INTRODUCTION: Worldwide, there is a paradigm shift in the screening for cervical cancer with the use of high-risk human papillomavirus (hrHPV) molecular testing. Before South Africa (SA) adopts this technology in the public sector, health funders will need data on the performance of the current cytology and colposcopy-based programmes. This study was done to establish baseline data on the performance of the cytology and colposcopy based cervical cancer screening programme at the Groote Schuur Hospital (GSH) colposcopy clinic. METHODS: This was a retrospective cohort study of all the women with high grade squamous intraepithelial lesion (HSIL) Pap smears seen at GSH colposcopy clinic between 01 January 2010 and 31 December 2015. The outcome measures were; diagnostic concordance between cytology, colposcopy and histology, large loop excision of the transformation zone (LLETZ) and cone biopsy complication rates, cure rate, treatment failure and invasive cervical cancer rates, median time from treatment to recurrence, follow-up default rates. Data were managed and analysed using IBM SPSS Statistics Version 25 and Microsoft Structured Query Language (SQL) version 2014. Regression methods were used to assess the independent effect of baseline sociodemographic characteristics and clinical covariates on treatment failure and clearance of disease in those who had persistent disease after treatment. Kaplan-Meier curves were used to represent the time from treatment to recurrence and from persistence to cure. Time-to-event methods were applied to determine factors associated with treatment to recurrence and persistence to cure. RESULTS: A total of 7601 women were referred to the GSH colposcopy clinic during the study period. HSIL or worse lesions (≥HSIL) were confirmed histologically in 74.1% (2282/3081) women. At the four-month follow-up visit, 61.2% (742/1213) of the women were considered cured, and 17.0% (206/1213) had persistent/residual disease. In women considered cured at four months, recurrence was very low, and it peaked at ten months at 1.5% (11/740). By 24 months the cumulative recurrence rate was 4.6% (34/742). In women with persistent disease at the four-month follow-up visit, only 0.5% (1/202) developed invasive cervical cancer. The default rate for follow-up was very high, at 81% at 24 months. LLETZ and cone biopsy complication rate was 7.2% (117/1628). Log-rank analysis showed that parity ≥ four was significantly associated with a higher risk of disease recurrence (p=0.0004). In a Coxregression model, taking HAART was the only factor associated with a reduced risk of disease recurrence (p=0.0261). CONCLUSION: LLETZ and cone biopsy are safe procedures. After cure, recurrence rates are low. In women who are treated for HSIL, cervical cancer is very rare. Taking HAART was associated with a reduced risk of disease recurrence. There is a need to mitigate on higher default rates to follow up.

Introduction: Pregnancy related sepsis is a major cause of maternal mortality and morbidity in South Africa. Caesarean section (CS) is the most important risk factor in the development of puerperal infection, and surgical site infection (SSI) after CS increases maternal morbidity as well as medical costs. Mowbray Maternity Hospital (MMH), is a secondary level, public maternity hospital. The caesarean section rate at MMH has increased considerably over the last fifteen years, and the perception has been that there have been increasing numbers of patients developing SSI post-CS. This study was designed to look more closely at the incidence of SSI and to describe the patients identified with SSI. Methods: This was a retrospective observational study. Cases of severe SSI, as defined by the Centres for Disease Control and Prevention (CDC), following CS at MMH from December 2011 to December 2014 were identified. Following ethical approval, patient records were sourced, data collected and analysed using Stata and Statistica. Results: In the 3-year study period, 14982 CS were performed with 98 patients identified with severe SSI. Folders were retrieved for 96 patients, with 2 patients' folders missing and 29 patients with a missing maternity case record (MCR). The overall incidence of severe SSI was 0.65%, with an incidence of 0.88% in Year 1, 0.90 in Year 2 and 0.70 in Year 3. Of the cases, 79 (80.6%) had been in labour, 16 (16.3%) patients had had prolonged rupture of membranes (PROM) and 32 (32.7%) had prolonged labour, with a median of 5 vaginal examinations. An emergency CS was performed in 90 (91.8%) patients, 7 (7.2%) had an elective CS and 1 (1.0%) patient had this data missing. Deep incisional SSI was diagnosed in 74 (75.5%) patients and 24 (24.5%) patients were identified with organ/space SSI. Intravenous (IV) antibiotics was the main treatment in all 96 cases, with 23 (23.5%) patients requiring a wound debridement, 17 (17.2%) a laparotomy, which proceeded to a hysterectomy in 12 (12.3%) patients. In the majority of cases, no organism was cultured, Whereas multiple organisms were cultured in 16 cases, of which 12 were identified as MRSA, and 18 as Klebsiella pneumoniae. There were no maternal deaths or Intensive Care Unit (ICU) admissions. Discussion and Conclusion: The incidence of severe SSI is in keeping with other institutions, with the lowest incidence being found in Year 3, which may be explained by the change in referral population and/ or the full implementation of the Best Care Always (BCA) bundles of care. Of the 98 patients with severe SSI, 80.6% had been in labour, 32.7% had prolonged labour and 91.8% had an emergency CS performed. These are all factors which are known to increase the likelihood for development of post-CS SSI.

