Peripartum hysterectomy: two years experience at Nelson Mandela Academic hospital, Mthatha, Eastern Cape South Africa.

BACKGROUND: Obstetric haemorrhage is the leading direct cause of maternal mortality in South Africa. OBJECTIVE: To determine the incidence, indications, associations and maternal outcomes of emergency peripartum hysterectomies. METHODS: A descriptive and retrospective analysis of patients who had peripartum hysterectomy between 1(st) February 2007 and 31(st) January 2009 in Nelson Mandela Academic Hospital at Mthatha city. RESULTS: The incidence of 0.95% of peripartum hysterectomies (n=63 or 9.5/1000 births) increased with the increasing maternal age from 0.121% at age of less than 20 years to 0.5% at age more or equal to 30 years. Similarly the incidence increased with parity from 0.332% for Primiparity to 0.468% at parity of four or more. The indications for the operation were uterine atony 19/63 (30.2%), secondary haemorrhage/puerperal sepsis 17/63 (27%) and ruptured uterus 16/63 (23.4%). The main intra operative complication was haemorrhage 13/63 (20.6%). Repeat laparotomy was done in 10/63 (15%) of patients due to haemorrhage. Admission to intensive care unit was 25/63 (39.7%). The case specific mortality rate was of 19 % (n=12). The main causes of death were hypovolaemic shock and septicemia. CONCLUSION: The incidence of peripartum hysterectomies was high and was associated with ruptured uterus and puerperal sepsis which are preventable.

Plasma vitamin C concentration in pregnant women with pre-eclampsia in Mulago hospital, Kampala, Uganda.

BACKGROUND: Oxidative stress plays a role in the aetiology of pre-eclampsia and vitamin C may prevent pre-eclampsia. OBJECTIVE: To determine the association between plasma vitamin C and pre-eclampsia in Mulago Hospital, Kampala, Uganda. METHODS: This case-control study was conducted at Mulago Hospital from 1(st) May 2008 to 1(st) May 2009; 207 women were the cases and 352 women were the controls. Plasma vitamin C was assayed in the women using a colorimetric method. An independent t test was used to find the difference in the means of plasma vitamin C and logistic regression was used to find the association between plasma vitamin C and pre-eclampsia. RESULTS: The mean plasma vitamin C was 1.7(SD=0.7) × 10(3) µg/L in women with pre-eclampsia and 1.9(SD=0.7) × 10(3) µg/L in women with normal pregnancy (P=0.005). Women with low plasma vitamin C were at an increased risk of pre-eclampsia (OR 2.91, 95% CI: 1.56-5.44). CONCLUSION: There was a strong association between low plasma vitamin C, and pre-eclampsia in women attending antenatal clinics at Mulago Hospital, Kampala. Health workers need to advise women at risk in the antenatal period about diet, especially foods which are rich in vitamin C to probably reduce pre-eclampsia.

Risk factors for severe pre-eclampsia and eclampsia in Mulago Hospital, Kampala, Uganda.

OBJECTIVE: To determine the risk factors for severe pre-eclampsia and eclampsia in Mulago Hospital, Kampala, Uganda. DESIGN: A case control study. SETTING: Mulago Hospital labour ward SUBJECT: One hundread and fourty three women with severe pre-eclampsia/eclampsia and 500 women with normal delivery. RESULTS: The predictors of severe pre-eclampsia/eclampsia were: low socio - economic status (OR 7.6, 95%CI 3.9 - 26.9), chronic hypertension (OR 26.9, 95% CI 4.3-170.4), family history of hypertension (OR 1.9, 95% CI 1.2-2.9), nulliparity (OR 2.2, 95% CI 1.2-4.3) and delivery of male babies (OR 1.5, 95% CI 1.0 to 2.3). CONCLUSION: Severe pre- eclampsia is one of the main causes of maternal morbidity and mortality in Mulago hospital. The predictors of severe pre - eclampsia were chronic hypertension, family history of hypertension, low socio - economic status, nulliparity and delivering male babies. Health workers need to identify women at risk and offer them counseling and, those who develop pre - eclampsia be referred and managed in hospitals with expertise and facilities. Those who develop severe pre-eclampsia should be delivered immediately so as to reduce the morbidity and mortality associated with this condition.

Risk factors for ruptured uterus in Mulago hospital Kampala, Uganda.

OBJECTIVE: To determine the risk factors for ruptured uterus. DESIGN: A case control study. SETTING: Mulago Hospital labour wards, Kampala, Uganda. SUBJECTS: Fifty two women with ruptured uterus were recruited between 15th November 2001 and 30th November 2002 and were compared with 500 mothers with normal delivery. RESULTS: The predictors for ruptured uterus were low socio-economic (OR 2.5, 95% CI 1.2-7.1), residing more than ten kilometres from Mulago hospital (OR 6.7, 95% CI 2.1-21.2). Delivery by Caesarean section in previous pregnancy (OR 22.3, 95% CI 9.2-54.2) delivery of babies weighing more than 3500 grams (OR 2.4, 95% CI 1.2-7.2) and testing HIV positive (OR 3.2, 95% CI 1.5-7.2). CONCLUSION: Uterine rupture is still common in our society and is associated with severe maternal morbidity and mortality. There is need for women to use maternity units during pregnancy and delivery, to monitor labour using a partograph and timely intervention of delivery will prevent uterine rupture.

