Preterm PRE labour rupture of membranes; effect of conservative management on Feto maternal outcome

The objective of this study is to describe the maternal and perinatal outcome of conservative management in PPROM. Descriptive prospective study. One year from August 2006 to August 2007. Maternal and child health [MCH] Centre PIMS Islamabad. 50 patients between 28-36 weeks of gestation presenting with PPROM. The mean age was 27+5.1 years, 14[28%] were having gestational age between 28to 32 weeks and 36 [72%] were between 33 to 36 weeks of gestation. 34 [68.0%] of the mothers had no history of abortions while 10 [20.0%] had 1-2 abortions and 6 [12.0%] had 3 or more abortions. Sixteen [32.0%] women had previous PRROM while 10 [20.0%] had previous history of preterm labor. Inverse correlation was observed between latency period and gestational age. Among 14[28%] women with gestational ages between 28 to 32 weeks 10 delivered within 48 hours and 4 after 48 hours. Among 36[72%] women with gestational ages between 33-36 weeks 31 [62%] delivered in less than 48 hours and 5 [10%] women delivered after 48 hours.14[28%] of the 50 babies were admitted in NICU with septicemia, 7[14.0%] with RDS, hypoglycemiain 2[4.0%] and necrotizing enterocolitis in 3[6.0%]. 3 neonates died from septicemiaand 2 from RDS. On first follow-up 34.0% mothers had infections and 8.0% had post-partum hemorrhage. Expectant management till 36 weeks is a suitable option as gestational age at delivery and birth weight both affect neonatal survival and offer time to administer corticosteroids to allow foetal lung maturity. Foetal deaths occurred due to septicaemia and RDS with direction co-relationship with low birth weight

Low dose heparin; therapeutic benefit in postpartum cerebral venous thrombosis

To evaluate the therapeutic benefit of low dose heparin in cerebral venous thrombosis, occurring during period of perpeurum. Descriptive study. Department of Medicine DHQ Hospital Mirpur [Department of Obs/Gynae DHQ Hospital Mirpur[AK]. January 2010 to November 2011. This study was carried on 100 patients with history of postpartum cerebral venous thrombosis. Out of which 48 on heparin and 52 formed the control group. The ages of all patients were between 20 to 30 years. Parameter recorded included history. Blood pressure.,the diagnosis was supported by cranial computed tomography. The secondary causes were ruled out on the basis of history and physical examination. The data and results were analyzed in SPSS. Out of 48 patients in heparin group 30 with non-heamorrhage lesion and 18 with haemorrhagic infarction. 52 in control group. 34 non-haemorriagic lesion and 18 with haemorragic infarct .in non-haemorrhagic CVT, there is no death in heparin group as compared to 5 deaths in control group. In patients with haemorriagic lesions, there were 5 deaths in heparin group as compared to 7 deaths in the control group. Heparin faed better than the control group, both in patients with haemorrhagic as well as non-haemorrhagic lesions. Low molecular weight [LMWH] at low doses is safe and effective for both non-haemorrhage and haemorrhgic infarct of postpartum cvt with regard to recovery and outcome as compared to control group

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

Efficacy of combined clomiphene citrate and gonadotrophin therapy

To measure the success rate of combined clomiphene citrate and gonadotrophin therapy in infertile patients. Observational analytical study. June 2009 to June 2010. In this observational analytical study, total of 100 infertile patients were selected for Combined Clomiphene Citrate and Human Menopausal Gonadotrophin [CC - hMG] regime and maximum of three treatment cycle were given. Out of 100 patients in our study, 74% [2/3 rd] patients were less than 30 years of age and 26% [1/3rd] were between 30 - 40 yrs of age. Primary infertility was seen also in 2/3rd of patients [73%] and secondary infertility in remaining 1/3rd [27%] of patients. Polycystic ovary [PCO] was the commonest cause of an ovulation seen in 62% of patients, obesity in 24% of patients and in 14% of patients cause was unknown [unexplained infertility]. on average only 4.1 Inj of gonadotrophin were required to get a mature follicle on an average 12th day [12.41 day] of the cycle. As concerned the treatment outcome, 82% of patient reported back after first course of treatment. Urine pregnancy test was positive in 18%. Remaining 64% patent were offered second course of treatment, out of which only 35% agreed for further treatment. After second course of treatment positive urine pregnancy test was seen in only 5% of patients. Remaining 30% of patients were advised third course of treatment. Out of these 30%, 8 patients took gonadotrophin regime, 10 patients agreed on follicle tracking only, 8% of patients refused further treatment and 4% did not report back. Our study shows the success rate of 23% with CC-HMG combined treatment which is double the CC alone and equal to HMG alone, thereby reducing the cost of treatment without sacrificing efficacy. In other words combined CC-HMG regime is cost effective technique in the management of infertile patients

Comparison of cervical Foly's catheter and prostaglandin E-2 at term

Labor can be induced through a myriad of ways. The aim of this study was to compare the effectiveness of the intracervical Foley balloon catheter and intra vaginal 3 mg prostaglandin E2 tablet[s] in preinduction cervical ripening at term. Prospective analytic study of a cohort of 280 women selected through non probability sampling admitted in Obstetrics units, in two private hospitals one at Rawalpindi and the other at Mirpur [Azad Kashmir], from January 2009 to March 2010. All women were randomized to receive an intracervical Foley catheter or prostaglandin E2 tablets. The primary measured outcome was ripening of the cervix as measured with the Bishop score. There were no differences in mean Bishop Scores between the prostaglandin and the Foley catheter groups. Bishop scores [mean +/- S.D.] after ripening were 6.6 +/- 0.81 and 6.7 +/- 0.86 for the Foley catheter and prostaglandin groups, respectively [P=0.54]. The prostaglandin group showed a statistically shorter induction to delivery time compared with the Foley catheter [16.5 +/- 2.2 and 20.51 +/- 3.89 h, respectively [P<0.01]. Both the groups showed no statistically significant difference between the occurrences of spontaneous vaginal delivery. Labor was established in 72% cases of cervical Foley group. On the other hand induction occurred in 76% cases in prostaglandin group. There was no statistical difference between the need of oxytocin infusion for labor augmentation between the two groups and fetal distress was equally frequent in both the groups. Foley catheter was as effective as Prostaglandin E-2 at term for induction of labor with additional advantage of being cheaper, readily available and had no systemic side effects

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