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Background & aim: Trial of labor after cesarean (TOLAC) to achieve vaginal delivery is considered acceptable in women with one previous cesarean. This study was performed to compare the success rate and maternal and neonatal outcomes of TOLAC after one and two previous cesarean sections.Methods: This cross-sectional study was conducted in September 2018 and March2020 by convenience sampling on 339 pregnant women with a history of one or two previous cesarean sections in Mashhad. TOLAC was performed for all eligible participants, if cesarean section performed due to any reason, it was considered a failed TOLAC. Maternal and neonatal outcomes by a check list were recorded during TOLAC and one week later. Data were analyzed by SPSS (version 24). Results: TOLAC was successful in 301 cases (94.1%), but 19 (5.9%) underwent cesarean section. Maternal age, parity, and frequency of comorbidities were significantly higher in those with two previous cesarean sections compared to those with one previous cesarean section (P0.05). Conclusion: Considering standard precautions in patient selection, TOLAC has a high enough success rate to justify recommending it to the selected women with one or two previous cesarean section.

Background & aim: One of the risk factors of premature rupture of membranes is striae gravidarum, which occurs in 50-90% of pregnancies due to poor skin elasticity. It was found that Equisetum arvense is a medicinal plant containing silicic acid, which can increase tissue elasticity, strength and resistance by stimulating collagen synthesis. Therefore, this study examined the effect of Equisetum arvense vaginal cream on premature rupture of membranes in primiparous women with striae gravidarum.Methods: This triple-blind randomized controlled trial was performed on 90 pregnant women with gestational age of 37-38 weeks who had moderate and severe striae gravidarum, referred to the prenatal governmental and private clinics in Mashhad, Iran, between 2020 and 2021. Intervention and placebo groups, who were randomly assigned using quadruple blocks, soaked every night the beginning of the vagina with a fingertip of 3% Equisetum arvense vaginal cream or placebo from the beginning of 37-38 weeks until delivery. The occurrence of premature rupture of membranes was confirmed in case amniotic fluid leaks two hours before the onset of uterine contractions. Data were analyzed using independent t-test and Mann-Whitney.Results: The subjects in the two groups were homogeneous in terms of demographic and obstetric variables. Premature rupture of membranes in the intervention group (13.0%) was significantly lower than the placebo group (38.6%) (p = 0.005).Conclusion: Equisetum arvense vaginal cream is effective in preventing premature rupture of membranes. Therefore, its use is recommended to prevent premature rupture of membranes in women with moderate and severe striae gravidarum.

Introduction: Eclampsia is defined as generalized tonic-clonic seizure in a pregnant woman with preeclampsia. Eclampsia is one of the leading causes of maternal and fetal mortality worldwide. This study was performed with aim to evaluate maternal and fetal complications in pregnancies with eclampsia in Ghaem Hospital of Mashhad. Methods: In this cross-sectional study, all patients with a diagnosis of eclampsia who were admitted to Ghaem Hospital between June 2018 and June 2020 were included in the study. Maternal and fetal complications were assessed. For all patients, a checklist was completed by the researcher including information and history of underlying diseases, surgery, obstetrics, and maternal and neonatal complications. Data were analyzed by SPSS statistical software (version 16). Results: In this study, 51 patients with eclampsia were evaluated. The frequency percentage of eclampsia in Ghaem Hospital was 0.45%. Eclampsia before delivery was 66.7% and was higher than during and after delivery. Maternal complications included: increased rate of cesarean section (70%), postpartum bleeding (1.96%), liver disorders (1.96%), PRES syndrome (13.7%), HELLP syndrome (9.8%), DIC (1.96%), placental abruption (3.9%) and pulmonary edema (1.96%). Fetal complications were low Apgar (43.1%), low birth weight (41.1%), NICU admission (33.3%), preterm delivery (25.4%), IUGR (19.6%) and neonatal and fetal deaths (27.5%) that 4 cases were stillbirth and 10 cases died up to 7 days after birth. There was no maternal death. Conclusion: Maternal complications were: preterm pregnancy, cesarean section due to placental abruption or IUGR, HELLP syndrome, ICU hospitalization and maternal death, respectively. Fetal complications were: preterm delivery, IUGR and NICU hospitalization and intrauterine fetal death, respectively.

Introduction: One of the important issues in obstetrics is labor induction in the inappropriate conditions of the cervix. Misoprostol improves the condition of the cervix and shortens the duration of the labor and help in delivery sucess. Some studies have been published on the effect of propranolol on labor process in favor of shortening the labor. Therefore, this study was performed with aim to compare the effect of propranolol plus misoprostol with misoprostol alone on labor induction. Methods: This double-blind clinical trial study was performed from November 2017 to September 2019 on 70 pregnant women referred to the maternities of Mashhad University Hospitals. The subjects were randomly divided into two groups. One group received 25 micrograms of sublingual misoprostol every 4-6 hours up to 6 doses plus a placebo capsule, and the other group received misoprostol with the same dose and method of the first group plus two doses of oral 20mg Propranolol tablet with interval of 4 hours. The interval between drug administration with onset of effective contractions, and onset of active phase and delivery were evaluated and compared in the two groups. Data were analyzed by SPSS statistical software (version 16). T-test and chi-square test were used to compare the groups, and equivalent non-parametric methods were used if necessary. Results: Mean interval of induction onset to effective contractions did not show any significant difference between the two groups (P=0.394). There was no significant difference between the two groups in the mean interval of induction onset to 4cm dilatation (P=0.82) and the mean interval of induction onset to delivery (P=0.108). Delivery complications showed no significant difference between the two groups (P=0.397). There was no significant difference between the two groups in the mean first and fifth minute Apgar score (P=0.715 and P=0.819, respectively). Conclusion: Propranolol use had no effect on decreasing the induction to delivery interval and reducing cesarean rate. Also, it didn’t cause changes in neonatal outcomes and maternal complications. There were no side effects of propranolol tablets, including bradycardia, hypotension, and drowsiness.

