SAJOG Vol 21, No 1 (2015)

ISSN 0038-2329

April 2015 Vol. 21 No. 1

• The quality of healthcare • Obstetric critical care services in South Africa • T he impact of waiting times for radiotherapy for cervical cancer • Cardiac arrest in pregnancy • U terine rupture in a primigravida with a term pregnancy • Entrapment of a vaginal ring pessary

SAJOG April 2015 Volume 21 No. 1

THE SOUTH AFRICAN JOURNAL OF OBSTETRICS AND GYNAECOLOGY

Editor William Edridge Editorial Board: SAJOG Alan Alperstein (Cape Town) Geoffrey Buga (Walter Sisulu) Hennie Cronje (Free State) Franco Guidozzi (Witwatersrand) Justus Hofmeyr (East London) Thinus Kruger (Stellenbosch) Gerhard Lindeque (Pretoria) Eddie Mhlanga (KwaZulu-Natal) Sam Monokoane (Limpopo) Jack Moodley (KwaZulu-Natal) Dan Ncayiyana (Durban) Hein Odendaal (Stellenbosch) Zephne van der Spuy (Cape Town) HEALTH & MEDICAL PUBLISHING GROUP (HMPG): Editor-in-Chief Janet Seggie Consulting Editor JP de V van Niekerk

Editorial 2

The quality of healthcare

W Edridge

Deputy Editor Bridget Farham Scientific Editor Ingrid Nye

Opinion

Technical Editors Emma Buchanan Paula van der Bijl

4

Obstetric critical care services in South Africa

E C Buga, G D Nethathe, L R Mathivha

News Journalist Chris Bateman

Research

6

A prospective study on the impact of waiting times for radiotherapy for cervical cancer at Charlotte Maxeke Johannesburg Academic Hospital, South Africa

Head of Publishing Robert Arendse

K N Lohlun, J A Kotzen, R Lakier

Production Manager Emma-Jane Couzens

Case Reports

10

Cardiac arrest in pregnancy: Case report and review of the literature

Art Director Brent Meder

S Budhram

12

Uterine rupture in a primigravida with a term pregnancy: Case report and lessons to learn

R Vatharajh, K Tunkyi, J Devjee, J Moodley

14

Entrapment of a vaginal ring pessary: Case report and review of the literature

Z Abdool

16

Primary amenorrhoea: Swyer syndrome in a woman with pure 46,XY gonadal dysgenesis and late presentation

A Chrysostomou

18

Live birth from a patient with a three-way balanced translocation t(5;8;12)

A Ramdeo, K Naidoo, T Ernest, K Pluta

22

Müllerian duct anomaly with congenital rectovaginal fistula: A rare case presentation

Y Dogra, S Minhas, P D Marwaha

24

CPD Questions

CEO and Publisher Hannah Kikaya

Design & Layout Carl Sampson Distribution Manager Edward Macdonald Head of Sales and Marketing Diane Smith Tel: (012) 481-2069 | dianes@samedical.org Cover Design Richard Smith ISSN 0038-2329 Journal website: www.sajog.org.za Use of editorial material is subject to the Creative Commons Attribution – Noncommercial Works License. http://creativecommons.org/licenses/ by-nc/3.0/ Plagiarism is defined as the use of another’s work, words or ideas without attribution or permission, and representation of them as one’s own original work. Manuscripts containing plagiarism will not be considered for publication in the SAJOG. For more information on our plagiarism policy, please visit http://www.sajog.org.za/index.php/ sajog/about/editorialPolicies

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Tel: 072 635 9825 E-mail: publishing@hmpg.co.za Website: www.hmpg.co.za All letters and articles for publication must be submitted online at www.sajog.org.za ©Copyright: Health and Medical Publishing Group (Pty) Ltd. Printed by Dash Communications

EDITORIAL

The quality of healthcare The quality of healthcare provided by a healthcare system is not always easily assessed. How can one assess the smile of reassurance from a nursing sister or the feeling of satisfaction of a patient when visiting a doctor in a resource-limited setting? There are, however, some objective measures of healthcare activity. In the case of obstetrics there is perinatal mortality. This can be adjusted to compensate for the rate of premature birth, and then expressed as the perinatal care index. Maternal mortality is another yardstick of care in obstetrics and that part of gynaecology that deals with early pregnancy.

The Millennium Development Goals were established on just this basis – that measures of mortality were a meaningful expression of the quality of life that a government could offer a population and the quality of medical care that is provided.

As well as providing simple numbers to enable one hospital, region or nation to compare itself with another, or with itself over time, it is also essential that each case of mortality is evaluated internally or externally to assess whether there are correctable deficiencies that may relate to patient activity, or the adequacy/ inadequacy of infrastructure, or the performance of medical staff. It is on this basis that nations have established Confidential Enquiries.

Not everything relates to mortality. Maternal morbidity can be monitored in ‘near-miss’ assessment, for which there is growing agreement of specific criteria in terms of intensive care admission, massive transfusion, need for hysterectomy, etc., since there are many disasters that can happen before the point of mortality is reached. As with mortality, near-miss assessment should focus on avoidable factors that can be addressed to improve care.

All of these measures can be an indication of the poor quality or good quality of the general health of the population that accesses a healthcare system, affected by levels of nutrition, living standards and sanitation, or can represent adequate or inadequate healthcare once the patient has arrived at the clinic or hospital door.

In the field of gynaecology, away from pregnancy, much of medical care and its impact are more difficult to measure. How does one reliably assess the accuracy of diagnosis or management of

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SAJOG • April 2015, Vol. 21, No. 1

pelvic inflammatory disease, endometriosis or heavy menstruation, or even assess the provision of contraception? One exception to this in gynaecology is oncology. In gynaecological oncology, survival and mortality, if statistics are available, provide an index of care.

Patients with certain stages of cancer have an internationally defined rate of cure or death.

But retrieval and recording of information is not always as easy in the developing world, from which much of the audience and many of the contributors to this journal come. Once treated, patients, who may have limited resources, have difficulty returning, and knowledge of outcome is lost. Yet there is care in these countries, sometimes better, sometimes worse; sometimes better resourced, sometimes not.

One concern in the developing world is the loss of resources that are available. These resources may be lost through bad management, poor infrastructure maintenance, needless expense, or the dreaded epidemic of corruption.

An article in this journal (Lohlun et al.[1]) deals with the growing failure of a radiotherapy unit in Johannesburg, South Africa, to match international standards. The outcome is not measured in mortality; those statistics, for reasons given, are not available, but in the upstaging of patients as treatment is delayed.

Many countries in our region do not have radiotherapy services, or in some cases do not have primary healthcare, and yet some of these countries do have resources. Unless every attempt is made to gather data, lobby concerned roleplayers and publicise deficiencies, the situation will not improve. If these efforts are made, perhaps it will.

William Edridge

Editor william.edridge@gmail.com 1. Lohlun KN, Kotzen JA, Lakier R. A prospective study on the impact of waiting times for radiotherapy for cervical cancer at Charlotte Maxeke Johannesburg Academic Hospital. S Afr J Obstet Gynaecol 2015;21(1):6-9. [http://dx.doi.org/10.7196/SAJOG.985]

S Afr J Obstet Gynaecol 2015;21(1):2. DOI.10.7196/SAJOG.1001

OPINION

Obstetric critical care services in South Africa E C Buga, MB ChB, FCOG (SA); G D Nethathe, MB ChB, DA (SA), MMed (Anaes), FCA (SA), Cert Critical Care (SA); L R Mathivha, MB ChB, FCPaed (SA) Critical Care, DBS (BM) Intensive Care Unit, Chris Hani Baragwanath Academic Hospital, and Division of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: G Nethathe (gladness.nethathe@wits.ac.za)

More than half of all global maternal deaths occur in Africa. A large percentage of these deaths are preventable, and lack of access to adequate critical care facilities is a contributing factor. There are limited published data on the clinical and management challenges presented by the critically ill obstetric patient admitted to the intensive care unit in our setting, and more data are required in order to better define the critical care needs of this group of patients.

S Afr J Obstet Gynaecol 2015;21(1):4-5. DOI:10.7196/SAJOG.954

The critically ill obstetric patient presents many management challenges to the treating physician.

When managing these patients, consideration needs to be given to the unique physiological changes that are associated with pregnancy, the wellbeing of the fetus, and the rapidity of reversal of many of these changes. The intensive care management of these patients can be complex and requires timeously instituted management from a multidisciplinary team consisting of intensivists, anaesthesiologists, physicians and obstetricians, among others.

Although obstetric conditions account for 55 - 80% of intensive care unit (ICU) admissions of obstetric patients, medical conditions are now increasingly contributing to maternal morbidity and mortality.[1] This is attributed to a number of factors, such as improved medical care leading to more women with severe medical conditions surviving and reaching child-bearing age, older age at the time of their first pregnancy, and assisted reproductive technology that has made it possible for women with chronic medical illnesses to conceive. The physiological changes of pregnancy may also exacerbate or mask severe medical conditions.[2] More than half of all global maternal deaths occur in Africa.[3] According to the United Nations data monitoring committee on maternal mortality, sub-Saharan Africa has the highest maternal mortality rate of 570/100 000 live births.[3] Few if any countries in sub-Saharan Africa are in a position to meet the Millennium Development Goal of reducing maternal mortality by three-quarters by 2015. This applies to South Africa (SA) as well. According to the Committee on the Confidential Enquiry into Maternal Deaths (CEMD) in SA, the five major causes of maternal death in the period 2008 - 2010 were non-pregnancy-related infections/AIDS, accounting for 40.5% of all deaths reported; obstetric haemorrhage (14.1%); hypertensive disorders (14%); medical and surgical disorders (8.8%); and pregnancy-related sepsis (5.3%).[4] A large percentage of these deaths were preventable, with patient-related factors contributing to 49% and health systems and healthcare worker-associated factors making up 35% of the avoidable factors leading to maternal deaths. The problems associated with health systems included failure of ambulance transport between levels of care, unavailability of blood and

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SAJOG • April 2015, Vol. 21, No. 1

blood products, inadequate staff numbers and lack of access to ICUs. Healthcare worker-associated problems related to lack of competence.[4] The situation is not very different in the First-World setting.

Recent reviews of maternal mortality in the USA, France and the UK suggest that 40 - 50% of maternal deaths are preventable.[5] This prompted the National Partnership for Maternal Safety to propose an obstetric early-warning system to identify those patients who develop clinical signs of critical or life-threatening illness so that necessary interventions can be instituted.

Retrospective heterogeneous data on critically ill obstetric patients are available, and highlight some aspects that may not necessarily apply to our setting; many of these studies are from well-resourced settings.

Kilpatrick and Matthay[6] in 1992 published a 5-year review of obstetric admissions to the ICU at the University of California, USA, and showed respiratory and haemodynamic instability to be the main reasons for admission. The overall rate of ICU admission of 0.4% was due to the main ICU being a distance from their obstetric unit. Bed availability and triage criteria dictated how many patients were admitted.

Zwart et al.[7] in 2009 carried out a 2-year nationwide populationbased cohort study on the incidence of and risk factors for obstetric intensive care admissions in the Netherlands. The overall incidence of admission of obstetric patients to the ICU in the Netherlands was 0.24%. Severe obstetric haemorrhage, hypertension and sepsis were the most common reasons for admissions. A third of patients with severe acute maternal morbidity (SAMM) were admitted, making ICU admission a good measure of the management of patients with SAMM in that setting.[7] The term SAMM, also referred to as a ‘near miss’, refers to a woman who has severe organ dysfunction or failure in pregnancy, childbirth or within 42 days of termination of pregnancy that could result in maternal death, but survives.[8] SAMM is used to judge the quality of maternal healthcare in instances where the maternal mortality statistics are low.

In a prospective review done by Wanderer et al.[9] in Maryland, USA, the overall rate of ICU admissions was 419.1/100 000 deliveries. Most admissions occurred ante partum. The leading

reasons for ICU admission were hypertensive diseases, cardio­ myopathy and haemorrhage. A rising rate of sepsis was also noted.

The researchers recommended that hospitals caring for pregnant women should plan for appropriate critical care management and/or transfer of women with severe morbidity during pregnancy.

The studies mentioned above also show a homology with the SA setting, where haemorrhage, hypertension and sepsis are the leading reasons for admission of obstetric patients to the ICU. The required resources for the intensive management of these patients also seem to differ depending on the setting.

A retrospective observational report from Australia by Paxton et al.[10] showed that, of the obstetric patients who were admitted to the ICU, a substantial number did not receive interventions typical of other critically ill patients, such as mechanical ventilation or inotropes, raising the question of whether the low threshold of ICU admissions in some settings is appropriate. In contrast to the report from Australia, Ashraf et al.,[11] in a retrospective review of ICU admissions in a teaching hospital in India, showed that obstetric haemorrhage and hypertensive disorders were the most common reasons for ICU admission of obstetric patients. Eighty-five per cent of the patients required mechanical ventilation and 78% required inotropic support. There was a maternal mortality rate of 13% due to multiorgan failure and disseminated intravascular coagulation.

