theme: saving mothers giving birthof emergency obstetrics and newborn care assessment data dr koyejo...

BOOK OF ABSTRACT& PROGRAM

RSOG 1st ANNUAL SCIENTIFIC CONFERENCE

Theme: Saving mothers giving birth

Kigali Serena Hotel, July 25-26th,2013

MINISTRY OF HEALTH

2 Kigali Serena Hotel, July 25-26th,2013


FOREWORD

The Rwanda Society of Obstetricians and Gynecologists (RSOG) is pleased to organize its first scientific conference from 25th to 26th July 2013. This will be preceded by 3 workshops on the 24th July. As CPD provider, RSOG considers this kind of event as a great opportunity for knowledge improvement and skills acquisition. Its mandate is to continually improve knowledge and performance of obstetricians

and gynecologists and other health professionals invested in maternal and reproductive health. Colleagues from the region, continent and the entire world have accepted to attend this conference and even give presentations. This makes the conference more interesting as experiences will be shared between colleagues around the world. The theme of the conference is: SAVING MOTHERS GIVING BIRTH. We could not find better theme than this one as we are approaching the Millennium Development Goals. Rwanda has done a lot in reducing maternal mortality by half for the last 10 years. We hope to be ready by 2015.

This conference will be preceded by workshops in the following area to improve skills of our doctor:

Office Hysteroscopy: will take place in Rwanda Military Hospital. This is a very important skill in the field of gynecology. It allows having a look in a woman womb with no anesthesia in few minutes. This can allow seeing properly if there is any pathology which can be even removed at the same occasion.

Colposcopy: will take place in Kibagabaga Hospital. Cervical cancer

Dr Eugene NGOGARSOG President

3Kigali Serena Hotel, July 25-26th,2013


is a second cancer killing woman in Rwanda. Yet it can be prevented. This skill is very important to acquire for the doctor to properly diagnose the pre-malignant lesion so a treatment can be instituted. It has been important to improve the skill of our doctors in this field.

Obstetrics Ultrasound: will take place in CHUK. Ultrasound has improved the management of pregnancy. All doctors need to be skilled enough in this area to make sure that the progress of the pregnancy is monitored.

At the end of this scientific conference we expect participants to be able to perform office hysteroscopy, colposcopy and ultrasound; to acquire new knowledge in the field of maternal and reproductive health for use in their daily practice.

I would like to thank all RSOG members and others who have put a lot of effort in the preparation of this conference for its success. We appreciate their time and dedication for better future of our mothers and newborns.

My gratitude goes also to all who have sent their abstracts and presentations for the conference. Without your commitment, this event could have not possible. The message from your presentation will allow participant to go back at their working place with confident.

Last but not least, I sincerely thank our partners who have financial supported this conference namely the Ministry of Health, UNICEF, VSI, RSSB, MNCHR, JPHIEGO and others. Your contribution shows that you value our work and are determined to be part of the changes which must translate into the improvement of maternal health.

Thank you and enjoy the conference.

Dr Eugene NGOGA

RSOG President



PROGRAMME

Kigali Serena Hotel, July 25-26, 2013

DAY 1: THURSDAY, JULY 25th, 2013Ball Room

Timing Event Responsible Session moderator

08:00 – 08:30 Registration Secretariat

Dr Okasha Mohamed

08:30 – 08:40 Welcome remarks President RSOG

08:40-09:00 Opening remarks Minister of Health

09:00-09:15

Success story of post-abortion care and next steps for scale-up in Rwanda

Dr Nuriye Hodo-glugil

09:15-09:30

New Advances and technologies in Medicine-Medication abortion

Dr Nuriye Hodo-glugil

09:30-09:45 Management of Ectopic pregnancy Dr Dawie Slabbert

09:45 – 10:15 Plenary Discussion

10:15-10:45 Coffee Break- Exhibition



10:45 – 11:00

Socio-economic, clinical and biolog-ical risk factors for mothers-to-child transmission of HIV in Muhima Health centre (Rwanda):a prospective cohort study

Dr John Muganda

Prof. Vyankan-dondera

Dr Aline Mukundwa

11:00-11:15

Are HIV exposed infants at higher risk of early Neonatal death?

Dr Juddy Orikiriza

11:15-11:30

High Risk of ART non-Adherence and delay of ART initia-tion among HIV pos-itive double Orphans in Kigali,Rwanda

Dr John Muganda

11:30-12:00 Plenary Discussion

12:00-12:15

Cervical Cancer screening Habit Among healthcare professionals in a District Level Hos-pital

A. Chen

12:15-12:30 Cancer in Pregnancy Prof. Hennie Botha

12:30-12:45

Fertility-sparing surgery in uterine (cervical and endo-metrial) cancer.

