Microalbuminuria as a Predictor of Pre-eclampsia in Pregnant Women Presenting in the Antenatal Clinic at Dhulikhel Hospital

Background Pre-eclampsia is described as a pregnancy-specific syndrome that can affect virtually every organ system. The appearance of proteinuria remains an important diagnostic criterion. Proteinuria is an objective marker and reflects system-wide endothelial leak, which characterizes the pre-eclampsia syndrome. Objective To determine protein values using the spot urinary albumin/creatinine ratio amongst the pregnant women and to identify whether this test can be used as the investigation of choice for predicting pre-eclampsia in near future. Method A hospital based observational cross-sectional study conducted from February 2016 to August 2017. The study included pregnant women from 20-28 weeks of gestation. They were tested for spot urinary albumin and creatinine. They were all followed up till term, delivery and post partum. Result The mean age of the study patients was 28 years (N+335), the most common age group being 25 to 29 years (43.6%). Pregnant women with higher values of urinary albumin/creatinine ratio were found to develop hypertension compared to women with normal values of urinary albumin/creatinine ratio in the third trimester with insignificant difference (p < 0.283) statistically. Conclusion Microalbuminuria is one of the predictor of pre-eclampsia however it cannot be used as routine investigation for predicting pre-eclampsia in future; further studies in large scales are needed to prove whether urinary albumin/creatinine ratio can be utilized as predictor for pre-eclampsia or not.

Clinical Estimation of Fetal Weight with Reference to Johnson's Formula: An Alternative Solution Adjacent to Sonographic Estimation of Fetal Weight

Background Fetal weight estimation plays a significant role in the antenatal management of high risk pregnancies. It is also an important parameter for predicting the neonatal outcome and informs decision for the mode of intra-partum management of the pregnant women. Among the various methods of prenatal fetal weight estimation, the most commonly used are clinical estimation and sonography. Objective The objective of this study was to compare the accuracy of clinical estimation of fetal weight using Johnson's formula and sonographic estimation with actual birth weight. Method This prospective study was conducted at Dhulikhel Hospital, Kathmandu University Hospital, from January 2017 to August 2018. The study included 335 pregnant women at term gestation. Result The estimation of fetal weight at term pregnancy using Johnson's formula is as effective as sonological method. For clinical method, the fetal weight falls between 95 gm and 183 gm at 95% confidence interval. With respect to ultrasound method, the fetal weight is found to be 45 gm and 132 gm at 95% confidence interval at p value < 0.001. Conclusion Clinical estimation of fetal weight can be utilized as an alternative to sonological estimation in the management of labor and delivery. Johnson's formula is a simple, easy, cost-effective, and universally applicable method to predict fetal birth weight and can be used anywhere by doctors, nurses, midwives and paramedics in centers where ultrasound is not available.

Co-morbidities, Maternal and Fetal Outcome of Teenage Pregnancy at Tertiary Care Hospital, Nepal

Background Teenage pregnancies constitute a serious health and social problem worldwide. World estimates in 2008 report about 16 million births to adolescent mothers, most of them occurring in low and middle income countries. Objective To assess pregnancy co-morbidities and outcome of teenage pregnancy. Method A cross-sectional study was conducted at obstetrics and gynecological department of Dhulikhel Hospital. Study was conducted for 18 month period from 1-07-2013 to 30-12-2014. All teenage pregnancy cases admitted at the time of study period were enrolled. Purposive sampling technique was used. Data were collected by face to face interview using clinical Performa and through record file of the patient. Collected data were analyzed in SPSS version 21.0. Result Total of 527 teenage mothers of varying age group (15 to 19 years ) were enrolled in the study. Teenagers who had never been to school were 3.0%; 66.2% of them were from low socioeconomic background , and 58.6% were from rural areas. Pregnancy co-morbidities detected were, Urinary tract infection (UTI) 18.4%, threatened preterm 12.9% followed by ante partum hemorrhage 4.7%. However, other major co-morbidities such as hypertensive disorder, gestational diabetes found to be very less such as, hypertension 0.8% and gestational diabetes found in only one woman. Conclusion Maternal and newborn outcome and co-morbidities among teenage pregnant women found less compare to other studies. Major pregnancy related morbidities such as hypertension, pre-eclampsia and diabetes were found very less. Most common maternal morbidity found was urinary tract infection during pregnancy but statistically not significant. Similarly, newborn mean weight was more than 2.5 kg and neonatal death found very less. However, teenage pregnancy is significantly associated with low economic status, illiteracy status, willingness to marriage by teenagers and ethnicity.

