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Background The dolutegravir-based antiretroviral regimen is the preferred first-line regimen for the management of people living with human immunodeficiency virus in Nepal recently. It is considered safe to transition to a dolutegravir-based regimen for children and adults on Nevirapine and Efavirenz-based regimens. Objective To determine the virologic response following the transition to a Dolutegravir-based regimen in people living with human immunodeficiency virus previously taking Nevirapine and Efavirenz-based regimen. Method This is a retrospective cohort study including people living with human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) who were transitioned to Tenofovir/Lamivudine/Dolutegravir previously on other antiretroviral therapy regimens for at least 6 months and who had their viral load test done before transition. The medical records of patients were reviewed from records available at the antiretroviral therapy clinic of Dhulikhel Hospital. The viral load done at least 3 months after switching to the Dolutegravir-based regimen was recorded. Descriptive analysis of socio-demographic and clinical characteristics data was done. Result Fifty-seven people living with human immunodeficiency virus/ acquired immunodeficiency syndrome who transitioned to a Dolutegravir-based regimen previously on other antiretroviral therapy regimens for at least 6 months were included in this study. Tenofovir/Lamivudine/Efavirenz (47.4%), Zidovudine/ Lamivudine/Nevirapine (22.8%) and Zidovudine/Lamivudine/Efavirenz (17.5%) were the most common antiretroviral regimens before transition. The majority of the patients (86%) had suppressed viral load of fewer than 40 copies/mL before the switch. Following the transition, 96.5% of the patients had suppressed viral load of fewer than 40 copies/mL. Conclusion Dolutegravir-based antiretroviral regimen led to untransmittable viral load following a switch from Nevirapine and Efavirenz-based regimen.

Background Urinary tract infection (UTI) is common in pregnancy and poses a great challenge because it has several adverse outcomes in both the mother and her unborn foetus. Objective This study aims to determine the incidence of culture positive urinary tract infection, culture and sensitivity of the common causative organisms and find out the maternal and perinatal outcomes in culture positive urinary tract infection. Method This prospective study was carried out in the Department of Obstetrics and Gynaecology at Dhulikhel Hospital over a period of one year. Urine routine and microscopy was done as a preliminary screening test for urinary tract infection and those with abnormal results were subjected to urine culture and sensitivity and ultrasonological evaluation. Result A total of 162 pregnant women were included in the study. Incidence of culture positive urinary tract infection was 25.9%, highest in age group 15-20 years (47.8%), more in primigravida (30.1%) and common at second trimester (40.4%). Escherichia coli (90.4%) was the commonest organism isolated and ceftriaxone was the most sensitive antibiotic. Patients with culture positive urinary tract infection had higher incidence of anaemia, preterm labour, need of surgical intervention. Such patients also had increased chances of preterm delivery, low birth weight babies and newborn intensive care unit (NICU) admission. Conclusion We conclude that urinary tract infection in pregnancy leads to adverse maternal and fetal outcomes. And we recommend urine culture and sensitivity at each trimester so that urinary tract infection can be diagnosed and treated on time.

Vaginal leiomyomas are rare, they are uncommon benign tumor with variable clinical presentation. They usually present as a mass per vaginum or dyspareunia or pressure symptoms on the neighbouring structures. We present a case of 47 years lady with mass per vaginum and difficulty in walking and chronic pelvic pain. Her clinical findings suggested a large mass in the left vaginal wall, the mass was approximately 12 x 10 cm in size hindering the visualization of the cervix. Her ultrasonography showed bulky uterus with mass occupying the cervix. This finding was not correlating with the clinical findings. Magnetic resonance imaging (MRI) was done and it was reported as mass lesion in pelvis separate from the cervix abutting the rectum posteriorly. Ultrasonography (USG) guided biopsy was done which was reported as Leiomyoma. She underwent vaginal myomectomy and was confirmed in histopathology as Leiomyoma. A leiomyoma is a smooth muscle tumor that arises from the muscular part of the uterus and rarely seen in the vaginal wall.

Background: The therapeutic goal in hypothyroidism is to achieve patients’ well-being and restore serum thyrotropin (TSH) to levels within the reference range. However, inadequate or over replacement is common in patients receiving levothyroxine. The Objective is to assess the treatment outcome of hypothyroid patients visiting outpatient clinic of medicine department of Kathmandu University Hospital, Dhulikhel, Nepal. Method: This is a cross sectional study on diagnosed Primary Hypothyroid patients who were taking levothyroxine replacement for at least six months. Patients were defined as euthyoid if their TSH was in the normal range (0.3-3.6 mmol/L) according to the hospital laboratory. Similarly patients were defined as over treated if TSH is 3.6 mmol/L. Results: A total number of 126 patients were enrolled for this study where mean age of participants was 40.88 ± 11.47 years and only 15 (11.1%) were male. Mean duration of hypothyroidism was 3.45 ± 2.57 years and mean Levothyroxine dose was 58.93 ± 26.89 mcg. In this study, nearly 70% of participants have normal TSH level. Similarly, 21% of participants have higher level of TSH and 9% have low TSH level. Multivariate logistic regression analysis did not show any significant co relation between treatment outcome and various variables. Conclusion: Treatment of hypothyroidism with levothyroxine being most effective, easily available, simple regimen and not costly, still one third of patients are not meeting the treatment outcome. However, being the pioneer study from Nepal, this study suggests improved treatment outcomes compared to similar studies from other countries.

