Decisions to perform emergency caesarean sections at a university hospital do obstetricians agree?

Objectives: This study was undertaken to assess the degree of agreement amongst obstetricians regarding decisions to perform emergency Caesarean section [CS] procedures at a university hospital

Methods: This retrospective clinical audit was carried out on 50 consecutive emergency CS procedures performed between November 2012 and March 2013 on women with singleton pregnancies at the Sultan Qaboos University Hospital in Muscat, Oman. Data on each procedure were collected from electronic patient records and independently reviewed by six senior obstetricians to determine agreement with the decision

Results: Of the 50 women who underwent CS procedures, the mean age was 28.9 +/- 5.1 years and 48% were primigravidae. A total of 65% of the CS procedures were category I. The most common indications for a CS was a non-reassuring fetal heart trace [40%] and dystocia [32%]. There was complete agreement on the decision to perform 62% of the CS procedures. Five and four obstetricians agreed on 80% and 95% of the procedures, respectively. The range of disagreement was 4-20%. Disagreement occurred primarily with category II and III procedures compared to category I. Additionally, disagreement occurred in cases where the fetal heart trace pattern was interpreted as an indication for a category II CS

Conclusion: The majority of obstetricians agreed on the decisions to perform 94% of the emergency CS procedures. Obstetric decision-making could be improved with the implementation of fetal scalp pH testing facilities, fetal heart trace interpretation training and cardiotocography review meetings

[Gestational and Pregestational Diabetes Mellitus in Omani women; comparison of obstetric and perinatal outcomes]

Objectives: The aim of this study was to assess the prevalence of gestational diabetes mellitus [GDM] and pregestational diabetes mellitus [PGDM] among pregnant women in Oman and compare their obstetric and perinatal outcomes

Methods: This retrospective study assessed the obstetric and perinatal outcomes of pregnant Omani women with GDM or PGDM who delivered at the Sultan Qaboos University Hospital in Muscat, Oman, between January 2009 and December 2010

Results: There were a total of 5,811 deliveries during the study period. Of the 5,811 women who gave birth, 639 women were found to have diabetes mellitus [11.0%]. A total of 581 of the diabetic women had GDM [90.9%] and only 58 [9.1%] had PGDM. Women with PGDM had a significantly higher incidence of pre-eclampsia [P = 0.022], preterm deliveries [P <0.001] and Caesarean sections [P <0.001]. Neonatal complications, such as respiratory distress syndrome [RDS], neonatal hypoglycaemia, neonatal jaundice and subsequent admission to a neonatal intensive care unit [NICU] were significantly higher for neonates born to mothers with PGDM compared to those born to mothers with GDM [P <0.001]. The corrected perinatal mortality rates for women with PGDM and GDM were 34.5 and 13.7 per 1,000 live births, respectively

Conclusion: In this Omani cohort, women with PGDM were at higher risk of developing obstetric and perinatal complications such as pre-eclampsia, preterm delivery and Caesarean delivery compared to women with GDM. In addition, neonates who had mothers with PGDM had higher rates of RDS, neonatal hypoglycaemia, neonatal jaundice and admission to the NICU

Peer review and audit of morbidity after three or more caesarean sections

A retrospective cohort study was conducted of caesarean sections for women who had previously undergone two or more caesarean section performed by six obstetrician registrars in Sultan Qaboos University Hospital, a tertiary referral hospital in Oman. Retrospective data were collected from electronic health records of 120 Omani women between January 2010 and December 2011 [20 per registrar]. Haemorrhage of more than 1000 ml was recorded in 10% of patients, one patient was found to have a bladder injury intraoperatively, and postoperative wound infection occurred in 5% of patients. Difficulty in opening the abdomen was found in one patient, and one case of deep vein thrombosis occurred despite prophylactic heparinisation. One infant was preterm, and four had intrauterine growth restriction. Intraoperative complications, such as blood loss, visceral injury and long mean operating time and postoperative complications, such as deep vein thrombosis, wound infection and febrile morbidity, were comparable among the registrars. The standard of the registrars was comparable, and similar to international standards

[ unusual cause of acute central chest pain during advanced pregnancy]

Acute chest pain in pregnancy can have diverse etiologies ranging from simple to life threatening conditions. A structured approach is needed to reach the correct diagnosis in these cases. We report a case of acute chest pain due to chicken bone impaction in esophagus in advanced pregnancy

Multiple enteric duplication cysts in a twin fetus

Enteric duplication cysts are rare congenital anomalies of the gastrointestinal tract. These can be suspected if cystic lesions are noted in the fetal abdomen during an antenatal ultrasonogram. The differential diagnoses of fetal intra-abdominal cystic lesions include fetal omental cysts, fetal mesenteric cysts, meconium pseudocysts and fetal ovarian cysts. We report an antenatally diagnosed enteric duplication cyst in one of a set of twin fetuses which was managed successfully

