Browsing by Subject "Obstetrics and Gynaecology"
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- ItemOpen AccessA review of intrauterine device placement during caesarean section at level two facilities in the Metro West, Cape Town(2020) Schutte, Marcelle; Patel, Malika; Petro, GregoryStudy 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.
- ItemOpen AccessA two phase local study, comparing liquid-based cytology to the conventional cervical pap smear(2005) Van Rensburg, Jacobus A; Denny, LynnCancer 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).
- ItemOpen AccessAccuracy of ultrasound beyond 14 weeks to determine chorionicity of twin pregnancies(2014) Momberg, Zoe; Stewart, Chantal; Van Zyl, HettaDetermining 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.
- ItemOpen AccessAcupuncture for women with refractive Overactive Bladder Syndrome(2010) Cloete, Marinus; Jeffery, StephenTo 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.
- ItemOpen AccessAdverse perinatal events observed in obese pregnant women in the Metro West Region(2014) Gadama , Luis Aaron; Horak, Tracey Anne; Fawcus, Susan RBackground. 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.
- ItemOpen AccessAn audit of caesarean sections performed for suspected fetal distress at Mowbray Maternity Hospital in 2018(2022) Moreri-Ntshabele, Badani; Fawcus, Susan; Kadwa, K; Petro, GregoryBackground 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.
- ItemOpen AccessAn 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, GregoryObstetric 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.
- ItemOpen AccessAn investigation of blood transfusion practices in a regional obstetric hospital with no on-site blood bank(2023) Bengesai, Daniel; Horak, Tracey; Fawcus SusanBackground 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.
- ItemOpen AccessAn 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 RIncludes synopsis. Includes bibliographical references.
- ItemOpen AccessAntenatal AVSD diagnosis at Groote Schuur Hospital A retrospective cohort study(2019) Annor, Charlene Adjoa Adobea; Stewart, Chantal; Osman, AyeshaThe 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.
- ItemOpen AccessAntenatal care an investigation of the time interval between the confirmation of pregnancy diagnosis and commencement(2018) Moshokwa, Molatelo Linneth; Fawcus, SusanIntroduction 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.
- ItemOpen AccessAudit Of Peri-Operative Care As Part Of The Enhanced Recovery Model For Caesarean Delivery(2022) Blumenthal, Abigail; Fawcus, Susan; Horak, TraceyIntroduction Mowbray Maternity Hospital (MMH) is a secondary level hospital serving a large population with low socioeconomic status. Around 10000 deliveries are done per year of which 40-50% are delivered by caesarean section (CS). There is much literature on peri-operative care for caesarean sections, under the model of fast-track surgery also known as Enhanced Recovery After Surgery (ERAS). ERAS protocols have antenatal, intra-operative and post-operative components. This audit aimed to evaluate how successfully MMH adheres to local and international guidelines for peri-operative care around elective caesarean section according to the ERAS model. It is hoped this will form the first step in a quality-improvement intervention resulting in better quality, evidence-based care appropriate for the low-resource setting. Materials & Methods: Women were invited to participate in the study in MMH postnatal ward between 24 and 48 hours after elective CS. Once consented, a structured questionnaire and data collection sheet was used to interview women and remaining details were obtained from the patient record. This covered four aspects of ERAS programmes: 1. peri-operative hydration and nutrition 2. peri-operative analgesia 3. time interval postoperatively until removal of intravenous lines and urinary catheterisation 4. time interval until first mobilisation The initial planned sample size was 50 women however after the start of the covid pandemic when in-person interviews were no longer possible, a folder audit was undertaken of the remaining files. A decision was made to therefore increase the sample size to increase the value of the data obtained from the folder audit given that there was to be more limited data from patient interviews. Anonymised data was entered into a secure online database using REDCap (Research Electronic Data Capture system). Data entry was verified by double entering all data. In total 75 folders were reviewed, of which 35% were interviewed face-to-face. Findings The audit showed that 92% of patients received exactly the same number of doses (four 10mg doses) of morphine post-operatively with more variation in the dosing of simple oral analgesics and no use of NSAIDs. It showed that 85% of patients had high pain scores (3 or more out of 5) in the first 24 hours post caesarean section but 85% also reported they were mildly or very happy with their pain management post-operatively. The audit highlighted that many patients were nilper-os for prolonged periods of time peri-operatively; on average 23 hours without food and 19 hours without oral fluid. Drips and catheters were removed on average at 12.5 hours post- operatively; and mobilisation occurred on average at 12 hours with few delays; the standard deviation was less than 1 hour. Conclusions The audit confirmed that Mowbray Maternity Hospital has good adherence to certain ERAS protocols. It confirmed that most patients were happy with their pain control despite often reporting high levels of pain. However, it highlighted several deficiencies such as poor use of regular simple oral analgesia and the lengthy duration of time for which many patients were fasted which could impact on general satisfaction with care, not to mention possible negative effects on tissue healing.
