Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Tranexamic Acid versus Carbetocin for Reduction of Blood Loss during Abdominal Myomectomy: A Randomized Clinical Trial

Abstract

Introduction: Uterine fibroids are benign tumours of the uterus. They represent the most common benign tumour of the female genital tract during reproductive period. The aim of this study was to decrease blood loss during myomectomy using carbetocin in comparison with tranexamic acid.

Material and Methods: In this randomized clinical trial, 132 patients with uterine fibroids were enrolled for our study at Gynaecology outpatient clinic, Suez Canal University Hospitals, from May 2016 to May 2018. Patients were assessed by full history, clinical examination, transvaginal ultrasound and laboratory investigations. After patients’ counselling and consent, they were randomly assigned into 2 groups (66 patients each); the first group received 30 ml of sodium chloride with added 50mg tranexamic acid, while the second group received 30 ml of sodium chloride with added 100 mg Carbetocin. Both drugs were delivered at the time of skin incision by intravenous infusion. The amount of blood loss was estimated intra-operatively and post-operatively and the collected data were statistically analysed.

Results: Total blood loss was significantly lower in the carbetocin group (399.27 ± 28.94ml) than the tranexamic acid group (535.15 ± 80.30ml) (p <0.001). Intra-operative blood loss was significantly lower in the carbetocin group (371.39 ± 27.54 ml) than the tranexamic acid group (478.48 ± 60.4ml) (p <0.001). Post-operative blood loss was significantly lower in the carbetocin group (27.88 ± 32.32 ml) than the tranexamic acid group (56.67 ± 53.13ml) (p 0.001).

Conclusion: Carbetocin is more effective than tranexamic acid on reduction of blood loss during abdominal myomectomy.

Keywords: Fibroids; Myomectomy; Blood loss; Tranexamic acid; Carbetocin

Introduction

Uterine leiomyomas represent the most common benign tumours encountered in women, originating from myometrium smooth muscle cells. These tumours are estrogen dependent and grow during the reproductive period with incidence of approximately 70% in the general population [1]. Approximately 20-40% of women with fibroids experience significant symptoms and consult gynecologic care. However, their true prevalence is probably under-estimated [2].

The standard approach for treating leiomyoma is hysterectomy for women who do not want to have more children and myomectomy for those who want to preserve fertility [3]. Bleeding during myomectomy is one of the major complications which can result in significant morbidity and mortality. Despite advances in reducing excessive haemorrhage during the procedure, it still remains a major challenge for gynecologic surgeons [4].

Several interventions have been developed to control bleeding during this operation such as dissection and embolization of uterine artery, use of mechanical tourniquets, use of uterotonic medications such as oxytocin, Carbetocin, ergometrine, misoprostol and manipulation of the coagulation cascade with antifibrinolytic treatment, especially aprotinin, tranexamic acid, epsilonaminocaproic acid, desmopressin and recombinant factor VIIa [5].

Tranexamic acid (TA), a synthetic lysine derivative with antifibrinolytic activity has been used since the 1960s in a variety of clinical settings where anti-fibrinolytic therapy is appropriate. It acts as an anti-fibrinolytic through the reversible blockade of lysine-binding sites on plasminogen molecules. It is an inhibitor of fibrinolysis. It has been routinely used for many years to reduce haemorrhage during and after surgical procedures. It has been shown to be very useful for reducing blood loss and blood transfusions [6].

Carbetocin is a synthetic long-acting oxytocin analogue. Its intravenous half-life is 85 to 100 min which is10 times longer than that of oxytocin. It has a rapid onset and long- lasting action. Carbetocin and uterine oxytocin receptors in the uterus caused rhythmic contraction, which can increase the frequency of existing contractions as well as uterine tone. During surgery, the uterine smooth muscles were made to contract, so that the tumour protrudes from the uterine surface and the level of the tumour cavity would be easy to find and peel [7].

There are no enough studies that compare the efficacy and safety of using intravenous tranexamic acid and intravenous Carbetocin for reduction of blood loss during myomectomy, therefore, this study aims to assess and compare between them for their ability to reduce blood loss during myomectomy.

Materials and Methods

This randomized clinical trial was carried out in the obstetrics and gynaecology department of Suez Canal University Hospital and included 132 female patients with uterine fibroids that necessitated abdominal myomectomy in the period from May 2016 to May 2018.

