Society of Obstetricians and Gynecologists Pakistan Guideline on Second Trimester Anomaly Scan Published in year 2022.

The Guideline on Second trimester anomaly scan has been prepared by the National Maternal Fetal Medicine guidelines committee, approved by the Society of Obstetricians and Gynecologists Pakistan. These guidelines are developed in 2022 and will be reviewed after two years. The current document provides guidance about the importance of second trimester scan to practicing clinicians and sonologists. It will enable them to offer it timely offer to their patient this scan and refer them to the Fetal medicine specialist when indicated. It is unique as the document is modified according to local needs. The Guidelines are developed in 2022 and will be reviewed after two years.

Guidelines on prevention of preterm birth.

This guideline has been prepared by the National Maternal Fetal Medicine guidelines committee and approved by the Society of Obstetricians and Gynecologists Pakistan. These recommendations will enable the practicing clinicians to optimally manage pregnancies at risk of preterm birth.

Frequency of Stillbirths in a Tertiary Care Hospital, Karachi.

BACKGROUND AND OBJECTIVE: Pakistan accounts for the highest stillbirth rate in the world. Therefore, this observational study was planned to determine the prevalence of stillbirths and its associated demographic characteristics in the given context. Hence our objective included: To determine the frequency of stillbirths with reference to parity and gestational age in a tertiary care public hospital, Karachi. To determine the socio-demographic characteristics of families with stillbirths. METHODS: All pregnant mothers who delivered stillbirth babies at Gynaecology and Obstetrics ward of Jinnah Postgraduate Medical Center, Karachi a tertiary care facility were prospectively enrolled from October 2012 to September 2013. Deliveries occurred before 28 weeks of gestational age were excluded. Gestational age was confirmed from hospital record and attending physicians. Data was collected on predesigned proforma and analyzed using descriptive statistics. RESULTS: Among 7708 registered deliveries, 137 were stillbirths. A total of 84 mothers were primiparous and 12% of mothers were below 20 years at the time of delivery. Majority of stillbirths were macerated type (80.3%) and 20% were fresh stillbirth. About 55% of still births occurred between 33-37 weeks and 20% between 28-32 weeks. Almost 80% (109) of stillbirths were low birth weight and only 20% (28) were normal birth weight. CONCLUSION: This study shows that stillbirths are more common in primiparous mothers in a given context. Conducting awareness sessions with special focus on antenatal and obstetrical care of primiparous may be helpful to reduce still births.

Infection remains a leading cause of neonatal mortality among infants delivered at a tertiary hospital in Karachi, Pakistan.

INTRODUCTION: The current cohort study was conducted to determine the frequency and compare the mortality rate with associated characteristics among low birth weight and normal birth weight infants during the neonatal period at a tertiary healthcare facility, Karachi. METHODOLOGY: Close-ended structured questionnaires were used to collect information from the parents of 500 registered neonates at the time of birth. Follow-ups by phone on the 28th day of life were done to determine the mortality among low birth weight and normal birth weight babies during the neonatal period. RESULTS: The neonatal mortality rate ranged from as low as 2.4% in the normal birth weight and 16.4% in the low birth weight categories to as high as 96% in the very low birth weight category. Respiratory distress syndrome (24.2%) and sepsis (18.2%) were reported as the leading causes of neonatal deaths. The babies' lengths of stay ranged from 2 to 24 hours, and around 90% of neonatal deaths were reported in the first seven days of life. More than 6% of neonates died at home, and 7.6% of the deceased babies did not visit any healthcare facility or doctor before their death. In the 12-15 hours before their deaths, 13.6% of the deceased babies had been unattended. Around 90% of the deceased babies were referred from a doctor or healthcare facility. CONCLUSIONS: The present estimates of neonatal mortality are very high among low birth weight and very low birth weight categories. Infectious diseases, including respiratory distress syndrome (24.2%) and sepsis (18.2%), were leading causes of neonatal deaths.

Emergency obstetric hysterectomy.

