The Domestication of Misoprostol for Abortion in Burkina Faso: Interactions Between Caregivers, Drug Vendors and Women

Misoprostol has been hailed as a revolution within global maternal health research and policy communities because of its potential to reduce maternal mortality from post-partum haemorrhage and unsafe abortion, allowing relatively safe abortion in legal and illegal settings. However, we know little about how women who want to use misoprostol access it to induce abortion. Based on 15 months of ethnographic fieldwork in Ouagadougou, Burkina Faso, this chapter describes and analyses how women gain access to misoprostol to induce abortion within a setting where induced abortion is legally restrictive and where the legal use of misoprostol is limited to post-abortion care and post-partum haemorrhage. The findings show that women seeking abortions in Ouagadougou are able to access misoprostol through unofficial channels, specifically through health workers and drug vendors. While this unofficial use of misoprostol is relatively safer, and more affordable than other options, access is not equally distributed and the cost women pay for the drug varies significantly. While women with strong social networks and financial resources can access misoprostol easily, other women who do not have money to buy misoprostol may become victims of sexual violence from men from whom they seek abortion services. In Ouagadougou, access to abortion with misoprostol is shaped by health workers and the social and economic conditions of the women who seek it. The study uses the concepts of ‘pharmaceutical diversion’ and ‘domestication’ as adjacent analytical frameworks to emphasize the changing pattern of access to misoprostol. The chapter introduces the importance of looking at safe access to safe abortion.

Teenage Pregnancy; Maternal and Fetal Outcomes

Objective: The aim of this study is to determine the adverse adverse maternal and fetal outcomes in teenage pregnant women. Study Design: Randomized controlled trial Place and Duration: Department of Gyne & Obs, Shahida Islam Teaching Hospital Lodhran, during from 15-04-2020 to 31-03-2021. Material and methods: Total one hundred and twenty patients were enrolled in this study. Patients were aged between 14- 40 years. Patients detailed demographics were recorded after taking written consent. Patients were equally divided into two groups I and II. 60 patients of aged between 14-18 years were included in group I and equally patients of aged >18 were included in group II. Frequency of pre-eclampsia, gestational diabetes mellitus and post-partum haemorrhage were calculated. Adverse outcomes among (cesarean section, instrumental delivery,induction of labor and prolong labor, hypertensive disorder) were calculated among both groups. Fetal outcomes Perinatal mortality, Low birth weight, Low Apgar score and NICU admission were observed. Complete data was analyzed by SPSS 22.0 version. Results: Mean age of the patients in group I was 17.88±1.42 years with mean BMI 22.09±4.66 Kg/m2 and in group II mean age was 19.16±8.64 years with mean BMI 23.87±4.57 Kg/m2. Fetal outcomes, perinatal mortality in group I 8 (13.3%) and in group II was 5 (8.3%), low birth weight in group I was among 25 (41.7%) and in group II was 9 (15%), low apgar score in group I was 10 (16.7%) and in group II was 7 (11.7%), 12 (20%) in group I went to NICU admission and 4 (6.7%) patient in group II admitted to NICU. Frequency of pre-eclampsia in group I were high among 27 (45%) patients as compared to group II 13 (21.7%) patients , frequency of gestational diabetes mellitus in group I was among 14 (23.3 %) patients and 5 (8.3%) patients were in group II, post partum haemorrhage was seen in 42 (70%) cases in group I and 23 (38.3%) cases in group II. Conclusion: Delaying intrauterine development and premature neonatal intensive care admissions are also on the rise in this study. Anemia, urinary tract infection, high blood pressure pregnancy, and surgical delivery are all associated with pregnancies in which the mother is a teenager. Keywords: Pre-eclampsia, Partum haemorrhage, Maternal outcome, Fetal outcome

A Comparative Study of Maternal and Fetal Outcome in Obese Non- Obese Pregnant Women

