Aggressive angiomyxoma of vulva

A lady of 44 years presented with progressively growing non-tender mass in the right labia majora over a period of one year. Ultrasound showed large perineal mass with predominantly echogenic low resistance type of arterial blood flow at different places on ultrasound. CT scan showed well-defined margins with attenuation less than that of muscle. MRI showed high signal intensity related to loose myxoid matrix and high water content of angiomyxoma

Identification of technical item flaws leads to improvement of the quality of single best multiple choice questions

The purpose of the study was to identify technical item flaws in the multiple choice questions submitted for the final exams for the years 2009, 2010 and 2011. This descriptive analytical study was carried out in Islamic International Medical College [IIMC]. The Data was collected from the MCQ's submitted by the faculty for the final exams for the year 2009, 2010 and 2011. The data was compiled and evaluated by a three member assessment committee. The data was analyzed for frequency and percentages the categorical data was analyzed by chi-square test. Overall percentage of flawed item was 67% for the year 2009 of which 21% were for testwiseness and 40% were for irrelevant difficulty. In year 2010 the total item flaws were 36% and 11% testwiseness and 22% were for irrelevant difficulty. The year 2011 data showed decreased overall flaws of 21%. The flaws of testwisness were 7%, irrelevant difficulty were 11%. Technical item flaws are frequently encountered during MCQ construction, and the identification of flaws leads to improved quality of the single best MCQ's

Colposcopy: a Valuable Screening Tool for the Diagnosis of Premalignant and Malignant Cervical Pathologies

To correlate colposcopic findings with the results of cervical biopsy and to prove colposcopy as a valuable screening tool for the diagnosis of premalignant and malignant cervical pathologies. A quasi experimental study Study was conducted from January 2008 to April 2010 in the Department of Obstetrics and Gynecology, Railway Hospital Rawalpindi. The study population included three hundred women who attended the outpatient department of Railway hospital over a period of two years. All these symptomatic women between the ages of 30-60 years were recruited with one or more of the complaints of post coital bleeding, intermenstral bleeding, postmenopausal bleeding, recurrent vaginal discharge or abnormal Pap smear. The recruited women were examined by speculum, followed by pap-smears. Out of 300 women Pap smear of 200 women was abnormal and showed inflammatory lesions at three consecutive times. These ladies were booked for colposcopy. However, any other women whose reports showed dyskaryotic changes were immediately booked for colposcopy. Biopsies from abnormal areas were taken and sent for histopathology. The reports of cervical biopsy were then analyzed. Out of 300 women recruited, 200 showed positive Pap smear. 108[54%] symptomatic women showed normal epithelium, while 92 women [46%] had abnormal transformation zone changes. Cervical biopsy reports of 92 women with abnormal colposcopic findings, showed up chronic cervicites in 60 cases, miscellaneous cervical pathologies in 10 cases, no dysplasia in 10 cases and cervical carcinoma was diagnosed in 12 cases. The study concluded that colposcopy followed by cervical biopsy proved to be a valuable screening tool for the diagnosis of premalignant and malignant cervical pathologies

Intrauterine Death - An Outcome of Post Term Pregnancy at Pakistan Railways Hospital Rawalpindi

The objective is to determine the frequency of intrauterine death in post term pregnancy at Pakistan Railway Teaching Hospital - Rawalpindi. It is an observational prospective study The study included four year data of all the deliveries conducted during 10th January 2005 -9th Jan 2011 at Pakistan Railways Teaching Hospital. Total 6540 deliveries were conducted during this time 104 Pregnant women with gestational age of 294 days or more, who were sure of their LMP were included. Detailed history was taken along with physical and ultrasound examination. All women with associated medical problems were excluded. Data collected about study variables was included in sample. All relevant data was collected using perform, that was developed in the light of objectives and variables. Data was analyzed on computer using SPSS Version 10. Frequency of intrauterine deaths in post term pregnancy was calculated and 95% confidence interval was calculated for it. The overall prevalence of post term pregnancy was 3.13% which is much less than those in different studies. Maternal and neonatal complications were compared with normal term pregnancy. This comparative study revealed increased risk to mother and fetus as pregnancy advances beyond term

