South African Journal of Obstetrics and Gynaecology - latest Issue
Volume 22, Issue 1, 2016
Author William EdridgeSource: South African Journal of Obstetrics and Gynaecology 22 (2016) http://dx.doi.org/10.7196/SAJOG.2016.v22i1.1110More Less
Since the 1970s the association between cancer and the human papillomavirus (HPV) has been known. Zur Hausen's belatedly awarded Nobel prize bears testament to this. We know that HPV is associated with cervical cancer, vulval cancer, anal cancer, vulvovaginal warts, and other non-gynaecological cancers. The place of HPV in the modern management of gynaecology may at first seem clear. Vaccination with the bivalent vaccine against HPV 16 and 18 (Cervarix, GlaxoSmithKline (GSK)) may prevent cervical, vulval and some anal cancers; vaccination with the quadrivalent vaccine (Gardasil, Merck) may prevent those conditions plus warts. The 9-valent vaccine (Gardasil 9, Merck) is currently recommended, as are the other two, by the American College of Obstetricians and Gynecologists (ACOG). The UK initiated vaccination with the bivalent vaccine and now recommends the quadrivalent vaccine. So far studies have demonstrated a significant decrease in dysplasia and warts, particularly in HPV-naive subjects. Whether these benefits translate to the prevention of cervical and other cancers has not yet been shown, but if one considers the natural history of the progression of dysplasia to cancer, this is quite reasonably presumed. Some have asked why young girls only are to be vaccinated, and not boys. Both sexes are involved in the process of transmitting the viruses. Australian, Austrian, Canadian, Danish, US and lately Swiss national health authorities have recommended vaccination of boys. A persistent question is the suitability of vaccination in subjects who have previously been exposed to HPV. Efficacy is significantly reduced. Some continue to recommend vaccination; others feel that the benefit in this group is too limited.
Source: South African Journal of Obstetrics and Gynaecology 22, pp 4 –7 (2016) http://dx.doi.org/10.7196.SAJOG.2016.v22i1.1019More Less
Objective. To assess the advantages and feasibility of performing postpartum sterilisations laparoscopically in a public healthcare facilityin South Africa (SA).
Methods. Retrospective review of postpartum sterilisations between June 2012 and December 2013 at Worcester Hospital, Western Cape, SA. A total of 78 postpartum sterilisations were included in the study (open n=26, laparoscopic n=52). Data analysis was performed using means and medians with range and standard deviations, two-sample Wilcoxon rank sum test, two-sample t-test and X2 test.
Results. It was considered preferable to perform laparoscopic sterilisations than the open procedure on patients with a higher body mass index (BMI). Duration of surgery was shorter in the laparoscopic group, especially in patients with BMI >30, and more patients were discharged on the same day as surgery in the laparoscopic group. There were fewer overall complications in the laparoscopic group (odds ratio 0.35, 95% confidence interval 0.08 - 1.43).
Conclusion. It is feasible to perform postpartum sterilisations laparoscopically in a public healthcare facility in SA. Advantages of the procedure are clinically significant and in keeping with international literature. Future research should be undertaken regarding acceptability of the procedure in the study population, laparoscopic training and the improvement of provision of requested postpartum sterilisations in public hospitals.
Avoidable factors associated with pregnant and postpartum patients admitted to two intensive care units in South Africa : researchSource: South African Journal of Obstetrics and Gynaecology 22, pp 8 –12 (2016) http://dx.doi.org/10.7196/SAJOG.2016.v22i1.1033More Less
Background. Identification and prevention of any avoidable factor (AVF) associated with pregnancy may reduce critical illnesses and the need for intensive care unit (ICU) admission.
Objectives. To determine AVFs that occurred prior to the admission of pregnant and postpartum patients to two ICUs in South Africa (SA) and the resulting maternal outcomes.
Methods. The hospital records of all pregnant and postpartum patients in two public hospital ICUs in Pietermaritzburg, SA, between 1 July 2010 and 30 April 2011 were assessed to identify pre-ICU AVFs. Each patient was followed up until the 7th day after ICU discharge or until hospital discharge (whichever came first), to observe maternal outcomes: survival, death or hypoxic ischaemic brain injury (HIBI).
Results. Of 84 patients assessed, 41 (48.8%) had ≥1 AVF. Patient-related, administrative and health-worker-related AVFs were identified in 32.1% (27/84), 19.0% (16/84) and 7.1% (6/84) of patients, respectively. The most common patient-related AVF was the commencement of antenatal care after 20 weeks' gestation. Unavailability of ICU beds was the most common administrative AVF. Iatrogenic pulmonary oedema associated with intravenous fluid resuscitation was the most frequent health-worker-related AVF. Of women who had AVFs, 9 (22.0%) died, 2 (4.9%) had HIBI and 30 (73.2%) survived. The relative risk of death or HIBI among patients with AVF/s was 1.2 (p=0.7).
