Prescribing in pregnancy

Objective: To assess the prescribing patterns and clinical practices in the use of pharmaceutical agents in pregnancy

Study Design: Observational, Cross-sectional study

Study Period: March 2002 to March 2003

Setting: Study was conducted at antenatal clinic, Jinnah Hospital, Lahore

Materials and Methods: 250 patients from antenatal clinic were interviewed to collect information regarding age, parity, gestational age, any medication, its indication, route, duration and prescriber during current pregnancy on a pre-designed proforma

Sampling Method: Patients were enrolled in this study on first come and enroll basis

Results: Most of the women [90%] visiting the antenatal clinic were in the age group 21-30years. 94% of the women were taking medications and the prescriptions included haematenics [88%], folic acid [61%], calcium supplements [63%], antibiotics [22%], anti-fungals [19%], antiemetics [8%] and laxatives [6%]. 6% of women were not taking any medication. Commonest prescribers were general practitioners [46%]. Rest of the prescribers were medical officers at antenatal clinic [28%], LHVs/nurses [11%] and specialists [9%]. Self-medication was seen in 6%. 47% of the women taking self-medications were among the educated group [Matric and above] and 53% of the women were among the uneducated group [P < 0.001]. 28% took treatment from general practitioners and lady health visitors without any certain diagnosis, on symptomatic grounds

Conclusion: The use of drugs in pregnancy is substantial and varied. Information on the use of drugs during pregnancy is scarce and anecdotal. Careful consideration of the benefits to the mother and risks to the fetus is required, when prescribing drugs during pregnancy. All prescriptions or drugs recommended in pregnancy must have solid evidence derived from current literature

Hysterectomy: the patient`s perspective

Objectives: Importance of information provision by the gynaecologist and its effects on women`s decision making about hysterectomy

Design of Study: Structured questionnaire and interview

Setting: Department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore

Materials and Methods: A questionnaire was given to 50 women who had undergone hysterectomy for benign menstrual problems and information was collected. Main Outcome Measures: Women`s experience and satisfaction, with the communication and information provision by the doctor about her disease before hysterectomy. To assess the influence of that counseling on the decision-making process of hysterectomy

Results: Most of the women undergoing hysterectomy were between the age group of 40 - 45yrs [40%]. Most common indication for hysterectomy was dysfunctional uterine bleeding [55%]. 32% women reported optimal satisfaction with decision made. 57 highlighted sub-optimal aspects of decision-making process. 37% complained of deficiency in communication skills of doctors and 63%, stated that information provided were incomplete [P<.001]. 11% had residual doubts about the appropriateness of hysterectomy

Conclusion: The efforts are required to ensure that women are adequately informed and involved in decision about gynecological treatment

Induction of labor Misoprostol vs Dinoprostone

Objective: To compare the safety and efficacy of misoprostol with PGE2 for induction of labor by intra vaginal administration

Study Design: It was a comparative and interventional study

Study Venue: The study was carried out in the Department of obstetrics and Gynaecology, Jinnah Hospital, Lahore

Subjects and Methods: 46 women with indications for labor induction at term and post-term were randomly assigned to two groups. Each woman received either 200 microgram of misoprostol or 3mg of prostaglandin E2 intravaginally. If labor was not initiated after 4 h, the same dose was repeated every 4 h to a maximum of 400 microgram of misoprostol or 6mg of PGE2, until adequate labor and vaginal delivery was achieved or patients delivered by abdominal route

Main Outcome Measures: The main parameters measured were: latent period, time from induction to vaginal delivery, delivery route, and occurrence of uterine tonus alterations, hypoxia and neonatal morbidity. The statistical analysis of the data was carried out in SPSS software

