Mustansiriya Medical Journal

Background: Massive obstetric hemorrhage is still one of the leading cause of pregnancy related death and placenta previa accreta remain one of the major predisposing factors. With the increasing rate of cesarean delivery the incidence of both placenta previa and accreta is steadily increase so we anticipate more cases of placenta previa accreta in our obstetric practice. Diagnosis can be achieved by ultrasound in the majority of cases.
Aim of the study: To determine the accuracy of trans-abdominal Doppler U/S in diagnosing of placenta previa accreta in patients with previous cesarean sections and comparing with intraoperative finding
Patient and Methods: The study included 80 pregnant women who had under gone previous cesarean section at Obstetrics and Gynecology department of Al-Yarmouk teaching hospital and were diagnosed to have partial or total placenta previa in the current pregnancy were subjected to trans-abdominal Doppler ultrasound examination after 28th week of gestation to determine the possibility of placenta accreta in comparison with intra operative finding.
Results: The result of the 80 placenta previa cases, twenty-six women exhibited characteristic color Doppler imaging patterns highly specific for placenta accreta. One of them had false positive color Doppler imaging, and twenty-five confirmed at cesarean section to have placenta accreta. Of the 54 women with negative color Doppler imaging results, two of them had placenta accreta both of them were posterior placenta previa. The sensitivity of color Doppler imaging in the diagnosis of placenta previa accreta was 92.6%, specificity was 98.1%, the positive predictive value was 96.2% and negative predictive value was 96.3%
Conclusion: Color Doppler U/S provides an opportunity for early and accurate diagnosis of placenta accreta

Background: Since the advent of coronary angioplasty more than 3 decades ago, the volume of percutaneous coronary interventions has been rising progressively. Contrast medium was used in diagnostic coronary angiography and percutaneous coronary intervention. The use of iodinated contrast medium is a common precipitator of contrast-induced nephropathy.
The objective of this study was to evaluate the incidence for the development of Contrast induced nephropathy in diabetic and non diabetic patients underwent percutaneous coronary intervention which was not studied in Erbil before.
Patients and methods: One hundred twenty five consecutive patients,64 diabetic and 61 non diabetic underwent Percutaneous coronary intervention were included in this study which was conducted in Erbil surgical specialty center in Erbil. The renal function has been assessed before the procedure , 24hours and 1 week post procedure.
Results: The incidence of contrast induce nephropathy was 5.6%(7patients) one day and 13.6% (17patients) one week post procedure. There were a statistically significant association between development of contrast induce nephropathy in diabetic patients (P value<0.001), non-diabetic (P value 0.001). hypertensive patients (p value 0.03), ,contrast volume (P value 0.001),those who receieved intravenous fluid (p value 0.01) . Comparing diabetic with non-diabetic group there were a statistically significant association between volume of contrast in diabetic group (p value 0.001) and non-significant association with the non-diabetic group (p value 0.1).
Conclusions: Contrast induce nephropathy is an important complication developed after percutaneous coronary intervention and ,it is more in diabetic patients .

Aim of the study: to find the artery and associated Doppler index most correlated to intrauterine growth restriction as a secondary complication to maternal preeclampsia
Type of the study: case control
Methods: over almost 3 years a total of 80 pregnant women with established IUGR were collected and their fetal weight and Doppler indices were taken for umbilical artery, middle cerebral artery and fetal renal artery and stored in excel sheets for further analysis. At the end of the study partial least square fit was used to find the Doppler index in any of the 3 mentioned arteries most correlated to fetal weight. All the data collected with regard to the umbilical artery and fetal weight was standardized so to overcome the natural changes in those variables which occur as pregnancy advances.
Results: the Doppler index and the artery with highest coefficient were the fetal renal artery and its resistance index. The coefficient for this Doppler index was 6.92. In other word the resistance index in fetal renal artery has the maximum predictive as well as diagnostic value for intrauterine growth retardation. Accordingly an equation was developed between resistance in the fetal renal artery as dependent index and gestational age as independent variable. From this equation an easy applicable table was constructed in clinical practice to evaluate the severity of the growth restriction from the calculated gestational age for the fetus with measured renal resistance Doppler index evaluated in the ultrasound department
Conclusion: this study has shown that resistance index in fetal renal artery is the Doppler index most correlated to fetal weight. And from the raw data an easy applicable table may be used as an auxiliary method in evaluation of fetuses with growth restriction. Under no circumstances this table should be used alone or as a 100% reliable table as useful in evaluation of fetuses with growth restriction until its clinical significance is evaluated by further searchers and clinical studies.

