Journal of the Society of Obstetrics and Gynaecologists of Pakistan <p>The&nbsp;<strong>Journal of&nbsp;the&nbsp;Society of Obstetrics and Gynaecologists of Pakistan (JSOGP). <span lang="EN-GB">ISSN 2307-7115(Online Version)&nbsp;</span>&nbsp;</strong>It is&nbsp;the&nbsp;journal of&nbsp;the&nbsp;Society of Obstetrics and Gynaecologists of Pakistan (SOGP). It is published on quarterly basis, multi-reviewed (internal external and statistics) reviewed journal.&nbsp;The&nbsp;journal is recognized from Pakistan Medical and Dental Council (PMDC), and Higher Education Commission of Pakistan (HEC&nbsp;Z category). The&nbsp;Journal is internationally indexed in Index Copernicus Poland , Directory of Research journal indexing DRJI. Enlisted&nbsp;in International Committee of Medical Journal Editors(ICMJE),&nbsp;</p> en-US (Editor Name) (Journal Coordinator) Tue, 01 Jan 2019 00:00:00 -0500 OJS 60 Investing in Family Planning in Pakistan – Road to Redemption <p>Pakistan has witnessed a rapid increase in population since independence in 1947. A country with a population of 33 million in 1947 has reached 207 million in 2017 – a massive population explosion.1 Besides this, Pakistan, with the exception of Afghanistan has one of the highest fertility rates in the region with the growth rate of 1.89% and the lowest rate of contraceptive use. The high fertility rate and the rapidly increasing population has contributed in making Pakistan the sixth most populous country in the world after China, India, USA, Indonesia and Brazil - all of which are countries with a vast area. Comparing Pakistan’s 310,401 square miles to 741,096 square miles of India and 3,286,470 of Brazil demonstrates the scarcity of land in Pakistan and its huge population density. The subject of family planning and contraception is unwelcome and less discussed even among healthcare professionals in Pakistan. Society, at large, has different approaches and misconceptions about contraceptive methods or use of methods to limit the family size.2</p> Rubina Sohail Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Tue, 01 Jan 2019 10:19:37 -0500 Exploring The Powers of Observation Pertaining to Post Partum Haemorrhage Conservative Management Using Compression Sutrures – Worldwide Benefits on Maternal Mortality (1997 – 2017) <p>Postpartum haemorrhage (PPH) is a serious medical problem. Around 14,000,000 million cases occur annually worldwide. The reported case-fatality rate is 1% with an estimated number of 140,000 deaths happening each year, making postpartum haemorrhage the third highest direct cause of maternal deaths.1<br>The appliance of the science of observation has created innovation in lifestyle activities and medical development for many years. Sir Isaac Newton, Friedrich von Stradonitz, Alexandra Fleming and Edwin Hubble are some of the most notable examples of scientists that made major breakthroughs in science using the powers of observation.</p> <p>&nbsp;</p> <p><a href="#_ftnref1" name="_ftn1"></a>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> Christopher B-Lynch Copyright (c) Tue, 01 Jan 2019 00:00:00 -0500 Short Term Outcome Measures of Chromic Catgut Versus Vicryl Rapide for Episiotomy Repair <p>Objective: To compare the short term outcome measures of chromic catgut versus vicryl rapide for episiotomy repair, in terms of frequency of perineal pain and wound dehiscence.<br>Place And Duration: This study was conducted in the Department of Obstetrics and Gynaecology Benazir Bhutto Hospital, Rawalpindi, during a period of six months from December 2014 to May 2015.<br>Methodology: Total 220 patients who fulfilled the inclusion criteria of study were included in the study. Patients were divided into two groups by lottery method. In Group A episiotomies were sutured with chromic catgut 1-0 (30mm, ½ circle round bodied needle) and Group B with for vicryl rapide 1-0 (36mm, ½ circle round bodied needle). All the episiotomies were right mediolateral and sutured by residents on call. The repair was done according to departmental protocols and suture material used according to randomization.<br>The main outcome measures were perineal pain and wound dehiscence. Perineal pain within 48 hours assessed by visual analogue scale (VAS) and wound dehiscence was recorded within 3 weeks postpartum. Chi-square test was applied and results tabulated. P- Value &lt;0.05 was taken as significant.