SAJOG Vol 21, No 2 (2015)

ISSN 0038-2329

December 2015 September 2011 21 No. Vol. 17 No. 23

• Attitudes to and knowledge about intrauterine • L aparoscopic myomectomy for infertile patients with contraceptive devices among women in a resourceintramural fibroids constrained setting Use of audit vaginal

by South African gynaecologists • A• clinical ofpessaries female urinary incontinence in a tertiary hospital • E ffect of topical lignocaine on postoperative pain after laparoscopic tubal sterilisation Knowledge, practice and • Female genital mutilation/cutting: experiences of schoolteachers in Nigeria • Use of family planning services by female university studentsofinmiddle Lesotho • Limitations cerebral artery peak systolic velocity in• the detection of severe anaemia2011 Abstracts: SASUOG Congress • Cornelia de Lange syndrome – a rarely seen disorder

SAJOG December 2015 Volume 21 No. 2

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):

CONTENTS

CEO and Publisher Hannah Kikaya | Email: hannahk@hmpg.co.za

Editorial

Editor-in-Chief Janet Seggie

26

How to acquire, retain or renew knowledge

W Edridge

Managing Editor Ingrid Nye Executive Editor Bridget Farham

Research

Technical Editors Emma Buchanan Paula van der Bijl

27

Attitudes to and knowledge about intrauterine contraceptive devices among women in the reproductive age group in a resource-constrained setting

P Monji Builu, T D Naidoo

33

A clinical audit of female urinary incontinence at a urogynaecology clinic of a tertiary hospital in Durban, South Africa

T Dehinbo, S Ramphal, J Moodley

39

Female genital mutilation/cutting: Knowledge, practice and experiences of secondary schoolteachers in North Central Nigeria

Online Support Gertrude Fani | Tel: 072 463 2159 Email: publishing@hmpg.co.za

A S Adeniran, A A Fawole, O R Balogun, M A Ijaiya, K T Adesina, I P Adeniran

ISSN 0038-2329

Case Reports 44

Limitations of middle cerebral artery peak systolic velocity in the detection of severe anaemia: A case report

L Geerts, J N Rossouw, A C van Wyk, C A Wright

46

Uterine artery embolisation in the management of recurrent vaginal haematoma

N S Chauhan, S B Dhodhapkar, M Daniel, M C Arokiaraj, R C Chauhan

48

Prolonged postpartum urinary retention: A case report and review of the literature

A Yarci Gursoy, M Kiseli, S Tangal, G S Caglar, A H Haliloglu, S D Cengiz

50

Spontaneous rupture of the spleen – a rare and potentially fatal surgical emergency in the second trimester: Report of a case

M Heetun, R Parameswaran, K Jamil

52

Cornelia de Lange syndrome – a rarely seen disorder

Y Çekmez, N Pişkinpaşa, T Tos

54

CPD Questions

Production Manager Emma-Jane Couzens DTP and Design Carl Sampson Head of Sales and Marketing Diane Smith Tel: 012 481 2069 | dianes@hmpg.co.za

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/

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EDITORIAL

How to acquire, retain or renew knowledge Obstetrics and gynaecology are vast subjects. Each contains 40 elements or so, many of which subdivide into separate topics. Medical students are expected to acquire knowledge of these in 6 weeks, 2 months or 3 months, and will be examined by someone who may have been rereading the information for 25 years. Medical students suffer from a further problem – someone once said, ‘What I hear, I forget; what I see, I remember; what I do, I understand.’ A student may never see one of the conditions in the exam and may never have been actively involved in the process of choice regarding investigation or management. The result may be that, to the untrained examiner, a bright student may appear ignorant, foolish or careless, and may be inappropriately marked down.

How do students acquire the knowledge required? From text­ books, from university department guidelines, from the internet (if available). Lecturing and bedside teaching are important; these relate to the visual, contextual element of learning. But this learning process is limited by the knowledge of the lecturer or bedside teacher.

Knowledge cannot be passed on if the teacher doesn’t have it.

The intern, resident or registrar is also a student. Often over­ worked, they must acquire knowledge at a higher level to face college examiners. Their sources of knowledge are the same as for the medical student.

Beyond medical school or college exams, learning continues.

Continuing medical education, or a similar phrase, continuing professional development, is now required by every college and university and by many district local hospitals, where colleagues gather over juice and sandwiches to learn. It continues, or should continue, until the shaking hand lays down the scalpel for the last time.

But what is this knowledge? Clearly, it is the accepted wisdom gathered by the good and the worthy, the many celebrated experts in their field or topic within a subject. That knowledge, however, may not always be completely accurate or correct. It is sometimes difficult to recognise that it is not correct, and difficult to have the courage to accept the enquiring eye of the student (at whatever level) who identifies the inconsistency.

When the emperor walked naked in the parade it was the child and not the cabinet minister who identified the governmental deficit. A senior registrar once criticised as hopelessly inappropriate a student's questioning of maternal weighing in the antenatal clinic in a reasonably nourished population – it neither predicts preeclampsia nor identifies intrauterine growth restriction. The senior registrar marked the student down. The student had gained the gold medal for the year in two of the previous three years. An entire medical school is unlikely to be wrong.

The twin disciplines of obstetrics and gynaecology have been beset with inconsistencies and inaccuracies. It was once believed that patients with regular but heavy menstrual bleeding were anovulatory. This was contained in textbooks; common sense says that that was wrong. It was. Similarly, if a woman is consistently regularly menstrual, tests of ovulation, requested by protocols, were superfluous. Blood sugars were once performed on patients with recurrent miscarriage. Yet how a patient whose difficulty has extended over months or years could be an undiagnosed diabetic and not in a coma was not considered; a brittle established diabetic might, however, suffer with miscarriage. It was once believed that

26

SAJOG • December 2015, Vol. 21, No. 2

cervical intraepithelial neoplasia should be treated with radiation; the misnomer ‘carcinoma in-situ’ although not without justification, did not help. Bedrest was recommended for a number of obstetric conditions without ever being evaluated; there was no benefit, and possibly a number of deep-vein thromboses and emboli resulted.

The combined oral contraceptive was once given to treat small simple ovarian cysts; that information also appeared in textbooks and guidelines but there is no benefit.

One way to minimise error in knowledge is to put good minds together. This produces college guidelines or the guidelines of accepted bodies and institutions. These guidelines are extremely helpful and excellent for teaching students. They also, however, demonstrate the inconsistencies in obstetrics and gynaecology – knowledge is rarely absolute. The American College forbids the use of prostaglandins for the induction of labour of a patient who has had a previous caesarean section, and this is sanctioned by the British College. The American College sanctions the use of misoprostol for induction of labour, but this is forbidden by the British College, fearing overstimulation, unless in a formal research setting. The British College forbids induction of labour where there is intrauterine growth restriction with evidence of fetal compromise. Although this is wise, there has not been such a provision in the American Practice Bulletin, though it seeks to comprehensively advise on the subject.

We rely on the adjudication of governing bodies to help us clarify diseases we see. Yet the International Society for the Study of Vulvovaginal Disease has reclassified vulval disease at least three times in the past 30 years, suggesting that some considerable confusion must have existed at any time during those 30 years.

The International Federation of Gynaecologists (FIGO),[1,2] when issuing its classification of abnormal uterine bleeding (the PALMCOEIN system, i.e. polyps, adenomyosis, leiomyoma, malignancy and hyperplasia –coagulopathy, ovulatory disorders, endometrial causes, iatrogenic, not classified), appropriately stated that this classi­ fication may be considerably reviewed in ensuing years, perhaps even to the extent of making the current classification unrecognisable.

Classification can clarify or cloud, can simplify or confuse.

When we teach and when we learn, guidelines, protocols, research papers and current information in general are a great assistance. They inform our debates and discussions. They assist us in steering away from the turbulence of medicolegal enquiry, rather to tread the path that is accepted and endorsed. But we should not forget that almost nothing is beyond challenge: that the inconsistencies that we cannot see trouble young minds; that it takes courage to accept their criticisms and to realise that we inhibit learning, stifle progress and prevent good logical care of patients by failing to observe what we see; and that when we sit with students or those who come to learn at our scanners or in our operating theatres, incomplete knowledge may hinder and not help.

William Edridge Editor

1. Munro MG, Critchley HOD, Broder MS, FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011;113(1):3-13. [http://dx.doi.org/10.1016/j. ijgo.2010.11.011] 2. Munro MG, Critchley HOD, Fraser IS. The FIGO classification of causes of abnormal uterine bleeding. Int J Gynaecol Obstet 2011;113(1):1-2. [http://dx.doi.org/10.1016/j.ijgo.2011.01.001]

S Afr J Obstet Gynaecol 2015;21(2):26. DOI:10.7196.SAJOG.1045

RESEARCH

Attitudes towards and knowledge about intrauterine contraceptive devices among women in the reproductive age group in a resource-constrained setting P Monji Builu, MB ChB, Dip Obst, Dip HIV Man, PGDip Public Health; T D Naidoo, FCOG, PhD Department of Obstetrics and Gynaecology, Grey’s Hospital, Pietermaritzburg, and Nelson Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: P Monji Builu (pierrotbwilu@gmail.com)

Background. One of the strategies to reduce maternal mortality includes accessible and appropriate contraceptive services to all women.

The intrauterine contraceptive device (IUCD) has been identified as a cheap and effective means of contraception by the South African National Department of Health.

Objective. To explore knowledge about the IUCD among women using the public health sector and identify any misconceptions.

Methods. A sample of 150 women attending antenatal/postnatal clinics were interviewed using a structured questionnaire.

Results. Forty-six percent (n=69) had some experience with the injectable form of contraception, and 2.7% (n=4) had used the IUCD; 70.7% (n=106) knew that the device does not prevent HIV transmission, 40.7% (n=61) knew that HIV-positive women can use the IUCD, 75.3% (n=113) believed that the IUCD causes heavy bleeding, 36.7% (n=55) knew that the device does not stop fertility indefinitely, 33.3% (n=50) knew that the IUCD can be inserted in the immediate postpartum period, and 26.7% (n=40) knew that the duration of use is 10 years. In terms of attitudes, 40.0% (n=60) expressed concern about the pain during insertion, 33.3% (n=50) believed the IUCD can cause cancer, and 32.0% (n=48) believed that the device interferes with normal sexual activity. Most participants 77.3% (n=116) acquired the information they had about the IUCD from the clinic during teaching and counselling sessions.

Conclusion. This survey documented poor knowledge about the IUCD among women using the public health sector. However, the fact that there are few misconceptions and that clients rely on the clinic information should be seen as an opportunity to improve the situation.

S Afr J Obstet Gynaecol 2015;21(2):27-32. DOI:10.7196.SAJOG.950

The rate of unplanned pregnancies remains high worldwide, including in South Africa (SA). Despite reported high contraceptive use, nearly 40% of women are at risk of unintended pregnancy.[1] In 2008 Frost and Darroch[2] reported that 38% of participants in their study had missed at least one active pill in the previous 3 months, and pregnancies among contraceptive users accounted for nearly half of all unintended pregnancies and were almost entirely due to inconsistent or incorrect contraceptive use. Credé et al.[3] in 2009 also reported that the majority of women had unplanned pregnancies, despite a high rate of use of contraception, and with no difference according to HIV status.

Unintended pregnancies result in an increase in rates of abortion, both legal and illegal. The SA Department of Health reported an increase in the rate of abortion, despite the fact that modern contra­ ceptives are available and free in the public sector.[4] Patel and Kooverjee[5] also found that the rate of abortion among young women in SA has continued to increase despite the availability of contraception, and that inconsistent contraceptive use was the main reason for unwanted pregnancy. Success in preventing unintended pregnancies requires long periods of effective contraceptive use.

Women who choose long-acting methods are least likely to experience method failure.[1] The intrauterine contraceptive device (IUCD) has an extremely high efficacy rate compared with other methods of contraception. The IUCD is not dependent on patient participation for correct use, which results in a very low failure rate,[6] estimated to be 2 - 3 pregnancies per 100 woman-years.[7]

Recently the SA government has decided to introduce long-acting contraceptives, particularly the Cu 380 IUCD, in the public health sector. These devices are free in public hospitals and clinics and can be inserted at any time, in the immediate postpartum period, after abortion or electively when the woman wishes.[8]

Objective

To evaluate knowledge about and attitudes towards the IUCD among women in the reproductive age group in a resourceconstrained setting.

Methods

We performed a survey of women attending antenatal/postnatal clinics at Northdale Hospital (NDH) and East Boom Community Health Centre (CHC) in Pietermaritzburg, SA. Both facilities offer maternity services including antenatal, postnatal, prevention of mother-to-child transmission of HIV and family planning services.

The study cohort consisted of women attending the public sector antenatal/postnatal clinics. Eligible participants were women who had attended the antenatal clinic at least once and who had heard about different methods of contraception, including the IUCD. Participants were excluded if they could not understand English or Zulu. They were also excluded if they had never heard of the IUCD. One client was excluded because of language and 26 clients because they had never heard of the IUCD before.

The sampling was a convenience one, and we interviewed 150 women in total.

SAJOG • December 2015, Vol. 21, No. 2

27

A brief explanation of the study was given to eligible participants and consent was obtained from all those who agreed to participate.

The researcher administered a structured questionnaire. Information on participants’ sociodemographic characteristics, previous contraceptive methods, knowledge and attitudes towards the IUCD and source of information was collected from October 2013 to March 2014. Data were analysed using the Statistica data analysis software system, version 12 (StatSoft Inc., USA).

Participants were categorised into three groups according to their parity. The first group (group A) comprised all participants who were nulliparous. Group B included all participants who were para 1 or 2, and group C all those who were para 3 or more. The researcher expected women with high parity to have better knowledge about the device than those with low parity. Counselling and information about different methods of contraception are given to women during each antenatal/ post­natal visit.

Summary statistics were estimated for all participants. Descriptive results were compared by parity status, HIV status and facility using the χ2 test. The differences between groups were considered significant if the p-value was <0.05.

The research was approved by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BE 302/13), the KwaZulu-Natal Department of Health (HRKM 298/13) and the Umgun­ gundlovu Health District office.

Results

Sociodemographic characteristics Most participants were in their twenties, with a mean age of 25; 76.7% (n=115) were <30 years old, 16.0% (n=24) were teenagers, and less than 5% (n=7) were aged 35 years or more (Table 1).

Most participants were single (69.3%, n=104) with only 17.3% (n=26) married and 13.3% (n=20) in a stable relationship.

Most participants had some form of formal education: 5.3% reported that they had never been to school, 52.7% had atten­ ded school up to secondary level, 9.3% had only primary school education and 32.7% had tertiary education. At the time of the survey, 52.7% of participants were unemployed, 18.7% were still studying and 28.7% had a job.

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SAJOG • December 2015, Vol. 21, No. 2

Most were HIV-negative (62.7%, n=94). All HIV-positive participants except one were on antiretroviral therapy at the time of the interview (Table 1).

3 years before their next pregnancy; 48.7% were unsure or had no clear plan at the time of the interview (Table 1).

Previous use of contraception and fertility desire

The study showed no significant difference among the three parity groups in terms of knowledge about the IUCD (p>0.05 for all the questions).

All the participants interviewed knew that the device is used to prevent pregnancy.

The majority of them knew that it does not protect against HIV, and there was no significant difference between the three groups regarding their answers. It is of concern, however, that some participants (29.3%, n=44) could not state with confi­ dence that the device does not prevent HIV transmission. Of these 44 participants,

The contraceptive injection was the type of contraception with which participants were most familiar; 46.0% had some experience with contraceptive injections, while only 2.7% had used the IUCD before, and 18.0% of participants had used no form of contraception before. Condoms alone were used as a form of contraceptive method by 26.0% of participants.

With regard to future plans to conceive, of those participants who had a plan, most indicated they would like to wait for at least

Knowledge about the IUCD

Table 1. Demographic characteristics and previous experience with contraceptives Parity group A (N=50)

Parity group B (N=50)

Parity group C (N=50)

Total (N=150)

21

24

29

25

Single

39 (78.0)

35 (70.0)

30 (60.0)

104 (69.3)

Married

2 (4.0)

10 (20.0)

14 (28.0)

26 (17.3)

Stable relationship

9 (18.0)

5 (10.0)

6 (12.0)

20 (13.3)

No schooling

1 (2.0)

2 (4.0)

5 (10.0)

8 (5.3)

Grades 1 - 7

4 (8.0)

2 (4.0)

8 (16.0)

14 (9.3)

Grades 8 - 12

29 (58.0)

24 (48.0)

26 (52.0)

79 (52.7)

Tertiary

16 (32.0)

22 (44.0)

11 (22.0)

49 (32.7)

Unemployed

24 (48.0)

24 (48.0)

31 (62.0)

79 (52.7)

Employed

12 (24.0)

13 (26.0)

18 (36.0)

43 (28.7)

Student

14 (28.0)

13 (26.0)

1 (2.0)

28 (18.7)

Positive

15 (30.0)

23 (46.0)

18 (36.0)

56 (37.3)

Negative

35 (70.0)

27 (54.0)

32 (64.0)

94 (62.7)

<12 months

0 (0.0)

0 (0.0)

0 (0.0)

0 (0.0)

12 - 24 months

1 (2.0)

1 (2.0)

3 (6.0)

5 (3.3)

25 - 36 months

4 (8.0)

3 (6.0)

2 (4.0)

9 (6.0)

>36 months

23 (46.0)

20 (40.0)

20 (40.0)

63 (42.0)

Unsure

22 (44.0)

26 (52.0)

25 (50.0)

73 (48.7)

The Pill

2 (4.0)

4 (8.0)

5 (10.0)

11 (7.3)

Injectable

16 (32.0)

19 (38.0)

34 (68.0)

69 (46.0)

IUCD

1 (2.0)

1 (2.0)

2 (4.0)

4 (2.7)

Condoms

19 (38.0)

14 (28.0)

6 (12.0)

39 (26.0)

None

12 (24.0)

12 (24.0)

3 (6.0)

27 (18.0)

Age (years), mean Marital status, n (%)

Education level, n (%)

Employment, n (%)

HIV status, n (%)

Next pregnancy plan, n (%)

Recently used contraceptive, n (%)

45.5% (n=20) belonged to group C, 31.8% (n=14) to group B and 22.7% (n=10) to the nulliparous group (Table 2, Fig. 1). While 70.7% (n=106) of all participants could tell without hesitation that the device does not prevent transmission of HIV, there was no significant difference when the three groups were compared (p=0.086).

