Thesis (MMed (Obstetrics and Gynaecology))--University of Stellenbosch, 2010. / Please refer to full text for abstract.

Thesis (MMed)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Objective: The aim of the study was to determine whether Beta-hCG levels at various time intervals during the follow-up period after primary treatment of molar pregnancies could be used to predict progression of the disease later, in an attempt to shorten the period of surveillance. Furthermore an assessment of the demographic details and risk factors for the development of persistent trophoblastic disease was examined. Levels of compliance to the current surveillance protocol were evaluated. Method: A retrospective analysis of all patients diagnosed with molar pregnancies at Tygerberg Hospital, Cape Town from January 2000 to December 2010. Results: Among the 120 patients, 13 (19.7%) of complete moles and 10 (20%) of partial moles developed persistent trophoblastic disease. There was no statistical significance of the demographic data when comparing the two types of moles. 66% of complete and 50% of partial moles were lost to follow-up within the first six months of surveillance. A potential Beta-hCG cut-off value of 148mIU/ml at week 6 offered a sensitivity of 0.89 and specificity of 0.88 that surveillance could be terminated. Conclusions: Patient compliance is a limiting factor in the evaluation of molar pregnancy surveillance. However, based on our results, the suggestion that termination of surveillance after primary evacuation could occur at 6 weeks if the Beta-hCG level was 148 mIU/ml or lower remains undecided, and it is our opinion that higher sensitivities and specificities are required. Further research is needed to solidify this claim. The acquisition of demographic information of our population remains a priority, in order for more informed decisions to be made. / AFRIKAANSE OPSOMMING: Doel: Die doel van die studie was om te bepaal of Beta-mCG vlakke of verskillende intervalle, gedurende die opvolg periode na primêre behandeling van mola swangerskappe gebruik kan word om siekte progressie te voorspel, en sodoende die tydperk van opvolg te verminder. Verder was die demografiese besonderhede en risiko faktore vir die ontwikkeling van persisterende trofoblastiese siekte ondersoek. Die nakoming tot die huidige toesighouding protokol was geevalueer. Metode: ‘n Retrospektiewe analise van al die pasiënte wat gediagnoseer is met ‘n mola swangerskap by Tygerberg Hospitaal, Kaapstad vanaf Januarie 2000 tot Desember 2010. Resultate: Van die 120 pasiënte het 13 (19.7%) van die volledige molas en 10 (20%) van die gedeeltelike molas persisterende trofoblastiese siekte ontwikkel. Daar was geen statistiese belang in die demografiese data, wanneer die twee tipe molas met mekaar vergelyk is nie. 66% van die volledige en 50% van die gedeeltelike molas was verlore met opvolg binne die eerste ses maande van opvolg. ‘n Potensiële Beta-mCG afsnywaarde van 148mIU/ml op ses weke het ‘n sensitiwiteit van 0.89 en spesifisiteit van 0.88 gewys dat toesighouding getermineer kan word. Opsomming: Pasiënt nakoming is ‘n beperkende faktor in die opvolg van mola swangerskappe. Alhoewel, gebaseer op ons resultate, ons kan voorstel dat terminasie van “surveillance/toesighouding” na primêre lediging, kan plaasvind op 6 weke indien die Beta-mCG vlak 148mIU/ml of minder is, bly dit onbeslis. Dit is ons opinie dat hoër vlakke van sensitiwiteit en spesifisiteit nodig is. Verdere navorsing is nodig om hierdie voorstelling te staaf. Die invordering van demografiese inligting van ons populasie bly ‘n prioriteit, om sodoende meer ingeligte besluite te neem.

