Maternal hemoglobin and risk of low birth weight: A hospital-based cross-sectional study in Nepal.

Background: Maternal hemoglobin during pregnancy is an important predictor of neonatal outcomes such as birth weight. The newborn weight of an infant is considered a crucial factor for morbidity and mortality. This study aimed to assess the association between maternal hemoglobin concentration and newborn weight at term pregnancy. Methods: A hospital-based cross-sectional study was conducted at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal from 14th April 2018 to 13th April 2019. Term singleton pregnant women who were admitted for delivery in the labor room of TUTH were included in this study. Maternal characteristics such as age, parity, birth space, ethnicity, education level, dietary habit, body mass index (BMI), and hemoglobin level were recorded. The newborn weight was taken immediately after delivery. The main outcome of this study was the birth weight. The association between hemoglobin level and newborn weight was analyzed using bivariate and multivariable logistic regression analysis. Results: Of 2,418 term pregnant women, the prevalence of low hemoglobin and high hemoglobin levels were 24% (95% CI: 22-25.4), and 17% (95% CI: 15.7-18.7), respectively. The prevalence of low birth weight (LBW) was 12.9% (95% CI: 11.7-14.4). Multivariable logistic regression analysis showed that those mothers who had low hemoglobin concentration (adjusted Odds Ratio/aOR = 3.77, 95% CI: 2.84-5.01), and high hemoglobin concentration (aOR = 3.07, 95% CI: 2.23-4.24) had higher odds of having LBW compared to mothers having normal hemoglobin level. Mothers with both young age pregnancy (aged 16-20 years) and older pregnancy (aged ≥31 years) (aOR = 1.60, 95% CI: 1.01-2.52) and (aOR = 1.60, 95% CI: 1.06-2.41), respectively had higher odds of LBW compared to mothers aged 21-25 years. Those mothers who attended a primary level of education had higher odds of (aOR = 1.93, 95% CI: 1.05-3.55) LBW compared to those mothers with a higher level of education. Moreover, mothers who belonged to Janajati ethnic group (aOR = 0.47, 95% CI: 0.34-0.65) compared to the Brahmin/Chhetri ethnic group, and mothers with a birth space of more than three years (aOR = 0.63, 95% CI: 0.41-0.97) compared to those who had less than three years of birth spacing and mothers who were overweight/obese (aOR = 0.74, 95% CI: 0.55-0.99) compared to normal nutritional status had lower odds of having LBW. Conclusions: Our study concludes that both low and high hemoglobin had an increased risk of having low birth weight. Policies and programs can benefit by adopting the findings of this study. More empirical research is critical to understanding the impact of hemoglobin levels on birth weight.

Histopathological Spectrum of Oral Mucosal Lesions in a Tertiary Care Hospital.

BACKGROUND: Neoplastic as well as non-neoplastic lesions commonly involve oral mucosa. It had been observed that benign lesions were more common than malignant ones. The present study was done to evaluate the pattern of distribution of various oral mucosal lesions in a tertiary care hospital. METHODS: This retrospective cross-sectional study reviewed the archival records in the Department of Pathology, Gandaki Medical College, Nepal from January 2017 to December 2020. The records of patients with histopathologic diagnosis of oral mucosal lesions were obtained. The histopathological diagnosis, age, gender, and the site of involvement were collected using a prepared form. Descriptive statistics was applied using SPSS 20 software. RESULTS: Oral mucosal lesions included 3.7% (180 out of total 4895) of cases diagnosed histopathologically. The cases were common among females (101cases/56.1%). Most of the oral mucosal lesions were diagnosed in more than 45 years old patients (75cases/41.7%). The non-neoplastic oral lesions (106cases/58.9%) were the most common lesions followed by neoplastic oral lesions (52cases/28.9%). Among non-neoplastic oral lesions, reactive hyperplastic oral lesions were the most common (50cases/27.8%). Reactive hyperplastic oral lesions frequently affected gingiva (18cases/36%). Neoplastic lesions (Benign neoplasm: 12cases/44.4%; Malignant lesions; 10cases/40%) frequently affected the tongue. CONCLUSIONS: Oral lesions were mostly non-neoplastic and reactive hyperplasia being the most commonest presentation Keywords: Neoplastic; non-neoplastic; oral mucosal lesions; reactive.

Elderly Gravida with Bombay Blood Group and Placenta Previa Managed with Autologous Blood Transfusion.

The Bombay blood group is a rare blood type with an incidence of around one in a million. There is no known reported case of an obstetric patient with the Bombay blood group from Nepal. People with this rare blood group can receive blood only from those with the same blood type. We report an elderly gravida with the Bombay blood group who had a pregnancy complicated by diabetes, placenta previa, and transverse lie (back up) following an in vitro fertilization. Placenta previa posed a greater risk of hemorrhage and hence the need for transfusion. The main challenge was arranging blood for transfusion, and as the Bombay blood group was unavailable, she was managed with autologous blood transfusion which was performed for the first time in a pregnant lady in our institute. She underwent Cesarean section for placenta previa with transverse lie, and both mother and baby were sent home in good health.

