Designing the Future of Medical Education: The EPA Framework as a Catalyst to Inform Family Planning and Reproductive Health Fellowship Training Program in Ethiopia Medical Education: An Exploratory Sequential Mixed Method Study.

Introduction: Entrustable Professional Activities (EPAs) are tasks or responsibilities within a specific field that can be given to a learner once they are competent to perform them independently. EPAs are being used in various specialty programs and serving as valuable tool to inform educational program. However, due to disparities in professional practice between different contexts, the automatic transfer of a set of core EPAs is not feasible. Hence, our study aims to develop an EPA framework to inform the Family Planning and Reproductive Health Fellowship Program in the local context of Ethiopia. Methods: We employed an exploratory mixed-method design, which involved the collection of qualitative data using the Nominal Group Technique and quantitative data through a nationwide survey in all residency training institutions across the country. Qualitative data analysis involved several steps, including compiling a list of tasks, removing duplicate tasks, reviewing EPAs using criteria and an equal rubric tool. For quantitative data analysis, descriptive statistics, validity index analysis, and intra-class correlation coefficients, were used. Results: Seven senior panelists were able to propose a total of 57 EPAs, with 17 remaining after qualitative data analysis. The panelist evaluated the relevance of each EPA in the second phase. As a result, 17 EPAs received a content validity index of >0.83, indicating satisfactory relevance. In the national survey, experts reached a high level of final agreement regarding the relevance and representativeness of all 17 EPAs (ICC = 0.815, 95% CI [0.0.756,0.865], p.0001). Conclusion: The final set of 17 end-of-training EPAs is valid, acceptable and representative of the discipline, and they can be used as a framework to inform Family planning and Reproductive Health Fellowship Program in Ethiopian medical education once these core EPA statements are described in sufficient detail. This can contribute to raise the quality of training and hence the quality of patient care.

Second-trimester dilatation and evacuation: Comparison of routine intraoperative ultrasonography versus problem-based intraoperative ultrasonography in reducing procedure-related complications: A pre-post study.

OBJECTIVE: To investigate whether routine intraoperative ultrasonographic guidance during second-trimester dilatation and evacuation (D&E) reduces procedure-related complications in an Ethiopian setting. METHODS: We conducted a pre-post study on routine ultrasonography during second-trimester D&E at St. Paul's Hospital Millennium Medical College (Ethiopia). Second-trimester D&E cases that were managed at the hospital between 2017 and 2022 were retrospectively analyzed by grouping them into an intervention group (using routine ultrasound intraoperatively for all cases) and a non-intervention group (problem-based intraoperative use of ultrasound, where ultrasound was used in problem cases only). SPSS version 23 was used for analysis and simple descriptive statistics, χ2 test, multivariate regression analysis, and Fisher exact test were performed as appropriate. P values less than 0.05 and odds ratio with 95% CI were used to present the results' significance. RESULTS: A total of 242 second-trimester D&E cases were analyzed (84 cases managed under routine intraoperative ultrasound guidance and 158 cases managed with a problem-based intraoperative use of ultrasound). Compared with problem-based intraoperative use of ultrasound (using it only in selected cases), routine intraoperative ultrasound use was not associated with a decrease in D&E complications (adjusted odds ratio [aOR] 0.22, 95% confidence interval [CI] 0.04-1.16). The two factors associated with increased D&E procedure complications were advanced gestational age (aOR 13.52, 95% CI 1.86-98.52), and need for additional mechanical cervical dilatation during the D&E procedure (aOR 9.53, 95% CI 1.32-69.07). Provider experience, cervical preparation methods (laminaria vs Foley), and maternal age were not associated with occurrence of D&E complications. CONCLUSION: Our study does not support the preference of routine intraoperative ultrasound guidance over problem-based (in selected cases) intraoperative ultrasound use during the second-trimester D&E procedure. More research is needed to make a strong clinical recommendation on using routine intraoperative ultrasound guidance during all second-trimester D&E procedures.

Localization and removal of nonpalpable contraceptive implants: Experience from a teaching hospital in Ethiopia: A case series.

