Effect of Sustained Uterine Compression versus Uterine Massage on Blood Loss after Vaginal Delivery: A Randomized Controlled Trial

OBJECTIVE

This study aimed to compare the effectiveness of sustained uterine compression versus uterine massage in reducing blood loos after a vaginal delivery.

STUDY DESIGN

This was a prospective randomized trial conducted at the American University of Beirut Medical Center (AUBMC) between October 2015 and October 2017. Inclusion criteria were women with a singleton pregnancy at ≥36 weeks of gestation, with less than three previous deliveries, who were candidates for vaginal delivery. Participants were randomized into two groups, a sustained uterine compression group (group 1) and a uterine massage group (group 2). Incidence of postpartum hemorrhage (blood loss of ≥500 mL) was the primary outcome. We assumed that the incidence of postpartum hemorrhage at our institution is similar to previously published studies. A total of 545 women were required in each arm to detect a reduction from 9.6 to 4.8% in the primary outcome (50% reduction) with a one-sided α of 0.05 and a power of 80%. Factoring in a 10% dropout rate. Secondary outcomes were admission to intensive care unit (ICU), postpartum complications, drop in hemoglobin, duration of hospital stay, maternal pain, use of uterotonics, or of surgical procedure for postpartum hemorrhage.

RESULTS

A total of 550 pregnant women were recruited, 273 in group 1 and 277 in group 2. There was no statistically significant difference in baseline characteristics between the two groups. Type of anesthesia, rate of episiotomy, lacerations, and mean birth weight were also equal between the groups. Incidence of the primary outcome was not different between the two groups (group 1: 15.5%, group 2: 15.4%; p = 0.98). There was no statistically significant difference in any of the secondary outcomes between the two groups, including drop in hemoglobin (p = 0.79).

CONCLUSION

There was no difference in blood loss between sustained uterine compression and uterine massage after vaginal delivery.

KEY POINTS

· Transabdominal uterine compression and uterine massage are appropriate to prevent postpartum hemorrhage.. · No significant difference in blood loss or maternal discomfort observed between the two techniques.. · Both methods are equally effective and either one can be used based on provider preference..

Vaccination in pregnancy

The evidence indicates that pregnancy is associated with increased severity of some infectious diseases. Given the high maternal morbidity associated with influenza in pregnancy and the high neonatal morbidity and mortality associated with pertussis, the traditionally two recommended vaccines during pregnancy were those against influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccines. The recent COVID-19 pandemic introduced a third vaccine that after much debate is now recommended for all pregnant women. Other vaccines can be offered based for high-risk pregnant women, and only when the benefits of receiving them outweigh the risks. The soon expected vaccines against group B streptococcus infection and respiratory syncytial virus infection will be a breakthrough in reducing perinatal mortality. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed.

Practice patterns of obstetric care in twin gestations: the value of MFM consultation

OBJECTIVES

To evaluate the practice patterns among Lebanese obstetricians regarding obstetric care of twins and to compare selected practice patterns between general obstetricians and maternal fetal medicine physicians.

METHODS

Questionnaires distributed during the annual meeting of the Lebanese Society of Obstetrics and Gynecology.

RESULTS

Questionnaires were returned by 69.2% of the 296 physicians approached. Ten percent had fellowship training in Maternal Fetal Medicine (MFM). Thirty-nine percent perform cervical length measurement at 20-24 weeks of gestation and 34% recommend vaginal progesterone in case of a short cervix. When comparing selected practice patterns between MFM & general obstetricians, MFM specialists were less likely to perform cervical cerclage in the first trimester (5.9% versus 49%, p = .001), more likely to offer prenatal screening for aneuploidy (66.6% vs 46.4%, p = .03), less likely to use vaginal progesterone in the second trimester in the case of a short cervix (42.1% vs 61.8%, p = .04), less likely to perform serial ultrasound exam in the third trimester to assess fetal growth (50% vs 78%, p = .005) and more likely to deliver monoamniotic twins at 32-34 weeks of gestation (55% vs 37%, p = .05).

CONCLUSION

Because of the different background of the Lebanese physicians, MFM specialists are more likely to follow obstetric care guidelines in twin gestation.

