Contraception knowledge and practices among students in Lebanese universities.

This study aimed to evaluate the proportion of contraception users among Lebanese youth, and the extent of knowledge and perception on birth control; and to raise awareness and sensitise young adults to sexual health, which remains taboo in Lebanon. The 30-item questionnaire was broadcasted to students in private and public universities in Lebanon, through social media and it collected information on contraception use and student knowledge. Over 30% of responders were medical students, and 41% have ever used contraceptives (mostly women); among which, 52.1% for contraception versus 47.9% for medical reasons. According to responders, the pill ranked high in terms of effectiveness (72.4% of responders perceive the pill as effective), followed by the male condom (69.1%) and the hormonal intrauterine device (29.6%). Some would not use contraception in the future, for religious reasons (30.8%) or for fear of complications (46.2%); indeed, around a third of contraceptive users (all female) have experienced adverse effects. Finally, students expressed concern about long-term complications of contraceptive use (pulmonary embolism/phlebitis, breast/endometrial/ovarian cancer, stroke, depression and myocardial infarction). Though less frequent than in the Western world, contraception use in Lebanon is non-negligible and gaps in university students' knowledge on contraception were identified; which should prompt sexual education and family planning initiatives in Lebanon.

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.

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.

Impact of female gender and perspectives of pregnancy on admission in residency programs.

BACKGROUND: Motherhood is a demanding part of any women's life. Female interns could encounter difficulties during selection for residency program according to their plans of conceiving. Our aim is to explore the influence of female gender on the selection process of residency programs. METHOD: A cross sectional study was conducted in 2016 at a University Hospital in Beirut, Lebanon. Female residents and chief of departments were interviewed about the impact of the timing of motherhood during residency on the interview for admission. The questionnaire reviewed concerns among female Lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities. RESULTS: Eighty nine female residents and 22 head of department agreed to participate in this study. During the interviews for residency acceptance, 29 residents (34.5%) were directly asked about their family and motherhood plans; 9% of them did not reveal their intention. 35% of the residents thought that this subject could affect the program directors' decision. 47% of residents felt that having pregnant colleagues would add to their workload, and almost half of them (46%) believed that pregnant colleagues showed less productivity. 45% of program directors stated that it was an important factor taken into consideration during the interview, and 68% believed that residents tended to choose their specialty according to their life priorities. CONCLUSION: Pregnancy during residency training represents major challenges for female residents and their program directors. Rules and laws designed to set a balance between career and personal life are required to improve women's ability to participate equally in the workforce.

Complexity of consenting for medical termination of pregnancy: prospective and longitudinal study in Paris.

BACKGROUND: We analyzed the patients' perception of prenatal diagnosis of fetal cardiac pathology, and the reasons for choosing to continue with pregnancy despite being eligible to receive a medical termination of pregnancy. We also identified the challenges, the motives interfering in decision-making, and the consequences of the decisions on pregnancy, child and mother. METHODS: This descriptive, prospective and longitudinal study was conducted in France, amongst pregnant women who wished to continue their pregnancy despite an unfavorable medical advice (incurable fetal cardiac pathologies). Socio-demographic data were collected through a questionnaire. Such questionnaire covered information assessing the parents/mother's perception of prenatal diagnosis, and medical termination of pregnancy, their interpretation of the established diagnosis and their motives for not considering pregnancy termination. RESULTS: 72 eligible patients were analyzed over one year: mean age 33 ± 6.89 years, 47 patients had already given birth to ≥1 healthy child. Mean gestational age at the detection of fetal cardiac pathologies was 30 ± 4.37 weeks of amenorrhea. Patients decided to keep the child after 3 ± 1.25 consultations. 56 (77.78%) patients made their decision with their husbands and 16 made their decision alone. Reasons for declining the medical termination were culpability and responsibility (n = 36), ideologies and convictions (n = 24), mistrust and hope (n = 12). Newborns of 67 patients died with a mean survival duration of 38 days. CONCLUSIONS: Patient informed consent should be sought before any decision in neonatology, even if conflicting with the medical team's knowledge and the pregnant mother's benefits. Decisions to accept or decline pregnancy termination depend on the patients' psychological character, ideologies, convictions, and mistrust in the diagnosis/prognosis, or hope in the fetus survival.

Accuracy of clinical fetal weight estimation by Midwives.

BACKGROUND: Clinical fetal weight estimation is a common practice in obstetrics. This study aims to evaluate the accuracy of fetal weight estimation by midwives, and to identify factors that may lead to overestimation or underestimation of fetal weight. METHODS: A cohort prospective study in a Lebanese university hospital, included weight estimation of singleton pregnancies above 35 weeks. Multiple pregnancies, unclear dating, growth retardation, malformations and stillbirths cases are excluded. The estimated fetal weight is recorded by midwives in a sealed envelope and compared to true weight later. The effects of BMI, weight gain, parity, diabetes, hypertension, neonate's sex and weight, uterine contractions, rupture of membranes and daytime or nighttime shift on these estimations were assessed. RESULTS: One hundred and sixty-six patients were included. Mean birth weight was 3246 ± 362 g. Mean absolute percentage error of weight estimation was 8.5 ± 6.7% (0-30.9%). Estimation was within the correct range of ±10% in 63% of cases. Maternal and fetal factors did not significantly change weight estimation. Fetuses with birth weights more than 4000 tended to be underestimated by midwives. Estimation improved over time (nonsignificant). CONCLUSIONS: Maternal and fetal factors, except for macrosomia, have limited impact on estimation of fetal birth weight. Macrosomia is challenging because of a consistent tendency of underestimation by midwives.

