A Rare Case of Large Hydatidiform Mole Mimicking a Term Pregnancy

Molar pregnancy is a type of abnormal pregnancy that usually presents with amenorrhea, vaginal bleeding and elevated serum ß-hCG levels. We report a rare case of complete hydatidiform mole occurring in a 46-year-old P2L2 lady who presented with a term size uterus and elevated serum ß-hCG level (> 15,00,000 per deciliter, anemia (hemoglobin: 8.1 g/dL), difficulty in breathing and minimal vaginal bleeding. During the course of her evaluation, she had profuse vaginal bleeding, she underwent suction and evacuation, but bleeding was not controlled despite measures to control it. She was given uterotonics and antifibrinolytic agents and uterine artery ligation. But was proceeded with emergency hysterectomy for uncontrolled hemorrhage. The content of suction and evacuation was vesicles with blood clots and histopathology was reported as complete hydatidiform mole. The patient received a total of 4 units of packed red blood cells. She was discharged from hospital on 5th postoperative day and was followed up serial serum ß-hCG level. Therefore, complete mole can present with enlarged uterus, vaginal bleeding and anemia. It is also important to note that intractable bleeding following suction and evacuation not being controlled with uterotonics and antifibrinolytic agents and uterine artery ligation may require hysterectomy to save the patient's life.

Microalbuminuria as a Predictor of Pre-eclampsia in Pregnant Women Presenting in the Antenatal Clinic at Dhulikhel Hospital

Background Pre-eclampsia is described as a pregnancy-specific syndrome that can affect virtually every organ system. The appearance of proteinuria remains an important diagnostic criterion. Proteinuria is an objective marker and reflects system-wide endothelial leak, which characterizes the pre-eclampsia syndrome. Objective To determine protein values using the spot urinary albumin/creatinine ratio amongst the pregnant women and to identify whether this test can be used as the investigation of choice for predicting pre-eclampsia in near future. Method A hospital based observational cross-sectional study conducted from February 2016 to August 2017. The study included pregnant women from 20-28 weeks of gestation. They were tested for spot urinary albumin and creatinine. They were all followed up till term, delivery and post partum. Result The mean age of the study patients was 28 years (N+335), the most common age group being 25 to 29 years (43.6%). Pregnant women with higher values of urinary albumin/creatinine ratio were found to develop hypertension compared to women with normal values of urinary albumin/creatinine ratio in the third trimester with insignificant difference (p < 0.283) statistically. Conclusion Microalbuminuria is one of the predictor of pre-eclampsia however it cannot be used as routine investigation for predicting pre-eclampsia in future; further studies in large scales are needed to prove whether urinary albumin/creatinine ratio can be utilized as predictor for pre-eclampsia or not.

Clinical Estimation of Fetal Weight with Reference to Johnson's Formula: An Alternative Solution Adjacent to Sonographic Estimation of Fetal Weight

Background Fetal weight estimation plays a significant role in the antenatal management of high risk pregnancies. It is also an important parameter for predicting the neonatal outcome and informs decision for the mode of intra-partum management of the pregnant women. Among the various methods of prenatal fetal weight estimation, the most commonly used are clinical estimation and sonography. Objective The objective of this study was to compare the accuracy of clinical estimation of fetal weight using Johnson's formula and sonographic estimation with actual birth weight. Method This prospective study was conducted at Dhulikhel Hospital, Kathmandu University Hospital, from January 2017 to August 2018. The study included 335 pregnant women at term gestation. Result The estimation of fetal weight at term pregnancy using Johnson's formula is as effective as sonological method. For clinical method, the fetal weight falls between 95 gm and 183 gm at 95% confidence interval. With respect to ultrasound method, the fetal weight is found to be 45 gm and 132 gm at 95% confidence interval at p value < 0.001. Conclusion Clinical estimation of fetal weight can be utilized as an alternative to sonological estimation in the management of labor and delivery. Johnson's formula is a simple, easy, cost-effective, and universally applicable method to predict fetal birth weight and can be used anywhere by doctors, nurses, midwives and paramedics in centers where ultrasound is not available.

