Sacrohysteropexy performed as uterus conserving surgery for pelvic organ prolapse: Review of case files

Objective: To assess the outcome and safety of sacrohysteropexy as uterus conserving surgery for pelvic organ prolapse in young women and to assess patients' satisfaction with the procedure

Methods:This is a case series of patients operated at Sind Government Lyari General Hospital and Civil Hospital Karachi, between January, 2007 to October, 2015. Data of the patients who had sacrohysteropexy were reviewed. Complications during surgery and post-operative period including haemorrhage, visceral injury, paralytic ileus and peritonitis were studied. Success of procedure, need of blood transfusion, hospital stay and condition on discharge and six weeks follow-up were noted. Data were analyzed using SPSS version 16. Mean +/- SD was calculated for numerical, while frequencies were computed for categorical variables

Results:Data of 60 patients were reviewed. Early post-operative success was 100%. Duration of surgery was less than two hours in 57 [95%] patients. Blood loss was negligible in majority of cases. Out of all 60 cases, 52 [86.7%] did not suffer any complication. One patient had ureteric injury, while one patient sustained bowel injury. Two patients had paralytic ileus. Four patients suffered from abdominal wound infection. All patients were managed satisfactorily. Mean duration of stay in hospital was four days. Upon follow up 96.7% patients were satisfied with results of operative procedure. Sixteen [26.7%] patients complained of backache on follow-up visit

Conclusion:This review concludes that sacrohysteropexy was successful in all cases in early post-operative period. It is a safe procedure and should be considered as an option for the treatment of pelvic organ prolapse in young women, in whom uterine conservation is required

Frequency and risk factors of low birth weight in term pregnancy

Objective: To determine frequency of Low Birth Weight [LBW] at term and to determine frequency of various associated risk factors

Methods: This cross-sectional study was conducted in Department of Obstetrics and Gynaecology Layari General Hospital and Dow University of Health Sciences Karachi between January 2007 to July 2008. Women with singleton pregnancy of 37 and above completed weeks were identified. Those women who gave birth to babies with less than 2500gm were recruited in the study. In all those patients who gave birth to LBW babies risk factors were assessed. The variables including age, parity, booking status, maternal weight and height, socioeconomic condition, smoking, fetal gender and birth weight were noted on a questionare. The data was analyzed on SPSS Version 15. Frequency of LBW and its associated risk factors were determined

Results: During study period 10.6% patients delivered LBW babies. Antenatal care was not received in 67% patients. Parity was less than three in 87%. In 26% of patients maternal weight was less than 50 kg and in 37% patients with LBW, maternal height was less than five feet. Majority of patients were anaemic [72%] including 20% with haemoglobin< 7 grams

Conclusion: LBW is associated with a group of factors which may be regarded as high risk factors. These include low socio economic status, anaemia, primiparity, short maternal height and less than average weight

Assessment of factors associated with practice of breast self-examination in a tertiary care health setting in Karachi

Objectives: [1] To determine the knowledge, attitude and practice towards breast self-examination [BSE] in tertiary care health setting in Karachi

[2] To assess factors associated with practice of BSE

Study Design: Cross sectional study

Place and Duration of Study: This study was carried out at the Dow University Hospital, Dow International Medical College and Dow Medical College / Dow University of Health Sciences Karachi from July to December, 2014

Materials and Methods: Study participants were medical students, interns, residents, consultants, as well as female patients and their lady attendants visiting General Surgical Out Patient Department. A questionnaire was developed including demographic details, knowledge about BSE, attitude towards and practice of BSE

These questionnaires were filled in by interns and residents of Department of General Surgery

Interviews were done in privacy after taking verbal consent

Data were entered and analyzed using SPSS version 16. Categorical variables about knowledge, attitude and practice are presented as frequencies. Predictors of BSE ie., age groups, level of education, occupation, income, marital status, personal history of benign breast disease and family history of breast cancer are also presented as frequencies

Their association with ever practice of BSE is determined by using chi square test

Results: Total of 729 women were interviewed to achieve a sample size of 500 positive responders, who had heard about BSE, which was 68.6%. Further questioning was done from these women

