Rate and risk factors of inadequate endometrial tissues after endometrial sampling among Bhutanese women at the national referral hospital of Bhutan: a cross-sectional study.

INTRODUCTION: Women presenting with abnormal uterine bleeding needs careful and thorough assessment including ultrasound examination of endometrium and histopathological assessment of the endometrial tissues. The objective of this cross-sectional study was to determine the rate and the factors associated with inadequate endometrial tissues after endometrial sampling using MedGyn® pipette among Bhutanese women at the colposcopy clinic, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Bhutan. METHODS: This cross-sectional study was conducted at the colposcopy clinic, JDWNRH, Thimphu between October, 2021 and March, 2022. Women included in this study underwent endometrial sampling using MedGyn® pipette without anesthesia as an office procedure. Data were collected using an interviewer-administered questionnaire and results extracted into a structured pro forma. The histopathology reports were extracted from the Department of Pathology and Laboratory Medicine, JDWNRH using the unique Bhutanese citizenship identity card number of the study participants. RESULTS: Inadequate endometrial tissues were noted in 27% (33 out of 122 cases). Among 89 patients with an adequate endometrial tissue, histologic results were normal in 30 (33.7%), benign pathology in 22 (24.7%), atrophy in 10 (8.2%), and hyperplasia in 27 (30.3%). In a univariate analysis, menopausal state (OR 1.6, 95% CI 0.708-3.765), overweight and obese (OR 1.6 95% CI 0.640-3.945), unemployed (OR 1.7, 95% CI 0.674-1.140), nulliparous (OR 1.7, 95% CI 0.183-15.816), primipara (OR 5.1, 95% CI 0.635-40.905) and use of hormonal contraception (OR 2.1, 95% CI 0.449-10.049) were associated with increased risk of inadequate endometrial tissues. On multivariate regression analysis, nulliparity (OR 1.1, 95% CI 0.101-12.061), overweight and obesity (OR 1.4, 95% CI 0.490-3.917), use of hormonal contraceptives (OR 2.2, 95% CI 0.347-13.889), and junior surgeons (OR 1.1, 95%CI 0.463-2.443) were found to be associated with inadequate endometrial tissues. However, the above associations were not statistically significant (p > 0.05). CONCLUSION: The rate of inadequate endometrial tissue following endometrial sampling using MedGyn® pipette was 27.0%. Factors associated with an increased risk of inadequate endometrial tissue after endometrial sampling were menopausal state, overweight and obese, unemployed, nulliparous, primipara and use of hormonal contraception.

Hemivertebra with pathogenic microdeletion of chromosome 9.

Hemivertebra is a rare congenital abnormality of the spinal column. Hemivertebra with other structural and cytogenetic abnormalities are reported. The prognosis is favorable with partial hemivertebra and with a single spinal defect as compared to a defect involving full segments and affecting different levels of the spines. The perinatal outcome is obscured when it is associated with other syndromes or cytogenetic abnormality. It is imperative to do serial thorough anatomical ultrasound scanning and to screen for chromosomal abnormality when hemivertebra is detected during pregnancy.

Population-level cancer screening and cancer care in Bhutan, 2020-2023: a review.

Screening of cancers is an important intervention in reducing the incidence and mortality related to cancers. Bhutan is one small country that is witnessing an increasing incidence and mortality related to cancers. The government implemented a time-bound population-level screening for gastric, cervical and breast cancers from 2020 to 2023 with an overall coverage of 91.2% of the eligible population. Among 370,225 individuals screened for H pylori, 32.4% tested positive; among 53,182 who underwent upper gastrointestinal endoscopy and biopsy, 255 (0.07%) had gastric cancer. Among 10,749 tested for HPV DNA, 9.3% were positive; among 9887 evaluated with colposcopy and biopsy, 154 (0.13%) had cervical cancer. For breast cancer screening, 72,283 underwent clinical breast examination, 845 mammography and cancer was detected in 73 (0.10%) individuals. In this article, we review how Bhutan implemented a population-level cancer screening programme with on boarding of multiple stakeholders and the participation of people across all districts.

