Aim: Polycystic ovarian syndrome (PCOS) is one of the most common endocrinopathies in women of reproductive age. It is associated with hyperinsulinemia and insulin resistance which is further aggravated during pregnancy. This mechanism has a pivotal role in the development of various complications during pregnancy. In the past few years, metformin, an insulin sensitizer, has been extensively evaluated for induction of ovulation. Its therapeutic use during pregnancy is, however, a recent strategy and is a debatable issue. At present, evidence is inadequate to support the long-term use of insulin-sensitizing agents during pregnancy. It is a challenge for both clinicians and researchers to provide good evidence of the safety of metformin for long-term use and during pregnancy. This study aimed to evaluate pregnancy outcomes in women with PCOS who conceived while on metformin treatment, and continued the medication for a variable length of time during pregnancy. Methods: This case-control study was conducted from January 2005 to December 2006 at the antenatal clinics of the Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan. The sample included 137 infertile women with PCOS; of these, 105 conceived while taking metformin (cases), while 32 conceived spontaneously without metformin (controls). Outcomes were measured in three groups of cases which were formed according to the duration of use of metformin during pregnancy. Comparison was made between these groups and women with PCOS who conceived spontaneously. Results: All 137 women in this study had a confirmed diagnosis of PCOS (Rotterdam criteria). These women were followed up during their course of pregnancy; data forms were completed once they had delivered. Cases were divided into three groups: group A, 40 women who stopped metformin between 4-16 weeks of pregnancy; group B, 20 women who received metformin up until 32 weeks of gestation; and group C; 45 women who continued metformin throughout pregnancy. All the groups were matched by age, height and weight. Comparison was in terms of early and late pregnancy complications, intrauterine growth restriction and live birth rates. In groups A, B and C the rate of pregnancy-induced hypertension/pre-eclampsia was 43.7%, 33% and 13.9% respectively (P < 0.020). Rates of gestational diabetes requiring insulin treatment in groups A and B were 18.7% and 33.3% compared to 2.5% in group C (P < 0.004). The rate of intrauterine growth restriction was significantly low in group C: 2.5% compared to 19.2% and 16.6% in groups A and B respectively (P < 0.046). Frequency of preterm labor and live birth rate was significantly better in group C compared to groups A and B. Overall rate of miscarriages was 7.8%. Controls were comparable to group A in terms of early and late pregnancy complications. Conclusion: In women with PCOS, continuous use of metformin during pregnancy significantly reduced the rate of miscarriage, gestational diabetes requiring insulin treatment and fetal growth restriction. No ...

Objective To estimate the prevalence of obstetric fistula, its duration and impact on women's daily life using robust data collection methods in a population-based sample in rural Pakistan.Design A population-based, cross-sectional study.Setting A rural community in Sindh Province, Pakistan.Population Randomly selected women aged 15 years or older.Methods A multistage random sampling strategy was used to recruit the women. Lady Health Workers interviewed women in their own homes using a structured questionnaire to obtain symptom data. Women with symptoms of incontinence were then examined by female gynaecologists in their local health facilities to confirm obstetric fistula.Main outcome measure Obstetric fistula confirmed by gynaecological examination.Results Among the 5064 women interviewed (96% response rate), 20 women with obstetric fistula were identified, showing a prevalence of 0.39% of all women (95% confidence interval [95% CI] 0.22-0.57%) and 0.45% of parous women (95% CI 0.25-0.65%). Significantly more of the women with obstetric fistula compared with parous women without fistula were primiparae and aged <20 years. Of the women with obstetric fistula, 40% had had this for >5 years and 90% reported a major impact on their lives, yet only four had consulted a doctor, three of whom had failed repairs.Conclusions The prevalence of obstetric fistula is high in rural Pakistan. Appropriate provision is needed for fistula repair to reduce the burden of the condition. Alongside this, the improvement of maternity care services is urgently needed to prevent its continued occurrence.

