Trends in Perinatal Mortality in Tribhuvan University Teaching Hospital: 13 Years Review.

Introduction: The perinatal mortality rate (PMR) in Nepal is still very high. In major hospitals of Nepal, it is still ranging from 20-30 per thousand births. This study was carried out with the objective to review PMR and classifying it according to Wigglesworth classification to identify the causes of perinatal deaths at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal over the past 13 years and assess need for improvement in care. Material and Methods: It was a retrospective study carried out in TUTH. Data of all stillbirths from 28 weeks of pregnancy and neonatal deaths within first seven days of life in the hospital was taken from monthly perinatal audit and annual mortality review. All the perinatal deaths were then classified according to Wigglesworth classification. Results: Over a 13 year period, there were total 42,746 births and 921 perinatal deaths giving a perinatal mortality of 21.5 per thousand births. Over this period PMR has decreased from 31 to 18 per thousand births. Still births contributed almost 50% of the perinatal deaths; deaths related to prematurity show an increasing trend and have increased by almost 70% in past 5 years. Deaths due to perinatal asphyxia were static. Conclusion: PMR over the years has shown declining trend at TUTH. There is need to improve antenatal, obstetric as well as intrapartum services to further reduce the still birth as well as deaths due to prematurity and perinatal asphyxia.

Comparison of Pain Response to Venepuncture Versus Heel Lance Blood Sampling in Term Neonates.

Introduction: Pain in neonates is largely underestimated and neglected. Pain experience can alter clinical outcome, brain development and subsequent behavior in newborns. Numerous newborns undergo blood sampling routinely in nurseries/NICUs and these procedures are often done without pain relieving measures. Heel lancing and venepuncture are two common procedures for blood sampling in neonates. The objective of this study was to compare pain response to venepuncture versus heel lance in full term neonates. Materials and Methods: A comparative observational study was conducted among 200 term neonates who were undergoing blood sampling for bilirubin or glucose estimation. Neonates were randomly assigned to heel lance (HL) and venepuncture (VP) groups with 100 babies in each group. During the procedure, pain was assessed by Neonatal/Infant pain Scale (NIPS). Heart rate (HR) and oxygen saturation (SpO2) were continuously monitored 5 minutes prior to procedure and upto 5 minutes after the procedure. Results: The median NIPS score in HL and VP were 7 and 3.5 respectively which showed statistically significant (p= 0.0001) higher level of pain experience in HL than in VP. During the procedure, both the groups (HL and VP) showed significant changes in heart rate and oxygen saturation i.e., increase in HR (p= 0.0001) and decrease in SpO2 (p= 0.0001), however the increase in heart rate and decrease in oxygen saturation were significantly more in HL than in VP (p= 0.0001). Conclusion: Neonates perceive pain as demonstrated by Neonatal Pain Scale and venepuncture is the less painful procedure than heel lancing for blood sampling in neonates.

Clinical Profile of Paediatric Cataract and Surgery in a Tertiary Eye Care Centre Nepal.

Introduction: Paediatric cataract is the opacification of lens and its capsule in children below 14 years of age. The management of paediatric cataract is lens aspiration with or without anterior vitrectomy, with or without intra-ocular lens implantation. The objective was to present the profile of pediatric cataract of operated eyes in children ≤14 years. Materials and Methods: This was a descriptive study in a hospital setting. A review of pediatric cataract cases operated between November 2007 and June 2009 in Tilganga Institute of Ophthalmology (TIO), a tertiary eye care centre in Nepal was carried out. The personal profile, preoperative and intra-operative details were noted. In the statistical analysis p value less than 0.05 is considered as significant. Results: A total of 175 eyes of 132 children had presented during study. The sex ratio was 1.6 male per female with mean age of 6.7 years (SD ±4.3). About one-third (32%) presented within the age of three years where as more than two-fifths (46%) presented at the age eight years and above. Seventy two cases were collected through door to door enumeration and screening clinics for children. The proportion of cataract was higher in males than in females (P>0.05). Visual acuity ranged from 6/18 to follows light. Conclusion: Nearly half of the paediatric cataract had presented after the age of eight years mainly from hilly region through the screening program. Most of the pediatric cataract cases presented with the whitish pupillary reflex with more than two-thirds of visual acuity of less than 3/60. The most common type of the cataract surgery performed was lens aspiration with anterior vitrectomy with lens implantation. The earlier the surgery better is the visual prognoses. Hence, community screening through as door to door screening and one day screening clinics will help for early referral and earlier surgery to reduce visual disabilities due to paediatric cataract.

