Introduction: Adhesions developed after cesarean sections (CS) vary according to the number of repeat section. Delivery times were reported to be increase with increased number of CS. Material and Methods: This is a prospective cohort study done in Assiut Women Health Hospital from August 2012 to August 2015 to evaluate the implications of doing adhesiolysis at CS either before delivery of the fetus or after that on maternal morbidity during current CS and recurrence rate in next sections. Adhesiolysis during CS avoid the use of anti-adhesion substances which is costly and not available in our low income society. Results: Fifty patients were included in the study. The dominant type of adhesion was omental, bladder and uterine adhesions forming bands with anterior abdominal wall. The uterovesical adhesion was present in all cases. No maternal morbidity occurred during adhesiolysis. Follow up of those patients were cone for 3 years. The percentage of adhesions in the next CS after this adhesiolysis was only 2 cases (4%) and both cases were omental adhesions. Conclusions: The use of adhesiolysis in repeat CS adhesions with ascending curve of experience is essential in our low socioeconomic countries and associated with no maternal or neonatal complications.

Introduction: Adhesions developed after cesarean sections (CS) vary according to the number of repeat section. Delivery times were reported to be increase with increased number of CS. Material and Methods: This is a prospective cohort study done in Assiut Women Health Hospital from August 2012 to August 2015 to evaluate the implications of doing adhesiolysis at CS either before delivery of the fetus or after that on maternal morbidity during current CS and recurrence rate in next sections. Adhesiolysis during CS avoid the use of anti-adhesion substances which is costly and not available in our low income society. Results: Fifty patients were included in the study. The dominant type of adhesion was omental, bladder and uterine adhesions forming bands with anterior abdominal wall. The uterovesical adhesion was present in all cases. No maternal morbidity occurred during adhesiolysis. Follow up of those patients were cone for 3 years. The percentage of adhesions in the next CS after this adhesiolysis was only 2 cases (4%) and both cases were omental adhesions. Conclusions: The use of adhesiolysis in repeat CS adhesions with ascending curve of experience is essential in our low socioeconomic countries and associated with no maternal or neonatal complications.

Objective: The purpose of this study was to determine the efficacy and safety of intrauterine extra-amniotic misoprostol solution for termination of second trimester missed abortion. Methods: A clinical pilot descriptive study that was done in Women Health Hospital, Assiut University, Egypt between March 2015 and June 2015. Fifty patients having missed abortion of gestational age between 13 to 24 weeks were included in the study. Insertion of an intrauterine Foley's catheter followed by infusion of sterile misoprostol solution through sterile infusion set at a constant drip rate. The primary outcome was successful expulsion of the fetus in 12 hours after starting misoprostol infusion. Results: The mean age of the study group was 27.25±4.08, the mean BMI was 26.35±3.6, the mean gestational age was 22.85±3.4 and the mean parity was 2.5±1.5. The mean induction expulsion interval was 5.27±2.66 hours. Six cases (12%) needed an analgesic. The need for surgical evacuation of retained contents was needed in 3 cases (6 %). Side effects in the form of rigors, fever and diarrhea were recorded in 4 cases (8%). No serious maternal events were recorded. Conclusion: The present results showed that intrauterine extra-amniotic misoprostol solution instillation appear to be an effective and safe method for termination of second trimester missed abortions.

Background: Termination of pregnancy in the second trimester using prostaglandins has been shown to be safe and effective. Misoprostol has multiple routes of administration; oral, vaginal, buccal, rectal and sublingual Objective: The study aims to compare the efficacy and safety of intrauterine extra-amniotic and vaginal misoprostol in a dose of 200 microgram every 4 hours for the termination of pregnancy in cases of second trimester miscarriage. Materials and Methods: A Prospective randomized open labeled clinical trial included patients with missed miscarriage in gestational age between 13 and 24 weeks. Patients were randomized to receive subsequent doses of 200 µg misoprostol every 4 hours either intra uterine extra-amniotic by Foley catheter or vaginally administered. Randomization was completed using a computer-generated random table. The primary outcome of this study was the mean duration from the initial misoprostol dose until complete fetal expulsion (induction-expulsion interval). Results: The study included 180 women. The mean gestational age was 17.74 weeks. The mean time to complete miscarriage in the intra uterine extra-amniotic group was 5.27 hrs, which was significantly lower (p=0.001) than the vaginal group (9.92 hrs). Side effects were more common in the vaginal group. Conclusions: Intra uterine extra-amniotic misoprostol with a dose of 200 ug every 4 hours appears to be more effective and safer than vaginal misoprostol in induction of second trimester miscarriage. Registration number: (Clinical Trials. Gov; NCT02669420)