Inclusion criteria included patients with age ranging from 18 to 50 years with documented uterine fibroids on pelvic imaging (pelvic ultrasound or MRI) within last 12 months, patients complaining of abnormal vaginal bleeding, chronic pelvic pain, pressure symptoms or reproductive disorders with pre-operative haemoglobin> 8g/ dl. Exclusion criteria included post-menopausal women together with patients previously treated with Depo-Lupron, Depo- Provera or oral contraceptive pills, patients with known bleeding/ clotting disorders, active liver, kidney or cardiovascular disease or receiving anticoagulant, NSAIDs or antiplatelet, previous history of gynecological malignancy, previous abdominal myomectomy or venous thromboembolism.

After approval to participate in the study by providing informed written consent, patients had been allocated to either group using Simple randomization by a randomization table created by a computer software program. A full history was taken included personal, menstrual, obstetrics, contraceptive, past and surgical histories. All patients had full clinical examination included general, abdominal and vaginal examinations. Laboratory investigations were done including haemoglobin, hematocrit, platelet count, prothrombin time and partial thromboplastin time. An abdominal or transvaginal ultrasound was done to assess the size, number, and location of myomas.

At the time of skin incision, the patients in the first group (n= 66) received 30 ml of sodium chloride with added 500mg tranexamic acid (Kapron 500 mg ampoule, Amoun pharmaceuticals) by intravenous infusion while cases in 2nd group (n=66) received 30 ml of sodium chloride with added 100 mcg Carbetocin (Pabal 100 mcg ampoule, Ferring Pharmaceuticals) also by intravenous infusion. The blood loss was assessed from the start of the operation till skin closure and also post-operative till the second post-operative day or till the removal of the drain. The weight of the dry surgical swabs (30g for each 30*30cm abdominal swabs) was measured before use and after being wet or soaked by blood. A highly accurate digital balance was used to measure the weight in grams. The weight difference was translated into the blood loss considering that 1g is equal to 1ml bl. The amount of intraoperative blood loss (ml) = (the weight of used towels–the weight of towels prior to surgery) + blood in suction apparatus. The amount of postoperative blood loss was assessed by the insertion of intraperitoneal tube drain and the calculation of amount of blood in the drain till the drain removed.

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Iris Publishers_ World Journal of Gynecology & Womens Health (WJGWH)

A Nomogram for Prediction of Risk Factors for Preeclampsia during Antenatal Care at a Tertiary Maternity Hospital

Abstract

Objective: The study aims to create a nomogram for prediction of risk factors for preeclampsia (PE) during antenatal care (ANC) in a tertiary maternity hospital.

Materials and Methods: A cross-sectional study was conducted between May 2016 and December 2017 in a tertiary maternity hospital. Two hundred thirty pregnant women were included, at first visit, personal data, family history of risk factors for PE, maternal medical, and obstetric history was collected. Physical examination, including blood pressure, weight, signs of edema, and urine analysis were done. Then follow up at 24 weeks and after 32 weeks gestation to know if she developed PE or not through the physician. Included nomogram, which was built based on the data of regression analysis, was used to predict the value of one or more responses from a set of predictors.

Results: The study included 230 women. Cases diagnosed with PE during all the follow up are 37 cases (16.1%). Five factors were not significant; maternal age (P=0.154, OR=1.076), consanguinity (P=0.821, OR=1.104), age at marriage (P=0.266, OR=1.404), age at first pregnancy (P=0.319, OR=0.735) and order of pregnancy (3rd or more) (P=0.951, OR=0.984). Only two factors significant; a history of diabetes mellitus (P=0.010, OR=5.923) and history of hypertension (P=0.045, OR=7.838). Probability of PE based on the finding of the nomogram was 68% with good discrimination.

Conclusion: History of diabetes mellitus and hypertension were the predictors in the final model among pregnant women for the development of preeclampsia.

Keywords: Prediction; Preeclampsia; Risk factors; Nomogram

Introduction

Hypertensive disorders of pregnancy are one of the leading causes of maternal and infant morbidity and mortality. Worldwide, hypertensive disorders of pregnancy affect 5-10% of all pregnancies and cause approximately 50,000 deaths among women every year [1]. The incidence of preeclampsia (PE) is influenced by parity, racial, genetic predisposition, and environmental factors may also have a role. The incidence of PE varies greatly worldwide. World Health Organization (WHO) estimates the incidence of PE to be seven times higher in developing countries (2.8% of live births) than in developed countries (0.4%) which is due to poor healthseeking behaviours and un-availability of health care facilities and personnel [2,3].

Maternal mortality due to PE varies between (2-30%) and is much higher in rural areas. In Egypt, the prevalence of PE is (10.7%) in a community-based study while, in hospital-based studies ranged from (9.1-12.5%) of all deliveries [1,4,5].

