Browsing by Department "Department of Obstetrics and Gynaecology"

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    A retrospective audit of young patients diagnosed with cervical cancer over ten years at Groote Schuur Hospital, Cape Town between 1 January 2003 and 31 December 2012, and their outcome at five-year follow-up compared to women in the prior decade
    (2020) Govindasamy, Suveshni; Mbatani, Nomonde; Fakie, Nazia
    Background : Cervical cancer is the second commonest gynaecological cancer amongst women worldwide and the leading cause of cancer deaths in developing countries – contributing 83% of new cases and 85% of all deaths annually to the burden of this disease. Information and awareness of this illness in the developing world is still inferior, and mortality is increasing. In the developing world, late presentation, advanced-stage disease and a poorly run screening programme (covering only 55% of the South African population) are all contributing factors to this statistic. Approximately 20% of all South African women in their reproductive age are also HIV positive. With the rising burden of cervical cancer and the emergence of HIV as an influencing comorbidity, South Africa adopted a national cervical screening programme, rolled out in 2000 as well as an HCT (HIV counselling and testing) programme formalised in 2011. With these initiatives now in place, this study examined trends and compared 5-year survival outcomes between two decades for cervical cancer among young women. Methods : The study undertook a retrospective audit of files and information on the pre-existing cervical cancer database, and appropriate data was extracted (HREC REF 344/2011). Survival and disease outcomes at five years, as well as time to recurrence, was assessed, together with other demographics of the study population. Patients included in the study were non-pregnant female patients, aged 40 years and younger at the time of registration with the Groote Schuur Hospital (GSH) Oncology Unit (LE 33). The diagnosis of cervical cancer had to have been confirmed histologically, as either squamous cell carcinoma or adenosquamous carcinoma or adenocarcinoma. Patients must have attended at the LE 33 unit on or from 1 January 1993 until and including 31 December 2012. The two decades were studied and 5-year outcomes from each decade were analysed and reviewed using Kaplan-Meier curves and univariate analyses. The study compared data using Log Rank tests and p-values. Findings : The two decade-groups under study showed no difference in trends of survival regarding age, treatment type and histology. Albeit small numbers, adenocarcinoma was the histology that had the best probability of survival during both decades. There were more patients with early-stage cancer (stage 1 and 2) diagnosed in decade B (2003 – 2012) than A (1993 – 2002). Within this early-stage cervical cancer cohort, there is a trend toward more locally-advanced (stage 2) cancer in the more recent decade. The proportion of patients presenting with stage 1a and 1b cancer with tumours 4 cm and less has halved from decade A to decade B. The proportion of stage 2 cancers presenting with tumours 2 – 4cm in size during decade B has risen almost 3-fold to that of decade A. This suggests a developing trend of presentation of more locally-advanced cancer. During both decades, stage 1 cervical cancers had the best probability of survival, with an improvement in mean survival from decade A (average of 44 months) to decade B (average of 58 months). The trend of stage 2 disease has deteriorated, with a decrease in mean survival (from 48 months in decade A to 21 months in decade B), an increase in cancer-related deaths and a shorter time to relapse. The number of patients presenting with late-stage disease (stages 3 and 4) has declined. HIV positive status played an influential role in tumour size on presentation and probability of 5-year disease-free survival. Young women who were HIV positive also fared less favourably when compared to NP (not positive) women in terms of mean survival. Due to the small sample size and that the majority of patients in decade A were untested, further HIV comparisons were not credible. Interpretation : The study suggests a moving trend towards young patients that are being diagnosed with the more locally-advanced early-stage disease in the more recent decade than ten years prior. HIV status seemingly played an influential comorbid role in patients diagnosed with cervical cancer. Patients with the locallyadvanced disease appear to have worse outcomes in the latter decade. In an attempt to curb this potentially curable disease in this subset of young women, a greater focus on earlier screening interventions, prompt diagnosis and appropriate and timeous treatment of cervical cancer, together with optimisation of comorbidities like HIV are needed.
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    A retrospective review (audit) of gynaecological emergency surgery at Groote Schuur Hospital for the period of January to December 2019
    (2024) Hlako, Tebogo Clive; Adams, Tracey Sheridan
    Background. Gynaecological emergencies are a common cause of morbidity and mortality among women of reproductive age worldwide. There is less audit done on the burden of emergency surgery in developing countries. Objectives. The planned study analysed the clinical processes and outcomes of gynaecological emergency surgeries performed at a tertiary level hospital in the Western Cape (Groote Schuur) in the year 2019. Methods. The study was a retrospective descriptive record review of patients who underwent emergency surgery at Groote Schuur Hospital. Data was captured manually and electronically using theatre data base. Statistical analysis was performed using SPSS Statistics for Windows 2021. Results. We analysed 290 completed women records. The mean age was 30.16, with 230 (79.3%) women of reproductive age. There were 234 (79.1%) pregnancy related surgical procedures done. The most common occurrence among pregnancy related surgeries was ectopic pregnancy, accounting for 112 (47.9%) cases. A total of 130 (44.8%) women had anaemia and 125 (43.1%) had a tachycardia prior to surgery. Twenty-seven (9.3%) women were in hypovolaemic shock before surgery. A total of 179 (61.7%) women had the surgery 4 hours after being booked in theatre. Only 46 (15.9%) women accessed surgery within 2 hours. Twenty (6.9%) women had to wait for more than 24 hours for their operation to be done. The most common reason for the 24-hour delay, accounting for 85% (N=17), was the lack of emergency theatre time, as other cases from different disciplines were given priority. There were 42 (14.5%) women with complications post operatively and no mortality recorded. Conclusion. The study indicates good outcomes for emergency gynaecological surgeries performed at Groote Schuur Hospital in 2019. However, significant delays between the decision for surgical intervention and the actual performance of the surgeries were highlighted. The delays in hypovolaemic women were attributed to the need to compete with other surgical disciplines for emergency theatre time.
