Role of Mifepristone in Trial of Labour after Previous Caesarean Delivery in Intrauterine Fetal Death

When a baby dies in utero, the options are either to wait for spontaneous labour or to induce it. An obstetrician, encounters with a perplexity of choosing a management plan when this worst situation of IUFD coalesced by history of previous caesarean delivery. The ideal drug for the termination should not only be efficacious and cost-effective, but also be convenient enough to avoid operative interference arising from a wasted pregnancy. The study was aimed to evaluate efficacy, safety and compliance of oral mifepristone in trial of labour in case of IUFD after previous caesarean section. This was a cross sectional descriptive type of observational study conducted in the Department of Obstetrics and Gynaecology, Mymensingh Medical College Hospital, Bangladesh from February 2018 to August 2018. Total 50 patients were selected purposively based on inclusion criteria and diagnosed as IUFD with previous caesarean delivery. The patients were received mifepristone once and reviewed after 48 hours and those who were not attained favourable Bishop's score were counseled for mechanical induction. Antibiotics and analgesia were administered according to requirement. Data analysis was done using SPSS version 22.0. All the 50 women received 200 mg oral mifepristone. Forty-four 44(88.0%) women was delivered vaginally among them 18(36.0%) were delivered following mifepristone induction only and 26(52.0%) required additional induction method. The earliest induction to delivery interval following mifepristone was 13 hours. Twenty eight (63.6%) cases were discharged within 72-120 hours. After 48 hours following induction there was significant improvement of Bishop's score. In this study 6(12.0%) out of 50 cases were reasoned for laparotomy and blood transfusion was required for them. There was no statistically significant difference according to gestational age in mode of delivery (p>0.05). There was no difference observed in mean induction to delivery interval between second and third trimester at 5% level of significance (p>0.05). In this study, the women showed drastic improvement in cervical score following induction with mifepristone and decreased repeat caesarean rate. Eventually, the length of agony of receiving dead baby was cut short without much more ailments. Hence, mifepristone may be considered as a safe, efficacious, convenient and cost-effective induction agent for labour induction in women with dead fetus in utero in previously scarred uterus.

HbA1c and Troponin-I Levels and Their Relationship in Patients with Acute Coronary Syndrome

Acute coronary syndrome is a growing public health concern. Diabetic patients are more vulnerable to develop acute coronary syndrome due to accelerated atherosclerosis. Acute coronary syndrome is common in diabetes mellitus and is a major cause of mortality and morbidity in these patients. Troponin-I is a biochemical marker for cardiac muscle injury. Elevated glycated hemoglobin (HbA1c) is also regarded as an independent risk factor for acute coronary syndrome in patients with diabetes mellitus.The aim of this study was to assess the relationship of HbA1c and Troponin-I level in patients with acute coronary syndrome. This cross-sectional study was conducted in the Department of Biochemistry, Dhaka Medical College, Dhaka, Bangladesh from July 2018 to June 2019. Total study subjects were ninety five of both gender selected from the admitted patients of the cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Dhaka. Diagnosis of acute coronary syndrome was confirmed by cardiologist. Diagnosis of diabetes mellitus was confirmed by Random Blood Glucose (RBG) level. Study subjects were grouped, acute coronary syndrome with diabetes mellitus as Group A and acute coronary syndrome without diabetes mellitus as Group B. Baseline parameters was recorded in data collection sheet. HbA1c, Troponin-I level of all study subjects were analyzed and recorded. Mean age of the study subjects in Group A and Group B were 51.06 years and 51.66 years respectively. Male gender was predominant in both groups. Mean SBP and DBP were significantly higher in Group A than Group B. Mean HbA1c level of the study subjects in Group A was significantly higher than Group B (p=0.001). Mean Troponin-I level in Group A was also significantly higher than Group B (p=0.023). HbA1c and Troponin-I levels were positively correlated in Group A (r=0.471, p=0.001). The present study demonstrated significant positive correlation of HbA1c and Troponin-I level in diabetic patients with acute coronary syndrome.