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population.

OBJECTIVE: Evaluate the outcome of prenatally diagnosed nuchal cord. METHODS: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction. RESULTS: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops. CONCLUSION: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.

Data on clinical significance of second trimester inflammatory biomarkers in the amniotic fluid in predicting preterm delivery.

In this article second trimester amniotic fluid biomarkers are measured for correlation with preterm delivery. One additional milliliter of amniotic fluid is collected during amniocentesis for dosages of IL-6, MMP-9, CRP and glucose levels, along with maternal serum CRP and glucose. MMP-9 and Il-6 levels were measured with the corresponding Human Quantikine(R) ELISA Kit (R&D systems) according to the instructions provided by the manufacturer. Cut-off values for AF MMP-9 and IL-6 were fixed by the kit sensitivity thresholds. Data includes ROC curves for glucose (Fig. 1), IL-6 (Fig. 2) and MMP-9 (Fig. 3), aiming to search for sensitivity and specificity in the prediction of premature delivery. Statistical analyses are performed with SPSS v20.0 software. Statistical significance is determined using the Mann-Whitney and one way ANOVA test. The association with preterm delivery is performed using a two proportions test. Correlations are measured using the Pearson׳'s coefficient. A p value<0.05 is considered statistically significant. The data is presented in the figures provided. Data relied on a previous publication "Prediction of preterm delivery by second trimester inflammatory biomarkers in the amniotic fluid" (A. Kesrouani, E. Chalhoub, E. El Rassy, M. Germanos, A. Khazzaka, J. Rizkallah, E. Attieh, N. Aouad, 2016) [1].

Prediction of preterm delivery by second trimester inflammatory biomarkers in the amniotic fluid.

OBJECTIVE: To search for a correlation between mid-pregnancy altered levels of inflammatory markers and preterm delivery. METHODS: A prospective cohort series included 39 patients undergoing amniocentesis one additional milliliter of amniotic fluid (AF) was stored for later dosage of interleukin-6 (Il-6), matrix metalloproteinase-9 (MMP-9), glucose and C-reactive protein (CRP). Maternal serum CRP and glucose levels were also obtained. Exclusion criteria were multiple pregnancies, chorioamnionitis, group B streptococcus colonization, bacterial vaginosis and cases with proven aneuploidy. We searched for correlation between AF and plasmatic markers and also for a difference between patients with term and preterm delivery. RESULTS: 33 participants were eligible and one third had preterm delivery. Levels of the plasmatic biomarkers did not correlate with the AF biomarkers except for plasmatic glucose and AF IL-6 levels (r=0.350; p=0.016). The levels of all AF biomarkers did not differ significantly between the pre-term and the term groups (p>0.05). The optimal screening cutoffs for identifying pregnancies at risk were different than the ones initially indicated. CONCLUSION: Mid-pregnancy amniotic fluid biomarker levels do not correlate with preterm delivery. Plasma CRP is not correlated with these markers. Cutoff levels suggested are sparse and heterogeneous. Larger studies are needed before advising routine measurement of these markers.

Feminine hygiene practices among female patients and nurses in Lebanon.

BACKGROUND: Inappropriate feminine hygiene practices are related to vulvovaginitis. We investigated the prevalence of personal hygiene habits among Lebanese women as well as their awareness of adequate practices. METHODS: Consists of a cross-sectional observational study. Female patients and nurses at Hotel-Dieu de France University Hospital in Beirut- Lebanon filled a questionnaire about their intimate hygiene habits and knowledge of proper practices. RESULTS: The study included 249 women. 21.3 % of the 136 nurses and 38.9 % of the 113 patients reported a history of vulvovaginitis. The majority of women took an intimate bath at least twice daily. 14 % of nurses and 17 % of patients douched.20. Seven percent of the nurses and 43.4 % of the patients used wet wipes. 1.5 % of nurses and 4.4 % of patients used feminine deodorant sprays. There was a significant lack of awareness mainly among patients about suitable hygiene practices as well for their adverse effects. CONCLUSION: Education provided by nurses, and other healthcare providers is essential to promote reproductive health among Lebanese women.

Use of Oral Misoprostol for Cervical Priming before Hysteroscopy: A Randomized Comparison of Two Dosages.

