Batool Hossein Rashidi, M.D.
The Journal of Family & Reproductive Health (JFRH) is the quarterly official journal of Vali–e–Asr Reproductive Health Research Center. This journal features fulllength, peerreviewed papers reporting original research, clinical case histories, review articles, as well as opinions and debates on topical issues. Papers published cover the scientific and medical aspects of reproductive physiology and pathology including genetics, endocrinology, andrology, embryology, gynecologic urology, fetomaternal medicine, oncology, infectious disease, public health, nutrition, surgery, menopause, family planning, infertility, psychiatry–psychology, demographic modeling, perinatalogy–neonatolgy ethics and social issues, and pharmacotherapy. A high scientific and editorial standard is maintained throughout the journal along with a regular rate of publication.
Perineal Massage for Prevention of Perineal Trauma and Episiotomy During Labor: A Systematic Review and Meta-analysis
Objective: Vaginal births are associated with a certain degree of trauma to the genital tract, with significant short-term and long-term morbidity. Awareness of morbidity following perineal trauma has led to application of different interventions during the late first stage and second stage of labour to prevent severe perineal trauma. This includes techniques such as perineal massage, warm and cold compresses, and perineal management techniques. Objective of this meta-analysis is to evaluate the effect of perineal massage during the late first stage and second stage of labour on the rate of episiotomy and risk of perineal trauma.
Materials and methods: Electronic databases (PubMed, Scopus, Cochrane Library and Science Direct) were searched from inception until August 2021. We included randomized controlled trials (RCTs) which compares perineal massage during labor (i.e., intervention group) with a control group in women with singleton gestation and cephalic presentation at ≥36 weeks. The primary outcome was severe perineal trauma and the rate of episiotomy. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI).
Results: Ten trials including 4,088 women were analyzed. Women with perineal massage during labor had a significantly lower incidence of severe perineal trauma (RR: 0.52, 95% CI 0.29- 0.94) compared to the control group. The incidence of episiotomy was lower in the perineal massage group (RR: 0.71, 95% CI 0.52-0.98 p < 0.01) but was statistically insignificant (P>0.05).
Conclusion: The finding of meta-analysis showed that perineal massage during labor could be effective in reducing the risk of severe perineal trauma, such as third- and fourth-degree spontaneous lacerations during labor.
Increased Surveillance or Increased Scrutiny: Curbing Inappropriate Screening of Endometrial Cancer in Transgender Men
Objective: The transgender male body is often considered a “black box” by even the most senior of attending physicians. Because of the stigma and fear associated with the utilization of Hormone Replacement Therapy (HRT) and the lack of clinical knowledge surrounding the subject, many transgender men will experience unnecessary testing for endometrial cancers.
Materials and methods: This narrative review looked through publicly available PubMed and GoogleScholar articles on the topic of the use of pelvic ultrasounds in gynecological screening in transgendered males. 18,000 articles were filtered by relevance, date, clarity of the topic, and clinical recommendations. Of these articles 37 were included for discussion.
Results: Of these 18,000 articles, only 37 were included for discussion. The resulting table, diagnostic tree, and discussion section are included within.
Conclusion: Herein, the authors discuss the current understanding of the role of imaging in the diagnosis and treatment of gynecological cancers in transgendered men and how unnecessary imaging studies can be curbed for the benefit of the patient and the medical system at large.
Comparative Analytical Study of Dinoprostone Gel and Hyaluronidase Injection for Induction of Labour in Term Primigravida in Tertiary Rural Medical Centre of Western Uttar Pradesh
Objective: To compare the efficacy of intracervical dinoprostone gel and hyaluronidase injection for induction of labour in term primigravida.
Materials and methods: This is a hospital based analytical prospective interventional study conducted in a rural tertiary care centre over a period of 18 months. A total of 70 patients who required induction of labour for one or another reason with Bishop score of less than 6 were included in the study. All the cases were randomly divided into two groups, Group A received dinoprostone gel and Group B received hyaluronidase injection. Chi square test & unpaired T test were applied for statistical analysis.
Results: Time interval from induction to active phase of labour was comparatively shorter in group A than in group B (10.74 ± 6.17 vs 15.94 ± 7.1) and the difference was significant (p= 0.001). Time interval from induction to delivery time was comparatively shorter in group A than group B (14.84 ± 8.86 vs 21.33 ± 7.86) and difference was significant (P= 0.009). Maternal complications were more common in group A as compared to group B.
Conclusion: This study showed that labour could be accelerated significantly by intracervical injection of hyaluronidase. Hyaluronidase injection has less maternal and fetal side-effects as compared to dinoprostone gel and can be a good choice for induction of labour.
Epidemiological Features of Spontaneous Abortion in the North Africa and the Middle East From 1990 to 2019: Results From the Global Burden of Disease Study 2019
Objective: Spontaneous abortion is one of the most common problems which a woman may encounter during her pregnancy which is one of the most important causes of maternal death. Therefore, the aim of this study was to report the epidemiological features of spontaneous abortion in North Africa and the Middle East (NAME) countries.
