Tehran University Medical Journal

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Background: Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is a specific dermatosis of the third trimester of pregnancy, commonly seen in primigravid women.
Case presentation: A 24-year-old primigravida woman who had developed a rash immediately after delivery was admitted to Razi Hospital in Tehran, Iran. She had an erythematous eruption, particularly concentrated on the abdominal striae with umbilical sparing and involvement of limbs and extremities. Skin biopsy of the lesions on the lower abdomen, showed superficial perivascular infiltrates with occasional neutrophils and eosinophils. Both direct and indirect immunofloresence assays were negative. The patient was ultimately treated with topical clobetasol butyrate and oral chlorpheniramine for pruritus. Within a week, the lesions and the itchings had disappeared completely.
Conclusion: Pruritic urticarial papules and plaques of pregnancy are often, but not always, seen during the third trimester of pregnancy, but sometimes they present in postpartum period without any prior manifestations during pregnancy.

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Background: Many studies have shown that periodontal pathogens are emerging as a risk factor for preterm delivery and low birth weight, but there are few studies about the relationship between other oral bacteria and pregnancy outcomes. The aim of the present study was to determine the relationship between salivary bacteria and pregnancy outcomes. Methods: This cohort study was performed on 300 pregnant women who were recruited from the prenatal clinic of Zeynab Hospital in Tehran during 2009-2010. The patients’ demographic and pregnancy data were recorded. Using samplers, saliva samples were collected about one hour after breakfast. Microbial evaluation was performed by counting the bacteria based on their shape and the Gram reaction. The studied bacteria were composed of gram-positive and negative cocci, gram-positive and negative bacilli, spirilla, spirochetes, yeasts, fusiform bacteria and actinomycetes. Results: The data on the bacteriological profile and pregnancy outcome of 243 out of the 300 eligible participants of the study were completed. Five cases (2%) had intra uterine fetal death (IUFD) while 238 (98%) delivered live infants. There was a significant statistical relationship between the mean of gram-negative cocci and IUFD (P=0.04). 10 cases (4.1%) of 243, experienced adverse delivery outcomes and 233 cases (95%) had normal delivery. The adverse pregnancy outcomes had a significant relationship with the presence of spirochetes in saliva (P<0.05) but this relationship was not true for the other bacteria. Conclusion: Some oral bacteria may pose a risk for premature deliveries and low birth weights.

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Background: Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. Metformin which is effectively used for the treatment of anovulatory PCOS improves pregnancy rate and endometrial receptivity and reduces the risk of miscarriage. The aim of this study was to evaluate the effects of metformin on the endometrium, the number of fetuses and hormonal levels of PCOS rats. Methods: Forty female adult Sprague-Dawley rats were assigned randomly into four equal groups. Group I: control rats, group II: rats receiving metformin (150 mg/kg/day), group III: Estradiol Valerate-induced PCOS rats (4 mg/rat) and group IV: induced PCOS rats receiving metformin. Body weight and serum levels of glucose, LH, FSH, testosterone, progesterone and estradiol were measured. Following mating, each group was divided into two subgroups and the rats were sacrificed on the 5th and 15th day of gestation to evaluate endometrial reaction to implantation and fetus count, respectively. Results: Hormone assay showed a significant increase in testosterone, estradiol, LH, FSH and blood glucose levels in group III compared to the controls (P≤0.01) and a significant decrease in blood glucose in group IV versus group III (P≤0.01). Progesterone concentration had no significant differences between groups III and the controls. Weight was higher in group III than group I but it had no decrease after metformin administration. No significant differences were detected regarding implantation rate and number of fetuses in all rats. Conclusion: Metformin has significant effects on pregnancy rate and the hormonal and blood glucose levels of Estradiol Valerate-induced PCOS rats.

