Obstetrics
Clinical Trials
Lignocaine versus bupivacaine infiltration for postpartum perineal pain after vaginal delivery with episiotomy in primigravidae: A prospective randomized, double-blind, clinical trial
Ahmed Mohamed Essam El-din Mansour1, Mohamed Taha Ismail Mahmoud1, Mostafa Mahmoud Serry Mohamed El Bukhari1,*, Ahmed Mohamed Abd El-Hamid Hassan1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: mostafa.mahmoud55@med.asu.edu.eg
Background: Local anesthetic infiltration with episiotomy offers effective pain relief. Bupivacaine is a long-acting local anesthetic that effectively reduces postoperative pain. Lignocaine is the most frequently employed local anesthetic in postpartum perineal pain.
Objectives: To compare the effect and safety of lignocaine versus bupivacaine infiltration for postpartum perineal pain after vaginal delivery with episiotomy in primigravidae.
Methods: This randomized, double-blind, clinical trial was conducted in the operating theatres of Ain-shams University Maternity Hospital, from March to September 2024. It included a total number of 60 participants divided into two groups: Group-A (Lignocaine-group), Group-B (Bupivacaine-group). Group-A received a perineal infiltration of 5 milliliters (100 milligrams) of lignocaine in the margins of the episiotomy, while Group-B received a perineal infiltration of 5 milliliters (20 milligrams) of Bupivacaine. Postoperative analgesic effect was assessed using numeric version of the visual analogue scale (VAS) and this was our primary outcome. Also, the time till first analgesic requirement after delivery, total analgesics (non-steroidal anti-inflammatory drugs) consumption (in milligrams) over 12-hours period postpartum, post-operative ambulation time, and postoperative complication were assessed as secondary outcomes. Assessments were done: (immediately after-delivery, 2-hours postoperative, 4-hours postoperative and 6-hours postoperative).
Results: The comparison between lignocaine versus bupivacaine infiltration for postpartum perineal pain showed significant difference regarding the numeric version of VAS with intensity range 1-2 for lignocaine and 1 for bupivacaine at 4-hours and 6-hours postoperative with p-value =0.038 and <0.001 respectively. These findings showed that bupivacaine has more analgesic effect than lignocaine regarding pain assessment but with no significant difference regarding the time till first analgesia postoperative, or total analgesics consumption (in milligrams) over 12-hours period postpartum, and no significant difference regarding ambulation and post-operative complications.
Conclusion: This study demonstrated that the comparison between lignocaine versus bupivacaine infiltration for postpartum perineal pain after vaginal delivery with episiotomy in primigravidae showed significant difference regarding the numeric version of the visual analogue scale (VAS) at 4 hours and 6 hours postoperative in favor of bupivacaine.
Keywords: Bupivacaine; Primigravidae; Postpartum perineal pain
Diathermy versus scalpel in cesarean section after skin incision: A randomized controlled trial
Mohammed Salah El-Sayed El-Sokkary1, Mohammed Ahmed Adel Faris1, Hamida Mostafa Ibrahim Salem Marei1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: hamida.salim@med.asu.edu.eg
Background: Cesarean section (CS) accounts for one in three deliveries in many high resource settings and exceeds 55 % in parts of Egypt. While lifesaving when indicated, CS carries risks of hemorrhage, pain, and wound complications. Electrosurgical (diathermy) skin incision may shorten cut time and reduce bleeding, but concerns remain regarding thermal injury and healing.
Objective: We compared diathermy versus traditional steel scalpel incisions in primary elective CS.
Methods: In this prospective, randomized trial at Ain Shams University Maternity Hospital (January–December 2024), 60 pregnant women scheduled for their first lower segment CS were screened and randomized in two groups : Group A (scalpel incision): the surgeon used a disposable No. 22 blade to incise tissues from the skin down to the peritoneum. Group B (diathermy incision): the surgeon used diathermy (cutting/coagulative) to incise the skin, fascia, and subcutaneous tissue. Primary outcome was blood loss during skin to peritoneum incision (weighed dry mops, no suction).
Results: There was statistically significant decrease in Diathermy group when compared to Scalpel group regarding volume of blood loss (1 vs. 2 mL/kg; p<0.05), incision time (median 5 VS 7 minutes), operative time. Postoperative pain scores measured by VAS were significantly reduced in diathermy group at 1, 4, 8, 12, and 24 hours postoperatively (p<0.001). Analgesic use, hospital stay, and wound complication rates did not differ.
Conclusion: Diathermy skin incisions in elective CS reduce blood loss, shorten operative time, and improve early postoperative comfort, without increasing wound related complications.
Keywords: Cesarean section; electrocautery; scalpel; incision time; blood loss; postoperative pain.
The impact of low-dose versus high-dose antibiotic prophylaxis regimens on surgical site infection rates after cesarean delivery
Mahmoud Galal Sayed Ahmed1,*, Mostafa Ibrahim Ibrahim1, Ahmed Mahmoud Hussein1, Abdul Rahman Mohammed Saleh1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Mahmoud.Galal@med.asu.edu.eg
Background: Surgical site infections (SSI) are a common consequence following CS, and they are responsible for increased maternal mortality and morbidity, patient dissatisfaction, longer hospital stays, and greater treatment expenses. There is strong evidence of the protective role of antibiotic prophylaxis to reduce the SSI rate.
Objective: to evaluate the impact of low-dose versus high-dose antibiotic prophylaxis regimens on surgical site infection rates after cesarean delivery.
Methods: this randomized controlled trial was conducted at Ain Shams University Maternity Hospital between September 2024 and March 2025. A total of 380 pregnant women who attended for elective CS were enrolled and randomly assigned to two groups; group 1 "control group" received a low-dose regimen (1g) of cefazolin and group 2 "study group" received a high-dose regimen (2g) 30 minutes before skin incision. We excluded women on therapeutic antibiotics preoperatively, PROM, nonviable fetus, multiple pregnancy, anemic patients, diabetics, patients with hypersensitivity to the antibiotic in our study. SSI was assessed by Southampton scoring system. The primary outcome was SSI in the first week. The secondary outcomes were incidence of SSI within 30 days post-surgery and association between high-dose antibiotic and puerperal sepsis.
Results: Regarding Southampton scoring system grades in the present study (wound healing, bruising, erythema, hematoma formation, and inflammation); there were no significant differences between both groups as regard primary {24 hours}, one week, and secondary SSI {30 days} after surgery; p= 0.968, 0.343 and 0.438 respectively. Also, there is no association between high dose antibiotic and puerperal sepsis.
Conclusion: low-dose antibiotic is as efficacious as high-dose antibiotic prophylaxis regimens on surgical site infection rates after cesarean delivery.
Keywords: Antibiotics; Cesarean; Wound Infection; Prophylaxis
Treatment of gestational diabetes mellitus with glyburide compared to subcutaneous insulin therapy and associated perinatal outcome: A randomized controlled study
Mohamed Ibrahim Mohamed Amer1, Walid El-Basuony Mohamed Ahmed Khalil1, Mohamed Mostafa Mokhtar1, Sherihan Aboelyazed Mohamed1, Fathi Abdi Mohamud1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: FathiHassan@med.asu.edu.eg
Background: Gestational diabetes mellitus (GDM) is a common metabolic disorder during pregnancy associated with increased maternal and neonatal complications. Although insulin remains the standard treatment, oral hypoglycemic agents such as glyburide have emerged as potential alternatives due to simpler administration and lower cost. However, evidence comparing the efficacy and safety of glyburide versus insulin remains limited.
Objective: to compare glyburide and insulin in achieving adequate glycemic control, as well as to evaluate their effects on perinatal outcomes in patients with gestational diabetes mellitus.
Methods: A randomized controlled study was conducted at Ain Shams Maternity Hospital from January 2024 to December 2024, including 160 pregnant women diagnosed with GDM after 24 weeks of gestation. Patients were randomized into two groups: Group A (Glyburide group) received glyburide, starting at 2.5 mg/day and titrated up to a maximum of 5 mg/day according to blood glucose monitoring. Group B (Insulin group) received subcutaneous insulin using a basal-bolus regimen, consisting of Levemir® (insulin detemir) for basal needs and NovoRapid® (insulin aspart) for prandial coverage, with a total daily dose ranging from 0.2 to 2 units/kg/day, individualized based on blood glucose profiles. Glycemic control was monitored using fasting blood glucose (FBG) and postprandial glucose (PPG) measurements. Maternal and neonatal outcomes, including birth weight, delivery mode, NICU admission, and neonatal hypoglycemia were assessed.
Results: Both groups achieved comparable glycemic control, with mean FBG (93.8 ± 9.5 mg/dL versus 92.1 ± 8.9 mg/dL in the glyburide and insulin groups respectively, p = 0.35) and mean 2-hour PPG (117.4 ± 11.2 mg/dL in glyburide group versus 115.6 ± 10.8 mg/dL in the insulin group, p = 0.42). Neonatal hypoglycemia and NICU admissions were slightly higher in the glyburide group but not statistically significant. No major maternal complications (preeclampsia, postpartum hemorrhage, and infections) were observed in either group.
Conclusion: Glyburide is a viable alternative to insulin for managing GDM, providing effective glycemic control with similar perinatal outcomes. We recommend considering glyburide as a first-line pharmacologic option for eligible GDM patients when insulin is not feasible or preferred.
Keywords: Gestational diabetes mellitus, glyburide, insulin, randomized controlled trial, perinatal outcomes, glycemic control.
Subcutaneous antibiotic irrigation to prevent wound infection in controlled diabetic patients undergoing elective cesarean section
Ahmed Mohamed Zeinhom1, Hebaallah Ali Ashour Ibrahim1,*, Laila Aly Farid1, Ebtihal Mohamed Mahmoud Eltaieb1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Hebaallah-ali@med.asu.edu.eg
Background: Surgical site infections (SSIs) are a significant cause of healthcare-associated infections, with rates ranging from 3% to 15% worldwide.
Objective: To assess the impact of subcutaneous gentamicin irrigation on the incidence of wound infections in diabetic patients with controlled blood sugar undergoing cesarean section.
Methods: This quasi-randomized clinical trial was conducted in the Obstetrics and Gynecology Department at Ain Shams University Maternity Hospital from June 2023 till June 2024. Fifty controlled diabetic women undergoing elective C-sections were quasi-randomized into 2 groups by alternation method. All women received Prophylactic 1 g cefazolin 30 minutes prior to skin incision, Group A (25 patients) received subcutaneous gentamicin irrigation using a 50 cm syringe for 5 minutes (120mg gentamicin in 250 ml normal saline), while group B (25 patients) did not receive the irrigation. Women were followed up for signs of SSI, including purulent discharge, fever, tenderness, erythema, or induration on postoperative days 7 and 14.
Results: The SSI rate was lower in the gentamicin group (4%) compared to the control group (16%), but this difference was not statistically significant (p = 0.35). Regarding hospital readmission, none of the women in the gentamicin group were readmitted, while one woman in the control group (4%) required readmission. This difference was also statistically insignificant (p = 0.99).
Conclusion: The study didn’t show enough evidence to recommend subcutaneous gentamicin irrigation to reduce SSIs after cesarean section in controlled diabetic women.
Keywords: Cesarean section, Gentamicin, Wound infection
Comparison between intravenous carbetocin, rectal misoprostol and intravenous syntocinon in prevention of primary postpartum hemorrhage following elective lower segment caesarean section
Ahmed Mohammed Essam El-din Mansour1, Mohamed Sayed Aly Salem1, Ahmed Gamal Abdelnasser1, Eman Mohamed Hassan Soliman1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: EmanSoliman@med.asu.edu.eg
Background: Cesarean section (CS) is a common but unsafe delivery method, with rising incidence in high- and middle-income countries, leading to significant postpartum hemorrhage (PPH) and maternal mortality.
Objective: The study aimed to evaluate the effect of intravenous carbetocin, rectal misoprostol, and intravenous syntocinon in preventing primary PPH following elective lower segment CS. The primary PPH is defined as blood loss ⩾ 1000 mL after cesarean section, estimated by counting the sanitary pads used after delivery. Each pad was confirmed to be clean before use. We aimed to evaluate the amount of blood loss, weigh the sanitary pads after delivery and subtract the dry weight, with a 100 g increase in mass equivalent to 100 mL of blood in the first 24 hours.