Prof. Hennie Botha


13:15-14:15 G Break-Lunch-Exhibition



14:15-14:30

Postpartum hem-orrhage prevention program in Rwanda

Eugene Kanya-manza

Prof. Kakoma JB

14:30-14:45

Management of Acutely Ill Post-partum Patient in resource limited setting

A Chen

14:45-15:00 A rare case of Postpartum Gastric rupture: Case series

Dr David Ntirushwa


15:30-15:45 Coffee Break-Exhibition

15:45-16:00

Second Trimester Uterine and Intesti-nal Rupture Follow-ing Blunt Trauma: Case Report

Dr Venant Niyikiza

Dr Patrick Bagambe

16:00-16:15Thoracophagus conjoined twins with single heart: Case Report

Dr Jean Kalibushi


16:30-17:00 Exhibition

19:00

GALA DINNEREntertainments: Cultural Troupe

All Participants



DAY 2: FRIDAY, JULY 26th, 2013Ball Room

Timing Event Responsible Session Moderator

08:00 – 8:30 Registration RSOG Secre-tariat

Dr Gaspard Ntahonkiriye

Dr John Muganda

Dr Jean Kalibushi

8:30-8:45

Incidence and factors associat-ed with maternal morbidity and mortality in Kigali University Teaching Hospital - RwandaA prospective study

Dr Stephen Rulisa

8:45-9:00Obstetric etiologies of Mater-nal Mortality in DRC : Case of Panzi

Dr Mukwege Denis

09:00 – 9:15 Prognosis of uretero-vesical fistula at Panzi Hospital (DRC)

Dr Denis Muk-wege

9:15-9:45 Plenary Discussion9:45-10:00 Coffee Break-Exhibition

10:00-10:15 Maternal and newborn sepsis Prof. Joseph Vyankandon-dera

10:15-10:30

Recurring weaknesses beset-ting delivery of maternal and newborn health services in Africa: A multicountry analysis of emergency obstetrics and newborn care assessment data

Dr Koyejo Oy-erinde

10:30-10:45Prevalence and Predictors of Giving Birth in Health Facilities in Bugesera District, Rwanda

Dr Stephen Rulisa


11:15-11:30 Health professional’s Percep-tion on Partograph in Burundi

Dr Aline Mukundwa

11:30-11:45Saving Mothers Lives: Jhpiego innovative approach to prevent Postpartum hemorrhage at fa-cility level using Mama Natalie

Dr Beata Mu-karugwiro




12:15-12:30 Conclusion and Recommen-dations

Dr Stephen Rulisa

RSOG Secretary

12:30-12:45 Official closing remarksDirector of MCH/Dr Ngabo Fidele

12:45-13:45 Break-Lunch-Exhibition13:45 – 15:00 Exhibition

15:00-18:00 RSOG AGM RSOG Presi-dent

18:00 COCK TAIL All

ORAL ABTRACT

Socio-economic, clinical and biological risk factors for mothers-to-child transmission of HIV in Muhima Health centre (Rwanda):a prospective cohort study.

Maurice Bucagu1*, Jean de Dieu Bizimana2, John Muganda3 and Claire Perrine Humblet4

Background Three decades since the first HIV-1 infected patients in Rwanda were identified in 1983; the Acquired Immunodeficiency Syndrome epidemic has had a devastating history and is still a major public health challenge in the country. This study was aimed at assessing socioeconomic, clinical and biological risk factors for mother – to –child transmission of HIV- in Muhima health centre (Kigali/Rwanda).

Methods The prospective cohort study was conducted at Muhima Health centre (Kigali/Rwanda).



During the study period (May 2007 – April 2010), of 8,669 pregnant women who attended antenatal visits and screened for HIV-1, 736 tested HIV-1 positive and among them 700 were eligible study participants. Hemoglobin,CD4 count and viral load tests were performed for participant mothers and HIV-1 testing using DNA PCR technique for infants.Follow up data for eligible mother-infant pairs were obtained from women themselves and log books in Muhima health centre and maternity, using a structured questionnaire.Predictors of mother-to-child transmission of HIV-1 were assessed by multivariable logistic regression analysis.

ResultsAmong the 679 exposed and followed-up infants, HIV-1 status was significantly associated with disclosure of HIV status to partner both at 6 weeks of age (non-disclosure of HIV status, adjusted odds ratio [AOR] 4.68, CI 1.39 to 15.77, p < 0.05; compared to disclosure) and at 6 months of age (non-disclosure of HIV status, AOR, 3.41, CI 1.09 to 10.65, p < 0.05, compared to disclosure).A significant association between mother’s viral load (HIV-1 RNA) and infant HIV-1 status was found both at 6 weeks of age (> = 1000 copies/ml, AOR 7.30, CI 2.65 to 20.08, p < 0.01, compared to <1000 copies/ml) and at 6 months of age (> = 1000 copies/ml, AOR 4.60, CI 1.84 to 11.49, p < 0.01, compared to <1000 copies/ml).

