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THE CASE RECORDS AND COMMENTARIES IN OBSTETRICS AND GYNAECOLOGY SUBMITTED BY DR. JOHN ODERoloNG’ECH IN PART FULFILLMENT FOR THE DEGREE OF AAASTER OF MEDICINE IN OBSTETRICS AND GYNAECOLOGY OF THE UNIVERSITY OF NAIROBI JULY 2003 MEDICAL LIBRARY UNIVERSITY o f NAIROBI TABLE OF CONTENTS page Acknowledgem ents................................................. (iv) Dedication ............................................................ (v) Declaration............................................................ (vi) Certification.......................................................... (vii) Introduction......................................................... 1 OBSTETRIC SHORT CASES No. 1. Preeclampsia at 35 weeks, conservative management up to 38 weeks, live baby................................................... 16 2. Cardiac disease at 34 weeks, live baby................................ 26 3. Pregestational insulin dependent diabetes mellitus in pregnancy, unfavorable Outcom e................... ....................... 35 4. sickle cell disease in pregnancy, emergency caesarean section ,live baby............................................................. 49 5. Rhesus negative primigravida at 40 weeks........................... 57 6. Urinary track infection at 38 weeks gestation, live baby........... 64 7. Antepartum hemorrhage - abruption placenta, at 32 weeks, fresh still birth................................................... 71 8. post term pregnancy - successful labor induction..................... 80 9. Preterm premature rupture of membranes at 34 weeks, labour induction, live b a b y...................................... 86 10. Deep venous thrombosis at 29 weeks, live baby at 34 weeks...... 95 11. Malaria at 34 weeks gestation, live baby at 36 weeks.............. 102 12. Breech in primigravida at 38 weeks with reduced fetal movement, emergency caesarean section, live baby................ 108 13. HIV in pregnancy, elective caesarean section at 38 weeks........ 115 14. Cervical incompetence, cervical cerclage, live baby at term....... 126 15. Twin pregnancy in labour at 36 weeks, live babies................ 133 OBSTETRIC LONG COMMENTARY: Knowledge, Attitude and Practice on Perinatal HIV transmission and preventive measures among antenatal mothers at Kenyatta National Hospital................................. 142 ii GYNAECOLOGY SHORT CASES Page 1. Gestational Trophoblastic Disease - chemotherapy................... 176 2. Carcinoma of the ovary stage III - Laparatomy and chemotherapy..................................................................... 182 3. Secondary infertility - tuboplasty done....................................190 4. Dysfunctional uterine bleeding .total abdominal hysterectomy (TAH) d one.................................................... 198 5. Symptomatic uterine fibroids, TAH done .................................205 6. Cervical cancer stage IB, wertheims hysterectomy followed by radiotherapy......................................................214 7. Imperforate Hymen, cruciate incision.................................... 223 8. Acute pelvic inflammatory disease - antimicrobial therapy.........229 9. Bartholins Cyst, Marsupialization. ..................................235 10. Ruptured Ectopic pregnancy, right partial salpingectomy............ 239 11. Uterine prolapse - vaginal hysterectomy with anterior colporrhaphy and repair of enterocele.................................. 247 12. Sexual assault, EUA and repair of vaginal and perineal te a rs................................................................ 254 13. Genito - urinary fistula (vesico - uterine) , Repair done.......... 262 14. Incomplete Abortion, manual vacuum Aspiration done............. 270 15. Burst Abdomen after caesarean section, secondary repair......... 276 GYNAECOLOGY LONG COMMENTARY: Post Abortion Care services at Kenyatta National Hospital............................................. 281 Appendix I .................................................................................. 315 Obstetric data collection Questionnaire Appendix I I ................................................................................322 Gynaecology data collection Questionnaire Appendix III...................................................................................329 Letters of ethical approval iii AKNOWLEDGEMENT I would like to thank Kenyatta National Hospital training committee for having recommended me for full sponsorship for the postgraduate training at the university of Nairobi. I am greatly indebted to and sincerely thank all the consultants, lecturers and senior registrars of the department of Obstetrics and gynaecology for having dedicated their time to see that I acquired all the necessary knowledge and skills