Perineal injuries during vaginal birth in low-resource countries.

Birth related perineal trauma (BRPT) and obstetric anal sphincter injuries (OASIS) are leading causes of anal incontinence in women, which negatively impacts on their quality of life, resulting in low self-esteem and abandonment. In low resource countries (LRC), the true incidence is not known and since most births are unattended or occur in community-based health care systems, one can anticipate that it is a significant problem. Dissemination of information to women, education of traditional birth attendants, improvement of resources and transport, and training of health professionals on the detection and appropriate surgical management of these injuries will reduce morbidity and improve outcome. Intrapartum measures such as controlled head descent and perineal support, correct episiotomy techniques and selective use of instruments to assist vaginal births is pivotal in avoiding these injuries. Policy makers should prioritize maternity care in LRC, and research is urgently needed to address all aspects of BRPT.

Expectant management of advanced abdominal pregnancies: Is it justifiable?

OBJECTIVE: To evaluate the outcome of a case series of women with advanced abdominal pregnancies (AAP) who underwent expectant management. STUDY DESIGN: A retrospective study that utilized prospective data of 46 women who were admitted for expectant management at a tertiary hospital in Durban, South Africa. All data was analyzed descriptively and presented in percentages. RESULTS: The average period of expectant management was 27 days; thirty-three (72 %) of the 46 women were discharged from the hospital with live babies. There were 11 (24 %) neonatal deaths and two cases of stillbirths. There were no maternal deaths and morbidity was minimal. CONCLUSION: When diagnosed after the 24th week of gestation, an option is expectant management which includes careful patient selection, prolonged hospitalization, and close antenatal fetal and maternal surveillance to achieve fetal viability. Management by experienced clinicians and a multidisciplinary team in a tertiary institution is recommended. Informed consent needs to take into consideration the risks with interventional laparotomy, social separation from family and friends, and the guarded perinatal outcome.

Histopathological features in advanced abdominal pregnancies co-infected with SARS-CoV-2 and HIV-1 infections: A case evaluation.

Objectives: This study aims to provide a semi-qualitative histopathological report of the dual SARS-CoV-2 and HIV infected placentae in the third trimester of Advanced Abdominal Pregnancy (AAP). Study design: Four AAP placentae in the third trimester of pregnancy (two positive for HIV-1 and two positives for SARS-CoV-2) were histologically examined. Results: The SARS-CoV-2+ HIV+ placentae were dysmorphic in shape compared to the flattened disc-like shape noted in the SARS-CoV-2+HIV-, SARS-CoV-2-HIV+and SARS-CoV-2-HIV- placentae. Diffused syncytial knots and syncytial degeneration were observed in all placentae. Intermittent cytotrophoblast increase, perivillous and intravillous fibrin deposition, mononuclear inflammatory cells with widespread degeneration/necrosis of the syncytiotrophoblast and microcalcification were pronounced in the SARS-CoV-2+HIV+ compared to the SARS-CoV-2+HIV- placentae. Vascular pathological changes included thrombi, ectasis, mural hypertrophy and atherotic vessels. Conclusion: Elevated syncytial trophoblast injury, villitis, microcalcifications and mineralisation of the syncytial basement membrane in the AAP placentae may be due to SARS-CoV-2 viral transgression instead of HIV infection alone. Vascular malperfusion is suggestive of a hypoxic insult arising from a compensatory response to meet the fetal oxygen and nutrient demands of an AAP. Placentae from HIV infected women on antiretroviral treatment were characterised by vascular malperfusion.

Laparoscopic approach to vesicovaginal fistulae.

The surgical repair of vesicovaginal fistula (VVF) over the last two decades has evolved from the transabdominal/transvaginal route to minimally invasive techniques of laparoscopy and robotic surgery. The indications for laparoscopic repair include supratrigonal fistulae, and stenotic/narrow vaginas that make vaginal access to the fistula site difficult. In the current published literature, comparable results have been reported with open surgery. The initial techniques were performed to simulate the open classic technique described by O'Conor, but with better imaging, exposure and magnification, the modified O'Conor (smaller cystotomy) and the extravesical approaches (no cystotomy) are being performed with comparable results. Difficulties such as depth perception, suturing and ergonomics together with the steep learning curve associated with laparoscopy have been overcome with the introduction of robotics. Reports on laparoendoscopic single site surgery (LESS) and transvesicoscopic VVF repairs with successful outcomes have been published, but studies on a large number of patients are needed to establish their effectiveness. Difficulties of managing suturing have been circumvented with the usage of the barbed suture; however, more data are required to establish its efficacy. Although the laparoscopic/robotic approach of a VVF repair offers numerous advantages, the best chance of success is achieved with the first surgical attempt using an approach that the surgeon is familiiar in performing.

Hepatic pregnancy managed conservatively.

We present a case of hepatic pregnancy and discuss expectant management, use of newer imaging techniques and approaches to management, such as leaving the placenta in situ, the use of magnetic resonance imaging and sonography in the follow-up of placental involution. This case report illustrates that conservative management is feasible.

An audit of obstetric fistulae in a teaching hospital in South Africa.

Obstetric fistulae are still common in the rural areas of South Africa. This study describes the demographic and clinical characteristics of 41 women with obstetric urinary fistulae. All were from poor socioeconomic backgrounds and had limited or no access to antenatal care.

Obstetric Urinary Fistulas in KwaZulu-Natal - What is the Extent of this Tragedy?