Conclusion In this study, the most relevant factors independently associated with increased risk of mother – to –child transmission of HIV-1 included non-disclosure of HIV status to partner and high HIV-1 RNA. Members of this cohort also showed socioeconomic inequalities, with unmarried status carrying higher risk of undisclosed HIV status.



The monitoring of maternal HIV-1 RNA level might be considered as a routinely used test to assess the risk of transmission with the goal of achieving viral suppression as critical for elimination of pediatric HIV, particularly in breastfeeding populations.

KeywordsSocioeconomic, Clinical and biological risk factors, HIV-1, Mother - to – child transmission, Cohort,Muhima/Rwanda.

ARE HIV EXPOSED INFANTS AT A HIGHER RISK OF EARLY NEONATAL DEATH?: 2008-2010 Rwanda Military Hospital neonatal audits.Orikiiriza.J1, Mushimiyimana. F1, Karenzi.B11 Rwanda Military Hospital, Kigali, Rwanda

Background Africa’s neonatal mortality rate (MR) is the highest in the world at 40/1000 live births. Rwanda neonatal mortality contributes 25% of infant mortality. Our aim of study was identifying factors associated with neonatal mortality.

Method Case notes of admitted neonates January 2008 to December 2010 were retrospectively reviewed.

ResultsA total of 1543 babies were admitted, commonest causes of admission included birth asphyxia 484/1543 (31%), neonatal septicemia 460/1543 (30%) and prematurity 370/1543 (24%). Male: female ratio was 1.5 average age 3 days standard deviation (SD) 6.4 days, average birth weight 2.7kg (SD: 0.8) and mean APGAR score 6.5 (SD: 3.2).

Average hospital stay was 8.4 days (SD: 8.3), 977/1413(69%)



were vaginal deliveries, 794 (51.5%) had HIV status documented with HIV exposure prevalence of 17% (137/794). Admissions in 2008, 2009 and 2010 were 380/1543 (25%), 558/1543(36%) and 605/1543 (39%) respectively; Risk ratio (RR): 1.0 (95% CI: 0.8- 1.2) p= 0.7.MR was 16% (246/1543) with HIV exposed neonates having the highest MR 23%; RR=2 (95% CI: 1.3 - 2.7) p=0.001 compared to non exposed (12.5%). MR in neonates delivered vaginally was 172/977 (18%), caesarian delivery was 13% (56/436) RR: 1.4 (95% CI: 1.0 -1.8) p=0.027. Factors associated with neonatal mortality were being HIV exposed (HR=1.7), low APGAR score <5 (HR=3.0) and birth asphyxia (HR=3.7).

ConclusionHigh MR among HIV exposed neonates is likely to be caused by labor duration, the mode of delivery, birth weight, mother’s infection burden, parity, age and nutritional status of mother. Prospective studies are needed to alieniate the problem.Acknowledgment: The Neonatology staff at RMH.

High Risk of ART non-Adherence and delay of ART initiation among HIV positive double Orphans in Kigali,Rwanda.

Kimiyo Kikuchi1, Krishna C. Poudel1, John Muganda2, Adolphe Majyambere3, Keiko Otsuka1,Tomoko Sato4, Vincent Mutabazi3, Simon Pierre Nyonsenga3, Ribakare Muhayimpundu3,Masamine Jimba1, Junko Yasuoka1*

BackgroundTo reduce HIV/AIDS related mortality of children, adherence to antiretroviral treatment (ART) is critical in the treatment of HIV



positive children. However, little is known about the association between ART adherence and different orphan status. The aims of this study were to assess the ART adherence and identify whether different orphan status was associated with the child’s adherence.

Methods A total of 717 HIV positive children and the same number of caregivers participated in this cross-sectional study.Children’s adherence rate was measured using a pill count method and those who took 85% or more of the prescribed doses were defined as adherent. To collect data about adherence related factors, we also interviewed caregivers using a structured questionnaire.

Results Of all children (N = 717), participants from each orphan category (double orphan, maternal orphan, paternal orphan, non-orphan) were 346, 89, 169, and 113, respectively. ART non-adherence rate of each orphan category was 59.3%,44.9%, 46.7%, and 49.7%, respectively. The multivariate analysis indicated that maternal orphans (AOR 0.31, 95% CI 0.12–0.80), paternal orphans (AOR 0.35, 95% CI 0.14–0.89), and non-orphans (AOR 0.45, 95% CI 0.21–0.99) were less likely to be non-adherent compared to double orphans. Double orphans who had a sibling as a caregiver were more likely to be nonadherent.The first mean CD4 count prior to initiating treatment was 520, 601, 599, and 844 (cells/ml), respectively (p,0.001). Their mean age at sero-status detection was 5.9, 5.3, 4.8, and 3.9 (year old), respectively (p,0.001).

