Association of Postoperative Complications with Anemic Women Underwent Gynecologic and Obstetric Surgeries

Objective: Preoperative anemia among women has been recognized as a risk factor for adverse postoperative complications following gynecologic and obstetric surgeries. Therefore, this retrospective analysis was conducted to assess the association of postoperative complications and comorbidities with anemia in women underwent gynecologic and obstetric surgeries. Methodology: A retrospective study was carried out in the Department of Obstetrics and Gynecology of Hamdard hospital, Karachi by using non-probability, purposive sampling technique. A total of 200 women were chosen for this study wherein 89 women were anemic and 111 were non-anemic. Duration of the study was one year from July 2018 – June 2019. Adult female patients of 18 to 65 years having elective or emergency surgical procedure were included. Chi square test was applied to evaluate the association between religion, socioeconomic status, comorbidities, and postoperative complications with anaemia. Results: The study results showed that the mean age of studied women was found 32.04±7.79 years and mean hospital stay was reported 3.38±1.08 days. Regarding Comorbidities, 89(100.0%) non diabetic were anemic while 6(5.4%) diabetic and 105(94.6%) non-diabetic were non-anemic with a significant association of diabetes with anemia (p=0.026). Regarding postoperative complications, significant association of fever was found with anemia (p<0.001). Moreover, 71(79.8%) anemic and 39(35.1%) non-anemic reported postoperative nausea and vomiting with a significant association between them (p<0.001). As far as wound infection is concerned, significant association of wound infection was observed with anemia (p=0.020). Conclusion: This study concluded that postoperative fever, nausea and vomiting were observed significantly higher in anemic women than non-anemic underwent gynecologic and obstetric surgeries. Wound infection was also significantly associated with anemia. Therefore, educational and nutritional policies should be planned to persuade women to use iron-rich diet in order to decrease the burden on patients facing these complications.


