Maternal mortality in a tertiary care hospital

Death of a woman during pregnancy and child birth is an extremely tragic event. It is a waste of a precious life that leaves great feeling of grief and pain for the family and hospital staff and has devastating influence on the community overall. Maternal morbidity and mortality can be prevented by awareness of reproductive health in a community, availability, and utilisation of organised antenatal care, skilled intrapartum management and careful postnatal follow up. Objective was to analyse the pattern of maternal mortality over the period of five years in a tertiary level hospital receiving high risk referred patients from periphery. All patients admitted in Gynae 'A' Unit, Ayub Teaching Hospital from January 2006 to December 2010 were included in the study and number and causes of maternal deaths were noted. During these 5 years there were 78 maternal deaths out of 11,997 obstetrical admissions. There were 7,380 total births and 78 maternal deaths during the study period and Maternal Mortality Rate was 1,057/100,000. The main cause of maternal death was eclampsia and its complications [28.2%]. Eclampsia is the leading cause of maternal mortality in our setup. Proper and timely referral is an important measure to prevent it

Septic induced abortions

Induced abortions are not infrequent in our community. Being the only tertiary level care hospital in Hazara division, Ayub Teaching Hospital frequently receives cases of induced abortions with complications attempted by inappropriately trained personnel. It was decided to study the frequency of such cases in our admitted patients, complications and their outcome in such risky situation. A cross sectional study was conducted from January 2006 to December 2007 in Gynae-B Unit, Ayub Teaching Hospital, Abbottabad. All admitted patients in the unit in the 1[st] trimester of pregnancy and handling outside the hospital were included in the study. In two years period total Gynae admissions were 1090. There were 152 [13.95%] cases of spontaneous 1st trimester abortions and 52 [4.7%] cases of induced abortions which are included in the study. Age range of the patients was between 20-45 years, with a mean of 35 years. Majority of the patients were grand multigravidas belonging to lower socioeconomic group and not using any contraception. Twenty patients [38.4%] presented with heavy per vaginal bleeding due to incomplete nature of the procedure. Twelve patients 23% presented in shock due to excessive per vaginal bleeding. Ten patients 19.2% had uterine perforation and intraperitoneal haemorrhage. Two patients 3.8% had gut injury associated with uterine perforation. Three patients 5.7% developed septicaemia due to uterine gangrene. Ten patients 19.2% had acute pelvic infection presented with pelvic abscess and acute pelvic inflammatory disease. Maternal motility in our study was 2 out of 52 [3.8%]. Induced septic abortions contribute significantly to maternal morbidity and mortality. Improving literacy rate in our female population and effective family planning should reduce its incidence. Different resources should be used to develop awareness of the hazards of induced abortions in the community

Dubin-johnson syndrome

A young man presented with recurrent episodes of mild jaundice. Apart from conjugated hyperbilirubinemia, other liver function tests were always normal. Clinical suspicion of Dubin-Johnson syndrome was raised. Liver biopsy showed diffuse deposition of coarse granular dark brown pigment in hepatocytes. Dubin-Johnson syndrome is a benign condition, which results from a hereditary defect in biliary secretion of bilirubin pigments, and manifests as recurrent jaundice with conjugated hyperbilirubinemia. The defect is due to the absence of the canalicular protein MRP2 located on chromosomes 10q 24, which is responsible for the transport of biliary glucuronides and related organic anions into bile. No treatment is necessary and patients have a normal life expectancy

Maternal morbidity and mortality due to primary PPH-experience at Ayub Teaching Hospital Abbottabad

Postpartum Haemorrhage [PPH] remains a significant cause of maternal mortality and morbidity like hypovolemic shock, anaemia, multi organ failure, consumptive coagulopathy, disseminated intra vascular coagulation [DIG], blood transfusion related complications and hysterectomy leading to loss of childbearing potential. The present study was conducted to determine the frequency of PPH and the associated maternal morbidity at the Department of Gynaecology Unit 'B', Ayub Teaching Hospital Abbottabad. The study was carried out in the Department of Obstetrics and Gynaecology Unit B of the Ayub teaching Hospital Abbottabad from 18[th] April 2006 to 17 July 2006. The study population included all cases admitted with primary PPH during the study period. For calculation of frequencies, the total number of deliveries in the setting during the study period was used. All subjects underwent a complete obstetrical clinical workup comprising of history, general physical examination, abdominal and pelvic examination, relevant laboratory investigations. The maternal condition was assessed and managed according to established hospital protocols which included both pharmacological and surgical intervention. All maternal complications were noted and recorded on pre-designed proformas. Data was entered and analyzed by computer. A total of 50 cases of primary PPH were recorded during the study period. The frequency of PPH was calculated as 7.1%. The major cause of PPH was uterine atony found in 29 [58%] cases, followed by cervical, vaginal and perineal tears in 12 [24%] cases. Initially all patients were managed pharmacologically followed by surgical intervention. Subtotal [haemostatic] hysterectomy was performed in 10 [20%] cases. Maternal morbidity was detected in 31 [62%] of cases; the major morbidities were DIC in 3 [6%] cases, Acute renal failure in 3 [6%] patients and shock in 2 [9.9%] cases and anaemia in 20 [90.1%] cases. The study concludes that the frequency of primary PPH in this setting is in keeping with globally cited frequencies. Other findings such as causes of primary PPH and maternal morbidity data also agree with most national and international studies on this topic

