Jyothi Shetty

“Near Miss” Obstetric Events and Maternal Deaths in a Tertiary Care Hospital: An Audit

Objectives. (1) To determine the frequency of maternal near miss, maternal near miss incidence ratio (MNMR), maternal near miss to mortality ratio and mortality index. (2) To compare the nature of near miss events with that of maternal mortality. (3) To see the trend of near miss events. Design. Audit. Setting. Kasturba Hospital, Manipal University, Manipal, India. Population. Near miss cases & maternal deaths. Methods. Cases were defined based on WHO criteria 2009. Main Outcome Measures. Severe acute maternal morbidity and maternal deaths. Results. There were 7390 deliveries and 131 “near miss” cases during the study period. The Maternal near miss incidence ratio was 17.8/1000 live births, maternal near miss to mortality ratio was 5.6 : 1, and mortality index was 14.9%. A total of 126 cases were referred, while 5 cases were booked at our hospital. Hemorrhage was the leading cause (44.2%), followed by hypertensive disorders (23.6%) and sepsis (16.3%). Maternal mortality ratio (MMR) was 313/100000 live births. Conclusion. Hemorrhage and hypertensive disorders are the leading causes of near miss events. New-onset viral infections have emerged as the leading cause of maternal mortality. As near miss analysis indicates the quality of health care, it is worth presenting in national indices.

The effect of three mouthwashes on radiation-induced oral mucositis in patients with head and neck malignancies: a randomized control trial.

AIMS The present study was done to assess the effect of three alcohol-free mouthwashes on radiation-induced oral mucositis in patients with head and neck malignancies. MATERIALS AND METHODS Eighty patients with head and neck malignancies, scheduled to undergo curative radiotherapy, were randomly assigned to receive one of the three alcohol-free test mouthwashes (0.12% chlorhexidine, 1% povidone-iodine, or salt/soda) or a control. The patients were instructed to rinse with 10 ml of the mouthwash, twice a day, for a period of 6 weeks. Mucositis was assessed at baseline and at weekly intervals during radiation therapy, using the World Health Organization criteria for grading of mucositis. The baseline demography of the four groups was matched for age, sex, stage of cancer, and whether the patient had cancer of oral or extraoral regions. A post hoc test for repeated measures was used to find the difference of mean mucositis scores between the groups at various week intervals. RESULTS Among the 76 patients who completed the study, patients in the povidone-iodine group had significantly lower mucositis scores when compared to the control group from the first week of radiotherapy. Their scores were also significantly lower when compared to the salt/soda and chlorhexidine groups from the fourth and fifth week, respectively, after radiotherapy. CONCLUSIONS This study demonstrates that use of alcohol-free povidone-iodine mouthwash can reduce the severity and delay the onset of oral mucositis due to antineoplastic radiotherapy.

Clinical utility of fetal autopsy and its impact on genetic counseling.

We aimed to analyze the utility of fetal autopsy in terms of its contribution to establishing a definitive diagnosis and its impact on genetic counseling.

Leiomyoma in Vulva: A Diagnostic Dilemma

With the help of this case we summarize some crucial features to be picked up from history and examination before labeling a case as Bartholins abscess or cyst. A 20-year old unmarried girl, deaf and mute since birth, was initially diagnosed to have Bartholins abscess. On careful reexamination after inflammation subsided, a decision of excision of this tumor was taken. Intraoperatively it was found to be well encapsulated. Histopathology ascertained the diagnosis of vulval leiomyoma.

Fetal Head Position during the First Stage of Labor: Comparison between Vaginal Examination and Transabdominal Ultrasound

Introduction. Recent evidence indicates that clinical examination, for determination of fetal head position, is subjective and inaccurate. Present study was aimed to compare transabdominal ultrasound for fetal head position with vaginal examination during first stage of labor. Material and Methods. This prospective study was performed at a tertiary center during a two-year period. Before or after clinically indicated vaginal examinations, transverse suprapubic transabdominal real-time ultrasound fetal head position assessment was done. Frequencies of various ultrasound depicted fetal head positions were compared with position determined at vaginal examination. Results. In only 31.5% of patients, fetal head position determinations by vaginal examinations were consistent with those obtained by ultrasound. Cohens Kappa test of concordance indicated a poor concordance of 0.15. Accuracy of vaginal examination increased to 66% when fetal head position at vaginal examination was recorded correct if reported within +45° of the ultrasound assessment. Rate of agreement between the two assessment methods for consultants versus residents was 36% and 26%, respectively (P = 0.17). Conclusion. We found that vaginal examination was associated with a high error rate in fetal head position determination. Data supports the idea that intrapartum transabdominal ultrasound enhances correct determination of fetal head position during first stage of labor.

Jejunal atresia and postaxial polydactyly: a newly recognized phenotype.

