Nucleic acid amplification tests (NAATs) for gonorrhoea diagnosis in women: Experience of a tertiary care hospital in north India.

Background & objectives: Gonorrhoea is among the most frequent of the estimated bacterial sexually transmitted infections (STIs) and has significant health implications in women. The use of nucleic acid amplification tests (NAATs) has been shown to provide enhanced diagnosis of gonorrhoea in female patients. However, it is recommended that an on-going assessment of the test assays should be performed to check for any probable sequence variation occurring in the targeted region. In this study, an in-house PCR targeting opa-gene of Neisseria gonorrhoeae was used in conjunction with 16S ribosomal PCR to determine the presence of gonorrhoea in female patients attending the tertiary care hospitals. Methods: Endocervical samples collected from 250 female patients with complaints of vaginal or cervical discharge or pain in lower abdomen were tested using opa and 16S ribosomal assay. The samples were also processed by conventional methods. Results: Of the 250 female patients included in the study, only one was positive by conventional methods (microscopy and culture) whereas 17 patients were found to be positive based on PCR results. Interpretation & conclusions: The clinical sensitivity of conventional methods for the detection of N. gonorrhoeae in female patients was low. The gonococcal detection rates increased when molecular method was used giving 16 additional positives. Studies should be done to find out other gene targets that may be used in the screening assays to detect the presence of gonorrhoea.

Placenta accreta in placenta previa; frequency of previa with or without scarred uterus

To calculate the frequency of placenta accreta in placenta previa with or without scarred uterus and compare clinico demographic features of cases with or without placenta accreta.Cross sectional study. Department of Obst and Gynae Allied Hospital, Faisalabad from 1st June 2007 to 31st May 2008. 200 patients of placenta previa, 100 with history of previous cesarean section and 100 without history of previous C-section fulfilling inclusion criteria were taken. They were evaluated by history, examination and ultrasound noting placental location and type. Placenta accreta was diagnosed during delivery. Out of 200 patients, frequency of placenta accreta was significantly increased with history of previous C-section. It was 20% in patients with previous C-sections and 6% in patients without previous C-sections. Our data suggests that frequency of placenta accreta is greater in patients with previous C-section and its frequency increases with increasing number of C-sections especially with anterior and central placenta previa

Mid trimester termination; PGF2 alpha versus misoprostol

The objective of study was to compare the efficacy of extra amniotic prostaglandin F2 alpha and vaginal misoprostol for termination of 2nd trimester pregnancy. It was quasi experimental study. The study was conducted at Gynae Unit II, DHQ Hospital affiliated with Punjab Medical College, Faisalabad for a period of one year from July 2012 to June 2013. This study included 100 patients who presented with congenitally anomalous foetus or IUD during 2nd trimester for termination of pregnancy. Outcome was evaluated by percentage of successful cases for TOP and induction to delivery interval. As regards the efficacy of misoprostol, success rate for termination of pregnancy was 86% and mean induction to delivery interval was 13.16+/-1.987 hours. Regarding PGF2 alpha success rate for TOP was 88% and mean induction to delivery interval was 16.07+/-3.202 hours. Misoprostol is comparable in its efficacy to PGF2 alpha for mid trimester termination and can be used as a cheaper alternative

Efficacy of systemic methotrexate in unruptured tubal pregnancy

Objective: to observe the efficacy of systemic methotrexate for the treatment of unruptured tubal pregnancy

Material and Methods: it was a descriptive study carried out over a period of 6 months from 01-10-2012 to 31-03-2013 in the department of obstetrics and gynecology unit 111, Services Hospital, Lahore. A total of 65 cases were included in this study. Patients were given single dose of injection methotrexate 50mg/m[2] intramuscularly and beta- hCG level was assessed at 4th and 7th day for each patient. In those patients in which beta hCG level did not fall more than 15% on day 4th and 7th were surgically treated by doing laparotomy

Results: among 65 patients, age distribution showed 7 patients [10.8%] were less than 20 years of age, 41 patients [63%] were between 20 -30 years and 17 patients [26.2%] were between 30-40 years of age. Mean age was 29.7+/-4.9 years. According to distribution of parity, 17 women [26.2%] were primigravida, 38 women [58.4%] were para 2-4 while 10 women were para 5-7. Out of65 women, 11 [16.9%] presented at <6 weeks of gestation and 54 [83.1%] at 6-8 weeks of gestational age. Mean gestational age was 6.7+/-1.9 weeks. Efficacy of methotrexate for the treatment of unruptured tubal pregnancy observed in 44 women [67.7%] in term of fall in beta hCG level>15%

Conclusion: methotrexate is an effective medical management for ectopic pregnancies in a society where tubal conservation is of utmost importance

Frequency of different symptoms and clinico-pathological features of surgically managed adnexal masses

Objective: The objective of this study was to study the frequency of different symptoms, patient characteristics, clinical presentations and outcome in women who underwent laparotomy for adnexal masses suspected as ovarian tumors.

