Department of Obstetrics and gnaecology

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    Spontaneous rupture of bladder in puerperium
    (African Health Sciences, 2004) Wandabwa, Julius; Kiondo, Paul; Otim, Tom Charles
    Abstract Spontaneous rupture of bladder and extravasation of urine in the peritoneum without evidence of trauma is rare. This condition is an emergency. It presents in a unique way therefore, the diagnosis and treatment is usually delayed. This patient presented with an acute abdominal pain and oliguria. She had delivered normally eight days before re-admission. Investigations were done and an exploratory laparotomy was performed. There was a tear in the fundus of the bladder and the peritoneal cavity contained urine. Peritoneal lavage was done and the bladder was repaired in layers. She was put on continuous bladder drainage for three weeks followed by bladder training. The bladder resumed its normal function. Early diagnosis and appropriate management decreases the morbidity and mortality associated with this condition. African Health Sciences 2004; 4(2) 138-13
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    Prophylactic antibiotics to reduce pelvic infection in women having miscarriage surgery – The AIMS (Antibiotics in Miscarriage Surgery) trial: study protocol for a randomized controlled trial
    (Trials, 2018) Lissauer, David; Wilson, Amie; Daniels, Jane; Middleton, Lee; Bishop, Jon; Hewitt, Catherine; Merriel, Abi; Weeks, Andrew; Mhango, Chisale; Mataya, Ronald; Taulo, Frank; Ngalawesa, Theresa; Chirwa, Agatha; Mphasa, Colleta; Tambala, Tayamika; Chiudzu, Grace; Mwalwanda, Caroline; Mboma, Agnes; Qureshi, Rahat; Ahmed, Iffat; Ismail, Humera; Gulmezoglu, Metin; Oladapo, Olufemi T.; Mbaruku, Godfrey; Chibwana, Jerome; Watts, Grace; Simon, Beatus; Ditai, James; Otim, Tom Charles; Acam, Jane-Frances; Ekunait, John; Uniza, Helen; Iyaku, Margaret; Anyango, Margaret; Zamora, Javier; Roberts, Tracy; Goranitis, Ilias; Desmond, Nicola; Coomarasamy, Arri
    Abstract Background: The estimated annual global burden of miscarriage is 33 million out of 210 million pregnancies. Many women undergoing miscarriage have surgery to remove pregnancy tissues, resulting in miscarriage surgery being one of the most common operations performed in hospitals in low-income countries. Infection is a serious consequence and can result in serious illness and death. In low-income settings, the infection rate following miscarriage surgery has been reported to be high. Good quality evidence on the use of prophylactic antibiotics for surgical miscarriage management is not available. Given that miscarriage surgery is common, and infective complications are frequent and serious, prophylactic antibiotics may offer a simple and affordable intervention to improve outcomes. Methods: Eligible patients will be approached once the diagnosis of miscarriage has been made according to local practice. Once informed consent has been given, participants will be randomly allocated using a secure internet facility (1:1 ratio) to a single dose of oral doxycycline (400 mg) and metronidazole (400 mg) or placebo. Allocation will be concealed to both the patient and the healthcare providers. A total of 3400 women will be randomised, 1700 in each arm. The medication will be given approximately 2 hours before surgery, which will be provided according to local practice. The primary outcome is pelvic infection 2 weeks after surgery. Women will be invited to the hospital for a clinical assessment at 2 weeks. Secondary outcomes include overall antibiotic use, individual components of the primary outcome, death, hospital admission, unplanned consultations, blood transfusion, vomiting, diarrhoea, adverse events, anaphylaxis and allergy, duration of clinical symptoms, and days before return to usual activities. An economic evaluation will be performed to determine if prophylactic antibiotics are cost-effective
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    A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery
    (The New England Journal of Medicine, 2019) Lissauer, D.; Wilson, A.; Hewitt, C.A.; Middleton, L.; Bishop, J.R.B.; Daniels, J.; Merriel, A.; Weeks, A.; Mhango, C.; Mataya, R.; Taulo, F.; Ngalawesa, T.; Chirwa, A.; Mphasa, C.; Tambala, T.; Chiudzu, G.; Mwalwanda, C.; Mboma, A.; Qureshi, R.; Ahmed, I.; Ismail, H.; Oladapo, O.T.; Mbaruku, G.; Chibwana, J.; Watts, G.; Simon, B.; Dita, J.; Otim, C. Tom; Acam, J.F.; Ekunai, J.; Unzia, H.; Iyaku, M.; Makiika, J.J.; Zamora, J.; Robert, T.; Goranitis, I.; Bar-Zee, S.; Desmond, N.; Arulkumaran, S.; Bhutta, Z.A.; Gulmezoglu, A.M.; Coomarasamy, A.
