Pregnancy is a normal, healthy state that most women aspire at some point in their lives. Yet while pregnancy and child birth should be an occasion for rejoicing, life threatening complications / out comes may occur, which if in appropriately managed, could lead to maternal deaths or disability 1. Each year an estimated 123 million women succeed to get pregnant. A substantial additional number of women around 87 million become pregnant unintentionally 2.
Complications of pregnancy and child birth out comes are a leading cause of death and disability among women of reproductive age in most developing countries. For teenagers, these are leading cause of death 3.
Direct causes of pregnancy-related death and disabilities world wide are;
Severe bleeding 25 %
Infection 15 %
Hypertensive Disorders 12 %
Obstructed labor 08 %
Others 08 % 4
Pregnancy out comes or complications in the form of morbidity or disability can diminish mothers contributions to both the family and the economy in the struggle against the poverty. And if a mothers death occur that can be devastating to the children left behind, who become vulnerable to poor health, poverty and exploitation without a mothers love and protection 5. At least 35 % of women in developing countries receive no antenatal care during pregnancy, almost 50 % give birth without a skilled attendant and 70 % receive no post partum care in the six weeks following delivery. Many physical, social and cultural causes contribute to this tragic mortality 6.
The typical profile of Pakistani women is "an illiterate individual, getting married at an early age, rising 5 - 6 malnourished children (25 % being born with low birth weight), has restricted mobility and decision powers, and is often physically, mentally, and socially abused and dies in the process of child birth." The situation is worse for women living in rural areas. Over 04 million women get pregnant in Pakistan each year, Pakistan reports a total fertility rate of 5.366.
The association of convulsions and pregnancy has been realized even by early civilizations. The word "Eclampsia" is derived from the Greek word "lightning". The history of the disease dates back to many countries 7. It is a disease peculiar to humans8. Eclampsia is one of the most dangerous conditions that can affect a pregnant women and her faetus. It is the occurrence of generalized convulsions during pregnancy, labor or within seven days of delivery but not due to epilepsy or other convulsive disorders 9. In the United States, the over all incidence of eclampsia is 01 : 1000 total deliveries 10. Eclampsia is a rarity in the prosperous west, the incidence being 4.9 / 10000 in England. However, the incidence is much higher in the developing countries. The incidence reported in a study conducted in Nigeria is 42 / 10000, one study of India shows an incidence as high as 220 / 10000. A report from Peshawar, Pakistan states an incidence of 120 / 10000. it is estimated that 10 % of all maternal death in the developing world are associated with eclampsia 11.
Ante partum haemorrhage or vaginal bleeding in the third trimester complicates 04 % of all pregnancies. It is considered an obstetric emergency because hemorrhage remains the most frequent cause of maternal morbidity and mortality in United States. It is critical for the well being both the mother and fetus 12. The incidence of placenta previa is 0.5 % and that of Abruptio placentae is 0.5 % -- 1.5 % of all pregnancies 12. A research carried out in one of the developed countries i.e. France, Paris on maternal morbidity from direct Obstetric causes according to them incidence of placenta previa was 1.9 % and for abruptio placentae was 3.7 % 13.
The incidence of placenta previa in a study carried out in Israel was 0.387% 14. In one study at Lahore, Pakistan conducted at Allama Iqbal Medical College 2.0 % of patients had placenta previa 15. In Ayub Teaching Hospital Abbotabad, Pakistan abruptio placentea was recorded as 4.4 % 16.
Obstructed labor is common and preventable cause of maternal and perinatal morbidity and mortality in developing countries and continues to plague thousands of women each year. The prevalence of obstructed varies from one country to another, but it is most common in developing countries 17. In developing countries, the incidence of obstructed labor is difficult to estimate, primarily because of poor data collection procedures and secondarily because most of the reported studies are based on from large, tertiary hospitals 18.
Obstructed labor is said to cause 08 % of maternal deaths world wide. Obstructed labor occurred in 3.6 % of pregnancies in a hospital based study in Nigeria 19. A study done in Jamshoro, Hyderabad, Pakistan indicated that 2.1 % of patients were admitted as obstructed labor 20.
Pre-term birth is global obstructical challenge. The estimated incidence of pre-term labor varies from 05 - 10 % of all births in the developed countries, in Pakistan parinatal mortality rate is 96 per 1000 live births. 21. It is a major public health problem in terms of loss of life, long term disability of new born (cerebral palsy, blindness, deafness, chronic lung disease) and health care cost both in developing and developed world. In the USA, approximately. 450 Thousand (11.5 %) pre-term births occur annually. Many developing countries are unable to cope with the health care cost associated with managing neonates that are born pre-term, resulting in higher and often un-acceptable neonatal morbidity and mortality22. One study of Africa in Mozambique reported an incidence of pre-term delivery of 15 %. Another study in rural Malawi described 22 % 23. Another study of Jamshoro, Hyderabad Pakistan stated 13.36 % incidence 24.
The overall scenario present the seriousness of problems and reveals how much is the depth of gravity, though these are not exact and accurate figures and just gives only estimates but despite that these are very important clues. These situation emphases the importance of strengthening the safe mother-hood programs in the community from grass root level so that good out come of pregnancy for the mother and the child can be achieved.
The aim of this study is also to estimate the depth of the problem regarding outcomes or complications of pregnancy that are ante partum hemorrhage, eclampsia, obstructed labor and pre-term in Liaquat University Hospital, Hyderabad, so as to help authorities to make policies and arrange facilities accordingly.
OBJECTIVES
To estimate the frequency of third trimester pregnancy outcomes such as placenta previa , abruptio placentae , eclampsia, obstructed tabor and pre term labour at Gynaecology and Obstetric wards at Liaquat University Hospital Hyderabad.
To estimate frequency of age, education and booking status with Eclampsia and evaluate maternal mortality ratio at Gynaecology and Obstetric wards at Liaquat University Hospital Hyderabad.
To evaluate relation of age along with gestational age with placenta previa at Gynaecology and Obstetric wards at Liaquat University Hospital Hyderabad.
To identify the frequency of age and booking status with abruptio placentae at Gynaecology and Obstetric wards at Liaquat University Hospital Hyderabad.
To analyze the relation of factor as age, locality and mode of delivery with obstructed labour at Gynaecology and Obstetric wards at Liaquat University Hospital Hyderabad.
To assess the frequency of age, booking status and socio-economic status with pre term labor at Gynaecology and Obstetric wards at Liaquat University Hospital Hyderabad.
