The increasing use of the WHO Safe Childbirth Checklist: lessons learned at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon

BACKGROUND

Safe childbirth remains a daunting challenge, particularly in low-middle income countries, where most pregnancy-related deaths occur. Cameroon's maternal mortality rate, estimated at 529 per 100,000 live births in 2017, is significantly high. The WHO Safe Childbirth Checklist (SCC) was designed to improve the quality of care provided to pregnant women during childbirth. The SCC was implemented at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital to improve the quality of care during childbirth.

METHODS

This study was a retrospective study to determine the adoption rate of the SCC and its association with maternal (eclampsia, perineal tears, and postpartum haemorrhage) and neonatal (stillbirth, neonatal asphyxia and neonatal death) complications. Data were collected 6 months after the introduction of the SCC. Multivariate binary logistic regression was used to analyse the association between the use of the SCC and maternofoetal complications.

RESULTS

Out of 1611 deliveries conducted, 1001 records were found, giving a retrieval rate of 62%. Twenty-five records were excluded. During the study period, the checklists were used in 828 of 976 clinical notes, with an adoption rate of 84.8% and a utilization rate of 93.9% at 6 months. Severe preeclampsia/eclampsia was associated with the non-use of the SCC (2.1 vs 5.4%, p = 0.041). Stillbirth, neonatal asphyxia, and neonatal death rates were not significantly different between the checklist and non-checklist groups. However, for all neonatal outcomes, the proportion of complications was lower when the checklist was used.

CONCLUSION

The use of the SCC was associated with significantly reduced pregnancy complications, especially for reducing the rates of severe pre-eclampsia/eclampsia. The use of the SCC increased to 93.9% of all deliveries within 6 months. We advocate for the use of the WHO Safe Childbirth Checklist in maternity units.

Prediction of clinical outcomes in women with placenta accreta spectrum using machine learning models: an international multicenter study

INTRODUCTION

Placenta accreta spectrum is a major obstetric disorder that is associated with significant morbidity and mortality. The objective of this study is to establish a prediction model of clinical outcomes in these women.

MATERIALS AND METHODS

PAS-ID is an international multicenter study that comprises 11 centers from 9 countries. Women who were diagnosed with PAS and were managed in the recruiting centers between 1 January 2010 and 31 December 2019 were included. Data were reanalyzed using machine learning (ML) models, and 2 models were created to predict outcomes using antepartum and perioperative features. ML model was conducted using python^® programing language. The primary outcome was massive PAS-associated perioperative blood loss (intraoperative blood loss ≥2500 ml, triggering massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Other outcomes include prolonged hospitalization >7 days and admission to the intensive care unit (ICU).

RESULTS

727 women with PAS were included. The area under curve (AUC) for ML antepartum prediction model was 0.84, 0.81, and 0.82 for massive blood loss, prolonged hospitalization, and admission to ICU, respectively. Significant contributors to this model were parity, placental site, method of diagnosis, and antepartum hemoglobin. Combining baseline and perioperative variables, the ML model performed at 0.86, 0.90, and 0.86 for study outcomes, respectively. Ethnicity, pelvic invasion, and uterine incision were the most predictive factors in this model.

DISCUSSION

ML models can be used to calculate the individualized risk of morbidity in women with PAS. Model-based risk assessment facilitates a priori delineation of management.

Prediction of success of uterus-preserving management in women with placenta accreta spectrum (CON-PAS score): A multicenter international study

OBJECTIVE

To create a model for prediction of success of uterine-preserving procedures in women with placenta accreta spectrum (PAS).

METHODS

PAS-ID is a multicenter study that included 11 centers from 9 countries. Women with PAS, who were managed between January 1, 2010 and December 31, 2019, were retrospectively included. Data were split into model development and validation cohorts, and a prediction model was created using logistic regression. Main outcome was success of uterine preservation.