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800x600 Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Intrauterine insemination (IUI) is a less expensive and less invasive treatment in comparison with other assisted reproductive techniques, and it has been widely used for a variety of indications as well as in the treatment of couples with infertility. The outcome of IUI may be affected by numerous factors but in this study, we evaluated the effects of cervical mucus removal undertaken before IUI on clinical pregnancy rates.
Methods : In this randomized clinical trial study, all infertile women who were candidates for IUI and attended Shahid Akbar Abadi Hospital during 2009 and 2010 were recruited. The participants were randomly assigned into two groups. Cervical mucus was removed prior to IUI in patients in group A but in group B, a classic IUI was done without removing the cervical mucus. Pregnancy rates were assessed in the two groups by serum levels of β-HCG and detection of fetus in the uterus. 
Results : 291 women including 143 in the classic IUI group and 148 in cervical mucus removal group completed the study. The pregnancy rates were 14.2% (21 pregnancies upon 148 cycles) in the cervical mucus removal group and 7% (10 pregnancies upon 143 cycles) in the control group (P=0.04, OR: 2.199 CI 95%: 0.997-4.85).
Conclusion: The findings showed that cervical mucus removal could result in a two-fold increase in pregnancy rate in comparison with classic IUI. Thus, we suggest this practical and noninvasive method to improve pregnancy rate in these patients.

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800x600 Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Diabetes insipidus is a rare disease which can be considered as a part of broad spectrum of preeclampsia manifestations.
Case presentation : A 39-year old primigravid woman, with an unremarkable past medical history, was admitted in the 33rd week of gestation for elevated blood pressure. On admission, her blood pressure was 140/90 mmHg and the only abnormal laboratory findings were trace proteinuria and elevated liver enzymes. During the following days her blood pressure rose to 150/100 mmHg with deterioration of clinical and paraclinical status of the patient characterized by excessive thirst, polydipsia and excretion of large amounts of diluted urine. Having considered the patient's aggravating status, termination of pregnancy was planned. Fortunately, all the clinical and paraclinical presentations, including those related to the probable diabetes insipidus disappeared on the second day of postpartum period.
Conclusion: Sign and symptoms of diabetes insipidus should be considered in all cases admitted for preeclampsia.

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Background: Tubal sterilization is the permanent and effective contraception method. This can be performed at any time, but at least half are performed in conjunction with cesarean or vaginal delivery and are termed puerperal. The most complication after tubal ligation is ectopic pregnancy. Ectopic pregnancy is the leading cause of maternal death in first trimester.
Case presentation: We present a 33 years old woman gravida5, para4, all normal vaginal delivery, presented with complaints of delayed menstrual period, pelvic pain and spotting. She underwent tubal ligation for two times. For the first time she had puerperal Pomeroy tubal sterilization after third child delivery. Intra uterine pregnancy occurred three years later. One day after vaginal delivery of fourth child, she underwent post partum tubal ligation with the Parkland method. Tubal pregnancy occurred nine months later. Physical examination identified acute abdomen. Pelvic ultrasound showed no gestational sac in uterine cavity. The sac with fetal pole was in right adnexa. Beta-HCG was 2840mIU/ml. She underwent laparotomy. Surgical management included salpingectomy with cornual resection in both sides. The surgery identified Ectopic pregnancy.
Conclusion: Any symptoms of pregnancy in a woman after tubal ligation must be investigated an ectopic pregnancy should be excluded. Ectopic pregnancy must be considered, in any woman with lower abdominal pain, missed period and vaginal bleed-ing. Conception after tubal sterilization can be explained by fistula formation and re-canalization of fallopian tube.

