Emergency peripartum hysterectomies at Muhimbili National Hospital, Tanzania: Review of cases from 2003 to 2007

A retrospective review of all cases of emergency peripartum hysterectomy performed between January 1, 2003 and December 31, 2007 at Muhimbili National Hospital was done to determine the incidence, indications and complications, background characteristics, antenatal care attendance, referral status, and maternal and foetal outcomes. There were 55,152 deliveries during the study period and 165 cases of emergency peripartum hysterectomy, giving the incidence of emergency peripartum hysterectomy of 3 per 1000 deliveries. The main indication was uterine rupture (79%) followed by severe post-partum haemorrhage due to uterine atony (12.7%). The case fatality rate was 10.3% where as perinatal mortality rate was 7.7 per 1000 deliveries. The common complication identified intraoperatively was severe haemorrhage which accounted for 39.4% where as intensive care unit admissions (14.4%) and febrile morbidity (12.4%) were common after the operation. Blood was ordered in all cases but in 31 cases it was indicated that it was not available. Seventy nine patients received blood transfusion with the maximum number of units given to one patient being eight. Twenty two patients were given fresh frozen plasma (FFP), the median number of units given was two (range = 1– 6). In conclusion, emergency peripartum hysterectomy is a life saving procedure and very common at MNH. The most common indication was ruptured uterus followed by severe postpartum haemorrhage. More than half of the patients underwent emergency peripartum hysterectomy were referred from other health facilities with ruptured or suspected ruptured uterus. The procedure was associated with unacceptably high maternal and perinatal morbidity and mortality

Intermittent fetal heart rate monitoring using a fetoscope or hand held Doppler in rural Tanzania: a randomized controlled trial

Background: Neonatal mortality is a global challenge, with an estimated 1.3 million intrapartum stillbirths in 2015. The majority of these were found in low resource settings with limited options to intrapartum fetal heart monitoring devices. This trial compared frequency of abnormal fetal heart rate (FHR) detection and adverse perinatal outcomes (i.e. fresh stillbirths, 24-h neonatal deaths, admission to neonatal care unit) among women intermittently assessed by Doppler or fetoscope in a rural low-resource setting. Methods: This was an open-label randomized controlled trial conducted at Haydom Lutheran Hospital from March 2013 through August 2015. Inclusion criteria were; women in labor, singleton, cephalic presentation, normal FHR on admission (120–160 beats/minute), and cervical dilatation ≤7 cm. Verbal consent was obtained. Results: A total of 2684 women were recruited, 1309 in the Doppler and 1375 in the fetoscope arms, respectively. Abnormal FHR was detected in 55 (4.2%) vs 42 (3.1%). (RR = 1.38; 95%CI: 0.93, 2.04) in the Doppler and fetoscope arms, respectively. Bag mask ventilation was performed in 80 (6.1%) vs 82 (6.0%). (RR = 1.03; 95%CI: 0.76, 1.38) of neonates, and adverse perinatal outcome was comparable 32(2.4%) vs 35(2.5%). (RR = 0.9; 95%CI: 0.59, 1.54), in the Doppler and fetoscope arms, respectively. Conclusion: This trial failed to demonstrate a statistically significant difference in the detection of abnormal FHR between intermittently used Doppler and fetoscope and adverse perinatal outcomes. However, FHR measurements were not performed as often as recommended by international guidelines. Conducting a randomized controlled study in rural settings with limited resources is associated with major challenge

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider’s perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. Trial registration: Registered clinical trial at www.clinicaltrials.gov (NCT01409824). Registered May 2009

Intramuscular Artesunate for Severe Malaria in African Children: A Multicenter Randomized Controlled Trial.

