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you get the money to create your program? Potential ... and Misoprostol) pack to the clients through providers at reduced ... genitourinary or rectovaginal fistula occurring after .... Abdominal surgery has higher risk than vaginal ..... Diversion methods include ileal conduit, ... urinary diversion to reestablish the bladder's storage.
NEPAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY NJOG | VOL 8 | NO. 2 | ISSUE 16 | Jul-Dec, 2013

CONTENTS

EDITORIAL 1. Social Marketing in Health: Developing Country’s Perspective Jha N

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REVIEW ARTICLE 2. Obstetric Fistula in Developing Countries: An Agonising Tragedy Dangal G, Thapa K, Yangzom K, Karki A

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ORIGINAL ARTICLE 3. Determinants of Intra-uterine Contraceptive Device Use Among the Women of Urban Areas of Nepal Joshi R, Bhattarai S, Simkhada K, Thapa S 4. HIV in Women: The Gynecological Frontier Goswami S, Chattopadhyay S 5. Assessment of Pelvic Organ Prolapse by Pelvic Organ Prolapse

16-20 21-25 26-29

Pradhan T, Regmi MC, Rai R, Bhatta R, Rijal P, Uprety DK 6. Use of Oral Misoprostol for Treatment of Incomplete Abortion Kayastha S, Tuladhar H, Gurung S, Jaishe S 7. Comparative Study of Rectal Misoprostol to Oxytocin Infusion in Preventing Postpartum Haemorrhage After Caesarean Section Adanikin AI, Orji E, Adanikin PO, Olaniyan O 8. Severe Acute Maternal Morbidity and Intensive Care at Paropakar Maternity and Women's Hospital Upadhyaya I, Chaudhary P 9. Reference Values of Fetal Peak Systolic Velocity in the Middle Cerebral Artery at 19–40 Weeks of Gestation in Nepalese Population Shrestha U, Shrestha I, Ghimire RK, Paudel S 10. Overview of Eclampsia at a Tertiary Care Hospital Shakya B, Vaidya A 11. Single Versus Multiple Dose Regimen of Prophylactic Antibiotic in Cesarean Section Bhattachan K, Baral GN, Gauchan L CASE REPORT 12. Cervical Dystonia in Pregnancy in a Woman with Three Kidneys, Uterine and Ocular Anomalies Madu AE 13. Spontaneous Rupture of Bicornuate Uterus Caused by Levorotation Due to Congenital Band Jain M, Tripathi R, Jain S, Verma A, Bajpai N 14. Primary Papillary Serous Carcinoma of the Peritoneum Jayakumar NM, Sangam PS, Grampurohit VU, Myagery AF 15. Double Trouble: A Combined Ovarian and Axial Torsion Varadarajan R, Shivalingaiah N BRIEF COMMUNICATION 16. Imaging and Initial Management of Loin Pain in Pregnant Women in District General Hospital Kadi N 17. Subcutaneous Sterile Water Injection for Labor Pain: A Randomized Controlled Trial Rai R, Uprety DK, Pradhan T, Bhattarai BK, Acharya S

30-33 34-37 38-41 42-45 46-49 50-53

54-56 57-59 60-62 63-64

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Jha M, Chitrakar NS, Shakya B, Jha R LETTERS TO EDITOR 19. An Unusual Prenatal Ultrasound Image of Placental Lake in High Risk Pregnancy Bursac D, Kulas T, Madzarac V, Kardum V, Skrtic A, Hrgovic Z 20. Aggressive Angiomyxoma of Vulva Iyengar RS, Padmasri R

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NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

NESOG Journal Committee

NESOG Executive Committee 2013-2015

Founder Chief Editor Prof. Ashma Rana

President Prof. Pushpa Chaudhary

Original Concept Prof. Chanda Karki

Immediate Past President Prof. Ashma Rana

Editor-in-Chief Dr. Ganesh Dangal Editors Dr. Archana Amatya Dr. Bandana Gurung Prof. Heera Tuladhar Dr. Isha Shrestha Dr. Jitendra Pariyar Dr. Junu Shrestha Dr. Kesang Diki Bhatso Bista Dr. Rachana Saha Prof. Rashmi Prasad Yadav Dr. Suman Raj Tamrakar

President Elect Dr. Lata Bajracharya Vice President Dr. Aruna Karki General Secretary Prof. Heera Tuladhar Joint Secretary Dr. Ganesh Dangal Treasurer Dr. Indra P. Prajapati

Advisory Board Prof. Ashma Rana Prof. Pramila Pradhan

Joint Treasurer Dr. Archana Amathya

International Editors Prof. Anibal Faundes, Brazil Dr. Asim Kurjak, Croatia Dr. Bart Vander Paleste, Belgium Prof. David Talyor, UK Prof. Eric Blyth, England Prof. Gamal I Serour, Egypt Dr. Harsha Seneviratne, Sri Lanka Dr. Jaideep Molhotra, India Dr. Jeffrey Tan, Australia Prof. Jeffrey Low, Singapore Dr. Krzysztof Kuczkowski, USA Dr. LK Yap, Singapore Prof. Luis Cabero, Chile Dr. Malcolm A Moore, Japan Prof. Michael Quinn, Australia Dr. Narendra Molhotra, India Dr. Philip D. Darney, USA Prof. Pierana Randaoharison, Madagaskar Dr. Sirish Seth, India Dr. Shahida Zaidi, Pakistan Prof. Walfrido W. Sumpaico, Phillipines Prof. Yuji Murata, Japan

Prof. Rashmi Prasad Yadav Joint Dr. Padam Raj Pant Members Dr. Bandana Gurung Dr. Madhu Tumbahangphe Dr. Usha Shrestha Dr. Sadhikshya Singh Rana Dr. Arju Chand

The papers in this journal are published under the terms of

Design and Layout : Mr. Sudip Bajagain Email: [email protected] Phone: 9808793004

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EDITORIAL

NJOG 2013 Jul- Dec;8(2):1-4

Social Marketing in Health: Developing Country’s Perspective Jha N Karnali Academy of Health Sciences, Jumla, Nepal.

changing over the past two decades. It has evolved from a one-dimensional reliance on public service announcements to a more sophisticated approach, which draws from successful techniques used by commercial marketers, termed “social marketing”. Rather than dictating the way that information is to be conveyed from the top-down, public health professionals are learning to listen to the needs and desires of the target audience themselves, and building the program from there. This focus on the “consumer” involves in-depth research and constant re-evaluation of every aspect of the program. In fact, research and evaluation together form the very cornerstone of the social marketing process. Social marketing (SM) is “the application of commercial marketing techniques to the analysis, planning, execution, and evaluation of programs audiences in order to improve their personal welfare and that of their society”.1 It differs from commercial marketing in a number of ways, like the products are more complex, the demand is varied, target audiences are more challenging to reach, consumer involvement is more intense and competition is more varied. Social marketing of health is the systematic application of marketing concepts and techniques to achieve

Social marketing was “born” as a discipline in the 1970s, when some experts realized that the same marketing principles that were being used to sell products to consumers could be used to “sell” ideas, attitudes and behaviors. Social marketing is also only with respect to the objectives of the marketer and the target audience and the general society”. This technique has been used extensively in international health programs, especially for contraceptives and oral rehydration therapy (ORT), and is being used with more frequency in the United States for such diverse topics as drug abuse, heart disease and organ donation.2 Concepts of SM must be target (client/consumer/ audience) centered. SM looks at behavior change from the viewpoint of the consumer. It is about action! What do you want people to do? It focuses on is more than perceived cost. The principle involved is or de-emphasize the barriers. There must be an exchange. Features of social marketing are consumer orientation, exchange theory, data based decision making, competition and willingness to change.

and reducing health inequalities.It targets low income and high-risk groups.1

CORRESPONDENCE Dr Nilambar Jha Rector, Karnali Academy of Health Sciences, Jumla. Email: [email protected] Phone: +977-025525555

The papers in this journal are published under the terms of the

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Like commercial marketing, the primary focus is on the consumer, learning what people want and need rather than trying to persuade them to buy what we happen to be producing. Marketing talks to the consumer, in stead of the product. The planning process takes this consumer focus into account by addressing the elements of the “marketing mix”. This refers to decisions about 1) the conception of a Product, 2) Price, 3) Distribution (Place) and 4) Promotion. These are often called the “Four Ps” of marketing.2,3 Social marketing adds few more “P’s” like public, partnership, policy and purse strings to this.4 The product audience, unique, competitive and real. The social marketing “product” is not necessarily a physical offering. A continuum of products exists, ranging from tangible, physical products (e.g. condoms), services (e.g. medical examinations), practices (e.g. breastfeeding, ORT or eating a healthy diet) and protection). In order to have a viable product, people and that the product offering is a good solution for that problem. The role of research here is to discover the consumers’ perceptions of the problem and the product, and to determine how important they feel it is to take action against the problem. Price refers to what the consumer must do to obtain the social marketing product. This cost may be monetary, or it may instead require the consumer to give up intangibles, such as time or effort, or to risk embarrassment and disapproval. If the costs outweigh the offering will be low and it will be unlikely to as greater than their costs, chances of trial and adoption of the product is much greater. In setting the price, particularly for a physical product, such as contraceptives, there are many issues to consider. If the product is priced too low, or provided free of charge, the consumer may perceive it as being low in quality. On the other hand, if the price is too high, some will not be able to afford it. Social marketers must balance these considerations, and often end up charging at least a nominal fee to increase perceptions of quality and to confer a sense of “dignity” to the can be determined through research, and used in positioning the product.

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Place describes the way that the product reaches to the consumer. The channels of information for promotion are health institutions, counseling centers, NGO and INGOs (where service is provided), concerts, events, camps and other social gatherings, pharmacy and shops. For a tangible product, this refers to the distribution system-including the warehouse, trucks, sales force, retail outlets where it is sold, or places where it is given out for free. For an intangible product, place is less clear-cut, but refers to decisions about the channels through which consumers are reached with information or training. This may include doctors’ home demonstrations. Another element of place is deciding how to ensure accessibility of the offering and quality of the service delivery. By determining the activities and habits of the target audience, as well as their experience and satisfaction with the existing delivery system, researchers can pinpoint the most ideal means of distribution for the offering. Finally, the last “P” of SM is promotion. Because of its visibility, this element is often mistakenly thought of as comprising the whole of social marketing. Promotion consists of the integrated use of advertising, public relations, promotions, media advocacy, personal selling and entertainment vehicles. The focus is on creating and sustaining demand for the product. Public service announcements or paid ads are one way, but there are other methods such as coupons, media events, editorials, “Tupperware”-style parties or in-store displays. Research is crucial to determine target audience and increase demand. Additional social marketing “P’s” are public, partnership, policy and purse strings.4 Public refers to both the external and internal groups involved in the program. External public includes the target audience, secondary audiences, policymakers and gatekeepers, while the internal publicare those who are involved in some way with either approval or implementation of the program. Partnership-Social and health issues are often so complex that one agency can’t make a dent by itself. You need to team up with other organizations in the out which organizations have similar goals to yoursnot necessarily the same goals and identify ways to work together. Policy-Social marketing programs can do well in motivating individual behavior change, but that is

supports that change for the long run. Often, policy change is needed, and media advocacy programs can be an effective complement to a social marketing program. Purse Strings-Most organizations that develop social marketing programs operate through funds provided by sources such as foundations, governmental grants or donations. This adds another dimension to the strategy development-namely, where will you get the money to create your program? Potential applications of SM in health are to promote healthy behavior, promote services, increase utilization rates, improve customer satisfaction and enhance compliance. SM is popular, because it works by bringing about behavior change, is more cost effective and reaches to larger numbers of people. Strengths of social marketing are useful in creating awareness and interest, useful in persuasion, helpful by reinforcing through repetition of message. and it may create negative public sentiments. Example of a Marketing Mix Strategy As an example, the marketing mix strategy for a breast cancer screening campaign for older women might include the following elements: 1. The product could be any of these three behaviors: getting an annual mammogram, seeing a physician each year for a breast exam and performing monthly breast selfexams. 2. The price of engaging in these behaviors includes the monetary costs of the mammogram and exam, potential discomfort and/or embarrassment, time and even the 3.

4.

5.

6.

The place that these medical and educational services are offered might be a mobile van, local hospitals, clinics and worksites, depending upon the needs of the target audience. Promotion could be done through public service announcements, billboards, mass mailings, media events and community outreach. The “public” you might need to address include your target audience (let’s say lowincome women age 40 to 65), the people husbands or physicians, policymakers, and media directors. Partnership could be cultivated with local or national women’s groups, corporate

sponsors, medical organizations, and service clubs or media outlets. 7. The policy aspect of the campaign might focus on increasing access to mammograms through lower costs, requiring insurance coverage of mammograms or increasing government funding for breast cancer research. 8. The purse strings, or where the funding will come from, may be governmental grants or foundation grants. Each element of the marketing mix should be taken into consideration as the program is developed, for they are the core of the marketing effort. Research is place, promotion and related decisions. Social marketing in health was started in Nepal with contraceptives in 1960s but became widespread since 1981 with USAID’s effort. In 1983, the CRS/ MCH project was converted into a private “social marketing” autonomous company known as Nepal Contraceptive Retail Sales (CRS) Company. In the 1990, condom social marketing program was developed as part of HIV/AIDS prevention program. CRS Nepal program includes family planning, HIV/ AIDS and STI prevention, child health, maternal health and other health products. Population Service International (PSI/Nepal) program includes HIV prevention, reproductive health, family planning, malaria prevention, control and treatment, safe water education. PSI also supplies Medabon (Mifepristone and Misoprostol) pack to the clients through providers at reduced price for abortion care. Positive impacts of SM on health in Nepal are due to CRS company (successful), sutkeri samagri (delivery kit) and safe motherhood program/maternal incentive program (Aama Surakshya). These led to increase in delivery assisted by skilled birth attendants (36%), a higher institutional delivery (37%) and increased contraceptive prevalence rate (44%).5 There are successful stories of SM in other countries too (Priti, a brand of condom in Sri Lanka), but more things can be done, especially for maternal and child health. Everyday mothers are dying during childbirth in remote areas. This may be due to inadequate antenatal checkup (ANC) visits, unsafe home delivery, delay in reaching health institutions and lack of proper medical care. Now time has come to solve these problems through SM, by selling the idea of ANC visits at school level and also in the family, by providing “sutkeri samagri” as a reward to pregnant women during ANC check-up, making hospitals/

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health institutions mother-friendly, thus encouraging women for institutional delivery. Again SM can play a vital role to reduce unmet need for family planning by making contraceptive easily available even in the place of faith healers in the remote areas. Similarly SM can play a big role in the “Integrated Management of Childhood Illness”, especially diseases like be fought with. These could be done by involving mother groups and faith healers with help of NGOs. Department of health services, NGO, INGOS and most importantly community based organizations should promote and practice more social marketing approach to improve the health status of people, especially in maternal and child health care to achieve the millennium development goals.

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REFERENCES 1.

Hendrika Meischke. Social Marketing Theory. [cited 2012 August19]. Available from http://www.scribd.com/ doc/2600124/Social-Marketing-Theory

2.

Cheng H, Kotler P, Lee NR. A synopsis of social marketing; 2009.

3.

Evans WD. Analysis and comment. BMJ. 2006;332:1207-10.

4.

Hastings G, Michael Saren M. The critical contribution of social marketing theory and application. Marketing Theory. 2003;3(3):305-22.

5.

Department of Health Services, Government of Nepal. Annual report 2010/2011.

NJOG 2013 Jul- Dec;8(2):5-15 REVIEW ARTICLE

NJOG 2013 Jul- Dec;8(2):5-15

Obstetric Fistula in the Developing World: An Agonising Tragedy Dangal G,1 Thapa K,2 Yangzom K,3 Karki A1 Department of Obstetrics and Gynaecology, Kathmandu Model Hospital, Kathmandu, Jhpiego, Lalitpur, Nepal 3 Department of Obstetrics and Gynaecology, Patan Academy of Health Sciences, Lalitpur. 1 2

often abandoned by their husbands and family, and forced to live in shame. They occur almost entirely in the developing

the best approaches to both prevention and treatment should be the priority. The materials published in PubMed, Lancet, Medline, WHO and Google Scholar web pages from 1990 to 2013 have been utilized to prepare this paper. Keywords:

INTRODUCTION

is far from the hyper-vigilant standards employed for women living in wealthy nations. In developed

reproductive tract and the urinary tract or alimentary

result of gynecologic surgery, and less commonly by infections, radiation injury, sexual violence or obstetrical trauma.

several days of prolonged or obstructed labour. The labor and its complications are labeled as obstetric 1-4

problem in developing world where unattended obstructed labor is common and maternal mortality is unacceptably high. It is a tragedy of developing world because of illiteracy, poverty, ignorance and

creates one of the most challenging clinical scenarios in soft-tissue reconstructive surgery. The preparation for surgery, surgical technique, and post-operation opportunity for successful outcome. Fistula recurring after attempted surgical repair is often bigger,

completely prevented by the provision of proper

programming is predicated on the principle that all

countries where access to intra-partum clinical care

of patient preparation, meticulous reconstructive surgical technique, and rigorous post-operative care paradigms.1,2

CORRESPONDENCE Dr Ganesh Dangal Department of Obstetrics and Gynaecology, Kathmandu Model Hospital, Exhibition Road, Kathmandu, Nepal. Email: [email protected] Phone: +977-9851055036

The papers in this journal are published under the terms of the

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METHODS We did a literature review for assessing the OF publications. The literature search focused mainly national and international levels. The method adopted for review was literature search from PubMed, Medline, Lancet, WHO and Google Scholar web pages published from 1990 to 2013. Different search

used to locate relevant references and the location of the relevant journal articles. This was augmented by unpublished literature and relevant experience We also looked at other relevant publications like reports, training manuals and books.

