Prescribing practices of Hormone Therapy for Menopausal females by OBGYN of Pakistan.

Objectives: To assess the prescribing practice of obstetricians and gynecologists (OBGYN) regarding Menopausal Hormone therapy (MHT) for menopausal females and assess the knowledge regarding indications for prescribing MHT and identify the barriers to HRT. Methods: This was a cross-sectional study conducted from May 2021 to December 2021. The participants were OBGYN experts (MCPS, FCPS, MRCOG) and senior experts. The tool was formulated after looking at contemporary literature and then validated by experts for face, content and construct validity. It was piloted and hence fourth given to study participants after approval by IRB of JSMU. Data was analyzed by SPSS version 22. Mean and Standard Deviation of categories in Likert scale were calculated. Results: Majority of the participant gynecologists prescribed HRT for Hot flushes and vaginal dryness having the highest mean scores nearing 4 on a Likert scale of (1-5). The prescription for other menopausal symptoms was observed to be less. The highest score for category of women in whom hormone therapy is specifically justified was "Premature ovarian failure" (4.37) followed by "Hysterectomy with bilateral oophorectomy before the age of 50" (4.23). Conclusion: Pakistani gynecologists are more cautious in their management strategies concerning MHT. Most of the gynecologists showed good and up to date information while prescribing MHT however knowledge for preventing fractures, alleviating anxiety/depression and weight gain was less among the gynecologist of Pakistan. We recommend refresher courses and online webinars for updated information on menopause and its management.

Clinical characteristics, obstetric and perinatal outcome of COVID-19 Infection in pregnant women.

OBJECTIVE: To determine clinical characteristics, obstetrics and perinatal outcome of coronavirus disease 2019 infection in pregnant women. METHODS: The cross-sectional study was conducted at the Department of Obstetrics and Gynaecology of the Ruth Pfau Civil Hospital, Karachi, and Dow University of Health Sciences, Karachi, from August 2020 to July 2021, and comprised pregnant women with suspicion of coronavirus disease 2019 infection, who underwent recommended testing, and were found to be positive. Oral swabs for the presence of infection were also taken from the neonate within 24 hours of delivery. Data was analysed using Stata 11. RESULTS: There were 41 women with a mean age of 27±5 years, a mean gestational age of 35±3 weeks, and mean parity 1.2±1.01. Of them, 3(7.3%) women died. Medical complications found along with coronavirus disease 2019 infection were pregnancy-induced hypertension 2(4.8%), eclampsia 4(11%) and diabetes mellitus 2(4.8%). Fever was the most common symptom seen in 12(30%) women, followed by cough 7(20%) and shortness of breath 6(14%). Majority 32(82%) of the women underwent caesarean section. The most common maternal complication was postpartum haemorrhage 6(20%). Also, 36(86%) women required intensive care unit stay for a mean 5±9 days. CONCLUSIONS: Fever, followed by cough and breathlessness, were the most common clinical features. Most common maternal and foetal complication was postpartum haemorrhage and low birth weight, respectively.

Exploring Reproductive Health Impact of COVID 19 pandemic: In Depth Interviews with key stakeholders in Pakistan.

OBJECTIVE: To explore the effects of COVID 19 on reproductive and child health services and gender relations. METHODS: This is a Qualitative Exploratory Research. Due to lockdown, setting was online interviews on Zoom. Sampling was purposive. Five in-depth interviews were conducted in June 2020 followed by compilation of results and manuscript writing in July and August 2020. RESULTS: Maternal Neonatal morbidity and mortality will rise as part of collateral damage of C19. As all routine services of maternity care, family planning, post abortion care and vaccination were also in lockdown. Baby boom, unwanted pregnancies, unsafe abortions and violence against women will be the secondary consequences of C19. CONCLUSION: Some critical services should never stop which include maternal and neonatal essential services. MNCH service continuity has to be maintained to optimize maternal neonatal health, prevent unwanted pregnancy and abortion. With appropriate standard operating procedures, and protective equipments, health facilities need to open. LHWs and community mobilisers with PPEs should continue services.

A needs assessment for faculty development at two medical colleges of Dow University of Health Sciences, Karachi.