    BACKGROUND Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection, which is an important complication of this surgery, particularly in low-resource countries. METHODS We conducted a double-blind, placebo-controlled, randomized trial investigating whether antibiotic prophylaxis before surgery to complete a spontaneous abortion would reduce pelvic infection among women and adolescents in low-resource countries. We randomly assigned patients to a single preoperative dose of 400 mg of oral doxycycline and 400 mg of oral metronidazole or identical placebos. The primary outcome was pelvic infection within 14 days after surgery. Pelvic infection was defined by the presence of two or more of four clinical features (purulent vaginal discharge, pyrexia, uterine tenderness, and leukocytosis) or by the pres- ence of one of these features and the clinically identified need to administer anti- biotics. The definition of pelvic infection was changed before the unblinding of the data; the original strict definition was two or more of the clinical features, without reference to the administration of antibiotics. RESULTS We enrolled 3412 patients in Malawi, Pakistan, Tanzania, and Uganda. A total of 1705 patients were assigned to receive antibiotics and 1707 to receive placebo. The risk of pelvic infection was 4.1% (68 of 1676 pregnancies) in the antibiotics group and 5.3% (90 of 1684 pregnancies) in the placebo group (risk ratio, 0.77; 95% confidence interval [CI], 0.56 to 1.04; P = 0.09). Pelvic infection according to origi- nal strict criteria was diagnosed in 1.5% (26 of 1700 pregnancies) and 2.6% (44 of 1704 pregnancies), respectively (risk ratio, 0.60; 95% CI, 0.37 to 0.96). There were no significant between-group differences in adverse events. CONCLUSIONS Antibiotic prophylaxis before miscarriage surgery did not result in a significantly lower risk of pelvic infection, as defined by pragmatic broad criteria, than placebo. (Funded by the Medical Research Council and others; AIMS Current Controlled Trials number, ISRCTN97143849.)
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    Mothers’ perceptions of the practice of kangaroo mother care for preterm neonates in sub-Saharan Africa: a qualitative systematic review protocol
    (JBI Database of Systematic Reviews and Implementation Reports, 2019) Bayo, Pontius; Alobo, Gasthony; Feyissa, Garumma Tolu; Belaid, Loubna
    Objective: The objective of this review is to explore the experiences of mothers with the practice of kangaroo mother care (KMC) for preterm neonates at home in sub-Saharan Africa. Introduction: About 7000 newborn babies die every day around the world. About 80% of these deaths occur in sub-Saharan Africa and southern Asia. Preterm birth and low birth weight (LBW) are major causes of newborn deaths in these regions. Kangaroo mother care is an alternative way to care for LBW preterm neonates; however, the rate of practice remains low. Studies have identified a range of barriers, primarily at the healthcare system level, but there is a dearth of evidence on the factors and enablers at the community level. Inclusion criteria: The review will consider studies conducted in sub-Saharan Africa on the perceptions and experiences of mothers who have given birth to preterm babies and have practiced KMC at home. Qualitative studies in English and French conducted from January 1979 to the present that exclusively use qualitative research methods including, but not limited to, phenomenology, grounded theory, ethnography, action research and feminist research will be included. Methods: PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Academic Search Complete, CINAHL complete, Education Source and Health source: Nursing/Academic Edition will be searched. Eligible studies will be critically appraised using the standardized Joanna Briggs Institute tool. Findings will be pooled using the meta-aggregative approach, and confidence will be assessed according to the ConQual approach.