Abruptio placentae and its complications at Ayub teaching hospital Abbottabad

Abruptio placentae remains a major cause of perinatal morbidity and mortality globally, though of most serious concern in the developing world. As most known causes of abruptio placentae are either preventable or treatable, an increased frequency of the condition remains a source of medical concern. The present study was undertaken at the Department of Obstetrics and Gynaecology, Unit B, of the Ayub Teaching Hospital, Abbottabad, Pakistan, from July 2003 to June 2004. Patients of abruptio placentae were selected from all cases of 28 weeks or greater gestation, presenting with ante partum haemorrhage during the study period. Patients underwent a complete obstetrical clinical workup including history, general physical examination, abdominal and pelvic examination. Relevant investigations such as laboratory tests and imaging were performed. Patients were managed according to maternal and fetal condition. Any maternal and/or fetal complications were noted and recorded. All data were collected on predesigned proformas and analyzed by computer. A total of 53 cases of abruptio placentae were recorded out of 1194 cases [4.4%] admitted for delivery during the study period, giving a rate of 44 cases of abruptio placentae per 1000 deliveries. Induction of labour was required in 27 [50.9%] cases, while caesarean section was performed in 16 [30.2%] cases. Major complications were intra uterine fetal demise [31/53, 58.5%], fetal distress [8/22 live births, 36.4%] and post partum haemorrhage, which occurred in 10 [18.9%] cases. A higher than expected frequency of abruptio placentae exists in our setting and the consequences of abruptio placentae for neonatal mortality outcome are alarmingly high. The majority of patients presented with intra uterine death so that any management protocol directed at abruptio placentae or its consequences is of little help in preventing perinatal mortality

Use of Foley's catheter and prostaglandin F-2 alpha in second trimester termination of pregnancy

Termination of pregnancy [TOP] in the second trimester is associated with three to five times higher risk of maternal morbidity and mortality than termination during first trimester. The main concern of obstetrician is to provide the most effective and safest regimen which combines the shortest expulsion interval with least side effects. This study was undertaken to compare the use of Foley's catheter with extra-amniotic instillation of PGF2 alpha for second trimester TOP so that a choice of the safer and cost-effective method could be available. The study was conducted in Department of Obstetrics and Gynecology Unit 'B' at Ayub Teaching Hospital Abbottabad between August 2003 and July 2004. Sixty patients recommended for TOP [missed abortion or anencephalic fetus confirmed on ultrasonography] were randomly allocated into two groups. In group 'A', Foley's catheter alone was used while in group 'B' extra amniotic instillation of Prostaglandin F-2 alpha [PGF2 alpha] was done via a Foley's catheter. After expulsion of catheters in both cases oxytocin infusion containing 30 units were started till the expulsion of fetus, placenta and membranes. The mean induction to expulsion time and the mean induction to delivery time for both groups were noted as well as total cost of treatment. Difference in time interval with regard to induction to expulsion time of catheter and induction to delivery time between the two groups was significant being 3 hours and 5 hours respectively less in group 'B' [p < 0.001]; however only 25% of patients in group 'B' had a significant short induction to delivery time as compared to group 'A'. The difference in costs of treatment between the groups was also significant [p < 0.001]. Use of PGF 2 alpha is preferred, though for poor patients Foley's catheter may be used, but only in a tertiary care setting

Analysis Maternal mortality in a tertiary care hospital to determine causes and preventable factors

All pregnant women are at risk of obstetrical complications and most of these occur during labor and delivery that lead to maternal death. In our setup maternal mortality is seriously under estimated. Safe motherhood as a priority for action can not be identified with out properly assessing maternal mortality. The objectives of this study were to determine causes and preventable factors responsible for maternal mortality. This study was conducted in Gynaecology 'C' unit of Ayub Teaching Hospital, Abbottabad, from January 2000 to December 2001. Patients were admitted through emergency obstetrics care unit and Gynaecology out patient department. Patients' demographic record including age, parity, education, socio-economic status along with antenatal care record, level of care and distance from hospital were noted. Causative factors leading to maternal death and contribution factors evaluated. All this information was collected from patients records. Twenty-six maternal deaths were recorded during study period. The major causative factors were haemorrhage 9 [34.6%], eclampsia 8 [30%], sepsis 5 [19.2%], anaesthetic complications 3 [11.5%] and hepatic encephalopathy 1 [3.8%]. Maternal mortality ratio was 12.7/1000 live births [26/2040]. The age range was between 18'42 years. There were 16 [61.5%] patients in >30 years age group. Most of them [69%] were grand multiparas [Parity >5]. Education, antenatal booking and socio-economic status were poor. The distance from hospital was between 10 and 100 KM. The level of care available at nearest health facility was estimated, 40% were attended by traditional birth attendants, 33% by lady health visitors, 10% by doctors and to 17% no level of care was available. Obstetrical haemorrhage and hypertensive disorders are still major causes of maternal deaths. Most maternal deaths are preventable. The provision of skilled care and timely management of complications can lower maternal mortality in our setup

