South African Journal of Obstetrics and Gynaecology
SAJOG is a bi-annual, general specialist obstetrics and gynaecology journal that carries original research articles, editorials, clinical practice, personal opinion, South Africa health-related news, obituaries and general correspondence.
The SAJOG is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited. Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
Copyright (c) 2025 W Edridge https://creativecommons.org/licenses/by-nc/4.0
Super-specialisation and the death of the generalist
Copyright (c) 2025 https://creativecommons.org/licenses/by-nc/4.0
Translation and validation of the Malay version of the Pelvic Floor Distress Inventory (M-PFDI-20) and Pelvic Floor Impact Questionnaire (M-PFIQ-7)
Background. Pelvic floor disorders substantially affect womens quality of life. The Pelvic Floor Distress Inventory (PFDI‐20) and Pelvic Floor Impact Questionnaire (PFIQ‐7) are widely used patient‐reported outcome measures, but no validated Malay versions exist. Linguistic and cultural validation is essential to ensure accurate assessment of pelvic floor symptoms and their impact among Malay‐speaking women. Objective. To translate and validate the Pelvic Floor Distress Inventory (M‐PFDI‐20) and Pelvic Floor Impact Questionnaire (M‐PFIQ‐7) questionnaires into the Malay language. Methods. This cross‐sectional study at a public university involved 196 women who understand the Malay language. Both questionnaires underwent forward and backward translations. Subsequently, face validation was done among five women, followed by a pilot study among 30 women. Using the final version, a cross‐sectional study was done, followed by test‐retest reliability after 4 weeks. Results. In M‐PFIQ‐7, inter‐item correlation ranged between 0.40 and 0.90 and in M‐PFDI‐20, all but nine items ranged between 0.3 to 0.6. However, as the extraction communalities for all items exceeded 0.3, no items were excluded. Both questionnaires showed no correlation between factors exceeded 0.7 and demonstrated adequate construct validity. The internal consistency for M‐PFDI‐20 and M‐PFIQ‐7 was excellent, with Cronbach’s alpha values of 0.906 and 0.976, respectively. Both showed low Cronbach’s alpha value in test‐retest analysis. Conclusion. The Malay versions of the PFDI‐20 and PFIQ‐7 demonstrate good construct validity and excellent internal consistency, supporting their use for assessing pelvic floor distress and impact among Malay‐speaking women. However, limited test‐retest reliability suggests caution when using these instruments for longitudinal assessment.
Copyright (c) 2026 S Daud, B Abdullah, S Idris, M R Isa, F Sham https://creativecommons.org/licenses/by-nc/4.0
Subtypes of endocervical cancer: A retrospective, observational study at Charlotte Maxeke Johannesburg Academic Hospital
Background. Cervical cancer is the second most common malignancy in women, particularly in developing countries. Endocervical adenocarcinoma (ECA) is less common than cervical squamous cell carcinoma (SCC), but its incidence is increasing globally, particularly in young women. The decline in the incidence of SCC is attributed to effective screening programmes. Objectives. To assess the prevalence of ECA and its subtypes and to describe the clinicopathological characteristics of patients with these tumours at a tertiary South African institute between 2017 and 2019. Methods. This was a cross-sectional, descriptive study of 156 ECA patients. Following ethical clearance, demographic data, clinical information and disease characteristics were obtained from departmental histopathological reports. Descriptive statistics were used to calculate the prevalence of ECA. We analysed the association between age, Papanicolaou (Pap) smear results, human papillomavirus (HPV) status, and HIV status with ECA. Results. The prevalence of ECA was 6.8% and it was more commonly diagnosed in younger women. HPV-associated subtypes were the most common variants. The usual type of ECA accounted for 24.4% of cases. HIV status was documented in 64.0% of cases, of which 34.0% were positive. There were no statistically significant associations between ECA subtype and HIV status (p=0.81) or between ECA subtype and Pap smear results. Conclusion. In South Africa, the prevalence of ECA is lower compared with Western countries, reflecting inadequacies in screening modalities of ECA at primary healthcare facilities. HPV prevails as a cause of endocervical carcinoma. HPV morphologic hallmarks serve as a practical guide in classifying ECAs according to their HPV status.
Copyright (c) 2025 S Bulane, R Wadee https://creativecommons.org/licenses/by-nc/4.0
Takayasu’s arteritis in pregnancy: A case report
Takayasu’s arteritis (TA) is a large-vessel vasculitis predominantly affecting the aorta and its branches. It most commonly affects women in the second and third decades of life. Although analyses of case series and case studies have been done, no definitive consensus on optimal management has been reached. We describe the clinical course of an 18-year-old woman at 31weeks and 5 days’ gestation with active TA Type III (with multiple areas of stenosis, including both renal arteries, and areas of aneurysmal dilatation), uncontrolled hypertension and uveitis, with a favourable maternal and fetal outcome through a multidisciplinary approach.
