Rabih H  Chahine,  MDChair,  Department  of  Obstetrics  &  GynecologyRafik Hariri  University  HospitalMEMA  2017

} Number  of  Syrian  refugees  Until  July  2016:  

} 1,170,000  refugee  (registered  at  UNHCR)

1,170,000refugiés  

In  Lebanon:1  person  in  5  is  a  Syrian  refugee

} Given the  pyramid of  age of  a  young syrian population  ;à Reproductive  age  women:    ~  582,000.

} Among  Syrians,  Women  having  had  at  least  one  child  in  the  last  year  :  22.4  %  

130,500  Deliveries!  

} To  Compare  with  the  Lebanese  Host  population  :    8.6  %  69,000  Deliveries!

Antenatal  care  in  LebanonLocation  of  Antenatal  Care  in  Lebanon  by  Population

Sector  in  Which  Syrian  Refugee  Women  Delivered  by  Region  

Sector  in  Which    Women  Delivered  

Anetnatal Consultations    In  the  1st trimester:-‐ 53%  among  Syrian  refugees  -‐ 79%    among  Lebanese

The  Syrian  War…      A  huge  number  ofrefugees referred to  our center.  

7.7 11.6

75.5 79 71.7

92.3 88.4

24.5 2128.3

2006 2007 2013 2014 2015

Syriennes LibanaisesNumber of  admissions    to  the    department of  Obstétrics &  Gynecology at RHUH  according to  nationality.

} Magnitude  of  the  problem:    an  unprecedented  crisis…  

} No  well  defined  criteria  as  to  the  role  of  a  tertiary  center  facing  such  ..    

} Other  tertiary  centers  in  Lebanon  (traditionally  leaders)  …  immediately  and  a-‐priori  phased  out  of  the  loop  (financial,  administrative  reasons)?

Anticipated  ?No  adequate  response  system  !!} The  national  level..} The  level  of  international  organizations  ..

Poor,  inadequate  (and  frequently  too  little  too  late)  and  falling  short  of    minimum  needs  and  requirements

§ Governmental  center§ Tertiary  care  facility§ Teaching  and  academic§ The  department    has  already    started  being    on  the  national  map  of  the  prestigious  national  obstetrics  and  Gynecology    centers

In  the  Eye  of  the  storm  !!!

} Relatively  a  young  department} 2006  war..  Pivotal  role  in  obstetrical  services  in  a  almost  a  war  zone    

} 2011:Syrian  crises  ..few  years  after  its  kick  start} 2012…  overwhelming  influx  of  Syrian  refugees  to  Lebanon…  

OBGYN    Department  

clinical  services  

Delivery  suite  

6  labor  and  delivery    rooms

2  obstetrical   intermediate  care  room

2  bed  Preparation    room

Triage/Ultrasound   room

Patients  ward   26  beds  with  4  single  bed  rooms

0

500

1000

1500

2000

2500

3000

3500

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Number  of  admissions

Syrian  war…  Huge  number  of  refugees  are  referred  to  our  hospital

2006 2007 2013 2014

% of  non  Lebanese 7.7% 11.6% 75.5% 79%

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Total  Deliveries 1202 1258 1199 1600 1543 1500 1731 2852 2859 2067

total  cesareans 408 411 327 478 428 455 611 872 899 804

primary  cesareans 171 191 150 231 181 191 247 305 323 359

%  primary  cesareans 17.7 18.4 14.6 17.07 13.96 15.4 18.0 13.4 14.1 16.2

0

100

200

300

400

500

600

700

800

900

1000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Nb  total  des  césariennes

Nb  des  césariennes  primaires

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 total

Hypertensive    disorders 7 9 5 22 56 39 30 45 51 43 307

Diabetes 5 3 6 13 18 18 14 18 20 19 134

IUFD 3 1 2 5 10 10 12 69 81 65 258Epilepsy 1 1 2 2 3 3 1 9 3 0 25

Heartdiseases 0 0 1 1 1 0 1 1 2 1 8

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Mild  PE  GestationalHTN -‐ -‐ 1 5 8 8 6 7 17 7Severe Pre-‐eclampsia 7 9 4 17 47 31 24 35 34 36Eclampsia 1 3

2013 2014 2015

HELLP 5 5 5

0

10

20

30

40

50

60

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Eclampsie

préE  sévère

HTA  gravidique  -‐ préE  légère

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 total

PPH-‐atony 2 16 12 7 11 9 13 26 7 9 112

Placenta  Previa 2 10 4 1 2 1 2 4 4 2 32

Abnormally  Adherent  Placenta 0 2 3 2 2 2 6 5 3 12 37Placental  Abruption 2 7 2 1 4 -‐ 7 12 10 9 54

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

%  High  risk  pregnancies 2% 3.8% 2.8% 3.3% 7.2% 4.9% 4.4% 5.6% 4.8% 7.7%

High  Risk Obstetrics

012345678

2006 2007 2008 2009 2010 2011 2012 2013 2014

%  des  grossesses   à  risque  

} A  multidisciplinary   team  established  at  RHUH

} Comprehensive   care  approach

} RHUH  ObGyn …  National  Referral  center    for  AAP  .

