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Background: Glycosylated haemoglobin (HbA1c) level during early pregnancy has been proposed as a predictor of gestational diabetes mellitus (GDM). Objectives: To determine the mean value of first trimester’s glycosylated haemoglobin (HbA1c) in gestational diabetes mellitus cases. Methods: An analytical cross-sectional study was conducted among GDM cases at the Obstetrics and Gynaecology Department of Kathmandu Medical College after ethical clearance. Purposive sampling was done to enrol 102 cases that presented over a period of August 2020 to January 2021. First trimester HbA1c levels were recorded. The HbA1c values were grouped into two taking 5.7% as a cut-off which is an established threshold for prediabetes in a normal population. Results: The mean age of participants was 28.74 ± 4.1 years and mean body mass index was 29.13 ± 2.73 kg/m2. Mean value of HbA1c was 5.52 ± 0.44%. Mean value of fasting blood glucose and postprandial glucose after oral glucose tolerance test (OGTT) was 102.25 ± 7.36 mg/dl and 167.55 ± 10.91 mg/dl respectively. Out of total participants, only 40 (39.21%) had HbA1c value more than 5.7% while 62 (60.78%) had HbA1c value less than 5.7%. There was weak positive correlation between HbA1c and Fasting Blood Glucose (Pearson’s correlation coefficient r = 0.13). Similarly, correlation between HbA1c and blood sugar after OGTT (r = 0.17) was also insignificant. Conclusion: This study concluded that the HbA1c value of first trimester is not very different than normal population. Hence, diabetic range of HbA1c value in first trimester is useful in diagnosing overt diabetes.

Background: Enhanced Recovery After Surgery (ERAS) is a multimodal patient centred perioperative care pathway aimed at accelerating patient recovery, improving patient satisfaction, decreasing length of hospital stay, and post-operative complications. Objectives: To assess patient satisfaction with ERAS protocol in the most common surgical procedure in the world, elective Caesarean Section. Methods: A descriptive cross-sectional study was carried out in the department of Obstetrics and Gynaecology at Kathmandu Medical College Teaching Hospital (KMCTH) from July 2020 to February 2021 after ethical approval. The study included all pregnant ladies undergoing elective Caesarean section under ERAS protocol by convenient sampling and their satisfaction with the treatment received was recorded using a pre-validated questionnaire at the time of discharge. Data was analysed using SPSS. Results: A total of 140 patients were enrolled in the study. Majority of the patients considered the introduction of feeding (100, 71.4%) and ambulation (115, 82.1%) to be on time. Seventy-three patients (52.1%) considered themselves fit for discharge on the second post-operative day and 70 (50%) were discharged on the second post-operative day itself which is earlier compared to the hospital protocol of discharge on the third or fifth post-operative day. Most of the women (136, 97.1%) were satisfied with the care they received and 132 (94.3%) of them would prefer to undergo surgery under the ERAS protocol in the future. Conclusion: Most women were satisfied with the surgical experience and would prefer to undergo surgery under the same protocol in the future.

Uterine scar dehiscence or rupture is a rare but potentially life-threatening complication of caesarean delivery. It is the opening of the uterine incision line that can lead to postpartum haemorrhage, pelvic hematoma, pelvic abscess, endomyometritis, generalised or localised peritonitis and sepsis. Here we report a case of a 25 years old female who presented with puerperal pyrexia. Investigations revealed uterine scar rupture with a uterovesical collection. The case was managed conservatively with intravenous antibiotics, an intracervical Foley's catheter and a gonadotropin-releasing hormone agonist.caesarean section; case reports; postpartum; rupture; scar.

Uterocutaneous fistula is a rare complication that occurs after cesarean section and other pelvic operations. Here we report a case of a 27 years woman presented to our department with a mass and pus-like discharge coming from her previous Pfannenstiel incision for 1 month. The definitive treatment of such cases is hysterectomy but the case was managed by fistulectomy along with gonadotropin-releasing hormone agonist.

Introduction: Vitamin-D deficient pregnant women are more likely to have pregnancy complications like pre-eclampsia, intrauterine growth restriction, diabetes, preterm birth, etc. Associated factors include ethnicity, skin coverall, use of sun protection, overweight, vitamin-D intake, and smoking. The objective of this study is to determine the prevalence of Vitamin-D deficiency among pregnant women in a tertiary level hospital. Methods: This study descriptive cross-sectional study was conducted at a tertiary care hospital from September 15th, 2020 to November 15th, 2020 where the pregnant women visiting for an antenatal checkup in the first trimester were enrolled. Ethical clearance was taken from the Institutional Review Committee of Kathmandu Medical College (reference no. 1808202003). A convenience sampling method was used. All the data were entered in the Statistical Package of the Social Sciences version 20.0 and analyzed. Point estimate at 90% Confidence Interval was calculated along with frequency and percentage for binary data. Results: Among a total of 47 cases, vitamin-D deficiency was seen in 21 (44.6%) (32.67-56.52 at 90% Confidence Interval). Conclusions: The prevalence of vitamin-D deficiency was similar to other studies done in similar settings.