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    A review of intrauterine device placement during caesarean section at level two facilities in the Metro West, Cape Town
    (2020) Schutte, Marcelle; Patel, Malika; Petro, Gregory
    Study rationale In the Western Cape there are many intrauterine contraceptive devices (IUDs) inserted during caesarean section (C/S). Little is known about the long-term outcomes in the Metro West area. Objective To assess placement of IUDs at C/S and describe follow-up, with a view to compile best practice guidelines for insertion and follow-up in our clinic setting. Method A retrospective descriptive audit of clinical records was performed of all women who received an IUD at C/S between January and June 2018 at Mowbray Maternity Hospital (MMH) and New Somerset Hospital (NSH) in Cape Town. Results There were 2310 and 1376 C/S performed at MMH and NSH respectively. The IUD insertion rate was 17.4% (n=402) at MMH and 14.3% (n=197) at NSH. Almost two third of insertions were performed at the time of emergency caesarean section (59.1%; n=276). The majority of women experienced no immediate complications (84.4%). Only 77 women attended follow-up. The continuation rate at follow-up was 71.6%. The overall expulsion rate in hospital and at follow-up was 3%. Strings were visible in 53.2% of patients. An ultrasound was performed in 67.5 % (52/77) of patients. The IUD removal rate at follow-up was 24.7% (19/77). Discussion The poor follow-up rate is concerning, and measures must be taken to address this. The continuation rate of 71.6% is lower than expected but may have been biased by the low follow-up rate. Continuation rates improved with the experience of inserters which highlights the importance of training and supervision. Conclusion The immediate postpartum period may be the only opportunity to provide long acting reversable contraception to some women. In our study population follow-up rates are poor and therefore conclusions are difficult to accurately gauge. Measures must be taken to improve follow-up.
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    A Review of Women with Epithelial Ovarian Carcinoma in a Middle-Income setting: Groote Schuur Hospital, Cape Town, South Africa: Demographics, Treatment and Outcomes of Patients between 2005 and 2015
    (2024) Loggenberg, Francisca; Adams, Tracey
    Background: In 2020 there were 313 959 new cases of Ovarian carcinoma worldwide.1 It is one of the most challenging female gynaecological cancers to manage with a poor prognosis for latestage disease and high recurrence rates. Ovarian Carcinoma ranks 8th amongst new cancer cases in women and accounts for 4.7% of reported cancer deaths.1 Women often present late with advanced disease of which the prognosis remains poor. The 5-year survival rate of stage 3 disease being 52-59% and only 17% for stage 4B disease.2 Overall the 5-year survival rate of many malignancies have improved over the past 30 years due to advances in screening, diagnosis and treatment, but despite these advances the survival rate of ovarian carcinoma has shown only a modest improvement.3 Methods: The study is a retrospective descriptive study of patients with epithelial ovarian carcinoma treated at Groote Schuur Hospital in Cape Town between 2005 and 2015. The study included all patients with epithelial ovarian carcinoma registered with and treated at our combined multidisciplinary clinic. There were 168 patients included in this study. Data was collected from patient folders and an existing cancer database(R016/2013). Data collection sheets were used and the data was entered into a secure database for analysis Results: The study population included 168 patients. The mean age was 59.4 years (standard deviation 11.6). High grade serous ovarian carcinoma was the most prominent histology accounting for 64.3% of cases. Endometroid and Mucinous histology was reported in 12.5% and 11.9% of cases respectively. Only 33.9% of patients presented with early-stage disease. Patients with advanced stage disease accounted for 66.1% of our study population. Of the 163 patients who underwent primary cytoreductive surgery, 72 (44.2%) patients were completely debulked with no residual disease, 18 (11%) were optimally debulked to less than 1cm residual disease and 72 (44.2%) still had gross residual disease. A complete response was achieved in 62.5% of our patients, 60 (57.1%) of these patients had recurrent disease with a median time to recurrence of 11.5 months. The median overall survival was 27.2 months with 5-year overall survival of 21%. The 5-year disease specific survival was 27%. Conclusion: Ovarian carcinoma remains one of the most challenging gynaecological malignancies to manage even in high resource settings. Rates of complete cytoreductive surgery were lower at our unit than reported in high income settings. Recurrence rates were high with shorter time to recurrence. The median survival of our patients was also much shorter than reported in literature. This may reflect the limitations in limited resource setting when managing patients with epithelial ovarian carcinoma.
