Endometrial stromal sarcoma: a rare entity

Endometrial Stromal Sarcoma [ESS] is a hormone sensitive tumor. It is a rare gynecological tumor and is considered to occur more often in pre-menopausal women. A proper pre-operative diagnosis is difficult and confirmed in most cases after hysterectomy for a presumed benign disease. Endometrial sampling, ultrasound, and magnetic resonance imaging can provide diagnostic clues. For early disease complete surgical cure is possible, however, adjuvant therapy is available for recurrence. This case of Low Grade Endometrial Stromal Sarcoma [LGESS] in a 21 years old woman was presented as irregular vaginal bleeding. Clinical diagnosis of fibroid was made but analysis of endometrium showed ESS confirmed on hysterectomy specimen. One should consider it in any case with rapid fibroid enlargement

Assessment of gestational age; comparison between transcerebellar diameter versus femur length on ultrasound in third trimester of pregnancy

To compare correct assessment of gestational age between Transcerebeller diameter versus femur length in third trimester [28-40] using first day of last menstrual period for actual period of gestation. Cross-sectional descriptive study. Department of Obstetrics and Gynecology, Bahawal Victoria Hospital, Bahawalpur from Jun 2012 to Dec 2012. This study was performed on 327 patients in third trimester of pregnancy from 28-40 weeks fulfilling the inclusion criteria. Ultrasound measurements of transcerebellar diameter [TCD] and femur [FL] were made with commercially available real time ultrasound equipment Toshiba Nemio-10 model 2009, Transducer frequency 50/60 Hz. Collected data was analyzed by SPSS version 10. Out of 327 patients, TCD was found to give correct assessment corresponding to the gestational age by LMP in 262 [80.1%] patients, while in 232 [70.9%] patients FL was found to give correct assessment corresponding to the gestational age by LMP. Transcerebellar diameter is more reliable method of gestational age determination in third trimester of pregnancy than femur length. TCD can be used as a tool to assist in the assessment of gestational age in third trimester

Gestational diabetes mellitus and obesity: an experience at a teaching hospital in Bahawalpur, Pakistan

To compare the frequency of gestational diabetes mellitus in second and third trimester in obese and non-obese women. It was a prospective study conducted at Department of Obstetrics and Gynaecology, Bahawal Victoria Hospital Bahawalpur. Sixty two obese and 62 non-obese women having singleton pregnancy were included in the study at their booking visit at tilde 14-20 weeks of gestation. Women having family history of obesity and chronic ailments and those with age >35 or parity > 5 were excluded. Mean age was 28.12 +/- 2.72 years among the group of obese women as compared to 27.89 +/- 2.34 years in non-obese group. Commonest parity among the obese women was 3-4 [n=31, 50%] compared to 46.8 % [n=29] in non-obese group. Development of gestational diabetes mellitus was 22.58% [n=14] in obese group which was significantly higher than 6.45% [n=4] in non-obese group [p=0.001]. Gestational diabetes mellitus developed in significantly higher number of obese women as compared to non-obese women

Comparison between transcerebellar diameter with biparietal diameter of ultrasound for gestational age measurement in third trimester of pregnancy

To determine the frequency of correct assessment by transcerebeller diameter [TCD] versus biparietal diameter [BPD] for gestational age measurement at 36 weeks of pregnancy using first day of last menstrual period [LMP] for actual period of gestation. Quasi experimental. Department of Obstetrics and Gynaecology, Bahawal Victoria Hospital, Bahawalpur from May to November 2010. This study was performed on 228 patients at 36 weeks of pregnancy fulfilling the inclusion criteria. Ultrasound measurements of TCD and BPD was made and compared with LMP. Collected data was analyzed by SPSS version 10. Proportoin of correct diagnosis by each measurement was determined and compared using chi-square test with significance at p < 0.05. Out of 228 patients, TCD was found to give correct assessment in 209 patients [91.7%; p = 0.001] corresponding to the gestational age by LMP i.e 36 weeks. BPD was found to give correct assessment corresponding to the gestational age by LMP in 176 patients [77.2%]. Although both BPD and TCD are accurate biometric parameters at 36 weeks of gestation, transcerebellar diameter is more reliable method of gestational age determination in third trimester of pregnancy than biparietal diameter. TCD can be used as a tool to assist in the assessment of gestational age in third trimester

