Successful pregnancy and delivery in a woman with achondroplasia.

Achondroplasia is a common form of dwarfism occurring in one out of 25,000 of live births. These patients present many problems during pregnancy and at the time of the delivery. The anaesthetist may also face several difficulties for both general and regional anaesthesia. The aim of this case report is to discuss various obstetric and anaesthetic considerations in such patients and ways to manage the difficulties. A 29-year-old woman expecting her first child, with achondroplasia -height of just 3'2'' (98 centimetres) - at 31 weeks of gestation, presented to our OPD for antenatal visit on May 15, 2018. Her successful elective lower segment caesarean section was performed on June 25, 2018 at 37 weeks in view of contracted pelvis under general anaesthesia. A live male baby was delivered, with no complications, good Apgar score and birth weight of 2.7kg. This shows that a woman with a genetic disorder like achondroplasia can become pregnant and deliver a healthy child at term.

Rising trends in iatrogenic urogenital fistula: A new challenge.

OBJECTIVE: To analyze trends in iatrogenic urogenital fistula among patients admitted for fistula repair at the Pakistan Institute of Medical Sciences, Islamabad. METHODS: In this longitudinal study, all patients who presented for fistula repair between 2006 and 2018 were included in the study. Patient data were collected on age, parity, and type and etiology of fistula, which was classified as ischemic or iatrogenic. RESULTS: Of 634 fistula patients, 371 (58.5%) had iatrogenic fistula, while 263 (41.5%) patients developed ischemic fistula due to obstructed labor. Mean age of patients was 31.6 years. Yearly trends showed an increase in iatrogenic fistula from 43.2% in 2006-2008 to 71.4% in 2017-2018. The major etiological contributor to iatrogenic fistula was hysterectomy (52.5%), followed by cesarean hysterectomy (26.4%), and cesarean delivery (19.9%). CONCLUSION: A rising trend in iatrogenic fistula was observed. This emphasizes the need for optimization of surgical approaches and surgical skills. Moreover, gynecologic surgeries should be restricted to authorized gynecologic surgeons.

Effect of Metformin Alone Compared with Metformin Plus Simvastatin on Polycystic Ovarian Syndrome in Pakistani Women.

OBJECTIVE: To determine the efficacy of metformin alone versus metformin plus simvastatin for treatment of polycystic ovariansyndrome (PCOS). STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Maternal and Child Health Centre, Unit II, Pakistan Institute of Medical Sciences (PIMS), from November 2014 to April 2015. METHODOLOGY: One hundred and eight patients (108) were randomly divided into metformin group (n=54) and metformin plus simvastatin group (n=54), detailed clinical history, including menstrual details, was taken with thorough examination performed. Baseline ultrasound was performed to evaluate ovarian size and these were considered enlarged with volume >10cc or with >12 follicles in any one ovary. Blood samples were taken at baseline and after three months of therapy to determine the LH/FSH ratio and lipid profile. Efficacy was defined as >15% decrease in the baseline values. RESULTS: The mean age of patients was 28.82 ±7.18 years. Mean BMI of the patients was 22.41 ±1.55 Kg/m2. Efficacy was achieved in 66.7% patients with metformin alone, while in 92.6% with combination medication (p=0.001). CONCLUSION: The combination of metformin plus simvastatin is more efficacious as compared to metformin alone for management of females with PCOS.

An audit of the knowledge and attitudes of doctors towards Surgical Informed Consent (SIC).

BACKGROUND: The Surgical Informed Consent (SIC) is a comprehensive process that establishes an information-based agreement between the patient and his doctor to undertake a clearly outlined medical or surgical intervention. It is neither a casual formality nor a casually signed piece of paper. The present study was designed to audit the current knowledge and attitudes of doctors towards SIC at a tertiary care teaching hospital in Pakistan. METHODS: This cross-sectional qualitative investigation was conducted under the auspices of the Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad over three months period. A 19-item questionnaire was employed for data collection. The participants were selected at random from the list of the surgeons maintained in the hospital and approached face-to-face with the help of a team of junior doctors detailed for questionnaire distribution among them. The target was to cover over 50% of these doctors by convenience sampling. RESULTS: Out of 231 respondents, there were 32 seniors while 199 junior doctors, constituting a ratio of 1:6.22. The respondents variably responded to the questions regarding various attributes of the process of SIC. Overall, the junior doctors performed poorer compared to the seniors. CONCLUSION: The knowledge and attitudes of our doctors particularly the junior ones, towards the SIC are less than ideal. This results in their failure to avail this golden opportunity of doctor-patient communication to guide their patients through a solidly informative and legally valid SIC. They are often unaware of the essential preconditions of the SIC; provide incomplete information to their patients; and quite often do not ensure direct involvement of their patients in the process. Additionally they lack an understanding of using interactive computer-based programs as well as the concept of nocebo effect of informed consent.