<br>Results: Among 220 total patients, majority of the patients between 21-30 years, seventy four percent (n=163) of patients were at gestational age of 31-40 weeks. Mostly patients were primigravidas 67.3% (n=148).<br>Perineal pain was recorded in 68.6% (n=151), the pain was mild in 45% (n=68), moderate in 36.4 %( n=55) and severe in 18.5% (n=28). (P-value=0.000) Wound dehiscence was found in 20% and 9.1% of Group A and B respectively. (P-value=0.034)<br>Conclusion: Vicryl rapide was the better suture material for episiotomy repair, which resulted in less perineal pain and better wound healing as compared to chromic catgut.</p> Misbah Naseer, Humera Noreen Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Tue, 01 Jan 2019 00:00:00 -0500 Incidence of Placenta Accreta and Association of Booking Status with Maternal Outcomes based on a study in a Tertiary Care Hospital of Rawalpindi <p><strong>Abstract</strong></p> <ol> <li>Umairah yaqub (Assistant professor, Army Medical College Rawalpindi)</li> <li>Maria Habib (Postgraduate trainee at KRL hospital, Islamabad)</li> </ol> <p><strong>Objective: </strong></p> <p>To determine the incidence of placenta accreta in our institution and to examine the effects of booking status and management of the placenta during the third stage on maternal outcomes.</p> <p>&nbsp;</p> <p><strong>Methodology:</strong></p> <p>This descriptive cross sectional study was conducted in a Military hospital, Rawalpindi from March 2016 to Feb 2018. Women having placenta accreta/increta/percreta diagnosed intraoperatively or during histopathological examination of placenta after hysterectomy were served as cases. Once the diagnosis of placenta accreta was made, then further information was recorded in the questionnaire by following that patient till recovery/death.</p> <p>Descriptive statistics and independent samples t-test were used for analysis.</p> <p>&nbsp;</p> <p><strong>Results:</strong></p> <p>Out of 11430 deliveries during the study period, 48 women were enrolled with diagnosis of placenta accreta thus making its incidence 41.4/10,000. 14.6% were booked and 85.4% were un-booked. Majority belonged to 35-37 weeks at delivery (68.8%). Increasing number of cesareans sections increased the risk of placenta accreta. Antenatal complications included antepartum hemorrhage (60.4%) and postpartum hemorrhage (22.9%). Majority were transfused with &lt;5 RCC transfusions (60.4%). 95.8% had undergone hysterectomy and in 4.2% uterus were conserved successfully. Injuries to the viscera were found in 66.7% patients and all of them were bladder injuries. Mortality rate was 8.3%. Internal Iliac artery ligation was done in 22.9% and second look laparotomy in 8.3% patients. Sepsis was found in 10.4 % and disseminated intravascular coagulation in 12.5% women. Most of the women had stay of intensive care unit for &lt;3 days. The correlation between visiting history and complications is highly significant i-e correlation value is 0.379 with the significance value of 0.08. It means that as visiting status improved, complication rates also improved.</p> <p><strong>Conclusion:</strong></p> <p>Our study has highlighted a sharp rise in the incidence of placenta accreta in the recent years because of increasing cesarean section rates. Booking status has significant correlation with the complications encountered by these women.</p> Umairah Yaqub, Maria Habib Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Tue, 01 Jan 2019 00:00:00 -0500 Frequency of Low Placental Weight in Preeclampsia <p><strong>Objective: </strong>To determine the frequency of low placental weight in women with preeclampsia visiting to tertiary care hospital.<br><strong>Methods: </strong>This descriptive prospective cross-sectional study was conducted in Department of Obstetrics and Gynecology, Unit I, Civil Hospital Karachi, DUHS from Jan 2015 to December 2015. A total of 187 women with preeclampsia were included in this study. All the young women of age (18-30), history of raised blood pressure after 20 weeks of pregnancy was&nbsp; taken and blood pressure was&nbsp; noted on two occasions 4 hours apart and urine was&nbsp; checked for proteinuria. After the delivery of baby and placenta, outcome variable for low placental weight was measured. After that relevant data was recorded on predesigned proformas.