OBJECTIVE:This study aimed to describe maternal and perinatal outcomes among pregnant women with echocardiographically high probability of pulmonary arterial hypertension (PAH) managed at a quaternary center and to compare outcomes between women with and without cardiac complications (CC). METHODS:This retrospective cohort study included pregnant women with echocardiographically estimated high probability of PAH and managed at a referral center between 2015 and 2022. Clinical, obstetric, and neonatal outcomes were obtained from medical records. CC were defined as heart failure, pulmonary edema, arrhythmia, pulmonary embolism, or maternal death during pregnancy or up to 6 weeks postpartum. Outcomes were compared between women with and without CC. Receiver operating characteristic (ROC) curve analysis was performed as an exploratory analysis to assess the discriminatory ability of pulmonary artery systolic pressure (PASP) for CC. RESULTS:Sixty-two pregnancies in 60 women (mean age 24.5 ± 6.5 years) were analyzed. Eight pregnancies (12.9%) were electively terminated, while 54 (87.1%) continued. CC occurred in 11 pregnancies (17.7%), mainly heart failure. Four maternal deaths (6.5%) were recorded. Among ongoing pregnancies, the median gestational age at delivery was 37.1 weeks, and the median birthweight was 2445 g. Fetal growth restriction occurred in 27.7%, and 62.9% of deliveries were by cesarean section. Neonatal mortality was 5.5%. In exploratory analysis, a PASP threshold of 64 mmHg predicted CC with 91% sensitivity and 60% specificity (area under the curve = 0.749). CONCLUSION:Pulmonary arterial hypertension is a high-risk condition in pregnancy, with substantial maternal and perinatal complications. Although maternal mortality was lower than historically reported in similar settings, the incidence of CC remained considerable. PASP might reflect disease severity and shows exploratory discriminatory ability but requires cautious interpretation.
OBJECTIVE:This study estimates the prevalence of various forms of intimate partner violence (IPV) and examines their associations with depressive and post-traumatic stress disorder (PTSD) symptoms among lesbian and bisexual women (LBW) in India. METHODS:This cross-sectional online survey included 53 self-identified LBW college women in India. Participants were recruited through social media platforms, instant messaging applications, and student listservs. Interested participants were invited to complete an online survey assessing IPV experiences and symptoms of depression and PTSD. RESULTS:Overall, 58.5% of participants reported experiencing at least one form of IPV. Psychological IPV was most prevalent (49.1%), followed by digital IPV (34%), physical IPV (28.3%), injuries (26.4%), and sexual IPV (26.4%). Approximately 26.4% of participants met the threshold for probable depression and 30% for probable PTSD. Correlational analyses revealed significant associations between various forms of IPV and symptoms of depression and PTSD. Negative binomial regression analyses indicated that experiencing IPV, particularly psychological and digital IPV, was associated with higher levels of depressive and PTSD symptoms. CONCLUSION:This exploratory study observed substantial IPV prevalence among lesbian and bisexual college women in India, highlighting its impact on mental health symptoms. Targeted interventions designed to address both IPV and its associated mental health consequences can potentially enhance help-seeking behavior within this vulnerable population.
Surgery continues to be a mainstay of treatment for patients with symptomatic fibroids. Hysterectomy is an option for those desiring definitive treatment and myomectomy is preferred for those that have not yet completed childbearing or wish to retain their uterus. While open laparotomy remains a viable approach to both hysterectomy and myomectomy, minimally invasive techniques for the surgical management of symptomatic fibroids are preferred options for many due to improved patient outcomes. These include hysteroscopic myomectomy, laparoscopic and robotically assisted myomectomy, and vaginal, laparoscopic, and robotically assisted hysterectomy. Patients have a faster recovery and less postoperative pain compared to a laparotomic approach. More recently, uterine-sparing outpatient modalities such as ultrasound-guided radiofrequency ablation and high-intensity focused ultrasound have emerged as promising alternatives for selected patients. Benefits include clinically significant reduction in fibroid size and menstrual bleeding with small or no abdominal incisions and an expedited convalescence. This article reviews preoperative evaluation and imaging for fibroids, as well as the techniques, approach, indications, patient selection, procedural management, and surgical and fertility outcomes for each surgical and procedural management of uterine fibroids.