Phloroglucinol for Acceleration of Labour: Double Blind, Randomized Controlled Trial

To determine the effect of Phloroglucinol Trimethylether vs Placebo on the duration of 1 stage of labour in term pregnancies. Quasi experimental study. Obs/Gynae wards IIMC, Railway hospital, Rawalpindi from June 2011 to May 2012. A double blind randomized placebo controlled trial was conducted on 131 patients in active phase of uncomplicated labour. The patients were randomized into two groups by simple random technique. After evaluation, patients were divided into group A and B. Neither the patients nor the doctor knew about the injection of phloroglucinol or distilled water. Sixty five patients in group a received Phloroglucinol Trimethylether 40 mg [4 ml] intravenous and 66 patients in group B received distilled water as placebo at 4 cm cervical dilatation. Dose was repeated after 60 minutes. Maximum 3 doses were given. Progress of labour was plotted on partogram. Any adverse effects of the drug on mother and fetus were noted. Student't-test was applied for statistical analysis. Out of 131 labouring patients, 61 patients from group A and 61 patients from group B were included in analysis. During 1[st] stage of labour 61 cases[100%] received 1 injection, whereas 11 cases [18.0%] were given 2 injections and 3 cases [4.91%] received 3 injections during the 1[st] stage of labour in group A and in group B 61 patients [100%] received 1 injection, 52 patients [85.2%] were given 2 injection and 37 cases [60.6%] were received 3 injection. The average duration of observed active phase of 1[st] stage of labour was shortened by almost two hours in patients receiving Phloroglucinol. The mean duration of 2[nd] stage of labour in group A was 25.16 mins and 34.52 mins in group B. Phloroglucinol definitely has a therapeutic role to play in obstetrics with its strong antispasmodic effect. In the presence of good and regular uterine contractions, it shortens the duration of labour, is non toxic to both mother and fetus and it also decreases the severity of labour pain

Emergency Peripartum Hysterectomy in Pakistan Railway Teaching Hospital Rawalpindi: Eleven Years Review

Emergency Peripartum Hysterectomy [EPH] is a major surgical procedure. There appears to be a rise in the rate of emergency peripartum hysterectomy [EPH] in the developed world. Peripartum hysterectomy is high risk but a life saving operation. It is usually associated with significant maternal and fetal morbidity and mortality. Obstetricians should identify patients at risk and anticipate the complications, as early intervention and proper management results in optimal outcome. To determine the incidence, indications, risk factors, complications and management of EPH over the last eleven years. A descriptive study. All cases of EPH performed in the period between January 2001 and December 2011 were included in the study. Study was conducted at Railway Teaching Hospital, Rawalpindi [in northern Pakistan]. Data of all the cases of EPH cases operated during the study period was collected from the hospital obstetric record. Data of basic demographics, mode of delivery, maternal and fetal outcome along with associated complications was collected and entered into the Statistical Package for Social Sciences version 14.0 [SPSS Inc., Chicago, IL, USA] for further analysis. Indications, pre-op planning, type of operation, emergency decision, blood loss, transfusion, complications, were compared and cross-tabulated. Statistical analysis included: Chi-square and Fisher exact tests, where appropriate, and two-sample t test. Total deliveries were 13560 in 11 years. Twenty Six EPH cases were performed among deliveries, giving an incidence of 1.8 per 1000 deliveries i.e. one in 566 deliveries. The indications were uterine atony [34.61%], ruptured uterus [23.07%] and cervical/vaginal tears [11.53%], placenta praevia [11.53%], invasive placental adhesion [accreta, increta, percreta [11.53%]]. A significant association between previous uterine surgery and abnormal placentation was shown [p=0.02], especially those with previous caesarean [p=0.003]. One maternal and six perinatal mortalities were recorded. Four perinatal deaths were of non-booked patients, handled by traditional birth attendants/private clinics. Out of two perinatal deaths of booked patients, one was pre-term and other was delivered by forceps. Maternal morbidity was prevalent, including twenty three intensive care admissions, three disseminated intravascular coagulopathies, three bladder injuries, three re-explorations, multiple blood, FFPs and platelet transfusions, two pulmonary embolism and one cardio- respiratory failure. Maternal death was of non-booked patient with previous scar, home delivery, uterine rupture and brought to hospital with un-recordable BP and very weak pulse. Incidence of peri-partum hysterectomy is increasing. It is a major operation, and almost always an emergency with significant blood loss. An early decision should be made to save life of the patient and prevent complications. The most important risk factor for peripartum hysterectomy in our patients is hemorrhage, most notably caused by uterine atony, uterine rupture, placenta previa and abnormally adherent placenta

