Reducing maternal mortality: a 10-year experience at Mpilo Central Hospital, Bulawayo, Zimbabwe

OBJECTIVES

Maternal mortality is one of the major Sustainable Development Goals (SDGs) of the global health community. The aim of the SDG 3.1 is to reduce global maternal mortality ratio considerably by 2030. The objective of this study was to document the epidemiological trends in maternal mortality for Mpilo Central Hospital.

METHODS

This was a 10 year retrospective study using readily available data from the maternity registers. The International Classification of Diseases-Maternal Mortality (ICD-MM) coding system for maternal deaths was used.

RESULTS

The maternal mortality ratio (MMR) declined from 655 per 100,000 live births in 2011 to 203 per 100,000 live births by 2020. The commonest groups of maternal mortality during the period 2011-2020 were hypertensive disorders, obstetric haemorrhage, pregnancy-related infection, and pregnancies with abortive outcomes. There were 273 maternal deaths recorded in the period 2011-2015, and 168 maternal deaths in the period 2016-2020. There was also a decline in maternal deaths due to obstetric haemorrhage (53 vs. 34). Maternal deaths due to pregnancy-related infection also declined (46 vs. 22), as well as pregnancies with abortive outcomes (40 vs. 26).

CONCLUSIONS

There was a 69% decline in the MMR over the 10 year period. The introduction of government interventions such as malarial control, the adoption of life-long Option B+ antiretroviral treatment for the pregnant women, the training courses of staff, and the introduction of strong clinical leadership and accountability were all associated with a significant decline in the causes of maternal deaths.

Maternal mortality decline in Zimbabwe, 2007/2008 to 2018/2019: findings from mortality surveys using civil registration, vital statistics and health system data

Background

Sustainable Development Goal (SDG) 3.1 target is to reduce the global maternal mortality ratio (MMR) to less than 70 maternal deaths per 100 000 live births by 2030. In the Ending Preventable Maternal Mortality strategy, a supplementary target was added, that no country has an MMR above 140 by 2030. We conducted two cross-sectional reproductive age mortality surveys to analyse changes in Zimbabwe’s MMR between 2007–2008 and 2018–2019 towards the SDG target.

Methods

We collected data from civil registration, vital statistics and medical records on deaths of women of reproductive ages (WRAs), including maternal deaths from 11 districts, randomly selected from each province (n=10) using cluster sampling. We calculated weighted mortality rates and MMRs using negative binomial models, with 95% CIs, performed a one-way analysis of variance of the MMRs and calculated the annual average reduction rate (ARR) for the MMR.

Results

In 2007–2008 we identified 6188 deaths of WRAs, 325 pregnancy-related deaths and 296 maternal deaths, and in 2018–2019, 1856, 137 and 130, respectively. The reproductive age mortality rate, weighted by district, declined from 11 to 3 deaths per 1000 women. The MMR (95% CI) declined from 657 (485 to 829) to 217 (164 to 269) deaths per 100 000 live births at an annual ARR of 10.1%.

Conclusions

Zimbabwe’s MMR declined by an annual ARR of 10.1%, against a target of 10.2%, alongside declining reproductive age mortality. Zimbabwe should continue scaling up interventions against direct maternal mortality causes to achieve the SDG 3.1 target by 2030.

The prevalence of and risk factors for stillbirths in women with severe preeclampsia in a high-burden setting at Mpilo Central Hospital, Bulawayo, Zimbabwe

OBJECTIVES

Stillbirth remains a global public health issue; in low-resource settings stillbirth rates remain high (>12 per 1,000 births target of Every Newborn Action Plan). Preeclampsia is major risk factor for stillbirths. This study aimed to determine the prevalence and risk factors for stillbirth amongst women with severe preeclampsia at Mpilo Central Hospital.

METHODS

A retrospective cross-sectional study was conducted of women with severe preeclampsia from 01/01/2016 to 31/12/2018 at Mpilo Central Hospital, Bulawayo, Zimbabwe. Multivariable logistic regression was used to determine risk factors that were independently associated with stillbirths.

