Effect of metformin alone compared with metformin plus simvastatin on polycystic ovarian syndrome in Pakistani women

Objective: To determine the efficacy of metformin alone versus metformin plus simvastatin for treatment of polycystic ovarian syndrome [PCOS]

Study Design: Randomized controlled trial

Place and Duration of Study: Maternal and Child Health Centre, Unit II, Pakistan Institute of Medical Sciences [PIMS], from November 2014 to April 2015

Methodology: One hundred and eight patients [108] were randomly divided into metformin group [n=54] and metformin plus simvastatin group [n=54], detailed clinical history, including menstrual details, was taken with thorough examination performed. Baseline ultrasound was performed to evaluate ovarian size and these were considered enlarged with volume >10cc or with >12 follicles in any one ovary. Blood samples were taken at baseline and after three months of therapy to determine the LH/FSH ratio and lipid profile. Efficacy was defined as >15% decrease in the baseline values

Results: The mean age of patients was 28.82 +/- 7.18 years. Mean BMI of the patients was 22.41 +/- 1.55 Kg/m[2]. Efficacy was achieved in 66.7% patients with metformin alone, while in 92.6% with combination medication [p=0.001]

Conclusion: The combination of metformin plus simvastatin is more efficacious as compared to metformin alone for management of females with PCOS

Impact of multidisciplinary care in gynecological cancer patients

Objective: To determine the impact of multidisciplinary care in Gynecological cancer patients through multidisciplinary meetings [MDM] at MCH centre, Pakistan Institute of Medical Sciences [PIMS], Islamabad

Study Design: A pre and post intervention comparative study

Place and Duration of Study: The study was conducted at MCH centre, PIMS and Nuclear Oncology and Radiotherapy Institute, Islamabad from 1[st] April 2009 to 31[st] Mar 2010

Material and Methods: MDM is a regularly scheduled meeting of core and limited team members for the purpose of prospective treatment and care planning of newly diagnosed cancer patients. It was started in 2009 in order to improve the management of the cancer patients according to the international recommendations. In a total of 1 year study period 24 meetings were held. The major audit tool was the documentation of the meeting and its outcomes, patient communication and record of the Nuclear Oncology and Radiotherapy Institute of Islamabad [NORI]. A postgraduate student was deputed for documentation

Results: The study identified that MDM helped in achieving many of the best practices of international recommendations which include team approach to treatment planning as well as to care provision, throughout the complete patient pathway. The workload almost doubled as regards the surgery and outdoor cancer claims. There was a shorter delay to first seen in the cancer clinic and shorter duration from diagnosis to treatment. Team members were present in 90-100% of the meetings

Conclusion: MDM has swiftly improved the quality of care and follow up of patients with gynecological cancers and should be conducted at all tertiary care hospitals. Problems of access to high quality and timely care of poor patients in public sector should be addressed as poor patients are not compliant to timely follow-up

Manual vacuum aspirator: a safe and effective tool for decentralization of post miscarriage care

To compare the efficacy and safety of Manual Vacuum Aspiration [MVA] performed as outpatient versus inpatient procedure in terms of success rate, blood loss, hospital stay and procedure related complications. A quasi-experimental study. Maternal and Child Health Centre [MCHC], Unit-I, Pakistan Institute of Medical Sciences [PIMS], Islamabad, from December 2009 to December 2010. Cases with early pregnancy failure [incomplete, missed and an embryonic] at gestational age less than 12 weeks were allocated to MVA as outpatient or elective procedure performed in the operation theatre. Studied variables were noted as above. A total of 177 women were eligible for study, out of whom 78 underwent MVA as outpatient procedure and 99 as indoor procedure. The baseline characteristics were comparable in both groups except significantly high multipara in the indoor group. Complete evacuation was achieved in 96.1% in outpatient vs. 79.7% in indoor cases [p=0.001]. Outpatient group had a shorter hospital stay [median 3 hours, IQR-1 vs. 10 hours, IQR-4; p < 0.001], though the median hospital cost was less but statistically insignificant [Rs. 800, IQR-25 vs. 735, IQR-1265; p=0.728]. Blood loss was comparable in both groups [median 60 ml, IQR-20 vs. 60 ml-IQR-30; p=0.350]. There were two uterine perforations noted in the inpatient group [2.02%] vs. none in outpatient setting. Outpatient based manual vacuum aspiration is a safe and effective tool for management of early pregnancy loss. A decentralized approach proved useful in reducing hospital stay

Informed consent for surgery: do our current practices conform to the accepted standards?