OBJECTIVE:In the present study, we aimed to evaluate the impact of vaginal birth after cesarean (VBAC) on quality of life, sexual function, sleep quality, and urinary incontinence and compare the results with those of vaginal birth (VB) and cesarean delivery (CD) via validated questionnaires. METHODS:A single-center retrospective cross-sectional observational study was conducted at the Bezmialem Vakıf University between 2017 and 2022. The participants were classified into three groups: VB (n = 49), CD (n = 54), and VBAC (n = 55). Postpartum maternal health outcomes were assessed via validated questionnaires: the Pittsburgh Sleep Quality Index (PSQI), Female Sexual Function Index (FSFI), Postpartum Quality of Life (PP-QoL), and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Statistical analyses were performed using SPSS version 29.0. RESULTS:There were no significant differences among the groups in terms of total PSQI scores or ICIQ-SF scores. However, the total FSFI and PP-QoL scores were significantly higher in the VBAC group (P < 0.001). Among the FSFI subdomains, only desire and pain scores remained significantly different after Bonferroni correction. CONCLUSION:Our findings suggest that while sleep quality and urinary incontinence symptoms did not significantly differ among the delivery groups, PP-QoL and FSFI scores were higher in the VBAC group than in the VB and CD groups.
OBJECTIVE:Mifepristone improves the effectiveness of medical termination of pregnancy (mTOP) but is expensive and restricted in some settings. Letrozole has been proposed as a potential alternative. This study aimed to evaluate whether letrozole is non-inferior to mifepristone as a pre-treatment for mTOP. METHODS:We conducted an assessor-blinded, randomized controlled non-inferiority trial comparing mifepristone versus letrozole pre-treatment for mTOP. Participants were randomized to one of two groups: the control group received oral mifepristone 200 mg on Day 1, while the intervention group received oral letrozole 10 mg daily from Day 1 to Day 3. On Day 3, both groups received per-vaginal misoprostol 800 mcg, followed by an additional 400 mcg after 4 h if there were no signs of abortion. Follow-up was conducted by Day 28 post-mTOP. The primary outcome was complete abortion, defined as a negative urine pregnancy test with no ongoing vaginal bleeding and no need for surgical evacuation by Day 28. Data was analyzed using SPSS Version 30.0. RESULTS:The intention-to-treat analysis included 135 participants, with a mean gestational age of 8.2 weeks. Complete abortion occurred in 72.1% (49/68) of the letrozole group compared with 85.1% (57/67) of the mifepristone group, with an absolute risk difference of -13.0% (95% CI -26.4 to +0.9). The lower bound of the 95% CI crossed the prespecified non-inferiority margin of -15%, so non-inferiority was not demonstrated. CONCLUSION:Letrozole could not be shown to be a non-inferior alternative to mifepristone as pre-treatment for mTOP. TRIAL REGISTRATION:This study was registered with ClinicalTrials.gov (ID: NCT05341817) on April 5, 2022, and received ethics board approval from the SingHealth Centralized Institutional Review Board (CIRB 202110-00035).
