Feto-Maternal Outcomes Of Maternal Sepsis: A Snapshot Of The Illness.

BACKGROUND: Maternal sepsis is a life-threatening condition with serious adverse feto-maternal outcomes. This descriptive cross-sectional study aimed to study the incidence of common feto-maternal outcomes of maternal sepsis in our hospital. METHODS: Pregnant females with singleton pregnancy as per inclusion/exclusion criteria were enrolled in the study. A detailed medical history was taken and physical and obstetrical examination was done. They were investigated for the cause of their febrile illness and managed as per department protocols. Data was recorded in a pre-designed pro forma. RESULTS: The most common cause of infection was UTI (32; 42.6%) followed by genital infections (20; 26.7%) and respiratory tract infections (15; 20%). In 8 (10.7%) patients, the cause couldn't be found. Only one patient developed sepsis and was admitted to the medical ICU. That pregnancy resulted in PROM and an infant with low birth weight was delivered. Both the mother and the child survived and were discharged from the hospital. There was no mortality in our study group. CONCLUSIONS: Though sepsis was associated with adverse feto-maternal outcomes in our study, the study design prevents us from drawing any conclusions from this study concerning maternal sepsis in our region. Further research is needed to determine the true magnitude of the problem.

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.

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.

Maternal And Foetal Outcome In Cesarean Hysterectomies Performed For Placenta Increta.

BACKGROUND: Placenta accreta is a serious obstetrical complication and is currently a very important indication for peripartum hysterectomy. The purpose of this study is to review the frequency of Caesarean hysterectomies performed for placenta accreta and maternal, foetal outcome of these patient. METHODS: In this cross-sectional study all the patients who underwent emergency hysterectomies for different obstetrical indications during this one year were included in this study. Among them the hysterectomies performed for massive antepartum haemorrhage due to placenta increta were reviewed in detail and risk factors were identified. RESULTS: Caesarean hysterectomies performed for different obstetrical indications were 47 and 10 were due to placenta previa increta (21.2%). The mean age of the patients was 30±5.5 years. Majority of the patients were multigravidas between 26 and 35 years of age. 30% of patients were Para-3 and 70% of patients were Para-4 and above. One patient (10%) had previous one Caesarean section with placenta previa increta, 02 patients (20%) had previous 02 C-Sections and low-lying placenta adherent to it and 04 patients (40%) had previous 03 C-Sections and major degree placenta previa and 03 patients (30%) had 04 C-Sections with placenta increta. Among the foetal outcome 04 babies (40%) were delivered between 28-32 weeks of gestation. Five foetuses (50%) were delivered between 33-36 weeks of gestation and one foetus (10%) was delivered at term. 02 babies delivered at 28 weeks of gestation had early neonatal death due to prematurity. There were no maternal deaths in this time period. CONCLUSION: placenta previa increta is a major obstetrical complication. Timely recognition and delivery in a tertiary care hospital with surgical expertise, blood bank facilities and intensive care facilities both for the mother and the baby are needed to improve maternal and foetal outcome.

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.

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.

Maternal morbidity and mortality due to primary PPH--experience at Ayub Teaching Hospital Abbottabad.

