A modified neo-vagina procedure in a low resource urogynecological unit: a case report of a 21 year old with Mayer-Rokitansky-Küster-Hauser (mrkh) Syndrome operated at Mbarara referral hospital, Southwestern Uganda.

BACKGROUND: Although vaginal agenesis as may occur in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare condition, it is associated with not only anatomical problems but also serious psychological and social problems like painful sexual intercourse, primary amenorrhea and infertility. Surgery, which is aimed at reconstruction of a vagina of adequate length and width to serve the function, is the main method of treatment. Many methods for vaginal reconstruction have been described but each has its complications and limitations. The most commonly preferred procedure for treating this condition is the McIndoe vaginoplasty which involves dissection into the recto-vesical space, inserting two split thickness skin grafts folded over a mold in this newly created space and regular dilatation of the neovagina postoperatively to avoid stenosis. However surgeons with this expertise in this part of the world are rare to find and where they are available, the special molds on which to fold the skin grafts into the neovaginal space are not readily available. CASE PRESENTATION: A 21-year-old female with vaginal agenesis was operated on using a modification of the McIndoe procedure using a cylinder of a 60cm3 syringe as a vaginal mold/form and kept in place. We left a Foley in place for 10 days and we did a dye test after removing the syringe to ensure that there was no leakage resulting from fistula formation. CONCLUSION: The operation was successful and on subsequent monthly reviews of the patient, she has a patent functional vagina of about 9 cm in length at 8 months after the operation with resumption of sexual intercourse.

Puerperal sepsis, the leading cause of maternal deaths at a Tertiary University Teaching Hospital in Uganda.

BACKGROUND: Maternal mortality is highest in sub-Saharan Africa. In Uganda, the WHO- MDG 5 (aimed at reducing maternal mortality by 75 % between 1990 and 2015) has not been attained. The current maternal mortality ratio (MMR) in Uganda is 438 per 100,000 live births coming from 550 per 100,000 in 1990. This study sets out to find causes and predictors of maternal deaths in a tertiary University teaching Hospital in Uganda. METHODS: The study was a retrospective unmatched case control study which was carried out at the maternity unit of Mbarara Regional Referral Hospital (MRRH). The sample included pregnant women aged 15-49 years admitted to the Maternity unit between January 2011 and November 2014. Data from patient charts of 139 maternal deaths (cases) and 417 controls was collected using a standard audit/data extraction form. Multivariable logistic regression analysis was used to assess for the factors associated with maternal mortality. RESULTS: Direct causes of mortality accounted for 77.7 % while indirect causes contributed 22.3 %. The most frequent cause of maternal mortality was puerperal sepsis (30.9 %), followed by obstetric hemorrhage (21.6 %), hypertensive disorders in pregnancy (14.4 %), abortion complications (10.8 %). Malaria was the commonest indirect cause of mortality accounting for 8.92 %. On multivariable logistic regression analysis, the factors associated with maternal mortality were: primary or no education (OR 1.9; 95 % CI, 1.0-3.3); HIV positive sero-status (OR, 3.6; 95 % CI, 1.9-7.0); no antenatal care attendance (OR 3.6; 95 % CI, 1.8-7.0); rural dwellers (OR, 4.5; 95 % CI, 2.5-8.3); having been referred from another health facility (OR 5.0; 95 % CI, 2.9-10.0); delay to seek health care (delay-1) (OR 36.9; 95 % CI, 16.2-84.4). CONCLUSIONS: Most maternal deaths occur among mothers from rural areas, uneducated, HIV positive, unbooked mothers (lack of antenatal care), referred mothers in critical conditions and mothers delaying to seek health care. Puerperal sepsis is the leading cause of maternal deaths at Mbarara Regional Referral Hospital. Therefore more research into puerperal sepsis to describe the microbiology and epidemiology of sepsis is recommended.

Uterine rupture in a teaching hospital in Mbarara, western Uganda, unmatched case- control study.

