Complications associated with cesarean section in HIV-infected patients.

OBJECTIVE: To document complications associated with cesarean section in HIV-infected women. METHOD: A cross-sectional study was done on 307 women who delivered by cesarean section. All these patients, irrespective of their HIV-status, were managed according to the same preset protocol. RESULT: Of the 307 women, 59 (19%) were HIV-positive. The only significant differences were a higher prevalence of positive serology for syphilis (32% vs. 12%, P=0.0014) as well as more cases of post-operative endometritis in the HIV-positive group (24% vs. 7%, P=0.0003). Post-operative endometritis was documented in 44% of HIV-infected patients with a CD4 count below 400. However, the severity of endometritis, measured by antibiotic treatment and duration of hospital stay, was similar in the two groups. Overall, there was no difference in the duration of hospital stay, post-operative anemia, wound infection, birth weight and perinatal mortality between the two groups. CONCLUSION: HIV-infected patients undergoing cesarean section are at increased risk for post-operative endometritis, but the severity of the infection is not different from that in HIV-negative patients.

Screening for cervical neoplasia in a developing country utilizing cytology, cervicography and the acetic acid test.

OBJECTIVE: To compare three screening tests for cervical neoplasia. METHOD: Women (6301) were screened simultaneously with cytology, cervicography and the acetic acid test (AAT). Biopsies were taken from the acetowhite lesions and every fifth seemingly normal cervix. Positive cases (both at screening and histology) were referred for colposcopy. The histology results served as the golden standard. RESULTS: Cytology was positive in 1.7% of cases, cervicography in 10.7% and the AAT in 17.8%. The sensitivity of cytology was 19.3%, of cervicography 41.8% and the AAT 49.4%. Corresponding specificities were 99.3%, 78.8% and 48.5%. In 23% of biopsies showing cervical intraepithelial neoplasia (grade I--III), all three screening tests were negative. By combining the three tests, a sensitivity of 76.9% was achieved. CONCLUSION: The sensitivity of cytology alone is not great enough for implementing as a screening test in a developing country where screening programs are often inadequate. Screening with a combination of tests, once or a few times per woman's life, is a more acceptable alternative since it allows for less screening events without sacrifying sensitivity.

Vaginitis, cervicitis, and cervical length in pregnancy.

OBJECTIVE: We sought to determine the possible association among vaginitis, cervicitis, and cervical length in pregnancy. STUDY DESIGN: Primigravid volunteers, between 20 and 36 weeks' gestation (n = 210), were examined. Vaginitis was diagnosed by pH determination and wet mount smear, cervicitis was diagnosed by cervicography, and cervical length was diagnosed by vaginal ultrasonographic measurement. Patients with both vaginitis and cervicitis (n = 70) were compared with those without any trace of infection (n = 23). The remainder (n = 117) had variable degrees of infection and were excluded. RESULTS: The mean gestational age was 28.3 weeks. No significant association was found among vaginitis, cervicitis, and cervical length. In the infection group (n = 70), however, a significant association between an elevated vaginal pH (>5) and a shortened cervical length (r = 0.29) was noted. CONCLUSION: No significant association exists among vaginitis, cervicitis, and cervical length, but in patients with clinical signs of infection, an elevated pH appears to be associated with a decreased cervical length.

Review of the granulosa-theca cell tumors from the emil Novak ovarian tumor registry.

OBJECTIVE: Our purpose was to review patients with granulosa and theca cell tumors as filed in the Emil Novak Ovarian Tumor Registry. STUDY DESIGN: Our study was a descriptive, retrospective study of 454 case records. RESULTS: The reviewed diagnoses were for 97 patients with granulosa cell tumors, 116 with theca cell tumors, and 97 with granulosa-theca cell tumors. The remaining cases (n = 144) were reclassified as "nonspecific" gonadal stromal tumors (n = 61), luteomas of pregnancy (n = 7), and 76 "other" cases. These included poorly differentiated cancer, metastatic cancer, mixed mesodermal tumors, and sarcomas. The tumor-related mortality rate for the 310 patients with granulosa, theca, and granulosa-theca cell tumors was 7% (37.3% for granulosa cell tumors only). The surgical stage of disease was the most significant prognostic factor, with a mortality rate of at least 40%, given that the tumor had spread beyond the ovary. CONCLUSION: Because the differential diagnoses of particularly granulosa cell tumors included several conditions with an extremely poor prognosis, an accurate histologic diagnosis is crucial.

Granulosa and theca cell tumors in children: a report of 17 cases and literature review.

The files of the Emil Novak Ovarian Tumor Registry (ENOTR) were searched for granulosa and theca cell tumors in children aged 12 years and less. In addition, an extensive literature search was done for English publications on children with these tumors aged 10 years or less. Of the 17 children from the ENOTR, 5 had adult-type granulosa cell tumors, 6 had juvenile granulosa cell tumors, and 1 had a luteinized granulosa cell tumor. In addition, there were three cases with gonadal stomal tumors, one theca cell tumor, and one granulosa-theca cell tumor. Precocious pseudopuberty was present in 70 percent of the children, abdominal pain in 24 percent, and ascites in 18 percent. The literature review revealed a tumor-related mortality rate of 9 percent (based on 163 cases with granulosa cell tumors, including the juvenile type). Some of these tumors are large with acute pain, but nevertheless, the prognosis is good, particularly in cases with precocious puberty. Treatment can be conservative.

