Menopause-related osteoporosis

Peak bone mass for spine and hip is reached in the mid-twenties and adolescents should be counselled on adequate nutrition to ensure sufficient calcium intake, regular weight-bearing exercise, maintaining normal body weight, avoiding smoking and limiting alcohol intake. These measures are important to prevent osteopenia and osteoporosis by obtaining a maximum peak bone mineral density (BMD) and to maintain it by avoiding excessive bone loss. One year before the onset of menopause, however, as a result of oestrogen deficiency, there is an increase in osteoclastic activity without a similar increase in osteoblastic activity, resulting in accelerated bone loss. The average decrease in BMD during the menopausal transition is estimated to be about 10% and a woman’s risk of sustaining an osteoporotic or fragility fracture doubles for each decade after the age of fifty. Half of women older than 50 years of age will be osteopenic compared to 10% who are osteoporotic and only 40% will have normal BMD. This article gives an overview of the prevention, diagnosis and management of osteoporosis during and before menopause.http://www.safpj.co.zaam201

Expressed informed consent for intimate gynaecological examinations

The doctor-patient relationship, although extremely important and essential to ensure optimal treatment outcomes, remains complicated. This relationship allows two people, unfamiliar with each other, with different value systems, to share intimate information, and allows the healthcare provider to perform intimate examinations on male or female patients. During the past two to three decades, the doctor-patient relationship has evolved from a mainly paternalistic relationship where the doctor knew what is best for the patient, and “good patients” were regarded as those who submissively accepted the proposed treatment or intervention, to a more patient centred model of mutual participation and decision making in caring for the patient. Although this model is based on equality, shared power and responsibility, the balance of power in this relationship in practice is not equal. The power balance tends to favour the doctor, regardless of how well the healthcare provider executes his or her responsibility in this regard. The patient is frequently in a compromised situation, having a health problem requiring treatment, with not many options than to rely and depend on the doctor’s specialised knowledge and skills. In some settings the patient does not even have the right to choose a healthcare provider of his or her choice and have to accept what is available, regardless of their perception of the individual professional that will be treating them.https://www.obstetricsandgynaecologyforum.comam2023Obstetrics and Gynaecolog

Meeting future requirements in gynaecological oncology subspecialty training

Subspecialty training in gynaecological oncology in South Africa is a very young venture in the discipline of gynaecology. In 2008, the first candidate fulfilled the requirements for the College of Obstetricians and Gynaecologists of South Africa's subspecialty certificate in Gynaecological Oncology. As a subspecialty, gynaecological oncology adds significant value to the management and care of women who are diagnosed with gynaecological cancer, and enhances survival and treatment outcome. Therefore, there is no doubt that it is judicious to train gynaecological oncologists in South Africa.http://www.sajgo.co.za/index.php/sajg

About this supplement…

In 2009, The Cancer Association of South Africa (CANSA) awarded its biggest research grant to date to the HPV Cervical Cancer Research Fund, under the auspices of Prof Greta Dreyer. This grant enabled a group of researchers from different disciplines to conduct a project to investigate large-scale cervical cancer screening of peri-urban women using cytology and molecular testing. The main findings of this study, performed in the Tshwane Health District, are reported in this supplement which is introduced by Dr Carl Albrecht, Head of Research, CANSA.http://www.sajgo.co.za/index.php/sajgoam201

Transverse vaginal septum in a young adolescent : a case report describing a novel approach in the initial surgical management

Transverse vaginal septum is a rare congenital anomaly. It is one of the variants of müllerian duct anomalies which results from defective fusion or recanalization of the vaginal and müllerian organs. It can present with primary amenorrhea with cyclical abdominal pain at early age or with infertility and dyspareunia later in life.https://www.obstetricsandgynaecologyforum.comam2023Obstetrics and Gynaecolog

The effect of human immunodeficiency virus prevalence on the epidemiology of conventional cervical cytological abnormalities : an institutional experience

