Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
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We wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
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Throughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\n
We wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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Exposure to endocrine disrupting chemicals (EDCs) during development may cause long-term health outcomes. This book, Endocrine Disruptors, includes eight chapters that illustrate potential endocrine-disrupting activities in water, sediments, crops, animals, and humans. This book assesses the relationship between the EDCs and development, reproduction, or obesity. Finally, detection of the levels of EDCs by autobioluminescent cellular bioreporters is discussed. Scientists, physicians, neuroendocrinologists, neurotoxicologists, and lay readers who have engaged in EDC studies or practice will discover that this book offers insight into all areas of EDC research.",isbn:"978-1-78984-152-7",printIsbn:"978-1-78984-151-0",pdfIsbn:"978-1-83881-799-2",doi:"10.5772/intechopen.74629",price:119,priceEur:129,priceUsd:155,slug:"endocrine-disruptors",numberOfPages:152,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"571f5c496c8b0e8db9043204fa58be2a",bookSignature:"Ahmed R. G.",publishedDate:"October 10th 2018",coverURL:"https://cdn.intechopen.com/books/images_new/7269.jpg",numberOfDownloads:8202,numberOfWosCitations:12,numberOfCrossrefCitations:12,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:15,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:39,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 5th 2018",dateEndSecondStepPublish:"February 26th 2018",dateEndThirdStepPublish:"April 27th 2018",dateEndFourthStepPublish:"July 16th 2018",dateEndFifthStepPublish:"September 14th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"138555",title:"Prof.",name:"R.G.",middleName:null,surname:"Ahmed",slug:"r.g.-ahmed",fullName:"R.G. Ahmed",profilePictureURL:"https://mts.intechopen.com/storage/users/138555/images/system/138555.jpeg",biography:"Dr. Ahmed RG received his Ph.D. in Developmental Biology (Developmental endocrinology) from Beni-Suef University, Egypt and received research training (postdoctoral fellowship) as a visiting scholar at the Katholic University, Belgium. He has outstanding record of scientific and academic accomplishments with multiple research funding, numerous publications (books/papers) in highly prestigious journals and various presentations in both national and international conferences. He is a member of a number of eminent societies, organizations and schools. On the other hand, he served as a scientific editors and reviewer for the national and international research institutions. He has been honored by the Society for Endocrinology in project of You and Your hormones. He is an assistant director of animal housing, Zoology department, Faculty of Science, Beni-Suef University, Egypt.",institutionString:"Beni-Suef University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"5",institution:{name:"Beni-Suef University",institutionURL:null,country:{name:"Egypt"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"178",title:"Endocrinology",slug:"medicine-endocrinology"}],chapters:[{id:"62763",title:"Occurrence of Endocrine Disruptor Chemicals in the Urban Water Cycle of Colombia",doi:"10.5772/intechopen.78325",slug:"occurrence-of-endocrine-disruptor-chemicals-in-the-urban-water-cycle-of-colombia",totalDownloads:1012,totalCrossrefCites:4,totalDimensionsCites:4,hasAltmetrics:0,abstract:"In developing countries such as Colombia, information on the occurrence of endocrine disruptors is still incipient. Bogotá, the capital of Colombia, has a complexity at an anthropogenic and environmental level that makes it particularly important to determine the possible presence of this type of compounds and the risks associated with its presence in aquatic environments. During the present study, the occurrence of endocrine disruptors, mainly pharmaceuticals, plasticizers, and hormones in different aquatic matrices including wastewater, surface water, runoff water, and drinking water was evaluated; the results show that phthalates present the highest occurrence followed by bisphenol A, with an important participation of carbamazepine (0.68–31.45 μg L−1), the most commonly found compound is bis(2-ethylhexyl) phthalate (BEHP). It was also found in the drinking water, this leads to the conclusion that endocrine disruptors in Colombia and Bogotá are a reality and deserve attention from researchers to deepen their potential sources of generation and control strategies, as well as the provision must start generating policies in this regard.",signatures:"Diego Fernando Bedoya-Ríos and Jaime Andrés Lara-Borrero",downloadPdfUrl:"/chapter/pdf-download/62763",previewPdfUrl:"/chapter/pdf-preview/62763",authors:[{id:"244192",title:"Ph.D. Student",name:"Diego Fernando",surname:"Bedoya Rios",slug:"diego-fernando-bedoya-rios",fullName:"Diego Fernando Bedoya Rios"},{id:"244227",title:"Dr.",name:"Jaime Andrés",surname:"Lara Borrero",slug:"jaime-andres-lara-borrero",fullName:"Jaime Andrés Lara Borrero"}],corrections:null},{id:"62104",title:"First Approach to Screening Endocrine Disruption Activity in Sediments from the Uruguay River (Uruguay Coast)",doi:"10.5772/intechopen.78736",slug:"first-approach-to-screening-endocrine-disruption-activity-in-sediments-from-the-uruguay-river-urugua",totalDownloads:808,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The Uruguay river basin supports intensive agricultural and forest production, and receives municipal sewage discharge and industrial effluent. Therefore, the river receives xenobiotic compounds which can be distributed in sediments, biota, water and particulate matter. There is evidence of the ability of several of these compounds to interfere with the endocrine system and the sediments are an important source. The aim of this study was to determine whether exposure of immature Cyprinus carpio\n to Uruguay river sediments undergo physiological and endocrine alterations. A 30-day semi-static assay was performed using sediments from four sites along the Uruguay river and compared with an unexposed group in dechlorinated water as a negative control. The results showed that plasma vitellogenin levels increased along the river, and significant differences were found in exposed fish. Significant difference in hepatosomatic index was observed in fish exposed to sediment from an industrial site. In the histological analysis, only reproductive stage of males showed differences, where the number of primary spermatocyte accumulations was lower in exposed ones, and some exposed individuals from industrial sites presented with testis-ova. Our results suggest that the Uruguay river sediments are a source of endocrine-disrupting compounds available to the aquatic organisms.",signatures:"Noelia Rivas-Rivera and Gabriela Eguren",downloadPdfUrl:"/chapter/pdf-download/62104",previewPdfUrl:"/chapter/pdf-preview/62104",authors:[{id:"245149",title:"Dr.",name:"Gabriela",surname:"Eguren",slug:"gabriela-eguren",fullName:"Gabriela Eguren"},{id:"245151",title:"Dr.",name:"Noelia",surname:"Rivas",slug:"noelia-rivas",fullName:"Noelia Rivas"}],corrections:null},{id:"62170",title:"Crop Protection Compounds: A Source of Endocrine Disruptors in Uruguay?",doi:"10.5772/intechopen.78735",slug:"crop-protection-compounds-a-source-of-endocrine-disruptors-in-uruguay-",totalDownloads:843,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The intensive use of agrochemicals in agriculture has been raised the concern about their potential effects on human health and the environment. In this way, regarding crop protection compounds a complex frameworks and restrictions had been established in several countries, particularly for compounds identified as endocrine disruptors. In Uruguay, the General Direction of Agricultural Services is the agency responsible for registry, but the authorization process does not consider the potential effects on endocrine system. Uruguay has significantly increased the use of crop protection compounds, of which several of them have been identified as endocrine disruptors and the environmental risks associated have not been studied. The aim of this study was to be bridging the gap between registry process and environmental protection policies. An eco-epidemiological analysis of the database of compounds imported in 2017, use guideline, national agricultural census as well as the public endocrine disruptor databases were carried out. Main class of crop protection compounds were ranked according to imported volumes and the top 10 of each class were contrasted with the disruptor databases. In function to recommended doses and geographical localization of the crops was identified the main hot spots associated to the use of agricultural compounds identified as endocrine disruptors.",signatures:"Gabriela Eguren and Noelia Rivas-Rivera",downloadPdfUrl:"/chapter/pdf-download/62170",previewPdfUrl:"/chapter/pdf-preview/62170",authors:[{id:"245149",title:"Dr.",name:"Gabriela",surname:"Eguren",slug:"gabriela-eguren",fullName:"Gabriela Eguren"},{id:"245151",title:"Dr.",name:"Noelia",surname:"Rivas",slug:"noelia-rivas",fullName:"Noelia Rivas"}],corrections:null},{id:"63253",title:"Interactions between Bisphenol S or Dibutyl Phthalates and Reproductive System",doi:"10.5772/intechopen.79264",slug:"interactions-between-bisphenol-s-or-dibutyl-phthalates-and-reproductive-system",totalDownloads:1045,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Endocrine disrupting chemicals (EDCs) adversely affect animals and human beings. This attracted the researchers in the previous decade to explore the possible association of these chemicals. However, among various studies, very limited data is available to explain the link between EDCs and reproductive tract outcome. One reason is that many potential EDCs and their probable mechanisms and underlying causes have not been studied so far. Bisphenol S (BPS) is used as an alternative of bisphenol A, after the worse effects of this bisphenol. Similarly, dibutyl phthalate (DBP) is the least studied of its group. Dibutyl phthalate is widely used in polyvinyl plastic products. The current chapter aims to explore the possibly association of these two chemicals with animals and humans.",signatures:"Irfana Liaqat",downloadPdfUrl:"/chapter/pdf-download/63253",previewPdfUrl:"/chapter/pdf-preview/63253",authors:[{id:"201351",title:"Dr.",name:"Irfana",surname:"Liaqat",slug:"irfana-liaqat",fullName:"Irfana Liaqat"}],corrections:null},{id:"62014",title:"Biotransformation of Bisphenol A and Its Adverse Effects on the Next Generation",doi:"10.5772/intechopen.78275",slug:"biotransformation-of-bisphenol-a-and-its-adverse-effects-on-the-next-generation",totalDownloads:1495,totalCrossrefCites:5,totalDimensionsCites:6,hasAltmetrics:1,abstract:"Although we are exposed to many chemical substances in routine daily life, the body has metabolic systems capable of detoxifying and eliminating these chemicals. Bisphenol A (BPA) is an endocrine disrupter of great concern because of its estrogenic activity, but studies have indicated no severe adverse effects in adult rodents exposed to BPA due to metabolic detoxification. BPA is metabolized by glucuronidation mediated by phase II enzymes such as UDP-glucuronosyltransferase. Numerous recent studies in rodents have indicated that maternal BPA exposure causes adverse effects in offspring. It was also shown that bisphenol analogs are efficiently absorbed via the oral route and distributed to the reproductive tract in pregnant rats, with its residue capable of crossing the placental barrier in the late stage of gestation. Both animal and human studies have demonstrated that BPA and the BPA metabolite BPA-GA are detectable in fetal and amniotic fluid, suggesting the presence of a placental transfer mechanism. In this review, we discuss the pharmacokinetics of BPA, particularly its (1) metabolism and disposition in the intestine, (2) metabolism and disposition in the liver, and (3) transfer from maternal tissues to the fetus.",signatures:"Hidetomo Iwano, Hiroki Inoue, Miyu Nishikawa, Jumpei Fujiki and\nHiroshi