Factors Associated with Intrauterine Fetal Death at Paropakar Maternity Women's Hospital

Background Intrauterine fetal death (IUFD) is a demise occurring at 20 or more weeks of gestation and weight 500 gram or more. Intrauterine fetal death at any point during gestation is a traumatic event not only to the patient but also to the care giver. The purpose of this study is to know the risk factors associated with intrauterine fetal death. Objective To determine the factors associated with intrauterine fetal death. Method Prospective observational study was conducted at Paropkar maternity women's hospital, Thapathali, Kathmandu. All the cases with intrauterine fetal death were admitted and delivered in the hospital with period of gestation 20 weeks to term pregnancy. All the relevant data were recorded in pre-designed proforma. The collected data were entered in SPSS 25 version for analysis. Result There was a total 5153 deliveries in three months, with prevalence of 1.2% and intrauterine rate of 12.03 per 1000 births. Out of 50 enrolled cases, 78% (n=50) of patient had not attended antenatal checkup. Majority (n=50; 74%), belonged to age group 21-35 years, 48% of intrauterine fetal death were term pregnancies of 37 to 42 weeks of gestation. Maximum 20% of IUFD, weighed between (1-1.5 kg) (1.5-2 kg) and (2.5-3 kg). Thirty-nine babies were macerated and eleven non-macerated. Pregnancy induced hypertension was most common (26%), followed by ante-partum hemorrhage (8%), hypothyroidism and anemia (6%), meconium stained liquor and cord prolapse (6%), gestational diabetes mellitus, congenital anomalies, chronic hypertension (4%), intrauterine growth restriction and urinary tract infection (2%). Twelve cases underwent cesarean section. Postpartum complications were found in 10 cases; 4 cases had postpartum hemorrhage, 4 had prolonged hospital stay and 2 cases developed hemolysis, elevated liver enzyme, low platelet count (HELLP) syndrome. Conclusion This study concluded that maximum no. of intrauterine fetal death were seen antenatally, as 78% of cases were found macerated. The commonest identified risk factor was pregnancy induced hypertension, followed by ante-partum hemorrhage, anemia, hypothyroidism, which seem to be preventable risk factors of intrauterine fetal death, but still unidentified risk factors are of great challenges for the obstetricians.

A Point Prevalence Study of the Use of Antibiotics in Six Tertiary Care Hospitals in the Kathmandu Valley, Nepal

Background Point prevalence survey (PPS) on antibiotic use developed by the WHO has already been used in many hospitals globally. Objective To obtain information on antibiotic prescribtion using point prevalence survey methodology in six private hospitals in the Kathmandu valley. Method This descriptive cross-sectional study was completed during 20th July to 28th July 2021 using point prevalence survey methodology. The study was conducted among inpatients admitted at or before 8:00 AM on the day of survey in various wards. Data was presented as frequencies and percentages. Result Maximum number of patients were above 60 years [34 (18.7%)]. Number of male and female participants were equal [91 (50%)]. Only one antibiotic was used in 81 patients (44.5%) followed by two antibiotics in 71 (39%) patients. Duration of prophylactic antibiotic use was one day in 66 (63.7%) patients. Blood, urine, sputum, and wound swabs were the common samples for culture. Cultures were positive for 17 (24.7%) samples. The common organisms isolated were E. Coli, Pseudomonas aeruginosa and Klebsiella pneumoniae. Ceftriaxone was the most used antibiotic. Drug and therapeutics, infection control committee and pharmacovigilance activities were present in 3/6 (50%) study sites. Antimicrobial stewardship was present in 3/6 (50%) and microbiological services was present in all hospitals. Antibiotic formulary and antibiotic guideline were present in 4/6 sites and facilities to audit or review surgical antibiotic prophylaxis choice in 2/6 (33.3%) sites, facility to monitor antibiotic use in 4/6 (66.6%) and cumulative antibiotic susceptibility reports in 2/6 (33.3%) study sites. Conclusion Ceftriaxone was the most used antibiotic. E. Coli, Pseudomonas aeruginosa and Klebsiella pneumonia were the commonly isolated organisms. Not all parameters for infrastructure, policy and practice and monitoring and feedback were present at the study sites. KEY WORDS.

Teenage Pregnancy and Associated Risk Factors and Outcome in Nepal From 2000-2020: A Systematic Review and Meta-Analysis

Background Teenage pregnancy is considered a high-risk pregnancy in terms of reproductive outcome and the subsequent financial constraint. Objective To assess the prevalence of teenage pregnancy, associated risk factors, and outcomes in the context of Nepal. Method We searched electronic databases to search relevant articles published from January 2000 till October 2020 using the keywords with appropriate Boolean operators. All the data were extracted into a standardized form designed in Excel. We conducted a statistical analysis using Comprehensive Meta-Analysis Software (CMA) version 3. Data pooled for proportion with 95% confidence interval (CI). A Forest plot was used to visualize the degree of variation between studies. Result Fourteen studies were included in the analysis after the rigorous screening of 4425 studies. Prevalence of teenage pregnancy was 13.2% (Proportion, 0.132; CI, 0.077- 0.215). Among teenage pregnancies, 11.8% were already multigravida (Proportion, 0.118; CI, 0.029-0.374). Among teen pregnancies, 18.6% were illiterate; among the literate, only 25.9% were of education above grade 10,31.9% were unaware of contraceptive methods, and only 3.2% reported using any contraception methods. 75.4% of teenage pregnancies had a vaginal delivery with or without episiotomy, 6.5% by instrumental deliveries, and 21.5% by cesarean section. Preterm delivery was 12.0%, and post-term delivery was 8.2%. Abortion was reported in 11.1% of teenage pregnancies. Major tears were reported in 52.9%, obstructed labor was in 4%, and pre-labor rupture of the membrane was in 7.0% of teenage pregnancies. The low birth weight of newborns was 19.4%. Stillbirth and neonatal deaths were 1.7% and 1.4%, respectively. Conclusion The prevalence of teenage pregnancy in Nepal was 13.2%. The majority of them did not use any form of contraceptives; and had low education. Several maternal and neonatal complications were reported among teenage pregnancies.

