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.

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.

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.

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.

Post partum thyroiditis in Saudi women.

Two hundred and seventy seven Saudi women were prospectively evaluated post-partum to determine the frequency of post-partum thyroiditis. Four to six weeks after delivery, 12 (4.3%) had positive antimicrosomal antibodies and 8 (2.9%) had positive antithyroglobulin antibodies. At 6-8 weeks post-partum, out of 82 subjects followed up, 4 (4.9%) had positive antimicrosoMal antibodies and 1 (1.2%) had positive antithyroglobulin antibodies. At 8-12 weeks post-partum, out of 70 subjects, antimicrosomal antibodies were detected in 5 (3.5%) subjects and antithyroglobulin in 2 (1.4%). Their routine thyroid function tests (T3, T4, and TSH) remained within the normal range. There was no clinical evidence of hyper- or hypothyroidism in any of the patients during the follow up. Post-partum thyroiditis, appears to be relatively uncommon in Saudi Arabia. It does not produce any clinical illness or cause significant subclinical thyroid dysfunction.

Pregnancy outcome in women with antiphospholipid antibodies.

The association of antiphospholipid antibodies (APA) or lupus anticoagulant (LA) and recurrent fetal loss (RFL) is well established; however, the spectrum of pregnancy outcome in relation to various therapeutic approaches versus placebo is unknown. We studied 49 women with RFL, 14 with immune thrombocytopenia (ITP) 13 of whom without a history of RFL, and 32 controls (all in the first trimester of pregnancy) for the presence of APA. Tests for APA were positive in 15/49 women with RFL (30%), 6/14 ITP (43%) and 2/32 controls (6%). Treatment in the APA positive patients consisted of: no treatment for the 8 patients who had no history of RFL (Group A; all 34 previous pregnancies successful), aspirin alone (Group B, 5 patients; all 30 previous pregnancies unsuccessful), aspirin with prednisolone (Group C, 9 patients; 69/80 previous pregnancies unsuccessful), or aspirin, prednisolone and immunoglobulin G for resistant cases (Group D, 4 patients, previously in Group C). 10/11 (90.9%), 3/7 (43%), 7/13 (53.8%) and 4/7 (57.1%) pregnancies were successful in Group A, B, C and D, respectively. There was a total of 19/45 (42%) failures including 3 pregnancies in one patient who failed to respond to all forms of therapy. This open study with small subgroups of patients draws attention to a wide range of pregnancy outcome in women with APA and to the fact that APA may serve only as a marker for a wide range of pathological conditions with variable degrees of disease severity. More studies are, however, needed to explore the real mechanism of RFL in women with APA and RFL, especially those who are resistant to therapy.

Ovarian pregnancy.

Ovarian ectopic pregnancy occurs very rarely; the reported incidence is only 1:7000-40,000 deliveries, despite various reports in recent years. We present four cases of primary ovarian pregnancy which were managed in the King Khalid University Hospital (KKUH) over a 5-year period representing a prevalence rate of 19.9 per 100,000 deliveries. All four cases complied with the four criteria of Spiegelberg. None of the patients were known to have used an intrauterine contraceptive device which had been suggested as the cause of ovarian pregnancies in several studies. Fertility after surgery in these cases was unaffected.

Fetal biophysical profile monitoring and perinatal outcome.

A prospective study of 109 high risk pregnancies on whom 279 fetal biophysical (FBP) examinations were performed showed positive and negative predictive values of 100% and 71.4%, respectively in the last FBP examination prior to delivery. The study confirmed other reports in the literature of a high correlation between normal examination and satisfactory perinatal outcome. The absence of perinatal mortality within one week of a normal FBP examination, which was also in agreement with other reported studies, reaffirms the reassuring nature of a normal examination. The high positive predictive value in our study may be due to several factors, including the use of a protocol which ensured standardization of the patient's condition prior to examination as well as repeat evaluations after non-reassuring tests. FBP evaluation is considered a simple, reliable and useful examination for the management of high risk pregnancies. Its main value would appear to be a reduction in the number of high risk pregnancy patients who would otherwise have been admitted on the basis of the clinical findings.

Separation of beta- and gamma-tocopherols in serum by high performance liquid chromatography.