OBJECTIVE: To assess the frequency of obstetric hysterectomy, its indications and associated maternal and perinatal morbidity and mortality. METHODS: The retrospective observational analytical study was conducted at the Department of Obstetrics and Gynaecology, Unit-I, Jinnah Postgraduate Medical Centre, Karachi from January 2003 to December 2009. Records of all patients who had underone hysterectomy at the study centre during the study period were explored for age, parity, booking status indication and the type of operation performed. Maternal and foetal morbidity and mortality were also recorded. SPSS 13.0 was used for statistical analysis. RESULTS: Against the total 44,612 deliveries during the period, 121 hysterectomies were performed for obstetric indications. The frequency of the procedure, as such, was 1 in 368 (0.27%) deliveries. The major indications were ruptured uterus in 57 (47.1%), and severe postpartum haemorrhage due to atony of uterus in 35 (28.9%). Other indications included severe haemorrhage due to placental abnormalities in 14 (11.6%); placenta previa in 3 (2.5%); abruptio placenta in 4 (3.3%); and severe infection following vaginal delivery in 3 (2.5%). Infection was the commonest complication seen in 14 (11.6%) patients. There were 11 (9.0%) maternal deaths and 65 (53.7%) perinatal deaths. CONCLUSION: Emergency obstetric hysterectomy remains a necessary tool for consultant obstetricians. Acting at the optimal time with clear judgment, and professional surgical technique can reduce morbidity and mortality in such cases.

Management of iron deficiency anaemia in gynaecological patients at Jinnah Postgraduate Medical Centre, Karachi.

OBJECTIVE: To determine the efficacy and safety of subcutaneously administered recombinant human erythropoietin in combination with intravenous iron sucrose for the management of iron deficiency anaemia in gynaecological patients in Jinnah Postgraduate Medical Centre Karachi. METHODS: It was an interventional quasi experimental study carried out in the Department of Obstetrics /Gynaecology, at JPMC from 1st Nov 2007 to May 2008. All patients with indications for major Gynaecological surgery with iron deficiency anaemia having a mean haemoglobin level of 7 gm/dl were selected and the target haemoglobin was 11 gm/dl. Patients who were symptomatic, had chronic bleeding, renal failure or had signs of anaemia other than iron deficiency were excluded from the study. All investigations were done on day one before the start of therapy, and then treatment was initiated with recombinant human erythropoietin in a dose of 5000 IU subcutaneously and injection Iron Sucrose 200 mg in 100cc NaCI intravenously on 3 alternate days. The parameters checked in succession on day 4 and day 10 included increase in haemoglobin level, haematocrit, reticulocyte count, and time required to reach the target haemoglobin. RESULTS: Twenty three patients fulfilled the inclusion criteria and were selected for the study. At the end of 10 days of starting therapy increase in haemoglobin was on an average of 2.8 gm/dl, increase in mean corpuscular volume was 4fl, Serum Iron increased by 99.86 ug%, total iron binding capacity decreased by 30.86%, transferrin saturation increased by 15.5% .There were no serious reactions to Erythropoietin or Iron sucrose CONCLUSION: It is concluded that recombinant erythropoietin along with iron sucrose safely increased the haemoglobin level in 10 days to the target level thus rendering the patients fit for surgery and, none of the selected patients needed blood transfusion.

Prevalence of hepatitis B and C: a Jinnah Postgraduate Medical Centre experience.

AIM: To determine the prevalence of carriers of hepatitis B and C viruses among the obstetrical and gynecological population, the incidence of vertical transmission in obstetrical patients and to ascertain the risk factors associated with their transmission. METHODS: We conducted a prospective study over a 1-year period, from 1 January to 31 December 2005, comprising of an obstetrical population of 5902 deliveries and 548 major gynecology surgery patients. The study population was recruited by simple convenient sampling at Unit-I, Department of Obstetrics and Gynecology, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. Booked obstetrical and major gynecological surgical patients were routinely screened by Enzyme Immunoassay for hepatitis B surface antigen (HbsAg) and anti-hepatitis C antibodies (anti-HCV) on venous blood samples. Liver function and carrier profile tests were performed on mothers who were positive for HBsAg. Babies of mothers with HbsAg were tested at birth for both HbsAg and HbeAg. RESULTS: Hepatitis B was detected in 275 pregnant women (4.6%) and in 70 (12%) gynecological patients. Hepatitis C was detected in 108 (1.8%) pregnant women and in 89 (16%) gynecological patients. Babies born to mothers with HBV or HCV infections tested negative. Four gynecological patients tested positive for both HBV and HCV infections. Unsafe surgery, injections and inadequately screened blood transfusions were the main underlying causes of infection. CONCLUSION: Routine screening of the obstetrical population detected more cases of HBV infection than HCV, whereas HCV was more prevalent in the gynecological population, emphasizing the need for safe medical practices and patient education.

