Out Come Of Trial Of Scar In Patients With Previous Caesarean Section.

BACKGROUND: Patients who had one caesarean section were previously not given a trial of scar due to fear of increased morbidity. However, recently there has been a trend to give a trial of labour to patients with a previous caesarean section for a non-recurrent cause. Medical evidence indicates that 60-80% of women can achieve vaginal delivery after a previous lower segment caesarean section. Proper selection of patients for trial of scar and vigilant monitoring during labour will achieve successful maternal and perinatal outcome. The objective of our study is to establish the fact that vaginal delivery after one caesarean section has a high success rate in patients with previous one caesarean section for non-recurrent cause. METHODS: The study was conducted in Ayub Teaching Abbottabad, Gynae-B Unit. All labouring patients, during the study period of five years, with previous one caesarean section and between 37 weeks to 41 weeks of gestation for a non-recurrent cause were included in the study. Data was recorded on special pro forma designed for the purpose. Patients who had previous classical caesarean section, more than one caesarean section, and previous caesarean section with severe wound infection, transverse lie and placenta previa in present pregnancy were excluded. Foetal macrosomia (wt>4 kg) and severe IUGR with compromised blood flow on Doppler in present pregnancy were also not considered suitable for the study. Patients who had any absolute contraindication for vaginal delivery were also excluded. RESULTS: There were 12505 deliveries during the study period. Total vaginal deliveries were 8790 and total caesarean sections were 3715. Caesarean section rate was 29.7%. Out of these 8790 patients, 764 patients were given a trial of scar and 535 patients delivered successfully vaginally (70%). Women who presented with spontaneous onset of labour were more likely to deliver vaginally (74.8%) as compared to induction group (27.1%). CONCLUSIONS: Trial of vaginal birth after caesarean (VBAC) in selected cases has great importance in the present era of the rising rate of primary caesarean section.

Safety of caesarean myomectomy.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: Myomectomy can be safely performed in majority of carefully selected patients with myomas without any serious life threatening complications.

Septic/unsafe abortion: a preventable tragedy.

BACKGROUND: Unsafe abortion is one of the greatest neglected problems of health care in developing countries like Pakistan. In countries where abortions are restricted women have to resort to clandestine interventions to have an unwanted pregnancy terminated. The study was conducted to find out the prevalence of septic induced abortion and the associated morbidity and mortality and to highlight the measures to reduce it. METHODS: This cross-sectional descriptive study was carried out in Obs/Gyn B Unit, Ayub Teaching Hospital, Abbottabad from January 2007 to December 2011. During this period all the patients presenting with pyrexia lower abdominal pain, vaginal bleeding, acute abdomen, septic or hypovolaemic shock after undergoing some sort of intervention for abortion outside the hospital were included. After thorough history, examination and detailed investigations including high vaginal and endocervical swabs for culture and sensitivity and pelvic ultrasound supportive management was given followed by antibiotics, surgical evacuation of uterus/ major laparotomy in collaboration with surgeon as required. Patients with DIC or multiple system involvement were managed in High Dependency Unit (HDU) by multidisciplinary team. RESULTS: During the study period out of a total 6,906 admissions 968 presented with spontaneous abortion. There were 110 cases (11.36%) of unsafe abortion, 56.4% presented with vaginal discharge, 34.5% with vaginal bleeding, 21.8% with acute abdomen, while 18.9% in shock and 6.8% with DIC. Forty-nine percent patients used termination as a method of contraception. Mortality rate was 16.36%, leading cause being septicaemia. CONCLUSION: Death and severe morbidity from unsafe abortions and its complications is avoidable through health education, effective contraception, early informed recognition and management of the problem once it occurs.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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%). CONCLUSION: 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.

Foetomaternal outcome in patients with or without premature rupture of membranes.

BACKGROUND: 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. METHOD: 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. RESULTS: 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). CONCLUSION: 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 and its obstetric complication.

BACKGROUND: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

BACKGROUND: 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. METHOD: 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. RESULT: 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. CONCLUSION: 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.

Presentation and management outcome of eclampsia at Ayub Teaching Hospital, Abbottabad.

BACKGROUND: This study was carried out evaluate to epidemiology, clinical presentation and prognostics aspects of patients presenting with eclampsia. METHODS: This study was carried out at Gynae "C" unit of Ayub Teaching Hospital Abbottabad from 1st July 2003 to 31st October 2004. All patients presenting with eclampsia to the labor ward were included in the study. The diagnosis was based on history and confirmed on clinical findings of hypertension, oedema, proteinuria superimposed with fits. Patients with history of fits during pregnancy, labor and peurperium other than eclampsia were excluded from study. History physical findings and base line investigation were recorded on a proforma. RESULTS: A total of 2100 admissions were made in the labor ward during this period and out of them 68 cases (3.23%) were of eclampsia. Out of them 28 were primigravidae, 14 multigravidae and 26 grandmultigravidae. The seasonal frequency of cases was 29.41% in winters, 42.64% in autumn, 19.11% in summers and 8.82% in spring. Out of these 11.76% cases were complicated with retroplacental haemorrage and the same number with aspiration pneumonia, while Cerebrovascular Accident (2.94%) Acute tubular necrosis (2.94%) and Disseminated intravascular clotting (4.4%) were also seen. Among the new borns prematurity was found to be the major cause of perinatal mortality. CONCLUSION: Eclampsia is a dreadful complication of Pre Eclamptic Toxemia of pregnancy associated with high perinatal and maternal mortality. A qualitative and quantitative improvement in prenatal consultation should make it possible to reduce incidence of eclampsia measuring arterial blood pressure daily during antenatal period and for at least 14-days postpartum appears to be necessary for diagnosis and treatment for all cases of hypertension.

A two years audit of complications of hysterectomy at Ayub Teaching Hospital Abbottabad.

BACKGROUND: Hysterectomy is one of the most common major surgical procedures performed in Gynaecology. Our objective was to determine the operative and postoperative complications of this procedure with an aim to improve management at our unit. METHODS: This study was conducted in the Department of Gynaecology, Ayub Teaching Hospital, Abbottabad form January 2002 to December 2003. Indications, complications and mortality associated with hysterectomy were assessed. RESULTS: Total number of hysterectomies performed in two years at our unit was 316. Major Indications for hysterectomies were dysfunctional uterine bleeding (38%) and fibroid uterus, (27%) followed by prolapse (22%). Complications developed in 14% out of these. The frequency of complications was related with indication for hysterectomy, age, parity and history of associated serious illness. It was found that frequency of complications in fibroid uterus was higher (1.2%) than that for Dysfunctional uterine bleeding (DUB) (1.0%). There was no operative death, while 5 (1.5%) patients died within 2 weeks of surgery. CONCLUSION: We have a fairly high frequency of morbidity and mortality associated with hysterectomy. In order to reduce these proper selection, pre-operative preparation and less invasive alternative treatment for the commonest indications of hysterectomy (that is fibroids and DUB) for example various methods of endometrial ablation or resections can be employed.

Partial hydatidiform mole along with term gestation and alive baby.

Gestational trophoblastic disease consists of a broad spectrum of conditions ranging from an uncomplicated partial hydatidiform molar pregnancy to stage-IV choriocarinoma with cerebral metastases. We describe a partial molar change in the placenta that was associated with a normal female fetus that was delivered at term and is alive and healthy.