Alternative routes for tranexamic acid treatment in obstetric bleeding (WOMAN-PharmacoTXA trial): a randomised trial and pharmacological study in caesarean section births.

OBJECTIVE: To examine the safety, efficacy and pharmacology of intravenous (IV), intramuscular (IM) and oral tranexamic acid (TXA) use in pregnant women. DESIGN: Randomised, open-label trial. SETTING: Hospitals in Pakistan and Zambia. POPULATION: Women giving birth by caesarean section. METHODS: Women were randomised to receive 1 g IV, 1 g IM, 4 g oral TXA or no TXA. Adverse events in women and neonates were recorded. TXA concentration in whole blood was measured and the concentrations over time were examined with population pharmacokinetics. The relationship between drug exposure and D-dimer was explored. The trial registration is NCT04274335. MAIN OUTCOME MEASURES: Concentration of TXA in maternal blood. RESULTS: Of the 120 women included in the randomised safety study, there were no serious maternal or neonatal adverse events. TXA concentrations in 755 maternal blood and 87 cord blood samples were described by a two-compartment model with one effect compartment linked by rate transfer constants. Maximum maternal concentrations were 46.9, 21.6 and 18.1 mg/L for IV, IM and oral administration, respectively, and 9.5, 7.9 and 9.1 mg/L in the neonates. The TXA response was modelled as an inhibitory effect on the D-dimer production rate. The half-maximal inhibitory concentration (IC50 ) was 7.5 mg/L and was achieved after 2.6, 6.4 and 47 minutes with IV, IM and oral administration of TXA, respectively. CONCLUSIONS: Both IM and oral TXA are well tolerated. Oral TXA took about 1 hour to reach minimum therapeutic concentrations and would not be suitable for emergency treatment. Intramuscular TXA inhibits fibrinolysis within 10 minutes and may be a suitable alternative to IV.

Overactive bladder: A multicenter study in Pakistan.

OBJECTIVE: To determine the overall prevalence of overactive bladder in Pakistan, and to determine the difference in prevalence in relation to gender. METHODS: The multicenter study was conducted from February 2017 to October 2018 at 11 institutions across the country, and comprised randomly selected healthy subjects of either gender who were assessed on the basis of symptoms defined by the International Continence Society for overactive bladder. Data was collected using a questionnaire based on the symptoms which was filled for the respondent by designated health workers. Data was analysed using SPSS 23. RESULTS: Of the 1291 respondents, 632(49%) were males with a mean age of 37.8±14.4 years, and 659(51%) were females with a mean age of 38.3±13.7 years. The overall prevalence of overactive bladder was 82(6.4%). Among the males, it was 15(2.4%) and among the females 67(10.2%) (p=0.001). Urgency, frequency and nocturia were reported by 82(6.4%) respondents; 15(1.2%) males and 67(5.2%) females (p=0.001). CONCLUSIONS: The prevalence of overactive bladder was found to be low when assessed with strict application.

The modified Robson criteria for Caesarean Section audit at Mother and Child Health Center Pakistan Institute of Medical Sciences Islamabad.

OBJECTIVE: To determine the rates of lower segment Caesarean Section and their indications using modified Robson criteria. METHODS: The retrospective study was conducted at Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and comprised review of records from October 1, 2016, to September 30, 2017,related to all Caesarean Sections. The data was classified according to Robson's Ten Group Classification System. SPSS 21 was used for data analysis. RESULTS: Of the 6155 deliveries, 2052(33.3%) were caesarean sections. According to the criterion used, the major contributor to overall Caesarean Section rate was Group 5 which entails previous Caesarian delivery, single, cephalic, >37 weeks. CONCLUSIONS: Women with previous scar should be assessed and offered trial of labour after caesarean section, where appropriate.

High burn out among doctors working in a tertiary care hospital; a wakeup call.