Cerebellar Mutism After Pineal Tumour Excision: A Case Report.

Cerebellar mutism syndrome (CMS) was first described by Rekate et al in 1985. This syndrome is a common complication of posterior fossa surgery in children with range of 11-29% and usually manifests as diminished speech, hypotonia, and ataxia. The cause is due to bilateral pertubation of the dentate nuclei and their efferent pathways by edema, perfusional defects, axonal damage or metabolic disturbances. Other rare causes of CMS like acute subdural hematoma of the posterior fossa, head injury, brainstem glioma surgery, meningitis and basilar artery occlusion have also been reported. CMS after supracerebellar resection of the pineal tumor is a very rare with very few cases reported. We report such a case in a 10- year old boy who underwent excision of a pineal tumor through the infratentorial supracerebellar route.

Sacrococcygeal Teratoma in a Child: A Case Report.

Sacrococcygeal teratomas (SCT) are tumors that arise in the sacrococcygeal area containing tissue from all three germ layers. SCT has an incidence of approximately one in 35,000 – 40,000 live births with malignant transformation with increasing age. We report a case in a four year old which was excised completely via the postanal route with no operative or postoperative morbidity. The histopathology was that of yolk sac variant and she is planned for chemoradiotherapy.

Bubble-CPAP in Neonatal Unit of TUTH.

Introduction: Nasal Continuous Positive Airway Pressure (CPAP) in newborn babies with respiratory distress reduces requirement for mechanical ventilation thereby decreasing referral to higher centre. In our neonatal unit prior to the use of this intervention, morbidity and mortality associated with respiratory distress was significant which has decreased after we started CPAP in Kartik 2065 (October 2008) including a decrease in referrals to higher centre for ventilator support.The objective of this study was to evaluate the outcome of bubbling CPAP in newborn babies who had respiratory distress. Methods: Observational study done in neonatal unit of TUTH over a period of 3 months i.e from Kartik to Poush 2065 B.S (mid of October to mid of January,2008) Results: 127 neonates were admitted, of whom 15 babies with respiratory distress (11.8% of total admissions) received CPAP. 11 babies improved, while 4 babies died. Among those attending follow up (8 babies) none had any features of chronic lung disease. Conclusion: In resource poor settings where level II neonatal care is already exists; CPAP can be easily applied for newborn babies with respiratory distress with promising results and it helps to decrease neonatal morbidity and mortality.

Lennox Gastaut Syndrome: A Case Report.

Lennox-Gastaut syndrome (LGS) is a severe form of childhood epilepsy that is defined by generalized multiple type seizures, slowness of intellectual growth, and a specific EEG disturbance. Children affected might previously have infantile spasms or underlying brain disorder but etiology can be idiopathic. LGS seizures are often treatment resistant and the long term prognosis is poor.

Apert Syndrome (Acrocephalosyndactyly): A Rare Syndromic Craniosynostosis.

We report a premature infant who had multisutural craniosynostosis with pointed head, syndactyly of 2nd, 3rd and 4th fingers of all four limbs and other findings that were consistent with Apert syndrome. This is perhaps the first case of Apert Syndrome reported from Nepal.

Profile of Asphyxiated Babies at Tribhuvan University Teaching Hospital.

Objective: To assess risk factors and outcome in the early neonatal period of babies who were asphyxiated at birth. Methodology: This was a retrospective study conducted at Tribhuvan University Teaching Hospital (TUTH) over a period of one year from 15th Feb 2007 to 14th Feb 2008. All the term babies who had Apgar score of less than < 6 at 1 minute of birth were included. Detailed maternal risk factors during pregnancy and labor were analyzed. The newborn babies who required admission in neonatal unit were again analyzed for development of hypoxic ischemic encephalopathy (HIE) and their outcome. Results: During the study period, out of 3594 term babies, 327 babies (9%) were asphyxiated. Of the total asphyxiated babies, 85% and 15% had moderate and severe asphyxia, respectively, at 1 minute of birth. Out of these asphyxiated babies, 51% and 7% had intrapartum and maternal risk factors, respectively. Intrapartum risk factors like meconium stained liquor, non-vertex presentation, and fetal heart rate abnormalities accounted for 4 fold risk of asphyxia. Of these babies, 26% required admission in nursery and 29% developed hypoxic ischemic encephalopathy. Among the admitted babies 6%expired, 2% left against medical advice and rest were discharged. Conclusion: Early identification and close monitoring of high risk mothers studies with maintaining partograph during labor will help to reduce neonatal asphyxia.

