The association between maternal intra-abdominal pressure and hypertension in pregnancy.

INTRODUCTION: Pregnancy leads to a state of chronically increased intra-abdominal pressure (IAP) caused by a growing fetus, fluid, and tissue. Increased intra-abdominal pressure is leading to state of Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome. Clinical features and risk factors of preeclampsia is comparable to abdominal compartment syndrome. IAP may be associated with the hypertension in pregnancy (HIP). OBJECTIVES: The study aimed to determine the antepartum and postpartum IAP levels in women undergoing caesarean delivery (CD) and association between hypertension in pregnancy, and antepartum and postpartum IAP levels in women undergoing CD. METHOD: Seventy pregnant women (55 normotensive, 15 HIP) undergoing antepartum, non-emergency CD, had their intravesical pressure measured before and after the CD, the intravesical pressure measurements obtained with the patient in the supine position were considered to correspond to the IAP. Multivariable linear regression models were used to study associations between intraabdominal pressure and baseline characteristics in normotensive pregnancies and hypertensive pregnancies. RESULTS: In normotensive pregnancies at mean gestation age of 38.2 weeks (95%CI 37.9 to 38.6), mean antepartum IAP was 12.7 mmHg(95%CI 11.6 to 13.8) and the mean postpartum IAP was 7.3 mmHg (95% CI 11.6 to 13.8). Multivariable linear regression models showed HIP group antepartum IAP positively associated with coefficient value of 1.617 (p = 0.268) comparing with normotensive pregnancy group. Postpartum IAP in HIP group positively associated with coefficient value of 2.519 (p = 0.018) comparing with normotensive pregnancy group. IAP difference is negatively associated with HIP (coefficient -1.013, p = 0.179). CONCLUSION: In normotensive pregnancies at term, the IAP was in the IAH range of the non-pregnant population. Higher Antepartum IAP and Postpartum IAP are associated with HIP. Reduction of IAP from antepartum period to postpartum period was less with HIP.

Oral Misoprostol for 48 hours Versus a Supra Cervical Foley Catheter for 48 Hours for Induction of Labour in Post Dated Pregnancies: A Randomized Control Trial.

Aims: To assess the feasibility of administration of three doses of oral misoprostol (OM) 50 µg four hourly per day for 48 hours versus the insertion of a supra cervical Foley catheter for 48 hours, in women at 40 weeks + 5 days gestation, and compare the effectiveness of the two methods for induction of labour (IOL). Method: An investigator blinded, randomized controlled trial was conducted at the academic obstetric unit, Teaching Hospital Mahamodara, Galle from 13.10.2016 to 30.04.2017. Consecutive women (n=144) with singleton uncomplicated pregnancies having Modified Bishop Score (MBS) <5 at 40weeks + 5days gestation were allocated by stratified (primigravidae/ multigravidae) block randomization to receive three doses of OM 50µg four hourly per day for 48 hours or a supra cervical Foley catheter for 48 hours. Results: Compared to the Foley, OM resulted in higher rates of successful IOL (67% vs 47%, RR 1.4, 95% CI 1.1 - 2.0, p =0.029), more vaginal deliveries within 24 hours and 48 hours, shorter mean induction delivery intervals and greater mean increase in MBS in those not in labour after 48 hours. There was non-significant increased frequency of excessive uterine activity, cardiotocograph abnormalities and meconium stained liquor after OM but no differences in the rates of caesarean deliveries and maternal or neonatal morbidity or mortality between the two groups. Conclusion: The administration of three doses oral misoprostol (OM) 50 µg four hourly per day for 48 hours as well as the insertion of a supra cervical Foley catheter for 48 hours were feasible for women at 40 weeks + 5 days gestation, but OM was more effective than the Foley catheter for IOL.

Analysis of high caesarean section rates: the second step after audits using the Ten Group Classification System

