Jessica Rahman

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 admissions to the intensive care unit: a 12-year review

ObjectiveThe objective was to ascertain the prevalence, causes and outcome of critically ill obstetric patients admitted to the intensive care unit (ICU).DesignThe design was a retrospective collection of data.SettingsThe setting was a multidisciplinary ICU in a University hospital.PatientsAll obstetric patients admitted to the ICU over a 12-year period from May 1992 to April 2004 were reviewed.MethodsData collected included demographic characteristics of the patients, pre-existing medical conditions, obstetric complications, invasive procedures required in the ICU and outcome of the patients.Results The incidence of obstetric admissions to the ICU represented 0.22% of all deliveries during the study period. The majority (84.4%) of patients were admitted to the ICU postpartum. Obstetric haemorrhage (32.8%) and pregnancy-induced hypertension (17.2%) were the two main obstetrical reasons for admission. The remainder included medical disorders (37.5%) and other causes (6.2%). Associated major complications included adult respiratory distress syndrome (ARDS) and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. The perinatal mortality rate was 20% and the maternal mortality rate 9.4%.Conclusions A team approach consisting treatment by obstetricians, intensive care specialists and anaesthesiologists provided optimal care for the patients. Improved management strategies for obstetric haemorrhage and hypertension may significantly reduce maternal morbidity.

Ovarian carcinoma associated with pregnancy. A review of 9 cases.

Background. The purpose of this study was to review patients with ovarian cancer in pregnancy, the effectiveness of the available methods of treatment and their prognosis.

Progression of retinopathy during pregnancy in type 1 diabetes mellitus.

Purpose:  The incidence and risk factors for progression of retinopathy during pregnancy in women with type 1 diabetes mellitus were retrospectively evaluated.

Pregnancy outcome in patients with homozygous sickle cell disease in a university hospital, Eastern Saudi Arabia

ObjectiveTo evaluate the maternal and fetal outcome in pregnant women with sickle cell disease and to highlight the complications encountered during pregnancy and delivery at a university hospital in the Eastern Saudi Arabia.Study designA retrospective study of 255 pregnancies in 145 patients with sickle cell disease (SCD) over an 8-year-period analyzed the perinatal complications and maternal and fetal outcomes compared with a control group of 500 Saudi females with the normal hemoglobin phenotype selected randomly that matched for age, parity and delivered during the study period.ResultsThe incidence of SCD was 1.3% of all deliveries with one maternal death (0.4%) and a perinatal mortality rate of 78.2/1,000 deliveries in the series. The major maternal complications in the 255 pregnancies were anemia 84.3%, sickle cell crisis 44.3% (26.6% painful and 17.7% hemolytic crises), infection 45.9%, fetal growth restriction 20.1%, preterm delivery 12.6%, and pregnancy-induced hypertension 10.6%. Blood transfusion was necessary in 34% pregnancies. Stillbirths accounted for 63% of the perinatal mortality.ConclusionsSaudi women with SCD are at a greater risk of morbidity and mortality in pregnancy than previously reported, with a high perinatal mortality rate. Early booking, meticulous antenatal care and supervised hospital delivery will improve the maternal and fetal outcomes in these patients.

Rupture of the Uterus in Labor: A review of 96 Cases

Abstract. Ninety‐six cases of ruptured uterus in labor treated in the University Teaching Hospitals, Benghazi, Libya between 1977 and 1980 are reported. An incidence of 1 in 585 deliveries remained unchanged during the period of study. Twenty uterine ruptures occurred in a previously scarred uterus. Rupture of the unscarred uterus is a more catastrophic event. There is a marked difference in both fetal and maternal outcome between the group with a previously scarred uterus and the group without a previous scar. The incidence and causes of uterine rupture in Libya differ greatly from those in developed countries. High parity is a frequent cause. Other common etiological factors were cephalopelvic disproportion, fetal malpresentation, oxytocin stimulation of labor and unwise obstetrical interference. The fetal wastage was high, a perinatal mortality of 75% being recorded, but 95% of the mothers were saved. Hysterectomy was commonly performed in this group. Repair of the uterus and sterilization should only be performed when the rupture is simple and transverse in the lower segment and without any sign of infection.

