Vaginal discharge during pregnancy and associated adverse maternal and perinatal outcomes.

OBJECTIVES: To observe the effects of vaginal discharge during pregnancy on maternal and fetal outcomes. METHODS: This observational study was undertaken form June 2018 to 31 May 2019 period in the Department of Obstetrics and Gynaecology at Liaquat University of Medical and Health Sciences hospital Jamshoro Unit IV. Data were collected from a convenience sample of 85 pregnant women. All the pregnant women with vaginal discharge were included in the study, while the women with bleeding and other medical disorders during pregnancy were excluded. Data was analyzed. RESULTS: Women's mean age as 27.4 (±4.7) years and most were 28-35 weeks pregnant (n=29, 34%) and primigravida (n=35, 41%). Seventy six women (89%) presented with vaginal discharge while nine women (11%) reported no vaginal discharge. Of those with vaginal discharge,53 women (69.7%) had vaginal infections: bacterial vaginosis (n=21, 39.6%), vaginal candidiasis (n=17, 32.1%) and vaginal trichomoniasis (n=15, 28.3%). Pathological vaginal discharge (PVD) was associated with vaginal irritation (n=30, p<0.0001), vaginal pain (n=50, p<0.0001), fever (n=12, p=0.015), uterine contractions (n=31, p<0.0001), premature membrane rupture (n=29, p<0.0001), abortion (n=13, p=0.009), pre-term delivery (n=24, p<0.0001) and post-partum endometritis (n=19, p=0.0006). PVD was associated with neonatal outcomes i.e. low birth weight (n=24, p<0.0001), low Apgar score at birth (n=22, p=0.0001), neonatal respiratory distress syndrome (n=21, p=0.0002), neonatal intensive care hospitalisation (n=20, p=0.002) and early neonatal death (n=16, p=0.003). CONCLUSION: Pathological vaginal discharge (PVD) during pregnancy is more frequent and is associated with adverse maternal and perinatal outcomes.

Acute renal morbidities with obstetrical emergencies: An important women health issue.

OBJECTIVE: To observe the impact of acute renal morbidities with obstetrical emergencies on maternal health. METHODS: In this study pregnant women between 28-40 weeks gestational period and delivered women in their puerperal period up to 42 days after delivery having acute renal problems associated with obstetrical emergencies were included. Pregnant and delivered women with obstetrical emergencies and associated other morbidities were excluded. These women were registered on the predesigned proforma after taking written informed consent and taking approval from institutional ethic research committee. The data was collected and analyzed on SPSS version 21. RESULT: Out of these 196 total registered women, majority of these women 81(41.32%) were between 21-30 years of age and multiparous women with parity four and above were 83(42.34%). Commonest presenting symptoms were generalized oedema 123(62.75%) and oligouria 92(46.93%). Frequent obstetrical emergencies observed were pre-eclampsia 53(27.04%), post partum haemorrhage 48(24.48%) and ante partum haemorrhage 36(18.36%) women. The complete recovery was observed in 86(43.87%) women, while mortality was seen in 56(28.57%) women. CONCLUSION: Renal morbidities were more frequently observed in obstetrical emergencies leading to high morbidity and mortality rate.

Labour induction with gestational hypertension: A great obstetric challenge.

