Assessment Of Caesarean Section Rate Using Robson Ten Group Classification System In A Tertiary Care Hospital: A Cross Sectional Study.

BACKGROUND: The growing rate of caesarean section is a major concern for quality of maternal life and public health. Concerns about such increases prompted the WHO to recommend Robson ten group classification system for assessing the Caesarean Section rate. The present study's aim was to assess the caesarean rate using Robson's ten group classification system and highlighted the reliable information system, in turn, helps to construct interventions to reduce avoidable caesareans. METHODS: This cross sectional study was carried out on 5796 women who delivered from 25th November 2021 to 24th November 2022 in Jinnah Post Graduate medical Centre Karachi. Data was collected from the women admitted for delivery using Robson's Pro forma. Relative size and caesarean rate of each group and overall caesarean section rate was calculated. RESULTS: Of the total 5796 deliveries, 2141 (36.9%) were caesarean deliveries and 3655 (63.1%) had normal deliveries. Out of Robson's ten groups system, Group 10 had a higher contribution of 705 (12.2%) to the overall caesarean rate followed by group 5 had 627 (10.8%). The contributing prevalence of Group 1, 2, 3, 4, 6, 7, 8 and 9 were 122 (2.1%), 317 (5.5%), 50 (0.87%), 167 (2.9%), 42 (0.72%), 35 (0.6%), 49 (0.85%) and 27 (0.46%) respectively. CONCLUSIONS: Our study concluded that Group 10 and 5 were the most responsible for the whole Caesarean Section rate. In all contributing groups, there is a need to identify the indications and to sub classify these groups further so that preventable caesarean sections can be avoided by reducing these factors.

Frequency of HIV among patients seeking antenatal care at a tertiary care hospital, Karachi.

Objective: To determine the frequency of human immunodeficiency virus among pregnant women reporting for antenatal care at a tertiary care hospital. METHODS: The cross-sectional study was conducted at Unit-1 of the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi, from August 2018 to January 2019, and comprised all women attending antenatal clinics aged 15-40 years having gestational age of at least 10 weeks confirmed by trans-vaginal/trans-abdominal scan. Data was collected using a predesigned questionnaire. Data was analysed using SPSS 21. RESULTS: There were 642 pregnant women with a mean age of 25.80±4.91 years, and mean gestational age of 24.34±5.38 weeks. Of the total, 5(0.7%) subjects had family history of human immunodeficiency virus and 1(0.2%) had a positive result for the virus. There was significant association of human immunodeficiency virus with family history of the disease (p=0.001) and with history of drug abuse (p=0.003). Conclusion: Screening of human immunodeficiency virus during the antenatal period is a useful tool for better management.

Awareness, screening, practices and attitudes of cervical cancer among doctors and nursing staff working at a tertiary care centre.

Objectives: To assess knowledge, attitude and practice of medical and paramedical staff about cervical cancer as well as its screening and prevention. METHODS: The descriptive cross-sectional study was conducted at the Jinnah Post-graduate Medical Centre, Karachi, from March 1 to August 30, 2019, and comprised women medical and paramedical staff randomly selected from different specialties. Data was collected using a structured questionnaire. Data was analysed using SPSS 20. RESULTS: Of the 347 participants 144(41.5%) were nurses and 203(58.5%) were doctors. The overall mean age was 26.22±6.38 years. Of the total, 108(30%) respondents were married and 239(68%) were single. Overall, 239(68.8%) were well aware of Pap smear being the screening test; 85(24.5%) were aware of the true guidelines to repeat the test; 152(43.8%) had an idea of the exact use of visual Inspection with acetic acid; 61(17.6%) had got a Pap smear done; and 156(45%) thought they were at risk of developing carcinoma cervix. The common risk factors identified were multiple sexual partners 254(73.2%), age at first sexual intercourse 160(46%), smoking 131(37.8%), foul-smelling discharge 221(63.7%), and post-coital bleeding 231(66.6%). CONCLUSIONS: Cervical cancer prevalence is rising due to inadequate knowledge and awareness among healthcare personals. Improvement can be brought by regular use of Pap smear.

