Urinary tract infections; etiological profile and antimicrobial susceptibility patterns of uropathogens

Background: Urinary tract infections [UTIs] constitute important bacterial disease which contributes to significant morbidity world-wide. Empirical treatment in patients suffering from UTI depends upon the local knowledge of common microorganisms responsible for UTI in that geographical area as well as their antimicrobial susceptibility patterns

Objectives: To determine the frequency and antimicrobial susceptibility of uropathogens which are responsible for urinary tract infections. Study Design: Experimental study. Setting: Department of Pathology, Frontier Medical and Dental College and Mohi Ud Din Islamic Medical College. Period: January 2015 to June 2015

Material and methods: Total of 113 patients were included in the study. Urine samples were cultured on MacConkey's agar and Cysteine Lactose Electrolyte Deficient [CLED] agar. Micro-organisms were identified using standard tests and antimicrobial susceptibility was checked using modified Kirby Bauer method following Clinical and Laboratory Standards Institute [CLSI] guidelines

Results: The average age of patients was 32.19 +/- 16.47 years. Gram negative organisms accounted for majority of cases, about 89 [78.76%] cases. Escherichia coli was the most common micro-organism which was found in 50 [44.24%] cases followed by Staphylococcus aureus in 24 [21.24%], Enterobacter spp. in 19 [16.81%], Klebsiella spp. in 11 [9.73%] and Proteus spp. in 9 [7.96%] cases. E. coli was sensitive to imipenem and ciprofloxacin and was resistant to amoxicillin/clavulanic acid and gentamicin

Conclusion: Gram negative organisms are largely responsible for UTIs and E. coli being the most common etiological agent. E. coli is sensitive to commonly prescribed drugs for UTI like ciprofloxacin

Smoking behavior among medical and dental students in Abbottabad, Pakistan

Objective: To assess the prevalence of smoking among young medical and dental students and explore the smoking habits and associated variables

Study Design: Cross-sectional observational study

Place and Duration of Study: The study was conducted in Frontier Medical and Dental College, Abbottabad, Pakistan during June-July, 2015

Materials and Methods: This was a cross-sectional observational study where anonymous, self-administered questionnaire was used to collect data like socio-demographic data and details about various aspects of smoking from 146 studysubjects

Results: The rate of smoking was found to be 23.28%, with male preponderance. The mean age of initiation of smoking was 18.79 +/- 1.68 years. The most common reason for starting smoking was company and peer pressure followed by stress or tension. The mean number of cigarettes smoked per day was 13.39 +/- 6.52. The commonly used product was cigarette [89.28%] among males and waterpipe[shisha], [83.33%], among females. Majority of study subjects, 63.70%, and 73.53% of smokers were aware of harmful effects of smoking. The most commonly known harmful effects included; lung cancer, carcinoma of oral cavity, respiratory and cardiovascular diseases

Conclusion: Smoking is common among medical graduates. Tobacco control measures should be introduced to reduce smoking as well as it should be made part of curricula taught at medical and dental colleges to increase awareness among students

Typhoid fever with jaundice; a clinical study in Abbottabad

Typhoid fever is a systemic infection which is caused by Samonella enterica serotype typhi. It is a multi-system disorder involving many organs including liver. Liver involvement could be in the form of jaundice, rise in liver enzymes or hepatomegaly. It can present as acute hepatitis in rare cases, called typhoid hepatitis. This study was carried out to study the association of typhoid fever in patients with jaundice. To determine the frequency of typhoid fever among patients presenting with jaundice. Descriptive cross sectional study. At Gastroenterology Unit, Ayub Teaching Hospital, Abbottabad. March 2011 to December 2011. Total 115 patients were included in the study based on inclusion and exclusion criteria. Typhidot IgM test was performed to confirm the diagnosis of typhoid fever. The mean age of patients was 28.5 +/- 10.14 years, with 54.8% male gender predominating the overall sample. The male to female ratio was 1.2:1. Typhoid fever was found in 22 [19.1%] out of 115 patients with jaundice and there were 68.2% were males and 31.8% were females. Typhoid fever is not rare to present as jaundice in our part of the world where typhoid fever is endemic. Therefore, all those patients who have fever, jaundice, abnormal liver function tests or hepatomegaly must be screened for typhoid fever especially in areas where typhoid fever is endemic

