Effects of surgical repair of obstetric fistula on severity of depression and anxiety in Ethiopia.

BACKGROUND: The surgical repair of fistula can address the physical symptoms, but may not end the psychological challenges that women with fistula face. There are a few studies that focus on women with this condition in Ethiopia. Hence, the aim of this study was to determine the effects of surgical repair of obstetric fistula on the severity of depression and anxiety in women with obstetric fistula in Ethiopia. METHOD: The study employed a longitudinal study design to investigate the changes in 219 women with obstetric fistula admitted to six fistula management hospitals in Ethiopia. The data were collected on admission of the patients for obstetric fistula surgical repair and at the end of six-month post repair. A structured questionnaire was used to obtain socio-demographic information and medical history of the respondents. Depression and anxiety symptoms were measured using the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) scales. The data was entered using Epi-Data software and then exported to SPSS for further analysis. The Mann-Whitney-U test, the Kruskal-Wallis test and Paired t-test were performed to measure the change in psychological symptoms after surgical repair. RESULT: Though 219 respondents were interviewed pre-obstetric fistula surgical repair, only 200 completed their follow up. On admission, the prevalence of depression and anxiety symptoms were 91 and 79% respectively. After surgical repair, the prevalence rate was 27 and 26%. The differences in the prevalence of screen-positive women were statistically significant (P < 0.001). CONCLUSION: The study concluded that the severity of depression and anxiety symptoms decrease post-obstetric fistula surgical repair. However, a woman with continued leaking after surgery seems to have higher psychological distress than those who are fully cured. Clinicians should manage women with obstetric fistula through targeted and integrated mental health interventions to address their mental health needs.

Surgery, obstetrics and anaesthesia: a Cambrian explosion for global health.

Our current global health structure has not yet evolved to do what the world needs of it. Despite significant advances in some areas of public health over the past few decades, disparities in health have worsened in many areas. The historical approach of global health governance to health issues has been overwhelmingly led by vertical, single disease efforts. Yet, this structure cannot effectively implement broad-reaching international development goals set forth by the United Nations. The solution requires a rapid evolution of the present health system conceptualisation. As the Cambrian period brought skeletal infrastructure to life on our planet with vertebrates, allowing life to take on new capabilities never before witnessed on earth, so will surgery, obstetrics and anaesthesia provide the much needed healthcare delivery infrastructure that will allow health system strengthening to take global healthcare along a new path. Surgery, anaesthesia and obstetrics form the core foundation upon which the whole of global health is built and serve as the skeletal structure and indicator of robust health systems. Integrating these domains as the backbone of health system strengthening will finally allow global health to stand and support all sectors of healthcare delivery as an equal partner in health.

Utilization of surgical antibiotic prophylaxis for obstetrics and gynaecology surgeries in Northern Nigeria.

Background Audit of antibiotic prophylaxis is an important strategy used to identify areas where stewardship interventions are required. Objectives To evaluate compliance with surgical antibiotic prophylaxis in obstetrics and gynaecology surgeries and determine the Defined Daily Dose (DDD) of antibiotic. Settings Three public tertiary hospitals located in Northern Nigeria. Methods This prospective study included women who had obstetrics and gynaecology surgeries with no infection at the time of incision. Appropriateness of antibiotic prophylaxis was determined by a clinical pharmacist. DDD of antibiotics was determined using ATC/DDD index 2017 from the World Health Organization Collaborating Centre for Drugs Statistics Methodology. Main outcome measure Compliance with antibiotic prophylaxis and DDD of antibiotic per procedure. Results A total of 248 procedures were included (mean age: 31.7 ± 7.9 years). Nitroimidazole in combination with either beta-lactam/beta-lactamase inhibitor or third generation cephalosporin were the most prescribed antibiotics. Redundant anaerobic antibiotic combination was detected in 71.4% of the procedures. Timing of antibiotic prophylaxis was optimal in 16.5% while duration of prophylaxis was prolonged in all the procedures (mean duration was 8.7 ± 1.0 days). The DDD of antibiotics prophylaxis was 16.75 DDD/procedure. Antibiotic utilisation was higher in caesarean section and myomectomy (17.9 DDD/procedure) than hysterectomy (14.5 DDD/procedure); P < 0.001. Redundant metronidazole represents one-third of total DDD and 87% of the DDD for metronidazole. Conclusion Excessive and inappropriate use of antibiotic prophylaxis was observed in women who had obstetrics and gynaecology surgeries. These observations underline the need for antimicrobial stewardship interventions to improve antibiotic use.