Copyright (c) 2026 J Locher, S Bhoora, J Zamparini https://creativecommons.org/licenses/by-nc/4.0
Predictors of successful vaginal birth after one caesarean section at selected hospitals in Lusaka, Zambia
Background. Repeat caesarean section (CS) carries an increased risk of both maternal and neonatal morbidity and mortality. Planned vaginal birth after CS (VBAC), with an estimated success rate of 60 - 80%, is clinically safer than elective repeat CS, and also limits the rise in CSs. There is no single generalised validated tool to predict success of VBAC. Objectives. To determine predictors of successful VBAC among mothers with one previous CS at selected hospitals in Lusaka, Zambia. Method. Determination of independent predictors with significant high odds of a successful VBAC among mothers offered a trial of labour (TOL) was conducted in a cross-sectional study. Women with a history of one previous lower-segment CS, who were carrying a singleton fetus and were in established labour or draining amniotic fluid and scheduled for TOL after CS, were included in the study. Convenience sampling was used to enrol 290 participants. Using SPSS version 22, bivariate analysis and logistic regression analysis were used to analyse data. An independent factor associated with successful VBAC and with a p-value <0.05 was considered significant. Results. Of the participants, 236 (81.4%) had a successful vaginal delivery and 54 (18.6%) failed to deliver vaginally and required emergency CS. Key independent predictors of success of VBAC were primary education level (adjusted odds ratio (AOR) 2.21; 95% confidence interval (CI) 1.01 - 4.84), multiparity (AOR 4.81; 95% CI 1.16 - 19.93), previous successful VBAC (AOR 9.94; 95% CI 1.29 - 76.70), inter-delivery interval after the primary CS (AOR 18.54; 95% CI 5.98 - 57.48), a history of fetal distress (AOR 9.33; 95% CI 2.48 - 35.08), malpresentation (AOR 6.13; 95% CI 1.65 - 22.70) or failed induction of labour (AOR 20.52; 95% CI 3.32 - 127.03) as indications for the primary CS, Bishop score (AOR 7.06; 95% CI 1.92 - 25.97), cervical dilation (AOR 11.62; 95% CI 3.86 - 35.03), duration of labour (AOR 20.78; 95% CI 5.62 - 76.80), birthweight (AOR 6.80; 95% CI 3.33 - 13.91) and Apgar score (AOR 28.42; 95% CI 5.67 - 142.38). Conclusion. A combination of independent sociodemographic and obstetric factors that have significant high odds for a good outcome of VBAC could help predict success of delivery in a given population. This information could also aid in counselling mothers on mode of delivery.
Vaginal birth after caesarean section (VBAC)
Trial of labour after caesarian section (TOLAC`)
Copyright (c) 2024 M Mukape, B Vwalika https://creativecommons.org/licenses/by-nc/4.0
The final stage: Investigating determinants of plasmin generation in the third trimester of pregnancy
Background. Changes in the fibrinolytic system that support haemostasis are seen in the third trimester of pregnancy. An imbalance between coagulation and fibrinolysis could increase either thrombotic episodes or haemorrhagic risk. Objective. To assess plasma D-dimer and plasmin-a2-antiplasmin (PAP) complex levels as indication of plasmin generation during late pregnancy. Methods. A sample of 41 healthy pregnant women in their third trimester participated in the study. Data on obstetric history, body mass index (BMI) and other demographic variables were recorded. Haematological analysis involved enzyme-linked immunosorbent assaying of venous blood samples. Statistical analysis was performed using SPSS version 21. Results. Mean maternal and gestational age, with associated standard deviations (SD), were 30.68 (4.69) years and 34.78 (3.34) weeks, respectively. Haematological analysis showed mean (SD) values of D-dimer and PAP complex to be 194 (24 ng/mL) and 175 (11 ng/mL), respectively. Both indicators were positively correlated with maternal age, gestational age and BMI grouping, although significantly only for maternal age. Multiple linear regression analysis showed that with every increasing year of maternal age, D-dimer levels increased by 2.0 ng/mL (95% confidence interval (CI) 0.4 - 3.6 ng/mL). PAP complex levels similarly increased by 0.8 ng/mL (95% CI 0.1 - 1.5 ng/mL), after controlling for gestational age and BMI. Conclusion. D-dimer and PAP levels increased with increasing maternal age, suggesting it to be an independent determinant of plasmin generation in the third trimester of pregnancy. If this finding is confirmed in larger studies, age should be considered when interpreting these indicator values during pregnancy.
Plasmin generation, pregnancy, third trimester
Copyright (c) 2025 H C Okoye, T Nwagha, J Enebe , C Efobi, O C Nnachi, J C Okwor https://creativecommons.org/licenses/by-nc/4.0
Best practice guidelines - Fetal Medicine
These are three best practice guidelines related to important areas in obstetrics. The first details the prenatal care of twin pregnancies. The second provides guidelines for the management of intrauterine growth restriction and the third provides guidance on the use of Doppler ultrasound in obstetrics, including technical aspects and safety.