Only 40.7% (n=61) of all participants knew that HIV-positive women can safely use the IUCD. Participants in the group with high parity who knew that HIV-positive women can also use the device represented 31.2% (n=19) compared with 36.1% (n=22) in the nulliparous group and 32.8% (n=20) in group B. The difference between these groups was not significant (p=0.82).

Among participants who knew that HIV-positive women can use the device safely, 59.0% (n=36) were HIV-negative and 41.0% (n=25) were HIV-positive. Of the 89 participants who said that HIVpositive women should not use the IUCD, 65.2% (n=58) were HIV-negative and 34.8% (n=31) were HIV-positive.

Of all the participants, 75.3% were un­certain about whether the IUCD causes heavy bleeding. The difference in answers between the three groups was significant (p=0.03), with more women of high parity than nulliparous clients considering the device to be a cause of bleeding.

Only 36.7% of the participants (n=55) knew that the device does not stop fertility indefinitely: 34.6% (n=19) of these women belonged to group C, another 34.6% (n=19) to group B and 30.9% (n=17) to group A. However, the dfference between the groups was not significant (p=0.89).

Knowledge about the quick return to fertility once the IUCD has been removed was very poor. Only 12.0% (n=18) of participants answered this question correctly; of these 50.0% (n=9) belonged to group C, 27.8% (n=5) to group B and 22.2% (n=4) to group A. The difference between the groups was not significant (p=0.27).

One-third of all participants knew that the IUCD can be inserted in the immediate postpartum period: 36.0% (n=18) belonged to group C, another 36.0% (n=18) to group B and 28.0% (n=14) to group A. More participants with higher parity than nulli­ parous participants knew that the device may be inserted after delivery (p=0.61).

Only 26.7% of the participants (n=40) knew that the Cu T380A could be used for 10 years. With most women planning for their next pregnancy in the next 3

Table 2. Knowledge about the IUCD per parity group Parity group A (N=50) n (%)*

Parity group B (N=50) n (%)*

Parity group C (N=50) n (%)*

Total, N

p-value

Know

40 (37.7)

36 (34.0)

30 (28.3)

106

0.08646

Do not know

10 (22.7)

14 (31.8)

20 (45.5)

44

Does not prevent HIV

HIV+ women can use IUCD Know

22 (36.1)

20 (32.8)

19 (31.2)

61

Do not know

28 (31.5)

30 (33.7)

31 (34.8)

89

0.82442

Does not cause heavy bleeding Know

18 (48.7)

7 (18.9)

12 (32.4)

37

Do not know

32 (28.3)

43 (38.1)

38 (33.6)

113

0.03603

Know

17 (30.9)

19 (34.6)

19 (34.6)

55

Do not know

33 (34.7)

31 (32.6)

31 (32.6)

95

Know

4 (22.2)

5 (27.8)

9 (50.0)

18

Do not know

46 (34.8)

45 (34.1)

41 (31.1)

132

Know

14 (28.0)

18 (36.0)

18 (36.0)

50

Do not know

36 (36.0)

32 (32.0)

32 (32.0)

100

Know

13 (32.5)

16 (40.0)

11 (27.5)

40

Do not know

37 (33.6)

34 (30.9)

39 (35.5)

110

Does not stop fertility 0.89094

Quick fertility return 0.27902

Postpartum insertion 0.61407

Can keep up to 10 years 0.52437

*Percentages of total answers for each response.

22%

32% 26%

Can keep it for up to 10 years Postpartum insertion Quick fertility return

28% 18% 10% 8%

38% 38% 34%

Does not stop fertility Does not cause heavy bleeding

36% 36%

14%

24%

HIV+ women can use it Does not prevent HIV Prevents pregnancy

36% 38% 40% 44% 60%

72%

80% 100% 100% 100%

A B C

Fig. 1. Knowledge in each parity group. (A = nulliparous; B = para 1 - 2; C = para ≥3.) years, we expected participants to know about duration of use, especially those in group C. Of these 26.7%, only 27.5% (n=11) belonged to group C, 40.0% (n=16) to group B and 32.5% (n=13) to group A. However, the difference between the

groups was not statistically significant (p=0.52).

When the two facilities included in the study were compared, there was a statistical difference (p=0.02) in respect of the res­ponse regarding duration of use. Among those who

SAJOG • December 2015, Vol. 21, No. 2

29

knew the correct duration of use only 30.0% (n=12) were from the clinic compared with 70.0% (n=28) from the hospital.

In general, knowledge about the IUCD among women visiting public sector facilities is very poor. Information that should be part of every counselling session on contra­ ception, such as the duration of use or the time of insertion, as it can influence client choice, is ignored. Even among women with higher parity knowledge is still poor.

Knowledge was poorer at the East Boom CHC compared with NDH. All participants knew that the device prevents pregnancy, but beyond this information knowledge is poor, as shown in Fig. 2.

Attitudes towards the IUCD Regarding attitudes towards the IUCD, the study showed that there are four concerns about this type of contraception that need to be addressed during every teaching and counselling opportunity, namely fear of pain, fear of cancer, concern about the device’s interfering with sexual activity, and fear of womb perforation. Forty percent of all partici­ pants expressed concern about pain during insertion, and more than 30% expressed fear that having the device in the uterus would cause genital cancer and fear of womb perforation. The belief that the device would interfere with normal sexual activity was expressed by more than 30% of participants.

Less than 10% of participants would not consider using the device because of their cultural or religious beliefs.

Twenty-four percent (n=36) of partici­ pants thought that the device was only for multiparous women (Table 3).

Almost 21% (n=31) of all participants believed their partner would stop using condoms if they used the device. This concern clearly demonstrates partners’ lack of understanding of the reason for the continued need for condom use to prev­ ent sexually transmitted diseases. It also elucidates the need for couple counselling, which may be a challenge to achieve in the public sector. In general there were some negligible differences among the three parity groups, as shown in Table 3, except for the issue regarding the fear of perforation. More nulliparous participants (46.8%) expressed fear of perforation com­ pared with multiparous clients.

Source of information The main source of information was the

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SAJOG • December 2015, Vol. 21, No. 2

16%

Can keep it for up to 10 years

29% 37%

Postpartum insertion

Quick fertility return

9% 15% 35%

Does not stop fertility Does not cause heavy bleeding

HIV+ women can use it

*

37%

39% 13%

*

36% 35%

Does not prevent HIV

47% 83% 59%

* 100% 100%

Prevents pregnancy

HOSPITAL CLINIC

Fig. 2. Knowledge per facility. (* = significant difference.) clinic; 77.3% (n=116) of all participants had acquired their information about the IUCD from the clinic during teaching and counselling sessions. Twelve percent (n=18) acquired their information from friends, 8.0% (n=12) from school, 5.3% (n=8) from the media and only 2.7% (n=4) from family members. It is worthwhile to note that some participants had more than one source of information.

Discussion

The study has shown that there is poor knowledge about the IUCD among women using public sector facilities. There was a negligible difference among participants based on parity status, contrary to the researchers’ expectation that women of higher parity might have a good knowledge of the long-acting reversible contraceptive (LARC) device.

Credé et al.[3] documented poor know­ ledge of LARC methods in their study conducted in Cape Town. However, this study was done before the government embarked on the process of promoting the IUCD. Some years down the road, knowledge is still poor and uptake of the device low. Only 2.7% of participants interviewed had used the IUCD before and most of them had experience with the injectable Depo-Provera. Most parti­ cipants in our study expressed the desire to space their children, and were ready to wait at least 3 years before their next

pregnancy, showing a need for LARC methods. It seems that clinic staff prefer to recommend the injectable method and in some situations just prescribe it, especially in the postnatal clinics. The study has shown a need for the facilities to relook at their method of promoting the device, especially as the Department of Health is in the process of introducing another LARC method, i.e. implants (Implanon NXT). Following a 12% pregnancy rate reported in a study from Swaziland among users of Implanon who were HIV-posi­ tive and also taking enzyme-inducing efa­ virenz as antiretroviral therapy,[9] the SA government has issued a caution regarding Implanon. Although the numbers were small, it has at present recommended the use rather of Depo-Provera in this group, as the increased metabolism of the active constituent is not so great (National Department of Health circular, available on the Southern African HIV Clinicians Society home page www.sahivsoc.org).

The participants interviewed were ignor­ ant about most information regarding the device. We believe that the facilities should make a clear plan to correct this situation, as most of this information will influence not only uptake of the device but also adherence. Nulliparous women and those with few children would like to be reassured, for example, that the return to fertility is relatively quick after removal of the IUCD. Very few participants (12%)

Table 3. Attitudes towards the IUCD per parity group Parity group A (N=50) n (%)*

Parity group B (N=50) n (%)*

Parity group C (N=50) n (%)*

Total, N

p-value

Agree

10 (32.3)

8 (25.8)

13 (41.9)

31

0.6185

Do not agree

36 (33.3)

37 (34.3)

35 (32.4)

108

No opinion

4 (36.4)

5 (45.5)

2 (18.2)

11

Agree

13 (56.5)

5 (21.7)

5 (21.7)

23

Do not agree

34 (30.1)

41 (36.3)

38 (33.6)

113

No opinion

3 (21.4)

4 (28.6)

7 (50.0)

14

Agree

21 (43.8)

11 (22.9)

16 (33.3)

48

Do not agree

26 (28.9)

33 (36.7)

31 (34.4)

90

No opinion

3 (25.0)

6 (50.0)

3 (25.0)

12

Agree

22 (46.8)

10 (21.3)

15 (31.9)

47

Do not agree

27 (31.8)

30 (35.3)

28 (32.9)

85

No opinion

1 (5.6)

10 (55.6)

7 (38.9)

18

Agree

22 (44.0)

11 (22.0)

17 (34.0)

50

Do not agree

23 (26.1)

35 (39.8)

30 (34.1)

88

No opinion

5 (41.7)

4 (33.3)

3 (25.0)

12

Agree

21 (35.0)

17 (28.3)

22 (36.7)

60

Do not agree

26 (33.3)

29 (37.2)

23 (29.5)

78

No opinion

23 (25.0)

4 (33.3)

5 (41.7)

12

Agree

11 (30.6)

12 (33.3)

13 (36.1)

36

Do not agree

36 (34.6)

35 (33.7)

33 (31.7)

104

No opinion

3 (30.0)

3 (30.0)

4 (40.0)

10

Agree

10 (27.8)

14 (38.9)

12 (33.3)

36

Do not agree

38 (38.0)

29 (29.0)

33 (33.0)

100

No opinion

2 (14.3)

7 (50.0)

5 (35.7)

14

Agree

2 (18.2)

4 (36.4)

5 (45.5)

11

Do not agree

48 (35.0)

46 (33.6)

43 (31.4)

137

No opinion

0

0

2 (100.0)

2

Agree

2 (22.2)

3 (33.3)

4 (44.4)

9

Do not agree

47 (33.6)

47 (35.6)

46 (32.9)

140

No opinion

1 (100.0)

0

0

1

Agree

3 (21.4)

7 (50.0)

4 (28.6)

14

Do not agree

47 (35.1)

42 (31.3)

45 (33.6)

134

No opinion

0

1 (50.0)

1 (50.0)

2

Agree

4 (28.6)

4 (28.6)

6 (42.9)

14

Do not agree

46 (33.8)

46 (33.8)

44 (32.4)

136

No opinion

0

0

0

0

Fear partner stops condoms

Causes sexually transmitted diseases 0.1060

Interferes with sex 0.2420

Fear of perforation 0.0086

Fear of cancer 0.1481

Fear of pain 0.7511

Only for multiparous 0.9738

Fear of gaining weight 0.3014

It is like abortion 0.1957

It is a sin 0.5762

Religion is against 0.4482

Tradition is against 0.7376

*Percentages of total answers for each response.

SAJOG â&#x20AC;˘ December 2015, Vol. 21, No. 2

31

knew this fact. This finding was similar to that of Credé et al.[3] in Cape Town. This may negatively affect uptake, not only among women of low parity but also among those who are advanced in age.

Clinics should ensure that issues regarding fertility return are dealt with during counselling, to improve uptake of the device.

Most women interviewed would like to wait for at least 3 years before their next pregnancy. We believe that they would like to know for how long it is safe to have a foreign body inserted in their uterus. Unfortunately only 26.7% of women interviewed knew that it is actually safe to use the IUCD for up to 10 years. Credé et al.[3] found that more than half of their participants did not know that they could use the device for 10 years. Studies conducted in SA by Gutin et al.[10] and in the USA by Whitaker et al.[11] reported that participants mentioned as an advantage the fact that the IUCD could be used for a long time.

With the high prevalence of HIV in SA, and particularly in KwaZulu-Natal, the researchers expected that most women, regardless of their HIV status, would know that HIV-positive women can safely use the IUCD. Only 41.0% of all participants knew that HIV patients can safely use it. Credé et al.[3] reported that more than half of their participants did not know that HIV-positive patients could safely use the IUCD. In our study, only 44.6% of HIVpositive women knew that it was safe for them to use the device, and 38.3% of HIV-negative participants knew that HIV-positive women can use it. It is also crucial to inform women that, unlike barrier contraceptives, IUCDs do not provide protection against HIV or other sexually transmitted diseases.[7] We believe one of the ways to improve the situation is to prepare a structured teaching presentation on contraception including all these facts to be used as a template. Clinics should refrain from prescribing one type of contraceptive; women should be allowed to choose freely after discussion of appropriate information. In fact, according to the World Health Organization’s evidencebased medical eligibility criteria for contraceptive use, LARC methods have few contraindications. Because of this and the potential to reduce unintended pregnancy rates, the American Congress of Obstetricians and Gynecologists suggests that LARC methods should be offered as first-line contraceptive methods and encouraged as options for most women.[12] There were few misconceptions about the IUCD as documented in the results above. Gutin et al.[10] also found that there was poor knowledge about the IUCD among SA women but few misconceptions. Neither religion nor traditional beliefs seem to be an obstacle when it comes to the use of the IUCD. The only elements that seem to be of concern are fear of pain, fear of cancer, fear of womb perforation and interference with sexual activity, even though none of these was an issue in more than 40% of the participants. These concerns should be addressed during every counsel­ling session if we expect to improve uptake of the device.

The answers from the hospital group showed greater knowledge and more accurate attitudes about IUCDs than those from the clinic group. The difference was significant in some cases, as shown in Fig. 2. This may be explained by the fact that the clinic had not yet started offering insertion of the IUCD and were referring their clients to the hospital.

Most of the participants (77.3%) acquired their knowledge from the clinic, indicating the need for the facilities to ensure that the information they are transmitting is comprehensive. None of the participants mentioned the leaflet as a source of information. The

32

SAJOG • December 2015, Vol. 21, No. 2

clinics should perhaps try to use leaflets in addition to the usual form of teaching. The advantage of this is that the leaflet can be taken at home and be shared with the partner/family, especially in an environment where men do not attend family planning clinics. Partner/family disapproval can influence uptake and reduce adherence.[13,14]

Study limitations and strengths The findings of this study are based on a convenience sample of women from a specific area, Pietermaritzburg. The trans­ferability of the results may therefore be limited. However, the study gave us a picture of the current situation in the public sector in this area.

This is the first study to investigate attitudes and knowledge about the IUCD among clients in this area. It has identified the main misconceptions among clients and showed that knowledge among clients is poor. The findings should be used by clinics to improve the situation.

Conclusion

This survey documents poor knowledge about the IUCD among women using the public health sector in Pietermaritzburg, SA. A notable finding of our study was fewer misconceptions compared with those documented in studies conducted in other parts of the country. This finding, coupled with the fact that most of the participants rely on the clinic as their source of information, should be seen as an opportunity to improve the situation. Diversification of methods of teaching and the involvement of the partner/family, either through direct contact or via documents such as leaflets, may help in terms of the uptake of the device and adherence.

1. Ong J, Temple-Smith M, Wong WCW, McNamee K, Fairley C. Contraceptive matters: indicators of poor usage of contraception in sexually active women attending family planning clinic in Victoria, Australia. BMC Public Health 2012;12(1):1108-1117. [http://www.biomedcentral.com/14712458/12/1108] 2. Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspectives on Sexual and Reproductive Health 2008;40(2):94-104. [http:// dx.doi.org/10.1363/4009408] 3. Credé S, Hoke T, Constant D, Green MS, Moodley J, Harries J. Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: A cross sectional study. BMC Public Health 2012;12(1):197205. [http://www.biomedcentral.com/1471-2458/12/197] 4. Department of Health, Republic of South Africa. National Contraception Clinical Guidelines.

2012. http://www.doh.gov.za/docs/policy/2013/contraception_clinical_guidelines_28jan2013 (accessed 13 March 2013).

5. Patel CJ, Kooverjee T. Abortion and contraception: Attitudes of South African university students. Health Care For Women International 2009;30(6):550-568. [http://dx.doi. org/10.1080/07399330902886105] 6. Chen AY, Baldwin S. Intrauterine devices. In: Shoupe D, Kjos SL, eds. Handbook of Contraception: A Guide for Practical Management. New York: Humana Press, 2006:129-145.

7. Anthony A, Repke JT. Puerperal problems. In: James D, Steer PJ, Weiner CP, Gonik B, Crowther CA, Robson SC, eds. High Risk Pregnancy: Management Options. New York: Elsevier Saunders: 2011:1313-1329.