Profile of Women receiving Second-trimester Safe Abortion Service at Paropakar Maternity and Women's Hospital

Background Second trimester abortions account for a small percentage of abortions globally. Abortion is one of the safest medical procedures. Accessibility of safe and high quality second-trimester abortion care can decrease severe complications associated with it. Objective The profile of women undergoing second-trimester abortion was assessed during the study. The profile includes demographic and clinical aspects. The study also aims to find out the rate of surgical and medical methods of abortion and to understand its indications. Method It is a study based on retrospective data collected from charts available at the comprehensive abortion care center at the Paropakar Maternity and Women's Hospital. The data from Shrawan to Magh 2077 B.S. was collected and calculations were done on MS Excel. Result Higher proportion of women receiving second-trimester abortion were of the age between 21-25 years (n=31; 31%). Most women were literate (n=69; 69%) and n=38(38%) were nulliparous. The most common indication for abortion was maternal mental issues (n=32; 32%). The rate of medical abortion was higher (n=71; 71%) than surgical method of abortion (n=29; 29%). Conclusion There exists both demographic and clinical variations in women undergoing secondtrimester abortion. Though few women undergo second trimester abortion than first-trimester the variation in profile is significant with most women referring to second trimester abortion due to later diagnosis of pregnancy, women facing financial and logistic barriers to health care, victims of violence and women with pregnancy complications or fetal anomalies.

COVID-19 Booster Vaccine: is it an absolute need?

Booster vaccine doses are meant to revive the fading immunity created by prior exposure to an immunizing antigen. They stabilize the antibody response ultimately leading to longer and higher protection against pathogens. Immunological studies done for COVID-19 vaccines have documented a steady decrease in antibody levels among vaccinated individuals and evidence of breakthrough infections over a course of time. With an emerging science behind the need for COVID-19 vaccine booster shots, there equally is a contrasting idea regarding its absolute necessity.

Vaginal Atresia with Cervical Agenesis, a Rare Congenital Malformation

Congenital vaginal atresia and cervical agenesis is a rare congenital abnormality of the female genital tract. Here we report a case of 15-year old girl with primary amenorrhea with hematometra, presented with lower abdominal mass. She was symptomatic since 5 months and visited local hospital after 4 months of onset of her symptoms when it became severe, where diagnostic laparotomy was performed for suspected Adnexal mass. Intraoperatively adnexal mass was adhered with and extended up to the uterus with 16 weeks size of uterus. Abdomen was closed without any further intervention and was referred to higher center for needful. When she presented to Kathmandu Model Hospital, she was asymptomatic on her 5th post-operative day of laparotomy. We planned for surgical intervention after examination and investigation. Drainage with vaginoplasty with amnion graft with placement of mould was done.

Revisiting Strategies for Maternal Health Care in the Face of COVID-19 Pandemic

Novel coronavirus (SARS-CoV-2) is a new strain of coronavirus causing COVID-19, first identified in Wuhan City, China towards the end of 2019. At present, there is no evidence that pregnant women are more likely to be severely ill, need ICU care, or die from the illness in comparison to non-pregnant adults. Evidences suggest that vertical transmission, might be possible. We searched and retrieved the published literature from PubMed and Google Scholar using various keywords. We further searched the official webpages of various organizations for the updated information. Pregnant individuals in particular are encouraged to take all available precautions to optimize health and avoid exposure to COVID-19. Adequate Testing should be prioritized in pregnant women admitted with suspected COVID-19. When a pregnancy is complicated by critical illness, the pregnant patient should ideally be cared for at a Level III or IV hospital. In the face of COVID-19, antenatal fetal surveillance and ultrasonography should continue as medically indicated when possible and elective ultrasound examinations should not be performed. Maternal immunizations continue to be an essential component of prenatal care and Obgyns should screen all pregnant individuals for mental health issues. Although the most commonly reported sign in COVID-19 is fever, nevertheless, other causes of intrapartum fever should not be overlooked. Cesarean delivery should be based on obstetric indications and not COVID-19 status alone. Infants born to patients with known COVID-19 should be considered infants with suspected COVID-19. The suspected or confirmed COVID-19 mother and infant can be allowed to remain together with enhanced precautions and suspected or confirmed maternal COVID-19 is not a contraindication to breastfeeding. If both the mother and the infant are healthy, it may be prudent to expedite discharge, so as to limit the risk of inadvertent exposure and infection. The Ob-gyns should commit to providing necessary care, although modifications to health care delivery approaches may be necessary.

COVID-19 Pandemic and Neonatal Health: What We Know so Far?

COVID-19 first time appeared in December 2019 in Wuhan, China. The number of cases increased rapidly in china and outside and the World Health Organization declared a pandemic on 11th March 2020. The pregnant and postpartum women, child, and neonatal populations are vulnerable to this disease due to immunological and physiological changes. This paper analyzed the published evidence for assessing the effect of COVID-19 on neonatal health and health care. Online published literature was searched from PubMed, Google Scholar, and other official webpages using keywords: "coronavirus/COVID-19/new coronavirus 2019"/SARS-CoV-2 and neonatal health/care/outcomes" and reviewed to prepare this article. COVID-19 is the potential to transmit either mother to fetus or mother/caregiver to neonates. However, neonates born from infected mothers did not show significant clinical features. Pharyngeal-swab, amniotic-fluid, cord-blood, and breast-milk test results were not found positive. Health facility-based vaginal/caesarian delivery was considered a low risk of transmission. However, recommended to separate neonates with infected mothers/caregivers and test immediately after birth to avoid the possible transmission. Mothers/caregivers should take routine preventive measures such as washing hands frequently and avoiding contact with infected people. If neonates suffered from the server acute respiratory distress requires intensive care urgently. Despite the possibility of the intrauterine transmission of COVID-19 direct evidence is still lacking so it needs more studies for further confirmation. The International Pediatric Association suggested preventive programs, curative care, vaccination, and telemedicine care as the minimum services and called on its members to address these cares during the pandemic.

