Saudi Journal of Obstetrics & Gynecology

The Saudi journal of obstetrics and gynecology

The official journal of “The Saudi Society of obstetrics and gynecology”.

الجمعية السعودية لأمراض النساء والولادة

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Saudi Journal of Obstetrics & Gynecology

Editor in Chief

Hassan Salah Abduljabbar General Fetal maternal Prof. Abdullah Basalamah. Prof. Nabeel S. Bondagji. Prof. Fawzia Ahmad Haibib. Dr. Yasir katib Dr. Nora Sahly Dr. Yasir Sabr

Reproductive Medicine Urogynecology Prof. Hasan S. Jamal Dr. Ahmad Al-Bader Dr. Hamad Sufyan Dr. Sameera Al-Basri Dr. Mohmmad Alboqna Dr. Faisal Kashgari

Oncology International advisors Dr. Ismail Badawi Prof. Aboubakr alnashar Prof. Khalid Sait Prof. Jamal Abu Soror Dr. Emad Saqr Prof. Faysal ElKak




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The Saudi journal of obstetrics and gynaecology

The Federation of Arab Gynaecology Obstetrics Societies (FAGOS)

Faysal El Kak MD MS ARCOG President- Federation of Arab Ob-Gyn Societies (FAGOS)

The Federation of Arab Gynecology Obstetrics Societies (FAGOS), initially founded as Arab Association

of Obstetrics and Gynecology Societies, was established in 1993 by an initiative of the Jordanian

Society of Obstetricians and Gynecologists, who along with other individual colleagues saw the

importance of having a Pan Arab Ob-Gyn group.




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Faysal El Kak MD MS ARCOG Senior Lecturer- HPCH- FHS , Clinical Associate- WHC-Dept OBGYN- AUBMC Vice President- International Federation Gynecology Obstetrics (FIGO) President- Federation of Arab Ob-Gyn Societies (FAGOS) American University of Beirut, Department of Health Promotion and Community Health- FHS-AUB Women’s Health Center-Department of Obstetrics and Gynecology- AUBMC, P.O. Box 11-0236 Riad El-Solh, Beirut 1107 2020, Lebanon, T: +961 (1) 350000 x 4672, T: +961(1)737377(99) E: [email protected]. www.drfaysalkak.com Introduction

The Federation of Arab Gynecology Obstetrics Societies (FAGOS), initially founded as Arab

Association of Obstetrics and Gynecology Societies, was established in 1993 by an initiative of the

Jordanian Society of Obstetricians and Gynecologists, who along with other individual colleagues

saw the importance of having a Pan Arab ObGyn group. In that regard, the first founding meeting

was held in Amman on 8th of April 1993 and it was attended by high level representatives of the

Arab Societies from Jordan, Tunis, Bahrain, Iraq, Yemen, Palestine and Syria. During the meeting,

discussions focused on the best way to initiate an Arab body of obstetrician’s gynecologists who will

create a critical mass of colleagues to improve the profession and promote Arab women health. The

meeting was successful ending by developing the By Laws of the Association and electing an

Executive Board with H.E , Dr Aref Batayneh from Jordan as President and Professor Ibrahim Hakki

from Syria as Vice President. The board was active initially in introducing the Federation to various

colleagues and national societies in different Arab countries, which was well received and

encouraged by all. In 1997 Dr Ibrahim Hakki was elected as the President, followed by Professor M.

Sammour from Egypt in 1999. Then in 2003 Professor Hasan Jamal from Saudi Arabia was elected as

President followed by Professor Abdullatif Ashmaiq from Sudan in 2007 and Dr. Mohammed

Rasheed Shehada from Syria in 2010. Dr Abdallah Adra from Lebanon was elected in 2014.

Currently FAGOS is presided by Dr Faysal El Kak from Lebanon, who is also the Vice President of

FIGO.

From the very beginning, FAGOS is run by an Executive Board and General Council which represents

presidents of national societies of OBGYN of member states of the Arab League.

It has been the practice that the scientific meetings of FAGOS be held annually in different Arab

cities, in collaboration with the national societies. These meetings aim to bring Arab colleagues

together, exchange expertise, and share common issues related to Arab women health. The first

meeting was held in Amman, Jordan, 1995, followed by one in Damascus, Syria, 1997, Cairo, Egypt,

1999, Beirut, Lebanon, 2001, Jeddah, KSA, 2002, Morocco, 2004, Syria, 2005, Khartoum, Sudan,

2007, and other places where national scientific meeting is held.

mailto:[email protected]

http://www.drfaysalkak.com/




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As of 2017, FAGOS board decided to establish regional and global networks to promote women

health in the MENA and Arab Regions. FAGOS collaborated with FIGO for the FIGO Regional meeting

held in Dubai, UAE, April 2018. It also collaborated with EMRO, WHO, on meetings related to

contraception and to maternal health held in Beirut 2017 and 2018. It was also decided to hold

standalone FAGOS meetings. The first one was held successfully in Beirut, September 2018, and

another one is planned in the same place in September 2019. Those meetings reflect the growing

presence and importance of FAGOS as a Regional body of global significance. In addition, The

Association is composed of 18 members of Arab Societies of OBGYN and it has Five Scientific

Groups,

– The Arab Fetomaternal Group: Active and holds yearly scientific meetings

– The Arab Fertility and Assisted Reproduction Group

– The Arab Menopause Group.

– The Arab Gyn-Oncology Group.

– The Arab Gyn-Urology Group

FAGOS also has a good presence on social media through a Facebook page and twitter account, to

stay in phase with global changes and debates

Twenty-six years has passed since the foundation of FAGOS, with competent, dedicated, and

passionate colleagues who led the federation forward to show case the expertise and excellence of

the profession and practice in the Arab Region. Efforts towards strategic plans to engage FAGOS

globally and at the Regional level will continue as well as communicate with policy makers and

funders to push and promote health and wellbeing of the Arab woman.

Faysal El Kak M.D. M.S. ARCOG

FAGOS President (2017-2020)




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Caesarean Myomectomy: safety and risk of intrauterine synechiae

Ibrahim Abd El Gafor Elsharkwy. Hosam Abdelfatah, Faculty of medicine Zagazig University, Zagazig, Egypt. Faculty of medicine Mansoura University, Mansoura, Egypt Correspondence: Hosam Abdelfatah Zagazig, Egypt e-mail [email protected]

Abstract:

Background

in the past cesarean myomectomy was considered a dread procedure as it carries many potential risks, the aim

of this study is to evaluate the safety and feasibility of performing myomectomy during cesarean section also to

estimate the risk of intrauterine adhesions after the operation.

Methods

in this prospective study 36 pregnant women who underwent cesarean myomectomy (study group) were

compared to 42 pregnant women who underwent cesarean delivery without myomectomy (control group), then

three months after delivery hysteroscopy was done for all patients and 5 patients with intrauterine adhesions

was compared to 31 patients without intrauterine adhesions.

Findings:

no statistically significant differences in hemoglobin change (p= 0.52), duration of operation (p= 0.53), hospital

stay (p= 0.15), blood transfusion (p= 0.18) and postoperative fever (p= 0.42) between cesarean myomectomy

and control groups respectively. No statistically significant differences in breach of cavity (p= 0.25), mean

hemoglobin change (p= 0.39) and myoma characters between group with intrauterine adhesions and group

without.

Conclusions: cesarean myomectomy is a safe procedure with no additional risk of intrauterine adhesions.

Keywords; Cesarean, myomectomy, safety, intrauterine synechiae




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Introduction Obstetricians commonly meet pregnancy complicated with leiomyomas, the frequency of myoma in

pregnancy is about 2–4 % [1]. The trend of females to delay childbearing and the recent advances in

assisted reproduction techniques result in a steady rise of pregnant women with leiomyomas [2].

The incidence of fibroid with pregnancy concomitantly rises with increase age of the first pregnancy

[3].

Obstetricians have traditionally discouraged myomectomy throughout cesarean delivery. With the

exclusion of pedunculated and small myomas nearly all the chief obstetric textbooks counsel against

excision of myoma during cesarean section owing to the theoretical threat of intractable bleeding

and increased subsequent complications [4].

A number of new studies show that it is safe to practice myomectomy with cesarean delivery

without increased risk of complications during operation or postpartum [5]. Intrauterine adhesions

logically follow surgeries involving uterine cavity as myomectomy and cesarean sections [6]. The

reported incidence of intrauterine adhesions following myomectomy was 1.3% [7].

We conducted this prospective trial to study the safety and practicability of performing

myomectomy during cesarean section and to evaluate the risk of intrauterine adhesions.

Material and Methods

Our prospective study was carried out from January 2010 to December 2015 in the Departments of

Obstetrics and Gynecology, Zagazig University Hospital and Mansoura University hospital, Egypt.

University Ethics Committee approval for the study was obtained.

All women included in the study gave informed consent for myomectomy during cesarean delivery.

study group consisted of 36 pregnant women who were diagnosed to have myoma either during

pregnancy by ultrasonography or by the way discovered intra-operatively, the control group

consisted of 42 pregnant women who underwent cesarean delivery without myomectomy in the

similar period.

Control cases were matched for parity, age, preoperative hemoglobin level and gestational age at

cesarean delivery. Exclusion criteria included patients with a history of coagulation disorder,




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antepartum hemorrhage, previous myomectomy and where additional operative procedures were

performed with cesarean section (like excision of ovarian cyst) .

A meticulous history was obtained, clinical assessment and usual investigations were performed for

all the patients and carefully analyzed.

Information like parity, age, cesarean section indications, gestational age at delivery and

preoperative hemoglobin level were recorded. Myoma was excised by the conventional method

which involves creation of an incision over the fibroid by means of monopolar cautery and dissecting

it, and then obliteration of dead space with 1-0 Vicryl interrupted sutures in at least two layers

followed by closure of uterine serosa with 2-0 Vicryl. Usually, myomectomy was done after delivery

except if the fibroid was situated in the lower uterine segment rendering delivery of baby before

myomectomy difficult.

Two layers closure of LSCS uterine incision with 1-0 Vicryl, at the end tremendous hemostasis was

ensured, an intraperitoneal drain was left and the abdominal wall was closed in layers. Prophylactic

sustained intravenous oxytocin infusion was continued throughout the immediate postoperative

stage to avoid bleeding.

Other data retrieved were the duration of operation, size, number of fibroids excised, the amount of

blood loss at surgery, the requirement for blood transfusion, breach of the uterine cavity,

postoperative hemoglobin level after 24 hours of operation and occurrence of complications.

Diagnostic hysteroscopy was done for all patients three months after delivery and intrauterine

adhesions were graded as mild, moderate and severe relied on the scoring system recommended by

the American society for reproductive medicine (table 1) [8].

Statistical analysis

SPSS (Statistical Package for the Social Sciences) Statistics software version 16.0 was used for

analysis of recorded data. Continues variables were represented by mean±standared deviation

while categorical variables were represented by number and percentage. Student t-test and chi-

square tests were used to determine statistical significance .Significance was considered when p-

value <0.05.




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Table1. American fertility society classification of intrauterine adhesions. American Fertility Society (1988)

Results

Table (2)

Characteristics of patients

Cesarean myomectomy group (n=36) Control group (n=42)

(Mean ± SD) (Mean ± SD) P value

Maternal age (y) 29.6 ± 5.4 28.9 ± 5.1 0.47

parity 1.2 ± 1.1 1.6 ± 0. 0.36

Gestational age at delivery (Wk) 37.7 ± 2.42 37.5 ± 2.16 0.28

Cavity involved Type of adhesions

<1–3 1 Filmy

1/3–2/3 2 Filmy and dense

>2/3 3 Dense

Menstrual pattern

1 Normal 0

2 Hypo menorrhea 2

3 Amenorrhea 4

Prognostic classification

HSG score

Hysteroscopy score

Stage I (mild) Stage II (moderate) Stage III (severe)

1–4 5–8 9–12




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Patients characteristics with no statistically significant differences in age, parity and Gestational age at delivery between two groups. (Table 2) Table 3 Characteristics of myomas

Cesarean myomectomy group (n=36 )

Control group (n=42 )

P value

Type Subserous Intramural Submucous

8 (22%) 15 (42%) 13 (36%)

10 (24%) 19 (45%) 13 (31%)

0.56 0.59 0.64

Location Body Cervix Body and Cervix

32 (89%) 3 (8%) 1 (3%)

38 (90%) 2 (5%) 2 (5%)

0.71 0.74 0.88

Number 1.66 ± 0.89 1.78 ± 1.2 0.41

Diameter of myoma 5.7 ± 3.0 6.2 ± 2.9 0.21

There were no statistically significant differences in type, location, number, and diameter of myomas between two groups (Table 3).




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Table 4 Operative outcome

Cesarean myomectomy group (n=36)

(Mean ± SD)

Control group (n=42)

(Mean ± SD)

P value

Preoperative Hb (g/dl) 11.9 ± 1.3 12.2 ± 0.8 0.33

Postoperative Hb (g/dl) 9.7 ± 1.2 10.4 ± 1.1 0.62

Mean change in Hb (g/dl) 1.8 ± 0.6 1.4 ± 0.5 0.52

Duration of operation (minutes)

45.0 ± 17.5 38.6 ± 12.3 0.53

Hospital stay (days) 3.0 ± 1.2 3.0 ± 0.4 0.15

Blood transfusion n (%) 4 (11%) 2 (5%) 0.18

Postoperative fever 8 (22%) 6 (14%) 0.42

The operative outcome, there were no statistically significant differences in hemoglobin change (1.8

± 0.6 vs. 1.4 ± 0.5 p= 0.52), duration of operation (45.0 ± 17.5 vs. 38.6 ± 12.3 minutes p= 0.53),

hospital stay (3.0 ± 1.2 vs. 3.0 ± 0.4 days p= 0.15), blood transfusion (11% vs. 5% p= 0.18) and

postoperative fever (22% vs. 14% p= 0.42) between cesarean myomectomy and control groups

respectively. (Table 4)




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Table 5 Comparison between Cesarean myomectomy groups with and without intrauterine adhesions

Group with adhesions (n = 5)

Group without adhesions (n = 31)

P value

Size (cm) 6.1 ± 1.2 5.9 ± 2.2 0.24

Number 1.6 ± 0.6 1.9 ± 0.3 0.32

Type Sub serous Intramural Submucous

1(20%) 2 (40%) 2(40%)

12 (39%) 9 (29%) 10 (32%)

0.18 0.12 0.11

Cavity breached 3(60%) 15 (48%) 0.25

Mean change Hb (g/dl) 1.7 ± 0.4 1.5 ± 0.6 0.39

No intrauterine adhesions have been reported in control group, only five cases were recorded with

mild intrauterine adhesions in cesarean myomectomy group, further study of cesarean

myomectomy group regarding postoperative intrauterine adhesions has demonstrated that group

with intrauterine adhesions has no statistically significant difference in size (p=0.24) number

(p=0.32) and type of myomas when compared with group without intrauterine adhesions, in

addition there were no statistically significant differences in breach of cavity (p= 0.25) and mean

hemoglobin change (p= 0.39) between two groups (Table 5).




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Discussion

Removal of fibroid at cesarean delivery improves obstetric outcome by preventing many

complications related to the existence of fibroid in the future pregnancy [9]. In our study, there

were no statistically significant differences in hemoglobin change, duration of operation, hospital

stay, blood transfusion and postoperative fever between cesarean myomectomy cases and those

with cesarean section without myomectomy.

In accordance with our study, many studies have documented safety and effectiveness of cesarean

myomectomy in properly selected cases and skilled surgeons [10-14], a relatively large study [15]

and one recent study [12] have found no significant differences in hematocrit change between

patients who underwent cesarean myomectomy and patients who underwent cesarean section

only. In contrast to our study, other studies have found the duration of operation was significantly

longer in cesarean myomectomy than cesarean section alone [16,17].

Similar to our findings, Park et al. have found no association between intraoperative complications

and location of myomas [13] but others have advised against performing myomectomy during

cesarean section with myomas located near fallopian tubes, corneal myoma and intramural fundal

myoma [18].

Others have considered the size of myoma and stated that cesarean myomectomy is safe in patients

with huge myomas [19,20]. Furthermore Leanza et al. have documented a successful removal of a

22cm myoma during cesarean section [21].

The Occurrence of peritoneal adhesions after abdominal myomectomy has been considered by a lot

of studies [22]. There is a realistic evidence on the existence of intrauterine adhesions after

myomectomy and cesarean section [23].

One of the most important predisposing factors for intrauterine adhesions is hysteroscopic

myomectomy [24,25]. But a little number of studies has evaluated post open myomectomy

intrauterine adhesions [26]. One of these studies has stated that the incidence of intrauterine

adhesions after open myomectomy was 50%, this high incidence was explained by increased

number of myomas removed [27]. Asgari et al have found no difference in incidence of intrauterine

adhesions between laparoscopic and open myomectomies but assessment of cavity was based on

hysterosalpingography three months after operation [28].