OBJECTIVE:The aim of the present study was to evaluate the association between intertwin birth weight discordance and fetal and neonatal outcomes in twin pregnancies, and to assess its relationship with mode of delivery. METHODS:This retrospective cohort study included twin pregnancies delivered at a tertiary referral center. Intertwin birth weight discordance was calculated as the percentage difference between the larger and smaller twin and categorized as 0%-15%, 15%-25%, and >25%. Fetal and neonatal outcomes were analyzed as predefined composite outcomes. Multivariable logistic regression models were used to assess associations, adjusting for gestational age at delivery, antenatal corticosteroid exposure, chorionicity, and mode of delivery. RESULTS:A total of 1408 twin pregnancies (2816 newborns) were included. In bivariate analyses, higher intertwin birth weight discordance was associated with increased rates of adverse fetal and neonatal outcomes. However, after adjustment, birth weight discordance was not significantly associated with the fetal composite outcome (discordance >25%: odds ratio [OR] 2.55; 95% confidence interval [CI]: 0.89-7.27), although the magnitude of the effect suggested a possible increased risk, nor the neonatal composite outcome (OR 1.53; 95% CI: 0.97-2.40). Gestational age at delivery was inversely associated with both fetal (OR 0.75 per week; 95% CI: 0.66-0.84) and neonatal composite outcomes (OR 0.54 per week; 95% CI: 0.45-0.65). Cesarean delivery (OR 2.26; 95% CI: 1.58-3.25) and antenatal corticosteroid exposure (OR 1.75; 95% CI: 0.99-3.08) were associated with increased odds of neonatal composite morbidity. CONCLUSION:Intertwin birth weight discordance was not independently associated with adverse fetal or neonatal outcomes after adjustment. Prematurity emerged as the main determinant of perinatal risk, supporting interpretation of birth weight discordance as a contextual marker rather than an independent determinant of delivery strategy or timing.
OBJECTIVE:Obstructed labor is a preventable cause of maternal and perinatal mortality, with a disproportionately high burden in low-resource settings. In Somalia, decades of conflict have fragmented the health system, contributing to one of the world's highest maternal mortality ratios. The aim of the present study was to identify the determinants of obstructed labor among women delivering at Banadir Hospital, Mogadishu, Somalia. METHODS:A hospital-based unmatched case-control study was conducted from June to August 2025. A total of 450 participants were enrolled. Data were collected using a structured questionnaire through participant interviews. Multivariable logistic regression analysis was performed to identify independent risk factors associated with obstructed labor. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULTS:Cephalopelvic disproportion was the primary cause of obstructed labor (63.3%). Significant independent risk factors included diabetes in pregnancy (aOR = 9.09, 95% CI: 2.73-30.29), being referred from another health facility (aOR = 7.00, 95% CI: 2.98-16.46), labor duration ≥12 h (aOR = 5.11, 95% CI: 2.71-9.63), and attending fewer than four antenatal care (ANC) visits (aOR = 3.71, 95% CI: 1.21-11.40). Other determinants included residing outside Mogadishu (aOR = 2.84, 95% CI: 1.16-6.93), maternal overweight body mass index (BMI) (aOR = 2.56, 95% CI: 1.36-4.82), neonatal birth weight ≥3.5 kg (aOR = 2.41, 95% CI: 1.37-4.24), and a previous history of obstructed labor (aOR = 2.06, 95% CI: 1.20-3.53). Primiparity was also a major risk factor, as multiparity demonstrated a 90% reduction in risk (aOR = 0.10, 95% CI: 0.05-0.23). CONCLUSION:Obstructed labor in Mogadishu is driven by a convergence of physiological vulnerabilities and systemic health system failures, characterized by the three delays in accessing and receiving care. To reduce the burden of this condition, interventions must focus on strengthening the continuum of care. Key priorities include improving early risk identification and diabetes screening during ANC, streamlining referral pathways from peripheral clinics, and ensuring the consistent use of partographs for intrapartum monitoring to prevent dangerously prolonged labor.
