Obstetrics and Gynaecology

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Open Access
Severe morbidity and mortality associated with cardiac disease during pregnancy in the Free State public health service
(University of the Free State, 2000-11) Schoon, Marthinus Gerhardus; Cronje, H. S.; Ratnam, S. S.
English: Cardiac disease in pregnancy is an important component of maternal mortality. No good population based study on the extent of cardiac disease in pregnancy has, as yet, been published. A previous study conducted at this institution aimed to describe the morbidity and mortality of cardiac disease in pregnancy, but no guidelines to define morbidity in these cases were available. In 1999 a model was published by Mantel and eo-workers to define acute morbidity as organ dysfunction or failure that will lead to death without treatment. The aim of this study was to describe cardiac disease in a specific population by utilising this model and to try to determine the impact of the disease on the health system. From 1 January 1997 to 31 December 1998 all the available information of patients who presented with cardiac disease was documented. A research assistant was responsible to ensure that the completed hospital records of all the patients who were managed in Health Regions A and B of the Free State Province was available for evaluation. Ward registers and cardiac sonar reports in the regional and tertiary care hospitals (Pelonomi and Universitas) were also scrutinised to ensure that al possible cases were included. All cases with severe acute morbidity according to the Mantel criteria were classified as complicated. The information of the patients was also stratified as either part of the index population if they resided in Regions A or B (the population that was specifically targeted) or as the referred population if they lived in one of the other Regions and were referred to one of the two hospitals. During the 2-year study period 67 patients with cardiac disease were treated. In the study population there were 42 cases (prevalence of 0.12% of all deliveries in Regions A and B) and 31 (74%) were complicated and 11 (26%) uncomplicated. Rheumatic heart disease occurred in 14 (33%) of the cases whilst the majority (23, 54%) of the cases had cardiomyopathy. Four maternal deaths (9%) occurred which comprised 11.7 /100 000 deliveries in Regions A and B. Patients with valvular disease had predominantly mitral valve disease. Mitral regurgitation was the most common lesion, single or in combination with other lesions. Patients with mitral stenosis who were managed with beta-blockers developed less lung oedema. There were only five patients who had prosthetic valves of whom one (20%) died. This dramatic decrease in numbers compared to our previous report is probably due to an aggressive attempt to prevent pregnancies in this group of patients. As reported in the rest of Africa, cardiomyopathy was the most common lesion. It occurred in 1:4000 deliveries that took place in Regions A and B. Hypertension was present in 48% of these women. Only one case with a congenital abnormality and two cases with pericarditis were reported. The most expensive group to treat were those cases who were categorised according to the applied model as complicated cardiac disease. They also had significantly less specialist visits compared to the uncomplicated cases. The proposed model of acute morbidity is useful to evaluate cardiac disease in pregnancy and to monitor progress in the management of these patients. Specialist visits decrease the number of complications and should be encouraged. Management of patients with cardiac disease who did not receive antenatal care is expensive and communities should be informed of the advantages of antenatal care. Women with cardiac disease in pregnancy need specialist expertise and should preferably be evaluated and counselled prior to the onset of pregnancy.
Open Access
Non infective factors associated with leukocytospermia
(University of the Free State, 2017) Khalema, R. J.; Strydom, J. du P.
OBJECTIVE To investigate non-infective factors possibly associated with leukocytospermia 2. DESIGN Cross sectional study 3. SETTING Unit for Human Reproduction, Universitas Tertiary Hospital in Bloemfontein 4. PATIENTS A total of seventy three, (73) patients were included in the study 5. OUTCOME MEASURES Non infective factors possibly associated with leukocytospermia such as smoking, alcohol use, recreational drug use and HIV infection 6. RESULTS A total of 73 patients were included in the study and leukocytospermia was found in 36% (N=27/73). In the study the investigated variables were found not to be statistically significantly associated with leukocytospermia (P values>0.05). 7. CONCLUSION From our study, none of the variables were significantly associated with the presence of leukocytospermia
Open Access
Patient knowledge and acceptability of the Intrauterine contraceptive device (IUCD) at a tertiary level hospital.
(University of the Free State, 2017) Van der Westhuizen, N.; Hanekom, G. J.