Role of ultrasound scan in prenatal diagnosis of cloacal exstrophy.

Cloacal exstrophy is a rare and complex ventral abdominal wall defect. Prenatal diagnosis is possible with the use of detailed ultrasound scanning. Prenatal diagnosis of an anomalous fetus helps the parents and their families in making informed decisions. This write-up is to report a case of cloacal exstrophy diagnosed during the prenatal period using an ultrasound scan. The pregnant mother presented at 35 weeks of gestation underwent a detailed ultrasound scanning and note the findings; a large defect on the ventral surface of the anterior abdominal wall extending from the umbilicus to the inferior pelvis, with a large mass protruding through the defect, umbilical cord arising from the proximal part of the mass, with another tubular mass protruding from the inferior aspect of the larger mass giving an appearance of "elephant trunk," absent urinary bladder, absent anal dimple, and scrotum was seen inferior to the mass but failed to appreciate the phallus. Both kidneys were normal, and there was no spinal defect. In addition, pubic bones were widely separated, and there was splaying of the iliac bone. Based on the ultrasound scan findings, a prenatal diagnosis of cloacal exstrophy was made. The pregnant mother and their families were counseled about the anomalous fetus, and they decided to continue the pregnancy. At birth, the abnormalities present in the baby were consistent with the prenatal ultrasound scan findings. On postnatal day 5, the baby underwent a complete primary surgical repair of the defect which comprised of closure of the abdominal wall defect, repair of bladder defect, pelvic osteotomies, and creation of a colostomy. The abnormalities of cloacal exstrophy detected by the ultrasound scan during the prenatal diagnosis period were consistent with the abnormalities detected at birth. This concludes that an ultrasound scan is a reliable tool to diagnose cloacal exstrophy during the prenatal period.

Evaluation of decision to delivery interval and its effect on feto-maternal outcomes in Category-I emergency cesarean section deliveries in Phuentsholing General Hospital, 2020: A retrospective cross-sectional study.

Background and Aims: When there is an immediate threat to maternal or fetal life, it is recommended to deliver within 30 min of the decision to have favorable perinatal outcomes. However, there is no data on the delivery intervals for Category-I emergency cesarean section in Bhutan. The study evaluated the decision to delivery interval (DDI) and its effect on perinatal and maternal outcomes in Category-I emergency cesarean section. Methods: A retrospective cross-sectional study was conducted at the Phuentsholing General Hospital, Bhutan, from January 1, 2020 to December 31, 2020. Mothers who underwent Category-I emergency cesarean section were included. The demographic variables, patient transfer time, anesthesia time, operation time, DDI, and maternal and perinatal outcomes were recorded in a standard proforma. The data were analyzed using SPSS version 23. Results: Of 78 Category-I emergency cesarean sections, only 23 (29.5%) of the cases were able to perform within 30 min of the DDI. The median (interquartile range) DDI was 37 (30-44) min. More time was taken by anesthetists to administer anesthesia (20 [15-8] min). Fetal distress (40, 51.3%) was the commonest indication. The longest DDI was around 39 min for prolonged labor, and the shortest was 26 min for failed instrumental delivery. Over half of the newborns delivered more than 30 min of DDI had low APGAR scores (25, 32.1%) at 1 min and meconium was present (23, 29.5%). Intensive care was required in 11 (14.1%), of which there was 1 (1.3%) neonatal death. Conclusion: The Category-I emergency cesarean sections performed within recommended DDI of 30 min were much less. The main delay was due to the longer time taken for the patient transfer and time taken by the anesthetists to administer anesthesia. Perinatal outcomes were favorable when the deliveries were conducted within 30 min of DDI.

Impact of COVID-19 pandemic on reproductive, maternal, newborn, and child health care services in Phuentsholing General Hospital: A retrospective descriptive study.

