Perinatal mortality: a mirror image of maternal health

Perinatal mortality usually reflects health status of mother and is indicator of quality of care received by mother during her period of gravidness and fetus at birth. We carried out this study to evaluate the magnitude of perinatal mortality at our institute and its contributing factors. Cross sectional study. This study was conducted at Obst. and Gynae Unit II and Unit of Pediatric Medicine, Chandka Medical College hospital Larkana from 1[st] January 2012 to 31[st] December 2012. Women who delivered after 24 completed weeks were selected from labour room. Perinatal deaths including stillbirths and early neonatal deaths up to 7 days of life were studied. Outcome variables like maternal age, parity, communal standing and booking status were taken in to consideration. Complications arising during pregnancy or any medical illness, details of labour, fetal condition at birth were also noted. During the study period 4818 women delivered. There were 473 perinatal deaths with a perinatal mortality rate of 98/1,000 live births. Among these women only 9% were booked, while 91% un-booked. Perinatal death rate was more seen in maternal age group between21-30 years that were 51%. Women having parity of 2-5 had highest perinatal mortality of about 44%. Gestational age from 31-36 weeks contributed about 46%. Most prevalent condition reportedly causing perinatal death was prolonged and obstructed labour which added 30% of total, followed by antepartum hemorrhage causing 18% of perinatal deaths. Hypertensive disorders and other maternal medical diseases contributed about 15.5% and 6.5% respectively.10% fetuses died of congenital anomalies.11% neonatal septicemia seen. Unexplained still births seen in 9% of total. Perinatal mortality is stagnantly high among mothers with poor health even having no access for antenatal, intra partum and postnatal care. Unfortunately they report to hospital when already had developed some complication. Awareness programs at community level, training health workers providing facilities at remote health centers can make the lot of difference

Frequency of backache in pregnancy women attending antenatal clinic

To determine the frequency of backache and assess the efficacy of various treatment modalities used for the management of backache in pregnancy.Descriptive study. Outpatient department of obstetric services, Jinnah Hospital, Lahore. Patients coming to the antenatal clinic during February 2004 were asked about history of backache. A total of 918 women with complete data were recruited. Four hundred and thirty-two [47.05%] reported one or more significant episodes of back pain during their pregnancy. Of these 96 [22.22%] noted ongoing back pain at the time they became pregnant leaving a true incidence rate of [36.60%]. Twenty-one patients [4.86%] were less than 20 years, 407 [94.21%] were in between 20-40 years of age and 4 [0.92%] were above 40 years. Eighteen patients [4.16%] were less than 50kg, 345 [79.86%] had weight in between 50-70 kg and 69 [15.97%] were more than 70kg. Seventy-eight patients [18.05%] were primigravidas, 292 [67.59%] were multigravidas and 62 [14.35%] were grand multigravidas. Ninety-six patients [22.22%] had backache before pregnancy and 336 [77.77%] had it during pregnancy. No treatment was taken in 23 patients [5.32%], rest in 297 [68.75%], analgesic in 106 [24.52%] and massage by 6 [1.38%] patients. Subjective relief was up to 50.0% with rest, 75.0% with analgesics and up to 50.0% with massage. Backache is quite common in pregnancy. About one quarter of all pregnant women experience backache. About half of the patients took treatment mainly in the form of rest and analgesia. Chiroptic practice is also common in pregnancy and it gives some relief as well

