Diaa Eldeen M. Abd El Aal

Uterine artery Doppler blood flow in cases of hydatidiform mole and its correlation with β-hCG

OBJECTIVES To study the correlation between Doppler blood flow and beta-human chorionic gonadotropin (hCG), to assess the course of the disease and the follow up evaluation. SETTING This study was conducted in Assiut University Hospital, Department of Obstetrics and Gynecology. DESIGN Longitudinal study. SUBJECTS AND METHODS Fifteen cases of vesicular mole were recruited and followed up. The patients were evaluated the day before evacuation of the uterus. This included clinical assessment, Doppler uterine artery blood flow velocity waveforms using the Doppler indices and assessment of the serum level of beta-hCG. These cases were followed up every 2 weeks in the first 2 months, and every month thereafter until the 6 month. RESULTS Twelve patients showed continuous decrease in beta-hCG level from 1192+/-697 to 6+/-11 IU/ml by the end of the second month. Systolic-diastolic (S/D) increased from (2.57+/-1.13) to (15.9+/-2.07) (P<0.0001), RI increased from 0.55+/-0.15 to 1.0+/-0.26(P<0.0001) and PI increased from 1.02+/-0.47 to 6.12+/-2.34 (P<0.0001). One patient showed a fluctuating level of beta-hCG around the same level, and two showed a slowed decrease. Doppler indices showed similar results. There is a strong correlation between beta-hCG and all Doppler indices throughout the course of follow up: beta-hCG and S/D r<0.01, beta-hCG and RI r<0.01 and beta-hCG and PI r<0.01. CONCLUSION Doppler ultrasound can be used as an adjuvant tool in the follow up of cases of vesicular mole and can predict the progress in the course of the disease.

Levonorgestrel-releasing intrauterine system versus a low-dose combined oral contraceptive for treatment of adenomyotic uteri: a randomized clinical trial

INTRODUCTION This study compares the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) and a low-dose combined oral contraceptive (COC) in reducing adenomyosis-related pain and bleeding. MATERIALS AND METHODS A randomized clinical trial included 62 participants complaining of pain and bleeding that was associated with adenomyosis. Participants were randomly assigned to either LNG-IUS or COC treatment. The outcomes included the improvement of pain using a visual analogue scale, menstrual blood loss using a menstrual diary and estimated uterine volume by ultrasound for 6 months of treatment. We also compared uterine arteries and intramyometrial Doppler indices before and 6 months after treatment with both LNG-IUS and COCs. RESULTS Both treatments significantly reduced pain after 6 months of use; however, the reduction was greater in the LNG-IUS group (from 6.23±0.67 to 1.68±1.25) compared with the COCs group (from 6.55±0.68 to 3.90±0.54). Both treatment arms significantly decreased the number of bleeding days, uterine volume and Doppler blood flow in the uterus from before to after treatment. These effects were more significant in the LNG-IUS arm compared with the COC arm. CONCLUSION Both LNG-IUS and COCs decreased the pain and menstrual bleeding that is associated with adenomyosis. However, LNG-IUS is more effective than the COCs in reducing pain and menstrual blood loss. This effect may be secondary to the decrease in uterine volume and the increase in blood flow resistance.

Management of eclampsia at Assiut University Hospital, Egypt

To evaluate the protocol used for management of eclampsia at Assiut University Hospital, Assiut, Egypt.

Evaluation of the effectiveness of low-dose aspirin and omega 3 in treatment of asymmetrically intrauterine growth restriction: A randomized clinical trial

OBJECTIVE To test the effect of aspirin and omega 3 on fetal weight as well as feto-maternal blood flow in asymmetrical intrauterine growth restriction (IUGR). STUDY DESIGN This study is a clinically registered (NCT02696577), open, parallel, randomized controlled trial, conducted at Assiut Womans Health Hospital, Egypt including 80 pregnant women (28-30 weeks) with IUGR. They were randomized either to group I: aspirin or group II: aspirin plus omega 3. The primary outcome was the fetal weight after 6 weeks of treatment. Secondary outcomes included Doppler blood flow changes in both uterine and umbilical arteries, birth weight, time and method of delivery and admission to NICU. The outcome variables were analyzed using paired and unpaired t-test. RESULTS The estimated fetal weight increased significant in group II more than group I (p=0.00). The uterine and umbilical arteries blood flow increased significantly in group II (p<0.05). The birth weight in group II was higher than that observed in group I (p<0.05). CONCLUSION The using of aspirin with omega 3 is more effective than using aspirin only in increasing fetal weight and improving utero-placental blood flow in IUGR.

Reply to: Misoprostol during cesarean delivery: At which time and by which route?