8. Whiteman MK, Tyler CP, Folger SG, Gaffield ME, Curtis KM. When can a woman have an intrauterine device inserted: A systematic review. Contraception 2013;87(5):666-673. [http:// dx.doi.org/10.1016/j.contraception.2012.08.015] 9. Perry SH, Swamy P, Preidis GA, Mwanyumba A, Motsa N, Sarero H. Implementing the Jadelle implant for women living with HIV in a resource-limited setting: Concerns for drug interactions leading to unintended pregnancies. AIDS 2014;28(5):791-793. [http://dx.doi.org/10.1097/ QAD.0000000000000177] 10. Gutin SA, Mlobeli R, Moss M, Buga G, Morroni C. Survey of knowledge, attitudes and practices surrounding the intrauterine device in South Africa. Contraception 2011;83(2):145-150. [http:// dx.doi.org/10.1016/j.contraception.2010.07.009] 11. Whitaker AK, Johnson LM, Harwood B, Chiappetta L, Creinin MD, Gold MA. Adolescent and young adult women’s knowledge of and attitudes toward the intrauterine device. Contraception 2008;78(3):211-217. [http://dx.doi.org/10.1016/j.contraception.2008.04.119] 12. American Congress of Obstetricians and Gynecologists (ACOG). Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. 2011. http://www.acog.org/ resources_And_Publications/committee_opinions (accessed 21 May 2014).

13. Weston MRS, Martins SL, Neustadt AB, Gilliam ML. Factors influencing uptake of intrauterine devices among postpartum adolescents: A qualitative study. Am J Obstet Gynecol 2012;206(1):40. e1-40.e7. [http://dx.doi.org/10.1016/j.ajog.2011.06.094] 14. Haddad LB, Cwiak C, Jamieson DJ, et al. Contraceptive adherence among HIV-infected women in Malawi: A randomized controlled trial of the copper intrauterine device and depot medroxyprogesterone acetate. Contraception 2013;88(6):737-743. [http://dx.doi.org/10.1016/j. contraception.2013.08.006]

RESEARCH

A clinical audit of female urinary incontinence at a urogynaecology clinic of a tertiary hospital in Durban, South Africa T B T Dehinbo,1 MBBS, Dip Obstet (SA), FCOG; S Ramphal,1,2 MB ChB, FCOG; J Moodley,1,3 MB ChB, FCOG, FRCOG, MD epartment of Obstetrics and Gynaecology, King Edward VIII Hospital, Durban, South Africa D Urogynaecology and Endoscopy Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa 3 Medical Research Council Centre for Women’s Health and HIV Studies, Nelson Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 1 2

Corresponding author: T Dehinbo (banktitus@yahoo.com)

Background. Urinary incontinence (UI) is a common condition with an increasing prevalence worldwide. Although it is not a lifethreatening condition, it can be very disabling.

Objective. To describe the clinical profiles, risk factors, diagnosis, treatment and clinical outcomes of women with different subtypes of UI who attended a tertiary hospital in Durban, South Africa.

Methods. A retrospective chart review was performed. A structured data form was used to obtain the relevant information.

Results. Seven hundred and fifty-eight of 945 charts with a diagnosis of UI were analysed. Stress urinary incontinence (SUI) was the most common subtype of UI (30%). The mean (standard deviation (SD)) age was 50.9 (15.2) years; mean (SD) parity 2.8 (1.4) and mean (SD) body mass index 29.2 (5.3) kg/m2. Indians (n=366, 48.3%) were the predominant racial group; black Africans constituted 32.7% (n=248). Mid-urethral tape was the preferred surgical treatment for SUI (n=134, 62.0%). Urge UI was treated mainly with pharmaceutical agents (n=138, 74.2%) with physiotherapy as adjunctive therapy. Urogenital fistulas were repaired via laparotomy (n=42, 53.9%) and vaginally (n=25, 32%). Mid-urethral tapes and Burch colposuspension had success rates of 97% and 83.3%, respectively. Both laparotomy and vaginal fistula repairs had success rates of 95%.

Conclusions. Stress UI was the most common subtype of UI observed in this study. Patients were predominantly Indians and overweight or obese. The majority of patients with urogenital fistulas were black Africans. Surgical outcomes at our centre were in keeping with those in international reports.

S Afr J Obstet Gynaecol 2015;21(2):33-38. DOI:10.7196.SAJOG.983

Urinary incontinence (UI) is common in females and a major global health problem.[1] Although not a life-threatening condition, it can be disabling. It has been shown to have major physical, social and psychological impact on the quality of life.[1] The prevalence of UI is difficult to estimate because the definition varies between researchers and the thresholds of complaints differ among women. Approximately 35% of women experience some form of UI, and on average one in four will seek medical help.[2] The prevalence of socially disabling incontinence (i.e. resulting in fear of and lack of interaction with people) is much lower, at about 2%.[3] Racial differences have been postulated to be an associated factor in UI. Women of varying racial groups have different distributions of symptoms, different conditions causing their UI and different risk profiles for this condition.[1] Besides the management of urogenital fistula (UGF), other subtypes of UI have received very little medical attention in subSaharan Africa. This is understandable given the limited resources and high burden of deadly diseases such as HIV, tuberculosis and malaria. However, with increasing emphasis on quality-of-life issues and women’s awareness of available treatment options for UI, many women are now seeking help, resulting in UI becoming a major health problem. A urogynaecology unit (UGU) was commissioned at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South

Africa, in 2003 and patients from the Durban metropolis and KwaZulu-Natal Province were referred to the unit.

Objective

To establish the aetiological factors, demographic data, clinical profiles, treatment and clinical outcomes of women with UI referred to the UGU.

Methods

Study design This was a retrospective audit involving analysis of the clinical notes of women who presented to the urogynaecology clinic from January 2004 to December 2011. Information was obtained from a computerised database using a structured data sheet.

Definitions

Urinary incontinence. According to the International Contin­ ence Society, UI is defined as ‘involuntary loss of urine which is objectively demonstrable and with a social or/and hygienic prob­ lem’.[4] UI can present either as total incontinence (i.e. continuous leakage of urine) or as intermittent episodes. The latter present as stress urinary incontinence (SUI), urge urinary incontinence (UUI), mixed urinary incontinence (MUI) and overflow UI. Successful outcome. Successful management indicated that the patient had remained continent for a period of 1 year following treatment.

SAJOG • December 2015, Vol. 21, No. 2

33

Unit management protocol (summary)

Referring centre

First visit

A detailed relevant history and examination were followed by basic investigations, viz. full blood count, renal function tests (urea and electrolytes), urine microscopy, culture and sensitivity and a bladder diary.

Specific investigations included uro­dynamic studies (UDS), pelvic sonography, a voiding cystourogram (VCU) and computed tomo­ graphy intravenous pyelogram (CT-IVP); these were done where appro­priate. Patients with a presumptive diagnosis of SUI/MUI/ UUI were all referred for physiotherapy, lifestyle modifications, medical treatment for urogenital infections and the use of vaginal devices where applicable. Patients with signs and symptoms of a UGF were admitted for investigations and assessment of location, size and number of fistulas for adequate planning of surgical treatment.

Second visit This included a review of the results of all investigations, and an objective diagnosis was made. All patients confirmed as having intermittent UI were then reassessed to identify any improvement of symptoms and plan for definitive treatment.

Follow-up post definitive therapy Patients were assessed at 1-month, 3-month, 6-month and 1-year intervals following treatment. Clinical outcomes were assessed at each visit. The final surgical outcome was assessed at 1 year, while patients on medical management were followed up for 5 years.

Study population The study population was multiracial with varying cultural background and religious beliefs, comprising whites, black Africans, Indians and coloureds. The women were mainly of low socioeconomic status.

Statistical analysis All data were analysed using the Statistical Package for Social Sciences, version 21 (IBM, USA).

The independent sample t-test for equality of means (unequal variance assumed) was used to calculate the p-values for continuous data such as age, parity and body mass index (BMI), while the Pearson χ2 test was used for categorical data. A p-value of <0.05 was considered significant.

Descriptive statistics, namely frequencies and percentages, bar chart for categorical

34

SAJOG • December 2015, Vol. 21, No. 2

Specialist clinic

37%

32% 30%

27% 25%

16%

16%

14%

4%

Stress UI

Urge UI

Mixed UI

Fistula

0% Overflow UI

5%

*Assoc.

POP

Fig. 1. Comparison of initial diagnosis at referring centre and definitive diagnosis at the specialist clinic. (Assoc. POP = associated pelvic organ prolapse; *Presented with a subtype of UI in association with POP.) data, means and standard deviations (SDs) or medians and percentiles for continuous data, as appropriate, were calculated.

Results

There were 945 cases recorded. Of these patients, 141 were incorrectly booked to the clinic while 46 were referred for UDS. A total of 758 women who had UI over the 8-year study period were therefore included in the analysis.

Comparison of diagnosis at referring centre and specialist clinic (Fig. 1) The most common type of UI diagnosed at the referring clinic was MUI, followed by SUI, while the most common subtype following definitive diagnosis was SUI, followed by UUI. There was a notable discrepancy between the diagnoses made at the referring centre and those at the UGU, as shown in Fig. 1.

All patients with a diagnosis of overflow UI were referred to a urologist for further management.

Detailed demographic characteristics (Table 1) The mean (SD) age was 50.9 (15.2) years (range 13 - 84). Frequency of UI reached a peak in the age group 40 - 49 years. The mean parity was 2.8 (1.4) (range 0 - 5). UI was most common in obese/morbidly obese patients (38.8%), closely followed by those classified as overweight (38.4%).

It was noted that the predominant race was Indian, followed by black African.

Table 1. Detailed demographic characteristics of all patients Characteristics

n (%)

Age (years) <19

26 (3.4)

20 - 29

42 (5.5)

30 - 39

98 (12.9)

40 - 49

192 (25.3)

50 - 59

180 (23.7)

60 - 69

146 (19.3)

70 - 79

62 (8.2)

≥80

12 (1.6)

BMI* Underweight (<18.5)

8 (1.1)

Normal (18.5 - 25)

188 (24.8)

Overweight (25.1 - 30)

268 (38.4)

Obese/morbidly obese (>30)

294 (38.8)

Racial group Black African

248 (32.7)

White

96 (12.7)

Indian

366 (48.3)

Coloured

48 (6.3)

Parity 0

56 (7.4)

1

70 (9.2)

2

208 (27.4)

3

206 (27.2)

4

108 (14.2)

≥5

110 (14.5)

*WHO classification.

Specific UI and demographic characteristics (Table 2) UGF was most common in the age group 20 - 49 years.

Urge UI was maximal in the 60 - 69-yearold age group, SUI in 50 - 59-year-olds and MUI in the 40 - 49-year-olds, and associated pelvic organ prolapse (POP) in women older than 60 years.

The incidence of SUI increased with parity, while UGF was found to be highest among para 1s. MUI was common in nulliparas, but the peak incidence was in para 3s.

SUI predominates in obese/morbidly obese patients. UGF and UUI did not show any significant association with a particular BMI category.

UGF occurred predominantly among black African women (85.8%).

Mode of delivery (Table 3) Table 3 shows that women who had vaginal deliveries had a high rate of operative inter­

ventions; however, the rates of normal (uncomplicated) vaginal delivery (18.7%) and caesarean section (17.2%) are relatively similar.

Aetiology and race in urogenital fistula (Table 4) Most patients with UGF were black Africans.

The proportion of fistulas occurring secondary to gynaecological surgery was 28.2%.

The aetiological factors for UGFs were predominantly related to obstetric injury, constituting nearly two-thirds of the patients.

Prolonged labour was the most common factor, followed by forceps delivery.

Subgroup analysis: black African v. Indian (Table 5) Comparative analyses between black Afri­ can and Indian women with UI, based on demographic data as well as associated chronic medical conditions, are illustrated in Table 5.

Table 2. Distribution of clinically relevant demographic data and their relation to specific subtypes of UI Demographic data

SUI (%)

UUI (%)

MUI (%)

Fistula (%)

<20

0

1.2

0

13

20 - 29

0

1.2

2.6

26.1

30 - 39

7.7

13.4

9.2

23.9

40 - 49

27.5

23.2

30.3

28.3

50 - 59

39.6

20.7

25

4.3

60 - 69

16.5

32.9

15.8

4.3

70 - 79

8.8

7.3

13.2

0

≥80

0

0

3.9

0

0

0

17.7

21.3

21.8

1

8.9

14

7.2

2

18.8

16.1

3

24

12.7

4

25.3

≥5

23

Age groups (years)

Associated comorbid conditions such as hypertension (n=212), diabetes (n=106), respiratory disorders (n=79) and connective tissue disease (n=56) were not uncommon in this study. The Indian group significantly had higher frequencies of associated hyper­ tension, connective tissue disorders and diabetes.

Specific investigations and definitive treatment Table 6 shows that UDS were done in half of the patients with intermittent UI, VCUs were done in 95.8% and CT-IVP was done in addition to VCU in 75% of women with UGF. Table 3. Mode of delivery in all patients with UI Delivery

n (%)

Vaginal delivery

593 (61.9)

Normal vaginal delivery

179 (18.7)

omplicated by episiotomy/ C perineal tear

227 (23.7)

Operative vaginal delivery

187 (19.5)

Vacuum

29

Forceps

158

Caesarean section

165 (17.2)

Table 4. Aetiological factors and race in patients with UGF (N=78) n (%) Aetiological factor Obstetric-related

51 (65.3)

Prolonged labour

24

Caesarean section

10

47.2

Hysterectomy (post partum)

5

16.9

14.6

Forceps delivery

12

24.2

6.6

20.1

11.3

9.8

19.4

19

0

Parity

BMI

Gynaecological

22 (28.2)

Abdominal hysterectomy

14

Vaginal hysterectomy

8

Others

5 (6.5)

Underweight (<18.5)

0

0

0

100

Foreign body

3

Normal (18.6 - 25)

25.7

29.8

24.3

20.2

Sexual assault

1

Overweight (25.1 - 29.9)

31.6

29.8

24.6

14

31.2

24.3

26.8

17.7

Self-inflicted (psychiatric patient)

1

Obese + morbidly obese (≥30) Black African

16.9

29.0

12.3

85.8

Black African

67 (86.0)

White

32.7

2.5

29.3

5.2

White

1 (1.3)

Indian

25.1

35.4

30.1

9.0

Indian

8 (10.1)

Coloured

25.3

33.2

28.3

0

Coloured

2 (2.6)

Race

Racial group

SAJOG • December 2015, Vol. 21, No. 2

35

Specific treatment modalities varied accor­ ding to specific diag­ noses, as shown in Table 6.

following MUT insertion and another 2 had recurrence of POP.

Follow-up and clinical outcomes

There is great variation in the prevalence of UI in different regions of the world. The highest prevalence of UI was reported from the USA, where Raza-Khan et al.[5] reported rates of 70% and 75% of peripartum UI prevalence in nulliparous and multiparous women, respectively.

The distribution of the types of UI in our audit was as follows: 30% had SUI, 27% had UUI, 25% had MUI and 14% had fistula (overflow UI 4%). These figures are slightly lower than in other studies. Our audit only evaluated women referred to our specialist clinic (i.e. it is not a population-based study). Further, we reported four subtypes (SUI, MUI, UUI and fistula) rather than the three (SUI, MUI and UUI) that are usually reported, as we included women with UGFs, which are frequently referred to our unit.

SUI was found to be the most common subtype, which is consistent with most studies,[3] although MUI has been reported to be the leading subtype in few studies.[5] There was a wide variation in the diagnosis of the different subtypes of UI between referral health facilities and the specialist clinic (IALCH). This is not surprising, since lower levels of healthcare facilities were managed by medical officers who probably lacked adequate expertise and equipment such as UDS in order to make a definitive diagnosis of UI. Hence there was an overdiagnosis of SUI and MUI from referral facilities, with a paradigm shift to UUI and overflow UI following UDS. This study shows a 49.1% utilisation of UDS in the preoperative diagnosis of

The outcomes of specific management of each type of UI are summarised in Table 7.

Of the 172 procedures performed for SUI, 157 (91.3%) were successful, mid-urethral tape (MUT) insertions being most effective (97%). The success rate for UGF repair was 94.9%; both abdominal and vaginal approaches of repair were successful (95.2% v. 96%).

UUI was predominantly managed with pharmacotherapy; 69.1% of women repor­ ted relief of symptoms in the first 6 months, with some having recurrence of symptoms at a later stage.

Surgical complications Eighteen patients had varying compli­ cations: One patient each had bladder and bowel injuries; both were recognised intra­ operatively and repaired successfully.

Four patients had surgical site infections leading to breakdown of vesicovaginal fistula (VVF) repair; 4 cases of post­ operative urinary tract infection (UTI) were successfully treated with intravenous antibiotics.

Urinary retention occurred in 2 cases following MUT insertion; patients under­ went reoperation to release tension on the tape.

Two patients who presented with MUI associated with POP had symptoms of SUI following repair of prolapse; these symptoms were persistent and required MUT insertion. Two had mesh exposures

Discussion

Table 5. Analyses of risk factors: black African v. Indian

SUI, indicating that it is not employed as a mandatory preoperative diagnostic tool for non-complicated and easily demon­ strable SUI. This is corroborated by the conclusion of a recent randomised control trial from the USA (ValUE study[6]), which demonstrated that preoperative office evaluation alone was not inferior to evaluation with urodynamic testing in women with uncomplicated demonstrable SUI. The prevalence of UI differs with age. It was low in the age group <19 years, peaked in the age group 40 - 59 years (24.5%) and subsequently decreased in age groups over 60 years. In comparison the EPINCONT study,[7] a large Norwegian study on the epidemiology of UI, found an increasing Table 6. Specific managements of UI n (%) Specific diagnostic investigations Intermittent UI UDS

248 (49.1)

VCU

143 (28.4)

UDS +VCU

52 (10.2)

Sonar

62 (12.3)

Urogenital fistula VCU (total)

69 (95.8)

CT-IVP + VCU

54 (75.0)

Sonar (in addition)

12 (16.7)

Specific definitive treatments SUI MUT

134 (62.0)

Burch colposuspension

18 (9.5)

Physiotherapy + neuromodulation

38 (17.9)

Periurethral bulking

20 (10.6)

UUI Oxybutynin

130 (69.9)

Total (n*)

Black African (%*)

Indian (%*)

p-value

Oxybutynin + imipramine

8 (4.3)

Variables Age, years†

50.9

43.3 (16.9)

53.2 (12.4)

<0.01

Physiotherapy only:

36 (19.3) 32 (17.2)

Parity

2.8

2.4 (1.5)

2.7 (1.2)

0.06

Pelvic floor exercise

BMI

29.2

28.9

29.3

0.50

106

35.3

52.7

<0.049

elvic floor exercise + P electrostimulation

4 (2.1)

Diabetes Hypertension

212

26.7

60.3

<0.011

Botox

12 (6.5)

Connective tissue disease

56

27.0

52.5

<0.04

Respiratory disorders

79

37.1

28.1

0.40

Neuromuscular disease

34

19.0

30.4

0.10

†

‡

Fistula Laparotomy

42 (53.9)

Vaginal repair

25 (32.0)

*Unless otherwise indicated.