<br><strong>Results:-</strong>The mean age of the patients was 23.54±3.64 years. Frequency of low placental weight in women with preeclampsia was observed in 9.09% (17/187). <br><strong>Conclusion: </strong>Pre-eclampsia is assumed to be caused by placental dysfunction; however, our results suggest that placental weight is not a useful indicator for the placental dysfunction that may be involved in pre-eclampsia.</p> Duriya Rehmani, Maria Jabeen, Samar Abbas Jaffri, Sadia Sultan Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Tue, 01 Jan 2019 00:00:00 -0500 Maternal and Fetal Outcome in Patients with Obstetric Cholestasis <p>Objective: To determine maternal and fetal outcome in patients with obstetric cholestasis<br>Methdology: The descriptive case series study was conducted in obstetrics and gynaecology department of federal govt polyclinic hospital after approval from the ethical committee. The duration of study was from 1 may 2016 to 30 April 2017. In this study, total 100 patients were included. During study period,al patients presenting with pruritis and or deranged liver function tests were included.Patients with gestational amenorrhea more than 20 weeks with raised ALT and AST along with normal ultrasound abdomen and no preexisting liver disease were said to have obstetric cholestasis. Maternal and fetal outcome was observed. Maternal outcome include mode of delivery. Fetal outcome include prematurity,meconium staining of liquor and fetal distress.<br>Results: Out of 100 patients,38 had spontaneous vaginal deliveries with percentage of 38%.Lower segment caesarean section rate was 62%. 7% of patients had premature delivery.There were 2 intrauterine deaths and Neonatal Intensive Care Unit admission rate was 49%. 45% of patients had meconium staining of liquor.11% of patients went in to postpartum haemorrhage.There were 45 primigravidas and 55 multigravidas.<br>Conclusion: Caesarean section rate was high in this study.Some caesarean sections were due to failed induction of labor but majority were due to fetal distress.Whether this high rate was due to active management of obstetric cholestasis or due to disease process remains to be ascertained.Premature delivery rate was lower in this study and fetal outcome was also good on overall basis despite 49% NICU admission rate.Take home baby rate was high.All babies were well at one month follow up visit.</p> Asma Ehsan, Muhammad Ehsan-UL-Haq Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Tue, 01 Jan 2019 00:00:00 -0500 Role of Enoxaparin to Improve Obstetrical Outcome in Patients with IUGR and Oligohydramnios <p>Objective: To assess the role of enoxaparin to improve obstetrical outcome in patients with IUGR and oligohydramnios.<br>Study design: Randomized Controlled Trial study.<br>Setting and duration: Study was conducted at Department of obstetrics and gynecology, Aziz Fatimah Hospital, Faisalabad, from April 2017 to September 2018.<br>Methods: After taking approval from hospital ethical committee, a total of 104 pregnant women, 52 in each group were enrolled. Group A received Enoxaparin along with standard treatment and group B only standard treatment. All the patients were followed up two weekly till 28 weeks of gestation, on every visit all the patients had ultrasonographic measurement of amount of liquor, growth scans along with prothrombin time and platelet counts. After 28 weeks of gestation every patient was followed up every week.<br>Results: The mean maternal age in Enoxaparin group was 27.54 ± 3.74 years and 28.46 ± 3.49 years in Standard treatment group. The mean gestational age (37.65 ± 0.76 vs. 36.95 ± 0.84 weeks) in Enoxaparin group was significantly (p-value &lt; 0.05) higher as compared to Standard treatment group. The rate of miscarriages significantly (p-value &lt; 0.05) lesser in Enoxaparin group (11.54% vs. 38.46%) as compared to Standard treatment group. In Enoxaparin group the incidence of preeclampsia was (8.69% vs. 43.75%, p-value &lt; 0.05) lesser as compared to Standard treatment group. Preterm deliveries (15.22% vs. 25%) and preeclampsia rate (8.69 vs. 43.75%, P &lt; 0.05) was significantly lower in Enoxaparin group.<br>Conclusion: Low molecular weight heparin along with aspirin have shown high live birth rate, less chances of miscarriage, preeclampsia, preterm delivery and prematurity as compared to aspirin group only, in patients with IUGR and oligohydramnios.</p> Zonia Zaman, Fatima Imran, Muhammad Javaid Iqbal Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Thu, 14 Mar 2019 02:43:17 -0400 Ectopic Pregnancy: An Analysis of 54 Cases in A Tertiary Care Hospital of Mardan <p>Objective: The present study aims at determining the incidence, demographic profile, risk factors, clinical features and treatment modalities of ectopic pregnancy.