RESULTS

Out of 797 women with PAS, 587 were eligible. Uterus-preserving procedures were successful in 469 patients (79.9%). Number of previous cesarean sections (CS) was inversely associated with management success (adjusted odds ratio [aOR] 0.02, 95% confidence interval [CI] 0.001-3.63 with five previous CS). Other variables were complete placental invasion (aOR 0.14, 95% CI 0.05-0.43), type of CS incision (aOR 0.04, 95% CI 0.01-0.25 for classical incision), compression sutures (aOR 2.48, 95% CI 1.00-6.16), accreta type (aOR 3.76, 95% CI 1.13-12.53), incising away from placenta (aOR 5.09, 95% CI 1.52-16.97), and uterine resection (aOR 102.57, 95% CI 3.97-2652.74).

CONCLUSION

The present study provides a prediction model for success of uterine preservation, which may assist preoperative and intraoperative decisions, and promote incorporation of uterine preservation procedures in comprehensive PAS protocols.

Diagnostic ambiguity of aseptic necrobiosis of a uterine fibroid in a term pregnancy: a case report

Background

Uterine fibroids are the most common uterine tumours in females of reproductive age. During pregnancy, uterine fibroids may be complicated by aseptic necrobiosis. We herein report an ambiguous clinical presentation of uterine fibroids in pregnancy and discuss the diagnostic challenges encountered in our resource-constraint setting.

Case presentation

A term pregnant Cameroonian woman was admitted to our maternity unit with clinical findings suggestive of a strangulated umbilical hernia. She underwent an emergency caesarean section which fortuitously revealed aseptic necrobiosis of a uterine fibroid, managed within the same surgical intervention by myomectomy. Her post-operative course was uneventful.

Conclusion

The authors highlight the need for a high index of suspicion by healthcare providers, as well as the need for a multidisciplinary approach for a favourable maternal and foetal outcome.

Risk factors for ectopic pregnancy in a population of Cameroonian women: A case-control study

OBJECTIVE

To identify the risk factors for ectopic pregnancy (EP) in a population of Cameroonian women.

SAMPLE AND METHODS

We performed a matched case-control study; 88 women with diagnosed EP (cases), and 176 women with first trimester intrauterine pregnancy (IUP) (controls), who underwent questionnaires. Odds Ratio (OR) and 95% confidence intervals (CIs) were calculated and adjusted for potential confounding factors via multivariate logistic regression analysis.

RESULTS

Of the fifteen identified risk factors, 4 were independently associated with increased odds of EP: prior pelvic inflammatory disease (PID) (adjusted odds ratio [AOR] 13.18; 95% CI 6.19-27.42), followed by current use of levonorgestrel-only pills for emergency contraception (LNG-EC) (AOR 10.15; 95% CI 2.21-46.56), previous use of depot medroxyprogesterone acetate (DMPA) (AOR 3.01; 95% CI 1.04-8.69) and smoking at the time of conception (AOR 2.68; 95% CI 1.12-6.40).

CONCLUSION

The present study confirms the wide variety of EP's risk factors. Moreover, some new findings including current use of LNG-EC, previous use of DMPA, smoking at the time of conception are noteworthy. Thus, in our limited resources country where prevention remains the cornerstone for reducing EP chances of occurrence, clinicians should do enough counselling, especially to women with known risk factors. The necessity to facilitate access to more equipment to enable early diagnosis of EP is very crucial and should be seriously considered, in order to reduce the burden of EP in Cameroonian women.

Evaluation of patients' satisfaction after laparoscopic surgery in a tertiary hospital in Cameroon (Africa)

Introduction

Access to laparoscopy is low in Cameroon where customers' satisfaction has not been reported so far. We assessed patients' satisfaction with the process of care during laparoscopic surgery in a new tertiary hospital.

Methods

A questionnaire was addressed to consenting patients (guardians for patients under 18) with complete medical records who underwent laparoscopy at the Douala Gynaeco-Obstetric and Paediatric Hospital (Cameroon) from November 1, 2015 to July 31, 2016. The following modified Likert's scale was used to assess satisfaction: very weak: 0-2.5; weak 2.6-5; good: 5.1-7.5; very good: 7.6-10. Only descriptive statistics were used.

