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Please cite this paper as: Awwad J, Usta I, Succar J, Musallam K, Ghazeeri G, Nassar A. The effect of maternal fasting during Ramadan on preterm delivery: a prospective cohort study. BJOG 2012;119:1379-1386. Objective To determine the effect of fasting during the month of Ramadan on the rate of preterm delivery (PTD). Design A prospective cohort study of women with singleton pregnancies who elected to fast and matched controls. Setting Four medical centres in Beirut, Lebanon. Population Women presenting for prenatal care (20-34 weeks of gestation) during the month of Ramadan, September 2008. Methods Data were collected prospectively. The frequency of PTD was evaluated in relation to the duration of fasting and the stage of gestation at the time of fasting. Main outcome measures The primary endpoint was the percentage of pregnant women who had PTD, defined as delivery before 37 completed weeks of gestation. Results A total of 468 women were approached, of whom 402 were included in the study. There were no differences in smoking history and employment. There was no difference in the proportion of women who had PTD at <37 weeks (10.4% versus 10.4%) or PTD at <32 weeks (1.5% versus 0.5%) in the Ramadan-fasted group and the controls, respectively. The PTD rate was also similar in those who fasted before or during the third trimester. The mean birthweight was lower (3094 ± 467 g versus 3202 ± 473 g, P = 0.024) and the rate of ketosis and ketonuria was higher in the Ramadan-fasted women. On multivariate stepwise logistic regression analysis, fasting was not associated with an increased risk of PTD (odds ratio 0.72; 95% confidence interval 0.34-1.54; P = 0.397). The only factor that had a significant effect on the PTD rate was body mass index (odds ratio 0.43; 95% confidence interval 0.20-0.93; P = 0.033). Conclusions Fasting during the month of Ramadan does not seem to increase the baseline risk of preterm delivery in pregnant women regardless of the gestational age during which this practice is observed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of the study was to assess the rate of acceptance of preimplantation genetic diagnosis (PGD) as an alternative to prenatal diagnosis in Lebanese women with previously affected children with homozygous beta-thalassemia. METHODS: Women with a previously affected child attending a nongovernmentally funded thalassemia care center between 1 June 2005 and 31 May 2007 were offered a genetic counseling session. This was followed by administering a questionnaire through direct interview. RESULTS: All 97 women approached accepted to participate in the study (100% response rate). Sixty eight per cent of women considered PGD a better alternative to prenatal diagnosis. The most important perceived advantage of PGD was the avoidance of termination of an affected pregnancy. CONCLUSIONS: PGD is an acceptable alternative to conventional prenatal diagnosis in women at risk of conceiving a child affected with beta-thalassemia. This is particularly true in countries of the Middle-East where therapeutic abortions for fetal indications are prohibited by the law and religion. Copyright (c) 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine perinatal complications in infants >or = 4500 g according to delivery mode. STUDY DESIGN: Records of 231 mothers and live cephalic infants weighing >or = 4500 g over a 13-year period were retrospectively reviewed. Maternal and perinatal complications were compared in relation to delivery mode. RESULTS: Vaginal delivery (NVD) was achievable in 168/189 (88.9%) of women allowed to labor, of which 36.9% were operative. The cesarean delivery (CS) rate was 27.3%. The NVD group had a lower incidence of diabetes; however, hypoglycemia and transient tachypnea were more common in the CS group. The frequency of low Apgar scores at 1 and 5 minutes was similar in both groups. A total of 13 (7.7%) major fetal injuries were documented in the NVD group (arm weakness 3, hematoma 3, clavicular fracture 2, and brachial plexus injury 5). Shoulder dystocia was documented in only 7/13 (53.8%). CONCLUSION: Vaginal delivery is achievable in 88.9% of pregnancies with infants >or = 4500 g allowed to labor, at the expense of a 7.7% risk of perinatal trauma. [ABSTRACT FROM AUTHOR]

