Sirenomelia, the Mermaid syndrome: case report and a brief review of literature

Sirenomelia, the Mermaid Syndrome is a rare and lethal congenital anomaly with an incidence of one in 60,000 to 70,000 pregnancies. Sirenomelia is characterized by complete fusion of the lower limbs, commonly associated with renal agenesis, absent external genitalia and other gastrointestinal defects. Another pathognomonic finding is the presence of single umbilical, persistent vitelline artery which is the chief distinguishing anatomic finding from Caudal Regression Syndrome. We report a case of termination of pregnancy done on the basis of ultrasound diagnosis of bilateral renal agenesis with no liquor volume. The foetus was identified to have characteristic features of Sirenomelia at the time of termination

Obstetric cerebral venous thrombosis

Pregnancy and puerperium are most prevalent prothrombotic states leading to cerebral venous thrombosis. Likelihood of stroke to be of venous origin is greater in stroke associated with pregnancy compared to stroke unrelated to pregnancy. Pregnancy induces several changes in coagulation system, which persists at least during early puerperium, rendering it a prothrombotic state. Hypercoaguability worsens further after delivery as a result of volume depletion and trauma. During puerperium additional risk factors include infection and instrumental delivery or Caesarean section. The management follows general rules as for the venous thrombosis unrelated to pregnancy, however the prognosis is different

Factors Affecting the Midwifery-Led Service Provider Model in Pakistan

Background Pakistan has a high rate of maternal and infant mortality, and a shortage of skilled birth attendants (SBAs). Many efforts have been made through the health sector and the international agencies to resolve the problem of both a high Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR), but the desired outcomes have not been achieved so far. Literature shows that midwifery plays a significant role in the reduction of MMR and IMR in other parts of the world, and the implementation of a Midwifery-led Service Provider Model could help reduce these rates in Pakistan. This study aims to identify the factors affecting the development of Midwifery-led Service Provider Model in Pakistan. Methodology This was a quantitative, descriptive study conducted in the Pakistani districts of Chitral, Dera Ghazi Khan, Multan and Sahiwal. A sample of 48 midwives was selected through stratified random sampling from two health centres in Chitral, two government health centres and two private health centres in Dera Ghazi Khan, Multan, and Sahiwal, and two independent midwife practitioners in Multan were also included. Findings Factors were categorized under “Environment”, “Empowerment” and “Encouragement” according to the model described by Marion-Davis. Factors identified under Environment include: autonomy, supervisor support and awards to work effectively; under Empowerment were core competencies and attitudes; and under Encouragement they were salary, opportunity for professional development, and availability of SBAs, equipment and essential drugs. Implications/Recommendations This study presents some implications for midwifery practice, education, research, institutional administrators, and policy-makers. Recommendations include: the provision of autonomy in practice, higher education, opportunities professional development opportunities, better salary and incentives for midwives, the availability of equipment at health facilities, and the involvement of nursing/midwifery leaders in policy-making

Maternal genital tract colonisation by Group-B Streptococcus: A hospital based study

Objectives: To determine the prevalence of Group B Streptococcus genital tract infection in pregnant women and to determine the risk factors for its colonisation.Methods: The cross-sectional study was conducted at the Aga Khan University Hospital, Karachi and Sobhraj Hospital, Karachi, from May to August 2007. Pregnant women at 35-37 weeks gestation attending antenatal clinic at these hospitals constituted the study population. Based on stratified sampling, 405 patients were recruited. High vaginal swabs of these patients were taken in order to calculate the prevalence of infection at each hospital. Logistic regression was used to evaluate the risk factor association. SPSS 11.5 was used for statistical analysis.Results: The overall prevalence of colonisation was 17% (n=69) (95% CI: 13.4-20.7). Of the 155(38.27%) women at the Aga Khan Hospital, 35(22.6%) were positive, while among the 250 (61.72%) women at Sobhraj Hospital, the prevalence was 13.6% (n=34). The colonisation was found to be significantly associated inversely with the body mass index of the patient (OR 0.91; 95% CI: 0.08-1.0).Conclusion: Group B Streptococcus screening should be an integral part of antenatal care and should be offered to all pregnant women

Implementation of warning tool to improve maternal newborn health outcomes in a developing country

Objective: To improve health outcomes through the implementation of national early warning sign tool for babies delivered through emergency caesarean section in off-work hours. Methods: This comparative clinical study was conducted at the Aga Khan Hospital for Women and Children, Karachi, from April to August 2014, and comprised women who had an emergency caesarean section. Maternal and perinatal outcomes were compared of patients in Group A and Group B which represented individuals before and after the implementation of the national early warning score respectively. Results: Of the 200 participants, there were 100(50%) in each group. The overall mean age was 26.79±5.10 years. The mean age was 26.3±5 years in Group A, and 27.2±5 years in Group B (p=0.25). The two groups were also comparable in terms of parity (p=0.77) and co-morbidities (p =0.51). There was no stillbirth or maternal death, but decline in complications due to post-partum haemorrhage (p=0.00) was observed due to early recognition and timely management. None of the women required referral to higher facility. Conclusion: National early warning score was found to be a practical early warning tool for obstetric population

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. Conclusion: 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

A risk prediction model for the assessment and triage of women with hypertensive disorders of pregnancy in low-resourced settings: the miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) multi-country prospective cohort study.