Asymptomatic ovarian mucinous cystadenoma with a solid mural leiomyoma. Case report and brief review

Mucinous neoplasms of the ovary may have associated benign or malignant mural nodules. A leiomyomatous mural nodule is a rare, benign lesion associated with mucinous tumors of the ovary. We report a case of a mural leiomyomatous nodule arising in a benign mucinous cystadenoma in a 29-year-old woman who presented with a large heterogenous abdominal mass. After pre-operative evaluation, exploratory laparotomy was performed upon suspicion of ovarian malignancy. A pathological examination confirmed the benign nature of the mural nodule

Successful management of cornual ectopic pregnancy with systemic methotrexate

Cornual pregnancies remain the most difficult type of ectopic pregnancies to diagnose. The maternal morbidity and mortality rate of ruptured cornual pregnancy are still high. Ruptured cornual pregnancy usually presents dramatically with severe intra-abdominal bleeding necessitating urgent laparotomy. In unruptured cases, alternative treatment options like laparoscopic surgeries, local versus systemic methotrexate are found to be effective

Neonatal screening: mean haemoglobin and red cell indices in cord blood from Omani neonates

The aim of this study was to validate the interpretation of red blood cell indices in complete blood count [CBC] and high performance liquid chromatography [HPLC] results on cord blood samples in consecutive Omani neonates. Cord blood samples from 7,837 neonates, were analysed with CBC and HPLC using the beta-thalassaemia short programme. Direct sequencing of abnormal samples with HbS, HbD, HbE and HbC was performed to validate the HPLC results. Additionally, in cases with HbA <10%, the beta-globin gene was directly sequenced for beta-thalassaemia mutation analysis. Overall, 4,042 subjects [51.58%] had normal HPLC [HbA 22.88 +/- 8.03; HbF 77.02 +/- 8.04], whereas the presence of Hb Barts in the remaining 3,795 cases [48.42%] indicated the presence of alpha-thalassaemia. No case of HbH was detected. In the former subgroup respectively, the mean Hb [15.38 +/- 2.04 g/dl] red blood cell [RBC] count [4.69 +/- 0.68 x 10[12]/l], Hct [50.5 +/- 7.18%], mean corpuscular volume [MCV] [107.66 +/- 7.75 fl], mean corpuscular haemoglobin [MCH] [33.31 +/- 4.07 pg], mean corpuscular haemoglobin concentration [MCHC] [30.98 +/- 3.44 g/dl], red cell distribution width [RDW] [17.01 +/- 2.17%] whereas, in the latter group with alpha -thalassaemia, it was [14.79 +/- 2.90 g/dl]; [5.09 +/- 0.77 x 10[12]/l]; [49.7 +/- 7.40%]; [97.29 +/- 13.8 fl]; [29.74 +/- 11.80 pg]; [30.39 +/- 3.6 g/dl], and [18.09 +/- 2.56%] respectively. DNA sequencing of samples with abnormal haemoglobin could validate the CBC and HLPC interpretations in all cases. This is the first study comparing the hemoglobin and red cell indices in the cord blood from newborn Omani subjects with those from other countries in the region, showing comparable results to those seen in Saudi neonates. The study also validates the CBC and HPLC interpretations of the cord blood red cell indices in the Omani neonate. The incidence of alpha-thalassaemia diagnosed by the presence of Hb Barts in cord blood of neonates was 48.42%

Caudal regression syndrome with partial agenesis of the corpus callosum and partial lobar holoprosencephaly: case report

Caudal regression syndrome is a rare fetal condition of diabetic pregnancy. Although the exact mechanism is not known, hyperglycaemia during embryogenesis seems to act as a teratogen. Independently, caudal regression syndrome [CRS], agenesis of the corpus callosum [ACC] and partial lobar holoprosencephaly [HPE] have been reported in infants of diabetic mothers. To our knowledge, a combination of all these three conditions has not been reported so far

Metastatic malignant melanoma during pregnancy: case report and a review of the literature

Malignant melanoma is one of the most rapidly increasing cancers and, when it occurs during pregnancy, it can frequently metastasise to the placenta and the foetus. Earlier reports suggested a rapid progress of the disease during pregnancy with a poor prognosis; however, recent controlled studies found that stage for stage, the prognosis of melanoma during pregnancy is similar to that in a non-pregnant state. Early diagnosis and prompt treatment can avoid a tragic outcome

Ultrasound location of misplaced levonorgestrel releasing intrauterine system [LNG-IUS] - is it easy?

