Referral pattern of emergencies in obstetrics: Implications for defining scope of services and policy.

OBJECTIVE: To analyse referral pattern of high-risk obstetric cases from secondary to tertiary care hospitals and to assess their maternal and neonatal outcomes. METHODS: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised all referred obstetric cases from secondary-level hospitals to tertiary-level care within and outside the Hospital between January 2011 and December 2014. Day and time of referral, reason for referral as well as maternal and neonatal outcomes were collected. SPSS 19 was used for data analysis. RESULTS: Of the 634 obstetric referrals, 279(44%) patients were referred to the study site, while 355(56%) sought care in other hospitals. Of those patients who were referred to the AKUH, medical records of 195(69.9%) were available for review. The mean age of the participants was 28±4.7 years. Obstetric complications led to 122(61%) referrals. The top three reasons among these were pregnancy-induced hypertension, preterm labour and foetal causes. Medical causes such as viral infections were the cause of 50(27%) referrals. Moreover, 177(91%) patients were pregnant at the time of referral and the remaining 18(9%) were referred after delivery. Of the pregnant women, 133(75%) delivered at the study site. Caesarean section was the mode in 92(69%) deliveries. There was 1(0.75%) maternal death due to puerperal sepsis while 9(7%) neonatal deaths were recorded. CONCLUSIONS: The most common reason for referrals was obstetric indications. Moreover, a quarter of referrals were initiated due to medical conditions, most of which were due to infections.

Rates of caesarian section and trials and success of vaginal birth after caesarean sections in secondary care hospital.

We planned to investigate the rates of Caesarean Section (CS), potential Vaginal Births After previous Caesarean Section (VBAC), and successful VBAC in a secondary care hospital. We conducted an analytical retrospective study at Aga Khan Hospital for Women, Karimabad, Karachi, from October 2011 to September 2012. Data related to total deliveries, Lower Segment CS (LSCS), attempted VBAC and successful VBAC was retrieved from medical records. Total number of deliveries were 3266. Of these, 1021(31.26%) deliveries were conducted by CS. A total of 365(11.1%) had a previous history of one CS and VBAC trial was given to 33(9%) of these pregnancies. The success rate of VBAC was 21 (63.6%). Our results highlight that despite having limited resources, our rates of CS, VBAC trials and successful VBACs were within reasonable limits when compared with international rates.

Meckel Gruber Syndrome: Second trimester diagnosis of a case in a non-consanguineous marriage.

Meckel-Gruber Syndrome (MKS) is a rare, autosomal recessive genetic disorder, incompatible with life. It is characterized by enlarged polycystic kidneys and post axial polydactyly. Foetal or neonatal death is caused by pulmonary hypoplasia. We report a case of a 35 year old woman who presented at 7 weeks of gestation of her sixth pregnancy. A transabdominal anomaly ultrasound performed for her current pregnancy at 18 weeks of gestation showed features consistent with MKS. The termination of pregnancy was declined and a live newborn female was delivered via an emergency caeserean section at 34 weeks of gestation due to previous history of lower segment caesarean section (LSCS) & leaking. Physical examination of the neonate confirmed the features of MKS. The neonate died within 4-5 hours of birth. This case represented a second trimester diagnosis of a recurrent case of MKS in a non-consanguineous marriage.

Gastroschisis.

We report a case of gastroschisis which was not diagnosed antenatally and was delivered through lower segment caesarean section due to non-reassuring cardiotocograph and small for gestational age fetus in a 21-year old mother. It was associated with oligohydramnios and partial extension of wrist joint in the neonate. After delivery, baby was referred to tertiary care for specialized care by paediatric surgeon and neonatologist where he had silo reduction and surgical repair. Postnatally, the baby is in healthy condition till now.