To our knowledge, no studies have discussed intrauterine adhesions after cesarean myomectomy ,

our study has reported that, intrauterine adhesions after cesarean myomectomy was mild and




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neither the size, type and number of myomas nor breach of the uterine cavity has significant

relation to intrauterine adhesions formation.

The Incidence of intrauterine adhesions after cesarean myomectomy in this study was about 14%,

which was lower than that was reported after open myomectomy without pregnancy by other

studies 50% [28] and 21.57 % [29], this could be explained by high blood supply in pregnant uterus

which promotes good healing process after myomectomy, supporting the suggestion that

myometrial ischemia has a role in development of intrauterine adhesions [26,30]. However, a lower

incidence of intrauterine adhesions after open myomectomy was reported with the insertion of

Foley's catheter inside uterine cavity after myomectomy [31].

In consistence with the results obtained by other study [26], our study has stated that, breach of the

uterine cavity had no significant relation to development of intrauterine adhesions after open

myomectomy , ischemia with the resultant tissue necrosis and fibrosis could be responsible for

creation of intrauterine adhesions when the cavity was not opened, like intrauterine adhesions

following uterine artery embolization [32].

Conclusion

According to the results of current study, cesarean myomectomy can be considered as a safe

procedure with no additional risk of maternal mortality or morbidity, avoids the extra cost and

repeat surgery. The risk of intrauterine adhesions after cesarean myomectomy was minimal, the

issue which needs further larger studies as small sample size was a limitation in this study.

Author contribution:

Ibrahim Abd El Gafor Elsharkwy: project development, Data collection, Manuscript writing

Hosam Abdelfatah: Data collection, Data analysis, Manuscript editing

Compliance with Ethical Standards:

1-Conflict of interest:

Ibrahim Abd El Gafor Elsharkwy: none

Hosam Abdelfatah: none

2 -Ethical approval: All procedures performed in studies involving human participants were in

accordance with the ethical standards of the institutional research committee and with the 1964

Helsinki declaration and its later amendments or comparable ethical standards.

3- Informed consent was obtained from all individual participants included in the study.




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2. Parker WH (2007) Etiology, symptomatology and diagnosis of uterine myomas. FertilSteril

87: 725-736.

3. Neiger R, Sonek JD, Croom CS, Ventolini G (2006) Pregnancy related changes in the size of uterine leiomyomas. J ReprodMed 51:671-4.

4. Depp R (2002) Cesarean delivery. In: Obstetrics: normal and problem pregnancies 4th

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6. Nakhuda GS, Douglas NC, and Sauer MV (2005) “Clinically significant uterine synechiae

caused by transmural uterine incisions,” Journal of Gynecologic Surgery 2: 95–98.

7. Schenker JG and Margalioth EJ (1982) “Intrauterine adhesions: an updated appraisal,”

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9. Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, et al (2012) Adverse obstetric

outcomes associated with sonographically identified large uterine fibroids. Fertil Steril 97:107–110.

10. Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L (2005) Myomectomy during cesarean section. Int J Gynaecol Obstet 89:90–93.




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11. Ortac F, Gungor M, Sonmezer M (1999) Myomectomy during cesarean section. Int J Gynaecol Obstet 67:189–190.

12. Park BJ, Kim YW (2009) Safety of cesarean myomectomy. J Obstet Gynaecol Res 35(5):906-11.

13. Celal K, Hülya C (2011) The evaluation of myomectomies performed during cesarean section in our clinic. Niger Med J 52(3):186-8.

14. Incebiyik A, Hilali NG, Camuzcuoglu A, Vural M, Camuzcuoglu H (2014) Myomectomy during caesarean: a retrospective evaluation of 16 cases. Arch Gynecol Obstet 289(3):569-73.

15. Roman AS, Tabsh KM (2004) Myomectomy at time of cesarean delivery: a retrospective cohort study. BMC Pregnancy Childbirth 4(1):14.

16. Kwawukune EY Caesarean myomectomy (2002) Afr J Reprod Health. 6(3):38-43.

17. Özcan A, Kopuz A, Turan V, Sahin C, Töz E, Aksoy S, Ozeren M (2016) Cesarean myomectomy for solitary uterine fibroids: Is it a safe procedure? Ginekol Pol 87(1):54-8

18. Hassiakos D, Christopoulos P, Vitoratos N, Xarchoulakou E, Vaggos G, Papadias K (2006) Myomectomy during cesarean section: a safe procedure? Ann N Y Acad Sci1092:408-13.

19. KwonDH, Song JE, Yoon KR, Lee KY (2014) The safety of caesarean myomectomy in women with large myomas. Obstet Gynecol Sci 57: 367-372.

20. Senturk MB, Budak MS, Cakmak Y, Turan K (2015) Is myomectomy safe during cesarean section in large myomas? Medical Science and Discovery 2 (5):292-96.

21. Leanza V, Fichera S, Leanza G, Cannizzaro MA (2011) Huge fibroid (g. 3.000) removed during

cesarean section with uterus preservation: a case report. Ann Ital Chir 82:75-7.

22. Ahmad G, Duffy JM, Farquhar C, Vail A, Vandekerckhove P, Watson A, et al (2008) Barrier agents for adhesion prevention after gynecological surgery. Cochrane Database Syst Rev 2:CD000475.

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(2014) A rare case of Asherman's syndrome after open myomectomy: Sonographic investigations and possible underlying mechanisms. Gynecol Obstet Invest 77:194–200.




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24. Taskin O, Sadik S, Onoglu A, Gokdeniz R, Erturan E, Burak F, et al (2000) Role of endometrial suppression on the frequency of intrauterine adhesions after resectoscopic surgery. J Am Assoc Gynecol Laparosc 7:351–4

25. Yang JH, Chen MJ, Wu MY, Chao KH, Ho HN, Yang YS (2008) Office hysteroscopic early lysis of intrauterine adhesion after transcervical resection of multiple apposing submucous myomas. Fertil Steril 89:1254-9.

26. Gambadauro P, Gudmundsson J, Torrejón R (2012) Intrauterine adhesions following

conservative treatment of uterine fibroids. Obstet Gynecol Int 853269:1-6.

27. Conforti A, Krishnamurthy GB, Dragamestianos C, Kouvelas S, Micallef Fava A, Tsimpanakos I, et al (2014) Intrauterine adhesions after open myomectomy: An audit. Eur J Obstet Gynecol Reprod Biol 179:42-5.

28. Asgari Z, Hafizi L, Hosseini R, Javaheri A, Rastad H (2015) Intrauterine synechiae after

myomectomy; laparotomy versus laparoscopy: Non-randomized interventional trial. Iran J Reprod Med 13:161-8.

29. Bhandari S, Ganguly I, Agarwal P, Singh A, Gupta N (2016) Effect of myomectomy on endometrial cavity: A prospective study of 51 cases. J Hum Reprod Sci 9(2):107-11.

30. Saed GM, Diamond MP (2002) Hypoxia-induced irreversible up-regulation of type I collagen and transforming growth factor-b1 in human peritoneal fibroblasts. Fertil Steril 78:144–7.

31. Gupta S, Talaulikar VS, Onwude J, Manyonda I (2013) A pilot study of Foley's catheter

balloon for prevention of intrauterine adhesions following breach of uterine cavity in complex myoma surgery. Arch Gynecol Obstet 288:829-32.

32. Mara M, Fucikova Z, Kuzel D, Maskova J, Dundr P, Zizka Z (2007) Hysteroscopy after uterine

fibroid embolization in women of fertile age. J Obstet Gynaecol Res 33:316-24.




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Influence of genetic and environmental risk factors on the

development of venous thrombosis among female patients in the

western region of Saudi Arabia.

Correspondence author Dr. Galila F Zaher, MBBS, FRCPath Uk. Associate Professor, Hematology Department School of Medicine, King Abdulazaiz University King Abdulazaiz University Hospital, Jeddah, Saudi Arabia. [email protected]




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Abstract: Introduction Thrombophilia of genetic or acquired causes creates a hyper-coagulable state which can lead to arterial and/or venous thrombosis. The relationship between thrombophilia and VTE has been investigated. This association has become an undisputed fact in Caucasian populations, but there is insufficient knowledge concerning multi-ethnic populations such as the Saudi Arabia. The Arabian Peninsula is known by higher rates of consanguineous marriages which can increase the prevalence of heterozygous trait. Objectives. we conducted a retrospective case-control study to determine the prevalence of inherited and acquired thrombophilic conditions in a series of female patients with first attack and recurrent venous thromboembolism in a teaching hospital in the western region of Saudi Arabia. Patients: The study group included female patients seen in the hematology clinic with radiologically diagnosed first attack venous thromboembolism (VTE) or recurrent VTE. Methods. A total of 102 patients attending the hematology clinic between 2013 and 2017. Data were collected from computer-based patients' charts. All patients had baseline coagulation screen, functional activity of protein C , Protein S , antithrombin level and antiphospholipid both screening and confirmatory tests. Genetic thrombophilia screen included: Factor V Leiden , Prothrombin gene (G20210A), and Methylene tetrahydrofolate folate reductase (C677T) mutations. These mutations were assessed by polymerase chain reaction. Thirty -one age match healthy women controls were recruited. The control group never had DVT. Main Outcome Measure(s): The prevalence of functional thrombophilic defect, and polymorphism frequencies were recorded for each group and comparisons were made. Result(s). A total of 133 female participants aged between (15-54) years were included in this study, of those 102 were cases and 31 controls. Both Functional and genetic thrombophilia screen was checked for patients and control. Patients with first attack VTE had statistically lower levels of Protein C, Protein S and Antithrombin, p value ≤ 0.05. The logistic regression model showed that BMI, Protein S and Antithrombin were the only variables statistically related to the incidence of DVT. In our study, over-weight women (BMI≥ 27) is recognized as independent risk factor for developing VTE. Over-weight women (BMI≥ 27) were 4.5 times more likely to have DVT than subjects with BMI ≤ 27. In addition, patients who had PS deficiency were 37 times more likely to develop DVT more than those who had normal PS values. Conclusion. Our study revealed that these risk factors were not significant difference between patients with first episode of DVT and those who had recurrent DVT. Keywords. Venous Thrombosis, thrombophilia; Saudi; genetic environmental factors.




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Introduction

Background:

Venous thromboembolism (VTE) is a major cause of mortality and morbidity [1]. Thrombophilia

describe a coagulation system abnormality that increases the tendency towards thrombosis [2].

Hyper coagulable state may predispose to venous thromboembolism (VTE) consisting of deep

venous thrombosis (DVT) and or pulmonary embolism (PE). Thrombophilia can be hereditary or

acquired. Hereditary thrombophilia comprises a number of conditions, such as antithrombin (AT),

protein S (PS) and protein C (PC) deficiencies, factor V Leiden (FVL), prothrombin (FII G20210A)

mutation, and mutation of gene encoding the enzyme methylenetetrahydrofolate reductase

(MTHFR) C677T.

The association between thrombophilic conditions and VTE has become an undisputed fact in

Caucasian populations [3-5]. However, there is insufficient knowledge concerning multi-ethnic

populations such as the Saudi population who has a genetic mixture. Furthermore, Saudi Arabia is

well known by a high level of consanguineous marriages driven by ethnic or tribal considerations [6].

Material and Methods.

Patients and Controls

A total of 102 female patients presenting to hematology clinic with venous thromboembolism were

recruited between Aug 2013to Aug 2017. Inclusion criteria: all female patients referred to

hematology clinic with radiologically diagnosed first attack VTE or recurrent VTE. Exclusion criteria:

Elderly female >70 years were excluded from the study as well as those diagnosed as cancer related

thrombosis or patients on oral contraceptive pills. Medical histories, physical examinations,

laboratory tests and radiological evaluation were obtained from computerized hospital information

system. The control population consisted of thirty- one healthy age-matched women, with no

personal or family history of VTE . These women were recruited during their blood donation.

All patients and control group were tested in Hematology laboratory of King Abdulaziz University

(KAU) hospital for functional thrombophilia screen and at king Fahad research center for genetic




20

thrombophilia screen. Functional thrombophilia screen included antithrombin (AT), protein S (PS)

and protein C (PC) levels and lupus anticoagulant (LA screen and confirmatory) while, the genetic

thrombophilic included Factor V Leiden (FVL), Prothrombin gene (FII G20210A), and Methylene

tetrahydrofolate folate reductase (MTHFR C677T )mutations.

The research has been performed in accordance with the Declaration of Helsinki and had been

approved by an ethics committee at king Abdulazaiz university, Jeddah, Saudi Arabia. Informed

consent has been obtained from all individuals included in this study.

Sample collection

Blood samples drawn were outside the acute VTE presentation and avoiding patients on

anticoagulant therapy. Venous blood was collected on 0.129 mol/l trisodium citrate and was

centrifuged twice at 2000 g for 15 min at room temperature in order to obtain plasma with platelet

poor plasma. Plasma was then frozen and stored in small aliquots at – 70C until tested. Ethylene

diamineteraacetic acid (EDTA) anticoagulant samples were used for DNA analysis. EDTA blood was

snap-frozen and immediately stored at – 70C. Genomic DNA was prepared from blood samples

according to standard methods.

Laboratory Evaluation

Functional Thrombophilia screen were assayed by auto analyzer instrumentation laboratory Werfen

and HemosIL Kit . (Spain ) Protein C/ S and Anti thrombin chromogenic assay were performed as

per manufacture instructions. Normal ranges of PC and PS activity and AT were considered as 70-

140%, 63-135% and &70 -140% respectively.

The detection of the lupus anticoagulant (LA) was based on dilute Russell viper venom test as a

screening test and platelet neutralization procedure as a confirmatory test. The anticardiolipin

antibodies were detected by a standardized enzyme-linked immunosorbent assay, and the titer was

considered elevated if medium or high titers of both IgG and IgM isotypes were present in blood. A

diagnosis of Anti-Phospholipid syndrome (APS) is made if one of the following clinical criteria is

present, in addition to persistent abnormality >6 weeks apart of one of the following tests: (a) Lupus

anticoagulant, (b) anticardiolipin and B2 glycoprotein antibody IgG and IgM[7] Genetic

Thrombophilia screen included

The main genes investigated using PCR- RFLP (restriction fragment length polymorphism) were FVL

G1691A, FII G20210A and MTHFR C677T. Following DNA extraction, a Taq-polymerase based PCR

using specific primers for each gene was performed. The PCR product for each gene is then




21

fragmented using a specific restriction enzyme in order to target potential Single Nucleotide

Polymorphisms (SNPs) and separated according to their base pairs’ size by gel electrophoresis.

Statistical Analysis:

The statistical analysis was conducted using IBM SPSS v25 USA. The Shapiro-Wilk Test was used to

assess the normality of the data distribution. Quantitative variables with normal distribution were

expressed as a mean with standard deviation (± SD). T. Test was applied to compare the

demographic characteristics as well as the values of Protein C, Protein S and Antithrombin between

patients and controls. A logistic regression was then performed to assess the effects of congenital

and acquired risk factors on the likelihood that participants have DVT. A p-value of ≤ 0.05 was

considered statistically significant.

Results

A total of 133 female participants aged between (15¬ – 54) years were included in this study, of

those 102 were cases and 31 controls. The demographics of patients and controls are shown in

Table 1. The mean levels of protein S, protein C and anti-thrombin measured in cases and controls

are presented in Table 2. The results indicated that healthy control group had statistically higher

levels of Protein C, Protein S and Antithrombin, p value ≤ 0.05 (Figure 1).

Our results also showed that the incidence of PS , PC and AT deficiency among the patients’ group

was 48%, 13% and 0% respectively while 3%of control had low PS and none had PC or AT deficiency.

The mean of PS in patient group was 64.6 ± 24.9 while that in control group was 109 ± 18 which was

statistically significant P value =0.00** and the mean of AT in patients group was 95 ± 16 while

that in control group was 111 ± 7.2 which was also statistically significant P value =0.00**(Table 2).

The frequency of genetic thrombophilia screen among patients and control group is presented in

Table 2.

To further investigate the association between PS and AT level on the likelihood that participants

have developed DVT (Table 3). The logistic regression model was statistically significant, χ2 (9) = 66,

p < 0.00. The model explained 80% (Nagelkerke R2) of the variance in DVT and correctly classified

88% of the cases.

In this regression model BMI, Protein S and Antithrombin were the only variables statistically related

to the incidence of DVT. High BMI was associated with an increased likelihood of having DVT. On the




22

contrary low Protein S and Antithrombin levels were associated with increase in the likelihood of

developing DVT (Table 3, Model 1).