Results: 23 women were allocated to the misoprostol group and 23 to the prostaglandin E2 group. Misoprostol was more effective than PGE2 in producing cervical changes. Delivery within 10-12 h, after the first administration occurred more often in the misoprostol group than in the PGE2 [16 [69.56%] vs 2 [8.69%]]. Less patients in the misoprostol group required oxytocin augmentation than in the PGE2 [3 [13.04%] vs. 5 [21.73%]]. Uterine tachysystole and hyperstimulation occurred more frequently in the misoprostol group [3 [13.04%]] than in the PGE2 group [1 [4.34%]]. No statistically significant differences were noted between the two groups including mode of delivery and neonatal or maternal adverse outcome. The interval from induction to vaginal delivery was significantly shorter in the misoprostol group [6-8 hrs vs 11-12hrs]. Abdominal delivery rate was more frequent in misoprostol group because of fetal tachycardia and hyper-stimulation than prostaglandin group [2 [8.69%] vs 1 [4.34%]]. Repeat dose was required mainly prostaglandin group [6 [26.08%]] as compared with misoprostol [4 [17.39%]]

Conclusions: Compared with prostaglandin E2, intracervical misoprostol is more effective in cervical ripening and labor induction at term. The higher frequency of uterine hyper-contractility associated with the use of misoprostol did not increase the risk of adverse intrapartum and neonatal outcomes, but the vigilant fetomaternal monitoring is considered to be essential in every case of induction

Management of preterm labor

Aims and Objectives of Study: To compare the safety and efficacy of Ritodrine and Salbutamol in the management of preterm labour

Study Design: It was an interventional study in which the comparison between Salbutamol and Ritodrine was carried out for the prevention of preterm labour

Study Setting: Department of Obstetrics and Gynaecology, AIMC/ Jinnah Hospital, Lahore

Patients and methods: 50 patients admitted for prevention of preterm labour were randomly assigned to two groups having 25 patients in each group. One group was given 100mg Ritodrine [group I] in 500ml of 5% Dextose water, starting at a dose of 50Microg/min and increased by 50Microg/min every 15-30min till uterine activity ceased or dose of 350Microg/min reached or other in tolerable side effects appeared. The effective tocolytic dose without side effects was maintained for 24 hours during this period steroid cover was given. Another group was given 5mg Salbutamol [group-II] in 500ml of 5% D/S, at a dose of 10Microg/min to a maximum of 45 Microg/min until contraction ceased or side effects started. Continuous maternal and fetal monitoring was carried out in both groups

Results: Fifty patients presenting with preterm labour were studied. The maximum numbers of patients were in the age group of 30-34 years. Mean gestational age in group-I was 30.56weeks and group-II was 30.60weeks. 88% were with cephalic presentation, 8% had breech presentation and 4% presented with transverse lie in both groups. In group-I, 80%cases were < 32weeks of gestation and in group-II, 72% cases were <32 weeks of gestation. 52% in group-I and 56% in group-II were primigravida. Dilatation of the cervix at the time of first examination in group-I was 2cm in 22[88%] patients and 2-4cm in 3[12%] patients. In group-II 2cm in 20[80%] patients and 2-4cm in 5[20%] patients. The effacement of the cervix at the first examination was < 40% in 16 patients [64%]. 40-50 in 6 [24%] patients and 60% in 3 [12%] patients in group-I and in group-II < 40% in 14 [56%] patients, 6[24%] patients 40-50% effacement and 5[20%] patients had 60% effacement. Successful tocolysis was achieved in 76% of the cases with Ritodrine hydrochloride [Group-I] and in 72% of the cases with Salbutamol [Group-II]. The delay in the delivery for 48 hours, 7 days and till 36 weeks of gestation were 76%, 64%, and 52% of patient respectively for Ritodrine and 72%, 56% and 40% respectively for Salbutamol. Headache, nausea and vomiting were complained in 6[24%], 2[8%] and 1[4%] patient in group-I and 4[16], 3[12%], and 2[8%] in group-II respectively

Conclusion: This study shows that Ritodrine hydrochloride and Salbutamol are equally effective regarding delay of delivery and prolongation of gestation

Transabdominal sonography comparison with transvaginal sonography

Aims and Objectives: Transvaginal sonography [TVS] comparison with trans-abdominal sonography [TAS] in the diagnosis of pelvic masses

Study Design: Retrospective descriptive study conducted at Gynae clinic Jinnah Hospital Lahore with collaboration of radiology department

