فاطمه وحیدرودسری

Gestational trophoblastic neoplasia (GTN) is a curable disease that involves the development of malignant tumor in the woman after a normal or molar pregnancy. The position of surgery in GTN is not properly specified and is changing due to new chemotherapy protocols. However, the role of surgery is highlighted in chemotherapy-resistant GTN. Other indications of surgery in trophoblastic diseases are drug toxicity and uterine perforation. Based on the fact that most women in certain age tend to preserve fertility, this study reported 4 cases of successful treatment after fertility sparing surgery.

Case:

 A hospital-based case-report study was carried out to investigate the role of surgery in 4 patients with GTN. In this study, acute complications, such as intra-abdominal bleeding and liver dysfunction due to chemotherapy occurred in some patients. Surgery was performed and all cases underwent localized tumor removal while preserving the uterus. No hysterectomy surgery was performed.

Surgery is supposed in specific cases of GTN, who desire preserving fertility.

Chlamydia trachomatis is one of the most common diseases as sexually transferred in world. According to the World Health Organization statistics, approximately 92 million new Chlamydia trachomatis infection occur in the world. Chlamydia trachomatis (CT) is the cause of tubal obstruction, ectopic pregnancy and infertility in women. The aim of this study is prevalence evaluation of Chlamydia Trachomatis by PCR in female infertile referred to Montasarieh study center of infertility in Mashhad. The cervical swab specimens were collected from 100 infertile (as case) and 30 fertile (as control group) women attending to the infertility center of Mash-had Medical University. DNA extraction was performed from clinical specimens using DNA extraction kit. In this study, in addition to PCR reaction by commercial kit, PCR test was performed using specific primers and probe for CTCP gene. The results of PCR reaction using the kit was match with PCR test and showed that the prevalence of Chlamydia trachomatis is 21% in infertile women and 3.3% in normal fertile women that was statistically significant (p=0.024). Considering the high sensitivity of PCR method for diagnosis of Chlamydia trachomatis infection, this method can be useful for routine screening.

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. 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. 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.

Comparison of albumin and cabergoline in the prevention of OHSS. 95 high risk infertile women for OHSS (more than 20 follicles in both ovaries at day of Human Chorionic Gonadotropin (HCG) injection) were randomly divided into two groups. First group including 48 women received 10 unit intravenous albumin at starting oocyte retrieval, and second group including 47 women received 0.5 mg/day dopamine agonist (Cabergolin) at day of HCG injection till 8 days. The dosage of human Menopausal Gonadotropin (HMG) used, total number of follicles developed, number of oocytes retrieved, serum E2 concentrations during the luteal phase, development of ascites, number of embryos generated, clinical pregnancy rate, results of the in vitro fertilization-embryo transfer (IVF-ET) cycles and incidence and severity of any OHSS were evaluated. There was evidence of a statistically significant reduction in the incidence of OHSS in the cabergolin group (53.7%) versus albumin group (46.3%) (p=0.04). But there was no significant difference of a reduction in severe OHSS (p=0.62). There was no difference in clinical pregnancy rate too. Administration of cabergolin can prevent incidence of OHSS and does not appear to effect on its severity. Ovarian hyperstimulation syndrome (OHSS) is the most serious and potentially life-threatening iatrogenic complication associated with ovarian stimulation during Assisted Reproductive Technology (ART) protocols. OHSS typically is a result of ovarian expression of vascular endothelial growth factor (VEGF) which increases vascular permeability.

Abortion is a medical or surgical termination of pregnancy before the fetus is able to survive. Because of surgical complications، medical treatments are most commonly used. Since misoprostol (a prostaglandin E1 analogue) is cheaper، effective، and easily administrated by different methods، has been widely prescribed. The aim of this study was to evaluate vaginal and sublingual misoprostol for termination at second trimester pregnancy in patients with previous cesarean section.

