stitch in time, saves life; should B-Lynch suture be the first line surgical option for control of massive primary PPH due to refractory uterine atony? An experience at D.H.Q Hospital Faisalabad

Objective: to see the effectiveness of B-Lynch brace suture as first line surgical option to control massive primary postpartum hemorrhage due to uterine atony refractory to medical treatment

Study Design: quasi experimental

Place and duration of study: this research work was done in D.H.Q Hospital Faisalabad from 2002-2004. During the study period 21 women underwent B-Lynch Brace suture to halt bleeding resulting from refractory uterine atony. Data was collected in prospective manner on a specialized proforma from attending house officers and postgraduate trainee registrars. The B-Lynch technique was used. Postoperatively the patients were kept in high dependency area within labor room for 24-48 hours. Follow up was done in O.P.D after discharge

Materials and Methods: the women who had severe/ persistent primary postpartum hemorrhage due to uterine atony were initially resuscitated and simultaneously managed with ecbolics as per unit protocol [i-e; 40 units oxytocin in 1000cc Normal Saline infusion, inj. methergen [withheld women with specific contraindications for methergen], inj. F2 alpha in each uterine cornu, and per rectal misoprostol. However those women who remained unresponsive to the medical treatment, underwent B-Lynch Brace suture as first line surgical option

Results: the success rate was 85.7% [n18] in terms of control of hemorrhage and hysterectomy was averted in 95% [n20] of women. Whereas in two women it needed to be integrated with stepwise uterine de-vascularization procedures

Conclusion: B-Lynch suture is effective as first line surgical option to arrest postpartum hemorrhage due to refractory atonic uterus

Post-placental intrauterine contraceptive device at cesarean section

Objective: the objective of this study is to determine the efficacy of immediate post placental insertion of intrauterine contraceptive device [PPIUCD] at cesarean section in terms of expulsion and continuation

Study design: descriptive case study

Place and Duration of Study: department of obstetrics and gynecology, PMC and affiliated hospitals Faisalabad from 06/12/2012 to 05/06/2013

Material and Methods: a total of 146 patients were included in my study. The copper intrauterine contraceptive device [IUD] was placed at the time of cesarean section immediately after the delivery of placenta. Final outcome was observed at the end of six months at follow up visit and efficacy was labeled as per operational definition

Results: mean age of patients was 26.6+_4.5 years. Out of 146 patients, 98 [67.1%] patients were Para 1-3 and 48 [32.9%] were Para 4-6. At the end of six months expulsion of IUD were seen in 18 [12.3%] patients and 123 [84.2%] patients were willing to continue this method of contraception

Conclusion: immediate transecaesarean section PPIUCD is a safe, effective and acceptable method of contraception and should be offered to women undergoing cesarean section who are desirous of contraception

Frequency of different symptoms and clinico-pathological features of surgically managed adnexal masses

Objective: The objective of this study was to study the frequency of different symptoms, patient characteristics, clinical presentations and outcome in women who underwent laparotomy for adnexal masses suspected as ovarian tumors.

Methodology: Study Design: Observational descriptive study

Patients and Methods: From Jan 2012 to Dec 2012, 57 patients with palpable adnexal masses were admitted in Gynae unit II of DHQ Hospital Faisalabad. All those patients who underwent laparotomy for adnexal masses suspected as ovarian tumors, were included. 24/57 fulfilled the selection criteria. The demographic data of patients included [i-e; age, marital status, parity, blood group], personal and family history, presenting clinical symptoms, pre-operative ultrasound characteristics of adnexal masses, their per-operative gross appearance and finally histo-pathologic diagnosis

Exclusion Criteria: Patients with simple cysts on scan, who were managed conservatively and then discharged. All pregnant women [e.g; chronic ectopic, ruptured ectopic and those with intra uterine normal pregnancy but with an adnexal mass or cyst], and where data was not available or who were lost to follow up, were excluded from the study

Results: 42% [24/57] of women with palpable adnexal masses underwent laparotomy. On histopathologic examination 80% were benign and 20% were malignant. The majority of patients were in reproductive age group. 58% [14/24] were multipara, 29% [7/24] were nullipara, 12% [3/24] were single. Almost all [100%] patients were symptomatic at the time of presentation. 20% were postmenopausal, and the large adnexal mass turned out to be malignant ovarian tumor in 100% of postmenopausal women

Conclusion: Adnexal masses commonly affected the relatively younger women. Abdominal pain was the most common symptom. Ovarian malignancy was exceptional in younger groups but more frequently seen in postmenopausal women