Conclusions. The principal interventions that may prevent AVFs are ongoing community health promotion, strengthening of obstetric skills training on fluid resuscitation and expansion of critical care services.
Source: South African Journal of Obstetrics and Gynaecology 22, pp 13 –17 (2016) http://dx.doi.org/10.7196/SAJOG.v22i1.1034More Less
Background. Eclampsia is a major direct cause of maternal mortality in South Africa (SA). Most cases of morbidity and mortality are probably due to late booking for antenatal care, poor quality of care and poor interfacility transport. Publications on eclampsia in SA are mainly from tertiary hospitals and often do not provide clinical management details at the referring hospital.
Objective. To describe the obstetric outcomes of eclampsia in a rural area of KwaZulu-Natal (KZN) Province.
Methods. This was a chart review of cases of eclampsia admitted to a regional health facility serving 19 maternity clinics and 17 district hospitals in northern KZN.
Results. There were 58 cases of eclampsia with complete data during the 6-month study period. Forty-nine women had booked for antenatal care, of whom 11 (22.4%) had risk factors including persistent proteinuria and haematuria. Of the 11, 2 (18.1%) had gestational hypertension well controlled on methyldopa and managed on an outpatient basis, and 2 with mild to moderate pre-eclampsia on two different types of antihypertensive agents were being treated as outpatients; 3 (27.2%) of these had uncontrolled blood pressure levels on two repeated antenatal visits.
Conclusion. This clinical audit indicates that a number of cases of eclampsia could have been avoided if clinical protocols had been followed and timeous delivery and/or referrals had been considered.
Source: South African Journal of Obstetrics and Gynaecology 22, pp 18 –20 (2016) http://dx.doi.org/10.7196/SAJOG.2016.v22i1.1038More Less
Background. Pelvic organ prolapse (POP) is a common reason for gynaecological consultation, especially in the elderly. Associated symptoms have been shown to negatively affect bladder, bowel and sexual function, as well as general quality of life. Treatment options include either surgical repair with mesh or native tissue, or conservative management with vaginal pessaries. There is a lack of data regarding POP in South African (SA) women.
Objectives. To determine the demographic characteristics in patients presenting with symptomatic POP to a tertiary urogynaecology clinic, and to compare patients who opt for surgical treatment with those who request vaginal pessary insertion.
Methods. The study was conducted at the urogynaecology clinic at Steve Biko Academic Hospital, Pretoria, SA. Demographic information was recorded after a detailed history, physical examination and completion of a self-administered symptom questionnaire.
Results. A total of 305 patients were included in this study. The mean age was 62 (range 24 - 96) years and the mean vaginal parity was3.7 (range 0 - 13); 147 patients opted for surgical intervention and 158 for pessary treatment. Cystocele was the most common type of prolapse found on clinical examination. One-quarter of patients were sexually active (25.5%, n=242). Awareness and visualisation or feeling of a lump was the most common symptom reported. Age (p=0.004) and mean vaginal parity (p=0.003) were statistically significant in the pessary group. Finding of a cystocele was significantly greater in patients who opted for pessary insertion (p=0.005).
Conclusion. Patients who opt for vaginal pessary insertion are older and more vaginally parous than patients who opt for surgical intervention, and cystocele was statistically more significant in women opting for pessary insertion.
Inequities in resources and preparedness for surgical complications of caesarean section in southern Gauteng hospitals : researchSource: South African Journal of Obstetrics and Gynaecology 22, pp 21 –24 (2016) http://dx.doi.org/10.7196/SAJOG.2016.v22i1.1039More Less
Background. The number of maternal deaths from bleeding during and after caesarean section (BDACS) has increased in South Africa. Health-worker training and health-system strengthening are considered important prerequisites for improving maternal health outcomes.
Objectives. To determine preparedness for, and health-system constraints to, safe caesarean section in southern Gauteng hospitals.
Methods. This was a cross-sectional study in 15 hospitals. Data were collected by questionnaire from clinical heads of department in each hospital.
