Wafaa Ramadan

Fetal intracranial hemorrhage: sonographic criteria and merits of prenatal diagnosis

Abstract Purpose: To determine the sonographic criteria for diagnosis of fetal intracranial hemorrhage (ICH), using both gray scale ultrasound, and tomographic ultrasound imaging (TUI). Materials and methods: A prospective multicenter study, recruiting patients at risk of fetal ICH over four years. All cases with fetal ICH had serial ultrasound assessments, including TUI, fetal and postnatal MRIs. Results: Twenty-one patients were diagnosed with fetal ICH, two cases had extracerebral (subdural) hemorrhage, 16 cases had intracerebral (intraventricular) hemorrhage and three cases had combined hemorrhage. The mean gestational age at which they were diagnosed was 29.8 ± 5.2 weeks. Seventy-six percent of cases had no identifiable risk factors. IUGR was associated with 57.9% of cases. Using grey scale ultrasound, we demonstrated clear cut sonographic criteria for diagnosis of fetal ICH. TUI enabled us to detect some midline cerebral lesions not detected by grey scale 2D ultrasound alone. Fetal and postnatal MRI confirmed those findings. Conclusion: Ultrasonography can be used in the detection, classification and monitoring the progression of various types of ICH. TUI is an additional diagnostic tool that might help to detect the exact size, and extent of those lesions. Fetal MRI is not superior, but might aid in the diagnosis.

Manual removal versus spontaneous delivery of the placenta at cesarean section in developing countries: a randomized controlled trial and review of literature

Abstract Purpose: Cesarean section (CS) rates have increased; this is especially concerning in developing countries. The mode of placental delivery contributes to morbidity associated with CS and determines blood loss during CS. We aimed to compare manual removal versus spontaneous delivery of the placenta at CS. Methods: In a randomized controlled trial, 574 women admitted for primary or repeat elective CS were randomized into two groups. In group A, the placenta was manually removed, whereas in group B, the placenta was left for spontaneous delivery. Blood loss, operative and postoperative data were recorded. Results: Blood loss was 875.2 ± 524.2 ml in group A versus 731.8 ± 426.7 ml in group B (p = .001), with a significant drop in postoperative HB (p = .015) and HCT (p = .031). In group A, odds ratios for blood loss (>1000 ml), HB drop (> 4g/dl), postpartum hemorrhage and blood transfusion were 2.581, 2.850, 2.614 and 1.665, respectively. However, the total operative time (p = .326), duration of hospital stay (p = .916) and intensive care unit (ICU) admission (p = .453) were not statistically different between the two groups. Conclusions: Manual removal of the placenta at CS is associated with a higher risk of blood loss, postpartum hemorrhage and blood transfusion, with no decrease in operative time.

Amino acid chelated iron versus an iron salt in the treatment of iron deficiency anemia with pregnancy: A randomized controlled study

OBJECTIVE The aim of this study was to compare the efficacy and tolerability of iron amino acid chelate (IAAC) and ferrous fumarate (FF) in treatment of iron deficiency anemia (IDA) with pregnancy. STUDY DESIGN A total of 150 pregnant women having iron deficiency anemia (IDA) were randomized to receive either IAAC or FF for 12 weeks. Hemoglobin, red cell indices, serum iron, and serum ferritin were measured at baseline and then 4, 8, and 12 weeks after treatment. Adverse effects were questioned in both groups. RESULTS The mean values of hemoglobin, red cell indices, serum iron, and serum ferritin were not significantly different between both groups after 12 weeks of treatment. However, the rise in hemoglobin level after 4, 8, and 12 weeks of treatment was significantly faster in the IAAC group (p=<0.001). Constipation and abdominal colicky pain were significantly more common in the FF group (p=0.022 and 0.031 respectively). CONCLUSION IAAC and FF are comparable in curing IDA with pregnancy; however, IAAC has the advantage of providing a faster rate of improvement of hemoglobin level and is better tolerated by the patients.