Background: Granulomas of the female genital tract are rare and usually occur after operative procedures.Case: A patient with rheumatoid arthritis presented with vaginal discharge and bleeding with ulcerative, red, friable lesions of the cervix, which extended to the bladder floor and the right upper vaginal wall. Cervical biopsy was highly suggestive of rheumatoid nodules. This prompted revision of the diagnosis of tuberculosis, which was suspected several months earlier when pulmonary and renal lesions were noted. The cervico-vaginal lesions did not respond to local steroid treatment and improved when the systemic steroid dose was increased; however, they recurred on tapering the dose.Conclusion: Rheumatoid nodules can occur in the genital tract, which poses diagnostic and treatment challenges. [ABSTRACT FROM AUTHOR]

A response from the author of the article "Design and statistical analysis of observational studies" in the November 20, 2012 issue is presented.

Objective: This study aimed to compare the effectiveness of sustained uterine compression versus uterine massage in reducing blood loos after a vaginal delivery., Study Design: This was a prospective randomized trial conducted at the American University of Beirut Medical Center (AUBMC) between October 2015 and October 2017. Inclusion criteria were women with a singleton pregnancy at ≥36 weeks of gestation, with less than three previous deliveries, who were candidates for vaginal delivery. Participants were randomized into two groups, a sustained uterine compression group (group 1) and a uterine massage group (group 2). Incidence of postpartum hemorrhage (blood loss of ≥500 mL) was the primary outcome. We assumed that the incidence of postpartum hemorrhage at our institution is similar to previously published studies. A total of 545 women were required in each arm to detect a reduction from 9.6 to 4.8% in the primary outcome (50% reduction) with a one-sided α of 0.05 and a power of 80%. Factoring in a 10% dropout rate. Secondary outcomes were admission to intensive care unit (ICU), postpartum complications, drop in hemoglobin, duration of hospital stay, maternal pain, use of uterotonics, or of surgical procedure for postpartum hemorrhage., Results: A total of 550 pregnant women were recruited, 273 in group 1 and 277 in group 2. There was no statistically significant difference in baseline characteristics between the two groups. Type of anesthesia, rate of episiotomy, lacerations, and mean birth weight were also equal between the groups. Incidence of the primary outcome was not different between the two groups (group 1: 15.5%, group 2: 15.4%; p  = 0.98). There was no statistically significant difference in any of the secondary outcomes between the two groups, including drop in hemoglobin ( p  = 0.79)., Conclusion: There was no difference in blood loss between sustained uterine compression and uterine massage after vaginal delivery., Key Points: · Transabdominal uterine compression and uterine massage are appropriate to prevent postpartum hemorrhage.. · No significant difference in blood loss or maternal discomfort observed between the two techniques.. · Both methods are equally effective and either one can be used based on provider preference.., Competing Interests: None declared., (Thieme. All rights reserved.)

The evidence indicates that pregnancy is associated with increased severity of some infectious diseases. Given the high maternal morbidity associated with influenza in pregnancy and the high neonatal morbidity and mortality associated with pertussis, the traditionally two recommended vaccines during pregnancy were those against influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccines. The recent COVID-19 pandemic introduced a third vaccine that after much debate is now recommended for all pregnant women. Other vaccines can be offered based for high-risk pregnant women, and only when the benefits of receiving them outweigh the risks. The soon expected vaccines against group B streptococcus infection and respiratory syncytial virus infection will be a breakthrough in reducing perinatal mortality. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed., (© 2023 International Federation of Gynecology and Obstetrics.)