Majority of participants were young, 74% being less than 30 years of age. Around half of them were graduates and 21% were post-graduates

Sixty four percent respondents belonged to medical profession, while 22.2% were housewives and 13.8% had other professions

Majority belonged to high income group. 61.4% were married and 11.4% had family history of breast cancer. 29% respondents knew correct age to start BSE. Proposed frequency was stated correctly by 49.6%, appropriate time by 42.6%. Around 42% women said they knew how to perform and 36% could verbally explain the procedure correctly. More than 96% women thought that BSE was useful and should be practiced. Only 39.2% women claimed that they practiced BSE, while just 63 of the total 500 women interviewed, were doing it regularly

Level of education, profession, income, marital status and family member with breast cancer were found to be significant factors associated with BSE practice

Conclusion: Although overall awareness about BSE was average but correct knowledge and actual performance were poor. Medical profession, graduate level of education, handsome income, married status and family history of breast cancer were associated with BSE practice

Unplanned vaginal birth of singleton breech presentation at term

Objective: to determine the perinatal outcome in unplanned term breech vaginal deliveries

Study design: descriptive case series

Place and Duration of Study: department of Obstetrics and Gynaecology Unit I, Dow Medical College and Civil Hospital, Dow University of Health Sciences Karachi, from November 2014 to October 2015

Methodology: data of all the women with singleton pregnancy and breech presentation, gestational age between 37 to 41 weeks, who underwent breech vaginal delivery, were collected. Variables studied included maternal age, parity, gestational age, type of breech, reason for conducting breech vaginal delivery, maternal complications, neonatal status and complications

Results: total births during the study period were 3,932. Total patients presenting with breech were 172 [4.37%] and those presenting at term were 143 [3.6%]. Out of these, 54 [37.8%] patients underwent breech vaginal delivery. Overall frequency of breech vaginal delivery of patients at term was 1.37%. Mean maternal age was 26.87 year, majority were multiparous and none was beyond 40 weeks of gestation. There were no maternal complications in 48 [88.9%] patients. Mean birth weight of newborn was 2.75 kg and 63% were females. Eight babies were born dead, of whom 7 arrived with absent fetal heart sounds. The 5 minute APGAR score was less than 7 in 22% cases. There were two neonatal deaths in this group

Conclusions: fifty-four breech vaginal births were conducted during the study period. Skills related to vaginal birth in breech presentation must be learned by all those who manage pregnant women

Paternal factors in spontaneous first trimester miscarriage

To determine whether paternal factors i.e., age, tobacco use and genital tract infection increase the risk for spontaneous first trimester miscarriage. This case control study was conducted in the Department of Obstetrics and Gynaecology, Unit V / IV, Dow Medical College and Lyari General Hospital, Dow University of Health Sciences, Karachi, Pakistan. Duration of study was two and half years, from Nov, 2007 to Apr, 2010. Inclusion criteria were pregnant women with age 20 - 35 years irrespective of parity. Exclusion criteria were known medical illness in either partner, induced abortion and recurrent miscarriages. Studied paternal factors were age, tobacco use and genital tract infection. Data was computed using SPSS version 16. Significance of paternal factors was determined by Logistic Regression Analysis. Total cases studied were 200, while there were 400 controls. Mean maternal age was 27.6 +/- 4.9 years in cases and 26.5 +/- 4.5 years in controls. Mean paternal age was 35.5 +/- 6.2 years in cases and 32.3 +/- 5.4 years in controls. Paternal age was > 35 years in 54.5% cases and 16.8% controls. Spearman Bivariate correlation revealed paternal age > 35 years [p=0.000] and genital tract infection [p=0.043] as significant factors. Only paternal age >35 years [p=0.000] remained significant in Final Model after entering into logistic regression. Paternal age beyond 35 years was found to be significantly related to first trimester spontaneous miscarriages

