Department of Obstetrics and Gynaecology

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Browsing Department of Obstetrics and Gynaecology by browse.metadata.advisor "Gebhardt, Gabriel Stefanus"

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    Early onset pre-eclampsia with severe features necessitating fetal delivery: outcome of pregnancies with birthweight 1000-1800g at Tygerberg Hospital 2017
    (Stellenbosch : Stellenbosch University, 2021-12) Adlam, Jan Andries; Gebhardt, Gabriel Stefanus; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
    Introduction: Expectant management of early onset pre-eclampsia (EOPE) is an established practice at Tygerberg Hospital and some other tertiary institutions in South Africa. Its outcome has been documented in several studies. However, neonatal care has improved since many of these studies were done, e.g., nasal continuous positive airway pressure (NCPAP) plus intubation, surfactant, and extubation (InSurE) (introduced in 2006 at Tygerberg) and therapeutic hypothermia introduced in 2008. It is plausible that an interventionist approach (delivery after 48 hours of optimal maternal and fetal preparation, stabilisation of mother, antenatal corticosteroids and MgSO4 for neuroprotection, fetal evaluation with ultrasound, Doppler and electronic fetal monitoring) with access to good neonatal care can yield the same outcome without subjecting the mother to the additional dangers of expectant management. The women who do not qualify for expectant management (due to maternal or fetal contra- indications) can be a good proxy for an interventionist approach to EOPE. The outcome of ELBW (<1000g) babies at Tygerberg has been described previously. Methods: This was an observational cross-sectional study using data from the routinely collected PPIP database, electronic labour ward register and clinical data from patient folders. All pregnancies complicated by pre-eclampsia with a birthweight of 1000-1800g born at least 24 hours after admission in 2017 at Tygerberg Hospital were identified. Patients admitted for formal expectant management were excluded. By folder review, routine provincial admission and discharge data and mortality data, clinical outcome and neonatal survival were investigated. Findings: 139 Women were identified by total population sampling. The presenting diagnosis was EOPE (122 women, [88%]) LOPE (14 women [10%]) or eclampsia (3 women [2%]). Intra-uterine growth restriction (IUGR) was diagnosed in 41% of cases before delivery. The time to delivery was on average 81 hours. In total, 65 (46.7%) of deliveries were due to fetal indications. Maternal indications for early delivery in the remaining 74 women were: pregnancy that reached 34 weeks (n=28), specialist opinion (n=13), HELLP syndrome (n=7), pulmonary oedema (n=7), severe maternal ascites (n=6), uncontrollable hypertension (n=5), maternal request (n=3), eclampsia (n=3) or acute renal injury (n=2). There were no intrapartum deaths and only two neonatal deaths. The rest of the babies were discharged alive from hospital. For 22 babies, there were no accounts of follow-up visits in the province. Thirty babies iii attended the neurodevelopmental clinic for follow-ups. Of these, three had spastic cerebral palsy and two had fine or gross motor delay. The rest had no major disabilities noted. The remaining 84 babies all had contact with health services during the months after discharge, with minor problems. The mean number of neonatal days in hospital was 20 and ranged from 2 days to 116 days. Conclusion: Neonatal outcomes were acceptable and overall survival was better than the initial study done at Tygerberg Hospital (with 12 neonatal deaths in babies >1000g in the group of 340 women managed expectantly in 1992-1997). With these findings, a rethink of management strategies for pregnancies complicated by severe early onset pre-eclampsia is warranted and a randomised trial is recommended as the next step.
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    Experiences of women who survive major obstetric haemorrhage
    (Stellenbosch : Stellenbosch University, 2019-12) Bennett, Jason Gareth; Murray, L. R.; Gebhardt, Gabriel Stefanus; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.
    ENGLISH ABSTRACT: Severe post-partum haemorrhage is a major cause of maternal morbidity in South Africa. There is very little information about the experience of survivors of PPH in the local South African setting. This qualitative study investigated, by way of in depth interviews, the experience of 11 women who survived severe PPH at Tygerberg hospital. Several themes emerged, most notable self-blame, guilt and isolation. This information is important to ensure that future care of women with severe morbidity includes a mental health component, with appropriate referral for psychologic counselling and long-term follow up. The other important themes identified were pain and discomfort, near death, fear and loss of control.
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    Incidence, management, and outcomes of pregnancies complicated by major placenta praevia at Tygerberg Hospital: A two-year review
    (Stellenbosch : Stellenbosch University, 2022-11-21) Indongo, Justine Nalimanguluke; Gebhardt, Gabriel Stefanus; Swart, Hester Alida; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. Obstetrics and Gynaecology.