Objectives: To evaluate the practice patterns among Lebanese obstetricians regarding obstetric care of twins and to compare selected practice patterns between general obstetricians and maternal fetal medicine physicians., Methods: Questionnaires distributed during the annual meeting of the Lebanese Society of Obstetrics and Gynecology., Results: Questionnaires were returned by 69.2% of the 296 physicians approached. Ten percent had fellowship training in Maternal Fetal Medicine (MFM). Thirty-nine percent perform cervical length measurement at 20-24 weeks of gestation and 34% recommend vaginal progesterone in case of a short cervix. When comparing selected practice patterns between MFM & general obstetricians, MFM specialists were less likely to perform cervical cerclage in the first trimester (5.9% versus 49%, p  = .001), more likely to offer prenatal screening for aneuploidy (66.6% vs 46.4%, p  = .03), less likely to use vaginal progesterone in the second trimester in the case of a short cervix (42.1% vs 61.8%, p  = .04), less likely to perform serial ultrasound exam in the third trimester to assess fetal growth (50% vs 78%, p  = .005) and more likely to deliver monoamniotic twins at 32-34 weeks of gestation (55% vs 37%, p  = .05)., Conclusion: Because of the different background of the Lebanese physicians, MFM specialists are more likely to follow obstetric care guidelines in twin gestation.

We designed our study to evaluate the knowledge and immunization practices among Lebanese obstetricians and gynecologists (OBGYN) for women of different age groups. Anonymous questionnaires were used to assess the knowledge and immunization practices among OBGYN. The survey was conducted at the annual meeting of the Lebanese Society of Obstetrics and Gynecology on November 13-15, 2014. Data collected included demographics, type of practice, academic background and familiarity with vaccine guidelines. Descriptive statistical methods were used to evaluate the responses. The response rate was 54.8% (114/208). Only 62.3% (71/114) recommend vaccination(s) to pregnant women with only 25.9% of those who recommend the Tdap vaccine for pregnant women giving it during the recommended third trimester. In addition, 52.6% are unaware of the CDC/ACIP immunization schedule for women in general. However, 83.0% (93/112) of respondents are willing to integrate vaccination in their practice. Our study highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in addition to practices that are not in full accordance with common guidelines. Measures should be taken to spread proper awareness of the proper guidelines among Lebanese practitioners.