Introduction: Acute fatty liver of pregnancy (AFLP) has been noticed due to high mortality rate for mother and fetus. However, the cause and pathogenesis of AFLP are unclear, and the absence of specific symptoms precludes early diagnosis and effective treatment. Therefore, this study was performed with aim to investigate the pregnancy outcomes in patients with acute fatty liver of pregnancy. Methods: This cross-sectional descriptive study was performed in 2013-2018. A total of 1475 records of women suspected to acute fatty liver of pregnancy, HELLP syndrome, severe pre-eclampsia and Thrombotic Thrombocytopenic Purpura (TTP) who were hospitalized in the university hospitals of Mashhad were selected and evaluated. Chief complaints at admission, laboratory data and pregnancy outcomes were evaluated. Data were analyzed by SPSS software (version 23). Results: A total of 34 records with diagnosis of AFLP were included in this study. Nausea and vomiting (94.11%), abdominal pain (94.11%) and hypertension (52.94%) were three main complaints in these patients, respectively. Laboratory test showed an increase in bilirubin, liver enzymes, coagulation tests, creatinine and a decrease in albumin and platelet count. Mean gestational age at the time of pregnancy termination was 34.2±2.04 weeks. We found 5 cases of maternal and 4 cases of neonatal mortality. Mean recovery time was 6.03±2.53 days. Conclusion: AFLP is associated with maternal mortality and the complications like multi organ failure, Diseminated intravascular coagulation, preterm labor, postpartum hemorrhage, and neonatal mortality. Since in this study, the most common complications of patients with AFPL were nausea, vomiting and abdominal pain, it is recommended to evaluate all pregnant women in third trimester who refer with these symptoms for diagnosis of AFLP.

Background: Posterior reversible leukoencephalopathy syndrome (PRLS) is a clinical and radiological syndrome of heterogeneous etiologies that are grouped because of the similar findings on neuroimaging studies which may occur at any age. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. The syndrome is more commonly seen in women, RPLS has been described in several medical conditions, with hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressant drugs being the most common conditions. Prompt recognition and treatment are important in preventing the permanent damage that can occur in this otherwise typically reversible condition. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. This report aimed to introduce a case of reversible posterior leukoencephalopathy following postpartum thrombotic thrombocytopenic purpura (TTP). Case presentation: The patient was a 30-year-old primigravid woman at 33 weeks of pregnancy who was referred to the Ghaem hospital, Mashhad University of Medical Sciences in Mashhad in July 2017 due to high blood pressure, blurred vision, headache and generalized tonic colonic seizure. She did not report in previous history of high blood pressure or seizure before pregnancy. With a diagnosis of eclampsia remote from delivery, she underwent a cesarean section. After delivery, generalized tonic colonic seizure repeated several times and a significant reduction in consciousness level happened. Renal failure also occurred, so she underwent daily plasmapheresis with a diagnosis of TTP. After 35 days, she was discharged with a good general condition. Conclusion: In predisposing conditions, such as high blood pressure in pregnancy, in the case of clinical suspicion of posterior leukoencephalopathy, any attempt for early diagnosis and appropriate treatment are important factors in reducing the rate of morbidity and mortality.

Background: Nephrotic syndrome is a kidney disorder that is identified by signs of nephrosis, severe proteinuria, hypoalbuminemia, and edema. It is a component of glomerulonephrosis, in which different degrees of proteinuria may occur. The complications of this syndrome may include blood clots, infections, and high blood pressure. Essentially, decreased protein through the kidneys (proteinuria) leads to low protein levels in the blood (hypoproteinemia including hypoalbuminemia), which causes water to be drawn into soft tissues (edema). Severe hypoalbuminemia may also lead to different secondary problems, including water in the abdominal cavity (ascites), around the heart or lung (pericardial effusion, pleural effusion), high cholesterol (hyperlipidemia) and, loss of molecules regulating coagulation (increased risk of thrombosis). Other symptoms may be weight gain, feeling tiredness, and also foamy urine. This study aimed to introduce a case of successful treatment of nephrotic syndrome in twin pregnancy. Case Presentation: The patient was a 30-years old woman who presented with twin pregnancy in 31 weeks of gestation with a history of IVF (In-Vitro Fertilization) in the current pregnancy. She referred to Ghaem hospital of Mashhad University of Medical Sciences in March 2017 because of severe lower extremities edema and 3+ proteinuria. Considering severe proteinuria (more than 6 gr/24 hr), edema, hypoalbuminemia and hyperlipidemia, the nephrotic syndrome was diagnosed and she was treated with methylprednisolone, Hydrochlorothiazide and Fenofibrate. At last, premature rupture of membrane occurred at 36 weeks of gestation. Cesarean was done because of the breech presentation of both fetuses and two healthy neonates were born with an optimal Apgar score. Conclusion: Early diagnosis of nephrotic syndrome and accurate prenatal care in these patients could have optimal pregnancy outcomes, especially if it was not complicated by hypertension and renal dysfunction.

