Pregnancy with Complete Heart Block-An Emergency Cesarean Section with Temporary Pacemaker: A Case Report.

Management of a pregnant woman with complete heart block presenting during pregnancy and without pacing remains debatable. To bear up against any hemodynamic variations in peripartum period, temporary pacemakers have been advocated by some authors. Herein, we report a case of successful management of a 24 year old, pregnant woman with CHB who had an uneventful emergency caesarean delivery under spinal anesthesia after temporary pacing. She was an unbooked patient detected with CHB first time during active stage of labour. She delivered a healthy male baby and was discharged from the hospital in a stable and satisfactory condition on seventh postoperative day.

Anatomy of Internal Iliac Artery and Its Ligation to Control Pelvic Hemorrhage.

Pelvic hemorrhage is a major cause of maternal morbidity and mortality in developing countries. A sound clinical judgment, adequate assessment, and preparation of the patient are the best preoperative means to avoid its occurrence. Bilateral internal iliac artery ligation is a life-saving procedure to control massive obstetric and gynecological hemorrhage when other measures fail. This procedure significantly reduces the pulse pressure and rate of blood flow abolishing theâ€Ëœtriphammer effect’ of arterial pulsation and subsequently resulting in sluggish blood flow allowing effective thrombosis within the small bleeding vessels. This has helped to save many lives and uteruses for more than a century. No tissue necrosis occurs due to ample collateral circulation in the pelvis from the major pelvic anastomoses. An increased understanding of retroperitoneal anatomy and regional variations of the internal iliac artery is needed to reduce the risk of intraoperative and postoperative complications. Keywords: internal iliac artery ligation;operative complications;pelvic anastomoses;pelvic hemorrhage;retroperitoneal anatomy.

Risk Factors Related to Intrauterine Fetal Death.

BACKGROUND: Intrauterine fetal death is a traumatic event. Stillbirth rate is an important indicator to assess the quality of antenatal care. The objective of the study was to identify the risk factors related to intrauterine fetal death in patients admitted with intrauterine fetal death. METHODS: It was a descriptive study conducted in the department of Obstetrics and Gynaecology at B. P. Koirala Institute of Health Sciences from January to December 2014. Patients admitted with singleton pregnancy with intrauterine fetal death after 28 weeks gestation were included. RESULTS: There were 11,006 obstetric admissions. Of them, 152 women had intrauterine fetal death. There were 128(84.2%) women between 20-35 years of age. Out of 152, 81(53.3%) women were preterm and 39(2.1%) women were postterm. Primigravida were 77(50.7%) followed by 35(23%) of second gravida. Hypertension was the commonest identified risk factor in 30(26.78%) women. Out of 152 women, 49(32.2%) had not received formal education. Ten (6.6%) women had a past history of fetal death. Four (2.6%) women had medical disorder before pregnancy. One hundred and twenty five (82.2%) women had vaginal delivery, 21(13.8%) had caesarean section and 6(3.9%) had laparotomy for rupture uterus. The commonest indication for caesarean section was placenta previa for 7(33.33%) women. Four (2.6%) women had diabetes. Ninety five (62.5%) were male and 57(37.5%) were female babies. Five (3.3%) babies had malformations. CONCLUSIONS: Hypertension in pregnancy was found to be the most common identified risk factor for intrauterine fetal death.

Butorphanol in Labour Analgesia.

INTRODUCTION: Labour is the process where uterine contractions lead to expulsion of product of conception through the vagina into the outer world. Labour pain is one of the most severe pains which has ever been evaluated and its fear is one of the reasons women wouldn't go for natural delivery. Delivery is a painful experience for all of the women except a few of them. The labor pain results from some physiological-psychological causes. Different pharmacological and non-pharmacological methods have been tried for pain relief in labour. The objective of this study is to see the effect of butorphanol injection in labour pain. METHODS: It is a descriptive cross-sectional study conducted in B.P. Koirala institute of health sciences. We observed 200 pregnant women meeting the inclusion criteria and giving the informed consent who were on 1 mg butorphanol i.m. at the onset of active stage of labour every 4 hourly and on demand. Pain assessment was done by Numerical Pain analogue scale measured from 1 to 10. Fetal heart rate monitoring was done according to the hospital protocol. Caesarean section was performed for obstetrical indication. Neonatal outcome was evaluated by on duty pediatrician and APGAR score were noted at 1 and 5 min. RESULTS: The pain scores in first, second, third, fourth hour were (8.83±0.773), (9.84±0.544), (9.94±0.338), (9.6±0.298) respectively, where 1st and 2nd hour is statistically significant. CONCLUSIONS: Butorphanol is an effective labour analgesia without significant adverse effects on women and the neonatal outcome.

Significance of Serum Uric Acid in Pregnancy Induced Hypertension.