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    Obstetric Referrals to a Tertiary Hospital in Northern Uganda - A One Year Experience
    (Jemds.com, 2020) Nionzima, Elizabeth; Otim, Tom Charles
    BACKGROUND Delay in referral adversely affects maternal and neonatal outcome. We wanted to review the obstetric referrals, source of referrals, appropriateness of referrals and document the maternal and perinatal outcomes in a tertiary hospital in northern Uganda. METHODS This is a secondary data analysis from case records. A descriptive study of 780 eligible obstetric referrals, with ≥28 week’s gestation, referred to the hospital for a period of 12 months were analysed with SPSS version 23. RESULTS Obstetric referrals accounted for 16.3% (780/4799) of the total admissions in 2018, 43.8% were from CEMNOC sites and 32.3% from HC IVs, while 57% from without Lira District, showing lacunae in the emergency obstetric care given at the HC IV levels and the districts hospital in the region. Majority or 93.5% (729) were intrapartum admissions and 98.1% (715) of these had labour outcome recorded, showing the nature of referrals. Most common diagnosis at referral was labour or complications of labour and only 4.6% had other diagnoses. The diagnoses at the time of admission were normal labour (31.0%); obstructed labour (25.1%); prolonged labour (7.1%). About 29.9% presented with more than one medical/obstetric complications, and the most common one was obstructed labour, preeclampsia, IUFD and previous caesarean section scars. The outcome of the referred cases included 45.1% (327) vaginal delivery (either spontaneous or augmented), 54.4% (396) caesarean section, 0.5% (4) Caesarean hysterectomy, 3.1% (24) transferred out undelivered, 1.2% (09) missing outcome while the 3.6% (28) with medical conditions were managed and discharged. There were ten (10) maternal deaths among the referrals, during the study period and 3 were due to obstetric haemorrhage; and behind these there were many near misses which would provide valuable information on the quality of care at the peripheral facilities. 80.4% (627) were live babies, 10.5% (82) were FSB/MSB and 10% had APGAR score ≤5 at 5 minutes of birth while 13.2% were of low birth weight. CONCLUSIONS A wide spectrum of complicated and uncomplicated obstetric cases was referred to this hospital and majority were unjustifiable as majority of the referred conditions could be managed at the lower CEMONC sites. Unavailability of Comprehensive Emergency Obstetric Care (CEMONC) was the most common reason for referrals, even where infrastructure and human resource where known to be available. Most common diagnosis at the time of referral was prolonged/obstructed labour. Even today, obstetric haemorrhage is the leading cause of maternal mortality while prolonged/obstructed labour contributed to the high neonatal mortality. KEY WORDS Obstetric Referrals, Maternal, Outcome, Foetal Outcome, Referral Sites, Tertiary
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    Why women die after reaching the hospital: a qualitative critical incident analysis of the ‘third delay’ in postconflict northern Uganda
    (BMJ open, 2021) Alobo, Gasthony; Ochola, Emmanuel; Bayo, Pontius; Muhereza, Alex; Nahurira, Violah; Byamugisha, Josaphat
    Objectives To critically explore and describe the pathways that women who require emergency obstetrics and newborn care (EmONC) go through and to understand the delays in accessing EmONC after reaching a health facility in a conflict-affected setting. Design This was a qualitative study with two units of analysis: (1) critical incident technique (CIT) and (2) key informant interviews with health workers, patients and attendants. Setting Thirteen primary healthcare centres, one general private-not- for- profit hospital, one regional referral hospital and one teaching hospital in northern Uganda. Participants Forty-nine purposively selected health workers, patients and attendants participated in key informant interviews. CIT mapped the pathways for maternal deaths and near-misses selected based on critical case purposive sampling. Results After reaching the health facility, a pregnant woman goes through a complex pathway that leads to delays in receiving EmONC. Five reasons were identified for these delays: shortage of medicines and supplies, lack of blood and functionality of operating theatres, gaps in staff coverage, gaps in staff skills, and delays in the interfacility referral system. Shortage of medicines and supplies was central in most of the pathways, characterised by three patterns: delay to treat, back-and- forth movements to buy medicines or supplies, and multiple referrals across facilities. Some women also bypassed facilities they deemed to be non-functional. Conclusion Our findings show that the pathway to EmONC is precarious and takes too long even after making early contact with the health facility. Improvement of skills, better management of the meagre human resource and availing essential medical supplies in health facilities may help to reduce the gaps in a facility’s emergency readiness and thus improve maternal and neonatal outcomes.
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    Refractory convulsive syncope in pregnancy: a rare presentation of Takayasu’s arteritis - a case report and literature review
    (African Health Sciences, 2021-06-02) Alobo, Gasthony; Nahurira, Violah; Omona, Venice; Bayo, Pontius; Olum, Sam
    Background: Neurological manifestation of Takayasu’s Arteritis (TA) in pregnancy presenting as convulsive syncope is extremely rare, and poses a serious diagnostic dilemma due to other vast causes of fits in pregnancy. Objective: We aimed to present and shed more light on a case of TA with convulsive syncope in pregnancy refractory to anticonvulsants for seven weeks, and review the literature on the management of TA in pregnancy. Case presentation: A gravida 4 para 3+0 at 28 weeks of amenorrhea presented with repeated episodes of the sudden loss of consciousness, followed by a fall and jerking of the limbs. These were refractory to anticonvulsants that she had used for seven weeks. Physical examination revealed undetectable pulse and blood pressure (BP) in the upper limbs but elevated BP in the lower limbs. Further investigations confirmed TA and she improved on steroids and antihypertensives. Conclusion: This case typically describes the unexpected presentation of TA with convulsive syncope. It calls for meticulous clinical assessment of epileptic seizures in pregnancy to avoid a late diagnosis of TA and its potential poor outcomes.
