Comparison of pre and post Foley catheter Bishop's Score: A retrospective record review at Aga Khan University Hospital Karachi, Pakistan.

Objective: To compare pre and post Foley's catheter Bishop Score during labour induction. Methods: This study was a retrospective study conducted at the Aga Khan University Hospital Karachi, Pakistan after approval from ethical review board. All women who underwent induction of labour with Foley's Catheter at gestation of 37 weeks or more from September 2014-October 2015 were included. Data was entered and analyzed in Statistical Package for Social Sciences (SPSS) version 19.0. The comparison between pre and post Foley's catheter Bishop Score during labour induction will be calculated by Wilcoxon sign test. Results: There were 981 cases of inductions of labour, 749 (76.3%) received Foley's catheter, in combination with prostaglandins and oxytocin. About 68% were vaginal deliveries while 32% underwent C-section. Two third of women had bishop <4. Overall, Bishop score improved significantly in all patients with the catheter however, maximum benefit was seen in patients where the catheter was placed for 10-12 hours. Conclusion: Foley's is the better and safer option. In view of our results, It has been recommended to keep the Foley's for 10-12 hours to get significant improvement in bishop score.

Exploring terminology for puerperal sepsis and its symptoms in urban Karachi, Pakistan to improve communication, care-seeking, and illness recognition.

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols.

Risk factors and Compliance of surviving sepsis campaign: A retrospective cohort study at tertiary care hospital.

BACKGROUND AND OBJECTIVE: Sepsis is one of the leading causes of direct maternal mortality in Pakistan. It is recommended that the first three hours after the presentation are crucial. During this time implementation of surviving sepsis campaign resuscitation bundles reduces maternal mortality. Our objective was to assess the factors contributing to puerperal sepsis and the compliance of "surviving sepsis campaign resuscitation bundles in puerperal sepsis" for the management of puerperal sepsis. METHODS: This was a retrospective record review for five years from January 2011-December 2015. All women who fulfilled the inclusion criteria of puerperal sepsis were included and data from their files were collected and entered in SPSS version 19.0. Mean and standard deviations were calculated for continuous variables while for categorical variable proportion and percentages were used. RESULTS: This retrospective record review in five years showed the 396 patients had P-sepsis, among them 44 patients had severe sepsis with organ dysfunction. The culture was positive in 26(59%) with trend of E-coli in 9(20%) Among them 12(27%) had serum lactate more than ≥4mmol/L. Central venous pressure monitoring with fluid resuscitation was done as per protocol of survival bundle given to all 12(100%), Vasopressin was needed in half of these patients 6(50%). Amid 44 patients of severe sepsis 29(66%) were admitted to special care, while 15(34%) required intensive care admissions. Our 7(16%) patients failed to survive. All of them had multi-organ failure. CONCLUSION: There was moderate adherence of modified surviving sepsis campaign resuscitation bundles. Further improvement in compliance is warranted.

Agreement between simulated patients and faculty: Assessment of communication skills during objective structured clinical examination.

OBJECTIVE: Ensuring competence in communication skills amongst trainees is essential in health professions education. Involving faculty members for the same is a challenge in Obstetrics and Gynecology (OBGYN) due to their clinical commitments. The present study compares scores of OBGYN faculty, non-OBGYN faculty and simulated patients (SPs) on communication skills of postgraduate trainees during formative Objective Structured Clinical Examination (OSCE). METHODS: This is a psychometric study conducted in Feburary 2017 at the Aga Khan University Medical College (AKU-MC). All thirty-two postgraduate trainees of OBGYN gave consent. Each trainee was assessed by OBGYN faculty, non-OBGYN faculty and SP on communication skills at six stations using nine-point itemized rating-scale during formative OBGYN OSCE. The scores were reviewed using descriptive statistics, reliability was calculated using Cronbach's alpha and inter-rater reliability was analyzed using Pearson correlation and intra-class correlation coefficient. RESULTS: The score reliability of each of the examiners was >0.7. The mean scores showed that OBGYN faculty were most stringent while SPs were lenient examiners, however, non-OBGYN faculty scored in between. The inter-rater reliability among any two of the OBGYN, non-OBGYN and SP examiner was >0.84 using Pearson correlation and >0.9 using intra-class correlation. CONCLUSION: The SPs and non-OBGYN clinical faculty can also be used to assess communication and counseling skills on OBGYN OSCEs after required training as examiners.