Objectives: To assess the effectiveness and the level of the patient’s pain/discomfort experienced by different procedures applied for the treatment of the epistaxis in adult patients.
Patients and methods: A prospective observational study of 121 adult patients presented with epistaxis, from January 2016 to September 2016, at ENT Department in Al-Yarmouk Teaching Hospital in Baghdad, all the patients had been received an adequate treatment modalities accordance to a standard regimen, and at the end of each procedure, the level of their pain/discomfort experienced was assessed according to Visual Analogue Scale (VAS) questionnaire, and the success rate for each procedure was evaluated.
Results: The median VAS score for pain/discomfort in the anterior epsitaxis was in the following order; 1.5, 2.5, and 6, for chemical cauterization, electrical cauterization, and nasal packing, respectively, while for posterior epistaxis was 3, 3.5, 6, and 7.5, for electrical cauterization, endoscopic sphenoplatine artery ligation (ESPAL) surgery, nasal packing, and post nasal Foley\'s catheterization, respectively. The success rate for the anterior epistaxis treatment modalities was 89.36%, 78.37%, and 75%, for electrical cauterization, chemical cauterization, and nasal packing respectively, while for the posterior epistaxis; was 68.18%, 90%, 75%, and 100%, for nasal packing, electrical cauterization, Foley\'s post nasal catheterization, and (ESPAL) surgery respectively.
Conclusions: In the anterior epistaxis; the pain/discomfort experienced score for both chemical and electrical cauterization was mild, but the success rate was higher with electrical cauterization, while in the posterior epistaxis; both the endoscopic electrical cauterization, and the (ESPAL) surgery were associated with high patient`s tolerability, however the (ESPAL) surgery was found to be a superior method as associated with the highest success rate.

Parathyroid cysts are a rare cause of cystic swellings of the neck. They are usually non-functioning and predominate in middle age women. We report the case of an apparently healthy 17-year-old girl with a relatively large cystic left sided neck swelling of two years duration. Diagnosis of Parathyroid Cyst was obtained after surgical resection. The case history, intraoperative finding and pathology were presented, the pitfalls of diagnosis were highlighted and the condition was discussed with appropriate conclusions and recommendations.

Background: Left ventricular diastolic dysfunction (DD) is considered the first stage of diabetic cardiomyopathy; it occurs in absence of coronary artery disease, hypertension or valvular heart disease &can precede the systolic dysfunction in these patients.
Objectives of the study: The purpose of this study is to assess the diastolic function in diabetic patients of both types 1&2 using conventional, Doppler echocardiograghy and tissue Doppler imaging, and to reveal the impact of age, gender & duration of diabetes on prevalence and grading of DD.
Patients and methods: This is an observational case control analytic study in which 100 persons were enrolled, 50 of them were diabetic patients, and the other 50 were age, sex matched healthy control subjects. In both groups` systolic and diastolic functions were assessed by conventional, Doppler and tissue Doppler echocardiography.
Results: Among the 50 patients, 27 (54%) of them were females and 23 (46%) were males, 27 (54%) of them were type1 diabetes and 23(46%) were type2 diabetes. Control group consisted of 50 subjects including 24(48%) females and 26(52%) males. Patient’s age ranges from 15 to 70 years with mean age (39±16.09), control subject’s age ranges from 15 to 72 years with mean age (37.64±14.53).
There was significant relationship between aging and prevalence of DD (P value=0.02).Gender not related to prevalence of diastolic dysfunction. There was significant decrease in E/A ratio between both groups (P value=0.0007), while E/É ratio between both groups was not significant.
DD also was higher in type2 diabetes compared with type1 (P value<0.001).Diabetic duration has no impact on prevalence of DD.
Conclusion: Diabetic patients have significant DD detected on both conventional and tissue Doppler echocardiography. Diastolic function is affected with increasing age, but not with gender. The diabetic cardiac changes as well as the echocardiographic parameters seem not to be affected with diabetic duration.

Background: There are a different methods of umbilical hernia repair and there is controversy about which repair is better for small umbilical hernias.
Aim : Is to compare which method is superior the mesh or suture repair for small umbilical hernias in terms of clinical outcome and recurrence rate.
Methods: In this study , 120 patients were treated surgically using either suture or mesh repair for their umblical hernias from march 2013 to march 2015 at Al Imam Ali hospital.In 67 patients, the hernia was repaired by prolene suture and 53 patients their hernias were repaired by mesh. Both groups were followed for complications and recurence rate. The data was analysed statistically for significance using Fishers exact test.
Results: 89 patients (74.16%) were females,31 (25.84%) were males . ages of the patients were ranged between 21 to 67 years, mean age was (36.17).There was no significant difference statistically between two groups regading recurrence after one year follow up, 467 (6%)in suture repair and 153(1.9%)in the mesh repair.5patients(7.46%) got seroma in the suture repair group while 4 patients (7.54%) in the mesh repair.Hematoma developed in 2patients( 3%) in the suture repair group and nil in the mesh repair group.Regarding infection 3 (4.5%)in suture repair and 2patients (3.7%) in the mesh repair group .3patients (4.5%) treated by suture repair complained of chronic pain while only 2 (3.7%)in the mesh repair group.
Conclusion: This study showed no significant difference between two methods of repair regarding short term complications and recurrence rates.

Introduction: Neonatal jaundice is a common condition with 60% of newborns being clinically affected in the first days of life. Severe hyperbilirubinemia makes infants at considerable risk of potentially dangerous bilirubin encephalopathy with subsequent kernicterus.