Artificial insemination with donor sperm is a widely accepted form of treatment for severe male factor infertility. The introduction of quarantined, cryopreserved semen and the associated reduction in cycle fecundity when compared to fresh semen necessitated the development of strategies to improve the performance of frozen sperm. A prospective randomised clinical trail was undertaken in the Reproductive Medicine Unit at Groote Schuur Hospital to compare intrauterine insemination with intracervical insemination in a therapeutic donor insemination program with cryopreserved semen. The method of insemination was alternated in successive cycles in each patient after intitial randomised selection. Forty three patients underwent 61 intracervical insemination cycles and 48 intrauterine insemination cycles. Strict cycle control was exercised and the timing and frequency of insemination followed a specific protocol. Eighteen clinical pregnancies occurred following eleven intrauterine insemination cycles (22.9% per cycle) and seven intracervical insemination cycles (11.5% per cycle). Treatment outcome was influenced by patient age, the severity of the male factor and endometriosis. Most pregnancies followed insemination with 15 to 25 million motile sperm. Sperm fecundity differed amongst donors. The findings of our study and the current literature suggest that intrauterine insemination improves cycle fecundity in therapeutic donor insemination cycles with frozen donor sperm.

Includes bibliographical references.

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 / Introduction: Over the past few decades there has been an increase in caesarean section rates that has been well documented in many developed countries. The impact of this cannot be ignored as several studies have shown higher risks of maternal morbidity and mortality with caesarean section as compared to vaginal births. The reasons behind it are complex, with maternal request frequently being cited as a major contributor. A growing body of evidence shows that relatively few women would actually prefer to deliver by caesarean section. Caesarean section on request is not routinely offered in the public health care sector in South Africa, and is therefore unlikely to contribute significantly to the overall caesarean section rate. In the South African context very few studies examining women's preference for mode of delivery exist. Aims and Objectives: The primary aim of our study was to determine women's preference for mode of delivery during the third trimester of pregnancy in a low risk population. The secondary outcome was to describe the major reasons for their preferred mode of delivery. Methodology: We conducted a cross-sectional descriptive study of pregnant women attending antenatal care at two midwife obstetric units (MOUs) in Gugulethu and Mitchell's Plain in the Western Cape. Women were recruited during the third trimester of pregnancy and women over the age of 18, with a singleton low risk pregnancy, planning to deliver at the MOU, were eligible for inclusion. Two trained interviewers conducted an interview-based questionnaire regarding women's preference for mode of delivery. Data on demographic and socio-economic characteristics were also collected. We also described the major reasons behind women's preferred mode of delivery. Results: Of the 195 women that participated in our study, 160 (82.1 %) indicated a preference for vaginal delivery. This compared to only 5 (2.6 %) of the study participants who preferred a caesarean delivery, and 30 women (15.4 %) who were unsure about their preferred mode of delivery. Of the group preferring caesarean section, all five women (100 %) cited 'fear of vaginal birth' as the major reason for preferring a caesarean section. Of the 195 women that participated in our study, 106 (54.4 %) did not believe that women should be given the right to request a caesarean section in the absence of a medical indication, 14 women were unsure (7.2 %) and 75 of them believe that women should have the right to request a caesarean (38.5 %). Conclusion: The need for maternity services that are more women-centred has arisen, with an increasing emphasis on maternal choice and birth satisfaction. Our study contributed to the mounting body of evidence that the majority of women prefer to have a vaginal delivery. In the small group preferring caesarean section, 'fear of vaginal birth' was the major reason behind their preference. There were a considerable number of women in our study population who were unsure about their preference. This indicates a need for improved antenatal education. Knowledge about women's preference and the reasons they regard as important will aid health care providers in counselling patients appropriately regarding the risks and benefits of both delivery methods and thereby enable women to make an informed decision about their preferred mode of delivery.

