Use of follicular output rate to predict intracytoplasmic sperm injection outcome

Background: The measurement of follicular output rate [FORT] has been proposed as a good indicator for evaluating follicular response to the exogenous recombinant folliclestimulating hormone [rFSH]. This places FORT as a promising qualitative marker for ovarian function. The objective of the study was to determine FORT as a predictor of oocyte competence, embryo quality and clinical pregnancy after intracytoplasmic sperm injection [ICSI]

Materials and Methods: This prospective study was carried out on a group of infer- tile females [n=282] at Islamabad Clinic Serving Infertile Couples, Islamabad, Pakistan, from June 2010 till August 2013. Downregulated females were stimulated in injection gonadotropins and on ovulation induction day, pre-ovulatory follicle count [PFC] was determined using transvaginal ultrasound scan [TVUS], and FORT was determined as a ratio of PFC to antral follicle count [AFC]×100. Group I consisted of females with a negative pregnancy test, while group II had a positive pregnancy test that was confirmed with the appearance of fetal cardiac activity. Linear regression analyses of categorical variables of clinical pregnancy along with other independent variables, including FORT, were performed using SPSS version 15.0

Results: Pregnancy occurred in 101/282 women who were tested, recording a clinical pregnancy rate of about 35.8%. FORT values were higher in group II as compared to group I females [P=0.0001]. In multiple regression analysis, 97.7, 87.1, 78.2, and 83.4% variations were explained based on the number of retrieved oocytes per patients, number of metaphase II oocytes retrieved, number of fertilized oocytes, and number of cleaved embryos, respectively, indicating FORT as an independent predictor

Conclusion: FORT is a predictor of oocyte competence in terms of a number of retrieved, mature and fertilized oocytes. It also gives information about the number of cleaved embryos and clinical pregnancy rate

Near-miss obstetrical events and maternal deaths

To determine the frequency of near-miss cases, nature of near-miss events and mortality among obstetric patients. Cross-sectional, observational study. The study was conducted in the Obstetric Unit of Fatima Hospital, Baqai Medical University, from January 2006 to December 2006. Near-miss case definition was based on validated specific criteria comprising of five diagnostic features: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anemia. The main outcome measures were frequency and characteristics of near-miss cases, total hospital stay, high dependency unit/ICU stay and development of multiple organ dysfunction. Near-miss events and maternal deaths were described with respect to disease profiles. Mortality indices were determined for various disease processes to appreciate the standard of care provided for near-miss cases. The maternal death to near-miss ratio was calculated. There were 868 deliveries in the year 2006, 44 near-miss cases, 47 near-miss events and 6 maternal deaths. The maternal death to near-miss ratio was 1:7. The most common type of near-miss events were obstetrical haemorrhage, anemia and dystocia responsible for 51%, 21.2% and 14.8% respectively. Severe hypertensive disorders in pregnancy and infections accounted for 8.5% and 4.2% of near-miss events. Postpartum haemorrhage was responsible for 83.3% and infection for 16.6% of the maternal deaths. The mortality index was higher for infections [33.3%] than for haemorrhage [17.2%]. Organ system dysfunction/failure was diagnosed in 18.1% of near-miss cases. This study showed that for every 7 women who survived life threatening complications, one died. However, the underlying disease processes for near-miss and mortalities were almost same. Evaluation of the circumstances surrounding near miss cases could act as proxy for maternal deaths in the studied population

Complications of induced abortions

To determine the complications developed due to induced abortions. Descriptive case series. Department of Obstetrics and Gynecology, Fatima hospital, Baqai medical University Karachi, from January to December 2005. Records of patients admitted with induced abortion were analyzed retrospectively. Their presentation and complications were noted. Patients presented within 40 days of induced abortion were included in the study. While patients with spontaneous abortions or who were admitted after 40 days of induced abortion were excluded. During study period, total number of patients admitted was 124. Out of them 96 spontaneous abortions, 13 induced and 15 were threatened. The frequency of induced abortion was 10.4%. Out of 13 cases, 9 [69.2%] were married and 4[30.7%] were unmarried under the age of 20 years. Regarding parity 7[53.8%] were having >5 children. Traditional Birth Attendants performed abortions in 11[84.6%] of patients. Sepsis was the main complication developed in 7[53.8%] patients followed by uterine perforation found in 3 [23%] patients. Hemorrhage occurred in 2[15.3%] patients. Induced abortion caused mortality in 1[7.60%] patient. Induced abortions are a major cause of maternal complications. Education of traditional birth attendants to recognize the severity of complications and availability of family planning services can help to reduces morbidities and mortalities

Maternal mortality in a community based hospital

To determine the maternal mortality ratio, frequency of obstetrical causes and disease process leading to maternal mortalities over five years maternity services 2002-06 in a community based hospital. The study was conducted at Fatima Hospital, a tertiary care community based hospital, situated 20km away from Karachi city, covering the population of Gadap Area. The duration of study was from January 2002 - December 2006. All direct and indirect maternal deaths during pregnancy labor and perpeurium were included. The patients who expired after arrival were analyzed from their records. The reason for admission, disease process, cause of death and possible factors responsible for death were identified. The other information included age, parity, booking status, gestational age and relevant features of index pregnancy, along with the distance from hospital was recoded on proforma and analyzed by SPSS Version-11.0. There were total 3,287 deliveries and 2965 live births with 322 perinatal mortalities. Total 37 maternal deaths during five years reveals MMR = 1248 per 100,000 live births. The highest MMR = 2569 was recorded during the year 2004. Majority of the women who died [89.2%] were unbooked. The highest maternal mortality age group was 21-30 years in which 19 [51.4%] mortalities were observed during the entire study period except the year 2004. Out of 37 maternal deaths, 10 [27%] were primigravidas. Obstetrical hemorrhage was the most frequent cause followed by hypertensive disorders, sepsis and suspected pulmonary embolism. On arrival at hospital 4 [10.8%] of patients were dead. SIRS and MODS diagnosed in 14 [37.8%] and 17 [45.9%] of patients. Majority of maternal deaths 25 [67.5%] occurred within 24 hours after delivery. Obstetrical hemorrhage was the leading cause of maternal deaths. Community awareness, training of traditional birth attendants to recognize the seriousness of the disease and improving the referral system can reduce the maternal mortality