INTRODUCTION
Globally, Anemia remains an important public health dilemma disturbing 24.5-35.0% of Women of Reproductive Age (WRA); particularly lowincome nations are more affected [1]. When hemoglobin (Hb) level drops less than 12.0 g/dl that is a recognized cut-off value among Women of Reproductive Age (WRA) lead to develop anemia eventually impairs the ability of the blood to carry oxygen to the body [2][3][4]. Worldwide, approximately half a billion of WRA are affected by anemia. About two-thirds of WRA with anemia are affecting lower and middle socioeconomic nations [5,6]. In South-East Asian countries, 41.9% of WRA are anemic [6]. On contrary, in developed countries such as Europe only 2-5% of WRA are anemic [7]. Similar to other lower and middle socioeconomic nations, there is a huge trouble of anemia in Pakistan [8]. Several researches have predicted that 41.7% -77.0% of women of child bearing age are affected by anemia in Pakistan [8,9]. Prevalence of Anemia is more in the rural areas of Pakistan, where it exists frequently in severe condition and associated with adverse consequences like postpartum bleeding, stillbirth or preterm delivery and low birth weight newborns [10].
In pregnancy state, physiological hemodilution decreases hemoglobin level in the time period of first trimester, achieves a low point in the second trimester prior to increasing once again in the third trimester [11]. The hemoglobin concentrations continue to increase in puerperium and attain a peak in the postpartum immediately owing to diuresis-induced resolution of anemia induced by pregnancy along with redistribution of constricting uterine circulation to the systemic circulation [12]. Non-pregnant state recovers anemia in post-delivery by 12 weeks [13]. World Health Organization (WHO) stated that hemoglobin levels related to pregnancy are used to classify anemia in pregnancy; specifically, hemoglobin level 10-10.9 g/dl regarded as mild anemia, 7-9.9 g/dl regarded as moderate, and < 7 g/dl regarded as severe anemia [14].
Maternal anemia enhances the probability of perinatal mortality and morbidity such as the danger of miscarriages, stillbirths, preterm delivery, and low birth weight babies, [15]. trouble of depression and agitation [16]. and adverse mother-infant relations [17]. Wound healing is impaired by postpartum anemia that eventually raises the probability of readmission and/or lengthened hospitalization period, and increases the expenditure of health care for families [18]. Peripartum anemia is a critical health concern owing to rising rate of caesarean section in low-income countries [19].
Postoperative complications can cause by factors that could be related to either patient or surgeon. In the intraoperative state, inflamed bowel, ascites, distorted anatomy, former surgery, endometriosis, carcinomas, and pelvic inflammatory disease can raise the chances of injury. The patient's age, weight, comorbidities, compliance level, hygienic condition, nutritional and functional status may provide evidence to be directly or indirectly contributory factor of complications. Likewise, the sterilization of the operation theatre and hygiene of operating workers, aseptic conditions, and surgical inaccuracy can also leads to develop these complications [20].
Postoperative nausea and vomiting (PONV) is a frequent complication of anesthesia and surgery. It is recognized as the most usual reason of morbidity following anesthesia [21] and has important effects on patient contentment and expenditure [22]. Regardless of advancement in anti-emetic remedy, the occurrence of PONV is apparently 20 -30% and rise to around 70% of those with definite risk factors [23]. These risk factors comprise of female gender and middle ear, breast, gynecologic and obstetric surgery [24].
Globally, incidence of cesarean section has increased over the past few years that is predicted up to 41% in China and USA [25,26]. It is related to morbidity and mortality includes surgical site infection. This is estimated to be the most frequent infection in community hospital scenario [27]. In earlier researches carried out across Pakistan, it is reported that 9.1% to 24.3% cases are affected by wound infection [28,29]. SSI in Post cesarean section leads to raise maternal morbidity for instance longer hospital stay, repetitive surgical interventions, extended utilization of wide-ranging antibiotics, impaired wound healing, danger of hysterectomy as well as physical, financial, psychological crisis and on quality of life [30]. Surgical site infections are less reportedly in developed countries than developing countries. In developing countries, some predisposing factors lead to high SSI rate includes poverty, starvation, anemia, shortage of facilities, insanitary conditions, fatness and diabetes mellitus [31].
These postoperative complications can occasionally cause legal troubles to the surgeon. There is scarce data available in Pakistan regarding postoperative complications following gynecologic and obstetric surgeries. Appropriate management is imperative to avoid these complications. Therefore, the aim of this retrospective evaluation was to determine the association of postoperative complications and coexisting illnesses with anemic women underwent gynecologic and obstetric surgeries.

METHODOLOGY
A retrospective study was carried out in the Department of Obstetrics and Gynecology of Hamdard hospital, Karachi by using nonprobability, purposive sampling technique after taking ethical approval from the ethical review board of Hamdard University, Karachi. Study was performed over duration of one year from July 2018 -June 2019. A total of 200 women were chosen for this study wherein 89 women were anemic and 111 were non-anemic. Adult female patients of 18 to 65 years having elective or emergency surgical procedure were included in the study whereas patients admitted due to minor pathology, pathological fractures, other benign diseases, patients who at the same time having any other pathology at the time of admission, medical or obstetric complications, interoperative or immediate major postoperative complications (for example blood transfusion needed for any reason, oral fluid intolerance) were excluded from the study.
Data was collected by using prepared standardized Performa. Retrospective Data was gathered from departmental records. Demographic details like age, hospital stay, religion and socioeconomic status were documented. Type of comorbidities (obesity and diabetes mellitus) and postoperative complications were also documented.
Data was analysed by using SPSS version-16. Mean standard deviation was estimated for age and hospitalization stay. Frequencies and percentages were calculated for comorbidities (obesity and diabetes mellitus) and postoperative complication. Chi square test was applied to evaluate the association between religion, socioeconomic status, comorbidities, and postoperative complications with anaemia. A pvalue less than 0.05 was taken as statistical significant.

