Low-dose vaginal misoprostol with or without Foley catheter for late second-trimester pregnancy termination in women with previous multiple cesarean sections

Purpose: To compare between low dose vaginal misoprostol with and without Foley catheter for late second trimester pregnancy termination in women with previous multiple cesarean sections.

Materials and methods: A prospective randomized controlled clinical trial, patients were randomly allocated to either low dose vaginal misoprostol group (n?=?40) or combined low dose vaginal misoprostol plus Foley catheter group (n?=?38). The primary outcome was complete abortion. Secondary outcomes were induction-to-abortion interval, the number of misoprostol doses and occurrence of complications.

Results: Incomplete abortion rate was significantly lower in combined group than misoprostol only group (2.6%versus 15% respectively, p?=?.03). Induction-to-expulsion interval with the combined vaginal misoprostol plus Foley catheter was significantly shorter (p?=?.01) and the number of misoprostol doses in the combined group was significantly lower (p?=?.04). No statistically significant difference in the frequency of complications between both groups.

Conclusions: The combination of low dose vaginal misoprostol and Foley catheter is an effective and safe method for termination of second trimester pregnancy in women with previous multiple cesarean sections.     

Intravenous carbetocin shot is superior to oxytocin infusion for placental delivery in second trimester abortion: a pilot randomized controlled trial

Objective: To study the efficacy of 100?μg intravenous shot of carbetocin compared to 20?IU oxytocin intravenous infusion to prevent placental retention in second trimester medical termination of pregnancy.

Methods: A double-blinded randomized controlled trial was conducted at Ain Shams University Maternity Hospital from 1 April 2013 to 30 November 2013. A total of 132 women between 14 and 24 weeks gestation indicated for termination were randomized to receive either 20?IU oxytocin infusion (n?=?66) or 100?μg carbetocin shot (n?=?66) after fetal expulsion. Patients were observed for time elapsed between fetal and placental expulsion, presence of placental retention and blood loss.

Results: Third stage was 33.4?±?20.4?min in oxytocin group & 23.1?±?16.8?min in carbetocin group (p?=?0.002). Eight patients (12.1%) in oxytocin group had complete placental retention versus two patients (3.0%) in carbetocin group (p?=?0.05). Eight patients (13.8%) received oxytocin had remnants of placenta compared to four patients (6.2%) received carbetocin (p?=?0.04). Sixteen patients (24.2%) received oxytocin and six patients (9%) received carbetocin needed surgical curettage (p?=?0.04). Third stage blood loss was 87.2?±?33.7?ml in carbetocin and 206.9?±?35.2?ml in oxytocin groups (p?=?0.001).

Conclusion: Carbetocin is superior to oxytocin infusion for management of placental delivery in second trimester abortion.     

Comparison of oxidative stress in pregnancies with and without first trimester iron supplement: a randomized double-blind controlled trial

Abstract

Objective: Iron supplementation was found to be a cause of oxidative stress. The aim of this study was to compare oxidative stress in pregnancies with and without iron supplementation in the first trimester pregnancies.

Methods: One hundred and eight women in the first trimester of normal pregnancies were randomly assigned to three groups. Patients were grouped as following: Group 1 received placebo (n?=?36), group 2 received folate supplementation (n?=?36) and group 3 was directed to the iron supplementation (n?=?36). Oxidative stress was assessed at 14th week of gestation by the utilization of serum γ-glutamyl transferase level. Pregnancies were followed until delivery. Relationship between the oxidative stress and pregnancy outcome was assessed among groups.

Results: Mean age was similar among groups, mean gravidity and parity were significantly lower in group with Fe supplementation (p?<?0.05). Maternal weight and weight gain during pregnancy were also significantly lower in group 3 (p?<?0.05). Mean serum albumin levels were similar among groups while serum γ-glutamyl transferase (GGT) levels were significantly higher in group 3. There were 10 cases of oligohydramnios in group 3, two cases in group 2 and no cases in group 1 (p?<?0.001).

Conclusion: Iron supplementation during first trimester pregnancy was found to be associated with an increased oxidative stress.     

