Saudi Journal of Obstetrics & Gynecology
Transcript of 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
1
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
The Saudi journal of obstetrics and gynecology
The official journal of “The Saudi Society of obstetrics and gynecology”.
الجمعية السعودية لأمراض النساء والولادة
2
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.
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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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.
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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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)
The Saudi journal of obstetrics and gynecology
The official journal of “The Saudi Society of obstetrics and gynecology”.
الجمعية السعودية لأمراض النساء والولادة
5
The Saudi journal of obstetrics and gynaecology
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
The Saudi journal of obstetrics and gynecology
The official journal of “The Saudi Society of obstetrics and gynecology”.
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6
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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The official journal of “The Saudi Society of obstetrics and gynecology”.
الجمعية السعودية لأمراض النساء والولادة
7
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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The official journal of “The Saudi Society of obstetrics and gynecology”.
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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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The official journal of “The Saudi Society of obstetrics and gynecology”.
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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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The official journal of “The Saudi Society of obstetrics and gynecology”.
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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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The official journal of “The Saudi Society of obstetrics and gynecology”.
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13
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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The Saudi journal of obstetrics and gynaecology
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
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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 polymorph- ism) 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
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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
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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%
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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%)
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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%
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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
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a. Dependent variable b. Predictors c. Insignificant variables
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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.
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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].
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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
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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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The Saudi journal of obstetrics and gynaecology
Hysteroscopy before IVF Review and Update
Fawaz Edris, MD
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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).
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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].
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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.
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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.
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Conflict of Interest All the participants of this research declare no conflict of interest.
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7. Mansour R, Aboulghar M. Optimizing the embryo transfer technique. Hum Reprod. 2002; 17:
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8. Margalioth EJ, Ben Chetrit A, Gal M, Eldar-Geva T. Investigation and treatment of repeated
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endometrium in intracytoplasmic sperm injection patients with high order implantation failure.
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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
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16. El-Toukhy T, Sunkara SK, Coomarasamy A, Grace J, Khalaf Y. Outpatient hysteroscopy and
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The Saudi journal of obstetrics and gynaecology
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
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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
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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.
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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.
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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
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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.
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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.
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Figure 2: Graph on mode of delivery
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Figure 3: Graph on obstetric complication in current pregnancy
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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.
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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.
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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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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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The official journal of “The Saudi Society of obstetrics and gynecology”.
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The Saudi journal of obstetrics and gynaecology
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.
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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.
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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%)
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Obese Class 2 56 (7.4%)
Obese Class 3 17 (2.2%)
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)
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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.
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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.
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The Saudi journal of obstetrics and gynaecology
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
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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
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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
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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.
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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
The Saudi journal of obstetrics and gynecology
The official journal of “The Saudi Society of obstetrics and gynecology”.
الجمعية السعودية لأمراض النساء والولادة
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.
The Saudi journal of obstetrics and gynecology
The official journal of “The Saudi Society of obstetrics and gynecology”.
الجمعية السعودية لأمراض النساء والولادة
78
The Saudi journal of obstetrics and gynaecology
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
Volume 3 No.2 - 1440 H - June 2019 G
79
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
The Saudi Journal of
Obstetrics and Gynecology The official journal of
“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
80
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
The Saudi Journal of
Obstetrics and Gynecology The official journal of
“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
81
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.
The Saudi Journal of
Obstetrics and Gynecology The official journal of
“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
82
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.
The Saudi Journal of
Obstetrics and Gynecology The official journal of
“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
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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
The Saudi Journal of
Obstetrics and Gynecology The official journal of
“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
84
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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“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
85
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.
The Saudi Journal of
Obstetrics and Gynecology The official journal of
“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
87
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).
The Saudi Journal of
Obstetrics and Gynecology The official journal of
“The Saudi Society of obstetrics and gynecology”. الجمعية السعودية لأمراض النساء والولادة
Volume 3 No.2 - 1440 H - June 2019 G
88
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.
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