Efficacy of metformin versus insulin in the management of pregnancy with diabetes

To compare the efficacy of metformin with insulin in the management of pregnancy with diabetes. Randomized clinical trial. Department of Obstetrics and Gynaecology, Maternal and Child Health Centre [MCH], Pakistan Institute of Medical Sciences, Islamabad, from May 2010 to January 2011. A total of 68 pregnant patients with diabetes were included in this study. Patients were randomly divided in to two groups of each 34 patients based on table of random numbers. One was labelled as group-A and other was labelled as group-B. Group-A received insulin and group-B received metformin for the management of diabetes. The mean age was 29.82 +/- 4.58 and 29.35 +/- 4.97 years in groups-A and B respectively. Fasting blood sugar level after 1 month was controlled in 22 [64.7%] patients in group-A and in 27 [79.4%] in group-B [p > 0.05]. Fasting blood sugar level at term, remained controlled in 30 [88.2%] patients in group-A and 27 [79.4%] in group-B [p > 0.05]. Comparison of random blood sugar levels within normal limits after 1 month in 25 [73.5%] in group-A and in 24 [70.6%] in group-B. At term, random blood sugar level was controlled in 28 [82.4%] and 27 [79.4%] patients in group-A and B, respectively. Comparison of post-treatment HBA1C level depicts that diabetes controlled in 27 [79.4%] patients in group-A while in 28 [82.3%] patients of group-B. The efficacy of metformin and insulin in controlling diabetes was equal in two groups. There was no marked difference in efficacy of metformin and insulin in controlling diabetes in pregnant patients in two groups.

Placental site trophoblastic tumour

Placental Site Trophoblastic Tumour is a rare neoplastic condition developing from intermediate trophoblastic part of cytotrophoblast. Although grouped under Gestational Trophoblastic Neoplasias [GTNs], PSTT varies in its origin, presentation, diagnosis and response to treatment from other GTNs. Delay in treatment due to late presentation or diagnosis is common. Surgery in the form of hysterectomy is the main treatment option but uterus preserving surgical options have been suggested in case of future fertility desire

Diclofenac suppository for analgesia after perineal injury during child birth: a randomized controlled tria

To assess the effectiveness of analgesic rectal suppositories in pain relief from perineal trauma after child birth. A single blind randomized controlled trial. 1[st] February, 2006 to 30[th] April, 2006. Labour ward. Mother and Child health centre, PIMS, Islamabad. Sixty [30 cases and 30 control]. Delivered women with second-degree perineal tear or episiotomy. Women were randomly allocated to either diclofenac or control group with stratification for parity and mode of delivery. First suppository was inserted on completion of suturing and second 12 hours after birth. Women involved in the study were blinded to allocated treatment group. Women were asked to rate their pain according to visual analog scale from 0-10, at six, twelve and twenty four hours after child birth. A total of 60 women were recruited. Using visual analogue scale, women in diclofenac group significantly experienced less pain at 6 hours [p= 0.003] when compared to those who did not received rectal analgesia. There was no significant difference in pain experienced at 12 [p=0.8] and 24 [p=0.1] hour between the two groups. There was no significant difference in terms of need for additional analgesia and maternal satisfaction regarding pain relief [80% vs 70%]. There were no reports of local irritation, or discomfort. There were no side effects reported and no one expressed objections regarding route of administration. The use of rectal analgesic suppositories is a simple, effective and safe method of reducing the pain experienced by women after perineal trauma in the first 6 hours after child birth.

Magnesium sulphate therapy in pre-eclampsia and eclampsia: one year experience

To study the efficacy of Magnesium Sulphate Therapy for prevention and control of fits in patients with preeclampsia and eclampsia. Interventional Study. This study was conducted at the Department of Obstetric and Gynecology Unit II, Mother and Child Health Centre, Pakistan Institute of Medical Sciences, Islamabad from April 2002 to March 2003. Total 50 women with preeclampsia / imminent eclampsia and eclampsia fulfilling the study criteria were admitted in HAD, adjacent to labour ward. Magnesium Sulphate therapy started after complete evaluation of the patients according to the study protocol. Patients monitored carefully for any side effects of magnesium therapy and occurrence of convulsions. Primary outcome measures were development of eclampsia or recurrent seizures in patients with eclampsia, neonatal morbidity and mortality. Secondary outcome measures were serious maternal morbidity, magnesium toxicity and other side effects of MgSO[4] and complications of labour and delivery. Total 50 women were entered into the study over a period of one year. Out of these 12 [24%] women presented with eclampsia, 5 [10%] had imminent eclampsia and 33 [66%] were diagnosed as pre-eclampsia. Of the 12 women with eclampsia, none had recurrent seizures. Out of 38 women with pre-eclampsia and imminent eclampsia, only one [2%] woman developed eclampsia. There was no case of magnesium toxicity. Overall 12 [24%] of the babies were delivered with poor Apgar score. Two babies were expired within five minutes of delivery while 5 babies expired in NICU. There were 6 intrauterine deaths and 4 intrapartum deaths. Magnesium sulphate is an effective anticonvulsant for the treatment and prevention of eclampsia when used judiciously. In the dosage used it does not have any substantive harmful effects on women and their babiesstage repair is more appropriate with satisfactory results

