Management of spleen injuries at Algamhouria Teaching Hospital – Aden Yemen

Spleen is the most frequently injured organ in blunt abdominal trauma. This study is conducted to evaluate operative and non-operative management [NOM] performed for splenic trauma by comparing their outcomes. This is a prospective study, including 72 patients treated for splenic trauma, performed at Algamhouria General Hospital from 1st February 2009 to 31st January 2013. Data were analyzed using SPSS, version 17. A p – value = 0.05 was considered significant. Associated injury, blood transfusion requirements, morbidity, mortality and length of hospital stay was done and discussed. There were 52 males [72.2%] and 20 females [27.8%] patients, and the mean age was 30.93 +/- 15.41 years. Blunt and penetrating injuries were documented in 62 [86%] and 10 [14%] patients, respectively. Of the 72 patients, 38 patients [52.8%] were treated surgically and 34 patients [47.2%] were treated conservatively. Laparotomy was performed in 38 patients [52.8%], of which 34 patients [47.2%] undergone splenectomy and 4 patients [5.6%] undergone splenorrhaphy. The mean units of blood transfused in both groups were 2.29 +/- 1.89 units. Associated injuries were observed in 69 patients [95.8%], with head injury as the commonest one. The morbidity rate in all patients was 5.6%. The mortality rate was 5.6% for all patients. The mean length of hospital stay was 11.66 +/- 5.66 days. The selection of NOM in hemodynamically stable patients is safe, effective and associated with low morbidity and low mortality. However, this depends on the individual merits of each case and the available facilities of adequate scanning and ICU monitoring service.

Feasibility of colour doppler ultrasound in diagnosing vesicovaginal fistulas

The purpose was to evaluate the feasibility of diagnosing vesicovaginal fistulas by colour Doppler ultrasound with contrast media. Eighteen consecutive patients were examined by vaginal speculum, methylene blue test, cystogram and cystoscopy For ultrasound examination, the bladder was filled with saline, then diluted contrast media [Levovist] was instilled. Colour Doppler ultrasound revealed a jet phenomenon through the bladder wall toward the vagina, confirming the existence of the fistula. 17 patients had vesicovaginal fistulae, and one patient had a vesicoureterovaginal fistula. Colour doppler ultrasound had correct results in 17 of 18 patients [94%]. In follow-up examinations of four patients during a prolonged drainage of the bladder, we could correctly demonstrate the closure of one fistula. Colour Doppler ultrasound with contrast media is a new useful diagnostic tool in the evaluation and follow-up of vesicovaginal fistulas. It is less invasive than cystoscopy and needs no radiation exposure. The examination is well tolerated by the patients

Conservative laparoscopic management of tubal ectopic pregnancy

To study the success, safely and post-operative reproductive performane of conservative laparoscopic treatment of ectopic pregnancy [EP]. Study design: 32 cases of EP were retrospectively analyzed. These cases were managed during the period from Jnuary 1992 to Jnuary 1996. Out of these cases, 24 were primarily treated by laparoscopy and 8 with laparotomy due to hypovolemia and shock at the time of hospital admission [3], previous multiple abdominal surgery [2], extensive pelvic adhesions [1], associated uterine myomas [1] and anesthesia contraindication to laparoscopy [1]. The twenty four cases treated by laparoscopy were analyzed as regards the type and site of EP, type of sugery done, operation time and intra- and post-operative complications. Follow up of 28 out of the 32 patients was available as regards subsequent fertility. Out of the 24 patients primarily treated by laproscopy, 23 [95,8%] were successfully managed by laparoscopy alone and only one [4.2%] needed laparotomy due to intra-operative hemorrhage. Seventeen patients [70.8%] were subjected to laparoscopic linear salpingostomy, two patients had complete tubal abortion at the time of laparoscopy [8.4%] and laparoscopic salpiagectomy was done in the remaining 5 patients [20.8%] due to ruptured tube [4] and the absence of need for further pregnancy [1]. In all patients who were successfully treated by laparoscopy, there was no need for blood transfusion and no major intra- or post-operative complications. The mean duration for hospital stay was 25.3 hours for laparoscopically treated patients and 3.6 days for those treated by laparotomy. Twenty-eight patients [out of the original 32 cases of EP] requesting further pregnancy, 18 [64.3%] delivered a living infant within 24 months of follow up. Laparoscopic management of tubal EP is recommended in all cases except those who are shocked; hemodynamically unstable or those with other contra-indications to laparoscopy. Conservative salpingostomy is recommended in cases with unruptured tube that request future pregnancy

