Maternal mortality related to postpartum hemorrhage: a case-control study at the Befelatanana maternity of Madagascar

Background: Postpartum hemorrhage (PPH) remains the main cause of maternal death throughout the world. present goal was to determine the associated factors to maternal death in postpartum hemorrhage.Methods: This was a retrospective case-control study; carried out within Befelatanana maternity, in Antananarivo, from January 1st, 2013 to December 31st, 2015, on parturients who presented PPH. The cases were represented by the parturients who died despite well-managed care, and the control, by the living parturients.Results: Authors recorded 181 cases of PPH from 20,888 deliveries, with a prevalence of 0.86%; 47 of them died and 134 were alive; the mortality rate by PPH is 25.96%. Factors associated with death were low education (p=0.00 OR:3.2), non-working (p=0.01, OR:2.4), multiparity ( p:2.2 OR:0.01), absence of prenatal care (p:0.01 OR:2.2), cesarean section (p:0.00 OR:5.5); Intrauterine Fetal Death (p= 0.02, OR:2.2); uterine atony (p=0.03, OR 2.1); the state of shock (p=0.00 OR:57.8), sanitary evacuation (p=0.01 OR: 2.4), the need for blood transfusion (p=0.00 OR: 3, 7), use of catecholamines (p=0.00, OR:17.5); delayed management (p=0.01, OR:2.2), hemostasis hysterectomy (p=0.00 OR: 8.67).Conclusions: The decrease of maternal mortality related to PPH requires better monitoring of pregnancy, delivery and postpartum. Speed care management, improvement of technical platform and establishment of a powerful health system are also needed. Thus, the global reduction of poverty is indispensable

Ectopic pregnancy at Soavinandriana hospital center, Antananarivo, Madagascar

Background: In the first trimester pregnancy, ectopic pregnancy is the most life-threatening gynecological emergency. The aim of this study was to estimate the epidemiological, diagnostic and therapeutic aspects of ectopic pregnancy in Antananarivo, Soavinandriana Hospital Center.Methods: This was a prospective study carried out among consecutive patients of ectopic pregnancy admitted from January 2014 to February 2016. All cases of diagnosed ectopic pregnancy admitted and managed in the gynecological ward were included in the study. These were reviewed and information was extracted regarding women characteristics, clinical features, diagnosis, management and post-operative complications.Results: During this period, there were 41 ectopic pregnancies. The incidence was therefore 20/1000 births. The mean age was 32,26years. The peak age of incidence was the 30-39 years age group. Nulliparous were the most sufferers. The commonest risk factors identified were previous genital infection. (n=17; 41,46%) previous induced abortions (n=15; 36,58%) and the age ≥35 years old (n =16; 39,02%). Twenty seven patients (n=11) did not have a quantitative measurement of the β subunit of human chorionic gonadotropin (β-hCG). Pelvic ultrasound (transabdominal) was performed on all patients. The majority of patients had a laparotomy (n=35, 85,36%). Tubal pregnancies were noted in 90% (n=37) cases.Conclusions: Health educations on early presentation in hospitals are expected to reduce the incidence of EP and the consequent loss of reproductive potential. The majority of risk factors we identified can be early detected and treated

The women knowledge, attitude, and perceptions of pre-eclampsia and eclampsia in Madagascar

Background: Preeclampsia is a complication of pregnancy responsible for high rates of morbidity and mortality, particularly in Africa and Madagascar. The objective of present study was to assess patients' knowledge, attitudes and beliefs about pre-eclampsia in Madagascar.Methods: This is an observational study on the knowledge, belief and attitudes of women seen at the Befelatanana Gynecology and Obstetrics Hospital and conducted by questionnaires from 1 December 2017 to 30 May 2018.Results: During the study period, 102 patients agreed to answer our questionnaire. Terminology exists in the local language to describe convulsions and hypertension, but there were no terms that are specific to pregnancy. More than half of our patients knew preeclampsia. In 41% of cases, patients attributed excessive salt intake as a cause of high blood pressure during pregnancy and in 20% secondary to stress. Headache was the best-known symptom of patients. Signs of danger such as epigastric pain, genital bleeding, visual disturbances, convulsions and decreased sensation of fetal movements are not well known to patients. One-third did not know it was lethal. Regarding fetal complications, the occurrence of fetal death in utero was the best known. The majority of patients were aware that blood pressure measurements and urine dipstick testing were mandatory during pregnancy follow-up. To prevent preeclampsia, 46.07% thought that reducing salt intake would reduce the occurrence of preeclampsia.Conclusions: Few patients are aware of preeclampsia, its danger signs and its complications, especially during prenatal consultation. This requires the improvement of knowledge of all health actor. Community health workers should receive basic and ongoing training to facilitate dialogue and information for pregnant and non-pregnant women in each society

Uterine malformations and pregnancy: about 11 cases seen university hospital center of gynecology- obstetric Befelatanana Antananarivo Madagascar

