Prevalence and factors associated with lumbopelvic pain among pregnant women in their third trimester: a cross-sectional study

Introduction

pregnancy related lumbopelvic pain, which refers to low back pain and pelvic girdle pain, is a common musculoskeletal disorder affecting quality of life. The purpose of this study was to establish the prevalence and the factors associated with lumbopelvic pain among pregnant women in their third trimester.

Methods

four hundred and nineteen pregnant women were included in this institutional-based cross-sectional study. The study was carried out from October 2018 to March 2019 at Kawempe national referral hospital in Uganda. Pregnant women in the third trimester participated in the study. Pregnant women with preexisting backache, a fracture or surgery to the back, hip or pelvic area in the preceding 12 months were excluded. Lumbopelvic pain was defined as low back pain and pelvic girdle pain. Bivariate and multivariable logistic regression were carried out to establish the factors associated with lumbopelvic pain. The presence of lumbopelvic pain was assessed for and diagnosed using the illustrations in the pelvic girdle questionnaire.

Results

the prevalence of pregnancy related lumbopelvic pain was 46% (95% CI: 40.8-50.4). Most women who had pregnancy related lumbopelvic pain experienced lumbar pain. The factors independently associated with pregnancy related lumbopelvic pain (PLPP) were being HIV sero positive [adjusted odds ratio (AOR) 2.25, 95% CI: 1.17-4.35] and having no monthly income (AOR 0.53, 95% CI: 0.30-0.94).

Conclusion

in this study, PLPP is common in women attending antenatal clinic in their third trimester. The factors associated with PLPP were being HIV positive and having no income. In future pregnant women who come for antenatal care with pregnancy related lumbopelvic pain should be given appropriate advice and support.

Postpartum resolution of hypertension, proteinuria and acute kidney injury among women with preeclampsia and severe features at Mulago National Referral Hospital, Uganda: a cohort study

Background

The resolution of hypertension, proteinuria and AKI postpartum among women with preeclampsia is not well documented in Uganda.

Objective

To determine the time to resolution of hypertension, proteinuria and AKI postpartum until 6 weeks among women with preeclampsia in Mulago Hospital, Uganda.

Methods

Between August 2017 and April 2018, we measured blood pressure, urine protein and serum creatinine on days 1,7,21 and 42 postpartum among 86 women with preeclampsia. The primary outcomes were time to the resolution of hypertension, proteinuria and AKI. We fitted accelerated failure models using Stata 17's stintreg. command with a log normal distribution and obtained time ratios of selected exposures on time to resolution of hypertension, proteinuria and AKI intervals.

Results

The median time to resolution of hypertension, proteinuria and AKI was seven (7) days (Inter quartile range, IQR 1-21). The time to resolution of hypertension among primiparous women was 3.5 times that of multiparous women [TR 3.5, 95%CI 1.1, 11.3]. No differences were observed in resolution of hypertension, proteinuria and acute kidney injury.

Conclusion

The time to resolution of hypertension, proteinuria and AKI was seven days. We recommend larger studies with longer follow-up beyond six-weeks postpartum to inform revision of our guidelines.

Maternal and umbilical cord blood lactate for predicting perinatal death: a secondary analysis of data from a randomized controlled trial

BACKGROUND

In high resource settings, lactate and pH levels measured from fetal scalp and umbilical cord blood are widely used as predictors of perinatal mortality. However, the same is not true in low resource settings, where much of perinatal mortality occurs. The scalability of this practice has been hindered by difficulty in collecting fetal scalp and umbilical blood sample. Little is known about the use of alternatives such as maternal blood, which is easier and safer to obtain. Therefore, we aimed to compare maternal and umbilical cord blood lactate levels for predicting perinatal deaths.

METHODS

This was secondary analysis of data from a randomized controlled trial assessing the effect of sodium bicarbonate on maternal and perinatal outcomes among women with obstructed labour at Mbale regional referral hospital in Eastern Uganda. Lactate concentration in maternal capillary, myometrial, umbilical venous and arterial blood was measured at the bedside using a lactate Pro 2 device (Akray, Japan Shiga) upon diagnosis of obstructed labour. We constructed Receiver Operating Characteristic curves to compare the predictive ability of maternal and umbilical cord lactate and the optimal cutoffs calculated basing on the maximal Youden and Liu indices.

RESULTS

Perinatal mortality risk was: 102.2 deaths per 1,000 live births: 95% CI (78.1-130.6). The areas under the ROC curves were 0.86 for umbilical arterial lactate, 0.71 for umbilical venous lactate, and 0.65 for myometrial lactate, 0.59 for maternal lactate baseline, and 0.65 at1hr after administration of bicarbonate. The optimal cutoffs for predicting perinatal death were 15 0.85 mmol/L for umbilical arterial lactate, 10.15mmol/L for umbilical venous lactate, 8.75mmol/L for myometrial lactate, and 3.95mmol/L for maternal lactate at recruitment and 7.35mmol/L after 1 h.

CONCLUSION

Maternal lactate was a poor predictor of perinatal death, but umbilical artery lactate has a high predictive value. There is need for future studies on the utility of amniotic fluid in predicting intrapartum perinatal deaths.

Prediction of pre-eclampsia at St. Mary's hospital lacor, a low-resource setting in northern Uganda, a prospective cohort study

BACKGROUND

Pre-eclampsia is the second leading cause of maternal death in Uganda. However, mothers report to the hospitals late due to health care challenges. Therefore, we developed and validated the prediction models for prenatal screening for pre-eclampsia.