Practice and attitudes towards immunization among Lebanese obstetricians and gynecologists

We designed our study to evaluate the knowledge and immunization practices among Lebanese obstetricians and gynecologists (OBGYN) for women of different age groups. Anonymous questionnaires were used to assess the knowledge and immunization practices among OBGYN. The survey was conducted at the annual meeting of the Lebanese Society of Obstetrics and Gynecology on November 13-15, 2014. Data collected included demographics, type of practice, academic background and familiarity with vaccine guidelines. Descriptive statistical methods were used to evaluate the responses. The response rate was 54.8% (114/208). Only 62.3% (71/114) recommend vaccination(s) to pregnant women with only 25.9% of those who recommend the Tdap vaccine for pregnant women giving it during the recommended third trimester. In addition, 52.6% are unaware of the CDC/ACIP immunization schedule for women in general. However, 83.0% (93/112) of respondents are willing to integrate vaccination in their practice. Our study highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in addition to practices that are not in full accordance with common guidelines. Measures should be taken to spread proper awareness of the proper guidelines among Lebanese practitioners.

Intravenous Oxytocin Use to Decrease Blood Loss during Scheduled Cesarean Delivery: A Randomized Double-Blinded Controlled Trial (OXYTRIAL)

Objective The objective of this study was to determine the optimal dose of intravenous oxytocin administered during cesarean delivery (CD) to decrease the amount of blood loss. Methods Out of a total of 226 women presenting for CD, 189 patients were randomized into three groups by a computer-generated random number sequence table. Low-risk women with singleton term pregnancies undergoing scheduled CD were assigned to receive 20, 30, or 40 units (U) of oxytocin diluted in 500 mL of lactated Ringer solution intraoperatively. The primary outcome was the change in hemoglobin from pre-CD to post-CD. Results Overall, 63 women were assigned to each group. The primary outcome which was the drop in hemoglobin (1.4 ± 1.1 g/dL, 1.1 ± 0.8 g/dL, 1.0 ± 1.1 g/dL; p = 0.097) and the total calculated blood loss (798.6 ± 298.3 mL, 794.4 ± 313.5 mL, 820.2 ± 316.2 mL; p = 0.893) were not significantly different among the study groups. The incidence of intraoperative hypotension, postoperative systolic, and diastolic blood pressure changes was similar across the groups. Conclusion The amount of blood loss during CD was not significantly different among the three groups, thus the lowest dose of oxytocin infusion (20 U in 500 mL of lactated Ringer solution) seems to be an appropriate regimen.

Use of antenatal corticosteroids in the management of preterm delivery

OBJECTIVE

This narrative review of the literature explores the current evidence and recommendations in favor of antenatal corticosteroids use during impending preterm deliveries as well as related issues and concerns.

STUDY DESIGN

Synthesis of findings from published medical literature on antenatal corticosteroids and prematurity, retrieved from searches of computerized databases and authoritative texts.

RESULTS

It is now recognized that an intramuscular course of betamethasone or dexamethasone given to a woman expected to deliver preterm not only accelerates pulmonary epithelial development but also matures other organ systems, significantly decreasing the chances of neonatal morbidities and increasing chances of survival.

CONCLUSION

There remain uncertainties over the efficacy of the established protocol in populations such as the very early preterm, the late preterm, and multiple gestations. Alternative regimens remain controversial because of fear of adverse effects and doubts regarding whether benefits outweigh risks.

A randomised controlled double-blind clinical trial of 17-hydroxyprogesterone caproate for the prevention of preterm birth in twin gestation (PROGESTWIN): evidence for reduced neonatal morbidity

OBJECTIVE

To determine whether 17 alpha-hydroxyprogesterone caproate (17OHPC) prolongs gestation beyond 37 weeks of gestation (primary outcome) and reduces neonatal morbidity (secondary outcome) in twin pregnancy.

DESIGN

Randomised controlled double-blind clinical trial.

SETTING

Tertiary-care university medical centre.

POPULATION

Unselected women with twin pregnancies.

METHODS

Participants received weekly injections of 250 mg 17OHPC (n = 194) or placebo (n = 94), from 16-20 to 36 weeks of gestation. Randomisation was performed using the permuted-block randomisation method. Data were analysed on an intention-to-treat basis.

MAIN OUTCOME MEASURE

Preterm birth (PTB) rate before 37 weeks of gestation.