Approximately one third of women of reproductive age group are obese. Obesity significantly increases caesarean section rate. Not only is obesity associated with unfavourable clinical outcomes for both mother and childalso, performing caesarean sections in morbidly obese patients is a challenge for obstetricians, anaesthetists and the caregivers. In view of increased risks while performing Caesarean delivery in morbidly obese patient, this case report reviews the techniques and incisions used; the anaesthetic, logistical and practical challenges faced by the obstetricians while performing an emergency caesarean section in a women with BMI of 45.78kg/m2 who was also a diagnosed case of chronic hypertension with Grade I hypertensive retinopathy.

Introduction: Obstetric emergencies are unpredictable and inappropriate management of such events can result in serious maternal and neonatal morbidity and mortality. Simulation and drill provides obstetric emergency training in a safe environment with an aim of improving clinical outcome. The aim of this study was to evaluate the impact of obstetric emergency training on the change in the knowledge, clinical skill and teamwork performance of the participants in the management of common obstetric emergencies: eclampsia, shoulder dystocia and post-partum haemorrhage. Methods: A hospital based interventional study was conducted amongst 11 residents, 4 medical officers and 45 interns. Pre-training and post-training assessment of the knowledge by using Multiple choice questions (MCQs), clinical skills by using Objective Structured Clinical Examination (OSCE) and teamwork performance by using Mayo High Performance Teamwork Scale (MHPTS) was undertaken in each of the modules: Eclampsia, Shoulder dystocia and Post-partum haemorrhage. Training intervention was undertaken by using standardized lectures and simulated clinical emergency scenarios. The changes in MCQs, OSCE and MHPTS scores were analyzed. Results: There was a significant improvement in the mean MCQ score (p-value ˂0.001) and OSCE score (p-value ˂0.001), overall and individually, in each module. After the training, a greater number of participants could perform the clinical skill components. There was also a significant improvement in post training MHPTS score (p-value˂0.001). Conclusions: Obstetric emergency drill and training significantly increased the knowledge, clinical skills and teamwork performance of participants in the management of important obstetric emergencies. Keywords: eclampsia; obstetric emergency; post-partum haemorrhage; shoulder dystocia; simulation.

Leiomyomas are common benign tumors of the uterus, affecting 20-30% of women of reproductive age group. But vaginal leiomyomas remain an uncommon entity with only about 300 reported cases. The first case was described in 1733. Only a few cases have been reported in Nepal to date. Tumors are thought to arise from Mullerian smooth muscle cells in the sub-epithelium of the vagina. Vaginal leiomyomas are usually situated in the anterior vaginal wall. Here, we report a case of a 48-year old multipara who presented the outpatient department with the ultrasonographic report showing multiple uterine fibroids but was asymptomatic. A physical examination showed a mass in the right vaginal wall. Pervaginal removal of the tumor was performed and subsequent histopathology revealed a vaginal leiomyoma. Removal of the tumor by the vaginal route, wherever possible, with the subsequent histopathological examination, appears to be the optimum management plan.

Introduction: Caesarean delivery on maternal request in absence of any maternal and fetal indications and has become a concerning issue among obstetricians. It seems to be one of the contributory factors of increased cesarean rate all over the world. This study aims to find out the prevalence of cesarean delivery on maternal request among cesarean deliveries in a tertiary care hospital. Methods: This descriptive cross-sectional study was conducted from November 1st 2019 to February 1st 2020 among women undergoing cesarean section in a tertiary care hospital. The ethical clearance was taken from the Institutional Review Committee of Kathmandu Medical College (reference number: 201120192). Convenient sampling was used. Statistical Package for Social Sciences version 20.0 was used for analysis. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: Out of 386 cesarean sections, maternal request was the indication in 72 (18.65%) (95% Confidence Interval = 14.76–22.54) mothers. Among the 72, 38 (52.7%) chose cesarean section for fear of labor pain, 14 (19.4%) for date-of-birth selection, 10 (13.8%) for anxiety of labor pain, because of cord around the neck in four (5.5%), male baby in three (4.1%), to avoid pelvic trauma in two (2.7%), and to go abroad in one (1.3%). Conclusions: Our study showed a prevalence of cesarean delivery on maternal request higher than other national studies but was similar to the global prevalence. The commonest reasons were fear of labor followed by date-of-birth selection.