The regression analysis also showed that over -weight women (BMI ≥ 27) were 4.5 times more likely

to have DVT than subjects with BMI ≤ 27. In addition, patients who had Protein S deficiency (< 70

IU/dL) were 37 times more likely to develop DVT more than those who had normal protein S values

(Table 3. Model 2). Our regression analysis however, revealed no significant difference between

patients with first episode of DVT and those who had recurrent DVT (Table 3, Model 3).

Table 1:

Demographics of patients and controls enrolled in the study

Patients (N= 102) Controls (N = 31) P value

Age (Years) 33.5 ±9.5 29 ±9 0.008

Weight (kg) 72 ±18 70 ±14 0.588

Height (cm) 160 ±67 160 ±46 0.429

BMI 28 ±6.6 27 ±5.3 0.390

PT 12.5 ±1.5 11.5 ±1.5 0.42

APTT 32.9±4.5 30.9±4.5 0.40

Risk factors Frequency Percent

Surgery 13 12.7%

SLE 13 12.7%

Pregnancy 10 9.8%

CHF 4 3.9%

Trauma 1 0.9%

Recurrent DVT 23 22%




23

Data presented as mean and ± SD

Table 2: functional and genetic thrombophilia among patients and control group

Patients

(N= 102)

Controls

(N = 31)

P

value

Functional

Thrombophilia

Mean

PC 98.7 ± 28.9 113 ± 18.6 0.021*

PS 64.6 ± 24.9 109 ± 18 0.00**

AT 95 ± 16 111 ± 7.2 0.00**

Frequency

N (%)

PS<70 49 (48%) 1 (3%)

PC<70 13 (13%) 0

AT<70 5 (4.9%) 0

Abnormal LA 13 (13%) 0

Genetic

Thrombophilia

Patients

(N= 102)

Controls

(N = 31)

FVL

N (%)

Total 20 (19.8%) 3 (9.6%)

Homozygous 2 (2%) 0

Heterozygous 18(18%) 3(9.6%)

FII

G20210A

N (%)

Total 18(17%) None

Homozygous 18(17%) None

Heterozygous ---- None

MTHFR

N (%)

Total 45(45%) 17(54%)

Homozygous 33(33%) 5(16%)

Heterozygous 11(11%) 12(38.7%)




24

Protein C(PC), Protein S(PS), Antithrombin (AT), ** P- value is significant at 0.01 level * P- value is significant at 0.05 level

Table 3:

Regression model to identify factors influencing the likelihood of developing DVT

Model

statistics χ2

Nagelkerke

R2

Classificatio

n accuracy

B

Exp

(B)

Significance

Model 1 χ2 (9) = 66, p <

0.00*

0.80 88%

DVT a

Protein S b

-0.088 0.916 0.001*

Antithrombin b -0.101 0.904 0.045*

BMI b 0.183 1.201 0.047*

Age c 0.018 1.018 0.713

Protein C c -0.022 0.978 0.392

Abnormal LA c -18.648 0 0.999

Abnormal FVL c -1.081 0.339 0.527

Abnormal FII G20210A c -25.995 0 0.998

Abnormal MTHF c 1.658 5.247 0.102

Model 2 χ2 (9) = 66, p <

0.00

0.80 88%




25

DVT a

BMI > 27 b

1.507 4.5 0.040*

Protein S deficiency b 3.635 37 0.003*

Antithrombin deficiency c 17.07 260.8 0.999

Protein C deficiency c 18.07 667.8 0.999

Age c 0.046 1.04 0.209

Abnormal LA c 18.9 1731 0.999

Abnormal FVL c 0.689 1.99 0.508

Abnormal FII G20210A c 20.3 7059 0.999

Abnormal MTHF c -1.26 0.291 0.123

Model 3 χ2 (9) = 4.5, p <

0.869

0.114 88%

Recurrent DVT a

Age C

0.011 1.011 0.778

BMI C -0.072 0.931 0.38

Protein S Deficiency C 0.00 1 0.974

Protein C Deficiency C 0.003 1.003 0.888

Antithrombin Deficiency C -0.033 0.967 0.181

Abnormal LA1 C 0.426 1.532 0.667

Abnormality FVL C 0.637 1.892 0.48

Abnormal FII G20210 C 0.087 1.09 0.945

Abnormal MTHF C 0.369 1.447 0.64




26

a. Dependent variable b. Predictors c. Insignificant variables




27

a)

b)

c)

P value = 0.009* P value = 0.520

70 IU/dL

70 IU/dL

P value = 0.00* P value = 0.387

70 IU/dL

P value = 0.00* P value = 0.924

Figure 1

mean Protein C, protein S and antithrombin among healthy controls, patients with first attack VTE

and recurrent VTE.




28

Discussion:

Thrombophilic abnormalities can be hereditary or acquired. Hereditary thrombophilic conditions can

result from deficiencies of the natural anti-coagulant protein C, S and antithrombin which are rare

that occur in less than 1%- 2% of the general population [1-5]. However, less thrombogenic

conditions such as FVL, FII G20210A mutation, and MTHFR C677T can also result in hypercoagulable

state. Dahlback et al reported that 15% of the population in southern Sweden carried the FVL gene

[8]. On the other hand, the mutation is not present in African Blacks, Chinese, or Japanese

populations [8,9]. The Leiden Thrombophilia Study has demonstrated a prevalence of the FII

G20210A mutation of 2.3% among healthy controls [10]. Furthermore, the prevalence of MTHFR

C677T in general population reported the heterozygote and homozygosity frequency of 18%,

46%,45%, and 0.9%, 21%,11% respectively, in African American, Hispanics and Caucasians [11].

The inherited deficiency of one of the three natural anti-coagulant proteins was found in about 15%

of patients who present with VTE before the age of 45 [8]. Studies from the Netherlands and the US

have shown that congenital AT deficiency, PC deficiency and P S deficiency increases the risk of VTE

14,8-10 and 10 folds respectively [12,13].

The Leiden Thrombophilia Study by Koster et al provided a population-based case control study

assessed the relative risk for a VTE event was increased 7 to 80-folds for heterozygous and

homozygous individuals with FVL mutation respectively [14]. The FII G20210A gene mutation is

associated with an elevated risk of VTE, although to a lesser degree than FVL. The Leiden

Thrombophilia Study has demonstrated a prevalence of the FII G20210A mutation to be 6.2% among

VTE patients and 2.3% among healthy matched controls [10].

Most of the studies have been conducted in Caucasian populations and the association is almost

unclear in multiethnic populations such as the Saudi population. Furthermore, data about the

prevalence of thrombophilic polymorphisms, and its correlation with VTE in the Arabian Peninsula

are limited. In addition, the tidal movements of historical populations in and out of the Arab region

allowed the area to become an important bridge for the flow of genes between Africa, Asia, and

Europe [15]. In addition, Arabian Peninsula has a high rate of consanguineous marriages which could

increase the prevalence of autosomal recessive prothrombotic conditions [6].

The prevalence of PS, PC and AT deficiency in our control group was 3%, 0% and o% respectively as

compared to 48%, 13% and 4.9% which is higher than earlier reports from the western province of

the kingdom[16]. However, PS deficiency was found to be the most common, identified

thrombophilic condition followed by PC deficiency (14.5% and 8.4%), while AT deficiency was not

reported[16].




29

Furthermore, our data showed a prevalence of FVL , FII G20210A and MTHFR mutation of 9.6, 0 and

54% in control group as compared to 19.8, 17 and 45% in patients group respectively which is

higher than the reports from the eastern province of the kingdom, where, the prevalence of FVL

mutation , FII G20210A and MTHFR mutation range between 0.5 and 2%, 2% and 7-10%

respectively [17-19]. The prevalence of genetic thrombophilia screen in our patient group is more in

line with that of Egyptians 18.5%, Lebanese 14.65%, and Tunisians 13.6% [20,21]. These conflicting

reports can be explained by different inclusion and exclusion criteria of the enrolled patients or

regional or ethnic variation in the distribution of thrombophilic polymorphisms. Patients included in

previous studies from the central province or even the one from western region was a military

hospital where most patients were of tribal origin, however KAUH receive patients of different

eithenic group. Furthermore, our data have shown that VTE risk increases by 37 folds in patients

with PS deficiency (Table 3).

Obesity has emerged as a global health issue that is associated with wide spectrum of disorders.

Body mass index is the most common method to measure obesity in adults with a normal range of

18.5 – 24.9 kilograms per square meter (kg/m2) among adults. Someone with a BMI of 25 – 29.9

kg/m2 is considered overweight [22]. Over the past 3 decades, the prevalence of overweight and

obesity has increased dramatically worldwide. Saudi Arabia is now among the nations with the

highest overweight prevalence rates [23]. Obesity can be considered a chronic, low-grade

inflammatory state, as demonstrated by increased levels of the pro-inflammatory cytokines, and

acute phase proteins. [24]. Furthermore, obesity can induce oxidative stress and endothelial

dysfunction [25]. In addition, obesity decreases fibrinolysis, increases thrombin generation, and

platelet hyperactivity [26]. All of these mechanisms can be implicated in the prothrombotic state.

Obesity has been recognized as independent risk factor for developing VTE. (Odds Ratios [OR] of

2.26 comparing BMI >30 with BMI <25) [27].A prospective cohort study of 87,226 women showed

that the relative risk of unprovoked PE that was not associated with prior surgery, trauma, or cancer

raised by increasing BMI and approached a nearly six-fold greater risk among individuals with a BMI

≥ 35 kg/m2 (p < 0.001) [29]. Our data have shown that over-weight women (BMI ≥ 27) were 4.5

times more likely to have DVT than subjects with BMI ≤ 27 which is in line with other studies [27].

Limitations: There are several limitations to our study. Our study population was a referral

population and had a small sample size because of low funding support.

Strength: The strong point of our study was that all patients were attending a specialized

hematology clinic at the same hospital and under the care of the same consultant and investigations




30

were carried out in one laboratory. In addition, a complete thrombophilia screening both genetic

and functional was performed in all patients. Therefore, our results are valuable because they

confirm that the frequency of these inherited thrombophilia’s in our populations is not low.

Conclusion: In this study we determined that PS deficiency and High BMI are significantly higher in

patients with VTE compared with healthy controls which highlights the influence of genetic and

environmental factors as independent risk factors for developing VTE in this multi-ethnic population

from western region of Saudi Arabia. However, the same factors had no influence on recurrent VTE.

Larger and long-term comprehensive prospective case–control study is required to prove a definite

association of thrombophilic defects and obesity with first attack VTE among patients from this part

of the world.

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8. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions (1988) Fertil Steril 49(6):944–55.

9. Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, et al (2012) Adverse obstetric

outcomes associated with sonographically identified large uterine fibroids. Fertil Steril 97:107–110.

10. Kaymak O, Ustunyurt E, Okyay RE, Kalyoncu S, Mollamahmutoglu L (2005) Myomectomy during cesarean section. Int J Gynaecol Obstet 89:90–93.

11. Ortac F, Gungor M, Sonmezer M (1999) Myomectomy during cesarean section. Int J Gynaecol Obstet 67:189–190.

12. Park BJ, Kim YW (2009) Safety of cesarean myomectomy. J Obstet Gynaecol Res 35(5):906-11.

13. Celal K, Hülya C (2011) The evaluation of myomectomies performed during cesarean section in our clinic. Niger Med J 52(3):186-8.

14. Incebiyik A, Hilali NG, Camuzcuoglu A, Vural M, Camuzcuoglu H (2014) Myomectomy during caesarean: a retrospective evaluation of 16 cases. Arch Gynecol Obstet 289(3):569-73.

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17. Özcan A, Kopuz A, Turan V, Sahin C, Töz E, Aksoy S, Ozeren M (2016) Cesarean myomectomy for solitary uterine fibroids: Is it a safe procedure? Ginekol Pol 87(1):54-8

18. Hassiakos D, Christopoulos P, Vitoratos N, Xarchoulakou E, Vaggos G, Papadias K (2006) Myomectomy during cesarean section: a safe procedure? Ann N Y Acad Sci1092:408-13.

19. KwonDH, Song JE, Yoon KR, Lee KY (2014) The safety of caesarean myomectomy in women with large myomas. Obstet Gynecol Sci 57: 367-372.

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21. Leanza V, Fichera S, Leanza G, Cannizzaro MA (2011) Huge fibroid (g. 3.000) removed during cesarean section with uterus preservation: a case report. Ann Ital Chir 82:75-7.

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34


Hysteroscopy before IVF Review and Update

Fawaz Edris, MD




35

Fawaz Edris, MD Umm Al-Qura University. Faculty of medicine. Makkah, Saudi Arabia. [email protected]. Mobile +966505485268

Abstract Congenital or acquired abnormalities of the uterine cavity may affect the reproductive outcome adversely; therefore, exclusion of any intrauterine pathology becomes an important step in infertility work-up. Although hysteroscopy is considered the "gold standard" for the diagnosis and treatment of intrauterine pathologies, controversies still exist about routine hysteroscopy before in-vitro fertilization (IVF).





36

Introduction

Despite advances in the field of IVF, only one-third of cycles started end in a pregnancy and one-

fourth result in a live birth [1]. Intrauterine pathologies are found to be present in about 25% of

infertile patients [2]. Congenital uterine anomalies (e.g. uterine septum) and acquired uterine

lesions (e.g. endometrial polyps, submucous fibroids, or intrauterine adhesions) may affect the

reproductive outcome adversely, by interfering with implantation or causing spontaneous abortion.

Therefore, exclusion of any intrauterine pathology becomes an important step in infertility work-up.

Intrauterine abnormalities may be visualized using variety of techniques, including

hysterosalpingography (HSG), transvaginal sonography (TVS), sonohysterography (SHG), and

hysteroscopy which is considered the "gold standard" [3].

Discussion

Although the routine use of hysteroscopy before IVF is of high importance giving the high cost of IVF

[4]; however, this topic is still under debate.

Routine office hysteroscopy prior to IVF has been suggested as a minimally invasive and well

tolerated test to ensure normality of the uterine cavity [5]. Knowledge of the details of the uterine

cavity shape, length and direction makes it feasible to deposit the embryo at an optimal depth

within the cavity during embryo transfer [6]. Therefore, performing office hysteroscopy in the cycle

just before ovarian stimulation may increase the easiness of embryo transfer.

Because embryo transfer is the final and most crucial step in IVF [7], and there is evidence that IVF

outcome is related to the degree of difficulty of embryo transfer [8], therefore, hysteroscopic

cervical canal dilatation has been shown to reduce such difficulty, thus increasing the chance of

pregnancy after IVF [9].




37

Many studies have confirmed the favorable effect of the local endometrial injury before IVF [10-12].

Touching of the endometrium will stimulate the molecular dialogue between the implanting

conceptus and the endometrium which involves cell-cell and cell-extracellular matrix interaction

mediated in a phenomenon called "plasma membrane transformation" [13].

Moreover, uterine instrumentation during hysteroscopy inevitably causes a degree of endometrial

injury and provokes a post-traumatic reaction that involves release of different cytokines and

growth factors, including leukemia inhibitory effect, interleukin-11 and heparin binding EGF like

growth factor, which might induce rapid growth of the endometrial cells (decedualization) and

increase its implantation competency [14]. Commencing IVF treatment soon after hysteroscopy may

take advantage of this immunological response [15].

Many studies recommended integration of hysteroscopy in the routine work up of infertile couple

before IVF [16-19], especially in cases of recurrent implantation failure (RIF) [20-22]. However, many

other studies were in disagreement of this recommendation [23, 24].

A multi-centre randomized controlled study of pre-IVF outpatient hysteroscopy in women with

recurrent IVF implantation failure (Trial of Outpatient hysteroscopy-[TROPHY]) in IVF showed that

routine outpatient hysteroscopy does not improve IVF outcome in women with recurrent

implantation failure, who have a normal uterine ultrasound scan [25].

Smit et al. [26] showed that hysteroscopy does not improve live birth rates in women with a normal

trans-vaginal ultrasound of the uterine cavity who are scheduled for their first IVF cycle. They also

found that the prevalence of intrauterine anomalies diagnosed at hysteroscopy was only 12% of

women whose vaginal ultrasound was normal. This small percentage suggests that it is neither

useful nor cost effective to use hysteroscopy to screen for intra uterine pathology in women with

normal ultrasound.




38

De Spiezio et al. [27] concluded that there is no evidence about the role of hysteroscopy as a basic

infertility evaluation tool, and there is a very low-quality evidence that hysteroscopy, performed

before IVF, regardless of intrauterine abnormalities, improves pregnancy rate.

Armstrong et al. [28] recommend that hysteroscopy should be offered if intrauterine pathology is

suspected by transvaginal ultrasound. Hysteroscopy should not be routinely offered to infertile

women who have normal transvaginal ultrasound. In women who have normal transvaginal

ultrasound and are undergoing IVF, hysteroscopy does not improve the outcome.