Copyright (c) 2024 C Stewart, L Pistorius, L Geerts, S Budhram, P Naidoo, N Gubu-Ntaba https://creativecommons.org/licenses/by-nc/4.0
Copyright (c) 2023 https://creativecommons.org/licenses/by-nc/4.0
The prevalence, associated risk factors and pregnancy-related outcomes of large-for-gestational-age newborns delivered at Chris Hani Baragwanath Academic Hospital
Background. Large for gestational age (LGA) refers to a newborn birthweight equal to or greater than the 90th percentile for a given GA. Delivering an LGA newborn poses a high risk of morbidity and mortality for both mother and baby. Objectives. To describe the prevalence of term LGA newborns and identify the factors and pregnancy-related outcomes associated with delivering term LGA newborns at Chris Hani Baragwanath Academic Hospital (CHBAH), a tertiary hospital in Johannesburg, South Africa. Methods. We conducted a retrospective, institution-based cross-sectional study from 1 October 2020 to 31 March 2021, in which 275 LGA singleton term deliveries were reviewed. Patient demographics, medical factors and clinical outcomes were recorded and statistically analysed. Results. The prevalence of LGA newborns in singleton-term deliveries at CHBAH was 3.92%. Associated factors included maternal obesity, multiparity, prolonged pregnancy with a GA >40 weeks, previous LGA delivery and (newborn) male gender. Maternal complications included prolonged labour, increased caesarean delivery, postpartum haemorrhage, obstetric anal sphincter injuries and uterine rupture. Fetal and neonatal complications included shoulder dystocia, neonatal hypoglycaemia, and neonatal respiratory distress syndrome. Conclusions. LGA singleton term deliveries at CHBAH were associated with both maternal and neonatal morbidity. The presence of associated factors should alert maternity caregivers to closely monitor these pregnancies and plan for an appropriate mode of delivery. LGA newborns should be routinely screened and appropriately managed for hypoglycaemia.
Copyright (c) 2025 N Chibaya, N Odell, Dr Geogiou, N Frank https://creativecommons.org/licenses/by-nc/4.0
Post-caesarean section outcomes of obstetric patients with valvular heart disease at Charlotte Maxeke Johannesburg Academic Hospital, South Africa
Background. Valvular heart disease presents a unique set of conditions during pregnancy and delivery, with the potential for adverse outcomes increased by prior interventions and anticoagulation. Objectives. To describe the profile and outcomes of obstetric patients with valvular heart disease who delivered via caesarean section at Charlotte Maxeke Johannesburg Academic Hospital, South Africa. Methods. A 5-year retrospective descriptive cross-sectional study was performed. All patients with valvular heart disease who underwent caesarean section, irrespective of age, were included. Exclusion criteria were absence of important clinical data relevant to the study and outcomes data. All records of patients who delivered by caesarean section and were booked in the obstetric cardiac unit were reviewed. Data for those who had valvular heart disease were separated from non-valvular heart disease data. A total of 69 patients were included in the analysis. Univariate logistic regression analysis was done to assess the predictors of maternal and fetal outcomes. Results. The mean (standard deviation) age of the patients in the study was 30.1 (5.6) years, 82.6% were gravida 1 - 3 and 89.8% para 0 - 2, and the majority (56.5%) had an elective caesarean section. General anaesthesia was the most common mode used, and most of the patients had fixed-interval analgesia postoperatively. Approximately two-fifths of the patients (n=28; 40.6%) were on anticoagulants. A significantly higher percentage of those who were on anticoagulants had complications (n=12/28; 42.9%) compared with those who were not on anticoagulants (n=3/41; 7.3%) (p<0.001). There was a total of 19 complications, mainly bleeding (n=7) and cardiac arrhythmias (n=6). New York Heart Association class and use of anticoagulants were individually associated with adverse maternal outcomes after univariable logistic regression analysis (p=0.006 and p=0.017, respectively). In univariable logistic regression analysis, a low ejection fraction was associated with adverse fetal outcome (odds ratio 0.94; 95% confidence interval 0.90 - 0.99; p=0.032). One infant (1.4%) died, in the early neonatal period. Conclusion. Pregnancy in women with cardiac disease is possible, but it is not without risk, and a structured plan and multidisciplinary team approach to provide prehabilitation is therefore necessary. Our patients were young and with relatively good functional status (metabolic equivalent >4), and most pregnancies continued to term or early term (median (interquartile range) 37 (36 - 38) weeks). Some patients experienced adverse outcomes, mainly related to bleeding and arrhythmias, but none died. There was one early neonatal death. These patients need a structured multidisciplinary team care plan.
Copyright (c) 2023 Z Mfeka, A Nkuna, P Motshabi Chakane https://creativecommons.org/licenses/by-nc/4.0
Does adding coenzyme Q10 to dehydroepiandrosterone sulphate positively impact fertility outcomes in young, poor responder infertile women undergoing antagonist protocol for IVF/ICSI cycles?
Background. One of the biggest issues in reproductive medicine is treating women with low ovarian reserves or a poor ovarian response (POR) to stimulation. Oxidative stress was suggested as one of the major contributors to POR. However, the pathophysiology remains unknown. Focusing on certain subpopulations within the diverse group of poor responders may help determine the best therapy for these patients. Objective. To investigate the effect of adding coenzyme A Q10 to dehydroepiandrosterone (DHEA) in young, poor responder infertile females undergoing in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) cycles. Methods. One hundred and sixty-eight females with poor ovarian response (Poseidon Group 3) from multiple centres were randomly divided into two groups. The first group received DHEA orally along with coenzyme 10, while the second group received only DHEA. Both groups underwent controlled ovarian stimulation. Results. There was a significant improvement in the quality of oocytes and the number and quality of embryos transferred in the coenzyme A Q10 group. However, no significant differences were observed in other parameters between the groups. Conclusion. In young, poor-responder women with decreased ovarian reserve, pretreatment with CoQ10 enhances oocyte and embryo quality and boosts ovarian response to stimulation. An improvement in clinical pregnancy and live birth rates may be possible.