Computed tomography guided percutaneous transthoracic fine needle aspiration cytology in chest masses.

A retrospective, hospital based descriptive study was done to know the pathological spectrum of thoracic lesions and to correlate the radiological findings with cytological findings obtained from computed tomography guided percutaneous transthoracic fine needle aspiration of chest mass. The clinical, radiological and cytological data of 100 patients were studied who underwent CT guided FNAC from May, 2004 to May, 2007. Diagnostic accuracy of FNAC is 82%. Cytological examination showed that 51 cases were malignant and 31 cases were benign. Provisional diagnosis based on radiological findings were 50 and 32 cases of malignant and benign lesions respectively. Sensitivity and specificity, positive and negative predictive value of radiological findings in this study was 88%, 84%, 90% and 81% respectively. Post procedure complication were (a) pneumothorax in two cases and both the cases had to be hospitalized for active management (b) minimal perilesional hemorrhage and hemoptysis in three cases and (c) chest pain in six cases. CT guided FNAC is a simple and safe procedure with high diagnostic accuracy in the evaluation of focal chest lesions. Pneumothorax, perilesional hemorrhage, hemoptysis and chest pain are the usually encountered complications. Very few cases of complication require active management.

Leiomyoma of breast: a report of rare case.

Leiomyoma is a benign smooth muscle neoplasm. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus. Leiomyoma of breast is a rare benign non epithelial tumor. Most leiomyomas in the breast are found in the subareolar region. There are few cases being reported in the literature. Here we report a case of 52 years old lady who presented to us with a painless right sided breast lump. There was no history of nipple discharge, trauma or use of oral contraceptive pills. Excisional biopsy revealed a growth pattern of interlacing fascicles of smooth-muscle cells consistent with leiomyoma of breast.

Prevalence of diabetic retinopathy following a community screening for diabetes.

Diabetic retinopathy is a public health challenge in developing countries including Nepal and is not like other preventable or treatable causes of blindness. The aim of study was to estimate the prevalence of diabetic retinopathy following a community screening for diabetes. A community-based, cross sectional study was designed to screen for diabetes in people age > or =40 years in a semi-urban community of Kathmandu, Nepal. In those individuals with detected diabetes, a comprehensive eye examination was performed by an ophthalmologist and diabetic retinopathy was graded using a standard protocol. 1475 persons were screened for diabetes with a mean age of 54.7 +/- 12 years with sex ratio of 0.69 male per female. Thirty-four subjects were found to have impaired fasting glucose and sixty subjects had diabetes. The prevalence of diabetes mellitus was 4.1% (60) but 6.4% (94) had an abnormal blood sugar level. Fifty-seven diabetic patients visited at-Tilganga Eye Centre for ocular examination. Among examined patients, the prevalence of diabetic retinopathy was 19.3% (11). Only one person had clinically significant macular edema requiring laser therapy. The prevalence of hypertension and cataracts were the same among patients with and without diabetic retinopathy. The prevalence of diabetic retinopathy was low but one of sixteen newly diagnosed diabetics did have evidence of diabetic retinopathy. Eighty-four percent of known diabetics had never had their eyes examined for ocular complications. Community awareness and physician coordination should be emphasized to increase the eye examination rate.

Rett Syndrome: A Case report.

Rett syndrome (RS) is a severe neuro-developmental disorder leading to severe intellectual disability in females all around the world. A four-year-old girl from Kathmandu presented with classic features of Rett syndrome (RS), including developmental regression with dementia, loss of acquired speech and hand function, and stereotypic hand movements along with generalized tonic clonic convulsion.

Prevalence of and factors associated with diabetic retinopathy among diabetics in Nepal: a hospital based study.

