Reproductive Health.

Definition: Care of female gender starting right from female foetus upto the grave. Application of this concept is essential to alleviate all cruelities meted out to women in all fields such as female fetocide.

Background: It is a relatively recent term. Uplift of Society is not possible untill women are fully developed, given equal status in all matters, and are properly educated. They should be economically independent. All human rights must be implemented fully and forcefully as regards women in any society. Prejudices against them should be eliminated. These concerns were raised and policies adopted in very high profile conferences in Cairo in 1994 and later in Beijing.

Contrception use rate increases when literacy rate and income goes up. In Siri Lanka literacy rate is 98 % and number of children is 2.8/women. In India this is 3.4,in Pakistan it is 5.4.Infant and maternal mortality rates also improve with improvements in income, education and granting of more and more rights. Awareness about these things has to be created not only in ladies but in males also.

Expenditure on such essential sector is appauling low. One week’s expenditure on armaments worldwide is more than what is being spent on contraception in whole of the world.

Role of Family Physicians:

They should lead the crusade

§         for uplifting the nutritional, educational and all social indicators.

§         Awareness about the hazards of early age marriages.

§         Advice right after marriage about birth spacing.

§         To advocate and propagate about all human rights of women in the society.Especially to prepare the society to grant decision making power to the wives in the affairs of the family.To assist her to acquire the decisions about fertility matters

Sexually Transmitted Diseases, STDs:

§         Incidence is probably coming down. May be due to use of antibiotics.

§         Still vigilance about AIDS and Herpes Simplex is needed. There are cases of these infections. We need strong awareness in public and physicians about these.

§         Chlamydial infections are most common cause of tubal blockage.These are asymptomatic. Difficult to diagnose.

§         Use of codoms is much more desirable to avoid these STDs.An awareness compaign is much needed at this stage. Some users complain that they have allergy with condoms. A doctor must confirm allergy. If it is so low allegen condoms are also availabe or brand can be changed.

Prolapse of Uterus.

·        In the etiology one important factor is inappropriate handling and effort to deliver and asking the mother to bear down baby in the phase of undilated cervix.

·        Multiparity and chronic ill health are other factors.

·        Main symptoms are feeling of pressure and something coming out.

·        Pessaries can be used if family is not complete. Once Family is complete then surgical treatment is the only answer.

·        Prior to surgery treatment of any local ulcers is mandatory.

Vaginal Discharge.

q       This is most frequent complaint in our outdoors. Excessive but normal discharge needs only careful listening and giving due weight to the complaints of patients. Explanation of association with menstrual cycle and education may help the women to accept it as normal variant.

q       Leucorrhoea, which is though inflammatory and pathological but it, is not due to any infection. Speculam examination is essential. Cervical erosions (ectopy) are usually there. These need cautery.

q       Vaginal discharge associated with candida, trichomonas or anaerobes needs local treatment. First local treatment should be tried. If there is no response after 2 local courses then systemic therapy can be given.

q       Neither there is routine nor there are facilities available for culture and sensitivity of vaginal discharge. For anaerobes culture has to be inoculated and transmitted to the laboratory. Logistics involved are not feasible.

Urinary Incontinence

Mainly of 3 types. Urge, Stress and Detrusor instability.

q       Urge incontinence: Rule out U T I .It requires psychological management.

q       Stress incontinence/Detruser Instability.Whenever there is sudden rise in abdominal pressure ,some urine leaks.Pelvic floor excercises are quite useful to strengthen.Here patient should be educated that she should contract her muscles as she would do when she is having urge to pass urine but can not pass due to any reason and she is trying to control the leaking of urine. After contracting the muscles she should keep these muscles contracted till she counts upto 10.Then she should release the pressure. It should be repeated 10-20 times at one time.Drugs like oxybutanil may be helpful.

Abortions

Diagnosis.Ultrasound examination is single most important investigation to diagnose the status.

At 6 weeks foetal pole should be visible. As long as it is visible at this time abortion should be labelled as threatened only. At 7-week gestation cardiac activity should be seen. If in doubt USG can be repeated after another one week. Again as long as cardiac activity is visible, abortion is not there.Urine pregnancy test can also be of help to diagnose pregnancy.

Repeated Abortions.

Some figures. In the same patient

Chance of first abortion = 5 %

//          // Second abortion        = 20 %

//          Third abortion   = 23-25 %

//          Fourth abortion =30 %

So in the same patient even after 4 abortions chances of normal pregnancy are still 60-70 %.

Investigations.

Investigations like CBC, ESR, Urine, Blood Sugar, USG are in order.

Proper history should be taken. Complete pelvic examination by gynaecologist is essential.

Following investigations may be ordered for antithrombophilic syndrome.

·        Anti phospholipid antibodies.

·        Lupus antibodies.

·        Anti cardiolipin antibodies.

Chances of normal pregnancy are only 10 %. With use of low dosage aspirin this rises to 40 %. Still further it can go upto 70 % with low molecular wieght heparin.

Karyotyping can be ordered from AFIP Rawalpindi, if patient can afford after 3^rd abortion.