Teenage pregnancy.

OBJECTIVE: To study the frequency of teenage pregnancy and its complications as compared to controls. METHODS: A retrospective case record analysis of 2522 pregnancies, aged below 25 years was carried out, in the Department of Obstetrics, Riyadh Armed Forces Hospital during the period 1 January 1999 to 31st December 1999. RESULTS: The incidence of teenage pregnancy for 1999 was 6%. Three hundred and eighty five (76%) were carrying their first pregnancy while 42 (8%) mothers had 2 or more previous pregnancies and deliveries. The birth weight was less than 2.5 kg in 109 (21.5%) adolescents, as compared to 187 (9%) of the controls. The rate of instrumental deliveries and cesarean section in adolescents was 9% and 6% as compared to 5% and 10% in the controls. Seventy nine (16%) of adolescents delivered prematurely as compared to 216 (11%) of the controls. Forty seven (9%) of adolescents were unbooked compared to 133 (7%) who were controlled. The incidence of pre-eclampsia and preterm delivery in adolescents was 2% and 16% as compared to 1% and 11% in the controls. CONCLUSION: Teenage pregnancy, which showed a steady decline from 18% in 1979 to 6% in 1999 was associated with a significantly higher risk of preterm delivery, pre-eclampsia, low birth weight and instrumental delivery.

Pregnancy outcome of patients with previous four or more caesarean sections.

Between 1994 and 1999, of the 44 357 mothers delivered at the Riyadh Armed Forces Hospital (RAFH), 255 patients had four or more previous caesarean sections (CS). This comprised 0.5% of the obstetric population. One hundred and eighty-nine (74%) had four, 52 (20%) five, 12 (5%) six and two (0.4%) patients had seven CSs. Adhesions were severe in 128 (50%), moderate in 18 (7%), mild in 81 (32%) and no adhesions in 28 (11%) cases. The incidence of placenta praevia was five times that of the overall obstetric population (2.4% vs. 0.5%). One case of uterine rupture occurred, an incidence of 4/1000 cases. The incidence of placenta praevia rises with rising CS rate. Patients with multiple CS and placenta praevia should be counselled regarding the possibility of caesarean hysterectomy. Repeat CS is safe and tubal ligation should be advised, but not forced as it is not an absolute indication for sterilisation.

Changing trends in perinatal deaths at the Armed Forces Hospital, Riyadh, Saudi Arabia.

A total of 104522 babies were delivered at the Riyadh Armed Forces Hospital between 1979 and 1998, including 807 stillbirths and 658 neonatal deaths. The 20-year period was divided into four 5-yearly intervals for comparative purposes. The overall Perinatal Mortality Rate (PMR) for infants weighing 500 grams or more ranged between 20.2 per 1000 in 1979 and 13 per 1000 in 1998. The lowest PMR of 10.3 per 1000 was recorded in 1985. Thirty-one per cent of the perinatal deaths were unbooked. The corrected neonatal death rate (excluding congenital anomalies) dropped from 10.1 per 1000 in 1979 to 1.7 per 1000 live births in 1998 - The corrected stillbirth rate dropped from 12.1 per 1000 births in 1979 to six per 1000 in 1998. Of the 807 stillbirths, 24.1% had lethal congenital anomalies while 29.5% were unexplained, 4% had hydrops fetalis, 2% died as a consequence of toxaemia of pregnancy, 7.5% were associated with antepartum haemorrhage, 7.9% were mechanical, related to cord accident and ruptured uterus, 9.8% died as a consequence of maternal disease, 5.4% of intrapartum asphyxia and 6.4% placental insufficiency. Of the 658 neonatal deaths, 47.5% had lethal congenital anomalies, 2% had hydrops fetalis, 7.6% died as a result of intrapartum asphyxia, 38% died as a result of prematurity with its complications of severe respiratory dysfunction and intraventricular and pulmonary haemorrhage, 4.1% died in NICU of secondary infection and 0.7% were unclassified. The overall PMR for infants weighing 500 grams or more was 14.1 per thousand. Congenital anomalies and low birth weight/prematurity accounted for 85.5% of the neonatal deaths. Congenital anomalies and unexplained deaths accounted for 53% of total stillbirths while maternal disease was responsible for 9.8% of total stillbirths. Reducing congenital anomalies and preventing prematurity and provision of good antenatal care will help in reducing PMR still further.

Can the rate of cesarean section be reduced?

