Outcome of Pregnancy in the Morbidly Obese Woman

Background: Obesity is a growing global health problem. In South Africa, more than half of the adult women are overweight and almost 30% areobese. The problems associated with obesity, such as diabetes, hypertension, thrombo-embolism and coronary heart disease, are well described in the non-pregnant population, but the condition itself holds specific risks during the ante-, intra- and postpartum periods of the pregnant woman.Of particular concern is the intrapartum period. Complications such as slow progress during labour and increased rates of caesarean section arebest addressed proactively. For this reason certain sources advocate that all morbidly obese women be referred for evaluation of the pregnancy andplanning of labour and delivery by an anaesthetist and a specialist obstetrician. The aim of this study was to determine whether morbidly obese women are at increased risk of adverse outcomes, compared to women with a normal body mass index (BMI).Methods: A case control study design was used. In this study a normal BMI was defined as 20–25 kg/m2 and morbid obesity as a BMI of≥ 40 kg/m2. The BMI was calculated from the weight and height measured at the booking visit. The cases in this study comprised the first hundred morbidly obese women seen at the Obstetric Special Care Clinic in Tygerberg Hospital (TBH), a secondary and tertiary referral centre. The controls (n = 209) were women with normal BMIs and singleton pregnancies who booked as low-risk patients at the Bishop Lavis Midwife Obstetric Unit (MOU) during the same calendar period. A minimum ratio of 2:1 controls-to-case was used, with controls also matched for primi- or multiparity. Patients booking at the MOU with significant obstetric risk factors are referred to TBH for antenatal care. These women were not considered as controls. However, low-risk women who met the inclusion criteria at booking and who subsequently developed risks or complications were included, as the selection was done according to findings at the booking visit.The main outcomes to be determined were: ante-, intra- and postpartum maternal complications, rate of epidurals, and perinatal outcomes.Results: Women in the morbidly obese group were significantly older (p < 0.001) and of higher parity (p < 0.001) than those with normal BMIs. There was no difference in the numbers of primigravidae. Significantly more women in the morbidly obese group had experienced at least one miscarriage (p = 0.002). In similar fashion, significantly more of the previous deliveries in the morbidly obese group had been by caesarean section (p < 0.001). Again, significantly more women in the morbidly obese group had previously experienced pregnancies complicated by hypertension (p < 0.001). In the index pregnancies studied, morbidly obese women experienced more hypertension (p < 0.001), diabetes (p = 0.02) and urinary tract infections (p < 0.001) than controls. They underwent induction of labour more often (p < 0.001) and had a higher rate of caesarean delivery (p < 0.001). Epidural anaesthesia was planned for all morbidly obese patients, but only 14% received it. During delivery, perineal damage was more common in morbidly obese women (p < 0.001) and their babies were significantly larger (p < 0.001). There was one perinatal death.Conclusions: Morbidly obese women experienced increased complications during pregnancy and childbirth. Due to the high rate of caesareansections and the potential difficulties of emergency anaesthesia among these women, epidural anaesthesia during labour should be planned andadministered as often as possible

Lived experience of healthcare professionals providing safe abortion in Rwanda

BACKGROUND: Various countries have ratified the law declaring that safe abortion is a fundamental women’s right. Rwanda has expanded legal grounds for abortion in Law n° 68/2018 of 30/08/2018, determining offenses and penalties in general. This study aimed to gain an in- depth understanding of how physicians, midwives and nurses perceive safe abortion service provision and their experience of providing the service in Rwanda. METHODS: A qualitative, descriptive phenomenological method with transcendental theory devised by Husserl Edmund was used to guide this study. A non-random purposive sampling recruited twenty-three informants, and a semi-structured interview guide was used to collect data. The data analysis used NVivo pro 12 software to categorize and code ideas, while the eight steps of transcendental descriptive phenomenology were used to generate the final themes. RESULTS: Four themes with ten sub-themes were generated: (1) personal feelings and beliefs (humiliation and stigma, guilty and wonder); (2) resilient mechanisms (Clients’ protection, institutional support, appreciation of the law); (3) training and (4) informants’ recommendations (integrated service, community awareness, psychological support, follow-up). CONCLUSION: Healthcare providers’ willingness to provide safe abortion services depend on the individual’s beliefs about abortion. Professionalism and resilient mechanisms are key to sustaining the safe abortion service provision in addition to the law determining offenses and penalties in general in Rwanda

Outcomes following surgery in subgroups of comatose and very elderly patients with chronic subdural hematoma

