In an interesting case report, Nassozi J et al., describe a gravida 5, para 4, with 4 Cesarean sections, arriving in the second stage of labor and delivering a healthy term baby without any complication for the mother and newborn. Given the perinatal risks for mother and baby, she would surely have been advised a

cesarean section (CS) by most colleagues as the risk for serious morbidity and mortality is increasing with every CS. She was lucky, and a wise decision was

taken to have a tubal ligation postpartum. As rightfully stated by the authors, Cesarean delivery is one of the commonest surgical procedures and can be lifesaving for both mother and baby when indicated. However, CS rates are rising worldwide from 12% of all births in 2010 to 21% in 2015, mainly in women without medical indication and repeat CS. Overall, overuse of CS has not shown benefits and can create harm for mother and baby. Vaginal birth after cesarean section (VBAC) has been shown to be a safe technique lowering the CS rates. Hence, women with a previous CS should be offered a VBAC assuming there are no other conditions that would normally require a cesarean delivery. The VBAC success rates are between 40 and 75% and surely worth trying.

Background: Vaginal leiomyosarcomas are extremely rare. Approximately 288 cases have been reported in the literature.

Case presentation: A 60-year-old presented to the gynecological ward as a referral with a diagnosis of vaginal leiomyosarcoma for chemoradiation. She had a history of per vaginal discharge, bleeding, and a posterior vaginal wall mass. Wide local excision of the mass was done at the peripheral facility. The surgical margin was 4 mm and negative for malignant cells. The patient was started on paclitaxel and cisplatin. She underwent 25 sessions of external beam

radiotherapy and two sessions of brachytherapy. She is currently on follow-up through the gynecologicaloncology

clinic.

Conclusion: Surgical excision is the primary mode of treatment for vaginal leiomyosarcoma. Adjuvant chemoradiation following surgery has a role inreducing local recurrence and systemic relapse but with no appreciable effect on advanced disease.

Keywords: vaginal leiomyosarcoma, surgery, chemotherapy, radiotherapy

Background: Myomectomy is the surgical removal of fibroids with the preservation of the uterus for future childbirth. It may be complex when adhesions, multiple myomas of different sizes are present in various sites, and a repeat myomectomy.

Case presentation: A 40-year-old nulliparouspresented with primary infertility. She reported having heavy and prolonged menstrual bleeding that led to multiple blood transfusions due to symptomatic anemia. Physical examination revealed a palpable mass that was irregular, mobile, non-tender.Her fundal height was 16 weeks. Pelvic ultrasound demonstrated multiple uterine fibroids of varying sizes and locations. The patient desired fertility and was therefore scheduled for myomectomy. A total of 80 fibroids were excised. Tourniquet and vasopressin were used to reduce hemorrhage. Bilateral uterine artery ligation was done to achieve hemostasis.

Conclusion: Myomectomy complicated by multiple myomas up to 80 in number is possible. However, a meticulous surgical technique of myomectomy by an experienced surgeon is required. The use of tourniquet and vasopressin is vital to reduce hemorrhage during the operation.

Keywords: myoma, fibroid, complex myomectomy, infertility

Background: Vaginal birth after cesarean (VBAC) is rarely offered as a delivery option, for gravid women with more than two cesarean deliveries, due to the increased risk of adverse fetal and maternal outcomes.

Case presentation: A 38-year-old Para 4+0 Gravida 5 who had had four previous cesarean deliveries was

admitted in the second stage of labor in Maragua subcounty hospital. She delivered a live male infant by spontaneous vaginal delivery with no complications. She had an open bilateral tubal ligation on day two post-delivery and was discharged on day three postbilateral tubal ligation.

Conclusion: Vaginal delivery after cesarean delivery, while not recommended, is possible even in patients who have had multiple caesareans deliveries. Patient sensitization about antenatal care and involvement in their birth plans should also be prioritized.

Keywords: TOLAC, VBAC, bilateral tubal ligation (BTL)

Background: Mullerian developmental anomalies (MDAs) adversely affect pregnancy outcomes. These anomalies are frequently associated with renal and axial skeleton abnormalities.

Case presentation: A 33-year-old Para 0+3 was admitted to the gynecology ward with a history of three spontaneous abortions and secondary infertility for two years. She was sonographically diagnosed with a bicornuate uterus in 2016 as part of her workup for recurrent pregnancy losses. A repeat abdominal pelvic ultrasound done showed a bicornuate uterus and a right ectopic kidney. As a result, she was scheduled for hysteroscopy and laparoscopy, followed by open Strassman's metroplasty. Postoperatively, she still had bilateral tubal blockage despite having being hydrotubated intraoperatively using intraperitoneal spill.

Conclusion: Strassman’s metroplasty is effective in the management of bicornuate uteri. However, significant challenges exist in a low-resource setting which limits its access.

Keywords: bicornuate uterus, Strassman’s metroplasty, uterine malformations

Background: The availability, accessibility, and effective use of essential medical devices play a vital role in delivering quality health services. Unfortunately, in developing countries, including Kenya, it is estimated that as high as 70% of medical devices are partially or entirely non-functional. Therefore, this study sought to evaluate the clinical effectiveness, safety, reliability, and acceptability of a locally made low-cost suction aspirator (Maker) by comparing it to the standard of care equipment in a tertiary referral hospital routine setting.

Methods: This was an open-label, pragmatic, randomized controlled noninferiority trial. The mixed-methods approach with quantitative and qualitative data collection approaches was used. Women undergoing cesarean section and their babies (where needed) were randomized to either standard of care or Maker equipment for suction during surgery. A noninferiority margin of risk difference between the standard of care and Maker suction equipment was prespecified at 7%. Key informant interviews were conducted with clinicians and nurses to inform the utility of the Maker equipment.

Results: A total of 110 participants were recruited. Of these, 56 and 54 participants were randomly assigned to the standard care and Maker suction equipment arms, respectively. Using a per-protocol approach, suction was reported as successful in 96.4% (54/56) of the participants in the standard of care arm and 92.6% (50/54) of the participants in the Maker's arm. Fifty percent (n=28) of the participants in thestandard of care arm, had gauze used in place of the suction machine. Qualitative findings illustrate that the Maker equipment was reliable and acceptable with the improvements made such as overflow protection valve making it the preferred equipment.

Conclusion: The Maker equipment was observed to be any worse than compatible with the current standard of care. The high reliability and acceptability, and absence of safety concerns highlights the potential of local development of medical devices to address existing gaps.

Keywords: suction machine, medical devices, locally made, low cost, Maker Project

Background: Severe early-onset preeclampsia is associated with increased likelihood of maternal

complications and poor perinatal outcomes, regardless of expectant management.

Case presentation: A 17-year-old primigravida at 30 weeks' gestation presented to the obstetric ward with complaints of headaches and painless per vaginal bleeding for one day. Her blood pressure was 174/106 mmHg. She had proteinuria of 3+. The ultrasound revealed a 30-week single intrauterine pregnancy with a partial placenta previa. A diagnosis of severe earlyonset preeclampsia was made. She was started on expectant management with antihypertensives, antenatal corticosteroids, and magnesium sulfate with close monitoring. She developed hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome after seven days and was delivered by cesarean section. Her clinical condition improved markedly after delivery.

Conclusion: Expectant management of severe earlyonsetn preeclampsia can safely prolong pregnancy in select cases, with potential neonatal benefits.