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- Volume 20, Issue 1, 2014
South African Journal of Obstetrics and Gynaecology - Volume 20, Issue 1, 2014
Volume 20, Issue 1, 2014
Author William EdridgeSource: South African Journal of Obstetrics and Gynaecology 20 (2014) http://dx.doi.org/10.7196/SAJOG.847More Less
The world of infertility treatment has changed comparatively little in the past 10 years, and yet any infertility expert will tell you that modifications have been many and that there is a great difference between doing infertility well and not well. Much is dependent on adequate data, adequate research, and familiarity with that research.
Asymptomatic bacteriuria in women attending an antenatal clinic at a tertiary care centre : researchSource: South African Journal of Obstetrics and Gynaecology 20, pp 4 –7 (2014) http://dx.doi.org/10.7196/SAJOG.733More Less
Objective. To compare the diagnostic performance of urine microscopy, leucocyte esterase and nitrite dipstick tests and various combinations of these as screening tests for asymptomatic bacteriuria in pregnancy.
Methods. Pregnant women (N=800) attending an antenatal clinic were recruited at their first visit. Urine microscopy, culture and dipstick testing were performed on a random clean-catch midstream urine sample. A count of >105 colony-forming units of a single organism per millilitre of urine was taken as significant. Dipstick results were read as positive according to the manufacturer's instructions.
Results. A total of 800 eligible women were screened. The prevalence of asymptomatic bacteriuria as diagnosed by urine culture was 5.0% (n=40). Escherichia coli was the most prevalent uropathogen isolated by culture (60.0%). Neither urine microscopy nor the leucocyte test was found to be sufficiently sensitive to be used as a single screening test for asymptomatic bacteriuria in pregnant patients. The nitrite test alone had a sensitivity of 82.5% and a specificity of 99.9%. Combined dipstick testing had an improved sensitivity of 87.3% and a specificity of 96.2%. Addition of urine microscopy to combined dipstick testing increased the sensitivity to 95.0%, and the specificity became 92.4%.
Conclusion. Combined dipstick testing is a useful screening test for asymptomatic bacteriuria in pregnancy. Addition of urine microscopy to combined dipstick testing further improves its diagnostic performance.
A clinical audit of provider-initiated HIV counselling and testing in a gynaecological ward of a district hospital in KwaZulu-Natal, South Africa : researchSource: South African Journal of Obstetrics and Gynaecology 20, pp 8 –11 (2014) http://dx.doi.org/10.7196/SAJOG.603More Less
Background. Early initiation of antiretroviral therapy reduces transmission of HIV and prolongs life. Expansion of HIV testing is therefore pivotal in overcoming the HIV pandemic. Provider-initiated counselling and testing (PICT) at first clinical contact is one way of increasing the number of individuals tested. Our impression is that not all patients admitted to a general gynaecological ward are offered PICT.
Objective. To assess whether patients admitted to a gynaecological ward in a district-level hospital in KwaZulu-Natal, South Africa, are being offered PICT.
Methods. We conducted a retrospective chart review over an 8-month period. Patients who had a hospital stay of ≤3 days were enrolled. The case records were reviewed and relevant data, including demographic information and whether the patients were offered HIV testing, were recorded.
Results. Of 1 014 patients, 451 reported that they had been tested previously; 98 (21.7%) of these were HIV-infected. There were therefore 916 patients (563 not tested previously and 353 who reported that they had tested negatively previously) who should have been offered PICT. Of these, 157 (17.1%) were offered it; 116 (73.9%) accepted and 41 declined. Forty-five (38.8%) tested positive.
Conclusion. A large number of patients who stayed for ≤3 days in a gynaecology ward of a district-level hospital were not offered PICT. However, the high rate of HIV infection in those who accepted the offer of testing strengthens the case for PICT.
Postpartum anal incontinence in a resource-constrained setting : prevalence and obstetric risk factors : researchSource: South African Journal of Obstetrics and Gynaecology 20, pp 12 –17 (2014) http://dx.doi.org/10.7196/SAJOG.765More Less
Background. Postpartum anal incontinence (AI) is a common and debilitating condition, but data from resource-constrained settings are scarce.
Objective. To show that AI is common in a resource-constrained setting and that obstetric factors contribute to its development.
Methods. This prospective questionnaire-based study performed in the Durban metropolitan area of South Africa involved black Africans and Indians. Patients were recruited antenatally and followed up for 6 months after delivery. Data collected antenatally and 6 weeks and 6 months after delivery included demographics, obstetric factors and symptoms of AI. The association between these variables and AI were explored using bivariate and multivariate analysis.