OBJECTIVE: To determine the frequency of burnout and its associated factors among doctors in a tertiary care setting. METHODS: The descriptive study was conducted at Pakistan Institute of Medical Sciences, Islamabad, Pakistan, from October 1, 2016, to January 31, 2017, and comprised doctors working there regardless of age, gender and professional experience. A self-reported questionnaire with demographic data and Maslach Burnout Inventory was used. Levels of each component of and composite burnout score were calculated and associated with each independent variable. Data was analysed using SPSS 21. RESULTS: Of the 365 doctors, 238(65.2%) were females, 200(54.8%) were single, and the overall mean age was 28.68}4.58 years. Besides, 172(58%) subjects were postgraduate residents, 77 (21%) belonged to Obstetrics and Gynaecology, 198(54.2%) had 1-in-4 rota, and 123(33.7%) had job duration of 1-4 years. High burnout was reported by 49(13.5%) and moderate burnout by 227(62.2%) doctors respectively. Severe burnout frequency was the highest in Anaesthesia department 9(36%) followed by 18(23.4%) doctors in Obstetrics and Gynaecology. Overall, 140(38%) doctors reported high degree of emotional exhaustion, 100(27%) had high degree of depersonalization and 208(57%) had severely reduced personal accomplishment. Of the total, 120(33%) doctors wanted to leave their jobs. CONCLUSIONS: Different levels of burnout were found in doctors. Amongst the three components of burnout, severely reduced personal accomplishment was the highest.

Perinatal outcomes in twin pregnancies complicated by maternal morbidity: evidence from the WHO Multicountry Survey on Maternal and Newborn Health.

BACKGROUND: Twin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes, especially for the second twin. In addition, the maternal complications (potentially life-threatening conditions-PLTC, maternal near miss-MNM, and maternal mortality-MM) are directly related to twin pregnancy and independently associated with adverse perinatal outcome. The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth. METHODS: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), a cross-sectional study implemented in 29 countries. Data from 8568 twin deliveries were compared with 308,127 singleton deliveries. The occurrence of adverse perinatal outcomes and maternal complications were assessed. Factors independently associated with adverse perinatal outcomes were reported with adjusted PR (Prevalence Ratio) and 95%CI. RESULTS: The occurrence of severe maternal morbidity and maternal death was significantly higher among twin compared to singleton pregnancies in all regions. Twin deliveries were associated with higher rates of preterm delivery (37.1%), Apgar scores less than 7 at 5th minute (7.8 and 10.1% respectively for first and second twins), low birth weight (53.2% for the first and 61.1% for the second twin), stillbirth (3.6% for the first and 5.7% for the second twin), early neonatal death (3.5% for the first and 5.2% for the second twin), admission to NICU (23.6% for the first and 29.3% for the second twin) and any adverse perinatal outcomes (67% for the first twin and 72.3% for the second). Outcomes were consistently worse for the second twin across all outcomes. Poisson multiple regression analysis identified several factors independently associated with an adverse perinatal outcome, including both maternal complications and twin pregnancy. CONCLUSION: Twin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.

BACKGROUND: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS: From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Prevalence of Anxiety and Depression Among Women With Polycystic Ovarian Syndrome: A Cross-Sectional Study From a Tertiary Care Hospital of Islamabad, Pakistan.

