Obstetric Emergencies: Feto-maternal Outcome at a Teaching Hospital

Aims: This study was done to know the pattern of obstetric emergencies and its influence on maternal and fetal outcome. Methods: A descriptive study was carried out in the department of obstetrics and gynecology at Kathmandu Medical College Teaching Hospital from 1st June 2013 to 31st May 2014. Cases were categorized as early pregnancy emergencies (ruptured ectopic pregnancy, complications of abortion), ante-partum emergencies and intra-partum emergencies (antepartum haemorrhage, preeclampsia, eclampsia, preterm prelabor rupture of membranes, rupture uterus), post-partum emergencies (postpartum haemorrhage, retained placenta, placenta accreta, uterine inversion), puerperal emergencies (postpartum sepsis), fetal emergencies (cord prolapse, shoulder dystocia). Outcome noted were type of emergency, obstetric intervention done, maternal and perinatal morbidity and mortality. Results: A total of 80 (4.45%) obstetric emergencies occurred among 1796 deliveries .The most common obstetric emergencies were obstetric hemorrhage (62.5%), severe preeclampsia (23.5%) and preterm prelabor rupture of membranes (10%). The obstetric interventions done were cesarean section (43.75%), exploratory laparotomy (33.75%) and blood transfusion (40%). Obstetric emergencies were responsible for 66.6% of total maternal death and 24.56% of total perinatal death. Conclusions: In spite of best efforts, some obstetric emergencies do occur. Obstetric hemorrhage and severe preeclampsia are the frequent obstetric emergencies. Cesarean section, exploratory laparotomy and blood transfusion were the commonly performed interventions. A better outcome can be achieved by national policy of promoting utilization of antenatal care, institutional deliveries, skilled birth attendance at delivery, liberal blood transfusion and regular training of doctors and nurses. DOI: http://dx.doi.org/10.3126/njog.v9i1.11186 NJOG 2014 Jan-Jun; 2(1):37-40

Non-descent Vaginal Hysterectomy: Safety and Feasibility

Aims: To assess safety and feasibility of non-descent vaginal hysterectomy. Methods: A hospital based prospective study was conducted at the department of obstetrics and gynecology of Kathmandu Medical College Teaching Hospital from 1st January 2010 to 31st December 2011. All the patients undergoing non -descent vaginal hysterectomy for benign indication, without suspected adnexal pathology were included in the study. Vaginal hysterectomy was done in usual manner. In bigger size uterus morcellation techniques like bisection, debulking, myomectomy, slicing, or combination of these were used to remove the uterus. Data regarding age, parity, uterine size ,estimated blood loss, length of operation, complication and hospital stay were recorded. Results: A total of 50 cases were selected for non-descent vaginal hysterectomy. Among them 43 cases successfully underwent non-descent vaginal hysterectomy. Commonest age group was (41-45 years) i.e. 40%. All patients were parous. Uterus size was <10 weeks in 27 cases and >10 weeks in 23 cases. Commonest indication was leiomyoma of uterus (63%). Mean duration of surgery was two hours. Mean blood loss was 205.26ml. Reasons for failure to perform NDVH was difficulty in opening pouch of Douglas in three cases. In rest of four cases there was difficulty in reaching the myoma and transverse diameter was too large so as to prevent descent of the uterus. The most common complication was post –operative pain in 23% of cases. Febrile morbidity was present in 4.6% of cases. Blood transfusion was required in seven cases. Average duration of hospital stay was three days. Conclusions: Vaginal hysterectomy for benign gynecological causes other than prolapse is safe and feasible. For successful outcome size of uterus, size in all dimensions and location of fibroid should be taken into consideration.Today in the era of minimally invasive surgery, non descent vaginal hysterectomy needs to be considered and seems to be a safe option. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11134   Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 14-16

Subcutaneous mycoses caused by Rhytidhysteron species in an immunocompetent patient

Subcutaneous mycoses are chronic fungal infections of the skin and subcutaneous tissues caused by variety of fungal agents and usually occur following trauma with vegetative matter. We report a case of subcutaneous mycoses caused by rare fungus belonging to the genus Rhytidhysteron, in an immunocompetent male who presented with a subcutaneous nodule on left foot. This unusual species was identified and confirmed by molecular methods.

