The potential for preventing the delivery and perinatal mortality of lowbirth- weight babies in a black urban population

Objective. To determine the potentiaJ for preventing the delivery and perinatal  mortality of low-birth-weight (LBW) babies in a black urban population.Design. Cross-sectionaJ descriptive study.Setting. All women delivering babies weighing less than 2 500 g at Kalafong  Hospital in a 6-month period (December 1991 - May 1992).Main outcome measures. The primary obstetric reason for delivery; whether the  labour was of spontaneous onset or iatrogenic; whether labour was theoretically  preventable using currently accepted practice; the number of patients in whom suppression of delivery was attempted in the theoretically preventable group; and the perinatal mortality rate of that group.Results. There were 124 perinatal deaths (22.5%) in the 550 LBW babies delivered from 465 singleton pregnancies, 42 twin pregnancies and 1 triplet pregnancy. The  primary obstetric reasons for delivery were spontaneous preterm labour (28%), hypertensive diseases (19%), premature rupture of membranes (180/0),  spontaneous labour in lightfor-gestational-age babies (16%), unexplained intra-uterine deaths (8%), antepartum haemomhage (8%) and other causes (3%). A medical decision to terminate the pregnancy before labour was made in 177 (34.8%) cases, the major reason being hypertensive diseases (84 mothers;  47.5%). In the remaining 331 mothers with spontaneous onset of labour, labour was theoretically preventable in 63 (19%) and prevention was only attempted in 12 (2.4% of the total mothers). The major reason for not attempting to suppress labour in the others was that the patients arrived too late at the hospital for intervention to take place.Conclusion. Hospital staff can do little to prevent the delivery of LBW babies in a black urban population

Depression scores in a cohort of HIV positive women followed from diagnosis in pregnancy to eighteen months postpartum

Background Depression has been found in the literature to be a major problem in people living with HIV/AIDS. Not only does this impact on their daily functioning but has been shown to have negative HIV related outcomes, and result in poorer adherence to antiretroviral medication. The population under study was pregnant at the time of diagnosis. It would seem likely that their risk for depression would be greater than even a general HIV infected population, because of the pregnancy and the fact that they might have concerns around the health and future of the unborn infant. There are a limited number of studies looking at levels of depression over time and possible determinants of this depression even in a general HIV infected population. It was thus felt necessary to establish levels of depression and to establish if there were any factors associated with changes over time in this pregnant population. Method Two hundred and ninety three women were recruited at antenatal clinics in Tshwane from June 2003 and December 2004. They were interviewed at approximately 28 weeks gestational age and were followed for 18 months after the birth. Data included socio demographic variables, a “self efficacy score”, past history of violence, disclosure, CD4 count and knowledge score. Psychological variables included measures of stigma, social support, self esteem and coping. Depression was measured using a modified CES-D (Center for Epidemiological Studies Depression Score) Repeated measures mixed linear analysis was used to assess if there were changes in depression scores over time and if there were factors associated with these changes. Results Two hundred and twenty four women were included in the mixed linear analysis. The mean age of the women was 26.5 years (standard deviation -5.1). Seventy six percent (152) were single with a partner. Seventy six percent (171) had some form of secondary education and 14% (32) had some form of tertiary education. Sixty percent (135) lived in a brick house and 35% (79) had running water in the house. Twenty nine percent (64) had a per capita income below the poverty line. The prevalence of borderline depression (CES-D scores above 12) for this group of women at baseline was 45%. There were significant changes in depression scores over time. This was not a linear relationship (significant quadratic time to interview term p=0.008). This was evidenced by the fall off in scores at 3-9 months followed by a subsequent rise. The factors associated with higher depression scores overall were lower active coping (p=0.004), higher avoidant coping (p=0.003), higher internalised stigma (p=0.001), higher housing scores (0.026), lower self–esteem (0.002), a history of violence (p<0.0001) and having no partner (p=0.005). No factors were associated with changes over time. Conclusion There are significant changes in depression scores over time in this cohort of women Depression scores while falling after the birth of the child as in other cohorts, start to rise again. Although there are no specific factors associated with these changes, overall women who have a history of violence, who have no partner, who live in better housing circumstances, who have poor self esteem, who have high levels of internalized stigma and make use of negative coping strategies are more likely to be depressed. Women who make use of active coping strategies are less likely to be depressed. There are a large number of women at baseline who have scores considered to be diagnostic of borderline depression and because of the potential negative consequences to the woman and child, an intervention aimed at addressing the above issues should be devised. This should start in the antenatal period and carry on beyond this time. CopyrightDissertation (MSc)--University of Pretoria, 2010.Clinical Epidemiologyunrestricte

Is ward evacuation for uncomplicated incomplete abortion under systemic analgesia safe and effective? A randomised clinical trial