(OF) is not fully documented. In 2006, WHO estimated and quoted that “2 million women worldwide” were used to validate this widely quoted global number has never been disclosed.4 Literature on OF suggest empiric estimates or facility-based prevalence of OF admissions as a proportion of gynecologic sheer persistence of this preventable complication of pregnancy. The prevalence data for OF in Southeast Asia is, as in many parts of the world, suboptimal. In 2006, UNFPA’s survey on Status of Reproductive Morbidities in Nepal showed that three women out of 2070 women evaluated had OF. This data yielded an extrapolated population rate of 0.15%.5 Thousands of women in Nepal suffer silently from vesicocountry with intermediate incidence (until 0.6/1000), aged 15- 49 suffer from this condition. Thus, there are 4362 OF prevalent cases in Nepal.6 OF is known to occur in the rural and remote regions of Nepal. Lack of accurate prevalence for OF continues to challenge the medical community for providing care for these women.7 In developing countries, obstructed labor is one of percent of all maternal deaths occur in developing countries. In developed countries, obstructed labor is not permitted to progress beyond a few hours, and is no longer a source of maternal mortality. On the other 6

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hand, maternal mortality remains unacceptably high in developing countries. In developing countries, obstructed labor, hemorrhage, infection, hypertension, pregnancy related deaths.8 Even among women who do not die from obstructed labor, many still suffer from the dual devastation of a stillborn infant and bony pelvis crushes the vaginal soft tissue during the days of unattended obstruction. This causes ischemia and results in soft tissue necrosis. This ischemic adhesions between the uterus and/or vagina. The adjacent urinary and colorectal organs are also affected by the ischemia. These defects bypass the normal storage of anatomic functions of the urinary and colorectal tracts. These lead to profound and 3

Obstetric causes 1. Prolonged obstructed labor is the predominant 2. Other causes include: destructive delivery, instrumental deliver, cesarean delivery with or without hysterectomy, traditional practices, etc. Non-obstetric causes 1. Traumatic like coitus, sexual violence, accidental trauma and female genital mutilation 2. Infection such as granulomatous infection, tuberculosis and HIV infection 3. Congenital (rare) 4. Malignancy (especially cervical cancer) and /or radiotherapy 5. Iatrogenic (during pelvic surgery) labor without Emergency Obstetric Care (EmOC) interventions – oxytocin augmentation of labor, instrumental assisted vaginal delivery, and cesarean section being the mainstay therapies.The condition may be labeled “failure to progress” or “cephalopelvic disproportion” when managed appropriately on time and “obstructed labor” when management is delayed. The time taken to intervene at different stages of obstruction can lead to vastly different outcomes. Obstructed labor almost always is associated with fetal asphyxia and stillbirth. Many mothers may also suffer from lumbosacral compression neuropraxia that results in foot drop. Furthermore, extensive obstructed labor, such as in the case of rectovaginal

Dangal et al. Obstetric Fistula in Developing Countries

or vaginal tear repair suture lines, or due to cesarean cesarean section following labor that lasts less than a day, it is usually safely assumed to be due to errors of technique. However, it is challenging to assume cesarean section is performed for classic obstructed labor. In these circumstances, particularly in uterine rupture,the surgery is performed through tissue planes

particularly vulnerable to obstetric compression of the lumbosacral plexus. If left untreated, permanent peroneous muscles and contraction of the Achilles tendon may result, requiring surgical intervention.12 Walking as early as possible, with cane or crutches is highly advised as a prevention to full blown peroneal neuropraxia.1

with secondary severe distortion of intra-abdominal pelvic anatomic landmarks.9 The cause of any due to exacerbation of the edema/ischemia/necrosis cascade due to the introduction of an incision and suture line into the proximal aspects of the damaged more complex than it may have otherwise. surgery, most commonly following hysterectomy. Abdominal surgery has higher risk than vaginal hysterectomy, and an almost zero incidence with supracervical hysterectomy. In wealthy nations, gynecologic surgery is the most common cause of

result of reduced intake of water either due to lack of access to potable water or intentionally not taking enough water in order to reduce and control the volume for incontinence of both urine and stool. In addition, or other “sponge” material frequently, that may precipitate stones. Damage to the urethra may render the patient chronically incontinent even if the “hole is closed”, in a drainpipe-urethra stress incontinence condition.1 Damage to the parasympathetic plexus may cause overactive bladder to be considered in the expect that all pelvic functions will be normal after

rate quoted at 2% for benign hysterectomy surgical risk. Fistula may also occur after genital trauma, most often following foreign-body rape which is considered as a gender violence tool of warfare in some war-torn areas.10 Uterovaginal prolapse is rarely associated

patients for the possibility of infertility and vaginal scarring precluding normal coitus that will not be

involves an untended pessary-related erosion through

coital limitations caused by distorted, shortened and

erosion of uterovaginal prolapse.11

counseling helps to prepare herself for marital intimacy in a realistic fashion.

outcomes Overview of client assessment Careful evaluation of all potential involved anatomy renal sonogram or intravenous urography is best used liberally whenever available, to identify hydronephrosis/hydroureter and end-stage renal atrophy. Blood urea nitrogen and creatinine values provide a gross indication of overall renal function. With hydronephrosis, ureteric re-implantation is necessary. With end-stage renal atrophy, the ipsilateral non-functional saves much time and effort during the operation. Pelvic neuropraxia of the sacral nerve roots, caused by the same fetal impaction cascade, may result in saddle anesthesia with dermal ulcerations due to incontinence combined with the inability to sense pain, infection and necrosis in the numbed soft tissues of the affected dermatomes.1 The peroneal

vesicovaginal, as the rectal vault is not so entrapped by the bony pelvis during obstructed labor. It is quite

may also occur as a complication of episiotomy or spontaneous perineal tears sustained during normal, non-obstructed labor, and without any concomitant

well healed. symphyseal separation requiring binding, activity restriction and physical therapy. Osteitis pubis

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must be considered in the differential diagnosis list of obstructed labor. Some women suffer from ulcerations of the buttocks and ischial tuberosities due to neuropraxic saddle anesthesia, or severe urine dermatitis from constant incontinence.1 In such cases, pre-operative care includes active skin and wound care to reduce the cellulitis and heal open granulation near-100% rate of stillbirth, the 30-60% rate of marital abandonment, and extreme social isolation induces a reactive depression that may warrant ongoing care even after successful surgery, as the post-traumaticstress disorder features may be severe. History and clinical examination History taking A general history and physical screening allows the clinician to assess general health factors that will patients are not the type to go for check-ups and health screenings. A focused uro-gynecologic and colorectal history is obtained, with focused examination to that may affect uro-gynecologic/colorectal function daily leakage of urine with heavy lifting, or fecal incontinence to solid stool prior to the delivery that

evaluation, every effort must be made to correct and balance physiologic functions prior to surgery. (size, location from anatomic staging landmark, test (genitourinary), and drawing of the defect(s). A rectovaginal version of blue testing may be done by inserting blue exam gel into the rectum, ~ 15 ml. Compress the gel against the anterior rectal wall with vaginal wall with a retractor and bright lighting. Blue gel may express through small RVF in this fashion. Examination is performed for gross nutritional status, developmental stage and mental status. Review of respiratory, cardiovascular, abdominal, musculoskeletal and neurologic systems is done. Neurologic system is affected by symptoms (such as foot drop or saddle and pudendal nerve function are impaired, residual trouble the patient despite good anatomic repair. The external genitalia are examined for signs of ulceration and excoriation (‘urine dermatitis’) and bleeding, stone, genital mutilation, perineal tears, etc. Speculum and to take note of any characteristics that may affect treatment and outcome. Genitourinary dye test

noted. Neonatal status of last delivery and whether

Any other relevant information is obtained.

be carried out on screening evaluations, or during examination under anesthesia. A dye test is performed by inserting dry cotton swabs into the vagina and instilling methylene blue or other sterile colored solution into the bladder by means of a catheter. The swabs are removed after a few minutes. If the swab that was the lowest in the vagina is stained, the patient

Clinical examination nevertheless warrants a thorough head–to–toe, documented examination. Physical screening for nutritional, thyroid, cardiopulmonary, abdominal, retroperitoneal, neurologic, orthopedic and dermatologic pathology allows optimal woundhealing preparation for the extensive soft-tissue reconstructive surgery required for many OF. Unlike extirpative surgery involving the removal of organs, the success of any reconstructive surgery including wound healing. A woman with advanced thyroid disease, uncontrolled diabetes, extreme nutritional deprivation, or uncontrolled hypertension will 8

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if the upper swab is stained, the patient has a juxtais stained with urine but not with dye, the patient has Pre-operative investigations Some of the following investigations will not be available and probably not essential at all centers: 1. Hematocrit, blood group and Rh group 2. Additional tests: a. Blood tests for HIV infection, syphilis, hepatitis and renal function b. Urinalysis and urine culture: Almost all

Dangal et al. Obstetric Fistula in Developing Countries

genitourinary

and

many

intestine-urinary

consistent with active upper tract infection, pre-op urinalysis and/or urine culture to direct antibiotic therapy for cystitis is not proved to be helpful or necessary. c. Stool tests for occult blood, ova and parasites d. Ultrasound exploration of kidney, ureter and bladder. Look for stones and obstruction, especially if the patient previously had a (especially, a cesarean delivery or a hysterectomy). e. Radiologic exploration: Intravenous urography to look for stones and obstruction and assess renal function f. The indigo carmine test to look for ureteric g. Endoscopy: Cystoscopy and urethroscopy h. ECG and Chest X-ray when indicated i. Barium enema: Colorectal pathology, non-

Outcome and prognosis The critical factors affecting the prognosis of an scarring. Almost all defects can be closed. However, if the urethra has been crushed, denervated and shortened, it will not function and the patient may have total stress incontinence. The shorter the urethra and the greater the scarring, the higher is the chance of stress incontinence. Destroyed urethras can be repaired, but the prognosis for continence is not good. Incontinence persisting after repair can be predicted by the following by urethral involvement, important scarring, and size of defect and bladder capacity. of involvement, or not, of the closing mechanism since this will have consequences for the operative technique and the prognosis of the repair. the repair4

by surgeons fully trained and competent to A system should be descriptive, indicative as well as prognostic (i.e. present a description, indicate the operative technique to be applied and the outcome to expect) and it should be a reliable tool for study are so many variables that some surgeons feel that a

require referral to, and repair by, a specialist Table 1. Criteria based on the degree of

system cannot be recommended over another until

1.

2.

3. 4.

The Waaldijk System13 is based on whether the continence mechanism is impaired and on circumferential damage. Studies have been conducted to assess this system, which is presently used in West and East Africa. The Goh System14 is based on urethral involvement, size of defect, extent of scarring, whether scarring is circumferential, and whether repair has previously been attempted. Studies have been conducted to assess this system, which is presently used at several centers in East Africa. The Francophone System has been partially validated and is used in francophone Africa. The two-stage Tafesse System15 is based on urethral involvement, extent of scarring, whether the continence mechanism is affected, and bladder capacity. This system has not been assessed and is not validated.

Good prognosis/ Simple

Complicated/ Uncertain

Single

Multiple

Site

vesico-vaginal (VVF)

RVF, mixed VVF/ RVF, involvement of cervix

Size (diameter)

< 4 cm

> 4 cm

Involvement of the urethra/continence mechanism

absent

Present

Scarring of vaginal tissue

absent

Present

Presence of circumferential defect*

absent

Present

Degree of tissue loss

minimal

Extensive

Degree of tissue loss Ureter/bladder involvement

ureters are inside the bladder, not draining into the vagina

ureters are draining into the vagina, bladder may have stones

Number of attempts at repair

no previous attempt

failed previous attempts of repair

* the complete separation of the urethra from the bladder

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easy and early access to skilled professionals who women from underserved communities. Many women in remote villages go through labor either alone or with the help of family or a local, untrained birth attendant, far away from professional health care. Furthermore, they lack accessible means of transport when complications following labor arise. It is an unfortunate fact of humanity that life-threatening obstructed labor occurs with great frequency when women leave it “up to nature”. Evidence shows that common causes of maternal mortality still ravaging the developing world, obstructed labor being one of them.

Source: Global Competency-based Fistula Surgery Training Manual. FIGO and Partners. London: FIGO;2011.16

Lack of access to maternity care 4 In poor countries, majority of the women who die, because they did not receive the health care that they needed. This may be due to a lack of basic health-care provision or through an inability to access the local health-care services. Strategies for prevention of OF The need for OF prevention and treatment services will vary greatly between individual countries or areas.

complex cases to higher center. Recommendations to prevent OF fall into three types4 Primary-prevention strategies These are aimed at ensuring that pregnancies are planned, wanted, and occur at an optimal age. These strategies ensure that all women, their families and communities, understand the need for delaying the birth spacing and providing access to family planning. In developing world, girls and women receive less nutritious food. They have underdeveloped pelvises that often increase the incidence of obstructed labor. Girls are also less likely to be educated. The wider social determinants for the improvement of the general health of girls and women may include, for example, addressing issues such as better child and adolescent nutrition, recognizing a girl’s right to education and setting a minimum age for marriage. Secondary-prevention strategies When a woman is pregnant, the woman herself, her family and the community need to be aware of the need to seek antenatal care and the importance of skilled care at childbirth. This can be promoted by increasing community awareness, training traditional birth attendants, increasing women’s knowledge of normal pregnancy and delivery, and about when and where to seek help, and why. However easy access to a local essential obstetriccare facility is paramount.17 They should have access to comprehensive obstetric-care services.18 Consistent use of a partograph for the correct monitoring of labor has been proven effective for the early diagnosis and management of prolonged/obstructed labor. A referral to a setting in which a caesarean section or assisted vaginal delivery can be performed in a timely manner is the key intervention to prevent deaths and complications related to obstructed labor. Tertiary-prevention strategies These are designed to identify and prevent the women who are at risk. This includes monitoring every labor by use of a partograph. Midwives and

preventive and treatment services should: through health promotion and awareness, and the development of high-quality basic and comprehensive maternal health services, available to all. 10

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NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

without surgery by the use of an indwelling urinary catheter for mothers who have survived an obstructed labor.

Dangal et al. Obstetric Fistula in Developing Countries

diameter. Catheter drainage for 2-3 weeks, with or without post-fulguration anticholinergic medications, create one of the most challenging clinical scenarios in soft-tissue reconstructive surgery. Management of surgical treatment.

Catheter and debridement immediately postpartum after obstructed labor Immediate catheter drainage of the bladder prevents

bovine serum albumin mixed with glutaraldehyde. The albumin and glutaraldehyde induce a glue-like sealant in soft tissues. Used extensively in vascular surgical repair of the aorta, femoral and carotid arteries, it also has a documented utility in intestinovaginal 24,25 The choice to use porcine plug, cautery experience. The use of any of these therapies must

when inserted immediately after obstructed-labor achieve spontaneous closure by catheter drainage when inserted immediately after obstructed labor delivery.1 Excision or other debridement method of followed by thorough irrigation with saline should be done. After a caesarean section for prolonged obstructed labor, the catheter should be retained for at least 10 days. If there is urinary leakage after removal of the catheter, it should be reinserted immediately.

Fistulae may be successfully closed surgically at any point provided the tissue quality is optimized (no infection or crusting, minimal induration).19,20 Continuous bladder drainage by catheter should be maintained for a minimum of four to a maximum of to operate as soon as the vagina is clear of necrotic tissues. While others prefer to wait for two to three

Closure of the defect under no tension with wide mobilazation of bladder Avoid damage to upper urinary tract – stent ureters as needed Reinforce the bladder neck and anal sphincter when involved in the defect and grafts as needed incorporates principles of plastic surgery. Most contemporary techniques avoid multiple layer closure in order to preserve bladder capacity. Wound healing optimization and biologic grafts

glue

reconstructive surgery success rates have been

porcine of small intestine sub-mucosa facilitate in spontaneous closure of small rectovaginal

grafts. Though not currently popular in the obstetric

that mechanically closes the hole while catalyzing histologic aspects of wound heaing.21 This may be considered for women with small rectovaginal

high protein diet, adequate hydration, wound repair accelerating nutritional supplements, active management of diabetes, hypertension and chronic pulmonary disease, all warrant consideration in the pre

Several case series demonstrated the limited but

patient. In direct comparison to full thickness human skin (AlloDerm) and traditional woven Vicryl mesh, porcine submucosa (Surgisis) demonstrated superior collagen deposition and organization, and far superior neovascularization in an animal model study of abdominal hernia repair.26 Surgisis has demonstrated superior results in vaginal prolapse surgery, and has increasingly been used in the highly complicated

that are not in proximity to the urethra or ureters.22,23 Cautery may be carried out transvesically through a cystoscope, or vaginally, either as primary therapy or secondary treatment after surgical failure. Fistulae amenable to cautery are typically less that 0.7 cm in

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Dangal et al. Obstetric Fistula in Developing Countries

27,28 The possibility of incorporating porcine intestinal submucosal grafts warrants clinical trial in a high-prevalence obstetric

Wound healing optimization - potential frontiers The combination of stem cells and growth factors hasbeen shown to result in enhanced repair outcomes that emulated uninjured tissue. Preclinical evidence from gene therapy and stem cell studies are being used to move therapy from the experimental phase to clinical translation in other reconstructive surgical specialties.29,30 Flaps and interposition grafts are believed to improve to facilitate skin covering when the vaginal skin is wanes, with the Martius graft, used to be popular and believed to reduce recurrence in past years. However, it is now falling from favor as experience

is needed for as long as there is a foley’ scatheter inserted (usually a minimum period of 14 days) to prevent catheter blockage. Promoting wound healing A high protein diet, adequate hydration, and vitamin/ nutritional supplementation, designed to optimize wound healing, are advised. Menopausal and severely therapy. Using urinary tract drains Urinary catheters must be draining and patent at all times. A catheter blocked by kinking of tubing, or blood clot or mucus plug at the catheter tip in the bladder will quickly result in retention. Urinary the suture line. If the bladder is full to palpation, any kinks in the tubing must be corrected immediately. If there are no kinks, or un-doing the kink does separated from the collection tubing. If this does

labia minora, medial and/or lateral surface, and the to cover the anterior, and less commonly, posterior

obstruction, the catheter may be changed. Stents may also kink, bend or be blocked by clots or mucus. NonDuration of catheterization, traditionally 14 days,

posterior vaginal wall. Gracilis and wide buttock healing by secondary intention is undesired, and no other suitable grafts are available. Peritoneum from

case-by-case catheterization duration for as little as 7 days.32,33

may also be accessed, and if adequate in surface area, advanced intravaginally to cover the anterior or

Bowel management very loose, soft stool so that stool does not distend the suture line in transit during a bowel movement.

granulate spontaneously and where healing occurs by secondary intention. Meticulous nursing care and clinical monitoring is mandatory to the success of bed.2,31 Principles of post-operation care The three D’s of post-operative care are: Make sure that the client Drinks. Make sure that the client is Dry. Make sure that all drainages are Draining. Intensive care is normally only for 12-24 hours. The following morning the patients have to be mobilized like in any other operation; besides being good for their general health it is also good for prevention 12

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NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

Expected activity Most surgeons leave the patient in bed for a day or two, ambulating carefully thereafter. Ankle rotations and gentle range - of - motion exercises may be instituted during the bed-rest phase, to maintain circulation and prevent deep vein thrombosis. Pre-discharge patient education Prior to discharge, the patient and her partner and family members, if present, should receive basic health and nutritional education to ensure that she maintains her overall general health. Further, she and her partner should receive full advice on family planning, contraception and the management of any subsequent pregnancies in an equipped hospital.

