Maternal Near Miss Analysis in Three Hospitals of Nepal: An Assessment Using Three Delays Model

BACKGROUND

Maternal Near Miss cases have similarities with those dying from such complications and so present an important opportunity to improve practice. This study was conducted to assess the prevalence of Maternal Near Miss events and identify the delays experienced.

METHODS

This was a facility-based cross-sectional study conducted in three tertiary referral hospitals from three provinces of Nepal. All the women surviving a near miss event during six months data collection period were included in the study.

RESULTS

There were 67 near miss cases, 7 maternal deaths, and 9158 live births in the study hospitals during the data collection period. This resulted in Maternal Near Miss ratio of 7.31/1000 live births and facility-based Maternal Mortality Ratio of 76/100,000 live births. Severe obstetric haemorrhage (54%) was the most frequent clinical cause of near miss, followed by hypertensive disorders (43%). At least one type of delay was experienced by 85% women. First delay occurred in 63% (42 of 67) cases, second delay occurred in 52% (33 of 62) cases and third delay occurred in 55% (37 of 67) cases.

CONCLUSIONS

This study found out that all three delays were common among women experiencing maternal near miss event. Raising awareness regarding dangers signs, improving referral system and strengthening ability of health workers can help in reducing these delays.

Malignant Tumors of the Female Genital Tract – a Hospital Based Analysis

Aims: The incidence of cancer and the cancer related deaths are increasing worldwide. There is limited data regarding  gynecological cancers in Nepal. This study is conducted to analyze the trends of female genital tract malignancies in Paropakar Maternity and Women’s Hospital (PMWH) and compare it with the national/international data.Methods: This was a retrospective study conducted in Department of Obstetrics/Gynecology and Pathology in PMWH.  All female diagnosed with the genital tract malignancies from July 2013 to July 2015 were included in the study.Results: Among 62 cases, cervical cancer was the commonest (71%) followed by ovarian cancer (14%), endometrial cancer (8%) and choriocarcinoma (3%). Majority of women belonged to 50-59 years for each type of tumors. Four-fifth of endometrial, half of the cervical and one-third of ovarian cancers were among grand-multipara. Sixty nine percent of women received treatment with 22 (9 cervical, 9 ovarian, 3 endometrial and one of corpus uteri)  surgical and 21 primary chemo/radiotherapy but 19 (31%) were lost for follow-up. Squamous type of cervical cancer was the commonest (93%).Conclusions: Cervical cancer was the commonest genital tract malignancy followed by ovarian cancer, endometrial cancer and choriocarcinoma. For each type of tumors, 50-59 years was the common age group and grand multiparity was seen in half of the women with the cervical cancer. Squamous type of cervical cancer was the commonest variety.  

Recurrent pneumonia-H type Tracheoesophageal fistula, diagnostic dilemma

Tracheoesophageal fistula (TEF) without associated esophageal atresia (EA) is a rare congenital anomaly.  Most of the children are treated for episodes of pneumonia prior to definitive diagnosis.  A 5 months infant presented with recurrent pneumonia and diagnosis of H type TEF was made with contrast esophagram.DOI: http://dx.doi.org/10.3126/jnps.v34i1.8517   J Nepal Paediatr Soc 2014;34(1):71-73

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.

Anthropometric Measurements in Different Ethnic groups of Nepalese New Borns

Introduction: There is a wide variation in normal birth weight, length and head circumference of newborns. The standards formulated by Western workers may not be very reliable to this part of world because of wide variations in normal range of length, weight and head circumference in different ethnic groups. This study aims to determine the anthropometric values – birth weight, length and head circumference in Term and Preterm newborns of different ethnic groups in this region of the country and to see if this can be used as a standard for taking the anthropometric measurements.Materials and Methods: A prospective study of 600 newborns born in Manipal Teaching Hospital, Pokhara from July 2009–June 2010. A detailed anthropometric measurement (weight, length, and head circumference) of all newborns was taken on 3rd day of life. Results: Six major Ethnic groups were noted Brahmin, Gurung, Dalit, Chettri, Magar and Newar. There were 54 % males and 46% females among which 18.16% were preterms, 20.66% small for gestation age, 81.50% term and 0.33% posterm. The mean weight, length and head circumference of term babies were 2.817±0.61 gms, 47.68±2.48 cm, 33.56±2.02 cm and for preterm babies it was 2.215± 0.41 gms, 46.36±2.39 cm, 32.23±2.03 cm respectively. There were 25% low birth weight (n=151, highest number in Brahmins-27%), 74.16% normal weight (n=445) and 0.66% over weight (n=4, all were gurungs) babies. In Term newborns weight, length and head circumference was noted to be highest in Gurungs (3.3004gms, 49.35cm, 34.72cm) and was statistically significant (p<0.000). Weight and length of Brahmins was lowest (2.578 gms, 45.49cm) and head circumference was lowest in Dalits (30.88cm, statistically significant<0.000). In case of preterms highest weight and length was seen in Magars (2.387gms, 47.90cm) but head circumference was highest in Gurungs (34.18cm) whereas weight was lowest in chettri (2.1609gms), length in Brahmin (44.61cm) and OFC in Dalits (29.92cm). These parameters were directly proportion with gestation age and was statistically significant (p<0.000).Conclusion: The present study highlights the mean weight, length and head circumference of term and preterm newborns in different ethnic groups and gestation age. These parameters were directly proportion to gestation age but were variable in different Ethnic groups. Therefore a study in larger population could give us a different standard for anthropometric measurements in Nepalese newborns.Key words: Anthropometry Measurements; Newborn; NepalDOI: http://dx.doi.org/10.3126/jnps.v32i1.4880 J. Nepal Paediatr. Soc. Vol.32(1) 2012 1-8