Prevention of PE may be primary, secondary. Primary prevention involves avoiding pregnancy in women at high risk for PE, modifying lifestyles or improving nutrients intake in the whole population to decrease the incidence of the disease. Therefore, probably most of the cases of PE are unpreventable. Secondary prevention is based on interruption of known pathophysiological mechanisms of the disease before its establishment. Recent efforts have focused on the selection of high-risk women and have proposed an effective intervention, as early as it is possible, to avoid the disease or its severe complications [6].

The aim of the study was to create a nomogram for prediction of PE causing risk factors during antenatal care at a tertiary maternity hospital.

Patients and Methods

A cross-sectional study was conducted at Antenatal Care Clinic (ANC) in Assiut Women Health Hospital. This clinic is the main largest clinic in Assiut Governorate which provides antenatal care services for pregnant women.

A convenience sampling of pregnant women who attended at ANC for six months period from the beginning of May 2016 till the end of December 2016 and follow up waves ended in (March 2017). The total number of the study sample composed of 230 pregnant women was included and continued until the end of the study. All pregnant women who agree to participate in the study were included if gestational age was from 4th to 18th weeks and without mental disorders.

Two tools were utilized in the current study:

Tool 1

Structured interview questionnaire developed after reviewing the literature and previous research which were relevant to the present study, it included the following (3) parts:

Part 1: included the following:

1. Personal data scale which included: Age, name, telephone number, level of education, occupation …etc.

2. Family history of risk factors for PE such as previous PE, a family history of (diabetes mellitus, chronic hypertension, chronic kidney disease, cardiovascular diseases, thrombophilia, lupus, and smoking).

3. Maternal medical and obstetric history such as Gestational age at the beginning of the current study, consanguinity, age at marriage, age at first pregnancy, history of (preeclampsia, hypertension, diabetes mellitus.etc.).

Part 2

Physical examination of pregnant women, including (blood pressure, weight, signs of edema, and urine analysis).

During the first contact with the women that were enrolled, the physical examination (blood pressure, urine analysis, and signs of edema) was done.

Part 3

It included following up the pregnant women through three waves after the first contact with the pregnant women (4:18 weeks)

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Iris Publishers_ World Journal of Gynecology & Womens Health (WJGWH)

Benign Gynecologic Surgery in the Elderly Patient

Abstract

Benign Gynecologic surgery for the elderly patient has certain considerations for the provider to be aware of. As the population ages, more women require benign gynecologic procedures. To date, there are no guidelines regarding pre-operative, intra-operative, and post-operative care specific to this patient population. This outline provides a reference for providers when approaching the elderly patient in need of benign gynecologic surgery.

Introduction

The need for surgical treatment of benign gynecological conditions will increase as women are living longer and the incidence of pelvic floor disorders increase with aging. Pelvic floor disorders such as prolapse and urinary incontinence cause significant physical and emotional distress and sometimes require surgical management.

When preparing a patient for benign gynecologic surgery, there are certain chronic health issues to consider. For all patients, one must take into account the overall health of the patient, preoperative workup, surgery itself, and post-operative recovery. In the elderly patient, there are additional considerations to keep in mind. For many reasons including patient safety, the elderly should not be grouped into the same category as a younger, healthier patient when preparing for surgery. To date, there are no universal guidelines to assist the provider in preparing the elderly patient for benign gyn surgery. This paper outlines the pre-operative, intraoperative, and post-operative practices to optimize this surgical care.

The most common conditions for benign gynecologic surgery in the elderly population include post-menopausal bleeding, pelvic organ prolapse, urinary incontinence, and benign tumours such as persistent ovarian cysts. Surgical treatment for the above conditions include dilation and curettage, diagnostic and operative laparoscopy, vaginal and abdominal hysterectomy, laparoscopic hysterectomy, uterine/vaginal suspension procedures, vaginal obliteration, and mid-urethral retro pubic or trans-obturator slings. Most of these procedures are minimally invasive in nature or can be performed by minimally invasive techniques. According to the American College of Obstetrics and Gynaecologists (ACOG), when feasible a vaginal approach is the preferred route for hysterectomy since there are demonstrated improved patient outcomes, shorter operative time, and faster recovery. Also, vaginal approach allows for various anaesthesia techniques including regional, which is beneficial for the elderly patient. When vaginal approach cannot be achieved, laparoscopy should be considered. Both of these minimally invasive techniques are preferred over abdominal approach in the elderly population [1].

