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 ...

BackgroundEgo defense mechanisms (or factors), defined by Freud as unconscious resources used by the ego to reduce conflict between the id and superego, are a reflection of how an individual deals with conflict and stress. This study assesses the prevalence of various ego defense mechanisms employed by medical students of Karachi, which is a group with higher stress levels than the general population.MethodsA questionnaire based cross-sectional study was conducted on 682 students from five major medical colleges of Karachi over 4 weeks in November 2006. Ego defense mechanisms were assessed using the Defense Style Questionnaire (DSQ-40) individually and as grouped under Mature, Immature, and Neurotic factors.ResultsLower mean scores of Immature defense mechanisms (4.78) were identified than those for Neurotic (5.62) and Mature (5.60) mechanisms among medical students of Karachi. Immature mechanisms were more commonly employed by males whereas females employed more Neurotic mechanisms than males. Neurotic and Immature defenses were significantly more prevalent in first and second year students. Mature mechanisms were significantly higher in students enrolled in Government colleges than Private institutions (p < 0.05).ConclusionsImmature defense mechanisms were less commonly employed than Neurotic and Mature mechanisms among medical students of Karachi. The greater employment of Neurotic defenses may reflect greater stress levels than the general population. Employment of these mechanisms was associated with female gender, enrollment in a private medical college, and students enrolled in the first 2 years of medical school.

BackgroundThe developing world is faced with a high burden of anxiety disorders. The exact prevalence of anxiety disorders in Pakistan is not known. There is a need to develop an evidence base to aid policy development on tackling anxiety and depressive disorders in the country. This is the first pilot study to address the prevalence of anxiety disorders and their association with sociodemographic factors in Pakistan.MethodsA cross-sectional study was conducted among people visiting Aga Khan University Hospital (AKUH), a tertiary care facility in Karachi, Pakistan. The point prevalence of anxiety amongst the sample population, which comprised of patients and their attendants, excluding all health care personnel, was assessed using the validated Urdu version of the Hospital Anxiety and Depression Scale (HADS). The questionnaire was administered to 423 people. Descriptive statistics were performed for mean scores and proportions.ResultsThe mean anxiety score of the population was 5.7 ± 3.86. About 28.3% had borderline or pathological anxiety. The factors found to be independently predicted with anxiety were, female sex (odds ratio (OR) = 2.14, 95% CI 1.36–3.36, p = 0.01); physical illness (OR = 1.67, 95% CI 1.06–2.64, p = 0.026); and psychiatric illness (OR = 1.176, 95% CI 1.0–3.1, p = 0.048). In the final multivariate model, female sex (adjusted odds ratio (AOR) = 2, 95% CI 1.28–3.22) and physical illness (AOR = 1.56, 95% CI 0.97–2.48) were found to be significant.ConclusionFurther studies via nationally representative surveys need to be undertaken to fully grasp the scope of this emerging public health issue in Pakistan.

Previous studies have found a significantly increased risk of preterm delivery and low birth weight after cervical conization. Most of these studies were case-control studies or were small, hampering the ability to detect significant differences between gestational age groups. This population-based cohort study evaluated the adverse consequences of cervical conization on subsequent pregnancies. The investigators linked data from the Medical Birth Registry of Norway and the Cancer Registry of Norway for the years 1967 to 2003 on 15,108 births occurring in women who had previously had cervical conization and 57,136 who subsequently had the procedure. The 2,164,006 births during the study period by women who had never had cervical conization served as controls.The proportion of preterm birth (delivery before 37 weeks of gestation) was 17.2% [95% confidence interval (CI); 16.6%-17.8%] among women who gave birth after cervical conization; 6.7% (95% CI, 6.5%-6.9%) in women who gave birth before cervical conization; and 6.2% (95% CI, 6.2%-6.3%) in women who never had the procedure. The relative risk (RR) of premature delivery after cervical conization compared with women who never had cervical conization increased with decreasing gestational age: RR 2.5 (95% CI, 2.4-2.6) at 33 to 36 weeks; RR 3.4 (95% CI, 3.1-3.7) at 28 to 32 weeks; and RR 4.4 (95% CI, 3.8-5.0) at 24 to 27 weeks. The risk of a late abortion (Ͻ24 weeks of gestation) was higher after cervical conization compared with no conization; the RR was 4.0 with a 95% CI of 3.3 to 4.8. During the study period, the RR of preterm delivery declined, particularly for delivery before 28 weeks of gestation. These findings show that cervical conization increases the risk of preterm delivery in subsequent pregnancies, especially early in pregnancy when the clinical significance is highest. EDITORIAL COMMENT(As one would expect, the data that we have relating ablative and excisional procedures for cervical dysplasia to late abortion and prematurity were not derived from randomized studies. That is to say, reproductive age women with cervical dysplasia deemed to require cervical ablation or excision have not been randomized to therapy or to expectant management for the purposes of evaluating their subsequent preg-nancy performance. Nor has a study been done wherein women have been randomized to different methods of cervical ablation or excision for the purposes of comparing subsequent pregnancy outcomes. Clearly, randomized trials of this nature would be logistically extremely difficult to do, and, in some situations, ethically problematic. But they would be the best way to overcome the major problem in evaluating the OBSTETRICS Volume 64 Number 2 OBSTETRICAL AND GYNECOLOGICAL SURVEY ABSTRACTPrevious studies have shown that during cesarean section, the concentration of lactate in myometrial capillary blood is higher among women with dysfunctional labor compared with normal labor. Small increases in lactate concentrations have been associated with impairment in the strength an...

Acute bleeding after delivery can be a life-threatening complication. Emergency hysterectomy is usually undertaken as a last resort. This study was conducted in order to estimate the incidence, indications, risk factors and complications associated with peripartum hysterectomy performed at a tertiary care hospital. We retrospectively analysed 39 of 45 cases of emergency peripartum hysterectomy performed at the Aga Khan University Hospital from 1997-2006. Peripartum hysterectomy was defined as one performed for a haemorrhage after delivery which is unresponsive to other treatments. The most frequent indications for peripartum hysterectomy were morbidly adherent placenta (46%) and uterine atony (23%). The duration of surgery was shorter (P = 0.045) but the complications were higher (P = 0.029) in total compared with subtotal hysterectomies. Our results suggest that caesarean deliveries are associated with an increased risk for peripartum hysterectomy, which is of concern given the increasing rate of caesarean deliveries. Subtotal hysterectomy is a reasonable alternative in emergency obstetric hysterectomy.