Methodology: Study Design: Observational descriptive study

Patients and Methods: From Jan 2012 to Dec 2012, 57 patients with palpable adnexal masses were admitted in Gynae unit II of DHQ Hospital Faisalabad. All those patients who underwent laparotomy for adnexal masses suspected as ovarian tumors, were included. 24/57 fulfilled the selection criteria. The demographic data of patients included [i-e; age, marital status, parity, blood group], personal and family history, presenting clinical symptoms, pre-operative ultrasound characteristics of adnexal masses, their per-operative gross appearance and finally histo-pathologic diagnosis

Exclusion Criteria: Patients with simple cysts on scan, who were managed conservatively and then discharged. All pregnant women [e.g; chronic ectopic, ruptured ectopic and those with intra uterine normal pregnancy but with an adnexal mass or cyst], and where data was not available or who were lost to follow up, were excluded from the study

Results: 42% [24/57] of women with palpable adnexal masses underwent laparotomy. On histopathologic examination 80% were benign and 20% were malignant. The majority of patients were in reproductive age group. 58% [14/24] were multipara, 29% [7/24] were nullipara, 12% [3/24] were single. Almost all [100%] patients were symptomatic at the time of presentation. 20% were postmenopausal, and the large adnexal mass turned out to be malignant ovarian tumor in 100% of postmenopausal women

Conclusion: Adnexal masses commonly affected the relatively younger women. Abdominal pain was the most common symptom. Ovarian malignancy was exceptional in younger groups but more frequently seen in postmenopausal women

Risky grand multiparas

Grandmultiparity has long been classified as constituting a high risk factor in pregnancy. The complications associated with grandmultiparity have been divided into ante-partum, intra-partum and the postpartum. Intrapartum complications most commonly thought to be associated with grandmultiparity are malpresentations, placental disorders, postpartum hemorrhage and uterine rupture. Concerted effort should be instituted for effective family planning initiatives and specialized antepartum and intrapartum management

Objective: To determine the frequency of intrapartum complications and mode of delivery in grandmultipara

Material and Methods: It is descriptive case series study conducted in department of obstetrics and gynaecology, Punjab Medical College and affiliated hospitals, Faisalabad from March 11, 2010 to September 10, 2010

Results: Grandmultipara women who fulfilled the inclusion criteria were studied for intrapartum complications and mode of deliveries. One hundred and thirty nine patients were included in my study. Mean age of the patients was 32.38 years. Mean gestational age for delivery was 37.06 weeks. Grandmultiparas had more intrapartum complications including malpresentation [19.4%], placental abruption [5.8%], placenta previa [8.6%], postpartum hemorrhage [6.5%] and ruptured uterus [1.4%]. Mode of delivery was also assessed and 59%, 7.9 %, 31.7% of patients had normal vaginal delivery, instrumental vaginal delivery and cesarean section respectively

Conclusions: It is concluded that in the developing countries the incidence of grandmultiparity is still high with a significantly increased risk of complications. Grandmultiparity should be considered high risk and needs active intervention by improving literacy, health care facilities, provision of safe and effective contraception and reproductive health status

PROM; expectant vs active management

PROM is not uncommon in pregnancy. It occurs in 10% of term pregnancies. At term about 75% of women will go into labour within 24 hours of rupture of membranes. At term there are two options, either wait for spontaneous onset of labour or immediate induction to establish labour. For induction of labour different kinds of drugs are used according to Bishop score. If Bishop score is favorable [>/= 6], oxytocin can be used. It decreases the risk of chorioamnionitis and is more satisfying for mother. To compare the immediate induction with expectant management in PROM at term with favorable cervix in terms of frequency of caesarean section. This prospective randomized controlled trial was conducted in the department of obstetrics and gynaecology, Punjab Medical College and affiliated hospitals, Faisalabad from 1st June to 30th November 2010. One hundred and twenty pregnant ladies were randomly divided into two equal groups. Odd numbers were placed in group 1 who were given expectant management for 24 hours for spontaneous onset of labour. Even numbers were placed in group 2, who were started immediate induction with oxytocin infusion. In my study overall age was 25.64 +/- 2.98. In expectant group mean age was 25.18 +/- 3.21 and in induction group mean age was 26.10 +/- 2.69. The rate of c-section in immediate induction group was 8.3% while in expectant group it was 11.6%. In my study there was no significant difference regarding rate of c-section in both groups [p= 0.543]. Both expectant and immediate inductions are common management options in women with PROM, but immediate induction was favorable approach for both mother and fetus. The later was more satisfying for mother and decreased risk of maternal and neonatal infection