Pre-Operative

The pre-operative workup of an elderly patient undergoing benign gynecologic surgery should follow certain guidelines. As in all medical conditions, the most important first step is a thorough history and physical. Knowing the elderly patient’s medical history provides important information to be able to optimize her for elective surgery and minimize potential complications. The history of present illness, past medical and surgical history is primary areas of focus as we begin her workup.

The history of present illness lets the patient tell her story in her own words. It is essential to elicit the most bothersome symptoms since many benign gynecologic interventions in the elderly population are driven by the patient’s discomfort. Personal or familial history of thrombo-embolic events is important to consider so that deep venous thrombo-embolic prophylaxis can be offered. One important aspect of the history is the social history because many elderly depend on their family or health care proxy for immediate post op care and recovery assistance. This can identify any areas that need to be addressed before surgery, such as, social services, visiting nurses and rehabilitation facilities.

When performing a physical examination on the elderly patient, there are certain areas on which to focus. First, we note the general ambulation and nutritional status of a patient. For example, can she walk from the waiting room into the examination room? Does she need assistance with a walker or wheelchair? These initial observations give us a useful overview of the general health and performance status. The physical exam continues with a cardiopulmonary exam including heart, lung, and pulses. Next, joint mobility is determined as this may be limited in the elderly patient with history of arthritis. Joint mobility and limitation are important considerations during patient positioning in the operating room. Many gyn procedure are performed in dorsal lithotomy where hip and knee mobility, or lack thereof, can affect successful set up and surgery. Patients may need to be positioned in dorsal lithotomy prior to anesthesia induction to maximize patient comfort and safety. Throughout the history and physical examination, the neurologic status of the patient can be determined. If there is a question of the patient’s neurologic status, the mini-mental state examination, a 30-point questionnaire assessing cognitive function, can be employed. This may be helpful in determining capacity and ability of patient to fully understand informed consent.

Cardiovascular risk calculators

According to the most recent Centres for Disease Control and Prevention (CDC) guidelines, heart disease is the leading cause of death in women of all races and origins in the United States [2]. Therefore, when preoperatively evaluating the elderly gyn patient for surgery, cardiovascular risk assessment is essential. There is several cardiovascular risk calculators used preoperatively to predict certain cardiac events.

The revised cardiac risk index (RCRI) by Lee et al. has been validated and used for over 20 years to assess preoperative cardiac risk. The RCRI takes into account the patient’s history, current medical health condition, and type of surgery to stratify patient’s risk for a cardiac complication during a non-cardiac surgery. This tool provides the health care provider with the risk of a cardiac complication and can assess the need for further cardiac testing, but it does not identify non-cardiac risks for patients [3]. Another method is the National Surgical Quality Improvement Program (NSQIP) risk prediction calculator, which has been validated in over 1.5 million patients. This web-based decision-support tool estimates risk to patient and has proven accuracy in predicting morbidity and mortality [4]. Based on one of the above risk calculators, a provider will obtain a risk of cardiovascular event for a patient. If the risk is <1%, the patient is considered to be low risk and no further cardiac workup is needed. If the risk score is >1%, then the patient is considered higher risk and further testing may be necessary.

High risk cardiac patients should be considered for further cardiovascular evaluation. The 2014 American College of Cardiology/American Heart Association (ACC/AHA) is an important guide to determine the functional status of a patient. If she is able to complete four or greater metabolic equivalents (METS) without symptoms, no further cardiac testing is needed. For example, if she can climb one flight of stairs without shortness of breath, she may not need a comprehensive cardiac workup. If she is unable to do so, additional testing should be ordered [5].

Diabetes

In the elderly population, diabetes is a common condition that should be addressed since perioperative hyperglycaemia poses a significant infection risk and can delay wound healing. Elective surgery should only be performed when the patient’s HgbA1C is below 7 as this has been proven to decrease postoperative wound infection [6]. In addition, patients with a history of diabetes are also at increased risk of coronary heart disease, hypertension, obesity, all which increase perioperative risk. Early surgical start time (before 9AM) may present an additional advantage to the diabetic patient and minimizes disruption of management of glucose control.