Yokota",downloadPdfUrl:"/chapter/pdf-download/62014",previewPdfUrl:"/chapter/pdf-preview/62014",authors:[{id:"246393",title:"Prof.",name:"Hidetomo",surname:"Iwano",slug:"hidetomo-iwano",fullName:"Hidetomo Iwano"},{id:"256084",title:"Dr.",name:"Hiroki",surname:"Inoue",slug:"hiroki-inoue",fullName:"Hiroki Inoue"},{id:"256085",title:"Dr.",name:"Miyu",surname:"Nishikawa",slug:"miyu-nishikawa",fullName:"Miyu Nishikawa"},{id:"256086",title:"Dr.",name:"Jumpei",surname:"Fujiki",slug:"jumpei-fujiki",fullName:"Jumpei Fujiki"},{id:"256087",title:"Dr.",name:"Hiroshi",surname:"Yokota",slug:"hiroshi-yokota",fullName:"Hiroshi Yokota"}],corrections:null},{id:"61849",title:"Androgen Receptor Plays a Vital Role in Benomyl- or Carbendazim-Induced Reproductive and Developmental Toxicity and Endocrine-Disrupting Activity in Rats",doi:"10.5772/intechopen.78276",slug:"androgen-receptor-plays-a-vital-role-in-benomyl-or-carbendazim-induced-reproductive-and-developmenta",totalDownloads:851,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Benomyl and its metabolite carbendazim were reported to induce reproductive and developmental toxicity and endocrine-disrupting activity in rats. The exactly underlying mechanism of reproductive and developmental toxicity and endocrine-disrupting activity still remain unclear. Based on our unpublished data it showed that the antiandrogen flutamide can completely recover the reproductive and developmental toxicity including embryolethality induced by benomyl and carbendazim in rats. This manuscript aimed to review and generalize the results based on our previous reports. Androgen receptor might play an important role in benomyl- and carbendazim-induced reproductive and developmental toxicity and endocrine-disrupting activity. The evidences were (1) androgen- and androgen receptor-dependent mechanisms are possibly involved in carbendazim-induced toxicity; (2) carbendazim exposure in utero displays a transient and weak androgenic effect and reduces flutamide antiandrogenicity in male rats; (3) antagonistic effect of flutamide on the carbendazim-androgenic effect on mRNA and protein levels; (4) benomyl and carbendazim exhibit an androgenic effect, leading to increase weight of ventral prostate and seminal vesicles and uterine fluid retention in young adult rats. The molecular underlying mechanism of reproductive and developmental toxicity and endocrine-disrupting activity induced by benomyl and carbendazim through androgen receptor need to be further investigated.",signatures:"Shui-Yuan Lu",downloadPdfUrl:"/chapter/pdf-download/61849",previewPdfUrl:"/chapter/pdf-preview/61849",authors:[{id:"245140",title:"Ph.D.",name:"Shui-Yuan",surname:"Lu",slug:"shui-yuan-lu",fullName:"Shui-Yuan Lu"},{id:"257857",title:"Dr.",name:"Wei-Ren",surname:"Tsai",slug:"wei-ren-tsai",fullName:"Wei-Ren Tsai"}],corrections:null},{id:"62177",title:"Endocrine Disruptors and Reproductive Health in Males",doi:"10.5772/intechopen.78538",slug:"endocrine-disruptors-and-reproductive-health-in-males",totalDownloads:1272,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Nowadays, endocrine-disrupting chemicals are considered to be one of the main causes of the ever-increasing occurrence of problems with male fertility. These compounds of natural or anthropogenic origin are omnipresent in the environment and organisms are exposed to them practically nonstop through the air, water, food, and occupationally. Endocrine disruptors have the ability to mimic effects of reproductive hormones and demonstrably can interfere with the endocrine system leading to reproductive disorders at different levels, and considering male reproductive functions, most of the impacts are performed by the breakdown of estrogen- or androgen-mediated processes. A significant body of evidence based upon laboratory or wildlife animal experiments and meta-analysis of semen studies in men indicates that exposure to endocrine disrupting compounds is associated with male reproductive malfunctions, including impairment of spermatogenesis followed by reduced semen quality parameters (sperm concentration, motility, and morphology). Alkylphenols, bisphenol, and phthalates are substantial components of many products with which people come into contact daily. This brief review will emphasize on the possible effects of alkylphenols, bisphenol, and phthalates on the male reproductive system, and current research efforts related to these substances mainly in the context of two main processes taking place in testicular tissues—steroidogenesis and spermatogenesis.",signatures:"Tomas Jambor, Hana Greifova, Jana Bistakova and Norbert Lukac",downloadPdfUrl:"/chapter/pdf-download/62177",previewPdfUrl:"/chapter/pdf-preview/62177",authors:[{id:"199328",title:"Prof.",name:"Norbert",surname:"Lukáč",slug:"norbert-lukac",fullName:"Norbert Lukáč"},{id:"199382",title:"Dr.",name:"Tomáš",surname:"Jambor",slug:"tomas-jambor",fullName:"Tomáš Jambor"},{id:"199383",title:"MSc.",name:"Hana",surname:"Greifova",slug:"hana-greifova",fullName:"Hana Greifova"},{id:"204992",title:"Dr.",name:"Jana",surname:"Bistáková",slug:"jana-bistakova",fullName:"Jana Bistáková"}],corrections:null},{id:"61788",title:"Rapid, High-Throughput Detection of Endocrine Disrupting Chemicals Using Autobioluminescent Cellular Bioreporters",doi:"10.5772/intechopen.78378",slug:"rapid-high-throughput-detection-of-endocrine-disrupting-chemicals-using-autobioluminescent-cellular-",totalDownloads:878,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Overexposure to endocrine disruptor chemicals (EDCs) can result in serious health problems, yet they are commonly found in everyday items such as pesticides, personal care products, nutritional supplements, and plastics. The U.S. Environmental Protection Agency, along with other such agencies from around the world, have therefore mandated that new approaches be designed to screen these products for the presence of EDCs. However, despite the presence of several types of extant EDC detection assays, there still exists a backlog approaching 87,000 chemicals currently awaiting screening. Autobioluminescent detection systems, which utilize cellular bioreporters capable of autonomously modulating bioluminescent signals without the need for external stimulation or investigator interaction, provide an attractive means for addressing this backlog because of their reduced performance costs and increased throughput relative to alternative assay systems. This chapter reviews the variety of existing EDC detection assays and evaluates the performance of a representative autobioluminescent estrogen-responsive EDC bioreporter to provide an overview of how autobioluminescence can be used to improve EDC detection using in vitro assay systems.",signatures:"Tingting Xu, Andrew Kirkpatrick, Jody Toperzer, Marvin Steven\nFurches, Steven Ripp, Gary Sayler and Dan Close",downloadPdfUrl:"/chapter/pdf-download/61788",previewPdfUrl:"/chapter/pdf-preview/61788",authors:[{id:"34168",title:"Dr.",name:"Steven",surname:"Ripp",slug:"steven-ripp",fullName:"Steven Ripp"},{id:"89407",title:"Dr.",name:"Tingting",surname:"Xu",slug:"tingting-xu",fullName:"Tingting Xu"},{id:"187444",title:"Dr.",name:"Dan",surname:"Close",slug:"dan-close",fullName:"Dan Close"},{id:"256492",title:"Dr.",name:"Gary",surname:"Sayler",slug:"gary-sayler",fullName:"Gary Sayler"},{id:"256493",title:"Dr.",name:"M. Steven",surname:"Furches",slug:"m.-steven-furches",fullName:"M. Steven Furches"},{id:"256494",title:"Mr.",name:"Andrew",surname:"Kirkpatrick",slug:"andrew-kirkpatrick",fullName:"Andrew Kirkpatrick"},{id:"256495",title:"Ms.",name:"Jody",surname:"Toperzer",slug:"jody-toperzer",fullName:"Jody Toperzer"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6154",title:"Diabetes and Its Complications",subtitle:null,isOpenForSubmission:!1,hash:"79f08a2c1cbbcea2d1df2ad075d2f9fa",slug:"diabetes-and-its-complications",bookSignature:"Ahmed R. G.",coverURL:"https://cdn.intechopen.com/books/images_new/6154.jpg",editedByType:"Edited by",editors:[{id:"138555",title:"Prof.",name:"R.G.",surname:"Ahmed",slug:"r.g.-ahmed",fullName:"R.G. Ahmed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8224",title:"Growth Disorders and Acromegaly",subtitle:null,isOpenForSubmission:!1,hash:"889cf2b5a21e42ccdf34e5861c1cc0a4",slug:"growth-disorders-and-acromegaly",bookSignature:"Ahmed R.G. and Ahmet Uçar",coverURL:"https://cdn.intechopen.com/books/images_new/8224.jpg",editedByType:"Edited by",editors:[{id:"138555",title:"Prof.",name:"R.G.",surname:"Ahmed",slug:"r.g.-ahmed",fullName:"R.G. Ahmed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5854",title:"Germ Cell",subtitle:null,isOpenForSubmission:!1,hash:"e63c03c8b93ebc004eef632ab84d62ea",slug:"germ-cell",bookSignature:"Ahmed RG",coverURL:"https://cdn.intechopen.com/books/images_new/5854.jpg",editedByType:"Edited by",editors:[{id:"138555",title:"Prof.",name:"R.G.",surname:"Ahmed",slug:"r.g.-ahmed",fullName:"R.G. Ahmed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7175",title:"Placenta",subtitle:null,isOpenForSubmission:!1,hash:"447d49d62164c5437461f3b0aae7a67f",slug:"placenta",bookSignature:"Ahmed R. G.",coverURL:"https://cdn.intechopen.com/books/images_new/7175.jpg",editedByType:"Edited by",editors:[{id:"138555",title:"Prof.",name:"R.G.",surname:"Ahmed",slug:"r.g.-ahmed",fullName:"R.G. Ahmed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6581",title:"Adipose Tissue",subtitle:null,isOpenForSubmission:!1,hash:"85899eab2d8b01653e1297b168c470d7",slug:"adipose-tissue",bookSignature:"Leszek Szablewski",coverURL:"https://cdn.intechopen.com/books/images_new/6581.jpg",editedByType:"Edited by",editors:[{id:"49739",title:"Dr.",name:"Leszek",surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8797",title:"Adipose Tissue",subtitle:"An Update",isOpenForSubmission:!1,hash:"34880b7b450ef96fa5063c867c028b02",slug:"adipose-tissue-an-update",bookSignature:"Leszek Szablewski",coverURL:"https://cdn.intechopen.com/books/images_new/8797.jpg",editedByType:"Edited 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1. Introduction
Increasing population and food demand has forced the farming community to apply excess amount of chemical fertilizer that leads to degradation of soil health and causing environmental pollution. Factor productivity of the soil is also decreasing due to injudicious fertilization. The technology advancement and industrialization has created many challenges associated with sustainability. Sustainability is a concept of utilizing the natural resources without compromising the ability of future generation to meet their own needs. Rapid urbanization and industrial growth is worrisome with respect to huge amount of waste generation. Unscientific management of these wastes causing social, economic, and environmental problems. After consuming so much chemicals during the green revolution era, the soil eventually became unproductive due to a lack of sufficient organic matter amendments. Vermicomposting is one of the many potential approaches that have gained significant attention over decades. It is an eco-friendly concept of waste management where decomposition process is aided by microorganisms [1, 2, 3]. Earthworms are the biological engineers since the beginning of humankind. The technique of culturing earthworm for managing wastes and preparing compost is known as vermicomposting. Vermicomposting is defined as a bio-oxidative process where earthworms and decomposer microorganisms (bacteria, fungi, and actinomycetes) act synergistically to manage organic waste in a scientific way that also aids in improvement of soil physical, chemical, and biological properties [4]. A wide range of raw materials (Figure 1) such as agricultural waste [5], animal waste [6], and municipality [7] waste are decomposed by earthworms and microorganisms for preparing vermicompost. This bio-technique increases mineralization of waste material led to enhancement in bioavailability of essential plant nutrients. Vermicompost not only supplies plant nutrients and growth promoting hormones but also improves soil physical property through soil aggregation [8]. Hence it is used as a component of organic farming. Vermicompost has also been proven to be a miraculous plant growth stimulator [9]. Vermicast, the end product is also rich in hormones and enzymes which make the soil environment favorable for soil biota. Residue burning is a common issue nowadays that causing severe environmental hazards. This issue can also be overcome by adopting vermicomposting technique.