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Background: Recent studies have suggested that impaired fetal growth are indicators that may be present in the first trimester. The aim of this study was to investigate the relationship between crown-rump length (CRL) and pregnancy associated plasma protein-A (PAPP-A) measurements in first trimester for low birth weight (LBW).
Methods: This prospective cohort study were on 120 pregnant women in first pregnan-cy trimester, in Women's Hospital Mirza Kochak Khan in 2011-2012. Gestational age according to crown-rump length and gestational age according to last menstrual period (LMP), neonatal weight, small for gestational age, pregnancy associated plasma protein-A and low birth weight were recorded. Main outcome measures was weight and gestational age at birth. Statistical tests used included descriptive statistics, t-test, χ² and all tests were two-tailed and differences with P<0.05 were considered to be statistically significant.
Results: Our findings showed that a total of 120 cases were included CRL Z-score and log 10 (MOM PAPP-A) were positively correlated with fetal birth weight. The mean Crown-rump length Z-score was significantly can be reduced in LBW in first trimester pregnancy. (P<0.001) Mean PAPP-A in low birth weight was (0.4±0.11 MOM), but in normal weight infants was (1.04±0.7 MOM). (P=0.011) also mean PAPP-A in pregnant women with SGA infants is significantly less than other pregnant women (0.5±0.2 versus 1.1±0.7) (P<0.001).
Conclusion: Our data suggest that crown-rump length and maternal levels of PAPP-A measured during the first trimester are independent factors that influence fetal birth weight. But their predictive powers are not sufficiently good for them to be used alone for low birth weight screening.

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Background: Intrauterine insemination (IUI) is one the most common methods in infertility treatment, but its efficiency in infertile couples with male factor is controversial. This study is a retrospective study about correlation between semen parameters and male and female age with successful rate of IUI in patients attending to Royan Institute.
Methods: A total of 998 consecutive couples in a period of 6 months undergoing IUI were included. They were classified into two groups: couples with successful and unsuccessful pregnancy. Main outcome was clinical pregnancy. Data about male and female ages and semen analysis including concentration, total sperm motility, class A motility, class B motility, class A+B motility and normal morphology was extracted from patients’ records. Semen samples were collected by masturbation or coitus after 2 to 7 days of abstinence. Their female partners were reported to have no chronic medi-cal conditions and have normal menstrual cycles.
Results: One hundred and fifty seven of total 998 cycles (15.7%) achieved pregnancy. The average of female age in successful and unsuccessful group was 28.95±4.19 and 30.00±4.56 years, respectively. Mean of male age was 33.97±4.85 years in successful group and 34.44±4.62 years in unsuccessful group. In successful and unsuccessful groups, average of sperm concentration was 53.62±38.45 and 46.26±26.59 (million sperm/ml), normal morphology of sperm was 8.98±4.31 (%) and 8.68±4.81 (%), sperm total motility was 47.24±18.92 (%) and 43.70±20.22 (%) and total motile sperm count was 80.10±63.61 million and 78.57±68.22 million, respectively.
Conclusion: There was no significant difference in mean of females’ age and males’ age between successful and unsuccessful groups (P<0.05). In addition, there was no significant difference in semen parameters including concentration, total sperm motility, class A motility, class B motility, class A+B motility and normal morphology between two groups. It was shown that common semen analysis and male and female ages cannot predict IUI outcome.

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Background: To compare the success rate and side effects of letrozole and misoprostol versus misoprostol alone for medical termination of early pregnancy. Methods: The patients requesting termination of pregnancy up to 63 days of gestation were randomized into two groups. The letrozole group received letrozole 10 mg daily for 3 days followed by 800 micrograms of vaginal misoprostol, while the placebo group received placebo for 3 days followed by the same dosage of misoprostol. The complete abortion rate and the side effects profiles of the two groups were compared. The primary outcome measure was the abortion rate. Results: A total of 214 women were recruited. Overal complete abortion rate was 81.3%, complete abortion rate in the letrozole group was not significantly higher than that of the placebo group (84.1% compared 78.5%). After receiving 800 mcg misoprostol, 37 case (17.3%) had complete abortion that 13 cases (12%) of the misoprostol group and 24 patients (22.5%) of the cominabtion group and after receiving 1600 mcg, misoprostol, in 137 cases (77.4%) had complete abortion that 71 patients (75.5%) of the misoprostol group and 66 cases (79.5%) was obtained for the combination group. This difference was not statistically significant (P> 0.05). D & C in 40 cases (18.7%) reported that was not significantly different in the two groups, 17 cases (15.9 %) in the combination group versus 23 (21.5%) in the misoprostol group. Side effects such as fever, tachycardia, diarrhea and pain were similar in the two groups there were not significantly fewer women complaining of side effects in the letrozole group than those in the placebo group (P> 0.05). Conclusion: Combination of letrozole and misoprostol is as effective as misoprostol alone in complete abortion rate. Based on these results, the use of misoprostol in combination with letrozole is safe and not expensive.