Laparotomy + vaginal

10 (12.8)

Mean (SD).

Laparoscopy

1 (1.3)

†

Mean.

‡

36

SAJOG • December 2015, Vol. 21, No. 2

MUT = midurethral tape.

Table 7. Clinical outcomes of management Management/procedure

n (%)

Stress urinary incontinence (SUI) MUT (TVT/TOT)

134 (100.0)

Successful

130 (97.0)

Failed: incontinent

2 (1.5)

Urinary retention

2 (1.5)

Total failure

4 (3.0)

Burch colposuspension

18 (100.0)

Successful

15 (83.3)

Failed

3 (16.7)

Periurethral bulking

20 (100)

Successful

12 (60.0)

Recurrence

8 (40.0)

SUI overall success

157 (91.3)

Urogenital fistula (UGF) Laparotomy (abdominal)

42 (100.0)

Successful

40 (95.2)

Failed

2 (4.8)

Laparoscopic repair

1 (100.0)

Successful

1 (100.0)

Failed

0

Vaginal approach

25 (100.0)

Successful

24 (96.0)

Failed

1 (4.0)

ombined (vaginal + C abdominal)

10 (100.0)

Successful

9 (90.0)

Failed

1 (10.0)

UGF overall success

74 (94.9)

Outcome of medical treatment (UUI + MUI) Satisfactory

94 (31.5)

Effective initially

61 (20.5)

Not effective

104 (34.0)

Defaulted

39 (13.1)

Relief of symptoms 1 - 6 months

76 (69.1)

7 - 12 months

26 (23.6)

1 - 2 years

2 (1.8)

2 - 5 years

6 (5.5)

TVT/TOT = tension-free vaginal tape/transobturator tape.

prevalence during young adult life (20 30%), a broad peak around middle age (30 - 40%), and then a steady increase in the elderly (30 - 50%). The decreased prevalence observed in our study in the 70s - 80s age groups may be due to the fact that the older generation accept UI as part of the normal ageing process, may be

ignorant of the availability of treatment modalities, or are embarrassed to present with these complaints.

Overweight and obesity were common in our patient profile (77.2%). These find­ ings are congruent with several studies which have reported that a higher BMI is a risk factor for UI.[8] Obesity is a modifiable condition, and it has been reported that with loss of weight, resolution of some types of UI may occur.[8] An association between UI and comorbid ailments such as diabetes, connective tissue disorders and hypertension has been [9] reported previously in other studies.

Our study showed a statistically signi­ ficant difference in the occurrence of diabetes, hypertension and connective tissue disease among Indians compared with black Africans; this may explain the preponderance of UI among Indians.

The relationship of UI to route of delivery (vaginal and abdominal delivery) is conflicting. Our study showed an increased frequency of UI among patients who had vaginal delivery compared with caesarean section (CS). This may be related to the high percentage of instrumental delivery, difficult labour, perineal trauma and/or episiotomy during vaginal delivery.

A study by Chaliha et al.[10] showed that elective CS may protect against the development of SUI, but the risk of faecal incontinence and other urinary symptoms including UUI may not be reduced.

However, McKinnie et al.,[11] in a multicentre study on the prevalence of urinary and faecal incontinence after vaginal delivery and CS, found an increased risk of developing UI following pregnancy but no difference in the development of UI between vaginal delivery and CS groups. These authors concluded that CS does not decrease the risk of urinary or faecal incontinence compared with vaginal delivery.[11] UGFs occurred predominantly following obstetric complications (65.3%). This is corroborated in the Saving Mothers Report (2008 - 2010),[12] which suggested that poor intrapartum care and lack of skills in instrumental deliveries may be implicated in the frequency of maternal deaths and morbidity due to obstructed labour. It was recommended that all healthcare workers involved in maternity care should be trained in the ESMOE-EOST programme module.[12] It was disturbing that hysterectomy contributed to 28.4% of fistulas in our

study. Previous CS, enlarged multifibroid uteri and excessive intraoperative bleeding were three contributing risk factors for the development of fistulas. Urinary fistulas as a result of gynaecological surgery need to be critically evaluated.

The surgical procedure of choice in the management of SUI in our unit is MUT. The 1-year success rate of MUT was 97% in our series of 134 patients; the majority had transobturator tape (TOT) repair. The Evaluation of Transobturator Tapes (E-TOT) study was the first highquality randomised controlled trial, and included a 1-year follow-up study.[13] In their 1-year follow-up, a success rate of 81%, a 73% patient-reported success rate and a 70% satisfaction rate for TOT after 2 years was reported, indicating a significant deterioration over time. Although it is not easy to explain the difference in success rates between our audit and the multicentre E-TOT study, the latter had a variety of surgeons with differing experience per­ forming the surgical intervention. In our study there was a single surgeon, which may have contributed to the higher success rate.

Specific to UGFs, the overall success rate in our study was 94.9%. The results of fistula surgery are influenced by a variety of factors including fistula site, size and degree of scarring. In addition, the number of previous repair attempts, the severity of the lesions, the overall health of the patient, the availability of health facilities and the experience and expertise of the surgeon are important factors in successful surgical closure of obstetric fistulas.

Lee et al.,[14] in a retrospective chart review from 1996 to 2011, reported on 66 patients with VVFs, 42 undergoing primary treatment (n=31 vaginal approach v. n=11 abdominal); the overall repair success rate was 97%. It is difficult to compare the success rates between the two studies, as Lee et al. had no patients with complex UGFs as seen in our study. Furthermore, most patients in our study were from a poor socioeconomic background and often presented late to hospital, as also reported

by Ramphal et al.[15] The abdominal route of fistula repair predominated in our study (42 abdominal v. 25 vaginal). This was determined by the following factors, set as prerequisites for determining the operative route of repair in our unit: the abdominal route is preferred if the fistula site is in close proximity to, or involves, the ureter, the trigone area of the

SAJOG • December 2015, Vol. 21, No. 2

37

bladder or the uterus, or if there are multiple fistulas, a contracted vagina or poor vaginal access to the fistula site. The route of repair had no bearing on the surgical outcome, and this is in keeping with a study by Cron.[16] However, Cron reported that 85% of VVFs could be repaired successfully at the first attempt, and that closure rates were similar in the transvaginal and transabdominal routes.[16] This is consistent with findings in our study (95.2% abdominal v. 96% vaginal).

Study limitations and strengths No detailed record of deliveries was available, as most of these patients were referred from rural district and regional hospitals and referral notes were scanty.

The data on specific medical management for UUI and MUI were combined, so distinct outcome of treatment for either could not be assessed because of difficulty in stratifying this information.

This was not a population-based study, so it was difficult to make any inference on the epidemiology of the condition with regard to racial and age distributions observed.

However, one of the strengths of the study was that management of all the patients was carried out by a single specialist, vastly experienced in the management of female UI.

Conclusions

The distribution of each subtype of intermittent UI is similar to high-income countries and the underlying risk factors are similar.

SUI was found to be the most common subtype of UI. Successful treatment probably depends on the experience of the healthcare provider. The establishment of a urogynaecology subspecialty has played a major role in the management of UI.

38

SAJOG • December 2015, Vol. 21, No. 2

UGF, particularly secondary to obstetric complications, was rela­ tively common in our study. Its frequency is in keeping with results from low- and middle-income countries, particularly in subSaharan Africa.

1. El-Azab AS, Mohamed EM, Sabra HI. Prevalence and risk factors of urinary incontinence amongst Egyptian women. J Neurourol/Urodyn 2007;26(6):783-788.

2. Seim A, Sandvik P, Hermstad R, Hunskaar S. Female urinary incontinence, consultation behaviour and patients’ experience (epidemiology survey). Fam Prac J 1995;12(1):18-21. [http://dx.doi.org/10.1093/fampra/12.1.18] 3. Harrison GL, Memel DS. Urinary incontinence in women, its prevalence and its management in a health promotion clinic. Br J Gen Prac 1994;44(381):149-152.

4. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: A report from the Standardization Sub-committee of the International Continence Society. J Neurourol Urodyn 2002;21(2):167-178. [http://dx.doi.org/10.1002/nau.10052] 5. Raza-Khan F, Graziano S, Kenton K, Shott S, Brubaker L. Peripartum urinary incontinence in a racially diverse obstetrical population. Int Urogynecol J Pelvic Floor Dysfunct 2006;17(5):525-530. [http://dx.doi.org/10.1007/s00192-005-0061-y] 6. Nager CW, Brubaker L, Daneshgari F, Litman HJ. Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations.

Contemp Clin Trials 2009;30(6):531-539. [http://dx.doi.org/10.1016/j.cct.2009.07.001] 7. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence – the Norwegian EPINCONT Study. J Clin Epidemiol 2000;53(11):1150-1157. [http://dx.doi.org/10.1016/S0895-4356(00)00232-8] 8. Hunskaar S. A systematic review of overweight and obesity as risk factors and targets for clinical intervention for urinary incontinence in women. Neurourol Urodyn 2008;27(8):749-757. [http://dx.doi.org/10.1002/nau.20635] 9. Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194(2):339-345. [http://dx.doi.org/10.1016/j.ajog.2005.07.051] 10. Chaliha C, Digesu A, Hutchings A, Soligo M, Khullar V. Caesarean section is protective against stress urinary incontinence: An analysis of women with multiple deliveries. BJOG 2004;111(7):754755. [http://dx.doi.org/10.1111/j.1471-0528.2004.00155.x] 11. McKinnie V, Swift SE, Wang DO, et al. The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. Am J Obstet Gynecol 2005;193(2):512-517. [http:// dx.doi.org/10.1016/j.ajog.2005.03.056] 12. Moodley J, Pattinson RC. Saving Mothers 2008-2010, Fifth Comprehensive Report on Confidential Enquiries into Maternal Deaths in South Africa. Pretoria: Department of Health, 2012. http://www. sanac.org.za/resources/cat_view/7-publications/9-reports (accessed 1 December 2015).

13. Abdel-fattah M, Ramsay I, Pringle S, et al. Randomized prospective single-blinded study comparing ‘insideout’ vs ‘outside-in’ transobturator tapes in management of urodynamic stress incontinence: 1 year outcomes from the E-TOT study. BJOG 2010;117(7):870-878. [http://dx.doi.org/10.1111/j.1471-0528.2010.02544.x] 14. Lee D, Dillon BE, Lemack GE, Zimmern PE. Long-term functional outcomes following nonradiated vesicovaginal repair. J Urol 2014;191(1):120-124. [http://dx.doi.org/10.1016/j.juro.2013.07.004] 15. Ramphal SR, Kalane G, Fourie T, Moodley J. An audit of obstetric fistula in a teaching hospital in South Africa. Trop Doct J 2008;38(3):162-163. [http://dx.doi.org/10.1258/td.2007.070087] 16. Cron J. Lessons from the developing world: Obstructed labor and the vesico-vaginal fistula. Med Gen Med 2003;5(3):24.

RESEARCH

Female genital mutilation/cutting: Knowledge, practice and experiences of secondary schoolteachers in North Central Nigeria A S Adeniran,1 FWACS; FMCOG; A A Fawole,1 FWACS; O R Balogun,1 FWACS; M A Ijaiya,1 FWACS; K T Adesina,1 FWACS, FMCOG; I P Adeniran,2 RN, RPN 1 2

Department of Obstetrics and Gynaecology, University of Ilorin and University of Ilorin Teaching Hospital, Ilorin, Nigeria In-service Education Unit, Nursing Services Department, University of Ilorin Teaching Hospital, Ilorin, Nigeria

Corresponding author: A S Adeniran (acrowncord@hotmail.com)

Background. Despite global efforts at eradicating female genital mutilation/cutting (FGM/C), the act continues to be performed globally.

Objective. To determine the experience of schoolteachers about FGM/C and their possible role in contributing to its eradication.

Methods. A prospective cross-sectional survey involving secondary schoolteachers from 18 secondary schools in Ilorin, North Central Nigeria, was undertaken during October and November 2014. All consenting participants completed a self-administered questionnaire on FGM/C. Statistical analysis was with SPSS version 20.0 with χ2 and logistic regression; a p-value of <0.05 was considered significant.

Results. There were 371 participants (113 males (30.5%) and 258 females (69.5%)). More females than males were aware of FGM/C (205 v. 94; χ2 41.2; p=0.001); 180 women (69.8%) and 81 men (71.7%) wanted awareness and the implications of FGM/C to be taught in schools, while 46 women (17.8%) and 23 men (20.4%) had previously educated students about FGM/C. Also, 109 (42.3%) of the female teachers had been mutilated (mean (standard deviation) age 4.76 (4.86) years), and 49 mutilations (45.0%) had been performed by traditional circumcisers. Of the teachers, 44.0% of men and 24.5% of women had subjected their daughters to FGM/C (p=0.029), mostly for religious reasons. The men initiated the majority of their daughters’ mutilations, while the mothers-in-law were the main initiators among the women; 44 (17.0%) women and 23 (20.4%) men held the opinion that females should be circumcised, while the majority considered education and legislation to be the most important interventions to encourage its eradication. Predictors of the likelihood to support discontinuation of FGM/C include awareness of government policy about FGM/C and having a mutilated daughter.

Conclusion. Education, reorientation and motivation of teachers will position them as agents for eradicating FGM/C. S Afr J Obstet Gynaecol 2015;21(2):39-43. DOI:10.7196.SAJOG.1047

Female genital mutilation/cutting (FGM/C), also called female circumcision, is an old practice that ref­ lects human rights abuse with potential for medical compli­cations.[1] This has triggered efforts aimed at its eradication at international, national and community levels. However, it remains endemic in about 29 countries in Africa, the Middle East and Asia. Recent reviews identified advocacy (including education, information and advocacy tools to encourage local, national and international efforts), research and guidelines for health systems about treatment and counselling of mutilated women as pertinent.[2] Education and creating awareness have been identified as instrumental in the change of attitudes to support efforts at eradication of FGM/C.[3] Students are generally exposed to information and learning at school; this provides an avenue to provide information and education about FGM/C to potential future parents who will need to make decisions about their children and FGM/C. Equipping them with pertinent information will be a great advantage, creating an increased probability for making decisions against FGM/C later in life. In order to achieve this, the level of knowledge, views, attitudes and experience of the schoolteachers who would be entrusted with this responsibility need to be evaluated. This will determine the approach towards their ability to fulfil the vital role of providing education that will stimulate a behaviour change in favour of discontinuation of FGM/C.

Methods

The study was a cross-sectional survey conducted among school­ teachers in 18 secondary schools in Ilorin, North Central Nigeria,

during October and November 2014. A list of all secondary schools (public and private) was obtained from the Ministry of Education, and 18 institutions comprising equal numbers of public and private schools were selected by multistaged sampling with equal distribution in both rural and urban areas. All teachers were informed about the study, and consenting individuals were recruited using purposeful sampling.

Each participant was requested to complete a self-administered questionnaire consisting of open- and closed-ended questions evaluating knowledge of, views on, attitudes towards and experience of FGM/C. Non-teaching members of staff at the institutions and teachers who declined participation were excluded from the study.

Assessment of the correct definition of FGM/C was defined as the ability to recognise it as the removal of part or whole of the female external genitalia without a medical reason or disease.[1-3] The sample size was calculated using a previously described formula[4] and was based on the reported prevalence of FGM/C among Nigerian women (25%),[5] a confidence level of 95%, a degree of accuracy of 0.05 and an estimated attrition rate of 10%, giving a minimum sample size of 379.

The information collected included demographic parameters, personal experience of female teachers about FGM/C, i.e. whether women had been mutilated or not, and the events surrounding the experience. All participants were asked about their experience regarding the mutilation of their daughters and the associated events, their view about teaching on awareness and implications of FGM/C in schools, current government policy and discontinuation of FGM/C.

SAJOG • December 2015, Vol. 21, No. 2

39

Participants’ confidentiality was main­tained by using codes instead of names and allowing only the research team access to the data.

Statistical analysis was done using SPSS version 20.0 (IBM, USA). The results were expressed in tables with percentages, Pearson’s χ2 was used for comparison with calculation of odds ratios (ORs) at the 95% confidence interval (CI), and logistic regression; a p-value of <0.05 was considered significant.

Approval was obtained from the ethical review committee of the University of Ilorin Teaching Hospital, Ilorin, and the Kwara State Ministry of Education and Human Capital Development before comm­ encement of the study.

Results

There were 371 participants in the study, with 113 (30.5%) male (mean (standard deviation (SD)) age 34.90 (10.59) years; range 20 - 65) and 258 (69.5%) female teachers (mean (SD) age 36.30 (10.27) years; range 20 - 60). Of these, 69 males (61.1%) and 175 females (67.8%) were married, 44 males (38.9%) and 77 females (29.8%) were single, and 6 women (2.5%) were widowed.