Background: Termination of pregnancy in the second trimester using prostaglandins has been shown to be safe and effective. Misoprostol has multiple routes of administration; oral, vaginal, buccal, rectal and sublingual Objective: The study aims to compare the efficacy and safety of intrauterine extra-amniotic and vaginal misoprostol in a dose of 200 microgram every 4 hours for the termination of pregnancy in cases of second trimester miscarriage. Materials and Methods: A Prospective randomized open labeled clinical trial included patients with missed miscarriage in gestational age between 13 and 24 weeks. Patients were randomized to receive subsequent doses of 200 µg misoprostol every 4 hours either intra uterine extra-amniotic by Foley catheter or vaginally administered. Randomization was completed using a computer-generated random table. The primary outcome of this study was the mean duration from the initial misoprostol dose until complete fetal expulsion (induction-expulsion interval). Results: The study included 180 women. The mean gestational age was 17.74 weeks. The mean time to complete miscarriage in the intra uterine extra-amniotic group was 5.27 hrs, which was significantly lower (p=0.001) than the vaginal group (9.92 hrs). Side effects were more common in the vaginal group. Conclusions: Intra uterine extra-amniotic misoprostol with a dose of 200 ug every 4 hours appears to be more effective and safer than vaginal misoprostol in induction of second trimester miscarriage. Registration number: (Clinical Trials. Gov; NCT02669420)

Background: Termination of pregnancy in the second trimester using prostaglandins has been shown to be safe and effective. Misoprostol has multiple routes of administration; oral, vaginal, buccal, rectal and sublingual Objective: The study aims to compare the efficacy and safety of intrauterine extra-amniotic and vaginal misoprostol in a dose of 200 microgram every 4 hours for the termination of pregnancy in cases of second trimester miscarriage. Materials and Methods: A Prospective randomized open labeled clinical trial included patients with missed miscarriage in gestational age between 13 and 24 weeks. Patients were randomized to receive subsequent doses of 200 µg misoprostol every 4 hours either intra uterine extra-amniotic by Foley catheter or vaginally administered. Randomization was completed using a computer-generated random table. The primary outcome of this study was the mean duration from the initial misoprostol dose until complete fetal expulsion (induction-expulsion interval). Results: The study included 180 women. The mean gestational age was 17.74 weeks. The mean time to complete miscarriage in the intra uterine extra-amniotic group was 5.27 hrs, which was significantly lower (p=0.001) than the vaginal group (9.92 hrs). Side effects were more common in the vaginal group. Conclusions: Intra uterine extra-amniotic misoprostol with a dose of 200 ug every 4 hours appears to be more effective and safer than vaginal misoprostol in induction of second trimester miscarriage. Registration number: (Clinical Trials. Gov; NCT02669420)

Aim: High-grade glioblastoma multiforme (GBM) has a poor median overall survival (OS). The standard treatment after surgery is temozolomide and radiotherapy (RTH). Patients with unmethylated methylguanine-methyltransferase promoter (MGMT) have no or little benefit from temozolomide and are eligible for alternative therapies. Gemcitabine is a good radiosensitizer. We aimed to evaluate the combination of gemcitabine with RTH in newly diagnosed GBM. Methods: The study was a prospective phase II study. Eligible patients were required to have histologically proven anaplastic astrocytoma or GBM. Patients underwent biopsies or subtotal resection. The treatment consisted of fixed-dose rate gemcitabine 175 mg/m2 weekly followed after 24 h by standard cranial RTH for 6 weeks. Tumor response was evaluated by Macdonald criteria. In case of progression, patients received temozolomide (200 mg/m2/5 days every 28 days). Results: Thirty patients with a median age of 52 years (30-69), 73%/27% male/female, the Eastern Cooperative Oncology Group performance status 1 (range 0-2) were enrolled. Five patients had a partial-response (17%) and 13 stable-disease (43%). Median time to progression was 7.88 months (95% CI 6.1-9.69) and OS was 11.77 months (95% CI 9.97-13.56). The treatment was well tolerated with grade-3 neutropenia in 3, grade-3 anemia in 2 and impaired liver enzymes in 1 patient. Conclusion: Gemcitabine followed by radiotherapy is active and promising regimen in newly diagnosed GBM. Gemcitabine uptake is easy, with a long local retention of active metabolites, precluding systemic side effects of radiosensitization. In a phase III study this treatment should be evaluated in patients with unmethylated MGMT promoter who will not benefit from temozolomide.

