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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

This article is a review of the literature assessing pregnancy outcomes and the effect of metformin treatment among women with polycystic ovary syndrome (PCOS). A review of research published in English was undertaken using PubMed and MEDLINE databases. The weight of the available evidence suggests that pregnant women with PCOS are at an increased risk of developing gestational diabetes, hypertensive disorders of pregnancy, preterm birth and early pregnancy loss. Obesity is a contributory factor for the increased risk of gestational diabetes in this group of women and is estimated to affect 5–40% of pregnant women with PCOS. The prevalence of other obstetric complications is estimated at 10–30% for gestational hypertension, 8–15% for pre-eclampsia and 6–15% for preterm birth. The association between PCOS and early pregnancy loss may not be direct, wherein the presence of PCOS-associated hyperinsulinemia, leading to hyperandrogenemia, has been implicated in the pathophysiology of early pregnancy loss. Apart from the role of metformin in improving the metabolic consequences accompanying PCOS, it has been shown to improve pregnancy rates in women with PCOS who are resistant to clomiphene citrate. In conclusion, pregnancy in women with PCOS is associated with adverse obstetric outcomes (multiple adverse obstetric risk). Whether metformin should be administered throughout pregnancy still remains controversial. Further prospective studies that foster a larger number of participants and adjust for all potentially confounding factors are needed.

This study aims to investigate the association of human leukocyte antigen (HLA) class II genes and cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) with autoimmune thyroid diseases in the Lebanese population. A total of 128 patients with autoimmune thyroid disease (55 with Graves' disease (GD) and 73 with Hashimoto's thyroiditis (HT)) were typed for HLA DQA1 (0301 and 0501) and DQB1 (0201, 0302, and 0303) and for 49A/G CTLA-4 using PCR-based sequence-specific priming methods. A total of 186 matched controls were typed for the same alleles and compared to the diseased population. Results showed no significant differences in HLA DQB1*0201 or DQB1*0301 allelic frequencies or CTLA-4 polymorphisms between patients and controls. For GD, there was a weak association with HLA DQB1*0302 [34.6% (19 of 55) vs. 21.5% (40 of 186), P = 0.048, odds ratio (OR) = 1.926, confidence interval (CI) = 0.999-3.715] and HLA DQB1*0302-DQA1*0501 haplotype [56.36% (31 of 55) vs. 40.8% (76 of 186), P = 0.042, OR = 1.870, CI = 1.018-3.433]. For HT, the frequencies of DQB1*0302-DQA1*0501 haplotype [28.8% (21of 73) vs. 14.5% (27 of 186), P = 0.008, OR = 2.378, CI = 1.241-4.558] and DQB1*0302-DQA1*0301 haplotype [60.2% (44 of 73) vs. 38.7% (72 of 186), P = 0.002, OR = 2.402, CI = 1.381-4.180] were significantly higher in patients. On the other hand, weak association was found between HT and DQA1*0301 allele [32.9% (24 of 73) vs. 20.9% (39 of 186), P = 0.044, OR = 1.846, CI = 1.011-3.373]. Findings show that DQB1*0302-DQA1*0501 and DQB1*0302-DQA1*0301 haplotypes may play a role in the pathogenesis of HT in the Lebanese population. For the 49A/G CTLA-4 polymorphism, no significant difference was found between patients and controls.

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 χ2test. 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±5.2years; p

Goldenhar syndrome, also known as oculo-auriculo-vertebral spectrum, is a complex, heterogeneous condition characterized by abnormal prenatal development of facial structures. We present the occurrence of Goldenhar syndrome in an infant born to a woman with a history of prenatal Fluoxetine ingestion throughout her pregnancy. Because this is the first reported case associating maternal Fluoxetine intake with fetal craniofacial malformations, a potential mechanism of injury is discussed. The propositus, a male born from nonconsanguinous parents, had facial asymmetry with right microtia and mandibular hypoplasia; he also had bilateral hypoplastic macula, scoliotic deformity of the thoracic spine, and ventricular septal defect. The mother was under treatment with Fluoxetine 20 mg/day prior to conception and maintained the same dosage throughout her pregnancy. The drug is a selective serotonin re-uptake inhibitor, the most widely prescribed for the treatment of depression. The occurrence of developmental aberrations may be caused by a profound serotonin receptor suppressive state in utero leading to aberrant clinical manifestations of the first and second branchial arches. Despite the very many limitations of case reporting of teratogenic events, it remains an important source of information on which more advanced research is based.

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.

Background Cystic fibrosis is the most common autosomal recessive disorder in Caucasians. Little has been reported on its occurrence in Arab and Lebanese populations where mutation distribution seems to differ from that of Europeans. We report on the occurrence of a frameshift mutation 4016insG in two Lebanese Muslim siblings, products of consanguineous parents. This mutation generates a stop codon instead of Arginine-1301 and has never been reported before. Methods Both probands manifested early onset of severe respiratory and pancreatic involvement. DNA analysis was performed by PCR and sequencing for exons 1, 4, 10, 11, 20, 21 of the CFTR gene. Results Both probands were found to be homozygous for the 4016insG. Their parents were both heterozygous for the same mutation. Conclusion The frameshift mutation reported in this article is being described for the first time.

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A case-control study was conducted to examine whether occupational or environmental exposures, particularly to heavy metals, are associated with male infertility in Lebanon, a war-torn country with a history of environmental degradation. Seventy-four infertile cases and 76 fertile controls were selected from 2 major fertility clinics in Beirut. Data collection involved risk-factor interviews, semen analysis, and blood collection for heavy metal analysis. Multiple regression analysis showed that men with reported occupational exposures were twice as likely to be infertile as unexposed men. However, none of the subcategories of infertile men (based on semen analysis results) had significantly higher whole blood concentrations of heavy metals when compared to fertile controls. Blood concentrations were well within the range for referent populations of healthy individuals. Thus, despite Lebanon's poor record of occupational and environmental stewardship, exposure to metal pollutants does not appear to represent an important risk factor for male infertility.