Background Depression and anxiety are common psychological conditions associated with polycystic ovarian syndrome (PCOS). It is important to understand the role of various demographic and socio-economic factors that contribute to the development of these psychological conditions. Objectives The aims of this study were to determine the prevalence of anxiety and depression in women with PCOS and to find the association of various demographic and socio-economic factors with anxiety and depression. Methods This was a single-center cross-sectional study conducted at a tertiary care hospital in Islamabad, Pakistan, from May 2021 to August 2022. All female patients, aged 18 to 40 years and diagnosed with PCOS, who presented to the department of Gynecology during the study period were eligible to be enrolled in the study. The Hospital Anxiety and Depression scale (HADS) was used to determine the level of anxiety and depression in the participants. HADS comprises 14 items scored on a Likert scale ranging from 0 to 3. Seven items correspond to depression and anxiety each. The scores range from 0 to 21 for both domains. A score of 7 or less was considered normal, 8-10 as borderline, and 11 or above as abnormal for both anxiety and depression. Data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA). Results A total of 74 patients with PCOS were included in the study. The mean age of all the participants was 26.8 ± 5.2 and the mean body mass index (BMI) was 28.7 ± 5.4. The presence of PCOS-related symptoms was observed in all 74 cases. Menstrual cycle abnormalities were the most common symptom, which was present in 57 (77.0%) cases, followed by weight gain, which was present in 50 (67.6%) cases, and hirsutism, which was present in 41 (55.4%) cases. Diabetes mellitus and hypertension were present only in three (4.1%) and two (2.7%) cases, respectively, and positive family history of depression and/or anxiety was reported by 20 (27%) cases. The mean HAD score was 7 ± 3.8 for depression and 8 ± 3.7 for anxiety. Depression was diagnosed in 13 (17.6%) cases, and anxiety was diagnosed in 15 (20.3%) cases. Depression was found to be significantly associated with BMI (p = 0.015), level of education (p = 0.033), and monthly household income (p = 0.004). Anxiety was found to be associated with employment status (p = 0.009) and current pregnancy (p = 0.007). Rest of the factors such as age, marital status, ethnicity, menstrual irregularities, comorbidities such as diabetes mellitus and hypertension, and a family history of PCOS, anxiety, or depression did not show statistically significant association with either anxiety or depression (p < 0.05). Conclusion Anxiety and depression are common in patients with PCOS. These psychological conditions are associated with various demographic and socio-economic factors such as BMI, level of education, monthly household income, employment status, and pregnancy. It is recommended to involve a multidisciplinary team while managing patients with PCOS to timely identify and treat these psychological conditions in these patients.

Consensus Statements for Assessment and Management of Threatened Miscarriage in the First Trimester in Pakistan: A Three-Step Modified Delphi Approach.

BACKGROUND AND OBJECTIVE: It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan. METHODS: A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus. RESULTS: Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion. CONCLUSION: These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.

Job satisfaction in nurses working in tertiary level health care settings of Islamabad, Pakistan.

BACKGROUND: Job satisfaction greatly determines the productivity and efficiency of human resource for health. It literally means: 'the extent to which Health Professionals like or dislike their jobs'. Job satisfaction is said to be linked with employee's work environment, job responsibilities, and powers; and time pressure among various health professionals. As such it affects employee's organizational commitment and consequently the quality of health services. Objective of this study was to determine the level of job satisfaction and factors influencing it among nurses in a public sector hospital of Islamabad. METHODS: A cross sectional study with self-administered structured questionnaire was conducted in the federal capital of Pakistan, Islamabad. Sample included 56 qualified nurses working in a tertiary care hospital. RESULTS: Overall 86% respondents were dissatisfied with about 26% highly dissatisfied with their job. The work environments, poor fringe benefits, dignity, responsibility given at workplace and time pressure were reason for dissatisfaction. Poor work environment, low salaries, lack of training opportunities, proper supervision, time pressure and financial rewards reported by the respondents. CONCLUSION: Our findings state a low level of overall satisfaction among workers in a public sector tertiary care health organization in Islamabad. Most of this dissatisfaction is caused by poor salaries, not given the due respect, poor work environment, unbalanced responsibilities with little overall control, time pressure, patient care and lack of opportunities for professional development.

Fetomaternal outcome in triplet pregnancy.

