Intrauterine pregnancy with copper intrauterine contraceptive device in situ: A case report from Nepal.

Introduction: and importance: Intrauterine pregnancy on the background of intrauterine devices heralds its rare but possible failure. Despite having an excellent contraceptive pearl index, clients with copper-T may present with typical pregnancy symptoms. Case presentation: We present a case of a 22 year primigravida who after 42 months of successful use of copper-T, conceived an intrauterine pregnancy diagnosed at 7 weeks period of gestation.Clinical Findings and Investigations: A positive urine pregnancy test following cessation of menstruation for 2 months was reported by the patient on presentation. Urgent transabdominal ultrasound of the abdomen and pelvis revealed a gravid uterus containing a single gestational sac corresponding to 7 weeks of gestation. After a thorough explanation about possibility of viable pregnancy and also its pros and cons, she decided to terminate the pregnancy. Manual vacuum aspiration was done with removal of copper-T. Conclusion: Although ectopic pregnancy is a relatively common complication of intrauterine contraceptive device, it is necessary to consider the possibility of intrauterine pregnancy as a potential complication as well. Although, term pregnancies with excellent prognosis have been demonstrated in many studies after removal of intrauterine devices, close follow up is needed to identify misplaced copper-T and keep unwanted pregnancy at bay.

Abnormal Uterine Bleeding among Women Visiting Gynecology Out- patient Department of a Tertiary Care Hospital: A Descriptive Cross- sectional Study.

INTRODUCTION: Abnormal uterine bleeding accounts for more than 70% of complaints in peri- and post-menopausal women. The main purpose of investigating them is to rule out premalignant and malignant endometrial lesions. This study aimed to find out the prevalence of abnormal uterine bleeding among out-patients visiting the gynecology department of a tertiary care hospital. METHODS: This descriptive cross-sectional study was conducted in the Department of Obstetrics and Gynecology of a tertiary care center from August 1, 2020 to April 23, 2021. Ethical approval was obtained from the Institutional Review Committee of the same institution (IRC-LMC 07-C/020). A total of 2680 women visiting gynecology outpatient departments were included by convenience sampling technique. Women with abnormal uterine bleeding were evaluated by endometrial thickness measurement and endometrial biopsies. Statistical Package for the Social Sciences version 16 was used for data analysis. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean and standard deviation. RESULTS: Among 2680 women visiting the gynecology outpatient department, the prevalence of abnormal uterine bleeding was 240 (8.9%) (7.82-9.98 at 95% Confidence Interval). The mean endometrial thickness was 10.15±6.63mm. Majority of patients 104 (43.3%) had endometrial thickness >10mm. Sixty-six (27.8%) patients had disordered proliferative endometrium while endometrial carcinoma was noted in three (1.2%) patients. Atrophic endometrium was observed in 17 (7.2%) and endometrial hyperplasia in nine (3.8%) patients. CONCLUSIONS: The prevalence of abnormal uterine bleeding was found to be higher in comparison to other studies. Disordered proliferative endometrium was the most common histopathological finding followed by secretory phase endometrium.

History taking in gynecology revisited.

Nepal is one of the first South Asian countries to include anti discrimination laws against LGBTQ community, yet they face disparity in all sectors, including health. This group has special reproductive and sexual health needs, which has to be assessed and treated on an individual level. Most gynecologist in Nepal have not been trained to care for this vulnerable group and thus are not comfortable having them in clinical settings. History taking is essential to reach to an accurate diagnosis however, since the first year of medical school, history taking has been based on heteronormativity. To end disparities in reproductive health, learning modules for history taking for LGBTQ community is necessary for medical students, residents and for gynecologists. This would help display confidence and openness towards them and focus on individualized care.

Tied with Hair Strands- A Case of Hair Tourniquet Syndrome involving Labia Minora in an Adult Woman from Nepal.

