Background. Cervical cancer is the second most common malignancy in women, particularly in developing countries. Endocervical adenocarcinoma (ECA) is less common than cervical squamous cell carcinoma (SCC), but its incidence is increasing globally, particularly in young women. The decline in the incidence of SCC is attributed to effective screening programmes. Objectives. To assess the prevalence of ECA and its subtypes and to describe the clinicopathological characteristics of patients with these tumours at a tertiary South African institute between 2017 and 2019. Methods. This was a cross-sectional, descriptive study of 156 ECA patients. Following ethical clearance, demographic data, clinical information and disease characteristics were obtained from departmental histopathological reports. Descriptive statistics were used to calculate the prevalence of ECA. We analysed the association between age, Papanicolaou (Pap) smear results, human papillomavirus (HPV) status, and HIV status with ECA. Results. The prevalence of ECA was 6.8% and it was more commonly diagnosed in younger women. HPV-associated subtypes were the most common variants. The usual type of ECA accounted for 24.4% of cases. HIV status was documented in 64.0% of cases, of which 34.0% were positive. There were no statistically significant associations between ECA subtype and HIV status (p=0.81) or between ECA subtype and Pap smear results. Conclusion. In South Africa, the prevalence of ECA is lower compared with Western countries, reflecting inadequacies in screening modalities of ECA at primary healthcare facilities. HPV prevails as a cause of endocervical carcinoma. HPV morphologic hallmarks serve as a practical guide in classifying ECAs according to their HPV status.

Background. Changes in the fibrinolytic system that support haemostasis are seen in the third trimester of pregnancy. An imbalance between coagulation and fibrinolysis could increase either thrombotic episodes or haemorrhagic risk. Objective. To assess plasma D-dimer and plasmin-a2-antiplasmin (PAP) complex levels as indication of plasmin generation during late pregnancy. Methods. A sample of 41 healthy pregnant women in their third trimester participated in the study. Data on obstetric history, body mass index (BMI) and other demographic variables were recorded. Haematological analysis involved enzyme-linked immunosorbent assaying of venous blood samples. Statistical analysis was performed using SPSS version 21. Results. Mean maternal and gestational age, with associated standard deviations (SD), were 30.68 (4.69) years and 34.78 (3.34) weeks, respectively. Haematological analysis showed mean (SD) values of D-dimer and PAP complex to be 194 (24 ng/mL) and 175 (11 ng/mL), respectively. Both indicators were positively correlated with maternal age, gestational age and BMI grouping, although significantly only for maternal age. Multiple linear regression analysis showed that with every increasing year of maternal age, D-dimer levels increased by 2.0 ng/mL (95% confidence interval (CI) 0.4 - 3.6 ng/mL). PAP complex levels similarly increased by 0.8 ng/mL (95% CI 0.1 - 1.5 ng/mL), after controlling for gestational age and BMI. Conclusion. D-dimer and PAP levels increased with increasing maternal age, suggesting it to be an independent determinant of plasmin generation in the third trimester of pregnancy. If this finding is confirmed in larger studies, age should be considered when interpreting these indicator values during pregnancy.

Background. The severity of injury and associated management determine maternal and fetal outcomes in pregnant trauma patients. Objective. To describe the characteristics, mechanisms of injury, clinical interventions and maternal and fetal outcomes of obstetric trauma admissions at our institution. Methods. This was a retrospective record review of pregnant trauma patients admitted to Chris Hani Baragwanath Academic Hospital over a 5-year period (N=800). Patient records from several departments were reviewed, including the intensive care unit (ICU). Data were collected on sociodemographics, mechanism of injury, clinical interventions, and maternal and fetal outcomes. Results. The median maternal age and gestational age were 31.00 years and 26.00 weeks, respectively. Most patients were black African (n= 713; 89.1%) and the majority (70.3%; n=562) were single. More than half (n=484; 60.5%) were unemployed. Assault was the most frequent cause of trauma (n=330; 41.3%), followed by falls (n=265; 33.1%) and motor vehicle accidents (n=204; 25.5%). Almost a fifth of the patients (n=141; 18.0%) reported recent alcohol consumption. Four patients (0.5%) were admitted to ICU, of whom one died. Ten fetal deaths were recorded, of which three were delivered by patients admitted to ICU. Eleven neonates were delivered before 37 weeks. Conclusion. Our results show that pregnant patients who are single and unemployed were at increased risk of obstetric trauma. Assaults, falls and motor vehicle accidents were the most common causes of maternal trauma in our sample. Implementing strategies to detect and prevent intimate partner violence and improve road safety may contribute to reduced maternal and fetal mortality.

