Determinants of Covid vaccine uptake and perinatal outcome in pregnant women at a tertiary care center.

OBJECTIVE: To determine the factors for hesitancy and uptake of coronavirus disease-2019 vaccine, and to compare perinatal outcomes in vaccinated and nonvaccinated pregnant women. METHODS: The cross-sectional study was conducted from November 2021 to February 2022 at the Ruth Pfau Civil Hospital, Karachi, and the Holy Family Hospital, Karachi, and comprised pregnant women admitted in delivery suite for operative or vaginal delivery. Data was collected using a self-designed questionnaire which also explored knowledge about vaccine, contextual factors and reasons for and against vaccination. Perinatal outcomes included stillbirth, preterm delivery, low birth weight and Appearance-Pulse-Grimace-Activity-Respiration score. Also, 3cc blood was collected from the umbilical cord at the time of delivery, and enzyme-linked immunosorbent assay technique was used for antibodies titre. Data was analysed using SPSS 24. RESULTS: Of the 186 women, 114(61.3%) with mean age 27.9±4.1 years were vaccinated, and 72(38.7%) with mean age 27.5±5.2 years were not vaccinated. Physician's advise 104 (91.2%), vaccine safety and its effect on foetus 52(72.2%) were main determinants for vaccine uptake and refusal, repectively. Family and peer pressure was also responsible in 19(26.4%) cases for vaccine refusal. Body mass index, parity, level of education, socioeconomic status, history of coronavirus disease-2019 infection, booking status and presence of gestational diabetes mellitus were significantly different between the vaccinated and unvaccinated groups (p<0.05). Antibody titers and Appearance-Pulse-Grimace-Activity-Respiration score at 1 minute were significantly higher in the group of vaccinated women (p<0.05). CONCLUSIONS: Vaccine uptake was found to be low. Safety concern against vaccine, and doctor's advice were the main determinants for hesitancy and uptake. Antibody titers in newborns were higher in the group of vaccinated women.

Maternal and perinatal outcome of Ramadan fasting in women with gestational diabetes.

Objective: To compare maternal and perinatal outcome of Ramadan fasting during pregnancy in women with/without gestational diabetes. Methods: This prospective case-control study was conducted at Department of Obstetrics & Gynecology Unit 1 Ruth PKM Civil Hospital & Dow Medical College and Holy Family Hospital, Karachi during 1st April to 31st July, 2022. In this study normoglycemic pregnant women and those identified as gestational diabetes (n=52) on oral glucose tolerance test, who fasted during Ramadan were included. Women, on diet control or diet plus metformin were included in the study. Study questionnaire included demographic details, days of fasting, self-reported hypoglycemic episodes. Maternal outcomes included preterm birth, pregnancy induced hypertension. Perinatal outcome included hyperbilirubinemia, hypoglycemia, weight of placenta, and apgar score. Result: Eighty two women were included in the study, gestational diabetes (n=57) and normoglycemic (n=25). Average days of fasting were 16 ±9.0 days (range 5-30). Women with GDM were older (28.6 vs. 26.0 years, p-value=0.034), had raised levels of HbA1c (5.5 vs. 5.1, p-value=0.004), mean FBS (102.8 vs. 84.6 mg/dl, p-value <0.001), mean RBS (135.3 vs. 106.4 mg/dl, p-value <0.001) and had higher BMI at delivery (31.0 vs. 26.6 kg/m2, p-value=0.004). HbA1c (p-value=0.016) and head circumference of baby (p-value=0.038) were found lower in the group who fasted for more than 20 days among normoglycemic pregnant women. No other maternal and neonatal outcomes were found to be significantly affected by Ramadan fasting among pregnant women with/without GDM. Conclusion: Gestational diabetes do not affect maternal and perinatal outcome among pregnant women.

Efficacy of multiple Biomarkers: NGAL, KIM1, Cystatin C and IL18 in predicting pregnancy related acute kidney injury.

