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Addressing optimal maternal weight and exercise during the preconception period and pregnancy
C.P. Moutos, V. Lozovyy, S.M. Clark
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (5): 622-628.   DOI: 10.31083/j.ceog.2020.05.9041
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Pregnancy is an opportunity for women to access the healthcare system and address their health needs. Before and during pregnancy, providers should emphasize assisting women in interventions aimed at establishing a healthy weight and exercise regimen and should tailor their guidance based on a woman's baseline level of fitness. Doing so will improve a woman's likelihood of pregnancy and improve outcomes if she does become pregnant. Our goal is to propose actions providers should take to improve a woman's understanding of and ability to manage her weight and exercise goals during the preconception and pregnancy periods.
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Less Residual placental blood volume left when cord pulsation ceases than when early cord clamping at 60 seconds
H. Y. Zhang, Y. Wu, R. Guo, M. Huang, Y. Ling, Y. H. Huang
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 202-207.   DOI: 10.31083/j.ceog.2020.02.4958
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Objectives: Our goal was to test the volume of residual placental blood volume (RPBV) left with delayed cord clamping occurring when pulsation of the umbilical artery ceases as compared to early cord clamping at 60 seconds along with an assessment of its effects on maternal and neonatal outcomes. Materials and Methods: From March to June 2015 in Haikou maternal and child health hospital, 403 single-term patients with normal vaginal births and healthy babies were enrolled with randomization into two groups. The experimental group (n = 201) received delayed cord clamping after pulsation of the umbilical artery ceased with the control group (n = 202) having the umbilical cord cut at exactly 60 seconds. RPBV was collected when the cord was cut in both groups. Maternal and neonatal conditions were recorded. Results: In the control group, RPBV per birth weight (RPBV (mL/kg) range) [21.0 ± 14.9 (2.9-73.2)] was higher than that in experimental group [4.3 ± 3.5 (0.8 - 19.1)] (p < 0.01); peak total serum bilirubin (TSB) level (mg/dL) [(13.6 ± 3.5) (5.0 - 20.7) mg/d1] was higher in the control than that in experimental group [11.9 ± 2.9 (4.5 - 24.5)] (p < 0.01); and postpartum blood loss in control group [(187.8 ± 104.6) (80-650.00) mL] was higher than that in experimental group [(160.2 ± 72.9) (70 - 450) mL] (p = 0.02). Maternal age, gestational age and Apgar score at one and five minutes were not of statistically different between groups. No neonatal deaths were recorded in either group at one month’s follow up. Conclusions: Delayed cord clamping until the umbilical artery pulsation ceased is a safe intervention and reduces the residual placental blood volume without any adverse maternal or neonatal effects. The data suggests that more placental transfusion occurs in the newborn with delayed cord clamping.
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Current methods of non-invasive fetal heart rate surveillance
A. Theodoridou, A. Athanasiadis, G. Tsakmakidis, Ι. Tsakiridis, A. Pilavidi, C. Vosnakis, T. Dagklis, G. Mavromatidis, A. Mamopoulos
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (4): 459-464.   DOI: 10.31083/j.ceog.2020.04.5422
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Introduction: As accurate fetal evaluation during labor is essential, there is a continuous need for better noninvasive ways of monitoring. Electronic fetal monitoring (EFM) is an essential tool towards effective fetal assessment during labor, with the invasive Intrapartum ST Segment Analyses (STAN) system an early favorite. There are very few non-invasive EFM devices worldwide, with only two having Food and Drug Administration (FDA) approval. Methodology: This state of the science review focuses on the most recent available scientific data regarding the role of non-invasive EFM and its effect on perinatal outcomes. Results: The Monica AN24 system, FDA approved and comparable to an external Doppler CTG, is independent of maternal BMI. The Mind child Meridian monitor, the second EFM device with FDA approval, is comparable to STAN, but with up to 32 electrodes for improved accuracy it can be difficult for medical professionals to master. The Nemo System, new to the market, was found to be highly acceptable as a 24-hour monitoring device by pregnant women in a single inaugural pilot study. Discussion: Non-invasive monitoring technology is making progress but there are still issues with signal acquisition and quality that stem from the newfound mobility of the monitored pregnant women. The two FDA approved devices are promising with a few caveats and there are also new devices that aim to improve on the shortcomings of the leaders with promising advances in signal acquisition and processing via additional electrodes and setups.

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Proof of concept study of a novel bioadhesive clindamycin phosphate 2% vaginal gel to treat bacterial vaginosis
A. Dupre, H.H. Alur, D.R. Friend
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (4): 516-518.   DOI: 10.31083/j.ceog.2020.04.5304
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The objective of the study was to evaluate the efficacy and safety of a novel single 2% clindamycin phosphate vaginal gel for the treatment of bacterial vaginosis (BV). The vaginal gel, a thermosetting bioadhesive formulation containing 2% clindamycin phosphate, was studied in a single center, single arm, open-label study. Patients (n = 30) were screened for BV using the four Amsel criteria (visit 1). A subset of ten women were also assessed using Nugent scores. Eligible patients were consented and provided a single dose of 2.0% clindamycin phosphate gel in a prefilled vaginal applicator (5-gram total dose). Patients returned to the clinic 7 to 14 days (visit 2) after dosing and again between 21 and 30 days (visit 3). Two subjects were excluded from cure rate calculations. Of the evaluable 28 patients, 24 (86%) were successfully treated (clinical cure) with a single dose of 2% clindamycin gel at visit 2. Of the ten patients evaluated for Nugent scoring, seven subjects were evaluable for bacteriologic cure. After a single dose of 2% clindamycin gel, four of seven (57%), and four of seven (57%) had a bacteriologic and therapeutic response, respectively. Of the 24 women who completed visit 2 and were cured based on Amsel criteria, 23 (96%) remained cured at visit 3. Of the subset of ten patients evaluated using Nugent scoring (bacteriologic evaluation), seven of nine (78%) had a score of 3 or less at visit 3. In this group, six of nine women were considered therapeutically cured (67%). There were no reports of adverse reactions, including local reactions to the vaginal gel product over the course of the study. These data support the expanded clinical evaluation of 2% clindamycin gel.