Abstract not available
Open Access
Evaluation and management of a rectocele in a resource limited setting
(University of the Free State, 2017-01) Henn, Etienne Wilhelm; Wessels, P. H.
English: INTRODUCTION: A rectocele can be expected in approximately 11-19% of women and is present in 40-85% of women requiring pelvic floor surgery for other disorders. There is considerable international variation in the evaluation and management of these women, particularly in regards to surgical treatment. The healthcare environment of the Free State is one with limited resources and innovative clinical approaches are often required to allow for optimal service provision to continue. OBJECTIVES: The objective of this thesis was to research the assessment and management of women who presented with rectoceles in a resource limited setting through innovative and frugal methods, whilst maintaining a pragmatic clinical inclination. METHODOLOGY: The methodologies included the linguistic and cultural psychometric validation of pelvic floor questionnaires, the randomized assessment of the clinical impact that transperineal ultrasound has on patient management, the randomized evaluation of the value which a rectopexy might add in combination with a sacrocolpopexy, the retrospective review of a rectocele plication and description of this novel surgical technique, the retrospective review of the benefit which a perineal body repair in combination with a posterior repair might confer as well as the randomized assessment for non-inferiority of a rectocele plication compared to a defect-specific repair in women with rectoceles. RESULTS: The PFDI-20, PFIQ-7 and PISQ-12 pelvic floor questionnaires were validated in South African women for the languages of Afrikaans and Sesotho and shown to be responsive to clinical change. The integration of transperineal ultrasound findings resulted in an alteration of the definitive management plan in 37.6% of women and this was most evident for those with posterior compartment disorders. A rectopexy was not found to add significant clinical benefit in women with advanced multi-compartment pelvic organ prolapse who underwent an extensive sacrocolpopexy. The rectocele plication procedure, which involves the repair of the anterior rectal wall though a vaginal approach, was found to result in anatomic success of 88.6% after a mean follow-up period of 27 months with an associated significant improvement in symptoms and quality of life. The addition of a perineal body repair in those women who underwent a rectocele plication was not observed to be of any clinical benefit in this population. The randomized assessment of a rectocele plication compared to a defect-specific repair demonstrated that the new procedure was not inferior to the existing operation in regards to anatomic outcome. The anatomic success rates were 92.3% and 76.9% respectively (p=0.2485, 95% CI -13.6; 42.5). The rectocele plication did however demonstrate significantly superior symptomatic and functional outcomes compared to a defect-specific repair after 1 year. A significant observation was that of voiding dysfunction in this population of women with isolated rectoceles. This was the second most prevalent initial complaint and it was significantly improved (p= 0.0011) after surgical correction of a rectocele in both the retrospective and prospective evaluations. CONCLUSION: This research compilation demonstrated that a thorough assessment of women with posterior compartment disorders through the use of validated instruments and standardized investigations in combination with innovative surgical procedures resulted in clinical outcomes not inferior to those reported elsewhere in the literature. It emphasized that pragmatic innovation in a limited resource healthcare environment can produce internationally equivalent clinical results.
Open Access
Normal platelet count in the HIV positive pregnant patient
(University of the Free State, 2019-04) Van Wyngaard, Bianca; Zondagh, Inge
Background. Thrombocytopenia complicates 6.6% – 11.6% of all pregnancies. Gestational Thrombocytopenia accounts for the majority of cases, it is usually mild with spontaneous resolution postpartum. It is estimated that more than 25% of pregnant South African patients are HIV positive. Objectives. The objective of the study was to determine the platelet count for HIV positive pregnant patients. This will lead to minimizing unnecessary invasive testing and workup for other pathologies. Method. This was a prospective descriptive study in which low and mild risk pregnant patients with WHO stage 1 HIV disease were recruited for participation. In patients that needed routine blood tests drawn, a platelet count was added. Patients were either first visit patients or following up for routine antenatal care. Results. For all participants (n = 120), the mean platelet count was 270.9 x 10 ⁹/L (range 91 –488). For first trimester participants (n = 37), the mean platelet count was 282.3 x 10 ⁹/L (range 103 – 441). For the second trimester participants (n = 28), the mean platelet count was 263.7 x 10 ⁹/L (range 91 - 470). For the third trimester participants (n = 34), the mean platelet count was 260.2 x 10 ⁹/L (range 99 - 488). For the participants where no trimester was indicated (n = 21), the mean platelet count was 278.1 x 10 ⁹ /L (range 181 - 426). Discussion and Conclusion. Stage 1 HIV does not have a clinical significant impact on the platelet count in pregnant patients.