Gestational diabetes; accuracy of glucose challenge test [GCT] for screening

To determine the Accuracy of GCT for screening of gestational diabetes in high risk population comparing oral Glucose Tolerance Test [GTT] as gold standard. Accuracy of GCT. Cross-sectional study. The study was conducted in outpatient department of Punjab Medical College and affiliated hospitals, Faisalabad. 207 patients. High risk women from outpatient department were recruited on the basis of inclusion and exclusion criteria after explaining pros and cons of procedure. These women were subjected to GCT and GTT. GTT was taken as gold standard test and results of GCT were compared with it. Main outcome measures recorded and results obtained. Out of 207 women, GCT truly diagnosed 24 women as having diabetes [true positive] and 175 women were found to have normal glucose metabolism [true negative]. GCT failed to diagnose 5 diabetic women [false negative] and wrongly diagnosed 3 normal women as diabetics [false positive] against gold standard GTT. So GCT has diagnosed Gestational diabetes mellitus with the sensitivity of 82.7%, specificity of 98.3%, positive predictive value of 88.8%, and negative predictive value of 97.2% and accuracy of 96.1%. GCT is a simple, easy, convenient and sensitive test that has no limitation for time or prior fasting for gestational diabetes screening

Postpartum hemorrhage; comparison of efficacy of ergometrine with misoprostol in prophylaxis in cesarean section

Worldwide PPH remains one of the most common cause of maternal mortality and is largely preventable maternal deaths mainly in low income countries. 80% of it occurs due to uterine atony and uterotonics can decrease the risk of uterine atony. Misoprostol has powerful uterotonic effect because it is well absorbed and has potential to be used more widely than would be possible with injectable uterotonics alone. The objective of this study is to compare efficacy of misoprostol with ergometrine in cesarean delivery for management of PPH. Randomized controlled trial. The duration of study was six months from 1/1/2010 to 30th/6/2010. Department of Gynae and obstetrics, DHQ hospital, Faisalabad. All patients fulfilling inclusion criteria were included in study and before cesarean section Hb was carried out and Patients were divided into two groups, GP[1], and GP[2]. GP[1] was given 800 ug MP per rectal just before starting cesarean Section and GP[2] was given intravenous ergometrine at delivery of head or anterior 2 shoulder. Blood loss was measured objectively after delivery of the baby with help of standard size kidney tray of 500cc and post operative Hb was Carried out on 3rd post operative day. 187 Patients were randomly allocated in GP[1] and GP[2] each. In GP[1], misoprostol was given 800 microg per rectal just before starting cesarean section and 13 patients [7%] out of 187 have blood loss more than 500ml measured by standard size kidney tray while in GP[2] intravenous ergometrine was given at delivery of the head and in this group 25 patients [13.5%] out of 187 had 2 blood loss more than 500ml, so misoprostol was found to be a better uterotonic than ergometrine for prevention of PPH. On the third post operative day Hb was carried out and in GP[1] 13 patients [7%] out of 187 had their Hb less than 9 g/dl while in GP[2] 25 patients [13.5%] had Hb less than 9 g/d1. Mp is stable, cost effective and easily administrable drug and was found to be comparatively more powerful uterotonic than ergometrine for preventing uterine atony

Efficacy of tranexamic acid in menorrhagia in comparison to norethisteron

To compare the efficacy of tranexamic acid with norethisterone in the management of menorrhagia. Total 66 patients were included in this study [33 patients randomly allocated to Group Aand B]. In group Aand group B mean age was 33.12_4.98 and 31.42 +/- 5.47 years respectively. After management, number of towels used/day were reduced in group A and B and were 3.21 +/- 0.65, 2.85 +/- 0.62, 2.33 +/- 0.54, 2.21 +/- 0.60 and 3.30_0.88, 3.15 +/- 0.87, 2.94 +/- 1.03, 2.85 +/- 1.06at one, two, three and six months follow-up respectively with significant difference between two groups [p=0.002]. Passage of blood clots in group Aand B at one, two, three and six months were reduced in patients 19 [57.5%], 19 [57.5%], 20 [60.6%], 23 [69.6%] and 10 [30.4%], 13 [39.4%], 12 [36.4%], 12 [36.4%] respectively [p=0.0035]. Haemoglobin level in group A was 9.633 +/- 0.946 g/dl at six months while in group B it was 9.385 +/- 1.061 g/dl with insignificant result in both groups [p=0.159]. Tranexamic acid is more safe, effective and tolerable treatment than norethisterone for patients with ovulatory menorrhagia with avoidance of possibly unnecessary surgery