Background Nepal has a high prevalence of congenital anomaly contributing to high infant mortality. Ultrasound, an important tool to detect congenital anomalies and manage maternity-related risk factors, is not properly used in Nepal because Nepali doctors have limited opportunities for learning ultrasound techniques. Hence, we developed and implemented an ultrasound education program from 2016 to 2018. The objective of this study is to evaluate the education program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Methods We conducted a mixed-method study to evaluate each component of RE-AIM. The team collected quantitative data from administrative records, tests, surveys, and an online follow-up survey. Qualitative data were collected from individual in-depth interviews at least a year after the program. The proportions, means, and t-tests were used for quantitative data, and thematic coding for qualitative data. Results A total of 228 healthcare workers representing 27.3% of the districts of Nepal were reached from 2016 to 2018. The program improved participants’ knowledge (29.3, 8.7, and 23.8 increases out of 100, each year, pn=85) and self-confidence (0.6, 0.3, 1.3 increases out of 4.0, pn=111). The participants were highly satisfied with the program (4.2, 4.1, and 4.0 out of 5.0, n=162). Among the respondents of the online follow-up survey (n=28), 60.7% had used ultrasound in their daily practice after the education program, and a medical institution established an ultrasound training center. The absence of clear accreditation and practical guidelines in ultrasound use were presented as barriers for adoption and maintenance. Conclusion The program was successful in improving participant’s knowledge and self-confidence in ultrasound techniques and showed great potential for the adoption and maintenance of the techniques in their practice. Continuous implementation of the program and institutional policy changes to facilitate ultrasound use may increase the ultrasound use and improve ultrasound service quality in Nepal.

Vaginal leiomyomas are rare, they are uncommon benign tumor with variable clinical presentation. They usually present as a mass per vaginum or dyspareunia or pressure symptoms on the neighbouring structures. We present a case of 47 years lady with mass per vaginum and difficulty in walking and chronic pelvic pain. Her clinical findings suggested a large mass in the left vaginal wall, the mass was approximately 12 x 10 cm in size hindering the visualization of the cervix. Her ultrasonography showed bulky uterus with mass occupying the cervix. This finding was not correlating with the clinical findings. Magnetic resonance imaging (MRI) was done and it was reported as mass lesion in pelvis separate from the cervix abutting the rectum posteriorly. Ultrasonography (USG) guided biopsy was done which was reported as Leiomyoma. She underwent vaginal myomectomy and was confirmed in histopathology as Leiomyoma. A leiomyoma is a smooth muscle tumor that arises from the muscular part of the uterus and rarely seen in the vaginal wall.

Introduction: Ultrasound is a valuable diagnostic tool for detecting the congenital anomalies in the fetus. Congenital anomalies are detected in 14% of new born. Major anomalies are detected in 2 to 5% of new born. This accounts for 20 % to 30% of total perinatal deaths. Prenatal diagnosis provides variety of management options for the pregnant women ranging from termination of pregnancy, elective delivery or intrauterine manipulation of the anomalies. Aims: To determine the prevalence of the fetal congenital anomalies at 20- 24 weeks ultrasonography. Methods: This is prospective study conducted at Dhulikhel Hospital. Pregnant ladies with singleton pregnancy at 20 to 24 weeks were enrolled for transabdominal ultrasound for detecting congenital anomalies. Results: Of 1027 pregnant ladies screened, anomalies were detected in 31 ladies during mid trimester ultrasound. The overall prevalence of congenital anomalies detected in our study is 3.02% (31 cases), which has sensitivity of 87.8%, specificity of 99.7% and positive predictive values of 93.5%. In our study, mean gestational age during scan was 21+5 weeks of gestation. And 13 pregnant ladies pregnancies were terminated between 20-24 weeks for having major congenital anomaly in fetus. Conclusion: Mid trimester ultrasonography is a valuable method for pregnant ladies to detect the congenital anomalies in fetus. When major anomalies are detected, timely termination of pregnancy have saved the cost and tragedy of losing viable fetus.

Background Pregnancy or gestation is the time during which a single or more children grows and develops inside a woman. Antenatal care improves the pregnancy outcomes under which a group of medication i.e. iron, folic acid and calcium are supplemented. Despite the effectiveness of such supplements, poor clinical outcomes are often encountered because of poor-adherence to the regimen. Objective To determine the adherence pattern and factors affecting adherence in antenatal care patients under iron, folic acid, and calcium therapy. Method A cross-sectional study was conducted in Dhulikhel Hospital, Kathmandu University Hospital. Pregnant women attending antenatal care under iron, folic acid, and calcium therapy fulfilling the inclusion criteria were enrolled in this study. After obtaining the informed consent from the patients, structured questionnaire was used to interview the patients. Statistical analysis was performed by using SPSS 23.0. P-value < 0.05 was considered as statistically significant. Result Among 191 patients enrolled in this study majority (39.3%) of them belonged to age group 26-30 years. More than half (61.3%) of the patients were illiterate. Of the total 191, 64.40% were non-adherent to the medication. Forgetfulness was the main reason for missing the dose in majority (52.06%) of the non-adherent subjects while adverse effects (55.40%) was the most prominent cause for discontinuing the medication among non-adherent participants. Significant association was found between patients’ adherence and busy work schedule, visiting doctor for follow up. Conclusion More than half of the patients had not adhered to the medication under antenatal care. Forgetfulness was the most common factor for missing the dose in nonadherent patients. Illiteracy was associated with poor adherence. Patient-provider relationship, Socio-economic factors were determined as major barrier to medication adherence.