Methods: A randomized controlled clinical trial was conducted at Ain Shams University Hospital from June to December 2024 and involved 270 low-risk women (without any medical or obstetric complications, e.g., coagulopathy, macrosomia, IUGR, previa, PPH, contraindication to or hypersensitivity to study drugs). In group I, each participant received 10 IU/mL of oxytocin intravenously after neonatal delivery. In group II, participants received an ampoule of carbetocin (100 μg/mL) intravenously after neonatal delivery. In group III, participants received two tablets of misoprostol rectally (200 μg) before sterilizing the patient.
Results: In terms of outcomes, the occurrence of PPH in Group I had an incidence of 12.2% compared to Group II (2.2%) and Group III (1.1%), with a significant difference (p=0.001).According to adverse effects, in terms of overall occurrence, Group II had the highest proportion of patients without adverse effects (95.5%) compared to Group I (70.7%) and Group III (68.2%), showing a highly significant difference (p<0.001).
Conclusion: These findings suggest that the carbetocin had the most favorable profile in terms of both safety and efficacy.
Keywords: Intravenous Carbetocin, Rectal Misoprostol, Intravenous Syntocinon, Primary Postpartum Hemorrhage, Elective Lower Segment Caesarean Section
Impact of using synthetic absorbable monofilament versus multifilament suture material for uterine closure on the development of uterine isthmocele: A randomized controlled clinical trial
Mohammed Essam Eldin Mohammed1,*, Mohammed Elkady1, Mohammed Hamed1, Mourad Moustafa Atteya1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Mohammed.Essam@med.asu.edu.eg
Background: Isthmocele, a cesarean scar defect, is an underrecognized postoperative complication that may result in uterine rupture, infertility, abnormal bleeding, and cesarean scar ectopic pregnancies. Despite advancements in cesarean techniques, the optimal approach to uterine closure remains debatable—particularly regarding the impact of suture material on scar healing.
Objective: To assess the impact of using synthetic absorbable monofilament versus multifilament suture material in uterine closure on the severity of isthmocele formation six months after elective primary cesarean section.
Methods: This randomized controlled trial was conducted at Ain Shams University Maternity Hospital over a 12-month period (December 2023 to December 2024). A total of 140 women undergoing elective primary cesarean section were randomly allocated into two groups. Group A received uterine closure using 1/0 Monocryl® (monofilament), and Group B received 1/0 Vicryl® (multifilament), with both groups undergoing two-layer continuous unlocked closure. The primary outcome was severity of isthmocele assessed by transvaginal ultrasound (TVUS) six months postpartum. Measurements included niche depth, width, residual myometrial thickness (RMT), adjacent myometrial thickness, and shape of the defect. A scar defect was diagnosed if the depth was ⩾2 mm. Secondary outcomes included intraoperative blood loss, need for additional hemostatic measures, and early postoperative complications.
Results: Isthmocele was detected in 17.1% of patients in Group A and 37.1% in Group B. The mean residual myometrial thickness was significantly greater in Group A (7.12 ± 0.88 mm) compared to Group B (5.93 ± 0.99 mm), with a mean difference of 1.19 mm (95% CI: 0.83–1.55; p < 0.001). The mean defect width and depth were also significantly smaller in Group A (width: 2.6 ± 0.6 mm vs 3.3 ± 0.9 mm, p < 0.001; depth: 2.1 ± 0.5 mm vs 2.8 ± 0.7 mm, p < 0.001). There were no statistically significant differences in estimated blood loss, additional hemostatic measures, or postoperative complications between the groups.
Conclusion: Uterine closure using monofilament absorbable suture material was associated with better scar healing parameters and reduced severity of isthmocele compared to multifilament suture. These findings support the consideration of suture type in cesarean closure techniques to potentially improve long-term uterine integrity.
Keywords: Isthmocele, Cesarean section, Uterine scar defect, Monocryl, Vicryl, Residual myometrial thickness, Uterine closure technique
The effect of local application of gentamycin on caesarean section wound healing and infection
Salah Taha Ahmed Fayed1, Nermeen Ahmed Mostafa Elghareeb1, Alaa Mohamed Atef Karim-Eldein1, Amr Mohamed Fawzy Elbadrawy1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: amr.elbadrawy@med.asu.edu.eg
Background: Cesarean section (CS) is associated with a notable risk of surgical site infection (SSI). Topical antibiotic application, such as gentamycin, may provide additional local protection without systemic side effects.
Objective: To evaluate the effect of local gentamycin application on wound healing and infection rates following elective cesarean delivery.
Methods: This randomized controlled trial was conducted at Ain Shams University Maternity Hospital from November 2024 till April 2025 and included 150 full-term pregnant women undergoing elective CS. Participants were randomly allocated into two groups. Group A received 160 mg of gentamycin applied to the subcutaneous tissue before skin closure, while Group B received normal saline. All patients received standard systemic prophylaxis with Cefotax 1 g. The primary outcome was the presence of wound inflammation during the first postoperative week, defined as redness, hotness, induration, pus formation, pain or skin dehiscence. Secondary outcomes included any allergic reaction to gentamycin and wound inflammation with the same criteria at three weeks postoperatively.
Results: At one week, inflammation was absent in 97.3% of the gentamycin group and 93.3% of the control group (p = 0.557). At three weeks, complete healing occurred in 100% versus 97.2% (p = 0.497). Infection rates were lower in the gentamycin group at both week 1 (2.7% vs. 6.7%, p = 0.442) and week 3 (0% vs. 2.7%, p = 0.497), though differences were not statistically significant. No allergic reactions were reported. Higher BMI was the only significant predictor of wound infection (OR = 1.775; 95% CI: 1.162–2.710; p = 0.008).
Conclusion: Topical gentamycin is safe but does not significantly reduce wound infection or improve healing after CS. BMI remains the key risk factor.
Keywords: Cesarean Section, Surgical Site Infection, Gentamycin, Wound Healing
Observational Studies
Clinical impact of preoperative 2D ultrasound and color Doppler on surgical outcomes among patients with high risk of placenta accreta spectrum (PAS) disorders
Hagar Ibrahim Saad Abou Saif1,*, Ahmed Ramy Mohamed Ramy1, Rehab Mohamed Abdelrahman1, Fady Mohammed Nabil1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: hagar.abusaif@gmail.com
Background: Placenta Accreta Spectrum (PAS) disorders are associated with significant maternal morbidity and mortality, primarily due to severe hemorrhagic complications. Antenatal detection using ultrasound and Doppler imaging can improve surgical outcomes and reduce complications in high-risk cases.
Objective: To evaluate the role of preoperative 2D ultrasound and color Doppler in predicting surgical outcomes and diagnostic performance in patients at high risk for PAS disorders.
Methods: This diagnostic test accuracy study was conducted at Ain Shams Maternity Hospital, Egypt, involving 82 pregnant women identified as high-risk for PAS. Patients underwent preoperative ultrasound and Color Doppler imaging to assess features predictive of PAS. The 2D Us and color Doppler abnormalities are (loss of retroplacental sonolucent zone, irregular of retroplacental sonolucent zone, thinning of serosa-bladder interface, presence of exophytic mass, abnormal placental lacunae, diffused or focal lacunar flow, diffused lakes with turbulent flow (PSV>0.15), hyper-vascularity of serosa-bladder interface and marked dilated blood vessels over peripheral sub-placental zone. The findings were compared with intraoperative outcomes and histopathological diagnoses. Statistical analyses were performed to determine diagnostic accuracy and associations with surgical outcomes.
Results: The number of ultrasound abnormalities (⩾5) demonstrated a high diagnostic accuracy (AUC = 0.947) for predicting morbidly adherent placenta, followed by abnormal placental lacunae, then irregular retroplacental sonolucent zone. Also, the number of ultrasound abnormalities highly predicted the surgical outcomes. Number of abnormalities >6 highly predicted the occurrence of hysterectomy (AUC=0.87). While using cutoff point (>5) predicted bladder injury (AUC=0.714). If using cutoff point (>4), this predicted receiving blood transfusion (AUC=0.918).
Conclusion: Preoperative ultrasound and Color Doppler imaging significantly enhance the prediction of PAS severity and associated surgical outcomes. The number of ultrasound abnormalities serves as a reliable diagnostic marker, aiding preoperative planning and management in high-risk cases.
Keywords: Placenta Accreta Spectrum, Ultrasound, Color Doppler, Surgical Outcomes, Antenatal Diagnosis, Morbidly Adherent Placenta, PAS Disorders.
Role of measurement of main pulmonary artery Doppler in prediction of fetal respiratory distress syndrome in cases of preterm rupture of membranes
Ahmed Ramy Mohammed Ramy1, Rehab Mohamed Abdelrahman1, Moustafa Mohammed Helal1, Rita Girguis Samir1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: RitaGirguis@med.asu.edu.eg
Background: Neonatal Respiratory Distress Syndrome (RDS) is a significant cause of neonatal morbidity and mortality, due to insufficient pulmonary surfactant. Recent advances have suggested that Doppler ultrasonography of the fetal main pulmonary artery (MPA) could serve as a non-invasive predictive tool for RDS.
Objective: The aim of the study was to evaluate the predictive value of fetal MPA Doppler measurements, for neonatal RDS in pregnancies complicated by PROM.
Methods: A prospective cohort study was conducted at Ain Shams University Maternity Hospital from August 2024 till January 2025. We included 50 patients with singleton pregnancy, between 34-37 weeks, diagnosed with preterm rupture of membranes and delivered within 48 hours from main pulmonary artery Doppler measurement, while women with medical conditions that may affect lung maturity like diabetes mellitus or hypertension were excluded, also patients with major fetal structural anomalies or received corticosteroids within the previous week before delivery were excluded. Doppler ultrasonography was performed to measure the MPA parameters, including pulsatility index (PI), resistance index (RI), peak systolic velocity (PSV), and acceleration time / ejection time AT/ET ratio. Neonatal outcomes, including RDS incidence which was the primary outcome was recorded. Data analysis was performed with statistical significance set at p ⩽ 0.05. ROC curve analysis was employed to evaluate the diagnostic performance of Doppler indices.
Results: The AT/ET ratio demonstrated the highest diagnostic accuracy among Doppler indices, with an area under the curve (AUC) of 0.898. and cut-off of ⩽0.29 yielded strong sensitivity 82.4%, specificity 93.9% and overall diagnostic accuracy 90.0%.
Conclusion: The fetal MPA AT/ET ratio is a reliable, non-invasive predictor of neonatal RDS in cases of PROM.
Keywords: Respiratory Distress Syndrome, Premature Rupture of Fetal Membranes, Pulmonary Artery, Doppler Ultrasonography.
Risk factors and neonatal outcome associated with early- versus late-onset preeclampsia in overweight and obese women
Osama Ismail Kamel1, Mohamed Samir Sweed1, Rehab Hashem Abd EL-Motti1,*, Radwa Rasheedy Ali1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: rehab.hashem@med.asu.edu.eg
Background: Preeclampsia is a placental disorder, with clinical manifestations that vary based on the gestational age at onset. Early-onset and late-onset preeclampsia were defined as that diagnosed before 34.0 and ⩾34.0 weeks, respectively and are considered phenotypically distinct conditions, each with different maternal and neonatal implications.
Objective: To examine maternal risk factors and early neonatal outcomes in early and late-onset preeclampsia in obese and overweight women.
Methods: This study is a secondary analysis of data from a prospective study that evaluated two different magnesium sulfate maintenance dosing protocols in overweight and obese women diagnosed with preeclampsia with severe features. The study was conducted at Ain Shams University Maternity Hospital between July 1, 2024, and December 31, 2024. A total of 100 pregnant women diagnosed with preeclampsia with severe features, aged 20 to 40 years, with a body mass index (BMI) of ⩾25 kg/m², singleton pregnancies, and a gestational age of more than 28 weeks were included. Women with intrauterine fetal death were excluded. The primary outcome was the assessment of different demographic and clinical risk factors associated with early-onset and late-onset preeclampsia. Neonatal outcomes were evaluated as secondary outcomes.
Results: Among the participants, 33% had early-onset preeclampsia, while 67% had late-onset preeclampsia. Primiparity was observed in 13 (39.4%) women with early-onset preeclampsia and 24 (35.8%) women with late-onset preeclampsia. Chronic hypertension was more common in late-onset cases (61.2% vs. 54.5%), as was diabetes mellitus (21.2% vs. 16.4%). Neonatal respiratory distress syndrome was significantly higher in early-onset cases (93.9% vs. 23.9%), and neonatal deaths occurred exclusively in this group (33.3%).