Open Access
Profiles of women presenting with obstetric fistulae at Universitas Academic Hospital, Free State province, South Africa
(University of the Free State, 2019-07) Marokane, Masekhokho M. P.; Baloyi, Shisana
Background: Obstetric fistula is a serious consequence of prolonged and obstructed labour, common in low income countries were accessibility to emergency obstetric care may be limited. Most common cause is ischemia and necrosis of the soft tissues of the birth canal caused by the compression of the foetal presenting part against the bony pelvis. This results in abnormal communication between the vagina, bladder and/or rectum with resultant leakage of stools or/and urine through the vagina. Other causes may be tearing of those tissues or iatrogenic injury during abortions. Objectives: Primary objective To determine the prevalence of obstetric fistula at Universitas Academic Hospital urogynaecology clinic Secondary objective To determine the demographic characteristics of the women presenting with obstetric fistulae. Study design and methods: Retrospective descriptive-analytical study. Medical records and demographic characteristics of all patients referred to Universitas Academic Hospital's urogynaecology clinic with obstetric fistulae from 01 January 2013 to 31 December 2017. A 21- item data sheet was used to collect data and the latter was analysed on the Microsoft excel spreadsheet. Limitations: Small sample size, only 46 patients met the inclusion criteria over the 5 year study period. Results: The prevalence of obstetric fistula at UAH urogynaecology clinic was found to be 1% which correlates with the global estimates in the literature. The most common type of fistula was found to be rectovaginal fistula (63.04%) and mostly they developed as a result of soft tissue lacerations not necessarily ischemia and necrosis. Only 5(10.87%) patients in our population group delivered before the age of 20 though it is reported globally that this condition is the most in teenagers. Fifty percent of the study population were not married and only 2(4.35%) of the married ones were divorced. 63.04% of the study population had high school level education and only 8.7% of them were employed. Out of 46 participants only 2 (4.35%} did not seek antenatal care, the median number of follow-up in this group was 4 antenatal visits. Almost all of them {91.3%) delivered normally and only 4 had episiotomies. The perineal (71.74%) tears were common in this study group and some remained not sutured. Most of them delivered at a level 2 health care facility. Conclusion: The prevalence of obstetric fistula in our setting although shown to be low, like in the rest of the world, more attention should be paid to maternal health services as this complication of child birth is the indicator of poor/inadequate health service. Although the level 2 facilities are regarded as well equipped to deal with obstetric emergencies authorities are urged to pay more attention to skill development of the personnel rendering the maternity care as most of these cases were not appropriately managed during the intrapartum period, use of partogram during labour during be encouraged so that those patients who will end up with obstructed labour can be identified timeously.
Open Access
Profile of cardiac patients who delivered at Universitas Academic Hospital (UAH) in Bloemfontein South Africa: 2012 – 2017
(University of the Free State, 2019-09) Makgato, C. M.; Baloyi, S. M.; Nondabula, T.