GA-optimized feedforward-PID tracking control for a rugged electrohydraulic system design

Rugged electrohydraulic systems are preferred for remote and harsh applications. Despite the low bandwidth, large deadband and flow nonlinearities in proportional valves valve and highly nonlinear friction in industry-grade cylinders that comprise rugged systems, their maintenance are much easier than very sophisticated and delicate servocontrol and servocylinder systems. With the target of making the easily maintainable system to perform comparably to a servosystem, a feedforward control has been designed here for compensating the nonlinearities. A PID feedback of the piston displacement has been employed in tandem for absorbing the unmodeled effects. All the controller parameters have been optimized by a real-coded genetic algorithm. The agreement between the achieved real-time responses for step and sinusoidal demands with those achieved by modern servosystems clearly establishes the acceptability of the controller design.

Effect of Some Non Functional Surfactants and Electrolytes on the Hexavalent Chromium Reduction by Glycerol: A Mechanistic Study

Hexavalent chromium is a widespread environmental contaminant and a known human carcinogen. Kinetics of reduction of hexavalent chromium by bio-molecule glycerol in micellar media have been studied spectrophotometrically. The cytoplasmic reduction of hexavalent chromium to trivalent chromium occurs in micro-heterogeneous systems. In vitro, the micelles are considered to mimic the cellular membranes. The electron transfer processes occurring in the micellar systems is considered as model to obtain insight into the electron transport process prevailing in biological systems. Micellar media is also a probe to establish the mechanistic paths of reduction of hexavalent chromium to trivalent chromium. Effects of electrolytes common to biological system are studied to establish the proposed reaction mechanism strongly.

Stability-indicating Reversed-phase Liquid Chromatographic Method for Simultaneous Determination of Losartan Potassium and Ramipril in Tablets

A stability-indicating reversed-phase liquid chromatographic method has been developed and validated for simultaneous determination of losartan potassium and ramipril. Separations were achieved using a C(18) column with mobile phase consisting of acetonitrile and (0.2% v/v, pH 2.5) aqueous trifluoroacetic acid (45:55, v/v) in isocratic mode at 1 ml/min flow rate. Column effluent was monitored at 210 nm using a UV detector. The method was validated for selectivity, linearity, accuracy, precision, sensitivity and robustness. Novel microwave-assisted forced degradation technique was employed for evaluation of selectivity. The method demonstrated excellent linearity for losartan potassium and ramipril with regression coefficients of 0.9999 and 0.9998, respectively. The linearity range was found to be 62.5-5000 ng/ml and 125-10,000 ng/ml with the mean percentage recoveries of 100.36% (±2.27) and 100.16% (±3.33) for losartan potassium and ramipril, respectively. In a robustness study, a full factorial design revealed that the analytical response remains unaffected by small variations in the critical chromatographic factors. The method was found to be sensitive with quantification limits of 44.30 and 79.93 ng/ml for losartan potassium and ramipril. The method was successfully employed for the determination of losartan potassium and ramipril in commercially available and in-house prepared tablets.

Hip fracture patients in India have vitamin D deficiency and secondary hyperparathyroidism

SUMMARY

This study evaluated the parameters of bone mineral homeostasis including 25(OH)D and PTH in 90 Indian patients with hip fracture and 90 controls. Hypovitaminosis D, secondary hyperparathyroidism, and biochemical osteomalacia was present in 77, 69, and 50 % patients, respectively, significantly higher compared to controls. Vitamin D deficiency is an important risk factor for hip fracture.

INTRODUCTION

The prevalence of vitamin D deficiency is not well known in hip fracture patients from India. Therefore, the present study was conducted to evaluate the parameters of bone mineral homeostasis including 25(OH)D and intact PTH in hip fracture from North India.

METHODS

Ninety consecutive patients with hip fracture and similar number of age- and sex-matched controls were enrolled in the study. The fasting venous samples were analyzed for 25-hydroxyvitamin D (25-OHD), intact parathyroid hormone (PTH), alkaline phosphatase (ALP), calcium, and phosphorus. Vitamin D deficiency was defined as serum 25-OHD of <20 ng/dl.