Table 1 shows that more females than males had heard about FGM/C (205 v. 94; p=0.001), and that compared with males they had heard about it earlier (mean (SD) age 14.27 (6.69) v. 15.31 (7.0) years; t=1.229;

Table 1. Knowledge of FGM/C among participants Variables

Male

Female

t/χ2

p-value

Yes

94 (83.2)

205 (79.5)

41.207

<0.001

No

19 (16.8)

53 (20.5)

16.056

<0.001

15.31(7.00)

14.27 (6.69)

1.229

0.220

Radio

27 (23.9)

27 (10.5)

0.000

1.000

TV

14 (12.4)

25 (9.7)

3.103

0.078

My parents

60 (53.1)

145 (56.2)

35.244

<0.001

My teachers

21 (18.6)

25 (9.7)

0.348

0.555

My friends

14 (12.4)

41 (15.9)

13.255

<0.001

Book

21 (18.6)

27 (10.5)

0.750

0.386

Poster

10 (8.8)

10 (3.9)

0.000

1.000

Correct

81 (71.7)

199 (77.1)

49.729

<0.001

Wrong

20 (17.7)

38 (14.7)

5.586

0.018

Do not know

12 (10.6)

21 (8.1)

2.455

0.117

Heard about FGM, n (%)

Age heard about FGM/C (years), mean (SD) Source of information, n (%)

Definition of FGM/C, n (%)

Educated on FGM/C as a student Yes

37 (32.7)

80 (31.0)

15.803

<0.001

No

76 (67.3)

178 (69.0)

40.961

<0.001

Education level when educated, n (%) Primary

10 (8.8)

23 (8.9)

5.121

0.023

Secondary

20 (17.7)

44 (17.1)

9.000

0.002

Tertiary

7 (6.2)

13 (5.0)

1.800

0.179

Should students be educated about FGM/C?, n (%)

Table 2. Experience of female teachers who had undergone FGM/C (N=109*) Variables Age when mutilated/ circumcised (years), mean (SD)

4.76 (4.86)

Who performed it?, n (%) Medical personnel

35 (32.1)

Doctor

16 (14.7)

Nurse

19 (17.4)

Religious leader

7 (6.4)

Older woman

18 (16.5)

Traditional circumciser

49 (45.0)

Describe your experience, n (%) Painful

44 (40.4)

Lost much blood

4 (3.7)

Yes

81 (71.7)

180 (69.8)

37.552

<0.001

Enjoyed it

3 (2.8)

No

32 (28.3)

78 (30.2)

19.236

<0.001

Cannot remember

58 (53.2)

Primary

24 (21.2)

78 (30.2)

28.588

0.003

Secondary

53 (46.9)

96 (37.2)

12.409

<0.001

Happy/satisfied

30 (27.5)

0.527

Proud of it

20 (18.3)

Hated it

26 (23.9)

Do not know

33 (30.3)

At what level in school?, n (%)

Tertiary

4 (3.5)

6 (2.3)

0.400

Have you ever educated students about FGM/C?, n (%) Yes No

40

p=0.220), knew the correct definition of FGM/C (199 v. 81; p<0.001) and were taught about awareness and implications of FGM/C as students (80 v. 37; p=0.001).

Also, 20 males (17.7%) and 44 females (17.1%) were educated about FGM/C in secondary school, 180 females (69.8%) and 81 males (71.7%) wanted students to be taught about awareness and implications of FGM/C in schools, and 46 females (17.8%) and 23 males (20.4%) had educated students about FGM/C. Table 2 shows that 109 (42.2%) of the female teachers had been mutilated, at a mean (SD) age of 4.76 (4.86) years. Of these procedures, 49 (45.0%) were performed by traditional circumcisers and 35 (32.1%) by medical personnel.

Among the 50 men and 159 women who had daughters at the time of the interview, 22 males (44.0%) and 39 females (24.5%) had subjected their daughters to FGM/C (p=0.029), mainly for religious reasons. Male teachers were the major initiators of FGM/C for their daughters (9, 40.9%) while mothersin-law were responsible among the female teachers (16, 41.0%), as shown in Table 3.

Views about FGM/C and its eradication are shown in Table 4: 44 females (17.1%) and

SAJOG • December 2015, Vol. 21, No. 2

23 (20.4) 90 (79.6)

46 (17.8) 212 (82.2)

7.667 49.285

0.005 <0.001

Feeling when you remember you were circumcised, n (%)

*Among the 258 female teachers who participated in this study, 109 (42.2%) had undergone FGM/C.

had undergone FGM/C (OR 12.688; 95% CI 2.791 - 57.673; p=0.001).

Table 3. Experience of teachers whose daughters had undergone FGM/C* Male (N=22) n (%)

Female (N=39) n (%)

χ2

p-value

Home

9 (40.9)

12 (30.8)

0.429

0.512

Hospital

9 (40.9)

13 (33.3)

0.727

0.393

Traditional herbalist at home

4 (18.2)

11 (28.2)

3.267

0.070

Others

0 (0.0)

3 (7.7)

3.000

0.083

Religion

14 (63.6)

21 (53.8)

1.400

0.236

Cultural

5 (22.7)

10 (25.6)

1.667

0.196

Pressure from others

0 (0.0)

1 (2.6)

1.000

0.317

Because I was circumcised

1 (4.6)

5 (12.9)

2.667

0.102

Other girls were circumcised too

2 (9.1)

2 (5.1)

0.000

1.000

Painful

11 (50.0)

20 (51.3)

2.613

0.105

Lost a lot of blood

0 (0.0)

3 (7.7)

3.000

0.083

No problem

10 (45.4)

15 (38.4)

1.000

0.317

Cannot remember

1 (4.6)

1 (2.6)

0.000

1.000

Happy/satisfied

13 (59.1)

22 (56.4)

2.314

0.128

Proud of it

2 (9.1)

3 (7.7)

0.200

0.654

Regretted it

0 (0.0)

2 (5.1)

2.000

0.157

Hated it

2 (9.1)

6 (15.4)

2.000

0.157

Do not know

5 (22.7)

6 (15.4)

0.000

1.000

Myself

9 (40.9)

9 (23.1)

0.000

1.000

Husband

1 (4.5)

5 (12.9)

2.667

0.102

My mother

6 (27.2)

4 (10.3)

0.400

0.527

Mother-in-law

1 (4.6)

16 (41.1)

13.235

<0.001

Relatives/friends

1 (4.6)

1 (2.6)

0.000

1.000

Others

4 (18.2)

4 (10.3)

0.00

1.000

Yes

18 (81.8)

31 (79.5)

3.449

0.063

No

4 (18.2)

8 (20.5)

1.333

0.248

Variables Place where FGM/C was performed

Reason for FGM/C

Daughter’s experience

Parent’s feeling on remembering daughter underwent FGM/C

Initiator of daughter’s circumcision

Did you agree when your daughter was circumcised?

*Of the 113 male teachers, 50 (44.2%) had daughters and 22 (44.0%) of these had circumcised daughters; of the 258 female teachers, 159 (61.6%) had daughters and 39 (24.5%) had circumcised daughters.

23 males (20.4%) supported continuation of FGM/C, 71 males (62.8%) and 195 females (75.6%) agreed with government efforts to eradicate FGM/C, and 28 males (24.8%) and 51 females (19.8%) indicated that they would circumcise their future daughters. The male teachers suggested partnership with religious leaders (n=27, 23.9%), while female teachers suggested education (n=54, 21.0%) as the top priority interventions to stop FGM/C. Table 5 shows that the predictors of the likelihood of participants (whole study popu­ lation) supporting discontinuation of FGM/C

were having heard about FGM/C before (OR 0.315; 95% CI 0.133 - 0.747; p=0.009), having a daughter who had undergone FGM/C (OR 3.887; 95% CI 1.852 - 8.159; p=0.001) and awareness of government policy on FGM/C (OR 0.307; 95% CI 0.148 0.636; p=0.002). Among female teachers, the predictors were having heard about FGM/C (OR 0.230; 95% CI 0.087 - 0.609; p=0.003) and awareness of government policy on FGM/C (OR 0.204; 95% CI 0.087 0.476; p=0.001). The predic­ tor among male teachers was having a daughter who

Discussion

In this study, about a third of the teachers had been made aware of and taught about the implications of FGM/C while they were at school, but the majority had never educated their students, although they held the opinion that its awareness and implications should be taught in schools.

The prevalence rate of FGM/C among female teachers was 42.3%; a quarter of the female and about half of male teachers had circumcised their daughters, mainly for religious reasons. The male teachers were the major initiators of FGM/C for their daughters, while among the female teachers the mothers-in-law were responsible. Most teachers felt that education and legislation were possible interventions towards eradi­ cation of FGM/C. Strengths of the study are the evalua­ tion of teachers in both rural and urban areas, and relating their knowledge to their views, attitude and practice.

Limitations include the fact that mutilation of female teachers was selfreported without physical verification, and the challenge of recall of their age at the time of mutilation.

Knowledge about FGM/C among partici­pants in this study was higher than the national averages of 68% (women) and 62% (men).[5] The reported prevalence of FGM/C among female teachers in this study was higher than the national prevalence rate of 25% among women in Nigeria,[5] but lower than the average rate of 33% for women in West Africa. [6] This may be because participants were educated, which offers the opportunity for social networks and a higher level of knowledge about FGM/C and may have contributed to their disclosure. The mean age at which they had suffered genital mutilation reported by women in this study was similar to the report of <5 years in most countries[7] and 83.2% of FGM/C before age 5 in the study locality. [5] Traditional circumcisers performed the high­ est proportion of FGM/C among female teachers in this study, similar to reports from most countries where it is performed,[7] but lower than the national average of 80% involvement of traditional circumcisers in Nigeria.[5] Traditional circum­­cisers are usually lay men with little or no knowledge of human anatomy[8] who

SAJOG • December 2015, Vol. 21, No. 2

41

Table 4. Views of teachers about FGM/C and its eradication Male n (%)

Female n (%)

χ2

p-value

Yes

23 (20.4)

44 (17.0)

6.582

0.010

No

47 (41.6)

146 (56.6)

50.782

<0.001

I don’t know

43 (38.0)

68 (26.4)

5.631

0.017

Wickedness against women

46 (40.7)

140 (54.3)

47.505

<0.001

Old fashioned

42 (37.2)

77 (29.8)

10.294

0.001

Good for girls

18 (15.9)

25 (9.7)

1.140

0.285

Makes a girl a real woman

7 (6.2)

16 (6.2)

3.522

0.060

Yes

19 (16.8)

38 (14.7)

6.333

0.011

No

94 (83.2)

220 (85.3)

50.561

<0.001

Yes

65 (57.5)

175 (67.8)

50.417

<0.001

No

48 (42.5)

83 (32.2)

9.351

0.002

Yes

71 (62.8)

195 (75.6)

57.805

<0.001

No

42 (37.2)

63 (24.4)

4.200

0.040

Education

25 (22.1)

54 (21.0)

10.646

0.001

Appeal to parents

17 (15.1)

53 (20.5)

18.514

<0.001

Radio/TV announcements

18 (15.9)

50 (19.4)

15.059

<0.001

Law and punishment

25 (22.1)

40 (15.5)

3.462

0.062

Arrest parents who circumcise

1 (0.9)

8 (3.1)

5.444

0.019

Partner with religious leaders

27 (23.9)

53 (20.5)

8.450

0.003

Yes

28 (24.8)

51 (19.8)

6.696

0.009

No

85 (75.2)

207 (80.2)

50.973

<0.001

Both are good

24 (21.2)

32 (12.4)

1.143

0.285

Female circumcision good, male bad

1 (0.9)

3 (1.2)

1.000

0.317

Male good, female bad

65 (57.5)

185 (71.7)

57.600

<0.001

Both are bad and should be stopped

8 (7.1)

12 (4.6)

0.800

0.371

Do not know

15 (13.3)

26 (10.1)

2.951

0.085

Variables Should females be circumcised?

Participant description of FGM/C

Do you know any benefits of FGM/C?

Awareness of government effort to stop FGM/C

Do you agree with this government effort?

What are your suggestions to stop FGM/C?

If you have another daughter, will you circumcise her?

Compare male and female circumcision

also play a central role in the community, such as attending to childbirth.[2] Medicalisation of FGM/C refers to its practice by any category of healthcare provider, whether in a public or private clinic, at home or elsewhere.[9] Generally, FGM/Cs by health workers range from <1% to between 9% and 74%;[9] the 32.1% in this study was higher than national average of 12 - 13% in Nigeria,[5] while the World Health Organization (WHO) reported medicalisation in over 18% of cases.[2] Increasing trends in medicalisation have been documented by the WHO despite the ban on the act,[10] and this may make its eradication difficult.[1,9]

42

SAJOG • December 2015, Vol. 21, No. 2

The majority of the teachers wanted aware­ ness and implications of FGM/C to be taught in schools, similar to the United Nations Children’s Fund (UNICEF) recomm­­ endation to create opportunity for discussion locally and internationally about the act.[7] However, this was not a predictor of support for its discontinuation, perhaps reflecting the interplay between social, moral and legal norms on FGM/C for which the social may dominate, thereby blunting the expected influence.

Religious obligation was the indication for FGM/C in more than half of the teachers who circumcised their daughters,

unlike the National Demographic Health Survey 2013, which showed that religion was not a major indication in Nigeria.[5] This buttresses the debate around religion and FGM/C, as no religion requires it, but all religious groups practise it.[8] Many participants in this study viewed FGM/C as wickedness against women (40.7% of men and 54.3% of women), similar to its designation as violence against women by UNICEF. In this study, 80.2% of female teachers expressed the desire not to circumcise their future daughters, similar to 62% of women in a previous study in Nigeria.[7] This suggests increasing support among women regarding eradication of the act.

A major concern from this study is that male teachers whose daughters had undergone FGM/C were the major initiators and supporters of the act. This brings to the fore the dominant role of men in decision-making about the health matters of women and girls. This is prevalent in Africa and other maledominated cultures, and reportedly stems from deep-rooted inequality between the sexes.[2] This is important, since male teachers are central in addressing eradication of FGM/C. In addition, the role of mothers-in-law as the initiators and major supporters of FGM/C and its continuation corroborates an earlier report that older women are sometimes unwilling to give up the practice, and may be major propagators of the act.[11] The disparity in information, view, practice and belief among about 20% of the teachers expressing their resolve to circumcise their future daughters calls for a social movement within a broader social context to be strengthened by legislation,[1] education, partnership with religious leaders, parents and information on the mass media.

In Nigeria there is no legislation at national level except in a few states,[1] excluding the study locality. With 11% of girls and women with FGM/C living in Nigeria alone,[10] it is imperative to explore all possibilities to eradicate the act.

Although it has been documented that there was a reduction of 1% per year in FGM/C globally between 2005 and 2010,[6] this has been shown to be inadequate to achieve its eradication. Reports have also shown that FGM/C has continued despite strict legislation against it,[12] emphasising the need for other supportive interventions.

Table 5. Logistic regression predicting likelihood of participant agreeing that FGM/C should be stopped Variables

p-value

OR

95% CI

Gender

0.196

1.664

0.769 - 3.559

Heard about FGM/C

0.009

0.315

0.133 - 0.747

Correct knowledge of FGM/C

0.474

0.751

0.342 - 1.646

Was educated on FGM/C as student

0.080

1.935

0.925 - 4.047

Daughter has undergone FGM/C

0.001

3.887

1.852 - 8.159

Aware of government policy to stop FGM/C

0.002

0.307

0.148 - 0.636

Heard about FGM/C

0.003

0.230

0.087 - 0.609

Correct knowledge of FGM/C

0.138

0.499

0.199 - 1.249

Was educated on FGM/C as student

0.099

2.166

0.864 - 5.431

Has undergone FGM/C

0.182

0.436

0.129 - 1.477

Daughter has undergone FGM/C

0.127

2.111

0.808 - 5.518

Aware of government policy to stop FGM/C

0.001

0.204

0.087 - 0.476

Heard about FGM/C

0.724

0.661

0.066 - 6.587

Correct knowledge of FGM/C

0.259

3.050

0.440 - 21.153

Was educated on FGM/C as student

0.156

3.102

0.649 - 14.834

Daughter has undergone FGM/C

0.001

12.688

2.791 - 57.673

Aware of government policy to stop FGM/C

0.892

0.886

0.156 - 5.031

Whole study population

Female teachers only

Male teachers only

A practice guideline[13] in the UK has indi­ cated a vital role for teachers in eradication of FGM/C. It recommends a central role for teachers who are likely to be approached by girls under threat of FGM/C or their friends who may be aware of the threat. They may also recognise indicators such as absenteeism, a sudden

decline in performance and emotional changes in girls who are being threatened with FGM/C, and offer support and counselling. [13] Countries where FGM/C remains endemic could explore this oppor­tunity, although mutilation in early childhood (<5 years) in these countries may pose a major challenge.

In conclusion, this study shows that al­though secondary schoolteachers have a role in era­ dication of FGM/C, they are curr­ ently illequipped to perform this role. We recommend efforts to raise awareness about the dangers and human rights abuses of FGM/C among teachers, produce and circulate appropriate information materials, and use reorientation and moti­vation to encourage their effective­ ness as agents for FGM/C eradication.

1. UNICEF. Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change. New York: UNICEF, 2013. http://www.unicef.org/publications/ index_69875.html (accessed 10 October 2014).

2. WHO. Female Genital Mutilation. Fact sheet No. 241; updated February 2014. http://www.who.int/mediacentre/factsheets/ fs241/en/ (accessed 11 March 2015).

3. The Point: Gambia News For Freedom and Democracy.

Circumcisers from Kombo South Trained on FGM and Rights of Women and Children. 22 December 2010. www.fgcblogger (accessed 24 September 2012).

4. Araoye MO. Research Methodology with Statistics for Health and Social Sciences. Ilorin: Nathadex Press, 2003:115-121.

5. National Population Commission (Nigeria). Nigeria Demographic and Health Survey (2013). Abuja: NPC, 2014.

6. UNFPA. Projections of number of young girls ages 15-19 who will experience FGM/C from 2010-2030. UNFPA, 2013. http:// www.unfpa.org/public (accessed 20 May 2014).

7. UNICEF. Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change. New York: UNICEF, 2013. http://data.unicef.org/child-protection/ fgmc (accessed 20 December 2013).

8. Althaus FA. Female circumcision: Rite of passage or violation of rights? Int Fam Plann Perspective 1997;23(3):130-133.

9. World Health Organization. Global strategy to stop healthcare providers from performing female genital mutilation.

UNFPA, UNHCR, UNICEF, UNIFEM, WHO, FIGO, ICN, IOM, MWIA, WCPT, WMA. Geneva: WHO; 2010. http:// www.int/reproductivehealth/publications/fgm/rhr_10_9/en/ index.html (accessed 12 August 2014).

10. World Health Organization. An Update on WHO’s Work on Female Genital Mutilation (FGM): Progress Report. Geneva: WHO, 2011. http://www.who.int/en/ (accessed 10 August 2014).

11. UNFPA. A Holistic Approach to the Abandonment of Female Genital Mutilation/ Cutting. New York: UNFPA, 2007. http:// www.unfpa.org/public/ (accessed 1 February 2013).

