Episiotomy and its complications: A cross sectional study in secondary care hospital

Episiotomy is a commonly performed procedure at the time of vaginal delivery to prevent perineal lacerations. A study was conducted to evaluate the complications of episiotomy. A sample size of 235 patients was taken. The complications were divided in two groups depending on the time of occurrence after delivery. Out of 235 patients, immediate complications were reported in 10(4.3%) patients. These included perineal tears, postpartum haemorrhage, extended episiotomy, perineal pain, inability to pass urine or stool and vaginal haematoma. Early complications including wound infection, gaping wound and resuturing of wound were reported in 21(8.9%) patients. On multivariate analysis, it was seen that age (19-29 years) was significantly associated with complications. Mediolateral episiotomy is a safe obstetrical surgical procedure in order to prevent third and fourth degree perineal tears and is not associated with increased incidence of complications

Comparing neonatal respiratory morbidity in neonates delivered at term by elective Caesarean section with and without dexamethasone: retrospective cohort study

Objective: To assess the effect of dexamethasone on neonatal respiratory morbidity in babies delivered by early term elective lower segment Caesarean section. Method: The retrospective cohort study was conducted at a secondary level hospital in Karachi. It reviewed the medical record of pregnant women and their babies who were delivered by elective lower segment Caesarean section between January 1 and June 30, 2013, at 37-38+6 weeks of pregnancy. The women were divided into exposed group (Group A) who received prophylactic dexamethasone, and non-exposed group (Group B) who did not receive dexamethasone Neonatal respiratory morbidity was compared between the two groups. Data was analysed using SPSS 19.Results: The 196 subjects in the study were equally divided in two groups. In Group A, only 1(1%) baby developed transient tachypnoea compared to 10(10%) babies in Group B (p=0.005). Besides, 11(11%) babies were admitted to nursery in Group B compared to 1(1%) in Group A (p=0.005). No baby was referred to any tertiary care hospital for intensive care.Conclusion: Beneficial effects of prophylactic dexamethasone in neonatal respiratory morbidity were found, but further prospective studies with large sample size are required

Factors associated with failed induction of labour in a secondary care hospital

Objective: To assess the factors associated with failed induction of labour (IOL) in a secondary care hospital.Method: This is a retrospective cross sectional study on women admitted for labour induction in Aga Khan Hospital for women Karimabad from 1st Jan, 2009 to 31st Dec, 2009. Induction was considered successful if the patient delivered vaginally and failed if it ended up in Caesarean Section.Result: Eighteen percent of our pregnant population who underwent induction of labour failed to deliver vaginally. About 25% of 328 nulliparous women had failed induction. With a Bishop score of \u3c5 in 84.3%. In 28.2% with prolonged latent phase of more than 20 hours in Caesarean section had to be performed.Conclusion: Nulliparity, poor Bishop score and prolonged latent phase had strongest association with failed Induction of Labour. Macrosomia, gestation age, bad obstetric history and pre labour rupture of membranes were other significant risk factors for emergency caesarean sections in IOL

Assessing the adherence of obstetricians towards postpartum diabetes screening guidelines: A pre- and post-intervention study at secondary care hospital in Karachi, Pakistan

Objective: To assess the adherence level of obstetricians towards postpartum diabetes screening guidelines. Methods: The quasi-experimental pre- and post-intervention study was conducted from May 2014 to April 2015 at Aga Khan Hospital for Women-Karimabad, Karachi, and comprised all obstetricians practicing at the time. All the booked women with gestational diabetes delivered in the 6 months before refresher lecture (group 1) and those delivering in the 6 months following the intervention (group 2) were included. Data was analysed using SPSS 19. Results: Of the 550 cases, 275(50%) each were in groups 1 and 2. All pregnant women had live-birth. The intervention made it thrice likely (95% confidence interval: 7.83) that a physician advised postpartum oral glucose tolerance test. Caesarean section increased the chances of getting test advice almost 4 times (95% confidence interval: 1.70, 9.10) compared to women who delivered vaginally. Women managed on insulin with / without metformin were 4 times likely to being advised the test compared to women managed on diet (confidence interval: 1.00, 17.09). Full-time employees advised 7 times more than the visiting obstetricians (confidence interval: 1.33, 35.16). Conclusion: It is time for more strategic planning regarding patient education the benefits of detection of abnormal glucose tolerance in early postpartum perio