<br>Study Design: Prospective Descriptive Study<br>Place and Duration of Study: Obstetrics and Gynaecology Department, MTI/Mardan Medical Complex, Mardan Pakistan, From 01st February 2016 to 31st January 2017<br>Methodology: This was a prospective descriptive study comprising 54 cases admitted to Obstetrics and Gynaecology department of Mardan Medical complex, Mardan from 1st February 2016 to 31st January 2017. All women of any age or parity with diagnosis of ectopic pregnancy were included and treated surgically, medically or expectantly.<br>Results: The incidence of ectopic pregnancy was 0.74% or 1:134 deliveries. Majority of patients (57.4%) were young and were between 26 to 35 years of age. It was most common in multi parous women (57.4%). Pelvic inflammatory disease was seen in 40% followed by history of tubal ligation (14%) and history of infertility (12%) while no identifiable risk factors were observed in 18% of ectopic pregnancies. Most common presenting symptoms were lower abdominal pain (92.6%), amenorrhea (76%), cervical excitation (72%), adnexal fullness (55.5%), p/v bleeding (48%) and shock (40.7%). Majority of patients (72%) underwent surgical treatment.<br>Conclusion: Timely diagnosis and referral to health care facility, equipped with blood bank services and aggressive management can reduce the ectopic pregnancy associated maternal morbidity and mortality.</p> Samina Jadoon, Maimoona Qadir, Shah Muhammad Khan Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Thu, 14 Mar 2019 04:51:16 -0400 Awareness of Reproductive Health Among Adolescent and Young Adult Females; A Comparative Study in Urban and Rural Areas <p>Objective: To compare the knowledge of adolescent and young adult females of rural and urban areas regarding reproductive health.</p> <p>Study Design: &nbsp;Descriptive Cross-Sectional study.</p> <p>Place And Duration Of Study: Rural and urban areas of District Rawalpindi, from 30th April 2018 to 20th May 2018.</p> <p>Methodology: A population-based survey was carried out using a self-administered structured questionnaire among 120 girls, 60 each from rural and urban area by systematic random sampling.</p> <p>Results: Adolescents and young adults do have some knowledge about sexual and reproductive health and issues pertaining to them. Surprisingly, rural respondents are more knowledgeable about reproductive physiology (R= 51%; U= 31%), sexually transmitted infections (R=41%; U=30%), the utilization of health services (R=50%; U=20%) and also for the doctors and health staff workers are the main source of information about sexual and reproductive health (R= 41%; U=3% statistically significant), rural prefer government setup, while urban prefer private hospital/clinics. (R=54%; U=17% statistically significant)&nbsp; Both urban and rural groups had some good awareness about menstruation and its hygiene. Yet, a large majority needs clarification on their concepts and perceptions regarding reproductive health overall.</p> <p>Conclusion: Healthy adolescence, the need of the hour. In the present study, poor knowledge about reproductive health in both groups is the main concern right now. Although, they believe that having sound knowledge about this matter will promote mother and child health and eventually family health. Involving families and communities will enhance the effectiveness</p> Sana Latif, Syeda Mayedah, Naheed Bano Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Tue, 01 Jan 2019 00:00:00 -0500 Biochemical Analysis and Frequency of Vitamin D Deficient People in Different Age and Gender <p>Biochemical Analysis and Frequency of Vitamin D Deficient People in&nbsp; Different Age and Gender</p> <p>Objective: To analyze different biochemical Parameters in Vitamin D deficient population and to estimate prevalence of vitamin D deficiency in different age and gender.</p> <p>Methodology: This cross sectional study was conducted at Islamabad Diagnostic Centre (IDC), Islamabad from January 2017 to March 2018. In this study a total of 721 participants were recruited. Vitamin D3, total calcium, phosphorus, urea, creatinine and uric acid were analyzed on Architect 1000. Statistical analysis was analyzed by SPSS version 19.0.