Perinatal Priorities



The 22nd Conference on Priorities in Perinatal Care in South Africa was held under the auspices of the Priorities in Perinatal Care Association and sponsored by Abbott Laboratories SA (Pty) Ltd

Editor’s Note:

The articles included in these Proceedings were received electronically and have been included as submitted by the presenter/author. Some articles have been shortened. Abstracts are included in single spacing where articles were not submitted.

INFORMAL COMMENTS FROM PROFESSOR WENDY GRAHAM, UNIVERSITY OF ABERDEEN, SCOTLAND

Preamble

The organisers of this 22nd conference are to be congratulated on a stimulating and vibrant meeting. The agenda was full and diverse, and there was lively discussion, both within and outside the formal sessions. As one of the keynote speakers, I found the audience engaged and engaging, and appreciated the opportunity to meet about the challenges to perinatal health currently faced by South Africa. The following comments relate primarily to possible areas for further research and future meetings, and are offered in as positive a spirit as no doubt they will be received. These suggestions are presented as bulleted points and in no particular order, but rather as they arose from the discussion and presentations.

• Measurement of maternal mortality: although the latest CEMD acknowledges that the national estimate for the maternal mortality ratio of 150 per 100 000 live births is probably an underestimate this figure appears to still be widely used and quoted. Coming from the 1998 South Africa DHS, the figure strictly refers to a reference period of 1992-1998 and appears to be based on just 19 maternal deaths. It would perhaps be helpful to have this as a topic for specific discussion at the 23rd Priorities conference, both as bulleted points and in no particular order, but rather as they arose from the discussions and presentations.

• Proportion of maternal deaths occurring outside health facilities: this appears to be a crucial “unknown” in the current picture for South Africa. Whilst one might expect this proportion to be significant where there is a high percentage of births at home, research in other countries has revealed this is not always the case. There are a number of possible approaches to gaining population-based estimates for the proportion of deaths outside of facilities, and some of these are also appropriate for exploring the reasons for home deaths.

• Maternal death and other relevant explanatory factors or co-variates: during the meeting, several issues emerged which deserve further exploration, including:

o State on admission to institution where death occurred and in particular the proportion admitted in normal labour.

o Place of delivery relative to place of death.

o Socio-demographic and particularly poverty status.

o Time since discharge after delivery and subsequent admission for serious complications.

o Apparent increase in proportion of haemorrhage-related deaths.

o Postpartum deaths according to time since delivery.

• Kangaroo Mother Care:

o Several papers indicated considerable lengths of stay for mother-baby pairs. Whilst accepting the impressive “health gains” for the neonate and the significant potential health service savings, it would be important to also explore the consequences for the mother in terms of family commitments, particularly in the case of dependent children.

o The PPIP database could usefully be explored to see if KMC is impacting upon survival rates for preterm/SGA babies.

• Uptake of antenatal and delivery care:

o A number of presentations appeared to be suggesting that uptake was declining and it is important that this is reliably confirmed or refuted. The forthcoming DHS could provide an opportunity to establish this for all deliveries in the last 5 years.

o Changes in the characteristics of the “booked/unbooked” population: since the availability of free care in 1994, it was suggested that the booked cases now emcompass a wider socio-demographic and obstetric risk case-mix, whilst the unbooked now reflect a particular sub-group of high risk women. Research to confirm or refute this is important.

• Cost-effectiveness, equity and sustainability: these issues cropped up on several occasions and future meetings could usefully include at least one session or paper which raises awareness of the relevance and measurement of these dimensions.

• General observations on possible improvements to studies presented:

o Greater use of multivariate analysis.

o Presentation of percentages should also indicate numbers involved, especially where these are small.

o Confidence intervals and/or power calculations as well as p values should be presented where appropriate, again especially when the numbers are small.

o Where RCT have high refusal rates, it is important to explore wherever possible the characteristics of those omitted as this may have significant implications for the relevance of the trial findings to the general population.

o Studies using qualitative techniques should be encouraged to give more details on these methods and how quality and validity are assured.

o Research using alternative outcomes to just mortality and morbidity i.e. maternal satisfaction or anxiety, should be encouraged.

• Organisational issues

o Given the popularity of the conference and the limited time to discuss papers, organisers may wish to revisit the use of parallel sessions. These should be configured to maintain the highly productive interchange between midwives, obstetricians and neonatologists.

o Greater multi-disciplinarity might be helpful, especially involvement of social scientists, health services researchers, economists, demographers, epidemiologists, and statisticians.

o As Priorities’ remit is Southern Africa, would it be possible to encourage greater involvement from groups elsewhere in the region?