BACKGROUND AND OBJECTIVE: Hypertension is one of the common medical complications of pregnancy and contributes significantly to maternal and perinatal morbidity and mortality. Uric acid (UA) is filtered, reabsorbed and secreted by the kidney. Thus, this study was conducted to assess the serum UA levels in PIH and to evaluate the diagnostic value of serum UA level in PIH. MATERIALS AND METHODS: This is a hospital based comparative cross-sectional study conducted in BPKIHS. Ninety study participants were included; forty five participants were diagnosed of PIH and forty five in control group after obtaining informed consent from study participants from August 2014 to May 2015. Serum UA was done by Uricase method and serum creatinine was done by Jaffe's alkaline picrate method in cobas c311 autoanalyser. Data were expressed in frequency, percentage, mean ± S.D., median (IQR), and Independent t-test, Mann-Whitney U test were applied. p Value <0.05 is considered to be significant. RESULTS: Mean serum UA levels was higher in PIH compared to control group (5.46 ± 1.51 vs 4.03 ± 0.69) respectively. ROC curve demonstrated that serum UA showed a superior diagnostic efficiency (Sensitivity - 79.07%, Specificity - 71.19%) compared to creatinine (Sensitivity - 62.75%, Specificity - 27.45%) in PIH respectively. CONCLUSION: The present study shows that serum UA is significantly raised in PIH compared to the control group. Assessment of uric acid is a convenient and cost-effective method for determination of severity in PIH. Thus, serum uric acid can still be used as prevalent marker for risk assessment in PIH.

Cystatin-C as a Marker for Renal Impairment in Preeclampsia.

Preeclampsia is a devastating pregnancy-associated disorder characterized by the onset of hypertension, proteinuria, and edema with limited plausible pathophysiology known. Cystatin-C, a novel marker for the detection of renal impairment, is increased in preeclampsia at an early stage. This study was aimed to evaluate the diagnostic efficiency of Cystatin-C as an early marker of renal function in preeclampsia comparing it to the traditional renal markers. A hospital based comparative cross-sectional study was performed on 104 women (52 diagnosed cases of preeclampsia and 52 healthy pregnant women). Concentrations of Cystatin-C, creatinine, urea, and uric acid were measured in both the study groups. Mean serum Cystatin-C and uric acid levels were elevated in preeclampsia cases compared to controls (1.15 ± 0.37 versus 0.55 ± 0.12; 5.40 ± 1.44 versus 3.97 ± 0.68, resp.). ROC curve depicted that Cystatin-C had the highest diagnostic efficiency (sensitivity, 88.24%; specificity, 98.04%) compared to creatinine and uric acid. Serum Cystatin-C consequently seemed to closely reflect the renal functional changes, which are believed to lead to increased blood pressure levels and urinary excretion of albumin and may thus function as a marker for the stage of the transition between normal adaptive renal changes at term and preeclampsia.

HYPEREMESIS GRAVIDARUM IN A TERTIARY CARE CENTRE IN EASTERN NEPAL: A PROSPECTIVE OBSERVATIONAL STUDY.

BACKGROUND: Hyperemesis gravidarum (HG) is the most severe form of nausea and vomiting of pregnancy which can have potentially dangerous complications if untreated. Its treatment is basically supportive as the condition itself is self-limiting. The aim of our study was to evaluate maternal characteristics in patients with HG including risk factors and treatment outcome with respect to improvement in Pregnancy Unique Quantification of Emesis (PUQE) scores, number of doses of antiemetics used, weight gain during treatment and duration of intravenous fluid therapy METHODS: A cross-sectional study where all women admitted to B.P. Koirala Institute of Health Sciences with a diagnosis of HG during a period of one year were studied for different maternal characteristics. The severity of disease was quantified using Modified PUQE score and the various treatment outcomes considered. RESULTS: The admission for hyperemesis gravidarum (n=81, including 13 readmissions) was 10.64% of total early pregnancy admissions (n = 735).The condition was more common in nulliparous patients (56%) at a mean period of gestation of 8.93 ± 2.33 wks. Most patients suffered from moderate to severe disease at presentation, mean PUQE scores being 12.29 ± 1.59. The median number of doses of intravenous antiemetics used was three (IQR 3-6), median weight gain was one kg (IQR 0-1 kg), median duration of intravenous fluid therapy was 24 hrs (IQR 24-48 hrs) and mean length of hospital stay was 3.2 ± 1.48 days. CONCLUSIONS: Hyperemesis is one of the common causes of hospitalization in early pregnancy. Treatment has favourable outcome with early recovery.

Asymptomatic bacteriuria in pregnant women.

INTRODUCTION: Asymptomatic bacteriuria is the significant presence of bacteria in urine of an individual without symptoms. The aim of the study is to determine the prevalence of asymptomatic bacteriuria in pregnant women. METHODS: This study was a prospective study conducted in the department of Obstetrics and Gynaecology at B. P. Koirala Institute of Health Sciences. The duration of the study was six months from January to June 2012. A total of 600 pregnant women were enrolled. All women were clinically identified to have no signs and symptoms of UTI. Clean catch midstream urine sample was collected from each patient into a sterile vial. The urine samples were examined for microscopic and culture sensitivity test. RESULTS: Out of 600 pregnant women, 52 were positive for significant bacteriuria with a prevalence rate of 8.7%. There was a significant difference in prevalence of asymptomatic bacteriuria with respect to trimester (p=0.005). Age did not show any significant difference in the prevalence of asymptomatic bacteriuria (p=0.807). There was not any significant difference in the prevalence of asymptomatic bacteriuria with respect to parity (p=0.864) and booking status (p=0.397). Escherichia coli (35%), Acinetobacter species (15%), Enterococcus species (12%) and Klebsiella pneumoniae (10%) were the common isolates. Most of the isolates were sensitive either to Nitrofurantoin, Norfloxacin or Amikacin. CONCLUSIONS: Asymptomatic bacteriuria is common in pregnancy. Urine culture sensitivity should be carried out routinely on all pregnant patients in order to prevent the dangerous complications associated with it.