Brain tumor in pregnancy

A thirty-four year old Bahraini woman, para 4, at 32 weeks of gestation had developed progressive loss of vision, headaches and nausea. She was referred from neurosurgery to obstetrics department for urgent premature induction of labor. A Cesarian section was performed. A premature baby was resuscitated by neonatal pediatrics and the patient was referred to neurosurgery for excision of the tumor. The tumor was diagnosed as meningioma. This case was reported because of its rarity and to present an update on methods of treating brain tumor in pregnancy

Postpartum hemorrhage caused by pseudoaneurysm associated with malformations of the uterus

Uterine vascular abnormalities and pseudoaneurysm are rare but could cause serious delayed postpartum hemorrhage. Bleeding is usually recurrent and may be severe and occasionally potentially life-threatening. We present the first diagnosed case reported from Bahrain. The patient was 23 years old, para 1, abortion 0, had recurrent postpartum hemorrhage following cesarean section caused by a traumatic pseudoaneurysm which was treated with hysterectomy. The treatment of choice is uterine artery embolization if diagnosed early and this method is particularly helpful to preserve the reproductive function in women

Cervical cancer prevention in Bahrain: Review

Cervical cancer is estimated as the second most common cause of death worldwide from cancer in women. Approximately 650 women die from this cancer every day; half-million are diagnosed each year. Until recently, the few available reports on the prevalence of cancer from the Arabian Gulf Council States [GCC] were suggestive that the incidence of uterine cancer in general was less common compared with those reported from western country. Cancer registries in the GCC States in the last five years indicate that uterine cancer has moved to the third on the list of leading causes of cancer in the region. Among a population of 1,025, 000 in the kingdom of Bahrain, it is estimated that 10-15 new cases of cervical cancer are diagnosed each year [2001-2007], and approximately 4-6 deaths from this disease per annum. There is an evidence of a gradual increase in the incidence of cervical cancer compared with the figures two decades ago. The ratio of endometrial compared with cervical cancer was 1:2 but the two incidences are presently reversed. Cytology screening for uterine cancer was started in Bahrain in 1971, which soon was integrated in postnatal and in gynecological clinics. Recently successful program of public health screening was introduced against breast cancer in Bahrain; it is imperative that a similar program of national screening against uterine and cervical cancer combined with a national campaign for immunization of adolescent girls against human papilloma virus be integrated in the program and thus reducing the mortality from these two leading causes of cancer death among women. In this article a review of definitions, prevalence and history of cervical cytology service in Bahrain will be presented. Contemporary concepts of cervical cytology, new standard of care and current practice guidelines in screening and prevention will be reviewed. Finally, a discussion on the ways and means of improving the existing cytology and prevention programs in Bahrain will be discussed

Antenatal diagnosis and management of fetal mid-gut volvulus

Fetal volvulus is an uncommon cause of bowel obstruction, which is rarely detected by an antenatal ultrasound scan. We report a case which presented with fetal stomach and small bowels dilatation at 33 weeks of gestation detected by ultrasonography. She was referred to our unit for safe delivery at 34th week of gestation following a spontaneous rupture of membranes and signs of fetal distress. Delivery was accomplished by Cesarean section. Postnatally, the infant was surgically explored with resection of ileum and end to end anastomosis because of bowel gangrene and volvulus. Ultrasound diagnosis during pregnancy with fetal bowels dilatation is an important tool and may lead to early diagnosis and optimal management of intestinal obstruction

hospital-based epidemiologic study of hypertensive disease in pregnancy

Analyze the epidemiologic characteristics of hypertensive disease in pregnancy among women attending for care and delivery in the Salmaniya Medical Complex and peripheral Maternity Units in Bahrain between 1[st] Jan. 2001 to 31[st] Dec. 2003. Retrospective analytical study of all maternity admissions anti deliveries during this period. Archival records, labor ward registers, the Medical Records 'data base' and case records of patients were reviewed [with regard to nationality age, parity, antenatal care, onset and severity of hypertension, albuminuria gestational age at delivery, mode of delivery, complications of intra partum and post partum complications. Among 31639 patients delivered during this period there were 934 patients with hypertension [incidence rate 2.8%] The Bahrainis comprised 85.8% while the non Bahrainis were mainly from the Indian subcontinent [8.6%], from the Philippines [2.9%] and [2.5%] for different nationalities The median age was 29.81[SD +/- 7.207] with 26% in 15-25 year age group, 49% in 26-35 group and 24% in 36-45 year group. Primiparity seems to be a significant risk factor fur hypertension and 30% of patients belonged to this group. The risk decreased gradually with every further gestation until the fourth. After wards the risk is more parallel to age than to parity. There is an obvious seasonal variation in the incidence of pregnancy induced with higher number of admissions in the Sumner months [Aug.-Nov] and lower incidence during the mild winter-spring season [Dec.-May]. According to the prevalence of PIH in relation to the period of gestation 62% of cases occurred during the antenatal period, 22% where intra partum and 16% in post partum. Severe preeclampsia wag observed in 28.3% of cases while mild to moderate in 62.5°A. Cases of hypertension without albuminuria were 10.2%. There were 11 cases of eclampsia [1.2%] and two cases of HELLP syndrome [0.2%]. Small for gestational age occurred in 30.3%. our of which 67.6% were delivered preterm and 23% were at term. The Caesarean section rule was 32.7%, with 65.7% emergency and 34.3% were elective. There was only one maternal death in this series in a case of abruption followed by severe post partum hemorrhage, 9 cases of stillbirth [1%] and 8 neonatal deaths 10.9%]. Although incidence of preeclampsia is relatively low and the management is effective in preventing and treating cases of pre-eclampsia and eclampsia in this study the morbidity was considerable with longer hospitalization, higher incidence of caesarean deliveries. critical care [ICU], perinatal mortalities and maternal death. The extent of morbidity is much worse when the patients had little onto prenatal care. This calls fur new strategies for the prevention and early diagnosis of pregnancy induced hypertension

case of uterine papillary serous carcinoma presenting with ascitis and deep venous thrombosis