JUSTIFICATION
Maternal health appears as a pervasive concern within the frame work of the Millennium Development Goals. It finds explicit expressions in the goals 4 & 5 pertaining
To reproductive and child health, reducing maternal mortality rate and increases the proportion of birth attendants by skilled health personals. Goal 5 calls for reducing the rate of maternal mortality by 75 % by 2015.
Statistics reveal that every minute, one woman some where in the world dies from complications related to pregnancy or child birth. In the year 2000, more than a half million women died in child birth or from pregnancy related complications. Over 99 % of these deaths occur in developing countries. And these could be avoided if the proper health resources and services were available to women in developing nations.
The international community regards reproductive health as a basic human right. To exercise this right, the people must have enabling environment and access to complete reproductive health information and services so they can make free and comfortable decisions. In Pakistan 2/3 of pregnant women deliver at home and most (80 %) deliver without assistance from skilled birth attendants. The availability, access and the quality of the basic and comprehensive obstetrical services and their utilization are low in Pakistan. Only 5 % of the government health facilities are estimated to offer EmOC services round the clock.
Because of the deficiency of the quality services and skilled personnel at grass root levels, number of obstetric problem remain hidden, just like an ice berg whose only tip is visible while major portion is in-visible.
The cases reaching the tertiary hospitals are mostly filtered thought many health centers and do not represent the actual figures but despite that they are very helpful for calculations and estimations.
The purpose of this study is also to estimate the frequency of pregnancy related outcomes or complications, and maternal mortality ratio in relation to the described variables, they are, eclampsia, anti-partum hemorrhage, obstructed labor and pre-term labor at the gynecology and obstetrics wards of Liaquat University Hospital Hyderabad.
LITERATURE REVIEW
One of the millennium development goals (MDG) is the improved maternal health, with the target of reducing the maternal mortality by three quarters between 1990 & 2015. While some developing countries have shown great progress in improving maternal health.
Progress remains slow and levels of maternal mortality are persistently high in much of the developing world. It is estimated that each year, some 8 million women suffer pregnancy - related complications and over 500,000 women die, with 99 percent of these maternal deaths taking place in developing nations, mainly in sub-Saharan Africa and south Asia. The direct obstetric complications that cause majority of maternal ill health through out the developing countries are haemorrhage, hypertensive disorders of pregnancy, obstructed labor, sepsis, and unsafe induced abortion. What is especially tragic is that the most of these maternal conditions could be averted with very cost-effective interventions, even where resources are limited. The poorest countries are progressing slowly towards reducing maternal mortality; low income countries have reducing maternal mortality by 2.4 % a year, compared to middle income countries 4.9 %.
The death or illness of women of reproductive age has clear implications for a country's productive capacity, labor supply and economic well being, and also translated into substantial economic loss and social hardship for her family. Pregnancy related disease burden associated with frequent or too early pregnancies, poor maternal health and pregnancy complications drains women's productive energy jeopardizes their income earning capacity and contributes to their poverty. Especially important is women wage earning is critical to the family unit, community and over all poverty reduction, and in fact, benefit family welfare more then men's wage earning. Experience in Bangladesh has shown that women have an income; they invest their money towards the well being of their families, particularly their children's health and education. Children whose mother die or disable in child bearing have vastly diminished prospects of leading a productive life. Thus, poor maternal health exacts cost and incur losses not only at the house hold level, but at the community and the national level as well.
Poor maternal health and health care for example; lack of skilled care not only affects women's survival but has serious implications for the survival of their new born as well. Pregnant women poor nutrition contributes to lower birth weight in 20 million babies each year. The risk of death for children less than five years is doubled if their mother die in child birth, and at least 20 % of the burden of disease among children under the age of five is attributable to conditions directly associated with poor maternal and re-productive health, nutrition and the quality of the new born care. It is also recognized that mother less children, especially girls are less likely to have access to education and health care resources as they grow up.
Because of physiological and social factors, pregnant adolescent girls are vulnerable to life threatening complications. The complication from pregnancy and child birth are the leading cause of death and disability in young women aged 15-19 years in developing countries. It is estimated that 70 thousand young mother die annually because they have children before they are physically ready. "Save the children" estimates that one-tenth of all births, approximately 13 million births, are to women below the age of 20 yrs, more then 90 % of these births are in developing countries. Further, babies to adolescents are 50 % more likely to die then children born to women in their 20's, (Save the Children 2004) 25.
PAKISTAN
Pakistan has a population of approximately 150 million, 67% of whom live in rural areas; 43.4% are under age 15; 21.6% are women of reproductive age. The crude birth rate is 27.3 per 1000; and the annual population growth rate 2.4% . An estimated 400,000 infant and 16,500 maternal deaths occur annually in Pakistan . The maternal mortality ratio is estimated at 350-435 per 100,000 live births . WHO and UNICEF in 1996 estimated that one in every 38 women dies from pregnancy related causes, most preventable. During the period 1990 to 2002, three national health policies (1990, 1997 and 2001) were announced in Pakistan. Though all policies and programs emphasized maternal health, safe motherhood, and availability of female staff, ensuring the provision of obstetric care. One report stated that in Azad Jammu and Kashmir, many people prefer private sector health services as they consider government hospitals to provide low quality services and care. 26
According to UN minimum recommendations and based on the assumption that 15% of pregnant women in will develop complications and require access to EmOC, at least 15% of all births should occur in health facilities providing EmOC. Less than 15% means that women in need of services are not receiving them. Childbirth at home is common in Pakistan. Some women cannot or do not seek obstructed services or identify warning signs. Only 5.7% of births take place in government facilities. Many women who need treatment are not seeking care at government hospitals (where charges are comparatively much less) because of lack of number of reasons. 26
ECLAMPSIA
The association of convulsions and pregnancy has been realized even by early civilizations. The word "Eclampsia" is derived from the Greek word "lightning". The history of the disease dates back to many countries 7. It is a disease peculiar to humans8.
Eclampsia, is a dramatic and often unpredictable complication of pregnancy-induced hypertensive disorders, is characterized by sudden hypertension, proteinuria, edema, and seizures.