Bosteels et al. [29] suggested that there is uncertainty concerning an important benefit with the

hysteroscopic removal of submucous fibroids for improving the clinical pregnancy rates in women

with otherwise unexplained subfertility. The available low-quality evidence suggests that the

hysteroscopic removal of endometrial polyps suspected on ultrasound in women may improve the

clinical pregnancy rate compared to simple diagnostic hysteroscopy.

A recent Cochrane systematic review [30] suggested that there is no high-quality evidence to

support the routine use of hysteroscopy as a screening tool in sub fertile women with a normal

ultrasound or hysterosalpingogram for improving reproductive success rates. In women undergoing

IVF, low-quality evidence suggests that performing a screening hysteroscopy before IVF may

increase live birth and clinical pregnancy rates. However, it is uncertain whether be it for all women

or those with two or more failed IVF attempts. There is insufficient data to draw conclusions about

the safety of screening hysteroscopy.

Conclusion

There is still no strong evidence to include hysteroscopy as a routine procedure in all cases seeking

fertility. Therefore, further randomized controlled trials are needed to verify the effect of diagnosing

and treating subtle hysteroscopic abnormalities on reproductive outcome, and to provide

international guidelines on hysteroscopic indications in infertility and IVF.




39

Conflict of Interest All the participants of this research declare no conflict of interest.

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Fertil Steril. 2007; 87: 198-201.

11. Zhou L, Li R, Wang R, Huang HX, Zhong K. Local injury to the endometrium controlled ovarian

hyperstimulation cycles improves implantation rates. Fertil Steril. 2008; 89: 1166-1176.

12. Zadeh MA, Rozbahani M, Tabibnejad N. Endometrial local injury improves the pregnancy rate

among recurrent implantation failure patients undergoing in vitro fertilisation/intra cytoplasmic

sperm injection: a randomised clinical trial. Aust NZJ. Obstet Gynaecol. 2009; 49: 677-680.

13. Adams SM, Gayer N, Terry V, Murphy CR. Manipulation of the follicular phase: Uterodomes and

pregnancy- is there a correlation? BMC Pregnancy Childbirth. 2001; 1: 2.

14. Rong Li, Guiqin Hao. Local injury to the endometrium: its effect on implantation. Curr Opin

Obstet Gynecol. 2009; 21: 236-239.

15. Lea RG, Sandra O. Immunoendocrine aspects of endometrial function and implantation.

Reproduction. 2007; 134: 389-404.




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16. El-Toukhy T, Sunkara SK, Coomarasamy A, Grace J, Khalaf Y. Outpatient hysteroscopy and

subsequent IVF cycle outcome: a systematic review and meta-analysis. Reprod Biomed Online.

2008; 16: 712-719.

17. Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, et al. The

effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other

gynaecological symptoms: a systematic review, Human Reprod Update. 2010; 16: 1-11.

18. Potdar N, Gelbaya T, Nardo LG. Endometrium injury to overcome recurrent embryo

implantation failure: a systematic review and meta-analysis. Reprod Biomed Online. 2012; 25:

561-571.

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systematic review and meta-analysis. Reprod Biomed Online. 2014; 28: 151-161.

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patients with recurrent IVF failure. Reprod Biomed Online. 2004; 8: 590-594.

21. Raju RG, Kumari SG, Krishna KM, Prakash GJ, Madan K. Assessment of uterine cavity by

hysteroscopy in assisted reproduction programme and its influence on pregnancy outcome.

Arch Gynecol Obstet. 2006; 274: 160-164.

22. El-Mazny A, Abou-Salem N, El-Sherbiny W, Saber W. Outpatient hysteroscopy: a routine

investigation before assisted reproductive techniques? Fertil Steril. 2011; 95: 272-276.

23. Crosignani PG, Rubin BL. Optimal use of infertility diagnostic tests and treatments. The ESHRE

Capri Workshop Group. Hum Reprod. 2000; 15: 723-732.

24. Yu HT, Wang CJ, Lee CL. The role of diagnostic hysteroscopy before the first in vitro

fertilization/intracytoplasmic sperm injection cycle. Arch Gynecol Obstet. 2012; 286: 1323-1328.




42

25. El-Toukhy T, Campo R, Khalaf Y, Tabanelli C, et al. Hysteroscopy in recurrent in-vitro fertilisation

failure (TROPHY): a multicentre, randomised controlled trial. Lancet. 2016; 387: 2614-2621.

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CD012856.




43


Perinatal Outcomes in Women with Preeclampsia at King Abdulaziz

University Hospital

Yara A.AlMalki* ,Lama A AlMalki, Maram N AlJishi, Sara A AlMaghrabi, Hanadi AlHozali and Samera F. AlBasri

King Abdulaziz University Hospital Faculty of Medicine

King Abdulaziz University Jeddah-Saudi Arabia

Abstract Objective: To determine the perinatal outcome in women with preeclampsia. Material & Method Retrospective chart review of all women diagnosed with preeclampsia over five years period from 2010 to 2015. The review was made from birth registry of labor and delivery room at obstetrics and gynecology department looking at perinatal outcomes. Results The total birth during this period was 62701 deliveries with 569 women diagnosed with preeclampsia during the study period (0.9%) Conclusion Preeclampsia still one of the most common obstetric condition that increases the perinatal morbidity and mortality due to associated risk of intrauterine fetal death and preterm birth. Keywords: preeclampsia, obstetric outcome, perinatal outcome, maternal outcome




44

Yara A.AlMalki* Lama A AlMalki Maram N AlJishi Sara A AlMaghrabi Hanadi AlHozali and Samera F. AlBasri

King Abdulaziz University Hospital, Faculty of Medicine King Abdulaziz University Jeddah-Saudi Arabia Introduction Hypertensive disorders with pregnancy including preeclampsia are one of the most common medical

diseases in pregnancy They affects approximately 5% to 10% of all pregnancies and it is one of the

most common leading causes for maternal and perinatal morbidities and mortalities 3 Preeclampsia

is a pregnancy induced hypertension that has a significant proteinuria, and is considered one of the

key causes of maternal mortality globally. 4 Preeclampsia presents with widespread vascular spasm

and endothelial malfunctions in the vessels that occurs after 20 weeks of pregnancy, but can occur

late after childbirth for up to 4 to 6 weeks. It is clinically defined by proteinuria and hypertension,

which either has or doesn’t have pathologic edema. Preeclampsia refers to the presence of (1)

systolic blood pressure (SBP) which is ≥140 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg or

higher, on two occasions which are at least four hours apart in a patient who previously was

normotensive, or (2) an SBP ≥160 mm Hg or a DBP ≥10 mm Hg or higher (where for this particular

case, it is possible to confirm hypertension within minutes to allow timely antihypertensive therapy.).

5

In addition to the blood pressure criteria, proteinuria of ≥0.3 grams in a 24-hour urine specimen, a

protein (mg/dL)/creatinine (mg/dL) with a 0.3 ratio or even higher, or a urine dipstick protein of 1+

(if the quantitative measurement is not available) is supposed to diagnose preeclampsia. 5




45

Preeclampsia which has adverse features is defined as the presence of one of the following signs or

symptoms in the presence of preeclampsia 5 :

Systemic blood pressure of 160 mm Hg or higher or Diastolic blood pressure of 110 mm Hg or

higher, taken on two separate events that are 4 hours apart or more with the patient on bed

rest

Evidence of liver function impairment through the normal tests which include elevated liver

enzymes (to up to twice the normal concentrations), constant severe pain in the upper

quadrant or severe epigastric pain that is unresponsive to analgesic therapy and is not as a

result of other diagnoses

Progressive kidney failure with serum creatinine values of more than 1.1 mg/dL or

measurements of twice the normal serum creatinine without evidence of kidney disease

Occurrence of new cases of cerebral or visual impairment

Pulmonary edema

Thrombocytopenia (platelet count of less than 100,000/μL)

In a patient with new-onset hypertension without proteinuria, the new onset of any of the

following is diagnostic of preeclampsia:

Thrombocytopenia ( platelet count less than 100,000/μL)

Serum creatinine level greater than 1.1 mg/dL or doubling of serum creatinine in the absence

of other renal disease

Liver transaminase levels which are at least twice the normal concentrations

Pulmonary edema

Cerebral or visual symptoms

In 2014 they account for 18% of all maternal deaths world-wide and two-third of perinatal

morbidities and mortalities related to iatrogenic prematurity and its associated risk 6.




46

Our study is aimed to look at perinatal outcome in women with preeclampsia at our academic

center; King Abdulaziz University Hospital over the period from 2010 to 2015. Objective: To study the

perinatal outcome in women with preeclampsia .

Material and method: Ethical approval was obtained from the Research Ethics Committee. A retrospective chart review of

all women diagnosed with preeclampsia over five years period from 2010 to 2015. The review was

made from birth registry of labor and delivery room at obstetrics and gynecology department. Data

was collected for women with admission diagnosis of preeclampsia: age, nationality, gestational age

at diagnosis and delivery and maternal complications. Data was collected for perinatal outcome

includes: gestational age at birth, gender, weight, admission to intensive neonatal care unit.

Statistical Package for Social Science (SPSS) version 20 for windows program was applied to analyze

the present data. The data were expressed as means +/- standard deviation (SD) or number (%) as

appropriate. Comparison of variables between groups was performed using Chi- Square test for non-

parametric parameters or paired Student's t-test for parametric parameters as appropriate.

Statistical significance was considered at P-value < 0.05.

Results: The study is a retrospective single academic center performed on women admitted with a diagnosis

preeclampsia between 2010 and 2015. Patients were included provided they had a diagnosis

preeclampsia.




47

Table (1)

Years Total No. Delivery No. of C/S Rate of C/S %

2010 4238 989 23.3

2011 4760 1158 24.3

2012 4599 1118 24.3

2013 4373 1138 26.0

2014 3286 930 28.3

2015 3553 1062 29.8

Total 24809 6395 21.4

Figure 1: A chart on baby delivery from 2010 to 2015




48




49

Table (2): Demographic characteristics of the patients (n= 569).

Data Value Significant

Age (years) 30.27±7.36 (14.00 – 51.00)

Nationality

Saudi 167 (29.30%) 0.0001

Missing 5 (0.90%)

None- Saudi 397 (69.80%)

Number of children 2.17±2.60 (0-12)

Past history Past history

Previous abortion/

intrauterine fetal death

(IUFD)

Yes 148 (26.00%) 0.0001

No 421 (74%)

Previous pre-eclampsia

Yes 12 (2.10%) 0.0001

No 557 (97.90%)

Past medical diseases of

mothers

Past medical diseases of

mothers

Hypertension 14 (2.50%) 0.0001

Diabetes mellitus 4 (0.70%) 0.0001

Cardiac diseases 2(0.40%) 0.0001

Data are expressed as mean +/- standard deviation (minimum – maximum) or number (%) as appropriate. Comparison between groups was made using Chi- Square test.




50

Table (3): Obstetric outcomes

Data Value Significant

Obstetric complication in current pregnancy

Diabetes mellitus 42 (7.40%) 0.0001

Antepartum hemorrhage 9 (1.60%)

Cardiovascular complications 3 (0.50%)

Intrauterine fetal death 39 (6.90%)

Admission to intensive care unit 5 (0.90%)

Mode of delivery

Emergency cesarean section 325 (57.2%) 0.0001

Spontaneous vaginal delivery 223 (39.4%)

Instrumental delivery 16 (2.9%)

Elective cesarean section 5 (0.9%)

Gestational age at onset of PET (Weeks) 35.95±4.25 (22.00-44.00)

Gender of the baby

Girl 291+7 +7 0.0001

Boy 255 +7 +2

Birth outcome - NICU admission 117 (20.60%)

Birth outcome - weight (grams)

1st baby (grams) 2.33±0.92 (0.401-5.09)

2nd baby 1.97±0.57 (0.732-2.700)

3rd baby 2.03±0.21 (1.73-2.19)

Birth outcome- umbilical artery pH 7.20±0.17

Data are expressed as mean +/- standard deviation (minimum – maximum) or number (%) as appropriate. Comparison between groups was made using Chi- Square test.




51

Figure 2: Graph on mode of delivery




52

Figure 3: Graph on obstetric complication in current pregnancy




53

Discussion Pregnancy is marked by various physiological changes. Here, hypertensive disorders are termed to be

major causes for fetal mortality and morbidity. Hypertension affects close to 5-10% of all

pregnancies [5, 6]. These disorders include gestational hypertension and pre-eclampsia [7].

Gestational hypertension and pre-eclampsia differ in that the former is new-onset hypertension (>

140/90 mm Hg) without proteinuria after 20 weeks of gestation while the latter is the onset of new

hypertension with proteinuria after 20 weeks of gestation. In preeclampsia proteinuria, a 24-hour

urine sample contains 300 mg of protein after 20 weeks of gestation [7]. Evidence shows that

gestational hypertension progresses to preeclampsia in 10-20% of pregnant women [8]. First

pregnancy, family history of preeclampsia, pre-existing hypertension, renal disease, advanced

maternal age, multiple gestation and diabetes mellitus are risk factors associated with preeclampsia

[9]. There is also an increased risk for cardiovascular disease in pregnant women with hypertensive

disorders [10–16].

The present study was consistent with findings obtained from past studies which showed high

perinatal mortality among perinatal women with hypertensive disorder of pregnancy. The present

study indicated that the occurrence of preeclampsia was approximately 8.0%. The finding was

almost similar to studies that were conducted in Ethiopia which was 7.6% [17] and Iran which was

9.5% [18]. The results obtained were higher than the findings from developed countries which was

approximately 1.4%-5.0% [19]. Nevertheless, the finding were lower than the findings from studies

conducted in Northern Finland which was 13.9% [20], Nigeria 16% [21], and Birmingham 11.9% [22].

The difference observed between the current finding and those of the other studies might be because

of the study designs and geographical differences.




54

The majority of patients (43%) belonged to the 21-30 years age group followed by 39 percent

belonged to 31-40 years age group, 10 percent belonged to below 20 years age group and 8 percent

belonged to above 41 years age group. Based on nationality, 70% of the patients were non-Saudi

originated from different nationalities. Most of the patients previously did not have pre-eclampsia.

Among the 569 patients, only a small proportion had co-morbidities such as diabetes mellitus,

hypertension, and cardiac diseases. The correlation of maternal age and preeclampsia development

was declared in studies conducted at Iran [23] and Finland [15].

Of the 569 pre-eclamptic patients, 42 developed diabetes mellitus during pregnancy, followed by 39

patients who developed intrauterine fetal deaths. Other reported incidents are shown in Table 6. An

emergency cesarean section was the most common mode of delivery (56.80%) followed by

spontaneous vaginal delivery (31.10%), ventouse delivery (2.30%), elective cesarean section (0.90%),

forceps delivery (0.40%), emergency cesarean section and assisted breech (0.20%), ventouse delivery

and spontaneous vaginal delivery (0.20%) and emergency cesarean section and spontaneous vaginal

delivery (0.20%). Pregnant women with history of diabetes mellitus had a higher possibility of

developing preeclampsia. The report in the current study was almost similar to a study conducted in

Thailand [25]. Generic factors had a higher responsibility of predisposing women to an enhanced risk

of preeclampsia.

More maternal and neonatal complications were encountered in women in whom preeclampsia was

severe and pregnancy had to be terminated earlier. The risks posed by the preeclampsia to the foetus

include severe intra uterine fetal growth restriction, hypoxaemia, acidosis, premature birth, intra

uterine death and birth asphyxia. Risk factors for preeclampsia include multiparity, multifetal

gestation, black race, young age, obesity, family history of preeclampsia, preeclampsia on a previous

pregnancy.




55

The significantly enhanced risk of perinatal mortality that was observed among babies with low birth

weight and gestational age in the present study was consisted with other several past studies [26,

27, 28, 29]. The finding of a strong correlation of perinatal mortality with low birth weight and low

gestational age is probably in line with an enhanced risk of perinatal mortality among babies that

have been observed to have antepartum onset of preeclampsia.

Finally, the results obtained from the study on fetal and neonatal mortality was consistent with past

studies that were conducted on preeclampsia as the primary cause of death prenatal deaths [30, 31].

The study aimed at establishing whether there is a relationship between severe maternal

complications and prenatal death. The findings for this study were almost similar to the results

obtained from those studies which indicated there was a high fetal and neonatal mortality due to

life-threatening maternal complications.

Conclusion

Preeclampsia still one of the most common obstetric condition that increases the perinatal morbidity

and mortality due to associated risk of intrauterine fetal death and preterm birth.

Limitations

Retrospective study and review of emergency cases that were variable in some cases between

electronic and paper documents with lack of control group

Funding: none Conflict of interest: None

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pregnancy: a retrospective cohort study. International scholarly research notices. 2015;2015.

