Obstetrics and Gynaecology

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Spot urine protein to creatinine ratio testing : new techniques for detecting proteinurra in pre-eclampsia.
(2008) Gangaram, Rajesh.
Background: The most commonly employed screening method for proteinuria is a semi- quantitative dipstick urinalysis, but it has been shown to be inaccurate in pregnancy. New developments in the assessment of proteinuria have included the use of urinary albumin measurements. The Clinitek Microalbumin Reagent Strip (Bayer Healthcare LLC, USA) is a semi-quantitative dipstick test. It is used to measure the spot urinary microalbumin to creatinine ratio that is read using the Clinitek 50 portable urine chemistry analyzer. Aims We embarked on a pilot study to validate the Clinitek 50 system by determining the accuracy of spot urinary microalbumin to creatinine ratio dipsticks and conventional visual dipsticks (Makromed) compared to the laboratory urinary microalbumin to creatinine ratio quantification to detect significant proteinuria in normotensive and hypertensive antenatal attendees. The accuracy of spot urinary microalbumin to creatinine ratio dipsticks and conventional visual dipsticks were then compared to a 24 hour urinary protein (gold standard) to detect significant proteinuria in hypertensive disorders of pregnancy. We then determined the role of proteinuria as assessed by the diagnostic accuracy of both the 24 hour urinary protein (gold standard) and the spot urinary microalbumin to creatinine ratio dipstick, in pregnancy outcomes of these participants. Methods This was a prospective study conducted at hospitals serving the Durban Metropolitan region in South Africa. To validate the urinary microalbumin to creatinine ratio dipstick, fifteen normotensive healthy pregnant women and 11 women with new onset hypertension in pregnancy were recruited .Each women had a spot midstream urine, which was assessed for proteinuria using a semi-quantitative visual dipstick (Makromed) and analysed using the semi-quantitative urinary microalbumin to creatinine ratio dipsticks (Clinitek® Microalbumin) read on the Clinitek® 50 urine chemistry analyser. A result of 1 + on visual dipsticks and a spot urinary microalbumin to creatinine ratio UAC of > 300mg/g (33.9mg/mmol) was considered as positive for significant proteinuria. The results were compared to the laboratory quantitative measurement of the urinary microalbumin to creatinine ratio. The study group comprised 163 women presenting with newly diagnosed hypertension during pregnancy after 20 weeks of gestation, being recruited from antenatal clinics. Each participant had a spot urine sample that was tested by trained midwives for proteinuria using a semi-quantitative visual dipstick (Makromed). Participants were admitted to the ward where a spot midstream urine sample was collected and analysed using the semi-quantitative urinary microalbumin to creatinine ratio dipsticks. A 24 hour quantitative urinary protein analysis was completed. The results of the urinary microalbumin to creatinine ratio dipsticks and conventional visual dipsticks were compared to the 24 hour urinary protein (gold standard) to detect significant proteinuria. A urinary microalbumin to creatinine ratio of < 300mg/g (nil and trace on visual urine dipsticks) was considered to be a negative result. A urinary microalbumin to creatinine ratio 300 mg/g (1+ to 4+ on visual urine dipsticks) was considered to be a positive result. Urinary protein 0.3 g/24 hours was considered significant proteinuria. The outcomes of pregnancy in 2 sub-categories viz. those with and without significant proteinuria were compared using the 24 hr urinary protein measurement. A secondary analysis of outcomes of pregnancy was performed by subcategorizing the participants according to the diagnostic accuracy of the urinary microalbumin to creatinine ratio dipsticks. In the 26 patients enrolled in the initial study , the visual dipstick had a sensitivity of 25% ( 95% CI [0.04-0.64] ) and specificity of 89% ( 95% CI [0.64 -0.98]).The urinary microalbumin to creatinine ratio dipsticks had a sensitivity of 88% ( 95% CI [0.47-0.99]), specificity of 89% (95% CI [0.64-0.98]), negative predictive value (NPV) of 94% (95% CI [0.69-1.00]) and positive predictive value (PPV) of 78% (95% CI [0.40-0.96]). In the 163 patients subsequently enrolled the visual dipstick had a sensitivity of 51 % ( 95% CI [0.41-0.61]) and specificity of 91% (95% CI [0.81-0.96]) .The PPV and NPV was 89 %( 95% CI [0.77-0.95]) and 58% (95% CI [0.48-0.67]) respectively. The urinary microalbumin to creatinine ratio dipsticks had a sensitivity of 63% (95% CI [0.52-0.72]) and specificity of 81 % (95% CI [0.70-0.89]). The PPV was 82% (95% CI [0.71-0.90]) and NPV was 62% (95% CI [0.51-0.71]). Our results show that in hypertensive pregnant women, significant proteinuria determined by the quantitative 24 hour urinary protein is associated with delivery at an earlier gestational age, increased induction of labour and lower birthweights compared to the non-proteinuric hypertensives (gestational hypertension). There is also a trend towards an increased maternal morbidity and perinatal mortality. When the groups were classified into pre-eclampsia and gestational hypertension using the diagnostic accuracy of the urinary microalbumin to creatinine ratio dipsticks, there were no differences in the clinical outcomes between the false negatives and true negatives except a trend towards a higher caesarean section rate in the false negatives. Conclusion The urinary microalbumin to creatinine ratio dipstick read on the Clinitek 50 system provides a semi – quantitative result of the urinary microalbumin to creatinine ratio that has good sensitivity and specificity. Furthermore, the urinary microalbumin to creatinine ratio dipstick has a good negative predictive value and a result of < 300mg/g rules out significant proteinuria and avoids unnecessary investigations in pregnancy. Both the visual dipstick (Makromed) and the urinary microalbumin to creatinine ratio dipstick read on the Clinitek 50 system are not accurate when compared to the total 24 hour urinary protein. Differences between the urinary microalbumin to creatinine ratio and 24 hour total urinary protein may be due to the variation in the albumin fraction of the total urinary protein of pre-eclampsia, technical problems with imprecision of the assay technique and clinical causes of false positives and negatives. The improved sensitivity of the automated urinary microalbumin to creatinine ratio dipstick over the visual dipstick suggests it may be a suitable substitute for the visual dipstick in clinical practice Hypertension in pregnancy associated with significant proteinuria is associated with greater adverse maternal and fetal outcome. Outcome of pregnancy is similar when a classification of gestational hypertension is made based either on the 24 hour urinary protein or the urinary microalbumin to creatinine ratio dipstick read on the Clinitek 50 system. The urinary microalbumin to creatinine ratio dipstick is a good screening test to rule out significant proteinuria. It has the potential to improve accuracy of screening for proteinuria and enhancing safety by preventing incorrect diagnosis and unnecessary investigation. Further research is required to determine its full impact and cost effectiveness in the clinical setting.