Care of Non COVID Patients in COVID-19 Era

The consequences of the COVID-19 pandemic are extensive and far-reaching. Non COVID communicable diseases continue to spread and non-communicable diseases continue to progress. People may access healthcare facilities little bit late due to fear of contracting COVID-19 and present with severe symptoms, even with complications. Nepal has been facing dual burden of both non-communicable and communicable diseases. The number of COVID-19 patients has continuously been rising in Nepal since the start of May 2020. There is an anticipated surge of infectious disease such as malaria, dengue fever, enteric fever, scrub typhus, leptospirosis during summer and monsoon seasons in Nepal. There will be surge of cases of acute undifferentiated febrile illness (AUFI) during monsoon. As fever is one of the very common symptoms of COVID-19, so COVID-19 needs to be considered in differential diagnoses of acute undifferentiated febrile illness.

The Impact of COVID-19 on Women's Health in Nepal

COVID-19 has significantly impacted the world and Nepal is no exception. The pandemic has caused a reduction in health service delivery, especially for women's health conditions, resulting in an increase in challenges for an already vulnerable group. Maternity care, reproductive health services, preventive interventions, nutritional advice and mental health care are not being addressed and with an increase in domestic violence, the health and wellbeing of women in Nepal is precarious and needs to be addressed immediately.

Virology, Clinical Features and Diagnosis of COVID 19: Review Analysis

COVID-19 requires unprecedented mobilization of the health systems to prevent the rapid spread of this unique virus, which spreads via respiratory droplet and causes respiratory disease. There is an urgent need for an accurate and rapid test method to quickly identify many infected patients and asymptomatic carriers to prevent virus transmission and assure timely treatment of the patients. This article aims as an outcome of review of the evidence on viral load and its virulence of SARS-CoV2,so that it will help in further understanding the fact useful for investigating and managing the COVID-19 cases. A search of available evidence was conducted in pub-med "COVID-19 viral load and virulence" and its associated characters world-wide and Google Scholar to capture the most recently published articles. The WHO and Centre for Disease Control and Prevention (CDC) database of publications on novel coronavirus were also screened for relevant publications. Abstracts of 55 articles were screened by two authors and 15 were included in this study based on the inclusion criteria. SARS-coV2, the causative agent of COVID-19 falls under the coronavirus family but it has higher infectivity compared to SARS and MERS with higher reproduction numbers(Ro). Virulence has been found to be different throughout the world,however lower compared to SARS and MERS,till date. The most common clinical features have been found to be cough and fever. RT - PCR remains the most sensitive and specific method for the diagnosis of COVID-19 although it is time consuming, costly and requires highly skilled human resources. Hence, newer modalities like RT- LAMP can be alternative for point of care diagnosis as this is both cost effective and requires less skilled human resources. Despite recent advances in disease diagnosis and treatment outcomes using latest technological advances in molecular biology, the global pandemic COVID-19 remains a major headache for governments across the world due to limited testing capacity and lack of appropriate treatment and vaccine.

COVID-19 Pandemic: What is Known Till June 2020 and What is Yet to Know?

Since first cluster of unknown pneumonia from China reported in December 2019 to World Health Organization, more than 10.5 million new cases and more than 0.513 million deaths have been reported till June 30, 2020 in six months' time. World got to know lot of facts about COVID-19 within short period of six months and success stories too concerning its containment. The situation has constantly been unfolding every moment educating people regarding public health and clinical aspects of the infection and disease and its impact on countries and communities. But still lot of information and evidences are required with regard to pharmacological interventions including effective drugs and efficacious vaccine to mitigate the impact of COVID-19 pandemic at all levels. It seems that we have to live with COVID-19 months-years as the virus is going to stay for longer period of time. The option is to continue practice of effective non-pharmacological interventions as to minimize spread of COVID-19 and ensure adequate provision of PPE to healthcare workforce and testing of health-care workers (HCWs) as to alleviate the anxiety of HCW and lessen their depletion by unnecessary quarantine thereby protect their health and reduce in hospital transmission.

Prevalence of Hepatitis B and C among HIV Infected Patients in Nepal over 1990-2020

Background Hepatitis B and C (HBV and HCV) are viral infections caused by corresponding viruses. Here in this study we planned to conduct this meta-analysis to pool data on the prevalence and risk factors of HBV and/or HCV among HIV patients in Nepal. Method We used MOOSE guideline for the systemic review of available literature. We searched online databases using appropriate keywords. We used CMA-3 for data synthesis. Odds ratio, and proportion were used to estimate the outcome with a 95% confidence interval where appropriate. We assessed the heterogeneity using the I-squared (I2 ) test. Result We included nine studies for our synthesis. Pooling of data showed HBV in 4.6% (CI: 3.7-5.6), HCV in 19.7% (CI: 10.8-33.0), both HBV and HCV in 1.3% (CI: 0.5-3.7) in HIV affected individuals. Among HBV co-infected HIV positive patients, 59.5% (CI: 25.5-86.3) were male; 76.1% (CI: 30.1-96.0) were married and 43.6% (CI: 3.8-93.8) had a history of intravenous drug use (IVDU). Among HCV co-infected HIV positive individuals 88.3% (CI: 73.6-95.4) were male; 63.6% (CI: 55.4-71.1) were married; 91.5% (CI: 68.6-98.1) were literate; 59.2% (CI: 49.9-67.9) were on ART; and 92.2% (95%CI: 84.9-96.1) had a history of IVDU. Conclusion The pooled prevalence of co-infection with HBV, HCV, and combined HBV and HCV were 4.6%, 19.7% and 1.3% respectively among HIV positive patients. Thus, it is necessary to appropriately screen for HBV and HCV in individuals diagnosed with HIV and high-risk populations. IVDU remains the most common risk factor found in co-infected individuals.

