A Two-Year Analysis Of Uterine Rupture In Pregnancy.

BACKGROUND: Uterine rupture, an obstetrical emergency though rare but still has grave implications. Uterine rupture is the occurrence of breach in the wall of uterus. Complete rupture involves complete disruption of uterine wall resulting in spillage of uterine contents into the abdominal cavity whereas an incomplete rupture has intact peritoneum or serosa. The most commonly reported risk factor in developed countries is previous caesarean section whereas in developing countries neglected and obstructed labour are more frequently reported predisposing factors. METHODS: This was a cross sectional descriptive study which was carried out for a period of 2 years from January 2015 to December 2016 in Gynae "A" unit of Ayub Teaching Hospital Abbottabad. RESULTS: In our study frequency of uterine rupture was 0.63%. Previous scar dehiscence was the most common risk factor for uterine rupture. Maternal mortality was 4% out of total 52 ruptured uterus, while 94.2% was perinatal mortality. CONCLUSION: Although uterine rupture can be prevented but its frequency is still high. Therefore, proper antenatal care, health education, utilisation of health facilities is needed to reduce adverse outcome associated with this avoidable condition..

Analysis Of Two Years Cases Of Ectopic Pregnancy.

BACKGROUND: Ectopic pregnancy is the leading cause of pregnancy related deaths in the first trimester. The aim of this study was to evaluate the frequency of risk factors, clinical presentation, diagnostic methods and site of ectopic pregnancy. METHODS: This descriptive cross sectional study was conducted in Gynaecology and Obstetrical Unit-A of Ayub Teaching Hospital Abbottabad from 1st October 2013 to 31st October 2015. All women diagnosed with ectopic pregnancy were included in the study. A predesigned proforma was used to record the details about demographic features, risk factors, clinical features at presentation, diagnostic methods and site of ectopic pregnancy. RESULTS: Out of total 6675 patients admitted during the study period, 45 cases of ectopic pregnancy were diagnosed with frequency of ectopic pregnancy to be 0.65%. Mean age of the patients was 28.98±5.525. Majority of patients were primigravida14 (31.3%), 9 (20.0%) gravida 2, 5 (11.1%) gravida 3, 4 (8.8%) gravida 4, 7 (15.5%) gravida 5, 6 (13.3%) found grand multi out of total 45 ectopic pregnancies, 45% of the patients had no identifiable risk factors, however history of infertility 20 (22.22%), history of Pelvic inflammatory disease (PID) 10 (22.22%), previous ectopic 2 (4.44%) and previous abdominal pelvic surgery 3 (6.67%) were identified as common risk factors of 45 ectopic pregnancies. Out of total 45 sufferers 23 (51.11%) were clinically diagnosed, 20 (44.44%) through abdominal ultrasound and 2 (4.44%) through transvaginal ultrasound. The most frequent clinical presentation was amenorrhea 30 (66.67%) followed by abdominal pain 28 (62.22%), irregular vaginal bleeding 18 (40.00%), asymptomatic patients with routine ultrasound 18 (40.0%) and 10 (22.22%) presented in shock. Twenty-eight (62.2%) of the ectopic pregnancies were found in right sided fallopian tube and 17(37.8%) were found in left sided fallopian tube. The commonest site of ectopic pregnancy was ampulla 29 (64.44%) followed by 11 (24.44%) Isthmus, 4 (8.89%) fimbrial end and 1 (2.22%) were rudimentary horn of uterus out of total 45 ectopic pregnancies. Evidence of 32 (71.1%) patients with ruptured ectopic was recorded. Thirteen (28.9%) were unruptured ectopic. CONCLUSIONS: Amenorrhea and abdominal pain are the most consistent features of ectopic pregnancy.

ZIKA VIRUS INFECTION; VERTICAL TRANSMISSION AND FOETAL CONGENITAL ANOMALIES.

Zika virus (ZIKV) is an arbovirus belonging to flaviviridae family that includes Dengue, West Nile, and Yellow Fever among others. Zika virus was first discovered in 1947 in Zika forest of Uganda. It is a vector borne disease, which has been sporadically reported mostly from Africa, Pacific islands and Southeast Asia since its discovery. ZIKV infection presents as a mild illness with symptoms lasting for several days to a week after the bite of an infected mosquito. Majority of the patients have low grade fever, rash, headaches, joints pain, myalgia, and flu like symptoms. Pregnant women are more vulnerable to ZIKV infection and serious congenital anomalies can occur in foetus through trans-placental transmission. The gestation at which infection is acquired is important. Zika virus infection acquired in early pregnancy poses greater risk. There is no evidence so far about transmission through breast milk. Foetal microcephaly, Gillian Barre syndrome and other neurological and autoimmune syndromes have been reported in areas where Zika outbreaks have occurred. As infection is usually very mild no specific treatment is required. Pregnant women may be advised to take rest, get plenty of fluids. For fever and pain they can take antipyretics like paracetamol. So far no specific drugs or vaccines are available against Zika Virus Infection so prevention is the mainstay against this diseases. As ZIKV infection is a vector borne disease, prevention can be a multi-pronged strategy. These entail vector control interventions, personal protection, environmental sanitation and health education among others.