Conclusions Double orphans were at highest risk of ART non-adherence and especially those who had a sibling as a caregiver had high



risk. They were also in danger of initiating ART at an older age and at a later stage of HIV/AIDS compared with other orphan categories. Double orphans need more attention to the promote child’s adherence to ART.

Cervical Cancer screening Habit Among healthcare professionals in a District Level Hospital

A. Chen*, J Alanyo, A Odong, Maria Laura Fibbi, E. ODONG* for contact, Austin Chen, MD, [email protected] any given month from Jan 2012 to June 2013, an average of 10 or more women range from 21-81 will show up at an Northern Uganda hospital with a set of tell-tale complaints that announce the presence of advanced cervical cancer. All of them are beyond stage 2A where surgery can’t offer reasonable treatment. Over 99% of these patients can’t afford the cost of 5 hour trip to the only radiation treatment facility in the country, nor the cost of having an attendant that will care for them during the waiting and treatment period.

Additionally, a steady fraction of the self referred patients had history of having abdominal surgery within the last 3 yrs. This suggests a need to sensitize the surgeons about the value of cervical cancer screen preoperatively. Many experienced surgeons have started their practice at a time when the capacity to conduct cervical cancer screening was absent and continue to be absent in their current setting due to lack of capacity such as a reliable and good quality pathology department.

In our facility where the capacity to perform Pap, colposcopy, evaluate cytology& histology and surgical treatment for early stage cancer are available, follow up and tracking patients who have abnormal results remain a challenge to effectively reduce the burden of cervical cancer.



Our study aims to examine, as a starting point, quantitatively the cervical cancer screening exposure among staff, the prevalence of pap smear in the preop checklist among surgeons within our hospital, and the retrieval rate of cytology & histology results among patients.

Abbreviatioins: GOPD, Gyn Ob Outpatient Department; LEEP, Loop Electrical Exicision Procedure; VVF, vesicovaginal fistula; PPH, postpartum hemorrhage

Methdology

Cytology and Histology records were reviewed from Jan 2012 to June 2013, an 18 month period.

After pap smear or colposcopic biopsy was done, patients are instructed individually by trained nurse to return in 4-6 wks for results. When a patient returns, the original report is removed from a dedicated file and stapled to the medical record file the patient keeps with high degree of diligence. The number of unclaimed reports are tabulated.

Exposure of pap screening, among staff working in Maternity/gyn/Theater/GOPD, were surveyed through individual interviews. Age of the subjects and most recent year of exposure are extracted.

Reviews of data from pathology department on female patients whose name appeared in OR Theater record from Jan 2012-June 2013 were conducted for presence of pap cytology or colposcopic histotology. Patient chart reviews for documentation of pap smear history were also performed.



ResultsExposure of Screening Among MedicalStaff from maternity, gyn, and Theater35% (total N=43) had pap screening within the last 3yrs. 4% had been screen once but >5yrs ago.61% had never been screened. 100% are aware of Pap screening.

Cytology and Histology Unclaimed 745 Pap cytology was performed in 2012. 161(22%) reports were not claimed. Among the unclaimed reports, 23.6%( 38/161) had result that requires further investigation.333 Pap cytology was performed from Jan-June 3 2013. 76(26%) reports were not claimed. Among the unclaimed reports, 5% ( 4/76) had result that requires further investigation.

Preop Cervical cytology/histology among female patients( excluding ones for cancer staging)( both documented in writing or cytology/histology record found in chart)

In 2012, 2032 female patients, age > or =20yr, underwent surgery in Theater. After excluding patients having procedure due to cervical pathology ( staging, LEEP), <1% had had cervical screening preoperatively.

Demographics of Advanced Cancer Cases experienced at LacorIn 2012, 141 cases of advance ca of cervix( beyond 2A) were admitted for transfusion, biopsy and palliative care0% are between 21-25 years old, 11%( total N=141) are between 26-35 years old. 23% are between 36-45 years old, 38% are between 46-55 years old.