Dangal et al. Obstetric Fistula in Developing Countries

Re-integration Many patients are the poorests of poor and certainly the patient is dry, she will re-integrate and, if she is wet, she may not. Those patients who are cured can then become educators for their own community.

vagina and rectum, and to reduce suture line tension

The choice to proceed with abdominal repair dependson a combination of factors such as revisualize and mobilize from below, leaking only per cervical os, the possibility indicating vesicouterine

Special considerations

and the delicate architecture that creates particular mobilization require special attention. Transected urethra may be patent at the proximal end or blindended. When blind-ended, one may often restore patency with gentle pressure applied to the inserted metal catheter. With patency of the proximal urethral tube established, re-anastomosis to the bladder may involve postero-lateral compensatory reconstruction, or circumferential re-anastomosis to the robustly mobilized and advanced anterior and posterior/ trigonal bladder walls.2

34,35

The commonly cited “supratrigonal location” of VVF as an indication that abdominal access is inaccurate. Fistula located in the bladder dome, well above the level of the trigone, have been repaired vaginally by 36 Vesicovaginal careful evaluation of the location of the ureteric safeguard throughout. Bladder stay-stitches are recommended to prevent the low bladder dissection from extending into the urethra. Vesicouterine uterine wall in addition to bladder closure. Dissection may be direct – circumferential around the defect, or by bladder-bivalve; incising vertically down to entirety, closing the bivalved bladder wall afterwards. High rectovaginal, rectouterine/cervical or intestino-

RVF is healed, in order to reduce contaminant load and infection related failure of the VVF repair. The principles of RVF repair are the same as VVF repair, with the added problem of coliform contamination of the repair, and the possibility of constipated hard stool creating mechanical stressors on the repair suture line, warranting aggressive post-operation bowel management to keep stool soft. Care must be taken to screen for concomitant rectal stricture in the presence of RVF, and stricture revision may be rotated from the anterior rectum to create a neovaginal skin covering when vaginal and labial skin is not of adequate dimensions. Transverse closure of rectal defects reduces the possibility of repairrelated rectal stricture. When occurring in proximity to the rectal sphincter, it is sometimes best to transect sphincteroplasty. Perineoplasty and/or interposing levatorplasty may be used as needed to restore normal outlet anatomy, create an interposed layer between

in advance of surgery. In addition, coliform/ anaerobic antibiotic coverage, careful adherence to the principles of intestinal dissection and suturing including adequate mobilization, avoiding intestinal devascularization, and transverse closure of intestinal lumens with Lambert suture technique are the mainstays. For high RVF, vaginal mobilization followed by abdominal closure may prove most

Fistulae involving the ureter and ureteric stenosis causing proximal hydro-ureter or hydronephrosis require ureteric re-implantation. Adequate mobilization is crucial to a tension-free reanastomosis of the ureter into the bladder. Once mobilization is complete, the ureter is transected at the lowest point, usually adjacent to the uterine artery. the bladder may be tubularized on the lateral aspect to form a new distal ureter, and the anastomosis is proximal native ureter.

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Dangal et al. Obstetric Fistula in Developing Countries

deemed the patient beyond the reach of normal pelvic reconstruction, the patient would be labeled incurable. Diversion methods include ileal conduit, continent ileal diversion, Mitrofanoff continent caecal diversion, and Mainz pouch diversions, where ureteric implantation into a detubularized sigmoid reroutes urine to stoma-free voiding per rectum. Reimplanted ureters may stricture and develop severe requires constant monitoring in applicable diversion procedures, stones may form in the pouch, stomas, continent and incontinent, may stricture, prolapse, avulse, or develop soft tissue infection of the stoma itself or adjacent dermis.2,31 If the post-diversion conditions cannot be met, a diversion procedure is diverted stoma.

may be caused by: an overactive bladder, a poorly compliant- low capacity bladder, stress incontinence from urethral and/or direct sphincter damage, a combination of these conditions. In its severest form, a totally non-functional urethral tube, called “drainpipe urethra”, causes stress incontinence. Drainpipe urethra is common in full reconstruction of neo-urethra, as the urethra has no tract alpha-adrenergic innervation of the bladder neck sphincter. There is a reconstructed bladder neck, but no nerves, and no sphincter. Loss of bladder wall surface

surgery Dysfunctions of storage (incontinence) and emptying (voiding dysfunction all the way up to total urinary retention; defecatory dysfunction all the way up to fecal impaction or rectal obstruction) may occur individually or in combination after successful closure

may lead to severe loss of bladder compliance. Rather than a 300-600 ml low-pressure urine reservoir, the bladder may have the volume capacity and elasticity of a walnut, requiring staged bladder augmentation or urinary diversion to reestablish the bladder’s storage functions. Sling surgery will not help incontinence in this type of bladder. Any woman suffering from bladder storage (incontinence) or voiding phase (obstruction or impaired detrusor contractility)

symptomatic, but voiding and defecatory dysfunction may not be symptomatic, or may be symptomatic in

consideration of all possible bladder conditions of storage and voiding.

For instance, some patients with overactive bladder may have post-void detrusor overactivity, where the bladder continues to contract even though it is empty. These patients often complain of incomplete emptying, when in fact they empty quite well, but the continued detrusor contraction makes them feel as if they still have more urine to void. A detailed history, careful physical examination and simple

CONCLUSIONS

diagnosis are the key to successful treatment. Delineation of therapeutic success may be related capacity, fertile, pain-free, neurologically intact), surgically closed and continent, closed and somewhat incontinent, closed and severely incontinent, and closed with lower urinary or colorectal dysfunction other than incontinence.

National and International Organizations in developing countries like Nepal should effectively condition a preventable and treatable tragedy. The from the provision of essential obstetric care service; however, the needs of those who have already is an enormous need for increasing the resources and skilled staff available locally to treat obstetric with this condition. Moreover, effective preventive reach those in need at the rural settings.

Persistent lower urinary tract dysfunction after

REFERENCES

Up to 30% of patients suffer from urinary incontinence 34,35 The prevalence

1.

14

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basics. Paris: WAHA International; 2010.

Dangal et al. Obstetric Fistula in Developing Countries 2.

Brian Hancock. Practical Obstetric Fistula Surgery. London: Royal Society of Medicine Press Ltd; 2009.

3.

Ahmed S, Genadry R, Stanton C, Lalonde AB. Dead women

with Crohn’s disease using new biomaterials. Surg Innov. 2009;16(2):162-8. 22.

Gyncol Obstet. 2007;99:S1-3. 4. for clinical management and programme development. Geneva: World Health Organization; 2006. 5.

UNFPA. Status of reproductive morbidities in Nepal. Kathmandu: UNFPA-Nepal; 2006.

23. 60. 24.

de la Portilla F, Rada R, Vega J, Cisneros N, Maldonado VH, Sanchez-Gil JM. Long-term results change conclusions on BioGlue in the treatment of high transsphinteric anal

25.

Garcia S, Dissanaike S. Case report: treatment of rectovaginal

26.

Rice RD, Ayubi FS, Shaub ZJ, Parker DM, Armstrong PJ, Tsai JW. Comparison of Surgisis, AlloDerm and Vicryl Woven Mesh grafts for abdominal wall defect repair in an animal model. Aesthetic Plast Surg. 2010;34(3):290.

27.

Armitage S, Seman EI, Keirse MJ. Use of surgisis for treatment of anterior and posterior vaginal prolapse. Obstet Gynecol Int. 2012; 376251.[Epub 2012 Jan 15].

28.

Schwandner O, Fuerst A, Kunstreich K, Scherer R.

6. UNFPA; 2011. 7.

Stanton C, Holtz SA, Ahmed S. Challenges in measuring

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World Health Organization Maternal Mortality Fact Sheet. Geneva: World Health Organization; 2012.

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Onsrud M, Sjoveain S, Mukwege D. Cesarean deliveryGynaecol Obstet. 2011;114(1):10-14.

10.

Onsrud M, Sjoveian S, Luhiriri R, Mukwege D. Sexual Congo. Int J Gynaecol Obstet. 2008;103(3)265-9.

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29.

Isaac C, Gharaibeh B, Witt M. Wright VJ, Huard J. Biologic approaches to enhance rotator cuff healing after injury. J Shoulder Elbow Surg. 2012;21(2):181-90.

30.

Nixon AJ, Watts AE, Schnabel LV. Cell-and gene-based approaches to tendon regeneration. J Shoulder Elbow Surg. 2012;21(2):278-94.

31.

Atlas of Pelvic Surgery. Clifford Wheeless and Marcella Roenneberg. [cited 2013 March 7]. Available from http:// www.atlasofpelvicsurgery.com

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Barone MA, Frajzyngier V, Arrowsmith S, Ruminjo J, Seuc A, Landry E, et al. Non-inferiority of short-term urethral col for a randomized-controlled trial. BMC Womens Health. 2012;12:5. tula repair after 10 day versus 14-day Foley catheterization. Int J Gynaecol Obstet. 2012;118(1):21-3.

Wall LL, Arrowsmith SD, Briggs ND, Lassey A. Urinary International Continence Society Committee 12.

13.

using Surgisis mesh. Tech Coloproctol. 2009;13(2):135-40.

Head RB, Walker K, Secrest C. Large cystocele with doi: 10.1016/j.urology.2012.05.020. [Epub 2012 Jul 26].

Waaldijk K. Step by Step Surgery of Vesico-Vaginal Fistulas. Edinburgh: Campion Press; 1994.

14. University of Queensland Press; 2004. 15. Obstet Gynaecol Can. 2008;30(5):394-5. 16. FIGO and Partners. London: FIGO; 2011. 17.

Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva: World Health Organization; 2004.

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Global action for skilled attendants for pregnant women. Geneva: World Health Organization; 2004.

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Blaivas JG, Heritz DM, Romanzi LJ. Early versus late repair

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review. Int J Gynaecol Obstet. 2007;99(Suppl)1:S40-6.

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Waaldijk K. The immediate management of fresh obstetric

Arrowsmith SD, Ruminjo J, Landry EG. Current practices BMC Pregnancy and Childbirth. 2010;10:73.

J Urol. 1995;153:1110. 20.

Stovsky MD, Ignatoff JM, Blum MD, Nanninga JB, O’Conor VJ, Kursh ED. Use of electrocoagulation in the treatment of

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Frajzyngier V, Ruminjo J, Asiimwe F, Barry T, Bello A,

prospective cohort study. BJOG. 2012. doi: 10.1111/j.14710528.2012.03461.x. [Epub ahead of print].

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ORIGINAL ARTICLE

Determinants of Intrauterine Contraceptive Device Use Among the Women of Urban Areas of Nepal Joshi R,1 Bhattarai S,2 Simkhada K,2 Thapa S3 Unit for Health Promotion, University of Southern Denmark, Esbjerg, Denmark Department of Nursing, Nepal Institute of Health Sciences, Boudha, Kathmandu, Nepal 3 Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium. 1 2

Aims: This study aimed to identify the determinants of Intrauterine Contraceptive Device (IUCD) use among the married women of reproductive age group living in urban areas of Nepal. Methods: This study was an analytical cross-sectional study which aimed to compare different factors between 110 IUCD users and 110 non-users. Both groups were selected randomlyand interviewed by using semi-structured questionnaire. Chi-square test was used to detect the difference between two groups and corresponding odds ratios Results: When the IUCD users were compared to non-users, religion, occupational status of women, occupational status of the husbands, total number of children, sources of information about IUCD, having wrong beliefs about with the use of IUCD.The main reason for using IUCD was due to the effectiveness for longer duration and for not using IUCD was due to the feeling of no need. Conclusions: Wrong beliefs about the device discouraged women from using IUCD, hence, awareness programs are strongly recommended. Keywords: intrauterine contraceptive device, reproductive intention, spousal communication.

INTRODUCTION

IUCD program in Nepal needs information related to women’s socio-demographic and behavioral factors

Intra Uterine Contraceptive Device (IUCD) is proven to be effective worldwide.1 However, IUCD is one of the least used devices in Nepal and it is often ignored by the women especially living in the urban areas.2,3 On the other hand, women lack adequate information about health services including family planning which is contributing to high burden of reproductive morbidities in Nepal.4-7 Several studies done in other countries revealed that factors like education, place of residence, culture, religion, literacy, occupation, income, reproductive intention, spousal communication and service related 8-16

Studies had shown that the reason for non-use is the fear of side effects.17,18 However, studies from Nepal did not provide adequate reliable information about the factors for use and non-use of the device.2,4,19-21 CORRESPONDENCE Mr Subash Thapa Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium. Email:[email protected] Phone: +32 479492780 16

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there is a strong need for research in this area. Hence this study was carried out to identify the information regarding determinants of IUCD use among the women living in urban areas of Nepal. METHODS This analytical cross-sectional study was carried out among married women of reproductive age group in three districts namely Kathmandu, Bhaktapur and Lalitpur. These areas have been selected purposively due to the presence of a large number of samples and representing the most developed areas in Nepal.The study population included women having at least one child who are currently using IUCD as IUCD users and currently not using IUCD as IUCD non-users.

The papers in this journal are published under the terms of the

Joshi et al. Determinants of Intra-uterine Contraceptive Device Use

The sampling frame containing the name list of IUCD users and non-users was collected from district and Lalitpur. Both the IUCD users and IUCD nonusers were randomly selected proportionate to the selected districts. Semi-structured interview was carried out to collect the data using a questionnaire. The questionnaire was pre-tested among the women attending Gokarna primary health care center to insert IUCD. The required sample size to detect the difference between IUCD users and non-users was 110 for users and 110 for non-users by taking level of 22 All analyses were done using SPSS version 18.0 for windows. Chisquare statistics was used to identify the difference between users and non-users. Crude Odds ratio and

Table 1. Socio-demographic and family planning related characteristics of the women and association with IUCD use (n=220). IUCD Users

IUCD Nonusers

Number

Percent

Number

Percent

Literate

79

71.8

80

72.7

1 (Reference)

Illiterate

31

28.2

30

27.3

1.04(0.58-1.88)

80

72.7

94

85.5

1 (Reference)

30

27.3

16

14.5

2.20(1.12-4.32)*

children >2 children

Sex of the last child Female

38

34.5

43

39.1

1 (Reference)

Male

72

65.5

67

60.9

1.21(0.70-2.10)

> Nonpoor

38

34.4

52

47.3

1 (Reference)

72

65.5

58

52.7

1.69(0.987-2.92)

RESULTS Table 1 shows the socio-demographic and family planning related characteristics of both groups. The mean age of IUCD users and non-users was 31 years (SD 6.0 years) and 30 years (SD 6.4 years) respectively (p value >0.05). A majority of women from both groups were Hindu (76.4% of users and 62.7% of non-users). Regarding the literacy status of the women, 93.6% of the users and 92.7%of nonusers were literate. Similarly, 13.6% of users and 4.5% of non-users were engaged in farming. Having illiterate husbands comprised only 7% in both groups. A majority of the women in both groups (72.7% in users and 85.5% in non-users) had one or two children. Similarly, 65.5% of users and 60.9% of the non-users had a male child in the last pregnancy. Among 65.5% of users and 52.7% of non-users, the per-capita income was lower than the median income that was computed as US$ 13.3. Wrong beliefs about IUCD was found among 13% of the users and 35% of the non-users. Availability of the IUCD services was positively associated with IUCD use. A great majority of users (94%) had IUCD service available in nearby center. Accessibility to nearby family planning center was slightly higher among non-users (90.4% in users and 93.9% of nonusers). A majority of users (82.7%) and non-users (69.1%) had an intention to limit the child birth. Similarly, 75.5% of users discussed about using IUCD with the husband.

Odds ratio 95% CI

Wrong beliefs about IUCD (Users, n= 79 and non users, n=42) Yes

11

13.9

15

35.7

1 (Reference)

No

68

86.1

27

64.3

3.43(1.40-8.40)*

Availability of IUCD services in the nearest family planning centers No

6

5.5

24

26.7

1 (Reference)

Yes

104

94.5

66

73.3

6.30(2.4416.23)*

Accessibility to the nearest family planning center Not accessible

10

9.6

4

6.1

1 (Reference)

Accesible

94

90.4

62

93.9

0.60(0.18-2.02)

Birth spacing

19

17.3

34

30.9

1 (Reference)

Birth limiting

91

82.7

76

69.1

2.14(1.13-4.06)*

Spousal communication No

27

24.5

44

40

1 (Reference)

Yes

83

75.5

66

60

2.04(1.15-3.65)*

*

Regarding the source of information about IUCD, the most popular source for users was female community health volunteers (FCHV){72.7%} followed by radio (57.3%). On the other hand, radio (63.3%) and health personnel (56.7%) were the most popular sources of information in non-users.

