Masters Degrees (Obstetrics and Gynaecology)

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Browsing Masters Degrees (Obstetrics and Gynaecology) by browse.metadata.advisor "Gebhardt, G. S."

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    Elective delivery of women with a previous unexplained intra-uterine fetal death at term (≥ 39 weeks) : a prospective cohort study at Tygerberg Hospital, South Africa
    (Stellenbosch : Stellenbosch University, 2014-12) Oberholzer, Leana; Gebhardt, G. S.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
    ENGLISH ABSTRACT: Introduction Pregnancies in women with a previous unexplained stillbirth may be jeopardized by increased antenatal surveillance and higher rates of induction of labour and caesarean delivery without clear evidence of benefit. Despite the fact that there have been no studies that adequately tested fetal benefit in routine induction of labour for a previous stillbirth, a policy of routine induction of labour at 38 weeks, with all the associated maternal, fetal and health-care associated costs, was in practice at Tygerberg Hospital for the past 30 years. This study aimed to investigate the safety of continuation of these pregnancies until term (≥39 weeks). Aims and Objectives To assess the clinical outcome and impact on the health service in a pregnancy with a previous unexplained intra-uterine demise (IUD) by routine induction of labour at term instead of at 38 weeks. Methodology This was a prospective observational study on the safety of a new hospital protocol which was introduced in 2012. The protocol extended the gestation for induction after a previous IUD from 38 weeks to term. The study population included all pregnant patients with a current singleton pregnancy, and a previous unexplained or unexplored (no data available) singleton fetal demise ≥24 weeks/500grams. All patients with a previous stillbirth in the metropolitan drainage area of Tygerberg Hospital are referred to Tygerberg for further care; and all referrals during 2012 were recruited for the study. Patients with known or recurrent risks for intra-uterine death were managed according to the relevant clinical condition and were excluded from the study. Results During the audit period, 306 patients with a previous intra-uterine fetal death were referred for further management. Of these, 161 had a clear indication for either earlier intervention or no intervention and were excluded from the protocol. Of the remaining 145 patients, 9 met exclusion criteria and there were 2 patients who defaulted. Forty-two of the study patients (with no known previous medical problems) developed complications during their antenatal course that necessitated a change in clinical management and earlier (<39 weeks) delivery. Of the remaining 92 patients in the audit, 47 (51%) went into spontaneous labour before their induction date. There were no intra-uterine deaths prior to delivery. Conclusions Careful follow up at a high risk clinic identifies new or concealed maternal or fetal complications in 29% of patients with a previous IUD and no obvious maternal or fetal disease in the index pregnancy. When all risks are excluded and the pregnancy allowed to progress to 39 weeks before an induction is offered, 51% will go into spontaneous labour.
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    A retrospective audit of post-caesarean sepsis at Tygerberg Hospital
    (Stellenbosch : Stellenbosch University, 2017-12) Coetzer, Marsel; Murray, L. R.; Gebhardt, G. S.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
    ENGLISH SUMMARY: INTRODUCTION: Caesarean section (CS) is one of the most common surgical procedures performed worldwide and remains the most important individual risk factor for developing pregnancy related sepsis. Pregnancy related sepsis leads to an estimated 75 000 maternal deaths worldwide each year, with most of these deaths occurring in low and middle-income countries. According to the 2015 Saving Mothers Annual Report, pregnancy related sepsis remained the 3rd leading cause of direct maternal deaths in South Africa. In the USA, the attributable costs (per case) of post CS surgical site infection and post CS endometritis were estimated around $3500 and $3900 respectively in 2010. AIM & METHOD: To audit post-CS sepsis at Tygerberg Hospital in order to determine the incidence, as well as to describe the risk-factor profile and determine the outcome of women who develop post-CS sepsis. A retrospective audit of patient records of all women who delivered by CS in a three-month period between 1 February 2014 and 30 April 2014 was undertaken. All records were followed up for thirty days after delivery, in order to identify cases with post-CS sepsis. The CDC diagnostic criteria for surgical site infection (both superficial and deep) and endometritis were used. RESULTS: During the 3-month study period a total of 1 834 deliveries were managed at Tygerberg Hospital. Eight hundred and forty eight CS were performed, with a hospital-based CS rate of 46.24%. A total of 811 patient records were audited and 38 women with post-CS sepsis were identified. The cumulative incidence for post-CS sepsis was therefore 4.69%. Patient characteristics illustrated the high-risk nature of the patient population served by Tygerberg Hospital, with a high incidence of known risk factors for post-CS sepsis such as obesity, hypertension and HIV. Risk factors associated with post CS sepsis included: HIV infection without antiretroviral therapy (Risk Ratio 5.83, 95% Confidence Interval 1.72 – 19.77, p=0.005) and prolonged surgical duration (Risk Ratio 3.01, 95% Confidence Interval 1.10 – 8.19, p=0.03). Thirty-three women had severe post-CS sepsis and were treated as inpatients. Of these women, 12 required repeat surgery or admission to a high care or intensive care unit. CONCLUSION: Despite a post-CS sepsis incidence that compares well with high-income countries (4.69% vs. 3.5 – 8.11%) post-CS sepsis remains a significant contributor to maternal morbidity in the South African setting. Risk factors for post-CS sepsis remain multifactorial and in the setting of a referral hospital, all women should be treated as potentially at risk. Optimization of chronic medical conditions, vigilant intra-partum care, meticulous surgical technique and recognition of early signs of post-CS sepsis are essential in order to prevent maternal morbidity.