Objective  The objective of this study was to determine the optimal dose of intravenous oxytocin administered during cesarean delivery (CD) to decrease the amount of blood loss. Methods  Out of a total of 226 women presenting for CD, 189 patients were randomized into three groups by a computer-generated random number sequence table. Low-risk women with singleton term pregnancies undergoing scheduled CD were assigned to receive 20, 30, or 40 units (U) of oxytocin diluted in 500 mL of lactated Ringer solution intraoperatively. The primary outcome was the change in hemoglobin from pre-CD to post-CD. Results  Overall, 63 women were assigned to each group. The primary outcome which was the drop in hemoglobin (1.4 ± 1.1 g/dL, 1.1 ± 0.8 g/dL, 1.0 ± 1.1 g/dL; p  = 0.097) and the total calculated blood loss (798.6 ± 298.3 mL, 794.4 ± 313.5 mL, 820.2 ± 316.2 mL; p  = 0.893) were not significantly different among the study groups. The incidence of intraoperative hypotension, postoperative systolic, and diastolic blood pressure changes was similar across the groups. Conclusion  The amount of blood loss during CD was not significantly different among the three groups, thus the lowest dose of oxytocin infusion (20 U in 500 mL of lactated Ringer solution) seems to be an appropriate regimen., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: This narrative review of the literature explores the current evidence and recommendations in favor of antenatal corticosteroids use during impending preterm deliveries as well as related issues and concerns., Study Design: Synthesis of findings from published medical literature on antenatal corticosteroids and prematurity, retrieved from searches of computerized databases and authoritative texts., Results: It is now recognized that an intramuscular course of betamethasone or dexamethasone given to a woman expected to deliver preterm not only accelerates pulmonary epithelial development but also matures other organ systems, significantly decreasing the chances of neonatal morbidities and increasing chances of survival., Conclusion: There remain uncertainties over the efficacy of the established protocol in populations such as the very early preterm, the late preterm, and multiple gestations. Alternative regimens remain controversial because of fear of adverse effects and doubts regarding whether benefits outweigh risks., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB)., Objectives: To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA)., Search Strategy: We searched international scientific databases, trial registration websites, and references of identified articles., Selection Criteria: Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment., Data Collection and Analysis: Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB., Main Results: Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75)., Author's Conclusions: In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Intrahepatic cholestasis of pregnancy (ICP) has a varying prevalence worldwide. The etiology behind this disease remains not fully understood with multiple factors influencing its development including genetic variations, dietary factors, hormonal changes, and environmental influences. Presenting mainly during the third trimester with generalized itching and resolving spontaneously postpartum, this condition is still associated with fetal morbidity and mortality. The diagnosis is based on clinical presentation in association with biochemical abnormalities. Elevation in total bile acid levels is the most frequent laboratory abnormality and seems to be the most important for gauging further management of the disease. The most appropriate gestational age for the delivery of women with ICP is yet to be determined. In this review we discuss the epidemiology, clinical features, diagnosis, etiology, and management of ICP, trying to shed light on some controversial aspects of the disease., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To assess the effect of sildenafil citrate in a rat model of Nω-nitro-l-arginine methyl ester (L-NAME)-induced intrauterine growth restriction (IUGR)., Study Design: An in vivo experimental study was conducted where 40 pregnant Sprague-Dawley rats were randomly assigned to receive either: (1) control, (2) L-NAME 50 mg/kg/d by gavage (days 14 to 19), (3) L-NAME and sildenafil 15 mg/kg/d by gavage, or (4) sildenafil (days 14 to 21). On day 21, a hysterotomy was performed and all fetuses (live and dead) were counted, examined, and weighed. The primary outcome measure was the difference in pup birth weight., Results: The median number of live pups per dam was 11.5 (range: 1 to 15), 13.5 (2 to 17), 13.5 (7 to 16), and 11.5 (4 to 17) in controls, L-NAME, sildenafil, and combined drug groups, respectively (p = 0.02). Rats treated with L-NAME had a significantly higher number of stillbirths compared with control (p = 0.013) and sildenafil (p = 0.008) groups. L-NAME reduced pup birth weight compared with controls (4.53 ± 1.49 versus 5.65 ± 1.63 g, p < 0.001); this effect was more pronounced in the L-NAME and sildenafil groups (3.37 ± 1.25 g, p < 0.001)., Conclusion: Our data indicate that sildenafil citrate does not ameliorate L-NAME-induced IUGR, and in the doses utilized in this study might even have a synergistic negative effect on pup birth weight., (Copyright © 2012 Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.)

Preterm labor (PTL) is a major cause of neonatal morbidity and mortality worldwide. Among the available tocolytics, indomethacin, a prostaglandin synthetase inhibitor, has been in use since the 1970s. Recent studies have suggested that prostaglandin synthetase inhibitors are superior to other tocolytics in delaying delivery for 48 hours and 7 days. However, increased neonatal complications including oligohydramnios, renal failure, necrotizing enterocolitis, intraventricular hemorrhage, and closure of the patent ductus arteriosus have been reported with the use of indomethacin. Indomethacin has been also used in women with short cervices as well as in those with idiopathic polyhydramnios. This article describes the mechanism of action of indomethacin and its clinical applications as a tocolytic agent in women with PTL and cerclage and its use in the context of polyhydramnios. The fetal and neonatal side effects of this drug are also summarized and guidelines for its use are proposed., (Copyright © 2012 by Thieme Medical Publishers, Inc.)