Objective: Several biomarkers like NGAL, KIM-1, IL-18, and Cystatin C has been previously reported as reliable marker to predict AKI. However, their predictive accuracy varies widely. We aim to observe the efficacy of multiple markers, NGAL, KIM-1, Cystatin C and IL-18, in obstetric population who are at risk of developing AKI. Methods: This prospective study was carried out between June 2021 to March 2022 at Department of Obstetrics & Gynecology Unit II, Ruth Pfau KM Civil Hospital and Sindh Institute of Urology & Transplant (SIUT), Karachi Pakistan. On women brought to OBGYN-ER with the diagnosis of hemorrhage (antepartum and postpartum), hypertension (pre-eclampsia and eclampsia) and sepsis. The urine samples and 3cc blood was collected at the time of admission, blood sample processed for biochemistry at time of admission and repeat blood samples for serum creatinine at 24 and 48 hours. Urine was stored at -80ºC and later evaluated for NGAL, KIM-1, Cystatin C and IL-18. Serum Cystatin C was also processed for the time zero sample. The biomarkers were tested using ELISA assays. Results: A total of 149 women were included in the study, 83% of these women were non-booked. Twenty-six (17%) women developed AKI. Serum Cystatin C, urinary Cystatin C and urinary NGAL were found significantly raised in women who developed AKI. While KIM-1 and IL-18 were not raised to statistical significance in this population. However, urinary KIM-1 along with urinary Cystatin C were significantly raised in women with positive quick sequential organ failure assessment (qSOFA). Conclusion: This study validates the use of serum and urinary Cystatin C and urinary NGAL as highly predictable biomarkers for the development of AKI and nullifies urinary IL-18 and KIM-1 in this regard.

Post-caesarean necrotizing soft tissue infection leading to maternal death: A case report.

Necrotizing soft tissue infection is lethal and can lead to sepsis, multi-organ failure, and death. Here we describe a case, which reported to us within 24 hours of Caesarean section, with acute abdominal pain, tachycardia, and tachypnoea. Local examination revealed a large area of necrotic subcutaneous tissue involving a Caesarean section scar. Immediate debridement was carried out and repeated twice after the initial procedure but she could not survive.

Clinical characteristics, obstetric and perinatal outcome of COVID-19 Infection in pregnant women.

OBJECTIVE: To determine clinical characteristics, obstetrics and perinatal outcome of coronavirus disease 2019 infection in pregnant women. METHODS: The cross-sectional study was conducted at the Department of Obstetrics and Gynaecology of the Ruth Pfau Civil Hospital, Karachi, and Dow University of Health Sciences, Karachi, from August 2020 to July 2021, and comprised pregnant women with suspicion of coronavirus disease 2019 infection, who underwent recommended testing, and were found to be positive. Oral swabs for the presence of infection were also taken from the neonate within 24 hours of delivery. Data was analysed using Stata 11. RESULTS: There were 41 women with a mean age of 27±5 years, a mean gestational age of 35±3 weeks, and mean parity 1.2±1.01. Of them, 3(7.3%) women died. Medical complications found along with coronavirus disease 2019 infection were pregnancy-induced hypertension 2(4.8%), eclampsia 4(11%) and diabetes mellitus 2(4.8%). Fever was the most common symptom seen in 12(30%) women, followed by cough 7(20%) and shortness of breath 6(14%). Majority 32(82%) of the women underwent caesarean section. The most common maternal complication was postpartum haemorrhage 6(20%). Also, 36(86%) women required intensive care unit stay for a mean 5±9 days. CONCLUSIONS: Fever, followed by cough and breathlessness, were the most common clinical features. Most common maternal and foetal complication was postpartum haemorrhage and low birth weight, respectively.

Ramadan Fasting: Perception and maternal outcomes during Pregnancy.

