Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Recurrent vaginal vault dehiscence and evisceration following total laparoscopic hysterectomy, successfully repaired with polypropylene mesh and sacrocolpopexy(Oxford University Press, 2022) Rathigashini, R.; Wanniarachchi, W.A.D.P.; de Silva, A.; Herath, R.P.Recurrent vault dehiscence is a rare and potentially serious complication following hysterectomy. We report a rare case of recurrent vault dehiscence and evisceration following a total laparoscopic hysterectomy (TLH) which was successfully repaired with polypropylene mesh and sacro-colpopexy. A 47-year-old multiparous woman underwent TLH for adenomyosis. During the surgery, vaginal wall was incised with monopolar diathermy and sutured with synthetic absorbable barbed suture in a single layer. She presented 12 weeks later with vault dehiscence and evisceration of omentum. Laparoscopically, eviscerated omental part was removed and the vaginal cuff was repaired vaginally with absorbable synthetic suture. She came with a recurrence in 3 months with vault dehiscence and a vault prolapse without any evisceration. She underwent laparoscopic mesh repair of the vault combined with laparoscopic Sacro-colpopexy with complete recovery. Incidence of vault dehiscence is found to be higher in TLH than abdominal or vaginal hysterectomy. Treatment options for recurrent vault dehiscence involve strengthening the vault with tissues, or with a prosthesis.Item Childbirth Experience Questionnaire (CEQ) in the Sri Lankan setting: translation, cultural adaptation and validation into the Sinhala language(BioMed Central, 2020) Patabendige, M.; Palihawadana, T.S.; Herath, R.P.; Wijesinghe, P.S.OBJECTIVE: To adapt the CEQ into Sri Lankan Sinhala cultural context and to determine the psychometric properties of CEQ. This would yield an opportunity to evaluate childbirth experience among Lankan population. RESULTS: Out of 390, 226 (57.9%) postnatal mothers completed the CEQ after 1 month postpartum. Face validity and content validity were demonstrated with all participants stating that CEQ was easy to understand and complete. For reliability, internal consistency was acceptable for the overall score (0.85) and for all four domains in CEQ (0.65, 0.80, 0.70, 0.83 for "own capacity", "professional support", "perceived safety" and "participation", respectively). A weighted kappa of 0.61-0.80 for all 22 items in CEQ demonstrated a good test-retest reliability. This Sri Lankan version showed fit statistics in line with standard recommendations in exploratory factor analysis. Women with spontaneous onset of labour (except for "professional support" in women with spontaneous onset of labour) and women with a normal birth showed significantly higher CEQ scores. However, oxytocin augmentation could not yield a difference in CEQ scores. KEYWORDS: Birth satisfaction; Childbirth experience questionnaire; Low-resource settings.Item Use of antimicrobials in obstetric practice – A Narrative review(Sri Lankan Society for Microbiology, 2020) Patabendige, M.; Herath, R.P.; Athulathmudali, S.R.; Wijesooriya, W.R.P.L.I.ABSTRACT: Improvement of the outcome of infectious diseases by early and appropriate antimicrobial therapy is of paramount importance in any clinical discipline. Special considerations need to be given for the use of antimicrobial agents in obstetric practice, as it relates to the safety of both the mother and the fetus. However, their use and misuse are associated with significantly increasing antibiotic resistance. The objective of this review was to provide a useful overview for the practicing obstetrician, of current recommendations for the use of antibiotics in common situations related to pregnancy and the postpartum period. KEYWORDS: Antibiotic use, Obstetrics, Maternal health, Sepsis in pregnancy, Postpartum sepsis.Item Hyperglycaemia in pregnancy and anthropometric parameters in the offspring at 10 Years: A community-based retrospective cohort study in Sri Lanka(Hindawi Publishing Corporation., 2020) Herath, H.P.; Herath, R.P.; Wickremasinghe, R.BACKGROUND: Studies of developmental origins of health and disease have highlighted the possible role of intrauterine hyperglycaemia, increasing the future risk of obesity, diabetes, and cardiovascular diseases in the offspring. There is limited evidence from South Asian populations for risk estimates for childhood obesity that are attributable to maternal diabetes in utero. OBJECTIVE: The aim of this study was to determine the association between hyperglycaemia in pregnancy (HIP) and anthropometric