We appreciate the interest shown by Dr. Shehata in our recently published paper [1]. We would like to thank him for his valuable comments that add much more to our own published findings. Regarding the cost of misoprostol, we disagree with the author that misoprostol is costly than oxytocin wherever in Egypt or worldwide. A recent study demonstrated that the mean cost of misoprostol was significantly lower than the oxytocin (2.0 ± 0.8 vs. 5.1 ± 0.9 US dollars; P < 0.00001) [2]. Additionally, Vlassoff et al., 2016 in reported that misoprostol was more cost effective than oxytocin when given prophylactically after vaginal delivery in low-resource setting; Senegal similar to Egypt [3]. Shehata states that misoprostol costs one Dollar while one oxytocin ampoule costs 0.25 Dollar, although he provides no citations to prove this. Shehata states that the large systematic review by CondeAgudelo et al. [2] reported no statistically significant differences between misoprostol and oxytocin in reducing intraoperative and postoperative bleeding at cesarean delivery. We agree with him, but the review included four clinical trials; one of them showed a significant reduction in the mean postoperative blood loss with sublingual misoprostol (MD 1⁄4 23 ml; P < 0.00001) [4]. In the other 3 studies, there was a lower mean intraoperative blood loss with sublingual misoprostol (MD 1⁄4 55 ml) although it was not statistically significant; P 1⁄4 0.07. This coincides with our study results; however we reported a statistically significant lower blood loss with misoprostol (MD 1⁄4 111 ml, P 1⁄4 0.025) [1]. On the other hand, the mentioned meta-analysis byMousa et al. [5] was evaluating the role of misoprostol in treatment of primary postpartum hemorrhage (PPH), unlike our study which evaluated its prophylactic role in PPH. Finally, Conde-Agudelo et al. [2] reported in their systematic review that equivalence or non-inferiority randomized controlled trials with sufficient statistical power are still needed to compare the

Effects of oral ginkgo biloba extract on pregnancy complicated by asymmetrically intrauterine growth restriction: a double-blinded randomized placebo-controlled trial

Objectives: to evaluate the effect of oral ginkgo biloba extract (GB)) on asymmetrical intrauterine growth restriction (IUGR). Study Design: A randomized trial conducted at Assiut Women Health on 226 pregnant women with asymmetrical IUGR. The patients randomly received GB extract or placebo for 6 weeks. The main outcome measures were improvement in fetal weight and feto-maternal blood flow. The data were analyzed by Student’s ttest and chi-

Color Doppler ultrasound to improve the diagnostic accuracy of the transvaginal ultrasound in the diagnosis of adenomyosis: a cross-sectional study

Objectives To measure the accuracy of combined two-dimensional (2D) transvaginal ultrasound (TVS) and color Doppler in the diagnosis of adenomyosis and to assess the role of Doppler indices of the uterine artery and the intramyometrial blood vessels in the diagnosis of adenomyosis. Study design This was a cross-sectional observational study. Setting This study was carried out at the Women Health Hospital, Faculty of Medicine, Assiut University. Patients and methods One hundred women complaining of pelvic pain and/or uterine bleeding, clinically and sonographically diagnosed with adenomyosis, and scheduled for hysterectomy were approached for participation. Eighty patients were recruited and subjected to color Doppler examination in a trial to obtain a more accurate diagnosis of adenomyosis. In addition, uterine artery and intramyometrial Doppler studies (systolic/diastolic ratio, resistance, and pulsatility index) were measured before the scheduled hysterectomy to detect its role in diagnosis. The findings of 2D-TVS and color Doppler were compared with a gold standard of histopathology of the uterine specimens retrieved. Sensitivity, specificity, positive and negative predictive values, and overall accuracy were measured. Results Fifty specimens out of 80 uteri were histologically confirmed to have adenomyosis by histopathology. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the 2D-TVS in the diagnosis of adenomyosis were 76.0, 83.3, 88.4, 67.6, and 78.8%, respectively. However, for combined 2D-TVS and the color Doppler ultrasound, the values were 86.0, 86.67, 91.5, 78.8, and 86.3%, respectively. Myometrial cysts were the most commonly diagnosed (53.8%) ultrasonographic criteria. Neither uterine artery nor intramyometrial vessels systolic/diastolic ratio, resistance index, and pulsatility index showed a significant association with adenomyosis. Conclusion Combined 2D-TVS and color Doppler ultrasound is superior to 2D-TVS alone in the diagnosis of adenomyosis. Uterine artery and intramyometrial Doppler studies were of no diagnostic value in adenomyosis.

The unexpected presence of a huge cystic hygroma with thanatophoric dysplasia type I: a case report

Introduction: The presence of a thin-walled, multicystic structure posterior to the fetal head and neck with an intact vertebral column is known as a cystic hygroma. Thanatophoric dysplasia is the most lethal skeletal dysplasia. Thanatophoric dysplasia (TD) is an autosomal dominant disorder with two phenotypes. TD type I is characterized by a normal shaped skull with bowed femurs and micromelia, while TD type II is characterized by straight femurs with a cloverleaf deformity of the skull and micromelia. We report here a case of thanatophoric dysplasia type I associated with cystic hygroma, this association needs further evaluation. Case history: A 30 year old woman was referred at 26 weeks of gestation because of marked polyhydramnios. Ultrasonographic examination of the fetus revealed a narrow chest, protuberant abdomen, short curved femur, normal shaped skull with accidentally cystic hygroma were present. No other anomalies were detected. We explained to the patient the nature and severity of the anomaly and the patient preferred the termination of pregnancy. Induction of abortion was done successfully. Conclusion: This case report has highlighted the association between cystic hygroma and thanatophoric dysplasia type I. To our knowledge, this is the first report in the literature reporting the association of cystic hygroma and thanatophoric dysplasia type I. We believe that this case is useful for obstetricians and pediatricians. We also highly recommend the genetic evaluation of the fetus and parents. Women Health Hospital, Assiut, Egypt