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    A two phase local study, comparing liquid-based cytology to the conventional cervical pap smear
    (2005) Van Rensburg, Jacobus A; Denny, Lynn
    Cancer of the cervix is the most common cancer in women in developing countries and constitutes 33% of all malignant tumours in black women in South Africa. Four out of every 5 cases of cervical cancer occur in developing countries, where only 5% of women receive a repeat PAP smear within a five year period. The lifetime risk for the development of cervical cancer in black South African women is an estimated 1 :26 compared to 1 :83 for white South African women, the majority of whom have been screened. The age standardised incidence rates (ASIR) of cervical cancer are expressed as the number of cases of cervical cancer per 100 000 women in the population. In 1992, the South African pathology-based Cancer registry reported the ASIR of cervical cancer as 35/100 000 for black women and 12/100 000 for white women. 11: is believed that many women who die of cervical cancer in developing countries do not reach hospitals and do not have their disease diagnosed histologically, so the rates quoted are probably an underestimate of the true incidence. (See Table 1).
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    Accuracy of estimated fetal weight using ultrasound at term in pregnant women diagnosed with gestational and pre-gestational diabetes at Groote Schuur Hospital
    (2018) Venter, Mareli; Schoeman, L
    Background The incidence of diabetes is rising globally. Similarly, there has also been a rise in the incidence of diabetes in pregnancy, both pre-gestational as well as gestational. These patients are at risk of multiple perinatal complications, including macrosomia. There is an increased risk of perinatal complications with a fetal weight at birth of more than 4 000 g, especially if macrosomia occurs in the context of diabetes. In order to predict fetal macrosomia, fetal weight estimation remains an important component of antenatal surveillance. Despite the relative inaccuracy of ultrasound fetal weight estimation, the current National Institute for Health and Care Excellence (NICE) guideline on the care of diabetic patients, recommends offering 4 weekly ultrasound scans from 28 to 36 weeks to assess fetal growth and wellbeing. In addition, the Western Cape guidelines recommend offering an elective caesarean section to diabetic patients with an estimated fetal weight of 4 000 g or more at term with a fetal abdominal circumference greater than the 90th percentile. This practice has subsequently resulted in a large number of caesarean deliveries performed to prevent fetal and maternal complications related to presumed macrosomia. Objectives The aim of this study was to assess the accuracy of ultrasound fetal weight estimation performed in diabetic women at term, as well as to determine the incidence of macrosomia in the study population and the accuracy of ultrasound identification of macrosomia. Methods A retrospective audit was undertaken in women who attended antenatal services at Groote Schuur Hospital (GSH). This study reviewed women with an abnormal glucose tolerance test (GTT) during pregnancy or with known diabetes preceding pregnancy attending GSH during a 12-month period were included. Women with a singleton pregnancy at 36 weeks or more that underwent a documented ultrasound for fetal weight estimation within 7 days of delivery were included in this audit. Results A total of 97 women in the study population met the inclusions criteria. Seventy patients (72%) had gestational diabetes and 22 (18%) had pre-gestational diabetes. Ultrasound weight estimations were accurate to within 10% of birth weight in 70,1% of all patients. Eleven (11,3%) patients had macrosomic (> 4 000 g) babies. In these patients only 54,5% of fetal weight estimations were accurate to within 10% of birth weight. Ultrasound for detection of macrosomia had a sensitivity of 58,3% (CI: 36-82%) and a specificity of 96,5% (CI: 93-99%). Conclusion The accuracy of ultrasound fetal weight estimation performed in diabetic patients at GSH appears similar to that of other international studies. Ultrasound estimations become increasingly inaccurate in extremes of fetal weight. One in four fetal weight estimations had an estimation error of > 10% with a tendency towards underestimation in macrosomic fetuses. Ultrasound fetal weight estimation as a predictor for fetal macrosomia should therefore remain under scrutiny, especially in the context of the high perinatal morbidity associated with macrosomia and shoulder dystocia as well as the rising litigation related to birth complications.
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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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    Acupuncture for women with refractive Overactive Bladder Syndrome
    (2010) Cloete, Marinus; Jeffery, Stephen
    To evaluate the efficacy of acupuncture in refractive OAB. The primary aim was to evaluate the effect on frequency, nocturia and urge urinary incontinence. The secondary aim was to evaluate the effect of the response on self-perceived quality-of-life.