OBJECTIVES: To see perception and knowledge of women about Ramadan fasting and maternal effects of fasting. METHODS: The study design was prospective, case-controlled. This study was conducted at Holy Family Hospital from 1st May 2020 to July 2020. Pregnant women with spontaneous conception and singleton pregnancies, who fasted for seven or more days, were cases, and those who did not fast were taken as controls. Questionnaire was filled regarding perception of women about maternal fasting. Primary maternal outcomes included preterm delivery, pregnancy induced hypertension, and gestational diabetes mellitus. The analysis was conducted using Statistical Package for Social Sciences version 16.0. RESULTS: A total of 215 women were included in the study, 123 women fasted, and 92 women did not fast. Only 2.8% of women knew that fasting is forbidden in pregnancy. Sixty five percent of women reported weakness as the main reason for not fasting. The rate of gestational diabetes, pregnancy induced hypertension and preterm delivery was higher among women who fasted (17% vs 14%, 7% vs 2%, 9% vs 9%) respectively, compared to non-fasting women, but were not found statistically significant. There was no difference in anthropometric measurements of newborn, among both groups. CONCLUSION: Ramadan fasting does not affect maternal outcomes during pregnancy.

Blood transfusion and high-order cesarean delivery; Report from a developing country.

BACKGROUND AND OBJECTIVE: Blood loss in cesarean deliveries has already been established in previous researches but a detailed insight into the correlates has not been done. This study examined whether the number of previous Cesarean sections is related to the need for blood transfusion, and risk factors for blood transfusion. METHODS: A retrospective review of 239 females who had undergone two or more Cesarean sections during the time period of 2015-2018 was done. Data collected included type of surgery (elective or emergency), age, parity, body mass index, estimated blood loss, operating time, level of surgeon, presence or absence of adhesions and number of transfused packed cell volume. RESULTS: About 9.2% patients received blood transfusion with an estimated average blood loss of 618.18 ml. Patients with adhesions from previous surgery, presence of placenta previa, multiparity were significantly likely to receive blood transfusion. It was found that women with more than two caesarian sections had high proportion of blood transfusion as compared to women who had two caesarian sections. However non-significant difference was observed in numbers of caesarean sections with blood transfusion. CONCLUSION: Women undergoing Cesarean sections combined with any of the risk factors like increased body mass index, dense adhesions, uterine atony, hypertension and presence of placenta previa, were found to be at increased risk for a need for blood transfusions.

Perinatal outcome among fasting and non fasting mothers during the month of Ramadan.

OBJECTIVE: To compare the perinatal outcome among fasting and non fasting pregnant mothers. METHODS: A total of 180 women, who came for delivery in the labor suite were included, after verbal informed consent. These women were divided in two groups fasting (n=100), and non-fasting (n=80). RESULTS: The mean age of the mothers was 27.16±4.27 years in the fasting group and 27.36±4.92 years in non-fasting group. The average BMI of mothers was 25.31±3.26 kg/m2in fasting group while 25.64±3.58 kg/m2in non-fasting group. Perinatal outcomes, the birth weight, head circumference and mid arm circumference were almost similar between the two groups. Weight of placenta was 537.80±80.01g in fasting group while 540.50±84.29 g in non-fasting group and height of baby was 45.79±3.07 cm in fasting group while 46.61±2.92 cm in non-fasting group. In fasting group, placenta weight was 531.5±92.80 g in boys while 544.8±62.79 g in girls and ratio of placental to birth weight was 18.8±2.28 in boys while 19.4±2.70 in girls. CONCLUSION: Maternal fasting affects placental weight and length of baby, with effect more pronounced in male babies.

Postpartum management of diabetes pregnancy.

Diabetes mellitus has assumed the role of an epidemic. Previously considered a disease of affluent developed countries, it has become more common in developing countries. Pakistan is included among the countries with a high prevalence of diabetes. In this scenario, postpartum management of a woman with diabetes mellitus becomes more important as in this period counseling and educating a woman is essential. Counselling includes life style modifications to prevent future risks involving all the systems of the body. This review article discusses management of diabetes mellitus in postpartum period, guidelines for postpartum screening of women with gestational diabetes mellitus, risks involved in future life and stresses upon the need of local population based studies. Primary care providers and gynaecologists must realize the importance of postpartum screening for diabetes mellitus and provide relevant information to women as well.

Clinical spectrum of Posterior Reversible Encephalopathy Syndrome (PRES) in patients with eclampsia.

