Suleiman A. Al-Suleiman

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.

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.

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.

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)

Maternal mortality: a twenty-year survey at the King Faisal University Hospital, Al-Khobar, Eastern Saudi Arabia

This was an institutional study of all maternal deaths that occurred among 56 422 total births at the King Faisal University Hospital, Al-Khobar, Saudi Arabia, between 1983 and 2002. The underlying cause of each maternal death and potentially avoidable factors were analysed. There were 16 maternal deaths in the hospital during the study period, giving a maternal mortality rate of 28.4/100 000 maternities. The leading cause of death was haemorrhage in seven (43.75%) patients, followed by pulmonary embolism in four (25%) and general anaesthesia in two (12.5%) mothers. The risk factors noted were maternal age ⩾ 35 years and parity ⩾ 5 coupled with iron deficiency anaemia. The main avoidable factors were failure of the patients to seek timely medical care and to follow medical advice. More than half the number of direct obstetrical causes of death was thought to be preventable. A rapidly changing attitude of women towards childbirth is occurring through progressively increasing female education and community health programmes in the region. Further reduction of maternal mortality rates in the community is envisaged through greater patient acceptance of medical advice, family spacing and proficient obstetric services.

Obstetric complications and perinatal outcome in triplet pregnancies.

Summary 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.

Outcome of Treatment with Bromocriptine in Patients with Hyperprolactinaemia

EDITORIAL COMMENT: The results obtained in Ms series of hyperprolac‐tinaemic women indicates the efficacy and safety of bromocriptine therapy. Not everyone would agree with the need for routine surgical excision of pituitary macroadenomas nor with the cessation of the medication at 12 to 16 days after the first missed menstruation, since microadenomas may also enlarge in pregnancy.