An audit of stillborn babies in mothers with diabetes mellitus at a tertiary South African Hospital

Objectives and design: This study is a retrospective audit spanning six years following the implementation of a new guideline on the management of diabetes in pregnancy. It aims to describe the patient profile of pregnancies complicated by diabetes and stillbirth.Setting: The study was performed in Tygerberg Hospital, Cape Town, a secondary and tertiary referral centre.Subjects: Fifty-eight pregnancies were complicated by stillbirth (> 500 g). Outcome measures: the patient profile, gestational age, co-morbidities, foetal/placental monitoring and avoidable factors were described.Results: Many patients (32%) booked after 24 weeks' gestation and missed appointments were common (26.2%). Stillbirths ascribed to diabetes constituted 2.3% of all stillbirths at the hospital during the study period. Of the stillbirths 28.1% had Type I diabetes mellitus (DM), 64.9% had Type II and 7.0% were in patients with gestational diabetes. The median HbA1c at delivery was 8.4% (range 6.0­14.1%). In the Type II group, 31 (77.5%) of the stillbirths occurred after 36 weeks, while those among the Type I cases ranged from 26 to 38 weeks.Conclusion: Stillbirths amongst pregnant women with diabetes constituted a small percentage of the total stillbirth burden. Emphasising the importance of appropriate antenatal care to women with diabetes and increased surveillance from 36 weeks' gestation may lower the number of stillbirths

Outcome of Pregnancy in the Morbidly Obese Woman

Background: Obesity is a growing global health problem. In South Africa; more than half of the adult women are overweight and almost 30are obese. The problems associated with obesity; such as diabetes; hypertension; thrombo-embolism and coronary heart disease; are well described in the non-pregnant population; but the condition itself holds specific risks during the ante-; intra- and postpartum periods of the pregnant woman. Of particular concern is the intrapartum period. Complications such as slow progress during labour and increased rates of caesarean section are best addressed proactively. For this reason certain sources advocate that all morbidly obese women be referred for evaluation of the pregnancy and planning of labour and delivery by an anaesthetist and a specialist obstetrician. The aim of this study was to determine whether morbidly obese women are at increased risk of adverse outcomes; compared to women with a normal body mass index (BMI). Methods: A case control study design was used. In this study a normal BMI was defined as 20-25 kg/m2 and morbid obesity as a BMI of = 40 kg/m2. The BMI was calculated from the weight and height measured at the booking visit. The cases in this study comprised the first hundred morbidly obese women seen at the Obstetric Special Care Clinic in Tygerberg Hospital (TBH); a secondary and tertiary referral centre. The controls (n = 209) were women with normal BMIs and singleton pregnancies who booked as low-risk patients at the Bishop Lavis Midwife Obstetric Unit (MOU) during the same calendar period. A minimum ratio of 2:1 controls-to-case was used; with controls also matched for primi- or multiparity. Patients booking at the MOU with significant obstetric risk factors are referred to TBH for antenatal care. These women were not considered as controls. However; low-risk women who met the inclusion criteria at booking and who subsequently developed risks or complications were included; as the selection was done according to findings at the booking visit. The main outcomes to be determined were: ante-; intra- and postpartum maternal complications; rate of epidurals; and perinatal outcomes. Results: Women in the morbidly obese group were significantly older (p 0.001) and of higher parity (p 0.001) than those with normal BMIs. There was no difference in the numbers of primigravidae. Significantly more women in the morbidly obese group had experienced at least one miscarriage (p received it. During delivery; perineal damage was more common in morbidly obese women (p 0.001) and their babies were significantly larger (p 0.001). There was one perinatal death. Conclusions: Morbidly obese women experienced increased complications during pregnancy and childbirth. Due to the high rate of caesarean sections and the potential difficulties of emergency anaesthesia among these women; epidural anaesthesia during labour should be planned and administered as often as possible