Introduction: Outcome prediction tools have the potential to provide significant adjunctive information for intensivists. Critically ill obstetric and gynaecology patients constitute a unique subset of the general ICU (intensive care unit) population yet, there exists no outcome prediction model developed specifically for these patients. Objectives: To evaluate the APACHE II score, prospectively develop and validate an outcome prediction model, evaluate organ failure (Organ Failure score and SOFA score) and review the SIRS (Systemic Inflammatory Response Syndrome) response in a cohort of critically ill obstetric and gynaecology patients. Design: A prospective study conducted over a 2 year period in the Surgical ICU at King Edward VIII Hospital, Durban. Institutional ethics approval was obtained. Patients were allocated to one of the following categories: Obstetric hypertensive group (Group I), Obstetric non-hypertensive group (Group II) and Gynaecology group (Group III). Group III was further subdivided into a pregnant (Group IIIa) and a non-pregnant group (Group IIIb). Data captured included demographic details, clinical assessment, investigations, treatment, variables required for calculating the APACHE II score, organ failure (OF) assessment, SIRS criteria and patient outcome. The APACHE II system, organ failure assessment and SIRS was evaluated in the entire patient subset. For the purpose of the outcome prediction model, the subset was divided into 2 groups: a development group and a validation group. STATA 7 software was utilised for data analysis. Results: The dataset comprised 260 inpatients. Obstetrics and gynaecology cases represented 18.5 % of the total ICU population (n=1408). The majority of the patients were young (mean age 27 ± 10.5 years). The mean ICU stay was 5.5 ± 7.9 days. The observed mortality for Groups I, II, III, IIIa and IIIb was 23.4%, 43.2%, 42.9%, 33.3% and 55.5% respectively. The mean APACHE II score was significantly higher in nonsurvivors compared to survivors for all patient subgroups (p< 0.0001). However the APACHE II system performed variably in each of the 3 groups. The area under the curve for the ROC curves in each of the 3 main subgroups varied from 0.81 to 0.94 for APACHE II. Groups IIIa and IIIb were too small to permit ROC curve analysis. Age, mean arterial pressure, respiratory rate, temperature, the Glasgow Coma Scale score and pH were identified as significant outcome predictors. Using these parameters an obstetric and gynaecology outcome prediction (OGOP) model was developed for Groups I, II and III. The area under the curve for the ROC curves in each of the subgroups was >0.9 for the OGOP Model. A predictive equation could not be developed for Groups IIIa and IIIb (due to a small number of admissions in these two groups.) Duration and the number of organ failures, correlated with outcome. The duration and number of organ failures associated with mortality differed for each group. Three OF exceeding 72 hours, 3 OF exceeding 48 hours and 3 OF equal to 48 hours were invariably fatal in Groups I, II and III/IIIa/IIIb respectively. SOFA scores were significantly higher in nonsurvivors compared to survivors (p<0.0001). A day one SOFA score equal to 18 (Group I), 15 (Group ll) and 13 (Group III, IIIa, IIIb) was also invariably fatal. A SIRS response was noted in 94.2% of the patient cohort (245/260). The SIRS response varied in the subgroups. Sterile shock and septic shock were associated with a high mortality rate. Groups IIIa and IIIb differed with respect to the mean age, duration of hospital and ICU stay and mortality rate. Although these subsets were numerically restricted (24 and 18 admissions respectively), the results suggest that the two subsets are distinctly different in nature. Comment: The OGOP model is easier to calculate and it is superior to the APACHE II System. It needs to be validated in other local and international units. Organ failure assessment as well as the SIRS response provides useful supplementary outcome information. Although current outcome prediction tools are not designed for individual application, continued research and refinement of the available tools, as well as the exploration of novel methods, may one day result in "near-perfect" prediction estimates and further broaden the scope of their utility. / Thesis (Ph.D)-University of KwaZulu-Natal, 2006.

