Deliveries in Lebanon, the Country with the Highest Refugee Density in the World: A Descriptive Review

PURPOSE

The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes.

DESCRIPTION

Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons.

ASSESSMENT

Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001).

CONCLUSION

Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries.

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.

FIGO good clinical practice paper: management of the second stage of labor

This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.

Don't forget eclampsia in the efforts to reduce maternal morbidity and mortality

Hypertensive disorders are a leading cause of maternal morbidity and mortality worldwide. Despite advances in prevention and clinical management, women in low-resource countries continue to bear the burden of the sequelae of severe pre-eclampsia-eclampsia. Sustainable strategies to improve the care of women with hypertensive disease, to identify those at risk for hypertensive disease, and to reduce the risk of eclampsia will require partnerships between clinicians and health policy makers. Resources are needed to scale up healthcare access and infrastructure, establish evidence-based protocols for care, and ensure an adequate supply of equipment and drugs. Additionally, efforts for a sustained workforce of perinatal clinicians and staff trained in the assessment and management of hypertensive disease are needed. Effective postpartum care and monitoring are essential to prevent morbidity and mortality due to cardiovascular disease. Culturally appropriate strategies are needed to educate women and their families on the symptoms of pre-eclampsia to address delays in seeking care during pregnancy and postpartum. With targeted, sustained efforts and resources, eclampsia and its associated co-morbidities can be preventable.

FIGO/ICM guidelines for preventing Rhesus disease: A call to action

The introduction of anti‐Rh(D) immunoglobulin more than 50 years ago has resulted in only a 50% decrease in Rhesus disease globally owing to a low uptake of this prophylactic approach. The International Federation of Gynecology and Obstetrics, International Confederation of Midwives, and Worldwide Initiative for Rhesus Disease Eradication have reviewed current evidence regarding the utility of anti‐Rh(D) immunoglobulin. Taking into account the effectiveness anti‐Rh(D), the new guidelines propose adjusting the dose for different indications and prioritizing its administration by indication.

These FIGO/ICM guidelines review the evidence regarding the usefulness of anti‐Rh(D) immunoglobulin, prioritizing its administration by indication.

FIGO position paper on reference charts for fetal growth and size at birth: Which one to use?

Publication of the Intergrowth-21st and WHO growth charts raises the question of which growth data prenatal providers should use in clinical practice. Is it better to use a universal chart applied globally, or metrics based on local or regional growth patterns? And what about customized charts versus local charts? FIGO has reviewed the different growth charts and studies assessing their reproducibility and predictive values for small- and large-for-gestational age newborns and, where available, adverse fetal outcomes. It concludes that local or regional charts are likely to be best for identifying the 10th percentile of newborns at highest risk. However, international standards for growth may also be used when coupled with locally appropriate thresholds for risk interpretation.

FIGO Statement: Vaccination in pregnancy

Pregnant women and their fetuses are among the vulnerable populations that can be severely affected by communicable diseases. As such, some vaccines such as the influenza and the Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines are strongly recommended in each pregnancy, with generally safe profiles. Other vaccines can be offered based on risk factors, and only when the benefits of receiving them outweigh the risks. Development of vaccines against group B streptococcus infection and respiratory syncytial virus infection are of great importance. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed. The FIGO Committee for Safe Motherhood and Newborn Health Committee endorses the recommendations to vaccinate all pregnant women against influenza during the influenza season at any time during the pregnancy and against Tdap preferably between the 27th and 36th weeks of pregnancy in each pregnancy.

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.

Episiotomy: history, present and future - a review

Childbirth has always carried traumatic stress to the woman's body. To deliver with less perineal trauma, obstetricians have used episiotomies. Episiotomy is still a common practice despite the controversy regarding its use. Weighing the risks and benefits, the scientific literature supports its selective use. With the worldwide trend to reduce the rate of episiotomy, several techniques have been proposed to achieve that. However, further research is still needed to prove their efficacy. This review will shed light on the historical background of episiotomy, its different techniques, indications, and the future of its practice.

