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

Bacteriuria and urinary retention following gynaecological surgery: comparing short vs long term catheterization

BACKGROUND

Post operative bladder drainage is important care following gynaecological surgeries. This study was done to compare the incidence of urinary retention and bacteriuria following long term versus short term catheterization.

METHODS

The patients who were admitted for gynaecological major surgeries were enrolled in this study. One group of patients had post operative indwelling catheterization for 24 hrs (short term catheterization) and another group of patients had catheterization for more than 48 hrs (long term catheterization). The urine examination and culture sensitivity was sent for all patients at the removal of catheter. The patients were followed after removal of catheter for urinary retention.

RESULTS

Total of 102 patients were studied. There were 48 patients in short term catheterization group and 54 patients in long term catheterization group. In short term catheterization group, 3 (6.2%) cases had bacteriuria and no cases of urinary retention were observed. In prolonged catheterization group, 6 cases (11.1%) had bacteriuria and 2 cases (3.7%) had urinary retention.

CONCLUSIONS

This study has concluded that short time catheterization following gynaecological surgery had fewer incidences of bacteriuria and urinary retention than long term catheterization.

Rupture uterus in primigravida: morbidity and mortality

OBJECTIVE

This paper is aimed to present "Rupture of the uterus (RU) in primigravida "- unscarred cases which are supposed to be extremely rare.

MATERIAL AND METHOD

The charts of patients labelled as "Rupture Uterus" for the period 1985 - 2005 AD (2042 - 2061 BS), 20 years were taken out and analysed.

RESULT

There were 251 cases of rupture uterus during the study period giving the incidence of 0.09% i.e. 1:1100 among live births in a very busy tertiary maternity hospital of capital, Kathmandu of Nepal. There were 60% spontaneous, 29% scar dehiscence and 11% Iatrogenic/traumatic rupture and death due to RU was 7.9%(n=20). Fifteen cases (6%) were primigravid patients -- six were young primi (age 19 and below) and 9 primigravid patients. Five cases were referred from the district hospitals. Ten cases were brought from very far off i.e. more than 50 KM from the city. One case presented at 34, one at 41 and all the others presented between 38 to 40 weeks of gestational age. Only three cases had attended ante-natal clinics. All were having labour pain for more than 48 hours at home. Findings of laparotomy: The lesions found were: ruptured bladder and complete lower segment (CLS) up to the cervix - 1, CLS & cervix -2, complete lower segment (CLS) 1, Complete upper segment (CUS) - 2, Complete upper & lower segment (CULS) - 6, (one had tear at posterior wall of the uterus and the other had tear up to posterior vaginal wall) and Incomplete lower segment (LS) 2. Blood grouping & Rh: six cases had O+, four had A+, four had AB+ and one had B positive. The blood transfusion given was 1 - 4 units. The treatment given was laparotomy and repair in 10; one had LUSCS, repair of bladder and cervical injury. One had repair and bilateral tubal-ligation, one had subtotal hysterectomy and another had hysterectomy & repair of posterior wall of vagina. Four cases were admitted in the state of shock among which 1 had irreversible shock and died before surgical intervention. Another died on the 3rd post-operative day due to convulsions and shock. Maternal mortality (MM) was 13% (2/15) in primips. All cases presented with intrauterine fetal death (IUFD) and had still births (one baby was hydrocephalic). The hospital stay varied from 3 - 170 days. Four cases had vesico-vaginal fistula (VVF) CONCLUSION: Rupture of uterus in primigravida though rare, has been common in developing countries with low socio-economic status.

A study of Body Mass Index (BMI) of Nepalese women attending gynaecology clinic

This prospective study was carried out to find out the body mass index (BMI) of all the women attending a gynaecological clinic at Kathmandu Valley. Total of 1450 women attended this clinic over the study period. After excluding few hundreds of women, one thousand women of reproductive age (15-49) were enrolled. Detail history was taken, general, systemic and pelvic examinations were performed and a provisional diagnosis was made on the clinical ground. In this process height and weight of each patient was measured then Body Mass Index (BMI) was calculated. Eight percent (8%) of women were underweight and equal numbers of them were obese too. Forty-four point six percent were healthy and 37.3 were overweight. Most of them were diagnosed vaginitis, urinary tract infection (UTI), pelvic inflammatory disease (PID), subfertility, menstrual disorders, and cervical conditions. In eleven percent no gynaecological abnormalities were detected (NAD). Commonly diagnosed conditions were vaginitis, UTI, PID, primary subfertility and menstrual disorders were the commonly diagnosed conditions.

Rupture of the pregnant uterus--a 20 year review

Nepal is a land-locked developing country located in between China and India with a population of 2.34 millions. The male: female ratio being 49:51 and very high maternal mortality. (539/100,000 live birth-1996) The geography of the country makes the situation very much divergent and difficult to cater the health services, especially operative procedures in remote places. THE AIMS OF THE STUDY ARE:- 1. To find out the incidence of R.U, distance from where the patients came, age, parity antenatal attendance, type of rupture, type of intervention and foetal outcome. 2. To suggest the concerned authorities to focus their attention to strengthen and expand comprehensive emergency obstetric care service (CEOCS) in remote areas of the country.

