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

Intrauterine Deaths in High-Risk Pregnancies with Normal and Borderline Umbilical Artery Doppler Flow Velocity Waveforms

Objective. To investigate the use of a personal computer (PC)-based; continuous-wave Doppler device by a trained midwife at the fetal evaluation clinic at a tertiary hospital to assess flow velocity waveforms (FVWs) of the umbilical artery flow in referred women. Methods. Pregnant women referred for suspected poor fetal growth were evaluated from June 2002 through December 2004. The Umbiflow device (still prototype; developed by CSIR/MRC/Stellenbosch University); consisting of a Pentium 3 PC with an ultrasound transducer plugged into the USB port; was used to analyse the FVW of the umbilical artery. Pregnancies in which the resistance index (RI) was 75th percentile (P75) were not further evaluated for fetal well-being unless the clinical condition of the mother had changed. Pregnancies with an RI P75 were followed up according to a specific protocol. Primary endpoints were intrauterine death and intrauterine growth restriction. Results. Doppler FVWs were assessed in 955 pregnancies. The RI was P75 in 529 participants (55.4); between the P75 and P95 percentile in 350 (36.6) and P95 in 53 (5.5). In 23 cases (2.4) end-diastolic flow was absent or reversed (AREDF). Intrauterine death within 1 week of the test occurred in 1; 4; 0 and 2 women respectively in these four groups; and 16.7; 34.5; 54.9and 65.5respectively gave birth to infants that were small for gestational age. Conclusions. Intrauterine death; within 1 week of the test; was extremely rare when the RI was P75 (0.2). Relatively more deaths within a week of the Doppler examination occurred in the P75 - P95 group. This group should be regarded as being at high risk and needs careful antenatal surveillance

The Sexual Function and Influence of Urinary Incontinence Questionnaire (SF-IUIQ) - Assessing Sexual Function of Urinary Incontinent Women in South Africa

Objective. To develop and psychometrically validate a questionnaire that assesses sexual function of urinary incontinent women in South Africa and the influence of inconti- nence on their sexual function. Design. A prospective descriptive study. Setting. Urogynaecology and gynaecology outpatient clinics at Tygerberg Hospital; Stellenbosch University; South Africa. Subjects. All patients attending the urogynaecology or gynaecology outpatient clinic at Tygerberg Hospital; who were older than 18 years; not pregnant and could communicate in either Afrikaans or eng. Outcome measures. The content validity; reliability (internal consistency) and construct validity (convergent and discrimi- nant validity) of the Sexual Function and Influence of Urinary Incontinence Questionnaire (SF-IUIQ). Results. Of the subjects 33were not sexually active. Sexual quality of life was significantly influenced by urinary incontinence in 37.7of individuals. Leakage during sexual activity occurred in 32.Conclusions. The SF-IUIQ is a reliable and valid measure of sexual function in urinary incontinent women; and ofthe influence of urinary incontinence on sexual function

Investigation of the haemolytic effects of Ancylostoma ceylanicum: observations on infected dogs in vivo and human and dog blood in vitro.

Investigations into the probable role of haemolysins in the causation of hookworm anaemia have been undertaken in living infected dogs. Secondly, the effects of living hookworms and various worm products on erythrocytes in vitro have been assessed. In dogs infected with varying numbers of A. ceylanicum, severe microcytic anaemia developed in the most heavily infected animals six weeks after infection. Erythrocytes from the latter animals showed significantly greater autohaemolysis in the presence of added glucose. When serum bilirubin and methaemalbumin, plasma haemoglobin, urinary urobilinogin and osmotic fragility of their red cells were measured, however, no evidence of haemolysis was detected. Erythrocytes from these animals appeared normal under scanning electron microscopy. In in vitro studies varying concentrations of adult worm extract had no effect on the haemolysis of either dog or human erythrocytes in the presence or absence of glucose nor on their mechanical fragility. There was no increase in 51Cr release from dog or human labelled red cells when incubated with either adult worm extract or excretory/secretory products of worms. Living adult worms caused an increase in 51Cr release from human but not dog labelled erythrocytes. Thus, the role of haemolysins in the genesis of hookworm anaemia is minimal.

