Normal standards of fetal behavior assessed by four-dimensional sonography

Objective.?In this prospective randomized study, fetal behavior was investigated in order to determine the standard parameters of fetal movements and facial expressions in all three trimesters of normal pregnancy.

Methods.?Sixty-three pregnant women with singleton pregnancies in all trimesters were included in the investigation. Four-dimensional (4D) ultrasound was performed for each patient over a 30-minute period. Variables of maternal and fetal characteristics including gestational age, eight fetal movement patterns in the first trimester, and sixteen parameters of fetal movement and fetal facial expression patterns in the second and third trimesters were recorded for the construction of fetal neurological charts.

Results.?In the first trimester, a tendency towards an increased frequency of fetal movement patterns with increasing gestational age was noticed. Only the startle movement pattern seemed to occur stagnantly during the first trimester (p > 0.05). At the beginning of the second trimester, the frequency of fetal movement patterns tended to increase. During the second and third trimester, multiple regression and polynomial regression revealed statistically significant changes in tongue expulsion (p < 0.05), smiling (p < 0.05), grimacing (p < 0.05), swallowing (p < 0.05), eye blinking (p < 0.01), head movements, and all hand to body contact movements (p < 0.01), except for head anteflexion (p > 0.05). There were no statistically significant changes during the second and third trimesters in mouthing, yawning, and sucking (p > 0.05). At the middle of the third trimester, the fetuses displayed decreasing or stagnant incidence of fetal facial expressions except for eye blinking, which showed increased frequency with increasing gestational age. A statistically significant correlation was found between all head movements and hand to body contact patterns during the second and third trimesters except for head anteflexion (r = ?0.231; p > 0.05).

Conclusions.?The full range of quantitative fetal facial expressions and fetal movement patterns can be assessed successfully by 4D sonography. It is important to be able to assess normal fetal behavior throughout gestation to identify abnormal behavior before birth.     

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.     

Assessment of nitrite oxide and maternal–fetal Doppler parameters during pregnancy

Objective: The objective was to evaluate and compare the whole blood nitrite concentration in the three trimesters of pregnancy. Additionally, we investigate whether there is any relation between nitrite concentrations and Doppler ultrasound analysis of some maternal and fetal vessels.

Methods: Thirty-three healthy pregnant women were examined at the first (11–14 weeks), second (20–24 weeks) and third trimester (34–36 weeks) of pregnancy. In the three exams, we determined the maternal whole blood nitrite concentration and uterine arteries Doppler analysis to determine pulsatility index (PI), and resistance index (RI). In the second and third trimester we also performed fetal umbilical and middle cerebral arteries PI and RI. We compared the concentrations of nitrite in three trimesters and correlated with Doppler parameters.

Results: No difference was observed in the whole blood nitrite concentrations across trimesters: 151.70?±?77.90?nmol/ml, 142.10?±?73.50?nmol/ml and 147.10?±?87.30?nmol/ml; first, second and third trimesters, respectively. We found no difference in correlation between whole blood nitrite concentration and Doppler parameters from the evaluated vessels.

Conclusions: In healthy pregnant women, the nitrite concentrations did not change across gestational trimesters and there was also no strong correlation with Doppler impedance indices from maternal uterine arteries and fetal umbilical and middle cerebral arteries.     

Fetal heart rate response to cordocentesis and pregnancy outcome: A prospective cohort

Objective.?To evaluate fetal cardiac response to cordocentesis and whether such changes may affect pregnancy outcome.

Methods.?117 singleton pregnant women requiring percutaneous trans-abdominal cordocentesis were prospectively included. Fetal heart rate was continuously evaluated by ultrasound for 1?min after completion of cordocentesis and intermittently for 20?min more. Fetal and pregnancy outcomes were analyzed by grouping fetal cardiac response to cordocentesis into bradycardia, normal heart rate and tachycardia groups.

