Background: Menopause is a universal event and today most women are reaching the age when menopause occurs. Very little research has been done in South Africa about the perimenopausal period, particularly with regard to quality of life (QoL). The Utian Quality of Life Scale (UQOL) was designed to determine the QoL in peri- and postmenopausal women, and not just to measure their symptoms. The aim of this study was to validate the UQOL in a local urban population in State sector hospitals in Cape Town. Methods: This was a prospective, cross-sectional study. Participants were recruited from the Mature Women's Clinic at Groote Schuur Hospital (GSH), and Gynaecology Out Patient Departments (GOPD) at GSH and New Somerset Hospital (NSH). Four questionnaires were administered- a demographics questionnaire, the UQOL, the WHOQOL-BREF and the Greene Climacteric Scale. Women were contacted telephonically after 3-14 days for retest of the questionnaires to establish reliability. Results: Fifty two participants were initially recruited and 49 were retested. Results showed that the UQOL is a valid instrument with which to measure QoL in our study population. The test-retest reliability was good, with only 2 questions having significantly different answers (p-value < 0.05). Internal consistency (Cronbach's alpha) was >0.7 for the occupational domain of the UQOL only. The health, emotional, and sexual domains had alpha values of 0.673 and 0.691 and 0.634 respectively, which are acceptable. The Cronbach's alpha for the health domain improved to 0.739 when question 8 was removed from the health domain. Construct validity was demonstrated by a statistically significant correlation between the domains of the UQOL and the WHOQOL-BREF. Secondary factor analysis confirmed the domain structure of the UQOL. The scores from the domains seem to indicate that perceived QoL in our study population is not significantly impaired, with the sexual domain showing the most negative impact on QoL. The WHOQOL-BREF demonstrated good internal consistency in our study population. Conclusions: The UQOL is a valid instrument to measure QoL related to the menopause in our patients. No questions were deleted from the original scale. Further research is needed in Afrikaans and Black African languages. The sexual experiences of peri- and post-menopausal women should also be explored. Menopause did not seem to adversely affect QoL in the women who participated in this study. The WHOQOL-BREF is a good tool to measure general QoL in our study population.

Includes bibliographical references / Background: Nutrition in pregnancy has important implications for both the mother and the fetus, hence the importance of an accurate assessment at the booking visit. Body mass index is currently the gold standard for measuring body fatness. However, pregnancy associated weight gain and oedema, as well as late booking in our population setting, questions the reliability of using the BMI to assess body fat or nutritional state in pregnancy. Mid upper arm circumference has been used for many decades in children under the age of five, to assess malnutrition. Many studies have shown a strong correlation between MUAC and BMI in the adult population. MUAC is a much simpler anthropometric measure to take as it eliminates the need for height charts, scales and calculations. One of the other main advantages of using MUAC is that there is minimal change in the MUAC during pregnancy, which may be a better indicator of pre-pregnancy body fat and nutrition. Objectives: To assess if there is a correlation between the mid upper arm circumference and body mass index in pregnant woman booking in the Metro West area. Methods: This was a cross sectional study of women booking at four MOUs in the Metro West area. Anthropometric measurements namely height, weight and MUAC were carried out on pregnant women booking for the first time in four midwives obstetrics units in Metro West area, Cape Town, South Africa. The participants were divided into two groups, early gestational age group for patients who booked less than twenty weeks, and a late gestational age group for those who booked more than twenty but less than thirty week Results: The results showed that there is a strong correlation between MUAC and BMI in pregnant women up to thirty weeks gestation. The correlation was calculated at 0.92 for the entire group. A regression analysis showed that there is a statistical difference in the mathematical relationship between BMI and MUAC, between the two groups (EGG and LGG). MUAC of 27cm and 31cm had sensitivities and specificities of more than 80% for identifying pregnant women as overweight and obese respectively. Conclusion: The MUAC correlates strongly with BMI in pregnancy up to a gestation of thirty weeks in women in Metro West maternity services. In a low resource settings, the simpler MUAC measurement to assess nutritional status and screen women who are at risk for potential adverse pregnancy outcomes could reliably be substituted for BMI estimation.

