Fasting plasma glucose and risk factor assessment: Comparing sensitivity and specificity in identifying gestational diabetes in urban black African women.

BACKGROUND: Identifying women with gestational diabetes mellitus (GDM) allows interventions to improve perinatal outcomes. A fasting plasma glucose (FPG) level ≥5.1 mmol/L is 100% specific for a diagnosis of GDM. The International Association of Diabetes and Pregnancy Study Groups acknowledges that FPG <4.5 mmol/L is associated with a low probability of GDM. OBJECTIVES: The validity of selective screening based on the presence of risk factors was compared with the universal application of FPG ≥4.5 mmol/L to identify women with GDM. FPG ≥4.5 mmol/L or the presence of one or more risk factors was assumed to indicate an intermediate to high risk of GDM and therefore the need for an oral glucose tolerance test (OGTT). METHODS: Consecutive black South African (SA) women were recruited to a 2-hour 75 g OGTT at 24 - 28 weeks' gestation in an urban community health clinic. Of 969 women recruited, 666 underwent an OGTT, and of these 589 were eligible for analysis. The glucose oxidase laboratory method was used to measure plasma glucose concentrations. The World Health Organization GDM diagnostic criteria were applied. All participants underwent a risk factor assessment. The χ2 test was used to determine associations between risk factors and a positive diagnosis of GDM. The sensitivity and specificity of a positive diagnosis of GDM were calculated for FPG ≥4.5 mmol/L, FPG ≥5.1 mmol/L, and the presence of one or more risk factors. RESULTS: The prevalence of overt diabetes mellitus and GDM was 0.5% and 7.0%, respectively. Risk factor-based selective screening indicated that 204/589 (34.6%) of participants needed an OGTT, but 18/41 (43.9%) of positive GDM diagnoses were missed. Universal screening using the FPG threshold of ≥4.5 mmol/L indicated that 152/589 (25.8%) of participants needed an OGTT, and 1/41 (2.4%) of positive diagnoses were missed. An FPG of ≥5.1 mmol/L identified 36/41 (87.8%) of GDM-positive participants. The sensitivity and specificity of the presence of one or more risk factors were 56% and 67%, respectively. The sensitivity and specificity of FPG ≥4.5 mmol/L were 98% and 80%, respectively. CONCLUSIONS: Universal screening using FPG ≥4.5 mmol/L had greater sensitivity and specificity in identifying GDM-affected women and required fewer women to undergo a resource-intensive diagnostic OGTT than risk factor-based selective screening. A universal screening strategy using FPG ≥4.5 mmol/L may be more efficient and cost-effective than risk factor-based selective screening for GDM in black SA women.

Why women bleed and how they are saved: a cross-sectional study of caesarean section near-miss morbidity.

BACKGROUND: Maternal deaths from 'bleeding during and after caesarean section' (BDACS) have increased in South Africa, and have now become the largest sub-cause of deaths from obstetric haemorrhage. The aim of this study was to describe risk factors and causes of near-miss related to BDACS and interventions used to arrest haemorrhage and treat its effects. METHODS: Cross-sectional prospective study in 13 urban public hospitals in South Africa, from July to December 2014. RESULTS: There were 93 cases of near-miss related and 7 maternal deaths related to BDACS. The near-miss rate was 2.1/1000 live births, and the case fatality rate was 3.5/10 000 caesarean sections. Associated near-miss risk factors were previous caesarean section in 60% of multiparas, pre-operative anaemia (55%), abruptio placentae (20%) and placenta praevia and/or accreta (20%). Atonic uterus (43%) was the most frequent anatomical cause of bleeding for near-miss, followed by surgical trauma (29%). The median duration of the operations resulting in near-miss was 90 min, with 81% noted as difficult by the surgeon. Interventions in cases of near-miss included second-look laparotomy (46%), hysterectomy (41%), B-Lynch brace suture (9%), intensive care unit admission (32%) and red cell transfusion ≥3 units (21%). CONCLUSION: Cases from maternal near-miss from BDACS were frequently associated with pre-operative risk factors. Extensive life-saving interventions were required during and after the operations. An important factor in initiating the sequence of interventions is the realisation by the surgeon that the caesarean section is difficult, so that the progression from uneventful operation to near-miss to death can be arrested.

