Reproductive outcome following resectoscope metroplasty in women having a complete uterine septum with double cervix and vagina

Objective

To evaluate reproductive outcomes in women with complete uterine septum with double cervix and vagina following resectoscope metroplasty.

Methods

The pregnancy outcomes of 21 women who underwent vaginal and uterine septum resection were compared with those of 15 untreated women with similar clinical characteristics. The Fisher exact test and the Mann-Whitney test were used for statistical analysis.

Results

Cycle fecundity was better (33.4% ± 28.5% vs 12.2% ± 4.7%; P = 0.046), the rate of term delivery significantly increased (P < 0.05), and the rate of spontaneous abortion decreased (P < 0.05) in the treatment group.

Conclusion

Resectoscope metroplasty was found to improve the pregnancy outcomes of women having primary infertility or a history of pregnancy loss associated with a complete uterine septum with double cervix and vagina.     

Análisis de la finalización de la gestación y morbilidad materna en las gestaciones de 41 semanas

Objective

To evaluate the mode of delivery and maternal morbidity associated with pregnancies ending at 41 weeks.

Material and methods

We designed a retrospective cohort study. The mode of delivery and maternal complications of 230 pregnancies ending at 41 weeks were compared with those in 234 pregnancies ending between 37 and 40 weeks at the Miguel Servet University Hospital in 2005.

Results

Women delivering at 41 weeks had an increased risk of membrane sweep, unfavorable Bishop score at admission, induction and longer duration of labor. These increases were also seen in the rates of operative vaginal delivery (25.6 vs 17.6%, p < 0.001) and cesarean section (21.7 vs 8.5%, p < 0.001).

Conclusions

The rates of maternal peripartum complications increase as pregnancy reaches 41 weeks. Accurate investigation of these rates is important to determine the gestational age at which the risk of continuing the pregnancy outweighs the risk of labor induction.     

Laparoscopic ovarian cystectomy of endometriomas: surgeons' experience may affect ovarian reserve and live-born rate in infertile patients with in vitro fertilization-intracytoplasmic sperm injection

Objective

To assess whether the laparoscopist's experience can affect ovarian reserve and pregnancy outcome in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) patients who previously underwent laparoscopic conservative treatment for ovarian endometriomas.

Study design

One hundred and forty-nine IVF-ICSI cycles with infertile patients who previously underwent laparoscopic conservative treatment for ovarian endometriomas were enrolled. There were 76 cycles with an inexperienced surgeon and 73 cycles with an experienced surgeon.

Results

The number of antral follicle count (7.5 ± 3.8 vs. 9.6 ± 6.6; p = 0.011), and live-born rate per cycle (9.3% vs. 32.9%; p < 0.001) were significantly lower in the inexperienced group comparing with the experienced group. However, the mean number of oocytes, fertilization rate, mean number of embryos transferred, rate of good-quality embryos transferred, implantation rate and clinical pregnancy were similar between both groups.

Conclusions

The experience of the laparoscopist may affect ovarian reserve and live-born rate after treating ovarian endometrioma in infertile women with IVF-ICSI.     

Effect of estradiol on oocyte development

Objective

To determine whether elevated serum estradiol (E₂) concentrations in oocyte donors affect assisted reproduction outcome.

Method

In a retrospective cohort study of 58 consecutive oocyte donation cycles, donors were stratified into 2 groups according to E₂ concentration, group 1 (n = 32; E₂ ≤ 2000 pg/mL [range 456-2000 pg/mL]) and group 2 (n = 27; E₂ > 2000 pg/mL [range, 2062-6957 pg/mL]). Data were analyzed using the t test and χ² test.

Results

Donors in group 1 produced significantly less oocytes than donors in group 2 (19.3 ± 1.7 vs 12.0 ± 1.4; P < 0.001), and recipients of oocytes from group 1 had significantly fewer numbers of embryos available for transfer (10.4 ± 1.1 vs 6.4 ± 0.8; P = 0.003). However, the mean number (3.3) of embryos transferred and the pregnancy rate were the same in both groups.

