Maternal Health in Sri Lanka: 75 years of national commitment towards excellence.

Sri Lanka has a legacy of religious and cultural practices promoting health, and its rulers have been responsive to health needs of the populace. The healthcare milieu that prevailed in the pre-colonial and colonial periods favorably influenced the evolution of maternal health in the last 75 years. Since independence, maternal health in the country improved in many dimensions and directions, in the backdrop of multiple sociodemographic changes and geopolitical fluxes, while far-reaching advances in the medico-technological and communication fields were taking place at global level. By 1948, maternal health services were extensive with maternity hospitals, midwifery training school and functional health units in place. The establishment of a cadre of government-trained midwives instead of training traditional birth attendants (TBAs) was a key policy decision that brought long-term dividends. The WHO supported training primary health care workers even before opening their country office in 1952. In the early days, obstetricians relied mostly on their skills to conduct dexterous maneuvers with the generous use of rotational forceps rather than resorting to abdominal deliveries. The Family Planning Association was founded in 1953, which introduced family planning services to the country till the government took over the subject in 1958. A rigorous campaign (punchi pawla raththaran), promoting sterilization was conducted for population control in 1974 ,which resulted in the total fertility rate coming down significantly. Maternal Death Surveillance and Response system (MDSR) was established in 1981 which has been recognized globally as a success and is being upscaled to a confidential Inquiry status. Commitment and untiring efforts of the Ministry of health: Family Health Bureau, professional organizations, development partners including the WHO, have contributed for the achievements in the area of women's health.

An Unusual Presentation of COVID-19 Associated Multisystem Inflammatory Syndrome in Adults (MIS-A) in a Pregnant Woman.

Based on available literature, pregnant women are at an increased risk of severe illness from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, compared to nonpregnant women. Consequences of coronavirus disease 2019 (COVID-19) in pregnancy have many implications in women's lives other than unfavorable obstetric outcomes. In addition to managing acute respiratory illness and symptoms, caregivers should be equipped to detect and manage the short-term, intermediate, and long-term consequences of SARS-CoV-2 infection as well. Many pregnant women can remain asymptomatic and continue their pregnancy without being diagnosed. Pregnancy outcomes and consequences of SARS-CoV-2 infected yet asymptomatic mothers have not been very well explained. Reports of a new multisystem inflammatory syndrome in children (MIS-C) and multisystem inflammatory syndrome in adults (MIS-A) following COVID-19 have been described. However, MIS-A in pregnancy is an extremely rare presentation that can cause a huge diagnostic dilemma to caregivers. We describe the successful management of a pregnant woman with MIS-A following SARS-CoV-2 infection.

Ovarian lymphoma in a patient on long-term sulfasalazine for ulcerative colitis.

We report a case of ovarian lymphoma in a 59 year old woman with ulcerative colitis for over 20 years. She presented with intermittent high fever and right sided abdominal pain for 3 weeks. An ultrasound scan and CT scan revealed a right adnexal mass measuring 71 X 54 mm which was well defined with a thick wall and internal septations and enlarged pelvic and para aortic lymph nodes. The patient underwent bilateral salpingo oophorectomy and omentectomy. Histology confirmed a diffuse large B cell Non Hodgkin's lymphoma and she was referred for chemotherapy. After 6 cycles of chemotherapy she showed a good response. Lymphoma of the gastrointestinal tract arising in a background of ulcerative colitis has been known to occur, ovarian lymphoma with a background of ulcerative colitis has not been reported.

Therapeutic uses of post-partum tissue-derived mesenchymal stromal cell secretome.

Human post-partum tissue mesenchymal stromal cells (hPPT-MSCs) are widely used in research to investigate their differentiation capabilities and therapeutic effects as potential agents in cell-based therapy. This is ascribed to the advantages offered by the use of MSCs isolated from hPPT over other MSC sources. A paradigm shift in related research is evident that focuses on the secretome of the human MSCs (hMSCs), as therapeutic effects of hMSCs are attributed more so to their secreted growth factors, cytokines and chemokines and to the extracellular vesicles (EVs), all of which are components of the hMSC secretome. Positive therapeutic effects of the hPPT-MSC secretome have been demonstrated in diseases related to skin, kidney, heart, nervous system, cartilage and bones, that have aided fast recovery by replacing damaged, non-functional tissues, via differentiating and regenerating cells. Although certain limitations such as short half -life of the secretome components and irregular secreting patterns exist in secretome therapy, these issues are successfully addressed with the use of cutting-edge technologies such as genome editing and recombinant cytokine treatment. If the current limitations can be successfully overcome, the hPPT-MSC secretome including its EVs may be developed into a cost-effective therapeutic agent amenable to be used against a wide range of diseases/disorders.

Recurrent empty follicle syndrome with different stimulation protocols - A case report.

We report a case of recurrent empty follicle syndrome (EFS) where no oocytes were aspirated in two separate IVF cycles using two different protocols. In the second cycle, oocyte aspiration in one ovary was delayed for 24 hours after administering a second dose of human chorionic gonadotropin injection (hCG) and still no oocytes were recovered. In view of the presence of severe male factor infertility and failure to retrieve oocytes in 2 stimulated cycles, the couple was offered donor embryo transfer which resulted in a singleton pregnancy. A baby girl weighing 2800 g was delivered by an elective caesarean section at term. This case highlights that the change of protocol or repeat hCG administration is unlikely to change the outcome of genuine empty follicle syndrome.

