Adjunctive sublingual misoprostol for secondary prevention of post-partum hemorrhage during cesarean delivery: double blind placebo randomized controlled trial

Background: Cesarean delivery is the most frequently performed major operative procedure worldwide. Objective of present study was to evaluate randomized evidence regarding efficacy and safety of sublingual misoprostol for secondary prevention of post-partum hemorrhage during and after cesarean delivery in women receiving prophylactic oxytocin as primary preventive tools and bleed around 500ml by visual analogue estimation.Methods: A prospective, randomized, double-blind, placebo-controlled trial was performed at an obstetrics and gynecology department Aswan university hospital, Egypt, between October 2015 and September 2017. Women were eligible if they were undergoing elective cesarean under spinal anesthesia and were bleed around 500ml by visual analogue estimation. All participants received 10 IU oxytocin after delivery of the newborn. Participants were randomly assigned (1:1) to receive 400 μg misoprostol or matched placebo sublingually using a computer-generated random number sequence. Participants and providers were masked to assignment. The primary outcomes were intraoperative and postoperative blood loss.Results: There was high significant reduction in intraoperative blood loss in misoprostol group (711.0±188.41) compared with placebo group (915.33±293.72) (P=0.0001). The all estimated blood loss during CS and 24 hours postoperative was significant lower in misoprostol group (890.39±194.49) than that in placebo group (1096.9±300.05) (p=0.0001).Conclusions: Misoprostol as an adjunct to oxytocin as secondary prevention of pot partum hemorrhage seemed to be more effectively reduce blood loss than did placebo with oxytocin alone

Intravenous Carbetocin to decrease blood loss during open myomectomy: a randomized placebo-controlled study

Background: Uterine leiomyomas are benign tumors of the uterus, which represent the most common neoplasms in women of reproductive age, and have a lifetime incidence of approximately 70% in the general population. The objective of this study was to assess the effect of using a single pre-operative dose of IV 100 μg Carbetocin on intra-operative blood loss in abdominal myomectomy surgeries.Methods: In a randomized double-blind placebo-controlled trial, 86 women undergoing abdominal myomectomy for symptomatic uterine leiomyomas were randomly assigned to receive a single dose of pre-operative of IV 100 μg Carbetocin (n = 43) or placebo (n = 43) just before the operation. The primary outcome was intra-operative blood loss.Results: Intra-operative blood loss was significantly lower in those women randomized to receive IV Carbetocin versus the placebo group (714.19±186.27 ml versus 1033.49±140.9 ml), p = 0.0001 The incidence of blood transfusion was increased in placebo group (69.8%) compared with (18.6%) in Carbetocin group, (P = 0.0001). Also, there was a significant reduction in operative time in Carbetocin group (66.35%±10.18) compared with placebo group (95.95±9.16), (P = 0.0001).Conclusions: A single pre-operative dose of IV Carbetocin (100 μg) is a simple applicable method for reducing intra-operative blood loss and operative time in abdominal myomectomy

Adjunctive IV tranexamic acid versus topical tranexamic acid application of the placental bed for prevention of postpartum hemorrhage in women with placenta previa: a randomized controlled trial

