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

Magnesium sulphate in the prophylaxis and treatment of eclampsia

Magnesium Sulphate is considered to be the agent of choice for the control of eclamptic seizures in pregnant women. Our objectives were to determine frequency of eclampsia and pre-eclampsia in our unit and to determine the effect of initial loading dose of magnesium sulphate on maternal and fetal outcome. This study was carried out in Department of Gynaecology at Lady Reading Hospital, Peshawar. In the year 2000 only 133 patients received magnesium sulphate out of 228 cases of eclampsia and pre eclampsia due to the problems with the continuous supply of the drug. This included 53 cases of eclampsia and 80 cases of pre-eclampsia. Information regarding the dosage of magnesium sulphate labor out cone, maternal and fetal outcome, side effects and complications of therapy were evaluated from hospital case records. The magnesium sulphate regimen consisted of 4 gm loading dose as 20% solution intravenously over 10-15 minutes followed immediately by 5 gm into each buttock. Dose of 5gm intramuscularly was repeated only if the patient developed convulsions. Eclampsia and pre-eclampsia occurred in I in 25.5 and 1 in 34.4 deliveries respectively. Majority of patients received the initial loading dose of magnesium sulphate, but in 2 patients's dose had to be repeated. In two patients of pregnancy induced hypertension convulsions occurred soon after delivery unheralded by any signs and symptoms of impending eclampsia. Perinatal mortality was 19 [35.8%] and 16 [20%] in eclampsia and pre-eclampsia respectively. High perinatal mortality was attributed to prematurity as only 16.98% of eclampsia and 57.5% of Pre eclampsia were more than 37 weeks. One patient of sever pre-eclampsia developed postpartum hemorrhage and acute renal failure, but she recovered while another one developed sudden postpartum collapse immediately after delivery and died due to cerebrovascular accident. 8 patients of eclampsia died despite intensive management. All of them were referred from periphery with history of multiple fits and were brought in a serious state. Frequency of eclampsia and pre-eclampsia is high in this region with high perinatal and maternal morbidity and mortality. Magnesium sulphate is an effective drug to prevent and control seizures. It is easy to administer and subsequent nursing is easy. Seizures usually terminate after the initial loading dose of magnesium sulphate

Fallopian tube prolapse after abdominal hysterctomy

A 38 year old lady who had total abdominal hysterectomy, for chronic pelvic pain, presented with profuse vaginal discharge per vaginum along with a cystic pelvic mass of 10 week size. There was a polypoidal fleshy growth present in the vault. It was diagnosed to be a fallopian tube on histopathology. Patient was treated with bilateral salpingo-ophorectomy through an open laparotomy

audit of obstetrical hysterectomy

Analysis of all obstetrical hysterectomies, performed in hospital during one year period, to find out its rate of incidence and indications Design: All obstetrical hysterectomies during one year period were studied. Clinical details, operative findings, postoperative complications and specific data leading to obstetrical hysterectomy was evaluated. Place and Duration of Study: A prospective study was done from January 1995 to December 1995 in obstetrics and gynaecology unit 'B' of Postgraduate Medical Institute-Lady Reading Hospital, Peshawar. Subjects and The study was conducted on eighty-eight patients undergoing hysterectomy in the obstetric and gynaecology unit of Lady Reading Hospital, Peshawar. Record of all the patients was analyzed. Out of a total 7647 obstetric admissions. Out of these 2940 patients delivered. This included 439 [14.39%] caesarean sections. 88 [2.9%] patients had emergency obstetric hysterectomies. Incidence was 1 in 33 deliveries. All hysterectomies were performed as lifesaving procedures mainly due to ruptured uterus [54.5%], uncontrollable hemorrhage due to atonic uterus [27.27%], laceration [7.9%], and placenta increta [5.6%]. Other indications included placenta previa, placenta percreta, infected septic uterus and fibroid in the lower segment. Subtotal abdominal hysterectomies were done in 78 [88.6%] patients while 10 patients [11.36%] had total abdominal hysterectomies. Despite multiple pre-operative obstetric complications 73 patients recovered completely while 15 maternal deaths occurred [17.04%]. Of these 9 were considered inevitable because of delay in being transferred to hospital while 6 were unexpected and were considered preventable. Bilateral ligation of internal iliac artery was performed in 18 patients. Postoperative morbidity occurred in 67.0%. The high incidence of obstetrical hysterectomies indicate the lack of knowledge and negligence among population about pregnancy and child birth. Adequate education of primary health providers, traditional birth attendants and early referral is essential to reduce this condition