Impact of methods for uterine incision closure on repeat caesarean section scar of lower uterine segment

To compare the effect of different suturing techniques in repeat caesarean section in terms of scar thickness, blood loss, operative time and scar dehiscence at the time of next caesarean section. A randomized double blinded trial. Obstetrics and Gynaecology Department of Bahawal Victoria Hospital, Bahawalpur, from June 2005 to June 2010. Ninety patients undergoing repeat caesarean section were included and randomly assigned to one of the three groups. Group A underwent one layer closure; Group B underwent two layer closure while Group C underwent modified two layer closure of the uterine incision. Ultrasonographic evaluation of the scar thickness was performed at 6 weeks post operatively and longer follow-up was done in next caesarean for scar dehiscence. Frequency percentages were obtained and compared using chi-square test with significance at p<0.05 In only 2 [6.6%] of modified two layer closure cases, it was necessary to use additional haemostatic sutures, compared with 16 [53%] of one layer closure group, and 10 [33%] of the two layer closure group. At 6 weeks, the mean scar thickness in group C [17.08 +1.635 mm] was significantly greater [p<0.001] as compared to group A [13.19 +1.32 mm] and group B [14.58 +1.18 mm]. At long-term follow-up, only 1 [6%] case from group C showed the "uterine window" at the time of repeat caesarean section as compared to 3 [23%] in group A and 2 [14%] in group B. Scar thickness was significantly increased with modified two layer closure when compared with traditional one and two layer closure of lower transverse uterine incision at the time of repeat caesarean section

Preterm prelabor rupture of membranes at 34-37 weeks: conservative versus active management

To compare the fetal and maternal morbidity in terms of fetal distress, chorioamnionitis and mode of delivery in conservative and active management of preterm prelabor rupture of membranes [PPROM] at 34-37 weeks of pregnancy. Quasi experimental study. Department of Obstetrics and Gynaecology, Bahawal Victoria Hospital, Bahawalpur from January 2007 to December 2007. A total of 100 cases were included in the study and divided into two groups of 50 each, Group "A" patients were managed conservatively and group "B" underwent active management with immediate induction of labor. Eighteen [18%] patients developed chorioamnionitis. Out of these 13 [26%] were in conservatively managed group and 5 [10%] in actively managed group. Twelve [12%] patients developed fetal distress. 7 [14%] in conservatively managed group and 5 [10%] in actively managed group. A total of 20 [20%] patients underwent cesarean section. Out of these 11 [22%] were from conservatively managed group and 9 [18%] from actively managed group. Induction of labor at presentation is a better option than conservative management in terms of chorioamnionitis but the results are not significantly different for the fetal distress and mode of delivery

Abdominal techniques for surgical management of vaginal vault prolapse

To evaluate and compare the short and long term safety and effectiveness of different abdominal techniques for surgical management of vaginal vault prolapse. Observational Cross sectional study. Department of Obstetrics and Gynaecology Unit II, Bahawal Victoria Hospital, Bahawalpur, from January 2001 to December 2008. A total of 80 cases were divided into four Groups [20 patients in each]. In Group A, patients were managed by sacrocolpolexy with polypropylene [Prolene mesh, Group B had sacrocolpopexy with autologous rectus sheath, Group C underwent high uterosacral ligament suspension and Group D had vault suspension with an autologous fascial sling of rectus shealth.. All cases were analyzed regarding their complaints, clinical examination, investigations and follow up. No recurrence occurred in group A, as compared to 10%, 20% and 15% in Group B, C and D respectively. No patient from Group A reported with incisional hernia as compared to 10%, 5% and 10% in Group B, C and D. Operative time was less in Group A as compared to Group B but longer as compared to Group D and almost same as in Group C. The complaint of low persistent backache remained same in Group A and B [30%] as compared to 35% in Group C and D. Least blood loss was observed in Group A. Sacrocolpopexy is gold standard procedure for treatment of vault prolapse. If it is performed with prolene mesh best results are expected

Misoprostol for the purpose of mid-trimester termination of pregnancy: a comparative study with prostaglandin f(2) alpha