BACs-on-Beads™ assay, a rapid aneuploidy test, improves the diagnostic yield of conventional karyotyping

BACs-on-Beads (BoBs™) assay is a rapid aneuploidy test (RAT) that detects numerical chromosomal aneuploidies and multiple microdeletion/microduplication syndromes. This study was conducted to appraise the usefulness of the BoB™ assay as a complementary diagnostic tool to conventional karyotyping for the rapid detection of chromosomal aneuploidies. A total of 485 prenatal (amniotic fluid and chorionic villi) and blood/products of conception samples were collected between July 2013 and August 2018, and analyzed by the BoBs™ assay and cytogenetic karyotyping and further validated by fluorescence in situ hybridization (FISH). Forty-three of 484 qualifying samples (8.9%) were identified as abnormal by the BoBs™ assay. The assay was comparable to karyotyping in the detection of common structural abnormalities (trisomy 21, trisomy 18, X, and Y), with a sensitivity of 96.0% and a specificity of 100%. BoBs™ assay detected 20 microdeletion and microduplication syndromes that were missed by karyotyping. BoBs™, however, missed 10 cases of polyploidies and chromosomal rearrangements which were identified by conventional karyotyping. Our findings suggest that BoBs™ is a reliable RAT which is suitable in combination with conventional karyotyping for the detection of common aneuploidies. The assay also improves the diagnostic yield by recognizing clinically relevant submicroscopic copy number gains and losses.

FIGO Statement: Restrictive use rather than routine use of episiotomy

International standards for clinical staffing of delivery care in maternity units are currently lacking, with resulting gaps in provision leading to adverse outcomes and very poor experiences of care for women and families. While evidence‐informed modelling approaches have been proposed based on population characteristics and estimated rates of complications, their application and outcomes in low‐resource settings have not been reported. Here, FIGO's Safe Motherhood and Newborn Health Committee proposes indicative standards for labor wards as a starting point for policy and program development. These standards consider the volume of deliveries, the case mix, and the need to match clinical care requirements with an appropriate mix of professional skills among midwifery and obstetric staff. The role of Shift Leader in busy labor wards is emphasized. Application of the standards can help to assure women and their families of a safe but also positive birthing experience. FIGO calls for investment by partners to test these clinically‐informed recommendations for delivery unit staffing at hospital and district level in low‐ and middle‐income country settings.

Hybrid Simulation in Teaching Clinical Breast Examination to Medical Students

Clinical breast examination (CBE) is traditionally taught to third-year medical students using a lecture and a tabletop breast model. The opportunity to clinically practice CBE depends on patient availability and willingness to be examined by students, especially in culturally sensitive environments. We propose the use of a hybrid simulation model consisting of a standardized patient (SP) wearing a silicone breast simulator jacket and hypothesize that this, compared to traditional teaching methods, would result in improved learning. Consenting third-year medical students (N = 82) at a university-affiliated tertiary care center were cluster-randomized into two groups: hybrid simulation (breast jacket + SP) and control (tabletop breast model). Students received the standard lecture by instructors blinded to the randomization, followed by randomization group-based learning and practice sessions. Two weeks later, participants were assessed in an Objective Structured Clinical Examination (OSCE), which included three stations with SPs blinded to the intervention. The SPs graded the students on CBE completeness, and students completed a self-assessment of their performance and confidence during the examination. CBE completeness scores did not differ between the two groups (p = 0.889). Hybrid simulation improved lesion identification grades (p < 0.001) without increasing false positives. Hybrid simulation relieved the fear of missing a lesion on CBE (p = 0.043) and increased satisfaction with the teaching method among students (p = 0.002). As a novel educational tool, hybrid simulation improves the sensitivity of CBE performed by medical students without affecting its specificity. Hybrid simulation may play a role in increasing the confidence of medical students during CBE.

Correlation between neonatal outcomes of twins depends on the outcome: secondary analysis of twelve randomised controlled trials

OBJECTIVE

To estimate the magnitude of the correlation between neonatal outcomes of twins and demonstrate how this information can be used in the design of randomised controlled trials (RCTs) in women with twin pregnancies.

DESIGN

Secondary analysis of data from 12 RCTs.

SETTING

Obstetric care in multiple countries, 2004-2012.

POPULATION OR SAMPLE

4504 twin pairs born to women who participated in RCTs to assess treatments given during pregnancy.

