Maternal mortality in a tertiary care hospital

Death of a woman during pregnancy and child birth is an extremely tragic event. It is a waste of a precious life that leaves great feeling of grief and pain for the family and hospital staff and has devastating influence on the community overall. Maternal morbidity and mortality can be prevented by awareness of reproductive health in a community, availability, and utilisation of organised antenatal care, skilled intrapartum management and careful postnatal follow up. Objective was to analyse the pattern of maternal mortality over the period of five years in a tertiary level hospital receiving high risk referred patients from periphery. All patients admitted in Gynae 'A' Unit, Ayub Teaching Hospital from January 2006 to December 2010 were included in the study and number and causes of maternal deaths were noted. During these 5 years there were 78 maternal deaths out of 11,997 obstetrical admissions. There were 7,380 total births and 78 maternal deaths during the study period and Maternal Mortality Rate was 1,057/100,000. The main cause of maternal death was eclampsia and its complications [28.2%]. Eclampsia is the leading cause of maternal mortality in our setup. Proper and timely referral is an important measure to prevent it

Maternal morbidity and mortality due to primary PPH-experience at Ayub Teaching Hospital Abbottabad

Postpartum Haemorrhage [PPH] remains a significant cause of maternal mortality and morbidity like hypovolemic shock, anaemia, multi organ failure, consumptive coagulopathy, disseminated intra vascular coagulation [DIG], blood transfusion related complications and hysterectomy leading to loss of childbearing potential. The present study was conducted to determine the frequency of PPH and the associated maternal morbidity at the Department of Gynaecology Unit 'B', Ayub Teaching Hospital Abbottabad. The study was carried out in the Department of Obstetrics and Gynaecology Unit B of the Ayub teaching Hospital Abbottabad from 18[th] April 2006 to 17 July 2006. The study population included all cases admitted with primary PPH during the study period. For calculation of frequencies, the total number of deliveries in the setting during the study period was used. All subjects underwent a complete obstetrical clinical workup comprising of history, general physical examination, abdominal and pelvic examination, relevant laboratory investigations. The maternal condition was assessed and managed according to established hospital protocols which included both pharmacological and surgical intervention. All maternal complications were noted and recorded on pre-designed proformas. Data was entered and analyzed by computer. A total of 50 cases of primary PPH were recorded during the study period. The frequency of PPH was calculated as 7.1%. The major cause of PPH was uterine atony found in 29 [58%] cases, followed by cervical, vaginal and perineal tears in 12 [24%] cases. Initially all patients were managed pharmacologically followed by surgical intervention. Subtotal [haemostatic] hysterectomy was performed in 10 [20%] cases. Maternal morbidity was detected in 31 [62%] of cases; the major morbidities were DIC in 3 [6%] cases, Acute renal failure in 3 [6%] patients and shock in 2 [9.9%] cases and anaemia in 20 [90.1%] cases. The study concludes that the frequency of primary PPH in this setting is in keeping with globally cited frequencies. Other findings such as causes of primary PPH and maternal morbidity data also agree with most national and international studies on this topic

comparison of placental removal methods on operative blood loss

On an average 1 litre of blood is lost during Caesarean Section. Many variable techniques have been tried to reduce this blood loss. Many study trials have shown the spontaneous delivery of placenta method to be superior over manual method because of reduced intra operative blood loss and reduced incidence of post operative endometritis. The main objective of our study was to compare the risk of blood loss associated with spontaneous and manual removal of the placenta during caesarean section. Quasi Experimental. September 2004 to September 2005, a 13 months study at Islamic International Medical Complex Islamabad. This study was conducted at Department of Obstetrics and Gynaecology, Islamic International Medical Complex, Islamabad from September 2004 to September 2005. All Women undergoing elective or emergency caesarean section were included in the study. Exclusion criteria were pregnancy below 37 weeks, severe maternal anemia, and prolonged rupture of the membranes with fever, placenta praevia, placenta accreta and clotting disorders. Patients were allocated to the two groups randomly. Group A comprised of women in whom the obstetrician waited a maximum of 5 minutes till the placenta delivered spontaneously. In group B the obstetrician manually cleaved out the placenta as soon as the infant was delivered. The primary outcome measures noted were difference in haemoglobin of >2 gm/dl [preoperatively and postoperatively], time interval between delivery of baby and placenta, significant blood loss [>1000 cc], additional use of oxytocics, total operating time and blood transfusions. Data was analysed by SPSS. Statistical tests used for specific comparison were chi 2-test and Student's t-test. One hundred and forty-five patients were allocated to two groups randomly. Seventy-eight patients were allocated to group A and 67 patients allocated to group B. Mean maternal age, birth weight, and total operating time were the same in two groups, but blood loss as measured by a difference in haemoglobin of greater then 2 grams/dl was statistically significant. Significant blood loss [>1000 cc] and time interval between delivery of infant and placenta were also statistically significant between the two groups. Spontaneous delivery of placenta has significant reduction of blood loss as compared to manual removal at caesarean section