Background: There should be high index of suspicion for timely detection of any complications for safe trial of labor in case of vaginal birth after cesarean. Emergency obstetric care must be available. Even with these provisions the vaginal birth after cesarean rate is decreasing in Dhulikhel Hospital in recent years. Methods: This retrospective study was conducted to compare different modes of delivery and pattern vaginal birth after cesarean in a gap of ten years in Dhulikhel Hospital (i.e. 2007 to 2009 versus 2017 to 2019). In this study factors associated with the successful vaginal birth after cesarean were also analyzed. Results: A total of 4215 deliveries conducted in the year 2007 to 2009, of them 890 (21.1%) were cesarean deliveries. Likewise altogether 9298 deliveries conducted in the year 2017 to 2019, of them 2849 (30.6%) were cesarean deliveries. Vaginal birth after cesarean rate is significantly decreased from 18.33% (33/180) to 8.8% (63/713) (p value = 0.0004). Instrumental deliveries, normal vaginal deliveries were significantly decreased in comparison to these in the year 2007 to 2009. Duration of labor of vaginal birth after cesarean (7.05±1.25 vs 7.13±2.02, p=0.8362) and mean fetal weight of vaginal birth after cesarean baby (2818.71±686.37 vs 2820.79±511.78, p=0.9867) were not much different. Conclusions: Over the years, vaginal birth after cesarean rate is decreased. Keywords: Cesarean section; fetal distress; institutional delivery; obstetric care; uterine rupture

Background: Ultrasound has revolutionized the pattern of care and management. Mid trimester ultrasound (transabdominal) is a valuable method for pregnant clients to predict preterm births. Objectives: To assess cervical length at 20 to 24 weeks obstetric scan for predicting risk of preterm delivery and to determine the sensitivity and specificity of assessing cervical length as a predictor of preterm delivery. Methodology: This is a prospective study conducted at a Tertiary Hospital. Pregnant clients with singleton pregnancy at 20 to 24 weeks were enrolled for transabdominal ultrasound for assessing cervical length as a predictor of preterm delivery. Results: Of 1027 pregnant clients screened, the mean age was 22.92±3.45. Mean gestational age during scan was 21+5 weeks of gestation. About 2.43% of clients were found to have short cervix < 2.5 cm with mean cervical length 3.8 cm. The risk of preterm delivery was almost two fold when cervical length was < 2.5 cm. The sensitivity, specificity, positive predictive value and negative predictive value to predict preterm delivery were 32%, 85.9%, 5.44% and 98.04% respectively. Conclusion: Assessment of the cervical length at mid-trimester can be useful tool for predicting risk of preterm delivery.

Objective To evaluate obstetric hemorrhage outcomes and present data specific to adoption of pneumatic circumferential abdominopelvic compression devices. Methods Two resource-limited locations added low-cost pneumatic compression devices to their standard protocols for obstetric hemorrhage between 2010 and 2019. Providers in rural Nepal and Papua New Guinea used devices that incorporated a bicycle tube or soccer ball ("Ball and Binder") to provide abdominopelvic pressure after all available routine treatments had failed. Data were collected during the entire period as part of ongoing obstetric quality improvement. Data presented include obstetric event, etiology of bleeding, need for surgery, transfusion, transport, length of transports, maternal survival, and complications. Results Circumferential abdominopelvic compression was used 106 times. The devices were used primarily after vaginal birth with atony, but also for obstetrical lacerations, miscarriages, and post-abortion bleeding. In all cases the bleeding stopped "promptly." All women survived, none required hysterectomy, and no complications were reported resulting from device use. Only 15 (14%) patients were transported to a referral hospital. Conclusion In this quality improvement project, obstetric hemorrhage was controlled when circumferential pressure was applied after usual care had failed.

Background: Thyroid dysfunction and hyperglycemia are common metabolic problem. Unrecognized thyroid dysfunction may amplify existing cardiovascular disease risk in hyperglycemic subjects. Early recognition and management of thyroid dysfunction helps to control blood glucose and prevent associated morbidity. The aim of this study was to assess thyroid function among prediabetics and compare it with healthy controls. Methods: This study conducted in Kathmandu University hospital was reviewed and approved by Institutional review committee. The total of 200 participants were recruited for the study among which 106 were prediabetics (HbA1c 5.7–6.4%) and 94 apparently healthy controls (HbA1c

Cervical carcinoma is the most common gynecological malignancy and almost curable cancer, if identifiedat an early stage. Cervical biopsy remains the ‘gold standard’ for the diagnosis of precancerous cervicallesion. The objective of this study was to review the histopathological findings of cervical biopsy includingcervical polypectomy and hysterectomy specimens at Dhulikhel Hospital from January 2008 to December2018. Out of 2098 cases, almost half of the cases (49.3%) were of Brahmin/Chhetri castes. There weresignificant differences in mean ages among hysterectomy cases (47.55±9.26), cervical biopsy cases(43.08±11.50) and polypectomy cases (33.59±12.47) (p value < 0.005). Out of 925 cervical specimens (cervicalbiopsy and polypectomy), colposcopy and hysteroscopy were performed in 18.2% and 12.7%, respectively.Out of 1173 hysterectomies, there were 110 cases (9.4%) of malignancies and cervical cancer was the mostcommon (67, 60.9%). The mean age of cervical cancer patients was 52.87±11.94 years. Cervical cancerdetected in age group of 40 – 59 years was significantly high (p value < 0.005). Incidence of cervical cancerwas lowest in Brahmin/Chhetris (2.4%) compared to Newars (3.4%) and other Janajatis (12.8%) and thedifference was statistically significant (p value < 0.005). The findings of thisstudy is useful in updating thehistopathological pattern of cervical biopsies. Keywords : Biopsy, cervical cancer,colposcopy, hysterectomy,polypectomy