METHODS

Intraclass correlation coefficients (ICCs) were estimated using log-binomial and linear models.

MAIN OUTCOME MEASURES

Perinatal death, respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular haemorrhage, necrotising enterocolitis, sepsis, neonatal intensive care unit admission, birthweight, low birthweight and two composite measures of adverse neonatal outcome.

RESULTS

ICCs for the composite measures of adverse neonatal outcome were all above 0.5, indicating moderate to strong correlation between adverse outcomes of twins. For individual neonatal outcomes, median ICCs across trials ranged from 0.13 to 0.79 depending on the outcome. An example illustrates how ICCs can be used in sample size calculations for RCTs in women with twin pregnancies.

CONCLUSIONS

The correlation between neonatal outcomes of twins varies considerably between outcomes and may be lower than expected. Our ICC estimates can be used for designing and analysing RCTs that recruit women with twin pregnancies and for performing meta-analyses that include such RCTs. Researchers are encouraged to report ICCs for neonatal outcomes in twins in their own RCTs.

TWEETABLE ABSTRACT

Correlation between neonatal outcomes of twins depends on the outcome and may be lower than expected.

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.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Pregnancy outcomes in Lebanese women with multiple sclerosis (the LeMS study): a prospective multicentre study

OBJECTIVE

The Lebanese Multiple Sclerosis (LeMS) study aims to assess the influence of pregnancy and delivery on the clinical course of multiple sclerosis (MS) in Lebanese women.

SETTING

This prospective multicentre study took place in three MS referral university medical centres in Lebanon.

PARTICIPANTS

Included were 29 women over 18 years who had been diagnosed with MS according to the McDonald criteria, and became pregnant between 1995 and 2015. Participating women should have stopped treatment 3 months before conception and become pregnant after the onset of MS. Women were followed up from 1 year preconceptionally and for 4 years postpartum.

MAIN OUTCOME MEASURES

The annualised relapse rates per participant during each 3-month period during pregnancy and each year postpartum were compared with the relapse rate during the year before pregnancy using the paired two-tailed t test. p Values <0.05 were considered statistically significant for all analyses (95% CI).

RESULTS

64 full-term pregnancies were recorded. All pregnancies (100%) resulted in live births, with no complications or other diseases. In comparison with the prepregnancy year, in which the mean relapse rate±SE was 0.17±0.07, there was a significant reduction in the relapse rate during pregnancy and in the first year postpartum (p=0.02), but an increase in the rate in the second year postpartum (0.21±0.08). Thereafter, from the third year postpartum through the following fourth year, the annualised relapse rate fell slightly but did not differ from the annualised relapse rate recorded in the prepregnancy year (0.17±0.07).

CONCLUSIONS

Pregnancy in Lebanese women with MS does not seem to increase the risk of complications. No relapses were observed during pregnancy and in the first year postpartum; however, relapses rebounded in the second year postpartum, and over the long term, returned to the levels that preceded pregnancy.

Postpartum sacral stress fracture: a case report

BACKGROUND

Stress fractures are classified as insufficiency and fatigue fractures. Insufficiency fractures occur when normal stresses are placed on bone with decreased mineralization and elastic resistance; whereas fatigue fractures occur when abnormal forces are applied to normal bone.

CASE PRESENTATION

We report a case of postpartum bilateral sacral fracture in the absence of documented osteoporosis in a 30 year old Lebanese female, thus satisfying the classification of fatigue fractures. Clinical presentation was mainly low back pain, pelvic pain, and abnormal gait.

CONCLUSIONS

This case stresses the importance of including sacral fractures in the differential diagnosis of patients presenting with similar symptoms during pregnancy or the postpartum period.

