A.M. Abdelmagied

Effectiveness of vesicoamniotic shunt in fetuses with congenital lower urinary tract obstruction: an updated systematic review and meta-analysis

To evaluate the effect on perinatal and postnatal survival of vesicoamniotic shunt (VAS) as treatment for fetal lower urinary tract obstruction (LUTO).

Fetal cerebro-placental ratio and adverse perinatal outcome: systematic review and meta-analysis of the association and diagnostic performance.

Abstract Objective: The objective of this meta-analysis is to assess the value of fetal cerebro-placental Doppler ratio (CPR) in predicting adverse perinatal outcome in pregnancies with fetal growth restriction (FGR). Methods: Three databases were used: MEDLINE, EMBASE (with online Ovid interface) and SCOPUS and studies from inception to April 2015 were included. Studies that reported perinatal outcomes of fetuses at risk of FGR or sonographically diagnosed FGR that were evaluated with CPR were considered eligible. Perinatal outcomes include cesarean section (CS) for fetal distress, APGAR scores at 5 min, neonatal complications and admission to neonatal intensive care unit (NICU). Pooled data were expressed as odds ratio (OR) and confidence intervals (CI), and the summary receiver operating characteristic (SROC) curve was used to illustrate the diagnostic accuracy of CPR. Results: Seven studies were eligible (1428 fetuses). Fetuses with abnormal CPR were at higher risk of CS for fetal distress (OR=4.49, 95% CI [1.63, 12.42]), lower APGAR scores (OR=4.01, 95% CI [2.65, 6.08]), admission to NICU (OR=9.65, 95% CI [3.02, 30.85]), and neonatal complications (OR=11.00, 95% [3.64, 15.37]) than fetuses who had normal CPR. These risks were higher among studies that included fetuses diagnosed with FGR than fetuses at risk of FGR. Abnormal CPR had higher diagnostic accuracy for adverse perinatal outcomes among “sonographically diagnosed FGR” studies than “at risk of FGR” studies. Conclusion: Abnormal CPR is associated with substantial risk of adverse perinatal outcomes. The test seems to be particularly useful for follow up of fetuses with sonographically diagnosed FGR.

Periprocedural Outcomes Comparing Fibroid Embolization and Focused Ultrasound: a Randomized Controlled Trial and Comprehensive Cohort Analysis.

BACKGROUND: Uterine fibroids are a common problem for reproductive‐aged women, yet little comparative effectiveness research is available to guide treatment choice. Uterine artery embolization and magnetic resonance imaging–guided focused ultrasound surgery are minimally invasive therapies approved by the US Food and Drug Administration for treating symptomatic uterine fibroids. The Fibroid Interventions: Reducing Symptoms Today and Tomorrow study is the first randomized controlled trial to compare these 2 fibroid treatments. OBJECTIVE: The objective of the study was to summarize treatment parameters and compare recovery trajectory and adverse events in the first 6 weeks after treatment. STUDY DESIGN: Premenopausal women with symptomatic uterine fibroids seen at 3 US academic medical centers were enrolled in the randomized controlled trial (n = 57). Women meeting identical criteria who declined randomization but agreed to study participation were enrolled in a nonrandomized parallel cohort (n = 34). The 2 treatment groups were analyzed by using a comprehensive cohort design. All women undergoing focused ultrasound and uterine artery embolization received the same postprocedure prescriptions, instructions, and symptom diaries for comparison of recovery in the first 6 weeks. Return to work and normal activities, medication use, symptoms, and adverse events were captured with postprocedure diaries. Data were analyzed using the Wilcoxon rank sum test or χ2 test. Multivariable regression was used to adjust for baseline pain levels and fibroid load when comparing opioid medication, adverse events, and recovery time between treatment groups because these factors varied at baseline between groups and could affect outcomes. Adverse events were also collected. RESULTS: Of 83 women in the comprehensive cohort design who underwent treatment, 75 completed postprocedure diaries. Focused ultrasound surgery was a longer procedure than embolization (mean [SD], 405 [146] vs 139 [44] min; P <.001). Of women undergoing focused ultrasound (n = 43), 23 (53%) underwent 2 treatment days. Immediate self‐rated postprocedure pain was higher after uterine artery embolization than focused ultrasound (median [interquartile range], 5 [1–7] vs 1 [1–4]; P = .002). Compared with those having focused ultrasound (n = 39), women undergoing embolization (n = 36) were more likely to use outpatient opioid (75% vs 21%; P < .001) and nonsteroidal antiinflammatory medications (97% vs 67%; P < .001) and to have a longer median (interquartile range) recovery time (days off work, 8 [6–14] vs 4 [2–7]; P < .001; days until return to normal, 15 [10–29] vs 10 [10–15]; P = .02). There were no significant differences in the incidence or severity of adverse events between treatment arms; 86% of adverse events (42 of 49) required only observation or nominal treatment, and no events caused permanent sequelae or death. After adjustment for baseline pain and uterine fibroid load, uterine artery embolization was still significantly associated with higher opioid use and longer time to return to work and normal activities (P < .001 for each). Results were similar when restricted to the randomized controlled trial. CONCLUSION: Women undergoing uterine artery embolization have longer recovery times and use more prescription medications, but women undergoing focused ultrasound have longer treatment times. These findings were independent of baseline pain levels and fibroid load.

