Acute uterine inversion following an induced abortion.

Acute uterine inversion is a rare and potentially life-threatening obstetric emergency. Its occurrence as a result of a mid-trimester abortion is an even rarer consequence. We report a case of a 32-year-old woman who presented with complete acute uterine inversion and hemorrhagic shock following an incomplete medical abortion at 14 weeks of gestation. Our attempts at non-operative reversal of the inversion failed. Therefore, we resorted to the manual replacement of the uterus via laparotomy without using surgical instruments or an incision in the cervical ring. The laparotomic manual replacement served as a successful alternative with minimal immediate or long-term morbidity that may have resulted from trauma and scarring of the uterus.

Rare complication of fibroids in pregnancy: Spontaneous fibroid rupture.

Uterine fibroids in pregnancy present with numerous complications. However, spontaneous rupture is a rare and potentially life-threatening event. We report a case of a 43-year-old multiparous woman who presented with hypovolemic shock secondary to a ruptured uterine fibroid 2 days after a spontaneous vaginal delivery. Emergency laparotomy confirmed massive intra-abdominal hemorrhage from the ruptured capsule of a 10-cm subserosal fibroid. A myomectomy was performed. Her postoperative recovery period was uneventful. This case is very rare, with fewer than 30 cases of hemoperitoneum secondary to rupture of fibroids having been reported in published works. It demonstrates how a benign and common condition, such as fibroids, can lead to an obstetric emergency that mimics a surgical abdomen requiring swift diagnosis and surgical intervention.

Disseminated adult Wilms tumor in pregnancy: Leveraging multidisciplinary care in a low-resource setting.

Wilms tumor (WT) occurring in adults is rare and even much more rarely found to coexist with pregnancy. Clinical outcome in adults is worse overall compared with pediatric patients with WT and is often misdiagnosed with no standardized protocols for care guided by high-evidence clinical trials. We present a case of a 23-year-old woman diagnosed with WT who was found to be pregnant immediately following nephrectomy. Workup findings showed that she had disseminated disease but was successfully managed in a multidisciplinary team setting with modified intrapartum chemotherapy followed by postpartum chemotherapy. In low-resource settings, management protocols for adult patients with WT can be individualized by multidisciplinary teams to leverage available resources for best outcomes.

Preterm birth in low-middle income Countries.

Preterm birth (PTB), remains a major cause of significant morbidity and mortality world-wide with about 12-15million preterm births occurring every year. Although the overall trend is decreasing, this is mainly in high-income countries (HIC). The rate remains high in low-and middle-income countries (LMIC) varying on average between 10 and 12% compared to 9% in HIC. The pathogenesis of PTB is complex and multifactorial. Attempts to reduce rates that have focused on PTB as a single condition have in general been unsuccessful. However, more recent attempts to phenotype PTB have resulted in targeted preventative approaches which are yielding better results. Prevention (primary or secondary) is the only approach that has been shown to make a difference to rates of PTB. These include identifying risk factors pre-pregnancy and during pregnancy and instituting appropriate measures to address these. In LMIC, although some approaches that have been shown to be effective in some HIC are adaptable, there is a need to involve stakeholders at all levels in utilizing evidence preferrably generated in LMIC to implement strategies that are likely to reduce the rate of PTB. In this review, we focus on prevention and how to involve policy makers in the process of applying evidence into policy that would reduce PTB in LMIC.

Corrigendum: Perinatal autopsy in Ghana: healthcare workers knowledge and attitude.

[This corrects the article DOI: 10.3389/fgwh.2022.1021474.].

Causes of death identified in neonates enrolled through Child Health and Mortality Prevention Surveillance (CHAMPS), December 2016 -December 2021.

Each year, 2.4 million children die within their first month of life. Child Health and Mortality Prevention Surveillance (CHAMPS) established in 7 countries aims to generate accurate data on why such deaths occur and inform prevention strategies. Neonatal deaths that occurred between December 2016 and December 2021 were investigated with MITS within 24-72 hours of death. Testing included blood, cerebrospinal fluid and lung cultures, multi-pathogen PCR on blood, CSF, nasopharyngeal swabs and lung tissue, and histopathology examination of lung, liver and brain. Data collection included clinical record review and family interview using standardized verbal autopsy. The full set of data was reviewed by local experts using a standardized process (Determination of Cause of Death) to identify all relevant conditions leading to death (causal chain), per WHO recommendations. For analysis we stratified neonatal death into 24-hours of birth, early (1-<7 days) and late (7-<28 days) neonatal deaths. We analyzed 1458 deaths, 41% occurring within 24-hours, 41% early and 18% late neonatal deaths. Leading underlying causes of death were complications of intrapartum events (31%), complications of prematurity (28%), infections (17%), respiratory disorders (11%), and congenital malformations (8%). In addition to the underlying cause, 62% of deaths had additional conditions and 14% had ≥3 other conditions in the causal chain. The most common causes considering the whole causal chain were infection (40%), prematurity (32%) and respiratory distress syndrome (28%). Common maternal conditions linked to neonatal death were maternal hypertension (10%), labour and delivery complications (8%), multiple gestation (7%), placental complications (6%) obstructed labour and chorioamnionitis (5%, each). CHAMPS' findings showing the full causal chain of events that lead to death, in addition to maternal factors, highlights the complexities involved in each death along with the multiple opportunities for prevention. Highlighting improvements to prenatal and obstetric care and infection prevention are urgently needed in high-mortality settings.