Natural acquired humoral immunity against serotype-specific group B Streptococcus rectovaginal colonization acquisition in pregnant women.

Group B Streptococcus (GBS) rectovaginal colonization in pregnant women is associated with invasive GBS disease in newborns, preterm delivery and stillbirths. We studied the association of GBS serotype-specific capsular polysaccharide (CPS) antibody on new acquisition and clearance of rectovaginal GBS colonization in pregnant women from 20 weeks until 37 to 40 weeks' gestation. Serum serotype-specific CPS IgG antibody concentration was measured by multiplex enzyme-linked immunosorbent assay and opsonophagocytic activity (OPA) titres. Rectovaginal swabs were evaluated for GBS colonization, using standard culture methods and serotyping by latex agglutination, at five to six weekly intervals. Higher serotype III CPS antibody concentration was associated with lower risk of rectovaginal acquisition of serotype III during pregnancy (p 0.009). Furthermore, serotype-specific OPA titres to Ia and III were higher in women who remained free of GBS colonization throughout the study compared to those who acquired the homotypic serotype (p <0.001 for both serotypes). Serum CPS IgG values of ≥1µg/mL for serotype V and ≥3µg/mL for serotypes Ia and III were significantly associated with protection against rectovaginal acquisition of the homotypic serotype. A GBS vaccine that induces sufficient capsular antibody in pregnant women, including high OPA titres, could protect against rectovaginal colonization during the latter half of pregnancy.

Declining maternal mortality in the face of persistently high HIV prevalence in a middle-income country.

OBJECTIVE: To estimate maternal mortality ratio (MMR) and determine maternal death causes and trends in Greater Soweto, Johannesburg, South Africa. DESIGN: Cross-sectional study. SETTING: Chris Hani Baragwanath Maternity Hospital (CHBMH) in Greater Soweto. POPULATION: Maternal deaths at CHBMH. METHODS: Record review of maternal deaths from 1997 to 2012, using hospital death records, with denominator data from the district health information system and the hospital. MAIN OUTCOME MEASURES: Maternal mortality ratio per 100,000 live births, and causes of death classified as in the South African confidential enquiries. RESULTS: There were 479 deaths, with a peak MMR of 139 in 2004 and a decline to 86 in 2012. Of 332 women tested, 245 (74%) were HIV-infected. Nonpregnancy-related infection (40%) was the most frequent cause of death, followed by hypertension (16%) and obstetric haemorrhage (13%). HIV infection rates in these groups were 92%, 30% and 61%, respectively. Previous caesarean section was associated with obstetric haemorrhage death (odds ratio [OR] 3.2, 95% confidence interval [95% CI] 1.7-6.0), maternal age ≥35 years with hypertension death (OR 2.2, 95% CI 1.2-3.7) and antenatal anaemia with nonpregnancy-related infection death (OR 4.0, 95% CI 2.3-6.9), compared with other causes of death. CONCLUSION: There is evidence of a decline in MMR since HIV treatment for pregnant women was introduced in 2004. Previous caesarean section, advanced maternal age, and anaemia were associated with death from obstetric haemorrhage, hypertensive disorders of pregnancy and nonpregnancy-related infections, respectively. MMR may be further reduced with accelerated initiation of HIV treatment during pregnancy.

Clinical Abdominal Palpation for Predicting Oligohydramnios in Suspected Prolonged Pregnancy