A randomized clinical trial of the efficacy of single versus double-daily dose of oral iron for prevention of iron deficiency anemia in women with twin gestations

Abstract Objective: The study aims to assess the efficacy of single versus double-daily oral iron dose on prevention of iron deficiency anemia in women with twin gestations. Materials and methods: A randomized controlled trial (NCT02858505) conducted at Womans Health Hospital, Assiut, Egypt, between August 2015 and June 2016 included 120 non-anemic pregnant women with twin gestations in the first trimester. Women were randomly assigned to either group I (27 mg elemental iron) or group II (54 mg elemental iron) daily starting from 12 weeks of pregnancy till 36 weeks. The primary outcomes included the mean level of hemoglobin, hematocrit and serum ferritin at 36 weeks’ gestation. Results: Both iron doses maintained the mean hemoglobin and hematocrit within the normal level from 12 weeks to 36 weeks (p = 0.378 and p = 0.244, respectively). However, the mean serum ferritin level was higher in group II than group I (p = 0.000) at 36 weeks’ gestation. Moreover, women in group II reported more side effects than group I at 36 weeks’ gestation. Conclusions: Doubling the prophylactic iron dose is comparable to single dose in the prevention of iron deficiency anemia among women with twin gestations with more side effects.

FIRSTT Study: Randomized Controlled Trial of Uterine Artery Embolization Versus Focused Ultrasound

Background: Uterine leiomyomas (fibroid tumors) cause considerable symptoms in 30–50% of women and are the leading cause of hysterectomy in the United States. Women with uterine fibroid tumors often seek uterine‐preserving treatments, but comparative effectiveness trials are lacking. Objective: The purpose of this study was to report treatment effectiveness and ovarian function after uterine artery embolization vs magnetic resonance imaging‐guided focused ultrasound surgery from the Fibroid Interventions: Reducing Symptoms Today and Tomorrow study. Study Design: The Fibroid Interventions: Reducing Symptoms Today and Tomorrow study, which is a randomized controlled trial of uterine artery embolization vs magnetic resonance imaging‐guided focused ultrasound surgery, enrolled premenopausal women with symptomatic uterine fibroid tumors; women who declined randomization were enrolled in a parallel observational cohort. A comprehensive cohort design was used for outcomes analysis. Our target enrollment was 220 women, of which we achieved 41% (n=91) in the randomized and parallel arms of the trial. Primary outcome was reintervention for uterine fibroid tumors within 36 months. Secondary outcomes were change in serum anti‐Müllerian hormone levels and standardized measures of fibroid symptoms, quality of life, pain, and sexual function. Results: From 2010–2014, 83 women (mean age, 44.4 years) were treated in the comprehensive cohort design (43 for magnetic resonance imaging‐guided focused ultrasound surgery [27 randomized]; 40 for uterine artery embolization [22 randomized]); baseline clinical and uterine characteristics were similar between treatment arms, except for higher fibroid load in the uterine artery embolization arm. The risk of reintervention was higher with magnetic resonance imaging‐guided focused ultrasound surgery than uterine artery embolization (hazard ratio, 2.81; 95% confidence interval, 1.01–7.79). Uterine artery embolization showed a significantly greater absolute decrease in anti‐Müllerian hormone levels at 24 months compared with magnetic resonance imaging‐guided focused ultrasound surgery. Quality of life and pain scores improved in both arms but to a greater extent in the uterine artery embolization arm. Higher pretreatment anti‐Müllerian hormone level and younger age at treatment increased the overall risk of reintervention. Conclusion: Our study demonstrates a lower reintervention rate and greater improvement in symptoms after uterine artery embolization, although some of the effectiveness may come through impairment of ovarian reserve. Both pretreatment anti‐Müllerian hormone level and age are associated with risk of reintervention. Clinical Trial Registration Number: NCT00995878, clinicaltrials.gov