Evaluation of haematological parameters and immune markers in HIV-infected and non-infected pre-eclamptic Black women.
(2007) Naidoo, Kalendri.; Moodley, Jagidesa.
This study focuses on women with both pre-eclampsia and Human Immunodeficiency Virus (HIV). Pre-eclampsia is a pregnancy-specific syndrome that occurs after 20 weeks gestation. Thrombocytopenia is the most common haematological abnormality in pre-eclampsia. Further, studies suggest that the immunological mechanism plays some role in the aetiology of pre-eclampsia. The immunological hallmark of HIV infection is a progressive decline in the number of CD4 T lymphocytes and significant haematological abnormalities are also common in HIV-infected individuals i.e. anaemia, thrombocytopenia and leukopenia. The study population comprised of two groups i.e., pre-eclamptic HIV-positive African women and preeclamptic HIV-negative African women as the control group. Samples were analysed for haematological parameters (full blood count) and immunological markers (flow cytometry). There was no statistical significance in the following parameters: RBC, Hb, haematocrit, MCV, MCH, MCHC, platelets, MPV, WBC, lymphocytes, neutrophils, eosinophils, monocytes, basophils and CD8. There was a statistical difference in the CD3 and CD4 counts between both the groups. However, the CD3 and CD4 counts were within the normal range in the HIV-negative pre-eclamptic group and even though CD3 decreased, it was still within the normal range in the HIV-positive pre-eclamptic group, with CD4 decreasing below the normal range in the HIV-positive pre-eclamptic group. This suggests that immune mechanisms involving CD estimations do not play a role in pre-eclampsia since the decrease in the counts can be solely attributed to HIV infection. Results obtained in this study do not show any severe haematological or immunological abnormalities when women have both pre-eclampsia and HIV infection.
Profile of mortality amongst women with gestational trophoblastic disease (GTD) infected with the human immunodeficiency virus (HIV) in relation to HIV non-infected women.
(2008) Budhram, Samantha.; Moodley, Mathew.
OBJECTIVES: To determine if women with Human Immunodeficiency Virus infection with severe degrees of immunosuppression are more predisposed to mortality from Gestational Trophoblastic Disease compared with HIV-infected women with less severe degrees of immunosuppression and Human Immunodefiency Virus (HIV) non-infected women. DESIGN: Retrospective review of case records. METHOD: A retrospective review was performed on all patients with Gestational Trophoblastic from 2003 to July 2007. A chart review was conducted and information captured on a data sheet. This retrospective audit was performed at the combined gynaecology oncology clinic of Inkosi Albert Luthuli Central Hospital. All information was kept confidential and was strictly for the purposes of the audit. STATISTICS: Factors associated with mortality were tested using Fisher's exact test. Odds ratios were reported as a measure of the strength of association. Breslow-Day's test for homogeneity in odds ratios was used to compare mortality in HIV-infected and HIV non-infected women. The analysis was done using Stata 9. i RESULTS: A total of 78 patients with Gestational Trophoblastic Disease were reviewed. There were 53 patients with invasive molar pregnancy and 25 patients with choriocarcinoma. The HIV sero-prevalence was 31%. There were 15 deaths (19%). There were 8 HIV-infected (33%o) and 7 HIV non-infected (13%) women who demised. Of the 8 patients with CD4 counts less than 200 cells/ uL, 7 patients demised. There were no mortalities amongst patients with CD4 counts more than 200 cells/uL. Of the 15 deaths, 5 HIV-infected patients and 5 HIV non-infected patients received chemotherapy. There were 5 patients admitted in very poor general condition precluding the administration of chemotherapy. Amongst the 10 patients who received chemotherapy and demised, the causes of death included widespread disease, multiorgan failure and toxicity due to chemotherapy. CONCLUSION: The overall survival of all patients managed with Gestational Trophoblastic Disease was 82% in keeping with the expected high survival reported elsewhere. The majority of patients who demised were admitted in poor general condition and had abnormal blood profiles. Despite resuscitation, these patients failed to improve precluding the administration of chemotherapy which is the mainstay of treatment. Although the numbers are small, there is clear evidence that if patients are HIV-infected with CD4 counts 200 cells/uL despite transient grade 2 myelotoxicity.