Reducing Maternal Mortality in Papua New Guinea: Contextualizing Access to Safe Surgery and Anesthesia.

Papua New Guinea has one of the world's highest maternal mortality rates with approximately 215 women dying per 100,000 live births. The sustainable development goals outline key priority areas for achieving a reduction in maternal mortality including a focus on universal health coverage with safe surgery and anesthesia for all pregnant women. This narrative review addresses the issue of reducing maternal mortality in Papua New Guinea by contextualizing the need for safe obstetric surgery and anesthesia within a structure of enabling environments at key times in a woman's life. The 3 pillars of enabling environments are as follows: a stable humanitarian government; a safe, secure, and clean environment; and a strong health system. Key times, and their associated specific issues, in a woman's life include prepregnancy, antenatal, birth and the postpartum period, childhood, adolescence and young womanhood, and the postchildbearing years.

The Changing Scenario of Obstetrics and Gynecology Residency Training.

BACKGROUND: Significant changes have been noted in aspects of obstetrics-gynecology (ob-gyn) training over the last decade, which is reflected in Accreditation Council for Graduate Medical Education (ACGME) operative case logs for graduating ob-gyn residents. OBJECTIVE: We sought to understand the changing trends of ob-gyn residents' experience in obstetric procedures over the past 11 years. METHODS: We analyzed national ACGME procedure logs for all obstetric procedures recorded by 12 728 ob-gyn residents who graduated between academic years 2002-2003 and 2012-2013. RESULTS: The average number of cesarean sections per resident increased from 191.8 in 2002-2003 to 233.4 in 2012-2013 (17%; P < .001; 95% CI -47.769 to -35.431), the number of vaginal deliveries declined from 320.8 to 261 (18.6%; P < .001; 95% CI 38.842-56.35), the number of forceps deliveries declined from 23.8 to 8.4 (64.7%; P < .001; 95% CI 14.061-16.739), and the number of vacuum deliveries declined from 23.8 to 17.6 (26%; P < .001; 95% CI 5.043-7.357). Between 2002-2003 and 2007-2008, amniocentesis decreased from 18.5 to 11 (P < .001, 95% CI 6.298-8.702), and multifetal vaginal deliveries increased from 10.8 to 14 (P < .001, 95% CI -3.895 to -2.505). Both were not included in ACGME reporting after 2008. CONCLUSIONS: Ob-gyn residents' training experience changed substantially over the past decade. ACGME obstetric logs demonstrated decreases in volume of vaginal, forceps, and vacuum deliveries, and increases in cesarean and multifetal deliveries. Change in experience may require use of innovative strategies to help improve residents' basic obstetric skills.

Análisis de las causas de prolongación de la estancia en la Unidad de Reanimación del Hospital Maternal La Paz en el año 2008 / Analysis of the causes for increases in the length of stay in the Recovery Unit of La Paz Maternity Hospital in 2008