Periprocedural Outcomes Comparing Fibroid Embolization and Focused Ultrasound: A Randomized Controlled Trial and Comprehensive Cohort Analysis

(Abstracted from Am J Obstet Gynecol 2017;216:500.e1–500.e11) Although uterine fibroids are a common problem among reproductive-aged women, few comparative effectiveness studies are available to guide treatment decisions. Two minimally invasive treatments—uterine artery embolization (UAE) and magnetic resonance imaging–guided focused ultrasound surgery (MRgFUS)—have been approved by the US Food and Drug Administration for treatment of symptomatic uterine fibroids.

Reply to: Fetal cerebroplacental ratio and adverse perinatal outcome

*Corresponding author: Ahmed A. Nassr, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA; and Women’s Health Hospital, Assiut University Hospitals, Assiut, Egypt, Tel.: +1 507 319 2332, E-mail: Nassr.Ahmed@mayo.edu; ahmedabobakr@aun.edu.eg Ahmed M. Abdelmagied and Sherif A.M. Shazly: Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA; and Women’s Health Hospital, Assiut University Hospitals, Assiut, Egypt Letter to the Editor – Reply

Prevalence of prior reproductive surgery among women scheduled for IVF

OBJECTIVE: Optimization of the function and anatomy of reproductive organs either by medications or surgery is the main target of many clinicians prior to IVF in order to get favorable cycle outcomes. Our objective was to evaluate the prevalence of reproductive surgery in women scheduled for IVF, and to correlate the baseline characteristics of these women to the probability of undergoing a reproductive surgery. DESIGN: Prospective cross-sectional cohort. MATERIALS AND METHODS: Through one-year cross sectional survey, infertile women scheduled for IVF were categorized into 3 groups based on their history of prior reproductive surgery. Group 1 comprised women who did not undergo any reproductive surgery before; group 2 included women with history of one reproductive surgery; while group 3 included subjects with history of 2 or more surgeries. The 3 groups were compared as regards their baseline demographic and clinical characteristics. Statistical methods used for comparisons included t-test, Chi-square test, Wilcoxon rank sum test and logistic regression. RESULTS: 244 women accepted to participate in the study; 76% of them (n1⁄4185) reported prior reproductive surgery.Women in group 3 (n1⁄459) were more likely to have a longer duration of infertility (Mean SD; 5.8 3 vs. 5.2 3.2 vs. 4.5 3; p1⁄40.009), and comprised more women with endometriosis (50.8% vs. 21.45% vs. 1%; p1⁄40.000) and tubal block (22% vs. 11.1% vs. 3.4%; p1⁄40.000), when compared to groups 2 and 1 respectively. The total number of surgical procedures in the whole cohort was 238 surgical procedures. Out of them; 29.4%, 18.9%, and 16.4% were procedures for endometriosis, uterine procedures, and diagnostic laparoscopies, respectively. In stepwise multivariate regression analysis, after adjustment of other variables; longer duration of infertility (aOR 1⁄4 1.2, 95% CI1⁄41.04-1.3, P1⁄40.007), having moderate endometriosis (aOR1⁄4 12.1, 95% CI1⁄45.6-26.4, P1⁄40.000), and having tubal disease (aOR 1⁄4 6.7, 95% CI1⁄42.7-16.6, P1⁄40.000) were significantly associated with likelihood of an IVF woman to have 2 surgical reproductive procedures through her infertility treatment. CONCLUSIONS: Reproductive surgeries are common among IVF women presenting a sort of financial burden. Women with endometriosis have substantial probability of undergoing a high order reproductive surgery.