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A giant placental chorioangioma with a resultant live birth; a discussion of management options
Saša Raičević, Duško Kljakić, Filip Vukmirović, Miloš Z. Milosavljević
Clinical and Experimental Obstetrics & Gynecology    2021, 48 (2): 426-430.   DOI: 10.31083/j.ceog.2021.02.2260
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Introduction: Chorioangiomas are benign, nontrophoblastic tumors of the placenta. Giant chorioangiomas (larger 5 cm) are infrequent and have unfavorable outcomes due to their strong association with maternal and fetal complications. We describe a case of a giant chorioangioma that had a good outcome without complications. Case report: A 27-year-old woman, primipara, with a regularly monitored pregnancy was admitted to the hospital at 37 + 5 weeks of gestation due to pain in the lower half of the abdomen, rupture of the amniotic sac and accumulation of thick, green, amniotic fluid. Ultrasonography performed at 33 weeks of gestation indicated the presence of a tumor mass 12.5 × 7.7 cm in diameter that was localized near the chorionic surface. Cardiotocography indicated variable decelerations, which necessitated an emergency cesarean section. A live, healthy, male child was born without complications via Dorfler's cesarean section. The encapsulated tumor mass was manually removed from the uterus, and angiomatous chorioangioma of the placenta was diagnosed by pathohistological examination. Conclusion: Ultrasonographic monitoring is the choice method for the accurate diagnosis and intervention of chorioangioma, but only pathohistological examination can confirm the diagnosis. This case report demonstrates that giant placental chorioangioma may have a favorable outcome without any medical intervention.
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Substitution of hemoglobin levels in pregnant women with iron supplement: A prospective randomized clinical study
A. Daniilidis, G. Dryllis, G. Chorozoglou, M. Politou, R. Dampali, K. Dinas
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (4): 579-583.   DOI: 10.31083/j.ceog.2020.04.5310
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Introduction: Iron deficiency anemia (IDA) is the most common form of anemia. Women who are pregnant or lactating and young children are the most affected. Iron protein acetyl aspartilate is a ferroprotein complex that is more efficient versus iron protein succinylate in relatively short periods of time, for example 30 days. Objective: The aim of this clinical study was to investigate the efficacy of acetyl aspartate iron protein supplement in the treatment of anemia in pregnant women after the first trimester. This is the first real-time clinical study testing the usage of an iron protein supplement in a specific population, as there are not sufficient data for such studies in the literature. Study Design: 28 pregnant women with hemoglobin < 10.5 gr/dL and after completing the 12th week of pregnancy, initiated acetyl aspartate protein iron at a daily dose yielding 80g of elemental iron in two uptakes. Similarly, 35 women were studied who received different iron supplements at the same daily dose. After 30 days, hemoglobin values were measured. Inclusion criteria included: age > 18, gestational week > 12, Hb < 10.5 g/dL, Ht < 32%. Exclusion criteria included: age <18, pregnancy < 12 weeks, many pregnancies, history: allergy to iron preparations, ulcer, cirrhosis, hemodialysis, hemochromatosis, aplastic anemia, chronic disease anemia, pancreatitis, renal disease. Results: Treatment with acetyl aspartylated iron lead to higher levels of hemoglobin after four weeks of treatment. Following successive measurements of hemoglobin levels in the 28 women of the study group, Hb levels increased from an initial mean Hb value of 10.04 gr/dL to 10.69 gr/dL. In the control group of 35 pregnant women, an increase in the mean hemoglobin from Hb was observed from 9.99 gr/dL to 10.46 gr/dL. The difference was statistically significant with p < 0.0001. Conclusions: The use of acetyl aspartate iron protein is a very promising option, as there has been an increase in hemoglobin levels to 0.5 gr/dL.

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The effects of vaginal lubricants on the human vagina: an in vitro analysis
Dong-Wook Park, Han Tae Jo, In-Ho Lee, Chan-Woo Park, Ju Tae Seo
Clinical and Experimental Obstetrics & Gynecology    2019, 46 (3): 427-433.   DOI: 10.12891/ceog4671.2019
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Purpose: Vaginal lubricants are widely used by women to resolve intercourse difficulties or as performance enhancers. However, little information is available regarding the safety of over-the-counter (OTC) lubricants. Therefore, in this study, a set of commercial lubricant products available on the Korean online market were selected and evaluated in vitro for their safety relevant to their osmolality. Materials and Methods: Five commercially available gel-based OTC lubricant products were included in this study. Osmolality was determined using a vapor pressure 5520 osmometer. Cell viability was measured by MTT assay and Western blotting. Human vaginal tissue integrity was measured by immunohistochemistry. Results: Four OTC lubricant showed hyper-osmolality, while one OTC lubricant was within the minimum WHO-recommended standards. The findings showed that four hyperosmolal OTC vaginal lubricants showed cellular damage to the cultured vaginal cell line and human vaginal explant. One iso-osmolal OTC vaginal lubricant showed less cellular damage to both cultured vaginal cell lines and human vaginal explants. Conclusion: Present study showed that the osmolality of OTC vaginal lubricant is a major factor affecting epithelial cell survival and tissue integrity. The effect of each ingredient contained in OTC lubricants was not considered. Thus, additional research is needed to evaluate formulae to enable production of safer OTC vaginal lubricants.

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Caesarean section between doctrine to heresis. Medicoethical and deontological view of caesarology: an opinion
Dubravko Habek, Matija Prka, Anto Čartolovni, Anis Cerovac, Domagoj Dokozić
Clinical and Experimental Obstetrics & Gynecology    2021, 48 (1): 1-4.   DOI: 10.31083/j.ceog.2021.01.2305
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Increasing the incidence of caesarean section is not in line with professional and deontological guidelines. Elective cesarean section prevents primordial prevention of chronic cardiovascular, gastrointestinal, imunological, endocrinological morbidity by peripartal programming. Elective non-medical indicated caesarean section is not a procedure that respects deontological, clinical etics, scientific and professional principles. It is like an unacceptable surgery outside the scope of medical ethics. Clientelism in high-risk clinical obstetric medicine is not a professional and deontologically correct category: a physician should not be a provider on request of healthy pregnant women with the potential to have a medically incorrect procedure and complications associated with it and to put a healthy pregnant/maternity and child status in the patient's status. The financial, social, political and cultural components must not outweigh good clinical practice and the moral principles of medicine.
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Asymptomatic adnexal mass in postmenopausal women
A. Vatopoulou, A. Papanikolaou
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (3): 320-323.   DOI: 10.31083/j.ceog.2020.03.5254
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The widespread use of vaginal ultrasound as an integral part of the gynecologic clinical examination in many countries has led to the unexpected finding of adnexal mass. The implications of the finding of an adnexal mass in an asymptomatic postmenopausal woman can be serious if it is malignant and is not excised, because ovarian cancer has an indolent course and when it becomes symptomatic it is often fatal. The aim of the present review is to discuss the evaluation and management of incidental adnexal masses in postmenopausal women. Despite careful evaluation with ultrasound and biomarkers, a small number of patients will remain without a conclusive diagnosis. It is our opinion, based on empirical evidence discussed here, that conservative therapy with observation can be safely applied in the majority of these patients.