Medications

A complete review of all medications both prescribed and over the counter is important. Some medications should be discontinued weeks before surgery, while others should be continued until the morning of the procedure. For patients with hypertension, beta, alpha and calcium channel blockers should be continued as prescribed and taken the morning of surgery with a sip of water. In particular, stopping beta blockers prior to surgery has proven to increase cardiac morbidity and mortality [7-9]. Because of the risk of rebound hypertension with acute cessation of alpha-2 blockers such as clonidine, these medications should also be continued pre-operatively. Continuing calcium channel blockers during perioperative period has no proven contraindications.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensive-2 receptor blockers (ARBs) are common antihypertensive that should be used with caution preoperatively. Patients taking either ACE inhibitor or ARB in combination with a diuretic are at risk for intraoperative hypotension [10]. Therefore, these medications should not be taken the morning of surgery. ACE inhibitors, ARBs, and diuretics may be resumed within 48 hours postoperatively. Patients taking statins should continue this therapy. In fact, in one international prospective cohort study, the use of statins in patients undergoing non-cardiac surgery was associated with a lower risk of cardiovascular outcomes 30 days after surgery [11]. However, no studies exist that suggest starting routine statin use in a patient not already using this medication.

Women who are taking hormone replacement therapy (HRT) are encouraged to stop prior to surgery. HRT increases the risk of venous thromboembolism (VTE), and since surgery alone also increases this risk, the compounded effect of HRT in a surgical patient should be avoided [12]. Many women on HRT are perimenopausal or at the start of menopause. The elderly patient population is usually not on HRT, so this becomes less of a consideration. On the other hand, selective estrogen receptor modulators (SERM) may more commonly be used in the elderly gynecologic population in treatment of breast cancer (tamoxifen) or osteoporosis (raloxifene). SERMs increase the risk of VTE and care must be taken prior to surgery. Raloxifene should be stopped 3 days prior to surgery. Tamoxifen as a breast cancer prevention strategy should be stopped 2 weeks prior to surgery. However, when tamoxifen is being used for breast cancer treatment, one can consider continuation of the drug with additional measures for VTE prophylaxis [13].

Prevention VTE

All surgical patients are risk stratified for risk of VTE. The American College of Chest Physicians Caprini score is universally used as a preoperative assessment tool for VTE during surgery and guides intra-operative prevention. Women aged 61-74 years old receive 2 points on the risk score model, while women aged 75 years and older receive 3 points. Other points that apply to the elderly gyn population include cancer, prior VTE, estrogen use, smoking, and obesity. Low risk patients (Caprini score 1-2) have 1.5% estimated baseline risk of VTE should have mechanical prophylaxis during surgery. Moderate risk patients (Caprini score 3-4) should have intermittent pneumatic compression device applied and can be considered for chemical prophylaxis with low molecular weight heparin or low dose unfractionated heparin if they do not have a bleeding risk. Finally, high risk patients (Caprini score greater than or equal to 5) have a 6% estimated baseline risk of VTE and should receive chemical VTE prophylaxis intraoperative in addition to mechanical prophylaxis [14].

Informed consent

Informed consent begins with a discussion regarding the nature of the patient’s problem and degree of bother. It continues with reviewing treatment options and desired outcomes. Once preoperative assessment is completed, a surgeon is better able to provide the patient with specific benefits and risks of various treatment options. Having a family member present for preoperative consent can be helpful for the patient in recalling the discussion and the salient points critical to informed consent. Also, the pre-operative visit can be an overwhelming experience for any patient. Being accompanied by a trusted confident, family member or friend may alleviate some anxiety while providing a personal witness to the conversation. We encourage having a family member or care provider present because they will also be involved in perioperative instructions and post-op care.

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Iris Publishers_ World Journal of Gynecology & Womens Health (WJGWH)

Assessment of the Immunomodulatory Role of Dydrogesterone in Preventing Pregnancy Loss in Threatened Abortion

Abstract

Objective: To assess the immunomodulatory role of Dydrogesterone in preventing pregnancy loss in cases of threatened abortion.

Materials and methods: This were a prospective interventional study that included two groups each included 16 women. Group 1 included 16 pregnant women presented with symptoms of threatened abortion, and group 2 that included 16 health females with normal pregnancy. All of the studied females were subjected to complete clinical assessment. Laboratory assessment of serum levels of IL-4 (Marker of T-helper 2), IFN γ (Marker of T-helper 1) and serum progesterone level were done for all participants. All women in group 1 were treated with certain doses of Dydrogesterone while women in control group were not allowed to use any form of progesterone. Participants were assessed for IL-4, IFN-γ and progesterone after treatment. Also continuing pregnancy rates were calculated.

Results: Both groups were matched as regarding patients’ characteristics and baseline parameters. Dydrogesterone has resulted in significant decrease of Th1/Th2 ratio with shift from Th1 predominance to Th2 predominance. Continuing pregnancy rate in the threatened abortion group was 93.8%.