Twin birth weight discordance: associated factors and outcome

To determine the frequency of twin birth weight discordance and compare the maternal characteristics and neonatal outcome in discordant and concordant twin gestations. Cross-sectional comparative study. MCH Centre, Unit-II, Pakistan Institute of Medical Sciences, Islamabad, from January 2005 to December 2007. All twin gestations delivered at>28 weeks gestation were included. Birth weight discordance was defined as>20% twin birth weight difference and two groups were developed accordingly. Prenatal complications, gestational age at delivery, mode of delivery and neonatal outcome were compared using chi-square and Fischer exact test with significance at p<0.05. Two hundred and fifty three pairs of twins were delivered during the three years. The frequency of birth weight discordance was 19% [48 verses 205 concordant twin pairs]. Preterm delivery [68% vs. 25%], pre-labour rupture of membranes [33% vs. 9%] and pregnancy induced hypertension [22% vs. 12%] were significantly more frequent in birth weight discordant compared to concordant gestations. The cesarean section rate was 29% and 21% respectively. Twelve [12%] discordant and 29 [7%] concordant infants required NICU admission. There were 10 intrauterine deaths [10%] and one [1%] neonatal death among the discordant twins while 18 [4%] intrauterine deaths and 10 [2.4%] neonatal deaths occurred in concordant twins, resulting in uncorrected PNMR of 114.5 and 43.9 per 1000 births respectively. Twin pregnancies with birth weight discordance are at higher risk of prenatal complications and have less favourable perinatal outcome. Their timely antenatal detection is, therefore, important for closer surveillance and timely delivery

Management of ectopic pregnancy: a two-year study

Ectopic pregnancy is the most important cause of maternal mortality and morbidity in the first trimester. Over the past few decades, the management of ectopic pregnancy has been revolutionized; various modalities of treatment are currently in practice. The purpose of this study was to determine the frequency of these modes of treatment of ectopic pregnancy and their outcome. Fifty two patients diagnosed to have ectopic pregnancy at MCH Center unit II in the year 2004 and 2005 were included in the study. A cross-sectional analytical study was done. Four modes of treatment were given according to patient's condition, ultrasound findings and ?-hCG levels; these were laparotomy, operative laparoscopy, methotrexate injection and conservative management. The outcome measures included success of each treatment modality, need for second mode of treatment in each group and duration of hospital stay. A total number of 52 patients with ectopic pregnancy were identified and studied. The rate of ectopic pregnancy was 1:100 deliveries. Emergency laparotomy was performed in 30 [57.9%] women, 15 [28.8%] received methotrexate injection. Seven women [13.3%] were managed conservatively and operative laparoscopy was not used as primary treatment in any of the patient. All cases of laparotomy did not require any further procedure. Twelve out of fifteen [80%] cases of medical treatment were successful while one [6.7%] proceeded to emergency laparotomy, one [6.7%] to operative laparoscopy and one [6.7%] to laparoscopy preceding laparotomy. Five out of seven patients [71.4%] on conservative treatment did not require any further intervention while two [28.6%] of them resolved with methotrexate injection. The duration of hospital stay in laparotomy, medically treated and conservatively managed groups was 6.5, 5.9 and 1.7 days respectively. In the institutional setting ectopic pregnancy accounted for 1% of total deliveries. More than half of all women with ectopic pregnancy presented with acute abdomen and required emergency laparotomy. About 40% women could be managed with non-surgical modalities with 80% success for methotrexate injection and 71% for conservative treatment in the present study