Figure 1.
Vermicompost and its role in agriculture.
In spite of having so many benefits, use of vermicompost is still not accepted widely due to lack of awareness and technology barriers. There is a need for proper extension to explore the potentialities of vermicompost. So, this study was conducted with the objectives for getting a precise idea about general properties, preparation methods, benefits and its limitations, and most importantly understanding the significance of vermicompost in crop production.
2. Earth worm and its kind
Among the soil biota, earth worm is one of the major kinds and a key component of tropical and subtropical ecosystems [10, 11]. It helps is soil aggregation, nutrient recycling, litter decomposition, etc. Earthworm improves the soil environment by producing cast, pellets, and galleries. Mucus secretion from the gut of earth worm enhances microbial activity. Around 3000 species of earthworms documented so far [12]. The earthworms are of three types that have been described in Figure 2.
Figure 2.
Earth warm classification.
The most common earthworms [13] have successfully used in India for vermicompost preparation are:
Perionyx excavates (a native species)
Eisenia fetida (exotic species that have colonized many ecosystems)
Eudrilus eugeniae (exotic species largely confines to experimental setup)
Apart from being ecological engineer, earth worm is a rich source of protein thus it can be used as high quality feed to farm animals. Das et al. [13] reported that earthworm cast increases mushroom production. The brief difference between chemical fertilizer and vermicompost is given in Table 1.
Indices
Chemical fertilizers
Vermicompost
Synthesis process
They are synthesized and manufactured in factories.
They are the product of natural decomposition of organic matter with the help of earth worms.
Macronutrients
Major chemical fertilizer contains only one macronutrient (either nitrogen or phosphorus or potassium).
Vermicompost contains almost all the primary minerals along with some quantities of secondary minerals (Ca, Mg, and S) [14].
Micronutrients
Not present.
Significant amount of micronutrients: Zn, B, Mn, Fe, Cu, etc. also present [15].
Soil structure
Over use of chemical fertilizer degrades soil structure.
It improves soil aggregation, water holding capacity, soil aeration, etc.
Biological activity of soil
It reduces biological activity of soil.
It improves activity of soil microbes thus enhances soil fertility [16].
Environmental impact
Excessive use of chemical fertilizers causes environmental pollution.
Use of chemical fertilizers increases the cost of cultivation.
The farmer/consumer can expect approximately $110–$350 in additional income from applying one ton of vermicompost due to offset costs of traditional fertilizer and pesticides [18].
Table 1.
Difference between chemical fertilizer and vermicompost.
Most commonly used earthworm species are: African earthworm (E. eugeniae), that is, Figure 3, Tiger worm (E. fetida), that is, Figure 4, and Asian worms (Perionyx excavatus), that is, Figure 5.
Figure 3.
African earthworm (Eudrilus eugeniae).
Figure 4.
Tiger worm (Eisenia fetida).
Figure 5.
Asian worms (Perionyx excavatus).
3. General properties of vermicompost
In terms of sustainable crop production, the acceptability of vermicompost has been rising rapidly as soon as the human realizes the significance of organic inputs in crop field. The excreta of earthworms, which is considered as the main product, that is, vermicompost has several characteristics. These are:
3.1 Physical properties
A good vermicompost is always non-toxic, well-decomposed, ecologically compatible, and environment friendly.
Any type of green waste viz. municipal waste, agricultural waste, sewage sludge, industrial waste, and human feces can be used for the conversion by earthworm.
When turning of soil is occurred in proper manner, it is symptomatic to aerobic decomposition which will produce normal odor after preparation. If there is improper aeration, foul odor can be formed.
The final outcome of vermicomposting would be comprising of fine particulate structure, granular form.
Vermicompost plays the role of a “soil conditioner” by improving the soil porosity, drainage, and water holding capacity [19].
3.2 Chemical properties
Vermicompost is rich in almost all essential macro and micro plant nutrients. Several experiment states that average nutrient content of vermicompost is greater than other conventional compost, produced from other procedures.
Among all the secondary nutrients, calcium content in vermicompost is higher than other compost.
In contrast with other conventional compost, vermicompost contains worm mucus which facilitates in preventing washing away of nutrients present there [20].
Due to vermi-conversion, heavy metal present in feeding material is found to be reduced in earthworm cast owing to its accumulation in worm tissue. According to the feed used, the rate of removal of heavy metal depends in vermicomposting techniques. This property makes vermicompost lesser contaminant than any other compost. Thus, it becomes more environmentally sustainable [21].
There are certain differences found in chemical properties between simple farm yard compost and vermicompost. Vermicompost ranges higher in macro and micro-nutrients as well as soil organic carbon status that can be observed from the Table 2 [22].
Properties
Compost
Vermicompost
pH
7.16
7.72
EC (dSm−1)
3.65
6.88
OC
20.5
17.3
Total N (%)
2.42
3.5
Total P (%)
0.88
0.71
Total K (mg.kg−1)
653.5
950.5
Total Ca (%)
2.9
3.5
Total Mg (%)
1.5
2.8
Total Fe (mg.kg−1)
4467
6045
Total Zn (mg.kg−1)
115.5
189.5
Total Cu (mg.kg−1)
59
38
Total Mn (mg.kg−1)
221.45
344.15
C:N
8.47
5.51
Table 2.
Chemical properties of compost and vermicompost.
3.3 Biological properties
The by-product of earth casting is an inhabitant of several microorganism, viz. bacteria, fungi, and actinomycetes. These micro-organisms release several enzyme and phytohormones which helps in improving plant growth. Thus, vermicompost facilitates both microbial and enzymatic activity [22, 23].
The microbial population of nitrogen fixer bacteria and other symbiotic associative bacteria are supposed to be in a good range of numbers in the excreta of earthworm.
In addition, earthworm casts harbor a large number of vesicular-arbuscular mycorrhiza (VAM) propagules. These propagules survive up to 11 months on the cast, and helps in increasing microbial activity to produce nitrogen and phosphorus in readily available form to the plant (Table 3) [24].
Properties
Impact
References
Soil physical properties
Soil aggregation, soil structure, and water holding capacity, infiltration rate improves after vermicompost application.
Effect of vermicompost on different soil properties.
4. Preparation methods
Earthworms are often termed as “Bio-engineers” because of their unique ability to convert organic wastes into dark brown nutrient rich compost materials. We use these worms along with some easy-available inputs to produce the vermicompost. In South-Asian countries like India, we often see market price of the vermicompost is very low, which is attributed to the low-cost inputs of this compost. This vermicompost can be prepared in various techniques, among all those two most common methods are: bed and pit methods.
Bed method is easy to prepare and maintain throughout the process as here composting is done on pucca or kachcha floor by making the bed with organic materials like hay, straw, corn silage, etc.
Pit method is comparatively strenuous process where composting is done on cemented pits of approx. The unit is covered with grass or any other organic mixtures (Figures 6–10).
Figure 6.
Bed method.
Figure 7.
Pit method.
Figure 8.
Spraying of water in bed.
Figure 9.
Adult worms in compost.
Figure 10.
Fully prepared vermicompost.
4.1 Step by step of preparation methods
5. Beneficial effects of vermicompost
5.1 Effect of vermicompost on the soil physiochemical properties
Addition of vermicompost improves soil physico-chemical properties viz. soil structure, soil water holding capacity, penetration resistance, bulk density, soil organic carbon, aggregation, nutrient content, etc. According to the findings of various long term research addition of vermicompost reduces the bulk density of the soil and increases the water holding capacity of soil [25]. Aksakal et al. [26] found that when vermicompost was added in the soil, the mean bulk density, and mean total porosity were the least. Air permeability rose and penetration resistance reduced dramatically as wet aggregate stability improved and bulk density reduced. Increased microbial population and activity led in the development of aggregates and increased soil porosity, resulting in decreased particle and bulk densities. Physicochemical characteristics such as pH, electrical conductivity (EC), porosity, moisture content, water holding capacity, and chemical properties like nitrogen, phosphorous, potassium, calcium, and magnesium were all found to be significantly improved in vermicompost treated soil, while the corresponding physicochemical values in control soil were minimal in rice crop [27]. Vermicompost has indeed been found to have significant concentration of total and bioavailable nitrogen, phosphorus, potassium (NPK), and micronutrients, as well as microbial and enzyme activity and growth regulators [28]. Polysaccharides appeared to be abundant in vermicompost [29]. Polysaccharide worked as a cementing ingredient in the soil, causing aggregate stability, which helped to establish and maintain the soil structure for improved aeration, water retention, drainage, and aerobic conditions. The preservation of soil structure is essential for root elongation and nutrient uptake. The inclusion of mucus secretion and microorganisms from the earthworm’s gut improves the soil’s aggregate stability. The absorbent organic matter in vermicomposts increases the soil’s water retention capacity by holding only the quantity of water required by the plant roots [30]. Vermicomposts have been found to have a higher base exchange capacity and a higher oxidation potential rise [31]. The C/N ratio of vermicompost is usually lower, indicating that it is more suited for use as a soil amendment. By altering the physiochemical parameters of the soil, vermicompost was able to limit the loss of nutrients through leaching [32]. Humic acid and biologically active compounds like plant growth regulators are abundant in vermicompost [33]. Humic acid has been proven to improve nutrient accretion in situations where nutrients are scarce or when additional nutrients are provided. Humic acids may have a hormone-like effect on plant growth and productivity as a result of their involvement in cell respiration, photosynthesis, oxidative phosphorylation, biogenesis, and a variety of other enzymatic functions.
5.2 Effect of vermicompost on the soil biological properties
Biological properties of soil can be enhanced through application of vermicompost. Recent studies founded that soil biological characteristics viz. soil organic carbon as well as soil microbial biomass, enzymatic activity, population of different beneficial microorganism, hormones, etc. significantly enhanced with application of vermicompost [34]. The activity of the dehydrogenase enzyme, which is commonly employed to quantify the respiratory activity of microbial communities, was shown to be higher in vermicompost than in commercial medium [35]. Application of vermicompost improved the nitrogen status of soil by introducing the beneficial microorganism in the rhizosphere of the plant which ultimately enhances the nitrogenase activity in soil, which is the enzyme responsible for nitrogen fixation (Tables 4 and 5).
Vermicompost has a great importance to increase the soil fertility level. In recent years organic amendments are getting more importance for nutrient management and sustainable crop production since the long-term use of inorganic fertilizer lacking organic additives has the ability to ruin soil qualities [34]. Long-term treatment of balanced inorganic fertilizers led to reduced soil bulk density, improved total porosity, and higher water-holding capacity. Inorganic fertilizers also promoted soil aggregation in deeper soil layers and raised maize and wheat grain and straw yields [38]. In their research, using farmyard manure (organic fertilizer) instead of inorganic fertilizer improved soil qualities in a similar way. Furthermore, compost provides substantially higher boosts in soil organic carbon as well as some plant nutrients when compared to mineral fertilizers [39, 40]. Thus, using vermicompost improves overall soil fertility by improving numerous soil physical, chemical, and biological qualities.