A two-stage increase in the dose of misoprostol improves the efficacy of medical abortion with mifepristone and prostaglandins

Objective?To compare the efficacy and side effects of three regimens of intravaginal misoprostol for second-trimester abortion.

Methods?A total of 118 women requiring second-trimester pregnancy termination were randomly assigned to one of three treatment groups: 400?μg 3-hourly in group A (n?=?39), 600?μg 6-hourly in group B (n?=?39), and 800?μg 12-hourly in group C (n?=?40). Misoprostol tablets moistened with 3?ml of 5% acetic acid were placed into the posterior vaginal fornix.

Results?The median induction-abortion times in groups A (8?h [range: 3–64]) and B (9?h [4–81]) were significantly shorter (p?p?p?Conclusions?Misoprostol moistened with acetic acid is effective for second-trimester pregnancy termination when given vaginally 3-hourly, 6-hourly or 12-hourly. The former two regimens are significantly more effective than the latter.     

Effect of early versus conventional epidural analgesia during labor on cytokine production

Abstract

Objective.?To compare the effect of early epidural analgesia (EEA) vs. conventional epidural analgesia (CEA) on cytokine production in mother and neonate.

Methods.?Healthy parturients with uncomplicated term pregnancies were randomized into two groups: EEA – parturients who would receive epidural analgesia before onset of pain and the control group, CEA – parturients who would receive epidural analgesia after onset of pain. Cytokines were measured in maternal blood at randomization Visual Analog Scale (VAS) < 30], 24 h postpartum, and in cord blood.

Results.?Forty-one women were studied. Epidural was performed in EEA when VAS was 23 ± 10 and in CEA when VAS was77 ± 10 (p < 0.0001). Background data were similar except for ruptured membranes at admission (EEA 15%, CEA 46.6%; p?=?0.03), transient hypotension (EEA 20%, CEA 0%; p?=?0.03), and meconium (EEA 25%, CEA 0%; p?=?0.01). No significant differences were found in cytokine levels between groups at any time. Interleukin (IL)-6 levels changed significantly only in the control group (p?=?0.046). There was significant correlation between baseline maternal IL-6 level and cord blood level in CEA (r?=?0.59, p?=?0.005), while no significant correlation existed in EEA (r?=?0.33, p?=?0.16).

Conclusion.?Although there was no significant difference in cytokine levels between the groups, EEA prevented the significant increase in IL-6 during labor and interrupted IL-6 fetal-maternal dependency.     

Comparison of perinatal outcomes of selective termination in dichorionic twin pregnancies performed at different gestational ages

Objective: To determine the perinatal outcomes of selective termination in dichorionic twin pregnancies discordant for major but non-lethal fetal anomalies performed at different gestational ages.

Methods: Thirty-one dichorionic twin pregnancies that underwent selective termination for discordant major but non-lethal fetal anomalies between January 2004 and February 2015 were retrospectively reviewed. The patients were grouped into three, according to the gestational age at which selective termination of pregnancies was performed; Group 1 (15–19 weeks), Group 2 (20–24 weeks) and Group 3 (30–33 weeks). Perinatal outcomes in all the three groups were reviewed and analyzed.

Results: The overall live birth, term birth and pregnancy loss rate were 93.6%, 54.8% and 9.6%, respectively. The overall live birth rate was 66.6% in Group 1, this rate was 100% in Group 2 and Group 3 (p?=?0.01). The rate of pregnancy loss was significantly higher in Group 1 (p?=?0.01). The overall preterm delivery rate was 38.7%. While the overall preterm delivery rate was significantly higher in Group 3 (p?=?0.04), the rate of extremely and very preterm birth was significantly lower (p?=?0.03).

Conclusion: Late selective feticide performed during the third trimester of pregnancy seems to be a safe approach and can be offered as an alternative method to reduce the total pregnancy loss and extremely and early pre-term birth rates.     

The effect of rectus muscle re-approximation at cesarean delivery on pain perceived after operation: a randomized control trial

Background: Cesarean section rate has increased dramatically worldwide but there is still debate about the optimum operative technique of cesarean section.

Objective: The purpose of this study was to assess the effect of rectus muscle reapproximation at cesarean delivery on the postoperative pain.