Misleading Diagnosis of Dysgerminoma in a Young Asymptomatic Patient

Dysgerminomas account for approximately one third of all malignant ovarian germ cell tumors (tumors arising from ovarian germinal elements) and are the most common ovarian malignancy detected during pregnancy. They are the only germ cell malignancy with a significant rate of bilateral ovarian involvement that is 15-20 percent. They have a variable gross appearance, but in general are solid, pink to tan to cream colored lobulated masses. They have the best prognosis of all malignant ovarian germ cell tumor variants. Two thirds are stage I at diagnosis, and prognosis is excellent even for those with advanced disease due to exquisite tumor chemosensitivity. The 5 year disease specific survival rate approximates 99 percent. This is a case report of a huge ovarian dysgerminoma in a young unmarried lady that was quite asymptomatic. She underwent laparotomy with right ovarian cystectomy.

Pregnancy Complicated by Acute Pancreatitis with Ascariasis

Ascariasis lumbricoides infections are common in tropical and sub-tropical countries. As it is one of the common causes for common bile duct obstruction. But in pregnancy is a rare entity. It may present with complications like acute pancreatitis. Here we present a case of 24 year female gravida 2 para 1 at 34 weeks of pregnancy presented with chief complain of pain over epigastric region radiating to back and associated with two episodes of vomiting, non bilious, not mixed with blood. Ultrasonography showed long tubular hyperechoic structure in gallbladder lumen most likely ascariasis and then she was diagnosed as a case of acute pancreatitis with alive ascariasis.

Vesico-vaginal fistula post Right radical nephroureterectomy with bladder cuff excision

Case: 61 years, female presented at KMH OPD with involuntary urinary leakage per vaginum for seven months following Right radical nephreureterectomy with bladder cuff excision for urinary bladder carcinoma at other centre. Dye test was positive. Cystoscopy revealed VVF defect around 2 cm (Goh’s stage 3biii) at right posterior wall of urinary bladder. Ureteric catheter was placed in left ureter and VVF repair was done. Dye test following 14 days of Foley’s catheterization was negative and patient went home dry. We present here a case of successful repair of VVF following Right radical nephreureterectomy with bladder cuff excision.  Key words: dye test, Goh’s stage, pelvic surgeries, urinary tract injuries, vesico-vaginal fistula

Profile of Obstetric and Iatrogenic Fistula Surgeries At Kathmandu Model Hospital

Aims: To find out the pattern of urogenital fistula. Methods: This was a retrospective study of 222 patients who underwent fistula surgery during the period of January 2012 to March 2018 in Kathmandu Model Hospital. The data were collected from the hospital records. The fistulae were classified according Goh system.  Patients’ demography, obstetric characteristics and surgical outcome were reviewed. The primary outcome was in terms of urinary continence. Results: Among 222 cases, majority of the patients had fistula due to obstetrical cause, contributing 58% (n=127) and 42% (n=95) had fistula after gyanaecological surgery. The age ranged from 15 to 65 years. Most of the patients had fistula of type 1a, contributing 38% (n=84) and only 0.01% (n=3) of type 3c and 4b according to Goh’s classification. Hundred (78.7%) cases of obstetric fistula patients were dry and continent after surgery, whereas 95(89.4%) cases of fistula after gynecological surgery were successfully repaired. Eighteen patients with obstetric fistula and 6 patients with fistula after gynecological surgery had failed repair. Conclusions: Our study showed obstructed and prolonged labor was the major cause of obstetric fistula, but   fistula resulting after gynecological surgery should not be overlooked. Keywords: fistula, iatrogenic, labour

Menopausal Health Status of Nepalese Women

INTRODUCTION

Menopause is an unavoidable and sometimes problematic condition in which women may suffer from a number of health problems. Knowledge of the major symptoms associated with menopause helps reduce the burden and stress associated with the condition. In this context, a study was conducted to establish baseline data regarding menopausal health problems among Nepalese women.

METHODS

A descriptive cross-sectional study was conducted among 2000 women aged over 40 years to identify their knowledge, attitude and practice related to menopausal health problems. Data was collected by interviewing the women and doing physical examination. Analysis was done using descriptive statistics and SPSS software was used for data analysis.

RESULTS

A cohort of 2073 women (ages 40-60 years) participated in the research, among them 2000 yielded complete response. The study revealed that 820 (41%) women had reached menopause. The average age of menopause was 48.7 years. Majority of the women 1183 (59.2%) in the study did not know about menopausal health problems. Abnormal bleeding 353 (17.65%), sweating 315 (15.75%), hot flushes 299 (14.95%), joint/muscle pain 285 (14.25%) were the most common menopausal symptoms known by the women. Joint pain 736 (36.8%), hot flushes 584 (29.2%), irregular bleeding 582 (29.1%) were the most common experienced symptoms of menopause and only 586 (29.3%) consulted the health workers to alleviate menopausal symptoms. Moreover, most of the women 926 (46.3%) accepted menopause as a part of life.

CONCLUSIONS

The research has tried to establish the baseline of menopausal health problems in the Nepalese women. The average age of menopause was 48.7 years. Majority did not know about menopausal health problems. Further researches with nationally representative sample are recommended to further explore the menopausal health problems of Nepalese women.