OBJECTIVE: To identify the perceptions of the faculty about their current level of pedagogical skills and their desire to improve these skills in future. METHODS: This cross-sectional study was conducted at two medical colleges of Dow University of Health Sciences, Karachi from March 1, 2015 to April 30, 2015. A re-validated questionnaire was used comprising three parts; 1) Demographic details, 2) Fifteen educational domains each having 2 statements, first indicating minimum knowledge of domain and second showing maximum. Each statement had two 9-point anchored scales, first indicating current knowledge and second, desired knowledge of the faculty. 3) Factors which are important considerations for attending educational workshops. The data was analyzed by statistical software SPSS 17. RESULTS: The response rate was 54%. The mean age of faculty was 43.42 ± 8.41, largest proportion being assistant professors (85; 47%). For all educational domains, faculty perceived their knowledge to be moderately high (Mean = 5.9 +/- 1.8 to 6.8 +/- 1.7 and Median: 6 to 7). However, they desired to improve their pedagogical skills further in all domains (Mean = 8.2 +/- 1.1 to 8.4 +/- 1.1, Median: 9), p-values < 0.001. Nearly 95% teachers are willing to attend faculty development workshops. CONCLUSION: Our faculty perceives their current pedagogical skills to be moderately high. However, they would like to improve these skills to a higher level in all educational domains.

Physicians' perspective regarding direct to consumer marketing of nutraceuticals products.

OBJECTIVES: Recently pharmaceutical marketers have expanded their audience by directly to the consumers advertising (DTCA) which is almost always limited to non-prescription drugs. DTCA has substantial effects on patient behavior and physician prescription. The aim of this study was to assess the perspectives of physicians regarding the rapidly proliferating trend of direct to consumer marketing of nutraceutical drugs (ND). METHODS: It was a cross-sectional study from June 2016 to December 2016 which included 325 physicians from various cities of Pakistan who completed a structured questionnaire after providing informed consent. Questions were asked to assess physicians' perception of the increasing trend of Direct to Consumer advertisement of nutraceuticals and its influence on their practice. The data was analyzed using SPSS (SPSS Inc., Chicago, Illinois, USA). RESULTS: There were 182 (56%) male and 143 (44%) female physicians in the study. Most of them were general practitioners (48%), spent an average weekly time of 1-2 hours gaining medical knowledge (56%), and most of them (52%) utilized internet as their source. Most physicians (88%, n=286) experienced knowledgeable patients who inquired about their diseases and treatment plans. Most of the physicians believed that e-detailing (72%, n=234) and DTCA (68%, n=221) of nutraceuticals helps practitioners in shaping a more effective treatment plan. Almost (62%, n=201) physicians prescribed medications their patients requested them to. CONCLUSION: Physician perception of DTCA and e-detailing of nutraceuticals seems to be promising. However, physicians must be more prepared to deal with knowledgeable patients and put in maximum efforts to counsel them in such a manner that the prescription doesn't contain "request specific" drugs but only the ones that are most beneficial for the patients.

Simulation based medical education; teaching normal delivery on intermediate fidelity simulator to medical students.

OBJECTIVE: To assess the effectiveness of medium fidelity simulator in teaching normal vaginal delivery to medical students. METHODS: The quasi-experimental study was conducted at the professional development centre of the Jinnah Sindh Medical University, Karachi, from June to December 2015, and comprised medical students. Third-year medical students were included. They were divided into two groups. Group A was taught normal delivery through traditional PowerPoint and group B through simulator. The instruments used for assessing knowledge were pre-test and post-test, for skills of labour/delivery checklist of performance was used, and perception forms were filled to evaluate workshops/learning environment by students. RESULTS: Of the 76 participants, there were 36(47.4%) in group A and 40(52.6%) in group B. The overall mean age of the participants was 20.86±0.76 years in group B and 20.60±0.95 years in group A (p=0.19). The mean grade point average of the participants was 2.89±0.47 in group A and 2.87±0.48 in group B (p=0.81).Group B performed much better in skill of delivery having a mean score of 8.91±3.20compared to group A which had mean of 5.67±1.84 (p<0.01). CONCLUSIONS: Simulation-based skill learning showed significantly better results.

Comparison of Cognitive Professionalism in Residents of Public and Private Hospitals of Karachi.