Implementation of an individual patient prospective database of hospital births in Sri Lanka and its use for improving quality of care.

OBJECTIVES: This study was aimed at piloting a prospective individual patient database on hospital deliveries in Colombo, Sri Lanka, and at exploring its use for developing recommendations for improving quality of care (QoC). DESIGN: Observational study. SETTING: De Soysa Maternity Hospital, the largest referral hospital for maternity care in Sri Lanka. DATA COLLECTION AND ANALYSIS: From July 2015 to June 2017, 150 variables were collected for each delivery using a standardised form and entered into a database. Data were analysed every 8 months, and the results made available to local staff. Outcomes of the study included: technical problems; data completeness; data accuracy; key database findings; and use of data. RESULTS: 7504 deliveries were recorded. No technical problem was reported. Data completeness exceeded that of other existing hospital recording systems. Less than 1% data were missing for maternal variables and less than 3% for newborn variables. Mistakes in data collection and entry occurred in 0.01% and 0.09% of maternal and newborn data, respectively. Key QoC indicators identified in comparison with international standards were: relatively low maternal mortality (0.053%); relatively high maternal near-miss cases (3.4%); high rate of induction of labour (24.6%), caesarean section (30.0%) and episiotomy (56.1%); relatively high rate of preterm births (9.4%); low birthweight rate (16.5%); stillbirth (0.97%); and of total deaths in newborn (1.98%). Based on key indicators identified, a list of recommendations was developed, including the use checklists to standardise case management, training, clinical audits and more information for patients. A list of lessons learnt with the implementation of the data collection system was also drawn. CONCLUSIONS: The study shows that the implemented system of data collection can produce a large quantity of reliable information. Most importantly, this experience provides an example on how database findings can be used for discussing hospital practices, identifying gaps and to agree on recommendations for improving QoC.

Hyperechoic amniotic fluid in a term pregnancy.

The presence of highly echogenic amniotic fluid (AF) is uncommon, and presence creates a dilemma in the mind of the clinician. Echogenic AF has been attributed to meconium, blood, and vernix caseosa. Many studies have shown that the presence of meconium is unlikely in most cases. We report a case of highly echogenic AF detected at 37 weeks which was managed conservatively with careful fetal monitoring for further 2 weeks expecting spontaneous onset of labor. Labor was induced due to reduced fetal movements at 39 weeks. Healthy baby weighing 3130 g was delivered by cesarean section after a failed induction with prostaglandin.

Service provider perceptions of the trend in severity of symptoms and complications in women admitted following an incomplete abortion.

BACKGROUND: Sri Lankan abortion law which dates back to the year 1883, and still unchanged, only allows a legal termination when the mother's life is in danger. Many studies undertaken in the country estimates that even in the light of such a backdrop, and with a high contraceptive prevalence rate, many women attempt an abortion when faced with an unwanted pregnancy. This study aims to describe the changes in abortion-related complications in the country over a period of time and explore the reasons for any changes in severity of symptoms among women hospitalized following an abortion based on the perceptions of healthcare service providers. METHOD: Using an interviewer guide, in-depth interviews were carried out among 30 service providers of post abortion care with more than 5 years of experience in obstetrics and gynecology in Sri Lanka. RESULTS: Service providers perceived that the number of women presenting to hospitals after an induced abortion caused by a mechanical method is minimal or not at all at present. Over time, a significant reduction is seen in the number of women presenting with any abortion-related complications and the severity of complications has also reduced significantly. The common method of termination at present identified by the providers was the use of "drugs" or "the drug - Misoprostol." CONCLUSION: Over the years, women appear to have switched from surgical and mechanical methods to medical means (drugs) to induce an abortion and this change has contributed to reduce the severity of complications.

Guillain-Barré syndrome in pregnancy: A conservatively managed case.

Guillain-Barré syndrome (GBS) is an autoimmune disease. Estimated population incidence ranges from 0.62 to 2.66 cases per 100,000 person-years across all age groups. We report a case of GBS in a 22-year-old primigravida who presented at 36 weeks of the period of gestation (POG), with complaints of bilateral progressive lower limb numbness and weakness for 2 weeks duration. Magnetic resonance imaging of the brain was done to exclude other possible causes. Diagnosis of GBS was made according to the Brighton criteria, which our patient falls into Level 2. She received intensive care management. The patient improved rapidly without any specific management. She went to labor spontaneously and delivered a healthy baby with a birth weight of 2.8 kg at 38 weeks of POG. She continued to receive supportive therapy and improved significantly.

Luteinized ovarian thecoma in a postmenopausal women presenting with virilization.

We report a case of luteinizing thecoma in a 58-year-old postmenopausal woman who presented with progressive androgenic features and hypertension of one year duration. She did not notice a significant change in her body weight or appetite. Her total serum testosterone level was 4.5 ng/mL. Ultrasound scan revealed a normal-sized uterus and a right-sided solid ovarian mass of 5 cm x 5 cm. Left ovary was normal. She had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and an omentectomy performed. Histological examination confirmed the diagnosis of luteinized thecoma. This case illustrates the necessity to consider the rare possibility of luteinized ovarian thecoma as a cause for virilization in a menopausal woman.