Background: COVID-19 pandemic has derailed health care services. The health resources and manpower were prioritized and diverted to curb the COVID-19 infections at the cost of routine medical services to the people. The impact of the COVID-19 pandemic on maternal and child health is unknown. This study aimed to assess the impact of the Covid-19 pandemic on maternal and child health care services in Phuentsholing General Hospital. Methods: A descriptive retrospective study was conducted at Phuentsholing General Hospital from January 1 to June 30, 2022. The patient medical records were reviewed for the prepandemic years 2018, and 2019, and the pandemic years 2020, and 2021. The medical records of all the female patients and newborns who came to the Maternal and Child Health Unit (MCH), those who were admitted to the gynecology ward, and who underwent obstetrical and gynecological surgeries were reviewed. The data were analyzed using SPSS version 23. Descriptive statistics such as frequencies and percentages were used to describe the study variables. The line graph and bar graph were used to determine the trends and to compare the impact of COVID-19 on MCH services between the pre-pandemic and pandemic years. Results: During the COVID-19 pandemic, the total admission dropped by 10% to 14.4%; the total deliveries dropped by 16.1%; Cesarean section rate dropped to 12.9%; and fewer gynecological surgeries were performed (13.9% from 20.6%). There was a significant drop in antenatal and postnatal follow-up visits (31.5% and 24.51%) respectively; Pap smear dropped by 93% and colposcopy by 52%. The overall immunization coverage has dropped drastically during the pandemic period. Conclusion: The pregnant mothers and newborn babies missed antenatal and postnatal follow-up visits, missed immunization, and women were not able to be screened for cervical cancers during the pandemic. These negative impacts of the COVID-19 pandemic on maternal and child health care were profound.

Assessment of excessive vaginal discharge among women who presented to Phuentsholing General Hospital: A hospital-based study.

Introduction: Excessive vaginal discharge is troublesome for females. The majority of the women seek gynecological consultation due to excessive vaginal discharge. The causes vary from physiological to pathological discharge. Unless the cause is identified and treated, women will remain in distress. The present study was thus carried out to determine the most common cause of the excessive vaginal discharge. Methods: A cross-sectional study was conducted at the Phuentsholing General Hospital, Chukha, Bhutan, from May 1 to October 31, 2021. All females aged 18 years and older, irrespective of marital status, who presented with excessive vaginal discharge were recruited for the study. With due informed consent, a sterile speculum examination was performed and a high vaginal swab was collected and subjected to various tests. The data collected were analyzed using SPSS 23 software. Descriptive statistical tests were used for frequencies, percentages, mean, and standard deviations; the χ 2 test was used to determine associations, and a logistic regression test was performed to determine the effect of independent variables on dependent variables. Results: A total of 400 women were recruited for the study, of whom 362 (90.5%) women had infective causes for vaginal discharge. Trichomoniasis was the most common infection identified in 162 (40.5%) women, followed by bacterial vaginosis (91, 22.8%) and vulvovaginal candidiasis (52, 13.0%). In 38 (9.5%) women, infective cause was not found and categorized as physiological vaginal discharge. Malodorous, profuse discharge, vulval itching, dyspareunia, dysuria, and lower abdominal pain were significantly associated with infectious vaginal discharge. Conclusions: Excessive vaginal discharge was mainly caused by infections. The most commonly detected infection was trichomoniasis, followed by bacterial vaginosis and vulvovaginal candidiasis. Every female with vaginal discharge requires proper evaluations to identify the infection and treat it adequately.

Bell's palsy with preeclampsia in pregnancy.

