Deliveries in Lebanon, the Country with the Highest Refugee Density in the World: A Descriptive Review.

PURPOSE: The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes. DESCRIPTION: Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons. ASSESSMENT: Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001). CONCLUSION: Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries.

Workplace wellness across the lifespan: A pilot program for health promotion in a low- and middle-income country.

Considering that a sizable segment of the population spends significant amount of time at work, workplaces have been identified as practical platforms for health educational programs. Although employee wellness programs in high-income countries have shown measurable benefits in productivity and physical and mental health, evidence-based programs in low- and middle-income countries, such as Lebanon, are unavailable. The aim is to develop and implement a pilot workplace wellness program focusing on health-related areas to improve health knowledge and behavior among working men and women of reproductive age. In collaboration with March of Dimes, the National Collaborative Perinatal Neonatal Network developed a culturally sensitive health education program focusing on lifestyle, infection, nutrition and family planning. Sessions were delivered by a multidisciplinary team of specialists at a local bank in Lebanon. To assess the impact of the program, participants completed Knowledge and Behavior Assessment Questionnaire (KBAQ) before and after implementation. KBAQ was conducted 6 months after implementation to measure retention and continuing impact. Forty-seven participants completed the program, of whom 44.7% are male, 98% have university degree and 56.5% are married. Total knowledge score improved significantly from 64.2 to 74.3 and remained significant at 6 months post-implementation with a score of 71.7 (p < 0.001). At 6-month follow-up, emotional score improved (p = 0.028), while smoking decreased (p = 0.008). Also, employees' health knowledge and behavior showed sustained and significant improvement. We plan to implement our program at other sites and among employees from different backgrounds to understand the impact of the wellness program on employees' knowledge and behaviors at a larger scale.

Effect of Sustained Uterine Compression versus Uterine Massage on Blood Loss after Vaginal Delivery: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to compare the effectiveness of sustained uterine compression versus uterine massage in reducing blood loos after a vaginal delivery. STUDY DESIGN: This was a prospective randomized trial conducted at the American University of Beirut Medical Center (AUBMC) between October 2015 and October 2017. Inclusion criteria were women with a singleton pregnancy at ≥36 weeks of gestation, with less than three previous deliveries, who were candidates for vaginal delivery. Participants were randomized into two groups, a sustained uterine compression group (group 1) and a uterine massage group (group 2). Incidence of postpartum hemorrhage (blood loss of ≥500 mL) was the primary outcome. We assumed that the incidence of postpartum hemorrhage at our institution is similar to previously published studies. A total of 545 women were required in each arm to detect a reduction from 9.6 to 4.8% in the primary outcome (50% reduction) with a one-sided α of 0.05 and a power of 80%. Factoring in a 10% dropout rate. Secondary outcomes were admission to intensive care unit (ICU), postpartum complications, drop in hemoglobin, duration of hospital stay, maternal pain, use of uterotonics, or of surgical procedure for postpartum hemorrhage. RESULTS: A total of 550 pregnant women were recruited, 273 in group 1 and 277 in group 2. There was no statistically significant difference in baseline characteristics between the two groups. Type of anesthesia, rate of episiotomy, lacerations, and mean birth weight were also equal between the groups. Incidence of the primary outcome was not different between the two groups (group 1: 15.5%, group 2: 15.4%; p = 0.98). There was no statistically significant difference in any of the secondary outcomes between the two groups, including drop in hemoglobin (p = 0.79). CONCLUSION: There was no difference in blood loss between sustained uterine compression and uterine massage after vaginal delivery. KEY POINTS: · Transabdominal uterine compression and uterine massage are appropriate to prevent postpartum hemorrhage.. · No significant difference in blood loss or maternal discomfort observed between the two techniques.. · Both methods are equally effective and either one can be used based on provider preference..

Raine syndrome: Report of a novel mutation and review of the different antenatal imaging modalities used to diagnose this disease.

INTRODUCTION: Raine syndrome is an autosomal recessive disorder characterized mainly by the presence of exophthalmos, choanal atresia or stenosis, osteosclerosis, and cerebral calcifications. There are around 50 cases described in the literature with a prevalence of less than 1/1,000,000. It is secondary to pathogenic variants in the FAM20 C gene, located on chromosome 7p22.3. CASE REPORT: We report a consanguineous family with three affected pregnancies. In the first two, exophthalmos and bone abnormalities were noted, ending in one intra-uterine demise and one neonatal death, without identifying any genetic disorder. During the couple's most recent pregnancy, fetal anomaly sonogram and fetal CT scan revealed microcephaly, intracranial calcifications, exophthalmos, hypertelorism, depressed nasal bridge, midface hypoplasia and thoracic hypoplasia. Fetal blood sampling for whole exome sequencing revealed a novel pathogenic homozygous variant c.1363+1G > A in the FAM20 C gene associated with Raine syndrome. Delivery occurred at 26 weeks of gestation after rupture of membranes followed by neonatal death due to respiratory failure. REVIEW: A review of the distinctive features of Raine syndrome, the contribution of different prenatal imaging modalities (Ultrasound, Computed Tomography and Magnetic Resonance Imaging) in making the diagnosis and the molecular characterization of this disorder is provided.