OBJECTIVE: To observe the fetomaternal morbidity and mortality with induction of labour in pregnant women with gestational hypertension. METHODS: The subjected study population included was 138 pregnant women with gestational hypertension. These pregnant women were between 34-40 weeks of gestational period in whom labour was induced, while the pregnant women who had labour induction for other reasons were excluded. These women were registered on the predesigned proforma. The data was collected and analyzed on SPSS version 21. RESULT: Out of the 138 cases, mean age of the women was 25.93±5.037, prim gravid women were 78(56.5%), gestational period in majority of these women 71(51.4%) varied between 35-38 weeks. The common presenting symptoms were oedema 119(86.23%), headache 90(65.21%). Labour induction in majority of the cases 81(58.7%) was carried with prosten pessary. The Caesarean section was needed in 39(28.3%) women in emergency due to maternal and fetal reasons or due to failed induction. Maternal complications were uncontrolled hypertension 23(16.7%), intensive care unit admission 21(15.2%), fits 15(10.9%), post partum haemorrhage 13(9.4%). Fetal complications were birth asphyxia 49(35.5%), neonatal intensive care unit admission 17(12.3%), neonatal death 14(10.1%). CONCLUSION: The emergency Caesarean section rate was quite high with induction of labour in pregnant women with gestational diabetes. The maternal morbidity as well as fetal morbidity and mortality rate was also high.

Iron deficiency anaemia is still a major killer of pregnant women.

OBJECTIVE: To observe the effects of iron deficiency anaemia on the health and life of pregnant women. METHODS: This cross sectional study was conducted at the Department of Obstetrics and Gynaecology Unit IV, Liaquat University of Medical and Health Sciences Jamshoro from 1st June 2015 to 30(th) November 2015, for the period of 6 months. During this study period all the pregnant women from 13-40 weeks of pregnancy with iron deficiency anaemia having haemoglobin level less than 9 gram% were included, while the pregnant women with other medical disorders were excluded from the study. The data was collected and analyzed on SPSS version 21. RESULT: Out of the 305 pregnant registered women with iron deficiency anaemia most women were young 170(55.73%) between 20-30 years, belonged to low socioeconomic group 254(83.27%), they were multiparous 104(34.09%), having very low haemoglobin level between 1-3 gram % in 54(17.70%) women and between 4-6gram% in162 (53.11%) women. These women were prone to high complications such as ante partum haemorrhage 49(16.06%), renal failure 48(15.73%), disseminated intravascular coagulation 54(17.70%) and 16(5.24%) women died. CONCLUSION: Iron deficiency anaemia is common in pregnant women with higher rates of complications.

Acute Hepatitis E Viral Infection in Pregnancy and Maternal Morbidity.

OBJECTIVE: To determine the maternal morbidity in pregnant women with acute hepatitis E viral infection. STUDY DESIGN: Observational, cross-sectional study. PLACE AND DURATION OF STUDY: Departments of Obstetrics and Gynaecology and Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, Red Crescent General Hospital and Saint Elizabeth Hospital, Hyderabad, from January 2011 to December 2013. METHODOLOGY: The study population was pregnant women with acute hepatitis E infection confirmed by ELIZA technique. Pregnant women with other hepatic viral infections were excluded. All medical and obstetric conditions, and mortality were noted on the predesigned proforma. RESULTS: Out of the total 45 admitted pregnant women with hepatitis E viral infection, 22 women (48.9%) had severe morbidity. The most common were hepatic coma in 8 (36.36%) cases and disseminated intravascular coagulation in 14 (63.63%) cases. Highest mortality rate was seen in women with hepatic coma (100%), while in those with disseminated intravascular coagulation, one out of the 14 cases (7.14%) died. CONCLUSION: The acute viral hepatitis E infection in pregnant women is associated with maternal morbidities and high mortality rate.

Elective caesarean section for breech presentation in first pregnancy and subsequent mode of labour.

