Bladder injuries during cesarean section in a University Hospital: a 25-year review.

OBJECTIVES: The objective was to determine the prevalence of bladder injury during cesarean section (CS) and identify the risk factors causing these injuries, their management and the outcome. METHODS: We retrospectively reviewed the medical records of all the patients who had bladder injury during CS over a period of 25 years (1983-2007) at the King Fahad Hospital, Al-Khobar, Saudi Arabia. Demographic data, obstetric, surgical details, mechanism of injury, anatomic location, diagnosis, management and outcome were assessed. RESULTS: Thirty-four cases of bladder injury were identified among 7,708 cesarean deliveries performed during this period with an overall incidence of 0.44%. Primary CS was found in 41.2% of the patients and 58.8% had repeat CS giving an incidence of 0.27 and 0.81%, respectively. Bladder injury occurred when surgical difficulties were encountered during opening of the peritoneal cavity and while developing the bladder flap over the lower uterine segment, mainly due to adhesions and scar tissue resulting from previous abdominal surgery. All the bladder injuries were recognized intraoperatively and repaired with an overall satisfactory outcome. Repeat CS and presence of adhesions were found to be statistically significant risk factors in the study, while operator experience and emergency nature of the CS were considered risk factors in a few cases of bladder injury. CONCLUSIONS: Data presented in this study indicates that bladder injury when adequately repaired is rarely associated with any complications. Multiple cesarean deliveries is a significant risk factor for bladder injury at the time of repeat CS and patients should be counseled regarding this risk before surgery.

Disseminated gonococcal infections.

A four-year retrospective review of 55 patients with disseminated infections from Neisseria gonorrhoeae revealed that this complication occurs in young adults, with a predominance in women (80%). The most common manifestation of disseminated gonococcal infection was arthritis, which occurred in 47 patients (85.5%). The second most common manifestation of disseminated gonococcal infection was dermatitis, which occurred in 33 patients (60%). A thorough history, a careful physical examination, and a high index of suspicion are essential for the diagnosis. Disseminated gonococcal infection can be confirmed by isolation of gonococci from potential sites, including urethra, cervix, rectum, oropharynx, and blood. Early diagnosis and adequate therapy are necessary to prevent serious complications. The role of the gynecologist in preventing, diagnosing, and/or treating this disorder is emphasized.

Advanced abdominal pregnancy--observations in 10 cases.

Advanced abdominal pregnancy was encounter 10 times in 102,000 deliveries over a period of 10 years at 1 hospital. The clinical features, difficulties in diagnosis and management, and the outcome of this uncommon condition are discussed. The most frequent symptoms encountered in this series were abdominal pain (100%), nausea and vomiting (70%), general malaise (40%), and painful fetal movements (40%). The commonest physical findings were abdominal tenderness (100%), an abnormal fetal lie (70%), and a displaced uterine cervix (40%). The incidence of diagnostic error was 60%. Multiple diagnostic procedures are needed to reduce the incidence of error. The maternal mortality was 20% and the perinatal mortality 40% in this series. The postoperative morbidity and mortality were high when the placenta was left in situ. Methotrexate was used in 5 cases to expedite degeneration of the trophoblastic tissue in the residual placenta. The value of this drug in managing the abdominal placenta could not be established. Removal of the placenta, when it is safely possible, gives the best results.

Microbiology of postoperative wound infection: a prospective study of 1770 wounds.

A prospective study of postoperative wound infection was carried out over a 12-month period. Intra-operative swabs from the patients' anterior nares, the opened viscus and parietes were cultured using standard bacteriological techniques. Of the 1770 wounds studied, 167 (9.4%) became infected. Wound infection rates, according to clinical wound types, were clean 5.9%, clean-contaminated 10.7%, contaminated 24.3% and dirty 52.9%. The figures according to microbiological wound types were clean 4.7%, and potentially, lightly and heavily contaminated 15.3%, 22.1% and 30.2% respectively. The commonest causative organisms were Staphylococcus aureus 23.7%, Escherichia coli 16.9%, Staphylococcus epidermidis 13.5% and Pseudomonas aeruginosa 13.0%. When isolated intra-operatively, Enterobacter spp., Proteus spp., Klebsiella spp. and P. aeruginosa appeared to have a high probability of causing postoperative wound infection, but the intra-operative isolation of Bacteroides sp. was a poor predictor of subsequent wound infection.

Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia.

The perinatal deaths of all singleton births that occurred at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia during a 4-year period are analysed. The causes of death are classified into 12 groups using an extended modification of the Aberdeen classification. There were 165 perinatal deaths in 8057 singleton births, giving a perinatal mortality rate of 20.47 per 1000 total births. Fetal malformations occurred in 29 (17.57%) cases. Of the remaining 136 normal infants, 77 (56.6%) were stillbirths and 59 (43.4%) died within 1 week of delivery. Spontaneous premature labor was the commonest cause of death (23.52%) followed by birth trauma (11%) and maternal diseases (9.55%). The cause of death was not known in 22 (16.17%) cases. In conclusion, prevention of premature labor, better intrapartum fetal monitoring, early recognition of fetal distress and improvement of neonatal care should reduce the perinatal mortality rate.