A relatively rare syndrome, eclampsia complicates approximately 3 in 1000 pregnancies, with higher incidence rates in preeclamptic or twin pregnancies, women of low socioeconomic status or in developing countries, and nulliparous patients younger than 20 years or multiparous patients older than 35 years of age.27
Eclampsia is a most severe degree of a disease which in its mild form is called pre-eclampsia, any woman who is suffering from pre-eclampsia runs a risk of developing eclampsia which is characterized by the occurrence of convulsions or fits. The fits last approximately 1 minute and are followed by a period of unconsciousness. Eclampsia occurs in late pregnancy or it may begin during labour or even after delivery. When a convulsion happens, usually all the signs and symptoms of pre-eclampsia are present:
Raised blood pressure.
Generalized swelling or oedema.
Protein in the urine.
Abnormally high weight gain.
Symptoms of Eclampsia
The woman also suffers one or more of the following symptoms:
Severe headache
severe headache occurring characteristically over the front part of the head above the eyes and associated with an abnormal rise in blood pressure. It is persistent and is not relieved by aspirin or other normal 'headache tablets'
Visual disturbances
these may be flashes of light before the eyes, coloured moving spots or blurring of vision and occasionally complete although temporary blindness.
Irritability
The woman is irritable, apprehensive and unable to tolerate noise or other mild disturbances.
Abdominal pain
Pain in the upper abdomen which may be mistaken for indigestion is usually severe, persistent and may be accompanied by actual vomiting which fails to relieve it.28
Other Common Symptoms of Eclampsia are:
vomiting, and
sudden swelling of feet, ankles, faces and hands and excessive weight gain because of fluid retention.
Causes of Eclampsia
first pregnancy,
family history of the condition, suggesting a genetic link,
pre-eclampsia in a previous pregnancy. Women who have had pre-eclampsia have a 1 in 10 chance of developing the condition again in later pregnancies,
teenagers and women over 40 years,
women with medical problems (e.g. diabetes, kidney disease, migraine or high blood pressure), and
multiple pregnancies (twins or triplets). 28
Eclampsia is a potentially fatal disorder of pregnant women that has been prevalent since the time of Hippocrates; it remains an important cause of maternal mortality throughout the world, accounting for about 50,000 deaths worldwide. In developed countries, eclampsia complicates about 1 in 2000 deliveries. In developing countries, the prevalence of eclampsia varies widely, from 1 in 100 to 1 in 1700. It is a common problem in developing countries because illiteracy, lack of health awareness and education, poverty, and superstitious beliefs prevent women from seeking medical advice during pregnancy.29
Eclampsia, is a serious obstetrical and medical emergency and carries a high risk of maternal and perinatal mortality and accounts for 5000 maternal deaths per year internationally. Today in the developing countries, already having a high maternal mortality there is a great need to take serious steps to decrease the incidence of eclampsia by good antenatal care, identification of high risk pregnancies, timely intervention and good control of the disease, thus decreasing the already existing high rates of maternal mortality.30
Eclampsia is a grave condition, maternal well-being should always receive priority. However, if convulsive fits can be controlled and the features promptly stabilized with treatment before fetal maturity has been attained , continuation of the pregnancy for a few weeks may be considered. Continuation of pregnancy for a few more weeks with the hope of delivering a more mature baby should be weighed against the potential risk conferred by such a procedure. Not only the underlying disease process flare up at any moment, but there is a considerable risk that the baby will die in utero or become undernourished and that spontaneous premature labor will occur. Thus, only in selected cases is one justified to continue the pregnancy; this requires keeping the patient in the hospital with close monitoring of maternal and fetal condition and strictly following the management protocol recommended for severe pre-eclampsia.31
The incidence of eclampsia is extraordinarily high in Bangladesh -- 7.9% (not including pre-eclampsia), according to the results of a house-to-house survey. Eclampsia is the third major cause of maternal death in Bangladesh (16%), preceded by hemorrhage and sepsis. In developed countries, deaths from hemorrhage and infection have almost disappeared and eclampsia has become the prime killer, indicating that death from eclampsia is particularly difficult to prevent. 29
According to a study of Lahore Hospital Pakistan the incidence of eclampsia was recorded as 0.75% of all deliveries. None of the patient had any antenatal checkup . Mean age of patients was 22.95 ± 4.12 years and mean parity 1.2 ± 1.08. The mean gestational age at the time of developing eclampsia was 33.8 ± 4.43 weeks. Maternal mortality was 5.26%. 73.68% came from urban areas and 26.31% from rural areas. 89.47% were uneducated.32
An other study of Lahore Pakistan from year January 2001 to December 2002 reveals incidence of eclampsia 2.2%, primigravida 59.6%, 85% of patents were uneducated, 90% belonged to lower socioeconomic class, 94% cases were un booked, 71.6% delivered by normal vaginal delivery and maternal mortality rate was 89.5 per 100000 live birth.11
OBSTRUCTED LABOUR
Perhaps one of the most famous accounts of obstructed labor is the case of Princess Charlotte of England. In 1817, Princess Charlotte, daughter of George IV, was the only eligible heir to the British throne in her generation. Her grandfather, George III, had 7 sons and 5 daughters, but Charlotte was the only legitimate grandchild. Thus, when the newspapers announced her pregnancy in early July 1817, the entire country was closely following this most important event in British history. On November 3, 1817, 42 weeks after her last menstrual period, Princess Charlotte went into labor. Fifty hours later -- after 24 hours of being in the second stage of labor and 6 hours of perineal pressure -- Charlotte delivered a 9-pound stillborn. Five and half hours after delivery, the Princess died, presumably from hypovolemic shock after a postpartum hemorrhage from uterine atony, likely a direct result of her obstructed labor. Three months later, Sir Richard Crofts, Princess Charlotte's obstetrician, committed suicide, unable to bear the burden of responsibility for the death of the heir. As this event resulted in the death of the infant, the patient, and the physician, it has historically been referred to as the "Triple Obstetric Tragedy." Nonetheless, some will question how tragic this truly was for the country, as after Charlotte's death, her uncle married Princess Mary Louisa Victoria, who went on to give birth to the famous heir, Queen Victoria.33
This story serves to illustrate the consequences of obstructed labor. Fortunately, advances in obstetric care have made the serious consequences of obstructed labor nearly obsolete in the developed world. However, in the developing world, obstructed labor continues to be a common, serious medical problem, with thousands of women suffering significant morbidity each year.