Thesis (MMed)-- Stellenbosch University, 2013. / ENGLISH ABSTRACT: Aims of the study Urodynamic studies (UDS) have been suggested to be performed as part of the pre-operative work-up of patients undergoing prolapse surgery. Some women with POP have occult stress urinary incontinence (OSUI) and even if subjectively continent, have a higher incidence of developing de novo stress urinary incontinence (SUI). The aim of this study was to describe the outcome of a group of patients who had pre-operative UDS and manual prolapse reduction. Methods This was a retrospective descriptive study including all women who had prolapse surgery during the period January 2006 to December 2011. Patients received routine pre-operative UDS and manual reduction of prolapse, performed at maximum bladder capacity determined by UDS. Patients demonstrating urodynamic SUI or OSUI were offered a concomitant anti-incontinence procedure. Post-operative follow-up data included symptoms of SUI and clinical evidence of SUI. Results The final group consisted of 131 women. The mean age of the patients was 57 years (range 33 to 79) and parity 3.6 (range 0 to 7). The mean body mass index was 32 (range 19 to 53). Twenty-four (18.3%) women had demonstrable SUI on clinical examination at initial presentation in the clinic. At the time of urodynamic studies, forty patients (30.5%) had evidence of SUI determined by either UDS and/ or cough test in the standing position at maximum bladder capacity. Ninety-one women (69.5%) had no evidence of UI on UDS, of which 20(15.3%) demonstrated OSUI (SUI on manual reduction of prolapse at maximal bladder capacity determined by UDS). Of the 40 women with UI on UDS, 36 had 1-step surgery (combination of anti-incontinence procedure and prolapse repair) and 4 had prolapse surgery alone. Of the 20 women with OSUI on UDS, 16 had 1-step (combined) surgery and 4 prolapse surgeries only. Of the 4 who had prolapse surgery alone, 3 complained of post-operative SUI. In the group with no SUI on UDS and manual reduction of POP, 69 of the 71 women had follow-up data. Only 1 had demonstrable SUI on examination. The manual reduction test had a sensitivity of 42.9% and a specificity of 98.5% (95% CI, 92.0-99.9%). The positive predictive value was 75.0% (95% CI, 19.4-99.3%), with a high negative predictive value of 94.4% (95% CI, 86.2-98.8%). Conclusion The numbers in our study are too small to determine sensitivity and positive predictive value of UDS and manual prolapse reduction for the detection of OSUI. However, our data shows promise in identifying POP patients without OSUI, which is a complement of the hypothesis. We recommend that UDS can be performed pre-operatively in women undergoing prolapse surgery, to identify patients with urodynamic stress incontinence. Manual reduction of the prolapse at maximum bladder capacity can then be done to identify a subgroup of patients without OSUI. Future research is needed on the true predictive value of reduction stress testing with larger numbers. / AFRIKAANSE OPSOMMING: Doel van die studie Urodinamiese studies (UDS) word voorgestel as deel van die pre-operatiewe ondersoeke voor prolaps chirurgie gedoen word. Sommige vroue met genitale prolaps het verborge druklek, en selfs as hulle subjektief kontinent is, het hulle ‘n groter insidensie van de novo druklek. Die doel van die studie was om die uitkoms van ‘n groep pasiënte wat pre-operatiewe UDS en manuele prolaps reduksie gehad het, te beskryf. Metodes Die studie was ‘n retrospektiewe beskrywende studie. Al die pasiënte wat prolapse chirurgie in die tydperk Januarie 2006 tot Desember 2011 gehad het, is ingesluit. UDS en manuele prolaps reduksie tydens maksimale blaaskapasiteit, bepaal deur UDS, was deel van die roetine pre-operatiewe ondersoeke. In die gevalle waar urodinamiese druklek of verborge druklek demonstreer is, is die opsie van ‘n meegaande prosedure vir kontinensie tydens prolaps chirurgie aangebied. Post-operatiewe opvolg inligting het simptome van druklek en kliniese bewys van druklek ingesluit. Resultate Die finale groep was 131 vroue reikwydte. Die gemiddelde ouderdom van die pasiënte was 57 jaar (reikwydte 33 - 79) en pariteit 3.6 (reikwydte 0 - 7). Die gemiddelde liggaamsmassa indeks was 32 (reikwydte 19 - 53). Vier-en-twintig (18.3%) vroue het aantoonbare druklek gehad met kliniese ondersoek tydens die eerste kliniek afspraak. Tydens UDS het 40(30.5%) pasiënte druklek getoon tydens UDS en/ of hoestoets in die staande posisie teen maksimale blaaskapasiteit. Een-en-negentig (69.5%) het geen tekens van urinêre inkontinensie tydens UDS demonstreer nie, waarvan 20(15.3%) verborge druklek demonstreer het (druklek met reduksie van prolapse tydens maksimale blaaskapasiteit, bepaal deur UDS). Veertig pasiënte het urodinamiese druklek gehad, waarvan 36 een-stap chirurgie (‘n kombinasie van prolaps herstel en meegaande kontinensie prosedure) en 4 prolaps chirurgie alleenlik gehad het. Uit die 20 vroue met verborge druklek tydens UDS, het 16 een-stap (kombinasie) chirurgie en 4 prolaps chirurgie alleen gehad. Uit die 4 wat prolaps chirurgie alleen gehad het, het 3 post-operatiewe klagtes van druklek gehad. In die groep wat geen inkontinensie tydens UDS en manuele prolaps reduksie gehad het nie, het 69 van die 71 vroue opvolg data gehad. Druklek kon net by een pasiënt met ondersoek demonstreer word. Die manuele reduksie toets het ‘n sensitiwiteit van 42.9% en ‘n spesifisiteit van 98.5% (95% CI, 92.0-99.9%) gehad. Die positiewe voorspellingswaarde was 75.0% (95% CI, 19.4-99.3%), en die negatiewe voorspellingswaarde was 94.4% (95% CI, 86.2-98.8%). Gevolgtrekking Die getalle in ons studie was te min om te bepaal wat die sensitiwiteit en positiewe voorspellingswaarde van UDS and manuele prolaps reduksie is om verborge druklek te demonstreer. Die belowende data om pasiënte te identifiseer met genitale prolaps sonder verborge druklek (‘n kompliment van die hipotese). UDS kan pre-operatief gedoen word in pasiënte wat prolapse herstel chirurgie benodig, om pasiënte met urodinamiese druklek te identifiseer. Manuele reduksie van die prolaps tydens maksimum blaas kapasiteit kan dan volg, om ‘n subgroep van pasiente sonder verborge druklek, uit te ken. Verdere navorsing, met groter getalle word benodig om die werklike voorspellende waarde van die reduksie toets te ondersoek.