Results. The median age of the 1 248 participants was 24 years (range 13 - 45 years). The majority were black Africans (n=1 004, 80.4%), 86 (6.7%) underwent induction of labour, 95 (7.6%) required augmentation, 186 (14.9%) had epidural analgesia, 418 had mediolateral episiotomies (33.5%), and 51 (4.1%) had third- or fourth-degree tears. The antenatal prevalence of AI was 57.9% (n=722). Six weeks after delivery, 23.1% more women had symptoms of AI compared with the antenatal prevalence. At 6 months, only 0.7% of women reported symptoms. Being black African was significantly associated with AI (odds ratio (OR) 1.7, 95% confidence interval (CI) 1.2 - 2.7) and having had epidural analgesia was significantly associated with faecal incontinence (OR 1.7, 95% CI 1.1 - 2.9) at 6 weeks after delivery. At 6 months most women reported no symptoms of AI.
Conclusion. Postpartum AI is common in our resource-constrained setting and appears to be transient, with most cases resolving by 6 months.
Source: South African Journal of Obstetrics and Gynaecology 20, pp 18 –21 (2014) http://dx.doi.org/10.7196/SAJOG.798More Less
Background. Many forms of minimally invasive treatment have gained substantial popularity, both with the medical fraternity and the public. With the correct clinical indications and in skilled hands, uterine artery embolisation (UAE) has been accepted internationally as part of the standard of care that should be offered to patients with symptomatic uterine leiomyomas (fibroids).
Objectives. To introduce UAE as an effective and safe treatment option in patients with symptomatic fibroids in the Western Cape Provincial Service, South Africa.
Methods.Setting: Groote Schuur and Tygerberg hospitals, Western Cape. Design: Prospective observational multi-centre study. Methods: 36 women (mean age 38 years, range 30 - 47 years) with symptomatic fibroids were treated with UAE between November 2009 and February 2012. Pre-procedure magnetic resonance imaging (MRI) followed by a 6-month clinical follow-up plus MRI or an ultrasound scan were performed.
Results. The presenting symptoms were menorrhagia, dysmenorrhoea, pressure symptoms and intermenstrual bleeding. Three women were treated for primary infertility. Uterine artery sub-selection and embolisation was successful in all patients. Complications included low-grade pyrexia (3/36, 8.3%) and readmission (1/36, 2.8%). The average reduction in uterine volume at 6 months was 50%. At follow-up (mean 15 months, range 7 - 32), 91.7% (33/36) had complete symptomatic resolution and 83.3% (30/36) were 'completely satisfied'. Participants treated for primary infertility and concurrent adenomyosis did not receive any benefit from UAE.
Conclusion. Uterine artery embolisation is associated with a high clinical success rate. This study suggests that UAE should be offered as an attractive alternative to surgery in our practice.
Source: South African Journal of Obstetrics and Gynaecology 20, pp 22 –26 (2014) http://dx.doi.org/10.7196/SAJOG.675More Less
Background. Clinicians working in maternity units must recognise the risks associated with induction of labour (IOL). They need to analyse the indications for IOL, methods used and outcomes on a regular basis to reduce complications.
Objective. To determine the indications for IOL and outcomes of current methods at a regional hospital in rural KwaZulu-Natal, South Africa.
Methods. Clinical data for all patients who had IOL over an 8-month period were collected and analysed.
Results. There were 6 649 deliveries, and of these patients 532 had IOL (induction rate 8.0%); 502 patient files had complete information for analysis. The main indications for IOL were hypertensive disorders of pregnancy (43.6%, n=219), post-dates pregnancy (25.9%, n=130) and pre-labour rupture of the membranes (14.7%, n=74). Other indications accounted for 15.7% of cases (n=79). The most common methods of IOL were oral misoprostol (63.5%, n=319) and vaginal misoprostol (30.3%, n=152). Vaginal deliveries were achieved in 59.8% of patients (n=300), and 40.2% (202) had caesarean sections (CSs); 69.7% of patients (n=350) delivered within 24 hours (this includes CSs and vaginal deliveries). Normal vaginal births within 24 hours accounted for 44.4% of total deliveries (n=223), and CSs within 24 hours for 24.3% (n=122). There were 34 babies (6.8%) admitted to the neonatal intensive care unit. Prematurity accounted for 10 of these admissions (2.0% of all babies), hypoxic ischaemic encephalopathy for 9 (1.8%), and congenital pneumonia for 7 (1.4%). There was 1 early neonatal death.
Conclusion. Current methods of IOL at the rural study site are associated with outcomes similar to those in a report from an urban regional hospital in South Africa.