The Levonorgestrel intrauterine device [LNG-IUD] is a hormone-containing device licensed for treatment of menorrhagia and contraception. Though complications such as perforation have been reported similar to other non-hormonal intrauterine devices, the diagnosis of such complications is difficult with this device because the LNG-IUD has a different ultrasound appearance compared to copper devices and these case reports are intended to emphasize this point

Untwisting and fixation of ovarian torsion in early pregnancy

Adnexal torsion is a common gynecological emergency with an incidence of around 2-3%. Torsion may present as acute or chronic lower abdominal pain, which can be intermittent or constant. Risks of prolonged torsion include atrophy, necrosis, loss of ovarian functions and even premature menopause. [2] Traditionally, adnexal torsion has been treated in a radical manner without prior detorsion, due to fear of embolus migration from the twisted pedicle[3]. As there 1909, ovrian conservation was proposed to avoid castration in young women[4]. The concern of miscarriage due to removal of corpus luteum in early pregnancy encourages conservative surgery for ovarian torsion during pregnancy. We report two cases of ovarian torsion happened in the first trimester of pregnancy which successfully treated by untwisting and fixation of the affected adnexa

Recurrent cervical stenosis - a troublesome clinical entity

Cervical is a troublesome clinical problem. It usually follows surgery on cervix; also seen with endometrial and cervical malignancies. There is a high recurrence rate after the traditional treatment which is cervical dilatation. Various other treatment options have been tired. We report a case of recurrent cervical stenosis successfully treated with a different technique

Isolated torsion of a tubal ectopic pregnancy- a rare event

Adnexal torsion accounts for 2.7% of all gynaecological emergencies, but isolated torsion of fallopian tube is an infrequent yet significant cause of lower abdominal pain in women, which generally presents in the reproductive age group. The overall incidence is 1 in 1.5 million women and is generally isolated and unilateral. Patients typically present with intermittent pain related to torsion and detorsion of the involved adnexa. Early diagnosis and treatment is necessary if a twisted tube or part of it is to be preserved; early laparoscopy may be a considerable diagnostic tool in these cases. We report a case of isolated torsion of fallopian tube containing an ectopic pregnancy

Use of intravenous sulprostone for the termination of pregnancy with fetal death in second and early third trimester of pregnancy

To study the efficacy of intravenous sulprostone [Nalador] for the termination of pregnancy with fetal death in second and early third trimester of pregnancy. This is a retrospective collection and analysis of data from a cohort of 97 women with fetal death between 12-30 weeks gestation treated with intravenous infusion of a prostaglandin analogue, sulprostone, to achieve expulsion of the products of conception. It was conducted in the Department of Obstetrics and Gynaecology, Sultan Qaboos University Hospital, Oman. The data collected was from January 2000 to December 2005. Sulprostone was started as an intravenous infusion of 15 micro gm/hr and titrated to a maximum of 240 micro gm/hr to a total dose of 1500 micro gm/day, as per the departmental protocol. The patients- demographic data, gestational age, induction-expulsion interval, the need for evacuation, side effects and complications were studied. Out of the 97 women who received sulprostone, 90 aborted within 24 hours. The average induction-expulsion interval was 11.9 +/- 8.0 hours. Sulprostone use was associated with few side effects and was well tolerated by patients. Although most of the patients required evacuation and curettage, the blood loss was minimal. Only six out of 97 women required blood transfusions and two patients needed hysterotomy. We found sulprostone an efficient drug for termination of pregnancy with fetal death in second and early third trimester of pregnancy

Fetal macrosomia. Risk factors and outcome

To determine the risk factors predisposing to fetal macrosomia and assess the maternal and perinatal outcome in these patients. This was a retrospective analysis of all macrosomic deliveries in the Department of Obstetrics and Gynecology, Sultan Qaboos University Hospital, Sultanate of Oman, during a 3-year period from January 2001 - December 2003. The maternal and neonatal records of infants with birth weight of >/= 4000 g [n=275] were reviewed. Outcome variables included demographic profile, antenatal risk factors, mode of delivery and maternal and perinatal complications. A total of 7367 deliveries occurred during the study period. The rate of macrosomic deliveries was 3.75% and the rate of deliveries >/= 4500 g was 0.48%. The mean birth weight of the study group was 4230 +/- 220 g. Obesity, diabetes, prolonged gestation and postpartum hemorrhage were significantly higher in the study group. The cesarean section rate was 25.8% for the study group compared to the general incidence of 13.1% during the study period [p<0.0001]. The incidence of shoulder dystocia was 7.6% compared to the general incidence of 0.48% during the study period [p<0.0001]. There were 7 cases of Erb's palsy, all except one recovered without sequelae by 3 months of age. Gestational diabetes, maternal obesity, increasing age and parity were the main risk factors for fetal macrosomia. The incidence of shoulder dystocia, birth injuries and neonatal morbidity increased in this group