An audit and trends of perinatal mortality at the Jinnah Postgraduate Medical Centre, Karachi.

OBJECTIVE: To prospectively review the extent and determinants of perinatal mortality (PNM), at a large Government referral teaching hospital in Karachi and to compare the rate with previous data. METHODS: One year study from 1st January to 31st December 2001 was carried out in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi. A prospective review of all stillbirths from 28 weeks of pregnancy and neonatal deaths within first seven days of life in the hospital either in the obstetric ward or in the neonatal nursery was done. The details of each mother and newborn delivered were recorded on standardized proforma. Aberdeen (Obstetric) classification of perinatal deaths was applied in the survey for classification of perinatal causes. RESULTS: During the one year period from 1st January to 31st December, 2001, there were 7743 deliveries and 753 perinatal deaths. Five hundred and sixty nine were still born and 184 died within 7-days of birth. The perinatal mortality rate (PNMR) was 97.2/1000 total births and still birth rate 73.4/1000 total births. The leading cause of stillbirth was hypertensive disease of mother in 180 (24%). This included Pregnancy Induced Hypertension (PIH) 106 (14%) and eclampsia 74 (10%). The next common cause was mechanical, accounted for 161 (21.4%). Antepartum haemorrhage (APH) was responsible for 151 (20%) perinatal deaths and low birth weight (LBW) was identified in 108 (14.4%). Congenital malformation caused deaths in 47 (6.2%), maternal medical disorders as jaundice, anaemia and diabetes in 24 (3.2%) and neonatal infections as Respiratory Distress Syndrome (RDS), probable pneumonia, bleeding disorders and septicaemia caused deaths in 35 (4.8%). CONCLUSION: Perinatal deaths are largely the result of poor maternal health, low socio-economic status, lack of health awareness and inadequate care during antepartum, intrapartum and postpartum period. Perinatal mortality rate has largely remained unchanged over the last 40 years at the premier referral and teaching institution of Karachi, due to higher patient influx and referral rate.

Child birth in squatting position.

OBJECTIVE: To assess the risks and benefits of squatting position during second stage of labour and its comparison with the supine position. METHODS: The study was conducted at the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi from 1st January 1999 to 31st January 2000. A total of two hundred patients of similar ante partum, intrapartum and socio-economic conditions were selected. Only patients of gestation more than 37 weeks, presenting in active labour with cephalic presentation were included. Patients with multiple gestation, malpresentation, previous scar, maternal fever and prenatal diagnosed fetal malformation were excluded from the study. Random selection was done after informed consent and alternately divided into two groups A and B. Both groups were ambulatory during first stage of labour. In second stage, group-A adopted the squatting position, while group-B remained supine in lithotomy position. The third stage of labour in both the groups was conducted in the supine position. RESULTS: There was no difference in the application of episiotomies in both groups, however extension of the episiotomy occurred in 7% patients of the non-squatting group (P < 0.05). Para urethral tears occurred in 5% patients in squatting group, but all occurred in patients who were not given an episiotomy. Second degree, and third degree perineal tears occurred in 9% patients in the non-squatting group but none in the squatting group (P < 0.05). Forceps application was also significantly less in group-A 11% and 24% in group-B (P < 0.05).There were two cases of shoulder dystocia in group B but none in the group-A. During the Third stage of labour there were no cases of retained placenta in group A but there were 4% cases of retained placenta and 1% case of postpartum haemorrhage of more than 500 ml due to atony of the uterus in group-B. One patient in the non-squatting position had to have a caesarean section due to persistent occipito posterior position. There was no significant difference in the apgar scores, foetal heart rate patterns or requirement of neonatal resuscitation. CONCLUSION: It appears that squatting position may result in less instrumental deliveries, extension of episiotomies and perineal tears.

