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.

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.