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Joshi et al. Determinants of Intra-uterine Contraceptive Device Use

Table 2. Reasons for using or not using IUCD by the women (n=220). Number

Percent

Highly effective

42

38.2

Long acting method

88

80

13

11.8

Fewer side effects

36

32.7

Convenient to use

6

5.5

Encouraged by FCHVs

70

63.6

Fear of side-effects

33

30

No need

63

57.3

Husband disapproval

7

6.4

Desire for a child

13

11.8

Lack of information

35

31.8

Reasons for using IUCD (multiple response; n=110)

Easy to remove

insert

and

Reasons for not-using IUCD (multiple response; n=110)

Table 2 shows reasons for using and not using IUCD. When the women were asked about the reason for using IUCD, believing in long-term effectiveness of the method (80%) was the most popular reason followed by encouragement by FCHV (70%). In addition, fewer side-effects (32.8%) as compared to other hormonal devices and its high effectiveness (38.2%) were also found as some important reasons behind using IUCD. On the other hand, more than the half of the non-users (57.3%) mentioned that IUCD use was not necessary followed by lack of information (31.8%). Nearly one third of IUCD nonusers reported side-effects as a reason for not using aware about IUCD as a method of contraception. Desire for a child and disapproval from husband were also noted as a reason for not using IUCD. DISCUSSION of women, occupational status of the husbands, total number of children, having wrong beliefs about IUCD, availability of IUCD services, reproductive intention and spousal communication and sources of information being FCHV and health worker were

18

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Similar to Ozyurda’s study23 in Turkey, this study also corroborated the fact that women belonging to the religions other than Hindu were more unlikely to use IUCD. A possible explanation could be that the majority of people in Nepal are Hindu and there are no restrictions for family planning matters by religion. The report of Nepal Demographic Health Survey showed that income has a positive correlation with IUCD use.5 Women earning more could consult the health workers more and could get access to health information more than those who earn less. However, this study found no relationship between income and IUCD use. This might be due to the fact that the study has been done in urban areas of Nepal where living status of women is relatively better. Besides, women and there husbands involved in farming were more likely to use IUCD. This suggests that women and there husband who are involved in works needing more physical effort and time, mostly prefer IUCD. FCHVs are the backbone of the health system of Nepal. Their role in improving the maternal health status of the country has been well appreciated by the international community as well.12 Similarly, this study also highlighted that the FCHVs as the source with IUCD use. This association might have been attributed due to the fact that the Government of Nepal has provided incentive for FCHVs for tracking the client to increase the use of IUCD.20 On the other hand, this study added information that FCHVs were also working actively in the urban areas especially in Geographical access seemed not to be associated with IUCD use in this study, however it had already been found that the distance from home to the health facility is strongly negatively associated with the use of IUCD.10 This is also due to the fact that health services in urban areas are available closely. This study found that availability of services were determining the women’s choice of family planning devices. IUCD services are not available in subhealth posts and in most health posts, as there are no IUCD trained staff and IUCD insertion equipment in both the rural and urban areas.19,20 There are more private health care providers in urban areas who do

This study corroborated with a study in Egypt15 that with IUCD use. It is also logical that reproductive intentions are governed by the total number of children.

Joshi et al. Determinants of Intra-uterine Contraceptive Device Use

Two child norm has been established as a family planning policy led by the Government of Nepal. However, this study found an association between a high number of children and IUCD use, which shows that two child norm has not been strictly followed by most of the couples. Similarly, communication of contraceptive use with husband was positively associated with the use of IUCD in this study. This Engender Health, which found that 86.2% of IUCD users had discussed about using the method with their husbands. A study in Bangladesh16 pointed out that one of the reasons for using IUCD were attractiveness of having a long-acting contraceptive which was also

beliefs of women about IUCD. Second, the health centers in urban areas need to be supported to make IUCD insertion services easily available. And lastly, to comprehensively explore information related to social as well as behavioural contexts involved in making choices of family panning methods, further design is required.

21

reason for not using IUCD was lack of information regarding the method and side-effects which was in line with the result shown by a study in England.17 In addition, having wrong beliefs about IUCD was also found to be negatively associated with IUCD use. This emphasizes that awareness programmes are very essential to make women aware about IUCD use and also to change the negative attitude toward the device. Regarding the limitations of this study, this crosssectional study cannot identify the temporality of cause and effect relationship. As the study area and the study population were selected purposively, generalizations should be considered cautiously. Recall bias could also have affected the true associations between the variables. Similarly some pregnancy, accessibility and income were not shown be due to the selection of the study area purposively. Further, no correction has been carried out to correct the effect of multiple testing in the observed

ACKNOWLEDGEMENT The authors thank all the members of the district Lalitpur for helping through providing the list of users and non-users of IUCD. REFERENCES 1.

United Nations- Department of economic and social affairs.World contraceptive use; 2011. [cited 2012 October 6]. Available from f

2.

Thapa S, Paudel IS, Bhattarai S, Joshi R, Thapa K. Factors affecting IUCD discontinuation in Nepal: a nested case-control study. Asia Pac J Public Health; 2012. doi:10.1177/1010539512458522. [cited 2012 September 15]. Available from http://aph.sagepub.com/content/early/2012/08/24/1010539512458522

3.

Thapa S. Early discontinuation of intrauterine device in Nepal: a retrospective study. WHO south east asian journal of public health.2012;1(3):309-19. [cited 2012 December 7]. Available from http://www.searo.who.int/publications/journals/seajph/media/whoseajphv1i3p309.pdf

4.

Marie Stopes International. Barriers to IUCD in Nepal. Reproductive health research; 2002. [cited 2012 October 7]. Available from f

5.

Government of Nepal. Nepal demographic health survey 2011. Ministry of health and population; 2012.

6.

Thapa S, Angdembe M, Chauhan D, Joshi R. Determinants of pelvic organ prolapse among the women of western part of Nepal:a case control study. ; 2013. doi:10.1111/jog.12168. [cited on 2013 October 20]. Available from http://onlinelibrary.wiley.com/doi/10.1111/ jog.12168/abstract

7.

The reproductive and child health aliance. IUDs - Increasing women’s option: a study to provide the basis for IUCDpromotion. Combodia; 2001. [cited 2012 September 15]. Available from http://www.racha.org.kh/rc2008/197/_14_Studies__IUD-_Increasing_Women_Option.pdf

8.

Hiza MT, Ruminjo JK. An exploratory study to determine and document factors affecting IUCD use in Tanzania; 2002. [cited on 2012 October 6]. Available from http://www. k4health.org/sites/default/files/An%20exploratory%20 study%20IUDC%20use_tanzania.pdf

9.

Dan A, Duolao W. Socio-demographic determinants of intrauterine deviceuse and failure in China. Medical Statis-

are still valid and applicable. CONCLUSIONS Given the socio-demographic factors like- religion, occupational status of women, occupational status of the husbands and total number of children, and family planning-related factors like- having wrong beliefs about IUCD, availability of IUCD services, reproductive intention, spousal communication and sources of information being FCHV and health worker are mostly determining using IUCD in our analysis, several recommendations can be made. First, awareness programs through mobilization of FCHVs can be conducted to increase awareness in

NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

19

19

Joshi et al. Determinants of Intra-uterine Contraceptive Device Use tic Unit; 2002. 10.

Hong R, Montana L, Mishra V. Family planning services quality as a determinant of use of IUD in Egypt. BMC Health Serv Res. 2006;11:79. doi: 10.1186/1472-6963-6-79. [cited 2012 October 2]. Available from

11.

Shekhar KS, Khan ME. Increasing the accessibility, acceptability and use ofthe IUD in Gujarat, India. Frontiers in reproductive health program. Population Council, Gujarat, India; 2008. [cited 2012 October 2]. Available from http:// www.popcouncil.org/pdfs/frontiers/FR_FinalReports/India_IUD.pdf

12.

Azmat SK, Shaikh BT, Hammed W, Bilgrami M, Mustafa G, et al. Rates of IUCD discontinuation and its associated a social franchising network in Pakistan. BMC Womens Health. 2012;12:8. doi:8.10.1186/1472-6874-12-8.

13.

Carlos B. Availability and acceptability of IUDs in Guatemala; 2003. [cited 2012 October 23]. Available from http:// www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Guatemala_IUD.pdf

14.

Hasan R. Follow-up study conducted among IUD acceptors of Java, Indonesia. Asia and near east operations research and technical assistance project; 1995. [cited 2012 October 25]. Available from http://www.popcouncil.org/pdfs/frontiers/OR_TA/Asia/indo_IUD.pdf

15.

Egyptian fertility care society. IUD use dynamics in Egypt. 1993.p.12. [cited 2012 October 16]. Available from http:// www.popcouncil.org/pdfs/frontiers/OR_TA/Asia/egypt_ IUD.pdf

16.

E-Alam M, Bradley J, Shabnam F.IUD use and discontinu-

20

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ation in Bangladesh. ACQUIRE evaluation and research studies; 2007. 17.

Asker C, Bean J, Stokes-Lampard H, Wilson S. What is it Factors that make women non-use: qualitative study. J Fam Plann Reprod Health Care. 2006;32(2):89-94.

18.

Carranza JM, Janowitz B, Johnson LM, Katz KR. Reasons for low level of IUD use in El Salvador. International Family Planning Perspective. 1985;11:77-86. [cited 2012 Ocotber 10]. Available from http://www.guttmacher.org/pubs/ journals/2802602.html

19.

National Consultative Meeting. Repositioning family planning: strategic review of Nepal national family planning program; 2006.

20.

Population Service International. Drivers and barriers of IUD use among women in Nepal. Kathmandu: PSI Nepal; 2010.

21.

Engender Health. Contraceptive use and discontinuation pattern in Nepal: norplant, IUCD, pill and injectables; 2003. [cited 2012 September 10]. Available from planning/nepal_report_on_contraceptive_use.pdf

22.

Lemeshow S, Hosmer DW, Klar J, Lwanga SK. Adequacy of sample size in health studies. New York: John Wiley and Sons;1990.

23.

Ozyurda F. The demographic and fertility characteristics of women using IUDs. Nufusbil Dregs Turkey. 1986;8:105-15.

NJOG 2013 Jul- Dec;8(2):5-15 ORIGINAL ARTICLE

NJOG 2013 Jul- Dec;8(2):21-25

HIV in Women: The Gynecological Frontier Goswami S,1 Chattopadhyay S2 1 2

Department of Obstetrics and Gynaecology, Department of Anesthesiology, Medical College and Hospital, Kolkata, India.

Aims: The objective of the paper was to study the spectrum of gynecological disorders in HIV positive woman, which are often not given much importance as the issue of antiretroviral therapy and management of opportunistic infections occupy the major share of their treatment strategy. Methods: It was an observational study which included 135 women. The study was conducted in the Medical College and Hospital, Kolkata from January 2010 to December 2012 after obtaining permission from the institutional ethics committee. All the HIV positive women who came to the gynecological outpatient department with gynecological complaints were included in the study. Results: The seropositive women suffered from the same range of gynecological problems as in non-infected women. The most common complaints at presentation were vaginal white discharge and pruritus vulvae. The most common postoperative complication was fever. Conclusions: The HIV/AIDS is taking the shape of a generalized epidemic and with the advances in the antiretroviral therapy, the life expectancy of the patients is increasing. With the improvement of survival more and more of HIV positive women would present with problems pertaining to any system of the body and the gynecological complaint is not an exception. Addressing these problems would lead to boosting up of the care and support of this subset of women. Keywords: antiretroviral therapy, gynecological problems, HIV infection, pregnancy.

INTRODUCTION As the infection with HIV has gradually blown up to take the shape of a pandemic, the proportion of women affected by the same has also expanded. The disease has changed its character over the years and what initially emerged as a disease of gay men, now affects women and men equally. Globally women account for 50% of the people living with HIV/AIDS (PLWHA)1 and in India they occupy a share of 39%.2 Majority of these women are in the reproductive age group and can suffer from the same range of gynecological problems as the non HIV population but are often overlooked. This study ventured at

CORRESPONDENCE Dr Sebanti Goswami Department of Obstetrics and Gynaecology, Medical College and Hospital, Kolkata. Email: [email protected] Phone : (+91) 9831135933

exploring the spectrum of gynecological problems amongst them. METHODS This observational study was conducted in the Department of Obstetrics and Gynecology, Medical College and Hospital, Kolkata from January 2010 to December 2012 after obtaining permission from the institutional ethics committee and informed consent of the patients. All the HIV positive women who attended the out patients department with gynecological problems were included in the study. All were examined, investigated and treated according

The papers in this journal are published under the terms of the

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Goswami et al. HIV in Women

to their presenting complaints and diagnosis. Our institution being an apex centre for HIV, the case load is around forty patients per day.3 A total of 135 women were included in the study. RESULTS Out of 135 seropositive women who attended our outpatient department for gynecological problems; 41 had candidiasis, 39 had abnormal uterine bleeding, cervical intraepithelial neoplasia (CIN), three had carcinoma cervix, two had vulval carcinoma and two women came for the treatment of infertility. Vaginal white discharge and pruritus vulvae due to candidiasis were the most common problems (Table1). Table 1. Types of gynecological disorders (n= 135). Gynecological disorder

Number (%)

cases of carcinoma cervix one was an operable case (stage IIA) and two were inoperable (stage III). Two women presented with the complaint of an ulcerative swelling of the vulva. Biopsy proved them to be vulvar carcinoma. Two women came with the complaint of infertility. One of them had a history previously and both her fallopian tubes were blocked. Twenty six women required surgical interference (Table 3). The most common postoperative complication was fever (Table 4). All the twenty six women who were operated had CD4 count above 350. Viral load could not be done as it could not be afforded by our patients. Eleven of these operated women were on highly active anti-retroviral therapy. Table 3. List of gynecological surgery performed (n=26). Surgery performed

Number (%)

Candidiasis

41 (30.4)

Menstrual disorder

39 (28.9)

Total abdominal hysterectomy

PID

37 (27.4)

Fibromyoma

7 (53.8%)

CIN

11 (8.1)

Adenomyosis

2 (15.3%) 4 (30.7%)

Total =13 (50%)

Invasive cervical carcinoma

3 (2.2)

High grade SIL

Vulval Carcinoma

2 (1.5 )

Laparotomy for Tubo Ovarian mass (TO)

Infertility

2 (1.5)

CIN= Cervical Intraepithelial Neoplasia

Menstrual abnormalities were encountered in the form of menorrhagia, metrorrhagia and menometrorrhagia. Other causes of abnormal menstruation were cervical polyp, adenomyosis, abnormal uterine bleeding and carcinoma cervix. We did not come across any case of secondary amenorrhoea (Table 2). Table 2. Causes of abnormal menstruation (n=39). Causes Uterine Leiomyomas Abnormal uterine bleeding

Number (%) 19 (48.7) 9 (23.0)

Adenomyosis

7(17.9)

Polyp

4 (10.2)

disease, nine had tubo-ovarian mass and underwent laparotomy. All of these women came with the complaint of chronic pelvic pain with intervening acute episodes. Eleven women had cervical dysplasia on Pap smear. Seven had low grade squamous intraepithelial lesion and four had high grade squamous intraepithelial lesion. Out of the three 22

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Total = 9 (34.6%)

#TAH with BSO

2 (22.2%)

Removal of TO mass

7 (77.7%)

Radical Hysterectomy

1 (3.8%)

Radical Vulvectomy

2 (7.6%)

Lap chromopertubation

1 (3.8%)

#TAH with BSO = Total abdominal hysterectomy with bilateral salpingoophorectomy

Table 4. Complications following surgery (n=26). Complications

Number (%)

Fever

5 (19.2%)

Post-operative nausea and vomiting

4 (15.3%)

Wound infection Bleeding PV hysterectomy

2 (7.6%) following

1 (3.8 %)

DISCUSSION Though HIV positive women have the same gynecological problems as the non-infected women, often the gynecological problems take a backseat as the acute problems related to HIV infection get precedence. Apart from the usual gynecological problems as encountered in the HIV negative women, the seropositive woman may suffer from consequences

Goswami et al. HIV in Women

of the infection / antiretroviral treatment. Women with lack of access to high-quality HIV care and belonging to poor socioeconomic status are disproportionately affected by the HIV epidemic. Gender norms and, women to refuse unprotected sex, and can contribute to higher infection rates in women and delayed entry to care.4 It has also been reported that women may have a faster disease progression than men with equivalent viral loads and are more likely than men to develop bacterial pneumonia and may have higher rates of sexually transmitted diseases.5 HIV has been recognized as an independent risk factor for the development of cervical abnormalities. HIV positive women are more likely to be infected with multiple strains of oncogenic Human Papilloma Virus (HPV) genotype.6 The HPV viral load in their cervical secretions have been found to be higher and the HPV infection are more persistent among them. The reason for this is not yet fully understood, but it may be because clinical expression of HPV infection is dependent on systemic and local cell mediated immunity which are both suppressed in HIV infection.7 The likelihood of regression of cervical intraepithelial neoplasia is decreased in HIV positive women and there is more rapid progression to invasive carcinoma. The recurrence rate of cervical intraepithelial neoplasia following treatment is also higher in this subset of patients. In our study also, 11 women had cervical dysplasia on Pap smear. Seven had low grade squamous intraepithelial lesion, four had high grade squamous intraepithelial lesion and three had cervical carcinoma (Table 1). Abnormal uterine bleeding often encountered in seropositive women may have an array of causes. between high viral load, low CD4 counts and abnormalities of cycle length. A large study on HIV positive and high risk HIV negative women from the HIV Epidemiology and Research Study (HERS) and Women’s Interagency HIV Study (WIHS) declared that the serostatus had very little contribution in alteration of cycle length.8 Other studies by Harlow et al9 and Ellerbrock et al10 also do not show much of a difference in the cycle length of HIV positive women. However abnormality of menstruation may be attributable to some confounding variables like drug abuse, acute weight loss or chronic disease. Candidiasis is commonly associated with HIV infection as also seen in our study (Table 1). The infection tends to be more severe and persistent. Various studies have shown the association between

low CD4 count and increased preponderance of candidiasis thus indicating the role of immunosuppression.11 However, it is not clear whether antiretroviral therapy improves the infection. Recurrence is also quite common among this subset of women and they require long term therapy with weekly Fluconazole. seropositive women has been found to be higher than that in the non-infected population. We had the similar specimens Kerr et al12 found endometritis to be twice more common in HIV positive than in HIV negative women. Some of the studies even suggested that the course and clinical presentation of pelvic more severe.13 The association between vulvar carcinoma and HIV is not as strong as that of cervical carcinoma. We got two cases (Table 1), both were relatively young (one 32 years and the other 37 years) compared to the usual age of incidence of vulvar carcinoma (around 60 years). Casolati et al14 stated in their review of vulval neoplasia in HIV positive women, that in recent years increased prevalence and incidence of high grade vulval intraepithelial neoplasia and vulvar invasive carcinoma in young patients (below 45 years of age) have been reported. The main group of affected cases is represented by HIV infected women. The patients having HIV have multisystem involvement. Concurrently, anti-retroviral therapy has cardiac problems (myocarditis, cardiomyopathy, accelerated atherosclerosis) with protease inhibitors, respiratory opportunistic infections (bacterial pneumonias and aspergillosis), central nervous system involvement (encephalopathy, demyelinating syndromes, infection induced space occupying lesions, dementia among others), diarrhea along with associated electrolyte abnormalities, nephropathy (may be associated with protease inhibitors like adefovir and indinavir), pancytopenia (aggravated by nucleoside reverse transcriptase inhibitors (NRTIs), thrombotic episodes in late stages, metabolic problems (lipodystrophy, insulin resistance aggravated by protease inhibitors), lactic acidosis and pancreatitis with NRTIs, allergic reactions and hepatic involvement with non-nucleoside reverse transcriptase inhibitors (NNRTIs), apart from autonomic and peripheral neuropathy which are quite common in HIV positive patients.15 Oropharyngeal and esophageal pathology may make some patients

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Goswami et al. HIV in Women

aspiration.16 Protease inhibitors and non-nucleoside reverse transcriptase inhibitors are the most commonly implicated group of anti-retrovirals in drug interactions. The choice of anesthesia for these patients has to be a judicious one taking into account the physical status of the patient along with investigations like complete hemogram, CD4 counts, electrocardiogram, chest X ray, coagulation screen, electrolyte status and assessment of liver function and renal function in all patients. Both general and regional anesthesia has been given in women having HIV. Of central concern is the fact that under no situation should the patient stop the anti-retroviral therapy. General anesthesia is acceptable but drug interactions, multisystem involvement of the disease process and transient immune suppression should be considered. Regional anesthesia is safe but one must take into consideration the presence of local infections, bleeding problems and neuropathies.17 We have chosen to give subarachnoid block to most of our patients (Table 3). This is based on evidence to show that this technique is not detrimental to HIV infected patients except in cases where it is clearly contraindicated.14 Only concerns about adequate relaxation and longer duration of operative procedures prompted administration of general anesthesia. Though epidural anesthesia has been given in HIV patients, we avoided this techniqueas epidural catheters may act as a source of post-operative infection. A decade or two ago the point of addressing the issue of infertility in HIV positive couples was out of question. Even drastic steps like tubectomy were undertaken and advised to prevent the HIV infected women from getting pregnant as the life span of these individuals was thought to be limited and preventive measures against mother to child transmission of HIV were also not well outlined. But with the advent of Highly Active Antiretroviral Therapy (HAART)

of discordant couples who desire to have children without transmitting infection to their partners. In these cases the issues of advanced infertility treatment like donor intrauterine insemination and sperm washing need to be addressed. We are not far from the time when management of HIV infected couples will become an important problem, making its own niche in the domain of infertility. CONCLUSIONS HIV/AIDS has become such an entity since its inception into human race, that its killing power is much focused along with the stigma and discrimination that surround it. Often we forget the individual and start concentrating only on the HIV status and the symptoms associated with it, forgetting the fact that like any other individual they are also human beings who may require care for disorders pertaining to any system of the body which might not be related to the positive serostatus, one such area is the gynecological disorder in women. Every seropositive woman needs to be reviewed for her gynecological problems too. This is becoming essential with more and more women having longer life span due to the entry of more effective drugs into the armamentarium of antiretroviral therapy. REFERENCES 1.

