BackgroundInvestigating cases of severe maternal morbidity (SMM) and severe maternal outcome (SMO) and the quality of maternal health care using near-miss approach has become popular over recent years. The aim of this study was to determine facility based incidence and the determinants of severe maternal outcome (SMO) using this approach.MethodsProspective cross-sectional study among all mothers who presented to study facility while pregnant, during child birth and/or within 42 days after termination of pregnancy seeking care and found to have SMM and SMO during the study period was carried out.ResultsThere were total of 2737 live births, 202 SMM and 162 SMO (138 maternal near-misses (MNM) and 24 maternal deaths (MD)) cases. The SMO ratio was 59.2 per 1000 live births and the MNM mortality ratio, mortality index (MI) and maternal mortality ratio (MMR) were: 5.8:1, 14.8% and 876.9 per 100,000 live births respectively. Close to three-fourth of all women with SMO had evidence of organ dysfunction on arrival or within 12 h of hospitalization. The commonest underlying causes for SMO were uterine rupture 27%, followed by hypertensive disorders 24% and obstetric hemorrhage 24%. The highest case fatality rate was found to be associated with eclampsia 28%. Maternal age, residential area, educational status and occupation were associated with SMO (P < 0.0001). On binary multivariable logistic regression the occurrence of any delay, intrapartal detection of complication, the mode of delivery and duration of hospitalization had statically significant association with SMO (p < 0.05). Optimal number of antenatal care (ANC) visits and delivery by emergency cesarean section (C/S) were found to be protective of SMO.ConclusionThe occurance SMO in the facility thus in the population served was high. Most of these factors associated with SMO are modifiable; some amenable to social change and the others are within the control of the health system. Thus the finding of this research calls for planning for such changes which can enhance timely and proper detection and management of pregnancy related complications.

BACKGROUND: Leiomyoma with secondary changes arising from Mullerian remnant may mimic ovarian tumor in women with Mayer-Rockitansky-Kuster-Hauser (MRKH) syndrome in patients with pelvic mass and urologic abnormalities. CASE DETAIL: The patient was a 40 years old known case of MRKH, presented with lower abdominal pain and swelling for over one year. On physical examination, large pelvic mass (about 15cm by 10cm) was found and a diagnosis of ovarian tumor was made by imaging which also showed absent right kidney. Finally, the mass was found to be a big leiomyoma with areas of hyaline, edematous and cystic degenerations. CONCLUSION: Although leiomyoma arising from rudimentary Mullerian bulb is a rare condition, it should be considered in differential diagnosis of pelvic mass in patients with MRKH. Possibility of urologic abnormalities should also be considered in these patients and appropriate work up per local context should be made.

Uterine rupture is one of the most catastrophic complications during pregnancy. It is a rare complication in developed countries but a frequent cause of maternal and perinatal morbidity and mortality in Africa. Uterine rupture occurs in 1.6% of patients suffering blunt abdominal trauma. Here we report a unique case of complete fundal rupture of the unscarred uterus following fall from motorcycle in 39-week-pregnant mother who was managed with total abdominal hysterectomy and left salpingo-oophorectomy and survived, though fetus died before intervention. We also reviewed similar cases reported from different parts of Africa. This is a preventable complication had the woman been properly instructed on transportation safety during her antenatal care visits.

Conjoined twin is a rare complication of monozygotic twins resulting from incomplete splitting of an embryo into two separate twins or early secondary fusion of two originally separated embryos. When diagnosed at early gestation, one can get adequate time to counsel the family on whether to continue with the pregnancy and proper intervention can be planned. On the other hand, undiagnosed cases may be first recognized in labor after they have caused labor-related complications. In the present case report, an undiagnosed case of a conjoined twin has presented in labor followed by delivery of one baby with the retention of the second baby. This presented a unique challenge to the managing team and required hysterotomy to effect delivery of the unborn baby. We report this case to highlight the importance of early diagnosis of a conjoined twin. On another hand where this does not happen and a conjoined twin is suspected for the first time after it has caused labor-related complications, the management should be individualized based on the clinical circumstance.

Background: Weight discordance of ≥ 20 percent is present in 15 percent of twin pairs and mostly the smaller twin's birth weight <10 th percentile and the larger twin is nearer appropriate size for gestational age. We report twin pairs where the larger twin is macrosomic with smaller twin having normal birth weight. We could not find a similar report in the literature.Case presentation: The twins were born to 29 years old gravida 3 para 2 lady at 38 weeks and 3 days of gestation. The first of twins was male and macrosomic (4500 gm) and his twin sister was of normal birth weight (3500 gm), with 22 percent birth weight discordance. Conclusion:We report this case as there is no similar report in the literature on abnormal growth of twins with macrosomia and discordance: an out of the box presentation. Both of our cases are large for gestational age an adjustable fetal weight standard for twins.

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