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Cesarean section scar ectopic pregnancy is rare pregnancy complication. They have become common due to an increase in cesarean sections worldwide. The following report outlines two cases of scar pregnancy in women; both women had a history of two previous cesarean sections. Both were type 2 scar pregnancies as they protruded from the uterine myometrium towards the uterine serosa.1 The first woman initially received suction evacuation. The products, however, could not be entirely evacuated. As a result, laparotomy was performed. The second patient also underwent laparotomy due to her symptoms. Obstetricians need to keep a high index of suspicion while managing women with risk factors for an ectopic scar pregnancy. Failure to detect and pledge rapid treatment can lead to uterine rupture, massive hemorrhage, and maternal death. In the following report, presentations, and management of these two cases are discussed followed by a review of published literature.

Leiomyoma are common benign tumors of the uterus but its presence elsewhere in the body is a rare entity. Vaginal leiomyoma is even rarer and uncommon and present with variable symptoms and at different age groups. We present a case of vaginal leiomyoma in a young woman who was initially diagnosed as vaginal cyst and present with a dragging sensation. The mass was removed under general anesthesia and the histopathology confirms the leiomyoma. Key words; misdiagnosis,vaginal tumor, young woman

Aim The correlation of subclinical hypothyroidism (SCH) and polycystic ovary syndrome (PCOS) is a still insufficiently explored entity. The aim of this study was to determine the correlation between SCH and PCOS along with the impact of SCH on metabolic and hormonal parameters in women with PCOS. Methodology This cross-sectional study was conducted at the Gynecology Outpatient Department of Ziauddin Hospital Kemari, Karachi, Pakistan, from June 2019 to December 2019. A total of 90 diagnosed cases of PCOS were enrolled in the study. A non-probability consecutive sampling technique was used. After taking informed consent, participants were evaluated through clinical interviews, a questionnaire, and anthropometric measurements. The participants underwent the following assessments, i.e., transabdominal ultrasonography, hormonal profile (free testosterone, follicle-stimulating hormone, luteinizing hormone), and fasting blood sugar. Participants were divided into two groups based on thyroid-stimulating hormone (TSH) into the euthyroid group and subclinical hypothyroid (SCH) group. The Mann-Whitney test was used for comparing the two groups. Results Our results showed a significant difference in weight, body mass index (BMI), insulin, homeostatic model assessment of insulin resistance (HOMA-IR), and TSH were found in the SCH group as compared to the euthyroid group. A significant correlation of TSH with waist-hip ratio (WHR), weight, body mass index (BMI), insulin, and the homeostatic model assessment of insulin resistance (HOMA-IR) in PCOS patients. Conclusion This study showed a significant correlation of subclinical hypothyroidism with polycystic ovary syndrome. We found subclinical hypothyroidism may aggravate the insulin resistance; therefore, PCOS patients must be screened with a thyroid profile.

Objective: To determine the frequency and types of vaginal delivery in womenwith previous one caesarean section and to observe the effect of women age on success ofvaginal birth. Method: A descriptive study was carried out in the department of obstetrics& gynecology, Ziauddin University Hospital Kemari campus Karachi from January 2011 toJanuary 2013. 200 patients with previous one caesarean section for a non recurrent cause wereincluded in the study after fulfilling the inclusion and exclusion criteria. The women selectedwere evaluated and counseled for trial of labor. The frequency and mode of vaginal delivery wasrecorded in cases of successful trial of labor and caesarean section was performed in case offailed trial of labor. Results: Successful vaginal delivery was achieved in 67% of the patients andrepeat emergency caesarean section was carried out in 33% of the patients. Leading indicationfor repeat caesarean section was failure to progress, fetal distress and scar tenderness. Nomaternal and fetal complication occurred. We also observed that patients of less than 30 yearswere more likely to have a successful vaginal delivery (82%) as compared to patients older than30 years (18%). Conclusions: The trial of labor should be encouraged with vigilant monitoringin patients with previous one Caesarean section and is a safe and successful option if carefullyselected and monitored.

Background: Spontaneous preterm labor that is labor before 37 weeks ofgestation is the main cause of preterm delivery. With increasing gestation the level of Serummagnesium levels decreases. Magnesium inhibits uterine contractions by antagonizing calcium.Hypomagnesaemia also causes hyper excitability of neuromuscular junction bringing in musclecramps and uterine hyperactivity. Objectives: To determine the mean serum magnesium levelsin women presenting with preterm labor. Study Design: Cross Sectional Study. Location andduration of study: Ziauddin University Hospitals, Karachi from 8th December 2015 to 7th June2016. Methodology: Total 40 women of age 18-40 years having singleton pregnancy between28-36 weeks gestation with established preterm labor having cervical dilatation less than 3cm.were included. 5ml blood was collected and analyzed. Outcome in terms of Mean StandardDeviation were noted. Descriptive statistics were applied. Stratification was done using studentt-test and ANOVA where appropriate. The p-value ≤0.05 was considered as significant. Results:The mean age was 26.25±2.38 years. Mean gestational age was 32.77±2.11 weeks. Meancervical dilatation was 1.85±0.39 cm. Mean serum magnesium level was found 1.43±0.25 mg/dl. The results showed that there was significant difference in mean serum magnesium level forgestational age but not significant for age, cervical dilatation, parity and gravida. Conclusion:The results showed that serum magnesium level reduced with increased gestational age.Preterm labor can be predicted by serum magnesium levels.

