Lidocaine vs. tramadol vs. placebo wound infiltration for post-cesarean section pain relief: a randomized controlled trial.

OBJECTIVES: In low-income settings, postoperative pain relief could be challenging as a high patient/nurse ratio limits pain assessment and adequate analgesics administration. The multi-center prospective double-blinded parallel randomized controlled trial was done to compare lidocaine, tramadol, and placebo (saline) intraoperative wound infiltration to relieve post-cesarean section wound pain during the first 24 h. METHODS: Ninety-nine cases were equally randomized into three groups, each containing 33 pregnant women undergoing cesarean section under general anesthesia. During operation, the wound was infiltrated subcutaneously with 20 mL of 2% lidocaine solution in the first group, 2 mg/kg tramadol in the second group, and saline in the third group. The primary outcome was to assess the postoperative pain at 2, 4, 6, 12, and 24 h by the Yes-No-Don't Know (YNDK) Scale, while the secondary outcome was to assess the need for further postoperative analgesia. RESULTS: Wound infiltration with lidocaine or tramadol was effective in pain relief, and both were superior to placebo. Wound infiltration with tramadol was superior to lidocaine in pain relief at 2 h and up to 24 h. CONCLUSIONS: Wound infiltration with tramadol has a more prolonged pain relief effect than lidocaine in post-cesarean section pain relief in patients performing cesarean section under general anesthesia lasting up to 24 h, and both are superior to placebo in pain relief.

Pre-operative tranexemic acid vs. etamsylate in reducing blood loss during elective cesarean section: randomized controlled trial.

OBJECTIVES: To investigate whether etamsylate may be an alternative to tranexamic acid in reduction of blood loss during elective cesarean section. METHODS: Prospective double-blinded multi-center randomized controlled trial involving 180 qualified women equally divided into three groups each containing 60 women received either tranexamic acid, etamsylate or placebo 20 min before elective cesarean section and blood loss was estimated. RESULTS: Mean blood loss, cases needing blood transfusion and cases needing further interventions were significantly lower in tranexamic acid and etamsylate group than placebo group, while mean postoperative hemoglobin and hematocrite were significantly higher in both tranexamic acid and etamsylate as compared to placebo. CONCLUSIONS: Etamsylate is an effective second-line therapy (after tranexamic acid) in reducing blood loss during elective cesarean section with low risk of side effects, therefore, it can be an effective alternative to tranexamic acid in cases with contraindications or anticipated to be at high-risk of developing side effects from tranexamic acid.

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.

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.

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.

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.

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.

Lidocaine gel vs lidocaine spray in reducing pain during insertion of the intrauterine contraceptive device.

OBJECTIVES: The aim of this study was to compare the pain-relieving effect of intracervical lidocaine gel with that of lidocaine spray or no local anaesthesia in decreasing pain during insertion of the intrauterine contraceptive device (IUCD). METHODS: In a prospective multicentre non-randomised comparative study design, 420 women were divided into three groups of 140 and fitted with the same type of IUCD. Group 1 received cervical lidocaine gel, group 2 received cervical lidocaine spray and group 3 received no topical anaesthesia. A visual analogue scale was used to measure the degree of pain experienced. RESULTS: There were no significant differences between the three groups with regard to baseline characteristics such as age and number of deliveries. Significantly less pain was felt during cervical traction in women using a local anaesthetic. However, there were no significant differences in pain due to IUCD insertion. CONCLUSIONS: Application of a local anaesthetic decreased the pain resulting from cervical traction but not that resulting from IUCD insertion.

Cesarean Delivery in a Case of Persistent Second Trimester Ovarian Hyperstimulation Syndrome.

Background Ovarian hyperstimulation syndrome develops as an iatrogenic complication related to ovulation induction. It is usually self-limiting with complete resolution expected within 10-14 days. Case The current case is a report of an unusually prolonged course of ovarian hyperstimulation syndrome persisting until 22 weeks of gestation, accidentally discovered and managed by cesarean section due to an obstetric indication. Conclusion Clinicians should be aware of this possibility when managing cases of IVF pregnancy.

Infiltrating Mammary Duct Adenocarcinoma in the Right Labia Majora Along the Milk-Line.

