Background: Ectopic pregnancy after hysterectomy is a rare event. To date there are 73 defi nitive cases of post-hysterectomy ectopic pregnancy. The fi rst case was reported by Wendler in 1895.Case: A 31 year old P2G4 (one miscarriage) presented with a history of severe lower abdominal pain of three days duration. She previously had a subtotal hysterectomy four years prior her current presentation for a septic miscarriage with multiple organ dysfunction. She had a background history of being HIV reactive on antiretroviral therapy initiated two days before her presentation. Her CD4 count was 54 cells/uL, negative cryptococcal latex test. She was fi rst diagnosed with HIV in 2015, however had not been on antiretroviral therapy since then. On clinical examination she was hemodynamically stable, normal blood pressure and pulse, afebrile and no stigmata of AIDS. She had an acute abdomen and on pelvic examination a cervical stump was palpable with no blood from the cervical os. Her haemoglobin was 13.4g/dl. Urine pregnancy test was positive. Her quantitative beta-HCG of 3979 IU/L. Pelvic ultrasound showed fl uid collection in the pelvis, no defi nite masses seen, no uterus seen and ovaries could also not be visualised. Abdominal ultrasound did not show any abnormalities in the rest of the abdomen. The patient was counselled for surgery. Preparation with multidisciplinary consultation was done. Intraoperatively, 100ml haemoperitoneum was found. There were dense pelvic adhesions. Adhesiolysis was done and a bleeding right fallopian tube ampullary pregnancy was found. The right ovary was grossly normal. The contralateral adnexa could not be identifi ed. A right salpingectomy was done. Total blood loss was 100ml. She recovered well post operatively and was discharged three days later to continue her antiretroviral therapy.Discussion: A rare case of tubal ectopic pregnancy after hysterectomy is presented. Access to the peritoneal cavity and fallopian tube through the cervical canal, we postulated as the mechanism in this case. Ectopic pregnancies after hysterectomy are classifi ed into early and late. The former being associated with a pregnancy (or viable gametes) that was present at the time of hysterectomy. These present soon after the hysterectomy. The latter present long after the hysterectomy. Conception can occur after hysterectomy through access via a prolapsed fallopian tube, a fi stula or defect in the vault. Cervical stump pregnancy is also described. Surgical intervention is the most common intervention described amongst the case reports.Conclusion: Pregnancy after a hysterectomy is a rare possibility with possible adverse outcomes. Clinicians must have a strong index of suspicion for a possible ectopic pregnancy in patients that present with abdominal pain after hysterectomy.
New scientific and technological discoveries in all spheres of Medicine continuously challenge the boundaries of healthcare. To this end, the discipline is considered progressive and accomplished. The birth of this heavily professionalized discipline has leveraged the potential for the healthcare industry to innovate, regulate and disseminate proprietary products with relative ease. The rise and fall of four novel gynaecological devices represent excellent examples of ethical dilemmas in clinical medicine. This paper aims to deconstruct the power versus knowledge conflict, and suggest that reappraisal and recourse to Aristotelian virtue ethics will assist in shifting the decisional power balance primarily towards the physician.
Heterotopic pregnancy is defi ned as the coexistence of intrauterine and extra uterine pregnancy. A high index of suspicion is needed for early and timely diagnosis and intervention. Clinicians should remain alert to the possibility of heterotopic pregnancy even when an intrauterine pregnancy is confi rmed. Management options for heterotopic pregnancy includes expectant management, surgical intervention, medical management as well as transabdominal sonographic guided aspiration of the ectopic gestational embryo.With early diagnosis and treatment, 70% of the intrauterine pregnancies will reach viability
Amniotic band destruction syndrome is rare. It is a constellation of major and minor abnormalities, which arises from lacerated amniotic band. The amniotic band syndrome involving umbilical cord constriction is even rare. We describe a case of umbilical cord constriction resulting in fetal demise and limb defects in second trimester.
The Oxford dictionary defines the word “atopic” as “…a form of allergy in which a hypersensitivity reaction such as eczema or asthma may occur in a part of the body not in contact with the allergen.” 1 Atopic dermatitis (AD), commonly known as eczema, is a chronic inflammatory disease of unknown origin, that is characterised by eczematous, intensely pruritic lesions, dry skin (xerosis), as well as lichenification (thickening of skin). 2,3 A worsening of the condition (flare) alternates with periods of remission. 4
A total of 921 maternal deaths were entered on the Database for the Retrospective Analysis of Maternal Anaesthesia (DRAMA) during the triennium 2017-2019. All of these patients had received anaesthesia. In 22% of these maternal deaths, the anaesthetic was either the primary or a significant secondary cause of death. There were 921 maternal deaths entered on the Database for the Retrospective Analysis of Maternal Anaesthesia (DRAMA). These were maternal deaths who had received anaesthesia during the triennium 2017-2019. The assessments in all provinces are performed by specialist anaesthetists, who are referred every maternal death who has received an anaesthetic in that specific province.
This special edition of the O and G Forum commemorates 21 years of work by the National Committee for Confidential Enquiry into Maternal Deaths (NCCEMD), and there is an article describing in detail the achievements of this important committee in improving maternal health outcomes and reducing deaths of mothers in South Africa. Whilst this has been a truly collective effort involving national NCCEMD members, provincial assessors, national and provincial MCWH clusters, and the facilities that notified the maternal deaths; in this brief piece I would like to acknowledge the contributions of two stalwarts, whose tenure on the committee has now come to an end.