OBJECTIVE: To assess the outcome of women presenting with nonpalpable contraceptive implants to a referral center in Ethiopia. In addition, we discuss our approach and experience with localization and removal of nonpalpable contraceptive implants. METHODS: We conducted a facility-based retrospective review of patients evaluated for a nonpalpable contraceptive implant between September 2019 and March 2022 at St. Paul's Hospital Millennium Medical College (SPHMMC) located in Addis Ababa, Ethiopia. SPHMMC is a tertiary teaching hospital with Obstetrics and Gynecology (OBGYN) residency as well as a Family Planning fellowship program. The present study was approved by the institutional review board of SPHMMC. RESULTS: Of the 68 patients reviewed, 48 were referred from other facilities. A total of 24 (35.3%) patients had at least one previous failed attempt at removal before referral. On ultrasound examination, 27 (40.3%) implants were found below the muscle fascia. Implant removal procedures were successfully done at the outpatient clinic in 65 (95.6%) patients including 40/40 (100%) suprafascial and 25/27 (92.6%) subfascial implants. Removal of subfascial implants was performed in the operating room in two patients. We failed to localize the device in one patient currently on follow-up. All removals were performed by OBGYNs with subspecialty training in family planning or current fellows supervised by subspecialists. No post-procedure complications have been documented. CONCLUSION: Our findings show that with meticulous evaluation and careful patient selection, localization and removal of nonpalpable implants in outpatient settings are successful. Initial ultrasonography minimizes delays and allows for same-day implant localization and removal.

Foley catheter for cervical preparation prior to second trimester dilation and evacuation: A supply-based alternative for surgical abortion: A case series.

Objective: To document the use of Foley catheter as an alternative to osmotic dilators for cervical preparation before second trimester dilation and evacuation at a tertiary setting in Ethiopia. Methods: This is a retrospective case series conducted at St. Paul's Hospital Millennium Medical College (Ethiopia) from April 1, 2021 to August 30, 2021. Forty-three cases of dilation and evacuation (D&E) in which overnight intra-cervical Foley catheter placement was used to prepare the cervix were reviewed. Data were analysed using SPSS version 23 and simple descriptive statistics were applied to analyze the clinical characteristics of study subjects and procedure outcomes. Percentages and frequencies were used to present the findings. Results: The calculated median gestational age was 21.4(17-24.2) weeks. Around 40%(17/43) of cases had cervical dilation of 3 to 4 cm, with another 33% (14/43) achieving cervical dilation of 1.5 to 2.5 cm. Additional dilation during the procedure was required only in 12 cases (28%) prior to D&E procedure. In 36 cases (84%), the procedure was attended by family planning fellow. Conclusion: Cervical preparation using overnight Foley catheter before second-trimester D&E resulted in majority of the cases requiring no additional dilation immediately prior to D&E procedure. Where osmotic dilators are not available, Foley catheter can be an alternative method to prepare the cervix prior to D&E procedures. Implications: In the absence of osmotic dilators, Foley catheter can be used as an alternate, and readily available means of cervical preparation for second trimester D&E procedures.

Effectiveness of intra-cardiac lidocaine and intra-amniotic digoxin at inducing fetal demise before second trimester abortion past 20 weeks at a tertiary Hospital in Ethiopia: A retrospective review.