Effects of dilute acetic acid on the cervical smear.

OBJECTIVE: To evaluate the effect of 5% acetic acid on the cells and cellular content of cervical smears. STUDY DESIGN: A randomized, controlled trial was performed with 42 patients in each group. The study group received acetic acid application to the cervix followed by a smear, while the sequence was reversed in the control group. Cytologic evaluation of the smears was done without knowledge of the group allocation in each case. RESULTS: The group in which acetic acid was applied before the smear was taken showed significantly poorer staining properties of the smear (P < .0001) and also significantly lower cellular content (P = .0006). CONCLUSION: Acetic acid has adverse effects on the cervical smear and should be applied after the smear is taken.

Cardiac disease during pregnancy--a Free State perspective on maternal morbidity and mortality.

AIM: Description of maternal outcome of pregnancies complicated by cardiac disease. SETTING: Pelonomi Hospital, Bloemfontein. POPULATION: Black African women of low socio-economic background who presented with cardiac disease during pregnancy. SAMPLE: All patients who delivered from 1 January 1990 to 1 January 1995. DESIGN: Descriptive retrospective study. RESULTS: Cardiac disease complicated 0.6% of pregnancies. Rheumatic valvular disease dominated in this population. The maternal mortality rate was 9.5% while the maternal morbidity rate ranged from 50% to 100% for the various lesions. CONCLUSIONS: Cardiac disease in pregnancy has high maternal mortality and morbidity rates. Hypertension, anticoagulation therapy, late referrals and inadequate counselling were important contributing factors. A high priority should be given to meticulous contraceptive counselling in patients with cardiac disease. Collaboration between obstetricians, physicians and cardiothoracic surgeons in imperative.

Reregistration of gynaecologists in South Africa--results of a 1-year trial run.

OBJECTIVE: Evaluation of an Australian system of reregistration with recommendations for a possible future South African system. DESIGN: Cohort descriptive study. SETTING: Gynaecologists from both private and full-time academic practices. PARTICIPANTS: One hundred and eighty volunteers participated for a period of 1 year. INTERVENTION: Each participant had to obtain a minimum of 25 points and an additional subminimum in at least two of the following practice-related categories: audit, continuing medical education (CME), self-study and research or tuition. OUTCOME MEASURES: Compliance with the rules of the system and participants' comments. RESULTS: Ten of the 180 volunteers withdrew from the study. Only 42% of the remaining 170 participants returned their logbooks and a mere 32% their self-study questionnaires. The majority were in favour of self-study programmes or CME as future methods of reregistration. CONCLUSION: A future system of reregistration must be based on self-study programmes and a well-structured and relevant CME curriculum.

Maternal deaths in Bloemfontein, South Africa--1986-1992.

OBJECTIVE: Determination of the maternal mortality ratio and the main causes of maternal death. SETTING: Pelonomi Hospital, a tertiary care and referral hospital in Bloemfontein. METHODS: Review of prospectively completed structured questionnaires on all maternal deaths from 1986 to 1992. RESULTS: The maternal mortality ratio at our institution was 171 per 100 000 live births. Haemorrhage (25%), infection (24%) and hypertensive disease (18%) were the most important causes of death. Seventy-one per cent were direct obstetric deaths and 23% indirect; in the remaining 6%, the cause was uncertain. Of all deaths, 35% were considered preventable. CONCLUSIONS: The maternal mortality ratio has decreased since our previous report for the period 1980-1985, and haemorrhage has replaced infection as the leading cause of death.

Utilisation of maternity services by black women in rural and urban areas of the Orange Free State.

An epidemiological survey was undertaken to evaluate the utilisation of maternal services for black women in the Orange Free State. Two hundred and forty clusters were selected from the rural (farms) and urban (local authorities) black population and eight households were interviewed in each cluster. Information was gathered from 237 rural women (from 959 households) and 168 urban women (from 926 households) who had delivered a baby or aborted during the preceding year. Antenatal care was received by 71% of the rural women and 87% of the urban women. Rural women delivered at home in 60% of cases while 37% delivered in hospitals. Only 23% of urban women delivered at home while 67% of their deliveries were conducted in hospitals. Nurses supervised deliveries in both instances in more than 60% of cases, but in rural areas traditional midwives managed 26% of the confinements. The conclusions are that the maternity service was largely provided by nurses and was predominantly limited to hospitals and homes. It is recommended that the quality of service be upgraded and more emphasis placed on midwife obstetric units.

Reregistration of gynaecologists in South Africa--the profession's opinion.