OBJECTIVE: To determine the effect on subsequent mode of labour in case of previous elective caesarean for breech presentation in primiparous women. STUDY DESIGN: A cohort study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology, Liaquat University of Medical and Health Sciences, Jamshoro, Unit-1 and 1V, from January 2005 to December 2009. METHODOLOGY: All women with previous one elective caesarean section for breech or cephalic presentation visited OPD for antenatal checkup or admitted in emergency in maternity or labour ward were recruited for the study, while the women with previous 2 and 3 caesarean section were excluded from the study. The case records of these women were reviewed thoroughly, and entered in predesigned pro forma. The main outcome measure was mode of labour in current pregnancy decided electively or adopted in emergency. RESULTS: Out of the total, 131 (16.92%) women had previous elective caesarean section due to breech presentation while 643 (83.07%) women had previous elective caesarean section with cephalic presentation. Overall repeat caesarean section rate was 92 (70.22%) in women with previous breech presentation (n=131) in comparison with 475 (73.87%) women with previous cephalic presentation n=643 (RR=1.04, p=0.32). The vaginal birth rate after elective caesarean section due to breech presentation was 39 (29.77%) in comparison with 168 (26.12%) cases with previous cephalic presentation (RR=0.98, p=0.83). CONCLUSION: Women having elective caesarean section for breech presentation in their previous pregnancy had about 1 in 6 chance of having repeat elective caesarean section.

Iatrogenic risks and maternal health: Issues and outcomes.

OBJECTIVE: To observe acute maternal morbidity and mortality due to iatrogenic factors and outcomes. METHODS: This observational cross sectional study was conducted at intensive care unit of Liaquat University of Medical and Health sciences Jamshoro from 1-January-2011 to 31-December-2012. In this study all the delivered or undelivered women who needed intensive care unit (ICU) admission due to management related life threatening complication referred from periphery or within this hospital were included, while those women who had pregnancy complicated by medical conditions were excluded. These women were registered on the predesigned proforma containing variables like Demographic characteristics, various iatrogenic risk factors, complications and management out comes. The data was collected and analyzed on SPSS version 20. RESULTS: During these study period 51 women needed ICU care for different complications due to adverse effects of medical treatments. Majority of these women were between 20-40 years of age 41(80.39%), multiparous 29(56.86%), unbooked 38(74.50%), referred from periphery 39(76.47%), common iatrogenic factors were misuse of oxytocin 16(31.37%), fluid overload/cardiac failure 8(15.68%), blood reaction 7(13.72%), anesthesia related problems were delayed recovery 3(5.88%), cardiac arrest 2(3.92%), spinal shock 2(3.92%), surgical problems were bladder injury 5(9.8%), post operative internal haemorrhage 3(5.88%), 37(72.54%) women recovered and 14(27.45%) expired. CONCLUSION: The maternal morbidity and mortality rate with iatrogenic factors was high and majority of these factors were avoidable.

Risk factors and complications of puerperal sepsis at a tertiary healthcare centre.

OBJECTIVE: To determine the risk factors and complications of puerperal sepsis. METHODS: This was an observational prospective Cohort study conducted from January 2011 to December 2011 at the Obstetrics and Gynaecology Department Liaquat University of Medical & Health Sciences Jamshoro/Hyderabad, Sindh Pakistan. During this study period, all the women who delivered in this hospital or referred to this hospital within 42 days after delivery with puerperal pyrexia/sepsis diagnosed on clinical examination as well as with relevant investigations were included in the study. Women with other ailments like malaria, typhoid fever and postpartum eclampsia during the puerperal period were excluded. The subjects were registered on predesigned proforma after giving informed written consent. The data was collected and analyzed using SPSS version 17. RESULTS: During this period there were 3316 obstetrical admission and out of these 129(3.89%) women had puerperal sepsis. Most of these women 84(65.11%) were aged 31 years and above, multiparous 101 (78.29%), and unbooked 98 (75.96%) cases. Common risk factors found were absent membranes in 108(83.72%) of the women, delivered or undelivered and mismanaged, referred cases 95(73.64%), are being delivered in this hospital 34(26.35%). Morbidities seen were septicemia in 35 (27.13%) cases, and disseminated intra vascular coagulation in 23(17.82%) cases, while 11 (8.52%) of the women died. CONCLUSION: Common risk factors were anaemia; suboptimal personal hygiene as well as improper sterilization which resulted in severe health hazards such as septicemia, disseminated intravascular coagulation as well as death.

Infertility and weight reduction: influence and outcome.