The antenatal management of the twin fetus from 30 weeks gestation.
(1979) Houlton, M. C. C.; Philpott, R. Hugh.
An aetiological study of white vulval skin lesions amongst patients attending the gynaecological clinic at R.K. Khan Hospital, Durban.
(1998) Moodley, Manivasan.; Moodley, Jagidesa.
BACKGROUND White vulva! skin lesions may be due to various conditions, including benign and non-benign causes. The dilemma faced by the clinician with such a patient is the aetiology of the lesion, as well as the approach to management. AIM To establish the aetiology of white vulva! skin lesions in patients attending the gynaecology clinic and to evaluate the role of Collin's test and vulvoscopy. SETTING R. K. Khan Hospital, which is a secondary level hospital in Durban, KwaZulu Natal. METHOD Sixty-two patients with white vulva! skin lesions whom consented to the study were recruited. The investigations consisted of Pap smear, colposcopy of the vulva [Vulvoscopy], perineum and where appropriate, vaginoscopy and colposcopy; Collin's test and biopsy of all abnormal areas detected by these tests. RESULTS Pruritus vulvae was the commonest presenting symptom [70%1. No vulvoscopic abnormalities were detected in 97% of patients, whilst 3% had acetowhite areas indicative of Human papilloma virus infection. Collin's test was positive in 40% of patients, although, histologically these areas were benign. All patients in the study had benign lesions on histology. CONCLUSION All patients in this study had benign causes of white vulval skin lesions. However, this cannot lead us to conclude that there is no role for doing Vulvoscopy and Collin's test, as premalignant and malignant lesions should be detected by these tests had they been present.
The impact of pneumonia in human immunodeficiency virus (HIV-1) infected pregnant women on perinatal and early infant mortality.
(2007) Khan, Munira.; Moodley, Jagidesa.
Background: Although the prevalence of pneumonia in pregnancy is reported to be less than 1%, the pregnant state and risk factors associated with the development of pneumonia adversely influence the outcome of pregnancy. KwaZulu-Natal is at the epicenter of the dual epidemics of tuberculosis and HIV-1 and the impact of these diseases occurring concurrently in pregnant women at King Edward VIII hospital (KEH), South Africa have been described previously. The impact of antenatal pneumonia in HIV-1 infected and uninfected women however has not been described in the study population and was investigated. Methods: Pregnant women with clinical and radiological evidence of pneumonia were recruited from the antenatal clinic and labour ward at KEH. The study was conducted prospectively between January and December 2000. The clinical profile of these women and the causative organisms were determined. In addition the impact of HIV-1 infection, maternal immunosuppression and maternal pneumonia on obstetric and perinatal outcomes were evaluated. Mothers diagnosed with tuberculosis and multi drug resistant tuberculosis were hospitalised at King George V hospital until delivery. Results: Twenty nine women were diagnosed with antenatal pneumonia (study arm) with Mycobacterium tuberculosis the only causative organism isolated. A control arm of 112 pregnant women was also studied. Maternal and perinatal mortality was restricted to the study arm with a maternal mortality ratio of 99 per 100 000 live births and a perinatal mortality rate of 240 per 1000 births. Pneumonia was significantly associated with a negative overall obstetric outcome in the presence of HIV- l infection, antenatal care, anaemia and second trimester booking status. In addition, the presence of pneumonia was significantly associated with maternal mortality. There was a highly significant association between exposure to pneumonia and poor neonatal outcome. Maternal pneumonia, maternal HIV infection and the presence of medical and obstetric conditions were significantly associated with low birth weight and neonatal pneumonia. Further, maternal pneumonia (p <0.001) and concurrent HIV infection (p=0.002) was significantly associated with neonatal death. Conclusion: The presence of pneumonia in the antenatal period impacts negatively on maternal and neonatal morbidity and mortality. Health care providers must maintain a high degree of suspicion when managing a pregnant woman with unresolving upper respiratory tract symptoms and refer timeously for further investigation. Pneumonia and in particular pulmonary tuberculosis associated with HIV co- infection in pregnancy is a threat to mother and baby. Therefore in areas endemic for TB and HIV infection, it may be prudent to screen HIV positive pregnant women for symptoms suggestive of pneumonia and thereby identify women requiring further investigations such as sputummicroscopy and cultures, and a screening chest radiograph.
A descriptive analysis of patients presenting with ectopic pregnancies at King Edward VIII hospital, Durban.
(2011) Singh, Nikhil.; Bagratee, Jayanthilall Sarjoo.