Understanding Research and Scientific Publication

No abstract available

Profile of Ectopic Pregnancy at Kathmandu Model Hospital

Aims: The study was done to analyze the epidemiology, diagnosis and treatment aspect of patients with ectopic pregnancy at Kathmandu Model Hospital.Methods: This was a retrospective study of patients with ectopic pregnancy who received treatment at Kathmandu Model Hospital from January 2008 to September 2015. Data were analyzed from patient records and discharge summary. Delivery number was obtained from maternity record.Results: There were 61 cases of ectopic pregnancy with the hospital incidence of 1.46%. Highest number of patients 20 (32.79%) were in the age range of 28-32 years. Most of the patients were nullipara 22 (36.06%) or with parity two 20 (32.79%). Some risk factors were found in 29 (47.54%) cases. The commonest risk factor was pelvic inflammatory disease in 12 (19.67%). All presented with pain abdomen, 48 (78.68%) had per vaginal bleeding, 17 (27.87%) presented in shock. Cervival excitation was present in 38 (62.29%). Urine for pregnancy test was positive in all and 37 (60.66%) had ultrasonography. Ten (16.39%) patients underwent emergency laparoscopic surgery and 40 (65.57%) had emergency laparotomy. Salpingectomy was required in 53 (86.89%) cases. The average hospital stay was 5 days.Conclusions: The study showed that ectopic pregnancy could occur at any reproductive age without obvious risk factors. Although not all patients gave history of amenorrhoea, pain abdomen was present in all.

Menopausal Health Status of Women of Kapilvastu District of Nepal

BACKGROUND

Women face numerous health problems in their post-reproductive and menopausal years, including issues such as pelvic pain, incontinence and obstetric fistula. In Nepal, the importance of these health issues is increasing with the aging of the population, yet women are often unable to access adequate health care due to entrenched gender structures and misconceptions regarding menopause. This study aimed to describe the prevalence of menopause, the associated health problems and their severity amongst women aged 40-60 years in Kapilvastu.

METHODS

A descriptive study was conducted in Kapilvastu district. Multi stage cluster sampling technique was adopted: Illakas of Kapilvastu were identified, then one Village Development Committee (VDC) from each Illaka of the district, and two wards from each of these VDCs, were selected randomly.

RESULTS

The median age of onset of menopause was 47 years (25 th and 75 percentiles = 43 and 50 years), and >90% of women had entered menopause by 54. All symptoms in the Menopause Rating Scale were experienced to some extent by at least 30% of women, even amongst the premenopausal group. The most common problems experienced by menopausal women were: sexual problems (81.7%, 95%CI: 78.0-85.4), physical and mental exhaustion (81.5%, 95%CI: 77.8-85.2) and joint and muscular discomfort (78.5%, 95%CI: 74.6-82.4). The symptoms most frequently deemed "severe" or "very severe" were: sexual problems (40.5%), joint and muscular discomfort (27.4%), and sleep problems (21.0%). th

CONCLUSIONS

Middle-aged women in Kapilvastu experienced menopausal symptoms to a substantial degree. The prevalence and severity of these symptoms increased with the menopausal transition, and with increasing age. Menopause itself did not appear to be the primary risk factor for typical "menopausal" symptoms.

Medical and Surgical Abortion in the Second Trimester of Pregnancy

Aims: This study was done to know the demographic profile of women undergoing second trimester abortion at Kathmandu Model Hospital. The aim was to see the success rate of combination of mifeprostone and misoprostol for the medical induction and misoprostol alone for the cervical dilation in case of surgical evacuation.Methods: A retrospective study was done by looking at the profiles of 540 clients on whom second trimester abortion was performed during the period of October 2010 to October 2014. Twenty-nine women underwent dilatation and evacuation (D&E) with misoprostol cervical priming, and 510 underwent medical induction with mifeprostone and misoprostol whereas one client absconded. Furthermore, the reasons for seeking second trimester abortion were also investigated.Results: It can be seen that the age of women undergoing second trimester abortion at Kathmandu Model Hospital was greatest (33.33%) for the age group of 26-30 years. Most women were illiterate (31.67%) and a majority of the women were housewives (89.81%). A greater proportion of the women had never undergone abortion. Mental cause appeared to be the major reason for abortion constituting 82.04%. Success was 90.58%, expulsion with total five doses of misoprostol. The median induction to abortion time was 4-7 hours. The expulsion hours increased as the gestational age increased. The median number of dose of misoprostol required was two for medical induction and three for surgical abortion.Conclusions: Mifeprostone and misoprostol, as combination was a good method for the medical induction of second trimester pregnancy and misoprostol alone for the cervical preparation in surgical evacuation was promising.

Abortion Practices in Nepal: What does Evidence Show?

Twenty-five years have passed since the global community agreed in Nairobi to address the high maternal mortality by implementing the Safe Motherhood Initiative.  However, every year around 22 million women seek unsafe abortion in developing countries. Globally, the unsafe abortion accounts for 13% maternal deaths. Out of the total aborted women, around five million women were admitted to hospitals as a result of unsafe abortion. Similarly, more than three million women suffer from severe complications from unsafe abortion every year. In 2002, responding to the public voices and high attribution of unsafe abortion on maternal mortality, Nepal granted legal access to safe abortion introducing safe abortion act. Women can seek abortion up to 12 weeks of gestation for any indication. However, sex selective pregnancy termination is prohibited in Nepal. This study aimed to assess the results of various studies on abortion practices in Nepal. Literature published in PubMed, Lancet, Medline, WHO and Google Scholar web pages from 1990 to 2014 were used to prepare this paper. From 2004 to 2014, more than half a million women sought safe abortion care in Nepal. Despite the considerable progress, unsafe abortion is still a major issue in Nepal as it has been estimated that it constitutes half of all abortions undertaken every year. Published literature further showed that still an unmet need of safe abortion services exists in Nepal. However, the overall awareness of legal abortion was found to be high among Nepalese women. We found negative attitude of most people towards women who sought abortion care. Similarly, a large number of unmarried women were found at risk for seeking abortion care due to socio-cultural norms, values and stigmas in Nepal.