The researchers showed that a dedicated obstetric ICU in a tertiary hospital can minimise delay in patient care and help reduce maternal mortality.

Chawla et al.,[12] in a study done in India, showed in a caseseries analysis of data that 0.26% of obstetric patients required ICU admission. Forty-six per cent of the patients admitted to an ICU required ventilatory support, with pre-eclampsia and obstetric haemorrhage being the commonest diagnoses in these patients.

These studies highlight the great demand for obstetric critical care services in areas with a high maternal mortality rate and perhaps the over-utilisation of these services in well-resourced centres in countries with a low maternal mortality rate.

Although the demand for critical care for obstetric patients is high, in SA there are only two dedicated obstetric ICUs in the public health sector, both in the Western Cape Province. One is attached to the Department of Obstetrics and Gynaecology of the University of Cape Town, and the other is at Tygerberg Hospital, in the Department of Obstetrics and Gynaecology, Stellenbosch University.

In addition there are no published data on the clinical challenges presented by critically ill obstetric patients in our setting, in particular with reference to the indications for admission, their clinical characteristics, organ support interventions required, and maternal mortality. Few if any studies in our setting have reviewed the incidence, possible risk factors and characteristics of obstetric patients admitted to the ICU. There is therefore a need to better describe the critical care needs of critically ill obstetric patients, as well as to highlight the need for establishing well-equipped, well-staffed high-dependency and dedicated obstetric critical care service units in the public sector.

1. Karnad DR, Lapsia V, Krishman A, et al. Prognostic factors in obstetric patients admitted to an Indian intensive care unit. Crit Care Med 2004;32(6):1294-1299. [http://dx.doi.org/10.1097/01. ccm.0000128549.72276.00] 2. Kaaja RJ, Greer IA. Manifestations of chronic disease during pregnancy. JAMA 2005;294(21):27512757. [http://dx.doi.org/10.1001/jama.294.21.2751] 3. UNICEF Data: Monitoring the situation of children and women. http://data.unicef.org/maternalhealth/maternal-mortality (accessed 6 December 2014).

4. Moodley J, Pattinson RC, Fawcus S, et al. The confidential enquiry into maternal deaths in South Africa: A case study. BJOG 2014;121(S4):53-60. [http://dx.doi.org/10.1111/1471-0528.12869] 5. Mhyre JM, D’oria R, Hameed A, et al. The maternal early warning criteria. Obstet Gynecol 2014;124(4):782-786. [http://dx.doi.org/10.1097/aog.0000000000000480] 6. Kilpatrick SJ, Matthay AM. Obstetric patients requiring critical care: A five-year review. Chest 1992;101(5):1407-1414. [http://dx.doi.org/10.1378/chest.101.5.1407] 7. Zwart JJ, Dupuis JRO, Richters A, Öry F, van Roosmalen J. Obstetric intensive care unit admission: A 2-year nationwide population-based cohort study. Intensive Care Med 2010;36(2):256-263. [http://dx.doi.org/10.1007/s00134-009-1707-x] 8. Cochet L, Pattinson RC, Macdonald AP. Severe acute maternal morbidity and maternal death audit – a rapid diagnostic tool for evaluating maternal care. S Afr Med J 2003;93(9):700-702.

9. Wanderer JP, Leffert LR, Mhyre JM, et al. Epidemiology of obstetric-related intensive care unit admissions in Maryland: 1999-2008. Crit Care Med 2013;41(8):1844-1852. [http://dx.doi. org/10.1097/ccm.0b013e31828a3e24] 10. Paxton JL, Presneill J, Aitken L. Characteristics of obstetric patients referred to an intensive care in an Australian tertiary hospital. Aust NZ Obstet Gynecol 2014;54(5):445-449. [http://dx.doi. org/10.1111/ajo.12211] 11. Ashraf N, Mishra SK, Kundra P, et al. Obstetric patients requiring intensive care: A one year retrospective study in a tertiary institute in India. Anesthesiol Res Pract 2014(2014):789450. [http://dx.doi.org/10.1155/2014/789450] 12. Chawla S, Nakra M, Mohan S, et al. Why do obstetric patients go to the ICU? A 3-year study. Med J Armed Forces India 2013;69(2):134-137. [http://dx.doi.org/10.1016.mjafi.2012.08.033]

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RESEARCH

A prospective study on the impact of waiting times for radiotherapy for cervical cancer at Charlotte Maxeke Johannesburg Academic Hospital, South Africa K N Lohlun, MB BCh, MMed, FC Rad Onc (SA); J A Kotzen, BSc, MB BCh, MMed Rad (T); R Lakier, BSc, MMed Rad (T) Division of Radiation Oncology, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa Corresponding author: K N Lohlun (kim@kimlohlun.co.za)

Background. Radiotherapy plays a vital role in the management of cervical cancer. However, because of high patient load and limited resources, waiting lists are unacceptably long. This is a highly curable malignancy that often occurs in economically active, relatively young women. The impact of treatment delays on society is therefore disproportionately large when compared with many other malignancies.

Delays also impact negatively on the healthcare system and place further stress on an already burdened department.

Objective. To evaluate the potential impact of radiotherapy delays.

Methods. Eighty-one patients requiring radical radiotherapy for cervical cancer were selected. Patients were re-evaluated every 4 weeks while waiting, and again at simulation.

Results. Median delay from first consultation to simulation was 55 days. Longer delays were not statistically correlated to tumour progression.

Most of the upstaging occurred around 40 - 65 days. One in four patients received blood transfusions and required hospital admission. Four patients needed haemostatic brachytherapy for bleeding.

Conclusion. A relationship between time waited and disease progression could not be proven. However, numbers were small and statistical tests were probably underpowered. The study does, however, highlight unacceptably long delays for radiotherapy, and a wait of less than 40 days is recommended.

S Afr J Obstet Gynaecol 2015;21(1):6-9. DOI:10.7196/SAJOG.985

Despite significant advances in screening and management over the past few decades, cervical cancer remains a significant burden, particularly in developing countries, where more than 80% of cases are diagnosed.[1] Cervical cancer comprises 22.2% of all cancers in women of sub-Saharan Africa and carries the highest rate of cancer-related mortality.[2] The National Cancer Registry of 2003 showed that cervical cancer is the third leading malignancy in South African (SA) women, after breast and basal cell carcinomas. In black women, it is the leading cancer.[3] The lifetime risk of developing cervical cancer for SA women is one in 31.[4] The burden of disease in developing countries, including SA, therefore remains high. Meanwhile, radiation and other treatment facilities are poorly staffed and poorly equipped, ultimately leading to inability to cope with the large numbers of patients.

Forty per cent of the country’s malignancies are diagnosed in Gauteng Province, probably because this region has the highest number of cancer-diagnosing laboratories. At our Gauteng-based institution, we see approximately 750 cases of cervical cancer annually – about 20% of the total number of cases referred, which is comparable with the 17 - 20% noted for national statistics.[4,5] Patients seen at our clinic tend to present with more advanced disease than those in First-World countries. This may be due to several factors, including poor education and lack of awareness, inadequate screening programmes, poor access to healthcare, lack of funding and staff shortages. As radiotherapy is the mainstay of treatment for advanced disease, it plays a vital role in the management of cervical cancer in our country.

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SAJOG • April 2015, Vol. 21, No. 1

Because of large numbers of patients and insufficient machine time to cater for all these patients, Charlotte Maxeke Johannesburg Academic Hospital was, at the time of the study, experiencing waiting lists of up to 16 weeks for patients with cervical cancer. Delays in treatment become a burden not only to the patient and her family, but also to doctors, nurses and other staff.[6] During the delay, patients may require blood transfusions, hospital admissions and/or brachytherapy to stop vaginal bleeding. This increases the financial costs of patient care. On follow-up reviews, it is sometimes noted that the tumour has progressed or that performance status has deteriorated, prompting alterations in radiotherapy from radical to palliative regimens. These unwanted events could possibly be prevented or reduced if waiting times for radiation were decreased. In order to do this, the extent of the problem needs to be properly assessed.

This study was conducted to assess the extent of waiting times for radiation treatment and the potential impact that these delays might have (such as disease progression), as well as to define the need for extra supportive measures.

Methods

We prospectively looked at waiting times for radiation treatment for cervical cancer and the impact that delay had on the patients and their overall management.

Eighty-one patients, who presented to the department between May 2010 and July 2011, were included in the study. These patients were all scheduled for radical radiotherapy. Patients for palliative radiation regimens, with poor expected overall survival, were excluded, as well as patients who required postoperative radiation. Patients were recruited

according to the availability of the researcher to recruit in a busy clinical context. This therefore represents a convenience sample with no obvious bias in those recruited that might affect the outcome. Patient charac­ teristics are presented in Table 1.

Written informed consent for both radiation and participation in the study was obtained at first visit. Ethical clearance was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (clearance certificate M10440).

Table 1. Patient characteristics (N=81) Characteristic

n (%)

Age group (years) 20 - 30

4 (5)

31 - 40

11 (14)

41 - 50

28 (35)

51 - 60

26 (32)

61 - 70

10 (12)

71 - 80

2 (3)

Histological type Squamous cell carcinoma

71 (88)

Adenocarcinoma

6 (7)

Adenosquamous carcinoma

1 (1)

Basaloid squamous carcinoma

1 (1)

Unknown

2 (3)

Tumour grade I (well differentiated)

1 (1)

II (moderately differentiated)

51 (63)

III (poorly differentiated)

14 (17)

IV (undifferentiated)

1 (1)

Unknown

14 (17)

Tumour stage IB1

1 (1)

IB2

2 (3)

IIA

1 (1)

IIB

44 (54)

IIIA

2 (3)

IIIB

31 (38)

Patients were reviewed every 4 weeks until simulation. At each visit, the following parameters were checked: any blood transfusions received, number of units received, hospital admissions, vaginal bleeding, and bladder or bowel complaints. The administration of haemostatic brachytherapy (because of excessive bleeding or the requirement of multiple blood transfusions) was also documented. A physical examination was done. Special note was taken of the overall performance status, and of local tumour extent or progression. The same patient review was repeated at the simulator.

Statistical methods Statistical tests were performed using IBM SPSS version 20.0. A p-value of <0.05 was considered statistically significant A one-sample Kolmogorov-Smirnov test was used to assess whether time from consultation to simulation was normally distributed. As results indicated non-normality (p<0.001), median values were used instead of mean values, which would not have provided a relevant reflection of the average patient’s experience because of higher than normally expected values.

The Mann-Whitney U-test was used to determine statistical significance for differences in frequency distributions of waiting times, with exact significance testing used if numbers were low (n<30).

Kaplan-Meier estimates were used to determine length of time elapsed while waiting for simulation before stage progression occurred. These methods, using logranks, were also employed to evaluate differences in stage progression according to original tumour stage, HIV status and histological grade.

Results

Median time from first consultation to simulation was just short of 2 months (55 days), as demonstrated in Table 2. The

wait from simulation to commencement of treatment took on average another 19 days.

Median total delay in starting treatment as a consequence of departmental waiting lists was therefore 74 days. However, this does not take into account delays due to other factors, such as patients defaulting or being unreachable by both telephone and telegram.

The maximum delay from day of first consultation to simulation was 211 days.

This was due to patient factors rather than departmental delay. If we exclude the top five outliers of the valid population (6%), who waited longer than 70 days from first consultation to simulation, the median waiting time would still be 55 days.

One in four patients received blood transfusions while waiting for simulation.

However, the median haemoglobin level was only 11.1 g/dL, with the minimum referral haemoglobin being as low as 3.8 g/dL. The Mann-Whitney U-test showed no statistical difference in waiting time between those who received blood transfusions and those who did not (p=0.70).

Of the 79 patients who returned for follow-up, 21 (27%) were admitted to hospital during the wait. Most of the admissions were for anaemia, where a blood transfusion was required. Only three were admitted and did not receive a blood transfusion. Two of these were admitted for transport reasons, as they had no other means to get to the radiation unit. The third patient said she was admitted for ‘an operation to treat the cancer’, but this was not done. As she had already presented with stage IIB cancer, this admission was most likely the result of a mix-up or miscommunication problem. Longer waiting times from first consultation to simulation did not predict for hospital admission (p=0.84).

Four (5%) of the participants were given brachytherapy for haemostasis while awaiting treatment.

HIV status Negative

44 (54)

Positive

37 (46)

Table 2. Delay times Time interval (days)

ECOG performance status

Mean

Median

Min.

Max.

SD

0

0 (0)

Diagnosis to consultation (n=81)

45

36

6

274

34

1

80 (99)

Consultation to simulation (n=77)

54

55

18

211

25

2

1 (1)

Hospital level

Simulation to treatment (n=77)

20

19

1

76

11

Diagnosis to treatment (n=77)

119

108

65

324

39

73

74

30

222

26

Secondary

4 (5)

Consultation to treatment (n=77)

Tertiary

77 (95)

SD = standard deviation.