Hormonal Parameters in Diverse Phenotypes of Polycystic Ovarian Syndrome

Polycystic ovary syndrome (PCOS) is a polygenic and multifactorial condition, regarded as the most common endocrine abnormality of women in reproductive period. It is commonly assumed that insulin resistance, hyperandrogenism and obesity significantly influence the pathophysiological process of PCOS. This study was designed to estimate hormonal parameters in different phenotypes of PCOS. The cross sectional descriptive type of observational study was carried out at Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2018 to June 2019. Data were collected from purposively selected 107 patients with PCOS by interview, clinical examination and laboratory investigations using a pretested case record form. Data were analyzed by computer software, SPSS-version 22.0. Hormonal parameters in different phenotypes of PCOS were compared with ANOVA test. Phenotype A was found in highest number (59.8%) followed by phenotype B (14.9%), phenotype D (14.0%) and phenotype C (11.2%). Biochemical hyperandrogenism was observed highest in phenotype A (57.8%) followed by phenotype B (36.4%) and phenotype C (6.1%). Biochemical or clinical hyperandrogenism was not observed among patients of phenotype D. Altered LH:FSH ratio was high in phenotype A (14.1%) and Phenotype B (2.8%). Increased serum prolactin level was found highest in phenotype A (10.3%) and increased serum TSH was found highest in phenotype D (4.7%). Statistically significant difference was observed among levels of serum testosterone of different phenotypes (p<0.001). Hormonal derangements among different phenotypes reflect the severity of reproductive dysfunction and metabolic aberrations. Screening for metabolic risks of diverse phenotypes is important to detect and prevent long term health consequences of PCOS.

Association of Serum Triglycerides and Total Cholesterol Levels with Impaired Fasting Glucose in Adults at a Tertiary Level Hospital of Bangladesh

Impaired fasting glucose (IFG) is known as an intermediate state in the development of diabetes mellitus. It may be considered as a potential indicator for prevention of diabetes mellitus (DM) and cardiovascular diseases (CVDs). Dyslipidemia is characterized by high or low level of triglycerides and total cholesterol. It is known that, triglycerides and total cholesterol level raises in the DM patients. An endeavor was taken in this study to show the relationship of triglycerides (TG) and total cholesterol (TC) with IFG. This cross-sectional analytical study was carried out in Biochemistry Department of Sir Salimullah Medical College, Dhaka, Bangladesh from March 2018 to February 2019 on 120 subjects. The study subjects were 25-55 years of age. Subjects were classified into two groups i.e., Normal fasting glucose (NFG) group and IFG group. Oral glucose tolerance test (OGTT) was performed from the collected blood. TG and TC levels were measured from serum. TG and TC levels were higher (p<0.01) in IFG group than NFG group (185.56±10.32 mg/dl vs. 137.9±10.3 mg/dl) and (194.74±19.96 mg/dl vs. 174.59±13.20 mg/dl) respectively. Pearson's correlation analysis shows significant positive correlation of FPG with TG (r=0.278, p= <0.01) and TC (r=0.105, p= <0.05) in IFG subjects. Multiple regression analysis of the relation between Fasting plasma glucose (FPG) with TG and TC by adjustment of other factors revealed that IFG was significantly (p<0.01) associated with TG and TC. The AUROCs of TG, TC for IFG was found to be 0.819 (95% CI: 0.745 - 0.893), 0.652 (95% CI: 0.553-0.751) with accuracy of 76.67% and 63.33% respectively.

Association of Obesity and Serum Gamma Glutamyl Transferase with Impaired Fasting Glucose in Adults at a Tertiary Level Hospital of Bangladesh