Obstructed labor has been a topic in the medical literature for hundreds of years. The oldest evidence of obstructed labor can be found in the remains of Queen Henhenit, the wife of Egypt's ruler around the time of 2050 BC. The Queen's mummy was originally sent to the Metropolitan Museum of Art in 1909. It was then returned to Cairo in 1923, where an extensive anatomical review found a defect in the bladder communicating directly with the vagina. It has been hypothesized that severe damage to Queen Henhenit's bladder and vagina occurred at the time of parturation, likely resulting in her death. As it has been noted, "to Queen Henhenit belongs the dubious honor of having suffered the most antique vesico-vaginal fistula documented.34
In the 11th century, the Persian physician Avicenna made the connection between obstructed labor and vesico-vaginal fistulas. He noted, "In cases which women are married too young, and in patients who have weak bladders, the physician should instruct the patient in ways of prevention of pregnancy. In these patients the fetus may cause a tear in the bladder those results in incontinence of urine. The condition is incurable and remains so until death.34
Obstructed labor occurs when the passage of the fetus through the pelvis is mechanically obstructed. When it is not diagnosed quickly, or when it is improperly managed, obstructed labor is associated with significant complications. It is a major cause of maternal mortality, accounting for 1-5 deaths/1000 live births.35
Obstructed labor is one of the most common preventable causes of maternal and perinatal morbidity and mortality in developing countries. Among the common causes are cephalopelvic disproportion, malpresentation, and malposition. Recognizing the causes of obstructed labor is important if the complications are to be prevented. Adequate prevention, however, can be achieved only through a multidisciplinary approach aimed in the short term at identifying high-risk cases and in the long term at improving nutrition. Early motherhood should be discouraged, and efforts are needed to improve nutrition during infancy, childhood, early adulthood, and pregnancy. Improving the access to and promoting the use of reproductive and contraceptive services will help reduce the prevalence of this complication.
Nutrition is important in reproduction, including the safe delivery of infants. the failure to achieve a normal delivery was directly related to the height of the mother, which is influenced by nutritional status in childhood and adolescence. Flattening of the pelvis is generally associated with a height <152 cm. Other factors that can cause poor or distorted pelvic growth are rickets in infancy and childhood and osteomalacia in adolescence and adulthood. Early studies of the African pelvis showed that although the brim of the pelvis has a normal female shape, it is markedly smaller in all its diameters, and the resulting disproportion between the fetal head and the maternal pelvis (cephalopelvic disproportion) is a major indication for cesarean delivery due to obstructed labor.35
The prevalence of obstructed labor varies from one country to another, but it is more common in developing countries17 because of the lack of adequate health care delivery facilities, poor nutrition, poverty36 , and socioeconomic and cultural factors that oppose orthodox antenatal care and delivery37. In developing countries, the incidence of obstructed labor is difficult to estimate, primarily because of poor data collection procedures and secondarily because most of the reported studies are based on data from large, tertiary hospitals. Nevertheless, reported incidences vary from 1-2/100 deliveries in Nigeria18 to 3/100 deliveries in India38.
Once obstructed labor has been diagnosed, the obstruction must be relieved. The method of relief will be determined by various factors, including the state of the mother, the state of the fetus, associated complications, and the environment. In developing countries, management should aim to reduce complications and simultaneously ensure that the woman and her family maintain some confidence in the health care facility. This is important because women with obstructed labor often avoid hospitals in the first instance because of fear of cesarean delivery. Moreover, performing a cesarean delivery that does not result in a live baby will further reinforce a woman's fears and result in her delivering at home in subsequent pregnancies, which increases the risk of uterine rupture and possibly maternal mortality.35
A clinical study of 204 cases of obstructed labour admitted over a period of 5 years between 1991-92 and 1996-97 in a rural institute in central India. They constituted 1.9% of births. Seventy-one per cent of the cases were from the rural area, 31.4% women were primigravida. Of the subjects, 64.7% were between 20 and 29 years. Of the women, 12.5% had intrapartum or postpartum sepsis.39
An other study carried out at Jamshoro Pakistan shows that the frequency of obstructed labour was 2.1%, only 29.5% cases had received antenatal care at some stage. About 72.2% patents belonged to rural areas. Caesarean section was the most common mode of delivery that is 84.1%.20
An other study carried out at Karachi Pakistan showed that total of 94 women with obstructed labour were included in the study. More than half of the study group were primigravida & aged below 25 years. A total of 61 (64.89%) were primigravida. Peak cases were between 20- 25 years of age that was 42 (44.7%). Mode of delivery was Caesarean section in 82 (87.23%) cases, Maternal morbidity with sepsis (34.04%), Maternal mortality was one (1.06%).40
ANTE PARTUM HAEMORRHAGE
Haemorrhage from the vagina after the 24th week of gestation is classified as antepartum haemorrhage. The factors that cause antepartum haemorrhage may be present before 24 weeks.
The major causes of uterine bleeding are:
• Placenta praevia
• Abruptio placentae or accidental haemorrhage
PLACENTA PRAEVIA
The placenta is said to be praevia when all or part of the placenta implants in the lower uterine segment and therefore lies in front of the presenting part.
Incidence
Approximately 1% of all pregnancies are complicated by clinical evidence of a placenta praevia. Unlike the incidence of placental abruption, which varies according to social and nutritional factors, the incidence of placenta praevia is remarkably constant. Placenta praevia occurs more commonly in multiparous women, in the presence of multiple pregnancy and where there has been a previous caesarean section.41
In the US: Placenta previa occurs in 0.3-0.5% of all pregnancies. The risks increase 1.5- to 5-fold with a history of cesarean delivery. With an increased number of cesarean deliveries, this risk can be as great as 10%. Recent studies show that a previous cesarean delivery did not increase the odds for detecting a placenta previa.
Of all placenta previas, the frequency of total placenta previa ranges from 20-45%, partial placenta previa accounts for approximately 30%, and marginal placenta previa accounts for the remaining 25-50%.
Mortality/Morbidity: The perinatal mortality rate associated with placenta previa ranges from 2-3%.
Race: Placenta previa has no predilection for any race.
Age: Age is associated with a varying prevalence of placenta previa. The risk of placenta previa in relation to age is as follows:
Aged 12-19 years - 1%
Aged 20-29 years - 0.33%
Aged 30-39 years - 1%
Older than 40 years - 2%
Causes:
Hemorrhage, if associated with labor, would be secondary to cervical dilatation and disruption of the placental implantation from the cervix and lower uterine segment. The lower uterine segment is inefficient in contracting and thus cannot constrict vessels as in the uterine corpus, resulting in continued bleeding.