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Background: Normal vaginal delivery is the best method of delivery. Vaginal delivery is followed by the best pregnancy outcomes. Reducing the rate of cesarean delivery has been a health goal for the United States with economic and social advantages. This study has been conducted with aim of maternal and neonatal outcomes of Normal Vaginal Delivery (NVD) and comparing with cesarean delivery. Methods: This descriptive- analytic study was conducted in Ghaem University Hospital in Mashhad during years 2007 until 2013. Five hundred thirty six full term infants aged 3- 14 day, born either by NVD as control group or cesarean delivery as case group par-ticipated in this study. Sampling was a convenient method. The data in questionnaire containing maternal information (maternal age, mode of delivery, maternal weight, du-ration of delivery, duration of maternal hospitalization, let down reflex, breast feeding status) and neonatal information (age, sex, Apgar score, urination frequency and defe-cation frequency) were collected by a researcher. Results: According to the findings of this study, the infant’s age (P=0.425), admission weight (P=0.278), jaundice access (P=0.162), urination frequency (P=0.165), maternal weight (P=0.869) showed no statistically significant difference between two delivery methods. Time of the first breast feeding after childbirth (P=0.000), defecation fre-quency (P=0.000), maternal age (P=0.000), maternal parity (P=0.003), duration of de-livery (P=0.000), duration of maternal hospitalization (P=0.025), feeding position (P=0.029), let down reflex (P=0.012), mastitis (P=0.025) and breast problems (P=0.027) showed statistically significant difference between the groups. It means defecation frequency, duration of maternal hospitalization, Apgar score, mastitis and breast problems were more in cesarean group, but early breast feeding after delivery, duration of delivery, proper breastfeeding position and let down reflex were more in NVD group. Conclusion: The results of this study showed in comparison with cesarean delivery, normal vaginal delivery provides better outcomes in terms of breast problems, breast feeding status, duration of labor and duration of maternal hospitalization for both mother and infant. So, adopting careful instructions in management and administration of deliveries will help the prevalence of making decisions for normal vaginal delivery and the recovery of delivery outcomes.

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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.

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Background: Considering nitric oxide (NO) has an important role in many biologic processes of cells and tissues such as in the digestive system and in this system act as a second messenger in pathological and physiological events in gastrointestinal region, in this study we investigated the effects of L-NG-Nitro arginine Methyl Ester (L-NAME) as the NO formation inhibitor on parietal cells of stomach in pregnant rats. Methods: Twenty four female rats were prepared and with eight weeks old and 200-250 g weight were used in this study. After matting of the female rats with the male rats, time of observing vaginal plaque considered as the zero day of pregnancy. Then the animals were divided into three groups of studying. Each group was containing eight rats. In this study, except the control group, the saline group received 2 ml/kg normal saline and experimental group received 20 ml/kg L-NAME interaperitoneally (IP), respectively on third, fourth, and fifth days of pregnancy for evaluation of its effects. On the 18th day of pregnancy, after anesthesia with ether, the animals were killed and dissected and the laparotomy was performed to separate the mother’s stomach. Then, the stomach was fixed in 10% formalin and after tissue passage, the sections were stained with Hematoxylin-Eosin (H&E). Then the changes of count and diameter in parietal cells were observed via light microscopy and Image Tools III. Results: Results of this study after analysis showed the significant changes in parietal cells count (mean 61.3±4.32) and its diameters (mean 16.12±1.18 µm) in L-NAME group in comparison to control and the sham groups in pregnant rats (P≤0.05). Conclusion: Results of this study showed L-NAME with effects on NO synthesis can reduce the count of parietal cells and increase its diameter in pregnant rats and has destructive effects on structure of stomach parietal cells in pregnancy rats.