Increasing age and lower pre-operative Glasgow coma score (GCS) are associated with worse outcome after surgery for chronic subdural haematoma (CSDH). Only few studies have quantified outcomes specific to the very elderly or comatose patients. We aim to examine surgical outcomes in these patient groups. We analysed data from a prospective multicentre cohort study, assessing the risk of recurrence, death, and unfavourable functional outcome of very elderly (≥ 90 years) patients and comatose (pre-operative GCS ≤ 8) patients following surgical treatment of CSDH. Seven hundred eighty-five patients were included in the study. Thirty-two (4.1%) patients had pre-operative GCS ≤ 8 and 70 (8.9%) patients were aged ≥ 90 years. A higher proportion of comatose patients had an unfavourable functional outcome (38.7 vs 21.7%; p = 0.03), although similar proportion of comatose (64.5%) and non-comatose patients (61.8%) functionally improved after surgery (p = 0.96). Compared to patients aged < 90 years, a higher proportion of patients aged ≥ 90 years had unfavourable functional outcome (41.2 vs 20.5%; p < 0.01), although approximately half had functional improvement following surgery. Mortality risk was higher in both comatose (6.3 vs 1.9%; p = 0.05) and very elderly (8.8 vs 1.1%; p < 0.01) groups. There was a trend towards a higher recurrence risk in the comatose group (19.4 vs 9.5%; p = 0.07). Surgery can still provide considerable benefit to very elderly and comatose patients despite their higher risk of morbidity and mortality. Further research would be needed to better identify those most likely to benefit from surgery in these groups

Antibiotic Sensitivity Patterns Of Enterobacteriaceae Isolated At King Faisal Hospital, Kigali - A Three Years Study

Introduction: A great concern exists about the emergence of antibiotic resistant organisms. The goal of this study is to delineate antibiotic sensitivity patterns at King Faisal Hospital. Methods: A three years study, from Jan 2009 to Dec 2011 was conducted in the Microbiology unit, department of Laboratory, King Faisal hospital, Rwanda. All the specimens and antibiotic sensitivity were processed according to the standard guidelines. Microorganisms and their sensitivity data were reviewed and compiled by using hospital information system. Results: Over the 3-year period, several Enterobacteriaceae pathogens declined in susceptibility to various antimicrobial agents. A total of 2153 Enterobacteriaceae were isolated. Most common isolate was Escherichia coli (1413) followed by Klebsiella species (550), Enterobacter species (110), Proteus species (165), Citrobacter Species (79), Shigella species (110) and other species. Most notable were the decreased sensitivities to cefuroxime: E. coli (84% to 72%), Klebsiella (78% to 33%), Enterobacter (50% to 41%) Proteus(67% to 59%) and Shigella to ciprofloxacin (100% to 96%). And also decreased sensitivities to Imipenem: E. coli (100% to 98%) and Klebsiella species (100% to 94%). Conclusion: These decreased antibiotic sensitivities reflect increased bacterial selection pressure as a result of widespread antibiotic use. A combined approach involving infection-control specialists, infectious disease physicians, and hospital administrators is necessary to address this increasingly difficult problem.Introduction: Une grande préoccupation existe au sujet de l’urgence des organismes résistant aux antibiotiques. Le but de cette étude est de tracer les modèles d’antibiotiques sensibles à l’Hôpital Roi Fayçal. Méthodes: La période d’étude était de trois ans, de Janvier 2009 jusqu’à Décembre 2011. Le lieu d’étude était l’unité de microbiologie du département de laboratoire de l’ Hôpital Roi Fayçal, Rwanda. Tous les échantillons et les antibiogrammes ont été traités selon les directives standard. Résultats: Au cours de la période de trois ans, plusieurs agents pathogènes d’entérobactériaceae ont augmenté la résistance aux certains antibiotiques. Dans 2153 des entérobactériaceae isolées. Le plus isolé était l’ Escherichia coli (1413) suivi de Klebsiella(550), Entérobacter (110), Proteus (165), Citrobacter (79), Shigella (110) et autres espèces. L’étude note la diminution de la sensibilité au cefuroxime : Escherichia coli (84% à 72% ) Klebsiella (78% à 33%), Entérobacter (50% à 41%) Proteus(67% à 59%) et Shigella au ciprofloxacin (100% à 96%). Et également la diminution de la sensibilité à l’Imipenem: Escherichia coli (100% à 98%) et Klebsiella (100% à 94%). Conclusion:Cette diminution de la sensibilité aux antibiotiques reflète l’augmentation de la sélection de la pression bactérienne en raison de l’utilisation de nombreux antibiotiques. Une approche combinée faisant participer divers spécialistes, les infectiologues et l’administration de l’hôpital est nécessaire pour aborder ce problème de plus en plus difficile