BACKGROUND: Uterine rupture is one of the most devastating complications of labour that exposes the mother and foetus to grave danger hence contributing to the high maternal and perinatal mortality and morbidity in Uganda. Every year, 6000 women die due to complications of pregnancy and childbirth, uterine rupture accounts for about 8% of all maternal deaths. METHODS: Case-control design of women with uterine rupture during 2005-2006. Controls were women who had spontaneous vaginal delivery or were delivered by caesarean section without uterine rupture as a complication. For every case, three consecutive in-patient chart numbers were picked and retrieved as controls. All available case files, labour ward and theater records were reviewed. RESULTS: A total of 83 cases of uterine rupture out of 10940 deliveries were recorded giving an incidence of uterine rupture of 1 in 131 deliveries. Predisposing factors for uterine rupture were previous cesarean section delivery(OR 5.3 95% CI 2.7-10.2), attending < 4 antenatal visits (OR 3.3 95% CI 1.6-6.9), parity ≥ 5(OR 3.67 95% CI 2.0-6.72), no formal education (OR 2.0 95% CI 1.0-3.9), use of herbs (OR15.2 95% CI 6.2-37.0), self referral (OR 6.1 95% CI 3.3-11.2) and living in a distance >5 km from the facility (OR 10.86 95% CI 1.46-81.03). There were 106 maternal deaths during the study period giving a facility maternal mortality ratio of 1034 /100,000 live births, there were 10 maternal deaths due to uterine rupture giving a case fatality rate of 12%. CONCLUSION: Uterine rupture still remains one of the major causes of maternal and newborn morbidity and mortality in Mbarara Regional referral Hospital in Western Uganda. Promotion of skilled attendance at birth, use of family planning among those at high risk, avoiding use of herbs during pregnancy and labour, correct use of partograph and preventing un necessary c-sections are essential in reducing the occurrences of uterine rupture.

Individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda.

BACKGROUND: Obstructed labour is still a major cause of maternal morbidity and mortality and of adverse outcome for newborns in low-income countries. The aim of this study was to investigate the role of individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda. METHODS: A review was performed on 12,463 obstetric records for the year 2006 from six hospitals located in south-western Uganda and 11,180 women records were analysed. Multivariate logistic regression analyses were applied to control for probable confounders. RESULTS: Prevalence of obstructed labour for the six hospitals was 10.5% and the main causes were cephalopelvic disproportion (63.3%), malpresentation or malposition (36.4%) and hydrocephalus (0.3%). The risk of obstructed labour was statistically significantly associated with being resident of a particular district [Isingiro] (AOR 1.39, 95% CI: 1.04-1.86), with nulliparous status (AOR 1.47, 95% CI: 1.22-1.78), having delivered once before (AOR 1.57, 95% CI: 1.30-1.91) and age group 15-19 years (AOR 1.21, 95% CI: 1.02-1.45). The risk for perinatal death as an adverse outcome was statistically significantly associated with districts other than five comprising the study area (AOR 2.85, 95% CI: 1.60-5.08) and grand multiparous status (AOR 1.89, 95% CI: 1.11-3.22). Women who lacked paid employment were at increased risk of obstructed labour. Perinatal mortality rate was 142/1000 total births in women with obstructed labour compared to 65/1000 total births in women without the condition. The odds of having maternal complications in women with obstructed labour were 8 times those without the condition. The case fatality rate for obstructed labour was 1.2%. CONCLUSIONS: Individual socio-demographic and health system factors are strongly associated with obstructed labour and its adverse outcome in south-western Uganda. Our study provides baseline information which may be used by policy makers and implementers to improve implementation of safe motherhood programmes.

Predictors and outcome of surgical repair of obstetric fistula at a regional referral hospital, Mbarara, western Uganda.

BACKGROUND: Obstetric fistula although virtually eliminated in high income countries, still remains a prevalent and debilitating condition in many parts of the developing world. It occurs in areas where access to care at childbirth is limited, or of poor quality and where few hospitals offer the necessary corrective surgery. METHODS: This was a prospective observational study where all women who attended Mbarara Regional Referral Hospital in western Uganda with obstetric fistula during the study period were assessed pre-operatively for social demographics, fistula characteristics, classification and outcomes after surgery. Assessment for fistula closure and stress incontinence after surgery was done using a dye test before discharge RESULTS: Of the 77 women who were recruited in this study, 60 (77.9%) had successful closure of their fistulae. Unsuccessful fistula closure was significantly associated with large fistula size (Odds Ratio 6 95% Confidential interval 1.46-24.63), circumferential fistulae (Odds ratio 9.33 95% Confidential interval 2.23-39.12) and moderate to severe vaginal scarring (Odds ratio 12.24 95% Confidential interval 1.52-98.30). Vaginal scarring was the only factor independently associated with unsuccessful fistula repair (Odds ratio 10 95% confidential interval 1.12-100.57). Residual stress incontinence after successful fistula closure was associated with type IIb fistulae (Odds ratio 5.56 95% Confidential interval 1.34-23.02), circumferential fistulae (Odds ratio 10.5 95% Confidential interval 1.39-79.13) and previous unsuccessful fistula repair (Odds ratio 4.8 95% Confidential interval 1.27-18.11). Independent predictors for residual stress incontinence after successful fistula closure were urethral involvement (Odds Ratio 4.024 95% Confidential interval 2.77-5.83) and previous unsuccessful fistula repair (Odds ratio 38.69 95% Confidential interval 2.13-703.88). CONCLUSIONS: This study demonstrated that large fistula size, circumferential fistulae and marked vaginal scarring are predictors for unsuccessful fistula repair while predictors for residual stress incontinence after successful fistula closure were urethral involvement, circumferential fistulae and previous unsuccessful fistula repair.