UNAIDS Report on the Global AIDS Epidemic 2012. [cited 2013 July 19]. Available from http://www.unaids. org/en/resources/campaigns/20121120_global report 2012 / global report

2.

National AIDS Control Organization Annual Report 2011-2012. [cited 2013 July 19]. Available from http:// www.aidsdatahub.org/sites/default/files/ documents / NACO_Annual_Report _2011_12. pdf

3.

Talukdar A, Ghosal MK, Sanyal D, Talukdar PS, Guha P, Guha SK, et al. Determinants of quality of life in HIVinfected patients receiving highly active antiretroviral treatment at a medical college ART center in Kolkata, India. Journal of International Association of Providers of AIDS Care. 2013;12(4):284-90.

4.

Aziz M, Smith KY. Treating women with HIV: is it different than treating men? Curr HIV/AIDS Rep. 2012;9(2):171-8.

5.

Zorrilla CD. Antiretroviral combination therapy in HIV-1 infected women and men: are their responses different? Int J Fertile Womens Med. 2000;45(2):195-9.

of parent to child transmission the situation has changed. Infertility can be due to tubal blockage as to anovulation due to premature ovarian failure. One of the women in our study had undergone medical advised by medical practitioners to do so because of the chance of transmission to her newborn. She herself did not understand the fact that HIV is a lifelong disease and she wanted motherhood in future because of personal and social implications. She had bilateral tubal block. Down the years we are witnessing a share 24

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Goswami et al. HIV in Women 6.

Levi JE, Fernandes S, Tateno AF, Motta E, Lima LP, Eluf-Neto J, et al. Presence of multiple human papillomavirus types in cervical samples from HIV-infected women. Gynecol Oncol. 2004;92(1):225-31.

12.

7.

Sun XW, Kuhn L, Ellerbrock TV, Chiasson MA, Bush TJ, Wright TC Jr. Human papillomavirus infection in

13.

virus. N Engl J Med. 1997;337(19):1343-9. 8.

Zierler S, Mayer K, Moore J, Stein M, Schoenbaum E, Schuman P, et al. Sexual practices in a cohort of US

Kerr-Layton JA, Stamm CA, Peterson LS, McGregor JA. Chronic plasma cell endometritis in hysterectomy specimens of HIV-infected women: a retrospective analysis. Infect Dis Obstet Gynecol. 1998;6(4):186-90.

34. 14.

Casolati E, Agarossi A, Valieri M, Ferrazzi E. Vulvar neoplasia in HIV positive women: a review. Med Wieku Rozwoj. 2003;7(4 Pt 1):487-93.

virus. HIV Epidemiology Research Study. J Am Med Women’s Assoc. 1999;54(2):79-83.

15.

Hignett R, Fernando R. Anesthesia for the pregnant HIV patient. Anesthesiol Clin. 2008;26:127-43.

9.

Harlow SD, Schuman P, Cohen M, Ohmit SE. Effect of HIV infection on menstrual cycle length.J Acquir

16.

Parthasarathy S, Ravishankar M. HIV and anesthesia. Indian J Anaesth. 2007;51:91-9.

10.

Ellerbrock TV, Wright TC, Bush TJ, Dole P, Brudney K, Chiasson MA. Characteristics of menstruation in women infected with human immunodeficiency virus. Obstet Gynecol. 1996;87(6):1030-4.

17.

Avidan MS, Groves P, Blott N. Low complication rate associated with cesarean section under spinal anesthesia for HIV-1 infected women on antiretroviral therapy. Anesthesiology. 2002;97(2):320-4.

11.

Duerr A, Heilig CM, Meikle SF, Cu-Uvin S, Klein RS, Rompalo A, et al. Incident and persistent vulvovaginal infected women: risk factors and severity. Obstet Gynecol. 2003;101(3):548-56.

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ORIGINAL ARTICLE

Assessment of Pelvic Organ Prolapse by Pelvic Organ Prolapse Pradhan T, Regmi MC, Rai R, Bhatta R, Rijal P, Uprety DK

Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Dharan.

Aims: This was performed to examine pelvic organ prolapse using POP-Q technique and correlate pre-existing urinary symptoms with segments of pelvic organ prolapse. Methods: All patients admitted with pelvic organ prolapse were included. Patients were asked regarding any concomitant urinary symptoms and then all patients were examined by POP-Q technique and correlation of urinary symptoms was done with various segments of pelvic organ prolapse. Results: Eighty patients were studied in one year duration. Majority of patients had presented with stage 4 prolapse (58.8%). Majority of patients had urinary symptoms among which 87.5% had increased urinary frequency, 88.8% had dysuria, 65% had stress urinary incontinence (SUI), 72.5% had incomplete evacuation. Dysuria and SUI was

Conclusions

Keywords: pelvic organ prolapse, POP-Q, urinary symptoms.

INTRODUCTION Pelvicorgan prolapse (POP) is a bulge or protrusion of pelvic organs and their associated segments into or through the vagina. In Nepal, prevalence of pelvicorgan prolapse is high. It exceeds 10 percent of women in reproductive age group and 24 percent in women of age group between 45 to 49 years.1 Among women diagnosed with POP, 69.1 percent had second and third degree prolapse.2 Pelvic organ prolapse possesses major suffering in women’s life, psycho-socially, economically and physically. (POP-Q) was introduced by International Contintence CORRESPONDENCE Dr Tarun Pradhan Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Nepal. E-mail: [email protected] Phone: +977-9841305611 26

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anatomical landmark, minimizing inter-observer assessing patients during follow up.3,4 So far, few studies have been carried out studying pelvic oragn prolapse using POP-Q technique and correlation with urinary symptoms in Nepalese population. Annually, 100 or more patients with pelvic organ prolapse are assessed and operated in our department, so the demand of getting along with new system is This study attempted to measure all patients admitted with pelvic organ prolapse by POP-Q technique pre-operatively and stage the prolapse according to

The papers in this journal are published under the terms of the

Pradhan et al. Pelvic Organ Prolapse Assessment by POP-Q Technique

ordinal staging3 and also correlate the measurements with existing urinary symptoms. METHODS This was a descriptive study in patients who were admitted in Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences (BPKIHS). The study was conducted from 15th February 2009 to 15th February 2010 after getting for surgery with diagnosis of pelvic organ prolapse after taking informed consent were included. Patients for surgery; were excluded. Women were inquired regarding their urinary symptoms as per performa and were examined with sterile measuring metal scale calibrated in centimetres with sterile gloves, sterile sims speculum, and sterile volsellum. Patients were examined in dorsal position before and after evacuation of bladder. Demonstration of pelvic organ prolapse was done by Valsalva manoeuvre or by of prolapse were done using POP-Q technique, the measurements were then plotted in a three by three grid and ordinal staging was done. score is used to describe, quantify and stage pelvic

to +3 cm when a defect in the anterior vaginal wall is present. Ba is located most distally between Aa and C. In women with no defect in the anterior vaginal wall, Ba is also at -3 cm from the hymen. In women with a defect in the anterior vaginal wall, the value is between -3 cm and, in the most severe cases of 3 cm above the hymen on the posterior vaginal wall. The range of the measurement for the distance of Ap to the hymen during the Valsalva maneuver is -3 cm (normal) to +3 cm. Bp is located most distally between Ap and C. In women with no defect in the posterior vaginal wall, Bp is at -3 cm from the hymen. In women with a defect in the posterior vaginal wall, the value is between -3 cm and, in the most severe cases of prolapse, the entire TVL.The measurements were then recorded in a table so that comparisons could be made pre- and post-surgery. The data were analysed using SPSS. Median range was calculated for measurement obtained from POP-Q test were done for evaluating relation between urinary symptoms and various POP-Q measurements. RESULTS Eighty patients were included in the study and their demographic information at admission is as shown in Table1.

six different points in the vagina and the hymen, Valsalva maneuver. These six points are located above the hymen in women without a prolapse, and their distance from the hymen was measured negatively when they remain above the hymen during the maneuver. The distance was measured positively when the prolapse protrudes past the hymen, such that the points are located below the hymen, during the Valsalva maneuver. Of these six points two are located on the anterior vaginal wall (Aa and Ba), two are located onthe posterior vaginal wall (Ap and Bp), one is located at the anterior lip of the cervix or, in women who had a hysterectomy, at the vaginal cuff (C) and one is located in the posterior fornix inwomen who have not had a hysterectomy (D). The genital hiatus (Gh) and the perineal body (Pb) were also measured at rest and during the Valsalva maneuver. Total vaginal length (TVL), however, was only measured at rest. along the midline on the anterior vaginal wall. The range of the measurement for the distance of Aa to the hymen during the Valsalva maneuver is -3 cm (normal)

Table 1. Demographic information of the study population (n=80). Characteristics

Number (%)

Age (yrs)

Duration (yrs)

of

20-40

14 (17.5)

41-60

45 (56.3)

> 60

21 (26.3)

POP 1-10

53 (66.3)

Menopause Smoker Chronic cough Constipation Early resumption of work

11-20

14 (17.5)

> 20

13 (16.3)

Yes

59 (73.8)

No

21 (26.3)

Yes

19 (23.8)

No

61 (76.3)

Yes

15 (18.8)

No

65 (81.3)

Yes

10 (12.5)

No

70 (87.7)

Yes

54 (67.5)

No

26 (32.6)

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Majority of the patients were above 40 years of age and 73.8 percent were menopausal.The duration of prolapse was less than 10 years in 53 patients, of which 23.8 percent gave history of smoking and 18.8 percent gave historyof chronic cough. Interestingly, 67.5 percent of the patients had resumed house-hold activity with in one week post-partum. Table 2. Distribution of sites of prolapse segments outside the hymenby POP-Q measurements (n=80). POP-Q

Segment outside the hymen (%)

Aa

91.3

Ba

96.3

C

98.8

Ap

45.0

Bp

91.3

D

78.0

Table 4 shows distribution of stage of prolapse. Table 4. Distribution of ordinal staging of POP (n=80). Ordinal Stage

Number (%)

2

12 (15.0)

3

21 (26.3)

4

47 (58.8)

DISCUSSION In the study, all our patients were questioned verbally before examination regarding set of urinary symptoms. Majority had increased urinary frequency 70 out of 80 (87.5%), dysuria 71 of 80 (88.8%), SUI 52 of 80 (65%), incomplete evacuation 58 of 80 (72.5%), but comparatively small number of patients had symptoms of urinary retention 22 of 80 (27.5%) {Table 3}.

Table 2 shows distribution of POP-Q measurements, those found to beoutside the hymen. We categorised the POP-Q measurements in two: (a) when measurements are inside the hymen and (b) when measurements are outside the hymen. Majority of measurements showed segments outside the hymen and in addition anterior vaginal segments decent were more than posterior segment decent. Table 3. Correlation of urinary symptoms with various sites of POP as measured by POP-Q

Similar to our study, a study conducted by Marijke et al5 symptoms and POP-Q anatomical notations. Presence of urge incontinence was found to have anterior vaginal wall decent. They also concluded that anterior compartment prolapse was related with urge urinary incontinence and posterior compartment prolapse was related with bowel disorder. But our results differed from Bradley et al6 in which most

Ba

C

Ap

Bp

D

Increased 0.004* frequency

0.001* 1.0

0.125

1.0

1.0

0.680

bowel disorder, feeling of anal prolapse, manual evacuation of stool per vaginum and per anum. They also found that lower portion of anterior vaginal wall decent was associated with bladder pain and obstructive symptoms but with out urge incontinence.

Dysuria

0.002*

0.001*

0.113

1.0

0.581

0.676

obstructive urinary symptoms like retention of urine.

SUI

0.048*

0.040*

0.350

0.488

1.0

0.776

Incomplete evacuation

0.086

0.019

0.275

1.0

1.0

0.769

Retention 0.181 of urine

0.557

1.0

0.047*

0.667

1.0

Symptoms

Aa

Table 3 shows p-value of correlation of urinary symptoms with various measurements of pelvic organ prolapse by POP-Q technique. P- value less than 0.05

In this study, the stage of POP started from stage 2 to 4 as 15%, 26.3% and 58.8% respectively (Table 4). Most of the POP was of stage 4 with dysuria and with increasing stage of prolapse. In contrast to this study Marijke et al5 had no correlation with stages of prolapse with urinary symptoms but they had association with feeling of bulge or dragging sensation. In addition, Digesue et al7 showed poor correlation of urinary symptoms except for feeling of incomplete evacuation and need of straining during micturation with pelvic organ prolapse. But segment descent with bowel symptoms. In contrast, this study had very poor correlation with obstructive bowel symptoms. In study done by Swift et al8 also

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Pradhan et al. Pelvic Organ Prolapse Assessment by POP-Q Technique

women with pelvic organ prolapse with the leading edge of the prolapse beyond the hymenal remnants (some stage II and all stage III) had increased urinary symptoms.

4.

pelvic prolapse staging. J Med Life. 2011;4(1):75-81. 5.

Marijke C, Hove S, Annelies L, Goudzwaard P, Marinus JC, Regine PM, et al. The prevalence of pelvic organ prolapse symptoms and sign and their relation with bladder and bowel disorder in a general female population. Int Urogynecol J. 2009;20(9):1037-45.

6.

Bradley CS, Zimmerman MB, Wang Q, Nygaard IE. Vaginal

CONCLUSIONS POP-Q technique in assessment of pelvic organ was with less inter-observer variation. Anterior segment prolapse asmeasured by POP-Q technique symptoms. Therefore adoption of POP-Q technique in examination of pelvic organ prolapse marks step towards using new system approved and encouraged worldwide. REFERENCES 1.

2.

3.

Gurung G, Rana A, Amatya A, Bista KD, Joshi AB, Sayami J. Pelvic organ prolapse in rural Nepalese women of reproductive age groups: what makes it so common? N J Obstet Gyaecol. 2007;2(2):35-41. Dhital R, Otsuka K, Poudel KC, Yasuoka J, Dangal G, Jimba M. Improved quality of life after surgery for pelvic organ prolapse in Nepalese women. BMC Women’s Health. 2013;13:22. [cited 2013 December 10]. Available from http://www.biomedcentral.com/1472-6874/13/22. doi:10.1186/1472-6874-13-22 Bump RC, Mattiasson A. The standardization of terminology of female pelvic organ prolapse and pelvic

Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic

women: a longitudinal 111;1148-53.

study.

Obstet Gynecol. 2008;

7.

Digesu GA, Chaliha C, Salvatore S, Hutchings A, Khullar V. The relationship of vaginal prolapse severity to symptoms and quality of life. Int J Obstet Gynaecol. 2005;112:971-6.

8.

Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol. 2003;189:372-9.

9.

Zimmerman CW. Pelvic organ prolapse: basic principles. In: Rock JA, Jones HW, editors. Te-Linde’s Operative Gynaecology. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2008. p. 854-73.

10.

Richter HE, Varner RE. Pelvic organ prolapse. In: Berek JS, editor. Berek and Novak’s Gynecology. 14th ed. USA: Lippincott Williams and Wilkins;2007.p.897-934.

11.

Bonetti TR, Eepelding A, Pathak LR. Reproductive morbidity: a neglected issue? A report of a clinic based study held in far-western Nepal. Kathmandu, Nepal: Ministry of health, GTZ and UNFPA; 2002.

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NJOG 2013 Jul- Dec;8(2):30-33

ORIGINAL ARTICLE

Use of Oral Misoprostol for the Treatment of Incomplete Abortion Kayastha S,1 Tuladhar H,2 Gurung S,1 Jaishe S1 Department of Obstetrics and Gynaecology, Nepal Medical College Teaching Hospital Department of Obstetrics and Gynaecology, KIST Medical College Teaching Hospital, Nepal.