Introduction: COVID-19 is a beta coronavirus that is transmitted by physical interaction or close contact. This Coronavirus Pandemic has also created stress and anxiety among pregnant women all over the world. The disease was first identified in Wuhan city, China, in late December 2019 and was declared pandemic by the World Health Organization on 11th March 2020. Concern and stress in pregnancy are associated with pre-eclampsia, intrauterine growth restriction, preterm labour, depression etc. Pregnancy is an immune-compromised state and poses a high risk to this risk. This study aims to identify anxiety about the coronavirus infection among pregnant women visiting a tertiary care centre in Kathmandu, Nepal, during this COVID–19 pandemic. Methods: This is a descriptive cross-sectional study conducted at Kathmandu Medical College and Teaching Hospital from 15th July 2020 to 30th July 2020 after taking the ethical clearance from the Institutional Review Committee of Kathmandu Medical College (reference no. 207202002). Convenient sampling method was used. All the data were entered in Statistical Package for the Social Sciences data 20.0 and analyzed. Data was presented in frequencies, charts and percentage. Results: Among the total 273 cases, only 2 (0.73%) cases had a score between 25-30 corresponding to moderate to severe anxiety, 21 (7.69%) had a score between 18-24, which corresponds to mild to moderate anxiety and 250 (91.57%) had score 0-17 which corresponds mild status. Conclusions: Most of the participants in the study reported a mild status of anxiety. Very few participants reported moderate to severe anxiety.

Background: Induction of labour is one of the most important interventions done in modern obstetric practice and the success of induction techniques depends upon its role in cervical ripening and improvement in the Bishop’s score.Objectives: This study was done to compare the improvement in Bishop’s score among the women receiving oral mifepristone and oxytocin infusion to ripen the cervix prior to induction of labour at term.Methods: This was a hospital based, prospective randomized controlled trial conducted from August 2015 to February 2016. A total 68 patients were randomized into two groups: Mifepristone group and Oxytocin group. The improvement in Bishop’s score prior to and after 48 hours of cervical ripening, induction to delivery interval in vaginal delivery, mode of delivery, any adverse maternal and foetal outcome were recorded in both the groups.Results: The study demonstrated an overall significant improvement in Bishop’s score in mifepristone group compared to oxytocin group (p-value=0.003). A significant number of patients in mifepristone group had improved mean Bishop’s score (p-value=0.001) after 48 hours of cervical ripening. There were more vaginal deliveries in the mifepristone group, with shorter mean induction to delivery interval as compared to the oxytocin group. There were no maternal side effects and adverse perinatal outcomes in both the groups.Conclusions: Mifepristone is a good alternative to oxytocin for cervical ripening for induction of labour.

Background: Evaluation of severe obstetric morbidity is an important aspect of optimum maternal health. Towards this, the Water stone and Mantel criteria have been used to know the incidence, predictors and causes of severe obstetric morbidity.Objectives: The study aimed to estimate incidence, predictors and causes of obstetric morbidity at Kathmandu Medical College and Teaching Hospital.Methods: A hospital-based prospective study was carried out from 1st September 2014 to 31st August 2015. All cases of severe obstetric morbidity according to the Mantel and Water stone criteria were identified. The socio-demographic and healthcare characteristics of extremely severe cases were compared with controls which included women who were admitted before and after the indexed cases.Results: There were 2270 deliveries during the study period, out of which 74 cases of severe obstetric morbidities were identified i.e. an incidence of 32.5 per 1000 deliveries. During the study period, there were three maternal deaths attributed to conditions studied. Disease-specific morbidities per 1000 deliveries were 18.9 for haemorrhage, 9.2 for severe pre-eclampsia, 0.88 for eclampsia, 0.44 for haemolysis elevated liver enzyme and low platelet count and 3.08 for sepsis. A total of 26 patients were admitted in Intensive care unit which was 1.145 per 100 of total deliveries.Conclusion: Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone. In this study, most events are related to obstetric haemorrhage and severe pre-eclampsia.Journal of Kathmandu Medical College Vol. 5, No. 2, Issue 16, Apr.-Jun., 2016, page: 44-48

Background: In the recent years, with the advancement of laparoscopic surgery, management of ovarian dermoid cysts is possible with laparoscopic approach. Concerns regarding safety of the procedure has been raised.Objective: To analyze the safety of laparoscopic surgery done for ovarian dermoid cyst at Kathmandu Medical College Teaching Hospital.Methods: This is a descriptive study done from July 2012 to June 2015. All the cases with the diagnosis of ovarian dermoid cyst managed laparoscopically during the study period were enrolled in the study. Thorough history, clinical examination fi nding and diagnostic modalities were noted. Three port laparoscopy was done for the management of dermoid cyst. Thorough peritoneal lavage with warm saline was done at the end of the procedure in the cases with spillage.Variables like preoperative diagnosis, postoperative diagnosis, and type of surgery performed, rate of spillage, features of chemical peritonitis if any and duration of hospital stay were noted and analyzed.Results: Total 52 cases with the preoperative diagnosis of dermoid cyst were managed with laparoscopy during the study period. Of these, only 46 cases (88.46%) were dermoid cyst on laparoscopy. In majority of the cases (45.65%) diagnosis was incidental by Ultrasound scan done for other indications. Cystectomy was performed in 42 cases (91.30%) and in 4 cases (8.69%) oophorectomy was done. Spillage occurred in approximately 89% of the cases but there were no cases of chemical peritonitis. Duration of hospital stay ranged between 2 to 5 days.Conclusion: Laparoscopic management of ovarian dermoid cyst is a safe procedure.Journal of Kathmandu Medical CollegeVol. 5, No. 1, Issue 15, Jan.-Mar., 2016, Page: 18-22