Objective To compare patient satisfaction with two routes of misoprostol for term labour induction. Design Prospective randomised trial. Setting Tertiary care hospital. Population A total of 170 women admitted at ≥37 weeks of gestation for induction of labour. Methods Women were randomised to receive 50 micrograms of either sublingual or vaginal misoprostol. Main outcome measures Patient satisfaction with the route of administration. Results Despite a similar proportion reporting the labour induction as more painful than expected in both groups, a significantly lower proportion mentioned that the pelvic examinations were very painful in the sublingual group (19.7 versus 36.1%, relative risk [RR] 0.5, 95% CI 0.3–0.9). Request for analgesia was similar in both groups. More women in the sublingual group thought that the labour experience was better than expected (RR 2.0, 95% CI 1.2–3.3), had a positive attitude towards induction in subsequent pregnancies (RR 1.6, 95% CI 1.1–2.3) and preferred the same route in subsequent pregnancies (RR 3.1, 95% CI 2.2–4.5). Mean number of misoprostol doses, oxytocin augmentation, tachysystole and hyperstimulation, induction to vaginal delivery interval, vaginal delivery after a single dose, vaginal birth within 12 and 24 hours, and caesarean delivery rates were similar in both groups. Conclusion Sublingual misoprostol (50 micrograms) is associated with a significantly higher patient satisfaction rate compared with a similar dose of vaginal misoprostol. Sublingual administration offers additional choice to women, in particular those wishing to avoid vaginal administration.

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.

Background. Desmoids are benign tumors, with local invasive features and no metastatic potential, which have rarely been described to be pregnancy associated.Case. We described the rapid growth of an anterior abdominal wall mass in a 40-year-old pregnant woman. Due to its close proximity to the enlarged uterus, it was misdiagnosed to be a uterine leiomyoma by ultrasound examination. Final tissue diagnosis and radical resection were done at the time of abdominal delivery.Conclusion. Due to the diagnostic limitations of imaging techniques, desmoids should always be considered when the following manifestations are observed in combination: progressive growth of a solitary abdominal wall mass during pregnancy and well-delineated smooth tumor margins demonstrated by imaging techniques. This case emphasizes the importance of entertaining uncommon medical conditions in the differential diagnosis of seemingly common clinical manifestations.

To study the perinatal outcome of vaginally delivered twins when twin B is more than 250 g larger than twin A.Maternal and neonatal charts of live-born, nonanomalous twins,25 weeks' gestation and vaginally delivered over a period of 17 years were reviewed. The results of this review were distributed among two groups: (1). those with twin B more than 250 g larger than twin A (DeltaBW250) and (2). those where the difference was250 g (DeltaBW250). For vaginally delivered twin gestations, the perinatal outcome of twin B in the group DeltaBW250 was compared to that of its co-twin, and to that of twin B in the group DeltaBW250.Of the 679 twin gestations reviewed, 138 (20.6%) were in the group DeltaBW250, of whom 73 (52.9%) delivered vaginally despite malpresentation in 39.7%. The vaginally delivered twin pregnancies in the groups DeltaBW250 (n=73) and DeltaBW250 (n=303) had similar demographics, parity, presentation, gestational age at delivery, and duration of the first stage of labor. Discordant twins were more frequent in the group DeltaBW250 (26.0 versus 9.5%, p=0.001). Twin B in the group DeltaBW250 was smaller, with higher incidence of growth restriction, low 5 min Apgar score, and hyperbilirubinemia compared to twin B in the group DeltaBW250. There was no difference in the incidence of intraventricular hemorrhage, seizures, sepsis, neonatal death, and median nursery stay. Except for a lower median Apgar score at 1 min in twin B and a longer median nursery stay in twin A, twins A and B in the group DeltaBW250 were similar regarding all other neonatal outcome variables.When twin B is more than 250 g larger than A, and both are delivered vaginally, the perinatal outcome is similar to its co-twin as well as to that of twin B of all other vaginally delivered twins. That twin B is larger than A is not itself a contraindication to attempted vaginal delivery.

Premature ovarian failure (POF) may be due to a variety of genetic mechanisms. We report here, for the first time, telomere association of the long arms of chromosome 19, identified at low frequency (1%) in the peripheral blood cultures of a 30-year-old female with POF. Repeat cultures identified, in addition, the presence of 16q and 22q associations at a lower frequency (0.5%). These consistent observations are suggestive of a non-random event. Their association with POF may just be coincidental or may hypothetically explain it by an abnormal mechanism of chromosome separation, a constitutional telomere anomaly or an unidentified chromosome instability disorder.

Objective: To describe a previously unreported isolated congenital cervical diverticulum and its gynecologic, reproductive, and obstetrical implications. Design: Case report. Setting: A university hospital. Patient: A 31-year-old woman presenting with menometrorrhagia and primary infertility. Investigation revealed an isolated collecting cervical diverticulum causing prolonged postmenstrual spotting, possibly interfering with sperm capacitation and access to the uterine cavity. Intervention(s): The examination included hysterosalpingography and magnetic resonance imaging. The combined hysteroscopy and laparoscopy revealed a 5 × 5 cm cervical diverticulum, around 1 cm from the external cervical os, leading to a short cervical canal connected to a normal uterine cavity. The patient achieved a pregnancy after controlled ovarian hyperstimulation and ultrasonographically guided intrauterine insemination. Main Outcome Measure(s): Pregnancy and obstetrical outcome. Result(s): Extensive evaluation revealed the patient's condition to be a previously undescribed congenital cervical anomaly. The patient's infertility was corrected by ovulation induction and sonographically guided intrauterine insemination, which resulted in a twin pregnancy. After 27 weeks of gestation, preterm labor complicated the delivery. Conclusion(s): The diagnosis and management of this unusual congenital cervical diverticulum present a particular challenge, as this congenital abnormality has not been previously described or reported.

