Asymptomatic Bacteriuria in women presenting to Antenatal clinic at a tertiary care hospital in Karachi, Pakistan

Objective: To determine the frequency, risk factors, and common causative agents of asymptomatic bacteriuria in pregnant women attending antenatal clinic at JPMC Karachi

Study Design: Cross sectional study

Place and Duration of Study: Jinnah Postgraduate Medical Center Karachi, from Jul 2014 to Sep 2015

Material and Methods: One hundred seventy seven women participated according to pre-determined inclusion criteria. All of them underwent urine examination on midstream urine and urine was cultured in case of a positive test [>10 leukocytes per microliter of urine]

Results: Incidence of asymptomatic bacteriuria was 12.4 percent of the 177 women. Low socioeconomic status was found to be the only statistically significant risk factor associated. The most common causative agent was E. coli

Conclusion: Pregnant women belonging to lower socioeconomic status are more likely to have asymptomatic bacteriuria. The recommendations stemming out of the study include complete examination of urine of all pregnant women to be carried out at first antenatal visit and culture of urine to follow if indicated

Concordance between visual inspection with acetic acid test and Pap smear in detection of cervical cancer

Objective: to determine the agreement between visual inspection with acetic acid test [VIT] and Pap smear in detection of cervical cancer

Study design: cross-sectional study

Place and Duration of study: department of Obstetrics and Gynaecology Unit-II, Jinnah Postgraduate Medical Centre Karachi, from March 2013 to April 2014

Methodology: attendants of the patients visiting antenatal clinic were included in this study. VIA test was performed by the application of 05% acetic acid on the cervix through cotton tipped applicator. After 5 minutes a naked-eye assessment was performed under direct illumination of a 100-watt halogen lamp. A positive visual inspection with acetic acid test was defined as opaque, acetowhite lesions with raised surface and well defined margins present on the cervix. The Pap smear sample was obtained by conventional method and fixed with 95% ethanol for 30 minutes before sending to the laboratory for reporting

Results: a total of 217 patients were selected. Positive agreement between VIA test and Pap smear was found in 158 [72.8%] cases. Agreement was also cross checked with cervical cancer risk factors like age, parity, literacy and socio-economical status. Mean age of the study participants was 34.46 year. Majority [n=89 - 41%] of the women were illiterate, belonged to the poor socioeconomic class [n=52 - 24.1%] and multipara [n=149 - 68.6%]

Conclusion: overall agreement of similar results between VIA test and Pap smear was found in majority of the patients

Outcome of induction of labour with intracervical foley catheter in women with previous one caesarean section

Objective: To compare the rates of vaginal delivery after one caesarean section in mechanically induced and spontaneous labour

Study design: Cross Sectional Study

Place and Duration of study: Department of Obstetrics and Gynecology Unit-II, Jinnah Postgraduate Medical Centre Karachi, from January 2011 to July, 2011

Methodology: Pregnant women with one previous caesarian section were included in the study after informed consent. They were divided into two groups. Group I included women in whom labour occurred spontaneously. Those women who did not enter into labour up to 40 weeks of gestation were put into group II. They were induced with intracervical Foley catheter. Satisfactory outcome measure was the vaginal birth

Results: A total 112 patients were included. Significant difference was not observed between groups in relation to mode of delivery [Chi square = 1.09, p=0.57]. Out of 112 pregnant women, satisfactory outcome was observed in 74 [66.1%], which was not significant between the two groups [66.1% vs. 66.1% p=0.999]

Conclusion: Mechanical induction of labour in patients with previous one caesarean section is the reasonable option, when patients are carefully and properly selected, coupled with vigilant intrapartum monitoring

Comparison of misoprostol with dinoprostone for induction of labor in postdated pregnancy

To compare the efficacy of misoprostol with dinoprostone in induction of labor in nulliparous women at and beyond 41 weeks of gestation. Experimental comparative study. Department of Obstetrics and Gynecology Unit-II, Jinnah Post Graduate Medical Center, Karachi, from September 2007 to October 2010. A total of 105 women with more than 287 days [41weeks] gestation with unfavorable cervix and intact membranes were selected for induction of labor. Dinoprostone was inserted in 41 patients while 64 patients were induced with intravaginal misoprostol. The primary outcome measures were induction-delivery interval, number of doses required for induction, rate of spontaneous vaginal delivery, C-section and instrumental delivery. Secondary outcomes were the incidence of meconium stained amniotic fluid, fetal weight at the time of delivery, fetal distress and need for admission to NICU. Out of 63 patients in the misoprostol group, 43 [67.1%] women had spontaneous vaginal delivery [SVD] while 26 [63.4%] patients out of 41 in dinoprostone group had SVD. The induction to delivery interval was 13.03 +/- 3.52 hours in misoprostol group while it was 14.12 +/- 3.31 hours in dinoprostone group. With misoprostol, induction of labor started in 18, 33 and 13 women with 1, 2 and 3 doses respectively within 24 hours but in dinoprostone group 16 women were successfully induced with 1 tablet only, while 21 patients required 2 doses for induction. The need for oxytocin infusion was the same in both the groups. The neonatal weight was 3.54 +/- 3.38 kg in misoprostol group as compared to 3.10 +/- 0.26 kg in dinoprostone group [p=0.41, t=1.57]. Four neonatal deaths were reported in the misoprostol group as compared to two with dinoprostone. Sixteen neonates were admitted to NICU in misoprostol group as compared to five patients in dinoprostone group. Twenty-eight [44.4%] patients in misoprostol group had meconium stained liquor as compared to 14 [34%] patients in dinoprostone group. Dinoprostone was most effective in comparison with misoprostol in gravida with 41 weeks and above gestation. Misoprostol though showed comparable results, but is not the drug of first choice