Birth defects in the uterus result from abnormal fusion of the miler ducts and / or failure. Uterine malformations are a common cause of infertility, but if pregnancy occurs absorption from the septum. They are relatively frequent and concern 0.1-3% of the female population, such a situation is potentially high risk obstetric. We report here, 11 cases of uterine malformations during pregnancy seen at the CHUGOB from May 01, 2017 to May 01, 2018. We observed 11 cases of uterine malformations during pregnancy, including 3 cases of didelphus uterus, 3 cases of pseudo-unicornuate uterus, 3 cases of bicornuate uterus, 1 case of septate uterus and 1 case of true unicornuate uterus. The age of the parturients ranged from 22 to 26 with a mean of 23.63 years. Regarding pregnancy, 5 women were primigest, 4 were paucigest and 2 were multiparous. For gestational age, 09 cases came to term and 2 cases pregnancy stopped at 17 weeks. The average birth weight was 2215g. The diagnosis of the malformation was made before the caesarean section in 2 out of 10 cases. Eight out of 10 cases of the fetuses were alive. Congenital uterine malformations are often asymptomatic. The occurrence of pregnancy in a malformed uterus is a rare but potentially serious situation. The diagnosis of these abnormalities is based on new advanced imaging means such as 3D ultrasound

Infected delayed puerperal hematoma complicated by retention of urine: a case report and literature review

The puerperal hematoma corresponds to a tissue cleavage, most often paravaginal or vulvar, in which the vascular wounds, linked to the detachment, have no spontaneous tendency to haemostasis. The aggravation of this pathology is progressive. Diagnosis and management must be an obstetric emergency. Author report a case of infected puerperal hematoma complicated by rectal compression and acute retention of urine. This is a 26-year-old patient with a history of chronic hypertension. Labor was induced by misoprostol. The delivery was uneventful at 37 weeks vaginally. Ten days after delivery, she returned to the obstetrical emergency service for acute urine retention. The examination with the vaginal speculum showed a tumefaction of six centimeters on the left lateral side of the vagina. Surgical treatment has been performed. The suite was without particularity. The diagnosis of puerperal hematoma must be early. Even for the delayed form, the complications are identical. Blood loss, compression of proximity organs and infection are the most common complications. The care must be multidisciplinary. Resuscitation of the patient associated with haemostasis of the vessel is the main treatment in cases of large hematoma with hemodynamic instability

Spontaneous pregnancy at term with uterus didelphys: a case report

The uterus didelphys results from the absence of fusion of the bilateral mullerian ducts. It is a rare pathology. This malformation concerns 5% of uterine malformations from mullerian ducts and affects one woman in 1,000-30,000. Obstetrical complications of this malformation are numerous. The chance of reaching term for pregnancies with didelphys uterus is reported as 20%–30%. Authors report a case of spontaneous term pregnancy in a 21-year-old primiparous woman with a didelphic uterus. The patient had an unexplained seizure with fetal bradycardia. An emergency cesarean section was performed and allowed the birth of a hypotropic neonate of 2240g and the discovery of didelphic uterus. Pregnancy developed in the left hemi-uterus. Speculum examination at the end of the procedure showed a longitudinal vaginal septum. There was no associated urinary tract and renal malformation. Scheduled cesarean will be performed from her next pregnancy. The uterus didelphys should be diagnosed early. MRI and 3D echography are necessary for diagnosis. Pregnancy is often complicated, and follow-up needs to be planned. Cesarean section is not systematic

Obstetrical and neonatal prognosis of a teenage primiparous pregnancy at the Zafisaona Gabriel Majunga university hospital center

Background: Women's fertility is early and high in Madagascar. Through this study, want to know the obstetric and neonatal risks in teenage primiparous pregnancies.Methods: Carried out a retrospective comparative study of teenage primiparous pregnancies who gave birth beyond 22 weeks of amenorrhea (SA) at the Zafisaona Gabriel Mahajanga university hospital between the period from January 1 to March 31, 2015. The control group is made up of first-time mothers aged 20 to 35 who gave birth in the same center.Results: The mean age of the patients was 16.77±1.12 years. In 43.1% of cases, the pregnancy was poorly followed. 22.41% of new-borns to adolescent mothers were hypotrophic at birth. Teenage primiparous pregnancies had a risk of poor pregnancy monitoring compared to their elders (RR: 2.17, 95% CI [1.35-3.47]) and a risk of giving birth to a low birth weight child (RR: 2.1, 95% CI [1.05-4.44]). The risk of preeclampsia, death in utero, caesarean section, instrumental extraction was identical between the two groups. Regarding the outcome of newborns, the frequency of premature birth, early neonatal infection, neonatal asphyxia, early neonatal death was not significant.Conclusions: Apart from fetal hypotrophy, adolescent girls have the same maternal, fetal and neonatal prognosis as their elders

Retained plastic instrument after 5 years of illegal abortion: a case report and literature review