LEFORT'S COLPOCLIESIS IN ELDERLY WOMEN HAVING PELVIC ORGAN PROLAPSE AND MEDICAL COMORBIDITIES.

Lefort's colpocliesis is surgery done in patients having pelvic organ prolapse associated with medical co-morbidities. Added to this it is done in elderly patients no more interested in marital relations. This procedure is not commonly done in our setup and there are few case reports in our region. We have very few successful case of this procedure. Here we are presenting a report of successful repair. This elderly lady presented to us with chief complaints of 3rd degree prolapse. She was diagnosed as a cardiac patient after proper investigation, so she was unfit for general anaesthesia and major surgery. Ultimately she was operated upon Lefort's procedure. On her first follow-up visit she was having healthy wound and good satisfaction.

Frequency of placenta previa in women with history of previous caesarean and normal vaginal deliveries.

BACKGROUND: Placenta previa is known to be associated with previous caesarean deliveries, advanced maternal age, increasing parity, smoking, curettage and myomectomy. This study was carried out to compare the frequency of placenta previa, in women with previous caesareans versus those with normal vaginal deliveries. METHODS: It was one year study conducted at the Department of Obstetrics and Gynaecology Unit B, Ayub Teaching Hospital, Abbottabad. One hundred women were included in the study, 50 in Group A with previous caesarean deliveries, and 50 in Group B with previous normal vaginal deliveries. Frequency of placenta previa in both groups was analysed. RESULTS: Placenta previa was found in one (2%) woman in Group A, and in two women (4%) in Group B. It was not found in para 4 or less in both groups. One woman in Group A and two women in Group B with parity 4 or more had placenta previa (p < 0.05). None of the women with previous one scar had placenta previa, while with previous 2 scars one had placenta previa (p < 0.05). One woman with placenta previa in Group A and both women with placenta previa in Group B were more than 25 years old. Placenta previa was not found in women below 25 years of age. CONCLUSION: Previous one caesarean section did not increase the frequency of placenta previa. Increasing number of scars, increasing maternal age beyond 25 years and increasing parity beyond 4 were associated with placenta previa.

Disseminated intravascular coagulation.

BACKGROUND: Disseminated Intravascular Coagulation (DIC) is a complex systemic thrombohaemorrhagic disorder characterised by widespread endothelial damage. Aim of this study was to assess the prevalence of DIC in different obstetrical conditions. METHODS: This descriptive study was carried out in the Department of Obstetrics and Gynaecology Unit 'A', Ayub Medical College, Abbottabad from January 2010 to December 2011. All 40 diagnosed cases of DIC were included, and their risk factors and maternal/foetal outcome were evaluated. RESULTS: Out of 4,334 obstetrical admissions, DIC was diagnosed in 40 (0.92%) patients. Risk factors noted were eclampsia 28 (70%), abruptio placentae 7 (17.5%), septicaemia 3 (7.5%), pancytopenia 1 (2.5%), and 1 (2.5%) patient had DIC secondary to haemorrhagic shock due to placenta previa. Mean age range of patients was 31 +/- 6.69 (19-48) year, and parity was 3.17 +/- 2.56 (0-10). Mode of delivery of 34 (85%) patients was by caesarean section, and vaginal delivery occurred in 3 (7.5%) patients. Eleven (27.5%) patients had caesarean hysterectomy. Maternal mortality was 25% and perinatal mortality was (47.5%). Majority of our patients were critical and were managed in ICU. CONCLUSION: DIC is serious life threatening condition secondary to any underlying pathology. There is spontaneous resolution of DIC after correction of pathology.

Maternal mortality in a tertiary care hospital.

BACKGROUND: Death of a woman during pregnancy and child birth is an extremely tragic event. It is a waste of a precious life that leaves great feeling of grief and pain for the family and hospital staff and has devastating influence on the community overall. Maternal morbidity and mortality can be prevented by awareness of reproductive health in a community, availability, and utilisation of organised antenatal care, skilled intrapartum management and careful postnatal follow up. Objective was to analyse the pattern of maternal mortality over the period of five years in a tertiary level hospital receiving high risk referred patients form periphery. METHODS: All patients admitted in Gynae 'A' Unit, Ayub Teaching Hospital from January 2006 to December 2010 were included in the study and number and causes of maternal deaths were noted. RESULTS: During these 5 years there were 78 maternal deaths out of 11,997 obstetrical admissions. There were 7,380 total births and 78 maternal deaths during the study period and Maternal Mortality Rate was 1,057/100,000. The main cause of maternal death was eclampsia and its complications (28.2%). CONCLUSION: Eclampsia is the leading cause of maternal mortality in our setup. Proper and timely referral is an important measure to prevent it.