DOI: https://doi.org/10.3126/njog.v13i3.23427 Aims: The aim of this study is to assess learning curves for laparoscopic hysterectomies, compare the performance of surgeons and review demographic parameters of the patients, varieties of complications experienced and indications of the procedures. Methods: A retrospective study was conducted in Kathmandu University Hospital, Kavre of January 1, 2011 to June 30, 2018. Results: A total of 1849 cases were already performed by mid 2018. Of them, 261 (14.12%) cases were LAVH and TLH cases. Mean duration for laparoscopic hysterectomies (for both LAVH and TLH) was 142.21±43.46 minutes (range 55 to 310 minutes) and one third of the cases performed in a range of 121 to 150 minutes. There is difference in mean duration of operation between surgeons which is statistically significant (p

Background: Ovarian tumours account for 15% to 25% of all primary malignancy and the leading cause of death from gynaecolgical malignancies. There are limited publications related to ovarian tumours from Nepal. Ovarian related surgeries are the common surgeries in Kathmandu University Hospital. This study aims to provide basic information related to ovarian tumours from this geographical region of Nepal. Objectives: To review the nature of ovarian problems and certain socio-demographic information namely: caste, age, address and co-morbid condition of the patients presenting with ovarian problems. Methodology: This is a retrospective study of patients seeking surgical treatment of ovarian lesions in Kathmandu University Hospital from January 1, 2011 to June 30, 2018. This study was undertaken by reviewing the inpatient, outpatients and OT records in the Department of Obstetrics and Gynaecology and the records from Department of Pathology. All the files and computer records were reviewed and analyzed for nature of ovarian problems and certain demographic variables. Results: Out of the 860 cases, about 61% were non-neoplastic while benign ovarian tumours and malignant ovarian tumours were 35% and 3.7 % respectively. Almost one third of the cases were of Brahmin/Chhetri (37.3%) and 58.3% of the patients were from Kavre district. Mean age of the patients with ovarian problems was 34.89±11.15 years (range 12-72 years). There was no statistically significant difference between the mean age of patients with non-neoplastic ovarian lesions and neoplastic ovarian lesions (p value = 0.3371). There was statistically significant difference between the mean age of patients with benign ovarian tumours and malignant ovarian tumours (p value = 0.0001). And malignant ovarian tumours were significantly high among patients above 41 years in comparison to benign ovarian tumours of same age group (p value = 0.0008). Out of 32, ten malignant ovarian tumours occurred in relatively young age group. Of the 860 ovarian lesions, 438 and 422 ovarian lesions were removed through open technique and laparoscopic techniques respectively. Mature cystic teratoma (64.1%) was the commonest benign tumor and serous cyst adenocarcinoma (43.8%) was the commonest malignant tumour in this study. Conclusion: Ovarian tumours are one of the gynaecological diagnoses in Kathmandu University Hospital. If only ovarian neoplasms are considered, most of the ovarian tumours are benign and few are malignant. Minimal invasive surgeries are possible, except that for malignant ovarian tumours.

The first case of coronavirus disease 2019 was reported on December 31, 2019 in Wuhan, China where the average case fatality rate was 6.1 ± 2.9%. There are 453 deaths as of September 24, 2020 in Nepal. We report the first death of a 29-years-old postpartum woman due to COVID-19 in Nepal who was referred from a rural health center to Dhulikhel Hospital. On arrival, she was taken to the acute respiratory zone of the emergency department to provide immediate lifesaving procedures. Despite the repeated resuscitative measures, return of spontaneous circulation could not be achieved. The real time polymerase chain reaction test was positive. Our case report highlights the importance of early clinical suspicion, importance of "safety first" in healthcare settings, and the chain of management in such patients. We consider the fact that a postpartum woman registered as the first case of COVID-19 related death in Nepal to be an area of further study.

Background Obstetrical hemorrhage continues to be the leading cause of maternal death; additional means of treatment are needed to reach women who are currently not being saved. We developed the "Ball and Binder", an inexpensive and innovative pneumatic abdominal-pelvic compression device made with a cloth binder and soccer ball. Objective To measure the change in distal aortic blood flow before and after placement of the device. Method A comparative study was done on nine healthy volunteers measuring the flow in the distal aorta before and after placement of a pneumatic abdominal binder. Result Distal aortic flow decreased by over half when the device was inflated. Conclusion An inexpensive pneumatic external abdominal compression "Ball and Binder" device was able to decrease flow to the pelvis by over half. This provides an additional tool for rapid treatment of postpartum hemorrhage unresponsive to routine initial measures.

Background The clustering of risk factors in metabolic syndrome increases the risk of atherosclerotic cardiovascular disease and all-cause mortality. The prevalence of coronary heart disease is high in diabetic patients with metabolic syndrome than non diabetic patients with metabolic syndrome. Objective To determine the prevalence of metabolic syndrome in new onset Type 2 Diabetes Mellitus (T2DM) and to study the risk components of metabolic syndrome. Method This is a hospital based cross sectional study conducted in 132 newly diagnosed T2DM patients at Dhulikhel Hospital, Kathmandu University Hospital in Nepal in 2018. The socio-demographic profile, clinical characteristics, and biochemical parameters were analyzed to study the prevalence, risk factors, and concordance between various definitions of metabolic syndrome. Statistical analysis was done using Student's t-test, Chi-square test and Kappa statistics. Result One hundred and thirty two newly diagnosed T2DM patients were included in the study. Majority of the patients (58.9%) were in the age group of 40-60 years with the mean age of 49.72±12.44 years. The prevalence of metabolic syndrome was 111 (84.1%), 106 (80.3.%), 94 (71.2%) and 82 (62.1%) using World Health Organization(WHO), Harmonized, National Cholesterol Education Program-Adult Treatment Panel III (NCEP ATP III) and International Diabetes Federation (IDF) definitions respectively. One hundred and six patients (80.3%) had 3 or more individual components of metabolic syndrome. There was substantial agreement between NCEP ATP III-Harmonized (k=0.714, p0.001) and Harmonized-WHO (k=0.716, p0.001) definitions for diagnosing metabolic syndrome. The increased prevalence of metabolic syndrome in females than males is due to increased prevalence of abdominal obesity (p0.05), dyslipidemia (low HDL cholesterol (p0.05)) and presence of diabetes. Conclusion The prevalence of metabolic syndrome in newly diagnosed T2DM is high in the Nepalese population. The central obesity and low HDL cholesterol were significant risk factors in female diabetic patients predisposing to metabolic syndrome.