OBJECTIVE:Anti-Müllerian hormone (AMH) and antral follicle count (AFC) are usually correlated, yet discordance might complicate counseling in elective fertility preservation (EFP). This study evaluated whether discordant ovarian reserve markers affect oocyte yield in healthy women undergoing EFP. METHODS:This retrospective cohort study included 230 healthy women aged 30-41 years undergoing their first EFP cycle at a university-affiliated tertiary fertility unit. Participants were categorized based on AMH (<1.1 or ≥1.1 ng/mL) and AFC (<7 or ≥7) thresholds. Analyses focused on concordant versus discordant AMH-AFC groups. The primary outcomes were the number of oocytes retrieved and vitrified. Multivariable linear regression assessed independent predictors of oocyte yield. RESULTS:The overall discordance rate was 30.43%. Women in Group 1 - Normal AFC (≥7) with low AMH (<1.1 ng/mL) (n = 67) had significantly fewer retrieved (mean 6.7 ± 4.5) and vitrified oocytes (mean 4.9 ± 3.4) than those in Group 4 - Normal AFC (≥7) with normal AMH (≥1.1 ng/mL) (n = 149; 14.6 ± 8.1 and 10.6 ± 6.8, respectively; P < 0.001), which represented the two largest study groups. AMH was the strongest independent predictor of oocyte yield. Discordance independently contributed additional explanatory value for the number of retrieved oocytes, with discordant patients predicted to achieve fewer oocytes than concordant-normal counterparts. The concordance status did not significantly affect the number of vitrified oocytes. CONCLUSION:AMH-AFC discordance (specifically low AMH in the presence of normal AFC) is an independent predictor of reduced oocyte yield in EFP but not of the number of vitrified oocytes. Joint interpretation of both markers might facilitate more accurate patient counseling and expectation management.
OBJECTIVE:Congenital toxoplasmosis (CT) remains a major global health concern, with particularly high incidence in Latin America. Despite its relevance, prospective data from Brazilian cohorts are scarce. METHODS:We conducted a prospective cohort study at the Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG/UFRJ), Rio de Janeiro, including 55 pregnant women with confirmed Toxoplasma gondii infection and their infants (January 2022-April 2025). Maternal sociodemographic, obstetric, behavioral, and clinical data were collected prospectively. Infants were classified as infected or exposed based on serological, molecular, radiologic, and clinical criteria. Regression analysis was used to compare the groups. RESULTS:Among 55 mother-infant pairs followed, 11 (20%) infants were diagnosed with CT. No significant associations were observed with maternal sociodemographic or environmental factors. However, mothers of infected infants had diagnosis later during gestation (24.3 vs. 16.4 weeks; P = 0.02), cohort entry later during gestation (31.2 vs. 24.3 weeks; P = 0.02), and more prenatal visits (7.7 vs. 4.9; P = 0.04 visits) (more prenatal visits likely reflecting increased monitoring after diagnosis). Adenomegaly (P = 0.04) and other systemic symptoms (P = 0.05) were more frequent among mothers of infected infants. Neonatal parameters did not differ significantly, but five infected infants presented neuroimaging abnormalities, five had ophthalmologic lesions, and six tested positive for IgM and/or PCR. CONCLUSION:Toxoplasmosis diagnosis later during gestation and symptomatic maternal infection were associated with CT. These findings highlight the need for systematic maternal screening, considering maternal clinical manifestations, timely referral, and close clinical monitoring to prevent vertical transmission and adverse neonatal outcomes.
OBJECTIVE:This study evaluates the diagnostic performance of two-dimensional (2D) microvascular flow imaging combined with standardized ultrasound markers for predicting placenta accreta spectrum disorders in pregnancies complicated by placenta previa or low-lying placenta. METHODS:This prospective observational study included 61 women with placenta previa or low-lying placenta who underwent cesarean delivery between 32 and 38 weeks of gestation. All participants underwent standardized 2D microvascular flow imaging using the Samsung Hera W10 Elite system. The microvascular vascularization index was quantified as the percentage ratio of color-coded vascular pixels within a defined placental region of interest. Conventional Doppler indices and standardized ultrasound markers associated with placenta accreta spectrum were recorded. Placental invasion was confirmed histopathologically in 23 patients. Statistical analyses included Mann-Whitney U-testing, receiver operating characteristic (ROC) analysis, 95% confidence interval estimation, pairwise ROC comparison using the DeLong method, and exploratory internally validated machine-learning classification models. To avoid conceptual overlap and double counting, the total placenta accreta spectrum (PAS)score was excluded from the corrected machine-learning models. Intraobserver reproducibility of repeated MVI measurements was assessed using the intraclass correlation coefficient. RESULTS:The vascularization index was significantly higher in PAS cases than controls (47.65 ± 9.35 vs. 26.58 ± 8.93, P < 0.001). Conventional Doppler parameters did not differ significantly between groups. ROC analysis identified the vascularization index as the strongest single quantitative predictor of PAS, with an AUC of 0.985, sensitivity of 95.7%, and specificity of 97.4% at a cut-off value of 37.11. The corrected Placental Invasion Risk Score, calculated without the total PAS score, showed excellent diagnostic performance, with an AUC of 0.998. Exploratory machine-learning models excluding the total PAS score demonstrated improved discrimination after inclusion of the vascularization index, with logistic regression achieving an AUC of 0.990. Intraobserver reproducibility of repeated MVI measurements was excellent, with an intraclass correlation coefficient (ICC) of 0.977. For prediction of cesarean hysterectomy, the vascularization index also demonstrated excellent discriminatory performance at an optimal cut-off value of ≥53.51. CONCLUSION:The 2D MV-Flow vascularization index is a strong quantitative biomarker for predicting PAS in pregnancies complicated by placenta previa or low-lying placenta. When combined with individual ultrasound markers, but not redundantly with the total PAS score, it may improve antenatal risk stratification and preoperative planning. However, the exploratory machine-learning findings require external validation in larger multicenter cohorts.