Factors Associated with Ruptured Ectopic Pregnancy: A 10-Year Review at a District Hospital in Ghana.

Background: Approximately 1-2% of all pregnancies are ectopic. Despite a decline in ectopic pregnancy-related mortality, there is still a paucity of information on the factors associated with clinical presentation and outcomes in Sub-Saharan Africa which is essential in determining the most appropriate treatment modalities. Methods: We performed a ten-year retrospective chart review of cases of ectopic pregnancies managed at the Lekma hospital and assessed them for peculiar risk factors, clinical presentation, and outcomes. Associations between patients' sociodemographic characteristics, clinical presentation, and treatment outcome were evaluated using multiple logistic regression and reported as adjusted odds ratios (AOR). The confidence interval (CI) was set at 95%, and a p value <0.05 were considered significant. Results: Over the ten-year period, there were 115 ectopic pregnancies and 14,450 deliveries (7.9/1,000). The mean age ± standard deviation of the 115 patients was 27.61 ± 5.56. More than half of the patients were single (59/115, 51.3%). The majority (71.3%) of the patients presented with a ruptured ectopic pregnancy. After adjusting for covariates, the odds of an ectopic pregnancy presenting as ruptured among single patients was 2.63 times higher than that of married patients (AOR = 3.63, 95% CI: 1.33-9.93, p=0.01). Ectopic pregnancies located in the isthmic region of the tube had a 77% lower odds of presenting as ruptured than those located in the ampullary region (AOR = 0.23, 95% CI: 0.07-0.74, p=0.01). The odds of rupturing were 1.69 times increased for every additional week after the missed period (AOR = 2.69, 95% CI: 1.56-4.64, p < 0.01). No mortalities were reported as a result of an ectopic pregnancy. Conclusion: Most of the cases of ectopic pregnancy presented ruptured. Marital status and period of amenorrhoea were significantly associated with rupture.

Perinatal autopsy in Ghana: Healthcare workers knowledge and attitude.

Background: Perinatal mortality refers to stillbirths and early neonatal deaths. Stillbirth, the death of a foetus from 28 weeks or with a birth weight below 1,000 g, and early neonatal deaths, the death of a new-born within 24 h of delivery, are among the most distressing global health problems, with approximately 2 million stillbirths occurring annually. Although a post-mortem examination of the stillborn baby is essential for understanding and learning the cause of stillbirth, many couples decline the procedure. Sub-Saharan Africa has one of the highest stillbirth rates in the world, yet there is a dearth of studies on post-mortem uptake from the region. Aim: To explore healthcare professionals' views and perceptions of perinatal autopsy in Ghana. Methods: Mixed-method approach consisted of semi-structured interviews and an electronic cross-sectional survey to evaluate the views and perceptions of healthcare professionals at Korle-Bu Teaching Hospital on autopsy for stillbirths and early neonatal deaths. Descriptive quantitative data were summarised in frequencies and percentages, and statistical results and descriptions were tabulated and coded in terms of types of barriers. For the qualitative aspect, the audio-taped interviews were transcribed, themes generated, and direct quotes and descriptions were coded for all knowledge, beliefs, attitudes and practices concerning the barriers and facilitators for post-mortem. Results: Ninety-nine healthcare professionals participated. No participant had formal training regarding counselling for perinatal autopsy and 40% had " no idea " who is responsible for counselling and obtaining consent for a perinatal autopsy. Forty-four percent (44%) of the participants knew of only the "Conventional/ Full" autopsy and <4% were aware of less invasive methods of performing an autopsy. Qualitative data showed healthcare worker influence, religious and financial considerations impede the implementation of perinatal autopsies. Despite the low uptake of perinatal autopsies, interviews from healthcare workers suggest acceptance rates would improve if parents knew about different options, especially less invasive procedures. Conclusion: At Ghana's largest referral centre, perinatal autopsy counselling and uptake are at extremely low levels. Most healthcare professionals have little knowledge, skills, and capacity to advise parents regarding perinatal autopsies. Training is needed to update the workforce on recommended perinatal autopsy practices.

