Obstetrics & Gynecology

 

The Department of Obstetrics and Gynecology at King Faisal Specialist Hospital and Research Center, Riyadh is a tertiary care center providing up-to-date evaluation and management in Maternal-Fetal Medicine, Reproductive Endocrinology and Infertility, and Gynecologic Oncology patients.

Our staff has special qualifications and experience in dealing with high risk antenatal cases, difficult gynecology and obstetrics surgical procedures, and provide care for couples with infertility problems and those with a variety of genetic disorders through a dedicated pre-implantation genetic diagnosis program.

 

 

The department is composed of three sections:  

Maternal Fetal Medicine (MFM)

The Section of MFM handles all types of high risk pregnancies with fetal and maternal complications, facilitate high standards excellent obstetrical care in the community, and embrace contemporary and innovative knowledge and technology in an ethical manner.

Our role in patient care

Members of the division provide services for maternal and fetal complications of pregnancy. Medical complications include chronic hypertension, diabetes, cardiac disease, venous thromboembolic disorders, hematological disorders, pulmonary diseases, gastrointestinal disorders, renal disease, collagen vascular disease and neoplastic disease. The team manages these problems in active collaboration with other specialties and programs such as internal medicine, endocrinology, gastroenterology, immunology, microbiology, thromboembolic and hematology.

Pregnancy complications such as preterm labor, preterm rupture of the membranes, pregnancy induced hypertension, eclampsia, chorioamnionitis, placental abruption, and other obstetrical complications are managed by expert staff.

Fetal complications such as Rh isoimmunization, intrauterine growth restriction, macrosomia, polyhydramnios, oligohydramnios, multiple-pregnancy, evidenced of fetal compromise, fetal malformations and other fetal/placental disorders are referred to our section from all over the kingdom. Prenatal diagnosis, genetics and fetal dysmorphology services are available for the prenatal detection, evaluation and counseling of patients and/or pregnancies at risk of or complicated by fetal malformations, chromosomal and genetic disorders. Procedures offered include invasive prenatal diagnostic procedures: chorionic villous sampling, amniocentesis, fetal blood sampling and fetal tissue sampling. Non-invasive prenatal screening with nuchal translucency and detailed advanced ultrasound evaluation using state of art ultrasound equipment with 3D/4D scans. When fetal anomalies are identified, we provide a team approach for the care of the fetus and the mother during the course of pregnancy and the postnatal period. The team is unique to each case but often includes neonatology, medical genetics and dysmorphology, pediatric nephrology, pediatric neurosurgery, pediatric cardiology and/or pediatric surgery.

 The fetal therapy program was developed for the in-utero management of complicated fetal problems such as Twin-Twin Transfusion Syndrome, fetal diaphragmatic hernia and other conditions which if left untreated will lead to increased perinatal mortality.

 

Reproductive Endocrinology and Infertility (REI)

The Infertility/IVF Unit performs the latest Assisted Reproductive Technologies (ART) from conventional IVF to all types of micromanipulation techniques. Pre-implantation Genetic Diagnosis (PGD) is one of the unique hi-tech services offered by IVF unit.

Our clinical work includes some of the world’s finest technicians and physicians who have pioneered new innovations and been honored for their outstanding contributions to the field of reproductive medicine. We accept referral cases for diagnosis, and treatment of endocrine and reproductive disorders including abnormal menses, amenorrhea, infertility, recurrent early pregnancy loss, ovulatory problems, uterine or tubal abnormalities. And for Men’s Fertility Services, we provide Semen analysis, Sperm preparation for intra-uterine insemination, andrology testing, Urology referrals.

Therapies may include hormonal and/or surgical treatment or advanced technologies such as In Vitro Fertilization IVF and ICSI (Intra-Cytoplasmic Sperm Injection).

Our role in patient care

Controlled Ovarian-stimulation, In Vitro fertilization, ICSI intracytoplasmic sperm injection, cryopreservation, and pre-implantation genetic diagnosis PGD a well-organized program.

The REI Laboratory

Our andrology laboratory uses CASA (Computer Assisted Semen Analyzer)—another example of cutting edge technology in the laboratory, headed by leading medical technologists.

 

Gynecology and Gynecologic Oncology

The Division of Gynecologic Oncology delivers an up to date care to women with all types of gynecologic malignancies. The services include cancer screening, early diagnosis as well as surgical and medical management of all gynecologic cancer cases as a premiere treatment institution in our field and the quality of care provided by KFSHRC-Riyadh to cover all referral cases of suspected or diagnosed gynecological malignancies.

