Comparison of performance of risk assessment tools for low BMD and fracture risk identification in Pakistani women

Objective: To evaluate the efficacy of four risk assessment tools for identifying low Bone Mineral Density [BMD] in a sample of Pakistani females

Methodology: It was a cross sectional study including 200 females above 40 years. DXA scans were performed. Subjects were categorized into low risk and high risk categories for low BMD on the basis of T scores. Questionnaires were filled and risk indices were calculated for all subjects. Sensitivity, specificity, positive and negative predictive values were calculated, Receiver Operating characteristic [ROC] curves were plotted and Area Under Curve [AUC] were obtained

Results: A total of 200 females including 174[87%] postmenopausal, and 26[13%] premenopausal were included. Average age was 60.76+/-10.52 years with average age of menopause being 47.64+/-6.63 years. In terms of sensitivity, specificity and AUC, the WHO risk assessment tool FRAX showed the best performance with a sensitivity of 79%, specificity 94% and AUC of 0.869 for detecting low BMD

Conclusion: It is not cost effective to use DXA for screening purposes. We propose that risk assessment tools such as FRAX may be utilized to identify individuals with low BMD. This may prove beneficial in minimizing the medical and social burden that fragility fractures pose to developing health care systems

Recurrent miscarriage and associated factors

The incidence of recurrent pregnancy loss in women of reproductive age group is 0.5%-3%, And idiopathic causes accounts for 50%-60% of recurrent pregnancy losses. Approximately 30%-50% of conceptions end in spontaneous miscarriage before the completion of first trimester. Miscarriages mostly occur at the time of implantation. The causes of recurrent pregnancy loss are many including parental chromosomal abnormalities, maternal thrombophilias, immunologic causes and endocrine disorders. Recurrent pregnancy loss is an extremely distressing clinical problem for women as well as health professinals. According to current studies the decidualized endometrium act as a biosensor of good quality embyos, if it is faulty ,may lead to implantation of embryos resulting in miscarriage. Other factors implicated in the pathophysiology of miscarriage are Systemic and placental oxidative stress. Vascular endothelial damage, abnormal vascularity of placenta and immunologic reactions have been proposed to play some role in causing recurrent miscarriage. The objective of this review is to discuss the causes of recurrent miscarriage, based on the published research articles

Fibroid uterus updates in treatment

Fibroids or leiomyoma of myometrium are the most common benign tumor in females. There are currently many modalities, both medical and surgical, for the management of fibroid in today's practice such that it is often confusing as to which treatment to apply to which patient. Fibroid patients often present with a variety of symptoms and demographic aspect. Therefore a single guideline is not sufficient to encompass the case management for a specific Fibroid patient. Similarly the incidence of uterine sarcoma in patients undergoing fibroid treatment is thought to be minimal, but there is a current debate whether this risk is underestimated. The novel approach towards fibroids has allowed greater extent of uterine preservation but at the cost of decreased direct histological access, hence resulting in delay of diagnosis, especially in the case where uterine sarcoma is a possibility. Therefore gynecologists have to face the clinical dilemma to diagnose accurately and choose the most suitable treatment from the vast array of options available for each patient. The purpose of this article is to reconsider the different methods of treatments available and apply the most tailored treatment in each patient. This is a platform to better counsel for fibroid patients and their management

Retrospective analysis of maternal mortality at tertiary care hospital, during 2012- 2014

Background: The Maternal Mortality Ratio [MMR] of a country is indicative of its health and developmental status. The aim of the study is to determine the frequency of maternal mortality and identify the causes with different age groups, parity and gestational in 4 campuses of Ziauddin University and Hospitals, during the period 2012- 2014

Methods: A descriptive study conducted at the Gynecology and Obstetrics units of Ziauddin university hospitals with retrospective review of validated records of hospital registers in the last 3 years during January 2012 to December 2014. Convenience sampling used to access the records. A self-structured proforma designed to collect data on variables like age, parity, gestational age, cause of death, condition at the time of admission, duration of stay in hospital before death, cause of delay were part of the questionare

Results: In the three years period from January 2012 to December 2014 there were 32 maternal deaths. Total number of births was 14219 out of which 14184 were live births. MMR [Maternal Mortality Ratio] was 226 per 100000 live births. Eclampsia and haemorrhage were the leading cause of maternal mortality. Seven [21.8%] patients died due to postpartum haemorrhage and 7 [21.8%] from eclampsia and its complications, while 4 [12.5%] patients had puerperal sepsis