Polycystic ovary syndrome (PCOS) afflicts at least 5 % of women. Both metformin and statin have been used as methods to ameliorate symptoms and improve prognosis. To test the efficacy of concomitant usage of metformin and statins in PCOS patients. This is a prospective, randomized, double-blinded, placebo controlled study. 37 patients received rosuvastatin (10 mg/day) for a period of 3 months, then the patients were randomly allocated to one of two groups: the first group (or intervention group) received rosuvastatin (10 mg/day) plus metformin (850 mg twice daily after meals), and the second group (referred to as control group hereafter) received rosuvastatin (10 mg/day) plus placebo for a period of 3 months. Biochemical and clinical data were collected at each time point. There were no significant differences between the intervention and control groups for baseline lipid profile (LDL, HDL, triglycerides, total cholesterol), CRP, homocysteine, DHEAS, testosterone and insulin (p > 0.05 for all variables). There were no significant differences in lipid profile, CRP, homocysteine, DHEAS, testosterone and insulin between the intervention and placebo groups at 3 and 6 months after treatment (p > 0.05 for all). Significant differences in the outcome variables of LDL, total cholesterol and FBS emerged within the intervention group, with significantly higher levels at 6 months compared to 3 months. We also did not find any significant group differences in unit change of the outcome variables between baseline and 3 months. We found that the combination of statin and metformin has no advantage in PCOS management. In fact, the increase of LDL, total cholesterol and FBS within the intervention group warrants reassessment of current regimens to avoid any patient harm.

Occurrence of intimate partner violence (IPV) against women in the Lebanese society has been largely ignored by local legal and religious authorities. Our aim is to estimate the prevalence of IPV among married Lebanese women, and investigate perception of abuse, referral patterns, and measures taken to deal with abusive situations. In this cross-sectional study, married women aged 20 to 65 presenting to the American University of Beirut Medical Center for gynecological care were interviewed on various forms of IPV. Out of 100 women invited to participate, 91 consented to take part in the survey of whom 37 (40.67%) gave a history of physical abuse, 30 (33.0%) of sexual abuse, 59 (64.8%) of verbal abuse, and 17 (18.7%) of emotional abuse. Spouse-imposed social isolation was reported in 20 (22.0%) women, and economic abuse in 30 (33.0%). Reasons for deciding to stay in an abusive relationship were “lack of any family or social support” (40.5%), “lack of financial resources” (40.5%), and “fear that the partner may take away the children” (37.8%). Women expressed satisfaction with their spouse’s treatment irrespective of the existence of various forms of violence. A significant increase in the risk of weapon use against wife was correlated with decreased monthly income of the household, whereas a protective effect was conferred by an increased number of children. This study highlights the need for routine screening in health care settings for better identification of victims of violence. The selective conventional perception of abuse and the reactive normalization of violence observed indicate the necessity for culturally informed interventional strategies to complement screening.

The purpose of this study was to validate the suitability of the severe combined immunodeficient (SCID) mouse as an experimental model for endometriosis, by defining the morphological and histological features of induced endometrial implants, and characterizing specific biochemical properties of these implants. Human secretory endometrial tissues were injected into the peritoneal cavity of SCID/SCID CB17 mature female mice. Successful peritoneal implantation was observed in 55 of 57 (96.5%) SCID mice and consisted of circumscribed elevated nodules. Haematoxylin-eosin staining of implanting lesions demonstrated the presence of endometrial glandular tissue in a mixed background of stromal and inflammatory cells. When progesterone was administered to mice, epithelial glands underwent well-defined secretory changes. Immunohistochemical analysis using polyclonal human pan-cytokeratin antibodies demonstrated selective positive staining in the glandular epithelium of the human implants with none in the surrounding stroma. In-situ hybridization analysis using complement component 3 cDNA radiolabelled riboprobes yielded significantly more intense signals in glands compared to stroma. As human endometrial implants in SCID mice were shown to retain specific histological, functional and biochemical properties, we conclude that the SCID mouse is an attractive animal model for the study of endometriosis.

To assess the effect of wearing powdered gloves during embryo transfer as compared to un-powdered gloves on the pregnancy outcome of IVF cycles.Patients, undergoing embryo transfer procedures, were prospectively randomized into two groups: In the first (group A, n=356) group embryo transfer was performed while wearing powdered gloves; in the second (group B, n=356) group embryo transfer was performed while wearing un-powdered gloves. The primary end point of the study was the clinical pregnancy rate.The two groups were comparable with respect to the mean age, mean number of grade one embryos obtained, and the mean number of embryos transferred. The clinical pregnancy rates of the two groups were not different.Powdered gloves, worn during embryo transfer, have no adverse effect on the pregnancy outcome of IVF cycles.