Conclusion: Dydrogesterone is useful in the treatment of threatened abortion via modulating cytokine profile and causing shift in Th1/Th2 ratio for Th2 predominance and more specifically via decreasing level of Th1 markers as IF-γ.

Keywords: Dydrogesterone; Immunomodulation; Pregnancy; Threatened abortion

Introduction

Women with threatened abortion present with vaginal bleeding and/or uterine cramps while the cervix is still closed. This critical state may end up in spontaneous abortion or pregnancy may continue normally [1]. Tolerance of the maternal immune system to paternally derived fetal antigens is mandatory for a successful pregnancy. Disturbed immunological response towards the growing embryo may lead to pregnancy failure [2].

Several theories have been developed. One of these hypotheses is Th1/Th2 shift. A shift from the pro-inflammatory T-helper 1 (Th1) cell-dependent cytokines i.e. tumor necrosis factor-α (TNF- α), interferon-γ (IFN- γ), interleukin (IL), IL-12, IL-18] to Th2-dependent anti-inflammatory cytokines (i.e. IL-3, IL-4, IL-5, IL-6, IL- 10, IL-13) seems to be typical for a successful pregnancy [2].

Shifting of the immune response towards the Th2 pattern would be of paramount benefit to the fetus, whereas dominance of pro-inflammatory Th1 cells may be hazardous. This hypothesis was supported by researches on different mouse strains with Leishmania infection during pregnancy, that lead to an anti-infectious Th1 response which was associated with failed implantation [3,4].

Progesterone has been proposed as a crucial immunomodulatory agent during early pregnancy, as it plays a role in the signaling chain of Th2-cell-dependent cytokines, and successful pregnancy is known to be a Th2-type phenomenon [4,5].

Dydrogesterone, an orally active progestogen, is similar to endogenous progesterone in its molecular structure and has a high affinity for progesterone receptors. It has the advantage of being devoid of androgenic side-effects in the mother (e.g. hirsutism, acne) or masculinizing effect on the female fetus [4,5]. The present study aimed to assess the immunomodulatory role of Dydrogesterone in preventing pregnancy loss in threatened.

Materials and Methods

After approval of our research ethics committee, this prospective interventional study was conducted in the obstetrics and gynecology department of Suez Canal University Hospitals from May 2017 to May 2019. The study was carried out among 32 pregnant females divided into two groups. Group 1 (study group) included 16 pregnant females who presented with symptoms of threatened abortion (bleeding, spotting and uterine cramps). Group 2 (control group) included 16 healthy females with normal healthy pregnancy with no symptoms of abortion and no history of habitual abortion as a reference group. Pregnant females with gestational age > 13 weeks, chronic medical disorders, genital tract anomalies, history of use of progesterone prior to or during the study, and females with history of hypersensitivity to Dydrogesterone were excluded from the study.

Methods

All of the studied patients were subjected to the following:

Thorough obstetric history taking with emphasis on:

• First day of the last menstrual period

• Obstetric history

• Symptoms of threatened abortion (bleeding, spotting, uterine cramps)

Complete general and obstetric examination:

• Vital signs

• Height, weight and BMI

• Per vaginal examination for assessment of the cervical state

Abdominal/vaginal ultrasound: This was performed to all patients to evaluate gestational age of the fetus, to exclude multiple pregnancies and to confirm viability of pregnancy.

Laboratory measurement:

• Routine laboratory assessment (CBC, Rh factor, and urine analysis).

• Maternal serum levels of IL-4 were determined as a marker of T-helper 2 cell activity and values of IFN-γ as a marker for T-helper 1 cell activity before and at the end of treatment in both groups. Serum IL-4 and IFN-γ levels were measured by enzyme- linked immunosorbent assay (ELISA) technique

• Serum progesterone was determined by enzyme immunosorbent assay (ELISA) before and after treatment

Treatment:

• Group 1 (Threatened abortion group) received Dydrogesterone 40mg (4 tablets) as an initial dose then 10mg tablets every eight hours until symptoms subside (at least one week after symptoms subside)

• Group 2 (control group) participants were not allowed to use any progestogens prior to or during the study. They received placebo daily until they reached 13 weeks gestation.

• Both groups received their regular antenatal care according to NICE clinical guidelines [6]

• Ethical approval: This study was carried out after obtaining ethical approval on 01/04/2017 with a research number 3467#.

