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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Seizure patterns, preconception care and pregnancy outcomes in women with epilepsy in a tertiary care hospital(Journal of the Ceylon College of Physicians, 2020) Motha, M.B.C.; Palihawadana, T.S.; Jayasinghe, C.; Ranawaka, U.K.INTRODUCTION AND OBJECTIVES: Data on epilepsy in pregnancy is limited from South Asia and other resource-limited countries. We sought to describe seizure patterns, preconception care and pregnancy outcomes in women with epilepsy attending a Sri Lankan tertiary care hospital. METHOD: All pregnant women with epilepsy admitted to University Obstetrics Unit, Colombo North Teaching Hospital during the period January 2017 February 2020 were recruited. Data were collected by a single physician using an interviewer-administered questionnaire. RESULTS: Out of 9520 pregnant women screened, 63 had a history of epilepsy (prevalence 6.6/1000); 46% generalized epilepsy, 22.2% focal epilepsy. Of 38 women on antiepileptics at conception, only 44.7% were given folic acid 5 mg preconceptionally. 42.9% were seizure free over preceding 2 years. Majority (55%) had a seizure during current pregnancy (average number of seizures per patient: 1s1 trimester 1.85, 2nd trimester 2.2, 3rd trimester 2.95, postpartum 2.5). 18.4% of seizure events were attributed to sleep deprivation, and 2.7% to unsatisfactory drug compliance. 81.6% were on monotherapy at conception and 18.4% were on two antiepileptic. 22.2% had a hypertensive disorder of pregnancy and 9.5% spontaneous premature delivery. 33.3% underwent caesarian delivery. 1.58% each had a stillbirth and neonatal death. Low birth weight was seen in 42.9%. Major congenital malformations were found in 11.1% of newborns. CONCLUSIONS: Pre-conceptional folic acid coverage was poor. Seizures occurred in more than half of the women and were more common in third trimester and postpartum. Rates of hypertensive disorders, caesarean deliveries, low birth weight and congenital malformations were high.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 Metabolic syndrome and risk of endometrial carcinoma among asymptomatic, postmenopausal, urban Sri Lankan females: a community cohort follow-up study(Wiley Publishing, 2017) Dias, T.; Niriella, M.; de Silva, S.; Motha, C.; Palihawadana, T.S.; Ediriweera, D.; de Silva, J.OBJECTIVES: Metabolic syndrome (MetS) has been recognised as a risk factor for malignancies. The aim of this study was to evaluate the association of MetS and risk of endometrial carcinoma (EC), by measuring endometrial thickness (ET). METHODS: The Ragama Health Study (RHS) recruited 35-64-year-old female cohort by age-stratified random sampling in 2007 and re-evaluated them in 2014, using a structured interview, anthropometric measurements and biochemical tests. Liver ultrasound to detect fatty liver was performed in 2007. Pelvic ultrasound to detect ET was performed in 2014 among consenting participants. MetS was diagnosed on established International Diabetes Federation (IDF 2012) criteria. Increased ET was defined as >5mm. Simple logistic regression was used to screen variables and multiple logistic regression was used to obtain adjusted effects of risk factors for increased ET. RESULTS: 813/1636(49.7%) of the original female cohort attended follow-up; ET was measured in 567(69.7%). Median (IQR) age of females was 61 (56-66) years. 323 fulfilled criteria for MetS (prevalence 57.1%) in 2007. 57(10.1%) had increased ET in 2014. Increasing plasma triglycerides [OR=1.004 per mg/dl, 95%CI:1.001-1.007, p<0.05] and being hypertensive [OR=2.16, 95%CI:1.11–4.08, p<0.05] were associated with increased ET, while advancing age [OR=0.93 per year, 95%CI:0.89–0.98, p<0.01] and being diabetic [OR= 0.34, 95%CI:0.10–0.89, p<0.05] were protective. CONCLUSIONS: Hypertension and increased plasma triglyceride levels, in the pre-menopausal period, were risk factors for future asymptomatic increased ET.Item Study on age-ralated variation in ovarian volume and proportion of endometrial thickness abnormalities in women of advanced and post-reproductive age(Wiley Publishing, 2016) Pieris, V.; Dias, T.; Palihawadana, T.S.; de Silva, J.OBJECTIVES : To describe the variations in endometrial thickness and the ovarian volume among peri and postmenopausal women. METHODS : A cross-sectional analysis was done in a study population of a longitudinal study. This was a community-based study and included 888 women randomly selected from the Ragama, Sri Lanka. This was done as part of a larger ongoing study, the “Ragama Health Study”. All study participants underwent a transvaginal pelvic ultrasound scan and the endometrial thickness and the ovarian size were measured. The ovarian volume was calculated using the formula for a prolate ellipsoid (0.523 h x w x l). RESULTS: The mean age of the study population was 59.45 yrs (SD=7.601) and 85.8% (n = 762) of them had undergone menopause. The prevalence of an endometrial thickness (ET) > 10 mm among premenopausal women was 14.98% while 0.9% (n = 1) had an ET>15 mm. Among postmenopausal women an ET >4 mm was seen in 16.01%. This included 1.3% (n = 10) who had an ET >10 mm. The mean of average ovarian volumes of the study population, according to age is shown in the figure. CONCLUSIONS : The study demonsatrated the proportion of asymptomatic women with a thickened endometrium among perimenoausal and poatmenopausal women (>15 mm and >4 mm resepectively) that necessitate evaluation is around 1%. It also described the age related changes in ovarian volume.Item Nutcracker syndrome in pregnancy: a worrying presentation of a benign condition(Sri Lanka Medical Association, 2017) Motha, M.B.; Palihawadana, T.S.; Dias, T.D.; Wijesinghe, P.S.Item Study on age-ralated variation in ovarian volume and proportion of endometrial thickness abnormalities in women of advanced and post-reproductive age(John Wiley & Sons, 2016) Pieris, V.; Dias, T.; Palihawadana, T.S.; de Silva, J.Objectives: To describe the variations in endometrial thickness and the ovarian volume among peri and postmenopausal women. Methods: A cross-sectional analysis was done in a study population of a longitudinal study. This was a community-based study and included 888 women randomly selected from the Ragama, Sri Lanka. This was done as part of a larger ongoing study, the “Ragama Health Study”. All study participants underwent a transvaginal pelvic ultrasound scan and the endometrial thickness and the ovarian size were measured. The ovarian volume was calculated using the formula for a prolate ellipsoid (0.523 h x w x l). Results: The mean age of the study population was 59.45 yrs (SD=7.601) and 85.8% (n = 762) of them had undergone menopause. The prevalence of an endometrial thickness (ET) > 10 mm among premenopausal women was 14.98% while 0.9% (n = 1) had an ET>15 mm. Among postmenopausal women an ET >4 mm was seen in 16.01%. This included 1.3% (n = 10) who had an ET >10 mm. The mean of average ovarian volumes of the study population, according to age is shown in the figure. Conclusions: The study demonsatrated the proportion of asymptomatic women with a thickened endometrium among perimenoausal and poatmenopausal women (>15 mm and >4 mm resepectively) that necessitate evaluation is around 1%. It also described the age related changes in ovarian volume.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 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 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.
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