Background: There is a world-wide rise in caesarean section rateduring the last three decades and has been a cause of alarm and needs an in-depth study. The objective of this study was to determine the rate and clinical indications of Caesarean Section. Methods: A hospital based study was carried out from 15th June 2015 to 15th January 2016 in Department of Obstetrics and Gynecology at Kathmandu Medical College, Sinamangal, Nepal. Patients who delivered by caesarean section were included in the study. Basic demographic data and clinical indications were noted. Results: A total of 1172 deliveries were carried out during the study period. Total number of caesarean section was 537 accounting to 45.81%. Most of the patients were of the age group of 25-29 years (42.8%). Most of the patients were primigravida (n=274; 51%). Emergency caesarean section was 411 (76.5%) and elective caesarean section was 126 (23.4%). Multigravida (71%) underwent more elective procedure than primigravida (25. 39%).The most frequent indication was fetal distress19.55% (n=105), failed induction 19.73%(n=106), and previous caesarean section 21.3% (n=115). Conclusions: The rate of cesarean section is quite high than that recommended by WHO which is (10-15%). Most of the caesarean sections were emergency caesarean section with previous caesarean being the leading cause.

Background: Gestational diabetes mellitus is a metabolic disorder defined as glucose intolerance with the onset or fi rst recognition during pregnancy. Gestational diabetes mellitus is associated with higher incidence of maternal diabetes mellitus later in life. It poses a risk to the pregnant woman and to the fetus. Hence, it is imperative for an early detection and management of the disease to ensure better maternal and foetal outcomes. Objective: To assess the prevalence of gestational diabetes mellitus and to analyze the maternal and perinatal outcomes of gestational diabetes mellitus patients who delivered in the hospital during the study period. Methods: A hospital based descriptive observational study was conducted at Kathmandu Medical College Teaching Hospital for a period of one year from 1st January 2013 to 31st December 2013. All the cases of gestational diabetes mellitus were included in the study. Patients were followed from the time of admission to the time of discharge after delivery. Pertinent information obtained were demography, gestational age at diagnosis and delivery, pregnancy complications, intervention and perinatal morbidity and mortality. Results: Out of 2845 deliveries, 45 patients were diagnosed as gestational diabetes mellitus and admitted during the period of study. The prevalence of gestational diabetes mellitus was 1.58% in this hospital. The most common maternal and neonatal complications were gestational hypertension (20%), hypoglycemia (8.89%) and macrosomia (8.89%) respectively. Conclusion: This study is important in providing information about the maternal and neonatal outcomes of gestational diabetes. By proper monitoring and good glycaemic control during the antenatal period, the adverse maternal and neonatal complications of gestational diabetes mellitus can also be reduced.DOI: http://dx.doi.org/10.3126/jkmc.v3i3.12246Journal of Kathmandu Medical CollegeVol. 3, No. 3, Issue 9, Jul.-Sep., 2014, Page: 107-112

Ectopic pregnancy is a serious complication of pregnancy in which embryo gets implanted any where other than the uterine cavity. In interstitial pregnancy, the pregnancy is located in that part of the fallopian tube that penetrates the muscular layer of the uterus. Overall incidence of ectopic pregnancy is one to two percent among which the incidence of interstitial pregnancy is only two percent. Interstitial pregnancy being the hazardous type requires immediate management. Though surgical treatment is the management of choice, its association with decreased fertility rate and increased rate of uterine rupture in future pregnancy cannot be ignored. We hereby report of medical management of interstitial ectopic pregnancy with single oral dose of Mifepristone 200mg along with single dose of Methotrexate 50miligram intramuscularly.Journal of Kathmandu Medical College, Vol. 4(1) 2015, 34-36

Background: Pregnancy though physiological and uneventful can be associated with major maternal morbidity with potential catastrophic consequences requiring utilization of facilities of Intensive Care Unit (ICU). Reports regarding such admissions are few from developing countries.Objective: To study the indication for admission, intervention and outcome of obstetric patients admitted to intensive care unit at Kathmandu Medical College Teaching Hospital and also to identify risk factors for admission to intensive care unit.Methods: A hospital based descriptive observational study was conducted from 1st January 2012 to 31st December 2013. All obstetric admissions to the ICU up to 42 days postpartum were included. Data obtained included demography, obstetric history, pre- existing medical problems, indication for ICU admission, intervention in ICU and outcome. Risk factors were assessed by comparing cases with control which included women who delivered before and after the indexed cases.Results: A total of 50 obstetric patients required ICU admission during the study period. This accounts for 0.87% of total hospital deliveries and 4.32% of all ICU admissions. Forty-two percent of the patients were admitted due to hypertensive disorders of pregnancy. Sixteen percent patients were of obstetric haemorrhage. Heart diseases topped the list with 16% in non-obstetric group. Risk factors for admission included lesser gestational age, Caesarean section, blood loss and co-morbid conditions of the patient. Mean age was 24.5±4.8 years; average length of stay in ICU was 3.44±3.7 days. Inotropic support was received by six patients (12%), CVP monitoring was done in three patients (6%). Ventilator support was needed in six (12%). There were three cases (6%) of mortality which accounts for 2.09% of total ICU mortality. Seventeen patients (34%) were referred from other centres.Conclusion: Hypertensive disorders of pregnancy, Obstetric haemorrhage and Heart disease were the most common indications of ICU admissions. Risk factors for admission included lesser gestational age, caesarean section, blood loss, and co- morbid conditions of the patients. Optimal outcome was achieved with combined effort of multidisciplinary team.DOI: http://dx.doi.org/10.3126/jkmc.v2i4.11777Journal of Kathmandu Medical CollegeVol. 2, No. 4, Issue 6, Oct.-Dec., 2013Page: 196-200