</p> <p>Results: Out of 721 recruited patients, there were 374 (51.8%) male and 347 (48%) were female. The mean values of vitamin D, total calcium, phosphorus, urea, creatinine and uric acid were 23.4 ng/ml (± 18.40 SD), 9.1 mg/dl (± 0.66 SD), 3.4 mg/dl (± 0.60 SD), 30.2 mg/dl (± 1.4 SD), 0.94 mg/dl (± 0.68 SD) and 5.6 mg/dl (± 1.5 SD) respectively. The overall vitamin D deficiency (Deficient + Insufficient) was seen in 558 (77.4%) study participants while 160 (22.1%) participants having sufficient level. Vitamin D toxicity was seen in only 03 (0.41) patients. It was observed that there is statistical significant difference (p&lt;0.05) in the mean value of all parameters.</p> <p>Conclusion: Vitamin D deficiency in Pakistan is becoming endemic and it is much predominant in elder and female population. Female are more deficient due to social and religious limitations. They need more care of vitamin D blood levels due to less exposure to sun light in cities. Based on our finding renal function tests, serum calcium and phosphorus levels are not the conjecturer of vitamin D deficiency.</p> Dr Jamila, Rizwan Ahmed Kiani Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Fri, 08 Feb 2019 00:00:00 -0500 The Effect of Chewing Gum on Return of Bowel Activity after Caesarean Section: A Randomized Controlled Study <p>Objective: To compare mean time to return of bowel motility and passage of first flatus after elective caesarean section between gum chewing and control group.</p> <p>Study Design: Randomized controlled study</p> <p>Place and Duration: Department of Obstetrics and Gynecology, DHQ Teaching Hospital, Rawalpindi, &nbsp;from 30th Dec, 2016 to 30th Jun, 2017.</p> <p>Methodology: After taking approval from the Ethical Review Committee of DHQ hospital and permission from all concerned authorities, study was initiated. All patients fulfilling the above mentioned inclusion criteria were explained the purpose and procedure of the study. Written informed consent was taken from the patient. A detailed history was taken and thorough physical examination was performed. Women were randomized by lottery method into two groups; group A (gum-chewing group) who had received one stick of sugar free gum for 15 minutes every 2 hours after surgery, and group B had a control group (non gum-chewing group). The two groups were followed up postoperatively and were monitored and compared for return of bowel activity by auscultation of bowel sounds every 2 hours and recording time to first pass of flatus.</p> <p>Results: Total 160 patients were included in the study according to the inclusion criteria of the study. Mean age (year) was 25.39+3.60. Mean time to return of bowel motility after elective caesarean section in both the group was 7.23+1.06 and 27.00+1.03 which was statistically significant (p-value 0.000). Similarly, mean time of passage of flatus after elective caesarean section in both the group was 8.39+0.94 and 28.15+1.13 which was statistically significant (p-value 0.000).</p> <p>Conclusion: The study concludes that mean duration of appearance of return of bowel motility and mean time of passage of stool after elective caesarean section in patients of chewing gum group was less than in control group. Thus, at the very least, gum-chewing immediately after surgery is more effective and harmless intervention to reduce postoperative ileus</p> Shahla Manzoor, Asma Hameed, Wajida Tayyab, Sobia Nawaz, Aamir Afzal Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Sat, 26 Jan 2019 00:00:00 -0500 Modified Bishop Score, Does It Need Any Remodification <p>Objectives: To determine an association between modified bishop score and success of induction of labour in nulliparous women.<br>Methodology: A total of 97 nulliparous pregnant women at a gestation period of 37-42 weeks presented in Maternal and Child Health (MCH) center in outdoor antenatal clinic at Pakistan Institute of Medical sciences (PIMS) Islamabad were appraised for predicting successful labor induction. All five parameters of modified bishop score such as cervical length, dilation, cervical consistency, cervical position, station and overall score were evaluated for successful labour induction. Effect modifiers like Body mass index, age of the mother, gestational age were controlled by stratification. For estimation purpose, descriptive statistics and multiple regression approaches were used to determine the parameters in the prediction of successful vaginal delivery within 24 hours.