BACs-on-Beads™ assay, a rapid aneuploidy test, improves the diagnostic yield of conventional karyotyping.

BACs-on-Beads (BoBs™) assay is a rapid aneuploidy test (RAT) that detects numerical chromosomal aneuploidies and multiple microdeletion/microduplication syndromes. This study was conducted to appraise the usefulness of the BoB™ assay as a complementary diagnostic tool to conventional karyotyping for the rapid detection of chromosomal aneuploidies. A total of 485 prenatal (amniotic fluid and chorionic villi) and blood/products of conception samples were collected between July 2013 and August 2018, and analyzed by the BoBs™ assay and cytogenetic karyotyping and further validated by fluorescence in situ hybridization (FISH). Forty-three of 484 qualifying samples (8.9%) were identified as abnormal by the BoBs™ assay. The assay was comparable to karyotyping in the detection of common structural abnormalities (trisomy 21, trisomy 18, X, and Y), with a sensitivity of 96.0% and a specificity of 100%. BoBs™ assay detected 20 microdeletion and microduplication syndromes that were missed by karyotyping. BoBs™, however, missed 10 cases of polyploidies and chromosomal rearrangements which were identified by conventional karyotyping. Our findings suggest that BoBs™ is a reliable RAT which is suitable in combination with conventional karyotyping for the detection of common aneuploidies. The assay also improves the diagnostic yield by recognizing clinically relevant submicroscopic copy number gains and losses.

Hybrid Simulation in Teaching Clinical Breast Examination to Medical Students.

Clinical breast examination (CBE) is traditionally taught to third-year medical students using a lecture and a tabletop breast model. The opportunity to clinically practice CBE depends on patient availability and willingness to be examined by students, especially in culturally sensitive environments. We propose the use of a hybrid simulation model consisting of a standardized patient (SP) wearing a silicone breast simulator jacket and hypothesize that this, compared to traditional teaching methods, would result in improved learning. Consenting third-year medical students (N = 82) at a university-affiliated tertiary care center were cluster-randomized into two groups: hybrid simulation (breast jacket + SP) and control (tabletop breast model). Students received the standard lecture by instructors blinded to the randomization, followed by randomization group-based learning and practice sessions. Two weeks later, participants were assessed in an Objective Structured Clinical Examination (OSCE), which included three stations with SPs blinded to the intervention. The SPs graded the students on CBE completeness, and students completed a self-assessment of their performance and confidence during the examination. CBE completeness scores did not differ between the two groups (p = 0.889). Hybrid simulation improved lesion identification grades (p < 0.001) without increasing false positives. Hybrid simulation relieved the fear of missing a lesion on CBE (p = 0.043) and increased satisfaction with the teaching method among students (p = 0.002). As a novel educational tool, hybrid simulation improves the sensitivity of CBE performed by medical students without affecting its specificity. Hybrid simulation may play a role in increasing the confidence of medical students during CBE.

Intravenous Oxytocin Use to Decrease Blood Loss during Scheduled Cesarean Delivery: A Randomized Double-Blinded Controlled Trial (OXYTRIAL).

Objective The objective of this study was to determine the optimal dose of intravenous oxytocin administered during cesarean delivery (CD) to decrease the amount of blood loss. Methods Out of a total of 226 women presenting for CD, 189 patients were randomized into three groups by a computer-generated random number sequence table. Low-risk women with singleton term pregnancies undergoing scheduled CD were assigned to receive 20, 30, or 40 units (U) of oxytocin diluted in 500 mL of lactated Ringer solution intraoperatively. The primary outcome was the change in hemoglobin from pre-CD to post-CD. Results Overall, 63 women were assigned to each group. The primary outcome which was the drop in hemoglobin (1.4 ± 1.1 g/dL, 1.1 ± 0.8 g/dL, 1.0 ± 1.1 g/dL; p = 0.097) and the total calculated blood loss (798.6 ± 298.3 mL, 794.4 ± 313.5 mL, 820.2 ± 316.2 mL; p = 0.893) were not significantly different among the study groups. The incidence of intraoperative hypotension, postoperative systolic, and diastolic blood pressure changes was similar across the groups. Conclusion The amount of blood loss during CD was not significantly different among the three groups, thus the lowest dose of oxytocin infusion (20 U in 500 mL of lactated Ringer solution) seems to be an appropriate regimen.