OBJECTIVE:This study examined the association between fear of childbirth (FOC) and exposure to violence during pregnancy, identified using diagnoses based on the International Classification of Diseases, 10th Revision. METHODS:This population-based cohort study included 1 177 569 births in Finland between 2000 and 2020. Data from the Finnish Medical Birth Register and the Hospital Discharge Register were used to identify women diagnosed with FOC and exposure to violence. Logistic regression analyses were conducted to estimate crude and adjusted odds ratios (ORs) with confidence intervals (CIs), adjusting for major sociodemographic and clinical factors. RESULTS:Fear of childbirth was diagnosed in 23 246 women (2.0%), while 1 154 323 women (98.0%) had no diagnosis of FOC. Women with FOC had a higher prevalence of exposure to violence (0.9%) compared with women without FOC (0.3%). The association remained strong after adjustment for confounders (adjusted OR 3.07; 95% CI 2.66-3.54). A higher prevalence of FOC was observed among parous compared to nulliparous women, divorced women, students, and women experiencing long-term unemployment. CONCLUSION:Women with FOC were substantially more likely to have been exposed to violence. Recognizing FOC as a potential marker of underlying vulnerability might facilitate earlier identification, timely referral, and more responsive psychological and obstetric care.
OBJECTIVE:Given the recognized role of chronic low-grade inflammation in polycystic ovary syndrome (PCOS), the aim of the present study was to investigate the role of the serum high-mobility group box 1 (HMGB1)-Toll-like receptor 4 (TLR4)-interferon beta (IFN-β) signaling axis and its association with immune-metabolic dysfunctions in women with PCOS. METHODS:This was a case-control study involving 90 Iraqi women aged 18-45 years, including 50 newly diagnosed PCOS patients and 40 healthy controls. Serum levels of HMGB1, soluble Toll-like receptor 4 (sTLR4), and INF-β were measured using enzyme-linked immunosorbent assay (ELISA). An automated analyzer was employed to assess the hormonal profile. Molecular docking simulations were performed using MOE software to evaluate the interaction of HMGB1 with both membrane-bond TLR4 and its soluble form. RESULTS:The PCOS group exhibited significant alterations in hormonal profiles compared to healthy controls. Serum levels of HMGB1, sTLR4, and INF-β were significantly elevated, consistent with a state of low-grade inflammation. Molecular docking analysis demonstrated favorable binding of HMGB1 to both TLR4 and sTLR4, with a slightly stronger affinity for sTLR4 (-7.20 kcal/mol; RMSD 2.13 Å) than TLR4 (-6.23 kcal/mol; RMSD 1.73 Å). CONCLUSION:The HMGB1-TLR4-INF-β signaling axis appears to contribute to low-grade inflammation in PCOS. The soluble form of TLR4 may act as a regulatory modulator that attenuates inflammatory signaling. The integration of biochemical and computational data findings provides novel insights into immune-metabolic dysregulation in PCOS and highlights potential therapeutic targets for modulating inflammation.
