Obstetrics and Gynaecology Forum - latest Issue

Dear Reader

In your hand or on your screen you have the first issue of the new “O&G FORUM”!

The O&G Forum has a proud track record and has never skipped an issue as far as I could ascertain. This journal is a long-term favourite among students, registrars and specialists. However, in view of changes in the landscape of medical publications worldwide and locally, it became important to rethink the journal. Considerations included the financial model and its viability, the printing process, distribution and number of copies, the online version and access to it and the targeted readership.

Obstetricians & Gynaecologists in South Africa currently face a medico-legal crisis of serious proportions. The premiums of occurrence based indemnity insurance is now more than R1 million per annum, forcing many obstetricians to reconsider not only their choice of indemnity cover provider, but also their ability to provide obstetric care to patients in private practice. Although data is not available, this state of affairs most likely affects the choices prospective registrars with an interest in the discipline is making, resulting in the potential loss of high quality registrars being attracted to the profession.

Urinary incontinence is defined as the involuntary loss of urine. It is a ubiquitous disorder, thought to occur more commonly than more familiar health issues such as hypertension, diabetes, and depression. It is a condition whose profile of affected patients includes women of all age groups and which transcends socio-economic and cultural circumstance. Given the above, the social, emotional, and economic impact of the disease on individuals and communities is self-evident.

Assisted vaginal delivery refers to the use of instruments such as forceps or vacuum device to expedite birth for the benefit of either the mother or baby or both. Globally about 10 – 20% of deliveries are assisted, of which the majority are caesarian sections, with assisted vaginal deliveries on the decline. It is known worldwide that caesarian section rate is on the rise. The indications for assisted vaginal delivery are fetal distress, shortening of second stage and delayed second stage. The decline in assisted vaginal deliveries is a trend in both developed and developing countries, this is due to the acceptance of caesarian section as a better option for these indications, and the lack of skill of operators in our labour wards. Caesarian section is a reasonable option when assisted vaginal delivery is contraindicated. It also has its consequences especially when done for second stage, it is associated with an increase risk of major obstetrics haemorrhage, prolonged hospital stay and neonatal ICU admission when compared to completed assisted vaginal delivery.

Vulva cancer has been regarded as a rare disease in elderly women, diagnosed at a mean age of 70 years. Over the past few decades however, vulva cancer has shown an increasing incidence with a concurrent decreasing mean age. The increased incidence of human papilloma virus (HPV) is believed to be linked with the increasing incidence in younger women.

Background: The Choice of Termination of Pregnancy (CTOP) Act 92 of 1996 allows women to exercise reproductive choices and aims to improve public access to safe abortion services in South Africa. In spite of this provision, there is a number of patients admitted to the gynaecology wards at Dora Nginza Hospital (DNH), who have had termination of pregnancy performed on them outside the provisions of the Act and without following procedure as stipulated in the act. Little is known about the profile, clinical presentation and outcome of these patients, and this study aims to investigate these issues.

Methods: This was a retrospective descriptive study of 33 patients who met the inclusion criteria admitted with induced abortions in DNH gynaecological ward between 1 January 2013 and 31
December 2016.

Results: Twenty-eight women (84,8%) were unmarried with a mean age of 23.6 years. Eighteen women (55%) stayed within five kilometres of DNH. The mean gestational age was 19 weeks. Patients presented to DNH about 2.6 days after the procedure. Misoprostol tablets were used by 31 women (94%) and 22 women (67%) aborted at home. Lay abortionists provided termination services to 19 women (58%). Six women (18%) were diagnosed with generalised sepsis, five women (15%) with foul smelling products and two women (6%) with gangrenous cervix. Uterine evacuation in theatre was performed on 15 women (45%), two women (6%) underwent hysterectomy, one woman (3%) required ICU admission, seven women (21%) high care admission, and 13 women (39%) required blood transfusion.

Conclusion: Despite the provision of the CTOP Act, unsafe abortions remain a burden to the health service and the community, and result in undesirable clinical outcomes. More research need to be done to understand the reasons for these women’s reproductive health challenges.

Ethical responsibilities in post-abortion care - background and recommendations

Background: Insertion of intrauterine contraceptive device at the time of uterine evacuation decreases the incidence of subsequent unintended pregnancies and repeat abortions. It also has advantages as the patient is known not to be pregnant, the uterine cervix is still dilated and the patient still under anaesthesia or sedation resulting in less pain during insertion. However, feasibility and uptake of IUD has not been investigated in South Africa.

Materials and methods: This was a prospective, descriptive study over a period of 13 months describing the results of a cohort of 297 women presenting with first and second trimester miscarriages at the emergency gynaecological service at Kalafong Provincial Tertiary Hospital (KPTH) in Atteridgeville, Pretoria. These women were offered IUD insertion following uterine evacuation. They were reviewed after six weeks post insertion to assess the satisfaction and continuation rate.

Results: Two hundred and ninety seven women were recruited to the study. Sixteen patients were excluded from the analysis for various reasons. Of the remaining 281 women, 135 (48.0%) accepted the offer of IUD insertion immediately following uterine evacuation, and 146 (52.0%) declined the offer of IUD insertion. Seventy one patients (52.6%) who had IUD insertion followed up after six weeks. Fifty one women (71.8)% women were satisfied and 57 (80.3%) elected to continue with the IUD as a form of contraception. One patient reported expulsion for an expulsion rate of 1.4%.

Conclusion: The uptake IUD insertion at the time of uterine evacuation in women with incomplete miscarriage is high and it is feasible with a low expulsion rate. Most women are satisfied with the IUD and the continuation rate was high.

A 41 year-old, gravida 2, para 2, was referred with abnormal uterine bleeding that got progressively worse over the past 6 months. Examination and ultrasound revealed a large fundal myoma of 8 x 8cm. Pap smear and endometrial biopsy was normal. Patient opted for a hysterectomy after appropriate counselling. Histopathology reported a smooth muscle tumours of uncertain malignant potential (STUMP).

Women consulting with O&G specialists are frequently in situations where important decisions must be made. These women receive detailed information on illness, treatment options and prognosis. Memory of medical information is therefore essential to understand recommended treatment. Ley’s model of effective communication in medical practice highlights the importance of memory, understanding of information and satisfaction with treatment. It is estimated that 40-80% of medical information provided by healthcare workers is forgotten immediately. The greater the amount of information provided; the smaller the proportion correctly recalled.

A Caesarean section is a procedure to deliver a baby by a surgical operation. Your doctor (surgeon who specialises in childbirth) has recommended that you have your baby delivered by caesarean section. However, it is your decision to go ahead with the operation.

This document will give you information about the benefits and risks to help you to make an informed decision. If you have any questions that this document does not answer, ask your obstetrician or the healthcare team.