OBJECTIVE: To evaluate and compare the cognitive professionalism in resident medical officers (RMOs) of public and private hospitals of Karachi. STUDY DESIGN: Across-sectional survey. PLACE AND DURATION OF STUDY: Civil Hospital and Ziauddin Medical University Clifton Campus, Karachi, from August to December 2014. METHODOLOGY: This survey was conducted in one public and one private medical college. All residents from Gynecology and Obstetrics, Medicine and Surgery departments were included with non-probability purposive sampling. Avalidated tool (Barry Challenges to Professionalism questionnaire) was used to assess professionalism, containing six challenges to professionalism (acceptance of gifts, conflict of interest, confidentiality, physician impairment, sexual harassment, and honesty) with multiple-choice responses. Data was analyzed with SPSS version 17 and chi-square test was used for determining significant difference between public and private institutes. RESULTS: Forty-three residents from both the places responded. The frequency of acceptable answers to the six scenarios ranged from 0% to 55.8%. Acceptable responses were more from private-sector institute residents than public-sector residents, but no statistical significant difference was seen. CONCLUSION: Most residents did not provide appropriate responses to professional challenges. The postgraduate training programs are very stringent on medical knowledge and skills. However, it is needed to address formally professional attitudes and behaviors and include them as a competency in the training program.

Physicians' Migration: Perceptions of Pakistani Medical Students.

OBJECTIVE: To study the perceptions of medical students about factors responsible for physicians'migration. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Dow Medical College and Civil Hospital, Karachi, from April to May 2015. METHODOLOGY: Aself-administered structured questionnaire was used including demographic details, attitudes about push and pull factors of migration, and reasons for migrating or not migrating abroad. Final year students and interns were included. Likert scale from 1 to 4 (1=strongly disagree to 4=strongly agree) was used to assess attitudes. Data was analyzed by SPSS version 16. RESULTS: Atotal of 240 medical students, mostly females (n=181, 75%) (60% final year and 40% interns), participated in the study. Majority wished to go abroad (n=127; 54%) with United States being the favourite destination (n=80; 66.1%) and internal medicine fields being the preferred choice for specialization (n=126; 54%). The major pull factors were better quality of postgraduate education abroad (n=110; 48.2%) and economic prospects (80; 35.2%); while the push factors were a weak healthcare system (n=219; 94.3%), inadequate salary structure (n=205; 88.3%), insecurity (n=219; 93.9%) and increasing religious intolerance in Pakistan (n=183; 78.5%). CONCLUSION: This survey highlights the continuing trend of physician migration from Pakistan owing to an interplay of various push and pull factors. Majority of our medical students wish to migrate, mainly due to low salaries, poor job structure, and insecurity. Urgent interventions are required to reverse this trend of medical brain-drain.

Patient safety: Perceptions of Medical Students of Dow Medical College, Karachi.

OBJECTIVE: To assess medical students' perceptions about patient safety issues before the teaching of "patient safety" can be recommended. METHODS: The cross-sectional survey was undertaken at the Dow Medical College and Civil Hospital, Karachi, in September, 2013. Data collection tool was a structured questionnaire administered to medical students. The main outcome measures were students' perceptions about patient safety issues and their attitude towards teaching of patient safety curriculum. RESULTS: There were 229 medical students in the study with a response rate of 100%. Overall, 129(57%) students agreed that medical errors were inevitable, but 106 (46.9) thought competent physicians do not make errors. While 167(74%) students said medical errors should be reported, 204(90%) thought reporting systems do not reduce future errors. Besides, 90(40%) students thought only physicians can determine the causes of error and nearly 177(78%)% said physicians should not tolerate uncertainty in patient care. Overall, 217(96%) agreed that patient safety is an important topic; 210(93%) agreed that it should be part of medical curriculum; 197(87%) said they would like to learn how to disclose medical errors to patients and 203(90%) to faculty members. CONCLUSIONS: A significant knowledge gap existed among medical students regarding patient safety issues. The teaching of 'patient safety' was highly supported by students and needs to be included in medical curriculum on an urgent basis.

Psychosocial determinants of nutritional neglect in a developing country.

