Impact of colposcopy on management outcomes of patients with abnormal cervical cytology.

BACKGROUND: With stringent cervical cytology screening programmes for women in reproductive age group, cervical cancer is, to a large extent, preventable. Back-up confirmatory colposcopic evaluation is necessary in order for cytology to have impact on cervical cancer-related morbidity and mortality. OBJECTIVES: To track the management outcomes of abnormal cervical cytology and hence confer credence to the value of colposcopy in management of abnormal cervical cytology. DESIGN: Retrospective descriptive study. SETTING: Kenya Medical Women Association Colposcopy Clinic. MAIN OUTCOME MEASURES: Correlation of cervical cytologic abnormalities with colposcopic outcomes and eventual management outcomes. RESULTS: The population was young, with 50.6% being 25-34 years old, and 59.3% less than 35 years of age. Parity was also low, with nearly 75% being para three or less. A substantial proportion of women had normal colposcopic findings (42.0, 26.7,18.6 and 11.1% for cytologic abnormalities CIN I, CIN II, CIN III and invasive carcinoma respectively). Colposcopic abnormality detection rate, irrespective of the severity of the lesion, increased with severity of cytologic lesion (from 58.0% CIN I to 89.0% for invasive carcinoma). The sensitivity of cervical cytology was 58, 59 and 65% for CIN I,II and III respectively, while respective specificity was 72, 71 and 85%. The concordance rates between cytological and colposcopic findings were 38.6, 32.5 and 60% for CIN I, II and III respectively. The eventual management outcome was operative (LEEP and Hysterectomy) in greater frequency as the severity of the cytologic lesion increased. CONCLUSION: Colposcopy has significant impact on the management outcomes of abnormal cervical cytology and is therefore an invaluable procedure in management of abnormal cervical cytology. For this reason, it is imperative that governments avail these services to all women, in addition to enforcing regular cytologic screening for cervical cancer.

Severe meconium aspiration syndrome: case report.

This is a case report on severe meconium aspiration syndrome (MAS) that resulted in early neonatal death. Antenatal care was provided at a low-cost non-governmental organization (NGO) clinic. First stage of labour lasted for only 2 hours and 45 minutes. There were no foetal heart rate abnormalities that were noted during the first stage of labour. Artificial rupture of membranes was done in second stage of labour. There was no liquor amnii seen but scanty thick old meconium was noted. Delivery was easy. The baby's skin, nails, umbilical cord, placenta and vernix were deeply stained yellow with old meconium. Resuscitation included suction through direct laryngoscopy, nasotracheal intubation with pulmonary toilet, as well as administration of 100% oxygen. The condition of the baby did not improve. A diagnosis of severe MAS with hypoxic ischaemic encephalopathy (HIE), persistent pulmonary hypertension (PPH), persistent foetal circulation syndrome (PFCS) and meconium chemical pneumonitis was made. The baby was admitted to the intensive care unit (ICU) for assisted ventilation and critical care. The condition of the baby continued to deteriorate and demise occurred 18 hours after birth. The pathophysiologic processes of intrauterine meconium release, mechanisms of foetal effects and dilemmas in management are discussed.

Perceptions and practices of vaginal birth after Caesarean section among privately practicing obstetricians in Kenya.

OBJECTIVE: To determine perceptions, preferences and practices of vaginal birth after Caesarean. DESIGN: Cross-sectional descriptive study. SETTING: Private clinics of obstetricians in five major towns of Kenya. SUBJECTS: Obstetricians in private practice. MAIN OUTCOME MEASURES: Practice and experiences in trial of labour (TOL); need for, and application of, selection criteria in TOL; perceptions on outcomes of TOL and patient preference; perception on trends of vaginal birth after Caesarean (VBAC) and need for policy on TOL. RESULTS: Nearly all respondents (98.4%) believed in the need for, and application of, selection criteria for allowing TOL. However, only 23% believed in routine screening with radiological pelvimetry, while 63.2% believed in routine foetal weight estimation. All obstetricians (100%) have ever managed TOL in private practice, and 74% had managed at least one case in the last six months. Despite lack of tangible selection criteria, 83.1% think that most women prefer TOL while 95.1% discourage it if perceived as inappropriate. Failure rate of TOL was perceived to be more than 50% by 35.2% of the respondents. A majority of the respondents (about 75%) would prefer TOL on themselves or their spouses. Those who perceived that there was a falling trend of VBAC were 58%, citing increased demand by mothers (45.7%), obstetricians' convenience (40.0%) and fear of litigation (26.8%) as the reasons for this observation. A fluid policy of "TOL whenever it is deemed as appropriate" was preferred by 88.7%. CONCLUSION: The perception of obstetricians is that desire for VBAC predominates over elective repeat Caesarean. However, consensus on appropriate selection criteria is lacking, which leaves the obstetrician in a management dilemma. Hence, there is need to study outcomes of both ERC and TOL in order to come out with objective policy guidelines on management of one previous Caesarean in pregnancy.

Incidence of wound infection after caesarean delivery in a district hospital in central Kenya.

OBJECTIVE: To determine the incidence of post-caesarean wound infection. DESIGN: Prospective descriptive study. SETTING: Maternity unit of Kiambu District Hospital in Central Province of Kenya. SUBJECTS: All women undergoing caesarean delivery during the study period. MAIN OUTCOME MEASURES: Overall incidence of post-caesarean wound infection, relationship between incidence and socio-demographic characteristics, pre-operative labour events, intrapartum events as well as HIV status. RESULTS: The caesarean delivery rate was 7.8%. The overall post-caesarean wound infection rate was 19%. The incidence was 32% among single women as compared to 16% among married women, but this difference is not statistically significant. Among the 35% of women who laboured for more than 12 hours, the incidence of wound infection was 33% compared to 15% among those who laboured for 12 hours or less (p < 0.01). Rupture of membranes (ROM) for more than 12 hours was associated with high incidence of wound infection than among women in whom ROM was 12 hours or less (38% and 14% respectively, p < 0.001). Also duration of operation exceeding 60 minutes was associated with much higher incidence of wound infection (71%) compared to when the operation lasted 60 minutes or less (16%, p < 0.001). The incidence of post-caesarean wound infection does not appear to be significantly affected by HIV status or whether caesarean delivery was emergency or elective. CONCLUSION: The overall post-caesarean wound infection rate is quite high. Prolonged pre-operative duration of labour, prolonged ROM and long duration of operation are associated with significantly higher incidence of wound infection. This should be seen against a background of a relatively low caesarean delivery rate and high incidence of prolonged labour. Strict labour management policies need to be inculcated in labour wards in District Hospitals in order to ensure timely caesarean delivery interventions, and hence, reduce post-caesarean wound infection rates.