METHODS

This was a prospective cohort study at St. Mary's hospital lacor in Gulu city. We included 1,004 pregnant mothers screened at 16-24 weeks (using maternal history, physical examination, uterine artery Doppler indices, and blood tests), followed up, and delivered. We built models in RStudio. Because the incidence of pre-eclampsia was low (4.3%), we generated synthetic balanced data using the ROSE (Random Over and under Sampling Examples) package in RStudio by over-sampling pre-eclampsia and under-sampling non-preeclampsia. As a result, we got 383 (48.8%) and 399 (51.2%) for pre-eclampsia and non-preeclampsia, respectively. Finally, we evaluated the actual model performance against the ROSE-derived synthetic dataset using K-fold cross-validation in RStudio.

RESULTS

Maternal history of pre-eclampsia (adjusted odds ratio (aOR) = 32.75, 95% confidence intervals (CI) 6.59-182.05, p = 0.000), serum alkaline phosphatase(ALP) < 98 IU/L (aOR = 7.14, 95% CI 1.76-24.45, p = 0.003), diastolic hypertension ≥ 90 mmHg (aOR = 4.90, 95% CI 1.15-18.01, p = 0.022), bilateral end diastolic notch (aOR = 4.54, 95% CI 1.65-12.20, p = 0.003) and body mass index of ≥ 26.56 kg/m² (aOR = 3.86, 95% CI 1.25-14.15, p = 0.027) were independent risk factors for pre-eclampsia. Maternal age ≥ 35 years (aOR = 3.88, 95% CI 0.94-15.44, p = 0.056), nulliparity (aOR = 4.25, 95% CI 1.08-20.18, p = 0.051) and white blood cell count ≥ 11,000 (aOR = 8.43, 95% CI 0.92-70.62, p = 0.050) may be risk factors for pre-eclampsia, and lymphocyte count of 800 - 4000 cells/microliter (aOR = 0.29, 95% CI 0.08-1.22, p = 0.074) may be protective against pre-eclampsia. A combination of all the above variables predicted pre-eclampsia with 77.0% accuracy, 80.4% sensitivity, 73.6% specificity, and 84.9% area under the curve (AUC).

CONCLUSION

The predictors of pre-eclampsia were maternal age ≥ 35 years, nulliparity, maternal history of pre-eclampsia, body mass index, diastolic pressure, white blood cell count, lymphocyte count, serum ALP and end-diastolic notch of the uterine arteries. This prediction model can predict pre-eclampsia in prenatal clinics with 77% accuracy.

Prediction of stillbirth low resource setting in Northern Uganda

Background

Women of Afro-Caribbean and Asian origin are more at risk of stillbirths. However, there are limited tools built for risk-prediction models for stillbirth within sub-Saharan Africa. Therefore, we examined the predictors for stillbirth in low resource setting in Northern Uganda.

Methods

Prospective cohort study at St. Mary’s hospital Lacor in Northern Uganda. Using Yamane’s 1967 formula for calculating sample size for cohort studies using finite population size, the required sample size was 379 mothers. We doubled the number (to > 758) to cater for loss to follow up, miscarriages, and clients opting out of the study during the follow-up period. Recruited 1,285 pregnant mothers at 16–24 weeks, excluded those with lethal congenital anomalies diagnosed on ultrasound. Their history, physical findings, blood tests and uterine artery Doppler indices were taken, and the mothers were encouraged to continue with routine prenatal care until the time for delivery. While in the delivery ward, they were followed up in labour until delivery by the research team. The primary outcome was stillbirth 24 + weeks with no signs of life. Built models in RStudio. Since the data was imbalanced with low stillbirth rate, used ROSE package to over-sample stillbirths and under-sample live-births to balance the data. We cross-validated the models with the ROSE-derived data using K (10)-fold cross-validation and obtained the area under curve (AUC) with accuracy, sensitivity and specificity.

Results

The incidence of stillbirth was 2.5%. Predictors of stillbirth were history of abortion (aOR = 3.07, 95% CI 1.11—8.05, p = 0.0243), bilateral end-diastolic notch (aOR = 3.51, 95% CI 1.13—9.92, p = 0.0209), personal history of preeclampsia (aOR = 5.18, 95% CI 0.60—30.66, p = 0.0916), and haemoglobin 9.5 – 12.1 g/dL (aOR = 0.33, 95% CI 0.11—0.93, p = 0.0375). The models’ AUC was 75.0% with 68.1% accuracy, 69.1% sensitivity and 67.1% specificity.

Conclusion

Risk factors for stillbirth include history of abortion and bilateral end-diastolic notch, while haemoglobin of 9.5—12.1 g/dL is protective.

Covariates of Pica among Pregnant Women Attending Antenatal Care at Kawempe Hospital, Kampala, Uganda: A Cross-Sectional Study

Pica is the craving and purposive eating of nonfood items. It is common worldwide and presents among vulnerable populations like children and pregnant women. Its etiology and health consequences are not well understood. The aim of this study was to determine the prevalence and covariates of pica among pregnant women attending antenatal clinic at Kawempe hospital in Uganda. We conducted a cross-sectional study from July 2019 to December 2019. Participants in this study were 307 pregnant women who had come to attend antenatal clinic at the hospital. The prevalence of pica was computed. Bivariate and multivariable analysis was done to establish the factors that were independently associated with pica. The prevalence of pica was 57%. The most common type of pica was geophagia (eating clay and sand) followed by pagophagia (eating ice). Of the women who practiced pica, half consumed the nonfood items daily. Factors independently associated with pica were being in the third trimester (adjusted OR [aOR]: 3.60; 95% CI: 1.36-9.48] and having nausea in pregnancy (aOR: 2.11; 95% CI: 1.20-3.70). At Kawempe hospital, pica is common among women who attend the antenatal clinic and is associated with having nausea in pregnancy and being in the third trimester. Health workers need to counsel pregnant women about the dangers of pica so as to reduce helminth infections and micronutrient deficiency associated with it.