Introduction: Acute pancreatitis during pregnancy is a rare event that its frequency has been estimated as ranging from of 1/1000 to 1/10000 births. The aim of this study was to report a case of acute pancreatitis during pregnancy and its maternal and neonatal outcomes following conservative management. Case presentation: A 25 years old woman G2ab1(second pregnancy, one abortion) with gestational age of 30 weeks and sudden epigastria pain from the last night who had referred to the Ghaem hospital of Mashhad due to severe stomach pain along with nausea and vomiting.. MRI reported increase in gall bladder thickness and pancreatic inflammation and left plural effusion. In laboratory tests, amylase and lipase were three time higher than normal. With diagnosis of pancreatitis, the patient underwent conservative treatment. At 6th day of hospitalization, 38°C fever and uterine contractions were started. A preterm neonate was born. The mother and neonate discharged from the hospital with good conditions. Conclusion: Acute pancreatitis during pregnancy can lead to preterm delivery. Early diagnosis and conservative treatment can be associated with desirable maternal and neonatal outcomes.

Introduction: Uterine prolapse and bladder exstrophy (BE) during pregnancy is a rare condition. The aim of this study was to present a rare case of pregnancy which complicated by both the bladder exstrophy and uterine prolapse. Case presentation: A 39 year old pregnant woman (gravid 2, para 1) presented to the maternity department at 39 weeks of gestation with labor pain. Physical examination showed regular uterine contractions; the cervix was completely out of the vaginal opening with dilatation 3 cm and effacement 30%. She had the history of multiple surgeries for correction of bladder exstrophy and also suffered from uterine prolapse .In active labor, abnormal fetal heart rate tracing happened, so emergent cesarean section was planned and a healthy neonate with the normal Apgar score was born. At regular follow-up until 4 months after delivery, there was no sign or symptom of uterine proplase. Conclusion: Multidisciplinary management of patients with BE and uterine prolapse may result in the optimal perinatal outcomes. Uterine prolapse may disappear after delivery even in the complicated case of bladder exstrophy.

Uterine rupture often occurs in the third trimester of pregnancy or during labor. Its occurrence in early pregnancy and in the absence of any predisposing factors is very rare. Untimely diagnosis and a low index of suspicion could be life-threatening. Here we report the case of a 29-year-old woman with a history of two previous cesarean sections. An ultrasound report revealed a dead fetus in the abdominal cavity at 14 weeks into the abdominal cavity due to a rupture at the site of the previous cesarean scar. Awareness of probable diagnosis of uterine rupture in a pregnant woman with abdominal pain could be important for timely diagnosis and proper management.

Background Delivery is the only definite cure for hypertensive disorders. Therefore, cervical ripening and labor induction are important to achieve favorable outcomes. Objective This Randomized Control Trial (RCT) is aimed to compare the effects of sublingual misoprostol and Foley catheter in cervical ripening and labor induction among patients with preeclampsia or gestational hypertension. Materials and Methods A total number of 144 women with preeclampsia or gestational hypertention with indication of pregnancy termination, who were referred to academic hospitals of the University of Medical Sciences in Mashhad, Iran, between March 2015 and December 2016, were randomly divided into two groups. In group one (n = 72), 25 µg of misoprostol tablet was administrated sublingually every 4 hr up to six doses. In group two (n = 72), a 16F Foley catheter was placed through the internal cervical os, inflated with 60 cc of sterile saline. Results There were no significant differences between groups regarding the demographic characteristics, primary bishop score, and pregnancy termination indication. The cervical ripening time (primary outcome) (8.2 vs 14.2 hr, p < 0.00), induction to delivery interval (15.5 vs 19.9 hr, p < 0.00), and vaginal delivery before 24 hr (63.9% vs 40%, p = 0.03) were significantly different between the two groups. There was no significant difference between groups in view of oxytocin requirement (p = 0.12), neonatal Apgar score (p = 0.84), or neonatal intensive care unit admission (p = 78). Conclusion This trial showed that the application of sublingual misoprostol, compared to the Foley catheter, can reduce cervical ripening period and other parameters related to the duration of vaginal delivery. This misoprostol regimen showed inconsiderable maternal complications.