Risk factors for postcaesarean surgical site infection

To identify the risk factors associated with surgical site infections [SSI] after cesarean section [CS]. Descriptive study. Maternal and Child Health Centre [MCH], Pakistan Institute of Medical Sciences [PIMS], Islamabad. From January 2003 to June 2004. All post cesarean patients in postnatal ward with surgical site purulent discharge as well as patients readmitted on postoperative follow up in Outpatient department with SSI Patients with SSI after gynecological surgery were excluded Main outcome measures were association of SSI with preexisting maternal and intrapartum factors, level of surgeon, causative organisms and their sensitivity and postoperative hospital stay. There were 841 cesarean sections done during study period SSI occurred in 34 [4.0%] patients. Frequency of SSI after elective cesarean sections was 1.7% and after emergency CS was 4.8%. The associated risk factors were anemia [13 cases] i.e 38.2%, dai handling in 4[11.8%] cases, prolonged ruptured membranes in 9[26.5%], prolonged labour in 5[14.7%] and diabetes 3[8.8%] cases. The category distribution of surgeons in such cases was found to be consultant in 2[6%], senior registrar in 2[6%], third year resident in 10[32%], second year resident in 14[41%], first year resident in 6[17.6%]. The organisms isolated on wound swab cultures were Staphylococcus aureus 8[23.5%], Pseudomonas 3[8.8%], E-coli 2[6%], Klebseilla 2[6%], Proteus 1[3%] and no organism was isolated in 18[53%] cases. The antibiotics given after culture and sensitivity report were Quinolone 8[23.5%] and first and third generation Cephalosporin in 17[50%] cases. The mean length of post operative stay of SSI cases was 17.8 +/- 7.8 days. The frequency of surgical site infection was more in emergency cesarean sections. Anemia and prolonged Prelabour Rupture of Membranes [PROM] were frequently associated factors in SSI after the operation

Outcome of mechanical mode of induction in failed primary labor induction

To determine the role of an alternate [mechanical] inducing agent in failed labor induction. Quasi-experimental study. Labor Ward at Mother and Child Health Center [MCH], Pakistan Institute of Medical Sciences [PIMS] from May 1999 to July 2003. Women with singleton term gestation and normal live fetus undergoing indicated induction of labor were included if Bishop score was < 5 after 12-18 hours of primary induction with PGE2 vaginal tablets. They were then induced with mechanical method i.e. intracervical foley catheter, if fetal status was reassuring and no evidence of labor onset. The main outcome measure was mode of delivery. Secondary outcome measures were induction labor interval and induction delivery interval after second mode of induction and neonatal Apgar score. Thirty-six women received a second mode of induction for failed induction. Four patients were excluded. Of 32 eligible women, 24 [75%] delivered vaginally. Eight patients [25%] had emergency caesarean section. Mean induction labor interval after second mode of induction was 6.8 hours and mean induction delivery interval was 12.39 hours. Mean Apgar score at 1 minute and 5 minutes was similar in both vaginal deliveries and caesarean sections. When an alternate mechanical method was used, 75% of women labeled as "failed induction" delivered vaginally

Fetomaternal outcome in pregnancy with cardiac disease

To determine fetal and maternal outcomes in women presenting with heart disease during pregnancy and labor. Descriptive study. Department of Gynae/Obstetrics, MCH, Center, Unit II, PIMS, Islamabad, during a period of 2 years from March 2001 to February 2003. Forty-two pregnant women with heart disease delivered at MCH Center, Unit II, during the study period were included. Maternal outcome measures included obstetric and medical complications and maternal mortality while fetal outcome measures were prematurity, intrauterine growth restriction and perinatal mortality, intrauterine death and indicated terminations of pregnancy. The mean age was 27.50 ' 5.17 years [standard deviation]. Of the 42 women, 33 [78.6%] were booked for antenatal care and 9 [21.4%] were non-booked. Congenital heart disease was present in 7 [16.7%] while 28 [65.3%] had rheumatic heart disease and mitral valve disease was the commonest. Among the remaining 7 women with acquired heart disease, 3 [7.1%] women had ischemic heart diseases [IHD], 1 [2.4%] had primary pulmonary hypertension, 2 [4.8%] patients had peripartum cardiomyopathy and 1 [2.4%] had aortic dissection. Based on New York Heart Association Functional classification [NYHA] 16 [38.1%] patients were asymptomatic [class I] and 3 [7.1%] in class IV. Thirty-two [76.2%] achieved spontaneous vertex delivery [SVD], LSCS was performed in 4 [9.5%] women, 2 [4.8%] women had spontaneous expulsions of dead fetus and 2 [4.8%] had suction and curettage for therapeutic termination of pregnancy on medical grounds. Obstetric complications occurred in 17 [40.4%] women, 5 [11.9%] had medical complications and 3 [7.1%] maternal mortalities occurred. Regarding fetal outcome, 6 [14.3%] infants had intrauterine growth restriction [IUGR], 2 [4.8%] perinatal deaths occurred due to prematurity while there was 1 [2.4%] intrauterine death. Indicated terminations of pregnancy were done for 4 gestations [7.1%]. Low birth weight was noted in 12 [28.6%] infants. Heart disease with pregnancy is a very high risk condition and maternal mortality ratio [MMR] was 7142/100,000 births. The management of these cases should be multidisciplinary to optimize care for these patients and large families be strongly discouraged