BACKGROUND: Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications. METHODS AND FINDINGS: From 1 July 2008 to 31 March 2012, in five LMICs, data were collected prospectively on 2,081 women with any hypertensive disorder of pregnancy admitted to a participating centre. Candidate predictors collected within 24 hours of admission were entered into a step-wise backward elimination logistic regression model to predict a composite adverse maternal outcome within 48 hours of admission. Model internal validation was accomplished by bootstrapping and external validation was completed using data from 1,300 women in the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) dataset. Predictive performance was assessed for calibration, discrimination, and stratification capacity. The final miniPIERS model included: parity (nulliparous versus multiparous); gestational age on admission; headache/visual disturbances; chest pain/dyspnoea; vaginal bleeding with abdominal pain; systolic blood pressure; and dipstick proteinuria. The miniPIERS model was well-calibrated and had an area under the receiver operating characteristic curve (AUC ROC) of 0.768 (95% CI 0.735-0.801) with an average optimism of 0.037. External validation AUC ROC was 0.713 (95% CI 0.658-0.768). A predicted probability ≥25% to define a positive test classified women with 85.5% accuracy. Limitations of this study include the composite outcome and the broad inclusion criteria of any hypertensive disorder of pregnancy. This broad approach was used to optimize model generalizability. CONCLUSIONS: The miniPIERS model shows reasonable ability to identify women at increased risk of adverse maternal outcomes associated with the hypertensive disorders of pregnancy. It could be used in LMICs to identify women who would benefit most from interventions such as magnesium sulphate, antihypertensives, or transportation to a higher level of care

Predictors of restless legs syndrome in pregnancy: a hospital based cross sectional survey from Pakistan.

Restless legs syndrome (RLS) is more common in pregnant women. The objective of our study was to determine frequency of RLS in pregnant women and predictors of RLS in pregnancy in Pakistan. All pregnant women admitted at The Aga Khan University Hospital for delivery from June to July 2005 were enrolled. Eighty-one of 271 (30%) interviewed women fulfilled the diagnostic criteria of RLS. One hundred seventeen (43%) of the subjects dropped their haemoglobin during the pregnancy. No significant difference in haemoglobin drop was noted between the RLS group and healthy group. On multivariate analysis family history of RLS (OR: 8.43, CI: 2.32-30.57, p valu

Intrauterine insemination with controlled ovarian hyperstimulation in the treatment of subfertility

Objective: To determine the success rate of intrauterine insemination (IUI), following controlled ovarian hyperstimulation (COH) and to identify the prognostic factors associated with successful outcome in couples undergoing this form of assisted reproduction.Design: Case series.Place and Duration of Study: Concept Fertility Centre, Karachi, Pakistan from January - December 2004.Patients and Methods: A total of 290 IUI procedures carried out for the treatment of unexplained and male factor subfertility were included. The age of women ranged from 20 to 44 years and the duration of subfertility were variable. All women had tubal patency confirmed before undergoing COH with one of the three regimens. IUI was performed at follicular maturity of \u3e 16 mm and endometrial thickness of \u3e 7 mm. Main outcome measures analyzed were pregnancy rate per cycle of IUI, miscarriage rate and ongoing pregnancy rate. Other variables observed were the various prognostic factors associated with successful outcome in IUI, such as maternal age, effect of different regimen of COH, motile sperm count and numbers of pre-ovulatory mature follicles \u3e 16 mm. Data was collected and entered in SPSS version 10. Chi- square test of significance was applied and p-value determined.Results: The cycle pregnancy rate (CPR), miscarriage rate and ongoing pregnancy rate was 10%, 13.8% and 8.6% respectively. CPR was 12% in women 3% in \u3e35 years (p-value 0.03). Significant difference was not observed in the CPR with three different COH regimes. CPR increased dramatically with motile sperm count of \u3e10 millions/ml compared with \u3c 10 millions/ml (12.3% vs. 2.8%, p-value 0.02). Significantly higher pregnancy rate was observed with increasing number of mature follicles \u3e16 mm (6.2%, 12.9% and 30% with one, two and three follicles, p-value 0.0019). There was no case of OHSS and only one case of twin gestation.Conclusion: The overall CPR in patients undergoing IUI following COH at our clinic is comparable to the pregnancy rates as shown in different studies. Younger age, motile sperm count of \u3e 10 millions/ml and two or three mature follicles \u3e16 mm are good prognostic factors for successful outcome. However, no significant difference was observed in CPR with different COH regimes

Midwives\u27 perception about their practice in a midwifery-led care model in Karachi, Pakistan

Objective: To explore the experiences and perceptions of midwives practising the midwifery-led care model at two private facilities of women and children hospital in Karachi, Pakistan. Methods: The descriptive qualitative data was collected through semi-structured questionnaires with 10 midwives. Results: The findings of the study revealed one theme and four related categories. The theme of the study emerged as ‘struggling to be a professional midwife’ and the related four categories were: (i) asking to perform within the full scope of practice, (ii) obstetricians’ reliance and trust in midwives\u27 expertise, (iii) raising concerns about expensive midwifery services, and (iv) encountering barriers to practise midwifery as independent practitioners. Conclusion: Midwives face some challenges practising the midwifery-led care model such as lack of visibility in society, low salaries and increased workload due to the shortage of staff. Lack of higher education was also highlighted by the midwives as they have no opportunities for career growth. This study will increase midwives\u27 autonomous role and decision-making in the clinical setting