Anaemia in pregnancy: occurrence in two economically different clinic populations of Karachi

According to previous WHO standards, anaemia in pregnancy denoted a haemoglobin level of 11.0 gms/dl or less, but this is now considered to be variable1 as it differs from country to country depending on local reference ranges and socio-economic conditions. Each country should “lay down minimal acceptable standards” below which an individual is considered to be anaemic, taking into account the available fmancial and manpower resources and other health needs of the country2. There is a wide divergence in the quoted prevalence of anaemia in Pakistan and neigh­bouring countries.3-6 This study was undertaken to determine a range of haemoglobin levels and frequency of anaemia in pregnancy in 2 clinic populations of Karachi. This study emphasises the relationship between anaemia and socio-economic levels of the population

Massive primary postpartum haemorrhage: Setting up standards of care

Objective: To review practice of massive primary postpartum haemorrhage management and develop a protocol.Methods: Cross-sectional study conducted at the Department of Obstetrics and Gynaecology at Aga Khan University Hospital, Karachi between January 1, 2003 and July 31, 2004. Women with primary postpartum haemorrhage and had blood loss \u3e1000ml were included in the study. Medical record files of these women were reviewed for maternal mortality and morbidities which included mode of delivery, possible cause of postpartum haemorrhage, supportive, medical and surgical interventions. Results: Approximately 3% (140/4881) of women had primary postpartum haemorrhage. \u27Near miss\u27 cases with blood loss \u3e1500ml was encountered in 14.37% (20/140) of these cases. Fifty-six percent (18/32) of the women who had massive postpartum haemorrhage delivered vaginally. Uterine-atony was found to be the most common cause, while care in High Dependency Unit (HDU) was required in 87.5% (28/32) of women. In very few cases balloon tamponade (2-cases) and compression sutures (2-cases) were used. Hysterectomy was performed in 4-cases and all of them encountered complications. Blood transfusions were required in 56% of women who had massive postpartum haemorrhage. Conclusion: This study highlights the existence variable practices for the management of postpartum haemorrhage. Interventions to evaluate and control bleeding were relatively aggressive; newer and less invasive options were underutilized. Introduction of an evidence-based management model can potentially reduce the practice variability and improve the quality of car

Factors influencing medical student participation in an obstetrics and gynaecology clinic

Objective: To identify factors influencing medical student participation in an obstetrics and gynaecology (OBGYN) setting.Methods:This was a cross sectional study carried out on patients admitted in OBGYN wards of Aga Khan University Hospital, Karachi, Pakistan. A total of 250 patients consented to participate in this study.Results: Eighty three percent of the people responded \u27yes\u27 to the question of being initially seen by a medical student. People who consented were 3.5 times more likely to know that their primary consultant was a teacher at a medical school i.e. they were initially aware that they were in a teaching hospital (p-value \u3c 0.01). Additionally, people who did consent were 3.5 times more likely to have been admitted because of labour/delivery (p-value \u3c 0.001) and 2.7 times more likely to have a monthly income of more than Rs. 20,000 (p-value \u3c 0.05).Conclusions: A number of factors have been identified in our study along with proposed solutions. Identification of these potentially modifiable factors in the medical student-patient interaction is important to improve the involvement of medical students in the care of the patients

Intracytoplasmic sperm injection outcome using ejaculated sperm and retrieved sperm in azoospermic men.

Introduction:We aimed to determine pregnancy and miscarriage rates following intracytoplasmic sperm injection (ICSI) cycles using retrieved epididymal and testicular sperm in azoospermic men and ejaculated sperm in oligospermic and normospermic men. Materials AndMethods: This retrospective study was carried out on 517 couples who underwent ICSI. They included 96 couples with azoospermia and 421 with oligospermia or normal sperm count in the male partner. Of the men with azoospermia, 69 underwent percutaneous epididymal aspiration (PESA) and 47 underwent testicular sperm extraction (TESE). In the 421 men with oligospermia or normal sperm count, ejaculated sperm was used for ICSI. The differences in the outcomes of ICSI using PESA or TESE and ejaculated sperm were evaluated. The main outcome measures were pregnancy and miscarriage rates.Results: No significant differences were seen in pregnancy and miscarriage rates with surgically retrieved and ejaculated sperm. The pregnancy rates (including frozen embryo transfer) were 43.5%, 36.2%, and 41.4% in couples with PESA, TESE, and ejaculated sperm, respectively (P = .93). The miscarriage rates were 16.7%, 23.5%, and 12.1%, respectively (P = .37).Conclusion: Intracytoplasmic sperm injection in combination with PESA and TESE is an effective method and can successfully be performed to treat men with azoospermia. The outcomes with these procedures are comparable to ICSI using ejaculated sperm

Helicobacter pylori Infection of Gastrointestinal Epithelial Cells in vitro Induces Mesenchymal Stem Cell Migration through an NF-κB-Dependent Pathway

