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.

Background The cardiotocograph (CTG) is used for fetal monitoring antenatally and in labour, to detect potential fetal hypoxia and thus prevent perinatal morbidity and mortality. An abnormal CTG influences decisions clinicians make in terms of timing and mode of delivery, as the type of abnormality may warrant immediate delivery by caesarean section (CS). However caesarean section rates are increasing worldwide and in South Africa, and ‘fetal distress' is one of the common indications. The increased CS rate also increases the risk of maternal morbidity and mortality. At Mowbray Maternity Hospital, weekly review meetings show that ‘pathological CTG' and ‘non reassuring CTG' accounted for the majority of emergency CS. Therefore, this study was undertaken to see if ‘fetal distress' is being over-diagnosed leading to unnecessary CS, or to affirm that the CS are correctly indicated for this diagnosis. Hence an investigation of caesarean sections done for ‘fetal distress in 2018 was performed in order to audit emergency CS performed at MMH for abnormal CTG tracings. Methods A retrospective observational study with a comparative component was performed. The PASS 2022 software was used to calculate the sample size. The calculation was made for proportions of agreement using a kappa statistic which was calculated to be 114 cases. The study population was derived from the institutional theatre register, in which patients, who had an emergency CS for an abnormal CTG or ‘fetal distress', between 01 January 2018 and 31 March 2018 were included. The CTGs were interpreted by the two obstetric specialistts (experts) and this was compared with the original interpretation made by the attending doctor. In addition, the independent experts assessed the appropriateness of the decision for CS. Data was also obtained on co-existing obstetric conditions, and perinatal and maternal outcomes. Ethics approval for the study was attained from the University of Cape Town Human Research Ethics Committee (UCT HREC) and facility approval from MMH. Results Ninety cases were identified from the study period and analysed. The attending doctor assessed 22 (24.4%) CTGs as suspicious and 68 (75.6%) as pathological, whereas the experts assessed 7 (7.8%) as normal, 22 (24.4%) as suspicious and 61 (67.8%) as pathological. There was overall agreement in CTG interpretation between the experts and the attendant doctor for 61 cases (67.8%). The reliability of this agreement was measured using Cohen's Kappa and was 0.247 (CI 0.153-0.341). This is a ‘fair' level of agreement. A further analysis showed that there was a higher proportion of agreement with pathological CTGs and a lower proportion of agreement for suspicious CTGs which accounted for 52 (57.8%) and 9 (10%) cases, respectively. A review of the medical records showed that 69 (77%) of patients had one or more co-existing obstetric condition such as prolonged pregnancy, hypertensive disorders, prolonged rupture of membranes and meconium-stained liquor etc. When considering these obstetric factors as well as the CTG, the experts assessed 16 women (17.8%) to have had unnecessary caesarean sections. In terms of neonatal outcomes, the mean five-minute APGAR was 8, and only 3 babies had a five-minute APGAR which was less than 7. Twelve babies (13.3%) babies were admitted to the neonatal unit and of those, 4 (4.4%) were admitted for low Apgar scores. The commonest maternal complication was PPH which affected 8.9% of the patients. Conclusion The inter-observer agreement in CTG interpretation at MMH was fair, which is comparable to other studies done in the world, with agreement on the indication for CS of 82.2%. The agreement in CTG interpretation was high with pathological CTGs and poor with suspicious CTGs. A second opinion for CS for abnormal CTG may reduce the number of unnecessary CS especially for suspicious CTGs. A normal CTG tends to affirm good fetal wellbeing, however an abnormal CTG does not always mean that there is fetal compromise, therefore the clinical condition must be evaluated together with the CTG to make an appropriate decision with regards to timing and mode of delivery.

Includes abstract. Includes bibliographical references.

Background:   Porphyrias are inherited disorders with impaired heme biosynthesis. Acute intermittent porphyria (AIP) is the most common porphyria in Sweden. AIP attacks may be life-threatening. Female sex hormones are regarded as important precipitating factors. Hepatocellular carcinoma (HCC) is a severe complication in the older AIP population. The aim of the thesis was to describe the clinical expression of AIP in women, experience of hormonal contraception and hormonal replacement therapies (HRT) and of pregnancies. Secondly, we evaluated gonadotropin-releasing hormone (GnRH) agonist treatment for prevention of menstrual-cycle-related AIP attacks. Thirdly, we evaluated whether an altered sex-steroid metabolism was present in AIP women compared with controls. Finally, we evaluated the benefit of screening for HCC in AIP in a 15-year follow-up study. Methods and results: In a retrospective population-based study in northern Sweden, 166 female AIP gene carriers ≥18 years of age participated. Manifest AIP (MAIP) was reported in 55%; 82% had severe attacks and 39% had menstrual-cycle-related attacks. Hormonal contraceptives were used by 94, and 12 reported that this precipitated AIP attacks. HRT and local vaginal treatments in menopause did not precipitate AIP attacks. Only 10% reported impairment of AIP symptoms during pregnancy. In the retrospective follow-up study of GnRH-agonist treatment, 11 of 14 women improved during treatment. Porphyria attacks were triggered in two women after estradiol add-back and in 5 of 9 women after progesterone add-back. In the sex-steroid metabolism study, levels of s-progesterone, estradiol, allopregnanolone and pregnanolone during the menstrual cycle in 32 AIP gene carriers were compared with 20 healthy controls. Progesterone metabolism in the AIP group differed from controls. In the AIP group levels of allopregnanolone, but not pregnanolone, were significantly lower. In the prospective HCC screening study AIP gene carriers aged >55 years were included. On average 62 subjects participated during 15 years. HCC was diagnosed in 22 of 180 eligible AIP gene carriers in the region (male:female, 12:10, 73% MAIP). The annual incidence of HCC was 0.8%. The risk of HCC was 64-fold higher than in the general population over 50 years of age in this region, and even higher for AIP women (93-fold). Increased 3- and 5-year survival was seen in the regularly screened AIP group. Liver lab tests were not useful in HCC screening. Conclusion: The clinical expression of AIP in women is pronounced and menstrual-cycle-related attacks are common. Hormonal contraceptives can induce AIP attacks and caution is recommended. GnRH-agonist treatment can ameliorate menstrual-cycle-related attacks of porphyria. Dose findings for GnRH-agonists and add-back regimes, especially for progesterone, are intricate. Progesterone metabolism in the AIP group differs from that in healthy controls. HCC screening in AIP gene carriers >50 years of age enables early diagnosis and a possibility for curative treatments. Annual HCC screening with liver imaging is recommended in AIP gene carriers >50 years of age.