Objective. To compare evacuation under systemic analgesia (fentanyl and midazolam) in a treatment room (ward group) with evacuation under general anaesthesia in theatre.Design. A prospective randomised clinical trial.Setting. A tertiary medical centre serving a black urban population.Subjects. One hundred and forty-two patients with uncomplicated incomplete abortions.Intervention. Randomisation into two groups, those for evacuation under systemic analgesia and those for evacuation under general anaesthesia.Main outcome measures. Both groups were compared in terms of safety, efficacy, acceptability, blood consumption and time delay between admission and evacuation.Results. Significantly less blood was used in the ward group (37 units for 13 patients) than in the theatre group (65 units for 24 patients) (P &lt; 0,03). Significantly less time was taken between admission and evacuation in the ward group (median 7 hours 15 minutes) than in the theatre group (median 12 hours 38 minutes) (P &lt; 0,0003). Evacuation under fentanyl and midazolam was safe, effective and acceptable for the majority of patients compared with evacuation under general anaesthesia.Conclusion. Patients with uncomplicated incomplete abortions (uterine size equivalent to a pregnancy of 14 weeks' duration or less) can undergo evacuation safely and effectively under fentanyl and midazolam and have a significantly smaller chance of requiring a blood transfusion

The accuracy of preoperative serum CA-125 levels to predict lymph node metastasis in a population of South African women with endometrial carcinoma

BACKGROUND: The purpose of the study was to evaluate the predictive value of serum CA-125 levels in the preoperative assessment of endometrial carcinoma in a setting where late presentation is common. METHOD: This retrospective study evaluated women with pathologically proven endometrial carcinoma scheduled for surgery between January 2012 and January 2017, who had preoperative serum CA-125 test results. The association of CA-125 with a variety of histological factors was evaluated using Spearman’s correlation and receiver operator characteristic (ROC) curves to evaluate sensitivity and specificity. RESULTS: Fifty-eight patients were included in the study, 34 (58.6%) of whom were FIGO stage II–IV. Elevated CA 125 levels were significantly correlated with late FIGO stage (p < 0.001), myometrial invasion (p < 0.001) and lymph node metastases (p < 0.001). The most appropriate cut-off point of CA-125, where an increase in sensitivity was not associated with a fall-off in specificity, was 20 IU/ml, reaching a sensitivity of 90% and a specificity of 67% for detection of lymph node metastases. CONCLUSION: Among this group of women with endometrial cancer, the preoperative serum CA-125 level was associated with lymph node metastases and we found a CA-125 of 20 IU/ml or more to be predictive. These findings suggest that, among similar populations, CA-125 could be done preoperatively and could be used to determine the need for node dissection. Since our findings are from a small retrospective cohort, this should be validated in a prospective study on early stage disease.https://medpharm.tandfonline.com/toc/ojgo20/currentpm2020Obstetrics and Gynaecolog

Where are the men? Targeting male partners in preventing mother-to-child HIV transmission

Involvement of male partners may increase adherence to and improve outcomes of programs to prevent mother-to-child HIV transmission (PMTCT). Greater understanding of factors impeding male voluntary HIV counseling and testing (VCT) is needed. A crosssectional study was conducted in Tshwane, South Africa. Semi-structured interviews were completed with men whose partners had recently been pregnant. Of 124 men who participated, 94% believed male HIV testing was important, but 40% had never been tested. Of those tested, 32% were tested during the pregnancy, while 37% were tested afterward. Fifty-eight percent of men reported that their female partners had disclosed their test results during pregnancy. A man’s likelihood of testing during pregnancy was associated with prior discussion of testing in PMTCT, knowing the female partner had tested, and her disclosure of the test result (all p < 0.05). In terms of increasing malepartner HIV testing rates, 74% of the men reported they would respond favorably to a written invitation for VCT from their partners. Based on themes that emerged during the interviews, six partner invitation cards to encourage male involvement in PMTCT were designed. Responses to the cards were elicited from 158 men and 409 women. One invitation card framed by the themes of fatherhood and the baby was selected by 41% of men and 31% of women as the most likely for women undergoing PMTCT to bring to their male partners and the most successful at encouraging men to be tested. In conclusion, this study found that a substantial proportion of men whose partners were recently pregnant had never been tested themselves; of those who had tested, most had done so only after the pregnancy. Encouraging partner communication and clinic attendance using an invitation card could facilitate increased male testing and participation in PMTCT.Wilbur G. Downs International Health Fellowship and a Yale University School of Medicine Medical Student Research Fellowshiphttp://www.tandfonline.com/loi/caic20hb201

Barriers to male-partner participation in programs to prevent mother-to-child HIV transmission in South Africa

Efforts to prevent mother-to-child HIV transmission (PMTCT) in sub- Saharan Africa have focused overwhelmingly on women, to the unintended exclusion of their male partners. A cross-sectional study was conducted in Tshwane, South Africa, to determine barriers to male-partner participation during PMTCT. In-depth interviews were conducted with 124 men whose partners had recently been pregnant, and five focus group discussions were held with physicians, nurses, HIV counselors, and community representatives. Qualitative analysis revealed that while most fathers believed that HIV testing is an important part of preparing for fatherhood, there are formidable structural and psychosocial barriers: the perception of clinics as not “male-friendly,” a narrow focus on HIV testing instead of general wellness, and a lack of expectations and opportunities for fathers to participate in health care. Coupled with more family-oriented approaches to PMTCT, measurable improvements in the way that male partners are invited to and engaged in HIV prevention during pregnancy can help PMTCT programs to achieve their full potential.http://www.guilford.comhb201

