Multiple repeat cesarean sections: operative difficulties, maternal complications and outcome.

OBJECTIVE: To determine maternal/neonatal complications and outcome in patients with multiple repeat cesarean sections (CSs). STUDY DESIGN: A retrospective case-control study of 144 pregnant women with > or = 4 cesarean sections was compared with a control group of 288 women having 2-3 cesarean sections for maternal, operative and neonatal complications. RESULTS: The study patients had longer operating times (p = 0.0001) due to severe adhesions (p = 0.0005), with increased blood loss and blood transfusion (p = 0.0001). Rupture of the uterus (p = 0.0015), placenta previa (p = 0.0372), gestational age at delivery (p < 0.0002), preterm birth (p = 0.0497) and Apgar scores < 7 at 5 minutes (p = 0.0140) were significant in the study group. There was no significant difference of placenta accreta, bladder and bowel injury, cesarean hysterectomy, wound infection and postoperative pyrexia between the 2 groups. Among the neonates of the 2 groups, NICU admissions, small-for-gestational-age birth weights, large-for-gestational-age birth weights and perinatal mortality were similar. No mother died in the series. The incidence of a single major complication was higher in women with > or = 4 cesarean deliveries (p = 0.0011). CONCLUSION: Repeated CS increases the risk of uterine rupture and intraoperative complications, making these patients a high-risk group. No absolute upper limit for the number of repeat cesarean deliveries can be given. Patients must be informed of the risks of multiple CSs and encouraged to have tubal ligation.

Massive Hematometra due to Congenital Cervicovaginal Agenesis in an Adolescent Girl Treated by Hysterectomy: A Case Report.

A case of massive hematometra with a bicornuate uterus in a 14-year-old mentally handicapped girl complicated by vaginal agenesis and absent cervix is presented. She was managed by abdominal hysterectomy and right salpingo-oophorectomy that included the ovarian cystadenoma. The left ovary was conserved. This treatment was considered appropriate for this patient.

Grandmultiparity: a potential risk factor for adverse pregnancy outcomes.

OBJECTIVE: To assess the incidence of antenatal and intrapartum and perinatal outcomes in grandmultiparae in an affluent society with available modern perinatal care. STUDY DESIGN: A case-control study in a tertiary referral hospital in Eastern Saudi Arabia of 2,122 grandmultiparae was undertaken. Each patient was compared with an age-matched multipara who delivered during the 10-year study period. Data was obtained from the computerized hospital information systems and their statistical analysis performed to determine the significant categorical variables. RESULTS: Grandmultiparity was associated with a significantly higher risk of iron deficiency anemia, diabetes mellitus, antepartum hemorrhage, malpresentation, cesarean section rate, postpartum hemorrhage and a high perinatal mortality rate. There was no significant difference in chronic hypertension in pregnancy, preterm labor, congenital fetal malformations, obstructed labor and cord prolapse between the two groups of patients. CONCLUSION: Grandmultiparae are a high-risk obstetric group of patients liable to develop a number of antepartum and intrapartum complications with adverse neonatal outcome. The best prophylaxis of these high risks in pregnancy would be the prevention of grand multiparity. Women need to be informed of the dangers of high-order births and advised to practice effective family planning methods to prevent pregnancy.

Risk factors for wound infection after lower segment cesarean section.

UNLABELLED: The incidence of post caesarean wound infection and independent risk factors associated with wound infection were retrospectively studied at a tertiary care hospital. A retrospective case controlled study of 107 patients with wound infection after lower segment caesarean section (LSCS) was undertaken between January 1998 and December 2007. The control group comprised of 340 patients selected randomly from among those who had LSCS during the study period with no wound infection. Chart reviews of patients with wound infection were identified using the definitions from the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance Systems. Comparisons for categorical variables were performed using the X (2) or Fisher exact test. Continuous variables were compared using the 2-tailed Student t test. P < 0.05 was considered significant. Logistic regression determined the independent risk factors. The overall wound infection rate in the study was 4.2% among 2 541 lower transverse CS. The independent risk factors identified for wound infection were, obesity, duration of labor >12 hours, and no antenatal care. Patients' age and parity, diabetes mellitus, premature rupture of membranes (PROM) >8 hours and elective vs. emergency surgery was not found to be significantly associated with wound infection. CONCLUSION: The independent risk factors could be incorporated into the policies for surveillance and prevention of wound infection. Antibiotic prophylaxis may be utilized in high risk patients such as PROM, obese patients and prolonged labor.

Management of adenomyosis in subfertile women and pregnancy outcome.