In 2013*, 4% are between 21-29 years old, 13% are between 21-35 years old, 21% are between 36-45 years old, 36% are between 46-55 years old, ( from Jan to May; N=56)

figure 1

ConclusionInternational efforts to decrease the burden of maternal-child morbidity and mortality in Africa have, over the last 20yrs, effectively prolonged the lives of many women during their childbearing years. Early recognition and timely referrals of obstructed labor, PPH and obstetric VVF continue to improve among health centers in many districts. For women in villages and rural areas of Northern Uganda, awareness of hospitals and specialists with capacity to manage and prevent these complications are high, as evidenced by the referral cases seen in our facility.

The success also exposes advanced cervical cancer as the next major challenge on the horizon that affect women across all age groups in this region. Deep-rooted desire among both women and men to have high parity as soon as possible, coupled with the accepted social norm of having many ‘wives’ and sharing ‘husband’ with other women have escalated the spread of high risk HPV infection and its sequelae..

Cancer, like other chronic disease such as diabetes and



hypertension are silent at its early stage. By the time contact bleeding, foul odor discharge and lower abdominal pain are present, there is no room for successful intervention in resource limited setting.

Prevention is not a familiar concept among women in many African regions. Instability of lives from famine to war facilitate the development of a reactive, rather than preventive, approach to living a life.

Recognizing these social factors made clear the unique role of healthcare professionals in our hospital facility. Their buy in of cervical cancer screening can breathe momentum to the much needed cervical cancer screening campaign.

Our study aims to identify areas of effort we need to strengthen in Lacor Hospital. We are raising funds to sponsor biennial free pap screening for all staff and develop preoperative checklist that includes pap screening for all female patients age 20 and above.

Cancer in pregnancy

Prof Hennie Botha Unit for Gynaecological Oncology Stellenbosch University and Tygerberg Hospital South Africa

For some women, the happiest time in their lives is complicated by the scariest times in their lives. Around 1 in 1,000 pregnant women will be diagnosed with cancer. When surgery is indicated the best time is between 16 – 18 weeks, however abdominal surgery may increase the premature delivery rate.



Chemotherapy can often be used safely after 14 weeks gestation and radiotherapy with proper screening of uterine cavity may be applied safely.A multi-disciplinary team approach with individualised care is essential for the best outcome in this infrequent clinical scenario.

Fertility-sparing surgery in uterine (cervical and endometrial) cancer.

Prof Hennie Botha Unit for Gynaecological Oncology Stellenbosch University and Tygerberg Hospital South Africa

Cervical cancer remains a common disease and worldwide nearly 500 000 women are diagnosed annually. Many of these women are in their reproductive years and may wish to retain their fertility after treatment. Historically gains in survival after surgical treatment have been achieved by becoming progressively more radical in approach. Understanding the factors affecting survival better, it is now possible to tailor surgery for early cases without compromising cure rates. Factors affecting prognosis are nodal metastasis, resection margins status, tumour volume and depth of invasion. Recently the importance of lymphovascular space invasion has become clearer. Careful staging before planning treatment is of utmost importance.

Pathological examination of cone and other biopsies should be done according to strict criteria. Decisions about treatment are best done by a specialist multi-disciplinary team.

Cold knife conisation may be adequate surgery for stage Ia1 cervical carcinoma. Radical trachelectomy with pelvic lymphadenectomy is an option for selected cases of stage 1a2



– 1b1 tumours. Size of tumour, lymphovascular space invasion and nodal status are important prognostic indicators.The oncological outcomes of cases managed with trachelectomy compare well with standard surgical treatment. Pregnancy after trachelectomy or cold knife cone for cervical cancer may be complicated by premature labour or cervical incompetence. Tubal factor infertility may be a problem after open abdominal procedures. Ovarian tissue cryopreservation or transposition may be an option to protect endocrine function in patients with more advanced disease requiring pelvic radiotherapy.

14% of cases of endometrial cancer occur in premenopausal women. Hormonal therapy for highly selected cases may be effective treatment and result in fertility conservation. Hysteroscopic resection of localised tumours and omission of oophorectomy are surgical options in selected cases.

Management of Acutely Ill Postpartum Patient in resource limited setting

—A Case Presentation A Chen, G. Kansiime, E Odong Lacor Hospital, Gulu, Uganda

IntroductionThree quarters of the critically ill patients are living in resource limited setting( RLS). Majority of management algorithm for this group of patients were developed in resource rich setting. Practical adaptations for physicians working in RLS, with the exception of sepsis management, are few. Consequently, outcomes are still unpredictable. Case contributions from doctors who have cared for critically ill patients can add value to the emergence of useful guidelines



Case28 year old, G 7 P 4+2, history of grade 4 previa in last and present pregnancy and 1 PS, was taken by neighbor who is a hospital staff in the ambulance to Lacor Hospital due to antepartum hemorrhage. She is 22 w in gestation by date and size. This is her third admission in 2months.