Prevalence Of Six Periodontal Pathogens In Rwandan Women’S Gingival Crevicular Fluid

Periodontium or periodontal tissues, are tissues that surround, support and maintain the teeth in the maxillary and mandibular bones. Like other tissues, the periodontal tissues are subject to a number of diseases. The most periodontal pathogens associated with periodontal disease are Tannerella forsythia , Porphyromonas gingivalis , Treponema denticola , Prevotella Intermedia , Fusobacterium nucleatum and Agregatibacter actinomycetemcomutans . Female hormones have been suggested to play an important role in periodontal disease infection. The objective of this study was to identify the prevalence of the above periodontal pathogens associated with periodontal disease in a population of Rwandan women. This study requested the participation of randomly selected women admitted in the department of obstetric-gynecology of the teaching hospital of Butare in Rwanda. Gingival crevice fluid was collected from four teeth (16, 26, 36, 46) with filter paper strips by inserting the strips into the base of the pocket for one minute per tooth. PCR was used for the detection of the presence of the 6 target bacteria in GCF. F. nucleatum was the most prevalent with 86.2 %, P. intermedia (73.5 %), T. forsythia (47.6 %), A. actinomycetemcomutans (45 %), P. gingivalis (28.4%) and T. denticola with (24.3 %). One hundred and eighty six (93.0 %) of the patients harboured at least one of the six periodontopathogens. This study showed that there is an urgent need to improve oral health care and research in Rwanda, on the African continent in general and especially in women who are more exposed to periodontal diseases than men.Les tissus paradontals sont des tissus qui entourent, supportent et maintiennent les dents sur les os maxillaires et mandibullaires. Comme tous les autre tissus, les tissus paradontals sont exposés à de nombreuses maladies. Les bactéries qui sont associées le plus souvent avec les maladies paradontales sont: Tannerella forsythia , Porphyromonas gingivalis , Treponema denticola , Prevotella Intermedia , Fusobacterium nucleatum and Agregatibacter actinomycetemcomutans . Les hormone femelles ont été suggérées avoir joué un grand rôle dans les infections des maladies paradontales. L’objectif de cette étude était d’identidier la prévalence des bactéries ci-haut citées qui sont associées le plus souvent avec les maladies paradontales dans une population des femmes au Rwanda. Les participants de cette étude étaient des femmes admises à l’hopital universitaire de Butare dans le départment de gynécologie-obstétrique. Le liquide créviculaire gingival provenant des quatre dents (16, 26, 36, 46) était collecté à l’aide du papier filtre en insérant ce dernier dans la base des poches pendant une minute par dent. Le PCR était utilisé pour détecter la présence de ces 6 bactéries dans le liquide créviculaire gingival. F. nucleactum était le plus prévalent avec 86,2 %, P. intermedia (73,5 %), T. forsythia (47,6 %), A. actinomycetemcomutans> (45 %), P. gingivalis (28,4%) et T. denticola avec (24,3 %). Cent quatre-vingt six (93,0 %) des patients avaient au moins un des six bactéries parandontales. Cette étude montre qu’il y a un besoin urgent pour améliorer l’hygiène dentaire et la recherche dans ce domaine au Rwanda et en Afrique en général et ceux-ci surtout sur les femmes qui sont plus exposées à ces maladies que les hommes

Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014

Setting: Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. Objective: To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. Design: A retrospective descriptive cohort study using routinely collected data involving adult patients aged 18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. Results: Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. Conclusion: By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs

Treating persistent asthma in rural Rwanda: characteristics, management and 24-month outcomes

SETTING: In 2007, the Rwandan Ministry of Health, with support from Partners In Health, introduced a district-level non-communicable disease programme that included asthma care. OBJECTIVE: To describe the demographics, management and 24-month outcomes of asthma patients treated at three rural district hospitals in Rwanda. DESIGN: We retrospectively reviewed electronic medical records of asthma patients enrolled from January 2007 to December 2012, and extracted information on demographics, clinical variables and 24-month outcomes. RESULTS: Of the 354 patients, 66.7% were female and 41.5% were aged between 41 and 60 years. Most patients (53.1%) were enrolled with moderate persistent asthma, 40.1% had mild persistent asthma and 6.8% had severe persistent asthma. Nearly all patients (95.7%) received some type of medication, most commonly a bronchodilator. After 24 months, 272 (76.8%) patients were still alive and in care, 21.1% were lost to follow-up, 1.7% had died and 0.3% had transferred out. Of the 121 patients with an updated asthma classification at 24 months, the severity of their asthma had decreased: 17.4% had moderate and 0.8% had severe persistent asthma. CONCLUSION: Our findings show improvements in asthma severity after 24 months and reasonable rates of loss to follow-up, demonstrating that asthma can be managed effectively in rural, resource-limited settings.</p

