Maternal and Perinatal Outcome of Urinary Tract Infection in Pregnancy at Dhulikhel Hospital, Kathmandu University Hospital

Background Urinary tract infection (UTI) is common in pregnancy and poses a great challenge because it has several adverse outcomes in both the mother and her unborn foetus. Objective This study aims to determine the incidence of culture positive urinary tract infection, culture and sensitivity of the common causative organisms and find out the maternal and perinatal outcomes in culture positive urinary tract infection. Method This prospective study was carried out in the Department of Obstetrics and Gynaecology at Dhulikhel Hospital over a period of one year. Urine routine and microscopy was done as a preliminary screening test for urinary tract infection and those with abnormal results were subjected to urine culture and sensitivity and ultrasonological evaluation. Result A total of 162 pregnant women were included in the study. Incidence of culture positive urinary tract infection was 25.9%, highest in age group 15-20 years (47.8%), more in primigravida (30.1%) and common at second trimester (40.4%). Escherichia coli (90.4%) was the commonest organism isolated and ceftriaxone was the most sensitive antibiotic. Patients with culture positive urinary tract infection had higher incidence of anaemia, preterm labour, need of surgical intervention. Such patients also had increased chances of preterm delivery, low birth weight babies and newborn intensive care unit (NICU) admission. Conclusion We conclude that urinary tract infection in pregnancy leads to adverse maternal and fetal outcomes. And we recommend urine culture and sensitivity at each trimester so that urinary tract infection can be diagnosed and treated on time.

A Rare Case of Large Left Lateral Wall Vaginal Myoma

Vaginal leiomyomas are rare, they are uncommon benign tumor with variable clinical presentation. They usually present as a mass per vaginum or dyspareunia or pressure symptoms on the neighbouring structures. We present a case of 47 years lady with mass per vaginum and difficulty in walking and chronic pelvic pain. Her clinical findings suggested a large mass in the left vaginal wall, the mass was approximately 12 x 10 cm in size hindering the visualization of the cervix. Her ultrasonography showed bulky uterus with mass occupying the cervix. This finding was not correlating with the clinical findings. Magnetic resonance imaging (MRI) was done and it was reported as mass lesion in pelvis separate from the cervix abutting the rectum posteriorly. Ultrasonography (USG) guided biopsy was done which was reported as Leiomyoma. She underwent vaginal myomectomy and was confirmed in histopathology as Leiomyoma. A leiomyoma is a smooth muscle tumor that arises from the muscular part of the uterus and rarely seen in the vaginal wall.

First Reported Death of a Postpartum Woman Due to Coronavirus Disease 2019 in Nepal: A Lesson Learnt

The first case of coronavirus disease 2019 was reported on December 31, 2019 in Wuhan, China where the average case fatality rate was 6.1 ± 2.9%. There are 453 deaths as of September 24, 2020 in Nepal. We report the first death of a 29-years-old postpartum woman due to COVID-19 in Nepal who was referred from a rural health center to Dhulikhel Hospital. On arrival, she was taken to the acute respiratory zone of the emergency department to provide immediate lifesaving procedures. Despite the repeated resuscitative measures, return of spontaneous circulation could not be achieved. The real time polymerase chain reaction test was positive. Our case report highlights the importance of early clinical suspicion, importance of "safety first" in healthcare settings, and the chain of management in such patients. We consider the fact that a postpartum woman registered as the first case of COVID-19 related death in Nepal to be an area of further study.

Control of Pelvic Blood Flow Using a Novel Pneumatic Abdominal Binder

Background Obstetrical hemorrhage continues to be the leading cause of maternal death; additional means of treatment are needed to reach women who are currently not being saved. We developed the "Ball and Binder", an inexpensive and innovative pneumatic abdominal-pelvic compression device made with a cloth binder and soccer ball. Objective To measure the change in distal aortic blood flow before and after placement of the device. Method A comparative study was done on nine healthy volunteers measuring the flow in the distal aorta before and after placement of a pneumatic abdominal binder. Result Distal aortic flow decreased by over half when the device was inflated. Conclusion An inexpensive pneumatic external abdominal compression "Ball and Binder" device was able to decrease flow to the pelvis by over half. This provides an additional tool for rapid treatment of postpartum hemorrhage unresponsive to routine initial measures.