5.4 Effect of vermicompost on plant growth and development
Vermicompost promotes the growth and development of a variety of plant species, especially various horticulture crops, that is, sweet corn, tomato, strawberry [41], cereals crop rice [27], wheat, sorghum [32], fruit crops papaya [42], and pineapple [43]. Several growth and yield metrics viz. stem diameter, plant height, marketable yield per plant, mean leaf number, and total plant biomass of tomato plant were recorded significantly higher with the application of vermicompost (Figure 11).
Figure 11.
Effect of vermicompost on growth parameters of Phaseolus vulgaris (20 DAS). Source: Ref. [34]. T1: Control (without application of inorganic NPK or vermicompost), T2: 100% recommended dose of NPK (20:80:40 kg ha−1), T3: 100% recommended dose of vermicompost (5 t ha−1), and T4: 50% vermicompost supplemented with 50% NPK (W/W).
The increase in growth and development of plant is due to the improving action of vermicompost application on soil physical, chemical, and biological properties which ultimately improves the overall soil fertility, which enhances the plant growth and development. Vermicompost has been demonstrated to improve plant dry weight [44] and uptake of plant N [45] serve as a naturally available, slow released sources of plant nutrients.
5.5 Effect of vermicompost on plant diseases
Various studies had showed that vermicompost is useful for remedies of different plant diseases. Many plant diseases caused by soil-borne, foliar plant pathogens, and pests have been suppressed by vermicompost products, which have been proven to be effective as organic fertilizers and biological control agents. In conventional agriculture, excessive and repeated use of chemical pesticides resulted in “biological resistance” in crop diseases and pests. As a result, significantly higher doses are now needed to inhibit them for the growth of high-yielding crops that are more sensitive to pests and diseases [46]. A study was conducted to compared the inhibition performance of two different methods, in which two nonconventional chemicals ZnSO4 and oxalic acid, as well as the bio-control agent Pseudomonas syringae, were practiced as foliar sprays and seed coatings, respectively, against collar rot of chickpea caused by Sclerotium rolfsii, with the combination of vermicompost substitution. When compared to controls, vermicompost substitutes reduced chickpea mortality significantly, but inhibition was much more efficient for treatments that included pre inoculation with nonconventional pesticides as foliar sprays against pathogen [47]. Vermicompost applications suppressed the tomato late blight caused by Phytophthora brassicae, Phytophthora nicotianae, and tomato Fusarium wilt produced by Fusarium lycopersici, as described by. Earthworm has stimulatory effect on soil microbial activities thus it suppressed the plant diseases more potentially than aerobic compost. There is a lot of research on the suppression effect of organic matter amendments in soils, with gratifying levels of reduction in plant parasitic nematode infestations. There are few scholarly publications on the suppressing effect of solid vermicomposts on numbers and outbreaks of plant parasitic nematodes relative to OM and thermophilic compost additives. Solid vermicompost applications for control of plant parasitic nematode populations have been studied [48]. Solid vermicomposts ranging from 2 to 8 kg ha−1 were applied to tomatoes, peppers, strawberries, and grapes in field treatments. They were able to suppress plant parasitic nematodes with great success. These researchers investigated the suppression capacity of plant parasitic nematodes in vermicomposts made from paper waste, food waste, and cattle manure under field circumstances and found considerable suppression.
5.6 Effect of vermicompost on bioremediation and detoxification of industrial wastes
Vermicompost has a greater importance in bioremediation and detoxification of industrial waste. Because of their robust metabolic system and the participation of earthworm gut bacteria and chloragocyte cells, earthworms have the potential to valorize and detoxification of heavy metals in industrial by-products. The majority of research found that vermicompost made from organic waste comprises greater concentrations of humic chemicals, which are important for plant growth [49]. Earthworm has a vast role in bioconversion of waste materials. Because of their robust metabolic system and participation of varied intestinal micro biota, enzymes, and chloragocyte cells that decrease hazardous forms to benign forms, earthworms have the ability to bio-convert and detoxify most heavy metals in industrial sludges (Table 6) [51].
Industry sludge type
Earthworm species used
Physico-chemical properties and heavy metals reduction
References
Sewage sludge derived biochar
Eisenia fetida
Biochar injected before composting lowered E. fetida’s bioavailability of Cd and Zn. Except for higher Cr concentrations, the biochar-added vermicomposts had good fertilizing capabilities.
Effect of different types of earthworm species on heavy metal reductions of industrial sludge.
6. Limitations of vermicompost
Vermicomposting is a time taking process. It requires almost 6-month for decomposing the organic wastes to prepare vermicompost.
In comparison to the traditional composting process, vermicompost requires higher maintenance.
Vermicompost may harbor pest and diseases as the temperature of vermicomposting pit have to be cool enough to support earthworm life.
7. Conclusion
Since vermicompost is organic in nature, it is not harmful for the environment. Vermicomposting process is also easy to operate and can be successfully prepared by unskilled small and marginal farmers. Amidst the environmental degradation and increasing food demand, vermicompost can be a solution. Although, its use alone in agriculture would not be able to meet the food demand but its use with chemical fertilizer through integrated manner can achieve sustainability in food production. The adoption rate of vermicompost is low and there is tendency of adopting vermicompost by female famers only. The potentiality of vermicompost is still not fully exploited yet. Hence, there is a need to appoint more extension worker to educate the farmers about vermicomposting and its benefits for achieving sustainability.
\n',keywords:"vermicompost, soil fertility, sustainability, earthworm, soil health",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/80406.pdf",chapterXML:"https://mts.intechopen.com/source/xml/80406.xml",downloadPdfUrl:"/chapter/pdf-download/80406",previewPdfUrl:"/chapter/pdf-preview/80406",totalDownloads:118,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:1,totalAltmetricsMentions:0,introChapter:null,impactScore:0,impactScorePercentile:0,impactScoreQuartile:0,hasAltmetrics:0,dateSubmitted:"January 3rd 2022",dateReviewed:"January 12th 2022",datePrePublished:"February 26th 2022",datePublished:"July 6th 2022",dateFinished:"February 8th 2022",readingETA:"0",abstract:"Agricultural production depends on so many things. Proper nutrient management is one of them. It becomes a trend to apply excess amount of fertilizer for enhancing productivity without considering its effect on soil health. Vermicomposting is a process of scientifically decomposing agricultural, municipality, and industrial wastes into nutrient enriched compost by earthworms. Vermicompost not only balance underground soil environment and makes is a suitable habitat for soil micro biota but also improves above ground environment. Microbes are the fundamental element of ecosystem. Use of vermicompost increases growth and proliferation of microbes that amplify environment’s betterment. Vermicomposting is also affordable for resource poor small and marginal farmers. Therefore, vermicompost use is more economical than synthetic organic fertilizer. So, economic viability, environmental stability, and enhancing livelihood quality are the major causes for its worldwide adoption in food production.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/80406",risUrl:"/chapter/ris/80406",book:{id:"11357",slug:"sustainable-crop-production-recent-advances"},signatures:"Priyanka Saha, Anamika Barman and Anurag Bera",authors:[{id:"448401",title:"Ms.",name:"Priyanka",middleName:null,surname:"Saha",fullName:"Priyanka Saha",slug:"priyanka-saha",email:"priyankasaha9933@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"451438",title:"Ms.",name:"Anamika",middleName:null,surname:"Barman",fullName:"Anamika Barman",slug:"anamika-barman",email:"anamika1998ubkv@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"451581",title:"Mr.",name:"Anurag",middleName:null,surname:"Bera",fullName:"Anurag Bera",slug:"anurag-bera",email:"anuragbera123@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Earth worm and its kind",level:"1"},{id:"sec_3",title:"3. General properties of vermicompost",level:"1"},{id:"sec_3_2",title:"3.1 Physical properties",level:"2"},{id:"sec_4_2",title:"3.2 Chemical properties",level:"2"},{id:"sec_5_2",title:"3.3 Biological properties",level:"2"},{id:"sec_7",title:"4. Preparation methods",level:"1"},{id:"sec_7_2",title:"4.1 Step by step of preparation methods",level:"2"},{id:"sec_9",title:"5. Beneficial effects of vermicompost",level:"1"},{id:"sec_9_2",title:"5.1 Effect of vermicompost on the soil physiochemical properties",level:"2"},{id:"sec_10_2",title:"5.2 Effect of vermicompost on the soil biological properties",level:"2"},{id:"sec_11_2",title:"5.3 Effect of vermicompost on the soil fertility",level:"2"},{id:"sec_12_2",title:"5.4 Effect of vermicompost on plant growth and development",level:"2"},{id:"sec_13_2",title:"5.5 Effect of vermicompost on plant diseases",level:"2"},{id:"sec_14_2",title:"5.6 Effect of vermicompost on bioremediation and detoxification of industrial wastes",level:"2"},{id:"sec_16",title:"6. Limitations of vermicompost",level:"1"},{id:"sec_17",title:"7. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'Grappelli A, Tomati U, Galli E. Earthworm casting in plant propagation. Horticultural Science. 1985;20(5):874-876'},{id:"B2",body:'Kale RD, Bano K. Field trials with vermicompost (vee comp. E.83 UAS) an organic fertilizer. 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Management of Sclerotium rolfsii with integration of non-conventional chemicals, vermicompost and Pseudomonas syringae. World Journal of Microbiology and Biotechnology. 2008;24(4):517-522'},{id:"B48",body:'Arancon NQ, Galvis P, Edwards C, Yardim E. The trophic diversity of nematode communities in soils treated with vermicompost: The 7th International Symposium on Earthworm Ecology·Cardiff·Wales 2002. Pedobiologia. 2003;47(5-6):736-740'},{id:"B49",body:'Bhat SA, Singh S, Singh J, Kumar S, Vig AP. Bioremediation and detoxification of industrial wastes by earthworms: Vermicompost as powerful crop nutrient in sustainable agriculture. Bioresource Technology. 2018;252:172-179'},{id:"B50",body:'Malińska K, Golańska M, Caceres R, Rorat A, Weisser P, Ślęzak E. Biochar amendment for integrated composting and vermicomposting of sewage sludge—The effect of biochar on the activity of Eisenia fetida and the obtained vermicompost. 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Division of Agronomy, ICAR-Indian Agricultural Research Institute, India
Department of Agronomy, Dr. Rajendra Prasad Central Agricultural University, India
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1. Introduction
Considered the second most commonly performed operation after cesarean section worldwide, hysterectomy may be classified as abdominal (laparotomy, laparoscopy, or robotic assistance) and vaginal (via an incision through the superior part of the vagina).
The most common indications for hysterectomy are benign conditions such as uterine fibroids, endometriosis, genital prolapse, pelvic pain, heavy menstrual bleeding, but the technique is also used for gynecological malignancy (usually ovarian, uterine, or cervical) and risk-reducing surgery (in cases of BRCA 1 or 2 mutations or Lynch syndrome) [1, 2, 3, 4].
