Classic congenital adrenal hyperplasia: a delayed presentation

Congenital adrenal hyperplasia [CAH] is a rare congenital disorder, which in cases of female genotype may result in virilization. Specific enzyme deficiencies in adrenocorticoid hormones biosynthetic pathway lead to excess androgen production causing virilization. Classic type presents early in infant life as salt losing or simple virilizing type, whereas non classic form presents late at puberty or in adult life. Depending on the type of classic CAH, type of adrenocorticoid deficiency, extent of virilization and genotype, surgical corrective procedures, glucocorticoid and mineralocorticoid replacement therapy are the mainstay of management. We present here a case of classic congenital adrenal hyperplasia of simple virilizing type, which presented later in childhood

Partogram depicted labour dysfunction and feto-maternal outcome in primigravidas

To determine the frequency of labour dysfunction and associated feto-maternal outcome in primigravidas. Descriptive case series. Obstetrics and Gynaecology Unit II Civil Hospital Karachi, from January 2007 to August 2007. A total of 100 primigravidas were included, having term singleton foetus in active phase of labour. The process of labour was recorded on partogram with maternal and foetal parameters. Among the study participants, partogram curve of 74% primigravidas showed labour dysfunction and required augmentation. Median duration of first stage of labour was 9 hours, second stage of 30 minutes and third stage of 8 minutes. Out of total patients, 82% neonates were observed with good Apgar score and 18% had poor Apgar score. There were 2% cases of puerperal pyrexia but no case of PPH, ruptured uterus and obstructed labour. Partogram is an inexpensive and efficient method of labour monitoring which depicts any dysfunction in labour timely so that early intervention could take place. With the use of partogram the mean duration of labour was reduced.

Perinatal outcome and near-miss morbidity between placenta previa versus abruptio placentae

To compare perinatal outcome and near-miss morbidities between placenta previa versus abruptio placentae in patients of antepartum haemorrhage [APH]. Cross-sectional, analytical study. Gynaecology Unit II, Civil Hospital, Karachi, from August 2007 to July 2009. Patients with APH diagnosed as placenta previa and abruptio placentae who delivered after 24 weeks of pregnancy were selected from labour room. Outcome measures were birth weight, neonatal intensive care admission, stillbirth, perinatal mortality rates, near-miss, surgical intensive care admission, postpartum haemorrhage, hysterectomy, massive transfusion, renal failure, coagulopathy and maternal death. Stillbirth was defined as a fetus weighing >/= 500 gm showing no sign of life after birth. Near-miss was defined as severe organ dysfunction which if not treated appropriately, could result in death. Descriptive statistics were calculated and chi-square was applied with significance level < 0.05. Stillbirths and perinatal mortality rates were significantly higher in abruptio placentae, 52.97% versus 18.18% and 534/1000 versus 230/1000 [p < 0.01]. Near-miss cases were also significantly higher in abruptio placentae, 22.27% verus 11.18% [p < 0.01]. Hypovolemic shock and coagulation failure were also significantly higher in abruptio placentae [p < 0.05]. Abruptio placentae carry significantly higher perinatal mortality and near-miss morbidity than placenta previa

Role of Nifedipine in Preterm Labour

The objective of the study was to assess the efficacy of Nifedipine for suppression of preterm labour. Quasi experimental study. The study was conducted at Department of obstetrics and Gynaecology unit II, Civil Hospital Karachi from november, 2004 - October 2005. 65 singleton pregnancies with preterm labour occurring between 28 and 34 weeks of gestation were selected. Patient presenting with Preterm labour, having cervical dilatation <3cm with intact membrane included in the study. Nifedipine was used as a tocolytic agent. Successful tocolysis was achieved in 70% [45 /65] of patients, while in remaining 30% [20/65] tocolysis was not achieved. Nifedipine effectively suppressed uterine contractions and delayed delivery for >48hours, a period which is sufficient for the effect of corticosteroid or inutero transfer