OBJECTIVE: To describe the patient profile, clinical features, risk factors, management options and complications in women with ectopic pregnancy. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: King Edward VIII Hospital, Congella, Durban from July 2005 – June 2006. MATERIALS AND METHODS: 130 case notes of women with the final diagnosis with ectopic pregnancy were examined retrospectively. Data was retrieved through a structured proforma. The variables studied included age, parity, signs and symptoms, treatment, management, complications and associated maternal morbidity and mortality. RESULTS: One hundred and twenty women diagnosed with ectopic pregnancy were included in this study. Ten patients were excluded due to failure to obtain clinical records. Women’s ages ranged from 17-40 years with 32 patients (26.7%) being nulliparous and 88 patients (73.3%) between parity 1-4. Twelve patients (10%) had a history of previous ectopic pregnancy. The commonest presenting symptom was abdominal pain in 106 (88.3%) patients whereas amenorrhoea and vaginal bleeding were found in 88 (73.3%) and 84 (70%) patients respectively. The most common physical sign was tenderness: Adnexal tenderness in 99 (82.5%) and pelvic tenderness in 91 (75.8%) of women. Fourteen women (11.7%) presented to the gynaecological outpatient’s department in acute shock with a blood pressure < 90/60 mmHg. The commonest ultrasound findings were the presence of an adnexal mass and an empty uterus in 82 (68.3%) and 80 (66.7%) women respectively. The most frequent risk factors were previous genital infection in 34 patients (28.3%) and multiple sexual partners in 32 patients (26.7%). One hundred and eleven 92.4%) women were managed by laparotomy: One hundred and four (87.4%) women via emergency laparotomy and 6 women (5%) had an elective laparotomy. One patient (0.8%) had a diagnostic laparoscopy which was converted to laparotomy. Only 8 patients (6.7%) were managed laparoscopically. Surgical treatment consisted of salpingectomy 101/120 (84.9%) and salpingotomy in 4 (3.4%) patients. Post- operation complications were minimal however the one maternal death was probably due to a pulmonary embolus. CONCLUSION: Risk factors may not always be present, hence ectopic pregnancy should be suspected in every women of reproductive age who present with unexplained abdominal pain, amenorrhoea and vaginal bleeding. Most women presented with ruptured ectopic pregnancies at King Edward VIII Hospital warranting emergency laparotomy.
An audit of couples attending the infertility unit at Inkosi Albert Luthuli Central Hospital (IALCH), Durban.
(2011) Jogessar, Jithesh Vinod.; Bagratee, Jayanthilall Sarjoo.
An audit of Couples attending the Infertility Unit at Inkosi Albert Luthuli Central Hospital (IALCH), Durban Objectives To determine the patient profile, causes of infertility and the success rates of medical and surgical treatment of infertility thus emphasizing the need for assisted reproductive treatment Methods Data was obtained retrospectively from the medical records of 281 couples that presented to Inkosi Albert Luthuli Central Hospital Infertility Unit between January 2004 and December 2006. Information was recorded on a structured proforma and data analysed using SPSS version 15.0 Results The causes of infertility were anovulation (32.7%), tubal factor (30.3%), male factor (11.7%), endometriosis (7.8%), uterine factor (4.3%) and unexplained infertility in 7.1% of cases. Couples with both male and female factors contributed to 6.1% of infertility cases. Twenty two percent of patients with severe male factor and tubal infertility could not be offered any treatment because of the unavailability of assisted reproductive technology (ART). The pregnancy rate was 24.3% after medical treatment and 14.3% after surgery. When both modalities were employed, the pregnancy rate was 26%. The overall pregnancy rate was 16% with 84% of couples requiring further treatment. Conclusion Anovulation and tubal factors were the major causes of infertility. This audit illustrates that the majority of couples (84%) require gonadotrophins and / or assisted reproductive services to achieve conception. A dedicated infertility unit should provide a full range of services including ART. A significant proportion of couples are denied this health service in the public sector in KwaZulu Natal.
The effect of childbirth on the anal sphincters demonstrated by anal endosonography and neurophysiological tests.
(1994) Sultan, Abdul Hameed.; Nicholls, R. John.; Green-Thompson, Randolph Robert.
Obstetric trauma is a major cause of faecal incontinence in women resulting in considerable social disability. Until recently the development of faecal incontinence has been attributed largely to damage to the pelvic nerves. However the advent of anal endosonography has added a new dimension to our understanding of the pathophysiology of faecal incontinence. In this thesis, gross dissection and histological studies of 19 anorectal specimens was performed to demonstrate the normal anatomy. Simultaneous dissection and sonography of the anorectum (14 in vivo and 12 in vitro studies) has clarified the normal sonographic anatomy of the anal sphincters. Anal endosonography was performed in 114 healthy volunteers to demonstrate gender differences in anal sphincter anatomy. A prospective study of 12 patients undergoing secondary sphincter repair and 15 patients undergoing lateral internal anal sphincterotomy has validated the appearance of sonographic sphincter defects. A new technique of demonstrating the anal sphincters at rest using vaginal endosonography has been demonstrated in 20 women. A prospective study of 202 pregnant women using anal endosonography and neurophysiological tests has demonstrated that 35% of primigravidae (13% symptomatic) and 44% of multigravidae (23% symptomatic) develop occult anal sphincter defects during vaginal delivery. Although pudendal nerve damage can be identified in 16% of women 6 weeks after delivery, in the majority this recovers with time. Forceps delivery was identified as the single independent variable associated with sphincter damage although damage was also sustained in the absence of instrumental delivery. In a separate study of 50 women who sustained a recognized third degree tear 47% were found to be symptomatic despite a primary sphincter repair. In 85% of these women persistent anal sphincter defects were identified sonographically. In a further study of 43 women who had an instrumental delivery (17 vacuum and 26 forceps) anal sphincter defects were identified in 81% (38% symptomatic) of women who were delivered by forceps compared to 12% (21% symptomatic) delivered by the vacuum extractor. One hundred and fifty doctors and midwives were interviewed to assess their knowledge and training in perineal anatomy and repair. There was a clear deficiency in knowledge and inconsistencies in classification of third degree tears were apparent highlighting the need for more focused training in perineal anatomy and repair.