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    Advanced abdominal pregnancy: diagnosis, evaluation and surgical management in a resource constrained setting
    (2022) Elijah, Regis; Fawcus, Susan; Moja, Letticia M; Godi, Nthandho P
    Introduction Advanced abdominal pregnancy (AAP) is a pregnancy of over 20 weeks gestation, with a foetus living, or showing signs of having once lived and developed, in the mother's abdominal cavity. It is a rare obstetric complication associated with high maternal and perinatal morbidity and mortality. The question of whether to leave the placenta in or to remove it has been the subject of debate. When such cases present outside high resource settings, where a multi-disciplinary approach may not be possible, there are many challenges to effective treatment. The management of this rare but serious complication of pregnancy at Rob Ferreira Hospital (RFH), a rural provincial tertiary hospital, in Mpumalanga, was investigated. Methods This was a retrospective observational study of patients with AAP identified from theatre registers from January 2011 to January 2018 at RFH. Data was collected on patient demographics, diagnostic challenges, preoperative evaluation, and surgical management particularly of the placenta, and outcomes. Delivery data for RFH was retrieved from the provincial database. Results There were 26 cases of AAP identified, for which 21 folders could be retrieved from the registry. The incidence of AAP was 66.2 per 100, 000 deliveries. Abdominal pain was a presenting complaint in 100% of patients. Ultrasound scan (USS) accuracy, prior to surgery, was eventually 90.5%. However, for 61.9% the diagnosis of AAP was missed at initial USS and for 33% of these, AAP was only diagnosed after failed attempts at induction of labour (IOL). AAP was diagnosed intra-operatively in 9.5%, for a supposed caesarean delivery and 19 (94.7%) were diagnosed pre-operatively. Intra-operatively, 36.8% patients had placental site bleeding for which partial placental removal was 2 necessary in 71.4%. This group had more adverse maternal outcomes. For 73.7% of patients there was no bleeding from placental bed and the placenta was left in situ; but 7.1% required relook laparotomy for haemorrhage. There was one maternal death. Overall neonatal survival rate was 14.3% and pregnancy loss rate was 71.4%. Conclusion This study shows that planned management of AAP in a resource constrained setting with tailored approach and management, can be performed without compromising maternal outcomes. However, poor outcomes occurred when pre-operative diagnosis was not made and AAP was discovered during emergency CS, emphasising the importance of antenatal diagnosis. USS and a high index of suspicion remains the best diagnostic tool. From this study it appears safe to leave the placenta undisturbed unless it can be safely removed, or the patient is already bleeding from the placental site. There were very low neonatal survival rates, and this needs to inform counselling of patients with AAP.
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    Adverse perinatal events observed in obese pregnant women in the Metro West Region
    (2014) Gadama , Luis Aaron; Horak, Tracey Anne; Fawcus, Susan R
    Background. Obesity is increasing globally and is defined as a Body Mass Index (BMI) over 30 kgms/m². It’s prevalence in the Metro West Maternity service is unknown. Objective .To assess the prevalence of obesity and determine its association with adverse perinatal and maternal outcomes among pregnant women in the Metro West Region, Cape Town, South Africa Study Design. This was a retrospective observational study that compared perinatal outcomes in women with normal pregnancy BMI to outcomes in women with high pregnancy BMI. Setting. Mitchells Plain and Guguletu Midwife Obstetric Units, Mowbray Maternity Hospital and Groote Schuur Hospital, Metro West Region, Cape Town, South Africa Population. A total of 970 pregnant women divided into BMI groups that had their first antenatal booking visit between January and April 2011. Methods. A list of folder numbers was compiled from the antenatal booking registry at the two MOUs. From the list, maternal folders were then traced through the CLINICOM tracking system, MOU delivery registers, antenatal clinic transfer registers and labour ward transfer registers to find place of delivery or outcome of pregnancy. Maternal and perinatal characteristics were then extracted from the folders into the data collection sheet and data was analysed by STATA. Descriptive statistics included proportions with percentages and median with interquartile ranges. Inferential statistics included Chisquared tests, Fisher Exact tests, Kruskal Wallis test, univariate and multivariable logistic regressions. Main outcome measures. Perinatal outcomes (stillbirth, macrosomia, shoulder dystocia, 5 minute Apgar Score less than 7, congenital abnormalities) observed in obese and morbidly obese compared to normal BMI pregnant women.
