Operative management of ankle fractures during pregnancy: case series

Trauma affects approximately 5% of pregnancies and is the leading non-obstetric cause of maternal death. Ankle fractures occurring in pregnancy although minor, can nonetheless create diagnostic and therapeutic challenges for the patient and the surgeon. There is limited information on the operative management of ankle fractures during pregnancy in literature. We retrospectively reviewed hospital records of pregnant patients with ankle fractures who underwent surgery over a six month period from January to June 2013 in a private hospital in Nairobi. We present four cases of displaced ankle fractures in pregnancy that were fixed with good pregnancy outcomes. These case series highlight the management considerations of ankle fractures in pregnant women whose time to delivery is more than six weeks

An improbable diagnosis of acute abdomen in the immediate post-partum period: Case report

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Uterine Rupture in a Primigravida with Mullerian Anomaly at 27 Weeks Gestation

Mullerian anomalies are rare and are often associated with infertility, chronic pelvic pain and pregnancy  wastage. This is a case report of a primigravida at 27 weeks gestation, who presented in shock. Intra- operatively, a mullerian anomaly with a ruptured left horn was found and excised. She made remarkable  recovery and was discharged home. Uterine anomalies should be ruled out in the evaluation of pregnancy  wastage. When present, management should be individualized based on the clinical history, presentation, anatomical aberration and the patient’s future fertility desire

Tubo-Ovarian Presentation of Burkitt’s Lymphoma: Case Report

Burkitt’s lymphoma rarely presents as a primary of the ovary. High index of suspicion is required to avoid delay of definitive management. There are a few case reports presented on ovarian Burkitt’s lymphoma. We present a case of a 23 year old, para 1+1 HIV negative patient who presented to the Kenyatta National Hospital with a one month history of progressive abdominal swelling, fatigue, lower limb swelling, nausea and vomiting. Abdominal examination, revealed bilateral adnexal masses confirmed by ultrasonography. She underwent emergency laparotomy following a diagnosis of bilateral ovarian masses with torsion. Surgical specimen  showed tubo-ovarian tissue with sheets of lymphoid cells of small to intermediate size, with numerous tangible body macrophages depicting a starry sky appearance. Immunohistochemistry demonstrated a strongly positive CD20, a positive CD 10, a 90-95% positive Ki67, a positive Bcl6 and a negative pan-CK. A definitive diagnosis of tubo-ovarian Burkitt’s was made. The patient unfortunately succumbed before commencement of chemotherapy. Autopsy, concluded the cause of death to be widely disseminated Burkitt’s lymphoma, with a most likely tubo-ovarian primary and intestinal obstruction. Burkitt’s lymphoma should be considered as a differential diagnosis in ovarian masses for timely diagnosis and management

Task Shifting in HIV Clinics, Western Kenya

Background: United states Agency for International development-Academic Model for Providing Accesses to Healthcare (USAID-AMPATH) cares for over 80,000 HIVinfected patients. Express care (EC) model addresses challenges of: clinically stable patient’s adherent to combined-antiretroviral-therapy with minimal need for clinician intervention and high risk patients newly initiated on cART with CD4 counts ≤100 cells/mm3 with frequent need for clinician intervention. Objective: To improve patient outcomes without increasing clinic resources. Design: A descriptive study of a clinician supervised shared nurse model. Setting: USAID-AMPATH clinics, Western Kenya. Results: Four thousand eight hundred and twenty four patients were seen during the pilot period, 90.4% were eligible for EC of whom 34.6% were enrolled. Nurses performed all traditional roles and attended to two thirds and three quarters of stable and high risk patient visits respectively. Clinicians attended to one third and one quarter of stable and high risk patient visits respectively and all visits ineligible for express care. Conclusion: The EC model is feasible. Task shifting allowed stable patients to receive visits with nurses, while clinicians had more time to concentrate on patients that were new as well as more acutely ill patients.East African Medical Journal Vol. 87 No. 7 July 201

Quality of comprehensive emergency obstetric care through the lens of clinical documentation on admission to labour ward

Background: Clinical documentation gives a chronological order of procedures and activities that a patient is given during their management.Objective: To determine the level of quality of comprehensive emergency obstetric care, through the lens of clinical documentation of process indicators of selected emergency obstetric conditions that mostly cause maternal mortality on admission to labour wardDesign: Multi-site cross sectional survey.Setting: Twenty two Government Hospitals in Kenya with capacity to offer comprehensive emergency obstetric care.Subjects: Process variables were abstracted from patient’ case records with a diagnosis of normal vaginal delivery, obstetric haemorrhage, severe pre eclampsia/eclampsia and emergency cesarean section.Results: Availability of structure indicators were graded excellent and good except for long gloves, misoprostol, ergometrin and parenteral cefuroxime that were graded low. A total of 1,216 records were abstracted for process analysis. The median (IQR) for the: six variables of obstetric history was five (4-5); five variables of antenatal profile was four (1-5); five variables of vital signs documentation was three (2-4); five variables for obstetric exam was four (4-5); seven variables of vaginal examination one (0-2); ten variables for partograph was seven (2-9); five variables for obstetric hemorrhage was three (2-4) and eleven variables for severe pre-eclampsia/eclampsia was five (3-6). The median (IQR) from decision-to-operate to caesarean section was three (2-4) hours.Conclusion: Quality of emergency obstetric care based on documentation depicts inadequacy. There is an urgent need to objectively address the need for proper clinical documentation as an indicator of quality performance

Antenatal care and pregnancy outcomes in a safe motherhood health voucher system in rural Kenya, 2007-2013.

SETTING: A rural private health facility, Ruby Medical Centre (RMC), participating in a safe motherhood health voucher system for poor women in Kiambu County, Kenya. OBJECTIVES: Between 2007 and 2013, to determine 1) the number of women who delivered at the RMC, their characteristics and pregnancy-related outcomes, and 2) the number of women who received an incomplete antenatal care (ANC) package and associated factors. DESIGN: Retrospective cross-sectional study using routine programme data. RESULTS: During the study period, 2635 women delivered at the RMC: 50% were aged 16-24 years, 60% transferred in from other facilities and 59% started ANC in the third trimester of pregnancy. Of the 2635 women, 1793 (68%) received an incomplete ANC package: 347 (13%) missed essential blood tests, 312 (12%) missed the tetanus toxoid immunisation and 1672 (65%) had fewer than four visits. Presenting late and starting ANC elsewhere were associated with an incomplete package. One pregnancy-related mortality occurred; the stillbirth rate was 10 per 1000 births. CONCLUSION: This first assessment of the health voucher system in rural Kenya showed problems in ANC quality. Despite favourable pregnancy-related outcomes, increased efforts should be made to ensure earlier presentation of pregnant women, comprehensive ANC, and more consistent and accurate monitoring of reproductive indicators and interventions

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access