Background The major goal of antiretroviral therapy (ART) is immunological recovery and virological suppression. Immunological and virological response in People Living with HIV (PLHIV) undertaking ART has to be monitored to assess the treatment response, diagnosing treatment failure and switching antiretroviral therapy. Objective To assess the immunological and virological response to antiretroviral therapy among Human Immunodeficiency Virus (HIV) infected individuals. Method This is a cross-sectional study including people living with HIV (PLHIV) taking antiretroviral therapy for at least 6 months and was conducted in Dhulikhel Hospital in 2017. The socio-demographic profile, clinical characteristics, CD4 count and viral load were analyzed. Descriptive analysis of socio-demographic and other characteristics was done. Result Fifty-two patients undertaking antiretroviral therapy were included in the study with the mean age of 29.69±9.59 years at diagnosis. The majority of the patients were male (51.9%). Sexual transmission was the dominant mode of transmission (78.9%). The mean CD4 count at baseline was 244.08±214.32 cells/µL. Four patients (7.7%) had a virological failure. There was a discordance between immunological and virological response in patients taking antiretroviral therapy for more than 2 years' duration with four patients with a recent CD4 count of ≤250 cells/µL had virological suppression. The mean CD4 count at treatment increased from 229.65 cells/µL to 453.33 cells/µL after 1 year of commencement of antiretroviral therapy (p0.001). Conclusion There are optimal CD4 recovery and virological suppression as expected with antiretroviral therapy use.

Background One of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery. Dhulikhel Hospital is one of the very few institutions in Nepal where minimal invasive gynaecological surgeries are being regularly performed since early years of its establishment. There are very few publications related to experiences of minimal invasive gynaecological surgeries published in Nepal. Objective To review the varieties of minimal invasive gynaecological surgeries and find out the different milestones those were crossed in this field. Method This is retrospective study of minimal invasive gynaecological surgeries performed from January 1, 2004 to June 30, 2018. Result A total of 1849 cases were performed by mid 2018. Almost half of the cases were of Brahmin/Chhetri caste (49.9%). Mean age of the patients who underwent gynaecological minimal invasive surgeries in DH was 36.70±10.60 years (with range 12-81 years). More than half of the patients were from Kavre (58.2%). Abnormal uterine bleeding, ovarian lesions and chronic pelvic pain were the most common indications for these procedures. Among these procedures, hysteroscopy (769 cases), diagnostic laparoscopy with or without chromotubation (385 cases), operative laparoscopy (419 cases) and LAVH/TLH (242 cases) were performed. In this study, 34 minimal invasive surgeries cases (1.8%) were converted to laparotomy for certain reasons. Of them eight cases were of laparoscopic hysterectomies. Only very few major and minor complications were experienced during this period. Conclusion Varieties of minimal invasive surgeries for various gynaecological problems were performed with minimal complications. We scaled up these minimal invasive surgeries over the period.

Background Dysmenorrhea is the most common gynecological disorder in women of reproductive age with implications as reduced quality of life and school absenteeism. Mental stress is possibly the most important known predisposing factor for primary dysmenorrhea. Objective This study aims to assess the relationship between stress and dysmenorrhea amongst the Nepalese medical students. Method This is cross-sectional descriptive study, conducted from 1st Dec. 2012 to 31st Jan. 2013. The study was conducted in Kathmandu University School of Medical Sciences. A total of 184 participants consented for this study and each one was given a questionnaire to complete. This study included only unmarried nulliparous, healthy (all through first to final years) female medical students, in age group of 16 to 24 years. Result The mean age of the participants was 19.43(±3.9) years. Among them, 67% of the participants experienced dysmenorrhea. Of them, 85% experienced increase in frequency and severity of dysmenorrhea after joining medical college. Similarly, 65% of participants considered medical education to be stressful. Of participants experiencing dysmenorrhea, 29.45% missed classes and 17.39% participants had positive family history of dysmenorrhea in first and second degree relatives. Conclusion The present study indicated a positive relationship between psychological stress and dysmenorrhea. Dysmenorrhea is the leading cause of recurrent short-term school absence in young ladies; this issue certainly needs to be addressed.