Predictors of Intrapartum Stillbirths among Women Delivering at Mulago Hospital, Kampala, Uganda

BACKGROUND

Over the last decade, Uganda has registered a significant improvement in the utilization of maternity care services. Unfortunately, this has not resulted in a significant and commensurate improvement in the maternal and child health (MCH) indicators. More than half of all the stillbirths (54 per 1,000 deliveries) occur in the peripartum period. Understanding the predictors of preventable stillbirths (SB) will inform the formulation of strategies to reduce this preventable loss of newborns in the intrapartum period. The objective of this study was to determine the predictors of intrapartum stillbirth among women delivering at Mulago National Referral and Teaching Hospital in Central Uganda.

METHODS

This was an unmatched case-control study conducted at Mulago Hospital from October 29, 2018 to October 30, 2019. A total of 474 women were included in the analysis: 158 as cases with an intrapartum stillbirth and 316 as controls without an intrapartum stillbirth. Bivariable and multivariable logistic regression was done to determine the predictors of intrapartum stillbirth.

RESULTS

The predictors of intrapartum stillbirth were history of being referred from lower health units to Mulago hospital (aOR 2.5, 95% CI: 1.5-4.5); maternal age 35 years or more (aOR 2.9, 95% CI: 1.01- 8.4); antepartum hemorrhage (aOR 8.5, 95% CI: 2.4-30.7); malpresentation (aOR 6.29; 95% CI: 2.39-16.1); prolonged/obstructed labor (aOR 6.2; 95% CI: 2.39-16.1); and cesarean delivery (aOR 7.6; 95% CI: 3.2-13.7).

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Referral to hospital, maternal age 35 years and above, obstetric complication during labor, and cesarean delivery were predictors of intrapartum stillbirth in women delivering at Mulago hospital. Timely referral and improving access to quality intrapartum obstetric care have the potential to reduce the incidence of intrapartum SB in our community.

Asymptomatic bacteriuria among pregnant women attending antenatal care at Mbale Hospital, Eastern Uganda

Background

Asymptomatic bacteriuria in pregnancy (ASBP) is associated with adverse pregnancy outcomes such as pyelonephritis, preterm or low birth weight delivery if untreated. The aim of this study was to determine the prevalence of asymptomatic bacteriuria, the isolated bacterial agents, and their antibiotic sensitivity patterns in pregnant women attending antenatal care at Mbale Hospital.

Methods

This was a cross sectional study in which 587 pregnant women with no symptoms and signs of urinary tract infection were recruited from January to March 2019. Mid-stream clean catch urine samples were collected from the women using sterile containers. The urine samples were cultured using standard laboratory methods. The bacterial colonies were identified and antibiotic sensitivity was done using disc diffusion method. Chi squared tests and logistic regression were done to identify factors associated with asymptomatic bacteriuria. A p value < 0.05 was considered statistically significant.

Results

Out of the 587 pregnant women, 22 (3.75%) tested positive for asymptomatic bacteriuria. Women aged 20–24 years were less likely to have ASBP when compared to women aged less than 20 years (AOR = 0.14, 95%CI 0.02–0.95, P = 0.004). The most common isolates in descending order were E. coli (n = 13, 46.4%) and S.aureus (n = 9, 32.1%). Among the gram negative isolates, the highest sensitivity was to gentamycin (82.4%) and imipenem (82.4%). The gram positive isolates were sensitive to gentamycin (90.9%) followed by imipenem (81.8%). All the isolates were resistant to sulphamethoxazole with trimethoprim (100%). Multidrug resistance was 82.4% among gram negative isolates and 72.4% among the gram positive isolates.

Conclusion

There was high resistance to the most commonly used antibiotics. There is need to do urine culture and sensitivity from women with ASBP so as to reduce the associated complications.

Single dose ceftriaxone and metronidazole versus multiple doses for antibiotic prophylaxis at elective caesarean section in Mulago hospital: A randomized clinical trial

Objective: To compare the incidence of post-operative infections among mothers who received single dose pre-operative ceftriaxone and metronidazole compared to multiple doses after delivery by elective caesarean section. Methods: This was (parallel, balanced randomization, 1:1) open label randomized controlled trial conducted Mulago Hospital, Department of Obstetrics and Gynaecology. Participants included in this study were pregnant women who had been admitted for elective caesarean section. The mothers were randomized to receive single dose of ceftriaxone and metronidazole minutes before the operation or multiple doses 30-60 during the operation and postoperatively. The primary outcome was post-operative wound infection. Secondary outcomes were clinical endometritis and febrile morbidity. The 174 eligible participants were randomized into one of the two treatment arms in a ratio of 1:1. The research assistants who collected the outcomes were blinded to the study allocation. Results: Of the 174 eligible participants who recruited; 87 were randomized to the single dose group while 87 to the multiple doses group. The participants were recruited from 17th September 2015 up to 29th February 2016. All the participants were followed up for two weeks after delivery.  Outcome data was available for 79 women in the single dose group and 81 women in the multiple dose group. There were no differences in the incidence of post-operative wound infections between the single dose arm versus the multiple dose arm (RR 1.895; 95% CI (0.2-21.4). There was no clinical endometritis and febrile morbidity observed during the 14 days of follow up. Conclusion: Single dose pre-operative antibiotic prophylactic with ceftriaxone and metronidazole is as effective as multiple doses in prevention of post-operative infectious morbidity in women who undergo elective caesarean section. We recommend the use of single dose ceftriaxone and metronidazole in women undergoing elective caesarean section in our setting. Trial registration: NCT02736682. Registration date, 7th April, 2016.