Objetivo: Establecer el espectro de enfermedades de la paciente obstétrica que implican la estancia prolongada en la unidad de reanimación de un hospital maternal monográfico; analizar la gravedad de dichas alteraciones en función de las medidas requeridas para su resolución, así como identificar los factores que influyen en la morbilidad del postoperatorio de la paciente obstétrica. Material y métodos: Se revisan todas las historias clínicas de todas pacientes que ingresaron en la Unidad de Reanimación del Hospital Universitario Maternal La Paz durante el año 2008, y se selecciona a las que requirieron un ingreso más largo de lo habitual, es decir, más de 6 h tras una cesárea y todo ingreso que se produjera durante la gestación o tras un legrado o el parto. Resultados: De un total de 10.419 nacimientos que se produjeron en 2008, 3.000 pacientes obstétricas pasaron por la Unidad de Reanimación del Hospital Maternal, de las que 285 (9,5%) necesitaron cuidados críticos. La causa más frecuente de la estancia prolongada fue la hemorragia obstétrica, seguida de los estados hipertensivos del embarazo. Ninguna paciente obstétrica falleció en esta unidad en 2008. Conclusiones: La cifra de pacientes que tuvieron que prolongar su estancia en la Reanimación del Hospital Maternal es similar al porcentaje de pacientes graves obstétricas que ingresan en unidades de cuidados intensivos de países como Canadá o Reino Unido, pero con una mortalidad menor en nuestro servicio en el año evaluado. Las principales causas son la hemorragia obstétrica y los estados hipertensivos del embarazo. Por ello, se debe vigilar y monitorizar a las pacientes con factores de riesgo de sufrir estas complicaciones(AU)

Objective: To establish the spectrum of diseases in the obstetric patient that involves an increase in the length of stay in the Recovery Unit of a specialist Maternity Hospital. To analyse the severity of these conditions as regards the means required for their resolution, as well as to identify the factors that influence on post-operative morbidity in the obstetric patient. Material and methods: All the case histories of all the patients admitted to the Maternity Hospital Recovery Unit during the year 2008 were reviewed. Those who required a longer stay than usual were selected, which included, those with more than 6 hours after a caesarean, and all admissions made during pregnancy, or after dilation and curettage or partum. Results: Out of a total of 10 419 births delivered in 2008, 3000 obstetric patients were admitted to the Maternity Hospital Recovery Unit, of which 285 (9.5%) required critical care. The most frequent cause of increased length of stay was obstetric haemorrhage, followed by hypertensive states of pregnancy. No patients died in this Unit in the year 2008. Conclusions: The number of patients who had an increased length of stay in the Maternity Hospital Recovery Unit is similar to the percentage of patients who are admitted to Intensive Care Units in countries such as Canada or the United Kingdom, but our Unit had a lower death rate in the year evaluated. The main causes are obstetric haemorrhage and hypertensive states of pregnancy, thus patients with risk factors for developing these complications must be observed closely and monitored(AU)

Open cornual resection versus laparoscopic cornual resection in patients with interstitial ectopic pregnancies.

OBJECTIVE: To compare laparotomy and laparoscopic management of interstitial ectopic pregnancies. STUDY DESIGN: The medical records of 109 patients diagnosed with interstitial ectopic pregnancies at the Korea University Medical Center, the Republic of South Korea, between January 1998 and October 2009 were reviewed retrospectively. Eighty-eight women were treated by open cornual resection or laparoscopic cornual resection. A case-controlled study was performed. The outcomes were operative time, length of hospital stay, estimated blood loss, blood transfusion, and complication. Nominal variables were analyzed by the Fisher's exact test or the χ(2) test. RESULTS: The frequency of cornual ectopic pregnancies was 4.31% at this medical center. In patients with a cornual resection, primary laparotomy was performed in 49 women and laparoscopy was performed in 39 women. Laparoscopy was converted to laparotomy in five patients. There were no statistically significant differences between the two groups for the mean operation time, estimated blood loss, blood loss of more than 1000 mL, blood transfusion requirements, and complications. The mean number of postoperative hospital days was shorter in the laparoscopy group than in the laparotomy group (4.53 ± 1.44 days versus 5.89 ± 1.86 days, respectively; P<0.001). CONCLUSION: Laparoscopic cornual resection is a safe and less invasive procedure with a reasonable complication rate and shorter hospital stay.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures.