RESULTS
A total of 200 women wherein 89(100.0%) were anemic and 111(100.0%) were non-anemic who underwent gynecologic and obstetric surgeries were selected for this study their mean age was found 32.04±7.79 years and mean hospital stay was reported 3.38±1.08 days, as shown in Table 1. 89(100.0%) non diabetic were anemic and 6(5.4%) diabetic and 105(94.6%) non-diabetic were non-anemic with a significant association of diabetes with anemia (p=0.026). Regarding postoperative complications, significant association of fever was found with anemia (p<0.001). Moreover, 71(79.8%) anemic and 39(35.1%) non-anemic was reported postoperative nausea and vomiting with a significant association between them (p<0.001). As far as wound infection is concerned, significant association of wound infection was observed with anemia (p=0.020). Additionally, an insignificant association of Paralytic lleus (p=0.118), abdominal distention (p=0.413), wound dehiscence (p=0.203), bleeding per vagina (p=0.929), postoperative gastritis (p=0.366) was observed with anemia, as shown in Table 3.

DISCUSSION
Postoperative complications such as wound infection, wound dehiscence, fever, nausea and vomiting are the serious complications associated with obstetrics and gynecologic surgeries that are more aggravated by the presence of lower hemoglobin level and coexisting illnesses. With the increasing incidence of cesarean section all over the world its intrinsic risks are also predicted to be on the rise including SSI, thus it has a clinical importance [31]. This study demonstrated the post operative complications reported with the associated comorbidities in the obstetrics and gynecologic surgeries.
One research included 145 patients and determined the frequency and association of surgical site infection with comorbidities and factors accountable for it after urgent cesarean section. Mean age of the studied patients was found 30.93 years [32] that was in harmony with further research [31]. The present study was consistent to some extent with the above reported studies and revealed that mean age of the studied patients was found to be 32.04±7.79 years.
Similarly, one research reported that 35 patients found high rate of development of surgical site infection and 58.6% patients reported anemia who progressed SSI and showed significant association [32]. The incidence of anemia in obstetric populace is extraordinarily elevated in emergent nations. It has an unfavorable effect on the wound healing owing to lower supply of oxygen to tissue therefore may encourage the progression of wound infection [32]. One study conducted at Novo Scotia, observed 2.7%, Surgical site infection rate [33]. Another study from Thailand observed 5.9% rate of wound infection, [34] 48% reported from Tanzania study [35]. Furthermore, a research by Ghazi et al found 82% patients were anemic who had emergency Cesarean section [36]. As far as the present study is concerned, wound infection was observed at low rate but significantly associated with anemia. (p=0.020).
Concerning anemia, one of the studies demonstrated that a higher hemoglobin concentration is associated with a lower SSI risks. Moreover, it was also reported that patients suffered from moderate anemia had a higher chances to develop wound infection [37]. This increasing the possibility of wound infection by compromising the action of the macrophages and prevents the progression of the wound healing by decreasing collagen synthesis. Therefore, a less stable scar develops and encourages wound dehiscence and infection [38]. And this is endorsed by other studies as well [39,40]. The present study was also supported to above mentioned researches and revealed that frequency of wound infection was significantly associated with anemia (p=0.020) thereby proving anemic women had more chances to develop wound infection than nonanemic.
Another research by Harvey observed a total prevalence of postoperative nausea and vomiting (PONV) was 2.9% in the recovery room in Guyana that was significantly lower than Caucasian people [41]. The present study was not in accordance with the above reported research and proved that postoperative nausea and vomiting was observed in most of the anemic women 71(79.8%) and proving significantly higher (p<0.001) cases reported in anemic than non-anemic women.
Similarly, one research demonstrated the significant relationship between the incidence of complications and parameters such as age, surgical approach, parity, time period of surgery, preoperative interval of hospital stays, in addition to blood transfusion preoperatively. On the other hand, no significant relationship was reported with regard to earlier abdominal surgeries, comorbidities, menopausal status, and BMI [21]. One research by Gevariya et al. have revealed no significant association between surgical complications and age and parity [42]. The present study was not supported the above reported studies because we did not find the association between postoperative complication with age, parity, approach of surgery, duration of surgery and interval of hospital stays.

CONCLUSION
This study concluded that postoperative fever, nausea and vomiting were observed significantly higher in anemic women than non-anemic underwent gynecologic and obstetric surgeries. Wound infection was also significantly associated with anemia. Therefore, educational and nutritional policies should be planned to persuade women to use iron-rich diet in order to decrease the burden on patients facing these complications.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
Ethical Approval was taken from the ethical review board of Hamdard University, Karachi.