Effect of hydrosalpinx on uterine and ovarian hemodynamics in women with tubal factor infertility

OBJECTIVE To evaluate the effect of hydrosalpinx on uterine and ovarian blood flows in women with tubal factor infertility. STUDY DESIGN In a cross-sectional study at a university teaching hospital, 60 women with hydrosalpinx-related tubal infertility (hydrosalpinx group) were compared with 60 women with male or unexplained infertility (non-hydrosalpinx group). In the mid-luteal (peri-implantation) phase of the cycle, endometrial thickness, uterine and ovarian artery pulsatility index (PI) and resistance index (RI), and endometrial and ovarian volume and 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured in both groups. RESULTS The endometrial VI (p=0.002), FI (p=0.041), and VFI (p=0.018), and ovarian VI (p=0.011), and VFI (p=0.015) were significantly lower in the hydrosalpinx group than in the non-hydrosalpinx group. However, the endometrial thickness, uterine artery PI and RI, ovarian artery PI and RI, endometrial volume, and ovarian volume and FI were not significantly different between the two groups. CONCLUSION Hydrosalpinx is associated with impaired endometrial and ovarian blood flows which may adversely affect endometrial receptivity and oocyte quality.

Can AMH levels predict the need for increased medication during IVF/ICSI in PCOS women?

Abstract Purpose: To investigate the ability of anti-Mullerian hormone (AMH) to predict the step up of human menopausal gonadotropins (HMG) dose in women with polycystic ovarian syndrome (PCOS) undergoing IVF/ICSI cycles. Methods: AMH was drawn before ovulation induction in 976 PCOS women scheduled for IVF/ICSI. After all cycles ended, a receiver operating characteristic (ROC) curve analysis was done to investigate the ability of AMH to predict step up of the HMG. Results: The area under the curve (AUC) was 0.820 95%CI (0.792–0.848), and a cutoff value of 4.6 ng/ml (sensitivity 74%, specificity 82%) for AMH was taken (p < 0.01). Cases were divided into two groups retrospectively; group (A) (AMH ≤4.6 ng/ml), and group (B) (AMH >4.6 ng/ml). No difference in the mean age (p = 0.147); BMI (p = 0.411), basal FSH (p = 0.221), and starting dose (p = 0.195); however, the dose at which the first response occurred was higher in group (B) (p < 0.01). The total dose and number of days were higher in group (B) (both p < 0.01) irrespective of the PCOS subtype or androgen levels. Severe OHSS was also higher in group (B) (p = 0.026). Conclusions: PCOS with AMH >4.6 ng/ml are resistant to HMG stimulation, require dose step up during ART cycles, and are at higher risk for severe OHSS.

Periconceptional risk factors of spina bifida among Egyptian population: a case-control study.

Abstract Objective: To study the preconceptual & early conceptional risk factors predisposing to the development of spina bifida (SB) among Egyptian population. Study design: The study involved 197 pregnant women undergoing fetal anatomy scan; 97 women proved to have fetal SB and 100 women with normal fetuses as a control group. The control group was recruited randomly in the same period from patients undergoing anatomical scan. Risk factors that might lead to SB were investigated including maternal age, gravidity, parity, residence, history of diabetes mellitus or drug intake, smoking, infections, exposure to X-ray, history of congenital anomalies in other offspring, parental consanguinity, positive family history, and folate supplementations. Results: SB affected the lumbo-sacral region in the majority of cases (89.7%). It was associated with hydrocephalus in 66 cases (68%), polyhydramnios in 12 cases (12.4%). The SB group showed significantly higher parity (p = 0.005), more frequent history of drug intake (p < 0.001), higher frequency of infection with CMV (p = 0.004), and HSV (p = 0.013) and less proportion of folate supplementation (p < 0.001). Conclusion: The rate of SB in the tested group was five per 1000. Risk factors were lack of folate supplementation and history of antiepileptic drugs intake.

Effect of clomiphene citrate on uterine hemodynamics in women with unexplained infertility