Effect of Honey on Healing Process of Extraction Socket in Rabbits

Background Honey is regarded as the oldest wound dressing. It accelerates wound healing in burn, infected and open wounds. Its effect on wound healing process in extraction socket is not fully established till today. Objective To evaluate the effect of honey on the healing process of socket after tooth extraction in New Zealand White rabbits. Method Extraction of first premolar tooth on both sides of lower jaw in six rabbits was done under general anesthesia produced by ketamine and Xylazine followed by local application of honey on one socket (honey group) and normal saline (control group) in the opposite socket. On 7th day, biopsy was taken from the extraction site and histopathological examination was done. Student's t-test was used for comparison between the groups and the differences were considered to be statistically significant at P-value less than 0.05. Result There was a significant difference between control group and honey group in terms of fibroblast proliferation (p = 0.0019) and bony trabeculae formation (p=0.0003). Inflammatory cells were also observed in both groups and it was statistically not significant (p=1.0000). Overlying epithelium was hyperplastic in the both groups. Conclusion Local application of honey promoted the healing process by increasing fibroblast proliferation and bony trabeculae formation. Further studies in larger animals and human should be conducted to confirm the efficacy of honey in extraction socket healing.

Pregnancy Outcomes in Patients with Hypothyroidism

Background Pregnancy is an important event in reproductive years of women life. It has a reversible effect on the thyroid gland and its functions. The role of thyroid gland function and conception has been known for a long time. The most common thyroid gland dysfunction in pregnancy is hypothyroidism. It is estimated that the prevalence is 1.5-4.4% of pregnant women. It is known to cause complications during pregnancy leading to adverse pregnancy outcomes. Objective To observe the pregnancy outcomes in patients with hypothyroidism. Method This is a retrospective study conducted from January 2015 to December 2018. Two hundred and thirty nine patients with hypothyroidism were included. They were investigated for thyroid stimulating hormone (TSH), free tri iodothyronin (FT ), free thyroxine (FT ) levels and for auto-antibodies against thyroperoxidase (anti TPO). All these patients after the detection of hypothyroidism were under thyroxine hormone replacement. Result Amongst 239 ladies with hypothyroidism 97.5% came from hilly region. Seventy seven (32%)of them had history of abortions. Twenty three (9.8%) of them had antepartum hemorrhage. Eleven (4.6%) had preeclampsia during this pregnancy. Seven (2.9%) had fetuses with intrauterine growth restriction (IUGR). Seven (2.9%) had fetuses with preterm delivery. Twenty seven (11.3%) of fetuses had APGAR Score of < 6. Conclusion Of 239 women with hypothyroidism, many had history of recurrent abortions and also complications during antenatal period like preeclampsia, abruption placenta, IUGR and preterm delivery. After thyroxine replacement, risk is much lowered and it has a positive outcome.

Minimal Invasive Gynaecological Surgeries in Dhulikhel Hospital: One and Half Decade Long Experience

Background One of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery. Dhulikhel Hospital is one of the very few institutions in Nepal where minimal invasive gynaecological surgeries are being regularly performed since early years of its establishment. There are very few publications related to experiences of minimal invasive gynaecological surgeries published in Nepal. Objective To review the varieties of minimal invasive gynaecological surgeries and find out the different milestones those were crossed in this field. Method This is retrospective study of minimal invasive gynaecological surgeries performed from January 1, 2004 to June 30, 2018. Result A total of 1849 cases were performed by mid 2018. Almost half of the cases were of Brahmin/Chhetri caste (49.9%). Mean age of the patients who underwent gynaecological minimal invasive surgeries in DH was 36.70±10.60 years (with range 12-81 years). More than half of the patients were from Kavre (58.2%). Abnormal uterine bleeding, ovarian lesions and chronic pelvic pain were the most common indications for these procedures. Among these procedures, hysteroscopy (769 cases), diagnostic laparoscopy with or without chromotubation (385 cases), operative laparoscopy (419 cases) and LAVH/TLH (242 cases) were performed. In this study, 34 minimal invasive surgeries cases (1.8%) were converted to laparotomy for certain reasons. Of them eight cases were of laparoscopic hysterectomies. Only very few major and minor complications were experienced during this period. Conclusion Varieties of minimal invasive surgeries for various gynaecological problems were performed with minimal complications. We scaled up these minimal invasive surgeries over the period.

A veil in the oral cavity: report of two cases of oral synechiae

An oral synechia is an adhesion between the maxilla and the mandible; these adhesions can be found at various locations in the oral cavity. The presence of oral synechiae associated with cleft palate represents a rare congenital deformity. Oral synechiae with cleft palate can have serious implications for airway management and feeding in babies, and hence requires early intervention to reduce morbidity. Two cases of congenital oral synechiae accompanied by cleft palate, in which the synechiae veiled the oral cavity restricting a detailed intraoral examination, are reported here.

