431 Electronic Structured Response Tool for Deteriorating Surgical Patients

Aim The Scottish Patient Safety Programme created the National Early Warning Score to have early recognition of deteriorating patients. Clear communication and documentation during and after episodes were found to improve outcomes. SIGN guidance recommended 9-component that should be included in structured response, creating a paper-based structured response tool (SRT). We aimed to review medical assessments of deteriorating patients in general surgical wards and compare to a formulated electronic SRT in promoting best practice. Method Patients scoring over NEWS 4 were identified at eight 2-week time points over a 18-month period and initial assessments evaluated. Results 101 patients were identified with a NEWS ≥ 4 between July 2018-Feb 2019. Implementation of electronic SRT occurred in Nov 2018 and Feb 2019. Average NEWS was 5.9 (range 4-12). Comparing collection periods, following electronic SRT implementation, documentation of re-review times rose from 37.5% to 79.5%. Documentation of frequency of observations and management plans increased from 24.5% to 65% and 79% to 97% respectively. There was a statistically significant rise in recording of escalation plans following implementation of electronic SRT from 35% to 94% (p = 0.008). Conclusions Usage of electronic SRT promoted documentation of all components recommended by SIGN. There is further scope to extend usage outside of surgical wards for all junior doctors by introducing electronic SRT at medical induction.

Successful dilation and evacuation for second trimester conjoined twin: a case report and review of the literature

Background Conjoined twins are a rare clinical event occurring in about 1 per 250,000 live births. Though the prognosis of conjoined twins is generally low, there is limited evidence as to the optimal method of pregnancy termination, particularly in cases of advanced gestational age. We report a successful dilation and evacuation (D&E) done for conjoined twins at 22 weeks of gestation. Case presentation A 20-year-old primigravid woman was diagnosed with a conjoined, thoraco-omphalopagus twin pregnancy after undergoing a detailed two-dimensional (2D) fetal ultrasound anatomic scanning. Assessment and counseling were done by a multidisciplinary team. The team discussed the prognosis and options of management with the patient. The patient opted for termination of pregnancy. Different options of termination were discussed and the patient consented for D&E, with the possibility of reverting to hysterotomy in case intraoperative difficulty was encountered. A 2-day cervical preparation followed by D&E was done under spinal anesthesia and ultrasound guidance. Conclusion In this patient, D&E was done successfully without complications. Adequate cervical preparation, pain control, and ultrasound guidance during the procedure are critical for optimal outcomes. A literature review of methods of pregnancy termination for conjoined twins in the second trimester revealed 75% delivered vaginally through medical induction while 18% underwent cesarean section. Only one other report described successful D&E for conjoined twins after 20 weeks. D&E can be safely performed for carefully selected cases of conjoined twins beyond 20 weeks’ gestations avoiding the need for induction or hysterotomy.

Medical Induction for Mid trimester Abortion: A Hospital-based Descriptive Cross-sectional Study

Introduction: Second trimester abortion is known as termination of pregnancy from 13- 28 weeks of gestation which can be further divided into early second trimester as 13-22 weeks and late as 23-28 weeks. In our study we have limited up to early second trimester. We intend to see the success rate of combination of mifepristone and misoprostol for medical induction, median time required for expulsion, complication and need of dilation and evacuation in some cases. This study also aims to give a review of current literature in mid trimester abortion with respect to efficacy, complication and also to provide evidencebase recommendation for safe regimens for mid trimester pregnancy termination. Methods: This was hospital-based descriptive cross-sectional study conducted among 40 pregnant women at second trimester admitted for termination of pregnancy in Kathmandu medical collage teaching hospital for the period of six month. Ethical approval was taken from the Institutional Review Committee of Kathmandu Medical College (Ref: 2207202002). Convenient sampling was done. All the pregnant women who need to terminate their pregnancy at second trimester (13-22 weeks) were admitted at Kathmandu Medical College Teaching hospital for termination of pregnancy were included in the study. Results: Among the 40 women, who had termination of pregnancy at second trimester 37 (92.5%) had successful medical termination whereas 3 (7.5%) needed dilatation and evacuation. Conclusions: The combination of Mifepristone and Misoprostol have excellent result for termination of pregnancy if appropriately used after evaluating the patient with minimal complications.

