A new conservative surgical approach for placenta accreta spectrum in a low-resource setting.

OBJECTIVE: To assess the efficacy and safety of a new surgical approach for uterine preservation among patients with placenta accreta spectrum in a low-resource setting. METHODS: The present prospective cohort included 63 women diagnosed with placenta accreta spectrum undergoing cesarean deliveries who desired future fertility at the obstetrics department of Menoufia University Hospital from January 2018 to November 2019. Surgical management involved direct bilateral uterine arteries clamping below placental bed after broad ligament opening by round ligaments division and ligation and gentle downward dissection of vesical from myometrial tissues from lateral aspect toward trigone of the bladder. Outcomes included intraoperative and postoperative adverse events, hysterectomy rate, and postoperative hospitalization. RESULTS: Mean operative blood loss was 1860 ± 537 mL (range, 1040-3111 mL) and the incidence of bladder and ureteric injuries were 6.3% (n = 4) and 0%, respectively. The mean length of hospital stay was 4.46 ± 1.39 days. Overall, 7 patients (11.1%) required postoperative blood transfusion, and 2 patients (3.2%) required ICU admission. Five patients required peripartum hysterectomy (7.9%). CONCLUSION: Our conservative surgical approach is a safe alternative to peripartum hysterectomy with high uterine preservation rate, less intraoperative and postoperative morbidity and less need for blood transfusion in low resource settings. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; NCT04161521.

Scalpel versus diathermy skin incision in Caesarean section.

Surgical scalpels are traditionally used for skin incisions during a Caesarean delivery; the great evolutions in electrosurgical devices bring an alternative method for skin incision by the usage of cutting diathermy. This was a prospective randomised comparative study conducted during the period from March 2016 to February 2017 on 200 patients, 100 patients had skin incisions using the surgical scalpel, while 100 patients had skin incisions with a diathermy, in order to judge the variations in the postoperative pain, the incision time, the incision blood loss, the operative time, the wound healing and the wound complications. We observed a significant difference between the two groups regarding the incision time (p < .001), incisional blood loss (p < .001), operative time (p < .001) and the postoperative pain (p < .001), where these parameters were less in the diathermy group. No significant difference observed between the two groups regarding the wound healing (p = .389) and wound complications (p = .470). We can conclude that the proper usage of diathermy in making the skin incision during a Caesarean section in this study achieved better results than the scalpel incision. Impact statement What is already known on this subject? Surgical scalpels are traditionally used in making the skin incisions during a Caesarean section; diathermy incisions, on the contrary, are less popular among the surgeons. It has been hypothesised that the application of extreme heat may result in a significant postoperative pain and poor wound healing. There has been a widespread use of diathermy for hemostasis but fear of production of large scars and improper tissue healing has restricted their usage in making skin incisions. What do the results of this study add? The use of diathermy for skin incisions in Caesarean section in this study was associated with a reduced incisional blood loss, incisional time, operative time and postoperative pain. It had no effect on wound closure and was not associated with any delay in wound healing. Also, the wound complications rate was equal in both types of incisions. What are the implications of these findings for clinical practice and/or further research? Most surgeons prefer the scalpel in making skin incision during a Caesarean section due to the fear of surgical site infection. Our findings proved different, we proved that cutting diathermy could be accepted as an alternative technique for making a skin incision without increased rates of wound infections. Also, the advantages of cutting diathermy will give benefits to both the patients and the surgeons.

Body mass index is linked to cervical length and duration of pregnancy: An observational study in low risk pregnancy.

In this prospective cohort study, one hundred participants were allocated into four groups according to their body mass indices. Vaginal ultrasound was performed at enrolment to measure cervical length. The shortest cervical measurement was recorded. Overweight and obese groups had significantly longer mean cervical length than women in the normal weight group when measured at 20-22 weeks of gestation (p < .001). Underweight women had the shortest mean cervical length. The incidence of preterm delivery was the highest in underweight women (RR; 1.5). The incidence of post-term delivery was 10% in total in overweight and obese women. Underweight women were more likely to have short cervical length and subsequent preterm delivery compared to overweight and obese women.

Management of postpartum hemorrhage with intrauterine balloon tamponade using a condom catheter in an Egyptian setting.

