AFJOG

African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 27 ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | A retrospective review of gynaecological emergency surgery at Groote Schuur Hospital for the period of January to December 2019: a snapshot into women’s health in a Middle-Income Country, South Africa. amongst all different surgical disciplines. The Timing of Acute Care Surgery (TACS) classification study indicated that most institutions worldwide use a colour triage system for acute surgical emergencies which was also recommended by the study itself based on their findings on how effective it can be. It is unfortunate that there is no literature that has looked at the triage mechanisms specifically for gynaecological emergency surgery, as compared to obstetrics. It is critical for gynaecology to have a standardized triage mechanism, especially within our settings where conditions like ectopic pregnancy and miscarriages remain the common causes of morbidity and mortality in South Africa. [14] At Groote Schuur Hospital, we are aligned with international institutions as we also follow the same colour code triage system in theatre. In our audit, we had 174 women (60%) in which the decision for surgery was made within 4 hours of arrival and 207 (71.4%) within 10 hours. Thirty-nine (13.4%) women were booked after 24 hours. Fourteen of these women required medical management for PID (pelvic inflammatory disease) initially, which was attempted but failed. The rest of the other cases booked after 24 hours were patients who had to wait for biochemical and imaging investigations. Among the women who experienced hypovolaemic shock (N=27), a total of 20 (74.1%) were promptly booked for surgery within an hour. Out of the 7 cases, 4 (14.8%) were booked within 2 hours, while the remaining 3 (11.1%) were scheduled within 4 hours. Some of the contributing factors identified for patients not being booked within an hour were related to initial assessments made by junior doctors before a senior assessment was conducted. Furthermore, it was observed that the resuscitation of patients with blood products occurred in cases that were booked later than an hour. Based on the TACS classification, the general finding of the study indicated a good triaging and no real delays in decision making. The audit also found valuable delays in patients getting into theatre for surgical intervention from the time they were booked. There was disproportion of the DIT findings in the study in relation to the colour code triage mechanism used at Groote Schuur Hospital, which is similar to the TACS study. [27] Out of the 27 women in hypovolaemic shock, only 2 (7.4%) were able to immediately make it to theatre within 1 hour DIT. There was no patient who had a DIT of 30 minutes. The rest of the DITs of hypovolaemic women were as follows: 1-2h = 33.33% (N=9) ; 2-4h =37.03% (N=10) ; 4-10h = 18.51% (N=5) and 10-15h =3.70% (N=1). The 27 women in hypovolaemic shock had ectopic pregnancy (N=14), incomplete miscarriage (N=12) and intra-abdominal bleeding (N=1). Evidence has indicated that hypovolaemic shock carries high morbidity and mortality rate. [28,29] The 2014-2016 and 2017-2019 Saving Mothers report indicated that mortality because of ectopic pregnancy was caused by hypovolaemic shock in 83% and 81% respectively. [14,33] There were no mortalities in this audit. This may be that our cohort was predominantly young women with less comorbidities and resilient physiological response. [28] Another reason may be that women were adequately resuscitated prior to surgery. A total of 179 (61.7%) participants went to theatre after 4 hours of being booked in theatre. Only 46 (15.9%) women accessed surgery within 2 hours. There was a total of 20 (6.9%) women who had to wait for more than 24 hours for their operation to be done. Out of the 20 patients, 17 (85%) cases were delayed due to lack of emergency theatre time as other cases in other surgical disciplines were prioritised by theatre management. In the remaining 2 (10%), the surgery was postponed by the surgeon and one (5%) of the patients was unfit for anaesthesia at the time. No delays were encountered for any of the women due to having eaten or being stable and surgery anticipated to be challenging in the early hours. The number of delays exceeding 24 hours may seem to be small in our setting, but this is not in keeping with the hospital triage system and TACS study. [27] Many of these patients had pregnancy related conditions (79.1%) and underwent pregnancy losses. In the literature review, it has been found that patients frequently experience both stress and grief with early pregnancy loss.[30] The quality of service offered to the women has the potential to alleviate rather than worsen these negative outcomes. [31] Women who are compromised both medically, as well as experiencing pregnancy loss, grief and who need to undergo surgery, should not be competing to survive. Further findings of the study regarding the outcomes of surgeries were generally good. There were only 14,5% of complications post operatively and no mortality was recorded. Most complications were found to be minor based on the Gravien Dindo classification used to grade post operative surgery complications. [32] While there were good outcomes in this study and setting, delays in accessing theatre for women may be catastrophic in more limited-resourced hospitals in the Western Cape and other provinces in South Africa. A total of 193 (66.6%) women spent only 3 nights from admission to discharge as expected due to the type of surgical procedures they underwent. There were only 97 (33.4%) women who spent more than 3 nights. Limitations of the study The retrospective nature of the study is a limitation. In addition, the quality of care as experienced by the women could not be assessed. In South Africa, there is a lack of previous similar studies for comparison, as most are conducted internationally. 5. CONCLUSION: The study indicates favourable outcomes for emergency gynaecological surgeries performed at Groote Schuur Hospital. However, there were notable delays between the decision for surgical intervention and the actual performance of the surgeries. All the delays experienced by our hypovolaemic shocked women were because of competing with other surgical disciplines for emergency theatre time. This is due to the absence of designated theatres for early pregnancy complications or emergency gynaecological surgery for women. Maternal morbidity and mortality is a priority, especially in low and middle- income countries. In the care of women, however, it is important to include surgical care beyond maternal mortality. We hope that this study will encourage further discussions and audits in the surgical field of Gynaecology both locally and nationally. As this study was retrospective, we also recommend that the quality of care should also be explored. Most women in this audit had surgery and experienced a pregnancy loss at the same time. The time delays in having definitive surgery and being kept starved while waiting, associated with the process of grieving, has not been explored in the literature. Women’s health and surgery needs to be made a priority.