Outcome of pregnancy after peripartum cardiomyopathy: search of literature and case series

Peripartum Cardiomyopathy [PPCM] is a rare life threatening disease and affects young women. Relevant literature has been searched. Symptoms of PPCM vary greatly and may be obscured by common physiological aspects of pregnancy. Therefore incidence rate might be higher. Echocardiography and MRI can confirm or rule out PPCM. Unfortunately there is no specific risk factor profile available. We have collected data of three such cases in which we followed the outcome of pregnancy in patients who had PPCM in previous pregnancies. Increasing awareness for PPCM among general practitioners, obstetricians and cardiologists may help in early diagnosis in order to start adequate treatment. We are presenting the outcome of pregnancy of three patients with history of PPCM in previous pregnancies.

Frequency of postpartum haemorrhage in caesarean section in anaemic and non anaemic patients

To determine the frequency of postpartum haemorrhage during caesarean section in anaemic and non anaemic patients. Cross sectional study. This study was conducted at the department of Obstetrics and Gynecology Pakistan Railways Hospital Rawalpindi, from 1[st] April 2009 to 30[th] September 2009. A total of 112 patients with term pregnancy were included in the study. The inclusion criteria consisted of patients with gravidify less than 5 undergoing elective or emergency caesarean section due to obstetric indications. Patients with twin pregnancy, placenta previa, placental abruption, grand multipararity, diabetes and coagulation disorders were excluded. On the basis of pre operative hemoglobin patients were divided into anaemic and non anaemic groups. Anaemic group had Hb <11.0 g/dl, and non-anaemic group had Hb >11.0 g/dl. A prestructured proforma was used to collect the data regarding age of the patient, gravidity, parity, duration of gestation, pre operative and post operative hemoglobin concentration, Intraoperative blood loss was measured by blood collected in suction bottle and weighing the blood soaked abdominal packs, gauze pieces and napkins. Post operative blood loss was measured by weighing the blood soaked sanitary pads. Post operative hemoglobin was checked on 3[rd] post operative day to check fall in hemoglobin level. Mean +/- SD age of patients undergoing caesarean section was 25.31 +/- 4.176 years. Mean +/- SD gestational age was 39.11 +/- 1.118 week. Mean +/- SD gravidity was 2.11 +/- 1.102. Primigravida comprised of 45 [40.2%] patients. Preoperatively 48 patients [42.9%] had hemoglobin <11 gm/dl. Postoperatively 80 patients [71.42%] had hemoglobin <11gm/dl. Seven patients [6.3%] manifested post partum hemorrhage. Out of these one had Hb >11 gm/dl and 6 patients had Hb<11gm/dl. Anaemia in pregnancy is one of the important risk factors for post partum haemorrhage. Prevention and treatment of anaemia in pregnancy can help us in reducing the risk of post partum haemorrhage.

Maternal and fetal outcome of pregnancies with umbilical cord problems

To seek relationship between cord problems [like long cords, short cords, nuchal cord and cord knots] and its effects on fetus as well as mode of delivery. Descriptive [case series] Obs/Gynae wards Railway hospital, Rawalpindi from September 2006 to August 2007. It was a descriptive case series study. Hundred patients with umbilical cord problems, detected at delivery were included.Effects of these cord problems on mode of delivery and fetal outcome were observed. Twenty two percent patients had long cord, 14% had short cords.41% had single nuchal cord, 22% had double loop of cord around the neck, and 4% patients had triple loops of Nuchal cord. It was observed that 4% patients were having true kanots in umbilical cord and and only 26% patients had false knots in umbilical cord. In the patients with cord problems, rate of SVD was more than 70% and LSCS < 20%. These problems did not show significant effects on birth weight and Apgar scores when present alone.But multiple cord problems in a single pregnancy were associated with fetal complications. Long and short umbilical cords, umbilical cord knots and Nuchal cords had no significant effects on mode of delivery and Apgar score in 5 minutes. But multiple umbilical cord problems in same case may pose problems to the fetus and early diagnosis can prevent fetal harm

