Incidence, risk factors and management of post cesarean section surgical site infection (SSI) in a tertiary hospital in Egypt: a five year retrospective study.

BACKGROUND: Surgical site infection (SSI) is one of the commonest complications following cesarean section (CS) with a reported incidence of 3-20%. SSI causes massive burdens on both the mother and the health care system. Moreover, it is associated with high maternal morbidity and mortality rate of up to 3%. This study aims to determine the incidence, risk factors and management of SSI following CS in a tertiary hospital. METHODS: This was an observational case control retrospective study which was conducted at Minia maternity university hospital, Egypt during the period from January 2013 to December 2017 (Five years). A total of 15,502 CSs were performed during the studied period, of these, 828 cases developed SSI following CS (SSI group). The control group included 1500 women underwent cesarean section without developing SSI. The medical records of both groups were reviewed regarding the sociodemographic and the clinical characteristics. RESULTS: The incidence of SSI post-cesarean section was 5.34%. Significant risk factors for SSI were; chorioamnionitis (adjusted odds ratio (AOR) 4.51; 95% CI =3.12-6.18), premature rupture of membranes (PROM) (AOR 3.99; 95% CI =3.11-4.74), blood loss of > 1000 ml (AOR 2.21; 95% CI =1.62-3.09), emergency CS (AOR 2.16; 95% CI =1.61-2.51), duration of CS of > 1 h (AOR 2.12; 95% CI =1.67-2.79), no antenatal care (ANC) visits (AOR 2.05; 95% CI =1.66-2.37), duration of labor of ≥24 h (AOR 1.45; 95% CI =1.06-2.01), diabetes mellitus (DM) (AOR 1.37; 95% CI =1.02-2.1 3), obesity (AOR 1.34; 95% CI =0.95-1.84), high parity (AOR 1.27; 95% CI = 1.03-1.88), hypertension (AOR 1.19; 95% CI = 0.92-2.11) and gestational age of < 37 wks (AOR 1.12; 95% CI = 0.94-1.66). The mortality rate due to SSI was 1.33%. CONCLUSIONS: The obtained incidence of SSI post CS in our study is relatively lower than other previous studies from developing countries. The development of SSI is associated with many factors rather than one factor. Management of SSI is maninly medical but surgical approach may be needed in some cases. REGISTRATION: Local ethical committee (Registration number: MOBGYN0040).

A ten year analysis of maternal deaths in a tertiary hospital using the three delays model.

BACKGROUND: Reducing maternal mortality ratios (MMRs) remain an important public health issue in Egypt. The three delays model distinguished three phases of delay to be associated with maternal mortality: 1) first phase delay is delay in deciding to seek care; 2) second phase delay is delay in reaching health facilities; and 3) third phase delay is delay in receiving care in health facilities. Increased health services' coverage is thought to be associated with a paradigm shift from first and second phase delays to third phase delay as main factor contributing to MMR. This study aims to examine the contribution of the three delays in relation to maternal deaths. METHODS: During a 10 year period (2008-2017) 207 maternal deaths were identified in a tertiary hospital in Minia governorate, Egypt. Data were obtained through reviewing medical records and verbal autopsy for each case. Then data analysis was done in the context of the three delays model. RESULTS: From 2008 to 2017 MMR in this hospital was 186/100.000 live births. Most frequent causes of maternal mortality were postpartum hemorrhage, hypertensive disorders of pregnancy and sepsis. Third phase delay occurred in 184 deaths (88.9%), second phase delay was observed in 104 deaths (50%), always together with other phases of delay. First phase delay alone was observed in 13 deaths (6.3%) and in 82 deaths (40%) with other phases of delay. One fifth of the women had experienced all three phases of delay together. Major causes of third phase delay were delayed referral from district hospitals, non-availability of skilled staff, lack of blood transfusion facilities and shortage of drugs. CONCLUSIONS: There is a paradigm shift from first and second phases of delay to the third phase of delay as a major contributor to maternal mortality. Reduction of maternal mortality can be achieved through improving logistics, infrastructure and health care providers' training. TRIAL REGISTRATION: This study is a retrospective study registered locally and approved by the ethical committee of the Department of Obstetrics and Gynaecology, Minia University Hospital on 1/4/2016 (Registration number: MUEOB0002).

Effect of intrathecal fentanyl on the incidence, severity, and duration of postdural puncture headache in parturients undergoing caesarean section: A randomised controlled trial.

