ROLE OF LIGNOCAINE JELLY APPLICATION TO ALLEVIATE VAGINAL PAIN DURING 1ST TRIMESTER MTP UNDER LOCAL ANAESTHESIA
Jignesh J Kansaria, Sv Parulekar
A study of application of lignocaine jelly to alleviate vaginal pain during 1st trimester MTP under local anaesthesia was undertaken in 100 primigravidas. Signi.cant pain relief was achieved by this method on analyzing vaginal pain score before and during MTP, and patient satisfaction score after MTP.
Uterine cramps is a common complaint d u r i n g first trimester medical termination of pregnancy (MTP) by suction and evacuation (S and E) technique done under paracervical block (when the anaesthesia is inadequate). But a more frequent complaint is vaginal discomfort and pain, which has no relation with adequate paracervical block. We studied patients who underwent first trimester MTP with paracervical block and used liberal adequate amount of 2% lignocaine jelly to alleviate vaginal pain and discomfort. The outcome of the use of lignocaine jelly applied locally to the vagina, in terms of vaginal pain score and patient satisfaction score was assessed.
MATERIAL AND METHODS
One hundred patients who desired .rst trimester MTP for varying indications were selected. These patients were all primigravidas, with h/o MTP in the past, the gestational age was 12 weeks or less. All the patients had normal vaginal caliber and no e/o vaginitis. They were counselled regarding MTP under local anaesthesia and willingly opted
for MTP under local anaesthesia. Haemoglobin and blood group of all patients were done. Vaginal pain score was assessed before MTP and then during the procedure following application of lignocaine jelly to the vagina and paracervical block. No sedation was given. MTP was done by S and E technique. 14 ml of 1% lignocaine was given by paracervical
block and 3 gms of 2% lignocaine jelly appliedto vagina.
None of the patients had any complications. The Sims speculum was introduced in the vagina 5 minutes after application of lignocaine jelly to the vagina and the S and E was started 3 minutes after paracervical block. Vaginal pain score of 0-4 was given by the physician based on pain behaviour during 2 finger per vaginum examination, and insertion of vaginal speculum during procedure. Pain behaviour was assessed by observation of patients verbal and motor behaviour before
and during MTP, which includes sighs, moans, complaints (verbal) and facial grimacing.
Vaginal pain score
0 no pain
1 patient sighs
2 patient moans and facial grimacing
3 verbal complaints
4 patients shouts, lifts the buttocks during the procedure
After the procedure, the patient was questioned regarding the degree of pain relief which was analyzed as patient satisfaction score (score of 0 to 3).
Patient satisfaction score
0 no pain relief
1 25%-50% pain relief
2 50%-75% pain relief
3 75% or more pain relief
The outcome of the vaginal pain score and patient satisfaction score in these patients was analyzed and interpreted accordingly.
These patients who underwent first trimester MTP under paracervical block with vaginal application of lignocaine jelly were assessed for vaginal pain score, its relation to marital status and patient satisfaction score.
TABLE 1: Average age of these patients
Group Age (years) Youngest 18 Eldest 31 Average 22awareness.
The average age of these women undergoing MTP was 22 years. Youngest being 18 years and eldest 31 years.
Marital status Vaginal Pain Score Total
0 1 2 3 4
TABLE 2: Correlation of duration of marriage to vaginal pain score before MTP
Unmarried 0 0 5 3 3 11 Married < 6 m 0 2 19 17 5 43 Married > 6 m 0 6 16 24 6 46
No correlation was found between duration of marriage to vaginal score.
Patients satisfaction score of 3 was seen in 47%.
HAEMATOLOGICAL CHANGES SIGNAL OUTCOME IN SARS PATIENTS
Lymphopenia was present in 98%, neutrophilia in 82%, and thrombocytopenia in 87%. Also, low CD4 and CD8
cell counts and a high concentration of lactate dehydrogenase at presentations were associated with adverse outcome. Depletion of lymphocytes, which was found in various lymphoid organs at postmortem examination, may be a good.
BMJ, 2003; 326 : 1358.
TABLE 3: Vaginal pain score before MTP
Score No. of patients 0 0 1 2 2 41 3 44 4 12
Majority of patients had vaginal pain score of 0 and 1 during and after MTP. Comparing Table 4 and 5, itself gives us an idea that significant pain relief has been achieved
TABLE 5: Patient satisfaction score after MTP
Score No. of patients 0 0 1 8 2 45 3 47
of these patients undergoing MTP i.e. almost 50% of patients had adequate pain relief.
Many primigravida patient present in out patient department for termination of pregnancy for varying socio-economic, medical, eugenic and humanitarian reasons. Most of them want a short (2 to 4 hours) hospital stay. But many of these patients tend to be uncooperative when MTP is done under adequate local anaesthesia (paracervical block), due to
extreme vaginal discomfort, making the procedure dif.cult, forcing us to opt for MTP under general anaesthesia. Liberal application of lignocaine jelly (2%) to the vagina prior to the initiation of procedure leads to adequate vaginal relaxation
during the procedure.
This is well seen from comparing Tables 4 and 5, where we .nd majority patients (85%) had vaginal pain score of 2 and 3 prior to MTP and 80% of patients had vaginal pain score of 0 and 1 during and after MTP. Even objective questioning to the patient after MTP yielded a positive result with a patient satisfaction score of 2 in 45 patients and score of 3 in 47 patients.
Ours is a unique study of its kind being reported for the 1st time. We have used both physician and patient related response to assess the magnitude of pain in these patients. Pain behaviour patterns form an important tool for the physician to assess patient's vaginal pain score.
DC Turk, A Okifuji 1999(1) state measurement of pain rely on patients self reports, or the inferences physicians make on the basis of the patients behaviour. Patients can quantify their pain by rating the intensity of pain- is your usual pain mild moderate or severe? or rate your typical pain from 0 (no pain) to 10 (the worst pain you can imagine).
Liberal application of lignocaine jelly to the vagina prior to 1st trimester MTP (S and E) under paracervical block provides adequate relief from
DIAGNOSIS OF KALA-AZAR - AN IMPORTANT STRIDE
ELISA has been used as a serodiagnostic tool in leishmaniasis. The technique is highly sensitive but its speci.city depends upon the antigen used. Several antigens have been tried. Most commonly used is a crude soluble antigen (CSA) derived by lysing the leishmania promastigotes.
It has been found to be 100% sensitive and 100% speci.c in the diagnosis of VL by ELISA.
They are expensive, require skilled personnel, expensive equipment, and electricity, and are technically demanding. Parasite diagnosis by splenic and marrow smear examination remain the "gold standard", with their usual limitations. rK39 strip test in an important step forward in the diagnosis of VL, and it has the potential to be used underfield conditions.
JAPI, 2003; 51 : 753-4.