comparison of modified uterine stitch with the standard two layered uterine closure during caesarean section

OBJECTIVE: To compare the two methods of closure of uterine incision i.e an additional single figure of eight stitch at the centre of uterine incision after a double layered closure versus the standard double layered closure during caesarean section in terms of intra operative haemorrhage, post operative blood loss, use of oxytocics and additional haemostatic sutures

STUDY DESIGN: Randomized controlled trial

PLACE AND DURATION OF STUDY: The obstetrics and Gynaecology Department of Combined Military Hospital Rawalpindi from March 2005 to March 2006

MATERIALS AND METHODS: A total of 130 selected pregnant women between 37 and 42 weeks of gestation were admitted and randomly divided into two groups i.e the standard double layered closure [group-I] and the modified uterine stitch [group-II]. Caesarean section was performed according to the standard procedures except uterine closure .In group-I, standard double layered closure was performed and in group-II, an additional figure of eight stitch at the centre of uterine incision was applied and outcomes like operation time, intra operative haemorrhage, post operative blood loss, need for oxytocics, additional haemostatic sutures and agents, difference in pre and post operative haemoglobin levels, febrile morbidity and length of hospitalization were recorded. Statistical analysis was done using SPSS V 14

RESULTS: There was a significant difference in pre and post operative blood loss [mean 1,035.83 ml vs 694.00 ml; p 0.002 and mean 398.34 ml vs 282.88 ml; p 0.005] as well as difference in haemoglobin levels [mean 1.46 g/dl vs 1.01 g/dl; p 0.008] in the Group-I and Group-II respectively; use of oxytocics and additional haemostatic sutures in favour of the modified uterine stitch Group. There was no significant difference in febrile morbidity [p 0.89] and length of hospitalization [p 0.686] between the two groups

CONCLUSION: This uterine stitch is associated with less intra and post operative haemorrhage as well as less need for additional haemostatic sutures and agents

Management and maternal outcome in morbidly adherent placenta

Background: Morbidly adherent placenta [MAP] with its variants is one of the most feared complications causing high morbidity and mortality in obstetrics. The objective of this study was to analyse different management options and maternal outcome in diagnosed cases of morbidly adherent placenta. Methods: Descriptive case series was carried out in Obstetrics and Gynaecology Department, Combined Military Hospital, Rawalpindi and one private hospital from Jan 2008 to Dec 2010. During this period all cases of morbidly adherent placenta diagnosed by colour flow Doppler and MRI were analysed. Operative delivery was carried out in all patients. Three different surgical managements namely total abdominal hysterectomy with non separation of placenta, subtotal hysterectomy and trial haemostasis with uterine sparing surgery were carried out on when and where required basis. The outcome like total blood loss, blood transfused, Intensive unit care, postnatal complications including febrile morbidity, hospital stay and prolonged follow ups, were recorded. Results: Total 32 cases of morbidly adherent placenta diagnosed by colour Doppler ultrasound/MRI [magnetic resonance imaging] were identified. In this study the frequency of morbidly adherent placenta found to be 1/274.8 deliveries and 1/122.6 caesarean sections. Initially total caesarean hysterectomy was performed in 16 patients, while subtotal hysterectomy in 9 and Trial haemostasis with uterine sparing in 7 cases out of which two cases underwent total hysterectomy due to massive postpartum haemorrhage same day. One case in subtotal hysterectomy for placenta percreta with bladder invasion had re-laparotomy for bladder fistula, while two for severe postpartum haemorrhage. Two needed ventilator support. Maternal morbidity was greater in subtotal hysterectomy and uterine sparing group. One patient died in this study. Conclusion: Antenatal diagnosis of morbidly adherent placenta followed by well-planned total abdominal hysterectomy with non-separation of placenta adapting multidisciplinary approach is the best surgical option to reduce maternal morbidity/mortality. Keywords: morbidly adherent placenta, total abdominal hysterectomy, Trial haemostasis

Frequency and types of anemia in an antenatal clinic in the third trimester of pregnancy

To determine the frequency and the types of anemia in a specific sample of patients reporting to Combined Military Hospital, Rawalpindi. Design and A descriptive study with retrospective data was conducted in outdoor patients department of Combined Military Hospital, Rawalpindi by screening/testing haemoglobin and haematocrit in the third trimester of pregnancy. Five hundred patients that reported to outdoor patient department of Combined Military Hospital, Rawalpindi from July 2002 to January 2003, were selected for study according to the inclusion and exclusion criteria by convenience sampling. Study was carried out on automated electronic cell counters and chemical analyzers. Any abnormal results in routine investigations were followed up. Inclusion criteria was educated women with at least a high school degree in their third trimester with age ranging between 20 to 30 years, gravidity between 1 to 3 and birth spacing of at least 2 years. The significant out come of the study was that iron deficiency anemia exists substantially in this socioeconomic group [educated middle class]. Out of the total 500 cases, 241 [48.2%] were found to be anemic, according to the severity was 39.8% mild, 7.6% moderate and 0.8% severe anemia. The mean + SD haemoglobin was 10.3 +/- 0.3 g/dL for mild, 8.9 +/- 0.41 g/dL for moderate and 6.8 +/- 0.22 g/dL for severe anemia. Seventeen patients out of the original sample were lost to follow up. The major categories of anemia to effect the study sample were iron deficiency anemia and beta thalassaemia trait. The percentages obtained were 41.6% and 4.8% respectively. Iron deficiency is quite frequent during third trimester of pregnancy is our study population. A comprehensive research in our country is needed on how to improve existing iron supplementation programs and the overall health care and nutritional status of women before they enter their reproductive years