Testicular Sperm Extraction and Intracytoplasmic Sperm Injection in Management of Obstructive Azoospermia: A Two-Year Multicenter Review in Ghana.

Background: The objective of this study was to evaluate treatment outcomes and assess predictors of clinical pregnancy in obstructive azoospermia cases treated with testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) in Ghana. Methods: This study was a retrospective study conducted on 67 men seeking treatment for obstructive azoospermia at two study sites in Ghana from January 2018 to December 2019. First, archived data were reviewed and treatment outcomes of cases of obstructive azoospermia from the hospital records were evaluated. Infertile men who met the inclusion criteria were recruited. Descriptive data were expressed in the form of frequencies and percentages. The dependent and independent variables were analyzed using multiple logistic regression and reported as odds ratios (ORs). The confidence interval (CI) was set at 95% and a p-value <0.05 was considered significant. Results: The mean age of male participants was 42.43±9.11 years (mean±SD) while the mean age of their partners was 32.89±5.73 years (mean±SD). The average duration of infertility before intervention was 5.01±3.60 years (mean±SD). Successful pregnancy was observed in 52.2% (35/67) of the participants. After adjusting for confounders, the rate of a successful clinical pregnancy was 0.07 lower for every additional year increase in the male's age [AOR=0.93 (95%CI=0.87-0.99), p=0.02]. Conclusion: Overall the rate of clinical pregnancy following TESE/ICSI from our study was 52.2%. A man's age was a strong predictor of successful clinical pregnancy among couples treated with TESE-ICSI for obstructive azoospermia in Ghana.

Venous thromboembolism risk and prophylaxis in hospitalized obstetric patients at a tertiary hospital in Accra, Ghana: A comparative cross-sectional study.

OBJECTIVE: To determine the prevalence of venous thromboembolism risk and thromboprophylaxis among obstetric inpatients, comparing prenatal and postnatal women. METHODS: We assessed 546 obstetric inpatients at the Korle-Bu Teaching Hospital for the prevalence study. Out of this number, 223 were recruited, comprising 111 prenatal and 112 postnatal mothers. A structured interviewer-administered questionnaire was used to obtain data on participants' venous thromboembolism risk, which was categorized into high, intermediate, and low using the Royal College of Obstetricians and Gynaecologists guidelines. Data on thromboprophylaxis were also obtained and analyzed. Values were considered statistically significant at p < 0.05. RESULTS: Overall venous thromboembolism risk among the study population was 82/223 (36.8%). All patients at high risk were prenatal, 59/112 (52.7%) of postnatal mothers were at intermediate risk, compared with 20/111 (18.0%) of prenatal women (p < 0.001). Prevalence of thromboprophylaxis was 5/82 (6.1%). All prenatal high-risk patients received thromboprophylaxis, whereas only 2/20 (10.0%) of women with intermediate risk received thromboprophylaxis. The incidence of venous thromboembolism was 3/546 (0.6%) in the obstetric inpatients. CONCLUSION: Our study found a high prevalence of venous thromboembolism risk among obstetric inpatients at the Korle-Bu Teaching Hospital. However, thromboprophylaxis was low. Further research is needed to audit recent practice of thromboprophylaxis and perinatal outcome.

Cerebro-placental ratio as a prognostic factor of fetal outcome in pregnancy complicated by maternal sickle cell disease.

OBJECTIVES: To assess the role of the cerebro-placental ratio (CPR) in predicting adverse fetal outcomes among women with sickle cell disease (SCD). METHODS: A prospective cohort study at Korle-Bu Teaching Hospital, Accra, Ghana, between January and June 2016. Pregnant women with SCD at 34 gestational weeks or more underwent weekly fetal umbilical and middle cerebral artery Doppler assessment until delivery. Participants were categorized into two study arms based on CPR (<1.1 or ≥1.1). The primary outcome, a composite of adverse perinatal outcomes including intrauterine growth restriction, stillbirth, low birthweight, and neonatal intensive care unit admission, was compared between groups. RESULTS: Overall, 48 pregnant women with SCD were enrolled, and 5 had a fetus with CPR less than 1.1. Low CPR (<1.1) had a sensitivity and specificity of 29.4% and 100%, respectively, for predicting composite adverse perinatal outcomes. Sensitivity and specificity were, respectively, 100% and 93.5% for predicting stillbirth, and 40.2% and 97.4% for predicting low birthweight. Perinatal outcomes did not differ between the two major sickle cell genotypes (hemoglobin SS and hemoglobin SC). CONCLUSIONS: Among women with SCD, CPR less than 1.1 was associated with adverse perinatal outcomes, particularly low birthweight and stillbirth.