Serum uric acid as predictor model for pre eclampsia

To determine that serum uric acid as a predictor in pre-eclampsia during pregnancy. To determine fetal and maternal outcome in pregnancy with hypertension. Case control study. Gyne Unit-2, Civil Hospital Karachi. Duration: 8 months [1st March 2008 to 30 October 2008]. 30-Cases of singleton primigravida with BP > 160/110 mmHg and 30-Cases of singleton primigravida with Normal BP 120/80 mmHg were studied at the time of delivery. Thirty Patients with pre-eclampsia taken along with thirty patients with normal BP, since higher proportion of un-booked woman in Pre-eclampsia group than normotensive group. Significantly low gestational age in Pre-eclampsia group mean is 34 weeks and 37 weeks for normotensive group. Mean age of marriage for both groups is 1-2 years in both groups. No difference in mean age in pre-eclampsia and normotensive group that may be due to duration of marriage and early marriage trend in our culture. History of hypertension is seen in 19 [63.3%] of patients. The average birth weight of patients with pre-eclampsia is 2.5 Kg and 3 Kg for normotensive group. Difference may be due to preterm delivery in pre-eclampsia. Apgar score low in pre-eclampsia group. Increase caesarean rate is 93.3% Vs 20% in pre-eclampsia and normotensive group. This difference is due to the fact the caesarean section is considered to be safest mode of delivery for pre-eclampsia group. Uric acid level > 0.45 mmol/1 was observed in 15 patients [50% of pre-eclampsia group] and 7 patients [23.3% of woman with normal blood pressure]. Maternal hyper uricemia is a strong predictor of maternal disease progression and fetal outcome. Thus it can be used as useful and inexpensive marker of predicting pre-eclampsia and fetal growth retardation in women presenting with gestational hypertension

Clinico-pathological study of abdominal hysterectomies

To correlate indications of abdominal hysterectomy with the histo-pathological findings, in order to determine the percentage of pre-operative diagnosis that was confirmed on histopathology and to determine the frequency of unexpected pathologies. This cross sectional study was conducted in the Department of Obstetrics and Gynecology, Unit II, Civil Hospital Karachi, during January 1995 to December 1996 and Department of Obstetrics and Gynecology, Unit V, Dow Medical College and Lyari General Hospital, Karachi, during August 2005 and October 2008. One hundred sixty six patients undergoing abdominal hysterectomy for gynecological disease, were studied. Data was recorded on proformas, including demographic characteristics and clinical features. Indication for the procedure was documented. Surgical specimens were sent for histopathology and reports were analyzed and compared with the indications of surgery. Commonest indication for hysterectomy was fibroid in 40% followed by dysfunctional uterine bleeding [DUB] in 29% cases. Histopathological confirmation of pre-operative diagnosis was 100% for malignancy, endometrial hyperplasia, endometritis and hydatidiform mole, 94% for fibroids, 83% for adenomyosis, 60% for pelvic inflammatory disease and 14.1% for DUB. Majority of cases [65%] pre-operatively diagnosed as DUB were found to have adenomyosis. One case of undifferentiated uterine sarcoma was discovered on histopathology. Histo-pathological analysis correlates well with the pre-operative diagnosis indication for hysterectomy. Histo-pathology is mandatory for ensuring diagnosis and thus management, in particular of malignant disease