OBJECTIVE: Testing of the profession's opinions and attitudes with regard to a possible reregistration system. METHODS: A questionnaire was sent to all the gynaecologists in South Africa to test their opinions and attitudes with regard to reregistration. RESULTS: After two mailings, 62.4% of the 603 gynaecologists had responded. Seventy per cent of the respondents were in private practice while 19% were in full-time academic positions. More than two-thirds (68%) of the respondents resided in a city, close to a medical school. Although 74% were in favour of the implementation of a reregistration system, only 56% were enthusiastic about it. Congress attendance and self-study programmes were the categories in which more than 85% of the respondents would be able to earn points. The general feeling was that such a system should be governed by the profession. CONCLUSIONS: The profession was in favour of a system of reregistration, but great concern was expressed at the contents of such a programme and the manner in which it would be governed.

Prevalence of vaginitis, syphilis and HIV infection in women in the Orange Free State.

OBJECTIVE: To determine the prevalence of vaginitis, syphilis and HIV infection in women in the Orange Free State. METHOD: By cluster sampling, 120 rural (farm) and 120 urban (local authority) clusters, each containing 4 women, were selected. Women aged 18-49 years who were included in the study had a cervical smear taken for cytological evaluation and blood specimens drawn for syphilis and HIV testing; they were questioned on their knowledge of AIDS. RESULTS: Trichomonas vaginalis vaginitis was present in 27.4% of the rural women and 29.6% of the urban women, Gardnerella vaginalis in 7.2% and 8.4% and Candida spp. in 2.6% and 6.7% respectively. Syphilis serology was positive in 12% of rural and 16% of urban women. HIV was present in 0.4% of rural and 1.5% of urban women. Ninety per cent of urban women and 74% of rural women knew AIDS was a sexually transmitted disease. CONCLUSIONS: The prevalences of trichomonas vaginitis and syphilis were unusually high, while HIV positivity was similar to that in other reports in South Africa.

Vaginal delivery after one cesarean section.

OBJECTIVE: To determine the success rate and safety of vaginal delivery after a previous cesarean section in a South African teaching hospital serving a developing community. METHOD: One hundred eighty-nine women with a history of one previous cesarean section were studied during a 10.5-month period. Maternal morbidity was studied in 92 of these patients who had infants weighing 2500 g or more. During the study period 5044 women delivered at the hospital. RESULTS: In the study group of 189 women, 85 (44.9%) delivered vaginally, 65 (34.4%) by cesarean section during labor and 39 (20.6%) had elective cesarean sections. One maternal and two perinatal deaths occurred. In the subgroup of 92 women with babies weighing 2500 g or more at birth, 10 women (10.9%) experienced morbidity related to trial of scar. CONCLUSION: Vaginal birth was accomplished less often in this population compared with reports from developed countries, but the procedure was equally safe.

Syphilis in pregnant patients and their offspring.

OBJECTIVES: To determine the prevalence of syphilis in antenatal women and their babies at birth. METHODS: A cross-sectional study was made of 1508 women who delivered consecutively at Pelonomi Hospital, Bloemfontein. The initial test on each mother was a rapid plasma reagin test (RPR). If reactive, it was followed by a venereal disease research laboratory test (VDRL) and a confirmative Treponema pallidum hemagglutination test (TPHA). Cord blood was tested by a RPR test. Babies with reactive tests were examined clinically, and in addition the cord blood was tested with the VDRL test as well as the enzyme linked immunosorbent assays (ELISA) for IgG and IgM. RESULTS: At delivery the data on 1476 mothers and 1399 babies were available for analysis. Sixty-five percent of the mothers had attended antenatal clinics at least once and 17% of them had tested positive for syphilis. Only 22% of these patients had been completely treated. At delivery 15% of the mothers (including women without antenatal care) tested positive for syphilis and 8% of the babies had a reactive RPR test. Clinical stigmata of congenital syphilis were evident in 15% of these babies. CONCLUSIONS: An extremely high prevalence of syphilis (15%) was documented, as well as a major deficiency in the treatment program of these patients.

Validity of symphysis fundus growth measurements.

OBJECTIVES: Evaluation of symphysis fundus measurements in a large antenatal clinic. METHODS: The obstetrical records were reviewed for all patients that had delivered over a 3-month period. From this group of 1455, a sample of 386 was taken that had a singleton pregnancy, had booked before 24 weeks' gestation and had attended the antenatal clinic at least twice. The study group comprised 65 patients with less than expected symphysis fundus growth and a control group of 249 in whom growth seemed adequate. The remaining 72 subjects' files were either incomplete or the interobserver variation of the symphysis fundus measurements at the end of pregnancy seemed too high. RESULTS: Deficient intra-uterine growth, as shown by the symphysis fundus measurements, was significantly associated with both low birthweight (< 2500 g) (odds ratio 3.02) and intra-uterine growth retardation (IUGR) (odds ratio 3.43), but no association was found with perinatal mortality. The sensitivity for detecting IUGR was 42%. CONCLUSIONS: Symphysis fundus measurements, as made in our antenatal clinic, seem of limited value. We propose that the number of observers be restricted in order to decrease the interobserver variation.