Postpartum sacral stress fracture: a case report.

BACKGROUND: Stress fractures are classified as insufficiency and fatigue fractures. Insufficiency fractures occur when normal stresses are placed on bone with decreased mineralization and elastic resistance; whereas fatigue fractures occur when abnormal forces are applied to normal bone. CASE PRESENTATION: We report a case of postpartum bilateral sacral fracture in the absence of documented osteoporosis in a 30 year old Lebanese female, thus satisfying the classification of fatigue fractures. Clinical presentation was mainly low back pain, pelvic pain, and abnormal gait. CONCLUSIONS: This case stresses the importance of including sacral fractures in the differential diagnosis of patients presenting with similar symptoms during pregnancy or the postpartum period.

Study protocol: Mother and Infant Nutritional Assessment (MINA) cohort study in Qatar and Lebanon.

BACKGROUND: The Middle East and North Africa region harbors significant proportions of stunting and wasting coupled with surging rates of non-communicable diseases (NCDs). Recent evidence identified nutrition during the first 1000 days of life as a common denominator not only for optimal growth but also for curbing the risk of NCDs later in life. The main objective of this manuscript is to describe the protocol of the first cohort in the region to investigate the association of nutrition imbalances early in life with birth outcomes, growth patterns, as well as early determinants of non-communicable diseases. More specifically the cohort aims to 1) examine the effects of maternal and early child nutrition and lifestyle characteristics on birth outcomes and growth patterns and 2) develop evidence-based nutrition and lifestyle guidelines for pregnant women and young children. METHODS/DESIGN: A multidisciplinary team of researchers was established from governmental and private academic and health sectors in Lebanon and Qatar to launch the Mother and Infant Nutritional Assessment 3-year cohort study. Pregnant women (n = 250 from Beirut, n = 250 from Doha) in their first trimester are recruited from healthcare centers in Beirut, Lebanon and Doha, Qatar. Participants are interviewed three times during pregnancy (once every trimester) and seven times at and after delivery (when the child is 4, 6, 9, 12, 18, and 24 months old). Delivery and birth data is obtained from hospital records. Data collection includes maternal socio-demographic and lifestyle characteristics, dietary intake, anthropometric measurements, and household food security data. For biochemical assessment of various indicators of nutritional status, a blood sample is obtained from women during their first trimester. Breastfeeding and complementary feeding practices, dietary intake, as well as anthropometric measurements of children are also examined. The Delphi technique will be used for the development of the nutrition and lifestyle guidelines. DISCUSSION: The Mother and Infant Nutritional Assessment study protocol provides a model for collaborations between countries of different socio-economic levels within the same region to improve research efficiency in the field of early nutrition thus potentially leading to healthier pregnancies, mothers, infants, and children.

Use of antenatal corticosteroids in the management of preterm delivery.

OBJECTIVE: This narrative review of the literature explores the current evidence and recommendations in favor of antenatal corticosteroids use during impending preterm deliveries as well as related issues and concerns. STUDY DESIGN: Synthesis of findings from published medical literature on antenatal corticosteroids and prematurity, retrieved from searches of computerized databases and authoritative texts. RESULTS: It is now recognized that an intramuscular course of betamethasone or dexamethasone given to a woman expected to deliver preterm not only accelerates pulmonary epithelial development but also matures other organ systems, significantly decreasing the chances of neonatal morbidities and increasing chances of survival. CONCLUSION: There remain uncertainties over the efficacy of the established protocol in populations such as the very early preterm, the late preterm, and multiple gestations. Alternative regimens remain controversial because of fear of adverse effects and doubts regarding whether benefits outweigh risks.

Improving awareness of preconception health among adolescents: experience of a school-based intervention in Lebanon.