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3. Osungbade KO, Ige OK. Public health perspectives of preeclampsia in developing countries: implication for health system strengthening. Journal of pregnancy. 2011;2011.




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4. Tessema GA, Tekeste A, Ayele TA. Preeclampsia and associated factors among pregnant women attending antenatal care in Dessie referral hospital, Northeast Ethiopia: a hospital-based study. BMC pregnancy and childbirth. 2015 Dec;15(1):73.

5. Guideline: American College of Obstetricians and Gynecologists, Task Force on Hypertension

in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov. 122 (5):1122-31.

6. Khader YS, Batiehha A, AlNjadat RA and Hijazi SS: Preeclampsia in Jordan: incidence, risk factors and its associated outcomes; J Matern. Fetal Noeonatal Med: 2017 Mar8: 1-7.

7. E Abalos, C Cuesta, G Carroli, Z Quresshi, M Widmer, JP Souza: Preeclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry survey on maternal and neonatal health, 2014 RCOG

8. Ngoc NT, Merialdi M, Abdel-Aleem H, Carroli G, Purwar M, Zavaleta N, et al. Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries. Bull World Health Organ. 2006 Sep. 84(9):699-705.

9. Cunningham FG, Veno KJ, Bloom SL, et al. Pregnancy Hypertension. In: Williams Obstetrics. 23e. 2010.

10. WHO, 2004. Bethesda, MD. Global Burden of Disease for the Year 2001 by World Bank Region, for Use in Disease Control Priorities in Developing Countries, National Institutes of Health: WHO. Make every mother and child count. World Health Report, 2005, Geneva:World Health Orga... 2nd ed.

11. Lisonkova S, Joseph KS. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease. Am J Obstet Gynecol. 2013 Aug 22.

12. Buchbinder A, Sibai BM, Caritis S, et al. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia. Am J Obstet Gynecol. 2002 Jan. 186(1):66-71.

13. Guideline: Tuffnell DJ, Shennan AH, Waugh JJ, Walker JJ. Royal College of Obstetricians and Gynecologists. The management of severe pre-eclampsia/eclampsia. 2006.

14. Ching-Ming Liu, Po-Jen Cheng, Shuenn-Dyh Chang: Maternal complications and Perinatal Outcomes associated with Gestational hypertension and sever preeclampsia in Taiwanese women; J Formos Med Assoc, 2008- Vol 107 No 2

15. Gezahagen Endeshaw and Yiffru Berhan: Perinatal outcome in Women with hypertensive disorder of pregnancy: A retrospective cohort study; Hindawi publishing corporation Vol 2015

16. Perinatal outcome in preeclampsia: A prospective study; G B Doddamani and Wolde Z, Segni H, Woldie M. Hypertensive disorders of pregnancy in Jimma University specialized hospital. Ethiopian journal of health sciences. 2011;21(3).

17. Direkvand-Moghadam A, Khosravi A, Sayehmiri K. Predictive factors for preeclampsia in pregnant women: a unvariate and multivariate logistic regression analysis. Acta Biochimica Polonica. 2012 Nov 30;59(4).




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18. Roberts CL, Ford JB, Algert CS, Antonsen S, Chalmers J, Cnattingius S, Gokhale M, Kotelchuck M, Melve KK, Langridge A, Morris C. Population-based trends in pregnancy hypertension and pre-eclampsia: an international comparative study. BMJ open. 2011 Jan 1;1(1):e000101.

19. Kaaja R, Kinnunen T, Luoto R. Regional differences in the prevalence of pre-eclampsia in relation to the risk factors for coronary artery disease in women in Finland. European heart journal. 2004 Nov 30;26(1):44-50.

20. Guerrier G, Oluyide B, Keramarou M, Grais RF. Factors associated with severe preeclampsia and eclampsia in Jahun, Nigeria. International journal of women's health. 2013;5:509.

21. Lydakis C, Beevers M, Beevers DG, Lip GY. The prevalence of pre-eclampsia and obstetric outcome in pregnancies of normotensive and hypertensive women attending a hospital specialist clinic. International journal of clinical practice. 2001;55(6):361-7.

22. Kashanian M, Baradaran HR, Bahasadri S, Alimohammadi R. Risk factors for pre-eclampsia: a study in Tehran, Iran. Archives of Iranian medicine. 2011 Nov 1;14(6):412.

23. Lamminpää R, Vehviläinen-Julkunen K, Gissler M, Heinonen S. Preeclampsia complicated by advanced maternal age: a registry-based study on primiparous women in Finland 1997–2008. BMC pregnancy and childbirth. 2012 Dec;12(1):47.

24. Aksornphusitaphong A, Phupong V. Risk factors of early and late onset pre‐eclampsia. Journal of Obstetrics and Gynaecology Research. 2013 Mar 1;39(3):627-31.

25. Ananth CV, Basso O. Impact of pregnancy-induced hypertension on stillbirth and neonatal mortality in first and higher order births: a population-based study. Epidemiology (Cambridge, Mass.). 2010 Jan;21(1):118.

26. Abalos E, Cuesta C, Carroli G, Qureshi Z, Widmer M, Vogel JP, Souza JP. Pre‐eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Mar 1;121:14-24.

27. Onuh SO, Aisien AO. Maternal and fetal outcome in eclamptic patients in Benin City, Nigeria. Journal of Obstetrics and Gynaecology. 2004 Jan 1;24(7):765-8.

28. Ndaboine EM, Kihunrwa A, Rumanyika R, Im HB, Massinde AN. Maternal and perinatal outcomes among eclamptic patients admitted to Bugando Medical Centre, Mwanza, Tanzania. African Journal of Reproductive Health. 2012;16(1).

29. Vogel JP, Souza JP, Mori R, Morisaki N, Lumbiganon P, Laopaiboon M, Ortiz‐Panozo E, Hernandez B, Pérez‐Cuevas R, Roy M, Mittal S. Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on

30. Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Mar;121:76-88.

31. Vogel JP, Souza JP, Mori R, Morisaki N, Lumbiganon P, Laopaiboon M, Ortiz‐Panozo E,

Hernandez B, Pérez‐Cuevas R, Roy M, Mittal S. Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Mar;121:76-88.




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A Survey of Perinatal Management of Obese Pregnant Women in

IMC Hospital in Jeddah

Manal Al Kherbash, Hanaa Abdelal, Sadia Waseem, Samina Shafi, Ahmed Boraei, Dr. Ayman Oraif,

Abstract Objectives: To survey our unit's practice regarding the perinatal management of obese pregnant women and associated intrapartum and post partum complication and its effect on the mode of delivery. Background: Saudi Arabia ranks 29th in obesity prevalence in a 2007 international survey. The percentage of citizens overweight (BMI>25) was recorded at 68.3%. This has a major effect on the general health of the population and pregnant women in particular. Methodology: Retrospective study on 200 cases with BMI>=30 who were admitted for delivery. The information was collected from the files and computer system to determine the perinatal management of obese pregnant women and the possible intrapartum and postpartum complication. Results: We collected information about 200 cases with BMI range from 30-47.5 (the average BMI is 34.4). 28% of the obese ladies are Class II (severely obese>=35) and 8.5% are class III (morbid obese >=40). Regarding our antenatal care, only 7.5% are referred to dietician and 19% were referred to an obstetric anesthetist to identify any potential difficulties with venous access, regional or general anesthesia. 2.5% received Jospin 81 mg OD during their antenatal follow up. Only 16 % of obese pregnant ladies received post-delivery thromboprophylaxis, the dose 40 mg Enoxaparin was given in 93% of these cases with BMI range from 30-45. Regarding the mode of delivery, 34% of cases went for emergency cesarean section, 66% delivered vaginally, 11% of those cases had assisted delivery-using Kiwi. Regarding intrapartum and postpartum complications, PPH occurred in 5 % of cases, sepsis in 0.5%. All these ladies had BMI>=40. Blood transfusion was required in 0.5%. No cases of DVT or Pulmonary embolism were reported. Conclusion: Our survey shows that we need more work for management of obesity in pregnancy by establishing a national guideline in line with the international guideline.




59

Authors: Manal Al Kherbash, Hanaa Abdelal, Sadia Waseem, Samina Shafi, Ahmed Boraei, Ayman Oraif,

IMC Hospital in Jeddah Corresponding Author:

Dr. Ahmed Boraei; IMC Hospital in Jeddah mobile: 00966563448801, Email: [email protected]. Introduction:

Obesity is a worldwide problem. The WHO reports that 2.8 million people die annually from obesity

related problems.1 Data suggests the prevalence of obesity in Saudi Arabia is around 74% to 86% in

women.2 In the pregnant populations it is estimated that 34% are overweight or obese.3

There are numerous complications during pregnancy associated with obesity, including gestational

diabetes and preeclampsia.4 The risk of maternal morbidity and mortality rises with the rise of Body

Mass Index (BMI). Studies have shown an association between stillbirth and maternal obesity.5

Accordingly, the management of pregnancy in the obese and overweight population requires higher

rates of outpatient visits, increased investigations, prescriptions and days of hospitalization.6,7,8

At the time of writing this study there were no guidelines in the hospital on the management of

overweight and obese pregnant women. Guidelines have been published internationally but surveys

of practices have shown wide variation in physicians’ individual practices.9,10

The purpose of this study was to examine the variation in the service provision between clinicians as

to our knowledge no such survey has been conducted in the Kingdom of Saudi Arabia.





60

Methodology:

The study was conducted in a private hospital in Jeddah Saudi Arabia. The obstetric unit in the

hospital is a Tertiary referral center and averages 4200 deliveries a year. 200 consecutive cases of

obese women who delivered in the obstetric unit were identified in the period between November

and December 2017. Inclusion criteria were adult women (above the age of 18) who had a delivery

at full term (more than 37 weeks’ gestation).

The BMI at booking was used and registered at above 30, as we did not include overweight women

in the study. Cases who did not book and follow-up their pregnancy in the unit were excluded. Data

was gathered from the electronic records of the parturient. Comparative data was obtained from

the unit’s monthly Key Performance Indicators (KPI) records.

Categories for obesity were adopted from the WHO BMI categories; Underweight (BMI less than

18.5), Normal weight (BMI 18.5-24.9), Overweight (BMI 25-29.9), Obesity Class 1 (BMI 30-34.9),

Obesity Class 2 (BMI 35-39.9), Obesity Class 3 (BMI 40 or higher).

Simple descriptive statistical methods were used to analyze the data. Variables were coded,

entered, and analyzed using the Statistical Package for Social Science version 16 (SPSS Inc., Chicago,

USA). P-values were considered significant if those were <5%.

Results: A total of 754 deliveries were conducted in the time frame studied. The rate of obesity was 26.5%. The average age of the surveyed population was 29 years. Table 1 Demographics (parity, age and BMI)

Demographic Variables #, Mean, Standard Deviation, Percentage

Age 29 years ±5.6

P0 24 (12%)

P1 63 (31.5%)

P2 54 (27%)

P3 34 (17%)

P4 13 (6.5%)

P5 and more 12 (6%)

Normal Weight 361 (47.8%)

Overweight 193 (25.5%)

Obese Class 1 127 (16.8%)




61



Regarding the antenatal care services provided, 5mg folic acid was prescribed for 10.5% (21 obese

women). Only 15 cases (7.5%) were referred to dietician services and 38 women (19%) were

referred to an obstetric anesthetist to identify any potential difficulties with venous access, regional

or general anesthesia.

Only 80% had a one-hour Glucose Tolerance Test (GTT) done and of these 20% went on to have a

three-hour GTT. The average gestational age for the one-hour GTT was 28 weeks. None of the

women who had a normal GTT done below 20 weeks had it repeated.

Five cases (2.5%) received 81 mgs of acetylsalicylic acid for no other reason than obesity. Four cases

were Class 1 obese and one case was Class 3.

As regards epidural anesthesia during labor 65% received it, but only 2% received it early. The rate

of epidural anesthesia in the normal weight population was 62%. The difference was not statistically

significant (p=0.46).

Of the 17 cases with Class 3 obesity only 7 received thromboprophylaxis and only 2 received an

appropriate dose (11.7%). The Class 1 and 2 cases that required thromboprophylaxis were 109

cases. Only 24 (22%) of them received an appropriate dose of low molecular weight heparin

(LMWH).

The rate of cesarean section and postpartum hemorrhage was higher in the obese population

compared to the individuals with normal weight, but the difference was not statistically significant

(p=0.2). There were no cases of sepsis or deep venous thrombosis in the studied population.

Table of pregnancy outcomes Cesarean section and Postpartum Hemorrhage

Variables Normal weight Obese Chi Square and P Value

Cesarean section 104 68 1.63 (p=0.2)

Postpartum hemorrhage 28 10 1.54 (p=0.2)




62

Discussion:

This study was designed to indicate the actual services provided to the obese pregnant

population. While there are a few studies that looked at the variations in the physician and

midwifery approach to obesity in pregnancy, we have not identified any published papers

that surveyed or audited the actual services provided. This is important as factors other

than intent and policies, affect the provision of services. Examples of such factors include

the awareness of the pregnant population of the importance of management of obesity in

pregnancy. Another is the financial and insurance constraint, particularly in the private

sector.

Many of the service provisions offered to the patients may not have been offered due to

obesity. For example, the epidural rate was similar in the obese and the no obese

population. The glucose tolerance testing was done once, and considerably late, which does

not conform with the current international guidelines on the management of obesity in

pregnancy. These may all be related to the financial burden they bring. The same would

apply to referral to dieticians and anesthetists antenatally. Simple measures, however, have

not been provided, such as a 5mg dose of folic acid, or risk assessment for

thromboprophylaxis. As such, the authors suggest that the reason for not offering the

services lies in the lack of agreed upon national guidelines.

The study revealed a significant variation in practices. Mostly, the services provided

deviated from published international guidelines on the management of obesity in

pregnancy.

In Saudi Arabia there are published guidelines regards the general management of obesity,

but none that focus on the pregnant population.11 The author suggests that having a

national guideline would streamline the services and improve the quality of care provided.

It would also reduce the financial cost. Studies have shown that obesity in pregnancy

increases the burden on the healthcare service provision with a concomitant increased

financial load.12

Our survey was not designed to measure the pregnancy outcomes in the pregnant

population; hence the lack of statistical significance in the outcomes measured was

reported as a finding but is not an indication of the effects of obesity on pregnancy.




63

Conclusion:

The study revealed the need for a national guideline in Saudi Arabia and the Middle East.

This would reduce the significant variation in the management of the obese pregnant

population and create a gold standard to measure the services provided against.

References:

1. World Health Organization (WHO). (2011) Obesity and Overweight factsheet from the WHO [Online].

Available from: http://publichealthwell.ie/node/82914[Accessed: 24th February 2019]

2. El-Gilany AH, Hammad S. Body mass index and obstetric outcomes in Saudi Arabia: a prospective

cohort study. Annals of Saudi medicine. 2010 Sep;30(5):376.

3. Al-Asmari BA, Alsaleem SA, Al Shahrani AM, Al Khaldi YM, Alqahtani MM, Alhamdan TM. Weight

status among pregnant women in Aseer region, Saudi Arabia. Saudi Journal of Obesity. 2015 Jul

1;3(2):55.

4. Meher-Un-Nisa MA, Ahmed SR, Rajab M, Kattea L. Impact of obesity on fetomaternal outcome in

pregnant saudi females. International journal of health sciences. 2009 Jul;3(2):187.

5. Fitzsimons KJ, Modder J, Greer IA. Obesity in pregnancy: risks and management. Obstetric medicine.

2009 May 22;2(2):52-62.

6. Denison FC, Aedla NR, Keag O, Hor K, Reynolds RM, Milne A, Diamond A, Royal College of

Obstetricians and Gynaecologists. Care of Women with Obesity in Pregnancy: Green‐top Guideline

No. 72. BJOG: An International Journal of Obstetrics & Gynaecology. 2018 Nov 23.

7. Gunatilake RP, Perlow JH. Obesity and pregnancy: clinical management of the obese gravida.

American journal of obstetrics and gynecology. 2011 Feb 1;204(2):106-19.

8. Davies GA, Maxwell C, McLeod L, Gagnon R, Basso M, Bos H, Delisle MF, Farine D, Hudon L,

Menticoglou S, Mundle W. SOGC Clinical Practice Guidelines: Obesity in pregnancy. No. 239, February

2010. International journal of gynaecology and obstetrics: the official organ of the International

Federation of Gynaecology and Obstetrics. 2010 Aug;110(2):167-73.

9. Kominiarek MA, Chauhan SP. Obesity before, during, and after pregnancy: a review and comparison

of five national guidelines. American journal of perinatology. 2016 Apr;33(05):433-41.