Comparison of foeto-maternal outcome in pregnant women with hepatitis E - A review of 12 years.

OBJECTIVE: To compare adverse maternal and foetal outcome in pregnant women with hepatitis E immunoglobulin M reactive versus non-reactive. METHODS: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised records of pregnant patients at any gestational age with clinical and biochemical evidence of hepatitis E from January 2002 and December 2014. . Maternal and perinatal outcome of the subjects were analysed. SPSS 20 was used for data analysis. RESULTS: Out of the 200 subjects, 168(84 %) were hepatitis E immunoglobulin M reactive and 32(16%) were non-reactive. The overall mean age was 26.7±4.5 years. Also, 12(7%) patients in the immunoglobulin M reactive group were admitted to intensive care unit compared to no one from the non-reactive group. Similarly fulminant hepatic failure was seen in 12(7.1%) patients in the immunoglobulin M reactive group compared to no one in the other group. Post-partum haemorrhage was more frequent in the immunoglobulin M reactive group compared to the non-reactive group. There were 5(3%) maternal deaths in the reactive group compared to no death in the other group. Moreover, 34(20.2%) neonates of the immunoglobulin M reactive group needed neonatal intensive care unit admission compared to none in the non-reactive group. There were 4(2.4%) neonatal deaths in the reactive group. CONCLUSIONS: Participants in the immunoglobulin M reactive group had a higher percentage of adverse foeto-maternal outcomes compared to the non-reactive group.

Effect of body mass index on outcome of labour induction.

The retrospective study to explore the adverse effect of obesity on pregnancy and labour was conducted at Aga Khan University Hospital, Karachi, Pakistan, and comprised data of all patients booked between 12-14 weeks and required induction of labour from January 1 to December 31, 2012. Women were grouped into two body mass index categories: normal weight (<22.9 kg/ m2) as controls and exposed group (>23 kg/m2). Obesity increased the risk of development of gestational hypertension and diabetes. Therefore obese women were more likely to be induced due to medical indication whether primiparous or multiparous adjusted odds ratio =2.89(95% confidence interval 1.29-6.48) and 2.77 (95% confidence interval 1.07-7.19) respectively. There was increased chance of having caesarean section in primigravida adjusted odds ratio = 1.45 (95% confidence interval 0.72-2.92), duration of caesarean section and blood loss during the procedure were not significantly associated with high body mass index (p>0.05). Obesity may lead to a lot of problems in primigravida, but it did not have major impact.

Diagnostic methods to determine microbiology of postpartum endometritis in South Asia: laboratory methods protocol used in the Postpartum Sepsis Study: a prospective cohort study.

BACKGROUND: The South Asian region has the second highest risk of maternal death in the world. To prevent maternal deaths due to sepsis and to decrease the maternal mortality ratio as per the World Health Organization Millenium Development Goals, a better understanding of the etiology of endometritis and related sepsis is required. We describe microbiological laboratory methods used in the maternal Postpartum Sepsis Study, which was conducted in Bangladesh and Pakistan, two populous countries in South Asia. METHODS/DESIGN: Postpartum maternal fever in the community was evaluated by a physician and blood and urine were collected for routine analysis and culture. If endometritis was suspected, an endometrial brush sample was collected in the hospital for aerobic and anaerobic culture and molecular detection of bacterial etiologic agents (previously identified and/or plausible). DISCUSSION: The results emanating from this study will provide microbiologic evidence of the etiology and susceptibility pattern of agents recovered from patients with postpartum fever in South Asia, data critical for the development of evidence-based algorithms for management of postpartum fever in the region.

Service quality in contracted facilities.