Evaluation of an intensive care unit in a teaching hospital in Saudi Arabia.

Intensive Care Units (ICU) in general hospitals have become a standard requirement in tertiary care centres. However, the appropriateness of their use is not widely known. We have used the Therapeutic Intervention Scoring System (TISS) to evaluate a multidisciplinary ICU in a teaching hospital in Saudi Arabia. The average occupancy rate was 79%, the nurse: patient ratio was 1:1.4, duration of stay 4.1 +/- 3.5 days, and mortality was 1.4%. The distribution of severity of illness was as follows: Classes I & II, 82%, and Classes III & IV, 18%. The average TISS points were: daily per patient 15.1 +/- 2.7 (range 11.5-21.7), total per day 125.6 +/- 38.2 (range 35-211), and patient points per nurse was 21.1. We conclude that, although less than 20% of patients required unique ICU services, the use of our ICU was appropriate to the current medical and manpower training needs of the community it was designed to serve, but the basis of nurses' complaints of overwork remains to be determined.

Obstetric complications and perinatal outcome in triplet pregnancies.

The incidence of multiple pregnancies with more than two fetuses has significantly increased since the introduction of ovulation agents and assisted reproductive technologies. Over a 15-year period there were 35 triplet pregnancies beyond 24 weeks that delivered at the King Fahad Hospital, an incidence of 1 in 1,099 deliveries. Early diagnosis is important for improving the rate of fetal salvage in triplet pregnancy. These pregnancies were managed on an outpatient basis. Prophylactic interventions were not utilised. A total of 91% of the pregnancies had at least one antenatal complication, pre-term labour being the most common (80%) followed by anaemia (43%). The average gestational age at delivery was 31.7 weeks (SD 4.2 weeks). A total of 94.3% of the patients were delivered by lower segment caesarean section. The mean birth weight of the neonates was 1,552 g (SD 510 g) and mean 5-min Apgar score was 7.6 (SD 0.8). The corrected perinatal mortality rate in the study was 152/1,000. Pregnancy outcome did not vary with birth order or mode of conception. Higher rate of pre-term births among triplet pregnancies make considerable demands on the neonatal intensive care unit. All methods of assisted reproduction should aim at prevention of multifetal pregnancies.

Laparoscopy in the management of women with chronic pelvic pain.

A review of 232 women who had diagnostic laparoscopy for chronic pelvic pain was undertaken. Diagnostic error in the preoperative pelvic examination in the series varied from 21% to 61%; of 135 patients who had normal pelvic examination findings preoperatively, 82 (61%) were found to have pelvic pathology on diagnostic laparoscopy, whereas 21 of 97 women (21.6%) who had abnormal pelvic examination, had normal findings on laparoscopy. The overall incidence of pelvic pathology in the series was found to be 69%. Our results suggest that there is poor correlation between findings of pelvic examination and the existence of pelvic disease. Laparoscopy has a definite place in the evaluation of patients with chronic pelvic pain and certainly justifies its increasing use in their management.

Pregnancy complicated by maternal cardiac disease: a review of 274 patients.

The outcome of 274 viable pregnancies in 229 patients with cardiac disease that delivered at the King Fahad Hospital, Al-Khobar, Saudi Arabia, between 1982 and 1998 was reviewed. The incidence was 0.6% of deliveries. Rheumatic heart disease complicated 208 (75.9%) pregnancies, congenital heart lesion in 49 (17.9%) and the remaining 17 (6.2%) pregnancies were a miscellaneous group that included supraventricular tachycardia, ectopic beats, ischaemic heart disease and cardiomyopathies. The NYHA grading was between 1-2 in 243 (88.7%) pregnancies antenatally. Thirty-one patients developed heart failure, most commonly in the antenatal period, 29 of whom were of Grade 1-2. One mother in the series died from heart failure following a cesarean section. She had had a mitral valvotomy before pregnancy and was categorised as Grade 2, antenatally. The perinatal mortality rate was 14.6/1000 deliveries in the study group. Prophylactic antibiotics were given to all the patients an hour before delivery. There were two instances of bacterial endocarditis in the series.

Ovarian tumours in pregnancy.