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Iris Publishers_ World Journal of Gynecology & Womens Health (WJGWH)

Time from Decision to Completion of Emergency Caesarean Section and Prognosis in N’Djamena Mother and Child University Hospital

Abstract

Background: Caesarean section is a surgical procedure that performs delivery after opening the abdomen and uterus. According to the WHO, the ideal caesarean section rate should be between 10 and 15%. In Chad, the average rate of Caesarean section in urban areas is 9.3% [1]. Despite this rate, enough evidence can be identified to hinder the performance of emergency Caesarean section. That is why we initiated this study in order to see the minimum time required to perform an emergency cesarean section.

Patients and method: This were a descriptive and analytical study that collected prospective data, during a period of 2 months from July 1st, 2019 to August 31st, 2019, about time required to perform an emergency cesarean section and prognosis in N’Djamena Mother and Child University Hospital. All patients at whom emergency cesarean section was performed were included after getting their consent.

Result: During the study period, we record 287 cesareans sections among 845, giving a frequency of 33.9%. Two hundred sixty-one section cesarean was performed in emergency that 90.9%. One hundred and sixty-two patients (62%) were not referred. The average gestational age was 37.7 SA ± 2.9 gestational weeks with extremes of 28 gestational weeks and 42 gestational weeks. Among the 261 emergency Caesarean sections 219 cases (83.9%) were absolute emergencies. The main indications for cesarean section were scarring uterus (24.1%), fetal and maternal disproportion (13.7%), and stagnation of the cervix dilation (13%), eclampsia/preeclampsia (11.4%) perinatal asphyxia (6%). The interval time form indication of caesarean section and fetal extraction was between 90-119 minutes for 117 patients (44.8%). The family refusal was the first reason of the delay representing 19.9%. Beyond 60 minutes of the delay the maternal prognostic is worst. We had recorded 33 complications (12.6%). After 60 mn more fetal complication are noted represented by perinatal asphyxia, neonatal infection and fetal death.

Conclusion: The average time to perform emergency Caesarean section remains high by compared with standards. The family’ refusal of the cesarean section is the first cause of the delay to perform the emergency cesarean section.

Introduction

Caesarean section is a surgical procedure that performs delivery after opening the abdomen and uterus [1]. Globally, there is a disparity in Caesarean section rates, with rates as high as 40% in some areas and 5% in the developing world [2]. According to the WHO, the ideal caesarean section rate should be between 10 and 15% [2]. Regardless of its prevalence, it must be performed within a reasonable time that does not threaten maternal and fetal life. However, there are various factors that can delay it [3]. That is why the literature reported an inequality in the minimum time required to perform a cesarean section. In the same way Lucas [3,4,5], proposed the minimum time for performing cesarean sections according to the codes. In Chad, the average rate of Caesarean section in urban areas is 9.3% [6]. Despite this rate, enough evidence can be identified to hinder the performance of emergency Caesarean section. That is why we initiated this study in order to see the minimum time required to perform an emergency cesarean section.

Patients and Method

This was a descriptive and analytical study that collected prospective data, during a period of 2 months from July 1st, 2019 to August 31st, 2019, about time required to perform an emergency cesarean section and prognosis in N’Djamena Mother and Child University Hospital. All patients at whom emergency cesarean section was performed were included after getting their consent.

Patients were recruited by the medical students without informing the surgeon and other staff member. Then patients and newborns are followed until they are discharged from hospital to identify a complication. The studied variable was epidemiological, clinical and prognoses. SPSS version 18.0 was used to analyze data p value was significant when less than 0.05.

Results

Frequency

During the study period, we record 287 cesareans sections among 845, giving a frequency of 33.9%. Two hundred sixty-one section cesarean was performed in emergency that 90.9%.

Admission mode

One hundred and sixty-two patients (62%) were not referred. The remainder was referred by surrounding health center (38%) (Table 1).

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Iris Publishers_ World Journal of Gynecology & Womens Health (WJGWH)

Experience of Surgical Treatment of Adenomyosis and Reproductive Outcomes

Introduction

Adenomyosis is a benign tumor process of the uterus, one of the forms of endometrioid disease. Surgical treatment of adenomyosis to this day is the subject of discussion by many authors, but the principle of surgical interventions remains the same - excision of the myometrium affected by glandular invasion. The article discusses the main methods of adenomyomectomy, the results of surgical interventions in terms of the reproductive function of women. In addition, its own original technique for suturing the uterus after surgical interventions is given.

Adenomyosis, being one of the frequent diseases that cause uterine bleeding, algomenorrhea, infertility, is an indication for prolonged hormone therapy or hysterectomy [1-4]. The use of organ-saving methods of surgical treatment for adenomyosis in order to maintain fertility and eliminate symptoms is an important modern aspect of therapy [5,6]. Among all the causes of female infertility, adenomyosis accounts for about 20% [7].

