Severe acute maternal morbidity; a review in a tertiary care hospital

To determine the frequency and pattern of severe obstetric morbidity and mortality. Cross sectional study. Period: 1st Oct 2005 to 30th Sep 2007. Military Hospital Rawalpindi. Cases of severe acute maternal morbidity and maternal mortality were collected and comparisons made of disease profile, organ system dysfunction, parity, mode of delivery, whether incident occurred at home or in the hospital and also whether patient was booked or unbooked. One hundred and ten cases of Severe Acute Maternal Mortality [SAMM] and eleven cases of maternal mortality were identified. More maternal deaths occurred in patients who had not booked themselves for antenatal care. The four most frequent cases of severe morbidity were: hypertension 36 [32%], haemorrhage 32 [29%], anemia 16 [14%], sepsis12 [10%] in this order. The four causes of deaths were: sepsis 4 [36%], hypertension 4[36%], amniotic fluid embolism 2[18.%], haemorrhage 01[10%]. There were statistically significant number of patients in mortality arm of sepsis group [p=0.01]. In patients with SAMM there was a higher percentage of patients undergoing caesarean sections in haemorrhage and hypertension arm compared to background rate of 35%. Multi organ failure, cerebral and respiratory system involvement was linked to both SAMM and morbidity. Maternal mortality index was highest for sepsis [25%], and lowest for haemorrhage [3%] with hypertension intermediate in position [10%]. Conclusions: A review of Severe Acute Maternal Morbidity offers a non threatening stimulus for improving quality of care. Comparison of Severe acute maternal morbidity with maternal death gives a different disease pattern and shows that different factors operate in each condition. Therefore both reviews complement each other

Impact of antenatal diagnosis and management strategies in morbidity adherent placenta

To study the pattern, demography and management options in placenta accreta in a tertiary care centre. 1st January 2004 to 15 August 2008 at Military Hospital, Rawalpindi and between 1[st] Sep 2008 to 30[th] Oct 2009 at Combined Military Hospital, Multan. All cases of placenta accreta seen during the study period were included in the study. Placenta accreta was defined as placenta being adherent to uterine wall without easy separation. Patient's demography, presence or absence of prenatal diagnosis and the management strategy i.e. conservative or otherwise was documented on a proforma. Success or failure of surgical approach used was noted. Assessment of maternal morbidity in the form of amount of blood/blood product transfused and early and late complications was made and compared with other cases that were antenatally diagnosed or were undiagnosed. A total of 28 cases were analyzed during study period. The incidence of placenta accreta was 6.3/10000. Mean maternal age was 30.7 years. Placenta praevia obstetrical hysterectomy was performed in 17 [61%] cases and had to be backed up by internal iliac artery ligation in 7[25%] Requirement for blood transfusion in antenatally diagnosed cases was almost 50% less than those of undiagnosed cases and the same was true for fresh frozen plasma [3.75 +/- 4.18 versus 6.75 +/- 5.41], platelet transfusion [P=0.04], stay in intensive care unit [1.56 +/- 1.82 versus 3.41 +/- 3.28] and use of mechanical ventilation [7% versus 11%]. There was no mortality in this series. Intra-operative internal iliac artery ligation reduces blood loss before and after hysterectomy and should be done in cases with placents accreta to reduce morbidity and mortality

Three-year prospective study of the prognosis of cardiomyopathy with pregnancy and its outcome at a single institution

To describe the characters of pregnancy with cardiomyopathy and its outcome. A case series study. This study was done in the Armed Forces institute of Cardiology [AFIC] and Military Hospital Rawalpindi from October 2003 to October 2006. The study of case series consisted of thirteen consecutive women who were admitted with diagnoses of Cardiomyopathy with pregnancy. For the diagnosis of Peripartum Cardiomyopathy [PPCM], strict 4 point criteria were used. During the study period we managed a total of 13 pregnancies with Cardiomyopathy as outdoor cases, 08 with PPCM 4 with hypertrophic Cardiomyopathy and one due to thyroid disease. The number of patients were only 11 as 2 were back again within a year. We had one mortality with peripartum Cardiomyopathy who presented within 20 days of delivery with sudden cardiac failure. For peripartum Cardiomyopathy the average age at presentation was 28 years. Most patients presented with dyspnoea 4 cases, palpitations 7 and one patient with syncope. Left Ventricular Ejection Fraction [LVEF] was 0.35 on the average. The time of diagnosis was antepartum for three patients and postpartum for five. There were no cases of multiple pregnancies in this series. In hypertrophic cardiomyopathy majority of the patients had caesarean sections, less so in other categories. These were performed under general anaesthesia due to uncertainty about the safety of regional anaesthesia in these cases. Cardiomyopathy is a poorly understood ominous complication of pregnancy. It accounts for a rising proportion of maternal mortality. Diagnosis should be considered whenever women present with heart failure in peripartum period. Improved case ascertainment requires heightened awareness among obstetricians and cardiologists

Adolescent ovarian tumors: a clinicopathlogical review of 15 cases

To prospectively review the clinicopathologic pattern and out come in 15 patients with adolescent ovarian tumours in Military Hospital Rawalpindi between Jan 2004 to Sep 2007. All cases of adolescent ovarian tumours reporting to the gynaecology department of Military Hospital Rawalpindi during the period of enrolment. Out of 15 cases 12 were managed surgically. Data was recorded regarding clinical presentation, patient's age, size of tumour, bilaterality, histopathology, staging if tumour was malignant and sites of extra ovarian involvement. All patients were followed up for one year. Majority of patients fell in the subgroup 14-16 year age. Majority harboring ovarian malignancy belonged to subgroup 17-19 years. Clinical presentation in the majority was mass abdomen and abdominal distension. Approach was transcutaneous in 3 [20%], laparoscopic in 2[20%], and open laparotomy in 10 [60%]. Frozen section was performed in 3 cases. Histopathology was benign in 11 cases and malignant in 4. In 3 cases cyst fluid was negative for malignancy. In 2 cyst wall biopsy and one patient where entire cyst was removed histopathology revealed benign serous cyst adenoma/luteal cyst [26%]. There were 5 cases of dermoid cysts [33.3%], one patient had bilateral dermoids, one malignant and one benign. All 4 malignancies were found to be to non-epithelial on histopathology. One case had surgery twice. Unilateral oopherectomy followed by recurrence and total abdominal hysterectomy and contralateral salpingo-oopherectomy after 2 years. This study shows the preponderance of non-epithelial tumours and high percentages of malignant germ cell tumours in adolescents. The incidence of malignant tumours in adolescents is higher than in adults. Early correct diagnosis could be reached by careful physical examination, imaging and tumour markers Surgery should as much as is safely possible be fertility preserving