Clinical profile of pregnancy loss and placental histopathology at a University Hospital

Aims: To review the clinical features of abortion and intrauterine fetal demise with histopathological findings in their placenta Methods: A retrospective study conducted at Kathmandu University Dhulikhel Hospital from 2008 to 2018. Results: A total of 431 placentas were examined over one decade. One third of them (33.2%) had abortion. Mean age of the patients with abortion was 24.72±5.5 years and that of intrauterine fetal demise (IUFD) was 25.36±5.4 years (p=0.2288). Two thirds of patients with abortion presented with vaginal bleeding and/or lower abdominal pain; 73% of IUFD presented with decreased fetal movement. Gross anomaly was the most common comorbid condition in abortion group while pre/post term, antepartum hemorrhage and PIH were the commoner conditions in IUFD group. In this study, 17.4% abortion cases and 18.3% IUFD cases were with histopathologically proven infection. Conclusions: Placental examination helps in revealing unseen pathologies in cases of poor obstetric outcomes in the form of abortion or fetal demise. The service provider should collect and provide required clinical information before studying the placenta to establish a hidden diagnosis.

Minimal Invasive Gynaecological Surgeries in Dhulikhel Hospital: One and Half Decade Long Experience

Background One of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery. Dhulikhel Hospital is one of the very few institutions in Nepal where minimal invasive gynaecological surgeries are being regularly performed since early years of its establishment. There are very few publications related to experiences of minimal invasive gynaecological surgeries published in Nepal. Objective To review the varieties of minimal invasive gynaecological surgeries and find out the different milestones those were crossed in this field. Method This is retrospective study of minimal invasive gynaecological surgeries performed from January 1, 2004 to June 30, 2018. Result A total of 1849 cases were performed by mid 2018. Almost half of the cases were of Brahmin/Chhetri caste (49.9%). Mean age of the patients who underwent gynaecological minimal invasive surgeries in DH was 36.70±10.60 years (with range 12-81 years). More than half of the patients were from Kavre (58.2%). Abnormal uterine bleeding, ovarian lesions and chronic pelvic pain were the most common indications for these procedures. Among these procedures, hysteroscopy (769 cases), diagnostic laparoscopy with or without chromotubation (385 cases), operative laparoscopy (419 cases) and LAVH/TLH (242 cases) were performed. In this study, 34 minimal invasive surgeries cases (1.8%) were converted to laparotomy for certain reasons. Of them eight cases were of laparoscopic hysterectomies. Only very few major and minor complications were experienced during this period. Conclusion Varieties of minimal invasive surgeries for various gynaecological problems were performed with minimal complications. We scaled up these minimal invasive surgeries over the period.

Dysmenorrhea and Stress among the Nepalese Medical Students

Background Dysmenorrhea is the most common gynecological disorder in women of reproductive age with implications as reduced quality of life and school absenteeism. Mental stress is possibly the most important known predisposing factor for primary dysmenorrhea. Objective This study aims to assess the relationship between stress and dysmenorrhea amongst the Nepalese medical students. Method This is cross-sectional descriptive study, conducted from 1st Dec. 2012 to 31st Jan. 2013. The study was conducted in Kathmandu University School of Medical Sciences. A total of 184 participants consented for this study and each one was given a questionnaire to complete. This study included only unmarried nulliparous, healthy (all through first to final years) female medical students, in age group of 16 to 24 years. Result The mean age of the participants was 19.43(±3.9) years. Among them, 67% of the participants experienced dysmenorrhea. Of them, 85% experienced increase in frequency and severity of dysmenorrhea after joining medical college. Similarly, 65% of participants considered medical education to be stressful. Of participants experiencing dysmenorrhea, 29.45% missed classes and 17.39% participants had positive family history of dysmenorrhea in first and second degree relatives. Conclusion The present study indicated a positive relationship between psychological stress and dysmenorrhea. Dysmenorrhea is the leading cause of recurrent short-term school absence in young ladies; this issue certainly needs to be addressed.

Imaging in Infertile Female Patients Who Underwent Hysterosalpingography Investigation at Dhulikhel Hospital