OBJECTIVE: To determine the demographic features and psycho-social and economic determinants of nutritional neglect in order to suggest interventional strategies. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Department of Paediatrics, Dow University of Health Sciences (DUHS) and Civil Hospital Karachi (CHK), from January 2009 to December 2010. METHODOLOGY: All children suffering from nutritional neglect suggested by weight and height less than the third centile for age, and their mothers were recruited in the study through non-probability consecutive sampling. A team comprising of paediatrician, psychologist, medical social worker and social motivator interviewed the mothers and children suffering from nutritional neglect. Information about demographic, social, economic and psychological factors was obtained. The results were analyzed and described as frequency distribution and percentage. RESULTS: A total of 658 children suffering from nutritional neglect were inducted. Around 75% of children were below 5 years of age, 51% were females. Other determinants of nutritional neglect were, large family size (family of > 5 members (84%), young mother (60%), uneducated parents (67% father and 77% mothers being illiterate), low income (77% earning less than Rs. 7000/month), addiction (23%), tobacco smoking (50%) and non-nutritive substance use (51%). Psychological indicators identified in mothers were depression (70%), anxiety (73%), helplessness (70%), displaced aggression (50%) and insecurity (36%). Psychological factors identified in children as a secondary outcome were aggression (80%), rebellious behaviour (75%), lack of confidence (70%), lack of social interaction (70%) and paranoid tendencies (60%). CONCLUSION: Psycho-social and economic factors are important determinants of neglect. A holistic approach and intervention at multiple levels is required to address these issues.

Spot urine protein-creatinine ratio and 24-h urine protein excretion: Diagnostic accuracy in women with pre-eclampsia.

OBJECTIVE: To compare the efficacy of spot urinary protein/creatinine ratio with 24h urinary protein excretion in women with pre-eclampsia. METHODS: A total of 85 women with hypertensive disorders during pregnancy were prospectively studied. Urine protein/creatinine ratio in spot urine sample was compared with 24h urinary protein. Sensitivity and specificity for urinary spot P/C (protein/creatinine) ratio was assessed, and receiver operating curve was used to determine the value against the gold standard of >300mg proteinuria in 24h urinary sample. RESULTS: Of 85 women, complete data were available for 81 women. There was a strong correlation between spot urinary P/C ratio and 24h urine protein excretion (r=0.81, P value <0.000). The optimal spot P/C ratio cut-off point was 0.14 for 300mg/24h of protein excretion (preeclampsia) with a sensitivity of 82% and specificity of 79%. CONCLUSION: We found a strong correlation between spot urinary P/C and 24h urinary protein. Spot urinary protein/creatinine ratio is a good predictor of proteinuria for pre-eclampsia.

Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan.

OBJECTIVE: To study the mortality and morbidity of unsafe abortion in a University Teaching Hospital. METHODS: A cross-sectional, descriptive study was conducted in Department of Obstetrics and Gynaecology, Unit III, Dow Medical College and Civil Hospital Karachi from January 2005 to December 2009. Data regarding the sociodemographic characteristics, reasons and methods of abortion, nature of provider, complications and treatment were collected for 43 women, who were admitted with complications of unsafe abortion, and an analysis was done. RESULTS: The frequency of unsafe abortion was 1.35% and the case fatality rate was 34.9%. Most of the women belonged to a very poor socioeconomic group (22/43; 51.2%) and were illiterate (27/43; 62.8%). Unsafe abortion followed an induced abortion in 29 women and other miscarriages in 14 women. The majority of women who had an induced abortion were married (19/29, 65.5%). A completed family was the main reason for induced abortion (14/29; 48.2%) followed by being unmarried (8/29, 27.5%) and domestic violence in 5/29 cases (17.2%). Instruments were the commonest method used for unsafe abortion (26/43; 68.4%).The most frequent complication was septicaemia (34; 79%) followed by uterine perforation with or without bowel perforation (13, 30.2%) and haemorrhage (9; 20.9%). Majority of induced abortions were performed by untrained providers (22/26; 84.6%) compared to only 3/14 cases (21.4%) of other miscarriages (p = 0.0001). CONCLUSION: The high maternal mortality and morbidity of unsafe abortion in our study highlights the need for improving contraceptive and safe abortion services in Pakistan.

Transfusion of blood and blood component therapy for postpartum haemorrhage at a tertiary referral center.

