Patient satisfaction and experience with various modes of Xylocaine administration for cervical dilatation and endometrial curettage: a randomized interventional study

Background: Patient satisfaction after a surgical procedure is an important outcome of hospital care. Many of the gynaecological menstrual problems such as abnormal uterine bleeding, postmenopausal bleeding requires endometrial evaluation which is done traditionally by dilatation and curettage. But this procedure is painful and requires appropriate pain management protocol. The aim is to evaluate the post-operative patient satisfaction following dilatation and curettage procedure.Methods: This study was conducted in a tertiary care hospital belonging to a medical college. A total of 236 patients were recruited for the study who subsequently underwent dilatation and curettage with different mode of Xylocaine anesthesia for pain relief. Of them 16 patients were excluded due to valid reasons and the remaining 220 were interviewed face to face following the procedure. The level of anxiety was assessed using Beck’s Anxiety inventory and also perception of satisfaction was documented along with complication related to the anesthesia.Results: The overall level of satisfaction was higher in the group receiving both paracervical block and intrauterine instillation of lidocaine during the procedure of dilatation and curettage. A further analysis showed that increase in level of satisfaction was due to improvement in pain scores due to combined mode of paracervical and endometrial anesthesia.Conclusions: A multimodal pain management protocol which involves pre-procedural sedation, combined cervical and endometrial anesthesia improves overall outcome with respect to reduction in anxiety scores and postoperative satisfaction levels.

Sonographic assessment of fetal head deflexion using occiput: spine angle measured during first stage of labour and its role in predicting the mode of delivery among nulliparous women

Background: The attitude of the fetal head during labour significantly influences the progress and outcome of delivery and is mainly diagnosed by vaginal examination during labour. The aim of the study was to quantify the extent of deflexion of the fetal head by measuring the fetal occiput spine angle (OSA) through transabdominal ultrasonography in the first stage of labour and to determine whether the fetal OSA can predict the mode of delivery.Methods: We conducted a prospective observational study on 145 nulliparous uncomplicated singleton pregnant women without occiput-posterior position of the fetus during active labour. The OSA was measured as the angle between the two tangential lines to the occipital bone and the vertebral body of the first cervical spine, during active labour and monitored until delivery. Intra- and interobserver reproducibility of the OSA measurement and the correlation between the OSA and mode of delivery were also evaluated.Results: For the study population, the mean value of the OSA measured in the active phase of the first stage was 124.2±11.5⁰. The OSA measurement showed excellent intraobserver agreement (r = 0.82; 95% confidence interval [95% CI] 0.70-0.80) and fair-to-good interobserver agreement (r = 0.62; 95% CI 0.51-0.71).  The mean OSA was significantly less for the group of patients who required conversion to cesarean section due to labour arrest (n=32) as compared to those who had vaginal delivery (n=113) (116.25±9.2⁰ versus 126.53±11.1⁰, P<0.01). An OSA of ≥121° was associated with vaginal delivery in 80.5% (91/113) of women, whereas 87.5% (28/32) of the women who delivered by cesarean section had an OSA <121⁰.Conclusions: Measurement of the OSA, by sonography is feasible, reproducible and an objective tool to assess the degree of fetal head deflexion during labour and to predict the mode of delivery.

Kidney length, a visceral parameter predicts foetal age between 24 to 40 weeks of gestation

Background: Accurate estimation of gestational age is important in providing appropriate antenatal care. Recent evidence suggests that weightage should also be given to kidney length in addition to standard biometric parameters in determining the duration of pregnancy by ultrasound.Methods: In a single centre, prospective cross-sectional study was done in 120 pregnant women. In addition to standard biometric parameters, kidney length was also measured between 24 to 40 weeks at two-week intervals. A total of 240 renal vertical measurements were done and average of right and left renal lengths was taken as a final kidney length. Descriptive analysis was carried out to find the mean and standard deviations for each variable. Regression analysis was carried for each variable either singly or in combinations and Pearson regression coefficients was used to find the association between gestational age and various foetal parameters and to determine which of the regression model gives the best fit for prediction of gestational age.Results: Foetal kidney length progressively increased throughout the gestation (from 23.2 mm at 24 weeks to 40.1 mm at 40 weeks). The regression formula using only kidney length as an independent variable (gestational age=2.195±0.942 X kidney length) had high degree of correlation (R2 0.97, p<0.001, SE of prediction 4.7±3.9), which was superior to other prediction models using standard biometric parameters. In multiple regression models using several conventional parameters, when femur length was added in a stepwise manner, there was significant improvement in forecasting gestational age.Conclusions: Present study showed that foetal kidney length is a reliable indicator of gestational age between 24 to 40 weeks of pregnancy and may be of utility in pregnancies with wrong dates, non-availability of dating scan and women who have conceived during lactational period.

Understanding King’s Health Questionnaire (KHQ) in assessment of female urinary incontinence.

Urinary incontinence has emerged as one of the leading medical problems for the geriatric population worldwide. Women are affected physically, mentally and socially and face embarrassment, depression and isolation. Increased life expectancy further adds to the prevalence of the condition and social, economic and health care burden. Although not sinister by itself, urinary incontinence has a profound impact on a woman‟s quality of life and warrants appropriate management. The efficacy of interventional procedures is measured by the caregiver mainly by improvement in urodynamic parameters. However, these gadgets do not assess the individual's satisfaction and feeling of wellbeing following the therapeutic intervention. Several generic QoL tools have been developed in an attempt to quantify these changes. But ironically, generic QoL questionnaires lack precision when applied to subjects with specific disease condition. In the context of female urinary problems, various QoL tools have been designed and investigated. King‟s Health Questionnaire (KHQ), which was formulated as early as 1997 by the group of researchers from King‟s College Hospital London still enjoys popularity till today, because of its strong psychometric properties, ease of administration and it adds objectivity to patient‟s subjective symptoms. However, the available information about KHQ is somewhat inadequate for the novice research scholar. The following brief essay aims at easy understanding of implementation, documentation, analysis and interpretation of King‟s Health Questionnaire in research settings.

Twin pregnancy with Hydatidiform Mole and Co-existent Live Fetus: Lessons Learnt

This is a case report of a twin pregnancy with one fetus and a coexistent mole diagnosed at 13 weeks. After thorough counseling, the pregnancy was continued as per the patient’s desire. The pregnancy was closely monitored with serial S β hCG, ultrasound for fetal growth, size of molar sac, and theca lutein cysts, which gradually decreased in size during the second trimester of pregnancy. An emergency caesarean delivery was done at 36 weeks due to breech in early labour. A live baby weighing 1.8 kg was delivered in good condition. Her S β hCG reached normal levels at the end of three weeks, and she is now on post-molar surveillance. Though the general trend is to terminate pregnancy in twins with coexistent mole in anticipation of complications, under close surveillance, optimal outcomes can be achieved. Monitoring of S β hCG, serial ultrasound for fetal growth, size of molar component, and theca lutein cysts can help to predict good patient outcomes.

Ethical issues in laparoscopic hysterectomy.

Hysterectomy is performed for a wide range of benign and malignant conditions, such as fibroids, menorrhagia and pelvic pain, and gynaecological malignancies. One in four women has a chance of undergoing hysterectomy in her lifetime. Conventionally abdominal hysterectomy is done through the open approach. However, many patients assume that the modern laparoscopic hysterectomy is superior to the standard approach. Laparoscopic surgical centres are mushrooming in major cities. This article presents ethical considerations involved in the decision-making process of choosing from the surgical options available.