Infant Feeding Practices in Kaski District, Pokhara

Background: Children in developing countries are prone to infectious diseases due to insufficient and inappropriate feeding practices. Socio-demographic and socio-economic factors directly and indirectly play a role in influencing infant feeding practices.  This study was conducted to assess the socio-demographic and economic factors associated with initiation of breastfeeding, complimentary feeding, and the various prelacteal feeds practiced in Kaski, Pokhara. Materials and Methods: In this prospective study, interviews were conducted to 500 mothers at Manipal Teaching Hospital who brought their child for treatment. The interviews were conducted in a questionnaire format relating to their demographic and financial statuses. Results: A total of 500 mothers were questioned, out of which 86.6% gave their child breastmilk as its first food. 47% initiated breastfeeding within half an hour of child’s birth. 86% gave Jaulo as the first complementary food to their children. About 26% of the mothers gave complementary feeding to their children before the recommended time of 6 months. Conclusion: Initiation of breastfeeding after life and complementary feeding practices overall has improved from previous studies. There is still need of making awareness campaigns and such in order to further improve this trend. Key words: Breastfeeding; Complimentary feeding; Malnourishment DOI: http://dx.doi.org/10.3126/jnps.v32i1.5339     J. Nepal Paediatr. Soc. Vol.32(1) 2012 23-27

Maternal and Perinatal Outcome of Pregnancy with Hepatitis E Infection

Objective

To see the prevalence of HEV infection in the cases of acute hepatitis among pregnant women, and maternal and perinatal outcome of pregnancy complicated by HEV infection.

Methods

This was a descriptive study done at two tertiary care hospital in Kathmandu, Nepal between July 2006 and June 2007. Women presenting with acute hepatitis were tested for HEV using commercial rapid HEV test kit (assure HEV IgM Rapid test by MP diagnostics). Pregnant women, who tested positive for HEV, were enrolled as study group. Maternal and perinatal outcome of these women were analyzed.

Results

Ninety-three pregnant women with acute hepatitis due to HEV were admitted during the study period. Of these 93 cases, acute liver failure occurred in 24 (25.8%), acute renal failure in eight (8.6%) and maternal mortality occurred in 18 (19.35 %). Five women (5.4%) had miscarriage and 79 delivered (53 preterm and 26 term). Pregnancy continued in nine. Perinatal mortality occurred in 16 (20.2%) of which nine were still birth and seven neonatal deaths.

Conclusion

Hepatitis E virus infection is a major cause of acute hepatitis in pregnant women with adverse maternal and perinatal outcome.

Safe abortion services in Nepal: initial years of availability and utilization

INTRODUCTION

Following the liberalization of the very strict Nepalese abortion law in 2002, the first services for safe induced abortion were introduced in 2004 at the nation's largest women's hospital. This paper examines the client profile, the context of demand for services, affordability and satisfaction with services.

DATA AND METHODS

Data for the analysis came from a survey of women who presented themselves at the hospital for induced abortion services and subsequently received the services.

RESULTS

Based on a survey of 672 clients, the median age was 26, and most women were married with an average of two living children. The majority reported being impregnated by the husband. Nearly three out of five gave their primary reason for termination as already having the number of children desired; another 42% cited finances. About two-thirds made the decision to abort jointly with the male partner. Most were satisfied with the services received and expenses incurred. About two-fifths reported having used a modern contraceptive method at the time the unwanted pregnancy occurred, while 22.6% reported practising either the safe-period or withdrawal methods.