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    Gaps in available published data on abortion in Uganda and the missed opportunity to inform policy and practice
    (International Journal of Gynecology & Obstetrics., 2022) Inzama, Wilfred; Kaye, Dan K.; Kayondo, Simon P.; Nsanja, John P.
    Globally, 25% of pregnancies end up in induced abortion, the majority of which are unsafe. Abortion is safe when conducted according to WHO recommendations. The objective of the present study was to identify gaps in the data published on abortion and make recommendations to the Ministry of Health, Uganda. The search strategy included PubMed, Google Scholar articles (from October 2020 to May 2021) on unsafe abortion in Uganda, reviewed data from the Association of Obstetricians and Gynecologists of Uganda (AOGU) members' baseline survey (2019), Health Management Information System (HMIS) summary data (2015–2016 to 2019–2020), and the Uganda Demographic and Heath Survey (DHS) report (2011, 2016). From the 200 articles and national health surveys identified, 37 articles and two national representative surveys met our criteria: prevalence, factors, estimating cost of induced abortion, and complications associated with safe and unsafe abortion in both low-and high-income countries. There are many unsafe abortions in restrictive environments. Abortion is one of the leading causes of maternal and morbidity. Physicians favor dilatation and curettage over manual vacuum aspiration and medical methods for the evacuation of retained products. Several gaps still exist in the published articles, HMIS data, and DHS data, leading to missed opportunities for data to inform policy and practice.
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    Estimating the Risk of Maternal Death at Admission: A Predictive Model from a 5-Year Case Reference Study in Northern Uganda
    (Obstetrics and Gynecology International, 2022) Alobo, Gasthony; Reverzani, Cristina; Sarno, Laura; Giordani, Barbara; Greco, Luigi
    Background. Uganda is one of the countries in the Sub-Saharan Africa with a very high maternal mortality ratio estimated at 336 deaths per 100,000 live births. We aimed at exploring the main factors affecting maternal death and designing a predictive model for estimation of the risk of dying at admission at a major referral hospital in northern Uganda. Methods. )is was a retrospective matched case-control study, carried out at Lacor Hospital in northern Uganda, including 130 cases and 336 controls, from January 2015 to December 2019. Multivariate logistic regression was used to estimate the net effect of the associated factors. A cumulative risk score for each woman based on the unstandardised canonical coefficients was obtained by the discriminant equation. Results. )e average maternal mortality ratio was 328 per 100,000 live births. Direct obstetric causes contributed to 73.8% of maternal deaths; the most common were haemorrhage (42.7%), sepsis (24.0%), hypertensive disorders (18.7%) and complications of abortion (2.1%), whereas malaria (23.5%) and HIV/AIDS (20.6%) were the leading indirect causes. )e odds of dying were higher among women who were aged 30 years or more (OR 1.12; 95% CI, 1.04–1.19), did not attend antenatal care (OR 3.11; 95% CI, 1.36–7.09), were HIV positive (OR 3.13; 95% CI, 1.41–6.95), had a caesarean delivery (OR 2.22; 95% CI 1.13–4.37), and were referred from other facilities (OR 5.57; 95% CI 2.83–10.99). Conclusion. Mortality is high among mothers referred late from other facilities who are HIV positive, aged more than 30 years, lack antenatal care attendance, and are delivered by caesarean section. )is calls for prompt and better assessment of referred mothers and specific attention to antibiotic therapy before and after caesarean section, especially among HIV-positive women.