Includes bibliographical references. / Background External Cephalic Version (ECV) is the manipulation of the baby, through the mother’s abdomen to a cephalic presentation. ECV is typically performed antenatally, in women with a breech presentation who are not in labour, at or near term, to improve their chances of having a normal vaginal delivery. ECV is one of the few obstetric interventions for which there is evidence that its use leads to a fall in caesarean section rates. ECV is an intervention that gives women another option, prior to considering caesarean section. Objective: To evaluate whether there were missed opportunities for performing ECV in women that had caesarean sections for breech presentation at term, and to determine the reasons why ECV was not offered or attempted for women with breech presentation, who had a caesarean section for that reason.

Includes bibliographical references. / Background: The Lesbian, Gay, Bisexual and Transgender (LGBT) community has historically been marginalised. Increased international awareness of the LGBT profile has led to the recognition that the medical profession has overlooked the health needs of lesbian women, with a resultant paucity of data regarding lesbian women’s health risks. International literature has shown that lesbians remain at risk of sexually transmitted infections and HIV; are at significant risk of mental health disorders; exhibit a high-risk profile for cardiovascular disease, diabetes, as well as cancer, and underutilise health care services due to experiences of homophobia. South African data is almost non-existent. Objective: To explore Cape Town wsw’s (women who have sex with women) experiences with, and trends of utilisation of Reproductive Healthcare Services. Study Design: Cross Sectional Survey. Methods: A sample of self-identified wsw was recruited using a snowball sampling method to complete an anonymous, self-administered online questionnaire during February 2013. Outcome Measures: Predominantly descriptive, with an aim to validate the study questionnaire for the South African context. Results: A total of 116 responses were analysed. The mean age of the population was 37 years of age, with the majority identifying as lesbian. The population comprised predominantly of Caucasian, middle class suburban residents, with most having medical aid, and accessing private health care. A significant proportion of respondents reported previous intercourse with a male sexual partner. Barrier contraception was not always used during intercourse with men and almost never during sex with women. There were a significant number of sexually transmitted infections in women with no previous male sexual partners. Most respondents considered themselves to be at low risk of contracting HIV, and at intermediate risk of cervical and breast cancer, and showed higher than average utilization of cervical screening practices for 4 this population, despite a general perception that screening is unnecessary in lesbian women. A general trend towards disclosure of sexual orientation was noted; however users of private healthcare were significantly more likely to have disclosed their orientation to their physician than users of public and NGO services. Respondents held a preference for practitioners that were themselves gay/lesbian.The study tool was validated for use in the South African context; however redundancy could not be formally excluded from the questionnaire. Conclusions: Wsw from Cape Town experience internationally comparable exposures and risks of gynaecological problems. Further research is required to fully understand the healthcare needs of lesbian women living in lower socio-economic conditions.

Introduction: The cost of ART remains amongst the most prevalent barriers to treatment, especially in resource limited countries where many people are poor and inadequately covered by private and public health insurances. This study aims to assess the financial consequences of out of pocket payment for ART in the South African setting and the ability of couples to financially recover. Methods: A prospective follow-up study was carried out at the Infertility Clinic of the Reproductive Medicine Unit, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town. All 135 participants from the original study were invited to participate with no exclusion criteria. A six part questionnaire, developed for the original study, was adjusted to assess recovery from out of pocket expenditure for ART. Indicators of recovery included the recuperation of savings, settlement of debt and reacquisition of sold assets. Persistence of coping strategies such as reduction in spending and additional work was also assessed. Results: A follow-up rate of 54% percent was achieved. The minimum and maximum follow up period was three and five years respectively. Nineteen percent of couples reported complete financial recovery, assessed as the recovery of savings, repayment of all debt and recovery of a sold asset. Forty percent of couples were unable to settle their debt incurred during the original study. The average amount still owed was R 7 750 (SD R5 140). At follow up, 75% of couples who had reduced expenditure to offset the original cost of ART were still reporting a reduction in expenditure while 39% were still engaged in additional work. The majority of couples reporting difficulties at the time of follow up in paying bills or for basic amenities and healthcare were from the poorest socioeconomic tertiles with 64% of all couples indicating that they were not coping financially at the time of follow up. Conclusion: This study documented a long-lasting impact of OPP for ART among all HH but especially among the poorest. Given the high prevalence of infertility, its impact on individuals, couples and communities, the associated mental, emotional and financial consequences, and existing barriers to adequate and affordable treatment should be minimised as South Africa is moving towards the implementation of a national health system.