Journal of Obstetrics and Gynaecology of Eastern and Central Africa

FIELD NOTE: BEYOND THE SCIENCE: BREAKING THE BARRIER BETWEEN THE RESEARCHER AND THE POLICY MAKER

2024-07-25T09:13:57+00:00

HIGH PREVALENCE AND SEVERITY OF POSTPARTUM RETINOVASCULAR CHANGES FOLLOWING PRE- ECLAMPSIA WITH SEVERE FEATURES COMPARED TO NORMAL PREGNANCY.

2024-02-07T00:29:07+00:00

Background: Hypertensive retinopathy complicates about 40-100% of pregnancies with hypertensive disorders and its severity worsens with progression of hypertension.

Reactive retinal vessel changes demonstrably also mirror cardiovascular changes in the course of normal pregnancy. There is low utility of fundoscopy in assessing target organ damage and prognosis in pre-eclampsia in low resource setting.

Objective: To compare postpartum maternal retinovascular (RV) findings between pregnancies complicated with preeclampsia with severe features (PES) and normal pregnancies at Kenyatta National Hospital (KNH).

Methodology:

Design: Comparative cross-sectional study conducted between May 2017 and March 2018. Setting: KNH, a regional Teaching and Referral hospital.

Study population: Sixty-five women within 72 hours postpartum without preexisting ocular or medical co morbidities following normal pregnancy (n=35) or pregnancies complicated with PES (n=30).

Data collection: Participants were interviewed on sociodemographic and reproductive health characteristics and clinical parameters obtained from medical records. Visual acuity assessment was done using a portable LogMAR chart and non-mydriatic fundus photography used for retinovascular evaluation. RV changes were graded using Keith Wagner grading.

Data analysis: Postpartum retinovascular findings and severity grades were analyzed and presented as percentages and compared between the two groups using Chi square or Fisher’s exact test. Odds ratios (OR) of retinovascular changes following pre-eclampsia compared to normal pregnancy was estimated. A p value of <0.05 and 95% confidence interval (CI) that doesn’t include the null value were considered significant.

Results: Overall prevalence of hypertensive retinovascular change was 90.8% (83.3% in PES versus 97.1% in normal pregnancies). We found statistically significantly greater odds, OR 5.05 CI (0.93, 27.6) of severe retinovascular changes after pregnancies complicated with PES (p=0.045).

Conclusion: There is high but comparable prevalence of maternal retinovascular changes within 72 hours postpartum after pregnancies complicated with PES or normal pregnancy. PES is associated with greater odds of postpartum retinovascular changes Compared to normal pregnancies.

FACTORS ASSOCIATED WITH ADVERSE PREGNANCY OUTCOMES AMONG HOME AND HEALTH FACILITY DELIVERIES IN LAMU COUNTY, KENYA: A COMPARATIVE CROSS SECTIONAL STUDY

2024-02-07T00:51:20+00:00

Introduction: The burden of adverse perinatal and maternal outcomes is still unacceptably high in low- and middle-income countries. Although much is known on the risk factors, very little is known about specific aspects in Lamu County. This is compounded by the fact that the maternal mortality ratio in Lamu almost doubles the national rate. This study was aimed at providing a framework to assess the probable risk factors for adverse pregnancy outcomes in the County following both hospital and home deliveries.

Methodology:

Study design: Comparative cross-sectional study.

Setting: Lamu County, both home and hospital deliveries.

Study population: Female residents of Lamu County interviewed within a month of data collection, having delivered in the year 2017 at gestation age of ≥28 weeks and age ≥14 years.

Sample size: Using Fleiss formula for comparative cross-sectional study; the sample size was approximated to be 400 participants after adjusting for attrition.

Data collection and management: Data were collected using a questionnaire by trained research assistants, and entered into an Excel spreadsheet.

Data analysis: Analysis was done using Statistical Package for Social Sciences (SPSS) version 20. Relevant tests of significance were applied.

Results: The most prevalent adverse obstetric outcomes were post-partum hemorrhage (PPH) requiring transfusion of at least 2 units of blood and preterm births. PPH was more common following home delivery. Pre-existing medical conditions, other obstetric emergencies (OR 128.17, CI 14.88 – 110.4, p< 0.001) and long distance were associated with adverse obstetric outcomes. There was no significant difference in the prevalence of adverse outcomes between home and hospital deliveries (OR 0.94, C.I 0.55-1.61, p= 0.812).