"Outcomes of COVID-19 infection in patients with hematological malignancies- A multicenter analysis from Pakistan".

PURPOSE: COVID-19 infection resulting from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began to spread across the globe in early 2020. Patients with hematologic malignancies are supposed to have an increased risk of mortality from coronavirus disease of 2019 (COVID-19) infection. From Pakistan, we report the analysis of the outcome and interaction between patient demographics and tumor subtype and COVID-19 infection and hematological malignancy. PATIENTS AND METHODS: This multicenter, retrospective study included adult patients with a history of histologically proven hematological malignancies who were tested positive for COVID-19 via PCR presented at the oncology department of 5 tertiary care hospitals in Pakistan from February to August 2020. A patient with any known hematological malignancy who was positive for COVID-19 on RT-PCR, was included in the study. Chi-square test and Cox-regression hazard regression model was applied considering p ≤ 0.05 significant. RESULTS: A total of 107 patients with hematological malignancies were diagnosed with COVID-19, out of which 82 (76.64%) were alive, and 25 (23.36%) were dead. The significant hematological malignancy was B-cell Lymphoma in dead 4 (16.00%) and alive group 21 (25.61%), respectively. The majority of the patients in both the dead and alive group were on active treatment for hematological malignancy while they came positive for COVID-19 [21 (84.00%) & 48 (58.54%) p 0.020]. All patients in the dead group were admitted to the hospital 25 (100.00%), and among these, 14 (56.00%) were admitted in ICU with a median 11 (6-16.5) number of days. Among those who had contact exposure, the hazard of survival or death in patients with hematological malignancies and COVID-19 positive was 2.18 (CI: 1.90-4.44) times and 3.10 (CI: 2.73-4.60) times in patients with travel history compared to no exposure history (p 0.001). CONCLUSION: Taken together, this data supports the emerging consensus that patients with hematologic malignancies experience significant morbidity and mortality resulting from COVID-19 infection.

Frequency of Abruptio Placenta in Women With Pregnancy-Induced Hypertension.

BACKGROUND: Bleeding that takes place after premature separation of the normally situated placenta, usually after 20 weeks of pregnancy, is known as abruptio placenta. Factors increasing chances of abruptio placenta are advanced age pregnancy, parity, smoking, pregnancy-induced hypertension, pre-eclampsia, and previous incidence of abruptio. The objective of the study was to find the frequency of abruptio placenta in women with pregnancy-induced hypertension. METHODS: This descriptive prospective study was conducted in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi, from January to July, 2021. Women of gestational age above 20 weeks were included. Patients with blood pressure ≥140/90mmHg were considered as having pregnancy-induced hypertension. Early separation of the normally placed placental from the uterine wall was defined as placental abruption with clinical signs of painful vaginal bleeding (concealed or revealed), uterine contractions, and non-reassuring fetal heart rate. Descriptive statistics were calculated. Stratification was done and the post-stratification chi-square test was applied. P-value ≤ 0.05 was taken as significant. RESULTS:  A total of 205 patients were included in the study. The mean age was 24.26±2.92 years. The mean gestational age was 30.82±3.22 weeks. The mean parity was 2.59±0.80 children. Mean systolic blood pressure was 148.48±5.99 mmHg and mean diastolic blood pressure was 94.85±3.05 mmHg. Bleeding was reported in 110 (53.7%) cases. Lower abdominal tenderness in 125 (60.5%) cases. Fetal heart rate was normal in 16.6% of the cases. Abruptio placenta was observed in 29 (14.1%) patients. CONCLUSION: Abruptio placenta is a life-threatening condition that occurs during pregnancy that can result in both maternal and fetal morbidity and mortality. Adequate and urgent intervention can result in a favourable outcome.

Relationship Between Foot Length and Gestational Age in Pakistan.