RESULTS

Of 469 women that met the inclusion criteria, 46 had a stillbirth giving a stillbirth prevalence of 9.8%. The risk factors for stillbirths in women with severe preeclampsia were: unbooked status (adjusted odds ratio (aOR) 3.01, 95% (confidence interval) CI 2.20-9.10), frontal headaches (aOR 2.33, 95% CI 0.14-5.78), vaginal bleeding with abdominal pain (aOR 4.71, 95% CI 1.12-19.94), diastolic blood pressure ≥150 mmHg (aOR 15.04, 95% CI 1.78-126.79), platelet count 0-49 × 10⁹/L (aOR 2.80, 95% CI 1.26-6.21), platelet count 50-99 × 10⁹/L (aOR 2.48, 95% CI 0.99-6.18), antepartum haemorrhage (aOR 12.71, 95% CI 4.15-38.96), haemolysis elevated liver enzymes syndrome (HELLP) (aOR 6.02, 95% CI 2.22-16.33) and fetal sex (aOR 2.75, 95% CI 1.37-5.53).

CONCLUSIONS

Women with severe preeclampsia are at significantly increased risk of stillbirth. This study has identified risk factors for stillbirth in this high-risk population; which we hope could be used by clinicians to reduce the burden of stillbirths in women with severe preeclampsia.

Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys

Background

Reducing maternal mortality is a priority of Sustainable Development Goal 3.1 which requires frequent epidemiological analysis of trends and patterns of the causes of maternal deaths. We conducted two reproductive age mortality surveys to analyse the epidemiology of maternal mortality in Zimbabwe and analysed the changes in the causes of deaths between 2007-08 and 2018-19.

Methods

We performed a before and after analysis of the causes of death among women of reproductive ages (WRAs) (12-49 years), and pregnant women from the two surveys implemented in 11 districts, selected using multi-stage cluster sampling from each province of Zimbabwe (n=10); an additional district selected from Harare. We calculated mortality incidence rates and incidence rate ratios per 10000 WRAs and pregnant women (with 95% confidence intervals), in international classification of disease groups, using negative binomial models, and compared them between the two surveys. We also calculated maternal mortality ratios, per 100 000 live births, for selected causes of pregnancy-related deaths.

Results

We identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in the WRAs decreased by 82% in diseases of the respiratory system and 81% in certain infectious or parasitic diseases' groups, which include HIV/AIDS and malaria. Pregnancy-related deaths decreased by 84% in the indirect causes group and by 61% in the direct causes group, and HIV/AIDS-related deaths decreased by 91% in pregnant women. Direct causes of death still had a three-fold MMR than indirect causes (151 vs. 51 deaths per 100 000) in 2018-19.

Conclusion

Zimbabwe experienced a decline in both direct and indirect causes of pregnancy-related deaths. Deaths from indirect causes declined mainly due to a reduction in HIV/AIDS-related and malaria mortality, while deaths from direct causes declined because of a reduction in obstetric haemorrhage and pregnancy-related infections. Ongoing interventions ought to improve the coverage and quality of maternal care in Zimbabwe, to further reduce deaths from direct causes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13321-7.

Inflammatory pseudo-tumour of the colon mimicking acute appendicitis: A case report

Introduction

Presentation of case

Discussion

Conclusion

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Inflammatory pseudotumours are often mistaken for malignant lesions

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This error can result in unnecessary resection being performed

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We investigated whether radiography can diagnose inflammatory pseudotumours

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Our findings reveal that radiography may not be effective in this context

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Further studies may be required to prevent unnecessarily extensive resection

475 DEVELOPING A VIRTUAL CARE HOME SUPPORT FORUM DURING THE COVID-19 PANDEMIC

Introduction

COVID-19 has had a devastating effect on care homes, increasing both morbidity and mortality of residents and staff. Between 2 March and 12 June 2020, COVID-19 was the main cause of death in male care home residents (33.5%) and second for female (26.6%).1 By 1 May 2020, the death rate from all causes in care homes exceeded that in hospital (6,409 versus 6,397).2 Thus, care homes had to rapidly adapt to facilitate safe care of patients and staff.

Method

An expert outreach team visited a number of care homes in Surrey and Sussex to explore COVID-19 issues in care homes. Key themes were identified that informed topics for the Virtual Care Home Forum, where a series of virtual teaching, training and peer support sessions were hosted either live or on-demand, accessible for all care home staff.

Results

12 sessions were held with an average attendance of 25 people, predominantly care home managers and community healthcare professionals. Real time qualitative feedback was collected and an electronic survey was completed at the end of the series which showed 100% felt the sessions had improved their understanding of the topic, 100% felt the knowledge and skills obtained from the sessions would be useful in their job, 87.5% agreed the sessions would impact or change their practise and 100% felt more supported during the pandemic.