Bowel injuries secondary to induced abortion: a dilemma

To study the pattern of bowel injuries incurred by induced abortion, and the morbidity and mortality associated with them. Prospective descriptive study from December 2002 to December 2005. Surgical Unit three Gynaecology and Obstertrics Unit two, Civil Hospital, Karachi. All patients with bowel injuries due to induced abortion. Detailed data of all the patients was collected and analyzed. A total of 22 patients, mostly young with an average age of 26.86 years, presented with bowel injuries following induced abortion. Severe hemorrhage occurred in 8[36.4%] patients while 11[50%] had ileal perforation; 9[40.9%] underwent primary repair and 2[9.1%] ileostomy formation. Two [9.1%] patients with jejunal perforation had primary repair, whereas two with both jejuna and ileal perforations underwent resections with anastomosis in one and ileostomy in another. Seven [31.8%] with large gut involvement had colostomy formation. Septicemia and wound infection occurred in 7[31.8%] patients each, faecal fistula and abdominal wound dehiscence in 3[13.6%], and pelvic abscess in 1[4.6%] patients. The total mortality in this series was 6[27.3%] patients. Iatrogenic injuries during induced abortion, most commonly caused by quacks, can be minimized substantially if the procedure is performed by qualified medical personnel in proper health care facilities. There is a need for radical overhauling of the mind set in our society together with legislation

Frequency of congenital anomalies and associated maternal risk factors in the lower socio-economic group

To determine the frequency of congenital abnormalities in the lower socio-economic group and to identify associated maternal risk factors. Prospective descriptive study from January 2002 to December 2004. Out-Patient Department [OPD] of Gynae. and Obstetrics [Unit II] and Labour Room, Civil Hospital, Karachi. All patients in the lower socio-economic group who were detected to have or delivered abnormal babies. Women with an abnormal baby in-utero were identified from the Antenatal Clinic of the Gynae. And Obstetrics [Unit II] OPD or were inducted into the study after the delivery of an abnormal baby. These patients were further evaluated by taking a detailed history of the risk factors for congential abnormality. General physical examination of the mother was carried out, with detailed physical examination of the baby born with congenital abnormality. Investigations of the mother carried out included Blood Group, Blood CP and Random Blood Sugar. During the study period 246 patients delivered babies with congential malformation, making a frequency of 28/1000 deliveries. Neural Tube Defects, mainly Hydrocephalus, was the commonest congenital abnormality seen in 54.6% cases. Consanguineous marriage was found in 63.3% of cases, constituting as the leading risk factor for congential abnormalities. The incidence of congential abnormalities is high due to increased number of consanguineous marriages and non-availability of early prenatal diagnostic facilities. There is a need to improve public awareness regarding problems related to maternal age and consanguineous marriages

Adolescent mothers and their health related life style practice

To explore health related life style practices of adolescent mothers in order to develop 'culturally sensitive' adolescent programmes. Cross-sectional, descriptive study from Sept. 2005 to Feb. 2006. Outpatient clinic of the Dept. of Gynaecology and Obstetrics at Civil Hospital, Karachi. Adolescent mothers who already had outcome of first pregnancy and were pregnant again or visited the clinic for some other problem. All the women included in the study were interviewed using a semi-structured guide. The data thus collected was analyzed. One hundred and twenty women were included in the study. Amongst them 82% had less than high school education, 50% were supported by the biological parents, 98% had no sex education and only 20% had knowledge of contraception. The nutritional behaviour was unsatisfactory; eating of junk food was common. Breast feeding practices were satisfactory. Most of them had some element of depression after delivery, 86% pregnancies were unplanned. About 20% had either 1st or 2nd pregnancy terminated and 10% had some element of social support. Problems of our adolescent mothers are different from those of the developed world. Culturally sensitive programmes should be implemented to solve their problems

frequency of complications of fibroid during pregnancy

The aim was to study the prevalence of complications in pregnant women with .fibroid and their outcomes. A cross sectional comparative study from Jan.2001 to Dec.2004. It was conducted at the high-risk pregnancy clinic of obstetrics OPD Gynae CHK. 50 patients were included in the study that had been diagnosed either before or during pregnancy or as an incidental finding or referred from other health care centers and private clinics. The methodology adopted was to identify patients having pregnancy with fibroid. The patients were evaluated by taking detailed history and then regularly followed in OPD for antenatal checkup. A routine Ultrasound was performed in 2nd trimester for site of myoma and placental localization and in 3rd trimester, for malpresentation and size of myoma. During the study period 50 patients were admitted with the diagnosis of fibroid with pregnancy. Among these 12 pts [24%] were primigravida, 14[28%] were multigravida, 6 patients .[24%] were admitted with acute abdominal pain, 20 [40%] delivered vaginally 6[12%] and pregnancies ended up in abortion. The results indicate that presence offibroid leads to various complications during pregnancy but with proper care, early referral to a tertiary care unit and appropriate management and provision of healthy baby in the hand of a healthy mother is possible

