Gynecology and obstetrical conditions requiring intensive care admission.

OBJECTIVE: Gynecological admissions to the surgical intensive care unit vary from the obstetrical cases. Pregnant women are of prime age and can tolerate the pregnancy and delivery well. There are certain rare conditions or complications, which make the pregnant women's life pass through a critical time. These are dealt with in a high dependency area, which is short of the intensive care unit. In King Khalid University Hospital there is no such arrangement, so the mildly affected and critically ill patients together are cared for in the surgical intensive care unit. The objective of this study is to study the gynecological and obstetrical conditions requiring intensive care admission in King Khalid University Hospital, surgical intensive care unit. METHODS: All obstetrical and gynecological patients who were admitted to the surgical intensive care unit were included. The demographic particulars, reason for admission, the course of the surgical intensive care unit stay and outcome were studied. RESULTS: During the study period of 3 years, there were 83, (100%) obstetrical and gynecological admissions to the surgical intensive care unit. Two (2%) cases were due to anesthesia complications. The majority of causes of admissions were due to obstetrical (n=63, 76%) complications or combination of medical and surgical conditions. Gynecological admissions comprised only 18 (22%) cases. There was no mortality in the group studied. CONCLUSION: Management of major obstetrical emergencies and gynaecological patients require an understanding of medical conditions' influence on the patients, and the physiological changes of normal and abnormal pregnancies. Intensive care unit management is an essential part in raising the level of patient care; health personnel training and continuing health care education may be improved.

Lipids and related parameters in Saudi type II diabetes mellitus patients.

BACKGROUND: Non-insulin dependent diabetes mellitus (type II DM) is frequently associated with abnormal levels of lipids, particularly in patients with poor diabetic control. This study was designed to investigate the influence of type II DM on levels of plasma lipids and other related parameters in Saudi patients. Saudi Arabia has a high prevalence of diabetes mellitus in the adult population. Since the Saudi population presents a unique group with different dietary habits, lifestyle and genetic make-up, we investigated the lipids, lipoprotein and apolipoprotein pattern in Saudi type II DM patients. MATERIALS AND METHODS: This study was conducted on 2835 diabetic patients (1361 males, 1474 females) and 200 age-matched healthy adults from the same areas with no history of diabetes mellitus. Data collected included height, weight, body mass index (BMI), blood pressure and other relevant parameters. Lipids, lipoproteins and apolipoproteins were estimated, and correlation studies were carried out between these parameters. Lipids, lipoproteins and apolipoproteins were also correlated with the fasting blood glucose. RESULTS: Our results showed significant elevation in cholesterol and triglyceride, apo A and apo B levels in the diabetic males and females compared to the controls. Approximately 37% of the total DM patients fell in the borderline risk group, while 28.4% fell in the high-risk group for development of cardiovascular disease. Lipoproteins did not differ significantly. Cholesterol, triglyceride, VLDL, LDL and Hb A1c correlated positively with glucose (P<0.05), while triglyceride, VLDL, HDL, LDL, apo A and apo B showed significant correlation with cholesterol, where all parameters increased with cholesterol except HDL, which decreased as cholesterol increased. CONCLUSION: The findings point toward high prevalence of dyslipidemia in type II DM Saudi patients.

Abdomino-pelvic packing to control severe haemorrhage following caesarean hysterectomy.

Surgically uncontrollable peri-operative obstetric haemorrhage associated with coagulopathy, developed in five women who were managed by emergency caesarean hysterectomy. All women had a morbidly adherent anterior placenta praevia and a previous lower segment caesarean section scar. Conventional medical and surgical therapy to control bleeding from pelvic and abdominal raw surfaces were unsuccessful. Abdomino-pelvic packing was performed with 10-12 dry laparotomy pads applied firmly over bleeding sites. The abdomen was closed after observation of the cessation of bleeding for 5-10 minutes. Following correction of coagulation and haemodynamic disorders relaparotomy for pack removal was performed 34-48 hours later. One patient developed small bowel obstruction on the 5th post-operative day, however, there was no long term gynaecological morbidity in any of the cases. Abdomino-pelvic packing achieved complete haemostasis in all of the five women which we believe may have been impossible using alternative measures.