parameters in the offspring at 10-11 years of age. METHODS: A community-based retrospective cohort study was conducted in Colombo district, Sri Lanka. In the first stage, children born in 2005 were identified, and the availability of antenatal records was assessed. In the second stage, the exposure status of participants was ascertained based on antenatal records and predefined criteria. In the third stage, height, weight, waist circumference, and triceps skinfold thickness (TSFT) of eligible participants were measured to ascertain the outcome status. Background characteristics were collected by interviewing mothers. A 24-hour dietary recall and a 3-day diet diary were recorded. RESULTS: 159 children of mothers with HIP (exposed) and 253 children of mothers with no HIP (nonexposed) participated. Mean ages (SD) of exposed and unexposed groups were 10.9 (0.3) and 10.8 (0.3) years, respectively. The median BMI (17.6 vs 16.1, p < 0.001), waist circumference (63 cm vs 59.3 cm, p < 0.001), and triceps skinfold thickness (13.7 mm vs 11.2 mm, p < 0.001) were significantly higher in the exposed group. Offspring of women with HIP were more likely to be overweight (aOR = 2.6, 95% CI 1.4-4.9) and have abdominal obesity (aOR = 2.7, 95% CI 1.1-6.5) and high TSFT (aOR = 2.2, 95% CI 1.06-4.7) at 10-11 years than children who were not exposed after adjusting for maternal BMI, maternal age at delivery, and birth order. CONCLUSIONS: Intrauterine exposure to HIP is a significant determinant of overweight, high TSFT, and abdominal obesity in the offspring.Item Nonpuerperal uterine inversion: What the gynaecologists need to know?(Hindawi Pub. Corp., 2020) Herath, R.P.; Patabendige, M.; Rashid, M.; Wijesinghe, P.S.INTRODUCTION: Nonpuerperal uterine inversion (NPUI) is a rare clinical problem with diagnostic and surgical challenges. The objective of our study was to review the literature on NPUI and describe causative pathologies, diagnosis, and different surgical options available for treatment. MATERIALS AND METHODS: A comprehensive literature review was carried out on MEDLINE and Google Scholar databases to look for NPUI using the term "non-puerperal uterine inversion," and further went through the cross-references of the published articles. Data are published case reports from 1911 to September 2018. Of the 153 published cases, 133 reports had adequate details of surgery for analysis. These reports were analyzed, concerning the clinical presentation, methods of diagnosis, and surgical treatment. RESULTS: Mean age of the women was 46.3 years (standard deviation: 18, N = 153). Leiomyoma remained the commonest (56.2%) aetiology. While malignancies contributed to 32.02% of cases, 9.2% were idiopathic. High degree of clinical suspicion and identification of unique features on ultrasonography and magnetic resonance imaging enable prompt diagnosis. In cases of uncertainty, laparoscopy or biopsy of the mass was used to confirm the diagnosis. Hysterectomy or repositioning and repair of the uterus are the only treatment options available. The surgical methods implemented were analyzed in three aspects: route of surgical access, method of repositioning, and final surgical procedure undertaken. The majority (48.8%) had only abdominal access, while 27.1% had both abdominal and vaginal access. Haultain procedure was the most useful procedure for reposition (18.0%) of the uterus. The majority (39.7%) required abdominal hysterectomy with or without debulking of the tumour abdominally, while 15.0% had uterine repair after repositioning. We reviewed the different surgical techniques and described and proposed a treatment algorithm. CONCLUSIONS: Fibroids were the commonest cause for NPUI. Malignancies accounted for one-third of cases. A combined abdominal and vaginal approach, followed by hysterectomy or repair after repositioning, seems to be better for nonmalignant cases.Item Conservative management of Placenta Percreta: Three cases and a review of the literature regarding conservative management of Placenta Accreta Spectrum (PAS) Disorders.