Deaths due to Non Pregnancy Related Infections remain the leading cause of maternal mortality for the triennium 2017-2019. However, from the year 2011, there has been a continual reduction in both numbers of maternal deaths and maternal mortality ratios, because of the implementation of live long antiretroviral treatment for HIV infection and the prevention of mother to child transmission programmes in South Africa.
Background: The current COVID-19 pandemic caused by the SARS-CoV-2 virus has reached the stage of community spread in South Africa Asymptomatic carriers have been reported amongst pregnant women Against this background, a strategy of universal testing of all patients visiting facilities for antenatal care should be considered, as this information will allow proper planning of obstetric services as well as reducing risk to health care workers and patients
Cerebrovascular accidents at any age is a cause of concern. It is a condition frequently encountered at an old age. The reported frequency for young adults (<45 years) is between as 8.7% to 21% in hospital based studies. The stroke in a young adults have different profile of risk factors than found in old adults. The uncommon causes like coagulation disorders, pregnancy related disorders, systemic inflammatory conditions, illicit drugs, cardiac or vessel disorder should be considered along with the common risk factors of an old age stroke like atherosclerosis. It can result in long term morbidity at a time of decisive career moves and need by socio-familial members. Here, we present a case of cerebral infarction in a young girl who was on oral contraceptive pills for menstrual irregularity, found to have with protein S deficiency during evaluation.
Background: Thyroid disorders are common endocrine disorders affecting pregnant women. Hypothyroidism, hyperthyroidism and thyroid autoimmunity are frequent. This prospective study was undertaken to know the pregnancy outcome in women diagnosed and treated for thyroid disorders. Materials and methods: This was a prospective observational study done in Dr TMA Pai hospital, Udupi. Serum TSH levels were estimated at booking visit and if abnormal, fT3, fT4 and thyroid antibody levels were estimated. Women with hypothyroidism were treated with levothyroxine and hyperthyroidism were treated with propylthiouracil and carbimazole. Serum TSH was estimated every 4 - 6 weeks and dosage adjusted. The pregnancy outcomes studied were abortion, hyperemesis, gestational hypertension, pre-eclampsia, abruptio placenta, gestational diabetes mellitus, preterm delivery and low birth weight. Results: Among 1320 pregnant women screened for TSH levels, 81 had thyroid disorders. The prevalence of thyroid disorders was 6.8%; hypothyroidism in 5.7% and hyperthyroidism in 1.1%. Thyroid peroxidase antibody was positive in 36.5% of hypothyroid women and they needed 37% more dose of levothyroxine. The levothyroxine dose needed was significantly more (133%) in overt as compared to subclinical hypothyroidism. All the variables except hyperemesis had similar rate of occurrence in both groups. Women positive for thyroid peroxidase antibody had more incidence of hyperemesis (8.69%,0), abortion (13%,2.3%), gestational hypertension (13%,4.65%) and LBW (21.7%,9.3%). Conclusion: With a prevalence of 3.5% and complications similar to that of overt hypothyroidism, subclinical hypothyroidism must be identified and treated in pregnancy. Inclusion of TSH screening in the early pregnancy antenatal panel would prevent maternal and perinatal complications due to thyroid disorders in pregnancy.
Since 1999, seven triennial reports have been submitted by the South African National Committee for the Confidential Enquires into Maternal Deaths (NCCEMD) to the Minister of Health along with recommendations on methods to reduce maternal mortality. The committee, via an extensive network of provincial assessors, has documented the rise and fall of maternal deaths with the institutional Maternal Mortality Ratio (iMMR) reaching a peak of 189/100000 live births in 2009 and dropping below 100/100000 live births in 2019 for the first time since the start of the enquiry. All provinces have shown a decline in the iMMR, with the Free State, KwaZulu-Natal, Mpumalanga, North West and Northern Cape halving their iMMR from their peaks. The enquiry documented the dramatic rise in deaths due to non-pregnancy related infections until 2008-2010 and a sharp decline from 2011-2013 deaths due in deaths. Consistently more than 90% of the women who died in this category were HIV positive, and the sharp decline is associated with the widespread availability and use of antiretroviral therapy. A decline in hypertensive disorders of pregnancy deaths from 2005-2007 after an early rise in 2002-2004 was observed and an increase obstetric haemorrhage deaths mostly due to bleeding during and after caesarean delivery, followed by a decrease from 2014-2016 once the problem had been identified and addressed. Unfortunately, there has been a steady rise in early pregnancy deaths and deaths due to pre-existing medical and surgical conditions. Interventions contributing to the downward trends include the introduction of safe antiretroviral therapy regimens, the district clinical specialist teams (DCST), the scale-up of Essential Steps in Managing Obstetric Emergencies (ESMOE) training, BANC plus, the Safe Caesarean delivery programme, and the Hypertensive disorders of pregnancy (HDP) guidelines. The proportion of all deaths that were potentially preventable has declined steadily indicating a steady continual improvement in the quality of care, but the types of missed opportunities and sub-standard care have remained constant. The confidential enquiry into maternal deaths (CEMD) system in South Africa has been very useful in describing the causes of maternal death, both pathological and health system failures, and for suggesting effective interventions which were adopted in the National Department of Health's Strategic Plans.