Bell's palsy in pregnancy is not frequently seen. The association of preeclampsia with Bell's palsy is reported in the research, however, the exact link between Bell's palsy and preeclampsia is unknown. The treatment of Bell's palsy during the pregnancy is difficult and controversial. We report two cases of Bell's palsy with preeclampsia diagnosed during the third trimester of the pregnancy. The first case was diagnosed with Bell's palsy with severe preeclampsia with placental abruption with fetal distress; the pregnancy was terminated by cesarean section. Another case was diagnosed with Bell's palsy with mild preeclampsia. She had a spontaneous vaginal delivery at term. Both the cases achieved complete recovery from Bell's palsy after treatment with corticosteroid and antiviral drugs. Every obstetrician should be able to recognize Bell's palsy in pregnancy and initiate early treatment with corticosteroid and mount surveillance for preeclampsia.

A successful Vasovasostomy operation.

Vasectomy is performed as a permanent method of contraception for men after completing the family. Many men are seeking vasectomy reversal operations after remarrying new partners. The reversal operation is seen as a challenging procedure that requires a skilled surgeon and sophisticated instruments. This write-up reports a case of vasovasostomy performed successfully on an elderly man using the minimal available facilities at Phuentsholing General Hospital, Bhutan.

Indications and factors associated with cesarean section in Bhutan: A hospital-based study.

OBJECTIVE: To investigate the factors associated with cesarean section (CS) in Bhutan. METHODS: This was a cross-sectional study, using the retrospective data from the birth registers maintained in comprehensive emergency obstetric care centers for the year 2018. The data were entered in excel 2013 and analyzed using STATA 13. Multiple logistic regression was used to understand the factors associated with CS in Bhutan. RESULTS: The rate of CS in Bhutan was 18.7%. The indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. The factors associated with CS were maternal age over 25 years, male child, women with smaller number of living children, multiple pregnancy, and gestation over 40 weeks. In addition, mothers delivering in Samtse Hospital and Central Regional Referral Hospital had higher odds of CS. CONCLUSION: In Bhutan, CS was commonly performed for mothers with previous CS, fetal distress, and prolonged labor. Increasing maternal age, multiple pregnancy, and postdated pregnancy and those with one child, or none, were more likely to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS rate as well as preventing over-diagnosis of prolonged labor by focusing on the partograph.

Where chloroquine still works: the genetic make-up and susceptibility of Plasmodium vivax to chloroquine plus primaquine in Bhutan.

BACKGROUND: Bhutan has made substantial progress in reducing malaria incidence. The national guidelines recommend chloroquine (CQ) and primaquine (PQ) for radical cure of uncomplicated Plasmodium vivax, but the local efficacy has not been assessed. The impact of cases imported from India on the genetic make-up of the local vivax populations is currently unknown. METHODS: Patients over 4 years of age with uncomplicated P. vivax mono-infection were enrolled into a clinical efficacy study and molecular survey. Study participants received a standard dose of CQ (25 mg/kg over 3 days) followed by weekly review until day 28. On day 28 a 14-day regimen of PQ (0.25 mg/kg/day) was commenced under direct observation. After day 42, patients were followed up monthly for a year. The primary and secondary endpoints were risk of treatment failure at day 28 and at 1 year. Parasite genotyping was undertaken at nine tandem repeat markers, and standard population genetic metrics were applied to examine population diversity and structure in infections thought to be acquired inside or outside of Bhutan. RESULTS: A total of 24 patients were enrolled in the clinical study between April 2013 and October 2015. Eight patients (33.3 %) were lost to follow-up in the first 6 months and another eight patients lost between 6 and 12 months. No (0/24) treatment failures occurred by day 28 and no (0/8) parasitaemia was detected following PQ treatment. Some 95.8 % (23/24) of patients were aparasitaemic by day 2. There were no haemolytic or serious events. Genotyping was undertaken on parasites from 12 autochthonous cases and 16 suspected imported cases. Diversity was high (H E 0.87 and 0.90) in both populations. There was no notable differentiation between the autochthonous and imported populations. CONCLUSIONS: CQ and PQ remains effective for radical cure of P. vivax in Bhutan. The genetic analyses indicate that imported infections are sustaining the local vivax population, with concomitant risk of introducing drug-resistant strains.