Copyright (c) 2024 M Dawoud, A Abd Al Waheed, S H Gad Allah, F Abd Al Kader Hemila, A Eid Abd El Mohsen, A Ibrahim Ogila https://creativecommons.org/licenses/by-nc/4.0
Uterine balloon volume shifts using a free-flow uterine balloon in the management of refractory postpartum haemorrhage.
Background. Uterine balloon tamponade (UBT) is used as part of the post partum haemorrhage (PPH) algorithm for the treatment of PPH. Objectives. The free-flow Ellavi uterine balloon controls the pressure in the uterine balloon by adjusting the height of the supply bag above the patient and allows for expulsion of water from the balloon. The study quantified the volume shifts in the supply bag and assessed the optimal use of the Ellavi UBT by reducing the intrauterine pressure at regular intervals. Methods. A prospective descriptive study of consecutive patients with refractory PPH was conducted. For group A, the supply bag was weighed every 30 minutes with a sensitive digital scale. Additionally, for group B the supply bag was lowered by 50% and the uterus gently massaged for 30 seconds. Results. Thirteen patients were included in the study. The mean volume was 23.5 mL for Group A and 132.7 mL for Group B. The difference in the means of groups A and B was borderline significant (p=0.06). Conclusion. The study did find volume shifts in the free-flow system, which may be enhanced by lowering the supply bag halfway at regular intervals.
Copyright (c) 2024 T Hassim, G B Theron, E J Langenegger, M Kidd https://creativecommons.org/licenses/by-nc/4.0
Obstetric trauma admissions in a Level-1 trauma centre in South Africa: A 5-year retrospective review
Background. The severity of injury and associated management determine maternal and fetal outcomes in pregnant trauma patients. Objective. To describe the characteristics, mechanisms of injury, clinical interventions and maternal and fetal outcomes of obstetric trauma admissions at our institution. Methods. This was a retrospective record review of pregnant trauma patients admitted to Chris Hani Baragwanath Academic Hospital over a 5-year period (N=800). Patient records from several departments were reviewed, including the intensive care unit (ICU). Data were collected on sociodemographics, mechanism of injury, clinical interventions, and maternal and fetal outcomes. Results. The median maternal age and gestational age were 31.00 years and 26.00 weeks, respectively. Most patients were black African (n= 713; 89.1%) and the majority (70.3%; n=562) were single. More than half (n=484; 60.5%) were unemployed. Assault was the most frequent cause of trauma (n=330; 41.3%), followed by falls (n=265; 33.1%) and motor vehicle accidents (n=204; 25.5%). Almost a fifth of the patients (n=141; 18.0%) reported recent alcohol consumption. Four patients (0.5%) were admitted to ICU, of whom one died. Ten fetal deaths were recorded, of which three were delivered by patients admitted to ICU. Eleven neonates were delivered before 37 weeks. Conclusion. Our results show that pregnant patients who are single and unemployed were at increased risk of obstetric trauma. Assaults, falls and motor vehicle accidents were the most common causes of maternal trauma in our sample. Implementing strategies to detect and prevent intimate partner violence and improve road safety may contribute to reduced maternal and fetal mortality.
Copyright (c) 2025 B Moyo, R E Mashayamombe, R B Nyakoe, G Nethathe https://creativecommons.org/licenses/by-nc/4.0
Prevalence and severity of depression and anxiety in infertile female patients attending an academic hospital in central South Africa
Background. Infertility has an incidence of 15 - 20% in South Africa (SA). It may lead to the development of psychological disorders such as anxiety and depression. Objective. To determine the prevalence of depression and anxiety among infertile women attending the Infertility Clinic at a tertiary hospital in central SA. Methods. In this prospective analytic cross-sectional study, information captured included sociodemographic variables such as age, employment status, type and duration of infertility, marital status, type of marriage and education level. The Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) test were used to screen for depression and anxiety, respectively. Results. In total, 100 of 108 infertile women completed all the questionnaires correctly. Forty-two (42.0%) of the patients were >35 years and 58.0% were married, with five (8.6%) being in a polygamous marriage. Fifty-three (53.0%) women had never been pregnant before. The prevalence of depression was 53.0%, with 45.0% of these patients showing moderate to moderately severe levels of depression. The level of education was significantly associated with depression (p<0.025). Half of the participants (50.0%) screened positive for anxiety, with 12 (24.0%) having severe anxiety. In total, 40.0% of the participants screened positive for both anxiety and depression. No statistically significant association was observed between depression or anxiety and age, duration of infertility, marital status and employment status. Conclusions. Depression and anxiety disorders are common and often underdiagnosed in women undergoing infertility treatment. Practitioners should screen for these conditions at the initial patient presentation and refer patients for psychological support.