Placenta accreta in placenta previa; frequency of previa with or without scarred uterus

To calculate the frequency of placenta accreta in placenta previa with or without scarred uterus and compare clinico demographic features of cases with or without placenta accreta.Cross sectional study. Department of Obst and Gynae Allied Hospital, Faisalabad from 1st June 2007 to 31st May 2008. 200 patients of placenta previa, 100 with history of previous cesarean section and 100 without history of previous C-section fulfilling inclusion criteria were taken. They were evaluated by history, examination and ultrasound noting placental location and type. Placenta accreta was diagnosed during delivery. Out of 200 patients, frequency of placenta accreta was significantly increased with history of previous C-section. It was 20% in patients with previous C-sections and 6% in patients without previous C-sections. Our data suggests that frequency of placenta accreta is greater in patients with previous C-section and its frequency increases with increasing number of C-sections especially with anterior and central placenta previa

Risky grand multiparas

Grandmultiparity has long been classified as constituting a high risk factor in pregnancy. The complications associated with grandmultiparity have been divided into ante-partum, intra-partum and the postpartum. Intrapartum complications most commonly thought to be associated with grandmultiparity are malpresentations, placental disorders, postpartum hemorrhage and uterine rupture. Concerted effort should be instituted for effective family planning initiatives and specialized antepartum and intrapartum management

Objective: To determine the frequency of intrapartum complications and mode of delivery in grandmultipara

Material and Methods: It is descriptive case series study conducted in department of obstetrics and gynaecology, Punjab Medical College and affiliated hospitals, Faisalabad from March 11, 2010 to September 10, 2010

Results: Grandmultipara women who fulfilled the inclusion criteria were studied for intrapartum complications and mode of deliveries. One hundred and thirty nine patients were included in my study. Mean age of the patients was 32.38 years. Mean gestational age for delivery was 37.06 weeks. Grandmultiparas had more intrapartum complications including malpresentation [19.4%], placental abruption [5.8%], placenta previa [8.6%], postpartum hemorrhage [6.5%] and ruptured uterus [1.4%]. Mode of delivery was also assessed and 59%, 7.9 %, 31.7% of patients had normal vaginal delivery, instrumental vaginal delivery and cesarean section respectively

Conclusions: It is concluded that in the developing countries the incidence of grandmultiparity is still high with a significantly increased risk of complications. Grandmultiparity should be considered high risk and needs active intervention by improving literacy, health care facilities, provision of safe and effective contraception and reproductive health status

PROM; expectant vs active management

PROM is not uncommon in pregnancy. It occurs in 10% of term pregnancies. At term about 75% of women will go into labour within 24 hours of rupture of membranes. At term there are two options, either wait for spontaneous onset of labour or immediate induction to establish labour. For induction of labour different kinds of drugs are used according to Bishop score. If Bishop score is favorable [>/= 6], oxytocin can be used. It decreases the risk of chorioamnionitis and is more satisfying for mother. To compare the immediate induction with expectant management in PROM at term with favorable cervix in terms of frequency of caesarean section. This prospective randomized controlled trial was conducted in the department of obstetrics and gynaecology, Punjab Medical College and affiliated hospitals, Faisalabad from 1st June to 30th November 2010. One hundred and twenty pregnant ladies were randomly divided into two equal groups. Odd numbers were placed in group 1 who were given expectant management for 24 hours for spontaneous onset of labour. Even numbers were placed in group 2, who were started immediate induction with oxytocin infusion. In my study overall age was 25.64 +/- 2.98. In expectant group mean age was 25.18 +/- 3.21 and in induction group mean age was 26.10 +/- 2.69. The rate of c-section in immediate induction group was 8.3% while in expectant group it was 11.6%. In my study there was no significant difference regarding rate of c-section in both groups [p= 0.543]. Both expectant and immediate inductions are common management options in women with PROM, but immediate induction was favorable approach for both mother and fetus. The later was more satisfying for mother and decreased risk of maternal and neonatal infection

