Includes abstract. / Includes bibliographical references (leaves 58-67). / Miscarriage is the commonest complication of pregnancy and affects 12-31% of all conceptions. About 1% of all couples trying to conceive will have recurrent pregnancy loss (RPL). Several causes for RPL have been documented and these include chromosomal abnormalities, peas, thrombophilias and anatomical anomalies such as cervical incompetence. In many couples the aetiology of the pregnancy loss is often not defined but nutritional deficiencies have been postulated as possible causes. In particular selenium deficiency is associated with reproductive failure in animals and, more recently, in some human studies. This study was undertaken to assess the selenium levels in women with RPL without an identified cause.

Abstract Over the last 50 years botulinum toxin has become an effective medical therapy, used in a variety of specialities for different indications. A growing body of evidence indicates its beneficial effects in treating medication refractory detrusor over activity. This modality of treatment has been offered at Groote Schuur Hospital (GSH) in South Africa since 2012. Therefore, a review of our outcomes is necessary. Objective: Primary: 1. Determine the subjective success following intravesical Botox injections for the treatment of OABS. Secondary: 1. Describe the population of patients receiving intravesical Botox injections for the treatment of refractory OABS 2. Determine the rate and type of complications associated with intravesical Botox injection and the duration of treatment success. 3. Determine any patient factors associated with shorter duration of treatment success following the treatment of refractory OABS with intravesical Botox injections Methods: We conducted a quantitative, descriptive, retrospective study. The data collection sheet included the following details from the participants: demographic details, pre-existing medical conditions, method of diagnosis, and any previous treatment, the reason for stopping previous treatment, intra operative details and early complications at 1-6 weeks. Also included were details of any symptoms at follow up visits at 6- and 12-months post procedure. Subjective success was defined as the patients reporting improvement of symptoms at the first follow up visit. Duration of treatment success was defined as the time that lapsed between the date of Intravesical Botox injections and when the patient requested repeat treatment. Inclusion and exclusion criteria: We included patients who received intravesical Botox injections for OABS from 1 January 2016 - 31 December 2018. We excluded those who received intravesical Botox treatment for reasons other than OABS. Statistical analysis: A sample of 50 subjects was used. Summary statistics for age were reported as mean and standard deviation. Categorical variables were reported as simple frequencies and percentages. Associations between categorical variables were evaluated using the Fisher's exact test. Groups were compared in terms of age using the Tow-sample Mann-Whitney test. Analyses were performed using Stata Version 16. Results: The age of our participants ranged from 25 to 85 years (m = 54.72, ds = 14.74). 36% were post- menopausal, 92% were para 1 or more, 52% had a BMI of more than 30 kg/m2 , 30% were smokers, 40% were hypertensive and 10% had diabetes mellitus. All the patients reported improvement of symptoms at the 2-6 weeks' follow-up review. At the 6 months follow up visit less than a third of the participants complained of overactive bladder symptoms with only four (8%) patients requesting repeat intravesical Botox treatment. At the 12 months follow up visit just over half of the patients were experiencing overactive bladder symptoms with 21 (42%) requesting repeat intravesical Botox injections. There were few complications related to the intravesical Botox injection procedure. All the procedures were performed under local anaesthesia none of which needed to be abandoned due to pain of bleeding. Seven (14%) patients required temporary clean intermittent catheterisation (CIC). Eight (16%) patients had experienced a UTI (urinary tract infection) by the six weeks follow up visit. We found that hypertensive patients were significantly more likely to request repeat Botox at six months compared to non-hypertensive patients. Fisher's exact of 0,020. No other patient related factors showed any significant association in relation with repeat Botox injections at 6 months and 12 months. Conclusion: Our findings confirmed the benefit of intravesical Botox injection treatment in patients with OABS with minimal complications.