Although the role of insulin resistance in the pathogenesis of polycystic ovary syndrome is now well established, confusion exists in common daily practice regarding the role of insulin-sensitizing drugs (ISDs) in the management of this condition. This chapter is an attempt to formulate practice points on the value of ISDs in improving pregnancy outcomes, ameliorating androgen excess symptoms, and modifying metabolic risks in view of available evidence. Clearly, there is a lack of high-quality evidence about effectiveness at all identified outcome endpoints. Moderate-quality evidence indicates a beneficial role for metformin monotherapy in the reproductive management of nonobese women (BMI

Oculo-auriculo-vertebral (OAV) spectrum summarizes a continuum of ocular, auricular, and vertebral anomalies. Goldenhar syndrome is a variant of this spectrum and is characterized by pre-auricular skin tags, microtia, facial asymmetry, ocular abnormalities, and vertebral anomalies of different sizes and shapes. Most cases are thought to be sporadic. However, a few families were reported to have an autosomal recessive inheritance and other families' presentation of the syndrome strongly supported an autosomal dominant inheritance. We report OAV in a female infant presenting with tracheomalacia, diaphragmatic hernia, encephalomeningocele, sacral neural tube defect, and cardiac defect and her brother having no more than dysmorphic features. The mode of inheritance in this family supports an autosomal recessive inheritance where the transmission was from normal first-degree consanguineous parents to one of the sons and to the daughter. This report further broadens the clinical presentation and symptoms of OAV and supports the hypothesis advancing OAV as a genetically heterogeneous disorder.

alpha 2-Macroglobulin (A2M) is a broad spectrum plasma protease inhibitor previously described in uterine effluents and recently demonstrated to bind and possibly modulate the functions of cytokines. As cytokines, proteases, and protease inhibitors are important in implantation and endometrial physiology, we sought to investigate and characterize the pattern of production of A2M in the endometrium. Endometrial tissues from different phases of the menstrual cycle were analyzed for A2M production. Tissues were incubated in methionine-free Minimum Essential Medium with [35S]methionine for 12 h at 37 C in 5% CO2. Conditioned media were immunoprecipitated with a polyclonal antibody to human A2M. Recovered proteins were resolved under reducing and nonreducing conditions by 5% sodium dodecyl sulfate-polyacrylamide gel electrophoresis and analyzed by autoradiography. Immunohistochemistry was performed on both cryostat sections of OCT-embedded tissue and formalin-fixed paraffin-embedded tissue. The intensity of staining was evaluated, and a histochemical score was assigned. Comparisons between histochemical scores were performed using the nonparametric Wilcoxon rank sum test. Immunoprecipitation with A2M antibody yielded a single 320-kilodalton protein band under nonreducing conditions and a single 182-kilodalton band under reducing conditions. Both physical and immunological properties of the recovered protein were consistent with A2M. A2M was identified in all endometrial samples and represented approximately 2% of the total radiolabeled proteins produced. Immunohistochemical analysis revealed prominent stromal, but no glandular, staining for A2M throughout the menstrual cycle. The stromal staining in secretory endometrial samples was significantly more intense than that in proliferative samples. In the proliferative phase, staining was more intense in the spongiosum and basalis layers, and less intense in the superficial compactum layer. In the secretory phase, it remained very intense in the spongiosum, but less so in the basalis layer. These findings indicate that A2M is predominantly produced by the stromal component of endometrial tissue. This production is menstrual cycle dependent, with zonal differences in A2M expression within the endometrium, which may indicate a functional significance relevant to the process of implantation that merits further investigation.

OBJECTIVE: This study aimed to determine the prevalence of pelvic organ prolapse (POP) in a village in East Lebanon and to evaluate related risk factors and clinical predictors. METHODS: Five hundred four ever-married women aged 15 to 60 years were interviewed and underwent physical and pelvic examinations and laboratory testing. Prolapse was determined according to a simplified version of the POP quantification system. RESULTS: Two hundred fifty-one (49.8%) women had clinically significant POP. When stratified by life decade POP prevalence was 20.4% for women aged 20 to 29 years 50.3% for women aged 30 to 39 years 77.2% for women aged 40 to 49 years and 74.6% for women aged 50 to 59 years suggesting a plateau in prevalence in the decade after menopause. Clinically significant POP was found in 3.6% of nulliparous 6.5% of primiparous 22.7% of secondiparous 32.9% of triparous and 46.8% of tetraparous women. Increasing age increasing vaginal parity and a body mass index higher than 24 kg/m were found to be significant risk factors for POP with relative risks of 1.09 (P < 0.001) 2.31 (P < 0.0001) and 1.62 (P = 0.048) respectively. Combined clinical symptoms of pelvic heaviness urinary disturbances and a feeling of bulge in the vagina were predictive of POP. CONCLUSIONS: Our findings suggest that cost-efficient interventions to reduce the burden of POP in this and similar remote communities include the following: family planning awareness campaigns focusing on the risks of grand multiparity; nutritional education and weight management programs to help reduce the progression of POP before the age of menopause; and consideration of symptom-based screening to identify affected women who might benefit from a referral to specialty care at a tertiary care center.

Background Complementary and alternative medicine (CAM) is widely used for the treatment of infertility. While the Middle East and North Africa region has been shown to house one of the fastest growing markets of CAM products in the world, research describing the use of CAM therapies among Middle-Eastern infertile patients is minimal. The aim of this study is to examine the prevalence, characteristics and determinants of CAM use among infertile patients in Lebanon. Methods A cross sectional survey design was used to carry out face-to-face interviews with 213 consecutive patients attending the Assisted Reproductive Unit at a major academic medical center in Beirut. The questionnaire comprised three sections: socio-demographic and lifestyle characteristics, infertility-related aspects and information on CAM use. The main outcome measure was the use of CAM modalities for infertility treatment. Determinants of CAM use were assessed through the logistic regression method. Results Overall, 41% of interviewed patients reported using a CAM modality at least once for their infertility. There was a differential by gender in the most commonly used CAM therapies; where males mostly used functional foods (e.g. honey & nuts) (82.9%) while females mostly relied on spiritual healing/prayer (56.5%). Factors associated with CAM use were higher household income (OR: 0.305, 95% CI: 0.132–0.703) and sex, with females using less CAM than males (OR: 0.12, 95% CI: 0.051–0.278). The older patients were diagnosed with infertility, the lower the odds of CAM use (p for trend Conclusions The considerably high use of CAM modalities among Lebanese infertile patients, added to a poor CAM use disclosure to physicians, underscore the need to integrate CAM into the education and training of health professionals, as well as enhance infertile patients' awareness on safe use of CAM products.