Gestational diabetes; accuracy of glucose challenge test [GCT] for screening

To determine the Accuracy of GCT for screening of gestational diabetes in high risk population comparing oral Glucose Tolerance Test [GTT] as gold standard. Accuracy of GCT. Cross-sectional study. The study was conducted in outpatient department of Punjab Medical College and affiliated hospitals, Faisalabad. 207 patients. High risk women from outpatient department were recruited on the basis of inclusion and exclusion criteria after explaining pros and cons of procedure. These women were subjected to GCT and GTT. GTT was taken as gold standard test and results of GCT were compared with it. Main outcome measures recorded and results obtained. Out of 207 women, GCT truly diagnosed 24 women as having diabetes [true positive] and 175 women were found to have normal glucose metabolism [true negative]. GCT failed to diagnose 5 diabetic women [false negative] and wrongly diagnosed 3 normal women as diabetics [false positive] against gold standard GTT. So GCT has diagnosed Gestational diabetes mellitus with the sensitivity of 82.7%, specificity of 98.3%, positive predictive value of 88.8%, and negative predictive value of 97.2% and accuracy of 96.1%. GCT is a simple, easy, convenient and sensitive test that has no limitation for time or prior fasting for gestational diabetes screening

comparison of effectiveness of hydrostatic membrane sweeping with intracervical foley's catheter ballooning alone in pre induction cervical ripening

Induction of labor is a keystone in modern obstetricpractice and a safe procedure. The success ofinduction, however depends upon whether thecervix is ripe or unripe. Hydrostatic membranesweeping is a better option as this is more effectiveand can be used in situations where pharmacologicalmethods are contraindicated

Study design:Randomised clinical trial

Place and duration:Department of obstetrics and gynaecology unit II,Punjab Medical College and affiliated hospitals,Faisalabad from 15-12-2008 to 15-6-2009

Subjectsand methodology: 260 Patients each in group Aand B were randomly assigned for cervical ripeningby Foley's catheter ballooning alone [foley] andhydrostatic membrane sweeping [HMS] methodrespectively. The patients were reassessed at thetime of spontaneous expulsion of the catheter or atthe onset of effective uterine contractions or after 18hours of insertion. Amniotomy was done andsyntocinon infusion was started at this point. Theimprovement in Bishop score and mode of deliverywere studied

Results: 260 patients were allocatedeach in Group A and B. Improved Bishop score [>8]was achieved in 67.3% [175/260] of patients inGroup A and 76% [197/260] of patients in Group B.Out of 260 patients in Group A 70% [182] hadvaginal delivery and 30% [78] were delivered bycaesarean section. In Group B, out of 260 patients,78% [203] delivered vaginally and 22% [57] bycaesarean section. P value was 0.036

Conclusion:Both Foley's catheter ballooning and hydrostaticmembrane sweeping are effective methods ofcervical ripening however the later was moreeffective for improvement in Bishop Score and inachieving vaginal delivery

Postpartum hemorrhage; comparison of efficacy of ergometrine with misoprostol in prophylaxis in cesarean section

Worldwide PPH remains one of the most common cause of maternal mortality and is largely preventable maternal deaths mainly in low income countries. 80% of it occurs due to uterine atony and uterotonics can decrease the risk of uterine atony. Misoprostol has powerful uterotonic effect because it is well absorbed and has potential to be used more widely than would be possible with injectable uterotonics alone. The objective of this study is to compare efficacy of misoprostol with ergometrine in cesarean delivery for management of PPH. Randomized controlled trial. The duration of study was six months from 1/1/2010 to 30th/6/2010. Department of Gynae and obstetrics, DHQ hospital, Faisalabad. All patients fulfilling inclusion criteria were included in study and before cesarean section Hb was carried out and Patients were divided into two groups, GP[1], and GP[2]. GP[1] was given 800 ug MP per rectal just before starting cesarean Section and GP[2] was given intravenous ergometrine at delivery of head or anterior 2 shoulder. Blood loss was measured objectively after delivery of the baby with help of standard size kidney tray of 500cc and post operative Hb was Carried out on 3rd post operative day. 187 Patients were randomly allocated in GP[1] and GP[2] each. In GP[1], misoprostol was given 800 microg per rectal just before starting cesarean section and 13 patients [7%] out of 187 have blood loss more than 500ml measured by standard size kidney tray while in GP[2] intravenous ergometrine was given at delivery of the head and in this group 25 patients [13.5%] out of 187 had 2 blood loss more than 500ml, so misoprostol was found to be a better uterotonic than ergometrine for prevention of PPH. On the third post operative day Hb was carried out and in GP[1] 13 patients [7%] out of 187 had their Hb less than 9 g/dl while in GP[2] 25 patients [13.5%] had Hb less than 9 g/d1. Mp is stable, cost effective and easily administrable drug and was found to be comparatively more powerful uterotonic than ergometrine for preventing uterine atony