Background. This study describes the demographics and clinical characteristics of women with obstetric fistulas attending the urogynaecological unit at King Edward VIII Hospital (KEH); KwaZulu-Natal (KZN); South Africa. Method. A prospective clinical review of all women admitted with the diagnosis of an obstetric fistula at KEH from 1999 to 2003. Results. A total of 41 cases from the rural areas of KZN and the Eastern Cape were identified. The mean age was 29 years (range 15 - 51 years); and 21 were primi- gravidas; 14 of whom had unplanned pregnancies. All were from low socioeconomic backgrounds and had limited or no access to antenatal care; either due to their social cir- cumstances or to lack of health care facilities. The duration of labour was prolonged in all; there were 5 live births; and 2 neonatal deaths. Conclusion. Obstetric fistulas are still common in KZN and the Eastern Cape; and occur mainly in women from rural areas

Emergency gynaecology.

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.

The value of magnetic resonance imaging in the diagnosis and management of extra-uterine abdominal pregnancy.

AIM: To determine the value of magnetic resonance imaging (MRI) in the detection of the location of the placenta and placental adherence in patients with extra-uterine or abdominal pregnancy. METHODS: A retrospective study of patients with a suspected diagnosis of extra-uterine pregnancy was performed over a 12-month period. MRI images on hard and soft copy were reviewed by two radiologists blinded to the clinical and operative findings. RESULTS: Nine patients with 10 foetuses were imaged. Nine foetuses were in an extra-uterine position; three were delivered dead, one from intrauterine growth retardation and one from a fatal congenital anomaly. The placenta was located correctly in all nine patients with placental adherence demonstrated in four patients. The placenta was safely delivered in six patients and left in situ in three in which there was MRI evidence of placental adherence. CONCLUSIONS: MRI is valuable in accurately demonstrating the location of the placenta within the abdomen and the presence of placental adherence, which directly affects the decision whether to remove or leave the placenta in situ.

Ventral pre-public herniation of bladder following incontinence surgery

Objective: Ventral pre-pubic herniation of the bladder through an incisional hernia is an uncommon condition and reports in the literature are confined to one or two cases. We describe nine patients who presented with this condition 1 to 5 years after undergoing Burch colposuspension operations for stress urinary incontinence [SUI]. Patients and Method: All patients developed the condition following Burch colposuspension operations for stress urinary incontinence. Their non-specific presenting symptom complex is described and emphasized. The incisional hernias were difficult to diagnose on initial clinical examination and easily missed; unless the patient was examined in the erect position with a full bladder. Lateral cystography was the definitive diagnostic imaging modality. CT findings were dramatic and informative but not essential for the diagnosis. On urodynamic investigation bladder pain and urgency on low volumes were found; but no abnormal contractions were seen. Cystoscopy was essential to exclude other intravesical pathology and the specific findings are described. As these patients had intractable bladder symptoms; surgical repair was performed. The anatomical defect in the anterior abdominal wall was always more extensive than anticipated and closure incorporating Prolene mesh and sutures was performed. Co-morbid vaginal prolapse was repaired 4 to 6 months later. Recurrent stress urinary incontinence in one patient was preferably treated with a transobturator suburethral tape. Results: Two patients developed recurrent incisional hernias within the first year. Our first patient who had a primary closure only; had a subsequent successful closure with Proline mesh. One other patient developed a recurrence in the upper part of the wound. The other patients were all symptomatically satisfied with their results at 6-month follow-up. The symptoms of bladder overactivity had reduced dramatically to satisfactory levels and clinically the repairs were secure. The subsequent vaginal repairs of their recurrent cystoceles and rectoceles in three patients seemed successful on short follow-up. The patient who had the transobturator suburethral tape placed is clinically continent. Conclusion: The condition is probably more common than realised and significantly under diagnosed. It should be considered and actively excluded in patients with symptoms of bladder irritability and pain after previous suprapubic incontinence or prolapse surgery. Surgical repair utilising Prolene mesh is recommended and co-morbid urogenital prolapse or recurrent stress urinary incontinence can be adequately treated 4-6 months later

Passive ileal segment urinary diversion in advanced cervical carcinoma--a retrospective review.

OBJECTIVES: Urinary diversion is a clinical management option that gynaecological oncologists often use for urinary fistulas associated with cervical cancer. We retrospectively reviewed the indications and postoperative morbidity and mortality associated with this procedure. METHODOLOGY: The case records of all patients with cervical carcinoma undergoing a passive ileal segment urinary diversion at King Edward VIII Hospital in Durban between 1 January 1991 and 31 December 1995 were reviewed retrospectively. The patient profile, indication for the operation and postoperative morbidity and mortality were noted. RESULTS: Sixty-five patients were entered into the study. Thirty-two patients (49%) had untreated advanced cervical carcinoma, 12 (19%) had had prior palliative irradiation for cervical carcinoma and 21 (32%) had received prior radical radiotherapy for cervical carcinoma. Fifty per cent of patients experienced significant postoperative morbidity. This was especially high in those patients who had received prior radical radiotherapy (67%). Twelve patients (19%) died before discharge. Six (50%) of those who had received prior radical radiotherapy died following the procedure. Advanced age (more than 65 years), previous radical radiotherapy, extrapelvic metastatic carcinoma and re-laparotomy for complications of the procedure were significant risk factors for postoperative mortality in our study. CONCLUSION: Careful patient selection, the use of bowel free of radiation injury, supportive management of postoperative complications and the establishment of a specific unit of trained staff are essential in order to ensure a successful outcome in patients undergoing this procedure.