C.Section is a major abdominal surgery which can be life saving for mother & the baby-Prof. Farrukh Zaman

Familycon 2013 Clinical Proceedings-II

C.Section is a major abdominal surgery which can be
life saving for mother & the baby-Prof. Farrukh Zaman

Obesity in women, prolonged labour, use of fertility drugs,
delayed child bearing, increase in induced labour, multiple
birth deliveries have increased C. Section in most of
the developing countries during last two decades

KARACHI: One of the sessions during the recently held FAMILYCON 2013 at Lahore was devoted to obstetrics and gynecology in which many important topics were discussed by various obstetricians and gynaecologists. Dr. Neelofer from CMH presented NICE Guidelines on how to manage Gestational Diabetes Mellitus in labor. She pointed out that the baby should stay with mother unless it requires special care. Hypoglycemic drugs should be discontinued after delivery and these women should be advised to have their blood sugar checked annually.
Prof. Ambreen Mumtaz made a presentation on Pelvic Inflammatory Diseases and discussed at length the low disease area, sub-optimal management and acute chronic clinical syndrome. Infection, she said, spreads through vagina and cervix through sexual transmission. The causative factors include early sexual intercourse at young age, many partners, frequent sexual intercourse etc. it increases the changes of ectopic pregnancy 6-10 times and has a 25% recurrence. Severe pain and tenderness in lower abdomen, backache and bulky tender uterus are some of the presenting symptoms. Appendicitis and ectopic pregnancy were mentioned in differential diagnosis. She also talked about laboratory tests studies in PID. Rest and sexual abstention are advised for management. Surgery is indicated in acute and severe Pelvic Inflammatory Disorders. In primary prevention she suggested sexual counseling, safe sex and limiting number of partners. PID in women, she opined, is a silent epidemic which can have serious consequences and one has to be aware of clinical limitations. Treatment of male partner is important. She also stressed the importance of screening for PID.

Prof. Amtullah Zarrin from AIMC gave details of views from different religious scholars regarding abortion in Islam. This subject, she said is quite sensitive and controversial. About forty six million abortions are performed and eighty million unintended pregnancies take place annually globally. According to estimates there are about nineteen million unsafe abortions every year resulting in death of sixty eight thousand mothers. There has been no change in unsafe abortions from 1995-2003 and unqualified and untrained persons continue to perform abortions. Some of the reasons for seeking abortion are unintended pregnancy, young age, poverty, too late pregnancy and extra marital affairs. About two hundred countries allow abortion to save mother, fifty countries prevent abortion for any reason while 50% of countries allow abortion in rape cases. In Pakistan abortion is allowed to save women’s life. There are no legal rights as regards abortion on demand. She suggested effective contraception when indicated besides family planning counseling.

This was followed by an interesting presentation by Prof. Farrukh Zaman who talked about why Caesarean Section rate is increasing. WHO guidelines, he said, suggest that C.Section should not be more than 15% of all deliveries. In monitored emergency obstetric care the C.Section rate is between 5-15% but if it is less than 5%, it also means that many women who need it are not getting this. Prolonged labour can have many serious complications. In Pakistan, generally C. Section rate is less than 9%. Brazil has a very high C.Section rate which is 80%, in USA one in three babies are being delivered through C. Section and it is likely to increase further. Previous C.Section is the most common cause. Prevalence of C.Section in UK is about 25%, in N. Ireland it is 30%, in Australia it is between 25-31%. During the Year 2000-2009 there has been an increase in C.Section rate in all the developing countries and the reasons have been obesity in women, long labour time, use of fertility drugs, delayed child bearing, increase in induced labour, and decline in attempted VABC and increase in multiple birth, deliveries. It is estimated that up to 50% of women do not get skilled birth attendant in Pakistan. Though we have a low C. Section rate at national level, there are differences in rural and urban areas, government hospitals and private hospitals. In private practice C.Section rate is high. In my practice now I do C.Section earlier and do not see many very sick babies. Social pressures, available facilities of advances in technology, blood transfusion have helped increase in C. Section rate. It is a major abdominal surgery but can be life saving for mother and baby and it also has many complications, he added. WHO has set a limit of 15% for C.Section which should not be acceded in the normal circumstances? Responding to a question during the discussion, Prof. Farrukh Zaman agreed that the Society of Obstetricians and Gynaecologists should come up with its own guidelines on indications for C. Section keeping in view our own environment, facilities and cultural values.