Background Nuchal translucency (NT) is the fluid collection behind the fetal neck which can be measured by ultrasound at 11-14 weeks of gestation. Increase in the nuchal translucency thickness is associated with various congenital anomalies.Objective To study the relationship between nuchal translucency thickness, crown rump length and gestational age in normal fetus.Methods Prospective analytical study conducted on 211 pregnant women from March 2011 to August 2012. Measurement of Nuchal translucency thickness and crown rump length was performed by ultrasound at 11-14 weeks of gestation. The relationship between nuchal translucency thickness, crown rump length and gestational age was studied by using linear regression analysis.Results The mean CRL was 63.67+13.48mm (range 41.2-88mm) and mean NT thickness was 1.55+0.35mm (range 0.8-2.7mm), respectively. The median gestational age was 12.9 weeks. The regression equation which shows relation between median NT thickness and CRL was described as follows: expected NT thickness = 0.013CRL+0.725, (R2 = 0.258, p

Background Fallopian tube and uterine abnormalities are the most common cause of female infertility, accounting for 30% of cases. Hysterosalpingography is the safe, minimal invasive radiographic technique for evaluation of uterine cavity and fallopian tubes defects. The purpose of the study was to assess the various uterine and tubal abnormalities leading to infertility Objective To assess the abnormalities in uterus and fallopian tubes detected on Hysterosalpingography (as causative factors of infertility in a tertiary care centre for proper decision making in treatment. Method This is the prospective cross sectional study done in department of radiology Dhulikhel hospital, Kathmandu University Hospital between January 2015 to January 2016 with complain of infertility. Hysterosalpingography was performed using ionic contrast medium (10-20 ml of 76% urograffin) under digital fluoroscopy. Radiographic films were obtained and analyzed. Demographic data and radiological findings were reviewed and the obtained data analyzed with SPSS version 16. Result Out of the total 100 patient, 75 had primary infertility while 25 had secondary infertility. The age ranged from 19 to 43 years with mean age of 27.75 years. Normal Hysterosalpingography findings were seen in 37% cases. Tubal abnormalities were seen in 34%, uterine abnormalities in 23% and both tubal and uterine abnormalities in 6% patients. The most common tubal abnormality detected on Hysterosalpingography was tubal block 75%. Out of the 30 patients who had tubal block, unilateral block was noted in 76.7% patients whereas bilateral block was noted in 23.3%. Hydrosalphinx was seen in 25% cases with tubal abnormality. Among the 29 cases with various uterine abnormalities, bicornuate uterus 9% was the most common abnormality Conclusion Hysterosalpingography is an easily available radiographic procedure that can demonstrate a wide variety of uterine and tubal abnormalities for the initial assessment of infertility which can avoid unnecessary and sometimes more aggressive procedures.

Aims: Cervical cancer is a major cause of morbidity and mortality in gynecology clients. It accounts for the most common cancer in women. A Papanicolaou (Pap) smear test (cervical cytology screening) is one of the best tests to screen for cervical cancer in its premalignant stage. The objective of this study is to find out the prevalence of abnormal Pap smear results and to determine the contributing factors for it. Methods : The out patient clinic register was reviewed. Out-patients clinic register from 1 Jan 2008 to 31 Dec 2011showed that a total of 25511 gynecology clients were seen. In these four years duration, a total of 1506 Pap smear samples were taken which accounted for 5.9% of the total gynecology clients. The samples were collected only after proper counseling and consent from the clients who visited the clinic for various gynecology complaints. Assumed predictors of abnormal Pap smear results were examined through inferential way (Chi square test) using Software SPSS version 13.0 for Windows. Results: The preliminary analysis showed the mean age was 37.57 ± 10.72 years (ranging from 18 to 81 years). Most of them were of Newar caste (28.7%), with 3 children (37.6%) and from Kavre District (66%). Most of them (343 clients) were of age group 30 – 34 years whereas 15.8, 10.8, 3.1 and 10.0 % (clients were of 40 – 44, 45 – 49, 50 – 54 and 55 above respectively. A total of 1062 samples were normal whereas 379 samples were suggestive of inflammatory and 39 samples were inadequate for evaluation. We had 22 samples suspicious for malignancy and/or low grade squamous intraepithelial lesion (LSIL) and 4 frank malignant cases. This accounted for 1.7% of total Pap smear samples. These cases were scheduled for colposcopic guided biopsies and histologic evaluations. There was significant difference between the age groups and Pap smear results (p=0.003) and parity with Pap smear results (p=0.000, highly significant). But there was no significant difference between caste and Pap smear results (p=0.166). Conclusions: There is no doubt that Pap test is one of the best and easiest tests to screen for precancerous and cancerous cervical lesions. In order to have a high yield it has to be combined with other alternative tests like HPV testing and/or visual inspection with acetic acid (VIA) or Lugol’s Iodine (VILI). Besides its use as screening tool, we can also evaluate for chronic cervicitis, sexually transmitted infection (STI), pelvic inflammatory disease (PID)and genital prolapse (if any) in same setting. Thus the community people will have broader benefits from the screening program. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11137 Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 21-24

Background Spontaneous abortion refers to a pregnancy that ends spontaneously before the fetus has reached a viable gestational age or expulsion or extraction of an embryo or fetus weighing 500 g or less from its mother. The Maternal Mortality Morbidity Survey of Nepal 2008/09 reported that 7% of maternal deaths in Nepal were due to complications related to abortion.Objective The main objective of this study was to examine the histopathological changes in the chorionic villi and endometrial decidual tissue in products of conception obtained from women with spontaneous abortion.Method This is a retrospective study of 111 patients admitted in the Department of Obstetrics and Gynecology at Dhulikhel Hospital, Kathmandu University Hospital (DH-KUH) with the diagnosis of spontaneous abortion during the period of January 2013 to January 2014.Result Among 111 cases of spontaneous abortions, products of conception was seen in 73 (65.77%) and with only one cases of choriocarcinoma. Majority of cases belongs to age group 21-30 years. The most common decidual changes were inflammation (41.4%) followed by fibrin deposition 29.7%. Majority of the cases shows hydropic changes as histopathological changes in chorionic villi. In the present study, minimum age of lady was 15 years and the maximum age was 45 years and the mean age was 25.09±5.58 years at the time of abortion. Among the cases, maximum 69 (62.2%) of them belonged to age group 21-30 years. Correlating the age group with number of abortions was found to be significantly different (Chi-square= 92.35, df= 3, p < 0.001) among four different age groups.Conclusion The histopathological diagnosis of spontaneous abortion will help in further management of the patient. Further study is required to know the cause of different histopathlogical changes in villi as well as in the decidua.