Effect of the Mode of Application of Cryopreserved Human Amniotic Membrane on Adhesion Formation after Abdomino-Pelvic Surgery in a Mouse Model

Adhesions after abdomino-pelvic surgery are a cause of morbidity and reoperations. The use of human amniotic membrane (HAM) for adhesion prevention has given controversial results. The mode of administration of the amniotic membrane has not been well studied. This study assessed the efficacy of two modes of application of cryopreserved HAM, patch or fragmented in Lactated Ringer (LR) solution, for the prevention of pelvic adhesion formation postabdomino-pelvic surgery in a mice model. After a midline laparotomy incision, a small cautery lesion was done on each side of the abdominal wall peritoneum in mice. In Group A (control; n = 42), the abdomen was closed directly, Group B (n = 42) received 2.5 ml of LR prior to closure. In Groups C (n = 42) and D (n = 42), a 2 cm × 2 cm patch of HAM and another one fragmented and dispersed in 2.5 ml of LR were applied prior to closure, respectively. Two weeks later, a laparotomy was performed, and gross and pathological evaluation of adhesions, fibrosis, angiogenesis, and inflammation were conducted. Group D exhibited a significantly lower rate of gross adhesion formation. Fibrosis was significantly lowest in Group C as compared to the control. Group B had the lowest vascular formation in the adhesions. The use of HAM fragmented in LR solution is associated with a significantly lower incidence of postoperative adhesions in mice when compared to LR alone, HAM patch, or control. The mechanism of action of this reduction needs to be elucidated by future studies.

Echogenic intracardiac focus on second trimester ultrasound: prevalence and significance in a Middle Eastern population

OBJECTIVE

The association between echogenic intracardiac focus (EIF) and trisomy 21 is well established, with a recognized ethnic variation. Our study aimed to determine the prevalence of EIF in a Middle Eastern population and to examine its association with trisomy 21 and other adverse pregnancy outcomes.

METHODS

Retrospective case-control study of second-trimester obstetric sonograms (16-28 weeks) performed at a tertiary care center over a 5-year period. Cases with EIF were retrieved, and a matched control group with no EIF was identified. The incidence of trisomy 21 and other adverse pregnancy outcomes was compared.

RESULTS

A total of 9270 obstetric sonograms were examined, with an EIF prevalence of 2.5% (95% CI: 2.2-2.8%). Of patients with available outcome data, EIF was not associated with trisomy 21 (0/163 versus 1/163; p value = 1.00). Additionally, EIF was not associated with trisomy 18, trisomy 13, small for gestational age, preterm birth, fetal demise, cesarean delivery, operative vaginal delivery, or admission to the neonatal intensive care unit.

CONCLUSION

In a contemporary Middle Eastern population, EIF is a rare occurrence. As an isolated finding, it is not associated with aneuploidy or other adverse pregnancy outcomes. EIF appears to be incidental with no impact on clinical practice.

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.

Human papillomavirus vaccination: assessing knowledge, attitudes, and intentions of college female students in Lebanon, a developing country

Human papillomavirus (HPV) infection is a common cause for genital warts and cervical cancer. Developing countries in the Middle East such as Lebanon are traditionally considered to be conservative societies with low incidence of sexually transmitted infections. However, nowadays, there is an unexpected increase in the incidence of HPV infections among Middle Eastern females. Thus, the objective of this study is to assess the behavioral perceptions of HPV vaccination among female students attending an academic institution in Lebanon. This cross-sectional study invited 512 students to complete a self-administered questionnaire that assessed the knowledge, attitudes, and intentions towards HPV vaccination. Data analysis included the calculation of knowledge scores ranging from 0 to 100, attitude scores ranging from most positive (1) to most negative (5), and intention scores ranging from lowest intention (0) to highest intention (10). With a response rate of n=215 (42%), 36.5% never heard of the vaccine before, and only 16.5% were already HPV vaccinated. The median knowledge score of 52.7% ± 1.71 reflects poor to moderate knowledge. Still, the median attitude score of 2.47 ± 0.05 shows a general positive attitude towards HPV vaccination where most of the participants agreed that female college students in Lebanon have a good chance of contracting HPV (62.1%) and that all gynecologists should recommend the vaccine (76.0%). Students in graduate programs, health related majors, and those who are vaccinated had significantly higher knowledge scores compared with students in undergraduate programs, non-health related majors, and HPV non-vaccinated students, respectively. Finally, the survey helped in increasing the intention to obtain HPV vaccine as the intention score increased significantly from 5.24 ± 0.27 before the students went through the survey to 6.98 ± 0.22 after the students completed the survey. Our study highlights the importance of offering guidance to female college students about HPV and its vaccination in developing countries where the incidence of sexually transmitted infections is on the rise.