BACKGROUND: Maternal behavior before and after conception affects maternal and child health. Limited awareness of adolescents in preconception health may be addressed through school education. The aim of this intervention is to assess preconception health awareness among adolescents in Lebanese high schools and to test the effectiveness of a one-time educational session in improving preconception knowledge. METHODS: The intervention consisted of a 30-minute educational session about good practices in preconception health, developed by the National Collaborative Perinatal Neonatal Network's (NCPNN) research team. A convenience sample of high school Lebanese students in grades 10 to 12, aged 14 to 26 years old, from 70 private and public schools in all six Lebanese provinces, participated in the intervention in 2011 and 2012. A multiple-choice questionnaire administered prior to and 2 months after the session was used to assess knowledge improvement among the students. RESULTS: A total of 7,290 students were enrolled. After the session, mean scores of correct answers increased from 4.36 to 6.42 out of 10, representing a 47.2% improvement (p < 0.001). The percent of correct answers increased for all the questions regarding health practices (p < 0.001). The greatest improvement was observed for questions about Trisomy 21, folic acid intake and toxoplasmosis with percentages improvement of 96%, 172% and 83% respectively. Being female or in private school was a significant predictor of higher scores in both pre-test and post-test (p < 0.001). CONCLUSIONS: Awareness campaigns in schools increased the preconception health knowledge among high school students. We recommend expanding the scope of this intervention into universities in Lebanon.

A clinical approach to intrahepatic cholestasis of pregnancy.

Intrahepatic cholestasis of pregnancy (ICP) has a varying prevalence worldwide. The etiology behind this disease remains not fully understood with multiple factors influencing its development including genetic variations, dietary factors, hormonal changes, and environmental influences. Presenting mainly during the third trimester with generalized itching and resolving spontaneously postpartum, this condition is still associated with fetal morbidity and mortality. The diagnosis is based on clinical presentation in association with biochemical abnormalities. Elevation in total bile acid levels is the most frequent laboratory abnormality and seems to be the most important for gauging further management of the disease. The most appropriate gestational age for the delivery of women with ICP is yet to be determined. In this review we discuss the epidemiology, clinical features, diagnosis, etiology, and management of ICP, trying to shed light on some controversial aspects of the disease.

Recurrent twin pregnancy, with the second a heterotopic pregnancy, following clomiphene citrate stimulation: an unusual case and a review of the literature.

Multiple gestations are on the rise with the advent of artificial reproductive technologies. Even with ovulation induction using clomiphene citrate alone, the twinning rate can reach up to 9 percent. We report a case of recurrent twin gestation after treatment with clomiphene citrate, with the second pregnancy being heterotopic. We also review, using Medline and PubMed, previously reported cases of recurrent twin gestation after treatment with clomiphene citrate published before June 2014. Patients undergoing ovulation induction for oligoovulation, anovulation, or unexplained infertility should always be counseled about the possibility of multiple gestation prior to the treatment including the probability, although low, of a heterotopic pregnancy.

The Lebanese percreta group: A retrospective cohort study of both radical and conservative management outcomes of abnormally invasive placenta.

OBJECTIVE: The aim of the present study was to illustrate the outcomes of abnormally invasive placenta (AIP) cases managed in three leading centers in Lebanon. METHODS: We conducted a retrospective multicenter cohort study. Patients managed conservatively (cesarean delivery with successful placental separation) or radically (cesarean hysterectomy) were included in the study. Data included patient characteristics, surgical outcomes (blood loss, operative time, transfusion, partial bladder resection), maternal outcomes (death, length of stay, ICU admission, postoperative hemoglobin level) and neonatal outcomes (Apgar score, neonatal weight, admission to neonatal intensive care unit, neonatal death). RESULTS: The study included 189 patients. In the radical treatment subgroup (141/189), patients were para 3 and delivered at 34 4/7 weeks in average, bled 1.5 L and were transfused with three packed red blood cells, with operative time averaging 160 min. A total of 36% were admitted to the ICU and patients stayed on average for 1 week despite partial bladder resection in 19% of cases. Unscheduled radical delivery occurred at a lower gestational age, was associated with more blood loss, higher rate and volume of transfusion, and risk of maternal and neonatal death. In addition, patients delivered in an unscheduled fashion experienced higher rates of partial bladder resection and longer interventions. In the conservative treatment subgroup, on average patients were para 2 and delivered at 36 weeks, bled 800 mL on average with low rates of transfusion (35%) and ICU admission (22.9%). With regard to neonatal outcomes, the average neonatal birth weight was 2.4 kg in the radical subgroup and 2.5 kg in the conservative subgroup. Neonatal death occurred in 5.4% of cases requiring radical management while it occurred in 2% of patients treated conservatively. CONCLUSION: Through their multidisciplinary approach, the three centers demonstrated that management of AIP in Lebanon has led to excellent outcomes with no maternal mortality occurring in scheduled radical treatment. By comparison of the three leading centers, pitfalls in each center were identified and addressed.

Attitudes of Lebanese university students towards surgical hymen reconstruction.