Manual vacuum aspirator: a safe and effective tool for decentralization of post miscarriage care.

OBJECTIVE: To compare the efficacy and safety of Manual Vacuum Aspiration (MVA) performed as outpatient versus inpatient procedure in terms of success rate, blood loss, hospital stay and procedure related complications. STUDY DESIGN: A quasi-experimental study. PLACE AND DURATION OF STUDY: Maternal and Child Health Centre (MCHC), Unit-I, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from December 2009 to December 2010. METHODOLOGY: Cases with early pregnancy failure (incomplete, missed and an embryonic) at gestational age less than 12 weeks were allocated to MVA as outpatient or elective procedure performed in the operation theatre. Studied variables were noted as above. RESULTS: A total of 177 women were eligible for study, out of whom 78 underwent MVA as outpatient procedure and 99 as indoor procedure. The baseline characteristics were comparable in both groups except significantly high multipara in the indoor group. Complete evacuation was achieved in 96.1% in outpatient vs. 79.7% in indoor cases (p=0.001). Outpatient group had a shorter hospital stay (median 3 hours, IQR-1 vs. 10 hours, IQR-4; p < 0.001), though the median hospital cost was less but statistically insignificant (Rs. 800, IQR-25 vs. 735, IQR-1265; p=0.728). Blood loss was comparable in both groups (median 60 ml, IQR-20 vs. 60 ml-IQR-30; p=0.350). There were two uterine perforations noted in the inpatient group (2.02%) vs. none in outpatient setting. CONCLUSION: Outpatient based manual vacuum aspiration is a safe and effective tool for management of early pregnancy loss. A decentralized approach proved useful in reducing hospital stay.

Informed consent for surgery: do our current practices conform to the accepted standards?

A qualitative investigation was undertaken to determine and analyse the pattern of existing practices regarding informed consent for surgery at PIMS, Islamabad. Adult postoperative patients who had undergone surgical interventions were randomly selected face-to-face with the help of a team of junior doctors. A questionnaire was employed for data collection and the responses of the patients to the questions regarding various attributes of the consent process were analysed. Overall inadequacy existed in the prevailing practices. There is a need to revisit the consent related practices and make the process more informed and adequate. Instead of taking it as a casual formality, our doctors should regard it as an equally important exercise equivalent to other components of care such as the surgery itself.

Where does ergometrine stand in prevention of postpartum haemorrhage in caesarean section?

OBJECTIVE: To compare the safety and efficacy of 10 units of intravenous syntocinon alone with 10 units intravenous syntocinon and 0.25 mg intramuscular ergometrine in the prevention of atonic uterine haemorrhage during caesarean section. METHOD: The quasi-experimental study was conducted at the Maternal and Child Health Centre, Unit I, Pakistan Institute of Medical Sciences, Islamabad, from November 1, 2010 to February 28, 2011. All women undergoing caesarean section were included in the study. Patients were given intravenous 10 units syntocinon alone intraoperatively from November 1 to December 31,2010, while 0.25 mg ergometrine intramuscular was added to 10 units intravenous syntocinon from January 1 to February 28, 2011. Frequency of postpartum haemorrhage, adverse effects of drugs and maternal morbidity and mortality were assessed by using chi square test. P < 0.05 was taken as statistically significant. RESULTS: Of the total number of 701 subjects, 378 (54%) women were given 10 units syntocinon and 323 (46%) were given 0.25 mg ergometrine in addition to 10 units syntocinon. The mean age in the syntocinon group was 28 +/- 3.5 yrs with gestational age of 37.5 +/- 2 wks, while that in syntocinon-ergometrine group was 29 +/- 3.4 years and 38 +/- 2 weeks respectively. Postpartum haemorrhage in the syntocinon group was found in 38 (10%) women versus 05 (1.5%) women) in the other group (p < 0.001). Adverse effects like nausea, vomiting and raised blood pressure were slightly more with syntocinon-ergometrine than syntocinon alone (n = 56; 15.3% vs n = 35; 9.2%), but it was not statistically significant. Post partum haemorrhage was responsible for 40% of maternal mortality during the study period and that was in the syntocinon group. CONCLUSION: Prophylactic ergometrine in addition to syntocinon is superior to syntocinon alone in decreasing frequency of postpartum haemorrhage in caesarean section and associated maternal morbidity and mortality. Regarding safety profile, the two groups showed no statistically significant change.