OBJECTIVES: To assess the outcome of treatment with only gonadotropin releasing hormone agonists (Gn-RHa) versus combined conservative surgery and Gn-RHa therapy in the management of sub-fertile patients with symptomatic uterine adenomyosis. METHODS: A retrospective study of the two treatment modalities allocated to 40 sub-fertile patients with pathology-proven adenomyosis over a period of eight years was undertaken at the Obstetrics and Gynecology department, King Fahad Hospital, Dammam University, Saudi Arabia. Twenty-two patients (Group A) were treated with Gn-RHa alone, and 18 patients (Group B) received combined conservative surgery with Gn-RHa therapy. After completion of six courses of Gn-RHa injections, there was a 3-year follow up period for all patients. Treatment outcome included relief of symptoms, pregnancy rate and successful deliveries, which were compared between the two groups. RESULTS: The patients in group A were younger in age, had lower CA-125 levels and shorter infertile years than Group B. Three (13.6%) spontaneous pregnancies resulted upto 18 months of stopping Gn-RHa in group A, while 8 (44.4%) pregnancies resulted upto 36 months in group B patients, which was statistically significant (p=0.0393). Term delivery occurred normally in one (4.5%) Group A patient, while 6 (33.3%) patients in Group B had cesarean section at term (p=0.0328). CONCLUSION: Combined conservative surgery and Gn-RHa may provide effective symptom relief, better reproductive performance in subfertile patients with uterine adenomyosis and longer period of pregnancy prospects after treatment than patients who recieved Gn-RHa alone. Due to the nature of this study, a well conducted randomized trial is needed in the future to assess the benefits of the two treatment modalities.

Ovarian tumors in children and adolescents--a clinical study of 52 patients in a university hospital.

STUDY OBJECTIVE: To review the clinical presentation of ovarian tumors in children and adolescents treated at the University of Dammam and King Fahad University Hospital. DESIGN: Data of the patients was noted retrospectively from the hospital medical records regarding age, presentation, diagnosis, treatment, and outcome. SETTING: The study was carried out in the Ob/Gyn department at King Fahad Hospital of Dammam University, Saudi Arabia between January 1985 and December 2009. PARTICIPANTS: There were 52 patients between 6 and 20 years of age who presented with an ovarian tumor during the study period. INTERVENTION: Preoperative diagnostic approach included history, physical examination, ultrasonography, radiological examination, tumor markers, operative treatment, and histopathological examination of the tumor. Chemotherapy was given to patients where indicated. RESULTS: The main presenting symptom was abdominal pain in 30 (58%) patients. Of the neoplastic tumors, 87% were germ cell tumors, of which 73% were benign while 13% were malignant. Operative procedures included 48 (92%) exploratory laparotomies and 4 (8%) laparoscopic resections. Ovarian cystectomy was done in 23 (44%) patients and salpingoophorectomy in 28 (54%) patients. Of the 7 (13%) patients with malignant tumors, five received postoperative chemotherapy. Three patients with malignancy died in the series. CONCLUSION: Early diagnosis of ovarian masses in young girls is important. Since most of these masses are benign, operation should be designed to optimize future fertility, while the treatment of malignant tumors would involve complete staging, resection of the tumor, postoperative chemotherapy when indicated, to give the patient a chance for future childbearing.

Ovarian tumors associated with pregnancy: a 20-year experience in a teaching hospital.

OBJECTIVE: Pregnancy associated with ovarian tumors was reviewed over a 20-year period to determine the maternal and fetal outcome in patients undergoing surgery during pregnancy. METHOD: A retrospective study of 94 cases of ovarian tumors treated surgically during pregnancy was investigated for incidence, clinico-pathological features and outcome in a teaching hospital between June 1987 and May 2007. RESULTS: The overall incidence of ovarian tumor in pregnant women was 1 in 505 (0.2%) deliveries. Diagnosis of 69.2% tumors resulted in the first and second trimesters of pregnancy. Twenty-two (23.4%) patients presented as an emergency at different periods of gestation and 16 (17.1%) tumors were incidentally discovered at cesarean section which underlines the significance of examining the ovaries routinely at cesarean section. Benign teratoma (39.4%) and serous cystadenoma (24.5%) were the most common types of ovarian tumors found in the study. The incidence of malignant tumors was 5.3%. Tumors with low malignant potential comprised 40% of malignancy. The miscarriage rate after surgery was 44.4% in the first trimester compared with 16.6% in the second trimester. The preterm birth rate was 4.3% in the series. CONCLUSION: The value of clinical and ultrasound examinations in early pregnancy as a diagnostic aid is highlighted. Whenever an ovarian tumor is detected in pregnancy, malignancy should always be suspected. Treatment of an ovarian tumor in pregnancy should be tailored according to the age, parity, clinical presentation, gestational age and histopathology of the tumor. Removal of persisting or enlarging ovarian masses as soon as possible is important to obtain a final histologic diagnosis and rule out malignancy. Early diagnosis and appropriate treatment of malignant tumors offers the best prognosis for the patient.

Maternal and fetal outcome of pregnancy complicated by HELLP syndrome.

