Rabih H Chahine,MD...
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Rabih H Chahine, MD Chair, Department of Obstetrics & Gynecology Rafik Hariri University Hospital MEMA 2017
Transcript of Rabih H Chahine,MD...
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 7971.7
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
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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
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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
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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
<5 PRBCs 5-‐10 PRBCs 11-‐15 PRBCS >15 u PRBCs
Number of patients 11 15 3 1
ICU Stay Yes No
Number 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
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