Conclusion

Elevated estradiol concentration in oocyte donors did not affect pregnancy outcome, suggesting that estradiol levels in donors do not affect oocyte development.     

Meperidine versus valethamate bromide in shortening the duration of active labor

Objective

To compare the efficacy and safety of meperidine hydrochloride and valethamate bromide against placebo in shortening the duration of active labor.

Method

We randomly assigned 160 nulliparous women with a singleton pregnancy at term who needed induction of labor to one of 3 treatments: 50 mg of meperidine (n = 53), 16 mg of valethamate bromide (n = 53), or a normal saline solution as placebo (n = 54). All medications were given by slow intravenous infusion. Labor duration was the main outcome measure.

Results

The intervals between infusion and complete cervical dilation and between infusion and delivery were significantly reduced (P < 0.001 and P < 0.01) in the meperidine group (103.0 ± 64.5 minutes and 119.8 ± 70.2 minutes), in contrast to the placebo group (173.9 ± 74.8 minutes and 192.2 ± 82.8 minutes). However, differences were not significant between the 2 treatment groups (139.6 ± 63.1 minutes and 160.6 ± 71.9 minutes), or between the valethamate bromide and the placebo group.

Conclusion

Meperidine, but not valethamate bromide, significantly shortened the duration of active labor in nulliparous women with a singleton pregnancy at term.     

Maternal and perinatal outcomes of visceral leishmaniasis (kala-azar) treated with sodium stibogluconate in eastern Sudan

Objective

To investigate maternal and perinatal outcomes when pregnant women with visceral leishmaniasis (VL, also known as kala-azar) are treated with the antimonial sodium stibogluconate.

Method

Forty-two pregnant women with VL were treated with sodium stibogluconate at Gadarif Hospital, Gadarif, Sudan, and mother and child were followed up for 1 year.

Results

The treatment began at a mean ± SD of 24.4 ± 9.2 weeks of pregnancy. None of the patients had malaria or HIV. Two (4.7%) who received the treatment in the first trimester had miscarriages; 4 (4.9%) died from hepatic encephalopathy during the second week of treatment; and 2 (4.7%) had preterm deliveries. One of the newborns had a myelomeningocele and died at 2 hours, and the other died from VL at 2 months.

Conclusion

Preventive measures against VL should be employed in the region, and more research on VL and its treatment during pregnancy is needed.     

Fluoxetine treatment for anxiety in women undergoing in vitro fertilization

Objective

To compare anxiety levels experienced during 4 stressful periods of in vitro fertilization (IVF) and treatment outcomes between women taking fluoxetine and a placebo.

Methods

A prospective, randomized, double-blind, placebo-controlled trial of patients allocated to receive either fluoxetine (FLX) or folic acid (FA). Anxiety state was assessed at the beginning of ovarian stimulation (OS), ovum pick-up, embryo transfer, and on the day of the pregnancy test (DPT) using the State-Trait Anxiety Inventory (STAI).

Results

Baseline STAI-S and STAI-T were normal. From OS to DPT, STAI-S increased from 42.8 ± 10.6 to 44 ± 9.0 in the FLX group and from 40.9 ± 8.1 to 45.3 ± 8.3 in the FA group (P = 0.03 and P = 0.001, respectively). IVF outcome was not affected by the treatment in the two groups.

Conclusions

Caution is needed in prescribing fluoxetine to alleviate anxiety in patients undergoing IVF. Studies are needed to determine whether other selective serotonin reuptake inhibitors or higher fluoxetine doses can relieve emotional distress without affecting IVF outcome.     

Intrauterine insemination in Jamaica as a low-cost subfertility treatment in a low-resource region

Objective

To determine the impact of intrauterine insemination on the management of subfertility in Jamaica.