Leptin levels in the hypertensive black African parturient.
(2001) Kafulafula, George Emmanuel.
Background: Leptin is a new adipose-derived hormone discovered in 1994. It is vital in energy balance and weight regulation in humans. During pregnancy the placenta is an extra source of leptin. The role of leptin in pregnancy is not established. This has generated a lot of interest in leptin research in pregnancy. Leptin is being examined in pathological states that may have origin in adipose tissue and the placenta such as pre-eclampsia, intrauterine growth restriction and obesity. Aim and Method: This study measured concentrations of serum leptin in Black African women during late pregnancy in 68 women with pre-eclampsia, 92 healthy normotensive pregnant women and in 32 healthy non-pregnant women. In each group leptin levels were compared between obese (body mass index, BMI = or > than 30 kgm-2) and lean women. Serum leptin concentrations were measured by radioimmunoassay (RIA) technique. Results: Serum leptin levels were higher in pregnancy compared to non-pregnant women (26.66+/-16.13 ng/ml, 25.89+/-15.83 ng/ml vs 17.97+/-11.98 ng/ml, p=0.02). This is due to firstly, the extra fat accumulated as part of the maternal adaptation to pregnancy and secondlv, to the placenta-derived leptin. Other pregnancy hormones such as insulin, hcG, prolactin and oestrogen may modulate the serum levels of leptin in pregnancy. Simple anthropometric parameters (weight, BMI, circumferences of the mid upper arm (MAC), waist (WC), hip (HC), and thigh (TC) and waist-hip ratio (WHR)) were used to explore the relationship between leptin concentrations and obesity. All the parameters showed a positive correlation with serum leptin concentration in all the groups with the exception of WHR. Weight and BMI showed the greatest correlation both in pregnant (r=0.61 and r=0.58, respectively, p<0.001) and non-pregnant (r=0.74 and 0.79, respectively, p<0.001) women. However we did not find a significant difference in the concentrations of leptin between women with and those without pre-eclampsia (26.66 ng/ml vs 25.89 ng/ml, p=0.95). This probably means that adiposity is the predominant factor influencing levels of leptin in pregnancy. The other factors mentioned above play only a minor role. Indeed the mean serum leptin levels were higher in obese compared to lean women in both pregnant and non-pregnant women. Conclusion: Pregnancy is a hyperleptinaemic state. There is no difference in serum leptin levels between women with pre-eclampsia and healthy normotensive pregnant women. Serum leptin concentration is largely determined by the degree of adiposity both in and outside pregnancy.
Critically ill obstetric and gynaecology patients : the development and validation of an outcome prediction model.
(2006) Paruk, Fathima.; Moodley, Jagidesa.
Introduction: Outcome prediction tools have the potential to provide significant adjunctive information for intensivists. Critically ill obstetric and gynaecology patients constitute a unique subset of the general ICU (intensive care unit) population yet, there exists no outcome prediction model developed specifically for these patients. Objectives: To evaluate the APACHE II score, prospectively develop and validate an outcome prediction model, evaluate organ failure (Organ Failure score and SOFA score) and review the SIRS (Systemic Inflammatory Response Syndrome) response in a cohort of critically ill obstetric and gynaecology patients. Design: A prospective study conducted over a 2 year period in the Surgical ICU at King Edward VIII Hospital, Durban. Institutional ethics approval was obtained. Patients were allocated to one of the following categories: Obstetric hypertensive group (Group I), Obstetric non-hypertensive group (Group II) and Gynaecology group (Group III). Group III was further subdivided into a pregnant (Group IIIa) and a non-pregnant group (Group IIIb). Data captured included demographic details, clinical assessment, investigations, treatment, variables required for calculating the APACHE II score, organ failure (OF) assessment, SIRS criteria and patient outcome. The APACHE II system, organ failure assessment and SIRS was evaluated in the entire patient subset. For the purpose of the outcome prediction model, the subset was divided into 2 groups: a development group and a validation group. STATA 7 software was utilised for data analysis. Results: The dataset comprised 260 inpatients. Obstetrics and gynaecology cases represented 18.5 % of the total ICU population (n=1408). The majority of the patients were young (mean age 27 ± 10.5 years). The mean ICU stay was 5.5 ± 7.9 days. The observed mortality for Groups I, II, III, IIIa and IIIb was 23.4%, 43.2%, 42.9%, 33.3% and 55.5% respectively. The mean APACHE II score was significantly higher in nonsurvivors compared to survivors for all patient subgroups (p< 0.0001). However the APACHE II system performed variably in each of the 3 groups. The area under the curve for the ROC curves in each of the 3 main subgroups varied from 0.81 to 0.94 for APACHE II. Groups IIIa and IIIb were too small to permit ROC curve analysis. Age, mean arterial pressure, respiratory rate, temperature, the Glasgow Coma Scale score and pH were identified as significant outcome predictors. Using these parameters an obstetric and gynaecology outcome prediction (OGOP) model was developed for Groups I, II and III. The area under the curve for the ROC curves in each of the subgroups was >0.9 for the OGOP Model. A predictive equation could not be developed for Groups IIIa and IIIb (due to a small number of admissions in these two groups.) Duration and the number of organ failures, correlated with outcome. The duration and number of organ failures