} Nearly  50  patients  admitted  over  the  past  10  years

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Numberof  

deliveries1258 1199 1600 1543 1500 1731 2852 2859 2105 2889

AIP2 3 2 2 2 6 5 3 12 14

Rate  of  AP                          %

0.15 0.15 0.13 0.13 0.13 0.34 0.18 0.1 0.5 0.48

Lebanese 28

Non-‐ Lebanese 9

2007 2008 2009 2010 2011 2012 2013 2014 2015

Nb ofcases 2 3 2 2 2 6 5 3 12

Programmed urgent

27 10

Accreta Increta Percreta Previa12 10 12 3

Intra-‐operative  complications

Number  of  Patients

Cystotomy   10

MASSIVE  TRANSFUSION

9

External   Iliac  artery   injury    

1

Number  of  units  transfused

15  u  PRBCs

Number of  patients 11 15 3 1

ICU  Stay Yes NoNumber  of  patients 5 40

Ø Adjunct  to  maternal  mortality  reviews…  focus  of  most  recent  attention.

Ø Mantel  et  al.      a  woman  with  SAMM as  :  a  very  ill  pregnant  or  recently  delivered  woman  who  would  have  died  had  it  not  been  but  luck  and  good  care  was  on  her  side.

Ø WHO  recommended  change  to    “near  misses”.Ø WHO  definition  of    maternal  near  miss  morbidity  as: a  woman  who  nearly  died  but  survived  a  complication  that  occurred  during  pregnancy,  childbirth  or  within  42  days  of  termination  of  pregnancy.

%    of  near  misses

severe  preeclampsia

eclampsia

HELLP  syndrome

severe  hemorrhage

uterine  rupture

other  high  risk  cases

24.5%

61%

12%

DM,  epilepsy,  heart  disease,Thyroid  disease,  gestational  thrombocytopenia,  etc  

2006 2007 2008 2009 2010 2011 2012 2013 2014 TOTAL

3 2 3 2 3 4 4 7 3 31

number Percentage    

Sepsis 5 16.1

Hypertensive disorder/HELLP 8 25.1

Hemorrhage 9 29.0

TTP 2 6.5

Leukemia  in  pregnancy 1 3.2

Amniotic fluid  embolism 1 3.2

Massive  Pulmonary  embolism   1 3.2

SLE    flare 1 3.2

Uterine rupture   2 6.5

Acute fatty  liver  of  pregnancy 1 3.2

Low  income  countries} 3.21%   in  Middle  Eastern,} 4.92%   in  Latin  American,  } 5.41%   in  Asian  } 6.03%   in  African  countries.

High-‐income  countries} Europe   reported    0.69%.

obstetric   ICU  admission  rate  ranges  between  0.04%   to  4.54%.

RHUH  department  ICU  admission  rate..    0.19%.

1-‐ Primigravid presented  with  severe  preeclampsia  ,  she  had  intractable  uncontrolled  severe  HTN,  she  had  hemorrhagic  stroke  and  died  in  ICU  around  2  weeks  post-‐partum.

2-‐ Patient  died  suddenly  3  days  post-‐partum,  r/o  massive  PE.  Patient  had  presented  with  a  picture  of  chorioamnionitisand  near  sepsis  few  days  earlier.  

3-‐ Patient  known  to  have  Thrombotic  thombocytopenicPurpura  (TTP),  developed  early  severe  preeclampsia  at  27  weeks  for  which  pregnancy  was  terminated.  She  developed    resistance  to  plasmapherisis and  medications  and  died  about  3  weeks  postpartum.  

4-‐ Patient  presenting  one  week  post-‐partum(NVD)  with  bleeding  and  retained  products  of  conception.  Underwent    evacuation.  Had  acute  respiratory  deterioration  few  hours  after  evacuation  and  died  (complicated  PE?)

5-‐ Patient  diagnosed  to  have  percreta,    referred  from  other  hospital  at  28    weeks  with  severe  hematuria,  died    in  OR  at  time  of  induction  of  anasthesia ,  concurrently  with  suction  and  irrigation  of  bladder  performed  by  uro team(bladder  blocked  with  blood  clots)

} In  our  department,  maternal  mortality  ratio    is  32  per  100,000  live  births.

Maternal  Mortality  Ratio

baby.  steps

2010..  “  Honey  Moon”..  Establishment  and  recognition  as  a  referral  center  for  obstetrics.

The  department  in  10  years..  3  phasesThe  department  in  10  years..  3  phases“  The  Real  Deal”Survival  mode  under  the  heavy  charge  of  the  refugees

} Instability  at  the  level  of  the  hospital  in  general..poor  support  to  the  Ob/Gyn department

§ lack  of  adequate  funding  to  the  hospital  from  the  government  

§ deterioration  in  the  level  of  services  over  the  last  5  years:  administrative  issues,  maintenance,  renewal  of    medical  resources..

§ Political  instability  ..  Uncertainty  and  inconsistency  of  government  support  reflecting  the  poor  vision  as  to  the  size  and  role  of  RHUH?  

§ inadequate  funding  from  organizations  covering  for  the  syrian refugees (UNHCR,  other  NGO’s)

§ Huge  referral  load  of  maternal  high  risk  /  critical  care  obstetrical  cases

Any  plans  at  the  level  of  policy  makers  /  Donors  ?-‐ Funding-‐ Logistic  support-‐ Donations  for  material/  drugs/  Equipment

Our  visions  and  plans  as  health  care  providers  for  women’s  health..  

ü Maintain  Function:  Tertiary  care  of  complicated  pregnancies  within  the  limits  of  available  resources

ü Triage  of  cases  for  more  adequate  referral    of  patients  in  case  of  saturation

ü Collaboration  with  2-‐3  tertiary  centers  in  Lebanon-‐ Diffuse  the  burden-‐ Provide  better  quality  of  care

ü Collaboration  with  several  academic  centers  -‐ Generate  more  research  /  data/  health  statistics-‐ Recommendations  to  policy  makers  and  providers    

for  better  and  more  efficient  quality  of  care

Thank YOu