SAJOG • April 2015, Vol. 21, No. 1

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From the time of first consultation to simulation, 35 (44%) of the 79 evaluable patients had progression of their tumours.

Twenty-two (28%) were upstaged. Nine­ teen (24%) required modification of their planned treatments to a less radical regimen (e.g. hypofractionated radiation), as per departmental protocol. It was sus­ pected that one patient had developed a vesicovaginal fistula at simulation review, which would have upstaged the tumour to stage IVA. However, this was not verified and the patient’s good performance status suggested a fair prognosis. She was therefore given radical radiation as planned.

In terms of both tumour progression and stage changes, the time waited from first consultation to simulation was not statistically significant, with p-values of 0.08 and 0.21, respectively. However, median values were slightly higher for the average patient whose disease became more advanced, with median waiting times of 55 and 53 days for tumours that had progressed v. those that had not, and 57 and 55 days for tumours that were upstaged v. those that were unchanged.

Fig. 1 shows a Kaplan-Meier plot of time from consultation to simulation against the proportion of patients whose tumour stage did not change. The steep drop in the curve indicates that the majority of those patients whose tumours progressed and were upstaged, experienced these changes between 40 and 65 days of waiting.

Complete

Neither HIV status nor histological differentiation (grade) was significant with regard to stage progression, with log-rank test p-values of 0.20 and 0.18, respectively.

Only five patients (6%) were evaluated as having a deterioration in Eastern Cooperative Oncology Group (ECOG) performance status, with the majority staying at an ECOG of I. There were too few changes in performance status to evaluate significance in respect of time waited.

Ten of the 81 patients in the study either missed (defaulted) one or more of their monthly reviews while waiting for a simulation date, or declined treatment at some point. Reasons for defaulting were often unclear, with some stating social problems and others giving no real explanation. Again, numbers were too low to do statistical tests on those who had defaulted. The patients who defaulted at some time had median waiting times from first consultation to simulation of 67 days, whereas those who did not default waited a median time of 55 days.

Of the patients who were treated or could be reached, none died while awaiting radiation. However, at least one patient progressed to stage IV disease and was given palliative radiation.

Discussion

The median delay from first consultation until commencement of treatment was 74 days. At the time of writing a protocol Censored

1.2

Cumulative proportion without stage change

1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 -0.1 -0.2

0

50

100

150

200

250

Consultation to simulation, days

Fig. 1. Kaplan-Meier plot of time from consultation to simulation against the proportion of patients whose tumour stage did not change.

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SAJOG • April 2015, Vol. 21, No. 1

for this study, it was noted that some patients had been waiting up to 4 months for simulation alone. The reason for this discrepancy was the introduction of a hypo­ fractionated radiation protocol, which was introduced with the aim of reducing waiting times by using higher, but fewer, daily doses of radiation, and thereby decreasing the overall duration of treatment.

Mackillop et al.[7] found that the median waiting time for patients with cervical cancer in Ontario was 27.2 days from diagnosis to commencement of radiotherapy. They observed, as with this study, that most of the wait lay in the period following the first consultation, but gave no figure for this time interval. We therefore compared their median total time of 27.2 days with our median total time of 108 days from diagnosis to treatment. Although Mackillop et al. cited waiting times as a problem in Ontario, it is clear that delays in the Canadian setting are in no way comparable with those at our institution, where the wait is four times as long.

At the time of simulation, 27% of the study patients had tumours that had progressed to a more advanced stage since the time of first consultation. This would, theoretically, translate to a poorer prognosis and decreased survival, given that 5-year survival rates are roughly 80%, 65% and 40% for stages I, II and III, respectively.[8] A longer follow-up of these patients would be required to assess lives lost as a result of treatment delay. The study, however, failed to show that tumour progression was increased with a longer delay.

Mackillop et al.[9] concluded that there is no theoretical reason to believe that any delay is safe and the best course would be to adopt an ASARA principle, i.e. to keep delays ‘As Short As Reasonably Achievable’, this being modelled from the ALARA principle of keeping radiation doses ‘As Low As Reasonably Achievable’. While this principle is both logical and sensible, it may be of benefit to define specific goals towards which radiation departments can aim.

In this study, progression of the tumours that were upstaged was noted between 40 and 65 days, using Kaplan-Meier plots.

Fortin et al.[10] looked at time waited from consultation to start of treatment for radically treated head-and-neck tumours, which are considered to have similar doubling times to cervical cancers. Their study demonstrated diminished locoregional control and overall survival for

patients who waited longer than 40 days for radiation treatment.

These patients had a 15% lower survival rate at 3 years. Although we looked at time from first consultation to simulation, rather than time to start of treatment, the trend of the plot (Fig. 1) implies that should patients have been re-evaluated at the start of treatment, the sharp drop between 40 and 65 days would still be relevant. This study, in accordance with Fortin et al.’s study, therefore supports the conclusion that a delay of more than 40 days may compromise tumour control and subsequent patient survival.

Bleeding per vagina is a common clinical presentation of cervical cancer. The longer patients wait for radiation treatment, the higher the chances that they will require multiple blood transfusions or haemostatic brachytherapy to stop the bleeding. In this study, one in four patients received a blood transfusion while waiting for simulation. The cost of one unit of red cell concentrate is ZAR1 369.39 in the state sector, while blood administration sets cost a further ZAR796.05 each.[11] This is over and above the price of the hospital stay.

Most of the patients who were transfused were admitted to hospital. According to statistics compiled by economist Schüssler, only 2% of the cost of a public sector admission is charged to the patient. The remaining 98% is borne by the taxpayer.[12] Zietsman[12] concludes, in his analysis of hospital costs, that while public healthcare appears cheaper than private care, the opposite is actually true when one takes into consideration the overall cost to the economy and the effectiveness of providing that care.

Brachytherapy for haemostasis is limited to only a few hospitals, and these facilities are already burdened with high patient volumes and insufficient treatment time. Four patients received haemostatic brachytherapy for bleeding.

Conclusion

Carcinoma of the uterine cervix remains a problem in the developing world, particularly in sub-Saharan Africa. Despite the large burden of disease, treatment facilities are still lacking. Supply is unable to keep up with demand, and waiting lists for radiotherapy are unacceptably long. This has consequences not only for patients’ health and life expectancy, but also on the healthcare system and society in general, given that these patients are often economically active individuals.

This study was conducted to assess the potential impact that treatment delays may be having on the healthcare system, the patients and their disease. Results did not reach statistical significance. However, median delay times of 10 weeks from first consultation to treatment, 43% of patients having progressive disease and 27% having tumours upstaged are all figures of concern.

Although tumour progression could not be correlated to time waited, it was noted that most of the tumours that were upstaged were upstaged between 40 and 65 days. Reasonable goals for the department would therefore be to decrease the wait from first consultation to simulation to less than 40 days.

This study provides a basic overview of times waited for radiotherapy for cervical cancer at Charlotte Maxeke Hospital. This will provide a platform for future comparisons and for assessment of progress and improvement within the department. Further studies may look at quality of life for patients awaiting treatment, patient satisfaction with the care received, staff and equipment requirements for improving waiting times, and outcomes for patients who were treated using the shortened hypofractionated protocol.

1. Denny L. Cytological screening for cervical cancer prevention. Best Pract Res Clin Obstet Gynaecol 2012;26(2):189-196. [http://dx.doi.org/10.1016/j.bpobgyn.2011.08.001] 2. Anorlu RI. Cervical cancer: The Sub-Saharan African perspective. Reprod Health Matters 2008;16(32):41-49. [http://dx.doi.org/10.1016/S0968-8080(08)32415-X] 3. National Cancer Registry. Incidence of histologically diagnosed cancer in South Africa. National Institute for Occupational Health (database online). 2003. http://www.nioh.ac.za/assets/files/ Cancer%20tables%202003.pdf (accessed 5 March 2014).

4. Mqoqi N, Kellet P, Sitas F, et al. Incidence of histologically diagnosed cancer in South Africa, 1998-1999. National Cancer Registry of South Africa. Johannesburg: National Health Laboratory Service, 2004:viii, 23.

5. Denny L. Cervical cancer: The South African perspective. Int J Gynaecol Obstet 2006;95(Suppl 1):S211-S214. [http://dx.doi.org/10.1016/S0020-7292(06)60036-2] 6. Dische S. Tumour growth while waiting: Does it really matter? Clin Oncol (R Coll Radiol) 2000;12:139. [http://dx.doi.org/10.1007/s001740070054] 7. Mackillop WJ, Fu H, Quirt CF, et al. Waiting for radiotherapy in Ontario. Int J Radiat Oncol Biol Phys 1994;30(1):221-228. [http://dx.doi.org/10.1016/0360-3016(94)90538-X] 8. Cannistra SA, Niloff JM. Cancer of the uterine cervix. N Engl J Med 1996;334:1030-1038. [http:// dx.doi.org/10.1056/NEJM199604183341606] 9. Mackillop WJ, Bates JH, O’Sullivan B, et al. The effect of delay in treatment on local control by radiotherapy. Int J Radiat Oncol Biol Phys 1996;34(1):243-250. [http://dx.doi.org/10.1016/03603016(95)02049-7] 10. Fortin A, Bairati I, Albert M, et al. Effect of treatment delay on outcome of patients with earlystage head-and-neck carcinoma receiving radical radiotherapy. Int J Radiat Oncol Biol Phys 2002;52(4):929-936. [http://dx.doi.org/10.1016/S0360-3016(01)02606-2] 11. South African National Blood Service. SANBS State Patients Price List 2012. http://www.sanbs.org. za/images/pdfdocs/state%20patients%202012.pdf (accessed 25 January 2013).

12. Zietsman G. Why Motsoaledi’s wrong about private sector hospital costs. Politicsweb.

13 April 2012. http://www.politicsweb.co.za/politicsweb/view/politicsweb/en/page71619?oid= 292572&sn=Detail&pid=71619 (accessed 5 March 2014).

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9

CASE REPORT

Cardiac arrest in pregnancy: Case report and review of the literature S Budhram, FCOG (SA), MMed (O&G) Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa Corresponding author: S Budhram (samant@absamail.co.za)

Cardiac arrest in pregnancy is a rare event, and resuscitation of the pregnant patient is complicated by the impact on resuscitative measures of the normal physiological changes of pregnancy. A case of successful resuscitation of a pregnant patient with a cardiac arrest and a normal neurocognitive outcome is reported.

S Afr J Obstet Gynaecol 2015;21(1):10-11. DOI:10.7196/SAJOG.929

Case report

A 38-year-old woman, gravida 5 para 4, booked at 14 weeks’ gestation. She had a history of ischaemic heart disease, chronic hypertension and hypercholesterolaemia, and had discontinued her medication (without medical advice) 5 months earlier because she was planning a pregnancy with her new partner. Additional risk factors identified were advanced maternal age, four preterm vaginal deliveries (the last of which was 8 years previously), a history of heavy smoking, and the current pregnancy being a twin gestation.

There was a delay in referral of the patient to the tertiary centre, and she was first seen at the combined obstetric-cardiac clinic at 22 weeks’ gestation. At this visit she was noted to be in a stable condition with satisfactory vital parameters and an intact twin gestation in keeping with 22 weeks’ gestational age (GA).

The cardiologist proceeded to perform an echocardiogram while attempts were being made to retrieve the patient’s notes relating to previous cardiology consultations.

Within 15 minutes of commencing the examination, the patient became acutely dyspnoeic. At this stage the limited echocardiogram showed left ventricular dysfunction with a left ventricular ejection fraction (LVEF) of 30%. The patient was immediately commenced on oxygen therapy and transferred to the obstetric critical care unit (OCCU) in a semirecumbent, left lateral position.

On arrival in the OCCU, a rapid initial assessment revealed that the patient was in severe respiratory distress with signs suggestive of frank pulmonary oedema. She received a bolus of 80 mg furosemide intravenously (IV). Resuscitative measures had been commenced by a multidisciplinary team (MDT) comprising an anaesthetist, an intensivist, a fellow in maternal-fetal medicine and intensive caretrained nursing staff, when the patient suffered a cardiac arrest.

She was immediately intubated in a rapid-sequence fashion, and cardiopulmonary resuscitation (CPR) was undertaken with the patient maintained in a 15° lateral tilt. She remained asystolic after 5 minutes of CPR and a total of 3 mg IV-administered adrenaline.

A decision was made to perform a perimortem hysterotomy to assist maternal resuscitative efforts. In the absence of operative instruments, a sterile 20 inch blade was used to perform the operation, with delivery of stillborn twins and the placenta.

Within 10 seconds the patient was documented to have a return

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of spontaneous circulation (ROSC), after a total of 6 minutes of asystole. The uterus and abdomen were closed with the aid of a suture pack and the patient was commenced on broad-spectrum antibiotic therapy and a concentrated infusion of oxytocin. She was initially ventilated with a fraction of inspired oxygen of 100% and a positive end-expiratory pressure of 10 cm H2O and maintained on infusions of dobutamine, adrenaline, furosemide, morphine and midazolam.