Spinal Anaesthesia Failure among Women Undergoing Caesarean Section in Kirtipur Hospital

Aims: This study was done to find out the spinal anaesthesia failure rate necessitating the conversion to general anaesthesia and use of intraoperative supplemental analgesia. Methods: This was a retrospective study undertaken in Kirtipur hospital in 660 patients. Spinal anaesthesia (0.5% heavy bupivacaine 2.2 ml) was given to women who had undergone elective or emergency caesarean section from January 2009 to December 2013. Results: In this study spinal anaesthesia failure rate was 1.66% (n=11/660). Among them complete failed spinal anaesthesia rate was 0.75% (n=5/660) requiring conversion to general anaesthesia. Intraoperative supplemental analgesic and sedation like pethidine, ketamine or midazolam was required in 0.90% (n=6/660). Conclusions: The failure rate of spinal anaesthesia given for caesarean section was low (1.66%) and it was within the acceptable range.

Profile of Caesarean Section in Kirtipur Hospital

Aims: This study was done to find out the incidence and outcome of caesarean sections done at Kirtipur Hospital. Methods: This was a retrospective study conducted from 1st January 2009 to 31st December 2013. Case files of 660 patients who underwent caesarean section for various indications were analyzed for incidence, indication of caesarean section, booking status, parity, and maternal and fetal outcomes. Results: Out of 1295 deliveries, 50.9% (n=660) had caesarean section. Most of the caesarean section was done for fetal distress (40.2%; n=265) and on account of previous history of caesarean section (13.5%; n=89). Majority of caesarean section (44.4%, n=293) was done in age group of 25-29 years. Among them, 65.9% (n=435) were nulliparous. There were 35.3% (n=563) booked cases. Emergency caesarean sections were performed in 62.4% (n=412) cases. Maternal morbidity was less (7.2%, n=48). Conclusions: The study showed high rate of caesarean section. The most common indication was fetal distress. Post-operative complications and fetal outcome were within acceptable range. DOI: http://dx.doi.org/10.3126/njog.v9i2.11763  

Marital Rape and its Social Demographic Factors Associated with Gynecological Problems in Kirtipur

Aims: This study aimed to find association of marital rape with gynecological problems and socio-demographic factors, which helped to explore possible underlying issues and to provide appropriate services to the women. Methods: A cross sectional quantitative study was carried out. Three hundred sixty two married women who came to the health care centres of Public Health Concern Trust (phect-NEPAL) for any kind of health services were enrolled for the study. Data was collected through semi structured interview questionnaire. Bivariate analysis and multiple binary logistic regression analysis were applied to identify the factors associated gynecological problems and marital rape. Results: The study revealed that out of 362 women, 194 (53.6%) experienced marital rape either everyday or sometime.  Out of 362 women, 48.6% (194) were suffered from gynecological problems. Women who had undergone rape had 2.32 times more likely to experience gynecological problems than those who did not (OR 2.3, 95% CI 1.52-3.55).  Marital rape was found statistical significantly associated (p-value < 0.05) with economic condition, interspousal communication, and difference among interspousal sexual desire, husband’s violent nature, husband's dominant attitude, husband’s alcohol intake and gynecological problem. Conclusions: Marital rape was associated with existence of gynecological problem in the wife. Therefore, women with gynecological problems should also be explored for marital rape and counseling and service should be provided. DOI: http://dx.doi.org/10.3126/njog.v9i2.11767   

Overview of Palliative Care

Patients diagnosed with a life threatening condition like cancer suffer physically, socially and mentally. Their quality of life can be improved by effective communication and good symptom control even when the disease is incurable. Pain is the most common symptom and can be controlled by optimal use of analgesics especially oral morphine if severe. Psychosocial issues like depression and anxiety can be minimized by counseling and use of medicines. Death is more painful than birth but can be minimized by understanding the reality and by honest sharing which will help to minimize unnecessary sufferings. Palliative care is the care of these patients and their family members to make their life comfortable. Modern palliative care has developed around the world since the 1960s and in Nepal, since the beginning of 21st century. Much remains to be done before palliative care can be an integrated part of health care in Nepal. In this context gynaecologist having knowledge and skills in palliative care, have an important role in improving the quality of life of patients with life threatening condition and their family members.DOI: http://dx.doi.org/10.3126/njog.v9i2.11724

Emergency Obstetric Care: Strategy for Reducing Maternal Mortality in Developing Countries

Twenty-five years have passed since the global community agreed in Nairobi to address the high maternal mortality by implementing the Safe Motherhood Initiative. However, every year nearly three million women die due to pregnancy related causes. This tragedy is avoidable if women have timely access to required emergency obstetric care. Emergency obstetric care refers to life-saving services for maternal and neonatal complications provided by skilled health workers. Since the beginning of the 1980’s, several efforts have been intensified to improve maternal and child health status and reducing the high morbidity and mortality. There was built on a worldwide consensus to provide improved maternal and child health care for addressing the high morbidity and mortality. All participant countries agreed to integrate emergency obstetric care services in their national health care system. Emergency obstetric care is one of the strategies for reducing the maternal mortality as pregnancy related complications are unpredictable. However, many women in developing countries do not have access to essential health care services including emergency obstetric care. Basic emergency obstetric care by skilled birth attendants or timely referral for further comprehensive emergency obstetric care can reduce maternal deaths and disabilities significantly. This paper is based on the results published in PubMed, Medline, Lancet, WHO and Google Scholar web pages from 1990 to 2013. DOI: http://dx.doi.org/10.3126/njog.v9i1.11179 NJOG 2014 Jan-Jun; 2(1):8-16