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Background: A balanced reciprocal translocation is a structural abnormality, which at least consist of breakage of two non-homologous chromosomes along with pieces exchange and form quadrivalant structure that can produce unbalanced chromosomes during meiosis I and result in a fetus abortion. The aim of the present study is to offer using preimplantation genetic diagnosis (PGD) 24sure array, which delivers aneuploidy screening of 24 chromosomes, within a few hours to increase fertility and bearing a child without chromosomal abnormality of this couple. This technique could replace embryo donation for child bearing of this couple. Case presentation: A young couple with recurrent pregnancy loss in 6th and 7th week of pregnancy without family history of recurrent miscarriage and any clinical signs had conferred. All laboratory tests including hormonal, infections, semen and hysterosalpingography were normal except karyotype that showed balanced reciprocal translocation between chromosomes 5 and 18 in male. Chromosomal study of male parents showed normal karyotype. Conclusion: A balanced reciprocal translocation carrier is phenotypically normal, but during meiosis І, carrier chromosomes cant pair normally and form quadrivalant instead of bivalant that depend on type of their segregation (alternate, adjacent 1, adjacent 2,3:1,4:0), produce gametes that are chromosomally unbalanced which can result in early fetus abortion. Considering the number of abnormal gametes, the most effective way to help couples with this problem seems to be PGD 24sure, since it can identify reciprocal and Robertsonian translocation and allows concurrent screening of all chromosomes for aneuploidy. Another technique that can be compared with PGD 24sure is fluorescence in situ hybridization (FISH), but it has several technical limitations such as it is expensive and complexity, in addition it has only few probes (for chromosomes 21, 13, 18, X, Y) so sometimes necessary to create patient specific protocols.

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Background: Septate uterus is the most common congenital malformation of the uterus in normal population and also patients with recurrent abortions. Pathogenesis of the disease is incompletely elucidated. It is clarified that incomplete absorption of paramesonephric ducts in the first trimester is responsible for septum formation. Hysteroscopy is known as the standard diagnostic and therapeutic procedure for septate uterus. In this study, our aim was to evaluated the effects of hysteroscopic septal resection in improving pregnancy outcomes in patients with unexplained infertility or recurrent abortion. Methods: Prospective cohort study was conducted in a Tehran University Medical Sci-ences affiliated hospital from April 2012 to May 2013. Eight patients were excluded from the study because of non-reproductive related complains. The other 40 patients went through a prospective cohort study and were treated for septate uterus. All patients had complete history taken and underwent physical examination. Septum size was measured by hysteroscopy. Patients underwent hysteroscopic metroplasty with resectoscope with an equatorial semicircular loop cutting 12 with monopolar energy. Some septum resected by 5 french hysteroscopic scissor. The patients were visited 2 month later for evaluated surgical outcome. This assessment was done by hysterosalpingography (HSG). Patient’s reproductive outcome were followed for 10.33 (SD:±6.43) months. Results: The mean age in patients was 31.5 (SD±3.02) years. In whole, 48 patients un-derwent hysteroscopic metroplasty. In 52.1% length of septum occupied two third of uterine cavity. Eight patients were excluded from the study because of non-reproductive related complains. There were 29 pregnant patients (72.5%). Fifteen patients became pregnant without intervention (51.7%). 14 patients had pregnancy under ART, while the pregnancy did not occur in 11 patients (27.5%) during this period. Among pregnant population there were 9 miscarriage (31%), 3 preterm (13.3%) and 17 term delivery (50%). Live birth rate in our study was 68.9%. In control hysterosalpingography (HSG), no patients had adhesion or residual ridge. Conclusion: The findings of this study indicate that hysteroscopic septoplasty is ac-ceptable for improving reproductive outcomes in patients with septate uterus.