Background: Polycystic ovarian syndrome (PCOS) is the most common cause of anovulatory infertility worldwide. In addition to a poor conception rate, pregnancy loss rates are significantly higher (30–50%) during the first trimester in women with PCOS. Insulin resistance (IR) in this syndrome is not only implicated toward early pregnancy loss (EPL) but also pathognomic for various obstetrical complications during pregnancy. We evaluated the role of Metformin in the reduction of EPL in women with PCOS who conceived spontaneously or after induction ovulation with or without Metformin. Objective: The primary objective was to evaluate the effectiveness of Metformin in the reduction of EPL in women with PCOS. Secondary outcomes like gestational diabetes, pregnancy-induced hypertension and intrauterine growth restriction were also analyzed at the end of the study. Material and Methods: This case-control study was conducted from March 2005 to March 2008 in the infertility and antenatal clinics of the Department of Obstetrics and Gynecology of Aga Khan University Hospital, Karachi, Pakistan. A total of 197 infertile women with PCOS were included. ‘Cases’ were women with PCOS who conceived while taking Metformin and it whom it was continued throughout pregnancy. ‘Controls’ were women in whom Metformin was either stopped in first trimester after confirmation of pregnancy (by serum βHCG or by ultrasound) or they conceived spontaneously without the use of Metformin. Results: All 197 women in this study had a confirmed diagnosis of PCOS (Rotterdam criteria). These women were followed till the final outcome of pregnancy was achieved. Both groups were compared for risk of EPL. It was found that continuation of Metformin during pregnancy reduces EPL, i.e. 8.8 vs. 29.4% in cases and controls, respectively (p < 0.001). In the subset of women with a prior history of miscarriage, the pregnancy loss rate was 12.5% in the Metformin versus 49.4% in control group (p = 0.002). Conclusion: Metformin continuation during pregnancy significantly reduces EPL in women with PCOS. IR may play a significant role in EPL.

Afghanistan is a net importer of wheat which is the staple food in the country. In order to improve the levels of food sufficiency, prevailing large yield gaps in wheat need to be reduced. This study assessed the reasons/factors influencing low wheat productivity and/or large yield gaps in different production systems in five major wheat-producing provinces in Afghanistan using a stochastic frontier production function model. The results indicated that the mean technical efficiency of wheat farmers was 0.67, and there was clear scope to improve wheat production by 33% in the short run with the same level of inputs. The potential yield gap could be reduced if adoption of good agricultural practices such as the use of improved wheat varieties with recommended seed rates was promoted through more effective transfer of technologies (training and extension) in the target provinces. Such efforts would help improve domestic wheat production and reduce dependency on wheat imports.

Objectives: To determine the prevalence of abnormal Papanicolaou (Pap) smears in patients visiting the gynecologic outpatient department at Aga Khan University Hospital, Karachi (AKUH) and their cytohistologic correlation. This data was also compared with other international institutions. Methods: A database search of all abnormal cervical cytological cases diagnosed in the gynecologic outpatient department at Aga Khan University Hospital in the last 10 years (i.e. from 1994 to 2004), as well as their follow-up biopsies, was carried out. The data was then analyzed. Results: Of the 66 617 Pap smears reviewed, 95% of cases had a diagnosis of ‘negative’, 2% of smears were labeled as ‘inadequate’, 0.54% Pap smears showed dysplastic changes, and 0.14% were labeled as ‘malignant’. These numbers are less than figures in Western countires, but are comparable with Asian figures. The pick-up rate for abnormal Pap smears was 8/1000, while the overall concordance rate was 74%; positive predictive values for high-grade cervical lesions and for carcinomas was high 92–100%, respectively; while for ASCUS and low-grade cervical lesion was 35% and 67%, respectively. A total number of 8 cases were identified where there was a discrepancy between cytological and histological diagnosis, they were reviewed critically. Conclusion: In most of the developing countries effective Pap screening faces certain barriers. This includes limited or poor quality of cytology services. In a low-resource country like Pakistan there is a subset of patients (those with atypical cellular abnormalities) who may benefit from repeat smears instead of early cervical biopsies. In order to improve the efficacy of our cytology services, we need to develop specific clinical protocols for subsequent management of abnormal smears