Diabetic retinopathy is the one of the leading cause of visual impairment in world including Nepal. The objective of the study is to estimate the prevalence of and factors associated with Diabetic Retinopathy among diabetics in a Tertiary Eye Care Centre, Nepal. A hospital-based, cross sectional study, was conducted at Tilganga Eye Centre, Nepal. 371 consecutive subjects were recruited during a period of study. Ophthalmologist performed comprehensive eye examinations, which were reconfirmed by senior ophthalmologist. Diabetic Retinopathy was graded using the Early Treatment Diabetic Retinopathy Study. Total 371 consecutive diabetics were examined, mean of 57.4 years (SD 12.0) having the sex ratio of 0.72 male per female. The prevalence of Diabetic Retinopathy was 44.7% (166) with non-proliferative Diabetic Retinopathy presented 85.5% (142) and 14.5% (24) were proliferative Diabetic Retinopathy. Clinically significant macular edema was found in 19.2% (32). The age at onset of diabetes, duration of diabetes and hypertension were significantly associated with Diabetic Retinopathy (p = < 0.05) whereas ethnicity, sex and cataract surgery were not associated with it (p = > 0.05). The prevalence of Diabetic Retinopathy was within the range of previous studies with a high rate of proliferative diabetic retinopathy. Factors associated with diabetic retinopathy were similar to other developed countries. To prevent this condition of Diabetic Retinopathy, the coordination between physician and ophthalmologist needs to be strengthened.

A Study of Early Neonatal Deaths at Kathmandu Medical College Teaching Hospital.

Introduction: Over 9 million deaths occur each year in the perinatal and neonatal periods globally. 98% of these deaths take place in the developing world. Nepal has a high neonatal mortality rate (NMR) of 38.6 per 1000 live births (2001). Two thirds of the newborn deaths usually occur in the first week of life (early neonatal death). Newborn survival has become an important issue to improve the overall health status and for achieving the millennium developmental goals of a developing country like Nepal. Aims and Objectives: This study was carried out to determine the causes of early neonatal deaths (ENND) at KMCTH in the two-year period from November 2003 to October2005 (Kartik 2060 B.S. to Ashoj 2062). Methodology: This is a prospective study of all the early neonatal deaths in KMCTH during the two-year study period. Details of each early neonatal death were filled in the standard perinatal death audit forms of the Department. Results: Out of the 1517 total births in the two-year period, there were 10 early neonatal deaths (ENND). Early neonatal death rate during the study period was 6.7 per 1000 live births and early neonatal death rate (excluding less than 1 kg) was 6.1 per 1000 live births The important causes of early neonatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and septicaemia. During the study period, there was no survival of babies with a birth weight of less than 1 kg. Among the maternal characteristics, 80% of the mothers of early neonatal deaths were aged between 20-35 years. 50% of the mothers were primigravida. 50% of the mothers of ENNDs had delivered their babies by caesarean section. Discussion: Most of the early neonatal deaths were due to extreme prematurity. Birth asphyxia was the second most important cause of early neonatal deaths. 70% of ENNDs were among LBW babies. Prevention of premature delivery, proper management of very low birth weight babies and early detection and appropriate management of perinatal hypoxia have become important interventional strategies in reducing early neonatal deaths in KMCTH. Conclusion: Early neonatal mortality at KMCTH is fairly low. Good care during pregnancy, labour and after the birth of the baby has helped to achieve these results. Low cost locally made equipments were used to manage the sick newborns. Reduction of early neonatal deaths require more intensive care including use of ventilators, surfactant and parenteral nutrition and prevention of preterm births.

Foreign body in the rectosigmoid colon.

A 55 years old male presented with history of assault and insertion of a "glass object" through his anus. Examination and investigation of the patient revealed a bottle in the rectosigmoid colon. The bottle was manipulated and delivered out transanally under general anesthesia.

Occurrence of soil-transmitted helminths in women at the Himalayan region of Nepal.

OBJECTIVE: To find the occurrence pattern and prevalence of the soil transmitted helminths in women of child bearing age group. METHODS AND MATERIALS: The study was conducted in Jiri , an area of Dolakha district at the altitude of 2100 meter from sea level. The faecal sample of 478 women of childbearing age (15 to 45 years) were taken randomly and examined for the ova of soil transmitted helianthus. RESULT: The occurrence pattern was 53.0%, 20.0% and 2.7% for Hookworms, Ascaries lumbricoids and Trichuris Trichuria respectively. Both Ascaries and Hookworm prevalence rates noticeably increased with increasing age, with the highest infection rate between the age of 36-45 years while trichuris infection reached the highest in women of 15-25 years of age. CONCLUSION: There is a high prevalence of hookworm and ascaries in women of childbearing age and necessary intervention is needed according to WHO guidelines.

Morbidity pattern of children with asthma: a prospective study.