To compare the efficacy of misoprostol verses prostaglandin F[2]alpha [PGF[2]alpha] in the medical management of termination of mid-trimester pregnancy due to medical reasons. This experimental study was conducted in Obstetrics and Gynaecology Department, Bahawal Victoria Hospital, Bahawalpur for a period of 6 months from April 2005 to September 2005. Time interval between induction with misoprostol or PGF[2]alpha and expulsion of foetus, number of tablets of misoprostol used and total dose of injection PGF[2]alpha used for termination of pregnancy as well as the complications experienced with both drugs. Fifty patients of 18-35 years of age were randomly selected who presented to Gynaecology and Obstetrics outdoor with mid-trimester foetal loss or congenitally malformed foetus incompatible to life, confirmed on ultrasonography. These women were randomised to receive either intravaginal misoprostol or extra-amniotic PGF[2]alpha. Ninety-six percent of cases were managed successfully with Misoprostol as compared to 92% where PGF[2]alpha was tried [p>0.5]. Mean induction to expulsion duration for misoprostol and PGF2alpha were 9.02 +/- 4.57 and 16.04 +/- 6.22 hours respectively [p<0.5]. Complications profile was low especially in cases of PGF[2]alpha and only one case experienced significant haemorrhage. Misoprostol and PGF[2]alpha were found to be of same success rate but former was found to be more efficacious in terms of induction to expulsion duration

Pattern and management of renal injuries at Pakistan institute of medical sciences

To determine the types and grade of various renal injuries and methods adopted for their management at the Department of Urology, Pakistan Institute of Medical Sciences, Islamabad. An observational study. Department of Urology, Pakistan Institute of Medical Sciences, Islamabad, from January 2005 to December 2007. The study included 50 patients with both blunt and penetrating renal trauma of either gender and aged above 13 years. Injuries, grade management and outcome was recorded. The data was entered in structured proforma and analyzed for descriptive statistics using SPSS version 10. Frequency was higher in males [82%]. The mode of renal injury was blunt in 78% and penetrating in 22% cases. Blunt injuries were mostly due to road traffic accident [94.9%] and penetrating injuries due to firearm [63.6%]. Hematuria was present in 86% and absent in 14% cases. Minor renal injury was seen in 74% and major injury in 26% cases. Seventy-two percent cases were managed conservatively. All grade-V [14%] and one grade-1V injury [2%] patients underwent nephrectomy. Renorrhaphy was done in 6% cases. Urinary extravasation was seen in one case [2%]. One patient developed renocolic fistula. No mortality was observed in non-operative group; however, 4% patients expired in operative group due to associated injuries. Blunt trauma accounts for majority of the cases of renal injury and non-operative treatment is the suitable method of management for most cases of blunt as well as selected cases of penetrating renal trauma, who are stable hemodynamically and without peritonitis

[PROM], active management at term with oral misoprostol

To assess and compare the number of subjects in both groups [Study and comparison], who went into active labour within 24 hours and to compare the various complications [maternal and fetal] in both groups. Quasi experimental. Convenience sampling. A total of 100 pregnant women presenting with history of leaking amniotic fluid at term [>/= 37 wks] to labour ward of obstetrics and Gynaecology unit, Bahawal Victoria Hospital, Bahawalpur were included in the study. The pregnant women fulfilling the inclusion criteria were enrolled as our study subjects. Rupture of membranes was confirmed by nitrazine test.The patients were randomized into two groups [50 women in study and 50 in comparison group]. In study group, 50 [Ligm of misoprostol was given orally after initial assessment of mother and fetus. The dose was repeated 4 hourly, if there was no uterine activity. The number of patients going into active labour and delivering within 24 hours were noted. Different complications [maternal and fetal] faced during all procedure were also recorded and managed. In comparison group, patients were managed were also recorded and managed. In comparison group, patients were managed conservatively for 24 hours. Like in study group, number of patients gong into active labour and delivering with in 24 hours were noted. Different maternal and fetal complications occurring in this group were also recorded and managed. A total of 100 Pregnant women were included in the study. The sample size [100 patients with PROM at term] was completed in 5 months. During that period over all 1105 deliveries were conducted, so the incidence of PROM at term in the study was 9.4%. It was observed in the study group, that all the patients [100%] went into active labour and 96% were delivered within 24 hours of PROM. While in comparison group 72% patients went into active labour and only 62% were delivered within 24 hours of PROM. The results showed that in study group 36 patients went into active labour with only one dose of oral misoprostol, 9 patients required 2 doses and 5 patients required 3 doses of oral misoprostol for going into active labour. When maternal complications were compared in both groups, 92% patients in study group had no complication while only 8% patients had to face different complications. In comparison group 86% had no complication and in 14% patients different complications occurred. Regarding fetal complications 4% fetus/neonates had to face different complications in each group. In current study there was no significant difference in the mode of delivery between the two groups. It was concluded that active management of pre labour rupture of membrances at term with oral misoprostol is a better option than the expectant management. Oral misoprostol in dose of 50 jugm is an effective agent for cervical ripening and induction of labour in PROM at term as significantly high percentage of patients delivered within 24 hours with no increase in maternal and fetal complications