RESULTS

The mean age of hip fracture subjects was 65.9 ± 12.6 which was comparable in men and women. Majority of study subjects were women (70 women and 20 men). The serum 25(OH)D and calcium levels were significantly lower, whereas the intact PTH and ALP levels were significantly higher in patients compared to controls. There was significant negative correlation between serum 25(OH)D and PTH. In the hip fracture group, 76.7 % of the subjects had vitamin D deficiency, and 68.9 % had secondary hyperparathyroidism. In the control group, vitamin D deficiency and elevated PTH levels were seen in 32.3 and 42.2 %, respectively.

CONCLUSION

About three fourths of hip fracture patients have vitamin D deficiency, and two thirds have secondary hyperparathyroidism. Therefore, the serum 25-OHD level may be a useful index for the assessment of risk of hip fracture in India.

Experiences of gynecological laparoscopic surgeries in a teaching hospital

BACKGROUND

Laparoscopic surgery has revolutionised the field of gynaecological surgery. Presently, almost all gynaecological procedures can find an alternative laparoscopic or hysterescopic approach. The aim of the study was to share the early experience of gynecological laparoscopic surgeries performed at Kathmandu Medical College Teaching Hospital.

METHODS

A study was carried out at Kathmandu Medical College Teaching Hospital from 1st January 2009 to 16th August 2012. All the patients undergoing gynecological laparoscopic surgeries were analyzed for the indication, type of procedure and its complications.

RESULTS

Overall 300 patients successfully underwent laparoscopy during the study period of which diagnostic laparoscopy was in 115. Operative laparoscopy was in 185. Sixty five cases underwent laparoscopic cystectomy. Sixty cases underwent laparoscopic assisted vaginal hysterectomy (LAVH). Salpingectomy for ectopic pregnancy was done in sixteen cases. Twelve cases contemplated for laparoscopic cystectomy underwent laparotomy. LAVH was converted to abdominal hysterectomy in four cases and laparotomy was done in two cases because of bladder injury and primary hemorrhage (from vault). Of minor complications the most common was port site infection and post-operative nausea and vomiting.

CONCLUSIONS

Laparoscopic gynecological surgery has tremendous potential in Nepal. Most of the surgeries can be carried out safely and favorable outcome has been noted in all the cases undertaken.

Applicability of Demirjian's method of age assessment in a North Indian female population

AIM

This study was conducted to determine whether the standards of dental maturation given by Demirjian et al. are applicable to North Indian children and to assess the relationship between dental age and chronological age.

METHODS

In this study OPGs of 100 females of 8-14 years were taken, and dental age was calculated according to the Demirjian method. Chronological age was recorded and compared to dental age.

STATISTICAL ANALYSIS

Collected data was statistically analysed. Pearson's correlation coefficient was used to correlate the dental and chronological age of the 100 girls. The statistical analysis was done by using SPSS version 10.0 software (SPSS Inc., Chicago IL). For all tests the p-value of <0.05 was considered for statistical significance.

RESULTS

A strong correlation was found between chronological and dental ages.

CONCLUSION

In the present pilot work it was concluded that the Demirjian method of dental age assessment showed high accuracy when applied to North Indian paediatric population.

Paediatric aesthetic dentistry: a review

AIM

A number of conditions can lead to aesthetically unacceptable dentitions like dental caries, discoloration, trauma, early loss of teeth, misalignment and any abnormality of shape and size. Today we have a large number of solutions available for aesthetic problems in paediatric dentistry. But the biggest dilemma is: How to choose what is best for a particular patient and that situation? Through this review we try to precisely highlight the various options for aesthetic restorations along with their indications, advantages and disadvantages.

METHODS

A search and analysis of international works on aesthetics in paediatric dentistry is presented.

RESULTS

A considerable number of studies have shown that people are more concerned about missing anterior teeth and their replacement than about posterior ones as aesthetics seems to be more important than function.

CONCLUSION

Dental caries, although not life threatening, causes nagging pain and physical as well as psychological discomfort. Nevertheless, it is clear that the condition is complex and multifactorial and hence it is important to review the various approaches available to restore the lost aesthetics.