RESULTS

There were no significant differences in the average gestational age at delivery, or in the rates of PTB before 37, 32, and 28 weeks of gestation, between the two groups. The proportion of very-low-birthweight neonates (<1500 g) was significantly lower in the 17OHPC group (7.6%) compared with placebo (14.3%) (relative risk, RR 0.5; 95% confidence interval, 95% CI 0.3-0.9; P = 0.01). Progestogen-treated neonates had a significantly lower composite neonatal morbidity (19.1%) compared with placebo (30.9%) (odds ratio, OR 0.53; 95% CI 0.31-0.90; P = 0.02), with significantly lower odds for respiratory distress syndrome (14.4 versus 23.4%; OR 0.55; 95% CI 0.31-0.98; P = 0.04), retinopathy of prematurity (1.1 versus 4.6%; OR 0.21; 95% CI 0.05-0.96; P = 0.04), and culture-confirmed sepsis (3.4 versus 12.8%; OR 0.24; 95% CI 0.10-0.57; P = 0.00).

CONCLUSIONS

Intramuscular 17OHPC therapy did not reduce PTB before 37 weeks of gestation in unselected twin pregnancies. Nonetheless, 17OHPC significantly reduced neonatal morbidity parameters and increased birthweight.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis

BACKGROUND

In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB).

OBJECTIVES

To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA).

SEARCH STRATEGY

We searched international scientific databases, trial registration websites, and references of identified articles.

SELECTION CRITERIA

Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB.

MAIN RESULTS

Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75).

AUTHOR'S CONCLUSIONS

In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.

A clinical approach to intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) has a varying prevalence worldwide. The etiology behind this disease remains not fully understood with multiple factors influencing its development including genetic variations, dietary factors, hormonal changes, and environmental influences. Presenting mainly during the third trimester with generalized itching and resolving spontaneously postpartum, this condition is still associated with fetal morbidity and mortality. The diagnosis is based on clinical presentation in association with biochemical abnormalities. Elevation in total bile acid levels is the most frequent laboratory abnormality and seems to be the most important for gauging further management of the disease. The most appropriate gestational age for the delivery of women with ICP is yet to be determined. In this review we discuss the epidemiology, clinical features, diagnosis, etiology, and management of ICP, trying to shed light on some controversial aspects of the disease.

Effects of sildenafil in Nω-nitro-L-arginine methyl ester-induced intrauterine growth restriction in a rat model

OBJECTIVE

To assess the effect of sildenafil citrate in a rat model of Nω-nitro-l-arginine methyl ester (L-NAME)-induced intrauterine growth restriction (IUGR).

STUDY DESIGN

An in vivo experimental study was conducted where 40 pregnant Sprague-Dawley rats were randomly assigned to receive either: (1) control, (2) L-NAME 50 mg/kg/d by gavage (days 14 to 19), (3) L-NAME and sildenafil 15 mg/kg/d by gavage, or (4) sildenafil (days 14 to 21). On day 21, a hysterotomy was performed and all fetuses (live and dead) were counted, examined, and weighed. The primary outcome measure was the difference in pup birth weight.

RESULTS

The median number of live pups per dam was 11.5 (range: 1 to 15), 13.5 (2 to 17), 13.5 (7 to 16), and 11.5 (4 to 17) in controls, L-NAME, sildenafil, and combined drug groups, respectively (p = 0.02). Rats treated with L-NAME had a significantly higher number of stillbirths compared with control (p = 0.013) and sildenafil (p = 0.008) groups. L-NAME reduced pup birth weight compared with controls (4.53 ± 1.49 versus 5.65 ± 1.63 g, p < 0.001); this effect was more pronounced in the L-NAME and sildenafil groups (3.37 ± 1.25 g, p < 0.001).

CONCLUSION

Our data indicate that sildenafil citrate does not ameliorate L-NAME-induced IUGR, and in the doses utilized in this study might even have a synergistic negative effect on pup birth weight.

Indomethacin in pregnancy: applications and safety

Preterm labor (PTL) is a major cause of neonatal morbidity and mortality worldwide. Among the available tocolytics, indomethacin, a prostaglandin synthetase inhibitor, has been in use since the 1970s. Recent studies have suggested that prostaglandin synthetase inhibitors are superior to other tocolytics in delaying delivery for 48 hours and 7 days. However, increased neonatal complications including oligohydramnios, renal failure, necrotizing enterocolitis, intraventricular hemorrhage, and closure of the patent ductus arteriosus have been reported with the use of indomethacin. Indomethacin has been also used in women with short cervices as well as in those with idiopathic polyhydramnios. This article describes the mechanism of action of indomethacin and its clinical applications as a tocolytic agent in women with PTL and cerclage and its use in the context of polyhydramnios. The fetal and neonatal side effects of this drug are also summarized and guidelines for its use are proposed.