Aims: This study was done to know the pattern of obstetric emergencies and its influence on maternal and fetal outcome. Methods: A descriptive study was carried out in the department of obstetrics and gynecology at Kathmandu Medical College Teaching Hospital from 1st June 2013 to 31st May 2014. Cases were categorized as early pregnancy emergencies (ruptured ectopic pregnancy, complications of abortion), ante-partum emergencies and intra-partum emergencies (antepartum haemorrhage, preeclampsia, eclampsia, preterm prelabor rupture of membranes, rupture uterus), post-partum emergencies (postpartum haemorrhage, retained placenta, placenta accreta, uterine inversion), puerperal emergencies (postpartum sepsis), fetal emergencies (cord prolapse, shoulder dystocia). Outcome noted were type of emergency, obstetric intervention done, maternal and perinatal morbidity and mortality. Results: A total of 80 (4.45%) obstetric emergencies occurred among 1796 deliveries .The most common obstetric emergencies were obstetric hemorrhage (62.5%), severe preeclampsia (23.5%) and preterm prelabor rupture of membranes (10%). The obstetric interventions done were cesarean section (43.75%), exploratory laparotomy (33.75%) and blood transfusion (40%). Obstetric emergencies were responsible for 66.6% of total maternal death and 24.56% of total perinatal death. Conclusions: In spite of best efforts, some obstetric emergencies do occur. Obstetric hemorrhage and severe preeclampsia are the frequent obstetric emergencies. Cesarean section, exploratory laparotomy and blood transfusion were the commonly performed interventions. A better outcome can be achieved by national policy of promoting utilization of antenatal care, institutional deliveries, skilled birth attendance at delivery, liberal blood transfusion and regular training of doctors and nurses. DOI: http://dx.doi.org/10.3126/njog.v9i1.11186 NJOG 2014 Jan-Jun; 2(1):37-40

Background: The use of prostaglandins has substantially reduced the risk related with mid- trimester abortions. Misoprostol is available in many countries worldwide and is advantageous from the rest of prostaglandin as it is inexpensive, thermo and light stable. It is easy to use and is cheap. It can be used by different routes. Misoprostol has route dependent pharmaco-kinetic profile with best absorption following vaginal administration. Objective: To find efficacy and safety of intra-vaginal Misoprostol for mid- trimester abortion. Methods: A hospital based prospective study was carried out at Kathmandu Medical College Teaching Hospital from 1st Jan 2009 to 31st Dec 2010. A total of 50 cases of mid- trimester termination of pregnancy were analyzed in that period using intra-vaginal Misoprostol 400 microgram every 12 hours till a maximum of 48 hours. Results: The most common indication for undergoing mid trimester abortion was missed abortion (56%) followed by congenital abnormalities (22%). Most of the women were married (98%). The mean age of the women was 26.21± 5.8 years (Mean± SD). The mean gravidity was 2.63 ±1.76. Mean gestational was 19.60±3.937 weeks. The success was defined if Misoprostol was able to induce abortion. Complete abortion was defined if fetus and placenta was expelled completely and was not resorted further to either medical or surgical means. The success rate was 96%. The complete abortion rate was 86%. The mean induction abortion interval was 13.067±6.21 hours. Mean dose of misoprostol was 616.667±285.34 microgram. The most common side effect was fever with chills and rigor. Conclusion: Intra-vaginal misoprostol is safe, effective, cheap and easily available method for second trimester termination of pregnancy.DOI: http://dx.doi.org/10.3126/jkmc.v2i2.10627Journal of Kathmandu Medical College, Vol. 2, No. 2, Issue 4, Apr.-Jun., 2013, page: 59-62