Conclusion: Although early- and late-onset preeclampsia share some etiological features, they result in distinct neonatal outcomes. Chronic hypertension and diabetes mellitus were the most common medical disorders associated with preeclampsia. Early-onset preeclampsia carried a significantly higher neonatal mortality risk.
Keywords: Keywords Hypertension; Neonatal respiratory distress syndrome; Preeclampsia; Primiparity
The efficacy of 3rd trimester sonographic sliding sign in prediction of pelvic adhesions in women undergoing repeat caesarean section
Amr Ahmed Mahmoud Riad1, Ahmed Ramy Mohamed Ramy1, Nada Hisham Mahmoud Abd El-Hameedv1,*, Abd El-Rahman Mohamed Saleh1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: nada.hisham@med.asu.edu.eg
Background: Cesarean sections (CS) are essential procedures that can prevent adverse maternal and fetal outcomes. However, the increasing rate of CS is associated with a higher risk of intra-abdominal adhesions, which complicate subsequent surgeries and increase the risk of injury to surrounding organs.
Objective: To evaluate the diagnostic accuracy of the third-trimester transabdominal sonographic (TAS) sliding sign in predicting pelvic adhesions in women with a history of previous cesarean section.
Methods: This was a prospective diagnostic test accuracy study conducted at Ain Shams University Maternity Hospital between January 2023 and December 2023. A total of 200 pregnant women at ⩾37 weeks of gestation, scheduled for elective repeat lower segment cesarean section (LSCS), were included. Women with placenta previa, suspected morbidly adherent placenta, or uterine anomalies were excluded. All participants underwent preoperative TAS examination to assess the presence or absence of the uterine sliding sign. The index test was the TAS sliding sign, and the reference standard was intraoperative assessment of pelvic adhesions by the operating surgeon, classified using the Tulandi and Lyell adhesion scoring system. The primary outcome was the diagnostic accuracy of the TAS sliding sign in predicting the presence of pelvic adhesions. Secondary outcomes included rates of bladder and bowel injury, excessive blood loss, and operative time.
Results: Of the 200 women included, 58 (29%) had intraoperative adhesions. The sliding sign was absent in 52 of these 58 women, yielding a sensitivity of 89.7% (95% CI: 78.8–96.1) and a specificity of 91.5% (95% CI: 85.6–95.5). The positive predictive value was 81.3%, and the negative predictive value was 95.4%. Among the secondary outcomes, there was a statistically significant increase in operative time and blood loss in patients with adhesions (p < 0.05); no significant difference in rates of bladder or bowel injury was observed.
Conclusion: The transabdominal sonographic sliding sign is an accurate, non-invasive, and practical tool for preoperative prediction of pelvic adhesions in women with previous cesarean sections, facilitating safer surgical planning.
Keywords: Cesarean sections, Sliding sign, Intraabdominal adhesions, Ultrasound.
Assessment of knowledge, attitude and perception of pregnant women regarding medications use
Ahd Yousif Ebrahim Ahmed1,*, Ahmed Khairy1, Ebtihal Eltaieb1, Rania Hassan Mostafa Ahmed1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: ahd.yousif23@med.asu.edu.eg
Background: Medication-use during pregnancy is often necessary to manage chronic diseases or pregnancy-specific conditions. However, the transplacental passage of drugs may pose risks to fetal development, especially during early embryogenesis. Despite regulatory guidelines like the FDA’s Pregnancy and Lactation Labeling Rule, self-medication—including over the counter (OTC) and herbal remedies—remains common, particularly in developing nations. Several global studies have shown varied levels of awareness, attitudes, and beliefs among pregnant women regarding medication use.
Objective: To assess the knowledge, attitudes, and perceptions of pregnant women toward medication use during pregnancy and examine their associations with socio-demographic variables.
Methods: A descriptive cross-sectional study was carried out among 150 pregnant women attending Ain Shams University Maternity Hospital between April and June 2025. Participants were selected via convenience sampling and completed a structured, anonymous questionnaire, adapted from previous validated research tools (Zaki & Albarraq, 2014; Tefera et al., 2020; Navarro et al., 2018). The survey evaluated demographic data, in addition to participants’ knowledge, attitudes, and beliefs regarding medication use in pregnancy. The questionnaire is publicly accessible at https://osf.io/89rdh/.
Results: Among participants, 87.3% had received formal education, while 12.7% were uneducated. Most were in their third trimester, followed by the second and first. Regarding knowledge, 62% had an intermediate level, 29.33% had poor knowledge, and only 8.67% demonstrated good knowledge. Most women 93.3% reported using medications (mainly supplements) during pregnancy, while 6.6% did not. About a third of participants (32%) used OTC, mostly paracetamol. Furthermore, 79.3% preferred not taking medications without medical advice, whereas 20.6% reported doing so. The questionnaire also revealed varied beliefs among the participants regarding medication use.
Conclusion: The study reveals that while many pregnant women have a moderate understanding of medication use, a significant proportion lack adequate knowledge and may practice self-medication without professional guidance. These findings underscore the need for structured educational initiatives and consistent counselling from healthcare providers to promote safe medication use during pregnancy.
Keywords: Pregnancy, Medication use, Knowledge and attitudes, Medication safety, Health care counselling
Correlation of fetal anterior abdominal wall thickness by ultrasound to predict fetal weight at term pregnancy
Maya Mahmoud Abdelrazek1, Alaa Sayed Hassanin1, Mohamed Ahmed Saad Abosena1,*, Rasha Medhat Abdelhady1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Mohamedabosena@med.asu.edu.eg
Background: Accurate estimation of fetal weight at term is crucial for anticipating delivery complications and optimizing perinatal care. Conventional ultrasound formulas, such as Hadlock, may be limited in precision, especially at weight extremes. Fetal anterior abdominal wall thickness (FAAWT) has been proposed as a novel marker of fetal adiposity, and a fast-scanning method for predicting neonatal birth weight.
Objectives: This study aimed to establish the correlation between FAAWT, as measured by ultrasound, and neonatal birth weight at term, assessed within the first hour of delivery using a digital baby weighting scale.
Methods: This prospective observational cohort study included 80 pregnant women at term (⩾37 weeks), scheduled for delivery within one week, recruited from Ain Shams University Maternity Hospital between February and May 2025. Standardized ultrasound examinations estimated fetal weight using the Hadlock formula (BPD, HC, AC, FL). FAAWT was measured in a transverse abdominal view at the level of AC as the thickness of anterior subcutaneous tissue at the midline. The primary outcome was correlation between FAAWT and neonatal birth weight within the first hour after delivery. Secondary outcomes included the predictive reliability of FAAWT, development of a regression-based weight estimation model, and the influence of gestational age and fetal gender. The study was approved by Ain Shams University Research Ethics Committee (FAMASU REC, No. MS 610/2024).
Results: FAAWT showed a strong correlation with birth weight (r = 0.83, p < 0.001). The regression equation Birth weight (kg) = -1.10 + 6.61 × FAAWT (cm) achieved 72.5% accuracy with a mean absolute error of ±189 g. FAAWT was significantly higher in macrosomic neonates (0.76 cm) compared to average (0.63 cm) and low birth weight (0.55 cm) groups (p < 0.001). ROC analysis showed excellent diagnostic performance for macrosomia (AUC = 0.981, cutoff ⩾ 0.72 cm, sensitivity 100%, specificity 94%) and low birth weight (AUC = 0.944, cutoff ⩽ 0.56 cm, sensitivity 90.9%, specificity 92.8%).
Conclusion: FAAWT is a fast, reliable, and easily measurable sonographic marker for fetal weight estimation at term, showing diagnostic performance equal or superior to conventional methods and providing a valuable tool for clinical decision-making.
Keywords: Fetal weight estimation, FAAWT (Fetal Anterior Abdominal Wall Thickness), Ultrasound, Term pregnancy, Macrosomia
Transperineal ultrasound in assessment of preterm pre-labor rupture of membranes compared to speculum examination: A diagnostic test accuracy study
Peter Thabet Saeed1,*, Mahmoud Youssef Abdallah1, Maya Mahmoud Abdelrazek1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: peterthabet@gmail.com
Background: Transperineal ultrasound (TPUS) provides a non-invasive method to assess amniotic fluid leakage from the cervix, essential for diagnosing PPROM.
Objective: This study evaluates the diagnostic accuracy and tolerability of TPUS compared to speculum examination in pregnant women with suspected preterm pre-labor rupture of membranes (PPROM).
Methods: This prospective observational study at Ain Shams University Hospital involved 100 pregnant women (24–37 weeks’ gestation) with suspected PPROM. TPUS was performed using a 3.5 MHz convex probe, covered with gel and a sterile glove. Participants were positioned supine with flexed lower limbs after bladder emptying. Images were captured in sagittal and transverse planes to assess fluid accumulation around the cervix, measuring the three largest dimensions of hypoechoic fluid collections. Each participant also underwent a speculum examination as the gold standard for diagnosis. Primary outcomes included TPUS accuracy, while secondary outcomes included cervical length measurement, presence of fetal parts or cord prolapse, and anxiety levels assessed using the State-Trait Anxiety Inventory (STAI).
Results: Of the participants, 66 women were diagnosed with rupture of membranes (ROM), with TPUS accurately diagnosing 63 cases. Cervical changes were present in 15%, and fetal parts or cord prolapse in one case. Anxiety scores during ultrasound ranged from 21 to 29 (mean 24.61 ± 2.06), significantly lower than speculum examination scores (P < 0.001). TPUS demonstrated a sensitivity of 95.45%, specificity of 94.11%, positive predictive value of 96.92%, negative predictive value of 91.42%, and overall diagnostic accuracy of 95%.
Conclusion: TPUS is a reliable, well-tolerated tool for diagnosing PPROM, with high sensitivity and accuracy compared to speculum examination, significantly reducing patient anxiety.
Keywords: Trans-perineal ultrasound, Preterm pre-labor rupture of membranes, Speculum examination, Patient anxiety.
Standard 2D transperineal ultrasound compared to digital examination in assessing labor outcome in nulliparous women before induction of labor: A prospective observational study
Safaa Hamdy Ibrahim1,*, Alaa Sayed Hassanin1, Mahmoud Yousof1, Maya Mahmoud Abdelrazek1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: safaahamdyibrahim@med.asu.edu.eg
Background: Accurate assessment before induction of labor (IOL) in nulliparous women is crucial for predicting labor outcomes. Digital examination (DE), the standard method for determining the Bishop score, is subjective and uncomfortable. 2D transperineal ultrasound (TPUS) offers an objective alternative, yet its predictive validity for labor outcomes requires validation.
Objective: This study compares the effectiveness of 2D-TPUS and DE in forecasting labor outcomes.
Methods: This prospective observational study was conducted at Ain Shams University Hospital from January 2023 to December 2024, included nulliparous women scheduled for IOL at term. Both 2D-TPUS (assessing anteroposterior diameter (APD) of levator hiatus, angle of progression (AoP), head perineum distance (HPD), and cervical length) and DE (Bishop score) were performed independently and blinded. The primary outcome was vaginal delivery rate; secondary outcomes included labor duration, instrumental delivery rates, and cesarean delivery. Receiver operator characteristic (ROC) analysis was used to determine the optimum cut off value for the studied diagnostic markers for predicting successful induction of labor.
Results: A total of 111 women were analyzed, with a vaginal delivery rate of 70%. The angle of progression (AoP) measured a mean of 114.5° ± 8.2° in the vaginal delivery group and 98.7° ± 7.5° in the cesarean group, a statistically significant difference (p < 0.001). The head-to-perineum distance (HPD) was 3.5 cm ± 0.7 cm in the vaginal group and 4.8 cm ± 0.9 cm in the cesarean group (p = 0.001). The fetal head stage also significant correlated with labor induction success (p < 0.001). Cervical length was significantly lower in successful induction cases compared to failed ones. The best cutoff values for predicting vaginal delivery were: HPD at 4 cm (sensitivity 78.2%, specificity 80.4%), AoP at 105 degrees (sensitivity 83.5%, specificity 75.9%), cervical length at 31.2 mm (sensitivity 82.5%, specificity 80.7%), and Bishop score at 5 (sensitivity 64.3%, specificity 84.6%).
