Myositis ossificans around an elbow following a major burn

This is a case report of a middle aged Indian male who suffered extensive burns following a gas explosion in his home. Following usual and customary management of the burns, he developed myositis ossificans in the right elbow some four weeks following completion of his treatment. This condition is rarely found subsequent to burn injuries. Movement of the elbow was painful and limited. This is the first such case to be reported from the Kingdom of Bahrain

Cryptogenic fibrosing alveolitis necessitating therapeutic termination of a first trimester pregnancy

Twenty-seven years old Bahraini lady, known to be suffering with fibrosing alveolitis for some eight years, presented to the accident and emergency department of Salmaniya Medical Complex. Recently her respiratory function had deteriorated and she had become house-bound on home oxygen therapy and nebulizers. She was taking Prednisolone tablets and Immuran. She was admitted to the Intensive Care Unit [ICU] in extreme respiratory distress for the past two days. While she was in the hospital, she complained of breast tenderness and supra pubic pain, her period being twenty days overdue. BIICG pregnancy test proved to be positive. Management and outcome of her case is herewith discussed

Amniotic fluid embolism

Amniotic fluid embolism, although fortunately rare, is one of the most catastrophic situations in obstetrics. It cannot be predicted nor prevented. The clinical events in this syndrome include respiratory failure, cardiopulmonary collapse, and disturbances of the clotting mechanism. Maintenance of oxygenation, circulatory support and correction of the coagulopathy can be life saving. Although maternal and fetal prognosis is grave, death need not be the inevitable outcome if diagnosis is made early and is followed by prompt and aggressive management. Future efforts must be directed towards more clearly delineating the presentation, pathogenesis, diagnosis and outcome of amniotic fluid embolism

Obstetric, neonatal and anesthetic considerations for preterm labor and delivery

Preterm birth is a continuing obstetric problem that contributes significantly to the incidence of perinatal death and long-term handicap. In this context, various studies have shown preterm births account for between 69% and 83% of neonatal deaths. Despite this, the incidence of preterm birth has remained static for many years. One explanation for this is that the management of preterm labor has altered very little in the past 30 years. Strategies aimed at reducing the incidence of preterm birth include the identification of risk factors that increase the likelihood of preterm delivery. Treatment is then designed to target those risk factors and limit their effect. Although perinatal mortality has declined, mostly due to the improved management of very low birthweight babies rather than prevention of preterm labor, efforts to prevent preterm birth have been largely unsuccessful so far and preterm birth still represents a major health care problem to both developed and developing countries

Screening for gestational diabetes by measuring fasting plasma glucose levels

To test the sensitivity and specificity of measuring fasting plasma glucose levels [FPG] as a screening test for gestational diabetes mellitus [GDM]. [b] To compare predicting levels of FPG levels with the one-hour, oral 50g non-fasting glucose challenge test [GCT] for predicting GDM. One thousand and six hundred pregnant women from the Health Centres, antenatal clinics and Salmaniya Medical Complex were screened by the GCT after 50g of oral glucose during 26-32 weeks gestation, giving a 13.5% incidence of GDM [using the Third International Workshop cutoff values of 7.8 mmol/l]. All patients also had an FPG estimation followed by the three-hour oral glucose tolerance test [oGTT]. Seventy eight percent of the patients were Bahraini, 19% Asian and 3% other nationalities. Their mean age was 27.2+0.2 years. Receiver-operating curves [ROC] were used to test the ability of the FPG and the oGTT to differentiate patients with GDM and identify the cut off values for predicting a diagnosis of GDM. FPG levels of 5.6 mmol/l and 5.4 mmol/l yielded sensitivities and specificities of 94% and 93% respectively. Measuring FPG as a screening test required a diagnostic oGTT in 32% compared with 13% when the GCT was used. Using FPG levels at a cutoff value of >/= 5.5 mmol/l is an easier, more acceptable test for patients compared to the GCT. Using the FPG levels is also more cost effective and allows nearly 70% of women to avoid the oGTT

HELLP Syndrome [hemolyisis, elevated liver enzymes and low platelets]: a review of the pathophysiology, diagnosis, management and anaesthetic considerations

HELLP syndrome [hemolysis, elevated liver enzymes, low platelets] is associated with poor maternal and fetal outcomes. Maternal mortality has been estimated as high as 24%. These patients are also at greater risks from pulmonary edema, adult respiratory distress syndrome [ARDS], abruption placentae, disseminated intravascular coagulopathy [DIC], ruptured liver hematomas, and acute renal failure [ARF]. Perinatal mortality is equally high ranging from 79 to 367 per 1000 live births, and neonatal complications correlate with the severity of maternal disease. Many clinicians view HELLP syndrome as an entity of preeclampsia, and with the varied symptomatology, the initial diagnosis may be obscured. Prodromal signs include: 1] right upper quadrant and/or epigastric pain, 2] nausea and vomiting, 3] headache, 4] visual changes, 5] increased tendency to bleed from minor trauma, 6] jaundice, 7] diarrhea and 8] shoulder or neck pain. Prior to delivery, aggressive obstetric management is directed toward stabilization of the affected organ systems and timely interruption of the pregnancy in the early phase of accelerated disease progression. Definitive therapy is delivery. Parturients with HELLP syndrome are often critically ill; their infants are frequently premature and compromised. Management criteria should include a multidisciplinary approach in a tertiary care centre. The obstetric anesthesia personnel should petform a thorough preanaesthetic evaluation and have considerable knowledge of the pathophysiology of this syndrome. Unless significant coagulopathy is diagnosed, epidural anesthesia is preferred over general anesthesia, and spinal anesthesia is perhaps contraindicated

Antiphospholipids [Hughes] syndrome pregnancy: a report of three cases and review of the literature

Since the discovery of the antiphospholipids syndrome in the early eighties, many clinical conditions have been described in patients with antiphospholipid antibodies. Complications include infertility, recurrent miscarriage and increased perinatal mortality. A more serious complication, however, are episodes of arterial thrombosis during pregnancy and puerperium. We have had six such cases in the last three years, of which, the three with major complications are reported here. The first patient had a combination of sickle cell disease, J3-thalassaemia and antiphospholipid antibodies during pregnancy. Put on heparin prophylaxis, she was delivered at 38 weeks by Caesarean section, but died postnatally of a massive pulmonary embolism. The second patient reported at eight weeks of gestation with evidence of a cerebro-vascular accident. Her condition improved and her pregnancy was terminated. The third, a young woman with a history of infertility, was treated with assisted reproductive technology and became pregnant but had a mid-trimester abortion. Eventually she had a normal gestation with heparin prophylaxis and delivered a live baby. Antiphospholipids syndrome is not uncommon in Bahraini pregnancies. Considering the impact of this disease on reproduction and the range of complications involved, screening of pregnant women with a bad obstetric history or recurrent miscarriage is essential