associated with mortality differed for each group. Three OF exceeding 72 hours, 3 OF exceeding 48 hours and 3 OF equal to 48 hours were invariably fatal in Groups I, II and III/IIIa/IIIb respectively. SOFA scores were significantly higher in nonsurvivors compared to survivors (p<0.0001). A day one SOFA score equal to 18 (Group I), 15 (Group ll) and 13 (Group III, IIIa, IIIb) was also invariably fatal. A SIRS response was noted in 94.2% of the patient cohort (245/260). The SIRS response varied in the subgroups. Sterile shock and septic shock were associated with a high mortality rate. Groups IIIa and IIIb differed with respect to the mean age, duration of hospital and ICU stay and mortality rate. Although these subsets were numerically restricted (24 and 18 admissions respectively), the results suggest that the two subsets are distinctly different in nature. Comment: The OGOP model is easier to calculate and it is superior to the APACHE II System. It needs to be validated in other local and international units. Organ failure assessment as well as the SIRS response provides useful supplementary outcome information. Although current outcome prediction tools are not designed for individual application, continued research and refinement of the available tools, as well as the exploration of novel methods, may one day result in "near-perfect" prediction estimates and further broaden the scope of their utility.
Awareness, knowledge and utilization of the human papillomavirus vaccine.
(2012) Allie, Naseera.; Moodley, Mathew.
OBJECTIVES To determine if health care workers are aware of the HPV vaccine and its availability, uptake of the vaccine and prescribing practices and reasons for non – uptake of the vaccine . METHODS Health care providers working in the private sector, in the Ethekweni health district in Kwazulu Natal, were interviewed. Health care workers included: 100 general practitioners, 50 gynaecologists, 50 paediatricians, 50 medical staff and 50 nursing staff. A questionnaire was designed for purpose of this study. Visits were be made to health care providers. All heath care providers who were willing to participate were interviewed. STATISTICS Comparisons of awareness among subgroups of health care providers was analysed using Chi-square tests. If significant, pairwise comparisons were made using a Bonferroni adjustment for multiple comparisons. Associations between awareness and other factors, such as demographic, uptake and beliefs were tested using a chi square test. Analysis was done by Stata v11 (StataCorp, 2009) i RESULTS Three hundred health care workers were interviewed - 50 gynecologists (16.7%), 52 pediatricians (17.3%), 99 general practitioners (33%), 49 other medical doctors (16.3%) and 50 (16.7%) nurses. Two hundred and sixty seven health care workers (89%) were aware of the HPV vaccine and one hundred and eighty eight health care workers (70.4%) informed patients of the availability of the HPV vaccine. Most (77.9%) practitioners have only prescribed the vaccine less than ten times. Gardasil® was prescribed by 46%, Cervarix® by 6.5% and prescription of either vaccine of health care workers was 50.2%. Practitioners were generally unaware that Gardasil® could be prescribed to males (62.9%). CONCLUSION Health care workers were aware of the HPV vaccine and prescribed the vaccine on request. However even though practitioners were aware of the vaccine, most have prescribed the vaccine less than ten times since licensing in 2008. Knowledge with regards to the licensed use of the HPV vaccines is deficient.
An audit of peripartum hysterectomy at the Pietermaritzburg complex of hospitals.
(2012) Uzoho, Nathan N.; Moodley, Jagidesa.
RATIONALE OF THE STUDY. To carry out a retrospective chart review of all patients who had a peripartum hysterectomy in hospitals at different levels of health care in the Pietermaritzburg Hospital Complex to examine the incidence and indications for peripartum hysterectomy. METHODS. The charts of 120 cases of peripartum hysterectomy operations performed between January 2003 and January 2008 in the Pietermaritzburg hospital complex of University of KZN were analysed retrospectively. The total number of deliveries were 48 964. The traditional indications, risk factors and associated complications were revisited to determine if there have been changes in current obstetric practice. RESULTS. The overall incidence of peripartum hysterectomy at the Pietermaritzburg complex of hospital was 0.25/1000 deliveries (95% C1 0.2 – 2.9). Uterine atony, bleeding abruption placentae, placentae praevia, uterine rupture following induction and extension of uterine incision into the uterine arteries comprised 87.9% of the indications for peripartum hysterectomy. By far, the most common complications were wound infection and haemorrhage due to difficult haemostasis. Both comprised 61% of complications, others were bladder injury and renal failure. Coagulopathy occurred in 16.7% of cases of whom 2 died due to massive uncontrollable haemorrhage and 26.7% cases had relaparatomy. There were 13.3% of haemorrhagic shock and 5% developed septic shock. All the patients had blood transfusion, 13.3% of patients received platelets in addition to blood. The results showed that 55.8% had previous caesarean sections while 12.5% had VBAC. There were 75.8% live babies. CONCLUSION. The review noted that there has not been a significant change in the incidence and indications for peripartum hysterectomy. The incidence of peripartum hysterectomy in the study 0.25/1000 compared favourably with the findings from similar studies in different parts of the world. Worldwide the incidence of PH ranges from 0.2 to 5.09/1000 deliveries, in our study the incidence was 0.25/1000.
