ten year review of emergency peripartum hysterectomy in a tertiary care hospital

Emergency peripartum hysterectomy [EPH] is a life saving procedure considered in cases of severe haemorrhage unresponsive to medical and conservative surgical procedures.The aim of present study was to review the frequency, indications, maternal morbidity and mortality associated with emergency peripartum hysterectomy in a tertiary care hospital in a developing country. This was a cross sectional study in which data was retrospectively collected from January 2000 to December 2010. Main outcome measures were maternal morbidity and mortality associated with EPH. The incidence of EPH was 10.52/1000 deliveries. The main causes of EPH were rupture uterus 76 [34.86%], atonic uterus 65 [29.81%], placenta accreta 19 [8.71%], placenta previa 17 [7.7%], and placental abruption 36 [16.5%]. Mostly subtotal hysterectomy was the preferred method done in 196 [89.9%] of cases, while total abdominal hysterectomy was done only in 22 [10.09%] of cases. The over all complication rate was 81.2% which included both minor and major complications like hypovolemic shock 180 [82.5%], febrile morbidity 108 [49.5%], wound infection 40 [18.3%], bladder injury 6 [2.75%], and thrombophlebitis 22 [10.09%]. The maternal mortality in present review was [10.5%]. Frequency of EPH was found to be high in this study. Obstetricians must be skilled in it particularly in developing countries where the main indication of hysterectomy is rupture uterus.

Safety of caesarean myomectomy

Uterine fibroids are the most common type of tumours in women arising from uterine myometrium and less commonly from cervix. Objective of the study was to check the safety of caesarean myomectomy. Patients attending Gynaecology-B Unit of Ayub Teaching Hospital having pregnancy with fibroid and undergoing myomectomy along with caesarean section [CS] were included in this prospective study during Jan 2010-Dec 2011. Intra-operative and postoperative maternal morbidity in terms of blood loss, operative time and length of hospital stay was compared to matched pregnant woman with caesarean section alone. Out of 6,000 antenatal mothers registered during the study period myoma was detected in 96 [1.6%] cases. Mean age of mother having myoma was 28 years, 70% were primigravida, and mean haemoglobin was 10.56 gm%. Size of myoma was 12 Cm in 30% cases 5 Cm in 23% and more than 1 myoma in 60% cases. There was no significant difference in intra-operative haemorrhage and length of hospital state in comparison matched women with CS although operating time was double than later. None required caesarean hysterectomy. Myomectomy can be safely performed in majority of carefully selected patients with myomas without any serious life threatening complications.

Foetomaternal outcome in patients with or without premature rupture of membranes

Preterm premature rupture of membranes is responsible for one third of all preterm births and is associated with significant maternal, foetal and neonatal risks. The objectives were to compare the foeto-maternal outcome in patient with and without preterm premature rupture of membranes. This prospective comparative study was conducted in Gynae-C Unit of Ayub Teaching Hospital from Sep 2005 to Mar 2006. Total 170 cases were recruited in the study, out of which 85 had Preterm Premature Rupture of Membranes [PPROM], and 85 had preterm labour without PROM. Patients' data were recorded on a performa. Maternal outcome was measured on the basis of presence of fever and mode of delivery. Foetal outcome was measured on the basis of weight of the baby, and presence of infection [fever], APGAR score and neonatal death. Analysis was performed using SPSS-10. The primary data arranged in groups was divided into PPROM and no-PPROM groups. The PPROM was found to be frequent in younger age group between 15-25 years while no-PPROM was common among the age group between 26-35 years [p=0.002]. Lower socioeconomic class and history of previous one or more preterm delivery was significantly associated with PPROM [p=0.001]. Maternal fever was also significant in the PPROM group [p=0.01]. Low birth weight was statistically significant in the PPROM group. Majority of the babies born to mother were either extremely low birth weight or low birth weight, i.e., between 1-25 kg [p=0.005]. Low APGAR score at the time of delivery [p=0.01] and foetal infection [p=0.002] between the PROM and no-PPROM group was found to be statistically significant Neo-natal deaths was also higher in the PPROM group as compared to no PPROM group [11 verses 2] [p=0.009]. In our study premature rupture of membrane had increased neonatal morbidity and mortality as compared to preterm birth. Strategies should be developed for its prevention