Objective: To compare maternal and neonatal outcomes of twin gestations in nulliparous and multiparous women., Design: Retrospective analysis of maternal and neonatal records., Setting: American University of Beirut Medical Center, a referral university-affiliated hospital., Population: Pregnant women who delivered twin gestations beyond 24 weeks from 1990 to 2004., Methods: The data collected were analyzed using Student's paired t-test or χ(2) test. Logistic regression analysis was used to study the effect of multiple variables on preterm delivery., Main Outcome Measure: Preterm birth rate., Results: Nulliparas (n=333) were more likely to be younger (28.1±5.4 vs. 30.0±5.2 years; p<0.001) and the pregnancy a product of assisted reproductive technology (23.1 vs. 4.5%; p<0.001) compared with multiparas (n=508). They were at significantly increased risk of preterm delivery (54.4 vs. 45.1%; p=0.009) at lower gestational age (35.6±3.2 vs. 36.2±3.0 weeks; p=0.004). They had longer first and second stages of labor and a higher cesarean delivery rate (61.3 vs. 44.9%; p<0.001). Except for a higher intensive care nursery admission rate and longer nursery stay for twins of nulliparas, all neonatal morbidities were comparable. On multiple logistic regression analysis, multiparity (relative risk 0.70, 95% confidence interval 0.51-0.97) and growth restriction (relative risk 0.16, 95% confidence interval 0.12-0.22) were protective, while discordance (relative risk 2.24, 95% confidence interval 1.40-3.60) was a predictor of preterm delivery., Conclusions: Nulliparous women with twin gestations are at significantly higher risk for preterm delivery and cesarean delivery compared with multiparous women. Although this was not translated into higher perinatal mortality, these women should be monitored closely and counseled regarding these risks and their attendant morbidity., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

A case of ectopia cordis (EC) with gastroschisis in a 27-year-old primigravida was diagnosed at 10(3/7) weeks of gestation. The pregnancy was terminated by suction dilatation and curettage. With the increasing use of first trimester ultrasonography, early detection of fetal abnormalities is becoming more frequent. We review other published cases of EC detected in the first trimester and discuss the possible advantages of early diagnosis including options of termination at earlier gestational ages which might decrease the physical and psychological trauma on some patients.

Preterm birth, the leading cause of neonatal morbidity and mortality, is estimated at incidence of 12.7% of all births, which has not decreased over the last four decades despite intensive antenatal care programs aimed at high-risk groups, the widespread use of tocolytics, and a series of other preventive and therapeutic interventions. Oxytocin antagonists, namely atosiban, represent an appealing choice that seems to be effective with apparently fewer side effects than the traditional tocolytics. This article reviews the available literature on the pharmacokinetics, mode of administration, and clinical utility of oxytocin antagonists for acute and maintenance tocolysis with special emphasis on its safety profile., (© Thieme Medical Publishers.)

Preterm birth continues to be the leading cause of perinatal morbidity and mortality. A wide range of tocolytics have been utilized for the management of preterm labor. Calcium channel blockers, namely nifedipine, gained popularity as tocolytics due to the oral route of administration, availability of immediate- and slow-release preparations, the low incidence of maternal adverse effects associated with their use, and the fact that they are inexpensive. This article reviews the available literature on the clinical utility of calcium channel blockers for acute and maintenance tocolysis with special emphasis on potential adverse effects, the most appropriate dose/regimen, and contemporary practice patterns among obstetricians. There are no randomized, placebo-controlled studies demonstrating the benefit of nifedipine in preterm labor. A suggested tocolytic protocol would be to start with the lowest dose of oral immediate-release nifedipine. For the first 48 hours thereafter, all attempts should be made not to exceed 60-mg daily doses., (Thieme Medical Publishers.)