INTRODUCTION: Maternal deaths related to cardiac disease in pregnancy is rising globally. Cardiac disease remains the leading cause of mortality and morbidity in women with medical and surgical conditions in South Africa. Prevalence of cardiac disease in pregnancy ranges between 0.10.9% in South Africa. Pre-existing cardiac disease also contributes to significant perinatal morbidity and mortality. OBJECTIVES: To assess the profile of women with cardiac disease who delivered at UAH, taking into account maternal and perinatal outcomes, and to identify underlying risks. METHODS: A retrospective analysis of 148 files of pregnant women with cardiac disease who delivered at UAH between January 2012 and December 2017 was carried out. Frequencies and percentages were used to summarise categorical data. Medians and percentiles were used to summarise numerical data. The data analysis was generated using the SAS statistical software. RESULTS: There were 3 154 deliveries at UAH during the study period. The prevalence of cardiac disease in pregnancy was 4.7% (n=148), with black women most affected (89.7%). The average age was 27.0 years. The youngest parturient was 16 years old and the oldest 43 years old. The majority of the patients (71.6%) booked antenatal care in the second trimester, with average gestational age at 19.5 weeks. One hundred and six women (71.6%) tested negative for HIV. The study population had an average BMI of 27. The average gestational age at delivery was 36.7 weeks, with 27.3% of the babies born preterm. Twenty-one (15.3%) of these neonates were admitted to the neonatal intensive care unit. There were eight stillborn deliveries with no neonatal deaths reported. The Caesarean section rate was 67.6%. Vaginal deliveries were 32.4% of all deliveries, and 31.9% (15) of these were assisted deliveries. Of the patients with cardiac disease, 85% were New York Heart Association class (NYHA) I and II. Rheumatic heart disease (RHD), congenital heart disease (CHD) and cardiomyopathy was diagnosed in 48.6% (n=72), 24.3% (n=36) and 18.9% (n=28) of cases respectively. Cardiac failure and pulmonary oedema contributed 56% of maternal morbidity. Cardiac failure was indication for 43.8% of intensive care unit admissions. Six deaths were reported, with a case fatality rate of 4.05%. Peripartum cardiomyopathy was the cause of death in five deaths and valve thrombosis in one death respectively. All deaths were NYHA functional class III and IV. CONCLUSION: The prevalence of cardiac disease among pregnant women is increasing, with rheumatic heart disease (RHD) being the leading aetiology. The most significant increase was that of congenital heart lesions. Pregnancies complicated by underlying cardiac disease are associated with maternal and perinatal morbidity.
Open Access
Fit for purpose? the strengths and weaknesses of Gauteng maternity services health care organisation / configuration in the context of reducing maternal deaths
(University of the Free State, 2021-03) Chauke, Hlengani Lawrence; Wessels, P. H.
BACKGROUND: Despite the availability of evidence-based and cost-effective interventions that are accessible to low and middle-income countries (LMICs), women continue to die of preventable pregnancy-related causes worldwide. Sub-Saharan Africa (SSA) carries a disproportionate burden of maternal mortality (68% of the global burden) relative to its size (has just below 16% of the world’s total population). The high burden of maternal deaths in SSA, including other LMICs, has been attributed to the failure of its healthcare system, in particular, poor quality of primary healthcare (PHC) orientated district healthcare services (DHS). The DHS-PHC model is the statutory model for service delivery in South Africa. This model has been blamed in studies conducted in low-and middle-income countries (LMICs) for the poor quality of both maternal and general healthcare services. Consequently, calls for the centralisation of maternity services to hospitals have started to emerge, the argument in favour of such a move is that centralising maternity services to hospitals would improve pregnant women’s access to emergency maternity healthcare services and skilled attendants in a timely manner. Others have however argued that a hospital-based model of maternity care is both costly and unsustainable for countries with limited resources and instead this group have called for the strengthening of the DHS-PHC. Informed by contextual realities, various African countries, as well as provinces in South Africa implemented different strategies aimed at strengthening the DHS-PHC model. For example, in the Western Cape and Gauteng, this took the form of a Comprehensive Service Plan (CSP) and Cluster Policy Framework (CPF). The two healthcare frameworks are based on a regional model but differ in philosophy and governance structures. Both models aim to strengthen the district health care system, improve health service efficiency as well as quality of care. Although only signed into policy in January 2019, the CPF model has been in operation in the Charlotte Maxeke Johannesburg Academic Hospital Cluster (CMJAH) since 2016, mainly in the Obstetrics and Gynaecology and Surgical disciplines. Unlike the Western Cape’s CSP model, the Gauteng CPF healthcare model has not been subjected to scientific evaluation since its implementation. Because maternal and neonatal healthcare services are national and provincial priority areas, maternity healthcare services presented a unique opportunity to evaluate the CPF, a healthcare innovation aimed at improving the quality and governance of healthcare services. AIM: The aim of the study was to assess the strengths