Methods: This study was a prospective, double-blind, randomized controlled trial. It included 280 primigravidas, with a singleton pregnancy, who underwent elective lower segment cesarean section at term. The patients were randomly allocated into two equal groups; Group (A): undergoing rectus muscle reapproximation, and Group (B): not undergoing rectus muscle reapproximation. Postoperative pain was assessed by visual analogue scale (VAS) from 0 (no pain) to 100 (maximum pain). Postoperative analgesia, operative time, changes in hemoglobin level, length of hospital stay, and occurrence of postoperative complication were also assessed.

Results: Postoperative pain score at the end of the first 24?hours and at the end of the next 24?hours were significantly higher among the group of rectus muscle reapproximation (a difference in VAS pain score of: 5, 95% confidence interval: 0.1–11, p value: .02) and (a difference of 1, 95% confidence interval: 0.1–2.9, p value: .01), respectively. As regards the narcotic use in the first 24?hours after cesarean section, in the form of injections of meperidine 50?mg, it was significantly higher among the group of rectus muscle closure (a difference of 10?mg, 95% confidence interval 3–21.7?mg, p value: .02). While in the next 24?hours, the NSAIDs use, in the form of diclofenac sodium injection, was significantly higher among the group of rectus muscle reapproximation (a difference of 10?mg, 95% confidence interval 3.7–31.7?mg, p value: .02).

Conclusions: Rectus muscle reapproximation among women undergoing primary caesarian section is associated with significant increase in the postoperative pain and analgesic requirements.     

Dynamic collagen changes in cervix during the first trimester and decreased collagen content in cervical insufficiency

Objective: To determine the changes in cervical collagen during the first trimester of pregnancy and to evaluate the collagen deficit in cases with a previous diagnosis of cervical insufficiency (CI).

Materials and methods: Cervical punch biopsies were obtained from 66 patients divided into three groups: patients with recurrent abortions due to CI (CI group; n?=?8); first-trimester abortion group (study group; n?=?37), subdivided into three groups according their gestational week (<7, 7–9 and 9–12 weeks), and patients with cervical biopsy due to gynecologic reasons (control group; n?=?12). Collagen quantity was determined by a biochemical method that measured the levels of hydroxyproline (HOP) in dry cervix tissue.

Results: The HOP concentrations were significantly higher at lower gestational ages (p?=?0.001). Collagen quantity was lowest in the CI group compared with other groups (p?<?0.001).

Conclusion: This study shows collagen component of cervix decreases as pregnancy advances through the first trimester. Cervical collagen concentration is lower in women with a history of CI compared to controls who has not a history of CI.     

A pilot study to determine whether progestogen supplementation using dydrogesterone during the first trimester will reduce the incidence of gestational hypertension in primigravidae

Background: Gestational hypertension (GH) remains one of the main causes of high maternal and perinatal morbidity and mortality worldwide with the highest incidence among primigravidae of about 10%–15%. However, it was noted that the incidence of GH in primigravidae who conceived following assisted reproductive technique (ART) or intrauterine insemination (IUI) supplemented with dydrogesterone during the first trimester was low.

Aim: To determine whether dydrogesterone supplementation during the first trimester can reduce the incidence of GH among primigravidae.

Method: A prospective cross-sectional comparative study was undertaken in 2010 on 116 primigravidae (study group) who conceived following ART or IUI and supplemented with dydrogesterone up to 16 weeks gestation. They were matched for age and race at 16 weeks gestation with a control patient from the early pregnancy clinic who were primigravidae (n?=?116) who conceived spontaneously without dydrogesterone supplementation.

Findings: The incidence of GH in the study group was significantly lower than the control group (1.7% versus 12.9%, p?=?0.001). The incidence of fetal distress was also significantly lower in the study group compared to the control group (4.3% versus 18.1%, p?=?0.001).

Interpretation: Dydrogesterone supplementation during the first trimester significantly reduced the incidence of GH and fetal distress in primigravidae.     

Hepatic vein and portal vein Doppler ultrasound of maternal liver in normal pregnancy

Objective: The purpose of our study was to evaluate the changes occurring in maximum flow velocity and waveform patterns of the portal and hepatic veins during pregnancy in second and third trimesters.