Serum microfilarial antibody titres before and after treatment of bancroftian microfilaraemia with diethylcarbamazine.

Eight Filipino patients with Wuchereria bancrofti microfilaraemia were treated with diethylcarbamazine. The intensity of microfilaraemia and titre of microfilarial agglutinating antibodies were measured over the ensuing six weeks. Nuclepore filtration of blood indicated clearing of microfilaraemia in five patients and a reduction in numbers in the other three. Several patterns of antibody response were observed. Five patients had high initial antibody titres; they did not change significantly after diethylcarbamazine therapy. Antibody was not detectable before treatment in three patients; elimination of microfilaraemia was associated with the appearance of antibody in two of the subjects, while microfilariae were not totally cleared and antibodies never appeared in the third patient. This study confirms that diethylcarbamazine is not always successful in the treatment of bancroftian microfilaraemia. It is consistent with, but does not prove, the hypothesis that the presence or absence of microfilariae and microfilarial antibodies depends upon the relative release of microfilariae into the bloodstream and the rate of synthesis of microfilarial antibodies.

Scanning electron microscopy of the penetration of newborn mouse skin by Strongyloides ratti and Ancylostoma caninum larvae.

The scanning electron microscopical appearances of infective larvae of Strongyloides ratti and Ancylostoma caninum have been described. Particularly noteworthy was the tail of S. ratti which was found to have a distal aperture surrounded by a row of eight projections. The penetration of larvae through newborn mouse skin was investigated. S. ratti larvae forced its way rapidly and directly through the stratum corneum. No larvae of A. caninum were observed in stages of partial penetration but the occasional empty sheath was seen.

Bancroftian filariasis in a Philippine village: entomological findings.

Bancroftian filariasis in an isolated Philippine village has been intensively investigated; this paper reports the entomological findings. Surveys were carried out six months apart in the driest and wettest months. Significant transmission was demonstrated only during the wet season. Aedes poicillius was the major vector of Wuchereria bancrofti. Ae. poicilius accounted for 58% of larvae found in the axils of banana plants and 31% of those in abaca axils; negligible numbers of larvae of this species were found in pandanus and gabi axils. Mosquitoes were collected from indoor harbourages twice weekly for five weeks during the wet season; 615 mosquitoes were caught of which 80% were Ae. poicilius and 9% were Culex quinquefasciatus. 11% of the former and 13% of the latter contained filariae; whereas all stages of development were seen in Ae. poicilius, no development beyond the first stage was seen in Cx. quinquefasciatus. Human bait trapping was used for 110 manhours; 371 mosquitoes were caught of which 58% were Ae. poicilius and 24% were Culex summorosus. Filarial larvae were seen only in Ae. poicilius; 3.7% of mosquitoes were positive and all stages of filarial development were seen. The mean landing/biting rate between 1900 and 0500 hours was 3.37 mosquitoes per man-hour with a maximum of almost seven mosquitoes per man-hour at midnight. Overall, 2.26% of vectors collected in the human studies were infective. There was an average of 3.38 third-stage larvae per infective mosquito. The efficiency of transmision was estimated as 6.1 x 10-5, or one new case of microfilaraemia for every 16, 400 bites by infective mosquitoes in the village population. In contrast to the human studies, large numbers of mosquitoes were caught by animal bait trapping in both the wet and dry seasons. The distribution of mosquito species was similar in the two seasons. Ae. poicillius represented only 1.0-1.5% of all mosquitoes seen. No filarial larvae were seen. It was concluded that transmission of filariasis in the village was inefficient and postulates were advanced to explain the increased intensity and severity of filariasis inmen as compared to women.