Hepatitis B and C virus infections; in haemodialysis patients in Abbottabad, Pakistan

Patients with end stage renal disease require haemodialysis as a part of their treatment. The incidence of hepatitis B and C virus infection is quite high in patients undergoing maintenance haemodialysis than in general population. This risk is specifically associated with use of blood and its products as well as repeated intravascular access in these patients

Objectives: To determine the seropositivity of hepatitis B and C virus infection in patients receiving haemodialysis

Design: Descriptive cross sectional study

Setting: Nephrology Department, Ayub Teaching Hospital, Abbottabad, Pakistan

Period: From October 2014 to April 2015

Methods: Five hundred patients were included in the study based on inclusion and exclusion criteria. Demographic data was recorded and detailed history was taken from each patient specifically about the no of blood transfusions received, the frequency of dialysis and the dialysis done in other centers. All patients were checked for the presence of hepatitis B surface antigen [HbsAg] and antibodies to HCV using third generation enzyme linked immunoassay [ELISA]

Results: Mean age of study sample was 46 +/- 5 years with 60.8% males. Incidence of hepatitis positive cases was 164 [32.8%], out of which 66 [13.2%] patients were HBV positive and 98 [19.08%] patients were HCV positive. The hepatitis B and C infections were more common in males than females. Seropositivity of HBV and HCV was higher [HBV 18.1% and HCV 22.2%] among haemodialysis patients who have received more than three blood transfusions. The frequency of HBV and HCV infections increases significantly with the increase in frequency of dialysis, with 49 [17.11%] patients were HBV positive and 70 [24.5%] patients were HCV positive cases, who have received haemodialysis for more than five times. There were 48 [15.7%] HBV positive cases as well as 68 [22.3%] HCV positive cases in patients who have received their treatment from a single center

Conclusion: Hepatitis B and C infection is quite common in patients undergoing haemodialysis. The risk of these infections can be reduced by following infection control guidelines, proper training of the staff and strict screening of blood and blood products specifically for hepatitis C virus

Bacteriological profile and antibiotic susceptibility of blood isolates in blood stream infections

The current study was aim to analyse Bacteriological Profile and Antibiotic Susceptibility of Blood Isolates in Blood Stream Infections. Experimental study. This study was conducted at Department of Pathology, Frontier Medical and Dental College, Abbottabad from January 2010 to August 2011. 1056 blood samples were collected aseptically. The positive blood isolates were identified by standard biochemical tests and their antimicrobial resistance patterns were checked using modified Kirby-Bauer method. Blood cultures were positive in 152 [14.39%] cases. Gram negative isolates were predominant with 104 [68.42%] cases, consisting, in decreasing frequency, of Salmonella typhimurium [39, 37.5%], Pseudomonas aeruginosa [23, 22.1%], Escherichia coli [18, 17.3%] and Klebsiella pneumoniae [14, 13.4%]. Staphylococcus aureus accounted for 30 [19.7%] cases followed by coagulase negative Staphylococcus aureus [CONS] in 11 [7.23%] cases among gram positive isolates. Gram positive bacteria were highly resistant to amoxicillin while they were sensitive to cefuroxime and aztreonam. Among gram negative organisms, Escherichia coli and Klebsiella pneumoniae were sensitive to ofloxacin while Pseudomonas aeruginosa to cefpirome and ceftazidime. Our study provides important information about the bacteriological profile and antibiotic resistance pattern of blood isolates in blood stream infections. It will help clinicians to choose an empirical antibiotic therapy to treat such infections

Pattern of hematological disorders in Abbottabad

To study the pattern of distribution of different hematological disorders in Abbottabad based on bone marrow examination results. Retrospective study. This study was conducted at the Aksa Laboratory, Abbottabad from January 2011 to December 2013. 143 patients, who presented to Aksa laboratory for bone marrow aspiration, were selected. Complete details of history, examination, blood tests were recorded. Bone marrow aspiration was performed using aseptic technique and bone marrow aspirate samples were prepared. Bone marrow aspirate results of 143 patients were studied. There were 104 cases [72.72%] of non-malignant hematological disorders while 39 [27.27%] of hematological malignancies. Among non-malignant hematological disorders, megaloblastic anemia was the most common disease affecting 31 patients [29.80%], followed by iron deficiency anemia in 20 patients [19.23%]. There were 39 cases [27.27%] of hematological malignancies. Out of these, 23 cases [58.97%] were of acute leukemia followed in descending order by 5 cases [12.82%] of multiple myeloma and 4 cases [10.25%] of chronic myeloid leukemia. Megaloblastic anemia was the most common disease followed by iron deficiency anemia among non-malignant hematological disorders. Acute leukemias were most common among malignant hematological disorders. Bone marrow aspiration was very useful in making a correct diagnosis and determining the cause of disease

