Obstetrical anal sphincter injury - risk factors and outcome of surgical repair by end-to-end re-approximation technique

Objective: To identify the obstetrical risk factors for anal sphincter injury and to review the outcome of our practice of end-to-end reapproximation technique for its repair

Study Design: A prospective observational study

Place and duration: Obstetrics and Gynaecology Unit-A, Khyber Teaching Hospital, Peshawar, from 1[st] January 2011 to 31[st] December 2013

Methodology: All patients with obstetrical anal sphincter injury [OASI] i.e. third and fourth degree perineal tears, after vaginal delivery were included. Data including age, parity, labour characteristics, types of delivery, fetal weight, degree of tear, any previous repair, follow up and outcome were recorded. Primary or secondary repair according to the case was done by end-to-end reapproximation technique. Post operative care was standardized, antibiotics, laxative and pelvic floor exercises were advised. Follow up was done at 6 and then 12 weeks

Results: Thirty two patient had OASI, n = 23 [71.87%] had third degree and n= 9[29.13%] had fourth degree perineal tear. Mean age was 26.07 + 1 S.D [range 19-40 years] including 16[50%] primipara, 12[37.50%] P2-P3 and 4[12.50%] P4 or more. Spontaneous vaginal delivery [SVD] in 21[65.63%], SVD with episiotomy in 5[15.62%] while Breech 1 and instrumental delivery in 5[15.62%]. The risk factors identified were nulliparity, heavier fetal weight [?3.8kg], instrumental delivery, fetal malposition, extension of episiotomy, induction of labour [IOL], oxytocin use and unattended labour. No risk factor could be identified in 6[18.75% patients, more than one factor was identified in 8 women. Seventeen [53.12%] patients with third degree and n= 9[28.13%] with fourth degree tear had primary repair and 9[28.13%] had secondary repair. At 12 weeks follow up over all n=28[87.75%] women were asymptomatic and continent, 1[3.12%] had faecal urgency, 1[3.12%] continence to flatus on physical exersion, in 2[6.25%] repair was unsuccessful with incontinence to stool and flatus. Minor complication were wound infection 2[6.25%] and dyspariuria in 4[12.50%]

Conclusion: Obstetrical risk factors commonly associated with anal sphincter tear were nulliparity, instrumental deliveries, heavier fetal weight, malpositions, prolong labour and delivery by unskilled birth attendants. Our practice of end-to-end approximation technique for repair anal sphincter tears was associated with good outcome in terms of anal continence at 6-12 weeks

Frequency and clinicopathological presentation of gynaecological malignancies

To describe the frequency and clinicopathological presentation of malignancies of the female genital tract presenting to a tertiary care hospital. This descriptive study was carried out at Department of Obstetrics and Gynaecology, Unit A of Khyber Teaching Hospital, Peshawar from January 2008 to December 2012. A total of 4657 patients were admitted during the study period and all the patients having genital tract malignancies were included. Detailed history was taken and relevant examinations and investigations were carried out. Surgical procedures were performed where needed and specimens were sent for histopathology. Clinical and surgical staging was also carried out. All the details were noted down on a semi-structured proforma. There were 43 cases of gynaecological malignancies with mean age of 43.74 +/- 15.51 years. Ovarian cancer was the most common [n=22, 51.22%] followed by uterine cancer [n=10, 23.33%]. The majority of patients diagnosed with ovarian cancers [n=9/22, 40.94%] were nulliparous, whereas the majority of uterine and cervical cancers were multiparous [n=7/10, 70.0%] and grand multiparous [n=7/9, 77.78%], respectively. Ovarian cancers mostly presented with an abdominal mass [n=16/22, 72.7%] while uterine and cervical cancer presented with irregular cycles [n=7/10, 70.0%] and post coital bleeding [n=4/10, 40%]. Advanced stage cancer cases were 19/43 [44.22%]. Serouscystadeno carcinoma was the most common ovarian malignancy [n=16/22, 72.73%] while endometrioid adenocarcinoma [n=9/10, 90%] was the most common uterine carcinoma and squamous cell carcinoma was the most common cervical carcinoma [n=7/9, 77.88%].Conclusions: Ovarian cancer was the most commonly encountered malignancyal though all gynaecological malignancies are rare

Magnesium sulphate therapy in eclampsia: a 5 years experience at a teaching hospital

To describe the presentation of eclampsia, its management and associated outcomes using magnesium sulphate [MgSO4], over a five years period at a tertiary care hospital. This descriptive study was conducted at Obstetrics and Gynecology Unit, Hayatabad Medical Complex, Peshawar from January 2004 to December 2008. Data was collected from all patients presenting with eclampsia. A total of 146 patients had eclampsia. Unbooked were 124 [84.93%]. Mean age 23 years +/- 5.3 years [range 18-38 years], primigravida were 69.17% [101 cases]. Antepartum fits in 72.6% [106 cases], intrapartum 14 [9.58%] and 27 [18.49%] postpartum. MgSO4 was used in all except 4 with oliguria, they were given diazepam. Recurrent fit occurred in only 20[13.69%]. MgSO4 toxicity occurred as respiratory depression in 9 cases, depressed tendon reflexes in 10 and decreased urine output in 13 cases Total deliveries were 23021, prevalence of eclampsia was 0.63%. Mode of delivery was Vaginal in 97 [66.43%], instrumental in 29 [19.98%] and cesarean section in 20 [13.69%] cases. There were 26[17.2%] stillbirths and 4 neonatal deaths. Complications included HELLP in 17 [11.64%], pulmonary complications in 17, renal failure in 7 [4.79%], DIC in 16[10.95%] and temporary blindness in 16 cases. Eleven [7.53%] maternal deaths occurred, causes included DIC in 1case, HELLP in 2, renal failure 1, cardiopulmonary failure in 2 and CVA [received deeply unconscious] in 5 cases. All were unbooked cases and with delay in reaching hospital. Eclampsia is common antenatally and in primigravidae, and a major cause of maternal morbidity and mortality in our region. It was effectively controlled with MgSO4, preventing recurrent fits and safe for both mother and fetus