Conclusion: Multiple factors are associated with adverse obstetric outcomes in Lamu. There is a need to: raise awareness on the need for greater facility-based skilled birth attendance; build capacity of facilities to provide comprehensive emergency obstetric care and to train traditional birth attendants to become ambassadors for early referral.

CHANGES IN PATTERN OF MATERNAL NEAR MISS MORBIDITY AFTER INTRODUCTION OF FREE MATERNITY POLICY IN A COUNTY HOSPITAL IN KENYA: A QUASI EXPERIMENTAL STUDY

2024-02-07T01:13:11+00:00

Background: The cost of healthcare is a major barrier to access of essential maternal services in the developing world. On 1st June 2013, Kenya introduced Free Maternity Services (FMS) in an effort to promote access and improve maternal outcomes. Subsequently, service utilization increased, resulting in pressure on existing resources, potentially compromising quality of care. The World Health Organization (WHO) maternal near

miss tool was used to evaluate maternal outcomes under FMS in a county referral hospital in Kenya. The objective was to compare the pattern of maternal near-miss morbidity before and after FMS.

Methodology:

Study design: Retrospective quasi-experimental (pre-post type).

Treatment group: Records of 186 women with near-miss morbidity after introduction of FMS. Post-period was June 2014 to May 2016.

Comparison group: Records of 185 women with near-miss morbidity before introduction of FMS. Pre period was October 2010 to May 2013.

Setting: Embu County Referral Hospital in Eastern Kenya.

Study population: Women offered maternity services at Embu county referral hospital between during the pre- and post-periods.

Data collection and analysis: The data abstraction form was adopted from the World Health Organization (WHO) Maternal Near-Miss tool. Analysis used Statistical Package for Social Science (SPSS) version 24. Pierson Chi-square test of significance was applied.

Results: The commonest causes of maternal near-miss was severe post-partum hemorrhage (S.PPH) and severe preeclampsia. S.PPH increased (91.0% up from 80.0% p= 0.005), while that of severe preeclampsia reduced in the post-period (13.0% vs. 6.5%, p= 0.029). Anemia was the biggest contributory cause of near misses but reduced in the post-period (43.8% vs. 30.1%, p= 0.020). Use of blood products increased significantly in the post-period (68.2% vs 78.5%, p< 0.001).

Conclusion: S.PPH remains a threat to women after introduction of free maternity services. There’s need to optimize care maternities so as to reduce the risk of maternal mortality.

ACCURACY OF THE URINE DIPSTICK VERSUS CULTURE TEST FOR DETECTING ASYMPTOMATIC BACTERIURIA IN PREGNANCY IN KENYA; A RETHINK OF THE TESTING STRATEGY?

2024-05-09T13:38:08+00:00

Background: The quantitative urine culture, the “gold standard” test for detection of asymptomatic bacteriuria (ASB), is time consuming, expensive, requires special equipment and trained personnel thus limiting its routine use in low-resource settings. Although the dipstick test is cheaper, easier to perform and interpret, its accuracy and role in detecting ASB in pregnancy in this setting has not been evaluated.

Methodology: This was a cross-sectional study of pregnant women without symptoms of urinary tract infection, who were receiving routine antenatal care at Kenyatta National Hospital, in Nairobi Kenya. Clean catch, mid-stream urine specimens from 132 eligible participants were subjected to concurrent dipstick urinalysis and bacteriologic culture. Markers of ASB in urine dipstick (presence of either or both leucocyte esterase (LE) and nitrites) were compared with culture. Accuracy of urine dipstick, as measured from the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) in detecting ASB was estimated using culture as the “gold standard.”

Results: Out of 320 women screened, 132 (41%) were eligible. Prevalence of ASB was 6.9%. Sensitivity, specificity, PPV and NPV were 66.7%, 74.4%, 16.2% and 96.8% respectively for LE; 44.4%, 97.5%, 57.1% and 95.9% respectively for nitrite; 22.2%, 100%, 100% and 94.5% for either LE or nitrite; and 88.9%, 71.9%, 19% and 98.9% for both LE and nitrite respectively. The PLR and NLR for LE was 2.61 and 0.45 whereas that of nitrite was 17.76 and 0.37 respectively.