Congratulations and thanks to the Priorities in Perinatal Care Association for yet another successful meeting, and good luck for the conference in 2004.

INDEX

THE OPTIMAL DOSAGE OF NIFEDIPINE IN PATIENTS WITH EARLY ONSET SEVERE PRE-ECLAMPSIA – A RANDOMISED CONTROLLED TRIAL. DW Steyn 1

EARLY ONSET SEVERE PRE-ECLAMPSIA: EXPECTANT MANAGEMENT AT A SECONDARY HOSPITAL IN CLOSE ASSOCIATION WITH A TERTIARY INSTITUTION.

C Oettle 6

EXPECTANT MANAGEMENT OF SEVERE PRE-ECLAMPSIA IN THE MID-TRIMESTER.

DR Hall 10

HOW DOES HIV SEROPOSITIVITY AFFECT THE INCIDENCE OF PRE-ECLAMPSIA.

KA Frank 12

THE VARIATION BETWEEN THE NEW PC BASED DOPPLER WAVEFORM ANALYZER AND THE VASOFLOW DUPLEX DOPPLER. GB Theron 13

FETAL MOVEMENT COUNTING FOR ASSESSMENT OF FETAL WELLBEING: A SYSTEMATIC REVIEW. L Mangesi 16

VIOLENCE AGAINST WOMEN – IMPACT ON REPRODUCTIVE HEALTH AND PREGNANCY OUTCOME. J Schoeman 20

PRE-ECLAMPSIA AT THE KALAFONG HOSPITAL (UNIVERSITY OF PRETORIA). A RETROSPECTIVE STUDY ILLUSTRATING SOME ASPECTS OF A TERTIARY REFERRAL CENTER PRE-ECLAMPSIA POPULATION IN SOUTH AFRICA.  J Cornette 23

THE GLOBAL PROBLEM OF MATERNAL MORTALITY: INEQUALITIES AND INEQUITIES. WJ Graham 24

SOCIO-ECONOMIC INEQUALITIES AND MATERNAL HEALTH IN SOUTH AFRICA.

D Blaauw 27

EXPLORING THE JOURNEY TO MATERNAL DEATH: GENDER AND HUMAN RIGHTS PERSPECTIVES. N Mbombo 33

50 YEAR AUDIT OF MATERNAL MORTALITY IN THE PENINSULA MATERNAL & NEONATAL SERVICE [1953 – 2002]. S Fawcus 40

ADDRESSING MATERNAL MORTALITY IN A RURAL EASTERN CAPE HOSPITAL THROUGH MATERNAL DEATH AUDIT REVIEW: FINDINGS AND RESULTS.

D Jackson 45

MATERNAL DEATHS IN THE FREE STATE: STATISTICS FOR 2002. JBF Cilliers 49

OVERVIEW OF MATERNAL MORTALITY FOR KWAZULU NATAL: 1998-2001.

ND Nyasulu 55

IMPLEMENTATION OF KANGAROO MOTHER CARE: A SUCCESSFUL CASE STUDY IN KWAZULU-NATAL. A-M Bergh 56

THE UKUGONA OUTREACH - IMPLEMENTATION OF KANGAROO MOTHER CARE IN KWAZULU-NATAL. I Arsalo 66

TELETUITION – AN OPTION FOR IN-SERVICE FACILITATION OF KANGAROO MOTHER CARE? M Patrick 72

KANGAROO MOTHER CARE FROM BIRTH COMPARED TO CONVENTIONAL INCUBATOR CARE. Nils Bergman 75

THE IRON STATUS AT 6 MONTHS CORRECTED AGE OF VERY LOW BIRTH WEIGHT INFANTS AFTER DISCHARGE FROM A KANGAROO MOTHER CARE UNIT.

G Kirsten 82

ECONOMIC IMPACT OF KANGAROO MOTHER CARE. R Ricardo Escobar 85

THE VALUE OF A KANGAROO MOTHER CARE (KMC) UNIT AT KALAFONG HOSPITAL. E van Rooyen 88

KANGAROO MOTHER CARE AT SEBOKENG HOSPITAL. NC Dlungwana 93

A SURVEY OF THE SOCIAL, CULTURAL AND EDUCATIONAL BACKGROUND OF MOTHERS ADMITTED TO THE KMC UNIT AT KALAFONG HOSPITAL.

