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

A case of recto-vaginal obstetrical fistula treated by the Martius lamp, seen at Befelatanana Madagascar

The rectovaginal fistulas are a pathological epithelialized communication between the vagina and the rectum, its frequency is 10 to 30%, and it is a disabling pathology because of the social repercussion. Many flap techniques have been described but the aim is to present a simple procedure according to a particular technique called Martius. This is a case of woman presenting a low rectovaginal fistula on obstetrical trauma. The surgical technique consists of a repair according to the technique of Martius. The operative follow-up was simple and the patient was able to resume sexual activity and normal anal sphincter function. It is a simple technique, easy to achieve for the technical platform in Madagascar whose evaluation of the results for a larger population should be considered. This technique therefore deserves to be known and widely used

Recurrent ipsilateral ectopic pregnancy after partial salpingectomy: case-report

Ectopic pregnancy is a life-threatening condition occurring in 1-2% of all pregnancies. The most common site of implantation for an ectopic pregnancy is the fallopian tube. Authors report a case of recurrent ipsilateral ectopic pregnancy following right partial salpingectomy of a 29-Year-Old woman that led to tubal rupture. The pregnancy was conceived spontaneously. Diagnostic of ruptured ectopic pregnancy was done after clinical and ultrasonography examination. The presence of a massive hemoperitoneum with a positive pregnancy urinary test that lead us to the diagnosis of ectopic pregnancy. She underwent a laparotomy for a suspicion of ruptured ectopic pregnancy. The ectopic pregnancy was identified in the left remnant fallopian tube. Partial salpingectomy, removal of tubal stump, and resection of the uterine cornua, was performed. The postoperative recovery was uneventful. She has stayed for five days at the Hospital. All patients, even though they have already received a definitive contraception by tubal section and ligature or unilateral or by bilateral salpingectomy for any reason, must seek an ectopic pregnancy in case of pelvic pain, vaginal bleeding and/ or amenorrhea. Authors propose to carry a total salpingectomy after a chosen surgical treatment

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

Heterotopic in spontaneous ruptured pregnancy with a living birth term: a case report in Madagascar

Heterotopic pregnancy is defined as the coexistence of an intrauterine pregnancy (UGI) and an ectopic pregnancy (EUS), regardless of its location. It is a rare pathology. Here, we report the case of a 29-year-old patient who had a heterotopic in spontaneous pregnancy complicated by hemoperitoneum at 7 weeks of amenorrhea. A laparotomy with salpingectomy was performed. The result was favourable with a live birth with 37 SA of the GIU. A heterotopic pregnancy must always be eliminated in the presence of acute pelvic pain in the pregnant woman. Laparotomy is a therapeutic alternative if laparoscopy is not available

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

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

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

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

Place of the misoprostol in 600 µg in intrarectale in case of hemorrhage of the post partum by uterine atony at the Befelatanana University Hospital Centre of Obstetric Gynecology in Antananarivo, Madagascar

Background: The hemorrhage of the post-partum (HPP) represents a major problem of public health because it hires the vital and obstetrical forecast of the mother in case of delay of taking care. Present study aims at assessing the effectiveness of the administration of 03 tablets of misoprostol in intra-rectal in the taking care of HPP by uterine atony and to determine the épidémio-clinical profile of HPP by atony.Methods: Authors performed a retrospective and descriptive study concerning the effectiveness of the misoprostol in the taking care of HPP by uterine atony. This study started from December 1st, 2016 till March 31st, 2017. The data processing was performed by Epi info 7 and Excel.Results: The rate of HPP represented 3.8% deliveries which 69.4% was due to uterine atony. HPP by uterine atony represented 2.60% deliveries. It happened at the women from 25 to 34 years old (46.16%), pauciparous (76.93%), with a lower working time at 8 hours (71.15%) and having performed at least 4 CPN (63.47%), giving of urgent babies with a medium weight of 3073.43 g. The administration of the misoprostol was efficient in 90.40% and we noticed no side effect or of serious complications during the taking care of HPP by uterine atony.Conclusions: HPP remains another major preoccupation of the obstetricians in our country because it is an emergency that can put into play the vital forecast and which requires a catch in quick load. The administration of 03 tablets (600 µg) of misoprostol in intra-rectal during HPP by uterine atony deserves its place in the armory of taking care because it is a sure method, efficient and easy to manipulate