Backache in pregnancy

This study was performed to determine the frequency of backache, its causes and to assess the efficacy of various treatment modalities used for the management of backache in pregnancy. The location of the study was outpatient department of obstetric services, Jinnah Hospital, Lahore. Patients attended to the antenatal OPD during February 2004 were asked about history of backache. A further information was obtained from patients who had history of backache. A total 918 ladies with complete data were recruited. Four hundred and thirty-two [47.05%] reported one or more significant episodes of back pain during their pregnancy. Of these 96 [22.22%] noted ongoing back pain at the time they became pregnant leaving, 1 true incidence rate of 36.60%. Twenty-one patients [4.86%] were less than 20 years, 407 [94.21%] were in between 20-40 years of age and 4 [0.92%] were above 40 years. Eighteen patients [4.16%] were less than 50kg, 345 [79.86%] had weight in between 50-70 kg and 69 [15.97%] were more than 70kg. Seven ty-eight patients [18.05%] were primigravida, 292 [67.59%] were multigravida and 62 [14.35%] were grand multigravida. Three hundred and twenty-nine patients [76.15%] were delivered vaginally, 5 [1.15%] had instrumental deliveries and 98 [22.68%] had lower segment caesarean section. In the later group, spinal anesthesia was given in 60 [61.22%], general anesthesia in 34 [34.69%] and epidural anesthesia in 4 patients [4.08%]. Ninety-six patients [22.22%] had backache before pregnancy and 336 [77.77%] had it during pregnancy. No treatment was taken in 23 patients [5.32%], rest in 297 [68.75%], analgesics in 106 [24.52%] and massage in 6 [1.38%] patients. Subjective relief was up to 50.0% with rest, 75.0% with analgesics and up to 50.0% with massage. Backache was found to be common in pregnancy. About one quarter of all pregnant women experience backache. The most common cause of backache in pregnancy is odd posture, heavy work and weight lifting. About half of the patients took treatment mainly in the form o f rest and analgesia. Chiroptic practice is also common in pregnancy and it gives some relief as well. Although, backache is so common in pregnancy still none of the patients had any concept about posture and exercise. It is advised that patients should be given special advice regarding posture and exercises

Mid-trimester termination of pregnancy-comparison of sublingual with vaginal misoprostol

This paper compares the efficacy, side effects and patient's satisfaction of sublingual with vaginal misoprostol for mid-trimester termination of pregnancy. The study was performed in the department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore. One hundred patients presenting for termination of pregnancy between 13-24 wks of gestation were selected. They were divided into two groups, group I was managed with sublingual and group II with vaginal misoprostol. The dose of misoprostol was 200 pg repeated at intervals of 6 hours up to a maximum of four doses. The primary outcome measure was induction expulsion interval and secondary outcomes were maternal complications, and women's acceptance of the termination procedure. Successful termination was achieved in 96% patients in group I and 94% in group II. The patients in the two groups were comparable regarding their parity, gestational age and indications for termination. As regards the dosage, 76% in each group required a dose of 400 - 600 ug [P value 0.000]. Induction expulsion interval was < 12 hrs in 92% patients in group 1 and 88% in group II, a difference not statistically significant [P value > 0.005]. Pyrexia > 38°C was found in 8% and 6% in each group respectively while 8% in group I and 4% in group II had nausea and vomiting. So, sublingual misoprostol is as effective as vaginal misoprostol but with more nausea and vomiting, which can be managed easily. As a conclusion misoprostol can play a very important role in the practice of obstetrics and gynecology in resource poor countries where cost of other prostaglandins is prohibitively high and temperature maintenance is a problem. In proper dosage the risk of complications is low and most of the patients achieve completion of expulsion in less than 12 hrs by both routes

psyche of caesarean

The present study was conducted to assess psychological, social and physical impact of caesarean on a woman. It is a Cross sectional and comparative study and was conducted at department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore. The study included random selection of two hundred and twelve women with recent caesarean section [within 6 weeks] admitted in the ward or presenting in out patient department of Jinnah Hospital, Lahore From January 2004 to April 2004. They were divided in two groups. Group I with one caesarean section included 124 patients and Group II with repeat caesarean sections included 88 patients. The women were interviewed according to a preset proforma. Out of the two hundred and twelve women interviewed, the age, social and educational status were comparable between the two groups. 40.3% of the patients in group I and 56.8% in group II [P value < 0.05] were apprehensive because of pain. 40.3% of group I and 50% of group II [P value > 0.05] patients were scared of immobility. 40.3% in group I and 36.4% in group II [P value > 0.05] said that they had to stay longer in the hospital. 56.5% in group I and 56.8% in group II [P value > 0.05] were afraid of anaesthesia. 27.4% in group I and 15.9% in group II [P value < 0.05] had reservations because of excessive blood loss. 9.7% in group I and 18.2% in group II didn't like caesarean section because of risk of infection [P value > 0.05]. 38.7% in group I and 40.9% in group II felt bad of scar in the abdomen [P value > 0.05]. 37.1% in group I and 31.8% in group II [P value > 0.05] had social pressures. 58.1% in group I and 56.8% [P value > 0.05] in group II had problems with care of the neonate [Feeding]. 4.0% of group I and 6.8% [P value > 0.05] of group II patients had mild psychological problems like anxiety and postpartum blues, which settled with psychological support and anxiolytics. 35.5% of group I and 28.4% of group II [P value > 0.05] had fears about future fertility. 25.8% in group I and 40.9% [P value < 0.05] in group II did not mind having caesarean in next pregnancy. Although there are some fears in the minds of women about caesarean section, the common problem are benign and manageable, they can be alleviated through counseling and better care. Larger studies are required to assess each variable independently