Obesity is a worldwide health concern due to its rising tendency both in developing and developed countries. Obesity is known to be associated with a number of disorders including type 2 diabetes mellitus, hypertension and cardiovascular diseases. Gamma glutamyl transferase (GGT) is synthesized in liver. GGT is considered as an oxidative stress marker. Serum GGT is increased in patients with cardiovascular diseases and diabetes mellitus (DM). Impaired fasting glucose (IFG) is a risk factor for cardiovascular diseases. The aim of this study was to find out the association of obesity and serum GGT with IFG. This cross-sectional analytical study was conducted in the Biochemistry department of Sir Salimullah Medical College, Dhaka from March 2018 to February 2019. The ages of the subjects were 25-55 years. The study subjects were 120 and were divided into two groups. The groups were Normal fasting glucose (NFG) group and IFG group according to WHO diagnostic criteria. Body mass index (BMI) was used as a measure of general obesity and waist circumference (WC) and waist-hip ratio (WHR) were used as measures of abdominal or central obesity. OGTT was performed from collected blood. GGT and lipid profile were measured from serum. In IFG group, BMI, WC, WHR and GGT levels were significantly elevated (p<0.01) than NFG group i.e. BMI (22.70±1.35 vs. 28.37±2.33kg/m²), WC (79.96±5.31 vs. 93.42±4.21cm), WHR (0.92±0.06 vs. 0.97±0.07), and GGT (24.19±8.41 vs. 67.23±14.40U/L). Fasting Plasma Glucose (FPG) level were significantly higher (p<0.01) in obese group than over weight and normal BMI groups 4.70±0.08, 5.30±1.3 and 6.50±0.3 respectively. FPG were higher in male and female obese group than normal WC group (4.8±1.1 vs. 6.3±0.60mmol/L) and (4.4±0.7 vs. 6.2±0.80mmol/L). Odds Ratio (OR) and (95% CI) for IFG were 6.53 and 21.0 with BMI tertile 2(23.1- 27.5kg/m²) and tertile 3(≥27.5kg/m²) where T₁ (<23.0kg/m²) was considered as reference category. OR for IFG were 4.1 and 20.25 with GGT tertile 2(24.0-42.0) U/L and tertile 3(>42.0) U/L where T₁ (<24.0) U/L was considered as reference category. Multiple regression analysis shows positive correlation of FPG with BMI, WC, WHR and GGT.

Association of Serum Uric Acid Level with Impaired Fasting Glucose in Adults at a Tertiary Level Hospital of Bangladesh

Impaired fasting glucose (IFG) is a vital risk factor for overt diabetes. Increased serum uric acid (UA) may reflect systemic inflammation and oxidative stress. Insulin secretion by pancreatic β cells is impaired due to oxidative stress. Serum UA levels are elevated in patients with diabetes or cardiovascular disease. The aim of this study was to explore the relationship between serum UA and impaired fasting glucose (IFG). This cross-sectional analytical study was conducted on 120 subjects aged 25-55 years in the department of Biochemistry of Sir Salimullah Medical College, Dhaka, Bangladesh from March 2018 to February 2019. The study subjects were divided into two groups with either normal fasting glucose (NFG) or impaired fasting glucose (IFG) according to WHO diagnostic criteria. Blood was collected to perform OGTT. Serum was separated to measure UA. Serum UA levels were significantly higher (p<0.01) in IFG group than NFG group (7.61±1.31 vs. 4.84±1.27). Odds Ratio (OR) for IFG were 2.05 and 17.69 with UA tertile 2 (5.7-7.5) mg/dl and tertile 3 (>7.5) mg/dl where T1 (<5.7) mg/dl was considered as reference category. Multiple regression analysis of the relation between fasting plasma glucose (FPG) and serum UA by adjustment of other factors revealed that IFG was significantly (p<0.05) associated with serum UA.

Association of Serum Gamma Glutamyl Transferase and Uric Acid Levels with Impaired Fasting Glucose in Adults at a Tertiary Level Hospital of Bangladesh

Impaired fasting glucose (IFG) is an important risk factor for overt diabetes. Gamma glutamyl transferase (GGT) is an oxidative stress maker that is synthesized in liver. Increased serum Uric Acid (UA) may reflect systemic inflammation and oxidative stress. Insulin secretion by pancreatic β cells is impaired due to oxidative stress. Serum GGT and UA levels are elevated in patients with diabetes or cardiovascular disease. The aim of this study was to explore the relationship between serum GGT and UA with IFG. This cross-sectional study was conducted on 120 subjects aged 25-55 years. The study subjects were divided into two groups with either Normal fasting glucose (NFG) or IFG according to WHO diagnostic criteria. Blood was collected to perform OGTT. Serum was separated to measure GGT, UA and lipid profile. GGT and UA levels were significantly higher (p<0.01) in IFG group than NFG group (67.23±14.40 vs. 24.19±8.41) and (7.61±1.31 vs. 4.84±1.27). Odds Ratio (OR) for IFG were 4.1 and 20.25 with GGT tertile 2 (24.0-42.0) U/L and tertile 3 (>42.0) U/L where T1 (<24.0) U/L was considered as reference category. Odds Ratio (OR) for IFG were 2.05 and 17.69 with UA tertile 2 (5.7-7.5)mg/dl and tertile 3(>7.5) mg/dl where T1 (<5.7)mg/dl was considered as reference category. Multiple regression analysis of the relation between Fasting plasma glucose (FPG) with serum GGT and UA by adjustment of other factors revealed that IFG was significantly (p<0.01) associated with serum GGT and UA.

