Effect of diclofenac suppository on tramadol consumption in posthysterectomy pain

To determine reduction in dose of tramadol and side effects in posthysterectomy patients on addition of diclofenac on rectal suppository. Randomized double blinded placebo controlled study. The Aga Khan University Hospital, Karachi, Pakistan, from August 2004 to January 2006. Seventy ASA I and II females, aged 20 and above, who underwent elective abdominal hysterectomy, were included in this study. Patients received identical looking suppository of either 100 mg diclofenac sodium or placebo after induction of anaesthesia and then 12 hourly for 24 hours. General anaesthesia was standardized and tramadol was given by patient controlled intravenous analgesia delivery system in the recovery. The mean dose +/- SD of tramadol used in first 24 hours was found to be 317 +/- 153 mg in the placebo-tramadol group compared to 258 +/- 192 mg in the diclofenac-tramadol group [p = 0.15, 95% CI = 1.24 to -1.34, 6.63]. Seventeen [49%] patients in the placebo-tramadol group and 14 [40%] in the diclofenac-tramadol group used rescue analgesia [p=0.47]. Sedation score was similar in both the groups and there was no difference in the incidence of nausea and vomiting and use of antiemetics between the groups. This study did not show any reduction in tramadol consumption, given via patient controlled intravenous analgesia when rectal suppository of 100 mg diclofenac was added

Massive primary postpartum haemorrhage: setting up standards of care

To review practice of massive primary postpartum haemorrhage management and develop a protocol. Cross-sectional study conducted at the Department of Obstetrics and Gynaecology at Aga Khan University Hospital, Karachi between January 1, 2003 and July 31, 2004. Women with primary postpartum haemorrhage and had blood loss >1000ml were included in the study. Medical record files of these women were reviewed for maternal mortality and morbidities which included mode of delivery, possible cause of postpartum haemorrhage, supportive, medical and surgical interventions. Approximately 3% [140/4881] of women had primary postpartum haemorrhage. 'Near miss' cases with blood loss >1500ml was encountered in 14.37% [20/140] of these cases. Fifty-six percent [18/32] of the women who had massive postpartum haemorrhage delivered vaginally. Uterine-atony was found to be the most common cause, while care in High Dependency Unit [HDU] was required in 87.5% [28/32] of women. In very few cases balloon tamponade [2-cases] and compression sutures [2-cases] were used. Hysterectomy was performed in 4-cases and all of them encountered complications. Blood transfusions were required in 56% of women who had massive postpartum haemorrhage. This study highlights the existence variable practices for the management of postpartum haemorrhage. Interventions to evaluate and control bleeding were relatively aggressive; newer and less invasive options were underutilized. Introduction of an evidence-based management model can potentially reduce the practice variability and improve the quality of care