Reducing the rate of primary caesarean sections--an audit.

OBJECTIVE: To evaluate how the implementation of universally acceptable standards affects rates for primary caesarean sections, without compromising maternal or foetal safety. METHODS: A complete audit cycle of all the primary caesarean sections performed in the maternity unit of Aga Khan University was conducted from 1st January to 31st March during years 2003 and 2004. New labour management guidelines were implemented after the first audit (appendix). The rates of caesarean section, induction of labour, failed induction, and maternal and foetal outcomes were compared before and after the implementation of the guidelines. RESULTS: Primary emergency caesarean section rate decreased from 16% to 12%. A reduction in primary caesarean sections was noted in the induced cases. Practice of checking cord blood for foetal pH and maintaining partograms improved markedly. There were no significant adverse maternal and perinatal outcomes. CONCLUSION: Implementation of standard labour management strategies can reduce primary caesarean section rate without compromising maternal and foetal safety.

Critical appraisal of endometriosis management for pain and subfertility.

OBJECTIVE: To critically appraise current best available management of pain and subfertility ascribable to endometriosis. METHODS: Medline and specialist computer databases were searched along with reference lists of known reviews and primary articles to identify cited articles not captured by electronic searches. We included all studies pertaining to treatment of pain and subfertility ascribable to endometriosis. DISCUSSION: Medical and surgical management options for pain and subfertility are presented as Evidence-based inquiries for critically appraised topics. Each problem is presented as an answerable question followed by assessment of literature search for level of evidence. This is followed by critical appraisal of results. In the end, take-home answer to individual problem is presented in view of best available evidence. CONCLUSION: Evidence-based management of endometriosis provides realistic therapeutic goals and expectations for the clinicians and women experiencing pain and subfertility due to this disease. It also promotes efficient and effective use of medical and surgical options when required.

Risk of uterine rupture after the partographic 'alert' line is crossed--an additional dimension in the quest towards safe motherhood in labour following caesarean section.

To determine if prolonged active phase of labour is associated with increased risk of uterine scar rupture in labour following previous lower segment caesarean section, a retrospective cohort study (1988-91) was done to analyse active phase partographs of 236 patients undergoing trial of labour following caesarean section, 7 (3%) of whom had scar rupture. After onset of active phase (3 cm cervical dilatation), a 1 cm/h line was used to indicate "alert". A zonal partogram was developed by dividing the active phase partographs into 5 time zones: A (area to the left of "alert" line), B (0-1 h after "alert" line), C (1-2 h after "alert" line), D (2-3 h after "alert" line) and EF (> 3 h after "alert" line). The relative risk of uterine scar rupture was calculated for different partographic time zones. The relative risk of uterine scar rupture was 10.5 (95% confidence interval 1.3-85.5, p = 0.01) at 1 hour after crossing the "alert" line; 8.0 (95% confidence interval 1.6-40.3, p = 0.009) at 2 hours after crossing the "alert" line; and 7.0 (95% confidence interval 1.6-29, p = 0.02) at 3 hours after crossing the "alert" line. In women undergoing trial of labour following caesarean section, prolonged active phase of labour is associated with increased risk of uterine rupture. A zonal partogram may be helpful in assessing this risk in actively labouring women who cross the partographic "alert" line.

Audit changes clinical practice! Impact on rate of justification of hysterectomy indication.

After performing a baseline audit in 1986-89, an ongoing quality assurance process was initiated in January, 1990 and all hysterectomies performed over the next 2 year period were analyzed. Hysterectomy indications were divided into two groups: one in which the uterine specimen was expected to show pathology and another in which no pathology was expected. The hysterectomy was considered justified in the former if the pathology report verified the indication or showed a significant alternate pathology. In the latter, validation criteria showing documentation of certain prerequisite diagnostic procedures performed before reverting to hysterectomy, were used to ascertain justification. The overall rate of justification in the ongoing audit was 96%, being 97% for the group where hysterectomy indication was potentially confirmable by pathologic study and 93% for the one where it was not. Comparison with baseline analysis showed that the justification rates were higher for all indications not potentially confirmable by pathologic study (93% vs 89%, p < 0.05), for recurrent uterine bleeding (90% vs 83%, p < 0.05) and for leiomyoma (97% vs 95%, p < 0.05). The improvement was associated with less frequent use of multiple indications in the ongoing study (10% vs 16%, p < 0.05). The justification rates for hysterectomy indication can be improved by prospective audit and by avoiding use of multiple indications.

Are non-diabetic women with abnormal glucose screening test at increased risk of pre-eclampsia, macrosomia and caesarian birth?