Bilateral ovarian edema with unilateral ovarian leiomyoma and double inferior vena cava: a case report.

BACKGROUND: Ovarian edema, ovarian leiomyoma, and double inferior vena cava are all rare clinical entities. The coexistence of all these entities has not been yet reported in the literature. CASE PRESENTATION: We report a case of a 25-year-old nulliparous tamang woman with all these rare clinical entities, who presented with a complaint of right-sided lower abdominal pain. After examination and investigation, an ovarian tumor was suspected and laparotomy was performed during which bilateral ovarian edema with a solid tumor on the left side was identified and left salpingo-oophorectomy was done preserving her right ovary. A histopathological examination confirmed the clinical findings. CONCLUSIONS: As ovarian edema is a rare entity, due to lack of clinical suspicion it is often overdiagnosed as a malignant tumor leading to radical surgery with subsequent loss of hormonal function and early infertility. A high degree of clinical suspicion during the intraoperative period is helpful for diagnosis to avoid unnecessary oophorectomy and infertility.

Sertoli Leydig Cell Tumour Initially Misdiagnosed as Polycystic Ovarian Syndrome and Congenital Adrenal Hyperplasia: A Case Report.

Sertoli-Leydig cell tumor of the ovary is an unusual neoplasm that belongs to a group of sex cord-stromal tumors of the ovary and accounts for less than 0.5% of all primary ovarian neoplasms. They are often characterized by the presence of mass with androgen production and signs of virilization. Due to the substantially low incidence of Sertoli-Leydig cell tumors, information on clinical behavior, prognostic factors, and optimal management arelimited. Here in, we report a case of aprimary ovarian Sertoli-Leydig cell tumor in a 21-year-old student, previously diagnosed to have polycystic ovarian syndrome and subsequently congenital adrenal hyperplasia, who presented with a large abdominal mass and features of virilization along with elevated serum testosterone levels. Fertility sparing unilateral salpingo-oophorectomy was done and adjuvant chemotherapy was given after histopathology showed moderate to poorly differentiated Sertoli-Leydig cell tumor. Following surgery, her features of hyperandrogenism resolved and serum testosterone levels returned to normal.

Improving the quality of maternity services in Nepal through accelerated implementation of essential interventions by healthcare professional associations.

OBJECTIVE: To assess whether the implementation of a package of activities through the joint action of three international healthcare professional associations (HCPAs) increased the use of essential interventions (EIs) for delivery and neonatal care. METHODS: A noncontrolled pre-intervention versus post-intervention study was conducted from June 13 to December 13, 2016, among women older than 18 years of age, who had delivered at one of two urban tertiary hospitals in Nepal. RESULTS: The study included 9252 women. Minimal change was found after the implementation of EIs that were used frequently at baseline (e.g. social support during delivery in the emergency room, and promotion and support for early initiation of breastfeeding). By contrast, an increase was recorded for some EIs that had not been used regularly at baseline. For example, the rate of timely administration of prophylactic antibiotics before cesarean delivery increased from 0.0% (0/496) to 94.0% (409/435) at one hospital. Nonetheless, some EIs with low use at baseline did not show improvement after implementation (e.g. kangaroo mother care). CONCLUSION: The present study strengthened previous findings regarding the uptake of EIs following joint promotion by HCPAs in low-income settings.

Effects of abortion legalization in Nepal, 2001-2010.

BACKGROUND: Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion. METHODS: We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010). RESULTS: 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75). CONCLUSION: Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Maternal mortality over the last decade: a changing pattern of death due to alarming rise in hepatitis in the latter five-year period.

AIMS: To study the causes of maternal mortality in two consecutive five year periods over a decade (1997-2001/2002-2006) in a university hospital. METHOD: A maternal mortality over 10 years (1997-2006) was analyzed prospectively from the Obstetrics/Gynecology Department of Tribhuvan University Teaching Hospital. RESULTS: The maternal mortality ratio of 267.5/100 000 live births was affected by 83 (41 [49.3%] direct, 36 [43.3%] indirect and six [7.2%] non-obstetric) maternal deaths in 31,021 live births. Direct cause was led by infections (n=23, 27.7%): 15 septic abortions (two [2.4%] spontaneous and 13 [15.6%] induced; seven of these occurred in 1997-2001); along with seven (8.6%) cases of puerperal sepsis; a case of antenatal septic shock; and a case of hemolysis, elevated liver enzyme levels, and low platelet count syndrome. There were eight (9.8%) cases of obstetric hemorrhage (six post-partum hemorrhage; two abortions); eclampsia (n=2); severe pregnancy-induced hypertension with hemolysis, elevated liver enzyme levels, and low platelet count syndrome (n=1); and cesarean complications included one from anesthesia and another surgical, which was included under post-partum hemorrhage. There were two cases of pulmonary embolism and four unexplainable deaths. Indirect causes included infective hepatitis (n=19, 22.8%) (13 of these occurred in the more recent 5-year period [2002-2006]), followed by heart disease (n=6), tuberculosis (n=5, 6%), anemia (n=3, 3.6%) and a case each of meningitis, chronic renal failure and diarrhea. Six non-obstetric deaths occurred: one from a road traffic accident; and five due to suicidal (n=1) and accidental (n=4) burns. CONCLUSION: Maternal mortality over a period of a decade in an institutional setting exhibited induced septic abortion as the main cause of maternal death during the first five years of the study period (1997-2001). In the second five years of the study period (2002-2006) an alarming rise in infective hepatitis became the main cause of maternal death.

