Felicia Lester

Use of the non-pneumatic anti-shock garment (NASG) to reduce blood loss and time to recovery from shock for women with obstetric haemorrhage in Egypt

Abstract Obstetric haemorrhage is one of the leading causes of maternal mortality. In many low-resource settings, delays in transport to referral facilities and in obtaining lifesaving treatment, contribute to maternal deaths. The non-pneumatic anti-shock garment (NASG) is a low-technology pressure device that decreases blood loss, restores vital signs, and has the potential to improve adverse outcomes by helping women survive delays in receiving adequate emergency obstetric care. With brief training, even individuals without medical backgrounds can apply this first-aid device. In this secondary analysis of hospital data from a pre-post intervention study in Egypt (N=364 women with obstetric haemorrhage and shock), 158 received standard care, while 206 received standard care plus the NASG. The NASG significantly reduced blood loss, time to recovery from shock, and, for those with postpartum haemorrhage due to uterine atony who received oxytocin, the NASG had a significant effect on blood loss independent of oxytocin. These results indicate that the NASG may be a valuable innovation for reducing maternal mortality in low-resource settings. Testing at community and household levels will be necessary in order to determine whether the NASG can help women survive the longest delays.

Teaching surgical skills using video internet communication in a resource-limited setting.

OBJECTIVE: To study the feasibility and acceptability of using video Internet communication to teach and evaluate surgical skills in a low-resource setting. METHODS: This case-controlled study used video Internet communication for surgical skills teaching and evaluation. We randomized intern physicians rotating in the Obstetrics and Gynecology Department at Mulago Hospital at Makerere University in Kampala, Uganda, to the control arm (usual practice) or intervention arm (three video teaching sessions with University of California, San Francisco faculty). We made preintervention and postintervention videos of all interns tying knots using a small video camera and uploaded the files to a file hosting service that offers cloud storage. A blinded faculty member graded all of the videos. Both groups completed a survey at the end of the study. RESULTS: We randomized 18 interns with complete data for eight in the intervention group and seven in the control group. We found score improvement of 50% or more in six of eight (75%) interns in the intervention group compared with one of seven (14%) in the control group (P=.04). Scores declined in five of the seven (71%) controls but in none in the intervention group. Both intervention and control groups used attendings, colleagues, and the Internet as sources for learning about knot-tying. The control group was less likely to practice knot-tying than the intervention group. The trainees and the instructors felt this method of training was enjoyable and helpful. CONCLUSION: Remote teaching in low-resource settings, where faculty time is limited and access to visiting faculty is sporadic, is feasible, effective, and well-accepted by both learner and teacher. LEVEL OF EVIDENCE: II

Intracesarean insertion of the Copper T380A versus 6 weeks postcesarean: a randomized clinical trial.

OBJECTIVES To compare rates of Copper T380A intrauterine device (IUD) utilization and satisfaction with immediate versus delayed IUD insertion after cesarean delivery in Kampala, Uganda. METHODS This study was a randomized clinical trial of women undergoing cesarean section who desired an IUD in Kampala, Uganda. Participants were randomly assigned to IUD insertion at the time of cesarean delivery or 6weeks afterward. The primary outcome was IUD utilization at 6months after delivery. RESULTS Among 68 women who underwent randomization, an IUD was inserted in 100% (34/34) of the women in the immediate insertion group and in 53% (18/34) in the delayed group. IUD use at 6 months was higher in the immediate insertion group (93% vs. 50% after delayed insertion; p<.0001). Infection and expulsion were rare and did not differ between groups. When we pooled both groups and looked at IUD users compared to nonusers, 91% (39/43) of IUD users were satisfied or very satisfied with their contraceptive method compared to 44% (11/25) of nonusers (p<.0001). Women who chose not to be in the study or had the IUD removed often did so because of perceived husband or community disapproval. CONCLUSION The 6-month utilization of an IUD after immediate insertion was significantly higher than after delayed insertion without increased complications. Contraceptive satisfaction was significantly higher among IUD users than nonusers. Community and husband attitudes influence IUD utilization and continuation in Kampala, Uganda. IMPLICATIONS This work is important because it shows the safety and efficacy of providing IUDs during cesarean section in a setting where access to any healthcare, including contraception, can be extremely limited outside of childbearing and the consequences of an unintended, closely spaced pregnancy after a cesarean section can be life threatening.

Impact of the Non-pneumatic Antishock Garment on pelvic blood flow in healthy postpartum women.