A qualitative investigation was undertaken to determine and analyse the pattern of existing practices regarding informed consent for surgery at PIMS, Islamabad. Adult postoperative patients who had undergone surgical interventions were randomly selected face-to-face with the help of a team of junior doctors. A questionnaire was employed for data collection and the responses of the patients to the questions regarding various attributes of the consent process were analysed. Overall inadequacy existed in the prevailing practices. There is a need to revisit the consent related practices and make the process more informed and adequate. Instead of taking it as a casual formality, our doctors should regard it as an equally important exercise equivalent to other components of care such as the surgery itself

Efficacy and safety of 12 hours versus 24 hours maintenance therapy of magnesium sulphate in patients with severe pre eclampsia

To determine the efficacy and safety of 12 hour magnesium sulphate maintenance therapy in management of severe pre eclampsia by comparing it with 24 hours standard magnesium sulphate maintenance therapy. Randomized control trial. MCH Centre PIMS from November 2011 to April 2012. All patients with severe preeclampsia [blood pressure of 160/110 mm of Hg or more, proteinuria 2+ on dipstick] or signs and symptoms of impending eclampsia were included in the study. After receiving the loading dose, patients were randomly assigned to 12 hours maintenance therapy of magnesium sulphate in group A versus 24 hours therapy in group B.The main Outcomes measures included: frequency of occurrence of fits, side effects of magnesium sulphate [major and minor], degree of rise in serum uric acid, SGOT and proteinuria, maternal complications and neonatal outcomes. Of 104 patients 52 patients were assigned to each group. Both groups were comparable with regards to maternal age, parity and gestational age. In group A [12 hours regimen] had higher baseline levels of S.uricacid, SGOT, proteinuria versus 24 hours of administration of magnesium sulphate [p=0.15]. Regarding outcome, none of patients in either group had eclamptic fit, conveying that 12 hour magnesium sulphate therapy was equally effective in term of prevention of eclampsia as 24 hours magnesium sulphate therapy. On the other hand group B had significantly higher frequency of minor side effects of magnesium sulphate [nausea, flushing] [p=0.09], compared with 12hours regime. No difference was found among 2 groups in terms of major side effects of magnesium sulphate [respiratory depression, renal failure],occurrence of eclamptic fits, maternal complications and neonatal outcomes. 12 hours maintenance therapy is equally effective in prophylaxis of eclamptic fits and maternal complications, as 24 hours maintenance therapy in patients with severe pre eclampsia and is associated with lesser side effects than 24 hours regime. Large scale studies are however required for generalization of results.

Association of maternal anthropometry with the neonatal birth weight in 3rd trimester of normal pregnancy

There is scarcity of data from Pakistan, which looks at the relationship of maternal nutritional status with the neonatal birth weight The objective of study was to investigate association of increase in the neonatal birth weight with maternal height and weight, in 3rd trimester in normal pregnancy. The study was conducted between the months of April-November 2007 at Gynecology and Obstetrics Unit of Pakistan Institute of Medical Sciences, Islamabad. This Descriptive case series included a total of 118 patients who were selected by consecutive sampling. Dietary history was taken by a semi structured Food Frequency questionnaire at the time of registration and 24 hours dietary recall was conducted at least three times from time of registration until the last visit before pregnancy and mean dietary intake for third trimester was calculated. Differences between group means were calculated by Student's t-test. Regression analysis was used to examine the trends between neonatal birth weight and the maternal dietary intake including energy, protein, carbohydrates and lipids. Energy consumption of the pregnant women was 2168.89 Kcal/day during the third trimester of pregnancy. Maternal energy intake showed a highly significant [P = 0.007] increase in the birth weight of the neonates. Neonatal birth weight was positively associated with increasing maternal height [p=0.02] as well as increasing maternal weight gain [P=0.008]. No significant difference was observed between the mean maternal energy consumption [kcal/day], maternal weight gain in the last trimester [g/wk], and neonatal birth weight [g] between the pregnant women belonging to the different categories of Body Mass Index and mean upper arm circumference. Maternal nutritional status is positively associated with the neonatal birth weight. Expecting mothers and young girls nutritions must be given special attention to ensure delivery of a healthy and a normal child