Treatment of non-communicable disease in rural resource-constrained settings: a comprehensive, integrated, nurse-led care model at public facilities in Rwanda

Background: Low-income countries face a dual burden of endemic chronic non-communicable diseases (NCDs) and limited resources to implement control strategies. Access to services is even more challenging for patients in countries like Rwanda, where more than 80% of the population reside in rural areas, and there is fewer than one health care provider per 1000 people. Many studies of NCD care delivery models in low-income countries are limited to simple conditions or focus on a single disease. Since 2007, Partners in Health/Inshuti Mu Buzima (PIH/IMB) has been supporting delivery of NCD services at Ministry of Health facilities. Here we describe the model implemented and baseline characteristics of patients served. Methods: Comprehensive NCD services are provided by nurses to patients with an array of complex conditions including heart failure, chronic cancer pain, hypertension, diabetes, and chronic respiratory diseases on disease-specific clinic days. Nurses receive training and longitudinal mentorship from specialist physicians and use reference-standardised diagnosis and treatment protocols. Point-of-care diagnostics are used, such as haemoglobin A1c for patients with diabetes and coagulation testing for patients on warfarin after cardiac valve surgery. Nurses are also able to perform simplified echocardiography to inform initial management of heart failure. Group education sessions and socioeconomic supports are also offered to patients. District hospital nurses serve as mentors for health centre nurses. Community health workers provide support to high-risk patients. Clinical information is documented in structured forms that are compiled in individual patient charts, and entered in an electronic medical records system. These programmes are integrated within MOH facilities and most clinicians are MOH employees. Findings: At Sept 30, 2014, three district hospitals and seven health centres have implemented PIH/IMB-supported NCD programmes. 3367 patients have been enrolled, of whom 67% are female (mean age 48·1 years [SD 19·8]). Disease categories, in descending order of predominance, are: hypertension (30%), chronic respiratory disease (26%), heart failure (26%), and diabetes (16%). A small proportion (2·5%) of patients are HIV positive and 1% have more than one NCD diagnosis. More than 80% (3014) of patients live in rural districts, and of these more than 60% of those with documented occupation (683 out of total documented 1112) are subsistence farmers. Interpretation: An integrated, nurse-led NCD care model has been effectively implemented in Rwanda, providing comprehensive longitudinal care embedded within the public health system in a rural resource-constrained setting. That so many patients have been treated highlights the NCD needs in rural poor populations. Positive outcomes have been described previously for heart failure, and outcomes assessments for diabetes, post-cardiac surgery, and hypertension are underway. The experience from these facilities has contributed to ongoing scale-up of district level NCD services throughout Rwanda. Funding: Ministry of Health, Rwanda, Partners in Health /Inshuti Mu Buzima (PIH / IMB), Medtronic Foundation

Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

Background In sub-Saharan Africa, continued clinical follow-up, after cardiac surgery, is only available at urban referral centres. We implemented a decentralised, integrated care model to provide longitudinal care for patients with advanced rheumatic heart disease (RHD) at district hospitals in rural Rwanda before and after heart surgery. Methods We collected data from charts at non-communicable disease (NCD) clinics at three rural district hospitals in Rwanda to describe the outcomes of 54 patients with RHD who received cardiac valve surgery during 2007–2015. Results The majority of patients were adults (46/54; 85%), and 74% were females. The median age at the time of surgery was 22 years in adults and 11 years in children. Advanced symptoms—New York Heart Association class III or IV—were present in 83% before surgery and only 4% afterwards. The mitral valve was the most common valve requiring surgery. Valvular surgery consisted mostly of a single valve (56%) and double valve (41%). Patients were followed for a median of 3 years (range 0.2–7.9) during which 7.4% of them died; all deaths were patients who had undergone bioprosthetic valve replacement. For patients with mechanical valves, anticoagulation was checked at 96% of visits. There were no known bleeding or thrombotic events requiring hospitalisation. Conclusion Outcomes of postoperative patients with RHD tracked in rural Rwanda health facilities were generally good. With appropriate training and supervision, it is feasible to safely decentralise follow-up of patients with RHD to nurse-led specialised NCD clinics after cardiac surgery