OBJECTIVE: To determine maternal outcome as antenatal and postnatal complications and neonatal outcome as birth weight, morbidity and mortality in triplet gestation. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Mother and Child Health (MCH) Centre, Pakistan Institute of Medical Sciences, Islamabad from May 2000 to April 2006. PATIENTS AND METHODS: All the patients with triplet pregnancy beyond 28 weeks gestation, who delivered at the study place during above period were included in the study. The primary outcome measures were frequency of maternal complications and neonatal birth, weight and morbidity. Secondary outcome measures included the frequency of assisted conception in the studied cohort. RESULTS: Eighteen women had triplet pregnancy beyond 28 weeks. Nine were booked, 6 non-booked and 3 of them were referred. Mean duration of gestation was 237.8 days (33.8 weeks). The antenatal complications were preterm delivery in 50%, hypertension in 50%, anemia in 44.4% and obstetric cholestasis in 5.6%. Eight patients (44.4%) suffered postpartum hemorrhage. One patient had peripartum hysterectomy and later expired in intensive care unit after three weeks. Maternal mortality ratio was 5.6%. Fifty five percent women had induction of ovulation with Clomiphene, while none had In Vitro Fertilization (IVF) or Intracytoplasmic Insemination (ICSI) or received gonadotrophins. Fifteen sets of triplets were delivered abdominally. Mean birth weights of 1st, 2nd and 3rd triplet were 1651, 1640 and 1443 grams respectively. Five sets of triplets (27.8%) had more than 25% discordance for birth weight. The mean Apgar scores of the babies at 1 and 10 minutes after birth were 6.0 and 8.0, 5.6 and 7.5; and 5.2 and 7.0 respectively. Of the 54 infants, 18 required Neonatal Intensive Care Unit (NICU) admission and 14 were admitted in nursery. Two died shortly after birth. Total perinatal mortalities were 13 including 4 cases of intra-uterine demise. Three babies suffered from jaundice, 7 had sepsis and 8 had respiratory distress syndrome. CONCLUSION: Triplet gestation had a high rate of fetomaternal complications. Majority had history of assisted conception.

Association Of Different Risk Factors In Prevalence Of Cerebral Infaraction.

BACKGROUND: WHO MCS in 2011 evaluated the incidence and management strategies linked with maternal and neonatal mortality in facilities across 26 countries including Pakistan. This study, a sub-analysis assessed the availability of essential obstetric and newborn care at referral level facilities of Pakistan that were selected for WHO MCS to correlate it with maternal and neonatal outcomes. METHODS: This cross-sectional study assessed the infrastructure, equipment and services in 16 referral level government hospitals participating in WHO MCS from 1st March to 30th May, 2011. The association was found between this data and maternal & neonatal outcomes of each facility using chi square test. RESULTS: The studied facilities had basic infrastructure, most components of Essential Maternal and Neonatal Obstetric Care services with part time/full time availability of obstetricians, anaesthetists and paediatricians. Adult intensive care unit was available in 68%, and neonatal intensive care unit was available in half of the facilities. The incidence of severe maternal outcomes had a positive correlation with presence of adult intensive care unit, mechanical ventilator and twenty-four hours (24/7) availability of anaesthesiologist, nurses & paramedics. The neonatal mortality was also higher in facilities with neonatal intensive care unit facility. CONCLUSIONS: Most components of Essential Maternal and Neonatal Obstetric Care were present in the studied facilities. Tertiary level facilities even with availability of Adult and neonatal intensive care units had more adverse maternal and new-born outcomes perhaps due to more disease burden.

Role of Kleihauer test in Rhesus negative pregnancy.

