Beyond severe acute maternal morbidity: a mixed-methods study on the long-term consequences of (severe pre-)eclampsia in rural Tanzania.

OBJECTIVES: To explore the long-term (perceived) consequences of (severe pre-)eclampsia in rural Tanzania. METHODS: Women were traced for this mixed-methods study 6-7 years after the diagnosis of (severe pre-)eclampsia. Demographic and obstetric characteristics were noted, and blood pressure was recorded. Questionnaires were used to assess physical and mental health. The qualitative part consisted of semi-structured interviews (SSI). A reference group consisted of women without hypertensive disorders of pregnancy. RESULTS: Of 74 patients, 25 (34%) were available for follow-up, and 24 were included. Five (20%) had suffered from (pre-)eclampsia twice. Hypertension was more common after (pre-)eclampsia than in the reference group (29% vs. 13%). Thirteen women (56%) had feelings of anxiety and depression, compared to 30% in the reference group. In SSIs, experiences during the index pregnancy were explored, as well as body functions, reproductive life course and limitations in daily functioning, which were shown to be long-lasting. CONCLUSIONS: Women who suffered from (severe pre-)eclampsia may experience long-term sequelae, including hypertension, depression and anxiety. Women lack information about their condition, and some are worried to conceive again. To address their specific needs, a strategy along the continuum of care is needed for women following a complicated pregnancy, starting with a late postnatal care visit 6 weeks after giving birth.

OBJECTIFS: Explorer les conséquences à long terme (perçues) de la (sévère pré-) éclampsie en zone rurale, en Tanzanie. MÉTHODES: Les femmes ont été suivies pour cette étude à méthodes mixtes durant 6 à 7 ans après le diagnostic de (sévère pré-) éclampsie. Les caractéristiques démographiques et obstétriques ont été notées et la pression artérielle a été enregistrée. Des questionnaires ont été utilisés pour évaluer la santé physique et mentale. La partie qualitative consistait en des entretiens semi-structurés (ESS). Un groupe de référence était composé de femmes sans troubles hypertensifs de la grossesse. RÉSULTATS: Sur 74 patientes, 25 (34%) étaient disponibles pour le suivi et 24 ont été incluses. Cinq (20%) avaient souffert de (pré-) éclampsie à deux reprises. L'hypertension était plus fréquente après la (pré-) éclampsie que dans le groupe de référence (29% vs 13%). Treize femmes (56%) avaient des sensations d'anxiété et de dépression, contre 30% dans le groupe de référence. Dans les ESS, les expériences au cours de la grossesse indice ont été explorées, ainsi que les fonctions corporelles, le cours de la vie reproductive et les limitations du fonctionnement quotidien, qui se sont révélées durables. CONCLUSIONS: Les femmes qui ont souffert de (sévère pré-) éclampsie pourraient éprouver des séquelles à long terme, y compris l'hypertension, la dépression et l'anxiété. Les femmes manquent d'informations sur leur état et certaines ont peur de concevoir à nouveau. Pour répondre à leurs besoins spécifiques, une stratégie tout au long du continuum des soins est nécessaire pour les femmes à la suite d'une grossesse compliquée, en commençant par une visite de soins postnatals tardive six semaines après l'accouchement.

Association between surgical technique, adhesions and morbidity in women with repeat caesarean section: a retrospective study in a rural hospital in Western Tanzania.

BACKGROUND: The worldwide incidence of birth by Caesarean Section (CS) is rising. Many births after a previous CS are by repeat surgery, either by an elective CS or after a failed trial of labour. Adhesion formation is associated with increased maternal morbidity in patients with repeat CSs. In spite of large-scale studies the relation between the incidence of adhesion formation and CS surgical technique is unclear. This study aims to assess maternal and neonatal morbidity and mortality after repeat CSs in a rural hospital in a low-income country (LIC) and to analyse the effect of surgical technique on the formation of adhesions. METHODS: A cross-sectional, retrospective medical records study of all women undergoing CS in Ndala Hospital in 2011 and 2012. RESULTS: Of the 3966 births, 450 were by CS (11.3%), of which 321 were 1st CS, 80 2nd CS, 36 3rd CS, 12 4th and one 5th CS (71, 18, 8, 3 and 0.2% respectively). Adhesions were considered to be severe in 56% of second CSs and 64% of third CSs. In 2nd CSs, adhesions were not associated with closure of the peritoneum at 1st CS, but were associated with the prior use of a midline skin incision. There was no increase in maternal morbidity when severe adhesions were present. Adverse neonatal outcome was more prevalent when severe adhesions were present, but this was statistically non-significant (16% vs 6%). CONCLUSIONS: Our results give insight into the practice of repeat CS in our rural hospital. Adhesions after CSs are common and occur more frequently after midline skin incision at 1st CS compared to a transverse incision. Reviewing local data is important to evaluate quality of care and to compare local outcomes to the literature.

