose, number of oocytes and embryos, and cancellation rate. RESULTS: There was no significant difference among the three groups in gonadotropin dose; duration of stimulation; endometrial thickness on trigger day; number of oocytes retrieved, injected, or fertilized; number of embryos, transferred embryos, or frozen embryos; or day of embryo transfer. Frequency of implantation (11/81 [14%] vs 6/96 [6%] or 5/155 [3%]), chemical pregnancy (20 [42%] vs 14 [30%] or 12 [14%]) and clinical pregnancy (15 [31%] vs 12 [22%] and 9 [11%]) was significantly higher for normal than for overweight or obese women, respectively. CONCLUSION: Implantation, chemical pregnancy, and clinical pregnancy rates were inversely related to increasing BMI. CLINICALTRIALS.GOV: NCT03457233.

Effect of maternal obesity on labor induction in postdate pregnancy.

OBJECTIVE: To test the hypothesis that there is a higher rate of unsuccessful induction of labor (IOL) in post-term obese pregnant women compared to non-obese ones. METHODS: In this prospective cohort study, 144 obese (BMI > 30) and 144 non-obese (BMI < 29.9) post-term (> 41 weeks) pregnant women were recruited. IOL was done by misoprostol or amniotomy and oxytocin infusion according to the Bishop score. Comparison of percentage of failed IOL in both groups (primary outcome) was performed by the Chi-test. Logistic regression and multivariable regression were performed to assess the odds ratio (OR) of cesarean section (CS) and coefficient of delay in labor till vaginal delivery (VD) in obese versus (vs) non-obese groups. Adjustment for gestational age, parity, Bishop Score, membrane rupture and amniotic fluid index was done in both regression analyses. RESULTS: CS rate was significantly higher in obese group [26.4 vs 15.9%; difference in proportion (95% CI) 0.1 (0.01, 0.19); P value 0.02]. 106 (73.6%) obese women and 121 (84.1%) non-obese women delivered vaginally. In addition, the duration till VD was significantly higher in obese group (22 vs 19 h, P value 0.01). After adjustment for possible confounding factors, the CS was still higher in the obese group in comparison to non-obese group (OR 2.02; 95% CI 1.1, 3.7; P value 0.02). This finding suggested that obesity was an independent factor for failure of IOL. In addition, after adjustment for these confounders, obesity had the risk of increasing labor duration by 2.3 h (95% CI 0.1, 4.5) in cases that ended in VD. CONCLUSION: Based on our results, we conclude that there is a higher risk of CS in obese postdate pregnant women undergoing IOL in comparison to non-obese counterparts. Therefore, obstetricians should pay more attention to advising pregnant women about optimal weight gain during pregnancy and counseling about the chances of VD in cases of IOL. CLINCALTRIAL. GOV ID: NCT02788305.

Manual removal versus spontaneous delivery of the placenta at cesarean section in developing countries: a randomized controlled trial and review of literature.

PURPOSE: Cesarean section (CS) rates have increased; this is especially concerning in developing countries. The mode of placental delivery contributes to morbidity associated with CS and determines blood loss during CS. We aimed to compare manual removal versus spontaneous delivery of the placenta at CS. METHODS: In a randomized controlled trial, 574 women admitted for primary or repeat elective CS were randomized into two groups. In group A, the placenta was manually removed, whereas in group B, the placenta was left for spontaneous delivery. Blood loss, operative and postoperative data were recorded. RESULTS: Blood loss was 875.2 ± 524.2 ml in group A versus 731.8 ± 426.7 ml in group B (p = .001), with a significant drop in postoperative HB (p = .015) and HCT (p = .031). In group A, odds ratios for blood loss (>1000 ml), HB drop (> 4g/dl), postpartum hemorrhage and blood transfusion were 2.581, 2.850, 2.614 and 1.665, respectively. However, the total operative time (p = .326), duration of hospital stay (p = .916) and intensive care unit (ICU) admission (p = .453) were not statistically different between the two groups. CONCLUSIONS: Manual removal of the placenta at CS is associated with a higher risk of blood loss, postpartum hemorrhage and blood transfusion, with no decrease in operative time.