Outcome Of B-Lynch Application In Patients With Post-Partum Hemorrhage Following Cesarean Section.

BACKGROUND: The most common cause of post partum hemorrhage after a cesarean section is uterine atony. Aims and Objective: The main aim of this study was to examine the outcomes of the B-Lynch procedure in patients who experienced primary PPH after cesarean section. METHODS: This study spanned one year, from August 2020 to August 2021, at Ayub Teaching Hospital. Patients who developed post-partum hemorrhage after a cesarean section were enrolled in this study and a thorough review of their records was conducted to identify those who received B-Lynch sutures and assess the resulting outcomes. RESULTS: Out of the 87 patients who experienced PPH, 24 (27.6%) patients received the B-Lynch procedure. Among these 24 patients, only two (8.3%) needed hysterectomy, while the remaining 22 successfully recovered after receiving the B-Lynch procedure. CONCLUSIONS: The B-Lynch technique proves to be a safe, effective, and easily applicable method for stopping hemorrhage in patients who experienced significant initial postpartum hemorrhage due to uterine atony.

Validity Of Transabdominal Ultrasound Scan In The Prediction Of Uterine Scar Thickness.

BACKGROUND: Caesarean section rate is increasing throughout the world, which increases the risk of complications in subsequent pregnancy with increased maternal and foetal morbidity and mortality. There is risk of uterine rupture in subsequent pregnancy with trial of labour after caesarean section (TOLAC). Therefore, accurate prediction of uterine rupture can be of significant value during the management of subsequent pregnancies after previous caesarean delivery. The aim of this study was to evaluate the accuracy of prenatal transabdominal sonography in determining the lower uterine segment thickness in women with previous caesarean section, to document relevant risk factors in the obstetric history of subjects predisposing to uterine scar rupture and to define a cut-off value of uterine thickness for prediction of uterine rupture. METHODS: This cross-sectional validation study was conducted in the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital, Abbottabad from May to October 2017.Transabdominal ultrasound was carried out in all patients before labour for the measurement of uterine scar thickness. Patients were followed till caesarean section and intraoperative findings were recorded. RESULTS: A total of 117 patients were enrolled. Out of these 33% had thin or dehiscence/rupture scar. At the cut-off value of ≤5 mm the sensitivity was 76.9%, specificity 48.7% and accuracy was 58.12%. No significant association was found between clinical features and scar dehiscence/rupture. CONCLUSIONS: No definite USG cut-off limit could be established to provide guidance regarding the clinical decision of opting for VBAC or repeat caesarean/section; scar thicknesses ≤5.0 mm should be judged cautiously.

Choriocarcinoma After Normal Vaginal Delivery; A Rare Entity.

Choriocarcinoma is a malignant gestational trophoblastic neoplasm with rare postpartum presentation. Its manifestation after full term delivery is very rare with paucity of data reported from Pakistan. We received a patient in the postpartum period with symptoms of distant metastasis. She was diagnosed with choriocarcinoma based on our workup and was referred for chemotherapy after management. Now she is receiving follow-up care.

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.

EMERGENCY PERI PARTUM HYSTERECTOMY--A LIFE SAVING PROCEDURE.