Background: In the past few decades, an increasing number of women have been participating in high-impact sports which involves jumping, landing and/ or running activities. Recent data have shown, however, that this kind of activity might be associated with adverse effects, including pelvic floor disorders. Nevertheless, there is very little in the literature about pelvic floor effects associated with endurance sports where high-impact exercise is performed at submaximal intensity for prolonged periods of time. Objective: The primary objective of the present paper is to describe the prevalence of pelvic floor dysfunction (PFD) in a female triathlete population. Methods: An anonymous on-line survey was administered from September 2015 to March 2016 to women who self-identified as triathletes. We used two validated questionnaires: the Pelvic Floor Distress Inventory Questionnaire short form (PFDI) and the Pelvic Floor Impact Questionnaire short form (PFIQ). In addition, respondents were asked for demographics (age, height, weight, occupation), general health status (medical history, pelvic/abdominal surgical history, pregnancy and birth history) as well as sport practice characteristics (duration of training, level of competition, number of hours spent per week swimming, cycling, and running), so as to characterise these female triathletes. The survey remained active online for seven months, during which time the majority of responses were obtained from having our survey on the IRONMAN December 2015 newsletter. The balance of responses came from various triathlon clubs which we had approached within Western Cape Province. Results: Sixty-seven female triathletes responded to the online survey which we designed on SurveyMonkey. The respondents were between the ages of 22 and 56 years, the mean being 37 years. They had a mean BMI of 22.6 kg/m2. None of them had any medical conditions known to increase the risk of PFD. Of the known surgical history risk factors, 74.6% had had no previous pelvic or abdominal surgery. In the cohort, 69.2% were nulliparous and 30.8% parous. Most of the respondents competed in the recreational age group (70.4%), compared with 29.6% who described themselves as being in the competitive age group. Over 94.4% of the participants had been involved in triathlon training for a period of more than 6 months. At the peak of their training, athletes described their weekly training regime as comprising a mean of 5.4 hours running, 3.9 hours swimming and 9.1 hours cycling. Of those who performed any form of 'core exercises', 29.6% performed pelvic floor exercises, 16.7% yoga, and 25.9% Pilates as part of their routine training. Eighty-two per cent of the triathletes had competed in the half IRONMAN and 37.8% in at least one full IRONMAN competition. The PFDI revealed a number of commonly occurring pelvic floor symptoms. The most reported urinary symptoms were urinary frequency, stress urinary incontinence (SUI) and urge urinary incontinence (UUI) (45.8%, 33.3% and 37.5%, respectively). The most reported colorectal symptoms were incomplete bowel emptying (41.7%), faecal urgency (43.8%), and flatal incontinence (41.7%). Pelvic organ prolapse symptoms were least reported, but those who had symptoms mostly experienced heaviness or dullness in the pelvic area (33.3%), pressure in the lower abdomen (31.3%) and a need for vaginal/rectal digitation in order to have or complete a bowel movement (25%). It was noteworthy to find that the nulliparous triathletes had more pelvic floor symptoms than the parous group. A higher prevalence of colorectal/rectal symptoms were reported by those who had had forceps deliveries. Colorectal symptoms were found to be slightly more prevalent in those who performed any pelvic floor exercises (PFE), yoga or Pilates than amongst those who did not. Even with the myriad symptoms reported, these women were not significantly bothered by their symptoms. Conclusion: It is apparent that PFDs are prevalent in the population reviewed, although the majority of individuals did not seem to be bothered by the symptoms that also did not appear to interrupt training or quality of life. For those who are concerned or troubled by the symptoms, it would be beneficial for them to be identified early so that management options can be offered to relieve the symptoms.

