This is the case of a 38 year-old Lebanese woman G2P1, history of previous cesarean section, presenting at 30+5 weeks of gestation with acute left-sided flank pain and a two-day history of chills and dysuria. In light of the clinical presentation, the patient was initially diagnosed with pyelonephritis and managed accordingly; however, her clinical status deteriorated with worsening hypotension and lethargy despite resuscitative measures and a normal abdominal ultrasound. Failure to revive the patient eventually led to a cardiac arrest for which a peri-mortem cesarean section was performed at bedside. Upon abdominal entry, an actively-bleeding ruptured splenic artery aneurysm (SAA) was identified, for which massive transfusion protocol was activated, and the patient was transferred to the operating room. The patient had a complicated postoperative course, the fetus was stillborn, and she was discharged home after 6 months of hospital stay. In view of the high mortality and morbidity associated with ruptured SAA in pregnancy, early recognition and prompt intervention are crucial for maternal and fetal benefit.

BackgroundBreastfeeding provides ideal infant nutrition, conferring several health benefits to children and their mothers. Women with inverted nipples, however, face difficulties that force them to prematurely terminate breastfeeding. Whereas available conservative measures for the correction of inverted nipples are of limited success, the use of an inverted syringe may be effective in achieving high rates of infant latching and exclusive breastfeeding. This technique, however, has not been investigated in a clinical trial.Methods/designThis open-label randomized controlled trial aims to investigate whether, in women with inverted nipples, the use of an inverted syringe increases the rate of exclusive breastfeeding at one month compared to standard care. One-hundred healthy women with grade 1 or 2 inverted nipples will be recruited as of 37 weeks of gestation. They will be randomly allocated to standard care (control group) or to an intervention group. The intervention consists of using an inverted syringe to evert the nipple before every breastfeed, starting with the first feed after delivery. The primary outcome measure is the rate of exclusive breastfeeding at 1 month. Secondary outcome measures include exclusive breastfeeding rates at 3 and 6 months, nipple eversion rate, successful latching rate, rates of any breastfeeding at 1, 3, and 6 months, breastfeeding-associated complications, maternal satisfaction with breastfeeding, maternal quality of life, and adverse events. Descriptive and regression analysis will be conducted under the intention to treat basis.DiscussionThe use of the inverted syringe to evert inverted nipples is a simple, inexpensive, and safe technique that can be performed by mothers with inverted nipples. Findings of this trial, if positive, will provide much needed evidence for a safe, affordable, readily available, and simple intervention to treat inverted nipples, and improve breastfeeding practice among affected women.Trial registrationClinicalTrials.gov, NCT03529630. Registered May 8, 2018.

Background Women with inverted nipples may struggle with breastfeeding and may stop exclusive breastfeeding before six months. The use of an inverted syringe to evert the nipples was successful in achieving high rates of infant latching and exclusive breastfeeding in case series but has not been tested in clinical trials. This open label, parallel group, randomized clinical trial investigated whether the use of the inverted syringe technique in women with inverted nipples would increase exclusive breastfeeding rate at one month, as compared to standard care. Methods/Design Between June 2018 and January 2020, healthy pregnant women (N=54) with grades 1 or 2 inverted nipples were randomly allocated to standard care or to an experimental group that used the inverted syringe technique to evert the inverted nipple prior to every breastfeeding. The primary outcome measure was the rate of exclusive breastfeeding at one month. Secondary outcomes included the rates of exclusive breastfeeding at three and six months, any breastfeeding at one, three, and six months, nipple eversion, successful infant latching, breastfeeding-associated complications, maternal satisfaction with breastfeeding, maternal quality of life, and adverse events. Descriptive and bivariate analyses were conducted according to the intention to treat principle. Results Participants in the experimental group were less likely to be exclusively breastfeeding at one (RR = 0.65, 95% CI: 0.44, 0.95; n = 47), and at three months (RR = 0.66, 95% CI: 0.47, 0.91; n = 45), or to practice any breastfeeding at six months (RR = 0.54, 95% CI: 0.34, 0.87; n = 44). Only 14.3% of women in the experimental group complied with the use of the inverted syringe during the first month. Breast pump and breastfeeding-associated complications were more commonly reported in the control group (p < 0.05 for both). Both groups had similar rates of nipple eversion, successful infant latching, and similar satisfaction with breastfeeding and quality of life issues. Conclusion The inverted syringe technique was not associated with improvement in breastfeeding outcomes of women with inverted nipples. Larger clinical trials are needed to confirm our findings. Trial registration ClinicalTrials.gov NCT03529630; Registered May 8, 2018.

INTRODUCTION: HPV is a major cause of anogenital, oropharyngeal and penile cancers. Currently, there are three safe and effective HPV vaccines, however introducing them in the Middle East is slow for various social, cultural and religious reasons. METHODS: At the women health center of the AUBMC, HPV vaccination was offered to women and their daughters since 2007. We will present a retrospective review of a prospectively collected database on 563 Lebanese females who received these vaccines. RESULTS: From 2007 to 2017, a total of 563 females were HPV vaccinated. (379 (67%) had Gardasil and 183 (33%) had Cervarix; P=0.00). Their average age was 25.64±5.86(12.16-51.12). hundred 449 (87%) completed 3 doses and 67 (13%) took only 2 doses. The 3 doses completion was highest between 2007-2013 [329/449 (72%)] while the 2 doses completion was more common from 2013-2017 [47/57 (70%)]. 2/175 (1.13%) of those who received Gardasil had subsequent abnormal Pap smears (mostly LSIL) after an average of 33 months, while 5/91 (5.5%) of those who received Cervarix had abnormal Pap smears [ASCUS: 3/91 (3.3%); HSIL: 2/91 (2.2%,) after an average of 5 months and 1 month respectively]. The average abnormal cytology rates at AUBMC is 1.9-2.2% during that period of time. CONCLUSION: We report successful introduction and continuation of HPV vaccine into our private patient Middle-Eastern population. Longer follow-up is needed to assess the proper impact on genital warts, pre-cancerous genital lesions and genital and other cancers.

Xanthogranulomatous pyelonephritis (XGP) is seldom seen nowadays due to the aggressive treatment of upper urinary tract infections as well as recent advances in the management of urolithiasis. It has been rarely reported in the peri-partum period. We present a case of XGP without any evidence of renal calculi, manifesting in a 26-year-old previously healthy woman immediately post-partum.