10. Heslehurst N, Dinsdale S, Sedgewick G, Simpson H, Sen S, Summerbell CD, Rankin J. An evaluation of

the implementation of maternal obesity pathways of care: a mixed methods study with data

integration. PloS one. 2015 May 27;10(5):e0127122.

11. Al-Shehri FS, Moqbel MM, Al-Shahrani AM, Al-Khaldi YM, Abu-Melha WS. Management of obesity:

Saudi clinical guideline. Saudi Journal of Obesity. 2013 Jan 1;1(1):18.

12. Withrow D, Alter DA. The economic burden of obesity worldwide: a systematic review of the direct

costs of obesity. Obesity reviews. 2011 Feb;12(2):131-41.

http://publichealthwell.ie/node/82914




64


Maternal and fetal adverse effects of maternal obesity

Mansoura experience

Hossam Abd El Fatah, Yousef Abo Elkher, Yasser Abd El Daim, Mohamed Elaraby Shalaby.

Correspondence author Hossam AbdElFatah Department Obstetrics and Gynecology Faculty of Medicine, Mansoura University Egypt. Mansoura Email [email protected] 01005635658





65

Abstract Background: Obesity is an epidemic not only in the United States and developed countries but also in the developing world. Pregnancy complications in obese women were identified as early as 1945. Objectives: To assess the relationship between maternal Body Mass Index (BMI) calculated at the first trimester of pregnancy and pregnancy-related outcomes regarding the mother and the fetus. Patients and methods: A prospective clinical study was carried out at the Obstetrics & Gynecology department , Mansoura University Hospitals during the period between march 2015 till October 2016 .86 pregnant ladies shared in this study;21 cases non obese and 65 obese according to BMI measured at first trimester .All cases had been followed up till delivery .Non obese and obese groups compared as regard to maternal, fetal ,neonatal outcome and also mode of delivery and any associated complications. Results: there were statistically significant differences between the obese groups (group 2,3,4)and control non obese group(group 1) regarding PET, gestational diabetes mellitus, post-partum hemorrhage and anesthetic complications (p < 0.05) and non-significant differences regarding abortion, preterm labor, malpresentation, wound sepsis and thromboembolism (p > 0.05).There were statistically significant differences between obese groups and non-obese group regarding macrosomia and congenital anomalies (p < 0.05) and non-significant differences regarding intrauterine growth restriction and intrauterine fetal death (p > 0.05).There is a significant difference between obese groups and non-obese group (p < 0.05) regarding the mode of delivery due to increasing rate of CS in obese groups. There were non-significant differences between studied groups regarding neonatal intensive care unit and early neonatal death (p > 0.05). Conclusion: Higher maternal and perinatal risks among obese mothers compared with the non-obese. Key Words: Obesity, waist-to-hip ratio, pregnancy, gestational diabetes, hypertension, macrosomia, mortality

66

Introduction

Background:

Obesity is an epidemic not only in the United States and developed countries but also in the

developing world. The WHO characterizes obesity as a pandemic issue, with a higher

prevalence in females, especially those of child-bearing age, than in males. Obesity is based

on the WHO categorization of Body Mass Index (BMI), which is calculated from

measurements of height and weight. BMI is inexpensive, practical and easily applicable in

large populations, which makes it suitable for epidemiological studies (1).

Obesity in pregnancy is usually defined as BMI of 30 kg/m2 or more at the first antenatal

consultation. There are three different classes of obesity: BMI 30.0–34.9 (Class I); BMI 35.0–

39.9 (Class 2); and BMI 40 and over (Class 3 or morbid obesity) (2).

Pregnancy complications in obese women were identified as early as 1945. There are both

short long-term complications and implications for both mother and fetus. In the short-term,

it has been associated with an increase in pregnancy complications such as gestational

diabetes mellitus (GDM), pre-eclampsia, congenital malformations and fetal growth

abnormalities, and has been associated with an increase in obstetric interventions such as

caesarean section and induction of labor (3).

In the long term, maternal obesity is associated with an increased life-long risk of diabetes

mellitus and cardiovascular disease for the woman and an increased risk of childhood

obesity for her offspring (4).

The aim of this study is to assess the relationship between maternal Body Mass Index (BMI)

calculated at the first trimester of pregnancy and pregnancy-related outcomes regarding the

mother and the fetus.

Patients and Methods

This prospective clinical study was carried out at the Obstetrics & Gynecology department,

Mansoura University Hospitals during the period between March 2015 till October 2016.

Study design:

Pregnant women were recruited from outpatient clinics and the schedule of the antenatal

visits was the traditional one (every month in the first six months of pregnancy and then

every two weeks in the 7th and 8th month of pregnancy and then every week till the end of

pregnancy) except when any complication arise it was managed according to the maternal

and fetal condition. Studied women were followed till delivery and their newborns were

examined for detection of any abnormalities.

Sample size:

116 pregnant women registered for antenatal care had accepted to participate in this study,

to be followed till delivery and 2 weeks postpartum. 30 patients dropped out while 86

67

patients continue the study. The sample was calculated through Epi-Info (Epidemiological

Information package) software version. They were assigned into groups according to BMI

calculated at the first trimester of pregnancy:

1. Group 1(control group):21 pregnant women with BMI (30).

2. Group 2: 22 pregnant women with BMI (30-35).

3. Group 3: 20 pregnant women with BMI (35-40).

4. Group 4: 23 pregnant women with (BMI) < 40).

Inclusion criteria:

Pregnant women more than 20 years old, At first trimester of pregnancy.

Exclusion criteria:

Pregnant women with past history of any prepregnancy chronic medical disease (e.g.,

hypertension, diabetes, chronic nephritis, cardiac, liver and blood disease), Pregnancy during

second or third trimester or multiple pregnancy , BMI less than 20 kg/m2.

Tools of the study:

A) A structured questionnaire:

The questionnaire providing the following information: Socio demographic data (age,

residence, education and occupation), Life style factors (caffeine intake, alcohol intake,

cigarette consumption, sport and different activities).. Menstrual and obstetric history (age

at menarche, regularity of menstrual cycle, duration of menstruation, parity and abortion

history), Illness at previous pregnancies(hypertension, anemia, DM ) , Bad obstetric

history(failed induction, shoulder dystocia, cephalopelvic disproportion, pervious maternal

injuries, preterm baby, macrosomia baby and congenital fetal anomalies), Current pregnancy

illness(nausea, easy fatigability, constipation, vomiting, reflux, diarrhea and others).

B) Maternal measurements:

Height: measured once with a stand meter approximated to 1 cm, with the mothers standing and without shoes.

Weight: obtained from the clinical record or self-reported by the mother in (kg) and measured with a calibrated electronic scale while subjects were wearing the lightest possible clothes.

Calculate BMI: By dividing the weight in (kg) on (the height in m²) 2log Height in meters. Pregnant women were classified according to pre pregnancy BMI (kg\m²) or BMI calculated at the first trimester of pregnancy into:

o Underweight (BMI<18.5). o normal (BMI 18.5- 24.9),• o overweight (BMI 25-29.9)• o and obese (BMI≥30 ) .

Maternal gestational age (length of gestation): Calculated according to the date of the last menstrual period and the sonographic examination.

C) Clinical examinations (general and abdominal):

According to the standard antenatal care record as routine examinations, and recording of

any complications or significant changes in the previously reported findings.

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D) Investigations:

Investigations were done at the first antenatal visit and then repeated at the mid second

trimester and mid third trimester and included: Ultrasonography (Transvaginal or

clotting time), fasting blood sugar or blood sugar curve, urine analysis , serum creatinine.

and Serum triglycerides.

E) Neonatal evaluation:

o o Optimal (2500-4000 g) o Above optimal (>4000g) (Hark et al., 2002). o Presence or absence of congenital anomalies. o The criteria of prematurity. o APGAR score.

F) Obstetric outcome:

were assessed by:

BMI calculated at the first trimester of pregnancy (at booking).

Ultrasonographic scan performed transabdominal or transvaginal at booking, second

trimester (16-24 weeks) and at third trimester (32-36 weeks).

Maternal screening for pregnancy induced hypertension, DM and

thromboembolism.

Maternal weight gains every antenatal visit.

Mode of delivery and neonatal outcome 6. serum triglycerides level at booking and

at mid third trimester.

Maternal complications:

Abortion.

Hypertensive complications e.g. pre-eclampsia (defined as persistently elevated blood pressure (office blood pressure ≥140\90 mmHg on more than 2occasions) with or without proteinuria.

Gestational diabetes.

Shoulder dystocia.

Preterm labor was defined as delivery before completed 37 weeks.

Wound sepsis.

Thromboembolism.

Postpartum hemorrhage.

Malpresentation.

Fetal and neonatal complications:

Intrauterine growth restriction.

Macrosomia was defined by birth weight ≥4000g.

69

Infant morbidity was assessed by admission to the neonatal intensive care unit

and low Apgar score (<7 at 5min).

Stillbirth.

Congenital anomalies.

Ethical considerations:

Ethical considerations were respected as verbal and written informed consent was obtained

from all mothers participating in this study. The participants were informed about the aim

and objectives of this study and insured that data were used in scientific purpose and their

rights to participate orrefuse were also kept .

Statistical analysis:

Data were analyzed with SPSS version 21. The normality of data was first tested with one-

sample Kolmogorov-Smirnov test.

Continuous variables were presented as mean ± SD (standard deviation) for parametric data

and median for non parametric data. Analysis Of Variance (ANOVA test) used for comparison

of means of more than two groups (parametric data) and in-between groups comparison

tested by post-hoc LSD. While Kruskal Wallis Test used for comparison of median of more

than two groups (non-parametric data).

For all above mentioned statistical tests done, the threshold of significance is fixed at 5%

level (p-value).

The results were considered:

• Non-significant when the probability of error is more than 5% (p > 0.05).

• Significant when the probability of error is less than 5% (p ≤ 0.05).

• Highly significant when the probability of error is less than 0.1% (p ≤ 0.001).

The smaller the p-value obtained, the more significant are the results.

Results

Four groups are matched for socio-demographic data as there were statistically a high significant difference between the studied groups regarding body mass index (p < 0.001) and a non-significant difference regarding age (p > 0.05) , gravidity, parity and previous cesarean section (p > 0.05) (table 1). There were statistically significant differences between the obese groups (group 2,3,4) and control non obese group (group 1) regarding PET, gestational diabetes mellitus, post-partum hemorrhage and anesthetic complications (p < 0.05) and non-significant differences regarding abortion, preterm labor, malpresentation, wound sepsis and thromboembolism (p > 0.05) (table 2). There were statistically significant differences between obese groups and non-obese group regarding macrosomia and congenital anomalies (p < 0.05) and non-significant differences regarding intrauterine growth restriction and intrauterine fetal death (p > 0.05) (figure 1).

70

There is a significant difference between obese groups and non-obese group (p < 0.05) regarding the mode of delivery due to increasing rate of CS in obese groups (figure 2). There were non-significant differences between studied groups regarding neonatal intensive care unit and early neonatal death (p > 0.05) (figure 3).

Discussion

Obesity is a global health problem that is increasing in prevalence. The World Health

Organization (WHO) characterizes obesity as a pandemic issue, with a higher prevalence in

females than males. Thus, many pregnant patientcare seen with high body mass index (BMI).

Obesity during pregnancy is considered a high-risk state that adversely affects both mother

and neonate and impairs the pregnancy outcome (5).

Our study analyzed 65 obese pregnant mothers (BMI above 30) and 21 non-obese mothers

with (BMI below 30) was used as the reference or comparison group for analysis and are

assigned into groups according to BMI calculated at the first trimester of pregnancy:

Group 1 (control group): 21 pregnant women with BMI (>30).

Group 2: 22 pregnant women with BMI (30-35).

Group 3: 20 pregnant women with BMI (35-40).

Group 4: 23 pregnant women with BMI)< 40).

All groups are matched for socio-demographic data and there was a statistically high

significant difference between them regarding body mass index (p< 0.001) and a non-

significant difference regarding age (p > 0.05).

In our study, there is no significant association between maternal obesity and past

menstrual history as most of both groups has the age of menarche at 10-13 years, the

menses is regular with average duration 2 -5 days. Our result agreed with a previous study in

Denmark by Li et al. (5), however, Challis et al.(6) reported a negatively associated obstetric

history with BMI.

Wolfe (7) recognized higher BMIs as a risk factor for both mothers and their newborns.

Aimukhametova et al.(8) concluded that maternal obesity is associated with increased risks

of both maternal and neonatal complications, and that such risks increase with advanced

age and parity of the mother. Hence, medical practices must consider these complications

by ensuring an adaptable and early management in order to improve mothers and their

neonatal health.

Regarding maternal complications, our results showed that there were statistically

significant differences between obese and non-obese groups regarding PET, gestational

diabetes mellitus, postpartum hemorrhage and anesthetic complications (p < 0.05) and non-

significant differences regarding abortion, preterm labor, wound sepsis and

thromboembolism (p > 0.05).

71

Ray et al. (9) found higher significant increase in blood pressure among obese pregnant

women, also low Hemoglobin level and increased level of glucose in follow up visits.

Regarding fetal complications, there were statistically significant differences between obese

and non-obese groups regarding macrosomia and congenital anomalies (p < 0.05) and non-

significant differences regarding intrauterine growth retardation and intrauterine fetal death

(p > 0.05).

Our results showed that there is a significant difference between obese and non-obese

patients (p < 0.05) regarding the mode of delivery due to increasing rate of CS in obese

groups. This result did not agree with Bednarek et al. (10) who found that no relation

between maternal obesity and the mode of delivery. However, Santoro et al. (11) found that

obese mothers are more liable to cesarean section and maternal injuries.

Nogueiras et al. (12) found an increased risk of cesarean section with increasing BMI

reported similar results. This difference may be explained by the fact that cesarean section

risk is related to multiple factors as complications during pregnancy, cephalopelvic

disproportion, macrosomia and protracted labor.

Catalano and Ehrenberg(4) found that obese mothers are more likely to get macrocosmic

baby and more likely to get preterm baby, low APGAR score and more congenital anomalies

in their babies that is due to obese mothers are more likely to be risky in their pregnancy.

There were linear trends in risk of pre-eclampsia with increasing mid-arm circumference,

increasing weight and increasing body mass index. After adjusting for potential confounding

factors, women in the highest percentile for mid-arm circumference (28-39 cm) were 4.4

times more likely to have had their pregnancy complicated by pre-eclampsia than women in

the lowest percentile (21-23 cm) (13).

The risk of preeclampsia typically doubled with each 5-7 kg/m2 increase in prepregnancy

body mass index. This relation persisted in studies that excluded women with chronic

hypertension, diabetes mellitus or multiple gestations, or after adjustment for other

confounders (14).

Conclusion

The results of this study indicated higher maternal and perinatal risks among obese mothers

compared with the non-obese. Including pregnancy induced hypertension, gestational

diabetes, wound sepsis, postpartum hemorrhage and birth defects of neonates. It is

concluded from this study that obesity brings many health hazards on obese mothers and

their babies as obese mothers exposed to cesarean section delivery, adverse pregnancy

outcome on their babies as preterm baby, macrocosmic baby and congenital anomalies.

Follow up visits of obese mothers showed significant increase in weight, BMI and blood

glucose levels compared to non-obese. Thus, medical practice must consider these

complications by ensuring adaptable and early management to improve both maternal and

neonatal health.

72

Recommendations

i. For obese mothers:

Health education programs about problems encountered to obese mothers during pregnancy and how to avoid.

Exercise programs on most days with information of health providers about how and when to regulate and even stop.

Special health eating schedules.

Advisory healthy life style with avoidance of stress and unhealthy bad habits as smoking and excess beverages.

Regular antenatal care for regular follow up of blood pressure, diabetes, anamia and other health problems.

ii. For health provider:

Awareness about possible complications that may occur with obesity.

Provider-based interventions that may lead to changes in gestational weight gain and related behaviors.

iii. For future research:

call for other researches and promote other types of epidemiological studies as intervention study and address a health education message among obese mothers.