Objective. In view of the scarcity of ultrasound in low-resource settings; to evaluate abdominal palpation for prediction of oligohydramnios in suspected prolonged pregnancy; using the ultrasound-obtained amniotic fluid index (AFI) as a gold standard; taking into account maternal and fetal factors that may affect amniotic fluid volume. Methods. A cross-sectional analytical study at Chris Hani Baragwanath Academic Hospital; Johannesburg; South Africa; on women referred from midwife-run clinics with suspected gestational age ?41 weeks. Eligible women had their AFI measured; then had abdominal palpation by the researcher; who was blinded to exact gestational age and AFI findings. Palpation focused on ballottability of fetal parts; ease of feeling fetal parts; and impression of fetal compaction. Gestational age was then recalculated using information from earlier ultrasound scans and menstrual dates. Univariable and multivariable logistic regression was performed with oligohydramnios (AFI 5 cm) as the dependent variable.Results. Of 100 women; 45 had a recalculated gestational age ?41 weeks. Twenty-three had oligohydramnios. Gestational age was a significant independent predictor for oligohydramnios (odds ratio (OR) 1.78; 95 confidence interval (CI) 1.08 - 2.94). The only component of palpation significantly associated with oligohydramnios; after adjustment for gestational age; was non-ballottability of the presenting part (adjusted OR 4.02; 95 CI 1.05 - 15.4). Non-ballottability had a sensitivity and specificity for oligohydramnios of 87 and 40; respectively; with a negative predictive value of 91.Conclusion. When ultrasound is not available; ballottability of the presenting part may have value for excluding oligohydramnios and assisting clinical decisions in suspected prolonged pregnancy

The Value of Routine Mid-Trimester Ultrasound in Low-Risk Pregnancies at Primary Care Level

This study investigated the effect of routine second-trimester ultrasound scanning on obstetric management and pregnancy outcomes. This was an open cluster; randomised; controlled trial. Clusters of women with low-risk pregnancies presenting in the second trimester were randomised to receive an ultrasound scan followed by usual antenatal care; or to an unscanned control group undergoing conventional antenatal care only. Out of the 962 women randomised; follow-up was successful for 804 (83.6); with 416 allocated to the ultrasound scan group and 388 controls. There were no significant differences between the ultrasound scan group and the control group in terms of prenatal hospitalisa- tion; mode of delivery; miscarriage; perinatal mortality rate and low birthweight rate. Ultrasound dating was associated with a lower rate of induction of labour for post-term pregnancy (1.4vs. 3.6; P=0.049). However; ultrasound scanning in low-risk pregnancies was not associated with improvements in pregnancy outcome

Level of fetal head above brim: comparison of three transabdominal methods of estimation, and interobserver agreement.

This study compared three intra-partum transabdominal methods of estimating the level of the fetal head above the brim, and determined interobserver agreement in fifths estimation of the fetal head. The researcher examined 508 women in term labour and estimated level of head in fifths by the Crichton method, in fifths by the Notelowitz finger-breadth method, and by symphysis-to-sinciput measurement (SSM). The attending clinicians also made their estimates, using the methods of their choice. Two-fifths of head or less was considered engaged. When two-fifths was palpable by the Crichton method, the Notelowitz method gave a mean of 2.40 fifths. The researcher and clinicians agreed on the level of head in 42.9% of examinations. Interobserver agreement was poor (kappa = 0.22). In conclusion, the Crichton method overestimates head descent in comparison with the Notelowitz method. SSM was easy to perform but requires validation. The fifths method of determining level of head appears inexact and poorly reproducible.

Accuracy of cervical assessment in the active phase of labour.

OBJECTIVE: To determine accuracy of clinicians in estimating cervical dilatation during the active phase of labour and how this is affected by clinician experience and obstetric factors. DESIGN: Prospective, cross-sectional, comparative study. SETTING: Chris Hani Baragwanath Hospital labour ward, Johannesburg, South Africa. POPULATION: Women at term in the active phase of labour, with vertex presentations and live fetuses. METHODS: The researcher performed cervical assessment immediately after the clinician on duty. The researcher and clinician were unaware of each other's findings. The researcher, used as the standard, was an experienced obstetric consultant, and the clinicians were hospital consultants and registrars at various levels of training. Accuracy was defined as agreement of the clinician's cervical dilatation estimate with that of the researcher. Multivariate logistic regression analysis was carried out to determine independent predictors of inaccuracy. MAIN OUTCOME MEASURE: Agreement in estimation of cervical dilatation between the researcher and the clinicians. RESULTS: Examinations were performed on 508 women. The researcher and clinicians agreed on the dilatation in 250 instances (49.2%) and differed by 2 cm or more in 56 (11.0%) (kappa = 0.40, 95% CI 0.34-0.45). Accuracy was greater at low (3-4 cm) and high (8-10 cm) dilatations. Reduced accuracy was associated with decreasing clinician experience and with lower stations of fetal head. CONCLUSION: This is the first study to investigate accuracy of cervical assessment in parturient women. Results were similar to those found in studies that used models, with about 90% of estimations accurate to within 1 cm.