Conclusion: Maternal mortality was high with leading causes as, eclampsia, haemorrhage, and sepsis in the age of 20-30 years and parity 1-4. Mostly, deaths were due to delay in getting full term females to the health facility in time

efficacy of doxylamine succinate and pyridoxine combination in nausea and vomiting of pregnancy

Background: Nausea vomiting of pregnancy [NVP] is a common problem .A severe form called hyperemesis gravidarum occurs in 0.3-2.3% of pregnancies, which can adversely affect the lifestyle. This study is conducted to improve the confidence of obstetricians for treatment of nausea and vomiting of pregnancy

Objective: To determine the efficacy of doxylamine succinate with pyridoxine combination in nausea and vomiting of early pregnancy

Methods: Study conducted at Dr. Ziauddin University and Hospitals Karachi, from 25-02-2011 to 25-07-2011. Study design was case series, during the period of study total number of OPD patients in gynaecology and obstetrics department Ziauddin hospital were 821, out of them 190 patients of 20 years to 39 years of age with 9+ 2 weeks gestation were enrolled and sample was taken by Consecutive sampling

Results: 182 [95.8%] patients reported improvement in symptoms i.e. positive efficacy, 7 patients [3.7%] reported no difference in nausea vomiting and only 1 patient i.e. 0.5% reported aggravation of her symptoms. Total PAQUE score before treatment was as high as 12.3526 with standard deviation of 2.12739, which reduced to 5.7211 with standard deviation 2.0908 after treatment of nausea vomiting with doxylamin succinate + pyridoxine combination. P value calculated for total PAQUE score before and after treatment is 0.000

Conclusion: This study concluded that for nausea and vomiting of pregnancy, doxylamine succinate is effective when given for moderate to severe symptoms. So it should be considered as 1st line of treatment for nausea and vomiting of pregnancy

Medical management with vaginal misoprostol versus surgical management for first trimester pregnancy failure

Background: The incidence of clinically recognized miscarriages remains around 10-20%.The most common type of early pregnancy failure include spontaneous abortion, anembryonic gestation and embryonic or fetal death [missed miscarriage].In this study we compared the effectiveness of vaginal misoprostol for the management of first trimester pregnancy loss in obtaining adequate evacuation of uterus as an alternative to surgical evacuation in a tertiary care hospital

Methods: This was a Quasi experimental trial conducted at Ziauddin University Hospital and the study participants were 180 women who presented with first trimester miscarriage upto 12 weeks of gestation. The women were divided into two groups according to their choice [90 women in each]. Group one named Misoprostol group who received tablet Misoprostol 800mcg vaginally, two dose 6 hours apart. Group two named surgical evacuation group, who underwent surgical evacuation under general anesthesia

Results: The success rate in achieving complete evacuation of uterus was 82.8% in misoprostol group in the current study while in surgical evacuation group it was 100%.No serious side effects were encountered in misoprostol group

Birth of quintuplets a great challenge

Different names have been used for multiple births depending on the number of offspring of which common multiples are 2 and 3, in our case we have 5. They are associated with high rates of complications like: preterm labor, pre eclampsia, low birth weight and significant perinatal mortality and morbidity. Quintuplets occur rarely making the survival of infants even rarer. We here report a case of non-booked woman who presented in her third trimester of gestation. Who on ultrasound was found to be having 4 babies but surprisingly at the time of delivery,5 babies were delivered by caesarean section, of which one was IUD [intrauterine death] and another baby expired on the second day of operation due to interventricular hemorrhage as the infant was of low birth weight and premature. The remaining infants were kept in NICU. This is a very precious pregnancy and since we found out that the frequency of multiple pregnancies with more than two fetuses has increased considerably since the introduction of methods of ovulation induction the case was looked on carefully according to the requirements

Undiagnosed cervical ectopic pregnancy is a threat to life

Cervical ectopic pregnancy implants in the lining of endocervical canal. Cervical ectopic is rare form of ectopic pregnancy and incidence of cervical ectopic pregnancy is 1:9000 pregnancies .We are reporting a case report of a 35 years old female P1+0 was presented in OPD with continuous per vaginal bleeding since 3 months. MRI pelvis showed 4.8x4.5x4.2 cm lesion involving the entire cervix including stroma with partial obstruction of endocervical canal. Growth was removed digitally with difficulty and was sent for frozen section and biopsy. Hemostasis was secured with great difficulty by taking sutures and cervix was packed. Report of frozen section showed products of conception. Injection Methotrexate was given intramuscularly. Cervical ectopic pregnancy was associated with significant hemorrhage which led to hysterectomy in the past. Mortality is limited and fertility is preserved by improved ultrasound resolution, MRI and earlier detection of these pregnancies which has led to the development of more conservative treatments