OBJECTIVE:This study develops and validates an integrated assessment system based on hysteroscopic features of microvascular morphology, lesion appearance, and extent, aiming to standardize the observational protocol and provide auxiliary judgment for diagnosing endometrial malignant lesions, especially for less experienced practitioners. METHODS:Data from 168 patients who underwent hysteroscopy with initial suspicion of endometrial malignant lesions at Hubei Maternal and Child Health Hospital from March 2020 to June 2021 were retrospectively analyzed. Hysteroscopic findings were systematically recorded according to lesion extent (localized/diffuse), microvascular classification (Type I-IV), morphological type (polypoid, nodular, papillary, ulcerative, hyperplastic), and the presence of necrosis or calcification. Biopsies were taken from suspicious areas for pathological examination. Using histopathology as the gold standard, the diagnostic performance of each indicator was evaluated. RESULTS:First, microvascular classification showed a significant correlation with lesion malignancy: Types I-II were most frequent in the hyperplasia without atypia group (68.6%), Type III was most frequent in the atypical hyperplasia group (54.9%), and Type IV was most frequent in the endometrial cancer group (48.4%). Second, among morphological types, the papillary pattern had the highest occurrence in the endometrial cancer group (58.1%) and, together with Type IV vessels, was significantly associated with malignant lesions (P < 0.001). Third, the proportion of postmenopausal patients in the endometrial cancer group was 64.5%, significantly higher than that in the benign group (P < 0.01). Fourth, a diagnostic model combining microvascular classification, lesion extent, and morphological type demonstrated excellent predictive value, with an AUC of 0.950 (95% CI: 0.912-0.989), a sensitivity of 87.1%, and a specificity of 84.7%. Finally, in this study, the under-diagnosis rate was 3.6%, and the over-diagnosis rate was 8.9%. CONCLUSION:The hysteroscopic microvascular and morphological classification system aids in distinguishing between benign and malignant endometrial lesions. Specifically, a papillary appearance and Type IV vessels are important indicators suggestive of malignancy. Combining multiple indicators improves diagnostic accuracy and can serve as an auxiliary tool for hysteroscopists, particularly for beginners.
OBJECTIVE:Laparoscopic ultrasound (LUS), performed with an endoscopic ultrasound probe, has shown potential in addressing challenges related to haptic perception and lesion detection in minimally invasive surgery. The aim of the present study was to evaluate the learning curve of gynecologic surgery fellows in achieving competency in LUS image acquisition during minimally invasive procedures. METHODS:This prospective single-center study included six gynecologic fellows with limited ultrasound experience who completed a one-day structured training program. Fellows performed laparoscopic ultrasound during elective surgeries for benign conditions and early-stage gynecologic cancers, assessing five anatomical sites. Competency was evaluated using learning curve cumulative summation (LC-CUSUM) analysis based on image quality and examination time. Learning curve time and quality score for each surgeon and anatomical site were measured. RESULTS:A total of 56 patients and examinations were analyzed. All fellows achieved competency within 2-5 procedures, with LC-CUSUM showing rapid and sustained skill acquisition. Ovarian imaging required fewer attempts than myometrial wall and iliac vessel imaging, with the right external iliac vessels being the most challenging. Patient characteristics did not differ among fellows. CONCLUSION:After targeted training, gynecologic surgery fellows can achieve proficiency in LUS within a short learning curve. These findings support the feasibility of integrating LUS training into gynecologic surgical education and highlight its potential to enhance surgical precision and to reduce surgical overall time.