Laparoscopic evaluation in infertility

To describe the different causes of infertility based on findings of diagnostic laparoscopy and their comparative frequency in primary and secondary infertility. A cross-sectional study. Obstetrics and Gynaecology Unit of Hayatabad Medical Complex, Peshawar, from January to December 2005. All patients undergoing diagnostic laparoscopy for primary or secondary infertility were included. Male factor infertility cases was excluded. Frequency of the causes and finding was determined. One hundred and thirty six [70.46%] patients with primary and 57 [29.54%] with secondary infertility underwent diagnostic laparoscopy. Seventy [51.47%] with primary and 26 [45.51%] with secondary infertility had no visible abnormality. Bilateral tubal blockage was found in 32 [23.53%] primary and 16 [28.07%] cases of secondary infertility. Dense pelvic adhesions forming adnexal mass were found in 9 [6.61%] and 6 [10.5%] of primary and secondary respectively. Two cases each of bicornuate uterus and double uterus in primary infertility patients. Ovarian pathology was found in 18 [13.23%] primary and 4 [7.01%] cases of secondary infertility. PCO [polycystic ovaries] were detected in 12 [8.82%] and 2 [3.5%] cases of primary and secondary infertility respectively. Endometriotic cysts and deposits were found in 15 [10.29%] cases of primary and 3 [5.26%] cases of secondary infertility. Tubal disease is a common factor responsible for infertility and diagnositc laparoscopy is a valuable technique for complete assessment of female infertility and making treatment decisions according to the cause

Pseudomyxoma peritonei: a review of 17 cases

To evaluate the various presentations, causes and management of Pseudomyxoma Peritonei [PMP], and to create awareness among young surgeons regarding its importance. Retrospective study from Jan. 1999 to Dec. 2005. Surgical Unit of Khyber Teaching Hospital, Peshawar and Gynaecology and Obstetrics Unit, Hayatabad Medical Complex, Peshawar. All patients who had Pseudomyxoma Peritonei during the study period. The clinical records of all patients undergoing laparotomy for various causes were reviewed and cases of PMP separated. Their biodata, clinical presentation, clinical diagnosis, investigation results, operative findings, histopathology report and outcome were recorded. Out of 23,573 cases that underwent laparotomy 17 cases of PMP were on record. All were diagnosed incidentally per-operatively. Most [47.05%] cases were seen in the age group of 30-40 years and 58.82% patients were females. Abdominal pain, mass, abdominal distension and intestinal obstruction were the common presenting features. Ultrasound and CT scan reported three cases as ovarian cysts, three as multiple encysted fluid collections with thin cyst walls, two as ascites, two as ascites with peritoneal thickening, but none as PMP. Surgery was the mainstay of treatment. Appendicectomy with clearing of mucin in 11[64.70%], oophorechtomy and appendicectomy in 3[17.64%], bilateral oophorechtomy and hysterectomy in 2[11.76%], right hemi-colectomy in 1[5.88%] and second look surgery for complications were done in 2[11.76%] cases. Mortality was 11.76% and due to complication including one due to intestinal obstruction and another due to septicemia following second look surgery. Histopathological tissue diagnosis was available in only 13 cases and included mucinous adenoma appendix in five, mucinous cystadenoma ovary in three, mucinous epithelial cells of unknown origin in four and mucinous cystadenoma of borderline malignancy in one case. PMP is under reported in our setup. Pre-operative diagnosis is difficult and incidental findings usually go unnoticed due to lack of awareness and standard management protocol. There is a need to create awareness among surgeons, radiologists, pathologist and oncologist regarding this condition for the better outcome

Eclampsia-management and outcome with magnesium sulpate as the anticonvulsant

To study the maternal outcome in terms of morbidity and mortality with the use of magnesium sulphate in eclampsia for seizure control and prophylaxis. A quasi experimental study. This study was conducted in Obstetrics and Gynaecology Unit of Hayatabad Medical Complex, Peshawar, from 1st September 2002 to 31st December 2003. All the patients admitted with eclampsia during this period were included in the study. A detailed history and clinical examination were recorded. Patients were monitored for number of fits, rise in blood pressure [BP], dose of magnesium sulphate administered and its side effects, development of complications of eclampsia, duration of labour, mode of delivery and use of other medications as well as maternal and perinatal outcome. During this period, 52 patients were admitted with eclampsia. Majority were unbooked. Primigravida were 31 [59.6%]. Common age group was between 21 and 30 years having 34 [65.4%] patients while 16 [30.7%] patients were 20 years or less than 20 years of age. Thirty-three [63.4%] patients had antenatal fits, 9 [17.3%] intrapartum fits and 11 [19.2%] had postpartum eclampsia. Twenty-six patients had term pregnancy, 22 patients with 28-36 weeks gestation while 4 patients developing eclampsia before 28 weeks gestation. Eighteen patients had spontaneous vaginal delivery; labour was induced in 21 patients while 6 patients underwent cesarean section. Maternal complications included pulmonary oedema, tongue bites, HELLP syndrome, placental abruption and coagulopathy. Side effects of magnesium sulphate were low. There were 4 [7.6%] maternal deaths due to eclampsia. Perinatal outcome was good with 33 [63.4%] live births, 3 IUDs and 10 still births, mostly due to prematurity. Magnesium sulphate was found to be an effective anti-convulsant both for control and prophylaxis of seizures in eclampsia and improved maternal and fetal outcome