Low birth weight and relationship with maternal dietary habits during third trimester of low risk pregnancies in a hospital based study in Pakistan

The study is conducted to observe the relationship of maternal diet in third trimester of pregnancy with the neonatal birth weight, in the women at a low risk of delivering low birth-weight neonates. This hospital based follow up study was conducted during the months of April-November 2007 at the Gynaecology and Obstetrics Unit of Pakistan Institute of Medical Sciences, Islamabad. Pregnant women with low risk of delivering low birth weight neonates were registered at 26 weeks of pregnancy, by employing consecutive [non-probability] sampling technique. Dietary history was taken by a semi structured Food Frequency questionnaire and 24 hours dietary recall at the time of registration. Written informed consent was obtained. Thirteen percent of women with normal pregnancies delivered low birth weight neonates weighing <2500 grams [including preterm and full term neonates]. The women delivering low birth weight neonates had significantly lower consumption of calories [P= 0.0002], carbohydrate [P=0.008], and lipid [P=0.00005] during the third trimester. In addition the mean maternal weekly weight gain and maternal hemoglobin concentration was also significantly lower in the women who delivered LBW neonates. The frequency of total protein, meat, carbohydrates and fruits consumption per week, calculated from food frequency questionnaire conducted at the start of third trimester was also lower in the women who delivered LBW neonates. The consumption of soft drinks and tea per week was higher in the women who delivered LBW neonates, although this finding was not statistically significant. This study suggests the importance of good maternal nutrition during pregnancy for the optimal newborn weight

Predictive accuracy of intrapartum cardiotocography in terms of fetal acid base status at birth

To find out the predictive value of intrapartum Cardiotocograph [CTG] in terms of fetal acid base status at birth in women undergoing emergency caesarean section for a suboptimal CTG trace. Observational study. At the MCH Centre, Pakistan Institute of Medical Sciences, Islamabad, from June 2004 to July 2005. All women undergoing emergency caesarean section for a suboptimal intrapartum CTG were recruited in the study. Immediately after the delivery of the baby a segment of umbilical cord was doubly clamped at a distance of 10 cm, and 2 ml of arterial cord blood was taken in a heparinized syringe for arterial blood gas indices analysis. All CTG tracings were reviewed using FIGO guidelines and compared for fetal arterial blood gas indices. Of the 57 patients who underwent cesarean section due to suboptimal CTG, 51 [89%] had suspicious trace while 6 [11%] had pathological trace. Positive predictive value of CTG was 18% for fetal hypoxia, 21% for fetal hypercarbia., 26% for fetal acidosis and 37% for base excess. Predictive value of suspicious trace for similar blood indices was 13%, 13%, 17% and 35% respectively. For pathological trace, predictive value was 50%, 83%, 100% and 66% and respectively. Based on the results, it is concluded, that the suspicious CTG trace has low predictive value in terms of fetal acid base status at birth and needs to be complemented with other diagnostic modalities before undertaking any operative intervention. Pathological CTG on the other hand is highly predictive of fetal acidosis at birth warranting immediate intervention