Incidence and risk factors of surgical site infection following cesarean section at Dhulikhel Hospital

BACKGROUND

Cesarean Section (CS) is one of the most commonly performed surgical procedures in obstetrical and gynecological department. Surgical site infection (SSI) after a cesarean section increases maternal morbidity prolongs hospital stay and medical costs.

OBJECTIVE

The aim of this study was to find out the incidence and associated risk factors of surgical site infection among cesarean section cases.

METHOD

A prospective, descriptive study was conducted at Dhulikhel Hospital, department of Obstetrics and Gynaecology from July 2013 to June 2014. Total of 648 women who underwent surgical procedure for delivery during study period were included in the study. Data was collected from patient using structred pro forma and examination of wound till discharge was done. Data was compared in terms of presence of surgical site infection and study variables. Wound was evaluated for the development of SSI on third day, and fifth post-operative day, and on the day of discharge.

RESULTS

Total of 648 cases were studied. The mean age was 24±4.18. Among the studied cases 92% were literate and 8% were illiterate. Antenatal clinic was attended by 97.7%. The incidence rate of surgical site infection was 82 (12.6%). SSI was found to be common in women who had rupture of membrane before surgery (p=0.020), who underwent emergency surgery (p=0.0004), and the women who had vertical skin incision (p=0.0001) and interrupted skin suturing (p=0.0001) during surgery.

CONCLUSION

Surgical site infection following caesarean section is common. Various modifiable risk factors were observed in this study. Development of SSI is related to multifactorial rather than one factor. Development and strict implementation of protocol by all the health care professionals could be effective to minimize and prevent the infection rate after caesarean section.

Real-time contrast-enhanced holographic imaging using phase coherent photorefractive quantum wells

We demonstrate wide-field real-time and depth-resolved contrast enhanced holographic imaging (CEHI) using the all-optical phase coherent photorefractive effect in ZnSe quantum wells. Moving objects are imaged at large depth-of-field by the local enhancement of a static reference hologram. The high refresh rate of the holographic films enables direct-to-video monitoring of floating glass beads and of living Paramecium and Euglena cells moving in water. Depth resolution is achieved by tilting the incident laser beam with respect to the normal of the cuvette. This creates double images of the objects, which are analyzed geometrically and with Fresnel diffraction theory. A two-color CEHI set-up further enables the visualization of a concealed 95 µm thick wire behind a thin layer of chicken skin.

Renal impairment among patients with pelvic organ prolapse in a tertiary care center

BACKGROUND

Pelvic organ prolapse is a multidimensional phenomenon. The manifestations of renal involvement following pelvic organ prolapse ranges from acute to chronic renal failure and may also lead to end stage renal failure. Prolonged duration and its severity in pelvic organ prolapse are responsible for renal impairment.

OBJECTIVES

This study will find out the incidence of renal impairment among women with pelvic organ prolapse undergoing surgical management. It will also help to establish the association of renal impairment with degree and duration of pelvic organ prolapse.

METHODS

This prospective study includes cases of pelvic organ prolapse who underwent surgical management from the year 2009-2012 in Dhulikhel hospital. Total 140 cases were assessed with age, duration and different symptoms. Clinical examination was done to find out the degree of prolapse and graded according to Baden Walker classification. Urine routine and microscopic examination, renal function test and abdominopelvic sonography were performed routinely. Renal impairment was assessed using hydronephrosis and creatinine clearance. Creatinine clearance was calculated using patient's weight and serum creatinine value by Cockcroft and Gault formula.

RESULTS

Among 140 cases, 8 (5.7%) patients had procedentia, 106 (75.7%) had third degree, 22 (15.7%) had second degree, and four (2.8%) patients had first degree uterine prolapse. The mean duration of prolapse was found to be 11.47 years. Total 5 (3.57%) patients had hydronephrosis. Four had moderate and one had severe hydronephrosis. Total 49 (34.1%) patients had moderate to severe renal failure. Forty six (32%) in stage III moderate reduction in creatinine clearance, 2 (1.4%) with severe reduction and 1(0.7%) in end stage renal failure.

CONCLUSION

Renal impairment is a common entity among women with pelvic organ prolapse. Both hydronephrosis and degree renal impairment correlates correspondingly with the duration and severity of prolapse.

Breech presentation among nullipara at term: an indication for caesarean section

BACKGROUND

Breech is the commonest malpresentation. Vaginal breech delivery in a nulliparous lady carries higher risk than in multiparous ladies. Poor neonatal outcome following vaginal delivery has made the mode of delivery a matter of controversy.

OBJECTIVE

To evaluate the outcome of planned caesarean section among nullipara ladies with breech presentation.