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Background: With introduction of intracytoplasmic sperm injection with testicular sperm extraction or precutaneouse epididymal sperm aspiration, effective treatment was provided for azoospermic men. The aim of present study was to compare clinical outcome following intracytoplasmic sperm injection using extracted testicular/epididymal sperm or ejaculated severe oligoasthenoteratozoospermic sperm. Methods: After retrospective evaluation of more than four hundred medical records of patients undergoing intracytoplasmic sperm injection Mehr medical institute (between 2011-2012), 45 cycles with severe eligoasthenoteratozoospermia and 34 cycles with azoospermia were included. Patients were treated with gonadotropin releasing hormone agonist. The clinical characteristics and intracytoplasmic sperm injection outcome such as the rate of fertilization, implantation and clinical pregnancy were compared between the two groups. Results were presented as mean±standard deviation and number (percent). Differences between variables were analyzed using student's t test and the chi-square test was used to examine differences between categorical variables. P value less than 0.05 were considered as statistically significant. Results: Mean of female age (29±4.9 vs. 30.2±5.8), body mass index (26.9±5.3 vs. 26.9±3.8), estradiol level on human chorionic gonadotropin administration day (1375.6±843.9 vs. 1181.8±673.1), total number of retrieved oocytes (9.7±5.3 vs. 9.2±5.9) and metaphase II oocytes (7.7±5.1 vs. 7.5±5.4) were similar between the two groups. Of 436 and 313 retrieved oocytes, respectively 232 and 163 oocytes were ferti-lized in oligoasthenoteratozoospermic and azoospermic groups (53.2% vs. 52.1%, P=0.214). There were not statistical differences between groups in number of trans-ferred top quality embryos (1.5±1.2 vs. 1±1.2, P=0.09), implantation rate (22.7% vs. 16.9%, P=0.238) and clinical pregnancy rate (21 (47.7%) vs. 11 (35.4%), P=0.199). Conclusion: Intracytoplasmic sperm injection with precutaneouse epididymal sperm aspiration and testicular sperm extraction are effective methods to treat azoospermic men and its clinical outcome were comparable to ejaculated sever oligoasthenoterato-zoospermic cycles. It can be concluded that the influence of sperm quality and origin on intracytoplasmic sperm injection outcome are the same.

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Background: The use of Methotrexate (MTX) is a good and common practice for the treatment of women who were diagnosed early with ectopic pregnancy (EP). The aim of this study is to determine the predictors of treatment failure with a single dose of MTX injection. Methods: In this quasi-experimental research, we studied 70 women with ectopic preg-nancies who were treated with MTX, according to a single dose protocol from 2010 to 2013. EP was diagnosed whenever an intrauterine gestational sac was not identified by transvaginal ultrasonography (TVUS), accompanied by an abnormal rise or plateau in human chorionic gonadotropin (beta-hCG) concentration. Briefly, women with ectopic pregnancies were considered candidates for MTX treatment if they were hemodynami-cally stable did not desire surgical therapy, agreed to weekly follow-up and did not have hepatic, hematologic, or renal disease. A Patient was considered a treatment suc-cess (group 1) if her beta-hCG levels decreased ≤10 m IU/ml after the first dose of MTX. Treatment failure (group 2) was defined as the need for a second or a third dose of MTX or surgery. The following risk factors were compared between the two groups: serum beta-hCG on the days 1 and 4, a ≥ 15% decrease in serum beta-hCG between the days 1-4 of the treatment, age, parity, gravidity, the size of the ectopic mass and the endometrial thickness. Results: The success rate of MTX treatment was 77.1%. There were no significant dif-ferences between the two groups in regard to the age, parity, gravidity, the size of ec-topic mass and the endometrial thickness in vaginal sonography, but the mean serum beta-hCG concentration on days 1 and 4 was lower in the success group than the failure group. We also observed a ≥ 15% decrease in serum beta-hCG in 80.9% of the women from the success group and in 38.5% of the cases whose treatment had failed. The presence of fetal heart activity was seen in only one patient and this patient’s treatment failed. Two patients had previous history of ectopic pregnancy and the treatment of both ended in failure. Conclusion: Among women with ectopic pregnancies who were candidates for MTX treatment, a high serum beta-hCG concentration on the days 1-4 and also a ≤ 15% fall in serum beta-hCG between the days 1-4 treatment, are the most important factors associated with the failure of the treatment with a single dose MTX protocol. It is better to use these factors for making decisions about the initiation of the treatment or the continuation of it.

