Barriers to obstetric care among maternal near-misses

Background. There are several factors in the healthcare system that may influence a woman’s ability to access appropriate obstetric care.Objective. To determine the delays/barriers in providing obstetric care to women who classified as a maternal near-miss.Methods. This was a descriptive observational study at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. One hundred maternal near-misses were prospectively identified using the World Health Organization criteria. The ‘three-delays model’ was used to identify the phases of delay in the health system and recorded by the doctor caring for the patient.Results. One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Phase I and III delays were the most important causes of barriers. Lack of knowledge of the problem (40%) and inadequate antenatal care (37%) were important first-phase delays. Delay in patient admission, referral and treatment (37%) and substandard care (36%) were problems encountered within the health system. The above causes were also the most important factors causing delays for the leading causes of maternal near-misses – obstetric haemorrhage, hypertension/pre-eclampsia, and medical and surgical conditions.Conclusions. Maternal morbidity and mortality rates may be reduced by educating the community about symptoms and complications related to pregnancy. Training healthcare workers to identify and manage obstetric emergencies is also important. The frequency of antenatal visits should be revised, with additional visits in the third trimester allowing more opportunities for blood pressure to be checked and for identifying hypertension

Early detection of pre-eclampsia

Pre-eclampsia is a major cause of maternal and perinatal morbidity and mortality. The current recommended screening approach is to identify risk factors from maternal history and demographic characteristics. Blood pressure and urinary proteins must be determined at every ante-natal visit. Patients with gestational hypertension and/or gestational proteinuria require increased antenatal surveillance because they have an increased risk for developing pre-eclampsia during pregnancy. We recommend that these patients be considered for management at District level. Local protocols must in place for emergency treatment and referral of patients who develop a sudden acute hypertensive emergency.http://reference.sabinet.co.za/sa_epublication/medogam2016Obstetrics and Gynaecolog

Metabolic syndrome at 6 weeks after delivery in a cohort of pre-eclamptic and normotensive women

BACKGROUND. The association between pre-eclampsia and the subsequent development of metabolic syndrome has not been well documented in low- and middle-income countries. OBJECTIVES. To compare the prevalence of metabolic syndrome at 6 weeks after delivery among women with pregnancies complicated by pre-eclampsia with that in a normotensive, low-risk control group in an urban South African (SA) setting. METHODS. This was a prospective cohort study at two tertiary-level hospitals and one district-level hospital in Pretoria, SA. Women were recruited after delivery and were followed up 6 weeks later to confirm or exclude the diagnosis of metabolic syndrome. RESULTS. Metabolic syndrome was diagnosed in 48/150 women with pregnancies complicated by pre-eclampsia (32.0%), compared with 33/150 (22.0%) of the control group (p=0.05). CONCLUSIONS. Women who developed pre-eclampsia during pregnancy had an increased chance of metabolic syndrome being diagnosed 6 weeks after delivery. Guidelines should be developed to identify women with cardiometabolic risk, so that interventions may be implemented to modify this risk before and after pregnancy.http://www.samj.org.zadm2022Obstetrics and GynaecologyStatistic

Maternal near miss and maternal death in the Pretoria Academic Complex, South Africa: A population-based study