Outcome of early versus delayed oxytocin augmentation in nulliparous women on the duration of labour and other, obstetric and neonatal outcome - a randomized controlled ftrial

To determine the outcome of early versus delayed Oxytocin augmentation in nulliparous women on the duration of labor and other obstetric and neonatal outcomes. Aprospective randomized trial. The study was conducted at Pakistan Railways Hospital, for the duration of 1 year with effect from January 2010 January, 2011. It is 400 bedded teaching hospital affiliated with IIMC-Tof Riphah International University, Islamabad. In healthy nulliparous women with normal pregnancy.the progress of labor was thoroughly monitored and documented every 23 hours. If there was still no progress 1 hour after amniotomy, the woman was randomly allocated to either labor augmentation by oxytocin infusion or to postponement of oxytocin augmentation for 3 hours [expectant group, n = 158]. Women whose labors had progressed satisfactory [1 cm/hour] after amniotomy were not randomized. Participants were managed according to a standard protocol entailing continuous documentation of the progress of labour, the amount of oxytocin administered, and obstetrical and neonatal outcomes. Oxytocin infusion was started at 6 mil/minute and was raised by 6 mU/minute every 30 minutes until efficient contractions were established in the early oxytocin group. In the expectant group, if no progress occurred after 3 hours, the women were reassessed regarding the need for oxytocin augmentation. Data were analyzed with SPSS 15.0. The MannWhitney U test was used to compare means. Proportions of events were compared with Fisher's exact test or chi-square analysis. Statistical significance was set at a P value of <0.05. The caesarean section rate was 9% in the early oxytocin group and 10.7% in the expectant group [OR 0.8, 95% Cl 0.51.4], and instrumental vaginal delivery 17% in the early oxytocin versus 12% in the expectant group [OR 1.5, 95% Cl 0.972.4]. Early initiation of oxytocin resulted in a mean decrease of 85 minutes in the randomization to delivery interval. Early administration of oxytocin did not change the rate of caesarean section or instrumental vaginal delivery but shortened labor duration significantly in women with a 2-hour arrest in cervical dilatation. No other clear benefits or harms were seen between early and delayed administration of oxytocin

Role of transvaginal sonography in assessment of abnormal uterine bleeding in perimenopausal age group

Abnormal uterine bleeding [AUB] is a common problem which prompts more than 20% of all visits to outpatient clinics, and may account for more than 25% of all hysterectomies. The objective of this study was to determine the role of transvaginal ultrasonography in women of perimenopausal age group presenting with abnormal uterine bleeding. This descriptive study was conducted in Department of Obstructs and Gynaecology, Railway General Hospital, Rawalpindi. One hundred and forty-one women who attended the gynaecology clinic with abnormal uterine bleeding [menorrhagia, intermenstrual bleeding, or postcoital bleeding] between 40-47 years of age from January 2006 and April 2007 were included in this study. The mean age was 44 years. Among 141 women endometrial lesions were detected in 77 cases on histopathology after Dialatation and Curettage [D and C], while 57 [40.42%] of these were confirmed on transvaginal ultrasongraphy as an endometrial pathology prior to this invasive procedure. Among the 64 remaining patients, showing normal proliferative endometrium on histopathology, 46 cases [71.87%] showed no abnormality on tranvaginal examination. Transvaginal sonography can be safely used as an initial investigation in the management of abnormal uterine bleeding as it is a noninvasive procedure for the detection of endometrial pathology. The incidence of detection of an abnormal pathology by ultrasongraphy is high when focal lesions as fibroids, polyps or foreign body is concerned. Dilatation and curettage being a blind procedure requires hospitalization and general anaesthesia which can be safely replaced by an alternate valid, safe and non-invasive technique for evaluating the endometrial pathology in women of perimenopausal age group with abnormal uterine bleeding