BACKGROUND: Current artesunate (ARS) regimens for severe malaria are complex. Once daily intramuscular (i.m.) injection for 3 d would be simpler and more appropriate for remote health facilities than the current WHO-recommended regimen of five intravenous (i.v.) or i.m. injections over 4 d. We compared both a three-dose i.m. and a three-dose i.v. parenteral ARS regimen with the standard five-dose regimen using a non-inferiority design (with non-inferiority margins of 10%). METHODS AND FINDINGS: This randomized controlled trial included children (0.5-10 y) with severe malaria at seven sites in five African countries to assess whether the efficacy of simplified three-dose regimens is non-inferior to a five-dose regimen. We randomly allocated 1,047 children to receive a total dose of 12 mg/kg ARS as either a control regimen of five i.m. injections of 2.4 mg/kg (at 0, 12, 24, 48, and 72 h) (n = 348) or three injections of 4 mg/kg (at 0, 24, and 48 h) either i.m. (n = 348) or i.v. (n = 351), both of which were the intervention arms. The primary endpoint was the proportion of children with ≥ 99% reduction in parasitemia at 24 h from admission values, measured by microscopists who were blinded to the group allocations. Primary analysis was performed on the per-protocol population, which was 96% of the intention-to-treat population. Secondary analyses included an analysis of host and parasite genotypes as risks for prolongation of parasite clearance kinetics, measured every 6 h, and a Kaplan-Meier analysis to compare parasite clearance kinetics between treatment groups. A post hoc analysis was performed for delayed anemia, defined as hemoglobin ≤ 7 g/dl 7 d or more after admission. The per-protocol population was 1,002 children (five-dose i.m.: n = 331; three-dose i.m.: n = 338; three-dose i.v.: n = 333); 139 participants were lost to follow-up. In the three-dose i.m. arm, 265/338 (78%) children had a ≥ 99% reduction in parasitemia at 24 h compared to 263/331 (79%) receiving the five-dose i.m. regimen, showing non-inferiority of the simplified three-dose regimen to the conventional five-dose regimen (95% CI -7, 5; p = 0.02). In the three-dose i.v. arm, 246/333 (74%) children had ≥ 99% reduction in parasitemia at 24 h; hence, non-inferiority of this regimen to the five-dose control regimen was not shown (95% CI -12, 1; p = 0.24). Delayed parasite clearance was associated with the N86YPfmdr1 genotype. In a post hoc analysis, 192/885 (22%) children developed delayed anemia, an adverse event associated with increased leukocyte counts. There was no observed difference in delayed anemia between treatment arms. A potential limitation of the study is its open-label design, although the primary outcome measures were assessed in a blinded manner. CONCLUSIONS: A simplified three-dose i.m. regimen for severe malaria in African children is non-inferior to the more complex WHO-recommended regimen. Parenteral ARS is associated with a risk of delayed anemia in African children. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201102000277177

Accuracy in diagnosis of postpartum haemorrhage using visual estimation of blood loss versus change in haematocrit in a tertiary teaching hospital in Tanzania

Postpartum haemorrhage is the leading cause of maternal death in the developing country and yet is poorly diagnosed due to inaccurate measurement of blood loss following delivery. A study was carried out at Muhimbili National Hospital (MNH) Tanzania between October 2005 and January 2006 to determine the accuracy of visual estimation of blood loss (VEBL) in comparison to laboratory measurement of blood loss in diagnosis of primary postpartum haemorrhage (PPH). A total of 426 pregnant women who were in active phase of labour were recruited and their venous blood was drawn for estimation of haematocrit before delivery and 12 hours thereafter. Active management of third stage of labour was conducted by giving 10IU of oxytocin (intramuscularly or intravenously) and this was followed by visual estimation of blood loss. The proportion of patients who developed PPH was then determined by both methods. The mean duration of third stage of labour was 8.3 minutes and mean blood loss was 164.9ml. The prevalence of PPH was 8.9% and 16.2% by VEBL and changes in haematocrit, respectively. Change in haematocrit in diagnosis of PPH was found to be more accurate, specific with high positive predictive values compared to VEBL. The need for additional uterotonics was 5.8% and the commonest labour complications associated with PPH were second degree tear, retained placenta and EUA for continued bleeding. In conclusion, VEBL using calibrated vessel will increase accuracy where conventional method using non calibrated method is used for diagnosis of PPH. Service providers working in labour wards need to be trained on how to estimate blood loss using simulated methods so as to increase their long term memory and accuracy in diagnosis of post-partum haemorrhage, hence provision of immediate intervention

Large neurofibroma of the labia majora: A case report

Neurofibromatosis is an autosomal dominant progressive disorder with an incidence of approximately 1in 3000 live births. Its recognized features include hyper-pigmented skin lesions (cafe-au-lait spots), neurofibromas, iris hamartomas, macrocephaly, central nervous system tumors, defects of the skull and facial bones, and vascularlesions. Involvement of the external genitalia is extremelyunusual. This report describes a case of a vulva neurofibroma in a 15-years old teenage girl with no history of trauma or features of Von Recklinghausen’s disease. Treatment involved total excision of the tumor under spinal anesthesia. The diagnosis of neurofibroma was confirmed by histological examination which showed spindle shaped cells with wavy nuclei arranged in a loose myxomatous stroma. No further treatment was offered but thepatient was counseled on the possibility of recurrence. She was seen one month after excision and there were no signs of recurrence

Emergency peripartum hysterectomies at Muhimbili National Hospital, Tanzania: a review of cases from 2003 to 2007