This prospective controlled nonrandomized pilot study was conducted to investigate whether split daily doses of recombinant human LH (rHLH) is more efficacious than the single daily dose in supporting follicular development and ovulation in primary hypogonadotrophic hypogonadism (HH). Twenty-seven women with HH received a 150 IU fixed daily subcutaneous dose of recombinant human FSH, supplemented by 75 IU daily dose of rHLH given either as a single dose (n=9; single-dose group) or four equally divided doses (n=18; split-dose group). Ovulation was defined by three efficacy end points: at least one follicle ⩾17mm in diameter, pre-ovulatory serum oestradiol ⩾400pmol/l and a midluteal progesterone ⩾25nmol/l. Although lacking statistical significance, the proportion of women in the rHLH split-dose group who fulfilled all three end points was higher than the single-dose group (72.2% versus 55.6%). Women in the split-dose group achieved higher serum oestradiol concentrations per follicle, endometrial thickness measurements and numbers of follicles than in the single-dose group (not statistically significant). The odds ratio for ovulation rate was 2.08 (not statistically significant). There were no serious untoward side effects. Administering rHLH in split daily doses could provide superior results compared with the traditional single daily dose. We conducted this clinical study to investigate whether a split daily dose protocol of recombinant human LH (rHLH) is more efficacious than the single daily dose in supporting follicular development and ovulation in primary hypogonadotrophic hypogonadism (HH). HH is an uncommon entity that can lead to very low or undetectable serum gonadotrophin concentrations. It manifests in anovulation, amenorrhoea and subsequent infertility. Twenty-seven women with HH received a 150 IU fixed daily subcutaneous dose of recombinant human FSH, supplemented by a 75 IU daily dose of rHLH given either as a single dose (n=9; single-dose group) or four equally divided doses (n=18; split-dose group). Ovulation was defined by these three efficacy end points: at least one follicle ⩾17mm in mean diameter, pre-ovulatory serum oestradiol concentration ⩾400pmol/l and a midluteal progesterone concentration ⩾25nmol/l. The proportion of women in the rHLH split-dose group who fulfilled all three end points was higher than the single-dose group (72.2% versus 55.6%). Women in the split-dose group achieved higher serum oestradiol concentrations per follicle, endometrial thickness measurements and numbers of follicles than in the single-dose group, without statistical significance. Women who received the split-dose regimen were more likely to have ovulation than the other group. We had no serious problematic side effects. Our results suggest that administering rHLH in split daily doses could provide superior results compared to the traditional single daily dose.

To examine the effect of epigallocatechin gallate (EGCG), a green tea catechin, on the bladder of rats exposed to water avoidance stress (WAS).Twenty female Sprague-Dawley rats were divided into four groups of five. The first group was exposed to WAS for7 days. The second group was pretreated with EGCG 1 mg/kg intraperitoneally (IP) for 7 days before exposure to WAS. The treatment was continued till the end of the experiment. The third group was placed on the platform in a container without water for 2 hr daily for 7 days (Sham WAS). The fourth group was pretreated with saline I.P. for 7 days before being exposed to sham WAS.Bladder wall evaluation for signs of inflammation and total and activated mast cell counts. Secondary outcome: fecal pellet output and micturition frequency at baseline, day 1 and day 7.Bladder walls from rats exposed to WAS revealed significantly higher inflammation score, total and degranulated mast cell counts compared to the sham WAS group. EGCG administration had an obvious protective effect on the bladder mucosa, as the inflammation score, total and degranulated mast cell counts were all significantly lower than in the WAS group. In the WAS group, fecal pellet output and micturition frequency increased above baseline throughout the experiment. Comparison of sham WAS group versus sham WAS with saline revealed no statistically significant difference in any parameter.EGCG given at 1 mg/kg I.P to rats has a significant protective effect against bladder degenerative changes following WAS.

OBJECTIVES: The purpose of this study was to determine if antenatal sonographic determination of fetal ear length is a useful screening method for identification of fetuses with Down syndrome. METHODS: Ear length measurements were recorded in 418 fetuses undergoing ultrasound scanning between 20 and 28 weeks of gestation. Four trisomy 21 and six trisomy 18 fetuses were identified by karyotyping. The relationship between ear length and gestational age in the normal population was determined by linear regression analysis: expected ear length = -6.000 + 1.075 gestational age. The ability of measured-to-expected ear length cut-off ratios to discriminate between affected and non-affected fetuses was assessed. RESULTS: The mean ear length and measured-to-expected ear length ratios were significantly lower in the affected group as compared to the normal one. A measured-to-expected ear length ratio of less than 0.8 was 75.0% sensitive and 98.8% specific in detecting Down syndrome fetuses, and resulted in an 8.5% positive predictive value in the general population. CONCLUSIONS: This preliminary study suggests that antenatal ear length measurements might be a promising sonographic screening method for the detection of Down syndrome in the second trimester of pregnancy.