Results.?Women included in the study were 30.5?±?4.0 years old and had a gestational age of 23.7?±?2.0 weeks. Fetal blood sample obtained by cordocentesis was 3.1?±?0.8?ml. Fetal heart rate before cordocentesis was 149?±?8 beats per minute (bpm), ranging from 130 to 169 bpm. Fetal heart rate post-cordocentesis was 145?±?30 bpm (from 32 to 175 bpm). The incidence of bradycardia and tachycardia was 10.3% (n?= 12) and 6.0% (n?= 7), respectively. Fetal heart rate returned to normal levels in all cases at ??5 minutes post-cordocentesis. In the tachycardia group, 6 cases had normal pregnancy outcome and one patient was lost to follow-up. In the bradycardia group, we observed two pregnancy terminations, one patient was lost to follow-up and nine were normal outcomes. In the group with normal heart rate (n?=?98), we observed one intrauterine fetal death, nine adverse fetal outcomes, eight pregnancy terminations and nine patients were lost to follow-up.

Conclusions.?Transient fetal tachycardia and bradycardia were uncommon and were not associated with adverse fetal or pregnancy outcomes.     

Maternal laboratory stress influences fetal neurobehavior: Cortisol does not provide all answers

Objective.?Maternal stress can have an impact on pregnancy. However, effects on fetal neurobehavior are not well understood. In this study, the effect of laboratory stress on maternal psychoneuroendocrinological response and on fetal neurobehavior was studied. Serum cortisol as a potential underlying mechanism was measured.

Methods.?Twenty-seven women made a single 1.5-h visit in their third trimester. The laboratory stressor involved an arithmetic task. Associations between maternal laboratory stress response and fetal neurobehavior were analyzed by studying 19 maternal–fetal dyads with high signal quality cardiotocograms.

Results.?Stress exposure changed participants stress perception (p?<?0.0001). However, only half of the participants (responders) had an HPA-axis response. Fetuses responded to the stress exposure depending on their mothers' stress response: (i) there was a fetal heart rate (FHR) group effect at the level of trend (p?=?0.06). Fetuses of responders had higher HR levels 20?min after the exposure (p?=?0.043), (ii) there were interaction (p?=?0.026) and group effects at the level of trend (p?=?0.078) found for FHR short-term variation (STV). Fetuses of responders had lower FHR STV 20?min after stress exposure (p?=?0.007). Cortisol as a potential underlying mechanism only seemed to be associated with short- and long-term variation of FHR.

Conclusions.?An activation of the maternal stress-system could result in a child being born having a history of responding to maternal stress.     

The effect on the fetal pituitary-adrenal axis of dexamethasone administration early in the second trimester of pregnancy

Objective.?To evaluate the effect of a single dose of dexamethasone to pregnant women at early second trimester on the fetal pituitary-adrenal axis.

Methods.?Thirty-eight women between 13 and 15 weeks' gestation were included in the study. Blood was taken from the mothers and their fetuses for the evaluation of plasma ACTH, cortisol, and free cortisol levels before and after treatment with a single dose of 1?mg of dexamethasone orally at 11 p.m. the night before the termination of pregnancy.

Results.?The mean plasma ACTH was significantly lower following dexamethasone administration (8.5?±?5.1 vs. 18.4?±?10.9 pg/ml). Similarly, plasma cortisol was significantly lower after dexamethasone treatment (208.3?±?168.7 vs. 772.7?±?206.1?nmol/l), as well as plasma free cortisol levels (2.6?±?0.0 vs. 6.1?±?6.1?nmol/l). Mean plasma ACTH levels were not significantly different in the fetuses after dexamethasone treatment (33.6?±?22.7 vs. 42.5?±?21.9 pg/ml). Moreover, mean fetal plasma cortisol was not different before and after treatment (108.2?±?27.2 vs. 94.3?±?47.2?nmol/l), as well as the mean free cortisol levels (7.7?±?5.2 vs. 7.0?±?4.3?nmol/l).

Conclusions.?A single dose of 1?mg of dexamethasone to the mother early in the second trimester of pregnancy does not result in a significant suppression of the fetal pituitary axis.     

Frontomaxillary facial angle at 11 + 0 to 13 + 6 weeks in Chinese population

Objectives.?To establish the normal range of frontomaxillary facial (FMF) angle in the first trimester in a Chinese population.

Methods.?In a prospective study from March 2007 to June 2007, three-dimensional (3D) volumes of the fetal profile in the mid-sagittal plane were recorded from 129 Chinese pregnant women who were screened for trisomy 21 by the combination of fetal nuchal translucency (NT) thickness, maternal serum free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at 11 to 13?+?6 weeks. 3D volumes were examined using multiplanar techniques. The FMF angle of each case was measured. The relationship between the measured FMF angle with the other parameter was also examined.