Intimate partner violence before and during pregnancy: experiences of postpartum women in Karachi, Pakistan.

OBJECTIVE: To assess the magnitude and determinants of intimate partner violence before and during pregnancy and attitude regarding domestic violence among a cohort of recently delivered women in Karachi, Pakistan. METHODS: A total of 300 women occupying every alternate bed in the postnatal wards of a public tertiary hospital were administered a structured questionnaire. RESULTS: Forty four percent (44%) of women reported lifetime marital physical abuse, 23% during the index pregnancy. Among the 132 women who were ever physically abused, all reported verbal abuse and 36% sexual coercion. The statistically significant risk factors, wife's education, consanguinity, and duration of marriage, were similar for lifetime marital abuse and during pregnancy. Over half (55%) of the women believed that antenatal care clinics were a good time to enquire about domestic violence. CONCLUSION: Annually an estimated one million pregnant Pakistani women are physically abused at least once during pregnancy. Reproductive health stakeholders should be encouraged to advocate for domestic violence screening.

Female surgical sterilization at a tertiary care hospital in Karachi.

BACKGROUND: Tubal ligation for sterilization is one of the common methods of contraception practiced by women in developing countries like Pakistan. This study was undertaken to study characteristics of couples undergoing surgical sterilization, and to identify ways of improving utililization of contraceptive services. MATERIAL AND METHODS: Details of 1148 women who underwent tubal ligation at the reproductive health center Jinnah Postgraduate Medical Center Karachi from January to December 2002 were recorded on a special proforma. The woman's age, duration of marriage, number of living children and the couple's educational status were recorded. Contraceptive use and duration, and associated medical conditions were documented. Data was entered in SPSS, frequency tables, means and standard deviations were obtained and comparative evaluation undertaken using non parametric methods, as indicated. RESULTS: Out of the 4210 initial clients, 1163 (27.62%) underwent surgical sterilization. This included 1148 (98.69%) tubal ligations and 15 (1.31%) vasectomies. Of these, 608 (52.96%) were carried out in the immediate puerperium. The mean age of women was 33.1+/-3.55 years, they had been married for 14.84+/-4.22 years and 44.34% had already had 6 or more children. CONCLUSION: Tubal ligation performed after careful selection and counseling, by experienced personnel under local anaesthesia is a safe procedure with very few complications. However older women with no history of contraception, who have already had 6 or more children, seem to avail it. Promotion of temporary contraceptives for birth spacing among younger couples is more likely to improve maternal and newborn health in addition to limiting the family size.

Sociocultural determinants of induced abortion.

OBJECTIVE: To determine the frequency of induced abortion and identify the role of sociocultural factors contributing to termination of pregnancy and associated morbidity and mortality in hospital setting. DESIGN: Prospective observational study. PLACE AND DURATION OF STUDY: The study was conducted in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi from January 1999 to June 2001. SUBJECTS AND METHODS: The patients who were admitted for induced abortion were interviewed in privacy. On condition of anonymity they were asked about the age, parity, family setup and relationships, with particular emphasis on sociocultural reasons and factors contributing to induction of abortion. Details of status of abortionist and methods used for termination of pregnancy, the resulting complications and their severity were recorded. RESULTS: Out of total admissions, 57(2.35%) gave history of induced abortion. All women belonged to low socioeconomic class and 59.6% of them were illiterate. Forty-three (75.5%) of these women had never practiced contraception. Twenty-four (42%) were grandmultiparae and did not want more children. In 29 women (50.9%) the decision for abortion had been supported by the husband. In 25 women (43.8%) abortion was carried out by Daiyan (traditional midwives). Serious complications like uterine perforation with or without bowel injury were encountered in 25 (43.8%) of these women. During the study period illegally induced abortion accounted for 6 (10.5%) maternal deaths. CONCLUSION: Prevalence of poverty, illiteracy, grand multiparity and non-practice of contraception are strong determinants of induced abortion.