Background. In order to reduce maternal mortality in South Africa (SA), it is important to understand the process of obstetric care, identify weaknesses within the system, and implement interventions for improving care.Objective. To determine the spectrum of maternal morbidity and mortality in the Pretoria Academic Complex (PAC), SA.Methods. A descriptive population-based study that included all women delivering in the PAC. The World Health Organization definition, criteria and indicators of near miss and maternal death were used to identify women with severe complications in pregnancy.Results. Between 1 August 2013 and 31 July 2014, there were 26 614 deliveries in the PAC. The institutional maternal mortality ratio was 71.4/100 000 live births. The HIV infection rate was 19.9%, and 2.7% of women had unknown HIV status. Of the women, 1 120 (4.2%) developed potentially life-threatening conditions and 136 (0.5%) life-threatening conditions. The mortality index was 14.0% overall, 30.0% for non-pregnancy-related infections, 2.0% for obstetric haemorrhage and 13.6% for hypertension. Of the women with life-threatening conditions, 39.3% were referred from the primary level of care. Vascular, uterine and coagulation dysfunctions were the most frequent organ dysfunctions in women with life-threatening conditions. The perinatal mortality rate was 26.9/1 000 births overall, 23.1/1 000 for women with non-life-threatening conditions, and 198.0/1 000 for women with life-threatening conditions.Conclusion. About one in 20 pregnant women in the PAC had a potentially life-threatening condition; 39.3% of women presented to a primary level facility as an acute emergency and had to be transferred for tertiary care. All healthcare professionals involved in maternity care must have knowledge and skills that equip them to manage obstetric emergencies. Review of the basic antenatal care protocol may be necessary

Cerebral Palsy and Criteria Implicating Intrapartum Hypoxia in Neonatal Encephalopathy – An Obstetric Perspective for the South African Setting

The science surrounding cerebral palsy indicates  that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway  to brain injury and later CP.  It is thus simplistic to base causation of cerebral palsy on only an intrapartum perspective with radiological ‘confirmation’, as is often the practice in medicolegal cases in South African courts. The present modalities (MRI and CTG when available) that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) are taken into account, success for plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this document to implicate acute intrapartum hypoxia in hypoxic ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medicolegal setting

Cardiac disease in pregnancy: When to raise the ‘red flag’

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality and is the second most common cause of indirect maternal death in South Africa. Although most women with cardiac disease cope well throughout pregnancy, some conditions are associated with an increased risk. Appropriate management of cardiac disease in pregnancy requires expert assessment, risk categorisation and ongoing care. The objective of this article is to assist clinicians to identify and modify risk factors associated with cardiac disease in pregnancy and thus reduce avoidable morbidity and mortality

Hypertensive disorders in pregnancy: 2019 National guideline

Background. Hypertensive disorders of pregnancy (HDP), including pre-eclampsia/eclampsia, account for significant maternal and fetal mortality globally and especially in South Africa. Objective. To formulate clinical guidelines for the management of HDP in order to substantially reduce the number of maternal deaths from HDP. Methods. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used to formulate the guidelines and included six domains: scope and purpose; stakeholder involvement; rigour and development; clarity of presentation; applicability; and editorial independence. Recommendations. The guideline stipulates management strategies for all levels of care where women with hypertensive disorders in pregnancy are seen. It also has a detailed implementation plan. Conclusion. A clinical guideline that is of practical value has been formulated by a wide group of stakeholders. It is hoped that its dissemination and implementation by all doctors and nurses will reduce mortality and morbidity associated with HDP

Starvation ketoacidosis in pregnancy presenting as euglycaemic high anion gap metabolic acidosis: A case report highlighting the significance of early recognition and prompt intervention

Starvation ketoacidosis (SKA) constitutes an important consideration in the pregnant patient who presents with profound metabolic acidosis. Pregnancy-related changes predispose the patient to develop SKA following relatively short periods (12 - 14 hours) of ‘starvation’. Patients also typically look clinically well in relation to the significant metabolic derangements that accompany the condition. Prompt recognition and early institution of appropriate therapy is therefore extremely important in terms of optimising maternal and fetal outcome. We describe a pregnant patient with SKA who presented with profound euglycaemic ketoacidosis that resolved rapidly following the early initiation of appropriate therapy. Furthermore, appropriate therapy resulted in our patient avoiding the need for an emergency caesarean section, which is often reported in this scenario. The ensuing discussion addresses SKA in pregnancy, the unique features of our patient, and management considerations from a maternal and fetal perspective. We also discuss the various causes of ketoacidosis such as diabetic ketoacidosis (DKA), euglycaemic DKA, alcohol-induced euglycaemic ketoacidosis and SKA in pregnant patients