Thesis (MMed)-- Stellenbosch University, 2013. / ENGLISH ABSTRACT: Background: Studies about management of prolonged pregnancy dealt with pregnancy with certain gestational age, confirmed with early ultrasound scans. Objective: The primary aim for the study is to review the current management of uncertain gestational age (GA) post term pregnancy in Tygerberg Academic Hospital (TBH). Women at 42 weeks with an uncertain GA and an amniotic fluid index (AFI) of ≥ 10 cm as well as reassuring cardiotocographs (CTG) would be assessed to determine whether follow up over one week or two weeks are required. Method: A retrospective descriptive study included all patients with an uncertain gestation of 42 weeks referred to TBH. Results: A total of 135 pregnant women were studied. Booking fundal height (BFH) was used to determine GA in 99% and last menstrual period (LMP) in 1% of patients. The time interval between first evaluation at 42 weeks and delivery varies between 0 to 46 days (median 10 days); 104 women delivered vaginally (71% spontaneously, 6% after induction of labour (IOL)); 31 women (23%) by caesarean section; 1 elective, 4 due to cephalopelvic proportion (CPD), 5 had failed IOL, 3 poor progress and 18 fetal distress. Out of the total 11 (8%) women with AFI ≥ 10 had caesarean sections for fetal distress within 2 weeks of the visit at 42 weeks. No neonatal morbidity or mortality was noted in this study. Conclusion: Weekly monitoring with AFI and CTG for women at 42 weeks with unsure gestation is safe. A follow-up following 2 weeks cannot be recommended as 8% of women required caesarean sections within less than 2 weeks due to fetal distress. / AFRIKAANSE OPSOMMING: Agtergrond: Studies oor verlengde swangerskap handel oor swangerskappe met seker swangerskapsduurte, bevestig met vroeë ultraklank skandering. Doelwit: Die primêre doelwit van die studie is om die huidige hantering van verlengde swangerskap met onseker swangerskapsduurte by Tygerberg Hospitaal (TBH) te beoordeel. Vroue wat volgens onseker swangerskapsduurte 42 weke swanger is met ‘n amnionvogindeks (AVI) van >10 en gerusstellende kardiotokogramme (KTG) sal nagegaan word om te bepaal of opvolg oor een of twee weke nodig is. Metode: ‘n Retrospektiewe studie wat alle pasiënte insluit wat na Tygerberg Akademiese Hospitaal verwys word wat ‘n onseker swangerskapsduurte van 42 weke het. Resultate: ‘n Totaal van 135 vroue is bestudeer. Die fundale hoogte is gebruik om swangerskapsduurte te bepaal in 99% van gevalle en die laaste menstruasie in 1%. Die tydsinterval tussen die eerste evaluasie op 42 weke en verlossing wissel tussen 0 en 46 dae (mediaan 10 dae); 104 vroue het ‘n vaginale verlossing gehad (71% met spontane aanvang van kraam, 6% na induksie van kraam); 31 (23%) is met keisersnitte verlos; 1 elektief, 4 as gevolg van skedelbekken disproporsie, 5 gefaalde induksies, 3 swak vordering en 18 met fetal nood. Uit die totaal was daar 11 (8%) vroue met ‘n AVI ≥ 10 wat keisersnitte vir fetale nood binne 2 weke van die besoek op 42 weke gehad het. Geen neonatale morbititeit of mortaliteit het in die studie voorgekom nie. Gevolgtrekking: Weeklikse monitering met AVI en KTG vir vroue wat 42 weke swanger is met onseker swangerskapsduurte, is veilig. Opvolg na 2 weke kan nie aanbeveel word nie want 8% het keisersnitte vir fetale nood gehad na minder as 2 weke.