Objective: To identify possible methods of reducing high caesarean section rates in a tertiary care hospital. Methods: Analysis of birth weight of neonates, maternal age and indications for caesarean section in the groups identified by a modification of Robson's 10 Group Classification of caesarean section (TGCS), which contribute significantly to the high caesarean section rates in the University Obstetric Unit, Teaching Hospital Mahamodara, Galle Sri Lanka during 2010 - to 2014. Results: Among nulliparous women, at term, having a singleton fetus, with a vertex presentation (NTSV) who underwent a caesarian section 25.6% delivered neonates weighing between 2500g and 2999g. Among multiparous women, at term, with no previous caesarean section, having a singleton fetes with a vertex presentation (MTSV) who underwent a caesarian section, those delivering neonates weighing between 2500g and 2999g ranged from 25.6% to 34.6%. Indications for ante part caesarean section included fetal distress, sub fertility, increased maternal age and cephalon-pelvic disproportion in NTSV, and fetal distress, vaginal varices, and a bad obstetric history in MTSV. Among multiparous women with one previous caesarean section undergoing repeat caesarean section, 29.8% delivered neonates weighing between 2500g and 2999g. Women >35 years had a higher risk of caesarean section, irrespective of whether they were nulliparous or multiparous, and whether they had a previous caesarean section or not. Conclusions: A reduction in caesarean section rates in NTSV and MTSV, and women with one previous caesarean section, especially in those with foetuses weighing 2500g - 2999g, should be considered. Increased maternal age and subfertility per se should not be routine indications for antepartum caesarean section. Antepartum caesarean section for vaginal varices and cephalo-pelvic disproportion should be avoided. The diagnosis of fetal distress should be improved.

Three doses of oral misoprostol versus an intra-cervical Foley catheter for 24 hours for pre-induction cervical ripening in post- dated pregnancies: a randomized controlled trial

Objectives: To compare three doses of oral misoprostol 50µg four hourly versus an intra-cervical Foley catheter for 24 hours, for pre-induction cervical ripening. Methods: Primary investigator blinded, randomised controlled trial conducted in 180 consecutive women with singleton uncomplicated pregnancies with Modified Bishop Score (MBS) 5 at 40 weeks + 6 days gestation, allocated by stratified (primigravida / multigravida) block randomization to receive three doses of oral misoprostol 50µg four hourly or an intra-cervical Foley catheter for 24 hours. MBS reassessed at 41 weeks gestation. If MBS 7, induction of labour (IOL) with amniotomy and intravenous oxytocin infusion. If MBS<7, cross over therapy with intracervical Foley catheter for misoprostol group, vaginal prostaglandin E2 for Foley group. Results: At commencement, no significant differences in age, parity, body mass index and MBS between the two groups. Greater proportions established labour in both primigravidae (30% vs. 9%; RR=4.4, 95% CI 1.3-14.6; p=0.01) and multigravidae (44%.vs.16%; RR=4.3; 95% CI 1.6-11.8; p=0.003) before 41 weeks of gestation in misoprostol group compared to the Foley group. Among the multigravidae, the mean increase of MBS was greater in the misoprostol group (3.1; 95% CI 2.4-4) compared to the Foley group (2.4; 95% CI 1.9-2.7, p=0.04). One primigravida and two multigravidae developed hyper stimulation after misoprostol therapy. No significant differences in the other maternal and perinatal outcomes. Conclusions: Compared to an intra-cervical Foley catheter for 24 hours, three doses of oral misoprostol 50µg four hourly was more effective for cervical ripening and even resulted in IOL.

Validation of the Sinhala translation of the International Consultation on Incontinence Modular Questionnaire for female lower urinary tract symptoms among women in Sri Lanka.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to translate the International Consultation on Incontinence Modular Questionnaire for female lower urinary tract symptoms (ICIQ-FLUTS) into Sinhala and validate the Sinhala translation for use in clinical practice. METHODS: The ICIQ-FLUTS was translated into Sinhala in accordance with the ICIQ validation protocol. The Sinhala translation was validated by administering it to 133 women with FLUTS, mainly urinary incontinence and or urgency, and to 118 women with symptoms other than FLUTS during the period 25 October 2013 to 23 December 2016, in the Academic Obstetrics and Gynaecology Unit, Teaching Hospital Mahamodara, Galle, Sri Lanka. RESULTS: The Sinhala translation had good content validity (assessed by a panel of clinicians including a content specialist, and a group of women with and without FLUTS), good internal consistency (Cronbach's alpha coefficient in the range 0.69-0.75) was stable (no significant differences between median test-retest scores in a subgroup of 24 women with FLUTS), had good construct validity (marked difference between median scores in women presenting with and without FLUTS, p < 0.001), and good responsiveness (marked improvements between scores before and after treatment, p < 0.001). CONCLUSIONS: The Sinhala translation of the ICIQ-FLUTS is valid and reliable for assessing Sinhalese-speaking women with FLUTS, especially urinary incontinence and/or urgency.

