Browsing by Author "Stewart, Chantal"

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    Accuracy of ultrasound beyond 14 weeks to determine chorionicity of twin pregnancies
    (2014) Momberg, Zoe; Stewart, Chantal; Van Zyl, Hetta
    Determining the chorionicity of twin pregnancies is extremely important as this influences the frequency of surveillance, timing of delivery and management of complications. Monochorionic twins have 2.5 times the perinatal mortality of dichorionic twins, and in the case of a single intra-uterine fetal demise, the surviving twin of a monochorionic pair is at significant risk of neurological damage compared to a dichorionic pregnancy. Chorionicity can be accurately determined before 14 weeks gestation using the lambda or T-sign. After 14 weeks, these ultrasonographic signs become less reliable and the pregnancy may be assumed to be monochorionic for management purposes. The implication of this assumption is that on occasion premature dichorionic fetuses may be delivered unnecessarily. In South Africa, many women have their first antenatal visit after the first trimester or are not scanned by an experienced sonographer until after 14 weeks. There is thus a need for an accurate means to determine chorionicity in the second and third trimesters.
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    Antenatal AVSD diagnosis at Groote Schuur Hospital A retrospective cohort study
    (2019) Annor, Charlene Adjoa Adobea; Stewart, Chantal; Osman, Ayesha
    The antenatal diagnosis of a fetal atrioventricular septal defect (AVSD) impacts the prognosis of an unborn child, and may have psychosocial and financial implications for mothers receiving this diagnosis. Outcomes relevant to our local population may be used to improve counselling for parents receiving this diagnosis. During a literature review, there was a lack of existing published data on antenatal AVSD outcomes from the developing world. To ascertain the outcomes of antenatal AVSD diagnosis in fetal, neonatal and infant life, we performed a retrospective study of all AVSD's diagnosed at a tertiary referral hospital in Cape Town (Groote Schuur Hospital) between 1 January 2010 and 31 December 2016. We examined ultrasound records and case folders from the antenatal, neonatal and infancy periods, up to a year of life or demise. The resultant cohort had a total of 55 cases. We found that fetal outcomes in Cape Town, South Africa are similar to those in developed countries. Pregnancies were terminated in just over a third of cases and similarly, the over-all survival to one year of life excluding termination of pregnancy was 29,73%. The bulk of these fetuses demised in the antenatal period, and the rate of demise positively correlated with the presence of associated organ abnormalities and aneuploidies. In those born alive, the correlation between an antenatal AVSD diagnosis and the same diagnosis during postnatal echocardiography was 59,09%, with the remaining 40,91% having other complex cardiac abnormalities diagnosed. Corrective cardiac surgery in the neonatal period or infancy occurred in 46,15% of those born alive, with good outcomes. This study shows similarity between survival of fetuses diagnosed with antenatal AVSD in the developing and developed world. It will be instrumental in appropriately counselling South African parents who receive the diagnosis. In order to assess if prenatal AVSD diagnosis improves neonatal and infant outcomes, a further study comparing this group to the outcomes of infants with postnatally diagnosed AVSD is necessary. More research is needed in an African context regarding the outcomes of babies diagnosed with antenatal anomalies.
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    Cohort Profile: The Western Cape Pregnancy Exposure Registry (WCPER)
    (2022-06) Kalk, Emma; Heekes, Alexa; Slogrove, Amy; Phelanyane, Florence; Davies, Mary-Ann; Myer, Landon; Euvrard, Jonathan; Kroon, Max; Petro, Greg; Fieggen, Karen; Stewart, Chantal; Rhoda, Natasha; Gebhardt, Stefan; Osman, Ayesha; Anderson, Kim; Boulle, Andrew; Mehta, Ushma
    Purpose: The Western Cape Pregnancy Exposure Registry (PER) was established at two public sector healthcare sentinel sites in the Western Cape province, South Africa, to provide ongoing surveillance of drug exposures in pregnancy and associations with pregnancy outcomes. Participants: Established in 2016, all women attending their first antenatal visit at primary care obstetric facilities were enrolled and followed to pregnancy outcome regardless of the site (ie, primary, secondary, tertiary facility). Routine operational obstetric and medical data are digitised from the clinical stationery at the healthcare facilities. Data collection has been integrated into existing services and information platforms and supports routine operations. The PER is situated within the Provincial Health Data Centre, an information exchange that harmonises and consolidates all health-related electronic data in the province. Data are contributed via linkage across a unique identifier. This relationship limits the missing data in the PER, allows validation and avoids misclassification in the population-level data set. Findings to date: Approximately 5000 and 3500 pregnant women enter the data set annually at the urban and rural sites, respectively. As of August 2021, >30 000 pregnancies have been recorded and outcomes have been determined for 93%. Analysis of key obstetric and neonatal health indicators derived from the PER are consistent with the aggregate data in the District Health Information System. Future plans: This represents significant infrastructure, able to address clinical and epidemiological concerns in a low/middle-income setting.
