Obstetrics and Gynaecology Forum - latest Issue

Stopping the spread of HIV and reducing the unmet need for contraception are global health priorities. South Africa (SA) and in particular the province of KwaZulu-Natal, is the epicenter of the HIV epidemic. In the last decade, through political will and huge financial investment, the country has seen a decreasing trend in HIV incidence and deaths. Globally, 40% of pregnancies are unintended. Accessible safe and effective contraception is a key public health tool. Barrier contraception (male and female condoms) remains the only form of contraception that prevents unintended pregnancies, HIV and sexually transmitted infections (STIs). SA boasts almost 100% knowledge about contraception and a 60% contraceptive prevalence rate yet the unmet need for contraception in sexually active women remains 19%.

Part one of this article deals with the assessment and medical management of the disease. The following will delve into surgical techniques in the armamentarium of treatment for both urge and stress urinary incontinence.

Measles is also known as Rubeola. Humans are the common host for the virus where it is found in the pharyngeal and nasal mucosa. The virus is transmitted via droplet spread or contact with an infected surface and then touching one’s nose, eyes or mouth. It can survive up to two hours in the air. Measles is highly infectious and 90% of individuals who are not immunized that come into contact with an infected patient, will become infected. The following are regarded as high risk individuals for measles infection: children under 5 years, adults above 20 years of age, pregnant women, immune compromised individuals, and those with malnutrition or Vitamin A deficiency.

The prevalence of endometriosis is estimated to be about one-third of adolescents with chronic pelvic pain and increase to 80% in adolescents with chronic pelvic pain who fail to respond to medical treatment. The most common presenting symptom is dysmenorrhea and chronic pelvic pain. Acyclic pain is more common in adolescents than in adults. Atypical and subtle lesions are seen with red lesions being the commonest. The majority have early stage disease but a significant proportion (up to 30%) have advanced disease. An ovarian endometrioma is the most common presentation with advanced disease. Management is challenging and includes distraught parents and patient. Surgery is beneficial in treating pain with all stages of endometriosis and improving fertility in adolescents with infertility. Optimal and complete laparoscopic excision might slow disease progression. Postoperative medical therapy may have benefit to treat endometriosis pain but is not conclusive with regard to preventing disease progression or recurrence.

Background: Most community service medical officers (CSMOs) experience difficulties in performing uncomplicated caesarean deliveries (CDs) during their community service.

Aim: To determine the perceptions and attitudes of community service medical officers regarding surgical skills training in Obstetrics and Gynaecology (O&G) during their internship.

Methods: A questionnaire based study included CSMOs working in hospitals in the Umgungundlovu District in KwaZulu-Natal, South Africa. Responses to statements in the questionnaire were recorded on a semi-structured format. Statements evaluating the experiences of CSMOs included five-point Likert scale type questions (strongly agree, agree, disagree and strongly disagree). Open-ended qualitative-style questions were also included to give the participants the opportunity to share their opinions on their experiences. Data was analyzed using simple descriptive statistics.

Results: Forty eight CSMOs took part in the survey. Caesarean deliveries were the main surgical procedure performed (range 10-50). Difficulties were encountered at CDs by all CSMOs however 78.8% were able to apply knowledge and skills learnt during internship. CSMOs also performed other surgical procedures. Postpartum haemorrhage was managed successfully by 8.8%
of CSMOs and 75% agreed that they applied knowledge and skills acquired through ESMOE training to manage obstetric complications and emergencies. Recommendations to improve internship training included: provision of “live” models, more practical skills exposure and simulation training.

Conclusion: The internship training program in O&G may have all the components necessary however there is a need for improvement of the training structure. Ensuring an improvement of skill will secure provision of a good quality healthcare system particularly in less specialized hospitals.

Background: Induction of labour (IOL) is commonly performed for the benefit of either the mother and baby, or both, where continuation of the pregnancy is deemed to have potential to yield adverse outcomes.

Objectives: To establish factors associated with successful IOL with oral misoprostol in term or post-term pregnancies amongst parous women.

Methods: This was a retrospective cohort study at Mahatma Gandhi Memorial Hospital (MGMH) in Durban, South Africa. A total of 205 pregnant women, ≥16 years with parity ≥1 and gestational age of ≥37 weeks were included. IOL was performed with oral misoprostol. Various factors were assessed as potential predictors and associations for successful IOL.

Results: Incidence of IOL was 14.6% at MGMH. The majority of the patients were 26-30 years. Induction was successful in 50.7% of cases. The common indications for IOL were post-dated pregnancy, hypertensive disorders of pregnancy and pre-labour rupture of membranes. The commonest causes of failed induction resulting in a caesarean section (CS) were fetal distress, cephalopelvic disproportion and unresponsiveness to misoprostol. High BMI was significantly associated with failed IOL (31.9±6.8 versus 29.2±5.7; p=0.002). Misoprostol doses correlated positively with BMI (r=0.142; p=0.04). The higher the BMI, the more misoprostol doses were required.

Conclusion: BMI influences IOL success and is positively correlated with misoprostol doses administered.

Background: Hepatocellular carcinoma (HCC) is one of the leading global causes of mortality. However, it is rarely seen in pregnancy. The prognosis of HCC in pregnant women is relatively poor for both mother and child.

Case: We present a case of a 36 year old woman at 36 weeks of gestation with jaundice and hepatomegaly. She was hepatitis B positive. The patient delivered a neonate of 2.040kg, however her condition worsened. She was subsequently diagnosed with HCC and became severely jaundiced, hypotensive and tachycardic with metabolic acidosis.

Conclusion: HCC was diagnosed late in gestation and the patient had a poor outcome. Early diagnosis and management of HCC may have resulted in a better prognosis.

Background: Genital tuberculosis is responsible for infertility in many women. This is especially seen in developing countries where early diagnosis of female genital tract tuberculosis (TB) is often challenging.

Case: We present a case of a 28 year old, nulliparous woman with secondary amenorrhea and infertility. She had a negative progesterone withdrawal challenge. In addition, she had intra-uterine adhesions and the biopsy showed extensive granulomatous inflammation with central micro-abscess formation. The acid fast bacilli test was negative however the diagnosis of genital TB was
still applicable in view of the presence of granulomatous lesions in the background of HIV sero-positivity.

Conclusion: The patient was managed as a case of genital TB and commenced with TB treatment. Following five months of TB therapy, she began menstruation again.