BACKGROUND: Postpartum Haemorrhage (PPH) remains a significant cause of maternal mortality and morbidity like hypovolemic shock, anaemia, multi organ failure, consumptive coagulopathy, disseminated intra vascular coagulation (DIC), blood transfusion related complications and hysterectomy leading to loss of childbearing potential. The present study was conducted to determine the frequency of PPH and the associated maternal morbidity at the Department of Gynaecology Unit 'B', Ayub Teaching Hospital Abbottabad. METHODS: The study was carried out in the Department of Obstetrics and Gynaecology Unit B of the Ayub teaching Hospital Abbottabad from 18th April 2006 to 17 July 2006. The study population included all cases admitted with primary PPH during the study period. For calculation of frequencies, the total number of deliveries in the setting during the study period was used. All subjects underwent a complete obstetrical clinical workup comprising of history, general physical examination, abdominal and pelvic examination, relevant laboratory investigations. The maternal condition was assessed and managed according to established hospital protocols which included both pharmacological and surgical intervention. All maternal complications were noted and recorded on pre-designed proformas. Data was entered and analyzed by computer. RESULTS: A total of 50 cases of primary PPH were recorded during the study period. The frequency of PPH was calculated as 7.1%. The major cause of PPH was uterine atony found in 29 (58%) cases, followed by cervical, vaginal and perineal tears in 12 (24%) cases. Initially all patients were managed pharmacologically followed by surgical intervention. Subtotal (haemostatic) hysterectomy was performed in 10 (20%) cases. Maternal morbidity was detected in 31 (62%) of cases; the major morbidities were DIC in 3 (6%) cases, Acute renal failure in 3 (6%) patients and shock in 2 (9.9%) cases and anaemia in 20 (90.1%) cases. CONCLUSION: The study concludes that the frequency of primary PPH in this setting is in keeping with globally cited frequencies. Other findings such as causes of primary PPH and maternal morbidity data also agree with most national and international studies on this topic.

Septic induced abortions.

BACKGROUND: Induced abortions are not infrequent in our community. Being the only tertiary level care hospital in Hazara division, Ayub Teaching Hospital frequently receives cases of induced abortions with complications attempted by inappropriately trained personnel. It was decided to study the frequency of such cases in our admitted patients, complications and their outcome in such risky situation. METHOD: A cross sectional study was conducted from January 2006 to December 2007 in Gynae-B Unit, Ayub Teaching Hospital, Abbottabad. All admitted patients in the unit in the 1st trimester of pregnancy and handling outside the hospital were included in the study. RESULTS: In two years period total Gynae admissions were 1090. There were 152 (13.95%) cases of spontaneous 1st trimester abortions and 52 (4.7%) cases of induced abortions which are included in the study. Age range of the patients was between 20-45 years, with a mean of 35 years. Majority of the patients were grand multigravidas belonging to lower socioeconomic group and not using any contraception. Twenty patients (38.4%) presented with heavy per vaginal bleeding due to incomplete nature of the procedure. Twelve patients 23% presented in shock due to excessive per vaginal bleeding. Ten patients 19.2% had uterine perforation and intraperitoneal haemorrhage. Two patients 3.8% had gut injury associated with uterine perforation. Three patients 5.7% developed septicaemia due to uterine gangrene. Ten patients 19.2% had acute pelvic infection presented with pelvic abscess and acute pelvic inflammatory disease. Maternal motility in our study was 2 out of 52 (3.8%). CONCLUSION: Induced septic abortions contribute significantly to maternal morbidity and mortality. Improving literacy rate in our female population and effective family planning should reduce its incidence. Different resources should be used to develop awareness of the hazards of induced abortions in the community.

The comparison of placental removal methods on operative blood loss.

