Female genital mutilation (FGM) in Egypt, knowledge and concepts of Egyptian medical students: a cross-sectional study.

There are many factors contributing to the existence of female genital mutilation (FGM). FGM has a long list of recorded complications, which include physical, obstetric, sexual, psychological and death. We assessed the knowledge, attitudes and perceptions of FGM practice among Egyptian medical students. An online questionnaire was distributed. One thousand one hundred and forty-one participants completed questionnaires. 71.2% were aware of FGM complications especially among females. Two-thirds reported illegality. 7.8% were in favour of FGM conduct with a higher male preference. Religious and traditional factors were the principle contributing factors to the practice. Three quarters of female students did not agree that FGM increased the chance of marriage. Almost one-fifth of female students reported having been subject to FGM, with a high level of dissatisfaction. It was shown that Egyptian medical students lacked knowledge about FGM with no structured training, so every effort should be done to end this inhumane practice.Impact StatementWhat is already known on this subject? The conduct of female genital mutilation (FGM) in Egypt is motivated by a variety of factors, including social notions, cultural beliefs and theological misunderstanding. FGM has a long list of recorded complications, which might include physical, obstetric, sexual, psychological and even death.What do the results of this study add? This study provides policy makers and community managers with the evidence needed to advocate for the addition of FGM education to be introduced across the board in medical school curriculums.What are the implications of these findings for clinical practice and/or further research? Possible elimination of the practice and further research on how to eradicate the roots behind it.

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).

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.

A comprehensive analysis of CDC20 overexpression in common malignant tumors from multiple organs: its correlation with tumor grade and stage.

High expression of cell division cycle 20 homolog (CDC20), a key component of the spindle assembly checkpoint (SAC), has been reported in various malignancies and plays a vital role in tumorigenesis and progression. The goal of this study was to evaluate the utility of CDC20 immunostaining in a wide range of malignant tumors. CDC20 immunohistochemistry was evaluated in normal tissues and compared to the most frequently occurring malignant tumors in these tissues (bladder, breast, cervical, colonic, endometrial, gastric, head and neck, liver, lung, ovarian, pancreatic, prostatic, renal, thyroid carcinomas, and testicular seminoma). Normal/non-neoplastic tissues showed positive CDC20 expression in 19.44 % of all examined cases. CDC20 staining was negative in normal and non-neoplastic tissues from the bladder, cervix, liver, stomach, and thyroid. From the all malignant tumors examined 55.7 % showed high CDC20 expression while low expression was found in 44.3 %. High expression of CDC20 was associated with high tumor grade in the bladder (p = 0.027), cervical (p = 0.032), colonic (p = 0.026), endometrial (p = 0.016), gastric (p = 0.033), liver (p = 0.028), ovarian (p = 0.044), prostatic (p = 0.040), and renal (p = 0.048) carcinomas. There was a significant correlation between high CDC20 expression and advanced tumor stage in carcinoma of the breast, colon, endometrium, and prostate (p = 0.021, p = 0.040, p = 0.047, p = 0.031, respectively). CDC20 expression may be useful as a biomarker of tumor prognosis and as a therapeutic target of human cancer.

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.

Correlation of NQO1 and Nrf2 in Female Genital Tract Cancer and Their Precancerous Lesions (Cervix, Endometrium and Ovary).

BACKGROUND: NAD (P) H/quinone oxidoreductase 1 (NQO1) is a metabolizing enzyme that detoxifies chemical stressors and antioxidants. Nuclear factor erythroid 2-related factor 2 (NrF2) is an important transcriptional activator involved in the cellular defense mechanisms against oxidative stress. METHODS: The immunohistochemical expression of NQO1 and Nrf2 in 80 cervical, 80 endometrial and 100 ovarian specimens with different lesions was studied. Then we study the relation of both NQO1 and Nrf2 expression and clinicopathological features of carcinoma cases. RESULTS: Immunohistochemical stain showed that NQO1 and Nrf2 were highly expressed in carcinoma compared with normal and precancerous lesions. Significant positive correlations were found between the mean expression of NQO1 and Nrf2 in different lesions. Moreover, there was significant correlation between the high level of NQO1 and Nrf2 expression and high tumor grade in cervical and endometrial carcinoma cases. Nrf2 expression was significant with advanced stage in endometrial and ovarian carcinomas. CONCLUSIONS: NQO1 and Nrf2 might be new biomarkers for early diagnosis and prognostic evaluation as well as being targets for therapy in patients with tumors in female genital tract.

Reproductive health awareness among educated young women in Egypt.

OBJECTIVE: To assess the awareness of female Egyptian university students regarding reproductive health (RH) issues, and determine the factors contributing to the students' awareness. METHODS: A cross-sectional survey was conducted, in which 220 female Egyptian university students selected by purposive random sampling were interviewed by means of an in-depth questionnaire. The interviews were private and confidential, and the questions concerned female reproductive anatomy and physiology; sexually transmitted diseases and HIV/AIDS; personal preferences, such as age of marriage and spacing between pregnancies; and where young women can access RH care. RESULTS: A large proportion of the participants exhibited misunderstanding or a complete lack of knowledge about important RH issues. This overall result, which was determined to be attributable to age and sociocultural factors such as education level, comes as a source of concern for both health service providers and policy makers. CONCLUSION: Awareness of RH is poor in Egypt, even among young women attending institutions of higher education. The present study not only highlights the persistent need for the ongoing RH information programs, but may also provide policy makers with data that will inform new strategies.

Circulating levels of matrix proteases and their inhibitors in pregnant women with and without a history of recurrent pregnancy loss.