Risk factors for severe post partum haemorrhage in Mulago hospital, Kampala, Uganda.

OBJECTIVE: To determine the risk factors for severe postpartum haemorrhage. DESIGN: A case control study. SETTING: Mulago hospital labour wards, Kampala, Uganda. SUBJECTS: One hundred and six mothers with severe postpartum haemorrhage were recruited between 15th November 2001 and 30th November 2002 and were compared with 500 women who had normal delivery. RESULTS: The predictors for postpartum haemorrhage were co-existing hypertension (O.R 9.3, 95% CI: 1.7-51.7), chronic anaemia (OR 17.3, 95% CI: 9.5-31.7), low socio economic background (OR 5.3, 95% CI: 3.0, 9.2), past history of postpartum haemorrhage (OR 3.6, 95% CI: 1.1-11.8), previous delivery by Caesarean section (OR 7.5, 95% CI: 3.5-14.3), long birth interval of more than sixty months (OR 5.2, 95% CI: 2.1-13.0), prolonged third stage (OR 49.1, 95% CI: 8.8-342.8) and non use of oxytocics (OR 4.3%, 95% CI: 1.2-15.3). CONCLUSION: Severe postpartum haemorrhage is common in our environment and is associated with a high maternal morbidity and mortality. The determinants of postpartum haemorrhage are useful in identifying mothers at risk and together with the services of a skilled birth attendant at delivery will prevent postpartum haemorrhage and reduce the maternal morbidity and mortality associated with this condition. In our study, the following risk factors were identified: pre-existing hypertension, chronic anaemia, low socio-economic background, history of postpartum haemorrhage, previous delivery by Caesarean section, longbirth interval of more than sixty months, prolonged third stage and non use of oxytocics were found to be significant.

Risk factors for Placenta Praevia Presenting with severe Vaginal Bleeding in Mulago Hospital; Kampala; Uganda

Objective: To determine the risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital; Kampala; Uganda. Design: A case control study. Set- ting: Mulago hospital labour suite Participants: Between 15th November 2001 and 30th November 2002 we identified and recruited thirty six parturients with placenta previa who developed severe bleeding and 180 women with normal delivery. The risk factors were studied. Variables of interest: Socio demographic characteristics; social and family history; gynaecological operations; blood transfusion; medical conditions; past and present obstetric performance and HIV status. Results: Significant predictors for severe bleeding in parturients with placenta praevia were: previous history of evacuation of the uterus or dilation and curettage (O.R. 3.6; CI: 1.1-12.5); delivery by caesa- rean section in previous pregnancy (O.R. 19.9; CI: 6.4-61.7); residing more than ten kilometres from Mulago hospital (O.R. 2.4; CI: 1.0-5.7) and recurrent vaginal bleeding during the current pregnancy (O.R. 7.3; CI 2.4-63.7). Conclusion: Severe bleeding in placenta praevia is associated with high maternal morbidity and mortality. The determi- nants of severe bleeding in placenta praevia can be used in the antenatal period to identify mothers at risk. These; with prompt interventions to deliver the women can be used to reduce the maternal morbidity associated with this condition

A randomised controlled trial of early initiation of oral feeding after caesarean delivery in Mulago Hospital.

BACKGROUND: The concept of early initiation of oral feeding after caesarean delivery is well tolerated by patients, yet not routinely practiced in Mulago Hospital. An effective postoperative dietary management schedule could have major implications on the management of maternal post-caesarean section mothers. OBJECTIVES: To compare the effect of time initiation of oral feeding on acceptability, benefits and gastrointestinal functions in women who had undergone caesarean section in Mulago Hospital. DESIGN: A randomised controlled study. SETTING: Mulago Hospital. SUBJECTS: One hundred and ninety two women admitted on the postnatal ward after emergency or elective caesarean section for various indications and who satisfied the eligibility criteria were recruited and randomized into the study. Assignment to the early feeding group or routine feeding group was done randomly using a computer generated numbers. The early feeding group were encouraged to take sips of water within six to eight hours followed by oral soup or milk at least 150 millilitres at a time within 8 to 12 hours post operative under supervision. The routine group were managed by restricting oral intake for twenty four hours and administration of orals sips of water 24 to 48 hours post operative. The outcome measures were rate of ileus symptoms, post operative presence of bowel sounds, maternal pyrexia and acceptability and benefits of early feeding. RESULTS: The mean age, parity and gravidity were similar in the two groups. The study shows that women of the early feeding group had more rapid return of their bowel function with significant more shorter mean post operative time intervals to bowels sounds (24.2 hours versus 34.2 hours), passage of flatus (51.6 hours versus 62.1 hours) and bowel movement (67.8 hours versus 75.8 hours). The women who fed early, made more rapid recovery and expressed their interest in earlier hospital discharge. The findings significantly indicated that women in the early feeding group got out of bed (patient mobilisation) earlier (p = 0.001) than their control group (15.1 hours versus 17.8 hours). This could probably have been because of the adequate rehydration and improved early energy intake. In comparison those who were fed early required less number of bottles of intravenous fluids (5.0 bottles versus 7.0 bottles). The average hospital stay was similar and not statistically significant in both groups (5.5 days versus 6.0 days). CONCLUSION: Early initiation of oral feeding after caesarean delivery is safe and well tolerated and can be implemented without an increase in gastrointestinal symptoms or paralytic ileus.