OBJECTIVES: To determine the morbidity pattern of asthma in children attending the paediatric asthma follow-up clinic. MATERIALS AND METHODS: Longitudinal prospective follow up of hundred and four patients, diagnosed as asthma, over a period of 2 years was done. Regular follow up by the same person during each visit and proper supervision of standard treatment along with parental education regarding the asthma, was done. RESULTS: The mean age of children presenting with asthma was 6.7 years. Majority of children 49 (47.5%) were graded as mild persistent asthma. Fifty nine (56.7%) children were missing school more than 7 days per month. Family history was present in forty one percent of the children. Fifty seven (54.8%) children were taking significant amount of junk food and were undernourished. Significant reduction in school-missing days and Emergency Room visits was noted in these children during the follow up period. CONCLUSION: Awareness of disease is an important aspect of asthma management. Proper treatment and follow up with emotional support and education of the care taker, about the asthma, can reduce the morbidity pattern of asthma in children.

Two year audit of perinatal mortality at Kathmandu Medical College Teaching Hospital.

INTRODUCTION: Perinatal mortality rate is a sensitive indicator of quality of care provided to women in pregnancy, at and after child birth and to the newborns in the first week of life. Regular perinatal audit would help in identifying all the factors that play a role in causing perinatal deaths and thus help in appropriate interventions to reduce avoidable perinatal deaths. AIMS AND OBJECTIVES: This study was carried out to determine perinatal mortality rate (PMR) and the factors responsible for perinatal deaths at KMCTH in the two year period from November 2003 to October 2005 (Kartik 2060 B.S. to Ashoj 2062). METHODOLOGY: This is a prospective study of all the still births and early neonatal deaths in KMCTH during the two year period from November 2003 to October 2005. Details of each perinatal death were filled in the standard perinatal death audit forms of the Department of Pediatrics, KMCTH. Perinatal deaths were analyzed according to maternal characteristics like maternal age, parity, type of delivery and fetal characteristics like sex, birth weight and gestational age and classify neonatal deaths according to Wigglesworth's classification and comparison made with earlier similar study. RESULTS: Out of the 1517 total births in the two year period, 22 were still births (SB) and 10 were early neonatal deaths (ENND). Out of the 22 SB, two were of < 1 kg in weight and out of 10 ENND, one was of <1 kg. Thus, perinatal mortality rate during the study period was 19.1 and extended perinatal mortality rate was 21.1 per 1000 births. The important causes of perinatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and associated maternal factors like antepartum hemorrhage and most babies were of very low birth weight. According to Wigglesworth's classification, 43.8% of perinatal deaths were in Group I, 12.5% in Group II, 28.1% in Group III, 12.5% in Group IV and 12.5% in Group V. DISCUSSION: The perinatal death audit done in KMCTH for 1 year period from September 2002 to August 2003 showed perinatal mortality rate of 30.7 and extended perinatal mortality rate of 47.9 per 1000 births. There has been a significant reduction in the perinatal mortality rate in the last 2 years at KMCTH. Main reasons for improvement in perinatal mortality rate were improvement in care of both the mothers and the newborns and the number of births have also increased significantly in the last 2 years without appropriate increase in perinatal deaths. CONCLUSION: Good and regular antenatal care, good care at the time of birth including appropriate and timely intervention and proper care of the sick neonates are important in reducing perinatal deaths. Prevention of preterm births, better care and monitoring during the intranatal period and intensive care of low birth weight babies would help in further reducing perinatal deaths. Key words: Perinatal mortality rate (PMR), still births, early neonatal death (ENND), Total perinatal death (PND).

A comparative study of pre-operative with operative diagnosis in acute abdomen.

In this observational study (from August 2000 to January 2001) 102 patients of all age group with non-traumatic acute abdomen were studied to see the negative laparotomy rate and the diagnostic accuracy and predictive values of different investigations in acute abdomen. The disease was most common in the age group 20-29 years with male predominance. More than half of the acute abdomen was due to the acute appendicitis. Neutrophil leucocyte count had the highest sensitivity (91.5%) while Plain X-ray abdomen showed the highest specificity (88.8%) and positive predictive value (88.6%) in diagnosing acute abdomen. Urinalysis showed the highest negative predictive value (93.3%). Overall diagnostic accuracy was 78.4%, which was statistically significant (p<0.05). Diagnostic accuracy was highest in bowel obstruction (82.4%) and lowest in peritonitis due to viscus perforation (69.0%). Negative laparotomy rate was 17.6% in the study, which was statistically significant (p<0.05). It was highest with peritonitis due to viscus perforation (20.7%), and lowest in bowel obstruction (11.8%).