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PCR positivity and D-dimer levels in pregnant women with COVID-19
K. Uzel, I. Lakhno
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (5): 638-644.   DOI: 10.31083/j.ceog.2020.05.2229
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Background: Every day brings us new data on COVID-19, which has come to affect all the dynamics of the society, and increasingly more scientific literature becomes available on the topic. However, research information about its effects on particular groups, e.g., pregnant women, is still very limited. Aims: This study was aimed to investigate D-dimer levels in pregnant women admitted to the hospital with suspected COVID-19. Study Design: This descriptive cross-sectional study was carried out among pregnant women admitted to our hospital between 1 April 2020 and 31 May 2020 with suspected COVID-19. The data about patients was obtained from patient records and the hospital automation system. Methods: The primary outcome variable of the study was the D-dimer levels. Secondary outcome variables were the presence/absence of cough, shortness of breath, headache, fever, weakness, proteinuria, diarrhoea, haematuria, loss of taste, hypertension, and gestational diabetes mellitus. Results: Data for 64 pregnant women were analyzed. Thirty-three (51.5%) of them had a positive polymerase chain reaction (PCR) results, and thirty-one (48.5%) had negative ones. The mean age of the participants was 26.33 ± 5.15 years. Of the pregnant women, 51.6% (n = 33) were PCR (+) for COVID-19, and 48.5% (n = 31) were PCR (-). The mean age of the participants was 26.33 ± 5.15 years. Headache occurred significantly more often in PCR (+) pregnant women than in PCR (-) ones (χ2 = 4.201, p = 0.040). A statistically significant difference was found when the groups were compared in regard to the presence of the fever symptom (χ2 = 5.036, p = 0.025). When PCR (+) and PCR (-) pregnant women were compared, a statistically significant difference was found in the D-dimer levels (Z = 2.896, p = 0.004). A logistic regression model with PCR positivity as the dependent variables and headache, fever, and D-dimer levels as independent ones revealed a Nagelkerke R2 of 26.8%, and relatively high sensitivity (87.9%) and specificity (59.1%) values in predicting PCR positivity. Conclusion: This research is the first study to have suggested a model for predicting PCR positivity in women suspected of having the COVID-19 disease, which can speed up decision-making in regard to pregnant women with COVID-19.
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A psychological factor associated with pain during intrauterine device insertion: emotional reactivity
Y. Akdemir, M. Karadeniz
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (3): 335-340.   DOI: 10.31083/j.ceog.2020.03.2073
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Objective: Although the experience of pain is multidimentional, and general psychological factors such as anxiety are found to be associated with acute pain, it is necessary to investigate individual emotional variables such as emotional reactivity (ER). The aim of this study was to determine if increased ER is associated with pain during intrauterine device (IUD) insertion even without existing pre-procedure anxiety. Study Design: Prospective cohort study. Methods: We measured the anxiety level in 237 women using the Beck Anxiety Inventory and the ER level using the Emotional Reactivity Scale (ERS) at Zonguldak Maternity Hospital between November 2018 and March 2019. The women rated their pain during IUD insertion. To evaluate the role of ER in the prediction of pain during IUD insertion, we divided the women into subgroups based on the presence of anxiety and level of pain during IUD insertion. Results: ER was higher in women who had anxiety and moderate-severe pain (p = 0.001). In women who were not anxious, ER was higher in those who had moderate-severe anticipated pain or IUD insertion pain than in those who had mild anticipated pain or IUD insertion pain (p = 0.001). In anxious women, the ERS cut-off value was ? 34 for predicting the level of pain whereas in non-anxious women, it was ? 25. Conclusion: ER is a psychological factor strongly associated with pain at IUD insertion and the ERS appears to be a beneficial tool for detecting ER for this purpose. Health professionals should be aware that psychological factors could contribute to perceived pain more than physiological factors do. Implications: ER is a psychological factor associated with pain at IUD insertion and increased ER is a predictive factor for pain during IUD insertion even without existing pre-procedure anxiety. ERS seems to be a beneficial tool for detecting ER.

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Breast changes in pregnancy and lactation observed by ultrasonography
A.A. Reginaldo de Holanda, A.K. Gonçalves, H.H. Carrara, T.M. de Oliveira Maranhão
Clinical and Experimental Obstetrics & Gynecology    2019, 46 (1): 7-11.   DOI: 10.12891/ceog4200.2019
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Purpose of Investigation: To assess the ultrasound aspects of breasts and laser Doppler flow measurements of the internal mammary arteries (IMA) in pregnant, lactating, and non-pregnant (control) women. Materials and Methods: A cross-sectional observation study of 102 women, divided into three groups: control (CG), third trimester (G3), and lactation group (LG). The study variables were skin, subcutaneous adipose tissue, fibroglandular tissue, retromammary adipose tissue thickness, duct diameter, and pulsatility (PI) and resistance indices (RI) of the internal mammary arteries. Statistical analysis calculated the means and standard deviations, using two models Multivariate Analysis of Variance (MANOVA) models to assess the effect of groups on the mean values found and adjusted ANOVA models for individual means. The Tukey-Kramer multiple comparisons test was used to analyze intergroup. Results: There was no intergroup age difference (mean = 27 ± 4.76 years). A significant difference was observed between the G3/LG and the CG in terms of skin (p = 0.001), fibroglandular tissue thickness, duct diameter, and laser Doppler flow measurements of the IMA (all three with p < 0.001) and subcutaneous adipose tissue (p = 0.045). Conclusion: This study showed alterations in skin, subcutaneous adipose tissue, fibroglandular tissue, and duct diameter measurements, with a difference between pregnant/lactating women and the non-pregnant controls.
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A systematic review and meta-analysis of the reported symptoms of Covid 19 in pregnancy
H.S.O. Abduljabbar, H. Abduljabar
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (5): 632-637.   DOI: 10.31083/j.ceog.2020.05.2223
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Introduction: The percentage of Symptomatic pregnant and non-pregnant women infected with Covid 19 is the same. The common symptoms in pregnant women are cough, fever, sore throat and myalgia. The objective of this is systematic review and meta-analysis of the commonly reported symptoms of COVID 19 in pregnancy and to compare it to non-pregnant. Methods: Study Design; Systematic review and meta-analysis of published retrospective studies. Searches conducted from December 2019 - April 2020 on PubMed. Medline, EMBASE, ISI Web of Science Electronic database used to collect data, corresponding to the (PRISMA) Preferred Reporting Items for Systematic Meta-Analysis, using the following search terms: keywords "coronavirus, COVID-19, pregnancy". Results: Figure 1 presents the study flow diagram. We identify 114 records through database searching, sixteen further studies recognized through other sources, and 98 papers isolated after duplicates, leaving 32 reports. After screening for titles and abstracts, we found only 27 reports to be potentially suitable and rescued these reports in full text. We excluded seven studies; 20 did not report symptoms of groups of interest. In the process of Screening, 16 were screened. Ten of full-text articles assessed for appropriateness, six full-text articles omitted with reasons, and only Four studies [12-15] were included in the review. Conclusion: The only symptoms that are more common in pregnant than non-pregnant are the sore throat. That concluded that when pregnant women start to have sore throat care should be taken to exclude COVID-19 infection.