Advancing age (>35)
Multiparity
Infertility treatment
Multiple gestation (larger surface area of the placenta)
Erythroblastosis
History of dilatation and curettage
Recurrent abortions
Nonwhite ethnicity
Low socioeconomic status
Smoking
Cocaine use
Other causes include digital exam, abruption (pre-eclampsia, chronic hypertension, cocaine use, etc) and other causes of trauma (eg, postcoital trauma).
Surgical Care: Cesarean delivery is the safest mode of delivery.
Fifty percent of women with placenta previa have preterm delivery.
Those cases complicated with vaginal bleeding and extreme prematurity are at an increased risk of perinatal death.
A greater incidence of fetal malformations and growth restriction is noted with placenta previa.42
Classification
From the point of view of management, there are three degrees of severity of placenta praevia.
• Lateral: The placenta encroaches on the lower uterine segment but does not reach the internal cervical os.
• Marginal: The placenta encroaches on or covers the internal cervical os before cervical dilatation occurs.
• Central: The placenta completely covers the os even with cervical dilatation.
Classification is important in relation to management because spontaneous delivery is extremely rare where there is central placenta praevia but normal labour and delivery may occur with lateral or marginal implantation.
Symptoms and signs
The main symptom of placenta praevia is painless vaginal bleeding. There may sometimes be lower abdominal discomfort where there are minor degrees of associated placental abruption.
The signs of placenta praevia are:
• Vaginal bleeding
• Malpresentation of the fetus
Ultrasound scanning: This is predominantly used to localize the placenta and has largely replaced other techniques. Errors in diagnosis are most likely to occur in posteriorly situated placentae because of difficulties in identifying the lower segment.41
ABRUPTIO PLACENTAE
Abruptio placentae or accidental haemorrhage is defined as haemorrhage resulting from premature separation of the placenta. The term 'accidental' implies separation as the result of trauma, but most cases do not involve trauma and occur spontaneously.41
Placental abruption (Also known as abruptio placenta) in biology, is the separation of the placental lining from the uterus of a female. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20-40% depending on the degree of separation. Abruption placenta is also a significant contributor to maternal mortality.43
Out of 7.5 million pregnancies in the USA, the incidence of placental abruption has been recorded as 6.5/1000 births with a perinatal mortality of 119/1000 births.
The incidence of placental abruption is increased in the presence of pre-eclampsia or essential hypertension. It must be remembered that hypertension and proteinuria may develop as a result of abruption. Whatever factors predispose to placental abruption, they are well-established before the abruption occurs. The fetus is more likely to be male and the birthweight is often low, indicating pre-existing growth retardation.
Three types of abruption have been described
• Revealed
• Concealed
• Mixed, or concealed and revealed.
Unlike placenta praevia, placental abruption presents with pain, vaginal bleeding and increased uterine activity.
• Revealed Haemorrhage
The major haemorrhage is apparent externally, as haemorrhage occurs from the lower part of the placenta and blood escapes through the cervical os. Under these circumstances the clinical features are less severe. Abruption tends to occur after 36 weeks gestation, with the fetal lie longitudinal.
• Concealed haemorrhage
In this case the haemorrhage occurs between the placenta and the uterine wall. The uterine content increases in volume and the fundal size appears larger. The patient will often be in labour and in approximately 30% of cases the fetal heart sounds will be absent and the fetus will be stillborn. The prognosis for the fetus is dependent on the extent of placental separation.
• Mixed, or concealed and revealed haemorrhage
In most cases the haemorrhage is both concealed and revealed. Haemorrhage occurs close to the placental edge and, after an interval when the haemorrhage is concealed, blood loss soon appears vaginally.
The diagnosis is made on the history of vaginal bleeding, abdominal pain, increased uterine tonus, proteinuria and the presence of a longitudinal lie. This must be distinguished from placenta praevia, where the haemorrhage is painless, the lie unstable and the uterus hypotonic.41
Effects
On the mother:
A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery.
The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract.
The mother may have problems with blood clotting for a few days.
A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland.
On the baby:
If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery.
The baby may be premature and need to be placed in the newborn intensive care unit. He or she might have problems with breathing and feeding.
If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth.
The newborn may have low blood pressure or a low blood count.
If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.43
Symptoms
contractions that don't stop
pain in the uterus
tenderness in the abdomen
vaginal bleeding (sometimes
Risk factors
Maternal hypertension is a factor in 44% of all abruptions.
Maternal trauma, such as motor vehicle accidents, assaults, falls, or nosocomial
Drug use is a factor, particularly tobacco, alcohol, and cocaine.
Short umbilical cord
Prolonged rupture of membranes (>24 hours)
Retroplacental fibromyoma
Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk.
Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk.
Multipara: Women who have given birth many times are at greater risk.
The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and not smoking or drinking alcohol.43
Vaginal bleeding after 24 weeks.
Placenta praevia
• Lower segment implantation
• Incidence 1%
• Classification - marginal, central and lateral.
• Diagnosis - painless loss, unstable lie, soft uterus.
• Diagnosis confirmed by ultrasound or MRI
• Management - conservative until 37 weeks
• Hospital admission for all major degrees
• Arrange blood - cross-matched
• Caesarean section unless marginal
• Prognosis for the fetus - good.