Conclusion: AoP and HPD outperform the Bishop score in predicting the success of labor induction, positioning TPUS as a valuable tool for pre-induction assessment and clinical decision-making.
Keywords: Angle of progression (AoP); Bishop score; Cesarean delivery; Digital examination (DE); Head perineum distance (HPD); Induction of labor (IOL); Levator hiatus; Nulliparous; Transperineal ultrasound (TPUS)
Case Reports/Series
Spontaneous twins in a non-communicating uterine horn: A case report
Maya M. Abdelrazek1,*, Ahmed Mohsen Hassan Mohamed1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: dr_maya89@med.asu.edu.eg
Background: We present a rare case of monochorionic-monoamniotic twin pregnancy in a non-communicating rudimentary uterine horn diagnosed at 14 weeks gestation.
Case: A 19-year-old woman, primigravida, was referred to our hospital with a spontaneously conceived monochorionic-monoamniotic twin pregnancy at 14 weeks gestation. She was first diagnosed as a case of extrauterine twin pregnancy upon which magnetic resonance imaging (MRI) was done that showed right cystic complex ovarian lesion 6.5X7 cm with empty uterine cavity. Laparoscopy was done showing a unicornuate uterus with a rudimentary horn. Then the patient was referred to our hospital. At presentation, she was asymptomatic and denied any abdominal pain, vaginal bleeding, chest pain, or syncope. She had no previous history of endometriosis, dysmenorrhea, infertility or confirmed renal anomaly. The woman was counseled about laparotomy and excision of the rudimentary horn containing the pregnancy prior to rupture. The patient underwent exploratory laparotomy through a transverse skin incision. Twin pregnancy was found contained within a rudimentary uterine horn and a left unicornuate uterus with normal left ovary and fallopian tube. The right fallopian tube and ovary were found to be arising from the horn. Excision of the horn containing the twin pregnancy was done with right salpingectomy. The right ovary was left in situ. No complications were noticed during the postoperative period.
Conclusion: This is a rare case of monochorionic-monoamniotic twin pregnancy occurring in a non-communicating rudimentary uterine horn. Although it is a rare case, it can be detected by early ultrasound scan by specialist. Early detection helps to prevent serious complications like rupture of horn, internal bleeding and shock.
Keywords: Twins; Non-Communicating; Rudimentary horn; Pregnancy
A challenging case of thrombotic antiphospholipid syndrome
Ahmed Selim1,*, Ahmed El Maraghy1, Rehab Hashem1, Asmaa Samir1, Yomna Ayman1, Menna Hatem1, Esraa Abdelhameed1, Sara1, Omar M Abdelhameed1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: dr.ahmedselim_89@med.asu.edu.eg
Background: Managing pregnancy in patients with recurrent pregnancy loss and high thrombotic risk presents significant challenges, particularly when compounded by complex comorbidities. We report a case of a 40-year-old woman with an exceptionally poor obstetric and medical history who achieved a successful full-term delivery.
Case Presentation: The patient had eight first-trimester miscarriages, two preterm births (one at home, one via emergency hysterotomy for intra-amniotic infection), and no living offspring. She also had early ovarian aging (AMH: 0.1) with failed ICSI, followed by spontaneous conception. Her medical history included mitral valve replacement, paroxysmal atrial fibrillation (AF), recurrent cerebral venous thrombosis (CVT), and high-risk thrombotic antiphospholipid syndrome. An ultrasound-indicated cerclage was placed early in the pregnancy. She received low-dose aspirin and therapeutic enoxaparin (80 mg/12h SC), which was later escalated to 90 mg/12h SC following an acute thrombotic stroke at 26 weeks’ gestation. The stroke involved the left middle cerebral artery (MCA) and was managed by urgent mechanical thrombectomy using a stent retriever within six hours, resulting in full neurological recovery. Throughout pregnancy, she required multiple ICU admissions due to paroxysmal AF and was maintained on digoxin as an antiarrhythmic agent. At 38 weeks, a cesarean delivery was scheduled. Given her extreme thrombotic risk, anticoagulation was not interrupted. Surgery was performed 12 hours after the last enoxaparin dose. Intraoperatively, the field was unexpectedly bloodless, and anticoagulation was resumed immediately postoperatively. A healthy full-term infant was delivered safely.
Conclusion: This case highlights that even in the presence of extreme thrombotic risk and poor obstetric history, full-term delivery is achievable through strict adherence to guidelines, timely interventions, and multidisciplinary collaboration.
Keywords: High-risk pregnancy, Recurrent pregnancy loss, Antiphospholipid syndrome, Thrombotic stroke, Mechanical thrombectomy
Nephrotic syndrome in pregnancy. . . What’s different? A case report of newly diagnosed Alport syndrome in pregnancy
Rania Hassan Mostafa Ahmed1,*, Nouran Haythem Gamil2, Salma Fathy Rezk2
1Obstetrics & Gynecology Dept, Ain Shams University;
2
Nephrology Dept, Ain Shams University
*Correspondence: raneyah@med.asu.edu.eg
Background: Proteinuria presenting during pregnancy before 20 weeks’ gestation usually points out a new or previously undetected renal disease. Management of nephrotic-range proteinuria during pregnancy confers challenges in diagnosis, treatment, as well as planning delivery and postpartum care.
Case presentation: We report a case of a 27-year-old female presented with hypertension, and proteinuria in the second month of pregnancy. The patient had no prior diagnosis of renal disease but had a family history of hearing impairment and end-stage kidney disease. Unfortunately, she didn't show up for further evaluation. At 27 weeks, she presented with worsening lower limb edema and hypertension, nephrotic-range proteinuria (protein/creatinine ratio 9.6), and creatinine 1.5 mg/dL. Immunological markers were negative except for a weak positive speckled ANA. Renal biopsy couldn’t be done as she was in the 3rd trimester. She was kept on low-dose aspirin, verapamil, torsemide, prednisolone, labetalol, and low molecular weight heparin. Fetal biometry, amniotic fluid, and Doppler blood flow indices were carried out fortnightly. At 35 weeks, creatinine increased (1.7 mg/dL), and blood pressure was uncontrolled (170/100 mmHg). She was diagnosed as a case of superimposed severe pre-eclampsia necessitating early delivery at 36 weeks. The baby was born in a good condition, weighing 2.4 Kg, but was admitted to the neonatal intensive care unit two days later because of worsening neonatal jaundice. Postpartum, she developed rapidly progressive renal failure and underwent a renal biopsy, which revealed crescentic glomerulonephritis with ultrastructural evidence of basement membrane thickening and lamellation, consistent with Alport syndrome. She required hemodialysis and received immunosuppressive therapy.
Conclusion: This case illustrates the first manifestation of Alport syndrome during pregnancy, culminating in crescentic glomerulonephritis and dialysis dependency. Early recognition of family history and extrarenal manifestations (hearing loss, ocular findings) are essential for diagnosis. Multidisciplinary management is the key to optimizing both maternal and fetal outcomes.
Keywords: Proteinuria, Pregnancy, Alport syndrome, Crescentic glomerulonephritis, Preeclampsia
Intra-aortic balloon pump in a case of acute heart failure with pregnancy undergoing emergency hysterotomy: A case report
Amr Saad Mahmoud Ahmed1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: amrsaadobygyn@med.asu.edu.eg
We report a case of a 35-year-old PG, 15-weeks pregnant woman (IVF-conceived) with known post-viral dilated cardiomyopathy and cardiac pacemaker who presented with symptoms and signs of acute decompensated heart failure (dyspnea, orthopnea, EF=25%). She was counselled for pregnancy termination, but she refused at the start and requested time to take a decision. In less than 24 hours, she developed cardiac arrest (ventricular fibrillation), CPR (cardiopulmonary resuscitation) successfully regained the cardiac rhythm but with circulatory support and mechanical ventilation. An MDT (multidisciplinary team) decision was made to prompt termination of pregnancy (within 6 hours from the cardiac arrest), so, preoperative intra-aortic balloon pump was chosen as a less invasive mechanical support compared to ECMO (extracorporeal membrane oxygenation), general anesthesia was selected avoiding myocardial depressants, hysterotomy was done giving dead fetus 100 gm, one packed RBCS given. Pacemaker dysfunction risk was minimized by non-use of electrosurgery and distance from the operative field. Patient was transferred to cardiothoracic center for postoperative care. Multidisciplinary approach with early mechanical support, careful cardiology and anesthesia planning, obstetric decision-making was pivotal for survival.
Keywords: Pregnancy, cardiomyopathy, aortic balloon
Inflammatory myofibroblastic tumor mimicking placenta accreta spectrum: A case report
Khadiga M H Hegab1,*, Mohamed H Salama1, Mohamed Shaker Abd El Aziz Ibrahim1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: khadigamhegab@med.asu.edu.eg
Background: Antepartum hematuria and hemorrhage are uncommon but serious presentations in pregnancy, often raising concern for obstetric or urological emergencies. Inflammatory myofibroblastic tumor (IMT) of the bladder is a rare benign neoplasm with intermediate malignant potential, capable of mimicking malignancy or other pelvic pathology. This report describes a rare case of IMT in pregnancy, initially suspected to be placenta accreta spectrum (PAS).
Case Presentation: A 29-year-old woman, para 1 with a history of previous caesarean delivery, presented at 25 weeks of gestation with massive hematuria and antepartum hemorrhage. She required blood transfusions for hypovolemic shock. Imaging (ultrasound and MRI) revealed an intravesical mass; differential diagnoses included placenta previa with possible PAS due to her obstetric history and inconclusive imaging findings, blood clot or a primary bladder mass. However, the latter remained an alternative diagnosis. The patient was resuscitated but initial conservative management failed to control the hematuria with deterioration in her vital signs, an urgent cystoscopy was attempted but failed to visualize the lesion due to active bleeding. A multidisciplinary decision was made to proceed with midline exploratory laparotomy, where no signs of placental invasion were noted. The urology team subsequently performed a cystostomy, revealing a large hemorrhagic mass which was excised. Histopathology revealed spindle-shaped neoplastic cells in myxoid background with lymphocytes and plasma cells, suggestive of IMT. Postoperative recovery was uneventful. The patient then delivered at full-term a healthy baby via planned cesarean section. A multidisciplinary meeting advised PET-CT and pathology slide re-review. She remained asymptomatic with no recurrent bleeding and is on regular follow up by the urology team.
Conclusion: This case underscores the importance of considering bladder-origin pathologies in pregnant women presenting with antepartum hematuria. IMT, though rare, may clinically resemble PAS. A multidisciplinary approach is vital for accurate diagnosis and timely intervention.
Keywords: Inflammatory myofibroblastic tumor, Antepartum hemorrhage, Bladder mass, Hematuria, Pregnancy, Placenta accreta spectrum, ALK-positive-myogenin-negative tumor
Reviews
Enhancing QUality Intrapartum CARE (EQUICARE)
Khaled Ismail1
1Obstetrics & Gynecology Dept, Charles University, Czech Republic
*Correspondence: Khaled.Ismail@lfp.cuni.cz
Evidence-based recommendations for the management of labor and childbirth have a significant impact on caesarean section rates, perineal trauma prevalence, core childbirth-related maternal outcomes and the woman’s experience in general. Indeed, intrapartum management, systematic perineal assessment, as well as suturing materials and techniques have been shown to be associated with significantly better clinical and women reported outcomes. However, these methods and materials are not consistently used despite international evidence-based recommendations. This results in high variability within and between maternity units globally. In view of the frequency of such injuries, the negative consequences of missed or incorrectly classified trauma on the woman and the lifetime burden of such problems, quality improvement interventions to enhance the implementation of evidence into practice can have a significant positive impact on women’s health. The Enhancing QUality Intrapartum CARE (EQUICARE) course has been designed to deliver integrated evidence-based interactive and practical multi-professional training in the management of labor, prevention, identification and repair of birth-related pelvic floor injuries. The guiding principles for the WHO’s intrapartum care model is that: Labor and childbirth should be individualized, and woman centered. No intervention should be implemented without a clear medical indication. Only interventions that have been proven to be beneficial should be promoted. A positive childbirth experience for the woman and her family should be at the forefront. The program was designed to facilitate the implementation of the WHO recommendations of the intrapartum care for a positive childbirth experience guideline with particular focus on the prevention and management of childbirth related perineal trauma.