Assisted breech delivery with transverse vaginal septum

The incidence of vaginal septum is rare. The infrequency of this anomaly makes accurate estimates of the true incidence very difficult to obtain. Diagnosis is based on careful history and examination. This is the case of a patient who presented with transverse vaginal septum in labour and breech presentation. The septum was resected and the foetus delivered normally. Careful vaginal examination should be performed in pregnant women at term before labour to detect such manageable abnormalities.

Seroprevalence of hepatitis B in outdoor female patients of reproductive age group at Ayub Teaching Hospital Abbottabad

Hepatitis B is inflammation of the liver caused by a Hepatitis B virus, having a parenteral mode of entry and infecting millions of people around the world. The present study was planned to assess the seroprevalence of Hepatitis B in women of reproductive age in Hazara in order to promote disease prevention in the perinatal period by vaccination against Hepatitis B. Women 15-45 years old belonging to Hazara Division were included in this descriptive, cross-sectional study conducted over a period of one year at the Department of Microbiology, Ayub Medical College, Abbottabad in collaboration with the Department of Pathology, Ayub Teaching Hospital, Abbottabad from 1[st] March 2006 to 28[th] February 2007. Non-probability convenience sampling was done to select 500 females from those visiting Ayub Teaching Hospital Abbottabad as outdoor patients or accompanying person. History, examination, and serum alanine aminotransferase estimation were followed by the initial screening for Hepatitis B surface Antigen [HBsAg] using immunochromatographic device. Enzyme linked Immunosorbent assay was used to confirm the presence of HBsAg. HBsAg was detected in 3% of the women. History of multiple injections was present in 100%, blood transfusion in 22%, dental procedure in 46% and surgical procedure in 43% of the subjects. Only 1% women had been vaccinated. Seroprevalence of the Hepatitis B is not different from the figures reported by the studies previously conducted on general population in Pakistan. However it is different from those reported for the special groups

Seroprevalence of hepatitis C in pregnant females of hazara division

Hepatitis C Virus [HCV], the causative agent of Hepatitis C is prevalent in different countries including Pakistan. Studies have been conducted on various aspects of HCV in Pakistan. The present study was planed to see the prevalence of hepatitis C in pregnant females of Hazara Division. Five hundred pregnant females of reproductive age group from Hazara Division selected by non probability convenient sampling technique were studied from 1st March 2006 to 28th February 2007 at Ayub Teaching Hospital, and District Headquarter Hospitals Abbottabad, Haripur and Mansehra. After initial serving by immunology technique positive cases were confirmed by Enzyme Linked Immunosorbant Essay [ELISA]. Seroprevalence of HCV in pregnant females of Hazara division was 8.9%. Females aged from 25-35 constituted the largest group among positive cases. HCV was more prevalent in District Abbottabad as compared to the other districts of Hazara division. Seroprevalence of HCV in pregnant females of Hazara Division is different from the figures already reported form the other parts of Pakistan

Extrapulmonary tuberculosis in Lady Reading Hospital Peshawar, NWFP, Pakistan: survey of biopsy results

Tuberculosis is a disease of poor countries. In the recent years, there has been an increase in the occurrence of extra-pulmonary tuberculosis [EPTB] world over. As very little data is available regarding the situation of EPTB in NWFP, this study was conducted to asses its frequency in various organ systems of the body and to evaluate the role of demographic factors like sex and age in its causation. A total of 525 cases of EPTB diagnosed histopathologically in the Department of Pathology, Lady Reading Hospital Peshawar in the years 2002-2005 were included in the study. Age, sex and sites of biopsies were recorded. High female preponderance was noted with a M:F ratio of 1:2. Mean age was 35 years and 70% of the patients were in the age group 15-45 years. Lymph nodes were the most common site of EPTB, involved in 66.4% of the cases. EPTB has high rates in females in their reproductive age. Tuberculous lymphadenitis is the most common form of EPTB. High occurrence of EPTB in female population needs immediate attention of tuberculosis control programs