Results.?The mean FMF angle decreased from 86.8° for a crown-rump length (CRL) of 45?mm to 76.0° for a CRL of 84?mm (FMF angle?=?99.49 ? 0.28×CRL, r?=^?0.377, p?<?0.0001). There was no significant association between the FMF angle with serum PAPP-A or β-hCG. The mean (SD) difference between FMF angle derived from Chinese formula and that from the published Caucasian equation was 1.47 (0.61) (95% CI 1.37–1.58) (p?<?0.0001).

Conclusions.?In the first trimester, the FMF angle decreases with fetal CRL. There was similarity in the normal value of FMF angle between the Chinese and Caucasian populations.     

Levels of asymmetric dimethylarginine throughout normal pregnancy and in pregnancies complicated with preeclampsia or had a small for gestational age baby

Objective: The aim of this study was to investigate maternal asymmetric dimethylarginine (ADMA) concentrations at the three trimesters of pregnancy in uncomplicated pregnancies and in women who developed preeclampsia or had small for gestational age infants (SGA) without preeclampsia. Methods: ADMA concentrations were retrospectively determined in the first, second and third trimester of pregnancy in 41 uncomplicated pregnancies, 10 pregnancies complicated with preeclampsia and 14 pregnancies that delivered a SGA baby. ADMA was measured with an ELISA kit. Results: Mean (±SD) concentrations of ADMA (µmol/L) in uncomplicated l pregnancies were: 0.51?±?0.14; 0.52?±?0.13; 0.58?±?0.16 in the three trimesters, respectively. ADMA concentrations in SGA pregnancies were significantly lower in each trimester compared to uncomplicated pregnancies: (0.40?±?0.10, p?=?0.005 1st trim; 0.42?±?0.10, p?=?0.007 2nd trim; 0.45?±?0.10, p?=?0.007 3rd trim). Although pregnancies that developed preeclampsia had higher ADMA concentration in all trimesters compared to uncomplicated pregnancies (0.58?±?0.10; 0.63?±?0.14; 0.68?±?0.11), the difference was statistically significant only in the 2nd trimester (p?=?0.02). Conclusions: Maternal serum ADMA concentration tends to increase during normal pregnancy. Pregnancies with SGA infants had significantly lower ADMA levels in all trimesters of pregnancy. ADMA concentrations in the 2nd trimester was significantly elevated in pregnancies that later developed preeclampsia.     

Estimation of fetal oxygen uptake in human term pregnancies

Objective.?Umbilical oxygen (O₂) uptake is a parameter of basic physiologic interest. It has been extensively studied in chronically catheterized animals but very few data have been obtained acutely in humans. Recent developments in ultrasound technology allow the estimation of umbilical venous blood flow in utero.

Methods.?In all, 26 normal term pregnancies were studied at the time of elective cesarean section in order to evaluate fetal O₂ uptake as the product of umbilical blood flow and umbilical O₂ veno-arterial difference. An ultrasound evaluation was performed within 1 h from delivery: umbilical vein area and flow velocity were recorded to calculate umbilical vein volume flow (Q_umb). Blood samples from the umbilical vein (uv) and artery (ua) were obtained at the time of fetal extraction for respiratory gases and acid–base evaluation.

Results.?Umbilical O₂ uptake was calculated as Q_umb ? (uv-ua)O₂ content: an average value of 0.84?±?0.40 mmol/min was obtained. Umbilical O₂ uptake per kg was 0.25?±?0.12 mmol/kg/min, significantly related to fetal O₂ delivery.

Conclusions.?We estimated umbilical blood flow by ultrasound and we measured umbilical O₂ uptake at term obtaining a value of umbilical O₂ uptake/kg similar to what previously reported in human pregnancies and chronically catheterized animals.     

Matrix metalloproteinase-13 and membrane type-1 matrix metalloproteinase in peritoneal fluid of women with endometriosis

Objective.?It is becoming more and more evident that different types of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) are involved in the pathogenesis of endometriosis. The aim of the present study was to measure levels of the active forms of MMP-13 and membrane type-1 matrix metalloproteinase (MT1-MMP)/MMP-14 as well as TIMP-2 in the peritoneal fluid of women with endometriosis.