Background: Cervical pregnancy is a rare type of ectopic pregnancy (EP) in which the pregnancy implants in the lining of the endocervical canal. It accounts for less than 1 percent of ectopic pregnancies. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role given an apparent association with a prior history of curettage or cesarean delivery. The most common symptom of cervical pregnancy is vaginal bleeding, which is often profuse and painless. Lower abdominal pain or cramps occur in less than one-third of patients; pain without bleeding is rare. It is important to think about the possibility of cervical pregnancy in such patients since early diagnosis is critical to avoidance of complications and successful treatment. Management of this pregnancy is dependent on the hemodynamic status of the patient. Conservative management and some more aggressive therapy such as emergency hysterectomy can be used. The aim of this report was to introduce a case of successful conservative management of cervical pregnancy. Case presentation: A 30-year-old G2L1 woman with history of a previous cesarean section and possible diagnosis of missed abortion referred to the Gynecology Clinic of Ghaem Hospital, Mashhad University of Medical Sciences, Iran, in 21 May 2017. Cervical pregnancy was diagnosed during curettage. Severe hemorrhage occurred after curettage and the hemodynamic status of the patient was unstable immediately after curettage. Severe threatening vaginal bleeding was controlled with intrauterine Foley catheter containing 60 cc normal saline and then vaginal packing. The patient was discharged with good general condition. Conclusion: In cervical pregnancy and unstable hemodynamic status and desire to preserve fertility, intrauterine Foley catheter and vaginal packing after curettage is helpful.

Various methods are used in order to describe the heart rate patterns of the fetus. The use of electronic monitoring during labor is widely accepted today. The aim of this study was to compare the neonatal outcomes of continuous Fetal Heart Rate (FHR) monitoring to intermittent auscultation among low-risk pregnant women during labor. This randomized clinical trial was conducted among 900 low-risk pregnant women who met inclusion criteria and were admitted to maternity wards of academic hospitals of Mashhad University of Medical Sciences for labor. They were randomly divided into two groups: the intermittent auscultation group and the Continuous FHR monitoring group. The pregnancy and neonatal outcomes were compared in two groups; data were processed in SPSS16 software. P less than 0.05 was considered as significant level. In this study, the first and fifth minutes Apgar scores, the rate of NICU admission, advance resuscitation requirement, neonatal seizure incidence, and the neonatal or fetal death did not differ significantly between two groups (P>0.05). In the Continues monitoring group, the rate of cesarean section due to fetal distress and operative vaginal delivery was significantly higher rather than the other group (P=0.001). The results of this study showed that continuous FHR monitoring in low-risk pregnancies during labor increases the risk of cesarean and instrumental delivery without improving neonatal outcomes.

Introduction: Postpartum hemorrhage is associated with highest rate of mortality and has many known etiologies. Inner myometrial laceration is one of the rare etiologies that lack of diagnosis can lead to maternal mortality. This report introduced a rare case of postpartum hemorrhage due to inner myometrial laceration. Case presentation: The patients were a 35-year-old woman (gravida 3 and live 2) referred to the hospital due to term pregnancy and premature rupture of membrane for pregnancy termination. Normal vaginal delivery was done following labor induction. After delivery of a 3700 gr neonate, severe postpartum hemorrhage occurred which was unresponsive to medical treatment and uterotonic drugs; she was transferred to operating room and hysterectomy was performed. Then, she was transferred to ICU. On the first day of Intensive Care Unit admission, the patient was complicated by ventricular tachycardia and bradycardia, and finally cardiopulmonary arrest. CPR was done, but it was unsuccessful, and the patient was expired. Pathological assessment revealed inner myometrial laceration at the posterior uterine wall. Conclusion: Considering inner myometrial laceration as one of the important and controllable causes of postpartum hemorrhage can lead to the diagnosis of this complication

Introduction: Oligomenorrhea is one of the most common menstrual disorders defined as the prolongation of menstrual intervals. This growing disorder reduce the quality of life for women of reproductive age due to complications, such as abnormal uterine bleeding, infertility, hirsutism and psycho-social consequences. Due to the complications of hormonal medications which are the common treatment of this disorder, the necessity of using complementary therapies is suggested; therefore, the present review study was conducted to investigate the therapeutic strategies of Persian medicine. Methods: In this review study, the main sources of Persian Medicine were investigated using the synonyms of oligomenorrhea such as “Ehtebās-e-tams”, “Habs-e- heiz”, reduction and discontinuation of menstruation. Then, to find new studies, the databases such as Google scholar, PubMed and ISI were searched with the keywords of Oligomenorrhea, Amenorrhea, PCOS, Persian Medicine and Traditional Medicine and the results were compared. Results: In texts of Persian Medicine, oligomenorrhea is referred as the "Ehtebas Tams". Therapeutic approaches to "Ehtebas Tams", like other treatments in Persian Medicine, in the first step include lifestyle modification, dietary modification, sleep and wake adjustment, exercise and bathing. The second step includes the use of emmenagogue herbal medicine which are mostly considered as phytoestrogen. These herbs are prescribed in various forms (Pill, Decoction, Herbal Tea, Vaginal Suppository, Vaginal Douche, ointment and sitz-bath). In the third step, manipulations such as wet cupping and phlebotomy are recommended as a therapeutic approach. Conclusion: Considering the effectiveness of some of these treatments in new studies such as Vitex agnus-castus, Mentha longifolia and Foeniculum vulgare, it is recommended to conduct more clinical studies based on Persian medicine therapies in addition to conventional medicine for treatment of oligomenorrhea.