STUDY OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal sonography compared to hysteroscopy in diagnosing benign endometrial pathology. DESIGN: Retrospective cross-sectional study. Canadian Task force classification II – 2 SETTING: Department of Gynaecology, Groote Schuur Hospital, Cape Town, South Africa. PATIENTS: Patients having an office hysteroscopy procedure between January 2014 and December 2016, with a record of a recent transvaginal ultrasound and endometrial histology were included in this study. All malignant cases were excluded. INTERVENTIONS: Transvaginal ultrasound, endometrial biopsy and office hysteroscopy. MEASUREMENTS AND MAIN RESULTS: A total of one hundred and forty two patients, pre- and postmenopausal, were included in this study. The most common indications for hysteroscopy were abnormal uterine bleeding and postmenopausal bleeding. Sensitivity, specificity, positive and negative predictive values were calculated for ultrasonography and hysteroscopy in diagnosing benign endometrial pathology by comparing them to histological diagnosis as gold standard. The most common pathologies identified at histology were polyps and fibroids. For those patients who had a normal endometrium at ultrasound (n=59), hysteroscopy revealed 33.9% polyps, 5.1% submucosal fibroids and 49.2% normal/atrophic endometrium. The remainder of these patients demonstrated proliferative or hyperplastic endometrium, suspicious endometrium and adhesions. For those patients who had a normal hysteroscopy (n=26), ultrasound demonstrated 7.7% polyps, 7.7% submucosal fibroids, 11.5% cystic areas, 3.9% no comment on endometrium and 69.2% normal endometrium. In diagnosing polyps, hysteroscopy had a higher sensitivity (78%) than ultrasound (37.3%). However, ultrasound had a higher specificity (85.5%), compared to that of hysteroscopy which was 71.1%. The negative predictive value of hysteroscopy for polyps was 81.9% and ultrasound, 65.7%. In the diagnosis of submucosal fibroids, ultrasound had a higher sensitivity than hysteroscopy but they both had similar specificity. Ultrasound and hysteroscopy had high negative predictive values and low positive predictive values. The combination of ultrasound and hysteroscopy did not improve sensitivity, PPV or NPV with a small decline in specificity. CONCLUSION: This study demonstrated that hysteroscopy was more accurate in the diagnosis of endometrial polyps than ultrasound with a higher sensitivity and negative predictive value. However hysteroscopy had a lower sensitivity when diagnosing submucosal fibroids.

Includes bibliographical references / Background: 33,4 Million people were living with the Human Immune Deficiency virus by the end of 2009 with sub-Saharan Africa the most affected region. Maternal HIV infection is the leading cause of maternal and child morbidity and mortality in South Africa. A meta-analysis of world literature suggests a clear association between HIV infection and perinatal mortality. Aims and Objectives: To study the effect of HIV status on perinatal outcome at Mowbray Maternity Hospital (a secondary level hospital in Cape Town, South Africa.) and its catchment MOUs. Specific aims: 1) To compare the perinatal mortality rate in the group of HIV exposed with the HIV negative group and the untested group. 2) To determine where possible, the primary obstetric cause of adverse outcome and compare this in HIV exposed to the HIV negative and the untested group. 3) To compare the incidence of Neonatal Encephalopathy in the group of HIV exposed with the HIV negative group and the untested group. Methods: The study was a retrospective descriptive and comparative audit. All deliveries at MMH and its referral midwife obstetric units from January 2008 to December 2008 were audited with respect to HIV status and other demographic data. All deliveries with perinatal mortality and or neonatal encephalopathy were identified and analyzed in detail. Results: There was a total of 18 870 deliveries at the units being studied. The number of deliveries to HIV positive mothers were 3259 (17,2 %). The stillbirth rate in the HIV positive population for the units being studied was 17,1 per 1000 deliveries. In the HIV negative population this rate was 8,3 per 1000 deliveries. The odds ratio was 2,07 [CI, 1.5-2.8] with a p-value of <0,0001. The neonatal death rate in the HIV positive population was 4,6 per 1000 deliveries, this as opposed to a rate of 3,1 per 1000 in the HIV negative population. The odds ratio was calculated as 1,46 [ CI, 0.8-2.6] with a p-value of 0,26. The perinatal mortality rate in the HIV population was 21,7 per 1000 deliveries. In the HIV negative population this rate was 11,7 per 1000 deliveries. The odds ratio was 1,91 [CI, 1.4-2.5] with a p-value of <0,0001. A comparison of the pattern of primary obstetric cause for perinatal mortality showed that infection, intra uterine growth restriction and ante partum haemorrhage were significantly more common as a cause for perinatal death in the HIV positive population. The risk of neonatal encephalopathy in the HIV exposed population was 4,9 per 1000 deliveries as opposed to 2,07 per 1000 deliveries in the HIV negative group. Comparing the two groups found an odds ratio of 2,36 [CI, 1.28- 4.35] with the p-value 0,008. The untested group of patients is shown in this study to be at particularly high risk of adverse perinatal outcome. This consists mostly of mothers who have had no antenatal care in the index pregnancy. Discussion: The perinatal mortality rate in the group of HIV exposed mothers was significantly higher than the HIV negative group due to a higher stillbirth rate. The lack of difference in neonatal death rate could be due to the high standard of neonatal care at the hospital. There was no significant difference in demographic data between the HIV positive and negative groups. Conclusion: Parturients who were infected with HIV were at significantly increased risk of perinatal mortality. Infection, intra uterine growth restriction and antepartum haemorrhage were significantly more common obstetric causes for mortality in the HIV infected population. The risk of neonatal encephalopathy was also significantly higher in the HIV positive population.