The role of bone marrow-derived mesenchymal stem cells (MSC) in the physiology of the gastrointestinal tract epithelium is currently not well established. These cells can be recruited in response to inflammation due to epithelial damage, home, and participate in tissue repair. In addition, in the case of tissue repair failure, these cells could transform and be at the origin of carcinomas. However, the chemoattractant molecules responsible for MSC recruitment and migration in response to epithelial damage, and particularly to Helicobacter pylori infection, remain unknown although the role of some chemokines has been suggested. This work aimed to get insight into the mechanisms of mouse MSC migration during in vitro infection of mouse gastrointestinal epithelial cells by H. pylori. Using a cell culture insert system, we showed that infection of gastrointestinal epithelial cells by different H. pylori strains is able to stimulate the migration of MSC. This mechanism involves the secretion by infected epithelial cells of multiple cytokines, with a major role of TNFα, mainly via a Nuclear Factor-kappa B-dependent pathway. This study provides the first evidence of the role of H. pylori infection in MSC migration and paves the way to a better understanding of the role of bone marrow-derived stem cells in gastric pathophysiology and carcinogenesis

Surgical repair of genital fistulae.

Objective: Genital fistula is one of the serious childbirth injuries that can occur among women in the developing countries. Complex fistulae still represent a challenging management problem. We report our experience of managing genital fistulae at the Aga Khan University Hospital (AKUH), Karachi, Pakistan. Methods: Eighty-seven women with genital fistulae were managed between January 1988 and December 2002. Sixty-eight cases were urogenital and 19 were rectovaginal fistulae. Three women had concomitant urogenital and rectovaginal fistulae. The position of patients for surgery and the route of repair were individualized according to the appropriate access to the fistulae. Results: Of the 68 cases of urogenital fistulae, 54 were successfully repaired at first attempt. Three patients were cured at second repair. A success rate of 83.8% was achieved. Four patient with ureterosigmoid anastomosis and seven patients who were lost to follow-up, were considered as failures. All of the 19 rectovaginal fistulae (100%) closed after single repair. Conclusion: With an experienced uro-gynecologic team using conventional approach and meticulous repair, a high percentage of patients with genital fistulae can be rendered dry and continent

Peripartum hysterectomy: a ten-year experience at a tertiary care hospital in a developing country

Acute bleeding after delivery can be a life-threatening complication. Emergency hysterectomy is usually undertaken as a last resort. This study was conducted in order to estimate the incidence, indications, risk factors and complications associated with peripartum hysterectomy performed at a tertiary care hospital. We retrospectively analysed 39 of 45 cases of emergency peripartum hysterectomy performed at the Aga Khan University Hospital from 1997-2006. Peripartum hysterectomy was defined as one performed for a haemorrhage after delivery which is unresponsive to other treatments. The most frequent indications for peripartum hysterectomy were morbidly adherent placenta (46%) and uterine atony (23 /0).The duration of surgery was shorter (P=0.045) but the complications were higher (P=0.029) in total compared with subtotal hysterectomies. Our results suggest that caesarean deliveries are associated with an increased risk for peripartum hysterectomy, which is of concern given the increasing rate of caesarean deliveries. Subtotal hysterectomy is a reasonable alternative in emergency obstetric hysterectomy

Prevalence of abnormal Papanicolaou smears and cytohistological correlation: A study from Aga Khan University Hospital, Pakistan

Objectives: To determine the prevalence of abnormal Papanicolaou (Pap) smears in patients visiting the gynecologic outpatient department at Aga Khan University Hospital, Karachi (AKUH) and their cytohistologic correlation. This data was also compared with other international institutions. Methods: A database search of all abnormal cervical cytological cases diagnosed in the gynecologic outpatient department at Aga Khan University Hospital in the last 10 years (i.e. from 1994 to 2004), as well as their follow-up biopsies, was carried out. The data was then analyzed. Results: Of the 66 617 Pap smears reviewed, 95% of cases had a diagnosis of ‘negative’, 2% of smears were labeled as ‘inadequate’, 0.54% Pap smears showed dysplastic changes, and 0.14% were labeled as ‘malignant’. These numbers are less than figures in Western countires, but are comparable with Asian figures. The pick-up rate for abnormal Pap smears was 8/1000, while the overall concordance rate was 74%; positive predictive values for high-grade cervical lesions and for carcinomas was high 92–100%, respectively; while for ASCUS and low-grade cervical lesion was 35% and 67%, respectively. A total number of 8 cases were identified where there was a discrepancy between cytological and histological diagnosis, they were reviewed critically. Conclusion: In most of the developing countries effective Pap screening faces certain barriers. This includes limited or poor quality of cytology services. In a low-resource country like Pakistan there is a subset of patients (those with atypical cellular abnormalities) who may benefit from repeat smears instead of early cervical biopsies. In order to improve the efficacy of our cytology services, we need to develop specific clinical protocols for subsequent management of abnormal smears