Expectant management of retained abnormally adherent placenta complicated by uterine prolapse after vaginal delivery.

The placenta accreta spectrum (PAS) describes invasion and adherence of the placenta onto or beyond the myometrium. Prenatal imaging improves management outcomes. In low- and middle-income countries (LMIC), however, the unavailability of ultrasonography in some health facilities delays the diagnosis, particularly if the prenatal period is asymptomatic. Following vaginal delivery, it often manifests as failure to remove a retained placenta manually. In the absence of haemorrhage, expectant management involving leaving the placenta in situ, is an option. In the presence of haemorrhage and/or sepsis, hysterectomy is usually recommended. We present a case of an expectantly managed PAS following a spontaneous preterm vaginal birth. The patient developed puerperal uterine prolapse with the placenta in situ, a previously unreported complication, but this was successfully reduced manually.

Does counselling improve uptake of long-term and permanent contraceptive methods in a high HIV-prevalence setting?

BACKGROUND: Studies have shown a reduced uptake of contraceptive methods in HIV-positive women of childbearing age, mainly because of unmet needs that may be a result of poor promotion of available methods of contraception, especially long-term and permanent methods (LTPM). AIM: To compare the uptake of contraceptive methods, and particularly LTPM, by HIV-positive and HIV negative post-partum mothers, and to assess the effects of counselling on contraceptive choices. SETTING: Three government district hospitals in Swaziland. METHODS: Interviews were conducted using a structured questionnaire, before and after counselling HIV negativeand HIV-positive post-partum women in LTPM use, unintended pregnancy rates, future fertility and reasons for contraceptive choices. RESULTS: A total of 711 women, of whom half were HIV-positive, participated in the study. Most (72.3% HIV-negative and 84% HIV-positive) were on modern methods of contraception, with the majority using 2-monthly and 3-monthly injectables. Intended use of any contraceptive increased to 99% after counselling. LTPM use was 7.0% in HIV-negative mothers and 15.3% in HIV-positive mothers before counselling, compared with 41.3% and 42.4% in HIV-negative and HIV-positive mothers, respectively, after counselling. Pregnancy intentions and counselling on future fertility were significantly associated with current use of contraception, whilst current LTPM use and level of education were significantly associated with LTPM post-counselling. CONCLUSION: Counselling on all methods including LTPM reduced unmet needs in contraception in HIV positive and HIV-negative mothers and could improve contraceptive uptake and reduce unintended pregnancies. Health workers do not always remember to include LTPM when they counsel clients, which could result in a low uptake of these methods. Further experimental studies should be conducted to validate these results.