E van Rooyen 96

MATERNAL HEALTH SERVICES IN SOUTH AFRICA, UGANDA, RUSSIA AND BANGLADESH: LESSONS OF A COMPARATIVE STUDY FOR SOUTH AFRICA.

L Penn-Kekana 100

THE NURSING CRISIS: PROJECTIONS AND POSSIBLE RESPONSES. N Bergman 105

AUDIT OF DECENTRALISED ANTENATAL SERVICES IN BLOEMFONTEIN/MANGAUNG LOCAL MUNICIPALITY. WJ Steinberg 112

WHAT FACTORS ACCOUNT FOR EARLY ANC VISITS IN FIRST VISIT CLIENTS?

B Ntsuntsha 116

THE BETTER BIRTHS INITIATIVE (BBI): EVALUATION IN THE EASTERN CAPE.

N Makinana 117

BETTER BIRTH INITIATIVE IN THE PMNS. N Jam-Jam, P Barnes 118

THE WHO REPRODUCTIVE HEALTH LIBRARY ISSUE 6, 2003. Z Mlokoti 122

A VISION OF PUBLIC-PRIVATE SECTOR CO-OPERATION IN COMMUNITY MATERNAL HEALTH CARE SERVICES: THE EFFECT OF INVOLVING PRIVATE PRACTITIONERS ON THE QUALITY OF ANTENATAL CARE OF THE INDIGENT POPULATION OF TEMBISA.

KR Mokhondo 123

THE WOMAN’S HEALTH MANAGEMENT TEAM (WHMT) AS AN ESSENTIAL FOUNDATION FOR MANAGING MATERNAL HEALTH SERVICES AT MUNICIPAL LEVEL. A CASE STUDY. H Philpott 130

A BASELINE ASSESSMENT OF THE QUALITY OF MATERNAL HEALTH SERVICES IN LIMPOPO PROVINCE: REFLECTIONS AND CHALLENGES IN IMPROVING THE RELIABILITY AND USE OF INFORMATION FOR PLANNING AND MANAGEMENT AT PRIMARY LEVEL. A Voce 138

IMPROVING THE QUALITY OF RECORDS: USING A QUICK SCORING SYSTEM AND INTEGRATING SPECIFIC INDICATORS TO IMPROVE QUALITY FOR ANTENATAL CLINIC AND LABOUR WARDS. RB Mia 146

CHALLENGES AND LESSONS LEARNT IN USING MODULAR TRAINING APPROACH TO IMPROVE QUALITY OF ANC SERVICES IN RURAL CLINICS IN ZULULAND.

WS Mbambo 148

ASSESSMENT OF THE QUALITY OF CARE PROVIDED TO FIRST ANTENATAL CARE CLIENTS IN RURAL AREAS IN KZN. RS Sibiya 150

MONITORING AND IMPROVING THE QUALITY OF THE PERINATAL AUDIT.

H Philpott 152

MONITORING PERINATAL DATA IN RURAL EASTERN CAPE HOSPITALS: IMPLICATIONS FOR MATERNITY SERVICES PROGRAMMES AND RESEARCH.

D Jackson 159

IMPLEMENTING THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME AS AN AUDIT AND OBSTETRIC INFORMATION SYSTEM IN A RURAL NAMIBIAN HOSPITAL.

A Paul 164

ANALYSIS OF PERINATAL DATA FROM ALL DELIVERIES IN TYGERBERG HOSPITAL OVER A FOUR MONTH PERIOD BY USING A SIMPLIFIED ICD-10 CODING MANUAL.

H van der Merwe 171

RETROSPECTIVE ANALYSIS OF ALL DELIVERIES IN UNIVERSITAS HOSPITAL FROM 01/05/02 TO 31/07/02 AS A TERTIARY REFERRAL CENTRE IN CENTRAL SOUTH AFRICA. DJ Jordaan 175

NASAL CONSTANT POSITIVE AIRWAY PRESSURE: PRACTICAL ASPECTS.

G Kirsten 177

FETAL HYPOXIA AND BIRTH ASPHYXIA. D Woods 182

PERINATAL DEATHS FROM INTRAPARTUM HYPOXIA. DH Greenfield 185

SERUM PROCALCITONIN AS AN EARLY MARKER OF NEONATAL SEPSIS.

