Clinical and Sociodemographic Characteristics Associated with Emergency Peripartum Hysterectomy due to Puerperal Sepsis in Malawi.

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.

Reinventing the Pregnancy Wheel to Improve Pregnancy Dating and Antenatal Care Visits: A Pilot Randomized Trial in Malawi.

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.

Persistent depression after obstetric fistula repair.

OBJECTIVE: To measure depression over time using the Patient Health Questionnaire 9 (PHQ-9) and identify characteristics associated with persistent depression. METHODS: A database of women undergoing obstetric fistula repair was used to examine associations between depression and variables such as demographics, type of fistula, and postoperative continence status. RESULTS: A total of 797 patients completed the PHQ-9 at the initial preoperative assessment; 365 (45.8%) had a PHQ-9 score of 5 or higher, indicating depression. Preoperatively, depression was associated with women aged 18-34 years, with no children, and with fistula for 5 years or less. Postoperatively, depression was associated with persistent incontinence. Over time, however, depression was rarely found among women returning for follow-up. CONCLUSION: Postoperative depression decreased over time in women who returned for follow-up, either due to selection bias or due to improved adjustment to one's circumstances. This study underscores the need for ongoing follow-up, especially for those not presenting for care or with persistent incontinence.

A study of the face recognition ability of orthodontists and lay persons of different age groups.

OBJECTIVE: To determine the face recognition ability of orthodontists and lay persons of different age groups. DESIGN: Cross-sectional study design, in which participants completed a 'Face Recognition Test'. SETTING: Participants were recruited from the Royal London Hospital, Ashford Hospital, Southend University Hospital and the British Orthodontic Society Conference, 2006. SUBJECTS AND METHOD: Colour photographs and 3D laser scans of eight volunteers were displayed and participants were asked to match the photographs of each face with the corresponding laser scan within 90 seconds. Participants consisted of 85 orthodontists under 50 years of age, 83 adolescents aged 15-18 years, 85 younger lay adults aged 19-49 years and 83 older lay adults aged 50-70 years. RESULTS: Female orthodontists were more successful in the face recognition test than female lay persons (P≤0·001) and were four times more successful than the male orthodontists (P = 0·003). There were no differences in face recognition ability between males and females in the lay persons groups (P = 0·970) or between male orthodontists and male lay persons (P = 0·240). When comparing age groups, no significant difference in successfully completing the face recognition test was detected between the adolescent, adult and older adult age groups (P = 0·070). CONCLUSIONS: Overall, our understanding of facial recognition is limited and the mechanisms by which lay people perceive and recognise other faces are important for the orthodontist to consider.

Surgical emphysema following a restorative procedure: A case report.

UNLABELLED: Surgical emphysema is a rare complication following a restorative procedure, despite the use of air-driven handpieces. Although most cases resolve spontaneously, it should be correctly managed to avoid potentially life-threatening situations, such as pneumomediastinum and pneumothorax. CLINICAL RELEVANCE: Surgical emphysema, although rare, can occur following certain dental procedures. It should be avoidable but, when it occurs, appropriate management is essential.