Management of major obstetric hemorrhage prior to peripartum hysterectomy and outcomes across nine European countries

Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy.

Material and methods
We merged data from nine nationwide or multi‐regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated.

A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births.

Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life‐saving procedure is associated with substantial adverse maternal and neonatal outcome.

Management Strategies and Role of Telemedicine in a Surgery Unit During COVID-19 Outbreak

At the end of 2019, in Wuhan, the capital of Hubei (China) were reported 27 cases of death caused by “severe acute respiratory virus coronavirus 2” (SARS-CoV-2) [1]. The World Health Organization (WHO) on March 11, 2020, has declared the COVID-19 outbreak a global pandemic [2]. Officially, Italian lockdown started on March 10th and ended on May 3rd, 2020. From 4 May a new phase of coexistence with the coronavirus began. This is characterized by a gradual reopening of commercial activities and by persistence of some important rules such as social distancing and use of masks in public transport. At the 20/05/2020 in Italy there are 226.699 total cases and 32.169 deaths, while in Campania region, total cases are 4.707 with 400 deaths [3]. In this situation, there was a rapid reorganization of public health system and hospitals. Also, for surgery there have been several changes. As part of COVID-19 containment strategy and with Intensive Care Unit (ICU) near collapse, elective operations were suspended while emergency surgery and the operative therapy of oncological patients continued. Moreover, have been deleted all non-urgent outpatients visits and endoscopic procedures.

The Role of the Orthopaedic Surgeon in the COVID-19 Era: Cautions and Perspectives

The current coronavirus disease 2019 (COVID-19) pandemic has revolutionized global healthcare in an unprecedented way and with unimaginable repercussions. Resource reallocation, socioeconomic confinement and reorganization of production activities are current challenges being faced both at the national and international levels, in a frame of uncertainty and fear. Hospitals have been restructured to provide the best care to COVID-19 patients while adopting preventive strategies not to spread the infection among healthcare providers and patients affected by other diseases. As a consequence, the concept of urgency and indications for elective treatments have been profoundly reshaped. In addition, several providers have been recruited in COVID-19 departments despite their original occupation, resulting in a profound rearrangement of both inpatient and outpatient care. Orthopaedic daily practice has been significantly affected by the pandemic. Surgical indications have been reformulated, with elective cases being promptly postponed and urgent interventions requiring exceptional attention, especially in suspected or COVID-19+ patients. This has made a strong impact on inpatient management, with the need of a dedicated staff, patient isolation and restrictive visiting hour policies. On the other hand, outpatient visits have been limited to reduce contacts between patients and the hospital personnel, with considerable consequences on post-operative quality of care and the human side of medical practice.

In this review, we aim to analyze the effect of the COVID-19 pandemic on the orthopaedic practice. Particular attention will be dedicated to opportune surgical indication, perioperative care and safe management of both inpatients and outpatients, also considering repercussions of the pandemic on resident education and ethical implications.

Giant Mesenteric Cyst: Successful Management in Low-Resource Setting

Introduction: Mesenteric cysts are rare, generally benign intra-abdominal lesions with a wide range of presentation in terms of size, clinical presentation, etiology, radiological features, and pathological characteristics.

Presentation of case: We reported a case of giant mesenteric cyst in a 16-month-old girl successfully managed in a low-resource setting.

Discussion: This case is particularly important not only due to the rarity of the presented case, but also for the highlighted aspects from a public health point of view. We faced of the problem of a late stage disease and the lack of preoperative diagnosis due to cultural and economic reasons and the weaknesses of healthcare systems, as in the majority of low- and middle-income countries.

Conclusion: Despite all these limitation, this case illustrates that complex, rare diseases can also be managed successfully in a low-resource setting. It is mandatory to strengthen and improve the health system both in terms of equipment both in terms of public health policies in order to offer a better and more effective quality of care to patients also in low-income countries.