Manual vacuum aspiration: a safe and cost-effective substitute of electric vacuum aspiration for the surgical management of early pregnancy loss.

OBJECTIVE: To compare the efficacy, safety and cost-effectiveness of Manual vacuum aspiration (MVA) with Electrical vacuum aspiration (EVA) in the management of first trimester pregnancy loss. METHODS: A single-centre randomized controlled trial (RCT) was conducted at Maternal and Child Health Centre (MCHC), Unit-I, Pakistan Institute of Medical Sciences (PIMS), Islamabad from April 2007-Dec 2008. A total of 176 cases with early pregnancy loss at < 12 weeks gestation, with a diagnosis of anembryonic pregnancy, incomplete, missed or septic induced abortion and molar pregnancy were randomly allocated to either MVA or EVA in the operation theatre. RESULTS: A total of 176 women were included out of which 70 underwent EVA and 106 had MVA. Baseline characteristics were similar in the two groups except significantly higher gestational age and gestational sac diameter in MVA group. Majority of EVA were performed under general anaesthesia (95.7%) while majority of MVA were performed under paracervical block (60.3%). Complete evacuation was achieved in 89.6% with MVA vs 91.4% with EVA (p=0.691). MVA was superior in terms of significantly less blood loss (62.08 +/- 32.19 vs 75.71 +/- 35.53; p=0.008), shorter hospital stay (12.26 hours +/- 6.97 vs 19.54 hours +/- 7.95; p=0.000) and less hospital cost (Rs 1419.5 +/- 1337.620 vs Rs. 3222.5 +/- 1816.02; p=0.000). Post-operative pain assessment by visual analogue score (VAS) at 0 and 6 hours showed no significant difference (p=0.845 and p=0.157 respectively). The only complication was uterine perforation in 2 (2.4%) cases both belonging to EVA. CONCLUSION: MVA is a safe and effective alternative of conventional EVA. It is superior to EVA in terms of reduced cost and need for general anaesthesia and is thus useful at low resource setting with scarcity of electricity and general anaesthesia.

Predictive accuracy of intrapartum cardiotocography in terms of fetal acid base status at birth.

OBJECTIVE: To find out the predictive value of intrapartum Cardiotocograph (CTG) in terms of fetal acid base status at birth in women undergoing emergency caesarean section for a suboptimal CTG trace. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: At the MCH Centre, Pakistan Institute of Medical Sciences, Islamabad, from June 2004 to July 2005. METHODOLOGY: All women undergoing emergency caesarean section for a suboptimal intrapartum CTG were recruited in the study. Immediately after the delivery of the baby a segment of umbilical cord was doubly clamped at a distance of 10 cm, and 2 ml of arterial cord blood was taken in a heparinized syringe for arterial blood gas indices analysis. All CTG tracings were reviewed using FIGO guidelines and compared for fetal arterial blood gas indices. RESULTS: Of the 57 patients who underwent cesarean section due to suboptimal CTG, 51 (89%) had suspicious trace while 6 (11%) had pathological trace. Positive predictive value of CTG was 18% for fetal hypoxia, 21% for fetal hypercarbia., 26% for fetal acidosis and 37% for base excess. Predictive value of suspicious trace for similar blood indices was 13%, 13%, 17% and 35% respectively. For pathological trace, predictive value was 50%, 83 %, 100% and 66% and respectively. CONCLUSION: Based on the results, it is concluded, that the suspicious CTG trace has low predictive value in terms of fetal acid base status at birth and needs to be complemented with other diagnostic modalities before undertaking any operative intervention. Pathological CTG on the other hand is highly predictive of fetal acidosis at birth warranting immediate intervention.