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    An audit of caesarean sections performed for suspected fetal distress at Mowbray Maternity Hospital in 2018
    (2022) Moreri-Ntshabele, Badani; Fawcus, Susan; Kadwa, K; Petro, Gregory
    Background The cardiotocograph (CTG) is used for fetal monitoring antenatally and in labour, to detect potential fetal hypoxia and thus prevent perinatal morbidity and mortality. An abnormal CTG influences decisions clinicians make in terms of timing and mode of delivery, as the type of abnormality may warrant immediate delivery by caesarean section (CS). However caesarean section rates are increasing worldwide and in South Africa, and ‘fetal distress' is one of the common indications. The increased CS rate also increases the risk of maternal morbidity and mortality. At Mowbray Maternity Hospital, weekly review meetings show that ‘pathological CTG' and ‘non reassuring CTG' accounted for the majority of emergency CS. Therefore, this study was undertaken to see if ‘fetal distress' is being over-diagnosed leading to unnecessary CS, or to affirm that the CS are correctly indicated for this diagnosis. Hence an investigation of caesarean sections done for ‘fetal distress in 2018 was performed in order to audit emergency CS performed at MMH for abnormal CTG tracings. Methods A retrospective observational study with a comparative component was performed. The PASS 2022 software was used to calculate the sample size. The calculation was made for proportions of agreement using a kappa statistic which was calculated to be 114 cases. The study population was derived from the institutional theatre register, in which patients, who had an emergency CS for an abnormal CTG or ‘fetal distress', between 01 January 2018 and 31 March 2018 were included. The CTGs were interpreted by the two obstetric specialistts (experts) and this was compared with the original interpretation made by the attending doctor. In addition, the independent experts assessed the appropriateness of the decision for CS. Data was also obtained on co-existing obstetric conditions, and perinatal and maternal outcomes. Ethics approval for the study was attained from the University of Cape Town Human Research Ethics Committee (UCT HREC) and facility approval from MMH. Results Ninety cases were identified from the study period and analysed. The attending doctor assessed 22 (24.4%) CTGs as suspicious and 68 (75.6%) as pathological, whereas the experts assessed 7 (7.8%) as normal, 22 (24.4%) as suspicious and 61 (67.8%) as pathological. There was overall agreement in CTG interpretation between the experts and the attendant doctor for 61 cases (67.8%). The reliability of this agreement was measured using Cohen's Kappa and was 0.247 (CI 0.153-0.341). This is a ‘fair' level of agreement. A further analysis showed that there was a higher proportion of agreement with pathological CTGs and a lower proportion of agreement for suspicious CTGs which accounted for 52 (57.8%) and 9 (10%) cases, respectively. A review of the medical records showed that 69 (77%) of patients had one or more co-existing obstetric condition such as prolonged pregnancy, hypertensive disorders, prolonged rupture of membranes and meconium-stained liquor etc. When considering these obstetric factors as well as the CTG, the experts assessed 16 women (17.8%) to have had unnecessary caesarean sections. In terms of neonatal outcomes, the mean five-minute APGAR was 8, and only 3 babies had a five-minute APGAR which was less than 7. Twelve babies (13.3%) babies were admitted to the neonatal unit and of those, 4 (4.4%) were admitted for low Apgar scores. The commonest maternal complication was PPH which affected 8.9% of the patients. Conclusion The inter-observer agreement in CTG interpretation at MMH was fair, which is comparable to other studies done in the world, with agreement on the indication for CS of 82.2%. The agreement in CTG interpretation was high with pathological CTGs and poor with suspicious CTGs. A second opinion for CS for abnormal CTG may reduce the number of unnecessary CS especially for suspicious CTGs. A normal CTG tends to affirm good fetal wellbeing, however an abnormal CTG does not always mean that there is fetal compromise, therefore the clinical condition must be evaluated together with the CTG to make an appropriate decision with regards to timing and mode of delivery.
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    An audit of peripartum hysterectomies at Groote Schuur hospital, 2014 -2019
    (2024) Adjei, Alfred; Fakier, Ahminah; Fawcus, Susan
    BACKGROUND Peripartum hysterectomy is a major surgical procedure performed in the se ng of life-threatening haemorrhage and uterine sepsis unresponsive to conserva ve measures. The opera on is considered one of the major interven ons in obstetrics and carries high maternal morbidity and mortality, mostly due to the reasons for which it is done. An audit of peripartum hysterectomies was performed at Groote Schuur Hospital during 1999-2003, which showed the main indica ons were uterine sepsis and obstetric haemorrhage. The problem of uterine sepsis was at a me when there was a high rate of HIV infec on with no treatment available for mothers.The introduc on of an retrovirals for pregnant women was commenced in the Western Cape in 2001 with the use of single dose Nevirapine during labour or prior to caesarean sec on. Currently, all pregnant women living with HIV are immediately provided with lifelong treatment regardless of CD4 count and adherence reinforced during the antenatal visits. It is thus of interest to repeat this audit twenty years later to evaluate if there is any difference in indica ons and outcomes. OBJECTIVES 1.To determine the incidence, indica ons, and complica ons associated with peripartum hysterectomy at Groote Schuur Hospital (GSH), New Somerset Hospital (NSH) and Mowbray Maternity Hospital (MMH) 2. To compare study results with a similar study conducted between 1999 to 2003 at Groote Schuur Hospital METHODOLOGY A retrospec ve descrip ve audit of peripartum hysterectomies was performed at GSH, NSH AND MMH for the years 2015-2019. Peripartum hysterectomy was defined as hysterectomy performed within 24 hours of delivery or within the same hospital admission or within 6 weeks of delivery. Pa ents who had peripartum hysterectomies during this period were iden fied from the labour ward and gynaecology theatre register, and data retrieved from their files. All sta s cal analysis was performed by using SPSS version 27.0.0.0 (IBM, Armonk, NY, USA).