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    Exploring the decision making process of women offered termination of pregnancy for serious congenital abnormality
    (2018) Malope, Malebo Felicia; Wessels, Tina-Marié; Fieggen, Karen; Stewart, Chantal
    Background: A weekly pregnancy counselling clinic is held in conjunction with foetal medicine experts at Groote Schuur Hospital for women with pregnancies complicated by foetal anomalies. In cases with poor prognoses, termination of pregnancy (TOP) may be offered. The women receive genetic counselling where the ultrasound findings, invasive testing and TOP options are discussed. Decision-making is the focus of these sessions. The experiences and decision-making processes of the women in this clinic are poorly understood, therefore this project aims to explore these women's experiences and what factors influence their decision-making regarding TOP. Methods: Qualitative research, drawing on principles of phenomenology was used as the study design. The sample for this study are women who had a prenatal diagnosis of a serious congenital abnormality and were offered TOP. The women were identified using the Division of Human Genetics pregnancy counselling database at the University of Cape Town in South Africa. Semistructured face-to-face interviews with open-ended questions were used to collect the data and close-ended questions were used to obtain the demographic data. The interviews were recorded and transcribed verbatim. The data were analysed using a thematic data analysis approach. A total of 12 women were interviewed. Results: Five themes were identified in this study. These include "Health care services", "Home", "Being a woman", "Finding meaning", and "The aftermath". The healthcare services impacted the manner in which the women made sense of the ultrasound findings. Support (or lack of) from family and the community impacted on their decision-making. Stigma attached to having a child with a disability and/or stigma against TOP and partner relationships played a role. The women questioned their role as a woman and obligations of child-bearing. Finding meaning for the event was important and this process continued until after the delivery or after the child was born. Following the event having a burial and giving away the child's clothes were found to play a significant role in their adjustment. Discussion and Conclusion: The decision-making process was multifaceted and unique to each woman. They consulted their families, partners and community but in the end they made the final decision. The women considered a multitude of factors but it seems that there may be one deciding factor. This in depth exploration of the women's experiences has provided valuable insight into the decision-making process, which can be used to improve the services offered to patients.
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    The outcome of prenatal sonographic diagnosis of fetal talipes in the Cape Town Metro district
    (2017) Swarts, Elfriede; Stewart, Chantal; Petro, Gregory
    Background: Talipes equinovarus, also termed club foot, is a congenital deformity of the ankle joint. Despite its prevalence of approximately 1 per 1000 live births, fetal talipes is relatively poorly studied since the introduction of percutaneous tendo Achilles tenotomies. Objectives: To document the associations, outcomes and prognosis of patients with antenatally diagnosed fetal talipes. The study aims to examine the association between, and prevalence of, fetal talipes and other abnormalities, structural and chromosomal, as well as the outcome in relation to postnatal surgery. The accuracy of prenatal ultrasound in diagnosing fetal talipes is also examined. Methods: A retrospective observational study was made of all cases presenting to the Fetal Medicine Unit between 1 January 2009 and 31 December 2014. All the identified cases were analysed to identify isolated talipes, associated abnormalities, and chromosomal abnormalities. The pregnancy outcomes were determined using the Astraia database as well as maternity records. When the outcome resulted in a live infant, these infants were followed up using the files at the referral hospital to determine the treatment method used and the number requiring surgery. Results: There were 155 cases, all referred to the Fetal Medicine Unit. Antenatal data included 75 who had other structural abnormalities and 75 who had isolated talipes. In five of the cases were no sufficient data could be found. Twenty-five cases were lost to follow-up, and 12 cases had no clubfoot at birth. Only one was labelled as having positional clubfoot. There were 91 live births. Of the cases of talipes with associated abnormalities, 21.19% were live births (excluding ENND). All terminations of pregnancy as well as 90.9% of intrauterine fetal deaths were complex talipes, and 94.52% of the cases of isolated talipes were live births. The most common associated abnormalities were of the central nervous system. Seventeen of the live births were lost to follow-up. Of the cases of isolated talipes, 53.19% had tenotomies and Ponseti treatment. The false positive rate of detecting fetal talipes on ultrasound was 7.74%. Conclusion: The study made it evident that complex talipes is associated with a poor pregnancy outcome defined as pregnancy loss, where isolated talipes is usually associated with a good pregnancy outcome. Ultrasound is a good diagnostic tool when diagnosing talipes antenatally but cannot diagnose the severity of the clubfoot. False negatives were not studied. The introduction of tenotomy can make a difference in the outcome of clubfoot in comparison with previous studies where tenotomies were not performed. Medical professionals need to address the importance of counselling, and a multidisciplinary team should be involved in cases involving prenatal counselling.