Conclusion

It has been an unprecedented year for the NHS, and the care home sector has suffered significantly. In order to provide the best level of care for patients and support for our community colleagues, we must work collaboratively, including provision of education and training. To ensure equal access for all, maintaining user-safety and compliance with government legislation, virtual webinars proved to be an excellent modality. We plan to continue providing training, teaching and support through this means in the future.

Resilience and vulnerability of maternity services in Zimbabwe: a comparative analysis of the effect of Covid-19 and lockdown control measures on maternal and perinatal outcomes, a single-centre cross-sectional study at Mpilo Central Hospital

BACKGROUND

On the 27th of March 2020 the Zimbabwean government declared the Covid-19 pandemic a 'national disaster'. Travel restrictions and emergency regulations have had significant impacts on maternity services, including resource stock-outs, and closure of antenatal clinics during the lockdown period. Estimates of the indirect impact of Covid-19 on maternal and perinatal mortality was expected it to be considerable, but little data was yet available. This study aimed to examine the impact of Covid-19 and lockdown control measures on non-Covid outcomes in a government tertiary level maternity unit in Bulawayo, Zimbabwe, by comparing maternal and perinatal morbidity and mortality before, and after the lockdown was implemented.

METHODS

This was a retrospective, observational study, using a cross-sectional design to compare routine monthly maternal and perinatal statistics three months before and after Covid-19 emergency measures were implemented at Mpilo Central Hospital.

RESULTS

Between January-March and April-June 2020, the mean monthly deliveries reduced from 747.3 (SD ± 61.3) in the first quarter of 2020 to 681.0 (SD ± 17.6) during lockdown, but this was not statistically significant, p = 0.20. The Caesarean section rates fell from a mean of 29.8% (SD ± 1.7) versus 28.0% (SD ± 1.7), which was also not statistically significant, p = 0.18. During lockdown, the percentage of women delivering at Mpilo Central Hospital who were booked at the hospital fell from a mean of 41.6% (SD ± 1.1) to 35.8% (SD ± 4.3) which was statistically significant, p = 0.03. There was no significant change, however, in maternal mortality or severe maternal morbidity (such as post-partum haemorrhage (PPH), uterine rupture, and severe preeclampsia/eclampsia), stillbirth rate or special care baby unit admission. There was an increase in the mean total number of early neonatal deaths (ENND) (mean 18.7 (SD ± 2.9) versus 24.0 (SD ± 4.6), but this was not statistically significant, p = 0.32.

CONCLUSIONS

Overall, maternity services at Mpilo showed resilience during the lockdown period, with no significant change in maternal and perinatal adverse outcomes, with the same number of man-hours worked before and during the lockdown Maternal and perinatal outcomes should continue to be monitored to assess the impact of Covid-19 and the lockdown measures as the pandemic in Zimbabwe unfolds. Further studies would be beneficial to explore women's experiences and understand how bookings and deliveries at local clinics changed during this time.

Hepatitis B infection in people living with HIV who initiate antiretroviral therapy in Zimbabwe

Setting

There is little information about the diagnosis and treatment of hepatitis B virus (HBV) infection in people living with HIV (PLHIV) in Zimbabwe despite recommendations that tenofovir (TDF) + lamivudine (3TC) is the most effective nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) backbone of antiretroviral therapy (ART) in those with dual infection.

Objective

To determine 1) numbers screened for hepatitis B surface antigen (HBsAg); 2) numbers diagnosed HBsAg-positive along with baseline characteristics; and 3) NRTI backbones used among PLHIV initiating first-line ART at Mpilo Opportunistic Infections Clinic, Bulawayo, Zimbabwe, between October 2017 and April 2019.

Design

This was a cross-sectional study using routinely collected data.

Results

Of the 422 PLHIV initiating first-line ART (median age 34 years, IQR 25-43), 361 (85%) were screened for HBV, with 10% being HBsAg-positive. HBsAg positivity was significantly associated with anaemia (adjusted prevalence ratio [aPR] 2.3, 95%CI 1.1-4.7) and elevated ala-nine transaminase levels (aPR 2.9, 95%CI 1.5-5.8). Of 38 PLHIV who were diagnosed HBsAg-positive, 30 (79%) were started on ART based on tenofovir (TDF) and lamivudine (3TC), seven were given abacavir (ABC) + 3TC-based ART and one was given zido vudine (ZDV) + 3TC-based ART.

Conclusion

In PLHIV, HBV screening worked well, the prevalence of HIV-HBV co-infection was high and most patients received appropriate treatment for both conditions. Recommendations to improve screening, diagnosis and treatment of HIV-HBV co-infection are discussed.

