Pregnancy following infertility: a concern?

This study is to assess whether a waiting time to pregnancy (WTP) >1 year elevates the risk of adverse pregnancy outcomes in essentially healthy women with a single normal fetus at a gestational age of >20 weeks. Comparisons were made between those who conceived spontaneously with those who conceived after treatment for infertility. A retrospective analysis of 1,020 pregnancies occurring after a delay (WTP) of >1 year was undertaken over a 6-year period. Of these pregnancies, 24 resulted from advanced reproductive techniques and were excluded, as were four first trimester abortions, leaving 992 women. Of these 992, study group A (treated) consisted of 553 (56%) women, of whom 312 (56%) were primigravidae (A1). The pregnancy outcomes were compared with those of the remaining 439 (46%) women who conceived spontaneously, group B (control, untreated). Of these women, 234 (53%) were primigravidae (B1). Results suggested that primigravidae in the study group showed an increased risk of pre-term births and this risk was statistically significant between the gestations of 34 and 37 weeks. This risk remained elevated after adjustment for covariates. Pregnancies of women in group A1 were appreciably shorter than those of primigravidae who got pregnant without treatment (36.1 +/- 0.8 weeks vs 39.2 +/- 2.1 weeks); had lower birth weights (2684 +/- 481 g vs 3481 +/- 703 g) and were more likely to be admitted to the neonatal intensive care unit. Primigravidae among the treated group showed a statistically significant risk of caesarean births.

Maternal mortality: a twenty-year survey at the King Faisal University Hospital, Al-Khobar, Eastern Saudi Arabia.

This was an institutional study of all maternal deaths that occurred among 56422 total births at the King Faisal University Hospital, Al-Khobar, Saudi Arabia, between 1983 and 2002. The underlying cause of each maternal death and potentially avoidable factors were analysed. There were 16 maternal deaths in the hospital during the study period, giving a maternal mortality rate of 28.4/100,000 births. The leading cause of death was haemorrhage in seven (43.75%) patients, followed by pulmonary embolism in four (25%) and general anaesthesia in two (12.5%) mothers. The risk factors noted were maternal age 35 years and parity 5 coupled with iron deficiency anaemia. The main avoidable factors were failure of the patients to seek timely medical care and to follow medical advice. More than half the number of direct obstetrical causes of death was thought to be preventable. A rapidly changing attitude of women towards childbirth is occurring through progressively increasing female education and community health programmes in the region. Further reduction of maternal mortality rates in the community is envisaged through greater patient acceptance of medical advice, family spacing and proficient obstetric services.

Correlation between Barr bodies and neutrophil drumsticks.

There is a marked difference between the frequencies of neutrophil nuclear drumsticks and mucosal cell Barr bodies in any given woman despite the fact that both represent an inactivated X chromosome. We present results of a prospective study carried out on 100 normal Saudi females to assess the statistical correlation between these two variables. We conclude that each is independent of the other. The lack of statistical correlation perhaps relates to maturational and nuclear configuration factors.

Evaluation of an intensive care unit in a teaching hospital in Saudi Arabia.

Intensive Care Units (ICU) in general hospitals have become a standard requirement in tertiary care centres. However, the appropriateness of their use is not widely known. We have used the Therapeutic Intervention Scoring System (TISS) to evaluate a multidisciplinary ICU in a teaching hospital in Saudi Arabia. The average occupancy rate was 79%, the nurse: patient ratio was 1:1.4, duration of stay 4.1 +/- 3.5 days, and mortality was 1.4%. The distribution of severity of illness was as follows: Classes I & II, 82%, and Classes III & IV, 18%. The average TISS points were: daily per patient 15.1 +/- 2.7 (range 11.5-21.7), total per day 125.6 +/- 38.2 (range 35-211), and patient points per nurse was 21.1. We conclude that, although less than 20% of patients required unique ICU services, the use of our ICU was appropriate to the current medical and manpower training needs of the community it was designed to serve, but the basis of nurses' complaints of overwork remains to be determined.

Congenital brachial palsy in the eastern province of Saudi Arabia.