(Hindawi Pub. Corp., 2020) Patabendige, M.; Sanjeewa, J.M.P.; Amarasekara, A.M.A.K.G.; Herath, R.P.BACKGROUND: The incidence of placenta accreta spectrum (PAS) disorders has risen over the last decades, and there has been a gradual shift towards expectant management. Conservative management of PAS is known to reduce major obstetric haemorrhage and salvage hysterectomy. There is a lack of consensus on the follow-up of patients undergoing conservative approaches. Here, we describe the follow-up of three patients with placenta percreta who were conservatively managed and review the literature for the conservative management of PAS. Case Presentation. We have successfully managed three cases of placenta percreta expectantly using combined methods involving symphysial-fundal height, serum beta-HCG, and ultrasonographic volume of placental mass.CONCLUSIONS: Use of a combined approach with symphysial-fundal height, serum beta-HCG, and ultrasonographic volume of placental mass with colour Doppler may guide the surveillance of these conservatively managed cases. However, at least one magnetic resonance imaging three months postoperatively may predict a further risk of delayed haemorrhage.Item Non-alcoholic fatty liver disease and pregnancy complications among Sri Lankan women: A cross sectional analytical study.(Public Library of Science, 2019) Herath, R.P.; Siriwardana, S.R.; Ekanayake, C.D.; Abeysekara, V.; Kodithuwakku, S.U.A.; Herath, H.P.BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the commonest cause of liver disease worldwide and is the hepatic manifestation of metabolic syndrome. Effects of NAFLD on pregnancy is still unclear with few studies showing an association to gestational diabetes and pre-eclampsia. We aimed to describe the association between the NAFLD and pregnancy complications. This is the first study, to our knowledge, in a South Asian population. METHOD: A cross sectional analytical study was done in Teaching Hospital, Ragama, Sri Lanka. Women carrying a singleton pregnancy, admitted for delivery were assessed for NAFLD with liver ultrasound scan. Data were extracted from interviewer administered questionnaire and antenatal and inpatient records. Pregnancy complications and labour outcomes were compared between the women with NAFLD and women without NAFLD (non-NAFLD). RESULTS: Out of the 573 women who participated, 18.2% (n = 104) were found to have NAFLD. Out of them, 58 (55.8%), 32(30.8%), and 14(13.5%) had fatty liver grade 1,2 and 3 respectively. Women with NAFLD were 2 times more likely to develop gestational hypertension and pre-eclampsia compared to the women in the non-NAFLD group, after adjusting for BMI, age and Hyperglycaemia in pregnancy [Adjusted OR 2.09, (95% CI 1.07-4.10)]. There was no association between the grade of steatosis and a composite outcome of gestational hypertension and pre-eclampsia, within the NAFLD group. Composite outcome of gestational diabetes mellitus and diabetes in pregnancy diagnosed during pregnancy was a significant complication in the NAFLD group compared to non-NAFLD group in the bivariate analysis (27.2% vs 17.7%; p<0.05), but the significance disappeared after adjusting for confounders. The current study did not demonstrate a significant association between NAFLD with preterm labour, caesarean section rate, low birth weight, and Apgar score of the baby. CONCLUSION: Women with NAFLD had a 2-fold higher risk of developing gestational hypertension and pre-eclampsia during pregnancy compared to women without NAFLD, after controlling for other confounding variables.Item A Case of labial adhesions following primary genital herpes infection(Kandy Society of Medicine, 2018) Casather, D.M.; Herath, R.P.; Ranathunga, R.D.J.; Pannala, W.S.Labial adhesions are usually associated with hypo-oestrogenism, but it is also a rare complication of genital herpes infection. We present a case report of a 23-year-old woman presenting with primary genital herpes infection, progressing to labial adhesions.Item A case of labial adhesions following primary genital herpes infection(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Casather, D.M.; Herath, R.P.; Ranathunga, R.D.J.; Pannala, W.S.INTRODUCTION: Genital Herpes is one of the common sexually transmitted diseases in Sri Lanka. Although, the labial adhesions usually associated with hypo-oestrogenism, it may occur as a rare complication of Genital Herpes infection. Here we present a case of almost complete thick band labial adhesions following Genital Herpes infection. Case Report: A 23 year old nulliparous woman presented with vulval pain, dysuria and fever for two days. On vulval examination she had extensive, multiple, painful genital ulcers with some blistering lesions over both labia majora and minora. She had been in a monogamous relationship with the partner, with last sexual exposure about 10 days prior to the development of ulcers. Presumptive diagnosis of primary genital herpes was made on clinical manifestations. She was treated with 7 days course of oral Acyclovir. Ten days later she presented with a complaint