Introduction: Pregnancy at a young age is considered high-risk, and the prevalence of teenage pregnancy has been reported to be on the rise. The present study aimed to evaluate the pregnancy outcomes in primigravid adolescents. Methods: This cross-sectional study was conducted at Ghaem Hospital in Mashhad, Iran during July 2012-2013. Sample population consisted of primigravid women aged 12-19 and 20-35 years at delivery. In total, 100 primigravid adolescents and 200 primigravid adults aged 20-35 years were enrolled in the study. A researcher-made questionnaire including the demographic characteristics, gestational age, and other variables (medical history, medical condition of the subjects at the current pregnancy, and neonatal status) was completed by the researcher for the subjects. Data analysis was performed in SPSS version 14 using Chi-square, Fisher’s exact test, and Mann-Whitney U test, and P-value of less than 0.05 was considered statistically significant. Results: Mean gestational age in the adolescents and adults was 38.35±3.15 and 37.2±3.08 weeks, respectively (P0.05), and only preeclampsia was significantly more prevalent in the adults compared to the adolescents (P0.05). In addition, no significant differences were observed between the groups regarding intended/unwanted pregnancies and smoking habits (P>0.05). Conclusion: Considering the favorable perinatal outcomes of teenage pregnancies, recommendations for early pregnancy may be rational, even in adolescent mothers.

Background: Complete molar twin pregnancy with coexisting fetus is a rare and important diagnosis in obstetrics. Preeclampsia, preterm labor and life-threatening vaginal bleeding are the serious complications of this type of pregnancy. Gestational trophoblastic neoplasia should be ruled out after termination of pregnancy. In this study we reviewed a molar twin pregnancy with a live coexisting triple x fetus which has not been reported till now. Case Presentation: Our case was a 22-year-old primigravida woman and 17-18th week of pregnancy, who referred to an University Hospital in Mashhad, Iran with complaint of vaginal bleeding On October 2016. Her first trimester ultrasonography in 13th week of gestational age, reported a live single fetus with an anterior great placenta and cystic formation regarding molar pregnancy. According to above-report, Amniocentesis was done in 15th weeks of pregnancy and its result was triple X. After severe and life-threatening vaginal bleeding, she underwent an emergent hysterotomy. A fetus with no obvious anomaly and a great hydropic and vesicular placenta delivered. Episodic crisis of her blood pressure was best controlled with anti-hypertensive drugs. In our case, chemotherapy with methotrexate was started after poor decline of βHCG titration and definite diagnosis of gestational trophoblastic neoplasia. Remission was completely achieved after four courses of chemotherapy. Conclusion: Differentiation between complete molar pregnancy with live fetus and partial mole is always challenging in obstetrics. Serious complications as preeclampsia and severe vaginal bleeding may become life-threatening. Coexisting molar pregnancy should be ruled out in a pregnancy associated with frequent and unexpectant vaginal bleeding. Amniocentesis and an expert radiologist can help to differentiate them. Following these patients is very important to reveal any trophoblastic neoplasia.

Background: Clomiphene citrate is one of the effective drugs for infertility treatment due to oligo-ovulation or anovulation. Intrauterine insemination (IUI) is one of more adherent methods for treatment of infertile cases which is followed by controlled ovarian hyperstimulation (COH). Objective: the aim of this study was to evaluate Clomiphene citrate versus letrozole with gonadotropins in IUI cycles. Materials and Methods: In this prospective randomized trial, 180 infertile women who were referred to Milad Hospital were selected. The first group received 5 mg/day letrozole on day 3-7 of menstrual cycle. The second group received 100 mg/day Clomiphene in the same way as letrozole. In both groups, human menopausal gonadotropin was administered every day starting on day between 6-8 of cycle. Ovulation was triggered with urinary Human Chorionic Gonadotropin (5000 IU) when have two follicles of ≥16 mm. IUI was performed 36 hr later. Results: The number of matured follicles, cycle cancellation, and abortion were the same in both groups. Endometrial thickness was higher at the time of human menopausal gonadotropin administration in letrozole group. Chemical and clinical pregnancy rates were much higher in letrozole group. Ovarian hyperstimulation was significantly higher in clomiphene group. Conclusion: Letrozole appears to be a good alternative to clomiphene citrate with fewer side effects.

Background: Placenta adhesive disorder (PAD) is one of the most common causes of postpartum hemorrhage and peripartum hysterectomy. The main risk factors are placenta previa and prior uterine surgery such as cesarean section. Diagnosis of placenta adhesive disorders can lead to a decrease of maternal mortality and morbidities. Objective: The purpose of this study was to compare the accuracy of color Doppler ultrasonography and magnetic resonance imaging (MRI) in the diagnosis of PADs. Materials and Methods: In this is cross-sectional study, Eighty-two pregnant women who were high risk for PAD underwent color Doppler ultrasound and MRI after 18 weeks of gestation. The sonographic and MRI findings were compared with the final pathologic or clinical findings. P

