Acceptance of family planning amongst patients attending Dhulikhel hospital obstetrics and gynecology department.

BACKGROUND: Knowledge of contraceptive methods is an important factor for an individual to use or not use of family planning methods. In Nepal, at least one modern method of family planning is universal amongst both men and women. OBJECTIVES: To assess the knowledge, attitude regarding various family planning methods and practice of contraceptives amongst couples attending Dhulikhel Hospital Obstetrics and Gynecology Department. METHODS: Five hundred and fifteen couples were interviewed. Their knowledge, attitude and practice of contraception were evaluated with the help of pre-evaluated questionnaire. The other variable used were the age of the couple, parity, educational status and economic status having effect on the contraceptive acceptance were taken into consideration. Descriptive analysis was conducted to obtain percentages. RESULTS: We observed that 74.98% of women were in the age group of 20-29 years and 59.22% of men were within the age group of 20-29 years. Teen age mothers were 17.86% and teen age fathers were 1.35%. In our study, we observed that higher the educational level better was the acceptance for family planning methods. The higher income group had less number of children compared to lesser income group. In our study, we noticed that all the couples knew about different methods of family planning, main sources of information were television, pamphlets and healthworkers. Only 16 males had undergone vasectomy and 32 women had undergone tubectomy. Fewer number of vasectomy was due to the belief that undergoing vasectomy will make the male partner weak physically. 13.20% of women preferred Depot medroxy progesterone as a temporary method of family planning, 13% of males preferred condom as a temporary method of family planning. CONCLUSION: We conclude that education plays a vital role in the acceptance of family planning. As couples who have higher education level tend to have higher income and they have lesser number of children. They are more receptive towards counseling and agree upon the various methods of family planning. The easy accessibility to the various media like radio, television tend to make people aware of various methods of family planning.

Ruptured primary ovarian pregnancy: a rare case report.

Ovarian pregnancy is an uncommon presentation of ectopic gestation and usually, it ends with rupture before the end of the first trimester. Its presentation often is difficult to distinguish from that of tubal ectopic pregnancy and hemorrhagic ovarian cyst. We report a rare primary ruptured ovarian pregnancy in a 26 years lady.

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.

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.

Rectal misoprostol versus intramuscular oxytocin for prevention of post partum hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) is an important cause of maternal morbidity and mortality especially in the developing countries.,Compared to expectant management, active management decreases the incidence of PPH. OBJECTIVE: To compare the effectiveness of rectal misoprostol with intramuscular oxytocin in the prevention of postpartum hemorrhage. METHODS: This is a prospective, randomized and analytical study from 1 st September 2009 to 28th February 2010 at Department of Obstetrics and Gynecology, Dhulkhel Hospital - Kathmandu University Hospital, Dhulikhel, Nepal. A total of 200 women were included to receive either 1000 micrograms rectal misoprostol tablets or 10 units of oxytocin intramuscularly. Primary outcome measures were the incidence of postpartum hemorrhage or a change in hematocrit or hemoglobin from admission to day two post delivery. Secondary outcome measures including severe postpartum hemorrhage and the duration of the third stage of labor were noted. Also the side effects of both misoprostol and oxytocin were recorded. RESULTS: The frequency of postpartum hemorrhage was 4% in the misoprostol subjects and 6% in the control subjects (P=0.886) There were no significant difference among the groups in the drop of hematocrit (P>0.05). Secondary outcome measures including severe postpartum hemorrhage and the duration of the third stage of labor were similar in both groups. Similarly, the side effects between the misoprostol and oxytocin group within 6 hours was statistically significant (p=0.003) whereas the side effects within 24 hours was statistically not significant (p=0.106). CONCLUSION: Rectal misoprostol is as effective as intravenous oxytocin in preventing postpartum hemorrhage with the similar incidence of side effects and is worthwhile to be used as a uterotonic agent for the routine management of third stage of labor.

The glucose challenge test for screening of gestational diabetes.