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Amniotic fluid embolism: the pathophysiology, diagnostic clue, and blood biomarkers indicator for disease prediction
R. Suvannasarn, T. Tongsong, P. Jatavan
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 159-165.   DOI: 10.31083/j.ceog.2020.02.5176
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Objective: This article aims to review and provide more understanding of current knowledge of amniotic fluid embolism regarding pathophysiology, diagnostic criteria, risk factors, indicating biomarkers, treatment strategies and outcomes of some case reports. Study design: A systematic literature review was performed using the PubMed database, restricted to articles published in English from 1992 to 2018. Original research, case reports, guideline recommendations, and review articles were reviewed in this study. Summary: Amniotic fluid embolism (AFE) is a rare catastrophic obstetric condition defined by clinical manifestations of pregnancy with sudden onset of cardiopulmonary arrest, consumptive coagulopathy or neurological deficits without other explainable illnesses. The incidence varies from 1.7-14.8 cases per 100,000 worldwide. The current understanding of AFE pathophysiology includes fetal components obstructing maternal microvessels with subsequent anaphylactoid reaction. Maternal pulmonary vasospasm and hematologic activation occur later, followed by heart failure and sudden cardiovascular collapse. Some of the possible risk factors for AFE include; 1) Maternal risk: age over 35 years, hypertensive disorder and diabetes mellitus; 2) Fetal risk: polyhydramnios, multiparity, non-vertex at delivery, fetal distress and fetal macrosomia; 3) Obstetric risks: amniocentesis, artificial amniotic fluid injection, oxytocin infusion, and placental abruption. Some of the useful biomarkers have been proposed including zinc coproporphyrin-1, squamous cell carcinoma antigen, carcinoembryonic antigen, cancer antigen 125, Siatyl Tn, monoclonal antibody TKH-2, C3, C4, tryptase, insulin-like growth factor binding protein-1, C1 esterase inhibitor. Management of AFE requires immediate basic life support and advanced cardiac life support. Adequate oxygenation, ventilation, coagulopathy correction, and appropriate vasopressors are recommended. However, the outcome prediction of AFE remains challenging.
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Hysteroscopic removal of retained products of conception with enhanced vascularity: a study of reliability
G. Garuti, E. Castellacci, S. Calabrese, S. Calzolari
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (4): 472-477.   DOI: 10.31083/j.ceog.2020.04.5259
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Purpose of Investigation: Retained products of conception (RPOC) is the leading cause of postpartum or post-abortion hemorrhage. RPOC showing high vascularity at ultrasound assessment (HV-RPOC) showed an enhanced hemorrhagic risk following blind surgical uterine emptying. The authors describe the clinical outcome of patients suffering from HV-RPOC undergoing hysteroscopic removal. Material and Methods: Cohort of symptomatic patients suffering from HV-RPOC following miscarriages, pregnancy terminations, and term deliveries. After ultrasound selection based on color-Doppler showing HV-RPOC, all patients underwent hysteroscopic resection. Results: Twenty-seven patients met the selection criteria. HV-RPOC were found in 14 and six women after first and second trimester pregnancy termination, respectively. In seven women RPOC were found after term delivery. In 18 women (66.6%) RPOC were found firmly adherent to myometrium. Neither intra- nor postoperative complications were recorded. Hysteroscopy follow-up was carried-out in 16 patients. Normal findings were found in 15 women in one case a mild adhesion was observed. Conclusion: HV-RPOC are often characterized by abnormally adherent placenta, suggesting that an accreta can be an underlying etiology. A reliable management can be accomplished by hysteroscopic resection.
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Clinical practice guidelines on polycystic ovary syndrome: a systematic review and comparative meta-analysis
J. Dun, X. Wang, J. Yang, J. Xu
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (4): 465-471.   DOI: 10.31083/j.ceog.2020.04.5240
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Objective: This study used a systematic review to evaluate the clinical guidelines for polycystic ovary syndrome (PCOS) to guide clinical applications. Materials and Methods: PCOS guidelines were electronically retrieved from Medline, EMBASE, the Cochrane Library, CBM, CNKI, and VIP. The time span for the search extended until December 2016. Two researchers searched the literature according to the inclusion and exclusion criteria, and applied appraisal of guidelines research and evaluation II (AGREE II) to evaluate the quality of the guidelines. In the case of disagreement the results were discussed with experts in obstetrics and gynecology. Results: Sixteen clinical guidelines were included in this study. The study years ranged from 2004-2016. Average scores from five domains were 65.62%, 62.15%, 46.55%, 91.15%, and 41.01%. The data distribution in the sixth domain was abnormal. One guideline included “strongly recommended,” 13 guidelines included “revise and improve the recommendation,” and 2 guidelines included “not recommended.” Sixteen guidelines involved diagnoses of infertility, metabolic and cardiovascular diseases, health problems, and long-term complications. Conclusion: It has been suggested that an evidence-based medical approach be used to develop clinical guidelines. The quality of guidelines from China should help to develop and improve high-quality care and shorten the gap in the international development.

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Uterine torsion in a 25-week pregnant female with congenital uterine didelphys and intraoperative complication of uterine atony: a report of a rare clinical case
Khac Tu Chau, Minh Tam Le, Doan Tu Tran, Vu Quoc Huy Nguyen
Clinical and Experimental Obstetrics & Gynecology    2021, 48 (1): 185-188.   DOI: 10.31083/j.ceog.2021.01.2230
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Uterine torsion is an extremely rare pregnancy-related complication. Its diagnosis is often difficult due to unspecific clinical symptoms, which can be mistaken for other conditions such as placental abruption. A 23-year-old pregnant woman with gestational age of 25 weeks presented with acute abdominal pain and hypertonic uterus. Vaginal examination revealed a septated vagina, double cervix, and double uterus. Bedside sonography revealed absence of fetal cardiac activity and signs of placental abruption. The patient was emergently operated with a preliminary diagnosis of severe placental abruption in the uterus didelphys. During surgery, we noted a double uterus and the fetus had implanted in the right uterus, which was twisted 180 degrees to the left. After detorsion, a low transverse hysterotomy was performed to extract the dead fetus. However, subsequently, the patient developed uterine atony. Subtotal hysterectomy and right adnexectomy were inevitable due to failure of conservative treatment with B-lynch suture. The patient's postoperative condition was stable, and she was discharged after 5 days.
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The effect of rhodiola rosea root extract on stress-induced ovarian damage, infertility and reproductive disorders in female rats
B.G. Kadioglu, B. Gundogdu, N. Kurt, A. Ozbek Bilgin, H. Suleyman, Z. Suleyman
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (4): 530-536.   DOI: 10.31083/j.ceog.2020.04.5428
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Purpose: The aim of the study was to examine the possible effect of Rhodiola rosea root extract (RRE) on ovarian damage, infertility (IF), delay in conception (DC), decrease in the number of offspring (NO) in female rats that have been stressed with compulsory immobilization method (CIM) and on retardation of intrauterine physical development (IPD) in offspring. Materials and methods: Female Albino Wistar rats were divided like: healthy (HG), stress-induced control (SC), and stress + 50 mg/kg RRE (S + REG) groups including sixteen rats in each group. Six rats from each group were killed for conducting biochemical and histopathological examinations in ovarian tissues and others were observed for IF, DC, NO, and IPD. Results: It was found that RRE significantly prevented the increase in oxidative parameters and proinflammatory cytokine levels in ovarian tissue of animals stressed with CIM. RRE suppressed the increase in IF rate and DC whereas caused a decrease in NO and in IPD retardation. Conclusion: These results suggested RRE may have beneficial effects in the treatment of stress induced reproductive dysfunction. Content: The effect of RRE on oxidative and inflammatory changes in ovarian tissue and reproductive changes of animals exposed to stress with compulsory immobilization method.