Study design.?We determined the levels of the active forms MMP-13 and MT1-MMP/MMP-14 as well as TIMP-2 in the peritoneal fluid of 20 women with endometriosis and 18 controls by different types of enzyme-linked immunosorbent assay.

Results.?We found that the concentrations (mean?±?standard deviation) of total active MMP-13 and endogenous active MT1-MMP/MMP-14 in the peritoneal fluid of patients with endometriosis were 1.69?±?0.67 and 3.12?±?1.07?ng/ml, respectively. In control women the corresponding values were 3.02?±?0.43 and 4.45?±?1.03?ng/ml. The differences were statistically significant (p?<?0.0001 and p?<?0.0004 for MMP-13 and MMP-14, respectively). Levels of TIMP-2 did not differ significantly.

Conclusions.?Decreased concentrations of active MMP-13 and MT1-MMP/MMP-14 may imply that the proteolytic activity of the peritoneal milieu of women with endometriosis is disturbed, which may have implications in the pathogenesis of the disease.     

Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia

Objectives: The aim of the study was to assess the efficacy and acceptability of a regimen using mifepristone and buccal misoprostol with unlimited dosing for second trimester abortion in Armenia.

Methods: Women seeking to terminate 13–22 week pregnancies were enrolled in the study. Participants swallowed 200?mg mifepristone in the clinic and were instructed to return to the hospital for induction 24–48?h later. During induction, women were given 400?μg buccal misoprostol every 3?h until the fetus and placenta were expelled. The abortion was considered a success if complete uterine evacuation was achieved without oxytocin or surgery.

Results: A total of 120 women with a median gestational age of 18 weeks participated in the study. All women began misoprostol induction around 24?h after taking mifepristone. Complete uterine evacuation was achieved in 119 (99.2%) women. The median induction-to-abortion interval was 10.3?h (range 4–17.4) with a mean of 9.5?±?2.5?h. A median of four misoprostol doses (range 2–6) with a mean of 4?±?1 misoprostol doses were administered. The induction-to-abortion interval, number of misoprostol doses, pain score and analgesia use increased as gestational age advanced. Acceptability of the method was high among both patients and providers.

Conclusion: The medical abortion regimen of 200?mg mifepristone followed 24?h later by induction with 400?μg buccal misoprostol administered every 3?h, with no limit on the number of doses used for the termination of pregnancies of 13–22 weeks’ gestation is an effective and acceptable option for women.     

Effectiveness of a screening protocol for gestational diabetes in pregnant Spanish women

Objective.?Screening for gestational diabetes mellitus (GDM) and its treatment can reduce health risks for the mother and child. This study estimated the prevalence of undetected GDM in Tenerife Island, to determine the rate of dropout from the diagnostic protocol and to identify the features of the protocol that reduced its effectiveness.

Methods.?We calculated GDM prevalence and the breaches of the diagnostic protocol out of 12,084 pregnant women who started the GDM detection program during 2004–2006. The prevalence of protocol breaches was used to estimate overall prevalence of GDM for the study population.

Results.?The overall prevalence of GDM was 6.4% (95% CI: 5.9–6.9%). Ten percent of them did not comply with the protocol. Noncompliant subjects were, on average, older (31.4?±?5.7 vs. 30.0?±?5.7 years, p?<?0.001) and those with higher fasting blood glucose, 83 vs. 78?mg/dl (4.6 vs. 4.3?mmol/l) p?<?0.001) than compliant subjects. About one third (30%) of the noncompliant women may be additional cases of GDM, which would increase the prevalence by 2.2% (95% CI: 1.9–2.5%) for an estimated total figure of 8.6% (95% CI: 8.1–9.1%).

Conclusions.?One out of every three cases of GDM may escape detection among women who do not complete the GDM screening protocol.     

Neonatal outcomes in women with sonographically identified uterine leiomyomata

Objective.?We sought to compare perinatal outcomes between women with and without leiomyomata.