BACKGROUND: On an average 1 litre of blood is lost during Caesarean Section. Many variable techniques have been tried to reduce this blood loss. Many study trials have shown the spontaneous delivery of placenta method to be superior over manual method because of reduced intra operative blood loss and reduced incidence of post operative endometritis. The main objective of our study was to compare the risk of blood loss associated with spontaneous and manual removal of the placenta during caesarean section. STUDY DESIGN: Quasi Experimental. SETTING AND DURATION OF STUDY: September 2004 to September 2005, a 13 months study at Islamic International Medical Complex Islamabad. PATIENTS AND METHODS: This study was conducted at Department of Obstetrics and Gynaecology, Islamic International Medical Complex, Islamabad from September 2004 to September 2005. All Women undergoing elective or emergency caesarean section were included in the study. Exclusion criteria were pregnancy below 37 weeks, severe maternal anaemia, and prolonged rupture of the membranes with fever, placenta praevia, placenta accreta and clotting disorders. Patients were allocated to the two groups randomly. Group A comprised of women in whom the obstetrician waited a maximum of 5 minutes till the placenta delivered spontaneously. In group B the obstetrician manually cleaved out the placenta as soon as the infant was delivered. The primary outcome measures noted were difference in haemoglobin of >2 gm/dl (preoperatively and postoperatively), time interval between delivery of baby and placenta, significant blood loss (>1000 cc), additional use of oxytocics, total operating time and blood transfusions. Data was analysed by SPSS. Statistical tests used for specific comparison were chi2-test and Student's t-test. RESULTS: One hundred and forty-five patients were allocated to two groups randomly. Seventy-eight patients were allocated to group A and 67 patients allocated to group B. Mean maternal age, birth weight, and total operating time were the same in two groups, but blood loss as measured by a difference in haemoglobin of greater then 2 grams/dl was statistically significant. Significant blood loss (>1000 cc) and time interval between delivery of infant and placenta were also statistically significant between the two groups. CONCLUSION: Spontaneous delivery of placenta has significant reduction of blood loss as compared to manual removal at caesarean section.

An audit of primary post partum hemorrhage.

BACKGROUND: Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Its causes & risk factors are important for its prevention and management. Poor, unhealthy, high parity women delivering away from health facility are usual victims. The purpose of this study is to determine causes of PPH, risk factors, preventable factors and to assess treatment measures adopted. METHODS: This retrospective study is carried out in Gynaecology 'B' unit of Ayub Teaching Hospital Abbottabad. All patients admitted with PPH or developed PPH within hospital from 1st Jan-31st Dec 2006 are included. Exclusion criteria were patients with bleeding disorders and on anticoagulants. Records of admissions, deliveries, caesareans, major & minor procedures and history charts were thoroughly evaluated for details. Details included age, parity, socioeconomic status, transportation facility, distance from hospital, onset of labours, birth attendant skilled/unskilled, evaluation of risk factors, duration of labour and mode of delivery. Patient's general health, anaemia, shock, abdominal and pelvic examination and laboratory findings were also taken in to account. Treatment measures including medical, surgical, blood transfusions were evaluated. RESULTS: The most important cause was uterine atony, 96 (70.5%) and traumatic lesions of genital tract, 40 (29.4%). Factors causing uterine atony were augmented labour 20 (20.9%), prolonged labour 21 (21.9%), retained placental tissues, 11 (12.5%), retained placenta, 11 (11.4%) Couvelliar uterus, 10 (10.4%), placenta preavia, 8 (8.3%), placenta increta, 7 (7.3%), chorioamnionitis 5 (5.2%), and multiple pregnancy, 2 (2.1%). Risk factors, grand multiparity 70 (51.5%), antepartum haemorrhage 12 (8.9%), instrumental delivery 10 (7.3%), previous PPH, 6 (4.5%), choreoamnionitis, 5 (3.6%), multiple pregnancy, 2 (1.5%), no risk factor, 21 (15.4%). Socioeconomic status was poor (75) & lower middle class (61). Induced labour, 33 (24.3%), augmented labour 62 (45.5%). Uterotonics used for prophylaxis in 30 (22%), for treatment of PPH, 106 (78%). Patients delivered by traditional birth attendants 70 (51.4%), lady health workers 40 (29.4%) & doctors 26 (19.2%). Uterine massage performed in 30 (22%), minor surgical procedures 33 (24.3%), manual removal of retained placenta, 11 (8%), hysterectomy, 50 (36.7%), & compression sutures were applied in 3 (2.2%). Maternal deaths due to PPH were 6 (40%). CONCLUSIONS: PPH can be prevented by avoiding unnecessary inductions/augmentations of labour, risk factors assessment and active management of 3rd stage of labour. It needs critical judgment, early referral and early resuscitation by birth attendant. There is room for temponade and compression sutures. Hysterectomy should be the last option.