Risk of uterine rupture after the partographic alert line is crossed - an additional dimension in the quest towards safe motherhood in labour following caesarean section

To determine if prolonged active phase of labour is associated with increased risk of uterine scar rupture in labour following previous lower segment caesarean section, a retrospective cohort study [1988-91] was done to analyse active phase partographs of 236 patients undergoing trial of labour following caesarean section, 7 [3%] of whom had scar rupture. After onset of active phase [3 cm cervical dilatation], a I cm/h line was used to indicate "alert". A zonal partogram was developed by dividing the active phase partographs into 5 time zones: A [area to the left of "alert" line], B [0-1 h after "alert" line], C[1-2 h after "alert" line], D [2-3 h after "alert" line] and EF [>3 h after "alert" line]. The relative risk of uterine scar rupture was calculated for different partographic time zones. The relative risk of uterine scar rupture was 10.5[95% confidence interval 1.3-85.5, p=0.01] at 1 hour after crossing the "alert" line; 8.0 [95% confidence interval 1.6-40.3, p=0.009] at 2 hours after crossing the "alert" line; and 7.0[95% confidence interval 1.6-29, p=0.02] at 3 hours after crossing the "alert" line. In women undergoing trial of labour following caesarean section, prolonged active phase of labour is associated with increased risk of uterine rupture. A zonal partogram may be helpful in assessing this risk in actively labouring women who cross the partographic "alert" line

Are non-diabetic women with abnormal glucose screening test at increased risk of pre-eclampsia, macrosomia and caesarian birth?

To determine, in non-diabetic women, the relationship of abnormal glucose screening test, with the incidence of pre-eclampsia, macrosomia and caesarian delivery, from 1988-92, 5646 consecutive women attending antenatal clinic were screened with a glucose challenge test [GCT] on their first visit [usually at 16-20 weeks]; those with risk factors i.e., history of unexplained perinatal loss, macrosomia or family member with diabetes and an initial abnormal screening test were rescreened at 28-32 weeks. In 482 cases the GCT was abnormal [plasma glucose value was > 140 mg percent 2 hours after 75 g glucose challenge]. Of these, 292 had one or more abnormal critical values at a 75g - 3 hour oral glucose tolerance test [GTT] and they were treated to maintain euglycaemia. The rest [n=190] had no evidence of glucose intolerance with no abnormal values at the GTT. The subjects were divided into 3 groups based on GCT values; A, randomly selected subjects with a normal GCT [n=1000]; B, those with abnormal GCT but normal GTT [n=190]; and C, those with abnormal GTT [n=292]. The variables studied were age, gravidity, parity, gestational age at delivery, pre-eclampsia, birth-weight and mode of delivery. The incidence of pre-eclampsia and caesarian birth varied, being the lowest in Group A [3.9% and 11.9% respectively] and then rising through group B [6.3% and 16.3% respectively] to the highest in Group C [12.6% and 26.0% respectively; test of linear trend, p<0.05]. For macrosomia, the incidence increased from Group A to B but there was a drop in Group C. The incidence of macrosomia was significantly higher for Group B as compared to A or C [9.5% and 3.3%, p<0.05]. These data show higher risk of complications associated with minor degrees of glucose intolerance emphasizing the need for vigilance in these patients

Audit changes clinical practice! Impact on rate of justification of hysterectomy indication

After performing a baseline audit in 1986-89, an ongoing quality assurance process was initiated in January, 1990 and all hysterectomies performed over the next 2 year period were analyzed. Hysterectomy indications were divided into two groups: one in which the uterine specimen was expected to show pathology and another in which no pathology was expected. The hysterectomy was considered justified in the former if the pathology report verified the indication or showed a significant alternate pathology. In the latter, validation criteria showing documentation of certain prerequisite diagnostic procedures performed before reverting to hysterectomy, were used to ascertain justification. The overall rate of justification in the ongoing audit was 96%, being 97% for the group where hysterectomy indication was polentially confirmable by pathologic study and 93% for the one where it was not. Comparison with baseline analysis showed that the justification rates were higher for all indications not potentially confirmable by pathologic study [93% vs 89%, p<0.05], for recurrent uterine bleeding [90% vs 83%, p<0.05] and for leiomyoma [97% vs 95%, p<0.05]. The improvement was associated with less frequent use of multiple indications in the ongoing study [10% vs 16% p<0.05]. The justification rates for hysterectomy indication can be improved by prospective audit and by avoiding use of multiple indications

Screening for cervical cancer by pap smear

Between November; 386 and February 1988, 2806 cervical smears were taken from every patient attending the Obstetrics and Gynaecology consulting clinics at The Aga Khan University Hospital [AKUH] Karachi. Of 2806 smears 2774 [98.9%] were adequate, cytology was positive in 35, a prevalence rate of 12.6 per 1000. The highest incidence was in the age group of 25-44 years. Eighty percent patients with positive cytology had no symptoms related to micro-invasive or invasive disease of cervix