This analectic-descriptive study was held on 70 pregnant women with previous cesarean section who referred for termination at second trimester pregnancy to Mashhad University of medical sciences academic hospitals. They were randomly divided into two groups of vaginal misoprostol 400μg max dose of 1600 μg and sublingual misoprostol 400 μg، next dose of 200 μg، and max dose of 1600 μg. Abortion complications and outcomes were analyzed in every individual. P value less than 0. 05 was considered statistically significant.

Mean age of patients was 29. 25±5. 48 years. Mean of reproductive age in all patients was 17. 90±4. 31 weeks (range 14-29 weeks). In each groups 3 persons (9%) had fever. Nausea was observed in 5 persons (7%) (4 people in vaginal and one person in sublingual group). There was no significant difference between two groups (p>0. 05). Among the cases، no one needed to undergo curettage and no one had uterus rupture.

Prescription of vaginal and sublingual misoprostol for medical termination of pregnancy at second trimester in person with previous cesarean section had less complication، and is very effective.

Delivery is the final and the most important part of pregnancy، and ripening of cervix is one of the main aspects of labor progress. Coitus in late pregnancy may stimulate cervical ripening and secrete prostaglandin which may lead to uterine contractility and labor onset. The aim of this study was to evaluate the relationship between sexual intercourse and onset of labor and prevention of post term pregnancy. This prospective study was held on 212 pregnant women over 39 weeks of low-risk referred to gynecology clinics at Ghaem and Omolbanin hospitals. Samples were selected by non-probable method based on objectives. Eligible individuals were chosen and categorized into two groups of control (102 persons) and case (110 persons). The Control group had no sexual intercourse until delivery. In case group first vaginal examination and Bishop Score determination and non-stress were done then they had sexual intercourse from the week 39 once or twice a week. Collected data were analyzed by the statistical SPSS software version 16، t-test، chi-square and Mann-Whitney tests. P value less than 0. 05 was considered statistically significant. The mean gestational age in two group had not significant different (p=0. 3)، need to stimulated delivery (p<0. 0001)، and rate of cesarean section (p<0. 034) were significantly lower while the Bishop scores was higher in the case group (p<0. 002). There was no difference in post term pregnancy (p<0. 88) and complication of delivery (p<0. 68) between two groups. Sexual intercourse at term may be associated with an earlier spontaneous onset of labor and less need to induction of labor and low cesarean section.

Normal female sexual function has an important role in feel healthy and increasing quality of their life. Attitudes, tendencies and understanding of sexual partner in sexual relationship, can be accounted as some branches of attachment to parents. According to Bowlby’s important theory about attachment and less access to studies that tested hypothesis derived from this theory about sexual problems, this research is accomplished to determine the relationship between adult attachment style to parents with female sexual function. This research is a kind of descriptive-correlation study, that 161 married women, between 15-44 years were selected by Ghaem Hospital and obstetricians’ of offices, in Mashhad. Data were collected by questionnaires of adult scale of parental attachment during their childhood, and female sexual function index. Data were analyzed by SPSS using liner regression; confidence coefficient was considered 95%. The entire domain of sexual function except sexual lubrication were related to secure attachment style to mother and all the domain of sexual function except sexual painless was negatively related to distant attachment style to father (P<0.05) Maternal secure attachment and paternal insecure distant attachment play important role in adulthood sexual function in the adulthood which is in agreement to Bowlby's findings

The physiological changes in thyroid gland during pregnancy have been suggested as one of the pathophysiologic causes of preeclampsia. The aim of this study was comparison of serum levels of Tri?iodothyronine (T3), Thyroxine (T4), and Thyroid?Stimulating Hormone (TSH) in preeclampsia and normal pregnancy. In this case?control study, 40 normal pregnant women and 40 cases of preeclampsia in third trimester of pregnancy were evaluated. They were compared for serum levels of Free T3 (FT3), Free T4 (FT4) and TSH. The data was analyzed by SPSS software with the use of t?student, Chi?square, Independent sample T-test and Bivariate correlation test. p?0.05 was considered statistically significant. The mean age was not statistically different between two groups (p=0.297). No significant difference was observed in terms of parity between two groups (p=0.206). Normal pregnant women were not significantly different from preeclampsia cases in the view of FT3 level (1.38 pg/ml vs. 1.41 pg/ml, p=0.803), FT4 level (0.95 pg/ml vs. 0.96 pg/ml, p=0.834) and TSH level (3.51? IU/ml vs. 3.10? IU/ml, p=0.386). The findings of the present study do not support the hypothesis that changes in FT3, FT4 and TSH levels could be possible etiology of preeclampsia.