Digital tools to facilitate the implementation of evidence into practice
Khaled Ismail1
1Obstetrics & Gynecology Dept, Charles University, Czech Republic
*Correspondence: Khaled.Ismail@lfp.cuni.cz
Medical emergencies have a disproportionate effect on the poorest and most vulnerable, particularly women and children. Furthermore, most preventable mortality and morbidity among women occur in humanitarian settings during disasters. Following the events of October 2023, the Palestinian health system has been struggling to respond to the ongoing influx of trauma cases, which impacted on provisions for the delivery of non-trauma, yet essential, medical services. At the peak of the problem, it was estimated that there were 50,000 pregnant women in Gaza with about 180 women of these struggling to access maternity services each day. The situation has also impacted on maternity services in the Westbank (WB) that resulted from increased number of checkpoints and road closures. The above has resulted in lack of availability of accessible specialist care. Indeed, the mainstay for delivery of health services was in makeshift medical points within schools, primary health centers or on site wherever they are displaced. In view of the above, an offline digital tool was devised to provide quick, reliable and effective guidance on the management of prioritized obstetric emergencies during critical and emergency situations. The presentation will cover the steps that could be followed to develop similar tools as a way of facilitating the implementation of evidence into practice and streamlining service delivery even in low- and middle-income healthcare settings.
The role of fetal medicine specialist in improving pregnancy outcome
Sherif Abdelfattah1,*
1Consultant in Fetal Medicine & Obstetrics, Bristol, UK; RCOG Council representative for the MENA region
*Correspondence: Sherif.Abdel-Fattah@bristol.ac.uk
The significant recent surge in the use of non-invasive prenatal testing (NIPT) for a variety, and constantly increasing, chromosomal and genetic abnormalities led to fewer invasive procedures for prenatal diagnosis been required. This has raised concerns and questions about the future role of fetal medicine specialists. This presentation discusses the several important conditions that require highly skilled fetal medicine specialists to manage, such as diagnosis, counselling and managing cases of non-chromosomal fetal abnormalities, but also the more important role of prevention and early management of common conditions that have serious impacts on maternal, fetal and neonatal outcomes, such as preterm labor and fetal growth restriction.
Gynecology
Clinical Trials
Aromatase inhibitor as co-treatment for induction of ovulation in poor responders undergoing ICSI using antagonist protocol
Mohamed Hassan Nasr El-Din1, Mohamed Hamed Abd El-Aziz1, Yassmin Nashaat Talaat1, Ahmed Hamed Ramadan Abu Zied1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: ahmed.hamed@med.asu.edu.eg
Background: In recent years, significant progress has been achieved in developing the optimal procedure for inducing ovulation in poor ovarian responders.
Objective: To demonstrate the impact of aromatase inhibitors as a co-treatment for ovarian induction in poor responders undergoing ICSI employing antagonist protocol, the work aims to compare two groups.
Methods: We used a randomized controlled clinical trial in the Ain Shams University Assisted Reproduction Unit. The Bologna criteria were used to identify poor ovarian responders. Our primary outcome was live birth rate, and secondary outcomes were number of oocyte retrieval, number of still birth, total dose of gonadotropin and cetrotide and side effects of letrozole. Our study consisted of 60 patients separated into two equal groups. The first group took letrozole [L] (2.5mg) two tablets daily (as an aromatase inhibitor) and another group took placebo [P] (two tablets of folic acid 500 mg daily) from third day of cycle and for five days. Human menopausal gonadotropin (HMG) was given on the third day of cycle and was calculated by the consultant in the assisted reproductive unit. Gonadotropin releasing hormone antagonist was given when at least one follicle reached a size of 17mm.
Results: In terms of positive biochemical pregnancy test (67% to [L] group and 57.6% to [P] group), delivery was (44.4% to [L] group and 30.8% to [P] group), and live birth rate was (37% to [L] group and 23% to [P] group), our study revealed no statistically significant difference between the two study groups. Regarding the overall dosage of gonadotropin and cetrotide, the number of oocytes retrieval and the number of stillbirths, there was no statistically significant difference between the two study groups. Patients who used letrozole reported no negative side effects.
Conclusion: Conducting randomized studies with a high sample size is advised because there is not enough evidence to support the use of letrozole as a co-treatment in stimulation protocols.
Keywords: Aromatase Inhibitor, Ovulation, Poor Responders, ICSI, Antagonist Protocol
High oocyte aspiration pressure during OPU procedure impact on number of oocytes in women undergoing ICSI
Tarek Hesham Elsayed1, Ahmed Mohamed Bahaaeldin Ahmed1, Sarah Tarek Mahmoud1,*, Amr Fathy Ahmed Abdelkarim1, Maya Mahmoud Abdelrazek1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: SarahTarek@med.asu.edu.eg
Background: Oocyte retrieval is a critical step in intracytoplasmic sperm injection (ICSI) cycles. The aspiration pressure used during oocyte pick-up can influence both the quantity and quality of retrieved oocytes.
Objective: to compare the effects of high versus conventional aspiration pressure during oocyte retrieval.
Methods: A quasi-randomized clinical trial was conducted at Ain Shams University Hospitals ART Unit from October 2024 to March 2025, including 70 women planned for ICSI aged 18–35 years with normal ovarian reserve parameters. Randomization allocation was done via computer-generated randomization chart to allocate which ovary to start with in each patient. On this side (group A) “conventional 180 mmHg” pressure was used, followed by using “high pressure 300 mmHg” on the other side (group B). Standard ovarian stimulation protocols were used, and oocyte retrieval was performed transvaginal under ultrasound guidance. Retrieved oocytes were assessed. Our primary outcome was oocyte yield, while secondary outcomes were: oocyte quality and maturity (cumulus cells, oocyte maturation stage), oocyte size and shape, cytoplasmic and extracytoplasmic features, proportion of ruptured oocytes, proportion of metaphase II (MII) oocytes, ICSI normal fertilization rate, ICSI damage rate, cleavage rate, day 3 embryo development rate, blastocyst quality grading, and procedural complications.
Results: The conventional-pressure group showed significantly higher oocyte yield, with a mean of 9.9±2.6 oocytes retrieved compared to 4.7±1.9 in the high-pressure group (p<0.001), as well as a higher oocyte-to-follicle ratio (1.2±0.1 vs. 0.9±0.1, p<0.001). Morphological assessments revealed no statistical difference as regards cumulus cells, cytoplasmic quality, and MII oocytes between both groups. Fertilization, cleavage, and blastocyst formation rates were improved in the conventional-pressure group. There were no significant differences in procedural complications. Conclusions: Conventional aspiration pressure during oocyte retrieval enhances oocyte yield, leading to improved fertilization and embryonic development without increasing procedural complications.
Keywords: Oocyte retrieval, Aspiration pressure, Intracytoplasmic sperm injection (ICSI), Oocyte quality, Fertilization rate, Embryo development, Assisted reproductive technology (ART).
Oral diclofenac potassium vs. hyoscine-n-butyl bromide combined with misoprostol to reduce pain during office hysteroscopy: A randomized controlled trial
Hend Mahmoud Abd Elgawad Mahmoud1,*, Mostafa Ibrahim Ibrahim1, Radwa Mansour Mohamed1, Ahmed Mohamed Abd El-Hamed1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Hend-Mahmoud@med.asu.edu.eg
Background: Office hysteroscopy (OH) is a minimally invasive procedure for diagnosing and treating various gynecological conditions. Non-steroidal anti-inflammatory drugs (NSAIDs) and hyoscine butyl bromide (HBB) can reduce pain during the procedure.
Objective: To compare oral NSAIDs versus oral HBB in reducing pain with OH.
Methods: The study was conducted at Ain Shams University maternity hospital at the early cancer detection and gynecological endoscopy unit. 62 patients were distributed into 2 groups: Group A received 50mg diclofenac potassium, and Group B received 20mg HBB orally one hour before the procedure. Both groups received misoprostol vaginally 12hours before the procedure. We included women above 18 years old, planned for diagnostic OH. The primary outcome was the mean visual analogue scale (VAS) pain scores immediately after introduction of OH and 30minutes after the end of the procedure. While secondary outcomes were the ease of OH, failure rate, duration of OH, adverse effects of the drugs, and complications of OH. Both the investigator who collected the outcomes data, and the clinician who performed the OH were blinded to the group assignment.
Results: The mean VAS score immediately after the introduction of hysteroscopy in Group A was significantly higher than Group B, mean ±SD: (3.27±1.23) versus (2.47±1.46), respectively with a p-value of 0.025. But there was no significant difference between the two groups regarding VAS score after 30 minutes after hysteroscopy, with a p-value (p>0.05). Also, there is no statistically significant difference between groups regarding the secondary outcomes: entry of OH, duration of hysteroscope, side effects of drugs, and complications.
Conclusion: The use of HBB or NSAIDs may control pain related to OH. HBB may be a better choice to control pain related to OH.
Keywords: Diclofenac potassium; Hyoscine-N-Butyl Bromide; Office hysteroscopy
Paracervical block for intrauterine device placement among class II obese women: a single-blinded randomized controlled study
Amr Ayyad1,*, Tarek Tamara1, Sherif Ashoush1, Ebtihal Eltaieb1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Amr.a.ayyad@gmail.com
Background: The intrauterine contraceptive device (IUCD) is the most used reversible contraceptive globally, valued for its effectiveness, reversibility, and safety. However, insertion-related pain, especially in obese women, can hinder its use. To manage this, various pain relief methods are used, with the paracervical block being a widely accepted, safe, and simple option.
Objective: To assess the effectiveness of paracervical block for management of pain during IUCD insertion in class II obese women.
Methods: A prospective, single-blinded, randomized controlled trial was conducted at the Family Planning Clinic of the Obstetrics and Gynecology Department, Ain Shams University Hospitals, from January 1 to December 31, 2024. The study included women aged 18–45 years, with a BMI of 35–39.9 kg/m², planning for intrauterine contraceptive device (IUCD) insertion, and presenting during the postmenstrual period. Patients were randomized by the researcher into 2 groups: Group A (non-intervention group): (70) patients who did not receive any local anesthesia. Group B (intervention group): (70) patients who had paracervical block. In Group A, a placebo procedure involved gentle application of a capped needle at the tenaculum site and vaginal fornices before IUCD insertion without analgesia to maintain blinding. In Group B, a 20 cc paracervical block, 18 cc 1% lidocaine (Debocaine 50ml DBK Pharma) with 2 cc sodium bicarbonate (Otsuka 8.4% 25ml) was administered—2 cc superficially at the vulsellum site and 18 cc equally at the 4 and 8 o’clock vaginal fornices, with precautions to avoid intravenous injection. IUCD placement was done 5 minutes after paracervical block or placebo. The primary outcome was assessment of pain, measured by a 10-point Visual Analog Scale (VAS) at six stages: speculum placement, tenaculum placement, paracervical block, uterine sounding, IUCD insertion, and 5 minutes post-insertion.
Results: Women who received the paracervical block reported less pain with IUCD insertion compared to women who received no block (median VAS: 3 vs. 5, p<0.0001), they also experienced less pain during vulsellum application (median VAS: 1 vs. 2, p<0.0001), uterine sounding (median VAS: 2.5 vs. 3, p<0.0001) and five minutes post-insertion (median VAS: 1 vs. 3, p<0.0001). However, there was no statistically significant perceived pain difference during speculum insertion (median VAS: 4 vs. 3, p=0.3248).
Conclusion: 20 ml lidocaine 1% paracervical block significantly decreased perceived pain during IUCD insertion compared to no intervention.
Keywords: Intrauterine contraceptive device, Lidocaine, Paracervical block, Pain
Gamma-irradiated amniotic membrane graft in posterior colporrhaphy: A pilot one-arm clinical trial
Nourhan Ashraf El-Sherbiny Abdelhady1,*, Ihab Fouad Serag1, Ahmed Mohamed Abbas1, Rania Hassan Mostafa Ahmed1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: nourhan.ashraf@med.asu.edu.eg
Background: Posterior vaginal wall prolapse is a frequent pelvic floor disorder impacting patient comfort and function. While conventional posterior colporrhaphy is widely used, recurrence rates and limitations in tissue support remain concerns. Biologic grafts like amniotic membrane offer regenerative potential. However, no enough clinical studies evaluated the use of gamma-irradiated sterilized amniotic membrane in posterior colporrhaphy, representing a significant gap in surgeries for prolapse repair.