Actually, there are three types of hysterectomy—total hysterectomy (the uterus and cervix are removed), subtotal or partial hysterectomy (the uterus is removed, but the cervix is left in place), and total hysterectomy with bilateral salpingo-oophorectomy (uterus, fallopian tubes, ovaries, and cervix are removed) [1, 2, 3, 4]. The term radical hysterectomy (removal of the uterus, cervix, parametrium, vaginal cuff, and fallopian tubes) is used to describe a wide range of procedures universally applicable to cervical cancer. However, the degree of radicality clearly depends on preoperative estimation of tumor location, surgical margins and the risk of occult lymphatic spread. Moreover, the ovaries may or may not be removed according to the patient age [1, 2, 3, 4]. In addition, supracervical hysterectomy is sometimes preferred to diminish the intraoperative complications and surgical times, as well as to limit the possibility of lower urinary tract issues and maintain normal sexual function [1, 2, 3, 4].
The best route for hysterectomy is multifactorial, depending not only on the surgeon’s skills and patient safety (minimally invasive procedures as vaginal, laparoscopic, laparoscopic-assisted, and robotic-assisted hysterectomies) but also on economic reasons [1, 2, 3, 4].
Hemorrhage after hysterectomy is recognized as an occasional life-threatening complication in modern gynecological surgery, assuming appropriate medical and surgical management [2, 3, 4, 5, 6, 7, 8, 9].
Classified as “reactionary” (postoperative bleeding within the first 24 hours following surgery) and secondary (bleeding occurring in the interval 3–22 days after surgery), unexpected hemorrhage may arise regardless of the route or subtype of hysterectomy [5, 6, 9]. Early recognition and prompt intervention (reoperation or arterial embolization) to arrest bleeding are essential strategies for the suitable outcome of the patient [2, 3, 4, 5, 6, 7, 8, 9, 10].
While the role of risk factors for “reactionary” hemorrhage is emerging and critical for a correct assessment of the patient, operative laparoscopy is still ideal to treat hemorrhage after vaginal hysterectomy, laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparotomy being necessary only in selected cases [2, 3, 4, 6, 9].
Secondary hemorrhage presents with varying degrees of severity and tends to be more common after laparoscopic hysterectomy, especially total laparoscopic hysterectomy than after the other hysterectomy approaches [5, 9]. Factors potentially responsible are vaginal vault infection, vault hematoma, a poor surgical technique including excessive thermal injury by electrocoagulation, and early resumption of physical activity, large uterus size, excessive use of an energy source for the uterine artery, and culdotomy [2, 3, 4, 5, 7, 9, 10].
Ultimately, the management of secondary hemorrhage is challenging and involves diverse approaches based on the exact cause of bleeding, comprising vaginal packing with or without vault suturing, laparoscopic coagulation of the uterine artery if the source of bleeding could not be identified vaginally or arterial embolization [6, 9, 10].
Because of elective gynecologic surgery, we encourage selective patients to donate their own blood before surgery [6, 11]. Several definitions are actually used:
autologous blood transfusion, when is done with the patient’s own blood; blood is stored and can be transfused during surgery;
homologous transfusion or transfusion from another woman;
parachute pack or umbrella pack is a useful tool for pelvic bleeding after pelvic exenteration;
peanut dissector; this tool is indicated for blunt pressure dissection of small places;
total blood volume; estimated blood volume of total body weight is 8% or 4.5–5.0 liters in the average women. When intraoperative blood loss exceeds 15% of the blood volume, blood transfusion must be taken into consideration in combating hypovolemic shock. About 15% of an adult blood volume can be calculated by amplification a patient’s weight in kg 10 times. The usual method of performing abdominal hysterectomy involved the use of clamps or forceps on vessels.
The present chapter will give an overview on different aspects of bleeding after hysterectomy such as incidence rate, risk factors, mechanisms, and management techniques aiming to expand our knowledge and skills in recognizing and treating this unexpected potentially serious complication. Furthermore, we intend to offer a guide toward standardizing treatment practice across bleeding issues following hysterectomy considering clear recommendations and algorithms.
2. Postoperative bleeding: Current trends/concepts
Postoperative hemorrhage represents a significant potential complication of contemporary gynecological surgery. Despite normal hemostasis, appropriate/suitable surgical technique and close monitoring, postoperative bleeding may occur, leading to the different clinical and operative scenarios and challenging even the most experienced operative team [2, 3, 4, 9, 11, 12].
2.1 Subtypes, incidence rate, location, predisposing factors, and complications
2.1.1 Postoperative bleeding subtypes
Based on their timing to surgery, two main subtypes of postoperative hemorrhage are actually recognized [5, 6, 7, 8, 9]:
subtype 1, early or reactionary postoperative gynecological hemorrhage where bleeding happens within the first 24 hours following surgery, commonly within the first 4–6 hours postoperative; early bleeding in modern gynecological surgery is reported irrespective of the route of intervention [6, 9];
subtype 2, delayed or secondary postoperative bleeding that develops in the interval 3–22 days after the surgery [5, 9]; secondary hemorrhage is rare and may arise more often after total laparoscopic hysterectomy than after other hysterectomy approaches [5].
2.1.2 Incidence rate of postoperative bleeding
Although the incidence of postoperative hemorrhage basically varies according to surgery, the difference between abdominal, laparoscopic, and vaginal hysterectomy remains statistically insignificant [5, 6, 7]. Indeed, some authors postulate that postoperative bleeding occurs more frequently after abdominal and laparoscopic than after vaginal hysterectomy, but overall, the incidence of hemorrhagic events after a hysterectomy varies from 0.2 to 3.1%, irrespective of surgical route [5, 6, 7, 8, 10, 13, 14].
On the other hand, the true frequency of delayed bleeding complications is still unknown, although the consequences can be particularly significant in women undergoing outpatient surgery [5, 6, 7, 8, 10, 13, 14]. Paul et al. reported an overall cumulative incidence of secondary hemorrhage after a total laparoscopic hysterectomy of 1.3% [5]. Although secondary hemorrhage is rare, it is more often reported after total laparoscopic hysterectomy than after other hysterectomy approaches [5, 6, 7, 8, 10, 13, 14].
Table 1 summarizes data on the incidence of postoperative hemorrhage reported by several authors.
Hemorrhage is responsible for about half of the postoperative complications following gynecological surgery, ranging from persistent venous oozing to massive blood loss from injury to retroperitoneal vessels [5, 6, 7, 12, 13].
Main bleeding sites comprise the anterior abdominal wall (both the suprapubic and the umbilical incision), the vaginal cuff (after laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy), and intraabdominal bleeding. Abdominal wall vessel injury occurs with increasing frequency, as the practice of laparoscopic surgery becomes wider and trocars become sharper [2, 3, 4, 7, 9].
The source of bleeding in secondary hemorrhage can be the uterine vessels or descending cervical/vaginal vessels; occasionally, uterine artery pseudoaneurysm can cause delayed heavy vaginal bleeding after laparoscopic hysterectomy [2, 3, 4, 7, 9]; additionally, the technique of vaginal vault closure may also contribute to the occurrence of secondary hemorrhage [5, 9].
Postoperative pelvic hematoma emerging after gynecological surgery may generate serious morbidity and impaired quality of life if large, infected, or incompletely resolved hematoma or hematoma with residual fibrosis and persistent pain [2, 3, 4, 9]. It usually develops above the vaginal vault, along the pelvic side-wall, retroperitoneal, in the paravesical space, in the abdominal wall as well as in the ischiorectal fossa and vulva [9]. According to its location, postsurgical hematoma may be recognized at routine abdominal and/or pelvic examinations in women with outstanding postoperative discomfort and unexpected anemia, but a definitive diagnosis can only be made by ultrasound or CT scan [5]. A simple or CT/ultrasound-guided or through abdominal incision drainage is commonly required to address the pelvic hematoma issue [2, 3, 4, 9].
Postoperative hemorrhage can result from failure to control vascular injury during surgery. Accurate clamp placement, gentle handling of tissues, and the accuracy of dissection are all important and contribute to maximum efficiency with minimum blood loss and minimum tissue damage when abdominal hysterectomy is performed [9].
The electrosurgical instrument can be used for a precise incision of the abdominal wall with minimal tissue injury. By holding the electrode close to the tissue or touching the metal clamp and pressing the coagulation button, superficial coagulation can be achieved [2, 3, 4, 9].
2.1.4 Predisposing factors
Intra- and post-operative bleeding generally develops in younger women or those with a more vascular pelvis who underwent a hysterectomy, especially laparoscopic hysterectomy in the presence of fibroids [6, 16].
Possible rationales for secondary hemorrhage comprise a bleeding vessel missed at the end of the procedure, effects of pneumoperitoneum, Trendelenburg position, low intraoperative pressure, wearing off the effect of vasopressin, subacute infection, postoperative analgesia, as well as bleeding disorders [2, 3, 4, 5, 7, 9].
Other potential factors accounting for delayed postsurgical bleeding are vaginal vault infection, vault hematoma, poor surgical technique with excessive thermal injury by electrocoagulation, and early resumption of physical activity [5, 7, 9]. A large-sized uterus, high vascularity, large-sized vessels, excessive use of an energy source for the uterine artery, and culdotomy also play a role in this hemorrhagic event [5, 7, 9].
2.1.5 Complications of bleeding
Most of the complications during or after hysterectomy are preventable or treatable. Other complications may exist as medical conditions before hysterectomy but are worsened during surgery, especially if not managed as part of holistic woman’s care.
Complications after surgery include [2, 3, 4, 9, 12]:
hemorrhage; occurs more often after laparoscopic hysterectomy as compared to vaginal surgery;
infections; occur more often after vaginal hysterectomy than keyhole surgery;
damage to internal organs such as bowel or urinary tract; the injury may occur to the ureter, bladder, or rectum and complications include incontinence, the urgency of urination, and infections;
vaginal cuff dehiscence; is more commonly reported in laparoscopic hysterectomy as compared to laparoscopic assisted procedures or vaginal hysterectomy;
anesthetic complications; smoking, obesity, and heart/lung infections are the most common causes of anesthetic complications;
ovarian failure; interruption to ovarian blood supply following removal of the uterus may precipitate the symptoms of menopause and lead to osteoporosis and ischemic heart disease;
low libido; the removal of the uterus may lead to less sexual enjoyment due to the loss of uterine contractions;
venous thromboembolism; prophylactic anticoagulants are associated with a lowering of the risk for such events;
depression; most of the women complain of feeling depressed because they have lost an important part of them.
In Romania, the mortality rate following a hysterectomy is very low.
Contemporary management of surgical interventions includes postoperative bleeding and the possibility of blood transfusion with risks of HIV transmission (in 1.9 million cases), the transmission of hepatitis B (one in every 180.000 cases), or a febrile reaction to transfusion (1% cases) [2]. Most experts recommend acute normovolemic hemodilution and cell salvage in women undergoing hysterectomy section who will not accept blood products.
Hypovolemic shock can occur after major bleeding as a direct result of uncontrolled hemorrhage. Depending on the total blood volume lost, hypovolemic shock may be divided into four classes: I (< 75 mL or 15%), II (750–1500 mL, or 15–30%), III (1500–2000 mL or 30–40%) and IV (>2000 mL or > 40%) [6].