Adherence to iron supplements among women receiving antenatal care at Mulago National Referral Hospital, Uganda-cross-sectional study

Background

Antenatal iron supplementation is a cost effective way of reducing iron deficiency anaemia among pregnant women in resource limited countries like Uganda. Poor adherence to iron supplements has limited its effectiveness in reducing maternal anaemia as evidenced by the high burden of iron deficiency anemia in Sub-saharan Africa. The aim of this study was to determine the level of and factors associated with adherence to iron supplementation among women attending antenatal clinic at Mulago National Referral Hospital, Kampala, Uganda.

Methods

Three hundred and seventy pregnant women were recruited in a cross sectional survey in Mulago National Referral Hospital antenatal clinic after informed consent between February and April 2014. Levels of adherence to iron supplements were assessed using visual analogue scale and factors associated collected using an interviewer administered questionnaire.

Results

About 12% (11.6%) of the mothers attending the antenatal clinic adhered to iron supplements over 30 day period. Mothers who had had four or more antenatal visits prior to the survey [odds ratio (OR) = 1.49, 95% confidence interval (CI) 1.12–1.97], had more than 2 week supply of iron supplements in the previous visit (OR 2.81, 95% CI 1.02–1.09), prior health education (OR 1.56, 95% CI 1.07–2.29) were more likely to adhere to iron supplements. Inadequate drug supplies and fear for side effects were the main reasons why participants missed the iron supplements.

Conclusions

There was low adherence to iron supplements among mothers attending antenatal clinic at Mulago National Referral  Hospital. We recommend a national evaluation of adherence to iron supplements and look at ways of increasing adherence.

Cervicovaginal Bacteriology and Antibiotic Sensitivity Patterns among Women with Premature Rupture of Membranes in Mulago Hospital, Kampala, Uganda: A Cross-Sectional Study

Background. A 2013 Cochrane review concluded that the choice of antibiotics for prophylaxis in PROM is not clear. In Uganda, a combination of oral erythromycin and amoxicillin is the 1st line for prophylaxis against ascending infection. Our aim was to establish the current cervicovaginal bacteriology and antibiotic sensitivity patterns. Methods. Liquor was collected aseptically from the endocervical canal and pool in the posterior fornix of the vagina using a pipette. Aerobic cultures were performed on blood, chocolate, and MacConkey agar and incubated at 35-37°C for 24-48 hrs. Enrichment media were utilized to culture for GBS and facultative anaerobes. Isolates were identified using colonial morphology, gram staining, and biochemical analysis. Sensitivity testing was performed via Kirby-Bauer disk diffusion and dilution method. Pearson's chi-squared (χ2) test and the paired t-test were applied, at a P value of 0.05. Results. Thirty percent of the cultures were positive and over 90% were aerobic microorganisms. Resistance to erythromycin, ampicillin, cotrimoxazole, and ceftriaxone was 44%, 95%, 96%, and 24%, respectively. Rupture of membranes (>12 hrs), late preterm, and term PROM were associated with more positive cultures. Conclusion. The spectrum of bacteria associated with PROM has not changed, but resistance to erythromycin and ampicillin has increased.

Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit

Background

Obstructed labour remains a major cause of maternal morbidity and mortality whose complications can be reduced with improved quality of obstetric care. The objective was to assess whether criteria-based audit improves quality of obstetric care provided to women with obstructed labour in Mulago hospital, Uganda.

Methods

Using criteria-based audit, management of obstructed labour was analyzed prospectively in two audits. Six standards of care were compared. An initial audit of 180 patients was conducted in September/October 2013. The Audit results were shared with key stakeholders. Gaps in patient management were identified and recommendations for improving obstetric care initiated. Six standards of care (intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching) were implemented. A re-audit of 180 patients with obstructed labour was conducted four months later to evaluate the impact of these recommendations. The results of the two audits were compared. In-depth interviews and focus group discussions were conducted among healthcare providers to identify factors that could have influenced the audit results.

Results

There was improvement in two standards of care (intravenous fluids and intravenous antibiotic administration) 58.9 % vs. 86.1 %; p < 0.001 and 21.7 % vs. 50.5 %; P < 0.001 respectively after the second audit. There was no improvement in vital sign monitoring, delivery within two hours or blood grouping and cross matching. There was a decline in bladder catheterization (94 % vs. 68.9 %; p < 0.001. The overall mean care score in the first and second audits was 55.1 and 48.2 % respectively, p = 0.19. Healthcare factors (negative attitude, low numbers, poor team work, low motivation), facility factors (poor supervision, stock-outs of essential supplies, absence of protocols) and patient factors (high patient load, poor compliance to instructions) contributed to poor quality of care.

Conclusion

Introduction of criteria based audit in the management of obstructed labour led to measurable improvements in only two out of six standards of care. The extent to which criteria based audit may improve quality of obstetric care depends on having basic effective healthcare systems in place.

The effects of vitamin C supplementation on pre-eclampsia in Mulago Hospital, Kampala, Uganda: a randomized placebo controlled clinical trial

Background

Oxidative stress plays a role in the pathogenesis of pre-eclampsia. Supplementing women with antioxidants during pregnancy may reduce oxidative stress and thereby prevent or delay the onset pre-eclampsia. The objective of this study was to evaluate the effect of supplementing vitamin C in pregnancy on the incidence of pre-eclampsia, at Mulago hospital, Kampala, Uganda.