Hair tourniquet syndrome is the strangulation of body appendages by a thread of hair. If neglected, it results in lymphatic obliteration, venous congestion, and arterial obstruction. A 25 years lady with a history of insect bite presented with intense itching and painful swelling in the left labia minora for three days. She had tied the swollen part with a bunch of hair strands leading to painful swelling. Local inspection revealed a 2x2 cm swelling in the left labia minora. The tourniquet effect was released by cutting the hair. Hair tourniquet syndrome involving female genitalia requires immediate recognition and treatment. Keywords: Hair tourniquet syndrome; hair-thread tourniquet syndrome; labia minora.

Witchcraft allegations and untouchability as forms of violence upon women in Nepal: A 7-year study.

The Nepalese constitution guarantees equal rights to both men and women regardless of caste, race, or ethnicity. However, the centuries-old superstitious practice of caste-based hierarchy in the Hindu community and discrimination against people of lower caste are still prevalent. Furthermore, witchcraft allegations are also not uncommon. Both these practices are derogatory and humiliating and violate human rights, and the law can penalise them in both instances. Due to the intersection of gender and caste, women often face multiple forms of discrimination and violence as the patriarchal society considers them a weaker gender. The present study aimed to see the trend of crimes upon women reported by Nepal Police in the form of witchcraft allegations and untouchability between the fiscal years 2013/14 and 2019/20.

Safe abortion services during the COVID -19 pandemic: a cross-sectional study from a tertiary center in Nepal.

Background: Abortion is an essential service, the need for which has increased during the coronavirus disease 2019 (COVID-19) pandemic. Because of the lockdowns at several periods, these services were hampered. This study analyzed the pattern of Safe Abortion Services (SAS) at a tertiary healthcare center during the first six months of the COVID-19 pandemic in Nepal. Methods: This is a cross-sectional analytical study. We compared the pattern of safe abortion services between the first three months of the pandemic when a lockdown was implemented and the second three months when the lockdown was eased. Demographic and obstetric profile of women, their abortion choices, method of termination, difficulty in accessibility, and level of psychological distress were studied. Results: A total of 52 women were provided SAS during the study period. The number of women coming for SAS during lockdown was 47.1% less than that after easing of the lockdown. During the lockdown, women came at a later period of gestation with a mean of 9.5 weeks compared to 7.5 weeks in the later three months. Because of fear of COVID-19, 19.2% (n=10) women opted for termination of pregnancy. Increased need of contraception was felt but 40% (n=12) had problems of accessibility. More women had probable serious mental illness during the lockdown period (p=0.008). Conclusion: Lockdown during the pandemic decreased the number of women coming for SAS due to barriers in accessibility. Contraceptive needs are also increased but access is difficult. The need for safe abortion services and contraception has increased during the pandemic but the lockdown caused inaccessibility. Psychological distress is prevalent, and fear of COVID-19 has become a common reason for termination of pregnancy. This pandemic can be taken as an opportunity to provide and improve contraception and abortion accessibility, and quality with integration of mental health support.

Accusations of witchcraft: A form of violence against women in Nepal.

Accusations of witchcraft and witch-hunting activities remain serious problems in Nepal, where many women are subjected to violence or torture following accusation and persecution. Many experience serious physical and mental injury, and some die. However, most of these incidents are not reported because women and their families fear reprisals. Poverty, systemic gender inequality and weak state laws provide a context in which this behaviour occurs. Allegations of witchcraft will, however, not be fully eradicated without improvements in education and legal safeguards.

Assessment of Client Satisfaction in Labour and Delivery Services in a Tertiary Hospital in Western Nepal.