Domestic violence and abuse (DVA) remains a major public health and human rights concern, with profound consequences for women's physical, psychological, and socioeconomic well-being. We report the case of a 32-year-old married woman and mother of two who experienced prolonged domestic violence, including physical, emotional, and economic abuse, compounded by her husband's alcohol dependence. Economic abuse escalated when debt incurred through a self-help group loan, intended to support the family's livelihood, was transferred to the survivor, reinforcing financial dependency and coercive control. Following a severe episode of physical violence that resulted in her displacement from the marital home, she sought support through a hospital-based crisis center established within a tertiary care women's hospital. Through crisis intervention, structured counseling, legal guidance, child welfare support, and employment assistance, the survivor achieved financial independence, secured safe accommodation, and initiated steps toward legal separation. This case highlights the often-overlooked role of economic abuse and debt bondage as mechanisms of control within abusive relationships. It also demonstrates the value of integrated, hospital-based crisis services and intersectoral collaboration in supporting survivors of violence. Strengthening routine identification of DVA within healthcare settings, expanding access to crisis centers, and promoting women's economic empowerment may contribute to improved safety and long-term recovery for survivors.
BACKGROUND:Tuberculosis remains a significant cause of extrapulmonary disease in endemic regions. Genital tuberculosis most commonly affects the fallopian tubes and endometrium, while cervical involvement is rare. Presentation as a cervical mass is particularly uncommon and may closely mimic cervical cancer, leading to diagnostic challenges. CASE:We report a case of a woman in her 40s with a history of long-standing secondary amenorrhea for 12 years who presented with postcoital bleeding. Clinical examination revealed a cervical growth. Histopathological evaluation of the cervical biopsy demonstrated inflammation with granulomas, no evidence of malignancy was identified. The tissue was positive for ZN stain and MGIT. MANAGEMENT AND OUTCOME:The patient was initiated on standard anti-tubercular therapy for 6 months. Patient had resolution of symptoms and interval reduction in cervical lesion at 6 months follow-up. CONCLUSION:Cervical tuberculosis, though rare, should be considered in the differential diagnosis of suspected carcinoma cervix, particularly in patients from endemic areas.
Accurate, timely diagnosis of postpartum hemorrhage (PPH) is critical for effective management. However, in low-resource settings, reliance on visual estimation leads to missed diagnoses in up to 50% of cases, underscoring the need for more objective and reliable methods. Evidence suggests that the use of tools for objective measurement of blood loss, such as calibrated drapes, can improve early detection and prompt treatment of PPH. This article shares learning from the Accelerating Measurable Progress and Leveraging Investments for Postpartum Hemorrhage Impact (AMPLI-PPHI) project's experience introducing calibrated drapes for PPH detection in coordination with governments of Nigeria and Zambia and supporting county government-led rollout in Kenya. Early implementation revealed key lessons including the importance of engagement of ministries of health and key stakeholders in decision-making on the type of calibrated tool to use. Care must be taken to prepare healthcare providers, communities, government authorities, and other stakeholders about the potential increase in reported PPH cases due to more accurate measurement and diagnosis. Persistent challenges remain concerning safe waste disposal and ensuring monitoring of blood loss and vital signs, including documentation of checks every 15 min in the first hour, as recommended by 2025 WHO-FIGO-ICM guidelines. Additionally, context-specific considerations may be required for scale-up of objective measurement of postpartum blood loss, such as understanding the cultural dynamics related to blood measurement and afterbirth practices, and ensuring the workforce is sufficient in numbers and capacity to provide close monitoring and measurement of blood loss necessary for early PPH detection.
Ensuring the availability of quality medicines is fundamental to achieving health outcomes and safeguarding public health. However, in many low- and middle-income countries, especially across Africa, the current quality assurance paradigm-largely driven by historical donor preferences for WHO prequalification and stringent regulatory authority approval-can unintentionally limit access, equity, and sustainability. While these requirements have been effective in ensuring client safety, they can result in higher expenditures, reduced coverage, and deepening inequities. Moreover, such narrow focus risks undermining the authority of national regulatory authorities (NRAs), diminished economic development opportunities, erosion of trust in local health systems, and vulnerabilities to external shocks. This paper argues for a more inclusive approach to defining quality standards for procurement eligibility. It proposes qualifying for procurement products with marketing authorizations granted by NRAs that have achieved at least Maturity Level 3-a designation based on the WHO Global Benchmarking Tool that indicates a stable, well-functioning, integrated regulatory system; establishing financing mechanisms to minimize the budget impact of more costly quality medicines; promoting regulatory reliance through regional harmonization; and investing in system-wide regulatory strengthening. Such a model would not only enhance access to safe and effective medicines but also foster local regulatory capacity, support domestic pharmaceutical industries, reduce overdependence on donors and imported products, and promote self-reliance. By rethinking quality assurance strategies and aligning them with regional progress and aspirations, Africa can build more resilient, autonomous health systems and advance toward sustainable health equity.