Methods

This was a (parallel, balanced randomization, 1:1) placebo randomized controlled trial conducted at Mulago hospital, Department of Obstetrics and Gynecology. Participants included in this study were pregnant women aged 15-42 years, who lived 15 km or less from the hospital with gestational ages between 12-22 weeks. The women were randomized to take 1000mg of vitamin C (as ascorbic acid) or a placebo daily until they delivered. The primary outcome was pre-eclamsia. Secondary outcomes were: severe pre-eclampsia, gestational hypertension, preterm delivery, low birth weight and still birth delivery. Participants were 932 pregnant women randomized into one of the two treatment arms in a ratio of 1:1. The participants, the care providers and those assessing the outcomes were blinded to the study allocation.

Results

Of the 932 women recruited; 466 were randomized to the vitamin and 466 to the placebo group. Recruitment of participants was from November 2011 to June 2012 and follow up was up to January 2013. Outcome data was available 415 women in the vitamin group and 418 women in the placebo group.

There were no differences in vitamin and placebo groups in the incidence of pre-eclampsia (3.1% versus 4.1%; RR 0.77; 95% CI: 0.37-1.56), severe pre-eclampsia (1.2% versus 1.0%; RR 1.25; 95% CI: 0.34-4.65), gestational hypertension(7.7% versus 11.5%; RR 0.67; 95% CI: 0.43-1.03), preterm delivery (11.3% versus 12.2%; RR 0.92; 95% CI: 0.63-1.34), low birth weight (11.1% versus 10.3%; RR 1.07; 95% CI: 0.72-1.59) and still birth delivery (4.6% versus 4.5%; RR 1.01; 95% CI: 0.54-1.87).

Conclusions

Supplementation with vitamin C did not reduce the incidence of pre-eclampsia nor did it reduce the adverse maternal or neonatal outcomes. We do not recommend the use of vitamin C in pregnancy to prevent pre-eclampsia.

Trial registration

This study was registered at the Pan African Clinical Trial Registry, PACTR201210000418271 on 25^th October 2012.

Adverse neonatal outcomes in women with pre-eclampsia in Mulago Hospital, Kampala, Uganda: a cross-sectional study

INTRODUCTION

Pre-eclampsia, which is more prevalent in resource-limited settings, contributes significantly to maternal, fetal and neonatal morbidity and mortality. However, the factors associated with these adverse outcomes are poorly understood in low resource settings. In this paper we examine the risk factors for adverse neonatal outcomes among women with pre-eclampsia at Mulago Hospital in Kampala, Uganda.

METHODS

Pre-eclampsia, which is more prevalent in resource-limited settings, contributes significantly to maternal, fetal and neonatal morbidity and mortality. However, the factors associated with these adverse outcomes are poorly understood in low resource settings. In this paper we examine the risk factors for adverse neonatal outcomes among women with pre-eclampsia at Mulago Hospital in Kampala, Uganda.

RESULTS

Predictors of adverse neonatal outcomes were: preterm delivery (OR 5.97, 95% CI: 2.97-12.7) and severe pre-eclampsia (OR 5.17, 95% CI: 2.36-11.3).

CONCLUSION

Predictors of adverse neonatal outcomes among women with pre-eclampsia were preterm delivery and severe pre-eclampsia. Health workers need to identify women at risk, offer them counseling and, refer them if necessary to a hospital where they can be managed successfully. This may in turn reduce the neonatal morbidity and mortality associated with pre-eclampsia.

Peripartum hysterectomy: two years experience at Nelson Mandela Academic hospital, Mthatha, Eastern Cape South Africa

BACKGROUND

Obstetric haemorrhage is the leading direct cause of maternal mortality in South Africa.

OBJECTIVE

To determine the incidence, indications, associations and maternal outcomes of emergency peripartum hysterectomies.

METHODS

A descriptive and retrospective analysis of patients who had peripartum hysterectomy between 1(st) February 2007 and 31(st) January 2009 in Nelson Mandela Academic Hospital at Mthatha city.

RESULTS

The incidence of 0.95% of peripartum hysterectomies (n=63 or 9.5/1000 births) increased with the increasing maternal age from 0.121% at age of less than 20 years to 0.5% at age more or equal to 30 years. Similarly the incidence increased with parity from 0.332% for Primiparity to 0.468% at parity of four or more. The indications for the operation were uterine atony 19/63 (30.2%), secondary haemorrhage/puerperal sepsis 17/63 (27%) and ruptured uterus 16/63 (23.4%). The main intra operative complication was haemorrhage 13/63 (20.6%). Repeat laparotomy was done in 10/63 (15%) of patients due to haemorrhage. Admission to intensive care unit was 25/63 (39.7%). The case specific mortality rate was of 19 % (n=12). The main causes of death were hypovolaemic shock and septicemia.

CONCLUSION

The incidence of peripartum hysterectomies was high and was associated with ruptured uterus and puerperal sepsis which are preventable.

Risk factors for pre-eclampsia in Mulago Hospital, Kampala, Uganda

OBJECTIVE

Pre-eclampsia contributes significantly to maternal, foetal and neonatal morbidity and mortality. The risk factors for pre-eclampsia have not been well documented in Uganda. In this paper, we describe the risk factors for pre-eclampsia in women attending antenatal clinics at Mulago Hospital, Kampala.

METHODS

This casecontrol study was conducted from 1st May 2008 to 1st May 2009. 207 women with pre-eclampsia were the cases, and 352 women with normal pregnancy were the controls. The women were 15-39 years old, and their gestational ages were 20 weeks or more. They were interviewed about their socio-demographic characteristics, past medical history and, their past and present obstetric performances.