    ENGLISH ABSTRACT: Introduction Obstetric haemorrhage is the third most important cause of direct maternal death (19,1% of all deaths) in South Africa. Although most of these deaths are due to postpartum haemorrhage, antenatal haemorrhage also contributes significantly. Placenta praevia is a major source of obstetric haemorrhage as it carries risks for both antepartum haemorrhage, intrapartum haemorrhage, and postpartum haemorrhage. Massive obstetric haemorrhage is also a major cause of perinatal morbidity and mortality. Placenta praevia represents a complex clinical challenge due to the prolonged in-patient monitoring that is often advised. Additionally, patients are at increased risk for hysterectomy and blood transfusions as well as perinatal morbidity and mortality mainly due to premature delivery. Methods This is a retrospective audit including all women with major placenta praevia during a twoyear period (1st January 2016 until 31st December 2017) at Tygerberg Hospital, a large regional and tertiary referral centre in the Western Cape province of South Africa. It was conducted as a retrospective folder review. Results The total number of deliveries during the study period was 15 780, of which 121 were diagnosed with major placenta previa, giving an incidence rate of 0.4%. Of the 121 patients in the study, complete data was available for 119 patients (98%) of which 31% (n=38) had a previous delivery by caesarean section. Of all the patients with major placenta praevia (MPP), 19.8% (n=24) had a morbidly adherent placenta (MAP). Intraoperative interventions used to control bleeding were multiple haemostatic sutures in 11.6% (n=14), followed by compression sutures 5.8% (n=7) and uterine artery ligation 2.5% (n=3). The hysterectomy rate was 16.5% (n=20). Of all the mothers, 24.8% (n=30) required a high dependency unit (HDU) of which 1.7% (2) went to the intensive care unit (ICU), 8.6% (n=8) to a step-down acute post-natal ward (APN) and the majority 16.5% (n=20) went to the obstetric critical care unit (OCCU). Relook laparotomy was required in 2.5% (n=3) of the cases. There were no maternal deaths. Of all the deliveries 62.8% (n=76) were preterm and 5.8% (n=6) required admission to neonatal intensive care unit (NICU), and 78.8% (n=93) had good APGAR scores (5-minute score ≥6), while 21,2% (n=25) had poor APGAR scores (5-minute score 5 or less). The overall hospital still birth rate (SBR) during the study period was 63 per 1000 births, and major placenta praevia accounted for 0.2% (16 per 1000 births) of all the still births. Conclusion The incidence of MPP was 0.4% which is comparable to other studies. MPP is one of the leading causes of feto-maternal mortality and significant morbidity. The prematurity rate was very high, however the majority (78.8%) of the babies had good 5-minute APGAR scores. Effective management protocols may help to identify high risk patients, thus improving management and outcomes of both the mother and the neonate.
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    Retrospective audit on outcomes of post caesarean section sepsis after additional azithromycin to the standard antibiotic at Tygerberg hospital, Cape Town
    (Stellenbosch : Stellenbosch University, 2023-12) Matabata, Thembani; Mbungu, Nomaphelo; Singini, Isaac; Gebhardt, Gabriel Stefanus; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. Obstetrics and Gynaecology.
    ENGLISH ABSTRACT: Background Surgical site infections (SSI) and endometritis are important causes of post caesarean delivery (CD) morbidity and mortality. They lead to prolonged hospital stay and increase in hospital expenditure. The global rate of SSI is 3-15% with the change in incidence being attributed to changes in population traits, risk factors, perioperative practices and time taken from the procedure. There is currently little clinical data on the incidence of post CD in the South African setting. The commonest organisms associated are Staphylococcus aureus, E. coli, Pseudomonas, Proteus mirabilis and Mycoplasma species. Some of the identifiable risk factors are prolonged labour, emergency CD, multiple vaginal examinations during labour, diabetes mellitus or high Body Mass Index (BMI). With the use of the standard antibiotic prophylaxis, the incidence of post CD sepsis remains high. With dual antibiotic prophylaxis (azithromycin 500mg IV in addition to the standard cephazolin) there is a 60% reduction in post CD sepsis with no adverse neonatal outcomes. Single agent pre-operative prophylaxis with a first-generation cephalosporin (e.g. cefazolin) was the standard of care during 2017, when a retrospective folder review showed a cumulative incidence for post-CS sepsis to be 4.69%. Dual prophylaxis became the standard of care during 2019 with its inclusion in the National Essential Medicine List. This was introduced at Tygerberg Hospital in September 2020. Aim To perform an audit of post caesarean section sepsis after implementation of the additional azithromycin to standard antibiotic protocol at Tygerberg hospital, Cape Town; to monitor adherence to this new protocol as well as to determine the incidence of post-CD sepsis. Methods 3 | Page A retrospective study was conducted on all pregnant women undergoing CD at Tygerberg hospital in from 01 September 2021- 30 November 2021. Records of the cases of the patients were retrieved from the Electronic Content Management (ECM) and followed up to 30 days after delivery to determine the rate of post-CD sepsis. Results A total of 457 records were audited, with 16 women identified with post CD sepsis (a hospital rate of 3.5%). This was 18% lower than the rate reported prior to dual prophylaxis (4.69%). The risk factors identified to be significantly associated with post CD sepsis were number of vaginal examinations >5 (p = 0.007), duration of active labour (p = 0.011), labour mechanism (p = 0.009) and noticeable intra-operative findings including difficult haemostasis and adhesiolysis (p= 0.003). Conclusion Addition of azithromycin to the standard antibiotic reduces the rate of post CD sepsis. Multiple vaginal examinations, duration of active labour, emergency CD and specific intraoperative findings were identifiable risk factors for post CD sepsis.