Background: Cervical cancer is one of the commonest cancers in Nepal. Fortunately, it is preventable by detecting precancerous lesions and early invasive cancers by various screening tools. Screening can be possible if women are aware of the problem and if they have positive attitude .Therefore this study was conducted to find out about the knowledge, attitude and practice of cervical cancer in Nepalese women attending a tertiary level hospital in Nepal. Methods: A cross-sectional questionnaire based study was conducted in gynaecological out patient department of Kathmandu Medical College from January to March 2011. Structured questionnaire was used. Demographic profile of women was noted and questions pertaining to knowledge, attitude and practice on screening for cervical cancer were asked. Results: There were 105 respondents, of whom 65.7% had heard about cervical cancer. However, only 42.9% and 18.1% had knowledge about screening for cervical cancer and Pap smear test respectively. More than 85% of women had positive attitude towards screening but the uptake of Pap smear test in the respondents was only 10.5%. It was found that advancing age and longer duration of marriage were significantly associated with better knowledge, attitude and practice. Conclusion: Knowledge and practice of the screening for cervical cancer was poor in gynaecological patients visiting a tertiary level hospital. However the attitude of women towards screening was positive. Nepal Journal of Medical Sciences | Volume 02 | Number 02 | July-December 2013 | Page 85-90 DOI: http://dx.doi.org/10.3126/njms.v2i2.8941

Uterovesical fistula is an abnormal communication between uterine cavity and the bladder. It is a rare type of fistula accounting for four percent of all cases of urogenital fistula. However the incidence of uterovesical fistula has been rising due to increasing incidence of lower segment caesarean section. Uterovesical fistula is seen more after repeated caesarean section rather than primary section. This is a case report of a primipara with uterovesical fistula following primary emergency Caesarean section on her 12th postoperative day for foetal distress. She was managed conservatively using IV antibiotics and catheterization for six weeks.DOI: http://dx.doi.org/10.3126/jkmc.v2i4.11799Journal of Kathmandu Medical CollegeVol. 2, No. 4, Issue 6, Oct.-Dec., 2013Page: 211-213

Aims: To assess safety and feasibility of non-descent vaginal hysterectomy. Methods: A hospital based prospective study was conducted at the department of obstetrics and gynecology of Kathmandu Medical College Teaching Hospital from 1st January 2010 to 31st December 2011. All the patients undergoing non -descent vaginal hysterectomy for benign indication, without suspected adnexal pathology were included in the study. Vaginal hysterectomy was done in usual manner. In bigger size uterus morcellation techniques like bisection, debulking, myomectomy, slicing, or combination of these were used to remove the uterus. Data regarding age, parity, uterine size ,estimated blood loss, length of operation, complication and hospital stay were recorded. Results: A total of 50 cases were selected for non-descent vaginal hysterectomy. Among them 43 cases successfully underwent non-descent vaginal hysterectomy. Commonest age group was (41-45 years) i.e. 40%. All patients were parous. Uterus size was 10 weeks in 23 cases. Commonest indication was leiomyoma of uterus (63%). Mean duration of surgery was two hours. Mean blood loss was 205.26ml. Reasons for failure to perform NDVH was difficulty in opening pouch of Douglas in three cases. In rest of four cases there was difficulty in reaching the myoma and transverse diameter was too large so as to prevent descent of the uterus. The most common complication was post –operative pain in 23% of cases. Febrile morbidity was present in 4.6% of cases. Blood transfusion was required in seven cases. Average duration of hospital stay was three days. Conclusions: Vaginal hysterectomy for benign gynecological causes other than prolapse is safe and feasible. For successful outcome size of uterus, size in all dimensions and location of fibroid should be taken into consideration.Today in the era of minimally invasive surgery, non descent vaginal hysterectomy needs to be considered and seems to be a safe option. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11134 Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 14-16

Background: Chronic pelvic pain is a common problem in reproductive age group women. Diagnosis of chronic pelvic pain needs multidisciplinary approach. Diagnostic laparoscopy is one of the investigations which can help in reaching the diagnosis. Objective: To know the etiology in chronic pelvic pain. Methods: This was a descriptive study done in the Department of Obstetrics and Gynaecology of Kathmandu medical college teaching hospital from January 2010 to June 2012 (30 months). All the cases of laparoscopic surgery done for chronic pelvic pain were noted and details of these cases were analyzed regarding age, parity and laparoscopic findings. Results: Total 48 cases of Chronic Pelvic Pain underwent diagnostic laparoscopy during the study period. Mean age of cases were 33 years, ranging from 20-46yrs. Almost half of the cases 43.75% were of parity two. Laparoscopic finding was negative in 29.17% and pelvic pathology was present in 70.83% of the cases. Out of the pelvic pathology endometriosis was present in 55.88% followed by pelvic adhesions, pelvic congestion and pelvic inflammatory disease, chronic ectopic in 20.58%, 14.70%, 5.88%, 2.94% respectively. Conclusion: Diagnostic laparoscopy is a useful modality in the diagnosis of etiology and management of Chronic pelvic pain. In our study, Pelvic endometriosis was the most common pelvic pathology in cases of Chronic pelvic pain. DOI: http://dx.doi.org/10.3126/jkmc.v1i2.8146 Journal of Kathmandu Medical College, Vol. 1, No. 2, Oct.-Dec., 2012: 100-102