Copyright (c) 2024 T Mulondo, S Baloyi, J B Sempa https://creativecommons.org/licenses/by-nc/4.0
The incidence of clinically impactful postoperative nausea and vomiting after spinal anaesthesia for caesarean section in an academic hospital
Background. Postoperative nausea and vomiting (PONV) are common side-effects following administration of spinal anaesthesia for caesarean section (CS). PONV is reportedly perceived to be more distressing than pain by patients, which necessitates assessment of its incidence to ensure that it is not undertreated and that effective measures are undertaken to address it. Objectives. To study the incidence of PONV and associated factors in patients delivering via CS. Methods. A total of 308 healthy parturients undergoing CS under spinal anaesthesia were recruited. This was a single-centre prospective observational study conducted at an academic hospital. The institution standard of practice for spinal anaesthesia for CS was employed and consisted of injecting 1.8 - 2.0 mL of hyperbaric bupivacaine 0.5% solution plus 10 μg fentanyl at the L3/L4 interspace after preloading the patient with intravenous fluid 10 - 15 mL/kg. Phenylephrine boluses were used in managing any spinalinduced hypotension according to standard protocol. The demographic data and patient characteristics were recorded. Complaints of PONV were recorded postoperatively in the recovery room and 3 hours after the procedure. The clinical significance of PONV was assessed using the PONV impact scale. Results. Of the 308 enrolled patients, 295 (95.8%) were black, 9 (2.9%) coloured and 4 (1.3%) white. The overall incidences of nausea and vomiting were 2.6% and 9.7%, respectively, with all episodes occurring during the first 3 hours after the procedure. The overall incidence of PONV was 10.1%. The odds of experiencing PONV for patients with increased birth weight, lowest blood pressure and Apfel score <3 were 1.0 (95% confidence interval (CI) 0.99 - 1.00), 1.01 (95% CI 0.98 - 1.04) and 0.35 (95% CI 0.11 - 1.12), respectively. There was no report of clinically significant PONV. Conclusion. The overall incidence of PONV in this study was 10.1%, and there was no clinically significant PONV.
Copyright (c) 2023 C Ogunjiofor, H J Moutlana, L T Lushiku, P Motshabi Chakane https://creativecommons.org/licenses/by-nc/4.0
The clinical significance of placental histopathological evaluation in the management of high-risk obstetric patients: A cross-sectional retrospective study
Background. Placental pathologies cause significant morbidity for both mother and fetus, and represent the largest category of causes of intrauterine death. Placental histopathology allows for recognition of treatment opportunities to prevent recurrence of adverse outcomes. Objectives. To determine the indications for and findings of placental histopathological evaluation and assess the clinical use of the findings in the management of high-risk obstetric patients. A secondary objective was to compare placental histopathological findings of patients with and without pre-eclampsia. Methods. A cross-sectional retrospective study was performed at Charlotte Maxeke Johannesburg Academic Hospital, South Africa, on patients who had placentas submitted for histological evaluation at the time of delivery (1 June 2018 - 31 May 2019). The clinical indications, histopathology results and proposed follow-up plan in view of those results were analysed. Results. We assessed 176 placental histopathology reports and hospital records. The most common indications were stillbirth (50.0%), pre-eclampsia (31.1%), late miscarriage (21.6%) and severe fetal distress (15.9%). The most common individual microscopic findings were increased syncytial knots (52.8%), patchy perivillous fibrin (48.9%) and chorioamnionitis (40.3%). The most common cluster diagnoses were maternal vascular malperfusion (51.1%) and ascending infection (35.8%). Of our patient cohort, 55.7% received a follow-up appointment date and 44.3% did not, and 65.3% of patients with a follow-up appointment did not attend it. A management plan for future pregnancies was formulated for only 52.9% of those who attended their follow-up appointment. While statistically significant individual microscopic features were noted in cases of pre-eclampsia, the most important associations were identified between cluster diagnoses such as maternal vascular malperfusion and pre-eclampsia (p<0.0001) and ascending infection and pre-eclampsia (p=0.003). Conclusion. This study showed that histopathology results are underutilised in formulating future management plans. In high-risk obstetric patients, management options for pregnancies must include review of previous placental histopathology results to prevent further adverse outcomes.
Copyright (c) 2023 R Stevens, N Odell, R Wadee https://creativecommons.org/licenses/by-nc/4.0
Catamenial pneumothorax: A neglected diagnosis
Background. Catamenial pneumothorax (CP) is an under-reported and misunderstood condition commonly defined as a recurrent, spontaneous pneumothorax occurring from the day before menstruation until 72 hours after its onset. It is the most common clinical manifestation of thoracic endometriosis. Case report. We describe the case of a 36-year-old woman who presented twice with significant shortness of breath during her menses at a regional hospital in Gauteng Province, South Africa. Chest radiographs showed bilateral spontaneous pneumothoraces on both occasions, indicating a very rare presentation of CP, which is more commonly a right-sided pathology and a rare presentation on its own. Video-assisted thoracoscopic surgery was performed at a tertiary institution. Significant thoracic endometriosis and a diaphragmatic hernia were found, confirming the diagnosis of endometriosis-related CP. Pleurectomy and closure of the diaphragmatic hernia were performed, and the patient was initiated on hormonal therapy. Conclusion. A high index of clinical suspicion is required for diagnosing CP and its associated conditions. This case highlights the need for awareness of this condition and the importance of long-term follow-up, especially in an overburdened and resource-limited healthcare system.