Objective To report a de novo exceptional complex chromosomal rearrangement (CCR) with four breakpoints in the male partner of a couple with recurrent abortions. Design Case report and review of the literature. Setting Genetics laboratory in a private hospital. Patient(s) A couple referred for recurrent abortions. Intervention(s) Cytogenetic and sperm fluorescence in situ hybridization (FISH) techniques. Main Outcome Measure(s) Karyotype and FISH sperm results. Result(s) The couple was phenotypically normal, with no family history of miscarriage or infertility. Female karyotype was normal. Male karyotype followed by FISH analysis showed a de novo CCR with four breakpoints: t(5,13,16)(q11.1, q14.3, q12.2), ins(16;13)(q12.2;q?q14.2). ish t(5;13;16)(wcp5+,wcp13+), ins(16;13)(wcp13+). Conclusion(s) Exceptional de novo CCR male carriers with recurrent abortions are extremely rare. Patients with CCRs have limited options to achieve a normal pregnancy. Careful consideration and assessment should be provided upon counseling of couples with CCRs.

Background: Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians; it is however, considered to be rare in the Arab populations. Reports of the cystic fibrosis transmembrane regulator (CFTR) mutations from Arabs, especially from the Lebanese population, are limited. Methods: Twenty-two unrelated Lebanese families, with at least one child with CF, were studied. DNA extracts from blood samples of patients and parents were screened for CFTR gene mutations. Results: Eleven different mutations were identified. Of the 44 alleles studied, the most common mutations were: F508del (34%), N1303K (27%), W1282X (7%), and S4X (7%). Five mutations – not previously reported in the Lebanese population – were identified; these are: S549N, G542X, 2043delG, 4016insG, and R117H-7T. Conclusions: The most common CFTR mutations in addition to five mutations not previously described in the Lebanese population were identified. Identification of CFTR mutations in the Lebanese population is important for molecular investigations and genetic counseling.

Male infertility is a neglected reproductive health problem, yet it contributes to at least half of all cases of subfertility worldwide. Consanguinity, or the intermarriage of two individuals who have at least one ancestor in common, may increase the risk for recessively inherited disorders, including genetic forms of male infertility. This chapter investigates the influence of consanguineous marriage on male infertility in Lebanon, where rates of consanguineous marriage remain high (26.9% among Muslims, 16.5% among Christians). Using a mixed-methods, ethnographic-epidemiological, and case-study design, it demonstrates a significant association between consanguinity and family clustering of male infertility cases, suggesting a strong genetic component to this reproductive health problem in Lebanon. Because consanguineous marriage is a socially supported institution throughout the Muslim world, culturally sensitive public health education programs, which support genetic counseling and risk management without condemning consanguineous marriage practices per se, are highly recommended.

Apoptosis is implicated in the fragmentation of preimplantation mammalian embryos, yet the extent of this association remains controversial. The aim of this study was to assess the ability of sphingosine-1-phosphate (S1P), a known anti-apoptotic substance, to reduce the fragmentation rate of human preimplantation embryos when added to their culture microenvironment. Mature human oocytes were inseminated using intracytoplasmic sperm injection, incubated for 3 days and evaluated for embryo quality and fragmentation by the same embryologist. Oocytes in the study group were manipulated and cultured in culture medium supplemented with S1P to a 20 micromol/l concentration. A total of 46 patients donated 177 mature oocytes for the study group and 546 oocytes for the control group. The fertilization rate was significantly lower in the S1P-supplemented group (52.4% versus 67.3%; P=0.002) and the proportion of grade I embryos with less than 15% fragmentation was significantly higher in the same group (79.5% versus 53.9%; P0.0001). Sphingosine-1-phosphate added to the culture medium of human preimplantation embryos is associated with a significantly lower fragmentation rate and hence better quality embryos. The clinical significance of these findings on reproductive outcome remains highly speculative awaiting further studies to translate this improvement in embryo quality into better pregnancy rates.

Crowther CA, 2006, LANCET, V367, P1913, DOI 10.1016-S0140-6736(06)68846-6; Kaimal A, 2007, AM J OBSTET GYNECOL, V197, pS40, DOI 10.1016-j.ajog.2007.10.102; Gilstrap LC, 2001, OBSTET GYNECOL, V98, P144; Roberts D., 2006, COCHRANE DB SYST REV, V3, DOI DOI 10.1002-14651858.CD004454.PUB2; Wapner RJ, 2006, AM J OBSTET GYNECOL, V195, P633, DOI 10.1016-j.ajog.2006.03.087

Objective: The objective of this study is to assess the effect of two methods of vaginal scrubbing before egg retrieval on the outcome of in vitro fertilization-embryo transfer (IVF-ET) cycles. Method: 721 consecutive cycles of IVF-ET, at the American University Hospital of Beirut, were randomized prospectively into one of two groups. In the study group the betadine used to scrub the vagina, prior to egg retrieval, was not washed out, whereas in the control group this betadine was cleansed by saline irrigation. The two groups were compared as to the outcome of their IVF-ET cycles. Result: Both groups were similar in age, mean dose of FSH received, the number of oocytes and embryos obtained, the number of grade 1 embryos obtained, and the fertilization rate. There was no difference in the total pregnancy, clinical pregnancy, missed abortion, and multiple pregnancy rates between the two groups. However, the chemical pregnancy rate was higher in the study group as compared to controls. Conclusion: Vaginal preparation by betadine does not seem to affect the results of IVF. However, because it is associated with an increase in the rate of chemical pregnancy, it is advisable to cleanse before oocyte aspiration.

