Sublingual Misoprostol versus Foley catheter for cervical ripening in women with preeclampsia or gestational hypertension: A randomized control trial

Background: Delivery is the only definite cure for hypertensive disorders. Therefore, cervical ripening and labor induction are important to achieve favorable outcomes. Objective: This Randomized Control Trial (RCT) is aimed to compare the effects of sublingual misoprostol and Foley catheter in cervical ripening and labor induction among patients with preeclampsia or gestational hypertension. Materials and Methods: A total number of 144 women with preeclampsia or gestational hypertention with indication of pregnancy termination, who were referred to academic hospitals of the University of Medical Sciences in Mashhad, Iran, between March 2015 and December 2016, were randomly divided into two groups. In group one (n = 72), 25 μg of misoprostol tablet was administrated sublingually every 4 hr up to six doses. In group two (n = 72), a 16F Foley catheter was placed through the internal cervical os, inflated with 60 cc of sterile saline. Results: There were no significant differences between groups regarding the demographic characteristics, primary bishop score, and pregnancy termination indication. The cervical ripening time (primary outcome) (8.2 vs 14.2 hr, p < 0.00), induction to delivery interval (15.5 vs 19.9 hr, p < 0.00), and vaginal delivery before 24 hr (63.9% vs 40%, p = 0.03) were significantly different between the two groups. There was no significant difference between groups in view of oxytocin requirement (p = 0.12), neonatal Apgar score (p = 0.84), or neonatal intensive care unit admission (p = 78). Conclusion: This trial showed that the application of sublingual misoprostol, compared to the Foley catheter, can reduce cervical ripening period and other parameters related to the duration of vaginal delivery. This misoprostol regimen showed inconsiderable maternal complications

Comparison of the Prevalence of Human Papillomaviruses among Fertile and Infertile Women in Mashhad, Northeast of Iran

Background: Human papillomaviruses (HPVs) are the most common viruses which can be sexually transmitted. They can cause different malignancies in asymptomatic women. The association of HPVs with infertility among men and women is controversial. In the current study, the authors compared the frequency of HPVs in fertile and infertile women in the city of Mashhad. Materials and Methods: In the present case-control study, cervical and vaginal smears were collected from infertile and fertile women. HPVs were detected by polymerase chain reaction. Data was analyzed by SPSS v.20 and P-value <0.05 was considered statistically significant. Results: In the current study, 115 infertile women with the mean age of 30.5±5.6 years and 60 fertile women with the mean age of 32.6±9.3 years were included (p=0.07). Among women who were infertile (cases), 121 (52.6%) of 230 smears were positive, while in control group (who were fertile), 50 (41.7%) of 120 smears were positive (p=0.052). Conclusion: Frequency of HPV in both groups was high, which could be due to lack of routine HPV vaccination. HPV can cause placenta abnormality, our infertile women had multiple abortion history and history of abortion had significant differences among infertile and control group. The frequency of HPV had no significant differences between the infertile and control groups

Persistent Low Levels of Beta-hCG: A Pitfall in Diagnosis of Retained Product of Conception

Persistent low level of beta-hCG (PLL) is defined as rising hCG level no more than two-fold over a three months period. Almost many types of PLL can lead to the wrong diagnosis. Here, we presented two cases of the retained product of conception (RPOC) with persistent low levels of beta-hCG. Both cases were presented with persistent low levels of beta-hCG and abnormal uterine bleeding since first-trimester pregnancy termination. Ultrasonography revealed a vascular mass with extension from the endometrial cavity to myometrium imitating gestational trophoblastic disease (GTD) or arteriovenous malformation (AVM). The final pathologies of both cases were retained product of conception. Imaging features of RPOC can closely imitate those of an AVM or GTN; so, hysteroscopy is one of the best non-invasive procedures which may be helpful in diagnosis and selection of appropriate treatment especially in young patients who desire to preserve their fertility.

Sudden Bilateral Sensorineural Hearing Loss Following Postpartum Hemorrhage: A Case Report

The prevalence of bilateral sudden sensorineural hearing loss (SSNHL) is less than 5% and the etiology of most cases is unknown. Due to many structural and functional similarities between the kidney and inner ear, many conditions, diseases, and drugs have both renal and cochlear effects and toxicities. There are several reports of SSNHL in patients with CRF, uraemic patient, hemodialysis treatment, and ARF. Here, we report a rare manifestation of SSNHL following severe postpartum hemorrhage that has simultaneous renal failure and cochlear impairment. The patient was a 22-year-old primigravida woman with term pregnancy who after delivery and episiotomy hematoma and postpartum hemorrhage subsequently suffered from kidney failure, oliguria, and SSNHL that occurred after 3 days of delivery. In conditions such as severe postpartum bleeding leading to acute renal involvement, the possibility of simultaneous involvement of cochlea due to hypoxia or received drugs should be considered