of narrowing of the vaginal introitus and dysuria. On examination vulval lesions were in the partial remission and there was thick band of adhesion on the upper two third of labia minora with multiple scars of healing ulcers on either side. Manual separation of adhesions was not attempted due to tense nature of the adhesions. Surgical separation of labial adhesions was done under general anesthesia. After two weeks she made complete remission of Genital herpes ulcers and there were no further labial adhesions. A further follow up appointment was arranged in three months. DISCUSSION: Labial adhesions are not common among women in reproductive age who are having well oestrogenised vulva, in comparison to prepubertal and postmenopausal women with less oestrogenised vulva. Labial adhesions are rare, but severe form of local complication of genital herpes infection. The formation of labial adhesions can be prevented by early treatment with adequate dose of oral acyclovir. Gentle application of local anaesthetic over the labia minora alleviates pain and prevents labial adhesions formation in patients with genital herpes. The usual solution for adult labial adhesion following genital herpes infection is surgical adhesiolysis. Manual separation of the labia under application of local anaesthesia can be considered in patients who have less dense adhesions. This is the first published material in Sri Lanka on this matter. The importance of this report is to maintain the vigilance among health care providers about this rare complication as Genital Herpes infection is a very common sexually transmitted infection in Sri Lanka.Item A case of pulmonary endometriosis treated by bronchial angiographic embolization(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Casather, D.M.; Herath, R.P.; Sanjeewa, J.M.P.; Sandaruwan, N.K.T.S.; Ganewatte, E.INTRODUCTION: Although usually confined to the pelvis, endometriosis can be found in extra-pelvic organs and tissues as well. One of the rare forms of extra-pelvic endometriosis is thoracic endometriosis (TE). It is characterized by presence of functional endometrial tissues within the pleura, in the lung parenchyma or the airway. We present a case of TE managed with bronchial angiographic embolization (BAE). CASE REPORT: A 32-year-old woman with two children presented with repetitive catamenial haemoptysis for 8 months’ duration Haemoptysis usually started on the first day or the second day of each menstruation and it continued for 5 to 6 days and it was identical with the menstrual interval. She had one vaginal delivery and one caesarean section 10 years ago and 6 years ago respectively. Two years ago, she had diagnostic laparoscopy for chronic pelvic pain and which revealed pelvic endometriosis. Her medical history was otherwise unremarkable. Physical examination of the respiratory system was normal. Chest X-ray had symmetrical thorax and plain lung markings without abnormal findings. A chest computed tomography taken during the menstruation revealed a focal consolidation with adjacent ground glass opacification in the basal segment of the right lower lobe. Since, haemoptysis spontaneously resolved with the menstruation we assumed this catamenial haemoptysis due to pulmonary endometriosis and planed for BAE. During the procedure ultrasound guided diagnostic descending aortogram was performed using a catheter placing in the proximal descending thoracic aorta. Angiogram revealed a hyperaemic area in the lower lobe of the right lung, supplied by the hypertrophied lower lobe branch of right intercosto-bronchial artery. Super selective cauterization and embolization of the feeding right bronchial artery was done with PVA particles. Post embolization angiogram revealed satisfactory occlusion of the arterial supply to the hyperaemic area. Post procedure course was uneventful and there were no recurrences of catamenial haemoptysis following the procedure. CONCLUSION: There is no guidance for the treatment of TE. Hormonal therapy can be considered to suppress the endometrial tissues. Considering the surgical options to treat TE, video assisted thoracic surgery was reported and which was found to be safer and less invasive than lobectomy. In general BAE is an alternative to surgery in the management haemoptysis caused by Tuberculosis and chest trauma. Even though, BAE has not been frequently used to treat TE we reported case of TE successfully treated with BAE. This suggests that BAE is an alternative treatment option for symptomatic TE.
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