Pelvic arterial embolization for the control of intractable pelvic hemorrhage: retrospective analysis of 13 cases

Background: Obstetric hemorrhage is one of the most important causes of maternal mortality. Severe postpartum hemorrhage is known to raise the mortality rate. There is a higher incidence of death from obstetric hemorrhage in developing countries as opposed to developed countries

Objective: To emphasize the role of interventional radiology in the management of obstetric and gynaecological haemorrhage in under developed countries like Pakistan

Methods: The retrospective data of all patients requiring pelvic artery embolization for the control of pelvic hemorrhage was studied at Ziauddin University Hospital during the period from April 2011 to June 2014. Main outcome measure was the effectiveness to control hemorrhage. Technical success was defined as the cessation of bleeding on the post embolization angiogram and cessation of vaginal bleeding at speculum inspection performed immediately after PAE. Clinical success was said when the bleeding stopped completely after the first course of PAE and no additional PAE or surgery was required

Results: A total of 13 patients underwent pelvic artery embolization [PAE] during this period. Five patients had primary postpartum haemorrhage [PPH], in which 3 patients had PPH after caesarean sections, one due to uterine atony secondary to triplets delivery, second had placenta praevia and third had placenta accreta. Two patients had uterine rupture, one following the normal vaginal delivery and other had previous 2 caesarean sections, uterine scar ruptured at 28 weeks of gestation. Two patients had secondary PPH, one due to uterine artery pseudo aneurysms after caesarean section and other had normal vaginal delivery. Six patients underwent pelvic artery embolization due to gynaecological cause i.e. heavy menstrual bleeding and pain secondary to fibroids. One patient had total abdominal hysterectomy and bilateral salpingoopherectomy due to fibroids but she continued to have bleeding from vaginal vault .Laparotomy was done twice but she continued to bleed so finally underwent pelvic arterial embolization after which bleeding stopped. All patients underwent selective embolization of the uterine artery or anterior divisional branch of the internal iliac artery with successful haemorrhage control and no immediate complications. PAE when done, in Gynae patients with fibroid resulted in severe abdominal pain immediately after the procedure for which analgesic medicines were given and the pain settled. These patients were followed in clinics and found to have significant decrease in their symptoms like 88% reduction in menorrhagia and 100% improvement in pain in six months period after procedure. Imaging scans were also done to follow the size of fibroid that were found reduced 17-63%

Conclusion: Selective pelvic embolization is a safe and effective treatment for acute obstetric or gynaecological haemorrhage and should be part of the management algorithm for PPH and for the treatment of symptomatic fibroids in females who especially want to conserve their uterus

Postpartum infection can be a disaster

Endometritis is the most common infection that occurs postpartum. Postpartum endometritis is tenfold to 20-fold more common among women who delivered by cesarean section than women who delivered vaginally. It can present with puerperal pyrexia, abscess formation and rarely rupture of uterus. Reported risk factors for dehiscence of the lower segment uterine scar following CS are multiparty, infection, and an incision placed too low in the lower uterine segment. The case presents a report of a 34 year old female Para 3+0 who was presented in emergency with high grade fever and abdominal pain. She undergone a caesarean delivery 9 days prior to presentation in a private clinic. Due to infection her uterus was found to be ruptured on exploratory laparotomy which is reported very rarely. Uterus was irreparable so obstetrical hysterectomy was done and patient was kept in ICU

Maternal and perinatal outcome in women having VBAC

Background: Caesarean section rate as a mode of delivery has been increasing in the recent years despite the three fold increased risk of mortality compared to vaginal deliveries. This study is conducted to determine the mode of deliveries and their maternal and fetal outcome

Objective: To determine the maternal and perinatal outcome in women having a VBAC [Vaginal Birth after Cesarean Section] and to assess the safety of VBAC

Methods: A total of 206 pregnant females fulfilling the inclusion criteria were selected via consecutive sampling. Patients with previous 1 LSCS were observed for outcome. This study was conducted at Department of Obstetrics and Gynecology, Ziauddin Hospital, Kemari Campus, Karachi employing case series over a period of one year

Results: Of the 206 patients 72.8% delivered vaginally. Of these 60% of the patients with VBAC had no maternal or perinatal complication while 27.8% has failed trial of labor and had emergency caesarean section due to different reasons .Approximately 13.6% of patients had impending uterine rupture while undergoing VBAC trial needing emergency LSCS with 1% complicated by scar rupture, 4% developed scar tenderness leading to emergency LSCS, 1% resulted in vaginal hematoma and 1% with cervical tear.The perinatal outcome in VBAC was a NICU admission of 6.9%; Meconium stain liquor: 6.8%; Fetal distress 1.9% and no perinatal death

