Pregnancy with sigmoid volvulus: A case report with literature review.

Sigmoid volvulus refers to torsion of a segment of the alimentary tract, which often leads to bowel obstruction and ischemic changes. Sigmoid volvulus is an acute surgical emergency because delay in diagnosis and management can cause adverse maternal and fetal complications. Sigmoid volvulus typically presents with acute-on-chronic abdominal distension that may develop slowly over 3-4 days. An early and effective resuscitation with fluid replacement, electrolyte balance correction, prophylactic antibiotics and nasogastric decompression is necessary. The standard goals of treatment are to relieve the obstruction, avoid colonic ischemia, and prevent recurrence either by endoscopic decompression or resection with primary anastomosis. A pregnant woman with sigmoid volvulus at 34 weeks and 1 day of gestation presented to our hospital with abdominal pain, vomiting, and constipation. The patient was jointly surgically managed with laparotomy, cesarean section, and detorsion of the sigmoid volvulus, and was discharged in a healthy state on the 5th postoperative day.

A study of post-caesarean section wound infections in a regional referral hospital, oman.

OBJECTIVES: The aim of this study was to determine the incidence of surgical site infections (SSI) in patients undergoing a Caesarean section (CS) and to identify risk factors, common bacterial pathogens and antibiotic sensitivity. SSI significantly affect the patient's quality of life by increasing morbidity and extending hospital stays. METHODS: A retrospective cross-sectional study was conducted in Nizwa Hospital, Oman, to determine the incidence of post-Caesarean (PCS) SSI from 2001 to 2012. This was followed by a case-control study of 211 PCS cases with SSI. Controls (220) were randomly selected cases, at the same hospital in the same time period, who had undergone CS without any SSI. Data was collected on CS type, risk factors, demographic profile, type of organism, drug sensitivity and date of infection. RESULTS: The total number of PCS wound infections was 211 (2.66%). There was a four-fold higher incidence of premature rupture of the membranes (37, 17.53%) and a three-fold higher incidence of diabetes (32, 15.16%) in the PCS cases compared with controls. The most common organisms responsible for SSI were Staphylococcus aureus (66, 31.27%) and the Gram-negative Escherichia coli group (40, 18.95%). The most sensitive antibiotics were aminoglycoside and cephalosporin. Polymicrobial infections were noted in 42 (19.90%), while 47 (22.27%) yielded no growth. A high incidence of associated risk factors like obesity, hypertension, anaemia and wound haematoma was noted. CONCLUSION: Measures are recommended to reduce the incidence of SSI, including the implementation of infection prevention practices and the administration of antibiotic prophylaxis with rigorous surgical techniques.

Giant placental chorioangioma with intrauterine fetal death.

Chorioangioma of the placenta is a common benign vascular tumour of the placenta consisting of blood vessels and stroma. Most of these tumours are small and have no adverse impact on the fetus. Large tumours are associated with complications affecting mother and the fetus which may cause intrauterine fetal death. Chorioangiomas probably act as peripheral shunts between arteries and veins (arteriovenous shunts) leading to progressive heart failure of the fetus. Prenatal diagnosis is achieved by ultrasonography and Doppler studies will confirm the highly vascular nature of the mass. As the tumour is associated with unfavourable effects on the mother and fetus like polyhydramnios, prematurity, toxaemia, hydrops and fetal heart failure pregnancy needs to have regular surveillance to detect and manage complications early. A case of giant placental chorioangioma in a primigravida associated with intrauterine fetal death at 30 weeks of gestation is reported.

Informed consent in clinical practice and literature overview.

Informed consent is a legal requirement to be fulfilled before any procedure is carried out in clinical practice. It has wide ramification and different interpretations in the present healthcare system. Free and informed consent is required for medical treatments and procedures, except in an emergency situation when informed consent cannot be obtained and there is no indication that a reasonable patient would refuse consent to treatment. Increasing litigations and other ethical considerations have prompted us to review this subject with a review of literature on subject and inferences by different experts in this field.

Ruptured rudimentary horn at 22 weeks.

Rudimentary horn is a developmental anomaly of the uterus. Pregnancy in a non-communicating rudimentary horn is very difficult to diagnose before it ruptures. A case of undiagnosed rudimentary horn pregnancy at 22 weeks presented to Nizwa regional referral hospital in shock with features of acute abdomen. Chances of rupture in first or second trimester are increased with catastrophic haemorrhage leading to increased maternal and perinatal morbidity and mortality. Management of such cases is a challenge till today due to diagnostic dilemma. Expertise in ultrasonography and early resort to surgical management is life saving in such cases.