An elderly, Bahraini woman, with an ascitis, was referred to the Gynecology Outpatient to exclude pelvic pathology. She had an abdominal MRI report suggestive of endometrial hyperplasia. The patient was admitted for endometrial biopsy and cervical polypectomy. The following morning after the biopsy she developed massive deep venous thrombosis requiring insertion of inferior vena cava filter. The histopathology of the biopsy was suggestive of papillary serous carcinoma. After her family was informed, they requested that she should not be told the diagnosis. The treatment was discussed with the anesthetist and oncologist who recommended that in the light of her advanced disease and high surgical risk a course of palliative radiotherapy was advisable

Spontaneous uterine rupture in the second trimester of pregnancy associated with red degeneration of fibroid

A thirty-nine year old woman with history of infertility was admitted at the 14th week of gestation complaining of acute abdominal pain. Ultrasound revealed a large intramural fibroid bulging into the uterine cavity showing signs of degeneration. It was pressing on the gestational sac with a normal intrauterine pregnancy. The internal cervical os was funneling indicating incompetence of the internal cervical os. A diagnosis of threatened abortion associated with red degeneration of fibroid and cervical incompetence was made. McDonald cerclage was performed. Six days after discharge, she was readmitted with acute abdomen. Laparotomy revealed hemoperitonium due to a spontaneous rupture of the uterine fundus, through which the fetus was extruded in the peritoneal cavity. A discussion of clinical management is presented in the light of the current literature

Chronic non puerperal inversion of uterus

Inversion of the uterus is a rare clinical problem. It occurs either as an obstetric emergency or as a gynecological complication where it is a diagnostic challenge. A rare case of non- puerperal inversion, caused by fundal leiomyoma, was encountered in a-59- year old woman resulting in severe vaginal bleeding. It was thought initially to be a large pedunculated fibroid polyp, but it was discovered to be associated with inversion during surgery. She was treated with total hysterectomy using an abdominal and vaginal approach

Sickle cell disease in pregnancy obstetric and anesthetic management perspectives

Recent advances in the pathophysiology, clinical investigations, and management of sickle hemoglobinopathies enables all physicians to better manage these disease states and their sequelae. Patients with sickle cell disease SCD are living longer and are thus more likely to contract unrelated diseases that require surgery and anesthesia. Patients with SCD continue to be a challenge to all branches of medicine particularly in obstetrics, surgery and anesthesia; however, the armamentarium of new knowledge and practice places a different perspective on the care of this old disease. In general, the literature to date suggests that neither prophylactic transfusion of pregnant sicklers nor the selection of an anesthetic in labor have a major impact on patient outcome; however, perioperative management can greatly affect the consequences. A thorough knowledge of the impact of the disease on clinical status can determine how, when, and why to manage parturients with SCD

Invasive malignant thymoma in early pregnancy

Thymomas are an uncommon tumor of the mediastinum. When they are malignant it is even rarer for a young or pregnant woman to be affected. The condition has a bad prognosis unless surgery is followed by radiation therapy and chemotherapy, which must be instituted. The urgency of treatment makes medical termination of pregnancy an important procedure, particularly if the tumor is discovered in early pregnancy. We present here the first case reported in Bahrain of an invasive malignant thymoma in early pregnancy. The epidemiology, pathology and management of such cases are discussed

Two lives at risk considerations for the pregnant trauma patient

Problems created by maternal and fetal trauma during pregnancy such as road traffic accidents, pelvic fractures and other severe trauma, both blunt and penetrating, are discussed. Assessment of maternal injuries and fetal well-being prior to surgery is reviewed Implications of the physiological changes in pregnancy along with the principle of teratology and other adverse fetal affects associated with commonly used analgesics, antibiotics and some anesthetic agents are shown. Finally, the prevention of preterm birth which is a major complication of trauma and/or incidental surgery in a pregnant woman is reviewed. The pregnant trauma victim presents a unique challenge to the health care team. Two patients are being treated, and expertise of care is needed for both. Physiological changes in pregnancy, along with concomitant anatomic changes, are factors which may after injury response and necessitate modified resuscitation techniques and therapy. Even societal trends for the pregnant woman to continue active employment and participation in most activities may predispose her to an increased risk of trauma from gait instability secondary to pelvic ligamentous laxity and/or increased abdominal protuberance. Physicians must be knowledgeable about these changes to ensure that appropriate and timely care is rendered to the injured gravida

case report and review of the literature: Pelvic congestion syndrome

Pelvic congestion syndrome [PCS] is a well described, but frequently overlooked cause of chronic pelvic pain. It is manifested by pelvic pain of variable intensity that is aggravated by prolonged standing, fatigue, menstruation or intercourse.Although the condition has been described since the middle of the nineteenth century, the exact cause of the condition is not fully understood. Recent advances in imaging and laparoscopy have helped in achieving an accurate diagnosis. Surgical procedures are not always helpful in managing cases of pelvic varices. The most recent breakthrough has been the management of gonadal varicosities by an embolization technique. This case was first suspected following a pelvic ultrasound study. The diagnosis was confirmed by venography and embolization was performed in the Radiology Depar tment. This treatment modality is the first ever in the Kingdom of Bahrain. It shows specialized skills can satisfactorily cure a hither to difficult disease with simple minimally invasive techniques

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

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

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