Role of laparoscopy in diagnosis and treatment of ectopic pregnancy

Laparoscopy has a great role in early and effective diagnosis and treatment of ectopic pregnancy. This study was carried out to evaluate the feasibility and role of laparoscopy in diagnosis and treatment of ectopic pregnancy. This is a prospective observational study conducted in the Department of Obstetrics and Gynaecology, Kathmandu Medical College Teaching Hospital from April 2009 to March 2011. All the women who underwent laparoscopy for ectopic pregnancy or diagnosed as ectopic pregnancy during laparoscopy done for other diagnosis were included. Data were collected by interviewing patients, operating surgeons, reviewing charts and operative notes and following up patients. There were 42 cases of ectopic pregnancy during study period, of whom 16 (38.1%) underwent laparoscopy. Preoperative diagnosis of ectopic pregnancy was confirmed clinically in 6 (37.5%) patients, who underwent laparoscopy as an operative procedure. In the remaining 6 (37.5%), laparoscopy was performed as a diagnostic procedure as clinical diagnosis was doubtful; two cases of negative laparoscopy was noted. Incidental diagnosis of ectopic pregnancy was made in another 4 (25%) patients who had undergone laparoscopy for other pre operative diagnosis. All the patients were surgically managed by laparoscopy without converting it to laparotomy. There were no intraoperative or postoperative complications except for primary port infection in few (25%). Therefore, laparoscopy has a significant role in the diagnosis of ectopic pregnancy and operative laparoscopy is a safe approach with minimal complications.

Do bicarbonate-based solutions for continuous renal replacement therapy offer better control of metabolic acidosis than lactate-containing fluids?

INTRODUCTION

Evidence that bicarbonate haemofiltration and dialysate fluids are superior to lactate in patients with acute kidney injury treated by continuous renal replacement therapy (CRRT) remains controversial.

METHODS

We prospectively audited acid-base during the first 48 h of CRRT in 62 patients, using bicarbonate and lactate fluids.

RESULTS

Baseline lactate was greater in the bicarbonate group (4.76 ± 0.77 vs. 2.92 ± 0.5 mmol/l, p < 0.01), but pH, bicarbonate, chloride and base excess were similar. Lactate fell significantly in the bicarbonate group to 2.88 ± 0.3 mmol/l at 24 h and 2.39 ± 0.2 mmol/l at 48 h, but not in the lactate group. Base excess improved more with bicarbonate, median increase in the first 24 h was 51.6% (29.1-96.9) versus 18.5% (-5 to 55) with lactate and 74.2% (38.5-123) versus 36.1% (-3.6 to 68), p < 0.05 at 48 h. However, there were no significant differences in bicarbonate, chloride, pH, blood pressure and vasopressor requirements. 13.3% of patients were switched from lactate to bicarbonate fluids due to failure to correct acidosis. Subgroup analysis of 19 patients with liver failure showed similar results.

CONCLUSION

Bicarbonate fluids led to a more rapid fall in lactate and greater improvement in base excess during CRRT, but not overall control of acidosis.

Changing routes of hysterectomy: a cross sectional and comparative study

Hysterectomy is one of the most frequently performed major surgical procedure in women. Traditionally, the uterus has been removed either by abdominal or vaginal route. In spite of the recommendations in favor of vaginal hysterectomy majority of the hysterectomies are still done by the means of abdominal route and vaginal route is utilized mostly for prolapsed uterus. This study was done to see the current trend of routes of hysterectomy for benign condition at Kathmandu Medical College Teaching Hospital and its indication. This was a cross-sectional and comparative study done for 24 months (Jan 2008- Dec 2009). Data for the year 2009 was collected prospectively and for the year 2008 case notes of all the cases of hysterectomy was reviewed. Total 317 cases of hysterectomy were done for benign condition in KMCTH during the 2 year study period. Of the 317 cases 124 was done during the year 2008 and 193 during 2009. Three major route namely vaginal hysterectomy (VH), Abdominal Hysterectomy (AH), and Laparoscopic hysterectomy (LH) was utilized for performing hysterectomy. Major indication for hysterectomy was pelvic organ prolapse (POP) followed by abnormal uterine bleeding (AUB), and fibroid uterus during both the years. Route of hysterectomy in the cases with non prolapsed pelvic organ were AH (94.0%) and LH (6.0%) during the year 2008 and VH (6.0%), AH (76%) and LH (18.0%) during the year 2009. Major indications for hysterectomy are POP, AUB, and fibroid uterus. VH is mainly done for the cases of POP. AH is still the major route for indications other than POP. Minimally invasive approach like VH for non descent uterus and LH although is rising needs to be practiced more.