Ovarian tumours associated with pregnancy were reviewed for the period 1982-1991. The overall incidence of this complication was 1:653 deliveries; 62.7% of the tumours were diagnosed in the first and second trimesters of pregnancy. The value of routine pelvic examination and ultrasonic scan as a diagnostic aid in early pregnancy is emphasized; 25.4% of patients presented as an acute emergency; 23.9% of the tumours were incidentally discovered at Caesarean section which underlines the importance of examining the ovaries at operation. Benign cystic teratomas were the most common ovarian tumours found, followed by serous cystadenomas. The incidence of malignant tumours was 4.5%. Whenever an ovarian tumour is found, the possibility of malignancy should always be borne in mind. Treatment of ovarian tumours in pregnancy should be tailored according to the age of the patient, parity, clinical presentation, gestational age and biology of the tumour.

The oversized infant. A study of 86 cases.

The maternal factors and perinatal and neonatal outcome of 86 oversized infants (birthweight 4,500g and above) were studied. 11.6% of mothers were diabetics while 34.5% demonstrated a hyperglycaemic glucose tolerance test. A comparison of the maternal variables and perinatal and neonatal morbidity was made between the diabetic and nondiabetic group. No significant difference in maternal age greater than or equal to 30 years, parity and obesity was observed in the 2 groups. Perinatal and neonatal complications were noted to be high in the study population but no significant difference in the 2 groups was noted except for a higher prevalence of hypoglycaemia in the infants born to the diabetic mothers. Oversized infants caused a high risk obstetric and paediatric situation independent of the diabetic status of the mother.

Screening for gestational diabetes in a teaching hospital in Saudi Arabia.

This study was undertaken to determine the incidence and severity of gestational diabetes in our hospital population which is predominantly Arab; 455 consecutive patients were screened by a 3-hour glucose tolerance test in the third trimester of pregnancy. The overall incidence of gestational diabetes was found to be 11% and the incidence increased with increasing maternal age, parity and weight. A high prevalence of more severe degrees of gestational diabetes was noted among the Arabs. Glucose intolerance was observed in 2 patients in the absence of any risk factor. The most common high risk factor in patients found to have gestational diabetes was maternal age of 30 years or more.

The low birth-weight infants of Saudi adolescents: maternal implications.

Maternal factors and perinatal outcome of low birth-weight (less than or equal to 2,500 g) infants of 46 adolescent mothers was studied and compared with 160 adolescents who delivered infants weighing greater than 2,500 g. The significant factors found in the low birth-weight group were anaemia, small maternal physique and preterm delivery. Expectedly, the perinatal mortality rate was significantly increased in low birth-weight infants.

PIP: From 1981-1985, researchers studies pregnancy outcomes of 206 female adolescents (= or 17 years old at the time of 1st hospital visit) at King Fahd Hospital in Al-Khobar, Saudi Arabia. 23% of all infants born to adolescents were classified as low birth weight (= or 2500g). 17.4% of these mothers were 15 years old or younger, 39.1% were 16, and 43.5% were 17. For mothers who delivered an infant 2500g, 17.5% were 15, 26.9% were 16, and 55.6% were 17. Mothers who had low birth weight infants (mean weight 53.48k) tended to weigh less at time of delivery than those who had infants 2500g (61.89kg; p.005). Further, the stature of 31.1% of those in the low birth weight group was 150cm whereas only 13.5% of the remaining mothers were 150cm. 64% of mothers who had low birth weight infants delivered before 37 weeks gestation (p.005). Anemia (Hb10.6g/dl) was the most significant complication contributing to low birth weight (38.6%; p.005). This suggests that many adolescent mothers did not take iron and vitamin supplements and that they did not take iron and vitamin supplements and that they did not eat adequately during pregnancy. Even though toxemia also contributed significantly to low birth weight (9%; p.05), its overall prevalence was markedly low (1.9% in 2500g group). The mode of delivery did not affect birth weight. Perinatal mortality for low birth weight infants stood at 14.6%. None of the .2500g infants died. All adolescent mothers should receive early prenatal care. In addition, more health education of health professionals and adolescents is needed to stress the importance of regular prenatal care, liberal hospitalization, intensive antepartum and intrapartum fetal monitoring.

Outcome of pregnancy in women with idiopathic thrombocytopenic purpura.

The obstetric management and haematological problems in 28 pregnancies of 23 mothers with idiopathic thrombocytopenic purpura (ITP) are analyzed. There was no maternal death and only 1 stillbirth occurred in the series. Ten infants were born by Caesarean section and 18 were delivered vaginally. Neonatal cord bloodplatelet counts showed thrombocytopenia in 12 infants, but in only 4 (14.3%) was the cord blood platelet count <50 x 10(9)/L. None of the 27 liveborn infants died, although 4 required supportive treatment with corticosteroids and IgG. No maternal characteristics could be used to predict the neonatal platelet count. These results are comparable with other studies reported in the literature. The rarity of poor neonatal outcome in mothers with ITP does not justify obstetric intervention solely on the basis of their platelet counts. The management of patients should be individualized and carefully planned.