BACKGROUND: The frequency of gestational diabetes mellitus (GDM) is 0.6% -15% of pregnant woman. The modern trend towards the delay starting family is the main factor responsible for increase prevalence of GDM. This condition is associated with the adverse effect on mother and fetus, so it is important to find out the GDM by screening of all the pregnant women. OBJECTIVE: To observe the feasibility of using the 50g GCT for all pregnant women attending Dhulikhel Hospital, Obstetric OPD. To determine the incidence of gestational diabetes in the population and to observe the maternal and fetal outcome among those having an elevated GCT level and gestational diabetes. METHODS: A prospective and analytical study of 1598 pregnant women booked and delivered between June 2009and August 2010. Glucose challenge test (GCT) performed by using 50gm glucose and diagnosis of gestational diabetes performed by using the Carpenter Coustan Criteria. Pregnancy outcomes were assessed by the gestation and mode of delivery. Similarly, neonatal outcomes assessed in terms of birth weights, APGAR scores, congenital abnormalities, hyperbilirubinaemia, hypoglycaemia or respiratory distress syndrome. RESULTS: The detected incidence of gestational diabetes was 0.75%. With the threshold plasma glucose level at140 mg/ dl, 198 women needed to undergo the 100g oral glucose tolerance test and 12 women had gestational diabetes. The diagnostic yield was 6.06%. Perinatal outcome was similar to the rest of the women with normal glucose challenge test. CONCLUSIONS: The 50g GCT is feasible and also helps to find out GDM. It is easy, user friendly, cheap and convenient for screening purpose.

Sonographic measurement of fetal pinna length in normal pregnancies.

BACKGROUND: Many studies have emphasized on fetal pinna measurements and morphologic features to use this structure as an additional marker for fetal chromosomal anomaly. OBJECTIVES: To assess relationship between fetal pinna length and gestation age and develop a nomogram. To assess relationship between fetal pinna length and head circumference and biparietal diameter. METHODS: Fetal pinna measurements from the tip of helix to the end of lobe were obtained prospectively in 850 singleton pregnant women between 15 and 40 weeks gestation Normal case was defined as normal sonographic findings during examination and normal infant examination at birth or both. Final study population was 787. The relationship between gestational age in weeks to pinna length in millimeters was analyzed by simple linear regression. Correlation of fetal ear length measurements with gestational age, biparietal diameter and head circumference were also obtained. RESULTS: Linear relationships were found between fetal pinna length and gestational age [Pinna Length (mm)=1.044xGestational age (weeks) -3.857]. A nomogram of normal pinna length was obtained. High correlation was found between pinna length and gestational age (r=0.942; p less than 0.001), pinna length and head circumference (r=0.931; p less than 0.001). Significant correlation was found between pinna length and biparietal diameter (r=0.934; p=0.004) CONCLUSIONS: The results of this study provide a nomogram for fetal pinna. The study also provides relationship and good correlation between pinna length and other biometric measurements.

Post partum haemorrhage: prevalence, morbidity and management pattern in Dhulikhel Hospital.

BACKGROUND: Post partum haemorrhage (PPH) is the leading cause of maternal death worldwide. PPH occurs in up to 18% of total births. Among different factors, PPH due to uterine atony is the primary and direct cause of maternal mortality comprising about 90%. OBJECTIVE: The objective of the present study was to assess the prevalence, morbidity and management pattern of PPH in Dhulikhel Hospital. MATERIALS AND METHODS: Hospital based retrospective study was carried out at Kathmandu University School of Medical Science, Dhulikhel Hospital from the period of January 2007 till October 2009. The study group included total of 60 patients. All women who had PPH both primary and secondary were studied. Information regarding total number of deliveries obtained from Obstetrics ward. The cases with PPH were identified and detail records were reviewed using standard format. The main outcome measures used for the analysis were amount of blood loss, cause of PPH and treatment methods. RESULTS: In Dhulikhel hospital, from January 2007 till October 2009 a total of 3805 deliveries took place. Out of which 60 women had PPH. The prevalence was 16/1000 deliveries. There are 41 (68.3%) cases of primary PPH and 19 (31.7%) cases of secondary PPH. PPH was found more in home deliveries, unbooked case and in multiparas. The mean blood loss was 1055 ml. As an aetiology, retained placenta and retained placental bits of tissue was found in 37(61.7%) cases, atonic uterus in 10 (16.7%) cases, genital tract trauma in 8(13.3%), sepsis of genital tract in 3(5%), case of ruptured uterus in one case and a case of angle bleeding from previous uterine scar following caesarean section. Among all 15 (25%) cases underwent manual removal of placenta, 5(8.3%) underwent controlled cord traction, 3 (5%) underwent manual removal of placenta followed by check curettage in cases of retained placenta, 16 (26.7%) cases were managed by check curettage for retained bits of placental tissue and membrane. Trauma in genital tract was managed by repair of trauma in 6 (10%) cases. Hysterectomy was required in 3 (5%) cases. Conservative management with uterotonics only required in 12 (20%) cases. CONCLUSION: Active management of third stage of labour can prevent PPH so delivery by skilled hand in hospital should be promoted. Secondary PPH besides primary can result in significant maternal morbidity. It also deserves similar attention.

