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.

The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon.

OBJECTIVE: To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. METHODS: A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. RESULTS: The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P = 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P = 0.02 and 0.01, respectively). CONCLUSION: The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.

Intraoperative Ultrasound in the Management of Placenta Accreta Spectrum: Waste of Time or Valuable Step.

Placenta accreta spectrum (PAS) is increasing worldwide paralleling the rising surge of the cesarean section rate. It is well known that sonographic screening for PAS in the second trimester in high-risk patients can predict and reduce major intraoperative hemorrhage during a cesarean hysterectomy. We report the importance of intraoperative ultrasound in the management PAS disorders. It has a crucial role in the reassessment of the placenta location and invasion, reconsidering the cesarean hysterectomy, localization of the hysterotomy, the bladder dissection, and in the conservative treatment. Workshops and hands-on training in intraoperative ultrasound among surgeons must be supported.

Fetal supraventricular tachycardia and maternal COVID-19 vaccination: is there any relationship?

Fetal supraventricular tachycardia accounts for 60-80% of the fetal tachyarrhythmias with prevalence ranging from 1/1000 to 1/25 000 pregnancies. It may be secondary to fetal anomalies or maternal factors. By reviewing the literature, there is no previous article that reports fetal arrhythmia after maternal vaccination. We present herein two cases of fetal supraventricular tachycardia following the administration of the Pfizer-BioNTech COVID-19 vaccine during pregnancy. Continued safety monitoring and more longitudinal follow-up are needed to evaluate the fetal impact after maternal COVID-19 vaccination.

Outcome of prenatal diagnosis of clubfoot: a single institution experience.

AIM: To assess the accuracy of antenatal diagnosis of clubfoot (CF), risk factors and outcomes in postnatal. PATIENTS & METHODS: Maternal characteristics, sonographic signs and postnatal outcomes were evaluated in 60 patients with a prenatal diagnosis of CF between 2007 and 2020. RESULTS: The rate of antenatal diagnosis of CF was 3.72/1000 live births. The false-positive rate was 6.67%. 66.7% of fetuses had bilateral CF and 33.3% had unilateral CF; 58.3% were isolated and 41.7% were complex; 58.3% were males and 41.7% were female; 16.7% were multiple pregnancies and 10% were cases of consanguinity. CONCLUSION: The accuracy of the diagnosis of CF depends on the operator's skills. A significant relationship is demonstrated between the interruption of pregnancy, consanguinity, laterality and complexity.

Cesarean section rates in a tertiary referral hospital in Beirut from 2018 to 2020: Our experience using the Robson Classification.

OBJECTIVE: To evaluate the cesarean section rate using the Robson Classification for the first time in Lebanon, at Hôtel-Dieu de France University Hospital, a tertiary referral center in Beirut. METHODS: Routine medical record data that included all live births from January 1, 2018 to September 30, 2020 was investigated. The overall cesarean section rate was recorded, and the size, cesarean section rate, and absolute and relative contributions were calculated within each group. RESULTS: The overall cesarean section rate was 56.8%. The highest relative contribution to this rate came from Robson groups 5, 2 and 10, respectively. A decrease in cesarean section rate was noted in 2020 among women admitted for induction of labor (groups 2 and 4) following the implementation of new department policies and the restrictions caused by the coronavirus disease 2019 pandemic. CONCLUSION: More than 50% of the deliveries in our department were by cesarean sections (CS). Strategies to reduce this rate should include stricter departmental policies for avoidance of unindicated primary CS and raising practitioners' and patients' awareness about trial of labor after cesarean section.

Splenic rupture after sexual intercourse in a pregnant woman: an extremely rare case.

A 33-year-old pregnant woman presented at 36 weeks gestation to the emergency with acute abdominal pain that started after vaginal intercourse. No bruising was present on the abdominal examination. An emergent cesarean delivery was performed for resistant hypotension and collapse. A fetus with cardiac arrest was delivered, and active spleen bleeding was identified at the splenocolic and gastrosplenic ligament insertion. The patient had a conservative treatment of the spleen and an uncomplicated postoperative course. The infant was resuscitated and discharged after 18 days. In conclusion, traumatic spleen rupture is an etiology to consider in pregnant women presenting with acute abdominal pain following sexual intercourse. Early suspicion and emergent cesarean delivery are the keys to optimize maternal and perinatal outcomes.

Case series of outcomes of a standardized surgical approach for placenta percreta for prevention of ureteral lesions.

OBJECTIVE: To report the outcomes of women with placenta percreta who were surgically treated by a specialized technique based on gynecologic oncology experience, and to demonstrate its safety in preventing ureteral lesions and reducing blood loss. METHODS: In the present retrospective study, data from patients with placenta percreta radically treated at Hôtel-Dieu de France, Beirut, Lebanon, between December 2012 and January 2017 were reviewed. Demographic, pathology, and delivery data, medical history, per-operative and postoperative information, and neonatal data were assessed. Operative and postoperative outcomes were compared between emergency and scheduled cases. RESULTS: Data from 35 patients were reviewed. Median gestational age at delivery was 34 weeks. Cesarean hysterectomy was scheduled in 20 (60%) cases. No ureteral lesions were noted. The median estimated blood loss was 1 L and a median of 3 units of red blood cells units was transfused. Emergency and scheduled cases presented comparable estimated blood loss, intra-operative transfusion, bladder injury incidence, and surgery duration (all P>0.05). The mean delivery weight was 2100 g; admission to the neonatal intensive care unit was needed for 30 (86%) neonates. CONCLUSION: The surgical technique developed for placenta percreta was found to be effective (operative and postoperative outcomes) and safe (prevention of ureteral lesions).

A definition of selectivity in laser coagulation of chorionic plate anastomoses in twin-to-twin transfusion syndrome and its relationship to perinatal outcome.

OBJECTIVE: This study was undertaken to correlate selectivity of surgery and perinatal outcome in twin-to-twin transfusion syndrome treated by endoscopic laser coagulation, using a quantitative definition of selectivity. STUDY DESIGN: 287 consecutive cases of severe twin-to-twin transfusion syndrome were reviewed. A selectivity index was built as the ratio of selective over nonselective coagulations per procedure. Outcome measures were survival at 28 days and failure of surgery as defined by recurrence of twin-to-twin transfusion syndrome or fetofetal hemorrhage. RESULTS: Two populations were identified: a high selectivity group (63.8%) and a low selectivity group (36.2%). Survival of at least one twin and survival of both twins were higher in the high-selectivity group (p = .007 and p = .04 respectively). Failure of surgery rates were similar in both groups. CONCLUSION: A quantitative definition of selectivity appears justified by the large variations found in the practice of a single center and by significant differences in outcome. Survival is significantly improved in highly selective procedures.