Obstetric outcome in the unbooked mother.

This study aimed at determining the outcome of pregnancy in unbooked mothers with regard to maternal complications and foetal outcome. This retrospective study was based on investigations of medical records of 467 unbooked mothers who presented for delivery at the Obstetrics Unit at King Khalid University Hospital, Riyadh, during the period 1991 and 1992, and 415 booked mothers with regular clinic attendance selected as controls. Data collected from the records included patients' socio-demographic characteristics, past obstetric history, prevalence of pregnancy-related diseases, and data relating to labour, delivery, and foetal outcome. Chi-square test and Fisher's exact test were used for assessing the statistical significance of the association between the various factors which were investigated. The tendency for mothers to be booked was found to be significantly associated with their age, occupation, parity, and gestational age at delivery. Booked and unbooked mothers did not differ significantly in relation to the mode of delivery and foetal outcome, although the prevalence of previous complications of pregnancy was generally lower among unbooked mothers. There was no statistically significant association between the absence of antenatal care and outcome of pregnancies, unbooked mothers had a higher proportion of MICU admissions and dead babies compared with the controls. Educating the community about the benefits of receiving regular antenatal care, even if at primary care level, may be of great importance in improving the pregnancy outcome.

Laparoscopy for ovarian pathology in infancy and childhood.

Conventionally, adnexal pathology in pediatric patients is treated by open laparotomy. As laparoscopic procedures are constantly finding wider application in pediatric surgery, the female child presenting with a suspected acute or chronic ovarian lesion may be an ideal candidate for laparoscopic surgery. From June 1994 to June 1996, eight girls aged 4 months to 11 years (mean 6.1 years) underwent laparoscopic procedures for various ovarian pathologies at King Khalid University Hospital (7) and Hamad Medical Corporation in Qatar (1). Four children had emergency laparoscopic surgery for lower abdominal crises; three of them were managed successfully for twisted adnexal lesions (2 simple ovarian cysts, 1 benign cystic teratoma), the fourth patient was converted to an open salpingo-oophorectomy. The other four patients had elective laparoscopic excision of adnexal lesions (two antenatally diagnosed ovarian cysts and two mature ovarian cystic teratomas). There were no operative complications; the mean operative time was 76.25 min, the mean hospital stay 2.25 days. Our initial experience and technique are presented. It appears that the laparoscopic approach to ovarian lesions in infancy and childhood is an effective and safe method for diagnosis as well as definitive therapy.

Correlation of smoking and coffee drinking with sperm progressive motility in infertile males.

The objective of the study was to assess the effect of some social characteristics on the forward progressive motion of sperms in males of infertile couples. The study was conducted in the Department of Obstetrics and Gynecology, King Kahlid University Hospital (KKUH), Riyadh, from September 1, 1994 to February 28, 1995. Semen specimens were obtained from 68 Saudi males of infertile couples, and 29 fertile males. Using computer-assisted semen analysis (CASA), sperm forward progressive motion was determined and graded on a scale of 1-4. The actuarial life table survival analysis method was used to investigate the sperm motility potentials across intervals 0-1, 1-2, 2-3, and 3-4 and the effect of smoking and coffee drinking was also determined on the sperm motility. Smoking was found to significantly improve sperm motility among the infertile group. Similarly, frequent coffee drinking was shown to enhance sperm motility. There is a need for further studies on the influence of smoking and coffee drinking, as well as the plethora of other influence of the daily life that may compound the detection of the subtle changes in semen quality.

Intravenous iron sucrose complex in the treatment of iron deficiency anemia during pregnancy.