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    Trans-vaginal ultrasound diagnosis of adenomyosis with histologic correlation
    (2013) Chunda, Reginald George; Dyer, Silke; Stewart, Chantal
    Adenomyosis, defined as the presence of ectopic endometrial tissue in the myometrium, is a cause of morbidity in afflicted women. Classically it presents with menorrhagia, dysmenorrhoea and dyspareunia. Traditionally the diagnosis has been by histology of post-hysterectomy specimens with reported prevalence of 5%-70%. With advances in imaging techniques, pre-surgical diagnosis can be made with a reasonable accuracy using trans-vaginal ultrasound (TVS) and magnetic resonance imaging (MRI) with the former being preferred due to cost effectiveness. Accurate presurgical diagnosis would facilitate alternative treatment options to hysterectomy. Different sonographic features of adenomyosis have been reported and well correlated with histology; there is however no general consensus as to the most specific features and whether the frequencies of these sonographic features hold true in other population settings like South Africa. We therefore conducted a cross-sectional diagnostic study of presurgical TVS diagnosis of adenomyosis with post-hysterectomy histological correlation. The primary objective was to determine the diagnostic performance of TVS for the diagnosis of adenomyosis using posthysterectomy histology as the reference standard. Secondary objectives were to determine the signs and symptoms in women with histologically confirmed adenomyosis and the prevalence of histological adenomyosis. The study was conducted at Groote Schuur Hospital and New Somerset Hospital over a period of 11 months (May 2011 to April 2012). There were two study groups. In study group A, women scheduled for hysterectomy completed a questionnaire capturing clinical symptoms and underwent TVS examination. A TVS diagnosis of adenomyosis was made if three or more features suggestive of adenomyosis were present. After hysterectomy, the uteri were examined by histopathologists. Both ultrasonographers and histopathologists were blinded to other findings. The TVS diagnosis of adenomyosis was compared with histopatholgy results. In study group B, histopathological results were collected prospectively in all women undergoing hysterectomy during the study period (including those in study group A). From the results, a histopathological profile of posthysterectomy specimens was made. There were 78 participants in group A. Histologically confirmed adenomyosis was found in 16 of the 78 women (20.5%). Seventy one clinical questionnaires were completed (missing data n=7). The only clinical finding that reached statistical significance was presence of a tender uterus in 31.5% of women with adenomyosis compared to 5.4% without adenomyosis (p<;0.05). Other clinical features seen in women with adenomyosis were heavy menstrual bleeding (62.5%), dysmenorrhea (50%) and a uterus that was less than twelve weeks gestation (62.5%) but these findings did not reach statistical significance compared to women without adenomyosis (p>0.05). Despite presence of characteristic signs and symptoms, a preoperative clinical diagnosis of adenomyosis was made in only 12.5% [95% CI: 3.5 - 36] of patients with histologically confirmed adenomyosis. TVS diagnosis of adenomyosis had a sensitivity of 50% [95% CI: 28-72], specificity of 80.6% [95% CI: 69.2 -88.6], accuracy of 74.4% [95% CI: 63.7- 82.7] and diagnostic odds ratio of 4.2 [95% CI: 1.3-13.4]. Of all TVS diagnostic features evaluated, heterogenous myometrial echotexture had the highest sensitivity 68.8% [95% CI: 44.4-85.8] but a poor specificity 62.9% [95% CI: 50.5-73.8]. The presence of subendometrial echogenic linear striations had the highest specificity 96.8% [95%CI: 89-99] and accuracy 78.2% [95% CI: 67.8-85.9] for the diagnosis of adenomyosis. TVS diagnosis of adenomyosis was ultrasonographer dependent. Study group B comprised 261 women. Leiomyomas were the most prevalent histopathological diagnosis (63.2% ; 95% CI: 57.2-68.4), followed byadenomyosis with a prevalence of 20.3% [95% CI: 15.9-25.6]. Data from this prospective study showed that a clinical presentation of menorrhagia, dysmenorrhea and a tender uterus less than twelve weeks suggested a diagnosis of adenomyosis. Despite characteristic signs and symptoms, clinicians only diagnosed adenomyosis in about one in ten women.