Effect of parity on maternal and neonatal outcomes in twin gestations

OBJECTIVE

To compare maternal and neonatal outcomes of twin gestations in nulliparous and multiparous women.

DESIGN

Retrospective analysis of maternal and neonatal records.

SETTING

American University of Beirut Medical Center, a referral university-affiliated hospital.

POPULATION

Pregnant women who delivered twin gestations beyond 24 weeks from 1990 to 2004.

METHODS

The data collected were analyzed using Student's paired t-test or χ(2) test. Logistic regression analysis was used to study the effect of multiple variables on preterm delivery.

MAIN OUTCOME MEASURE

Preterm birth rate.

RESULTS

Nulliparas (n=333) were more likely to be younger (28.1±5.4 vs. 30.0±5.2 years; p<0.001) and the pregnancy a product of assisted reproductive technology (23.1 vs. 4.5%; p<0.001) compared with multiparas (n=508). They were at significantly increased risk of preterm delivery (54.4 vs. 45.1%; p=0.009) at lower gestational age (35.6±3.2 vs. 36.2±3.0 weeks; p=0.004). They had longer first and second stages of labor and a higher cesarean delivery rate (61.3 vs. 44.9%; p<0.001). Except for a higher intensive care nursery admission rate and longer nursery stay for twins of nulliparas, all neonatal morbidities were comparable. On multiple logistic regression analysis, multiparity (relative risk 0.70, 95% confidence interval 0.51-0.97) and growth restriction (relative risk 0.16, 95% confidence interval 0.12-0.22) were protective, while discordance (relative risk 2.24, 95% confidence interval 1.40-3.60) was a predictor of preterm delivery.

CONCLUSIONS

Nulliparous women with twin gestations are at significantly higher risk for preterm delivery and cesarean delivery compared with multiparous women. Although this was not translated into higher perinatal mortality, these women should be monitored closely and counseled regarding these risks and their attendant morbidity.

Oxytocin antagonists for the management of preterm birth: a review

Preterm birth, the leading cause of neonatal morbidity and mortality, is estimated at incidence of 12.7% of all births, which has not decreased over the last four decades despite intensive antenatal care programs aimed at high-risk groups, the widespread use of tocolytics, and a series of other preventive and therapeutic interventions. Oxytocin antagonists, namely atosiban, represent an appealing choice that seems to be effective with apparently fewer side effects than the traditional tocolytics. This article reviews the available literature on the pharmacokinetics, mode of administration, and clinical utility of oxytocin antagonists for acute and maintenance tocolysis with special emphasis on its safety profile.

Calcium channel blockers for the management of preterm birth: a review

Preterm birth continues to be the leading cause of perinatal morbidity and mortality. A wide range of tocolytics have been utilized for the management of preterm labor. Calcium channel blockers, namely nifedipine, gained popularity as tocolytics due to the oral route of administration, availability of immediate- and slow-release preparations, the low incidence of maternal adverse effects associated with their use, and the fact that they are inexpensive. This article reviews the available literature on the clinical utility of calcium channel blockers for acute and maintenance tocolysis with special emphasis on potential adverse effects, the most appropriate dose/regimen, and contemporary practice patterns among obstetricians. There are no randomized, placebo-controlled studies demonstrating the benefit of nifedipine in preterm labor. A suggested tocolytic protocol would be to start with the lowest dose of oral immediate-release nifedipine. For the first 48 hours thereafter, all attempts should be made not to exceed 60-mg daily doses.

Effect of female nargile smoking on in vitro fertilization outcome

OBJECTIVE

Smoking is a significant health hazard that has been associated with poor reproductive outcome and reduced fertility in reproductive age women. The aim of this study was to assess the effect of nargile smoking on intra-cytoplasmic sperm injection (ICSI) outcome.

STUDY DESIGN

A prospective analysis of the outcomes of 297 women who underwent ICSI treatment at the ART Unit at the American University of Beirut Medical Center between January 1, and December 31, 2006 was done. The patients were divided into 3 groups based on their smoking status: cigarette smokers (n=42), nargile smokers (n=51) and non-smokers (n=204).