Includes bibliographical references. / Introduction: This study aimed to assess reproductive knowledge and use of contraception in women of reproductive age with cardiac disease or chronic hypertension attending outpatient clinics. Methods: This was a prospective descriptive study. Women aged between 18 and 45 years attending cardiac or hypertension clinics at Groote Schuur Hospital, Khayelitsha and Mitchells Plain Day Hospitals were recruited. The study tool was an administered questionnaire which included social, demographic and medical information, knowledge about their condition and the contraceptive history. Results: Two hundred women were interviewed, 100 with cardiac disease and 100 with chronic hypertension. Among the 84 cardiac and 90 hypertensive women who had previously been pregnant, there were 193 and 262 pregnancies respectively. Of these participants, 72% cardiac and 70% hypertensive women reported at least one unplanned pregnancy. Unemployed hypertensive women were more likely to have unplanned pregnancies (81%), than their employed counterparts (65%) (p<0.03). In the cardiac group employment did not affect planning of pregnancies. Forty cardiac and 46 hypertensive women were married. Married women in both groups had more planned pregnancies (46% cardiac, 43% hypertensive) in contrast to 10 Out of 200 women, only 2 were unaware of any contraceptive methods. One hundred and fifty eight participants were using modern contraceptive methods. None of the women accessed contraception at their routine medical clinics and less than half had received contraceptive advice there. Conclusion: This study showed that many pregnancies among participants with medical conditions were unplanned, and there was poor knowledge about the impact of their medical condition on pregnancy. There is an unmet need for reproductive health education in women with medical conditions, and ideally this should be part of the holistic care of any woman with a significant medical condition.

Includes bibliographical references. / Background. Obesity is increasing globally and is defined as a Body Mass Index (BMI) over 30 kgms/m². It’s prevalence in the Metro West Maternity service is unknown. Objective .To assess the prevalence of obesity and determine its association with adverse perinatal and maternal outcomes among pregnant women in the Metro West Region, Cape Town, South Africa Study Design. This was a retrospective observational study that compared perinatal outcomes in women with normal pregnancy BMI to outcomes in women with high pregnancy BMI. Setting. Mitchells Plain and Guguletu Midwife Obstetric Units, Mowbray Maternity Hospital and Groote Schuur Hospital, Metro West Region, Cape Town, South Africa Population. A total of 970 pregnant women divided into BMI groups that had their first antenatal booking visit between January and April 2011. Methods. A list of folder numbers was compiled from the antenatal booking registry at the two MOUs. From the list, maternal folders were then traced through the CLINICOM tracking system, MOU delivery registers, antenatal clinic transfer registers and labour ward transfer registers to find place of delivery or outcome of pregnancy. Maternal and perinatal characteristics were then extracted from the folders into the data collection sheet and data was analysed by STATA. Descriptive statistics included proportions with percentages and median with interquartile ranges. Inferential statistics included Chisquared tests, Fisher Exact tests, Kruskal Wallis test, univariate and multivariable logistic regressions. Main outcome measures. Perinatal outcomes (stillbirth, macrosomia, shoulder dystocia, 5 minute Apgar Score less than 7, congenital abnormalities) observed in obese and morbidly obese compared to normal BMI pregnant women.

The subject matter of this thesis might appear to consist of eleven separate essays. These have been grouped under the headings repair, by-pass and replacement. However, it is believed that the same theme might be apparent throughout, based chiefly on the following considerations: a. Retrospective survey of case notes forms no part of this thesis. It is a record of personal observation of every patient mentioned. The evolution of ideas and techniques is the result of close observation of the progress of these patients, sometimes modified after a careful evaluation of the observations of other workers as reported in the medical literatures b. At no time was a consideration of the patient, as an integrated whole, and the evaluation of the entire urinary tract, sacrificed in the approach to a study of the more localized pathology. It is firmly believed that such an omission will be to the detriment of the patient. Whatever part of the urinary tract is involved, therefore, the approach to the problem remains fundamentally the same. c. In the management of these cases there has always been the closest cooperation between the urological surgeon and his colleague in gynaecology. This has always ensured an objective and critical check in all decisions regarding management of cases. Such a close combination of two disciplines has promoted further uniformity of approach to problems varying in detail. Therefore, although the subject matter has been subdivided into eleven sections, the problem in them all remains basically the same and there is considerable overlap between the sections. only to facilitate systematic discussion.

Includes bibliographical references.