Osteopenia in the younger females

To find out the frequency of osteopenia in young females and compare the bone mineral density [BMD] in females of different age groups. Cross-sectional study. This study was conducted by the Department of Obstetrics and Gynaecology, Unit V, Lyari General Hospital during Dow University of Health Sciences Health Expo at Expo Centre, Karachi, held on October 12, 2009. All females visiting our stall were offered BMD testing, irrespective of age group and parity. Pregnant ladies were excluded. Age, marital status, parity and occupation were noted. BMD was tested using calcaneal quantitative ultrasound [BMD Sahara Hologic G 4262]. WHO criteria were used for defining BMD. Data was entered and analyzed using SPSS version 15. Chi square test was used to compare various groups. Results were considered significant if p value was <0.05. A total of 170 women were included in the study, with mean age of 37.89 +/- 12.6 years. BMD was found decreased in 64% of women of /= 45 years. Osteoporosis was more frequent in women with parity >/= 4. Non-working women were found to have lower BMD as compared to working women and students. Majority of young female population had osteopenia. Steps should be taken to address this problem at an earlier age so as to prevent its complications later in life

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

Efficacy and timing of single dose dexamethasone as prophylactic antiemetic in major surgeries

To determine the efficacy of single dose intravenous dexamethasone, administered one hour before surgery as prophylactic antiemetic. Single blinded, randomized, placebo controlled, interventional study. Usman Memorial Hospital Karachi, from January 2006 to June 2008. Patients admitted for elective general and gynecological surgery, having ASA I or II class were selected. They were randomly allocated to receive either 2 ml [8 mg] dexamethasone or 2 ml of normal saline, one hour before surgery. Surgery was performed under general anesthesia by a single anesthetist. Wound site was infiltrated with 20 ml of 0.5% bupivacaine. Injection ketorolac 30mg I/V was given prior to extubation and 30 mg I/V twice daily thereafter. Supplemental analgesia was provided with injection nalbuphine 10 mg diluted and supplemental anti emetic used was dimenhydrinate 50 mg I/V as required. Episodes of nausea and vomiting and drugs used were recorded on case files by nurse or doctor in the post-operative ward for 24 hours, who were blinded to pre-operative drug used. Any adverse events were also noted. Data was entered and analyzed using SPSS version 15. A total of sixty female patients were enrolled. They were divided into two groups, thirty in each [test group and placebo group]. Mean age of the patients was 42 years in both the groups. 61.7% patients had cholecystectomy, 15% had herniorrhaphy, 16.7% underwent abdominal hysterectomy and 6.6% had benign ovarian cystectomy. Duration of operation and anesthesia were comparable in both the groups. In the entire 24 hours period after surgery nausea occurred in 30% patients in test group A as compared to in placebo group B 77% [p=0.000], while vomiting in10% of test group versus 40% of placebo group [p=0.007]. Timed observations revealed that nausea occurred in 23% versus 70%, 10% versus 30% and 0% versus 6.7% in the first 6 hours, 6 - 12 hours and 12 - 24 post-operative hours respectively. Similarly vomiting occurred in 6.7% versus 40%, 0% versus 6.7% and 3.3% versus 3.3% patients. The number of episodes of nausea and vomiting were significantly reduced in the test group as was the need for supplemental antiemetics. Dexamethasone given as single I/V injection of 8 mg one hour before surgery is an effective drug for prophylaxis of post operative nausea and vomiting