Effects Of Maternal Anemia On Fetal Outcome i.e. APGAR score and birth weight

To determine the effects of maternal anemia on fetal outcome i.e. birth weight and fetal Apgar score at birth and at five minutes.Cross sectional comparative study from February 2002 to February 2005.Gynaecology Unit II, Civil Hospital, Karachi.150 pregnant women with anemia and 150 pregnant women without anemia, who were admitted in the labour room of Gynae. Unit II for delivery, were included in the study.These pregnant women were evaluated by taking a detailed history, doing examination and investigations like complete blood picture, random blood sugar and ultrasonography of pelvis for fetal well being and gestational age. The newborns of all these women were followed after delivery to record their birth weight and Apgar score at birth and after five minutes.The mean fetal birth weight was 2.47 +/- 0.331 Kg in the anemic women and 3.31 +/- 0.297 Kg in the non-anemic group, with a p-value of 0.000. The mean Apgar score of newborn at one minute in the anemic group was 6.29 +/- 0.93 and in the non-anemic group was 6.77 +/- 0.42, with a p-value of 0.000. The mean Apgar score of newborn at five minutes was 8.54 +/- 0.74 in the anemic group and 8.81 +/- 0.39 in the non-anemic women, with a p-value of 0.007. The mean fetal mortality in the anemic women was 9.3%, but it was zero in the non-anemic women. There was a significant difference between the two groups with a p-value of 0.007 on chi square test.This study show that anemic pregnant women who have haemoglobin levels of <11.0 GIdl deliver low birth weight babies with a high mortality rate and with a significant difference in Apgar scores of the new barns as compared to non-anemic pregnant women who have Hgb levels > 11.0 gm/dl

Partial hydatidiform mole

A case of partial hydatidiform mole is presented, occurring in a young primiparous woman after natural conception. She presented with incomplete miscarriage. Histological diagnosis of partial mole was made. Failure of beta HCG to fall resulted in the start of chemotherapy. WHO scoring placed her in low risk group. In spite of the low risk, she required third line chemotherapy for complete eradication of disease

Use of recombinant factor VII for massive posrtpartum haemhorrage: Case serie and review of literature

Recombinant activated factor VII is indicated mainly for the treatment of patients with haemophilia inhibitors. It has also been found successful in the treatment of platelet disorder Glanzmann's thrombasthenia. Recently, its use in trauma patients and in patients with intracereberal haemorrhage has become well established. We present three cases of massive post partum haemorrhage treated with rFVIIa, following caesarean section. The response of these three patients is discussed along with review of literature

Frequency of thrombophilia in patients with adverse pregnancy outcome

To determine the association between adverse pregnancy outcomes and thrombophilia. This is a descriptive study, incorporating retrospective analysis of patients with recurrent pregnancy losses, intrauterine deaths, abruptio placenta and early onset pre eclampsia. Patients with adverse pregnancy outcomes in whom co-morbid factors were excluded underwent screening for both acquired and inherited thrombophilia. A total of 40 patients were screened for acquired and inherited thrombophilia with adverse pregnancy outcomes. Anticardiolipin antibodies were found positive in 55% of patients and 45% of patients were found deficient for natural anticoagulants protein C and S. Two patients were found positive for both acquired and inherited thrombophilia. Thrombophilia, both acquired and inherited are associated with adverse pregnancy outcomes. Patients in whom other co-morbid factors are excluded, should be offered screening for thrombophilia. Liaison between hematologist and obstetrician is the corner stone for success

