Nahla W. Shady

A sandwich technique (N&H variation technique) to reduce blood loss during cesarean delivery for complete placenta previa: a randomized controlled trial

Abstract Objective: To investigate the effect of A sandwich technique Nahla & Hany variation (N&H) technique versus stepwise uterine devascularization on blood loss during cesarean section (CS) in patients with complete placenta previa. Methods: The study was single-blind randomized controlled trial carried out in a tertiary University Hospital between March 2015 to March 2018. We included patients scheduled for CS due to complete placenta previa. They were randomly allocated to group (I) managed by stepwise uterine devascularization, group (II) managed by double transverse compression suture at the lower uterine segment plus intrauterine inflated Foley’s catheter Balloon (H&N variation sandwich) at the lower uterine segment. The primary outcome was the amount of total estimated blood loss both intra- and post-operative. Results: One hundred and six patients were enrolled (nu2009=u200953 in each group). There was a great reduction in intraoperative blood loss in group II 570 (400–1300) compared with Group I 1030 (500–1540) (pu2009=u2009.0001), or blood in the intraabdominal drain in group II than group I (pu2009=u2009.0001) Also, there was no significant reduction in postoperative vaginal bleeding. Hence, the total estimated blood loss in group II 750 (550–1580) showed significant reduction compared with group I 1350 (780–1800) (pu2009=u2009.0001). Conclusions: N&H variation sandwich technique in the management of complete placenta previa is a simple technique, safe and effective to decrease blood loss.

Reducing Blood Loss During Abdominal Hysterectomy with Intravenous Versus Topical Tranexamic Acid: A Double-Blind Randomized Controlled Trial

ObjectivesTo assess the effect of intravenous versus topical tranexamic acid in reducing intraoperative and postoperative blood loss in women withxa0abdominal hysterectomy.Materials and MethodsThe study was a randomized double-blind placebo-controlled trial, carried out in a tertiary university hospital in Egypt, from November 2015 to October 2017. A total of 129 women undergoing abdominal hysterectomy for benign etiology were randomly assigned to three groups: Group I [43 patients received 110xa0ml normal saline IV just before skin in scion], Group II [43 patients received 1xa0g tranexamic acid in 100xa0ml saline IV just before skin in scion], and Group III [43 patients received 2xa0g topical tranexamic acid applied intra-abdominal after hysterectomy]. The primary outcome was intraoperative, postoperative, and all blood loss estimation.ResultsBoth Group II (IV tranexamic acid) and Group III (topical tranexamic acid application) showed great reduction in intraoperative and postoperative blood loss (blood in the intra-abdominal drain) compared with Group I (placebo group), (Pu2009=u20090.0001, 0.0001, 0.0001, 0.0001), so the overall estimated blood loss in groups II and III showed highly reduction compared with Group I (Pu2009=u20090.0001, 0.0001).ConclusionIntravenous and topical tranexamic acid application is a safe and reliable method to help decrease blood loss during and after abdominal hysterectomy.

Reply to: a sandwich technique (N&H variation technique) to reduce blood loss during cesarean delivery for complete placenta previa

We appreciate the interest shown by Dr Abbas in our recently published paper [1]. We would like to thank him for his valuable comments that add much more to our own published findings. But we need to clarify some points which have confused Dr Abbas. In our study when we decide to calculate the sample size, we decided to assume a type-1 error of 0.05 and a power of 90%. We calculated a sample size of 53 women per group to detect a 600-ml difference in total blood loss [(1350 (780–1800)) in the control arm] versus [(750 (550–1580)) in intervention arm], which was clearly the primary outcome of our study. To reach to our sample size, we did an interim analysis, and a decision made to stop enrollment, having considered the feasibility of continuing recruitment to reach an adequate sample size. Some authors decide to assume the primary outcome as expected from earlier studies, but there is a large discrepancy between the assumptions and the data onto their results, which raises a much more complex problem because investigators often must calculate a sample size of insufficient observations to estimate these assumptions. So, in our study, we calculated the needed sample size based on our primary outcome, not assuming one, and this is one of the strengths [2,3]. The study protocol was not registered on the clinical trial’s registry websites, this matter related to a technical problem with our university. Our university, Aswan University a new one begins at 2012, not registered on the database until 2016. Another point mentioned by Dr Abbas, about the methods of exclusion of the morbidly adherent placenta (MAP) in our patients. We state clearly, we do transabdominal and transvaginal us with Doppler and any patients with suspicion of MAP excluded from the study. A systematic review and meta-analysis showed that ultrasound has an overall good diagnostic accuracy in recognizing the depth and the topography of placental invasion and exclude MAP in cases with a placenta previa [4]. Another one-point mentioned by Dr Abbas, as he asked about the total blood loss reported in group I was 1350ml, while the real blood loss was 1250ml if we added the sums of intraoperative and postoperative blood loss reported in Table 2. It was not the total blood loss but the median of the total blood loss, moreover, it did not calculate the sum of the median of intraoperative and postoperative blood loss. We totally disagree with Dr Abbas about the value of nausea, vomiting, and diarrhea as any surgery done in the pelvis may complicate with intestinal injury and may translate to nausea and vomiting postoperative, moreover, paralytic ileus is also complicated pelvic surgery and may be manifested with nausea and vomiting. Also, we disagree with the opinion of the Dr Abbas judge about ANOVA test. Although ANOVA and t-test seem to be different, they give equal results when only two groups of people. We agree with the notes from Dr Abbas, in the results (there is a difference 9 years between the women’s age in both groups.). There was a typing mistake in the age in group 2 (30.7 ± 3.3 not 39.7 ± 3.3).