Conclusion: is safe and good modality to reduce caesarean section rate and should be offered and conducted under close monitoring and is successful with few maternal and perinatal complications

Misoprostol toxicity

Misoprostol is a synthetic prostaglandin E1 analogue, commonly used for the medical termination of pregnancy in the first trimester. We present a case of a 29-year-old woman who was admitted due to misoprostol overdose, for a self induced abortion followed by a second overdose for a suicidal attempt. Manifestations of toxicity included agitation, high-grade fever, abdominal pain, diarrhea and minimal pervaginal bleeding. She was managed by a multidisciplinary team involving Medical, Psychiatric and Gynaecological doctors. Treatment was supportive and included gastric lavage, administration of intravenous fluids, anti-pyretics and analgesics. The pregnancy and fetal viability was followed on serial beta hCG levels and ultrasound scan respectively, and required surgical management of miscarriage. Patient was discharged in satisfactory physical condition

Peritoneal tuberculosis - a gynecologist's dilemma

Tuberculosis [TB] can involve the entire gastrointestinal tract [GI] including the peritoneum and the pancreatobiliary system. Tuberculous infection of the peritoneum is rare in developed, countries but significant in countries with a high prevalence of TB. It is commonly seen in individuals less than 40 years of age with female predominance. It can be found in pulmonary and extra pulmonary sites. The case reported here is of tuberculous peritonitis in a 30 years old female which was diagnosed incidentally during caesarean section and was kept on antitubercular treatment [ATT]. She did not respond to ATT. Laparotomy was performed because of increasing pain, abdominal distension and multicystic lesions in ovaries. ATT alone may be an effective treatment in pelvic-peritoneal tuberculosis, obviating the need for invasive methods. Indications for surgery may include persistence of pelvic mass and recurrence of pain or bleeding after 9 months of ATT

Hypertension in pregnancy: a review of preecamplesia, its effects and management

Hypertension complicates 5% to 7% of all pregnancies. Pre-eclampsia is a major contributor to maternal mortality worldwide. In Africa and Asia they contribute to 9% of deaths. A subset of preeclampsia, characterized by new-onset hypertension, proteinuria, and multisystem involvement, is responsible for substantial maternal and fetal morbidity and is a marker for future cardiac and metabolic disease. It is a pregnancy-specific disease characterized by de-nova development of concurrent hypertension and proteinuria, sometimes progressing into a multi organ cluster of varying clinical features. Poor early placentation is especially associated with early onset disease. Symptomatic clinical management should be mainly directed to prevent maternal morbidity [e.g. eclampsia] and mortality. Expectant management of women with early onset disease to improve perinatal outcome should not preclude timely delivery - the only definitive cure

Complete heart block in pregnancy: a curable entity

Pregnancy complicated complete heart block is a high-risk situation. Maternal complete heart block [CHB], which manifests for the first time during pregnancy and peurperium, poses a challenge to treating physicians. Pace maker insertion is recommended early in case the patient is symptomatic or has a prolonged Q-T interval or left atrial enlargement on ECG. We are reporting a case of a pregnant woman G 2 para1+O with 31 weeks of pregnancy with complete heart block. She presented complains of sudden onset of localized epigastric pain which was accompanied with shortness of breath and non-projectile vomiting. Apart from these symptoms, she did not feel any palpitation. She was conscious and oriented with a pulse rate 44-bpm and BP 151/71mmHg. ECG confirmed the diagnosis of complete heart block. A permanent pacemaker was placed. She delivered at 37 weeks of gestation with an alive and healthy baby by. Caesarean section due to ruptured membranes. When a multidisciplinary approach is used, both maternal and neonatal outcomes are good

Massive endometroid ovarian carcinoma and synchronous uterine malignancy

The diagnosis of ovarian carcinoma is a challenging task especially when women usually present vague symptoms like abdominal distension and pain. The aim of this paper is to report a case of synchronous ovarian malignancy in a young patient. A 86 year old unmarried female presented with a huge right ovarian cystic mass occupying the, whole abdomen, breathlessness, jaundice and urinary retention. She underwent laparotomy for surgical removal of the mass and during the surgical procedure a frozen section was performed that showed malignancy. Total abdominal hysterectomy and bilateral salpingo ophorectomy was thereafter performed on her. Final histopathological report of the mass revealed well differentiated endometroid ovarian cancer and endometroid endometrial cancer. Synchronous endometroid tumors are generally present in young patients; these tumors tend to be of low grade malignancy. Prognosis of endometroid carcinoma is relatively better than other histological types