Children and adolescents on anti-retroviral therapy in Bulawayo, Zimbabwe: How many are virally suppressed by month six?

Background: Zimbabwe is one of the countries in sub-Saharan Africa disproportionately affected by human immunodeficiency virus. In the "treat all" era, we assessed the gaps in routine viral load (VL) monitoring at six months for children (0-9 years) and adolescents (10-19 years) newly initiated on anti-retroviral therapy (ART) from January 2017 to September 2018 at a large tertiary hospital in Bulawayo. Methods: In this cohort study using secondary data, we considered first VL done within six to nine months of starting therapy as 'undergoing VL test at six months'. We classified repeat VL≥1000 copies/ml despite enhanced adherence counselling as virally unsuppressed. Results: Of 295 patients initiated on ART, 196 (66%) were children and 99 (34%) adolescents. A total 244 (83%) underwent VL test at six months, with 161 (54%) virally suppressed, 52 (18%) unsuppressed and 82 (28%) with unknown status (due to losses in the cascade). Switch to second line was seen in 35% (18/52). When compared to children, adolescents were less likely to undergo a VL test at six months (73% versus 88%, p=0.002) and more likely to have an unknown VL status (40% versus 22%, p=0.001). Conclusion: At six months of ART, viral suppression was low and losses in the cascade high.

Maternal survival in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

OBJECTIVES

Maternal mortality is an important global subject. This dataset was generated from a retrospective cross-sectional study carried out at Mpilo Central Hospital, covering the period January 1, 2015 to December 31, 2018. The aim of the study was to compare how frequently the exposure to a risk factor was related to maternal death. Maternal deaths that were recorded during the study period were considered as cases. Controls were selected randomly from women of child-bearing age who survived during the study period. Low-resourced countries contribute significantly to global maternal deaths. Understanding risk factors could help reduce maternal mortality.

DATA DESCRIPTION

The dataset contains data of 387 pregnant women who were included in the study. Data were collected as secondary data using a data collection sheet, as recorded by the hospital staff that gave all necessary demographic details in birth and mortality registers. The data collected included socio-demographic and clinical data. The independent variables were maternal age, gravidity, parity, antenatal visits, booking status, marital status, educational status, days spent in hospital, mode of delivery, fetal outcomes, and maternal complications. The dependent variable was maternal mortality. The data can be used to determine the relationship between the independent variables and maternal death.

Early onset severe preeclampsia and eclampsia in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

OBJECTIVES

Early-onset severe preeclampsia is associated with significant maternal and perinatal morbidity and mortality especially in low-resource settings, where women have limited access to antenatal care. This dataset was generated from a retrospective cross-sectional study carried out at Mpilo Central Hospital, covering the period February 1, 2016 to July 30, 2018. The aim of the study was to determine the incidence of early-onset severe preeclampsia and eclampsia, and associated risk factors in a low-resource setting. The reason for examining the incidence of preeclampsia specifically in a low-resource setting; was to document it as women in these settings appear to suffer from poor outcomes.

DATA DESCRIPTION

The dataset contains data of 238 pregnant women who had a diagnosis of early onset severe preeclampsia/eclampsia. There were 243 babies from singleton and twin gestations. There were five sets of twins. There were 21,505 live births during the study period giving an incidence of 1.1%. The dataset contains data on maternal socio-demographic, signs and symptoms, therapeutic interventions and mode of delivery, adverse outcomes characteristics, and fetal characteristics. This large dataset can be used to calculate the incidence and risk factors for adverse maternal and fetal outcomes or develop predictive models in severe preeclampsia/eclampsia.

Factors associated with maternal mortality from sepsis in a low-resource setting: a five-year review at Mpilo Central Hospital, Bulawayo, Zimbabwe

Sepsis remains a major cause of maternal deaths globally. It is one of the major causes of maternal morbidity and mortality in women of reproductive age. It is important that such a major contributor is studied in low-resource settings. The aims of this study were to document the percentage of maternal deaths from sepsis among the total number of maternal deaths in a low-resource setting and to determine factors associated with maternal mortality from sepsis at Mpilo Central Hospital. This was a retrospective, descriptive, cross-sectional study carried out at Mpilo Central Hospital. Nearly one-third (29.3%) of maternal deaths were due to sepsis. The major factor associated with maternal mortality was post-abortal sepsis (41.7%).