To determine, in non-diabetic women, the relationship of abnormal glucose screening test, with the incidence of pre-eclampsia, macrosomia and caesarian delivery, from 1988-92, 5646 consecutive women attending antenatal clinic were screened with a glucose challenge test (GCT) on their first visit (usually at 16-20 weeks); those with risk factors i.e., history of unexplained perinatal loss, macrosomia or family member with diabetes and an initial abnormal screening test were rescreened at 28-32 weeks. In 482 cases the GCT was abnormal (plasma glucose value was > 140 mg% 2 hours after 75 g glucose challenge). Of these, 292 had one or more abnormal critical values at a 75 g-3 hour oral glucose tolerance test (GTT) and they were treated to maintain euglycaemia. The rest (n = 190) had no evidence of glucose intolerance with no abnormal values at the GTT. The subjects were divided into 3 groups based on GCT values; A, randomly selected subjects with a normal GCT (n = 1000); B, those with abnormal GCT but normal GTT (n = 190); and C, those with abnormal GTT (n = 292). The variables studied were age, gravidity, parity, gestational age at delivery, pre-eclampsia, birth-weight and mode of delivery. The incidence of pre-eclampsia and caesarian birth varied, being the lowest in Group A (3.9% and 11.9% respectively) and then rising through group B (6.3% and 16.3% respectively) to the highest in Group C (12.6% and 26.0% respectively; test of linear trend, p < 0.05). For macrosomia, the incidence increased from Group A to B but there was a drop in Group C.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship of fetal macrosomia to a 75g glucose challenge test in nondiabetic pregnant women.

We determined in nondiabetic women, the relationship of plasma glucose values obtained 2 hours after a 75 g oral glucose challenge test (GCT) at 16-20 weeks' gestation, with the incidence of macrosomia in term deliveries (37-41 weeks' gestation). From 1988-1990, in a systematic screening programme data collected prospectively from 1,331 women were analysed retrospectively. Women with gestational diabetes or impaired glucose tolerance (n = 53) were excluded. The rest (n = 1,278) had no evidence of glucose intolerance including 1,215 women with normal plasma glucose by GCT (< 7.8 mmol/L 2 hours after 75 g oral glucose load) and 63 women with abnormal GCT but not abnormal value at a glucose tolerance test. The GCT values were divided into 5 groups: Group A (< 4.5 mmol/L), B (4.5-5.5 mmol/L), C (5.6-6.6 mmol/L), D (6.7-7.7 mmol/L) and E (> 7.8 mmol/L). The variables studied were age, parity, gestational age at delivery and incidence of macrosomia. Using > 4 kg birth-weight as the definition of macrosomia, the incidence increased from 1.2% to 9.5% with increasing plasma glucose values in the GCT from Group A (> 4.5 mmol/L) to E (> 7.8 mmol/L). Similar trends of increasing incidences from 7.2% to 15.8% and 2.9% to 9.5% were noted when 90th and 95th birth-weight percentiles, respectively were used as definitions of macrosomia. The test of linear trend in this association was significant (p < 0.01). These results were not influenced by parity or gestational age at delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacteriuria and pregnancy outcome: a prospective hospital-based study in Pakistani women.

The prevalence of bacteriuria in Pakistani women and its association with complications of pregnancy was studied. Out of 1579 women, 77 had bacteriuria (4.8%). There was no association of age, gravidity, parity, haemoglobin, pre-eclampsia, mode of delivery, gestational age at delivery, preterm delivery and low birth-weight with presence of bacteriuria. With detection and treatment the pregnancy outcome of women with bacteriuria in pregnancy was the same as that of those without.

Experience with screening for abnormal glucose tolerance in pregnancy: maternal and perinatal outcome.

In order to determine the prevalence of glucose intolerance in pregnancy, 2,230 consecutive women attending the antenatal clinic at the Aga Khan University Medical Centre in Karachi, Pakistan were subjected on the first antenatal visit, irrespective of gestational age, to a 75 g glucose challenge followed 2 hr later by plasma glucose determination. The test, was repeated at 28-32 weeks of gestation for those patients who had an abnormal initial screen at less than 28 weeks gestation followed by a normal glucose tolerance test and for those who had a risk factor for gestational diabetes even though the initial screen at less than 28 weeks gestation was normal. The initial glucose challenge test was abnormal (2 hr plasma glucose greater than 140 mg%) in 8.6% of the screened population. An oral glucose tolerance test on these patients revealed a prevalence for the entire population of 3.5% of gestational diabetes and 1.9% of impaired glucose tolerance test based on the modified O'Sullivan criteria. Patients with abnormal glucose tolerance test were older, had higher parity, a past history of macrosomia and a family history of diabetes compared to the controls. These patients also had a higher incidence of preterm labour and caesarean section. In the neonates hypoglycemia and hyperbilirubinemia were similarly higher. The fetal abnormality rate was 5.6% and the perinatal mortality was 28/1,000 which were higher than the controls.

Platelets and leucocyte counts in pregnancy.

A study involving the obstetric clinic population of 3 major teaching hospitals of Karachi has been conducted to define changes in leucocyte and platelet counts as pregnancy progresses. 573 "normal" pregnant women--183 in the first trimester, 195 in the second trimester and 194 in the third trimester were included in this analysis. We have found leucocytosis to be a feature of normal pregnancy; the change is subsequent to a progressive increase in granulocytes. Platelet counts were found to decrease slightly as pregnancy progresses.