Ectopic pregnancy: a local experience

An analysis of women who were identified clinically to have ectopic pregnancy was done at the Department of Obstetrics and Gynaecology, Unit 2, Dow Medical College and Civil Hospital Karachi. The study period was from January 2002 to January 2003, over a period of 12 months. The objective of the study was to idents the risk factors for ectopic pregnancy, and to see the correlation between clinical sign and symptoms and the final diagnosis. A total of 35 cases were managed in the unit during the study period. Palpable adnexal mass was the most common sign observed in 28 [80%] patients, followed by amenorrhea and abdominal pain which were observed in 24 [68%%] cases. 80% of the patients gave no history of contraception, a factor which has been found significant for tubal rupture. Left fallopian tube was the most common site of rupture, seen in 60% of patients. All the patients presented late with either confirmed ectopic pregnancy on ultrasound, or with sign and symptoms of hypovolemic shock, characteristic of tubal rupture

Medical management of second trimester fetal demise using misoprostol

Surgical termination of pregnancy carries high risk for the women's health. Medical methods including prostaglandins are safe and reduce the above risk. This study was done to assess the efficacy of misoprostol as a medication for the termination of second trimester fetal demise. Design: Observational study. Setting: Department of Obstetrics and Gynecology Unit 2, Civil Hospital, Karachi and Dow Medical College. The study period was from January 2001-December 2001. A total of 50 patients requiring termination of pregnancy for fetal demise between 14 to 20 weeks of gestation were included in the study. Each woman received misoprostol vaginally. The dose was repeated at six hour interval, until adequate contraction or cervical ripening were achieved. Maximum dose given was 800 ug. [4 tablets]. The dose was not repeated after 4 tablets. Outcome measures included successful termination rates, mean expulsion time and side effects of medication. The mean dose of drug required was 200 ug. The average expulsion time was 9.3 hours. Evacuation of uterus was required in 2 patients and in 2 patients procedure failed, requiring other method of termination. The efficacy of the method was as high as 96%. Use of misoprostol in second trimester for fetal demise is recommended. It is not only safe but is effective as well

Uterine rupture in labour

A retrospective analysis of women, identified clinically with uterine rupture, in labour, was carried out at the Department of Obstetrics and Gynaecology unit 2 Civil Hospital Karachi between December 2000 to December 2001. The objective of the study was to identify the risk factors for uterine rupture in labor, to report maternal and fetal outcome and to identify preventive measures. There were 24 cases of uterine rupture. Of these, 4 were incomplete. The risk of uterine rupture was increased in grand multipara, women with previous caesarean section scars and those who had injudicious use of uterine stimulants. Lower uterine segment anteriorly was the commonest site of rupture. Vesico vaginal fistula, a serious morbidity was observed in 12.5%. There was one maternal death and 20.[83%] fetal losses

Ectopic pregnancy in noncommunicating rudimentary horn of uterus

Rudimentary horn ectopic pregnancy occurs very infrequently in gynecological practice. A case of rudimentary horn ectopic pregnancy, managed with salvage of the patient, is presented here in this report

Practice of peritoneal closure at cesarean delivery

To determine whether non-closure of visceral and parietal peritoneum at lower segment caesarean section has advantages over closure in terms of febrile morbidity endometritis, analgesic requirements, operative time and bowel activity. Department of Obstetrics and Gynaecology, Unit-II, Dow Medical College and Civil Hospital, Karachi. A prospective randomized trial of 100 women undergoing caesarean section, fifty women were randomized to norclosure group and fifty women were randomized to closure group. The incidence of febrile morbidity and analgesic requirement was greater in closure group. Operative time was also greater in-patients of closure group. Closure of peritoneum at lower segment caesarean section doesn't offer any additional advantage, rather is associated with more complications. Closure of the peritoneum should be abandoned at caesarean section