Background: Little is known about factors which influence women's attitudes toward and choice of contraception following mid-trimester termination of pregnancy. Contraceptive counselling is part of the work-up and is an essential part of the documentation required by the department of health. Aim: To investigate the motivation behind the contraceptive choice in those women who present for a mid-trimester termination of pregnancy presenting to Groote Schuur Hospital and New Somerset Hospital and to see if there were any differences in the choice of contraception between these two groups of women Methods: We interviewed women accessing mid-trimester TOPs at two state hospitals within the Cape Town West Metropole using a purpose built non-validated, qualitative questionnaire for the purpose of this study. Findings: The injectable was the most used contraceptive method before TOP and LARCS were more utilized after TOP. Duration of action of methods and personal preference were what motivated the choice of contraception for most women in this study with no statistically significant difference between the two groups. Women in this study did not indicate that counselling influenced their choice. However, there was an eight-fold increase in the uptake of LARCS post TOP. Knowledge of its long duration of action was the motivating factor for choosing a LARC and this information would have been imparted during the counselling process. Women who underwent a medical TOP were more likely to choose an injectable contraceptive whereas women who underwent surgical TOPs chose the IUCD. Delay to diagnosing pregnancy and decision to TOP where reasons for TOP being delayed to the mid trimester. Conclusion: Counselling provided at TOP, positively impacted women's contraceptive choices, improving the uptake of highly effective contraceptive methods. Stronger sexual education programmes that teach young women about their menstrual cycles, contraception and how to prevent unintended pregnancies needs to form part of basic education core curriculums as well as primary health care programmes. Negative staff attitudes towards this essential service needs to be addressed.

Determining the chorionicity of twin pregnancies is extremely important as this influences the frequency of surveillance, timing of delivery and management of complications. Monochorionic twins have 2.5 times the perinatal mortality of dichorionic twins, and in the case of a single intra-uterine fetal demise, the surviving twin of a monochorionic pair is at significant risk of neurological damage compared to a dichorionic pregnancy. Chorionicity can be accurately determined before 14 weeks gestation using the lambda or T-sign. After 14 weeks, these ultrasonographic signs become less reliable and the pregnancy may be assumed to be monochorionic for management purposes. The implication of this assumption is that on occasion premature dichorionic fetuses may be delivered unnecessarily. In South Africa, many women have their first antenatal visit after the first trimester or are not scanned by an experienced sonographer until after 14 weeks. There is thus a need for an accurate means to determine chorionicity in the second and third trimesters.

Background: Triplet pregnancy rates have increased over the past few decades due to the advancing maternal age at conception and assisted reproductive technology. It is well known that the risk to both the mother and fetus are greater in multiple pregnancy when compared to singleton pregnancy. Groote Schuur Hospital (GSH), as a tertiary hospital, is the main referral unit for patients with high risk pregnancies in the Metro West region of the Western Cape and provides care to women with triplet pregnancies. There are no studies in South Africa reviewing the outcomes of triplet pregnancies; this study provided the opportunity to do so. Objectives: The outcomes of all triplet pregnancies at GSH were reviewed from 1 January 2012 to 31 December 2016. The primary objective of the study was to review the fetal and neonatal outcomes of triplet pregnancies at GSH. Fetal complications included the prevalence of fetal abnormalities, miscarriage, twin to twin transfusion syndrome, intrauterine growth restriction and discordant growth, stillbirths, preterm delivery, premature rupture of membranes and low birth weight. Neonatal complications included respiratory distress syndrome or hyaline membrane disease, intraventricular haemorrhage and necrotising enterocolitis. The secondary objective was to review maternal complications and outcomes, including anaemia, hyperemesis gravidarum, hypertensive disorders, gestational diabetes, preterm labour, antepartum and postpartum haemorrhage and operative complications. The demographic information, mode of conception and mode of delivery were also included.

Study rationale In the Western Cape there are many intrauterine contraceptive devices (IUDs) inserted during caesarean section (C/S). Little is known about the long-term outcomes in the Metro West area. Objective To assess placement of IUDs at C/S and describe follow-up, with a view to compile best practice guidelines for insertion and follow-up in our clinic setting. Method A retrospective descriptive audit of clinical records was performed of all women who received an IUD at C/S between January and June 2018 at Mowbray Maternity Hospital (MMH) and New Somerset Hospital (NSH) in Cape Town. Results There were 2310 and 1376 C/S performed at MMH and NSH respectively. The IUD insertion rate was 17.4% (n=402) at MMH and 14.3% (n=197) at NSH. Almost two third of insertions were performed at the time of emergency caesarean section (59.1%; n=276). The majority of women experienced no immediate complications (84.4%). Only 77 women attended follow-up. The continuation rate at follow-up was 71.6%. The overall expulsion rate in hospital and at follow-up was 3%. Strings were visible in 53.2% of patients. An ultrasound was performed in 67.5 % (52/77) of patients. The IUD removal rate at follow-up was 24.7% (19/77). Discussion The poor follow-up rate is concerning, and measures must be taken to address this. The continuation rate of 71.6% is lower than expected but may have been biased by the low follow-up rate. Continuation rates improved with the experience of inserters which highlights the importance of training and supervision. Conclusion The immediate postpartum period may be the only opportunity to provide long acting reversable contraception to some women. In our study population follow-up rates are poor and therefore conclusions are difficult to accurately gauge. Measures must be taken to improve follow-up.