A survey of pathology specimens associated with impacted teeth over a 21-year period

Background

To compare the histologic diagnosis of lesions associated with impacted teeth from a South African population with literature data.

Material and Methods

A retrospective cross-sectional survey of tissue specimens associated with impacted teeth that were analyzed in the Department of Oral Pathology (University of the Witwatersrand, South Africa) between 1996 and 2016. Patient age, gender, impacted tooth location and the histologic diagnosis were recorded for statistical analysis.

Results

Odontogenic pathology was diagnosed in 389 (95.6%) specimens while dental follicle comprised 4.4% of tissue submissions. The mean age was 25.3 ±15.2 years with a male predilection (M:F=1.8:1). The 11-20 year age group was mostly affected and the overall frequency of odontogenic lesions reduced significantly with an increase in age (p=0.01). Dentigerous cyst (56.5%) and ameloblastoma (14%) were most commonly diagnosed.

Conclusions

This is the first African epidemiologic survey of histologic specimens associated with impacted teeth and shows striking differences in the ratio of pathologic to non-pathologic diagnoses compared to other populations. Locally aggressive odontogenic lesions appear to develop one to two decades earlier in patients from developing countries.

Key words:Ameloblastoma, biopsy, dentigerous cyst, histopathology, odontogenic cyst, odontogenic tumor.

Statistical risk prediction models for adverse maternal and neonatal outcomes in severe preeclampsia in a low-resource setting: proposal for a single-centre cross-sectional study at Mpilo Central Hospital, Bulawayo, Zimbabwe

Hypertensive disorders in pregnancy are a leading cause of maternal and perinatal morbidity and mortality, especially in low-resource settings. Identifying mothers and babies at greatest risk of complications would enable intervention to be targeted to those most likely to benefit from them. However, current risk prediction models have a wide range of sensitivity (42-81%) and specificity (87-92%) indicating that improvements are needed. Furthermore, no predictive models have been developed or evaluated in Zimbabwe. This proposal describes a single centre retrospective cross-sectional study which will address the need to further develop and test statistical risk prediction models for adverse maternal and neonatal outcomes in low-resource settings; this will be the first such research to be carried out in Zimbabwe. Data will be collected on maternal demographics characteristics, outcome of prior pregnancies, past medical history, symptoms and signs on admission, results of biochemical and haematological investigations. Adverse outcome will be defined as a composite of maternal morbidity and mortality and perinatal morbidity and mortality. Association between variables and outcomes will be explored using multivariable logistic regression. Critically, new risk prediction models introduced for our clinical setting may reduce avoidable maternal and neonatal morbidity and mortality at local, national, regional and international level.

Determinants of adverse maternal and perinatal outcomes in severe preeclampsia and eclampsia in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

Objective

Severe preeclampsia and eclampsia have dire consequences for both maternal and neonatal health. The objective of this study was to identify determinants of adverse maternal and perinatal outcomes in severe preeclampsia and eclampsia.

Results

Binary logistic regression showed the following were significantly associated with adverse maternal outcomes; mothers who had a baby born at 27–29⁺⁶ weeks of gestation were 8 times more likely to be associated with adverse maternal outcomes compared to mothers who gave birth at 37–39⁺⁶ weeks’ of gestation (OR 8.187, 95% CI 1.680–39.911, p = 0.02), holding other variables constant. Platelet count was also statistically significant for adverse maternal outcome. Mothers with platelet counts of 0–49 × 10⁹/l were 46 times more likely to be associated with adverse maternal outcome compared to mothers with normal counts of more than 150 × 10⁹/l (OR 46.429, 95% CI 17.778–121.253, p = 0.001). The following determinants were significantly associated with adverse perinatal outcomes. Mothers with platelet counts of 0–49 × 10⁹/l were 4 times more likely to be associated with adverse perinatal outcomes compared to mothers with platelet counts of above 150 × 10⁹/l (OR 3.690, 95% CI 1.752–7.775, p = 0.001).

Stillbirth rate and causes in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

A global concern is to end preventable stillbirths by the year 2030. The objective of this study was to document the stillbirth rate and causes of stillbirths in a low-resource setting. This was a retrospective descriptive study carried out at Mpilo Central Hospital, a tertiary teaching referral government hospital in Bulawayo, Zimbabwe during the period January to December 2016. There were 8801 live births and 268 stillbirths (rate: 30.5/1000). The majority(81.3%) were macerated. Pre-term labour, pre-eclampsia, eclampsia and abruptio placenta accounted for 51.1%. In 29.9%, the cause could not be identified. A high proportion of macerated stillbirths were unexplained; hence this calls for a renewed focus on community-based approaches to reduce delays in seeking care. Investment in robust diagnostic means and further training of healthcare workers to improve case definition are both urgently required.

