Adekunle A. Sobande

Pregnancy outcome in asthmatic patients from high altitudes

Objective: To compare pregnancy outcome in asthmatic and non‐asthmatic patients from high altitudes. Method: A prospective case‐control study over a 4‐year period. The setting was: Abha Maternity Hospital, south‐west region of Saudi Arabia. Eighty‐eight asthmatic pregnant patients were followed up on during their pregnancies and deliveries (cases). The control subjects were 106 non‐asthmatic patients who delivered during the same period. Results: There were no statistically significant differences in the mean age, parity and gestation at delivery between the cases and control subjects (P>0.05), while there were statistically significant differences in the mean birth weight, placental weight and number of abortions between the two groups (P<0.05). Antenatal complications occurred in 12.5% of the asthmatic patients and 1.9% of the control subjects. Pre‐eclampsia was diagnosed in 7.9% of the asthmatic group but in none of the control subjects. Induction of labor, cesarean section rate, perinatal mortality, congenital malformations and Apgar score <7 at 5 min were significantly higher in the asthmatic patients. Conclusion: Asthma occurring in pregnancy was associated with increased antenatal complications, increased perinatal loss and congenital malformations in our study population.

Removal of cervical mucus prior to embryo transfer improves pregnancy rates in women undergoing assisted reproduction

The removal of cervical mucus during embryo transfer has been postulated to increase the pregnancy and implantation rates by not interfering with embryo implantation. Even so, this is a time-consuming procedure that may increase the incidence of difficult transfers by removing the naturally lubricant mucus. In addition, any cervical manipulations at the time of embryo transfer may cause unwarranted uterine contractions. In this prospective, controlled study, 286 women undergoing embryo transfer between January and May 2006 were divided into two groups according to whether the cervical mucus was scheduled to be aspirated (group A) or not (group B). The two groups were similar with regards to the demographics, cause of infertility, characteristics of ovarian stimulation and embryos transferred. Even so, the clinical pregnancy rate was significantly higher in group (A) than group (B) (OR = 2.18, 95% CI = 1.32-3.58), although there were easier transfers in group (B) than group (A) (OR = 3.00, 95% CI = 1.05-8.55). This demonstrates that even though embryo transfers were easier to perform when the cervical mucus was left in place, aspiration resulted in an increased chance of clinical pregnancy.

Risk Factors and Pregnancy Outcome in Different Types of Placenta Previa

OBJECTIVE To compare risk factors and pregnancy outcome between different types of placenta previa (PP). MATERIALS AND METHODS We conducted a retrospective study of 306 women presenting with PP over a 10-year period from January 1996 to December 2005. Differences between women with major and minor PP regarding age, parity, history of Caesarean section, antepartum hemorrhage, preterm deliveries, placenta accreta, Caesarean hysterectomy, operative complications, and neonatal outcome were identified using Mann-Whitney U test, chi-square test, and multivariate logistic regression. RESULTS The overall incidence of PP was 0.73%. Major PP (complete or partial PP) occurred in 173 women (56.5%) and minor PP (marginal PP or low-lying placenta) in 133 women (43.5%). There were no differences between women with major and minor PP regarding age, parity, and previous miscarriages. After controlling for confounding factors, women with major PP showed a significantly higher incidence of antepartum hemorrhage (OR 3.18; 95% CI 1.58-6.4, P = 0.001), placenta accreta (OR 3.2; 95% CI 1.22-8.33, P = 0.017), and hysterectomy (OR 5.1; 95% CI 1.31-19.86, P = 0.019). Antepartum hemorrhage in women with PP was associated with premature delivery (OR 14.9; 95% CI 4.9-45.1, P < 0.001), more commonly in women with major PP. The only significant difference between women with major and minor PP regarding neonatal outcome was that major PP was associated with a higher incidence of admission to the neonatal intensive care unit (P = 0.014). CONCLUSION Complete or partial placenta previa is associated with higher morbidity than marginal placenta previa or low-lying placenta.

Multiple repeat caesarean sections: complications and outcomes.

OBJECTIVE To compare the complications and outcomes of Caesarean section (CS) in women who have had three or more previous lower segment Caesarean sections with those in women with one previous CS. METHODS We performed a retrospective study of 371 patients undergoing repeat CS. Of these, 115 (31%) had previously had three or more Caesarean sections (group 1) and 256 (69%) had previously had one CS (group 2). All 371 patients had the repeat CS performed at Abha Maternity Hospital, Saudi Arabia between June 2002 and May 2004. Demographic data, complications, and outcomes were compared using the Student t and chi-square tests. RESULTS There were statistically significant differences between the two groups with respect to mean maternal age, parity, gestation at delivery, and experience of the surgeon (P < 0.05). CS was performed as an emergency in 38 (32.9%) and 186 (72.6%) of patients in groups 1 and 2 respectively (P < 0.05). The consultant was involved in the decision to perform CS in 215 (84.6%) of patients with one previous CS. There were significant differences between the two groups in the type of skin incision, the presence of dense adhesions during surgery, and bladder injury (P < 0.05). There were no statistically significant differences in birth weight, stillbirth rate, low Apgar score, blood loss during surgery, duration of surgery, or the duration of postoperative hospital stay. CONCLUSION The prevalence of dense intra-abdominal adhesions and of bladder injury during CS was higher in women with a history of three or more previous CS than in women with one previous CS. Placenta previa and Caesarean hysterectomy occurred with equal frequency in each group, and wound dehiscence and uterine rupture were rare.

Cervical cerclage for prevention of preterm birth in women with twin pregnancy

To compare the effect of elective cervical cerclage in women with twin pregnancy on gestational age at time of delivery.