Includes bibliographical references / Aims and Objectives : To identify risk factors affecting rates of progression and regression of LSIL To determine the rates of progression and regression of disease in women with LSIL To compare the natural history of LSIL in HIV positive and negative women to determine patient adherence to colposcopy clinic in women with LSIL Methods: This is a retrospective, descriptive, cohort study of women who were referred to the colposcopy clinic with a cytological diagnosis of LSIL and followed for a minimum period of 2 years. Data was extracted from the colposcopy clinic data. Women who were referred and attended the clinic between 1st January 2009 and 31st December 2013 were included in the analysis. Statistical analysis was performed using Stata version 13.1 (StataCorp LP, 4905 Lakeway Drive, College Station, TX 77845, USA). All p-values <0.05 were deemed statistically significant. Results: The study population was 154 women with LSIL (N=154). Of these, 27 (17%) women were HIV negative, 106 (69%) were HIV positive and 18 had an unknown HIV status. The overall regression rate from LSIL to normality was 88.5% [95% CI = 83.9 - 92.1%], with 128 of the 154 women having had regression of disease. The overall progression to higher grade lesions included 31 women, giving a progression rate of 17.7% [95% CI = 15.4 -22.8%]. None of these women progressed to invasive cancer. HIV positive women made up 69% of the study population but there was no significant difference in regression and progression between the HIV positive and negative women. The mean age of the group was 37.8 years with 60% of women screened at this clinic falling between 30-49 years of age. All age groups had similar trends of regression and progression, but those over 60 years of age were 12 times more likely to regress and none of them progressed to HSIL [p=0.002]. Those using an IUCD made up 141 person-months studied, they were shown to have a 6 times greater likelihood to result in regression (p=0.01) compared to women on no contraception. Conclusion: The high regression and low progression rates of LSIL are in keeping with global data and substantiate the need for surveillance rather than surgical intervention i.e. LSIL is a risk factor rather than a precursor for cervical cancer. The lack of difference in regression-progression rates despite HIV status means we can follow-up positive and negative women similarly (12 monthly). Older women (60+) are most likely over-called during diagnosis due to genital atrophy and thus follow-up interval can be longer than 12 months. More research is required to assess IUCDs' effect on LSIL regression and to ascertain the possible reasons for patient adherence.

Includes abstract. / Includes bibliographical references. / Almost four million babies die in the first four weeks of life per year worldwide, most from preventable causes. In addition a million babies die during labour and delivery (Lawn J et al., 2005). In South Africa, ‘intrapartum hypoxia and birth trauma’ are among the top three causes of perinatal deaths. Severe intrapartum hypoxia is often preventable with appropriate maternal and fetal monitoring in labour. However, this remains a challenge in under-resourced settings, due to difficulties that accompany the use of a Pinard Fetal Stethoscope (PFS) which include user-dependence and lack of evidence based standardisation in taking measurements with it. Although intermittent fetal heart monitoring is as effective as continuous electronic monitoring in low risk labours (Banta DH and Thacker, 2001), the search is for reliable, robust and cheaper fetal monitoring devices. The innovative crank powered Doppler Ultrasound Fetal Heart Rate Monitor (DUFHRM) developed by Power-free Education and Technology is robust, cheaper and designed for use even in settings with no or erratic access to mains electricity and replaceable batteries, and overcomes some of the challenges that come with the use of PFS (Banta DH and Thacker, 2001). The aim of the study was to assess the accuracy of Fetal Heart Rates (FHRs)taken with the DUFHRM compared to FHRs taken with a PFS using a Cardiotocography (CTG) as a standard fetal heart rate monitoring device. This was a comparative diagnostic study conducted at Mowbray Maternity Hospital, a public sector maternity hospital in Cape Town during 2012. Women with singleton pregnancies in the active phase of the first stage of labour, who had consented to participation, were enrolled in the study. Paired readings of FHRs were taken with a DUFHRM and a PFS, by two midwives and also with a CTG during the active phase of the first stage of labour before and after two preferably consecutive uterine contractions. The midwives were blinded to the CTG measurements by silencing the CTG and turning it away from their view. The FHRs taken with a PFS were done over a 60 second period in accordance with the guidelines from professional bodies (ACOG, 1995, RANZCOG, 2002, RCOG, 2001a, Liston R et al., 2002) The DUFHRM and CTG readings were made at the start and end of each 60 second period of PFS monitoring. The proportion agreement of FHRs taken with a DUFHRM to FHRs recorded with a CTG, and the proportion agreement of FHRs taken with a PFS to FHRs recorded with a CTG were determined and compared using McNemar Exact Significance Probability test (mcc).