Analysis of Pap Smear Database in a Community Hospital

Aims: This study was done to find out age wise distribution pattern, cellular abnormality and adequacy of Pap smears. Methods: A retrospective study of 4800 Pap smears based on laboratory database was done from 2008 to 2011 at Helping Hands Community Hospital in Kathmandu, Nepal. Graphical method was used for normality test and frequency analysis was done using SPSS 16. Results: Out of 4794 analysable data 4.21% had abnormal cytology, all high-grade lesions were in 51-65 age group and 0.06% were detected as carcinoma. Age group of 30-65 years covers four-fifth of the samples (3811, 79.4%) and 85.6% of abnormal cytology (173 out of 202) with maximum samples (3313, 69%) at 30-50 years and 55.44% of abnormal cytology. Only 5.4% of samples categorized as inadequate by Bethesda reporting system. Age wise distribution of samples produced near normal Gaussian curve. Conclusions: Pap samples were normally distributed by age. Test requisition forms lack adequate clinical information. Even the inadequately sampled Pap smears were satisfactory for evaluation. DOI: http://dx.doi.org/10.3126/njog.v9i1.11182 NJOG 2014 Jan-Jun; 2(1):21-25

Maternal Mortality: Paradigm Shift in Nepal

Achieving Millennium Development Goal (MDG) 5 still remains a challenge to Nepal. It is necessary to collect reliable evidence on maternal health for tackling MDG 5 with limited resources. A continuous assessment of maternal mortality is required to assure the progress towards the MDG 5. This study aims to assess the results of the different studies on maternal mortality in Nepal.The results published in PubMed, Lancet, Medline, WHO and Google Scholar web pages from 1990 to 2012 have been utilized to prepare this paper. In spite of the low proportion of births attended by skilled persons and institutional delivery, the maternal mortality ratio (MMR) in Nepal has declined drastically between the years 1990 and 2011, from 850 to 229 deaths per 100,000 live births. In recent years, Nepal is also reaching progress in different maternal health indicators such as mothers receiving antenatal care from skilled providers (60%- up from 24% in 1996). More than one-third births in the past five years have been assisted by skilled care providers. Nearly, 45% of women received postnatal care for their last birth in the first two days after delivery, 38% of women is aware of abortion which has been legalized since 2003.Though maternal health is a priority agenda of Nepal among the policy makers and the country is likely to achieve Millennium Development Goal 5 by the year 2015, there is still a wide gap between policies and charted targets, and the real accessibility and availability of the quality health services. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11132   Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 3-8

Construction and Validation of a Women's Autonomy Measurement Scale with Reference to Utilization of Maternal Health Care Services in Nepal

INTRODUCTION

Women's autonomy is one of the predictors of maternal health care service utilization. This study aimed to construct and validate a scale for measuring women's autonomy with relevance to developing countries.

METHODS

We conducted a study for construction and validation of a scale in Rupandehi and further validated in Kapilvastu districts of Nepal. Initially, we administered a 24-item preliminary scale and finalized a 23-item scale using psychometric tests. After defining the construct of women's autonomy, we pooled 194 items and selected 24 items to develop a preliminary scale. The scale development process followed different steps i.e. definition of construct, generation of items pool, pretesting, analysis of psychometric test and further validation.

RESULTS

The new scale was strongly supported by Cronbach's Alpha value (0.84), test-retest Pearson correlation (0.87), average content validity ratio (0.8) and overall agreement- Kappa value of the items (0.83) whereas all values were found satisfactory. From factor analysis, we selected 23 items for the final scale which show good convergent and discriminant validity. From preliminary draft, we removed one item; the remaining 23 items were loaded in five factors. All five factors had single loading items by suppressing absolute coefficient value less than 0.45 and average coefficient was more than 0.60 of each factor. Similarly, the factors and loaded items had good convergent and discriminant validity which further showed strong measurement capacity of the scale.

CONCLUSIONS

The new scale is a reliable tool for assessing women's autonomy in developing countries. We recommend for further use and validation of the scale for ensuring the measurement capacity.

Obstetric Fistula in the Developing World: An Agonising Tragedy

Obstetric fistulae is the most tragic of preventable childbirth complications in the developing world, as affected women are often abandoned by their husbands and family, and forced to live in shame. They occur almost entirely in the developing world and their incidence is poorly studied. Their management requires accurate diagnosis, sufficient pre-operative work-up, fine surgery following standard surgical repair steps and principles by skilled surgeons, specialised post-op care, and follow-up. As obstetric fistula is a serious preventable public health issue in developing countries, national and international organizations should launch a campaign to end fistula by increasing the resources and skilled staff available locally to treat obstetric fistula for improving the lives of women currently living with this condition. Moreover, effective preventive strategies for obstetric fistula such as better education to women and provision of improved obstetric care and searching for the best approaches to both prevention and treatment should be the priority. The materials published in PubMed, Lancet, Medline, WHO and Google Scholar web pages from 1990 to 2013 have been utilized to prepare this paper.Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 2 / Issue 16 / July-Dec, 2013 / 5-15 DOI: http://dx.doi.org/10.3126/njog.v8i2.9759

Cervical Cancer and HPV Vaccine in Nepal: Issues and Challenges

NJOG 2011 Nov-Dec; 6 (2): 56-57 DOI: http://dx.doi.org/10.3126/njog.v6i2.6761

Impact evaluation of uterine prolapse surgery in Nepalese women

BACKGROUND

The problem of uterine prolapse exists throughout Nepal and negatively affects women's health and quality of life (QOL). The Government of Nepal recognizes it as a priority problem.

METHODS

This study was conducted in eight districts to examine the status and problems of women who have undergone prolapse surgery. Qualitative and quantitative methods were used to examine the issues of prolapse. Survey method was used to administer the questionnaire.

