Introduction Advanced abdominal pregnancy (AAP) is a pregnancy of over 20 weeks gestation, with a foetus living, or showing signs of having once lived and developed, in the mother's abdominal cavity. It is a rare obstetric complication associated with high maternal and perinatal morbidity and mortality. The question of whether to leave the placenta in or to remove it has been the subject of debate. When such cases present outside high resource settings, where a multi-disciplinary approach may not be possible, there are many challenges to effective treatment. The management of this rare but serious complication of pregnancy at Rob Ferreira Hospital (RFH), a rural provincial tertiary hospital, in Mpumalanga, was investigated. Methods This was a retrospective observational study of patients with AAP identified from theatre registers from January 2011 to January 2018 at RFH. Data was collected on patient demographics, diagnostic challenges, preoperative evaluation, and surgical management particularly of the placenta, and outcomes. Delivery data for RFH was retrieved from the provincial database. Results There were 26 cases of AAP identified, for which 21 folders could be retrieved from the registry. The incidence of AAP was 66.2 per 100, 000 deliveries. Abdominal pain was a presenting complaint in 100% of patients. Ultrasound scan (USS) accuracy, prior to surgery, was eventually 90.5%. However, for 61.9% the diagnosis of AAP was missed at initial USS and for 33% of these, AAP was only diagnosed after failed attempts at induction of labour (IOL). AAP was diagnosed intra-operatively in 9.5%, for a supposed caesarean delivery and 19 (94.7%) were diagnosed pre-operatively. Intra-operatively, 36.8% patients had placental site bleeding for which partial placental removal was 2 necessary in 71.4%. This group had more adverse maternal outcomes. For 73.7% of patients there was no bleeding from placental bed and the placenta was left in situ; but 7.1% required relook laparotomy for haemorrhage. There was one maternal death. Overall neonatal survival rate was 14.3% and pregnancy loss rate was 71.4%. Conclusion This study shows that planned management of AAP in a resource constrained setting with tailored approach and management, can be performed without compromising maternal outcomes. However, poor outcomes occurred when pre-operative diagnosis was not made and AAP was discovered during emergency CS, emphasising the importance of antenatal diagnosis. USS and a high index of suspicion remains the best diagnostic tool. From this study it appears safe to leave the placenta undisturbed unless it can be safely removed, or the patient is already bleeding from the placental site. There were very low neonatal survival rates, and this needs to inform counselling of patients with AAP.

BACKGROUND Recurrent disease after cervical excisional procedures has been linked to many factors. We aim to determine if positive margins and crypt involvement increased the rate of recurrence of premalignant disease in patients who had excisional procedures. METHODS In this retrospective review of the colposcopy database, patient records and pathology database, women who had cervical excisional procedures at the Groote Schuur Hospital colposcopy clinic in 2010 were followed up until 2015. Recurrence was based on high grade cytology or histology at follow up. Chi-square tests were used to compare recurrence rates. RESULTS Two hundred and seventy women were included in the final analysis. 130 women had CIN 3 and 94 had CIN 2 at the excisional procedure. Eighty five (31.5%) had endo-margin involvement, 46 (17%) had ecto-margin involvement, and 24 (8.9%) had dual margin involvement. Two hundred and thirteen (79.2%) had crypt involvement. Recurrence occurred in 30 (19.4%) of the 155 patients we had follow up data on. Of those that recurred, 19 (P<0.001) had positive endo-margin involvement, 10 (P=0.007) had ecto-margin involvement, 9 (P< <0.001) had dual margin involvement, and 28 (P=0.058) had crypt involvement. 155 women (43%) were lost to follow-up CONCLUSION Positive margins at excisional procedure of the cervix have a statistically significant increased risk of recurrence of pre-malignant disease. There was a trend towards recurrence of disease in those who have crypt involvement. In limited resource setting follow up protocols can be adjusted so that women without margin involvement can be seen at longer intervals.