Complications associated with cesarean section in the second stage of labor.

OBJECTIVE: To determine maternal and neonatal complications associated with cesarean section done in the second stage of labor. METHOD: Cohort study comparing cesarean sections done in the second stage of labor (cases) with those done for poor progress in the first stage (controls). Only singleton cephalic live pregnancies at 36 weeks or more, without previous cesarean section, were included. RESULT: There were 39 cases and 39 controls. Cesarean section in the second stage of labor took significantly longer (median 45 vs. 30 min; P<0.001), and was associated with more frequent postoperative pyrexia (10 vs. 2; P=0.012). There were more neonatal admissions in the case group (17 vs. 3; P<0.001). Hypoxic ischemic encephalopathy was more frequent in infants following second-stage cesarean section (8 vs. 1; P=0.013), as was subaponeurotic hemorrhage (6 vs. 0; P=0.012). CONCLUSION: Cesarean section in the second stage of labor is associated with significant intraoperative and neonatal morbidity.

Babies who die from labour-related intrapartum hypoxia: a confidential enquiry in South African public hospitals.

Seventeen hospitals, from a range of health-care environments, participated in confidential enquiries of perinatal deaths resulting from labour-related intrapartum hypoxia. There were 102 deaths, including 22 stillbirths and 80 neonatal deaths. The mean birthweight was 3021 g. The active phase of the first stage of labour was prolonged beyond 12 h in six cases, and oxytocin was used for induction or augmentation in 10 women. Fetal heart decelerations were detected in 39 (49%) of the babies that went on to die in the neonatal period, and meconium passage was evident in 50 (63%). There were six breech presentations, and seven cases of cord prolapse. The majority of these deaths occurred in low-risk women with apparently uncomplicated labour. There appears to be a failure to detect or respond to evidence of fetal distress. Intrapartum care for all women in labour requires close attention to detail in monitoring fetal health.

Does human immunodeficiency virus infection protect against preeclampsia-eclampsia?

OBJECTIVE: In view of recent suggestions that human immunodeficiency virus (HIV) infection may protect against preeclampsia, this study was done to evaluate whether untreated HIV-positive pregnant women have a lower rate of preeclampsia-eclampsia than HIV-negative women. METHODS: Subjects for this study were pregnant women from Soweto, South Africa, who gave birth from March to December 2002 at midwife-run clinics or at the Chris Hani Baragwanath Hospital and in whom the HIV status was known. A sample size calculation indicated that 2,588 subjects would be required to show statistical significance at P <.05 with a power of 80% for a reduction in the rate of preeclampsia from 8% to 5% with HIV seropositivity, assuming an HIV seroprevalence rate of 30%. Data collection was by record review from randomly selected patient files and birth registers. RESULTS: In the total sample of 2,600 women, 1,797 gave birth at the hospital and 803 at the midwife-run clinics. The HIV seroprevalence rate was 27.1%. Hypertension was found in 17.3% of women, with 5.3% having preeclampsia-eclampsia. The rates of preeclampsia-eclampsia were 5.2% in HIV-negative and 5.7% in HIV-positive women (P =.61). CD4 count results were available for only 13 women (0.5%). CONCLUSION: Human immunodeficiency virus seropositivity was not associated with any reduction in the risk of developing preeclampsia-eclampsia.

Where there is no ultrasound: delay and failure of antenatal diagnosis of twin pregnancy.

We investigate the problem of late diagnosis of twin pregnancy in Soweto, South Africa, where routine antenatal ultrasound is not available. One hundred consecutive pairs of twins were studied, using the notes of mothers who delivered twins at Chris Hani Baragwanath Hospital and the referring Soweto clinics. A positive history was found in 31 mothers (22 family history, nine previous history of twins). Six mothers did not attend for antenatal care. Twenty-five twin pregnancies were discovered at delivery, 15 of them in the second stage of labour, and 27 were diagnosed accidentally in the third trimester. Only 15 pregnancies were referred specifically for suspicion of twin pregnancy. Most twin pregnancies are detected only in the third trimester or at delivery. Until routine ultrasound is available to all pregnant women, the teaching of antenatal care in South Africa must give emphasis to clinical suspicion of twin pregnancy.