Septic induced abortions

Induced abortions are not infrequent in our community. Being the only tertiary level care hospital in Hazara division, Ayub Teaching Hospital frequently receives cases of induced abortions with complications attempted by inappropriately trained personnel. It was decided to study the frequency of such cases in our admitted patients, complications and their outcome in such risky situation. A cross sectional study was conducted from January 2006 to December 2007 in Gynae-B Unit, Ayub Teaching Hospital, Abbottabad. All admitted patients in the unit in the 1[st] trimester of pregnancy and handling outside the hospital were included in the study. In two years period total Gynae admissions were 1090. There were 152 [13.95%] cases of spontaneous 1st trimester abortions and 52 [4.7%] cases of induced abortions which are included in the study. Age range of the patients was between 20-45 years, with a mean of 35 years. Majority of the patients were grand multigravidas belonging to lower socioeconomic group and not using any contraception. Twenty patients [38.4%] presented with heavy per vaginal bleeding due to incomplete nature of the procedure. Twelve patients 23% presented in shock due to excessive per vaginal bleeding. Ten patients 19.2% had uterine perforation and intraperitoneal haemorrhage. Two patients 3.8% had gut injury associated with uterine perforation. Three patients 5.7% developed septicaemia due to uterine gangrene. Ten patients 19.2% had acute pelvic infection presented with pelvic abscess and acute pelvic inflammatory disease. Maternal motility in our study was 2 out of 52 [3.8%]. Induced septic abortions contribute significantly to maternal morbidity and mortality. Improving literacy rate in our female population and effective family planning should reduce its incidence. Different resources should be used to develop awareness of the hazards of induced abortions in the community

audit of primary post partum haemorrhage

Postpartum haemorrhage [PPH] is one of the leading causes of maternal morbidity and mortality .Its causes and risk factors are important for its prevention and management. Poor, unhealthy, high parity women delivering away from health facility are usual victims. The purpose of this study is to determine causes of PPH, risk factors, preventable factors and to assess treatment measures adopted. This retrospective study is carried out in Gynaecology 'B' unit of Ayub Teaching Hospital Abbottabad. All patients admitted with PPH or developed PPH within hospital from 1st Jan-31st Dec 2006 are included. Exclusion criteria were patients with bleeding disorders and on anticoagulants. Records of admissions, deliveries, caesareans, major and minor procedures and history charts were thoroughly evaluated for details. Details included age, parity, socioeconomic status, transportation facility, distance from hospital, onset of labours, birth attendant skilled/unskilled, evaluation of risk factors, duration of labour and mode of delivery. Patient's general health, anaemia, shock, abdominal and pelvic examination and laboratory findings were also taken in to account. Treatment measures including medical, surgical, blood transfusions were evaluated. Results: The most important cause was uterine atony, 96 [70.5%] and traumatic lesions of genital tract, 40 [29.4%]. Factors causing uterine atony were augmented labour 20 [20.9%], prolonged labour 21 [21.9%], retained placental tissues, 11 [12.5%], retained placenta, 11 [11.4%] Couvelliar uterus, 10 [10.4%], placenta preavia, 8 [8.3%], placenta increta, 7 [7.3%], chorioamnionitis 5 [5.2%], and multiple pregnancy, 2 [2.1%]. Risk factors, grand multiparity 70 [51.5%], antepartum haemorrhage 12 [8.9%], instrumental delivery 10[7.3%], previous PPH, 6 [4.5%], choreoamnionitis, 5 [3.6%], multiple pregnancy, 2 [1.5%], no risk factor, 21 [15.4%]. Socioeconomic status was poor [75] and lower middle class [61]. Induced labour, 33 [24.3%], augmented labour 62 [45.5%].Uterotonics used for prophylaxis in 30 [22%], for treatment of PPH, 106 [78%]. Patients delivered by traditional birth attendants 70 [51.4%], lady health workers 40 [29.4%] and doctors 26 [19.2%]. Uterine massage performed in 30 [22%], minor surgical procedures 33 [24.3%], manual removal of retained placenta, 11 [8%], hysterectomy, 50 [36.7%], and compression sutures were applied in 3 [2.2%]. Maternal deaths due to PPH were 6 [40%]. PPH can be prevented by avoiding unnecessary inductions/augmentations of labour, risk factors assessment and active management of 3rd stage of labour. It needs critical judgment, early referral and early resuscitation by birth attendant. There is room for temponade and compression sutures. Hysterectomy should be the last option