DE Ballot 189

FETAL ALCOHOL SYNDROME: A SOUTH AFRICAN PERSPECTIVE. DL Viljoen 193

FETAL EFFECTS OF IN UTERO EXPOSURE TO WARFARIN: PAST, PRESENT AND FUTURE. N Gregersen 197

CONGENITAL MALARIA: A CASE PRESENTATION. A Moodley 201

THE ANTEPARTUM AND INTRAPARTUM COURSE OF MOTHERS DELIVERING BABIES WITH BIRTH ASPHYXIA AT TYGERBERG HOSPITAL. S Nosarka 202

SKILLED ATTENDANCE AT DELIVERY. WJ Graham 203

FIRST DELIVERY EXPERIENCES. (AN ANALYSIS OF STUDENT REFLECTIVE COMMENTARIES). G Draper 207

THE USE OF ANALGESIA IN LABOUR WARDS IN TWO DISTRICT HOSPITALS.

L Penn-Kekana 212

EMPOWERMENT THROUGH THE ACTIVE BIRTH POSITIONS INTRODUCING PHYSIOLOGICAL BIRTHING POSITIONS INTO THE PUBLIC SECTOR.

B Rautenbach 218

EVIDENCE-BASED CAESAREAN SECTION TECHNIQUE. GJ Hofmeyr 225

THIRD TRIMESTER INDUCTION OF LABOUR WITH MISOPROSTOL: THE DURBAN EXPERIENCE. NF Moran 229

VAGINAL EXAMINATIONS DURING LABOUR: A SYSTEMATIC REVIEW.

M Singata 236

THE PERILS OF PRECOCIOUS PARTURITION. H Odendaal 237

PLANNED DECISION MAKING FOR DELIVERY OF VERY LOW BIRTH WEIGHT BABIES MAKES FOR A BETTER OUTCOME. A Moodley 242

STUDY ON THE OUTCOME OF EXTREMELY LOW BIRTH WEIGHT INFANTS (500-999G) BORN AT PRETORIA ACADEMIC HOSPITAL BETWEEN 1 JANUARY 2001–31 DECEMBER 2001. TW de Witt 243

SURVIVAL RATES AMONG VERY LOW BIRTH WEIGHT INFANTS ADMITTED AT CHRIS HANI BARAGWANATH HOSPITAL IN 2000-2001. S Velaphi 244

PROPHYLACTIC ORAL STEROIDS IN TWIN PREGNANCIES – A RETROSPECTIVE COHORT ANALYSIS. SH Raymond 247

APNOEA AFTER IMMUNIZATION IN EX-PREMATURE INFANTS. PA Cooper 254

SAVING BABIES: A PERINATAL CARE SURVEY OF SOUTH AFRICA 2001: EXECUTIVE SUMMARY. RC Pattinson 257

OPTIMISING INFANT FEEDING IN THE CONTEXT OF HIV: A PUBLIC HEALTH PERSPECTIVE. A Goga 261

EFFICACY OF TWO POST-EXPOSURE PROPHYLACTIC REGIMENS IN REDUCING MOTHER TO CHILD TRANSMISSION OF HIV-1 IN INFANTS BORN WITHOUT ACCESS TO ANTIRETROVIRAL THERAPY: A RANDOMIZED, OPEN LABEL, CONTROLLED CLINICAL TRIAL. M Urban 268

WHAT TYPE OF CLIENTS GO FOR VCT? EJ Buthelezi 269

ABSTINENCE PRE- AND POST-DELIVERY: DOES IT HAPPEN; IS IT A POTENTIAL RISK FACTOR FOR STI & HIV/AIDS? B Kunene 272

PERINATAL TUBERCULOSIS AND HIV-1 CO-INFECTION. M Adhikari 277

PUERPERAL PYREXIA IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION. IS CAESAREAN SECTION MORE RISKY? EJ Coetzee 281

INTEGRATION OF STI/HIV SERVICES IN ANTENATAL CARE. HOW EFFECTIVELY IS THIS DONE IN RURAL AREAS IN KWAZULU NATAL. AT Sibiya 284

SERUM PROTEIN ELECTROPHORESIS IN HIV SEROPOSITIVE AND SERONEGATIVE PREGNANT WOMEN. MG Schoon 285

THE OPTIMAL DOSAGE OF NIFEDIPINE IN PATIENTS WITH EARLY ONSET SEVERE PRE-ECLAMPSIA – A RANDOMISED CONTROLLED TRIAL.

