Prevalence of obstetric fistula: a population-based study in rural Pakistan.

OBJECTIVE: To estimate the prevalence of obstetric fistula, its duration and impact on women's daily life using robust data collection methods in a population-based sample in rural Pakistan. DESIGN: A population-based, cross-sectional study. SETTING: A rural community in Sindh Province, Pakistan. POPULATION: Randomly selected women aged 15 years or older. METHODS: A multistage random sampling strategy was used to recruit the women. Lady Health Workers interviewed women in their own homes using a structured questionnaire to obtain symptom data. Women with symptoms of incontinence were then examined by female gynaecologists in their local health facilities to confirm obstetric fistula. MAIN OUTCOME MEASURE: Obstetric fistula confirmed by gynaecological examination. RESULTS: Among the 5064 women interviewed (96% response rate), 20 women with obstetric fistula were identified, showing a prevalence of 0.39% of all women (95% confidence interval [95% CI] 0.22-0.57%) and 0.45% of parous women (95% CI 0.25-0.65%). Significantly more of the women with obstetric fistula compared with parous women without fistula were primiparae and aged <20 years. Of the women with obstetric fistula, 40% had had this for >5 years and 90% reported a major impact on their lives, yet only four had consulted a doctor, three of whom had failed repairs. CONCLUSIONS: The prevalence of obstetric fistula is high in rural Pakistan. Appropriate provision is needed for fistula repair to reduce the burden of the condition. Alongside this, the improvement of maternity care services is urgently needed to prevent its continued occurrence.

Urinary incontinence in women in rural Pakistan: prevalence, severity, associated factors and impact on life.

OBJECTIVE: To estimate the prevalence of urinary incontinence (UI) and its subtypes in women in rural Pakistan, associated factors, severity and impact on daily life. DESIGN: Population-based, cross-sectional study. SETTING: A rural community in Sindh Province, Pakistan. POPULATION: Randomly selected women aged 15 years or older. METHODS: A three-level random sampling strategy was used to select women: a random sample of health centres; a random sample of Lady Health Workers (LHWs) from each health centre; and a random sample of women in the LHW catchment areas. The LHWs used an interview-based structured questionnaire to collect data from women. MAIN OUTCOME MEASURE: Urinary incontinence reported by women. RESULTS: Among the 5064 participants (response rate 95.8%) the prevalence of any UI was 11.5% (581/5064; 95% CI 10.6-12.3). The most common subtype was stress incontinence, with a prevalence of 4.7% (95% CI 4.1-5.3), followed by urge incontinence, with a prevalence of 3.2% (95% CI 2.7-3.7), mixed incontinence, with a prevalence of 2.8% (95% CI 2.3-3.2), other incontinence, with a prevalence of 0.4% (95% CI 0.2-0.5) and continuous incontinence, with a prevalence of 0.5% (95% CI 0.3-0.6). Older age, higher parity and marriage at an early age were independently associated with UI. We found that 52% of women with UI reported leakage at least daily, and 45% reported a great or moderate impact on their daily life. Only 15.7% of women with UI had consulted a doctor. CONCLUSIONS: The prevalence of UI reported in rural Pakistan was lower than is generally found in studies from the developed world, but among the women affected it commonly occurred on a daily basis and impacted on their everyday lives, yet few had obtained medical advice.

Laparoscopic kidney transplantation: an initial experience.

Laparoscopic donor nephrectomy has the advantages of less pain, early ambulation and shorter hospitalization compared to open donor nephrectomy. Kidney recipient surgery is, however, traditionally performed by open surgery. Our aim was to study feasibility and safety of laparoscopic kidney transplantation (LKT). After permission from Internal Review Board, LKT was performed in four patients. All kidneys were procured from deceased donors. Left kidney was used for LKT and transplanted in left iliac fossa while right kidney was used for standard open kidney transplantation (OKT). All transplantation procedures were performed successfully. Cold ischemia time varied between 4 h and 14 h. For LKT, mean time for anastomosis was 65 (range 62-72) min, mean operative time was 3.97 (range 3.5-5) h, mean blood loss was 131.25 mL (range 45-350) mL. Mean wound length was 7 cm in LKT group and 18.4 cm in OKT group. Delayed graft function was observed in one patient in each group. One patient was lost in OKT group due to posttransplant bacterial meningitis. At 6 months, both groups have comparable value of serum creatinine. In conclusion, LKT is technically feasible and safe. Long term outcome needs to be evaluated in a larger study.