A retrospective review of all cases of emergency peripartum hysterectomy performed between January 1, 2003 and December 31, 2007 at Muhimbili National Hospital was done to determine the incidence, indications and complications, background characteristics, antenatal care attendance, referral status, and maternal and foetal outcomes. There were 55,152 deliveries during the study period and 165 cases of emergency peripartum hysterectomy, giving the incidence of emergency peripartum hysterectomy of 3 per 1000 deliveries. The main indication was uterine rupture (79%) followed by severe post-partum haemorrhage due to uterine atony (12.7%). The case fatality rate was 10.3% where as perinatal mortality rate was 7.7 per 1000 deliveries. The common complication identified intraoperatively was severe haemorrhage which accounted for 39.4% where as intensive care unit admissions (14.4%) and febrile morbidity (12.4%) were common after the operation. Blood was ordered in all cases but in 31 cases it was indicated that it was not available. Seventy nine patients received blood transfusion with the maximum number of units given to one patient being eight. Twenty two patients were given fresh frozen plasma (FFP), the median number of units given was two (range = 1– 6). In conclusion, emergency peripartum hysterectomy is a life saving procedure and very common at MNH. The most common indication was ruptured uterus followed by severe postpartum haemorrhage. More than half of the patients underwent emergency peripartum hysterectomy were referred from other health facilities with ruptured or suspected ruptured uterus. The procedure was associated with unacceptably high maternal and perinatal morbidity and mortality

Large neurofibroma of the labia majora: A case report

Neurofibromatosis is an autosomal dominant progressive disorder with an incidence of approximately 1 in 3000 live births. Its recognized features include hyper-pigmented skin lesions (cafe-au-lait spots), neurofibromas, iris hamartomas, macrocephaly, central nervous system tumours, defects of the skull and facial bones, and vascular lesions. Involvement of the external genitalia is extremely unusual. This report describes a case of a vulva neurofibroma in a 15-years old teenage girl with no history of trauma or features of Von Recklinghausen’s disease. Treatment involved total excision of the tumour under spinal anaesthesia. The diagnosis of neurofibroma was confirmed by histological examination which showed spindle shaped cells with wavy nuclei arranged in a loose myxomatous stroma. No further treatment was offered but the patient was counselled on the possibility of recurrence. She was seen one month after excision and there were no signs of recurrence

Indications for Caesarean Section for women of low obstetric risk - an audit

Introduction: The Caesarean Section (CS) rate is dramatically increasing across obstetric populations. This study aimed to determine the adherence to criteria for standard diagnosis of the common indications for CS among women of a low-risk group. This group, known as group 3 in the Robson classification, is multiparous, term with singleton pregnancy and have not had a previous CS. Methods: We conducted a cross-sectional study at Muhimbili National Hospital from August to December 2018. The criteria for standard diagnosis of foetal distress, obstructed labour, arrested labour and cephalopelvic disproportion were adopted from peer groups publications based on local expert consensus. Data were analysed using a statistical package for social sciences (SPSS) version 20. Results: A total of 1,670 emergency CS’s were performed during the study period, 392 (23.5%) were women of Robson group 3, of these women 101 (25.8%) had foetal distress, 92 (23.5%) obstructed labour, 88 (22.4%) arrested labour and 64 (16.4%) cephalopelvic disproportion. The proportion of CS’s which met the criteria for standard diagnosis of indications for CS were 61.4% foetal distress, 52.2% obstructed labour, 58% arrested labour, and 45.3% CPD with total average of 55.1%. Conclusion: Generally, the standard criteria for audited indications of CS have been met by 55.1% during the study period. Thus, follow up, on the job training and updating about adherence to standard criteria for best practice are recommended

Quality of life and associated factors among infertile women attending infertility clinic at Mnazi Mmoja Hospital, Zanzibar

Abstract Background Worldwide, it is estimated at least 50 million couples are affected by infertility with the prevalence of infertility being 16% in Tanzania. Psychological impact of infertility in patients negatively affects women’s Quality of Life (QoL) defined as a person`s perception of where they are in life in terms of culture and value in the emotional, mind-body, relational, social, environment and tolerability of treatment aspects. Poor Quality of Life is related to increased treatment discontinuation. The aim of this study was to determine the Quality of Life and associated factors among infertile women attending infertility clinic at Mnazi Mmoja Hospital, Zanzibar. Methods A hospital based cross–sectional study was conducted among 340 infertile women attending infertility clinic at Mnazi Mmoja Hospital, Zanzibar. Data was collected using FertiQoL tool. The factors associated with Quality of Life using FertiQoL tool in infertile women were estimated in a multivariable linear regression model at 95% confidence interval and 5% level of significance. Results Quality of life of infertile women at Mnazi Mmoja infertility clinic was 70.6 ± 10.0 on a scale of 0 to 100. It increased significantly with increase in educational level (p = 0.009). Women with female individual causes on average had 5.07 (B=- 5.07, 95%CI: -7.78, -2.35) and women with individual and respective male partner causes of infertility had on average 4.95 (B= -4.95, 95% CI: -7.77, -2.12) respective decrease in the FertiQoL scores compared to those who had their male partner with problems as reason for infertility. There was an average 4.50 (B=-4.50, 95% CI: 2.30, 6.70) decrease in quality of life in women with secondary infertility compared to women with primary infertility. Every month increase in duration of infertility led to an average of 0.04 (B=-2.57, 95%CI: -0.07, -0.01) decrease in FertiQoL scores. Conclusion The overall quality of life in this population was positively associated with level of education but negatively affected with reason for infertility, type of infertility and duration of infertility