Our staff of Gynecologic Oncologists are all board-certified women’s cancer specialists who are qualified and experienced in advanced medical and surgical training in treatment of gynecological malignancies. They provide unified, comprehensive medical and surgical care to women with reproductive-tract cancers from diagnosis to completion of treatment in liaison with other specialties in multidisciplinary approach e.g. medical oncologists, radiation oncologists and other supportive care.

Our role in patient care

Women who have recently been diagnosed with gynecologic cancer, including cervical, endometrial, ovarian, uterine, vaginal, and vulvar cancer, or Gynceological cancer during pregnancy, all receive treatment at our division. We also provide treatment for uterine sarcoma, molar pregnancy and all types of gestational trophoblastic disease.

Our approach for comprehensive management of our patients is of multidisciplinary effort, thru weekly tumor board meetings with our colleagues, medical and radiation oncologist, histopathologist and radiologist, advanced practice nursing, state of art diagnostic imaging medical oncology, social workers, and nutrition.

 

OB ULTRASOUND UNIT

We work to identify potential obstetrical or fetal problems as early as possible and provide clinically relevant diagnoses of fetal anomalies.

Our staff include highly trained experienced Sonographers in level III obstetrics scans. The unit is run and supervised by Maternal Fetal Medicine subspecialist consultants who provide patients’ counseling, plan further management and care for high risk pregnancies especially if fetal abnormalities are diagnosed.

Dignostic imaging:

We offer non-invasive screening for various genetic/ metabolic / cardiac and aneuploidy using Nuchal translucency scans at 11-14 weeks gestation, detailed early  anatomy scan offered from 16-18weeks for those at very high risk for recurrence of severe fetal anomalies, routine level III anatomical evaluation is done routinely at 20-22 weeks scan were uterine artery Doppler as screening for placental insufficiency is carried out in high risk patients,  serial growth scans with fetal well-being tests including fetal arterial , venous Doppler and Biophysical profile is done for high risk patients. Placental anomalies, abnormal placentation, hematomas and fibroids, evaluation of uterine cervix all were evaluated thoroughly. All the above offered also for multi-fetal pregnancy.

Annually we are doing 8000-9000 ultrasound examinations.

 

Innovative Achievements

Section of Gynecology Oncology:

1.Robotic Surgery

In gynecology is one of the fastest growing fields of robotic surgery. Robot-assisted surgery was developed to overcome limitations of minimally invasive surgery; it can be used to treat fibroids, endometriosis, ovarian tumors, pelvic prolapse, and female cancers. Using the robotic system, our gynecologists performed hysterectomies, myomectomies, and lymph node biopsies. The need for large abdominal incisions is virtually eliminated.

2.Laparoscopic Oophoropexy for Ovarian Function Reservation in Cancer Patient with New Techniques Such Single Port Laparoscopy

Minimally invasive technique for ovarian transposition (oophoropexy) can offered to any age premenopausal women with Hodgkins disease, brain tumors, cervical, vaginal, and others who is undergoing total Lymph Node Irradiation (TNI) deliver as a dose of 200-400 Centigray (CGY) It is safe and effective procedure for ovarian function preservation.

3.Intra-Operative Radiation Therapy (IORT)

In patients with recurrent gynecologic cancers in the pelvic sidewalls, para aortic or pelvic lymph nodes, the use of aggressive surgery and IORT appeals beneficial. Our colleagues with the surgical oncology and radiation oncology helped in establishing this new approach in gynecology oncology section.

4.Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

It became to be an important and potential curative treatment for intra-abdominal metastases for both advanced primary and recurrent ovarian and peritoneal cancers.

Our Section with the collaboration of surgical oncology team succeeded in achieving a combined program with very promising results.

 

Section of Maternal Fetal Medicine-Fetal Therapy Program

Established end of 2007 and the first case of Fetoscopic laser coagulation for stage III Twin to twin transfusion syndrome was performed early 2008.  The program is active in accepting patients from all over the kingdom and from the neighbouring Gulf region for evaluation of fetal pathology, and intervention when indicated.

 

As the program has expanded, a clinical coordinator joined the team, and a specialized clinic was opened to receive all the new referrals.  Cases will be evaluated through the Fetal Therapy team which consists of the Maternal Fetal Medicine subspecialists, neurosurgeons, pediatric cardiologists, neonatologist, and clinical coordinators.  All newly referred patients will be seen and evaluated by the appropriate team members and the plan of care will be explained and documented.  Patients requiring further testing or therapy will be scheduled for the procedures if indicated, another counselling session will be conducted with the family, the findings explained, the plan of care explained, the complete reports provided, and the patients could be referred back to their referring hospital for further pregnancy and delivery care.