Background. A multitude of data exists regarding global incidence of OASI as well as its contributing factors and complications. Little to no data exists regarding the incidence of OASI or its complications and the nature of these complications within South Africa. Objective. To describe the rate and nature of complications of OASI that occur within 6 weeks following primary repair of an OASI, followed up at the GSH perineal clinic. Secondarily, to investigate the incidence of OASI and follow up rate post primary repair Methods. This was a retrospective chart review. Participants were identified from theatre record books between January 2014 and December 2015. The charts of those that attended the perineal clinic follow up were reviewed and complications and possible associated risk factors were identified from the clinical notes. Primary aims were to identify the incidence and nature of complications seen in this population as well as possible related risk factors. The secondary aims were to determine the incidence of OASI and follow up rate for complication following primary OASI repair. Results. The mean age of participants was 25.85 years with a mean body mass index of 25.15kg/m2 . The mean birthweight seen was 3382.05 grams. Constipation (10.87%), pain with defaecation (11.96%) and anal incontinence (10.87%) were the most frequently reported complications. Wound infection was found on examination in 3.26% of participants and wound dehiscence was seen in 6.67%. Incidence of OASI in this study group was 8.64 per 1000 vaginal deliveries. The follow up rate of these participants was 26.20%. A total of 374 OASI were repaired within this region during the study period. Only 97 of these attended follow up, for which 93 folders were available to be included in analysis Conclusion. The Incidence of OASI in this Western Cape region is within the range seen worldwide but the proportion of complications seem to be less than global data suggests despite adverse conditions, theatre delays and the fact that repairs were mostly performed by specialists in training. It was not possible to identify any relationship with possible associated factors. There is a very poor follow up rate within this community which needs to be explored and systems need to be put in place to ensure all participants are given the opportunity of follow up.

Background: Venous thromboembolism is one of the leading causes of morbidity and mortality around the world. In addition to the immediate morbidity, there is significant implications on delivery plans, future options of contraception and thromboprophylaxis in subsequent pregnancies. At present, no pre-test probability assessments are being used to predict venous thromboembolism in pregnancy. This is the first study in South-Africa, addressing venous thromboembolism in the perinatal period which specifically examines the epidemiology and clinical presentation in pregnancy and the post-partum period. Objectives: To determine the incidence of venous thromboembolism in Groote Schuur Maternity Centre and to identify specific variables in the clinical presentation that had a predictive value of a thromboembolic event. Methods: A quantitative, retrospective study with a descriptive comparative research design, for a twelve-month period from January 2016 to December 2016. All pregnant and postpartum patients who were sent for a venous duplex ultrasound, ventilation perfusion study or computerized tomography pulmonary angiogram from the Groote Schuur Maternity center were included. A folder review was conducted and the diagnosis and clinical presentation of all the patients were documented and analyzed. Incidence of VTE were estimated as the number of events per 1,000 deliveries. The number of hospital deliveries in 2016 were used as the denominator for calculating this incidence. Results: A total of 41 (0.12%) patients had a venous thromboembolism. Six patients had a deep venous thrombosis (0.02%) and 37 had a pulmonary embolism (0.11%). Among the 186 retrieved medical records, 11 (28%) of the diagnosis occurred in the puerperal period and 28 (72%) during pregnancy. Among the 28 events during pregnancy, one (3%) was in the first trimester, nine (23%) in the second trimester and 18 (46%) in the third trimester. The majority of confirmed pulmonary emboli (72.22%) and deep venous thrombosis (66.67%) were diagnosed during the third trimester in pregnancy. Among individuals with deep venous thrombosis, the most frequently reported symptoms and signs were leg pain (66.7%), leg swelling (66.7%) and tachycardia (66.7%). Patients without deep venous thrombosis presented more with leg swelling (76.3%), red discolouration (10.5%) and cellulites (10.5%). The only presenting clinical features that were significantly different were haemoptysis (p=0.01) and coughing (p=0.03). Among those individuals without pulmonary embolus, tachycardia (77.3%) and dyspnoea (49.1%) were commonly reported. Among the patients with a PE, the most frequently reported symptoms were tachypnoea (78.4%), dyspnoea (64.9%), tachycardia (62.2%), chest pain (51.4%) and coughing (46%). Features in the clinical presentation that were statistically significant were chest pain (p=0.01), haemoptysis (p=0.07), tachypnoea (p=0.01) and tachycardia (p=0.03). The greatest statistically significant clinical feature was the symptom of coughing (p< 0.01). The stepwise logistic regression for the univariate analysis showed that coughing (OR=3.83; 95% CI: 1.71 to 8.58; P< 0.01), chest pain (OR=2.57; 95% CI: 1.2-5.53; P=0.02), tachycardia (OR=1.03; 95% CI: 1.0 to 1.06; P=0.03), tachypnoea (OR=1.06; 95% CI: 1.0 to 1.12; P=0.05) and a median symptom of 3.5 (1.58; 95% CI: 1.23 to 2.06; P< 0.01) were the best explanatory variables. The stepwise logistic regression for the multivariate analysis showed that both tachycardia (OR=1.03; 95% CI: 1.0 to 1.06; P=0.03) and coughing (OR=3.43; 95% CI: 0.88 to 11.30; P=0.05) predicted a positive pulmonary embolus. A logistic regression for tachycardia showed a 23% increase in pulmonary embolus for every increase of 5 beats per minute in the heart rate above 100Bpm. This association was statistically significant (OR=1.23; 95% CI:1.08 to 1.39; P=0.0004) A logistic regression analysis of the association between tachycardia, tachypnoea and chest pain and the risk of having a pulmonary embolus showed a 4% increase in the risk of pulmonary embolus for every single unit increase in heart rate. When controlling for tachycardia and tachypnoea, chest pain was also associated with a 3.8 times increase in the odds of having a pulmonary embolus. This association was statistically significant (p=0.0002) Conclusion: In this study, we found that the incidence of venous thromboembolism in the Groote Schuur Maternity Centre was the same as in other developed and developing countries around the world. The majority of confirmed venous thromboembolisms were diagnosed during the third trimester in pregnancy. This study found a lower incidence of deep venous thrombosis in comparison to other studies. The clinical features that had some predictive value for pulmonary embolism were chest pain, coughing, tachypnoea, tachycardia and more than three symptoms or signs. Tachycardia was significant in the univariate-, multivariate analysis and stepwise logistic regression. In addition, there was a statistically significant association between tachycardia, tachypnoea and chest pain and the risk of having a pulmonary embolus. This study has revealed the need to develop pre-assessment algorithms in pregnancy and postpartum patients to reduce maternal and fetal, morbidity and mortality. Until such algorithms are developed, clinicians should use their own clinical judgment and proceed to diagnostic imaging for suspected VTE, where indicated.