Placenta accreta is a life-threatening complication after previous cesarean delivery. The aim of this case report is to present a case of placenta percreta with bladder involvement and subsequent maternal death.

The patient was a 37-year old who had an unwanted pregnancy due to tubectomy failure two years afterwards. She was hospitalized at 26th and 30th week of gestation because of gross hematuria. Sonography reported placenta previa. Cesarean section was performed at 34th gestational week. Due to severe hemorrhage, hysterectomy with resection of some part of the bladder was done. Died at the operating room after four hours of severe uncontrollable hemorrhage.

The increasing prevalence of different forms of placenta accreta is the result of the ever-increasing rate of cesarean deliveries. One of the strategies to prevent this catastrophic obstetric complication is decreasing the number of cesarean deliveries without appropriate indications.

Sometimes despite an unripe cervix, induction of labor may be needed. In these cases, safe and suitable method should be considered for cervical ripening and pregnancy termination. The aim of this study was to assess the comparison of vaginal misoprostol with foley catheter for cervical ripening and induction of labor. This randomized clinical trial was performed on 110 pregnant women referred to the teaching hospit-als of Mashhad University of Medical Sciences during a time period of September 2007 to March 2008. The women were randomly divided into two groups: misoprostol (49 cases) and foley catheter (59 cases). For first group, 25 microgram vaginal misoprostol every 4 hour up to maximum 6 doses was administered. For second group, foley catheter 18F inflated with 50 cc of sterile water was placed through the internal os of the cervix. Data was analyzed by SPSS software. P < 0.05 was considered statistically significant. Two groups were similar in the view of demographic characteristics, cesarean indications, maternal-fetal outcomes and neonatal outcomes. Vaginal delivery was significantly higher in misoprostol group (89.9 vs. 62.7, P = 0.001). The mean of delivery time was significantly shorter in misoprostol group (11.08 ± 5.6 vs. 13.6 ± 16.0 h, P < 0.05). In the case of need to pregnancy termination and unripe cervix, two methods of misoprostol and foley catheter are suitable, but it seems that misoprostol decreases time of delivery and need to cesarean more than the other.

Increase of blood pressure is from prevalent disorders that can increase maternal and fetal-neonatal morbidity and mortality. The aim of the study was to survey the effect of prepregnancy body mass index (BMI) on the development of gestational hypertension and preeclampsia. This case-control study was performed on 200 pregnant women referred to maternity of Qaem Hospital related to Mashhad University in 2007. According to body mass index, the patients were divided into four groups (50 in each group) including gestational hypertension group, mild preeclampsia, severe preeclampsia and control group. Blood pressure, height and weight of pregnant women were measured carefully and BMI was calculated and then compared with prepregnancy BMI. In control group mean BMI before pregnancy was 24±3 kg/m2 and in gestational hypertension group was 26.1±5.4 and in mild preeclampsia group was 26±1 kg/m2 and in severe preeclampsia group was 26±4.1 kg/m2. There was a significant difference between prepregnancy BMI and three other groups. (p<0.05). According to the relationship between prepregnancy BMI and gestational hypertension and severe preeclampsia, we can suggest the women who have intended to be pregnant and have high weight that with the decrease of the prepregnancy weight can reduce mortality and morbidity in pregnancy.