Indications of caesarean section in a district head quarter hospital for women

Rates and indications of Caesarean Section [CS] are the subject of controversies. The safety of elective Caesarean Section in the developed world has given rise to another controversy. Now the women in the developed world are requesting elective caesarean section by choice as a mode of delivery in the absence of any specific indication. The indications of CS performed in a district hospital were studied The study is descriptive in type. It was carried out in District Headquarter Hospital for Women, D.I. Khan in 2002. The data was collected from the history sheets and labour room registers. During one-year period, 209 CS were performed. The rate of CS was 11.86%. Emergency CS were 82.38%, elective CS were 17.14%, 18.1% were booked and 81.9% were un-booked. Antepartum haemorrhage contributed to 23.92%, obstructed labour to 18.09%, failure of progress to 13.3%, previous CS to 11.9% and cephalopelvic disproportion to 11.9% of the indications. Miscellaneous conditions contributed to 7.14% of the cases. In the majority of cases more then one factors had operated. The study showed that all CS performed had specific indications. Caesarean Section was accepted as the last resort for delivery

Minilaparotomy and ovarian diathermy drilling for clomiphene resistant poly cystic ovarian disease

This study was carried out to determine the effectiveness and safety of minilaparotomy and ovarian drilling for sub fertile women with clomiphene resistant polycystic ovarian syndrome. During a 2 year period [August 2000 to August 2002] 16 patients with polycystic ovarian disease were managed by minilaparotomy and ovarian drilling by diathermy. All the patients underwent full infertility workup and then treated with cyclical clomiphene citrate for 6 months. Six patients [37.5%] presented in age group 15'25 years. Eight patients [50.0%] were in age group 26'35 years. Only 2 [12.5%] patients presented in age group 36'44 years. Eleven [68.75%] patients had primary infertility. Five [31.25%] patients presented with secondary infertility. After treatment and 6 months follow up, ovulation occurred in 14 [87.5%] patients. Eleven [68.75%] women conceived pregnancy. Ovarian drilling is a powerful tool in the treatment of polycystic ovarian disease

Role of dilatation and curettage and interpretation of endometrial biopsy in gynaecological cases

310 Cases of diagnostic D and C were collected randomly from Gynae unit of Lady Reading Hospital Peshawar from January 1990 to January 1991. These were cases of infertility 49.26%, menorrhagia 13.22%, irregular bleeding 29.67%, Postmenopausal bleeding 5.164%, primary and secondary infertility 30.96% and 18.38% respectively. Various aspects like age, parity, marital status, clinical features and histopathological results were analysed 6.45% were below the age of 20 years. 63.22% between 21 to 40 years, 25.16% between 40-50 years and 5.16% were above the age of 50 years. 16.45% patients were nullipara. 15.48% Primipara and 37.09% and 30.96% were multipara and grand multipara respectively. 0.64% patients were un-married, 84.83% were married and 40.51% were widows. Results of endometrial biopsies were as follows. Proliferative phase 47.74%. Secretory phase 35.48%, tuberculous endometritis 1.93%, cystic endometrial hyperplasia 8.38%, Adenomatus hyperplasia 1.29% and adenocarcinoma 0.96%

mortality and morbidity associated with umbilical cord prolapse

A prospective study was carried out on 15 cases of cord prolapse admitted in the study period between January 1995 and December 1995 in Gynae "A" unit at Women and Children Teaching Hospital, Abbottabad, managing 1500 deliveries annually. Survival rates were assessed by APGAR score at 1 and 5 minutes. The incidence of cord prolapse was in 100 in our study group. 8 babies were alive when cord prolapse was diagnosed and all except 1 survived inspite of severe bradycardia. Reason for low mortality rate of hospital diagnosed cases with alive fetuses was a short diagnosis to delivery interval [D.D.I.]

Early delivery by cesarean section in eclampsia can decrease maternal and foetal mortality and morbidity

This is a retrospective study of 90 cases of eclampsia admitted during a three year period [June 1992 to May 1995] in Unit A of Obstetrics and Gynaecology Department of Women and Children Hospital, Abbottabad. The incidence of eclampsia was 0.93%; 69 [76.67%] patients were primigravidae, 12 [13.33%] were para 1-4 and 9 [10%] were grandmultiparae. All these patients were unbooked and belonged to poor socio-economic class. Thirty [33.33%] were delivered by Caesarean section, indications for which were unfavourable Bishop's score [<5] and live foetuses. Maternal mortality was one [3.33%] among the patients who were delivered by Caesarean section and 12 [20%] among the 60 women who were delivered vaginally