Emergency contraception: knowledge, attitude and practices among doctors of a tertiary care hospital.

BACKGROUND: In Pakistan maternal mortality rate (MMR) is very high and more than one in five women die from pregnancy related causes; solution to this is to have low fertility rate. The emergency contraceptives (ECs) can be used to prevent unwanted pregnancies. The aim of this study was to assess the knowledge, attitude and practice about ECs among doctors. METHODS: Institution-based cross-sectional descriptive study on knowledge, attitude and practice of ECs was conducted at Rawal Hospital from Feb to May, 2012. Data was collected using structured questionnaire and analysed using SPSS-16. RESULTS: Fifty-seven percent of the respondents were > 30 years of age, 94% were Muslim, 81% were married and 51% were women. Ninety-seven percent had heard of ECs before, only 17% knew Intra-uterine contraceptive device (IUCD) a method of EC. Sixty-one percent responded that IUCD should be removed if patient gets pregnant (p = 0.007) and according to 31% ECs were not abortifacient (p = 0.045). Regarding attitude, 55.5% of the participants supported its use (p = 0.027) and agreed to its easy accessibility (p = 0.004). Thirty-eight percent responded an increased dose of birth control pills as a form of EC (p = 0.008), while 40% did not agree that ECs are effective when taken before intercourse (p = 0.011). CONCLUSION: Knowledge and practice of ECs is very low among doctors but a positive attitude is there. Evidence-based knowledge to family physicians regarding emergency contraception is strongly recommended to reduce the chances of MMR.

Vesical endometriosis.

Endometriosis affecting the urinary tract is very rare and the most common site of involvement is urinary bladder. The clinical features are urgency and frequency, hypo gastric pain and hematuria. Cystoscopic examination is the most valuable diagnostic test but definitive diagnosis requires histological confirmation. A 21-year-old unmarried female presented with lower urinary tract symptoms and blood in urine, more during menstruation. She gave history of left salpingo-oophorectomy. Ultrasonography revealed a mass in the bladder 2 x 3 cm on the posterior wall. Intravenous urography showed a filling defect in the bladder. Urethrocystoscopy performed and growth was resected and sent for histopathology. Histopathology confirmed the diagnosis of vesical endometriosis. She was advised Luteinizing hormone-releasing hormone (LHRH) but she refused as she could not afford it. She was managed on Tab 17-aethinyl testosterone.

Role of misoprostol for therapeutic termination of pregnancy from 10 -28 weeks of gestation.

OBJECTIVE: To assess efficacy, safety and cost effectiveness of misoprostol (prostaglandin E1 analogue) for termination of pregnancy. METHODS: A descriptive study was conducted from March 2003 to December 2004, at Fauji Foundation Hospital Rawalpindi. A total of 200 patients, at 10-28 weeks of gestation, requiring termination of pregnancy were included. Each woman received first dose of 400 microg of misoprostol vaginally. Second dose of 400 microg of misoprostol was administered after 4 hours, according to the cervical dilatation, softening and uterine contractions. Oxytocin infusion was started after six hours of administration of first dose of Misoprostol, depending upon the uterine contractility. The process of abortion was monitored to assess the outcome measures. RESULTS: Successful abortion was seen in 137 (68%) patients, with induction to delivery interval of 12.2 hours. In 40 (20%) patients surgical evacuation was performed. Out of 40 patients, 27 (13.5%) underwent surgical evacuation due to incomplete abortion and 13 (6.5%) for excessive per-vaginal bleeding. A total of 23 (12%) patients had failure of method for induction of abortion and needed either repeat dose of misoprostol after 24 hours or other methods of induction (besides misoprostol). Side effects included nausea, vomiting, diarrhoea and fever. Mean hospital stay for induction of abortion was 31 hours. CONCLUSION: Misoprostol is safe, efficacious and a cost effective drug for induction of the first and the second trimester abortions.

Radical vulvectomy by two different surgical incisions.

OBJECTIVE: To determine the outcome of radical vulvectomy by two different surgical incisions (butterfly vs triple incision) for the treatment of vulval carcinoma. METHODS: A comparative study was conducted from January 1992 to July 2003 at Military Hospital Rawalpindi and Fauji Foundation Hospital Rawalpindi. A total of 35 patients were included in this study. One patient received supportive therapy at stage IVB. Out of 34 patients, 23 (67.64%) underwent radical vulvectomy by butterfly incision and 11 (32.35%) radical vulvectomy by triple incision technique. Data regarding history, clinical examination, surgical procedures, per-operative complications, post-operative complications, hospital stay, recurrence and mortality was collected and analyzed. RESULTS: The percentages of partial wound dehiscence (86.36% vs. 18.18% p = 0.00), wound induration (100% Vs 72.7%, p = 0.008), infection (22.72% vs: 9.09%, p = 0.637) and lymphoedema (9.0% vs. Zero, p = 0.542) were higher in butterfly incision group as compared to triple incision group respectively. The per-operative blood loss (750 +/- 36.9 ml vs. 381 +/- 14.7 ml, p-value: < 0.01), operative time (136.91 +/- 14.73 min Vs 81.82 +/- 14.71 min, p = 0.00) and hospital stay (19.05 +/- 3.27 days Vs 9.09 +/- 0.7 days, p = 0.00) were significantly higher in butterfly incision as compared to triple incision respectively. The recurrence rate in butterfly incision was comparable to triple incision group (14.28% vs. 18.18%, p = 0.572). In the butterfly group one patient died per-operatively and another patient died within one year after surgery. CONCLUSION: Radical vulvectomy by triple incision has comparable recurrence rate but significantly less mortality and morbidity rates when compared to butterfly incision.

Presentation of polycystic ovary syndrome and its management with clomiphene alone and in combination with metformin.

BACKGROUND: This study was carried out to determine the pattern of presentation of Polycystic ovary syndrome (PCOS) in patients presenting at our unit and to compare effects of clomiphene alone and in combination with metformin in management of PCOS. METHODS: This study was conducted from Jan 2001-2003 at Military Hospital, Rawalpindi. All patients presenting with infertility were evaluated with a view to select 100 patients of PCOS with the help of history of oligomenorrhoea, hirsuitism and acne. Diagnosis was confirmed by ultrasonography and hormone analysis (LH, FSH, prolactin, testosterone along with LH:FSH>2). The 100 selected patients were divided into two equal groups. One was given combined clomiphene citrate (CC) and metformin for ovulation induction and the other CC alone. These patients were followed for six cycles for ovulation and conception. Follicle tracking on ultrasonography and day-21 serum progesterone level were used to detect ovulation while conception was confirmed by urine pregnancy test, serum B-HCG level and ultrasonography for gestational sac. RESULTS: Hirsuitism and oligomenorrhoea were the two most common clinical features of PCOS. In the first group 34 patients (68%) ovulated as compared with 18 (36%) in the second group. In the first group 18 out of 34 women (52.9%) conceived as compared with only 8 out of 18 (44%) in the second group. The difference was significant at >0.05 when ovulatory and pregnancy responses were compared among two groups. All patients tolerated metformin well and no teratogenic effects were observed in patients who conceived after treatment with metformin. CONCLUSION: A combination of metformin and clomiphene citrate significantly increases the ovulation and conception rates in these patients.