OBJECTIVE: To evaluate the safety and efficacy of intravenous iron sucrose complex (ISC) as compared with oral ferrous sulfate in the treatment of iron deficiency anemia during pregnancy. STUDY DESIGN: prospective, open, controlled study in which pregnant women with iron deficiency anemia were sequentially selected from the antenatal clinic and assigned either to ISC (study group) or to ferrous sulfate (control group). METHODS: Each study patient was given the total calculated amount of ICS (Hb deficit (g/l) x body weight (kg) x 0.3) in divided doses (200 mg (elemental iron) in 100 ml normal saline intravenously over 1 h daily) followed by 10 mg/kg to replenish iron stores. Each patient of the control group was given ferrous sulfate 300 mg (60 mg elemental iron) orally three times a day. All patients were monitored for adverse effects, clinical and laboratory response. RESULTS: There were 52 patients and 59 controls. ISC group achieved a significantly higher Hb level (128.5 +/- 6.6 g/l vs. 111.4 +/- 12.4 g/l in the control group P < or = 0.001) in a shorter period (6.9 +/- 1.8 weeks vs. 14.9 +/- 3.1 weeks in the control group, P < or = 0.001). ISC complex group showed no major side effects while 4 (6%) of the control group could not tolerate ferrous sulfate, 18 (30%) complained of disturbing gastrointestinal symptoms and 18 (30%) had poor compliance. CONCLUSION: We conclude that ISC is safe and effective in the treatment of iron deficiency anemia during pregnancy.

Normal levels of the natural anticoagulants (proteins C & S and antithrombin III) and the fibrinolytic factors (tPA and PAI) in Arab children.

The diagnosis of many hemostatic defects in infancy and childhood depends on the establishment of normal levels of various hemostatic factors. In this study, measurements of the natural anticoagulants (proteins C, S, and antithrombin III), as well as the fibrinolytic factors (tPA and PAI) were undertaken in healthy neonates (cord blood; n = 56), as well as in healthy children, up to 12 years of age (n = 103). The results were compared to normal adult values obtained from blood donors (n = 49). Neonatal values were found to be 50% of those obtained in adults and their mean concentrations were as follows: ATIII antigen = 48.4%, ATIII activity = 61.6%, protein C antigen = 47.7%, protein C activity = 57.2%, total protein S = 41.8% and tPA = 1.9 ng/mL. PAI level (25.7 ng/mL) was similar to adult values. In the first three years of life, almost all the hemostatic factors, other than PAI, gained adults levels. The diminished concentrations of the natural anticoagulants, in addition to the hypofibrinolysis in neonates, shifts the hemostatic balance towards fibrin formation and safeguards effective hemostasis. The values obtained in this study may serve as local reference values.

Diabetes mellitus and impaired glucose tolerance in Saudi Arabia.

This study was undertaken to determine the prevalence of diabetes mellitus (DM), insulin-dependent diabetes mellitus (IDDM), noninsulin-dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in different areas of Saudi Arabia. A household survey was conducted in 34 different areas of Saudi Arabia. Demographic data and medical history were taken and filled. Fasting and two-hour "post-glucose load" blood samples were collected from 23,493 Saudi males and females and blood glucose was estimated immediately. The diagnoses of DM and IGT were made based on the criteria of the World Health Organization (WHO). Diabetic patients were subgrouped as IDDM and NIDDM on the basis of age of onset and mode of treatment. In the overall group (two to 70 years), the prevalence of IDDM, NIDDM and IGT was 0.193%, 5.503% and 0.498% in the Saudi males and 0.237%, 4.556% and 0.900% in the Saudi females. When grouped on the basis of age, there were 8762 children (<14 years). Of these children, 15 (0.171%) had IDDM and 13 (0.148%) had maturity onset diabetes of the young (MODY). The prevalence of IGT in this group was 0.250%. In the 14-70-year age group, the prevalence of IDDM, NIDDM and IGT was 0.239%, 9.50% and 0.717% in the males and 0.248%, 6.820% and 1.347% in the females, respectively. A significant increase (P<0.001) was obvious in the age group >30 years, where the prevalence of NIDDM and IGT rose to 17.32% and 1.30% in the males and 12.18% and 2.2% in the females, respectively. IDDM showed a slight decrease in those over the age of 60 years. These results place Saudi Arabia among the countries that have a high prevalence for DM and a moderate risk for IGT. In light of these findings, it is clear that carefully planned programs are needed to achieve control and prevention of diabetes mellitus in Saudi Arabia.