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.

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.

Safety and efficacy of misoprostol for induction of labour.

BACKGROUND: Induction of labour is widely carried over the world in cases where continuation of pregnancy is hazardous to mother or fetus. Varieties of techniques are available for induction of labour. Prostaglandin is one of the most effective means for achieving cervical ripening and induction of labour. This study was carried out to see safety and effectiveness of Misoprostol for induction of labour. METHODS: This prospective study was carried out at Kathmandu University Hospital, Dhulikhel from Jan 2008 to Aug 2009. A total of 70 patients were included in this study. All patients received 50 µg of Misoprostol in the posterior fornix with maximum dose up to 3 doses at interval of 6 hours. Bishops scoring was reviewed each time before application of Misoprostol. When favourable cervix along with good uterine contraction is noted then augmentation with Oxytocinon was done holding Misoprostol. The measures used for the analysis of effectiveness and safety of Misoprostol were change in bishop score, total dose required, need for augmentation, side effects, duration of first, second and third stages of labour, duration from induction till delivery, mode of delivery and neonatal outcome. The primary outcome measures were induction to delivery interval and caesarean section rate. RESULTS: Out of 70 patients, 21 (30%) required augmentation. Among 70 patients, 46 (65%) underwent normal delivery, 6 (8.6%) underwent instrumental delivery and 18 (25%) patients underwent cesarean section for various indications (p=0.00). Total 31 (44%) patients delivered within 10 hours of induction, 16 (22%) within 15 hours and 4 (4.7%) took more than 18 hours. Duration of second stage of labour was also found to be shortened with use of Misoprostol for induction of labour. Duration of second stage of labour was less than 30 minutes in 42 (60%) cases and more than 30 minutes in 9 (17%) cases. CONCLUSIONS: Misoprostol is an effective cervical ripening agent with favorable outcome and comparable with other inducing agents.

Antenatal detection of conjoined twin.

Conjoined twin is a sporadic event with prevalence of 1 in 50000 to 1000000 birth. Incomplete division of embryonic disc results in conjoined twin. Ultrasound plays a major role for early detection and proper obstetric management. A case of cephalothoracopagus conjoined twin was detected at 20 weeks pregnancy in a primigravida woman by antenatal ultrasound. The pregnancy was terminated after proper counseling, despite the need to save the baby, as multidisciplinary team to separate the twins was not available.

Mathematically modeling the repair of heat-injured Listeria monocytogenes as affected by temperature, pH, and salt concentration.

Heat-injured cells of Listeria monocytogenes were inoculated into Listeria repair broth (LRB) adjusted to various pH levels (4.2, 5.0, 6.6, 8.0 and 9.6) and salt concentrations (0.5%, 2.5%, 5.0%, 7.5% and 10.0% w/v) at controlled temperatures (4, 10, 22, 37 and 43 degrees C) in a complete factorial manner (5(3)). Repair of the injured microorganisms was evaluated using selective and non-selective plating media. The Gompertz parameters, which were generated by fitting the equation with the bacterial counts, were used to calculate the repair percentage as a function of time from which the repair time was estimated. All growth curves fit the Gompertz equation well (R(2) > or = 0.972). A first-order model described the repair trend closely (R2 = 0.989 +/- 0.011). Heat-injured Listeria could fully repair in LRB only under 63 of 125 conditions tested during 21 days of incubation. Refrigeration temperature was the most effective means to prevent the repair of heat-injured Listeria. The minimum temperature required for repair increased with an increase in NaCl concentration. The pH ranges at which the repair could occur were narrower at 4 and 10 degrees C than those at higher temperature. The repair was observed in media containing 10% NaCl between temperatures of 22 and 43 degrees C at pH 6.6.