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Comparison between antral follicle count and anti-Müllerian hormonal level in the prediction of ovarian response and pregnancy outcome in intracytoplasmic sperm injection patients: implications in personalizing ovarian stimulation
H. Saleh, F. Moiety, A.F. Agameya, Y. Elkassar, R.M. El Sharakwy, D. Zeidan, H. Elmeligy
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 166-173.   DOI: 10.31083/j.ceog.2020.02.5148
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Antral follicle count (AFC) and anti-Müllerian Hormone (AMH) are considered the best markers of ovarian reserve and ovarian response to stimulation. It is not clear whether they complement each other or act interchangeably in predicting ovarian response and individualizing gonadotropin dosage. Objective: To compare the predictive value of AFC and serum AMH for ovarian response and pregnancy outcome in intracytoplasmic sperm injection (ICSI) patients stimulated by an antagonist protocol. Moreover, to decide if measuring both markers adds to the power of predicting a response. Materials and Methods: A prospective diagnostic test study of infertile women. Setting: A private in vitro fertilization unit, Agial Hospital, Alexandria, Egypt. Women aged 20–39 years (n = 700) and undergoing their first ICSI cycle were included in this study. AFC and AMH measurements were taken. All patients were stimulated with a fixed antagonist protocol with a starting dose of 200 IU of recombinant follicle stimulating hormone (rFSH). Main outcome measures included the number of oocytes retrieved and the clinical pregnancy rate. Results: Age, AMH, AFC, and a score combining both AMH and AFC (AMHxAFC) were statistically significant discriminators of the occurrence of an excessive response. The cutoff values for AMH, AFC, and AMHxAFC were > 3.75 ng/mL, > 23, and > 64.8. While AMH and AFC were equally effective in predicting an excessive response, the combined score AMHxAFC was significantly better than AFC or AMH alone. AMH, AFC, and AMHxAFC were significantly better predictors of an excessive response than age. Age, AFC, AMH, and the AMHxAFC were statistically significant discriminators of the occurrence of a poor response; however, AFC was the best predictor of a poor response, with a cutoff < 12. Age, AFC, and AMH were statistically significant discriminators of the occurrence of pregnancy, yet their predictive power is low. Conclusion: Measuring both AMH and AFC adds to their predictive power for a high or an excessive response. AFC alone is an excellent predictor of a poor response and is significantly better than age and AMH. Age, AMH, and AFC have poor predictive power for pregnancy.
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The association between repeated doses of vaginal PGE2 (Dinoprostone, Prostin®) and both maternal and neonatal outcomes among women in the north of Jordan
A.M. Sindiani, H.M. Rawashdeh, E.H. Alshdaifat, O.F. Altal, H. Yaseen, A.A. Alhowary
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (3): 329-334.   DOI: 10.31083/j.ceog.2020.03.5322
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Objective: To evaluate the association between repeated doses of vaginal PGE2 and the maternal and neonatal outcomes for primigravid and multiparous women. Study design: A retrospective descriptive study was conducted at a teaching university hospital in Jordan. The study involved 885 women with singleton live fetuses; these women had been admitted to the labor ward for an induction of labor by vaginal PGE2 (Dinoprostone, Prostin?) for different indications from January 2015 to December 2016. The women were classified according to parity into two main groups, namely, primigravid and multiparous. In the primigravid group, the women who had received two or fewer doses of a vaginal PGE2 tablet (3 mg Dinoprostone) were compared with those who had received a PGE2 tablet three times. In the multiparous group, the women who had received one or two doses of half the usual vaginal PGE2 tablet (1.5 mg Dinoprostone) were compared with those who had received the same dose three times. The main outcomes studied were the cesarean section rate and the APGAR score. Results: There was a statistically significant association, namely, X2 (1) = 13.96, P = 0.001, between the repeated doses of PGE2 and the mode of delivery. This indicates that primigravid women who received more than two doses of PGE2 were more likely to have a cesarean section (65.5%, n = 57 out of 87) compared with primigravid women who received two or fewer doses of PGE2 (42.9%, n = 132 out of 308). There was no significant association between repeated doses of PGE2 insertion and admission either to the nursery or the neonatal intensive care unit (NICU) X2 (1) = 2.11, P = 0.14. Moreover, the results also showed that there was no significant association between repeated doses of PGE2 insertion and the APGAR score X2 (1) = 0.06, P = 0.88. For multiparous women, there was no statistically significant association X2 (1) = 2.15, P = 0.14 between repeated doses of PGE2 insertion and the mode of delivery. Conclusion: In both groups of primigravid and multiparous women, the third dose of vaginal PGE2 was not associated with a significant increase in maternal or neonatal morbidity. In the primigravid group, despite the third dose of PGE2 being associated with a higher rate of cesarean section in comparison with two or fewer doses of it, nearly a third of the women nevertheless achieved vaginal delivery. In the multiparous group, the third dose of PGE2 was not associated with a higher rate of cesarean sections.

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Lung ventilation and the strength of the respiratory muscles of women in the third trimester of pregnancy in the aspect of physical activity
P. Okrzymowska, M. Kurtys, N. Smolarek, M. Kurzaj, R. Slopien, K. Rozek-Piechura
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (3): 324-328.   DOI: 10.31083/j.ceog.2020.03.5186
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The research concerned assessment of the respiratory function and function of the respiratory muscles of women in the third trimester of pregnancy in terms of the level of their physical activity. Using the ATS/ERS assessment criterion, there was no lung ventilation disorder in the studied groups of women. The results of the study indicate that in women who were more active, the values of all measured functional parameters of the respiratory system were higher. In almost all women, irrespective of the level of physical activity, the strength of the inspiratory muscles was found to decrease. The majority of surveyed women undertook physical activity in the form of walking with varying frequency during the week, but only a few of them had undertaken a more intense physical effort. Pregnant women frequently do not undertake more demanding activities due to concerns about the child.

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Miscarriage perceptions and experiences among Saudi women
A. A. Rouzi, R. Alamoudi, J. Turkistani, N. Almansouri, S. Alkafy, N. Alsinani, A. Wazzan
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 208-214.   DOI: 10.31083/j.ceog.2020.02.5088
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Objectives: To assess miscarriage perceptions and experiences of Saudi women. Materials and Methods: Between June 1, 2015, and August 30, 2016, women attending the obstetrics and gynaecology clinics at King Abdulaziz University Hospital in Jeddah (KAUH), Saudi Arabia were asked to participate in a cross-sectional survey. Demographic information, miscarriage opinions, and perceived causes were acquired from the entire cohort. Miscarriage data were obtained from women with miscarriage experience. Results: In a convenience sample of 296 women aged 18 to 57 years, 247 (83.4%) had never become pregnant, of whom 81 (32.8%) had a miscarriage history. Guilt, shame, and feeling alone were reported by 35%, 14%, and 22% of women after a miscarriage, respectively, and 10% reported all three, and 47% reporting none of these feelings. Only 14 (17%) were given a medical cause for the miscarriage, of whom five (36%) believed they had done something to cause it or could have done something to prevent it, compared with 35 of 67 (52%) women who were not given a reason for their miscarriage (p = 0.260). In the entire cohort, the most commonly agreed to causes of miscarriage were stressful event (72%), destiny/fate (65%), long-term stress (64%), lifting (57%), and past abortion (57%). Conclusions: While most participants with miscarriages reported receiving adequate support, there was inadequate knowledge about the causes of miscarriage. New education and support policies are warranted, particularly with regards to behaviours that do not need to be avoided for fear of miscarriage.
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Air travel during pregnancy: an update review and practical recommendation
R. Csorba, P. Tsikouras, A. Bothou, S. Zervoudis, G. Iatrakis, X. Anthoulaki, D. Deuteraiou, A. Chalkidou, G. F. von Tempelhoff
Clinical and Experimental Obstetrics & Gynecology    2019, 46 (6): 862-866.   DOI: 10.12891/ceog4885.2019
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Objective: Nowadays it is easier for pregnant women to travel abroad. The purpose of this review is to insure that healthcare providers advise pregnant women of the risks to travel by airplane. Materials and Methods: The authors provide an overview of the risks of thrombosis in pregnancy to travel by airplane and the risks of miscarriage and preterm labor. This study is based on electronic literature using the best available evidence from PubMed, Medline, Google Scholar, the American College of Obstetricians and Gynecologists (ACOG), the American College of Chest Physicians (ACCP), the Royal College of Obstetricians and Gynecologists (RCOG), and the British Thoracic Society (BTS). Results: In the lack of evidence-based information, physicians and pregnant women should only rely on guidelines and experts’ opinions. Conclusions: In the absence of a reasonable expectation for obstetric or medical complications, occasional air travel is safe in pregnancy. The specific airline recommendations should be always kept in mind.

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Outcome of shared decision-making in a patient with primary herpes gingivostomatitis during pregnancy: a case report
C.Y. Huang, T.C. Chao, H.C. Chien, Y.L. Liu
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (4): 604-606.   DOI: 10.31083/j.ceog.2020.04.5311
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Purpose: The authors present the case of a woman in the 20th week of pregnancy with herpes simplex virus (HSV)-related gingivostomatitis. They also provide information regarding the benefits and risks of acyclovir, valacyclovir, famciclovir, and shared decision-making (SDM) through which valacyclovir was selected. Case Report: A 26-year-old primigravida woman who denied having a history of systemic diseases presented with fever, general malaise, and abdominal pain at 20 weeks of gestation. As no strong evidence supports any current treatment for primary maternal HSV-1 gingivostomatitis during pregnancy, the authors used three key steps of SDM, namely choice talk, option talk, and decision talk, to help the patient make a decision based on the benefits and ill-effects of treatment with acyclovir, valacyclovir, and famciclovir. Valacyclovir was administered for one week. Her general condition improved gradually, and the symptoms abated without recurrence of fever. Conclusions: Thus, SDM-based treatment was effective in this patient.