The clinical manifestations of class I hypovolemia are not measurable and compensatory mechanisms restore plasma volume within a day. In class II hypovolemia, tachycardia is the most frequent clinical finding as a result of inadequate circulatory volume. The distinction between class I and II hypovolemic shock is made by recording blood pressure and pulse in the standing, sitting, or reclining position. Postural hypotension is observed as result of cardiac failure. Compensatory mechanisms begin to fail with the class III hypovolemic shock. This results in an increase in the arterial and venous oxygen difference with classic signs including worked tachycardia, tachypnea, oliguria, and cold skin. With the class IV hypovolemic shock, a patient’s survival depends on rapid transfusion of blood and immediate surgical intervention before cardiovascular collapse and death or organ system failure.
After initial resuscitative measures are instituted, it is highly recommended for patients to be carried out in a critical care unit. Use of sympathomimetic agents after sufficient hydration and vasodilator is normally preferred in the management of patients with hemorrhagic shock who have arterial pressure higher than 70 mm Hg.
Once restoration of the intravascular volume has been completed, it is important to reassess the patient’s response to blood transfusion when managing women with severe blood loss, especially in those patients who have pulmonary edema, myocardial infarction, or congestive heart failure [12].
Transfusion for patients with hemoglobin of 8–10 mg/dL is no longer recommended.
When major surgery is anticipated and transfusion is massive, platelets in addition to packed cell transfusion are required. It is recommended that cryoprecipitate be reserved for patients with deficiencies in von Willebrand factor, factor VIII, and fibrinogen factor XIII.
2.2 Management of postoperative hemorrhage
Recognized as an uncommon complication of hysterectomy, postoperative hemorrhage represents a true challenge in routine practice [8]; irrespective of the procedure, a close follow-up of the patient in a high-dependency unit is indicated in order to exclude recurrence of bleeding [6, 7].
The key to successful management is timely intervention meaning prompt diagnosis, urgent resuscitation if necessary and rapid decision for either arterial embolization or reoperation according to the severity of bleeding and the hemodynamic stability of the patient. Both techniques are highly effective to control bleeding; nevertheless, if the patient is hemodynamically unstable or of the interval since surgery is under 24 hours suggesting rapid hemorrhage, the emergency return to the operating theater to arrest the bleeding is preferred [6, 7, 9].
Current options for managing hemorrhage include [6, 7, 9]:
every patient should be carefully monitored postoperatively for signs of bleeding (hypotension, tachycardia, tachypnea, abdominal distension);
ultrasound can confirm intraperitoneal bleeding; more ways to determine intraabdominal hemorrhage include abdominal and pelvic CT scan; a routine coagulation profile should be done immediately for the patient with a rapid pulse, low blood pressure, and/or low urine output. The surgeon must take charge of the problem and execute the technical steps necessary to treat hemorrhagic shock in the operating room. Intraperitoneal bleeding can be hidden by incisional pain and analgesic medications. Despite adequate dissection, a small vessel may bleed or the suture may cut through tissue. Skeletonized vessels and small sutures should be used for significantly reducing the incidence of postoperative hemorrhage. Venous bleeding can be more life-threatening than arterial hemorrhage which can be clearly seen and controlled with fast small sutures or clamps.
the presence of unexpected drop in hematocrit or hemoglobin postoperatively.
A simplified algorithm to describe steps after gynecological surgery and potential post-surgery bleeding is provided in Figure 1.
Figure 1.
A simplified algorithm of post-surgery bleeding approach.
A closer look at the holistic management of postoperative blood should also underpin the following [9]:
to assess blood value and coagulation mechanisms;
to identify changes in the coagulation components, and to initiate replacement therapy in order to achieve adequate hemostasis. In assessing the patient’s coagulation status, it is very important to avoid such a situation known as the trauma triad of death consisting of—hypothermia, metabolic acidosis, and coagulopathy. In some patients with benign disease, blood transfusion is rarely indicated. Experience has shown that blood transfusion may be significant in women with malignant disease;
to establish the therapeutic strategy by measuring the level of prothrombin time < 14 sec, activated partial thromboplastin time (aptt) < 40 sec, fibrinogen >100 mg/dL, platelets >80 × 103 mL.
2.2.1 Reoperation
In hemodynamically unstable women (rapid pulse, falling blood pressure, with or without renal impairment) or if the bleeding occurs shortly in post-surgery (the so-called reactionary hemorrhage), it is desirable to return to the operating room [5, 6, 7, 8, 9].
A preoperative abdominal and pelvic ultrasound or CT scan is routinely required to visualize the source of bleeding as being intra- or retro-peritoneal, as well as adequate local examination without or under anesthesia. Moreover, the operative procedure should be mentally revised to identify any potential bleeding issue [9].
Surgical revision for postoperative bleeding may be performed transvaginally, laparoscopically, or both [5, 6, 7, 8, 9, 13, 14].
Postoperative hemorrhage from the vaginal vault recurrently originates from the vaginal artery in the lateral vaginal fornix or from one of its branches, since the lateral vaginal angle which includes the vaginal artery may not be accurately protected or turn into disligated [9, 13, 14]. Excessive vaginal bleeding needs to be objectively measured; since the vagina is a distensible organ, clots obstructing the vaginal introitus may lead to a large amount of blood accumulating and distending the vagina, subsequently covering the true significance of hemorrhage [9, 13, 14]. Vaginal bleeding can be controlled by clamping and ligating the bleeding point as well as by delayed-absorbable transfixion suturing of the vaginal mucosa and paravaginal tissue [9, 13, 14]. If such techniques are not enough or bleeding vessels have retracted, other tactics should be intended [8].
When no noticeable vaginal source, bleeding after abdominal or vaginal hysterectomy is traditionally treated by laparotomy or laparoscopy [7, 9]. While laparotomy is recommended in cases of intraperitoneal bleeding or unsuccessful conservative transvaginal treatment, operative laparoscopy is clearly indicated if the source of bleeding cannot be identified by the means of vaginal examination and/or if an intraabdominal bleeding source is suspected [7, 9, 13].
2.2.2 Laparotomy
Post-surgery bleeding requires laparotomy in two situations.
Firstly, if the surgical hemostasis cannot be achieved transvaginally, laparotomy may be necessary [9].
Secondly, if the patient underwent an abdominal hysterectomy, the incision should be reopened, succeeding the following steps (i) clots and blood evacuation from the abdomen and pelvic area; (ii) searching of the potential bleeding sites, commencing with the most expected places; (iii) ligating, suturing, or clipping of the identified bleeding sites; (iv) verifying the ureteral integrity as high risk of ureteral damage during reoperation; and (v) closing second time after a completely dry abdomen and pelvis [9].
2.2.3 Laparoscopy
The laparoscopic approach to postoperative bleeding following laparoscopic hysterectomy, vaginal hysterectomy, or laparoscopic-assisted vaginal hysterectomy is an attractive alternative to the abdominal surgical approach in the majority of patients [6, 7, 9, 13]. The procedure can be used to adequately evaluate the pelvis and the abdominal wall, which is occasionally the source of hemorrhage after laparoscopic hysterectomy. Moreover, whether the bleeding is from the abdominal wall, the surgical pedicles, or the vaginal cuff, it can be managed laparoscopically [8, 9]. Evidently, hemostasis can be more easily obtained in laparoscopic surgery because of magnification, close inspection, routine use of suction irrigation, and bipolar coagulation [7, 9]. Besides, bipolar coagulation, a Foley catheter introduced in the port-site bleeding, or a collagen-fibrin agent can be used to achieve local hemostasis during laparoscopy [7, 9].
Following laparoscopic irrigation/suction using Ringer’s solution to clear the operative field, a combination of laparoscopic suturing using absorbable suture material and laparoscopic bipolar coagulation is commonly recommended [6, 8, 9]. Also, electrosurgery is effective in controlling bleeding during laparoscopic surgery. Furthermore, different forms of fibrin adhesive are tested in gynecologic open surgery in order to stop oozing hemorrhages after primary hemostatic treatment with a high efficacy rate (98%) [6]. Holub and Kliment reported successful treatment of hemorrhage from damaged tissue near important pelvic structures using the laparoscope to apply collagen fleece combined with fibrin glue [7, 17].
To avoid further risk of injury to the abdominal wall and to improve the recovery time from surgery, single incision laparoscopic surgery is a viable option for the management of hemorrhage, particularly for those patients whose original surgery was accomplished via single incision laparoscopic surgery. Curlin et al. reported a case where single incision laparoscopy was used to manage postoperative hemorrhage after total laparoscopic hysterectomy with right salpingectomy and left salpingo-oophorectomy [8].
2.3 Arterial embolization
Conversely, if the patient is reasonably stable and there is not abrupt early bleeding (based on the volume of blood in the abdomen or retroperitoneal space as estimated by ultrasound and the time from surgery), it seems realistic to try to identify the bleeding artery and embolize it by transcatheter interventional radiological techniques [2, 3, 4, 9, 10].
Arterial embolization remains an important minimally invasive option for the management of delayed postoperative hemorrhage [2, 3, 4, 8, 9, 18]. Transcatheter arterial embolization has been shown to be an effective tool for the management of postoperative hemorrhage after gynecologic laparoscopy, but also after abdominal and vaginal hysterectomy [8, 9]. Selective angiographic arterial embolization is a quite simple and safe procedure with a clinical success rate up to 90% in routine practice and usually a low complication rate less than 10%, including a mild postembolization syndrome with pain, fever, high leucocyte count related to vascular thrombosis and tissue necrosis [8, 9]. Bladder necrosis, vesicovaginal fistula, neuropathies as well as renal toxicity are uncommon, isolated side effects [9].
Arterial embolization technique comprises the following main steps—(i) identification of the site of bleeding by angiofluoroscopy if more than 2–3 mL/min bleeding rate; (ii) percutaneous catheterization of the femoral artery or, uncommonly, brachial artery under local anesthesia with retrograde direct access to the hypogastric artery; (iii) canulation of the hypogastric artery or specific collateral vessel if appropriate; (iv) injection of the embolization material under angiographic observation (metal coins, autologous clot, small pieces of gelfoam, small silastic spheres, subcutaneous tissue, or other hemostatic materials; (v) repeat angiography to demonstrate the occlusion of the bleeding vessel; (vi) remove of the catheter followed by careful monitoring for further bleeding [8, 9, 10].
Although second surgery is often the initial choice for postoperative hemorrhage, for a patient who is hemodynamically stable but is experiencing postoperative hemorrhage, transcatheter arterial embolization is a welcome alternative to a second surgery [8, 9]. However, if rapid access to interventional radiology is not available or if transcatheter arterial embolization is unsuccessful, laparoscopy can still be considered [8, 9]. Besides, a potential advantage of surgical management of postoperative hemorrhage over transcatheter arterial embolization is the ability to evacuate the hemoperitoneum, which may decrease postoperative pain, the risk of infection, and the risk of ileus [8, 9].
3. Recommendations for managing postoperative bleeding in gynecological surgery
It is typical to expect some bleeding after hysterectomy in the 6–8 weeks following the procedure; the discharge may be red, brown, or pink. Bleeding should steadily decrease in the days and weeks following the surgery and should never be excessive at any point of recovery [18]. The exception is menstruation in women who have undergone a subtotal hysterectomy [18, 19]. In case of bleeding after hysterectomy, it is more likely to be of some pathologic cause instead of menstruation which needs to be ruled out [19].