Study design.?This is a retrospective cohort study comparing neonatal outcomes in women with and without uterine leiomyomata discovered at routine second trimester obstetric ultrasonography, all of whom delivered at a single institution. Potential confounders such as maternal age, parity, race, ethnicity, medical insurance, previous uterine surgery, fetal presentation, length of labor, mode of delivery, presence of placenta previa, placental abruption, chorioamnionitis, and epidural use were controlled for using multivariable logistic regression.

Results.?From 1993 to 2003, 15,104 women underwent routine second trimester prenatal ultrasonography, with 401 (2.7%) women identified with at least one leiomyoma. By univariate and multivariable analyses, the presence of leiomyomata was associated with statistically significant increased risks for preterm delivery at <34 weeks [adjusted odds ratio (AOR) 1.7, 95% confidence interval (CI) 1.1–2.6], <32 weeks (AOR 1.9, 95% CI 1.2–3.2), and <28 weeks (AOR 2.0, 95% CI 1.1–3.8). An association with increased risk for intrauterine fetal demise (IUFD) was also demonstrated (AOR 2.7, 95% CI 1.0–6.9). When IUFD was examined before and after 32 weeks’ gestation, the finding only persisted at earlier gestational ages (<32 weeks: AOR 4.2, 95% CI 1.2–14.7 vs. >32 weeks: AOR 0.82, 95% CI 0.1–6.2).

Conclusion.?Regardless of maternal age, ethnicity, and parity, pregnant women with leiomyomata are at increased risk for preterm birth and IUFD. This did not translate to lower birth weight outcomes among term patients, suggesting that LBW is more likely due to preterm birth than growth restriction. These results may be useful for preconception and prenatal counseling of women with leiomyomata.     

Efficiency of the Foley catheter versus the double balloon catheter during the induction of second trimester pregnancy terminations: a randomized controlled trial

Purpose

To compare induction-to-delivery intervals of Foley catheters and double balloon catheters in second trimester pregnancy terminations.

Methods

This randomized parallel study was conducted on women who underwent second trimester terminations between December 2016 and December 2017. Pregnant women in the second trimester with a Bishop score?<?6 were included in the study. Participants were randomized into two groups, the first being the Foley catheter group and the second being the double balloon catheter group. The time frames from insertion of catheters to the delivery were recorded in each group. A multiple regression analysis was carried out to examine the contribution of factors to the induction-to-delivery interval. A survival analysis was conducted to compare the Foley method and the double balloon method.

Results

A total of 91 pregnant women were included in the final analysis. The induction-to-delivery interval was shorter in the Foley catheter group than in the double balloon catheter group (38 h 54 min?±?21 h 6 min versus 58 h 17 min?±?25 h 56 min). We also found that women with intrauterine fetal death (IUFD) had a shorter time to delivery compared to women with live fetuses (39 h 12 min?±?18 h 46 min vs 51 h 30 min?±?26 h 42 min, p?=?0.04). Women with a history of vaginal delivery also had a shorter induction-to-delivery time compared to women who never delivered vaginally before (38 h 12 min?±?17 h 42 min vs 53 h 54 min?±?27 h 18 min, p?=?0.004). In the multiple regression analysis, the most significant contributor to the induction-to-delivery time was the method used for induction of labor and followed by other factors including the viability of the fetus (live/IUFD), history of vaginal delivery and PPROM. The survival analysis showed that the induction-to-delivery interval was significantly shorter in the Foley catheter group than in the double balloon catheter group (HR 2.51, 95% CI 1.57–4.00, p?=?0.001).

Conclusion

During the termination of second trimester pregnancies time from induction of labor to delivery is shorter with the Foley catheter compared to double balloon catheter.

     

Placement of laminaria tents does not improve time to delivery in patients undergoing second trimester labor induction with misoprostol

Objective.?We sought to determine whether placement of laminaria tents improve time to delivery compared with misoprostol alone in second trimester labor induction.

Methods.?We retrospectively reviewed all patients undergoing second trimester labor induction. Patients with ruptured membranes, abruption, cervical dilation and chorioamnionitis at presentation were excluded. Complications were defined as chorioamnionitis, retained placenta or other surgical procedures. Patients who received laminaria and vaginal misoprostol, 200?μg every 12?h, were compared to those who received misoprostol without laminaria.