Abruptio placentae and its complications at Ayub Teaching Hospital Abbottabad.

BACKGROUND: Abruptio placentae remains a major cause of perinatal morbidity and mortality globally, though of most serious concern in the developing world. As most known causes of abruptio placentae are either preventable or treatable, an increased frequency of the condition remains a source of medical concern. METHODS: The present study was undertaken at the Department of Obstetrics and Gynaecology, Unit B, of the Ayub Teaching Hospital, Abbottabad, Pakistan, from July 2003 to June 2004. Patients of abruptio placentae were selected from all cases of 28 weeks or greater gestation, presenting with ante partum haemorrhage during the study period. Patients underwent a complete obstetrical clinical workup including history, general physical examination, abdominal and pelvic examination. Relevant investigations such as laboratory tests and imaging were performed. Patients were managed according to maternal and fetal condition. Any maternal and/or fetal complications were noted and recorded. All data were collected on predesigned proformas and analyzed by computer. RESULTS: A total of 53 cases of abruptio placentae were recorded out of 1194 cases (4.4%) admitted for delivery during the study period, giving a rate of 44 cases of abruptio placentae per 1000 deliveries. Induction of labour was required in 27 (50.9%) cases, while caesarean section was performed in 16 (30.2%) cases. Major complications were intra uterine fetal demise (31/53, 58.5%), fetal distress (8/22 live births, 36.4%) and post partum haemorrhage, which occurred in 10 (18.9%) cases. CONCLUSIONS: A higher than expected frequency of abruptio placentae exists in our setting and the consequences of abruptio placentae for neonatal mortality outcome are alarmingly high. The majority of patients presented with intra uterine death so that any management protocol directed at abruptio placentae or its consequences is of little help in preventing perinatal mortality.

Use of Foley's catheter and prostaglandin F-2 alpha in second trimester termination of pregnancy.

BACKGROUND: Termination of pregnancy (TOP) in the second trimester is associated with three to five times higher risk of maternal morbidity and mortality than termination during first trimester. The main concern of obstetrician is to provide the most effective and safest regimen which combines the shortest expulsion interval with least side effects. This study was undertaken to compare the use of Foley's catheter with extra-amniotic instillation of PGF2 alpha for second trimester TOP so that a choice of the safer and cost-effective method could be available. METHODOLOGY: The study was conducted in Department of Obstetrics and Gynecology Unit 'B' at Ayub Teaching Hospital Abbottabad between August 2003 and July 2004. Sixty patients recommended for TOP (missed abortion or anencephalic fetus confirmed on ultrasonography) were randomly allocated into two groups. In group 'A', Foley's catheter alone was used while in group 'B' extra amniotic instillation of Prostaglandin F-2 alpha (PGF2 alpha) was done via a Foley's catheter. After expulsion of catheters in both cases oxytocin infusion containing 30 units were started till the expulsion of fetus, placenta and membranes. The mean induction to expulsion time and the mean induction to delivery time for both groups were noted as well as total cost of treatment. RESULTS: Difference in time interval with regard to induction to expulsion time of catheter and induction to delivery time between the two groups was significant being 3 hours and 5 hours respectively less in group 'B' (p < 0.001); however only 25% of patients in group 'B' had a significant short induction to delivery time as compared to group 'A'. The difference in costs of treatment between the groups was also significant (p < 0.001). CONCLUSION: Use of PGF2 alpha is preferred, though for poor patients Foley's catheter may be used, but only in a tertiary care setting.

Minilaparotomy and ovarian diathermy drilling for clomiphene resistant poly cystic ovarian disease.

BACKGROUND: This study was carried out to determine the effectiveness and safety of minilaparotomy and ovarian drilling for sub fertile women with clomiphene resistant polycystic ovarian syndrome. METHODS: During a 2 year period (August 2000 to August 2002) 16 patients with polycystic ovarian disease were managed by minilaparotomy and ovarian drilling by diathermy. All the patients underwent full infertility workup and then treated with cyclical clomiphene citrate for 6 months. RESULTS: Six patients (37.5%) presented in age group 15-25 years. Eight patients (50.0%) were in age group 26-35 years. Only 2 (12.5%) patients presented in age group 36-44 years. Eleven (68.75%) patients had primary infertility. Five (31.25%) patients presented with secondary infertility. After treatment and 6 months follow up, ovulation occurred in 14 (87.5%) patients. Eleven (68.75%) women conceived pregnancy. CONCLUSION: Ovarian drilling is a powerful tool in the treatment of polycystic ovarian disease.