MATERIAL AND METHOD

This is a retrospective study of rupture of pregnant uterus (RU) after 28 weeks of pregnancy for the period of 20 years from 1985 to 2005 A.D. (2042-2061 BS) admitted in the very busy tertiary centre for women (Maternity Hospital, Thapathali, Kathmandu.) with approximately 16000 deliveries and 11% Caesarean section rate per year. Available charts from hospital records of cases of R.U. admitted for the period of 20 years were analysed. During the period, 251 cases of R.U. were admitted.

RESULT

There were 272245 live births, 25819 Caesarean section, 270 maternal deaths and 11197 perinatal foetal deaths, during the study period. Incidence of rupture of pregnant uterus was (0.09%) 1:1100 live-birth. There were 60% spontaneous, 29% scar rupture and 11% traumatic rupture. Maximum cases were brought from distance of more than 70 kilometres away, between 25-29 years of age, (mean age 28.7), of third and fourth gravida at 36-40 weeks of gestational period with 68% without antenatal attendance. Seventy percent (70%) had complete rupture. Sixty percent (60%) were managed with suture repair with bilateral tubal ligation, 24% had only repair and 15% had hysterectomy. The case mortality of R.U. (n=20) was 7.9%. Two percent (n=5) cases died before intervention due to arrival in moribund condition. Seventy five percent (75%) cases had stillborn babies. Conclusion More cases of RU are coming to the hospital due to better communication and awareness of the people outside the capital, and case- mortality is reduced compared to previous years.

"Brought Dead" - cases of maternal mortality

Seven cases that were brought dead on the way to the hospital in 2057 BS (2000-2001 AD) have been presented in this study. Among seven, two cases were young primiparas, one was a grand multipara and four were between ages 20-25 years. Of these, one had post abortion complications, two were complicated by non-delivery and four had third stage complications. The information that the patient was dead on arrival to the hospital was received by the attendants in all cases with shock and disbelief so that it was very difficult to take proper history. An important point noted by this study was that only four maternal deaths occurred in the hospital and were recorded in the hospital statistics in that year, so that the number of deaths that occurred in transit to the hospital and were technically excluded from the hospital statistics exceeded the number of maternal deaths recorded in the hospital statistics. Another interesting point was that none of the seven women who expired on the way to the hospital were living at a distance greater than 15 Km from the hospital and yet had not attended antenatal clinic, implying that inadequate use of health services even in areas with relatively easy access to proper heath care is a major contributor to maternal death.

Primary Umbilical Endometriosis A Case Report

A 32 year old, Para 2 with normal vaginal delivery presented with cyclical bleeding from a dark brown painful umbilical nodule for 6 months. The ultra sonogram showed a subcutaneous nodule at the umbilicus without any other abnormality. FNAC of the nodule diagnosed it as a case of umbilical endometriosis. A diagnostic laparosopy ruled out any associated pelvic endometriosis. Umbilectomy was done for the treatment of the condition. Keywords: Endometriosis, Umbilicus, Umbilectomy DOI: http://dx.doi.org/10.3126/njog.v6i1.5253 NJOG 2011; 6(1): 51-52

Indications for labour induction and predictors for failed induction at KMCTH

Objective: To study the incidence and indications for labour induction and study the predictors of failed induction. Materials and methods: A hospital based prospective study done over a 12 month period between 1st November 2007 to 30th October 2008. Selection criteria: Singleton pregnancies beyond 37 weeks with vertex presentation and unscarred uterus requiring induction of labour. Results: The incidence of labour induction was 19.7%. Operative delivery was 34.6% in the study group and 27.4% in those with spontaneous onset of labour. 74.07% of the induction group required operative delivery for failed induction and 25.03% for foetal distress. The predominant indication for induction was post term pregnancy (51.28%) followed by PROM (17.3%), isolated oligohydramnios (8.97%), hypertensive disorders of pregnancy (8.33%), maternal perception of decreased foetal movements (7.69%) and others. Failed induction was higher in nulliparas (41.2%) as compared to multiparas (23.7%). Failure rate was 53.8% when maternal age >30y and 28.2% in those < 30y. Women with normal BMI had a failure rate of 25.6% compared to 36% for overweight and 44.4% for obese women. 24.1% had failed induction when Bishop score was >5 and 40.8% when Bishop score was < 5. Between 38-41 weeks pregnancy failed induction occurred in 28-31% while it was higher at 41 weeks pregnancy. The best outcome was seen when the birth weight was 2500-2900g (22.5% failures) while 72.7% had failed induction when the birth weight was >3500g. The duration of induction was >24 hours in 42.6% of women and 48.2% were in the latent phase of labour when taken for caesarean section. Conclusion: Despite the proven benefit of induction of labour in selected cases, one must keep in mind its impact on increasing the rates of operative delivery. Strategies for developing practice guidelines may help to prevent unwarranted case selection and help to reduce the current high operative delivery rates. Key words: caesarean section rate, failed induction, induction of labour. doi: 10.3126/kumj.v7i1.1760       Kathmandu University Medical Journal (2009), Vol. 7, No. 1, Issue 25, 21-25