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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 (pâ <â 0.001). At 6-month follow-up, emotional score improved (pâ =â 0.028), while smoking decreased (pâ =â 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.
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Conocimientos, Actitudes y Práctica en Salud , Promoción de la Salud , Lugar de Trabajo , Humanos , Promoción de la Salud/métodos , Proyectos Piloto , Masculino , Femenino , Adulto , Líbano , Persona de Mediana Edad , Salud Laboral , Conductas Relacionadas con la Salud , Estilo de Vida , Educación en Salud/organización & administración , Educación en Salud/métodos , Encuestas y Cuestionarios , Países en Desarrollo , Adulto JovenRESUMEN
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.
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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.
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Cesárea , Refugiados , Femenino , Humanos , Recién Nacido , Embarazo , Parto Obstétrico , Líbano/epidemiología , Salud PúblicaRESUMEN
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.
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Cesárea , Parto Obstétrico , Femenino , Humanos , Embarazo , Consejo , Cuerpo Médico , Atención Prenatal , Práctica Clínica Basada en la Evidencia , Guías de Práctica Clínica como AsuntoRESUMEN
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.
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Cesárea , Parto Obstétrico , Embarazo , Niño , Femenino , Humanos , Nigeria , Atención a la Salud , Europa (Continente)RESUMEN
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.
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COVID-19 , Vacunas contra Difteria, Tétanos y Tos Ferina Acelular , Gripe Humana , Tétanos , Tos Ferina , Recién Nacido , Femenino , Embarazo , Humanos , Gripe Humana/prevención & control , Tos Ferina/prevención & control , Pandemias , COVID-19/prevención & control , Vacunación , Tétanos/prevención & controlRESUMEN
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..
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Hemorragia Posparto , Femenino , Embarazo , Humanos , Masculino , Hemorragia Posparto/prevención & control , Estudios Prospectivos , Parto Obstétrico/efectos adversos , Masaje/métodos , HemoglobinasRESUMEN
Objectives: The study aims to report on the feasibility and associated adverse events of HPV-Vaccination (HPVV) in a private clinic setting in Lebanon and, when available, the results of subsequent cervical cancer screening. Methods: Opportunistic HPV vaccination is offered at the Women's Health Center of the AUBMC. We retrospectively reviewed the patients' demographic data, the incidence of adverse events, and their cytological screening. Results: A cohort of healthy women (n = 1013) aged 26.2 years (12-54 years) were opportunistically vaccinated with one of two HPV vaccines; 845 (83.4%) received the quadrivalent vaccine (Q4V), and 151 (14.1%) received the bivalent vaccine (B2V). The majority (75.8%) received three doses while 16% received two doses. Out of these women, 26.3% (267) became sexually active postvaccination (NS2), whereas 17% (174) were sexually active prior to vaccination (SA) and the rest 57% (572) reported no sexual activity (NS1). Among the SA group, 26% (46/147) presented with abnormal cytology at time of vaccination. As for the NS2 women, 5% (14/267) had subsequently abnormal screening within 37 (12-103) months following vaccination. Conclusions: In this observational study, we report the successful introduction of HPVV with negligible adverse events. The incidence of abnormal cervical cytology was low among our patients.
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OBJECTIVE: First, to evaluate the risks of stillbirth and neonatal death by gestational age in twin pregnancies with different levels of growth discordance and in relation to small for gestational age (SGA), and on this basis to establish optimal gestational ages for delivery. Second, to compare these optimal gestational ages with previously established optimal delivery timing for twin pregnancies not complicated by fetal growth restriction, which, in a previous individual patient meta-analysis, was calculated at 37 0/7 weeks of gestation for dichorionic pregnancies and 36 0/7 weeks for monochorionic pregnancies. DATA SOURCES: A search of MEDLINE, EMBASE, ClinicalTrials.gov, and Ovid between 2015 and 2018 was performed of cohort studies reporting risks of stillbirth and neonatal death in twin pregnancies from 32 to 41 weeks of gestation. Studies from a previous meta-analysis using a similar search strategy (from inception to 2015) were combined. Women with monoamniotic twin pregnancies were excluded. METHODS OF STUDY SELECTION: Overall, of 57 eligible studies, 20 cohort studies that contributed original data reporting on 7,474 dichorionic and 2,281 monochorionic twin pairs. TABULATION, INTEGRATION, AND RESULTS: We performed an individual participant data meta-analysis to calculate the risk of perinatal death (risk difference between prospective stillbirth and neonatal death) per gestational week. Analyses were stratified by chorionicity, levels of growth discordance, and presence of SGA in one or both twins. For both dichorionic and monochorionic twins, the absolute risks of stillbirth and neonatal death were higher when one or both twins were SGA and increased with greater levels of growth discordance. Regardless of level of growth discordance and birth weight, perinatal risk balanced between 36 0/7-6/7 and 37 0/7-6/7 weeks of gestation in both dichorionic and monochorionic twin pregnancies, with likely higher risk of stillbirth than neonatal death from 37 0/7-6/7 weeks onward. CONCLUSION: Growth discordance or SGA is associated with higher absolute risks of stillbirth and neonatal death. However, balancing these two risks, we did not find evidence that the optimal timing of delivery is changed by the presence of growth disorders alone. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42018090866.