BACKGROUND AND AIMS: Postdural puncture headache (PDPH) is a side effect of spinal anaesthesia (SA). This study was conducted to investigate the effect of intrathecal fentanyl on the incidence, severity, and duration of PDPH. METHODS: This was a prospective randomised controlled study including 220 parturients, who underwent Caesarean section (CS). They were divided into two groups for administration of SA with bupivacaine (bupivacaine group [B0], n = 111) or bupivacaine with fentanyl (bupivacaine fentanyl group [BF], n = 109). Haemodynamics, quality of anaesthesia, maternal side effects, and postoperative analgesia were noted. The neonatal Apgar score was recorded. The patients were followed up for 14 days after CS for the occurrence of PDPH, and its severity and duration. The collected data were statistically analysed, using the Statistical Package for the Social Sciences software version 25. RESULTS: Regarding haemodynamics, heart rate increased at 5 min post-induction and blood pressure decreased at 2min post-induction in both groups. Excellent intraoperative anaesthesia was obtained in 91.7% and 79.3% of cases in groups BF and B0, respectively (P < 0.01). Longer duration of postoperative analgesia was present in the BF group as compared to the B0 group (P < 0.001). The incidence of PDPH decreased in the BF group in a non-significant manner, whereas its severity and duration increased significantly in the B0 group. CONCLUSION: Although the addition of intrathecal fentanyl to bupivacaine for SA in CS patients did not reduce the incidence of PDPH significantly, its severity and duration decreased significantly.

Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study.

BACKGROUND: Placenta accreta spectrum (PAS) disorders have become a significant life-threatening issue due to its increased incidence, morbidity and mortality. Several studies have tried to identify the risk factors for PAS disorders. The ideal management for PAS disorders is a matter of debate. The study objectives were to evaluate the incidence and risk factors of PAS disorders and to compare different management strategies at a tertiary referral hospital, Minia, Egypt. METHODS: This prospective study included 102 women diagnosed with PAS disorders admitted to Minia Maternity university hospital, Egypt between January 2017 to August 2018. These cases were categorized into three groups according to the used approach for management: Group (A), (n = 38) underwent cesarean hysterectomy, group (B), (n = 48) underwent cesarean section (CS) with cervical inversion and ligation of both uterine arteries and group (C), (n = 16): the placenta was left in place. RESULTS: The incidence of PAS disorders during the study period was 9 / 1000 maternities (0.91%). The mean age of cases was 32.4 ± 4.2 years, 60% of them had a parity ≥3 and 82% of them had ≥2 previous CSs. Also, 1/3 of them had previous history of placenta previa. Estimated blood loss (EBL) and blood transfusion in group A were significantly higher than other groups. Group (C) had higher mean hospital stay duration. Group A was associated with significantly higher complication rate. CONCLUSIONS: The incidence of PAS disorders was 0.91%. Maternal age > 32 years, previous C.S. (≥ 2), multiparity (≥ 3) and previous history of placenta previa were risk factors. The management of PAS disorders should be individualized. Women with PAS disorders who completed their family should be offered cesarean hysterectomy. Using the cervix as a tamponade combined with bilateral uterine artery ligation appears to be a safe alternative to hysterectomy in patients with focal placenta accreta and low parity desiring future fertility. Patients with diffuse placenta accreta keen to preserve the uterus could be offered the option of leaving the placenta aiming at conservative management after proper counseling. TRIAL REGISTRATION: Registered 28th October 2015, ClinicalTrials.gov NCT02590484 .

Intra-abdominal infection (IAI) following cesarean section: a retrospective study in a tertiary referral hospital in Egypt.

BACKGROUND: The incidence of post cesarean intra-abdominal infection (IAI) and the independent risk factors associated with it were retrospectively studied at a tertiary referral hospital in Egypt. METHODS: The study targeted the period between January 2014 and December 2017 (4 years) at Minia University Hospital for Obstetrics and Gynecology (a tertiary referral hospital), Minia Governorate, Egypt. All cases that developed IAI following cesarean section (CS) during the study period were included (408 cases, which served as the case group); in addition, 1300 cases that underwent CS during the study period and were not complicated by IAI or surgical site Infection (SSI) were randomly chosen from the records (control group). The records of cases and controls were compared and bivariate analysis and multivariate logistic regression were used to identify risk factors for IAI. RESULTS: During the studied period, there were 35,500 deliveries in the hospital, and 14200 cases (40%) of these were by cesarean section, producing a rate of 40%. The incidence of IAI post CS was 2.87%, and the mortality rate was 1.2% (due to septicemia). The most identifiable risk factors for IAI were chorioamnionitis (AOR 9.54; 95% CI =6.15-16.2; p ≤ 0.001) and premature rupture of membranes (PROM) (AOR 7.54; 95% CI =5.69-10.24; p ≤ 0.001). Risk factors also included: prolonged duration of CS >  1 h (AOR 3.42; 95% CI =2.45-5.23; p = 0.005), no antenatal care (ANC) visits (AOR 3.14; 95% CI =2.14-4.26; p = 0.003), blood loss > 1000 ml (AOR 2.86; 95% CI =2.04-3.92; p = 0.011), emergency CS (AOR 2.24; 95% CI =1.78-3.29; p = 0.016), prolonged labor ≥24 h. (AOR 1.76; 95% CI =1.26-2.27; p = 0.034) and diabetes mellitus (AOR 1.68; 95% CI =1.11-2.39; p = 0.021). CONCLUSIONS: The incidence of IAI post CS in our hospital was 2.87%. Identification of predictors and risk factors for IAI is an important preventive measure.