Includes bibliographical references (leaves 231-252). / Infertility is a common reproductive health problem in Africa. The experiences of men and women who are unable to conceive, their constructs of infertility, their motives for parenthood, and their health-seeking behaviour are, however, inadequately documented in South Africa. In order to improve our understanding of the patients' perspective of infertility, seven studies were conducted employing both qualitative and quantitative research methodology. Study participants were recruited from the infertility clinic at Groote Schuur Hospital, Cape Town, a tertiary referral centre within the public health care system. The central themes explored in the qualitative studies included reproductive health knowledge, health-seeking behaviour, barriers to health care, experiences related to involuntary childlessness, and the reality of infertility and HIV infection. Data from both men and women were collected through in-depth interviews, and the results were analysed according to the principles of descriptive analysis. In the quantitative studies psychological distress was measured and motives for parenthood were assessed with the use of two standardised instruments ( the Symptom Checklist-90-R for the measurement of acute psychological symptom status and the parenthood motivation list). In addition, participants' attitudes towards reproduction in HIV-infected individuals were evaluated. Standard statistical methods were used to analyse quantitative data. The results of these studies demonstrated that men and women had limited knowledge about fertility, infertility, and biomedical infertility management. Some men and women held traditional beliefs and had accessed traditional healers. Most informants appeared highly motivated to engage in biomedical infertility management. Treatment satisfaction varied and reasons for non-compliance were both service and patient-related. Infertile couples gave many reasons for wanting a child and expressed a strong desire for parenthood. For many men and women the inability to conceive was associated with negative emotions, marital instability, abuse, stigmatisation, and loss of social status. Psychological distress levels were significantly higher in infertile women when compared to women using contraception, and in infertile men when compared to fertile men. Infertile women who reported intimate partner abuse were particularly distressed. The diagnosis of HIV infection did not eliminate the wish for a child in infertile couples, and in the absence of medical assistance many continued to attempt conception. The concomitant experience of infertility and HIV infection was associated with considerable suffering The majority of HIV-negative, infertile men and women opposed reproduction in HlV-positive couples. Collectively, the results of these studies provide new insights into the manner in which men and women who access the public health system in South African construct, experience, and respond to infertility. Understanding those details of the patients' perspective should improve the management of infertility in this patient population.

Includes bibliographical references (leaves 29-32). / Venous thromboembolism (VTE) is a major cause of maternal mortality worldwide. In many developed countries, all maternal deaths are investigated, and accurate statistics are available. In United Kingdom (UK) for example, VTE is the leading cause- and is increasing despite heightened awareness of risk factors, and wider use of thromboprophylaxis (1,2). The 1994-96 UK Confidential Enquiries reported an overall maternal mortality rate of 12.2 per 100, 000 deliveries, with specific mortality from VTE at 2.2 per 100, 000 deliveries, with approximately 15 deaths a year due to VTE.