OBJECTIVE: To determine the practice of transfusion of blood and blood products in cases of postpartum haemorrhage, at a tertiary referral center. METHODS: A retrospective study was conducted where medical records were reviewed for women, who either delivered or were admitted in labour suite with diagnosis of postpartum haemorrhage. The study period extended from Jan 2008 to Oct 2009. During a period of 22 months, records were reviewed for transfusion of blood and blood products in above group of women. Data were analyzed for descriptive statistics. RESULTS: During the study period, a total of 4744 patients were admitted in the labour suite. A total of 113 (2.36%) women were diagnosed with Post partum haemorrhage. Uterine atony was the commonest cause of PPH, followed by genital tract trauma. A total of 81 (71%) women received transfusion of blood and blood components (1.6%). The mean blood loss was 1088 ml (+/- 584 ml). Transfusion of blood and blood component therapy was significantly more in women who underwent caesarean section, compared to those women who delivered vaginally. There was one case of acute tubular necrosis due to PPH, and seven maternal deaths. The mean hospital stay was of +/- 3 days. CONCLUSION: In this hospital based study, the prevalence of PPH was 2.36%, and the rate of transfusion of blood and blood products was 1.6%.

Comparision of obstetric outcome among teenage and non-teenage mothers from three tertiary care hospitals of Sindh, Pakistan.

OBJECTIVE: To compare the obstetric outcome of teenage pregnancies with that of non teenage pregnancies. METHODS: A prospective case-control study was conducted in three tertiary care hospitals of Sindh, Pakistan from September 2008 to November 2008. The data regarding obstetric outcome of all teenagers (13-19 years) delivering in the three hospitals was compared with that of selected non teenage women (20 to 35 years) taken as controls. Chi-square and students' t-test were applied with 0.05 as level of significance. RESULTS: Teenage mothers were more likely to suffer from severe anaemia (8% versus 4.3%; p = 0.03) and chorioamnionitis (2.8% vs 0.8%, p = 0.01) and their infants were more likely to suffer from post maturity (4.6% vs 1.8%, P = 0.02) and meconium aspiration syndrome (6.5% vs 2.4%, p < 0.01) compared to non-teenage mothers. On the other hand they were less likely to be overweight than the non-teenagers. Teenagers had instrumental deliveries more often than non-teenagers (7.1% vs 2.2%, p < 0.01). The risk of preterm delivery, low birth weight infant, respiratory distress syndrome, foetal and perinatal death was not significantly different in the two groups. CONCLUSION: Teenage mothers are at a higher risk of developing severe anaemia and chorioamnionitis. They are more likely to have an instrumental delivery than non-teenagers. Post maturity and meconium aspiration syndrome are the neonatal complications seen in infants born to teenage mothers.

Home deliveries: reasons and adverse outcomes in women presenting to a tertiary care hospital.

OBJECTIVE: To identify the reasons and adverse outcomes of home deliveries in women presenting to a tertiary care hospital. METHODS: A prospective, descriptive study was undertaken in the Department of Obstetrics and Gynaecology, Unit III, Civil Hospital Karachi from 1st April, 2007 to 31st August, 2007. All patients who were admitted with any complication of home delivery during this period were included in the study. Patients and/or their attendants were interviewed to collect data regarding age, parity, sociodemographic characteristics, reasons for home delivery, presenting complaints and complications of home delivery. The data was recorded on structured questionnaires, analyzed by SPSS version 16 and presented as frequencies and percentages. RESULTS: The mean age of patients was 26 +/- 5.3 years and the median parity was 2. The majority of the patients were Urdu-speaking (57.5%) followed by Sindhi (20.3%) and Balochi-speaking (11.9%). Eighty-seven percent of women had received either no or just primary education. The two most frequent reasons quoted for home deliveries were family tradition in 190 (72.8%) and lack of affordability in 179 women (68.6%). Postpartum haemorrhage was the main adverse outcome in 132 women (50.6%) followed by retained placenta/placental pieces in 74 women (28.4%). CONCLUSION: The main reasons for having a home delivery are family tradition and poor socioeconomic condition of the family and the most important adverse outcomes of home delivery are postpartum haemorrhage and retained placental tissue.

Sublingual versus vaginal misoprostol in the management of missed miscarriage.