Uterine artery embolization in late postpartum hemorrhage due to pseudoaneurysm: case report

Background: Late postpartum hemorrhage (PPH) is defined as uterine bleeding between 24 hours until 12 weeks after delivery. Uterine artery pseudoaneurysm is a rare cause of life-threatening late postpartum hemorrhage (PPH). Emergency uterine artery embolization (UAE) is an appropriate method for control of hemorrhage. The aim of this report was to present a case of uterine artery embolization in late postpartum hemorrhage due to uterine artery pseudoaneurysm. Case Presentation: A 25-year-old woman with the history of three previous cesarean sections was admitted 35 days after the last cesarean. She had severe vaginal bleeding for 35 days after cesarean section. Because of severe vaginal bleeding 35 days after cesarean section, the patient was at nearly shock state (BP=90.60 mmHg, positive tilt test, tachycardia PR=120/m). In speculum examination, she had severe vaginal bleeding, but there was no lesion in vagina or cervix, also, bimanual examination of the uterus and adnexal area were normal. She reanimated by two liters of normal saline and uterotonic agents (oxytocin and methergine) were administered. Laboratory data showed severe anemia (Hb=6.5 gr/dl), but coagulation tests were normal. Ultrasonography didn’t show any abnormality. Because of continuation of vaginal bleeding after stabilization of the patient, UAE was planned. During pelvic angiography, a pseudoaneurysm was diagnosed and then it was treated by successful UAE. Conclusion: Uterine artery embolization is a conservative management for control of late postpartum hemorrhage. It can be a useful and alternative method for uterine and hypogastric artery ligation and hysterectomy, therefore it has an important role in treatment and fertility preservation for young women

Evaluation of Maternal- Neonatal Outcomes in Vaginal Birth After Cesarean Delivery Referred to Maternity of Academic Hospitals

Objective: To evaluate the maternal and neonatal complications of vaginal birth after cesarean section (VBAC). Materials and methods: This cross sectional study was conducted in Mashhad University of medical sciences. Eighty women with previous cesarean section who were candidate for VBAC were enrolled the study. Patients were followed up for 6 weeks after delivery. The complication of VBAC was compared between successful or unsuccessful VBAC cases. Data was analyzed by SPSS version 16. Results: VBAC success rate was 91%. Post-partumhemorrhage occurred in 2.7% of woman with successful VBAC and 1.3% of CS cases. Maternal and neonatal death did not happen during our study, and none of our cases experienced uterine rupture, dystocia and neonatal tachypnea. Neonatal complications include NICU admission and neonatal resuscitation frequency in VBAC and CS were 6.8% and 57.1%, respectively (p = 0.002). Birth weight of neonates in successful VBAC was 2940 ± 768 grams and 3764 ± 254 grams in unsuccessful VBAC and this difference was significant (p = 0.007). Mean maternal admission duration in VBAC and CS were 1 ± 0.1 days and 2 ± 0.4 days (p < 0.001). Successful breastfeeding rate were higher in VBAC patients (95.8%) in comparison with CS (42.9%) and this difference was statistically significant (p = 0.002). Conclusion: Our results revealed that VBAC can be considered as a safe maternal and neonatal delivery method in patients with past CS women.

Incomplete molar pregnancy with live coexisting fetus: a case report

Background: Twin pregnancy with a fetus and a diploid complete mole is not rare, but, the cases of twin pregnancy with a partial mole are rare. Nowadays, the prevalence of these cases has been increased due to the high rate of assisted reproductive techniques in reproductive medicine. The importance of twin pregnancy with a fetus and a diploid complete mole is mainly due to systemic complications such as hypertension and maternal hemorrhage and the possibility of trophoblastic tumor following delivery. Different studies have reported some results about similar cases, but limited case reports are presented in our country. The aim of this study is to report a case with incomplete molar pregnancy concomitant with a live fetus. Case presentation: A 21 yr old woman (G2 ab1) referred to emergency department of Ghaem University Hospital in Mashhad. She complained of scant vaginal bleeding and spotting and a sonography report of a combined molar and normal pregnancy with 15 weeks gestational aged. During hospitalization, the pregnancy complicated with hypertension and proteinuria. Termination of pregnancy was planned at 17th weeks of gestation due to severe preeclampsia. After evacuation of uterus, during follow up visits, -hCG titer raised. Metastasis evaluation was negative. Pathology reports showed patial mole. Then, three doses of methotrexate (50 mg/m2 intra muscular) was administered and finally, according to the monthly follow up, -hCG level was undetectable. Conclusion: The rate of pregnancy complications such as hypertension, hyperthyroidism, and obstetrics hemorrhage and also the risk of Gestational Trophoblastic Neoplasm (GTN) are increasing in incomplete molar pregnancy. Therefore, early diagnosis and timely treatment of molar pregnancy is very important to reduce maternal morbidity and mortality