The cardio-metabolic profile and bone mineral density in African and Indian postmenopausal women.
(2013) Moodley, Jayeshnee.; Bagratee, Jayanthilall Sarjoo.
AIMS. To determine the cardio-metabolic risk profile and incidence of low bone mineral density in African and Indian postmenopausal women attending the IALCH menopause clinic and to determine whether there is a correlation between cardio-metabolic parameters and low bone mineral density. METHODS. A retrospective, descriptive study involving all Indian and African postmenopausal women, above the age of 40, referred to the menopause outpatient clinic at IALCH from 01 July 2009 to 31 December 2010 was conducted. Data was collected from the medi-com database using a structured questionnaire. Cardio-metabolic data was analysed as continuous variables and summarized using means and standard deviations. Bone mineral density was treated as a quantitative variable and correlation analysis was used to assess relationships between the variables. This was done for each race group separately. The Students T-test was used to compare cardio-metabolic variables between the two ethnic groups. SPSS version 18.0 was used to analyse data. RESULTS. The records of 106 women were analysed (51 African and 55 Indian). In African and Indian women, the prevalence of hypertension was 54.9% vs 65.5%, the prevalence of diabetes was 31.4% vs 56.4%, the prevalence of dyslipidaemia was 17.6% vs 32.7% and the prevalence of ischaemic heart disease was 5.9% vs 14.9% respectively. The prevalence of low bone mineral density was higher in Indian women (40%) compared to African women (23.5%). The mean body mass index (BMI) of African women was significantly higher than Indian women, (33 vs 29). There were no significant differences between African and Indian postmenopausal women regarding their lipid profile, fasting glucose, fasting insulin and thyroid profile. The mean bone mineral density (BMD) in the hip and spine was lower in Indian women compared to African women, however the prevalence of osteopaenia and osteoporosis, as defined by T-scores, was not statistically significant. Statistically significant positive correlations were observed between an increasing BMI and BMD (p<0.001) and increases in weight and BMD (p<0.001). A statistically significant correlation were observed between serum LDL-cholesterol values and BMD (p=0.03), where serum LDL-cholesterol values were inversely proportional to BMD. There were no significant correlations between BMD and the remaining cardio-metabolic variables (ie blood pressure; waist-hip ratio; clinical stigma of dyslipidaemia; clinical stigma of insulin resistance; cholesterol; HDL; triglycerides; fasting glucose; fasting insulin and thyroid function). CONCLUSIONS. There is a high prevalence of cardiovascular risks and low BMD amongst the local menopausal population, irrespective of ethnicity. African and Indian postmenopausal women had a high prevalence of hypertension (60%), diabetes (44%), dyslipidaemia (25%) and obesity (54%). In African women, the incidence of low BMD was 35% in the hip, 53% in the neck of femur and 55% in the lumbar spine. In Indian women, the incidence of low BMD was 55% in the hip, 67% in the neck of femur and 69% in the lumbar spine. BMI and weight showed a positive correlation with bone mineral density. Regarding the cardio-metabolic variables, an increasing LDL value was negatively correlated with bone mineral density. It thus is apparent that a screening lipid profile during the peri-menopausal years, coupled with early and appropriate lifestyle management regarding body mass index/ weight may limit the burden of morbidity in later life.
The frequency of insulin resistance and hyperlipidaemia in women with polycystic ovarian syndrome (PCOS) attending Inkosi Albert Luthuli Central Hospital .
(2010) Magan, Nitasha.; Bagratee, Jayanthilall Sarjoo.