Compliance to antihypertensive drugs, salt restriction, exercise and control of systemic hypertension in hypertensive patients at Abbottabad

Hypertension is one of the most important cardiovascular risk factor but its control is still a challenge for physicians all around the world. Control of blood pressure can reduce cardiovascular morbidity and mortality, so the compliance to antihypertensive drugs and life style modification play an important role for the control of hypertension. This analytical [cross-sectional] study was conducted to assess prevalence of control of hypertension among hypertensive patients and to assess the relationship of control of hypertension with factors like compliance to antihypertensive drugs, salt restriction and exercise among the hypertensive patients. This study was conducted at outpatient clinic of medicine at Shahina Jamil Hospital Abbottabad from April 2007 to September 2007. Eighty-nine patients seen in the outpatient clinic of medicine were enrolled in the study. All the patients with age 15 years or above, diagnosed as a case of systemic hypertension were included. Among eighty-nine patients, 67 were female and 22 were male with mean age of 55.8 +/- 13.4 years, mean systolic and diastolic blood pressure of 160 +/- 28.6 and 97.8 +/- 14.1 mm Hg respectively, and pulse rate of 85.9 +/- 11.4 per minutes. Out of 89 patients, 25.8% were having controlled hypertension, 48.3% were compliant and 51.7% were not compliant to antihypertensive drugs, 55.1% were having salt restriction and 44.9% were having no salt restriction and 23.6% were used to do physical activity while 76.4% were not used to do physical activity. In group A consisted of patients with controlled hypertension, 95.7% patients were compliant to antihypertensive patients, 95.7% were having salt restriction, and 43.5% were used to do physical activity. In group B consisted of patients with uncontrolled hypertension, only 31.8% were compliant to antihypertensive drugs, 40.9% were having salt restriction, 16.7% were used to do physical activity. Hypertension can be controlled if the hypertensive patients have good compliance to antihypertensive drugs, salt restriction and do some sort of physical activity regularly and in this way, prevent themselves from the hypertensive complications

Frequency and characteristics of skin cancers diagnosed at Ayub Medical College, Abbottabad Pakistan from 1995-2003

Our histopathology laboratory serves mountainous area of Hazara Division in Northern Pakistan. This study is an analysis of the records of skin cancers reported over a nine years period to develop local statistics about frequency and characteristics of skin cancers. Data from 1995-2003 record of cancers reported by Department of Pathology, Ayub Medical College, Abbottabad were analysed to calculate cumulative and year wise frequency of skin cancers and their major types. Frequency distribution with reference to gender and age was also calculated. Skin cancers were 220 [1.04%] out of the total 21075 cancers recorded during this period. Squamous cell carcinoma was diagnosed in 118 [53.6%], Basal cell carcinoma in 88 [40%] and Malignant melanoma in 14 [6.4%] cases. The mean age for all skin cancers considered together was 58.75 +/- 15.21. Non Melanoma Skin Cancer [NMSC] were seen in all age groups [minimum 15, maximum 103 years], while no malignant melanoma patient was under 35 years of age. Gender difference in distribution was negligible with slight male preponderance [23:21]. Malignant melanoma was significantly [p<0.05] more in males [71.4%], while distribution of both the types of NMSC was non-significantly in favour of males. We found no significant rise or fall in total skin cancers or any type of skin cancer in this 9 years period. At present the frequency of skin cancer is stable at around 1% of total cancers reported at Ayub Medical College, reflecting a stable very low incidence rate of skin cancer in Hazara Division of Pakistan

Antimicrobial sensitivity pattern of urine isolates from asymptomatic bacteriuria during pregnancy