A cohort of women with ectopic pregnancy: challenges in diagnosis and management in a rural hospital in a low-income country.

BACKGROUND: Ectopic pregnancy (EP) is a serious complication of early pregnancy. In low-income countries diagnosis of EP is difficult and it is a major contributor to maternal mortality. We aimed to assess and improve the diagnostic process of women with EP. METHODS: We conducted a retrospective medical records study of all women with confirmed EP in Ndala Hospital from 2010 to 2012. We used data on demographics, symptoms, diagnostic procedures, surgical findings, treatment and post-operative status. RESULTS: Six thousand six hundred sixty-two women gave birth in the hospital, and 88 women were diagnosed with EP (incidence 1.3%). Thirty-nine percent of women did not report to be pregnant or to have a history of amenorrhea. On admission in Ndala hospital, a diagnosis of 'suspected EP' was made in less than half (47%) of the cases. Most women had a urine pregnancy test done (sensitivity of 98%). Peritoneal aspiration was done in 42%. The fifty-five women with EP who were diagnosed by ultrasound received a lower mean number of units of blood transfusion and had less often severe anaemia than women who were diagnosed by abdominal aspiration (abdominocentesis). The majority of women (65%) had surgery within 24 h after admission. CONCLUSIONS: Diagnosing EP in a rural hospital in Tanzania is challenging. Often there is a large doctors' delay before the right diagnosis is made. Abdominal aspiration can be useful for rapid diagnosis. A pelvic ultrasound, when available, allows the diagnosis to be made earlier with less intra-abdominal bleeding.

Antenatal corticosteroid therapy for foetal maturation in women with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania.

BACKGROUND: Preterm birth is a major cause of neonatal mortality, especially in low and middle income countries. Antenatal corticosteroid therapy for foetal maturation could have a significant impact and therefore is often referred to as an important strategy to reduce neonatal mortality. A recently conducted large multinational trial showed that antenatal corticosteroids can have adverse effects in low income countries, but this is likely to depend on the specific setting. In our hospital preterm birth is only recognized in patients with severe maternal disease, due to physician-initiated delivery. Spontaneous preterm births are rarely seen in the hospital and often take place in the community or while on the road to a health facility. OBJECTIVE: To investigate the effects of antenatal corticosteroid therapy in a rural hospital in Tanzania. METHODS: A secondary analysis of a retrospective medical records study of women with severe pre-eclampsia and eclampsia performed in Ndala Hospital between July 2011 and December 2012. We used data on gestational age, birth weight, Apgar score, time between admission and birth, use of corticosteroids and maternal and foetal survival. Ethical clearance was obtained from the directorate of research and publications of the University of Dodoma (ref. UDOM/DRP/346). RESULTS: Thirty-six women with forty live foetuses were analysed. Twelve women (13 neonates) were given corticosteroids and could be compared to 24 women (27 neonates) who did not get corticosteroids. The incidence of fresh stillbirths (antenatal death) was 20 %. The 13 neonates who received corticosteroids had significantly smaller birth weight, longer interval between admission and delivery and poorer outcomes (stillbirth and neonatal death). An analysis of 24 neonates with a birth weight between 1.5 and 2.5 kg showed a trend toward better outcome in neonates who did not receive antenatal corticosteroid therapy. CONCLUSION: Small retrospective studies as these have a low level of evidence, but this study helped to gain more knowledge of local conditions affecting the effectiveness of antenatal corticosteroid therapy in our setting of a small rural hospital. Reliability of estimating gestational age, epidemiology of preterm birth, exposure to infections, foetal monitoring and quality of neonatal care are likely to influence the effect of antenatal corticosteroid therapy. Further larger prospective studies should be conducted to determine the exact preconditions of antenatal corticosteroid therapy in low-income countries. Until that time, the WHO precautions seem reasonable and audits and small observational studies like ours can help in assessing whether a specific hospital is suited for antenatal corticosteroid therapy.

A language for generating tomographic images of mathematical phantoms.

A computer language is presented that can be used to generate image files, as if the images are created with a CT or a MR scanner. The language defines objects in the "scanner's" coordinate system, as sets of quadratic inequalities. Each of these objects, e.g., an ellipsoid or a half-plane or a cylinder, has its own density. Objects can be superimposed and collections of objects are allowed to translate and rotate. The language allows for a concise way of describing complex objects with precisely defined geometries and densities. An implementation of the language can be used for testing, developing, and analyzing diagnostic software, treatment planning systems, etc. A software module that is based on the language can be made available. The utility of the module for acceptance testing of radiation therapy treatment planning systems is described.