Prescribing in pregnancy

Objective: To assess the prescribing patterns and clinical practices in the use of pharmaceutical agents in pregnancy

Study Design: Observational, Cross-sectional study

Study Period: March 2002 to March 2003

Setting: Study was conducted at antenatal clinic, Jinnah Hospital, Lahore

Materials and Methods: 250 patients from antenatal clinic were interviewed to collect information regarding age, parity, gestational age, any medication, its indication, route, duration and prescriber during current pregnancy on a pre-designed proforma

Sampling Method: Patients were enrolled in this study on first come and enroll basis

Results: Most of the women [90%] visiting the antenatal clinic were in the age group 21-30years. 94% of the women were taking medications and the prescriptions included haematenics [88%], folic acid [61%], calcium supplements [63%], antibiotics [22%], anti-fungals [19%], antiemetics [8%] and laxatives [6%]. 6% of women were not taking any medication. Commonest prescribers were general practitioners [46%]. Rest of the prescribers were medical officers at antenatal clinic [28%], LHVs/nurses [11%] and specialists [9%]. Self-medication was seen in 6%. 47% of the women taking self-medications were among the educated group [Matric and above] and 53% of the women were among the uneducated group [P < 0.001]. 28% took treatment from general practitioners and lady health visitors without any certain diagnosis, on symptomatic grounds

Conclusion: The use of drugs in pregnancy is substantial and varied. Information on the use of drugs during pregnancy is scarce and anecdotal. Careful consideration of the benefits to the mother and risks to the fetus is required, when prescribing drugs during pregnancy. All prescriptions or drugs recommended in pregnancy must have solid evidence derived from current literature

Hysterectomy: the patient`s perspective

Objectives: Importance of information provision by the gynaecologist and its effects on women`s decision making about hysterectomy

Design of Study: Structured questionnaire and interview

Setting: Department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore

Materials and Methods: A questionnaire was given to 50 women who had undergone hysterectomy for benign menstrual problems and information was collected. Main Outcome Measures: Women`s experience and satisfaction, with the communication and information provision by the doctor about her disease before hysterectomy. To assess the influence of that counseling on the decision-making process of hysterectomy

Results: Most of the women undergoing hysterectomy were between the age group of 40 - 45yrs [40%]. Most common indication for hysterectomy was dysfunctional uterine bleeding [55%]. 32% women reported optimal satisfaction with decision made. 57 highlighted sub-optimal aspects of decision-making process. 37% complained of deficiency in communication skills of doctors and 63%, stated that information provided were incomplete [P<.001]. 11% had residual doubts about the appropriateness of hysterectomy

Conclusion: The efforts are required to ensure that women are adequately informed and involved in decision about gynecological treatment

Induction of labor Misoprostol vs Dinoprostone

Objective: To compare the safety and efficacy of misoprostol with PGE2 for induction of labor by intra vaginal administration

Study Design: It was a comparative and interventional study

Study Venue: The study was carried out in the Department of obstetrics and Gynaecology, Jinnah Hospital, Lahore

Subjects and Methods: 46 women with indications for labor induction at term and post-term were randomly assigned to two groups. Each woman received either 200 microgram of misoprostol or 3mg of prostaglandin E2 intravaginally. If labor was not initiated after 4 h, the same dose was repeated every 4 h to a maximum of 400 microgram of misoprostol or 6mg of PGE2, until adequate labor and vaginal delivery was achieved or patients delivered by abdominal route

Main Outcome Measures: The main parameters measured were: latent period, time from induction to vaginal delivery, delivery route, and occurrence of uterine tonus alterations, hypoxia and neonatal morbidity. The statistical analysis of the data was carried out in SPSS software