OBJECTIVE: The study aims to compare the safety and effectiveness of 200 and 400 µg of oral misoprostol for cervical priming before hysteroscopy. METHODS: A double-blinded randomized study included 70 patients scheduled for hysteroscopy in a Lebanese University Hospital. Two dosages of oral misoprostol (200 or 400 µg) were randomly distributed to these patients 1 h before surgery under general anesthesia. Subjective assessment of the ease of dilatation, size of the first used Hegar, cervical injuries, bleeding or uterine perforation, duration of the procedure and misoprostol adverse effect were all noted and compared. RESULTS: The difficulty of dilation until a Hegar 10 was similar for both treatment groups. Operative time was not reduced with a higher misoprostol dosage. We found 2 uterine perforations within the 200 µg group (6.7%), and none within the 400 µg group. Cervical lacerations and bleeding were similar (20%) for both treatment groups. A 2-fold increase in side effects (nausea, vomiting and cramps) is reported among the 400 µg group. CONCLUSIONS: Increasing the dose of misoprostol from 200 to 400 mg doubled the rate of side effects while no clinical benefit was noted. Larger trials are needed to assess rates of uterine perforation with the 200 µg dosage.

Early identification of women at risk of postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) in a sample of Lebanese women.

BACKGROUND: During the postpartum period, women are vulnerable to depression affecting about 10 to 20% of mothers during the first year after delivery. However, only 50% of women with prominent symptoms are diagnosed with postpartum depression (PPD). The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening instrument for PPD . The main objectives of this study are to assess whether an EPDS score of 9 or more on day 2 (D2) postpartum is predictive of a depressive episode between days 30 and 40 postpartum (D30-40), to determine the risk factors as well as the prevalence of PPD in a sample of Lebanese women and to determine a threshold score of EPDS predictive of PPD. METHODS: A sample of 228 women were administered the EPDS on D2. An assessment for PPD was done on D30-40 during a telephone interview. RESULTS: On D2, the average score on EPDS was 7.1 (SD = 5.2) and 33.3% of women had an EPDS score ≥ 9. On D30-40 postpartum, the average score was 6.5 (SD = 4.7) and 19 women (12.8%) presented with PPD. A positive correlation was shown between scores on EPDS on D2 and D30-40 (r = 0.5091, p < 0.0001). A stepwise regression shows that an EPDS score ≥9 on D2 (p < 0.001) and a personal history of depression (p = 0.008) are significantly associated with the diagnosis of PPD on D30-40. CONCLUSION: The EPDS may be considered as a reliable screening tool on as early as D2 after delivery. Women with EPDS score ≥ 9 and/or a positive personal history of major depressive disorder should benefit from a closer follow-up during the rest of the post-partum period.

Adnexal torsion: magnetic resonance findings in the viable adnexa with emphasis on stromal ovarian appearance.

PURPOSE: To evaluate ultrasound (US) and magnetic resonance (MR) findings in the viable twisted adnexa. MATERIALS AND METHODS: Ten patients underwent US and MR studies before surgical detorsion. Corrected cross-sectional area of the ovary was defined as cross-sectional area minus areas of cysts and follicles superior to 1 cm. On T2-weighted images, signal intensity of the stroma was graded as type 1 when it was equal to that of urine and type 2 when it was less than that of urine but markedly more than the contralateral side. RESULTS: The tube was twisted in six cases and the ovary in nine cases. All adnexa were viable. The largest ovarian cross-sectional area and the largest corrected ovarian cross-sectional area of the twisted ovary were significantly larger than those of the contralateral ovary (P = 0.043 for US; P = 0.012 and 0.017, respectively, for MR). These ovaries contained types 1 and 2 hyperintensity in six cases and only type 2 hyperintensity in three cases. Tubal thickening was seen on MR in five cases. CONCLUSION: Tubal thickening, enlargement of ovarian stroma as reflected by the corrected cross-sectional area, and hyperintensity of this stroma on T2-weighted images probably related to edema were useful findings in these viable torsions.

[TVT (tension-free vaginal tape) as treatment in female stress incontinence]. / Tampon transvaginal/TVT(tension-free vaginal tape)et incontinence urinaire d'effort chez la femme.

OBJECTIVE: Evaluation of the efficacy and the safety of the TVT as a surgical treatment for the female stress incontinence. MATERIAL AND METHODS: Prospective non-randomized study undertaken between January 1999 and December 2000 concerning 40 women admitted to the Hotel-Dieu de France Hospital, with specific inclusion criteria. The surgical procedure used is the TVT as described by Ulmsten. Patients' evaluation is made through valid criteria shown in the literature. RESULTS: The mean follow-up is 12 months. The mean operation time is 37 minutes. The mean duration of hospitalization is 2.6 days. Postoperative complications were transient urinary retention in 17.5% of cases, and lower urinary tract infection in 10% of patients. One case of bladder perforation was noted. The mean difference between the numbers of protections used daily before and after TVT is 2.03 +/- 1.89 (p < 10(-4)). 87.5% of patients were totally and objectively continent. The mean post-voiding residue is 85 +/- 91 ml. Bladder instability symptoms were significantly reduced (RR = 0.37). 97.5% of patients are cured or improved by the operation. CONCLUSION: The TVT is an effective procedure and easy to perform. The results obtained so far are promising. The failure rate is about 2.5%. A standardization of the indications is preferred for future studies.