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Background: Previous investigations have shown that pregnancy-associated plasma protein-A (PAPP-A) levels are associated with adverse pregnancy outcomes including intrauterine growth restriction (IUGR) fetuses as well as preterm delivery. The aim of this study was to determine the rate of preterm delivery in women with low PAPP-A and at intermediate risk for chromosomal abnormalities in the first trimester screening. Methods: A total of 137 women who underwent Down syndrome screening between 11 to 14 weeks of gestation were studied from September 2011 to September 2013 at Perinatal Care Clinic, Imam Khomeini Hospital, Ahvaz, Iran. From those, 52 patients had low PAPP-A. Inclusion criteria were singleton pregnancies, at 11 to 14 weeks of gestation, at intermediate risk for Down syndrome (risk in 1:101 to 1:1000). The intermediate risk was estimated based on maternal parameters, maternal serum markers (PAPP-A and β-hcG), and nuchal translucency (NT) using fetal medicine foundation (FMF), UK) software. The power of the study was 90%. The sample size was estimated based on prevalence of preterm delivery in pregnancies with low PAPP-A in the first trimester screening. Patients were followed-up until delivery to observe pregnancy outcomes. We evaluated the variables such as level of PAPP-A, outcomes of delivery, age, β-hCG, and gestational age. Results: Among 137 normotensive pregnant women at intermediate risk for Down syndrome, 52 cases (38%) had low PAPP-A (<0.4 MoM). Of 52, 14 cases (27%) had preterm delivery. None of our patients had pregnancy related or non related diabetes, preeclampsia, or chromosomal anomalies. 45 cases (86%) from 52 patients were equal or less than 35 years, while 7 patients were more than 35 years. Among 52 followed-up patients, 48 patients (92.4%) were at low-intermediate risk (risk in 1:251 to 1:1000), and 4 cases (7.6%) were at high-intermediate risk (risk in 1:101 to 1:250). Conclusion: We found high frequency of preterm delivery in pregnant women with low PAPP-A level at the first trimester screening. Hence, this group of patients needs special and early preventive management. Furthermore, we suggest that future researches to be conducted with larger sample size and also cervix length measurement to be included.

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Background: Spontaneous hepatic rupture is a rare condition during pregnancy. Pregnant women with Hemolysis, Elevated Liver enzymes and Low Platelete count (HELLP) syndrome are more susceptible to hepatic rupture. It can occur per 40000 to 250000 pregnancies with high mortality and morbidity. There is no agreement on the best approach to this severe pregnancy complication. This is the case report of a spontaneous hepatic rupture associated with HELLP syndrome during pregnancy which occurred for the first time in the West Azerbaijan Province, Iran. Case Presentation: A 33 years old lady gravida 6, 3 intrauterine fetal deaths, 2 neonatal deaths at 30th weeks of gestation was admitted for preeclampsia. On admission, she had thrombocytopenia and elevated liver enzyme. Cesarean section was performed due to fetal distress and a preterm fetus was born. Inspection of the abdomen revealed a large hematoma in the right liver lobe associated with rupture of the capsule. Liver packing was performed by general surgeon and the abdomen was closed without repairing of fascia. In the 2nd day after operation, the patient was oriented but the abdomen reopened because of very low blood pressure. There was no severe liver hemorrhage so the liver was packed again with many surgicels. She developed acute kidney and liver failure, pleural effusion and a major coagulopathy post-operatively. Three weeks after surgery the abdomen was reopened for dehiscence and fascia was closed. The patient discharged after 40 days. Conclusion: Spontaneous liver rupture associated with HELLP syndrome is a rare and life-threatening complication of pregnancy. Unruptured liver hematoma is also a rare condition during pregnancy with a very difficult diagnosis. Using clinical diagnostic tests such as CT scan or MRI would be helpful to improve clinical outcomes.