OBJECTIVE: To assess the effect of weight reduction in obese infertile women on conception rate spontaneously as well as with ovulation induction and pregnancy outcome. STUDY DESIGN: Observational experimental study. PLACE AND DURATION OF STUDY: Different private clinics at Mirpurkhas, Thana Bola Khan and Hyderabad, Sindh, Pakistan, from March 2008 to February 2011. METHODOLOGY: Infertile women who were obese with the body mass index (BMI) > 30 kg/ m2 and failed to conceive within 2 - 5 years after taking treatment of infertility for many cycles were inducted. These women underwent life style change program related to exercise and diet for 6 months and in the next 6 months they were observed for spontaneous conception. Those women who failed to conceive were prescribed ovulation induction (clomifene citrate) for the next 6 months and were observed for conception. After conception, they visited regularly during antenatal period till delivery. The data was collected and analyzed on SPSS version 17. RESULTS: The mean decrease in the body index observed was 9.6 ± 1.23 kg/m2, spontaneous conception rate was (n = 35, 41.17%) and miscarriage rate was (n = 9, 16.66%). CONCLUSION: Weight reduction leads to high spontaneous conception rate as well as with ovulation induction therapy and improves the pregnancy outcome.

Obstetrical trauma to the genital tract following vaginal delivery.

OBJECTIVE: To determine the frequency, types and complications of genital tract trauma during child birth. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology, Unit I, Liaquat University of Medical and Health Sciences, Jamshoro, from June 2006 to May 2010. METHODOLOGY: All women who sustained genital tract trauma during delivery at the study centre and those referred from periphery with the same condition within 40 days of delivery were enrolled in the study. Exclusion criteria were women who sustained genital tract injury with caesarean section and genital tract trauma due to accident. Studied variables included age of women, parity, place of labour, type of trauma received and its immediate complications. The data was expressed in terms of descriptive statistics. RESULTS: Out of a total 9216 cases admitted in maternity ward during the study period, 467 cases (5.06%) had sustained genital tract trauma. The most frequent obstetrical trauma seen in primiparous referral cases were vaginal tears in 16 cases (25.39%) and perineal tears in 12 cases (19.04%). Multiparous women were 196 (41.97%) and cervical tears were the most frequent obstetrical trauma in them (n=52, 26.53%). Grand multiparous women were 208 having cervical tears (44.4%) and uterine rupture in 77 cases (37.01%) each. Most frequent early morbidities were postpartum haemorrhage (n= 352, 75.37%), hypovolemic shock (n= 220, 47.10%) and infection (n=158, 33.83%). The mortality rate was 16.05%. CONCLUSION: Genital tract trauma is a common complication of vaginal birth mostly seen in grand multipara, leading to haemorrhage, shock and infection.

Frequency of second stage intervention and its outcome in relation with instrumental vaginal delivery versus caesarean section.

BACKGROUND: To determine the frequency of second stage intervention and the risk of maternal and foetal morbidity and mortality associated with instrumental vaginal deliveries versus caesarean section in our tertiary care set up. METHODS: This descriptive study was conducted in the Department of Obstetrics and Gynaecology (Unit-II) Liaquat University Hospital Hyderabad Sindh, Pakistan from January 2005 to December 2006. All the women who underwent instrumental vaginal delivery and caesarean section due to prolonged second stage of labour were included in this study. Data were collected on a pre-designed proforma, which included demographic details, maternal and perinatal morbidity as well as any complications etc. Finally, data were analysed through software program SPSS 10.0. RESULTS: Frequency of second stage intervention was 22.2%. Among, 400 women who undergone second stage intervention, 240 (60%) were delivered by caesarean section and 160 (40%) were delivered with the help of instruments. Majority of women, i.e., 49.25% were between 21-30 years of age, 73% were un-booked cases while 45% cases were primigravida. Complications with abdominal delivery were paralytic ileus in 35 (14.58%) cases, post partum haemorrhage in 30 (12.5%) cases and tear extension in 13 cases. Complications with instrumental delivery were vaginal tear in 28 (17.5%) cases, cervical tear in 12 (7.5%) and third degree perineal tear in 4 (2.5%) cases. The perinatal outcome with abdominal delivery (86.66%) was better as compared to instrumental delivery (72.5%). CONCLUSION: The frequency of second stage intervention seems high in our set up and is associated with significant maternal and perinatal morbidity. Maternal morbidity was more frequent abdominal delivery while neonatal morbidity and mortality was more frequent with instrumental delivery.

