Infertility services integrated within the maternal health department of a public hospital in a low-income country, Rwanda.

Objective: To describe the initiation, integration, and costs of reduced-cost infertility services within the maternal health department of a public hospital in a low-income country. Design: Retrospective review of the clinical and laboratory components of patients undergoing in vitro fertilization (IVF) treatment in Rwanda from 2018 to 2020. Setting: Academic tertiary referral hospital in Rwanda. Patients: Patients seeking infertility services beyond the primary gynecological options. Interventions: The national government furnished facilities and personnel, and the Rwanda Infertility Initiative, an international nongovernmental organization, provided training, equipment, and materials. The incidence of retrieval, fertilization, embryo cleavage, transfer, and conception (observed until ultrasound verification of intrauterine pregnancy with fetal heartbeat) were analyzed. Cost calculations used the government-issued tariff specifying insurers' payments and patients' copayments with projected delivery rates using early literature. Main Outcome Measures: Assessment of functional clinical and laboratory infertility services and costs. Results: A total of 207 IVF cycles were initiated, 60 of which led to transfer of ≥1 high-grade embryo and 5 to ongoing pregnancies. The projected average cost per cycle was 1,521 USD. Using optimistic and conservative assumptions, the estimated costs per delivery for women <35 years were 4,540 and 5,156 USD, respectively. Conclusions: Reduced-cost infertility services were initiated and integrated within a maternal health department of a public hospital in a low-income country. This integration required commitment, collaboration, leadership, and a universal health financing system. Low-income countries, such as Rwanda, might consider infertility treatment and IVF for younger patients as part of an equitable and affordable health care benefit.

Second Trimester Heterotopic Triplet Pregnancy with Intrauterine Twin Pregnancy and Ruptured Interstitial Pregnancy: A Maternal Near-Miss Case Report.

Heterotopic pregnancy is defined as the occurrence of simultaneous intrauterine and extrauterine pregnancies. It is a rare, potentially life-threatening condition and infrequent in natural conceptions. Here, we report a case of spontaneous heterotopic triplet pregnancy with ruptured cornual ectopic pregnancy and simultaneous twin intrauterine pregnancies at 18 weeks of gestation. The event led to miscarriage of all fetuses from both the ectopic and the intrauterine twin pregnancies.

Protocol for the study of cervical cancer screening technologies in HIV-infected women living in Rwanda.

INTRODUCTION: The optimal method(s) for screening HIV-infected women, especially for those living in sub-Saharan Africa, for cervical precancer and early cancer has yet to be established. METHODS AND ANALYSIS: A convenience sample of >5000 Rwandan women, ages 30-54 years and living with HIV infection, is being consented and enroled into a cross-sectional study of cervical cancer screening strategies. Participants are completing an administered short risk factor questionnaire and being screened for high-risk human papillomavirus (hrHPV) using the Xpert HPV assay (Cepheid, Sunnyvale, California, USA), unaided visual inspection after acetic acid (VIA) and aided VIA using the Enhanced Visual Assessment (EVA) system (Mobile ODT, Tel Aviv, Israel). Women positive for hrHPV and/or by unaided VIA undergo colposcopy, which includes the collection of two cervical specimens prior to undergoing a four-quadrant microbiopsy protocol. The colposcopy-collected specimens are being tested by dual immunocytochemical staining for p16INK4a and Ki-67 (CINtec PLUS Cytology, Ventana, Tucson, Arizona, USA) and for E6 or E7 oncoprotein for 8 hrHPV genotypes (HPV16, 18, 31, 33, 35, 45, 52 and 58) using the next-generation AV Avantage hrHPV E6/E7 test (Arbor Vita Corporation, Freemont, California, USA). Women with a local pathology diagnosis of cervical intraepithelial neoplasia grade 2 (CIN2) or more severe (CIN2+) or pathology review diagnosis of CIN grade three or more severe (CIN3+) will receive treatment. Clinical performance and cost-effectiveness (eg, sensitivity, specificity and predictive values) of different screening strategies and algorithms will be evaluated. ETHICS AND DISSEMINATION: The protocol was approved by local and institutional review boards for human subjects research. At the completion of the study, results will be disseminated to the scientific community through peer-reviewed publication and to the Rwandan stakeholders through an external advisory panel.

Gastric Rupture in Pregnancy: Case Series from a Tertiary Institution in Rwanda and Review of the Literature.

Background Gastric rupture is a rare, life-threatening condition during pregnancy. Case study We present three cases of gastric perforation during pregnancy and the puerperium. The first patient presented with gastric perforation 4 days following an uncomplicated cesarean delivery for obstetric indications. She initially complained of epigastric pain; however, those symptoms resolved. She later demonstrated worsening abdominal distension, intra-abdominal free fluid, and signs of peritonitis. At laparotomy, an ascariasis-associated gastric rupture was diagnosed. She died from sepsis 4 days following the laparotomy. The second patient presented 19 days following a normal vaginal delivery. She presented with hemodynamic instability and underwent emergent laparotomy due to suspected septic shock peritonitis. Gastric rupture was diagnosed intraoperatively. She improved clinically and was discharged home. The third patient underwent emergency cesarean delivery due to non-reassuring fetal status in the setting of preeclampsia. She was initially diagnosed with ascites and pulmonary edema as a result of preeclampsia. Later in her course, she developed features in favor of acute abdomen and signs of sepsis. At the time of emergent laparotomy, a gastric rupture was identified and repaired. She died 2 days later from sepsis. Conclusion We report the management and outcome of three cases of pregnancy-related gastric rupture. To our knowledge, these three cases represent the largest series of pregnancy-related gastric ruptures from a single institution.