Oxytocin use in South Africa - a review

Objective. Oxytocin is one of the most frequently used drugs in labour and there are many different dosage regimens. The aim of this study was to examine the use of oxytocin by obstetricians in South Africa. Methods. A specially designed questionnaire was drawn up and distributed to specialists according to an address list obtained from the South African Society of Obstetricians and Gynaecologists. Results. Three hundred and fifty questionnaires were distributed, with 174 processed for analysis. The majority of obstetricians (70.3%) reported that they would not use oxytocin for induction of labour in a patient with a previous would not consider the use of oxytocin in a patient with a multifetal pregnancy. Most respondents used oxytocin for induction of labour in multigravid patients and 91.9% also used oxytocin for augmentation in these patients. However, clinicians would not use oxytocin if the patient was a grand multipara. Conclusions. Most clinicians adhere to accepted protocols practised internationally, with a few exceptions. The use of oxytocin for both induction and augmentation of labour in women with one previous caesarean section is not practised in South Africa, despite evidence suggesting its safety. S Afr Med J 2004; 94: 839-845

Doctors' attitudes and practices regarding smoking cessation during pregnancy

Objective. To investigate the current smoking cessation practices and attitudes of doctors working in  the public antenatal services, as well as their perceived barriers to addressing the issue in the context of routine care.Study design. The study was qualitative, consisting of 14 semistructured, one-to-one interviews with doctors purposefully sampled from 5 public sector hospitals in Cape Town, South Africa.Results. The doctors in this study regarded HIV, poor nutrition, alcohol abuse and psychosocial stress as equal or higher risks to pregnant women than smoking. They tended to underestimate the magnitude of the risk of smoking during pregnancy. Doctors were unaware of the guidelines offering clinicians brief,  structured approaches to smoking cessation counselling and were generally pessimistic that they could influence the smoking behaviour of pregnant women, especially poor, disadvantaged women who face multiple barriers to achieving health-enhancing behaviour. However, most doctors were concerned about improving their communication with pregnant women about smoking and open to adopting new  approaches or tools that could assist them. Perceived barriers to providing smoking cessation interventions included a lack of counselling skills and educational resources, other pressing priorities, too little time, and the levels of stress currently experienced by doctors and midwives working in public sector hospitals as a result of dramatic staff and budget cuts.Conclusion. The study suggests that doctors working in the public sector antenatal services are not  routinely addressing the issue of smoking during pregnancy or using effective methods to assist women to give up smoking. Doctors need convincing that smoking cessation interventions can be effective. The promotion and provision of evidence-based guidelines such as the Clinical Practice Guideline for Treating Tobacco Use and Dependence (Fiore, 2000), with minimal training, is a possible strategy for integrating smoking cessation interventions into routine antenatal care in South Africa

The role of prenatal alcohol exposure in abruptio placentae

Objective. To investigate the association between preconception and prenatal alcohol use and abruptio placentae. Methods. A case-control study of women with the clinical diagnosis of abruptio placentae, 65 cases and 66 controls, at Tygerberg Academic Hospital, Western Cape, South Africa. Women in whom a retroplacental blood clot, covering at least 15% of the placental surface, was found at delivery at 24 weeks’ gestation or later were asked to complete a timeline follow-back questionnaire to determine their alcohol intake 12 and 3 months before and during pregnancy. The same questionnaire was administered to a control group of high-risk women who had no antepartum haemorrhage. Outcome. Women who drank alcohol 12 months before conception were more than 4 times more likely to develop abruptio placentae than the control group (odds ratio (OR) 4.49, p=0.00009). Women who drank alcohol 3 months prior to conception were 3 times more likely to develop abruptio placentae than the control group (OR 3.06, p=0.003). Drinking alcoholic beverages during pregnancy carried a more than 3 times greater risk of developing abruptio placentae (OR 3.52, p=0.0006). In the study group, women consumed a mean of 13.6, 12.0 and 11.2 standard drinks in a typical week at 12 and 3 months before and during pregnancy, respectively. The study group demonstrated a binge-drinking pattern, with two to four sessions per month. Conclusion. An association was found between preconception and prenatal consumption of alcohol and abruptio placentae

Preterm labour - Is Mycoplasma hominis involved?