Background. Sickle cell disease (SCD) is a common genetic disease in sub-Saharan Africa. The condition affects more than 7% of pregnant women worldwide, with complications including severe infections, vital organ damage, respiratory problems, bone marrow suppression and a high rate of maternal or fetal death. Objective. To evaluate the prevalence, management and maternal–fetal prognosis of pregnancies in women with major SCD. Methods. A prospective and descriptive study was conducted in the gynaecology and obstetrics department of the university hospital of Cocody, Abidjan, in Cote d’Ivoire over two years. Records of all pregnant women with homozygous SCD who had given birth or were followed up in the unit were reviewed. Women with an HbAA or HbAS genotype or any other normal electrophoretic profile or history of renal disease were excluded. Results. Out of 14 819 delivery records, 118 (0.8%) women presented with an abnormal haemoglobin profile; 75 were classified as having major SCD (0.51%). The majority of women (82.7%) were younger than 35 and 68% worked in the informal sector. About a third (37.3%) had no formal education. Heterozygous HbSC profiles were the predominant (88%) presenting form; HbSS genotypes were found in 12% of cases. The occurrence of complications during pregnancy was significant (44%). Conclusion. SCD in pregnancy is associated with an increased risk of maternal and fetal complications. Accurate and rigorous monitoring of these pregnancies by a multidisciplinary team, together with improved patient awareness and education, is required to reduce maternal and fetal health risks.

Background. Information about current gynaecological surgical practices and patient outcomes is integral to the provision of quality gynaecological care. An audit of surgical complications can provide important information needed for an assessment of current surgical practices and outcomes. Objective. To describe the cohort of patients undergoing gynaecological surgical procedures at Tygerberg Hospital, their complication rates and identify associated risk factors. Methods. We conducted a retrospective review of adult patients having emergency and elective gynaecological surgical procedures between 1 January and 31 December 2019. A total of 970 patients were included. We summarised categorical data as counts and percentages. We performed logistical regressions to assess factors associated with complications. Odds ratios (ORs) were reported as measures of association with the corresponding 95% confidence interval (CI). Statistical significance was set at a p-value <0.1 and p-value <0.05 in the bivariate and multivariate analysis, respectively. Results. Overweight and obese patients accounted for 60% of patients. The most common indication for surgical intervention was benign gynaecological conditions (23.3%). Total abdominal hysterectomy was the single most common procedure performed (23.7%). Intraoperative or postoperative complications occurred in 12.7% of patients, while 1.2% sustained both intraoperative and postoperative complications. The most common complications were infection-related (7.5%) and bowel injury (1.8%). Oncological surgery did not increase the likelihood of complications compared with non-oncological surgery (OR 1.14; 95% CI 0.66 - 1.97; p=0.63). Conclusion. The provision of quality gynaecological care requires information on gynaecological surgical practices and patient outcomes. The rates of surgical complications at our facility appear to be higher than local and international studies, with our main contributors being infection-related complications and bowel injuries. An extended course of prophylactic antibiotics could be considered, as well as auditing infection control measures. Patients who are at a higher risk of bowel injury should be identified preoperatively and the surgery approached with care.

Background. Large for gestational age (LGA) refers to a newborn birthweight equal to or greater than the 90th percentile for a given GA. Delivering an LGA newborn poses a high risk of morbidity and mortality for both mother and baby. Objectives. To describe the prevalence of term LGA newborns and identify the factors and pregnancy-related outcomes associated with delivering term LGA newborns at Chris Hani Baragwanath Academic Hospital (CHBAH), a tertiary hospital in Johannesburg, South Africa. Methods. We conducted a retrospective, institution-based cross-sectional study from 1 October 2020 to 31 March 2021, in which 275 LGA singleton term deliveries were reviewed. Patient demographics, medical factors and clinical outcomes were recorded and statistically analysed. Results. The prevalence of LGA newborns in singleton-term deliveries at CHBAH was 3.92%. Associated factors included maternal obesity, multiparity, prolonged pregnancy with a GA >40 weeks, previous LGA delivery and (newborn) male gender. Maternal complications included prolonged labour, increased caesarean delivery, postpartum haemorrhage, obstetric anal sphincter injuries and uterine rupture. Fetal and neonatal complications included shoulder dystocia, neonatal hypoglycaemia, and neonatal respiratory distress syndrome. Conclusions. LGA singleton term deliveries at CHBAH were associated with both maternal and neonatal morbidity. The presence of associated factors should alert maternity caregivers to closely monitor these pregnancies and plan for an appropriate mode of delivery. LGA newborns should be routinely screened and appropriately managed for hypoglycaemia.