OBJECTIVE: To determine the role of Kleihauer test in estimating fetomaternal haemorrhage and dose of injection anti-D. DESIGN: Analytical study. PLACE AND DURATION OF STUDY: MCH Center, Unit-II, PIMS, Islamabad, from February to December 2004. PATIENTS AND METHODS: A hundred Rhesus negative pregnant women delivered after 28 weeks gestation during the study period were studied. The main outcome measures were Kleihauer test estimation of fetomaternal haemorrhage and association of significant fetomaternal haemorrhage with antepartum haemorrhage (APH), amniocentesis, twin delivery, intrauterine death (IUD), external cephalic version (ECV), manual removal of placenta and cesarean section. RESULTS: Among the hundred women, 28 were primigravidae while 72 were multigravidae. Mean gestational age at delivery was 38.4+/-1.6 weeks. In 24% Rhesus-D negative subjects, potential sensitizing events occurred antenatally. In 11% of these, events occurred before 24 weeks of gestation. Two percent underwent ECV, 10 % had blunt abdominal trauma in third trimester while one patient had APH. Sixty five women had vaginal delivery and cesarean section was performed in 35. Outcome was alive baby in all cases except one intrauterine fetal demise (IUD). Four patients had placenta removed manually. Mean amount of fetomaternal haemorrhage was 2.7+/-1.01 ml (1.2-5.2 ml). The mean anti-D dose required was 67.3+/-25.3 microg. Twenty six women did not need anti-D as they had Rhesus negative infants. CONCLUSION: In this series routine postnatal Rhesus prophylaxis with 300 microg anti-D immunoglobulin covered all the feto-maternal haemorrhage. Therefore, Kleihauer test with added burden of cost is not indicated as a routine to rhesus negative women.

Management of ectopic pregnancy: a two-year study.

BACKGROUND: Ectopic pregnancy is the most important cause of maternal mortality and morbidity in the first trimester. Over the past few decades, the management of ectopic pregnancy has been revolutionized; various modalities of treatment are currently in practice. The purpose of this study was to determine the frequency ofthese modes of treatment of ectopic pregnancy and their outcome. METHODS: Fifty two patients diagnosed to have ectopic pregnancy at MCH Center unit II in the year 2004 and 2005 were included in the study. A cross-sectional analytical study was done. Four modes of treatment were given according to patient's condition, ultrasound findings and beta-hCG levels; these were laparotomy, operative laparoscopy, methotrexate injection and conservative management. The outcome measures included success of each treatment modality, need for second mode of treatment in each group and duration of hospital stay. RESULTS: A total number of 52 patients with ectopic pregnancy were identified and studied. The rate of ectopic pregnancy was 1:100 deliveries. Emergency laparotomy was performed in 30 (57.9%) women, 15 (28.8%) received methotrexate injection. Seven women (13.3%) were managed conservatively and operative laparoscopy was not used as primary treatment in any of the patient. All cases of laparotomy did not require any further procedure. Twelve out of fifteen (80%) cases of medical treatment were successful while one (6.7%) proceeded to emergency laparotomy, one (6.7%) to operative laparoscopy and one (6.7%) to laparoscopy preceding laparotomy. Five out of seven patients (71.4%) on conservative treatment did not require any further intervention while two (28.6%) of them resolved with methotrexate injection. The duration of hospital stay in laparotomy, medically treated and conservatively managed groups was 6.5, 5.9 and 1.7 days respectively. CONCLUSION: In the institutional setting ectopic pregnancy accounted for 1% of total deliveries. More than half of all women with ectopic pregnancy presented with acute abdomen and required emergency laparotomy. About 40% women could be managed with non-surgical modalities with 80% success for methotrexate injection and 71% for conservative treatment in the present study.

Fetomaternal outcome in pregnancy with cardiac disease.