Background: Current literature recommends inducing fetal demise prior to second trimester medication abortion beyond 20 weeks of gestation. There is inadequate literature regarding the practice and effectiveness of this procedure in low-income countries, such as Ethiopia. This study aimed at documenting the effectiveness of intra-cardiac lidocaine and intra-amniotic digoxin at inducing fetal demise before second trimester medication abortion in an Ethiopian setting. Methods: This is a retrospective chart review conducted at St. Paul's Hospital Millennium Medical College, in Ethiopia. A total of 65 cases of feticide administration before 2nd trimester medication abortion between 20 and 28 weeks of gestation (From April 1, 2021 to September 30, 2021) were reviewed. The primary outcome was cessation of fetal cardiac activity the day after the first feticide injection. Data were extracted by reviewing maternal charts using a data extraction tool prepared in English. Data were analyzed using SPSS version 23. Simple descriptive statistics were used to analyze baseline characteristics and fetal demise outcomes. Results were presented in percentages and frequencies. Results: More than three quarters of the feticide injections were with intra-amniotic digoxin, while the rest (24.6%, 16/65) were with intra-cardiac lidocaine. Injection of digoxin or lidocaine was effective at inducing fetal demise the day after administration in 92.3% (60/65) of the cases. Intracardiac lidocaine administration was 100% (16/16) effective at inducing fetal demise within the day after the injection while the effectiveness of digoxin within the same period was 89.8%. Conclusion: In this study, both intra-amniotic digoxin and intra-cardiac lidocaine were effective at inducing fetal demise, which is in support of findings from similar previous studies. Implications: In an Ethiopian setting, both intra-amniotic digoxin and intra-cardiac lidocaine injections are effective at inducing fetal demise before second trimester abortion beyond 20 weeks of gestation within the next day after feticide administration.

Etonogestrel contraceptive implant failure in a woman taking rifampin: a case report.

BACKGROUND: The etonogestrel subdermal implant is the most efficacious hormonal contraceptive currently available and provides 99.7% effective contraception. However, similar to other hormonal contraception, its effectiveness is compromised with the use of cytochrome P450 inducing drugs resulting in an unplanned pregnancy. Despite this risk, little is known about the outcome of concomitant use of rifampin and contraceptive implants. CASE PRESENTATION: A 24-year-old woman was provided with an etonogestrel implant in September 2018. In July 2020, she was started with rifampin based anti-tuberculosis for tuberculosis of the lymph nodes. In December 2020, she presented to the family planning clinic of St. Paul's Hospital Millennium Medical college with a diagnosis of failed implant and second-trimester pregnancy at a gestational age of 19 weeks. The etonogestrel implant was removed and the patient was linked to antenatal care follow up. CONCLUSION: Concomitant use of hepatic cytochrome P450 enzyme-inducing medications with certain hormonal contraceptives may reduce effectiveness resulting in unintended pregnancy. Women should be given detailed counseling about the potential for drug interactions and a multidisciplinary approach with consultation or referral to reproductive health specialists is crucial for optimal management of women who are at increased risk of contraceptive failure and unintended pregnancy.

Early experience on obstetric outcomes of pregnant women who tested positive for COVID-19 in Ethiopia: A case series analysis.

Severe acute respiratory syndrome affects all groups of population including pregnant women. Currently, there are limited evidences to show an increased risk of infection or increased mortality among pregnant women than the general population. On the 13th of March 2020, Ethiopian government reported the first case of COVID-19. Since then, until the time of this research compilation, more than 40 pregnant women have been managed at Eka Kotebe General Hospital, which is the first COVID-19 designated center in the country. The aim of this case series is to do an in-depth case review of the first four cases of pregnant women who tested positive for COVID-19. Out of the four cases discussed in this series, there was one maternal death, and three out of the four newborns delivered tested positive for COVID-19.

Unilateral Giant Hydronephrosis Secondary to Ureteropelvic Junction Obstruction in a Middle-Aged Woman.

BACKGROUND: Giant hydronephrosis is a rare urologic problem defined as a collection of more than one liter of urine in the collecting system. The radiologic appearance may mimic benign cystic disease of the kidney. We report a case of giant hydronephrosis in a 32-year-old female who presented with progressive abdominal swelling of two-year duration, caused by ureteropelvic junction obstruction with more than nine liters of urine in the collecting system. CONCLUSION: Giant hydronephrosis is a rare differential diagnosis for cystic intra-abdominal mass in adults with progressively increasing abdominal swelling. CT and MRI are important in confirming the diagnosis by localizing the origin of the swelling. Management depends on the underlying cause and appearance of the diseased kidney.

Successful dilation and evacuation for second trimester conjoined twin: a case report and review of the literature.