External cephalic version with salbutamol-Success rate and predictors of success

To determine the success rate of External Cephalic Version [ECV] with 0.25 mg Salbutamol in singleton term breech and to identify the predictors of success. Quasi experimental study. Mother and Child Health Centre, Pakistan Institute of Medical Sciences, Islamabad, from January 2000 to March 2005. Women, presenting with uncomplicated breech, between 37-40 completed weeks gestation, underwent ECV in day care ward. Fifteen minutes before the procedure, injection salbutamol 0.25 mg was administered subcutaneously. Cases with contraindication to ECV or Salbutamol injection were excluded from the study. The outcome measures included success rate of ECV [in terms of conversion from breech to cephalic presentation at the completion of procedure confirmed through ultrasound], association of maternal and fetal demographic characteristics with successful version and adverse effects related to the procedure in terms of fetal bradycardia, ante-partum still birth, antepartum hemorrhage and preterm labour. Rate of reversion to breech and drug-related side effects were also recorded as secondary outcome measures. Chi-square test was used for categorical variables and independent sample t-test for continuous variables. Of the 101 ECV procedures, 41 [40.5%] were successful. Success rate was significantly lower in nullipara [p=0.01] and with AFI 7 cm or less [p=0.04]. No significant association was found between success rate and gestational age [p=0.35] or fetal birth weight [p=0.57]. None of the patient suffered from serious maternal complications. Salbutamol related minor effects [tremors, anxiety and palpitations] were observed in 36 [35.6%] patients. Fetal tachycardia was seen in 17 [16.8%], reversible fetal bradycardia in 3 [2.9%] and intractable fetal bradycardia in one patient. External cephalic version with 0.25 mg Salbutamol was safe and a feasible option in term breech presentation in this series. Administration of tocolytic agent improved the success rate and reduced complication rate of the procedure. Major determinants of success were amniotic fluid index and parity

Impact of reduced prenatal visit frequency on obstetric outcome in low risk mothers

To determine an association between reduced prenatal visit frequencies and pregnancy outcome in women, found to be at low-risk of obstetric complications at initial prenatal visit. Prospective cohort study. Mother and Child Health Center, Pakistan Institute of Medical Sciences, Islamabad. from January to December 2002. The hospital case records of 1290 women, who were found to be at low risk of obstetric complications at their first prenatal visit. Prenatal visits were categorized into '<3', '3-6' and ' >/= 7 visits groups'. ' >/= 7' visits were taken as controls. The main outcome measures were peripartum maternal complications, obstetric interventions and perinatal outcome. The median number of prenatal visits was four, [range 1-14; lower quartile 2, upper quartile 6]. Women with less than 3 prenatal visits had significantly higher risk of antepartum complications, low birth weight neonates [<2500 grams], pre-term deliveries, neonatal morbidity, and peri-natal mortality. [OR: 2.58, 2.66, 6.3, 1.57 and 2.2 respectively]. However, they were at equal risk of obstetric interventions and postpartum maternal morbidity. No significant difference was found between 3-6 visits and >/= 7 visits group, except significantly higher risk of preterm deliveries in the former group [OR: 2.84]. Less than 3 prenatal visits were associated with significantly higher incidence of prenatal feto-maternal complications and low birth weight babies compared to 7 or more visits but were at equal risk of obstetric interventions and postpartum maternal morbidity. The obstetric outcome of 3-6 visits group was similar to 7 or more visits group except considerably higher incidence of preterm deliveries in the former group

Advanced abdominal pregnancy- a diagnostic and management dilemma

Advanced abdominal pregnancy is a complex condition demanding challenging management. High index of suspicion may reduce the diagnostic error. Management varies from patient to patient. Expectant management is a feasible option in a well-equipped tertiary care hospital in case of alive viable fetuses. This evidence-based report describes the author's experience of managing a series of advanced abdominal pregnancies at 24 weeks or more of gestation

Spontaneous pre-labour rupture of membranes [PROM] at term

A randomized prospective study involing 152 women with pre labour spontaneous rupture of memberanes at term was conducted over a period of three years [from 1st October 1993 to 30th September, 1996] at PIMS Islamabad. Out of these, 80 women were managed conservatively while 72 were managed actively. Comparison of two groups showed that out of 80 consevatively managed patients 65 [81.3%]went into spontaneous labour within 24 hours. There were lesser number of caesarean sections [10% vs 29%]in this group and lesser number of forceps deliveries [3.4% vs 29%]. Fewer women required analgesia [48.7% to 70.8%]. Mean number of vaginal examination was lesser [3.38% vs 4.64%]. Mean duration of second stage was shorter in this group [26.25 minutes to 42 minutes], although mean duration of 1st stage was similar in the two groups. Mean Apgar score [A/S] was higher in conservative group 9/10 vs 7/10.while mean 5 minutes A/S was compareable in two groups. Maternal febrile morbidity was lower in conservatively managed women [9.5% vs 25%]. Neonatal mobidity was also lower in this group[0% to 4%], there was no neonatal or maternal mortality in either of the two groups