Uterine Rupture During Medical Induction for Second Trimester Abortion

Medical induction is an alternative to dilatation and evacuation (D and E) in second trimester abortion, though it has higher risk of minor complications compared to D and E. Combination of mifepristone and misoprostol is commonly used for the medical abortion. A 32 years G3P2L2 with previous two cesarean delivery was referred to our center at sixteen weeks of gestation for termination of her pregnancy. After 63 doses of misoprostol, she had to undergo unintended major intra-abdominal surgery for partial uterine rupture. Keywords: Dilatation and evacuation; medical induction; second trimester abortion; uterine rupture.

Successful Pregnancy after Previous Uterine Rupture

Uterine rupture is a rare and catastrophic incidence with high maternal and fetal morbidity rates. It is most commonly seen in the scarred uterus. The unscarred uterus is least susceptible to rupture with the incidencebeing 1 in 8000 deliveries. In the past, pregnancy after uterine rupture was not widely advised and patients underwent hysterectomy or tubal ligation but with the evolving practice, women are motivated for pregnancy which can be successful with proper obstetric care and emphasis on time and mode of delivery. Here we present a case of 31 years old female, gravida-2 para-1 living 0 with previous uterine rupture after medical induction of labor with stillbirth 4 years ago. She underwent emergency laparotomy with the repair. The patient spontaneously conceived and had close antenatal care throughout the pregnancy. The patient was admitted at 34 weeks of gestation and kept under close surveillance. Corticosteroid was administered. She underwent spontaneous labor at 37 weeks of gestation and emergency cesarean section was planned, delivered via a breech presentation to a live baby of 2.4 kg, APGAR score of 8/10, 9/10 at 1 and 5 minutes.

Effect of Combined Medical and Surgical Induction of Labour in Term Pregnancy at Rajshahi Medical College Hospital

This prospective clinical study was conducted in the Department of Obstetrics & Gynaecology in Rajshahi Medical College Hospital from January to December 2007. A total sample of about 100 selected primigravid women were divided into two groups. Group-I was given medical induction by misoprostol orally and Group-II by oral misoprostol followed by artificial rupture of membrane (ARM) for induction of labour. This study specifically evaluated the effect of oral misoprostol and the combined medical & surgical method, on unripe cervix of primigravid women with term pregnancies and has shown that combined method can successfully initiate labour and also lower the rate of caesarean section and significantly lowering the induction delivery time. TAJ 2018; 31(2): 17-20

Prevalence of blighted ovum in first trimester of pregnancy: a hospital based study

Background: The aim of this study is to know the prevalence of blighted ovum among pregnant women in 1st trimester attending our hospital during their antenatal visits and to know the fate of blighted ovum either if there is spontaneous expulsion of the sac or need of medical induction or surgical evacuation.Methods: This observational study was conducted at Obstetrics and Genecology Department, Women Health Hospital and Sahel Selim Hospital, Egypt from November 2015 to February 2018. All patients recruited in this study attended the antenatal care clinics for antenatal follow-up during their first-trimester of pregnancies.Results: All cases of the study were less than 14 weeks. The mean gestational age was 8.93±1.01 (7.0-11.0) weeks. In patients less than 20 years old, (73%) there is a significant increase in surgical treatment (dilatation & curettage) after failure of medical treatment, patients more than 40 years old (50.7%) there is a significant increase in medical treatment after success taking misoprostol so there is no need to a surgical treatment by (dilatation & curettage) in the majority of cases.Conclusions: The prevalence of blighted ovum was 15.6%. Also, the prevalence of blighted ovum was statistically significant increased with increase maternal age and also, we noticed that there was a statistically significant association between early pregnancy failure and a history of previous early pregnancy loss.