Methods: A total of 204 patients were randomly divided into the study and control groups. The control group was classified as group I; the study group was divided into two groups: group II, second trimester pregnancy (14–26 weeks, n?=?91) and group III, third trimester pregnancy (26–40 weeks, n?=?63). Vein waveforms were classified as triphasic, biphasic and monophasic.

Results: Maximum flow velocities of both right hepatic vein and main portal veins were lower in group III compared with group I and group II (p?<?0.05). On the basis of hepatic vein and portal vein waveforms, the incidence of biphasic pattern was prominent in group II (p?<?0.05) whereas the monophasic pattern was prominent in group III (p?<?0.05).

Conclusion: The results demonstrate that as gestational age progresses, maximum flow velocities of both right hepatic vein and main portal veins intend to be decreased with an increased incidence of monophasic wave form pattern, and may be accepted as sensitive parameters of indicators of physiological adaptations related to pregnancy.     

Association between maternal circulating 25 hydroxyvitamin D concentration and placental volume in the first trimester

Objectives: We aimed to assess placental volume and placental mean gray value in vitamin D deficiency and healthy placentas in the first trimester of pregnancy using three-dimensional (3D) ultrasonography (USG) and Virtual Organ Computer-aided Analysis (VOCAL).

Methods: This prospective cross sectional study comprised 274 patients, divided into two groups according to the presence or absence of vitamin D deficiency (<20?ng/ml deficient, n?=?153, >20?ng/ml not deficient, n=?121) in the first trimester of pregnancy. Placental volume and placental volumetric mean gray values were evaluated. Placental volume (cm³) was analyzed using the VOCAL imaging program and a 3D histogram was used to calculate the volumetric mean gray value (%).

Results: Placental volume was significantly less in the vitamin D deficiency group (p?=?0.017) Volumetric mean gray value of the placenta was significantly higher in the vitamin D deficiency group (p=?0.003). Maternal serum PAPP-A (MoM) and f-β Hcg (MoM) were significantly lower in the vitamin D deficiency group (p=?0.008, p?=?0.003, respectively). In linear regression analyses, serum vitamin D concentration was significantly associated with the plasental volume (β?=?0.16; p?=?0.01).

Conclusion: Placental configuration and development were associated with vitamin D even in the first trimester of pregnancy. To ensure healthy pregnancy outcomes, vitamin D screening applied in the early stages of pregnancy or even before pregnancy.     

Sequential use of Foley catheter with misoprostol for second trimester pregnancy termination in women with and without caesarean scars: a prospective cohort study

Purpose: The aim of this study is to evaluate the effectiveness and safety of misoprostol and Foley catheter in second trimester termination in women with and without caesarean section (CS) scars.

Materials and methods: Women with an indication for pregnancy termination between 14 and 22 completed weeks of gestation were included to the study. Enrolled women were allocated into three groups: (1) women with no history of CS, (2) women with one CS and (3) women with ≥2 CS. Study consisted 337 patients (233 group 1, 88 group 2 and 16 group 3). Misoprostol and Foley catheter were used sequentially. The primary outcome was the induction to abortion interval. Secondary outcomes were the successful vaginal abortion rate, the percentage of abortions in 24?h and the rates of surgical removal of the placenta, Foley catheter use and major maternal complications (transfusions, thromboembolic events, uterine rupture and death).

Results: Demographic characteristics were comparable. All study outcomes were statistically similar among groups. There was no major maternal complication among all patients.

Conclusions: Sequential use of misoprostol and Foley catheter is safe and effective in second trimester pregnancy termination for patients with and without CS scars.     

Influence of antenatal physical exercise on heart rate variability and QT variability

Objective: We sought to characterise the influence of an antenatal exercise programme on ECG-derived cardiac variables.

Methods: Fifity-one healthy pregnant women were recruited and randomly assigned (2?×?2×2 design) to an exercise group or a control group. Exercising groups attended weekly classes from the 20th week of pregnancy onwards. Cardiovascular assessments (heart rate variabiliy (HRV), QT, and the QT variability index (QTVI)) were performed at 12–16, 26–28, 34–36 weeks and 12 weeks following birth, during supine rest and exercise conditions.