Materials and methods: The study population included 21 countries in the NAME region with a population of more than 600 million. The Global Burden of Disease (GBD) 2019 database was used. Incidence rates, the prevalence rates, death rates, the disability adjusted life years (DALYs) rates by age-standardized rate (ASR) per 100,000 people were measured. Also, the attributed burden to iron deficiency was reported.
Results: In 2019, the highest prevalence 39.44 (95% CI, 24.58_ 59.26) and incidence 4794.16
(95% CI, 3491.77_ 6353.03) rates of spontaneous abortion were in Afghanistan. In 2019, the
highest spontaneous abortion related-death 5.88 (95% CI, 3.23_ 8.97) and DALYs 339.12 (95% CI, 184.29_ 516.95) rates by ASR were in Yemen. In MENA, average prevalence (44.7 to 19.82) and incidence (5434.95 to 2409.61) rates have decreased by nearly 56%, and also average death (1990 4.51 to 2019 0.48) and DALYs (263.15 to 29.37) rates have decreased by nearly 89% between 1990 and 2019. The highest spontaneous abortion-related DALYs rate was attributed to iron deficiency. In 2019, Yemen (29%) had the highest attributed burden to iron deficiency.
Conclusion: This study on 21 countries in the NAME region with a population of more than 600 million showed that average prevalence and incidence rates of spontaneous abortion have decreased by nearly 56%, and also average and the disability adjusted life years (DALYs) rates have decreased by nearly 89% between 1990 and 2019.
Objective: Due to the Covid-19 pandemic crisis, which causes stress and threatens health, especially in vulnerable groups including pregnant women, the present study was conducted to determine the effect of individual counseling on the pregnant women’s stress of Covid-19.
Materials and methods: In this randomized controlled clinical trial, 66 pregnant women in 24 to
28 weeks were randomly divided into two groups of intervention (33 participants) and control
(33 participants). At the beginning of the study, both groups completed the questionnaires of demographic information and pandemic related pregnancy test. Then, the intervention was performed in 3 sessions with the interval of one week, in the form of individual counseling by BELIFE method for the experimental group. The control group received only the routine services of the centers. The post-test was performed two weeks after the last consultation session for both groups. Data were analyzed using Stata-13 software. Significance level was considered 0.05.
Results: The experimental and control groups were almost homogeneous in terms of quantitative and qualitative demographic variables. Total mean and standard deviation of stress score, before and after the intervention in the experimental group, were 40.27 ± 12.65 and 41.71 ± 1.74, respectively. These numbers in the control group were 33.84 ± 13.08 and 43.84 ± 1.69. Comparing the two groups in terms of stress score which was done after the intervention showed that although the stress score in the experimental group was lower than that in the control group, this difference was not statistically significant (p = 0.39).
Conclusion: The results of this study show that although individual counseling for pregnant women was able to reduce the mean scores of stress of Covid-19 in the experimental group, this difference was not statistically significant. Therefore, although the BELIFE individual counseling method for pregnant women, who naturally suffer from pregnancy stress, is an acceptable way to reduce their stress, it is recommended to plan and implement early and more effective interventions for these women because the course of stress is severe in them and has an upward trend during Covid-19 pandemic.
The Effect of the Time Interval From Sperm Processing to Intrauterine Insemination on the Pregnancy Outcomes of Infertile Women
Objective: Intrauterine insemination (IUI) is the first-line treatment in couples suffering from various causes of subfertility and infertility. Considering the relatively low rate of pregnancy achieved with each cycle in this method, optimizing various steps in the process including the time interval from sperm collection to IUI may result in an increased rate of success. The goal of this study was to assess the impact of time intervals from the end of sperm processing to IUI (SP-IUI) on the pregnancy rate in IUI.
Materials and methods: This single-center prospective cohort study evaluated couples with normal male partner sperm analysis and idiopathic female infertility undergoing IUI from 2018 to 2021. Cycles were stimulated using subcutaneous recombinant FSH and oral Letrozole. Ovulation was triggered using GnRH antagonist when the leading follicle’s size reached greater than 14mm. The participants were placed in one of the three groups based on SP-IUI: group 1 (0–60 min), group II (60–90 min), and Group III: (>90 min).
Results: 269 couples were included in the study. Sperm processing expectedly resulted in an increased concentration of total sperm count and sperm motility (P<0.001). The rate of chemical or clinical pregnancy, abortion, IUFD, multigestation, pregnancy, term birth, and ectopic pregnancy was not significantly different across study groups (P>0.05).
Conclusion: The results of this study suggest that SP-IUI intervals evaluated in this study do not vary in terms of pregnancy rate or adverse pregnancy outcomes in IUI with normal male partner semen analysis. Hence, infertile couples can be flexible in the collection of semen specimens without time and site (at home or hospital) limitations.