Success rate of IVF depends on infertility factors and its treatment cycle. Different methods of treatment and different centers have reported various rates of success. The aim of this study was to evaluate the fertility outcome after IVF and related factors. This descriptive analytic study was performed on 150 infertile couples following IVF in Montaserieh Infertility Center, Mashhad University of Medical Sciences, Mashhad, North – East of Iran during 2001-06. Data was collected by a questionnaire including woman's age, husband's age, infertility factor, spermogram, infertility period, the number of follicles caused by treatment, the number of oocytes, the number of produced and transferred fetus and treatment outcomes. Data was analyzed by SPSS software and Chi-square, t-studen test, One-way ANOVA and logistic regression. The mean age of women was 29.7±5.4. The mean±SD follicles oocytes and transferred fetus were 11±6, 6±3.9 and 2.6±1.5 respectively. There was significant relation between the number of follicles (P<0.05), obtained oocytes (P<0.05) and transfered fetus (P<0.05) with the success rate of IVF. The fertility rate was 24.6%. There was no significant relation between the age groups and fertility rate. This study showed that ovarian response to ovulation stimulation and the number of transferred fetus are the important and effective factors for predicting the outcomes of IVF.

Exercise could play an important role in health keeping during pregnancy. Few studies have been done to elucidate the causes of these effects of exercise in pregnancy outcomes in women. Due to the probability of poor outcomes of pregnancy accompanied by economic, physical and psychological consequences this research was carried out in order to investigate the effects of some simple exercises and proper daily activity on the outcome of pregnancy. This experimental study was conducted on 138 of pregnant women that were in eighth to twelfth weeks of their pregnancy who referred to the either health centers or the clinics of gynecologists for control of pregnancy. They were selected by block sampling methods. After thorough explanation of the goals of the study and obtaining the written consent, the enrolled women were randomly attributed into two study and control groups. The study group included 66 women and control group included 72 women. The research had four stages: 1) taking history, 2) a teaching program for study group, 3) collecting data, 4) assessment and analyzing data using Chi-square and T tests.The enrolled women in the study group did 60 minutes of light aerobic exercises for every other day for 30 weeks. The enrolled women in the study and control groups had normal labor in 98.4% and 61.1%, respectively. The Chi-square test showed significant differences between both groups based on parturition sort (χ2=14.5, p<0.05). Odd ratio of natural parturition in the study group was 5.36. The T test showed the significant statistical difference between both groups on the first minute Apgar score (P<0.009, t=0.85) and the fifth minute Apgar score (P<0.001; t=2.80). But there was no significant difference of the average weight gain of enrolled women during pregnancy between two groups. Findings of our study showed that doing exercises during pregnancy period not only resulted in no harm to the mother and fetus but also improved outcome of pregnancy.

Abortion is one of the prevalent problems of obstetrics throughout the world. Standard and usual method for pregnancy termination at first trimester is surgery (curettage). Another effective pregnancy termination method at first trimester is the use of medical treatments. The aim of this study is to compare the efficacy of misoprostol alone or in combination with methotrexate for termination of pregnancy at first trimester. This study is a Randomized Clinical Trial. A total of 200 pregnant women at first trimester of pregnancy were randomly divided into two groups for termination of pregnancy. First group received misoprostol alone (800 mg, vaginal, one or two dose) and second group received misoprostol in combination with methotrexate (50 mg/m2/IM and 800 mg vaginal misoprostol in one or two dose was administered 72 hours later). Sonography was administered at seventh day for both groups and curettage was done if pregnancy was continued or if fetus residual was existed.Successful abortion rate was 83% at first group and 81% at second group. There was a significant relation between dose of misoprostol and need for curettage and a significant relation between kind of pregnancy and need for curettage in both groups (P = 0.001 and P < 0.001, respectively). But there was no significant relation between gestational age and number of drug declaring in both groups (P = 0.934). No adverse events or side effects were reported side-effects were reported with the use of misoprostol and methotrexate. Pregnancy termination with medical method along with misoprostol alone or in combination with methotrexate is safe and cost effective.