Aim: 1. To assess relationship between fetal foot length and gestation age and develop a nomogram. 2. To assess relationship between fetal foot length and femur length. Meterials and Method: Cross sectional study. Fetal foot length was taken from the skin edge overlying calcaneus to the distal end of the longest toe on either plantar or the sagittal view in 860 singleton pregnant women between 15 and 40 weeks’ gestation. Normal case was defined as normal sonographic findings during examination and normal infant examination at birth or both. Final study population constituted 779 healthy fetuses. The relationship between gestational age to foot length was analyzed by simple linear regression. Correlation of fetal foot length with gestational age and femur length were also obtained. Results: A nomogram for fetal foot length was obtained. There is linear relationship between foot length and gestational age [foot length (mm)=2.494xGestational age (weeks)-15.46] with significant correlation (r=0.970 and p=0.000) and between foot length and femur length [foot length(mm)=1.049xfemur length (mm)+0.648] with significant correlation (r=0.980 and P=0.000). Femur length/ Foot Length ratio was 0.9 and 1.0 in most of the cases. Conclusion: Nomogram was obtained for fetal foot length at various gestational ages in our population. There is linear relationship and good correlation between foot length and gestational age and foot length and femur length. Fetal foot length can be used as an alternative fetal parameter to assess gestational age. Femur length/ Foot Length ratio is fairly constant throughout gestation. DOI: http://dx.doi.org/10.3126/njr.v1i1.6317 Nepalese Journal of Radiology Vol.1(1): 15-22

With the advent of ultrasound as a means of providing quality antenatal care, there is an increase in the diagnosis of nuchal cord in fetuses. The major cause of foetal or neonatal death during labor and in postpartum period is birth asphyxia and tight nuchal cord is a cause of birth asphyxia. Whilst there are instances in which fetuses with 3 to 4 loops of cord around the neck have been delivered by normal vaginal delivery, some cases have to be delivered by caesarean section due to foetal distress caused by a single loop of cord around the neck. The reason for conducting this study was also to analyze the incidence and other aspects of nuchal cord. Dhulikhel Hospital labour registry was reviewed between Jan 2010 and Dec 2011. A total of 289 cases with at least one loop of nuchal cord were recorded as study case. For comparison, 965 controls were randomly selected from the 4219 unaffected singleton births delivered during the same time period. Of 1254 neonates, nuchal cord was present at 6.85% of deliveries (n = 289). Of these the incidence was 6.57% at preterm, 49.13% at term, 39.79% at postdated and 4.50% at postterm. A total of 151 had one loop and 138 had two or more loops. There was significant difference in the maternal age and birth weight of among three groups (control, with one loop and with two or more loops) in this study (p = 0.002) and (p = 0.000) respectively. However, the incidence was not affected by caste, parity, gestational age, antenatal site, neonatal intensive care unit admission and other perinatal complications. Most were primigravida (62.98%) and about 85.12% were delivered vaginally but caesarean section had to be done in 30 cases. And 2.8% cases required neonatal intensive care unit admission for prematurity. Obstetrician working in the periphery should refer the clients to a tertiary care center to confirm a suspicion of nuchal cord (non-engaged foetal head, decreased foetal movements, meconium stained liquor, foetal distress or malpresentation etc.) and also as a routine basis for ultrasound. Clients with confirmed complication should be managed in tertiary hospitals or institutions with the facility of ultrasound, cardiotocography and emergency surgery. This would improve the health of both the mother and fetus.

Background World health Organization definition of intrauterine foetal demise encompasses any abortion or fetal demise prior to expulsion from its mother, and recommends different protocols according to gestational age. However, conventionally and also in our institution, foetal demise prior to 28 weeks of gestation is managed as abortion in a manner different from foetal demise post 28 weeks of gestation. Objective To find the incidence and characteristics of pregnancies that resulted in stillbirths. Methods A retrospective study, done in Dhulikhel Hospital, Kathmandu University Hospital in the year 2010 and 2011, among 4219 deliveries and 97 fetal deaths. Cases of multiple pregnancy and fetal death diagnosed by ultrasound before the 28th week of gestation were excluded. The included intrauterine foetal demise cases (n=90) were compared with a control group of randomly selected pregnancies (n = 537) delivered during the same time period. Assumed predictors of stillbirth were examined through inferential ways (Chi square, t test) using SPSS Version 13.0 for Windows. Results Incidence of intrauterine foetal demise was 2.13% in the year 2010 and 2011. Mothers in the stillbirth group were slightly older than mothers of live-born infants (25.47±5.64 years vs 23.62±4.31 years, p value=0.000). A slightly higher proportion of women in the stillbirth group were of Tamang ethnic origin and primiparous (p = 0.011, 0.000) . Foetus expelled after IUFD had lower weight compared to live births, (2925.14±444.14gram vs 2182.78±821.04gram, p=0.000) for gestational age. The stillborn babies were generally born at an earlier gestational age, as would be expected (p=0.000). Incidence of intrauterine foetal demise gradually decreases as parity advances. The incidence was higher in patients receiving antenatal care outside Dhulikhel Hospital, Kathmandu University Hospital. Conclusions While comparing the subject with the theme of the national conference of Nepal Society of Obstetricians and Gynaecologist, most of the cases were mother not receiving antenatal care or those receiving antenatal care in the periphery, There is no denying that there would be a massive improvement in women’s health if the co-ordination between the peripheral health care center and tertiary care center was to be improved. DOI: http://dx.doi.org/10.3126/kumj.v10i4.10994 Kathmandu Univ Med J 2012;10(4):44-48

