Conference Papers
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This collection contains abstracts of conference papers, presented at local and international conferences by the staff of the Faculty of Medicine
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Item Surgical management of Carcinoma of vulva: current trends(Sri Lanka College of Obstetricians and Gynaecologists, 2008) Wijesinghe, P.S.Vulval cancer is relatively rare. It accounts for approximately 5% of malignancies of the female genital tract, with an incidence of 2.2 per 100,000 women. This is predominantly a disease of postmenopausal elderly women, with the peak incidence at 65 to 75 years. The vast majority of vulval carcinomas are of squamous origin, Melanoma is the second commonest malignancy arising in the vulva. Rarely adenocarcinomas arise from bartholin glands and in conjunction with Paget's disease of vulva. Better understanding of the prernalignant lesions like VIN, lichen sclerosis and Paget's disease has led to appropriate interventions in preventing vulval carcinoma. Laser ablation and topical agents are used to treat prernalignant lesions. Surgical options such as wide local excision, skinning vulvectomy and simple vulvectomy are also used in some patients. The time tested treatment modality for primary vulva] carcinoma is radical surgery. In older women with significant co-morbid factors radical surgery is associated with unacceptable morbidity. Attempts have been made to overcome this by less invasive procedures in selected cases. Wide local excision for early disease has replaced radical surgery since the latter part of the last century, as the local recurrence rate for wide local excision compares favourably with that following radical vulvectomy (7.2% Vs 6.3%). Adequate resection margin of more than 8 mm is recommended since local recurrence increases with a reduction of disease free margin (>8mm — 0%, 8-4.8mm- 8%, <4.8mm-54%). Triple incision technique to remove the vulval lesion and bilateral nodes is preferred due to less postoperative morbidity and better cosmetic outcome. However, if there is evidence of tumour within the skin bridge between the primary tumour and inguinal nodes at the time of surgery, a radical vulvectomy with en bloc inguinal node dissection should be considered. The benefit of surgical modifications such as sparing of the saphenous vein at the time of surgery to reduce the lower limb complications is inconclusive. Women with lesions of >1 mm invasion will have to undergo either ipsilateral or bilateral inguino^femoral lymphadenectomy depending on the laterality of the tumour and the status of the ipsilateral nodes. Pelvic lymph-node involvement is only likely if the inguinofemoral nodes are involved. In terms of survival, surgical removal of the pelvic nodes has not been found to be superior to radiotherapy. Significant morbidity associated with inguino-femoral lymphadenectomy has led to interest in assessing the groin nodes with CT or MRT prior to performing lymphedenectomy. Sentinel node mapping with methylene blue or 99TC has gained interest in this regard due to its sensitivity (58% -100%). In situations where the lateral excision margin would involve anus or urethra, pre-operative radiotherapy may have a role in allowing local control without loss of function. Adjuvant radiotherapy is recommended if an adequate resection margin cannot be achieved and if there are two or more positive inguinal nodes. Radical radiotherapy and chemotherapy with curative intent may be used for advanced cancer. Usually basal cell carcinoma and verrucous carcinoma of the vulva are only superficially invasive and are rarely associated with lymph node metastasis. Thus wide local excision will suffice. In malignant melanoma, the depth of tumour penetration is an important prognostic factor. Lymphadenectomy does not influence the outcome though resection of enlarged nodes may be of palliative benefit.Item Needle stick and sharp injuries during surgical procedures: an ignored danger?