Ruptured uterus in primi para

Rupture of a gravid uterus is a surgical emergency. Spontaneous rupture of the uterus in a primipara is very rare. Furthermore, uterine rupture prior to the onset of active labor is extremely uncommon in a primipara, with very few reported cases. We present a case of antepartum uterine rupture in a 23-year-old gravida 2 para 0+1 with 26 weeks pregnancy in whom the clinical features resembled those of abruption placentae. She had past history of one uterine curettage and now presented with 26 weeks pregnancy and abdominal pain of sudden onset. After ultrasound scan, uterine rupture was diagnosed and an emergency laparotomy done. The entire amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus

large chorioangioma can result in adverse perinatal outcome

Chorangioma of the placenta is a common benign vascular tumor of the placenta with a frequency of about 1%. It is threatening as it often goes unnoticed and presents potentially serious fetal risks and making it necessary to keep the pregnancy under surveillance. It usually presents as a solitary nodule or, less frequently, as multiple nodules, consisting of blood vessels and stroma. Most of these tumors are small and have no adverse effects on the fetus. Large tumors are associated with complications affecting mother and the fetus which may cause sudden intrauterine fetal death. Chorangiomas act as peripheral shunts between arteries and veins, leading to progressive heart failure of the fetus. In the case prenatal diagnosis is achieved by ultrasonography and Doppler studies are used confirm the highly vascular nature of the mass. As the tumor is associated with unfavorable side-effects on the mother and fetus like polyhydroamnios, prematurity, toxemia, hydrops, fetal heart failure and, intra uterine death, regular monitoring is required to detect and manage complications early on in the pregnancy. A large size of the tumor is indicative of a higher probability of complications. The case presented is that of a large chorioangioma in a primigravida without any serious complications and a successful outcome

Acute fatty liver in pregnancy: a rare but catastrophic complication of late

Acute fatty liver of pregnancy [AFLP] is a sudden catastrophic illness occurring almost exclusively in the third trimester, where microvesicular fatty infiltration results in encephalopathy and hepatic failure. Although the exact pathogenesis is unknown but the disease has been linked to an abnormality in fetal fatty acid metabolism. This abnormality is a deficiency in the LCHAD [long-chain 3-hydroxyacyl-coenzyme A dehydrogenase] enzyme Clinical manifestation usually manifests in the third trimester [35 to 36 weeks of gestation] but some cases occur with a range of 28 to 40 weeks. The diagnosis of acute fatty liver of pregnancy is challenging task for clinician because of the nonspecific clinical presentation which may mimic conditions such as acute viral hepatitis, pre-eclampsia, HELLP syndrome. Ultrasound, CT, MRI may be used to diagnose this disease. Liver biopsy is the gold standard for the diagnosis of AFLP. The condition was previously thought to be universally fatal[2] but aggressive treatment by stabilizing the mother with intravenous fluids and blood products in anticipation of early delivery has improved prognosis. Liver transplantation may be the option for severe liver failure patients. The mortality from AFLP is approximately 18% and deaths are usually secondary to sepsis, renal failure, circulatory collapse, pancreatitis or gastrointestinal bleeding

Molar ectopic pregnancy; an unusal presentation. A case report

Ectopic molar pregnancy is a rare occurrence. Clinical diagnosis of a molar pregnancy is difficult but histopathology is the gold standard for diagnosis. The management of ectopic molar pregnancies consists of surgically removing the conceptus, follow up and chemotherapy, if required. We are reporting a case report of a 35-year-old married, nulliparous woman, admitted in emergency with a 6-week history of amenorrhea, severe abdominal pain and an episode of fainting at home. Per abdominal examination revealed tenderness over the right iliac fossa, with guarding and rigidity. Diagnosis of ruptured ectopic pregnancy was made.Emergency laparotomy was done. Histopathological examination, showed tubal ectopic pregnancy with partial hydatidiform mole and a separate corpus luteal cyst. She was followed up with serial beta hCG which became normal within 1 month. Although ectopic molar pregnancy is a rare entity but all ectopic pregnancies should be examined histologically to rule out presence of gestational trophoblastic disease to plan follow-up accordingly in order to avoid persistent gestational trophoblastic disease which has a chance of malignant conversion.The prognosis of ectopic molar pregnancies is the same as for other forms of gestational trophoblastic disease