Thesis (DMed (Obstetrics and Gynaecology))--Stellenbosch University, 2008. / Chapter 1 presents a literature study on the diagnostic debate of PCOS. The literature study includes a discussion of the recent Rotterdam consensus statement regarding the diagnosis of PCOS. This is followed by a discussion on the essential work-up of the patient presenting with PCOS. Finally, chapter 1 presents a discussion on the complexity of the different variations in women presenting with PCOS. Chapter 2 is a literature review on ovulation induction methods in patients who present with PCOS. This literature study puts special emphasis on the different available methods used for ovulation induction in women with PCOS and the profounding effect weight loss will have in managing these patients. This chapter also addresses the use of newer agents, like aromatase inhibitors (Letrozole), and the current role of each of these agents in ovulation induction protocols. Chapter 3 is a literature overview on the effect of Metformin in Clomiphene-resistant PCOS women. The inclusion criteria of this review was all prospective randomized trials where Metformin was added for ovulation in the Clomiphene-resistant PCOS patient. The data is presented as a metaanalysis. Chapter 4 is a prospective randomise control trial to evaluate the benefit of metformin if added to Clomiphene in a primary ovulation induction protocol in comparison to Clomiphene alone. This chapter also evaluates all factors influencing ovulation outcome. Finally in the discussion section all the recent studies published addressing this topic were reviewed. Chapter 5 is a literature review to evaluate the classification systems for semen parameters and the in vivo fertility potential. This data is also used to establish fertility/subfertility thresholds for semen parameters. This chapter also presents the results of a prospective and retrospective study of the semen analysis of the partners of women with PCOS. We believe that this population presents the best reference group to study the semen profile of the general male population. Chapter 6 is a summary of the results of these studies and serves as an evidence based approach for ovulation induction in women with PCOS.

Background: The most commonly employed screening method for proteinuria is a semi- quantitative dipstick urinalysis, but it has been shown to be inaccurate in pregnancy. New developments in the assessment of proteinuria have included the use of urinary albumin measurements. The Clinitek Microalbumin Reagent Strip (Bayer Healthcare LLC, USA) is a semi-quantitative dipstick test. It is used to measure the spot urinary microalbumin to creatinine ratio that is read using the Clinitek 50 portable urine chemistry analyzer. Aims We embarked on a pilot study to validate the Clinitek 50 system by determining the accuracy of spot urinary microalbumin to creatinine ratio dipsticks and conventional visual dipsticks (Makromed) compared to the laboratory urinary microalbumin to creatinine ratio quantification to detect significant proteinuria in normotensive and hypertensive antenatal attendees. The accuracy of spot urinary microalbumin to creatinine ratio dipsticks and conventional visual dipsticks were then compared to a 24 hour urinary protein (gold standard) to detect significant proteinuria in hypertensive disorders of pregnancy. We then determined the role of proteinuria as assessed by the diagnostic accuracy of both the 24 hour urinary protein (gold standard) and the spot urinary microalbumin to creatinine ratio dipstick, in pregnancy outcomes of these participants. Methods This was a prospective study conducted at hospitals serving the Durban Metropolitan region in South Africa. To validate the urinary microalbumin to creatinine ratio dipstick, fifteen normotensive healthy pregnant women and 11 women with new onset hypertension in pregnancy were recruited .Each women had a spot midstream urine, which was assessed for proteinuria using a semi-quantitative visual dipstick (Makromed) and analysed using the semi-quantitative urinary microalbumin to creatinine ratio dipsticks (Clinitek® Microalbumin) read on the Clinitek® 50 urine chemistry analyser. A result of 1 + on visual dipsticks and a spot urinary microalbumin to creatinine ratio UAC of > 300mg/g (33.9mg/mmol) was considered as positive for significant proteinuria. The results were compared to the laboratory quantitative measurement of the urinary microalbumin to creatinine ratio. The study group comprised 163 women presenting with newly diagnosed hypertension during pregnancy after 20 weeks of gestation, being recruited from antenatal clinics. Each participant had a spot urine sample that was tested by trained midwives for proteinuria