OBJECTIVE The Non-pneumatic Antishock Garment (NASG) is a compression device that has shown significantly decreased blood loss in cases of obstetric hemorrhage. However, there are no physiologic studies of the NASG in postpartum women. This study used Doppler ultrasound to measure the resistive index (RI) in the internal iliac artery, thus approximating blood flow to the pelvis with and without the garment applied. STUDY DESIGN In this study, RI of the internal iliac artery was measured in a sample of 10 postpartum volunteers with and without the NASG applied. Median RI was calculated and compared between baseline and full application. RESULTS Internal iliac artery median RI was 0.83 (SD 0.11) at baseline and increased to 1.05 (SD 0.15) with full NASG application (P = .02). CONCLUSION This study suggests a significant increase in internal iliac artery RI with NASG application and provides a physiological explanation of how the NASG might reduce postpartum hemorrhage.

Should women with HIV, or at high risk of contracting HIV, use progestogen-containing contraception?

Nearly 150 million women worldwide use hormonal methods of contraception, predominantly oral contraceptives taken daily (both combined hormonal pills and progestogen-only pills for the purpose of this article) and long acting injectables such as depot medroxyprogesterone acetate and norethisterone enantate.1 When used correctly, these are highly effective in preventing pregnancy and are reversible. Side effects of medroxyprogesterone are similar in those who are seropositive for HIV and those who are HIV negative,2 and antiretroviral therapy does not reduce its effectiveness.3 However, antiretroviral therapy can make oral contraceptives less effective at preventing pregnancy, and oral contraceptives can increase antiretroviral drugs’ toxicity.3 Concerns have been raised about possible harmful effects of hormonal contraception in patients infected with HIV and those at high risk of contracting HIV. These effects can be considered in three main categories: HIV acquisition, HIV infectivity, and rate of progression of HIV. Several biologically plausible mechanisms have been proposed for these effects, including effects on genital HIV viral shedding, vaginal epithelial thickness, degree of cervical ectopy, or local and systemic immune responses.4 However, there is little consistent evidence. Any potential for harm is important given that in sub-Saharan Africa, women of childbearing age are disproportionately affected by HIV. It is essential to offer women the opportunity to prevent HIV acquisition, not only for their own health but to prevent mother to child transmission. The most upstream means of primary prevention for HIV is preventing unintended pregnancy in the first place. Disease progression puts the woman at risk of opportunistic infections and increases the risk of transmitting the disease to an uninfected partner. However, it is equally important to avoid denying access to contraceptives without adequate evidence, since those areas where unintended pregnancy poses the greatest threat to women’s lives are often the same areas …

Radical trachelectomy for clear cell carcinoma of the cervix in a 6-year old: a case report, review, and description of the surgical technique

Clear cell carcinoma is a rare pediatric cervical cancer, seen primarily in the setting of in utero diethylstilbesterol exposure. Historically, this type of cancer has been treated with radical hysterectomy and lymph-node dissection, rendering patients incapable of carrying a pregnancy in the future. We describe a young patient with clear cell carcinoma of the cervix who, through a multidisciplinary collaboration, was managed by a fertility-sparing alternative surgical approach--a radical trachelectomy. We present the surgical technique and review the current evidence regarding the use of radical trachelectomy as a fertility-sparing procedure in young patients with cervical cancer.

Immediate versus delayed postpartum use of levonorgestrel contraceptive implants: a randomized controlled trial in Uganda

BACKGROUND: Use of long‐acting, highly effective contraception has the potential to improve womens ability to avoid short interpregnancy intervals, which are associated with an increased risk of maternal morbidity and mortality, and preterm delivery. In Uganda, contraceptive implants are not routinely available during the immediate postpartum period. OBJECTIVE: The purpose of this study was to compare the proportion of women using levonorgestrel contraceptive implants at 6 months after delivery in women randomized to immediate or delayed insertion. STUDY DESIGN: This was a randomized controlled trial among women in Kampala, Uganda. Women who desired contraceptive implants were randomly assigned to insertion of a 2‐rod contraceptive implant system containing 75 mg of levonorgestrel immediately following delivery (within 5 days of delivery and before discharge from the hospital) or delayed insertion (6 weeks postpartum). The primary outcome was implant utilization at 6 months postpartum. RESULTS: From June to October 2015, 205 women were randomized, 103 to the immediate group and 102 to the delayed group. Ninety‐three percent completed the 6 month follow‐up visit. At 6 months, implant use was higher in the immediate group compared with the delayed group (97% vs 68%; P < .001), as was the use of any highly effective contraceptive (98% vs 81%; P = .001). Women in the immediate group were more satisfied with the timing of implant placement. If given the choice, 81% of women in the immediate group and 63% of women in the delayed group would choose the same timing of placement again (P = .01). There were no serious adverse events in either group. CONCLUSION: Offering women the option of initiating contraceptive implants in the immediate postpartum period has the potential to increase contraceptive utilization, decrease unwanted pregnancies, prevent short interpregnancy intervals, and help women achieve their reproductive goals.