Background: Late postpartum hemorrhage (PPH) is defined as uterine bleeding between 24 hours until 12 weeks after delivery. Uterine artery pseudoaneurysm is a rare cause of life-threatening late postpartum hemorrhage (PPH). Emergency uterine artery embolization (UAE) is an appropriate method for control of hemorrhage. The aim of this report was to present a case of uterine artery embolization in late postpartum hemorrhage due to uterine artery pseudoaneurysm. Case Presentation: A 25-year-old woman with the history of three previous cesarean sections was admitted 35 days after the last cesarean. She had severe vaginal bleeding for 35 days after cesarean section. Because of severe vaginal bleeding 35 days after cesarean section, the patient was at nearly shock state (BP=90.60 mmHg, positive tilt test, tachycardia PR=120/m). In speculum examination, she had severe vaginal bleeding, but there was no lesion in vagina or cervix, also, bimanual examination of the uterus and adnexal area were normal. She reanimated by two liters of normal saline and uterotonic agents (oxytocin and methergine) were administered. Laboratory data showed severe anemia (Hb=6.5 gr/dl), but coagulation tests were normal. Ultrasonography didn’t show any abnormality. Because of continuation of vaginal bleeding after stabilization of the patient, UAE was planned. During pelvic angiography, a pseudoaneurysm was diagnosed and then it was treated by successful UAE. Conclusion: Uterine artery embolization is a conservative management for control of late postpartum hemorrhage. It can be a useful and alternative method for uterine and hypogastric artery ligation and hysterectomy, therefore it has an important role in treatment and fertility preservation for young women.

Background: Clomiphene citrate is one of the effective drugs for infertilitytreatment due to oligo-ovulation or anovulation. Intrauterine insemination (IUI) isone of more adherent methods for treatment of infertile cases which is followed bycontrolled ovarian hyperstimulation (COH). Objective: the aim of this study was to evaluate Clomiphene citrate versus letrozolewith gonadotropins in IUI cycles. Materials and Methods: In this prospective randomized trial, 180 infertile patientswho were referred to Milad Hospital were selected. The first group received 5mg/day letrozole on day 3-7 of menstrual cycle. The second group received 100mg/day Clomiphene in the same way as letrozole. In both groups, humanmenopausal gonadotropin was administered every day starting on day between 6-8of cycle. Ovulation was triggered with urinary Human Chorionic Gonadotropin(5000 IU) when have two follicles of ≥16 mm. IUI was performed 36 hr later. Results: The number of matured follicles, cycle cancellation, and abortion were thesame in both groups. Endometrial thickness was higher at the time of humanmenopausal gonadotropin administration in letrozole group. Chemical and clinicalpregnancy rates were much higher in letrozole group. Ovarian hyperstimulation wassignificantly higher in clomiphene group. Conclusion: Letrozole appears to be a good alternative to clomiphene citrate withfewer side effects.

Introduction: Regarding to the recent advances in assisted reproductive techniques (ART), twin and multiple pregnancies have increased during past years. Objective: This study was performed to compare obstetrics and perinatal outcomes of dichorionic twin pregnancy following ART with spontaneous pregnancy. Materials and Methods: In this cross-sectional study which was performed in Ghaem Hospital, Mashhad University of Medical Sciences, 107 dichorionic twin pregnancy were enrolled in two groups: spontaneous group (n=96) and ART group (n=31). Basic criteria and obstetrics and neonatal outcomes information including demographic data, gestational age, mode of delivery, pregnancy complications (preeclampsia, gestational diabetes, preterm labor, and intrauterine growth retardation (IUGR), postpartum hemorrhage), neonatal outcomes (weight, first and fifth minuteP PApgar score, Neonatal Intensive Care Unit (NICU) admission, mortality, respiratory distress, and icterus) were recorded using a questionnaire. Results: Preterm labor, gestational diabetes, and preeclampsia were significantly higher in ART group compared to spontaneous pregnancy group. However, other factors such as anemia, IUGR, postpartum hemorrhage, and intrauterine fetal death (IUFD) were not significantly different between groups. There were no significant differences between groups in terms of neonatal outcomes (weight, 1PstP and 5PthP min Apgar score

Background: Herpes encephalitis is the most common cause of fatal encephalitis in the world which often presents with sudden fever, headache, seizure, focal neurologic symptoms, and consciousness loss. The aim of this study was to report a case of maternal death caused by herpes encephalitis which appropriate antibiotic therapy delayed because of early diagnosis of eclampsia. Case Presentation: A 16-year-old pregnant woman at 36th weeks of gestation was referred to gynecology emergency department of Ghaem Hospital, Mashhad University of Medical Sciences in 2016. She was admitted due to 4 times of generalized tonic-clonic seizures and blood pressure of 140/90 mmHg with diagnosis of eclampsia. Cesarean section was performed for fetal distress and eclampsia remote from delivery. 6 hours after cesarean section because of higher than 39 °C and reduction in consciousness status, she was transferred to intensive care unit (ICU). The first brain magnetic resonance imaging (MRI) was normal. Lumbar puncture (LP) was performed and brain MRI was repeated that increased signal was observed in two sides of basal ganglia. Intravenous acyclovir was administered by possible diagnosis of viral meningoencephalitis. Cerebrospinal fluid (CSF) was positive in terms of herpes simplex virus type 1 (HSV-1). Unfortunately, the patient died 35 days after hospitalization by diagnosis of HSV-1 encephalitis and bilateral infarction with frequent seizures and clinical manifestation of septic shock refractory to treatment. Conclusion: Although the first diagnosis for generalized convulsion during pregnancy is eclampsia, but in case of recurrent and specially atypical seizures and low consciousness level, other diagnosis like meningoencephalitis, brain lesions and cavernous sinus thrombosis (CVT) must be considered and ruled out.