Management of bleeding from morbidly adherent placenta during elective repeat caesarean section: retrospective -record -based study.

BACKGROUND: Controlling massive haemorrhage from morbidly adherent placenta (MAP) at caesarean section is a major surgical challenge to obstetricians. This study compares different intra-operative interventions to control haemorrhage from morbidly adherent placenta and its impact on maternal morbidity. METHODS: Retrospective analysis was done for baseline characteristics, intra-operative and postoperative complications of 125 patients with morbidly adherent placenta who had elective CS at 35-38 weeks gestation in the period from 01/2012 to 01/2017. The included patients were categorized into three groups according to intra-operative interventions they had for controlling bleeding; Group A (n = 42) had only balloon tamponade, Group B (n = 40) had balloon tamponade and bilateral uterine artery ligation, in Group C (n = 43) all cases were managed by bilateral uterine artery ligation and inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment using the cervix as a natural tamponade. RESULTS: There were no differences of baseline characteristics of patients in all groups. Group C had significantly better outcomes as compared with groups A and B; less total blood loss (Group C 2869.5 ml vs Group B 4580 ml, Group A 4812 ml, P <  0.001), less requirement of blood transfusion more than 4 units (Group C 4/43, Group B 10/40,Group A 12/42, P <  0.02), significant reduction in prolonged hospital stay over 10 days (Group C 2/43, Group B 9/40,Group A 14/42, P < 0.001) and lower risk of coagulopathy (Group C 4/43, B 8/40, A 9/42), visceral injuries (Group C 4/43 vs B 8/40, A 10/42,P < 0.01) and need for hysterectomy (Group C 4/43 vs B 11/40, A 13/42,P < 0.001). CONCLUSION: A combination bilateral uterine artery ligation and using the cervix as a natural tamponade are very effective and simple methods in controlling bleeding resulting from separated placenta accreta. TRIAL REGISTRATION: The findings are part of the research project registered in ClinicalTrials.gov NCT02590484 . Registered 28 October 2015.

Perceptions and Practice of Labor Pain-Relief Methods among Health Professionals Conducting Delivery in Minia Maternity Units in Egypt.

INTRODUCTION: In low-resource settings (LRSs), pain relief during labor is often neglected. Women and health professionals (HPs) may lack awareness of analgesic options, may not accept these options, or may have concerns regarding their safety. Furthermore, even if women or HPs preferred labor analgesia, options may not be available at the hospital. This study was carried out to explore how HPs perceive and practice pain management during labor in Minia maternity units in Egypt. METHODS: A structured, self-administered questionnaire from 306 HPs in Minia maternity units from August 1, 2016, to August 30, 2017, after approval by the organizational Ethical Review Committee. RESULTS: The response rate was 76.5%. The majority, 78.2% of participants, believed in pain relief during labor. However, their practices are different. In the first stage of labor, almost 44.9% used nonpharmacological methods, whereas 36.8% used neither pharmacological nor nonpharmacological methods. Hospital-related factors were the major barriers against using pain-relief methods, as stated by HPs. CONCLUSION: Although most HPs understand the role of analgesia in labor pain relief, there is a wide gap between the use of pain-relief methods and women's need in Minia, Egypt; HPs claim this is due to health care facilities. There is an urgent need to identify the barriers against and raise the awareness among the community and HPs of the need to use pain-relief methods as part of improving the quality of care during labor.

Two week waits: What are we waiting for?