Objective: To evaluate the safety and effectiveness of gamma-irradiated amniotic membrane grafts in posterior colporrhaphy.
Methods: This pilot single-arm clinical trial was conducted on 25 women with symptomatic posterior vaginal wall prolapse (POP-Q Stage II–IV) at Ain Shams University Maternity Hospital during the period (January 2023- March 2025). All patients underwent posterior colporrhaphy using gamma-irradiated amniotic membrane as a graft on the defective area of rectovaginal septum. We assessed symptoms score using Pelvic Organ Prolapse Distress Inventory 6, sexual satisfaction by Female Sexual Function Index Questionnaire, and POP-Q staging preoperatively, and at 3 and 6 months postoperatively, as well as complication rates. Data were analyzed using repeated measures ANOVA and Friedman tests.
Results: There was a statistically significant reduction in symptom scores from 16.32 ± 3.48 at baseline to 4.96 ± 1.90 at 6 months (p < 0.001), with a mean percent reduction of 68.22% ± 14.54%. Patient satisfaction increased from 11.75 ± 3.55 to 30.80 ± 2.75, marking a 253.12% improvement. Anatomical assessment showed that 80% of patients achieved POP-Q Stage 0, while 20% reached Stage I by 6 months. No serious complications (wound dehiscence, visceral injury) were reported; however, 76% of patients experienced mild vaginitis. Conclusions: Posterior colporrhaphy using gamma-irradiated amniotic membrane grafts demonstrated significant improvements in anatomical correction, symptom relief, and patient satisfaction, with minimal complications. Further studies are needed to compare it to conventional colporrhaphy.
Keywords: Posterior colporrhaphy; Amniotic membrane; Gamma-irradiation; Pelvic Organ prolapse; POP-Q
Effect of cabergoline versus dienogest in women with chronic pelvic pain due to endometriosis
Zeinab Mohamed Taher Beder1,*, Mohammed Saeed El Din El Safety1, Alaa Sayed Hassanin1, Maya Mahmoud Abd El-Razek1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: zeinabmohamed429@gmail.com
Background: Endometriosis is a chronic, estrogen-dependent inflammatory condition characterized by pelvic pain and infertility. While hormonal treatments such as dienogest are effective, they are often marred by side effects and issues related to long-term tolerability. Cabergoline, a dopamine agonist with anti-angiogenic properties, emerges as a promising non-hormonal alternative.
Objective: To compare the effectiveness and safety of cabergoline to dienogest in managing endometriosis-associated chronic pelvic pain.
Methods: A randomized controlled trial was conducted at Ain Shams University Maternity Hospital from March to August 2023, approved by the Research Ethics Committee, Faculty of Medicine, Ain Shams University (REC-FMASU; MS 114/2023). Fifty women aged 18 to 40 with endometriosis-related pelvic pain and confirmed endometrioma size <3 cm were randomized to receive either cabergoline (0.5 mg twice weekly) or dienogest (2 mg daily) for three months. Mid-study, a reduced dose (0.25 mg) was administered to a subgroup (A2) of six patients in the cabergoline group due to adverse effects such as nausea, vomiting, headache, and mood changes. The primary outcome measured was the change in pain severity using the visual analogue scale (VAS). Secondary outcomes included endometrioma size, side effects, and Patient Global Impression of Change (PGIC) scores.
Results: Both treatment groups demonstrated significant reductions in pain; however, cabergoline at full dose resulted in a greater decrease in VAS scores at one-month (p = 0.013) and three months (p = 0.010), with no significant difference between full (A1) and reduced (A2) doses (p = 0.618). Adverse effects were more common with dienogest, particularly in terms of abnormal uterine bleeding and mood changes. The reduced dose cabergoline group (A2) reported the lowest incidence of adverse effects, including nausea and vomiting (p = 0.001), headache and mood changes (p = 0.009), and abnormal uterine bleeding (p = 0.008). Endometrioma size decreased in all groups, with no statistically significant differences observed (p = 0.403). PGIC scores (p = 0.040) and daily activity interference (p = 0.047) favored cabergoline at one month.
Conclusion: Cabergoline showed superior pain relief and enhanced tolerability compared to dienogest, particularly at lower doses, highlighting its potential as a non-hormonal alternative for managing endometriosis.
Keywords: Endometriosis, Cabergoline, Dienogest, Pelvic pain, Non-hormonal therapy, Quality of life
Observational Studies
Urinary tract injuries after hysterectomy for benign gynecological conditions
Yasser Mohmed Elshehawy1, Sherif Mohamed Habib1, Nermin Ahmed Mahmoud1, Mohamed Reda Elrefaie Mohamed1,*, Hatem Elsayed Mohamed1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Mohamed_Reda@med.asu.edu.eg
Background: Hysterectomy is one of the most commonly performed gynecological procedures. Despite advancements in surgical techniques, different hysterectomy modalities carry risk of urinary tract injuries, leading to potential morbidity and long-term consequences. The incidence of bladder injury ranges from 0.13% to 3.6%, while ureteral injury occurs in 0.1% to 1.8% of cases.
Objective: was to evaluate the incidence of urinary tract injuries across various hysterectomy modalities for benign gynecological conditions.
Methods: We conducted a retrospective cohort study included all women who underwent elective hysterectomy for benign gynecological conditions at Ain Shams University Maternity Hospital during the period from 1/1/2022 to 31/12/2024. We reviewed the medical records for data regarding women demographic and clinical data, the indication of surgery, and intra and post operative course.
Results: The risk of urinary tract injury varies significantly across different surgical approaches. Total laparoscopic hysterectomy has the highest incidence (3.8%), followed by total abdominal hysterectomy (1.6%), while vaginal hysterectomy has the lowest rate (1.38%).
Conclusion: Urinary tract injuries remain a significant concern during hysterectomy for benign gynecological conditions, with the risk varying based on the surgical approach. Total laparoscopic hysterectomy is associated with the highest incidence of injury, even when performed by experienced surgeons.
Keywords: Hysterectomy, Abdominal, Laparoscopy, Vaginal, Urogenital tract injuries
The relationship between depressive symptoms, physical performance, and self-reported fatigue in elderly women
Kholoud Mahmoud Mostafa Eid1,*, Doha Rasheedy Ali1, Sherine Mohamed Hassan1, Mona Hegazy Mohammed1
1Geriatrics & Gerontology Dept, Ain Shams University
*Correspondence: Kholoudmahmoud20142021@gmail.com
Background: Fatigue is a common symptom among older adults, with a disproportionately higher prevalence in women. It has multidimensional nature with physical, emotional, and cognitive components. Whether subjective fatigue reporting is associated with impaired physical performance and mood disturbances remains unclear and warrants further evaluation in older women.
Objective: to investigate the relationship between self-reported fatigue, physical performance, and depression in older women.
Methods: A case-control study was conducted between July 2024 and February 2025 with 130 elderly participants: 65 community-dwelling elderly with fatigue and 65 without fatigue. In this abstract, we present the analysis of a subgroup of elderly women (aged 60 and above) who were menopausal: 33 community dwelling older women with self-reported fatigue (cases) and 22 age-matched controls without fatigue. The case-control imbalance stems from six focused subgroup analyses. Fatigue was assessed using the Fatigue Severity Scale (FSS), physical performance was evaluated through the 6-minute walk test and chair stand test, depression was measured using the Geriatric Depression Scale (GDS), and disease burden was quantified using the Charlson Comorbidity Index (CCI).
Results: Women with self-reported fatigue demonstrated higher depressive symptoms (GDS: 8.12 ± 2.92 vs. 3.86 ± 2.64; p < 0.0001) and fatigue severity (FSS: 42.18 ± 5.94 vs. 22.73 ± 10.33; p < 0.0001) compared to controls. They also showed poorer physical performance, including shorter 6-minute walk distances (97.48 ± 68.23 vs. 341.64 ± 139.28 meters; p < 0.0001) and fewer chair test repetitions (4.27 ± 2.73 vs. 9.64 ± 2.04; p = 0.01). Cases exhibited higher rates of moderate to severe depression. Significant correlations were found between CCI, GDS, FSS, and physical performance measures (p < 0.0001 for all).
Conclusion: Older women who report fatigue demonstrate higher levels of depressive symptoms and reduced physical performance compared to their non-fatigued counterparts, underscoring the debilitating impact of fatigue in this population.
Keywords: Fatigue, Older women, Elderly, Menopausal, Self-reported fatigue, Physical performance, Depression, Geriatric Depression Scale, Fatigue Severity Scale, 6-minute walk test, Chair stand test, Charlson Comorbidity Index, Community-dwelling, Case-control study
Impact of stress on menstrual irregularities among female medical students at the University of Khartoum
Eman Abdelrahman1,*, Amna M. Elazrag1
1University of Khartoum
*Correspondence: Imanbashr@gmail.com
Background: Psychological stress is prevalent among medical students and may disrupt normal menstrual patterns. This study aimed to assess the influence of stress on menstrual cycle characteristics and identify common menstrual irregularities among female medical students at the University of Khartoum.
Methods: A cross-sectional analytical study was conducted in 2021 among female medical students from three different academic years at the University of Khartoum. Using systematic random sampling, 277 students were approached, and 186 completed the survey (response rate: 67.1%). A structured, pretested questionnaire—developed and piloted by the authors on a sample of 20 students prior to the study—was used for data collection. Variables included demographic data, menstrual characteristics, and stress levels, which were assessed using the Perceived Stress Scale (PSS). Data were analyzed to explore associations between stress and menstrual irregularities.
Results: The mean age of participants was 22 years. Irregular cycles were reported by 56.7% of students. The average duration of bleeding was 5 days, and 43.3% experienced clot passage. A statistically significant association was found between stress levels and the number of bleeding days (p = 0.02). Additionally, higher stress levels were significantly associated with the presence of menstruation-related symptoms such as fatigue, mood swings, and abdominal pain (p = 0.01).
Conclusion: This study demonstrates a significant association between elevated stress levels and menstrual irregularities, particularly changes in bleeding duration and the presence of menstrual symptoms. These findings highlight the need to integrate mental health support within academic institutions to promote both psychological well-being and reproductive health among female students.
Keywords: Stress, Menstrual cycle, Irregular periods, Premenstrual symptoms, Female medical students
Case Reports/Series
Placental site trophoblastic tumor locally invading the intestinal serosa: A case report
Mohammed Ahmed Abdelrazeq1,*, Ahmed Mohsen Hassan1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Rizo1411@med.asu.edu.eg
Placental site trophoblastic tumor (PSTT) is a rare type of gestational trophoblastic disease (GTD). It is a malignant tumor developed from extra villous intermediate trophoblasts. It is associated with less vascular invasion, necrosis and remains localized in the uterus with local invasion before metastasizing to regional lymph nodes or other metastatic sites. We report a case of 38 years old patient, para 4 with last three deliveries by cesarean section and previous two first trimester miscarriages, presented initially with persistent vaginal bleeding two months after evacuation of product of conception of intrauterine pregnancy at 8 weeks of amenorrhea which revealed normal product of conception. The patient showed persistent elevation of Human Chorionic Gonadotropin (HCG), and transvaginal ultrasound (TVUS) showed heterogenous highly vascular mass in the endometrial cavity extended to anterior uterine wall. No other symptoms were present. Biopsy was taken through dilatation and curettage, and pathological examination confirmed the diagnosis of placental site trophoblastic tumor. Therefore, she underwent abdominal hysterectomy and bilateral salpingectomy which showed a large intrauterine polypoid grayish vascular mass about 15 x 8 cm, invading serosa and adherent to loop of small intestine which showed grossly deposits of same tumor on intestinal serosal surface. So, resection of about 20 cm was done to resect all visible chemo resistant tumor tissue. Then primary intestinal anastomosis was done. Final pathology showed perforated uterus with PSTT with intestinal deposits; Ki67 more than 50%.
Conclusion: Patients with persistent vaginal bleeding after a normal non-molar pregnancy or miscarriage should have quantitative β-hCG testing to exclude GTD. PSTT is chemo-resistant, so the main treatment for non-metastatic stage I tumor is hysterectomy and resection of any tumor tissue detected intraoperatively to avoid recurrence.