Objective: Smoking is a significant health hazard that has been associated with poor reproductive outcome and reduced fertility in reproductive age women. The aim of this study was to assess the effect of nargile smoking on intra-cytoplasmic sperm injection (ICSI) outcome., Study Design: A prospective analysis of the outcomes of 297 women who underwent ICSI treatment at the ART Unit at the American University of Beirut Medical Center between January 1, and December 31, 2006 was done. The patients were divided into 3 groups based on their smoking status: cigarette smokers (n=42), nargile smokers (n=51) and non-smokers (n=204)., Results: The mean age of nargile smokers was significantly lower than the other groups; however, the 3 groups were similar with respect to the cause of infertility, total dose of follicular stimulating hormone (FSH), number of oocytes and embryos obtained, and number and quality of embryos transferred. There was no significant difference in the clinical pregnancy rate between nargile smokers and non-smokers (51.0% vs 43.6%). However, cigarette smokers had a significantly lower clinical pregnancy rate compared to non-smokers (23.8% vs 43.6%, p=0.0238). On multiple logistic regression analysis, factors that decreased the clinical pregnancy rates were cigarette smoking and maternal age., Conclusion: Although this study did not find a deleterious effect of nargile smoking on ICSI outcome, the results need to be confirmed in prospective studies that would include larger number of women with more objective measures of nargile smoke exposure., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Factors that influence a pregnant woman's decision to accept or decline genetic tests are largely undefined. The objective of this study was to determine the acceptance rate of prenatal diagnostic testing in Lebanon according to religion., Methods: Prenatal charts were reviewed to obtain information about prenatal genetic testing. Women were divided according to their religion and were compared regarding the acceptance of triple screen test (TST) or amniocentesis (AMN) and reasons for declining such tests. Differences between groups were examined using the student's t-test, chi(2)-test and multivariate analysis (age >or= 35 years, religion, education and class)., Results: The religious distribution was 73.8% Moslems, 14.0% Christians and 11.2% Druze. Utilization of TST, AMN, and either (TST/AMN) was 61.2%, 7.6% and 67.0%, respectively. Uptake of TST/AMN was highest in Christians and lowest in Moslems and that of AMN higher in Christians >or= 35 years compared with Moslems. On multivariate analysis, none of the factors studied significantly affected the utilization of TST or TST/AMN except for age >or= 35 years which was associated with a borderline decrease in the utilization of TST Odds Ratio (OR) 0.485 (95% CI 0.21-1.12). The utilization of AMN significantly increased with age >or= 35 years OR 7.19 (95% CI 2.65-19.56) and lower education., Conclusion: Religion does not seem to affect utilization of prenatal diagnostic tests in Lebanon., (Copyright (c) 2010 John Wiley & Sons, Ltd.)

Measuring cervical length using transvaginal ultrasonography is a useful tool to predict the risk of preterm birth in low- and high-risk pregnancies. Management of a short cervix poses a significant dilemma for clinicians. Different management plans have been proposed and studied, with mixed results in different clinical settings. This article reviews the various management options in the different patient subpopulations and proposes a scheme for management once a short cervix is identified., ((c) Thieme Medical Publishers.)

We compared two dose regimens of tocolytic oral nifedipine. Women with singleton pregnancies admitted in preterm labor (24 to 34 weeks) were randomized to high-dose (HD) nifedipine ( N = 49; 20 mg loading dose, repeated in 30 minutes, daily 120 to 160 mg slow-release nifedipine for 48 hours followed by 80 to 120 mg daily until 36 weeks) or low-dose (LD) nifedipine ( N = 53; 10 mg, up to four doses every 15 minutes, daily 60 to 80 mg slow-release nifedipine for 48 hours followed by 60 mg daily until 36 weeks). Uterine quiescence at 48 hours (primary outcome); delivery at 48 hours, 34 and 37 weeks; and recurrent preterm labor were similar. Gestational age at delivery was higher in HD (36.0 +/- 2.8 versus 34.7 +/- 3.7 weeks, P = 0.049). Rescue treatment was needed more in LD (24.5 versus 50.9%, odds ratio = 0.3; 95% confidence interval 0.1 to 0.7). Maternal adverse effects, birth weight, intensive care nursery admission, and composite neonatal morbidity were similar. However, neonatal mechanical ventilation was needed less and nursery stay was shorter in HD. HD nifedipine does not seem to have an advantage over LD in achieving uterine quiescence at 48 hours. Further studies should address the optimal dose and formulation of tocolytic nifedipine., (Thieme Medical Publishers.)

Uterine perforation can occur following first-trimester abortion or more commonly postpartum after evacuation of retained placental tissues. We report a case of a pregnancy at the site of a recent uterine perforation. Possible mechanisms of this rare condition and different therapeutic options are mentioned.