Endometriosis and Pregnancy: A Single Institution Experience

Endometriosis may compromise the physiological course of pregnancy. The aim of this prospective observational study was to evaluate whether endometriosis causes a higher prevalence of obstetric and neonatal complications as well as a higher risk of caesarean section and to detect a possible correlation between the presence, type, and location of endometriosis and obstetric complications, previous surgery, and pregnancy outcome, as well as the influence of pregnancy on the course of the disease. We compared two cohorts of women with spontaneous pregnancy, with and without endometriosis. Obstetric and neonatal outcomes, mode of delivery, presence, type, and location of endometriotic lesions and the effect of pregnancy on the disease were analyzed. A total of 425 pregnancies were evaluated: 145 cases and 280 controls. Patients with endometriosis showed a higher incidence of miscarriage, threatened miscarriage, threatened preterm labor, preterm delivery, placental abruption, and a higher incidence of caesarean section. A significant correlation with pregnancy-induced hypertension and preeclampsia was found in the presence of adenomyosis. No difference in fetal outcome was found. One case of hemoperitoneum during pregnancy was observed. Pregnancy in women with endometriosis carries a higher risk of obstetric complications, such as miscarriage, threatened miscarriage, preterm labor, preterm birth, and a higher caesarean section rate. Endometriosis does not seem to influence fetal well-being.

Management and outcomes following emergency surgery for traumatic brain injury – A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.

Epidemiology of severe traumatic brain injury.

About 5.48 million people are estimated to suffer from severe traumatic brain injury (TBI) each year (73 cases per 100,000 people). The WHO estimates that almost 90% of deaths due to injuries occur in low- and middle-income countries (LMICs), where the 85% of population live. Of these trauma-related deaths TBI is the main cause of one-third to one-half and represents the greatest cause of death and disability globally among all trauma-related injuries. The primary causes of TBI vary by age, socioeconomic factors, and geographic region, so any planned interventions must take in account this variability. The road traffic injuries (RTI) scenario is still strictly connected to the analysis of the global incidence of TBI, and to the reason why the LMICs experience nearly 3 times as many cases of TBI proportionally than high-income countries (HICs). The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). In HICs, falls and RTIs were reported most frequently as cause of TBI, but the traumas attributable to RTIs dropped from 39% in 2003 to 24% in 2012, while those attributable to falls increased from 43% to 54% respectively, with an increase TBI in the elderly (>65 years) due to falls. Differently from HICs, the population with the peak of TBI incidence is younger in LMICs, with an age between 28.8 and 33.1, as extensively reported. The burden of disease is significant; between 1,730,000 and 1,965,000 lives could be saved if global trauma care were improved in LMICs. Clinical practice recommendation should be developed and created in environments where the severe TBI mainly occurs. The applicability of high-income-country clinical research standards in LMICs is an important topic for future international research.

International Study of the Epidemiology of Paediatric Trauma: PAPSA Research Study.

Trauma is a significant cause of morbidity and mortality worldwide. The literature on paediatric trauma epidemiology in low- and middle-income countries (LMICs) is limited. This study aims to gather epidemiological data on paediatric trauma.

This is a multicentre prospective cohort study of paediatric trauma admissions, over 1 month, from 15 paediatric surgery centres in 11 countries. Epidemiology, mechanism of injury, injuries sustained, management, morbidity and mortality data were recorded. Statistical analysis compared LMICs and high-income countries (HICs).

There were 1377 paediatric trauma admissions over 31 days; 1295 admissions across ten LMIC centres and 84 admissions across five HIC centres. Median number of admissions per centre was 15 in HICs and 43 in LMICs. Mean age was 7 years, and 62% were boys. Common mechanisms included road traffic accidents (41%), falls (41%) and interpersonal violence (11%). Frequent injuries were lacerations, fractures, head injuries and burns. Intra-abdominal and intra-thoracic injuries accounted for 3 and 2% of injuries. The mechanisms and injuries sustained differed significantly between HICs and LMICs. Median length of stay was 1 day and 19% required an operative intervention; this did not differ significantly between HICs and LMICs. No mortality and morbidity was reported from HICs. In LMICs, in-hospital morbidity was 4.0% and mortality was 0.8%.

The spectrum of paediatric trauma varies significantly, with different injury mechanisms and patterns in LMICs. Healthcare structure, access to paediatric surgery and trauma prevention strategies may account for these differences. Trauma registries are needed in LMICs for future research and to inform local policy.