Surviving 27 weeks fetus expelled out of the ruptured rudimentary horn and detected a month later as a secondary abdominal pregnancy.

A pregnant woman, gravida 3 with two living children, who frequently experienced syncope from 23(+5) weeks of pregnancy onwards and recurring every week for a period of 3 weeks, was repeatedly treated in line for a case of acid peptic disease/appendicitis in various peripheral hospitals of Nepal, until ultrasonogram/magnetic resonance imaging diagnosis of an (undisturbed) live 27(+5) weeks abdominal pregnancy was made at our hospital. On laparotomy, this materialized to be secondary to the rupture of a left rudimentary horn pregnancy (evidenced from its sealed margin) which still retained a complete placenta, from where an umbilical cord was seen, traversing across towards the right side of the abdominal cavity just below the liver, securing its attachment to the surviving fetus and enclosed in an intact amniotic sac. Excision of the rudimentary horn containing the placenta was accomplished, after the delivery of a live baby weighing 650 g who unfortunately died on the third day of life.

Hysterectomy for hematometra in a 15-year-old mentally handicapped girl with congenital cervicovaginal agenesis and concomitant ovarian adenoma.

We report a case of hematometra and bilateral hematosalphinx in a 15-year-old mentally handicapped adolescent girl, complicated by vaginal agenesis over cervical atresia in the presence of an ovarian adenoma. The case was managed by abdominal hysterectomy and bilateral salphingectomy of the hematosalphinx, which had formed a tubo-ovarian mass. One ovary was preserved. This case also considers the management of the mentally handicapped patient unable to comprehend pain arising from cryptomenorrhea.

Vaginal foreign body causing recurrent discharge and vaginal stenosis--a case report.

Chronic vaginal discharge in children and adolescents is a common gynaecological complaint which is often resistant to antibiotic treatment. We present a 14 years old, premenarcheal girl who presented to us with the complaints of recurrent, foul smelling purulent occasionally blood stained vaginal discharge for eight years, where a foreign body in the upper vagina was found after releasing a dense adhesion of the lower vagina which was unable to detect by pelvic ultrasound.

Extensive torsion of umbilical cord: a rare cause of fetal compromise.

Extensive torsion of umbilical cord, a rare complication, shown by 2 fetuses with too frequent changes in their lie and presentation with subsequent development of fetal growth restriction (FGR), culminating intrauterine fetal death of one with transverse lie and survival of the other with decreased fetal movement worsened by impending eclampsia both managed by caesarean section is reported.

Induced septic abortion: a major factor in maternal mortality and morbidity.

BACKGROUND: Septic abortion is an infection of the uterus and its appendages following any abortion especially, illegally performed induced abortions. It is characterized by a rise of temperature to at least 100.4 degrees F, associated offensive or purulent vaginal discharge and lower abdominal pain and tenderness. AIM: To study maternal mortality and morbidity in induced septic abortions. METHODS: Induced septic abortions were analyzed between April 1992 and September 1999 in TU Teaching hospital. Morbidity indicators were surgery other than curettage, prolonged hospitalization and permanent damage. RESULTS: In 92 cases of induced septic abortions, comprising 6% of total abortions; nine deaths occurred because of disseminated intravascular coagulation, acute renal failure and adult respiratory distress syndrome. Vaginal, intraperitoneal and gum bleeding; epistaxis and malaena resulted in severe anemia (Hb < 6 gm/L) in 11 cases. Wound debridement and skin graft cured two cases of necrotizing fasciitis. One of four conservatively managed tubo-ovarian masses spontaneously drained rectally. In 15 cases laparotomy for pus drainage, salpingectomy, salpingo-oophorectomy, hysterotomy/uterine rent repair was conducted, along with four bowel surgeries and six hysterectomies were performed. Post-operative complications included burst abdomen (one case) and reopened pyoperitoneum, which resulted fecal fistula in three cases, one of these patients died. CONCLUSION: : Induced abortion was proven to be a major detrimental factor for maternal mortality. Morbidity was four times higher than mortality to the extent that patients suffered hemiplegia and forced barrenness.

Utero-vaginal prolapse due to portio vaginal fibroma.

Utero-vaginal prolapse can be caused by traction on to the cervix by heavy myoma. Here we present a unique case of huge, compressed, pedunculated fibromyoma of the cervix, which led to cervical elongation and third-degree utero-vaginal prolapse.

Mucocolpos due to complete transverse septum in middle third of vagina in a 17-year-old girl.

A 17-year-old girl had a large abdominopelvic mass (12 x 8cm) extending from vagina, due to the presence of a complete transverse vaginal septum in its middle third which on resection facilitated the drainage and disappearance of the mass finally diagnosed as a case of mucocolpos.