Objective: The aim of this study is to determine the adverse pregnancy outcomes in obese and non- obese women. Study Design: Randomized controlled trial Place and Duration: Department of Gyne & Obs, Shahida Islam Teaching Hospital Lodhran, during from 01-07-2020 to 31-07-2021. Methods: Total one hundred and eighty patients were enrolled in this study. Patients were aged between 18- 50 years. Patients detailed demographics were recorded after taking written consent. Patients were equally divided into two groups I and II. 90 obese patients were included in group I and equally non-obese patients were included in group II. Frequency of pre-eclampsia, gestational diabetes mellitus and post-partum haemorrhage were calculated. Adverse outcomes (cesarean section, instrumental delivery, induction of labor and prolong labor, hypertensive disorder) were also calculated among both groups. Fetal outcomes were perinatal mortality, Low birth weight, Low Apgar score and NICU admission were observed. Complete data was analyzed by SPSS 24.0 version. Results: Mean age of the patients in group I was 34.12±4.59 years with mean BMI 31.12±8.67 Kg/m2 and in group II mean age was 26.13 ±5.78 years with mean BMI 23.03±9.48 Kg/m2. Frequency of pre-eclampsia in obese group I were high among 40 (44.4%) patients as compared to group II 9 (10%) patients , frequency of gestational diabetes mellitus in group I was among 21 (23.3%) patients and 6 (6.7%) patients were in group II, post partum haemorrhage was seen in 57 (63.3%) cases in group I and 29 (32.2%) cases in group II. Fetal outcomes, perinatal mortality in group I 5 (5.5%) and in group II was 4 (4.4%), low birth weight in group I was among 21 (23.3%) and in group II was 45(50%), low apgar score in group I was 14 (15.5%) and in group II was 9 (10%), 43 (47.8%) in group I went to NICU admission and 28 (31.1%) patient in group II admitted to NICU. Conclusion: Pregnancy-related complications such as gestational diabetes, pre-term labour, and pre-eclampsia are more likely in obese women, according to our data. Having a baby with a woman who is obese might lead to serious difficulties for both mother and baby. Maternal obesity is connected with an increased risk of feto-maternal morbidity and mortality. Keywords: Pre-eclampsia, Gestational diabetes, Partum haemorrhage, Apgar score, NICU

Practices of Skilled Birth Attendants about AMTSL in Prevention of Post-Partum Haemorrhage: Cross-sectional Study

Aim: To assess the practices of SBAs about AMTSL working in labour room at tertiary level of care in-order to minimize the accidence of PPH. Study Design: Cross-sectional descriptive study. Methodology: This study with enrolled SBAs (n=120) was done following ethical review committee’s (ERC) approval at Government tertiary care hospitals of the Lahore-Pakistan. For data collection a WHO standardized check list as a questionnaire was used to assess the practices of SBAs. Results: Results showed that there were gaps in competencies of SBAs about AMTSL working in labour room. Most of the steps that are S1, S3, S4, S8, S12, S13, S14 and S15 were not done by the majority of the SBA working in labour room. Almost 12 (10%) out of 120 SBAs just got 60% and above marks, 100 (83.3%) out of 120 got marks between40 to 59% and only 8 (6.7%) got less than 40% marks. Conclusion: We concluded that SBAs had unsatisfactory knowledge about standardized check list of AMTSL by WHO and their practices were not according to standard. Keywords: Skilled Birth Attendants, Labour Stages, Post-partum Haemorrhage and Practices.