Results

Response rate was 90% (45/50). Of the 45 respondents, 39 (86.7%) were female, 14(31.1%) were referred and 39 (86.7%) paid by direct cash deposit. Mean age was 36.8±11.9 years. Laparoscopies were carried out in emergency for 3 (6.7%) patients. Digestive abnormalities indicated 13 (28.9%) laparoscopies while gynaecologic diseases accounted for 32 (71.1%) cases. Perception of the overall care process was good with a mean satisfaction score of 6.8 ± 1.4. Scores in categories were: 0% (Very weak); 13.3% (weak); 57.8% (good) and 28.9% (very good). Specifically mean satisfaction scores were: 7.8 ± 1.0 with doctors' care; 7.1 ± 1.3 with hospital administration; 7.0 ± 1.2 with nursing and 4.7 ± 1.4 with the costs. Main complaints were: long waiting time (73.3%), constraining geographical access (66.7%) and expensiveness (48.9%).

Conclusion

Patients were globally satisfied with the process of care but financial and geographical barriers should be addressed.

Maternal and neonatal outcomes of vaginal breech delivery for singleton term pregnancies in a carefully selected Cameroonian population: a cohort study

BACKGROUND AND OBJECTIVES

Vaginal breech delivery (VBD) is known to be associated with more perinatal and maternal complications. Very few studies on the subject have been carried out in poor-resource settings. The aim of this study was to determine maternal and neonatal outcomes in carefully selected cases of VBD for singleton term pregnancies in a tertiary centre in Cameroon.

DESIGN

A retrospective cohort study.

SETTING

A tertiary hospital in Yaounde, Cameroon.

PARTICIPANTS

Cases of VBD of newborns weighing 2500-3500 g were matched in a ratio of 1:4 to consecutive vaginal cephalic deliveries (VCDs) of newborns weighing 2500-3500 g over a 5-year period. Both groups were matched for maternal age and parity. We excluded cases of multiple gestations, footling breech, clinically inadequate maternal pelvis, preterm delivery, post-term pregnancies, fetal demise prior to the onset of labour, placenta praevia and fetal anomaly incompatible with vaginal delivery.

OUTCOME MEASURES

Neonatal and maternal adverse outcomes of VBD observed till 6 weeks after delivery analysed using Bonferroni correction.

RESULTS

Fifty-three (53) VBDs were matched against 212 VCD. Unlike women who had VCD, those who underwent VBD were more likely to have prolonged labour (OR 8.05; 95% CI 3.00 to 11.47; P<0.001), and their newborns were more likely to suffer from birth asphyxia (OR 10.24; 95% CI 4.92 to 21.31; P<0.001).

CONCLUSION

The study infers a strong association between VBD of singleton term pregnancies and maternofetal morbidity when specific protocols are applied. This, however, failed to translate into higher differences in perinatal mortality. This finding does not discount the role of VBD in low-income countries, but we emphasise the need for specific precautions like close monitoring of labour and adequate anticipation for neonatal resuscitation in order to reduce these complications.

Uterus preserving surgery versus hysterectomy in the treatment of refractory postpartum haemorrhage in two tertiary maternity units in Cameroon: a cohort analysis of perioperative outcomes

Background

Little evidence exists on the efficacy and safety of the different surgical techniques used in the treatment of postpartum haemorrhage (PPH). We aimed to compare uterus preserving surgery (UPS) versus hysterectomy for refractory PPH in terms of perioperative outcomes in a sub-Saharan African country with a known high maternal mortality ratio due to PPH.

Methods

This was a retrospective cohort study comparing the perioperative outcomes of all women managed by UPS (defined as surgical interventions geared at achieving haemostasis while conserving the uterus) versus hysterectomy (defined as surgical resection of the uterus to achieve haemostasis) for PPH refractory to standard medical management in two tertiary hospitals in Cameroon from January 2004 to December 2014. We excluded patients who underwent hysterectomy after failure of UPS. Comparison was done using the Chi-square test or Fisher exact test where appropriate. Bonferroni adjustment of the p-value was performed in order to reduce the chance of obtaining false-positive results.