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.

Management of calculi in a donor kidney.

INTRODUCTION: We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) and extracorporeal shock wave lithotripsy (ESWL) as means of rendering a donated kidney stone-free in living related and deceased donor renal transplantation. MATERIAL AND METHODS: Three cases with calculi in donor kidneys were managed; 1 was from a living related donor and 2 were from deceased donors. Immediately after cold perfusion, ExURS was performed with iced saline solution in 2 cases. Access to the collecting system was via the ureteral stump. Calculi were fragmented with pneumatic intracorporeal lithotripsy and fragments were removed with forceps. Posttransplantation ESWL was given to 1 patient for migration of a small lower caliceal calculus in the upper ureter in 1 allograft of a dual-kidney transplantation. RESULTS: Access to the renal collecting system and stone fragmentation was technically successful in both cases. Indwelling ureteral stents were kept during transplantation in all cases. There were no intraoperative or postoperative ureteral complications. Following ESWL, stone was fragmented and cleared on its own within a week. At mean follow up of 2.2 years no new stone formed in any recipient or donor. CONCLUSIONS: ExURS was technically feasible to render a stone-bearing kidney stone- free without compromising ureteral integrity or renal allograft function. ESWL could be performed at a later date.

Reducing the hospital stay following vaginal hysterectomy.

A rapidly increasing waiting list in a new National Health service district general hospital made it necessary to explore measures to reduce the length of hospital stay of gynecologic inpatients without lowering the standards of medical care. Three years of experience with patients undergoing vaginal hysterectomy after January 1972 is described. During this time, 290 vaginal hysterectomies were performed and combined with pelvic floor repair in 194 cases. The average hospital stay for such patients was 12.7 days in 1971 before this study was commenced; since then this has been reduced progressively to 7.2 days with a corresponding increase in the number of such operations carried out annually. The effects of routine chemoprophylaxis and a modified technic of vault closure are discussed.

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

[Pulsatility index and resistance index in the aortic bifurcation area of growth retarded fetuses]. / Pulzatility index a rezistencia index v oblasti bifurcatio aortae u plodov s detekovanou retardáciou rastu.

UNLABELLED: To specify diagnostic importance of fetoplacental flow parameters PI, RI during pregnancy complicated by ultrasonografically detected intrauterine growth retardation-IUGR. SETTING: Dpt. of Obstetric and Gynaecology, Safarik's University and University Hospital L. Pasteur, Kosice, Slovak Republic, Obst/Gynae Dpt., Victoria Hospital, Mahé, Seychelles Republic, Indian Ocean. SUBJECT AND METHOD: The autors measured fetal circulation on the level of descending aortal bifurcation. The results were compared in the Group-A of 112 pregnancies complicated by mild, moderate and several praeeclampsia, eclampsia with detected IUGR, and comparative Group-B of 106 pregnancies. INTERVENTION: The ACUSONIC 8, ALOKA 680 SSD using transabdominal 3.5 MHz probe with color doppler facility. The parameters were measured in weekly intervals according the clinical protocol for management of high risk pregnancies. SUBJECTS: There was opened a prospective comparative study of 112 risk pregnancies (Group-A) and a comparative Group-B of 106 pregnancies with normal growth of fetuses. Group-A was devided according classification of praeeclampsia to Subgroup-A1, mild praeeclampsia, Subgroup-A2, moderate praeeclampsia, Subgroup-A3, severe praeclampsia and Subgroup-A4, eclampsia. Parameters of vascular resistance in descending aorta were calculated from 28th week of gestation to termination of pregnancy and compared average values in corresponding stage in the Group-A and the comparative Group-B. Number of IUGR fetuses or restricted with the growth were calculated in Subgroups-A. RESULTS: Descending aorta presents significantly higher average values of PI, RI during pregnancy from 28th week of gestation in Group-A. There is no evidence of diastolic decrease after 34th week of gestation in Group-A. In Group-A 52.6% fetuses were ultrasonograficaly IUGR detected or restricted. In Subgroup-A1 of mild praeeclampsia were 20.5% of the IUGR fetuses. Subgroup-A2 of moderate praeeclampsia showed 51.3% and Subgroup-A3 severe praeeclampsia 87.8% of the IUGR fetuses of restricted. Three cases of eclampsia were restricted for growth. MAIN OUTCOME: Functional assessment of the descending aorta flow is the most reliable method for differentiation of praeclamptic and eclamptic pregnancies with suspected fetal starvation and intrauterine growth retardation.