and weaknesses of the organization/ configuration of maternity healthcare services in Gauteng, in particular, the CPF as implemented in the CMJAH maternity cluster in order to identify gaps/healthcare barriers and use this information to recommend healthcare services improvement strategies. METHODOLOGY: Informed by Stufflebeam’s Context, Input, Process and Product (CIPP) theoretical model /framework, and a convergent mixed method research design, quantitative and qualitative data were simultaneously and independently collected, analysed, results synthesized and merged through a process of triangulation. The quantitative component involved an audit of maternity healthcare facilities in terms of resources (number of facilities, distribution, bed capacity, human resource), service load (deliveries) and maternal deaths. Semi-structured interviews with frontline healthcare workers and their immediate supervisors/managers, facility visits and the review of the cluster morbidity and mortality (M&M) meetings minutes, as well as the Cluster Policy Framework (CPF), constituted the qualitative component. RESULTS: The CPF managed to establish clinical governance, standardised protocol, improved coordination of healthcare services, including creating an enabling environment for support, collaboration and sharing of knowledge and skills among healthcare workers from different levels of care and healthcare. During the period under study, the cluster saw a modest and sustained decline in maternal mortality despite an increase in maternity deliveries. However, the CPF faced challenges in the form of a mismatch between the demand and supply side of healthcare services. The mismatch was due to a number of factors, among those, poor leadership, management, governance, infective implementation of the CPF and a high rate of provincial and international migration. Together with leadership and management challenges, the mismatch between the demand and supply side of healthcare services, resulted in the over burdening of maternity healthcare services, increase in patient adverse events, disgruntled healthcare workers, poor quality of care and an increase in medico-legal challenges thereby setting on the stage, a vicious cycle with no end point. CONCLUSION: Gauteng CPF is an excellent example of health system innovation with a potential to strengthen the quality and coordination of not only maternity but healthcare services in general. The model retains all the advantages of the DHS-PHC model and at the same time, focus on improving clinical governance, distribution and sharing of scare resources. Poor leadership, governance, management lack of effective policy implementation, inadequate infrastructure, shortage and ineffective management of human resources, among other factors, have created bottlenecks and challenges in the health system, limiting the CPF model’s potential. These challenges would need to be addressed in order for the CPF to deliver on its promise. Failure to do so could result in a catastrophic failure of the much-awaited NHI.
Open Access
The prevalence of bleeding disorders in women with regular heavy menstrual bleeding at a secondary gynaecology clinic in central South Africa
(University of the Free State, 2021-06) Deiker, Motshidisi; Baloyi, S. M.; Coetzee, M. J.; Haupt, Leriska
Background: Heavy menstrual bleeding (HMB) affects 10-15% of women. Studies from developed countries show that 20% of females with heavy menstrual bleeding have an underlying bleeding disorder. The prevalence of bleeding disorders in patients with HMB has not been determined in South Africa. Objectives: To determine the prevalence of bleeding disorders in women with heavy menstrual bleeding in a tertiary gynaecology clinic in central South Africa and to evaluate the use of the Molecular and Clinical Markers for the Diagnosis and Management of Type 1 VWD bleeding assessment tool (MCMDM-1 VWD BAT) and the bleeding time in identifying women with HMB with underlying bleeding disorders. Methods: This was a prospective descriptive study. Forty-one patients with heavy menstrual bleeding not attributable to other causes in the PALM-COEIN classification were recruited. Demographic data were collected, the MCMDM-1 VWD BAT was administered, a modified Ivy bleeding time was done, and routine laboratory testing was done to exclude non-haematological conditions. Screening tests for coagulation disorders were done. Results: Forty-one patients were recruited for the study, but only 36 had a complete data set. None of the patients were identified to have an underlying bleeding disorder even though seven patients (19.4%) had an elevated MCMDM-1 VWD score, despite the lack of laboratory evidence of a bleeding disorder. One (2.5%) patient had an elevated bleeding time. All the patients were referred from primary healthcare clinics. Conclusion: The prevalence of bleeding disorders in this study is low when compared to studies done elsewhere, even though there was selection bias. Half of the patients were already on contraceptives, which might have reduced their bleeding symptoms. Our functional Von Willebrand factor assays were dependent on ristocetin and may have overestimated the Von Willebrand factor concentration. The MCMDM-1 VWD bleeding assessment tool was easy to administer. The bleeding time did not contribute to the diagnosis. The study needs to be repeated in a primary care setting, using Von Willebrand factor assays that are independent of ristocetin. Such studies are indicated to determine to true prevalence of bleeding disorders in patients with heavy menstrual bleeding in South Africa.

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