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Background and Objective: In Malawi, emergency peripartum hysterectomy continues to be routine for the management of puerperal sepsis. While the hysterectomy may be life-saving for the mother, it carries with it life-altering permanent sterility. The surgeon is left with a difficult dilemma: remove the infection source (uterus) to preserve the life of the patient at the cost of her fertility, or preserve the uterus and fertility but risk worsening infection and possible death for the patient. The objective of this study was to (1) identify characteristics associated with mortality post-laparotomy due to puerperal sepsis and (2) identify characteristics associated with emergency peripartum hysterectomy in the management of puerperal sepsis. Methods: In this retrospective chart review, we obtained medical records of patients who underwent laparotomy secondary to puerperal sepsis at a tertiary hospital in Lilongwe, Malawi. Data collected included demographic information and clinical findings. These data were compared between women with and without adverse outcomes. Chi-squared tests were used to determine if there were significant relationships between variables and outcomes. Results: Fifty-eight patient records met inclusion criteria. The following characteristics were significantly associated with mortality: age greater than 30, multiparity, vaginal delivery, and intensive care unit admission. Cesarean delivery and an intraoperative finding of necrosis were significantly associated with hysterectomy. Conclusion and Global Health Implications: Emergency peripartum hysterectomy in the setting of puerperal sepsis is a significant source of maternal morbidity and mortality. To prevent emergency peripartum hysterectomy, it is important to have prompt recognition and treatment of puerperal sepsis, to have access to adequate antibiotics, and to have standards to guide the role of hysterectomy as the definitive and necessary treatment for puerperal sepsis.
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BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the feasibility of a customized, culturally sensitive pregnancy wheel given to pregnant women to improve gestational age dating accuracy at the time of delivery and to improve antenatal care attendance. METHODS: This was a pilot randomized trial involving pregnant women presenting to a regional hospital in Lilongwe, Malawi. The primary outcome was accuracy of gestational age at the time of presentation to the hospital in labor. The secondary outcome was the number of antenatal visits. RESULTS: At final analysis, 14 subjects were included in the pregnancy wheel (intervention) arm and 11 in the standard care arm. Fifty percent (n=7) of women in the intervention arm were accurately dated at the time of presentation for delivery, compared to only 9% (n=1) in the standard antenatal care arm (p=0.04). There was not a significant difference in the number of antenatal visits between the two study arms. No patients met the World Health Organization's recommended eight antenatal care visits for prenatal care. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: The customized pregnancy wheel given to patients could improve gestational age dating accuracy, and as a result, clinical decision making. However, the barriers to greater antenatal care access are more complex and likely require a more complex solution. Significant attrition in this pilot trial limited statistical power, suggesting the need for future larger interventions. Accurate gestational dating requires access to ultrasonography and early antenatal care initiation, both of which are inadequate in Malawi. Although the customized pregnancy wheel did not improve antenatal care attendance, it improved gestational age dating accuracy in a pilot study at a central hospital in Lilongwe, Malawi.
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Women are particularly susceptible to unintended pregnancies in the first year after birth, with 10-44% of pregnancies being unintended. In many settings, post-partum birth control is initiated at the six-week post-partum visit but most women are sexually active by this time, and ovulation can occur as early as day 28. There are many potential advantages of initiating intrauterine contraception (IUC) and implants use in the immediate post-partum period, including their high efficacy and reversibility which rivals sterilisation as well as ease of access to providers trained in their insertion. This review aims to describe the benefits and risks of use of IUC and implants in the immediate post-partum period. It discusses the maternal and infant health safety issues of early initiation of the progestogen containing methods and provides a critical review of existing international guidelines. Overall low rates of adverse effects such as pain, bleeding, infection and perforation, are documented to occur in all studies regardless of the timing or route of IUC insertion. Expulsion rates are significantly higher immediately after vaginal delivery compared to interval insertions, but are no higher after insertion at caesarean section. Post-partum implants appear to have the same side effects as interval insertions, and to date, no adverse impact on breast milk or infant growth has been demonstrated. Most international evidence-based guidelines support the initiation of IUC and progestogen containing contraceptive methods in the immediate post-partum period as they regard the advantages of provision at this time to outweigh the risks.