OBJECTIVE: The study evaluated the maternal and fetal outcome in 64 pregnancies complicated by HELLP syndrome. METHODS: A retrospective analysis of the medical records was performed of patients with HELLP syndrome managed at this tertiary Obstetric unit between January 1996 and December 2005, who were admitted for preeclamsia/eclampsia and had documented evidence of hemolysis, elevated liver enzymes and low platelet count. Maternal and neonatal complications were recorded and analyzed. RESULTS: The incidence of HELLP syndrome in the study was 8.3%. Mean gestational age at delivery was 32.4 +/- 4.2 weeks and mean birth weight was 1851 +/- 810 g. Forty-two percent of the patients had deliveries <32 weeks and 28% IUGR. Respiratory distress syndrome was the main indication for NICU admissions (33.9%). The PNM rate was 20%. Maternal morbidity rate was 34%. The most common maternal complications were abruptio placentae (36.4%) and DIC (31.8%). There was no maternal death. CONCLUSION: Once the diagnosis of HELLP syndrome is confirmed, the management depends on several obstetric and maternal variables like gestational age, severity of laboratory abnormalities and fetal status. As soon as the maternal condition is stabilized and fetal assessment is obtained, prompt delivery of the fetus is indicated. It is not yet established whether expectant management in preterm pregnancies with HELLP syndrome would improve perinatal outcome.

Pregnancy outcome in patients with homozygous sickle cell disease in a university hospital, Eastern Saudi Arabia.

OBJECTIVE: To evaluate the maternal and fetal outcome in pregnant women with sickle cell disease and to highlight the complications encountered during pregnancy and delivery at a university hospital in the Eastern Saudi Arabia. STUDY DESIGN: A retrospective study of 255 pregnancies in 145 patients with sickle cell disease (SCD) over an 8-year-period analyzed the perinatal complications and maternal and fetal outcomes compared with a control group of 500 Saudi females with the normal hemoglobin phenotype selected randomly that matched for age, parity and delivered during the study period. RESULTS: The incidence of SCD was 1.3% of all deliveries with one maternal death (0.4%) and a perinatal mortality rate of 78.2/1,000 deliveries in the series. The major maternal complications in the 255 pregnancies were anemia 84.3%, sickle cell crisis 44.3% (26.6% painful and 17.7% hemolytic crises), infection 45.9%, fetal growth restriction 20.1%, preterm delivery 12.6%, and pregnancy-induced hypertension 10.6%. Blood transfusion was necessary in 34% pregnancies. Stillbirths accounted for 63% of the perinatal mortality. CONCLUSIONS: Saudi women with SCD are at a greater risk of morbidity and mortality in pregnancy than previously reported, with a high perinatal mortality rate. Early booking, meticulous antenatal care and supervised hospital delivery will improve the maternal and fetal outcomes in these patients.

Bladder injuries during cesarean section in a University Hospital: a 25-year review.

OBJECTIVES: The objective was to determine the prevalence of bladder injury during cesarean section (CS) and identify the risk factors causing these injuries, their management and the outcome. METHODS: We retrospectively reviewed the medical records of all the patients who had bladder injury during CS over a period of 25 years (1983-2007) at the King Fahad Hospital, Al-Khobar, Saudi Arabia. Demographic data, obstetric, surgical details, mechanism of injury, anatomic location, diagnosis, management and outcome were assessed. RESULTS: Thirty-four cases of bladder injury were identified among 7,708 cesarean deliveries performed during this period with an overall incidence of 0.44%. Primary CS was found in 41.2% of the patients and 58.8% had repeat CS giving an incidence of 0.27 and 0.81%, respectively. Bladder injury occurred when surgical difficulties were encountered during opening of the peritoneal cavity and while developing the bladder flap over the lower uterine segment, mainly due to adhesions and scar tissue resulting from previous abdominal surgery. All the bladder injuries were recognized intraoperatively and repaired with an overall satisfactory outcome. Repeat CS and presence of adhesions were found to be statistically significant risk factors in the study, while operator experience and emergency nature of the CS were considered risk factors in a few cases of bladder injury. CONCLUSIONS: Data presented in this study indicates that bladder injury when adequately repaired is rarely associated with any complications. Multiple cesarean deliveries is a significant risk factor for bladder injury at the time of repeat CS and patients should be counseled regarding this risk before surgery.

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. METHODS: A retrospective review of all women diagnosed to have cancer of the ovary associated with pregnancy who delivered at the authors' hospitals between January 1976 and December 2000. The demography, clinical presentation, time and mode of diagnosis, treatment, pregnancy outcome and maternal survival were noted. RESULTS: The incidence of ovarian carcinoma in pregnancy in the series was 0.08/1000 deliveries. Of the 9 patients, 7 had epithelial cancers; 4 serous cystadenocarcinoma, 2 mucinous cystadenocarcinomas and one undifferentiated cancer. One patient each had dysgerminoma and granulosa cell tumor. Six patients were in FIGO stage Ia, one Ic, one IIa. One patient was in stage III. Five patients were treated by unilateral salpingo-oophorectomy during pregnancy. Three patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy followed by chemotherapy. Debulking of the tumor was done in a patient in stage III with subsequent chemotherapy. This patient died 13 months from the time of diagnosis of the tumor. The overall 5-year survival rate in the series was 78% and 100% for stage Ia. CONCLUSIONS: Association of ovarian cancer with pregnancy is a rare occurrence. Early diagnosis and appropriate treatment offers the best prognosis for the patient. The higher survival rates in the series was attributed to a larger number of patients in stage I of the disease and 2 patients with a germ cell tumor and dysgerminoma which have the best prognosis. Aggressive postoperative chemotherapy also contributed to the better outcome.