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Enfermedades del Recién Nacido , Muerte Perinatal , Femenino , Retardo del Crecimiento Fetal/epidemiología , Edad Gestacional , Humanos , Recién Nacido , Muerte Perinatal/etiología , Embarazo , Embarazo Gemelar , Estudios Prospectivos , Estudios Retrospectivos , Mortinato/epidemiología , GemelosRESUMEN
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.
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Calcinosis , Exoftalmia , Muerte Perinatal , Anomalías Múltiples , Quinasa de la Caseína I/genética , Fisura del Paladar , Proteínas de la Matriz Extracelular/genética , Femenino , Humanos , Recién Nacido , Microcefalia , Mutación , Osteosclerosis , EmbarazoAsunto(s)
Oxitócicos , Hemorragia Posparto , Femenino , Humanos , Hemorragia Posparto/prevención & control , Embarazo , Factores de RiesgoRESUMEN
OBJECTIVE: To compare the burden and causes of maternal deaths between Syrian and Lebanese women for the period of 2010-2018. METHODS: A retrospective analysis was conducted of maternal deaths from the national notification system at the Ministry of Public Health in Lebanon during the period of 2010-2018. Maternal deaths among Syrian refugees and Lebanese citizens were compared based on cause of death, age of the woman, and nationality. Causes of maternal deaths were categorized as direct and indirect following WHO definitions. RESULTS: The maternal mortality ratio among the Syrian refugee women in Lebanon was higher than that of Lebanese women in the period 2010-2018, with its highest rate of 55.1 in 2017. Hemorrhage and indirect causes of maternal deaths are more common among Syrian refugee women whereas embolism and hypertension have higher proportions among Lebanese women. Maternal deaths within 48 h after birth are more common among Syrian than Lebanese women. CONCLUSION: Syrian refugee women carry an increased risk for maternal mortality in Lebanon. Improving timely access and equitable provision of appropriate care should be a priority for the health system in Lebanon.
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Muerte Materna , Refugiados , Femenino , Humanos , Líbano/epidemiología , Mortalidad Materna , Estudios Retrospectivos , SiriaRESUMEN
OBJECTIVES: To evaluate the practice patterns among Lebanese obstetricians regarding obstetric care of twins and to compare selected practice patterns between general obstetricians and maternal fetal medicine physicians. METHODS: Questionnaires distributed during the annual meeting of the Lebanese Society of Obstetrics and Gynecology. RESULTS: Questionnaires were returned by 69.2% of the 296 physicians approached. Ten percent had fellowship training in Maternal Fetal Medicine (MFM). Thirty-nine percent perform cervical length measurement at 20-24 weeks of gestation and 34% recommend vaginal progesterone in case of a short cervix. When comparing selected practice patterns between MFM & general obstetricians, MFM specialists were less likely to perform cervical cerclage in the first trimester (5.9% versus 49%, p = .001), more likely to offer prenatal screening for aneuploidy (66.6% vs 46.4%, p = .03), less likely to use vaginal progesterone in the second trimester in the case of a short cervix (42.1% vs 61.8%, p = .04), less likely to perform serial ultrasound exam in the third trimester to assess fetal growth (50% vs 78%, p = .005) and more likely to deliver monoamniotic twins at 32-34 weeks of gestation (55% vs 37%, p = .05). CONCLUSION: Because of the different background of the Lebanese physicians, MFM specialists are more likely to follow obstetric care guidelines in twin gestation.