To compare the efficacy and complications of misoprostal and prostaglandin F[2] alpha for second trimester pregnancy termination

To compare the efficacy and complications of Misoprostal and Prostaglandin F[2] alpha for Second Trimester Pregnancy termination. Sixty pregnancy women at 14-24 weeks of gestation divided into two group A and B. Group-A Misoprostal, Group-B Prostaglandin F[2]alpha. Patients needing terminations of pregnancy were 10%. The mean induction expulsion interval found in Group-A 19.13 hours and in Group-B 20.07 hours. The complication in Misoprostal group like dead fetus, pelvic infection, coagulopathy, rupture, incomplete abortion were less as compare to PGF[2] alpha group. Misoprostal is more effective then PGF[2] alpha for second trimester pregnancy terminations

Comparison of CT scan and colour flow doppler ultrasound in detecting venous tumour thrombous in renal cell carcinoma

Renal cell carcinoma has marked tendency to spread into renal vein, inferior vena cava and right side of heart. Extension of tumour thrombus into these veins will alter the surgical approach. We have compared the CT scan with Colour flow Doppler ultrasound in detecting venous tumour thrombus in renal vein and inferior vena cava. This cross-sectional study included 30 adult patients presenting with renal tumour. Patients of either gender were included in the study. Non probability convenience sampling was used. All patients underwent colour flow Doppler ultrasound and CT scan with contrast to asses the renal vein and inferior vena cava. The results were confirmed by intra operative findings and histopathology. The data was analyzed using SPSS version 12. Out of 30 patients, 20 [66%] were males and 10 [34%] female. The tumour was predominantly on the right side [60%], as was renal venous tumour thrombus [44%]. Inferior vena cava was involved in 4 cases predominantly due to right sided tumours. The sensitivity of Doppler ultrasound in detecting renal venous tumour thrombus [88% on right and 100% on left side] was higher than CT scan [63% on right and 60% on left side]. Doppler ultrasound was also superior to CT scan in detecting vena caval thrombus. The overall sensitivity of Doppler sonography was higher than CT scan in detecting tumour extension into renal veins and inferior vena cava. Therefore, it can be used as a complementary tool in equivocal cases

Role of metochlopramide and dimenhydrinate in orevention of postoperative nausea and vomiting in laparoscopic gynaecological surgery

To evaluate the role of metoclopramide and dimenhydrinate in controlling postoperative nausea and vomiting [PONV] and its cost effectiveness in gynaecological laparoscopy. This study was conducted in the department of anaesthesiology and intensive care unit, Pakistan Institute of Medical Sciences, Islamabad from June 2004 to March 2006. Ninety nine female patients belonging to American society of Anaesthesiologist [ASA] grading ASA-1 to ASA-111, scheduled for laparoscopic surgery, who did not fall in exclusion criteria were finally included. Anaesthetic technique was standardized for all patients. Injection Metocloparamide 10 mg and injection Dimenhydrinate 50 mg were administered 20 min before the procedure was over. At the end of procedure patients were transferred to the recovery room for observation for 10 hours. Four point verbal descriptive scale [VDS] was used to identify the presence and severity of PONV. Four out of 99 [4.04%] patients developed nausea soon after regaining consciousness and did not demand any medication for relief. Three [3.03%] patients developed vomiting. It was single episode and no rescue medication was needed. Most of the symptoms developed with in 10 -30 minutes of reversal. Metocloparamide and dimenhydrinate is a good combination to combat PONV and is costeffective in laparoscopic gynaecological surgery