12. Tanzania: How to eradicate FGM. www.fgcblogger (accessed 24 September 2012).

13. Multi-Agency Practice Guideline. Female Genital Mutilation. www.gov.uk (accessed 25 January 2015).

SAJOG • December 2015, Vol. 21, No. 2

43

CASE REPORT

Limitations of middle cerebral artery peak systolic velocity in the detection of severe anaemia: A case report L Geerts,1 MB ChB, MRCOG, BSc Hons (Human Genetics); J N Rossouw,1 MB ChB, MMed (O&G), FCOG (SA); A C van Wyk,2,3 MMed (Anat Path); C A Wright,2,4 FRCPath, PhD Department of Obstetrics and Gynaecology, Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa 2 Division of Anatomical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa 3 National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa 4 National Health Laboratory Service, Port Elizabeth, South Africa 1

Corresponding author: L Geerts (lgeerts@sun.ac.za)

Doppler examination of the fetal middle cerebral artery (MCA) is considered highly reliable in detecting severe fetal anaemia. We present a case of a mother with severe pre-eclampsia at 32 weeks’ gestation and non-immune fetal hydrops without obvious cause. Since the MCA peak systolic velocity (PSV) was normal, severe anaemia was not considered as a possible cause, but after delivery the infant was found to be severely anaemic and died. Histological examination of the placenta revealed multiple extensive haemorrhages (subchorionic, intraparenchymal and intravillous), and autopsy indicated that the most likely cause of death was severe anaemia and hypoxia due to multiple and extensive placental haemorrhages, which had developed over the course of several days. We postulate that the MCA PSV failed to indicate severe anaemia because of the combination of subacute anaemia with severe profound hypoxia due to placental insufficiency.

S Afr J Obstet Gynaecol 2015;21(2):44-45. DOI:10.7196.SAJOG.898

Doppler assessment of the peak systolic flow velocity (PSV) of the middle cerebral artery (MCA) is highly reproducible in trained hands and very effective in detecting severe anaemia of all causes.[1] In cases of fetal hydrops it guides management in terms of fetal treatment, expectant care or urgent delivery. We present a case of nonimmune hydrops fetalis (NIHF) where the MCA PSV was normal despite postnatal evidence of severe anaemia.

Case report

A 19-year-old healthy Rh-positive primigravida initiated antenatal care at 9 weeks with negative tests for syphilis and HIV. She had a normal ultrasound scan at 20 weeks and five uncomplicated visits before presenting at 28 weeks with generalised oedema, decreased fetal movements and pre-eclampsia. Ultrasound examination revealed a single male fetus with anasarca, bilateral hydrothorax, a pericardial effusion, cardiomegaly, severe ascites, polyhydramnios and decreased fetal movements. There was absent end-diastolic flow in the umbilical artery, a high pulsatility index (PI) (1.12) in the ductus venosus (positive a-wave) and a low MCA-PI (1.21). In view of the normal MCA PSV (40 cm/s), anaemia was considered unlikely.

In view of the early gestation, severity of the hydrops, absence of an overt treatable cause and lack of an intensive care bed at the time, the mother agreed to defer active intervention while awaiting special investigations (infectious work-up negative), betamethasone administration and maternal stabilisation. Several days later, she experienced a small antepartum haemorrhage with irregular contractions, and after an unmonitored labour a 1 820 g, very pale and oedematous male infant was delivered vaginally with Apgar scores of 1/1/1. Extensive resuscitation was withheld, and the infant died. Skin biopsy by quantitative fluorescent polymerase chain reaction was normal (for chromosomes 13, 18, 21, X and Y).

Autopsy revealed no additional macroscopic abnormalities. Extensive extramedullary haematopoiesis was seen in the liver, and fetal vessels contained moderately increased nucleated red blood cells (NRBCs), 44

SAJOG • December 2015, Vol. 21, No. 2

Fig. 1. Laminated intraparenchymal placental thrombus (haema­ toxylin and eosin stain, original magnification ×20). without intranuclear inclusions typical for parvovirus infection.

Neuropathology showed a grade 2 germinal matrix and subarachnoidal haemorrhage, both small and regarded as manifestations of terminal hypoxia rather than the cause of death. Starry-sky appearance of the thymus with loss of corticomedullary differentiation and pseudoacinar formation in the adrenal cortex suggested a period of intrauterine stress of at least a few days, consistent with hypoxia. The placenta was enlarged (460 g v. expected 229 - 357 g) and showed a 15% retroplacental haemorrhage, one large (45 mm) subchorionic and multiple small intraparenchymal haemorrhages with delayed villous maturation, marked diffuse villous oedema, multifocal intravillous haemorrhages containing NRBCs, and laminated intraparenchymal thrombi (Fig. 1).

Discussion

This report describes a case of fetomaternal hydrops due to multiple and extensive placental haemorrhages and questions why the MCA PSV did

not suggest severe anaemia as the underlying cause. This is of particular concern in view of the fact that fetal anaemia is one of the treatable causes of NIHF and associated with the best prognosis if actively managed, either by urgent delivery or intrauterine transfusion. We postulate that the MCA PSV was not raised because of the combination of hypoxia due to placental insufficiency and possibly episodes of hypovolaemia, superimposed on the effects of (sub)acute anaemia due to fetal blood loss.

Fetal hydrops has many causes and carries a very high mortality rate.

Approximately 10% of cases are caused by haematological disorders, with cardiac failure resulting from loss of oxygen-carrying capacity from either reduced or abnormal production or excessive loss of erythrocytes.

Large fetomaternal haemorrhages (FMHs) are rare (~1%) and can cause perinatal death and severe acute and long-term morbidity, but most occur unexpectedly before labour, and they are often chronic or intermittent. [2] Classic presenting symptoms include reduced fetal movements. Typical postmortem findings include severe pallor, hydrops, collapsed heart and vessels and histopathological features of chronic stress.[3] Typical placental findings are retroplacental haemorrhages and (laminated) intervillous thrombi with NRBCs in fetal organs and intervillous spaces.[4] Laminated intervillous thrombi (linear streaks of fibrin with degenerating red and white blood cells in between) are thought to be caused by leakage of fetal blood into the intervillous spaces via defects in the trophoblast, usually occurring at varying times and leading to clotting of mixed fetal-maternal blood as a mechanism to limit fetal blood loss and fetomaternal bleeding.[4] The utility of MCA PSV screening for fetal anaemia is based on the compensatory circulatory responses (aimed at maintaining tissue oxygenation) seen with non-acute progressive anaemia in fetuses with normal cardiovascular physiology and normal placental respiratory function. Initially decreased viscosity after haemodilution improves venous return and cardiac preload, thereby increasing cardiac output. With worsening anaemia, the resulting hypoxaemia initially causes redistribution of blood flow to the brain and coronary arteries, but ultimately tissue hypoxia leads to metabolic acidosis and myocardial dysfunction, manifesting as right atrial enlargement and placentomegaly due to congestion, and later overt fetal hydrops and demise due to high-output cardiac failure.

The hyperdynamic fetal circulation with subacute or moderate chronic anaemia has been mainly researched (and is now routinely used) in pregnancies with red cell isoimmunisation. In well-grown fetuses, the MCA PSV increase is related to the haemoglobin but not the partial pressure of oxygen (pO2), suggesting that this reflects decreased blood viscosity and increased venous return rather than an active fetal compensatory mechanism by pO2-related chemoreceptor stimulation (to increase cardiac contractility and cause vasodilatation).[1,5,6] Reports on MCA PSV in anaemia from other causes (parvovirus, haemoglobinopathies, inter-twin transfusion, haemorrhage, etc.) and in hydropic fetuses are limited, but a few authors have found a similarly high sensitivity of MCA velocity for severe anaemia in fetal hydrops, both immune and non-immune.[1,7] With (sub)acute severe fetal blood loss, however, the fetus may not adapt in a similar way, and while some cases of increased MCA PSV with acute fetal haemorrhage have been reported, no studies have systematically assessed the diagnostic accuracy of MCA PSV in those circumstances. Among 15 women with FMH, Cosmi et al.[7] found MCA PSV of value in 9 women with chronic abruption, but in 5 with acute abruption the result was false-negative.

Changes in MCA blood flow are also seen with fetal growth restriction (FGR) with placental insufficiency. The associated chronic fetal hypoxaemia results in redistribution of blood flow in favour of vital organs including the brain, initially characterised by decreasing MCA impedance due to increasing vasodilatation with worsening hypoxaemia.[8] MCA velocity changes in FGR have been less extensively studied, but Vyas et al.[8] showed

increasing MCA mean velocity with worsening fetal hypoxaemia and acidaemia in 81 FGR fetuses, possibly related to decreasing cerebral and increasing placental vascular resistance with redistribution of cardiac output (in favour of the left ventricle). Although FGR fetuses initially increase their red blood cell mass to improve oxygenation, they often become progressively anaemic as a result of nutritional problems, insufficient bone marrow response, microvascular consumption or dyserythropoiesis. Since the degree of anaemia could be an indicator of the severity of placental insufficiency, MCA PSV screening in FGR fetuses has been of interest. In contrast to alloimmunised fetuses, Hanif et al.[6] found no correlation bet­ ween MCA PSV and fetal haemoglobin in FGR but confirmed a correlation between MCA PSV and partial carbon dioxide pressure (pCO2) and pO2.

Makh et al.[9] found MCA PSV sensitivity for severe anaemia unacceptably low in 97 FGR fetuses; this was possibly explained by the attenuating effect of the decreased cerebral vascular resistance on the PSV elevation in combination with reduced forward cardiac function due to the increased afterload and intrinsic hypoxia-related cardiac dysfunction. MCA PSV is therefore clearly affected by different, competing mechanisms. The coexistence of significant hypoxaemia and anaemia may affect blood flow patterns in an unpredictable way as cardiovascular dynamics change in FGR and oxygen delivery to the tissues is further decreased.

This patient presented with reduced fetal movements of several days’ duration and the ultrasound features were typical of severe anaemia (fetomaternal hydrops with dominant ascites). Examination of the infant and placenta concurred with a relatively protracted course (severe pallor, changes in the adrenal gland and thymus, intervillous laminated thrombi, subchorionic, retroplacental and intraparenchymal haemorrhages). The MCA PSV would have been expected to reliably exclude severe anaemia in this non-acute setting. However, the placental pathology was of a nature that would have caused both severe chronic fetal hypoxaemia and (chronic and/ or subacute) anaemia, and the Doppler results indeed indicated very poor placental perfusion with significant redistribution and cardiac compromise.

The degree of fetal hypoxaemia in this case would have been disproportionate to the degree of anaemia seen in alloimmunised pregnancies, and the severe anaemia (resulting both from placental deprivation and recurrent blood loss) would have compromised the chronic poor fetal tissue oxygenation even further. This combination probably contributed to significant impairment of forward cardiac function, which may have prevented the fetus from increasing the MCA PSV in response to severe anaemia.

Conclusion

Clinicians should be aware of the limitation of MCA PSV screening for anaemia in cases where severe placental insufficiency is co­existent, since a potentially treatable cause of hydrops may be missed and a more active approach to management (either in utero intervention or urgent delivery) could be appropriate.

1. Schenone MH, Mari G. The MCA Doppler and its role in the evaluation of fetal anemia and fetal growth restriction. Clin Perinatol 2011;38(1):83-102. [http://dx.doi.org/10.1016/j.clp.2010.12.003] 2. Giacoia GP. Severe fetomaternal haemorrhage: A review. Obstet Gynecol Surv 1997;52(6):372-380.

3. Biankin SA, Arbuckle SM, Graf NS. Autopsy findings in a series of five cases of fetomaternal haemorrhages. Pathology 2003;35(4):319-324.

4. Devi B, Jennison RF, Langley FA. Significance of placental pathology in transplacental haemorrhage.

J Clin Pathol 1968;21(3):322-331.

5. Picklesimer AH, Oepkes D, Moise KJ Jr, et al. Determinants of the middle cerebral artery peak systolic velocity in the human fetus. Am J Obstet Gynecol 2007;197(5):526.e1-e4. [http://dx.doi. org/10.1016/j.ajog.2007.04.002] 6. Hanif F, Drennan K, Mari G. Variables that affect the middle cerebral artery peak systolic velocity in fetuses with anemia and intrauterine growth restriction. Am J Perinatol 2007;24(8):501-505. [http://dx.doi.org/10.1055/s-2007-986683] 7. Cosmi E, Rampon M, Saccardi C, Zanardo V, Litta P. Middle cerebral artery peak systolic velocity in the diagnosis of fetomaternal hemorrhage. Int J Gynaecol Obstet 2012;117(2):128-130. [http:// dx.doi.org/10.1016/j.ijgo.2011.12.016] 8. Vyas S, Nicolaides KH, Bower S, Campbell S. Middle cerebral artery flow velocity waveforms in fetal hypoxaemia. Br J Obstet Gynaecol 1990;97(9):797-803.

9. Makh DS, Harman CR, Baschat AA. Is Doppler prediction of anemia effective in the growthrestricted fetus? Ultrasound Obstet Gynecol 2003;22(5):489-492. [http://dx.doi.org/10.1002/uog.206]

SAJOG • December 2015, Vol. 21, No. 2

45

CASE REPORT

Uterine artery embolisation in the management of recurrent vaginal haematoma N S Chauhan,1 MS; S B Dhodhapkar,1 MD; M Daniel,1 MD, DGO; M C Arokiaraj,2 MD, DM; R C Chauhan,3 MD Department of Obstetrics and Gynecology, Pondicherry Institute of Medical Sciences, Puducherry, India Department of Cardiology, Pondicherry Institute of Medical Sciences, Puducherry, India 3 Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India 1 2

Corresponding author: N Singh Chauhan (drneelimasingh30@gmail.com)

We report a rare case of primary postpartum haemorrhage due to a traumatic cause following spontaneous vaginal delivery in which surgical intervention failed. It was successfully treated by transcatheter embolisation of the uterine artery. This technique, although well known, is still underused in such conditions.

S Afr J Obstet Gynaecol 2015;21(2):46-47. DOI:10.7196.SAJOG.906

Postpartum haemorrhage (PPH) is commonly defined as blood loss of 500 mL or more within 24 hours of birth; severe PPH is blood loss of 1 000 mL or more within the same time. PPH affects approximately 2% of all women following delivery, resulting in nearly one-quarter of all maternal deaths globally, and it is the leading cause of maternal mortality in most low-income countries. PPH is a significant contributor to severe maternal morbidity and long-term disability.[1-3] Uterine atony is the most common cause of PPH (70%), but genital tract trauma (i.e. vaginal or cervical lacerations), uterine rupture, retained placental tissue or maternal coagulation disorders may also result in PPH.[4] Coagulation disorders especially contribute to maternal morbidity rather than mortality.

When medical measures fail to control postpartum bleeding, bilateral uterine or hypogastric artery ligation may be attempted.

However, owing to extensive collateral circulation in the pelvis, the success rate of bilateral hypogastric artery ligation ranges from 40% to 100%[5] and uterine artery ligation has been shown to have a success rate of 92%.[6] Both these techniques aim to leave the uterus intact and preserve fertility. In 1979, transcatheter embolisation to control postpartum bleeding was initially described by Brown et al.[7] Since then, several authors have reported the usefulness of this technique as first-line treatment for atonic PPH in patients who are refractory to conservative treatment,[8,9] but its use in puerperal haematomas in which surgical intervention fails to control bleeding is still under-reported. We present this case report to highlight the use of transcatheter uterine artery embolisation in cases of postpartum haemorrhage due to vaginal haematoma that did not respond to surgical intervention.

Case report

A 28-year-old woman, G2P1L1, was admitted in active labour at 39 weeks’ gestation. Four hours later, she delivered a live baby weighing 3 250 g by spontaneous vaginal delivery with seconddegree laceration. Oxytocin 10 U intramuscularly was given as a bolus followed by an infusion of 10 U in 500 mL 0.9% saline over 4 hours. The delivery was uneventful and blood loss was estimated at 300 mL.

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The patient was initially stable with a blood pressure of 120/80 mmHg, pulse rate of 90 bpm and respiratory rate of 18/ min. Two hours later she complained of excessive vaginal pain.

Examination showed a blood pressure of 110/70 mmHg, a pulse rate of 100 bpm and a respiratory rate of 22/min. The uterus was well retracted, but vaginal examination revealed an 8 × 6 cm haematoma in the left lateral vaginal wall that was separate from the stitch line.

The patient was moved to theatre and intravenous sedation was given. The haematoma was explored, perineal stitches were removed and about 500 mL of blood clots were removed. The vagina was closed with deep continuous interlocking sutures. After complete haemostasis was achieved, the cervix and vagina were explored and found to be normal. The patient was catheterised and adminstration of oxytocin 40 U in 500 mL 0.9% saline was started, along with other uterotonics. After assessment of the patient’s condition, two units of blood were transfused and she was monitored hourly.

However, 6 hours later, the patient again experienced the same symptoms with accompanying hypotension. On examination, she was found to be pale with a blood pressure of 100/60 mmHg, a pulse rate of 108 bpm and a respiratory rate of 24/min. Abdominal examination showed the uterus to be well retracted, but there was a left ischiorectal fossa swelling. Vaginal examination again revealed a 12 × 12 cm haematoma in the left lateral vaginal wall, which was about 3 cm short of the left fornix. The anterior and other vaginal walls were free. On rectal examination, the mass was palpable in the rectovaginal space with the rectal mucosa free. After informed consent, the patient was transferred to the operating theatre for exploration and evacuation under general anaesthesia.

During exploration about 1 000 mL of blood clots were removed and resuturing was done. All bleeding points were identified and ligated. Dead space was obliterated with deep figure-of-eight sutures.

Vaginal packing was done after complete haemostasis was secured.

During surgery, the patient was transfused two units of blood and three units of fresh-frozen plasma (FFP) while the oxytocin infusion was continued. At the end of the operation, the patient was haemodynamically stable. In the recovery room after 1 hour her blood pressure dropped to 80/40 mmHg. Her heart rate was 110 bpm and oxygen saturation 99%. Examination revealed active bleeding from the vagina with a well-retracted uterus. A series of

haematological investigations were done, showing a haemoglobin concen­ tration of 7.2 g/dL and a platelet count of 78 × 109/L. Coagulation studies showed an international normalised ratio of 1.2 and activated partial thrombo­ plastin time (APTT) of 30.1 seconds (normal 26.2 seconds). After much discussion, embolisation of the uterine artery was planned.