- ItemOpen AccessBirth order, delivery and concordance of mother-to-child transmission of Human Immunodeficiency Virus in twin pregnancies(2013) Cloete, Alrese; Petro, GregoryDespite two decades of studies of mother to child transmission of HIV, very little data is available regarding vertical transmission in twin pregnancies. There is uncertainty whether discordance of HIV transmission exists between the first born (Twin A) and second born (Twin B) infant. Primary aim of the study was to examine if there is any discordance of HIV transmission in twin pregnancies when comparing Twin A to Twin B. Secondary objectives were to identify possible additional risk factors for HIV transmission in twin pregnancies. We assessed antenatal care, antiretroviral therapy, birth order, delivery route and feeding options as risk factors for mother to child transmission of HIV in twin pregnancies.
- ItemOpen AccessCauses, management, and outcomes of polyhydramnios, at a level 2 hospital in Cape Town(2023) Siveregi, Amon; Stewart, ChantelIntroduction: Polyhydramnios is defined as excessive accumulation of amniotic fluid and has an estimated incidence of 0.2% – 3.9%. It is associated with both maternal and fetal adverse outcomes. Mild polyhydramnios is often idiopathic and pregnancy outcomes in this group are usually no worse than in the general population of pregnant women. In contrast, conditions such as congenital anomalies, chromosomal abnormalities, or diabetes mellitus are often found in patients with moderate and severe polyhydramnios. Neonatal and maternal adverse outcomes, can be up to five times higher in this subgroup. Methodology: We conducted a retrospective cohort study at a Level 2 hospital in Cape Town. Folders of women diagnosed with polyhydramnios on ultrasound examination were reviewed. We recorded demographic data as well as information on underlying causes, management and outcomes. We summarised continuous variables using the mean (standard deviation) and categorical variables using count (percentage). We tested the association between categorical variables using the chi-square test. Statistical significance was set at p< 0.05. Results: A total of 136 patients with polyhydramnios (80 mild and 56 moderate + severe) were included from January 1, 2018 to December 31, 2020. Cases of idiopathic polyhydramnios accounted for 81.7% of the mild and 77.2% of the moderate + severe polyhydramnios group. Composite maternal and fetal adverse outcome occurred in 19/136 (14.0 %) polyhydramnios cases. Preterm labour occurrence was significantly higher in the moderate + severe polyhydramnios group (9/56; 16 %) compared to the mild polyhydramnios group (3/80; 3.8%, p = 0.01). There was a statistically significant difference in the occurrence of the composite adverse outcome in the moderate + severe group compared to the mild group [13/56(23.2 %) vs 6/80 (7.5 %) p = 0.001]. Elective delivery at 38 – 40 weeks for polyhydramnios was associated with an increased risk of composite perinatal adverse outcome (7.6% vs 3.4%) compared to those that awaited spontaneous labour or were delivered for other obstetric reasons. The difference was however not statistically significant (p = 0.14). Conclusions: Most cases of polyhydramnios are idiopathic, regardless of category. Adverse outcomes are, however, significantly lower in the mild group compared to the moderate + severe group. The rate of adverse outcome in the mild group is comparable to the background risk in the general population. Elective admission and delivery of patients for polyhydramnios between 38–40 weeks may be associated with adverse outcome compared to awaiting spontaneous labour or delivery indicated for other obstetric reasons.
- ItemOpen AccessChemoradiation in advanced vulval carcinoma(2008) Rogers, Linda Joy; Denny, Lynette; Van Wijk, A LVulval carcinoma is uncommon, affecting approximately 2 per 100 000 women annually. The treatment of choice is radical vulvectomy and inguinal lymph node dissection. ‘Advanced’ vulval carcinomas involve midline structures (such as clitoris, urethra or anus) and/or adjacent pelvic organs or bone, and adequate excision may require urinary diversion, colostomy or pelvic exenteration. Less morbid and less mutilating therapeutic alternatives have been investigated, particularly chemoradiation, which has shown significant success in the management of anal carcinomas. Primary chemoradiation has been used, instead of primary radical surgery, to treat advanced vulval carcinomas at Groote Schuur Hospital (GSH) since1982. Aims: 1) To assess the survival of women with advanced vulval carcinoma treated with primary chemoradiation. 2) To examine the role of surgery after treatment with primary chemoradiation.