Purpose The aim of the study was to evaluate the effect of clomiphene citrate on uterine artery blood flow using pulsed Doppler and endometrial and subendometrial micro vascularization using 3D power Doppler in unexplained infertility. Patients and methods In a prospective observational study at a university teaching hospital, the mid-luteal (peri-implantation) endometrial thickness and volume, uterine artery pulsatility index (PI) and resistance index (RI), endometrial and subendometrial vascularization index (VI), flow index (FI), and vascularization flow index (VFI), and serum estradiol and progesterone levels were compared between natural and clomiphene citrate stimulated cycles in the same group of 50 patients with unexplained infertility. Statistical analysis was done using paired t-test to compare different study variables. Results The primary outcome, which was the endometrial flow index, was significantly lower in the stimulated cycles (mean ± SD: 23.89±7.96 vs 27.49±8.73, mean difference (95% CI): −3.6 (−2, −5.9); P=0.03). The mean ± SD of endometrial thickness (10.92±3.04 vs 12.46±3.08 mm; P=0.01), volume (4.57±1.28 vs 5.26±1.32 cm3; P=0.009), endometrial VI (0.86±0.15 vs 0.95%±0.21%; P=0.02), VFI (0.25±0.08 vs 0.31±0.12; P=0.004), subendometrial VI (1.93±0.68 vs 2.26%±0.75%; P=0.02), FI (26.81±9.16 vs 30.73±9.87; P=0.04), and VFI (0.68±0.18 vs 0.79±0.21; P=0.006) were significantly lower in the stimulated cycles. However, there were no significant differences in the uterine artery PI (P=0.12) and RI (P=0.08) or serum estradiol (P=0.54) and progesterone (P=0.37) levels between natural and stimulated cycles. Conclusion Peri-implantation endometrial perfusion is significantly lower in clomiphene citrate stimulated cycles when compared to natural ones in patients with unexplained infertility.

Outcome of pregnancy after renal transplantation

Aim The aim of our study was to compare the outcome of pregnancy in patients who became pregnant within 24 months of renal transplantation and patients who became pregnant more than 24 months after renal transplantation. Materials and methods The sample population of our prospective cohort study comprised of 44 patients who became pregnant following renal transplantation. In all cases, living donors were used for renal transplantation. The patients were allocated into either group A, which included 24 patients who became pregnant more than 24 months after renal transplantation, or group B, which included 20 patients who inadvertently became pregnant within 24 months of renal transplantation. Serum creatinine and 24-hour urinary protein concentration were measured each trimester. The incidences of preeclampsia and gestational diabetes, the timing and mode of delivery, the rate of preterm labor, and the mean fetal birth weight were determined. Results The mean gestational ages in groups A and B were 35.8±3 weeks and 34.1±2.5 weeks, respectively. The mean fetal birth weights in groups A and B were 2,480±316 g and 2,284.5±262 g, respectively. These differences were statistically significant. The incidence of preterm labor was 45.8% in group A and 55% in group B. Proteinuria was significantly higher in group B during the third trimester of pregnancy. Preeclampsia occurred in 25% of the cases in group A and 30% of the cases in group B; this difference was not statistically significant. Gestational diabetes occurred in 2 out of 24 cases in group A and 2 out of 20 cases in group B. For group A and group B, normal vaginal delivery occurred in 58.3% and 55% of cases, respectively, and cesarean section was performed in 41.6% and 45% of cases, respectively. Conclusion A longer interval between renal transplantation and pregnancy is associated with better pregnancy outcome.

Randomized controlled trial of the effect of endometrial injury on implantation and clinical pregnancy rates during the first ICSI cycle

To assess whether endometrial injury in the cycle preceding controlled ovarian hyperstimulation during intracytoplasmic sperm injection (ICSI) improves the implantation and pregnancy rates.

Effect of ovarian endometrioma on uterine and ovarian blood flow in infertile women

Background Angiogenesis has been found to be among the most important factors in the pathogenesis of endometriosis. The formation of new blood vessels is critical for the survival of newly implanted endometriotic foci. The use of 3-D power Doppler allows for the demonstration of the dynamic vascular changes that occur during the process of in vitro fertilization (IVF). We aimed to evaluate the effect of ovarian endometrioma on uterine and ovarian blood flow in infertile women. Materials and methods In a case–control study at a university teaching hospital, 138 women with unilateral ovarian endometrioma scheduled for IVF were compared to 138 women with male-factor or unexplained infertility. In the mid-luteal (peri-implantation) phase of the cycle, endometrial thickness, uterine and ovarian artery pulsatility index and resistance index, endometrial and ovarian volume, 3-D power Doppler vascularization index (VI), flow index (FI), and vascularization FI (VFI) values were measured in both groups. Results There were no significant differences (P>0.05) in endometrial thickness, uterine ovarian artery pulsatility index and resistance index, endometrial and ovarian volume, or VI, FI, and VFI between the two groups. Furthermore, the endometrial and ovarian Doppler indices were not influenced by endometrioma size. No significant differences were observed in the ovarian Doppler indices between endometrioma-containing ovaries and contralateral ovaries. Conclusion Ovarian endometrioma is not associated with impaired endometrial and ovarian blood flows in infertile women scheduled for IVF, and it is not likely to affect endometrial receptivity or ovarian function through a vascular mechanism.