Cervical cancer screening program in a Muslim country: three-year experience at the Aga Khan University Medical Center, Karachi.

A systematic cervical cancer screening program was initiated in January 1987 at The Aga Khan University Medical Center, Karachi, Pakistan. The 8,784 cervical smears obtained in 3 subsequent years from 8,412 consecutive women attending the gynecology and antenatal clinics were reviewed. "Positive" smears were found in 111 (1.3%) patients; 107 (1.27%) smears showed squamous epithelial dysplasia and 4 smears showed adenocarcinoma. The highest incidence of abnormal smears was found in the 45-54 years age group. Colposcopy and biopsy was performed on all patients with "positive" smears except on those with atypical or mildly dysplastic ones, in whom only the persistence of the abnormality on repeated smears was considered an indication for tissue evaluation. The histopathologic diagnosis of these biopsy specimens revealed cervical intra-epithelial neoplasia in 60 patients and invasive cervical cancer in 6 patients.

Was that hysterectomy really necessary? Audit of operative justification at the Aga Khan University Medical Centre, Karachi.

Hysterectomy in Pakistan, like in other parts of the world is considered to be overused in a number of cases. As a part of a quality assurance process at the Aga Khan University Medical Centre, Karachi, 376 hysterectomies performed between January, 1987 and December, 1989 were retrospectively analysed and the results are presented. In 250 (66.5%) cases, where pathology was expected to be found, the hysterectomy was considered justified if the preoperative diagnosis was verified by the pathology report of if significant alternate pathology was present. In 126 (33.5%) cases, where no pathology was expected to be found 'validation criteria' were used to ascertain justification of the procedure. The results showed justification rates of 83% for recurrent uterine bleeding, 85% for adenomyosis, 90% for adnexal masses and endometrial carcinoma, 95% for fibroids, 97% for pelvic relaxation and 100% each for pregnancy catastrophe, endometriosis, chronic pelvic inflammatory disease and premalignant disease of uterus and cervix. In general 92.0% of all hysterectomies in this series were justified.

Gestational diabetes in a developing country, experience of screening at the Aga Khan University Medical Centre, Karachi.

In order to determine the prevalence of glucose intolerance in pregnancy, 1267 consecutive women attending the antenatal clinic of the Aga Khan University Medical Centre were subjected to a 75 g glucose challenge followed 2 hr later by plasma glucose determination irrespective of gestation on the first antenatal visit. The test was repeated at 28-32 weeks of gestation if the patients had an abnormal initial screen at less than 28 weeks gestation and a normal glucose tolerance test on diagnostic follow-up and for those who had a risk factor for gestational diabetes and a normal initial screen at less than 28 weeks gestation. The glucose challenge test was abnormal (2 hr plasma glucose greater than 140 mg%) in 8.6% of the screened population. Follow-up oral glucose tolerance test on these patients revealed a prevalence of 3.2% of gestational diabetes and 1.9% of impaired glucose tolerance test based on the modified O'Sullivan criteria. Improvement in cost effectiveness of screening programmes was adjudged possible by avoiding glucose tolerance tests in patients with 2 hr plasma glucose value of greater than 170 mg% after a 75 g oral glucose challenge for screening.

Anaemia in pregnancy--a study of 709 women in Karachi.

PIP: To determine contributory factors of anemia in pregnant women, 709 pregnant women in Karachi were studied from November 1986 to June 1988. Of the 709 patients, 400 were at a private institution while 309 were from governmental clinics. All subjects were attending the hospitals for their 1st antenatal care visit. Information was collected concerning socioeconomic status, age, parity, diet, and date of last menstrual period. The women ranged in age from 16 to 45 years and 17% were anemic. Anemia was common among primipara (16%), gravida 2-6 (16%, and gravida 7 (38%). Furthermore, it was found in 23% of the women in their 3rd trimester. Comparing patients in the private clinics and in the free clinics, 8% of the private clinic patients and 29% of the free clinic patients were anemic. Among fee clinic patients, anemia was shown 6% of the women having an adequate diet, 24% of those having a poor diet, and 58% of those having a very poor diet. Therefore, risk factors for anemia include low socioeconomic status, poor diets, gravida 7, and being in the 3rd trimester of pregnancy.^ieng

Changing patterns of caesarean section.

There has been a substantial rise in the rate of Caesarean section in the last 20 years. There are many reasons for this increase, but it has been argued that the fall in perinatal mortality justifies a higher Caesarean section rate. In this retrospective study 7,274 deliveries were reviewed and 650 Caesarean sections were analysed. There was only a marginal increase in the rate of Caesarean section (1.9%) during the 2 biennial periods studied (1974-1975 and 1984-1985), but overall perinatal mortality rate dropped by half during the second study period. This study confirms that in recent years the indications for Caesarean section have altered, but the marked rise in the Caesarean section rate cannot be explained purely on medical grounds and is certainly not solely responsible for the very significant drop in the perinatal mortality rate.