The retained of a foreign body during a surgical procedure is defined by the forgetting of a material, left by inattention in the body of the patient during this act. It is a rare event but is responsible for high morbidity and mortality. Authors report a retained foreign body incidentally discovered during a caesarean section. The patient had performed an illegal abortion by endo-uterine instrument which was complicated by uterine perforation five years previously. She was pregnant at 37 weeks and presented to the emergency department for bleeding and diagnosed as placenta previa. The antecedent of abortion had not been informed because it is an illegal act in Madagascar. The plastic instrument was in the broad ligament in contact with the ureter and the uterine artery. Caesarean section, the removal of the catheter and postoperative recovery was uneventful. Foreign body retention remains a malpractice and the diagnosis must be made in the face of chronic pain in patients who have undergone surgery

Emergency peripartum hysterectomy in a tertiary hospital in Antananarivo, Madagascar

Background: Postpartum hemorrhage is one of the leading causes of maternal death in the entire world. It affects 10% of deliveries. Emergency peripartum hysterectomy (EPH)defined as a lifesaving procedure involving the removal of the uterus to treat severe postpartum hemorrhage is one of the last-resort treatments for severe postpartum hemorrhage in case of failure of other techniques. Through this study, we aimed both to describe the epidemiological profile, to determine the etiologies, and maternal complications of EPH.Methods: It is about a descriptive retrospective study from January 1st, 2016 to January 1st, 2017 at the Befelatanana University Hospital of Obstetrics and Gynecology. We included all patients who underwent Emergency peripartum hysterectomy after 22 weeks of Amenorrhea (WA) regardless of the delivery route in the centre. We used the R software for the statistical analysis of the results.Results: We had 31 cases of EPH during this period with a prevalence of 0.44%. The average age was 26.38±5.61 years. Mean gestational age was 37±3.59 weeks of amenorrhea. In the 83.87% of cases, the patient received less than four prenatal consultations. Patients were referred in 45.16% of the cases. The delivery route was by cesarean section in 48.39% of cases. Eleven patients (35.48%) received a blood transfusion. Hysterectomy was subtotal in 96.77% of the cases. We had five (16.13%) maternal deaths during the study period. The leading cause of death was hemorrhagic shock (80%). The etiology of hysterectomy was dominated by uterine atony complicated by hemorrhage (48.39%), followed by retroplacental hematoma (25.81%) and uterine rupture (22.58%).Conclusions: EPH still holds its place in the management of postpartum hemorrhage in Madagascar. Maternal mortality remains high. Uterine atony was the most common indication for EPH. The prevention of postpartum hemorrhage by management of the third stage of labour should be carried out by any health actor

Uterine atony risk factor after vaginal delivery in a tertiary hospital in Antananarivo, Madagascar

Background: Postpartum hemorrhage is the leading cause of maternal death in developing countries. Uterine atony is the cause in 80% of cases. Through this study, we want to determine risk factors for uterine atony after vaginal delivery route with oxytocin-mediated delivery.Methods: This is a retrospective case-control study ranging from January 1st 2017 to June 31st 2018 at the Befelatanana University Hospital Centre of Gynecology-Obstetrics. The cases consisted of patients who had spontaneous vaginal delivery in the centre and had uterine atony. Authors studied maternal, obstetrical, neonatal parameters. Authors used the R software for the statistical analysis of the results.Results: We found 40 cases of uterine atony out of 5421 deliveries with a prevalence of 0,73%. The average age was 27.73 years old±6.46 years old (p=0.113). The average parity was 2.67±1.62 (p=0.22). The total duration of labor was 6.88±2.95 hours (p=0.0187). The average duration of rupture of the membrane was 5.80±11.90 hours (0.003376). We found as risk factor of uterine atony the increase in oxytocin infusion rate during labor (OR=18.67, 95% CI 2.21-157.57), the artificial rupture of membranes (OR=5, 27, 95% CI 2.11-13.19), artificial induction of labor (OR=7.08, 95% CI 2.06-24.28) and labor over six hours (OR=2.53, 95% CI) % 1.18-5.47). In univariate analysis, premature delivery and a hypotrophic fetus were a factor risk of uterine atony (OR=3.07, 95% CI 1.27-7.44 and OR=3.43 95% CI 1.48-8.09 respectively) but this risk is not statistically significant in multivariate analysis with logistic regression (OR=1.27, 95% CI 0.40-3.84 and OR=2.19 95% CI 0.77-6.22). The main treatment was uterotonic drug use (72.5%). Authors identified seven cases of haemostasis hysterectomy and two cases of maternal death.Conclusions: Present study confirms risk factors for uterine atony already known as prolonged labor and increased oxytocic infusion rate. Unrecognized factors have been identified as a risk factor for uterine atony such as the duration of rupture of the membranes and artificial rupture of the membranes. A minimal inflammation hypothesis that reduces susceptibility to oxytocin may explain this association. Knowing these factors would reduce the occurrence of uterine atony to reduce maternal mortality