- ItemOpen AccessClinical and ultrasonic estimation of fetal weight(1994) Brink, Derek Montagu; De Jong, Peter; Lindow, StephenSeveral clinical situations occur in obstetrics where it is useful to make an accurate assessment of fetal weight prior to delivery. A foreknowledge of the mass of the fetus can influence management in circumstances complicated by, for example, a previous caesarean section, a breech presentation, a compromised fetus of borderline viability and a diabetic pregnancy at term. Researchers have attempted to estimate fetal weight by assaying oestriol, human placental lactogen, and pregnanediol. These parameters have been found to be of limited value because of the indirect measurement of fetal mass. Since the introduction of ultrasound scanning techniques to obstetrics in the mid- 1960's, it has become possible to visualise the fetus and to make direct measurements of fetal anatomy. By using ultrasound, workers have tried to predict fetal weight by measuring fetal heart volume, hourly urine production, trunk diameter, circumference and placental volume. At present various combinations of head circumference (HC), biparietal diameter (BPD), femur length (FL), and abdominal circumference (AC) are the most commonly used measurements which, when used in different formulas and read off tables estimate fetal weight. Recently the gestational age (GA) has been incorporated into formulas specifically applied to small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA) fetuses. A sonographic estimation of fetal weight based on a model of fetal volume has also been developed. It was generally believed that with the refining of ultrasonic estimation of fetal weight an accurate assessment of fetal mass could, at last, be made. Some investigators believe that the ultrasound estimation of fetal mass is more accurate than clinical assessment. In contrast other workers have shown that the accuracy of clinical examination is comparable to ultrasound determination in estimating fetal weight.
- ItemOpen AccessClinical officers in Malawi : expanding access to comprehensive emergency obstetrics care(2009) Chilopora, Garvey Chipiliro; Fawcus, Susan RClinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors.
- ItemOpen AccessClinical Officers in Malawi: Expanding access to comprehensive emergency obstetric care(2009) Chilopora, Garvey Chiliro; Fawcus, Susan RBackground: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. Methods: During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. Results: During the study period, clinical officers performed 90% of all standard caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition = both immediately and 24 hours postoperatively - and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. Conclusion: Clinical officers perform the bulk of emergency obstetric operations, including complicated procedures, at district (level 1) hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.
- ItemOpen AccessComparability of an innovative Doppler ultrasound fetal heart rate monitor to a pinard fetal stethoscope using cardiotocography as a standard to assess the fetal heart rate in singleton pregnancies during labour at Mowbray Maternity Hospital(2013) Chinula, Lameck; Fawcus, Susan R; Woods, DavidAlmost four million babies die in the first four weeks of life per year worldwide, most from preventable causes. In addition a million babies die during labour and delivery (Lawn J et al., 2005). In South Africa, ‘intrapartum hypoxia and birth trauma’ are among the top three causes of perinatal deaths. Severe intrapartum hypoxia is often preventable with appropriate maternal and fetal monitoring in labour. However, this remains a challenge in under-resourced settings, due to difficulties that accompany the use of a Pinard Fetal Stethoscope (PFS) which include user-dependence and lack of evidence based standardisation in taking measurements with it. Although intermittent fetal heart monitoring is as effective as continuous electronic monitoring in low risk labours (Banta DH and Thacker, 2001), the search is for reliable, robust and cheaper fetal monitoring devices. The innovative crank powered Doppler Ultrasound Fetal Heart Rate Monitor (DUFHRM) developed by Power-free Education and Technology is robust, cheaper and designed for use even in settings with no or erratic access to mains electricity and replaceable batteries, and overcomes some of the challenges that come with the use of PFS (Banta DH and Thacker, 2001). The aim of the study was to assess the accuracy of Fetal Heart Rates (FHRs)taken with the DUFHRM compared to FHRs taken with a PFS using a Cardiotocography (CTG) as a standard fetal heart rate monitoring device. This was a comparative diagnostic study conducted at Mowbray Maternity Hospital, a public sector maternity hospital in Cape Town during 2012. Women with singleton pregnancies in the active phase of the first stage of labour, who had consented to participation, were enrolled in the study. Paired readings of FHRs were taken with a DUFHRM and a PFS, by two midwives and also with a CTG during the active phase of the first stage of labour before and after two preferably consecutive uterine contractions. The midwives were blinded to the CTG measurements by silencing the CTG and turning it away from their view. The FHRs taken with a PFS were done over a 60 second period in accordance with the guidelines from professional bodies (ACOG, 1995, RANZCOG, 2002, RCOG, 2001a, Liston R et al., 2002) The DUFHRM and CTG readings were made at the start and end of each 60 second period of PFS monitoring. The proportion agreement of FHRs taken with a DUFHRM to FHRs recorded with a CTG, and the proportion agreement of FHRs taken with a PFS to FHRs recorded with a CTG were determined and compared using McNemar Exact Significance Probability test (mcc).
- ItemOpen AccessA comparison of calcium levels in pre-eclamptic and normotensive pregnancies in a low dietary calcium setting(2011) Richards, Dominic G D; van der Spuy, Zephne MargaretPre-eclampsia is a leading cause of maternal mortality and morbidity in South Africa. At present this disease cannot be prevented and many interventions to reduce the incidence of pre-eclampsia have been investigated. Calcium supplementation of pregnant women at high risk of developing pre-eclampsia has been shown to be of some benefit in reducing the incidence of the disease, with the greatest benefit seen in low dietary calcium settings. While serum calcium is an unreliable indicator of chronic calcium status, hair analysis is an accurate and well documented method of determining long-term micronutrient status.