Preterm births have a high risk of mortality. Therefore, knowledge of the gestational age (GA) at birth is crucial to guide the appropriate management of a newborn. Common methods for estimating GA such as the last menstrual period, ultrasonography, and post-natal Ballard scoring have some limitations. This study aimed to determine the relationship between foot length and GA to develop and validate an equation for predicting GA of Pakistani newborns. We conducted a prospective study in a large obstetric hospital in Pakistan. Data for this analysis were extracted from the hospital files of eligible women by trained study midwives. Midwives were also trained in performing the Ballard examination and taking foot length using a disposable measuring tape within an hour of the birth. The GA was calculated using an android-based GA calculator. Simple and multiple linear regression were used to construct predicting equations for GA. Both the foot length and GA were available for 1542 cases. The median GA was 34.5 (IQR 4.7) weeks and the median foot length was 7 cm (IQR 1.4). There was a positive linear relationship between foot length and GA (r 2 81.7%, P-value < .001). Stratified analysis showed an r 2 of 81.7% for males and 81.6% for females. The r 2 for stillbirths was 84.1% and, 82.3% for live births. The r 2 for macerated stillbirths was 88.6% and 90.6% for fresh stillbirths. In resource poor settings, the use of foot length can estimate GA in both live births and stillbirths and can easily identify preterm infants.

Comparison of CLIF-C ACLF Score and MELD Score in Predicting ICU Mortality in Patients with Acute-On-Chronic Liver Failure.

Introduction Acute-on-chronic liver failure (ACLF) is a serious complication of liver cirrhosis which presents with hepatic and/or extrahepatic organ failure and often needs admission to an Intensive Care Unit (ICU). This condition typically needs organ support and carries a high mortality rate. ICU care may not benefit these patients. There are many scores to assess prognosis in these patients, such as the Model for End-stage Liver Disease (MELD) score, the MELD score refined to take into account serum sodium level (MELD-Na), the chronic liver failure organ failure (CLIF-OF) score, the CLIF Consortium acute-on-chronic liver failure (CLIF-C ACLF) score and the Child-Turcotte-Pugh classification. This study was conducted to compare CLIF-C ACLF and MELD scores for selecting patients at risk of high mortality, as ICU care to these patients in the absence of liver transplantation may be of no value. Methods The data of 75 patients admitted to the ICU of Shifa International Hospital in Islamabad were prospectively analyzed. CLIF-C ACLF and MELD scores were calculated at admission and then at 24 and 48 hours after the ICU stay. Data were analyzed with the assistance of SPSS. Mortality was the primary outcome. Results Comparison of both scores showed that a CLIF-C ACLF score ≥ 70 at 48 hours predicts mortality more accurately, with an area under receiver operating curve (AUROC) of 0.643 (confidence interval [CI] 95% 0.505-0.781; p=0.046) which was significantly higher than MELD scores of 30,40 and 50 at 48 hours. Organ failure and the need for supportive care were strong predictors of mortality (p= < 0.05). Conclusion We concluded that a CLIF-C ACLF score ≥ 70 at 48 hours and organ failure are better predictors of mortality and that ICU care in these patients does not benefit them. Definitive therapy in the form of liver transplantation may have a promising role, if considered early.

Perceptions of health professionals regarding minimally invasive tissue sampling (MITS) to identify the cause of death in stillbirths and neonates: results from a qualitative study.