A review by the cardiology team, with the patient’s previous cardiology notes, revealed that she had suffered a myocardial infarction (MI) 4 years ago. Investigations at that time revealed triple-vessel coronary artery disease and she was deemed not a suitable candidate for coronary artery bypass grafting or stent placement. She was to be considered for cardiac transplantation if her lifestyle could be modified.

Echocardiography, electrocardiograms and serial cardiac enzymes following this acute event were not suggestive of an acute MI. A diagnosis of cardiac failure in the background of severe ischaemic left ventricular dysfunction was made. This was probably precipitated and exacerbated by the exaggerated physiological changes accompanying the multiple gestation.

The plan to wean the patient off ventilation and the infusions and continue antifailure therapy was successfully achieved in the next 48 hours, and she was assessed to be neurocognitively intact.

She was recommenced on her chronic medication, and extensively counselled about the events that had occurred since admission, the vital importance of compliance with medical therapy and lifestyle modification. She was counselled against any future pregnancies and received a long-acting reversible contraceptive. A follow-up visit with the obstetric and cardiology teams was scheduled with a view to reassessment of her suitability for surgical intervention.

Discussion

Ischaemic left ventricular dysfunction, which in this case was probably a consequence of a previous MI, is characterised by dilatation and impaired systolic function of one or both ventricles (LVEF <40%). Presenting manifestations can include arrhythmias, heart failure and sudden cardiac arrest.

Cardiac arrest in pregnancy is a rare but catastrophic event, with an estimated incidence of 1/30 000 pregnancies.[1] The principles

of management include timely identification, initiation of CPR, treatment of readily correctible causes and expedited delivery of the fetus, within 4 - 5 minutes, to achieve optimal outcomes.

The normal physiological changes of pregnancy need to be considered when resuscitating the pregnant patient. These include: • Difficult airway resulting from pharyngeal oedema and enlarged breast tissue • Increased risk of aspiration due to relaxation of the oesophageal sphincter • Decreased chest wall compliance secondary to enlarged breasts • Decreased functional residual capacity due to upward displacement of the diaphragm by the gravid uterus • Sequestration of up to 30% of the circulating blood volume in the latter half of pregnancy, due to compression of the inferior vena cava, iliac vessels and abdominal aorta by the gravid uterus • Decreased effect of chest compressions as a result of decreased venous return, leading to supine hypotension • Obstruction of forward flow of blood by the gravid uterus, especially in cardiac arrest, where the arterial pressure and volume are already reduced.

In general, resuscitative algorithms are the same for pregnant as for non-pregnant patients, with a few exceptions to accommodate the normal physiological changes of pregnancy. These are: • Placing the patient in the left lateral position (at least 15º tilt) or manually displacing the uterus to the left of the abdomen • Early intubation, correctly applied cricoid pressure and use of a smaller-sized endotracheal tube • Consideration of perimortem hysterotomy/caesarean section early in resuscitative efforts.[2]

Studies[3,4] have shown that there are cases in which ROSC does not occur until the uterus is emptied by a perimortem hysterotomy/caesarean section. In addition, there are many case reports of unsuccessful resuscitation attempts with usual life-support measures, but which noted ROSC only after the uterus was emptied.

When deciding to perform a perimortem delivery, the following factors need to be considered: • GA <20 weeks – an emergency hysterotomy is unlikely to improve the situation • GA 20 - 23 weeks – an emergency hysterotomy may improve the likelihood of survival of the mother, although survival of the fetus is very unlikely • GA >24 weeks – emergency caesarean section will be likely to rescue both the mother and the fetus.[5]

Importantly, delivery needs to be embarked upon within 4 - 5 minutes of cardiac arrest to achieve optimal maternal and/or fetal outcomes.

Successful resuscitation is reported in 6 - 15% of patients who suffer an in-hospital cardiac arrest, although survival rates are likely to be lower in pregnant patients, as a result of the physiological changes of pregnancy complicating resuscitation. A patient whose heartbeat and respiration have ceased for less than 4 minutes has an excellent chance of recovery with CPR and advanced cardiac life support. Brain damage may occur after 4 minutes and becomes certain after 6 minutes.[6] Many leading healthcare facilities around the world employ percutaneous extracorporeal membrane oxygen (ECMO) in selected patients with cardiac-respiratory arrest, as part of their resuscitation algorithm. ECMO can provide both cardiac and respiratory support to patients whose heart or lungs are so damaged that they cannot perform their function. This is a temporising measure to allow time to address the problem that caused the arrest. There is a growing body of evidence of improved success and outcomes with the use of ECMO during resuscitation.

Conclusion

Cardiac arrest in pregnancy is a rare event. Early aggressive resuscitation by a well-trained MDT increases the chance of a successful outcome for the mother and/or fetus, as shown in our case report. Adherence to standard CPR algorithms with modifications to accommodate the physiological changes of pregnancy with early (within 4 - 5 minutes) hysterotomy/caesarean section may well benefit both the mother and the fetus.

In summary, our case illustrates that an optimal outcome for cardiac arrest in pregnancy is possible in a unit that is well set up (with trained staff and a fully equipped resuscitation area). This is only achievable with ongoing in-service training and ‘fire drills’ in resuscitation, as is the case in our unit.

1. Atta E, Gardner M. Cardiopulmonary resuscitation in pregnancy. Obstet Gynecol Clin N Am 2007;34(3):585-597. [http://dx.doi.org/10.1016/j.ogc.2007.06.008] 2. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81(10):1400-1433. [http://dx.doi.org/10.1016/j. resuscitation.2010.08.015] 3. Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: Were our assumptions correct?

Am J Obstet Gynecol 2005;192(6):1916-1920. [http://dx.doi.org/10.1016/j.ajog.2005.02.038] 4. Dijkman A, Huisman CM, Smit M, et al. Cardiac arrest in pregnancy: Increasing use of perimortem caesarean section due to emergency skills training? BJOG 2010;117(3):282-287. [http://dx.doi. org/10.1111/j.1471-0528.2009.02461.x] 5. Farinelli CK, Hameed AB. Cardiopulmonary resuscitation in pregnancy. Cardiol Clin 2012;30(3):453-461. [http://dx.doi.org/10.1016/j.ccl.2012.04.006] 6. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S640-861. [http://dx.doi.org/10.1161/circulationaha.110.970889]

SAJOG • April 2015, Vol. 21, No. 1

11

CASE REPORT

Uterine rupture in a primigravida with a term pregnancy: Case report and lessons to learn R Vatharajh,1 MB ChB, FCOG; K Tunkyi,1 MB ChB, FCOG; J Devjee,1 MBBS, Dip O&G, MBA; J Moodley,1,2 MB ChB, FCOG, FRCOG, MD 1 2

epartment of Obstetrics and Gynaecology, Addington Hospital, Durban, South Africa D Women’s Health and HIV Research Group, Department of Obstetrics and Gynaecology, Nelson Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: J Moodley (jmog@ukzn.ac.za)

Spontaneous uterine rupture (UR) in primigravidas with term pregnancies is a rare occurrence, but is increasing in frequency in high-income countries as a result of a concomitant rise in rates of gynaecological uterine surgery. We present a case from a low- and middle-income country of spontaneous UR at term with no known markers of such an adverse event. The spontaneous UR may have been due to the ingestion of traditional medicines. Health professionals and the community at large must be alerted to the possible dangers of the use of such medications in pregnancy.

S Afr J Obstet Gynaecol 2015;21(1):12-13. DOI: 10.7196/SAJOG.973

Recently there has been an increasing number of reports from high-income countries of spontaneous uterine rupture (UR) in term primigravidas. These reports relate mainly to women who have had uterine surgery such as hysteroscopic surgery, myomectomies, surgical correction of uterine anomalies and inadvertent uterine perforation.[1,2] We report a case of UR in a primigravida at term, which was probably due to the use of traditional/herbal medications, a common practice in low- and middle-income countries.

Case history

A 21-year-old primigravida presented to our hospital at 37 weeks’ gestation with severe lower abdominal pain and vaginal bleeding.

She had clinical and ultrasound features suggestive of hypovolaemic shock and intra-abdominal bleeding, and required an emergency laparotomy.

History of presenting complaint On the day of admission to our hospital, the patient reported lack of fetal movements but described what she felt as the baby ‘moving up and down’ in the upper abdomen. The patient stated that she had ingested half a cup of traditional medication (isiShlambezo; loosely translated this means ‘that which cleans’) the day before her hospital visit and had noticed increasing intensity of abdominal pain a few hours later. In the last month of her pregnancy she had also ingested a beaten-egg concoction daily, which her family had suggested would help to hasten her labour.

The patient had received antenatal care at our hospital; no abnormalities were detected on physical examination at the first antenatal visit and her basic antenatal laboratory investigations were normal. She had had two non-scheduled visits to our hospital in the last trimester of pregnancy for lower abdominal pains prior to admission. At the first non-scheduled visit she was found to be 36 weeks pregnant by symphysis-fundal height assessment and the fetus was lying in the longitudinal position with the cephalus presenting. At this consultation a diagnosis of false labour was made

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and the patient was counselled on signs of labour and given an appointment to return in a week’s time. On her second non-scheduled hospital visit she also complained of persistent lower abdominal pains and backache. According to early ultrasound findings she was 37 weeks pregnant by gestation and 38 by symphysis-fundal height measurement; pelvic examination revealed the cervical os to be closed. The patient was again thought to be in false labour and asked to return when she was in active labour. At both of these visits the patient had reactive cardiotocographic changes, uterine contractions were not palpable manually, and urine dipsticks were not indicative of a urinary tract infection.

The obstetric history revealed that the pregnancy had been planned and the patient denied any history of previous pregnancies, miscarriages or uterine curettage. She also denied the use of recreational drugs/substance abuse and there was no family history of collagen diseases.

Findings on physical examination at the time of admission The patient was pink and alert, with a blood pressure of 96/63 mmHg and pulse rate 93 bpm, regular and with good volume. The abdomen was distended, and it was difficult to ascertain the symphysis-fundal height. Fetal parts were palpable in transverse lie with free fluid noted in the abdomen. The fetal heart was not audible. The abdomen was peritonitic and blood was noted on the glove following the vaginal examination. Other systems were normal.

Ultrasound findings A non-viable extrauterine pregnancy was noted, with free fluid in the abdomen. The uterus measured 97 mm in its long axis and had an irregular fundal area. The fetus was in the transverse position, and the placenta was in the left side of the abdominal cavity outside the uterine cavity.

Definitive management A diagnosis of UR was made, and the patient was resuscitated prior to laparotomy. The findings at laparotomy were a ruptured

fundus of the uterus not involving the tubes or ovaries; the placenta extruded into the abdominal cavity with intact gestational sac and a macerated stillborn fetus. A haemoperitoneum of approximately 2 L was noted.

The uterus was repaired in two layers with good haemostasis.

The haemoglobin level before surgery was 9 g/dL and the patient received 2 units of red cell concentrate following surgery. She made an uneventful recovery and was provided with counselling regarding the stillbirth, and given full information about contraception, future pregnancies and the level of healthcare she needed to seek when pregnant again.

Ethics statement Ethical permission was not obtained, as this is a case report. However, verbal informed consent was obtained from the patient after assurance that no identifiers or pictures would be made available. This verbal consent was documented in the hospital records.

Discussion

UR in primigravidas is rare.[1] Well-known risk factors for UR are a previously scarred uterus following caesarean section, myomectomy and hysteroscopic surgery.[2] Recently, a case report indicated spontaneous UR at 32 weeks’ gestation in a patient with an unrecognised Müllerian tract anomaly.[3] Use or abuse of misoprostol for induction of labour has also been reported as a cause of UR in primigravidas.[2] In low- and middle-income countries such as South Africa (SA), it has been found that some patients use traditional medicines containing various decoctions made from medicinal plants to either improve fetal growth or induce labour. In our case, the patient ingested a traditional decoction a day prior to her adverse event and had been eating egg yolk daily for a month. The egg yolk was given to her by her family to facilitate labour. The chemical properties of egg yolk in respect of uterine contractility are unknown and may not have any relation to the UR. The use of traditional medicines during pregnancy is common in the province of KwaZulu-Natal, SA. Mabina et al.[4] found that 55% of patients presenting in early labour gave a history of ingesting herbal medications supplied by traditional healers or their families, or bought from medicinal shops or street vendors.