Many cultural and religious beliefs place virginity at a high level of social significance, in that women who lose their virginity before marriage may face humiliation, ostracism, divorce, and extreme violence. This led to an increase in the demand for virginity restoration through surgical hymen reconstruction among these cultures. However, data regarding the acceptance of hymenoplasty in societies that consider sexuality a taboo are scarce. In this cross-sectional study, we investigated the effects of gender and religion on sexual attitudes towards hymenoplasty, premarital sex, and virginity in a sample of 600 Lebanese university students. Our findings showed that approval of hymenoplasty was low among participants regardless of gender (25.7 % men vs. 19.1 % women) and religious affiliations (22.5 % Muslims vs. 22.3 % Christians). Arguments for rejection were rooted in moral ethics and personal convictions: "form of deceiving and cheating" (80.7 %) and "betrayal of honesty in the relationship" (80.4 %). Reasons for acceptance included: personal belief in "women's rights, autonomy, and freedom" (72.2 %) and "physical harm and death" (63.5 %).Male participants were more likely to approve premarital coital sex than females (61.0 vs. 27.3 %). Muslims were also more likely to reject marrying a non-virgin than Christians (39.9 vs. 18.0 %). Female participants expressed more tolerance towards marrying a non-virgin male partner (78.3 vs. 57.3 %). Low acceptance of hymenoplasty among Lebanese university students was found to be related to moral ethics and personal convictions independently from gender and religious affiliation. Differences in sexual attitudes towards premarital coital sex and virginity, however, were more significantly influenced by culture and religion.

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families.

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

FIGO opinion paper: Drivers and solutions to the cesarean delivery epidemic with emphasis on the increasing rates in Africa and Southeastern Europe.

Cesarean delivery rates are rapidly increasing in Southeastern Europe (to more than 60%), North Africa (with a rate as high as 72% in Egypt), and in urban areas in Southern Africa (a rate of over 50% in Lagos, Nigeria). Data on the background to these increases are scarce, but likely to include poor birthing facilities in general hospitals, convenience for the doctor, private medicine, fear of litigation, socioeconomic status, shortage of midwives and nurses, and disappearance of vaginal instrumental deliveries. Options to reverse cesarean delivery trends are discussed. In this context there is a need to be better informed about how women are being counseled regarding vaginal or cesarean delivery. The long-term consequences in subsequent pregnancies for mothers and children may well be largely ignored, while these risks are highest in LMICs where higher birth numbers are desired. FIGO has begun discussions with obstetric and gynecologic societies, healthcare bodies, and governments in several countries discussed in this article, to find ways to lower the cesarean delivery rate. The requests came from the countries themselves, which may prove beneficial in helping advance progress.

Vaccination in pregnancy.

The evidence indicates that pregnancy is associated with increased severity of some infectious diseases. Given the high maternal morbidity associated with influenza in pregnancy and the high neonatal morbidity and mortality associated with pertussis, the traditionally two recommended vaccines during pregnancy were those against influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccines. The recent COVID-19 pandemic introduced a third vaccine that after much debate is now recommended for all pregnant women. Other vaccines can be offered based for high-risk pregnant women, and only when the benefits of receiving them outweigh the risks. The soon expected vaccines against group B streptococcus infection and respiratory syncytial virus infection will be a breakthrough in reducing perinatal mortality. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed.

Pregnancy outcomes and the effect of metformin treatment in women with polycystic ovary syndrome: an overview.

This article is a review of the literature assessing pregnancy outcomes and the effect of metformin treatment among women with polycystic ovary syndrome (PCOS). A review of research published in English was undertaken using PubMed and MEDLINE databases. The weight of the available evidence suggests that pregnant women with PCOS are at an increased risk of developing gestational diabetes, hypertensive disorders of pregnancy, preterm birth and early pregnancy loss. Obesity is a contributory factor for the increased risk of gestational diabetes in this group of women and is estimated to affect 5-40% of pregnant women with PCOS. The prevalence of other obstetric complications is estimated at 10-30% for gestational hypertension, 8-15% for pre-eclampsia and 6-15% for preterm birth. The association between PCOS and early pregnancy loss may not be direct, wherein the presence of PCOS-associated hyperinsulinemia, leading to hyperandrogenemia, has been implicated in the pathophysiology of early pregnancy loss. Apart from the role of metformin in improving the metabolic consequences accompanying PCOS, it has been shown to improve pregnancy rates in women with PCOS who are resistant to clomiphene citrate. In conclusion, pregnancy in women with PCOS is associated with adverse obstetric outcomes (multiple adverse obstetric risk). Whether metformin should be administered throughout pregnancy still remains controversial. Further prospective studies that foster a larger number of participants and adjust for all potentially confounding factors are needed.