Gestational trophoblastic disease encompasses a diverse group of lesion. If molar changes in the placenta are known along with an alive fetus then the situation is difficult to manage. We present successfully managed case of partial degeneration of placenta in molar pregnancy with an alive fetus at second stage of preterm labour.DOI: http://dx.doi.org/10.3126/kumj.v9i3.6310 Kathmandu Univ Med J 2011;9(3):222-4

Background Cervical incompetence is one of the main contributors to repeated pregnancy loss, accounting for approximately 25% of the cases. Typically it results in progressive cervical dilatation, leading to a painless second- or early-third-trimester abortion. Objectives The main objective of the study was to explore the benefit from cervical cerclage in pregnant women with anatomical cervical incompetence Methods In a review of the operation and labour registers from January 2006 till January 2010, a total of 38 cervical cerclage procedures were performed at Dhulikhel Hospital (DH). In the study caste, parity, gestational age, diagnostic criteria, postoperative complications and pregnancy outcomes of the cases were analyzed. Results Two of the 38 cases didn’t come for delivery at Dhulikhel Hospital (Kathmandu University Teaching Hospital). Four women haven’t delivered at the time of data analysis. So pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. Of them 18 cases (47%) were Brahmin, 22 cases (58%) were between 20-25 years old and 32 cases (84%) were from Kavre district. All cases were booked cases (they had antenatal care in the hospital) and 14 patients (37%) were third gravida. Most cases had 2 to 4 antenatal visits prior to suturing. Two cases were diagnosed with a bicornuate uterus. 21 cases (55%) had a previous history of at least one dilatation and evacuation. 33 cases (87%) were diagnosed with cervical incompetence clinically and confirmed by ultrasound. The remaining 13% were assessed, in the absence of a history of mid-trimester abortion, of having a high suspicion of cervical incompetence after mid-trimester scan with measurement of cervical length. In 18 cases (47%), cervical cerclage were done at 15 to 20 weeks of gestation. The postoperative period was uneventful in all 38 cases. All cases (32) delivered in DH were assisted by consultant obstetricians. 19 out 32 cases (59%) were delivered vaginally at term. Conclusions 38 cases were included in the study. Pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. 31 out 32 cases were delivered with good foetal weight. It clearly shows pregnant women with anatomical cervical incompetence were benefitted from cervical cerclage. The authors recommend an early trans vaginal scan in any patient with a history of mid trimester abortion or preterm labour. The cervical cerclage procedure therefore should be available more widely to benefit those patients with proven or strongly suspected cervical incompetence. DOI: http://dx.doi.org/10.3126/kumj.v8i3.6222 Kathmandu Univ Med J 2010;8(3):321-24

Vaginal birth after caesarean section is the delivery of a baby through the vagina after a previous cesarean delivery. For this to be conducted safely and responsibly emergency obstetric care must be available. To study the different modes of delivery in Dhulikhel Hospital (DH), evaluate the frequency of attempted and successful vaginal birth after caesarean section and, in the VBAC group, to identify those factors that may influence outcome and safety. The study was a retrospective study of all women who were delivered via different routes and the subgroup who underwent attempted vaginal birth after caesarean section in DH from January 2007 to December 2009. In this study factors associated with the successful VBAC were also analyzed. During the study period a total of 4215 deliveries conducted in DH and a total of 890 lower segment caesarean sections (21.1% of all deliveries) were performed. Of the 890 caesareans performed, 743 were primary and 147 were repeat (69 were repeat elective and 78 were repeat emergency). In this period an additional 33 women with previous lower segment caesarean sections had a successful vaginal delivery. Hence 18.3% (33/180) vaginal birth after caesarean sections was conducted successfully among women with previous caesarean). The results of this study indicate that vaginal birth after caesarean section is a clear feature of obstetric practice in DH. This is possible because of the vigilance in managing these women and the availability in this hospital setting of resources for immediate cesarean section.

Background Obstetric hemorrhage remains the leading cause of maternal mortality in resource limited areas. An inexpensive pneumatic anti-shock garment was devised of bicycle tubes and tailored cloth which can be prepared from local materials in resource-limited settings. The main purposes of this study were: 1) to determine acceptability of the device by nurses and midwives and obtain suggestions for making the device more suitable for use in their particular work environments, 2) to determine whether a three hour training course provided adequate instruction in the use of this device for the application of circumferential abdominal pelvic pressure, and 3) determine production capability and cost in a resource-limited country. Methods Fifty-eight nurse and midwife participants took part in three sessions over eight months in Nepal. Correct device placement was assessed on non-pregnant participants using ultrasound measurement of distal aortic flow before and after device inflation, and analyzed using confidence intervals. Participants were surveyed to determine acceptability of the device, obtain suggestions for improvement, and to collect data on clinical use. Results Device placement achieved flow decreases with a mean of 39% (95% CI 25%-53%, p Conclusions Preliminary data suggest that an inexpensive, easily-made device is potentially an appropriate addition to current obstetric hemorrhage treatment in resource-limited areas and that further study is warranted.