Legal termination of pregnancy among teenagers and older women in Soweto, 1999-2001.

BACKGROUND: Legal termination of pregnancy (TOP) was introduced in South Africa in 1996. No data are available to relate the numbers of TOPs to the total number of pregnancies in specific health regions. The level of use of TOPs by women of different age groups is not known. OBJECTIVE: To determine the proportion of pregnancies that end in TOP, with special reference to maternal age, and to measure trends in use from 1999 to 2001. SETTING: Greater Soweto, Orange Farm and Lenasia, a densely populated urban health region served by Chris Hani Baragwanath Hospital and comprehensive primary care reproductive health services. METHODS: Two cross-sectional studies performed in 1999 and 2001, counting all pregnancies managed in state-run health services, including legal terminations, spontaneous miscarriages, ectopic pregnancies and deliveries. RESULTS: There were 5,412 pregnancies in the study period (9 weeks) in 1999, and 5,316 in the study period (8 weeks) in 2001. The TOP rates decreased from 16.1% to 13.6% (P = 0.20). The TOP rates for teenagers decreased from 22.3% to 16.3% (P = 0.006), but were higher than those for older women (15.2% in 1999 and 13.2% in 2001, P = 0.006 and 0.028 respectively). TOP rates for teenagers 13-16 years decreased from 28.0% to 23.0% (P = 0.44), and rates for older teenagers declined from 21.0% to 14.9% (P = 0.008). In 2001, 16.2% of women aged 35 and above underwent TOP, compared with 12.7% of women aged 20-34 years (P = 0.014). CONCLUSION: Use of TOP services was highest in women at the extremes of reproductive age. There was a significant decline in TOP rates among older teenagers between 1999 and 2001. These data, from a comprehensive urban reproductive health service, provide a benchmark for comparison elsewhere and in the future.

Intrapartum-related birth asphyxia in South Africa--lessons from the first national perinatal care survey.

BACKGROUND: The recent amalgamation of data by users of the Perinatal Problem Identification Programme (PPIP) throughout South Africa has culminated in the publication of the Saving Babies report. OBJECTIVES: To determine the absolute rate of death from intrapartum-related birth asphyxia, and the contribution of intrapartum-related asphyxia to total perinatal mortality in South African hospitals, and to identify the primary obstetric causes and avoidable factors for these deaths. METHODS: The amalgamated PPIP data for the year 2000 were obtained from 27 state hospitals (6 metropolitan, 12 town and 9 rural) in South Africa. In PPIP-based audit, all perinatal deaths are assigned primary obstetric causes and avoidable factors, and these elements were obtained for all deaths resulting from intrapartum-related birth asphyxia. RESULTS: There were 123,508 births in the hospitals surveyed, with 4,142 perinatal deaths among infants > or = 1,000 g, giving a perinatal mortality rate of 33.5/1,000 births. The perinatal mortality rate from intrapartum-related birth asphyxia was 4.8/1,000 births. The most frequent avoidable factors were delay by mothers in seeking attention during labour (36.6%), signs of fetal distress interpreted incorrectly (24.9%), inadequate fetal monitoring (18.0%) and no response to poor progress in labour (7.0%). The perinatal mortality rates for metropolitan, town, and rural areas were 30.0, 39.4 and 30.9/1,000 births respectively. The contribution of intrapartum-related birth asphyxia to perinatal mortality in these areas was 10.8%, 16.7% and 26.4% respectively. CONCLUSION: The high rates of perinatal death from intrapartum-related birth asphyxia in South Africa are typical of those in underdeveloped countries, with the most serious deficiencies in rural areas. Most of these deaths are avoidable and the reduction of these rates presents an important challenge to providers of perinatal care in this country. Areas worthy of research and action include provision of mothers' waiting facilities in rural regions, improvements in fetal monitoring, partogram-based labour management, and the establishment of midwifery staffing norms for South African labour units.