Trends in maternal mortality in Saudi Arabia.

OBJECTIVE: To identify trends and factors related to maternal death, and areas that need improvement. METHODS: A prospective national survey, a multistage sample of the hospitals of Saudi Arabia. The setting was a maternal mortality survey committee in Riyadh with field/area coordinators in different areas of the Kingdom. The subjects were women who died or who were dead on arrival in hospital during pregnancy or within 6 weeks of the end of pregnancy. All the data were coded and analyzed. EPINFO software was used to calculate the maternal mortality ratio (MMR) and the relative risk for the necessary variables. RESULTS: The MMR was 18 per 100,000 births (155/880 248). Mortality was higher in older multiparous women of low income and no education. Hemorrhage, both antepartum and postpartum, was the leading cause of maternal death, together with rupture of the uterus and abortive bleeding, constituting 43% of direct and 29% of total maternal deaths. Substandard care was identified in 73% of direct maternal deaths. CONCLUSIONS: The MMR in Saudi Arabia compares favorably with that of developed countries and the oil-producing Gulf states. Improving the number of booked patients, especially older grand multiparas, increasing the availability of banked blood and adopting a positive approach towards life-saving surgery are likely to reduce maternal deaths.

The prevalence of diabetes mellitus and impaired glucose tolerance in the population of Riyadh.

This study was conducted in Riyadh to determine the prevalence of diabetes mellitus and impaired glucose tolerance. Blood samples (3981) were collected from Saudi male and female adults (2402) and children (1579) during a household screening program conducted over a period of two years from September 1991 to September 1993. Fasting blood samples were collected and each individual was given an oral glucose load. Two-hour postprandial blood glucose was estimated and the World Health Organization (WHO) criteria were used to diagnose diabetes and impaired glucose tolerance. The diabetic patients were further grouped into noninsulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) depending on the age of onset and mode of treatment. The overall prevalence of diabetes mellitus (IDDM and NIDDM) was 4.76% in males and 4.10% in the females in the two-to 70-year age group. Ten individuals of the 3981 were suffering from IDDM, giving an incidence of two to three per 1000. When the children <14 years were removed, the prevalence increased to 8.235% and 6.476% in the males and females respectively, while in the >30 year old group, the prevalence increased to 16.0% and 12.34% in the males and females. Further significant increase in NIDDM and impaired glucose tolerance (IGT) was observed with age (P<0.05). NIDDM was more frequent in males while IGT was more frequent in females. This paper presents the results of screening in Riyadh and stresses the need for diabetes mellitus awareness programs in the Saudi population.

Consanguinity among the Saudi Arabian population.

This study was conducted on 3212 Saudi families to investigate the prevalence of consanguineous marriages. The families were interviewed and the information on the relationship between the husband and wife was obtained. The overall rate of consanguinity shows that 57.7% of the families screened were consanguineous. The most frequent were first cousin marriages (28.4%) followed by distant relative marriages (15.2%) and second cousin marriages (14.6%). The families were grouped according to the province of their origin and the consanguinity rates were calculated accordingly. There were slight differences in the consanguinity rates in the five provinces, which ranged from 52.1% to 67.7%. In each province first cousin marriages were the most frequently encountered pattern, ranging from 17.9% to 40.9%. The inbreeding coefficient (F) was calculated for each province and ranged from 0.020 to 0.030. Within each province, there were several significant differences among the populations in the different areas. The highest rate of consanguinity was 80.6% in Samtah and the lowest rate was around 34% in Abha in the South Western province. These results place Saudi Arabia among the countries of the world with a high rate of consanguinity. The possible consequences of increased consanguinity are presented and discussed.

Epidemiology of maternal mortality in Saudi Arabia.