Background\ud Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.\ud \ud Methods\ud In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.\ud \ud Findings\ud Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group.\ud \ud Interpretation\ud Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.\ud \ud Funding\ud London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation.

Infertility is very stressful event and is proven to associate with depression,anxiety, sexual dysfunction loneliness, sadness and impaired couple’s relationship. Objectives:To determine the frequency of depression in infertile females and to determine the various riskfactors associated with infertility and depression. Study Design: Prospective cross sectionalstudy. Setting: Department of Obstetrics and Gynecology of Ziauddin University Karachi. Period:January to June 2014. Methodology: Infertile women were interviewed and the diagnosis andseverity of depression was assessed together with the effects of different predicators such asage, duration of infertility, employment educational and socioeconomical status using PHQ-9 scale scoring. Results: This study showed that 199 (58%) of the infertile women sufferedfrom depression. There was a statistically significant association with socio economical statuswhile no significant association was detected with age of women, duration of infertility andeducational status. Conclusion: We found a high prevalence of depression among infertilewomen. Depression was more among women belonging to higher socioeconomic class.

Objective: To review the deliveries of macrocosmic babies and their obstetricaland neonatal outcomes. Methods: A prospective case control study involving a total of 3700deliveries at term of macrocosmic babies between Jan 2011 to Dec 2012 in Ziauddin HospitalKemari Campus. The study concerned risk factors, mode of delivery and the incidence ofmaternal and perinatal complications. Results: Macrosomia occurred in 5.2% of all deliveries.The main risk factors of macrosomia identified in our study were multiparty and diabetes mellitus.The significant maternal complications were caesarean section, postpartum hemorrhage andperineal tear. Significantly male gender, shoulder dystocia and admission to NICU were noted inmacrosomic group compared to controls. Conclusions: Macrosomia is potentially dangerousfor the mother and the neonate. It is important to identify the suspected fetal macrosomia toprevent its risk factors and complications. There is a need to provide all delivery facilities and careservices to prevent and reduce the maternal and neonatal complications.

Objective: The objective of this study was to investigate prevalence of urinary incontinence at 3 months postpartum andto study how continence status during pregnancy and different factors influence urinary incontinence at 3 months postpartum inprimiparous women. Setting: Pregnant women attending routine antenatal clinic at Ziauddin hospital and Kharader general hospitalKarachi were recruited to this study. Methods: Urinary incontinence before and during pregnancy was assessed at study enrolment earlyin the third trimester. Incontinence was re-assessed three months postpartum. Logistic regression analysis was used to assess the role ofmaternal and obstetric factors in causing postpartum urinary incontinence. Results: Urinary incontinence was reported in 15 women(10.6% ) out of 141 women, mode of delivery, onset of labor weight of the baby, episiotomy, and the length of the second stage of labor,were not predictive of urinary incontinence after delivery. Adjusted RR for incontinence after spontaneous vaginal delivery compared withelective caesarean section was 2.200(95% CI .6-7.28) among women who were continent during pregnancy. Conclusions: Urinaryincontinence was prevalent 3 months postpartum. The association between incontinence postpartum mode of delivery, onset of labor,perineal trauma and weight of baby was not statistically significant.

Objective: To identify the factors, causing the early termination of breast feeding i.e. from birth to six months of age. Design: A cross sectional study. Setting: Outpatient Department of Ziauddin Medical University, Kemari Campus, Karachi. Period: June 2008 to December. 2008. Methods: A structured questionnaire was put to mothers of children up to two years of age attending the outpatient department of pediatrics. Results: Significant associations existed between the early termination of breast feeding and family income, family structure (nuclear vs. extended), mode of delivery ,delayed in initiation of breast feeding early weaning and antenatal counseling with a p-value of

Objective: To determine what surgical techniques are used by obstetricians in Pakistan for caesarean section operations and to compare it with the recommendation, proposal and guidelines of Royal College of Obstetrician and Gynecologist (RCOG) and Cochrane Reviews. Methods: A questionnaire was set up regarding surgical technique used during caesarean section and one hundred obstetricians were part of study. Setting: Hospitals in two large cities of Pakistan i.e. Karachi and Rawalpindi were requested to fill them. Period: Jan 2009 to June 2009. Result: Substantial and remarkable and difference noted in the practice of caesarean section among the obstetricians. Certain practices and procedures performed by our obstetrician are same as proved to be beneficial and valuable based on evidence and recommended by the RCOG and Cochrane Data on pregnancy. Conclusion: We observed that our obstetricians follow different surgical techniques for performing caesarean section. Some of the techniques follow recommendations by RCOG and provide to effective and beneficial by cochrane data.