This was followed by yet another interesting presentation on Recurrent Miscarriage by Prof. Tayyab. He first narrated some of the misconceptions related to recurrent miscarriage and mentioned seeing a black cat, lunar eclipse, calling husband at his back, marrying an ugly husband, looking daily at the Mother-in-law etc. Speaking about the risk factors he mentioned maternal age, history of previous miscarriage, heavy smoking, and use of alcohol. Obesity is important while advanced paternal age was also a risk factor. Three or more miscarriage within less than ten weeks is termed as recurrent miscarriage. APS accounts for 5-15% while genetic factors are responsible for 2-5% of recurrent miscarriages. Other causes include congenital uterine malformations and cervical incompetence. PCOS can be a cause of miscarriage in 30-50% of cases and sonogram does not predict miscarriage. He also referred to insulin resistance besides thrombophelic disorders. During evaluation of these patients, he mentioned history, physical examination, GTT, TORCH, TFT are necessary. Speaking about treatment options, he suggested use of Aspirin daily with LMWH for APS which reduces the chances of miscarriage. Steroids do not improve the situation while Metformin has no role. There is no cause and recurrent miscarriage is idiopathic in almost 50% of cases. Up to 60-70% will have pregnancy without any treatment. If the underlying cause is identified, treatment is best. He also emphasized the importance of good antenatal supportive care. In case of PCO, use of metformin reduces the chances of miscarriages.
Dr. Tayyiba Wasim was the next speaker who said that there has been ten fold increase in C.Section rate and advised her colleagues to try to minimize C. Section in primary gravida. She also talked about massive haemorrhage, DIC, infections, pulmonary embolism, recent PPH and prolonged hospitalization. For managing these high risk patients one needs to first establish diagnosis, do counseling, make plan for treatment of life threatening complications, arrange blood transfusion and be prepared for prolonged hospitalization of these patients. If no facilities are available, it is advisable to refer these patients to some other unit. It is important to arrange for four to six pre operative blood transfusions. One should predict, prepare and handle PPH. In most cases one has to individualize treatment. Partial separation of placenta will lead to PPH. If medical treatment fails, opt for earlier surgical treatment. The objective should be to save the mother. She also talked about uterine artery embolization while hysterectomy was the definite treatment in such cases. She further stated that PPH is a nightmare for obstetricians, there is massive blood loss and increased C.Section rate. Counseling is the most important part in the management of these patients while hysterectomy is the treatment of choice. Her advise to her colleagues was that do not operate in inadequate facilities and conservative approach is always associated with more complications.

Prof. Ghazala Mahmood from PIMS discussed coagulation disorders in pregnancy, these disorders increase in pregnancy and thromboembolism is the major cause of mortality.
Prof. Arshad Chohan demonstrated the B-Lynch sutures technique. PPH, he said is a very serious situation, patient may be bleeding and the surgeon might get a call to come back to see the patient which is serious. It is extremely difficult and inconvenient for the lady doctors if they get such a call at night. He was of the view that no matter where the women deliver, birth should be a moment of joy and not a sentence to death. Death from haemorrhage is preventable and it should be our major goal in managing these patients. He also talked about treatment protocols on how to handle PPH. Uterine devascularization is effective in 80% of cases. Success rate for various uterine compression sutures have been reported up to 91%. The advantage is that it avoids hysterectomy. Hayman suture is a modified form of B-Lynch sutures. He then showed a video demonstrating various procedures with different suturing techniques.

Prof. Tasnim Ashraf President of Society of Obstetricians and Gynaecologists made a presentation on VIA technique for cancer screening. She pointed out that after breast cancer, cervical cancer is the most common cause of cancer death. Life time cervical cancer death risk is one in eighty. PAP smear like conventional cytology has 72% sensitivity and 94% specificity. VIA technique for cancer screening, she pointed out offers advantages over PAP smear as it results in increased screening coverage. There is no need for laboratory and cytopathologist. Trained nurses and paramedics even in small cities and towns can do it if they have been trained in this technique. The results depend on the quality of interpretation. VIA is indicated in serious patients with excessive vaginal discharge, post coital bleeding. She then discussed in detail how to prepare the women for VIA procedure. Management of VIA positive patients is with diathermy, cryotherapy and these procedures can be done at tertiary care hospitals. Cryotherapy is a simple out patient procedure, she added.
Prof. Shaheena Asif had selected a very provocative topic for her presentation i.e. Throw away the Forceps? In her presentation she highlighted in detail the complications of instrumental delivery like ectopic complications, shoulder dystocia and its consequences. Drop shoulder complications do occur. Other complications she mentioned included facial nerve palsy, skull fracture, intracranial haemorrhage. She was of the view that one should not opt for forceps delivery unless one has been adequately trained. Young obstetricians and gynaecologists need to do sufficient number of forceps deliveries under proper supervision darning their training, she remarked. Maternal complications include rectal, bladder vaginal trauma, pelvic injuries with the result that patient cannot sit properly. It is important to think and go for C.Section rather than instrumental delivery in such complicated cases; otherwise the patient will curse you for the rest of her life. Difficult forceps delivery may create more problems and you may not get time even to transfer the patient to some other center. In teaching hospitals, there are senior registrars, Assistant and Associate Professors and even Professors who can be called if need be but those working in private hospitals, may not find any such help. She also emphasized the fact that proper consent should be taken from the patient and educating the patient will avoid legal complications. It is better to transfer such high risk patients to a better unit where help is available. It is extremely important that there should be someone trained in fetal resuscitation which is a must. One should anticipate complications like shoulder dystocia. During the last five years there has been an increase in C. Section rate and decreased in forceps delivery. She then showed slides of brain haemorrhage due to forceps delivery, special injuries, broken collar bone, damaged eyes and mentally slow children. Her advice was that if you do not know how to use forceps, you are not properly trained, it is better to do C.Section.