BACKGROUND: Conjoined twins are a rare clinical event occurring in about 1 per 250,000 live births. Though the prognosis of conjoined twins is generally low, there is limited evidence as to the optimal method of pregnancy termination, particularly in cases of advanced gestational age. We report a successful dilation and evacuation (D&E) done for conjoined twins at 22 weeks of gestation. CASE PRESENTATION: A 20-year-old primigravid woman was diagnosed with a conjoined, thoraco-omphalopagus twin pregnancy after undergoing a detailed two-dimensional (2D) fetal ultrasound anatomic scanning. Assessment and counseling were done by a multidisciplinary team. The team discussed the prognosis and options of management with the patient. The patient opted for termination of pregnancy. Different options of termination were discussed and the patient consented for D&E, with the possibility of reverting to hysterotomy in case intraoperative difficulty was encountered. A 2-day cervical preparation followed by D&E was done under spinal anesthesia and ultrasound guidance. CONCLUSION: In this patient, D&E was done successfully without complications. Adequate cervical preparation, pain control, and ultrasound guidance during the procedure are critical for optimal outcomes. A literature review of methods of pregnancy termination for conjoined twins in the second trimester revealed 75% delivered vaginally through medical induction while 18% underwent cesarean section. Only one other report described successful D&E for conjoined twins after 20 weeks. D&E can be safely performed for carefully selected cases of conjoined twins beyond 20 weeks' gestations avoiding the need for induction or hysterotomy.

Comparison of surgical versus medical termination of pregnancy between 13-20 weeks of gestation in Ethiopia: A quasi-experimental study.

BACKGROUND: Dilation and evacuation is a method of second trimester pregnancy termination introduced recently in Ethiopia. However, little is known about the safety and effectiveness of this method in an Ethiopian setting. Therefore, the study is intended to determine the safety and effectiveness of dilation and evacuation for surgical abortion as compared to medical abortion between 13-20 weeks' gestational age. METHODS: This is a quasi-experimental study of women receiving second trimester termination of pregnancy between 13-20 weeks. Patients were allocated to either medical or surgical abortion based on their preference. A structured questionnaire was used to collect demographic information and clinical data upon admission. Procedure related information was collected after the procedure was completed and before the patient was discharged. Additionally, women were contacted 2 weeks after the procedure to evaluate for post-procedural complications. The primary outcome of the study was a composite complication rate. Data were collected using Open Data Kit and then analyzed using Stata version 14.2. Univariate analyses were performed using means (standard deviation), or medians (interquartile range) when the distribution was not normal. Multiple logistic regression was also performed to control for confounders. RESULTS: Two hundred nineteen women chose medical abortion and 60 chose surgical abortion. The composite complication rate is not significantly different among medical and surgical abortion patients (15% versus 10%; p = 0.52). Nine patients (4.1%) in the medical arm required additional intervention to complete the abortion, while none of the surgical abortion patients required additional intervention. Median (IQR) hospital stay was significantly longer in the medical group at 24 (12-24) hours versus 6(4-6) hours in the surgical group p<0.001. CONCLUSION: From the current study findings, we concluded that there is no difference in safety between surgical and medical methods of abortion. This study demonstrates that surgical abortion can be used as a safe and effective alternative to medical abortion and should be offered equivalently with medical abortion, per the patient's preference.

Intra-cardiac lidocaine administration to induce fetal demise before late second-trimester abortion: Retrospective review.

OBJECTIVE: To determine the efficacy and safety of intra-cardiac lidocaine administration to induce fetal demise before second-trimester medication abortion in a teaching hospital in Addis Ababa, Ethiopia. METHODS: We performed a retrospective chart review to collect selected sociodemographic and clinical information. All patients who received fetal intra-cardiac lidocaine between January 1, 2019 and April 30, 2019 were included in the study. Fetal demise was considered successful if achieved within 24 hours after fetal intra-cardiac lidocaine administration. We analyzed the data using SPSS version 20. We used frequency tables to describe the data and performed a multivariable analysis to determine associations between variables. RESULTS: A total of 80 fetuses were given intra-cardiac lidocaine.The mean gestational age was 23+1  weeks (range 21+0 -27+5  weeks). Twenty-four hours after lidocaine administration 76 (95%) pregnancies showed negative fetal cardiac activity. Fetuses at gestational ages of 21-23+6  weeks were five times more likely to have negative cardiac activity compared with those with gestational ages between 24 and 28 weeks (P=0.001). Two women developed nausea, vomiting, and a metallic taste, but no serious adverse events were reported. CONCLUSIONS: Intra-cardiac lidocaine is effective at inducing fetal demise before late second-trimester medication abortion with no associated serious adverse events or complications.