Patients who ingested traditional medications (isiShlambezo) had a higher incidence of grade II - III meconium-stained liquor and a

higher caesarean section rate than a group that did not ingest herbal concoctions/medications.[4] Although the active chemical agents in herbal medications used during pregnancy in KwaZulu-Natal have still not been identified, it has been postulated that the meconium is due to hyperstimulation and may lead to UR, particularly in parous women.[4] Furthermore, there is evidence that indigenous plants such as Agapanthus africanus and Pentanisia prunelloides, commonly used in traditional herbal remedies during pregnancy and childbirth, may have oxytocic properties.[5] Use of herbal medications in pregnancy in other countries has also been reported. An article on the frequency of UR in Ghana indicates a history of use of herbal medication in patients who had UR in over 50% of their cases.[6] Given the history of use of traditional medicines by the patient, the lack of risk factors of UR and the fact that she was a primigravida without previous uterine surgery of any type, we postulate that the traditional medicines might have led to uterine hyperstimulation and subsequent UR. Furthermore, there was no evidence of gross anatomical congenital abnormality of the uterus or substance use. There have been case reports of abuse of cocaine and UR.[7] In addition it has been suggested that collagen tissue disorders such as Ehlers-Danlos syndrome are associated with spontaneous UR.[1,2,7] This case illustrates that in low- and middle-income countries in sub-Saharan Africa, healthcare personnel need to be aware of the effects of traditional medicines. In women with lower abdominal pain at term in whom a diagnosis of false labour and abdominal pains not typical of uterine contraction is made, a history of ingestion of traditional medicines must be taken, uterine contractions palpated for, and a cardiotocographic recording done to rule out hyperstimulation.

1. Walsh CA, O’Sullivan RJ, Foley FE. Unexplained prelabour uterine rupture in a term primigravidae.

Obstet Gynecol 2006;108(3):725-727.

2. Uccella S, Cromi A, Bogani G, Zaffaroni E, Ghezzi F. Spontaneous prelabour uterine rupture in a primigravidae: A case report and review of the literature. Am J Obstet Gynecol 2011;205(5):e6-8. [http://dx.doi.org/10.1016/j.ajog.2011.08.013] 3. Mizutamari E, Honda T, Ohba T, Katabuchi H. Case report: Spontaneous rupture of an unscarred gravid uterus in a primigravid woman at 32 weeks of gestation. Case Rep Obstet Gynecol 2014(2014), Article ID 209585. [http://dx.doi.org/10.1155/2014/209585] 4. Mabina MH, Pitsoe SB, Moodley J. The effect of traditional medicines on pregnancy outcome.

Trop Doct 1997;27(2):84-86.

5. Kaido TL, Veale DJH, Havlik I, Rama DB. Preliminary screening of plants used in South Africa as traditional herbal remedies during pregnancy and labour. J Ethnopharm 1977;55:185-191.

6. Fofie C, Baffoe P. A two year review of uterine rupture in a regional hospital. Ghana Med J 2010;44(3):98-102.

7. Gonsoulin W, Borge D, Moise KJ jr. Rupture of the unscarred uterus in primigravid women in association with cocaine abuse. Am J Obstet Gynecol 1990;163(2):526-527.

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13

CASE REPORT

Entrapment of a vaginal ring pessary: Case report and review of the literature Z Abdool, MMed (O&G), FCOG (SA) Department of Obstetrics and Gynaecology, Steve Biko Academic Hospital and Faculty of Health Sciences, University of Pretoria, South Africa Corresponding author: Z Abdool (zeelha.abdool@up.ac.za)

The use of vaginal pessaries for symptomatic pelvic organ prolapse (POP) is well established. Recently pessaries have been offered routinely as a first-line treatment option for symptomatic POP, and in patients with medical comorbidity, those who are unfit for surgical intervention, and young women who still wish to bear children. The favourable physical and chemical properties of silicone have made pessaries safer to use for the treatment of POP. Complications associated with neglected pessaries are well documented, and it is probable that complications are rare when pessary care is regular. We present a case of partial encapsulation of a ring pessary despite regular follow-up at a tertiary urogynaecological unit, and review the literature pertaining to early entrapment of vaginal ring pessaries.

S Afr J Obstet Gynaecol 2015;21(1):14-15. DOI:10.7196/SAJOG.905

A variety of pessaries are available, but it is evident from the literature that the ring pessary is the most common type prescribed, regardless of compartmental defect. Although the early litera­ ture commonly reserved their use for patients who declined surgery, were unfit for surgery or required interim relief while awaiting surgery, and for young women who wanted to fall pregnant, their use as first-line treatment for symptomatic pelvic organ prolapse (POP) is currently common clinical practice among gynaecologists and allied health clinicians (nurses and physiotherapists).[1-4] Using a variety of questionnaires, several studies have demonstrated both a statistically and clinically significant improvement in prolapse, urinary and bowel sympotoms, sexual activity, and general quality of life.[5-8] Handa and Jones[9] reported a significant improvement in stage of prolapse (p=0.045) in a small group of 19 women who were fitted with a ring pessary for at least 1 year, and Matsubara and Ohki[10] reported correction/reversal of uterine prolapse in six women 42 months after removal of the ring pessary, suggesting a therapeutic effect.

Major complications associated with neglected ring pessaries, such as fistulas (vesicovaginal, rectovaginal), vaginal vault perforation, pessary incarceration, urosepsis and pessary entrapment/ embedment, are well noted in the literature.[11] Lone et al.[3] reported an overall minor complication rate of 12.1% (pain/discomfort, excoriation/bleeding, disimpaction/constipation) in symptomatic patients followed up over a 5-year period. Entrapment, also frequently referred to as embedment, is a common complication reported mainly with neglected and forgotten ring pessaries. We present a case of a ring pessary entrapped in a band of vaginal tissue despite frequent pessary care at a tertiary urogynaecology clinic.

The patient had initially been referred to the urogynaecology clinic for symptomatic POP in August 2009. She had had seven previous normal vaginal deliveries with no complications. Examination revealed anterior compartment prolapse, cystocele POP-Q stage 2.

The patient was offered either surgical intervention or a pessary as a treatment option. She opted for the latter. A 70 mm (size 4) siliconebased ring pessary (without support) was inserted. We routinely review the patient 2 weeks after insertion and then at 3-monthly intervals. She continued to present for her routine review on a 3 6-monthly basis as she could not attend at 3-monthly intervals.

She noted that the pessary had significantly improved her prolapse symptoms. At each visit the pessary was removed and cleaned and the vaginal mucosa inspected with a Cusco speculum, as per protocol. Vaginal oestrogen cream was prescribed intermittently as deemed necessary by the attending clinician.

On further examination of the retained pessary, a thick band of granulation tissue (approximately 2 cm) had grown over the pessary

Case report

A 64-year-old woman, para 7, gravida 7, presented to the uro­ gynaecology clinic for her routine 3 - 6-monthly pessary review visit. She had no current complaints and was satisfied using the ring pessary as a treatment option for symptomatic POP. On clinical examination the clinician failed to remove the ring pessary, which was retained.

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Fig. 1. Thick band of granulation tissue causing entrapment of the pessary.

(Fig. 1). Local anaesthetic was injected into the granulation tissue and it was incised in the examination room with no complications and no need for further analgesia. The vagina was packed and the patient was monitored for vaginal bleeding for 4 hours after the procedure.

She was discharged home without pessary reinsertion, with instructions to use vaginal oestrogen cream daily. She was reviewed 6 weeks later, and requested pessary reinsertion after declining surgical intervention. She gave written consent for publication of this case report.

Discussion

Vaginal pessaries form an important part of the treatment armamentarium for general practitioners, gynaecologists and nurses. They are prescribed as first-line treatment for prolapse by 77% of American urogynaecologists, 86.7% of UK gynaecologists and 24% of South African gynaecologists.[2,12] The simple ergonomic design of the ring pessary is appealing to both the healthcare provider and the patient, which may explain its popularity. It can be removed and replaced easily by both clinician and patient, and its use is not dependent on stage and type of prolapse, although some manufacturers recommend the ring pessary for first- and second-degree prolapse.

Major complications with ring pessaries rarely occur with fre­ quent follow-up, and minor clinical issues such as vaginal dis­ charge, odour, irritation and erosions are often tolerated by informed patients.[11] Lone et al.[3] performed a large prospective study to identify complications of pessary use and reasons for discontinuation over a period of 5 years. It was noted that most complications become apparent within the first 6 months after pessary insertion, and minor complications such as vaginal discharge, odour and excoriation/bleeding can be managed conservatively with local oestrogen application, a pessary ‘holiday’ and a change in pessary size at reinsertion. These patients were reviewed 6-monthly at a urogynaecology clinic and no major complications were noted in patients who continued use at 5 years (n=130).

Vaginal ring entrapment, also referred to as encapsulation, embedment or incarceration, is a recognised complication that is commonly reported in older patients who have either forgotten or neglected their pessary care routine. Early entrapment of a ring pessary in patients who attend for 3 - 6-monthly followup is uncommon. The literature reports three cases[13-15] of early entrapment of vaginal ring pessaries at 4 and 5 months post review/ insertion. The case reported by Thornton and Harrison[13] was a 59-year-old woman with procidentia awaiting surgical intervention.

A 95 mm polyvinyl (PVC) ring pessary was inserted, and it was removed under general anaesthesia 4 months later because of incarceration. Whitworth et al.[14] reported a 73-year-old patient with three-compartment prolapse who had been using an 80 mm PVC ring pessary for 10 years (poor surgical candidate). Five months after the last visit the pessary was described as incarcerated and vaginal tissue was excised uneventfully. In 2007 Govind and Lahki[15] reported entrapment of an 80 mm polyethylene (Portex) ring pessary only 4 months after insertion in a 75-year-old patient with a cystourethrocele. Although these cases were easily treated, in severe cases with neglected or forgotten pessaries a bone cutter can be used in theatre to remove the entrapped ring.[15]

Reasons postulated for early vaginal ring pessary entrapment may be related to the type of pessary material (vulcanised rubber v. silicone-based pessaries), concomitant vaginal atrophy, and inherent local tissue reaction in response to chronic vaginal irritation.

Watch-spring and vulcanite-based (combination of rubber and sulphur) pessaries were predominantly used in the early 1900s, and polythene-based as opposed to silicone-based pessaries in the mid1900s. These were not easily compressible and produced marked tissue reactions. Polythene, also referred to as ‘common plastic’, is composed of a long chain of hydrocarbons with differing molecular weights, as opposed to silicone, which consists of a silicone and oxygen backbone to which organic groups such as methyl, ethyl or phenyl are attached. The chain length, cross-linking and side-group attachment determine the properties and composition, e.g. gas, liquid, gel, rubber. The favourable physical and chemical properties of silicone, i.e. bioinert, stable and readily flexible, make it the best material currently available for pessary manufacture.

Conclusion

At present there are no universally standardised pessary protocols, and clinicians depend on expert opinion and manufacturer recommendations. However, it is widely agreed that a pessary clinic routinely review patients at 3 - 6-monthly intervals. At these followup visits, the vagina is carefully inspected for erosions/abrasions, especially the lateral vaginal fornices and apical area. The pessary should be cleaned with soap and water. If patients are comfortable about handling the pessary and performing self-care, intervals may be extended to 6 - 12-monthly intervals. All patients should be educated about self-care and the significance of strictly timed follow-up visits.

1. Bugge C, Hagen S, Thakar R. Vaginal pessaries for pelvic organ prolapse and urinary incontinence: A multiprofessional survey of practice. Int Urogynecol J Pelvic Floor Dysfunct 2013;24(6):10171024. [http://dx.doi.org/10.1007/s00192-012-1985-7] 2. Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use by members of the American Urogynecologic Society. Obstet Gynecol 2000;95(6):931-935. [http://dx.doi. org/10.1016/S0029-7844(00)00788-2] 3. Lone F, Thakar R, Sultan AH, Karamalis G. A 5-year prospective study of vaginal pessary use for pelvic organ prolapse. Int J Gynaecol Obstet 2011;114(1):56-59. [http://dx.doi.org/10.1016/j. ijgo.2011.02.006] 4. Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol 2005;106(3):615-634. [http://dx.doi. org/10.1097/01.AOG.0000175832.13266.bb] 5. Cundiff GW, Amundsen CL, Bent AE, et al. The PESSRI study: Symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol 2007;196(4):405.e1-405.e8. [http://dx.doi.org/10.1016/j.ajog.2007.02.018] 6. Komesu YM, Rogers RG, Rode MA, et al. Pelvic floor symptom changes in pessary users. Am J Obstet Gynecol 2007;197(6):620.e1-620.e6. [http:dx.doi.org/10.1016/j.ajog.2007.08.013] 7. Kuhn A, Bapst D, Stadlmayr W, Vits C, Mueller M. Sexual and organ function in patients with symptomatic prolapse: Are pessaries helpful? Fertil Steril 2009;91(5):1914-1918. [http://dx.doi. org/10.1016/j.fertnstert.2008.02.142] 8. Abdool Z, Thakar R, Sultan AH, Oliver R. Prospective evaluation of outcome of vaginal pessaries versus surgery in women with symptomatic pelvic organ prolapse. Int Urogynecol J 2011;22(3):273-278. [http://dx.doi.org/10.1007/s00192-010-1340-9] 9. Handa VL, Jones M. Do pessaries prevent the progression of pelvic organ prolapse? Int Urogynecol J Pelvic Floor Dysfunct 2002;13(6):349-351, discussion 352. [http://dx.doi.org/10.1007/ s0019202000078] 10. Matsubara S, Ohki Y. Can a ring pessary have a lasting effect to reverse uterine prolapse even after its removal? J Obstet Gynaecol Res 2010;36(2):459-461. [http://dx.doi.org/10.1111/j.14470756.2009.01162.x] 11. Arias BE, Ridgeway B, Barber MD. Complications of neglected vaginal pessaries: Case presentation and literature review. Int Urogynecol J Pelvic Floor Dysfunct 2008;19(8):1173-1178. [http://dx.doi. org/10.1007/s00192-008-0574-2] 12. Abdool Z. Evaluation of vaginal pessary use by South African gynaecologists. S Afr J Obstet Gynaecol 2011;17(3):64-67.

