Rafik Barakat

Reducing blood loss at abdominal myomectomy with preoperative use of dinoprostone intravaginal suppository: a randomized placebo-controlled pilot study

OBJECTIVE To determine the effect of a single preoperative intravaginal prostaglandin E(2) (PGE(2); dinoprostone) suppository on reducing intraoperative blood loss and the need for subsequent blood transfusion at abdominal myomectomy for symptomatic leiomyomas. STUDY DESIGN In a prospective randomized double-blind placebo-controlled pilot study, 108 women who had abdominal myomectomy for symptomatic leiomyomas were enrolled. Patients were randomly assigned to receive a single dose of intravaginal 20mg dinoprostone (n=54) or placebo (n=54) 60 min before the operation. The primary outcome was the operative blood loss. The secondary outcomes were the need for blood transfusion, change in hemoglobin (Hb) level 24h after operation, and the prevalence of side effects. RESULTS Blood loss and transfusion rate were significantly greater in the group without PGE(2) suppository (group B) than in the group with PGE(2) (group A): they were respectively 485.7 ± 361.3 mL vs 364.1 ± 279.4 mL (P=.02; relative risk [RR] 0.95; 95% confidence interval [CI], 0.63-1.45) and 18.5% vs 3.7% (P=.04; RR 1.32; 95% CI, 3.7-18.5). Group B had a significant decrease in Hb level 24h after operation compared with group A (P<.05). There was no difference in the patient demographics, intraoperative characteristics, postoperative stay, complications, and the side effects between the two groups. CONCLUSION A single pre-operative dose of dinoprostone administered intravaginally could be a safe and reliable method to help decrease blood loss during abdominal myomectomy. Further larger prospective studies are required to support this conclusion.

Subfertility treatment in women with systemic lupus erythematosus

This study comprised of 65 infertile patients with systemic lupus erythematosus (SLE). The aim was to study causes and different modalities used for the management of subfertile patients with SLE. All patients were diagnosed to have SLE according to the standard criteria of diagnosis. All patients were scheduled to expectant treatment, ovulation induction and timed intercourse, intrauterine insemination (IUI), intracytoplasmic sperm injection (ICSI). Anovulation was in 20 patients (20%), due to PCOS in 10 cases and due to other causes in three patients. A total of 28 patients (43.1%) needed laparoscopy for their work-up of infertility. Male factor for infertility was present in nine couples (16.7%). Ovulation induction and timed intercourse was adopted for a maximum 6 cycles and IUI for 3 cycles. In vitro fertilisation (IVF)/ICSI was needed in five cases using standard long agonist protocol. Four cases were complicated by significant ovarian hyperstimulation syndrome after conventional ovarian stimulation and cycles were cancelled. Pregnancy occurred in 20 women. Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well selected women with non-complicated SLE.

Evaluation of a single-step diagnosis and treatment of premalignant cervical lesion by LEEP

To explore whether a single‐step diagnosis and treatment of premalignant cervical lesions by the loop electrosurgical excision procedure (LEEP) is appropriate in women at high risk in low‐resource countries.

High-risk and low-risk human papilloma virus in association to spontaneous preterm labor: a case-control study in a tertiary center, Egypt

Abstract Introduction: This study aimed to detect the correlation between human papillomavirus (HPV) and spontaneous preterm labor in Egyptian women and its association to the human papilloma viral load and MPP2 gene expression. Material and methods: We performed an observational comparative case-control study in Department of Obstetric and Gynecology, Mansoura University Hospitals over women presented with spontaneous preterm labor, besides females admitted for giving birth at full term to detect conserved sequence in HPV-L1 gene (GP5/GP6) followed by genotype detection of high- and low-risk HPVs with quantification of the viral load and the MMP2 gene expression using real-time polymerase chain reaction (PCR). Results: The prevalence of HPV was 18.1% in preterm females, but only 4% in full-term women (p value = 0.019*). Twenty percent were PCR positive for HPV 16 and 40% for HPV 18 whereas none of the control was positive for any of the studied high-risk genotypes. Thirty percent were PCR positive for HPV 6 and 10% were positive for HPV 11. MMP2 gene expression was significantly higher in preterm than full term. Human papilloma viral load was found to be positively correlated to the rate of MMP2 expression and the gestational age was significantly related to the viral load and the rate of expression of MMP2 gene. Conclusion: Human pabilloma virus especially high-risk genotypes was correlated to spontaneous preterm labor in Egyptian females through increasing early expression of MMP2 gene. The time of occurrence of preterm labor was affected by the viral load and so the rate of expression of MMP2 gene.

Re-laparotomy after caesarean deliveries: Risk factors and how to avoid?