BACKGROUND. Polycystic ovarian syndrome is one of the commonest endocrinopathies in women of reproductive age. The prevalence of the disease is estimated to be around 5 % in general population (Azziz, 2004). Literature on the prevalence of PCOS in Black women is limited (Knochenhauer, 1998). This syndrome is a diagnostic conundrum due to the phenotypic variability of these women. The PCOS woman also has a greater disposition for impaired glucose homeostasis as well as hyperlipidaemia. OBJECTIVE. The hormonal and metabolic profiles of South African women with PCOS have not been described. Ethnic differences in the prevalence of PCOS have also not been well explored. Our study aims to describe and compare the phenotypic profile of African and Indian women with PCOS and to determine the frequency of insulin resistance and hyperlipidaemia in these women. METHODS. A retrospective audit of all patients attending gynaecology endocrine and infertility clinics over the period June 2005 to June 2009 was carried out. The biochemical and clinical profiles were analysed and a comparative analysis between the two largest groups, Indian and Black women were done. All women that attended these clinics were subjected to a fasting lipogram and fasting serum glucose. An abnormal fasting serum glucose would have necessitated a full glucose tolerance test. RESULTS. A total of 110 patients were analysed in this study. There were 87 Indian patients, 16 Black patients, 5 Coloured patients and 2 White patients. Eighty nine percent of PCOS women studied had an increased body mass index (>25). There was an increased LH:FSH in 66 (75.9%) of Indian women and 13 (81.3%) of Black women. Increased androgens were present in 26 (30.2%) in Indian women and 6 (37.5%) of Black women. An increase in fasting insulin was found in 48 (55.2%) of the Indian women and 5 (31.3%) of the Black women. Twenty five (29.1%) Indian women had an increase in fasting serum glucose compared to 1 (6.3%) in Black women. In the Indian population, 13 (14.9%) were found to have Diabetes Mellitus, and 9 (10.3%) had an impaired glucose tolerance test. In the Black population only 1 patient had impaired glucose tolerance. There were no Black patients with Diabetes Mellitus. No Black women were found to have hyperlipidaemia, however 12 (14.3%) Indian women were affected. None of these differences between the races were statistically significant. The major limitation of the study was the sample size of Black women. This is an ongoing study, and aims to recruit more Black women. This will be able to adequately address the correct perspective regarding the metabolic and cardiovascular abnormalities in these women. CONCLUSION. The prevalence of insulin resistance and hyperlipidaemia in local women with PCOS was 50.9%.and 11.3% respectively. Menstrual irregularities and infertility are the most frequent presenting complaints of women with PCOS. Features of hyperandrogenism are not common presenting complaints in South African women. There are no differences in the hormonal and clinical profile of South African Indian and Black women with PCOS, however, there is a trend toward Indian women having a greater prevalence of glucose abnormalities than Black women. We recommend further studies in the management of the metabolic abnormalities in local women with PCOS, in an attempt to develop a protocol to manage the metabolic complexities of PCOS.
Women and AIDS: epidemiology and gender barriers to prevention in KwaZulu-Natal, South Africa.
(2000) Abdool Karim, Quarraisha.; Coovadia, Hoosen Mahomed.; Moodley, Jagidesa.
No abstract available.
A retrospective review of uterine malignancies amongst women presenting to the gynaecology oncology clinic, Inkosi Albert Luthuli Central Hospital (IALCH).
(2009) Pupuma, Xanti Bongo S.; Moodley, Mathew.; Connolly, Catherine A.
Abstract can be viewed in PDF document.
Views and attitudes of pregnant women on decision making for LTOP for severe fetal abnormalities.
(2011) Ndjapa-Ndamkou, Constant.; Govender, Logie.
Aim: To study the views and attitudes of pregnant women with a severe fetal anomaly towards late termination of pregnancy (LTOP). Methods: Data was collected over a 3 month period using a pen and paper semi-structured interview of pregnant women with severe fetal abnormalities (lethal and non-lethal) detected after 24 weeks gestation at a tertiary / quaternary hospital. The interview was conducted during pregnancy and within 2 weeks after delivery. All women had prior counselling about their fetal anomaly by healthcare workers at the Fetal Unit. A variety of demographic and socio-economic characteristics were compared between the women that underwent termination of pregnancy (TOP) and those that continued with their pregnancy. The interview was conducted over approximately 30 minutes in the privacy of a counselling room or side ward. Informed consent was obtained from all participants and the study received ethical approval. The responses were analyzed using a statistical package with descriptive statistics calculated. A p-value of <0.05 was used for statistical significance. Results: During the study period, 15 pregnant women with severe fetal anomalies were interviewed. Of these, 5 (33%) women requested TOP and 10 (66%) opted to continue with the pregnancy. The mean (range) maternal age for those continuing with the pregnancy was 25 (20-32) years; and in those requesting termination was 31 (22–35) years. The patients who continued with pregnancy were significantly younger than those who decided to terminate (25 vs 31 years; p<0.05). The mean (range) parity was 1 (0-3) in the patients who continued with pregnancy and 2(1-3) in the patients who terminated. Eighty five percent of the women were Christians and there was no significant difference in their choices. Majority of the women indicated that their partners and immediate family members influenced their decision-making. Before delivery, the common reasons for continuing with the pregnancy included: fear of killing an unborn baby, the baby is God’s gift and the baby will be well after it is born, let nature take its course and there should be no interference to the pregnancy. All women indicated that they were given sufficient time by the hospital staff to make their own decision about their unborn baby after the options were explained. For those that opted to terminate the pregnancy, the main reasons were the cost implications of raising an abnormal baby; baby will suffer during life and unable to cope with severely handicapped child. Post delivery, most women felt that they made the correct choice after seeing the baby. Conclusion: Despite the small numbers, this study illustrates that even whilst pregnant with an anomalous fetus, women’s views and attitudes towards late TOP for severe fetal anomaly are variable. The younger primigravida are more likely to continue with the pregnancy in the hope that the baby will be born normal. Good support from partners / family after delivery was associated with a more favourable response towards decision-making for LTOP. Follow up larger studies assessing the long-term views and attitudes of women towards late TOP will be important for comparison with initial decision-making process and future prenatal counselling.
Attitudes towards and knowledge about intrauterine contraceptive devices among women in the reproductive age group in a resource-constrained setting.
Builu, Pierre Monji.; Naidoo, Thinagrin Dhasarathun.
Abstract available in PDF file.
Clinical profile and management of women treated for endometrial carcinoma in Durban.
(2017) Augustine, Leon.; Bagratee, Jayanthilall Sarjoo.
Abstract available in PDF file.

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