Pregnancy with fibroids and its obstetric complications

Pregnancy along with a fibroid is a high risk pregnancy which may lead to complication with unequal gravity. Objective of this study was to assess the prevalence and obstetric complications of fibroids during pregnancy, this cross-sectional study was carried out in the Department of Gynaecology, Unit 'C', Ayub Teaching Hospital Abbottabad. Data of all patients who presented with fibroid during pregnancy during two years, i.e., from Jan 2006 to Dec 2007 was recorded on a proforma and analysed using SPPS-12. Thirty patients were diagnosed to have fibroids during pregnancy out of 3468 deliveries, thus prevalence was 0.865% in our hospital. The age of 50% cases was from 20 to 30 years, and 30 to 35 Year [27%]. Twenty-one [70%] belonged to low socioeconomic status. Ninety percent patients reached up to term pregnancy between 37 to 40 weeks. Fibroids were found less common in patients in their first pregnancy [8, 23.66%]. Twenty-one [70%] patients were delivered by caesarean section, and in 1 [3.33%] patient hysterotomy was performed. Failure to progress and foetal distress was the commonest indication for caesarean section [8, 38.09%] followed by breech presentation [4, 19.04%], cord prolapse [3, 14.28%] and fibroids in the lower segment [2, 9.52%]. Anaemia was the commonest complication [20, 66.66%] followed by postpartum haemorrhage [PPH] [10, 33.33%]. Breech presentation was the commonest malpresentation [4, 13.33%] associated with fibroids during pregnancy. Premature rupture of membranes and cord prolapse was seen in 3 [10%] patients each. Four [13.33%] patients underwent abdominal hysterectomy. Intra uterine growth restriction IUGR was seen in 2 patients [6.66%], 2 patients ended up with abortions, 1 patient had a spontaneous pregnancy loss and the other underwent hysterotomy due to low lying placenta and heavy bleeding per vaginum. Compound presentation, neglected transverse lie, stuck head of breech, placenta increta, retained placenta, low lying placenta, were the other complications occurring in one patient each. One patient died during anaesthesia. Neonatal outcome was encouraging as 20 [67%] babies were of average birth weight and only 4 [13.33%] babies had low APGAR score and needed NICU admission. Perinatal mortality was 37/1000 live births. Pregnancy with fibroids leads to increase in caesarean section rate due to dysfunctional labour and malpresentation. There is also increased incidence of post partum haemorrhage along with associated complication of anaemia, anaesthesia and surgery

Neonatal outcome in obstetric cholestasis patients at Ayub Teaching Hospital Abbottabad

Obstetric cholestasis is a liver disease specific to pregnancy characterised by pruritus affecting the whole body but particularly the palms and soles and abnormal liver function tests. Objective of this cross sectional study was to evaluate obstetric cholestasis as a potential risk factor for adverse neonatal outcome. The study was conducted at Department of Obstetrics and Gynaecology, Unit 'B', Ayub Teaching Hospital, Abbottabad from April 1, 2007 to March 31, 2008. All patients presenting with obstetric cholestasis irrespective of their age and parity were included in the study. Patients presenting with other causes of pruritus during pregnancy like Hepatitis [A, B, C], eczema, pruritus gravidarum and herpes gestationes were excluded from the study. Patients with liver involvement due to pre-eclampsia were also excluded. Baseline investigations, liver chemistries, viral screening, liver autoimmune screen, liver and obstetrical ultrasound were all done before the diagnosis was confirmed. Patients were treated symptomatically. Neonatal outcome was calculated in terms of increased incidence of passage of meconium, preterm delivery and foetal distress requiring delivery by Caesarean-Section. Thirty patients were selected. Babies of 10 patients did well after delivery, 8 required NICU care within first 24 hours of birth and rest were delivered with low APGAR score. Two babies were delivered stillborn. Pruritus is quite common in pregnancy with obstetric cholestasis being one of them and earlier detection of the disease allows better identification of foetuses at risk

Prevalance of PPROM and its outcome

Prematurity is the leading cause of perinatal morbidity and mortality in developed as well as in underdeveloped countries. In one third of the patients with preterm labour there is associated premature rupture of membranes. This prospective observational study was carried out in Ayub Teaching Hospital to determine the prevalence of preterm premature rupture of membrane [PPROM] and its association with the demographic risk factors and its outcome. There were 889 deliveries in Gynaecology 'C' unit from September 2005 to March 2006. Out of these, 85 patients were confirmed to have PPROM. Detail history and examination along with the demographic risk factors were recorded on a performa. Every patient was followed till her delivery and the mode of delivery and maternal and foetal outcome was recorded. Prevalence of PPROM in this study was 16%. It was seen to be common among patients who were young [15-25 years] 58.8%, with low socioeconomic status [68.2%], and with an educational status of primary to middle [71.7%]. Risk of PPROM was seen to be highest among patients giving birth to their first child [42.2%], with gestational age between 30-35 weeks [43.5% cases] and 35-37 weeks [35.2%]. In 69.4% cases there was no previous history of preterm deliveries while in 30.6% cases, there were one, two, or more previous preterm deliveries. Normal vaginal delivery occurred in [65.86%], while instrumental delivery rate in PPROM was 20% and caesarean section rate was 14%. Postnatally 16.47% patients developed infection while 24 [28.2%] babies developed infection and required antibiotics. Majority of babies born to patients with PPROM were low birth weight [62.3%], and 30.5% babies required neonatal intensive care. Perinatal mortality rate was 129.9/1000 [13%] of total births. PPROM is an important cause of preterm birth, resulting in large number of babies with low birth weight, requiring neonatal intensive care. It is associated with increased foetal morbidity and mortality. Demographic variables can be applied to develop risk scoring so as to identify high-risk cases and treating them in time to prevent ascending infection along with its complications