Results: 23 women were allocated to the misoprostol group and 23 to the prostaglandin E2 group. Misoprostol was more effective than PGE2 in producing cervical changes. Delivery within 10-12 h, after the first administration occurred more often in the misoprostol group than in the PGE2 [16 [69.56%] vs 2 [8.69%]]. Less patients in the misoprostol group required oxytocin augmentation than in the PGE2 [3 [13.04%] vs. 5 [21.73%]]. Uterine tachysystole and hyperstimulation occurred more frequently in the misoprostol group [3 [13.04%]] than in the PGE2 group [1 [4.34%]]. No statistically significant differences were noted between the two groups including mode of delivery and neonatal or maternal adverse outcome. The interval from induction to vaginal delivery was significantly shorter in the misoprostol group [6-8 hrs vs 11-12hrs]. Abdominal delivery rate was more frequent in misoprostol group because of fetal tachycardia and hyper-stimulation than prostaglandin group [2 [8.69%] vs 1 [4.34%]]. Repeat dose was required mainly prostaglandin group [6 [26.08%]] as compared with misoprostol [4 [17.39%]]

Conclusions: Compared with prostaglandin E2, intracervical misoprostol is more effective in cervical ripening and labor induction at term. The higher frequency of uterine hyper-contractility associated with the use of misoprostol did not increase the risk of adverse intrapartum and neonatal outcomes, but the vigilant fetomaternal monitoring is considered to be essential in every case of induction

Anemia in grandmultipara

Objectives: To determine the prevalence of anemia in the grandmultiparas and compare it with the prevalence of anemia in women of lesser parities

Design: A prospective comparative study in which data was analyzed using p value and tests of significance

Patients and methods: Two thousand two hundred and ninety eight pregnant patients visiting the out patient department of Jinnah Hospital Lahore were evaluated for anemia. Among them 536 were grandmultiparas and 1762 were of lesser parity. Hemoglobin [Hb] percentage in both groups of patients was measured, on this basis anaemia was classified as mild, moderate or severe

Results: There was no significant statistical difference in the prevalence of mild and moderate anemia but severe forms of anemia were found in grandmultiparas as compared to females of lesser parity. Mild anaemia with haemoglobin [Hb] between 10-11 gm/dl was present in 54[10%] patients of group A and 170 [10%] of patients in group B. But the difference between these two groups was not significant statistically [p>0.05]. The patients suffering from moderate anaemia Hb 7-10 gm/dl were 460 [86%] in group A and 1550 [88%] in group B. The difference in moderate anaemia in the two groups was not statistically significant. The prevalence of severe anaemia was however significantly higher [p<0.05] among GMPs. Severe anaemia with Hb <7 gm/dl was present in 21 [4%] patients in group A out of total 536 and in group B out of total 1762 patients 36 [2%] had significant anaemia

Conclusions: Severe forms of anemia in grandmultiparas were due to closely spaced pregnancies, inadequate dietary intake, lack of effective contraception and social aspects

Sacrocolpopexy in management of vaginal vault prolapse

Aims and Objectives: To review the efficacy of Sacrocolpopexy in the management of vaginal vault prolapsed

Study Design: Interventional study

Setting and Population: Department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore. Women with vaginal vault prolapse after hysterectomy.

Methods and Main-outcome measures: Abdominal Sacrocolpopexy using proline mesh. Follow-up in these patients were carried out at one week, four weeks, six months, and one year

Results: Sacrocolpopexy was carried out in ten patients for vaginal vault prolapse after vaginal [6] and abdominal hysterectomy [4]. The mean age was 49.8 years. Parity was between P3 - P6 [Mean parity 4.3]. Mean operation time was 79.3 minutes. Estimated blood loss was less than 200m1. No intra-operative or post-operative complications occurred in any case

Conclusion: Abdominal sacrocolpopexy is effective and safe in the treatment of vaginal vault prolapse. This procedure has high success rate in correcting prolapse without a time dependent decrease in efficacy

Emergency contraception: knowledge, attitudes and practices of general practitioner