Introduction: Laparoscopic surgery is one of the most common procedures performed for benign ovarian masses. The aim of the study was to analyze all benign ovarian masses treated laparoscopically to assess safety, feasibility and outcome. Methods: A prospective study was carried out at Kathmandu Medical College Teaching Hospital, Sinamangal, Nepal. All the patients undergoing laparoscopic surgery for benign ovarian masses from 1 st January 2012 to 31 st December 2012 were included in the study. The pre-operative findings, intra-operative findings, operative techniques and post-operative complications were analyzed. Results: Thirty-six patients were taken for the study. Two cases were excluded since intra-operatively they were tubo-ovarian masses. The most common tumor was dermoid cyst (n=13; 38.23%) and endometriotic cyst (n=14; 41.17%). Out of 34 cases, five cases of endometriotic cyst (14.70%) were converted to laparotomy due to severe adhesions and four cases of endometriotic cyst underwent deroofing surgery. Two cases underwent laparoscopic assisted vaginal hysterectomy with bilateral salphingo-oopherectomy. Successful cystectomies were carried out in 22 cases. None were malignant. Major complications were not noted while minor complications like port-site infection (n=3; 8.82%) and subcutaneous emphysema (n=1; 2.9%) were present. Conclusions: Laproscopic management of benign ovarian masses is safe and feasible.

To compare the operative findings, operative procedure and complications, postoperative complications and hospital stay in patients with ectopic pregnancy managed by laparoscopy and conventional laparotomy.A cross-sectional, observational study.Department of Obstetrics and Gynaecology, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal, from October 2009 to October 2010.All patients with ectopic pregnancy confirmed during surgery, were included in the study. Patients with preoperative diagnosis of ectopic pregnancy but confirmed not to be so during surgery were excluded. Data regarding the studied variables were collected by interviewing patients postoperatively, reviewing the charts and operative notes and by following-up the patients till discharge.There were a total of 32 cases of ectopic pregnancy which was 4.4% of total deliveries during the study period. Twelve patients (37.5%) were managed by laparoscopy and 20 patients (62.5%) by laparotomy. All the patients who underwent laparoscopy and 40% patients who underwent laparotomy were haemodynamically stable pre-operatively. Laparoscopy was mostly performed for tubal abortion (40%) and unruptured ectopic pregnancy (25%) whereas laparotomy mostly for ruptured ectopic pregnancy (70%). Salpingectomy was the commonest procedure in both routes of surgery. One patient in the laparoscopy group and 4 patients (20%) in laparotomy group had complications with two of the latter requiring admission in intensive care unit.Laparoscopy is feasible and safer than laparotomy in the surgical management of ectopic pregnancy.

Background: Maternal mortality traditionally has been the indicator of maternal health all over the world. More recently review of the cases with near miss obstetric events has been found to be useful to investigate maternal mortality. Cases of near- miss are those in which women present with potentially fatal complication during pregnancy, delivery or the puerperium, and survives merely by chance or by good hospital care. Objectives : The objective of this study is to determine the prevalence and nature of near miss obstetric cases and maternal deaths at Kathmandu Medical College Teaching Hospital. Material and methods : This was a descriptive study done for the period of 24 months (1 January 2008 to 31 December 2009). Cases of severe obstetric morbidity were identified during daily morning meetings. All the cases were followed during their hospital stay till their discharge or death. Five factor scoring system was used to identify the near miss cases from all the severe obstetric morbidity. For each case of maternal death, data were collected from records of maternal death audit. Results : During the study period, 1562 women delivered at the institution and 36 women were identified as near-miss obstetrical cases. The prevalence of near miss case in this study was 2.3%. Five maternal deaths occurred during this period, resulting in a ratio of maternal death of 324 maternal deaths per 100,000 live births. Of the five maternal deaths three were due to pregnancy complicated with hepatitis E infection, one each due to Eclampsia and amniotic fluid embolism. Fifteen cases of near miss were due to haemorrhage (41.66%) and hypertensive disorder of the pregnancy was the cause in 10 (27.77%). Dystocia was the cause in 1(2.77%) case and infections in 7(19.4%) cases. Rare causes like anaesthetic complications were the cause in one case and dilated cardiomyopathy was the cause in two cases. Conclusion : The major causes of near-miss cases were similar to the causes of maternal mortality of Nepal. Need for the development of an effective audit system for maternal care which includes both near-miss obstetric morbidity and mortality is felt. Key words: Near-miss obstetric morbidity; Maternal mortality; Five factor scoring system DOI: 10.3126/kumj.v8i2.3563 Kathmandu University Medical Journal (2010), Vol. 8, No. 2, Issue 30, 222-226

The spontaneous conception & delivery of triplets occurs in 1: 6889 births. Most ofthe literature recommends caesarean section for triplets for better perinatal outcomeof especially second and third baby, however, we describe vaginally delivered tripletswith good perinatal outcome.1. Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal.Address for correspondence : Dr. Rachana Saha, LecturerDepartment of Obstetrics and GynaecologyKathmandu Medical College Teaching Hospital, SinamangalP. O: 5919, Kathmandu, NepalKey Words: Triplets, Mode of delivery, Neonatal outcome.