Methods

The present study was a retrospective analysis of all intrauterine insemination cycles completed from May 1, 2002, to August 31, 2005, at the University of the West Indies, Mona, Jamaica. The cycle pregnancy rate (CPR), live-birth rate (LBR), and cumulative pregnancy rate were obtained and prognostic factors were reviewed.

Results

The CPR, LBR, and cumulative pregnancy rate were 10.1%, 8.8%, and 13.9%, respectively. Improved success was significantly associated with a shorter period of infertility (3.10 ± 1.43 years vs 5.22 ± 2.89 years; P = 0.01). Women younger than 40 years of age, men with increased post-preparation sperm counts, and couples undergoing 2-3 cycles had improved outcomes.

Conclusion

Intrauterine insemination represents a safe and cost-effective option for mild male factor infertility or unexplained infertility, especially in resource-poor regions such as the Caribbean. Repeated failed cycles identify those who would probably benefit from early intervention with in vitro fertilization.     

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum hemorrhage with placenta accreta

Objective

To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta.

Method

This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta.

Results

Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental remnants completely disappeared within 8 months and ovulation resumed after a mean ± SD of 51.6 ± 3.2 days. Moreover, 18 women (75%) became pregnant within 12 months.

Conclusion

Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain fertile.     

Sublingual misoprostol for first trimester termination of pregnancy

Objectives

To compare blood loss, efficiency, and acceptability of repeated doses of sublingual misoprostol with the standard Tunisian regimen of mifepristone-misoprostol for first trimester medical abortion.

Methods

A prospective randomized trial of 252 healthy pregnant women requesting medical abortion in the first trimester (up to 56 days). Participants were randomized to receive 200 mg of oral mifepristone followed by 400 µg of oral misoprostol (group 1) or 800 µg of sublingual misoprostol repeated every 4 hours for up to a maximum of 3 doses (group 2). Primary outcome was blood loss assessed by decrease in hematocrit.

Results

Mean decrease in hematocrit at follow-up was significantly greater in group 1 than in group 2 (3.65% ± 1.18% vs 2.69% ± 1.89%, respectively; P = 0.02). There was no difference in efficiency rates between groups 1 and 2 (94.5% vs 92.1%; P = 0.7). Comparable proportions of women experiencing at least one adverse effect after misoprostol administration were reported in groups 1 and 2 (81.7% vs 79.4%; P = 0.75).

Conclusion

Compared with the most widely used regimen in Tunisia (mifepristone-misoprostol), sublingual misoprostol alone induces less blood loss (although not clinically significant); it is less expensive and offers reduced interval time to expulsion.     

Maternal serum protein S forms in pregnancies complicated by intrauterine growth restriction

Objectives

The clinical relevance of protein S deficiency in pregnant women remains controversial. Major debate exists regarding which parameter (total protein S antigen, free protein S antigen or functional protein S) should be evaluated in order to define protein S deficiency. The present study aimed to identify which of these parameters correlate with intrauterine growth restriction (IUGR).

Study design

A retrospective case-control study of women with IUGR (n = 27) and healthy controls (n = 123) in the third trimester of pregnancy.

Results

The maternal serum of women in the IUGR group had significantly lower levels of functional and free protein S compared with the control group: 54.07 ± 24.72% vs 65.20 ± 17.95% (p < 0.005) and 42.88 ± 11.01% vs 56.64 ± 13.30% (p < 0.0001), respectively. No significant correlation was found between total protein S and IUGR.

Conclusions

Levels of functional and free protein S are correlated with IUGR.     

Risk factors for rupture in tubal ectopic pregnancy: definition of the clinical findings

Objectives

The aim of this study is to determine the risk factors for rupture of an ectopic pregnancy (EP) to help physicians identify those women who are at greatest risk.