Ectopic pregnancy medical management

To assess the effectiveness of systemic methotrexate for treatment of unruptured ectopic pregnancy. Ectopic Pregnancy is pregnancy that occurs in any location other than the uterus. 95% to 98% are tubal ectopics, but the number of ovarian, abdominal and cervical implantations is rising as does the number of heterotopic pregnancies. Prospective experimental study. DHQ Hospital affiliated with Punjab Medical College Faisalabad. Jan-2009 to Dec-2009. A total of 45 women were admitted with diagnosis of extrauterine pregnancy. But only 10 women fulfilled the criteria for medical management. Out of these 80% patients required no surgical intervention. However 20% needed surgery. 60% patients suffered from lower abdominal or pelvic pain. 20% required 2nd dose of methotrexate. Average IJ-hCG resolution time was 35 days. With early diagnosis and proper selection criteria adoption, medical treatment of ectopic pregnancy with systemic methotrexate is an effective and safe alternative to surgical interventions

Asymptomatic bacteriuria among pregnant women

Objective: To determine the prevalence of asymptomatic bacteriuria [AB] during pregnancy

Study Design: Non interventional, cross sectional study

Place and Duration of Study: Department of Obst. and Gynae DHQ Hospital Faisalabad from May 2010 to July 2010

Materials And Methods: A total of 400 consecutive pregnant women were recruited for this study. All subjects were clinically identified to have no signs and symptoms of UTI. Clean catch midstream urine sample was collected from each patient into sterile container. The urine samples were examined microscopically and by cultural method

Socioeconomic Status and Education: Socioeconomic status is defined by key demographic and economic characteristics [reported in Government of Pakistan Economic Survey of Pakistan-2001-2, Islamabad, Ministry of Finance, June [2002].The most important variable describing and classifying SES was annual house hold income [US$<500 = Low, US$500-1000 = Middle]

Result: A total of 20 [5%] were positive for significant bacteriuria. Significant relationship was found between ASB with ages, parity and socioeconomic status. With regard to age, 5 [25%] women were below 25yrs 11[55%] between 25-35 and 4[20%] were above 35yrs. Regarding parity, 4[20%] were primigravida and 16[80%] were multigravida. As far as socioeconomic status is concerned 12 [60%] belong to low socioeconomic class and 8[40%] from middle. No significant relationship was determined between AB and gestational age and diabetes

Conclusion: Asymptomatic bacteriuria is not uncommon among antenatal patients. Routine urine cultural test should be carried out on all antenatal patients in order to identity any unsuspecting infection

Predisposing factors, maternal and perinatal outcome

Transverse lie is dangerous not only to fetus but may endanger the life of mother if timely intervention is not done. Good antenatal care is of tremendous importance for proper management of transverse lie. 1]. To determine the predisposing factors to transverse lie. 2]. To find out maternal and perinatal outcome in transverse lie. Facts were analyzed to find out the avoidable factors which make the maternal and perinatal outcome worse. Gynae and obstetric unit-II DHQ Hospital Faisalabad. It was a descriptive study. Six months from 15th September, 2006 to 15th March, 2007. Sixty cases of transverse lie were included in this study. These sixty patients were analyzed in great details, regarding predisposing factors, clinical features, intrapartum and postpartum management including the maternal and perinatal outcome. Predisposing factors were found in 42% of the primpara but in only 34% of the multipara. The mode of delivery was surgical and lower segment caesarean section was undertaken in 80% of cases. Maternal outcome in order of frequency were difficult surgery in 23.3%, obstructed Labour in 15%, delayed recovery from anaesthesia in 3.3% and uterine rupture in 1.6%. Fetal outcome in order of frequency were intrauterine death in 18.3%, hand prolapse in 20% and cord prolapse in 8.9%. Known predisposing factors to transverse lie withstand a closer and more accurate assessment of their incidence. The maternal and perinatal outcome can be improved by early diagnosis during antenatal care and hospital delivery, without any delay

Maternal mortality; a neglected tragedy

More than half a million maternal deaths occurred worldwide each year and 98% of these are in developing world. The objectives of the study were to calculate maternal mortality rate and determine the major causes of maternal mortality. A prospective study. Department of Obstetric and Gynaecology Unit-I, Allied Hospital, Faisalabad from 01.01.2002 to 31.12.2002. All maternal deaths during this period were included after taking detailed history and examination. There were total 25 maternal deaths and Maternal Mortality Rate [MMR] was 557/100,000 live births. The main causes were hemorrhage, septicemia and eclampsia. To achieve the objective of reduction in MMR, we must enhance emergency obstetric care with the adoption of the fast referral system particularly in the far-flung rural areas of Pakistan