Our study showed no effect of 33-day war in Lebanon on sex ratio. More research is needed to explore other modifying factors for a better understanding of the complex effect of wars on sex ratio changes.

In addition to the possible association between pregnancy in women with advanced maternal age and increased rates of obstetric and perinatal complications, those women and their children might suffer from long-term sequelae. In this review, the long-term consequences of delayed motherhood on the offspring and the possible association between advanced maternal age and the development of certain cancers are discussed.

Background: Factors influencing a pregnant woman's decision to accept prenatal testing are largely undefined. Our study aimed to compare the acceptance rate of prenatal diagnosis in women who conceived through IVF or ICSI (cases) with that of women who conceived spontaneously (controls)., Methods: Retrospective chart review in Lebanon of all primiparas carrying singletons who were offered prenatal testing (triple screen/amniocentesis) from 2004-2007. The influence of IVF/ICSI on the acceptance of prenatal screening was evaluated., Results: 336 pregnant women were offered prenatal testing (120 cases and 216 controls). Cases were less likely to perform prenatal testing compared with controls (52.5 versus 72.7%; P < 0.001). The rate of utilization of prenatal testing was independent of the infertility cause. Multiple logistic regression analysis revealed that women who conceived through IVF/ICSI [odds ratio (OR) 0.427, 95% confidence interval (CI) 0.252-0.724], those >or=35 years old (OR 0.184, 95% CI 0.102-0.329) and lower socioeconomic class (OR 0.339, 95% CI 0.197-0.584) were less likely to perform triple screen test, and women who conceived through IVF/ICSI (OR 0.354, 95% CI 0.131-0.958) and those of lower socioeconomic class (OR 0.113, 95% CI 0.033-0.403) were less likely to perform amniocentesis., Conclusions: There was a significant difference in acceptance rate of prenatal diagnostic testing between women who conceived through IVF/ICSI and those who conceived spontaneously. Women who conceived through IVF/ICSI were less likely to opt for prenatal diagnosis even after controlling for confounding variables.

More women are postponing pregnancy into the fourth and fifth decades of life for a variety of reasons. Advanced maternal age, traditionally defined as age more than 35 years, has been associated with increased obstetric morbidity and interventions. In addition, perinatal complications are reported to be higher in this patient population, although recent data point to a more favorable outcome. This article reviews the available literature with special emphasis on antepartum, intrapartum, and postpartum complications and perinatal outcome.

Objective: To assess whether application of cocoa butter lotion reduces the development of striae gravidarum (SG)., Design: Multicentre, double-blind, randomised and placebo-controlled trial., Setting: Beirut and Tripoli, Lebanon., Population: Nulliparous women presenting for prenatal care., Methods: Nulliparous women presenting in the first trimester were randomly assigned to receive a lotion containing cocoa butter or a placebo lotion. Women were instructed to apply the assigned lotion daily until delivery., Main Outcome Measure: The development of striae over the abdomen, breasts and thighs postpartum., Results: Of 210 women enrolled, 175 (83%) completed the study. Ninety-one women received the study lotion and 84 received the placebo. There was no difference in the development of SG (45.1% versus 48.8%; P = 0.730) or the severity of SG between cases and controls. The results did not change when presence of stretch marks at enrolment or compliance with the regimen were taken into account., Conclusion: Topical application of a lotion containing cocoa butter does not appear to reduce the likelihood of developing striae gravidarum.