(Sri Lanka College of Obstetricians and Gynaecologists, 2006) Palihawadana, T.S.; Sitbodhini, M.A.; Fernando, S.; Wijesinghe, P.S.Handling of needles and sharp instruments expose the surgeons to sharp injuries, which can transmit blood borne pathogens such as HIV, Hepatitis B and C. Obstetrics and Gynaecology has been shown to carry the highest risk on this regard for medical students during their training. Universal precautions have been described to prevent such disease transmission, but their effectiveness during surgical training has not been evaluated. In this study we assessed the frequency of such injuries among undergraduates, surgical and gynaecology post graduate trainees (PG trainees) and the theatre nursing staff at Teaching Hospital, Ragama. The procedures that exposed them to injury and the measures taken following the injury were also evaluated. Study was carried out from January to March, 2006 and the participants were asked to recall such injuries during their career and in the preceding year. Data were collected using a self administered questionnaire. Eighty medical students, 33 post graduate trainee medical officers, and 29 nursing officers were included in the study. The proportion suffered from such injuries during their carrier among medical students, PG trainees and nurses were 66%, 94%, and 82%. Within the preceding year it was 53%, 82% and 52% respectively. The mean frequency of injuries in the last year among PG trainees was significantly higher than medical students and nurses (3.1 vs. 1.67, 1.64; P<0.001). Assisting at major surgery caused the highest number of injuries to both PG trainees and nurses while repairing of episiotomy was the commonest procedure among medical students. A high proportion of members in all categories had received Hepatitis B vaccination. The actions taken following these injuries were inappropriate in a vast majority of participants. We conclude that needle stick and sharp injuries among surgical trainees is very common. Steps need to be taken to protect the individuals from serious blood borne pathogens.Item Surgical vs expectant Management in incomplete miscarriage: a randomised comparison(Sri Lanka College of Obstetricians and Gynaecologists, 2007) Marleen, F.S.; Wijesinghe, P.S.; Palihawadana, T.S.INTRODUCTION: Incomplete miscarriage is a common presentation in gynaecology. Surgical evacuation has been the cornerstone of management and an estimated 88% still undergo such interventions worldwide. Due to its risk of complications as well as the heavy financial burden on the health system, expectant management is suggested as an alternate management option in some selected patients. OBJECTIVE: To compare the efficacy and the safety of surgical and expectant management of incomplete miscarriage. METHOD: Study included 105 consecutive women presenting with incomplete miscarriage with a POA less than 14 weeks and was carried out at the university gynaecology unit, North Colombo teaching hospital, Ragama from August 2005 to May 2006. Fifty' one subjects received surgical evacuation while 54 underwent expectant management by random allocation. Surgical evacuation was carried out within 24 hours of ultrasound evaluation and a repeat scan was performed 24 hours after the procedure. The expectant group received inward treatment till bleeding settled and was followed up weekly as out¬patients to confirm complete expulsion. RESULTS: The mean age, POA, duration of bleeding and the haemoglobin level were similar in the two groups. The mean (SD) AP diameter of the retained products was 18.37(4.91) mm and 16.64(1.64), (P>0.05), in the surgical and expectant groups, respectively. A complete evacuation was achieved in all subjects in the surgical evacuation group as confirmed by ultrasound the following day. In the expectant group one subject required an emergency evacuation due to excessive bleeding. Complete expulsion was achieved in 85.1% (n-46) after one week and in 96.2% (n=52) after two weeks. No significant difference was observed in the mean change of haemoglobin level between the two groups. In the surgical group one subject required blood transfusion while another require a laparotomy following uterine perforation. Sepsis was not detected in any subject. The duration of hospital stay was significantly reduced in the expentant group with a mean (SD) stay of 1.5 days compared to 2.4 in the surgical group (p< 0.0001). CONCLUSION: In complete miscarriage with reduced amounts of retained products, expectant management is an option that could be offered. Expectant management up to 1 week will avert surgical intervention in 85% and up to 2 weeks in 96% of patients