Cardiorespiratory crisis at the end of pregnancy: a case of pheochromocytoma.

Pheochromocytoma during pregnancy is extremely rare. Its clinical manifestation includes hypertension with various clinical presentations, possibly resembling those of pregnancy-induced hypertension. The real challenge for clinicians is differentiating pheochromocytoma from other causes of hypertension (preeclampsia, gestational hypertension, and pre-existing or essential hypertension), from other cause of pulmonary edema (preeclampsia, peripartum cardiomyopathy, stress or Takotsubo cardiomyopathy, pre-existing cardiac disease [mitral stenosis], and high doses betamimetics), and from other causes of cardiovascular collapse (pulmonary embolism, and amniotic fluid embolism). Although, several cases of pheochromocytoma during pregnancy have been published, fetal and maternal mortalities due to undiagnosed cases are still reported. We report a case of a patient whose delivery by cesarean section was complicated by severe hemodynamic instability resulting in a cardiac arrest. Later on, pheochromocytoma was suspected based on computed tomography (CT) scan findings. Diagnosis was confirmed with special biochemical investigations that showed markedly elevated catecholamines in urine and metanephrines in serum, and later by histopathology of the excised left adrenal mass. This case illustrates the difficulty of diagnosing pheochromocytoma in pregnancy and raises the awareness to when this rare disease should be suspected.

The need for national medical licensing examination in Saudi Arabia.

BACKGROUND: Medical education in Saudi Arabia is facing multiple challenges, including the rapid increase in the number of medical schools over a short period of time, the influx of foreign medical graduates to work in Saudi Arabia, the award of scholarships to hundreds of students to study medicine in various countries, and the absence of published national guidelines for minimal acceptable competencies of a medical graduate. DISCUSSION: We are arguing for the need for a Saudi national medical licensing examination that consists of two parts: Part I (Written) which tests the basic science and clinical knowledge and Part II (Objective Structured Clinical Examination) which tests the clinical skills and attitudes. We propose this examination to be mandated as a licensure requirement for practicing medicine in Saudi Arabia. CONCLUSION: The driving and hindering forces as well as the strengths and weaknesses of implementing the licensing examination are discussed in details in this debate.

Adverse drug reactions related hospitalization identified by discharge ICD-9 codes in a univeristy hospital in Riyadh.

OBJECTIVE: To assess the feasibility of using International Classification of Disease code (ICD-9) to ascertain the prevalence, seriousness, and preventability of adverse drug reaction (ADRs). METHODS: A retrospective study between the years 1982 and 2005 was conducted at King Khaled University Hospital (KKUH), Riyadh, Saudi Arabia to examine the ICD-9 codes assigned on discharge to identify ADRs. A list of the ICD-9 codes related to ADRs were identified. These codes were entered into the hospital computer program at the study site to identify corresponding patients' medical records. The total number of patients admitted to the hospital each year was identified to calculate the prevalence of ADRs, and descriptive analysis was also conducted. RESULTS: A total of 89 patients were identified and included. Drug classes commonly associated with ADR include hormones and synthetic substitutes (14.6%), followed by primary systemic agents (13.5%). Almost 50% of cases had chronic conditions and use other drugs when the ADR had occurred. The majority of the ADRs were type A (54%) preventable, while 39% were type B non preventable, and only 6% were type C occur with long term use. The prevalence per year ranged from 0.07% in 1993 to 0.003% in 1999. CONCLUSION: Identifying ADRs causing hospital admission by using ICD-9 coding system is easy and practical. However, under or inaccurate recording of ICD-9 codes may be a limitation to the use of such an important tool.