Objective. To assess whether Mycoplasma hominis is associated with preterm labour in primigravidae  and multigravidae with previous midtrimester abortion or preterm labour.Design. Cohort analytical study. Setting. Tygerberg Hospital, a tertiary academic hospital in the Western Cape.Methods. Gram's stains were done on smears taken from the posterior vaginal fornix, at the first  antenatal visit, between 16 and 26 weeks' gestation, in primigravidae and multigravidae at risk for preterm labour. Cultures for M. hominis and other commonly occurring organisms were done ·from endocervical swabs taken at the same visit. The outcome of pregnancy in mothers with positive cultures for M. hominis was then compared with outcome in women with negative cultures.Outcome measures. Prevalence of Chlamydia trachomatis, Ureaplasma urealyticum, bacterial vaginosis and preterm delivery, birth weight and perinatal deaths.Results. Cultures for M. hominis were positive in 83 patients  (21 %) and negative in 312 (79%).  Significantly more mothers in the positive group (40%) delivered before 37 weeks' gestation than in the negative group (28%, P = 0.0313). Their babies weighed significantly less (2 669 g v. 2 864 g, P = 0.0141). The positive group was also associated with more alcohol use in pregnancy and fewer of them  were married. C. trachomatis was found in 18% of mothers in the positive group but in 8% of the negative group (P = 0.0082). U. urealyticum was cultured in 96% of mothers in the positive group in contrast to 81 % in the negative group (P = 0.001). Bacterial vaginosis was observed on 75% of mothers  with positive cultures for M. hominis but in 22% with negative cultures (P = 0.00001, odds ratio 10.21, 95% confidence interval: 5.63 - 18.65). Conclusion. Positive culture for M. hominis was associated with more preterm deliveries and also with a higher frequency of C. trachomatis, U. urealyticum and bacterial vaginosis

Preterm labour - is bacterial vaginosis involved?

Objective. To assess the efficacy of treatment of bacterial vaginosis (BV) using metronidazole to reduce  preterm labour in primiravidae and multigravidae with previous midtrimester abortion or preterm labour.Design. Randomised controlled trial.Setting. Tertiary academic hospital.Method. Two different groups of patients were screened for BV at the first antenatal visit, namely  primigravidae and high-risk multigravidae who had had a previous midtrimester abortion or preterm delivery. Patients where BV was diagnosed clinically or on Gram's stain of a smear taken from the posterior vaginal fornix, received either 400 mg metronidazole, or 100 mg vitamin C orally twice daily for 2 days. The Gram's stain was repeated after 4 weeks. If BV W?S found again, treatment with the same  drug was repeated.Outcome measures. Preterm delivery, birth weight and perinatal deaths.Results. One thousand and five patients entered the study, but 40 were excluded for various reasons and 10 were lost to follow-up. There were 464 primigravidae, of whom 150 (32%) had BV. Except for the 5-minute Apgar score, no significant differences were found between primigravidae negative for BV and those who received either metronidazole or vitamin C. There were 491 high-risk multigravidae, of whom 127 (26%) had BV. The mean gestational age in the BVnegative group was 37 weeks, in contrast to 37.4 weeks in the vitamin C group and 35.6 weeks in the metronidazole group. Birth weights in these three groups were 2 752 g, 2 759 g and 2 475 g respectively, significantly less (P == 0.0109) in the  metronidazole group in comparison with the BV-negative group. Delivery before 37 weeks occurred in 29% of high-risk multigravidae with no BV but in 24% of those who took  vitamin C and in 43% who took metronidazole. Differences were significant between the BV-negative and metronidazole groups (P = 0.0231) and also between the metrol'.idazole and vitamin C groups (P = 0.0274). Delivery before 28 weeks occurred in 4% of the high-risk multigravidae with no UV but in 10% of those with BV who took metronidazole. The difference was significant (P =0.0430). Analysis for maximum likelihood estimates for preterm labour identified only previous preterm labour or midtrimester abortion as risk factors.Conclusion. Metronidazole does not seem to reduce the prevalence of preterm labour when given for BV before 26 weeks' gestation

