Doctoral Degrees (Obstetrics and Gynaecology)

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Browsing Doctoral Degrees (Obstetrics and Gynaecology) by browse.metadata.advisor "Theron, Gerhardus Barnard"

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    A critical evaluation of health care reform in maternity services in the Western Cape Province of South Africa, 2007-2012
    (Stellenbosch : Stellenbosch University, 2016-12) Gebhardt, Gabriel Stephanus; Theron, Gerhardus Barnard; Stellenbosch University. Faculty of Medicine and Health Science. Dept. of Obstetrics and Gynaecology.
    ENGLISH ABSTRACT: This thesis is a critical evaluation of the impact of service delivery shifts within maternity care on the clinical governance of a well-defined geographical service delivery area (Metro East section of the Cape Town health district) during 2007 to 2012. This period saw the implementation of a comprehensive health plan that envisaged the provision of safe maternity care at a non-specialist hospital within the metropolitan area. The data presented in the first part of the thesis shows that well defined levels of maternity care can provide safe management of pregnancies in a large, well-functioning district hospital. A central event in this time period was the opening of a newly-built district hospital in Khayelitsha and the major change in the drainage boundaries of Tygerberg hospital to include referrals from this new hospital. The thesis presents all the clinical governance aspects that went into the planning and eventual execution of a maternity service and the impact it had on the base hospital. The second part investigates the role of the regional maternity service in Tygerberg hospital as it relates to the clinical governance of the regional and district service in the Metro East sub-district. To this extent a few chapters place quality of care aspects such as structural audits, caesarean section rates, maternal and perinatal mortality data, medico-legal liability, patient and provider satisfaction and protocol compliance within this context. An in-depth root-cause analysis was made of all the obstetrics and gynaecology medico-legal cases within the Western Cape which showed that poor clinical note keeping was a major factor hampering defence of cases. The information obtained from this thesis builds on the Western Cape healthcare plan for 2030 aimed at improving quality of care and wellness with an outcomes-based approach and the prioritisation of evidence-based interventions. It concludes with the description of a maternity dashboard for the Tygerberg labour ward and the Metro East maternity service based on the information obtained from this thesis. The tool can inform the hospital management on progress, successes and challenges within the system on a regular basis.
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    Maternal deaths, near misses and great saves. Severe maternal outcome in Metro East, Western Cape Province, South Africa
    (Stellenbosch : Stellenbosch University, 2023-12) Heitkamp, Anke; Theron, Gerhardus Barnard; De Vries, Johanna Inge Petra; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. Obstetrics and Gynecology.
    ENGLISH ABSTRACT: Objective To assess the incidence of Severe Maternal Outcome (SMO), comprising maternal mortality (MM) and near miss (MNM), in Metro East healthdistrict, Western Cape Province, South Africa between November 2014 and November 2015 and identify associated determinants leading to SMO with the aim to improve maternity care. Methods Design: Region wide population-based case control study. Women were included in the study, if they were maternal deaths or met MNM criteria, both as defined by World Health Organization. Characteristics of women with SMO were compared with a sample of women without SMO, matched for age and parity, taken from midwifery-led obstetric units from two residential areas in Metro East, using multivariate regression analysis. Results Incidence of SMO was 9.1 per 1000 livebirths, of MNM 8.6 per 1000 live births. Main causes of SMO were obstetric hemorrhage and hypertensive disorders. Factors associated with SMO were HIV (adjusted odds ratio (aOR) 24.8; 95% confidence interval (95% CI) 10.0 – 61.6), preeclampsia (aOR 17.5; 95% CI 7.9-38.7), birth by caesarean section (aOR 8.4; 95% CI 5.8-12.3) and chronic hypertension (aOR 2.4; 95% CI 1.1 – 5.1). Conclusion Evaluation of SMO incidence and associated determinants supports optimizing tailored guidelines in Metro-East health district to improve maternal health.
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    The Preeclampsia intervention with Esomeprazole (PIE) trial: A double blind, randomised, placebo-controlled trial to treat early onset severe preeclampsia
    (Stellenbosch : Stellenbosch University, 2019-04) Cluver, Catherine Anne; Theron, Gerhardus Barnard; Walker, Susan; Tong, Stephen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
    ENGLISH ABSTRACT: This body of work addresses the clinical dilemma posed by preterm preeclampsia. Firstly, we tested a potential therapeutic (esomeprazole) for the treatment of early preterm preeclampsia in a double-blind randomised controlled trial. The primary outcome of interest was prolongation of gestation, with secondary outcomes including maternal and perinatal outcomes. Importantly, this study was underpinned by extensive pharmacokinetic and biomarker studies on both plasma samples and placental tissue. We found that a daily dose of 40mg of esomeprazole did not prolong pregnancy in early preterm preeclampsia and there were no differences in maternal or neonatal outcomes or markers of endothelial dysfunction. The esomeprazole concentrations that were observed in our participants were within the lower range of concentrations used in our preclinical in vitro studies. We therefore concluded that 40 mg may not have been sufficient to have efficacy in treating preterm preeclampsia, and future studies should consider the role of a higher dose or intravenous administration, which has a higher exposure over time and peak concentration. Secondly, we assessed the impact of coexisting fetal growth restriction on pregnancy latency, obstetric, maternal and perinatal outcomes among women undergoing expectant management of early preterm preeclampsia. We found that the latency-to-delivery interval was significantly shorter among pregnancies with coexisting fetal growth restriction. These pregnancies were less likely to reach 34 weeks gestation and more likely to be delivered for suspected fetal compromise. More women with coexisting fetal growth restriction underwent an emergency caesarean section without a trial of labour induction and of those considered eligible for induction of labour, the rate of emergency caesarean section was higher among those with fetal growth restriction. Postnatally, the presence of coexisting fetal growth restriction was associated with a higher rate of postnatal death and necrotising enterocolitis. Interestingly, the rate of maternal complications did not differ between the groups. We concluded that coexisting fetal growth restriction, diagnosed at the same time as preeclampsia, is an important determinant of pregnancy outcome among women being managed expectantly for early preterm preeclampsia Thirdly, we sought to determine the role of expectant management of preeclampsia and the hypertensive disorders of pregnancy after 34 weeks gestation by assimilating the available data in a Cochrane systematic meta-analysis. Based on the limited data available, maternal outcomes appear better with planned early delivery for hypertensive disorders after 34 weeks’ gestation, but it is unclear whether this is associated with increased risks for the baby, especially at earlier gestations. It was not possible to determine whether planned early delivery was beneficial for different hypertensive conditions, particularly preeclampsia. We concluded that further studies are needed, preferably with reliable characterisation of hypertensive disease sub-types, to determine the ideal timing of delivery to optimise maternal and perinatal outcomes for hypertensive disorders of pregnancy occurring after 34 weeks gestation. This research provides new information about a candidate therapeutic for the treatment of preeclampsia. Clinical aspects of the hypertensive disorders of pregnancy that could further improve management are also discussed.