Drugs used to induce fetal demise prior to abortion: a systematic review.

Clinicians have used feticidal agents prior to second trimester abortion for many years. Despite the widespread use of various agents to induce fetal demise, a comprehensive or systematic review of the evidence is lacking on the safety, effectiveness, and most effective routes of administration. OBJECTIVES: To evaluate the existing drugs and routes of administration used in inducing fetal demise prior to abortion, and to determine the safety, effectiveness, and acceptability of these feticidal agents. METHODS: We searched PubMed, EMBASE, CINAHL, POPLINE, and Global Index Medicus to identify studies describing pharmacologic agents used to induce fetal demise prior to termination of pregnancy. We included randomized controlled trials and observational studies comparing digoxin, potassium chloride (KCL), and lidocaine to induce fetal demise. We included studies that evaluated the primary outcomes of safety and effectiveness, including success in achieving fetal demise, induction to expulsion time for medical abortion, dilation and evacuation time, as well as maternal side effects and complications. Two authors independently screened abstracts and full texts. One reviewer extracted data from the included studies, which was counterchecked by a second reviewer. RESULTS: We identified eight studies that met inclusion criteria: three randomized controlled trials, and five observational studies. A total of 4505 women received drugs to induce fetal demise at 17 to 38 weeks' gestation, including digoxin (n = 4174), KCL (n = 324), and lidocaine (n = 7). Intra-fetal digoxin was superior to intra-amniotic digoxin in achieving fetal demise (OR 3.51, 95% CI 1.60, 7.78). Intracardiac KCL 15% 2-3 mL reduced induction to expulsion time by 320 min (p <.006).Similarly, intracardiac KCL 15% 1-3 ml reduced dilation and evacuation time from 16.1 ± 7.9 min to 12.7 ± 5 min (p < 0.001). Intracardiac lidocaine 2% 10 mL was more effective at achieving fetal demise than intracardiac KCL 6 mmol (85.7% vs. 57.9%). Intra-amniotic and intra-fetal digoxin 1 mg, as compared to no feticidal agent, led to greater pre-procedure expulsion, hospital readmission, and the presence of one or more signs of infection. CONCLUSIONS: Evidence from included cohort studies demonstrates that digoxin, KCL, and lidocaine are all effective in inducing fetal demise. Intra-fetal administration of digoxin is superior to intra-amniotic digoxin administration. Administration of feticide using intracardiac KCL may shorten the abortion experience. Limited data from observational studies also supports an increase in maternal side effects and/or complications related to the administration of digoxin. IMPLICATIONS: Intra-fetal administration of digoxin is more effective in achieving fetal demise when compared to intra-amniotic administration. There is a knowledge gap in determining the single best drug for inducing fetal demise prior to abortion. Additional research is needed to compare different feticidal agents in terms of safety and effectiveness.

Adult case of giant sacrococcygeal teratoma: case report.

BACKGROUND: Sacrococcygeal teratomas are tumors originating from pluripotent embryonic germ cell layers located in the fetal coccyx. These tumors are highly vascular if they undergo malignant transformation. Typically, they are found in infants and children and occasionally can be diagnosed prenatally. Adult cases are very rare, and represent tumors present since birth with delayed detection. CASE PRESENTATION: We describe a case of a giant sacrococcygeal teratoma in a 25 years old female college student presenting with right gluteal swelling of 4 months' duration. In addition to the huge disfiguring mass on the perineal area, she also had lower abdominal pain, urinary complaints, and difficulty with ambulation. DISCUSSION: Pre-operative impression was of a sacrococcygeal mass and histopathology following complete surgical excision revealed a sacrococcygeal teratoma. She recovered well after surgery with no radiologic evidence of recurrence at six months. CONCLUSION: Although rare, sacrococcygeal teratoma should be considered as a differential diagnosis for female adults presenting with perineal and/or pelvic masses. Complete surgical excision remains the mainstay of treatment.