OBJECTIVES: Despite a shift towards other screening modalities, cervical cytology still has an important screening function in many settings. The worldwide human immunodeficiency virus (HIV) epidemic has impacted severely on cervical cancer, resulting in women presenting at a younger age with more advance disease and poorer prognosis. The objective of this study was to compare different datasets from different time periods to assess the possible impact of HIV infection on the epidemiological characteristics of conventional cervical cytology screening results. DESIGN: The design was a comparative overview of two different cervical cytology datasets collected at different times. SETTINGS AND SUBJECTS: Conventional cervical cytology screening data from non-pregnant patients at the gynaecological outpatient service of the Pretoria Academic Complex from 1991-2000, and data from pregnant patients attending the Kalafong Hospital antenatal clinic in 1993-1994 and 2008, were analysed. OUTCOME MEASURES: Abnormal smear rates, the distribution of different abnormal smears and HIV prevalence in pregnant women taking part in the annual, National Antenatal Sentinel HIV and Syphilis Prevalence Survey. RESULTS: The high prevalence of HIV in South Africa is associated with a higher prevalence of abnormal smears. It is also associated with a change in the distribution of detected abnormalities. High-grade squamous intraepithelial lesions (HSIL) are now much more common than low-grade squamous intraepithelial lesions (LSIL). The most pronounced change has been a shift in the ratio of LSIL to HSIL, where the value has changed from > 1 to < 1. CONCLUSION: The rate of abnormal smears as well as the distribution of abnormalities of conventional cervical cytology in South Africa has changed. It is possible that this change is associated with the high prevalence of HIV infection.http://www.sajgo.co.za/index.php/sajgoam201

The feasibility and uptake of the etonogestrel implant and the intrauterine device at the time of uterine evacuation in women managed with incomplete miscarriage

BACKGROUND: Unintended pregnancies account for an estimated 44% of all pregnancies worldwide and 75% of pregnancies in South Africa. The use of effective contraception decreases the incidence of unintended pregnancies and the subsequent termination of unwanted pregnancies. Professional counselling on contraception and the methods available should be offered at every patient contact. This has been shown to increase contraceptive uptake. OBJECTIVE: To investigate the feasibility and uptake of offering a choice of immediate etonogestrel implant (EI) or intra uterine device (IUD) insertion at the time of evacuation in women managed with incomplete miscarriage. Alternative contraceptive options chosen by participants who declined long acting reversible contraceptives (LARCs) and their motivation was also assessed. METHODS: This was a prospective study conducted at the Department of Obstetrics and Gynaecology, Kalafong Provincial Tertiary Hospital, Pretoria, South Africa over a six-month period. All women older than eighteen years who were able and willing to provide informed consent, diagnosed with and managed for first or second trimester incomplete miscarriages were eligible for recruitment into the study. All participants were managed according to standard protocol for patients presenting with incomplete miscarriage, counselled on all the contraceptive methods available to them and then allowed the opportunity to choose their preferred contraceptive. RESULTS: A total of 155 patients were enrolled. One hundred and thirty-two women (85.16%) opted to use contraception. Of these, 67 women (43.22%) opted for LARCs, of which 32 (20.65%) had an IUD inserted and 35 (22.58%) had an EI inserted. Sixtyfi ve (41.93%) women accepted other methods of contraception. The most common reason for declining LARCs was that the participant was comfortable with other forms of contraception. Twenty-three (14.84%) women declined any form of contraception, with the most common reason being the desire for another pregnancy. CONCLUSION: The uptake of all forms of contraception was very high amongst a population of women presenting with incomplete miscarriage. This fi nding emphasises the importance of offering all these women contraception at the time of managing their miscarriageshttp://www.journals.co.za/content/journal/medogpm2020Obstetrics and Gynaecolog

Reasons why unscreened patients with cervical cancer present with advanced stage disease

OBJECTIVE: Cervical cancer is the most common gynaecological cancer in South Africa, and the vast majority of women present with an advanced stage of the disease. This can be attributed to the absence of an implemented screening programme, resulting in patients becoming symptomatic prior to diagnosis. There are little data on the health-seeking behaviour of these women. The objective was to investigate the circumstances of patients who present with cervical cancer, as well as examine their presenting symptoms and behaviour following the onset of symptoms. DESIGN: Descriptive study. Data were collected from patients who were diagnosed with cervical cancer by means interviews and a questionnaire. SETTING AND SUBJECTS: Women diagnosed and managed with cervical cancer at the Gynaecological Oncology Unit, Kalafong Hospital, Pretoria. OUTCOMES MEASURED: Included demographic data, tumour characteristics, presenting symptoms, number of visits to and interventions performed at the primary healthcare contact. RESULTS: Eighty-five patients were recruited. Of these, 74% lived in rural areas, 81% had access to primary healthcare facilities and 83% lived close to a healthcare provider. Eight had early-stage disease. The most common presenting symptoms were vaginal bleeding, pain and vaginal discharge. After the onset of symptoms, 55% of patients visited their healthcare provider within four weeks. At the first visit, only 41% of patients had a gynaecological examination and only 15% were appropriately referred, compared to 23% at their second visit. Late presentation was significantly associated with no gynaecological examination (p-value < 0.01). CONCLUSION: The lack of a cervical cancer screening programme, suboptimal management of symptomatic patients and low levels of literacy and knowledge about cervical cancer and screening are compounding the plight of these patients.http://www.sajgo.co.za/index.php/sajgoam2013ay201