Clinical spectrum and management of ovarian tumours in young girls up to 20 years of age.

BACKGROUND: Ovarian tumours are one of the common malignancies all over the world affecting all age groups. This study analyses different clinical presentation and management of ovarian tumours in young girls up to 20 years. METHODS: Patients up to 20 years of age admitted with the diagnosis of ovarian tumour were included. Data collected on a proforma. Variables studied included age, presenting symptoms, investigations, surgical findings, type of surgery, histopathology reports and follow-up. The patients with malignant ovarian tumour were followed by oncologist as well as gynaecologist. Data analysis was done on SPSS. RESULTS: The mean age was 17.27 +/- 2.46 SD years. The common symptoms included abdominal mass, abdominal pain, urinary problems, menstrual irregularities and generalized malaise. All patients were operated after preliminary investigations. Patients were advised to have follow-up post-operatively after 1 month. The follow up was done by oncologist and gynaecologist. Six patients (12.5%) died and 22 (45.83%) were lost to follow up. CONCLUSION: Ovarian tumours are quite common in young girls. Majority of patients seek medical advice once the disease becomes symptomatic, complicated or advanced disease in the case of malignancy. Histopathology of the tumours revealed that epithelial cell tumour is the commonest tumour in contrast to germ cell tumour as reported by world literature.

Pattern of fetal deaths at a university hospital of Sindh.

BACKGROUND: Perinatal mortality is a significant public health problem throughout the world. Its prevalence is quite high in the developing countries on account of number of factors. Most of the causes are treatable and fetal outcome can be improved by provision of good health care facilities during antepartum and intrapartum periods and through public education regarding reproductive health and better utilization of health services. OBJECTIVE: To determine the pattern of intrauterine fetal deaths before or in the process of labor in our tertiary care set up. METHODS: This descriptive case series was conducted at Department of Obstetrics and Gynaecology (unit-IV) at Liaquat University Hospital, Jamshoro, Sindh,from April 2002 to October 2003. In total, 50 intrauterine fetal deaths from 24 weeks of gestation to full term pregnancy were analyzed. The case records of all the women were evaluated and data collected regarding their age, period of gestation, clinical features, antenatal records, previous obstetrical history, labor, mode of delivery as well as complications during or after the labor. RESULTS: Out of 697 deliveries, 50 (7.17%) babies were still born. Of these 84% were fresh still born. The commonest factors were antepartum hemorrhage (30%), mismanaged labor (26%), premature rupture of membranes (26%) and congenital anomalies (16%). CONCLUSION: Majority of fetal deaths in our set up are due to avoidable factors. Hence, there is strong need to improve the quality of care by proper antenatal care, identification of high risk cases and referral to tertiary care hospitals for proper management to prevent morbidity and mortality in this regard.

Adverse drug reactions: clinical assessment of drug induced disease.

Physicians are often confronted with patients who state that they are "allergic" to a drug. The goal of this review article is to help physicians to develop management plans for patients who present with drug induced diseases. It provides information that allows physicians to differentiate between reactions that are truly allergic in nature and those that are not immunologically mediated. The suggestions which may be helpful in the assessment are discussed and guidance is provided whether a drug may be safely readministered. Unfortunately until we are unable to thoroughly understand the mechanisms responsible for drug induced reactions, our management tools will remair limited.