Methotrexate treatment of ectopic pregnancy: experience at nizwa hospital with literature review.

OBJECTIVES: Ectopic pregnancy occurs when the embryo fails to implant within the uterine cavity. Methotrexate, a folic acid antagonist has been widely used to treat ectopic pregnancy. The aim of this study is to determine the efficacy of methotrexate treatment for ectopic pregnancies in our settings which will in-turn help us reduce maternal mortality and morbidity. METHODS: This was a retrospective review of 60 cases of ectopic pregnancy treated with single dose methotrexate in Nizwa hospital, Oman. Demographic data, clinical presentation, treatment progress, outcome, side effects and future fertility follow up were analysed using a computer database. Selection criteria included hemodynamically stable women with ß-hcg level of ≤5000 mIU/ml, adnexal mass ≤4 cm, absent cardiac activity and hemoperitoneum less than 100 ml. Human chorionic gonadotrophin (hcg) assay and clinical presentation were used to determine cases which warranted surgical intervention. RESULTS: The success rate of single dose methotrexate therapy in our study was 65% (n=39) and 35% (n=21) required surgical intervention compared to reported success rate of 67-100% published in various studies. Careful selection of cases and confining strictly to the criteria improved the success rate from 40% to 60% in five and half years of the study. The mean average time of resolution of ectopic pregnancy was 32 days for a single dose and 58 days for repeat second or third doses. Eight cases of pregnancy of unknown location were treated successfully with Methotrexate. No major side effects were noted. A successful fertility outcome of 30% in the first year followed by 13.3% in the subsequent second year with a secondary infertility rate of 11.6% was observed in this study. CONCLUSION: Methotrexate treatment of ectopic pregnancies is safe and effective with no major side effects. Intramuscular methotrexate has the advantage of tubal conservation and saves patients from requiring surgery. It is easier to administer than intraoperative route, which is by laparoscopy and needs expertise. Our study showed single dose methotrexate to be an effective treatment option for selected patients with unruptured tubal ectopic pregnancy.

Uterus didelphys with obstructed right hemivagina, ipsilateral renal agenesis and right pyocolpos: a case report.

Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis (OHVIRA Syndrome) is a rare congenital anomaly of the female genital tract. Uterus didelphys occurs when the midline fusion of the mullerian ducts is arrested, either completely or incompletely. Women with didelphic uterus may be asymptomatic and unaware of having a double uterus. They may present with complaints of dysmenorrhoea and dyspareunia. A 25 year old woman attending the infertility clinic at Nizwa regional referral hospital presented with history of dysmenorrhoea and foul vaginal discharge with right cystic pelvic mass. She was diagnosed as a case of double uterus with obstructed right hemivagina and right pyocolpos with ipsilateral renal agenesis after routine ultrasonography in the clinic followed by MRI. Excision of the right vaginal septum with drainage of 200 ml of purulent discharge was performed. She was relieved of her symptoms and conceived promptly after the surgical excision of the partial vaginal septum.

Colloid cyst of third ventricle presenting as pseudoeclampsia.

A 32 years old omani woman G6P4A1 at 39 weeks of pregnancy presented with complaints of headache and picture of eclampsia. Emergency caesarean section was done for maternal and foetal distress. Post caesarean section patient could not be extubated from general anaesthesia. Emergency computed tomography scan of the brain was done which revealed colloid cyst of the third ventricle with severe acute obstructive hydrocephalus leading to irreversible brain damage and death. Colloid cyst of the third ventricle is a rare benign intracranial tumour, and pregnancy often masks the symptoms. High index of suspicion and early detection of tumour may be life saving.

Rupture of non-communicating rudimentary uterine horn pregnancy.

Unicornuate uterus with rudimentary horn is a rare type of uterine malformation associated with obstetrical complications. Rupture of pregnant rudimentary horn is the usual presentation resulting in severe haemoperitoneum with increased maternal morbidity, and at times, mortality. A case of ruptured rudimentary horn pregnancy in a 24-year-old, second gravida, is reported. Exploratory laparotomy revealed a ruptured rudimentary horn pregnancy of 14 weeks gestation with haemoperitoneum. Excision of the rudimentary horn was done and an uneventful recovery followed.