Results.?Forty-three patients met inclusion criteria, 19 underwent induction with misoprostol alone and 24 with laminaria and misoprostol. The median times to fetal and placenta deliveries were 16.4 and 0.0?h in the misoprostol group, and 20.6 and 0.2?h in the laminaria group. There was no difference in complications. Post-hoc power analysis revealed >80% power to detect a difference in time to delivery of >12?h, and >90% power to detect a difference in time to placental delivery of ≥30?min.

Conclusions.?Placement of laminaria does not improve fetal or placental delivery times in patients undergoing second trimester pregnancy termination by labor induction.     

Frequent low-dose misoprostol for termination of second-trimester pregnancy

Objectives?To determine the efficacy of an application regimen of low-dose frequent misoprostol for second-trimester pregnancy termination.

Methods?A total of 250 women between 12 and 20 weeks of gestation who were scheduled for second-trimester pregnancy termination received 200?μg vaginal misoprostol followed by 100?μg oral misoprostol every 2?h until expulsion of the fetus. Mechanical cervical dilatation with a 16-French Foley balloon catheter was performed if no cervical dilatation was observed after 24?h. The main outcome measures were the delivery rate within 24?h and the factors influencing the interval between the onset of induction and abortion. Secondary outcome measures were the side-effects of the regimen and the total misoprostol dose required.

Results?With application of this protocol, 245 women (98%) delivered within 24?h of induction. The mean (± standard deviation) misoprostol dose used was 728?±?297?μg (200–2100?μg). Cox regression analysis revealed that vaginal spotting or nulliparity do not effect the induction–abortion time. On the other hand, using this regimen induction to abortion time tends to be longer in the presence of live fetuses (odds ratio (OR)?=?0.45; confidence interval (CI)?=?0.2–0.8; p?=?0.008) and pregnancies with gestational age >?16 weeks (OR?=?0.59; CI?=?0.4–0.8; p?=?0.003) when compared with cases of in utero death and pregnancies with a gestational age of 12–13 weeks, respectively. Twenty-seven women (10.8%) experienced one or more side-effects attributable to misoprostol.

Conclusion?The 100-μg oral misoprostol every 2?h following 200?μg vaginal misoprostol is a highly effective protocol for inducing abortion at 12–20 weeks of pregnancy. Cases with live fetuses or pregnancies with older gestational age (>?16 weeks) deliver in a longer time period.     

Benefits of vaginal misoprostol prior to IUD insertion in women with previous caesarean delivery: a randomised controlled trial

Objective: The aim of the study was to evaluate the value of vaginal misoprostol 6?h prior to intrauterine device (IUD) insertion in women with previous Caesarean delivery.

Methods: A double-blind randomised controlled trial was conducted in 120 women who were eligible for IUD insertion. Participants were randomly divided to receive either 600?μg vaginal misoprostol or placebo 6?h before IUD insertion. The primary outcome measure was the pain score during the procedure. Secondary outcome measures were failure of insertion, insertion difficulty score, complications of IUD insertion and side effects related to misoprostol.

Results: Pain and insertion difficulty scores were significantly lower in the misoprostol group compared with the placebo group (5.7?±?1.4 vs. 6.5?±?0.9 and 4.1?±?1.1 vs. 5.4?±?2.2, respectively; p?p?=?.06) and cramps (10 vs. 0; p?Conclusions: The use of misoprostol before IUD insertion is associated with less painful and easier placement.     

Effects of cetrorelix,a GnRH-receptor antagonist,on gonadal axis in women with functional hypothalamic amenorrhea

Background.?Gonadotropin Releasing Hormone (GnRH) antagonists (GnRHa) suppress gonadotropin and sex-steroid secretion. In normal women, acute GnRHa administration induces inhibitory effect on pituitary-gonadal axis, followed by Luteinizing Hormone (LH) rebound. Functional hypothalamic amenorrhea (HA) is characterised by impaired gonadotropin secretion and hypogonadism secondary to blunted GnRH pulsatility.