using a semi-quantitative visual dipstick (Makromed). Participants were admitted to the ward where a spot midstream urine sample was collected and analysed using the semi-quantitative urinary microalbumin to creatinine ratio dipsticks. A 24 hour quantitative urinary protein analysis was completed. The results of the urinary microalbumin to creatinine ratio dipsticks and conventional visual dipsticks were compared to the 24 hour urinary protein (gold standard) to detect significant proteinuria. A urinary microalbumin to creatinine ratio of < 300mg/g (nil and trace on visual urine dipsticks) was considered to be a negative result. A urinary microalbumin to creatinine ratio 300 mg/g (1+ to 4+ on visual urine dipsticks) was considered to be a positive result. Urinary protein 0.3 g/24 hours was considered significant proteinuria. The outcomes of pregnancy in 2 sub-categories viz. those with and without significant proteinuria were compared using the 24 hr urinary protein measurement. A secondary analysis of outcomes of pregnancy was performed by subcategorizing the participants according to the diagnostic accuracy of the urinary microalbumin to creatinine ratio dipsticks. In the 26 patients enrolled in the initial study , the visual dipstick had a sensitivity of 25% ( 95% CI [0.04-0.64] ) and specificity of 89% ( 95% CI [0.64 -0.98]).The urinary microalbumin to creatinine ratio dipsticks had a sensitivity of 88% ( 95% CI [0.47-0.99]), specificity of 89% (95% CI [0.64-0.98]), negative predictive value (NPV) of 94% (95% CI [0.69-1.00]) and positive predictive value (PPV) of 78% (95% CI [0.40-0.96]). In the 163 patients subsequently enrolled the visual dipstick had a sensitivity of 51 % ( 95% CI [0.41-0.61]) and specificity of 91% (95% CI [0.81-0.96]) .The PPV and NPV was 89 %( 95% CI [0.77-0.95]) and 58% (95% CI [0.48-0.67]) respectively. The urinary microalbumin to creatinine ratio dipsticks had a sensitivity of 63% (95% CI [0.52-0.72]) and specificity of 81 % (95% CI [0.70-0.89]). The PPV was 82% (95% CI [0.71-0.90]) and NPV was 62% (95% CI [0.51-0.71]). Our results show that in hypertensive pregnant women, significant proteinuria determined by the quantitative 24 hour urinary protein is associated with delivery at an earlier gestational age, increased induction of labour and lower birthweights compared to the non-proteinuric hypertensives (gestational hypertension). There is also a trend towards an increased maternal morbidity and perinatal mortality. When the groups were classified into pre-eclampsia and gestational hypertension using the diagnostic accuracy of the urinary microalbumin to creatinine ratio dipsticks, there were no differences in the clinical outcomes between the false negatives and true negatives except a trend towards a higher caesarean section rate in the false negatives. Conclusion The urinary microalbumin to creatinine ratio dipstick read on the Clinitek 50 system provides a semi – quantitative result of the urinary microalbumin to creatinine ratio that has good sensitivity and specificity. Furthermore, the urinary microalbumin to creatinine ratio dipstick has a good negative predictive value and a result of < 300mg/g rules out significant proteinuria and avoids unnecessary investigations in pregnancy. Both the visual dipstick (Makromed) and the urinary microalbumin to creatinine ratio dipstick read on the Clinitek 50 system are not accurate when compared to the total 24 hour urinary protein. Differences between the urinary microalbumin to creatinine ratio and 24 hour total urinary protein may be due to the variation in the albumin fraction of the total urinary protein of pre-eclampsia, technical problems with imprecision of the assay technique and clinical causes of false positives and negatives. The improved sensitivity of the automated urinary microalbumin to creatinine ratio dipstick over the visual dipstick suggests it may be a suitable substitute for the visual dipstick in clinical practice Hypertension in pregnancy associated with significant proteinuria is associated with greater adverse maternal and fetal outcome. Outcome of pregnancy is similar when a classification of gestational hypertension is made based either on the 24 hour urinary protein or the urinary microalbumin to creatinine ratio dipstick read on the Clinitek 50 system. The urinary microalbumin to creatinine ratio dipstick is a good screening test to rule out significant proteinuria. It has the potential to improve accuracy of screening for proteinuria and enhancing safety by preventing incorrect diagnosis and unnecessary investigation. Further research is required to determine its full impact and cost effectiveness in the clinical setting. / Thesis (M.Med.)-University of KwaZulu-Natal, 2008.