To assess the impact of the Women's Health Initiative (WHI) study on gynecologists' attitudes regarding hormone therapy (HT).Questionnaires were mailed to a random sample of Lebanese gynecologists (n=178). The questionnaires solicited practice patterns of HT for postmenopausal women and information provided while counseling before and after the WHI study. Descriptive statistical methods were used to evaluate the responses.Questionnaires were returned by 140 physicians (78.7%), 93.6% of whom were aware of the WHI study. More than 90% of respondents routinely offered HT prior to the study. Of the 85.6% who used a combination of oral estrogen and progesterone (E/P), 40.0% used conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA). Around 67% of gynecologists reported a change in their therapeutic approach after the study. The main changes were: not offering CEE+MPA (27.3%), prescribing CEE+MPA to a select group of patients (37.5%), using other forms of HT (56.8%), or abandoning any form of HT (6.8%). Other practice modifications included a shift to the use of tibolone (18.2%) or alternative therapies (29.5%). Whereas 76.2% of physicians counseled their patients about a decreased risk of cardiovascular events with HT prior to WHI study, only 34.1% continued to do so after the study (p0.001). The percentage of gynecologists that inform their patients of an increased risk of breast cancer on HT rose from 45.2 to 73.2% (p=0.018). Almost 51% of gynecologists allow their patients to participate in decision making regarding the type of HT, 42.4% would choose for their patients after counseling, while 6.8% of physicians do not counsel their patients in order not to confuse them.In a representative sample of Lebanese gynecologists, there was a significant change in physicians' attitudes towards HT following the publication of the WHI study.

Austin PC, 2008, STAT MED, V27, P2037, DOI 10.1002-sim.3150; Awwad J, 2012, BJOG-INT J OBSTET GY, V119, P1379, DOI 10.1111-j.1471-0528.2012.03438.x; Hansen BB, 2008, STAT MED, V27, P2050, DOI 10.1002-sim.3208; Hill J, 2008, STAT MED, V27, P2055, DOI 10.1002-sim.3245; Stuart EA, 2008, STAT MED, V27, P2062, DOI 10.1002-sim.3207

OBJECTIVE: To determine the prevalence of reproduction-related illnesses in a rural community in Lebanon. METHODS: Data were collected through interviews with women in their homes, physical examinations and history taking by physicians in a clinic in the community, and laboratory tests. A total of 557 ever-married women aged 15-60 years were selected randomly. FINDINGS: Just over half of the sample (268, 50.6%) had five or more children, and (320, 78.9%) of women aged < 45 years were using contraception. The prevalence of reproductive tract infections was very low: six (1.2%) women had sexually transmitted diseases and 47 (9.3%) had endogenous reproductive tract infections. None had chlamydial infection or a positive serological finding of syphilis. None had invasive cervical cancer, and only one had cervical dysplasia. In contrast, genital prolapse and gynaecological morbidity were elevated. Half of the women studied (251, 49.6%) had genital prolapse, and 153 (30.2%) were obese. CONCLUSION: The prevalence of reproductive tract infections in this conservative rural community in east Lebanon was low. Possible explanations include the conservative nature of the community, the high rate of utilization of health care services, and the liberal use of antibiotics without a prescription. More importantly, the study showed an unexpectedly high prevalence of genital prolapse and obesity--a finding that has clear implications for primary health care priorities in such rural communities.

Variants of the t(8;21)(q22;q22) involving chromosomes 8, 21, and other chromosomes account for approximately 3% of all t(8;21)(q22;q22) in acute myeloid leukemia (AML) patients. In this paper, we report a case of AML-M2 with a t(8;12;21)(q22;p12 approximately p13;q22) associated with chromosomal abnormalities, including loss of the Y chromosome and trisomy 8q22 approximately qter. Using a dual-color fluorescence in situ hybridization (FISH) analysis with ETO and AML1 probes, we demonstrated an ETO/AML1 fusion signal on the derivative chromosome 8. Using whole painting probes for chromosomes 8 and 12, we demonstrated a three-way translocation, t(8;12;21)(q22;p12 approximately p13;q22). Reverse transcription polymerase chain reaction (RT-PCR) analysis showed the presence of AML1/ETO fusion transcript. The present case highlights the importance of the combination of approaches, i.e., standard karyotyping, FISH, and RT-PCR, for the detection of variants of t(8;21)(q22;q22), shedding light on region 8q22 approximately qter which could harbor potential genes responsible for leukemogenesis.

To assess the prevalence and determinants of smoking prior to and during pregnancy in Lebanon.A cross-sectional study using two structured instruments. One instrument included information on demographic characteristics, smoking patterns in the index pregnancy and previous pregnancies, use of prenatal health services, stressful life events, and social support during pregnancy. The second was the Arabic General Health Questionnaire (GHQ-12). Women who delivered in 11 randomly selected hospitals in Beirut and its suburbs within 24 hours were asked to consent to participate in the study. The total sample interviewed was 576 women.The prevalence of pre-pregnancy smoking was 32% and 20% for smoking in pregnancy. Considering argileh smoking, the prevalence of tobacco use in pregnancy increased to 27% in Beirut and 25% in the suburbs. Pre-pregnancy smoking was associated with older maternal age [OR = 1.08, 95% CI (1.03, 1.14)], low and medium education [OR = 2.22, 95% CI (1.22,4.04)], increased psychiatric distress [OR = 3.11, 95% CI (1.77,5.46)], and a husband who smoked [OR = 5.00, 95% CI (2.98,8.39)]. Continued smoking during pregnancy was associated with low and medium education [OR = 3.77, 95% CI (1.31, 10.8)], younger age [OR = 1.11, 95% CI (1.02-1.20)], and a heavy pre-pregnancy smoking pattern [OR = 13.9, 95% CI (1.40,137.4)].Policies and programs to eliminate or reduce smoking during pregnancy should be targeted toward young and less educated females and involving the spouse. Obstetricians should promote smoking cessation during pregnancy using evidence-based methods.