OBJECTIVE: To evaluate uterine balloon tamponade using a condom catheter for the management of early postpartum hemorrhage (PPH). METHODS: In a prospective observational study at Menoufia University Hospital, Shebin Elkom, Egypt, women with early PPH were enrolled between May 2011 and September 2012. Uterine balloon tamponade with a condom catheter was applied in women who were unresponsive to uterotonics and bimanual compression; patients with successful catheter placement were included in analyses. The primary outcome was successful control (reduction or cessation) of bleeding. RESULTS: A condom catheter was successfully placed for 50 of the 151 women enrolled. The overall success rate of the procedure was 96% (48/50). The condom catheter was successful in all 28 cases of atonic PPH after vaginal or cesarean delivery. It successfully controlled PPH due placental site bleeding in 20 (91%) of 22 patients with placenta previa and a well-contracted uterus. CONCLUSION: Condom balloon catheter was found to effectively control PPH. The procedure is simple, inexpensive, and safe, and can preserve reproductive capacity, as well as saving the life of the mother. ClinicalTrials.gov:NCT02672891.

Predictors of patient responses to ovulation induction with clomiphene citrate in patients with polycystic ovary syndrome experiencing infertility.

OBJECTIVE: To identify predictors of clomiphene citrate-induced ovulation in patients with polycystic ovary syndrome (PCOS). METHODS: A prospective observational study of patients 18-40 years of age with PCOS experiencing infertility was conducted at Menoufia University Hospital between January 2011 and January 2013. A range of potential predictors of ovulation were recorded before patients received a 50-mg dose of clomiphene citrate. Following ovulation or no response to increasing clomiphene-citrate doses, correlations between predictors and treatment responses were analyzed. RESULTS: In total, 150 patients with PCOS experiencing infertility were enrolled. Following treatment, 110 (73.3%) patients ovulated. Highly significant differences were observed between treatment responders and non-responders in baseline amenorrhea, body mass index (BMI), waist circumference, total testosterone, anti-Müllerian hormone, fasting insulin, homeostatic model assessment of insulin resistance, and visceral fat area (P<0.001). Significant differences in mean ovarian volume (P<0.009) and ovarian stromal artery pulsatility index (P<0.003) were also observed. Total testosterone was the best individual predictor of clomiphene citrate treatment response. The area under the receiver operating characteristic curve in a multivariate prediction model was 0.98. CONCLUSIONS: A combination of patient amenorrhea, BMI, total testosterone, anti-Müllerian hormone, ovarian volume, ovarian stromal artery pulsatility index, and visceral fat area could be used to predict clomiphene-citrate treatment response in patients with PCOS experiencing infertility. ClinicalTrials.gov: NCT02269306.

Abdominal electromyography in laboring and non-laboring pregnant women at term and its clinical implications.

OBJECTIVE: To determine the patterns of uterine action potentials in laboring and non-laboring women at term using the non-invasive abdominal electromyography technique. METHODS: One hundred pregnant women at term who fulfilled the inclusion criteria were enrolled in the study and equally divided into two groups. Group I consisted of 50 women in active labor, while group II included 50 women not in labor. After enrollment, the cardiotocograph was applied to all women. Abdominal electromyographic recording was started and for every burst of action potential, we measured the amplitude, frequency and duration of action potential. The results were tabulated and statistically analyzed. RESULTS: Both groups were comparable in demographic characteristics. Four patterns of EMG were detected. The amplitude of action potentials was significantly higher in laboring compared to non-laboring women (77.44 ± 11.25 vs 13.71 ± 8.57, P < 0.001). Similar significantly longer durations of electrical bursts were also noted in laboring women (45.94 ± 8.77 vs 7.11 ± 4.68 s, P < 0.001). Specific electromyographic changes were noted in women passing from the non-laboring to laboring state and in women who required oxytocin augmentation during labor. CONCLUSION: Abdominal electromyography may help to distinguish between women in true active labor from those who are not. It also may help to identify women who will enter into labor within 24-72 h and those who require augmentation of labor.

Medication errors in the obstetrics emergency ward in a low resource setting.

OBJECTIVE: To investigate the patterns of medication errors in the obstetric emergency ward in a low resource setting. MATERIAL AND METHODS: This prospective observational study included 10,000 women who presented at the obstetric emergency ward, department of Obstetrics and Gynecology, Menofyia University Hospital, Egypt between March and December 2010. All medications prescribed in the emergency ward were monitored for different types of errors. The head nurse in each shift was asked to monitor each pharmacologic order from the moment of prescribing till its administration. Retrospective review of the patients' charts and nurses' notes was carried out by the authors of this paper. Results were tabulated and statistically analyzed. RESULTS: A total of 1976 medication errors were detected. Administration errors were the commonest error reported. Omitted errors ranked second followed by unauthorized and prescription errors. Three administration errors resulted in three Cesareans were performed for fetal distress because of wrong doses of oxytocin infusion. The rest of errors did not cause patients harm but may have lead to an increase in monitoring. Most errors occurred during night shifts. CONCLUSION: The availability of automated infusion pumps will probably decrease administration errors significantly. There is a need for more obstetricians and nurses during the nightshifts to minimize errors resulting from working under stressful conditions.