DW Steyn, DR Hall, H Odendaal

Department of Obstetrics and Gynaecology, Tygerberg Hospital and the University of Stellenbosch and the MRC Unit for Perinatal Mortality, Tygerberg

Introduction

Expectant management of selected patients with severe pre-eclampsia before 34 weeks’ gestation improves perinatal outcome without harming the mother. Careful control of maternal blood pressure is an integral part of this approach. We attempt to maintain diastolic blood pressure as measured by sphygmomanometer between 90 and 99mm Hg at all times. The results of a recent study performed in our unit indicate that nifedipine at a dosage of 10–20mg 8 hourly is the drug of choice to add where alpha-methyldopa (AMD) alone is insufficient to control the maternal blood pressure as required. However, it has been recommended that nifedipine be given as frequently as every six or even every four hours under similar circumstances. We therefore performed a randomised controlled trial (RCT) to determine the optimal dosage interval of nifedipine.

Patients and methods

A prospective open RCT was performed. Patients with severe early onset pre-eclampsia where AMD (750mg tds) alone has failed to control diastolic blood pressure as required were divided into two groups according to random numbers generated by computer. Women received nifedipine either 6 (Group A) or 8-hourly (Group B). Nifedipine was administered as short acting 10mg capsules. Management was otherwise according to departmental policy. Prazosin was added as third medication when required. Blood pressure was additionally monitored with the pregnancy validated Spacelabs 90207 monitor every 30 minutes between 09:00 and 09:00 the following day – these results were not available to managing clinicians.

Results

We successfully recorded 124 24-hour records in 22 multigravidae and 20 primigravidae with severe pre-eclampsia before 34 weeks’ gestation. (Table 1). Four women were delivered before the first 24 hour record was completed. Twenty-two women were randomised to receive nifedipine 6-hourly. The two groups were comparable at time of randomisation.

Table 1 Patient characteristics at the time of randomisation.

|Nifedipine |

| |6-Hourly (n = 22) |8-Hourly (n = 20) |

|Age |25.4 ( 5.8 |26.4 ( 5.0 |

|Gravidity |2 |2 |

|Parity |1 |1 |

|Gestational age |30.3 ( 2.2 |29.9 ( 2.4 |

|Systolic blood pressure |165 ( 13.7 |165 ( 14.4 |

|Diastolic blood pressure |102.7 ( 7.0 |106 ( 9.9 |

|Proteinuria |++ |++ |

The dosage of nifedipine was increased to 20mg in 6 women in the 6-hourly group, while prazosin was added in 9 cases. The corresponding numbers in the 8-hourly group were 9 and 7.

There were 2802 and 2870 successful individual systolic and diastolic blood pressure measurements in the 6-hourly and 8-hourly groups respectively. However, for the purpose of analysis, only the 1693 measurements of the first 24-hour recording of the 38 women who had at least one successful 24-hour recording were considered. The mean diastolic blood pressure was 81.7 ( 14.8mm Hg in Group A and 84.7 ( 14.8 mm Hg in Group B. (p < 0.05). There was no difference in the number of diastolic blood pressure values >110mm Hg. (19/876 vs. 17/817, OR = 0.96 (0.47 - 1.94)). However, there were significantly more values > 100mm Hg in women who received nifedipine 8-hourly. (12.6% vs. 9%; OR = 1.46 (1.06 - 2.01)). Correspondingly, there were more values below 70mm Hg (OR = 0.41 (0.31 – 0.54)) amongst women in the 6-hourly group (Figure 1). This was due to a significant fall in diastolic blood pressure following each dosage (Figure 2).

Figure 1 The distribution of diastolic blood pressure values in women receiving nifedipine either 6-hourly or 8-hourly.

[pic]

Figure 2 The diastolic blood pressure patterns in women receiving nifedipine 6-hourly (at 06:00, 12:00; 18:00 and 24:00) or 8-hourly (at 06:00, 14:00; and 22:00).

[pic]

There were no differences in neonatal outcome between the two groups. (Table 2).

|Nifedipine |

| |6 Hourly |8 Hourly |

|Days gained |6 (1 – 22) |6 (1 – 22) |

|Weight |1547 ( 341 |1436 ( 489 |

|Gestation |31.4 ( 2.0 |31.1 ( 2.5 |

|Apgar at 1 minute |8 (1 - 9) |8 (1 – 9) |

|Apgar at 5 minutes |9 (4 – 10) |9 (6 – 10) |

|Apgar at 10 minutes |10 (7 – 10) |10 (8 – 10) |

|ICU admission |3 |5 |

When all values obtained during the study were analysed on a intention to treat basis, the mean diastolic blood pressure was significantly higher in those women randomised to receive their nifedipine 6-hourly. (86.6 ( 14.4mm Hg vs. 83.4 ( 13.9 mm Hg). The number of measurements above 110mm Hg (106/2763 vs. 44/2836) and above 100mm Hg (1260/2763 vs. 971/2836) occurred significantly more often in group A. The percentage of measurements above 110mm Hg in the 6-Hourly group increased as the number of recordings increased (Figure 3).

