Bell’s palsy in pregnancy as a prodromal sign of preeclampsia: A report of three cases, pregnancy outcome, and literature review

Bell’s palsy is a less common neurological disorder in the general population. Its occurrence during pregnancy can be used as a predictor of adverse obstetric outcomes including preeclampsia and its complications. We report cases of three pregnant women from Botswana who presented with Bell’s palsy in the third trimester coexisting with preeclampsia and multiple complications. One of the patient was a case of maternal near-miss with multiple life threating complications including stage 3 acute kidney injury (AKI) and required hemodialysis. The second and third patients developed Bell`s palsy and preeclampsia at term, management of preeclampsia commenced with immediate delivery resulting in good maternal and neonatal outcome. In all the three patients preeclampsia and Bell`s palsy completely resolved post-delivery. Therefore, new onset Bell’s palsy in pregnancy may be used as a prodromal sign of preeclampsia. Such patients deserve close follow up for preeclampsia or gestational hypertension for a better obstetric outcome. La paralysie de Bell est un trouble neurologique moins fréquent dans la population générale. Son apparition pendant la grossesse peut être utilisée comme un prédicteur d'issues obstétricales défavorables, y compris la prééclampsie et ses complications. Nous rapportons les cas de trois femmes enceintes du Botswana qui ont présenté une paralysie de Bell au troisième trimestre coexistant avec une prééclampsie et de multiples complications. L'un des patients était un cas de quasi-accident maternel avec de multiples complications potentiellement mortelles, notamment une insuffisance rénale aiguë (IRA) de stade 3 et une hémodialyse nécessaire. Les deuxième et troisième patientes ont développé une paralysie de Bell et une prééclampsie à terme, la prise en charge de la prééclampsie a commencé avec l'accouchement immédiat, ce qui a donné de bons résultats maternels et néonatals. Chez les trois patientes, la prééclampsie et la paralysie de Bell ont complètement disparu après l'accouchement. Par conséquent, une nouvelle paralysie de Bell pendant la grossesse peut être utilisée comme signe prodromique de prééclampsie. Ces patientes méritent un suivi rapproché de la prééclampsie ou de l'hypertension gestationnelle pour un meilleur résultat obstétrica

Gender difference in the incidence of malaria diagnosed at public health facilities in Uganda.

BACKGROUND: Routine malaria surveillance data in Africa primarily come from public health facilities reporting to national health management information systems. Although information on gender is routinely collected from patients presenting to these health facilities, stratification of malaria surveillance data by gender is rarely done. This study evaluated gender difference among patients diagnosed with parasitological confirmed malaria at public health facilities in Uganda. METHODS: This study utilized individual level patient data collected from January 2020 through April 2021 at 12 public health facilities in Uganda and cross-sectional surveys conducted in target areas around these facilities in April 2021. Associations between gender and the incidence of malaria and non-malarial visits captured at the health facilities from patients residing within the target areas were estimated using poisson regression models controlling for seasonality. Associations between gender and data on health-seeking behaviour from the cross-sectional surveys were estimated using poisson regression models controlling for seasonality. RESULTS: Overall, incidence of malaria diagnosed per 1000 person years was 735 among females and 449 among males (IRR = 1.72, 95% CI 1.68-1.77, p < 0.001), with larger differences among those 15-39 years (IRR = 2.46, 95% CI 2.34-2.58, p < 0.001) and over 39 years (IRR = 2.26, 95% CI 2.05-2.50, p < 0.001) compared to those under 15 years (IRR = 1.46, 95% CI 1.41-1.50, p < 0.001). Female gender was also associated with a higher incidence of visits where malaria was not suspected (IRR = 1.77, 95% CI 1.71-1.83, p < 0.001), with a similar pattern across age strata. These associations were consistent across the 12 individual health centres. From the cross-sectional surveys, females were more likely than males to report fever in the past 2 weeks and seek care at the local health centre (7.5% vs. 4.7%, p = 0.001) with these associations significant for those 15-39 years (RR = 2.49, 95% CI 1.17-5.31, p = 0.018) and over 39 years (RR = 2.56, 95% CI 1.00-6.54, p = 0.049). CONCLUSIONS: Females disproportionately contribute to the burden of malaria diagnosed at public health facilities in Uganda, especially once they reach childbearing age. Contributing factors included more frequent visits to these facilities independent of malaria and a higher reported risk of seeking care at these facilities for febrile illnesses

Placental Plasmodium falciparum malaria infection: Operational accuracy of HRP2 rapid diagnostic tests in a malaria endemic setting

