Pakistani obstetricians' recognition of and attitude towards domestic violence screening.

OBJECTIVE: Our study assesses Pakistani obstetricians knowledge of the prevalence of domestic violence in clinical practice and attitudes towards instituting screening protocols during routine antenatal care. METHODS: One hundred obstetricians, all Karachi residents, were randomly drawn from a stratified sampling list taken from membership lists. A structured questionnaire assessing prevalence, attitudes, and beliefs on training and domestic violence screening protocols was administered. RESULTS: Nearly 70% of obstetricians reported that more than 30% of Pakistani women are victims of domestic abuse. Sixty-two obstetricians specified that they had identified a physically abused woman within the past year. Almost half of the respondents were favorably inclined to screen patients. Professional, personal and patient-related barriers were identified as the main hurdles preventing instituting screening. CONCLUSIONS: The desire for instituting routine screening despite the recognition of major hurdles by Pakistani obstetricians should propel reproductive health stakeholders to raise awareness about appropriately modifying standard antenatal care protocols.

Pregnancy following cardiac surgery.

OBJECTIVE: To determine the pregnancy outcome in women with cardiac disease who have undergone cardiac surgery. DESIGN AND SETTING: Prospective study in a tertiary care hospital. POPULATION: One hundred and thirteen pregnant women who had cardiac surgery due to valvular disease (commisurotomy as well as valve replacement), or other cardiac defects. These women were followed up in 170 pregnancies between January 1990 and December 1999. RESULTS: Rheumatic heart disease (91%) affecting the mitral valve, was the commonest indication for cardiac surgery (89%). Valve replacement with mechanical prostheses followed by anticoagulant therapy was carried out in 45%. There was no maternal death. Maternal morbidity from complications included pulmonary oedema (16%), cardiac arrythmias (4%), postpartum haemorrhage (3.5%). Other bleeding complications included epistaxis and haematoma at episiotomy site (2%). Impaired functioning of prosthesis (4%), severe pregnancy induced hypertension (2%) and thromboembolism (0.6%) were also observed. The abortion rate was 10.6%. There were 3 stillbirths (2%), another 6.7% babies were born preterm and 28% were lighter than appropriate for the period of gestation. There were no neonatal deaths. Coumarin derivatives were not associated with obvious foetal malformation. CONCLUSION: With appropriate care, the outcome of pregnancy in women who have had cardiac surgery is favourable, if their functional class is good.

Obstetrics hysterectomy--five years experience at Jinnah Postgraduate Medical Centre, Karachi.

During the five years period (1st January 1988 to 31st December 1992), 106 hysterectomies were performed for obstetric indications in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre (JPMC), Karachi. The frequency was 1 in 331 deliveries (total 35,172 deliveries). In all except one hysterectomy was performed as a life saving measure. The major indications were ruptured uterus in 61 (58%) cases and severe postpartum haemorrhage due to uterine atony in 18 (17%). Other indications included haemorrhage due to placenta praevia in 11 (10%), placenta accreta 7 (7%) and abruptio placentae 5 (5%), severe infection 2 (2%) and broad ligament haematoma following caesarean section 1 (1%). There were 10 (9%) maternal deaths all due to severity of the conditions necessitating hysterectomy. Obstetric hysterectomy can save many lives but requires proper judgement and skill. Senior resident staff in obstetric units in the developing countries should be trained for it.

Social and cultural factors leading to mothers being brought dead to hospital.

In a 12-year period (1981-1992) 150 pregnant or recently delivered women were dead when they reached the hospital. Relevant history with emphasis on the events of the previous 24 h and the reasons for delay in reaching the hospital were obtained from the relatives accompanying the patient. The probable cause of death was determined on the basis of history only; no autopsies were done. The causes of delay were economic (54), sociocultural factors (51) and inadequate maternal services (31). In 14 cases the reasons for delay could not be established. The medical problems were either preventable or treatable if managed in time. A combination of economic, social and cultural factors played a more significant role in these deaths than medical causes.

Rupture of the uterus in full-term pregnancy.

Of 48,519 deliveries conducted at Jinnah Postgraduate Medical Centre (JPMC) over 7 years (January, 1986 to December, 1992), 257 were of ruptured uterus, giving a rate of one in 189 deliveries. Main cause of rupture was obstructed labour. Maternal mortality was 3.9% and foetal mortality 88% in cases admitted with uterine rupture and 17.6% in rupture occurring within the hospital (JPMA 43: 172, 1993).

Evaluation of the role of craniotomy in developing countries.

A review of 32 cases of craniotomy performed at the Jinnah Postgraduate Medical Centre Karachi, over a period of 6 years from January, 1984 to December, 1989 is presented. Total number of deliveries during this period were 37,682. Frequency of craniotomy was 0.08% i.e., 1 in 1177 deliveries. Of these 32 craniotomies, 28 were done on non-deformed dead fetus, 16 because of obstructed labour, 7 in cases of after coming head of breech and 5 in failure to progress in second stage of labour. Four cases were of live hydrocephalic fetus in whom cephalocentesis was done followed by craniotomy due to failure to progress in labour. Maternal morbidity was 12.5% with no maternal death. We conclude that it is safe and quicker than caesarean section in selected cases. Though unpleasant to perform, is of great relief to the patient and her family.

Mothers brought dead: an enquiry into causes of delay.

In a 10 year period (1981-1990) 118 pregnant or recently delivered women were dead when they reached hospital. Relevant history with emphasis on the events of the previous 24 hr and the reasons for delay in reaching the hospital were obtained from the relatives accompanying the patient. The probable cause of death was determined on the basis of history only. Autopsy was not carried out on any case. The causes of delay were economic factors in 42, socio-cultural factors in 39 and inadequate maternal services in 24 cases. In 13 cases the reasons for delay could not be established. The medical problems were either preventable or treatable if managed in time. A combination of economic, social and cultural factors played a more significant role in these deaths than medical causes.

Culdocentesis in diagnosis of disturbed ectopic pregnancy still a useful procedure in developing countries.

Over a period of 5 years culdocentesis was carried out in 156 cases of suspected ectopic pregnancy using needle aspiration through the pouch of Douglas. The result was positive in 134 cases, with 131 being true positive and 3 false positive. In 22 cases the result was negative, 6 of which were false negative. It is concluded that culdocentesis is an effective method of diagnosing disturbed ectopic pregnancy.

Perinatal mortality in Jinnah Postgraduate Medical Centre, Karachi.

During the one year period from 1st January to 31st December, 1989, there were 6,826 deliveries and 695 perinatal deaths, of these 553 were still-born and 142 were neonatal deaths (died within 7 days of birth). The perinatal mortality rate was 101.8 per thousand total births. The still-birth rate was 81 per thousand total births. Of the perinatal deaths, 7.9% occurred in booked and 92.1% in non-booked cases. The commonest cause of death was antepartum haemorrhage (APH), 24.2% followed by mechanical which accounted for 23.6% deaths. Abruptio placentae was the leading cause among all still-births and low-birth weight (LBW) in all neonatal deaths.