An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa

BACKGROUND : Septic incomplete miscarriages remain a cause of maternal deaths in South Africa. There was an initial decline in mortality when a strict protocol based approach and the Choice of Termination of Pregnancy Act in South Africa were implemented in this country. However, a recent unpublished audit at the Pretoria Academic Complex (Kalafong and Steve Biko Academic Hospitals) suggested that maternal mortality due to this condition is increasing. The objective of this investigation is to do a retrospective audit with the purpose of identifying the reasons for the deteriorating mortality index attributed to septic incomplete miscarriage at Steve Biko Academic Hospital. METHODS : A retrospective audit was performed on all patients who presented to Steve Biko Academic Hospital with a septic incomplete miscarriage from 1st January 2008 to 31st December 2010. Data regarding patient demographics, initial presentation, resuscitation and disease severity was collected from the “maternal near-miss”/ SAMM database and the patient’s medical record. The shock index was calculated for each patient retrospectively. RESULTS : There were 38 SAMM and 9 maternal deaths during the study period. In the SAMM group 86.8% and in the maternal death group 77.8% had 2 intravenous lines for resuscitation. There was no significant improvement in the mean blood pressure following resuscitation in the SAMM group (p 0.67), nor in the maternal death group (p 0.883). The shock index before resuscitation was similar in the two groups but improved significantly following resuscitation in the SAMM group (p 0.002). Only 31.6% in the SAMM group and 11.1% in the maternal death group had a complete clinical examination, including a speculum examination of the cervix on admission. No antibiotics were administered to 21.1% in the SAMM group and to 33.3% in the maternal death group. CONCLUSION : The strict protocol management for patients with septic incomplete miscarriage was not adhered to. Physicians should be trained to recognise and react to the seriously ill patient. The use of the shock index in the identification and management of the critically ill pregnant patient needs to be investigated.http://www.biomedcentral.com/bmcpregnancychildbirtham201

A randomised controlled trial comparing laparoscopy with laparotomy in the management of women with ruptured ectopic pregnancy

We read with interest the article that appeared in the March 2017 issue of SAMJ[1] and would like to commend the authors on the publication of this important topic, demonstrating the advantages of laparoscopic surgery for the management of women with ruptured ectopic pregnancy (REP).http://www.samj.org.zaam2017Obstetrics and Gynaecolog

Barriers to early prenatal care in South Africa

OBJECTIVE : To understand the barriers delaying early prenatal care for women in South Africa. METHODS : Amixedmethods study was conducted at a center in Pretoria. RESULTS : Following interviews with 21women at a prenatal clinic in Pretoria, a quantitative survey was completed by 204 postpartum women. During interviews, women described presenting late owing to contemplating induced abortion, fear of HIV testing, and fear of jealousy and bewitching. The survey results demonstrated that a majority of women (133 [65.2%]) reported knowledge of recommendations to present before 12 weeks; however, the average gestational age at initial presentation was 19.1 ± 7.7 weeks. Women were more likely to present earlier if the pregnancy was planned (P = 0.013) and were less likely to if they had at any point contemplated induced abortion (P=0.021). Fears of bewitching and harmful psychological stress owing to a positive HIV test result prevailed in both the interviews and the surveys. CONCLUSION : Significant efforts should be devoted to improving access to contraception and prepregnancy counseling in order to improve early prenatal care attendance. Similarly, addressing cultural concerns and fears regarding pregnancy is imperative in promoting early attendance.In part by the Doris Duke Charitable Foundation through a grant supporting the Doris Duke International Clinical Research Fellows Program at Yale University.http://www.elsevier.com/locate/ijgo2017-01-30hb201

The coping strategies used over a two-year period by HIV-positive women who had been diagnosed during pregnancy

Structured interviews were conducted with 224 HIV-positive women diagnosed during pregnancy, at antenatal clinics in Tshwane, South Africa, in order to investigate the use of coping strategies during the first two years after diagnosis. Interviews were conducted between one and four weeks after diagnosis during pregnancy, with three follow-up interviews conducted post-partum. Coping strategies were assessed with an adapted version of the Brief COPE. It was found that active coping was used more often than avoidant coping throughout the study period. Active coping increased over time, while avoidant coping decreased at first but increased again between 6 and 21 months after diagnosis. The most frequently used coping strategies included acceptance, direct action, positive reframing, religion and distraction. At first, women coped through internalised strategies. Over time, outwardfocused strategies developed. Avoidant coping patterns differed from previous research indicating that women diagnosed during pregnancy deal with the consequences of HIV after the baby is born. Recommendations for mental health services are made.National Institute of Child Health and Human Development (NICHD) grant R24HD43558http://www.tandfonline.com/loi/caic20hb201