Background Fallopian tube and uterine abnormalities are the most common cause of female infertility, accounting for 30% of cases. Hysterosalpingography is the safe, minimal invasive radiographic technique for evaluation of uterine cavity and fallopian tubes defects. The purpose of the study was to assess the various uterine and tubal abnormalities leading to infertility Objective To assess the abnormalities in uterus and fallopian tubes detected on Hysterosalpingography (as causative factors of infertility in a tertiary care centre for proper decision making in treatment. Method This is the prospective cross sectional study done in department of radiology Dhulikhel hospital, Kathmandu University Hospital between January 2015 to January 2016 with complain of infertility. Hysterosalpingography was performed using ionic contrast medium (10-20 ml of 76% urograffin) under digital fluoroscopy. Radiographic films were obtained and analyzed. Demographic data and radiological findings were reviewed and the obtained data analyzed with SPSS version 16. Result Out of the total 100 patient, 75 had primary infertility while 25 had secondary infertility. The age ranged from 19 to 43 years with mean age of 27.75 years. Normal Hysterosalpingography findings were seen in 37% cases. Tubal abnormalities were seen in 34%, uterine abnormalities in 23% and both tubal and uterine abnormalities in 6% patients. The most common tubal abnormality detected on Hysterosalpingography was tubal block 75%. Out of the 30 patients who had tubal block, unilateral block was noted in 76.7% patients whereas bilateral block was noted in 23.3%. Hydrosalphinx was seen in 25% cases with tubal abnormality. Among the 29 cases with various uterine abnormalities, bicornuate uterus 9% was the most common abnormality Conclusion Hysterosalpingography is an easily available radiographic procedure that can demonstrate a wide variety of uterine and tubal abnormalities for the initial assessment of infertility which can avoid unnecessary and sometimes more aggressive procedures.

Nuchal translucency in normal fetus and its variation with increasing crown rump length (CRL) and gestational age

BACKGROUND

Nuchal translucency (NT) is the fluid collection behind the fetal neck which can be measured by ultrasound at 11-14 weeks of gestation. Increase in the nuchal translucency thickness is associated with various congenital anomalies.

OBJECTIVE

To study the relationship between nuchal translucency thickness, crown rump length and gestational age in normal fetus.

METHODS

Prospective analytical study conducted on 211 pregnant women from March 2011 to August 2012. Measurement of Nuchal translucency thickness and crown rump length was performed by ultrasound at 11-14 weeks of gestation. The relationship between nuchal translucency thickness, crown rump length and gestational age was studied by using linear regression analysis.

RESULTS

The mean CRL was 63.67+13.48mm (range 41.2-88mm) and mean NT thickness was 1.55+0.35mm (range 0.8-2.7mm), respectively. The median gestational age was 12.9 weeks. The regression equation which shows relation between median NT thickness and CRL was described as follows: expected NT thickness = 0.013CRL+0.725, (R2 = 0.258, p <0.001). There was increase in the incidence of NT thickness more than or equal to 2.5mm; 1.7% in fetus between 12-12.9 weeks of gestation to 15.1% in fetus between 14.0-14.9 weeks.

CONCLUSION

Our study offers normative data of NT thickness in normal fetus, which can be used as reference to screen various chromosomal and congenital abnormalities between 11- 14 weeks of gestation. NT thickness increased with increasing CRL and a false positive rate increases with increasing gestational age.

A Clinical Audit of Pap Smear Test for Screening of Cervical Cancer

Aims: Cervical cancer is a major cause of morbidity and mortality in gynecology clients. It accounts for the most common cancer in women. A Papanicolaou (Pap) smear test (cervical cytology screening) is one of the best tests to screen for cervical cancer in its premalignant stage. The objective of this study is to find out the prevalence of abnormal Pap smear results and to determine the contributing factors for it. Methods: The out patient clinic register was reviewed. Out-patients clinic register from 1 Jan 2008 to 31 Dec 2011showed that a total of 25511 gynecology clients were seen. In these four years duration, a total of 1506 Pap smear samples were taken which accounted for 5.9% of the total gynecology clients. The samples were collected only after proper counseling and consent from the clients who visited the clinic for various gynecology complaints. Assumed predictors of abnormal Pap smear results were examined through inferential way (Chi square test) using Software SPSS version 13.0 for Windows. Results: The preliminary analysis showed the mean age was 37.57 ± 10.72 years (ranging from 18 to 81 years). Most of them were of Newar caste (28.7%), with 3 children (37.6%) and from Kavre District (66%). Most of them (343 clients) were of age group 30 – 34 years whereas 15.8, 10.8, 3.1 and 10.0 % (clients were of 40 – 44, 45 – 49, 50 – 54 and 55 above respectively. A total of 1062 samples were normal whereas 379 samples were suggestive of inflammatory and 39 samples were inadequate for evaluation. We had 22 samples suspicious for malignancy and/or low grade squamous intraepithelial lesion (LSIL) and 4 frank malignant cases. This accounted for 1.7% of total Pap smear samples. These cases were scheduled for colposcopic guided biopsies and histologic evaluations. There was significant difference between the age groups and Pap smear results (p=0.003) and parity with Pap smear results (p=0.000, highly significant). But there was no significant difference between caste and Pap smear results (p=0.166). Conclusions: There is no doubt that Pap test is one of the best and easiest tests to screen for precancerous and cancerous cervical lesions. In order to have a high yield it has to be combined with other alternative tests like HPV testing and/or visual inspection with acetic acid (VIA) or Lugol’s Iodine (VILI). Besides its use as screening tool, we can also evaluate for chronic cervicitis, sexually transmitted infection (STI), pelvic inflammatory disease (PID)and genital prolapse (if any) in same setting. Thus the community people will have broader benefits from the screening program. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11137   Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 21-24