Reducing fresh full term intrapartum stillbirths through leadership and accountability in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

Background

Stillbirths are distressing to the parents and healthcare workers. Globally large numbers of babies are stillborn. A number of strategies have been implemented to try and reduce stillbirths worldwide. The objective of this study was to assess the impact of leadership and accountability changes on reducing full term intrapartum stillbirths.

Methods

Leadership and accountability changes were implemented in January 2016. This retrospective cohort study was carried out to assess the impact of the changes on fresh full term intrapartum stillbirths covering the period 6 months prior to the implementation date and 12 months after the implementation date. The changes included leadership and accountability. Fresh full term stillbirths (>37 weeks gestation) occurring during the intrapartum stage of labour were analysed to see if there would be any reduction in numbers after the measures were put in place.

Results

There was a reduction in the number of fresh full term intrapartum stillbirths after the introduction of the measures. There was a statistical difference before and after implementation of the changes, 50% vs 0%, P = 0.025. There was a reduction in the time it took to perform an emergency caesarean section from a mean of 30 to 15 min by the end of the study, a 50% reduction.

Conclusions

Clear and consistent clinical leadership and accountability can help in the global attempts to reduce stillbirth figures. Simple measures can contribute to improving perinatal outcomes.

Severe preeclampsia and eclampsia: incidence, complications, and perinatal outcomes at a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

Background

Severe preeclampsia is a disorder of pregnancy characterized by high blood pressure and significant proteinuria after 20 weeks gestation. Severe preeclampsia and eclampsia have considerable adverse impacts on maternal, fetal, and neonatal health especially in low-resource countries. Hypertensive disorders of pregnancy are the third leading cause of maternal deaths in Sub-Saharan Africa. Significant avoidable maternal and neonatal morbidity and mortality may result.

Objectives

This study aimed 1) to determine the incidence of severe preeclampsia/eclampsia in a low-resource setting; 2) to determine the maternal complications of severe preeclampsia/eclampsia in a low-resource setting; 3) to determine the perinatal outcomes of severe preeclampsia/eclampsia in a low-resource setting.

Methods

This was a retrospective descriptive cohort study carried out at Mpilo Central Hospital, a tertiary teaching referral government hospital in a low-resource setting in Bulawayo, Zimbabwe. Data were obtained from the birth registers in labor ward, intensive care unit, and neonatal intensive care unit of patients who had a diagnosis of severe preeclampsia or eclampsia for the period January 1, 2016, to December 31, 2016. The case notes were retrieved and the demographic, clinical, and outcome data were gathered.

Results

There were 9,086 deliveries at the institution during the period January 1, 2016, to December 31, 2016. There were 121 cases of severe preeclampsia/eclampsia. The incidence of severe preeclampsia/eclampsia was 1.3% at Mpilo Central Hospital. The most common major complication was HELLP syndrome (9.1%). Maternal mortality was 1.7%. There were 127 babies born with six sets of twins, 49.6% of the babies were lost through stillbirths and early neonatal deaths.

Conclusion

The incidence of severe preeclampsia/eclampsia at Mpilo Central Hospital was 1.3%. The most common maternal complication was hemolysis elevated liver enzymes low platelet syndrome. Maternal mortality was 1.7% due to acute renal failure. Nearly half (49.6%) of the babies born were lost to stillbirths and early neonatal deaths.

Challenges in the surgical management of ectopic pregnancy in a low-resource setting: Mpilo Central Hospital, Bulawayo, Zimbabwe

Background Ectopic pregnancy contributes to maternal morbidity and mortality, especially in low-resourced countries with limited facilities for early diagnosis and treatment. It is a very challenging condition to diagnose. Patients may collapse and die while undergoing investigation. Aims To assess surgical treatment given to patients presenting at Mpilo Central Hospital, the challenges that are faced and the outcomes; and also to document how women survive this dangerous condition in a setting challenged by low resources. Results All the patients had prompt life-saving surgery within 48 h of admission despite the challenges faced. The survival rate was 100% during the period of the study. Conclusion It is possible to prevent maternal mortality in low-resource countries by maintaining basic clinical and surgical skills.