Relationship of anti 22 - glycoprotein 1 antibody to pregnancy loss in patients with antiphospholipid antibodtes

The lupus anticoagulant [LA] and anticardiolipin antibodies [aCL] are clinically relevant because of their association with thrombosis and pregnancy loss. The group of antiphospholipid antibodies [aPL] includes antibodies primarily directed against various phospholipid-binding proteins, mainly beta 2-glycoprotein 1 [beta 2GP1]. Some studies suggest that there is an association between the presence of anti beta 2GPl antibodies [a beta GPl] of IgG issotype and thrombosis. Therefore, aPL defined according to the plasma protein to which they are directed appear to be more appropriate for the evaluation of their clinical importance. Using home-made ELISAs we evaluated the presence of a beta 2GP1 of both isotypes [IgG and IgM] in 80 patients with LA and/or aCL. The patients were divided into 2 groups group 1: 40 patients with history of pregnancy complication and group II: 40 patients without a history of pregnancy complication. The study demonstrated that the presence of a beta 2GPl-IgM correlates well with a history of pregnancy loss [OR 2.6; 95% CI 1.1 - 6.1]. So, the present study concluded that the measurement of a beta GP1 of both isotypes could help to identify a PL-positive patients with higher risk for pregnancy loss, although this association should be confirmed by other studies

Transvaginal sonography and color doppler imaging in the follow-up of patients with gestational trophoblastic disease

Uterine morphology assessed by transvaginal sonography [TVS] and the hemodynamics of intra-tumoral vessels assessed by color Doppler ultrasound [CDU] were prospectively correlated with the clinical outcome of 9 patients with gestational trophoblastic disease [GTD]. Six patients were managed and followed without treatment and 4 of them achieved complete local resolution. Three patients were referred for sonographic evaluation of persistent trophoblastic disease. Our four patients with one referred subject did not need any further treatment [Observation group, n = 5]. Two of our patients plus two of the three referred patients were found to have persistent disease and they received chemotherapy [Treatment group, n = 4]. In the observation group both techniques; TVS and CDU, had 100% accuracy in predicting local resolution or local persistence. Persistence was predicted 1-2 weeks before the increase of B human chorionic gonadotropin [B-hCG] levels, whereas resolution was observed up to 6 weeks before the disappearance of beta-hCG. In one patient normal uterine morphology and vascularization in the presence of elevated hCG levels was associated with extrauterine spread. In the treatment group, normal uterine ultrasound morphology and negative color Doppler results had 75% negative predictive value, A false-positive result was observed in one case. We conclude that ultrasound evidence of abnormal uterine morphology or persistent vascularization on color Doppler examination with persistent hCG levels is indicative of local persistence. Normal uterine morphology with negative color Doppler results may be associated with extrauterine spread

Diagnosis and management of failed ovum pickup, a postulated cause of unexplained infertility

To study the ovum pickup mechanism and the fimbrio-ovarian relation in fertile and cases of unexplained infertility and to design a method for investigation and anticipation of the state of ovum pickup. Prospective clinical study. Department of Obstetrics and Gynecology Kasr El Aini Hospital, Cairo University, Egypt. Fifty fertile and twenty five cases of unexplained infertility. In all cases the fimbrio-ovarian relation is studied by determining the length of the ovulation border, the site of ovulation on that border and the length of the firnbria ovarica. It is also determined by a simple test [The fimbrio-ovarian accessibility test]. The fimbrio are held by non-traumatizing grasper and their ability to reach and/or to cover the ovulation site are taken as prove for successful ovum pickup. In addition, cases having suspected failed ovum picking are treated by controlled superovulatton, drilling of the ovary at an accessible site to the fimbrio ovarica and also by freeing short fimbrio ovarica, or partial bisection of the ovarian ligament using bipolar diathermy to allow for more ovarian accessibility to the fallopian tube and hence improving the fimbrio -ovarian juxtaposition. The ovulation site is found to be usually accessible to the fimbrio end of the tube [94%] in the fertile cases and not accessible [92%] in the infertile cases. Correction of the fimbrio-ovarian relation in the infertile cases was associated with a cumulative ongoing pregnancy rate of 68%. Failed ovum pickup should be considered as one of the important causes of unexplained infertility. The suggested "firnbrio - ovarian inaccessibility" should be considered in these cases. Correction of the fimbrio-ovarian relation, to make ovum pickup possible, should be considered as a method for treating such cases