Prevalence and complications of asymptomatic bacteriuria during pregnancy

To study the prevalence and complications of asymptomatic bacteriuria during pregnancy. Descriptive Study [Cross. Sectional]. October 2001 to March 2002. There were 3000 houses in Satellite town and extension Behari colony Bahawalpur. Taking 40% of total, 1200 houses were selected by systemic random sampling and pregnant residents of these houses were included in the study. 580 ladies fulfilling the inclusion criteria were interviewed and tested for bacteriuria by Dip Stick test. 28 women had bacteriuria giving prevalence of 4.8%. Culture and sensitivity tests showed E-Coli to be the causative organism in 78.6% while 21.4% cases were due to other organisms. 35.7% bacteriuric women had positive past history of UTI compared to only 9.7% non-bacteriuriac women giving significant result regarding risk of recurrent infection [p<0.05]. Prevalence of anaemia was not much different in the two groups, 85.7% compared with 82.6%. [p>0.05]. Development of PIH was not found to be affected by bacteriuria as 10.7% bacteriuric and 8.9% non bacteriuric women developed PIH [p >0.05]. Similarly number of low birth weight babies was not much different in the two groups, 7.1% compared with 6.2% [p>0.05]. Bacteriuria was found to be a causative factor for preterm labour as 21.4% bacteriuric women compared with 4.9% non-bacteriuric women went into preterm labour [p<0.05]. Bacteriuria was found to increase the risk of symptomatic UTI as 14.2% bacteriuric and 2.7% non-bacteriuric women developed cystitis. [p<0.05]. Asymptomatic bacteriuria is a common infection during pregnancy and it increases the risk of symptomatic UTI and preterm birth

Frequency and risk factors of asymptomatic bacteriuria during pregnancy

To determine the frequency and risk factors of asymptomatic bacteriuria during pregnancy. Cross-sectional study. Satellite Town and Behari Colony, Bahawalpur from October 2001 to March 2002. Patients and There were 3000 houses in Satellite Town and Behari Colony, Bahawalpur. Taking 40% of total, 1200 houses were selected by systemic random sampling. Pregnant residents of these houses were included in the study. Data collected was coded, computed and analyzed on SPSS version 10. Frequencies were runned and chi-square test was used as test of significance. Five hundred and eighty women, fulfilling the inclusion criteria, were interviewed and tested for bacteriuria. Out of them, 4% were below 20 years, 4.6% were between 20-30 years and 5.4% women aged above 30 years [p=0.103]. Regarding parity 3.18% of primigravidae and 6.04% multigravida had bacteriuria [p=0.0039]. Regarding socioeconomic status, 6.45% from lower class and 2.5% from middle and upper middle class were the sufferer [p=0.0039]. Prevalence was 6.64% among uneducated and 3.06% among educated women [p=0.0039]. As for past history, 35.7% of women had an episode previously [p=0.001]. No association was found with anaemia. Asymptomatic bacteriuria is a common infection during pregnancy, having strong association with multiparity, lower socioeconomic status and illiteracy

Postmenopausal bleeding; an experience at Bahawal Victoria Hospital, Bahawalpur

To evaluate the etiology, incidence of malignancy and interval between menopause and onset of abnormal vaginal bleeding in postmenopausal women. Prospective study. Place and duration of study: The study was conducted at Bahawal Victoria Hospital, Bahawalpur for a period of 14 months [February 2002 to March 2003]. Subjects: Thirty five cases of postmenopausal bleeding. A detailed history was taken followed by a detailed general physical, abdominal, pelvic and per-rectal examination. Cervical pap smear was done in all the patients except those with obvious cervical growth. Besides routine laboratory work, abdominal ultrasonography was done in all the cases. All patients were invariably subjected to fractional curretage and cervical biopsy was taken where indicated. Malignancy was found to be the most common cause [51.42%] of postmenopausal bleeding. Carcinoma of the cervix was commonest and found in 34.28%, carcinoma of endometrium in 11.42%, atrophic endometrium in 11.42%, polyps in 8.57%, chronic cervicitis in 8.57%, endometrial hyperplasia in 5.71% carcinoma of ovary in 2.85%, liomyosarcoma in 2.85%, senile vaginitis, trauma, and forgotten IUCD each in 2.85% of cases. Etiology remained undetermined in 5.71% cases. Malignancy was directly related to years of clear span and was 88.88% in cases presenting 10 years or more after the menopause. Carcinoma of cervix was the commonest cause of postmenopausal bleeding in our study. Screening programme for early detection of carcinoma of cervix at a pre-invasive stage is highly recommended