Hysterectomy as a management option for morbidly adherent placenta

To determine the outcome of interval [delayed] hysterectomy as compared to cesarean [immediate] hysterectomy in cases of placental invasion in previous cesarean sections. Comparative study. Department of Obstetrics and Gynecology, Unit II, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from January 2008 to June 2011. The study subjects included 28 women with history of previous cesarean section who had low lying as well as morbidly adherent placenta [MAP] of variable degree. Patients were classified into two groups [group A and B] according to whether cesarean or interval hysterectomy was needed at time of delivery. Demographic data, obstetrical risk factors such as parity and number of previous cesarean sections were compared as well as radiological and histopathological findings, and details of the management. Chi-square, Fisher's exact and t-tests were used to compare proportions and mean values. The frequency of MAP in previous cesarean sections turned out to be 1.83/1000 [28/15,340] deliveries. Mean maternal age [26.54 vs. 29.13 years, p=0.05], mean gestational age [33.8 vs. 36 weeks, p=0.05], estimated blood loss [2615.38 vs. 1506.6 ml, p=0.001], volume of blood transfused [9.76 vs. 2.9 pints, p=0.001] and the duration of hospital stay [10.69 vs. 32.86 days, p=0.001] differed significantly between group A and group B. One maternal death occurred in each group. Eight patients had other complications in group A compared to 3 patients in group B. Three neonatal deaths occurred in group A compared to nil in group B. The frequency of morbidly adherent placenta was 1.83/1000 deliveries. The management and outcome differed markedly according to emergency and scheduled antenatal diagnosis. Counselling and antenatal radiological screening can reduce the high morbidity and mortality associated with it

Perinatal outcome in pregnant patients with moderately severe mitral stenosis

To determine the frequencies of prematurity, low birth weight babies and perinatal deaths in pregnant women presenting with moderately severe mitral stenosis. Descriptive case series. Department of Obstetrics and Gynecology, Jinnah Postgraduate Medical Centre Karachi, from October 2008 till April 2009. Pregnant women with moderately severe mitral stenosis [mitral valve area <2cm2] fulfilling inclusion criteria, selected through antenatal clinic were included in the study. Perinatal outcome in terms of prematurity, low birth weight, and perinatal mortality were assessed. There werea total of 54 pregnant women with moderately severe mitral stenosis managed during the study period. Preterm babies numbered 22[40.7%], low birth weight babies [<2.5kgs] were found in 17 [31.5%] cases and perinatal mortality seen in 7[13%] cases. Encouraging perinatal outcome was observed in this study which was targeting very high risk cardiac patients

Primary PPH; Role of uterine packing in control of haemorrhage

To determine the effectiveness and safety of uterine packing in selected cases of primary postpartum haemorrhage. Cross-sectional study. The study was conducted at Jinnah Postgraduate Medical Centre, Karachi, From September 2003 to April 2008. Women developing primary PPH due to uterine atony, placenta previa and coagulation failure were selected for uterine packing. Firm packing was done with enormous length of sterile ribbon gauze, using 'layering technique' under prophylactic antibiotic cover. Vagina was also packed to give additional pressure. Pack was removed after 12 - 36 hours or early in case of failure to control haemorrhage. Pulse, blood pressure, soakage of pads, height of uterine fundus and temperature were monitored to assess effectiveness and safety. 39 women were included in the study. Cause of PPH was uterine atony in 30 [76.9%], coagulation failure in 5 [12.8%] and placenta previa in 4 [10.3%] cases. Packing was successful in arresting haemorrhage in 32 [82.1%] and failed in 7 [17.9%] cases; 95% Confidence Interval 67-91. There was no case of concealed haemorrhage, four patients developed emdometritis and none had delayed haemorrhage. 13 laparotomies were prevented. The difference between the causes of haemorrhage in successful and failed cases did not show a definite trend. If employed early, uterine packing is a quick, effective and safe method for controlling primary PPH in carefully selected cases