A simple and sensitive high performance liquid chromatographic method for the analysis of tocopherols (alpha, beta, gamma and delta) in serum with UV detection is described. In normal phase mode excellent separation of positional isomers (beta and gamma) was achieved by adjusting the proportion of isopropanol in the mobile phase. Detection limits for both beta and gamma were 0.62 mg/L and 0.42 and 1.2 mg/L for alpha and delta isomers, respectively. Measurement of all the tocopherol structural isomers (alpha, beta, gamma and delta) in a sample required only 400 microL of serum and each run was completed in less than 22 min.

Computed tomographic changes of the brain in toxaemia of pregnancy.

Four cases of toxaemia of pregnancy examined with computed tomography scans of the brain are reported. A review of the literature reveals 19 other cases with previously reported CT brain scans. The review shows intracerebral oedema as the main finding. Haemorrhage, massive or punctate was noted in four cases. The pathogenesis of the CT changes and the clinico-radiological correlation of the visual disturbances are discussed.

Screening for toxoplasmosis in pregnancy.

Randomly collected sera from 386 pregnant women attending obstetric and gynecology clinics at Kind Khalid University Hospital, Riyadh, Saudi Arabia, were examined for toxoplasma antibodies by five serological methods, i.e. latex agglutination test (LAT), two indirect hemagglutination tests (IHAT) (Carter-Wallace, USA and Ismunit, Italy), enzyme immunoassay (EIA) and indirect fluorescent antibody test (IFAT). The percentage of sensitivity, specificity and coincidence value of these tests were compared with IFAT which was used as a reference test. For routine screening of toxoplasmosis, LAT has proved in this study to be the most suitable test. The LAT is cost effective and easy to perform. In this study of the three tests (IFAT, EIA, immunosorbent agglutination assay) to demonstrate specific IgM for toxoplasmosis, the EIA test proved to be the most satisfactory because of its 99% specificity. If EIA equipment is available, it can be used for routine screening (IgG) as well as IgM determination. The incidence of toxoplasmosis in pregnant women varied between 25.4% and 36.3% depending on the method used.

Practice and methods of contraception among Saudi women in Riyadh.

The use of contraceptives can have an impact on better spacing between children, better child care, improvement of children's health and preservation of the mother's health. In this study 2675 Saudi women attending a gynaecology out-patient clinic were interviewed about their contraceptive practices. The majority of the women (56.0%) were using or had used some form of contraceptive. Oral contraceptives were the most common method; 94.8% of the 1497 women who practised contraception were using or had used this form of contraception. Sterilization accounted for 0.9% of contraceptive practices, while the intrauterine device was a more common form of contraceptive among the more educated women.

The problem of grandmultiparity in current obstetric practice.

A retrospective analysis of 646 Arab grandmultiparas who booked for hospital confinement between 1983 and 1985 was carried out. The results were compared with that of non-grandmultiparas during the same period. In the grandmultiparas, the incidences of gestational diabetes, hypertension rheumatic heart disease, antepartum, postpartum hemorrhage and macrosomic infants were increased. However, contrary to some previous reports the incidences of anemia, cesarean sections, induced labor, dysmaturity and perinatal deaths were decreased. This is thought to be due to the provision of modern specialist perinatal care and improved socioeconomic standards.

PIP: A retrospective analysis of 646 Arab grandmultiparas who booked for hospital confinement at the King Abdul Aziz University Hospital in Riyadh, Saudi Arabia between 1983 and 1985 was carried out. Results were compared with that of nongrandmultiparas during the same period. In the grandmultiparas, the incidences of gestational diabetes, hypertension, rheumatic heart disease, antepartum, pospartum hemorrhage, and macrosomic infants were increased. However, contrary to some previous reports the incidences of anemia, cesariean sections, induced labor, dysmaturity and perinatal deaths were decreased. This is thought to be due to the provision of modern specialist perinatal care and improved socioeconomic standards. In communities where poor socioeconomic standards and inadequate health services still prevail, grandmultiparity is to be regarded as a risk factor associated with increased maternal and fetal morbidity and mortality. Under the improved conditions of present day obstetrics, including competent clinical staff, the grandmultipara faces the same risk to her life during pregnancy as the woman with lesser parity. The sample in this analysis ranged in age from 18 to 43 years with mean age at 33 years. 195 (30%) were older than 35 years. This is a similar age distribution to other centers in Saudi Arabia and in Malay and Indian grandmultipara of Singapore.