On admission, she was lethargic and cold, bp 74/44, p 50, T 35.6 C. Her Hgb was 8.1g/dl, unchanged from her last admission 1wk ago.Bedside ultrasound determined that baby is well but the patient decided to terminate her pregnancy as her bleeding continued unabated.

After resuscitation with crystalloid and 1 U of PRBC, patient was taken to theater after husband was reached and agreed to the termination. He was, however, not ready to agree to the bilateraltubal ligation.Patient had exploratory laparotomy and hysterotomy under general anesthesia.

Urine was port wine color with hemolyzed rbc. She was given another 1U PRBC and rectal misoprostol 600mcg in gyn ward.Seven hours after 1st procedure, nursing reported that patient complained of recurrence of continuous vaginal bleeding.

Patient was taken to theater for hysterectomy and resection of placental tissue involving vagina Postoperatively, patient developed oliguric AKI, febrile morbidity and spent 2 weeks at ICU. She was discharged to general ward when she was in polyuric phase of AKI . She received total of 6 units of PRBC from her attendants and blood bank during and after operation.

She was discharged home 4 wks after admission. Her creatinine was 2, from 5.1 during oliguric AKI.She was managed with fluid restriction, twice daily weight, mannitol every 8 hours



until urine output improves and lasix by intravenous line until polyuric. While in ICU, the patient had 6 hourly monitoring of BP, Temp, urine output and timely administration of medications from high dependency staff. The ICU has capacity to place central line for CVP but can only measure pressure manually. There are 3 automatic monitors for BP, MAP and pulse. The rest are done manually by staff. There are 3 Glostavent for patients who remained intubated, one roving suction machine, one pulse oximeter. Oxygen therapy for Glostavent comes from 3 cylinders which get refilled 5hrs away. The rest are oxygen concentrators with nasal cannula. Face masks are limited in supply. There is no air conditioning nor heating system. The floors are washed with disinfectant once a day. All visitors have to wear dedicated rubber clogs.

There is no FFP, cryoprecipitate in the blood bank. There is no RRT in the hospital. The lab can perform cbc, platelet counts and INR reliably, but can’t perform renal function testing regularly.

ConclusionThe case highlights the challenges of managing critically ill obstetric patients with reversible pathologies in resource limited setting. Early recognition of the reversible pathologies, collaboration among consultants from different specialties, and a high dependcy staff are the most important elements in optimized management in RLS.



CASE REPORT

SPONTANEOUS HEPATIC RUPTURE IN A WOMAN WITH HELLP SYNDROM IN POSTPARTUM.David Ntirushwa,Ob/Gyn resident

Spontaneous hepatic rupture in post partum is a rare but catastrophic condition. It is associated with poor maternal outcome especially in poor setting conditions where advanced interventions like liver transplantation are not an option .It is almost usually associated with underlying pre-eclampsia or HELLP syndrome though earlier recognition and accurate management of these conditions may improve/prevent this catastrophic complication.

We present a case report of a 36 y.o, G6P6006 who was admitted for post postpartum follow up, she was only concerned by her premature baby who developed postnatal respiratory distress. The baby was immediately admitted in our neonatal intensive care unity and the mother followed for routine post partum. The only clinical finding were high BP of 167/100mmHg on a background of pre-eclampsia, which motivated the initial doctor to admit her to control her BP. 8 hours later She suddenly developed epigastric pain and hemopertoneum was found on ultrasound.

Immediately emergent laparotomy was performed with poor post operative evolution that required a second laparotomy. Unfortunately the mother passed away only 48 hours since admissions, after receiving a number of blood transfusion,cloating factors replacement and two laparomies to attempt hemostasis.Our case report emphasize on challenges related to earlier detection or diagnosis of sub capsular hemorrhage and hepatic rupture before it is too late, It also focus on challenges



of management in case hepatic rupture already happened especially in poor setting conditions.

Further studies are of paramount importance to anticipate and prevent this catastrophic condition as well as early detection. We recommend evidence based and updated working protocols on management of Hypertensive disorders of pregnancy and HEELP syndrome on pregnancy to minimize he risks of developing such complications. We also emphasize on a multidisciplinary approach in management of hepatic rupture once it happened and detected to improve maternal and neonatal outcome Key words: Hepatic rupture, post partum and HELLP syndrome.

Thoracophagus conjoined twins with single heart.Kalibushi B J¹, Rodney W², Cindy C³.

Conjoined twins represent one of rarest type of twin gestation but occurring in about 1 of monochorionic twins with an estimated incidence ranging from 1/30.000 to 1/200.000 live births and 1 in 650 to 900 twin deliveries.



A 30 year old gravid presented with history of amenorrhea of 17weeks and 2days for second routine ultrasound which demonstrated thoracophagus conjoined twins. Patient was admitted for termination of pregnancy after explanation and family consent.