without an increased risk of complications. The decreased duration of hospital stay will be beneficial for both women as well as the health care providers.Item Vault prolapse in a patient with rokitansky syndrome(Sri Lanka College of Obstetricians and Gynaecologists, 2007) Herath, H.M.R.P.; Palihawadana, T.H.; Wijewardana, A.H.M.A.; Wijesinghe, P.S.INTRODUCTION: The Mayer—Rokitansky—Kuster-Hauser syndrome (MRKHS) is a rare congenital cause of primary amenorrhoea, due to agenesis of the uterus and the upper two thirds of the vagina. Since the vaginal vault is not suspended to the bony pelvis it is predisposed to prolapse. We report a case of MRKH syndrome with vaginal vault prolapse successfully treated with surgery. CASE REPORT: A 30 year old female married for two years, who was diagnosed to have MRKHS, presented with vaginal vault prolapse. This prevented her from having satisfactory sexual intercourse. She did not have symptoms of pelvic floor weakness such as urinary or faecal incontinence. An intravenous urograrn did not reveal any anomaly. At laparotomy normal ovaries with follicular activity and a rudimentary uterus were noted. A tape of proline mesh was fixed to the posterior surface of the rudimentary uterus and was brought forward to the rectus sheath through the broad ligament along the round ligament, to support the vaginal vault. The peritoneal cavity was opened through an incision in the vault of the blind vagina. Vaginal vault was anchored to the previously placed proline tape. A fibreglass mould was introduced and kept in place for seven days to keep the integrity of the dilated vaginal lumen. Two months after surgery the patient was asymptomatic with normal sexual activity. DISCUSSION: MRKHS occurs in one in 4000-5000 women. It may be associated with renal and skeletal anomalies. The blind ended vagina is usually short and originates from the urogenital sinus. The vaginal vault is susceptible to prolapse as it is not anchored to the bony pelvis. The incidence of vault prolapse in MRKHS is unknown and thought to be very rare. Many surgical methods have been described including abdominal sacrocolpopexy and sacrospinous fixation.Item Family planning among Medically ill people in a sri lankan setting: a descriptive study(Sri Lanka College of Obstetricians and Gynaecologists, 2007) Palihawadana, T.S.; Fernando, W.S.; Mallawaarachi, W.P.P.K.; Attanayake, A.M.J.H.; Motha, M.B.C.; Wijesinghe, P.S.INTRODUCTION: Sri Lanka has a high contraceptive prevalence with a low total fertility rate. In spite of this, unmet need of family planning among medically ill people is observed in day to day clinical practice. Medical illnesses complicating pregnancy are a major cause of maternal morbidity and mortality in Sri Lanka. This is thought to result from non usage as well as use of methods with low efficacy. We studied the contraceptive usage among people suffering from medical illnesses as a preliminary survey of a large scale study. METHOD: The study was carried out at the medical clinics of the Colombo North teaching hospital from March to July, 2007. Those who suffer from medical conditions that could complicate a pregnancy were interviewed to find out the family planning practices and identify the limiting factors for uptake of modern methods. Sixty seven sexually active subjects who are in their reproductive age group were interviewed for the research purpose. RESULTS: Study population comprised of 55% of Buddhists, 38% Catholics and 6% Islamics. Mostly encountered medical conditions were diabetes mellitus (n=18), hypertension (n=15), Valvular heart disease (n=10) and thyroid dysfunction (n=6). Seven subjects were planning for a pregnancy at the time of interview though none of them had been advised that it is safe to do so. Nearly 80% (n-53) of subjects admitted to practicing family planning. However, among them 71% (n=38) were using the traditional methods of family planning, where calendar method was the most commonly used (43.3%) followed by withdrawal (20.8%) and the cervical mucous (75%) methods. Norplant was the most commonly used modern method (13.2%) while other methods used included combined contraceptive pill (9.4%), intrauterine contraceptive device (3.8%) and DMPA (1.9%). None of the study subjects practiced male or female sterilisation. Of the total study population 35.8% (n=24) had