A three year maternal mortality survey in Saudi Arabia has identified the various epidemiologic risk factors for maternal deaths. Unbooked, uneducated and economically underprivileged females were at increased risk of maternal death, especially >para 7 females, who were found to be at increased risk of maternal death, particularly deaths due to hemorrhage, pulmonary embolism and uterine rupture. In Saudi Arabia, there are contradictory risk factors for maternal death; e.g. low female literacy rate, early marriage and unregulated high fertility, and affluence which has brought about improvements in all walks of life including health services. Increasing the number of booked patients, especially among the elderly grand multipara, improving the quality of emergency obstetric services and achieving a higher female education rate are likely to bring the present maternal mortality ratio (MMR) of 18 per 100,000 births down to a minimum. The MMR obtained in this study compared favorably with those of the oil-producing Gulf countries and the developing and developed countries of the world.

Lead concentration in breast milk of nursing mothers living in Riyadh.

Lead poisoning has proven to be one of the most difficult environmental health problems. Part of this difficulty is based on the lack of distinctive manifestations at an early phase in the process. Breast milk feeding with high lead concentration is one of the first sources of lead exposure in neonates. This study reported that lead in breast milk samples from 81% of nursing mothers varied from a low concentration of 0.318 microg/dL to a high of 2.5 microg/dL with an average of 0.768 +/- 0.42 microg/dL. The high lead concentration of 2.5 microg/dL recorded in this study is similar to the average lead concentration reported by others. Lead concentration was found to be low in young mothers and higher in mothers age 36 years or more with an average of 0.515 +/- 0.14 and 1.344 +/- 0.65 microg/dL respectively. There were no significant differences between lead concentration in samples obtained from right or left breasts and similarly, there were no significant differences in lead concentrations in milk samples in relation to the length of period of lactation (P>/=0.1). Breast milk samples obtained from mothers residing near industrial areas or highways, using copper casserole coated with white (rich in lead) inner coat and eating food material preserved for long periods in metal containers showed higher lead concentration than from those living in remote areas with reduced exposure. The diagnosis of lead poisoning required a constant awareness of its prevalence.

Multiple pregnancy management: The King Khalid University Hospital experience.

This review analyzes the multiple pregnancies in King Khalid University Hospital (KKUH) from January 1985 to December 1989. Over this period, the incidence of multiple pregnancy was found to be 10.25/1000. The study confirms a higher incidence of complications among multiple pregnancy cases. For example, the cesarean section rate was 32.2% as compared with 3.6% for the single pregnancies, and the neonatal deaths occurred in a higher number (3.3%) as compared to 1.0% in the controls. However, even though the overall prematurity rate (

Fertility following ectopic pregnancy.

In addition to the acute adverse consequencesof ectopic pregnancy, the subsequent reproductive potential of the affected women has continued to attract the attention of medical scientists in recent times. In a study to evaluate the fertility potentials in 138 patients treated for ectopic pregnancy in the King Khalid University Hospital (KKUH) Riyadh, 105 (76.1%) of the patients had follow-up management for periods varying from 12 to 60 months. Since all these patients desired pregnancies, they were classified as "at risk" for evaluation of their reproductive potentials. Of these, 51 (48.6%) eventually became pregnant and produced 63 viable pregnancies, 18 abortions and one repeat ectopic pregnancy. Many of those who failed to become pregnant over the follow-up period probably had tubal damage due to the antecedent pelvic inflammatory disease (PID),perhaps compounded by the effects of the ectopic pregnancy and the management, among other factors.

Ectopic pregnancy in a defined Saudi population.

Casesof ectopic pregnancies clinically had histopathologically confirmed and managed in the King Khalid University Hospital (KKUH) over a five year period are presented. With a prevalence rate of 6.9 per 1000 deliveries, ectopic pregnancy was depicted as not so common in this region of the world, although there has been a rising trend of the condition over the years. Of the risk factors, infertility treatment (19.7%), use of IUCD (10.9%), PID (8.7%) and chlamydia infections (2.9%) were found to be associated. However, there may be a need for nationally based as well as case controlled studies to evaluate the risk factors in this major gynecological catastrophy which is often associated with a high maternal morbidity and mortality, pregnancy wastage and impairment of fertility.