Objective: Lynch syndrome, previously called hereditary non-polyposis colorectal cancer (HNPCC), is one of the most common hereditary cancer syndromes with an association with gynaecological cancers. Members of affected families have an increased risk for colon cancer as well as extra colonic sites; in particular endometrial and ovarian cancer. A cohort of patients with Lynch syndrome in the Northern Cape, South Africa has been identified and followed up. According to recommendations by the International Collaborative Group on HNPCC (ICGHNPCC); women affected with the gene mutation warrant full gynaecological assessment to exclude endometrial and ovarian cancer. Thus far the recommended screening has not been possible and the apparent prevalence of gynaecological cancer or premalignancies among this high risk group has not been established. The aim of this study was to determine the actual apparent prevalence of gynaecological pathology in this cohort of patients; by way of screening. Methods: Women with a known gene mutation, or close relatives of affected family members, utilising the annual colorectal service in the Northern Cape, who fulfilled the inclusion criteria, were recruited to undergo gynaecological evaluation. The participants had a gynaecological examination which included a Papanicolaou smear, a pelvic ultrasound and endometrial sampling. The resultant data was captured on an Excel spread sheet and a descriptive analysis was done. Results: In total 43 women were recruited, of which 18 were postmenopausal and 25 premenopausal. 35 of these women had a known hMLH1 gene mutation. The eight remaining women had either normal genotyping (n=7) or were awaiting molecular test results (n=1). Only twenty-one of these participants agreed to endometrial sampling, in addition to pelvic ultrasound and gynaecological examination. Histological results were therefore available for the 21 participants. One patient was diagnosed with a grade-2 endometroid adenocarcinoma. No cases of endometrial hyperplasia were found. Thirty pelvic ultrasound scans were performed. Of these, one patient had an enlarged adnexal mass. No cervical premalignancies were diagnosed on cervical smears, with one abnormal smear of atypical cells of unknown significance (ASCUS) diagnosed. Conclusion: The apparent prevalence of gynaecological disease in this study population was lower than expected. We conclude however that this high risk group of women should still undergo regular gynaecological screening which should include history taking and clinical examination. Screening using routine endometrial sampling and pelvic ultrasound in asymptomatic women did not appear to be beneficial.