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    An audit of uterotonic use for the prophylaxis and treatment of haemorrhage at caesarean delivery at Mowbray Maternity Hospital, Cape Town, South Africa
    (2018) Pheto, Peloentle; Fawcus, Susan R; Petro, Gregory
    Obstetric Haemorrhage is the leading cause of maternal death globally (1) and the third leading cause of death in South Africa (2). Concern has been expressed in South Africa that bleeding associated with caesarean delivery (CD) accounts for one-third of haemorrhage deaths and this has increased over the last ten years (3). The underlying cause of bleeding at CD is commonly uterine atony, and the majority of the CDs were performed at district hospitals (2,3,4). The Saving Mothers Reports describe inadequate use and documentation of uterotonics to prevent or treat bleeding at CD and have promoted the development of a standardised national protocol. While there is international agreement on the dosage and administration route for oxytocin to prevent OH after vaginal delivery, there is lack of consensus or standardisation of protocols for its prophylactic use at CD, with marked differences between country and facility protocols. Anaesthetists are concerned about the hypotensive effect of high dose intravenous boluses of oxytocin, particularly in women under spinal anaesthesia, and some maternal mortalities in the United Kingdom have been partially attributed to this (5). Hence it is important to balance safety with efficacy by promoting the lowest effective doses to minimise side effects but enable uterine contraction. Aim: The aim of this study was to perform a clinical audit of the documented use of uterotonics at CD at MMH to see how it adheres to the national protocol; and as a secondary outcome to measure the rate of haemorrhage at CD. Methods: This was a retrospective folder review of women who delivered by CD at MMH during the months of June and July 2017, including both elective and emergency operations. Information was obtained from women’s folders kept in the medical records department, using especially designed data extraction sheets. Data analysis was by simple descriptive statistics. Results: Three hundred and nineteen (319) folders from the study period were interrogated. This included 239 emergency CDs (75%) and 80 elective CDs (25%). They were all performed by obstetric registrars or medical officers with 89% being done under spinal anesthesia. Prophylactic oxytocin boluses at CD were given in 302 (94.7%) women but there was no documentation of its use in 17 (5.3%). One of the 302 women had a high dose IV bolus (7.5 IU) but the remainder had boluses below 5 IU. There were 75 women (23.5%) patients who received the national recommended dose of 2.5 IU IVI while 227 (71.1%) received alternative low dose boluses which were all less than 5 IU. The dose most commonly given was 3 IU; to 169 patients (53%) as a single or divided dose. There was wide variation in the dosage of prophylactic infusions with only 18 (5.6%) patients receiving the recommended intraoperative 7.5 IU infusion, while 221 (66.5%) received alternate infusion doses. Only 49 (15%) were discharged from theatre recovery to the postnatal ward with a prophylactic infusion running. In total 65 (20.4%) of the women received a 20 IU oxytocin infusion but it was unclear whether this was for prophylaxis or treatment. No intramuscular doses of oxytocin or syntometrine were given for prophylaxis. Among the 319 CDs, 13 (4.1%) had documented blood loss over 1000 ml and 24 (7.5%) had uterine atony reported by the surgeon. The most common treatment was 20 IU infusion followed by misoprostol (13 women), syntometrine (three women) and tranexamic acid (one woman). Additional surgical measures required were B-Lynch compression suture for one, and haemostatic sutures for two. There were no re-look laparotomies or hysterectomies during the study period and there were no major morbidity or mortalities from either CD or from anaesthetic complications. Discussion: Low dose bolus oxytocin and infusion is widely used at CD post fetal delivery at MMH, although the dose of 3 IU was most commonly used in contrast to the recommended 2.5 IU in the national protocol. There was variation in the usage and dosage of prophylactic oxytocin infusion. The rate of PPH in the subjects was low (4.1%) with the low dose prophylactic regimens used, suggesting that they were effective, although this may also have been contributed to by the skill of the surgeons. Consensus is needed among anaesthetists and standardisation of protocols on oxytocin prophylaxis at CD, particularly for training doctors working in district hospitals. Repeating this audit in district hospitals where there are higher CD case fatality rates would be important to shed light on practice in such facilities and improve healthcare delivery.