during my training at the university of Nairobi. I would like to express by sincere gratitude to my supervisors Dr. M ’lmunya Machoki and Weston Khisa in their efforts to see that my proposal and long commentaries were properly written by offering expert advise and guidance and also making very meaningful critique of the long commentaries and the short cases,.I am also grateful to Dr. Orero and Khama Rogo for their guidance on the Gynaecology long commentary and Dr. Kiarie for the critical review of the obstetric long commentary. I am most grateful to all the people who helped in one way or another with the long commentaries. I would particularly like to mention Sr.Juma and Muthengi of clinic 18, Sr. Gakuo and Ong’ondo, the counselors in ward ID. Special thanks to Wanjiru Mwangi and Agneta who worked tirelessly in typing and preparing all the manuscrips and ensuring that I met all the deadlines. Mr. E.Muniu and Ngare James of Kemri also did a recommendable work in the scientific data analysis. Finally I would like to thank all my fellow registrars and colleagues, nurses and midwives and all the support staff who made it fun and easy during my training and for the teamwork. IV DEDICATION: This book is dedicated to my father Jeremiah Ong’ech Ogola for inspiring me to take a carrier in medicine and to my brother Joseph Ochieng Ong’ech for supporting me throughout my entire education life. DECLARATION I declare that all the cases recorded, research work and write ups in this book are my own original work and have not been presented for a degree course in any other university. I further declare that all the cases presented here were treated and operated on by me under supervision of the senior members of department of obstetrics and gynaecology at Kenyatta National hospital, Nairobi t e r Signed doL DR. JOHN ODERO ONG’ECH REGISTRAR DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI vi CERTIFICATE OF SUPERVISION This is to certify that the long commentaries in this book by Dr.J.O.Ong’ech were researched upon our guidance and supervision and that this book is submitted with our approval 1. Sigr )3 DR. M’l ANDRO AND LECTURER IN DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI <1) OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI Vll CERTIFICATION This is to certify that Dr. Ong’ech J.O managed obstetric cases nos. 14,15 and gynaecology cases nos. 2,3,15 under my supervision at Kenyatta National Hospital, Nairobi, Kenya. , __ • Date blfDvZ- PROF. OJWANG S.B.O, MD, MMED, DIP GYN.ONCOL PROFESSOR AND CONSULTANT DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI viii CERTIFICATION This is to certify that obstetric cases Nos.1, 3,4,13 and Gynecology cases Nos 12,4,6 were managed by Dr. Ong’ech J.O under my supervision at Kenyatta National Hospital Nairobi, Kenya. Date ^ DR. OYIEKE J.B.O MB.Ch B, MMED (OBS/GYN) SENIOR LECTURER, CONSULTANT AND CHAIRMAN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY UNIVERSITY OF NAIROBI IX CERTIFICATION This is to certify that obstetric case No.7 was management by Dr. Ong’ech J.O under my guidance and supervision at Kenyatta National Hospital 0, Signed Date I 7 / i . DR. WANJALA S.M.H, MBChB MMED (OBS/GYN) SENIOR LECTURER, CONSULTANT AND FORMER CHAIRAAAN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY UNIVERSITY OF NAIROBI, CERTIFICATION This is to certify that gynaecology case No 11 was managed by Dr. Ongech J.O under my guidance and supervision at Kenyatta National Hospital DR. KARANJA J.G. MBChB MMED (OBS/GYN) SENIOR LECURER, CONSULTANT AND FORMER CHAIRMAN DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI xi CERTIFICATION This is to certify that obstetric cases Nos. 5,6,10 and Gynecology cases Nos. 1,8,9,14 were managed by Dr. Ong’ech J.O under my supervision at Kenyatta National Hospital. Date XOO} DR MUIA NDAVI, MBChB, MMED(OBS/GYN), MSC-EPID, FHBR, DLSHTM SENIOR LECTURER AND CONSULTANT DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI Xll CERTIFICATION This is to certify that obstetric cases Nos 2,8,11,12 and Gynaecology cases Nos. 5,10,13 were managed by Dr. Ong’ech J.O under my supervision at Kenyatta DR. KOIGI KAMAU MBChB, MMED (OBS/GYN) SENIOR LECTURER AND CONSULTANT DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI xiii CERTIFICATION This is to certify that gynaecology case No7 was managed by Dr. Ong’ech J.O under my supervison at Kenyatta National Hospital. CONSULTANT AND CHIEF MEDICALL SPECIALIST, KENYATTA NATIONAL HOSPITAL HONORARY LECTURER DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UNIVERSITY OF NAIROBI xiv INTRODUCTION Kenyatta National Hospital is the largest hospital in the country. It serves as a referral, teaching and research centre. It provides facilities for undergraduates, postgraduates and paramedics training.

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