Obturator hernia: case report.

Obturator hernia, protrusion of abdominal content through the obturator foramen, is a rare type of abdominal wall hernia. Late patient presentation is associated with significant morbidity and mortality. We present rare case of obturator hernia causing small bowel obstruction in a 65-year-old-female patient. She presented with crampy abdominal pain, nausea and vomiting of three days duration. She was diagnosed with acute surgical abdomen and managed surgically at Arsi University College of health sciences, Assela, Ethiopia. Intraoperative finding revealed left-side obturator hernia, which is an extremely rare occurrence. Despite delayed presentation, our patient had smooth postoperative recovery. Obturator hernia is exceedingly rare, and it poses a diagnostic challenge as signs and symptoms are often nonspecific, making a preoperative diagnosis difficult. So, it should be considered as differential diagnosis in elderly patients presenting with acute surgical abdomen.

Iatrogenic pneumopericardium after tube thoracostomy: A case report.

INTRODUCTION: Pneumopericardium, the presence of air within the pericardial space, is a rare occurrence which usually follows positive pressure ventilation in infants, or blunt and penetrating thoracoabdominal injuries in adults. The occurrence of iatrogenic pneumopericardium following tube thoracostomy is extremely rare. PRESENTATION OF CASE: We present a rare case of iatrogenic pneumopericardium in a 1 year and 7 months old female child for whom a left side tube thoracostomy was done using nasogastric tube for an indication of left empyema thoracis. Later, she developed progressively worsening shortness of breath and imaging revealed iatrogenic pneumopericardium. She was managed conservatively and discharged home in good condition. DISCUSSION: Iatrogenic pneumopericardium can have a range of presentations from being asymptomatic to features of cardiac tamponade. Patient management depends on the presence of tamponade effect and age of the patient. Infants tend to develop cardiac tamponade earlier urging surgical intervention but selected patients can be managed conservatively. CONCLUSION: Iatrogenic pneumopericardium is a rare event but it might lead to death if not diagnosed and treated promptly. Although the tendency to develop tension pneumopericardium urging surgical intervention is high in pediatric patients, our patient has improved well with conservative management. While reporting of complications is not popular, this represents an opportunity to advance the safety during chest drain insertion.

Feasibility of intra-amniotic digoxin administration by obstetrics and gynecology trainees to induce fetal demise prior to medical abortion beyond 20 weeks.

BACKGROUND: Transient fetal survival is one issue that providers may face while managing late second-trimester abortion. Induction of fetal demise using digoxin and other means has been widely performed by maternal-fetal medicine and family planning subspecialists worldwide. However, there are no data available in Ethiopia as regards preventing transient fetal survival in late second-trimester medical termination of pregnancy. OBJECTIVE: The objective of the study was to document the feasibility of intra-amniotic digoxin administration for inducing fetal demise prior to medical abortion beyond 20 weeks of gestational age. Additionally, we aimed to demonstrate that this skill could be transferred to obstetrics and gynaecology residents at St Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia. METHODS: A retrospective cross-sectional study design was conducted to document the feasibility, safety and effectiveness of intra-amniotic digoxin. A structured questionnaire was used to collect selected sociodemographic data and clinical characteristics. Data were entered and analysed using SPSS statistical package version 20. RESULTS: During the study period, 49 women received intra-amniotic digoxin. The success rate of intra-amniotic digoxin in this study was 95.9%. Thirty-seven (75.5%) procedures were performed by obstetrics and gynaecology residents and 12 (24.5%) were performed by family planning faculties. There were two out of hospital expulsions with no signs of life, and no other serious maternal complications were observed. CONCLUSION: It is feasible for obstetrics and gynaecology trainees in Ethiopia to learn how to safely administer intra-amniotic digoxin to induce fetal demise for induced medical terminations.