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.

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.

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.

Rubella susceptibility and continuing risk of infection in pregnancy.

Sera of 2000 pregnant women attending the antenatal clinic of the Aga Khan University Hospital were tested for rubella antibodies. Of these 1684 (84.2%) were immune and 316 (15.8%) were susceptible to rubella. Majority (99.8%) of the women were Asian in origin. Susceptibility decreased with increasing age and parity. We conclude that apart from vaccination of all young children greater attention should be paid to immunization of women of child-bearing age.

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.

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)

Isolation and identification of Aeromonas species from human stools.

One thousand and three diarrhoeal stool samples were processed in our laboratory during the period 1996/1997 for the presence of enteric pathogens especially Aeromonas spp., which has emerged as a new agent causing diarrhoea. Ampicillin sheep blood agar was found to be the best medium for the isolation of Aeromonas spp. from stool specimens. Enteric pathogens were found in 200 (20%) stools, of which Aeromonas spp. was the second commonest pathogen isolated amounting to 21% of isolates. This study clearly indicates that Aeromonas spp. must be looked for in every diarrhoeal stool samples, specially in children below 10 years of age. Isolation and identification is cost effective and easy, if the given protocol is observed.

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.

Clinical features and management of malignant ascites.

Retrospective analysis of 45 patients (33 females, 12 males) with cytologically-proven malignant ascites is presented. Abdominal pain was the most frequent symptom (69%). Fiftythree percent cases had low serum albumin. Ascitic fluid was haemorrhagic or serosanguinous in 48% cases, in the rest it was clear or straw-coloured. Peritoneal effusion was exudative in 84% cases. Mean glucose content of ascitic fluid was 95 mg/dl and the mean white cell count of 919 cells/cmm. Vast majority (82%) of the cases had metastatic adenocarcinomas. Primary malignancy was mostly ovarian (47%) followed by non-Hodgkin's lymphoma (11%) and gall bladder carcinoma (9%). Primary site could not be identified in 13% cases. Sixty-two percent patients received systemic chemotherapy for the underlying malignancy, of these 43% had complete or partial resolution of the ascites. Of the patients whose long-term follow-up is available, 54% were alive with a median follow-up of 9 months.

A clinicopathological analysis of ovarian tumours.

We performed a retrospective analysis of patients with ovarian tumors who were admitted to the Aga Khan University Hospital from January 1985 to December 1989. Sixty one cases were reviewed. Mean age of the whole group was 44 years. Majority of the patients presented with abdominal pain and distention. Most frequent physical finding was a palpable mass on pelvic or abdominal examination. Overall these patients had a higher incidence of breast cancer than expected in the general population. Two-thirds of the tumors were malignant. Comparison of the patients with malignancy against those with benign tumors failed to show any correlation with parity. Majority of the patients with malignant disease were above forty and had ultrasound showing a cystic mass over 10 cms in size. Cancer was mostly epithelial in origin, with widespread disease (stage III or IV) at the time of presentation. Benign tumors, mostly of germ cell type, were predominantly seen in patients under the age of forty with ultrasound showing cystic mass of any size from under 5 cms to over 10 cms.

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.