Introduction: Neonatal mortality is a global health issue. Preterm delivery is considered as a leading cause of neonatal mortality and morbidity. Preterm neonates may develop complications such as Respiratory Distress Symptom (RDS), Intraventricular Hemorrhage (IVH) and neonatal sepsis. This study aimed to evaluate the effective factors in the prognosis of preterm infants. Materials and Methods: This cross-sectional study was conducted on 283 premature neonates born in Ghaem Hospital in Mashhad, Iran during September 2013-March 2014. Demographic data and perinatal mortality and morbidity rates were recorded for all the neonates. Data analysis was performed in SPSS Version19. Results:In this study, rates of morbidity and mortality were 33.2% and 18.7%, respectively. In total, 50.9% of the neonates were admitted to the neonatal intensive care unit. Among the study samples, 26.5% had RDS, 18.4% had neonatal sepsis, and 2.8% had IVH. Moreover, 18.4% of the neonates required mechanical ventilation. Increased gestational age and birth weight significantly reduced the rates of morbidity and mortality. Although mode of delivery and premature rupture of membranes affected the mortality rate, they had no significant associations with the morbidity rate of the neonates. Also, maternal factors such as age, gravidity, history of diseases or pregnancy complications, and drug use during pregnancy had no significant effects on the rates of neonatal morbidity and mortality. Conclusion: According to the results of this study, gestational age and birth weight were the most significant predictive factors for neonatal morbidity and mortality in preterm infants.

The prevalence of bilateral sudden sensorineural hearing loss (SSNHL) is less than 5% and the etiology of most cases is unknown. Due to many structural and functional similarities between the kidney and inner ear, many conditions, diseases, and drugs have both renal and cochlear effects and toxicities. There are several reports of SSNHL in patients with CRF, uraemic patient, hemodialysis treatment, and ARF. Here, we report a rare manifestation of SSNHL following severe postpartum hemorrhage that has simultaneous renal failure and cochlear impairment. The patient was a 22-year-old primigravida woman with term pregnancy who after delivery and episiotomy hematoma and postpartum hemorrhage subsequently suffered from kidney failure, oliguria, and SSNHL that occurred after 3 days of delivery. In conditions such as severe postpartum bleeding leading to acute renal involvement, the possibility of simultaneous involvement of cochlea due to hypoxia or received drugs should be considered.

Introduction: Acardiac twin refers to a monochorionic pregnancy in which there is a twin with absent or nonfunctioning heart and a normal co-twin. This was a very rare disorder of monozygotic twin pregnancy. The aim of this report was to introduce a case of acardiac acephalus twin pregnancy. Case Presentation: A 32- year- old woman (G3 P2 L2) referred to the hospital because of a decrease in fetal movement at 32 weeks of gestation. Ultrasonography showed a dead fetus. Her earlier sonography showed the possibility of acardiac twin pregnancy, but she did not have any appropriate or special prenatal care for this problem. After delivery, there was a normal dead fetus without any gross abnormality and another acardiac fetus. Conclusions: Early diagnosis of acardiac twin pregnancy and appropriate prenatal care are of prime importance for appropriate intervention and best fetal outcomes.

Persistent low level of beta-hCG (PLL) is defined as rising hCG level no more than two-fold over a three months period. Almost many types of PLL can lead to the wrong diagnosis. Here, we presented two cases of the retained product of conception (RPOC) with persistent low levels of beta-hCG. Both cases were presented with persistent low levels of beta-hCG and abnormal uterine bleeding since first-trimester pregnancy termination. Ultrasonography revealed a vascular mass with extension from the endometrial cavity to myometrium imitating gestational trophoblastic disease (GTD) or arteriovenous malformation (AVM). The final pathologies of both cases were retained product of conception. Imaging features of RPOC can closely imitate those of an AVM or GTN; so, hysteroscopy is one of the best non-invasive procedures which may be helpful in diagnosis and selection of appropriate treatment especially in young patients who desire to preserve their fertility.

Objective: To evaluate the maternal and neonatal complications of vaginal birth after cesarean section (VBAC). Materials and methods: This cross sectional study was conducted in Mashhad University of medical sciences. Eighty women with previous cesarean section who were candidate for VBAC were enrolled the study. Patients were followed up for 6 weeks after delivery. The complication of VBAC was compared between successful or unsuccessful VBAC cases. Data was analyzed by SPSS version 16. Results: VBAC success rate was 91%. Post-partumhemorrhage occurred in 2.7% of woman with successful VBAC and 1.3% of CS cases. Maternal and neonatal death did not happen during our study, and none of our cases experienced uterine rupture, dystocia and neonatal tachypnea. Neonatal complications include NICU admission and neonatal resuscitation frequency in VBAC and CS were 6.8% and 57.1%, respectively (p = 0.002). Birth weight of neonates in successful VBAC was 2940 ± 768 grams and 3764 ± 254 grams in unsuccessful VBAC and this difference was significant (p = 0.007). Mean maternal admission duration in VBAC and CS were 1 ± 0.1 days and 2 ± 0.4 days (p < 0.001). Successful breastfeeding rate were higher in VBAC patients (95.8%) in comparison with CS (42.9%) and this difference was statistically significant (p = 0.002). Conclusion: Our results revealed that VBAC can be considered as a safe maternal and neonatal delivery method in patients with past CS women.