Postpartum hemorrhage: incidence, risk factors, and outcomes in a low-resource setting

Background

Primary postpartum hemorrhage (PPH) is defined as blood loss from the genital tract of 500 mL or more following a normal vaginal delivery (NVD) or 1,000 mL or more following a cesarean section within 24 hours of birth. PPH contributes significantly to maternal morbidity and mortality worldwide. Women can rapidly hemorrhage and die soon after giving birth. It can be a devastating outcome to many young families. Women giving birth in low-resource settings are at a higher risk of death than their counterparts in resource-rich environments. PPH is a leading cause of maternal deaths globally, contributing to a quarter of the deaths annually.

Aims

This study aims 1) to document the incidence, risk factors, and causes of PPH in a low-resource setting and 2) to document the maternal outcomes of PPH in low-resource setting.

Methods

This was a retrospective descriptive cohort study carried out at Mpilo Central Hospital, a tertiary referral government hospital in a low-resource setting in Bulawayo, Zimbabwe. Data were obtained from the labor ward birth registers for patients who had a diagnosis of PPH during the period from January 1, 2016 to June 30, 2016. The case notes were retrieved and the demographic, clinical, and outcome data were gathered. Blood loss was estimated postdelivery by the attending clinician – either a midwife or a doctor. At this maternity unit, blood loss is not measured but estimated owing to prevailing resource constraints. The SPSS Version 21 statistical tool was used to calculate the mean and standard deviation (SD) values. Simple statistical tests were used on absolute numbers to calculate percentages.

Results

There were 4,567 deliveries at the institution during the period from January 1, 2016 to June 30, 2016. There were 74 cases of PPH during the study period. The incidence of primary PPH was 1.6%. The mean age was 27.7 years (SD ±6.9), mean gestational age was 38.6 weeks gestation (SD ±2.2), and mean birth weight was 3.16 kg (SD ±0.65) for the studied group of patients. Three-quarters (75.7%) of the cases had NVD. The majority of the cases (77.0%) had an identifiable risk factor for developing primary PPH. The most identifiable risk factor for primary PPH was pregnancy-induced hypertension followed by prolonged labor. Uterine atony was the most common cause of postpartum hemorrhage (82.4%). The women who delivered by NVD, who were diagnosed with a PPH, and who lost an estimated 500–1,000 mL of blood were 73.2%; 25% lost 1,000–1,500 mL of blood, and 1.8% lost more than 1,500 mL of blood. The women who delivered by lower-segment cesarean section, who were diagnosed with a PPH, and who lost an estimated 1,000–1,500 mL of blood were 77.8%, and 22.2% bled an estimated 1,500 mL of blood or more. The majority of the cases of primary PPH (94.6%) survived the condition and 5.4% died.

Conclusion

The incidence of PPH at Mpilo Central Hospital was 1.6% during the study period, lower than that reported elsewhere in similar setting in the literature. This study, therefore, is important as it documents for the first time for this maternity unit and for a Zimbabwean setting, the incidence of one of the most important causes of global maternal deaths. Future studies should involve the effect on maternal outcomes of PPH following widespread introduction of misoprostol therapy into practice. This data can help in mobilizing global efforts to improve women’s health.

Massive vulval Kaposi's sarcoma in pregnancy: case report

Introduction

The complications of HIV/AIDS can produce grossly abnormal pathology. In low-resourced settings, women can present late with huge lesions. Massive vulval pathology copresenting in pregnancy produces difficulties in managing the patients and may lead to poor maternal or fetal outcomes.

Case report

A 27-year-old P1 G2 (second pregnancy one live birth) patient presented at 30 weeks gestation with a massive vulval lesion. She was HIV seropositive and taking anti-retroviral therapy. She was anemic with a hemoglobin level of 5.9 and was transfused 4.0 of packed cells. She underwent examination under anesthesia and vulval biopsy. She went into preterm labor and was delivered by cesarean section. Unfortunately, the baby had died while receiving corticosteroid therapy. The histopathological report confirmed a Kaposi’s sarcoma, and she was referred to oncologists for chemotherapy.

Conclusion

Kaposi’s sarcoma can occur in pregnancy in both seropositive and seronegative patients. Kaposi’s sarcoma causes significant fetal and maternal health complications.