Adjunctive intrauterine Foley’s Catheter Balloon adding to hypogastric artery ligation in the conservative management of morbid adherent placenta previa

Background: Objective of present study was to demonstrate the efficacy of Foley’s catheters balloon tamponade as an adjuvant to control blood loss during and after a caesarian section in patient undergone hypogastric artery ligation (HAL) due to morbid adherent placenta previa (MAPP). Methods: A single-center retrospective case-control clinical trial was carried out in a tertiary university hospital between March 2015 and March 2018, 124 women were undergoing cesarean delivery for MAPP, were managed conservatively either with HAL or HAL plus inflated Intrauterine Foley’s Catheter Balloon to control post-partum hemorrhage secondary to MAPP. In the case of conservative treatment protocol failure, cesarean hysterectomy was performed. Results: 124 women were enrolled (n=62 in each group). group of women received HAL plus Intrauterine Foley’s Catheter Balloon (group II)) showed a significant reduction in intraoperative and 4 hours post-operative blood loss compared with (Group I) which received HAL without Intrauterine Foley’s Catheter Balloon. (P = 0.0001,0.0.015), so the overall estimated blood loss in group II showed significant reduction compared with group I (P = 0.0001). Conclusions: Adjunctive intrauterine Foleys catheter balloon adding to HAL ligation in the management of MAPP is a novel combination approach have proved to be effective to control of intraoperative and PPH and to preserve the uterus as possible and change in the concept of MAPP management always mandates hysterectomy. And may become an alternative valid option to planned cesarean-hysterectomy in well-selected cases who have a strong desire for future fertility.

The effect of regular daily walking on adverse pregnancy outcomes among overweight primigravidas: a prospective cohort study

Objective: The study aims to evaluate the effect of regular daily walking on the occurrence of adverse pregnancy outcomes among overweight

The effect of prophylactic oral tranexamic acid plus buccal misoprostol on blood loss after vaginal delivery: a randomized controlled trial

Abstract Objective: The objective of this study is to evaluate the effect of prophylactic oral tranexamic acid (TA) plus buccal misoprostol on the amount of blood loss after vaginal delivery in women at low risk for post-partum hemorrhage (PPH). Materials and methods: The study was a randomized open label clinical trial conducted in a tertiary University Hospital between January 2016 and June 2017. We included women who delivered vaginally with a singleton pregnancy. They were randomized into three groups: group I (women received 10u2009IU oxytocin IV after delivery of the baby), group II (women received 600u2009µg buccal misoprostol after delivery of the baby), and group III (women received 1000u2009mg oral TA at the end of the first stage of labor plus 600 µg buccal misoprostol after delivery of the baby). In each group, pre- and post-delivery pulse rate, blood pressure, temperature, and hemoglobin level were evaluated. Additionally, the amount of blood loss, need for blood transfusion, need for additional uterotonics, and side effects of the study medications were recorded. Results: There was a statistically significant lower hemoglobin level and higher blood loss in the misoprostol group compared with oxytocin group and TA plus misoprostol group (pu2009=u2009.0001). There was a statistically significant higher hemoglobin level and lower blood loss in the TA plus misoprostol group compared with the oxytocin group (pu2009=u2009.004 and .043, respectively). PPH occurred in 16.7% of women in the misoprostol group compared 1.7% in the oxytocin group and no cases of PPH in the TA plus misoprostol group (pu2009=u2009.0001). Conclusions: In settings like rural area or home delivery in which oxytocin is not available, alternative oral TA plus buccal misoprostol may be considered as an effective line in prevention of PPH.