Fetomaternal Outcome in Placental Abruption

Background: Placental abruption is a major contributor to obstetrical haemorrhage and a major cause of perinatal mortality in developing countries. This has been done to an attempt to recognize this condition at an earlier stage, prevent its complications and properly manage the complications if they do occur. Aim: To determine maternal and fetal outcome in females with placental abruption. Methods: Hundred patients with confirmed diagnosis of placental abruption were divided in three categories according to the grade of placental abruption. Their baseline investigations including blood group, haemoglobin and coagulation profile i.e. partial thromboplastin time, activated partial thromboplastin time, serum fibrinogen and FDP's were performed and recorded for each category separately. The effect of each grade of abruption was studied on maternal and fetal outcome as well as extent of coagulation disturbance. Results: The results of the study show that 66% babies were delivered alive and 34% were IUD/stillbirth. Gestational age at presentation was important in fetal outcome. Out of 30 babies presenting before 32 weeks of gestation 66% were IUD/stillbirth. 58% patients delivered vaginally and 42% had caesarean section. 32% patients had grade I abruption, 34% patients had grade 3 abruption. 18% patients had post-partum haemorrhage. Conclusion: All professionals working in labour ward must be aware of the causes, presentation and complications of disease and appropriate measures taken in time can help reduce the maternal and neonatal morbidity and mortality. Keywords: Placental abruption, maternal outcome, foetal outcome, coagulation disturbance

Complement activation and blockade in massive post-partum haemorrhage, thrombotic microangiopathy and acute kidney injury: a case report

Background Thrombotic microangiopathy (TMA)-mediated acute kidney injury (AKI) following massive haemorrhage is a rare but severe complication of the post-partum period. It is associated with a poor renal prognosis and a high risk of end-stage kidney disease. Complement activation may occur in this picture. However, whether complement activation, and thus complement blockade, may be critically relevant in this setting is unknown. Case presentation A 50 year-old woman presented with massive delayed post-partum haemorrhage (PPH). Despite bleeding control and normalization of coagulation parameters, she rapidly developed AKI stage 3 associated with dysmorphic microhematuria and proteinuria up to 2 g/day with the need of renal replacement therapy. Blood tests showed signs of TMA associated with markedly increased sC5b-9 and factor Bb plasma levels, respectively markers of terminal and alternative complement pathway over-activation. This clinical picture prompted us to initiate anti-C5 therapy. sC5b-9 normalized within 12 h after the first dose of eculizumab, factor Bb and C3 after seven days, platelet count after nine days and haptoglobin after 3 weeks. The clinical picture improved rapidly with blood pressure control within 48 h. Diuresis resumed after three days, kidney function rapidly improved and haemodialysis could be discontinued after the sixth and last dose. Serum creatinine returned to normal two years after presentation. Conclusions We suggest that massive PPH induced major activation of complement pathways, which ultimately lead to TMA-induced AKI. Various causes, such as oocyte-donation, the potential retention of placental material and the use of tranexamic acid may have contributed to complement activation due to PPH. The prompt administration of anti-C5 therapy may have rapidly restored kidney microcirculation patency, thus reversing signs of TMA and AKI. We propose that complement activation may represent a major pathophysiological player of this complication and may provide a novel therapeutic avenue to improve renal prognosis in TMA-induced AKI following massive PPH.

Adenomyosis a Rare Contributor to Severe Primary Post-Partum Haemorrhage

Adenomyosis is a challenging clinical condition for women of reproductive age with both proven and speculated, major gynaecologic and obstetric consequences. We present the case of a woman who had adenomyosis of the uterus, a successful in-vitro fertilized (IVF) conceived twin pregnancy, and severe primary postpartum haemorrhage (PPH) during caesarean section. The 38-year-old, gravida 2, para 0+1, with a 6-year history of prior infertility, had severe primary postpartum haemorrhage at caesarean delivery of a live set of twins at estimated gestational age of 35weeks. Conservative treatment included uterine compression and massage, blood transfusion, administration of intravenous carbetocin and application of multiple figure of eight haemostatic sutures at the placenta bed. Intra-operative finding on gross inspection of the uterus was in keeping with focal adenomyosis in the region of the placenta bed. Biopsy of the involved myometrial wall was avoided due to risk of provoking further severe haemorrhage. Her prior medical record revealed pelvic endometriosis at diagnostic laparoscopy prior to conception while being evaluated for infertility. Women with prior infertility and/or endometriosis, due to very probable co-existing adenomyosis, are at high risk of life-threatening, severe post-partum haemorrhage at delivery.