The clinical features of 57 patients (31 males, 26 females) with congenital brachial palsy seen at the King Fahd Hospital of the University over a 5-year period are described. Delivery was difficult in 32 (56%), 20 (35%) were large babies (birth weight greater than 3,600 g), and 20 deliveries required either forceps or vacuum extraction. The presentation at delivery was vertex in 45, breech in five, and shoulder in four. Associated injuries or features, encountered in 14 cases, were fractures of the clavicle and humerus (six cases each), and skull fracture and Horner's syndrome in one patient each. The right and left sides were involved in 31 and 24 cases, respectively, and both sides in only two cases. All the muscle groups of the affected limb were most commonly involved (40%), and hand muscles alone were affected in only one patient. Although 60% of the cases presented late to the hospital, functional recovery was observed in 63%. The major predisposing factors identified in this study were technically difficult deliveries, large infants, and breech or shoulder presentation with assisted delivery. It is suggested that early identification of these factors and improvement in obstetric care of both the mothers and babies during delivery would reduce the incidence and severity of this disability.

Effects of glucose-6-phosphate dehydrogenase deficiency upon sickle cell anaemia.

The levels of glycated haemoglobin, fetal haemoglobin and methaemoglobin in 618 Saudi subjects were determined. A statistically significant decrease in the percentage of glycated haemoglobin was observed in all haemoglobinopathic groups studied in comparison to normal controls. However, there was no significant difference in the percentage of glycated haemoglobin in patients with sickle cell anaemia when compared with those sickle cell subjects who were also glucose-6-phosphate dehydrogenase deficient. This suggests that there is little survival advantage or disadvantage in the combination of glucose-6-phosphate dehydrogenase deficiency and sickle cell anaemia.

Percentage glycosylated haemoglobin in normal, G6PD deficient and HbSS Saudi Arabs.

Reference values have been established for erythrocyte glycosylated haemoglobin levels in a normal Saudi population and in subjects with various haematological disorders. The mean glycosylated haemoglobin levels (SE) were 7.28% (0.039) for normal, 6.04% (0.057) for G6PD deficient, 4.40% (0.081) for homozygous sickle cell, and 6.44% (0.109) for heterozygous sickle cell subjects. Values of 6.26% (0.103) and 4.75% (0.127) for glycosylated haemoglobin were determined for heterozygous and homozygous sickle cell subjects with G6PD deficiency, respectively. Statistical analysis of the data shows significant differences in the extent of glycosylation between G6PD deficient, HbSS and normal controls. Where possible the results are compared to values reported for other populations.

Screening for gestational diabetes in a teaching hospital in Saudi Arabia.

This study was undertaken to determine the incidence and severity of gestational diabetes in our hospital population which is predominantly Arab; 455 consecutive patients were screened by a 3-hour glucose tolerance test in the third trimester of pregnancy. The overall incidence of gestational diabetes was found to be 11% and the incidence increased with increasing maternal age, parity and weight. A high prevalence of more severe degrees of gestational diabetes was noted among the Arabs. Glucose intolerance was observed in 2 patients in the absence of any risk factor. The most common high risk factor in patients found to have gestational diabetes was maternal age of 30 years or more.

Socio-biological correlates of bacteriuria in Saudi pregnant women.

Prevalence and socio-biological correlates of bacteriuria in Saudi pregnant women were investigated at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. Midstream sample specimens of urine were used for identification of significant bacteriuria (greater than or equal to 10.5 organisms of single species per milliliter of urine). The prevalence of bacteriuria was found to be 14.2%. It was more common in women below 20 years of age and among the parous as against the nullipara women. Bacteriuria was significantly associated with socio-economic conditions. It was higher in those with a low family income, of large family size (10+) and living in over-crowded conditions. Only one-fourth (25.8%) of bacteriuric women were symptomatic. Almost half (45.8%) had a past history of urinary tract infection. To identify the problem of urinary tract infection in a vulnerable group of women, as well as to reduce the load on laboratory facilities, it is suggested that routine antenatal screening for bacteriuria should be advocated on a selective basis, i.e. for the young teenage parous women, those coming from disadvantaged socio-economic conditions and in patients with a past history of urinary tract infection.

The King Faisal University fellowship training programme in family and community medicine.

A four year graduate programme for future primary care physicians is described. The programme is particularly oriented towards those who are likely to become leaders and teachers in the discipline but it is believed that the principles involved should be generally applicable in education for primary care practice. Arguments are advanced in favour of the strong basic science core which has been included in the programme, especially in the traditionally community oriented subjects of biostatistics, epidemiology and research methodology. Considerable emphasis is also given to a dissertation. Areas of required knowledge and experience are documented in the curriculum as 24 courses, each the subject of continuing assessment and end of course examination. There are also two comprehensive examinations, one just after the mid point of the programme and the other at the end. This combination of multiple course assessments and two comprehensive examinations is regarded as a means of maintaining high standards while, at the same time, ensuring that candidates with real potential are not lost to the discipline.

Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia.

The perinatal deaths of all singleton births that occurred at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia during a 4-year period are analysed. The causes of death are classified into 12 groups using an extended modification of the Aberdeen classification. There were 165 perinatal deaths in 8057 singleton births, giving a perinatal mortality rate of 20.47 per 1000 total births. Fetal malformations occurred in 29 (17.57%) cases. Of the remaining 136 normal infants, 77 (56.6%) were stillbirths and 59 (43.4%) died within 1 week of delivery. Spontaneous premature labor was the commonest cause of death (23.52%) followed by birth trauma (11%) and maternal diseases (9.55%). The cause of death was not known in 22 (16.17%) cases. In conclusion, prevention of premature labor, better intrapartum fetal monitoring, early recognition of fetal distress and improvement of neonatal care should reduce the perinatal mortality rate.

The low birth-weight infants of Saudi adolescents: maternal implications.

Maternal factors and perinatal outcome of low birth-weight (less than or equal to 2,500 g) infants of 46 adolescent mothers was studied and compared with 160 adolescents who delivered infants weighing greater than 2,500 g. The significant factors found in the low birth-weight group were anaemia, small maternal physique and preterm delivery. Expectedly, the perinatal mortality rate was significantly increased in low birth-weight infants.

PIP: From 1981-1985, researchers studies pregnancy outcomes of 206 female adolescents (= or 17 years old at the time of 1st hospital visit) at King Fahd Hospital in Al-Khobar, Saudi Arabia. 23% of all infants born to adolescents were classified as low birth weight (= or 2500g). 17.4% of these mothers were 15 years old or younger, 39.1% were 16, and 43.5% were 17. For mothers who delivered an infant 2500g, 17.5% were 15, 26.9% were 16, and 55.6% were 17. Mothers who had low birth weight infants (mean weight 53.48k) tended to weigh less at time of delivery than those who had infants 2500g (61.89kg; p.005). Further, the stature of 31.1% of those in the low birth weight group was 150cm whereas only 13.5% of the remaining mothers were 150cm. 64% of mothers who had low birth weight infants delivered before 37 weeks gestation (p.005). Anemia (Hb10.6g/dl) was the most significant complication contributing to low birth weight (38.6%; p.005). This suggests that many adolescent mothers did not take iron and vitamin supplements and that they did not take iron and vitamin supplements and that they did not eat adequately during pregnancy. Even though toxemia also contributed significantly to low birth weight (9%; p.05), its overall prevalence was markedly low (1.9% in 2500g group). The mode of delivery did not affect birth weight. Perinatal mortality for low birth weight infants stood at 14.6%. None of the .2500g infants died. All adolescent mothers should receive early prenatal care. In addition, more health education of health professionals and adolescents is needed to stress the importance of regular prenatal care, liberal hospitalization, intensive antepartum and intrapartum fetal monitoring.

Emergency hysterectomy in obstetrics--a review of 117 cases.

A series of 117 cases of emergency obstetric hysterectomy performed between 1976 and 1985 is reviewed. The indications included ruptured uterus (53.8%), intractable postpartum haemorrhage (20.5%), placenta accreta (7.7%), major degree of placenta praevia (7.7%), haemorrhage at Caesarean section (4.5%), couvelaire uterus (3.4%) and abdominal pregnancy (2.6%). Despite a general aversion to hysterectomy by the women in our society, these procedures were undertaken in a desperate attempt to save life. There were 6 (5.1%) maternal deaths, all due to the severity of the indication for the hysterectomy. Presence of an experienced obstetrician is important to make an early decision to operate before the patient's condition is extreme and to provide the technical skills required to minimize morbidity and mortality.

Obstetric problems in the grand multipara: a clinical study of 1330 cases.