Impact of maternal obesity on pregnancy outcome

To determine the frequency of overweight and obese pregnant women and to determine maternal and perinatal outcome in women with high pre-pregnancy body mass index [BMI] case Control study Private Maternity Home at Karachi, from January 2006 to April 2008. We included patients with parity between 0 to 4, booked before 10th week of pregnancy. They were followed regularly and delivered in the same facility. Exclusion criteria were multiple gestation, grand multigravidae and previous 2 or more caesarean sections. BMI calculated at booking visit was used for reference. Patients with BMI >/= 23 kg/m[2] were selected as study cases, while those with BMI between 18.5 to 22.9 kg/m[2] were taken as controls. Maternal and perinatal complications were studied. Data were entered and analyzed using SPSS version 15. Means with standard deviation were calculated for numerical variables and proportions for categorical variables. Significance of difference was calculated using Student t test, Chi square test and Fisher exact test where applicable. Total number of deliveries were 864 during the study period. The BMI of 509 patients [58.9%] was >/= 23 kg/m[2] at booking visit, while 249 [28.8%] had BMI >/= 25 kg/m[2]. The number of patients excluded from study were 391 on the basis of exclusion criteria and / or incomplete data. The number of patients selected were 118 patients. An equal number of controls were selected for comparison. Family history of diabetes was present in 75.8% cases and 47.5% controls [p=0.000], while that of hypertension was present in 30.3% cases and 12.1% controls [p=0.002]. Impaired glucose tolerance was found in 10.1% patients [p=0.001], gestational diabetes in 4% [p=0.121], pregnancy induced hypertension in 10.1% [p=0.297], urinary tract Infection in 20.2% [p=0.014], vaginal candidiasis in 36.4% [p=0.000] and surgical wound infection in 2% [p=0.242]. 36.4% patients had caesarean delivery [p=0.064] while 11.1% had instrumental delivery [p=0.027]. Shoulder dystocia was encountered in 4% patients [p=0.121] and 7.1% [p=0.170] experienced postpartum hemorrhage. The macrosomic babies were 16.2% [p=0.024] and 6.1% were born preterm [p=0.756]. The burden of overweight and obese pregnant women is high. There is a strong association of high pre-pregnancy BMI with family history of diabetes and hypertension. It should be regarded as a high risk state because of its association with adverse obstetric outcome

Review of Caesarean sections at Lyari General Hospital

To determine the indications, morbidity and fetal outcome of Caesarean section in our set-up. Cross sectional study from July 2005 to December 2006. Gynaecology and Obstetrics Unit V, Sindh Govt. Lyari General Hospital, Karachi. All patients undergoing Caesarean section. Details of all cases including patients' characteristics, operative details, outcome and post-operative complications were recorded on a pre-designed proforma, and analyzed. A total of 202 patients underwent Caesarean sections during the study period, the Caesarean section rate being 22.3%. Amongst these 26.2% patients were primigravidae, 56% were non-booked and 96.5% patients had co-morbid conditions. Dystocia [18.8%] was the most common indication for primary section, followed by malpresentations [17%] and foetal distress [17%]. The frequency of repeat Caesarean sections was 42%, contracted pelvis being the commonest [37.2%] indication. Wound infection was the commonest maternal complication seen in 6.4% cases, while 13.3% babies suffered birth asphyxia. The perinatal mortality rate was 47.6/1000 births. Primary Caesarean section should be performed with clear justification. Pregnant women should be educated to seek antenatal care for early identification and management of problems. Unskilled birth attendants should be trained for early referral, as this will reduce maternal and perinatal morbidity and mortality

Outcome of utero-vaginal packing in primary postpartum haemorrhage in a teaching hospital

1: To determine the effectiveness of utero-vaginal packing [UVP] to control primary postpartum haemorrhage [PPH] due to atonic uterus. 2: To determine the complications of UVP during six weeks following the procedure. Quasi-experimental study This study was conducted in the Department of Obstetrics and Gynecology, Kulsoombai Valika Social Security Hospital, Karachi, an affiliated hospital of Hamdard College of Medicine and Dentistry, between January 1999 to December 2004. UVP was performed when conventional methods had failed to control bleeding from an atonic postpartum uterus. Study patients were identified according to pre-set inclusion and exclusion criteria. UVP was performed under anesthesia, with long gauze rolls. The patients were observed for primary revealed hemorrhage and concealed hemorrhage. Total abdominal hysterectomy was carried out when UVP had failed. The patients were followed after discharge for 6 weeks after the procedure for evidence of secondary PPH and pelvic infection. During the study period, UVP was performed in 34 patients. The procedure was found successful in 31 ie., 91% cases. Failure was observed in 3 cases which was recognized by primary revealed hemorrhage within half hour of the procedure. Pelvic infection was seen in 5 ie., 14.7% cases, but pre-existing risk factors for infection such as prolonged rupture of membranes, obstructed labour and home delivery were present in all these cases. There was no case of concealed hemorrhage or secondary PPH. UVP seems to be an effective method for managing patients with atonic postpartum hemorrhage, with minimal maternal morbidity