Keywords: Placental site trophoblastic tumor (PSTT), Gestational trophoblastic disease (GTD), Extra villous intermediate trophoblasts, Vaginal bleeding, Human chorionic gonadotropin (HCG)
Can hair become harmful? A rare case of strangulated hair clitoral syndrome in a young girl: Diagnosis, treatment, and outcomes
Mohamed Hemdan*
*Correspondence: m.hemdan88@gmail.com
Introduction: Strangulated Hair Clitoral Syndrome (SHCS) represents a rare pediatric disorder in which a strand of hair encircles delicate anatomical regions, leading to sequelae such as ischemia, inflammation, and tissue necrosis. This phenomenon predominantly affects the genital area, particularly the clitoral hood in female children. Clinical manifestations include edema, discoloration, pruritus, and discomfort, with treatment strategies varying from conservative management to surgical intervention.
Case Report: A 7-year-old girl experienced recurrent episodes of clitoral hood hair tourniquet syndrome. The first occurred in April 2024 while on holiday in Spain, where her parents noticed genital swelling and redness at the beach. A strangulating hair was identified and removed under sedation at a local hospital, with full symptom resolution. In October 2024, she presented to Wythenshawe Hospital, UK, with painless swelling. A topical hair removal cream was applied and removed after 10 minutes. No hair was seen on examination. She was managed conservatively, and the swelling gradually resolved over the following weeks. However, in November 2024, she re-presented with sudden worsening, including bluish-black discoloration and discomfort. Examination under general anesthesia revealed necrotic clitoral hood tissue and a deeply embedded hair tourniquet, which was surgically excised. Histopathology confirmed coagulative necrosis from hair-induced strangulation. Recurrence is likely due to exposure to loose-hair from the child or caregiver during bathing, dressing, or sleeping. She was referred to the Adolescent Gynecology Clinic for follow-up. No further episodes have occurred. Discussion: The anatomical characteristics of children, particularly their delicate genital structures, render them more vulnerable to conditions like SHCS. This syndrome arises from the high tensile strength of hair strands, allowing them to create a constrictive loop around the clitoral hood when they become wet. As the hair dries, it contracts further, intensifying pressure and impeding both blood circulation and lymphatic drainage. Consequently, this can result in swelling, discomfort, and an increased risk of tissue necrosis. Prompt identification and treatment are essential to prevent significant tissue loss and associated complications.
Conclusion: Timely detection and management of SHCS are vital to avoid complications and alleviate psychological distress for affected individuals. Continuous monitoring and education for caregivers are imperative for effective long-term management. Healthcare providers maintaining a high level of clinical suspicion are crucial to ensuring early intervention and positive outcomes.
Keywords: Strangulated hair clitoral syndrome, Hair tourniquet syndrome, Pediatric gynecology, Genital ischemia
Uterine artery pseudoaneurysm following cesarean section: A case report
Ahmed Selim1,*, Ahmed Sanad1, Omnia Seyam1, Nooran Sherif1, Mohammed Waheed1, Mohammed Refaie1, Amane Tareq1, Aya Tamer1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: dr.ahmedselim_89@med.asu.edu.eg
Background: Uterine artery pseudoaneurysm (UAP) is a rare but potentially life-threatening complication that may follow cesarean delivery. Diagnosis is often challenging, particularly in atypical or delayed presentations.
Case Presentation: A 24-year-old woman, with one prior cesarean section, presented to the emergency department on March 30, 2025, with acute-onset severe uterine bleeding. Her previous cesarean on December 13, 2024, was complicated by intraoperative hemorrhage requiring four units of packed red blood cells and the involvement of a general surgeon. On examination, she was hypotensive (BP: 80/50 mmHg), tachycardic (HR: 120 bpm), and afebrile. Abdominal and pelvic exams were unremarkable. Transvaginal ultrasound revealed a 10 × 10 mm hypoechoic lesion in the right lateral uterine isthmus with a bidirectional swirling flow on Doppler (Yin-Yang sign), suggestive of a pseudoaneurysm. Hemoglobin dropped from 11 to 9 g/dL over four hours. She received resuscitation with two units of packed red cells and tranexamic acid. Bleeding resolved within 12 hours. Repeat ultrasound showed loss of Doppler flow and transformation of the lesion into a hyperechoic, well-defined area, raising suspicion of a resolving hematoma. As per interventional radiology recommendations, a triphasic CT was performed as a non-invasive step before angiography. The CT excluded vascular malformations but suggested a possible isthmocele rupture. Conservative treatment with antibiotics was initiated. The patient was counseled regarding laparoscopic repair if needed. One week later, a self-limited bleeding episode occurred; ultrasound was inconclusive. Another week later, Doppler re-demonstrated the Yin-Yang sign which prompted diagnostic angiography. Angiography confirmed two uterine artery pseudoaneurysms, successfully embolized with microcatheter and coil technique.
Conclusion: This case highlights the diagnostic complexity of UAP, the importance of repeated imaging, and the value of multidisciplinary coordination in managing abnormal uterine bleeding.
Keywords: Uterine artery pseudoaneurysm, Isthmocele, Doppler ultrasound, Embolization, Cesarean section
Overcoming complexity: Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy in a patient with uterine didelphys and dual endometrial pathology—A surgical approach in a complex anatomical variant
Mohamed Hemdan*, Hani Shuheibar, Theofanis Manias
*Correspondence: m.hemdan88@gmail.com
Background: Uterine didelphys, a rare Müllerian anomaly with duplicated uterine and cervical structures, presents significant diagnostic and surgical challenges. Atypical endometrial hyperplasia, a precancerous lesion with malignant potential, further complicates management. This case highlights the unique challenges encountered during total laparoscopic hysterectomy and bilateral salpingo-oophorectomy in the setting of altered pelvic anatomy.
Case Presentation: We present the case of a 48-year-old woman with uterine didelphys, found to have persistent atypical endometrial hyperplasia in one uterus and hyperplasia without atypia in the other, despite hormonal therapy. In view of the ongoing risk of malignant transformation, definitive surgical management was undertaken.
Surgical Approach: Pre-operatively, detailed imaging including renal ultrasound was performed to exclude associated renal anomalies; no abnormalities were found. Intraoperatively, total laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performed. Two separate uterine bodies and two cervices were confirmed. A standard four-port laparoscopic technique was used. A McCartney tube was inserted vaginally to aid identification of the fornices, maintain pneumoperitoneum post-colpotomy, and assist with vaginal vault closure. Each hemi-uterus and adnexa were mobilized. Ureters were identified bilaterally. The infundibulopelvic and round ligaments were coagulated and transected individually. Broad ligaments were opened, and uterine arteries skeletonized and secured bilaterally using a LigaSure device. The median raphe between the two cervices was carefully dissected. Circumferential colpotomy was performed around both cervices under McCartney tube guidance. Both uteri and adnexa were removed vaginally. The vaginal vault was closed laparoscopically with a continuous barbed V-Loc suture, ensuring good approximation and hemostasis.
Outcomes: The patient tolerated the procedure well and recovered uneventfully. Histopathological examination confirmed atypical hyperplasia in one uterine cavity and benign endometrium in the other, with no evidence of malignancy.
Conclusion: This case illustrates that surgical management of uterine didelphys can be performed safely and effectively with thorough preoperative planning and precise operative technique.
Keywords: Uterine didelphys, Müllerian anomaly, Atypical endometrial hyperplasia, Laparoscopic hysterectomy and bilateral salpingo-oophorectomy
Autologous rectus sheath graft for apical prolapse management: Is synthetic mesh essential? A case series evaluating mesh-free pectopexy
Hamdy Abdalhady1,*, Hani AL-Khalaf2
1Obstetrics & Gynecology Dept, Armed Forced Hospital Wadi Aldwaser, Saudi Arabia
2Plastic Surgery Dept, Armed Forced Hospital, Wadi Aldwaser, Saudi Arabia
*Correspondence: hamdytheproff@yahoo.com
Background: Abdominal sacrocolpopexy using synthetic mesh remains the gold standard for apical prolapse repair but poses risks of mesh-related complications. Pectopexy, a mesh-based alternative anchoring the vaginal apex to iliopectineal ligaments, offers technical simplicity but retains dependency on mesh. Autologous rectus fascia sheath (RFS) grafts, harvested from the patient’s abdominal wall, present a biocompatible alternative, eliminating mesh risks while maintaining efficacy. This study evaluates a novel mesh-free pectopexy technique using RFS grafts.
Objective: To assess anatomical outcomes and safety of autologous RFS grafts in pectopexy for apical prolapse.
Methods: A case series conducted at Armed Forces Hospital Wadi-AlDawaser, KSA (October 2022–June 2024) included consecutive patients with symptomatic apical defects (POP-Q stage ⩾ II). Pectopexy was performed via laparotomy (Pfannenstiel incision) using RFS grafts anchored bilaterally to iliopectineal ligaments and vaginal apex. Endpoints were anatomical success (POP-Q Point C ⩽ stage 0) and graft-related morbidity over ⩾12 months.
Results: Thirteen patients (mean age: 47 years) completed follow-up. Anatomical success was achieved in 11/13 cases (84.6%). No graft erosion, infection, or chronic pain occurred. One patient (7.7%) developed an incisional hernia requiring repair. Mean operative time was 104 minutes, with mean blood loss of 134 ml. Subjective symptom improvement was reported by 11/13 patients (84.6%). Notably, one patient with a 10-year history of secondary infertility conceived spontaneously nine months post-surgery and delivered a full-term baby via cesarean section.
Conclusion: Mesh-free pectopexy using autologous RFS achieved 84.6% anatomical success without graft-related complications, suggesting synthetic mesh may not be essential for durable apical support. The technique offers a safer alternative for patients avoiding synthetic materials, with incidental evidence of preserved fertility. While incisional hernia risk warrants attention, larger prospective studies are needed to validate long-term durability and broader applicability. This approach aligns with evolving trends favoring biocompatible, patient-derived solutions in pelvic reconstruction.
Keywords: Pectopexy, Autologous, Apical, Mesh
Reviews
Laparoscopic surgeries in the pregnant patient: Considerations and techniques
Radwa Rasheedy Ali1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: radwarasheedy@med.asu.edu.eg
Laparoscopic surgery during pregnancy, while historically contraindicated in advanced gestation, is now even preferred over open surgeries with better safety across all trimesters. Approximately 0.5–2% of pregnant women require non-obstetric surgery, commonly for acute appendicitis, cholecystitis, or adnexal torsion. Benefits over laparotomy include reduced maternal opioid use, shorter hospitalization, less pain, and lower thromboembolism risk. While uterine perforation risks preterm delivery or fetal injury, the Hasson technique may reduce this. Experienced surgical/anesthetic teams are essential, and non-urgent procedures should avoid the first and third trimesters. Key technical modifications could mitigate the risks: positioning in left lateral tilt minimizes aortocaval compression; port placement (e.g., Palmer’s point, supraumbilical) avoids uterine injury, guided by ultrasound if needed; insufflation pressure should be kept low (⩽12 mmHg) to preserve uteroplacental flow; and end-tidal CO2 must be monitored (target 32–34 mmHg). Anesthetic precautions include antacid prophylaxis and gastric decompression. Fetal heart monitoring pre/post-operatively is advised, while continuous intraoperative monitoring should be individualized.
Cancer during pregnancy
Helmy Motawe1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: helmymotawe@med.asu.edu.eg
The co-occurrence of cancer and pregnancy is fortunately a rare event. It is a challenging situation for all involved parties, as the risks and benefits of oncological treatments should be balanced for both the mother and the offspring. Cancer diagnosis and treatment in pregnant women is a challenging situation. A multidisciplinary network of specialists is required to guide both the expecting mother and the unborn child through the diagnostic workup and the cytotoxic therapy, by balancing the respective risks and benefits. Tumor entity, stage, biology and gestational week at diagnosis determine the appropriate approach
The new era of laparoscopic management of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) after the mesh restrictions
Tamer Farouk Borg1,*
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: tamerborg@med.asu.edu.eg
POP and SUI affect almost one in every three women during their lifetime. They affect both the medical aspect and social aspect of females and is detrimental to their quality of life. The use of Mesh and tapes was a cornerstone in urogynecology practice for decades. After the recent FDA warnings and restrictions on the hazards of mesh insertions in prolapse surgeries, there is a growing need for a new minimally invasive interventions utilizing native tissue in the corrections of pelvic floor defects.