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Effect of the methanol extract of the Lion’s Mane mushroom, Hericium erinaceus, on bone metabolism in ovariectomized rats
N. Morita, H. Matsushita, A. Minami, S. Shimizu, R. Tachibana, H. Kanazawa, T. Suzuki, K. Watanabe, A. Wakatsuki
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (1): 47-52.   DOI: 10.31083/j.ceog.2020.01.4987
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Purpose: Osteoporosis is a major health concern in postmenopausal women. The aim of the study was to investigate the effect of Hericium erinaceus (H. erinaceus), also known as the Lion’s Mane mushroom, consumption on bone metabolism in ovariectomized (Ovx) rats. Materials and Methods: Rats in the Baseline group were sacrificed immediately, whereas rats in the Sham group underwent sham surgery, and those in the Ovx and Ovx + HE groups underwent bilateral Ovx. A diet containing the methanol extract of H. erinaceus was given to the Ovx+HE group for 13 weeks. Results: There was no significant difference in the femoral bone mass between the Ovx and Ovx+HE groups. In the histomorphometric study of the proximal tibial metaphysis, the osteoblast surface, mineralizing surface, and fat cell number were lower in the Ovx+HE group than those in the Ovx group. Conclusion: The present findings suggest that H. erinaceus does not prevent but rather accelerates bone loss in Ovx rats.

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OEIS complex (omphalocele-exstrophy-imperforate anus-spinal defects) in monozygotic twins: a case report and literature review
Y. Q. Xu, X. L. Chen, S. Zhao, P. W. Chen, X. M. Yin, S. Y. Xiong, Z. Ding, F. Xiong, X. H. Yang
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 154-158.   DOI: 10.31083/j.ceog.2020.02.5141
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The omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex represents severe midline abdominal and pelvic defects of unknown etiology. This complex is rare, affecting 1 in 200,000 to 400,000 pregnancies and is extremely rare in twin or triplet gestations. Here, we report the OEIS complex in a spontaneous monozygotic twin pregnancy and previously reported OEIS complex in twin or triplet pregnancy are reviewed. Spontaneous pregnancy and unremarkable family history, but concordance of monozygotic twins for the defect may support the theory that early malformation complexes, e.g., OEIS, may be related to errors in monozygotic splitting in early blastogenesis.

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Tissue adhesive to repair first-degree perineal tear: a pilot randomized controlled trial
T. Trevisan Teixeira, A. de S. Caroci, W. Sousa Brunelli, M. L. Riesco
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 228-233.   DOI: 10.31083/j.ceog.2020.02.5131
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Purpose of Investigation: This pilot study proposes to verify the feasibility of conducting a randomized controlled trial (RCT) on the use of Epiglu tissue adhesive to repair first-degree tear. Materials and Methods: A pilot RCT was conducted in a birth center in S?o Paulo, Brazil. The sample consisted of 20 women with first-degree tear. These women were randomly assigned to the experimental group (EG=10) - perineal tear repair with Epiglu or the control group (CG=10) - perineal tear repair with absorbable synthetic thread. The measured outcomes were perineal pain, perineal healing, women’s satisfaction, and professional’s time spent repairing the perineum. Results: The intensity of perineal pain was significantly lower among women in the EG than that in the CG in all stages of the study (EG range: 2.0-0.2; CG range: 2.5-0.6). Additionally, perineal healing showed significantly better REEDA scores among women in the EG than those in the CG in all stages (EG range: 0.6-0.0; CG range: 1.8-0.7). Women’s satisfaction was significantly higher in the EG (100% were satisfied or very satisfied) than that in the CG (10% to 20% of them were dissatisfied or very dissatisfied). The mean time spent to repair the perineum was five minutes in the EG and 21 minutes in the CG (p < 0.001). Conclusion: This study shows that it is feasible to undertake an RCT on the use of the tissue adhesive Epiglu for first-degree perineal tear repair during normal birth.

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Prediction of severity of preeclampsia in Egyptian patients: role of neutrophil/lymphocyte ratio, platelet/lymphocyte ratio and C-reactive protein
A. E. Kholeif, M. Y. Khamis, S. Eltabakh, R. S. Swilam, A. Elhabashy, R. EISherif
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 183-188.   DOI: 10.31083/j.ceog.2020.02.5229
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Objective: In this study, the authors aimed to compare and correlate neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and C-reactive protein (CRP) levels in Egyptian patients with different degrees of preeclampsia (PE). Materials and Methods: The authors recruited 105 Egyptian pregnant women with gestational age ≥ 34 weeks. They were divided into 35 normotensive pregnant and 70 PE women, further subdivided into 35 mild and 35 severe PE cases according to ACOG criteria. Results: There was no statistically significant difference between patients with PE and healthy pregnant women as regards to NLR. PLR showed statistically significant difference between the control and severe PE cases and between mild and severe PE cases. CRP levels showed a statistically significant difference between the control and mild PE cases and between the control and severe PE cases. Conclusion: CRP was more sensitive and specific than PLR to predict PE in pregnant females, hence it can be used in prediction of PE. PLR was more sensitive but less specific than CRP to predict severity of PE in pregnant females, therefore PLR can be used for early prediction of severity. NLR cannot be used as a marker for prediction of PE or its severity.
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Bilateral ascending uterine arteries ligation for conservative management of complete placenta previa: three case reports
K. Relakis, A. Pontikaki, I. Kosmas, S. Sifakis
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (1): 144-146.   DOI: 10.31083/j.ceog.2020.01.5109
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Placenta previa (PP) is considered one of the major causes of both antepartum and intrapartum bleeding, which necessitates preterm delivery typically by cesarean section. The optimal management is controversial. Surgical techniques to control severe bleeding after placental removal include uterine/internal iliac artery ligation, compression sutures, and embolization of pelvic vessels; however, cesarean hysterectomy remains the ultimate rescue procedure for uncontrolled maternal hemorrhage. The authors present a modified surgical technique of the uterine arteries ligation for successful management of complete PP. The method was effective and hysterectomy was avoided in all cases. Serious complications such as hypovolemic shock, disseminated intravascular coagulopathy, urinary tract injuries, febrile infections, and uterine necrosis were not recorded. Double bilateral ligation of the ascending uterine arteries before placental removal constitutes a prophylactic method that prevents postpartum hemorrhage and emergency obstetric hysterectomy. This method has an additional advantage as if it proves ineffective for hemorrhage control, the basic steps for cesarean hysterectomy would have been done.