Intrauterine foetal death and its probable causes: two years experience in Dhulikhel Hospital-Kathmandu University Hospital

BACKGROUND

World health Organization definition of intrauterine foetal demise encompasses any abortion or fetal demise prior to expulsion from its mother, and recommends different protocols according to gestational age. However, conventionally and also in our institution, foetal demise prior to 28 weeks of gestation is managed as abortion in a manner different from foetal demise post 28 weeks of gestation.

OBJECTIVE

To find the incidence and characteristics of pregnancies that resulted in stillbirths. METHODS A retrospective study, done in Dhulikhel Hospital, Kathmandu University Hospital in the year 2010 and 2011, among 4219 deliveries and 97 fetal deaths. Cases of multiple pregnancy and fetal death diagnosed by ultrasound before the 28th week of gestation were excluded. The included intrauterine foetal demise cases (n=90) were compared with a control group of randomly selected pregnancies (n=537) delivered during the same time period. Assumed predictors of stillbirth were examined through inferential ways (Chi square, t test) using SPSS Version 13.0 for Windows.

RESULTS

Incidence of intrauterine foetal demise was 2.13% in the year 2010 and 2011. Mothers in the stillbirth group were slightly older than mothers of live-born infants (25.47±5.64 years vs 23.62±4.31 years, p value=0.000). A slightly higher proportion of women in the stillbirth group were of Tamang ethnic origin and primiparous (p=0.011, 0.000). Foetus expelled after IUFD had lower weight compared to live births, (2925.14±444.14 gram vs 2182.78±821.04 gram, p=0.000) for gestational age. The stillborn babies were generally born at an earlier gestational age, as would be expected (p=0.000). Incidence of intrauterine foetal demise gradually decreases as parity advances. The incidence was higher in patients receiving antenatal care outside Dhulikhel Hospital, Kathmandu University Hospital.

CONCLUSIONS

While comparing the subject with the theme of the national conference of Nepal Society of Obstetricians and Gynaecologist, most of the cases were mother not receiving antenatal care or those receiving antenatal care in the periphery, There is no denying that there would be a massive improvement in women's health if the co-ordination between the peripheral health care center and tertiary care center was to be improved.

Incidence of nuchal cord, mode of delivery and perinatal outcome: a notable experience in Dhulikhel Hospital - Kathmandu University Hospital

With the advent of ultrasound as a means of providing quality antenatal care, there is an increase in the diagnosis of nuchal cord in fetuses. The major cause of foetal or neonatal death during labor and in postpartum period is birth asphyxia and tight nuchal cord is a cause of birth asphyxia. Whilst there are instances in which fetuses with 3 to 4 loops of cord around the neck have been delivered by normal vaginal delivery, some cases have to be delivered by caesarean section due to foetal distress caused by a single loop of cord around the neck. The reason for conducting this study was also to analyze the incidence and other aspects of nuchal cord. Dhulikhel Hospital labour registry was reviewed between Jan 2010 and Dec 2011. A total of 289 cases with at least one loop of nuchal cord were recorded as study case. For comparison, 965 controls were randomly selected from the 4219 unaffected singleton births delivered during the same time period. Of 1254 neonates, nuchal cord was present at 6.85% of deliveries (n = 289). Of these the incidence was 6.57% at preterm, 49.13% at term, 39.79% at postdated and 4.50% at postterm. A total of 151 had one loop and 138 had two or more loops. There was significant difference in the maternal age and birth weight of among three groups (control, with one loop and with two or more loops) in this study (p = 0.002) and (p = 0.000) respectively. However, the incidence was not affected by caste, parity, gestational age, antenatal site, neonatal intensive care unit admission and other perinatal complications. Most were primigravida (62.98%) and about 85.12% were delivered vaginally but caesarean section had to be done in 30 cases. And 2.8% cases required neonatal intensive care unit admission for prematurity. Obstetrician working in the periphery should refer the clients to a tertiary care center to confirm a suspicion of nuchal cord (non-engaged foetal head, decreased foetal movements, meconium stained liquor, foetal distress or malpresentation etc.) and also as a routine basis for ultrasound. Clients with confirmed complication should be managed in tertiary hospitals or institutions with the facility of ultrasound, cardiotocography and emergency surgery. This would improve the health of both the mother and fetus.