RESULTS

The mean age of nargile smokers was significantly lower than the other groups; however, the 3 groups were similar with respect to the cause of infertility, total dose of follicular stimulating hormone (FSH), number of oocytes and embryos obtained, and number and quality of embryos transferred. There was no significant difference in the clinical pregnancy rate between nargile smokers and non-smokers (51.0% vs 43.6%). However, cigarette smokers had a significantly lower clinical pregnancy rate compared to non-smokers (23.8% vs 43.6%, p=0.0238). On multiple logistic regression analysis, factors that decreased the clinical pregnancy rates were cigarette smoking and maternal age.

CONCLUSION

Although this study did not find a deleterious effect of nargile smoking on ICSI outcome, the results need to be confirmed in prospective studies that would include larger number of women with more objective measures of nargile smoke exposure.

A short cervical length in pregnancy: management options

Measuring cervical length using transvaginal ultrasonography is a useful tool to predict the risk of preterm birth in low- and high-risk pregnancies. Management of a short cervix poses a significant dilemma for clinicians. Different management plans have been proposed and studied, with mixed results in different clinical settings. This article reviews the various management options in the different patient subpopulations and proposes a scheme for management once a short cervix is identified.

Two dose regimens of nifedipine for management of preterm labor: a randomized controlled trial

We compared two dose regimens of tocolytic oral nifedipine. Women with singleton pregnancies admitted in preterm labor (24 to 34 weeks) were randomized to high-dose (HD) nifedipine ( N = 49; 20 mg loading dose, repeated in 30 minutes, daily 120 to 160 mg slow-release nifedipine for 48 hours followed by 80 to 120 mg daily until 36 weeks) or low-dose (LD) nifedipine ( N = 53; 10 mg, up to four doses every 15 minutes, daily 60 to 80 mg slow-release nifedipine for 48 hours followed by 60 mg daily until 36 weeks). Uterine quiescence at 48 hours (primary outcome); delivery at 48 hours, 34 and 37 weeks; and recurrent preterm labor were similar. Gestational age at delivery was higher in HD (36.0 +/- 2.8 versus 34.7 +/- 3.7 weeks, P = 0.049). Rescue treatment was needed more in LD (24.5 versus 50.9%, odds ratio = 0.3; 95% confidence interval 0.1 to 0.7). Maternal adverse effects, birth weight, intensive care nursery admission, and composite neonatal morbidity were similar. However, neonatal mechanical ventilation was needed less and nursery stay was shorter in HD. HD nifedipine does not seem to have an advantage over LD in achieving uterine quiescence at 48 hours. Further studies should address the optimal dose and formulation of tocolytic nifedipine.

Ectopic pregnancy in a uterine perforation site

Uterine perforation can occur following first-trimester abortion or more commonly postpartum after evacuation of retained placental tissues. We report a case of a pregnancy at the site of a recent uterine perforation. Possible mechanisms of this rare condition and different therapeutic options are mentioned.

Acceptance of preimplantation genetic diagnosis for beta-thalassemia in Lebanese women with previously affected children

OBJECTIVE

The aim of the study was to assess the rate of acceptance of preimplantation genetic diagnosis (PGD) as an alternative to prenatal diagnosis in Lebanese women with previously affected children with homozygous beta-thalassemia.

METHODS

Women with a previously affected child attending a non governmentally funded thalassemia care center between 1 June 2005 and 31 May 2007 were offered a genetic counseling session. This was followed by administering a questionnaire through direct interview.

RESULTS

All 97 women approached accepted to participate in the study (100% response rate). Sixty eight per cent of women considered PGD a better alternative to prenatal diagnosis. The most important perceived advantage of PGD was the avoidance of termination of an affected pregnancy.

CONCLUSIONS

PGD is an acceptable alternative to conventional prenatal diagnosis in women at risk of conceiving a child affected with beta-thalassemia. This is particularly true in countries of the Middle-East where therapeutic abortions for fetal indications are prohibited by the law and religion.

Advanced maternal age. Part II: long-term consequences

In addition to the possible association between pregnancy in women with advanced maternal age and increased rates of obstetric and perinatal complications, those women and their children might suffer from long-term sequelae. In this review, the long-term consequences of delayed motherhood on the offspring and the possible association between advanced maternal age and the development of certain cancers are discussed.