13. Thornton CA, Harrison RF. Unusually rapid incarceration of a polyvinyl ring pessary. Ir J Med Sci 1977;146(4):116. [http://dx.doi.org/10.1007/BF03030943] 14. Whitworth JS, Thijs I, Bhal PS. Rapid incarceration of a ring pessary with its safe and immediate removal. J Obstet Gynaecol 2002;22(2):225-226.

15. Govind A, Lakhi N. The enigma of early entrapment of vaginal ring pessaries. J Obstet Gynaecol 2007;27(4):451-452. [http://dx.doi.org/10.1080/01443610701383258]

SAJOG • April 2015, Vol. 21, No. 1

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CASE REPORT

Primary amenorrhoea: Swyer syndrome in a woman with pure 46,XY gonadal dysgenesis and late presentation A Chrysostomou, MD, FCOG (SA), MMed Department of Obstetrics and Gynaecology, Johannesburg Hospital and University of the Witwatersrand, Johannesburg, South Africa Corresponding author: A Chrysostomou (andreas.chrysostomou@wits.ac.za)

Simple 46,XY gonadal dwysgenesis, also called Swyer syndrome, is a very rare condition, estimated to occur in approximately 1/100 000 people. The condition first becomes apparent in adolescence, with delayed puberty and primary amenorrhoea. This is a case study of a patient who presented with primary amenorrhoea and primary infertility. She was a 24-year-old phenotypically female patient with a delayed diagnosis of Swyer syndrome.

S Afr J Obstet Gynaecol 2015;21(1):16-17. DOI:10.7196/SAJOG.891

Case report

A 24-year-old nulliparous woman consulted for investigation of primary amenorrhoea and infertility at the gynaecological outpatient department of our tertiary academic hospital. The initial referral diagnosis was testicular feminisation syndrome. On physical examination, the patient was phenotypically female, height 178 cm, weight 72 kg, with normal secondary sexual characteristics (pubic and axillary hair present, breast development Tanner stage IV).

Normal external genitalia were present with a normal clitoris. On speculum examination vaginal length was normal, and the cervix appeared normal.

On bimanual examination the uterus was found to be of normal size and no adnexal masses were palpable. Investigations revealed the presence of elevated gonadotropins (follicle-stimulating hormone, luteinising hormone) and a low level of oestrogen. A karyotype study revealed a chromosome complement of 46,XY. A vaginal ultrasound scan confirmed the clinical findings of a normal-sized uterus; the ovaries could not be visualised.

The patient underwent diagnostic and operative laparoscopy, where streak ovaries were evident (Fig. 1). Bilateral gonadectomy was

Fig. 1. Laparoscopic findings of the uterus, tube and a streak gonad.

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SAJOG • April 2015, Vol. 21, No. 1

performed and histological examination confirmed that both gonads had features consistent with streak ovaries. There was no neoplasia.

Postoperatively the patient was started on combined oestrogen/ progestin treatment in the form of oral contraception (COC).

Discussion

Simple 46,XY gonadal dysgenesis, also called Swyer syndrome, is a very rare condition, and has been estimated to occur in approximately 1/100 000 people.[1,2] The condition first becomes apparent in adolescence, with delayed puberty and primary amenorrhoea. Pure gonadal dysgenesis (or Swyer syndrome) is characterised by a 46,XY karyotype in a female phenotypic patient.

Despite having XY chromosomes, the patient with Swyer syndrome appears female and has functional female genitalia and structures, including a vagina, uterus and fallopian tubes.

Embryogenesis is thought to be a likely cause; the indifferent gonads fail to differentiate into testes in an XY (genetically male) fetus. Several different gene loci, both on the Y chromosome and other chromosomes, have been identified where a defect may occur.

So-called ‘pure gonadal dysgenesis’ may be of the XX or XY type, or mixed, in which XX and XY cell lines appear. The other form of gonadal dysgenesis occurs in which an entire chromosome is missing; the most common is Turner’s syndrome.

In the absence of testes, no testosterone or anti-Müllerian hormone (AMH) is produced. Without testosterone, the external genitalia fail to virilise, resulting in normal female genitalia. The upper Wolffian ducts fail to develop, so no internal male organs are present. Without AMH, the Müllerian ducts develop into normal internal female organs (uterus, fallopian tubes, cervix and upper vagina).

As in this case, delay in diagnosis is often due to a normal phenotypic appearance, despite the fact that non-functional gonads result in amenorrhoea. Before puberty (even in normal females) the ovaries play little or no role in bodily changes. The problem manifests itself at puberty as a result of an inability of the streak gonads to produce sex hormones (both oestrogens and androgens).

Most of the secondary sexual characteristics do not develop, and menses are absent in the majority of phenotypically female patients with pure gonadal dysgenesis.

In this case, the secondary sexual characteristics did develop, as pubic and axillary hair was present. The breasts were not fully developed, although Tanner stage IV had been attained. The main source of oestrogens would be the peripheral aromatisation of androgens into oestrone, which is a weak oestrogen compared with ovarian-derived oestradiol.

The main complaints of this patient were primary amenorrhoea and primary infertility.

The gonads of XY pure gonadal dysgenesis have a high risk of gonadoblastoma and germ cell tumour, particularly dysgerminoma.[2,3] In this case, as typically occurs, the diagnosis was delayed and made at the age of 24 years. A study by Michala et al.[4] from the UK in 2008 showed that particularly in patients over the age of 30 years when data were collected, accurate diagnosis was delayed, and the mean age was 23 years; in those under 30 years at data collection, the age of diagnosis was 16 years. In the older cohort, medical practitioner delay contributed to late diagnosis. Early diagnosis is important, not only because of the need to be aware of the risk of gonadal malignancy, but also because hormonal therapy is vital for the induction of puberty. Breast development was close to normal in this patient, but failure of development has been reported. Hormone replacement is also necessary to prevent osteoporosis. In Michala et al.’s study[4] 60% of the 29 patients had evidence of osteopenia on dual-emission X-ray absorptiometry.

Following removal of the gonads, COC therapy was promptly initiated. The oestrogen-progestin sequential therapy supports female secondary sexual characteristics. The COC can usually induce menstruation and also increases the uterine size and improves its shape. Pregnancy can be achieved or fertility can be optimised by using donor oocytes, and successful pregnancies in patients with pure gonadal dysgenesis have been described. [4,5]

Conclusion

This a case of pure gonadal dysgenesis in a 46,XY phenotypically female patient, who presented with primary amenorrhoea and infertility. The primary care physician needs to be aware of this condition, as early referral to tertiary centres is necessary for appropriate management. Delay in presentation may be also be affected by patient delay in seeking help.

1. Coutin AS, Hamy A, Fondevilla M, Savingy B, Paineaou J, Vissez J. Pure 46,XY gonadal dysgenesis.

J Gynecol Obstet Biol Reprod (Paris) 1996;25(8):792-796.

2. Nadereh B, Mojgan KZ. Dysgerminoma in three patients with Swyer syndrome. World J Surg Oncol 2007;5(1):71-75. [http://dx.doi.org/10.1186/1477-7819-5-71] 3. Zielinska R, Zajaczek S, Rzepka-Gorskal. Tumours of genetic gonads in Swyer syndrome. J Pediatr Surg 2007;42(10):1721-1724. [http://dx.doi.org/10.1016/j.jpedsurg.2007.05.029] 4. Michala L, Goswami D, Creighton SM, et al. Swyer syndrome: Presentation and outcomes. BJOG 2008;115(6):735-741. [http://dx.doi.org/10.1111/j.1471-0528.2008.01703.x] 5. Plante BJ, Fritz MA. A case report of successful pregnancy in a patient with pure 46,XY gonadal dysgenesis. Fertil Steril 2008;90(5):2015e1-2015e2. [http://dx.doi.org/10.1016/j. fertnstert.2008.04.043]

In the April 2015 issue of the South African Medical Journal (Vol. 105 No. 4):

APRIL 2015

VOL. 105 NO. 4

Basic and comprehensive emergency obstetric and neonatal care

256

Optimal staffing to ensure safe maternity units

261

Food insecurity in urban South Africa Management of obstetric haemorrhage

268 271

MMed supervision – a path out of the swamp

275

Caesarean section and maternal death – latest Saving Mothers report

287

Intrapartum asphyxia and hypoxic encephalopathy

298

Safety versus accessibility in maternal and perinatal care R C Pattinson Bob Pattinson, MD, FRCOG, FCOG (SA), is Director of the MRC Maternal and Infant Health Care Strategies Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, South Africa. His main interests are in implementing effective healthcare interventions at primary and secondary levels of care.

Corresponding author: R C Pattinson (robert.pattinson@up.ac.za)

This article adds to the debate on appropriate staffing in maternity units. My starting point for assessing staffing norms is the staff required to provide a safe maternity unit. A survey in 12 districts showed that their health facilities were not adequately prepared to perform all the essential emergency services required. Lack of staff was often cited as a reason. To test this notion, two norms (World Health Organization (WHO) and Greenfield) giving the minimum staff required for the provision of safe maternity services were applied to the 12 districts.

Assuming the appropriate equipment is available and the facility is open 24 hours a day 7 days a week, at a minimum there need to be ten professional nurses with midwifery/advanced midwives to ensure safety for mother and baby in every maternity unit. The norms indicate that the units should do a minimum of 500 - 1 200 deliveries per year to be costeffective. All 12 districts had sufficient staff according to the WHO. When the numbers of facilities with maternity units were compared with Council for Scientific and Industrial Research and WHO norms for number of health facilities per population, a large excess of facilities was found. Per district there were sufficient personnel to perform the number of deliveries for that district using the WHO or Greenfield formulas, but per site there were insufficient personnel. In my view there are sufficient personnel to provide safe maternity services, but too many units are performing deliveries, leading to dilution of staff and unsafe services. A realignment of maternity units must be undertaken to provide safe services, even at the expense of accessibility.

S Afr Med J 2015;105(4):261-265. DOI:10.7196/SAMJ.9182

SAJOG • April 2015, Vol. 21, No. 1

17

CASE REPORT

Live birth from a patient with a three-way balanced translocation t(5;8;12) A Ramdeo, MB BCh, MRCOG; K Naidoo, N Dip Med Tech; T Ernest, BMedSci Hons; K Pluta, MSc, PhD C.A.R.E. Clinic (Centre for Assisted Reproduction and Endocrinology), Westville, Durban, South Africa Corresponding author: A Ramdeo (pcrlab.careclinic@gmail.com)

Background. Three-way balanced translocations are unusual and can lead to infertility as well as abnormal embryos. In this case report, we describe a couple who experienced repeated miscarriages as a result of the male partner being a carrier of a three-way translocation t(5;8;12).

Objectives. Array comparative genomic hybridisation (array-CGH) was used to screen embryos for chromosome imbalances.

Methods. Embryo biopsy, preimplantation genetic diagnosis using a 24sure+ kit to detect translocations in embryos.

Results. Of 10 embryos tested, 2 were found to have an unbalanced translocation, 4 were aneuploid, 2 failed to amplify and 2 were euploid. Transfer of the two euploid embryos resulted in a singleton pregnancy and subsequent birth of a baby.

Conclusion. Array-CGH in conjunction with a 24sure+ kit should be used as a routine screening method for embryos of balanced translocation carriers, as it can decrease the time to pregnancy and prevent repeated miscarriages.

S Afr J Obstet Gynaecol 2015;21(1):18-20. DOI:10.7196/SAJOG.922

Chromosome translocation, also known as chromosome rearrangement, is an abnormality caused by exchange of parts between non-homologous chromosomes. Translocations can be balanced (when exchange of material occurs with no genetic information extra or missing) or unbalanced (where the exchange of chromosome material is unequal, resulting in extra or missing genes).

Carriers of balanced translocations resemble a normal phenotype, while those who have unbalanced translocations may represent abnormal phenotype and functional disability.[1] Further subdivision of translocation types can be made according to the exchange of chromosomal material and are classified as: (i) reciprocal, when segments from two different chromosomes have been exchanged; or (ii) robertsonian, in five acrocentric chromosomes (13, 14, 15, 21 and 22), where long arms fuse to form a single chromosome with a single centromere. The short arms also join to form a reciprocal product, which typically contains non-essential genes and is usually lost within a few cell divisions.