The patient was transferred to the cardiac catheterisation laboratory. An injection of 10 mL xylocaine (2%) was infiltrated and the left femoral artery was cannulated with a 6F sheath. Angiogram using ioxol contrast showed active bleeding from the left uterine artery, and no other bleeding point (Fig. 1).

Embolisation was performed successfully with 500 µm polyvinyl alcohol (PVA) as shown in Fig. 2. A repeat angiogram showed no further bleeding (Fig. 3). The patient was transferred back to the intensive care unit and further blood products were transfused as required according to laboratory results.

Thirty-six hours after haematoma forma­ tion, the haematological para­ meters ret­ urned to acceptable limits (haemoglobin 9.6 g/dL, plate­ lets 92 × 109/L, INR 1.2, APTT 33 seconds). Chest X-ray showed no sign of acute lung injury. A total of six units of packed red cells and five units of FFP were transfused. The patient’s condition improved and she was discharged from hospital 8 days after her operation. At follow-up 4 weeks later, she remained well with no further complaints.

Discussion

Approximately 30% (in some countries over 50%) of direct maternal deaths world­ wide are due to haemorrhage, mostly in the postpartum period.[1] In India, PPH is currently the most common direct cause of maternal death.

During pregnancy the uterus, vagina, and vulva have rich vascular supplies that are at risk of trauma during the birth process; trauma to these highly vascular areas may result in formation of a haematoma. Puerperal haematomas occur in 1:300 - 1:1 500 deliveries and, rarely, are a life-threatening complication of childbirth.[10,11] Vaginal/paravaginal haema­ tomas result from injuries to branches of the uterine artery, mainly the descending branch.[12] These haematomas are usually

Fig. 1. Active bleeding from left uterine artery. associated with forceps delivery, but may also occur following a spontaneous delivery.

In contrast to the vulva, vessels in the vagina are surrounded by soft tissue and do not lie in the superficial fascia. Trauma to these vessels can therefore lead to a large accumulation of blood in the paravaginal space or ischiorectal fossa, resulting in considerable delay in diagnosis.

Transcatheter arterial embolisation has been reported as a method of haemorr­ hage control since the 1960s, and is widely used in the control of pelvic haemorrhage due to malignancy, trauma and radiation. This technique has recently been used successfully in the control of PPH.[13] Advantages of this procedure are easy identification of the bleeding site, preservation of the uterus and fertility, while rebleeding from collateral vessels is rare. Complications occur in only 8.7% of cases, the most common being lowgrade fever, and rarer ones including pelvic infection and groin haematoma.[13]

Conclusion

Our case shows that selective arterial embolisation of the uterine arteries is an effective method of treating puerperal haematoma refractory to conventional firstline therapy, and an effective alternative way of achieving haemostasis with minimal morbidity.

1. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, van Look PF. WHO analysis of causes of maternal death: A systematic review. Lancet 2006;367(9516):1066-1074. [http://dx.doi. org/10.1016/S0140-6736(06)68397-9] 2. Campbell OM, Graham WJ, Lancet Maternal Survival Series Steering Group. Strategies for reducing maternal mortality:

Fig. 2. Embolisation being performed.

Fig. 3. Angiogram showing no further bleeding.

Getting on with what works. Lancet 2006;368(9543):12841299. [http://dx.doi.org/10.1016/S0140-6736(06)69381-1] 3. Souza JP, Gülmezoglu AM, Carroli G, et al. The World Health Organization Multicountry Survey on maternal and newborn health: Study protocol. BMC Health Services Research 2011;11:286. [http://dx.doi.org/10.1186/1472-6963-11-286] 4. World Health Organization, Department of Reproductive Health and Research. Managing Complications in Pregnancy and Child­birth: A Guide for Midwives and Doctors. Geneva: WHO, 2000. http://www.who.int/reproductivehealth/publi­ cations/maternal_perinatal_health/9241545879/en/index. html (accessed 26 June 2014).

5. Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet 1985;160(3):250-253.

6. Abd Rabbo SA. Stepwise uterine devascularisation: A novel approach technique for management of uncontrollable postpartum haemorrhage with preservation of the uterus.

Am J Obstet Gynecol 1994;171(3):694-700.

7. Brown BJ, Heaston DK, Poulson AM, et al. Uncontrollable postpartum bleeding: A new approach to hemostasis through angiographic embolization. Obstet Gynecol 1979;54(3):361365.

8. Gonsalves M, Belli A. The role of interventional radiology in obstetric hemorrhage. Cardiovasc Intervent Radiol 2010;33(5):887895. [http://dx.doi.org/10.1007/s00270-010-9864-4] 9. Lee JS, Shepherd SM. Endovascular treatment of postpartum hemorrhage. Clin Obstet Gynecol 2010;53(1):209-218. [http://dx.doi.org/10.1097/GRF.0b013e3181ce09f5] 10. Zahn CM, Yeomans ER. Postpartum hemorrhage: Placenta accreta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol 1990;33(3):422-431.

11. Villella J, Garry D, Levine G, et al. Postpartum angiographic embolization for vulvovaginal hematoma: A report of two cases. J Reprod Med 2001;46(1):65-67.

12. Ridgway LE. Puerperal emergency. Vaginal and vulvar hematomas. Obstet Gynecol Clin North Am 1995;22(2):275-282.

13. Vedantham S, Goddwin SC, McLucas B, Mohr G. Uterine artery embolization: An underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997;176(4):938948. [http://dx.doi.org/10.1016/S0002-9378(97)70624-0]

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47

CASE REPORT

Prolonged postpartum urinary retention: A case report and review of the literature A Yarci Gursoy,1 MD; M Kiseli,1 MD; S Tangal,2 MD; G S Caglar,1 MD; A H Haliloglu,2 MD; S D Cengiz,1 MD 1 2

Department of Obstetrics and Gynecology, Faculty of Medicine, Ufuk University, Konya Yolu, Balgat, Ankara, Turkey Department of Urology, Faculty of Medicine, Ufuk University, Konya Yolu, Balgat, Ankara, Turkey

Corresponding author: A Yarci Gursoy (asliyarci@gmail.com)

Postpartum urinary retention (PUR), which is defined as difficulty in emptying the bladder completely after delivery, may be clinically pronounced or silent. The incidence differs according to the definition. Although many risk factors for this disturbance are identified in the literature, every patient at risk does not necessarily present with PUR. There is no consensus in the literature regarding management.

S Afr J Obstet Gynaecol 2015;21(2):48-49. DOI:10.7196.SAJOG.844

Postpartum urinary retention (PUR) is defined as inability to empty the bladder completely after delivery.[1] The detailed overt and covert classification by Yip et al.[2] has been widely used.

Overt urinary retention is defined as the inability to void spontaneously within 6 hours of delivery, and covert urinary retention is defined as a post-void residual bladder volume of ≥150 mL after spontaneous micturition. The incidence of PUR ranges between 0.05% and 37% as a result of variable definitions based upon different parameters.[3] There are only a few reports describing the prolonged form with an incidence of 0.05 - 0.06%,[4,5] described as clinical presentation lasting >7 days.[4] We report a case of prolonged PUR with long-term sequelae and review the literature.

Case report

A 28-year-old primipara who had given birth to a term 3 350 g infant in a maternity hospital was admitted to our outpatient clinic on day 4 post partum, complaining of abdominal pain, urinary incontinence and inability to void adequately. Her history revealed that her first stage of labour had lasted about 6 hours and the second stage only half an hour. Neither vacuum nor forceps application was needed during delivery, and the only intervention was mediolateral episiotomy.

At admission, gynaecological examination revealed that the episio­tomy scar was intact and there was no sign of periurethral or clitoral laceration or infection. Physical examination of the abdomen revealed a palpable and painful mass. Abdominal ultrasonography showed a very large (20 × 18 × 15 cm) distended bladder and right urethrohydronephrosis. The results of laboratory blood tests were as follows: creatinine 1.69 mg/dL, blood urea nitrogen 28.73 mg/ dL, haemoglobin (Hb) 7.9 g/dL, and white blood cells (WBCs) 10.3 × 10³/µL. Urine analysis revealed the following: protein 100 mg/ dL, leucocytes 75/µL, 7 WBCs/high-power field (HPF), and 8 red blood cells /HPF. Culture of the urine was negative for any microorganisms. The patient was catheterised immediately with a 16F nelaton catheter and 3 000 mL clear urine was drained. Her pain was instantly relieved.

The urinary catheter was removed 24 hours later, but the patient was unable to void spontaneously. After consultation with the

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urology and nephrology departments, she was catheterised for a second time for 10 days. Meanwhile, with appropriate hydration, renal function tests returned to the normal range within 24 hours.

Ten days later, attempts at spontaneous micturition failed for the second time, and the patient was catheterised again. Urodynamic tests and pelvic magnetic resonance imaging (MRI) were scheduled and clean intermittent self-catheterisation (ISC) was suggested as the next step. MRI excluded possible neurological problems such as spina bifida. Urodynamic tests revealed that bladder capacity was 650 mL without any urge for micturition and the maximum voiding phase detrussor pressure was 44 cm H2O. Uroflowmetry performed 10 days after removal of the catheter showed a maximum flow rate (Qmax) of 7 mL/s, a mean flow rate (MFR) of 5 mL/s, urine volume of 150 mL and residual volume of >100 mL. Renal ultrasonographic findings returned to normal within 2 weeks. The patient was followed up by ISC (after spontaneous voiding four times daily) and uroflowmetry intermittently. When the residual volume was less than 100 mL, ISC was stopped (about the second month post partum). At the fourth month post partum, the patient still had some voiding dysfunction (Qmax 15 mL/s, MFR 9 mL/s, post-void residual bladder volume <50 mL at uroflowmetry).

Discussion

Despite incontinence related to pregnancy or labour having been widely researched, mechanisms of disturbance resulting in PUR have not been fully explained. The reasons why this condition does not occur in all patients with predisposing risk factors have yet to be elucidated.

Changes during pregnancy, such as detrussor muscle hyper­ trophy, perineal or pudendal nerve damage during delivery and mucosal oedema after vaginal delivery, may result in voiding dysfunction.[6-8] The most important predisposing risk factors for covert PUR are instrumental delivery and prolonged labour (>700 minutes).[9,10] Regarding PUR, tissue oedema and bladder neck obstruction,[11] detrussor muscle injury,[12] catheterisation during labour,[13] epidural anaesthesia[14] and postpartum morphine[15] have also been implicated. In our case, the only predisposing risk factor for PUR was nulliparity, which according to the literature is the least

significant of the accepted risk factors.[1] In this case, prepartum unknown dysfunction of bladder or accompanying factors other than those that have previously been proposed may therefore have contributed to PUR. There is no standardised management protocol for PUR, although this clinical condition may be seen in up to 37% of patients after vaginal delivery.[16] Since a single episode of bladder distention may result in irreversible damage of the detrusor muscle, follow-up of voiding function in postpartum women is crucial.[17] Early diagnosis of the urinary retention may prevent further distention and possibly longer periods of voiding dysfunction.

A suggested first treatment step, after excluding infection, consists of analgesics, mobilisation and adequate patient privacy.[18] The second step involves urinary catheterisation for a recommended 24 - 48 hours; this time may be prolonged if the voiding function does not return to normal. Suprapubic catheterisation is another option, but a more invasive method for a woman who has to take care of her newborn baby. Our patient was catheterised for a short period of time, but since she could not void adequately, indwelling catheterisation for 10 days was performed, which resulted in a better voiding performance although it was still not adequate.

Urodynamics and MRI were performed to exclude any comorbid aetiology. Uroflowmetry, which is less invasive and easy to perform, was used for follow-up of the patient. Previously, in the follow-up of 55 patients with PUR, 10.4% stress incontinence, 8.3% overactive bladder and 6.3% voiding difficulties were reported with totally normal urodynamic evaluation.[10] Duration of the voiding dysfunction varies widely in the literature. In one review, it was postulated that most patients recover within 2 weeks of the failed trial of voiding.[3] An investigation of overt PUR revealed that resolution time was 48 hours in 45.0% of patients and 72 hours in 29.4%, and 25.5% had required ISC for up to 45 days.[19] The duration of PUR was also no longer than 8 weeks in cases reported by Humburg et al.[4,18] Among the prognostic factors in cases with PUR, a high volume of urine at the time of diagnosis is of concern. Urinary volumes greater than 700 - 750 mL have been known to result in extended duration of catheterisation.[20] In our case, 3 000 mL of urine drained at the time of admission is the only remarkable risk factor for such prolonged clinical symptoms. This patient had a very long duration of overt PUR. Spontaneous micturition was not possible before 25 days, and ISC had to be continued until the third month post partum. As far as we

know, our patient has the longest duration of voiding dysfunction reported to date.

In conclusion, PUR remains a matter for debate, since the aetiology and management have not yet been clarified. Also there appears to be an urgent need for longitudinal prospective studies to establish its long-term consequences.

Acknowledgements. The authors thank the patient for her participation in this report and all personnel at the obstetrics and gynaecology and urology departments for their contributions. This study received no financial support.

1. Mulder F, Schoffelmeer M, Hakvoort R, et al. Risk factors for postpartum urinary retention: A systematic review and meta-analysis. BJOG 2012;119(12):1440-1446. [http://dx.doi.org/10.1111/ j.1471-0528.2012.03459.x] 2. Yip SK, Brieger G, Hin LY, Chung T. Urinary retention in the post-partum period: The relationship between obstetric factors and the post-partum post-void residual bladder volume. Acta Obstet Gynecol Scand 1997;76:667-672.

3. Lim JL. Post-partum voiding dysfunction and urinary retention. Aust N Z J Obstet Gynaecol 2010;50(6):502-505. [http://dx.doi.org/10.1111/j.1479-828X.2010.01237.x] 4. Humburg J, Troeger C, Holzgreve W, Hoesli I. Risk factors in prolonged postpartum urinary retention: An analysis of six cases. Arch Gynecol Obstet 2009;283(2):179-183. [http://dx.doi. org/10.1007/s00404-009-1320-9] 5. Groutz A, Gordon D, Wolman I, Jaffa A, Kupferminc MJ, Lessing JB. Persistent postpartum urinary retention in contemporary obstetric practice: Definition, prevalence and clinical implications. J Reprod Med 2011;46(1):44-48.

6. Bennets FA, Judd GE. Studies of the postpartum bladder. Am J Obstet Gynecol 1941;42:419.

7. Seski AG, Duprey WM. Postpartum intravesical photography. Obstet Gynaecol 1961;18:548-556.

8. Chalia C. Postpartum bladder dysfunction. Reviews in Gynecological and Perinatal Practice 2006;6:133-139.

9. Kekre AN, Vijayanand S, Dasgupta R, Kekre N. Postpartum urinary retention after vaginal delivery.

Int J Gynaecol Obstet 2011;112(2):112-115. [http://dx.doi.org/10.1016/j.ijgo.2010.08.014] 10. Groutz A, Levin I, Gold R, Pauzner D, Lessing JB, Gordon D. Protracted postpartum urinary retention: The importance of early diagnosis and timely intervention. Neurourol Urodyn 2010;30(1):83-86. [http://dx.doi.org/10.1002/nau.20926] 11. Yip SK, Sahota D, Pang MW, Chang A. Postpartum urinary retention. Acta Obstet Gynecol Scand 2004;83(10):881-891. [http://dx.doi.org/10.1080/j.0001-6349.2004.00460.x] 12. Mayo ME, Lloyd-Davies, RW, Shuttleworth KED, Tighe JR. The damaged human detrussor: Functional and electron microscopic changes in disease. Br J Urol 1973;45:116-125.

13. Evron S, Dimitrochenko V, Khazin V, et al. The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: A randomized trial. J Clin Anesth 2008;20(8):567-572. [http://dx.doi.org/10.1016/j.jclinane.2008.06.009] 14. Demaria F, Boquet B, Porcher R, et al. Post-voiding residual volume in 154 primiparae 3 days after vaginal delivery under epidural anesthesia. Eur J Obstet Gynecol Reprod Biol 2008;138(1):110-113. [http://dx.doi.org/10.1016/j.ejogrb.2007.12.003] 15. Liang CC, Chang SD, Wong SY, Chang YL, Cheng PJ. Effects of postoperative analgesia on postpartum urinary retention in women undergoing cesarean delivery. J Obstet Gynaecol Res 2010;36(5):991-955. [http://dx.doi.org/10.1111/j.1447-0756.2010.01252.x] 16. Ismail SI, Emery SJ. The prevalence of silent postpartum retention of urine in a heterogeneous cohort. J Obstet Gynaecol 2008;28(5):504-507. [http://dx.doi.org/10.1080/01443610802217884] 17. McKinnie V, Swift SE, Wang W, et al. The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. Am J Obstet Gynecol 2005;193(2):512-517. [http:// dx.doi.org/10.1016/j.ajog.2005.03.056] 18. Humburg J, Holzgreve W, Hoesli I. Prolonged postpartum urinary retention: The importance of asking the right questions at the right time. Gynecol Obstet Invest 2007;64(2):69-71. [http://dx.doi. org/10.1159/000099306] 19. Carley ME, Carley JM, Vasdev G, et al. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. Am J Obstet Gynecol 2002;187(2):430-433. [http://dx.doi. org/10.1067/mob.2002.123609] 20. Teo R, Punter J, Abrams K, Mayne C, Tincello D. Clinically overt postpartum urinary retention after vaginal delivery: A retrospective case-control study. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:521-524. [http://dx.doi.org/10.1007/s00192-006-0183-x]

SAJOG â&#x20AC;˘ December 2015, Vol. 21, No. 2

49

CASE REPORT

Spontaneous rupture of the spleen – a rare and potentially fatal surgical emergency in the second trimester: Report of a case M Heetun, MRCS; R Parameswaran, FRCS; K Jamil, FRCPath St Mary’s Hospital NHS Trust, Isle of Wight, UK Corresponding author: M Heetun (heetun@hotmail.com)

Spontaneous (non-traumatic) rupture of the normal spleen in pregnancy is a rare clinical event that can endanger the lives of both mother and baby. The aetiology of the condition is unknown, but it occurs most commonly in multiple pregnancies and in the third trimester. We present a case of a spontaneous splenic rupture of a normal spleen at 14 weeks’ gestation. Following prompt and aggressive surgical intervention, both mother and baby survived.