<br>Results: Empirical findigns based on logistic regression indicate that cervical consistency appears to be the important independent variable in predicting the successful labor induction (Confindece interval= 95%, P-value = 0.048; ). Other independent variables such as, cervical dilation, cervical length, cervical position, have insignificant impact in determining successful labor induction. The CI and P-values are (CI= 95%, P-value = 0.116 CI=95%, P-value=0.908, CI= 95%, P-value = 0.381, respecively).Simiarly overall bishop score(CI=95%,P-value=0.274) has weak association in success of labour induction.<br>Conclusions: In all nulliparous women with singleton preganancies, cervical length,cervical dilation, cervical position, and Bishop score are weak indicators in predicting successful labor induction. However, cervical consistency is better conjecturers in determining the successful labor induction.</p> Qurat ul Ain, Sobia Luqman, Nasira Tasneem Copyright (c) 2019 Journal of the Society of Obstetrics and Gynaecologists of Pakistan Thu, 14 Mar 2019 05:38:29 -0400 The role of microbiome in preterm labor: Recent advances and future challenges <p><strong>Background:</strong> Our current understanding of preterm labor is limited in the context of dysbiosis of microbiome. Human microbiome is comprised of trillions of microorganisms, residing on and within our bodies that are associated with the vital function of organs and systems. Few studies have highlighted the role of maternal gut microbiome dysbiosis as a contributing factor for metabolic syndrome and may be associated with risk of preterm labor. A clear understanding of dysbiosis in placenta or vagina with early ripening of cervix for initiation of preterm labor is not fully elucidated.</p> <p><strong>Aim:</strong> Our aim is to contextualize the alteration in microbial community structure in maternal and fetal organs in association with risk of preterm labor.</p> <p><strong>Methods:</strong> In this review, we summarized the studies published from 2000 to 2016 in the field of microbiome in association with preterm labor.</p> <p><strong>Findings &amp; Discussion:</strong> Evidence suggest that placental microbiome has promising correlation with preterm labor, while findings are equivocal for maternal gut and vaginal microbiome in inducing preterm labor.&nbsp; Similar alteration in fetal intestinal microbiome of meconium is supposed to evoke an inflammatory response that may lead to preterm labor.</p> <p><strong>Conclusion:</strong> To understand the relationship of microbiome and preterm labor, both maternal and fetal microbiome should be studied in parallel to determine the causality. Dysregulation of immune response due to disturbance in normal or commensal flora might be an underlying cause of preterm labor.</p> Zehra Jamil, Kumail Ahmed, Fyezah Jehan, Najeeha Iqbal Copyright (c) Wed, 13 Mar 2019 12:00:00 -0400 Uterine Fibroid Tumour Mimicking Adnexal Mass <p><em>44-year-old healthy woman presented with 2 weeks of lower abdominal pain. Vaginal and abdominal ultrasound revealed a well-circumscribed structure measuring approximately 8x5 cm with anechogenic inclusios. The tumour was considered to belong to the left ovary. The tumour had a solid centre with positive Doppler signal, circumscribed by cystically septate part. Due to consistent pain a laparoscopic examination of the pelvis which revealed a tumour originating from the lateral uterine wall, growing into the broad ligament towards the anterior abdominal wall. Tumour was grey white, firm and hydropically degenerated. The histology revealed a uterine leiomyoma with hydropic degeneration.</em></p> Marinsek Markovic K, Kenda Suster N, Velikonja M, Kristina Drusany Staric Copyright (c) Wed, 13 Mar 2019 00:00:00 -0400 Pregnancy with a Large Leiomyosarcoma – A Case Report & Literature Review <p>In the modern era, radiological and pathological investigations have made the diagnosis of gynecological diseases easier and reliable. However, in rare instances, very large masses may mask the actual diagnosis and are mimicked by some other abdomino-gynecological diseases especially in pregnancy, where the diagnosis and treatment options both become very difficult. In case under discussion a very large uterine leiomyosarcoma, presented with second trimester pregnancy. Multidisciplinary team approach and anticipation of such differentials could be helpful in such scenarios.</p> Nighat Sultana Copyright (c) Wed, 13 Mar 2019 11:52:52 -0400