Translocations subdivided in groups regarding the number of chromosomes involved are: (i) one-way translocation with oneway transfer of a chromosomal segment to another chromosome; (ii) two-way translocation with two-way transfer of a chromosomal segment to another chromosome; and (iii) the most common group of complex chromosomal rearrangements (CCRs), with three or more chromosomes involved in the exchange.[2] This type of rearrangement takes place during meiosis I and involves formation of a hexavalent configuration that allows the full synapsis of homologous segments.

Chromosomal translocations can be formed de novo or can be inherited through so-called ‘familial transmission’.

Carriers of chromosomal translocations are known to have reduced fertility. In these patients, loss of fertility is mainly caused by the high prevalence of gametes that have lost or gained chromosome material as a result of the rearrangement of the derivative chromosomes or a generation of a recombinant chromosome.

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It has been reported that for translocation carriers, in vitro fertilisation combined with preimplantation genetic diagnosis (PGD) is a faster method of conceiving a child than natural conception.[3]

Case report

This report describes a couple who experienced five spontaneous abortions and one elective abortion due to an abnormal fetus. The couple had managed to have one spontaneous pregnancy resulting in a healthy child before experiencing recurrent miscarriages.

Peripheral blood analysis of the male partner revealed a modal number of 46, karyotype 46, XY, t(5;8;12)(5pter-5q33::8q24.1-8qter; 8pter-8q34.1::12p13-12pter;12qter-12p13::5q55-5qter). This meant that the male partner was a carrier of a balanced translocation involving chromosomes 5, 8 and 12. The mother of the male patient had the same balanced chromosome rearrangement, while his sister had an unbalanced form of this translocation with only derivative 5 and derivative 12 present, and not derivative 8, resulting in mental retardation. Two cousins of the same family were diagnosed with an unbalanced karyotype resulting in mental retardation. The same unbalanced karyotype was present in the fetus of the investigated couple, which had prompted them to undergo an elective abortion previously.

Semen analysis revealed a normal pH, volume, viscosity, lique­ faction, total count, progression motility and morphology. The female partner successfully responded to hormonal stimulation and 15 oocytes were collected, including 7 MII (metaphase II), 2 MI (metaphase I) and 6 GV (germinal vesicle). Of these, ten oocytes were injected with sperm and all fertilised. Ten of the fertilised oocytes resembled normal phenotype and had the following grades: 3 were hatched blastocysts, 4 were hatching blastocysts and 3 were at the blastocele stage. All ten embryos were subjected to array comparative genomic hybridisation (array CGH). The trophectoderm cells were lysed, and genomic DNA and negative control were amplified using the SurePlex DNA Amplification System (BlueGnome, UK) according to the manufacturer’s instruc­

tions. DNA samples and references were then labelled and hybridised using arrays designed for translocations (24sure+, BlueGnome, UK). Slides were washed, scanned with InnoScan710 AL (INNOPSYS, France) and processed using Bluefuse Multi Software (BlueGnome, UK).

Of the 10 embryos subjected to array CGH, 2 failed to amplify, 2 were euploid, 4 were aneuploid and 2 had unbalanced translocations.

Embryos 2 and 8, despite being graded as morphologically ‘good embryos’ showed an unbalanced complement of the trans­ location. In embryo 2, a partial loss of the long arm of chromosome 5 from 5q33.35q35.3 (24,951,204 bp), a partial loss of the long arm of chromosome 8 from 8q24.18q24.3 (23,417,117 bp) and a partial gain of

the short arm of chromosome 12 spanning 12p13.1-12p13.3 (5,727,495 bp) was observed (Fig. 1). In embryo 8, a partial gain of the long arm of chromosome 5 from 5q33.1-5q35.3 (29,602,079 bp) and a partial loss of the short arm of chromosome 12 spanning 12p13.31-12p13.33 (6,129,127 bp) was observed (Fig. 1).

On the basis of the array CGH results, two euploid embryos were transferred on day 6 post oocyte retrieval resulting in a singleton pregnancy. A normal healthy baby was born at 35 weeks by caesarean section.

Cytogenetic analysis revealed a normal karyotype of the baby.

Discussion

This report describes a selection process of embryos originating from a balanced three-

a) EMBRYO 2 Chromosome 5

Chromosome 8

Chromosome 12

Chromosome segment with breakpoints

12p13.31

5q35.3

8q24.3

–1.50 –0.80 0.00 0.80 1.50

–1.50 –0.80 0.00 0.80 1.50

–1.50 –0.80 0.00 0.80 1.50

b) EMBRYO 8 Chromosome 5

Chromosome 12 12p13.31

–1.50 –0.80 0.00 0.80 1.50

–1.50 –0.80 0.00 0.80 1.50 Log2ratio Ch1/Ch2

Fig. 1. Chromosomes affected by unbalanced translocation in embryos 2 (a) and 8 (b). (a) Embryo 2 showing partial loss of the long arm of chromosome 5 from 5q33.3-5q35.3 (24,951,204 bp), a partial loss of the long arm of chromosome 8 from 8q24.1-8q24.3 (23,417,117 bp) and a partial gain of the short arm of chromosome 12 spanning 12p13.112p13.3 (5,727,495 bp). (b) Embryo 8 showing partial gain of the long arm of chromosome 5 from 5q33.1-5q35.3 (29,602,079 bp) and a partial loss of the short arm of chromosome 12 spanning 12p13.31-12p13.33 (6,129,127 bp).

way reciprocal translocation carrier using array CGH. It proves that phenotypically normal embryos originating from a chromosomal translocation carrier may be carrying chromosomal imbalances.[4] The male patient was diagnosed with a balanced three-way reciprocal translocation after his female partner suffered repeated miscarriages and an elective abortion due to the fact that the embryo was affected with an unbalanced translocation. It has been reported that balanced translocation carriers have an increased risk of abnormal conceptions and miscarriages,[5] caused by either malsegregation of the derivative chromo­somes or the generation of a recombinant chromosome.[2] The mother and sister of our male patient had been diagnosed with balanced and unbalanced chromo­ somal translocations, respectively, highlighting that this was a familial chromosomal rearrangement.[6] The same type of reciprocal balanced three-way translocation involving chromosomes 5, 8 and 12 was previously reported in an Indian family from KwaZulu-Natal.[7] Several members across three generations of this family were affected. There were 13 adults with a balanced karyotype, 3 children with an unbalanced karyotype presenting with severe intellectual disability and dysmorphic characteristics, and a history of 3 miscarriages and 4 neonatal deaths.[7] Basic semen analysis of the male patient and the fact that he had previously fathered a healthy child indicated that his fertility was not affected by his chromosomal translocation, contrary to previous literature reports stating that male balanced translocations carriers are prone to sterility.[8,9] Array CGH was utilised to assess chromosomal imbalances in the embryos.

This method allows screening of all 23 chromosomes simultaneously, including the sex chromosomes (X and Y), making it more accurate than the recently used fluorescence in situ hybridisation (FISH) method, which only allows screening for a limited number of chromosomes.[10] Two out of ten screened embryos inherited an unbalanced version of the father’s translocation. It has been reported that three-way chromosomal rearrangements are particularly familial and can be transmitted from generation to generation.[9] Balanced chromosomal translocations have been found in approximately 4% of couples who experienced recurrent spontaneous abortions.[11] When present in par-

SAJOG • April 2015, Vol. 21, No. 1

19

ents, these chromosomal rearrangements can later lead to chromosome irregularities in offspring and may also be a cause of stillbirth and fetal malformations.

Using the array CGH technique in this patient reduced the risk of recurrent miscarriage and the associated emotional distress, and gave the patient a viable pregnancy. By the same method we may offer the chance of a viable pregnancy to other members of this family who are planning to conceive.

The limitations of array CGH is that it cannot detect balanced translocations or polyploidy, as it only detects copy number variation. Further karyotype testing of patients is advised.

In conclusion, chromosomal screening of couples with recurrent abortions and decreased fertility can enable these couples to achieve a healthy pregnancy in a shorter period of time. We advise that PGD be a part of the investigation of these patients.

1. Snustad DP, Simmons MJ, Jenkins JB, et al. Principles of Genetics. New York: John Wiley, 2000.

2. Gardner RJM, Sutherland GR, Shaffer LG. Chromosome abnormalities and genetic counselling.

Oxford: Oxford University Press, 2004.

3. Otani T, Roche M, Mizuike M, et al. Preimplantation genetic diagnosis significantly improves the pregnancy outcome of translocation carriers with a history of recurrent miscarriage and unsuccessful pregnancies. Reprod Biomed 2006;13(6):869-874. [http://dx.doi.org/10.1016/s1472-6483(10)61037-1] 4. Farcas S, Belengeanu V, Popa C, et al. Role of chromosomal translocations in recurrent spontaneous abortion. Timisoara Med J 2007;2:117-121.

5. Rai R, Regan L. Recurrent miscarriage. Lancet 2006;368(9535):601-611. [http://dx.doi.org/10.1016/ s0140-6736(06)69204-0] 6. Pellestor F, Anahory T, Lefort G, et al. Complex chromosomal rearrangements: Origin and meiotic behavior. Hum Reprod Update 2011;17(4):476-494. [http://dx.doi.org/10.1093/humupd/dmr010] 7. Winship WS, Beighton P. Genetic disorders in the Indian community of South Africa. S Afr Med J 2011;101(7):481-484.

8. Bartels I, Starke H, Argyriou L, et al. An exceptional complex chromosomal rearrangement (CCR) with eight breakpoints involving four chromosomes (1;3;9;14) in an azoospermic male with normal phenotype. Eur J Med Gen 2007;50:133-138.

9. Coco R, Rahn MI, Estanga PG, et al. A constitutional complex chromosome rearrangement involving meiotic arrest in an azoospermic male: Case report. Hum Reprod 2004;19:2784-2790.

10. Mastenbroek S, Twisk M, van Echten-Arends J, et al. In vitro fertilization with preimplantation genetic screening. N Engl J Med 2007;357(1):9-17. [http://dx.doi.org/10.1056/nejmoa067744] 11. Alfarawati S, Fragouli E, Colls P, et al. Embryos of robertsonian translocation carriers exhibit a mitotic interchromosomal effect that enhances genetic instability during early development. PLoS Gen 2012;8(10):e1003025. [http://dx.doi.org/10.1371/journal.pgen.1003025]

In the April 2015 issue of the South African Medical Journal (Vol. 105 No. 4):

APRIL 2015

VOL. 105 NO. 4

Basic and comprehensive emergency obstetric and neonatal care

256

Optimal staffing to ensure safe maternity units

261

Food insecurity in urban South Africa Management of obstetric haemorrhage

275 287

Intrapartum asphyxia and hypoxic encephalopathy

298

V Makhanya,1 MB ChB; L Govender,1 MB ChB, FCOG; J Moodley,1,2 MB ChB, FRCOG, FCOG, MD Department of Obstetrics and Gynaecology, Nelson Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 2 Women’s Health and HIV Research Group, Department of Obstetrics and Gynaecology, Nelson Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 1

Corresponding author: V Makhanya (vuyo.makhanya@ymail.com)

Background. High caesarean section (CS) rates are not only costly but associated with significant perinatal and maternal morbidity and mortality. It has recently been suggested that structured auditing of CSs may identify those groups in the obstetric population that contribute substantially to the high rates and for which focused interventions may bring about change.

Objective. To evaluate the utility of the Robson Ten Group Classification System (RTGCS) in determining appropriateness of CS at a regional rural hospital in KwaZulu-Natal Province, South Africa.

Methods. A retrospective review of the hospital records of women delivered by CS over a 3-month period was performed. The RTGCS was used to categorise women according to parity, age, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labour/delivery.

Results. There were 2 553 hospital births over the 3-month study period. The CS rate was 42.4% (1 082/2 553). According to the RTGCS, groups 1 (n=296, 27.4%), 5 (n=186, 17.2%) and 10 (n=253, 23.4%) were substantial contributors to the overall CS rate. The main indications for CS were fetal distress (36.5%) and cephalopelvic disproportion (26.8%).

Conclusion. The RTGCS is a useful tool with which to identify patient groups warranting interventions to reduce high CS rates in a rural regional hospital setting. Group 1 (nullipara: single cephalic term pregnancy; spontaneous labour) warrants the most attention. Applying stricter criteria and due diligence in decision-making for primary CS may decrease the high CS rates.

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Caesarean section and maternal death – latest Saving Mothers report

Utility of the Robson Ten Group Classification System to determine appropriateness of caesarean section at a rural regional hospital in KwaZulu-Natal, South Africa

S Afr Med J 2015;105(4):292-295. DOI:10.7196/SAMJ.9405

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MMed supervision – a path out of the swamp

SAMF

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CASE REPORT

Müllerian duct anomaly with congenital rectovaginal fistula: A rare case presentation Y Dogra, MD; S Minhas, MD; P D Marwaha, MD Department of Obstetrics and Gynaecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India Corresponding author: Y Dogra (gitu_22@yahoo.com)

Pregnancy in a rudimentary horn is a rare form of ectopic gestation and associated with high maternal mortality. Unicornuate uterus with a rudimentary horn is caused by disordered fusion of Müllerian ducts during embryonic life, which can be associated with ipsilateral renal agenesis, congenital rectovaginal fistula, imperforate anus, hypospadias and other anatomical variants of cloacal dysgenesis. Despite advances in imaging techniques such as ultrasound, the diagnosis of rudimentary horn remains elusive with confirmatory diagnosis made on laparotomy. Our patient presented with an unruptured rudimentary horn pregnancy in the second trimester with a past history of surgical correction of rectovaginal fistula. Exploratory laparotomy was done and the rudimentary horn was excised. We report this case because of the very rare association of unicornuate uterus with rudimentary horn with congenital rectovaginal fistula, which forms when the Müllerian eminence opens in the dorsal segment of the endodermal cloaca.