Screening women for asymptomatic bacteriuria [ASB] on the first antenatal visit is a part of standard obstetric care. Treating women with ASB decreases the chances of maternal and f0etal complications. This study was conducted to find out the spectrum of urine pathogens and their drug susceptibility pattern for ASB during pregnancy. The study was conducted in the Basic Medical Sciences Institute, Jinnah Postgraduate Medical Centre Karachi, from September 2001 to March 2002. Two hundred and ninety women, apparently normal with confirmed pregnancy, were registered. A voided midstream urine specimen was collected and cultured. A significant growth i.e. >/= 105 organisms/ml was identified with Analytical Profile Index 20 tests for identification of Enterobacteraceae [API-2o-E] and for Gram positive cocci by other standard methods. The prevalence of ASB was found 6.2%. Antimicrobial sensitivity was determined by disc diffusion Kirby Bauyer method after matching the turbidity with 0.5 McFarland's standard. Most of the recommended drugs were found to have encouraging results, however, Escherichia coli showed 66.67% resistance to ampicillins and sulphonamides. Enterobacters showed 100% resistance to ampicillins, cephalosporins and nitrofurantoin. Staphylococcus saprophyticus showed 66.67% resistance to ampicillins and sulphonamides. It was concluded that detection of ASB during pregnancy and appropriate use of antimicrobials is only possible after culture of urine. Empirical anti-microbial therapy cannot be relied upon because of possible risk of resistance

study of prevalence of malaria in adult population of D.I.Khan, Pakistan

Malaria is a serious global health challenge. It continues to be a threat to the developing countries. Epidemiological data from different regions of Pakistan is insufficient to exactly evaluate the incidence of various types of malaria. D. I. Khan is a hot area on the right bank of the river Indus, providing favourable circumstances for mosquito breeding. We conducted this study to see the prevalence and presentation of various types of malaria in adult patients presenting with fever, and its response to anti-malarial agents in this region. This cross-sectional study was conducted in the department of Medicine, Gomal Medical college, D. I. Khan, from 28[th] August 2005 to 27[th] February 2006. All adult patients presenting to the outpatient clinic with fever were included in the study. A total of 490 patients presented with fever as a chief complaint. After detailed history and thorough clinical examination, Giemsa stained thick and thin blood films were examined. Species determination and parasite count were performed. Patients were grouped into two; Group A having Falciparum malaria and Group B any other type. Group A patients were randomly given either Quinine or Artemnether. Group B patients were given Chloroquine, Quinine or Artemether in standard doses. MP and parasite count were repeated on day 7 and 14 and the presence of more than 25% parasitaemia as compared to pretreatment was taken as treatment failure. Out of 490 patients, ninety-eight [20%] were found positive for malaria, seventy-five males and 23 females. Comparing the symptoms in falciparum and vivax malaria, it was found that nausea/vomiting was twice as common in falciparum malaria. Comparing the anti-malarial drugs, Chloroquine and Quinine were found to be effective in all patients. On the other hand Artemether was found to be 100% effective in vivax malaria and poor response to therapy was observed in two [4%] patients with falciparum malaria. As a conclusion malaria is responsible for fever in every fifth adult patient in our setup. Males are three times more commonly affected than females. Plasmodium falciparumn is 1.5 times more common than vivax. Nausea/vomiting and pallor are more common in falciparum, while splenomegaly is seen in vivax malaria. Commonly used anti-malarial drugs are effective in most of the cases

Frequency of heart failure in patients with beta thalassemia major

Estimated prevalence of beta thalassemia is 3-8% in Pakistan. Over the past three decades, regular blood transfusions have significantly increased the survival of these patients. There has been an increase in the frequency of complications, mainly caused by iron overload. The aim of this study was to determine the frequency of heart failure in patients with beta thalassemia major in this region. It was a descriptive audit of ward record, carried out in the Department of Paediatrics, District Headquarter Teaching Hospital, D.I.Khan, Pakistan, from January 2004 to December 2005. Case records of all beta thalassemia major patients admitted during this period were analyzed for heart failure. Clinical data recorded was age, sex and cardiac status of patients. Investigations including ECG, chest x-ray and echocardiography were evaluated. Two hundred and twelve patients of beta thalassemia were admitted during the study period. Clinical congestive cardiac failure was observed in 33 [15.6%] patients with the age range of 8-21 years. Fifty four patients [25.5%] had cardiomegaly on chest x-ray but were not having clinical heart failure. Age range of these patients was 5-12 years. As a whole heart failure and cardiomegaly on chest x-ray was observed in 87 [41.1%] patients. All these patients were above the age of 5 years. Heart failure is not uncommon in patients with beta thalassemia major in our setup. Regular transfusions and chelation therapy are recommended to reduce this complication