OBJECTIVE: To determine fetal and maternal outcomes in women presenting with heart disease during pregnancy and labor. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Gynae/Obstetrics, MCH, Center, Unit II, PIMS, Islamabad, during a period of 2 years from March 2001 to February 2003. PATIENTS AND METHODS: Forty-two pregnant women with heart disease delivered at MCH Center, Unit II, during the study period were included. Maternal outcome measures included obstetric and medical complications and maternal mortality while fetal outcome measures were prematurity, intrauterine growth restriction and perinatal mortality, intrauterine death and indicated terminations of pregnancy. RESULTS: The mean age was 27.50 -/+ 5.17 years (standard deviation). Of the 42 women, 33 (78.6%) were booked for antenatal care and 9 (21.4%) were non-booked. Congenital heart disease was present in 7 (16.7%) while 28 (65.3%) had rheumatic heart disease and mitral valve disease was the commonest. Among the remaining 7 women with acquired heart disease, 3 (7.1%) women had ischemic heart diseases (IHD), 1 (2.4%) had primary pulmonary hypertension, 2 (4.8%) patients had peripartum cardiomyopathy and 1 (2.4%) had aortic dissection. Based on New York Heart Association Functional classification (NYHA) 16 (38.1%) patients were asymptomatic (class I) and 3 (7.1%) in class IV. Thirty-two (76.2%) achieved spontaneous vertex delivery (SVD), LSCS was performed in 4 (9.5%) women, 2 (4.8%) women had spontaneous expulsions of dead fetus and 2 (4.8%) had suction and curettage for therapeutic termination of pregnancy on medical grounds. Obstetric complications occurred in 17 (40.4%) women, 5 (11.9%) had medical complications and 3 (7.1%) maternal mortalities occurred. Regarding fetal outcome, 6 (14.3%) infants had intrauterine growth restriction (IUGR), 2 (4.8%) perinatal deaths occurred due to prematurity while there was 1 (2.4%) intrauterine death. Indicated terminations of pregnancy were done for 4 gestations (7.1%). Low birth weight was noted in 12 (28.6%) infants. CONCLUSION: Heart disease with pregnancy is a very high risk condition and maternal mortality ratio (MMR) was 7142/100,000 births. The management of these cases should be multidisciplinary to optimize care for these patients and large families be strongly discouraged.

Outcome of mechanical mode of induction in failed primary labor induction.

OBJECTIVE: To determine the role of an alternate (mechanical) inducing agent in failed labor induction. DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Labor Ward at Mother and Child Health Center (MCH), Pakistan Institute of Medical Sciences (PIMS) from May 1999 to July 2003. PATIENTS AND METHODS: Women with singleton term gestation and normal live fetus undergoing indicated induction of labor were included if Bishop score was < or = 5 after 12-18 hours of primary induction with PGE2 vaginal tablets. They were then induced with mechanical method i.e. intracervical foley catheter, if fetal status was reassuring and no evidence of labor onset. The main outcome measure was mode of delivery. Secondary outcome measures were induction labor interval and induction delivery interval after second mode of induction and neonatal Apgar score. RESULTS: Thirty-six women received a second mode of induction for failed induction. Four patients were excluded. Of 32 eligible women, 24 (75%) delivered vaginally. Eight patients (25%) had emergency caesarean section. Mean induction labor interval after second mode of induction was 6.8 hours and mean induction delivery interval was 12.39 hours. Mean Apgar score at 1 minute and 5 minutes was similar in both vaginal deliveries and caesarean sections. CONCLUSION: When an alternate mechanical method was used, 75% of women labeled as "failed induction" delivered vaginally.

Knowledge and attitude of older women towards menopause.

OBJECTIVE: To determine the knowledge and attitude towards menopause among postmenopausal women seeking gynecological treatment. DESIGN: A descriptive cross-sectional survey based on sample of convenience. PLACE AND DURATION OF STUDY: The study was conducted at the Gynecology outpatient department of MCH Center, PIMS, Islamabad from 1st June to 31st September, 2002. SUBJECTS AND METHODS: Seventy postmenopausal women over 45 years of age were interviewed. RESULTS: The mean age of respondents was 54.4 years. Fifty-two (74.3%) women knew about menopause, 39 (55.7%) were aware of symptomatology while only 7 (10%) knew sequelae of menopause. Fifty-three (75.7%) women were satisfied with cessation of menstruation and only 17 (24.3%) desired to continue menstruation. Twenty-four (34.3%) respondents were unhappy with their menopausal status. Thirty-two (45.7%) women were content with their present sexual relations, 18 (25.7%) were dissatisfied and 20 (28.6%) had no sexual activity. Fifty-two (74.3%) women felt a need for health education on menopause in educational institutions. Thirty-three (47.1%) considered treatment of menopause necessary. Four (5.7%) were aware of any treatment of menopause and 55 (78.6%) desired to learn more about menopause. CONCLUSION: Women have different views about menopause, few see it as a medical condition requiring treatment, whereas a majority consider it a natural transition. There was dearth of knowledge regarding significance of menopause.