Background: Placenta previa one of the famous etiology of excessive blood loss during and after cesarean section. The objective of this study was to determine the effect of prophylactic adjunctive IV versus topical tranexamic acid (TA) on calculated and measured blood loss during and after caesarean section due to placenta previa compared with standard IV oxytocin alone.Methods: In this double-blind randomized controlled trial, 120 women were undergoing caesarean delivery for placenta previa (PP) were randomly allocated to receive 10 IU oxytocin IV after placental delivery, or receive 1 gm tranexamic acid IV just before skin incision plus 10 IU oxytocin IV after placental delivery or received 10 IU oxytocin IV after placental delivery plus 2 gm topical tranexamic acid applied on placental bed. The main outcome was to measure blood loss during and 4-hour post caesarean delivery.Results: 120 women were enrolled (n = 40 in each group). Both groups of women received IV tranexamic acid (Group II) and topical tranexamic acid (Group III) showed great reduction in intraoperative and 4 hours post-operative blood loss compared with (Group I) which received 10 IU oxytocin only (P = 0.0001, 0.0001, 0.0001, 0.0001), so the overall estimated blood loss in group II and III showed highly reduction compared with group I (P = 0.0001, 0.0001).Conclusions: Prophylactic adjunctive TA topical application on the placental bed or iv administration reduces blood loss during and after caesarean delivery in women with a placenta previa. novel application of topical tranexamic acid on the placental bed is effective in reduce intraoperative and postoperative bleeding in comparison with IV route with elimination of theoretical risk of thrombi embolism complication with IV rout

Adjunctive intrauterine Foley’s Catheter Balloon adding to hypogastric artery ligation in the conservative management of morbid adherent placenta previa

Background: Objective of present study was to demonstrate the efficacy of Foley’s catheters balloon tamponade as an adjuvant to control blood loss during and after a caesarian section in patient undergone hypogastric artery ligation (HAL) due to morbid adherent placenta previa (MAPP).Methods: A single-center retrospective case-control clinical trial was carried out in a tertiary university hospital between March 2015 and March 2018, 124 women were undergoing cesarean delivery for MAPP, were managed conservatively either with HAL or HAL plus inflated Intrauterine Foley’s Catheter Balloon to control post-partum hemorrhage secondary to MAPP. In the case of conservative treatment protocol failure, cesarean hysterectomy was performed.Results: 124 women were enrolled (n=62 in each group). group of women received HAL plus Intrauterine Foley’s Catheter Balloon (group II)) showed a significant reduction in intraoperative and 4 hours post-operative blood loss compared with (Group I) which received HAL without Intrauterine Foley’s Catheter Balloon. (P = 0.0001,0.0.015), so the overall estimated blood loss in group II showed significant reduction compared with group I (P = 0.0001).Conclusions: Adjunctive intrauterine Foley's catheter balloon adding to HAL ligation in the management of MAPP is a novel combination approach have proved to be effective to control of intraoperative and PPH and to preserve the uterus as possible and change in the concept of MAPP management always mandates hysterectomy. And may become an alternative valid option to planned cesarean-hysterectomy in well-selected cases who have a strong desire for future fertility

Placenta accreta and emergency cesarean delivery correlates to cervical length and transcervical placental thickness measurement

Background: The study aims to evaluate the effect of cervical length and the transcervical placental thickness measurement at 28-30 weeks gestation in predicting the risk of antepartum haemorrhage (APH) and emergency preterm caesarean delivery (CD) in women with placenta previa accreta.Methods: A prospective cohort study conducted at Aswan university hospital from June 2015 to April 2017 included one hundred and five cases diagnosed as placenta previa accreta by transvaginal ultrasound (TVS) between 28-30 weeks gestation were divided into three groups according to their cervical length which measured by TVS: group I (cervical length >30 mm), group II (cervical length 20-30 mm) and group III (cervical length <20 mm). Also, placental thickness measurement was done. Cervical length and placental thickness and correlated with the clinical outcome regarding to gestational age at delivery, APH, emergency CD due to massive haemorrhage, the need for blood transfusion and caesarean hysterectomy.Results: APH and emergency CD due to massive bleeding were significantly higher in cases with short cervical length and thick placenta. APH occurred in 6 cases (15%) in group I, 14 cases (40%) in group II and 24 cases (80%) in group III, (p=0.0001). Emergency CD in group I was performed in 5 cases (12.5 %), 12 cases (34.3 %) in group II and 24 cases (80%) in group III, (p =0.0001). The incidence of APH was higher in thick placenta [6 cases (42.9 %) compared to none with thin placenta in group I (p=0.001), 13 cases (68.4%) compared to one case (6.2%) in group II (p=0.0001) and 21 cases (100%) compared to 3 cases (33.3%) in group III (p=0.0001)].Conclusions: Short cervical length and increased placental thickness may predict the risk of APH and emergency preterm CD in patients with placenta accreta