Outcome of treatment with bromocriptine in patients with hyperprolactinaemia.

Results in 136 hyperprolactinaemic women who presented with infertility, amenorrhoea, menstrual irregularities and/or galactorrhoea are reported. There was radiographic evidence of pituitary microadenoma in 21 (15.4%) patients and 5 (3.7%) had macroadenoma. Four patients were taking antidepressants, 2 antihypertensive drugs and 7 had taken oral contraceptives for a period of 6 months to 5 years. The remaining patients had no obvious cause for elevated prolactin levels. Patients with pituitary adenoma had a significantly higher (p less than 0.001) baseline serum prolactin level (182 +/- 4.6 ng/ml) than those with no adenoma (59.2 +/- 4.2 ng/ml). All patients in the study were treated with bromocriptine (2.5-10 mg) to normalize serum prolactin or to achieve a pregnancy. The patients without an adenoma required a significantly smaller dose of bromocriptine (2.5-5.0 mg) (p less than 0.005) than those with an adenoma. Galactorrhoea disappeared in all 64 patients within 2-4 months of treatment, sixty-six (71%) of the 93 patients who desired pregnancy achieved it within 3 to 8 months of bromocriptine therapy; 32 of these patients received additional treatment with clomiphene and human chorionic gonadotrophins for induction of ovulation. In the remaining 70 patients menstruation became regular and ovulation was evident in 40% of them. There was no significant difference in the pregnancy rate between the patients with or without pituitary adenoma. Similarly, presence of galactorrhoea or a high level of prolactin did not influence the pregnancy rate. No complications were observed during pregnancy related to pituitary adenomas; 8 (12%) pregnancies ended in first trimester abortion. No lethal congenital fetal abnormalities were observed in the patients treated with bromocriptine.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years' experience in a teaching hospital.

Fifty-two women with a rectovaginal fistula were managed over a period of 15 years. All the fistulae were caused by obstetric injury commonly resulting from breakdown of the repair of complete perineal tears or from unrecognised injury during forceps or precipitate delivery. In five patients the fistula healed spontaneously within 12 weeks of the injury. Thirty-nine patients underwent transvaginal purse-string repair by standard technique and eight patients had perineoproctotomy and sphincteroplasty for large fistulae associated with anal incontinence. Surgical repair was successful in all the 47 patients including two patients who had previous failed repair elsewhere. The routine postoperative follow-up period of the patients ranged between 6 months and 8 years. There were no residual symptoms of anal sphincter weakness in the patients treated with transvaginal purse-string repair. Two of the patients who underwent perineoproctotomy and sphincteroplasty complained of varying degrees of postoperative incontinence of flatus that resolved by 8 weeks postoperation. In our experience the transvaginal purse-string method of repair for small, low rectovaginal fistulae proved highly satisfactory with 100% cure rate. Perineoproctotomy and sphincteroplasty for larger fistulae associated with anal incompetence was equally successful with minimal postoperative morbidity.

Obstetric implications of pregnancy in adolescence.

Pregnancy in adolescence constitutes a high-risk obstetric situation and there is an obvious need for improvement in obstetric care for this age group. A retrospective study of 94 mothers, 17 years of age and under, was carried out at the Teaching Hospital of King Faisal University in order to assess the obstetric implications of adolescent pregnancy. This study has shown a significant increase in the incidence of low birth weight infants, breech presentation and preterm delivery. A significantly smaller number of adolescent mothers were found to have given birth spontaneously, vaginally. Adolescent primigravidas were noted to run a greater risk. It is imperative to institute a medical and educational service with comprehensive prenatal care for adolescent mothers in order to improve the outcome of their pregnancies.

Shoulder dystocia--a clinical study of 56 cases.

A retrospective analysis of 17,127 singleton vaginal deliveries revealed 56 cases of shoulder dystocia giving an incidence of 0.3%. Although an increasing incidence of shoulder dystocia was noted as the infant birth-weight increased, 41% of shoulder dystocia occurred in infants of average birth-weight (2,500-3,999g). Diabetes mellitus, postmaturity, maternal weight above 90 kg were each factors associated with a large sized infant which should signal the possible occurrence of shoulder dystocia. In the present series shoulder dystocia occurred in 2.7% of all infants weighing 4,000 g or more. Diabetic women experienced shoulder dystocia more often than non-diabetics. In the diabetics 15.7% of neonates of birth-weight 4,000 g and above sustained shoulder dystocia compared to 1.6% in the nondiabetic patients. Immediate neonatal injury was apparent in 43% of infants with shoulder dystocia, Erb palsy being the commonest injury. The perinatal mortality rate in the series was 54/1,000 deliveries. There was no maternal death. To avoid the potentially lethal and dangerous complications of shoulder dystocia, all clinical and technological methods available should be utilized to detect the excessive sized infants so that abdominal delivery may be performed before it is too late.