Oral vs vaginal misoprostol for induction of labour at term

Background: to determine the efficacy of oral and vaginal Misoprostol in induction of labour at term. To compare maternal and total outcome in oral. and virginal Misoprostol in Labour induction. Study Design was interventional Experimental study. Setting was Department of Obstetrics and Gynecology. Divisional Headquarters Hospital Faisalabad

Results: 100 -pregnant women requiring induction of labour at term were, included. After complete evaluation the cases were divided into groups. Oral Misoprostol group A and vaginal Misoprostol Group B. Initial dose is 50ug repeated at 4 hour internal at maximum of 6 doses in24 hours till labour was established. Results were-observedand-recorded by total doses of Misoprostol required· duration of labour, need of augmentation; mode of delivery, maternal, complication and fetal outcome. Statistical analysis was carried out with the help of SPSS Obstetrics parameters like parity route of drug, mode of delivery need of augmentation were presentation as frequency and percentage. Total number of doses in Group A were 1-6 and in Group B 1-4. The mean induction to delivery internal was 14 hour in Group A and 9 hour in Group B. 88% delivered vaginally in Oral group and 12% by cesarean section. 72% delivered vaginally and 28% by caesarian section in Group B. Cesarean section rate for fetal distress was 6% Vs 23% in oral and vaginal group. Hyper Stimulation rate was 2% Vs 20% and Postpartum hemorrhage was observed 4% Vs 24% in Group A and B respectively. No neonatal death was noted in both groups

Conclusion: in this way our lyphthosis was proved that oral Misoprostol in better than vaginal route

effectiveness of uterine arteries ligation in management of refractory postpartum hemorrhage

Background: the objectives of study were to see the effectiveness of uterine arteries ligation in· cases of massive postpartum hemorrhage [PPHand which required surgical intervention and to determine the morbidity in these patients after uterine devascularization during their hospital stay

Material and Methods: it was a descriptive study which was carried out in Obstetrics and Gynecology Unit of Divisional Head Quarter Hospital, Faisalabad which is a tertiary care center. All patients booked or unbooked admitted in labour ward with PPH refractory to medical treatment were included in this study between January 2003 to December 2005. The main outcome measures were satisfactory homeostasis achieved in terms of control of PPH, length of operative time, post-operative morbidity, re-exploration, total units of blood transfused and total hospital stay

Results: there were 62 patients of PPH during study period of 2 years. Uterine artery legation was done in 20 of these patients as 1st line surgical option; in 15 out of 20 [75% and it was done during caesarean section whereas in 5 [25% and it was applied after vaginal delivery. In 4 patients [20% and-ovarian artery ligation was also done to control PPH and 2 patients [10% and ended up in per partum hysterectomy. Uterine devascularization successfully controlled PPH in 99% cases. Failure of uterine devascularization was associated with disseminated intravascular coagulation and placenta accretes. Post-operative morbidity was less in terms of anesthetic complications [11% and, pyrexia [33% and; paralytic ileus [16.5and, wound infection [22%]

Conclusion: postpartum hemorrhage is a life threatening condition. Uterine devascularization has proved invaluable in the control of refractory PPH as an alternative to hysterectomy

Management and outcome of severe pre-eclampsia

To know how frequent this problem is encountered in our hospitals and to evaluate fetomaternal outcome by adopting a specific management protocol. This was a prospective observational study. The study was carried out in Labour Ward of Gyneacology and Obstetrics Units-II, Punjab Medical College, D.H.Q. Hospital Faisalabad from 1[st] January 2000 to 31[st] December 2000. Forty one pregnant women diagnosed as having severe pre-eclampsia were managed according to severity of disease and duration of pregnancy. After 34 weeks stabilization and delivery, in patients presenting before 26 weeks termination of pregnancy and for those between 26 to 34 weeks expectant management was done, using antihypertensives to control blood pressure, corticosteroids for fetal lung maturity and serial fetomaternal evaluation. Frequency of occurrence of pre-eclampsia was found to be 1.55%. Most patients were between 20-25 [44%] years of age and primigravidas were most afflicted [48.8%]. Eclampsia [2%] abruption [32%] acute renal failure [32%] HELLP Syndrome [8%] were the associated maternal complications. Maternal mortality was 4.*% and perinatal morality was 30%. Severe pre-eclampsia continues to present as one of leading causes of maternal morbidity perinatal and mortality. Improvement of antenatal care, early recognition and prompt intervention can reduce the bad outcome