Aim of study : To evaluate importance of clinical and laboratory factors affecting occurrence of acute bilirubin encephalopathy in neonates with severe neonatal hyperbilirubinemia.

Patients and methods: A cross sectional study was conducted in the central child teaching hospital/ neonatal ward/ Baghdad/ Iraq, over the period of 9.5 months(from 1st of October 2015 to 15th of July 2016), including neonates presented with severe hyperbilirubinemia, whom required phototherapy ± exchange transfusion. Neonates were less than 14 days of life, and were term and near term. Full history and physical examination was conducted, and features of acute bilirubin encephalopathy by using the BIND score were assessed.
Relevant laboratory tests were performed.

Results: A 120 neonates with severe hyperbilirubinemia were studied. Mean age of admission was 7.4±2.97 days. Males:female ratio was 2.16:1, mean gestational age was 37.5±1.1 weeks. Term neonates were 100, while preterms were 20. Hemolytic diseases were commonest causes of jaundice (Rh isoimmunization and ABO incompatibility), then followed by sepsis. Fifty one neonates were affected with acute bilirubin encephalopathy according to BIND score.
Neonates of BIND positive group were significantly younger (P <0.01), yet gender and weight were indifferent. Also neonates of BIND positive group were significantly
near terms (P 0.00), low body weight (P 0.024), caesarean delivered (P 0.04), and those needed exchange transfusion (P 0.00). Laboratory investigation in BIND positive group showed significantly higher total serum bilirubin, higher bilirubin/albumin ratio, and lower albumin (P <0.01, <0.01, <0.01 respectively).
ROC analysis identified a total serum bilirubin cut off value of 19.5mg/dl, and bilirubin/albumin ratio was 6.337mg/g, with bilirubin/albumin ratio was more sensitive than total serum bilirubin as a predictor of acute bilirubin encephalopathy.

Conclusion and Recommendations; Near term, low weight, and caesarean section deliveries carry risk for acute bilirubin encephalopathy. Bilirubin cut off value of 19.5mg/dl is critical in evaluating neonatal jaundice, while initial bilirubin/albumin ratio is a predictor of acute bilirubin encephalopathy in severe hyperbilirubinemia.
So we recommend early checkup of serum bilirubin and albumin of neonates with jaundice. Also, encourage term deliveries, and early feeding in cesarean deliveries, and encourage public educational programs about risks of developing neurological dysfunction in newborns with neonatal jaundice and the importance of early seeking medical advice.

Background: Preeclampsia (PE) is a pregnancy specific syndrome that affects 6–8% of pregnancies worldwide. The specific pathogenesis of preeclampsia remains incompletely elucidated. Many tests have attempted to establish the diagnosis of preeclampsia as early as possible, often even before the patients develop arterial hypertension.
Objective: This study aims to identify whether the platelet indices and fibrinogen level are significantly affected by preeclampsia compared to normal pregnancy
Patients and methods :This retrospective case-control study was done in AL- Batool Teaching Hospital-Department of Obstetrics and Gynecology, from the 1st of September 2014 to 30th of September 2015 , 75 woman who fulfill the inclusion criteria were included in the study , they were divided into two groups 25 pregnant woman with preeclampsia & 50 normal pregnant woman as control group(were all normotensive pregnant woman with single intrauterine gestation and the obstetric history is uneventful ) .
Results: Systolic, diastolic & MAP were highly different between the control & the patient groups. Regarding fibrinogen level it was lower in the patients with preeclampsia. Platelet count was also reduced in preeclamptic patients. While all platelet indices were higher in the patient group compared to the control group.
Conclusion: Platelet indices and fibrinogen level can be used in predicting preeclampsia.

Background: Pilon fractures of distal tibia result from axial load with high energy force That produce a spectrum of articular and metaphseal fractuers which are difficult to manage , especially when associated with soft tissue injuries with a high rate of complications when treated with primary open reduction & internal fixation, this drive the surgeon’s to use spanning external fixator & limited internal fixation like k-wirs as an alternative techique for definitive management.
Patients & Method:Twenty cases of fractures of tibial pilon were collected; studied & treated in Al-Yarmook teaching hospital and Red Crescent surgical hospital during the period from October 2013 - october 2015..
The average age of the patients were thirty five years (range from twenty to
fifty years),16 cases were male, 4 cases were female.. 14 cases of them had associated fibular fracture . all are managed by Spanning External fixation with k-wires supplment as an internal fixation to hold the scattered pieces of articular surface .. Results: among those 20 cases there are 8 cases had a good results regarding ankle movement a good union with preservation of ankle mortise .While 9 cases had fair results due to either mal-union or limitation of ankle movements and only 3 cases
ended with poor results. There were only two cases complicated with infection (tibial osteomyelitis) (caseNo. 10 & No. 13) & were treated by proper antibiotics according to culture & sensitivity, also we had nine patients complain from pin tract infection which were treated by antibiotics and daily dressing.
Discussion: The use of external fixation supported by k-wires to treat the metaphyseal portion of pilon (tibial plafond ) fractures with articular surface involvement has been reported to be associated with a lower rate of wound complications than open reduction & internal fixation.. and a good result of union .