Copyright (c) 2024 C Prior, S Rajan, C Naidoo https://creativecommons.org/licenses/by-nc/4.0
The safety and efficacy of immediate post placental IUD insertion versus the post puerperal IUD insertion in women undergoing cesarean delivery
Objective. To assess the safety and efficacy of immediate intrauterine contraceptive copper device (IUD) insertion following delivery of the placenta in women undergoing caesarean delivery. Methods. In this randomised clinical trial, 66 women were evenly divided into two arms, with 33 patients in each arm. The first group had an IUD inserted 10 minutes after delivery of the placenta (post-placental group), while the second group had their IUD inserted at 6 weeks following delivery (interval group). Results. The complication rate for post-placental IUD insertion was comparable with that of interval insertion. The expulsion and displacement rates were similar for both post-placental and interval groups at the 6-week and 3-month follow-up. Conclusion. Post-placental IUD insertion is a safe and attractive option for postpartum contraception that should be offered to all women undergoing elective caesarean section after proper counselling.
Copyright (c) 2023 M A M Dawoud, M O Awad, O M Helal, R O EL Komy, M M El Sherbiny https://creativecommons.org/licenses/by-nc/4.0
Maternal–fetal prognosis of major sickle cell disease in pregnant women at a university hospital in a low–middle-income country
Background. Sickle cell disease (SCD) is a common genetic disease in sub-Saharan Africa. The condition affects more than 7% of pregnant women worldwide, with complications including severe infections, vital organ damage, respiratory problems, bone marrow suppression and a high rate of maternal or fetal death. Objective. To evaluate the prevalence, management and maternal–fetal prognosis of pregnancies in women with major SCD. Methods. A prospective and descriptive study was conducted in the gynaecology and obstetrics department of the university hospital of Cocody, Abidjan, in Cote d’Ivoire over two years. Records of all pregnant women with homozygous SCD who had given birth or were followed up in the unit were reviewed. Women with an HbAA or HbAS genotype or any other normal electrophoretic profile or history of renal disease were excluded. Results. Out of 14 819 delivery records, 118 (0.8%) women presented with an abnormal haemoglobin profile; 75 were classified as having major SCD (0.51%). The majority of women (82.7%) were younger than 35 and 68% worked in the informal sector. About a third (37.3%) had no formal education. Heterozygous HbSC profiles were the predominant (88%) presenting form; HbSS genotypes were found in 12% of cases. The occurrence of complications during pregnancy was significant (44%). Conclusion. SCD in pregnancy is associated with an increased risk of maternal and fetal complications. Accurate and rigorous monitoring of these pregnancies by a multidisciplinary team, together with improved patient awareness and education, is required to reduce maternal and fetal health risks.
Copyright (c) 2025 M B Dehi, V A Angoi, C J Nsahlai, J Konan, K H Yeo, K Nguessan, S Boni https://creativecommons.org/licenses/by-nc/4.0
Predictive scores for critically ill obstetric patients in a resource‐limited setting: A retrospective validation of the Obstetric Early Warning Score.
Background. In South Africa (SA), an unacceptably high institutional maternal mortality rate persists due to failure to recognise critically ill patients. Early warning systems could assist in identifying these patients sooner. Objectives. We evaluated the Obstetric Early Warning Score (OEWS) as a predictor of maternal outcomes in an intensive care unit (ICU) and compared its prognostic validity with the Acute Physiology and Chronic Health Evaluation (APACHE) II and the quick Sequential Organ Failure Assessment score (qSOFA). Methods. Data were extracted on pregnant and post-partum ICU-admitted patients at a tertiary and regional centre in SA between October 2015 and April 2020. Clinical characteristics and outcomes were used to compare the three scoring systems. Results. Among 251 eligible patients, the mortality rate was 8.5%. The OEWS score failed to differentiate between survivors and non-survivors (odds ratio 1.13, 95% confidence intervals (CI) 0.972 - 1.311, p=0.113). APACHE II outperformed the OEWS (area under the receiver operating characteristics curve (AUROC) 0.69, 95% CI 0.540 - 0.846 v. 0.55, 95% CI 0.430 - 0.674). The OEWS (AUROC 0.55, 95% CI 0.430 - 0.674) and qSOFA (AUROC 0.60, 95% CI 0.500 - 0.703) showed no differences. Further analysis revealed that positive scoring for diastolic blood pressure and high systolic blood pressure weakened OEWS performance. Removing these variables improved OEWS prediction (AUROC 0.68). Conclusion. In a SA obstetric population, OEWS did not predict mortality in ICU-admitted patients and offered no advantages over APACHE II or qSOFA scores. Further research should identify critical outcome predictors for low-resource populations.
Copyright (c) 2024 N Kheswa, R Rodseth, R Wise, D G Bishop https://creativecommons.org/licenses/by-nc/4.0
Is medicine a process of scientific rigour?