Comparison of four methods of blood loss estimation after cesarean delivery.

OBJECTIVE: To assess agreement between four different methods of blood loss estimation after lower-segment cesarean delivery (LSCD). METHODS: A secondary analysis was undertaken of a randomized controlled trial of three timings of cord clamping during LSCD performed at a center in Sri Lanka between January 21 and April 30, 2013. Eligible women underwent prepartum LSCD at 37-39weeks of pregnancy. Estimated blood loss (EBL) was assessed by a combined method (direct measurements of spilled blood and sucker bottle volumes, and weighing of surgical towels and drapes before and after use), according to visual assessments by the surgeon and by anesthesiologists, and by measurement of preoperative and postoperative hemoglobin levels. RESULTS: Among 156 participants, mean EBL was 502mL (95% CI 370-618) from the combined method, 506mL (412-643) calculated from hemoglobin levels, 484mL (367-621) by the surgeon's estimation, and 491mL (361-612) by anesthesiologists' estimation (P=0.32). Visual assessment of EBL by anesthesiologists had the best intraclass correlation (0.713) and limits of agreement with the combined method. There were no significant differences between the proportion of cases in which anesthesiologists and the surgeon underestimated or overestimated the EBL when compared with the combined method. CONCLUSION: EBL should be ideally obtained by the combined method.

Anaemia in pregnancy.

Anaemia in pregnancy, defined as a haemoglobin concentration (Hb) < 110 g/L, affects more than 56 million women globally, two thirds of them being from Asia. Multiple factors lead to anaemia in pregnancy, nutritional iron deficiency anaemia (IDA) being the commonest. Underlying inflammatory conditions, physiological haemodilution and several factors affecting Hb and iron status in pregnancy lead to difficulties in establishing a definitive diagnosis. IDA is associated with increased maternal and perinatal morbidity and mortality, and long-term adverse effects in the new born. Strategies to prevent anaemia in pregnancy and its adverse effects include treatment of underlying conditions, iron and folate supplementation given weekly for all menstruating women including adolescents and daily for women during pregnancy and the post partum period, and delayed clamping of the umbilical cord at delivery. Oral iron is preferable to intravenous therapy for treatment of IDA. B12 and folate deficiencies in pregnancy are rare and may be due to inadequate dietary intake with the latter being more common. These vitamins play an important role in embryo genesis and hence any relative deficiencies may result in congenital abnormalities. Finding the underlying cause are crucial to the management of these deficiencies. Haemolytic anaemias rare also rare in pregnancy, but may have life-threatening complications if the diagnosis is not made in good time and acted upon appropriately.

Management of abnormal uterine bleeding in low- and high-resource settings: consideration of cultural issues.

In non industrialized countries the incidence of heavy menstrual bleeding (HMB) appears to be similar to that of industrialized countries, although data is scanty. In low-resource settings, women with abnormal uterine bleeding (AUB) often delay seeking medical care because of cultural beliefs that a heavy red menstrual bleed is healthy. Efforts to modify cultural issues are being considered. A detailed history and a meticulous examination are the important foundations of a definitive diagnosis and management in low-resource settings but are subject to time constraints and skill levels of the small numbers of health professionals. Women's subjective assessment of blood loss should be combined, if possible, with a colorimetric hemoglobin assessment, if full blood count is not possible. Outpatient endometrial sampling, transvaginal sonography, and hysteroscopy are available in some non industrialized countries but not in the lowest resource settings. After exclusion of serious underlying pathology, hematinics should be commenced and antifibrinolytic or nonsteroidal anti-inflammatory drugs considered during menses to control the bleeding. Intrauterine or oral progestogens or the combined oral contraceptive are often the most cost-effective long-term medical treatments. When medical treatment is inappropriate or has failed, the surgical options available most often are myomectomy or hysterectomy. Hysteroscopic endometrial resection or newer endometrial ablation procedures are available in some centers. If hysterectomy is indicated the vaginal route is the most appropriate in most low-resource settings. In low-resource settings, lack of resources of all types can lead to empirical treatments or reliance on the unproven therapies of traditional healers. The shortage of human resources is often compounded by a limited availability of operative time. Governments and specialist medical organizations have rarely included attention to AUB and HMB in their health programs. Local guidelines and attention to training of doctors, midwives, and traditional health workers are critical for prevention and improvement in management of HMB and its consequences for iron deficiency anemia and postpartum hemorrhage, the major killer of young women in developing countries.