The cost-effectiveness of introducing manual vacuum aspiration compared with dilatation and curettage for incomplete first-trimester miscarriages at a tertiary hospital in Manzini, Swaziland : researchSource: South African Journal of Obstetrics and Gynaecology 20, pp 27 –30 (2014) http://dx.doi.org/10.7196/SAJOG.780More Less
Background. Despite the proven efficacy of manual vacuum aspiration (MVA) for incomplete miscarriages its use is low in Swaziland, including Raleigh Fitkin Memorial (RFM) Hospital, Manzini. Uncertainty about the cost implications of introducing MVA to replace dilatation and curettage (D&C) is probably the major obstacle to change.
Objectives. To evaluate the cost-effectiveness of introducing MVA as an evacuation method for first-trimester incomplete miscarriages, as well as assess the implications of the introduction of MVA for the entire post-miscarriage care budget at RFM Hospital.
Methods. The methods comprised cost-effectiveness and budget-impact analyses from a healthcare perspective based on a theoretical cohort. Clinical outcomes data for procedures were obtained from the relevant literature. Costs were collated from prospective suppliers and then compared for the two treatment modalities. Future numbers of annual evacuations were extrapolated from previous annual figures. First-trimester miscarriages were in turn extrapolated from proportions found in previous studies. Total budgets were calculated under the current scenario, and for scenarios where MVA was introduced.
Results. With initial capital costs of ZAR11 093.00, introduction of MVA for first-trimester incomplete abortions would cut post-miscarriage care costs by 34.7%. MVA would cost ZAR819.86 per procedure, while D&C costs ZAR1 255.40 per procedure. An estimated 26 MVA procedures done instead of D&Cs would compensate for the initial capital investment. Introduction of MVA into the post-miscarriage care programme would save the hospital about ZAR516 115.30 annually, with clinical outcomes at least similar to D&C.
Conclusions. MVA should be considered as the first option in first-trimester post-miscarriage care.
Source: South African Journal of Obstetrics and Gynaecology 20, pp 31 –33 (2014) http://dx.doi.org/10.7196/SAJOG.683More Less
Objective. To design a user-friendly electronic health record system for infertility clinics (EHRIC) to capture quality data that will allow advanced audit and practice analysis, and to use the captured data for the South African Register of Assisted Reproductive Techniques (SARA) database and as a clinical research function.
Methods. The researcher did personal interviews with fertility specialists and the staff from various fertility clinics in South Africa regarding day-to-day running of an infertility clinic. Collection of annual data to be used for the South African Register of Assisted Reproductive Techniques (SARA) database proved to be a tedious task that is also open to inaccuracy. A local medical software design company designed an integrated system that will collect clinical, laboratory in vitro fertilisation, andrology and cryopreservation data.
Results. Phase 1 allowed the researcher to collect demographic and clinical data via a web-based program as well as entering clinical information. Phase 2, when complete, will allow for annual reports according to the SARA requirements.
Conclusion. The paperless infertility clinic is a possibility, but will require commitment and training of all staff involved.
Towards making assisted reproductive technology affordable and accessible : public-private interaction : commentarySource: South African Journal of Obstetrics and Gynaecology 20, pp 33 –34 (2014) http://dx.doi.org/10.7196/SAJOG.814More Less
Objective. To report the importance of public-private interaction (PPI) as a strategy to make assisted reproductive technology (ART) affordable.
Methods.Design: Commentary. Setting: Reproductive Medicine Unit, Tygerberg Academic Hospital.
Discussion. PPI together with simplified methods of IVF such as scaling down on personnel, mild ovarian stimulation protocols, oocyte retrieval without anaesthesia and simple embryo culture systems are strategies to make ART affordable and accessible.
Conclusion. This article illustrates that PPI can be one of the strategies to make ART treatment a reality in settings with very limited resources.
Source: South African Journal of Obstetrics and Gynaecology 20, pp 35 –36 (2014) http://dx.doi.org/10.7196/SAJOG.793More Less
Source: South African Journal of Obstetrics and Gynaecology 20, pp 37 –38 (2014) http://dx.doi.org/10.7196/SAJOG.727More Less
Osseous metaplasia should be kept in mind as a rare cause of failure to conceive, even in patients with primary infertility. We report a case of osseous metaplasia of the endometrium as a cause of primary infertility and present a literature review. The condition may be more common than expected or generally accepted, and should be kept in mind even in patients with primary infertility. Hysteroscopy is an effective diagnostic as well as treatment modality. The human endometrium contains populations of epithelial progenitor cells and mesenchymal stem cells. These cells are multipotent but rare, and are the most likely origin of the endometrial ossification. The cells can also differentiate into adipogenic and chondrogenic lineages.