PIP: From January 1982-December 1986, researchers reviewed 1130 patients who had 7 or more viable pregnancies at the University Teaching Hospital in Al-Khobar, Saudi Arabia. The majority of the patients (90%) received regular prenatal care and most of the remaining patients attended a prenatal clinic 3-4 times. For the grand multipara, the rate of spontaneous abortion was higher (24%) compared to total deliveries (13%) in that hospital during the study period. Anemia was the leading predelivery complication for the study group (16.6% vs. 3.5% for total deliveries). Preeclampsia followed as the 2nd leading complication (6.1% vs. 5.2% for total deliveries). In 1 case a 45 year old gravida 13 had eclampsia, and both mother and infant survived. Antepartum hemorrhage occurred in 5.8% of the multiparous women (2.3% for total deliveries) due to abruptio placentae in 43 patients and placenta previa in 34 others. 5.6% of the multiparous patients (1.2% for total deliveries) experienced unstable lie, while successful induction of labor at term occurred in 60% of these women. Diabetes mellitus caused the least predelivery complications (4.8% vs. 2.8%). 73.3% of all deliveries to grand multiparous women resulted in normal deliveries. Delivery complications were higher for the study group, however, than for total deliveries: breech deliveries, 7% vs. 2.7%; premature labor, 7.5% vs. 2.7; cesarean section, 11.4% vs. 8.9%; and postpartum hemorrhage. 6.5% vs. 3.1%. The perinatal mortality rate of 62/1000 for the grand multiparous women was 3 times the overall rate for the hospital (21/1000). Stillbirt accounted for 50% of perinatal deaths for the remaining deliveries. 1 maternal death occurred among the grand multigravida.^ieng

Parity, related sociodemographic factors and contraceptive use in Saudi Arabia.

"Parity and associated sociodemographic factors were studied in 1,250 Saudi female patients. 23.8 per cent of the study group were para 3 or more and a significant relationship between high parity and low education background of the couple was observed. The use of contraception was significantly more in educated and economically healthy multiparous women simply for the reason of spacing the pregnancies."

Obstetric implications of pregnancy in adolescence.

Pregnancy in adolescence constitutes a high-risk obstetric situation and there is an obvious need for improvement in obstetric care for this age group. A retrospective study of 94 mothers, 17 years of age and under, was carried out at the Teaching Hospital of King Faisal University in order to assess the obstetric implications of adolescent pregnancy. This study has shown a significant increase in the incidence of low birth weight infants, breech presentation and preterm delivery. A significantly smaller number of adolescent mothers were found to have given birth spontaneously, vaginally. Adolescent primigravidas were noted to run a greater risk. It is imperative to institute a medical and educational service with comprehensive prenatal care for adolescent mothers in order to improve the outcome of their pregnancies.

Rupture of the uterus in labor. A review of 96 cases.

Ninety-six cases of ruptured uterus in labor treated in the University Teaching Hospitals, Benghazi, Libya between 1977 and 1980 are reported. An incidence of 1 in 585 deliveries remained unchanged during the period of study. Twenty uterine ruptures occurred in a previously scarred uterus. Rupture of the unscarred uterus is a more catastrophic event. There is a marked difference in both fetal and maternal outcome between the group with a previously scarred uterus and the group without a previous scar. The incidence and causes of uterine rupture in Libya differ greatly from those in developed countries. High parity is a frequent cause. Other common etiological factors were cephalopelvic disproportion, fetal malpresentation, oxytocin stimulation of labor and unwise obstetrical interference. The fetal wastage was high, a perinatal mortality of 75% being recorded, but 95% of the mothers were saved. Hysterectomy was commonly performed in this group. Repair of the uterus and sterilization should only be performed when the rupture is simple and transverse in the lower segment and without any sign of infection.

Advanced abdominal pregnancy--observations in 10 cases.

Advanced abdominal pregnancy was encounter 10 times in 102,000 deliveries over a period of 10 years at 1 hospital. The clinical features, difficulties in diagnosis and management, and the outcome of this uncommon condition are discussed. The most frequent symptoms encountered in this series were abdominal pain (100%), nausea and vomiting (70%), general malaise (40%), and painful fetal movements (40%). The commonest physical findings were abdominal tenderness (100%), an abnormal fetal lie (70%), and a displaced uterine cervix (40%). The incidence of diagnostic error was 60%. Multiple diagnostic procedures are needed to reduce the incidence of error. The maternal mortality was 20% and the perinatal mortality 40% in this series. The postoperative morbidity and mortality were high when the placenta was left in situ. Methotrexate was used in 5 cases to expedite degeneration of the trophoblastic tissue in the residual placenta. The value of this drug in managing the abdominal placenta could not be established. Removal of the placenta, when it is safely possible, gives the best results.