Therapeutic termination of second trimester pregnancies with low dose misoprostol

To determine the effectiveness of 50micro g misoprostol for midtrimester termination of pregnancies. Experimental, cross-sectional study. Department of Gynaecology and Obstetrics, Unit II, Jinnah Postgraduate Medical Centre, Karachi, a tertiary care centre, from 1st Jan 2003 to 30th June 2005. The study subjects were 54 pregnant women admitted during the 2nd trimester [14-26 weeks] of gestation, willing or requiring termination of pregnancy. Those patients were included in the study who were admitted with closed cervical os, either had intrauterine death, fetal anomaly, medical disorder [hypertension or diabetes] or history of previous ceasrean section. Cases of placenta previa, acute asthma, glaucoma, cardiac diseases and allergy to prostaglandins were excluded. Each patient received 50micro g misoprostol intravaginally. Maximum 4 doses were given at 4 hours interval and state of cervical os was assessed by vaginal examination before insertion of next dose or at the onset of uterine contractions. After 4 doses of misoprostol, patients were kept under observation and watched for uterine contractions to start or for expulsion of products. Syntocinon infusion was started to augment labour where products of conception failed to expel out inspite of open os. Outcome measures include success rate of termination within 12, 24, 36 and 48 hours, mean induction - abortion time interval and maternal side effects. The success rate of termination within 12, 24, 36 and 48 hours were 27.7%, 83.3%, 94.4% and 96.3% respectively. Mean induction to abortion time interval, in case of abortion within 48 hours, was found to be 18.9 +/- 11.58 [range 4-48 hours]. Dead fetuses were aborted earlier than alive fetuses. The mean induction abortion time interval was 17.01 +/- 8.7 hours in dead and 23.4 +/- 15.9 hours in alive fetuses [t -value:1.9, p: 0.05]. Two patients failed to deliver within 48 hours of induction. Two patients suffered from febrile illness. Vaginal administration of 50 micro g misoprostol every 4 hourly is an effective and safe agent for ripening of cervix and convenient way of inducing abortion during 2nd trimester of pregnancy in a women either with alive or dead fetus. It is associated with a low frequency of side effect

study of abruption placentae

To determine the frequency of abruptio placentae and to find out associated risk factors and out come. Cross-sectional study. The Department of Gynaecology and Obstetrics Unit II, Jinnah Postgraduate MedicalCentre [JPMC], Karachi over one year period from July 2004 to June 2005. This study includes those patients who were brought to JPMC, Karachi with abruptio placentae after 28 weeks of pregnancy. Local causes of bleeding per vagina, placentae previa and ruptured uterus were excluded from the study both clinically and with the help of ultrasound. Total number of deliveries during one year from July 2004 to June 2005 was 4497. Total number of patients with placental abruptio were 102, making an incidence of 1:44 deliveries [2.26%]. Eight cases were booked while rest of the patients were nonbooked. Hypertension, preeclampsia [37.2%], anaemia 34.3% and grand multiparty were most common associated risk factors. Maternal age had no significant relation to occurrence of abruptio placentae. Most of the patients presented with bleeding per vaginum [93%] followed by onset of labour pains [80%]. Maternal morbidity was high. Most common complication was anaemia 34.4% followed by post partum infection [> 14%] Perinatal mortality was significantly high [62.5%]. There was only one maternal death due to irreversible shock. Incidence of abruption placenta is high [2.26%]. Resultant maternal morbidity and perinatal mortality is significant. This calls for early detection, regular visits, and special surveillance. There should be timely referral to tertiary care centre

Placenta percreta: a rare catastrophe

To document the clinical presentation, risk factors, management and management of placenta percreta. Case series. A 5 year study from January 2001 to December 2005 in Gynaecology and Obstetrics department, Unit II, Jinnah Postgraduate Medical Centre, Karachi. This study included patients of placenta percreta who were either diagnosed on ultrasound during antenatal period or accidentally found at exploratory laparotomy or caesarean section. A total of 11 cases of placenta percreta were managed during the study period. The frequency of the lesion was 1: 2058 deliveries. In 7 patients placenta had invaded and perforated the uterine wall, in 3 patients it had invaded the urinary bladder as well and in one patient there was broad ligament invasion. Most common risk factors were previous caesarean section [CS] in 91 percent cases and placenta previa [91 percent] followed by curettage [9 percent]. Hysterectomy was performed in all patients. Partial cystectomy and bladder repair was done in those cases where urinary bladder was invaded. Urinary bladder injury occurred in two [27.27 percent] patients. Two patients died, one due to irreversible shock and other due to acute renal failure. Placenta percreta is a rare catastrophe associated with high maternal morbidity and mortality. Early diagnosis and surgery following adequate resuscitation should be accomplished with multidisciplinary team