OBJECTIVES: To determine if women with Human Immunodeficiency Virus infection with severe degrees of immunosuppression are more predisposed to mortality from Gestational Trophoblastic Disease compared with HIV-infected women with less severe degrees of immunosuppression and Human Immunodefiency Virus (HIV) non-infected women. DESIGN: Retrospective review of case records. METHOD: A retrospective review was performed on all patients with Gestational Trophoblastic from 2003 to July 2007. A chart review was conducted and information captured on a data sheet. This retrospective audit was performed at the combined gynaecology oncology clinic of Inkosi Albert Luthuli Central Hospital. All information was kept confidential and was strictly for the purposes of the audit. STATISTICS: Factors associated with mortality were tested using Fisher's exact test. Odds ratios were reported as a measure of the strength of association. Breslow-Day's test for homogeneity in odds ratios was used to compare mortality in HIV-infected and HIV non-infected women. The analysis was done using Stata 9. i RESULTS: A total of 78 patients with Gestational Trophoblastic Disease were reviewed. There were 53 patients with invasive molar pregnancy and 25 patients with choriocarcinoma. The HIV sero-prevalence was 31%. There were 15 deaths (19%). There were 8 HIV-infected (33%o) and 7 HIV non-infected (13%) women who demised. Of the 8 patients with CD4 counts less than 200 cells/ uL, 7 patients demised. There were no mortalities amongst patients with CD4 counts more than 200 cells/uL. Of the 15 deaths, 5 HIV-infected patients and 5 HIV non-infected patients received chemotherapy. There were 5 patients admitted in very poor general condition precluding the administration of chemotherapy. Amongst the 10 patients who received chemotherapy and demised, the causes of death included widespread disease, multiorgan failure and toxicity due to chemotherapy. CONCLUSION: The overall survival of all patients managed with Gestational Trophoblastic Disease was 82% in keeping with the expected high survival reported elsewhere. The majority of patients who demised were admitted in poor general condition and had abnormal blood profiles. Despite resuscitation, these patients failed to improve precluding the administration of chemotherapy which is the mainstay of treatment. Although the numbers are small, there is clear evidence that if patients are HIV-infected with CD4 counts 200 cells/uL despite transient grade 2 myelotoxicity. / Thesis (MMed)-University of KwaZulu-Natal, Durban, 2008.

BACKGROUND White vulva! skin lesions may be due to various conditions, including benign and non-benign causes. The dilemma faced by the clinician with such a patient is the aetiology of the lesion, as well as the approach to management. AIM To establish the aetiology of white vulva! skin lesions in patients attending the gynaecology clinic and to evaluate the role of Collin's test and vulvoscopy. SETTING R. K. Khan Hospital, which is a secondary level hospital in Durban, KwaZulu Natal. METHOD Sixty-two patients with white vulva! skin lesions whom consented to the study were recruited. The investigations consisted of Pap smear, colposcopy of the vulva [Vulvoscopy], perineum and where appropriate, vaginoscopy and colposcopy; Collin's test and biopsy of all abnormal areas detected by these tests. RESULTS Pruritus vulvae was the commonest presenting symptom [70%1. No vulvoscopic abnormalities were detected in 97% of patients, whilst 3% had acetowhite areas indicative of Human papilloma virus infection. Collin's test was positive in 40% of patients, although, histologically these areas were benign. All patients in the study had benign lesions on histology. CONCLUSION All patients in this study had benign causes of white vulval skin lesions. However, this cannot lead us to conclude that there is no role for doing Vulvoscopy and Collin's test, as premalignant and malignant lesions should be detected by these tests had they been present. / Thesis (M.Med.)-University of Natal, Durban, 1998.

An audit of Couples attending the Infertility Unit at Inkosi Albert Luthuli Central Hospital (IALCH), Durban Objectives To determine the patient profile, causes of infertility and the success rates of medical and surgical treatment of infertility thus emphasizing the need for assisted reproductive treatment Methods Data was obtained retrospectively from the medical records of 281 couples that presented to Inkosi Albert Luthuli Central Hospital Infertility Unit between January 2004 and December 2006. Information was recorded on a structured proforma and data analysed using SPSS version 15.0 Results The causes of infertility were anovulation (32.7%), tubal factor (30.3%), male factor (11.7%), endometriosis (7.8%), uterine factor (4.3%) and unexplained infertility in 7.1% of cases. Couples with both male and female factors contributed to 6.1% of infertility cases. Twenty two percent of patients with severe male factor and tubal infertility could not be offered any treatment because of the unavailability of assisted reproductive technology (ART). The pregnancy rate was 24.3% after medical treatment and 14.3% after surgery. When both modalities were employed, the pregnancy rate was 26%. The overall pregnancy rate was 16% with 84% of couples requiring further treatment. Conclusion Anovulation and tubal factors were the major causes of infertility. This audit illustrates that the majority of couples (84%) require gonadotrophins and / or assisted reproductive services to achieve conception. A dedicated infertility unit should provide a full range of services including ART. A significant proportion of couples are denied this health service in the public sector in KwaZulu Natal. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.