Placental abruption
• Incidence 0.5-1.0%
• Diagnosis - uterus hypertonic
• Normal fetal lie
• Commonly associated with maternal hypertension
• Management - replace blood loss
• Check for DIC
• Deliver the infant if abruption severe
• Prognosis for fetus poor
• Maternal complications
• Renal tubular necrosis
• Uterine rupture41
The delivery haemorrhage is actually a problem of public health. It is responsible of 31.5 % of the maternal death in Tunisia. The goal of this work was to study the frequency of this complication, its gravity, its risk factors and its etiology. It was a retrospective study. of 65 cases of delivery haemorrhage recorded to the obstetric gynaecology service of the centre of motherhood and neonatology of Tunis during 4 years. The frequency of the delivery haemorrhage in there study was 1.19%. The middle age of the patient is of 31 years. Their middle parity is 2.4. Primiparity (33.8%), advanced maternal age (30.7%), pre-existent anaemia (24.6%).44
Women with placenta previa, who delivered at Nizwa Hospital, of Oman between October 1998 and September 2002, were analyzed retrospectively utilizing a case control approach. An incidence of 0.6% for placenta previa was noted in study. Nearly two thirds (64.8%) of the pregnancies resulted in antepartum bleeding. Higher parity (>/=5), maternal age (>/=30) and history of previous abortion had high odds of association with major placenta previa of 2.1, 2.4 and 2.5. The proportion of preterm deliveries was 55.5% in the study. There was a significant association between preterm outcome and presence of antepartum hemorrhage (OR 10.8; p<0.001). Antepartum hemorrhage, irrespective of severity, was a strong predictor of preterm outcome.45
A study of Khyber Teaching Hospital, Peshawar Pakistan showed a prospective study, 100 cases of pregnancy beyond 28 weeks of gestation, complicated by Placenta Previa. The total number of deliveries were 2828, patients presented with Placenta Previa were 100. Patients with placenta previa were 100 giving and incidence of 3.5%. The maximum number of patients were 35 years and above.46
A retrospective study based on 177 cases of abruptio placentae, and describing the epidemiological aspects. in the department of gynecology and obstetrics of the CHNYO of Ouagadougou. Abruptio placentae occurrence rate was about 9.6 per 1000 deliveries. In their study, this type of accident was most frequent with 30 to 34-year-old women (31.1%), with multiparous ones (56.5%), and with those suffering from arterial hypertension linked to pregnancy (31.1%). Vaginal delivery was preferred to cesarean section in 64.4% of the cases. Maternal death rate was about 3.9% and mainly caused by severe anemia (61.6%) and puerperal infections (7.9%).47
Abruptio placentae remains a major cause of perinatal morbidity and mortality globally, though of most serious concern in the developing world. As most known causes of abruptio placentae are either preventable or treatable, an increased frequency of the condition remains a source of medical concern. This study was undertaken at the Department of Obstetrics and Gynecology, Unit B, of the Ayub Teaching Hospital, Abbottabad, Pakistan, from July 2003 to June 2004. Patients of abruptio placentae were selected from all cases of 28 weeks or greater gestation, presenting with ante partum hemorrhage during the study period. Patients underwent a complete obstetrical clinical workup including history, general physical examination, abdominal and pelvic examination. A total of 53 cases of abruptio placentae were recorded out of 1194 cases (4.4%) admitted for delivery during the study period, giving a rate of 44 cases of abruptio placentae per 1000 deliveries. Caesarean section was performed in 16 (30.2%) cases.16
To determine the frequency of abruptio placentae and associated risk factors a cross-sectional study at Department of Gynaecology & Obstetrics Unit II, Jinnah Postgraduate MedicalCentre (JPMC), Karachi was done. This study includes those patients who were brought to JPMC, Karachi with abruptio placentae after 28 weeks of pregnancy. Total number of deliveries during one year from July 2004 to June 2005 was 4497. Total number of patients with placental abruptio were 102, making an incidence of 1:44 deliveries (2.26%). Eight cases were booked while rest of the patients were nonbooked. anaemia 34.3% and grand multiparity were most common associated risk factors. Maternal age had no significant relation to occurrence of abruptio placentae. Maternal morbidity was high. Most common complication was anaemia 34.4% There was only one maternal death. Incidence of abruption placenta is high (2.26%).48
In West African countries direct obstetric causes of severe morbidity were studied The main direct causes of severe maternal morbidity were: haemorrhage (3.05 per 100 live births); obstructed labour (2.05 per 100), hypertensive disorders of pregnancy (0.64 per 100), 38 cases of which involved eclampsia (0.19 per 100); and sepsis (0.09 per 100). Other direct obstetric causes accounted for 12.2% of cases. Case fatality rates were very high for sepsis (33.3%), and eclampsia (18.4%); those for haemorrhage varied from 1.9% for antepartum or peripartum haemorrhage to 3.7% for abruptio placentae.49
PRE TERM LABOUR
Preterm labor is labor that occurs before 37th week of pregnancy. (Most pregnancies last 38-42 weeks; due date is 40 weeks after the first day of your last menstrual period.)
Preterm labor can happen to any woman: Only about half the women who have preterm labor fall into any known risk group. About 12 percent of births (1 in 8) in the United States are preterm. Babies who are born preterm are at higher risk of needing hospitalization, having long-term health problems and of dying than babies born at the right time.
Three groups of women are at greatest risk of preterm labor and birth:
• Women who have had a previous preterm birth
• Women who are pregnant with twins, triplets or more
• Women with certain uterine or cervical abnormalities
Preterm labor may sometimes be stopped with a combination of medication and rest. More often, birth can be delayed just long enough to transport the woman to a hospital with a neonatal intensive care unit (NICU) and to give her a drug to help speed up her baby's lung development.
Treatment with a form of the hormone progesterone may help prevent premature birth in some women who have already had a premature baby.50
About a quarter of all preterm births are intentional. For example, your medical team might decide to induce labor early or perform a cesarean section because you have a serious medical condition such as severe or worsening preeclampsia, or because your baby has stopped growing.
The rest are known as spontaneous preterm births. You may end up having a spontaneous preterm birth if you go into labor prematurely, if your water breaks early (called preterm premature rupture of the membranes or PPROM), or if your cervix dilates prematurely with no contractions (called cervical insufficiency).
About 12 percent of babies in the United States are born prematurely. This number has gone up over the years, partly because more women are pregnant with twins or higher multiples, which tend to arrive early. Preterm birth can cause health problems or can even be fatal for the baby if it happens too early. The more mature a child is at birth, the more likely he is to survive and the less likely he is to have health problems.
Premature babies born between 34 and 37 weeks generally do very well. If you go into labor before 34 weeks, your medical team may be able to delay your labor for a few days so your baby can be given corticosteroids to help his lungs and other organs develop faster, which greatly increases his chances of survival.51
Some studies have found that certain lifestyle and environmental factors may put a woman at greater risk of preterm labor. These factors include:
Late or no prenatal care
Smoking
Drinking alcohol
Using illegal drugs
Exposure to the medication DES
Domestic violence, including physical, sexual or emotional abuse
Lack of social support
Stress
Long working hours with long periods of standing
Medical Risks.
Certain medical conditions during pregnancy may increase the likelihood that a woman will have preterm labor. These conditions include:
Urinary tract infections, vaginal infections, sexually transmitted infections and possibly other infections
Diabetes
High blood pressure
Clotting disorders (thrombophilia)
Bleeding from the vagina
Certain birth defects in the baby
Being pregnant with a single fetus after in vitro fertilization (IVF)
Being underweight before pregnancy
Obesity
Short time period between pregnancies (less than 6-9 months between birth and the beginning of the next pregnancy)
Researchers also have identified other risk factors. For instance, African-American women, women younger than 17 or older than 35, and poor women are at greater risk than other women. Experts do not fully understand why and how these factors increase the risk that a woman will have preterm labor or birth.50
What causes spontaneous preterm birth?