Abstract The aim of this study was to explore the risk factors for and how to avoid re-laparotomy after caesarean delivery and to present the experience of a university tertiary care referral hospital. The study comprised of 2,000 caesarean deliveries, among which re-laparotomy was needed in 18 patients (0.9). The study found that 16 of the 18 cases that needed re-laparotomy had previous caesarean sections (CS) and 9/18 had placenta praevia. The main indication for the procedure was internal haemorrhage (haemoperitoneum) (12/18, 66.6%). Significant haemoperitoneum of > 2 litres was reported in six cases (33.3%). Maternal mortality occurred in 3/18 (16.6%) patients. The uterus was preserved in most patients (15 patients, 83.3%). A total of 12 patients needed re-suturing of the uterine incision; 10 patients had bilateral uterine artery ligation; and four patients had bilateral internal iliac artery ligation. Uterine compression B-Lynch suturing was needed in five patients with uterine atony. Six patients (33.3%) were admitted to the intensive care unit (ICU) and were discharged well. Re-laparotomy after caesarean delivery has many risk factors leading to postoperative haemorrhage. Early signs, such as tachycardia and hypotension must be closely monitored to allow early intervention and to avoid morbidity and mortality related to late re-laparotomy.

Expulsion of Nova‐T380, Multiload 375, and Copper‐T380A contraceptive devices inserted during cesarean delivery

To compare the expulsion rate of Nova‐T380, Multiload 375, and Copper‐T380A intrauterine contraceptive devices (IUCDs) inserted during cesarean delivery.

A randomized clinical trial of preoperative versus postoperative misoprostol in elective cesarean delivery

To determine the optimum time for misoprostol administration to minimize blood loss during and after elective cesarean delivery.

Could ephedrine replace meperidine for prevention of shivering in women undergoing Cesarean Section under spinal anesthesia? A randomized study

Abstract Purpose To compare possible unlabeled effect of ephedrine, as shivering prophylaxis, with meperidine during spinal anesthesia for Cesarean Section. Methods After institutional ethical committee approval, 96 parturients scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated according to shivering prophylaxis to receive either 15 mg meperidine (group M, n = 48) or 6 mg ephedrine (group E, n = 48) intravenously before spinal block. Incidence and intensity of shivering as well as side effects of either drug were assessed. Results The incidence shivering in meperidine and ephedrine groups in women undergoing Cesarean Section under spinal anesthesia was comparable (27%, 29% respectively, P = 0.06). Also, intensity of shivering was not different between two groups. Moreover, phenylephrine requirement and incidence of nausea and vomiting were significantly less in ephedrine group (121 ± 2.2% and 4.1% respectively) relative to meperidine group (168 ± 3.2% and 16.6% respectively). Conclusion The prophylactic use of a low dose ephedrine is effective as meperidine for shivering prophylaxis in women undergoing Cesarean Section under spinal anesthesia as meperidine. Moreover, it is associated with less hypotension, nausea and vomiting.

Simultaneous cesarean delivery and craniotomy in a term pregnant patient with traumatic brain injury

The management of pregnant patients with traumatic brain injury is challenging. A multidisciplinary team approach is mandatory, and management should be individualized according to the type and extent of injury, maternal status, gestational age, and fetal status. We report a 27-year-old term primigravida presenting after head injury with Glasgow coma scale score 11 and anisocoria. Depressed temporal bone fracture and acute epidural hematoma were diagnosed, necessitating an urgent neurosurgery. Her fetus was viable with no signs of distress and no detected placental abnormalities. Cesarean delivery was performed followed by craniotomy in the same setting under general anesthesia with good outcome of the patient and her baby.

Women’s satisfaction and perception of control in childbirth in three Arab countries

Abstract Women’s satisfaction and perceived control in childbirth are important attributes of the childbirth experience and quality of care indicators. This article presents findings from the pre-intervention phase of a multi-centre implementation study in Egypt, Lebanon and Syria, to introduce a labour companionship model in these countries. A sample of 2620 women giving birth in three public teaching hospitals from November 2014 to July 2015 in Beirut and Mansoura, and from November 2014 to April 2015 in Damascus were interviewed by trained field workers. Additional information was abstracted from medical charts. An adapted version of the Mackey Childbirth Satisfaction Rating Scale was used to measure women’s satisfaction and the shortened version of the Labor Agentry Scale was used to assess perception of control. The total satisfaction score was high in all sites with the lowest being in Egypt. Perceived control was directly related to satisfaction. Women with low education levels had higher levels of childbirth satisfaction. Women who had fewer children from Egypt and Lebanon, and those who received care by a team including both male and female physicians in the Syrian hospital were more likely to be dissatisfied than their counterparts. Variations in the management and provision of care between the three countries may explain the differences in satisfaction levels observed. Further qualitative research is needed to deepen our understanding of the concepts of control and satisfaction in the Arab culture as well as to establish the factors associated with women’s positive childbirth experiences to inform the provision of quality maternity care.