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    An investigation of blood transfusion practices in a regional obstetric hospital with no on-site blood bank
    (2023) Bengesai, Daniel; Horak, Tracey; Fawcus Susan
    Background This study aimed to investigate blood transfusion practices in a regional obstetric hospital with no on-site blood bank. Underpinning this research was the argument that principles of evidence-based medicine should apply to blood transfusions in the same way they do to any other clinical practice area. Considering the limited availability of resources (financial, human and blood products) and the ever-increasing and competing needs facing South Africa, the practices surrounding the use of blood and blood products must be audited. Method This study used a retrospective descriptive audit approach to collect data on blood transfusion management from Mowbray Maternity Hospital, a Regional Hospital in Metro West, Cape Town, which receives complicated obstetric patients from satellite Midwife Obstetric Units (MOUs) and District Hospitals. In addition, an in-depth folder review of two months was also conducted for 118 women to ascertain the precise obstetric indications and decision-making processes. Results During the study period, there were 10030 deliveries, of which 4734 (47, 2%) were caesarean deliveries, 5081(50.7%), were vaginal deliveries, and 215 (2.1%) were assisted deliveries. Only 781women received blood products; thus, the incidence of blood transfusion during this period was 7.8%. Red blood cell concentrate (including emergency red blood cell concentrate) was the most transfused blood product, followed by fresh frozen plasma, cryoprecipitate, and platelets. Approximately 12.6% of the patients received emergency red blood cells, reflecting acute postpartum haemorrhage while cross-matched red blood cell concentrate (RBC), was transfused to 82.2% of the women in the sample. The clinical area was not labelled for 24.1% (n=189) of patients who received blood products. 58% of the blood transfusions were done after hours. Overall, different transfusion patterns were observed for women who received multiple blood products. The in-depth folder review on 118 patients indicated that the leading cause for blood transfusion was postpartum haemorrhage secondary to uterine atony, which accounted for viii 38.1 % of the transfusions. The range of the pretransfusion Hb was 4-9g/dl, with a mean of 6.51(SD±0.07), suggesting that all the women who received blood products were anaemic. Conclusion Overall, the results from this study indicate that the transfusion of blood products was in line with international practice, where RBC is the most transfused product, followed by FFP other products. Regarding the transfusion rate, although it was higher than in most developed countries, it was much lower than in other low-and medium-income countries. However, while a low rate of PPH and blood transfusion rate is preferable, it also indicates thatphysicians have fewer opportunities to train by self-experience. Therefore, the use of protocolsremains central to effective PPH management and the improvement of the quality of care at MMH, and this should be coupled with routine, retrospective audits, as in the case of this study. The specific reasons for blood transfusions also need to be explored in more detail so as to improve patient care accordingly. For instance, the fact that a significant proportion of women who received blood products were diagnosed with anaemia reinforces the need for early detection of and treatment of antepartum anaemia as well as increasing the use of parenteral iron. The results from this study also suggest that data management issues need to be considered, particularly the siloed nature of the data. It is recommended that MMH establish a unified and integrated system for capturing and managing data quality and storage.
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    An analysis of the caesarean section rate at Mowbray Maternity Hospital using Robson's Ten group Classification System by Tracey Anne Horak.
    (2012) Horak, Tracey Anne; Fawcus, Susan R
    Includes synopsis. Includes bibliographical references.
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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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    Antenatal care an investigation of the time interval between the confirmation of pregnancy diagnosis and commencement
    (2018) Moshokwa, Molatelo Linneth; Fawcus, Susan
    Introduction This study aimed to investigate the time interval between the confirmation of pregnancy diagnosis and the commencement of antenatal care at the Metro West district of Cape Town, and to explore reasons for delays between the confirmation of pregnancy and the first antenatal booking. Methods A cross sectional descriptive study was conducted in September 2015 at Vanguard MOU, in which 120 pregnant women were interviewed at their first antenatal visit, using a structured questionnaire. Subjects were grouped into those with a short time interval (less than 60 days) between confirmation of pregnancy diagnosis and booking, and those with a long time interval (more than 60 days). The two groups were compared. The study hypothesis was that income would be a significant determinant of this time interval. The data were divided into descriptive and categorical variables. A logistic regression analysis was conducted to determine the association between independent variables and the dependent variable (time interval). Results The average gestational age at confirmation of pregnancy was 10.75 ± 5.88 weeks and the average gestation at booking was 18.27 ± 7.27 weeks. The mean time interval between confirmation of pregnancy diagnosis and first antenatal visit was 7.50 ± 6.63 weeks. Seventy- three (60.83%) reported a short time interval (SI) while 47 (39.17%) reported a long time interval (LI). The prevalence of late booking (defined as booking at or after 20 weeks) in the total study sample was 38.30%. There was a significant association between late attendance and LI with 70.21% of the LI group attending late, as compared to 17.81% of the SI group (OR 10.88; 95% CI 4.23-28.43). The time interval was significantly influenced by the women’s type of residence, the perception of the women regarding knowledge of the timing of antenatal care, and perception of the timing of pregnancy complications. It was not influenced by monthly income, thus refuting our hypothesis. Previous obstetric complications did not influence the time interval. Private confirmation of pregnancy by a general practitioner or home pregnancy test was significantly associated with a long interval; 37 (78.7%) in the LI group compared to 43 (59.9%) in the SI group, (p= 0.016). Reasons for the delay in booking were mostly related to poor understanding by women of the role of antenatal care and the ideal time of booking. Discussion and Conclusion Even though some women confirm their pregnancy as early as three weeks, there were notable delays in booking for their first antenatal visit, thus delaying antenatal care. However, the time delays seemed shorter than found in the previous Cape Town study, and compared to other studies in Africa. Many women perceived antenatal care to be curative rather than preventive. It is suggested that the site where women confirm their pregnancy (pharmacy, general practitioner or family planning clinic) should refer women immediately for antenatal booking. Also antenatal care sites should offer pregnancy testing services so that booking could occur after pregnancy is confirmed on the same day and at the same site.