Includes abstract. / Includes bibliographical references. / Adenomyosis, defined as the presence of ectopic endometrial tissue in the myometrium, is a cause of morbidity in afflicted women. Classically it presents with menorrhagia, dysmenorrhoea and dyspareunia. Traditionally the diagnosis has been by histology of post-hysterectomy specimens with reported prevalence of 5%-70%. With advances in imaging techniques, pre-surgical diagnosis can be made with a reasonable accuracy using trans-vaginal ultrasound (TVS) and magnetic resonance imaging (MRI) with the former being preferred due to cost effectiveness. Accurate presurgical diagnosis would facilitate alternative treatment options to hysterectomy. Different sonographic features of adenomyosis have been reported and well correlated with histology; there is however no general consensus as to the most specific features and whether the frequencies of these sonographic features hold true in other population settings like South Africa. We therefore conducted a cross-sectional diagnostic study of presurgical TVS diagnosis of adenomyosis with post-hysterectomy histological correlation. The primary objective was to determine the diagnostic performance of TVS for the diagnosis of adenomyosis using posthysterectomy histology as the reference standard. Secondary objectives were to determine the signs and symptoms in women with histologically confirmed adenomyosis and the prevalence of histological adenomyosis. The study was conducted at Groote Schuur Hospital and New Somerset Hospital over a period of 11 months (May 2011 to April 2012). There were two study groups. In study group A, women scheduled for hysterectomy completed a questionnaire capturing clinical symptoms and underwent TVS examination. A TVS diagnosis of adenomyosis was made if three or more features suggestive of adenomyosis were present. After hysterectomy, the uteri were examined by histopathologists. Both ultrasonographers and histopathologists were blinded to other findings. The TVS diagnosis of adenomyosis was compared with histopatholgy results. In study group B, histopathological results were collected prospectively in all women undergoing hysterectomy during the study period (including those in study group A). From the results, a histopathological profile of posthysterectomy specimens was made. There were 78 participants in group A. Histologically confirmed adenomyosis was found in 16 of the 78 women (20.5%). Seventy one clinical questionnaires were completed (missing data n=7). The only clinical finding that reached statistical significance was presence of a tender uterus in 31.5% of women with adenomyosis compared to 5.4% without adenomyosis (p<;0.05). Other clinical features seen in women with adenomyosis were heavy menstrual bleeding (62.5%), dysmenorrhea (50%) and a uterus that was less than twelve weeks gestation (62.5%) but these findings did not reach statistical significance compared to women without adenomyosis (p>0.05). Despite presence of characteristic signs and symptoms, a preoperative clinical diagnosis of adenomyosis was made in only 12.5% [95% CI: 3.5 - 36] of patients with histologically confirmed adenomyosis. TVS diagnosis of adenomyosis had a sensitivity of 50% [95% CI: 28-72], specificity of 80.6% [95% CI: 69.2 -88.6], accuracy of 74.4% [95% CI: 63.7- 82.7] and diagnostic odds ratio of 4.2 [95% CI: 1.3-13.4]. Of all TVS diagnostic features evaluated, heterogenous myometrial echotexture had the highest sensitivity 68.8% [95% CI: 44.4-85.8] but a poor specificity 62.9% [95% CI: 50.5-73.8]. The presence of subendometrial echogenic linear striations had the highest specificity 96.8% [95%CI: 89-99] and accuracy 78.2% [95% CI: 67.8-85.9] for the diagnosis of adenomyosis. TVS diagnosis of adenomyosis was ultrasonographer dependent. Study group B comprised 261 women. Leiomyomas were the most prevalent histopathological diagnosis (63.2% ; 95% CI: 57.2-68.4), followed byadenomyosis with a prevalence of 20.3% [95% CI: 15.9-25.6]. Data from this prospective study showed that a clinical presentation of menorrhagia, dysmenorrhea and a tender uterus less than twelve weeks suggested a diagnosis of adenomyosis. Despite characteristic signs and symptoms, clinicians only diagnosed adenomyosis in about one in ten women.

Includes abstract. Includes bibliographical references (leaves 53-57).

Includes bibliographical references (leaves 107-119).

Incluedes abstract. / Includes bibliographical references (leaves 52-58). / The aim of this study was to explore the nature of fear experienced by a group of pregnant women utilizing the Cape Town public obstetric service who reported having severe fear of childbirth. The study was undertaken at antenatal clinics within the Peninsula Maternal and Neonatal Service in Cape Town. The subjects included fifteen pregnant women, 21 years and older, irrespective of gestation, who previously carried one pregnancy to at least 28 weeks gestation regardless of pregnancy outcome and who reported severe fear of childbirth in their current pregnancy (defined for the purpose of this study as a score of 7 or more on a visual analogue scale for fear).

Includes abstract. / Includes bibliographical references (leaves 64-71). / Aim: To determine whether HIV-positive patients have a longer time to healing, more complications and poorer functional outcomes after Obstetric Anal Sphincter Injury (OASI) than an HIV-negative control group.

Includes abstract. / Includes bibliographical references (leaves 70-75). / Pre-eclampsia is a leading cause of maternal mortality and morbidity in South Africa. At present this disease cannot be prevented and many interventions to reduce the incidence of pre-eclampsia have been investigated. Calcium supplementation of pregnant women at high risk of developing pre-eclampsia has been shown to be of some benefit in reducing the incidence of the disease, with the greatest benefit seen in low dietary calcium settings. While serum calcium is an unreliable indicator of chronic calcium status, hair analysis is an accurate and well documented method of determining long-term micronutrient status.