Morphological Effect of Ethanol Extract of Tinospora cordifolia on Gentamicin-induced Nephrotoxicity in Rats

Recent studies indicate that cellular lipid peroxidation by free radical is an underlying mechanism of acute renal failure induced by gentamicin (GM). Tinospora cordifolia (Tc) extract has been reported to have antioxidant and free radical scavenging activities that is why it is used in present study with the expectation to interrupt the toxic free radical chain reaction of lipid peroxidation in the course of gentamicin administration. For this purpose, sixty rats were divided into six equal groups. Gentamicin (80mg/kg/day, 7 days) was administered to produce nephrotoxicity and structural alterations were evidenced from histopathology of renal tissues which indicates the renal injury and dysfunction in rats. The ethanol extract of Tinospora (200mg/kg/day) was administered with gentamicin simultaneously and also sequentially to observe preventive and curative effects respectively. Both the groups recovered from the gentamicin-induced nephrotoxicity, evidenced from improvement of histopathological features, though accurate mechanism and safety profile is not confirmed by this study.

A Young Girl with a Complex Female Genital Tract Malformation

Complex malformations of the female genital tract are not as uncommon as they are thought to be. But because of their heterogeneous presentation they often pose a diagnostic dilemma and thus their management plan is crucial. Here we express a case report of a 12 year old girl with a rare and complex female genital tract malformation of uterine didelphys with obstructed hemi uterus due to unilateral cervical agenesis with ipsilateral renal agenesis and contralateral cervical dysgenesis. The girl presented to us with severe lower abdominal pain and progressive pelvic lump. In order to preserve menstrual function and fertility, a cervical fistula was made and the patient has been kept under follow up since then.

Knowledge, Attitude and Practice of Bangladeshi Women towards Breast Cancer: A Cross Sectional Study

In Bangladesh incidence rate of breast cancer was about 22.5 per 100000 females. Breast cancer has been reported as the highest prevalence rate (19.3 per 100,000) among Bangladeshi women between 15 and 44 years of age. For this prevailing situation a cross-sectional study was designed to assess the knowledge, attitude and practices of community-dwelling women in Bangladesh towards breast cancer at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2013 to June 2014. All female participants attending at outpatient department of BSMMU having age more than 20 years and education at least JSC, purposively selected until the sample size achieved 500. Only applying simple cost free method like self breast examination (SBE) and clinical breast examination (CBE) one can asses her breast. Thereby awareness develops regarding her breast so any mass newly appear can be assessed by the lady herself. Early diagnosis of the breast cancer will reduce the burden of treatment cost, mortality & morbidity. Research and development strategy of the project is to enhance the awareness of the community people about breast cancer prevention. Mean age of the study population was 36.16 years. Regarding education nearly 30% (n=150) of them studied up to Junior School, 16% (n=80) respondents completed masters and above remaining in between. Regarding occupation, almost 60% (n=300) were house wife, 32% (n=160) were service holder and only 8% (n=40) of them were students. Knowledge about common female cancer 60% (n=300) were aware about the cervical cancer, 24% (n=120) mentioned breast cancer, 4% (n=20) mentioned ovarian cancer, and 12% (n=60) don't know anything regarding common women cancer. Knowledge about early symptoms of breast cancer, majority of the respondents 66% (n=330) were aware that mass in the breast is the main symptom, 2% (n=10) mentioned pain in breast, 32% (n=160) mentioned that they don't know anything regarding the early symptoms. About the cause of breast cancer 60% (n=300) mentioned that, they don't know anything regarding the cause of breast cancer, 36% (n=180) were aware that non lactation is a cause of breast cancer. About 4% (n=20) of the study population mentioned others, like due to some ones bad did cancer occur as punishment. Knowledge about risk factor of breast cancer, 65% (n=325) have no idea about the risk of breast cancer, 32% (n=160) mentioned few risk factors which have relation with breast cancer and 3% (n=15) did not mention anything. Regarding diagnosis of cancer breast 72% (n=360) mentioned they don't know anything, 16% (n=80) by doing ultra sonogram of breast, 6% (n=30) mentioned about Mammography and 6% (n=30) MRI & others. Regarding screening for prevention of breast cancer 60% (n=300) mentioned that they don't know anything regarding screening. Thirty percent (n=150) were aware that there is screening method but they are not aware specifically regarding this method and they also not aware that breast cancer is a preventable disease. 10% (n=50) were fully aware about screening method like CBE & SBE. About the cause of not seeking medical advice for prevention of Breast cancer, majority of the respondents 40% (n=200) mentioned expenditure problems, 32% (n=160) they don't have any knowledge about this type of medical advice, 8% (n=40) mentioned communication problems and 20% (n=100) others. Regarding Practice of CBE & SBE 68% (n=340) never practice CBE & SBE, 30% (n=150) occasionally practiced CBE & SBE. Only 2% (n=10) mentioned that they were regularly practicing CBE & SBE.