Ovarian dysgerminoma presenting as a pregnancy: case report

A 32 year-old P4 G4 was referred from a rural hospital for fibroids in pregnancy. The pregnancy test was positive. An ultrasound scan reported a huge left extrauterine mass. The uterus was of normal size. There was no pregnancy demonstrated. A laparotomy was done through a midline incision. There was a huge left ovarian tumour occupying the pelvic/abdominal region right up to the xiphisternum. A left salpingo-oophrectomy was done. The post operative period was uneventful. The histopathological report confirmed the diagnosis of ovarian dysgerminoma FIGO stage 1A. She was referred to oncologists for adjvunt chemotherapy.

Onsite training of doctors, midwives and nurses in obstetric emergencies, Zimbabwe

PROBLEM

In Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths.

APPROACH

We established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital.

LOCAL SETTING

Maternal mortality in Zimbabwe has increased from 555 to 960 per 100,000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff.

RELEVANT CHANGES

Following an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014.

LESSONS LEARNT

Introducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required.

Massive hemoptysis and complete unilateral lung collapse in pregnancy due to pulmonary tuberculosis with good maternal and fetal outcome: a case report

Background

We report an extremely rare case of massive hemoptysis and complete left-sided lung collapse in pregnancy due to pulmonary tuberculosis in a health care worker with good maternal and fetal outcome.

Case presentation

A 33-year-old human immuno deficiency virus seronegative African health care worker in her fourth pregnancy with two previous second trimester miscarriages and an apparently healthy daughter from her third pregnancy presented coughing up copious amounts of blood at 18 weeks and two days of gestation. She had a cervical suture in situ for presumed cervical weakness.

Computed tomography of her chest showed complete collapse of the left lung; subsequent bronchoscopy was apparently normal. Her serum β-human chorionic gonadotropin, tests for autoimmune disease and echocardiography were all normal.

Her lung re-inflated spontaneously.

Sputum for acid alcohol fast bacilli was positive; our patient was commenced on anti-tuberculosis medication and pyridoxine.

At 41 weeks and three days of pregnancy our patient went into spontaneous labor and delivered a live born female baby weighing 2.6 kg with APGAR scores of nine and 10 at one and five minutes respectively. She and her baby are apparently doing well about 10 months after delivery.

Conclusion

It is possible to have massive hemoptysis and complete unilateral lung collapse with spontaneous resolution in pregnancy due to pulmonary tuberculosis with good maternal and fetal outcome.

Full-term abdominal extrauterine pregnancy complicated by post-operative ascites with successful outcome: a case report

Introduction

Advanced abdominal (extrauterine) pregnancy is a rare condition with high maternal and fetal morbidity and mortality. Because the placentation in advanced abdominal pregnancy is presumed to be inadequate, advanced abdominal pregnancy can be complicated by pre-eclampsia, which is another condition with high maternal and perinatal morbidity and mortality. Diagnosis and management of advanced abdominal pregnancy is difficult.

Case presentation

We present the case of a 33-year-old African woman in her first pregnancy who had a full-term advanced abdominal pregnancy and developed gross ascites post-operatively. The patient was successfully managed; both the patient and her baby are apparently doing well.

Conclusion

Because most diagnoses of advanced abdominal pregnancy are missed pre-operatively, even with the use of sonography, the cornerstones of successful management seem to be quick intra-operative recognition, surgical skill, ready access to blood products, meticulous post-operative care and thorough assessment of the newborn.

24 hour rhythm in the timing of pre-labour spontaneous rupture of membranes at term

OBJECTIVE

To study the timing of pre-labour spontaneous rupture of membranes (SROM) in term pregnancies.

DESIGN

Prospective cohort.

SETTING

A maternity hospital in the United Kingdom.

SAMPLE

Women who were more than 37 weeks gestation with confirmed spontaneous rupture of membranes and not in labour after 4 h.

METHODS

Women who were admitted into labour ward with a diagnosis of spontaneous rupture of membranes after 37 weeks of gestation were included. The women's demographic details were recorded and inquiries about whether they had sexual intercourse in the preceding 12 h. The final outcome of their pregnancy was recorded and analysed.

MAIN OUTCOME MEASURES

(1) The exact time of spontaneous rupture of membranes, (2) the time of onset of spontaneous labour, (3) delivery details.

RESULTS

One hundred and ninety-six women were studied. A 24 h rhythm in the timing of spontaneous rupture of membranes was found with 33.2% occurring between 00:00 and 04:00 h. When contractions representing the onset of labour occurred there was no diurnal rhythm to the timing of onset of contractions.

CONCLUSIONS

There is a 24 h rhythm in the timing of spontaneous rupture of membranes in term gestations. The physiological reasons for this rhythm are not understood at the present time.