Severe pre-eclampsia and eclampsia in Abha, the south west region of Saudi Arabia.

Summary A retrospective study was conducted over a 10-year period on 32,000 maternities at Abha General Hospital, Abha, Saudi Arabia, to estimate the contribution of eclampsia and severe pre-eclampsia to maternal mortality and morbidity and also fetal wastage. It included 18 cases of eclampsia and 297 cases of severe pre-eclampsia. Multiple regression analysis revealed that only the presence of prodromal symptoms significantly affected the occurrence of eclampsia, p < 0.05, while nulliparous patients were a high risk group for eclampsia. Maternal complications including eight cases of massive ascites occurred exclusively in severe pre-eclamptics. Although no maternal deaths were reported, the perinatal mortality rate was 16.6% and 14.1% among the eclamptics and severe pre-eclamptic patients, mainly from prematurity. Regarding the eclamptic patients, 17(94.4%) had the first fit before arrival at the hospital, 13(72.2%) before labour, while 3(16.6%) had fits before and during labour and 1(5.6%) had the fits after delivery. Suggestions are proffered to reducing maternal morbidity and perinatal mortality and morbidity.

Fundal hiatus discovered in a presumably unscarred uterus at emergency cesarean: an old perforation or rupture?

Rupture of the uterus is a disastrous event for both the mother and fetus and can be classified into three groups according to its etiology: rupture of a previous cesarean section scar iatrogenic or traumatic rupture of the intact uterus and spontaneous rupture of the intact uterus. The last scenario can further be subdivided into (a) those associated with uterine anomaly placenta percreta pyometra hydatidiform mole grand multiparity or pathological growth and (b) that occurring in a primiparous patient with a sound intact and normal uterus. The latter is a very rare entity. We present a case of an unexpected fundal hiatus discovered in a presumably unscarred uterus at emergency cesarean section in a twin pregnancy without labor. The appearance of the fibrotic edge of the defect strongly suggested a chronic event (rupture or previous perforation) with the expulsion of the second twin through the defect at a much later date. The two fetuses died in utero but in retrospect one of the fetuses might have been salvaged or even both if a suspected uterine perforation at previous evacuation was dealt with adequately. (excerpt)

A clinico-epidemiological review of cervical cerclage from the Assir region of Saudi Arabia.

A retrospective review was conducted on patients who had cervical cerclage performed because of suspected cervical incompetence over a 7-year period to assess the outcome of pregnancy and complications resulting from the cerclage. Other factors that could affect the outcome and complications were also assessed. Out of 196 patients who had the operation, 154 patients had adequate records available and therefore comprised the study population. There were 139 (90%) live births of which 76·6% weighed more than 2000 g. The outcome was not influenced by the experience of the surgeon, type of cerclage or the use of prophylactic antibiotics. There were no complications in 138 (90%) of the cases, and no cases of ruptured uterus, cervical lacerations and severe infections were encountered. The complications were seen more in multiple-order pregnancy and when the operation was performed as an emergency. The future role of cervical cerclage in the management of cervical incompetence in our community is discussed.

Induction of labor with prostaglandin E2 vaginal tablets in parous and grandmultiparous patients with previous cesarean section

Objectives: To compare the outcome of induction of labor with prostaglandin E2 vaginal tablets between lower parity (parity 1–5) and grandmultiparous (parity >5) patients with a history of one previous lower segment cesarean section. Methods: A prospective study of 113 patients conducted at King Faisal Military Hospital, Khamis Mushayt, Saudi Arabia during a 5‐year period spanning January1995 to December 1999. Results: There were no statistically significant differences in the two groups regarding mean maternal age, dose of prostaglandin used, gestation at delivery, mean birth weight, P>0.05. Syntocinon augmentation was used in 16 (21.9%) of the lower parity patients compared with 8 (20.0%) in the grandmultiparas but this was not statistically significant, (P=0.677). However, there was a statistically significant difference in the cesarean section rate between the two groups, P=0.019. Although no cases of uterine hyperstimulation were recorded, there was one rupture of the uterus in each of the two groups of patients; 1.36% and 2.5%, respectively, but this was not statistically significant, P=1.000. Conclusions: The complications of induction of labor with prostaglandin E2 vaginal tablets in grandmultiparous patients with previous cesarean section were similar to those with lower parity but the cesarean section rate was significantly higher. However, larger studies are needed for validation.

Changing patterns in the management and outcome of breech presentation over a 7-year period. Review from a referral hospital in Saudi Arabia.

A retrospective study that was conducted on 755 singleton breech deliveries over a 7-year period between January 1994 and December 2000 at a referral hospital in Saudi Arabia showed that it represented 3.35% of all deliveries. There was a statistically significant trend in caesarean section ( P = 0.001) accompanied by a modest linear trend in perinatal mortality ( P = 0.049). There were no statistically significant differences in the mean age, parity and birth weight when the women delivered during each year were compared ( P > 0.05), but there were statistically significant differences in the gestation at delivery ( P < 0.05). Furthermore, statistically significant differences were found in the trends of the preterm breech deliveries and booking status over the period of study ( P > 0.05). However, there was no statistically significant linear trend in the birth trauma ( P > 0.05). Nineteen cases of the fetal birth trauma (67.8%) were associated with vaginal breech delivery while nine cases (32.2%) were reported from caesarean section. This was statistically significant ( P = 0.00074). The role of selective external cephalic version as a way of reducing the caesarean section rate and also trauma during vaginal breech delivery at term in our community is discussed.