Study design

The study group comprised the cases of EP treated in our department from January 2003 to September 2009. The following parameters were retrospectively examined: rupture status, past history of pelvic infection or EP, use of an intrauterine device (IUD), parity and gestational age. Women with tubal rupture were compared to those without rupture. Where appropriate, univariate and multivariate analyses were used to identify predictors of the outcome of EP.

Results

Two hundred and thirty-two cases of EP were retrieved. Eighty-eight of them (37.9%) were cases with ruptured EP and 144 (62.1%) were cases with unruptured EP. No significant associations existed regarding IUD use, smoking, previous ectopic pregnancy, past history of pelvic inflammatory disease (PID) or history of endometriosis. The mean gestation (in weeks) since the last menstrual period and the mean level of βhCG were significantly higher in patients with ruptured EP compared with patients with unruptured EP (7.8 ± 1.09 versus 6.4 ± 1.2, p < 0.0001; and 8735.3 ± 11317.8 IU/ml versus 4506 ± 5673.7 IU/ml, p < 0.0001, respectively). Logistic regression analysis revealed that 6-8 weeks of amenorrhoea (OR: 3.67; 95% CI: 1.60-8.41) and >8 weeks of amenorrhoea (OR: 46.46; 95% CI: 14.20-152.05) and also 1501-5000 IU/ml of βhCG level (OR: 4.11; 95% CI: 1.53-11.01) and >5000 IU/ml of βhCG levels (OR: 4.40; 95% CI: 1.69-11.46) were the significant risk factors for tubal rupture.

Conclusions

Higher βhCG levels and higher gestational age seem to be significant risk factors for rupture of an EP.     

Oral misoprostol reduces vaginal bleeding following surgical evacuation for first trimester spontaneous abortion

Objective

To assess the effectiveness and tolerability of misoprostol to reduce the amount and duration of vaginal bleeding following surgical evacuation for first trimester spontaneous abortion.

Methods

A total of 160 patients who underwent surgical evacuation for first trimester spontaneous abortion between 8 and 12 weeks of pregnancy were randomized into 2 groups to receive either 200 µg of oral misoprostol immediately after evacuation followed every 6 hours for 48 hours or no misoprostol. Pain scores, duration and amount of bleeding, and endometrial thickness were assessed over 10 days.

Results

Women who received misoprostol had significantly fewer bleeding days after evacuation (4.11 ± 2.69 vs 5.89 ± 3.06; P < 0.001), fewer patients reported vaginal bleeding lasting 10 days or more (3.8% vs 15.0%; P = 0.014), and endometrial thickness 10 days after evacuation was less (6.25 ± 2.38 vs 7.23 ± 1.94; P = 0.05). Pain scores were comparable in both groups (1.54 ± 0.65 vs 1.63 ± 0.83; P = 0.40) after 10 days.

Conclusion

Oral misoprostol is effective in reducing the prevalence and amount of vaginal bleeding after surgical evacuation for first trimester spontaneous abortion.     

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery

Objective

To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously.

Methods

Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25 ± 11 minutes; n = 19); and forceps delivery for second stage arrest (137 ± 26 minutes; n = 19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n = 129).

Results

Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P = 0.07).

Conclusion

Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.     

Determinants of fertility and reproductive success after hysteroscopic septoplasty for women with unexplained primary infertility: a prospective analysis of 88 cases

Objective

To evaluate prospectively the effect of hysteroscopic septoplasty as therapy for unexplained primary infertility in women with uterine septum as a sole cause for reproductive failure and to define the factors influencing reproductive success.

Study design

In a prospective comparative study, we enrolled 103 infertile women with uterine septum as a sole cause for reproductive failure. They had had unexplained primary infertility >2 years and a follow-up >12 months. Uterine anomalies were diagnosed by means of hysterosalpingography (HSG) and 2D-transvaginal sonography (TVS) with intrauterine saline infusion. Hysteroscopic septoplasty was performed in the early follicular phase. Pregnancy rates (PR) according to patient and septum characteristics (septum size) were the main outcome measures.