OBJECTIVE: To identify the prevalence, demographic details and clinical features of PRES in women suffering from eclampsia. METHODS: Women admitted in the labor room suite with diagnosis of eclampsia were studied. The study period was from October 15. 2011 to March 15. 2012, in the department of obstetrics & gynecology unit 3, Civil hospital Karachi. Of all patients with diagnosis of eclampsia, 22 underwent neuro imaging by computerized tomography. Demographic details, clinical findings and maternal and perinatal outcome were entered on a predesigned Performa. RESULTS: Thirty four women were identified, with eclampsia. Neuro imaging was done in 22 women. Posterior reversible encephalopathy syndrome was recognized in 9 (22) patients. The mean systolic blood pressure was 161(±11) mm Hg, and mean diastolic blood pressure was 111(±10) mm Hg. Mean number of fits were three, and the mean gestational age of patients were 35 weeks. Gestational age was found significantly associated with PRES (p <0.3) Mean leukocyte count in patients with eclampsia was 20,083±16,165/cu mm. CONCLUSION: Our study shows presence of Posterior reversible encephalopathy syndrome (PRES) in women who are identified with eclampsia. There is need for awareness and long term neurological follow up in this group of women.

Unexpected postpartum hemorrhage due to an acquired factor VIII inhibitor.

Unexplained postpartum hemorrhage (PPH) refractory to standard hemostatic measures should trigger a heightened clinical suspicion of an acquired bleeding disorder. When hemostatic medical interventions and surgical procedures fail to control the bleeding, then significant postoperative blood loss, debilitating morbidity, loss of fertility, and death may occur. In the setting of an autoantibody inhibitor to factor VIII (FVIII), control of life-threatening PPH and avoidance of subsequent bleeding episodes depends on a timely and accurate diagnosis, prompt hemostatic treatment and eradication of FVIII inhibitors, and appropriate long-term patient care and management. Acquired postpartum hemophilia due to a FVIII inhibitor is a rare cause of PPH; however, delayed treatment can lead to increased maternal morbidity and mortality. Acquired FVIII inhibitors also pose an emerging bleeding threat to the neonate as a result of possible transplacental transfer of FVIII autoantibodies to the fetus during the last trimester of pregnancy. The purpose of this review is to increase awareness among hematologists and obstetricians/gynecologists regarding the occurrence of FVIII neutralizing autoantibodies as a cause of PPH, and emphasize the importance of collaboration between obstetrician/gynecologists and hematology specialists to optimize the diagnostic evaluation, treatment, and long-term management of women who experience PPH due to an acquired FVIII inhibitor.

Thrombophilia investigation in Pakistani women with recurrent pregnancy loss.

AIM: The aim of the study was to identify thrombophilic defects in women with a history of recurrent miscarriage. METHODS: This was a case-control study in which the cases were women who had undergone spontaneous recurrent pregnancy losses and the controls were women in matched reproductive age groups without any history of miscarriage or pregnancy loss. Both groups of women were identified from our department's high-risk and gynecological outpatient clinics. A total of 52 women with recurrent pregnancy losses and 268 controls were tested for protein C, protein S, factor V Leiden (FVL), antithrombin and anticardiolipin (immunoglobulin M and G) antibodies, and the odds ratio and P-values were calculated. RESULTS: The mean age was 28.0 ± 4.4 years in the cases and 32.0±8.0years in the controls. The mean number of abortions among women with recurrent losses was 3.40±1.23. The mean parity was 1.04±1.23 (range 1-6), and 3.27±2.51 among controls. Among women with recurrent pregnancy loss, 22 (42%) had first trimester losses, 19 (36%) had second trimester losses, and 11 (21%) women had both first and second trimester losses. Protein C deficiency was identified in three out of 52 cases and 18 out of 268 controls (P-value 0.49), protein S deficiency in two cases and 12 controls (P-value 0.35), factor V Leiden mutation in 10 cases and 27 controls (P = 0.059), antithrombin in one case and 41 controls (P=0.009), and anticardiolipin antibodies in one case and nine controls (P = 0.49). CONCLUSION: No significant association between inherited thrombophilia and recurrent pregnancy loss in Pakistani women was found.