Although the cause is often unknown, a variety of things can play a role in preterm birth:
• Certain genital tract infections,
• Having a problem with the placenta, such as placenta previa or placental abruption.
• Having structural abnormalities of the uterus or cervix, such as a cervix that's shorter than 25 millimeters and that effaces or dilates without contractions (called cervical insufficiency).
• Having an excessively large uterus, which is often the case when female is pregnant with multiples or have too much amniotic fluid.
• Other conditions that may be related to preterm labor include certain chronic maternal illnesses, such as diabetes, sickle cell anemia, severe asthma, lupus, inflammatory bowel disease, and chronic active hepatitis; non-uterine infections, such as a kidney infection or pneumonia; abdominal surgery, such as having your appendix taken out; trauma to the abdomen; severe gingivitis (gum disease) and periodontitis (a gum infection that goes into the bone and other tissue that supports your teeth).51
What are the risk factors for spontaneous preterm birth?
Although it's impossible to predict your chances of giving birth prematurely, you may be at an increased risk if you:
• Previously had a preterm delivery (The earlier in gestation your baby was born and the more spontaneous preterm births you've had, the higher the risk.)
• Are pregnant with twins or higher number multiples
• Are younger than 17 or older than 35
• Are African American (17.4 percent of African American babies are born prematurely)
• Don't gain enough weight during your pregnancy
• Were underweight before you got pregnant
• Are short
• Have had vaginal bleeding in more than one trimester
• Smoke, abuse alcohol, or use drugs (especially cocaine) during pregnancy
• Gave birth in the last 18 months (particularly if you gave birth within the last six months)
A few studies have found an association between high levels of stress and preterm birth. The theory is that severe stress can lead to the release of hormones that can trigger uterine contractions and preterm labor. Experts have also been studying occupational factors to see whether extremely physically demanding jobs or long working hours play a role. 52
Preventing Preterm Labor and Birth
You can help prevent preterm birth by learning the symptoms of preterm labor and following some simple instructions. The first thing to do is to get medical care both before and during pregnancy. If you do have preterm labor, get medical help quickly. This will improve the chances that you and your baby will do well.
Medications sometimes slow or stop labor if they are given early enough. Drugs called corticosteroids, if given 24 hours before birth, can help the baby's lungs and brain mature. This can prevent some of the worst health problems a preterm baby has. Only if a woman receives medical care quickly can drugs be helpful. Knowing what to look for is essential.
Treatment with a form of the hormone progesterone may help prevent premature birth in some women who have already had a premature baby.50
Advances in perinatal health care have reduced the incidence of perinatal mortality of babies but still having problems like maternal anxiety, cost of nursery, late health consequences of newborn.
Despite scientific advances, efforts to prevent preterm birth can be disappointing. Obstetric care must focus on strategies to improve the outcome of preterm infants . The major goal is to delay Preterm birth long enough to allow the transfer of women, about to deliver preterm to a facility with a neonatal intensive care unit and to administer corticosteroids to enhance fetal lung maturity.24
A study was conducted in a tertiary hospital in Northern India to determine the risk factors associated with preterm labour. The incidence of preterm labour was found to be 23.3%. The cases were older, shorter and lighter. They belonged to significantly lower income group and their educational status was lower. Mean pregnancy order was higher and mean parity was lower . 52
A Study of Punjab Medical College, Divisional Head Quarter Hospital, Faisalabad. Showed the Incidence of pre term births during the study period of one year among 2520 pregnant women who were delivered. Of these 136 were complicated by PPROM giving an incidence of about 5.4%.
There were two peaks in the incidence of pre term birth one between ages of 21-25 (44.1%) and another after 30 years (32.3%) The risk of PPROM was highest in women giving birth to their first child (35.3%) and in grand multi gravida (26.5%).
Most women were uneducated 48.5% and belonged to lower (66.2% cases) or middle class (28% cases) .
One hundred and seventy cases (86%) had vaginal delivery, whereas 19 (14%) were delivered by caesarean section.53
Variable
Number of women
with pre-Term
Percentage
Education
No education
66
48.5%
Primary
35
25.7%
Matric
29
21.3%
Above
06
4.4%
Social Class
Lower
90
66.2%
Middle
38
28%
High
08
5.8%
53
Dow University of Health Sciences & Civil Hospital, Karachi Pakistan conducted a study on pre term births in their hospital to estimate frequency and risk factors amongst the 100 women with preterm labour that were enrolled in this study, 50% were less than 25 years of age (p<0.05). Eighty cases belonged to the low socioeconomic group (p<0. 01). The antenatal booking status showed that only 30% were booked, reflecting on the lack of antenatal care as a key factor of poor obstetric outcome (p<0.01). The 40% cases being primigravidae, which shows that primiparity is associated with a higher rate of preterm labour (p<0.05).
Twenty five percent cases of preterm labour came with ruptured membranes, Relationship to mode of delivery showed that out of 85 delivered cases, 73% cases had spontaneous vaginal delivery, and 11% Caesarean delivery. 21
Gynaecology Unit-IV, Liaquat University Hospital Jamshoro Pakistan conducted study from January 2005 to December 2005. During this period 131 women (13.36%) were delivered at Preterm and in 39 cases (29.77%) gestational period was 24-29 weeks and in 92 (70.22%)cases gestational period was 30-36. Most of the cases were non-booked, i.e. 98 (74.80%). Most of the women were multiparous 71 (54.19%) and 20 (15.26%) were primigravida. Mode of delivery was vaginal in 91 (69.46%) and in 40 (30.53%) cases caesarean section was done.24
The preterm delivery rate has been relatively stable at 5-10% in developed countries for many years. The rate of preterm labor is high in our setup and its major effects are on fetal outcome like still birth and early neonatal death, prolonged stay at nursery.24
RSEARCH METHODOLOGY
1. STUDY SETTING:
The study was conducted at Department of Gynaecology and Obstetrics units I,II and III of L.U.H Hyderabad, a tertiary care institution which serves as the major referral center for other public, private hospitals and populations located within city and neighboring towns. Liaquat University of Medical Health Sciences is a degree awarding institution in Jamshoro, Sindh, Pakistan. Liaquat University of Medical & Health Sciences, the first public sector medical university in Sindh, has a long history of imparting medical education in the province. It started as a medical school in the present Civil Hospital, Hyderabad in 1881, the first seat of Medical learning in the province of Sindh. The school was upgraded to the status of Medical College, the Sindh Medical College, which was formally inaugurated by the then Governor of Sindh in 1945. The College was shifted to Karachi at the end of same year and was renamed as Dow Medical College. The Sindh Government subsequently started another College in the premises of same Civil Hospital and Hyderabad in 1951, which acquired its name, Liaquat Medical College after the first Prime Minister of Pakistan Quaid-e-Millat Liaquat Ali Khan. The Gynaecology and Obstetrics wards provide emergency care 24 hours a day although women are expected to pay for their services in emergency situations. Three consultant Professors, One Associate Professor, Six Assistant Professors, Approximately 20 Registrars and more then100 Resident Doctors run the Gynaecology and Obstetrics units I,II and III. Providing about 140 beds to the patients.