Improved rotor flux estimation at low speeds for torque MRAS-based sensorless induction motor drives

In this paper, an improved rotor flux estimation method for the Torque model reference adaptive schemes (TMRAS) sensorless induction machine drive is proposed to enhance its performance in low and zero speed conditions. The conventional TMRAS scheme uses an open loop flux estimator and a feedforward term, with basic low pass filters replacing the pure integrators. However, the performance of this estimation technique has drawbacks at very low speeds with incorrect flux estimation significantly affecting this inherently sensorless scheme. The performance of the proposed scheme is verified by both simulated and experimental testing for an indirect vector controlled 7.5-kW induction machine. Results show the effectiveness of the proposed estimator in the low- and zero-speed regions with improved robustness against motor parameter variation compared to the conventional method

The effect of regular daily walking on adverse pregnancy outcomes among overweight primigravidas: a prospective cohort study

Objective: The study aims to evaluate the effect of regular daily walking on the occurrence of adverse pregnancy outcomes among overweight primigravidas. Materials and Methods: A prospective cohort study conducted at Aswan University Hospital from March 2015 to December 2016. The study included 360 overweight primigravidas, with singleton pregnancies, who were divided into two groups: Group I (control group) and Group II (study group) under supervised regular walking 5 times per week for 30 minutes, starting from 10-12 weeks of gestational age to 38-39 weeks of gestational age. The primary outcome of the study was the rate of gestational weight gain in participants in both groups. Secondary outcomes included the rate of gestational diabetes mellitus, gestational hypertension, preeclampsia, preterm labor ( 4 kg), excessive maternal weight gain (>11.5 kg), and the rate of cesarean delivery. Results: There were no significant differences between groups with regard to the basic criteria. The exercise program decreased the incidence of preeclampsia (OR=0.120; 95% CI=0.015-0.970; p=0.037), postdate (OR=0.274; 95% CI= 0.099-0.759); p=0.008), excessive weight gain (OR=0.220; 95% CI=0.114-0.424), p=0.000), and cesarean delivery (OR=0.519; 95% CI=0.316-0.841, p=0.007). Conclusion: Regular maternal walking throughout the pregnancy may be a preventive tool for preeclampsia, postdate pregnancy, excessive weight gain and may decrease the incidence of cesarean delivery in primigravidas

Pregnancy outcome according to body mass index in primigravidas: a prospective cohort study

Objective: The study aims to evaluate the association between Body Mass Index (BMI), gestational weight gain (GWG) and adverse obstetric outcomes among primigravidas. Material and methods: This was a prospective cohort study conducted at a tertiary University Hospital between June 2015 and May 2017. The study included 480 primigravidas, with singleton pregnancies, who were divided into three groups: women with a healthy weight (BMI: 18.5–24.9 kg/m2) overweight (BMI: 25 – 29.9 kg/m2) and obese (BMI ≥ 30 kg/m2). The primary outcome of the study was the rate of GWG in the participants. Secondary outcomes included the rate of gestational diabetes mellitus (GDM), gestational hypertension, pre-eclampsia, preterm labor (PTL), postdate pregnancy, fetal macrosomia and the rate of birth by cesarean (CB). Results: There were no significant differences between groups regarding the socio-demographic criteria. The rate of GWG was significantly higher in obese women versus average weight women (11.4±1.73 vs. 10.49±1.09, p=0.0001). There was an increased incidence of GDM (p=0.008), gestational hypertension (p=0.001), pre-eclampsia (p=0.0001), PTL (p=0.002), postdate (p=0.0001) and macrosomia (p=0.0001) in women who were obese compared with women with a healthy weight. Additionally, there was an increased incidence of CB with increasing body mass (p=0.0001) Conclusions: Higher BMI in primigravidas is associated with increased GWG and with adverse pregnancy outcomes such as GDM, gestational hypertension, pre-eclampsia, PTL, postdate, fetal macrosomia and cesarean birth