1 2

Aims: This study was done to assess the feasibility and acceptability of use of Misoprostol 600 mcg orally for treatment of incomplete abortion. Methods: A hospital based prospective study was carried out in the Department of Obstetrics and Gynaecology of Nepal Medical College Teaching Hospital from 1st November 2010 to 30th abortion diagnosed clinically or by ultrasonogram were included in the study. They were given 600 mcg of Misoprostol orally. They were sent home, with advice to come for follow up after one week. Routine Ultrasound was carried out on recorded. Results: Out of 86 patients, 8.1% (7) had to undergo surgical evacuation. So the success rate was 91.9% (79 cases). All the cases which needed evacuation were of higher gestation, that is, nine weeks or more. The commonest side effect was severe abdominal pain (81.4%). Three cases required emergency surgical evacuation within 24 hours due heavy bleeding. Conclusions: It is feasible and acceptable to use Misoprostol orally for medical evacuation, especially in earlier gestation

Keywords: incomplete abortion, misoprostol, side effects, success.

INTRODUCTION Manual vacuum aspiration (MVA) is the effective treatment of incomplete abortion. But it requires specialized equipment and skill and risk of complications like cervical trauma, uterine perforation, infections are there. Some studies have shown that expectant management is effective in most of the cases of incomplete abortion.1,2 But it is not feasible for those patients who stay far away from health facilities. Expectant management is also associated with infection (3%) and required emergency evacuation in 7% of the cases.3 Many studies4-6 have indicated that the uterotonic properties

CORRESPONDENCE Dr Sanita Kayastha Department of Obstetrics and Gynecology, Nepal Medical College Teaching Hospital, Kathmandu, Nepal. Email: [email protected] Phone: +977-98510891893 30

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of the PGE1(Misoprostol) make it a safe and highly effective method of evacuating the uterus in cases of incomplete abortion. Some studies were conducted with multiple oral doses of Misoprostol.7,8 There were also studies where Misoprostol was used vaginally for treating incomplete abortion with similar success rate,9,10 but women may feel vaginal route less acceptable than oral route and the chance of introduction of infection may increase. Hence this study was conducted to assess the feasibility, acceptability and success of using oral Misoprostol 600 mcg as medical evacuation for incomplete

The papers in this journal are published under the terms of the

Kayastha et al. Misoprostol for Incomplete Abortion

METHODS It was a hospital-based study carried out from 1st November 2010 to 30th May 2013 in Nepal Medical College Teaching Hospital. All cases of incomplete abortion diagnosed clinically or by ultrasound were included. Those patients who had incomplete abortion of gestation weeks 12 or less with stable vital signs, without anaemia and history of Misoprostol allergy were included in the study. Informed written consent was taken. Then patients were given tablet Misoprostol 600 mcg orally. They were observed for three hours for side effects, per vaginal bleeding and expulsion of product of conception. Then they were sent home with advice for follow up after one week. They were given prophylactic antibiotics. Painkiller was prescribed as per need for pain management. Routine ultrasound was carried out during follow evacuation was complete, the patient was released from the study but if not then the woman was offered the choice between additional follow up visit in one week or immediate surgical evacuation. During follow up, the amount of blood loss, side effects of the drug, whether tolerable or not and level of satisfaction were inquired. All the data were recorded and statistical analysis was done. RESULTS There were total 86 patients enrolled in the study during the period of two and half years. Out of which 56 (65.1%) were of spontaneous abortion and 30 (34.9%) were of induced abortion. The age ranged from 18 to 35 years. The gestational age ranged from 5 to 12 weeks (Table 1). Table 1. Relation of gestation age and medical evacuation (n=86). Gestational age

Failure of complete evacuation

7 to 8 weeks

1 (1.2%)

9 to 12 weeks

6 (6.98%)

Among the 86 patients, only 7 (8.1%) had to undergo surgical evacuation. So the success rate was 91.9% (79). Among the failed cases, all were of 9 weeks or more gestation (Table 1). Regarding side effects of the medication, almost half of the patients had nausea 48 (55.8%), 70 (81.4%) patients had pain in abdomen, 11 (12.8%) had diarrhea, 13 (15.1%) had fever with chills and rigor (Table 2). Table 2. Side effects of Misoprostol (n=86). Side effects

Number (%)

Nausea

48 (55.81%)

Vomiting

12 (13.95%)

Abdominal pain

70 (81.40%)

Diarrhoea

11 (12.79%)

Fever with chills

13 (15.12%)

Heavy bleeding occurred in 10 (11.6%) patients (Table 3). Three patients required emergency surgical evacuation within 24 hours due to heavy bleeding. One (1.1%) case had prolonged and excessive bleeding which lasted for two weeks. There were two cases of prolonged lower abdominal pain, one case of Over all, the satisfaction level of the patients was

Table 3. Complications of medical evacuation (n=86). Complications

Number (%)

Heavy bleeding

10 (11.63%)

Prolonged bleeding

8 (9.30%)

Prolonged abdominal pain

1 (1.16%)

Infection

1 (1.16%)

Anaemia

1 (1.16%)

DISCUSSION The use of Misoprostol for medical evacuation is an effective method as shown by this study, with a high success rate of 91.9% (Table 1). The success rate seems to be a bit lower as compared to other studies which used the same regime of Misoprostol11,12 where it was 99% and 94.5%. The higher failure rate in our study may be due to use of routine ultrasound in the NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

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Kayastha et al. Misoprostol for Incomplete Abortion

CONCLUSIONS The success was more in earlier gestation. In another study similar results were reported with the success rate of 100% in 6 weeks or less, 86.3% in 7 to 9 weeks and 87% in 10 to 12 weeks.13 Tang et al14 reported the commonest side effect of Misoprostol to be diarrhea. In our study, although the side effects were common; they were reported to be tolerable and acceptable by the patients (Table 2). The commonest was pain in abdomen 70 (81.4%). The simplicity of use, fast action, non-invasiveness and cost effectiveness of the medical evacuation outweighed the side effects. There was only one case of infection. The less number of infections may be due to use of routine antibiotics for all patients and exclusion of already infected cases. Shannon et al15 reported that the rate of infection was only 0.9% and none in the study done by Gurung et al.13 One case of anaemia with prolonged bleeding came to hospital only on the 17th day with heavy bleeding and required three pints of blood transfusion and there were three cases of surgical evacuation done within 24 hours due to excessive bleeding (Table 3). So medical evacuation should be used in selected cases who stay close to health facility with proper set up, where emergency surgical evacuation can be done specially for those cases with higher gestation. As regarding patient satisfaction 82.6% higher than in the study done by Gurung et al (64.2%) and lower than the study done by Sajuna et al (88%) 16 and 86.6% in Ninimak et al.17 In a poor country like ours where surgical evacuation facilities are limited due to lack of skilled surgical providers and equipment, the use of just three tablets of Misoprostol given orally by health providers can be life saving and help us in reducing the maternal mortality. But larger studies need to be carried out in rural set-ups, especially where ultrasound facility is not available to see the feasibility of medical evacuation. Although Misoprostol is a very effective drug, thorough knowledge of the dosage, side effects, complications and contraindications should be given to health personnels who prescribe it. 32

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NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

Misoprostol 600 mcg given orally has been shown to be an acceptable, effective and safe method of medical management in early gestation incomplete abortion. Use in higher gestation increases risk of bleeding and need for surgical evacuation. Misoprostol 600 mcg was associated with minor side effects that were tolerable by the patients. REFERENCES

1.

Chipchase J, James D. Randomised trial of expectant versus surgical management of spontaeneous miscarriage. Br J Obstet Gynaecol. 1997;104:840-1.

2. trimester spontaeneous abortion. Lancet. 1995;345:84-6. 3. spontaneous abortion. Lancet. 1995;345:1179-80. 4.

Trinder J, Brocklehurst P, Porter R, Read M,Vyas S, Smith L. Management of miscarriage: expectant, medical or surgical? Results of randomized controlled trial{miscarriage treatment (MIST) trial}. Br J Obstet Gynecol. 2006;332:1235-8.

5.

Moodliar S, Bagrattee JS, Moodly J. Medical vs surgical Gynaecol Obstet. 2005;353:761-9.

6.

Ngoc NTN, Blum J, Durocher J, Quan TTV, Winkoff B. Medical Management of incomplete abortion using 600 versus 1200 mcg of misoprostol. Contraception. 2005;72:438-42.

7.

Pandian Z, Asok P, Templeton A. The treatment of miscarriage with oral misoprstol. Br J Obstet Gynaecol. 2001;108:213-4.

8.

Pang MW, Lee TS, Chung TK. Incomplete miscarriage: a randomized controlled trial comparing orally with vaginal misoprostol for medical evacuation. Hum Reprod. 2001;16:2283-7.

9.

Ngai SW, Chn YM, Tang OS, Ho PC. Vaginal misoprostol as Hum Reprod. 2001;16:1493-6.

10.

Sahin HG, Sahin HA, Kocer M. Randomised outpatient clinical trial of medical evacuation and surgical curettage in incomplete miscarriage. Eur J Contrcpt Reprod Health Care. 2001;6:141-4.

Kayastha et al. Misoprostol for Incomplete Abortion 11.

12.

13.

Shwekerela B, Kalumuna R, Kipingili R, Mashaka N, Westhimer E, Clark W, et al. Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania. Br J Obstet Gynaecol. 2007;114:1363-7. Doa B, Blum J, Thieba B, Raghavan S, Quedraego M, Lankoande J, et al. Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomized trial in Burkina Faso, West Africa. Br J Obstet Gynaecol. 2007;114:1368-75. Gurung G, Rana A, Baral J. Use of Misoprostol in the management of early pregnancy loss. Nepal J Obstet Gynaecol. 2012;7:9-13.

14.

Tang OS, Germzeill-Danielsson K, Ho PC. Misoprostol: Int J Gynaecol Obstet. 2007;99:5160-7.

15.

Shannon C, Brothers LP, Phillip NM, Winikoff B. Infection after medical abortion: a review of the literature. Contraceptive. 2004;70(3):183-90.

16. pregnancy failure. Al Ameen J Med Sci. 2010;3(3):195-200. 17.

Ninimaki M, Jouppila P, Martikainen H, Talvensaari-Matilla satisfaction in medical or surgical treatment of miscarriage. Fertil Steril. 2006;86(2):367-72.

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NJOG 2013 Jul- Dec;8(2):34-37

ORIGINAL ARTICLE

Comparative Study of Rectal Misoprostol to Oxytocin Infusion in Preventing Postpartum Haemorrhage After Caesarean Section Adanikin AI,1 Orji E,1 Adanikin PO,2 Olaniyan O1 Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospitals Complex, IleIfe, Nigeria 2 Health Centre, Obafemi Awolowo University, Ile-Ife, Nigeria. 1

Aims: primary postpartum haemorrhage after caesarean section. Methods: caesarean section were randomized to receive 600 µg rectal misoprostol and a placebo infusion intravenously or placebo rectally and a 20 iu oxytocin infusion. Post-operative blood loss four hours after surgery was estimated by application of pads of known weight. Results: misoprostol and oxytocin infusion group (100.08 ± 24.85 ml versus 108.20 ± 29.93 ml; p =0.144) and the change between the pre-operative and post-operative hematocrit was similar. Conclusions: post-partum haemorrhage. It is recommended for use as alternative uterotonic in settings where there is low refrigeration capacity. Keywords: caesarean section, misoprostol, oxytocin infusion, postpartum haemorrhage.

INTRODUCTION Misoprostol is a synthetic prostaglandin E1 analogue originally marketed for treatment/prevention of nonulcer.1 However, due to its uterotonic properties, it has gained wide use for labour induction2,3 and induction of abortion.4,5 Over the years, there has been expanding interest in the use of misoprostol toprevent and manage postpartum haemorrhage.6-8 With the World Health Organization (WHO) enlisting it as essential medicine for primary postpartum hemorrhage (PPH) in 2011,9 body of research is growing on the effectiveness and safety for this purpose. CORRESPONDENCE Dr Abiodun Idowu Adanikin Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria. Email: [email protected] Phone: +234 803 4252126 34

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After caesarean section, uterotonic in form of oxytocin infusion (20-40 iu) or rectal misoprostol for the succeeding 4-6 hours post-surgery in patients at risk of PPH.10-12 Although this practise is popular in our environment, objective comparative assessment of both measures is lacking; this study therefore made the comparison. METHODS This study was conducted at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria between August 1 and October 31, 2011. The Ethics Review Committee of the hospital approved the study

The papers in this journal are published under the terms of the

Adanikin et al. Rectal Misoprostol Versus Oxytocin in Preventing PPH

protocol. The primary outcome variable of the study was four-hour post-operative blood loss. Sample size In a study by Owonikoko et al13 comparing sublingual misoprostol with oxytocin infusion in reducing blood loss after caesarean section, they reported a mean 4 hour post-operative blood loss of 58.2 ± 20.7 ml for the misoprostol group and 80.5 ± 26.8 ml for the oxytocin infusion group. These data were used to calculate the study sample size via a formula derived by Kirkwood and Steme.14 Sample size of 50 (25 in each group) would have 90% power to detect a clinically important difference of 20.7 ml for the misoprostol group versus 26.8 ml for the oxytocin infusion group as observed by Owonikoko et al.13 Fifty women who were scheduled to undergo primary postpartum haemorrhage such as prolonged labour, obstructed labour, grand-multiparity, multiple gestations, polyhydraminous were enrolled for the study after written informed consent. Asthmatics or patients with hypersensitivity to prostaglandins were excluded. Study procedure By 1:1 computer-generated randomization, participants were assigned to their group while the pharmacy department provided the study drugs

normal saline solution, or identical placebo tablets iu of oxytocin. A resident doctor was responsible for the patient’s allocation according to randomisation table. The patients and the outcome assessor were blinded to the study medications. In accordance to the randomisation, after cord clamping participants infusion of 500 ml of 5% dextrose saline solution supplemented with placebo over 4 hours, or a rectal placebo plus an infusion of 500 ml of 5% dextrose saline solution supplemented with 20 iu of oxytocin over four hours. Additional administration of uterotonics was allowed in cases of bleeding in excess of 500 ml within the four-hour period, but no patient needed it.

Figure 1. Diagram of detailed study design. Calculation of blood loss Immediate blood loss up till four hours post-partum was measured by the application of pads of known weight to the perineum. These pads were weighed four hours post-partum, and the blood loss estimated from 15,16 The instrument used to weigh the pads was a MettlerPB153 weighing scale, which had a sensitivity of 0.001 gm. The scale was calibrated prior to weighing as well as during weighing of large numbers of products. The instrument was evaluated as stable; inter-weigher reliability was 0.98. The used pads were weighed in triplicate and the mean of the three weights were entered into the database. Haematocrit was checked before and two days after surgery. Statistical analysis Data were analyzed using the computer soft ware SPSS version 15. Frequency tables were generated. Association between continuous variables was tested using the student t-test while Chi square or Fisher’s exact test was used to test association between set at 0.05.

RESULTS Fifty women who met the inclusion criteria were enrolled and randomized into either misoprostol or oxytocin infusion group (Figure 1). NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

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Adanikin et al. Rectal Misoprostol Versus Oxytocin in Preventing PPH

Table 1. Baseline characteristics of participants (n=50). Variables

Misoprostol Oxytocin group group (n=25) (n=25)

Odd ratio

95%

P-value

Age (years)

30.6 ± 6.33

30.84 ± 5.69

0.671

GA (weeks)

39.03 ± 1.62

39.07 ± 1.26

0.853

Parity

1.88 ± 1.42

1.76 ± 1.09

0.726

Prolonged labour

8 (32)

7 (28)

1.00

Obstructed labour

1 (4)

4 (8)

4.57

0.51- 40.90

0.194

Multiple pregnancy

4 (16)

2 (8)

0.57

0.09- 3.57

0.577

Grand multiparity

4 (16)

2 (8)

0.57

0.09- 3.57

0.577

Fetal macrosomia

5 (20)

3 (12)

0.69

0.13- 3.60

0.673

Failed Induction

2 (8)

4 (16)

2.29

0.37-14.30

0.407

Others

1 (4)

3 (12)

3.43

0.38- 30.68

0.313

Spinal

20 (80)

22 (88)

1.00

General

5 (20)

3 (12)

0.55

0.13-2.36

0.440

Indications for C/S, n(%):

Type of Anaesthesia, n (%):

Duration of surgery (mins) 54.72±9.51 54.80 ± 8.77 0.974 Data presented as: mean ± standard deviation; n (%). There was no difference in occurrence of shivering (p C/S: Caesarean section.

Table 1 shows that the participants in both groups did

= 0.999), pyrexia (P= 0.667), nausea (p =0.999) and vomiting (p =0.999).

delivery, parity, indication for caesarean section, type of anaesthesia and mean duration of surgery.

DISCUSSION

Table 2. Operative outcome in both groups (n=50). Variables

Misoprostol Oxytocin P-value group infusion

Pre-operative hematocrit (%)

34.68 ± 3.67

Post operative hematocrit (%)

33.12 ± 3.77

4 hours post 100.8 ±24.8 operative EBL (ml)

34.24± 3.09

0.577

32.52± 3.54

0.436

108.20± 29.93

0.144

The mean immediate four hours post-operative blood studied. No patient had bleeding in excess of 500 ml to warrant additional uterotonic. This outcome conclusion by Nasr et al6 that rectal misoprostol was effective in reducing blood loss after delivery. Lapaire et al17 who compared oral misoprostol with oxytocin infusion post-caesarean section and found 13

Side effects: Shivering, n (%) 1(4)

2(8)

>0.999

Pyrexia, n (%)

2(8)

0.667

4(16)

Nausea, n (%)

2(8)

1(4)

>0.999

Vomiting, n (%)

2(8)

2(8)

>0.999

Data presented as: mean ± standard deviation; n (%). Abbreviations: EBL, estimated blood loss.

difference in pre-operative and post-operative hematocrit. The mean four hours post-operative two groups (100.08 ± 24.85 ml versus108.20 ± 29.93 ml; p =0.144). 36

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NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

to oxytocin infusion after caesarean section but with Side effect of misoprostol was not prominent in this study. Rectal misoprostol is known to have a steady serum rise with lower peak serum concentration and longer half life.18,19 This may account for the low effect of prolonging uterine contraction preventing a delayed haemorrhage.19,20

and

Post-surgery, other routes of administration of

Adanikin et al. Rectal Misoprostol Versus Oxytocin in Preventing PPH

misoprostol may not be favoured. There is likelihood that the surgeon may want patient to avoid immediate

8.