Temporizing management vs immediate delivery in early-onset severe preeclampsia between 28 and 34 weeks of gestation (TOTEM study) : An open-label randomized controlled trial

Peer reviewedPublisher PD

Antibiotic treatment of bacterial vaginosis to prevent preterm delivery: Systematic review and individual participant data meta-analysis.

BACKGROUND: Bacterial vaginosis (BV) increases preterm delivery (PTD) risk, but treatment trials showed mixed results in preventing PTD. OBJECTIVES: Determine, using individual participant data (IPD), whether BV treatment during pregnancy reduced PTD or prolonged time-to-delivery. DATA SOURCES: Cochrane Systematic Review (2013), MEDLINE, EMBASE, journal searches, and searches (January 2013-September 2022) ("bacterial vaginosis AND pregnancy") of (i) clinicaltrials.gov; (ii) Cochrane Central Register of Controlled Trials; (iii) World Health Organization International Clinical Trials Registry Platform Portal; and (iv) Web of Science ("bacterial vaginosis"). STUDY SELECTION AND DATA EXTRACTION: Studies randomising asymptomatic pregnant individuals with BV to antibiotics or control, measuring delivery gestation. Extraction was from original data files. Bias risk was assessed using the Cochrane tool. Analysis used "one-step" logistic and Cox random effect models, adjusting gestation at randomisation and PTD history; heterogeneity by I2 . Subgroup analysis tested interactions with treatment. In sensitivity analyses, studies not providing IPD were incorporated by "multiple random-donor hot-deck" imputation, using IPD studies as donors. RESULTS: There were 121 references (96 studies) with 23 eligible trials (11,979 participants); 13 studies (6915 participants) provided IPD; 12 (6115) were incorporated. Results from 9 (4887 participants) not providing IPD were imputed. Odds ratios for PTD for metronidazole and clindamycin versus placebo were 1.00 (95% CI 0.84, 1.17), I2  = 62%, and 0.59 (95% CI 0.42, 0.82), I2  = 0 before; and 0.95 (95% CI 0.81, 1.11), I2  = 59%, and 0.90 (95% CI: 0.72, 1.12), I2  = 0, after imputation. Time-to-delivery did not differ from null with either treatment. Including imputed IPD, there was no evidence that either drug was more effective when administered earlier, or among those with a PTD history. CONCLUSIONS: Clindamycin, but not metronidazole, was beneficial in studies providing IPD, but after imputing data from missing IPD studies, treatment of BV during pregnancy did not reduce PTD, nor prolong pregnancy, in any subgroup or when started earlier in gestation

Human Sclera Maintains Common Characteristics with Cartilage throughout Evolution