Effect of 1-month war in Lebanon on sex ratio

Our study showed no effect of 33-day war in Lebanon on sex ratio. More research is needed to explore other modifying factors for a better understanding of the complex effect of wars on sex ratio changes.

A randomised comparison of patient satisfaction with vaginal and sublingual misoprostol for induction of labour at term*

OBJECTIVE

To compare patient satisfaction with two routes of misoprostol for term labour induction.

DESIGN

Prospective randomised trial.

SETTING

Tertiary care hospital.

POPULATION

A total of 170 women admitted at > or = 37 weeks of gestation for induction of labour.

METHODS

Women were randomised to receive 50 micrograms of either sublingual or vaginal misoprostol.

MAIN OUTCOME MEASURES

Patient satisfaction with the route of administration.

RESULTS

Despite a similar proportion reporting the labour induction as more painful than expected in both groups, a significantly lower proportion mentioned that the pelvic examinations were very painful in the sublingual group (19.7 versus 36.1%, relative risk [RR] 0.5, 95% CI 0.3-0.9). Request for analgesia was similar in both groups. More women in the sublingual group thought that the labour experience was better than expected (RR 2.0, 95% CI 1.2-3.3), had a positive attitude towards induction in subsequent pregnancies (RR 1.6, 95% CI 1.1-2.3) and preferred the same route in subsequent pregnancies (RR 3.1, 95% CI 2.2-4.5). Mean number of misoprostol doses, oxytocin augmentation, tachysystole and hyperstimulation, induction to vaginal delivery interval, vaginal delivery after a single dose, vaginal birth within 12 and 24 hours, and caesarean delivery rates were similar in both groups.

CONCLUSION

Sublingual misoprostol (50 micrograms) is associated with a significantly higher patient satisfaction rate compared with a similar dose of vaginal misoprostol. Sublingual administration offers additional choice to women, in particular those wishing to avoid vaginal administration.

Marked hypocalcemia after tocolytic magnesium sulphate therapy

Symptomatic hypocalcemia has been reported infrequently in association with magnesium sulfate (MgSO (4)) tocolytic therapy. We report a 38-year-old woman who presented in preterm labor at 24 3/7 weeks. Twenty hours after starting MgSO (4), she developed chest pain. Studies revealed therapeutic serum Mg level, total serum calcium (Ca) = 5.5 mg/dL, 24-hour urine Ca = 763.9 mg, and low serum uric acid and phosphate levels. All studies corrected day 1 postpartum; urine Ca level corrected on day 2. Even short courses of MgSO (4) can result in severe hypocalcemia, raising the question of whether Ca levels should be routinely monitored.

Effect of War on the Menstrual Cycle

OBJECTIVE

To study the effect of a short period of war on the menstrual cycles of exposed women.

METHODS

Six months after a 16-day war, women in exposed villages aged 15-45 years were asked to complete a questionnaire relating to their menstrual history at the beginning, 3 months after, and 6 months after the war. A control group, not exposed to war, was also interviewed. The data collected were analyzed to estimate the effect of war on three groups of women: those who stayed in the war zone for 3-16 days (Group A), those who were displaced within 2 days to safer areas (Group B), and women not exposed to war or displacement (Group C-control).

RESULTS

More than 35% of women in Group A and 10.5% in Group B had menstrual aberrations 3 months after the cessation of the war. These percentages were significantly different from each other and from that in Group C (2.6%). Six months after the war most women regained their regular menstrual cycles with the exception of 18.6% in Group A.

CONCLUSION

We found a short period of war, acting like an acute stressful condition, resulted in menstrual abnormalities in 10-35% of women and is probably related to the duration of exposure to war. This might last beyond the war time and for more than one or two cycles. In most women the irregular cycles reversed without any medical intervention.

LEVEL OF EVIDENCE

II.

Pregnancy outcome in patients with previous uterine rupture

BACKGROUND

To review the outcome of subsequent pregnancies in conservatively managed cases of uterine rupture.

METHODS

Charts of patients with full thickness uterine rupture in the past 25 years were reviewed and information on subsequent pregnancies was extracted from maternal and neonatal charts.

RESULTS

Thirty-seven patients with uterine rupture were identified; the uterus was scarred in 62.2%. Ruptures were repaired in 26 (70.3%). Twelve patients subsequently conceived (24 pregnancies), with recurrence in 8/24 (33.3%) pregnancies or 5/12 (41.7%) patients. Patients with recurrence had a shorter median interval from previous rupture (2 versus 5 years), a higher incidence of previous longitudinal ruptures (60.0% versus 0.0%), and the median gestational age at the preceding rupture was lower without reaching statistical significance (34 versus 38 weeks; p = 0.209).