Objective: Worldwide, preeclampsia (PE) is a multifactorial disorder reported in 2–5% of pregnancies, which increases mortality during pregnancy. In general, 10–15% of maternal deaths are directly related to PE and eclampsia. One of the susceptibility genes for PE is tumor necrosis factor-α (TNF-α) expressed by most immune cells. TNF-α is a protein involved in various biological processes, including proliferation and apoptosis, as well as the expression of inflammatory genes. The goal of this study was to investigate the role of TNF-α single nucleotide polymorphism (SNP) -308G/A (rs1800629) and their relationship with TNF-α in PE patients.
Materials and methods: The SNP was genotyped in 90 cases and 90 controls. Whole blood was collected from women with PE and normal pregnancy in EDTA containing tubes, and DNA extraction was performed from their blood lymphocytes according to a standard phenol-chloroform procedure. Then, DNA was genotyped by real-time PCR and the polymorphism was detected by TaqMan assay. Serum levels of TNF-α protein were measured by enzyme-linked immunosorbent (ELISA) assay.
Results: TNF-α levels in women with PE were significantly higher than in healthy ones (p<0.001). We did not observe any correlation between allelic outbreak (p=0.3) and TNF-α-308G/A polymorphism (p=0.7) with the incidence of PE.
Conclusion: Although TNF-α-308G/A gene polymorphism does not appear to affect susceptibility to PE, an increased level of serum TNF-α can be used as a predictor for PE during pregnancy. We recommend that more research be conducted on possible factors related to the incidence of PE
Objective: To investigate the effect of cold plasma on Staphylococcus aureus destruction at different treatment times.
Materials and methods: Staphylococcus aureus was cultured on 4 plates of LB Agar medium each at
1.5 × 103 CFU / mL (colony-forming unit per milliliter) and one group was selected as the control group and the other 3 groups were treated with plasma for 5, 7 and 10 minutes. They were incubated for
24 hours at 37 °C. Finally, the number of colonies formed was counted.
Results: It was shown that treatment with cold atmospheric plasma significantly reduced bacterial colonies and in comparison to the control plate with a colony count of 1.5 × 103 CFU/mL treatment with air plasma for 10 minutes decreased the Pseudomonas colony count to zero.
Conclusion: It was observed that the cold atmospheric plasma jet device manufactured in atomic Energy Organization of Iran can significantly kill bacteria in a short time. Increasing the duration of treatment significantly reduces bacterial colonies.
Urethral Caruncle Masquerading a Primary Amelanotic Melanoma, the Risk of a Poor Prognosis due to Misdiagnosis
Objective: Primary malignant urethral melanoma is a rare condition, concerning less than 1% of melanomas and 4% of all urethral cancers. The early treatment of urethral melanoma is extremely important due to the tendency to early metastasis.
Case report: 88-year-old Caucasian lady presented vaginal bleeding. At first Gynaecological examination an urethral caruncle with otherwise normal trans-vaginal ultrasound was diagnosed. The patient not reassured asked for a second consultation opting to remove the reddish fleshy polypoid lesion protruding from the urethra. Histology revealed a urethral amelanotic melanoma. The patient underwent an excission of the urethral lesion. Urologist, oncologist and gynaecologist at tumor board meeting, considering patient’s age and negative PET, decided for conservative management with close clinical and imaging follow-up.7 months after, vaginal bleeding recurred and a nodule on the anterior vaginal wall was detected and biopsied and resulted a pigmented melanoma. The patient underwent a wide margin excision. At 10 months follow-up there were no evidence of recurrence nor distant metastasis. She started a prophylactic immunotherapy with Nivolumab; at her third administration she presented only asthenia as side effect.
Conclusion: It is importanto to keep in mind the urethral amelanotic melanoma to allow an early removal or biopsy, preventing diagnostic delay/misdiagnosis and aiding either in better patient management or outcome.
Umbilical Cord Hematoma and Uterine Torsion: Rare Pregnancy Complications at Tu Du Hospital in Vietnam and Review of Literature
Objective: Umbilical cord hematoma and uterine torsion are extremely rare complications in pregnancy. However, these should not be neglected in clinical practice in condition of abnormal fetal heart monitoring without others suspects. We hereby report rare case of umbilical cord hematoma and uterine torsion as well as review the literature. Through this report, we aim to mention on an available tool to investigate spontaneous umbilical cord hematoma on fetal well-being in such a case.
Case report: A women aged 35 years old (G1P0) admitted to our hospital for term gestation with uncomplicated pregnancy, except large uterine fibroid accompanied with cervical pessary. Then, an uncommon complication of umbilical cord hematoma was revealed accidentally upon cesarean section. Particularly, this dramatic event was happened along with an asymptomatic uterine torsion noticed at the same time. Preoperative diagnosis of two rare complications was missed, hence, we extracted timely baby based on another modality of management, computerized cardiotocography.
Conclusion: Umbilical cord hematoma along with uterine torsion is difficult to diagnosis due to its rarity. Moreover, no available tool could investigate umbilical cord hematoma prior to delivery. Surveillance on fetal heart rate monitoring may be helpful in this situation.