 

Section of Reproductive Endocrinology Infertility

Pre-implantation Genetic Diagnosis (PGD)

Preventing disease is a standard goal of medicine. PGD provides an early genetic diagnosis for an embryo before it is implanted into the uterus. It is an effective method to prevent the transmission of hereditary diseases to the next generations in the families with single gene disorders or chromosomal abnormalities. PGD requires combined expertise in the field of reproductive medicine together with molecular genetics and/or cytogenetic. It involves two stages: Firstly; IVF for ovarian stimulation, monitoring and timing of oocyte retrieval, fertilization and embryo biopsy. Secondly; a genetic diagnosis that is reliable and efficient is necessary to report the result in early enough time for embryo transfer to take place in the same cycle.

Reason for referrals, patient counselling, specialized genetic counselling:

Couples referred for PGD are at risk of having a pregnancy affected with a known genetic disease, the majority of them at least have one affected child of their own or in the close family. The available reproductive option for them was prenatal diagnosis, which remains an unsatisfactory solution for some couples at high genetic risk, e.g. couples who had undergone repeated termination of affected pregnancies often ask for diagnosis prior to pregnancy. Furthermore, the couples that find termination of pregnancy unacceptable for religious, emotional, and social reasons also ask for PGD. Such couples feel that starting a healthy pregnancy using PGD is the only option for them since pregnancy termination is particularly distressing.

There is also a group of patients who are sub-fertile, or with previous pregnancy with chromosomal abnormality, or had repeated miscarriages, recurrent implantation failure following IVF cycles, or for those mothers with advanced maternal age, PGD and  Preimplantation Genetic Screening (PGS) allows the screening for chromosomal abnormalities.

Another group of patients suffers from cancer predisposition such hereditary breast and/or ovarian cancer, or had inherited some genes that develops cancers such as the Familial adenomatous polyposis A genes (colon cancer). Most of the cancer patients receive radiotherapy/chemotherapy as part of their treatments which may permanently affect their fertility.  Therefore, IVF/ PGD cycles help them to diagnose the embryos, and those healthy embryos which do not have the cancer causing mutations can be transferred to the mother in order to initiate diseased free pregnancy. For those patients underwent radiotherapy/chemotherapy, fertility preservation is highly recommended as a part of the treatment supported with PGD following fertilization, where healthy embryos can be frozen and consider for transfer after completing the radiotherapy/chemotherapy treatments.

 

Acceptance criteria

Patients should meet the admission criteria outlined by the IVF clinic, and a clear genetic report should be provided by the referring physician.

 

Current Status or PGD service

No of families request the PGD service: 1550   families

No of diseases: 320 disease

No of cases performed: 1395 cycles

 

 The above information summarized the number of cases referred for the IVF/ PGD treatments and cycles performed. KFSHRC is considered as Tertiary care hospital “referral laboratory” therefore we also do accept cases from different IVF centers and hospitals within the country. Additionally this kind of service is not one time treatment, the chances of take home baby following IVF/ PGD cycle is 30-40%, which more or equal to traditional IVF cycle. Couples within the reproductive age will keep on requesting PGD until they reach the desired number of family.

 

Fluorescent in situ hybridization (FISH) is a technique used most often for preimplantation genetic screening (PGS) and for chromosomal rearrangements, while Polymerase chain reaction (PCR) is used for single gene disorders. The most up-to-date techniques Array Comparative Genome Hybridization (CGH-Array) and single nucleotide polymorphism (SNP) array “karyomapping” has been implemented.

 

Social impact

  • Psychosocial burden for couples before requesting PGD: ?Some couples are confused regarding the inheritance “Some believed that marrying their cousin was the reason of having an affected child, where others believed that it was inherited from one parent (most thought it was inherited from the mother side) These couples will require specialist genetic counseling.
  • Others showed various levels of guilt, and self-blame for their child’s condition, mainly because they were married to their cousin and did not undergo premarital screening “ which will not help for disease other than hemoglobinopathies (inherited blood disorders results in abnormal structure of one of the globin chains of the hemoglobin molecule).
  • They also complain from difficulties in family adjustments, which affect their social life, and stigmatization.
  • Most of them feel the anxiety toward IVF cycle being fertile couple. Therefore, couples had to be educated and counselled about IVF/ PGD cycle, the nature of the inherited disease, their reproductive options and the risk associated with the treatment.

 

Economic burden

In the absence of prevention, successful management can have unexpected cost implications, affected people survive into adult life instead of dying in childhood and at the same time as a new patients continued to be born. Therefore, the average cost of patient care is expected to rise annually multiplied by the annual births of newly diseased offspring. Prevention helps to contain the number of affected people reducing the overall treatment cost and it has priceless impact on the families.