Preeclampsia is a common gestational disorder which complicates 5-8% of pregnancies and it is associated with maternal, fetal and neonatal morbidity and mortality. Alterations in serum calcium (Ca) and magnesium (Mg) levels have been suggested as effective factors in causing preeclampsia. This study was conducted to compare serum calcium and magnesium levels in preeclamptic and normal pregnant women. In this case-control study, 50 preeclamptic and 50 normal pregnant women referring to Ghaem Hospital, affiliated to Mashad University of Medical Sciences, were selected during 2005. Blood samples of both groups with similar gestational ages were collected and compared for calcium and magnesium concentrations. The data were analyzed by student t-test, 2, Kolmogorov-Smirnov, Fishers exact tests and a general linear model. The demographic data in the two groups, had no significant difference (P<0.01) but there was a significant difference between them in terms of smoking history (P<0.05). Serum magnesium levels in the preeclamptic women were significantly lower than those of individuals with normal pregnancy (1.920.37 mg/dl vs. 2.290.69 mg/dl), (P<0.01) while calcium levels had no significant differences (9.160.75mg/dl vs. 9.471.58 mg/dl). This study revealed that serum magnesium level in preeclampsia is lower than that of the normal pregnant women. This result may support the hypothesis on the role of magnesium deficiency in preeclampsia pathophysiology and suggest the usefulness of its assessment in the early diagnosis of the disorder.

Placenta increta is an uncommon and life-threatening pregnancy complication. This disorder usually is presented with vaginal bleeding during difficult placental removal in the third trimester of pregnancy. However, the disorder may cause some other complications such as abortion at the first or second trimesters of pregnancy too, which make its diagnosis more difficult. This report discusses a case of hysterectomy due to placenta increta at the first trimester of pregnancy.

A 34-years old woman was admitted to Imam Reza Hospital in Mashad, with a history of severe vaginal bleeding. Evacuation curettage had been done due to incomplete abortion at her first admission in another hospital 18 days ago. She had a history of two previous cesarean sections too. Curettage was done to control the severe hemorrhage with a probable diagnosis of incomplete uterine evacuation. Since hemorrhage was not controllable, the patient was consulted for hysterectomy. Afterwards, the pathology report confined the diagnosis, reading “Lower uterine segment with placenta increta”.

Women with a history of previous caesarean sections are at risk for abnormal placentation. The condition is prone to complications such as uncontrollable vaginal bleeding in the first trimester which might necessitate immediate hysterectomy because of the complications due to abnormal nature of placenta increta.

About 10-15% of women in the reproductive ages suffer from infertility. The most common cause of infertility with female factor is ovulation disorders (35-40%) and among them polycystic ovary syndrome (PCOS) is the most common. These patients suffer from insulin resistance, obesity and increase in androgens; many recent studies have focused on the effects of insulin sensitizing agents like metformine on the patients with PCOS. The aim of this study was to evaluate the efficacy of the three therapeutic methods of clomiphen citrate (CC), metformine and clomiphen citrate plus metformine on infertile women with PCOS. This clinical trial study performed in the year 2004 at Montaserie Hospital of Mashhad University of Medical Sciences, on three groups of 20 PCOS Patients. This study was approved by the local committee of medical ethics. The women in the first group were treated with clomiphen citrate, the second group with metformine and the third group with clomiphen plus metformine for 3 months. Data were analyzed by SPSS software, by using t-student and c2. p£0.05 was statistically significant. Over all twenty nine (48.3%) of women conceived, with the highest rate (%70) belonging to the group treated with clomiphen citrate plus metformine (group three). There was a significant difference comparing to the other two groups (p=0.028). This finding was even more significant in the cases with high levels of serum testosterone and hirsutism. Combination of metfomine plus clomiphen citrate significantly improves ovulation and pregnancy rates in patients with PCOS

Uterine cervical incompetence is one of the risk factors for preterm labor and it is characterized by painless cervical dilatation and prolapse of membranes into the vagina in the second or third trimester of pregnancy. The aim of this report is to discuss a term pregnancy following complete bed rest in cervical insufficiency.

A 24-year old woman with a history of uterine cervical incompetence was admitted to hospital with cervical dilatation and effacement at the 24th week of gestation. She had a successful term pregnancy with bed rest and expectant management at the 39th week of gestation.

Expectant management with bed rest in an appropriate position, along with anti-coagulant prophylaxis is an effective and safe method for the management of cervical incompe-tency in advanced stages of pregnancy.