CONCLUSION

The clinic has provided affordable, quality abortion services to women in need. Findings also suggest that many areas need services strengthened, including the continued role of the family planning program in preventing unintended pregnancies.

Cutaneous Metastases from Carcinoma of Gall Bladder

Abstract

Cutaneous metastases from carcinoma of gall bladder

Cutaneous metastases from internal carcinoma are relatively rare. Metastasis to extremities is still rarer. We report a case of cutaneous metastasis from carcinoma of gall bladder in a 40-year female presenting as a mass in the left lower thigh. The mass was there for four months duration which was progressively growing in size and painful. Mass was 5 x 7 cm2 in size, mobile, hard and tender. The skin overlying the swelling was eroded with ulcer formation showing sloping edge and slough in the floor. Fine needle aspiration cytology and excisional biopsy revealed a metastatic adenocarcinoma. Cutaneous metastases have been regarded as a bad prognostic indicator.

Intravenous immunoglobulins and haematopoietic growth factors in the prevention and treatment of neonatal sepsis: ground reality or glorified myths?

Neonatal sepsis is a significant cause of morbidity and mortality in the neonatal intensive care unit. The epidemiology of neonatal infections is complex; however, they are in large part secondary to developmentally immature host defence mechanisms. These immunodeficiencies, which are exaggerated in premature and sick neonates, include quantitative and qualitative deficits in phagocytes, complement components, cytokines and immunoglobulins. Therapies that modulate or augment host defences may attenuate the virulence of neonatal infections. In this paper, we have reviewed immunotherapies that modulate the immune system of the neonate, including intravenous immunoglobulins and myeloid haematopoietic growth factors. Future studies should focus on investigating other abnormalities of neonatal host defence and/or combined immunotherapy approaches in an attempt to circumvent the immaturity of host defence and potentially reduce both the incidence and severity of neonatal sepsis.

Prognostic indicators in haemolytic uraemic syndrome

OBJECTIVE

This study aims to review the clinical presentations of Haemolytic Uraemic Syndrome (HUS) and to compare the poor prognostic indicators with mortality.

METHODS AND MATERIALS

Prospective study carried out in Renal Dialysis ward of Dhaka Shishu Hospital, Bangladesh from September 2001 November 2003 for a period of 26 months. All children admitted to renal dialysis ward with oliguria or anuria with pallor was included in this study. HUS was confirmed after laboratory investigations showing features of hemolytic anaemia, thrombocytopenia and renal insufficiency. Various clinical presentations were reviewed. Then bad prognostic factors were compared with mortality.

RESULTS

There were total 25 cases of HUS in 26 months.17 (68%) were males and 8(32%) females.21 (84%) children were < 5 years. Only 4(16%) were > 5 years. Before onset of HUS 40% children had bloody diarrhoea, 36% had acute watery diarrhoea and 24% had others symptoms. The other presentations noted were fever 88%, respiratory distress and convulsion 52% and oliguria 40%, anuria 60%, reluctant to feed 40% and cough 28%. The main physical findings noted were irritability 40%, pallor 100%, dehydration 28%, puffy face with oedema 32%, high blood pressure 16%, hepatomegaly 28%, jaundice, sclerema and petechial rashes 8%, lethargic 16%, acidotic breathing 48% and rectal prolapse 12%. 44% children died after HUS and 56% recovered from the illness. Mortality was 66% when duration of illness before onset of HUS was > 14 days. With duration of anuria < 3 days there was no mortality but it was 91% and 100% with anuria > 3 to 8 days and >8 days respectively. Mortality was 78% when age was < 18 months and it was 75% when age was > 5 years. Diarrhoea associated HUS had 27% and non diarrhoea associated HUS had 85% mortality. Mortality was 77% and 100% respectively when HUS was associated with convulsion and hypertension. WBC > 30,000 had mortality 100% and decreased platelet count < 30,000 had mortality 80%. With creatinine level > 700 micromol/L mortality was 80% and with Serum potassium level 5.6 to 7.5 mmol/L mortality was 67%.

CONCLUSION

HUS comprised of varieties of presentations. Diarrhoea was the commonest preceding illness before onset of HUS. The bad prognostic indicators carrying high mortality was duration of illness before onset of HUS >14 days, anuria > 3 days, age < 18 months and >5 years, Non diarrhoea associated HUS, HUS associated with convulsion and hypertension, WBC > 30,000/cumm, platelets < 30,000/cumm, creatinine level > 700 micromol/L and serum potassium level 5.6 to 7.5 mmol/L. Since bad prognostic factors may progress rapidly to mortality, consultation with paediatrician and transfer to a tertiary care centre should be done when HUS is diagnosed so that it can be managed appropriately in time.