A phase three open label randomized controlled trial to compare the efficacy of oral hypoglycemic agents (OHA) with insulin in the treatment of gestational diabetes mellitus (GDM)

Background: The incidence of GDM is 1 – 14 % (5 – 8 % reported in most areas). It is globally on the rise in parallel with type 2 diabetes. The short and long term adverse maternal, fetal and neonatal outcomes in pregnancy with Diabetes are well known. Insulin therapy has been regarded as the gold standard medical intervention in pregnancy. It has limitations especially in poorly resourced, illiterate and non-compliant population. Studies have shown that some oral hypoglycemic agents (OHA) ( FDA category B:Glibenclamide and Metformin) are safe in pregnancy. Studies comparing these with insulin have found them to be as effective as insulin with comparable outcomes in pregnancy. Objectives: Primary objective:To compare efficacy of Oral Hypoglycemic Agents and Insulin in the treatment of GDM (percentage of subjects achieving target blood sugars at delivery). Secondary objective :To compare cost and acceptability to treatment in both groups. Methods: This is a collaborative study between the Department of Obstetrics and Gynaecology and the Section of Endocrinology, Department of Medicine. Results and conclusions: This clinical trial is in progress and is recruiting patients. Results will be communicated later o

Strengthening recruitment and retention: Mitigation strategies in two longitudinal studies of pregnant women in Pakistan

Purpose: Global health researchers have a responsibility to conduct ethical research in a manner that is culturally respectful and safe. The purpose of this work is to describe our experiences with recruitment and retention in Pakistan, a low-middle-income country.Description: We draw on two studies with a combined sample of 2161 low-risk pregnant women who participated in a pilot (n = 300) and a larger (n = 1861) prospective study of psychological distress and preterm birth at one of four centers (Garden, Hyderabad, Kharadar, Karimabad) of the Aga Khan University Hospital in Karachi, Pakistan.Assessment: Challenges we encountered include economic hardship and access to healthcare; women\u27s position in the family; safety concerns and time commitment; misconceptions and mistrust in the research process; and concerns related to blood draws. To mitigate these challenges, we developed culturally acceptable study incentives, involved family members in the decision-making process about study participation, partnered with participants\u27 obstetrician-gynecologists, accommodated off site study visits, combined research visits with regular prenatal care visits, and modified research participation related to blood draws for some women.Conclusion: Implementation of these mitigation strategies improved recruitment and retention success, and we are confident that the solutions presented will support future scientists in addressing sociocultural challenges while embarking on collaborative research projects in Pakistan and other low-middle-income countries

Individual and collective contribution of antenatal psychosocial distress conditions and preterm birth in Pakistani women