Conclusion: A negative urine dipstick test rules out ASB in pregnancy and the need for routine culture. Positive dipstick test has low accuracy in detecting ASB in pregnancy and requires confirmatory testing with culture. This would avoid exposing pregnant women to unnecessary antibiotics and their side effects.

EARLY NEONATAL OUTCOMES AMONG MOTHERS RECEIVING VARIABLE DOSES OF DEXAMETHASONE FOR PRETERM PREMATURE RUPTURE OF MEMBRANES AT KENYATTA NATIONAL HOSPITAL: A RETROSPECTIVE COHORT STUDY

2024-05-09T14:47:09+00:00

Background: Antenatal corticosteroids have been shown to reduce complications that arise from preterm birth. Globally, the prevalence of preterm birth is 11.1%, with 60% of neonatal mortality in developing countries being due to preterm births. In Sub-Saharan Africa and Kenya, the preterm birth rate is 18% and 12% respectively. Currently, there is no consensus on the optimal dosing of antenatal corticosteroids. However, authors agree that they should be administered even when delivery is anticipated within 12 hours. Therefore, does incomplete dosing of dexamethasone confer any benefit to premature neonates?

Objective: To compare the early neonatal outcomes among mothers who had preterm premature rupture of membranes (PPROM) and received two 12 mg doses of dexamethasone to those who received one 12-mg dose of dexamethasone between 28 to 34 weeks of gestation at KNH

Methods: A retrospective cohort study involving neonates of mothers who had preterm premature rupture of membranes at 28 to 34 weeks gestation in KNH in the period between January 1, 2011, and December 31, 2015 and received either two 12 mg doses of dexamethasone (exposed group) or one 12-mg dose (unexposed group). The groups were compared for early neonatal outcomes. Sample size of 328 neonates was calculated, with 164 neonates in each arm.

Results: There were no differences in the early neonatal outcomes (Apgar score <7 at 5 minutes, RDS, NEC, mortality and duration of hospital stay) apart from neonatal septicemia which was higher in the two 12- mg dexamethasone cohort (RR 0.78, 95%CI 0.62 to 0.99; p=0.039). Subgroup analysis by gestational ages showed increased neonatal mortality in the single 12-mg dose group (RR 2.09 95%CI 1.11-3.93; p=0.023).

Conclusion: The incidence of early neonatal outcomes of mothers with preterm PROM at 28 to 24 weeks gestation at KNH in 2011 to 2015 were similar for mothers who received two doses of 12 mg dexamethasone and those who received single dose dexamethasone dose apart from early neonatal septicemia which was increased in the two 12 mg dexamethasone group.

LABORATORY FACTORS ASSOCIATED WITH MORTALITY AMONG PATIENTS WITH ECLAMPSIA AT THE KENYATTA NATIONAL HOSPITAL, NAIROBI, KENYA.

2024-05-09T15:19:01+00:00

Background: Eclampsia contributes significantly to maternal and neonatal morbidity and mortality both locally and globally. Identifying risk factors for mortality in women with eclampsia at KNH would serve to try and ameliorate these catastrophic outcomes.

Objective: To determine and compare the laboratory findings associated with mortality in women managed for eclampsia at KNH between 2007 and 2014.

Design: A hospital-based case control study. Cases were women who were managed for eclampsia and died while controls were those who survived eclampsia.

Results: A total of 262 records of patients with eclampsia managed at KNH between 1st January 2007 and 31st December 2014 were retrieved. Compared to controls, cases were older and less educated. Patients aged above 34 years had significantly higher odds of death compared to those between 14 and 24 years (OR 4.03; 95% CI 1.70 - 9.56; p= 0.002). Normal haemoglobin levels offered some protection against death (OR 0.37; 95% CI 0.14 – 0.95, p= 0.116). High creatinine levels significantly increased the odds of death, (OR 7.30; 95% CI 2.50 – 21.4; p< 0.001). High aspartate transferase (AST) levels were significantly associated with death (OR 5.14; 95% CI 1.12 – 23.49, p= 0.005). There was no significant association between death and potassium levels, alanine transaminase levels (ALT), educational attainment or marital status.

Conclusion: Patients on management for eclampsia at KNH aged above 34 years with elevated AST and creatinine levels had increased risk of mortality.

EDITORIAL : PUBLISH OR PERISH! MANUSCRIPT WRITING AND PUBLICATION OF POSTGRADUATE DISSERTATIONS

2024-05-09T15:40:08+00:00