Pregnancy in sick sinus syndrome with pacemaker - two cases

Sick sinus syndrome is a generalized abnormality of cardiac impulse formation that may be caused by extrinsic causes or by intrinsic disease of the sinus node making it unable to perform pace making function. It can be manifested for the first time in pregnancy. First case was diagnosed as sick sinus syndrome at 8 weeks of gestation having Mobitz type I heart block (Wenckebach block), and needed temporary pacemaker during caesarean section. Second case was diagnosed at 24 weeks of gestation having complete heart block and needed permanent pacemaker at 38 weeks of gestation due to exaggeration of the symptoms. Both the cases were dealt successfully by caesarean section under general anesthesia in close collaboration with cardiologists and anesthesiologists.

Controlling scabies in madrasahs (Islamic religious schools) in Bangladesh

OBJECTIVES

To assess the effectiveness of a scabies control programme in reducing the prevalence of scabies in urban Bangladesh madrasahs, where the condition is extremely common.

STUDY DESIGN

A controlled trial involving four intervention madrasahs (total students 2359) and four control madrasahs (total students 2465) in Dhaka Metropolitan Area.

METHODS

A baseline scabies sample survey was carried out on 40 and 44 students of four intervention and four control madrasahs, respectively. Another 40 students of the intervention madrasahs were administered a pre-intervention test on scabies knowledge. This was followed by mass treatment of all students, teachers and staff of the eight madrasahs with topical 5% permethrin cream. The subsequent intervention involved daily monitoring of students for five key personal hygiene practices, weekly 10-min scabies health education classes, supply of simple and inexpensive products to students to prevent cross-infestation to/from peers (e.g. plastic bags, clothes hangers), and chemotherapy of new students detected with scabies. After 4 months of the intervention, the prevalence of scabies, personal hygiene practices and scabies knowledge were assessed in students of the intervention madrasahs.

RESULTS

Before the intervention, the prevalence of scabies was 61% and 62% in intervention and control madrasahs, respectively (P = 1.00). After mass scabies treatment in all eight madrasahs and 4 months of intervention, the prevalence of scabies was reduced to 5% and 50% in intervention and control madrasahs, respectively (P < 0.001). There were significant improvements in all five personal hygiene practices at the intervention madrasahs. Mean test scores for scabies knowledge were 40% before the intervention and 99% after the intervention in the four intervention madrasahs. The cost of this programme was US$1.60 per student, and primarily included products such as plastic bags and clothes hangers, and health education material.

CONCLUSIONS

This programme demonstrates a pragmatic and cost-effective way to control scabies in a residential institutional setting. It is recommended that this programme should be scaled up to all residential madrasahs in Bangladesh.