Risk of major labour-related complications for pregnancies progressing to 42 weeks or beyond

Background Post-term gestation beyond 41+6 completed weeks of gestation is known to be associated with a sharp increase in the risk of stillbirth and perinatal mortality. However, the risk of common adverse outcomes related to labour, such as shoulder dystocia and post-partum haemorrhage for those delivering at this advanced gestation, remains poorly characterised. The objective of this study was to examine the risk of adverse, labour-related outcomes for women progressing to 42 weeks gestation or beyond, compared with those giving birth at 39 completed weeks. Methods We performed a state-wide cohort study using routinely collected perinatal data in Australia. Comparing the two gestation cohorts, we examined the adjusted relative risk of clinically significant labour-related adverse outcomes, including macrosomia (≥ 4500 at birth), post-partum haemorrhage (≥1000 ml), shoulder dystocia, 3rd or 4th degree perineal tear and unplanned caesarean section. Parity, maternal age and mode of birth were adjusted for using logistic regression. Results The study cohort included 91,314 women who birthed at 39 completed weeks and 4317 at ≥42 completed weeks. Compared to 39 weeks gestation, those giving birth ≥42 weeks gestation had an adjusted relative risk (aRR) of 1.85 (95% CI 1.55–2.20) for post-partum haemorrhage following vaginal birth, 2.29 (95% CI 1.89–2.78) following instrumental birth and 1.44 (95% CI 1.17–1.78) following emergency caesarean section; 1.43 (95% CI 1.16–1.77) for shoulder dystocia (for non-macrosomic babies); and 1.22 (95% CI 1.03–1.45) for 3rd or 4th degree perineal tear (all women). The adjusted relative risk of giving birth to a macrosomic baby was 10.19 (95% CI 8.26–12.57) among nulliparous women and 4.71 (95% CI 3.90–5.68) among multiparous women. The risk of unplanned caesarean section was 1.96 (95% CI 1.86–2.06) following any labour and 1.47 (95% CI 1.38–1.56) following induction of labour. Conclusions Giving birth at ≥42 weeks gestation may be an under-recognised risk factor for several important, labour-related adverse outcomes. Clinicians should be aware that labour at this advanced gestation incurs a higher risk of adverse outcomes. In addition to known perinatal risks, the risk of obstetric complications should be considered in the counselling of women labouring at post-term gestation.

A case series of post-partum haemorrhage managed using Ellavi uterine balloon tamponade in a rural regional hospital

Uterine balloon tamponade (UBT) should be attempted once emergency measures have been applied and medical treatment for post-partum haemorrhage (PPH) resulting from an atonic uterus has failed. Sinapi Biomedical (Pty) Ltd developed the Ellavi UBT, a free-flow pressure-controlled UBT unit. The device is affordable for use in lesser-resourced countries. A case series of Ellavi UBT used by medical officers in a rural regional hospital without specialist supervision was conducted. This case series was conducted in St Elizabeth’s Hospital in Lusikisiki, South Africa. The hospital serves as the regional hospital for the Ingquza Hill Subdistrict in the Eastern Cape Province. The Nelson Mandela Academic Hospital (NMAH) in Mthatha is the tertiary referral hospital. Workshops were conducted on the use of Ellavi UBT, and devices were made freely available to the hospital. The case series included 10 patients. Six patients delivered by caesarean section, and four had normal vertex deliveries. All patients had additional oxytocin infusions, and eight patients received misoprostol. Following the insertion and inflation of the Ellavi UBT, the PPH stopped in seven patients, was much reduced in one patient and reduced in one patient. In one case, the Ellavi UBT had no effect on the bleeding. All 10 patients were referred to the NMAH. All patients in the case series had good outcomes. The insertion of the Ellavi UBT and subsequent referral proved to be feasible in a rural regional hospital. All patients included in the case series arrived at the referral hospital and had a good outcome.