Preterm Gestation Along with Partial Hydatidiform Mole and Alive Foetus

Gestational trophoblastic disease encompasses a diverse group of lesion. If molar changes in the placenta are known along with an alive fetus then the situation is difficult to manage. We present successfully managed case of partial degeneration of placenta in molar pregnancy with an alive fetus at second stage of preterm labour.DOI: http://dx.doi.org/10.3126/kumj.v9i3.6310 Kathmandu Univ Med J 2011;9(3):222-4 

Ambispective study on Mac Donald suturing in pregnant ladies with cervical incompetence in Dhulikhel Hospital

BACKGROUND

Cervical incompetence is one of the main contributors to repeated pregnancy loss, accounting for approximately 25% of the cases. Typically it results in progressive cervical dilatation, leading to a painless second- or early-third-trimester abortion.

OBJECTIVES

The main objective of the study was to explore the benefit from cervical cerclage in pregnant women with anatomical cervical incompetence.

METHODS

In a review of the operation and labour registers from January 2006 till January 2010, a total of 38 cervical cerclage procedures were performed at Dhulikhel Hospital (DH). In the study caste, parity, gestational age, diagnostic criteria, postoperative complications and pregnancy outcomes of the cases were analyzed.

RESULTS

Two of the 38 cases didn't come for delivery at Dhulikhel Hospital (Kathmandu University Teaching Hospital). Four women haven't delivered at the time of data analysis. So pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. Of them 18 cases (47%) were Brahmin, 22 cases (58%) were between 20-25 years old and 32 cases (84%) were from Kavre district. All cases were booked cases (they had antenatal care in the hospital) and 14 patients (37%) were third gravida. Most cases had 2 to 4 antenatal visits prior to suturing. Two cases were diagnosed with a bicornuate uterus. 21 cases (55%) had a previous history of at least one dilatation and evacuation. 33 cases (87%) were diagnosed with cervical incompetence clinically and confirmed by ultrasound. The remaining 13% were assessed, in the absence of a history of midtrimester abortion, of having a high suspicion of cervical incompetence after midtrimester scan with measurement of cervical length. In 18 cases (47%), cervical cerclage were done at 15 to 20 weeks of gestation. The postoperative period was uneventful in all 38 cases. All cases (32) delivered in DH were assisted by consultant obstetricians. 19 out 32 cases (59%) were delivered vaginally at term.

CONCLUSIONS

38 cases were included in the study. Pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. 31 out 32 cases were delivered with good foetal weight. It clearly shows pregnant women with anatomical cervical incompetence were benefitted from cervical cerclage. The authors recommend an early trans vaginal scan in any patient with a history of mid trimester abortion or preterm labour. The cervical cerclage procedure therefore should be available more widely to benefit those patients with proven or strongly suspected cervical incompetence.

A study on mode of delivery and conduct of labour in women with vaginal birth after caesarean section in Dhulikhel Hospital

Vaginal birth after caesarean section is the delivery of a baby through the vagina after a previous cesarean delivery. For this to be conducted safely and responsibly emergency obstetric care must be available. To study the different modes of delivery in Dhulikhel Hospital (DH), evaluate the frequency of attempted and successful vaginal birth after caesarean section and, in the VBAC group, to identify those factors that may influence outcome and safety. The study was a retrospective study of all women who were delivered via different routes and the subgroup who underwent attempted vaginal birth after caesarean section in DH from January 2007 to December 2009. In this study factors associated with the successful VBAC were also analyzed. During the study period a total of 4215 deliveries conducted in DH and a total of 890 lower segment caesarean sections (21.1% of all deliveries) were performed. Of the 890 caesareans performed, 743 were primary and 147 were repeat (69 were repeat elective and 78 were repeat emergency). In this period an additional 33 women with previous lower segment caesarean sections had a successful vaginal delivery. Hence 18.3% (33/180) vaginal birth after caesarean sections was conducted successfully among women with previous caesarean). The results of this study indicate that vaginal birth after caesarean section is a clear feature of obstetric practice in DH. This is possible because of the vigilance in managing these women and the availability in this hospital setting of resources for immediate cesarean section.