73

Table (1): Demographic data of studied groups

Items

Group (1)

BMI <30

(n=21)

Group (2)

BMI 30-35

(n=22)

Group (3)

BMI >35-40

(n=20)

Group (4)

BMI >40

(n=23) Test of sig.

p-value

No % No % No % No %

Age/years

Mean ± SD 27.85±5.29 28.21±4.34 30.04±4.21 31.3±4.64 F=2.57

p=0.06

<30y 14 66.7 18 81.8 10 50.0 12 52.2 2= 6.05

p=0.109 >30y 7 33.3 4 18.2 10 50.0 11 47.8

BMI

Mean ± SD 26.62±1.89

abc

32.07±1.26 ade

36.67±1.26 bdf

42.47±3.55 cef

F=186.65

p=≤0.001**

Gravidity

Median (Min-

Max) 2 (1 -7 ) 2 (1 -4 ) 2.5 ( 1-5 ) 3 ( 1-7 )

KW=2.89

p=0.409

Parity

Median (Min-

Max) 1 ( 0-3 ) 1 ( 0-3 ) 1 ( 0-4 ) 1 ( 0-4 )

KW=1.483

p=0.686

Previous CS

Median (Min-

Max) 1 ( 1-3 ) 1.5 (1 - 2) 1 (1 - 4) 1.5 (1 - 2)

KW=0.129

p=0.988

74

Table (2): comparison between studied groups regarding maternal

complication

Items

Group (1) BMI

<30 (n=21)

Group (1) BMI

30-35 (n=22)

Group (3) BMI

>35-40 (n=20)

Group (4) BMI

>40 (n=23) Test of sig.

p-value No % No % No % No %

Abortion

Yes 1 4.8 1 4.5 2 10.0 2 8.7

2=0.745

p=0.862 No 20 95.2 21 95.5 18 90.0 21 91.3

Preeclampsia(PET)

Yes 1 4.8 3 13.6 6 30.0 10 43.5

2=10.94

p=0.012* No 20 95.2 19 86.4 14 70.0 13 56.5

PG1-G3= 0.032 PG1-G4= 0.003 PG2-G4= 0.027

Gestational DM

Yes 0 0 2 9.1 3 15.0 7 30.4

2= 9.06

p=0.028* No 21 100 20 90.9 17 85.0 16 69.6

PG1-G4=0.006

Preterm labor(PTL)

Yes 3 14.3 5 22.7 5 25.0 7 30.4

2=1.64

p=0.648 No 18 85.7 17 77.3 15 75.0 16 69.6

Anesthetic complication

Yes 0 0 0 0 0 0 4 17.4

2=11.49

p=0.009* No 21 100.0 22 100.0 20 100.0 19 82.6

PG1-G4=0.045 PG2-G4= 0.04 PG3-G4= 0.05

Wound sepsis

75

Yes 0 0 1 4.5 2 10.0 4 17.4

2=

4.96p=0.174 No 21 100.0 21 95.5 18 90.0 19 82.6

PG1-G4=0.045*

Thromboembolism

Yes 0 0 0 0 2 10.0 2 8.7

2=4.23

p=0.237 No 21 100.0 22 100.0 18 90.0 21 91.3

Postpartum hemorrhage

Yes 0 0 2 9.1 3 15.0 7 30.4

2= 9.06

p=0.028* No 21 100 20 90.9 17 85.0 16 69.6

PG1-G4=0.006

Malpresentation

Yes 0 0 1 4.5 2 10.0 4 17.4

2= 4.96

p=0.174 No 21 100.0 21 95.5 18 90.0 19 82.6

PG1-G4=0.045*

Figure (1): Comparison between studied groups regarding fetal complications

76

Figure (2): Comparison between studied groups regarding mode of delivery

Figure (3): Comparison between studied groups regarding neonatal outcome




77

References

1- Fattah, C., et al. Maternal weight and body composition in the first trimester of pregnancy. Acta obstetricia et gynecologica Scandinavica 2010; 89(7): 952-955.

2- Prentice, A. M. and S. A. Jebb. Beyond body mass index. Obesity Reviews 2001; 2(3): 141-147.

3- Leddy, M. A., et al. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol 2008; 1(4): 170-178.

4- Catalano, P. and H. Ehrenberg. Review article: The short‐and long-term implications

of maternal obesity on the mother and her offspring. BJOG: An International Journal

of Obstetrics & Gynaecology 2006; 113(10): 1126-1133. 5- Li, Z., et al. Health ramifications of the obesity epidemic. Surgical Clinics of North

America 2005; 85(4): 681-701. 6- Challis, B., et al. Mice lacking pro-opiomelanocortin are sensitive to high-fat feeding

but respond normally to the acute anorectic effects of peptide-YY3-36. Proceedings of the National Academy of Sciences of the United States of America 2004; 101(13): 4695-4700.

7- Wolfe, H. High prepregnancy body-mass index—a maternal–fetal risk factor, Mass Medical Soc, 1998.

8- Aimukhametova, G., et al. The impact of maternal obesity on mother and neonatal health: study in a tertiary hospital of Astana, Kazakhstan. Nagoya Journal of Medical Science 2012; 74(1-2): 83.

9- Ray, J., et al. Maternal and neonatal outcomes in pregestational and gestational diabetes mellitus, and the influence of maternal obesity and weight gain: the DEPOSIT stud. Qjm 2001; 94(7): 347-356.

10- Bednarek, M. A., et al. Potent and Selective Peptide Agonists of α-Melanocyte Stimulating Hormone (αMSH) Action at Human Melanocortin Receptor 5; their Synthesis and Biological Evaluation in vitro. Chemical Biology & Drug Design 2007; 69(5): 350-355.

11- Santoro, N., et al. Effect of the melanocortin-3 receptor C17A and G241A variants on weight loss in childhood obesity. The American Journal of Clinical Nutrition 2007; 85(4): 950-953.

12- Nogueiras, R., et al. The central melanocortin system directly controls peripheral lipid metabolism. The Journal of Clinical Investigation 2007; 117(11): 3475-3488.

13- Mahomed, K., et al. Risk factors for pre‐eclampsia among Zimbabwean women:

maternal arm circumference and other anthropometric measures of obesity. Paediatric

and perinatal epidemiology 1998; 12(3): 253-262.

14- O’brien, T. E., et al. Maternal body mass index and the risk of preeclampsia: a systematic overview. Epidemiology 2003; 14(3): 368-374.




78


Head Nurses' Perception Regarding Team Building at Main Mansoura

University Hospital

الرئيسي الجامعيمشرفات التمريض تجاه بناء الفريق بمستشفى المنصورة إدراك .

Hanaa Mahmoud Ahmed Ali B.Sc. Nursing Thesis Submitted for Partial Fulfillment of Requirements of Master Degree in Nursing Administration

Supervisors Prof. Dr. Sahar Hamdy El Sayed, Professor of Nursing Administration Faculty of Nursing -

Zagazig University Dr. Nehad Saad El-Wkeel , Lecturer of Nursing Administration, Faculty of Nursing

Mansoura University

Abstract Background: Team-building has emerged as an effective strategy for achieving positive results in health care organizations and essential to the organizations efficiency and effectiveness. It enables organizations to be flexible and responsive to the competitive global environment. Aim of the study: assess head nurses' perception regarding team building at Main Mansoura University Hospital through: Assessing head nurses' awareness regarding team building process and assessing their willingness to apply team building. Design: A descriptive study design was used. Setting: The study was carried out at Main Mansoura University Hospital. Subject and method: A convenience sample of 98 head nurses from the above-mentioned setting. Data collection of the present study was collected by utilizing a questionnaire sheet to assess head nurses' awareness regarding team building process and assess their willingness to apply team building. Results: The highest percentage of head nurses have average level of awareness regarding team building process (53.1%), while they had high level of willingness to apply team buildings in their work (96.9%). Conclusion: There was no statistically significant correlation between total head nurses score of awareness and willingness regarding team buildings. Recommendation: It is recommended that development of team building training programs for head nurses to improve their knowledge, skills, attitude toward teambuilding and promote their engagement in team building. Also, incorporate the concept of nursing teambuilding in nursing faculty and school curriculum. Key words: team, team building, perception, awareness, willingness.

The Saudi Journal of

Obstetrics and Gynecology The official journal of

“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة

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Introduction Nowadays, the use of teams has turned out to be an important trend of present heath care organizational lifestyles1 . Successful organizations today know that teams make a big difference in achieving strategic goals. Strong, flexible and productive teams can be the competitive edge needed to produce better results, achieve quality, lower cost and deliver better customer service. To achieve these objectives, teams will have to start doing things differently. Team members and leaders will need to communicate more effectively with each other, encourage more involvement, tap into creativity, overcome resistance to change and renew team spirit 2 . Team is a group of persons who are interdependent in their tasks, share the same responsibility as to the results, who perceive themselves and are perceived as forming a single entity, an intimate part of a greater social system and whose relationships axis upon organizational boundaries3 . Also, team is a small number of people with complementary skills who are committed to general purpose, performance goal and approach for which they are mutually accountable4 . The role of any team is to develop the open area for every person, because when we work in this area with others, we are at our most effective and productive state and the team are at its most productive too, this ensures good communication and cooperation 5 . Teams can be classified according to the objectives and the nature of the 3 interdependence of team members. It can be presented in many different forms inside the organization as: Problem solving teams, selfmanaged teams, cross functional teams, virtual teams, quality improvement teams, team based organization and task force team 6 . Team development process emphases on allowing a group of people to be more than the sum of its parts. Important elements in team development are good leadership, social processes in teams, clarity of goals, a good distribution of roles and responsibilities and development of the skills of individuals as well as the team as a whole 7 . Tuckman’s model is a widely used theory of team development process was introduced by Tuckman and Jensen (1977) they identified five stages of team development as: forming stage: where team members get to know each other, storming stage: where the team members try to find their places in the team and targets are clarified. This phase tends to be quite emotional as it is about setting up a power structure in the team. Also, many conflict arises, norming stage: In this stage the team members set up implicit or explicit rules about




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how they will achieve their goal, performing stage: this phase is characterized by motivation, creativity, focus on results, flexible relationships, pride, confidence, continuous learning and success. Adjourning stage: this is the phase after the task of the team ends and it is the period of disbanding 4, 7 . Team building is the ability to work together toward a common vision and the ability to direct individual activities toward organizational objective. It is the fuel that allows common people to attain uncommon results8 . Also, Team building is a specific intervention to address issues relating to the development of the team. Typically, it consists of a one or more day improvement of program focused on interpersonal relations, improved productivity or better alignment with organizational goals1 . Team building is the process of helping a workgroup become more efficient in accomplishing its tasks and in satisfying the needs of team members9 . Teambuilding can be affected by many factors of which a team needs to be aware: Individual factors (the skills of the people involved, the behaviors they model and the extent to which they believe in interdisciplinary teams) Team factors (the stage of the team’s development, the goals they set) Organizational factors (the extent that the organization supports teams and their development) Systemic factors (the extent that the external environment represented by the health care system supports the changes the team is proposing)10 . Head nurse is the person who holding a management position, conducting supervisory duties and is placed above staff nurses. A head nurse needs at least bachelor degree in nursing, Head nurse should has at least three to five years of experience in a care facility before applying for the position of a head nurse11 . Effective head nurses should possess clinical, organizational, human relations and critical thinking competencies that motivate and contribute to the quality goal of their organizations12 . Head nurse is responsible for the direction, organization and strategic planning of the nursing unit within a hospital or other healthcare facility, involved in assessing, evaluating and setting nursing care standards and objectives for the organization. In addition to overseeing the operations of the nursing unit, provide leadership and supervision to their direct reports, including nurse managers and the nursing staff 13 . Head nurse has an important role in teambuilding as encouraging team members to help build self-confidence and self–esteem of the others, maintaining constructive relationships and take the initiative to make better team. In addition, the head nurse should express appreciations and give positive reinforcement. Also, has the responsibility to plan, coordinate and monitor the team's




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activities and to convey a vision, inspiring team collaboration. Building a successful experience is also important. Documenting and communicating success make it easier to take the next steps14 . Head nurse perception is the process by which they interpret and organize sensation to produce a meaningful experience of something in the environment. Also, perception is defined as an act of being aware of one’s environment through physical sensation, which indicates an individual’s ability to understand 15 . Assessing head nurses perceptions of teambuilding are very important, as it has many benefits for patient, head nurses and the organization. For patients as being continuity of care and delivery of safer and better quality care, for head nurses the benefits have been identified as improved working relationships increased ability to share and work together and availability of a shared network and for the organizations the benefits have been identified as increase productivity and progress of the organization 16 . Significance of the study Team building is critical to the success of any organization. No single person can achieve the goals of a complex organization alone. That’s why, building a strong team is a key to your success. Also, the using of team approach in hospital setting is the second-hand to fulfill great demand that placed on each health care professional to provide the best quality of care efficiently, safely, and cost-effectively to optimize patient care outcomes 4 . Successful head nurses are those who work with successful team. Working with others is not easy. Nevertheless, groups constitute the basic building blocks of any organization. For many tasks, teams accomplish much work in less time than the same individuals can work separately. So, this study attempts to assess head nurses' perception regarding team building at main Mansoura University Hospital through: Aim of study The present study aimed to assess head nurses' perception regarding team building at main Mansoura University Hospital through: assessing head nurses' awareness regarding team building process and assessing their willingness to apply team building. The research questions: What is the level of head nurses' awareness regarding team building process? What is the level of head nurses' willingness to apply team building in their hospitals? Subjects and methods Research design: A descriptive design was used.




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Setting: The study was carried out at main mansoura university hospital, it consisted of (4) buildings with total bed capacity (1512) beds. The total number of head nurses were (114). A convenience sample of head nurses from the aforementioned settings (98) who agree to participate in the study. Tools of data collection: A questionnaire sheet was used to collect data of the study. The questionnaire consisted of three parts:-

Part I: Personal characteristics sheet: to collect data about head nurses such as name,

age, gender, education, years of experience, and social status. 5

Part II: Awareness questionnaire: It was developed by Khalid (2014). this part was

intended to assess the head nurses' awareness regarding team building process. It

consisted of twenty five item in the form of multiple choice grouped under six main

dimensions namely: concept of team building (5 item), forming stage (4 item),

storming stage (4 item), norming stage (4 item), performing stage (4 item) and

adjourning stage (4 item).

The items were scored (2) for aware and (zero) for not aware. The maximum possible

total scores were fifty. Scoring system: The head nurses' awareness level was

determined according to El sayed (2013) as the following: - If the score of awareness

range from 37 to 50, it’s considered good. - If the score of awareness range from 29 to

36, it’s considered average. - If the score of awareness range from 0 to 28, it’s

considered poor. Part III: Willingness questionnaire: It was developed by Ibrahim

(2014) and modified by the researcher.

This part was intended to assess the head nurses' willingness to apply team building. It

consisted of fifty seven items grouped under eight categories namely importance of

team (8 items), team structure (6 items), team cooperation (8 items), team efficiency

(6 items), team mutual support (9 items), team communication (10 items), team

confidence (5 items) and team leadership (5 items).

The items were measured on a three-point Likert scale. The willingness items were

scored "Willing" 2 point, "Uncertain" 1 point and" Never" Zero point Scoring

system:- Scoring system of Willingness questionnaire sheet according to Ibrahim

(2014) as the following: If the score of willingness is less than 60%, it’s considered

low. If the score of willingness range from 60% - 75%, it’s considered moderate. If

the score of willingness is more than 75%, it’s considered high.




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Preparatory phase: This phase involved reviewing of current, past, local and

international literatures related to the aim of the study. This review was done through

using text books, article, scientific journals and internet search and theoretical

knowledge of the various aspects concerning the topic of the study. The tool was

tested by using face and content validity.

Face validity aimed at verifying that the tool gives the appearance of measuring head

nurses' awareness regarding team building process and head nurses' willingness to

apply team building process. Content validity of the questionnaire were judged by

five panel: one assist professor and two lecturers from nursing administration

department, faculty of nursing Mansoura University and two lecturers from nursing

administration department from faculty of nursing Zagazig University. Based on their

recommendation corrections, addition or omission of some items were done.