RESULTS

Sixty-six percent women reported pelvic organ prolapse at an early age. The mean age of its occurrence was 28 years. In the hill/mountain districts, 52% women among the non-poor and 72% among the poor went to health camps for surgery indicating that the camps were fulfilling the demands of the poor. Majority (>75%) of them from remote districts went to health camps for surgery indicating the camps were more beneficial to women in remote areas. Counseling was weak in the health camps and the use of IEC materials was minimal. Majority had improved health status after surgery. The incidence of post-surgery problems were as follows: 10.1% in government hospitals, 11.1% in non-government hospitals and 15.1% in health camps.

CONCLUSIONS

Despite improved performance of health camps, the program for prolapse management still seems weak due to lack of ownership of local health institutions and lack of proper coordination among the stakeholders/ partners. However, these camps need to be scaled up for the benefit of the unreached population.

Surgical treatment for early cervical cancer: Experience at a cancer hospital in Nepal

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Background: The purpose of this study was to find out the clinocopathologic characteristics, post-operative findings and complications of patients with early (up to stage IIA) cervical carcinoma who underwent radical hysterectomy. This study concentrates on the evaluation of our early experience in radical hysterectomy for cervical cancer in Nepal. Methods: This was a retrospective analysis of 48 patients who had radical hysterectomy with bilateral pelvic lymphadenectomy for early cervical cancer at the BP Koirala Memorial Cancer Hospital (BPKMCH) from September 2002 through September 2005. Characteristics such as chief complaint, disease staging and duration, intraoperative and postoperative complications, histopathological findings, need for blood transfusion, and duration of hospital stay were considered for analysis. Results: Patients’ age ranged from 28–67 years. Age group of 40–49 had highest number of patients (58.3%). Majority (62.5%) were premenopausal women who presented with abnormal vaginal bleeding (73%) as the chief complaint. More than half of them (56%) had FIGO stage IIA disease. Thirty-three percent had intraoperative and postoperative complications such as urinary problems, wound infection and vessel injury/ureteric injury. All needed blood transfusion, 42% needing four pints. The average duration of hospital stay was 11 days. Forty-four had squamous cell carcinoma and four had adenocarcinoma. Pelvic lymph node metastasis was found in 10 patients. Resected margins were adequate in 42 patients. Majority (62.5%) of the women were premenopausal and 56% of them had stage IIA disease. Conclusions: Although the primary treatment of early-stage cervical carcinoma involves either surgery or radiation therapy with or without chemotherapy, surgery (radical hysterectomy) was used for lower-stage disease and smaller lesions in fit and young patients in our resource-poor set-up. The complication rate seems to be higher in Nepal; however, it will decrease as more experience is gained.

No significant financial relationships to disclose.

Teenage pregnancy: complexities and challenges

Teenage pregnancy is a common public health problem worldwide. It is a problem that affects nearly every society-developed and developing alike. There is a growing awareness that early child bearing has multiple consequences in terms of maternal health, child health and over all well-being of society. Although prevention of unwanted teenage pregnancy should be the primary goal the modern society, many adolescents continue to become pregnant. The purpose of this article is to review current trends and issues on adolescent pregnancy to update the practitioners. The readers are provided with more recent data on adolescent sexuality, contraceptive use, and childbearing as well as suggestions for addressing the challenges of teenage pregnancy.

GYNECOLOGICAL MALIGNANCY IN BPKMCH, BHARATPUR: A RETROSPECTIVE ANALYSIS OF 321 CASES

Gynecological Malignancy is the leading cancer in female not only in Nepal butworldwide. A retrospective study of histopathological specimens was conducted inBPKMCH Bharatpur from July 1999 to January 2001, duration of 19 months. Total321 cases of Gynecological Malignancy were diagnosed in Department of Pathologyof BPKMCH. Out of which 272(84.73%) cases of cancer of cervix; 17 cases (5.29%)of cancer of vulva; 14 cases (4.36%) of ovarian cancer, 12 cases (3.73%) of cancer ofvagina and 6 cases (1.86%) of endometrial cancer were detected. Cancer of cervixwas most common in 40-49 years age group followed by 50-59 years age group. Meanage of the patients with cancer of cervix was 50 years and 10 months; minimum of 29years and maximum of 76 years. Out of 272 cases of cancer of cervix, 266 (97.79%)were squamous cell carcinoma and rest 6 (2.20%) were adenocarcinoma. Commonesthistology in vulva and vagina was squamous cell carcinoma, whereas adenocarcinomawas commonest in endometrium and ovary. The higher incidence of gynecologicalmalignancies particularly carcinoma of cervix was observed in BPKMCH.Key Words: Cancer, Cervix, Vagina, Vulva, Ovary.

A study of endometrium of patients with abnormal uterine bleeding at Chitwan Valley

OBJECTIVE

To know the causes for the abnormal uterine bleeding in Women at Chitwan Valley and to compare the histopathological findings between the pre-menopausal and postmenopausal women.

DESIGN

A descriptive study of patients who have had vaginal bleeding during the period from January 2000 to July 2002.

SETTING

Department of Gynaecological Oncology of BP Koirala Memorial Cancer Hospital (BPKMCH), Chitwan, Nepal.

SUBJECTS

Eighty-four women (aged 45 year and above) having abnormal vaginal bleeding managed at BPKMCH.

MAIN OUTCOME MEASURED

Various characteristics of the patients including age, menopausal status, histopathological findings.

RESULTS

A total of eighty-four patients were studied. Majority (53.5%) of them were postmenopausal ladies presenting with abnormal vaginal bleeding. The age range was 45 to 81 years, with an average of 63. Only 37% had pathological bleeding including malignancy and about 16.6% of all had malignancies. Malignant diseases were found in 7.7% cases in the pre-menopausal ladies whereas it was 24.3%, three times higher, in the post-menopausal ladies.

CONCLUSION

Carcinoma of the cervix and of the endometrium occurred with increasing frequency with increasing age in this study. So, a thorough work-up is needed for the perimenopausal/postmenopausal women presenting with an abnormal vaginal bleeding especially to rule out malignancies.