Materials and Methods: Transvaginal Sonogram was compared with transabdominal sonogram in hundred women referred for evaluation of pelvic masses from gynae clinic. All the women were interviewed regarding their age, parity, duration of mass and associated symptoms. Diagnosis was based on the combination of clinical, sonographic [TVS, TAS] and surgical correlation. Both ultrasound modalities were compared for the details about the internal architecture and diagnostic information

Results: Most common age group with pelvic masses was between 26-35yrs. TVS was more sensitive for both uterine and adnexal masses. Sensitivity of TAS was 65% and TVS was 88%. There was a significant difference in diagnosing true positive cases by trans-vaginal approach. [P value < 0.001] Specificity of TAS was 89% and TVS 86% for both uterine and adnexal masses. Image quality was better in 87% of cases with trans-vaginal approach and 5% of cases with trans-abdominal approach and it was equivalent in 8% of cases. There was a significant difference in the image quality between two modalities [P value < 0.001]. Regarding anatomical details TAS was better in 12% of cases and TVS was better in 28% of cases and both were equivalent in 60% of cases, Diagnostic information of these two modalities was almost equivalent. TAS was better in 7% of cases and TVS was better in 8% of cases and both were equivalent in 85% of cases

Conclusion: The results suggest that TVS has considerable advantage over conventional TAS in evaluation of pelvic masses in women

Sacrocolpopexy in management of vaginal vault prolapse

Aims and Objectives: To review the efficacy of Sacrocolpopexy in the management of vaginal vault prolapsed

Study Design: Interventional study

Setting and Population: Department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore. Women with vaginal vault prolapse after hysterectomy.

Methods and Main-outcome measures: Abdominal Sacrocolpopexy using proline mesh. Follow-up in these patients were carried out at one week, four weeks, six months, and one year

Results: Sacrocolpopexy was carried out in ten patients for vaginal vault prolapse after vaginal [6] and abdominal hysterectomy [4]. The mean age was 49.8 years. Parity was between P3 - P6 [Mean parity 4.3]. Mean operation time was 79.3 minutes. Estimated blood loss was less than 200m1. No intra-operative or post-operative complications occurred in any case

Conclusion: Abdominal sacrocolpopexy is effective and safe in the treatment of vaginal vault prolapse. This procedure has high success rate in correcting prolapse without a time dependent decrease in efficacy

Emergency contraception: knowledge, attitudes and practices of general practitioner

We conducted a telephone survey among general practitioners from different localities of Lahore selected as convenience sample. Information was collected on a pre-designed questionnaire. The main outcome measures were the knowledge regarding preparations, efficacy, safety, side effects and their attitude toward EC. The relationship of knowledge with age, education and years of practice was also assessed. We interviewed 120 GPs [50 males, 70 females]. Among these 65% of the doctors were <40 years of age and 35% > 40 years. Of the responders 38% didn't know anything about emergency contraception, whereas 46% knew only about hormonal method of emergency contraception 15% about the hormonal and IUCD and none of them was aware of Mifepristone. Among these, the knowledge of 30% of the participants about emergency contraception was adequate and that of 70% was inadequate. The difference of accuracy of knowledge was statistically significant [p<0.05]. Only 10% of GPs were in routine practice to talk about EC as a backup support while discussing their patients about contraception. There was no statistically significant difference of knowledge among males and females [p>0.05]. Young GPs [<40 years of age] were more aware of IUCD as EC compared with those more than [>40 years] though the difference was not statistically significant but it might have a clinical significance. GPs with postgraduate education when compared with graduates were more likely to know and talk about EC [P <0.05]. Maximum knowledgeable GPs were those practicing for the last 5 years [30%] as compared to practicing for more than 10 years [6.7%] [p<0 05]. Ethically and morally all GPs were in support of EC and were having favourable attitude towards EC. These findings of our study suggest that the precise knowledge about emergency contraception among doctors [GPs] is inadequate. Prescription practices can improve by generating education and training of health care providers. It should be a routine practice to consider emergency contraception as a part of contraceptive discussion with the couple. The purpose of the present study was to assess the knowledge, attitude and practices of general practitioners toward emergency contraception from different localities of the city of Lahore, which has a population of more than 6 million