Results: Advancing gestation was associated with an increased maternal heart rate (p?=?0.001), shorter QT interval (p?=?0.003), diminished HRV (p?=?0.002) and increased QTVI (p?=?0.002). Each of these changes was reversed within 12 weeks postpartum (p?p?Conclusion: Advancing gestation is associated with a shift in HRV/QTVI towards values that have been associated with an elevated risk of arrhythmia. A 20-week exercise programme undertaken between mid and late pregnancy exaggerated these changes during rest in the third trimester of pregnancy.     

Maternal anemia effects during pregnancy on male and female fetuses: are there any differences?

Objective: Sideropenic anemia is a common pregnancy disorder. The relationship between anemia and adverse pregnancy outcome are contradictory, and it is related to the severity of the hemoglobin deficit. The aim of the study was to evaluate the relationship between maternal mild anemia at third trimester of pregnancy, fetal birth weight and fetal gender.

Study design: A retrospective study including 1131 single physiological term pregnancies was conducted. According to maternal Hb levels during the third trimester, pregnant women enrolled were divided in two groups: Group A (n?=?156) with Hb?≤?11?g/dl and Group B (n?=?975) with Hb?≥?11,1?g/dl.

Results: Maternal characteristics, gestational age at delivery, Apgar score and post-partum hemorrhage were similar between groups. However, when neonatal sex was considerate, female newborns of anemic women had a higher birth weight (p?=?0.01). Moreover, anemic women showed a significantly higher rate of emergency cesarean section (p?=?0.006), in particular when the newborn was a male (p=?0.03).

Conclusion: Maternal mild anemia in third trimester of pregnancy correlates with fetal birth weight, influencing fetal growth and delivery outcome on the basis of fetal gender. Even though the reason of this phenomenon is still unknown, these new data may represent a novel parameter to add significant prognostic information in relation to maternal mild anemia and neonatal outcome.     

The association between previous single first trimester abortion and pregnancy outcome in nulliparous women

Objective: To determine the association between single previous abortion and pregnancy outcome in nulliparous women.

Methods: A retrospective cohort study of all nulliparous women who delivered in a university-affiliated tertiary hospital (2009–2014). Pregnancy outcome of women with single previous first trimester abortion (study group) was compared to those of primigravida (control group).

Results: Of the 44?371 deliveries during the study period, 14?498 (32.6%) were of nulliparous women, of them 1501 (10.3%) had single previous abortion (<13 weeks). Except for a higher rate of diabetes mellitus in the study group (6.1 versus 4.4%, p?=?0.003), no differences were found between the groups regarding pregnancy complications. In multivariate analysis, previous single abortion was independently associated with induction of labor (OR?=?1.31, 95%C.I 1.04–1.63, p?=?0.01), cesarean section (OR?=?1.38, 95%C.I 1.18–1.60, p?<?0.001) and retained placenta (OR?=?1.29, 95%C.I 1.03–1.61, p?=?0.02). Among nulliparous women with previous single abortion no difference in pregnancy outcome was observed between those with previous induced termination of pregnancy and spontaneous abortion, except for increased risk for retained placenta in those with previous spontaneous abortion.

Conclusion: Single early previous abortion in nulliparous women was associated with higher rate of induction of labor, cesarean section and retained placenta compared to primigravida women.     

Changes in progesterone-induced-blocking-factor expression rates following mifepristone administration in termination of pregnancy at 5 to 8 weeks

Objective.?To study changes in the expression rate of PIBF by peripheral lymphocytes in healthy pregnant women after administration of mifepristone for non-surgical termination of pregnancy at 5–8 wks of gestation.

Methods.?Patients requesting early social termination of pregnancy, in a 3-month period, were included. A first venous blood sample was taken before oral administration of 600?mg of mifepristone (day 0). A second venous blood sample was taken 2 days later. PIBF on lymphocytes was determined by immunocytochemistry using a PIBF-specific polyclonal antibody.

Results.?Termination of pregnancy was successful and complete in all cases. In 17 out of 21 patients, the percentage of PIBF positive lymphocytes decreased after anti-progesterone administration. The percentage of PIBF-expressing lymphocytes significantly decreased from 52.8%?±?21.6% (day 0) to 39.8%?±?18.2% by day 2 (p?=?0.001).