OBJECTIVE: To describe the patient profile, clinical features, risk factors, management options and complications in women with ectopic pregnancy. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: King Edward VIII Hospital, Congella, Durban from July 2005 – June 2006. MATERIALS AND METHODS: 130 case notes of women with the final diagnosis with ectopic pregnancy were examined retrospectively. Data was retrieved through a structured proforma. The variables studied included age, parity, signs and symptoms, treatment, management, complications and associated maternal morbidity and mortality. RESULTS: One hundred and twenty women diagnosed with ectopic pregnancy were included in this study. Ten patients were excluded due to failure to obtain clinical records. Women’s ages ranged from 17-40 years with 32 patients (26.7%) being nulliparous and 88 patients (73.3%) between parity 1-4. Twelve patients (10%) had a history of previous ectopic pregnancy. The commonest presenting symptom was abdominal pain in 106 (88.3%) patients whereas amenorrhoea and vaginal bleeding were found in 88 (73.3%) and 84 (70%) patients respectively. The most common physical sign was tenderness: Adnexal tenderness in 99 (82.5%) and pelvic tenderness in 91 (75.8%) of women. Fourteen women (11.7%) presented to the gynaecological outpatient’s department in acute shock with a blood pressure < 90/60 mmHg. The commonest ultrasound findings were the presence of an adnexal mass and an empty uterus in 82 (68.3%) and 80 (66.7%) women respectively. The most frequent risk factors were previous genital infection in 34 patients (28.3%) and multiple sexual partners in 32 patients (26.7%). One hundred and eleven 92.4%) women were managed by laparotomy: One hundred and four (87.4%) women via emergency laparotomy and 6 women (5%) had an elective laparotomy. One patient (0.8%) had a diagnostic laparoscopy which was converted to laparotomy. Only 8 patients (6.7%) were managed laparoscopically. Surgical treatment consisted of salpingectomy 101/120 (84.9%) and salpingotomy in 4 (3.4%) patients. Post- operation complications were minimal however the one maternal death was probably due to a pulmonary embolus. CONCLUSION: Risk factors may not always be present, hence ectopic pregnancy should be suspected in every women of reproductive age who present with unexplained abdominal pain, amenorrhoea and vaginal bleeding. Most women presented with ruptured ectopic pregnancies at King Edward VIII Hospital warranting emergency laparotomy. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.

RATIONALE OF THE STUDY. To carry out a retrospective chart review of all patients who had a peripartum hysterectomy in hospitals at different levels of health care in the Pietermaritzburg Hospital Complex to examine the incidence and indications for peripartum hysterectomy. METHODS. The charts of 120 cases of peripartum hysterectomy operations performed between January 2003 and January 2008 in the Pietermaritzburg hospital complex of University of KZN were analysed retrospectively. The total number of deliveries were 48 964. The traditional indications, risk factors and associated complications were revisited to determine if there have been changes in current obstetric practice. RESULTS. The overall incidence of peripartum hysterectomy at the Pietermaritzburg complex of hospital was 0.25/1000 deliveries (95% C1 0.2 – 2.9). Uterine atony, bleeding abruption placentae, placentae praevia, uterine rupture following induction and extension of uterine incision into the uterine arteries comprised 87.9% of the indications for peripartum hysterectomy. By far, the most common complications were wound infection and haemorrhage due to difficult haemostasis. Both comprised 61% of complications, others were bladder injury and renal failure. Coagulopathy occurred in 16.7% of cases of whom 2 died due to massive uncontrollable haemorrhage and 26.7% cases had relaparatomy. There were 13.3% of haemorrhagic shock and 5% developed septic shock. All the patients had blood transfusion, 13.3% of patients received platelets in addition to blood. The results showed that 55.8% had previous caesarean sections while 12.5% had VBAC. There were 75.8% live babies. CONCLUSION. The review noted that there has not been a significant change in the incidence and indications for peripartum hysterectomy. The incidence of peripartum hysterectomy in the study 0.25/1000 compared favourably with the findings from similar studies in different parts of the world. Worldwide the incidence of PH ranges from 0.2 to 5.09/1000 deliveries, in our study the incidence was 0.25/1000. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2012.