Management of massive postpartum hemorrhage by "B-Lynch" brace suture.

Two cases of intractable postpartum hemorrhage managed by the B-Lynch Brace suture, a new technique for control of massive postpartum hemorrhage, are presented. Because of its simplicity and capability of preserving uterus, this procedure may be considered as first line surgical treatment before considering hysterectomy.

Trial of extra amniotic saline infusion with oxytocin versus prostaglandin E2 pessary for induction of labor.

OBJECTIVE: To determine the effectiveness and safety of cost-effective extra-amniotic saline infusion (EASI) and simultaneous intravenous oxytocin infusion versus prostaglandin E2 vaginal pessary (PGE2) for induction of labor. DESIGN: Prospective randomized comparative study. PLACE AND DURATION OF STUDY: Labor room at the Mother and Child Health Centre, PIMS, Islamabad from September 2000 to December 2001. SUBJECTS AND METHODS: Women with singleton alive pregnancies and Bishop score < or =6, requiring induction of labor at > or =37 weeks gestation were randomly assigned to induction either with PGE2 3 mg vaginal pessary in two doses 6 hourly or EASI for 12 hours with simultaneous intravenous oxytocin infusion. Artificial rupture of membranes was done 12 hours post-induction and oxytocin infusion started in PGE2. Main outcome measures were induction delivery interval and the mode of delivery. Secondary outcome measures were the change in modified Bishop score 6 hours postinduction and neonatal outcome in the two induction modes. RESULTS: After 4 exclusions, 100 women were recruited in each arm. Mean induction delivery interval was 11.1 and 14.3 hours (p=.00) in PGE2 and EASI respectively. The cesarean rate was 11% and 15% (p=0.4) in PGE2 and EASI respectively. Mean Bishop score at induction was 3.2 in PGE2 and 3.1 in EASI, while after 6 hours it was 4.8 and 6.8 (p=0.00) respectively. Mean APGAR scores at 1 and 10 minutes were identical that is 6.2 and 8.6 respectively. CONCLUSION: Both the modes of induction were equally safe and effective in terms of the mode of delivery and APGAR score. EASI, however, had more rapid cervical ripening and shorter induction delivery interval.

Efficacy of metformin versus insulin in the management of pregnancy with diabetes.

OBJECTIVE: To compare the efficacy of metformin with insulin in the management of pregnancy with diabetes. STUDY DESIGN: Randomized clinical trial. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology, Maternal and Child Health Centre (MCH), Pakistan Institute of Medical Sciences, Islamabad, from May 2010 to January 2011. METHODOLOGY: A total of 68 pregnant patients with diabetes were included in this study. Patients were randomly divided in to two groups of each 34 patients based on table of random numbers. One was labelled as group-A and other was labelled as group-B. Group-A received insulin and group-B received metformin for the management of diabetes. RESULTS: The mean age was 29.82 ± 4.58 and 29.35 ± 4.97 years in groups-A and B respectively. Fasting blood sugar level after 1 month was controlled in 22 (64.7%) patients in group-A and in 27 (79.4%) in group-B (p > 0.05). Fasting blood sugar level at term, remained controlled in 30 (88.2%) patients in group-A and 27 (79.4%) in group-B (p > 0.05). Comparison of random blood sugar levels within normal limits after 1 month in 25 (73.5%) in group-A and in 24 (70.6%) in group-B. At term, random blood sugar level was controlled in 28 (82.4%) and 27 (79.4%) patients in group-A and B, respectively. Comparison of post-treatment HBA1C level depicts that diabetes controlled in 27 (79.4%) patients in group-A while in 28 (82.3%) patients of group-B. The efficacy of metformin and insulin in controlling diabetes was equal in two groups. CONCLUSION: There was no marked difference in efficacy of metformin and insulin in controlling diabetes in pregnant patients in two groups.