RESULTS

The risk factors were low plasma vitamin C (OR 3.19, 95% CI: 1.54-6.61), low education level (OR 1.67, 95% CI: 1.12-2.48), chronic hypertension (OR 2.29, 95% CI 1.12-4.66), family history of hypertension (OR 2.25, 95% CI: 1.53-3.31) and primiparity (OR 2.76, 95% CI: 1.84-4.15) and para≥5 (3.71, 95% CI:1.84-7.45).

CONCLUSION

The risk factors identified are similar to what has been found elsewhere. Health workers need to identify women at risk of pre-eclampsia and manage them appropriately so as to prevent the maternal and neonatal morbidity and mortality associated with this condition.

Plasma vitamin C concentration in pregnant women with pre-eclampsia in Mulago hospital, Kampala, Uganda

BACKGROUND

Oxidative stress plays a role in the aetiology of pre-eclampsia and vitamin C may prevent pre-eclampsia.

OBJECTIVE

To determine the association between plasma vitamin C and pre-eclampsia in Mulago Hospital, Kampala, Uganda.

METHODS

This case-control study was conducted at Mulago Hospital from 1(st) May 2008 to 1(st) May 2009; 207 women were the cases and 352 women were the controls. Plasma vitamin C was assayed in the women using a colorimetric method. An independent t test was used to find the difference in the means of plasma vitamin C and logistic regression was used to find the association between plasma vitamin C and pre-eclampsia.

RESULTS

The mean plasma vitamin C was 1.7(SD=0.7) × 10(3) µg/L in women with pre-eclampsia and 1.9(SD=0.7) × 10(3) µg/L in women with normal pregnancy (P=0.005). Women with low plasma vitamin C were at an increased risk of pre-eclampsia (OR 2.91, 95% CI: 1.56-5.44).

CONCLUSION

There was a strong association between low plasma vitamin C, and pre-eclampsia in women attending antenatal clinics at Mulago Hospital, Kampala. Health workers need to advise women at risk in the antenatal period about diet, especially foods which are rich in vitamin C to probably reduce pre-eclampsia.

Human immunodeficiency virus and AIDS and other important predictors of maternal mortality in Mulago Hospital Complex Kampala Uganda

Background

Women with severe maternal morbidity are at high risk of dying. Quality and prompt management and sometimes luck have been suggested to reduce on the risk of dying. The objective of the study was to identify the direct and indirect causes of severe maternal morbidity, predictors of progression from severe maternal morbidity to maternal mortality in Mulago hospital, Kampala, Uganda.

Methods

This was a longitudinal follow up study at the Mulago hospital's Department of Obstetrics and Gynaecology. Participants were 499 with severe maternal morbidity admitted in Mulago hospital between 15^th November 2001 and 30^th November 2002 were identified, recruited and followed up until discharge or death. Potential prognostic factors were HIV status and CD4 cell counts, socio demographic characteristics, medical and gynaecological history, past and present obstetric history and intra- partum and postnatal care.

Results

Severe pre eclampsia/eclampsia, obstructed labour and ruptured uterus, severe post partum haemorrhage, severe abruptio and placenta praevia, puerperal sepsis, post abortal sepsis and severe anaemia were the causes for the hospitalization of 499 mothers. The mortality incidence rate was 8% (n = 39), maternal mortality ratio of 7815/100,000 live births and the ratio of severe maternal morbidity to mortality was 12.8:1.

The independent predictors of maternal mortality were HIV/AIDS (OR 5.1 95% CI 2-12.8), non attendance of antenatal care (OR 4.0, 95% CI 1.3-9.2), non use of oxytocics (OR 4.0, 95% CI 1.7-9.7), lack of essential drugs (OR 3.6, 95% CI 1.1-11.3) and non availability of blood for transfusion (OR 53.7, 95% CI (15.7-183.9) and delivery of amale baby (OR 4.0, 95% CI 1.6-10.1).

Conclusion

The predictors of progression from severe maternal morbidity to mortalitywere: residing far from hospital, low socio economic status, non attendance of antenatal care, poor intrapartum care, and HIV/AIDS.

There is need to improve on the referral system, economic empowerment of women and to offer comprehensive emergency obstetric care so as to reduce the maternal morbidity and mortality in our community.

Risk factors for severe pre-eclampsia and eclampsia in Mulago Hospital, Kampala, Uganda

OBJECTIVE

To determine the risk factors for severe pre-eclampsia and eclampsia in Mulago Hospital, Kampala, Uganda.

DESIGN

A case control study.

SETTING

Mulago Hospital labour ward

SUBJECT

One hundread and fourty three women with severe pre-eclampsia/eclampsia and 500 women with normal delivery.

RESULTS

The predictors of severe pre-eclampsia/eclampsia were: low socio - economic status (OR 7.6, 95%CI 3.9 - 26.9), chronic hypertension (OR 26.9, 95% CI 4.3-170.4), family history of hypertension (OR 1.9, 95% CI 1.2-2.9), nulliparity (OR 2.2, 95% CI 1.2-4.3) and delivery of male babies (OR 1.5, 95% CI 1.0 to 2.3).

CONCLUSION

Severe pre- eclampsia is one of the main causes of maternal morbidity and mortality in Mulago hospital. The predictors of severe pre - eclampsia were chronic hypertension, family history of hypertension, low socio - economic status, nulliparity and delivering male babies. Health workers need to identify women at risk and offer them counseling and, those who develop pre - eclampsia be referred and managed in hospitals with expertise and facilities. Those who develop severe pre-eclampsia should be delivered immediately so as to reduce the morbidity and mortality associated with this condition.

Risk factors for severe post partum haemorrhage in Mulago hospital, Kampala, Uganda

OBJECTIVE

To determine the risk factors for severe postpartum haemorrhage.