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Forehead and facial heights in Down syndrome and normal fetuses in the midtrimester of pregnancy
I. H. Kalelioglu, S. G. Erzincan, R. Has, A. Yuksel
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 220-227.   DOI: 10.31083/j.ceog.2020.02.5434
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Objectives: To compare forehead height (FH), facial heights (FaHs) and the ratios of biparietal diameter (BPD) and femur length (FL) to these heights in midtrimester normal and Down syndrome (DS) fetuses. Methods: 150 normal and 26 DS fetuses were scanned at 15-25 weeks of gestation. At the mid-sagittal image of the fetal profile, FH, FaH, upper facial height (UFaH) and lower facial height (LFaH) were measured in millimeters with “two line distance” tool. The results were expressed as multiples of the gestation-specific normal median (MoMs) using the regression of the equation derived from normal fetuses. The ratios of BPD/UFaH, BPD/LFaH, BPD/FaH, BPD/FH, FL/UFaH, FL/LFaH, FL/FaH, FL/FH were also assessed. Results: In normal fetuses, FH and FaHs increased linearly with gestational age (GA). UFaH increased linearly from 5.2 mm at 15 weeks to 15.7 mm at 25 weeks. LFaH increased from 9.3 mm at 15 weeks to 32 mm at 25.2 weeks. FaH increased from 16 mm at 15 weeks to 39 mm at 25 weeks. FH increased from 17.7 mm at 15 weeks to 42.8 mm at 25 weeks. Only UFaH was found to be significantly smaller in DS fetuses (with a mean of 0.91 MoM, 95% CI, 0.7-1.1, p = 0.003), than in normal fetuses (1 MoM, 95% CI, 0.6-1.3). Concomitantly, none of the ratios changed with gestation and all were found to be statistically higher in DS fetuses (p < 0.05). Conclusions: UFaH, is smaller in DS fetuses compared with normal fetuses in the midtrimester of pregnancy. The ratios of BPD and FL to all heights are higher in fetuses with DS than in normal fetuses.
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Patient suffering from lichen sclerosus together with partial labial fusion (adhesion) and inflammatory infection of the vulva, vagina and anal area
Grażyna Jarząbek-Bielecka, Małgorzata Mizgier, Jacek Boroch, Magdalena Pisarska-Krawczyk, Mariola Pawlaczyk, Ewa Jakubek, Witold Kędzia
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 315-319.   DOI: 10.31083/j.ceog.2020.02.5167
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The etiology of lichen sclerosus is not fully known, due to its chronic and progressive nature. The predisposing factor is physiological hypoestrogenism, hence the condition concerns girls during their developmental phase considered as estrogen silent (even as early as at the age of 6 months). The paper presents a 5-year-old patient coming from a rural area and suffering from lichen sclerosus together with partial labial fusion (adhesion) and inflammatory infection of the vulva, vagina and anal area. These symptoms intensified after antibiotic therapy the girl had undergone due to a respiratory tract infection. There were changes in the skin of the labia majora and buttocks indicating lichen sclerosus - swelling, traces of scratches, secondary redness, partial fusion of the labia minora on the side of the crotch known as the fourchette, and a runny yellow-white discharge from the vagina.

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Liver rupture as a complication in cardiopulmonary resuscitation for cardiac arrest after vaginal hysterectomy
D. Damnjanovic, M. Zamurovic, D. Zamurovic, S. Krusic
Clinical and Experimental Obstetrics & Gynecology    2019, 46 (6): 1031-1033.   DOI: 10.12891/ceog4980.2019
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Liver rupture is a rare, yet life-threatening complication of cardiopulmonary resuscitation. It occurs as a complication in 0.6-3% cases of cardiopulmonary resuscitation. Its early diagnostics and urgent surgical treatment is thus very important in order to prevent an undesired outcome for the patient. This paper presents diagnostics and treatment of liver rupture resulting as a complication of cardiopulmonary resuscitation (CPR) due to cardiac arrest in the early postoperative period after vaginal hysterectomy performed for uterine myomatosis in a 50-year-old patient.

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Uterine necrosis following selective embolization for postpartum hemorrhage: report of four cases and review of literature
K. Lee, S. Lee, H. N. Lee, H. Lim, I. J. Kim, I. Y. Park, M. J. Kim
Clinical and Experimental Obstetrics & Gynecology    2019, 46 (6): 1020-1025.   DOI: 10.12891/ceog4935.2019
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Uterine necrosis is one of the rare complications that may follow uterine arterial embolization for postpartum hemorrhage (PPH), and its incidence remains unknown. The authors report four cases of uterine necrosis in Korea. The mean time interval between uterine artery embolization (UAE) and diagnosis of uterine necrosis was 72 days. Patients' main symptoms were abdominal pain, fever, profuse vaginal discharge, and vaginal bleeding. Decisions related to management depended on the condition of the patient and the patient's desire regarding conservation of the uterus. Based on these cases, the authors suggest helpful decisions for the therapeutic guidelines for uterine necrosis after UAE.

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Extracellular matrix metalloproteinases in the etiopathogenesis of endometriosis: a systematic review and critical appraisal
M. Ζafrakas, Κ. Κοtronis, P. Papasozomenou, P. Eskitzis, G. Grimbizis
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 147-153.   DOI: 10.31083/j.ceog.2020.02.5140
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Despite extensive research in the field, the etiopathogenesis of endometriosis remains an unresolved enigma. The possible role of different enzymes of the extracellular matrix, in particular the role of the matrix metalloproteases or metalloproteinases (MMPs) in the etiopathogenesis and the mechanisms involved in the processes of benign dissemination of endometriosis have been widely investigated in recent years. Various members of the enzymatic system of the MMPs, as well as their inhibitors, termed tissue inhibitors of metalloproteinases (TIMPs) and their inducer, termed extracellular matrix metalloproteinase inducer (EMMPRIN), have been implicated in the mechanisms involved in endometriosis formation, progression, and maintenance. The aim of the present paper was to provide an overview and critical evaluation of existing experimental evidence on this issue. For this purpose the authors have conducted a systematic review of the literature and evaluated relevant papers regarding experimental animal models, in vitro experiments, and analyses in human samples and studies regarding genetic polymorphisms in humans. In conclusion, members of the system of matrix MMPs, their inhibitors and inducers could be useful as novel diagnostic and prognostic biomarkers in determining the severity of endometriosis and response to therapy. Furthermore, in depth knowledge in this field could possibly lead to the development of more efficient treatment modalities. Future research should focus on the systematic investigation of the entire MMPs system in endometriosis, as well as on the interaction between its members.