Figure 3 The percentage of diastolic blood pressure measurements > 110 mm Hg over time calculated on a intention to treat basis.

[pic]

Discussion

Nifedipine given 6 hourly is associated with fewer diastolic blood pressure measurements >100mm Hg as well as more diastolic blood pressure measurements 160/110 were treated with oral nifedipine or intravenous dihydralazine. Betamethasone was given on admission, 24 hours later, and weekly to 33 weeks. All patients were assessed twice daily by the consultant and/or registrar. Women were delivered on achieving 34 weeks, or earlier if the blood pressure was not controlled on three drugs, if the fetal heart rate pattern became non-reassuring, if intrauterine death occurred, or if the mother developed major complications, viz. ascites, HELLP syndrome, pulmonary oedema, renal failure, eclampsia or abruptio placentae. The route of delivery was that deemed appropriate by the consultant. Induction of labour with prostaglandins was attempted if there was no fetal distress; otherwise a caesarean section was performed. Women were transferred to the tertiary centre (Tygerberg Hospital) if it was felt by the attending consultant in consultation with the Tygerberg staff that they and/or their babies required tertiary care. The women were kept in hospital after delivery until stable, and then discharged on treatment. Well neonates weighing 1800g or more were kept with their mothers in the ward. Smaller and/or sick neonates were admitted to the high care neonatal unit until they had stabilised and gained weight. Kangaroo Mother Care was used where possible. Babies were transferred to Tygerberg Hospital if the attending paediatrician thought it necessary, in consultation with the neonatal ICU staff there.

Results

A total of 131 women were included in the study, of whom 116 (88.5%) were managed entirely at the secondary hospital. Eighty-eight (67.2%) of the women were multigravidas, and there were four twin pregnancies. The median age was 26 years (range 15-41). The mean gestation on admission was 29.9 weeks (SD +2.4). One hundred and sixteen (89.9%) women were admitted with a diastolic blood pressure of > 110mmHg; the remaining 10.1% arrived at the hospital with their blood pressure already controlled with anti-hypertensive agents. The mean blood pressure on admission was 173/115mmHg [SD (20/8].

A mean of 11.6 (SD +12.5) and median of 8 days (range 1-89) were gained by expectant management. Ninety-two percent of the women gained 48 hours or more, allowing adequate time for the steroids given to work. The mean gestation at delivery was 31.8 weeks (SD +2.2). The indications for delivery are given in Table 1. Twenty-nine women (22.1%) reached 34 weeks gestation without complications. Of these 17 had labour induced electively, of which 12 (58.7%) delivered normally. Overall, 101 women (77.1%) required caesarean section.

Table 1 Indications for delivery

|Indication |N (%) |

|Fetal distress |71 (54,2%) |

|Elective delivery at 34 weeks |29 (22,1%) |

|Spontaneous labour |12 (9,2%) |

|Maternal reasons |10 (7,6%) |

|Intrauterine death | 4 (3,1%) |

|Fetal reasons other than distress | 3 (2,3%) |

|Maternal/fetal reasons | 2 (1,5%) |

|Total |131 (100%) |

Major maternal complications occurred in 44 patients (33.6%) and are shown in Table 2.

Table 2 Maternal complications

|Complication |N (%) |

|Abruptio placentae |30 (22.9%) |

|HELLP syndrome |6 (4.6%) |

|Ascites |5 (3.8%) |

|Loss of BP control |4 (3.1%) |

|Severe renal impairment |3 (2.3%) |

|Eclampsia |3 (2.3%) |

|Admission to ICU |2 (1.5%) |

|Pulmonary oedema |1 (0.76%) |

|Cerebrovascular accident |1 (0.76%) |

|Maternal death |1 (0.76%) |

Patients may have more than one complication.

The maternal death was a 23 year old P2G3 who presented at 29 weeks gestation. She developed a HELLP syndrome and a DIC, and was transferred to Tygerberg Hospital, where she died two days later from sepsis and renal failure.

One case included in the study, was not managed according to our protocol. She was a massively obese woman (136kg) admitted at 26 weeks gestation with a blood pressure of 220/130, and 302mg of protein in a 24 hour urine sample. Her blood pressure responded to therapy and she was discharged with a diagnosis of chronic hypertension, for high-risk out-patient follow-up. She presented in labour at 39 weeks and delivered a 3800g live baby.

Women stayed in hospital for a median of 4 days (1-13) after delivery.