She was induced with misoprostol (cytotec) 400mcg vaginally and orally but after 5 courses of cytotec, we put the Foley catheter ballooned with 60cc, and the patient expulsed vaginally conjoined twin of combined weight around 320grs with one umbilical cord but the placenta was delivered manually under general anesthesia and placenta weighting 410grs.

In conclusion, conjoined twins are present in Rwanda but an early diagnosis with specialized ultrasound can prevent feto maternal complications due to abnormal gestation.

Keywords: Conjoined, Thoracophagus, Antenatal diagnostic ultrasonography, vaginal delivery.

1. MD MMED Consultant in Ob/Gyn BUTH2. Assistant Professor HRH/Rwanda3. Professor HRH/Rwanda



Incidence and factors associated with maternal morbidity and morbidity in University Teaching Hospital of Kigali- Rwanda. A prospective studyStephen Rulisa, UmuziranengeImmaculleeAuthors address: National University of Rwanda, University teaching hospital of Kigali

ObjectiveTo determine the incidence and factors associated with severe (‘near miss’) maternal morbidity and mortality in the University Teaching Hospital of Kigali – Rwanda.

MethodsWe conducted a prospective study of all women admitted to the tertiary care University Hospital in Kigali with severe maternal morbidity and mortality during 12 months period using WHO criteria for ‘near miss’ maternal mortality. We assessed maternal demographic characteristics and disease processes associated with severe obstetric morbidity and mortality.

Results Preliminary analysis has indicated that the calculated incidence of severe maternal morbidity was 104 per 1000 deliveries and case fatality rate of 1 in 5. Sepsis/peritonitis (28.9%), hypertensive disease (27.8%), and hemorrhage (18.9%) were the leading causes of severe obstetric morbidity and mortality. The majority of patients were referred from district hospitals in the eastern part of the country, and had low socioeconomic status.

ConclusionSevere maternal morbidity in University Teaching Hospital of Kigali (CHUK) accounts for at least 10,4% of all pregnancies seen with an incidence of 104 per 1000 deliveries. The study



has identified late transfer as main cause of most cases of severe maternal morbidity and mortality. The high incidence of peritonitis reflected suboptimal intraoperative and intrapartum management of high-risk patients. More studies are needed to further clarify these findings.

Recurring weaknesses besetting delivery of maternal and newborn health services in Africa: A multicountry analysis of emergency obstetric and newborn care assessment data.By Koyejo Oyerinde, MD MPH FAAP

BackgroundThere is widespread agreement that the pace of maternal mortality reduction in most African countries is inadequate and they will not meet their MDG 5 targets. Similarly, MDG4 targets will not be met in most countries especially due to persistently high levels of neonatal mortality.

ObjectiveTo present a review of common findings from 5 recent emergency obstetric and newborn care (EmONC) assessments.

MethodologyAMDD conducts nationwide facility-based assessments for the capacity of health systems to deliver quality emergency obstetric care and other maternal and newborn health services. These assessments have been done in more than 20 countries across Africa. Common findings from the assessments in Benin, Liberia, Gambia, Ghana, and Malawi are presented.

ResultsPoor coverage of EmONC services, inequitable distribution of services, focus on hospitals and poor lower level facilities,



inadequate numbers of skilled attendants and inadequate number of workers to provide assisted vaginal delivery, removal of retained products and manual removal of placenta were found in all 5 countries. Finally, the poor supervision of staff especially in peripheral facilities and poor coordination between levels of the health service further weaken the health systems in these countries.

ConclusionAttainment of targets in 2015 and beyond demands that all these issues are resolved swiftly. Strong leadership from the ministries of health is needed.

Prevalence and predictors of giving birth in health facilities in Bugesera district, Rwanda

Shahrzad Joharifard1,Stephen Rulisa2,3, Francine Niyonkuru2,3, Andrew Weinhold4, Felix Sayinzoga5, Jeffrey Wilkinson6 Jan Ostermann7, , Nathan M. Thielman7,8

1Duke University, School of medicine, Durham, NC, USA.2Department of Clinical Research, University Teaching Hospital of Kigali, Kigali, Rwanda.3Faculty of Medicine, National University of Rwanda, Butare, Rwanda.4University of North Carolina, Gillings School of public health, Chapel hill, NC<, USA.5Department of maternal and Child health, Ministry of health, Republic of Rwanda.6Department of obstetrics and gynecology, University of North Carolina, Chapel hill, NC, USA.7Duke Global health institute, Durham, NC, USA.8Duke University, Medical centre, Durham, NC, USA



ObjectiveTo quantify trends in health facility delivery and identify factors that affect the uptake of intrapartum healthcare services among women living in Bugesera District, Rwanda.