However, a sudden and significant increase in bleeding during recovery should be considered abnormal. Points of concern comprise but are not limited to—bright red vaginal bleeding (indicating active bleed), temperature over 100.4°F, severe nausea or vomiting, increasing pelvic pain, a local complication such as redness, swelling, or drainage at the incision site as well as difficulty in urinating or pain with urination suggesting either an infection or a neurogenic bladder [18].
Delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy usually requires emergent reoperation. Several studies have described continued cyclical bleeding from the cervical stump after supracervical hysterectomy in 0–25% of cases [20].
Effective interventions addressing hemorrhage after hysterectomy are needed to reduce women’s mortality worldwide.
3.1 Recommendations
Counseling
Prior to hysterectomy, these women should be offered specific counseling and have a prospective plan for the management of their disease, developed by gynecologists of how their condition and hysterectomy interact. Prehysterectomy counseling services starting for all women planning this surgical intervention are a key part of hospital services and should be an integral part of the local health services network. They could be provided by general practitioners or specialist clinicians or surgeons, all of whom should be suitably trained or may require different management or specialized services before hysterectomy. There are special circumstances as congenital or acquired coagulation disorders that should be considered to evaluate by a thorough history and lab tests.
Professional interpretation services for women who do not speak English.
It is not clear how much the specific medical terminology is conveyed to the patient. Healthcare providers have to invest in technology, security, specialists, and translators to ensure healthcare becomes world-class. Medical tourism is growing each year. Romania provides the highest quality healthcare at the lowest price. Also, the cost of hysterectomy in Romania is lower than the same treatment in UK or UE. In developed countries as the USA, UE countries or Canada patients have to wait a long time for major surgeries. The cost involved in treating a patient depends upon factors like—type of hysterectomy needed, hospital and physician selected for it, and duration of staying.
Communication and referrals among professionals.
Good communication among professionals is essential. Referral between specialties involved should be rapid. They can use a variety of communication methods including—mobile phone, email, fax, Whatsapp, Instagram, Tik Tok, Facebook, etc. In many cases, junior trainees in the front line did not have proper support and need to have clear guidelines about when to seek senior help.
Women with serious medical conditions
They require immediate and appropriate multidisciplinary specialist care; women will require referral to tertiary or specialist medical centers for their preexisting medical or mental conditions before hysterectomy. Conditions that require prehysterectomy counseling and advice include—epilepsy, diabetes, asthma, congenital or known acquired cardiac disease, autoimmune disorders, renal and liver disease, obesity (BMI > 30), severe mental illness, or psychiatric conditions that require a change of medication, HIV infection. Women with potential serious underlying preexisting medical on mental health conditions should be immediately referred to appropriate specialist centers of expertise as soon as their symptoms develop.
Clinical training
All clinical staff must undertake regular training for the identification and management of serious disease conditions or potential emergencies or signs and symptoms of potentially life-threatening conditions, circulatory failure, severe hypertension or major hemorrhage, pyrexia >38°C, tachycardia >100 bpm, breathlessness. The local clinicians may be excellent at the management of severely ill women but must also accept written, documented, and audited courses. There should be a well-trained team of doctors for recording and charting investigations performed, obtaining quick results, ensuring that abnormal results are followed up promptly and have resulted in a better outcome.
Identifying and managing very sick women with critical illness before, during or after hysterectomy
In very acute situations, a team approach can be very healthful. The management of patients with an acute severe illness with circulatory failure, arterial hypertension, and major hemorrhage requires a team approach and help from the anesthetic and critical care services. There are some healthcare professionals who failed to manage crisis situations outside their immediate area of expertise; therefore, it is crucial to recognize their limitations and to know when and whom to call for another opinion once the patient was admitted to the hospital.
Coagulation factors, hematocrit, serum calcium, glucose, and electrolytes could be assessed every 120 minutes or after 10 U of transfusion; these lab tests are very helpful for the diagnosis of postoperative bleeding.
RCOG guidelines of the responsibilities of the consultant on call should be followed.
Bilateral hypogastric artery ligation can reduce blood loss to a minimum during hysterectomy [9].
Hypotensive anesthesia is also a safe and effective technique in reducing the circulation to the operative field [9].
Serious incident and women death reporting
Health professionals, senior or junior, must recognize an act on the signs and symptoms of potentially life-threatening conditions.
The evaluation of such a report must include clinicians from relevant disciplines (including anesthetics) who were not involved with the deaths. This report is recommended to be a requirement in the future.
The identification and act on women’s death should be reviewed as a serious incident and disseminated to all health professionals, junior or senior. Women’s deaths are generally underreported because of incorrect classification of cause.
Fatal hemorrhage can result from laceration of the external iliac vein or the hypogastric vein where they join together which are at risk of injury when the surgeon dissects between the distal common iliac artery, the psoas muscle, and the area of lumbosacral nerve trunks [9]. These vessels cannot be clamped and ligated with clips or sutures [9].
Dissection around the aorta and vena cava done with inadequate exposure performed in order to remove lymph nodes around them can result in serious hemorrhage. Bleeding usually can be avoided by placing a finger over the laceration and a vascular needle is used to close the laceration from side to side. The same technique may be used for common and external iliac veins [9].
Also, bleeding can occur by dissecting pararectal space and presacral space as well as obturator fossa [9].
Pathology
Patient death autopsy must be improved and require more expertise.
In Romania, the number of women death after hysterectomy (death rate) is very small and many of the autopsies reviewed were considered adequate. When an autopsy is needed, the body can be taken to another area for more expert examination. Despite evaluation by many examiners in the different specialties, the final diagnosis could not be resolved because of inadequate clinical data, poor autopsy quality, or the unmanageable nature of some death.
4. Conclusion
The lack of routine observation in the postoperative period or a failure to appreciate blood loss or recognition of abnormal vital signs such as oxygen saturation and respiratory rate can lead to death after hysterectomy. The patient should be evaluated before hysterectomy for risk factors and the medical conditions of the women should be diagnosed by a careful history and lab tests in order to decrease the possibility of hemorrhage.
The risks of blood transfusion, the transmission of HIV or hepatitis B should be discussed before surgical procedure.
The peace of surgical intervention should be governed by good exposure of the tissue, accuracy of dissection, and clamping or suturing the vessels in a precise manner. The skills and experiences of the surgeon without wasting time with unnecessary hesitation or indecision will reduce the risk of uncontrolled hemorrhage after a hysterectomy.
The surgeon should control the life-threatening hemorrhage by judgment, knowledge, and technical skills. The patient’s medical history for vital signs, blood loss volume, and levels of coagulation factors will determine how quickly blood transfusion is initiated. Careful postoperative clinical evaluation of the patient by the surgeon and surgical team with abdominal or pelvic ultrasound or CT scanning will help to prevent or minimize significant blood loss after hysterectomy and localize the site of bleeding.
Acknowledgments
No funding was received for this chapter.
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Recommendations for managing postoperative bleeding in gynecological surgery",level:"1"},{id:"sec_14_2",title:"3.1 Recommendations",level:"2"},{id:"sec_16",title:"4. Conclusion",level:"1"},{id:"sec_17",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'Dawood AS, Elbohoty SB, Abbas AM, Elgergawy AE. Colpotomizer-assisted total abdominal hysterectomy (CATAH Technique): A new technique for uterine removal in benign pathologies. Gynecology and Minimally Invasive Therapy. 2021;10(2):109-113'},{id:"B2",body:'Jones HW III, Hysterectomy A. In: Rock J, Jones H III, editors. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 727-744'},{id:"B3",body:'Kovac RS. Vaginal Hysterectomy. In: Rock J, Jones H III, editors. TeLinde’s operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 744-763'},{id:"B4",body:'Howarsd F. Laparoscopic Hysterectomy. In: Rock J, Jones H III, editors. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 763-776'},{id:"B5",body:'Paul PG, Prathap T, Kaur H, et al. Secondary hemorrhage after total laparoscopic hysterectomy. JSLS. 2014;18(3):e2014.00139. DOI: 10.4293/JSLS.2014.00139'},{id:"B6",body:'Erian M, Mc Laren G, Khalil A. Reactionary hemorrhage in gynecological surgery. JSLS. 2008;12(1):81-84'},{id:"B7",body:'Holub Z, Jabor A. Laparoscopic management of bleeding after laparoscopic or vaginal hysterectomy. JSLS. 2004;8(3):235-238'},{id:"B8",body:'Curlin H, Scheib S. Single incision laparoscopy for the management of postoperative hemorrhage. JSLS. 2012;16(3):478-480'},{id:"B9",body:'Jones HW III, Rock WA Jr. Control of pelvic hemorrhage. In: Rock J, Jones H III, editors. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 371-394'},{id:"B10",body:'Takeda A, Koyama K, Mori M, Sakai K, Mitsui T, Nakamura H. Diagnostic computed tomographic angiography and therapeutic emergency transcatheter arterial embolization for management of postoperative hemorrhage after gynecologic laparoscopic surgery. Journal of Minimally Invasive Gynecology. 2008;15:332-341'},{id:"B11",body:'Katz VL. Preoperative counseling and management – patient evaluation, informed consent, infection prophylaxis, avoidance of complications. In: Katz V, Lentz G, Lobo R, Gershenson D, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby Elsevier; 2007'},{id:"B12",body:'Katz VL. Postoperative counseling and management – fever, respiratory, cardiovascular, thromboembolic, urinary tract, gastrointestinal, wound, operative site, neurologic injury, psychological sequelae. In: Katz V, Lentz G, Lobo R, Gershenson D, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby Elsevier; 2007'},{id:"B13",body:'Wilke I, Merker A, Schneider A. Laparoscopic treatment of hemorrhage after vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH). Surgical Endoscopy. 2001;15(10):1144-1146'},{id:"B14",body:'Yamashita Y, Harada M, Yamamoto H, et al. Transcatheter arterial embolization of obstetric and gynaecologic bleeding: Efficacy and clinical outcome. The British Journal of Radiology. 1994;67:530-534'},{id:"B15",body:'Makinen J, Johansson J, Tomas C, et al. Morbidity of 11 110 hysterectomies by type of approach. Human Reproduction. 2001;16:1473-1478'},{id:"B16",body:'McPherson K, Metcalfe MA, Herbert A, et al. Severe complications of hysterectomy: The VALUE study. BJOG: An International Journal of Obstetrics and Gynaecology. 2004;111(7):688-694'},{id:"B17",body:'Holub Z, Kliment L. The effectiveness of collagen fleece combined with a fibrin glue in hemostasis during laparoscopic surgery. Journal of Gynecologic Surgery. 1999;15:185-191'},{id:"B18",body:'Whitlock J. Bleeding after a hysterectomy. Available from: https://www.verywellhealth.com/bleeding-after-a-hysterectomy-3156906 [Accessed: October 15, 2021]'},{id:"B19",body:'Lyngdoh BT, Kriplani A, Garg P, et al. Post-hysterectomy menstruation: A rare phenomenon. Archives of Gynecology and Obstetrics. 2010;281:307-309. DOI: 10.1007/s00404-009-1173-2'},{id:"B20",body:'Holloran-Schwartz MB, Potter SJ, Kao MS. Massive delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy. Case report. Case Reports in Obstetrics and Gynecology. 2012;2012:871041. DOI: 10.1155/2012/871041'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Eugen Ancuța",address:"eugen01ro@yahoo.com",affiliation:'
Research Department, “Elena Doamna” Obstetrics and Gynecology Clinical Hospital, Romania
University of Medicine and Pharmacy “Grigore T. Popa”, Romania
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IntechOpen’s Academic Editors and Authors have received funding for their work through many well-known funders, including: the European Commission, Bill and Melinda Gates Foundation, Wellcome Trust, Chinese Academy of Sciences, Natural Science Foundation of China (NSFC), CGIAR Consortium of International Agricultural Research Centers, National Institute of Health (NIH), National Science Foundation (NSF), National Aeronautics and Space Administration (NASA), National Institute of Standards and Technology (NIST), German Research Foundation (DFG), Research Councils United Kingdom (RCUK), Oswaldo Cruz Foundation, Austrian Science Fund (FWF), Foundation for Science and Technology (FCT), Australian Research Council (ARC).