Management of massive postpartum hemorrhage by B-lynch brace suture

A 28 years old, 4th grade with three alive females delivered by lower segment cesarean section, was admitted at 29 weeks gestation with the complaint of mild off and on bleeding per vaginum for five weeks. She was a diagnosed case of major degree of anterior placenta praevia with intrauterine growth restriction. She was managed conservatively during her antenatal stay for 22 days in the hospital. One unit of blood was transfused. She had an emergency cesarean section at 32 weeks for sudden onset of heavy vaginal bleeding [more than 500 ml in two hours]. An alive female baby weighing 1.2 kg was delivered. Lower segment was highly vascular and bled more than 1000 ml during the operation despite ecbolics, haemostatic sutures to the placental bed in the lower uterine segment and pressure pack. B-Lynch suture was applied successfully. One unit of blood was transfused peroperatively. Patient remained well and was discharged on 5th postoperative day. She reported significant lower abdominal cramps on first two days after operation

Knowledge and attitude of older women towards menopause

Objective:To determine the knowledge and attitude towards menopause among postmenopausal women seeking gynecological treatment. Design: A descriptive cross-sectional survey based on sample of convenience. Place and Duration of Study: The study was conducted at the Gynecology outpatient department of MCH Center, PIMS, Islamabad from 1st June to 31st September, 2002. Subjects and Seventy postmenopausal women over 45 years of age were interviewed. The mean age of respondents was 54.4 years. Fifty-two [74.3%] women knew about menopause, 39 [55.7%] were aware of symptomatology while only 7 [10%] knew sequelae of menopause. Fifty-three [75.7%] women were satisfied with cessation of menstruation and only 17 [24.3%] desired to continue menstruation. Twenty-four [34.3%] respondents were unhappy with their menopausal status. Thirty-two [45.7%] women were content with their present sexual relations, 18 [25.7%] were dissatisfied and 20 [28.6%] had no sexual activity. Fifty-two [74.3%] women felt a need for health education on menopause in educational institutions. Thirty-three [47.1%] considered treatment of menopause necessary. Four [5.7%] were aware of any treatment of menopause and 55 [78.6%] desired to learn more about menopause. Women have different views about menopause, few see it as a medical condition requiring treatment, whereas a majority consider it a natural transition. There was dearth of knowledge regarding significance of menopause

Trial of extra amniotic saline infusion with oxytocin versus prostaglandin E2 pessary for induction of labor

To determine the effectiveness and safety of cost-effective extra-amniotic saline infusion [EASI] and simultaneous intravenous oxytocin infusion versus prostaglandin E2 vaginal pessary [PGE2] for induction of labor. Design: Prospective randomized comparative study. Place and Duration of Study: Labor room at the Mother and Child Health Centre, PIMS, Islamabad from September 2000 to December 2001. Subjects and Women with singleton alive pregnancies and Bishop score < 6, requiring induction of labor at >37 weeks gestation were randomly assigned to induction either with PGE2 3 mg vaginal pessary in two doses 6 hourly or EASI for 12 hours with simultaneous intravenous oxytocin infusion. Artificial rupture of membranes was done12 hours post-induction and oxytocin infusion started in PGE2. Main outcome measures were induction delivery interval and the mode of delivery. Secondary outcome measures were the change in modified Bishop score 6 hours postinduction and neonatal outcome in the two induction modes. After 4 exclusions, 100 women were recruited in each arm. Mean induction delivery interval was 11.1 and 14.3 hours [p=.00] in PGE2 and EASI respectively. The cesarean rate was 11% and 15%[p=0.4] in PGE2 and EASI respectively. Mean Bishop score at induction was 3.2 in PGE2 and 3.1 in EASI, while after 6 hours it was 4.8 and 6.8 [p=0.00] respectively. Mean APGAR scores at 1 and 10 minutes were identical that is 6.2 and 8.6 respectively. Both the modes of induction were equally safe and effective in terms of the mode of delivery and APGAR score. EASI, however, had more rapid cervical ripening and shorter induction delivery interval