BACKGROUND. Polycystic ovarian syndrome is one of the commonest endocrinopathies in women of reproductive age. The prevalence of the disease is estimated to be around 5 % in general population (Azziz, 2004). Literature on the prevalence of PCOS in Black women is limited (Knochenhauer, 1998). This syndrome is a diagnostic conundrum due to the phenotypic variability of these women. The PCOS woman also has a greater disposition for impaired glucose homeostasis as well as hyperlipidaemia. OBJECTIVE. The hormonal and metabolic profiles of South African women with PCOS have not been described. Ethnic differences in the prevalence of PCOS have also not been well explored. Our study aims to describe and compare the phenotypic profile of African and Indian women with PCOS and to determine the frequency of insulin resistance and hyperlipidaemia in these women. METHODS. A retrospective audit of all patients attending gynaecology endocrine and infertility clinics over the period June 2005 to June 2009 was carried out. The biochemical and clinical profiles were analysed and a comparative analysis between the two largest groups, Indian and Black women were done. All women that attended these clinics were subjected to a fasting lipogram and fasting serum glucose. An abnormal fasting serum glucose would have necessitated a full glucose tolerance test. RESULTS. A total of 110 patients were analysed in this study. There were 87 Indian patients, 16 Black patients, 5 Coloured patients and 2 White patients. Eighty nine percent of PCOS women studied had an increased body mass index (>25). There was an increased LH:FSH in 66 (75.9%) of Indian women and 13 (81.3%) of Black women. Increased androgens were present in 26 (30.2%) in Indian women and 6 (37.5%) of Black women. An increase in fasting insulin was found in 48 (55.2%) of the Indian women and 5 (31.3%) of the Black women. Twenty five (29.1%) Indian women had an increase in fasting serum glucose compared to 1 (6.3%) in Black women. In the Indian population, 13 (14.9%) were found to have Diabetes Mellitus, and 9 (10.3%) had an impaired glucose tolerance test. In the Black population only 1 patient had impaired glucose tolerance. There were no Black patients with Diabetes Mellitus. No Black women were found to have hyperlipidaemia, however 12 (14.3%) Indian women were affected. None of these differences between the races were statistically significant. The major limitation of the study was the sample size of Black women. This is an ongoing study, and aims to recruit more Black women. This will be able to adequately address the correct perspective regarding the metabolic and cardiovascular abnormalities in these women. CONCLUSION. The prevalence of insulin resistance and hyperlipidaemia in local women with PCOS was 50.9%.and 11.3% respectively. Menstrual irregularities and infertility are the most frequent presenting complaints of women with PCOS. Features of hyperandrogenism are not common presenting complaints in South African women. There are no differences in the hormonal and clinical profile of South African Indian and Black women with PCOS, however, there is a trend toward Indian women having a greater prevalence of glucose abnormalities than Black women. We recommend further studies in the management of the metabolic abnormalities in local women with PCOS, in an attempt to develop a protocol to manage the metabolic complexities of PCOS. / Thesis (M.Med)-University of KwaZulu-Natal, Durban, 2010.

Thesis (MMed)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Background: During caesarean section mothers can be in different positions. Theatre tables could be tilted laterally, upwards, downwards or flexed and wedges or cushions could be used. There is no consensus on the best positioning at present. Objectives: We assessed all available data on positioning of the mother to determine if there is an ideal position during caesarean section that would improve outcomes. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009), PubMed (1966 to 14 September 2009) and manually searched the references of retrieved articles. Selection criteria: Randomised trials of women undergoing caesarean section comparing different positions. Data collection and analysis: Two authors assessed eligibility, trial quality and extracted data. Results: We identified 17 studies with a total of 683 woman included. We included nine studies and excluded eight studies. Included trials were of variably quality with small sample sizes. Most comparisons had data from single trials. This is a shortcoming and applicability of results is limited. The incidence of air embolism was not affected by head up versus horizontal position (risk ratio (RR) 0.91; 95% confidence interval (CI) 0.65 to 1.26). We found no change in hypotensive episodes when comparing left lateral tilt (RR 0.11; 95% CI 0.01 