S Afr J OG 2015;21(1):22-23. DOI:10.7196/SAJOG.746

A unicornuate uterus with a rudimentary horn is a rare Müllerian abnormality that may cause many gynaecological and obstetric complications.[1] Any disturbance in the orderly fusion of the Müllerian ducts during early embryological life (8 - 12 weeks’ gesta­ tion) will result in a uterine malformation, the degree of the anomaly depending on the time the causative agent exerts its influence on the developing embryo. If the development is arrested early the uterus may remain rudimentary, and in the extreme it may even be absent. Unilateral faulty development following lack of fusion results in a uterus with one segment or one half well developed, while the other remains rudimentary or ill developed.[2] Müllerian abnormality is frequently associated with renal and axial skeletal abnormalities. Congenital rectovaginal fistula, imperforate anus, hypospadias and other anatomical variants of cloacal dysgenesis can also be associated with maldevelopment of the Müllerian and mesonephric duct derivatives. Pregnancy in the rudi­ mentary horn is rare and represents a form of ectopic gestation.[3] It carries grave consequences for the mother and the fetus.[4,5] The incidence varies from 1/100 000 to 1/150 000 pregnancies.[6] Rupture of the pregnant rudimentary horn in the second trimester is the usual presentation, resulting in maternal morbidity and even mortality.[1,4] Early diagnosis of rudimentary horn pregnancy (RHP) is challenging. The natural history of RHP is usually rupture during the second or third trimester, resulting in life-threatening heavy bleeding. Early prerupture diagnosis is therefore of major importance.[5] Despite advances in ultrasound prenatal diagnosis remains elusive, with confirmatory diagnosis being made at laparotomy. Because of the variable muscular constitution of the wall of the rudimentary horn, pregnancy can be accommodated until a late stage, when rupture commonly manifests as an acute abdomen with a high risk of maternal mortality.[3]

Case report

A 28-year-old unbooked woman, gravida 3, para 2 + 0, presented to the gynaecological outpatient department at Kamla Nehru Hospital,

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Shimla, Himachal Pradesh, India, with a history of amenorrhoea for 5 months and pain in the abdomen for 5 days. She brought an ultrasound report suggestive of intrauterine gestation corresponding to 20 weeks with missed abortion. She had had two previous normal vaginal deliveries at term, with an uneventful course post partum.

At the age of 14 years, after menarche, she had undergone anogenital surgery; an anal opening had been created along with the correction of a rectovaginal fistula. Since then she had had normal bowel habits.

On abdominal examination the height of the uterus corresponded to the period of gestation, fetal parts were palpable, and the uterus was relaxed with adequate liquor. On vaginal examination, the os was closed and the cervix uneffaced. An ultrasound scan revealed an intrauterine missed abortion. Induction was done with misoprostol 200 mg, 5 doses at 4-hourly intervals, but there was no response. On repeat vaginal examination the uterus was deviated to the right side with fullness in the left fornix corresponding to period of gestation.

With a secondary abdominal pregnancy or a broad-ligament heterotopic pregnancy in mind, it was decided to perform exploratory laparotomy. On exploration, a non-communicating rudimentary horn of gravid uterus was found on the left side, with a parous-size uterus on the right (Fig. 1). Hysterotomy was done, with extraction of a 400 g macerated male abortus along with the placenta. No gross congenital anomaly was detected (Fig. 2), and no communication between the gravid rudimentary horn and the cervix was found. Excision of the rudimentary horn was done (Fig. 3) and haemostasis was achieved.

Right-sided tubectomy was performed. The kidneys were normal.

Discussion

Unicornuate uterus with a non-communicating horn that contains menstruating endometrium is caused by asymmetrical obstruction of lateral fusion of the Müllerian ducts with ipsilateral renal agenesis.

A unicornuate uterus can be present alone or with a rudimentary horn or bulb on the opposite side. Most rudimentary horns are noncommunicating. The two sides may be connected by a fibromuscular

Fig. 1. Gravid rudimentary horn with unicornuate uterus attached by fibromuscular band.

Fig. 2. Macerated male fetus.

segment of the endodermal cloaca.[9] Unicornuate uterus with noncommunicating rudimentary horn is a rare condition but is associated with many gynaecological and reproductive morbidities. A 7-year study conducted by Goel et al.[10] showed that preoperative diagnosis of noncommunicating RHP was possible in 2 out of 18 cases of unicornuate uterus with non-communicating rudimentary horn found on laparo­ tomy. Pregnancies in women with this condition were associated with high incidences of abortion, preterm labour, malpresentations and caesarean delivery.[10] A retrospective study[11] on 42 women with a unicornuate uterus and rudimentary horn was undertaken in a university hospital in Finland. The rudimentary horn was removed in 21 cases. Right unicornuate uterus with a non-communicating rudimentary horn was the most common type of uterine anomaly.

Unilateral renal agenesis was found in 38% of cases and ectopic pregnancy occurred in 22%. The pregnant uterine horn ruptured in 3 of 7 cases. The high number of ectopic pregnancies indicates removal of rudimentary horn and its tube when diagnosed.[11] The availability of technological advances such as ultrasonography and magnetic resonance imaging (MRI) has made the diagnosis of RHP possible at an early stage of gestation. However, in advanced pregnancy such cases can sometimes pose a diagnostic dilemma and are recognised only when the patient presents with abdominal pain and collapse and is taken for laparotomy.[12] Tsafrir et al.[13] suggested the following criteria for early sonographic diagnosis of rudimentary horn pregnancy: (i) a pseudopattern of asymmetrical bicornuate uterus; (ii) absent visual continuity tissue surrounding the gestation sac and the uterine cervix; and (iii) presence of myometrial tissue surrounding the gestational sac. MRI has proved to be a very useful, non-invasive tool for diagnosis of Müllerian abnormalities. It offers multiplanar images without the hazards of ionising radiation and is able to show both internal and external uterine structures.[13]

Conclusion

Detailed clinical evaluation with a high degree of suspicion is required in patients presenting with an acute abdomen, especially when other Müllerian/mesonephric duct abnormalities are present.

Every effort should be made to diagnose RHP in time to prevent rupture, which may be associated with high maternal mortality. If diagnosed on laparotomy, the excision of the rudimentary horn with ipsilateral tubectomy should be undertaken.

Fig. 3. Excised rudimentary horn. band, or there may be no connection and no communication between the two uterine cavities. Because most cases of unicornuate uterus have a non-communicating rudimentary uterine horn on the opposite side, pregnancy in the rudimentary horn can result from transperitoneal migration of sperm or ovum from the opposite side.

Signs and symptoms of an ectopic pregnancy develop, with eventual rupture of the horn if the pregnancy is not detected early. Rupture through the wall of the vascular rudimentary horn is associated with sudden and severe intraperitoneal haemorrhage and shock. Death can occur in a few minutes.[7] Congenital rectovaginal fistula, imperforate anus, hypospadias and other anatomical variants of cloacal dysgenesis can also be associated with maldevelopment of the Müllerian and mesonephric duct derivatives.[8] Rudimentary horn with congenital rectovaginal fistula forms when Müllerian eminences open in the dorsal

1. Chopra S, Suri V, Aggarwal N. Rudimentary horn pregnancy: Prerupture diagnosis and management. Indian J Med Sci 2007;61(1):28-29. [http://dx.doi.org/10.4103/0019-5359.29595] 2. De Silve PHDH. Rudimentary horn of a bicornuate uterus: Discussion of 16 cases with a review of literature. J National Sci Coun Sri Lanka 1976;4(1):55-73.

3. Elsayegh A, Nwosu EC. Rupture of pregnancy in the communicating rudimentary horn at 34 weeks. Hum Reprod 1998;13(12):3566-3568. [http://dx.doi.org/10.1093/humrep/13.12.3566] 4. Dhananjaya BS, Shobha UN, Nanda SK, Nandagopal KM, Anitha MS. A rare case of pregnancy in the rudimentary horn of unicornuate uterus (on table diagnosis) which had a successful outcome: A case report. Journal of Clinical and Diagnostic Research 2011;5(7, Suppl 2):1461-1463.

5. Nagarathna G, Navada HM, Poornima B, Bhat R. Pre-rupture diagnosis and management of rudimentary horn pregnancy in second trimester. Int J Pharm Biomed Res 2011;2(3):179-181.

6. Ural SH, Artal R. Third-trimester rudimentary horn pregnancy. A case report. J Reprod Med 1998;43(10):919-921.

7. Edmonds DK. Dewhurst’s Textbook of Obstetrics & Gynaecology. 7th ed. Hobokon, NJ: Blackwell, 2007:331.

8. Rock JA, Jones HW. Te Linde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, 2008:539-544, 574-575.

9. Jacob A. A Comprehensive Textbook of Midwifery & Gynecological Nursing. 3rd ed. New Delhi: Jaypee, 2012:702-709.

10. Goel P, Aggarwal A, Devi K, Takkar N, Saha PK, Huria A. Unicornuate uterus with noncommunicating rudimentary horn – different clinical presentations. J Obstet Gynecol India 2005; 55(2):155-158.

11. Heinonen PK. Unicornuate uterus and rudimentary horn. Fertil Steril 1997;68(2):224-230. [http:// dx.doi.org/10.1016/S0015-0282(97)81506-3] 12. Jain R, Gami N, Puri M, Trivedi SS. A rare case of intact rudimentary horn pregnancy presenting as hemoperitoneum. J Hum Reprod Sci 2010;3(3):113-115. [http://dx.doi.org/10.4103/0974-1208.69335] 13. Tsafrir A, Rojansky N, Yitzhak Sela H, Gomori JM, Nadjari M. Rudimentary horn pregnancy: Firsttrimester prerupture sonographic diagnosis and confirmation by magnetic resonance imaging. J Ultrasound Med 2005;24(2):219-223.

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CPD True (A) or false (B): Obstetric critical care services in South Africa: 1. According to United Nations data, the maternal mortality rate in sub-Saharan Africa is 570/100 000 live births.

2.

According to the 2008 - 2010 South African Confidential Enquiry into Maternal Deaths, non-pregnancy-related infections/AIDS accounted for 40.5% of maternal deaths.

Waiting times for radiotherapy at Charlotte Maxeke Hospital: 3.

Thirty-five per cent of all cervical cancers worldwide are reported from the developing world.

4. According to a reported study, the lifetime risk of a woman developing cervical cancer in South Africa is 1 in 31.

Cardiac arrest in pregnancy: 5. Cardiac arrest in pregnancy is a rare but catastrophic event with an estimated incidence of 1/30 000 pregnancies.

6. Successful resuscitation is reported in 3% of patients who have a cardiac arrest in hospital.

Uterine rupture in a primigravid term pregnancy: 7.

Risk factors for uterine rupture include previous caesarean section, myomectomy and hysteroscopic surgery.

8. A quoted study from Ghana reported the use of herbal medicine in 25% of cases of uterine rupture.

Entrapment of vaginal ring pessary: 9. Indications for vaginal ring pessaries in prolapse include patients who decline surgery or are unfit for surgery, and relief for those patients awaiting surgery.

10. Pessaries are prescribed as first-line treatment for prolapse by more than 70% of American urogynaecologists and more than 80% of UK gynaecologists.

11.

Major complications with ring pessaries often occur despite frequent follow-up.

12. A quoted report states that most pessary complications occur after 12 months from the time of insertion.

Primary amenorrhoea: Swyer syndrome: 13. Swyer syndrome has an incidence of 1 in 10 000.

14. The testis, the source of anti-Müllerian hormone, is not present in Swyer syndrome.

15. So-called ‘pure gonadal dysgenesis’ may be of the XX or XY type.

16. Swyer syndrome tends to present at puberty, and in most cases a mature female phenotype does not develop.

17. Osteopenia (and later osteoporosis) is a potential complication of Swyer syndrome if hormone replacement therapy is not started appropriately.

Live birth from a patient with a three-way balanced translocation: 18.

Recurrent miscarriage can be associated with either partner having a balanced translocation.

19. Preimplantation diagnosis and embryo selection is a possible way to reduce recurrent miscarriage if a partner has a balanced translocation.

20. Chromosomal translocations can only be inherited.

The CPD programme for SAJOG is administered by Medical Practice Consulting: CPD questionnaires must be completed online at www.mpconsulting.co.za A maximum of 3 CEUs will be awarded per correctly completed test.

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