Risk Factors and Clinical Profile of Preterm Deliveries at Dhulikhel Hospital, Kathmandu University Hospital

Background Preterm delivery is one of the major determinants of neonatal morbidity and mortality and has long term adverse health outcomes. Objective To study the risk factors of preterm deliveries and the clinical profile of preterm births presenting to a tertiary center in Kavre district. Method A hospital based prospective study was carried out in the Department of Pediatrics and Department of Obstetrics and Gynaecology, Dhulikhel Hospital, Kavre from 1st April 2016 to 31st October 2017. Result Study included 152 babies born premature and attending Dhulikhel Hospital. There were 5.26% babies less than 1000 grams and the least weight being 700 grams. Majority of the premature babies were male (57.24%). Most of the babies were in the gestational age of 28 to 32 weeks (60%). Steroids were given to 42.10% of the cases. Mode of delivery was vaginal route (60.53%) followed by cesearean section in 37.50%. Hyperbilirubinemia (53.29%), neonatal sepsis (46.05%) and respiratory distress syndrome (43.42%) were the commonest morbid conditions. Among the 152 cases, mortality was seen in 13.82%. The minimum weight to have survived was 900 grams. The most common modifiable risk factors responsible for preterm birth in mother were inadequate antenatal visits (29.60%), history of premature rupture of membranes (28.29%), history of urinary tract infection (21.05%) and weight less than 45 kg (14.47%). The non modifiable risk factors were mothers with blood group A (33.55%) and height of less than 145 cm (20.40%). Conclusion The modifiable risk factors such as inadequate antenatal visits, history of premature rupture of the membranes and urinary tract infection and under weighing mothers can be corrected by early interventions and preventive measures which will help in reducing perinatal morbidity and mortality.

Correlation of Cervical Pap Smear with Biopsy in the Lesion of Cervix

Background Cervical cancer can be controlled to a greater extent by screening to improve morbidity and mortality. Pap smear is important screening method, which has proven to be highly effective in reducing the number of cases and the mortality from cervical carcinoma. Any abnormality detected in pap smear has to be confirmed with cervical biopsy, which remains the reference investigation. Objective To find the changes of cervical cytology by pap smear, to classify cervical lesions into malignant and benign groups on cytological and histopathological basis and to correlate the changes observed in cervical cytology with cervical biopsy. Method This is a prospective cross sectional study done in between July 2014 and July 2015 in Dhulikhel Hospital, Kathmandu University Hospital. During the period, all the samples requested for pap smear were studied. The cases who had undergone both pap smear and cervical biopsy were compared. Clinical data were obtained from requisition submitted along with the cytology and tissue specimens received in the department. Result During the study period, total 1922 pap smears were performed and out of them 75 patients were advised to do cervical biopsy. On cytology, out of total 1922 number of cases, 67.90% were normal, 27.90% were inflammatory smears, 3.80% were unsatisfactory (inadequate) and 0.40% were high grade intraepithelial lesions. Highest numbers of patients screened for pap smear ranged from 31 to 40 years. On histopathology, 78.70% had chronic cervicitis, 8% had normal findings, 1.30% had moderate and 6.70% had severe squamous intraepithelial lesions. The frank malignancy was found in 5.30%. The mean age ± SD for carcinoma was 52.75±6.29. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value of pap smear were 77.80%, 100%, 100% and 97% respectively considering cervical biopsy as the gold standard Conclusion This study revealed a good correlation of cervical cytology with cervical biopsy. Pap is a cost effective screening method for early detection of premalignant and malignant cervical lesions. However, biopsy is considered as the gold standard for the confirmation of abnormalities detected in cervical smear.

Clinicomorphological Spectrum of Ovarian Cystic Lesions

Background Ovarian cysts, which present as neoplastic and non-neoplastic lesions, are the most common gynaecological cause of hospital admissions. Early diagnosis is difficult due to asymptomatic nature. Clinical, radiological and gross examination alone cannot distinguish benign from malignant lesions, hence, histopathological examination is important for diagnostic, therapeutic and prognostic approach. Objective The objective of the study is to analyze the spectrum of ovarian cystic lesions with their clinico-morphorgical features. Method This is a prospective study done in between July 2014 and July 2015 in Dhulikhel Hospital-Kathmandu University Hospital. Clinical data of patients were obtained from hospital records and requisition submitted along with the tissue specimens received in the department. Result A total 84 cases of ovarian cystic lesions were studied. Among these, 47 (55.9%) were non-neoplastic lesions, 33 (39.3%) were benign neoplasms, two (2.4%) were borderline and two (2.4%) were malignant neoplasms. The most common nonneoplastic lesions were follicular cysts, 26 (55.3%) followed by simple cysts 14 (29.8%), hemorrhagic cysts five (10.6%) and corpus luteal cysts two (4.3%). Among all neoplasms, 19 (51.4%) were mature cystic teratoma followed by 10 (27.0%) cases of mucinous cystadenoma and four (10.8%) cases of serous cystadenoma. Between two (5.4%) malignant cases, one was immature cystic teratoma and the other was mucinous cystadenocarcinoma. Besides these, two (5.4%) cases of borderline mucinous cystadenoma were also present. Conclusion Ovarian cystic lesions are difficult to categorize on the basis of clinical and radiological findings. Histopathological examination plays a significant role to differentiate benign lesion from malignant as well as for the proper management.