Learning styies; learners and their career choice

1. To study the prevalence of learning styles in intermediate level students in Rawalpindi according to Kolb's Learning Style Inventory. 2. To study the correlation of learning types with career choices of intermediate level students in Rawalpindi. 3. To compare the results of the study with the learning styles of clinical students of a medical college. Cross sectional. Descriptive. The study was done on the intermediate level students of Government College of Rawalpindi. It included the Pre-Medical, Pre-Engineering and humanities students. All students were given a questionnaire based on Kolb's learning style inventory, and responses collected. Instructions to fill the questionnaire were given verbally to all students. Each student was also instructed to present three career choices in order to priority. Data was collected. Prevalence of different learning styles in medical students and intermediate level students is shown in table-I and table-II respectively. The prevalence and pattern of learning styles of intermediate level learners and medical students is different. Majority of intermediate level learners have the converger learning styles in contrast with the medical students in whom accommodators are in overwhelming majority. Most learners choosing "Doctor" as their preferred career among intermediate level learners were of assimilator style, followed by convergers. Accommodators were on third place in choosing "Doctor" as preferred career. The most preferred career among intermediate level learner was "Teacher"

Management of first trimester missed miscarriage with minimal surgical intervention

To observe the efficacy of Prostaglandin E1 analogue [misoprostol] in management of 1st trimester missed miscarriage. Observational study The study was done from June 2005 to June 2007 at Pakistan Railway Hospital Rawalpindi All patients presenting with 1st trimester missed miscarriage excluding suspected ectopic pregnancy, massive vaginal bleeding at admission, previous 3 scars, severe anaemia, history of handling before and history of bleeding disorders were subjected to the 1000 microgram regime of oral misoprotol in divided doses in 6 hours 400 micrograms orally stat and then 200 microgram 2 hourly 3 doses. After informed counselling and consent of the patient, a detailed Pelvic scan, blood complete picture, Hepatitis screening, blood sugar random and blood group was done. The patients were hospitalized and counselled as soon as first dose was given. The main outcome measures which were evaluated were complete abortion, incomplete abortion, severe haemorrhage, gastro-intestinal disturbances like nausea / Vomiting and any surgical intervention, if required like dilatation and curettage and evaculation and curettage. A total of 100 women were recruited to this study, 97% patients completed the 6 hours dosage regime and 3% patients expelled completely after initial doses. In 30% patients' evacuation was done which means that no cervical dilatation was required and the time of surgery/general anaesthesia was less than 6 minutes on average. Nausea and vomiting were seen in only 6% patients but considered as tolerable and transient. Only 1% patient had heavy bleeding and required an emergency evacuation, histopathology of which revealed molar tissue. None of them required blood transfusion. Majority of patients had no side effects. Patient satisfaction with oral misoprostol treatment was high, as many participants reported that they would prefer the same treatment if they have another miscarriage. Medical management of missed abortion is effective, reduces the need of dilatation and curettage, and is associated with high levels of patient satisfaction

study of students' learning styles in medical institution in Pakistan

To determine the learning styles of medical students in a medical college in Pakistan and to match the learning styles of students with the instructional strategies in clinical classes. The cross-sectional descriptive study involved medical students of the Islamic International Medical College [IIMC], in clinical classes. Both male and female students were administered a questionnaire based on Kolb's learning style inventory. Instructions to fill the questionnaire were given verbally to all students. Majority of students had the accommodators learning style [N=83, 54.6%] while convergers, divergers and assimilators were less in number. The learning scheme consists mainly of lecture based learning [42 hours per week] and case based learning [31 hours per week] Majority of students of clinical classes of IIMC had the accommodator learning style, followed by converger, diverger, and assimilator learning styles. The learning scheme of IIMC provided learning opportunities for all styles of learning and consisted of adequate instructional strategies