The present report describes a 27-year-old woman diagnosed with Ann Arbor stage IE primary malignant lymphoma of the cervix. Radiation therapy was instituted as conventionally advocated at this early stage of the disease. Despite adequate local tumor response, central nervous system metastasis occurred a few months later. She succumbed to her condition 7 months after initial diagnosis. As occult distant foci may not be amenable to detection by available imaging techniques at the time of initial work-up, combination chemotherapy alone or in conjunction with radiation therapy may be the most appropriate first line of therapy in patients with stage IE primary malignant lymphoma of the cervix.

OBJECTIVE: To compare the perinatal outcome of the presenting twin to its co-twin. STUDY DESIGN: All live nonanomalous twin gestations delivered at >25 weeks' gestation between 1984 and 1994 (N=461) were identified. Twin A was compared to twin B regarding the following variables: presentation, Apgar score (AS)

Chemotherapeutic agents administered for the treatment of malignancies can result in the incidence of premature ovarian failure (POF). Ovarian failure is reflected by elevated serum follicle-stimulating hormone (FSH) levels that may reach menopausal levels, at which the chances of a pregnancy are considered extremely rare. We report a case of a 26-year-old female who experienced two successful pregnancies, despite her diagnosis with chemotherapy-induced POF. This case suggests that patients who suffer from POF secondary to chemotherapy might still retain enough ovarian function with good quality oocytes that could support a healthy pregnancy.

Purpose : To prospectively follow a group of women with breast cancer on tamoxifen for the development of ovarian cysts. Methods : 72 women were followed every 6 months with pelvic examination and vaginal ultrasound. Chi square and Student's t- test were used for statistical analysis. Results : The duration of treatment was 31.5±20 months. The mean age was 51.2±9.8 years. 55.6% were post-menopausal. Out of 72 women, 18 (25%) developed ovarian cysts. The mean age of women who developed ovarian cysts was significantly lower than in those who did not (47.0±7.0 and 52.5±10.2 years, respectively, P =0.03), however, the mean duration of treatment was not significantly different (33.3±17.4 and 29.3±20 months, respectively, P =0.45). Out of 32, 14 (43.8%) pre-menopausal and out of 40, 4 (10%) post-menopausal women developed ovarian cysts ( P =0.003). They developed the cysts after an average duration of 33.3±18 and 50.7±6.2 months, respectively ( P =0.7). The average diameter of the cysts was 2.8±1.2cm. All cysts were simple except for one pre-menopausal women. All the cysts in post-menopausal women resolved spontaneously. One pre-menopausal patient had a multi-loculated cyst, was operated and had a serious cystadenoma. In nine patients, the cysts resolved spontaneously and in three after discontinuation of tamoxifen, and one patient was lost to follow-up. All cysts were asymptomatic. Conclusion : Ovarian cysts frequently develop in women with breast cancer on tamoxifen. The majority of the cysts resolve spontaneously, therefore an expectant management with follow-up ultrasonography is recommended.

Background Dubowitz syndrome is a rare, autosomal recessive disorder characterized by intrauterine and postnatal growth retardation, severe microcephaly, psychomotor retardation, hyperactivity, eczema, and characteristic dysmorphic facial features. Although many cases have been reported, the cause of this disease is still unknown. Case We present here the case of a Lebanese girl with Dubowitz syndrome in whom an unpleasant urine odor was persistently reported since birth. Conclusion Although Dubowitz syndrome has been largely described in the medical literature, this is the first time that a peculiar urine odor was reported. This case report adds a new and unusual feature to the numerous findings related to this rare polymorphous syndrome.

Background The harmonic scalpel is an ultrasonically activated surgical instrument for tissue dissection. Despite its expanding surgical applications, there are no reports about associated complications. Case A 35-year-old woman sustained injury to the sigmoid colon from the use of the harmonic scalpel during laparoscopic lysis of pelvic adhesions. The injury was identified and repaired laparoscopically in a primary fashion with no subsequent sequelae. Conclusion Acoustic energy coupling and overheating of the laparosonic blade extender sheath occur with bending of the instrument. This can happen with steering of the blade extender during laparoscopic surgery and may increase the exposure risk of adjacent tissues to injury.

C3 production by the human endometrium has been previously described. The objective of the current study was to localize the site of expression and regulation of the third component of complement, C3, in the endometrium. Eight secretory and eight proliferative archival endometrial samples from hysterectomy and endometrial biopsy specimens were used for in situ hybridization analysis. This analysis was performed with a radiolabeled riboprobe synthesized from a 736-bp template representing sequence 1944-2680 of the human C3 complementary DNA. Duplicate sections were hybridized with sense and antisense riboprobes. Resultant autoradiograms were analyzed qualitatively by light- and darkfield microscopy. In proliferative endometrium, minimal expression of C3 was observed and was limited to a few stromal patches and glands throughout the section. In the secretory samples, prominent C3 expression was observed in both the glands and stroma of the basalis layer. Endometrial lymphocytes did not express C3. Endometrial stromal and glandular cells express the C3 gene. Endometrial lymphocytes did not express C3, but other nondistinct lymphoid elements scattered in the stroma may be expressing C3. There was a visibly more intense expression of C3 in the basalis layer of the secretory endometrium than in proliferative endometrium. The spatial and temporal pattern of C3 expression may have implications in normal menstrual physiology and in the immunological response of the endometrium to the invading trophoblast during placentation.