A descriptive study of acute kidney injury in obstetric patients at Kalafong Provincial Tertiary Hospital

BACKGROUND : Acute kidney injury (AKI) in pregnancy presents with complexities relating to the pathophysiology of the disease. It is associated with an increased risk of maternal and perinatal morbidity and mortality. Cases may be mild or severe, requiring renal replacement therapy. The physiological changes of pregnancy make diagnosis difficult due to an increase in glomerular fi ltration rate and reduction in serum creatinine. Due to these physiological changes, there is inadequate information to aid the precise defi nition of the disease in pregnancy. In addition, data on AKI in pregnancy is limited in the South African population. AIM OF THE STUDY : The aim of the study was to describe the characteristics of obstetric patients who developed AKI from 22 weeks of gestation to 6 weeks postpartum. METHODS : Pregnant women admitted to Kalafong Provincial Tertiary Hospital (KPTH) from July 2019 to July 2020 were screened based on admission status and special investigations. The inclusion criteria were all consenting pregnant women above 18 years, gestational age of 22 weeks or more. RESULTS : A total of 38 patients were recruited. Twenty-fi ve (66%) of these patients had a hypertensive disorder in pregnancy. AKI was graded as stage 1, 2 or 3 using the KDIGO classifi cation. Seventeen patients (45%) had stage 1 AKI, 11 patients (29%) were in stage 2, and 10 (26%) were diagnosed as stage 3. Fifteen patients (39%) were admitted to the intensive care unit. Thirty-three patients (87%) recovered fully. However, two patients demised, of which one had an amniotic fl uid embolus complicated by postpartum haemorrhage and another was diagnosed sepsis unrelated to the pregnancy. CONCLUSION : AKI in pregnancy was associated with varying conditions, with hypertensive disorders making up most of the conditions. However, the recovery rate was good despite the degree of AKI, with only one of the patients in the study requiring dialysis.https://www.obstetricsandgynaecologyforum.comam2023Obstetrics and Gynaecolog

A randomised controlled trial comparing oxytocin and oxytocin + ergometrine for prevention of postpartum haemorrhage at caesarean section

BACKGROUND. Globally 166 000 women die annually as a result of obstetric haemorrhage. More than 50% of these deaths occur in sub- Saharan Africa. Uterine atony is the commonest cause of severe postpartum haemorrhage (PPH). Bleeding at or after caesarean section (CS) is responsible for >30% of maternal deaths due to obstetric haemorrhage in South Africa (SA). OBJECTIVE. To compare oxytocin alone with oxytocin + ergometrine in terms of primary prophylaxis for PPH at the time of CS. METHODS. This was a double-blind randomised controlled interventional study comparing oxytocin with oxytocin + ergometrine administered during CS. Patients were randomised to receive oxytocin alone intravenously as a bolus or oxytocin + ergometrine intramuscularly, with the placebo being an injection of sterile water. The study population consisted of women undergoing CS at Kalafong Provincial Tertiary Hospital in Atteridgeville, Gauteng, SA. RESULTS. Five hundred and forty women were randomised and data for 416 women, of whom 214 received oxytocin and 202 oxytocin + ergometrine, were available for analysis. In the oxytocin group 19 women (8.9%) required blood transfusion, compared with seven (3.5%) in the oxytocin + ergometrine group (p=0.01; relative risk = 2.78; 95% confidence interval 1.21 - 6.4). There were no statistically significant differences in the mean estimated visual and mean calculated blood loss. CONCLUSIONS. The overall need for blood transfusion was significantly reduced by about two-thirds in women receiving the oxytocin + ergometrine combination. Consideration should be given to using oxytocin + ergometrine for prophylaxis of PPH at CS.http://www.samj.org.zaam2016Obstetrics and Gynaecolog