Background: We determined whether dimensions of psychosocial distress during pregnancy individually and collectively predicted preterm birth (PTB) in Pakistani women as it may be misleading to extrapolate results from literature predominantly conducted in high-income countries.Methods: This cohort study included 1603 women recruited from four Aga Khan Hospital for Women and Children in Sindh, Pakistan. The primary binary outcome of PTB (i.e.,livebirth before 37 completed weeks\u27 gestation) was regressed on self-reported symptoms of anxiety (Pregnancy-Related Anxiety (PRA) Scale and Spielberger State-Trait Anxiety Inventory Form Y-1), depression (Edinburgh Perinatal Depression Scale (EPDS)), and covariates such as chronic stress (Perceived Stress Scale) assessed with standardized question and scales with established language equivalency (Sindhi and Urdu).Results: All 1603 births occurred between 24 and 43 completed weeks\u27 gestation. PRA was a stronger predictor of PTB than other types of antenatal psychosocial distress conditions. Chronic stress had no effect on the strength of association between PRA and PTB and a slight but non-significant effect on depression. A planned pregnancy significantly lowered risk of PTB among women who experienced PRA. Aggregate antenatal psychosocial distress did not improve model prediction over PRA.Conclusions: Like studies in high-income countries, PRA became a strong predictor of PTB when considering interactive effects of whether the current pregnancy was planned. Women\u27s resilience and abilities to make sexual and reproductive health decisions are important to integrate in future research. Findings should be generalized with caution as socio-cultural context is a likely effect modifier. We did not consider protective/strength-oriented factors, such as resilience among women

Reasons of refusal and drop out in a follow up study involving primigravidae in Pakistan

Objective: To determine the reasons underlying the refusals to participate and drop outs from a follow up study involving primigravidae. Design: A descriptive study. Methods: Aga Khan University and Aga Khan Hospital for Women, Karachi, jointly initiated a nested case-control study on primigravidae for determining the predictability of preeclampsia using various biochemical markers in blood. The protocol-eligible study subjects were counseled along with their accompanying family members to participate in the study. All women recruited in this study were followed up throughout their pregnancy till delivery. Results: One thousand six hundred and sixty-five primigravidae were identified as the potential study subjects. Out of which, 1,307 (78.5%) consented and 358 (21.5%) refused to participate in the study. The most common reason underlying the refusal was inability to get permission from the family members (n=84, 34.4%) followed by fear of prick (n=51, 20.9%). For 114 refusals, either the reason was not mentioned by the counseled women (n=60) or the data was missing (n=54). Out of 1,307 women recruited in the research, only 611 (46.7%) women completed the study according to the prescribed protocol. Among the rest, 102 (7.8%) subsequently withdrew from the research, 503 (38.5%) were dropped out, and 91 (7.0%) were lost to follow up. Conclusions: Refusal to participate and drop out from the research program are two significant factors hindering the smooth flow of a study. In Pakistan, the major reason for the refusal by the protocol-eligible pregnant women for participating in a research program is the unwillingness of the family members

Allostatic load as a mediator and perceived chronic stress as a moderator in the association between maternal mental health and preterm birth: A prospective cohort study of pregnant women in Pakistan

Introduction: The complex biopsychosocial pathways linking maternal mental health with preterm birth (PTB) are not well understood. This study aimed to explore allostatic load (AL) as a mediator and perceived chronic stress as a moderator in the pathway linking maternal mental health and PTB.Methods: A cohort study of pregnant women (n = 1,567) recruited at clinic visits within 10-19 weeks of gestation was assessed for maternal mental health (i.e., pregnancy-related anxiety, state anxiety, depressive symptoms) and perceived chronic stress. Blood pressure and levels of cortisol, total cholesterol, C-reactive protein, and glycosylated hemoglobin were used to create a composite measure of AL.Results: AL had the most significant effect on PTB (odds ratio (OR) = 1.84, 95% CI = 1.26-12.67, p = 0.001), while systolic blood pressure emerged as the only significant individual marker using variable selection (OR = 22%, 95% CI = 1.06-1.40, p \u3c 0.001) in multiple logistic regression analysis. A mediation analysis revealed that maternal mental health did not have a significant direct effect on PTB (p = 0.824), but its indirect effect mediated by AL was significant (z = 2.33, p \u3c 0.020). Low and high levels of perceived chronic stress, relative to the mean, moderated this indirect effect (z = 3.66, p \u3c 0.001).Conclusions: AL has a significant direct influence on PTB and mediates the effect of maternal mental health on PTB; however, the indirect effect of AL is indistinguishable between women with higher or lower levels of perceived chronic stress than normal