Clinical summary Fetal anomalies were detected by ultrasound scan in a 26-year-old G3 P2 + 0 and she was referred for counseling at 28 weeks of gestation. She has a consanguineous marriage; her first pregnancy ended in intrauterine death of the fetus at 26 weeks of gestation, which was not investigated further, and her next pregnancy resulted in the birth of a healthy male, now 3 years old. There were no antenatal illnesses, no evidence of maternal diabetes mellitus, and no exposure to known teratogens. Echogenic bowel loops with a cystic lesion measuring 2.5 2.2 cm along with a rim of calcification, located anterior to the stomach bubble, were visualized on antenatal ultrasonography (Fig. 1). Polyhydramnios and a two-vessel cord were also noted. Following intrauterine fetal death at 33 weeks of gestation, a perinatal autopsy was requested. The female fetus weighed 1284 g (5th centile) and measured 37 cm in length (– 2 SD). The fetus had postaxial polydactyly of both feet and the right hand (Fig. 2). There was a sacral pit (Fig. 3a) and a single umbilical artery (Fig. 3b) was also noted. An intraabdominal mass on the left side (Fig. 4a) was found to comprise a distended duodenum and jejunum with a gangrenous mass of 3 4.5 cm diameter filled with meconium in the middle of the jejunum. An abrupt narrowing of the jejunum distal to the mass suggested type I atresia (Fig. 4b). There was no facial dysmorphism. The lungs, heart, major vessels, diaphragm, stomach, liver, kidneys, adrenals, ureters, urinary bladder, ovaries, uterus, vagina, and rectum of the fetus were normal. Fetal radiographs were unremarkable. Fetal chromosomal analysis could not be carried out. Both parents were healthy and neither had polydactyly nor any known history of this. The study received the approval of the institutional ethics committee.

Jack in the box: inguinal endometriosis

A 39-year-old woman with a left-sided inguinal swelling was referred to us with a diagnosis of inguinal hernia. On asking leading questions, the patient gave a typical history of cyclical pain and increased swelling during menstruation. Fine-needle aspiration biopsy revealed endometrial glands. Preoperatively, the extent of the endometriotic lesion was delineated using MRI. The lesion was approached through the patients caesarean scar for cosmetic reasons and excised in toto. Final diagnosis was round ligament endometriosis. The patient was asymptomatic at 3, 6 and 12 months’ follow-up. This case re-emphasises the fact that endometriosis is an enigmatic disease and can be found anywhere in the body. Thus, a woman of reproductive age presenting with any cyclical symptom should be asked about its relation to her menstrual cycle.

Sublingual misoprostol: a better choice for cervical priming before manual vacuum aspiration

BACKGROUND Misoprostol is effective for cervical priming before manual vacuum aspiration (MVA). Aim of study was to determine whether sublingual misoprostol with a shorter interval of 2 hours before MVA would be as effective as its standard vaginal administration. STUDY DESIGN This randomized control trial included 82 women randomly assigned to receive 400 mcg of misoprostol, either sublingually or vaginally. MVA was performed 2 hours and 3 hours after in sublingual and vaginal group, respectively. RESULTS Cervical dilatation of 8 mm was achieved within 2 hours in sublingual group. Mean time taken for procedure (14.4 ± 5.3: sublingual group and 16.2 ± 5.7: vaginal group), and blood loss was comparable (12.2 ± 9.7 ml in sublingual group and 13.7 ± 8.5 ml in vaginal group). CONCLUSION 2 hour of cervical priming with 400 mcg of sublingual misoprostol before MVA was as good as 3 hours with vaginal administration of the same dose.

Cervical Cancer as a silent killer: A rare case report with review of literature

Advanced-stage cervical cancer almost always presents either with abnormal vaginal bleeding or with foul-smelling vaginal discharge. We present here a rare case, where a postmenopausal lady presented almost silently with stage IVA cervical cancer. Fortunately, timely referral, correct diagnosis, and multispecialty team work could save her life.

Labour Analgesia When Epidural Is Not a Choice: Tramadol versus Pentazocine.

Background. Parenteral opioids, thus, are still popular for pain relief in labor in many countries throughout the world. Aim. To evaluate and compare the efficacy of intramuscular tramadol and pentazocine in the first stage of labor. Method. Sixty-five patients were divided into pentazocine group and tramadol group. Subjects received either 30 mg pentazocine or 1 mg/kg tramadol intramuscularly. Pain was assessed using visual analog scale (VAS) before the administration of the drug, at 1 h, 2 h, 4 h, and at full dilatation. Maternal and neonatal side effects were determined. Results. Analgesic effect of the two drugs was not significantly different. Neither of these analgesics was effective towards the end of the first stage. However, in the tramadol group, the majority of women (55%) rated pain as severe, whereas in the pentazocine group, the majority of women (60%) rated pain as moderately severe. There were not many side effects with either of the drug in the given dosage. Mean injection to delivery interval was significantly shorter in the tramadol group as compared to the pentazocine group. Conclusion. Pentazocine or tramadol can be given for labor pain relief as an alternative to epidural analgesia in resource poor setting.