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Ginecología , Obstetricia , Medición de Longitud Cervical , Femenino , Humanos , Embarazo , Embarazo Gemelar , Progesterona , Derivación y ConsultaRESUMEN
BACKGROUND: Rate of cesarean section (CS), including elective CS has globally increased. Studies have found that term elective CS before 39 weeks of gestation is associated with increased risk of adverse respiratory outcomes. OBJECTIVE: To determine the rate of elective CS and examine the association between timing of elective term CS and adverse neonatal outcomes in a large population of Lebanese women. METHODS: A Multi-Center Study was conducted using data from the National Collaborative Perinatal Neonatal Network database. Simple and multivariable logistic regression models were used to examine the association between timing of term elective CS and adverse neonatal outcomes. Some of the neonatal adverse outcomes we examined included respiratory distress syndrome, admission to the NICU, and a composite of respiratory outcomes. RESULTS: A total of 28,997 low risk mothers who delivered through primary and repeat elective CS were included in the study. Uncomplicated elective planned term CS constituted 25% of all CS deliveries in Lebanon. Primary and repeat CS at 37 weeks of gestation increased the odds of most of the studied adverse neonatal outcomes. There were few associations between CS and adverse neonatal outcomes at 38 weeks of gestation. CONCLUSIONS: Term primary and repeat cesarean delivery prior to 39 weeks of gestation is associated with respiratory and other adverse neonatal outcomes. Delaying birth 1-2 weeks till 39 weeks of gestation can prevent 64-77% of adverse respiratory outcomes.
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Cesárea/efectos adversos , Procedimientos Quirúrgicos Electivos/efectos adversos , Hospitalización/estadística & datos numéricos , Unidades de Cuidado Intensivo Neonatal/estadística & datos numéricos , Síndrome de Dificultad Respiratoria del Recién Nacido/patología , Adulto , Femenino , Edad Gestacional , Humanos , Recién Nacido , Embarazo , Resultado del Embarazo , Síndrome de Dificultad Respiratoria del Recién Nacido/etiología , Estudios Retrospectivos , Factores de TiempoRESUMEN
The introduction of anti-Rh(D) immunoglobulin more than 50 years ago has resulted in only a 50% decrease in Rhesus disease globally owing to a low uptake of this prophylactic approach. The International Federation of Gynecology and Obstetrics, International Confederation of Midwives, and Worldwide Initiative for Rhesus Disease Eradication have reviewed current evidence regarding the utility of anti-Rh(D) immunoglobulin. Taking into account the effectiveness anti-Rh(D), the new guidelines propose adjusting the dose for different indications and prioritizing its administration by indication.
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Isoinmunización Rh/inmunología , Globulina Inmune rho(D)/inmunología , Femenino , Humanos , EmbarazoRESUMEN
Pregnant women and their fetuses are among the vulnerable populations that can be severely affected by communicable diseases. As such, some vaccines such as the influenza and the Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines are strongly recommended in each pregnancy, with generally safe profiles. Other vaccines can be offered based on risk factors, and only when the benefits of receiving them outweigh the risks. Development of vaccines against group B streptococcus infection and respiratory syncytial virus infection are of great importance. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed. The FIGO Committee for Safe Motherhood and Newborn Health Committee endorses the recommendations to vaccinate all pregnant women against influenza during the influenza season at any time during the pregnancy and against Tdap preferably between the 27th and 36th weeks of pregnancy in each pregnancy.
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Vacunación/métodos , Vacunas/administración & dosificación , Adulto , Vacunas contra Difteria, Tétanos y Tos Ferina Acelular/administración & dosificación , Femenino , Humanos , Recién Nacido , Vacunas contra la Influenza/administración & dosificación , Embarazo , Factores de Riesgo , Poblaciones VulnerablesRESUMEN
This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.
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Parto Obstétrico/métodos , Segundo Periodo del Trabajo de Parto , Episiotomía/métodos , Femenino , Humanos , Partería , Parto , EmbarazoRESUMEN
Worldwide, health systems and care approaches vary widely due to local reality, distance to facilities, cultural norms, resources, staff availability, geography, and politics. Consequently, globally maternal-newborn dyad care and outcomes are highly variable, leading to approximately 800 maternal deaths daily with a 100-fold difference among high- and low-resource countries. Irrespective of where care is received, maternal safety and wellbeing should be preserved. Despite ongoing efforts, however, this is not the case. Large gaps exist between spending and clinical outcomes. Segmented health care, coupled with poor planning and inadequate resource distribution, results in failure to provide essential life-saving treatment. The proposed solution is a regional integrated care model from midwife to advanced level III/IV care and the newborn unit, achieved through effective coordination by site, staff, and clinicians. This model has been successfully implemented in high- to low-resource countries in the past 20 years. In the large diverse population of the United States, constructive steps have been implemented to reduce high maternal mortality in black and rural communities. The COVID-19 pandemic demonstrates the feasibility of rapid resources coordination to provide effective advanced care. The proposed integration of resources will have a major positive impact on the maternal-newborn dyad.