OBJECTIVES: To evaluate the two-week referral system by analysing the 2-week wait (2WW) referrals to the rapid access gynaecology clinic over one year. We have also sought to identify the risk factors for endometrial cancer to help setting criteria that can be used to prioritise urgent appointments, refine subsequent management strategies. STUDY DESIGN: Retrospective review of the data of all women referred for suspected gynaecological cancers over one year via the 2 WW office at Queen's Hospital, Romford, UK. Data of all other women in whom a diagnosis of a gynaecological malignancy was made during the same period following non-urgent (non-2WW) referrals were also collected. RESULTS: Over one year, a total of 1105 women were referred under the 2WW for suspected gynaecological malignancy. A total of 765 patients (69.23%) were referred with suspected endometrial cancer and the main indication for referral was postmenopausal bleeding. Hundred-seventy nine women (16.20%) were referred with suspected ovarian cancer. A pelvic mass found in 62 of these women and this was the main indication of referral. The number of women referred with suspected cervical cancer was 117 (10.59%) and the main indication for referral was postcoital bleeding. Forty-four women (3.98%) referred with suspected vulvo-vaginal cancer and the main presentation was vulval lesion. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulvo-vaginal malignancy was 8.1%, 9.5%, 5.98% and 13.64% and the overall predictive value for diagnosing gynaecological malignancy was 8.33%. The predictive values of the 2WW referrals for diagnosing different types of gynaecological cancers in premenopausal women are low compared to postmenopausal women (1.86% and 9.89% respectively, p<0.001). The number of cancers diagnosed through non-urgent system was higher than the number diagnosed through urgent system (95 vs. 92). Presence of diabetes mellitus, increased endometrial thickness, prolonged bleeding and advancing age represent the best model for predicting endometrial cancer. CONCLUSION: The overall predictive value of the 2WW system for suspected gynaecological malignancies is low particularly in premenopausal women. The current referral criteria need to be modified with a view to incorporating risk factors to prioritise urgent appointments and refine subsequent management plans.

Does laparoscopy still has a role in modern fertility practice?

BACKGROUND: More than 3 decades after the introduction of in vitro fertilization (IVF) and despite the improved success rates of assisted reproductive technologies, the argument for performing laparoscopy as a part of the infertility workup still stands. OBJECTIVE: To evaluate the role of laparoscopy±hysteroscopy in diagnosis and management of infertility in our setting in view of modern fertility practice. MATERIALS AND METHODS: This case control study was carried out on 600 infertile women subjected to laparoscopy or combined laparoscopy and hysteroscopy at endoscopy unit in Minia University Hospital, Egypt during the period from January 2012 to December 2014. RESULTS: The causes of infertility as identified by laparoscopy±hysteroscopy were polycystic ovary syndrome (25.1%), tubal factor (30%), uterine cause (4%), and endometriosis (2.7%). No cause was identified in 38.2% of cases. Based on operative findings, women were treated with different options. Expectant management was used in 92 cases (15.3%). Ovulation induction with anti-estrogens or gonadotropins was used in 372 cases (62%). Sixty cases (10%) had intrauterine insemination and sixty four cases (10.7%) underwent in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) treatment. Within 1 yr after laparoscopy, 180 cases achieved pregnancy (30%). The most favorable outcome was recorded in women with unexplained infertility (36.7% of cases got pregnant) followed by women with polycystic ovary syndrome (27.8%). Participants with uterine and tubal infertility factor achieved pregnancy in 25% and 22.8% of cases, respectively. The worst outcome was recorded in women with endometriosis. CONCLUSION: Laparoscopy still has an important role in the diagnosis and treatment of infertility.

The cervix as a natural tamponade in postpartum hemorrhage caused by placenta previa and placenta previa accreta: a prospective study.

BACKGROUND: Placenta previa and placenta accreta carry significant maternal and fetal morbidity and mortality. Several techniques have been described in the literature for controlling massive bleeding associated with placenta previa cesarean sections. The objective of this study was to evaluate the efficacy and safety of the use of the cervix as a natural tamponade in controlling postpartum hemorrhage caused by placenta previa and placenta previa accreta. METHODS: This prospective study was conducted on 40 pregnant women admitted to our hospital between June 2012 and November 2014. All participating women had one or more previous cesarean deliveries and were diagnosed with placenta previa and/or placenta previa accreta. Significant bleeding from the placental bed during cesarean section was managed by inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment. RESULTS: The technique of cervical inversion described above was successful in stopping the bleeding in 38 out of 40 patients; yielding a success rate of 95%. We resorted to hysterectomy in only two cases (5%). The mean intra-operative blood loss was 1572.5 mL, and the mean number of blood units transfused was 3.1. The mean time needed to perform the technique was 5.4 ± 0.6 min. The complications encountered were as follows: bladder injury in the two patients who underwent hysterectomy and wound infection in one patient. Postoperative fever that responded to antibiotics occurred in 1 patient. The mean duration of the postoperative hospital stay was 3.5 days CONCLUSIONS: This technique of using the cervix as a natural tamponade appears to be safe, simple, time-saving and potentially effective method for controlling the severe postpartum hemorrhage (PPH) caused by placenta previa/placenta previa accreta. This technique deserves to be one of the tools in the hands of obstetricians who face the life-threatening hemorrhage of placenta accreta. TRIAL REGISTRATION: ClinicalTrials.gov NCT02590484 . Registered 28 October 2015.