Jadesimi A, Okonofua FE. Tackling the unacceptable: Nigeria approves misoprostol for postpartum haemorrhage.J Fam Plan Reprod Health Care. 2006;32(4):213-4.

away vaginal misoprostol. Rectal administration is therefore an appropriate route. In tropical developing countries, tendency of oxytocin losing potency is high as proper refrigeration capability is low. Because of this, there are occasions where post-partum haemorrhage ensues despite the use of oxytocin. Misoprostol on the other hand, is stable in tropical climate while still maintaining its potency.21

9.

Medicines. 17th ed. [cited 30 March 2011]. Available from http:// www.who.int/medicines/publications/Essential medicines/en 10.

controlled trial. J Gynecol Obstet Biol Reprod. 2009;38(7):58893. 11.

This study showed that misoprostol was as effective as oxytocin infusion in preventing PPH. Misoprostol can serve as alternative to oxytocin in tropical climates with little capability for refrigeration for prevention of post-partum haemorrhage. Authors recommend further studies on this subject.

Eftekhari N, Doroodian M, Lashkarizadeh R. The effect of sublingual misoprostol versus intravenous oxytocin in reducing bleeding after caesarean section. J Obstet Gynaecol. 2009;29(7):633-6.

12.

Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30-3.

REFERENCES Monk JP, Clissold SP. Misoprostol: a preliminary review of

13.

Owonikoko KM, Arowojolu AO, Okunlola MA. J Obstet Gynecol Res. 2011;37(7):715-21.

its pharmacodynamic and pharmacokinetic properties, and 14. Drugs. 1987;33:1-30. 2.

Fekih M, Jnifene A, Fathallah K, Ben Regaya L, Memmi A, post-partum hemorrhage in caesarean section: a randomized

CONCLUSIONS

1.

World Health Organization. WHO Model Lists of Essential

Kirkwood BR, Sterne JAC, editors. Essential medical statistics. 2nd ed. Massachusetts: Blackwell Science Ltd; 2003.

Kulier R, Gulmezoglu AM, Hofmeyr GJ, Cheng LN, Campana A.

15.

per measure of perimenopausal menstrual blood loss. Womens

Syst Rev. 2004;(2):CD002855. 3.

Health Issues. 2004;14:242-7.

Fawole AO, Adegbola O, Adeyemi AS, Oladapo OT, Alao MO.

16.

Misoprostol for induction of labour: a survey of attitude and

Schorn MN. Measurement of blood loss: review of the literature. J Midwifery Womens Health. 2010;55:20-7.

practice in southwestern Nigeria. Arch Gynecol Obstet. 2008; 17.

278(4):353-8.

Lapaire O, Schneider MC, Stotz M, Surbek DV, Holzgreve W, Hoesli IM. Oral misoprostol vs. intravenous oxytocin in reduc-

4.

Neilson JP, Hickey M, Vazquez J. Medical treatment for early

ing blood loss after emergency caesarean delivery. Int J Gynaecol

fetal death (less than 24 weeks). Cochrane Database Syst Rev.

Obstet. 2006;95:2-7.

2006;19(3):CD002253. 18. 5.

O’Brien P, El-Refaey H, Gordon A, Geary M, Rodeck CH.

Menakaya U, Otoide V, Omo Aghoja L, Odunsi K, Okonofua

Rectally administerted misoprostol for the treatment of post-

F. Experience with misoprostol in the management of

partum haemorrhage unresponsive to oxytocin and ergometrine:

missed abortion in the second trimester. J Obstet Gynaecol.

a descriptive study. Obstet Gynecol. 1998;92(2):212-4.

2005;25(6):583-5. 19. 6.

Khan RU, El-Refaey H. Pharmacokinetics and adverse-effect

Nasr A, Shahin AY, Elsamman AM, Zakherah MS, Shaaban OM. Rectal misoprostol versus intravenous oxytocin for prevention of postpartum hemorrhage. Int

labor. Obstet Gynecol. 2003;101:968-74.

J Gynaecol Obstet.

2009;105(3):244-7.

20.

Zieman M, Fong SK, Benowitz NL, Banskter D, Darney PD. Absorption kinetics of misoprostol with oral and vaginal

7.

Enakpene CA, Morhason-Bello IO, Enakpene EO, Arowojolu

administration. Obstet Gynecol. 1997;90:88-92.

AO, Omigbodun AO. Oral misoprostol for the prevention of primary post-partum hemorrhage during third stage of labor. J Obstet Gynaecol Res. 2007;33(6):810-7.

21.

Tang OS, Schweer H, Seyberth HW, Lee SW, Ho PC. Pharmacokinetics of different routes of administration of misoprostol. Hum Reprod. 2002;17:332-6.

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ORIGINAL ARTICLE

Severe Acute Maternal Morbidity and Intensive Care in Paropakar Maternity and Women’s Hospital Upadhyaya I, Chaudhary P Department of Obstetrics and Gynaecology, Paropakar Maternity and Womens Hospital, Thapathali. Aims: Maternal morbidity occurs due to complications arising in pregnancy or within 42 days of delivery. Women with those women requiring intensive care. Methods: A study was conducted at Paropakar Maternity and Women’s Hospital in which records of patients admitted in Maternal Intensive Care Unit (MICU) were evaluated for demographics, disease responsible for critical illness, complications that prompted MICU admissions, interventions required, length of MICU stay and resulting maternal morbidity and mortality. Results: Over the study period, 159 obstetric patients were transferred to MICU, representing 2.23% of 7109 deliveries. Hypertensive disorders of pregnancy (50%) and postpartum haemorrhage (14.46 %) were the two major obstetrical conditions responsible admission into MICU. Conclusions: Auditing of severe maternal morbidity will improve the quality of obstetric care and decrease the incidence of maternal morbidity and maternal mortality. Keywords: maternal intensive care unit, pregnancy complications, severe maternal morbidity.

INTRODUCTION

METHODS

Severe maternal morbidity emerges as a new quality indicator of obstetrical care. WHO describes it as near-death but survival from complications which occurred during pregnancy, childbirth or within 42 days of termination of pregnancy.1,2 Each year nearly 5,29,000 women die globally due to pregnancy causes. For each death, nearly 118 women suffer from life threatening events.3

This was a cross-sectional study conducted at Paropakar Maternity and Women’s Hospital

In Nepal, maternal mortality has decreased from 539/100000 live births in 1998 to 229 in 2008/2009.4 Exploration of severe maternal morbidity is required services. The obstetrics morbidity results from obstetric complications of pregnancy, labour and puerperium. The recognition of signs, symptoms and severity of illness, antenatal and postnatal care seeking are associated with maternal mortality and morbidity.5 This study aimed to explore the case series requiring maternal intensive care.

critically ill obstetrics patients who were transferred to Maternal Intensive Care Unit (MICU) from 3 April 2011 to 13 July 2011 were enrolled in the study. Research was conducted after ethical approval from hospital authority and written consent from patients and relatives. All data were analyzed manually and with the help of software excel and statistical analyses were done accordingly. RESULTS Over the study period, 159 obstetrics patients were transferred to MICU representing 2.23% of 7109 deliveries. The mean duration of stay at MICU was 2.6 days with standard deviation of 1.84 days.

CORRESPONDENCE

Dr Indira Upadhyaya Department of Obstetrics and Gynaecology, Paropakar Maternity and Womens Hospital, Thapathali, Nepal. Email: drindira @hotmail.com Phone: +977-9851074598 38

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Upadhyaya et al. Severe Acute Maternal Morbidity and Intensive Care Table 1. Obstetrical characteristics of the patients(n=159). Gestational age (weeks)

Number (%)

< 13

22

(13.18)

13 - 27

8

(5.03)

89

(55.97)

40

(25.16)

0

63

(39.62)

1-2

78

(49.06)

Postpartum Parity

3-4

14

(8.80)

4

(2.52)

Booking status Booked in PMWH Unbooked in PMWH

59

(37.11)

100

(62.89)

Table 1 outlines the obstetrical characteristics of the patients. Majority of the patients (55.97%) were at gestation, 5.03 % at 13-27 weeks of gestation and 25.16% were postpartum cases. Regarding parity, 39.62 % were nulliparous and majority of them were para 1 to 2 (49.06%). Table 2. Diseases responsible for illness (n=159). Hypertensive disorders in pregnancy

Number (%)

PIH

18 (11.32)

Severe Pre-Eclampsia (PE)

43 (27.04)

Superimposed PE

3 (1.89)

Table 2 shows the diseases responsible for maternal illnesses. Hypertensive disorder of pregnancy was the leading cause of maternal illness, responsible for >50% of all MICU admissions. Forty-three (27%) were of severe pre-eclampsia while 16 (10%) were of eclampsia. In this study renal failure was the major complication of severe pre-eclampsia for which four cases were referred to specialised hospitals. The second most common diagnosis was obstetric haemorrhage leading to MICU transfer in 23 (14.5%) cases. Causes of haemorrhage included uterine atony (eleven from twenty cases of PPH), retained placental tissue (nine cases) and genital tract injury (one case following vacuum delivery). Caesarean hysterectomy and sub-total hysterectomy were performed in two cases to controlled intractable haemorrhage. In this study 17 (10.7%) women had puerperal sepsis (six hospital and 11 home delivery), of which manual removal of placenta were done in seven cases and two had explorations for retained placental tissues. Medical disorders responsible for obstetric ICU admission included gestational diabetes mellitus, heart disease, cardiomyopathy, postpartum psychosis and UTI constituting 7.5% of the total MICU admission. Sixty-one (38.3%) of the cases admitted in MICU were for intensive monitoring of the patient with severe morbidity (Table 3).

Number (%) 2

(1.26)

Vasoactive infusion

8

(5.03)

Intensive monitoring

61

(38.36)

Obstetrical Haemorrhage

Blood transfusion

52

(32.71)

Early pregnancy

Magnisium sulphate therapy

36

(22.64)

Eclampsia

16 (10.06)

Puerperial sepsis

17 (10.69)

Ectopic pregnancy

9 (5.66)

Abortion

7 (4.40)

H. Mole

2 (1.26)

Late pregnancy Placenta praevia

6 (3.77)

Rupture uterus

3 (1.89)

Postpartum haemorrhage Primary PPH Secondary PPH

20 (12.58) 3 (1.89)

Others Chest infection

2 (1.26)

UTI

2 (1.26)

GDM

2 (1.26)

Heart disease

2 (1.26)

Cardiomyopathy

2 (1.26)

Epilepsy

1 (0.63)

Postpartum psychosis

1 (0.63)

Mechanical ventilation

The patients who received magnesium sulphate therapy for eclampsia and pre-eclampsia constituted 22.6%. Vasoactive drugs infusion was performed in eight cases, two with postpartum haemorrhage, incomplete abortion in shock. There were two maternal deaths (2.5%), which were because of sudden postpartum collapse of a patient in whom induction of labor with Misoprostol was done and another was a case of severe pre-eclampsia resulting into pulmonary oedema. Postmortem was not done so the actual cause of death could not be revealed. DISCUSSION Critical incidence audit and feedback are recommended interventions to improve the quality of obstetrics care. This concept is relatively new in maternal care, but it is increasingly becoming important in areas with low maternal mortality ratios NJOG I VOL. 8 I NO. 2 I ISSUE 16 I Jul-Dec, 2013

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Upadhyaya et al. Severe Acute Maternal Morbidity and Intensive Care

and where the geographic area is small. This has the advantage of events still being rare enough not to overload clinicians and data capturing personnel within the facility.5,6 In our study, 159 patients were transfered to MICU, representing 2.23% of 7109 deliveries corresponding to 1.34 to 1.4% of other developing countries’ reports. However, this rate seems to be high as 0.17 to 0.26% are documented from developed world.3 In a study from Ibadan et al, 1.4% of deliveries required ICU admission during a 7 Serious forms of maternal morbidity occur in about 1% of women in the United States in contrast to 3.01- 9.05% in some developing settings8 as in this current study. Worldwide, the leading causes of severe morbidity are haemorrhage and pregnancy related hypertensions or eclampsia/pre-eclampsia (PE).8 This study showed that the leading cause of maternal morbidity causing intensive care unit admission were severe pre-eclampsia, haemorrhage, pregnancy induced hypertension (PIH), sepsis and eclampsia 27.04%, 14.47%, 11.32%, 10.69% and 10.06% respectively. Similar results were reported in the European population based study by the MOMS-B survey.9 Studies from India showed maternal morbidity leading to transfer to ICU were pre-eclampsia (35%), haemorrhage (35%) and sepsis (13%) and other medical conditions (11%).10,11 The rates of sepsis and other medical conditions are comparable to our study (Table 2). According to Pakistan reproductive health and family planning survey,9 59.5% of rural women did not receive prenatal care and 86.5% delivered at home by untrained attendants; as in our country. These untrained birth attendants do not follow clean and safe delivery rules and are unable to predict and handle pregnancy complications. Shortage of beds in hospital especially in MICU and lack of high dependency units in obstetric departments are responsible for high morbidity and mortality too.3 It is estimated that 5-10% of pregnancies are complicated due to pre-eclampsia. The attending maternal mortality is very high. In developed countries with better facilities and improved antenatal care, the of the conditions such as acute renal failure and intracranial haemorrhage are usually the causes of the major complication of the severe pre-eclampsia causing four cases to be refered to other hospitals in our study. Therefore, an antenatal service with aggressive management of pre-eclampsia particularly in labour is to be encouraged. The provision of an elaborate and intensive care unit for eclamptic patients especially in certain designated areas of labor suites with excellent nursing care would be helpful. In this study eclampsia was the third commonest 40

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indication for admission in the MICU among hypertensive disorders in pregnancy (Table 2). This 8-11

Magnesium sulphate has been used for more than 10 years in our hospital. Magnesium Sulphate is an evidence-based protocol for treating eclampsia.6,7 The reasons for persistently high maternal morbidity due to sepsis is multi-factorial like home deliveries by unskilled birth attendants in unhygienic conditions, late referral to hospital, low socio economic conditions, prolonged and neglected labor, induced miscarriage and illiteracy. A total of 32 (20.13%) obstetrical haemorrhages were studied. There were 23 (14.47%) women with postpartum haemorrhage which represented 20 cases of primary and three were secondary postpartum haemorrhage, among them nine cases (5.66%) were transferred to ICU with the diagnosis of placenta previa in six (3.77%) and (1.89%) rupture uterus in three (Table 1). Initially post-partum haemorrhages were managed conservatively: uterine massage, use of oxytocis. Intra uterine balloon catheter (condom tamponade) were used in two patients (8.69%) which correlates to the results (9.7%) of a study by Zwart et al in 154 women.12 Re-laparotomy was performed in one patient (4.35%) for hemoperitoneum following caesarean section. B-Lynch suture was applied in one case (4.35%) for uterine atony. Most of the women who developed post-partum haemorrhage due to uterine atony were of severe pre-eclampsia. Scarcity of blood was a big hurdle in the timely intervention and provision of free and safe blood banking services round the clock at tertiary care hospitals like ours is likely to yield better outcomes.3 Haemorrhage is reported to be the leading cause of maternal death in Japan and Europe as a whole and the third most common cause of death in the United States.6 Another study2 reported the rate of major obstetrical haemorrhage as 4.5 per 1000 deliveries, whereas it was 3.23 per 1000 deliveries in our study. Admission to MICU was 14.47% in our study compared to 27% for major obstetrical haemorrhage in the abovementioned study. There were three women with uterine rupture (with incidence of 2%) during the study period (Table 2) and is comparable to the result of a study contributing 1 to 3%.3 No cases of pregnancy related death due to uterine rupture occurred. Causes of rupture uterus included use of prostaglandin in primipara for labor induction, another one was a case of previous caesarean section done for fetal distress that was kept for vaginal birth after caesarean section and one case had silent rupture of previous transverse scar. A total of twelve cases were studied as other causes leading to severe maternal morbidity with transfer to MICU (Table 2). Chest infection, UTI, Gestational DM, heart disease and epilepsy are the

Upadhyaya et al. Severe Acute Maternal Morbidity and Intensive Care

co-morbid conditions needing MICU admission. Cardiomyopathy and postpartum psychosis are the postpartum complication that can cause not only morbidity but mortality also.7,10 Interventions during ICU stay (Table 3) included mechanical ventilation in two women (1.26%), vasoactive support in 8 (5.03%) and intensive monitoring in 61 (38.35%). Blood were transfused in 52 women (32.7%, range 1-7 units). Similar ICU interventions were reported from other countries too.6,11-13 Severe maternal morbidity should be considered internationally as a new indicator of the quality of obstetric care. Substandard care was found in the majority of assessed cases due to limited resource available in own country. Reduction of severe maternal morbidity seems a mandatory challenge. Therefore auditing of severe maternal morbidity at local or regional level should be encouraged to improve the quality of obstetric care and decrease the incidence of maternal morbidity and maternal mortality.11-13 intensive care units vary between countries and from one region to another within the same country. Pilot studies in Brussels suggested that the threshold for transfer to intensive care units might vary according to the clinical work load of the hospital.14-16 To wrap studies showing the major obstetric causes of severe maternal morbidities are hypertensive disorder of pregnancy, haemorrhage and sepsis.17

maternal morbidity and intensive care in a public sector university hospital of Pakistan. J Ayub Med Coll Abbottabad. 2008; 20(1):109-12. 4.

Nepal maternal mortality and morbidity study 2008/09. Kathmandu: Family Health Division, Government of Nepal; 2010.

5.

Say L, Pattinson RC, Gulmezoglu AM. WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near-miss). Reprod Health. 2004;1(1):3.

6.

Knight M, Kurinczuk JJ, Spark P, Brocklehurst P. Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities. BMJ. 2009;338:b542.

7.

Faponle AF, Adenekan AT. Obstetric admissions into the intensive care unit in a Sub-urban University Teaching Hospital. Nepal J Obstet Gynaecol. 2011;6(2):33-6.

8.

Wilson RE, Salihu HM. The paradox of obstetrics “nearmisses”: converting maternal mortality into morbidity. Int J Fertil Womens Med. 2007;52(2-3):121-7.

9.

Zhang WH, Alexander S, Bouvier-Colle MH, Macfarlane A. Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey. Br J Obstet Gynaecol. 2005;112:89-96.

10.

Chhabra P, Guleria K, Saini NK, Anjur KT, Vaid NB. Pattern of severe maternal morbidity in a tertiary hospital of Delhi, India: a pilot study. Trop Doct. 2008;38(4):201-4.

11.

Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe near-miss. Br J Obstet Gynaecol. 1998;105(9):985-90.

12.

