Frequency of post dural puncture headache in patients undergoing elective cesarean section under spinal anesthesia with median versus paramedian approach

Objective: Post dural puncture headache [PDPH] is one of major complications of spinal anesthesia. There are two approaches to administer spinal anesthesia i.e. median and paramedian. We conducted this study to compare the frequency of PDPH after spinal anesthesia for cesarean section with median versus paramedian approach using 25 gauge pencil point needle

Methodology: This randomized controlled trial was conducted at Departments of Anesthesiology, Surgical Intensive Care and Pain Management Centre as well as Gynecology and Obstetrics, Peoples University of Medical and Health Sciences, Nawabshah, Benazirabad [Pakistan]. One hundred and twenty females underwent elective cesarean section under spinal anesthesia were enrolled. After informed written consent, the parturients were randomly divided into two equal groups by lottery method; Group A patients received spinal block with median approach and Group B patients received it with paramedian approach. All spinal blocks were performed with 25 gauge pencil point needle. The patients were asked about the presence or absence of headache through Visual Analogue Scale [VAS] in the next 72 hours

Results: In median approach [Group A], 3 patients [5%] had PDPH; whereas in paramediannapproach [Group B] only 1 patient [1.6%] had PDPH. All the patients were of younger age and low parity. They developed PDPH within 24 -48 hours which was of mild to moderate in degree on VAS and relieved by rest, plenty of fluids and simple analgesics containing caffiene in mild case. While strong analgesics and muscle relaxants were added in cases of moderate PDPH. PDPH was relieved within 2-3 days in all cases without any complication. The difference was statistically insignificant [p-value=0.30]

Conclusion: Paramedian approach is better than median approach in terms of reduction in the frequency of PDPH, though the results were statistically insignificant?

Unruptured ectopic pregnancy is still uncommon in our setup

To analyze the frequency of ectopic pregnancy, treatment modalities, maternal outcome and why the unruptured ectopic pregnancy is presented less frequently in our set up. Cross sectional descriptive study. This study was conducted at the Department of OBGYN PUMHS Nawabshah from January 2008 to December 2010. All the patients who have a clinical suspicion for ectopic pregnancy or diagnosed by ultrasonography included in the study. Verbal interviews were taken in the post operative period for assessment of educational and socio economic status of patient along with the behavior of the referring authority. Patients' records were reviewed for clinico surgical finding and maternal outcome. Eighty eight [88] women were presented with ectopic pregnancy out of 13286 deliveries at PUMHS Hospital Nawabshah during 03 years study period making a frequency of 0.66%. No risk factor identified in 58[65.9%] of cases. 56[63.63%] patients presented in acute way. Regarding treatment modalities 86[97.72%] patients underwent laparotomy amongst them salpingectomy was performed in 50[56.81%], salpingo-oophorectomy in 28[31.81%], milking of tube were carried out in 03[3.40%] patients and complete tubal abortion was found in 05[5.86%] patients. 02 patients with unruptured ectopic pregnancy were selected for medical treatment, 01 was successful and other failed and treated by salpingectomy. Maternal outcome was satisfactory; no maternal death was found in the study group. Blood transfusion was required in 100% of patients [1-4 pints]. Regarding the aspect of why we are not receiving the patients with unruptured ectopic pregnancy, we found that > 90% of our patients belong to poor socioeconomic group and uneducated. Remaining patients belong to middle social class and were able to write their name. We found it an important factor in starting late antenatal care. We also assessed the behavior of referring authority as well as in our out- patient department; urine for the P.T was the preferable method of diagnosing first trimester pregnancy. Ultrasound was only advocated once patients presented with acute symptoms of ectopic pregnancy. The detection of unruptured ectopic pregnancy is almost nil in our setup due to late reporting to hospital by women when pregnant and inability of the health care providers to suspect it when faced with early pregnancy problems of lower abdominal pain and irregular vaginal bleeding. A change in the health professional behavior, provision of beta HCG estimation and transvaginal ultrasound in public sector hospitals are the modalities to improve the detection of unruptured ectopic pregnancy

Eclampsia: still a dreadful situation

To study the prevalence of eclampsia, its related maternal morbidity, mortality and perinatal outcome. Observational Study. This study was conducted in the Department of Obstetrics and Gynaecology at Peoples Medical College Nawabshah from 1st January 2009 to 31st December 2009. All the patients admitted with eclampsia were included in this study and they were analyzed according to their age, parity, duration of gestation, timing of convulsions, mode of delivery, complications and feto-maternal outcome. 107 patients of eclampsia presented during the study period, giving a frequency of 2.43%. Mean age group involved was 15-24 years [47.7%] and 25 - 34 years [44.9%] while 7.5% were > 35 years. Majority of the patients belong to 15-24 years age group and found to be statistically significant [p-0.000]. Primi gravida [65%] were highly effected population. 57% [62] patients had fits in antenatal period while 9.3% [10] patients had intrapartum and 32% [35] patients had postpartum fits. Vaginal was the commonest mode of delivery 49 [45.5%]. Assisted vaginal delivery in 21 [19.6%], while cesarean section was performed in 37 [34.6%] patients. 39 [36.44%] maternal deaths occurred during study period, while 7 materanl deaths were attributed to eclampsia. Regarding the neonatal outcome, 64.5% [69] were born alive, 20.6% [22] were IUD and 15% [16] were dead during neonatal period mostly due to prematurity [75.7%].Eclampsia is a big challenge in obstetrics, it can lead to very high maternal and perinatal mortality and morbidity. It is a 3rd commonest cause of maternal death in developing countries. Community health education coupled with availability of emergency obstetric and neonatal care service at doorstep would reduce the incidence of eclampsia and its associated morbidity and mortality in Pakistan

audit of primary postpartum hemorrhage

The purpose of this study is to determine the causes of PPH, its risk factors, and treatment measures adopted. This prospective study was carried out in. the Department of obstetrics and gynaecology, Peoples Medical Collage Hospital Nawabshah from January 2009 to December 2009. Treatment measures including medical, surgical and blood transfusion were evaluated. A total of 165 cases of primary PPH were managed in one year. Uterine atony was identified major cause 128 [77.5%], traumatic causes of genital tract were 37 [22.4%], socioeconomic status was poor in 110 [66%] and lower middle class in 41 [24%]. Most of the patients 86 [52.1%] were delivered by traditional birth attendant, lady health visitors 36 [21.8%] and qualified medical doctors 29 [17.5%]. Blood pressure was unrecordable in 43 [26.0%], systolic B.P was below 80 mm in 55 [33.3%], systolic B.P above 100 mm in 67 [40.6%], hemoglobin [Hb%] level were b/w 8-10 gm% in 89 [53.93%], and less than 8 gm% in 76 [46.06%]. Blood transfusion was done in all cases. Uterine massage was done in 45 [27.27%]. Minor surgical procedures were performed in 57 [34.5], manual removal of placenta in 8 [4.8%], compression suture were applied in 2 [1.2%], hysterectomy in 20 [12.12%], and repair of uterus in 5 [3%]. Out of 62 cases who developed complications, 35 [21.21%] developed anemia, acute renal failure in 10 [6.06%], and disseminated intravascular coagulation in 3 [1.81%], maternal deaths due to irreversible shock and renal failure were in 10 [6.06%]. Maternal mortality during year 2009 due to PPH was 10 [29.41%]. PPH is a preventable problem. Maternal mortality and morbidity resulting from it can be reduced by identifying the risk factors, early referral, proper assessment and treatment of the cause. Conservative procedures should be considered prior to undertaken hysterectomy, and hysterectomy should be performed as the last option