Molar twin pregnancy with a live coexisting triple X fetus: case report

Background: Complete molar twin pregnancy with coexisting fetus is a rare and important diagnosis in obstetrics. Preeclampsia, preterm labor and life-threatening vaginal bleeding are the serious complications of this type of pregnancy. Gestational trophoblastic neoplasia should be ruled out after termination of pregnancy. In this study we reviewed a molar twin pregnancy with a live coexisting triple x fetus which has not been reported till now. Case Presentation: Our case was a 22-year-old primigravida woman and 17-18th week of pregnancy, who referred to an University Hospital in Mashhad, Iran with complaint of vaginal bleeding On October 2016. Her first trimester ultrasonography in 13th week of gestational age, reported a live single fetus with an anterior great placenta and cystic formation regarding molar pregnancy. According to above-report, Amniocentesis was done in 15th weeks of pregnancy and its result was triple X. After severe and life-threatening vaginal bleeding, she underwent an emergent hysterotomy. A fetus with no obvious anomaly and a great hydropic and vesicular placenta delivered. Episodic crisis of her blood pressure was best controlled with anti-hypertensive drugs. In our case, chemotherapy with methotrexate was started after poor decline of &beta;HCG titration and definite diagnosis of gestational trophoblastic neoplasia. Remission was completely achieved after four courses of chemotherapy. Conclusion: Differentiation between complete molar pregnancy with live fetus and partial mole is always challenging in obstetrics. Serious complications as preeclampsia and severe vaginal bleeding may become life-threatening. Coexisting molar pregnancy should be ruled out in a pregnancy associated with frequent and unexpectant vaginal bleeding. Amniocentesis and an expert radiologist can help to differentiate them. Following these patients is very important to reveal any trophoblastic neoplasia

Obstetrics and perinatal outcomes of dichorionic twin pregnancy following ART compared with spontaneous pregnancy

Introduction: Regarding to the recent advances in assisted reproductive techniques (ART), twin and multiple pregnancies have increased during past years. Objective: This study was performed to compare obstetrics and perinatal outcomes of dichorionic twin pregnancy following ART with spontaneous pregnancy. Materials and Methods: In this cross-sectional study which was performed in Ghaem Hospital, Mashhad University of Medical Sciences, 107 dichorionic twin pregnancy were enrolled in two groups: spontaneous group (n=96) and ART group (n=31). Basic criteria and obstetrics and neonatal outcomes information including demographic data, gestational age, mode of delivery, pregnancy complications (preeclampsia, gestational diabetes, preterm labor, and intrauterine growth retardation (IUGR), postpartum hemorrhage), neonatal outcomes (weight, first and fifth minuteP PApgar score, Neonatal Intensive Care Unit (NICU) admission, mortality, respiratory distress, and icterus) were recorded using a questionnaire. Results: Preterm labor, gestational diabetes, and preeclampsia were significantly higher in ART group compared to spontaneous pregnancy group. However, other factors such as anemia, IUGR, postpartum hemorrhage, and intrauterine fetal death (IUFD) were not significantly different between groups. There were no significant differences between groups in terms of neonatal outcomes (weight, 1PstP and 5PthP min Apgar score <7, NICU hospitalization, mortality, respiratory distress, and icterus). Conclusion: With regard of significantly higher poor outcomes such as preeclampsia, gestational diabetes and preterm labor in ART group, the couples should be aware of these potential risks before choosing ART

Successful conservative management of cervical pregnancy: case report

Background: Cervical pregnancy is a rare type of ectopic pregnancy (EP) in which the pregnancy implants in the lining of the endocervical canal. It accounts for less than 1 percent of ectopic pregnancies. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role given an apparent association with a prior history of curettage or cesarean delivery. The most common symptom of cervical pregnancy is vaginal bleeding, which is often profuse and painless. Lower abdominal pain or cramps occur in less than one-third of patients; pain without bleeding is rare. It is important to think about the possibility of cervical pregnancy in such patients since early diagnosis is critical to avoidance of complications and successful treatment. Management of this pregnancy is dependent on the hemodynamic status of the patient. Conservative management and some more aggressive therapy such as emergency hysterectomy can be used. The aim of this report was to introduce a case of successful conservative management of cervical pregnancy. Case presentation: A 30-year-old G2L1 woman with history of a previous cesarean section and possible diagnosis of missed abortion referred to the Gynecology Clinic of Ghaem Hospital, Mashhad University of Medical Sciences, Iran, in 21 May 2017. Cervical pregnancy was diagnosed during curettage. Severe hemorrhage occurred after curettage and the hemodynamic status of the patient was unstable immediately after curettage. Severe threatening vaginal bleeding was controlled with intrauterine Foley catheter containing 60 cc normal saline and then vaginal packing. The patient was discharged with good general condition. Conclusion: In cervical pregnancy and unstable hemodynamic status and desire to preserve fertility, intrauterine Foley catheter and vaginal packing after curettage is helpful