Maternal and fetal outcome of pregnancy complicated by HELLP syndrome

Objective. The study evaluated the maternal and fetal outcome in 64 pregnancies complicated by HELLP syndrome. Methods. A retrospective analysis of the medical records was performed of patients with HELLP syndrome managed at this tertiary Obstetric unit between January 1996 and December 2005, who were admitted for preeclamsia/eclampsia and had documented evidence of hemolysis, elevated liver enzymes and low platelet count. Maternal and neonatal complications were recorded and analyzed. Results. The incidence of HELLP syndrome in the study was 8.3%. Mean gestational age at delivery was 32.4 ± 4.2 weeks and mean birth weight was 1851 ± 810 g. Forty-two percent of the patients had deliveries <32 weeks and 28% IUGR. Respiratory distress syndrome was the main indication for NICU admissions (33.9%). The PNM rate was 20%. Maternal morbidity rate was 34%. The most common maternal complications were abruptio placentae (36.4%) and DIC (31.8%). There was no maternal death. Conclusion. Once the diagnosis of HELLP syndrome is confirmed, the management depends on several obstetric and maternal variables like gestational age, severity of laboratory abnormalities and fetal status. As soon as the maternal condition is stabilized and fetal assessment is obtained, prompt delivery of the fetus is indicated. It is not yet established whether expectant management in preterm pregnancies with HELLP syndrome would improve perinatal outcome.

Ovarian Tumours in Pregnancy

EDITORIAL COMMENT: We agree with the authors of this paper that routine ultrasonography in the first trimester will diagnose many ovarian cysts that have been missed on clinical examination. However, we consider that the possibility of finding an unrecognized ovarian tumour is not an important item in the case for routine ultrasonography in pregnancy. Most cysts found incidentally are less than 5–10 cm in diameter, are asymptomatic, and can be treated conservatively; most are probably cysts of the corpus luteum. If the cyst is large, symptomatic or suspicious of malignancy (solid elements or complicated echos), then laparotomy is indicated as recommended by the authors. It should be noted that follicular and corpus luteum cysts, of which only 10 were included in this series, can occasionally reach large dimensions. In the rare patient who has rapid growth of an ovarian tumour during pregnancy, the histology is usually benign, mucinous cystadenoma. Figures 1A and B and the following mini‐case report are included in this comment to illustrate that even a huge cyst can be overlooked on clinical examination.

Emergency hysterectomy in obstetrics--a review of 117 cases.

Summary: A series of 117 cases of emergency obstetric hysterectomy performed between 1976 and 1985 is reviewed. The indications included ruptured uterus (53.8%), intractable postpartum haemorrhage (20.5%), placenta accreta (7.7%), major degree of placenta praevia (7.7%), haemorrhage at Caesarean section (4.5%), couvelaire uterus (3.4%) and abdominal pregnancy (2.6%). Despite a general aversion to hysterectomy by the women in our society, these procedures were undertaken in a desperate attempt to save life. There were 6 (5.1%) maternal deaths, all due to the severity of the indication for the hysterectomy. Presence of an experienced obstetrician is important to make an early decision to operate before the patients condition is extreme and to provide the technical skills required to minimize morbidity and mortality.

Shoulder Dystocia — A Clinical Study of 56 Cases

EDITORIAL COMMENT: This study confirms the well known fact that shoulder dystocia is more common with macrosomia, but also shows that the large baby of a diabetic is significantly more at risk than an equally large baby of a nondiabetic. There is much attention in the literature to the need to recognize the small for dates infant because of increased risk of perinatal mortality and morbidity. There is less emphasis on the need to recognize the large for dates baby although this can be equally important, especially in diabetics. Most authors have concluded that shoulder dystocia is usually unpredictable ‐ i.e. without clear indication for elective Caesarean section to avoid the risk; nobody would recommend elective section for all macrosomic babies since most are delivered uneventfully. However, past history of shoulder dystocia can justifv elective Caesarean section when the fetus appears large on clinical evidence. Delay in the second stage of labour and slow descent of the head in an obese multipara should warn the clinician that Caesarean section rather than mid‐forceps delivery is the best decision, especially when the fetus seems large. Unfortunately clinical judgement in these cases is often not helped by ultrasonographic evidence of birth‐weight, in this editors experience. The obese multipara labouring ineffectively should always be taken as a warning that the baby may be larger than expected, and that Caesarean section, not enhancement of labour with oxytocin, is the proper management. Since there is often no time to summon aid, all accouchers should have a plan of how to manage shoulder dystocia ‐ the authors provide most details and it shoulder be noted that all their patients were delivered in the lithotomy position ‐ the dorsal position does not allow downwards traction to release the anterior shoulder, and time is short when the complication has occurred. (See previous comment on Shoulder Dystocia, Aust NZ J Obstet Gynaecol 1988; 28: 107)