OBJECTIVES: To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a woman's lifespan. METHODS: Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed. RESULTS: More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a woman's lifetime. CONCLUSION: Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women. LEVEL OF EVIDENCE: III.

Surgical treatment of intractable postpartum hemorrhage and changing trends in modern obstetric perspective.

PURPOSE: To update the prevalence and risk factors of intractable postpartum hemorrhage (IPH) and evaluate the effectiveness of surgical treatment modalities. METHODS: Between January 2002 and January 2008, IPH diagnosis was made in 86 cases. They were evaluated retrospectively. RESULTS: Placental implantation abnormalities were the leading cause, responsible for 45.6% of cases. Organ preserving surgery (OPS) methods were utilized in 47 cases, with a success rate of 76.6%. Among these cases, 11 were proceeded to hysterectomy. Hysterectomy was performed in 45 cases as definitive treatment. CONCLUSIONS: Compression sutures were quite effective in controlling hemorrhage due to placenta accreta and previa. For women who are hemodynamically stable and desirous for future fertility, OPS modalities should be applied first. Shorter operating time, hospital stay and less blood transfusion were seen with subtotal type hysterectomy, so in case of nonbleeding lower uterine segment, subtotal type should be performed first.

Incontinencia urinaria de esfuerzo en la mujer. Comparación de la técnica de Raz y de la técnica de Bologna / Comparison of Raz bladder neck suspension and the Bologna procedure for the treatment of urinary stress incontinence

Nuestra situación es la de comparar las complicaciones y los resultados sobre la incontinencia de esfuerzo de 2 técnicas de suspensión cervicouretral: la técnica de Raz y la técnica de Bologna. Se ha evaluado retrospectivamente a 199 pacientes que se han beneficiado de un tratamiento de incontinencia urinaria de esfuerzo, bien mediante la técnica de Bologna (grupo 1, 99 pacientes), bien por la técnica de Raz (grupo 2, 100 pacientes). Los datos clínicos preoperatorios, los parámetros urodinámicos y las complicaciones postoperatorias se han comparado en cada uno de los 2 grupos. El margen entre el tratamiento de la incontinencia urinaria y la recidiva se ha comparado con los 2 grupos por un test logarítmico. Se fabricó un modelo multivariante con la ayuda de un modelo de Cox, a fin de exponer los parámetros explicativos del fracaso quirúrgico. La duración de la curación en el grupo 1 es significativamente más larga que en el grupo 2 (p = 0,00001). La mediana de duración del intervalo libre sin incontinencia (éxito) es de 51 meses en el grupo 1 y de 21 meses en el 2 (p = 0,00001). La frecuencia de las complicaciones operatorias (lesión vesical y hemorragia) y postoperatorias (hemorrágicas, infecciosas y embólicas) no difieren en los 2 grupos. El análisis multivariante según el modelo de Cox muestra que la única variable preoperatoria explicativa de las recidivas es la técnica de colposuspensión realizada: Raz y Bologna. Después de este estudio comparativo, la técnica de Bologna debe preferirse a la de Raz para tratar los pacientes con IUE por el hecho de la presencia de suficiente pared vaginal anterior para confeccionar las cinchas vaginales. Si tal no es el caso, la técnica de Raz, tal y como nosotros la habíamos practicado, se debe abandonar en beneficio de otros métodos de colposuspensión (AU)