Results

Follow-up was complete for 88 patients. The mean (±SD) age of the patients was 36.1 ± 2.1 years. Forty-two patients became pregnant (40.7%). The mean (±SD) delay in conception was 7.5 ± 2.6 months. Nearly 80% of the pregnant women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. The PR was significantly higher in women <35 years of age or with <3 years of unexplained primary infertility. Moreover, in women with a septum size larger than one-half of their uterine length the PR was significantly higher than those with septum size <1/2 of their uterus (P = .12).

Conclusion

Fertility and pregnancy after hysteroscopic septoplasty in women with unexplained primary infertility and uterine septum as a sole cause for reproductive failure seems to depend on patient age, duration of infertility before septoplasty, and septum size. Women with a septum size larger than one-half of their uterine length have a higher chance of successful pregnancy after hysteroscopic septoplasty.     

The use of quality control performance charts to analyze cesarean delivery rates nationally

Objective

To examine the use of quality control performance charts to analyze cesarean rates nationally.

Methods

Information on cesarean rates was obtained for all 19 Irish maternity hospitals receiving state funding in 2009. All women who underwent cesarean delivery of a live or stillborn infant weighing 500 g or more between January 1 and December 31 were included. Deliveries were classified as elective or emergency. Individual hospitals were not identified in the analysis.

Results

The mean rates per hospital of elective and emergency cesarean were 12.9 ± 2.6% (n = 9337) and 13.8 ± 3.0% (n = 9989), respectively—giving an overall mean rate of 26.7 ± 4.2% (n = 19326) per hospital. Cesarean rates were normally distributed. Using a quality control performance chart with a cutoff 2 standard deviations from the mean, 1 hospital was above the normal range for both total and elective cesareans, indicating that its pre-labor obstetric practices warrant clinical review. Another hospital had a mean emergency cesarean rate above the normal range, indicating that its labor ward practices warrant review.

Conclusion

Quality control performance charts can be used to analyze cesarean rates nationally and, thus, to identify hospitals at which obstetric practices should be reviewed.     

A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle

Objective

Vascularized groin lymph node flaps have been successfully transferred to the wrist to treat postmastecomy upper limb lymphedema. This study investigated the anatomy, mechanism and outcome of a novel vascularized submental lymph node (VSLN) flap transfer for the treatment of lower limb lymphedema.

Methods

Bilateral regional submental flaps were dissected from three fresh adult cadavers for histological study. A unilateral submental flap was dissected in another six fresh cadavers after latex injection. The VSLN flap was transferred to the ankles of seven lower extremities in six patients with chronic lower extremity lymphedema. The mean patient age was 61 ± 9.4 years. The average duration of lymphedema symptoms was 71 ± 42.2 months.

Results

There was a mean of 3.3 ± 1.5 lymph nodes around the submental artery typically at the junction with the facial artery, on the six cadaveric histological sections. Mean of 2.3 ± 0.8 sizable lymph nodes were dissected and supplied by the submental artery in six cadaveric latex-injected submental flaps. All seven VSLN flaps survived. One flap required re-exploration for venous congestion but was successfully salvaged. There was no donor site morbidity. At a mean follow-up of 8.7 ± 4.2 months, the mean reduction of the leg circumference was 64 ± 11.5% above the knee, 63.7 ± 34.3% below the knee and 67.3 ± 19.2% above the ankle.

Conclusion

The transfer of a vascularized submental lymph node flap to the ankle is a novel approach for the effective treatment of lower extremity lymphedema.     

Methotrexate therapy followed by suction curettage followed by Foley tamponade for caesarean scar pregnancy

Objectives

Caesarean scar pregnancy (CSP) is a very rare and dangerous form of pregnancy because of the increased risk of rupture and excessive hemorrhage. There is currently no consensus on the treatment. We studied if methotrexate (MTX) therapy followed by suction curettage followed by Foley tamponade was a viable treatment for patients with CSP.