DESIGN

A case control study.

SETTING

Mulago hospital labour wards, Kampala, Uganda.

SUBJECTS

One hundred and six mothers with severe postpartum haemorrhage were recruited between 15th November 2001 and 30th November 2002 and were compared with 500 women who had normal delivery.

RESULTS

The predictors for postpartum haemorrhage were co-existing hypertension (O.R 9.3, 95% CI: 1.7-51.7), chronic anaemia (OR 17.3, 95% CI: 9.5-31.7), low socio economic background (OR 5.3, 95% CI: 3.0, 9.2), past history of postpartum haemorrhage (OR 3.6, 95% CI: 1.1-11.8), previous delivery by Caesarean section (OR 7.5, 95% CI: 3.5-14.3), long birth interval of more than sixty months (OR 5.2, 95% CI: 2.1-13.0), prolonged third stage (OR 49.1, 95% CI: 8.8-342.8) and non use of oxytocics (OR 4.3%, 95% CI: 1.2-15.3).

CONCLUSION

Severe postpartum haemorrhage is common in our environment and is associated with a high maternal morbidity and mortality. The determinants of postpartum haemorrhage are useful in identifying mothers at risk and together with the services of a skilled birth attendant at delivery will prevent postpartum haemorrhage and reduce the maternal morbidity and mortality associated with this condition. In our study, the following risk factors were identified: pre-existing hypertension, chronic anaemia, low socio-economic background, history of postpartum haemorrhage, previous delivery by Caesarean section, longbirth interval of more than sixty months, prolonged third stage and non use of oxytocics were found to be significant.

Risk factors for ruptured uterus in Mulago hospital Kampala, Uganda

OBJECTIVE

To determine the risk factors for ruptured uterus.

DESIGN

A case control study.

SETTING

Mulago Hospital labour wards, Kampala, Uganda.

SUBJECTS

Fifty two women with ruptured uterus were recruited between 15th November 2001 and 30th November 2002 and were compared with 500 mothers with normal delivery.

RESULTS

The predictors for ruptured uterus were low socio-economic (OR 2.5, 95% CI 1.2-7.1), residing more than ten kilometres from Mulago hospital (OR 6.7, 95% CI 2.1-21.2). Delivery by Caesarean section in previous pregnancy (OR 22.3, 95% CI 9.2-54.2) delivery of babies weighing more than 3500 grams (OR 2.4, 95% CI 1.2-7.2) and testing HIV positive (OR 3.2, 95% CI 1.5-7.2).

CONCLUSION

Uterine rupture is still common in our society and is associated with severe maternal morbidity and mortality. There is need for women to use maternity units during pregnancy and delivery, to monitor labour using a partograph and timely intervention of delivery will prevent uterine rupture.

Risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda

OBJECTIVE

To determine the risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda.

DESIGN

A case control study.

SETTING

Mulago hospital labour suite

PARTICIPANTS

Between 15th November 2001 and 30th November 2002 we identified and recruited thirty six parturients with placenta previa who developed severe bleeding and 180 women with normal delivery. The risk factors were studied.

VARIABLES OF INTEREST

Socio demographic characteristics, social and family history, gynaecological operations, blood transfusion, medical conditions, past and present obstetric performance and HIV status.

RESULTS

Significant predictors for severe bleeding in parturients with placenta praevia were: previous history of evacuation of the uterus or dilation and curettage (O.R. 3.6, CI: 1.1-12.5), delivery by caesarean section in previous pregnancy (O.R. 19.9, CI: 6.4-61.7), residing more than ten kilometres from Mulago hospital (O.R. 2.4, CI: 1.0-5.7) and recurrent vaginal bleeding during the current pregnancy (O.R. 7.3, CI 2.4-63.7).

CONCLUSION

Severe bleeding in placenta praevia is associated with high maternal morbidity and mortality. The determinants of severe bleeding in placenta praevia can be used in the antenatal period to identify mothers at risk. These, with prompt interventions to deliver the women can be used to reduce the maternal morbidity associated with this condition.

A randomised controlled trial of early initiation of oral feeding after caesarean delivery in Mulago Hospital

BACKGROUND

The concept of early initiation of oral feeding after caesarean delivery is well tolerated by patients, yet not routinely practiced in Mulago Hospital. An effective postoperative dietary management schedule could have major implications on the management of maternal post-caesarean section mothers.

OBJECTIVES

To compare the effect of time initiation of oral feeding on acceptability, benefits and gastrointestinal functions in women who had undergone caesarean section in Mulago Hospital.

DESIGN

A randomised controlled study.

SETTING

Mulago Hospital.

SUBJECTS

One hundred and ninety two women admitted on the postnatal ward after emergency or elective caesarean section for various indications and who satisfied the eligibility criteria were recruited and randomized into the study. Assignment to the early feeding group or routine feeding group was done randomly using a computer generated numbers. The early feeding group were encouraged to take sips of water within six to eight hours followed by oral soup or milk at least 150 millilitres at a time within 8 to 12 hours post operative under supervision. The routine group were managed by restricting oral intake for twenty four hours and administration of orals sips of water 24 to 48 hours post operative. The outcome measures were rate of ileus symptoms, post operative presence of bowel sounds, maternal pyrexia and acceptability and benefits of early feeding.