BACKGROUND: Pakistan is considered to be one of the riskiest places in the world for childbirth as measured by its high stillbirth and neonatal mortality rates. Complete diagnostic autopsy remains the gold standard to determine the cause of death (CoD); however, it is not routinely implemented due to religious objections, sociocultural beliefs, limited resources and low demand from physicians and families. Recently, minimally invasive tissue sampling (MITS) using needle biopsies of multiple tissues to obtain tissue for histological examination and organism identification with PCR has been developed and promoted to determine CoD in low-resource areas. To ensure successful implementation of MITS, it is important to understand health professionals' attitudes and perceptions related to MITS. METHODS: A qualitative study was conducted at the National Institute of Child Health (NICH), Karachi, Pakistan. Focus group discussions (FGDs) and Key-informant interviews (KIIs) were conducted with health professionals including doctors, nurses, trainees, clinicians, bioethics experts and public health experts to explore their perceptions and views on acceptability of MITS. Data were analyzed using NVivo 10 software. RESULTS: A total of 12 interviews (FGDs = 4; KIIs = 8) were conducted. Four overarching themes were identified: (I) acceptability of MITS; (II) perceived benefits of the MITS procedure; (III) factors facilitating the implementation of MITS; and (IV) health system requirements for implementing the MITS procedure. Generally, MITS was considered as a positive development for the health system. Diagnostic accuracy and identification of less common causes of death were highlighted as two main benefits of the MITS procedure. The study highlighted a number of facilitators for the acceptability of MITS including effective counseling, building trust with parents, fast procedure time, and approaching families within a few hours of death. In addition, lack of skilled staff, poorly equipped healthcare facilities and the potential high cost to conduct MITS were identified as challenges for the implementation of MITS. CONCLUSIONS: This formative research provided a unique opportunity to explore health professionals' views and attitudes towards the MITS procedure. Such insights are crucial to ensure successful implementation and integration of a new technique into the existing health system. The research identified the factors influencing the acceptability of MITS among health professionals in Pakistan. The study also informed factors that could help facilitate the implementation of the MITS procedures in the context of Pakistan and similar settings.

Perceptions of parents and religious leaders regarding minimal invasive tissue sampling to identify the cause of death in stillbirths and neonates: results from a qualitative study.

BACKGROUND: Recently, the minimal invasive tissue sampling (MITS) procedure has been developed to support determination of the cause of death as an alternate to conventional autopsy, especially in countries where complete diagnostic autopsy is not routine. To assess the feasibility of implementation of the MITS procedure for a study to determine cause of death in premature births and stillbirths in south Asia, we explored the views and perceptions of parents and religious leaders on the acceptability of MITS. METHODS: A qualitative study was conducted at the National Institute of Child Health (NICH) hospital of Karachi, Pakistan. Focus group discussions (FGDs) were conducted with parents of newborns who visited well-baby clinics of the NICH hospital for post-natal check-ups. Key-informant interviews (KIIs) were conducted with religious leaders. Data were analyzed using NVivo 10 software. RESULTS: A total of 13 interviews (FGDs = 8; KIIs = 5) were conducted. Three overarching themes were identified: (I) acceptability of MITS; (II) concerns affecting the implementation of MITS; and (III) religious and cultural perspectives. Participants' acceptance of MITS was based on personal, religious, cultural and social beliefs. Parents widely recognized the need for this procedure in cases where the couple had experienced multiple stillbirths, neonatal deaths and miscarriages. Counseling of parents was considered vital to address emotional concerns of the parents and the family. Religious leaders indicated acceptability of the MITS procedure from a religious perspective and advised that respect for the deceased and consent of the guardians is mandatory when performing MITS. CONCLUSIONS: This qualitative study provided a unique opportunity to understand the views of parents and religious leaders towards the use of MITS. Generally, MITS appears to be an acceptable method for identifying the cause of death in neonates and stillbirths, provided that the deceased is respected and buried as soon as possible without any delays and parents are counseled appropriately. Findings from this research are essential in approaching families for consent for MITS.

Perceptions of parents and healthcare professionals regarding minimal invasive tissue sampling to identify the cause of death in stillbirths and neonates: a qualitative study protocol.