S Afr J Obstet Gynaecol 2015;21(2):50-51. DOI:10.7196.SAJOG.858

Case report

A 27-year-old woman at 14 weeks’ gestation and with one previous normal delivery presented to the emergency department with a history of sudden onset of severe generalised abdominal pain and collapse. She had no previous significant past medical history. An ultrasound scan 1 month previously had confirmed a viable intrauterine pregnancy.

Initial observations revealed hypo­ tension (77/40 mmHg) and tachycardia (112 bpm).

Physical examination rev­ealed diffuse abdom­ inal tenderness, re­bound and guarding. Bowel sounds were absent. Preliminary blood tests showed a haemoglobin concentration of 8.7 g/ dL and a normal coagulation profile.

An ultrasound scan performed in the emergency department further confirmed an intrauterine pregnancy, but revealed the presence of free fluid within the pelvis.

However, no obvious source for this free fluid could be identified. Aggressive fluid resuscitation was initiated, and the immediate decision was taken to proceed to a laparotomy with a combined surgical and obstetric team.

A large exploratory midline incision was performed. On entry into the abdominal cavity, approximately 3 litres of blood were evacuated. Active bleeding was seen at the splenic hilum, consistent with a splenic rupture. Large abdominal packs were left in the abdominal cavity to apply pressure to the spleen. On further inspection, the uterus, ovaries, fallopian tubes and other

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Fig. 1. Rupture of the splenic capsule was confirmed on histological examination of the spleeen. abdominal organs were intact. Splenec­ tomy was performed by the general surgeon and a non-suction drain left in the subphrenic space. The patient received a total of seven units of blood and five units of fresh-frozen plasma. She made a good recovery in the intensive care unit and auscultation revealed normal fetal heart sounds. She was subsequently transferred to a general surgical ward where her postoperative course was unremarkable and she was discharged 7 days later.

She received the postsplenectomy triple vaccine. Histological examination of the spleen confirmed rupture of the splenic capsule (Fig. 1). At the time of writing, her pregnancy had continued without complication.

Discussion

Spontaneous rupture of the spleen is rare in the absence of trauma and in the nonpregnant female. It is most commonly

caused by pre-existing splenic pathology such as a splenic artery aneurysm or an infective cause such as infectious mononucleosis, malaria and typhoid.

Orloff and Peskin[1] devised the following criteria for spontaneous splenic rupture in the context of a normal spleen: no history of trauma; the absence of systemic disease affecting the spleen; the absence of perisplenic adhesions to suggest trauma; and the presence of macroscopically and histologically normal splenic parenchyma, vasculature and capsule.

Spontaneous rupture of the normal spleen in pregnancy is also a rare clinical event, presenting as an acute surgical emergency with high maternal and fetal mortality. The diagnosis can be challenging as it can mimic other conditions such as ruptured ectopic preg­ nancy, placental abruption and uterine rupture. The most common clini­ cal presentation includes left-sided abdominal pain, which can often radiate to the patient’s shoulder. If left untreated, the pain becomes more generalised, leading to distension, guarding and rigidity.

Haemorrhagic shock then follows, with a reported maternal mortality rate of approximately 70%,[2] necessitating surgical intervention. In only a few specific cases, especially in Afro-Caribbean patients, splenic preservation is a possible option to avoid diminished immunological com­ petence. However, a low threshold for surgical intervention is still required in these patients.[3]

The aetiology of splenic rupture in pregnancy remains unknown.

It has been reported to be more common in multiple pregnancies and in the third trimester. Wang et al.[4] postulate a number of mechanisms for its cause. Minimal trauma, such as straining for a bowel movement or coughing and sneezing, acts as the inciting event through an increase in intra-abdominal pressure and its transmission to a number of abdominal organs including the spleen.

The increase in the circulating blood volume in pregnancy and the reduced space in the peritoneal cavity as a result of the expansion of the gravid uterus may make the spleen more fragile, and therefore more susceptible to rupture. They also suggest that circulating hormones such as oestrogen and progesterone cause structural changes to the spleen in pregnancy that possibly increase the risk of rupture, even after minor trauma.[4] We detailed a case of spontaneous rupture of a normal spleen in a pregnant woman at 14 weeks’ gestation. This led to haemorrhagic shock necessitating emergency surgery. Our case fitted the criteria stipulated by Orloff and Peskin[1] in respect of diagnosis of spontaneous rupture of a normal spleen. However, it was unique in that it occurred in the second trimester of pregnancy rather than the third, when the majority of cases occur. To the best of our knowledge, no cases of spontaneous rupture of a normal spleen during the second trimester of pregnancy have been reported in the English literature. If splenic rupture is suspected,

an exploratory laparotomy (via a midline vertical incision to maximise access and exposure) should be performed in the vast majority of patients to stop the bleeding. This case highlights the fact that this rare and enigmatic condition can occur at any time during pregnancy and that prompt and aggressive surgical intervention is paramount to saving the lives of both mother and baby.

Learning points • Spontaneous rupture of the spleen is a life-threatening clinical event with high maternal and fetal mortality.

• Its aetiology is unknown, but it is more common in the third trimester and in multiple pregnancies.

• It can mimic other acute conditions such as ruptured ectopic pregnancy, uterine rupture and placental abruption.

• In the overwhelming majority of patients, aggressive surgical intervention is indicated to stop the bleeding.

1. Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen: A surgical enigma. Int Abstr Surg 1958;106(1):1-11.

2. Tanchev S, Popova M, Slalov I. The ‘splenic emergency syndrome’ during pregnancy (a report of 2 cases). Akush Ginekol (Sofia) 1992;31(1):32-34.

3. Fletcher H, Frederick J, Barned H, Lizarraga V. Spontaneous rupture of the spleen in pregnancy with splenic conservation. West Indian Med J 1989;38(2):114-115.

4. Wang C, Tu X, Li S, Luo G, Norwitz ER. Spontaneous rupture of the spleen: A rare but serious case of acute abdominal pain in pregnancy. J Emerg Med 2011;41(5):503-506. [http://dx.doi. org/10.1016/j.jemermed.2010.05.075]

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51

CASE REPORT

Cornelia de Lange syndrome – a rarely seen disorder Y Çekmez,1 MD; N Pişkinpaşa,2 MD; T Tos,3 MD Department of Obstetrics and Gynaecology, Umraniye Medical and Research Hospital, İstanbul, Turkey Department of Obstetrics and Gynaecology, Manisa Government Hospital, Manisa, Turkey 3 Department of Obstetrics and Gynaecology, Dr Sami Ulus Medical and Research Hospital, Ankara, Turkey 1 2

Corresponding author: Y Çekmez (yaseminkandicekmez@hotmail.com)

Cornelia de Lange syndrome (CdLS) is a rare genetic disorder of unknown causation, associated with multiple congenital anomalies.

Prenatal genetic diagnosis is possible, and the syndrome can occur in subsequent pregnancies of families with affected children as a result of mosaicism. The syndrome has been diagnosed antenatally by careful ultrasound examination, but is usually only diagnosed after birth.

We report the case of a patient admitted to our clinic with intrauterine death of the fetus. CdLS was diagnosed on the basis of multiple structural abnormalities seen after delivery.

S Afr J Obstet Gynaecol 2015;21(2):52-53. DOI:10.7196.SAJOG.890

Cornelia de Lange syn­ drome (CdLS), also known as Brachmann de Lange syn­­ drome, is a rarely seen genetic disorder charac­ terised by facial features such as monobrow (syno­ phrys), long eyelashes, anteverted nostrils, a long filtrum and thin lips. Failure to thrive, mental retardation, hirsutism and multiple congenital anomalies have also been described.[1] The prevalence of CdLS has been reported to vary between 1/10 000 and 1/50 000 births, and there is a 2 - 5% risk of recur­rence in a subsequent pregnancy.

The causation appears to be multifactorial, and most cases are sporadic. Inheritance is autosomal dominant or recessive.[1,2] On microscopic examination, a decrease in the number of oligodendrocytes and a myelin defect in transverse fibrils are seen.

A relationship between total deficiency of pregnancy-associated plasma protein A, a gestational protein, and CdLS has been reported. Increased nuchal translucency and a dysmorphic appearance of the upper extremities can be useful in diagnosing CdLS prenatally. Degrees of severity differ even between members of the same family, and it is impossible to make a diagnosis phenotypically in most cases. We report the case of a patient admitted to our clinic with intrauterine death of the fetus. CdLS was diagnosed on the basis of multiple structural abnormalities seen after delivery.

and Research Hospital, Ankara, Turkey, with decreased fetal movement, backache and groin pain. Her last delivery had been by caesarean section, she did not know her date of last menstrual period, there was no consanguinity, and her surviving children had no anomalies. There was no other medical history of note. She had found out that she was pregnant when she saw a doctor at about 8 weeks’ gestation, but had not been followed up. TORCH screening at 8 weeks had been negative.

An ultrasound scan showed no fetal heartbeat. The biparietal diameter was 88.3 mm (corresponding to a gestation of 35 weeks and 5 days) and the femur length 68.1 mm (35 weeks). Pelvic examination showed cephalic presentation, and the cervix was 4 cm dilated with 60% efface­ ment. The patient was in labour, and as she had had a previous caesarean section and requested tubal ligation, emergency caesarean section was performed. A dead fetus weighing 2 980 g and 48 cm in length was delivered. The fetus had dysmorphic facial features, a depressed nasal bridge, synophrys, a wide frenulum, hirsutism, low-set ears, ectrodactyly in the left hand and phocomelia on right (Figs 1 and 2). The skin was stained with yellowbrown meconium. On the basis of these findings, CdLS was diagnosed and genetic counselling was provided to the family.

Autopsy of the fetus was suggested, but the family did not agree to it.

Case report

Discussion

A 27-year-old woman, para 5, gravida 7, was admitted to the Dr Sami Ulus Medical

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Some signal pathways with important modu­ lation roles in development of the

Fig. 1. Typical facial features in CdLS: mono­ brow (synophrys), long eyelashes, anteverted nostrils, long filtrum and thin lips.

Fig. 2. Ectrodactyly on the left hand and phocomelia on the right. embryo, starting from the early stages of morphogenesis, also have a basic role in creating the anatomical structure of the musculoskeletal system. Although mal­ formations related to the basic differentiation processes are very rare in humans, most congenital anomalies are related to these processes in the early phases of morphogenesis. This applies especially to disorders that have syndromic characteristics as a result of their anomaly pattern and are therefore easily recognised.

CdLS is one of these.[3] CdLS is a rare and clinically well-defined syndrome. Growth retardation, micro­ cephaly, synophrys, long curved eyelashes, thin lips with facing-down convexity and a

long filtrum are seen in all cases.[1,4] Verma et al.[2] reported in their series of 180 cases that all patients had microcephaly and pubertal delay, 97% had hirsutism, and 68% were of low birth weight.[2] In our case, synophrys, a wide frenulum and a hirsute forehead were noted.

The cause of CdLS is unknown. A defect on chromosome 3q26.3 has been shown in cases with a family history or intermarriage.[5] In sporadic and familial cases, mutations of the NIPBL (nipped-Blike) gene, which is a cohesin regulator at the 5th chromosome, have been described.[6] Bhuiyan et al.[7] reported NIPBL mutation in 56% of 39 cases of CdLS. Our patient reported no intermarriage or family history.

Findings suggesting a diagnosis of CdLS in the prenatal period are increased nuchal translucency in the first trimester, symmetrical intrauterine developmental restriction (SIDR), significant defects in the upper extremities, and a dysmorphic facial appearance.[8-10] Sekimoto et al.[9] reported SIDR in 95% of patients diagnosed with CdLS, skeletal anomalies in 81%, facial dysmorphism in 50% and fetal diaphragmatic hernia in 50%. Polyhydramnios was reported in 2 cases and nuchal translucency in 4. A prenatal diagnosis could be made in 6 cases only.[11-12] Our patient also had a dysmorphic facial appearance and phocomelia on the right.

As in our case, because the findings on prenatal ultrasonography are nonspecific, CdLS can usually only be diagnosed after birth.

As prenatal genetic diagnosis is possible and there is a risk that

the syndrome will recur in subsequent pregnancies because of mosaicism, genetic counselling should be provided to the families of affected children.[13] 1. Weichert J, Schröer A, Beyer DA, Gillessen-Kaesbach G, Stefanova I. Cornelia de Lange syndrome: Antenatal diagnosis in two consecutive pregnancies due to rare gonadal mosaicism of NIPBL gene mutation. J Matern Fetal Neonatal Med 2011;24(7):978-982. [http://dx.doi.org/10.3109/14767058 .2010.531312] 2. Verma L, Passi S, Gauba K. Brachman de Lange syndrome. Contemp Clin Dent 2010;1(4):268-270. [http://dx.doi.org/10.4103/0976-237X.76399] 3. Horsfield JA1, Print CG, Mönnich M. Diverse developmental disorders from the one ring: distinct molecular pathways underlie the cohesinopathies. Front Genet 2012;12(3):171. [http://dx.doi. org/10.3389/fgene.2012.00171] 4. Reddy HB, Neelaveni K, Hari Kumar KV. Cornelia de Lange syndrome. Indian J Endocrinol Metab 2013;17(4):763. [http://dx.doi.org/ 10.4103/2230-8210.113779] 5. Boyle MI, Jespersgaard C, Brøndum-Nielsen K, Bisgaard AM, Tümer Z. Cornelia de Lange syndrome.

Clin Genet 2015;88(1):1-12. [http://dx.doi.org/10.1111/cge.12499] 6. Gillis LA, McCallum J, Kaur M, et al. NIPBL mutational analysis in 120 individuals with Cornelia de Lange syndrome and evaluation of genotype-phenotype correlations. Am J Hum Genet 2004;75(4):610-623. [http://dx.doi.org/10.1086/424698] 7. Bhuiyan ZA, Klein M, Hammond P, et al. Genotype-phenotype correlations of 39 patients with Cornelia de Lange syndrome: The Dutch experience. J Med Genet 2006;43(7):568-575. [http:// dx.doi.org/10.1136/jmg.2005.038240] 8. Boog G, Sagot F, Winer N, David A, Nomballais MF. Brachman-de Lange syndrome: A cause of early symmetric fetal growth delay. Eur J Obstet Gynecol Reprod Biol 1999;85(2):173-177. [http:// dx.doi.org/10.1016/S0301-2115(99)00021-4] 9. Sekimoto H, Osada H, Kimura H, Arai K, Sekiya S. Prenatal findings in Brachmann-de Lange syndrome. Arch Gynecol Obstet 2000;263(4):182-184. [http://dx.doi.org/10.1007/s004040050278] 10. Huang WH, Porto M. Abnormal first-trimester fetal nuchal translucency and Cornelia de Lange syndrome. Obstet Gynecol 2002;99(5):956-958. [http://dx.doi.org/10.1016/S0029-7844(02)01982-8] 11. Chong K, Keating S, Hurst S, et al. Cornelia de Lange syndrome (CdLS): Prenatal and autopsy findings. Prenat Diagn 2009;29(5):489-494. [http://dx.doi.org/10.1002/pd.2228] 12. Akahori Y, Masuyama H, Masumoto Y, Hiramatsu Y. Three-dimensional ultrasound findings in Cornelia de Lange syndrome: A case report. Case Rep Obstet Gynecol 2012;2012:568351. [http://dx.doi.org/10.1155/2012/568351] 13. Slavin TP, Lazebnik N, Clark DM, et al. Germline mosaicsm in Cornelia de Lange syndrome. Am J Med Genet A 2012;158A(6):1481-1485. [http://dx.doi.org/10.1002/ajmg.a.35381]

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CPD Attitudes towards intrauterine contraceptive (IUCD) use 1. An American study published in 2004 identified that almost 40% of contraceptive pill users confessed to missing at least one active pill in the previous 3 months.

2. The Pearl index (number of pregnancies per 100 woman-years of use) for the IUCD is 4 - 5 per 100 woman-years.

3.

Concern has been expressed regarding the metabolism of etonorgestrel-containing implants in users of the anti­retroviral agent efavirenz that might effect contraceptive efficacy.

An audit of female incontinence 4. Approximately 35% of women will experience urinary incon­ tinence during their lives.

5.

Of those experiencing incontinence, only approximately a quarter will seek medical help.

6.

Published success rates for the transobturator tape for stress incontinence may be affected by a variety of surgeons in multicentre studies with lower success rates and the benefit of single surgeons in single-unit experience.

7. In the closure of urogenital fistula, where the fistula involves the ureters or trigone, the vaginal route is preferred.

Attitudes to female genital mutilation 8.

Female genital mutilation is also referred to as female circumcision.

9. Female genital mutilation is still practised in 29 countries in Africa.

10.

The majority of practitioners who perform female genital mutilation are women.

Middle cerebral artery peak systolic velocity 11.

Doppler examination of the fetal middle cerebral artery is usually considered reliable in detecting fetal anaemia.

12. The normal middle cerebral artery peak systolic volume is 80 m/s.

13. Fetal anaemia is one of the treatable causes of non-immune hydrops fetalis.

14. Haematological causes make up 1% of cases of hydrops fetalis.

Uterine artery embolisation for vaginal haematoma 15. Severe primary postpartum haemorrhage is defined as blood loss of 1 500 mL within the first 24 hours after birth.

16.

In India, primary postpartum haemorrhage is currently the commonest cause of maternal death.

Postpartum urinary retention 17.

Postpartum urinary retention can, by one definition, be divided into overt (inability to void within 6 hours of delivery and covert (a residual volume of ≥150 mL after spontaneous micturition).

18. Up to 25% of patients who experience postpartum urinary reten­ tion may require intermittent self-catheterisation for over a month.

Cornelia de Lange syndrome 19. Cornelia de Lange syndrome is a condition of multiple con­ genital abnormalities of unknown cause that may recur due to mosaicism.

20. Cornelia de Lange syndrome is associated with asymmetrical growth restriction.

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.

Accreditation number: MDB015/149/02/2015(Clinical)

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