Background. Repeat caesarean section (CS) carries an increased risk of both maternal and neonatal morbidity and mortality. Planned vaginal birth after CS (VBAC), with an estimated success rate of 60 - 80%, is clinically safer than elective repeat CS, and also limits the rise in CSs. There is no single generalised validated tool to predict success of VBAC. Objectives. To determine predictors of successful VBAC among mothers with one previous CS at selected hospitals in Lusaka, Zambia. Method. Determination of independent predictors with significant high odds of a successful VBAC among mothers offered a trial of labour (TOL) was conducted in a cross-sectional study. Women with a history of one previous lower-segment CS, who were carrying a singleton fetus and were in established labour or draining amniotic fluid and scheduled for TOL after CS, were included in the study. Convenience sampling was used to enrol 290 participants. Using SPSS version 22, bivariate analysis and logistic regression analysis were used to analyse data. An independent factor associated with successful VBAC and with a p-value <0.05 was considered significant. Results. Of the participants, 236 (81.4%) had a successful vaginal delivery and 54 (18.6%) failed to deliver vaginally and required emergency CS. Key independent predictors of success of VBAC were primary education level (adjusted odds ratio (AOR) 2.21; 95% confidence interval (CI) 1.01 - 4.84), multiparity (AOR 4.81; 95% CI 1.16 - 19.93), previous successful VBAC (AOR 9.94; 95% CI 1.29 - 76.70), inter-delivery interval after the primary CS (AOR 18.54; 95% CI 5.98 - 57.48), a history of fetal distress (AOR 9.33; 95% CI 2.48 - 35.08), malpresentation (AOR 6.13; 95% CI 1.65 - 22.70) or failed induction of labour (AOR 20.52; 95% CI 3.32 - 127.03) as indications for the primary CS, Bishop score (AOR 7.06; 95% CI 1.92 - 25.97), cervical dilation (AOR 11.62; 95% CI 3.86 - 35.03), duration of labour (AOR 20.78; 95% CI 5.62 - 76.80), birthweight (AOR 6.80; 95% CI 3.33 - 13.91) and Apgar score (AOR 28.42; 95% CI 5.67 - 142.38). Conclusion. A combination of independent sociodemographic and obstetric factors that have significant high odds for a good outcome of VBAC could help predict success of delivery in a given population. This information could also aid in counselling mothers on mode of delivery.

Background. Catamenial pneumothorax (CP) is an under-reported and misunderstood condition commonly defined as a recurrent, spontaneous pneumothorax occurring from the day before menstruation until 72 hours after its onset. It is the most common clinical manifestation of thoracic endometriosis. Case report. We describe the case of a 36-year-old woman who presented twice with significant shortness of breath during her menses at a regional hospital in Gauteng Province, South Africa. Chest radiographs showed bilateral spontaneous pneumothoraces on both occasions, indicating a very rare presentation of CP, which is more commonly a right-sided pathology and a rare presentation on its own. Video-assisted thoracoscopic surgery was performed at a tertiary institution. Significant thoracic endometriosis and a diaphragmatic hernia were found, confirming the diagnosis of endometriosis-related CP. Pleurectomy and closure of the diaphragmatic hernia were performed, and the patient was initiated on hormonal therapy. Conclusion. A high index of clinical suspicion is required for diagnosing CP and its associated conditions. This case highlights the need for awareness of this condition and the importance of long-term follow-up, especially in an overburdened and resource-limited healthcare system.

Background. The incidence of placenta praevia (PP) is 0.3 - 0.5% of pregnancies and it is a major risk factor for placenta accreta syndrome (PAS). PP and PAS cause immense feto-maternal morbidity and mortality and, as a result, place a huge burden on healthcare resources. Hence, accurate diagnosis prenatally of PP and associated PAS is essential as this allows adequate preparation for potential complications. Objective. To ascertain the accuracy of prenatal diagnosis of PP and PAS, and the feto-maternal effects of these conditions in women diagnosed at Chris Hani Baragwanath Academic Hospital (CHBAH) Methods. This was a retrospective, descriptive study that reviewed the medical files of 55 women diagnosed with PP at CHBAH in 2018. Results. Complete data was obtained for 28 women. The incidence of PP was 0.3%. The mean age, gravity and parity of women with PP were 31.65 (6.0) years, 3.0 (1.3) and 1.7 (1.3), respectively. The mean birthweight was 2 244 (730) g. Eighteen (56.2%) of newborns had birth weight <2 500g. The incidence of adverse outcomes was increased in patients with suspected PAS on prenatal ultrasound compared with patients showing no prenatal ultrasound evidence of PAS. Ultrasound had a positive predictive value of 50% while MRI correctly identified PAS in 33.3% of patients. Conclusion. PP and PAS increase the likelihood of maternal and neonatal morbidities. Ultrasound is a useful tool in evaluating placenta implantation and can assist in anticipating adverse feto-maternal outcomes in PP and PAS. MRI has limited clinical value in this setting Keywords. Placenta praevia (PP), Placenta accreta syndrome (PAS), Chris Hani Baragwanath Academic Hospital (CHBAH), Magnetic Resonance Imaging (MRI) currently, and should not be done routinely.

These are three best practice guidelines related to important areas in obstetrics. The first details the prenatal care of twin pregnancies. The second provides guidelines for the management of intrauterine growth restriction and the third provides guidance on the use of Doppler ultrasound in obstetrics, including technical aspects and safety.