BACKGROUND: Globally, around 2.6 million neonatal deaths occur world-wide every year and the numbers of stillbirths is almost similar. Pakistan is ranked among the highest countries in the world for neonatal mortality. In 2016, for every 1000 babies born in Pakistan, 46 died before the end of the first month of life. Also, Pakistan had the highest rate of stillbirths (43.1/1000 births) in 2015. To meet sustainable development (SDG) targets of reducing neonatal mortality and stillbirths, it is essential to gain understanding about the causes of neonatal death and stillbirths. In Pakistan, full autopsies are conducted only in medico-legal cases and are very rarely performed to identify a definitive cause of death (CoD) and because of cost and insufficient staff are generally not feasible. Recently, minimally invasive tissue sampling (MITS) has been used to determine CoD in neonates and stillbirths as it addresses some of the socio-cultural and religious barriers to autopsy. However, it is not known how families and communities will perceive this procedure; therefore, exploring family and healthcare professionals' perceptions regarding MITS is essential in determining acceptable and feasible approaches for Pakistan. METHODS: The study will employ an exploratory qualitative research design. The study will be conducted at the National Institute of Child Health (NICH) hospital of Karachi. The data collection method will consist of key-informant interviews (KIIs) and focus group discussions (FGDs). FGDs will be conducted with the families and relatives of newborns who are visiting the outpatient department (OPD) and well-baby clinics of NICH hospital. KIIs will be conducted with the NICH - medical director, healthcare providers, professionals involved in proceedings related to death and dying, religious leaders, health sector representatives from the government, public health experts, maternal and child health (MCH) specialists, obstetricians and neonatologists and experts from the bioethics committee. Study data will be analyzed using NVivo 10 software. DISCUSSION: The research will help explore specific cultural, religious and socio-behavioral factors that may increase or decrease the acceptability of MITS for identifying COD in neonates and stillbirths. The findings of the qualitative study will provide a better understanding of parents' and healthcare professionals' attitudes towards the use of MITS on neonatal deaths and stillborns.

Spontaneous rupture of primigravid uterus due to morbidly adherent placenta.

Morbidly adherent placenta in a nulliparous woman is a rare phenomenon. An unusual case of a 20 years old primigravida presented in emergency with unstable haemodynamics and abdominal pain at 17 weeks of gestation is reported. She was found to have complete placental invasion and haemoperitoneum on laparotomy. Although there is an increased risk of placental invasion (increta and percreta) causing uterine rupture in previous cesareans but morbid adhesion resulting in placenta percreta without previous uterine surgery is a rarity. Exact pathogenesis is still unknown. Prenatal diagnosis with the help of Doppler ultrasound and MRI is important to reduce both fetal and maternal morbidity and mortality.

Therapeutic termination of second trimester pregnancies with low dose misoprostol.

OBJECTIVE: To determine the effectiveness of 50 microg misoprostol for midtrimester termination of pregnancies. DESIGN: Experimental, cross-sectional study. PLACE AND DURATION OF STUDY: Department of Gynaecology and Obstetrics, Unit II, Jinnah Postgraduate Medical Centre, Karachi, a tertiary care centre, from 1st Jan 2003 to 30th June 2005. PATIENTS AND METHODS: The study subjects were 54 pregnant women admitted during the 2nd trimester (14-26 weeks) of gestation, willing or requiring termination of pregnancy. Those patients were included in the study who were admitted with closed cervical os, either had intrauterine death, fetal anomaly, medical disorder (hypertension or diabetes) or history of previous ceasrean section. Cases of placenta previa, acute asthma, glaucoma, cardiac diseases and allergy to prostaglandins were excluded. Each patient received 50 microg misoprostol intravaginally. Maximum 4 doses were given at 4 hours interval and state of cervical os was assessed by vaginal examination before insertion of next dose or at the onset of uterine contractions. After 4 doses of misoprostol, patients were kept under observation and watched for uterine contractions to start or for expulsion of products. Syntocinon infusion was started to augment labour where products of conception failed to expel out inspite of open os. Outcome measures include success rate of termination within 12, 24, 36 and 48 hours, mean induction - abortion time interval and maternal side effects. RESULTS: The success rate of termination within 12, 24, 36 and 48 hours were 27.7%, 83.3%, 94.4% and 96.3% respectively. Mean induction to abortion time interval, in case of abortion within 48 hours, was found to be 18.9 +/- 11.58 (range 4 - 48 hours). Dead fetuses were aborted earlier than alive fetuses. The mean induction abortion time interval was 17.01 +/- 8.7 hours in dead and 23.4+/-15.9 hours in alive fetuses (t -value:1.9, p: 0.05). Two patients failed to deliver within 48 hours of induction. Two patients suffered from febrile illness. CONCLUSION: Vaginal administration of 50 microg misoprostol every 4 hourly is an effective and safe agent for ripening of cervix and convenient way of inducing abortion during 2nd trimester of pregnancy in a women either with alive or dead fetus. It is associated with a low frequency of side effect.