received family planning advice from the family health midwife after diagnosis of their condition, while only 6% (n=4) had such advice at the medical clinic. CONCLUSIONS: Though family planning is practiced by a high proportion of medically ill people, only a minority use modern methods. High prevalence of traditional family planning usage make this group vulnerable to unintended pregnancies due to the low efficacy of the methods used by them. Family planning advice does not seem to adequately reach this more deserving population. Possible reasons for this could be either the reluctance of field health workers to dispense modern methods of family planning to these people or the deficiencies in the family planning program to reach such special groups, thus stressing the point that such services should be integrated at the level of the medical clinic.Item Do we handle fetal heart Traces correctly? A completed audit cycle(Sri Lanka College of Obstetricians and Gynaecologists, 2007) Herath, H.M.R.P.; Attanayake, A.M.J.H.; Mohomad, H.Z.; Wijesinghe, P.S.INTRODUCTION: Electronic fetal monitoring has become an integral part of modern obstetric practice. Appropriate use and interpretation of CTG is necessary to achieve the expected benefits of electronic fetal monitoring. On the other hand incorrect usage of it can lead to unnecessary interventions. OBJECTIVE: To audit the standards of interpretation of and documentation on intrapartum CTGs. METHOD: An audit was conducted to assess the standard of documentation on the CTG, accuracy of interpretationand the appropriateness of subsequent action taken. Ninety six CTGs taken in July and August 2007 were audited according to standards given in NICE guidelines. The findings of the audit were presented to the team members and a discussion was conducted to improve awareness. A re -audit was conducted during the subsequent week and another 69 CTGs were studied. RESULTS: There were 96 CTGs audited during the first cycle. Patients name, date and time of taking the CTG were mentioned in 79(82.3%), 78(81.3%) and 79(82.3%) of CTGs respectively. Though 78(81.3%) CTGs were signed, the time of seeing the CTG was mentioned only in 19 (19.8%). Although an opinion about the CTG was given in 59 (61.5%), the fetal heart tracing was described only in 13 (13.5%) cases. Most of the interpretations were correct and the subsequent action taken was appropriate. Sixty nine CTGs were audited during the second cycle. Documentation showed a significant improvement with patients name date and time being documented on 64(92.8%), 65(94.2%), 67(97.1%) of CTGs respectively. Majority 56(81.2%) was signed and the time of seeing was noted in 47(68.7%) of CTGs. Comparatively higher proportion (72.5%) of CTGs was described. Second cycle also showed most of the opinions given to be accurate. DISCUSSION: Interpretation of CTGs is fairly satisfactory. Documentation on CTGs is not up to the expected standards. Regular auditing will help to achieve better standards with regard to documentation.Item Audit on management of past section(Sri Lanka College of Obstetricians and Gynaecologists, 2005) Padumadasa, G.S.; Ratnatilake, R.M.K.R.M.; Amarasena, J.M.T.; Wijesinghe, P.S.OBJECTIVE: To audit management of women with one past section. DESIGN AND SETTING: A retrospective audit at the University Obstetric Unit, North Colombo Teaching Hospital. Method: Twenty five records of women with one past section awaiting delivery, who presented between 01 April 2005 and 22 May 2005 were analyzed. "Whether the placental site was checked, estimated fetal weight assessed and pelvic assessment done was assessed. Ninety percent was considered the target, Results: The mean age of the women was 33.1 years (SD 2.6). The mean period of gestation was 37.6 weeks (SD 0.7) and the mean height of the women was 152.4cm (SD 2.7). In eight women a decision was taken to subj ect them to a trial of scar and in 11, it was decided to perform an elective caesarean section. Six women underwent emergency caesarean section on admission. The placental site was checked in 13 (52 %), estimated fetal weight assessed in 12 (48 %) and pelvic assessment done in four (16 %) women. Out of the eight women who were awaiting a trial of scar, seven (87 %) had the placental site checked and seven (87 %) had the estimated fetal weight assessed. However