The aim of this study was to evaluate and compare perioperative morbidity and the long-term results of Raz colposuspension and the Bologna procedure in the treatment of urinary stress incontinence in women. Data from 199 women who underwent either the Bologna procedure (group 1; n = 99) or Raz colposuspension (group 2; n =100) for urinary stress incontinence were retrospectively analyzed. Preoperative clinical data, urodynamic parameters and postoperative complications were compared between the two groups. Logarithmic analysis was used to compare time to recurrence of stress incontinence between the two groups. Multivariate analysis using a Cox proportional hazards regression model was performed to identify possible outcome predictors. The success rate was significantly higher in group 1 than in group 2 (p = 0.00001). The median incontinence- free interval was 51 months in group 1 and was 21 months in group 2 (p = 0.00001). No differences were found between the two groups in the frequency of intraoperative complications (inadvertent cystotomy, hemorrhage) and postoperative complications (hemorrhagic, infectious and embolic complications). Multivariate analysis using the Cox regression model showed that the only variable correlated with the surgical cure rate was the type of surgical anti-incontinence procedure adopted: Bologna or Raz (p = 0.00001). The results of this study indicate that the Bologna procedure should be preferred over Raz colposuspension in the treatment of urinary stress incontinence when sufficient anterior vaginal tissue is available to create vaginal bands. When this is not the case, Raz colposuspension, as performed in the present study, should be abandoned in favor of other colposuspension methods (AU)

[Progress in ambulatory anesthesia applied to gynecological surgery]. / Progrès de l'anesthésie ambulatoire appliqués à la chirurgie gynécologique.

Ambulatory gynecological surgery enables fast recovery of vital functions, ambulation and a relational life of quality. Patients whose disease is well-controlled at the anesthesia consultation can benefit from ambulatory procedures. Improved material and surgical practices broaden potential indications, limiting the risk of postoperative pain which can be controlled with simple analgesic protocols. The choice of the anesthesic techniques or the agents used during the intervention ensures fast recovery of higher functions. Nausea and vomiting, which may develop after returning home and compromise oral drug intake, must be prevented. More ambulatory gynecological procedures can be expected in the near future, pointing out the importance of developing more adapted medical structures.

Trends for inpatient treatment of tubal pregnancy in Maryland.

OBJECTIVE: The purpose of this study was to determine the burden of tubal pregnancy in Maryland in hospitalized patients and to elicit treatment trends. STUDY DESIGN: Patients who were admitted with tubal pregnancy from January 1, 1994, through March 31, 1999, were identified with the use of the Maryland Health Service Cost Review Commission discharge database. Combining this with census data, we calculated the incidence. Cases were then stratified by demographics, presentation, and surgeon volume. Outcome measures included type of medical treatment,conservative (salpingostomy or salpingotomy) or extirpative operation (salpingectomy, salpingo-oophorectomy, oophorectomy, hysterectomy), length of stay, charges, and disposition. The treatment groups were compared with the use of t tests and linear regression, and associations between demographics and type of operation were analyzed with logistic regression. RESULTS: The database included 3729 cases, which yielded an annual incidence of 5.2 per 10,000 women aged 15 to 45 years. Subjects averaged 29.6 years old and were predominantly African American(52.6%) and white (43.3%). Most of the women (67.8%) were seen in the emergency department and were treated surgically (90.7%). Conservative operation was performed in 18.1% of the women; extirpative operation was performed in 81.9% of the women. Significant predictors for extirpative operation were emergency department admission (odds ratio, 1.44; 95% CI, 1.18-1.75), increasing age (odds ratio, 1.07; 95% CI, 1.06-1.09), African American race (odds ratio, 1.87; 95% CI, 1.51-2.31), higher surgeon volume (odds ratio, 1.28; 95% CI, 1.04-1.57), and market area. Length of stay and total charges were higher for the extirpative group(P <.0001). The study lacked the power to detect differences in outcomes for other nonwhite races (5% power), laparoscopy versus laparotomy (15% power), or operating room charges (14% power). CONCLUSION: These data are limited to hospitalized patients and probably underestimate the true incidence of tubal pregnancy. Most patients underwent extirpative operation. Acuity of presentation and increasing age were appropriate predictors of this group. However, physician volume and black race were also predictors. This may be due to differences in the prevalence of disease, unmeasured clinical factors, patient and physician preferences for treatment, barriers that delayed care, or other socioeconomic factors.