Results. The 15 hospitals included 5 district hospitals, 7 regional hospitals and 3 central (university academic) hospitals. The number of deliveries per hospital ranged from 893 to 44 256 for 2013 - 2014, with a total of 201 314 births and 70 095 caesarean sections (34.8%). Despite similar numbers of births, there were 20 deaths from BDACS at regional hospitals and 6 at central hospitals (p=0.008). Service delivery constraints included an unequal staff distribution between central hospitals and lower levels of care, as well as non-availability of essential drugs and a lack of surgical capacity to arrest severe haemorrhage at district and regional hospitals.
Conclusion. The findings of this study reflect inequity in maternity services. Compared with central academic hospitals, district and regional hospitals are inadequately prepared for the management of complications from BDACS.
A study of the attitude and knowledge of teenagers in the Pietermaritzburg area towards contraception : researchSource: South African Journal of Obstetrics and Gynaecology 22, pp 25 –28 (2016) http://dx.doi.org/10.7196/SAJOG.2016.v22i1.1044More Less
Background. Preventing teenage pregnancy is an important means of improving adolescent health and reducing perinatal mortality. Objectives. To improve our understanding of teenagers' attitudes towards and knowledge about contraception, access to contraception and sexual activity in our health district.
Methods. A descriptive, cross-sectional, questionnaire-based study analysed demographic data, knowledge about, access to and use of contraceptives and knowledge about sexually transmitted infections (STIs) in teenagers from 13 to 17 years of age in seven schools in the Pietermaritzburg area, KwaZulu-Natal, South Africa.
Results. Of the 350 participants who answered the questionnaire completely, 24.9% reported being sexually active, of whom 70.1% used contraception. Knowledge about emergency contraception (EC) was generally poor (8.7%). Sexually active respondents were more aware of condoms (78.6% v. 56.9%), injectable contraception (57.4% v. 41.8%) and EC (14.6% v. 6.1%) than those who were not. Knowledge about STIs was generally good (71.7%) and improved with increasing grade at school. Males had a better understanding of condoms being protective against STIs than females (60.8% v. 39.4%).
Conclusion. Knowledge about condoms and injectable and oral contraception is adequate, whereas that about EC and dual contraception needs to be improved. Use of contraceptives other than condoms is poor, indicating a disparity between knowledge and use.
Source: South African Journal of Obstetrics and Gynaecology 22, pp 29 –32 (2016) http://dx.doi.org/10.7196/SAJOG.2016.v22i1.1052More Less
Retained abdominal swabs remain a difficult problem. This review highlights the risk factors and index pathology, as well as markers that raise clinical suspicion, of a condition that may be elusive in presentation on account of its otherwise nonspecific signs and symptoms. A review of the English literature reporting retained abdominal swabs between 1992 and 2012 revealed 100 cases. Fifty-six percent of patients presented with pain, most commonly coupled with an abdominal mass or symptoms of bowel obstruction; 6% of patients presented with a fistula or a sinus; and 6% presented with extrusion of the swab; only 7% presented with signs indicative of sepsis. The most common initial surgery was obstetric and gynaecological (in 44% of cases); the second most common was general surgery (36%), most commonly following cholecystectomy. Plain abdominal X-ray was done in 45% of patients, followed by ultrasound,computed tomography (CT) scan or both. CT scan is the best preoperative diagnostic tool currently. The varying presentations exhibited by this postsurgical entity will continue to perplex the attendant practitioner. Clinical suspicion assisted by ultrasound and CT scan will improve definitive diagnosis. While there are many checkpoints to prevent this rare yet significant complication, human error and the unpredictability of surgery may make elimination impossible. The challenges presented with a retained swab, although rare, will persist, and with it the devastating consequences for both patient and clinician. Because of this, especially in the era of a litigious mindset, surgical vigilance and pre-emptive measures cannot be emphasised enough.
Source: South African Journal of Obstetrics and Gynaecology 22, pp 33 –34 (2016) http://dx.doi.org/10.7196/SAJOG.2016.v22i1.995More Less
Although appendicitis is largely a clinical diagnosis, on occasions diagnostic modalities may be needed to aid with the diagnosis. Despite the use of adjuncts and exploratory surgery, the diagnosis may not be clear until a histological diagnosis is achieved. Endometriosis of the appendix mimicking appendicitis is one of these diagnoses described in several case reports. Endometriosis of the meso-appendix has been described in association with intussusception of the appendix in several case reports. However, to our knowledge, endometriosis of the meso-appendix mimicking appendicitis has not been reported to date. We present the case of a 33-year-old woman with classic clinical signs and symptoms of appendicitis endorsed on computed tomography imaging. The patient underwent a laparoscopic appendicectomy with the postoperative histology demonstrating a normal appendix with endometriosis of the meso-appendix.