Influenza and its treatment during pregnancy: A review

The influenza viral infection has dramatic effects during pregnancy on the mother and the fetus. We present a review article on the prevention and treatment recommendations of influenza infection in pregnant women, and the effects of antiviral medications on maternal-fetal outcomes. This viral infection not only leads to miscarriages, preterm deliveries and a high maternal mortality rate, but it also poses negative risks to the fetus including small-for-gestational age infants, and admissions to neonatal intensive care units. Vaccination is the most effective strategy for preventing influenza infection during pregnancy whereby can protect both maternal and fetal immunities. The safety profiles of antiviral drugs during pregnancy are limited. Available risk-benefit evidence has indicated that pregnant women with suspected or confirmed influenza should receive prompt antiviral therapy where these medications reduce the risk of complications among pregnant women, and attenuate the teratogenic effects of the influenza infection. Post-exposure prophylaxis is not recommended for most pregnant women, but it may be prescribed in pandemic settings, particularly to non-vaccinated women. Although some ex vivo models for pharmacokinetic studies have revealed that the transplacental transfer of oseltamivir to fetal circuits may occur, there is no evidence of adverse fetal outcomes as a result of most in utero exposures to neuraminidase inhibitors. Due to the large number of confounding variables, large, population-based studies are needed to assess the association between in utero oseltamivir exposure and fetal outcome.

Recurrent twin pregnancy, with the second a heterotopic pregnancy, following clomiphene citrate stimulation: an unusual case and a review of the literature

Multiple gestations are on the rise with the advent of artificial reproductive technologies. Even with ovulation induction using clomiphene citrate alone, the twinning rate can reach up to 9 percent. We report a case of recurrent twin gestation after treatment with clomiphene citrate, with the second pregnancy being heterotopic. We also review, using Medline and PubMed, previously reported cases of recurrent twin gestation after treatment with clomiphene citrate published before June 2014. Patients undergoing ovulation induction for oligoovulation, anovulation, or unexplained infertility should always be counseled about the possibility of multiple gestation prior to the treatment including the probability, although low, of a heterotopic pregnancy.

Intimate Partner Violence in a Lebanese Population Attending Gynecologic Care: A Cultural Perspective

Occurrence of intimate partner violence (IPV) against women in the Lebanese society has been largely ignored by local legal and religious authorities. Our aim is to estimate the prevalence of IPV among married Lebanese women, and investigate perception of abuse, referral patterns, and measures taken to deal with abusive situations. In this cross-sectional study, married women aged 20 to 65 presenting to the American University of Beirut Medical Center for gynecological care were interviewed on various forms of IPV. Out of 100 women invited to participate, 91 consented to take part in the survey of whom 37 (40.67%) gave a history of physical abuse, 30 (33.0%) of sexual abuse, 59 (64.8%) of verbal abuse, and 17 (18.7%) of emotional abuse. Spouse-imposed social isolation was reported in 20 (22.0%) women, and economic abuse in 30 (33.0%). Reasons for deciding to stay in an abusive relationship were "lack of any family or social support" (40.5%), "lack of financial resources" (40.5%), and "fear that the partner may take away the children" (37.8%). Women expressed satisfaction with their spouse's treatment irrespective of the existence of various forms of violence. A significant increase in the risk of weapon use against wife was correlated with decreased monthly income of the household, whereas a protective effect was conferred by an increased number of children. This study highlights the need for routine screening in health care settings for better identification of victims of violence. The selective conventional perception of abuse and the reactive normalization of violence observed indicate the necessity for culturally informed interventional strategies to complement screening.

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.

Vitamin D in endometriosis: a causative or confounding factor?

OBJECTIVE

The aim of this paper is to review the evidence from studies that evaluated the relationship between vitamin D and endometriosis.

DESIGN

Comprehensive review.

MATERIALS AND METHODS

Systematic literature search in Medline for relevant publications from 1946 until June 2013.