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    Mothers’ perceptions of the practice of kangaroo mother care for preterm neonates in sub-Saharan Africa: a systematic review of qualitative evidence
    (JBI Evidence Synthesis, 2022) Bayo, Pontius; Alobo, Gasthony; Sauve, Caroline; Feyissa, Garumma Tolu
    Objective: The objective of this review was to explore the experiences of mothers with the practice of kangaroo mother care for preterm neonates at home in sub-Saharan Africa. Introduction: Newborn deaths globally have remained high despite the significant reductions in deaths among under-fives over the past few decades. More than 7000 deaths occur daily around the globe, but mostly in sub- Saharan Africa. Of these deaths, 60% to 80% are due to preterm birth and low birth weight. Kangaroo mother care is known to offer a cheap and effective way to care for low birth weight, preterm neonates; however, its practice is still low. There is limited evidence on the factors that hinder or facilitate the practice of kangaroo mother care at the community level. Inclusion criteria: The review considered studies conducted in sub-Saharan Africa on the perceptions and experiences of mothers who had given birth to preterm babies and had practiced kangaroo mother care wholly or in part at home. Qualitative studies in English and French conducted from January 1979 to March 2019 were considered for inclusion if they exclusively used qualitative research methods including, but not limited to, phenomenology, grounded theory, ethnography, action research, or feminist research. Methods: PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Academic Search Complete, CINAHL Complete, Education Source, and Health Source: Nursing/Academic Edition were searched in March 2019. Eligible studies were critically appraised using the standardized JBI tool. Findings were pooled using the metaaggregative approach, and confidence was assessed according to the ConQual approach. Results: Following the systematic search and critical appraisal process, six studies were included in the review for data extraction and synthesis of findings. Three of the six studies were based on in-depth individual interviews, while two employed both individual interviews and focus group discussions, and one study used only focus group discussions. Twenty-six primary findings were generated from the review process that were aggregated into 10 categories, which generated four meta-synthesized findings: i) Cultural and contextual factors: The traditional way of carrying babies on the back and providing them warmth through lighting lamps or charcoal make kangaroo mother care appear odd and shameful (level of confidence: low). ii) The technical content of the intervention: The practice of kangaroo mother care is perceived to be technically cumbersome, especially because it has to be continuous; there is fear of making the baby’s cord bleed; it creates difficulty in positioning for breastfeeding; and there is difficulty in maintaining the position while sleeping and doing other household chores (level of confidence: moderate). iii) Health system factors: The health care systems have no clear strategies to promote kangaroo mother care at the community level. Most mothers learned about the practice for the first time from health care workers only after birthing; however, peer-to-peer information sharing was noted to be a powerful source of trusted information about kangaroo mother care. Community leaders and religious leaders could be used to promote use of kangaroo mother care (level of confidence: moderate). iv) Individual and family factors: Although mothers realize the importance of kangaroo mother care for their infants’ recovery, their individual and family conditions affect their decision to practice the intervention (level of confidence: moderate). Conclusions: There is a link between the perceptions and experiences of kangaroo mother care that influences its practice in sub-Saharan Africa. The health care systems have failed to create awareness among communities before the birth of a preterm neonate. The traditional practices make kangaroo mother care stigmatizing at the community level, and the practice is perceived to be difficult and cumbersome, requiring substantial social support. Strategies to make the practice less cumbersome need to be devised, focusing on the comfort of mothers. Further qualitative studies are needed to explore community-level experiences of kangaroo mother care in sub-Saharan Africa.
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    Septic shock, acute renal and liver failure following unsafe abortion using bitter leaves and wandering jew in northern Uganda: A case series
    (Clinical Case Reports, 2022) Alobo, Gasthony; Reverzani, Cristina; Nahurira, Violah; Sarno, Laura
    Unsafe abortion is a major problem in Uganda, being one of the leading causes of maternal morbidity and mortality. Abortions are performed mostly under unsafe conditions, by people without medical training. In rural areas in northern Uganda, women often resort to traditional providers, who use local herbs as abortion remedies, usually with adverse outcomes. Little is known about the biological properties of these herbs and their toxicity profile. Here, we present the case series of two women, of 31 and 24 years of age, who underwent unsafe abortion for unintended pregnancy by using herbal medicines, that is, Commelina Africana (wandering jew) and Vernonia amygdalina (bitter leaf), respectively. While the first case resulted in uterine necrosis and pelvic peritonitis, which required multiple surgical interventions and the use of reserve antibiotics, the second case resulted in liver and renal failure that led to the death of the patient. This case series describes the unusual severe toxicity of two herbal medicines that are frequently used to induce abortion in northern Uganda. It highlights possible associations of Commelina Africana (wandering jew) with uterine necrosis complicated by sepsis, and of Vernonia amygdalina (bitter leaf) with acute liver and renal failure.