Pilot study: A pilot study was conducted on a sample of 10 head nurses working from different department of main Mansoura university hospital whom were selected randomly and excluded from total sample. The pilot study was done after the development of the tool and before starting data collection, in order to assess clarity and applicability of the tool. It helps in identifying potential problems that might be encountered during the period of data collection. Reliability test by cronphach’s 6 alpha for questionnaire sheet was 0.70 and correlated test retest 0.82 for awareness part and was 0.963 and correlated test retest 0.981 for willingness part. Field work: The actual field work started from October 2015 to August 2016. The researcher met the head nurses five days per week during morning shift at their work units and introducing herself to them after giving a brief idea about the aim of the study and explained for them how to complete this tool and reassured them that the information would be used only for scientific research. Then each head nurse received a copy of the questionnaire sheet and completed it. The time consumed in answering the questionnaire ranged from 10 -15 minutes some of them completed it in the same day and some other take it and complete in the next day then give it back to the researcher. Ethical consideration: Prior to the pilot study, ethical approval was obtained from the research ethics committee of the faculty of nursing Mansoura University, The researcher clarified the objective and aim of




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the study to the head nurses included in the study. They were assured that anonymity and confidentiality would be guaranteed, they have the right to withdraw from the study at any time. Statistical Analysis Data were collected, coded, computed and statistically analyzed using Statistical Package of Social Sciences (SPSS) software program version 16. The categorical variables were presented as frequency and percentages, while quantitative variables were presented as

mean ± SD. For comparison 2 test was used to compare categorical variables and student t test was used to quantitative variables in two groups and one way ANOVA for more than two groups. Correlation coefficient (r) is used to measure correlation between two quantitative variables. Difference was considered significant when P was ≤ 0.05. Results Table (1): Personal characteristics of head nurses (n = 98)

Personal characteristics No (98) 100%

Age in year: <20 20- 30- 40+

0 6 44 48

0.0 6.1 44.9 49.0




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Mean ± SD = 40.54 ± 6.33 years

Gender: Males Females

5 93

5.1 94.9

Education: Bachelor in nursing Nursing Diploma

95 3

96.9 3.1

Social status: Single Married Widow

14 81 3

14.3 82.7 3.1

Years of experience: < 5 year 5 - < 10 years ≥ 10 years

2 5 91

2.0 5.1 92.9

Mean ± SD = 17.68 ± 6.45 years

Department: Medical Surgical Emergency Administration

39 39 6 14

39.8 39.8 6.1 14.3

Table (1) shows personal characteristics of head nurses. Nearly half of the head nurses were at the age group 40 years old and more with the mean age of (40.54± 6.33 year). The highest percentage of them were females, had bachelor degree in nursing, were married and have more than equal ten years of experiences and more in nursing (94.9%, 96.9%, 82.7% and 92.9% respectively). Most of the head nurses were working in medical and surgical departments (39.8%). Table (2): Total awareness level of the head nurses regarding team building (n= 98).

Awareness level No %

Poor 42 42.9




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Average 52 53.1

Good 4 4.1

Table (2) shows total awareness level of head nurses regarding team building. More than half of the head nurses had average level of awareness regarding team building (53.1%), while few of them (4.1%) had good level of awareness.

Figure (1): Total awareness level of head nurses regarding team building. Table (3): Total willingness level of head nurses regarding team building (n= 98).

Willingness level No %

Low 0 0.0

Moderate 3 3.1

High 95 96.9

Table (3): Shows total willingness level of head nurses regarding team building. The highest percentage of head nurses (96.9%) had high willingness level regarding team building and only (3.1%) of them had moderate level.




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Figure (2): Total willingness level of head nurses regarding team building. Table (4): Relationship between head nurses awareness score regarding team building and their personal characteristics (n = 98).




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Personal characteristics Awareness score

Significance test P - value Mean ± SD

Age in years 20 – 30 – 40+

27.00 ± 5.08 29.59 ± 3.99 29.79 ± 4.21

F=1.192

0.368

Gender Males Females

28.80 ± 4.23 29.57 ± 4.16

t= 0.398

0.692

Education Bachelor in nursing Nursing diploma

29.62 ± 4.23 29.33 ± 5.03

t= 0.115

0.908

Social status Single Married Widow

28.57 ± 4.80 29.65 ± 4.16 30.67 ± 2.31

F=0.505

0.605

Years of experience < 5 years 5 - < 10 years ≥ 10 years

21.00 ± 1.41 29.60 ± 3.68 29.71 ± 4.10

F=4.521

0.013 **

Department Medical Surgical Emergency Administration

28.72 ± 4.60 29.18 ± 3.99 31.00 ± 2.67 32.43 ± 3.44

F=2.773

0.046 *

(*) Statistically significant at p<0.05. (**) Statistically significant at p<0.01.

Table (4) shows relationship between the head nurses awareness score regarding team building and their personal characteristics. There are statistically significant differences between head nurses awareness and their years of experience and department of work (F = 4.521 & 2.773 and P = 0.013 & 0.046 respectively).




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Table (5): Relationship between the head nurses willingness score regarding team building and their personal characteristics (n = 98).

Personal characteristics willingness Score

Significance test P - value Mean ± SD

Age in years 20 – 30 – 40+

101.67 ± 15.27 110.52 ± 7.73 112.08 ± 3.49

F=6.421

0.002 **

Gender Males Females

104.80 ± 13.44 111.06 ± 6.58

t= 1.969

0.049 *

Education Bachelor in nursing Nursing diploma

110.79 ± 7.21 109.33 ± 1.15

t= 0.348

0.729

Social status Single Married Widow

106.86 ± 13.49 111.30 ± 5.31 114.00 ± 0.00

F=2.753

0.069

Years of experience < 5 years 5 - < 10 years ≥ 10 years

82.00 ± 1.41 111.20 ± 1.10 111.35 ± 5.96

F=25.999

0.000 ***

Department Medical Surgical Emergency Administration

111.44 ± 5.26 110.23 ± 8.59 109.86 ± 8.46 111.67 ± 3.61

F=0.291

0.832

(*) Statistically significant at p≤0.05 (**) Statistically significant at p≤ 0.01 (***) Statistically significant at p≤ 0.001

Table (5): shows relationship between head nurses willingness score regarding team building and their personal characteristics. There are statistically significant differences between




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willing score of head nurses and their age, years of experience and gender (F= 6.421, 25.999, T= 1.969, P= 0.002, 0.049 & 0.000 respectively).

Table (6): Correlation between total awareness and willingness score of the head nurses regarding team building (n=98)

Total willingness score

Total awareness score R P

0.044 0.666

Table (6): shows correlation between total awareness and willingness score of the head nurses regarding team building. There is no statistically significant correlation between awareness and willingness score (r=0.044, P = 0.666). Discussion Teambuilding in nursing is a dynamic technique involving a lot of health care professionals with complementary backgrounds and skills, sharing common health goals and workout combined physical and mental effort in assessing, planning or evaluating patient care. Additionally team building in health care concentrate on providing the best quality patient care and dealing along toward this common goal. The head nurse has an important role in team building as she/he has the responsibility to plan, coordinate, and monitor the team's activities and to convey a vision, inspiring team collaboration4. So, the aim of this study was to assess head nurses perception regarding team building at main Mansoura university hospital through assessing head nurses awareness regarding team building process and assessing their willingness to apply team building. Findings of the present study revealed that nearly half of head nurses were at the age group forty years old and more and the highest percentage of them were females, had bachelor degree in nursing, were married and have equal and more than ten years of experiences in nursing. In addition most of them were working in medical and surgical departments. This results may be due to the nursing profession was a feminist profession so the highest percentage of studied head nurses were female.




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As well as, the hospitals policy occupy the head nurse position only for nurses who had bachelor degree in nursing and the highest number of head nurses from medical and surgical units, this give explanation to the present findings. This findings agree with the study carried out in Egypt by20 who assess the impact of nursing team work on missed nursing care in intensive care unit at Zagazig University Hospitals and found that the majority of nurses were females. Also, this findings agree with the study carried out in Egypt by 17 who assess head nurses point of view regarding team building concept at Ain Shams University Hospitals and found that the mean age of head nurses were forty years with an average of ten years of experience, the majority of them had bachelor degree in nursing, were married and working in medical and surgical units. On the other hand findings disagree with the study carried out in Egypt by2 who assess perception of head nurses regarding the importance and willingness to apply team building at Assuit University Hospitals and found that the age of head nurses ranged between twenty to less than forty years. They had experiences in nursing range from one to ten years, and slightly more than half of them were single. Also, the study carried out in Egypt by19 who assesse operating room personnel perception toward team work at Banha University Hospital and found that most of nurses had nursing diploma and their age ranged from twenty to twenty five years old. Finding of the present study revealed that slightly more than half of head nurses had average awareness level toward team building. This result may be due to that the team building process among head nurses in the hospital has been little understood and ignored as results of lack of team training and programs regarding team building as well as inadequate support from the nursing director in the hospital. This finding disagree with the study carried out in London by21 who identify key stressors for emergency department staff, investigate positive and negative behaviors associated with working under pressure and consider interventions that may improve how team functions and found that the highest percentage of head nurses had low awareness toward teambuilding. Also, this finding disagree with study was carried out in California by22 who assess the perception of nurse-physician regarding teamwork in the emergency department and found that the head nurses had low perception of teamwork. On the same line the study carried out by19 who found that the head nurses had low perception toward teamwork. Findings of the present study revealed that the highest percentage of head nurses had high willingness level regarding team building. This may be due to most of the head nurses realize that effective teambuilding is an essential aspect for their success, and help them to behave,




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think, and make decisions in order to increase creativity which enable them to contribute to the continuous productivity and the ongoing success of the organization. This finding agree with study carried out in Jordan by23 who identify the extent to which managers are willing to implement teamwork and found that managers have high willingness to implement teambuilding philosophy. While, this result disagree with 20 who found that the majority of nurses’ willingness toward teamwork was low. Findings of the present study revealed that there were no statistically significant correlation between total awareness and willingness score of the head nurses regarding team building. This may be due to head nurses had a high level of willingness to apply teambuilding but their awareness toward team building is average this was a result of lacking in training and staff development programs about how to build a team for head nurses. This finding agree with17 who found that there was non-significant correlations between total level of head nurses' awareness regarding team building process and their willingness to apply team building. On the other side this finding disagree with 2 who found that there were positive statistically significant relations between the awareness of head nurses regarding team building and their willingness to apply the elements of team building. The findings of present study revealed that there are statistically significant differences between head nurses awareness regarding team building and their years of experience in nursing and department of work. This may be due to the increase in years of experience, head nurses acquire knowledge and skills related to team building strategies through attending training programs, courses and conferences about teambuilding and they exposed to situations that enhance their awareness about team building. Also, the nature of works and tasks in the emergency and administrative department need to use team building process and to utilize its strategies like communication, collaboration, commitment, cooperation, using effective decision making and problem solving strategies. This result agrees with the study carried out in Brazil by24 who aimed to analyze the strategies used by nurses to promote teamwork in a hospital emergency room and found that the head nurse who work in the emergency unit were aware with the strategies that used for promoting team building which were articulating professional actions, establishing relationships of cooperation, building and maintaining friendly ties and managing conflict. On the other side this result disagrees with the study carried out in USA by25 who assess nurses' knowledge and attitudes toward pain management team and found that there were no correlation between years of experience of nurses and their awareness toward team




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building. Furthermore, this finding disagrees with 19 who found that there was no significant difference among nurses who work in operation room perception toward teamwork and their years of experience. Also, this finding disagree with 17 who found that head nurses with more than ten years of experience had good level of awareness, with no statistically significant relation between head nurses' level of awareness and their years of experience. Finding of present study revealed that there were statistically significant differences between willingness score of head nurses regarding team building and their age, years of experience and gender. This may be due to the highest number of head nurses were female and with increasing age and years of experience of head nurses give them a chance to attend programs and courses related to team building this increases their willingness regarding importance of team building, phases of team building process, cooperation and how to use communication skills effectively with team member. This result agree with 24 who found that there is statistically significant difference between the head nurses’ willingness to implement teamwork and their years of experience In addition to 19 who found that the female nurses had higher willingness toward team work than male nurses. Conclusion In the light of the current study finding, it was concluded that, there was no statistically significant correlation between total score of head nurses awareness and willingness regarding team buildings. Also, the highest percentage of the head nurses have average level of awareness regarding team building process, while they had high level of willingness to apply team buildings in their work. Recommendation

1. Development of team building training program for head nurses to improve their knowledge, skills and attitude toward teambuilding and promote their engagement in team work.

2. The development training program should be about assertive communications and conflict management for the head nurse and staff nurse.

3. Inspire every nurse to share in development objectives of team building to accomplish their goals.

4. Incorporate the concept of nursing teambuilding in nursing faculty and school curriculum.




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5. The head nurses must place a basis of commitment to the teambuilding concept to make teams comfortable with their new responsibilities.

6. Reassure the team member to share in decision making, and problem solving, which face them in their work and they develop new methods to develop their work.

7. Define roles accomplishments of the team work and let them put suitable rules that regulate team behaviors.

8. Recognize and praise the team efforts rather than giving threat and criticism 9. Promoting head nurses’ attitudes towards delegation of authority.

References

1. Kriek, H. S., and Venter, P., (2009): The Perceived Success of Teambuilding Interventions in South African Organizations Southern African Business Review 13 (1) Pp: 112-13

2. Morsy, S.M. (2009): Perception of Head Nurses Regarding the Importance of Team Building Elements among Nurse, The new Egyptian journal of medicine, 43(2), pp122-34.

3. Phaneuf, M. R. N., (2009): Team Building: Urgently Needed in Nursing, Available at Web Site Www.Infiressources.Ca/.../Team_BuildingUrgently_Needed Accessed at 7/11/2015

4. Kelly, P., (2012): Nursing Leadership and Management 3rd Ed, Thomson Delmar Learning Company, USA, Pp: 268

5. Akhilesh, K.B. (2014): R&D Management 1st Ed Published by Springer New Delhi, Heidelberg, New York, Dordrecht and London. Pp: 145

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7. Koch, K., (2015): Handbook of Human Resources Management. Published by Springer-Verlag Berlin Heidelberg. Pp: 2-24.

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9. Aronu, C. O., Bilesanmi, A. O. (2013): Assessing the Knowledge, Attitude and Factors Affecting Team Building Amongst Health Workers in Nigeria Using the Permutation




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Method for Hotelling T-squared Analysis. American Journal of Theoretical and Applied Statistics, 2 (6), pp. 184-90. Doi: 10.11648/ j.ajtas.20130206.15

10. Pauzé, E., MacLean, T., Kates, N., (2009): The Team Building Resource Guide for Family Health, Published by Quality Improvement & Innovation Partnership (QIIP (Ontario, Canada. Pp: 7-13, available at web site https://www.google.com.eg/?gfe_rd=cr&ei=QxbtVovvK6mx8weIsKiYBA&gws_rd=ssl#q=team+building+resource+guide accessed at 4/8/2015

11. Healthcareer, (2011): Qualities Desired in a Head Nurse available at web site https://www.healthecareers.com/article/healthcare-news/qualities-desired-in-a-head- nurse accessed at 13/12/2016

12. Ezeukwu, D.N. (2011): Nurse Leader Competencies and Their Relationship to Quality of Nursing Care: A Case Study, Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Capella University, Published by Proquest LLC, UMI 3491472.

13. Dzaher, A. (2016): 5 Important Qualities looked for Head Nurse available at http://today.mims.com/topic/5-important-qualities-looked-for-in-head-nurse accessed at 28/11/2016

14. Marriner, A., (2009): Guide to Nursing Management and leadership 8 Ed. Mosby Elsevier. 1183 owes line industrial 1st. Louis, Missouri 63146 Printed in Canada pp. Pp373-83

15. Ayo, H.T. (2009): Perception and Conflict. Published by National Open University of Nigeria, Pp. 18, available at URL: www.nou.edu.ng accessed at 3/10/2016

16. Ferguson, L. (2011): Team Nursing: Experiences of Nurse Managers in Acute Care Settings. Published by Australian Journal of Advanced Nursing 28 (4). Accessed at 30/10/2016

17. Khalid, M. A. A., (2014): Head Nurses Point of View Regarding Team Building Concept at Ain Shams University Hospitals, Master Thesis in Nursing Science, Nursing Administration, Ain Shams University.

18. El Sayed, S.M. (2013): The effect of implementing SBAR shift report on quality of reporting of patient care, Doctorate thesis in nursing science, nursing administration, faculty of nursing, Ain shams university, p 47.

19. Ibrahim, R.S. (2014): Perception of Operating Room Personnel toward Teamwork at Banha University Hospital Master Thesis, Nursing Administration Science, Faculty of Nursing. Banha University.

20. Attia, N.M. (2014): The Impact of Nursing Team Work on Missed Nursing Care In Intensive Care Unit at Zagazig University Hospital Un Published Thesis Submitted For Partial Fulfillment of Master Degree In Nursing Administration, Faculty of Nursing Zagazig University.




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21. Flowerdew, L., Brown, R., Russ, S., Vincent, C., Woloshynowych, M. (2011): Teams under pressure in the emergency department: an interview study. Published by group.bmj.com doi:10.1136/emermed-2011-200084 Pp: 1-6

22. Ajeigbe, D.A (2012): Nurse-Physician Teamwork in the Emergency Department, UCLA Electronic Theses and Dissertations Degree, Ph. D., Nursing (PHD) 0046UCLA P 20.

23. Al-Madi, F.; Al-Zawahreh, A. and Al-Sawadha, S. (2012): The Implementation of Teamwork in Jordan, European Journal of Economics, Finance and Administrative Sciences, ISSN 1450-2275 Issue 45. Available online at: http://www.eurojournals.com/EJEFAS.htm accessed at 11/9/2016

24. Santos J, Lima M, Pestana A, Colomé I, Erdmann AL (2016): Strategies Used By Nurses To Promote Teamwork In An Emergency Room. Rev Gaúcha Enferm. 37(1): e 50178. doi: 10.1590/19831447.2016.01.50178.

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