OBJECTIVE: To look into all cases with previous one cesarean section who were cared for and delivered at Armed Forces Hospital, Riyadh, between January 1990 and December 1998, to determine its prevalence, final method of delivery, and outline measures of reducing its incidence. METHODS: Retrospective analysis of hospital records of all women with previous one cesarean section who had either a repeat cesarean section or delivered vaginally after cesarean section. RESULTS: Between 1990 and 1998, 61,060 mothers were delivered. Two thousand five hundred and seventy eight patients had one previous cesarean section. They represented 3.5% of the total number of deliveries. Nine hundred and sixty eight (37.5%) cases had repeat cesarean section. Of the 1610 (62.5%) mothers who achieved vaginal delivery, 102 (6%) had ventouse, 42 (3%) had forceps and 22 (1%) had an assisted breech delivery. Rupture of uterine scar was reported in 15 cases. There were no maternal or perinatal deaths. CONCLUSION: Patients with one previous cesarean section are three times more likely to have a cesarean section as compared to mothers with unscarred uterus. Reducing the overall cesarean section rate is possible through a closer look at the primary indication for the first cesarean section. A protocol is needed to allow more cases with one or more previous cesarean section to have trial of vaginal delivery under close monitoring and involve the senior staff more in the diagnosis and management of cases of dystocia and the use of Oxytocin when indicated.

Cesarean section in the primigravid.

OBJECTIVE: To review all cases of cesarean section in the primigravid mother delivered at the Riyadh Armed Forces Hospital between January 1996 and December 1997. To determine its incidence, describe the clinical indications, outcome and highlight areas of improvement in an attempt to reduce the rate of cesarean section. METHODS: Retrospective case record analysis. RESULTS: During the study period there were 15301 deliveries. The overall cesarean section rate for 1996 was 12% and for 1997 was 13%. The rate of cesarean section in the primigravid was 12%. The rate of cesarean section in primiparas breech was 41%. Cesarean section in the unbooked primiparas was 15% as compared to 12% in the booked ones. Fetal distress with or without failure of progress was the main indication for cesarean section in singleton cephalic presentations. In breech presentations, cesarean section was carried out as an elective procedure in 45% and fetal distress was the indication in 21% of cases. Fetal distress was the main indication in twins. CONCLUSION: The rate of cesarean section in the primiparas was similar to the rate of cesarean section in the obstetric population. The rate of cesarean section in the primiparas breech was slightly higher than cesarean section in the multiparas breech. Fetal distress was the leading indication for cesarean section in twins and those with cephalic presentation. The rate of cesarean section can be safely reduced by reviewing and auditing the primary indication for cesarean section, the Consultants doing frequent rounds on delivery suites and being involved directly in cesarean section decision, careful interpretation of fetal monitoring and allowing more patients with breech presentation to have vaginal delivery under close observation.

Twin pregnancies: incidence and outcome - Riyadh Armed Forces Hospital experience.

A retrospective study of twin births at the Armed Forces Hospital, Riyadh, from January 1987 to December 1996 was carried out. There were 62 739 deliveries and 598 sets of twins. The incidence of twins was one in 105 maternities. The perinatal mortality rate was 46 per 1000 births compared with 12.3 per thousand for singletons. Premature delivery (<34 weeks) and very low birth weight infants (<1500 g) accounted for 12.5% and 8.7% of the twin deliveries respectively, but contributed to 60% and 63.6% of the total deaths respectively. Nineteen (3.2%) patients received no antenatal care, however, they contributed to 16.2% of the total deaths. This report represents our experience at the Armed Forces Hospital, Riyadh, Saudi Arabia on the management of twin pregnancies during a period of 10 years.

Transabdominal cervicoisthmic cerclage.

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Intrapartum rupture of the gravid uterus.

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Screening for gestational diabetes.

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Cesarean delivery of the second twin after vaginal delivery of the first twin.

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Emergency peripartum hysterectomy.

A total of 54 166 mothers delivered at the Riyadh Armed Forces Hospital between 1990 and 1997, including 6119 (11.3%) caesarean sections. Emergency peripartum hysterectomy for obstetric haemorrhage was carried out in 16 cases (0.3/1000 deliveries). The operation followed major degrees of placenta praevia in 12 (75%) cases and atonic postpartum haemorrhage in four (25%). All patients required blood transfusion. There was one neonatal death and no maternal deaths. Although the operation was straightforward, bladder injury occurred in five (31%) cases which was repaired with no residual damage. Placenta accreta was confirmed histologically in 12 (75%) patients. In conclusion, all obstetricians should be aware of the strong association between a scarred uterus, placenta praevia and placenta accreta which can be very adherent and difficult to remove causing bleeding and necessitating hysterectomy. The operation should be performed by an experienced obstetrician before the patient's condition is extreme.

Transabdominal cervicoisthmic cerclage: the Riyadh Armed Forces Hospital experience.

Between 1985 and 1996, 17 transabdominal cervicoisthmic cerclage procedures were performed and followed up through 28 pregnancies at Riyadh Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia. Fourteen procedures were carried out during pregnancy and three preconceptionally. Twenty-four pregnancies continued beyond 36 weeks of gestation and three were premature deliveries. The material used was an infant feeding tube size 6 and the knot was tied posteriorly. The sole miscarriage was at 6 weeks' gestation. All deliveries were by caesarean section. Fetal survival was 92%. In conclusion, abdominal cerclage is an effective and safe operation which helped the pattern of pregnancy wastage to be restored to normal in selected patients.