<p>Abstract</p> <p>Background</p> <p>Malaria has a negative effect on the outcome of pregnancy. Pregnant women are at high risk of severe malaria and severe haemolytic anaemia, which contribute 60-70% of foetal and perinatal losses. Peripheral blood smear microscopy under-estimates sequestered placental infections, therefore malaria rapid diagnostic tests (RDTs) detecting histidine rich protein-2 antigen (HRP-2) in peripheral blood are a potential alternative.</p> <p>Methods</p> <p>HRP-2 RDTs accuracy in detecting malaria in pregnancy (MIP >28 weeks gestation) and placental <it>Plasmodium falciparum </it>malaria (after childbirth) were conducted using Giemsa microscopy and placental histopathology respectively as the reference standard. The study was conducted in Mbale Hospital, using the midwives to perform and interpret the RDT results. Discordant results samples were spot checked using PCR techniques.</p> <p>Results</p> <p>Among 433 febrile women tested, RDTs had a sensitivity of 96.8% (95% CI 92-98.8), specificity of 73.5% (95% CI 67.8-78.6), a positive predictive value (PPV) of 68.0% (95% CI 61.4-73.9), and negative predictive value (NPV) of 97.5% (95% CI 94.0-99.0) in detecting peripheral <it>P. falciparum </it>malaria during pregnancy. At delivery, in non-symptomatic women, RDTs had a 80.9% sensitivity (95% CI 57.4-93.7) and a 87.5% specificity (95%CI 80.9-92.1), PPV of 47.2% (95% CI 30.7-64.2) and NPV of 97.1% (95% CI 92.2-99.1) in detecting placental <it>P. falciparum </it>infections among 173 samples. At delivery, 41% of peripheral infections were detected by microscopy without concurrent placental infection. The combination of RDTs and microscopy improved the sensitivity to 90.5% and the specificity to 98.4% for detecting placental malaria infection (McNemar's <it>X </it>²> 3.84). RDTs were not superior to microscopy in detecting placental infection (McNemar's <it>X </it>²< 3.84). Presence of malaria in pregnancy and active placental malaria infection were 38% and 12% respectively. Placental infections were associated with poor pregnancy outcome [pre-term, still birth and low birth weight] (aOR = 37.9) and late pregnancy malaria infection (aOR = 20.9). Mosquito net use (aOR 2.1) and increasing parity (aOR 2.7) were associated with lower risk for malaria in pregnancy.</p> <p>Conclusion</p> <p>Use of HRP-2 RDTs to detect malaria in pregnancy in symptomatic women was accurate when performed by midwives. A combination of RDTs and microscopy provided the best means of detecting placental malaria. RDTs were not superior to microscopy in detecting placental infection. With a high sensitivity and specificity, RDTs could be a useful tool for assessing malaria in pregnancy, with further (cost-) effectiveness studies.</p

Extended balloon labour induction: A single arm proof of concept trial

Background: Mechanical labour induction with a transcervical balloon is as effective as pharmacological methods, with fewer adverse effects. Its use has been limited to labour induction with an unfavourable cervix able to retain the balloon. We have developed an innovative approach using 2–3 balloons side-by-side to extend the benefits of mechanical labour induction/augmentation with a favourable cervix without having to resort to amniotomy or uterotonics. Objectives: To assess the effectiveness of side-by-side balloons for extended labour induction/augmentation. Methods: We conducted a single arm proof of concept trial at Princess Marina Hospital (PMH) in Gaborone, Botswana. Participants were assessed as unsuitable for single balloon labour induction based on a modified Bishop cervical score of 7 or more. Three Foley catheters taped symmetrically side by side were passed through the cervix and inflated with 60mls each. Traction was applied with a weight of 250mls water suspended over the bed-end. The use of uterotonics, time from induction to birth, mode of birth, Apgar scores and adverse maternal and neonatal outcomes were recorded. Participants’ satisfaction with the method of labour induction was assessed using a descriptive scale. Results: We enrolled 20 participants of whom two were nulliparous. Indications for labour induction were mainly late term (70%) and hypertensive disorders of pregnancy (25%). The mean cervical score was 7.2. Overall, 17 (85%) of the participants achieved a vaginal birth, of whom 5 required oxytocin for labour augmentation. Four of these had requested removal of the balloons, one due to discomfort and three felt the process was taking too long. Three participants underwent caesarean birth. The mean time from initiation of labour induction to vaginal birth was 16 h (standard deviation (SD) 8.4) and 20 h for caesarean birth (SD 10.5). There were no 5-minute Apgar scores below 7 nor neonatal admissions. One baby required brief resuscitation. There were no adverse maternal outcomes. Conclusion: This proof-of-concept study suggests that use of side-by-side balloons in participants with favourable cervix is effective in achieving vaginal birth in most participants without uterotonics or amniotomy. There were no adverse outcomes, though the study was too small to exclude the possibility of rare adverse outcomes. This offers a novel option for labour induction/augmentation, particularly where uterotonics or amniotomy are best avoided such as prior caesarean birth, vertical infection transmission risk and in settings with limited capacity for fetal surveillance. The results clearly justify larger randomized trials to evaluate this novel approach with greater precision. On the basis of the current study we are developing a purpose-designed balloon for extended balloon labour induction

Management of post abortion complications in Botswana -The need for a standardized approach.