The role of professional associations in the health ecosystem is crucial as they establish and uphold standards of professional practice, ethics, and continuing education, thereby safeguarding patient welfare and promoting accountability among practitioners. Their role is particularly important in combating postpartum hemorrhage (PPH), as outlined in the WHO PPH Roadmap's four strategic pillars: research, norms and standards, implementation, and advocacy. Professional societies, such as obstetrics/gynecology and midwifery associations and other collaborating cadres, such as anesthetists and pharmacists, can elevate PPH as a political and public health priority by raising awareness of its prevention and treatment. Advocating for access to quality uterotonics like heat-stable carbetocin is critical for effective PPH management, especially in countries that lack effective cold chain or have supply chains that cannot guarantee access to quality oxytocin. The Accelerating Measurable Progress and Leveraging Investments for Postpartum Hemorrhage Impact (AMPLI-PPHI) project, through the professional associations across six countries (Democratic Republic of the Congo, Guinea, India, Kenya, Nigeria, and Zambia), aimed to generate implementation evidence, create an enabling environment, and prepare national supply chains and markets for the adoption of three WHO newly recommended PPH drugs: heat-stable carbetocin, tranexamic acid, and misoprostol for advance distribution, in low- and middle-income countries. The Policy Change Cycle tool and SMART Advocacy approach were used during the project to influence government action on PPH management and commodity adoption. Progress was tracked and reviewed using the SMART Advocacy tool. Across six diverse countries, professional associations of obstetrics and gynecology successfully advocated for the institutionalization of WHO-recommended PPH interventions, by leveraging their trusted relationship with government, employing strategic advocacy frameworks, and navigating complex policy environments. Key enablers included the credibility of professional associations with Ministries of Health, strong collaboration among stakeholders, and alignment with government priorities. Barriers included insufficient government budget allocation to implement the PPH interventions nationwide, as well as professional associations' limited financial resources and insufficient capacity for effective advocacy. The AMPLI-PPHI experience demonstrates that national health professional associations, when supported with adequate financing and technical advocacy skills, can be powerful catalysts of health policy and practice. Formalizing and strengthening the role of professional associations in global and national health policy processes and advocacy is essential for accelerating progress toward achieving maternal health goals and building resilient, evidence-driven health systems.
Postpartum hemorrhage (PPH) affects about 6%-10% of women giving birth and is the leading cause of maternal mortality worldwide. Following its launch in the Democratic Republic of the Congo, Guinea, India, and Kenya in October 2022, and more recently in Nigeria and Zambia, the Unitaid-supported Accelerating Measurable Progress and Leveraging Investments for Postpartum Hemorrhage Impact (AMPLI-PPHI) project established regional and national exchange networks and learning hubs. These networks aim to propel dynamic learning and build on existing partnerships, through country and state level obstetrics and gynecology societies, under the umbrella of FIGO. As part of the AMPLI-PPHI project's exchange hub activities, professional associations in the target countries organized webinars, in-person meetings, and maintained regular communication through regional events, emails, and phone calls to share various aspects of the project with their colleagues in the platform. These hubs facilitated the transfer and application of learning from target countries to help propel PPH prevention, detection, and treatment across all exchange countries. In addition to these exchanges and as part of the hubs, target countries undertook advocacy training through cross-country learning sessions. This contributed to strengthened clinical leadership in women's health to raise their voices more effectively regarding the scale-up and expansion of access to life-saving medicines and essential health products for PPH. While this article focuses particularly on the work in Guinea, it also shares key lessons learned from all project target countries and their extended exchange hubs. The hubs have created an effective network of professional associations that can share evidence and clinical lessons, accelerating required processes and enabling effective wider adaptation and scale-up of essential and innovative PPH products.