Gamma knife radiosurgery for trigeminal neuralgia: dose-volume histograms of the brainstem and trigeminal nerve.

OBJECT: The purpose of this study was to assess the relationship between the volume of brainstem that receives 20% or more of the maximum dose (VB20) and the volume of the trigeminal nerve that receives 50% or more of the maximum dose (VT50) on clinical outcome following gamma knife radiosurgery (GKS) for trigeminal neuralgia (TN). METHODS: Patients with TN were treated with a single 4-mm isocenter with a maximum dose of 75 Gy directed at the trigeminal nerve close to where it leaves the brainstem. The VB20 and VT50, as determined on dose-volume histograms, were correlated with clinical outcomes at 6 and 12 months, laterality, presence of multiple sclerosis (MS), and each other. At 6 months excellent pain relief (no pain or required medicine) was achieved in 27 of 48 patients (p = 0.009) when VB20 was greater than or equal to 20 mm3 and in 25 of 78 when VB20 was less than 20 mm3, when all patients are considered. At 12 months excellent pain relief was achieved in 16 of 32 patients (p = 0.038) when VB20 was greater than or equal to 20 mm3 and in 14 of 52 when VB20 less than 20 mm3, when all patients are considered. When VB20 was less than 20 mm3 in MS patients, five of 21 had an excellent result at 6 months and two of 13 at 12 months. The VB20 was 20 mm3 or more in 38 of 64 on the right side and in eight of 41 on the left side (p < 0.001) in patients with TN and without MS. There is a difference between left and right dose-volume histograms even when the same isodose is placed on the surface of the brainstem. The VB20 was 20 mm3 or more in 45 of 105 patients with TN and without MS but in only three of 21 patients with TN and MS (p = 0.014). There was an inverse relationship between VB20 and VT50 (p = 0.01). CONCLUSIONS: Isocenter proximity to the brainstem, as reflected in a higher VB20, is associated with a greater chance of excellent outcome at 6 and 12 months. Worse results in patients with TN and MS may be partly explained by a lower VB20.

Tissue-air ratios for narrow 60Co gamma-ray beams.

This study introduces a table of tissue-air ratios (TAR) for narrow 60Co gamma-ray beams. The table is consistent with recently published TAR data for broad 60Co gamma-ray beams [Table 4.1, Br. J. Radiol. Suppl. 25 (1996)]. Narrow-beam TARs are derived analytically from broad-beam data of Table 4.1 and are tabulated for circular fields ranging from 0.2 to 2.2 cm in radius--an approximate equivalent of a 0.4 cm x 0.4 cm to 4 cm x 4 cm square-field range. The extent of depth is from 0.5 to 30 cm in water.

An approximation of central-axis absorbed dose in narrow photon beams.

In narrow photon beams of therapeutic energy range, the absorbed dose derived from experimental measurements is subject to a significant error. The error stems from high dose gradients characteristic to small radiation fields and from finite probe dimensions. In this study, a simple model for the narrow-beam absorbed dose is described. It is shown that broad-beam dose data are sufficient to predict a narrow-beam dose. The dose is calculated as a sum of primary and scatter components given in the form of respective analytical functions. For both functions, numerical coefficients are determined in broad-beam geometry. The model is evaluated by comparing calculated dose values with the Monte Carlo simulated narrow-beam dose data for 6 and 15 MV x rays.

The elements of tissue-air ratio and systematic error.

The definition of tissue-air ratio (TAR) is based on the concept of primary dose. To determine TAR, both in-phantom and in-air ionization measurements are utilized. To convert ionization in the phantom into dose and that in air into primary dose, correction factors must be applied to chamber readings in both geometries. Due to difficulties in selecting proper correction factors, TAR is subject to systematic error. The error comes from two sources of uncertainty: (1) Primary dose cannot be measured. Therefore approximate methods, such as in-air ionization measurements, are used. (2) Detectors of ionization are of finite dimensions and they are inhomogeneous. In this study, analytical expression for a systematic error is derived. Because in this derivation systematic error is an accumulative error, it is no longer necessary to convert ionization, both in air and in phantom, into a dose when calculating TARs. A method of determining systematic error is described. This method is based on the ability to produce accurate zero-field data in photon beams by means of a linear extrapolation technique. Using 60Co gamma radiation in water as an example, it is shown how to generate TAR data free of systematic error. A possibility of determining TARs for therapeutic x rays is discussed.