METHOD

This is a prospective, analytical study conducted in Dhulikhel Hospital Kathmandu University Hospital from January 2008 to June 2012 among 102 nullipara ladies at term gestation with breech presentation. All cases underwent caesarean section either elective or emergency. During section cause of breech presentation was searched for. Neonatal condition was evaluated using APGAR Score, need for resuscitation and admission in NICU. Post partum status was also recorded for evaluation of maternal morbidity and mortality.

RESULTS

These Nullipara ladies often had some reason for breech presentation, the most common being cord around the neck. Perinatal outcome was uneventful in 97(95%) neonates, there were two (2%) still birth and three (3%) needed NICU care. APGAR was good in 92 neonates, average in eight and poor in two. Total 16(15.6%) ladies stayed hospital for more than eight days. Among them 11(10.7%) developed wound infection and five stayed in hospital waiting for baby.

CONCLUSION

Nullipara ladies with breech presentation should have elective caesarean section as a preferred route of delivery.

Rectal Misoprostol versus Intramuscular Oxytocin for Prevention of Post Partum Hemorrhage

Background Postpartum hemorrhage (PPH) is an important cause of maternal morbidity and mortality especially in the developing countries. Compared to expectant management, active management decreases the incidence of PPH. Objective To compare the effectiveness of rectal misoprostol with intramuscular oxytocin in the prevention of postpartum hemorrhage. Methods This is a prospective, randomized and analytical study from 1stSeptember 2009 to 28th February 2010 at Department of Obstetrics and Gynecology, Dhulkhel Hospital - Kathmandu University Hospital, Dhulikhel, Nepal. A total of 200 women were included to receive either 1000 micrograms rectal misoprostol tablets or 10 units of oxytocin intramuscularly. Primary outcome measures were the incidence of postpartum hemorrhage or a change in hematocrit or hemoglobin from admission to day two post delivery. Secondary outcome measures including severe postpartum hemorrhage and the duration of the third stage of labor were noted. Also the side effects of both misoprostol and oxytocin were recorded. Results The frequency of postpartum hemorrhage was 4% in the misoprostol subjects and 6% in the control subjects (P=0.886) There were no significant difference among the groups in the drop of hematocrit (P>0.05). Secondary outcome measures including severe postpartum hemorrhage and the duration of the third stage of labor were similar in both groups. Similarly, the side effects between the misoprostol and oxytocin group within 6 hours was statistically significant (p=0.003) whereas the side effects within 24hours was statistically not significant (p=0.106). ConclusionRectal misoprostol is as effective as intravenous oxytocin in preventing postpartum hemorrhage with the similar incidence of side effects and is worthwhile to be used as a uterotonic agent for the routine management of third stage of labor.http://dx.doi.org/10.3126/kumj.v9i1.6254 Kathmandu Univ Med J 2011;9(1):8-12 

Outcome of pregnancy complicated by threatened abortion

BACKGROUND

Threatened abortion is the most common complication in the first half of pregnancy. Most of these pregnancies continue to term with or without treatment. Spontaneous abortion occurs in less than 30% of these women. Threatened abortion had been shown to be associated with increased incidence of antepartum haemorrhage, preterm labour and intra uterine growth retardation.

OBJECTIVE

This study was to asses the outcome of threatened abortion following treatment.

METHODS

This prospective study was carried out in Dhulikhel Hospital - Kathmandu University Hospital from January 2009 till May 2010. Total 70 cases of threatened abortion were selected, managed with complete bed rest till 48 hrs of cessation of bleeding, folic acid supplementation, uterine sedative, and hormonal treatment till 28 weeks of gestation. Ultrasonogram was performed for diagnosis and to detect the presence of subchorionic hematoma. Patients were followed up until spontaneous abortion or up to delivery of the fetus. The measures used for the analysis were maternal age, parity, gestational age at the time of presentation, previous abortions, presence of subchorionic hematoma, complete abortion, continuation of pregnancy, antepartum hemorrhage, intrauterine growth retardation and intrauterine death of fetus.

RESULTS

Out of 70 cases subchorionic haematoma was found in 30 (42.9%) cases. There were 12 (17.1%) patients who spontaneously aborted after diagnosis of threatened abortion during hospital stay, 5 (7.1%) aborted on subsequent visits while 53 (75.8%) continued pregnancy till term. Among those who continued pregnancy intrauterine growth retardation was seen in 7 (13.2%), antepartum hemorrhage in 4 (7.5%), preterm premature rupture of membrane in 3 (5.66%) and IUD in 3 (5.66%). Spontaneous abortion was found more in cases with subchorionic hematoma of size more than 20 cm2.

CONCLUSION

In cases of threatened abortion with or without the presence of subchorionic hematoma, prognostic outcome is better following treatment with bed rest, uterine sedatives, folic acid supplementation and hormonal treatment.