RESULTS

The mean age, parity and gravidity were similar in the two groups. The study shows that women of the early feeding group had more rapid return of their bowel function with significant more shorter mean post operative time intervals to bowels sounds (24.2 hours versus 34.2 hours), passage of flatus (51.6 hours versus 62.1 hours) and bowel movement (67.8 hours versus 75.8 hours). The women who fed early, made more rapid recovery and expressed their interest in earlier hospital discharge. The findings significantly indicated that women in the early feeding group got out of bed (patient mobilisation) earlier (p = 0.001) than their control group (15.1 hours versus 17.8 hours). This could probably have been because of the adequate rehydration and improved early energy intake. In comparison those who were fed early required less number of bottles of intravenous fluids (5.0 bottles versus 7.0 bottles). The average hospital stay was similar and not statistically significant in both groups (5.5 days versus 6.0 days).

CONCLUSION

Early initiation of oral feeding after caesarean delivery is safe and well tolerated and can be implemented without an increase in gastrointestinal symptoms or paralytic ileus.

Clinical presentation and management of alleged sexually assaulted females at Mulago hospital, Kampala, Uganda

OBJECTIVE

To determine the presentation and treatment offered to sexually assaulted females attending emergency gynaecological ward in Mulago Hospital, Kampala, Uganda.

SETTING

Mulago hospital gynaecological emergency ward.

STUDY DESIGN

Prospective descriptive study.

PARTICIPANTS

Fifty eight sexually assaulted females were recruited from 1 st March 2000 to 31 st December 2000. They were interviewed, examined, given appropriate treatment and followed up for three months.

OUTCOME VARIABLES

Socio demographic characteristics, genital and bodily injuries, relationship to the assailant, and prevalence of sexually transmitted infections.

RESULTS

The mean age was 9.5 with a range of 1-35 years. Seventy two percent of the victims were children below 12 years. Fifty percent of the assault occurred at the assailant's home. The majority (79.3%) of the victims knew the assailant and cases of gang rape were only 6.9%. The injuries sustained were extra genital (19.0%), genital (75.4%). The emotional or psychological disturbance was present in 22.4% of the patients. The sexually transmitted infections found included trichomonas vaginalis (1.7%) and syphilis (3.7%). All cases received counseling and prophylactic treatment for sexually transmitted infections. Those in reproductive age group were offered emergency contraception. None of the victims got post exposure HIV therapy because it was not available in the hospital.

CONCLUSION

Sexual assault is common in Uganda and is one of the most dehumanizing human crimes against women. It is associated with adverse medical and social problems. There is urgent need to sensitize the community about reporting early for medical treatment after sexual assault.

Spontaneous rupture of bladder in puerperium

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.

Maternal and fetal outcome of gestational diabetes mellitus in Mulago Hospital, Uganda

OBJECTIVE

To determine the maternal and foetal outcomes in mothers with gestational diabetes mellitus attending antenatal clinics in Mulago Hospital Kampala Uganda.

DESIGN

This was a cohort study.

SETTING

Mulago Hospital antenatal clinics.

PARTICIPANTS

Ninety mothers with gestational ages between 24-32 weeks were recruited from April to September 2001.They were followed up to the time of delivery. The WHO criterion for the diagnosis of gestational diabetes was used. Thirty mothers with a 2 hrs post prandial capillary blood sugar more than 140 mg/dl were the exposed group and 60 mothers with less than 140 mg/dl were the unexposed group. Blood sugar was measured using a one touch glucometer.

OUTCOME VARIABLES

Socio demographic characteristics, maternal complications, mode of delivery and the foetal outcomes.

RESULTS

The mean age of mothers in both groups was similar: 28.6 years vs 27.5 years. Both groups had similar body mass index more than 26. The mothers with gestational diabetes mellitus (GDM) were four times more likely to have hypertensive disease(p=0.04) and nine times more likely to have vaginal candidiasis(p=0.002). The modes of delivery were similar in both groups but genital injuries were more common among mothers with GDM. The indications of Caesarian section in mothers with GDM were two times more likely to be due to big babies and obstructed labour. The babies for mothers with GDM were more likely to be macrocosmic, still born, and have shoulder dystocia than those of normal mothers.

CONCLUSION

Gestational diabetes mellitus exists in Uganda and is associated with adverse maternal and foetal outcomes. There is need to routinely screen mothers for gestational diabetes in this environment.

Sexual practices of women within six months of childbirth in Mulago hospital, Uganda

OBJECTIVES

To establish the sexual practices and their associated morbidity among women within 6 months of childbirth in Kampala Uganda.

DESIGN

Cross-sectional descriptive study.

SETTING

The three Mulago hospital child immunization clinics.

PARTICIPANTS

Two hundred and seventeen eligible mothers took part in the study from November to December 2001.

OUTCOME MEASURES

Time to resumption of sexual intercourse after childbirth, reasons for resumption and problems associated with it.

METHODS

Partially coded questionnaires

RESULTS

Sexual intercourse was resumed by 66.4% of the women within six months of childbirth. Of these 49.3% did so during the puerperium. The main reasons for early resumption of sexual intercourse were husbands' demands, cultural demands and inherent inability to do without sexual intercourse but not level of education of mothers. Of the mothers who resumed sexual intercourse 22.2% had sexual problems. The problems included vaginal pain (62.5%), discharge (18.8%), bleeding (15.6%) and bruises or tears (3.1%). Perineal or genital damage at the time of delivery was not associated with a delayed resumption of sexual intercourse with (OR1.08, 95% CI 0.51-2.30). Of those who had sexual intercourse and had problems only 59.4% sought medical assistance. The reasons for not resuming sexual intercourse within six months of delivery included advise from health workers (38.4%), husbands were away (21.9%), no interest (21.9%) and not feeling well(17.8%).

CONCLUSION

Most women resumed sexual intercourse within six months of childbirth and had high morbidity. There is need for appropriate postpartum sexual practice advice. SITE OF STUDY: Mulago hospital.