Congenital adrenal hyperplasia causing clitoromegaly

Congenital Adrenal Hyperplasia [CAH] is caused by congenital insufficiency of the enzyme 21 - hydroxylase [21-OHD] in the cortisol synthesis pathway. Because of the virilizing effects of androgens over-production, affected girls develop clitoral hypertrophy. Three patients with CAH are discussed below along with their surgical management and follow-up

Contraceptive knowledge, attitude and practice among rural women

To assess the knowledge, attitude regarding family planning and the practice of contraceptives among rural women. A cross-sectional observational study. The gynaecological outpatient clinic of Fatima Hospital, Baqai Medical University, Karachi, from July to December 2005. One-hundred women between the ages 15-45, living with their husbands and coming from rural area [villages] were interviewed. Women who were pregnant, had a child younger than 2 years, or had any medical disorder were excluded. Their knowledge, attitude and practice on contraceptives were evaluated with the help of a predesigned questionnaire. The other variables used were the age of women, parity and educational status. Descriptive analysis was conducted to obtain percentages. Out of 100 interviewed women with mean age of 29.7 years, 81[81%] had some knowledge about family planning methods. The media provided information of contraceptives in 52 out of 81 [64%] women. Regarding the usage of contraceptive methods, only 53 [53%] of the respondents were using some sort of contraception. Barrier method [condoms] was in practice by 18 [33.9%] and 12 [22.6%] of women had already undergone tubal ligation. The women using injectables and intrauterine contraceptive devices were 10 [18.8%] and 7 [13.2%] respectively. Six were using oral contraceptive pills [11.3%]. Positive attitude towards contraception was shown by 76 [76%] of them, while 41[41%] stated their husbands' positive attitude towards contraception. In the present study, there was a low contraceptive use among women of rural origin despite good knowledge. Motivation of couples through media and health personnel can help to achieve positive attitude of husbands for effective use of contraceptives

Drug induced hirsutism

Hirsutism is a symptom or sign, which may have more serious associations than cosmetic and psychological concern alone, such as adrenal hyperplasia and ovarian tumor, particularly if it develops well after puberty. Some medicines having androgenic activity may also cause this problem. Here, we present a case of a young unmarried girl who was given anabolic steroid for the treatment of dysmenorrhoea which resulted in hirsutism

Complete androgen insensitivity syndrome in AN X Y female

An 18 years old, unmarried girl, attending the Gynaecological outpatient department, with history of primary amenorrhea, presented an ultrasonography report which revealed absence of uterine contours in that patient. There was no history of cyclical pain. Patient had two step sisters, aged 13 and 10 [born of different father], out of whom the elder had started menstruating. On clinical examination, the height of the patient was 167.5 cm and she weighed 52 kg. She had welldeveloped breasts. Her pubic and axillary hairs were scanty. Patient was admitted for further investigations, which showed elevated serum gonadotrophins [FSH=21.9 miu/ml LH= 9:46 miu/ml] and testosterone levels [5.08 ng/ml]. The pelvic ultrasonography was repeated which showed absent uterus but gonads were present bilaterally. Barr bodies were absent on buccal smear examination and karyotyping revealed 46 XY chromosomes. Examination of the patient under anaesthesia was carried out which showed normal labia majora, minora and uretheral opening and a short vagina. Gonadectomy was performed and subjected to histopathological examination, histopathology report showed that the gonads were testicular tissue. Patient's postoperative period was uneventful. She was advised to use vaginal dilators to increase the length of vagina. Hormone replacement therapy was prescribed to prevent early osteoporosis. She attended OPD for regular follow-up, no complaint were reported by the patient during this period

Myasthenia gravis and pregnancy

A 33 years old multigravida lady presented at 8 weeks of gestation for booking, with a history of previous three caesarean sections. In 1995, her first pregnancy ended up in spontaneous abortion. The development of classical symptoms of MG during her second pregnancy and delayed recovery from nondepolarizing muscle relaxant [used for general anaesthesia] led to the suspicion of MG. The neonate also suffered from transient neonatal MG. Later on, she was investigated and found to have raised anticholinesterase receptor antibodies [117 nmol/L], cholinesterase level [4355 micro /L] and serum anti-DNA [3.9 I.V/ml]. Other antibodies including ANA, AMSA and AMA were negative. The treatment for MG started with an anti-cholinesterase agent in a dose of 60 mg daily. Thymectomy was carried out in 1998 for enlarged thymus gland and her symptoms further improved. Thereafter, the dose of anti-cholinesterase drug was reduced to half i.e., 30 mg daily during subsequent three pregnancies. The present pregnancy was supervised intensively by an obstetrician and neurologist. An elective C. section with bilateral tubal ligation was carried out on term under spinal anaesthesia. A male baby weighing 4 kg was delivered with an APGAR scores of eight at one minute and ten at five minutes. The patient continued her normal oral therapy before and after the operation. Her puerperium was uneventful