Zwart JJ, Ricsteras JM, Ory F, de Vries JIP, Bloemenkamp KWM, Roosmalen VJ. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nation wide population-based study of 371000 pregnancies. Br J Obstet Gynaecol. 2008;115:842-50.

13.

Zwart JJ, Dupuis JR, Richters A, Ory F, Roosmalen J. Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study. Intensive Care Med. 2010;36(2):256-63.

14.

Oladapo OT, Sule-Odu AO, Olatunji AO, Daniel OJ. “Nearmiss” obstetric events and maternal deaths in Sagamu, Nigeria: a retrospective study. Reprod Health. 2005;2:9.

15.

van den Akker T, van Rhenen J, Mwagomba B, Lommerse K, Vinkhumbo S, van Roosmalen J. Reduction of severe acute maternal morbidity and maternal mortality in Thyolo district, Malawi: the impact of obstetric audit. PLoS One. 2011;6(6):e20776.

16.

Ronsmans C, Filippi V. Reviewing severe maternal morbidity: learning from survivors from life-threatening complications. In beyond the numbers: reviewing deaths and complications to make pregnancy safer. Geneva: World Health Organization; 2004. p.103-24.

17.

Rana A, Baral G, Dangal G. Maternal near-miss: a multicenter surveillance in Kathmandu valley. J Nepal Med Assoc. 2013;52(190):299-304.

CONCLUSIONS The most common obstetric events among the severe acute maternal morbidity were hypertensive disorders in pregnancy, obstetric haemorrhage and sepsis. These events can be reduced by provision adequate and effective care. Team approach involving obstetricians, intensivists and anaesthetists is needed for early meticulous assessment and aggressive intervention. Therefore, auditing of severe maternal morbidity should be encouraged to improve the quality of obstetric care and decrease the incidence of maternal morbidity and maternal mortality. REFERENCES 1.

Pattinson R, Say L, Souza JP, Broek N, Rooney C. WHO Health Organ. 2009;87(10):734.

2.

Cecatti JG, Souza JP, Parpinelli MA, Haddad SM, Camargo RS, Pacagnella RC, et al. Brazilian network for the surveillance of maternal potentially life threatening morbidity and maternal near-miss and a multi-dimensional evaluation of there long term consequences. Reprod Health. 2009;6:15.

3.

Bibi S, Memon A, Sheikh JM, Qureshi AH. Severe acute

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ORIGINAL ARTICLE

Reference Values of Fetal Peak Systolic Velocity in the Middle Cerebral Artery at 19–40 Weeks of Gestation in Nepalese Population Shrestha U,1 Shrestha I,2 Ghimire RK,1 Paudel S1 1 Department of Radiodiagnosis and Imaging, Kathmandu, Nepal 2 Department of Obstetrics and Gynaecology, Kathmandu, Nepal. Aims: The purpose of this study was to construct new reference range for fetal middle cerebral artery peak systolic velocity (MCA-PSV) in uncomplicated pregnancy at 19-40 weeks of gestation. Methods: This was a prospective cross-sectional study involving 400 singleton pregnancies between 19 and 40 weeks of gestation without any known risk factors of adverse pregnancy outcome who were referred for routine obstetric examination. The protocol included the doppler examination of fetal middle cerebral artery (MCA) within 2 mm after its doppler parameter for different gestational age. Results: Among 400 singleton uncomplicated pregnancies between 19 and 40 weeks of gestation maximum number of pregnancies (10%) was at 19 weeks of gestation and minimum (2.5%) was at 31 weeks. The fetal peak systolic blood of gestation which increased to 67.73 ± 9.92 at 40 weeks. The MCA-PSV showed continuous increment with increasing gestational age Conclusions: Continuous increment in the peak systolic volume with advancing gestational age was obtained which was for the serial measurement of the peak systolic volume of the middle cerebral artery for complicated pregnancies. Keywords: fetal middle cerebral artery, fetal peak systolic velocity, pregnancy.

INTRODUCTION Introduction of doppler velocimetry to obstetrics offered a non-invasive method of assessing fetoplacental circulation.1 Advance of ultrasonogaphy have revolutionized prenatal diagnosis of fetal anemia and intrauterine-growth-restriction (IUGR).2 Use of fetal middle-cerebral-artery peak-systolicvelocity (MCA-PSV) for diagnosis of fetal anemia has reduced the number of invasive tests in the assessment of red cell alloimmunised pregnancies by >70%.3 Measurement of fetal MCA-PSV has a predictable relationship with fetal hemoglobin.3-5 The decreasing red-cell-mass leads to decreased blood viscosity and increased cardiac output resulting in increased fetal arterial-PSV. MCA-PSV is mainly

used for the prediction of fetal anemia,5-7 however a preliminary study8 has reported increased MCA-PSV in IUGR fetuses. Detection of truly high-risk pregnancy needs a strong tool with suitable reference ranges, the accuracy of which is important. Several fetal MCA-PSV reference ranges are currently in use3 however none are available for Nepalese population. This study was conducted to establish the reference values for fetal MCA-PSV in uncomplicated pregnancies between 19-40 weeks gestation in Nepalese population.

CORRESPONDENCE

Dr Umesh Shrestha Department of Radiodiagnosis and Imaging, Civil Service Hospital, Kathmandu, Nepal. Email: [email protected] Phone: +977-9851134799 42

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Shrestha et al. Reference Values of Fetal Peak Systolic Velocity in the Middle Cerebral Artery

METHODS This was a prospective cross-sectional study done in the Department of Radiology and Imaging, Tribhuvan University Teaching Hospital, Nepal from September 2009 to August 2010. Four hundred singleton pregnancies between 19-40 weeks of gestation without any known risk factors of adverse pregnancy outcome who were referred for routine obstetric ultrasonography were studied. Those with undetermined period of gestation, maternal smoking, multiple pregnancy, diagnosed fetal abnormality in current pregnancy, previous history of preeclampsia, intrauterine growth retardation, abruptio placenta or preterm delivery, history of any pre-existing medical condition (such as hypertension, diabetes mellitus, renal disease), risk of developing fetal anemia including Rhesus negative women and those not willing to give consent for the study were excluded. Gestational age was determined from ultrasound examination before 20 weeks of gestation or from last menstrual period. While calculating the gestational age, those at three days and below were taken in lower gestational week and those after four days and above were taken in higher gestational week. The doppler examination of fetal middle cerebral artery was done within 2 mm after its origin from the internal carotid artery with the angle of insonation kept at six

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REFERENCES 1.

Attapattu JA, Prussia PR, Menon S. Torsion of a non1994;45:163-4.

2.

Matsumoto H, Ohta T, Nakahara K, Kojimahara T, Kurachi H. Torsion of a non-gravid uterus with a large ovarian cyst: usefulness of contrast MRI. Gynecol Obstet Invest. 2007;63:163-5.

3.

Hibbard LT. Adnexal torsion. Am J Obstet Gynecol. 1985;152:456-61.

4.

Burnett LS. Gynecologic causes of the acute abdomen. Surg Clin North Am. 1988;68:385-98.

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BRIEF COMMUNICATION

Imaging and Initial Management of Loin Pain in Pregnant Women in District General Hospital Kadi N Department of Education, North Cumbria University Hospitals, Carlisle, United Kingdom.

diagnostic as well as therapeutic dilemma. This article highlights the usual imaging modalities that are used to investigate loin pain and the initial management in pregnant women. Keywords: imaging, loin pain, pregnancy.

INTRODUCTION Hydronephrosis in pregnancy can be physiological and may begin as early as the sixth week of gestation. Ninety percent of pregnant women will have some element of physiological hydronephrosis by the 28th week.1,2 The mechanism of hydronephrosis is unclear, but it may be the result of a combination of pressure on the ureters at the pelvic brim and smooth muscle relaxation secondary to the hormonal changes of pregnancy.1,3 Hydronephrosis is more common on the right, possibly because of dextrorotation of the uterus and the sigmoid colon cushioning the ureter on the left.1,3 Most of the patients with hydronephrosis remain asymptomatic1 and the hydronephrosis resolves post-delivery. However, a small percentage may complain of loin pain.1,4-11 Moreover, up to 28% of cases of loin pain are misdiagnosed in pregnant women11 because of common pregnancy symptoms such as vomiting, back pain and urinary frequency. ASSESSMENT Assessment of patient with loin pain includes history and thorough clinical examinations. The initial investigations include blood tests to check white

cell count and differentiation, urea and electrolytes, urine dipstick, urine for culture and sensitivity, and requesting urgent renal imaging. Primary Imaging modality in pregnancy, as they are non-invasive and they do not involve radiation. It is best to avoid ionising radiation in pregnancy, particularly during However, ultrasound scans are operator dependent and sensitivity ranges from 34 to 92.5%.12-13 Another useful radiological modalities is limited (three shot) intravenous urogram (IVU). It involves limited radiation exposure. Lead shielding of the pelvis is 15 and 30 or 60 min images post intravenous contrast administration.14-18 Magnetic resonance imaging (MRI) is generally safe in pregnancy but it provides limited information about ureteric calculi.15,19 Usual course of loin pain in pregnancy Ninety percent of patients with loin pain will respond analgesia. These patients are usually monitored usually planned postpartum.1-13,20-22 Urgent urological

CORRESPONDENCE Dr Nourdin Kadi Department of Education, North Cumbria University Hospitals, Carlisle, Cumbria CA2 7HY, United Kingdom. Email: [email protected] Phone: 00447891892657

The papers in this journal are published under the terms of the

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opinion should be considered if patients have sepsis, intractable loin pain which is not controlled with analgesia (which mean failure of conservative therapy), patients who have obstruction of solitary kidney or if there is deteriorating renal function.1,6,9,15 Sepsis Obstruction of solitary kidney Deteriorating kidney function Failed conservative therapy Yes

No

Urgent urology Opinion

Prophylactic antibiotic Analgesia

Figure 1. Algorithm of management of loin pain in pregnancy. INTERVENTIONS Percutaneous nephrostomy Insertion of a percutaneous nephrostomyis a common method of interventions.6,23 This procedure is usually performed under local anaesthesia with ultrasound guidance. This is especially useful in the presence of severe sepsis to avoid general anaesthesia.6,23,24 The complications of nephrostomy are uncommon and include a 3% risk of tube dislodgement23-25 and a 1.3 and 1.6% risk for major sepsis and haematuria respectively.26 Periodic changes of the nephrostomy may be required prior to delivery (nephrostomy tube is at risk of encrustation and blockage during pregnancy due to elevated urinary sodium, uric acid and calcium concentrations).2,4 Cystoscopy Cystoscopy and insertion of a retrograde ureteric stent is usually performed under general anaesthesia. This procedure can be performed with pelvic lead shielding 6,14 Ureteric stents are also at risk of encrustation and blockage during pregnancy.2,4 Other disadvantages of this procedure include the risk of ascending pyelonephritis due to symptoms due to stent irritation.9,14,16,20-22 Ureteric stent also might need to be changed periodically prior to delivery.

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Primary ureteroscopy There are published data of small series of patients treated by primary ureteroscopy.27-31 Lithoclast and laser were used during ureteroscopy to treat ureteric calculci.27,31 The risk of primary uretroscopy in pregnancy include a 5% risk for minor abrasions,32,33 2% risk of perforation and creation of a false passage,32,33 1% risk of avulsion and stricture formation32,33 and the risk of preterm labour and delivery. However, an experienced urologist should perform ureteroscopy with special interest in endoscopic surgery. Ureteroscopy is not recommended in the presence of sepsis or multiple calculi.6,8 The choice of the investigations and interventions should be tailored to the individual patient’s situation and discussed with the urologist and radiologist. CONCLUSIONS In the absence of sepsis initial treatment in loin pain in pregnancy should be conservative, given that the majority of patients will recover with analgesia, antibiotics and hydration. Efforts should be made to minimise the radiation exposure of patient and fetus without delaying diagnosis or compromising early treatment. Intervention in loin pain in pregnancy should be considered in patients who have sepsis or a solitary kidney, symptoms refractory to conservative measures and worsening of renal function. REFERENCES 1.

Gulmi F, Felsen D, Vaughan ED. Pathophysiology of urinary tract obstruction. Campbell’s Urology. 8th ed. Philadelphia: Saunders; 2002.

2.

Stables D. The Renal Tract. In: Cunningham FG, MacDonald PC, Gant NF, editors. Physiology in childbearing with anatomy and related biosciences. Edinburgh: Hauscent Publishing Limited; 2000. p. 236-46.

3.

Cunningham FG, MacDonald PC, Gant NF. Physiology of pregnancy: maternal adaptations to pregnancy. In: Cunningham FG, MacDonald PC, Gant NF, editors. William’s Obstetrics. 20th ed. London: Prentice Hall International; 1999;2191-265.

4.

McAleer SJ, Loughlin KR. Nephrolithiasis and pregnancy. Curr Opin Urol. 2004;14(2):123-7.

5.

Biyani CS, Joyce AD. Urolithiasis in pregnancy I: pathophysiology, fetal considerations and diagnosis. Br J Urol Int. 2002;89(8):811-8.

6.

Biyani CS, Joyce AD. Urolithiasis in pregnancy II: management. Br J Urol Int. 2002;89(8):819-23.

7.

Lewis DF, Robichaux AG III, Jaekle RK, Marcum NG, Stedman CM. Urolithiasis in pregnancy: diagnosis, management and pregnancy outcome. J Reprod Med. 2003;48(1):28-32.

Kadi. Imaging and Initial Management of Loin Pain in Pregnany 8.

Butler EL, Cox SM, Eberts EG, Cunningham FG. Symptomatic nephrolithiasis complicating pregnancy. Obstet Gynecol. 2000;96:753-6.

21.

Fainaru O, Almog B, Gamzu R, Lessing JB, Kupferminc M. The management of symptomatic hydronephrosis in pregnancy. Int J Obstet Gynaecol. 2002;109(12):1385–7.

9.

Ferguson T, Bechtel W. Hydronephrosis of pregnancy. Am Fam Physician. 1991;43(6): 2135-7.

22.

10.

Meron M, editor. Urinary lithiasis: aetiology, diagnosis and medical management. Campbell’s Urology. 8th ed. Philadelphia: Saunders; 2002.

Zwergel T, Lindenmeir T, Wullich B. Management of acute hydronephrosis in pregnancy by ureteral stenting. Eur Urol. 1996;29(3):292–7.

23.

Stothers L, Lee LM. Renal colic in pregnancy. J Urol. 1992;148(5):1383-7.

Khoo L, Anson K, Patel U. Success and short-term complication rates of percutaneous nephrostomy during pregnancy. J Vasc Interv Radiol. 2004;15(12):1469–73.

24.

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BRIEF COMMUNICATION

Subcutaneous Sterile Water Injection for Labor Pain: A Randomized Controlled Trial Rai R,1 Uprety DK,1 Pradhan T,1 Bhattarai BK,2 Acharya S3 Department of Obsterics and Gynaecology, 2Department of Anesthesiology and Critical care, BP Koirala Institute of Health Sciences, Dharan, 3 Department of Obstetrics and Gynaecology, College of Medical Sciences, Bharatpur, Nepal. 1

Aims: This study was done to evaluate the effectiveness of subcutaneous injection of sterile water compared with placebo in reduction of labor pain. Methods: labor were randomized to receive either subcutaneous injection of sterile water (study group, n=120) or normal saline as placebo (control group, n=120) at painful point in lumbosacral region. Pain score was measured before and 10, 45 and 90 minutes after the injections. Main outcome measured was reduction of low back labor pain using visual analogue scale. Results: among the intervention group compared to the control group at 10, 45, 90 minutes after injection. There was no difference between the two groups with regard to rate of instrumental delivery, cesarean rate and neonatal outcome. Conclusions: The subcutaneous injection of sterile water administered at painful point in lumbosacral area was effective in reducing low back labor pain during labor. Keywords: labor pain, low back pain, subcutaneous sterile water, visual analogue scale.

INTRODUCTION Labor pain is one of the most painful events with severity ranging from women to women with 30% of them experiencing severe low back pain during labor.1 There is anatomical support for assumption that low back pain in labor is referred pain from the uterine cervix and corpus supplied by afferent neurons ending in dorsal horns of spinal segments T10-L1. Based on gate-control theory2 various techniques entailing anesthesia or stimulation of lumbosacral areas have been attempted in order to inhibit pain transmission to dorsal horn with varying results. Although there are various methods for reducing labor pain, options are limited due to lack of monitoring facilities and human resource constraints especially in developing countries with resource poor set-up.

In such condition sterile water injection seems to be a plausible option for this purpose. The aim of the present study was to evaluate the effectiveness of subcutaneous injection of sterile water compared to placebo for reduction of labor pain. METHODS The study included 240 pregnant women at more than 37 weeks of gestation who were admitted in labor room of BP Koirala institute of health sciences. A randomized single blind trial was conducted. To qualify for participation in study they had to be dilatation of more than 4 cm and severe low back pain measured by visual analogue scale of >/=7 requiring pain relief. Patient receiving opoid analgesics prior to inclusion in the study, patients with language barrier,

CORRESPONDENCE

Dr Rubina Rai Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Nepal. Email: [email protected] Phone: +977-025525555- 5345

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The papers in this journal are published under the terms of the

Rai et al. Subcutaneous Sterile Water Injection for Labor Pain

previous uterine scar, infection in area of injection were excluded from study. Informed consent as approved by the ethical committee of the institution was obtained from each participant. The women were randomized into two groups according to computer generated random number table. The intervention group received simultaneously four subcutaneous injection of sterile water at four different sites in the lumbosacral region-Michaelis’ rhomboid. The intervention group received four subcutaneous injection of sterile water in the lumbosacral region-Michaelis’ rhomboid. The control group received four subcutaneous injection of isotonic saline in the same region. In both the groups,1 used. Volume of each injection used was 0.1 ml. The injection of sterile water gave a sharp transient local pain sensation. In order to mask the difference in pain sensation between the two treatments, the injections were given during uterine contraction. The pain score was measured prior to the injection and at 10, 45, 90 minutes after the injection using Visual Analogue Scale. The scale ranged from no pain (0 end) to unbearable pain (10 end). No rescue medication was used in the event of no pain relief following injection. Progress of labor was assessed according to labor room protocol. Mode of delivery and neonatal outcome were recorded. Data was analyzed using the SPSS (statistical program for the social sciences, SPSS Inc, Chicago, USA) software version 11.1. Student T test was used to compare continuous variables between intervention and control groups. For discrete variables Chi-square test set at 5% (p