There were 15 transfers to the referral hospital, of which 13 took place in the antenatal period. Five women were referred for purely maternal reasons that included HELLP syndrome, pulmonary oedema, renal failure and morbid obesity. Four cases were referred where an extremely low birthweight was anticipated in the face of imminent delivery, while in three cases there were combined reasons (ascites, HELLP, renal failure in the setting of very low estimated fetal weight). A single case was kept inadvertently by the referring hospital after being referred for a Doppler investigation. During the post partum period, one woman was referred for HELLP, ascites and a DIC, while another accompanied her infant who needed ventilation.

A total of 135 babies were delivered, of which 4 (3.1%) were intra-uterine deaths. The mean birthweight was 1624g (SD+486) and 20 (15.3%) had five-minute Apgar scores of 6 or less. The mean birthweight of the 15 transfers to TBH was 1272g (SD (498). The male:female ratio was 44:56. Of the 117 live born babies delivered at the secondary hospital, 73 (62.4%) required admission to the neonatal high care unit, where the median stay was 18 days (1-72). Overall, 15 (11,5%) of the 131 live born babies needed ventilation.

The perinatal mortality rate was 44.4/1000 (for all babies >1000g) and 59.2/1000 for babies >500g. A total of 14 (10,7%) live born babies died; four died within the first week, another six died in the next three weeks, and a further four died before discharge. This represents an early neonatal death rate of 30,5/1000 for babies >500g. Three of the four stillbirths occurred as a result of placental abruption. The remaining death was as a result of severe placental insufficiency with intra-uterine growth restriction.

Conclusions

Expectant management of early onset severe pre-eclampsia at a secondary level hospital appears to be acceptably safe for mother and child, if a scheme of intensive monitoring is applied, and if referral to a tertiary centre is possible for the relatively small proportion of extremely high risk pregnancies. This approach substantially reduces tertiary centre workload and costs, and keeps patients closer to their communities. It does not require particularly complicated equipment, but it does need competent and highly motivated staff at the secondary hospital, as well as supportive staff at the tertiary unit. There is no room for complacency in the management of these very high-risk cases.

EXPECTANT MANAGEMENT OF SEVERE PRE-ECLAMPSIA IN THE MID-TRIMESTER

DR Hall, HJ Odendaal, DW Steyn

Introduction

Severe pre-eclampsia that develops in the mid-trimester is an uncommon but particularly challenging problem. The condition itself poses significant dangers to the mother such as intracerebral haemorrhage, renal failure, placental abruption and eclampsia, as well as being associated with high perinatal morbidity and mortality. A study by Sibai et al emphasised these points and concluded that expectant management across a wide spectrum of gestational ages in the mid-trimester was a futile exercise. In 1988 Pattinson et al, reported no fetal survival when mothers presented with severe pre-eclampsia before 24 weeks, but noted an improving survival rate from 24-27 weeks’ gestation. Thereafter Sibai et al, in a follow-up publication on the same subject, noted an improved maternal and fetal outcome when severe pre-eclampsia from 25-27 weeks was managed expectantly. Since the publication of Pattinson et al in 1988 from the Tygerberg unit, the practice of expectant management has been further refined, especially with regard to blood pressure management and fetal evaluation. The availability of surfactant has also improved the chances of perinatal survival although neonatal intensive care (NNIC) facilities at this unit remain a limited and expensive resource.

Objective

To determine maternal and perinatal outcomes with expectant management of severe pre-eclampsia in the mid-trimester, using a defined entry point.

Design

Prospective case series. Thirty-nine women admitted from 24-27 week’s gestation with severe pre-eclampsia, whose pregnancies were otherwise stable, were managed expectantly with careful clinical and biochemical monitoring of maternal and fetal status, together with careful blood pressure control, in a high-care obstetric ward. The aim was to safely prolong the pregnancies and thereby improve perinatal outcome.

Results

Gestation was prolonged by a median number of 12 (range 3-47) days, with greater periods gained at earlier gestations. The overall perinatal loss was 25.6% and the neonatal loss 17.1%. The relative rates of significant maternal complications were low.

Figure 1 Days gained at each entry gestation

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Table 1 Maternal complications

|Complication |Number |% |

|Placental abruption |5 |13 |

|Pulmonary oedema |2 |5 |

|HELLP |2 |5 |

|ICU admission |2 |5 |

|Eclampsia |1 | |

|Acute renal failure |1 | |

|Death |0 | |

Conclusion

Expectant management of selected women with severe pre-eclampsia from 24-27 weeks’ gestation in a tertiary care unit is acceptably safe and improves perinatal outcome.