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Outcomes of prophylactic and emergency cerclage versus expectant management for cervical insufficiency: a single-center retrospective, comparative study
E. J. Shim, H. J. Kim, I. Y. Kim, K. Y. Oh, Y. S. Yang, C. H. Jin
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 262-267.   DOI: 10.31083/j.ceog.2020.02.5200
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Aim: To compare the outcomes after prophylactic cerclage, emergency cerclage, and expectant management in women with cervical insufficiency. Materials and Methods: From 2011 to 2015, Eulji University Hospital’s database was retrospectively analyzed to identify women with cervical insufficiency without premature rupture of membranes (PROM), clinical chorioamnionitis, or labor pain from 12 to 26 weeks of gestation. Gestational age at delivery, term delivery rate, after-34-weeks-of-gestation delivery rate, intensive-careunit admission rate, neonatal sepsis, and neonatal mortality rate were compared between each group. Results: Forty-eight women underwent prophylactic cerclage: 56 emergency cerclage and 21, expectant management. Prolongation of pregnancy was longer in the prophylactic cerclage group than in the emergency group (22.8 ± 2.7 weeks vs. 13.3 ± 6.1 weeks, p < 0.001). Preterm delivery rate < 34 gestational weeks was significantly higher in the emergency cerclage group than the prophylactic group (37.5% vs. 14.6%, p = 0.009). Elevated pre-cerclage C-reactive protein (CRP) was associated with delivery before 34 weeks in the emergency cerclage group [odds ratio (OR): 15.849; 95% confidence interval (CI): 1.289-194.898, p = 0.031]. Comparing the emergency cerclage and expectant groups, prolongation of pregnancy was higher in the emergency group than the expectant group (13 ± 6.1 weeks vs. 8 ± 5.7 weeks, p = 0.002). However, there were no significant differences between the two groups regarding preterm delivery < 34 weeks and perinatal outcomes. Conclusions: Preterm delivery rate < 34 gestational weeks was higher in the emergency cerclage group than the prophylactic group. There were no significant differences between the emergency cerclage and the expectant groups in pregnancy and perinatal outcomes.
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The efficacy of third-generation cephalosporin plus metronidazole versus third-generation cephalosporin plus clarithromycin in neonatal outcomes and oxidative stress markers in women with preterm premature rupture of membranes
J. W. Kim, Y. H. Kim, J. H. Moon, H. A. Jung, E. J. Noh
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (2): 194-198.   DOI: 10.31083/j.ceog.2020.02.5046
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Purpose of Investigation: The purpose of this study is to compare neonatal outcomes and oxidative stress markers of preterm premature rupture of membranes (PPROM) treated with third-generation cephalosporin plus metronidazole (regimen A) with those treated with third-generation cephalosporin plus clarithromycin (regimen B). Materials and Methods: The present study included patients with singleton pregnancies with PPROM at earlier than 34 gestational weeks who were admitted to the Chonnam National University, Gwangju, Korea, between February 2007 and December 2015. Latency period, neonatal outcomes, and oxidative stress markers (including oxygen radical absorbance capacity, malondialdehyde (MDA), protein carbonyl, and interleukin-6) were compared between two groups. Results: Latency period from PPROM to delivery did not differ between the groups (11.0 ± 13.1 vs. 11.5 ± 8.6, p = 0.791). However, there were no significant differences in rate of latency period longer than seven days. More women were delivered after 48 hour in the regimen B group than in the regimen A group (83.6% vs. 94.7%, p = 0.022). However, there were no significant differences in rate of latency period longer than seven days. There was no significant difference in oxidative stress markers after the administration of antibiotics between regimens A and B. Conclusion: The present results show that there was no difference between the two regimens on the latency period and improvement of neonatal outcomes. Although there was no significant difference in neonatal outcomes, the regimen using third-generation cephalosporin plus clarithromycin may have a beneficial effect for short-term prolongation of pregnancy (up to 48 hours) to allow for the administration of antenatal corticosteroids and transfer to the tertiary center.
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Uterine torsion in the second trimester of pregnancy with a large leiomyoma identified in a cesarean section for abruptio placentae: a case report and literature review
A. Komatsu, K. Kawakami, H. Koike, T. Nagamatsu, Y. Osuga, T. Fujii
Clinical and Experimental Obstetrics & Gynecology    2019, 46 (6): 1026-1027.   DOI: 10.12891/ceog4937.2019
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The authors report a case of uterine torsion in the second trimester pregnancy with a large leiomyoma. A 28-year-old pregnant woman with a leiomyoma approximately 15 cm in size, was diagnosed with preterm premature rupture of membranes (pPROM) and abruptio placentae at 23 weeks and 0 days of gestation. Because the fetal heart rate pattern was extremely variable and decelerated to lower than 70 bpm before a prolonged deceleration to approximately 80 bpm, an emergency cesarean section was performed. Uterine torsion was identified after the uterine incision was sutured. The uterus was rotated 150 degrees clockwise, and the uterine incision had therefore unfortunately been performed in the back wall of the uterus. Because torsion was suspected to result from an increase in uterine size, the existence of a leiomyoma was viewed as the main cause of uterine torsion in this second trimester of pregnancy. This case indicates that it is important to consider the potential risk of uterine torsion when indicated, especially in cases with a risk of having a large leiomyoma.

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Pelvic floor rehabilitation in patients with levator ani muscle avulsion
J.A. García-Mejido, C. Suarez-Serrano, E.M. Medrano-Sanchez, M.J. Bonomi Barby, A. Armijo Sánchez, J.A. Sainz
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (3): 341-347.   DOI: 10.31083/j.ceog.2020.03.5252
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Objective: To determine if physiotherapy treatment applied to patients with levator ani muscle (LAM) avulsion identified after a vaginal delivery, reduces the LAM hiatus area. Material and Methods: A prospective observational study of 52 nulliparous (26 in the experimental and 26 in the control group). We included patients with LAM avulsion, diagnosed by 3-4D/transperineal ultrasound performed 3 months after delivery. Patients in the experimental group underwent a program of pelvic floor exercises, assisted by biofeedback and lumbopelvic stabilization exercises. Assessment of LAM was carried out at 6 and 9 months postpartum, using 3-4D/transperineal ultrasound, and taking the following measurements: levator hiatus area at rest, during Valsalva and at maximum contraction; LAM area, and thickness of right and left LAM. Results: Patients in the experimental group presented a reduction in the levator hiatus area at rest (17.0, 15.7, 15.9 cm2), during Valsalva (23.0, 20.8, 19.9 cm2) and at maximum contraction (15.6, 14.4 and 13.5 cm2), in comparison with patients in the control group, who presented a levator hiatus area at rest of 17.4, 17.2 and 16.8 cm2, during Valsalva of 21.0, 20.8 and 20.3 cm2, and at maximum contraction of 16.6, 16.1 and 15.6 cm2, at 1, 6 and 9 months postpartum respectively (P < 0.05). However, no changes were appreciated in the successive examinations regarding LAM area between study groups: experimental 9.5, 8.9, 9.6 cm2 versus 8.9, 9.0, 9.2 cm2 in the control group. Conclusions: Physiotherapy treatment based on pelvic floor exercises with lumbopelvic stabilization exercises in patients with LAM avulsion reduces the levator hiatus area at rest, during Valsalva and at maximum contraction.

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Mechanistic study of vitamin C attenuation of endometriotic fibrosis
X.J. Shi, L.B. Shi, S.Y. Zhang
Clinical and Experimental Obstetrics & Gynecology    2020, 47 (3): 383-390.   DOI: 10.31083/j.ceog.2020.03.5297
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Background: Endometriosis is a common disease in females that seriously affects quality of life. The principal pathological process of endometriosis is pelvic inflammation, and local and peripheral fibrosis. Treatment of endometriosis requires both pharmacological and surgical approaches. Vitamin C can scavenge oxygen free radicals and thus accelerate repair of damaged endometrium. This aim of this study was to investigate whether vitamin C can reduce fibrosis in endometriotic lesions. Methods: After establishing a rat model of endometriosis, vitamin C solution (vitamin C group) or physiological saline solution (control group) was injected into the abdominal cavity. We compared the indices of fibrotic endometriotic lesions between the two groups. Results: The volume of endometriotic lesions and degree of fibrosis observed in rats within the vitamin C group was significantly reduced compared with those observed in the control group. Immunohistochemistry showed that transforming growth factor-β1 (TGF-β1), connective tissue growth factor (CTGF), α-SMA, and collagen type I staining in lesions of the vitamin C group was significantly less than that observed in lesions from the control group (P < 0.05). Quantitative, real-time PCR (RT-PCR) determined that relative mRNA expression levels of TGF-β1, CTGF, α-SMA, and collagen type I in lesions obtained from the vitamin C group were significantly lower than levels measured in lesions obtained from animals in the control group. Conclusion: Vitamin C can reduce the volume of endometriotic lesions and inhibit fibrosis of lesions in rats. This study supports the use of vitamin C in the treatment of endometriosis.

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Pregnancy complicated with colon cancer: a case report and review of the literature
S.Z. Yang, J.J. Yu, Y.R. Mao
Clinical and Experimental Obstetrics & Gynecology    2019, 46 (6): 1028-1030.   DOI: 10.12891/ceog4920.2019
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Colorectal cancer in pregnancy is a rare disease and the authors present the case of a 29-year-old patient along with a review of the literature.

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