Keywords: Pelvic prolapse, Stress urinary incontinence, Laparoscopic surgeries, Mesh
Recent update on endometrial cancer management
Ahmed Sekotory M Ahmed, MD, FRCOG, FACOG1,*
1Consultant Obstetrician & Gynecologist, Hon. Prof Gyn-Oncology; NCI; Cairo
*Correspondence: ahmedsekotory@hotmail.com
Endometrial cancer remains the most frequent gynecological cancer worldwide. Traditionally, it has dichotomously been classified into Type-1 and Type-2 cancers where type-1 being usually of early stage and carries a favorable prognosis. Further knowledge led to the identification of five clinicopathological risk groups as endorsed by ESGO, ASTRO, ESP in 2021; these were based on disease stage, grade, depth of myometrial invasion and lymphovascular-space invasion. Adjuvant treatment was tailored according to the combination of these factors. This has resulted in either improved disease-free survival or less morbid treatment modalities in certain groups. The Cancer Genomic Atlas (TCGA) research network has, in 2013, investigated the genomics of endometrial cancer and identified four distinct molecular subgroups. These groups were the POLE ultra-mutated, microsatellite instability hyper-mutated, copy number low and copy number high. It was importantly shown that these groups only overlap in less than 5% of cases. Moreover, disease prognosis was largely affected by these profiles independent of the traditional clinicopathological risk factors. In an important step to make this molecular classification widely available to clinical practice; surrogate immunohistochemistry markers were used to identify certain molecular subgroups. Mismatch Repair (MMR) Gene deficiency used to identify the Microsatellite unstable hypermutated tumors; testing for TP53 replaced the copy number low (TP53 wild type) and copy number high (TP53 mutant). TP53 mutant tumors (26%) carried the worst prognosis, whereas POLE Ultramutated ones (7%) were generally of good prognosis. The MMR deficient (28%) and TP53 (39%) wild type tumors, were of intermediate prognosis. Intensifying treatment for early stage TP53 mutant tumors was therefore proposed. On the contrary, a more expectant approach was proposed for early-stage POLE Ultramutated tumors. Immunotherapy was also assessed in MMR deficient & POLE mutated tumors with promising results. Knowledge is still evolving and perhaps these molecular subgroups would highlight different diseases altogether. Clinical research into prognostic significance within each group would be the next step in translating this into day-to-day clinical practice.
Study Protocols
Assessment of cesarean scar healing following conservative surgery for placenta accreta spectrum: A prospective cohort study protocol
Yasmine Ashour Mahmoud1,*, Mohamed Samir Sweed1, Marwa Abd Elmawla Elgendy1, Radwa Rasheedy Ali1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: Ahmed151haitham@gmail.com
Background: The rising incidence of cesarean deliveries, coupled with advancements in imaging techniques, has led to increased recognition of cesarean scar defects. Cesarean scar healing may be compromised following conservative management of placenta accreta spectrum that may have implications for future pregnancies and gynecological health.
Objective: This study aims to evaluate the healing of cesarean scars following conservative surgical management of placenta accreta spectrum, using saline sonohysterography.
Methods: This prospective cohort study will be conducted at Ain Shams University Maternity Hospital. Women with a history of conservative surgery for placenta accreta spectrum will be recruited for evaluation at least six months post-surgery. Conservative surgery involves en bloc resection of the affected myometrium along with the placenta, followed by uterine reconstruction. Participants will undergo saline sonohysterography to assess the presence of cesarean scar defects (CSD) and evaluate various niche parameters. A single experienced operator will perform all assessments to ensure consistency. Measurements will include anterior myometrial thickness adjacent to the scar, residual myometrial thickness, and niche dimensions (depth and width). Additionally, the healing ratio will be calculated to assess the extent of myometrial restoration. The healing ratio is the thickness of residual myometrium covering the defect divided by the sum of the thickness of residual myometrium covering the defect and the height of wedge-shaped defect.
Discussion: This study can provide valuable insights into the healing process of cesarean scars following conservative management of placenta accreta spectrum, contributing to improved clinical decision-making and future management strategies for affected patients. This study was approved by ethics committee FMASU MS 745/2024
Keywords: Accreta, Placenta, Niche, Saline sonohysterography
Laparoscopic versus transvaginal closure of the vaginal vault after total laparoscopic hysterectomy: A single blinded randomized comparative study
Rowan Ashraf Sakr1,*, Amgad Alsaid Abou-Gamrah1, Radwa Rasheedy Ali1, Yasser Mostafa El-Refaey1
1Obstetrics & Gynecology Dept, Ain Shams University
*Correspondence: 150232@med.asu.edu.eg
Background: The method of vaginal vault closure—laparoscopic (LPS) or transvaginal (TV)—is a critical step in total laparoscopic hysterectomy (TLH) that may impact patient outcomes, complications, and sexual function.
Objectives: This study aims to compare LPS and TV approaches for vaginal vault closure, focusing on the risk of vaginal vault hematoma (primary outcome) and other complications, including vaginal cuff bleeding, infection, and sexual dysfunction (secondary outcomes).
Methods: This single-blinded randomized controlled trial will enroll 58 patients, randomly allocated in a 1:1 ratio to LPS or TV vault closure. Surgeons with at least five years of experience will perform the procedures. Postoperative assessments will include per vaginal and speculum examinations, ultrasound for hematoma detection, and evaluation of bleeding, granulation, and infection. Sexual function will be assessed using the Female Sexual Function Index (FSFI) questionnaire preoperatively and four months postoperatively. Statistical analysis will employ Student’s t-test for continuous variables, the Mann-Whitney U test for skewed data, and the chi-square test for categorical variables. Ethical approval (IRB No. FMASU MS 34/2025) and ClinicalTrials.gov registration (NCT06867614) have been obtained.
Discussion: This study may resolve the ongoing debate regarding the benefits and complications of LPS versus TV vault closure. The LPS approach may offer better visualization, more secure suturing, and reduced exposure of sutures to vaginal flora, potentially lowering infection risks. However, it may be technically challenging and time-consuming. While LPS closure could preserve vaginal length, its impact on sexual function remains controversial. The findings will provide valuable insights into the advantages and limitations of each technique, aiding surgeons in optimizing patient outcomes.
Keywords: Total Laparoscopic Hysterectomy, Vaginal vault closure, Vaginal vault hematoma, Sexual dysfunction
Author Index
Abbas, Ahmed Mohamed, 15
Abdalhady, Hamdy, 20
Abdallah, Mahmoud Youssef, 9
Abdelfattah, Sherif, 2, 13
Abdelhady, Nourhan Ashraf El-Sherbiny, 15
Abdelhady, Rasha Medhat, 9
Abdelhameed, Esraa, 11
Abdelhameed, Omar M, 11
Abdelkarim, Amr Fathy Ahmed, 14
Abdelnasser, Ahmed Gamal, 5
Abdelrahman, Eman, 17
Abdelrahman, Rehab Mohamed, 6, 7
Abdelrazek, Maya Mahmoud, 9, 10, 14
Abdelrazeq, Mohammed Ahmed, 18
Abosena, Mohamed Ahmed Saad, 9
Abou-Gamrah, Amgad Alsaid, 22
Ahmed, Ahd Yousif Ebrahim, 8
Ahmed, Ahmed Mohamed Bahaaeldin, 14
Ahmed, Ahmed Sekotory M, 21
Ahmed, Amr Saad Mahmoud, 12
Ahmed, Mahmoud Galal Sayed, 3
Ahmed, Rania Hassan Mostafa, 8, 11, 15
AL-Khalaf, Hani, 20
Ali, Doha Rasheedy, 17
Ali, Radwa Rasheedy, 7, 20, 21, 22
Amer, Mohamed Ibrahim Mohamed, 4
Ashoush, Sherif, 15
Atteya, Mourad Moustafa, 5
Ayman, Yomna, 11
Ayyad, Amr, 15
Beder, Zeinab Mohamed Taher, 16
Borg, Tamer Farouk, 21
Bukhari, Mostafa Mahmoud Serry Mohamed El, 2
Eid, Kholoud Mahmoud Mostafa, 17
El-Aziz, Mohamed Hamed Abd, 13
El-Din, Mohamed Hassan Nasr, 13
El-Hamed, Ahmed Mohamed Abd, 14
El-Hameedv, Nada Hisham Mahmoud Abd, 8
EL-Motti, Rehab Hashem Abd, 7
El-Razek, Maya Mahmoud Abd, 16
El-Refaey, Yasser Mostafa, 22
El-Sokkary, Mohammed Salah El-Sayed, 3
Elazrag, Amna M., 17
Elbadrawy, Amr Mohamed Fawzy, 6
Elgendy, Marwa Abd Elmawla, 21
Elghareeb, Nermeen Ahmed Mostafa, 6
Elkady, Mohammed, 5
Elsayed, Tarek Hesham, 14
Elshehawy, Yasser Mohmed, 16
Eltaieb, Ebtihal, 8, 15
Eltaieb, Ebtihal Mohamed Mahmoud, 4
Farid, Laila Aly, 4
Faris, Mohammed Ahmed Adel, 3
Fayed, Salah Taha Ahmed, 6
Gamil, Nouran Haythem, 11
Habib, Sherif Mohamed, 16
Hamed, Mohammed, 5
Hashem, Rehab, 11
Hassan, Ahmed Mohamed Abd El-Hamid, 2
Hassan, Ahmed Mohsen, 18
Hassan, Sherine Mohamed, 17
Hassanin, Alaa Sayed, 9, 10, 16
Hatem, Menna, 11
Hegab, Khadiga M H, 12
Helal, Moustafa Mohammed, 7
Hemdan, Mohamed, 18, 19
Hussein, Ahmed Mahmoud, 3
Ibrahim, Hebaallah Ali Ashour, 4
Ibrahim, Mohamed Shaker Abd El Aziz, 12
Ibrahim, Mostafa Ibrahim, 3, 14
Ibrahim, Safaa Hamdy, 10
Ismail, Khaled, 12, 13
Kamel, Osama Ismail, 7
Karim-Eldein, Alaa Mohamed Atef, 6
Khairy, Ahmed, 8
Khalil, Walid El-Basuony Mohamed Ahmed, 4
Mahmoud, Hend Mahmoud Abd Elgawad, 14
Mahmoud, Mohamed Taha Ismail, 2
Mahmoud, Nermin Ahmed, 16
Mahmoud, Sarah Tarek, 14
Mahmoud, Yasmine Ashour, 21
Manias, Theofanis, 19
Mansour, Ahmed Mohamed Essam El-din, 2, 5
Maraghy, Ahmed El, 11
Marei, Hamida Mostafa Ibrahim Salem, 3
Mohamed, Ahmed Mohsen Hassan, 10
Mohamed, Hatem Elsayed, 16
Mohamed, Mohamed Reda Elrefaie, 16
Mohamed, Radwa Mansour, 14
Mohamed, Sherihan Aboelyazed, 4
Mohammed, Mohammed Essam Eldin, 5
Mohammed, Mona Hegazy, 17
Mohamud, Fathi Abdi, 4
Mokhtar, Mohamed Mostafa, 4
Motawe, Helmy, 20
Nabhan, Ashraf, 2
Nabil, Fady Mohammed, 6
Ramy, Ahmed Ramy Mohamed, 6, 7, 8
Refaie, Mohammed, 19
Rezk, Salma Fathy, 11
Riad, Amr Ahmed Mahmoud, 8
Saeed, Peter Thabet, 9
Safety, Mohammed Saeed El Din El, 16
Saif, Hagar Ibrahim Saad Abou, 6
Sakr, Rowan Ashraf, 22
Salama, Mohamed H, 12
Saleh, Abd El-Rahman Mohamed, 8
Saleh, Abdul Rahman Mohammed, 3
Salem, Mohamed Sayed Aly, 5
Samir, Asmaa, 11
Samir, Rita Girguis, 7
Sanad, Ahmed, 19
Sara, 11
Selim, Ahmed, 11, 19
Serag, Ihab Fouad, 15
Seyam, Omnia, 19
Sherif, Nooran, 19
Shokry, Dina, 2
Shuheibar, Hani, 19
Soliman, Eman Mohamed Hassan, 5
Sweed, Mohamed Samir, 7, 21
Talaat, Yassmin Nashaat, 13
Tamara, Tarek, 15
Tamer, Aya, 19
Tareq, Amane, 19
Waheed, Mohammed, 19
Yousof, Mahmoud, 10
Zeinhom, Ahmed Mohamed, 4
Zied, Ahmed Hamed Ramadan Abu, 13