to 1.94), right lateral tilt (RR 1.25; 95% CI 0.39 to 3.99) and head down tilt (mean difference (MD) -3.00; 95% CI -8.38 to 2.38) with horizontal positions or full lateral tilt with 15-degree tilt (RR 1.20; 95% CI 0.80 to 1.79). Hypotensive episodes were decreased with manual displacers (RR 0.11; 95% CI 0.03 to 0.45), a right lumbar wedge compared to a right pelvic wedge (RR 1.64; 95% CI 1.07 to 2.53) and increased in right lateral tilt (RR 3.30; 95% CI 1.20 to 9.08) versus left lateral tilt. Position did not affect systolic blood pressure when comparing left lateral tilt (MD 2.70; 95% CI -1.47 to 6.87) or head down tilt (RR 1.07; 95% CI 0.81 to 1.42) to horizontal positions, or full lateral tilt with 15-degree tilt (MD -5.00; 95% CI -11.45 to 1.45). Manual displacers showed decreased fall in mean systolic blood pressure compared to left lateral tilt (MD -8.80; 95% CI -13.08 to -4.52). Position did not affect diastolic blood pressures when comparing left lateral tilt versus horizontal positions. (MD-1.90; 95% CI -5.28 to 1.48). The mean diastolic pressure was lower in head down tilt (MD -7.00; 95% CI -12.05 to -1.95) when compared to horizontal positions. There were no statistically significant changes in maternal pulse rate, five-minute Apgars, maternal blood pH or cord blood pH when comparing different positions. Authors' conclusions There is limited evidence to support or clearly disprove the value of the use of tilting or flexing the table, the use of wedges and cushions or the use of mechanical displacers. Larger studies are needed. / AFRIKAANSE OPSOMMING: Agtergrond: Tydens keisersnitte kan moeders in verskillende posisies wees. Teater tafels kan lateraal, opwaarts, afwaarts of gebuig word, of 'n wig en kussings kan gebruik word. Op die oomblik is daar geen konsensus oor die beste posisie nie. Doelwitte: Ons het alle beskikbare data oor die plasing van die moeder ondersoek, met die doel om 'n ideale posisie vir 'n verbeterde uitkoms tydens 'n keisersnit vas te stel. Metodes: Ons het die “Cochrane Pregnancy and Childbirth Group's Trials Register“ (September 2009), PubMed (1966 tot 14 September 2009) deursoek en die herwinde artikels se verwysings per hand nagegaan. Keuringskriteria: Gerandomiseerde proewe van vroue wat keisersnitte ondergaan het, is in verskillende posisies vergelyk. Data insameling en analise: Twee outeurs het die kwaliteit, die geskiktheid en data van die studie beoordeel. Resultate: Ons het 17 studies geidentifiseer wat 'n totaal van 683 vroue ingesluit het. Ons het nege studies ingesluit en agt uitgesluit. Die ingeslote studies was van wisselvallige gehalte en die monster groepe was klein. Die meeste vergelykings het data van enkele studies gegee. Dit is 'n tekortkoming en die bruikbaarheid van die resultate is beperk. Die plasing van kop-op teenoor horisontale posisie het die voorkomssyfer van lug embolisme nie geaffekteer nie.(risiko verhouding RR 0.91;95% 95% vertroue interval Cl 0.65 tot 1.26). Daar is geen hipotensiewe veranderinge gevind toe 'n vergelyking gemaak is tussen linker laterale kantel (RR 0.11; 95% Cl 0.01 tot 1.94) regter laterale kantel (RR 1.25; 95% Cl 0.39 tot 3.99) en kop-af kantel (“mean difference” MD -3.00; 95%Cl -8.38 tot 2.38) teenoor horisontale posisies of volle laterale kantel met 'n 15 grade kantel nie (RR 1.20;95% Cl 0.8. tot 1.79). Hipotensiewe episodes het verminder met hand verplasers (RR 0.11; 95% Cl 0.03 tot 0.45), 'n regter lumbale wig in vergelyking met 'n regter bekken wig (RR 1.64; 95% Cl 1.07 tot 2.53) en 'n vermeerdering van die regter laterale kantel (RR3.30; 95% Cl 1.20 tot 9.08) teenoor die linker laterale kantel. In die vergelyking tussen die posisie van linker laterale kantel (MD 2.70; 95% Cl -1.47 tot 6.87) of kop-af kantel (RR 1.07; 95% Cl 0.81 tot 1.42) teenoor horisontale posisies, of volle laterale kantel met 15 grade kantel (MD -5.00; 95% Cl -11.45 tot 1.45) het die posisie nie die sistoliese bloeddruk geaffekteer nie. Hand verplasers het 'n verminderde daling in gemiddelde sistoliese bloeddruk veroorsaak in vergelyking met linker laterale kantel plasing (MD -8.80;95% Cl-13.08 tot -4.52). In die vergelyking tussen linker laterale kantel en horisontale posisie was daar geen effek op die diastoliese bloeddruk nie (MD -1.90; 95% Cl -5.28 tot1.48). Die gemiddelde diastoliese druk was laer in die kop-af kantel (MD -7.00; 95% Cl -12.05 tot -1.95) in vergelyking met horisontale posisies. In die vergelyking tussen die verskillende posisies was daar geen betekenisvolle statistiese veranderinge in die moeder se polstempo, vyf minute Apgartellings, moederlike bloed pH of naelstringbloed pH nie. Outeur se gevolgtrekkings: Daar is beperkte getuienis om die waarde van kantel, buiging van tafel, die gebruik van wieë en kussings of die gebruik van maganiese verplasers te ondersteun of totaal te verwerp. Groter studies is nodig.