2. STUDY DESIGN:
This is descriptive study (Cross sectional Type).
3. STUDY DURATION:
Data is collected form 20th January 2007 to 20th February 2007.
4. SAMPLE SIZE:
All women with inclusive criteria from the total numbers of 609 obstetric admissions at Department of Gynaecology and Obstetrics Wards, Liaquat University Hospital Hyderabad, are studied.
5. SAMPLING TECHNIQUE :
Convenient strategy. (Non Probability Type)
6. INCLUSIVE CRITERIA:
All pregnant women delivered after 28 weeks of gestation with with anti partum hemorrhage (Placenta Previa & Abruptio Placentae), eclampsia, obstructed labor and pre-term labor admitted at Department of Gynaecology and Obstetrics Wards, Liaquat University Hospital Hyderabad
7. EXCLUSIVE CRITERIA:
All the remaining cases admitted in Obstetrics wards or with gynaecological problems or unwilling women.
OPERATIONAL DEFINATIONS
ECLAMPSIA
The word "Eclampsia" is derived from the Greek word "lightning".7. It is a disease peculiar to humans8. Eclampsia is unpredictable complication of pregnancy-induced hypertensive disorders, is characterized by sudden hypertension, proteinuria, edema, and seizures.
OBSTRUCTED LABOR:
Labor is said to be obstructed when there is no progress inspite of strong uterine contractions. This may be shown by failure of the cervix to dilate or failure of the presenting part to descend through birth canal.(Obstetrics by Ten Teachers 16th Edition)
ANTE PARTUM HAEMORRHAGE
Haemorrhage from the vagina after the 24th week of gestation is classified as antepartum haemorrhage. 41
Placenta praevia
The placenta is said to be praevia when all or part of the placenta implants in the lower uterine segment and therefore lies in front of the presenting part or in close proximity to the internal cervical os. 41
Abruptio placentae
Abruptio placentae or accidental haemorrhage is defined as haemorrhage resulting from premature separation of the normally situated placenta. 41
PRE TERM LABOUR
Preterm labor is labor that occurs after 24 weeks and before 37th week of pregnancy.50
PARITY
All births after 24 weeks with what ever result alive or dead.
REFERRED
Means the cases that are referred from other hospitals or clinics to L.U.H.
BOOKING STATUS
Means the women had antenatal checkups for three times at any time during pregnancy.
DATA COLLECTION AND ANALYSIS
Data will be collected through a pre-designed proforma (see annexure-1 attached). Inform consent will be taken from every woman before participating in the study. Their provided information will not be shared with any one except for the use of study objectives.
Data will be analyzed through SPSS version 10.0. Results will be presented as frequencies, percentages and descriptive statistics for each variable separately.
VARIABLES
Age
Address
Education
Socio Economic Class
Booking Status
Gestational Age
Mode of Delivery
Maternal Mortality (Deaths)
RESULTS
During the study period of one month at Gynaecology and obstetric ward I, II and III of Liaquat University Hospital Hyderabad, The total number of patients admitted through labour room in obstetric ward were 609.
Table -1 shows the frequency and percentage distribution of the patients in relation to the total number of obstetric admissions. In this table out of 609 cases , 28 cases were Eclampsia with 4.60% , 22 (3.61%)cases of Obstructed labour. Placenta previa admissions were 21 that account for 3.45%, Abruptio palcentae accounted for 13 cases giving 2.13% and Pre Term labour accounted for 10 admissions making 1.64%. From the total 609 admissions complicated pregnancies accounts are 94 (15.44% ).
Table-2 indicates that total number of complications of pregnancy outcomes are 94 cases out of these cases Eclampsia is at highest scale showing 28 cases with 29.79% next comes Obstructed labour with 22 (23.40%), according to ranking Placenta previa is three giving 21 (22.34%), Abruptio placentae are 13 cases with 13.83% and in the last pre-term labour showing 1 cases with 10.64%.
Table-3 gives a detail information about the variables with total 96 cases. The age variable is divided in two groups, less than 30 and grater than 30 years, 45 women were in less than and reaming 49 were in more than 30 years.
Regarding the Race the ratio of Sindhi women were high that is 60 Urdu were 18 and Panjabi were 16.
Profession wise distribution was as mostly were house wives those are 76 and other 18 were attached with agriculture work.
The proportion of patients come from rural areas were 67 as compared to urban 27 cases.
The education status showed that 77 women were illiterate and only 17 women having primary education where as no any woman was having secondary or higher education.
Regarding socio economic class 78 cases belong to lower income group and other 16 cases were from middle class.
In table-4 the relation between booked and non- booked cases shows 7 and 87 respectively.
Cases those are referred from out side to the hospital shows the frequency that 33 cases were referred on the other hand 61 cases reached directly.
About gestational age of pregnancy 56 patients delivered with full term and 38 were pre-term.
Normal vaginal delivery occurred in 42 cases as compared to 52 cases delivered by caesarean section.
Blood transfusion was given to 58 patients and 36 didn't have any such treatment.
Fever occurred in seven patients and one patient expired.
Table-5 shows the frequency and percentage of individual pregnancy outcome i-e placenta previa, abruptio placentae, eclampsia, obstructed labour and pre term labour in association with individual variable. Relating to frequency of patients with age less than 30 years in above outcomes are 8, 3, 17, 12 and 5 where as the frequency of patients with age above 30 years are 13, 10, 11, 10 and 5 respectively.
Pertaining to residential area that is divided in to rural and urban categories are associated with pregnancy outcomes. From rural areas for placenta previa were 13 patients , abruptio placentae 9 patients, eclampsia 22 patients,