Conclusions.?These data suggest a strong relationship between early termination of pregnancy induced with mifepristone and disturbances of progesterone-mediated immunosuppression.     

Effect of aspirin in prevention of adverse pregnancy outcome in women with elevated alpha-fetoprotein

Abstract

Background: To evaluate the effect of low-dose aspirin in prevention of adverse pregnancy outcomes (APO) in women with second trimester alpha-fetoprotein (AFP) >2.5 multiple of median (MOM) and to compare aspirin effect on women with normal and abnormal uterine artery (UtA) Doppler. The primary outcome was the adverse pregnancy outcome.

Methods: This randomized controlled trial was conducted in singleton pregnant women, who had unexplained AFP >2.5 MOM and gestational age between 15 and 18 weeks of gestation. They were assigned randomly to receive either aspirin (N?=?65) or control (N?=?68). UtA Doppler velocimetry studies were performed at the time of targeted ultrasonographic exam.

Results: Two groups were comparable regarding the maternal characteristics. The frequency of APO in aspirin and control groups were 26.1% versus 44.1% (p?=?0.045), the frequency of preterm delivery before 34 weeks were 3.2% versus 22.0% in aspirin and control group, p?=?0.001. Other outcomes were similar in both groups. The frequency of adverse outcomes in women with abnormal UtA Doppler was 39.1% in aspirin and 60.0% in control group, p?=?0.556.

Conclusion: Low-dose aspirin reduces APO and delivery before 34 weeks of gestation in pregnant women with unexplained elevated AFP.     

Maternal serum laeverin (aminopeptidase Q) measured in the first trimester of pregnancy does not predict preeclampsia

Objective: The aim of this study was to compare the laeverin level in maternal serum from first trimester (11–14 weeks) of pregnancy between normal pregnancies and pregnancies that later developed preeclampsia (PE).

Material and methods: This was a case-cohort study. The laeverin concentration was measured in cases with preterm PE (n?=?55), term PE (n?=?95), and a reference group of randomly selected women with normal pregnancy outcome (n?=?200) in stored serum samples collected from the double-test as part of the combined first trimester trisomy 21 screening program. The samples were thawed and analyzed for laeverin. The median gestational age at blood sampling was 77 days (range 57–96 days). Multiple regression analysis was performed to establish a normal median. Concentrations were converted to multiples of the median (MoM) and groups were compared using the Mann–Whitney U-test.

Results: In the reference group, laeverin was significantly correlated with gestational age (r?=?0.18, p?=?.01) and its concentration ranged from 41–393 µg/L. No significant differences in the median laeverin MoM were found between the reference group (1.01 MoM) and cases with preterm PE (0.98 MoM) or term PE (0.96 MoM).

Conclusions: First trimester maternal serum laeverin level cannot be used to predict preeclampsia.     

Comparison of intravaginal misoprostol and intracervical Foley catheter alone or in combination for termination of second trimester pregnancy

Objectives: To examine the effectiveness, safety and acceptability of intravaginal misoprostol and intracervical Foley catheter alone or in combination for termination of second trimester pregnancy.

Methods: This clinical study was conducted on 90 pregnant patients intended for termination of pregnancy between 13 and 24 gestational weeks for any indication. Enrolled women are equally allocated into three groups:

??Group I (Misoprostol group): a standard regimen of moistened misoprostol (400?μg) 4 hourly inserted vaginally.

??Group II (Catheter group): intracervical Foley catheter inserted, inflated and placed on traction.

??Group III (Combined group): intracervical Foley catheter inserted with a standard regimen of moistened misoprostol (400?μg) 4 hourly intravaginally was used.

Procedure efficacy (defined as complete abortion performed on site), safety and acceptability were assessed.

Results: The induction to abortion interval was 7.5?±?1.25?h in the combined group, compared to 11.76?±?1.63?h in the misoprostol group and 19.76?±?1.52?h in the catheter group (p value?Conclusions: The present results confirmed the high success rate with the shortest induction to abortion interval with a combined use of intracervical Foley catheter and misoprostol for termination of second trimester pregnancy.