External cephalic version with salbutamol - success rate and predictors of success.

OBJECTIVE: To determine the success rate of External Cephalic Version (ECV) with 0.25 mg Salbutamol in singleton term breech and to identify the predictors of success. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Mother and Child Health Centre, Pakistan Institute of Medical Sciences, Islamabad, from January 2000 to March 2005. METHODOLOGY: Women, presenting with uncomplicated breech, between 37-40 completed weeks gestation, underwent ECV in day care ward. Fifteen minutes before the procedure, injection salbutamol 0.25 mg was administered subcutaneously. Cases with contraindication to ECV or Salbutamol injection were excluded from the study. The outcome measures included success rate of ECV (in terms of conversion from breech to cephalic presentation at the completion of procedure confirmed through ultrasound), association of maternal and fetal demographic characteristics with successful version and adverse effects related to the procedure in terms of fetal bradycardia, ante-partum still birth, antepartum hemorrhage and preterm labour. Rate of reversion to breech and drug-related side effects were also recorded as secondary outcome measures. Chi-square test was used for categorical variables and independent sample t-test for continuous variables. RESULTS: Of the 101 ECV procedures, 41 (40.5%) were successful. Success rate was significantly lower in nullipara (p=0.01) and with AFI 7 cm or less (p=0.04). No significant association was found between success rate and gestational age (p=0.35) or fetal birth weight (p=0.57). None of the patient suffered from serious maternal complications. Salbutamol related minor effects (tremors, anxiety and palpitations) were observed in 36 (35.6%) patients. Fetal tachycardia was seen in 17 (16.8%), reversible fetal bradycardia in 3 (2.9%) and intractable fetal bradycardia in one patient. CONCLUSION: External cephalic version with 0.25 mg Salbutamol was safe and a feasible option in term breech presentation in this series. Administration of tocolytic agent improved the success rate and reduced complication rate of the procedure. Major determinants of success were amniotic fluid index and parity.

Advanced abdominal pregnancy--a diagnostic and management dilemma.

Advanced abdominal pregnancy is a complex condition demanding challenging management. High index of suspicion may reduce the diagnostic error. Management varies from patient to patient. Expectant management is a feasible option in a well-equipped tertiary care hospital in case of alive viable fetuses. This evidence-based report describes the author's experience of managing a series of advanced abdominal pregnancies at 24 weeks or more of gestation.

Impact of reduced prenatal visit frequency on obstetric outcome in low-risk mothers.

OBJECTIVE: To determine an association between reduced prenatal visit frequencies and pregnancy outcome in women, found to be at low-risk of obstetric complications at initial prenatal visit. DESIGN: Prospective cohort study. PLACE AND DURATION OF STUDY: Mother and Child Health Center, Pakistan Institute of Medical Sciences, Islamabad. from January to December 2002. PATIENTS AND METHODS: The hospital case records of 1290 women, who were found to be at low risk of obstetric complications at their first prenatal visit. Prenatal visits were categorized into '<3', '3-6' and 'z 7 visits groups'. 'z7 visits were taken as controls. The main outcome measures were peripartum maternal complications, obstetric interventions and perinatal outcome. RESULTS: The median number of prenatal visits was four, (range 1-14; lower quartile 2, upper quartile 6). Women with less than 3 prenatal visits had significantly higher risk of antepartum complications, low birth weight neonates (<2500 grams), pre-term deliveries, neonatal morbidity, and peri-natal mortality. (OR: 2.58, 2.66, 6.3, 1.57 and 2.2 respectively). However, they were at equal risk of obstetric interventions and postpartum maternal morbidity. No significant difference was found between 3-6 visits and z7 visits group, except significantly higher risk of preterm deliveries in the former group (OR: 2.84). CONCLUSION: Less than 3 prenatal visits were associated with significantly higher incidence of prenatal feto-maternal complications and low birth weight babies compared to 7 or more visits but were at equal risk of obstetric interventions and postpartum maternal morbidity.The obstetric outcome of 3-6 visits group was similar to 7 or more visits group except considerably higher incidence of preterm deliveries in the former group.