Characteristics of women having first trimester termination of pregnancy in a district/regional hospital in KwaZulu-Natal.

Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.Introduction: Despite the availability of contraceptives, some women still seek an induced abortion. If these women are known, they can be targeted for intensive contraceptive counseling. An accessible termination of pregnancy health facility can also be provided to those who still wish to have an abortion. Aim: To determine the characteristics of women having first trimester induced termination of pregnancy in Newcastle Provincial Hospital in Amajuba district. Methods: Quantitative retrospective chart review. Seven hundred and fifty eight women had an induced first trimester abortion between 1st January and 31st December 2008 at Newcastle Provincial Hospital. The medical records of 254 were systematically sampled and the data obtained from these medical records were analyzed descriptively. Results: Most women (75%) were aged between 20 and 34 years. The commonest age was 23 years while the mean age was 25.27 years. Two percent were less than 16 years of age. Ninety seven percent of the sample were of African race, 75.6% reported having at least one child alive, 93.3% were single, 70.1% of the women reside in Newcastle sub-district while 19.7% reside outside Amajuba district. Eighty nine percent of the women were not using any contraception before the pregnancy that was terminated. Four (1.6%) women had previously had a termination of pregnancy. Fifty eight percent of the women requested abortion between 9 and 12 weeks of gestation (commonest gestational age was 8 weeks). Seventy four percent of the women were self-referred. Ninety six percent of the women reported having an abortion because of socio-econornic reasons. Only 69.7% disclosed their intention to procure abortion to a second person. Every woman was counseled before her pregnancy was terminated. Conclusions: In our patient population, women who are more likely to have an induced first trimester abortion are: in their twenties; African; single; parous; sexually active and not using any contraceptive; residing in Newcastle sub-district and of poor socioeconomic status. These groups of women should be targeted for intensive contraceptive counseling. The proportion of women who are less than 16 years of age shows that statutory rape is still a challenge in South Africa and deserves more attention. Further study is needed to establish if the location of Newcastle Provincial Hospital is denying women living in other sub-districts in Amajuba (apart from Newcastle sub-district) the opportunity to procure an induced abortion. Such a study will thus guide the place where future termination of pregnancy services may be established in Amajuba

The hazards of conducting induction of labour in high-risk pregnancies at district hospitals in low- and middle-income countries: lessons to learn from a case report

Background: Induction of labour (IOL) is an obstetric procedure that should be conducted in a healthcare facility with the capacity to provide optimal care based on the patient risk status. Inadequate monitoring, untimely procedure and lack of readily available and experienced medical staff to participate in the care of the patient undergoing induction are hazardous with snowball effects. Methods: A 38-year-old G4P2+1 had IOL because of oligohydramnios at term in a district hospital. The procedure was inadequately monitored and fetal demise occurred. The duration of second stage was prolonged and sequential use of vacuum and forceps deliveries were unsuccessfully performed. Results: At the ensuing caesarean delivery, uterine rupture/tear was diagnosed, and the patient died due to haemorrhage during an emergency hysterectomy. Conclusion: This report highlights important clinical lessons on IOL in a high-risk pregnancy. The timelines for monitoring during IOL, particularly when there is fetal demise in labour, are proposed

Ectopic pregnancy in the ampulla of the fallopian tube at 16 gestational weeks: lessons from a case report

Background: It is uncommon to find ampullary tubal pregnancy in the second trimester. Methods: A 35-year-old G4P3 at 16 gestational weeks presented with a day history of sudden severe lower abdominal pain and no vaginal bleeding. The patient had a normal pulse of 82/minutes, haemoglobin concentration of 6.3 g/dl and ultrasonography showed an empty uterus with an alive fetus in the right adnexa. She was provisionally diagnosed to have an abdominal pregnancy. Results: The patient had an emergency laparotomy where 2.2 L of haemoperitoneum and a slow-leaking right ampullary tubal pregnancy were found. Right total salpingectomy was performed and she had an uncomplicated post-operative follow-up. Histology of the lesion confirmed tubal pregnancy. Conclusion: The growth of a pregnancy in the ampulla beyond the first trimester is possibly due to increased thickness and or distensibility of the fallopian tube. A tubal pregnancy may present with a normal pulse despite significant haemorrhage

Pre-eclampsia with severe features: management of antihypertensive therapy in the postpartum period