Objective: To study the recurrence risk of shoulder dystocia in women who have previously experienced at least once shoulder dystocia., Design: A retrospective study of vaginal deliveries complicated by shoulder dystocia. Setting. American University of Beirut Medical Center - Lebanon., Sample: Vaginal deliveries complicated by shoulder dystocia over a 15-year period who had subsequent vaginal delivery. Methods. Charts of index and subsequent deliveries beyond 24 weeks' gestation were reviewed for demographics and intrapartum events. Women were divided into those with recurrent shoulder dystocia (group I) and those with uncomplicated subsequent delivery (group II) and compared., Main Outcome Measures: Recurrent shoulder dystocia and characteristics of women with recurrence., Results: The incidence of shoulder dystocia was 0.9% of all vaginal deliveries. Of 193 shoulder dystocia cases, 48 women had a subsequent delivery. After excluding cesarean deliveries (n=4), 44 women were analyzed. Eleven had recurrent shoulder dystocia (25.0%). Mean birthweight was larger (4,019+/-430 vs. 3,599+/-398 g, p=0.005) with a higher rate of macrosomia > or =4,000 g (63.6 vs. 15.2%, p=0.004) and the birthweight in the subsequent pregnancy was larger than the index pregnancy in a significantly larger proportion of women in group I compared with group II (72.7% vs. 33.3%, p=0.035). Otherwise, maternal age, gestational age at delivery, parity, duration of labor, gender, history of macrosomia, and interval between pregnancies were similar., Conclusions: The risk of recurrence of shoulder dystocia is around 25%. When counseling women about recurrence risk, the absence of macrosomia and a smaller birthweight than the previous pregnancy could be reassuring.

Background: To compare the obstetric outcome of teenage pregnancies with that of older women., Methods: Retrospective chart review of singleton births > or =24 weeks' gestational age at the American University of Beirut from 1994 to 2003. Adolescents (<20 years) were compared to subsequently delivered women aged 25-30 years (controls), n=486 each., Results: Only 131 (27.0%) adolescents were <18 years. More adolescents were nulliparous (79.8 versus 17.9%; p<0.0001). Preterm delivery <37 but not <34 weeks occurred more frequently in cases (11.1 versus 5.8%, p=0.004). Pre-eclampsia was more commonly encountered (2.9 versus 0.6%; p=0.012) and mean predelivery haematocrit was lower in cases (30.6+/-3.3 versus 33.8+/-4.3%, p<0.001), but the incidence of gestational diabetes, placenta previa, abruptio placentae, breech presentation, or meconium-stained amniotic fluid were similar. Caesarean delivery was performed less frequently in cases (9.2 versus 14.0%; p=0.028), but primary caesarean and operative vaginal delivery rates were similar though vacuum was used more frequently in multiparous controls (0.2 versus 2.7%, p=0.011). Nulliparous cases had shorter first and second stages of labour (384+/-304 versus 524+/-339 min, p<0.0001 and 47+/-36 versus 63+/-50 min, p=0.002), respectively. Mean birth weight was higher in controls (3177+/-567 versus 3284+/-511 g, p<0.001), but intrauterine growth restriction, birth weight <2500 g, low Apgar scores, intrauterine fetal death, and stillbirths were similar in both groups., Conclusions: Adolescents are more likely to deliver preterm than older women, and are more likely to suffer from anaemia and pre-eclampsia. Nulliparous adolescents have a quicker progress of labour while multiparous adolescents require vacuum less frequently compared to their older counterparts. In most other respects, they have comparable maternal and perinatal morbidity.

Objective: To assess the effect of the Lebanese civil war on sperm parameters., Design: Retrospective review of patient records., Setting: Males providing semen samples at a university laboratory. Semen samples collected 1985-1989 (during the war) were compared with those obtained 1991-1995 (postwar)., Patient(s): Males with or without a history of infertility providing semen samples at a university central laboratory., Intervention(s): None., Main Outcome Measure(s): Standard clinical semen analysis., Result(s): The sperm concentration was significantly lower during the war compared with the postwar period. However, the percentage of abnormal sperm morphology increased in the postwar period. War had no significant effect on volume and motility. Postwar, the percent azospermic and those <10 million remained the same, but there was a shift in the count from the borderline count (11-20 million) to normal (>20 million)., Conclusion(s): There was a significant decline in sperm concentration during the Lebanese civil war. Increased stress level during the war is believed to be one of the main factors leading to this finding.