Poor invasion of trophoblast cells in early pregnancy has been associated with preeclampsia and intrauterine growth restriction as well as other adverse pregnancy outcomes such as miscarriage, preterm birth and intrauterine death. Hypertensive disorders of pregnancy, including pre-eclampsia are one of the leading causes of maternal mortality in South Africa (Third report on Confidential Enquiries into Maternal Deaths in South Africa (2002-2004)) and the rest of the world. The currently accepted mechanism underlying the development of preeclampsia implicates poor trophoblast invasion and inadequate transformation of the maternal spiral arteries. Despite extensive research in this area, the control of trophoblast invasion and early placental development remains poorly understood. A whole host of factors such as oxygen tension, activation of matrix metalloproteinases (MMPs), angiogenic factors (VEGF-A) and immunological factors such as TNF alpha, interleukins and TGFβ have been shown to be involved in the control of trophoblast invasion. Our knowledge of the molecular details of pregnancy is unfortunately limited to in-vitro experiments and animal studies. Recently kisspeptins and their cognate receptor GPR-54 originally involved in tumour metastasis suppression and regulation of puberty, have been implicated in the inhibition of trophoblast invasion. Expression levels of kisspeptin and its receptor in trophoblast cells are highest in the first trimester, when control of trophoblast invasion is critical, and lower towards term.

Background: The association between maternal haemoglobin concentration and the outcome of pregnancy has been a source of continual controversy. Preterm delivery and low birth weight are major causes of stillbirths and early neonatal deaths. Pre-eclampsia is a major complication which occurs during pregnancy and leads to significant maternal and fetal morbidity and mortality. This study aims to assess the association between maternal haemoglobin concentration and pregnancy outcome. Objectives: To assess the association between maternal haemoglobin concentration and pre-eclampsia, preterm birth and low birth weight. Methods: Retrospective analysis of 191 patients who delivered an infant of 28 weeks gestation or more from 1st to 22nd May 2017 at New Somerset Hospital with documented maternal haemoglobin concentration at 22 – 33 weeks gestation. The maternal haemoglobin concentration used was the lowest documented during 22 – 33 weeks gestation. Main outcome measures: Development of pre-eclampsia, low birth weight and preterm birth. Results: The distribution of pre-eclampsia, low birth weight and preterm birth were skewed towards the higher side of the maternal haemoglobin concentration spectrum. There were statistically significant differences in the development of pre-eclampsia, low birth weight and preterm birth between maternal haemoglobin concentrations =>13g/dl and that of < 13g/dl. Pre-eclampsia was associated with relatively lower birth weight, preterm birth and low placental weight independently of the haemoglobin status. Conclusion: High maternal haemoglobin concentration at 22 – 33 weeks gestation is associated with an increased prevalence of pre-eclampsia, low birth weight and preterm birth.