PURPOSE: The purpose of this paper is to explore the readiness of contracted and non-contracted first-level healthcare facilities in Pakistan to deliver quality maternal and neonatal health (MNH) care. A balanced scorecard (BSC) was used as the assessment framework. DESIGN/METHODOLOGY/APPROACH: Using a cross-sectional study design, two rural health centers (RHCs) contracted out to Aga Khan Health Service, Pakistan were compared with four government managed RHCs. A BSC was designed to assess RHC readiness to deliver good quality MNH care. In total 20 indicators were developed, representing five BSC domains: health facility functionality, service provision, staff capacity, staff and patient satisfaction. Validated data collection tools were used to collect information. Pearson χ2, Fisher's Exact and the Mann-Whitney tests were applied as appropriate to detect significant service quality differences among the two facilities. FINDINGS: Contracted facilities were generally found to be better than non-contracted facilities in all five BSC domains. Patients' inclination for facility-based delivery at contracted facilities was, however, significantly higher than non-contracted facilities (80 percent contracted vs 43 percent non-contracted, p=0.006). PRACTICAL IMPLICATIONS: The study shows that contracting out initiatives have the potential to improve MNH care. ORIGINALITY/VALUE: This is the first study to compare MNH service delivery quality across contracted and non-contracted facilities using BSC as the assessment framework.

Pseudohypoglycemia: a cause for unreliable finger-stick glucose measurements.

OBJECTIVE: To identify patients with an inaccurate diagnosis of hypoglycemia and discuss predisposing factors. METHODS: We describe our patient's clinical presentation, laboratory work-up, hospital course, and follow-up and review similar cases from the literature. RESULTS: A 27-year-old woman with Raynaud phenomenon was admitted because of symptomatic hypoglycemia. Physical examination showed tremulousness, sweating, and the classic Raynaud color changes of the hands during episodic symptoms. A 72-hour fast revealed finger-stick capillary glucose values ranging from 32 to 45 mg/dL on multiple occasions, while concurrent plasma glucose values were consistently 1.5 to 2 times higher. Capillary measurements of glucose performed in the arms and legs at room temperature and after warming of each extremity disclosed an increase in glucose levels from a range of 35 to 52 mg/dL at room temperature to a range of 82 to 100 mg/dL after warming, confirming a discordance between capillary and venous blood results. The diagnosis of pseudohypoglycemia was made. Pseudohypoglycemia has been reported in patients with Raynaud phenomenon, peripheral vascular disease, and shock and may result from increased glucose extraction by the tissues because of low capillary flow and increased glucose transit time. CONCLUSION: Pseudohypoglycemia should be suspected in the setting of impaired microcirculation and can be confirmed by readily available means.

Breech delivery before and after the term breech trial recommendation.

OBJECTIVE: To compare the outcome of breech delivery at term in women before and after the term breech trial (TBT) recommendation. METHODS: A retrospective study carried out at Abha Maternity Hospital, Abha, Kingdom of Saudi Arabia comprising 796 women with breech presentation at term who delivered at our hospital between May 1997 and February 2005 divided into 2 groups. Group 1 consisted of 394 patients who were delivered 4 years before the recommendation of the TBT, and group 2 comprised 402 patients delivered 4 years after the recommendation. RESULTS: There were no statistically significant differences between the 2 groups with regards to the mean maternal age and birth weight, p>0.05, however, parity, gestational age at delivery, booking status, and cesarean section (CS) rate reached statistically significant levels, p<0.05. Assisted vaginal delivery was conducted in 106 (26.9%) of patients in group 1 and 69 (17.1%) in group 2, this also was statistically significant. No statistically significant differences were found between the 2 groups regarding the perinatal mortality, low Apgar score, <7 at 5 minutes and complications during delivery, p>0.05. CONCLUSION: There was a dramatic increase in the rate of CS without a corresponding improvement in the neonatal outcome in the years following the TBT recommendation in our hospital. We suggest that the policy is formulated to reduce the number of unbooked patients with breech presentation at term in our community to reduce the CS rate in these groups of patients.