Introduction: there is variance in both the types and combinations of antihypertensive drugs used for managing pre-eclampsia in the postpartum period. Knowledge of the most common and suitable single or combination antihypertensive drug therapies in the postpartum period will minimize harmful effects, promote adherence to medications, overcome any fears that lactating mothers may have about these drugs and will assist in healthcare planning. Objective: to determine the types of antihypertensive drug therapies used in managing pre-eclampsia with severe features (sPE) in the postpartum period in a regional hospital in South Africa. Methods: fifty consecutively presenting pregnant women with sPE were followed up prospectively from the pre-delivery period (within 48 hours before delivery) until day 3 postpartum. The antihypertensive drug therapies administered to the participants were observed. Their blood pressures were measured daily at 04:00, 08:00, 14:00 and 22:00 hours. Results: nifedipine was the commonest rapid-acting agent used for severe hypertension. Prepartum, 9 different combinations of antihypertensive drugs were prescribed; alpha-methyldopa was the commonest single long-acting agent used. Postpartum, the number of different drug combinations administered were 15, 18, 22 and 16 on days 0, 1, 2 and 3 respectively. Alpha-methyldopa was the commonest single agent used on postpartum days 0 - 2 while hydrochlorothiazide was the most frequently used single agent on postpartum day 3. Postpartum, the commonest combination therapy was alpha-methyldopa and amlodipine on day 0; alpha-methyldopa and amlodipine as a regimen as well as alpha-methyldopa, amlodipine and hydrochlorothiazide as another regimen on day 1; alpha-methyldopa and amlodipine on day 2; and many amlodipine-based regimens on day 3. Conclusion: a variety of antihypertensive drug combinations were used in the postpartum period indicating the need for standardised guidelines; however, detailed studies are required to evaluate their efficacies completely

Atypical preeclampsia-eclampsia syndrome at 18 weeks of gestation: A case report

Background: Preeclampsia is currently defined as new-onset hypertension occurring with significant proteinuria, maternal organ dysfunction, and/or placental insufficiency at or after 20 weeks of gestation. In the majority of cases, it occurs before 48 h postpartum. Therefore, preeclampsia occurring before 20 weeks of gestation or after 48 h postpartum is atypical and may not be easily diagnosed. Aim: A case of atypical preeclampsia is presented to highlight the need for increased vigilance by healthcare professionals to ensure timely diagnosis and treatment to prevent adverse outcomes. Case Presentation: A 29-year-old woman, gravida 3, para 1, with one previous miscarriage, commenced antenatal care at 10 weeks of gestation. Based on history and physical examination, the only risk factor for preeclampsia identified was a primipaternity. The patient had a single mid-trimester scan but no robust multimodal screening for preeclampsia using ultrasound or biomarkers. At 18 weeks of gestation, she presented to a primary healthcare clinic with headache, epigastric pain, and a documented single blood pressure reading of 169/71 mmHg. She was placed on alpha-methyldopa and managed as an outpatient. A day later, she had two episodes of seizures and was transferred to a tertiary hospital. She was diagnosed with atypical eclampsia and HELLP syndrome. Following MgSO4 therapy and stabilization, an uneventful termination of pregnancy was performed, and she recovered fully. Conclusion: Robust screening for preeclampsia using history and physical examination, ultrasonography, and biomarkers in the first trimester to identify women at high risk of the disease for prophylactic therapy with aspirin may prevent this disorder

The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy.

BackgroundThe imbalance between circulating concentrations of anti- and pro-angiogenic factors is usually intense in preeclampsia with severe features (sPE). It is possible that pre-delivery circulating levels of angiogenic factors in sPE may be associated with postpartum antihypertensive drug requirements.ObjectiveTo determine the predictive association between maternal pre-delivery serum concentrations of angiogenic factors and the use of ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in sPE on postpartum days zero to three following caesarean delivery.Study designWomen with sPE (n = 50) and normotensive pregnancies (n = 90) were recruited prior to childbirth. Serum samples were obtained from each participant ResultsThe majority 58% (29/50) of sPE had multiple severe features of preeclampsia in the antenatal period with the commonest presentation being severe hypertension in 88% (44/50) of this group, followed by features of impending eclampsia which occurred in 42% (21/50). The median gestational age at delivery was 38 (Interquartile range, IQR 1) vs 36 (IQR 6) weeks, p ConclusionA pre-delivery sFlt-1/PIGF ratio (< 181.5) is a promising predictor for excluding the need for ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in the immediate postpartum period in sPE