Background: Twin pregnancy with a fetus and a diploid complete mole is not rare, but, the cases of twin pregnancy with a partial mole are rare. Nowadays, the prevalence of these cases has been increased due to the high rate of assisted reproductive techniques in reproductive medicine. The importance of twin pregnancy with a fetus and a diploid complete mole is mainly due to systemic complications such as hypertension and maternal hemorrhage and the possibility of trophoblastic tumor following delivery. Different studies have reported some results about similar cases, but limited case reports are presented in our country. The aim of this study is to report a case with incomplete molar pregnancy concomitant with a live fetus. Case presentation: A 21 yr old woman (G2 ab1) referred to emergency department of Ghaem University Hospital in Mashhad. She complained of scant vaginal bleeding and spotting and a sonography report of a combined molar and normal pregnancy with 15 weeks gestational aged. During hospitalization, the pregnancy complicated with hypertension and proteinuria. Termination of pregnancy was planned at 17th weeks of gestation due to severe preeclampsia. After evacuation of uterus, during follow up visits, -hCG titer raised. Metastasis evaluation was negative. Pathology reports showed patial mole. Then, three doses of methotrexate (50 mg/m2 intra muscular) was administered and finally, according to the monthly follow up, -hCG level was undetectable. Conclusion: The rate of pregnancy complications such as hypertension, hyperthyroidism, and obstetrics hemorrhage and also the risk of Gestational Trophoblastic Neoplasm (GTN) are increasing in incomplete molar pregnancy. Therefore, early diagnosis and timely treatment of molar pregnancy is very important to reduce maternal morbidity and mortality.

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

Background: Placenta accreta is a life-threatening complication after previous cesarean delivery. The aim of this case report is to present a case of placenta percreta with bladder involvement and subsequent maternal death.Case presentation: The patient was a 37-year old who had an unwanted pregnancy due to tubectomy failure two years afterwards. She was hospitalized at 26th and 30th week of gestation because of gross hematuria. Sonography reported placenta previa. Cesarean section was performed at 34th gestational week. Due to severe hemorrhage, hysterectomy with resection of some part of the bladder was done. Died at the operating room after four hours of severe uncontrollable hemorrhage. Conclusion: The increasing prevalence of different forms of placenta accreta is the result of the ever-increasing rate of cesarean deliveries. One of the strategies to prevent this catastrophic obstetric complication is decreasing the number of cesarean deliveries without appropriate indications.

Background and Objective: Success rate of IVF depends on infertility factors and its treatment cycle. Different methods of treatment and different centers have reported various rates of success. The aim of this study was to evaluate the fertility outcome after IVF and related factors. Materials and Methods: This descriptive analytic study was performed on 150 infertile couples following IVF in Montaserieh Infertility Center, Mashhad University of Medical Sciences, Mashhad, North – East of Iran during 2001-06. Data was collected by a questionnaire including woman's age, husband's age, infertility factor, spermogram, infertility period, the number of follicles caused by treatment, the number of oocytes, the number of produced and transferred fetus and treatment outcomes. Data was analyzed by SPSS software and Chi-square, t-studen test, One-way ANOVA and logistic regression. Results: The mean age of women was 29.7±5.4. The mean±SD follicles oocytes and transferred fetus were 11±6, 6±3.9 and 2.6±1.5 respectively. There was significant relation between the number of follicles (P

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

Introduction: Wernicke’s Korsakoff syndrome is the most important complication of severe thiamine deficiency. Confusion and gait ataxia are the most prevalent symptoms, respectively. The aim of this study was report of a case of Wernicke’s encephalopathy following hyperemesis gravidarum. Case report: A 28-years-old pregnant woman in 19th weeks of gestation referred to the hospital with hyperemesis, gait ataxia, and dysarthria. MRI showed hyperdense lesion which was characteristic of wernicke’s encephalopathy. Rapid improvement in patient’s condition occurred after thiamine infusion. Conclusion: In hyperemesis gravidarum, presence of either symptoms of ocular or mental disorder or ataxia must be considered to rull out Wernicke’s syndrome which can cause maternal death.

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

BACKGROUND: Prophylaxis of Rh immunization has a critical role in the Rh negative pregnant women for prevention of fetal erythroblastosis. The aim of this study was to evaluate the fetomaternal hemorrhage (FMH) in relation to the delivery mode. METHODS: In this case- control study. 170 pregnant women (85 terminated by normal vaginal delivery and equal number by cesarean section) were studied in 2005 in Ghaem hospital affiliated to Mashhad university of medical sciences. The data was collected by a questionnaire, Klei hauver and Betke test was done, and the correlation between measured variables and FMH was studied. The results were analyzed by SPSS software (SPSS, Inc. Chicago, IL) version 11.5 by using The Students’t and Man-Whitney U tests. FINDINGS: The extent of fetomaternal hemorrhage was significantly different according to the gestational hypertension, twin pregnancy, still birth, abruptio placenta, placenta previa, gestational age and sex of the fetus; but there was no significant difference according to the mode of delivery, maternal blood group and Rh, maternal age, gravidity and the extent of fetomaternal hemorrhage. CONCLUSION: In this study, there was no difference in the extent of FMH according to the mode of delivery and so the needed doses of anti-D. KEY WORDS: Fetomaternal hemorrhage, Kleihauer–Betke test, vaginal delivery, cesarean delivery, Rh isoimmunization, Rhogam