Does lidocaine gel produce an effective analgesia prior to copper IUD insertion? Randomized clinical trial

Background: IUD is a small contraceptive device, often containing either copper or levonorgestrel, which is inserted into the uterus. Objective of present study was to determine if lidocaine gel prior to intrauterine device (IUD) insertion decreases pain with the insertion procedure among multiparous women choosing the copper T380A-IUD.Methods: It is a randomized double-blind controlled trial carried out at Assiut Women's Health Hospital, Assiut, Egypt. Parous women eligible for Copper IUD insertion attended the Family Planning Clinic were recruited and randomized in a 1:1 ratio to lidocaine gel or placebo. Two ml of the study medications were topically placed on the cervix 3 minutes before IUD insertion. The primary outcome was the difference in pain scores using a 10-cm Visual Analogue Scale (VAS) during IUD insertion. We considered a 1.5 cm difference in VAS scores between study groups as clinically significant.Results: One hundred women consented to participate and randomized either to group I:  lidocaine group or group II: placebo group. Both groups were homogenous in baseline socio-demographic data. There was significant difference in mean pain scores for IUD placement between women who received lidocaine gel and placebo at two steps of insertion (at vulsellum application and at uterine sounding) while the rest of steps show no statistical significant difference (p=0.000). There were no statistical significant differences between both group as regard the ease of insertion, the duration of insertion and the satisfaction score after the procedure (p>0.05).Conclusions: This study depicts that the use of lidocaine gel prior to copper IUD insertion in multiparous women could partially reduce the pain during tenaculum placement and uterine sounding

Prophylactic use of temporary uterine packing combined with topical tranexamic acid reduces blood loss and transfusion requirements in patients undergoing cesarean section: A double-blind, randomized controlled trial

Background: since antiquity post-partum haemorrhage (PPH) has been a terrible event for obstetricians. It accounts for 34% of maternal deaths in Africa and developed countries. It complicates 6% of cesarean delivery (CD) and still raising and correlates with increased frequency of caesarean sections, many uterotonic agents have successfully used alone or in combinations for prevention of such catastrophic, but the most effective medication is still up for controversy. Objective: To compare the efficacy and safety of temporary uterine packing combined with topical tranexamic acid (TA) as adjunct for reducing blood loss following an elective cesarean delivery with intravenous tranexamic acid and placebo in women who have at least one risk factor for postpartum hemorrhage. Patients and methods: A double-blind, randomized clinical trial (: NCT03706339) conducted on 450 pregnant women at term (38–40 weeks) gestation scheduled for elective cesarean delivery, who were assigned to either intravenous TA, topical TA, or placebo(saline). The main outcome measures were blood loss at and 6 hours after cesarean delivery, the need for any additional oxytoxic drugs, and TA-related side effects. Results: There was a significant decrease in the intraoperative blood loss and total blood loss in both topical TA and IV TA groups compared to placebo group (p=0.0001,0.0001,0.0001,0.0001). Also, the need to extra uterotonics was significant decrease in IV TA group, 9 (6%) patients compared to 33 (22%) patients in placebo group, and 24 (16%) patients in topical TA group, (p=0.0001 and 0.006) respectively. Finally, operative time, hospital stay, postoperative hemoglobin, and post-operative complication showed no significant difference between the three groups (P= 0.276, 0.126, 0.853, 0.955, 1.00, 1.00) respectively. Conclusion: IV TA and temporary uterine packing combined with topical tranexamic acid is more effective than placebo in reducing total blood loss during and after cesarean delivery in women who have at least one risk factor for postpartum hemorrhage, but IV TA more effective