OBJECTIVE: To compare the efficacy of sublingual and vaginal misoprostol in the medical management of missed miscarriage. METHODS: Fifty women diagnosed as having missed miscarriage of gestational age less than 20 weeks were assigned randomly to receive 400 microg of either sublingual or vaginal misoprostol every three hours, up to a maximum of five doses. The primary outcome measures were, complete evacuation of products of conception, mean induction to delivery time and the occurrence of side effects. RESULTS: There was no significant difference in complete evacuation rates between the sublingual misoprostol and the vaginal misoprostol groups (52% vs. 48%, p = 0.571) mainly within the first 24 hours. Mean induction to delivery time was also similar for both groups (13.07 +/- 6.95 hours for sublingual versus 13.29 +/- 5.63 hours for vaginal group) as was the total number of doses required (4.44 +/- 1.04 for sublingual versus 4.52 +/- 0.96 for vaginal misoprostol). Side effects were seen in 18 women (72%) in the sublingual group compared to 5 women (20%) in the vaginal group (p < 0.001). The incidence of unpleasant taste was significantly higher in the sublingual group than in the vaginal group (60% versus 4%, p = < 0.001). CONCLUSION: Sublingual misoprostol is as effective as vaginal misoprostol for medical management of missed miscarriage but is associated with an increased risk of side effects especially an unpleasant taste.

Socio-demographic characteristics and the three delays of maternal mortality.

OBJECTIVE: To describe the socio-demographic characteristics and the three delays of maternal mortality in a tertiary teaching hospital. STUDY DESIGN: Retrospective, observational study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology, Unit III, Civil Hospital, Karachi, from April 2005 to May 2008. METHODOLOGY: One hundred and four consecutive maternal deaths were reviewed. Data regarding age, parity, sociodemographic characteristics, booking status, referral source, cause of death and the three delays was collected on structured proformas, analyzed by the statistical software, SPSS version 13, and presented in the form of frequencies and percentages. RESULTS: The projected maternal mortality ratio was 1650/100,000 live births. The mean age was 28+/-6.2 years and median parity was two. Seventy-one women (68%) were uneducated, 65 (62.5%) belonged to lower socioeconomic class and 60 (58%) had received no antenatal care. Ninety-eight women (94%) had one or more delays, with 70 (71%) having the first delay, 73 (74%) having the second delay and 47 (48%) the third delay. The most frequent reasons for first, second and third delays were lack of awareness in 88.5% women, long distance in 39.7% women and difficulty in getting blood in 49% women respectively. CONCLUSION: The very high maternal mortality ratio suggests lack of access of women to quality healthcare facilities. A majority of these women suffered first and second delays in their management, which could be due to their poor sociodemographic factors.

Ectopic pregnancy: presentation and risk factors.

OBJECTIVE: To describe the clinical features and risk factors in ectopic pregnancy. DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: The study was conducted in Unit III of the Department of Obstetrics and Gynaecology, Civil Hospital, Karachi from January 2002 to December 2003. PATIENTS AND METHODS: A total of 38 women diagnosed with ectopic pregnancy were included in the study. Data was retrieved from the charts of all the patients diagnosed with ectopic pregnancy through a structured proforma. The variables studied included age, parity, symptoms and signs, risk factors, treatment and associated maternal morbidity. RESULTS: Among the clinical features, the most common presenting symptom was abdominal pain in 37 (97.3%) patients whereas history of amenorrhea and vaginal bleeding were found in 28 (73.6%) and 22 (57.8%) patients respectively. The most common physical sign was tenderness: abdominal tenderness in 28 (73.6%) and pelvic tenderness in 23 (60.5%) patients. Cervical excitation was only present in 19 (50%) patients. Risk factors were present in 23 patients (60.5%), the most frequent being infertility in 9 patients (23.6%). Other risk factors were tuberculosis in 6 patients (15.7%), previous ectopic pregnancy in 3 (7.8%) and previous tubal surgery in 1 (2.6%) patient. History of IUCD was present in 1 (2.6%), injection Depo-provera in 4 (10.5%) and OCP in 3 (7.8%) patients. History of D & C and C-section were present in 7 (18.4%) and 4 (10.5%) patients respectively. CONCLUSION: Abdominal pain was the single most consistent feature of ectopic pregnancy. Risk factors may not always be present. Therefore, ectopic pregnancy should be suspected in every woman of reproductive age who presents with unexplained abdominal pain, irrespective of amenorrhea and vaginal bleeding and whether risk factors were present in the past history or not.