HOW DOES HIV SEROPOSITIVITY AFFECT THE INCIDENCE OF PRE-ECLAMPSIA

KA Frank, EJ Buchmann, R Schackis

University of the Witwatersrand, Chris Hani Baragwanath Hospital

Introduction

Recent studies have demonstrated a lower rate of pre-eclampsia in women who are HIV positive, than that in HIV negative women, suggesting a strong immunological basis for the development of pre-eclampsia.

Objectives

To compare the rate of pre-eclampsia and other hypertensive disorders in HIV positive and HIV negative Sowetans.

Methods

A record review was undertaken, of women who delivered from January 2002 to October 2002 at Chris Hani Baragwanath Hospital and the Soweto clinics. Selection was by random cluster sampling. Non-Sowetans and women without HIV results were excluded from the study.

Results

(These are provisional results)

A total of 2603 records were reviewed. The rate of gestational hypertension for the study was 9.5%, with a rate of 5.7% having proteinuric hypertension.

The rate of HIV positive patients was 27.1%. The incidence of gestational proteinuric hypertension in HIV positive patients was 5.8%, and 5.7% in HIV negative patients (chi-squared, P=089).

Conclusion

There does not appear to be a significant difference in the incidence of pre-eclampsia between HIV positive and HIV negative women, and while there may be an immunological basis for pre-eclampsia, HIV infection does not seem to be protective.

THE VARIATION BETWEEN THE NEW PC BASED DOPPLER WAVEFORM ANALYZER AND THE VASOFLOW DUPLEX DOPPLER.

GB Theron, AM Theron, D Grove’, AE Bunn*, J Wallis#. Department of Obstetrics and Gynaecology and the MRC Unit for Perinatal Mortality, Faculty of Health Sciences, Stellenbosch University, Tygerberg.

* Technology Developement and Transfer, MRC, Parow.

# M+M Technology, CSIR, Pretoria.

Objective

To determine the accuracy of the resistance index (RI) of flow velocity waveforms of the umbilical artery as measured by the PC based Doppler waveform analyzer (Umbiflow) both with regards to systematic and random variations when compared to the present gold standard (Vasoflow). It was important to include the gestational age range (24 to 40 weeks) and sufficient patients with abnormal values (>95th centile).

Study design: A cohort analytic study.

Study patients

All patients referred to the Fetal Evaluation Clinic (FEC) at Tygerberg Hospital with suspected chronic placental insufficiency.

Measurements

A single observer determined the RI using the best value as determined by auscultation followed by visualisation on a screen. The Vasoflow and the Umbiflow was alternated. The outcome of the pregnancies was determined. Patients with a RI of 75 and 95th centile more intensive fetal monitoring. With absent or reversed flow patients were admitted to hospital for intensive fetal monitoring or delivery.

Results

A total of 249 patients were included in the study. Gestational age was confirmed by early ultrasound in 195 (78.3%) of the patients. The most common reasons for referring patients for Doppler were: poor symphysis fundus growth (34.1%), previous pregnancy complications (24.5%), hypertension (19.7%) and pre-eclampsia (14.9%). The median gestational age at referral was 30 (21-40) weeks.

The mean resistance index (RI) of the first Doppler assessment was 0.69 (S=0.11) and 0.67 (S=0.11) with the Vasoflow and Umbiflow respectively. A second test was done on 59 (36.7%) patients with continuing pregnancies because the RI was >75 centile. The mean RI was 0.69 (S=0.10) and 0.66 (S=0.10) with the Vasoflow and Umbiflow respectively. A third test was done on 13 (5.2%) patients with the mean RI 0.76 (S=0.12) and 0.75 (S=0.11) with the Vasoflow and Umbiflow respectively.

The correlation coefficient of the RI as measured with the Vasoflow and the Umbiflow were:

1st test 2st test 3rd test

Pearson 0.8465 0.8264 0.9571

Spearman 0.7890 0.7307 0.7966

The mean differences and the distribution of these differences between the Vasoflow and the Umbiflow were:

1st test 2st test 3rd test

N 249 59 13

Mean 0.0234 0.0203 0.0054

SD 0.0617 0.0580 0.0366

+2SD 0.1468 0.1364 0.0659

-2SD -0.0100 -0.0960 -0.0767

With the first assessment the following shift in categories occurred:

Centiles Vasoflow Umbiflow

75 and 75 and 95 15 (6.0%) 11

>75 and ................
................

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