BACKGROUND: Patient satisfaction is an individual's positive evaluation of a distinct dimension of health care. This study aimed to assess client satisfaction with maternity care in a tertiary hospital in the western region of Nepal. METHODS: This cross-sectional study was conducted among 405 delivered women. A structured questionnaire of 21 items was used as a tool during exit interviews at their discharge. Each item was assessed on 5 points Likert scale. Student's t-test and one-way ANOVA tests were applied to analyse parametric data. Binary logistic regression analysis was applied to identify the association of predictors with the satisfaction level. Strength of association was interpreted using odds ratio and 95% confidence interval. RESULTS: The mean waiting time was 16.94 +5.57 minutes. Education level of the clients was statistically significant with the mean satisfaction score (p<0.001). Women with unwanted pregnancies were more satisfied than those with wanted pregnancies (p<0.001). Lower complete satisfaction rates were observed for pain control (6.4%), information at discharge (14.6%) and the degree of privacy in the ward (13.6%). Mothers who underwent instrumental delivery were less satisfied with health worker's attitudes than those having vaginal deliveries (odds ratio 0.20, 95% confidence interval:0.05-0.84). Those having uncomplicated deliveries were 3.5 times more likely to be satisfied (odds ratio 3.50, 95% confidence interval: 1.1-11.5) with health workers communication. Mothers with waiting time less than 15 minutes were more satisfied. CONCLUSIONS: Lower educational level, unwanted pregnancy and shorter waiting time were associated with higher maternal satisfaction.

Reproductive Health Issues and Depression in Wives of Labor Migrant Workers.

BACKGROUND: Young Nepalese men have been forced to migrate to other countries in search of better opportunities. Wives of these migrant workers are in a vulnerable state and face various problems. The aim of this study wasto assess the prevalence of reproductive health problems and depression in this sub-population and to compare it with women living together with their husbands. METHODS: This is a hospital based case control study where depression and reproductive health problems including gender based violence were compared between wives of migrant workers and women living with their husbands. Structured questionnaire was used to assess reproductive symptomatology and Becks depression Inventory-II was used to measure level of depression. RESULTS: During the study period, 38.65% (2193) of all women were wives of migrant workers. India was the country where most 34.6% (73) men migrated. Mean duration of migration was 51.96 months (SD= 63.27). Moderate to severe depression was present in 42.6% (90) of wives of migrant workers and 80.09% of these women experienced some form of gender based violence. Reproductive tract symptoms and gender based violence and depression were significantly more present in these women (p<0.000). CONCLUSIONS: Depression and reproductive health problems weremore prevalent in wives of labor migrant workers than in women living with their husbands. The physical and mental health needs of this sub-population warrants screening strategies and preventive measures.

Safety, Efficacy and Acceptability of Early First Trimester Abortion using Oral Mifepristone and Sublingual Misoprostol.

BACKGROUND: With the legalization of medical abortion in Nepal, mifepristone-misoprostol combination via different routes has been widely used for early abortion. This study aims to evaluate the efficacy and acceptability of 200 milligrams mifepristone orally followed by 800 micrograms sublingual misoprostol in outpatient setting. METHODS: It was an open-label prospective study conducted in outpatient department of a tertiary hospital over a period of 13 months. Clients upto nine weeks of pregnancy were enrolled. 200 milligrams of mifepristone orally followed by 800 micrograms of misoprostol sublingually 36 to 48 hours later were prescribed. They were followed up in 14 days sonologically or verbally through telephone. Side effects and satisfaction to the regimen were assessed through acceptability questionnaire. Mann-Whitney U test was used for analyzing categorical data. RESULTS: A total of 47 clients were enrolled. The mean age and gestational age were 29.38 years (SD+5.914) and 6.2 weeks (SD+1.28) respectively. The commonest indications for termination were completed family and unwanted pregnancy (40.4% each). The average duration of bleeding was 5.76 days (SD +3.61). Abdominal cramping was the most common side effect (95.7%). The least acceptable parameter was the bleeding time (80.9%). For 97.9% clients, the adverse effects were acceptable. The overall success rate of the regimen was 87.2%. CONCLUSIONS: With a comparable success rate to vaginal use, home based sublingual use of misoprostol in low resource settings offers an acceptable and cost effective alternative for medical abortion upto nine weeks of pregnancy. Lesser gestational age is a useful predictor for successful abortion.