We conducted a telephone survey among general practitioners from different localities of Lahore selected as convenience sample. Information was collected on a pre-designed questionnaire. The main outcome measures were the knowledge regarding preparations, efficacy, safety, side effects and their attitude toward EC. The relationship of knowledge with age, education and years of practice was also assessed. We interviewed 120 GPs [50 males, 70 females]. Among these 65% of the doctors were <40 years of age and 35% > 40 years. Of the responders 38% didn't know anything about emergency contraception, whereas 46% knew only about hormonal method of emergency contraception 15% about the hormonal and IUCD and none of them was aware of Mifepristone. Among these, the knowledge of 30% of the participants about emergency contraception was adequate and that of 70% was inadequate. The difference of accuracy of knowledge was statistically significant [p<0.05]. Only 10% of GPs were in routine practice to talk about EC as a backup support while discussing their patients about contraception. There was no statistically significant difference of knowledge among males and females [p>0.05]. Young GPs [<40 years of age] were more aware of IUCD as EC compared with those more than [>40 years] though the difference was not statistically significant but it might have a clinical significance. GPs with postgraduate education when compared with graduates were more likely to know and talk about EC [P <0.05]. Maximum knowledgeable GPs were those practicing for the last 5 years [30%] as compared to practicing for more than 10 years [6.7%] [p<0 05]. Ethically and morally all GPs were in support of EC and were having favourable attitude towards EC. These findings of our study suggest that the precise knowledge about emergency contraception among doctors [GPs] is inadequate. Prescription practices can improve by generating education and training of health care providers. It should be a routine practice to consider emergency contraception as a part of contraceptive discussion with the couple. The purpose of the present study was to assess the knowledge, attitude and practices of general practitioners toward emergency contraception from different localities of the city of Lahore, which has a population of more than 6 million

Symptomatology of functional ovarian cysts

Objective: To study the symptomatology of functional ovarian cysts. Study Design: Cross-sectional, observational study. Setting: Outpatient Department of Gynae Unit, Jinnah Hospital, Lahore from June 2003 to December 2003

Material and Methods: All patients attending Gynae outpatient department Jinnah Hospital, Lahore who met the inclusion criteria were selected. Information regarding age, symptoms like abdominal pain, menstrual cycle pattern, dyspareunia, hirsuitism and obesity were documented

Results: During the six months period fifty-seven patients were included in the study, 38 patients [66.66%] of the study population was less than 30 Yrs of age, 26 patients [45.61%] had dysmenorrhoae, 14 patients [24.56%] had menorrhagia. No other menstrual irregularities were noted. 11 patients [19.29%] presented with lower abdominal pain. 27 patients [47.36%] had body mass index of greater than 30. Acne was seen in 20 [35.08%] patients and melasma in 12 [21.05%]. Family history of ovarian cysts was reported in 3 patients [5.26%] only

Conclusion: Functional Ovarian Cysts are often asymptomatic and seen in relatively younger age group [less than 30 years]. The results of this study reflected a positive association between functional ovarian cyst and obesity. Although dysmenorrhea was also seen in half of the patients of functional ovarian cysts, more studies with larger patients base are required to judge any association

Oral contraceptives, pill; myths and the truth

Objective of Study: To assess the efficacy, safety popular believes, regarding oral contraceptives in general public and their validity in the face of medical evidence. Design: A cross-sectional and observational study. The sample consisted of 328 sexually active women using Combined Oral Contraceptives [COC] as mode of contraception. These women were interviewed according to a questionnaire, seeking information about the age, parity, education, social status and age at which first COC was taken. In women who ever used COCs, information was obtained regarding the duration, preparation, side-effects and their believes regarding COC

Setting: Department of Obstetrics and Gynaecology, Allama Iqbal Medical College and Jinnah Hospital, Lahore. Period: November, 2003- June, 2004

Material and Methods: Women presenting in OPD and wards

Results: 17% women were taking oral contraceptive pills as mode of contraception. 78% believed that pill causes weight gain. 67% thought that women need a break while taking the pill. 42% considered pills as effective acne treatment and 62% thought that COCs affect fertility. 55% women believed that pills reduce sexual performance. 75% thought that pill causes breast cancer while 58% had no knowledge about non-contraceptive benefits of the pill. 80% had no information that pill can protect from ovarian cancer

Conclusions: Despite myths, pill is still widely used worldwide. There are some women who will not consider the pill because of the myths they have heard. It is very important for women to be educated about the birth control pill so that they are able to base their contraceptive decisions on facts and not on myths and misinformation