RESULTS

Endometriosis risk may be influenced by dietary vitamin D intake and plasma hydroxyvitamin D concentration. Vitamin D receptor and vitamin D metabolizing enzymes, 24-hydroxylase and 1-α hydroxylase, are found in the normal cycling endometrium and also in the eutopic and ectopic endometrium of women with endometriosis. The endometrium is a target of 1, 25 dihydroxyvitamin D actions through regulation of specific genes and via immunomodulation. The endometrium in endometriosis expresses dysregulation of some vitamin D enzymes and receptors. If vitamin D and its metabolites are implicated in endometriosis-associated infertility, it is likely through interference with HOXA10 gene expression. The Gc2 phenotype of vitamin D binding protein is prevalent in women with endometriosis and may be implicated in its pathogenesis. In a mouse model, Elocalcitol, a VDR-agonist was shown to reduce the development of endometriotic lesions and recurrence.

CONCLUSION

A biological plausibility for a role of vitamin D, as an immunomodulator and anti-inflammatory agent, in the pathogenesis and treatment of endometriosis is suggested in this article, but is difficult to illustrate due to sparse evidence from human studies limited primarily to case-control studies. A significant knowledge gap precludes the establishment of a clear cause-effect relationship. The intriguing leads presented herein need to be investigated further with placebo-controlled supplementation trials.

Vaginoscopic resection of vaginal septum

We report the resection of a vaginal septum while preserving the virginity of a 12-year-old girl with Herlyn-Werner-Wunderlich Syndrome (HWWS) having a didelphys uterus, obstructed hemivagina, and an ipsilateral renal agenesis with follow-up at 18 months. Successful resection of the vaginal septum with conservation of the hymenal ring and complete drainage of both the hematocolpos and the hematometra were achieved. Cyclic dysmenorrhea and pelvic pain were completely resolved on follow-up visits at 4, 6, and 18 months. Office hysteroscopy performed during the last follow-up visit revealed a patent vaginal vault without evidence of adenosis or recurrence of the vaginal septum. Vaginoscopy is a safe, convenient, and efficient diagnostic and therapeutic modality that can be used in the management of patients with an obstructed hemivagina. It maintains the patient's virginity and it is useful in patients with a restrictive vaginal opening or narrow vaginal canal. Furthermore, the hysteroscopic excision of the vaginal septum offers minimal risk of recurrence of the septal defect.

Pregnancy in a woman with homozygous familial hypercholesterolemia not on low-density lipoprotein apheresis

Pregnancy in women with homozygous familial hypercholesterolemia (FH) has been rarely reported and might pose risks on the mother and her fetus. Although most reported cases remained on low-density lipoprotein (LDL) apheresis, there are no clear guidelines regarding the management of this entity. We report the first case of an uncomplicated pregnancy in a 24-year-old homozygous FH woman who was not maintained on LDL apheresis. FH expresses a wide variability in the phenotype, and management of homozygous FH cases who desire to become pregnant should be individualized based on preconceptional assessment with frequent antenatal follow-up. Decisions on management should be made after weighing the risks versus benefits of LDL apheresis.

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.

Progestogens to prevent preterm birth in twin pregnancies: an individual participant data meta-analysis of randomized trials

Background

Preterm birth is the principal factor contributing to adverse outcomes in multiple pregnancies. Randomized controlled trials of progestogens to prevent preterm birth in twin pregnancies have shown no clear benefits. However, individual studies have not had sufficient power to evaluate potential benefits in women at particular high risk of early delivery (for example, women with a previous preterm birth or short cervix) or to determine adverse effects for rare outcomes such as intrauterine death.

Methods/design

We propose an individual participant data meta-analysis of high quality randomized, double-blind, placebo-controlled trials of progestogen treatment in women with a twin pregnancy. The primary outcome will be adverse perinatal outcome (a composite measure of perinatal mortality and significant neonatal morbidity). Missing data will be imputed within each original study, before data of the individual studies are pooled. The effects of 17-hydroxyprogesterone caproate or vaginal progesterone treatment in women with twin pregnancies will be estimated by means of a random effects log-binomial model. Analyses will be adjusted for variables used in stratified randomization as appropriate. Pre-specified subgroup analysis will be performed to explore the effect of progestogen treatment in high-risk groups.

Discussion

Combining individual patient data from different randomized trials has potential to provide valuable, clinically useful information regarding the benefits and potential harms of progestogens in women with twin pregnancy overall and in relevant subgroups.

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.