BACKGROUND: Sub-total abdominal hysterectomy is a surgical procedure in which body of the uterus is removed while ovaries and cervix are preserved. The study was done with the objectives of assessing the frequency of peripartum hysterectomies, common indications and risk factors associated with this surgery. The postoperative complications including the severity of andemia in these patients and need for blood transfusion and use of blood products like fresh frozen plasma and platelet concentrates were also studied. METHODS: The study was based on the review of the records of Gynae 'A' Unit, Ayub Teaching Hospital, Abbottabad from January 2011 till December 2012. Data was collected from the unit record and patient's personal files. All the patients who underwent emergency peripartum hysterectomy were included in the study. RESULTS: During this study period there were 6535 total deliveries in the unit, 2153 vaginal deliveries and 1786 caesarean sections. Emergency perpartum hysterectomy was needed in 72 patients. In the majority of the patients the gestational age was at term. The commonest indications for this operation was haemorrhage (placental abruption) 26 patients (36% ) followed by ruptured uterus in 18 patients (25%), prolonged and obstructed labour promoted uterine atony needing hysterectomy in 13 patients (18%). Placenta previa major degree needed hysterectomy in 9 patients (12.5%) while placenta increta and chorioamnionitis each accounted for 3 cases (4.2%). At admission the majority of the patients were severely anaemic 31 patients (43.05%). The most important risk factor identified was hypertensive disorders of pregnancy 26 patients (36%), followed by uterine atony in 13 patients (18.05%). CONCLUSION: High risk obstetric patients, prone to peripartum hysterectomy, should be identified by health personnel working in the rural areas and should be timely referred to the hospitals where appropriate facilities are available for the management of such patients.

Attenuation of haemodynamic response to laryngoscopy and oral endotracheal intubation in coronary artery bypass surgery patients: intravenous morphine and lidocaine versus intravenous morphine and lidocaine spray.

BACKGROUND: Sympathetic response associated with laryngoscopy and endotracheal intubation is recognized as a potential cause for a number of complications especially in coronary bypass surgery patients. Various methods have been used to attenuate these hemodynamic responses, The aim of our study was to compare lidocaine spray in addition to intravenous morphine on attenuating the hemodynamic response to laryngoscopy and endotracheal intubation with intravenous lidocaine and morphine in coronary artery bypass surgery patients. METHOD: Sixty patients, scheduled for elective coronary bypass grafting surgery were included in this randomized controlled trial. The patients randomly divided in group-A (Intravenous Morphine 0.1mg/kg and Intravenous lidocaine 1.5 mg/kg) and group-B (Intravenous Morphine 0.1mg/kg and lidocaine spray 1.5 mg/kg). RESULTS: Demographic data was comparable in both groups. There was no statistically significant difference between two groups in the duration of laryngoscopy and intubation. There was statistically insignificant attenuation in heart rate in both groups (p=0.134), the trends of attenuation of systolic blood pressure, diastolic blood pressure and mean arterial pressure in group-A compared to group-B (p=0.933), (p=0.768) and (p=0.136) respectively were statistically insignificant. CONCLUSIONS: Under the present study design, lidocaine spray in addition to intravenous morphine had no better effect on attenuating the hemodynamic response to laryngoscopy and endotracheal intubation as compared to intravenous lidocaine and morphine in coronary artery bypass surgery patients.

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.

Duration of lactational amenorrhoea: a hospital based survey in district Abbottabad.

BACKGROUND: The study was carried out to investigate the duration of lactational amenorrhoea in women of district Abbottabad. The objective of this survey was to determine the duration of lactational amenorrhoea in female population of district Abbottabad, NWFP, Pakistan. METHODS: A survey was conducted at Ayub Teaching Hospital from June to August 2006 by selecting admitted females and their attendants at random and subjecting them to questionnaires and interviews to collect relevant data. Majority of the sampled females belonged to different districts of Hazara division. RESULTS: Fifty nine (59) mothers of parity 1-5 were included in the study. The frequency of breast feeding ranged from 60.0% to 100% (mean 66.1%) in different pregnancies; bottle feeding frequencies ranged from 10-12.5% (mean 6.8%); frequencies of combined breast and bottle feeding ranged from 25-30% (mean 27.1%). The mean duration of lactational amenorrhoea for different pregnancies ranged from 6.0 +/- 0.0 weeks to 22.6 +/- 25.1 weeks (overall mean 15.8 +/- 15.2 weeks). Weaning times ranged from 2 to 12 months, with the mean weaning time ranging from 4.8 +/- 1.5 to 5.1 +/- 1.8 months (overall mean 4.8 +/- 1.1 months). CONCLUSION: Maternal hormonal cycles appear to be more involved in regulating the post partum amenorrhea observed in lactating mothers.

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.