Study design

Forty-five patients with CSP in our hospital received a single dose of 50 mg/m² MTX by intramuscular injection. If gestational cardiac activity was seen on transvaginal ultrasound, local injection of MTX was given. After 7 days, suction curettage was performed to remove the retained products of conception and blood clot (CSP mass) under transabdominal sonography (TAS) guidance. After the suction curettage, a Foley catheter balloon was placed into the isthmic portion of cervix.

Results

Forty-two subjects were successfully treated and 3 subjects failed treatment. The mean estimated blood loss of all 45 patients was 706.89 ± 642.08 (100-3000) ml. The resolution time of the serum β-hCG was 20.62 ± 5.41 (9-33) days. The time to CSP mass disappearance was 12.57 ± 4.37 (8-25) days.

Conclusions

MTX administration followed by suction curettage followed by Foley tamponade was an effective treatment for caesarean scar pregnancy.     

Risk of heart failure relapse in subsequent pregnancy among peripartum cardiomyopathy mothers

Objective

To quantify the level of risk for heart failure relapse in a subsequent pregnancy in women who have had peripartum cardiomyopathy (PPCM), and to test the hypothesis that meeting additional criteria may help lower the risk.

Methods

Prospectively-identified PPCM patients volunteering between 2003 and 2009 were identified from the PPCM Registry of Hôpital Albert Schweitzer, Deschapelles, Haiti, and an internet support group. Data were assessed for full adherence to monitoring and diagnostic criteria, clinical data, statistical analysis, and reporting.

Results

Of 61 post-PPCM pregnancies identified, there were 18 relapses (29.5%) of heart failure. Of 26 pregnancies with a left ventricular ejection fraction (LVEF) of less than 0.55 prior to the pregnancy, relapse occurred in 12 (46.2%) pregnancies. Of 35 pregnancies with an LVEF of 0.55 or greater prior to the pregnancy, relapse occurred in 6 (17.1%) (P < 0.01). No relapses occurred in 9 women who also demonstrated adequate contractile reserve.

Conclusion

The most important criterion associated with reduced risk for heart failure relapse in a post-PPCM pregnancy is recovery defined by an LVEF 0.55 or greater before the subsequent pregnancy. Exercise stress echocardiography showing adequate contractile reserve may help to identify women at an even lower risk of relapse.     

Oxidized low-density lipoproteins in cord blood from neonates with intra-uterine growth restriction

Objective

We verified whether oxidative stress indices (oxidized low-density lipoproteins and malondialdehyde) and inflammatory biomarkers (circulating C-reactive protein, interleukin-6, tumour necrosis factor-α, serum amyloid A and soluble intercellular vascular cell adhesion molecule) are increased in the umbilical vein of placental insufficiency induced intra-uterine growth restricted neonates.

Study design

The prospective cohort study, involving 3 tertiary care centers, consists of 200 consecutively recruited pregnant women carrying twins. We chose the twin pregnancy model because both fetuses share the same maternal environment, thereby avoiding potential confounding factors when comparing oxidative stress and inflammation biomarkers. We analysed only twin pairs with one with intra-uterine growth restriction (N = 38) defined as fetal growth < 10th percentile with abnormal Doppler of the umbilical artery. Blood samples were taken at birth from the umbilical vein. Intra-pair comparisons on the biomarkers were performed using the Student paired t-test.

Results

We observed increased cord blood levels of oxidized low-density lipoproteins, (2.394 ± .412 vs 1.296 ± .204, p = .003) but not of malondialdehyde in growth restricted neonates when compared to their normal counterparts. Although indices of inflammation tended to be increased in cord blood from growth restricted newborns, the difference did not reach statistical significance.

Conclusion

In the twin model, intra-uterine growth restriction is associated with low-density lipoprotein oxidation without apparent dysregulation of inflammation biomarkers.

Condensation

Increased oxidized low-density lipoproteins are observed in growth restricted twins compared to their co-twins with normal growth at birth.