Oesophageal corrosive injuries in children: a forgotten social and health challenge in developing countries.

PROBLEM: An unsafe environment is a risk factor for child injury and violence. Among those injuries that are caused by an unsafe environment, the accidental ingestion of corrosive substances is significant, especially in developing countries where it is generally underreported. APPROACH: To address this challenging, unmet medical need, we started a humanitarian programme in Sierra Leone. By reviewing the current literature from developing countries and our own experience in the field, we developed a flowchart for management of this clinical condition. LOCAL SETTING: This injury is underreported in developing countries. Data available are heavily skewed towards well-resourced centres and do not reflect the entire reality of the condition. Late oesophageal strictures are usually severe. Parent's lack of knowledge, crowded living conditions and availability of chemicals in and around houses account for most ingestions. The widespread lack of any preventive measures represents the strongest risk factor. RELEVANT CHANGES: Timely admission was observed in 19.5% of 148 patients studied. A gastrostomy was performed on 62.1% of patients, 42.8% had recurrent strictures and 19% are still on a continuous dilatation programme. Perforation and death rate were respectively 5.6% and 4%. LESSONS LEARNED: The majority of oesophageal caustic strictures in children are observed late, when dilatation procedures are likely to be more difficult and carry a significantly higher recurrence rate. Gastrostomy is necessary to maintain adequate nutritional status but mothers need training in feeding techniques. Both improvement in nutritional status and sustained oesophageal patency should be the reference points to a successful dilatation.

Diagnostic and Management Challenges of Caesarean Scar Ectopic Pregnancy in a Lower Middle Income Country.

Caesarean scar ectopic pregnancy is defined as the implantation of the blastocyst in a previous Caesarean scar. It is a rare type of ectopic pregnancy. The incidence is however rising due to the increasing rates of Caesarean sections as well as in-vitro fertilization embryo-transfer. It can be diagnosed early by ultrasound. This remains a challenge in lower middle income countries where the availability of high resolution ultrasound and the skill for such sonography may be lacking. Misdiagnosis or a delay in diagnosis often leads to poor treatment outcomes. We present a case of a gravida 3 para 2 + 0 who had laparotomy for a caesarean scar pregnancy and highlight the challenges associated with diagnosis and management of this rare ectopic pregnancy in a lower middle income country.

Two cases of Pentalogy of Cantrell diagnosed antenatally at Korle Bu Teaching Hospital, Accra.

Pentalogy of Cantrell is a rare congenital malformation syndrome that may be associated with other congenital anomalies. The syndrome is said to affect males and females in equal numbers and the prognosis is generally poor. We report two cases of Cantrell's Pentalogy diagnosed antenatally at the Korle Bu teaching Hospital. The 2 cases described in this report demonstrate the complete and incomplete variant of the syndrome. The cases were referred as an omphalocoele and a detailed anomaly scan confirmed the diagnosis of Pentalogy of Cantrell. Both cases were females and neither survived beyond 24 hours. Although this condition is associated with a poor prognosis, there have been some reported cases of survival in the literature. Thus, accurate prenatal diagnosis and a multidisciplinary approach to the management may offer improved outcomes.

Fetal middle cerebral artery Doppler indices and clinical application at Korle Bu Teaching Hospital, Accra, Ghana.

OBJECTIVE: To determine normal ranges for various Doppler flow velocity indices of the fetal middle cerebral artery (MCA) and their trends in normal pregnancies at Korle Bu Teaching Hospital, Accra, Ghana. METHODS: A prospective cross-sectional study was conducted at Korle Bu Teaching Hospital in 2015. Included women had a singleton pregnancy of 20-40weeks' duration, dated using an early ultrasonography scan, and normal fetal growth. Interviews were conducted to collect data on sociodemographic characteristics, followed by Doppler ultrasonography of the MCA. The resistive index, pulsatility index, systolic-to-diastolic ratio, and peak systolic velocity of the MCA were determined for all participants. RESULTS: Overall, 458 pregnant women were recruited. The peak systolic velocity increased with advancing gestational age and a positive correlation of r=0.725 (P<0.001) was demonstrated between the peak systolic velocity and the gestational age. The resistive index, pulsatility index, and systolic-to-diastolic ratio of the MCA decreased with advancing gestational age in a parabolic pattern. CONCLUSION: The reference curve for the peak systolic velocity increases with gestational age, whereas the other indices decrease in a parabolic pattern.