The Cerebro-placental Ratio as a Prognostic Factor of Foetal Outcome in Patients with Third Trimester Hypertension

Background: Hypertensive disorders of pregnancy can cause complications in both the maternal and fetal circulations resulting in poor fetal outcome. These circulations can be safely and non-invasively assessed using arterial Doppler indices of the umbilical and middle cerebral arteries to obtain the cerebro-placental ratio. The study objective was to determine the role of the cerebro-placental ratio as a prognostic factor of fetal outcome in patients with hypertensive states of pregnancy delivered at least 32 weeks of gestation by dates.Methods: This was a prospective cohort study undertaken at Kenyatta National Hospital, a tertiary referral hospital in Nairobi. A total of 160 gravid patients of median age 28 years and at least 32 weeks gestations were recruited from labor ward over a 9 month study period by consecutive sampling method. Doppler ultrasound analyses of the foetal umbilical and cerebral arteries were done and the cerebro-placental ratio calculated.Results: At sonography, the average ultrasound age was 31 weeks. The median gestation at admission was 34 weeks. Twenty nine percent had an abnormal Cerebro-placental ratio (<1.0).125/160 (78%) delivered via caesarean section and 35/160(22%) delivered vaginally.51/160(32%)  severe pre-eclamptic toxaemia out of which 39% had cerebroplacental ratio<1.0 109/160(68%) had mild pre-eclamptic toxaemia out of which 24% had cerebroplacental ratio <1.0 Still births were 12.5 times more likely in mothers with cerebroplacental ratio <1.0 than those with CPR 1.0 (p value 0.05). A foetal birth score < 7 was 66 times more often in  mothers with cerebro-placental ratio< 1.0 than mothers with CPR 1.0. (P 0.05). Low birth weight was 4.7 times more likely among mothers with cerebroplacental ratio < 1.0.as compared to those with mothers with CPR1.0 (95% CI 2, 11.1; p0.001). A foetal birth score < 7 was 66 times more likely among neonates delivered vaginally as compared to those born via caesarean section(95% CI 1.3, 23; p=0.02). Still births were 14.5 times more often than among neonates born vaginally as compared to those born via caesarean section (95% CI 3, 84; p0.001). The prognostic Odds Ratio for cerebro-placental ratio was 12.5 for live births (95% CI 2, 74; p=0.005), 66 for fetal birth score <7 (95% Confidence interval 13, 340; p< 0.001) and 4.7 for low birth weight (95% CI 2, 11.1; p< 0.001) and 1.1 (95% CI 0.9, 1.4; p=0.327).Conclusion: Cerebro-placental ratio is significantly predictive of adverse perinatal outcome when used to monitor mothers with hypertensive states of pregnancy. Cerebroplacental ratio.Key words: Cerebro-placental Ratio, Prognostic Factor, Foetal Outcome, Third Trimester, Hypertensio

Linking women who test HIV-positive in pregnancy-related services to HIV care and treatment services in Kenya: a mixed methods prospective cohort study.

INTRODUCTION: There has been insufficient attention to long-term care and treatment for pregnant women diagnosed with HIV. OBJECTIVE AND METHODS: This prospective cohort study of 100 HIV-positive women recruited within pregnancy-related services in a district hospital in Kenya employed quantitative methods to assess attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services. Qualitative methods were used to explore barriers and facilitators to navigating these services. Structured questionnaires were administered to cohort participants at enrolment and 90+ days later. Participants' medical records were monitored prospectively. Semi-structured qualitative interviews were carried out with a sub-set of 19 participants. FINDINGS: Only 53/100 (53%) women registered at an HIV clinic within 90 days of HIV diagnosis, of whom 27/53 (51%) had a CD4 count result in their file. 11/27 (41%) women were eligible for immediate antiretroviral therapy (ART); only 6/11 (55%) started ART during study follow-up. In multivariable logistic regression analysis, factors associated with registration at the HIV clinic within 90 days of HIV diagnosis were: having cared for someone with HIV (aOR:3.67(95%CI:1.22, 11.09)), not having to pay for transport to the hospital (aOR:2.73(95%CI:1.09, 6.84)), and having received enough information to decide to have an HIV test (aOR:3.61(95%CI:0.83, 15.71)). Qualitative data revealed multiple factors underlying high patient drop-out related to women's social support networks (e.g. partner's attitude to HIV status), interactions with health workers (e.g. being given unclear/incorrect HIV-related information) and health services characteristics (e.g. restricted opening hours, long waiting times). CONCLUSION: HIV testing within pregnancy-related services is an important entry point to HIV care and treatment services, but few women successfully completed the steps needed for assessment of their treatment needs within three months of diagnosis. Programmatic recommendations include simplified pathways to care, better-tailored counselling, integration of ART into antenatal services, and facilitation of social support