Introduction Breast tissue rarely arises from the vulva and malignancy might develop in it. Case Thirty-eight-year-old woman presented with a suspicious ulcer in the right labia majora discovered accidently and removed by wide local excision. Histopathology revealed infiltrating mammary duct adenocarcinoma along the milk line. Immunohistochemistry was positive for estrogen and progesterone receptors and equivocal overexpression for HER2 protein with a score of 2+. Metastatic work-up was clear. Inguinal lymph nodes were enlarged and lymphadenectomy done which showed positive lymph nodes on the right side and none on the left. She is receiving adjuvant therapy. Conclusion Mammary duct carcinoma along the nipple line is rare but should be considered when dealing with suspicious vulvar lesions.

The use of rotational bladder flap and hemostatic matrix sealant (FloSeal): a modified transabdominal approach to repair supratrigonal and complex vesicovaginal fistula.

Vesicovaginal fistula (VVF), commonly caused by prolonged obstructed labor, is one of the worst complications of childbirth and poor obstetric care in the developing world. We investigated the clinical efficacy and outcome of technical modifications of the current transperitoneal supravesical technique for supratrigonal and complex vesicovaginal fistula. We studied a total of 20 patients with iatrogenic supratrigonal and complex vesicovaginal fistula following obstetric trauma and hysterectomy. All patients underwent a modified transabdominal technique: the modifications consisted of passing a Foley catheter through the fistulous opening, inflating the balloon, and applying traction on the catheter to provide effective anchorage and to minimize the oozing from the cystotomy edges. The cystotomy was directed in the parasagittal line, and medial side of the bladder was rotated as a flap into the bladder defect; the urethral de Pezzare catheter was used for urinary drainage. We used hemostatic matrix sealant (FloSeal, Baxter BioSurgery, Westlake Village, California) to promote healing and hemostasis. The vesicovaginal fistula was successfully corrected in all patients after the first attempt, and no significant bladder dysfunction or decrease in bladder capacity was seen after repair. Interposition flaps were used in all patients, and six patients (30%) required ancillary procedures for other associated anomalies at the time of fistula repair. At a mean follow-up of two years, fourteen women were sexually active, and 5 (35%) from this group of patients complained of mild-to-moderate dyspareunia. In our study, supratrigonal VVFs were repaired with a transabdominal, transperitoneal, transvesical approach. Tailoring the cystotomy in a parasagittal line permitted closure of fistula by rotation of bladder flap into the defect. This excellent method should be a viable option when repairing complex VVF.

Effect of Intra Uterine Granulocyte Colony Stimulating Factor vs. Human Chorionic Gonadotropin at Ovum Pick Up Day on Pregnancy Rate in IVF/ICSI Cases With Recurrent Implantation Failure.

OBJECTIVE: Recurrent implantation failure is defined as failure to achieve clinical pregnancy after the transfer of four or more good-quality embryos in a minimum of three fresh or frozen cycles in a woman aged less than 40 years. The objective is to compare between the effect of intrauterine G-CSF, hCG, and saline solution injection (as placebo) at the day of ovum pick-up on clinical pregnancy, chemical pregnancy, implantation, and miscarriage rates in patients with recurrent implantation failure undergoing IVF/ICSI. METHODS: This prospective, double blind, parallel, randomized controlled trial included 150 patients equally divided into 3 groups, each containing 50 individuals. Subjects in Group 1 received intrauterine injections of G-CSF; Group 2: received intrauterine injections of 500 IU of hCG; and Group 3 received intrauterine injections of saline solution as placebo. The primary outcome measure is clinical pregnancy rate. Secondary outcomes are biochemical pregnancy, implantation, and miscarriage rates. RESULTS: Clinical pregnancy, biochemical pregnancy, and implantation rates were highest in the group given G-CSF and lowest in the group administered saline solution; miscarriage rates were not significantly different between the groups. CONCLUSIONS: Intrauterine administration of G-CSF at a dose of 100 µg/1.0 cc at the time of ovum pick-up is associated with better clinical pregnancy, chemical pregnancy, and implantation rates as compared with intrauterine saline solution administration. Further studies are needed to determine the optimum timing of intrauterine administration of G-CSF that achieves the best results, and longer follow-up is needed to determine take-home baby percentages.

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.

RETRACTION NOTE TO: Comparing sequential vs. day 3 vs. day 5 embryo transfers in cases with recurrent implantation failure: randomized controlled trial

This corrects the article DOI: 10.5935/1518-0557.20200083.