Background: Leptin is a new adipose-derived hormone discovered in 1994. It is vital in energy balance and weight regulation in humans. During pregnancy the placenta is an extra source of leptin. The role of leptin in pregnancy is not established. This has generated a lot of interest in leptin research in pregnancy. Leptin is being examined in pathological states that may have origin in adipose tissue and the placenta such as pre-eclampsia, intrauterine growth restriction and obesity. Aim and Method: This study measured concentrations of serum leptin in Black African women during late pregnancy in 68 women with pre-eclampsia, 92 healthy normotensive pregnant women and in 32 healthy non-pregnant women. In each group leptin levels were compared between obese (body mass index, BMI = or > than 30 kgm-2) and lean women. Serum leptin concentrations were measured by radioimmunoassay (RIA) technique. Results: Serum leptin levels were higher in pregnancy compared to non-pregnant women (26.66+/-16.13 ng/ml, 25.89+/-15.83 ng/ml vs 17.97+/-11.98 ng/ml, p=0.02). This is due to firstly, the extra fat accumulated as part of the maternal adaptation to pregnancy and secondlv, to the placenta-derived leptin. Other pregnancy hormones such as insulin, hcG, prolactin and oestrogen may modulate the serum levels of leptin in pregnancy. Simple anthropometric parameters (weight, BMI, circumferences of the mid upper arm (MAC), waist (WC), hip (HC), and thigh (TC) and waist-hip ratio (WHR)) were used to explore the relationship between leptin concentrations and obesity. All the parameters showed a positive correlation with serum leptin concentration in all the groups with the exception of WHR. Weight and BMI showed the greatest correlation both in pregnant (r=0.61 and r=0.58, respectively, p<0.001) and non-pregnant (r=0.74 and 0.79, respectively, p<0.001) women. However we did not find a significant difference in the concentrations of leptin between women with and those without pre-eclampsia (26.66 ng/ml vs 25.89 ng/ml, p=0.95). This probably means that adiposity is the predominant factor influencing levels of leptin in pregnancy. The other factors mentioned above play only a minor role. Indeed the mean serum leptin levels were higher in obese compared to lean women in both pregnant and non-pregnant women. Conclusion: Pregnancy is a hyperleptinaemic state. There is no difference in serum leptin levels between women with pre-eclampsia and healthy normotensive pregnant women. Serum leptin concentration is largely determined by the degree of adiposity both in and outside pregnancy. / Thesis (M.Med.)-University of Natal, Durban, 2001.

AIMS. To determine the cardio-metabolic risk profile and incidence of low bone mineral density in African and Indian postmenopausal women attending the IALCH menopause clinic and to determine whether there is a correlation between cardio-metabolic parameters and low bone mineral density. METHODS. A retrospective, descriptive study involving all Indian and African postmenopausal women, above the age of 40, referred to the menopause outpatient clinic at IALCH from 01 July 2009 to 31 December 2010 was conducted. Data was collected from the medi-com database using a structured questionnaire. Cardio-metabolic data was analysed as continuous variables and summarized using means and standard deviations. Bone mineral density was treated as a quantitative variable and correlation analysis was used to assess relationships between the variables. This was done for each race group separately. The Students T-test was used to compare cardio-metabolic variables between the two ethnic groups. SPSS version 18.0 was used to analyse data. RESULTS. The records of 106 women were analysed (51 African and 55 Indian). In African and Indian women, the prevalence of hypertension was 54.9% vs 65.5%, the prevalence of diabetes was 31.4% vs 56.4%, the prevalence of dyslipidaemia was 17.6% vs 32.7% and the prevalence of ischaemic heart disease was 5.9% vs 14.9% respectively. The prevalence of low bone mineral density was higher in Indian women (40%) compared to African women (23.5%). The mean body mass index (BMI) of African women was significantly higher than Indian women, (33 vs 29). There were no significant differences between African and Indian postmenopausal women regarding their lipid profile, fasting glucose, fasting insulin and thyroid profile. The mean bone mineral density (BMD) in the hip and spine was lower in Indian women compared to African women, however the prevalence of osteopaenia and osteoporosis, as defined by T-scores, was not statistically significant. Statistically significant positive correlations were observed between an increasing BMI and BMD (p<0.001) and increases in weight and BMD (p<0.001). A statistically significant correlation were observed between serum LDL-cholesterol values and BMD (p=0.03), where serum LDL-cholesterol values were inversely proportional to BMD. There were no significant correlations between BMD and the remaining cardio-metabolic variables (ie blood pressure; waist-hip ratio; clinical stigma of dyslipidaemia; clinical stigma of insulin resistance; cholesterol; HDL; triglycerides; fasting glucose; fasting insulin and thyroid function). CONCLUSIONS. There is a high prevalence of cardiovascular risks and low BMD amongst the local menopausal population, irrespective of ethnicity. African and Indian postmenopausal women had a high prevalence of hypertension (60%), diabetes (44%), dyslipidaemia (25%) and obesity (54%). In African women, the incidence of low BMD was 35% in the hip, 53% in the neck of femur and 55% in the lumbar spine. In Indian women, the incidence of low BMD was 55% in the hip, 67% in the neck of femur and 69% in the lumbar spine. BMI and weight showed a positive correlation with bone mineral density. Regarding the cardio-metabolic variables, an increasing LDL value was negatively correlated with bone mineral density. It thus is apparent that a screening lipid profile during the peri-menopausal years, coupled with early and appropriate lifestyle management regarding body mass index/ weight may limit the burden of morbidity in later life. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2013.