Copyright (c) 2022 https://creativecommons.org/licenses/by-nc/4.0
Age-related changes in serum anti-Müllerian hormone in women of reproductive age in Kenya
Background. Anti-Müllerian hormone (AMH) is produced by the granulosa cells of ovarian antral follicles and plays a role in the recruitment of dominant follicles during folliculogenesis. The serum level of AMH is proportional to the number of developing follicles in the ovaries and reflects ovarian reserve. Nomograms of AMH variation with age exist from Caucasian populations, but there are none drawn from local African data. Objectives. To establish age-specific median serum AMH levels in an unselected East African population of women of reproductive age. Methods. We retrospectively analysed data on 1 718 women who underwent AMH testing using the Beckman Coulter AMH Gen II enzyme-linked immunosorbent assay during the period 2015 - 2019 at Aga Khan University Hospital, Nairobi, Kenya. Age-specific median AMH levels were derived and presented in 5-year age bands. AMH levels were then log-transformed and, using linear regression in a natural spline function, presented on a scatter plot to demonstrate variation across reproductive age. Results. The median (interquartile range (IQR)) age of women who were tested for AMH was 38 (19 - 49) years. For the study population, the median (IQR) serum AMH level was 0.87 (0.01 - 17.10) ng/mL. The AMH concentration was inversely related to age, with a progressive decline whereby an increase of 1 year resulted in a corresponding decrease in AMH of 0.18 ng/mL. The proportion of women with decreased ovarian reserve increased exponentially with age from 14.9% in those aged 20 - 24 years to 48.7% at 35 - 39 years. Conclusion. From a large dataset of mainly black African women, this study confirms that serum AMH declines with advancing age, as reported elsewhere in Caucasian populations. There was, however, a higher than expected number of women with diminished ovarian reserve for age. Future studies prospectively exploring ovarian reserve in the general population could unravel underlying biological, reproductive and environmental factors that may influence AMH levels and reproductive capacity in this indigenous population.
Copyright (c) 2022 M Andhavarapu, D Maina, A Murage, C Muteshi https://creativecommons.org/licenses/by-nc/4.0
Prevalence of and sociodemographic factors associated with antenatal depression among women in Limpopo Province, South Africa
Background. Pregnancy-related depression is a common psychiatric disorder and a major public health concern in both developed and developing countries, but the disorder receives little attention and few resources, particularly in developing countries. Objectives. To assess the prevalence of antenatal depression and its sociodemographic risk factors among pregnant women in Limpopo Province, South Africa. Methods. This was a cross-sectional descriptive study conducted in a district hospital from 8 March to 12 April 2021. Consecutive women attending antenatal care services during the data collection period were included in the study. The Edinburgh Postnatal Depression Scale was used to assess depression symptoms. Results. The prevalence of antenatal depression was 31% (95% confidence interval 26.1 - 36.3). Being unmarried, being a smoker, being without financial support from a partner, having a violent partner and having a less-educated partner were significant predictors of antenatal depression in these women. Conclusion. Nearly one-third of the pregnant women in our study had depressive symptoms. The important predictors of antenatal depression included being unmarried, smoking, lack of financial support from a partner, intimate partner violence and having a lesseducated partner. These findings may help healthcare workers to identify women at risk early, so that support can be offered during pregnancy and childbirth.
Copyright (c) 2022 M C Ramohlola, E Maimela, T S Ntuli https://creativecommons.org/licenses/by-nc/4.0
How to care for fetuses with prenatally diagnosed severe abnormalities
Ultrasound in pregnancy has become standard of care, resulting in an increased number of antenatally diagnosed fetal anomalies. It is important to have a consistent approach to the management of these abnormalities. This may include offering termination of pregnancy, standard care or non-aggressive/palliative care. A categorisation of anomalies and management options is proposed to assist with these decisions, underpinned by an ethical framework.
Copyright (c) 2022 C J M Stewart https://creativecommons.org/licenses/by-nc/4.0
Comparison of obstetric and perinatal outcomes in women with diabetes at Steve Biko Academic Hospital
Background: Diabetes and obesity in pregnancy have been associated with increased rates of adverse maternal and neonatal outcomes compared to women with normoglycaemia and normal weight. The aim of this study was to investigate the effect of diabetes and pre-pregnancy obesity on obstetric and perinatal outcomes. Methods: This study included women with pregestational diabetes (type 1 (T1DM) and type 2 diabetes (T2DM)), gestational diabetes (GDM) and normoglycaemia who attended the antenatal clinic at Steve Biko Academic Hospital between 2017 and 2022. Women were followed up until delivery. Data collected included obstetric history and care, diabetes, obstetric and perinatal outcomes. Results: A total of 183 women were recruited; 13 (7.1%) with T1DM, 65 (35.5%) with T2DM, 39 (21.3%) with GDM and 66 (36.1%) normoglycaemic controls. Women with T2DM and GDM were older (p < 0.01) and were more likely to have a history of chronic hypertension (p= 0.025) compared to controls. Women with GDM were more likely to be obese than their T1DM counterparts (p= 0.036). T1DM and T2DM were associated with higher rates of preterm delivery compared to controls (p= 0.002). The frequency of GDM was significantly higher in women with obesity (p= 0.039). The frequency of caesarean section before the onset of labour was higher in women with weight ≥ 80 kg compared to women with weight < 80 kg (p= 0.015). Conclusion: Diabetes in pregnancy is associated with adverse obstetric and perinatal outcomes. Therefore, adequate glucose control should be accompanied by preconceptual weight optimisation to reduce adverse outcomes during pregnancy.