only four (50 %) had a pelvic assessment performed. CONCLUSION: The results were discussed at an audit meeting. It was concluded that assessment in women with one past section awaiting delivery was not adequate. The importance of proper assessment was stressed to the team members. A re-audit is planned in three months to assess any improvement.Item Dengue fever with bleeding manifestations in pregnancy: our experience(Sri Lanka College of Obstetricians and Gynaecologists, 2004) de Silva, B.A.; Palihawadana, T.S.; Fernando, W.S.; Wijesinghe, P.S.Dengue fever, a mosquito borne flavivirus infection is endemic in Sri Lanka. An increased number of cases are seen in the recent past. An increase in the number of patients with secondary infection who are prone to develop complications such as bleeding manifestations, are expected due to repeated outbreaks of the disease, We report four cases of serologically confirmed Dengue fever. Different management strategies were adopted in each patient according to the clinical circumstances. Three antenatal mothers presented in 33, 38 and 39 weeks of POA and bleeding manifestations were present in all three of them. One of them died of an intracerebral haemorrhage after Caesarean section to deliver a stillborn following intrauterine death. Post Partum Haemorrhage (PPH) was experienced in another mother following caesarean section. In one patient bleeding manifestation appeared 2 days following normal delivery. She was managed conservatively. Though the clinical presentations may be similar to that of non pregnant patients, there can be many pitfalls in diagnosis and management of dengue fever occurring in pregnancy. Two of the patients described above developed acute dengue viral hepatitis, which needs to be differentiated from HELLP syndrome and acute fatty liver of pregnancy. Serological tests have a special place in diagnosis than in the non pregnant patients. The classical criteria used to identify Dengue Haemorrhagic fever (DHF), such as an increased haemotocrit and postural hypotension were not present in these patients. In management, the administration of intravenous fluids needed to be more closely observed. They seemed to be more prone to develop bleeding manifestations than non pregnant patients and therefore platelet transfusions were required in early stages. Early interventions to deliver the baby, if the other circumstances permit, seem to offer a better outcome in patients presenting in the antenatal period.Item A Descriptive study of deep vein thrombosis (DVT) in a tertiary care hospital(Sri Lanka Medical Association, 2008) Botheju, W.I.K.; Navaratne, A.C.R.; Somarathne, C.K.; Balasooriya, B.L.P.P.; Wijebandara, R.J.K.S.; Mandawala, M.B.S.N.; Ruwanpathirana, T.; Kasturiratne, K.T.A.A.; Hewawitharana, C.P.; Rathnasena, B.G.N.; Fernando, P.; Wijesinghe, P.S.; Premawardhena, A.OBJECTIVE: The incidence and risk factors for DVT are not well established for the Sri Lankan population. Though believed to be an effective screening tool for DVT, the Well's Clinical score is not widely used in Sri Lankan hospitals. DESIGN, SETTING AND METHODS: Over a period of 8 months, a total of 23274 patients who presented to four units (including one general medical, one general surgical, one Gynaecology & Obstetrics, and the Orthopedic ward) of the North Colombo (Teaching) Hospital were screened for asymmetrical limb swelling more than 2 cm. The latter group were subjected to risk assessment for DVT, Well's scoring and CDU (Colour Duplex Ultrasound). RESULTS: Of the 23274 patients, 93 (0.4%) had unilateral limb swelling of which 12 (12.9%) were CDU confirmed to have DVT (0.5 per 1000). Limb swelling for more man two weeks was significantly commoner among DVT patients when compared to those without DVT (75% Vs 25.9%: p=0.001). None of the patients had been evaluated with the Well's score as a guide to refer for CDU by the relevant clinical teams. In 55 (59.1%) subjects, Well's score was 0 or less (minimum probability of DVT) and there were no subjects with DVT in this group. All 12 patients with DVT had a moderate or high probability Wells score. CONCLUSIONS: Overall incidence of DVT in the study population was lower than in other comparable published studies from Asia. Well's score which was underused by the clinicians is a highly sensitive screening tool for DVT.