Intervention to increase detection of childhood tuberculosis in Bangladesh

BACKGROUND

Despite a well-functioning adult tuberculosis (TB) control programme, children with TB remain grossly under-detected in Bangladesh. It is conservatively estimated that annually around 21,000 children with TB go undetected, due to an almost exclusive focus on sputum smear-positive TB and the absence of training or guidelines in paediatric TB.

OBJECTIVE

To double child TB detection by increasing general awareness and training of health care workers at microscopy centres supported by the Damien Foundation (DF) Bangladesh.

METHODS

A cluster-randomised trial was carried out with provision of child TB guidelines, training and logistics support to staff of 18 microscopy centres, while 18 non-adjacent microscopy centres continued their usual practice and served as controls. Paediatric data on TB suspect referral and case detection were collected at baseline and during the intervention at both control and intervention sites.

RESULTS

Child TB case detection increased in both intervention and control microscopy centres, but the increase was three times the baseline in the intervention centres (from 3.8% to 12%) in comparison to less than double the baseline in the control centres (from 4.3% to 7%, P = 0.001).

CONCLUSION

Simple guidelines and training on child TB case detection, together with basic logistics support, can be integrated into the existing National TB Control Programme and improve service delivery to children in TB-endemic areas.

Sarcomatoid renal cell carcinoma with huge retroperitoneal metastasis

Sarcomatoid Renal Cell Carcinoma (SRC) is a very rare form of renal neoplasm with very poor prognosis. A case of sarcomatoid renal cell carcinoma (SRC) is reported herein at the National Institute of Kidney Diseases and Urology (NIKDU), Dhaka. A 40 year old man presented with swelling in right loin with dragging abdominal pain and intermittent low grade fever. A huge, fleshy and highly vascular retroperitoneal mass was found peroperatively. Tumor affected the lower pole of right kidney invading the renal capsule, perinephric fat and continued to grow as a large tumor mass in the right retroperitoneal space Histologically, it revealed the features of sarcomatoid renal cell carcinoma.

Mycosis fungoides - a case of cutaneous lymphoma

A 65 years old male, retired chemical factory worker presented with generalized erythematous plaques of various sizes for 2 years. Sun exposure of the skin lesion was painful and pruritic. Lymph nodes were palpable in the neck, axilla and inguinal region after the appearance of skin lesions. He did not give any history of prolonged pyrexic illness, night sweating and significant weight loss. On peripheral flood film examination, lymphocytosis and eosinophilia with few atypical lymphocytes suggestive of Sezary cells were noted. Histopathological examination of skin tissue confirmed the diagnosis of mycosis fungoides.

IgA nephropathy in teaching hospitals of Dhaka

A light and immunofluorescence microscopic study on renal biopsies were performed on 42 patients. Nephrotic syndrome with accompanying microhematuria and recurrent hematuria (Macroscopic/microscopic) with or without renal failure were the commonest indications for renal biopsy. Primary IgA nephropathy was diagnosed in five cases. Among the IgA nephropathy patients, the commonest light microscopic finding was mesangial proliferative glomerulonephritis. Macroscopic hematuria with proteinuria was the commonest feature. Three of the patients had hypertension at the time of renal biopsy. The age of the patients ranged from 19-38 years with a mean of 26 years. The high frequency of hypertension, degree of proteinuria and associated renal failure in one patient that it is a progressive disease. This preliminary study revealed that IgA nephropathy exists in Bangladesh. Larger samples need to be studied with a view to find out its prevalence and its peculiarities in this part of the world.

Thoracopagus conjoined twin - a case report

A patient at her 38+ wks of pregnancy as a ultrasonographically diagnosed case of conjoined twin admitted in our department with ruptured membrane. Two live female babies joined at the chest were delivered by caesarean section. The parents refused a separation operation and the mother and the babies were discharged from hospital at 6th post natal day. A review of the literature suggests that early diagnosis by a combination of ultrasound and MRI is essential for management as it provides prognosis for viability and process of surgical separation and also the opportunity for early counseling of parents and termination if indicated. Key world: Conjoined twins; thoracopagus; prenatal diagnosis; separation procedure DOI: http://dx.doi.org/10.3329/bjms.v10i4.9504 BJMS 2011; 10 (4): 289-292