Impact of mode of delivery on pregnancy outcomes in women with premature rupture of membranes after 28 weeks of gestation in a low-resource setting: A prospective cohort study

Background Despite the high prevalence of premature rupture of membranes (PROM) in low-resource settings, the preferred mode of delivery remains unclear. We compared the perinatal mortality in a prospective cohort of women with PROM after 28 weeks following vaginal or caesarean delivery at Mulago Hospital with the aim of adopting evidence based practice and improving patient care. Methods Between November 2015 and May 2016, 1455 women with PROM after 28 weeks of gestation and their newborns were prospectively followed from admission to discharge at Mulago Hospital. The primary outcome was perinatal mortality. Secondary neonatal outcomes included sepsis and admission to the Special Care Unit. Maternal outcomes included maternal deaths and complications. Outcomes were compared between women who had vaginal vs. caesarean delivery using multivariable logistic regression. All statistical tests were 2-sided with the level of statistical significance set at p < 0.05. Results The incidence of PROM was 12.1%. The perinatal mortality following PROM was 65 per 1000 live births. Of the 1425 women with PROM, 991 (69.5%) had vaginal delivery and 434 (30.5%) underwent Caesarean section. There was no statistical difference in perinatal mortality by the mode of delivery (vaginal vs. caesarean) in PROM (p = 0.12). The risk factors for perinatal mortality included chorioamnionitis, failure to administer corticosteroids in preterm PROM, gestational age (28–33 weeks), duration of drainage of liquor (24–48 hours), and presence of maternal complications. Caesarean delivery was associated with increased maternal postpartum infections, admission to the Special Care Unit and maternal death. Conclusion In low resource settings, vaginal delivery is the preferred mode of delivery for PROM after 28 weeks gestation. It is associated with lesser maternal and perinatal morbidity when compared to caesarean delivery.

Development and preliminary validation of a post-fistula repair reintegration instrument among Ugandan women

BackgroundObstetric fistula is a debilitating and traumatic birth injury affecting 2–3 million women globally, mostly in sub-Saharan Africa and Asia. Affected women suffer physically, psychologically and socioeconomically. International efforts have increased access to surgical treatment, yet attention to a holistic outcome of post-surgical rehabilitation is nascent. We sought to develop and pilot test a measurement instrument to assess post-surgical family and community reintegration.MethodsWe conducted an exploratory sequential mixed-methods study, beginning with 16 in-depth interviews and four focus group discussions with 17 women who underwent fistula surgery within two previous years to inform measure development. The draft instrument was validated in a longitudinal cohort of 60 women recovering from fistula surgery. Qualitative data were analyzed through thematic analysis. Socio-demographic characteristics were described using one-way frequency tables. We used exploratory factor analysis to determine the latent structure of the scale, then tested the fit of a single higher-order latent factor. We evaluated internal consistency and temporal stability reliability through Raykov’s ρ and Pearson’s correlation coefficient, respectively. We estimated a series of linear regression models to explore associations between the standardized reintegration measure and validated scales representing theoretically related constructs.ResultsThemes central to women’s experiences following surgery included resuming mobility, increasing social interaction, improved self-esteem, reduction of internalized stigma, resuming work, meeting their own needs and the needs of dependents, meeting other expected and desired roles, and negotiating larger life issues. We expanded the Return to Normal Living Index to reflect these themes. Exploratory factor analysis suggested a four-factor structure, titled ‘Mobility and social engagement’, ‘Meeting family needs’, ‘Comfort with relationships’, and ‘General life satisfaction’, and goodness of fit statistics supported a higher-order latent variable of ‘Reintegration.’ Reintegration score correlated significantly with quality of life, depression, self-esteem, stigma, and social support in theoretically expected directions.ConclusionAs more women undergo surgical treatment for obstetric fistula, attention to the post-repair period is imperative. This preliminary validation of a reintegration instrument represents a first step toward improving measurement of post-surgical reintegration and has important implications for the evidence base of post-surgical reintegration epidemiology and the development and evaluation of fistula programming.