Maternal deaths due to indirect causes: Report from a tertiary care center of a developing country.

Objective: To assess the causes of indirect maternal deaths. Setting: The Department of Obstetrics & Gynecology, of a tertiary referral center in Karachi, Pakistan, from January 2018 to December 2020. Maternal deaths were categorized according to World Health Organization guidelines into direct and indirect deaths. Result: The total maternal deaths during the study period were 96, with 26 (27%) due to indirect causes. The mean age in the indirect group was 27 (range: 20-35) years, with only eight (31%) registered (attending for three of more antenatal visits). The mean gestational age was 33 (range: 22-39) weeks. Cesarean section was the main mode of delivery, in 13 (50%). Perinatal mortality was 68%. Cardiac and hepatic diseases (each six deaths, 23%) were the main causes of indirect maternal deaths. The majority of women (20; 76%) died during the postpartum period. Delays in seeking medical help, referral, and appropriate treatment were observed in 10, 9, and 7 cases, respectively. Conclusion: Indirect maternal deaths are an important cause of maternal mortality.

Transfusion of blood and blood component therapy for postpartum haemorrhage at a tertiary referral center.

OBJECTIVE: To determine the practice of transfusion of blood and blood products in cases of postpartum haemorrhage, at a tertiary referral center. METHODS: A retrospective study was conducted where medical records were reviewed for women, who either delivered or were admitted in labour suite with diagnosis of postpartum haemorrhage. The study period extended from Jan 2008 to Oct 2009. During a period of 22 months, records were reviewed for transfusion of blood and blood products in above group of women. Data were analyzed for descriptive statistics. RESULTS: During the study period, a total of 4744 patients were admitted in the labour suite. A total of 113 (2.36%) women were diagnosed with Post partum haemorrhage. Uterine atony was the commonest cause of PPH, followed by genital tract trauma. A total of 81 (71%) women received transfusion of blood and blood components (1.6%). The mean blood loss was 1088 ml (+/- 584 ml). Transfusion of blood and blood component therapy was significantly more in women who underwent caesarean section, compared to those women who delivered vaginally. There was one case of acute tubular necrosis due to PPH, and seven maternal deaths. The mean hospital stay was of +/- 3 days. CONCLUSION: In this hospital based study, the prevalence of PPH was 2.36%, and the rate of transfusion of blood and blood products was 1.6%.

Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan.

OBJECTIVE: To study the mortality and morbidity of unsafe abortion in a University Teaching Hospital. METHODS: A cross-sectional, descriptive study was conducted in Department of Obstetrics and Gynaecology, Unit III, Dow Medical College and Civil Hospital Karachi from January 2005 to December 2009. Data regarding the sociodemographic characteristics, reasons and methods of abortion, nature of provider, complications and treatment were collected for 43 women, who were admitted with complications of unsafe abortion, and an analysis was done. RESULTS: The frequency of unsafe abortion was 1.35% and the case fatality rate was 34.9%. Most of the women belonged to a very poor socioeconomic group (22/43; 51.2%) and were illiterate (27/43; 62.8%). Unsafe abortion followed an induced abortion in 29 women and other miscarriages in 14 women. The majority of women who had an induced abortion were married (19/29, 65.5%). A completed family was the main reason for induced abortion (14/29; 48.2%) followed by being unmarried (8/29, 27.5%) and domestic violence in 5/29 cases (17.2%). Instruments were the commonest method used for unsafe abortion (26/43; 68.4%).The most frequent complication was septicaemia (34; 79%) followed by uterine perforation with or without bowel perforation (13, 30.2%) and haemorrhage (9; 20.9%). Majority of induced abortions were performed by untrained providers (22/26; 84.6%) compared to only 3/14 cases (21.4%) of other miscarriages (p = 0.0001). CONCLUSION: The high maternal mortality and morbidity of unsafe abortion in our study highlights the need for improving contraceptive and safe abortion services in Pakistan.