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Background: Maternal mortality is one of the most important indicators of women health standard in developing countries. This study aimed to determine the prevalence of risk factors and etiology of maternal mortality in a geographic region of Iran. Methods: This descriptive- analytic cross sectional study included all pregnant women who died during pregnancy and six weeks after delivery due to pregnancy related fac-tor. The study was done in Sistan region in the north of Sistan and Baluchestan Prov-ince of Iran from April 2002 to March 2014. The immigrant women were excluded. Data were collected using 3 parts questionnaire. The validity and reliability of ques-tioner were approved by experts in this field. Data were analyzed using the statistical software SPSS version 18, Chi-square test and ANOVA analysis were performed. Results: The total number of deliveries during this time period was 60496. The total number of maternal mortality was 57 patients which means 94.2 out of 100.000 live births. Most of the dead mothers had more than 35 years old (46.9%), gestational age was more than 22 weeks (77.2%), gravidity more than 4 (21.1%), pregnancy interval lower than two years (46.9%) and 75.4% of death was in post-partum. The main cause of mortality was post-partum hemorrhage (19.3%). Conclusion: Based on our findings, some factors including multiparity, pregnancy his-tory more than 4 times, short interval between pregnancies lower than 2 years and ma-ternal age more than 35 years were some risk factors for maternal death. Maternal mortality in the postpartum period was more than pre-delivery period. Bleeding was the main cause of maternal mortality. Therefore monitoring of vital signs in the post-partum period and the proper management of bleeding are very important. It is sug-gested that risk assessment should be done for pregnant women in delivery ward for detecting high risk pregnant women. Suitable management for these women especially for patients with postpartum hemorrhage plays an important role to decrease the ma-ternal mortality.

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Background: Diabetes can cause undesirable changes in structure of the placenta, re-sulting increase in size and weight of placenta. The aim of this study was, to investigate the placenta weight, size and birth weight of infants in pregnant women with controlled gestational diabetes compared with normal pregnancy. Methods: This study was conducted from October, 2012 to February, 2014 in two dif-ferent hospitals, Valiasr and Shariati Hospitals in Tehran. Sixty-seven healthy singleton pregnant and 42 pregnant women with diabetes were selected during 26-28 weeks of gestational ages. Glucose tolerance tests (GTT) were performed to evaluate blood glu-coses. Blood glucoses were controlled in diabetic cases very well. Length and width of the placentas were measured using ultrasonography during pregnancy. After termina-tion of pregnancy, placental weights were measured and recorded using weighting scale with 10 gram accuracy by someone who didn't know about diabetes status. Baby weights were measured after birth and initial stabilisation. Results: In this study, there were no significant differences between gestational diabe-tes mellitus (GDM) and healthy groups in Body Mass Index (BMI) factors. There was no statistically significant differences between the mean weight of infants born with gestational diabetes and control groups. There were no statistically significant differ-ences between the mean placental weights between two groups. Ratio of the placental weights to the birth weights between the two groups were not statistically significant. The mean placental length, width and placenta length times by width in two groups had no significant differences, but the mean gravidities in healthy group was 1.7910 and in gestational diabetes mellitus was 1.9762 that are significantly different (P=0.0217). The mean parities respectively were 0.6567 and 0.8100 which was not sig-nificantly different (P=0.0183). Conclusion: The present study has shown there was no significant differences between fetal and placental weights in normal pregnancies and women with controlled gesta-tional diabetes.