Amniotic fluid embolism is a rare emergency in obstetrics with high mortality rate. Here we report a case of amniotic fluid embolism managed successfully. Key word: Amniotic Fluid Embolism doi:10.3126/njog.v1i2.2399 N. J. Obstet. Gynaecol Vol. 1, No. 2, p. 55-58 Nov-Dec 2006

Aim: To analyse the measures taken for controlling primary Post-partum haemorrhage (PPH). Methods: A hospital based descriptive and retrospective study was carried out from 1st January 2005 to 31st December 2006 in the department of Obstetrics & Gynaecology at KMCTH. All patients of having primary Post-partum haemorrhage were analysed for the treatment they received. Results: There were 15 cases of primary Post-Partum Haemorrhage (PPH) from a total delivery of 700 in the year 2005. 9 cases were solely of atonic post-partum haemorrhage. 2 cases were genital tract injuries, 1 case of retained placenta, 1 case of vulval haematoma and 2 cases were of combined cervical tear and atonic primary post-partum haemorrhage. Atonic post-partum haemorrhage remained most important cause. The most common treatment was use of oxytocic. Surgical procedure bilateral uterine artery ligation was frequently performed in 6 cases but it was not effective as a single procedure. B-Lynch brace suture was applied in 5 cases and was successful without further intervention. There were 2 maternal deaths from post-partum haemorrhage. In the year 2006 total number of deliveries was 835 and there were total 11 cases of post partum haemorrhage. The trend changed to from atonic PPH to traumatic PPH. There were 8 cases of traumatic PPH and there were 2 cases of placenta accrete. There was one case of atonic PPH. The overall incidence in two years was 1.6%. Conclusion: Among the various surgical methods adopted B-Lynch brace suture was found to be simple, effective and minimally invasive. Keywords: Atonic post-partum haemorrhage (PPH), surgical management of PPH. doi:10.3126/njog.v3i1.1432 NJOG 2008 May-June; 3(1): 10 - 13

Aim: This study was done to compare the effectiveness of drotaverine hydrochloride and valethamate bromide in shortening duration of labour. Methods: It is a hospital based prospective study, carried out in the department of Obstetrics & Gynaecology at Kathmandu Medical College Teaching Hospital (KMCTH), Sinamangal from 1st June to 31st August 2005. 99 patients, who were in active labour, were taken into the study. Out of which 50 were in drotaverine group (Group 1) who had received 40 mg of drotaverine hydrochloride intramuscularly at 3 to 5 cm dilatation of the cervix. Rest of 49 patients were in valethamate bromide group (Group 2). They received 3 doses of 8 mg valethamate bromide and 20 mg hyoscin butyl bromide intravenously half an hour interval. Result: The injection-delivery interval was studied in both Groups. The duration of injection-delivery interval was found to be almost equal in primigravidae of both Groups (p=0.72). But in multigravidae interval was significantly shorter in drotaverine Group (p=0.03). Conclusion: Both drotaverine and valethamate bromide are equally effective in shortening duration labour in primigravidae, where as drotaverine is more effective in multigravidae in accelerating labour. Keywords: Drotaverine, Valethamate bromide, cervical dilatation, labour acceleration doi:10.3126/njog.v2i2.1447 N. J. Obstet. Gynaecol 2007 Nov-Dec; 2 (2): 9 - 11

Objective: Overall objective of the study was to see effects of active management of third stage of labour (AMSTL) with oxytocin. Specific objective of the study was to look for incidence of Post-Partum Haemorrhage (PPH), length of 3rd stage, incidence of retained placenta and average blood loss. Methodology: A hospital based prospective, descriptive, observational study was carried out from 1st July 2005 to 30th June 2006 at department of Obstetrics and Gynaecology, Kathmandu Medical College Teaching Hospital (KMCTH). All patients undergoing vaginal delivery excluding twins, polyhydraminios and instrumental deliveries were included in the study. The active management of 3rd stage included administration of 10 units IU of oxytocin, early cord clamping, controlled cord traction and uterine massage. Blood loss was estimated by visual inspection and measured by jar pressed against perineum. Result: Total number of deliveries during the study period was 530. There were 13 cases of PPH. Incidence of PPH was 2.4%. There were six cases each of uterine atony and genital tract trauma. One case was of retained placenta requiring Manual Removal (MRP). Average third stage duration was less than 5 minutes. Average blood loss was 90 ml. In 2 cases the third stage lasted more than 30 mins. Conclusion: Active management of 3rd stage of labour reduces the incidence of PPH from uterine atony, reduces the duration as well as average blood loss during third stage.condition. Key words: Labor analgesia; epidural, combined spinal epidural; complications, dural puncture, postdural puncture headache (PDPH); prevention. doi:10.3126/njog.v1i2.1490 N. J. Obstet. Gynaecol Vol. 1, No. 2, p. 25 - 27 Nov-Dec 2006