Copyright (c) 2023 Nompumelelo Malaza, Prof, Dr, Prof https://creativecommons.org/licenses/by-nc/4.0
Feto-maternal outcomes of patients with placenta previa and accuracy of diagnosis of placenta accreta syndrome at Chris Hani Baragwanath Academic Hospital
Background. The incidence of placenta praevia (PP) is 0.3 - 0.5% of pregnancies and it is a major risk factor for placenta accreta syndrome (PAS). PP and PAS cause immense feto-maternal morbidity and mortality and, as a result, place a huge burden on healthcare resources. Hence, accurate diagnosis prenatally of PP and associated PAS is essential as this allows adequate preparation for potential complications. Objective. To ascertain the accuracy of prenatal diagnosis of PP and PAS, and the feto-maternal effects of these conditions in women diagnosed at Chris Hani Baragwanath Academic Hospital (CHBAH) Methods. This was a retrospective, descriptive study that reviewed the medical files of 55 women diagnosed with PP at CHBAH in 2018. Results. Complete data was obtained for 28 women. The incidence of PP was 0.3%. The mean age, gravity and parity of women with PP were 31.65 (6.0) years, 3.0 (1.3) and 1.7 (1.3), respectively. The mean birthweight was 2 244 (730) g. Eighteen (56.2%) of newborns had birth weight <2 500g. The incidence of adverse outcomes was increased in patients with suspected PAS on prenatal ultrasound compared with patients showing no prenatal ultrasound evidence of PAS. Ultrasound had a positive predictive value of 50% while MRI correctly identified PAS in 33.3% of patients. Conclusion. PP and PAS increase the likelihood of maternal and neonatal morbidities. Ultrasound is a useful tool in evaluating placenta implantation and can assist in anticipating adverse feto-maternal outcomes in PP and PAS. MRI has limited clinical value in this setting Keywords. Placenta praevia (PP), Placenta accreta syndrome (PAS), Chris Hani Baragwanath Academic Hospital (CHBAH), Magnetic Resonance Imaging (MRI) currently, and should not be done routinely.
Copyright (c) 2024 M N A Hammond, J Jeebodh, C Georgiou https://creativecommons.org/licenses/by-nc/4.0
An assessment of mismatch repair deficiency in ovarian tumours at a public hospital in Johannesburg, South Africa
Background. Epithelial ovarian carcinomas (EOCs) are lethal female genital tract malignancies with high-grade serous, low-grade serous, endometrioid, clear cell, mucinous and malignant Brenner subtypes. The lifetime risk for developing ovarian carcinoma (OC) is 15% in females who have mismatch repair deficiency (MMR-d). MMR-d is associated with Lynch syndrome, a cancer predisposition condition. Patients who have MMR-d may benefit from immunotherapy. To the best of the authors’ knowledge, MMR-d testing of OCs in South Africa (SA) has not been undertaken to date. Objectives. To assess the clinicopathological characteristics and mismatch repair (MMR) status of non-serous EOCs at a single institution in SA. Methods. Following ethical clearance and application of exclusion criteria, 19 cases of non-serous EOC from the Department of Anatomical Pathology at Charlotte Maxeke Johannesburg Academic Hospital were retrieved and assessed. Four immunohistochemical markers (MLH1, MSH2, MSH6 and PMS2) were used to evaluate MMR status. Results. Most tumours were early-stage, unilateral, mucinous EOCs, without capsular breach or lymphovascular invasion (LVI). A single case of grade 1, stage I, unilateral, endometrioid EOC showed MMR-d for MLH1 and PMS2 MMR proteins. This patient had been diagnosed with endometrioid endometrial carcinoma 2 years prior to the diagnosis of OC. Conclusion. Our study documented a lower proportion of MMR-d OCs compared with international studies. However, our results are concordant with global studies regarding tumour subtype, laterality, grade, stage, LVI and capsular breach. Larger studies are required to estimate the true incidence of MMR-d OCs in SA and to direct effective treatment options globally.
A proposed fetal risk scoring system for gestational diabetes to assist in optimising timing of delivery
Background. The pathophysiology of gestational diabetes, which is related to abnormal gluocose tolerance and hyperinsulinaemia, renders standard fetal monitoring models ineffective, insufficient and inappropriate, as these models revolve around detecting and prognosticating on placenta-mediated disease rather than increased metabolic rates due to hyperinsulinaemia, functional hypoxia and ischaemic trophoblastic thresholds. To improve perinatal morbidity and mortality in gestational diabetes, there is therefore a need to introduce new prognostic parameters and scoring systems. Objectives. A proposed risk scoring system has been developed, based on our previous studies, to risk-categorise patients with gestational diabetes in terms of fetal outcome in view of the fact that the pathophysiology of gestational diabetes is not recognised by standard monitoring models, which revolve around placental insufficiency rather than metabolic anomalies. Methods. Patients with diabetes from four case-control studies were combined to form a total sample of 159 cases for validation of the risk scoring system. Univariate logistic regression analysis was used to assess the effect of individual risk factors with proposed cut-offs on adverse pregnancy outcome. The diagnostic accuracy of the total summative score was assessed by computing the area under the receiver operating characteristic (ROC) curve. Results. Four potential parameters were identified to risk-categorise fetuses in a pregnancy complicated by gestational diabetes, i.e. the myocardial performance index (MPI), the E/A ratio (early diastolic filling/late diastolic filling, a marker of diastolic dysfunction), increasing fetal weight (macrosomia), and an increased amniotic fluid index. The total score, obtained by summation of the composite scores for these parameters, ranged from 0 to 11. The total score performed as an excellent predictor of adverse outcome, evidenced by an ROC area under the curve of 0.94. A cut-point of 6 on the score confers a sensitivity of 84.2% and specificity of 90.2% for predicting adverse outcome. Conclusion. To our knowledge, this is the first gestational diabetes scoring system proposed to predict an adverse outcome.