Results

We included 24 cases of UPS against 36 cases of hysterectomy. The indications of surgery were dominated by uterine rupture and uterine atony in both groups. Types of UPS performed were seven bilateral hypogastric artery ligations, seven hysterorraphies, six bilateral uterine artery ligations, three B-Lynch sutures and one Tsirulnikov triple ligation with an overall uterine salvage rate of 83.3%. Types of hysterectomies were 26 subtotal hysterectomies and 10 total hysterectomies. UPS was associated with maternal deaths (RR: 2.3; 95% CI: 1.38–3.93.; p: 0.0015) and postoperative infections (RR: 1.96; 95% CI: 1.1–3.49; p: 0.0215). The association of UPS with maternal death was not attenuated after Bonferroni correction. Hysterectomy had no statistically significant adverse outcome.

Conclusion

Hysterectomy is safer than UPS in the management of intractable PPH in our setting. The choice of UPS as first-line surgical management of PPH in resource-limited settings should entail diligent anticipation of these adverse maternal outcomes in order to lessen the perioperative burden of PPH.

The diagnosis of uterine cervical polyps in a low resource setting: the positive predictive value of clinical judgment--a series of 192 cases at the Yaounde Gynaeco-Obstetric and Paediatric Hospital, Cameroon

As far as we know, the accuracy of clinical judgment in diagnosing uterine cervical polyps has not been assessed in sub-Saharan Africa. Our objective was to discover the positive predictive value (PPV) of clinical judgment in the diagnosis of cervical polyps. This is a retrospective descriptive study of 192 patients, carried out by the Departments of Pathology and Gynaecology of the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon. The diagnosis of cervical polyp was confirmed by histopathology examination in 169 patients, giving a PPV rate of 88.0%. The PPV of clinical judgment in the diagnosis of cervical polyps is acceptable in our setting but the frequency of premalignant and malignant lesions encountered is too high (10.4%), even in the presence of a confirmed cervical polyp (8.9%). Even in areas where there are limited resources, we recommend a systematic histopathology examination of any clinically suspected cervical polyp.

Pregnancy outcome at advanced maternal age in a group of African women in two teaching Hospitals in Yaounde, Cameroon

Introduction

Women older than 40 years have been termed “advanced maternal age” and considered to be at risk of adverse pregnancy outcome. This study aimed to examine the obstetrical outcomes among primiparous and multiparous African advanced maternal age women.

Methods

We conducted a retrospective cohort study study at two teaching hospitals at Yaounde, Cameroon. From the hospital records, obstetrical characteristics of 585 consecutive women aged 40 or above who delivered from January 2007 to December 2011 were compared with those of 1816 younger mothers aged 20 to 29 years as control cases. Associations between maternal age and selected obstetrical variables were assessed with the contigency X² test or two-tailed Fisher exact test.

Results

Primiparous and multiparous advanced maternal age were more likely to undergo cesarean delivery than were their younger counterparts (38.5% vs 13.5%, RR=2.85, p<0.05 and 16.1% vs 9.1%, RR=1.76, p<0.05). Older primiparous women had similar perinatal outcomes than their younger counterparts. Older multiparous women had increased incidence of preeclampsia/eclampsia (2.4% vs 0.6%, RR=4, p<0.01); antepartum hemorrhage (1.8% vs 0.8%, RR=2.25, p<0.01); fetal distress (3.5% vs 1.3%, RR=2.69, p<0.01); fetal death (3.5% vs 1.6%, RR= 2.18, p<0.05); postpartum hemorrhage (2.4% vs 1.2%; RR=2, p<0.05); preterm delivery (12% vs 9.2%, RR=1.30, p<0.05); low birth weight (11% vs 7.7%, RR=1.42, p<0.05); admission to special care neonatalogy unit(14.1% vs 10.2%, RR=1.38, p<0.05); low Apgar scores at 1min and 5min; and perinatal mortality (3.5% vs 1.6, RR=2.18, p<0.05).