Methods.?We studied the effects of a GnRHa, cetrorelix (CTX 3.0?mg), in six women with HA (age 30.7?±?3.2 years; BMI 21.5?±?1.7 kg/m²) and six control subjects (CS, 28.2?±?0.6 years; 22.6?±?0.9 kg/m²) on LH, Follicle-Stimulating Hormone (FSH) and oestradiol levels over 4?h (08.00–12.00 am) before, +24?h and +96?h after CTX; LH, FSH, and oestradiol were also evaluated at +6, +8, +12, +48, +72?h after CTX.

Results.?CS: CTX reduced (p?<?0.05) LH, FSH, and oestradiol (nadir at +12?h, +24?h, and +24?h); LH rebounded at +96?h, FSH and oestradiol recovered at +48?h and +72?h. The 4-h evaluation showed LH and FSH reduction (p?<?0.05) at +24?h, with LH rebound at +96?h. HA: CTX reduced (p?<?0.05) LH, FSH, and oestradiol, (nadir at +24?h, +48?h, and +48?h, recovery at +48?h, +72?h, and +96?h). The 4-h evaluation showed gonadotropin reduction (p?<?0.05) 24?h after CTX, without any rebound effect.

Conclusions.?One single CTX dose still modulates gonadotropin secretion in HA. Its ‘paradoxical’ stimulatory effect on gonadotropins needs to be verified after prolonged administration.     

The predictive nature of uterocervical angles in the termination of second trimester pregnancy

Aim: To establish how useful and the predictive capacity of uterocervical angles (UCA) in the termination of second trimester pregnancies.

Material and methods: This prospective cohort study was conducted at a tertiary center with a total of 120 singleton pregnancies delivered between 14 and 24 gestational weeks. Before the beginning of misoprostol induction, patients were screened for both cervical length (CL) and uterocervical angles (UCA). The UCA is defined as an angle constructed by the measurement of the cervical canal and lower uterine segment. The study population was subdivided into four groups; successful and failed terminations at the end of 24?hours of induction and successful and failed terminations at the end of 48?hours of induction. We decided to further evaluate our study population based on their UCAs, and placed them into four categories; UCA ≥95°, UCA <95°, UCA ≥105°, and UCA <105°.

Results: In the 24-hour time frame group, the mean UCA was 105.50?±?15.38 degrees in the successful termination group and was 100.22?±?11.12 degrees in the failed group (p?=?.001). In the 48-hour time frame group, the mean UCA was 104.19?±?13.51° in the successful termination group and was 93.52?±?7.84° in the failed group (p?=?.007). The mean hour of induction was shortest in the UCA ≥105° group.

Conclusions: Regardless of the time frames, patients who had successful terminations had a broader angle, less amount of misoprostol use and shorter duration of induction as compared to the failed termination groups. What do the results of this study add? The uterocervical angle has never been measured in second trimester pregnancies to predict the timing of termination. Our study demonstrated the useful application of this ultrasonographic finding in the prediction of successful second trimester terminations.

Trial registration: ClinicalTrials.gov identifier: NCT03220607.     

A prospective randomized study comparing misoprostol and oxytocin for premature rupture of membranes at term

Objective.?The aim of this randomized trial was to compare the efficacy and safety of vaginal misoprostol and oxytocin for cervical ripening and labor induction in patients with premature rupture of membrane (PROM) at term.

Methods.?Ninety-seven women with PROM at term were assigned randomly to receive intravaginal misoprostol or oxytocin. The primary outcome measure was the induction–delivery interval. Secondary outcomes included the number of women who delivered vaginally within 12 hours of the start of the induction in the two groups, the cesarean, hyperstimulation, and failed induction rates, the mode of delivery, and the neonatal outcome.

Results.?Forty-eight women were assigned to intravaginal misoprostol and 49 to oxytocin administration. The mean interval from induction to delivery was 10.61 ± 2.45 hours in the misoprostol group and 11.57 ± 1.91 hours in the oxytocin group (p = 0.063). The rates of vaginal delivery were 83.3% and 87.7% and cesarean delivery were 16.7% and 8.2% in the misoprostol and oxytocin groups, respectively. Neonatal outcomes were not significantly different. Of the cases, 8.3% in the misoprostol group and 8.2% in the oxytocin group revealed uterine contraction abnormalities.

Conclusion.?Our study demonstrates that, intravaginally, misoprostol results in a similar interval from induction of labor to delivery when compared to oxytocin.