Introduction This study aimed to investigate the time interval between the confirmation of pregnancy diagnosis and the commencement of antenatal care at the Metro West district of Cape Town, and to explore reasons for delays between the confirmation of pregnancy and the first antenatal booking. Methods A cross sectional descriptive study was conducted in September 2015 at Vanguard MOU, in which 120 pregnant women were interviewed at their first antenatal visit, using a structured questionnaire. Subjects were grouped into those with a short time interval (less than 60 days) between confirmation of pregnancy diagnosis and booking, and those with a long time interval (more than 60 days). The two groups were compared. The study hypothesis was that income would be a significant determinant of this time interval. The data were divided into descriptive and categorical variables. A logistic regression analysis was conducted to determine the association between independent variables and the dependent variable (time interval). Results The average gestational age at confirmation of pregnancy was 10.75 ± 5.88 weeks and the average gestation at booking was 18.27 ± 7.27 weeks. The mean time interval between confirmation of pregnancy diagnosis and first antenatal visit was 7.50 ± 6.63 weeks. Seventy- three (60.83%) reported a short time interval (SI) while 47 (39.17%) reported a long time interval (LI). The prevalence of late booking (defined as booking at or after 20 weeks) in the total study sample was 38.30%. There was a significant association between late attendance and LI with 70.21% of the LI group attending late, as compared to 17.81% of the SI group (OR 10.88; 95% CI 4.23-28.43). The time interval was significantly influenced by the women’s type of residence, the perception of the women regarding knowledge of the timing of antenatal care, and perception of the timing of pregnancy complications. It was not influenced by monthly income, thus refuting our hypothesis. Previous obstetric complications did not influence the time interval. Private confirmation of pregnancy by a general practitioner or home pregnancy test was significantly associated with a long interval; 37 (78.7%) in the LI group compared to 43 (59.9%) in the SI group, (p= 0.016). Reasons for the delay in booking were mostly related to poor understanding by women of the role of antenatal care and the ideal time of booking. Discussion and Conclusion Even though some women confirm their pregnancy as early as three weeks, there were notable delays in booking for their first antenatal visit, thus delaying antenatal care. However, the time delays seemed shorter than found in the previous Cape Town study, and compared to other studies in Africa. Many women perceived antenatal care to be curative rather than preventive. It is suggested that the site where women confirm their pregnancy (pharmacy, general practitioner or family planning clinic) should refer women immediately for antenatal booking. Also antenatal care sites should offer pregnancy testing services so that booking could occur after pregnancy is confirmed on the same day and at the same site.

Background: Postpartum haemorrhage (PPH) is a direct leading cause of maternal death in developing countries including South Africa, and atonic uterus is responsible for up to 80% of cases of postpartum haemorrhage. The introduction of the uterine compression suture (UCS) by C B-Lynch revolutionised the conservative surgical management of postpartum haemorrhage. Its use is simple, does not require special training and reduces the need for hysterectomy. Many small studies have been conducted in different parts of the world on its effectiveness but no published studies have been found from Africa. To understand the unique challenges in developing countries, especially those in Africa, it would be relevant to establish if uterine compression sutures are beneficial in a low resource setting for the management of PPH. Accordingly, the aim of the present study was to audit the use of uterine compression suture (UCS) in our regional hospital, with a focus on the circumstances in which it was used and its success rate in treating postpartum haemorrhage. Methods: This was a retrospective folder review study of all women who had a UCS inserted to treat obstetric haemorrhage in Mowbray Maternity Hospital during the period between January 2010 and June 2016, following ethical approval from the UCT HREC and Mowbray Maternity Hospital's management. Cases were identified from theatre registrars and a designated UCS book. Patients' records were retrieved and data collected and analyzed using the Excel spreadsheet software. Results: During the 6.5-year study period, there were 132, 612 deliveries in the population served by Mowbray maternity Hospital, of which 102,261 (78%) were by normal vaginal delivery and 30,351 (22%) by caesarean section. A total of 150 UCS cases were identified giving a rate of 0.87 UCS per 1000 deliveries (at MMH and its referral MOUs). Of the 150 cases, 115 (77%) patient files could be retrieved for further analysis. UCS was performed more commonly after ceasarean section (107; 93%) than after vaginal delivery (8; 7%) The majority were performed by obstetric registrars (73; 63.4%) compared to 21 (18.3%) performed by consultants and by medical officers. The UCS was successful in stopping haemorrhage without the need for hysterectomy in 107 (93%) of all analyzed cases. Among the 8 failures, all required a hysterectomy and one woman died. The majority of UCS (50%) were performed in cases with estimated blood loss over 1000 mls, with 20.9% having blood loss more than 2000mls. Of note, 13.9% had an estimated blood loss (EBL) less than 500 mls (the majority of which were performed by medical officers). Short term morbidity of UCS cases included blood transfusion (42%), admission to ICU (8.7%), post ceasarean section sepsis (9.6%), and prolonged hospital stay (46.1%). Discussion and conclusion: This study is one of the largest case series and the first done in an African setting. Our success rate of 93% is similar to other previously reported published studies with similar low rates of short term morbidity. Our study confirmed that the success of the UCS is achievable even in low-resource environments and that UCS can be safely performed by surgeons with different levels of surgical expertise (medical officers as well as registrars and consultants).