Many authors point to a steady increase in the detection of adenomyosis in all age groups, including a tendency to increase the incidence of adenomyosis in young women who did not realize reproductive function. The frequency of its detection in the population, according to various authors, varies from 10 to 61% [8-12]. After hysterectomies in the preparations, the frequency of detection of adenomyosis reaches 46–70% in the population [13]. The lack of effect of conservative treatment methods leads to an increase in the number of radical surgical interventions in young women [14].

At the same time, a review of the medical literature shows that since 1990 at least 2,300 adenomyomectomies have been performed, including 2,123 (89.8%) in Japan. 397 pregnancies were reported after organ-saving surgeries. In 337 (84.89%) pregnancies ended in childbirth, while 23 pregnancies were complicated by uterine ruptures [15-17].

Adenomyomectomy is a recognized method of treatment of manifest adenomyosis in combination with uterine myoma, manifested by dysmenorrhea, menorrhagia and infertility. However, pregnant women after adenomyomectomy have a higher risk of spontaneous abortion, uterine scar failure or spontaneous uterine rupture during pregnancy and childbirth, says Ota Y, et. al. [18]. The impact of surgical energies during uterine surgery increases the risk of uterine rupture [15,16]. Various surgical treatments for adenomyosis are currently being tested. Indications for surgery are dysmenorrhea and hypermenorrhea, resistant to conservative therapy, infertility, habitual miscarriage, and the desire to maintain fertility or menstrual function with a significant increase in the size of the uterus.

Surgical Treatment

Organ-preserving surgical treatment of adenomyosis in young women was first described by Van Praagh in 1952 [19]. Then the technique of wedge-shaped resection of the myometrium was adopted. In 1991, the results of resection of the affected myometrium in 37 patients were presented. In the described cases, microsurgical resection of the affected myometrium by laparotomy access was performed. As a result, 6 women became pregnant after the operation, and all pregnancies ended in childbirth [20]. It was reported that in 1993 a series of operations of this modification was performed with partial removal of adenomyoma in 28 patients. Of the 18 women trying to get pregnant, 13 achieved the desired result. As a result, there were 9 (50.5%) live births and 7 (38.8%) miscarriages, according to Fedele L, et. al [21].

Interesting experience in performing Fujishita A, et. al. [22] laparotomic modification of adenomyomectomy with an H-shaped incision in the bottom of the uterus with a wide separation of the serous part [6]. The altered myometrial tissue was dissected using an electrosurgical scalpel or scissors. The uterine wall was restored with a two-row suture. The first row of sutures (muscular-muscular) restored the uterine wall, while the suture was also hemostatic. Bilateral serous flaps that appear after a vertical incision, as well as upper and lower flaps resulting from a transverse incision, were sutured with nodular gray-serous sutures.

Based on the data collected before 2010, in 41 patients undergoing the H-section method, 31 attempted to become pregnant; 12 (38.7%) reached clinical pregnancy, 5 (16.1%) miscarriages and 7 (22.5%) reported live births [22]. In another study, Nishimoto M, et. al. 14 women were registered who performed this technique [23]. At the same time, all women after the operation planned a pregnancy, 3 (21.4%) reached pregnancy, and all had healthy children.

In a recent study by Saremi AT, et al. [24] a wedge-shaped resection of the uterine wall was reported up to the endometrium after a sagittal section of the uterus [24]. Reconstruction of the uterine wall is performed by a continuous horizontal mattress suture. A screw-on gray-serous suture is then applied to reduce the risk of adhesions. Of the 103 patients operated on, 70 attempted to become pregnant during the study period, of which 21 (30%) reached clinical pregnancies. In 16 (22.8%) pregnancies ended in successful live births.

The methods of complete excision of adenomyosis include the triple flap method. This adenomyomectomy technique is based on a completely new idea that differs from standard surgical methods [25]. The method involves reconstruction of a defect in the uterine wall using the remaining normal uterine muscle. In a study by Osada H, et al. 2017 [16], in which 113 women were evaluated after surgery using this method, it was shown that within 6 months the blood flow in the area of action returned to normal in almost all cases (92/113, 81.4 %). Of the 62 women planning a pregnancy, 46 became pregnant and 32 gave birth to a healthy baby through a planned cesarean section. There were no cases of uterine rupture. During the study period (27 years), only 4 cases (3.5%) of relapses requiring repeated surgical treatment were recorded. In cases where the resection of uterine adenomyosis is performed without opening the uterine cavity, and the uterine wall is formed by a serous-muscular flap, the operation is called the double flap method [15].

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