Post abortion complications are the third leading cause of maternal death after hemorrhage and hypertension in Botswana where abortion is not legalized. This study aimed at assessing the management of post abortion complications in Botswana.A retrospective study was conducted at four hospitals in Botswana in 2014. Socio-demographic, patient management and outcomes data were extracted from patients' medical records. Descriptive statistics and chi-square test were used to analyze and present the data.A total of 619 patients' medical records were reviewed. The duration of hospital stay prior to uterine evacuation ranged from less than an hour to 480 hours. All the patients received either prophylactic or therapeutic antibiotics. Use of parenteral antibiotics was significantly associated with severity of abortion, second trimester abortion, use of blood products and the interval between management's decision and uterine evacuation. Uterine evacuation for retained products of conception was achieved by metallic curettage among 516 (83.4%) patients and by vacuum aspiration in 18 (2.9%). At all the study sites, Misoprostol or Oxytocin were used concurrently with surgical evacuation of the uterus. None use of analgesics or anesthetics in the four hospitals ranged between 12.4% to 28.8%.There is evidence of delayed patient care and prolonged hospital stay. Metallic curette was the primary method used for uterine evacuation across all the facilities. Pain management and antibiotics use was not standardized. A protocol has to be developed with the aim of standardizing post abortion care

Recurrent vaginal epithelioid leiomyosarcoma; a case report from Botswana and review of the literature

Primary vaginal leiomyosarcoma is a rare gynecological malignancy. The clinical presentation is a benign looking well circumscribed mobile mass which might however occasionally present with distant metastases. Post treatment recurrence is common, and the clinical course is often unpredictable. Primary surgical management plus radiotherapy is the commonly practiced treatment of choice. We report a case of primary vaginal epithelioid leiomyosarcoma that recurred twice after local surgical resection. The patient subsequently underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy for a recurrent vaginal leiomyosarcoma. Histopathology of the vaginal mass revealed an epithelioid leiomyosarcoma of the vagina. She also received a course of adjuvant radiotherapy. The patient was free of recurrence at 3 year follow up. Vaginal mass must be evaluated with a high index of suspicion for malignancy. Local surgical resection alone is insufficient for primary vaginal leiomyosarcoma. Surgical resection with adjuvant radiotherapy offers better treatment outcomes with decreased risk of recurrence. Empirical oophorectomy in patients with completed family size might confer additional benefit in preventing disease recurrence in resource limited settings where testing for estrogen and progesterone receptor status of the tumour is unavailable. Due to the unpredictable course of the disease, lifelong patient follow-up is critical for better outcomes. Le léiomyosarcome vaginal primaire est une tumeur maligne gynécologique rare. La présentation clinique est une masse mobile bien circonscrite d'aspect bénin qui peut cependant occasionnellement présenter des métastases à distance. La récidive après le traitement est courante et l'évolution clinique est souvent imprévisible. La prise en charge chirurgicale primaire associée à la radiothérapie est le traitement de choix couramment pratiqué. Nous rapportons un cas de léiomyosarcome épithélioïde vaginal primitif récidivant deux fois après une résection chirurgicale locale. La patiente a ensuite subi une hystérectomie abdominale totale avec salpingo-ovariectomie bilatérale pour un léiomyosarcome vaginal récidivant. L'histopathologie de la masse vaginale a révélé un léiomyosarcome épithélioïde du vagin. Elle a également reçu un cours de radiothérapie adjuvante. Le patient était sans récidive à 3 ans de suivi. La masse vaginale doit être évaluée avec un indice de suspicion élevé de malignité. La résection chirurgicale locale seule est insuffisante pour le léiomyosarcome vaginal primaire. La résection chirurgicale avec radiothérapie adjuvante offre de meilleurs résultats de traitement avec un risque réduit de récidive. Une ovariectomie empirique chez les patients dont la taille de la famille est complète pourrait conférer un avantage supplémentaire dans la prévention de la récidive de la maladie dans des contextes à ressources limitées où le test du statut des récepteurs aux œstrogènes et à la progestérone de la tumeur n'est pas disponible. En raison de l'évolution imprévisible de la maladie, le suivi des patients tout au long de la vie est essentiel pour de meilleurs résultats

Medical management, uterine evacuation and means of pain control in patient care.

<p>Medical management, uterine evacuation and means of pain control in patient care.</p

Relationship of selected variables with parenteral antibiotics use and means of uterine evacuation.

<p>Relationship of selected variables with parenteral antibiotics use and means of uterine evacuation.</p

Time duration in relation to the course of patient in post abortion care.

<p>Time duration in relation to the course of patient in post abortion care.</p