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Open Access publication costs can often be designated directly in the grants or in specific budgets allocated for that purpose. Many of the most important funding organisations encourage, and even request, that the projects they fund are made available at no cost to the wider public. IntechOpen strives to maintain excellent relationships with these funders and ensures compliance with mandates.
\n\n
In order to help Authors identify appropriate funding agencies and institutions, we have created a list, based on extensive research on various OA resources (including ROARMAP and SHERPA/JULIET) of organizations that have funds available. Before consulting our list we encourage you to petition your own institution or organization for Open Access funds or check the specifications of your grant with your funder to ascertain if publication costs are included. Where you are in receipt of a grant you should clarify:
\n\n
\n\t
Does your institution already have a budget for covering Open Access publication costs?
\n\t
Does your grant list Open Access publication fees as legitimate direct/indirect costs?
\n
\n\n
If you are associated with any of the institutions in our list below, you can apply to receive OA publication funds by following the instructions provided in the links. Please consult the Open Access policies or grant Terms and Conditions of any institution with which you are linked to explore ways to cover your publication costs (also accessible by clicking on the link in their title).
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Catarina Guedes and F. Xavier Malcata",authors:[{id:"83136",title:"Prof.",name:"F. Xavier",middleName:null,surname:"Malcata",slug:"f.-xavier-malcata",fullName:"F. 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Labella, C. Berbel, M. Manchado, D. Castro and J.J. Borrego",authors:[{id:"67855",title:"Prof.",name:"Juan J.",middleName:null,surname:"Borrego",slug:"juan-j.-borrego",fullName:"Juan J. Borrego"},{id:"71146",title:"Dr.",name:"Alejandro",middleName:null,surname:"Labella",slug:"alejandro-labella",fullName:"Alejandro Labella"},{id:"71148",title:"Dr.",name:"Concepcion",middleName:null,surname:"Berbel",slug:"concepcion-berbel",fullName:"Concepcion Berbel"},{id:"71149",title:"Dr.",name:"Manuel",middleName:null,surname:"Manchado",slug:"manuel-manchado",fullName:"Manuel Manchado"},{id:"71151",title:"Dr.",name:"Dolores",middleName:null,surname:"Castro",slug:"dolores-castro",fullName:"Dolores Castro"}]}],mostDownloadedChaptersLast30Days:[{id:"35141",title:"Antibiotics in Aquaculture – Use, Abuse and Alternatives",slug:"antibiotics-in-aquaculture-use-abuse-and-alternatives",totalDownloads:19357,totalCrossrefCites:138,totalDimensionsCites:293,abstract:null,book:{id:"2052",slug:"health-and-environment-in-aquaculture",title:"Health and Environment in Aquaculture",fullTitle:"Health and Environment in Aquaculture"},signatures:"Jaime Romero, Carmen Gloria Feijoo and Paola Navarrete",authors:[{id:"72898",title:"Dr.",name:"Jaime",middleName:null,surname:"Romero",slug:"jaime-romero",fullName:"Jaime Romero"},{id:"79684",title:"Dr.",name:"Paola",middleName:null,surname:"Navarrete",slug:"paola-navarrete",fullName:"Paola Navarrete"},{id:"83411",title:"Dr.",name:"Carmen",middleName:null,surname:"Feijoo",slug:"carmen-feijoo",fullName:"Carmen Feijoo"}]},{id:"69948",title:"Floating Cage: A New Innovation of Seaweed Culture",slug:"floating-cage-a-new-innovation-of-seaweed-culture",totalDownloads:974,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Eucheumatoid cultivation continues to expand with a variety of methods that can increase production. This chapter will discuss an innovation in seaweed cultivation of the genus Eucheuma, which is the prime marine commodity in the tropical regions of the world. Research conducted during 2015-2017 and 2019 in Southeast Sulawesi Province, Indonesia, provided an overview of the use of floating cage that showed very significant growth results. The research result showed that the growth rates of Eucheuma denticulatum and Kappaphycus alvarezii in floating cage seemed faster and resulted in better thallus morphology. Daily production of E. denticulatum and K. alvarezii that were cultivated in floating cage was higher than daily production of E. denticulatum and K. alvarezii cultivated on longline. Specific growth rate (SGR) of E. denticulatum and K. alvarezii cultivated by using floating cage method was also higher than E. denticulatum and K. alvarezii cultivated by using longline method. Moreover, the cultivation by using floating cages produces good growth rates with no effect of herbivore attacks.",book:{id:"8928",slug:"emerging-technologies-environment-and-research-for-sustainable-aquaculture",title:"Emerging Technologies, Environment and Research for Sustainable Aquaculture",fullTitle:"Emerging Technologies, Environment and Research for Sustainable Aquaculture"},signatures:"Ma’ruf Kasim, Abdul Muis Balubi, Ahmad Mustafa, Rahman Nurdin, Rahmad Sofyan Patadjai and Wardha Jalil",authors:[{id:"309893",title:"Prof.",name:"Maruf",middleName:null,surname:"Kasim",slug:"maruf-kasim",fullName:"Maruf Kasim"},{id:"313040",title:"MSc.",name:"Abdul Muis",middleName:null,surname:"Balubi",slug:"abdul-muis-balubi",fullName:"Abdul Muis Balubi"},{id:"313041",title:"MSc.",name:"Wardha",middleName:null,surname:"Jalil",slug:"wardha-jalil",fullName:"Wardha Jalil"},{id:"313042",title:"MSc.",name:"Ahmad",middleName:null,surname:"Mustafa",slug:"ahmad-mustafa",fullName:"Ahmad Mustafa"},{id:"313043",title:"MSc.",name:"Rahman",middleName:null,surname:"Nurdin",slug:"rahman-nurdin",fullName:"Rahman Nurdin"},{id:"313044",title:"MSc.",name:"Rahmat Sofyan",middleName:null,surname:"Patadjai",slug:"rahmat-sofyan-patadjai",fullName:"Rahmat Sofyan Patadjai"}]},{id:"62842",title:"Integrated Rice and Aquaculture Farming",slug:"integrated-rice-and-aquaculture-farming",totalDownloads:1919,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"The burning problems like scarcity of food for ever-growing human population in the present world are addressed by adapting various methods for production of protein, carbohydrate, oils and other food materials. One of the methods to produce high amount of food is integrated farming including rice-aquaculture farming, which produces protein and carbohydrate as major components besides others. Rice-aquaculture farming produces grain (carbohydrate) and animal protein without affecting the quality and quantity of rice yield on the same piece of land and renders additional financial gain besides main crop (rice) like conventional monoculture. The aquatic species grown in the integrated culture are mainly distinct types of fishes, selected crustaceans and other selected species. Profitable rice-aquaculture integrated farming is popular in Asian countries than in Western countries. However, the integrated rice-aquaculture farming has its own limitations. The type of methods, culture species, influencing factors, and pros and cons of rice-aquaculture integrated farming are discussed in the present chapter.",book:{id:"7229",slug:"aquaculture-plants-and-invertebrates",title:"Aquaculture",fullTitle:"Aquaculture - Plants and Invertebrates"},signatures:"Pamuru Ramachandra Reddy and Battina Kishori",authors:[{id:"242524",title:"Dr.",name:"Ramachandra Reddy",middleName:null,surname:"Pamuru",slug:"ramachandra-reddy-pamuru",fullName:"Ramachandra Reddy Pamuru"},{id:"255022",title:"Dr.",name:"Kishori",middleName:null,surname:"Battina",slug:"kishori-battina",fullName:"Kishori Battina"}]},{id:"24074",title:"Embryonic and Larval Development of Freshwater Fish",slug:"embryonic-and-larval-development-of-freshwater-fish",totalDownloads:7466,totalCrossrefCites:1,totalDimensionsCites:2,abstract:null,book:{id:"612",slug:"recent-advances-in-fish-farms",title:"Recent Advances in Fish Farms",fullTitle:"Recent Advances in Fish Farms"},signatures:"Faruk Aral, Erdinç Şahınöz and Zafer Doğu",authors:[{id:"25600",title:"Prof.",name:"Faruk",middleName:null,surname:"Aral",slug:"faruk-aral",fullName:"Faruk Aral"},{id:"29132",title:"Dr.",name:"Zafer",middleName:null,surname:"Dogu",slug:"zafer-dogu",fullName:"Zafer Dogu"},{id:"39952",title:"Dr.",name:"Erdinc",middleName:null,surname:"Sahinoz",slug:"erdinc-sahinoz",fullName:"Erdinc Sahinoz"}]},{id:"68966",title:"Novel Biofloc Technology (BFT) for Ammonia Assimilation and Reuse in Aquaculture In Situ",slug:"novel-biofloc-technology-bft-for-ammonia-assimilation-and-reuse-in-aquaculture-in-situ",totalDownloads:1951,totalCrossrefCites:2,totalDimensionsCites:8,abstract:"Ammonia is one of the most harmful risks for success of fish and shrimp culture. There is no effective solution for harmlessness of ammonia in traditional aquaculture operations except exchanging water, which would bring negative effects on environment, or fixing expensive equipment. Biofloc technology (BFT) that appeared in recent years supplies a novel solution for this issue without exchanging huge water and fixing equipment. This technology could assimilate ammonia almost in real time with many other supplemental benefits. Because of the very high nutritional value for fish and shrimp, bioflocs, the by-product of BFT, could also be reused as a complemented food in situ or a gradient for feedstuff to replace expensive fishmeal or be processed to pellet diet to feed fish and shrimp directly. 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The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"24",title:"Sustainable Development",doi:"10.5772/intechopen.100361",issn:"2753-6580",scope:"
\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
\r\n
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\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
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\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
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\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
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\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
\r\n
\r\n\t
\r\n
\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
\r\n
\r\n\t
\r\n
\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
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\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
",coverUrl:"https://cdn.intechopen.com/series/covers/24.jpg",latestPublicationDate:"August 2nd, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:1,editor:{id:"262440",title:"Prof.",name:"Usha",middleName:null,surname:"Iyer-Raniga",slug:"usha-iyer-raniga",fullName:"Usha Iyer-Raniga",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRYSXQA4/Profile_Picture_2022-02-28T13:55:36.jpeg",biography:"Usha Iyer-Raniga is a professor in the School of Property and Construction Management at RMIT University. Usha co-leads the One Planet Network’s Sustainable Buildings and Construction Programme (SBC), a United Nations 10 Year Framework of Programmes on Sustainable Consumption and Production (UN 10FYP SCP) aligned with Sustainable Development Goal 12. The work also directly impacts SDG 11 on Sustainable Cities and Communities. She completed her undergraduate degree as an architect before obtaining her Masters degree from Canada and her Doctorate in Australia. 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