Homicidal deaths by firearms in Dera Ismail Khan: an autopsy study

Determine homicidal deaths due to firearm injuries in the district of Dera Ismail Khan [D. I. Khan] of the North West Frontier Province [NWFP] of Pakistan. District Head Quarters [DHQ] Teaching Hospital and the Department of Forensic Medicine and Toxicology of the Gomal Medical College. D. I. Khan. The study was conducted over 1 year. Data collected included all reported unnatural deaths from the urban areas of the district on which autopsies were conducted in the department. A total of 97 autopsies were conducted in 2004 of which 63 were homicidal deaths [64.9%]. All homicidal deaths were caused by firearm injuries and all were males. The most common firearm weapons [87.3%] were high velocity firearms [Kalashnikov, rifles, pistols] followed by low velocity rifled weapons [9.53%] and shot guns [3.17%]. A total of 77 injuries were found on different areas of the bodies, giving an average of 1.2 injuries per person. The head, neck and face sustained the highest number of injuries [49.1%], followed by thorax and abdominal area [19.4% and 18.1% respectively]. Extremities including buttock and genital areas were least affected [18.1%]. All reported homicides were caused by firearm injuries. The issues of possession of legal as well as illegal firearms and their use in cultural activities needs to be changed in order to reduce violent deaths

Study of patients presenting with acute flacid paralysis in Dera Ismail Khan, NWFP - Pakistan

A descriptive study was designed to analyse patients of acute flacid paralysis [AFP] in paediatric deptt of DHQ teaching hospital D. I. Khan during 2002. A total of 36 cases of AFP were reported during this period. They were clinically examined. History was taken with special reference to IM injection and OP vaccination. Stool samples were sent to NIH Islamabad for viral detection. Out of total of 36 patients, 15 were confirmed as polio, 5 were labelled as compatible with polio and 16 were non-polio cases. Out of 15 confirmed cases of polio, 12 [80%] had received IM injections and all had some residual paralysis / weekness after two months follow-up, while 3 of the non polio cases had received I.M. injections and non had residual paralysis / weekness on follow-up. Main cause of high polio prevalence seems to be due to low vaccination rate, particularly routine as compared to supplemental vaccination. It was concluded that supplemental polio vaccination should be continued in an improved and strengthened fession through NIDs and EPI

Mortality rate in adult tetanus patients in district D. I. Khan, NWFP - Pakistan

This study was conduct to know about the real and present situation in our set up where tetanus still remains an important cause of morbidity and mortality despite free availability of a safe and effective vaccine. The study was conducted in medical unit of DHQ teaching hospital D. I. Khan over a period of four years. A total of 150 cases of tetanus were studied with 120 patients being males and 30 females. Diagnosis of tetanus was based on clinical examination. The patients were given conventional therapy for tetanus and comparison was made with other studies. Among these 150 patients of tetanus, 29 [19.3%] patient died, 22 being males and 7 females. Mortality rate in adult patients with tetanus is lower than reported in most other studies

Reconstruction of postle leishmaniasis scar with lateral cheek rotation flap

The aim of this study was to find a simple and economical technique to remove postleishmaniasis scar from the face. Design: a non-randomized descriptive case series. Place and Duration of Study: the study was conducted between 1st January 1998 to 31st July 2000 in a private hospital of D.I.Khan. Patients and Ten patients with postleishmaniasis scar on the face were selected for excision and reconstruction in this study. They were operated as day care under local anesthesia. Their age ranged between 18-30 years, with an average of 23.5 years. The size of scar varied from 2 cm2 to 6 cm2 with an average of 4.1cm2. After scar excision, lateral cheek rotation flap [reverse face-lift] was used to reconstruct the defect. Results were statistically analyzed. No major complications were encountered. However, minor complications like edema of the flap, seroma under the flap, flap tip necrosis and temporary neurapraxia were noted in two patients. this is an excellent technique, which can be done on a day care basis under local anesthesia. Larger studies will help to explore this technique further

Still birth rate in district head quarter hospital Abbottabad

This retrospective study was done at District Headquarter Hospital, Abbottabad. The prevalence of still birth was studied among 853 infants born in maternity ward of DHQ Hospital, Abbottabad during two and a half years. The still birth rate observed was 112.5/1000. The rate was higher among multigravida and in females of more than 35 years age. The prominent aetiological factors were multiparity prolonged and obstructed labour and antepartum haemorrhage