MethodsUsing probability proportional to size cluster sampling, 30 villages were selected for cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Logistic regression was used to identify factors associated with facility delivery.

ResultsAnalysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of facility deliveries. Delivering a penultimate baby at a health facility (OR= 4.896 [3.281-7.306]), possessing health insurance (OR= 3.870 [1.784-8.394]), women managing household finances (OR= 1.980 [1.151-3.409]), attending more antenatal care visits (OR= 1.543 [1.168-2.037]), delivering more recently (OR= 1.415 [1.101-1.819]), and living closer to a health center (OR= 0.892 [0.821-0.970]) were independently associated with facility delivery.

ConclusionThe dramatic improvement in the facility delivery rate in Bugesera District coincides with important structural interventions in Rwanda, including the rapid scale- up of community-financed health insurance.To encourage greater uptake of health facility delivery, policies should promote sensitization campaigns targeting women who delivered their last baby at home and/or attended few ANC visits, universal health insurance, women’s empowerment, and improved access to transportation services for women living in remote areas.



Perception des prestataires de soins sur l’utilisation du partogramme au BurundiDr Aline Mukundwa, Laura Harris, Dr Sylvestre Bazikamwe, Dr Jean Francois Busogoro, Dr Koyejo Oyerinde

Introduction Le partogramme est un outil de surveillance du travail d’accouchement, qui est peu utilisé de façon régulière dans certains pays, dont le Burundi.

ObjectifCette étude avait pour objectif de documenter la perception des prestataires de soins à l’utilisation du partogramme et les barrières à son utilisation dans les formations sanitaires du Burundi.

MéthodesDes interviews et focus groups ont été réalisés avec des prestataires, en français et en langue locale le Kirundi. Des questionnaires en français ont été distribués aux prestataires qui ont répondu aux interviews. Les renseignements obtenus grâce aux interviews et focus groups ont été transcrits par thème et analysés par le logiciel Weft QDA. Les réponses au questionnaire ont été analysées par Microsoft Access.

RésultatsLe partogramme est apprécié par les répondants pour sa facilité de montrer la progression du travail et de communiquer entre soignants.

Cependant, plusieurs d’entre eux ont dit que le partogramme ne donne pas de valeur ajoutée dans la surveillance habituelle du travail. Il est donc souvent perçu comme un surplus de travail. Les facteurs décourageants son utilisation sont une surcharge



du travail dans un environnement qui souffre de pénurie en personnel et le manque de personnel formé.

ConclusionLes formations sur l’utilisation du partogramme ne suffisent pas pour déclencher et perpétuer son utilisation. Nous recommandons que les formations des prestataires à tous les niveaux de soins s’accompagnent d’un plaidoyer au niveau central pour permettre un bon suivi dans son utilisation.

Saving Mothers Lives: Jhpiego’s innovative approach to prevent postpartum hemorrhage at facility level using Mama Natalie

Mukarugwiro B, Jeremie Z, Cherrie E

BackgroundMaternal mortality is still high worldwide. About 800 women die from pregnancy- or childbirth-related complications around the world every day. In 2010, 287 000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented.

Post-partum hemorrhage is remaining the leading cause of maternal mortality: at 34% of in Africa from 1997 to 2002.Rwanda has the same situation with hemorrhage being the leading cause of maternal mortality at 31% in 2012 ( MoH, maternal death audit). \Efforts need to be continuously made to address this issue.



Jhpiego interventions in PPH prevention and treatment at facility level.

Among evidence based intervention to prevent PPH, there is AMSTL. Jhpiego has been actively involved in promoting and training front health care providers in AMSTL. To allow effectiveness of the intervention, all health care providers need to have capacity to perform AMSTL to standard.The Rwanda Quality of Care assessment conducted by MoH in collaboration with Jhpiego MCHIP shown there are still gaps in the provider’s competencies to perform effectively AMSTL: only 55% were able to perform it with respect of correct route and timing.

In collaboration with other partners, Jhpiego developed Helping Mothers Survive: Bleeding after Birth, an approach designed to help teams of frontline health workers who provide care at birth for women and newborns.

This is done by providing the Bleeding after Birth training that has been designed to help learners achieve mastery of competencies needed to safely and effectively prevent, detect, and manage postpartum hemorrhage. This training package was created with input from content experts from global stakeholders including FIGO, ICM, ICN and AAP. The training method and package was field tested in India, Malawi, and Zanzibar with good transfer of learner and skills.

The training is done by using Mama Natalie, an inexpensive anatomic model that simulates uterine atony and hemorrhage. It can be done hand in hand with Helping Babies Breathe.

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