BACKGROUND: The sclera maintains and protects the eye ball, which receives visual inputs. Although the sclera does not contribute significantly to visual perception, scleral diseases such as refractory scleritis, scleral perforation and pathological myopia are considered incurable or difficult to cure. The aim of this study is to identify characteristics of the human sclera as one of the connective tissues derived from the neural crest and mesoderm. METHODOLOGY/PRINCIPAL FINDINGS: We have demonstrated microarray data of cultured human infant scleral cells. Hierarchical clustering was performed to group scleral cells and other mesenchymal cells into subcategories. Hierarchical clustering analysis showed similarity between scleral cells and auricular cartilage-derived cells. Cultured micromasses of scleral cells exposed to TGF-betas and BMP2 produced an abundant matrix. The expression of cartilage-associated genes, such as Indian hedge hog, type X collagen, and MMP13, was up-regulated within 3 weeks in vitro. These results suggest that human 'sclera'-derived cells can be considered chondrocytes when cultured ex vivo. CONCLUSIONS/SIGNIFICANCE: Our present study shows a chondrogenic potential of human sclera. Interestingly, the sclera of certain vertebrates, such as birds and fish, is composed of hyaline cartilage. Although the human sclera is not a cartilaginous tissue, the human sclera maintains chondrogenic potential throughout evolution. In addition, our findings directly explain an enigma that the sclera and the joint cartilage are common targets of inflammatory cells in rheumatic arthritis. The present global gene expression database will contribute to the clarification of the pathogenesis of developmental diseases such as high myopia

Chlamydiatrachomatis and placental inflammation in early preterm delivery

Chlamydiatrachomatis may infect the placenta and subsequently lead to preterm delivery. Our aim was to evaluate the relationship between the presence of Chlamydiatrachomatis and signs of placental inflammation in women who delivered at 32 weeks gestation or less. Setting: placental histology and clinical data were prospectively obtained from 304 women and newborns at the Erasmus MC-Sophia, Rotterdam, the Netherlands. C.trachomatis testing of placentas was done retrospectively using PCR. C.trachomatis was detected in 76 (25%) placentas. Histological evidence of placental inflammation was present in 123 (40%) placentas: in 41/76 (54%) placentas with C.trachomatis versus 82/228 (36%) placentas without C.trachomatis infection (OR 2.1, 95% CI 1.2–3.5). C.trachomatis infection correlated with the progression (P = 0.009) and intensity (P = 0.007) of materno-fetal placental inflammation. C.trachomatis DNA was frequently detected in the placenta of women with early preterm delivery, and was associated with histopathological signs of placental inflammation

Birth weight in a large series of triplets

Background: Triplets are often born premature and with a low birth weight. Because the incidence of triplet births is rare, there are relatively few studies describing triplet birth weight characteristics. Earlier studies are often characterized by small sample sizes and lack information on important background variables such as zygosity. The objective of this study is to examine factors associated with birth weight in a large, population-based sample of triplets registered with the Netherlands Twin Register (NTR).Methods: In a sample of 1230 triplets from 410 families, the effects of assisted reproductive techniques, zygosity, birth order, gestational age, sex, maternal smoking and alcohol consumption during pregnancy on birth weight were assessed. The resemblance among triplets for birth weight was estimated as a function of zygosity. Birth weight discordance within families was studied by the pair-wise difference between triplets, expressed as a percentage of the birth weight of the heaviest child. We compare data from triplets registered with the NTR with data from population records, which include live births, stillbirths and children that have deceased within days after birth.Results: There was no effect of assisted reproductive techniques on triplet birth weight. At gestational age 24 to 40 weeks triplets gained on average 130 grams per week; boys weighed 110 grams more than girls and triplets of smoking mothers weighted 104 grams less than children of non-smoking mothers. Monozygotic triplets had lower birth weights than di- and trizygotic triplets and birth weight discordance was smaller in monozygotic triplets than in di- and trizygotic triplets. The correlation in birth weight among monozygotic and dizygotic triplets was 0.42 and 0.32, respectively. In nearly two-thirds of the families, the heaviest and the lightest triplet had a birth weight discordance over 15%. The NTR sample is representative for the Dutch triplet population that is still alive 28 days after birth.Conclusion: Birth weight is an important determinant of childhood development. Triplet status, gestational age, sex, zygosity and maternal smoking affect birth weight. The combined effects amount to a difference of 364 grams between monozygotic girl triplets of smoking mothers compared to dizygotic boy triplets of non-smoking mothers of the same gestational age. Birth weight in triplets is also influenced by genetic factors, as indicated by a larger correlation in monozygotic than in di- and trizygotic triplets