Conclusion

Advanced maternal age women are at higher risk to cesarean delivery. Increased risk of antepartum and intra partum complications among multiparous advanced maternal age women were associated to adverse perinatal outcome. Our results are in concordance with the view that increased risk of adverse perinatal outcome with advanced maternal age is indirectly related to age through the increased risk of obstetrical complications associated with age.

Sexual activity of adolescent school girls in an urban secondary school in cameroon

BACKGROUND

The objective of this study was to describe the extent of sexual activity in adolescent school girls.

METHODS

This was a cross-sectional study with prolective collection of data carried out at Lycée General Leclerc, Yaounde (Cameroon), from October 1 to November 30, 2011. Heterosexual coitus was considered as sexual activity. A pretested self-administered questionnaire was proposed to all consenting girl students aged 10 to 19 years. The data were analyzed using Epi Info 3.2.1 and Microsoft Excel 2007 software.

RESULTS

Of the 2660 students who responded to the questionnaire, 21.3% (566) admitted being sexually active. Out of these, 64.3% (364) were aged between 10 and 16 years at their first heterosexual contact. The mean age at the first sexual intercourse was 15.3 years. Although 56.4% (319) of the sexually active respondents had only one sexual partner, 43.6% (247) of them had at least two partners. Sexual activity was occasional in 71.4% of those being sexually active. Meanwhile, 52.1% (295) of the sexually active adolescent girls used condoms during sexual intercourse, 41.5% (235) did so occasionally, and 6.4% (36) had regular unprotected sex.

CONCLUSION

More than one-fifth of adolescent girls were sexually active in this study. Sexual intercourse started mostly at the age of 16 or less, and it was mostly occasional. Half of the cases had multiple sexual partners, and half were not using condoms during sexual intercourse. We, thus, recommend the implementation of interventions aimed at delaying the age of the first sexual intercourse and accessibility of condoms to students in this setting.

[Diagnosis and treatment of breast cancer in Cameroon: a series of 65 cases]

AIM

The objective was to describe the clinical and therapeutic aspects of breast cancer at the Yaounde Gynaeco-Obstetric and Pediatric Hospital, which is a referral centre for gynecological malignancies.

METHODS

It was a retrospective descriptive study over a period of four years, from June 1^st 2003 to May 31^st 2007.

RESULTS

Sixty five patients were identified during the study period. The mean age and parity were respectively 42.9 ±13.6 years and 3.9 ± 2.1. The mean age of onset of the first menses was 14.0 ± 1.5 years. Most patients were under 50 (72.3%) and had given birth at least once (89.2%). Non menopausal period (75.4%) and breastfeeding (76.9%) were frequently found. The patients consulted 9.2 ± 3.4 months after the onset of symptoms, with 78.5% of cases arriving at a local advanced clinical stage. Ductal carcinoma accounted for 75.4% of histological types, SBR grades 1 and 2 being the most frequent (89.2%). Chemotherapy (69.2% of the cases) and surgery (67.7% of the cases) often radical (three out of four) were the main treatment modalities used.

CONCLUSION

In Yaounde, breast cancer is often a ductal carcinoma of high histological grade, attacking the quarantine non menopausal woman, who gave birth and breastfed at least once, diagnosed with a local clinical advanced disease. Chemotherapy and surgery are the main therapeutic options implemented.

Conservative treatment of ectopic pregnancy in a sub-Saharan African setting

In the sub-Saharan African setting, laparotomy for salpingectomy is the common method of treatment for ectopic pregnancy (EP). The objective of this retrospective study was to find out how common EP is treated conservatively in the Yaounde Gynaeco-Obstetric and Paediatric Hospital, Cameroon. Of the 281 patient files analysed, 126 patients (44.8%) were treated conservatively and successfully for EP. Of these, 86 (68.2%) had received conservative surgical treatment while 40 (31.8%) had non-surgical treatment. Salpingostomy was the conservative surgery for 79.1% of the cases. According to the publications available for the sub-Saharan setting, the rate of conservative management of EP at the Yaounde Gynaeco-Obstetric and Paediatric Hospital, Cameroon is high. We recommend that this rate should be improved so that, eventually, the conservative treatment methods of EP become routine.