BACKGROUND: We have recently shown that serum relaxin-2 levels are attenuated in women with a history of recurrent pregnancy loss (RPL). We sought to determine whether a history of RPL is also associated with changes in serum matrix metalloproteases (MMPs) and tissue inhibitors of matrix metalloproteases (TIMP) -1 and -2. METHODS: We obtained serum from 20 pregnant women with a history of RPL and 20 age-matched pregnant women with no history of RPL (NRPL) at 6-8, 10-12, 20, and 34 weeks gestation, and from cord blood. We quantified total serum concentrations of MMP-1, MMP-3, MMP-9 and TIMP-1 and TIMP-2 by ELISA. We determined whether these serum marker levels were associated with a history of RPL and delivery before 37 weeks gestation. RESULTS: There was no difference in the rates of miscarriage, preterm birth or prelabour rupture of fetal membranes between RPL and NRPL. However babies born to RPL were lighter than those born to NRPL. Serum MMP-1, 9, and TIMP-1 did not differ between RPL and NRPL but MMP-3 was higher in RPL vs. NRPL at 6-8 weeks (P < 0.05). Serum TIMP-2 levels were higher in RPL women at all gestations (P < 0.01). The ratio of RLX-2 (reported previously) to TIMP-2 at 10-12 weeks gestation was more strongly associated with a history of RPL than either peptide separately - area under the ROC curves for RLX-2 0.79 (95% CI 0.57 to 0.92), TIMP-2 0.83 (95% CI 0.63 to 0.95), and for RLX-2:TIMP-2 ratio 0.92 (95% CI 0.74 to 0.99). CONCLUSIONS: Women with a history of RPL demonstrate increased serum TIMP-2 and reduced RLX-2 during a subsequent viable pregnancy. Determination of both markers in early pregnancy enhances the discrimination of women with a history of RPL. These observations suggest roles for these two peptides in early implantation and placental development. Whether these may prove to be reliable early predictive markers for subsequent pregnancy loss in the index pregnancy is unknown and will require further studies.

Serum relaxin levels are reduced in pregnant women with a history of recurrent miscarriage, and correlate with maternal uterine artery Doppler indices in first trimester.

OBJECTIVES: Defective implantation is a mechanism for recurrent pregnancy loss (RPL). We sought to determine whether the serum expression of human relaxin-2 (RLX) is impaired in women with a history of RPL. STUDY DESIGN: Employing a prospective case-controlled design we studied 20 pregnant women with a history of RPL and 20 age-matched women with no history of RPL (NRPL). We measured serum relaxin-2 levels by ELISA at 6-8, 10-12, 20, and 34 weeks gestation and in cord blood, and maternal uterine artery Doppler resistance index (RI) at >or=10 weeks gestation. RESULTS: Relaxin rose to a peak at 12 weeks, and gradually declined towards term. At all gestations, women with a history of RPL had lower RLX levels than women without. At 10-12 weeks gestation, uterine artery RI correlated with serum RLX for both RPL and NRPL. In the NRPL group at 10-12 weeks the presence of a notched waveform was associated with higher RLX levels than the absence of a notch (mean 2.1 ng/ml vs. 1.3 ng/ml, P<0.05) and also at 20 weeks (2.1 ng/ml vs. 0.95 ng/ml, P<0.05) but no such difference was seen in the RPL group. Umbilical venous RLX was 4-fold higher in the RPL group than the NRPL group. CONCLUSION: Women with a history of RPL demonstrate attenuated levels of serum RLX across all pregnancy trimesters. How dysregulated RLX metabolism may contribute to adverse pregnancy outcome in RPL requires further investigation.

Differential Expression Patterns of PTEN in Cyclic, Hyperplastic and Malignant Endometrium: Its Relation with ER, PR and Clinicopathological Parameters.

UNLABELLED: PTEN is a tumor suppressor gene, which is frequently mutated and involved in the control of cell proliferation, differentiation, and apoptosis in a variety of human tumors including endometrium. We hypothesized that PTEN expression in endometrium is variable throughout the menstrual cycle as well as different endometrial lesions, and that steroid hormones regulate PTEN expression because PTEN is critical in many steroid-sensitive tissues such as endometrium. AIM OF WORK: In this study, we aimed to assess the relationships between PTEN expression and estrogen (ER), progesterone receptors (PR) in normal endometrium, hyperplasia and endometrial carcinoma. We also evaluated the relationship between PTEN expression and clinicpathologic parameters including tumor grade, stage and myomrtial invasion in endometrial carcinoma. METHODS: Specimens included 12 cyclical endometrium, 12 cases endometrial hyperplasia without atypia, 8 cases atypical endometrial hyperplasia and 35 endometrial carcinoma specimens. Immunohistochemical staining for PTEN protein, ER and PR was performed with the Streptavidin-biotin method on formalin-fixed and paraffinembedded tissue samples. PTEN, ER and PR expression was represented as the staining score. RESULTS: Immunohistochemistry showed that PTEN, ER and PR were positive for nuclei of cells. The PTEN staining score of normal endometrium was higher in the proliferative phase than in the secretory phase. The PTEN scores in atypical hyperplasia and endometrial carcinoma were significantly lowered than those for cyclic and hyperplasia without atypia. In endometrial carcinoma, PTEN expression was significantly correlated with histological grade while no significant associations with either stage or myometrial invasion were seen. Significant correlations were detected between PTEN and PR in EC cases and between PR and ER in all lesions, while no correlation was seen between ER and PTEN in different lesions. CONCLUSIONS: PTEN expression has been changes throughout the menstrual cycle. We suggest that PTEN is involved in the early stages of endometrial carcinogenesis. In endometrial carcinomas, loss of PTEN expression is involved in tumor cell differentiation. KEY WORDS: PTEN - Cyclic - Hyperplastic - Malignant endometrium - Estrogen receptor - Progesterone Receptor.