Factors affecting home delivery in the Kathmandu Valley, Nepal

This nested case-control study compares the characteristics of mothers having home or institutional deliveries in Kathmandu, Nepal, and explores the reasons given by mothers for a home delivery. The delivery patterns of mothers were identified in a cross-sectional survey of two communities: an urban area of central Kathmandu (Kalimati) and a peri-urban area (Kirtipur and Panga) five kilometres from the city centre. 357 pregnant women were identified from a survey of 6130 households: 183 from 3663 households in Kirtipur and Panga, 174 from 2467 households in Kalimati. Methods involved a structured baseline household questionnaire and detailed follow-up of identified pregnant women with structured and semi-structured interviews in hospital and the community. The main outcome measures were social and economic household details of pregnant women; pregnancy and obstetric details; place of delivery; delivery attendant; and reasons given for home delivery. The delivery place of 334/357 (94%) of the pregnant women identified at the survey was determined. 272 (81%) had an institutional delivery and 62 (19%) delivered at home. In univariate analysis comparing home and institutional deliverers, maternal education, parity, and poverty indicators (income, size of house, ownership of house) were associated with place of delivery. After multivariate analysis, low maternal educational level (no education, OR 5.04 [95% CI 1.61-15.8], class 1-10, OR 3.36 [1.04-10.8] compared to those with higher education) and multiparity (OR 3.1 [1.63-5.74] compared to primiparity) were significant risk factors for a home delivery. Of home deliverers, only 24% used a traditional birth attendant, and over half were unplanned due to precipitate labour or lack of transport. We conclude that poor education and multiparity rather than poverty per se increase the risk of a home delivery in Kathmandu. Training TBAs in this setting would probably not be cost-effective. Community-based midwife-run delivery units could reduce the incidence of unplanned home deliveries.

Safe abortion service and post abortion care: Understanding complications

Aim: To see if unsafe abortions are getting lesser after the establishment of comprehensive abortion care (CAC) Unit since March 2004. Methods: Retrospective study of women admitted with complication of abortions [induced (medically/criminal) or spontaneous] during the entire ten years period after the inception of post abortion care (PAC) Unit 2095 May -2007 April; the last 3 years overlapping the service years of CAC Unit establishment. Result: CAC and PAC units both are using manual vacuum aspiration (MVA) to procure uterine evacuation. CAC clients in the last 3 years have reached to a little less than 10,000. This is close to MVA services provided in the PAC Unit in the last 10 years amounting to 11,519. But the number (n=3958) of service provided by the PAC Unit for a complete period of three years 2058-2060 (April 2001 - April 2004) showed a slight increase to (n=4323) as the CAC Unit became functional during the 2061-2063 (15th April 2004- 2007). The complications observed in PAC unit while providing MVA are much more than CAC unit (5.75%: 2%). But the nature of complication is much more serious in CAC Unit, 10 of them needing laparotomy for 20(0.02%) cases of uterine perforation. The induced abortion rate within the hospital, three years before and during CAC services is almost similar (4.07%: 4.34%). Seriousness of the problem has definitely reduced during recent 3 year's period (Baisakh 2061-2063 Chaitra) i.e. 52: 34 except for an unfortunate rise in uterine perforation from 8 to 29 cases, 10 being from the CAC Unit. Conclusion: Though the number of complicated cases of induced abortion seeking hospitalization has not changed much after inception of CAC services in the recent three years, there is definitely a decline in the admission of more serious complicated cases of induced abortion in the recent years with unfortunate rise in number of cases of uterine perforation.   doi:10.3126/njog.v2i1.1476 N. J. Obstet. Gynaecol Vol. 2, No. 1, p. 44 - 49 May -June 2007

Myelofibrosis in a Child with Tuberculosis: A Case Report

Myelofibrosis (MF), or fibrosis of the bone marrow, is an uncommon condition in children. Fewer than 100 cases have been described in the medical literature. Most cases in children arise secondary to other disease processes. We present a case of Myelofibrosis in a 12-year-old girl. The purpose of reporting this case is that this child had a diagnostic dilemma and was sent home with poor prognosis but with proper diagnosis and treatment she improved and may have a complete cure, as the myelofibrosis was secondary to tuberculosis. Key words: myelofibrosis, tuberculosis, acute megakaryoblastic leukemia (AMKL)   doi:10.3126/jnps.v27i2.1588 J. Nepal Paediatr. Soc. Vol.27(2) p.90-92