This study focuses on women with both pre-eclampsia and Human Immunodeficiency Virus (HIV). Pre-eclampsia is a pregnancy-specific syndrome that occurs after 20 weeks gestation. Thrombocytopenia is the most common haematological abnormality in pre-eclampsia. Further, studies suggest that the immunological mechanism plays some role in the aetiology of pre-eclampsia. The immunological hallmark of HIV infection is a progressive decline in the number of CD4 T lymphocytes and significant haematological abnormalities are also common in HIV-infected individuals i.e. anaemia, thrombocytopenia and leukopenia. The study population comprised of two groups i.e., pre-eclamptic HIV-positive African women and preeclamptic HIV-negative African women as the control group. Samples were analysed for haematological parameters (full blood count) and immunological markers (flow cytometry). There was no statistical significance in the following parameters: RBC, Hb, haematocrit, MCV, MCH, MCHC, platelets, MPV, WBC, lymphocytes, neutrophils, eosinophils, monocytes, basophils and CD8. There was a statistical difference in the CD3 and CD4 counts between both the groups. However, the CD3 and CD4 counts were within the normal range in the HIV-negative pre-eclamptic group and even though CD3 decreased, it was still within the normal range in the HIV-positive pre-eclamptic group, with CD4 decreasing below the normal range in the HIV-positive pre-eclamptic group. This suggests that immune mechanisms involving CD estimations do not play a role in pre-eclampsia since the decrease in the counts can be solely attributed to HIV infection. Results obtained in this study do not show any severe haematological or immunological abnormalities when women have both pre-eclampsia and HIV infection. / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, 2007.

Psychological problems are common in infertile women undergoing in vitro fertilization (IVF) treatment.  The aim of this thesis was to determine the prevalence of psychiatric disorders, such as mood and anxiety disorders, and related risk factors and personality traits in women and men undergoing IVF. Participants were 1090 consecutive women and men, 545 couples, attending a fertility clinic in Sweden during a two-year period. The Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), was used for evaluating mood and anxiety disorders. The participation rate was 862 (79 %) subjects. Any psychiatric disorder was present in 31 % of females and in 10 % of males. Major depression was prevalent in 11 % of females and 5 % of males. Only 21 % of the subjects with a psychiatric disorder had some form of treatment. A negative pregnancy test and obesity (BMI ≥ 30) were risk factors for mood disorders in women and the only risk factor for depression in men was unexplained infertility. Anxiety disorders were less common than in the general population and no IVF-related risk factors were identified. The Swedish universities Scales of Personality (SSP), a self-rating questionnaire, was used for evaluation of personality traits. High scores of personality traits related to neuroticism were associated with mood and/or anxiety disorders among both women and men. Another objective was to explore the experience of childlessness three years after unsuccessful IVF by a qualitative-approach, assessing data by interviews. Failure after IVF was experienced by women in terms of grief, whereas men took upon themselves a supportive role not expressing grief. A need for professional support and counselling in how to handle grief was described. An unstructured end after IVF treatment left unanswered questions. Three years after the end of treatment, men and women were still processing and had not adapted to childlessness, indicating the grieving process was unresolved.

Abstract can be viewed in PDF document. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2010.

This thesis was funded by the Department of Human Services (South Australia) to test the acceptability of nicotine patches to pregnant women and to assess the safety of nicotine patches for pregnant women, at least in terms of overall exposure to nicotine. The study was conducted in the antenatal clinics at the Women's and Children's Hospital, Adelaide and was a pilot for a planned larger study. If the pilot indicated that the nicotine patches could be used safely by this group of women, the larger study would examine the effectivemess of patches in a smoking cessation program. Four focus groups, three with pregnant women and one with their care providers, were used to elucidate issues for pregnant women related to smoking and the use of nicotine patches to aid cessation.