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    Antenatal gestational ageing
    (1972) Bennett, Michael Julian
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    Assessment of face mask use among peripartum women at mowbray maternity hospital during the covid-19 pandemic
    (2023) Adusei, Samuel; Stewart, Chantel
    Background: The current global COVID-19 pandemic has resulted in loss of life worldwide. According to the John Hopkins dashboard on COVID-19, 6 446 935 out of 595 645 271 infected patients lost their lives. There were 12 562 636 cases in Africa and 257 083 lost their lives as of 11th August 2022. South Africa recorded 4 007 080 cases with 101 982 mortalities and the Western Cape was one of the highest hit provinces in the same period (662 113 cases). Primary prevention for COVID-19 includes social distancing, hand washing, using alcohol- based hand sanitisers, and, mostly importantly, face mask use. Of these, face mask use is the least adhered to. Effective face mask use and reasons for use or non-use among a vulnerable population such as peripartum women are still unknown. Objective: To assess face mask use and associated factors among peripartum women at Mowbray Maternity Hospital during the COVID-19 pandemic. Method: An analytical cross-sectional study was used to assess the proportion of peripartum women who effectively wore face masks. Effective face mask use was measured with the WHO tool on mask usage in the context of COVID-19. A total of 500 women who visited the facility from the 1st of October 2020 to 31st October 2020 were first observed for effective face mask use before selection into the study to curb response bias. A structured interviewer-administered questionnaire was used to assess knowledge and perceived reasons for face mask use among 250 selected peripartum women. Data were analysed in STATA version 15.0. Frequencies and percentages were reported for categorical variables. Graphs and percentages were used to report the proportion of women who effectively used face masks in each of the stages of labour. The chi-square or Fisher's exact test (where necessary) were used to determine the association between effective face mask use and each independent variable. A multiple logistic regression model with a significance level set at p<0.05, was employed to determine the factors associated with effective face mask use. Results: Eighty-two percent of all women who visited the hospital wore their face mask effectively. Out of the 250 respondents, the proportion of effective face mask use was 78% (proportion = 78.0%; 95% CI = 72.3% - 83.0%); 90.0% had adequate knowledge of face mask use. More than half of the respondents, 133 (53.2%), agreed that they used face masks because they “felt susceptible to getting COVID-19 in the hospital”. One major reason for using face masks among most respondents ;227 (90.8%) was that “having COVID-19 will be troublesome as it may spread to loved ones”. Second/third stage of labour (aOR = 0.38; 95% CI = 0.17 - 0.83; p = 0.016), and secondary education (aOR = 0.25; 95% CI = 0.08 - 0.77; p = 0.016) were associated with ineffective mask usage, whereas disagreement with perception that pressure from mass media and government reminded them of the need to put on a face mask (aOR = 3.58; 95% CI = 1.44 - 8.93; p = 0.006), and adequate knowledge (aOR = 4.10; 95% CI = 1.49 - 11.28; p = 0.006) were factors associated with effective face mask use. Conclusion: Generally, effective face mask use was high amongst respondents but was lowest in the second/third stage of labour. Knowledge of effective face mask use was also high. Even though the use of face mask is of historic value now, it is worth noting these important factors associated with mask use, to ensure compliance during future respiratory pandemics like COVID-19. There is a need for health professionals at the hospitals to educate peripartum women with secondary education about the dangers of COVID-19 and the risk of spread, especially in the hospital
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    An assessment of the role of Doppler ultrasound velocity waveform analysis of the umbilical artery in the diagnosis of fetal distress in labour
    (1993) Stuart, Ian Peter; Lindow, Stephen; Van der Elst, Clive
    Introduction: An assessment of the role of Doppler ultrasound velocity waveform analysis of the fetal umbilical arteries in the diagnosis of fetal distress in labour is made from a review of the literature and clinical study. Study objectives: 1) To determine the value of screening with Doppler ultrasound in high-risk labours in the prediction of the development of indicators of fetal distress. 2) To determine whether Doppler velocimetry indices of the umbilical arteries change with the development of indicators of fetal distress in labour. Design: Repeated Doppler velocimetry in selected high risk labours. Setting: Groote Schuur Hospital, Cape Town, South Africa, a large tertiary referral centre. Subjects: Thirty six women with singleton pregnancies complicated either by gestational proteinuric hypertension or by intrauterine growth retardation or both with a normal cardiotocographic tracing at the onset of labour. Main outcome measures: 1) Acid-base status of the fetus was assessed after deli very by analysis of umbilical artery blood. 2) Apgar score was recorded at 1 and 5 minutes. 3) Neonates were carefully examined for clinical signs of perinatal hypoxia. Results: Twenty seven fetuses were followed through labour. No relation was found between umbilical artery Pourcelot ratio (resistance index) on admission in labour and umbilical artery base deficit. Six fetuses were born with an umbilical artery base deficit of more than 10 mmol 1-1. Zero change in mean Pourcelot ratio was noted in both normal and acidotic fetuses. None of the acidotic fetuses showed a change in Pourcelot ratio of more than 0.03. The study had an 80% power to detect a change in mean Pourcelot ratio of 0.07 in the normal fetuses and 0.16 in the acidotic fetuses at a 95% confidence level. No relation was found between Pourcelot ratio on admission in labour or change in Pourcelot ratio during labour and Apgar score. None of the neonates showed clinical signs of perinatal hypoxia. Conclusions: Doppler velocimetry of the umbilical arteries in labour as measured by the Pourcelot ratio does not contribute to the diagnosis of fetal distress in labour.