CONCLUSIONS

Longitudinal ruptures and short intervals between rupture and subsequent pregnancy predispose to recurrence of uterine rupture.

Liver infarction in a woman with systemic lupus erythematosus and secondary anti-phospholipid and HELLP syndrome

We report a 39-year-old primigravida, a case of systemic lupus erythematosus (SLE) and secondary anti-phospholipid syndrome (APS) with a smooth antenatal course who delivered by caesarean for non-reassuring foetal heart rate. On day 2 postoperatively, she developed a sudden severe colicky upper abdominal pain with tachypnoea, dyspnoea, and tachycardia, and blood pressure (BP) reaching 150/95 mmHg. Computed tomography of the abdomen revealed lesions consistent with liver infarction. She developed haemolytic anaemia, elevated liver enzymes, and low platelets (HELLP syndrome); heparin and methylprednisolone were started. On day 3, BP normalized, respiratory symptoms improved but abdominal symptoms persisted. Methylprednisolone was increased to 80 mg/day on day 8 when she had significant clinical response and was discharged on day 16. This case emphasizes that a morbid clinical course including liver infarction should be anticipated in patients with SLE and APS complicated with HELLP syndrome.

Acute pulmonary edema during tocolytic therapy with nifedipine

Calcium channel blockers are becoming more popular as first-line tocolytic agents. Serious side effects have rarely been reported and involved mainly intravenous use of nicardipine. We report the first case of acute pulmonary edema following tocolytic oral nifedipine. Possible contributing factors are mentioned.

Grandmultiparas in modern obstetrics

The objective of this study was to compare incidence of antenatal and intrapartum complications among women who had previously delivered five or more times (grandmultiparas cases, 155) with that of age-matched women with two to three previous deliveries (multiparas controls, 155) from 1998 to 2003. Grandmultiparity was associated with a low socioeconomic status, higher incidence of smoking, and a higher body mass index. Grandmultiparas had approximately 2-fold increased risk of gestational diabetes, hypertensive disorders, malpresentation, and preterm delivery, and a 3-fold increased risk of abruption; none reached statistical significance. No significant differences were found in antepartum hemorrhage, anemia, postdatism, polyhydramnios, or placenta previa. Intrapartum complications (labor induction, nonreassuring fetal heart, primary cesarean delivery, and intrapartum fever) were similar; however, operative vaginal delivery was significantly lower in grandmultiparas cases. Both groups were similar regarding birthweight, macrosomia, intrauterine growth restriction, Apgar scores, and stillbirth rates. Our study shows a trend toward an increased risk of adverse obstetrical outcome in grandmultiparas compared with multiparas independent of maternal age.

Pregnancy in patients with beta-thalassemia intermedia: outcome of mothers and newborns

Little is known about the outcome of pregnancy in women with beta-thalassemia intermedia (TI). Over 10 years, maternal and neonatal outcomes of women with TI followed at a single thalassemia center were reviewed. Nine spontaneous pregnancies in five women with TI were studied. Six pregnancies resulted in live newborns; two were complicated by first-trimester abortions and one by an unexplained intrauterine fetal death at 36 weeks' gestation. Two patients had splenectomy before pregnancy: one required cesarean delivery and splenectomy at 31(2/7) weeks' gestation for worsening hemolytic anemia and thrombocytopenia and another had splenectomy 8 weeks postpartum for symptomatic hypersplenism. Two patients had received transfusions before pregnancy, and two required them for the first time during pregnancy and developed antibodies, which contributed to worsening of their anemia and repeated transfusions. The mean number of transfusions received during pregnancy was 8.0 +/- 5.2 units. The mean lowest hemoglobin level in pregnancy was 5.2 +/- 2.0 g/dl. Cesarean delivery was performed in 42.9% of cases. Mean gestational age at delivery was 36.7+/- 3.1 weeks with intrauterine growth restriction (IUGR) complicating 57.1% of cases. In conclusion, IUGR complicates more than half of pregnancies with TI. Transfusions are needed in most cases, even in non-transfusion-dependent patients. Postpartum splenectomy might be necessary in some patients.