Aim: High-grade glioblastoma multiforme (GBM) has a poor median overall survival (OS). The standard treatment after surgery is temozolomide and radiotherapy (RTH). Patients with unmethylated methylguanine-methyltransferase promoter (MGMT) have no or little benefit from temozolomide and are eligible for alternative therapies. Gemcitabine is a good radiosensitizer. We aimed to evaluate the combination of gemcitabine with RTH in newly diagnosed GBM. Methods: The study was a prospective phase II study. Eligible patients were required to have histologically proven anaplastic astrocytoma or GBM. Patients underwent biopsies or subtotal resection. The treatment consisted of fixed-dose rate gemcitabine 175 mg/m2 weekly followed after 24 h by standard cranial RTH for 6 weeks. Tumor response was evaluated by Macdonald criteria. In case of progression, patients received temozolomide (200 mg/m2/5 days every 28 days). Results: Thirty patients with a median age of 52 years (30-69), 73%/27% male/female, the Eastern Cooperative Oncology Group performance status 1 (range 0-2) were enrolled. Five patients had a partial-response (17%) and 13 stable-disease (43%). Median time to progression was 7.88 months (95% CI 6.1-9.69) and OS was 11.77 months (95% CI 9.97-13.56). The treatment was well tolerated with grade-3 neutropenia in 3, grade-3 anemia in 2 and impaired liver enzymes in 1 patient. Conclusion: Gemcitabine followed by radiotherapy is active and promising regimen in newly diagnosed GBM. Gemcitabine uptake is easy, with a long local retention of active metabolites, precluding systemic side effects of radiosensitization. In a phase III study this treatment should be evaluated in patients with unmethylated MGMT promoter who will not benefit from temozolomide.

Aim: High-grade glioblastoma multiforme (GBM) has a poor median overall survival (OS). The standard treatment after surgery is temozolomide and radiotherapy (RTH). Patients with unmethylated methylguanine-methyltransferase promoter (MGMT) have no or little benefit from temozolomide and are eligible for alternative therapies. Gemcitabine is a good radiosensitizer. We aimed to evaluate the combination of gemcitabine with RTH in newly diagnosed GBM. Methods: The study was a prospective phase II study. Eligible patients were required to have histologically proven anaplastic astrocytoma or GBM. Patients underwent biopsies or subtotal resection. The treatment consisted of fixed-dose rate gemcitabine 175 mg/m2 weekly followed after 24 h by standard cranial RTH for 6 weeks. Tumor response was evaluated by Macdonald criteria. In case of progression, patients received temozolomide (200 mg/m2/5 days every 28 days). Results: Thirty patients with a median age of 52 years (30-69), 73%/27% male/female, the Eastern Cooperative Oncology Group performance status 1 (range 0-2) were enrolled. Five patients had a partial-response (17%) and 13 stable-disease (43%). Median time to progression was 7.88 months (95% CI 6.1-9.69) and OS was 11.77 months (95% CI 9.97-13.56). The treatment was well tolerated with grade-3 neutropenia in 3, grade-3 anemia in 2 and impaired liver enzymes in 1 patient. Conclusion: Gemcitabine followed by radiotherapy is active and promising regimen in newly diagnosed GBM. Gemcitabine uptake is easy, with a long local retention of active metabolites, precluding systemic side effects of radiosensitization. In a phase III study this treatment should be evaluated in patients with unmethylated MGMT promoter who will not benefit from temozolomide.

Aim: High-grade glioblastoma multiforme (GBM) has a poor median overall survival (OS). The standard treatment after surgery is temozolomide and radiotherapy (RTH). Patients with unmethylated methylguanine-methyltransferase promoter (MGMT) have no or little benefit from temozolomide and are eligible for alternative therapies. Gemcitabine is a good radiosensitizer. We aimed to evaluate the combination of gemcitabine with RTH in newly diagnosed GBM. Methods: The study was a prospective phase II study. Eligible patients were required to have histologically proven anaplastic astrocytoma or GBM. Patients underwent biopsies or subtotal resection. The treatment consisted of fixed-dose rate gemcitabine 175 mg/m2 weekly followed after 24 h by standard cranial RTH for 6 weeks. Tumor response was evaluated by Macdonald criteria. In case of progression, patients received temozolomide (200 mg/m2/5 days every 28 days). Results: Thirty patients with a median age of 52 years (30-69), 73%/27% male/female, the Eastern Cooperative Oncology Group performance status 1 (range 0-2) were enrolled. Five patients had a partial-response (17%) and 13 stable-disease (43%). Median time to progression was 7.88 months (95% CI 6.1-9.69) and OS was 11.77 months (95% CI 9.97-13.56). The treatment was well tolerated with grade-3 neutropenia in 3, grade-3 anemia in 2 and impaired liver enzymes in 1 patient. Conclusion: Gemcitabine followed by radiotherapy is active and promising regimen in newly diagnosed GBM. Gemcitabine uptake is easy, with a long local retention of active metabolites, precluding systemic side effects of radiosensitization. In a phase III study this treatment should be evaluated in patients with unmethylated MGMT promoter who will not benefit from temozolomide.