Quantitation of fetomaternal haemorrhage and F cells in unusual maternal blood samples by flow cytometry using anti-D and anti-HbF.

BACKGROUND: Fetomaternal haemorrhage (FMH) assessment by the Kleihauer-Betke test (KBT) is rapid but semi-quantitative and liable to false positive results. OBJECTIVES: To compare FMH estimated by KBT with flow cytometry (FC) quantitation for 37 patients with massive FMH, obstetric risk factors or technical problems. METHODS: Maternal blood was sent for analysis by FC after KBT. A variety of reagents including anti-haemoglobin F (HbF), anti-D and combined anti-HbF/anti-carbonic anhydrase (CA) were used. RESULTS: Eight cases of massive FMH (>100 mL fetal cells) causing fetal death or severe neonatal anaemia in late gestation were confirmed by FC. Anti-HbF FC identified maternal F cells and fetal cells. In some cases these red cell populations merged but they could be differentiated by anti-CA, labelling F cells only. Using KBT, false positive FMH results were obtained for 12 patients, who had strongly stained cells that were then shown by FC to be maternal F cells. All these patients had increased F cells (>5% of total red cells) whereas only 16% of patients with FMH and 22% of donors had elevated F cells. In contrast, anti-D FC was simple and rapid, quantitating D-positive FMH in all 15 D-negative patients except one with massive FMH of weak D fetal cells. Leucocytes in four samples bound anti-D, variably, giving erroneously high FMH, but they could be eliminated from FC analysis using combined anti-D/anti-CD45. CONCLUSION: FMH quantitation using anti-D by FC is suitable for the majority of maternal samples and could enable accurate targeted dosing of anti-D prophylaxis.

Malaria in pregnancy.

Malaria is a complex parasitic disease affecting about 32 million pregnancies each year in sub-Saharan Africa. Pregnant women are especially susceptible to malarial infection and have the risk of developing severe disease and birth complications. The target of Millennium Development Goal 6 is to end malaria deaths by 2015. Maternal and perinatal morbidity and mortality due to malaria may be reduced by implementing preventive measures, early diagnosis of suspected cases, effective antimalarial therapy and treatment of complications.

The effect of warfarin dosage on maternal and fetal outcomes in pregnant women with prosthetic heart valves.

There are several challenges in the management of pregnant women with mechanical heart valves. Pregnancy increases the risk of thromboembolism and there is currently no consensus on the safest anticoagulation method during pregnancy. The objective of the study was to determine the correlation between the warfarin dose and pregnancy outcome in pregnant women with prosthetic heart valves. Warfarin in pregnancy was associated with a low risk of valve thrombosis or maternal death. The risk for fetal abnormalities was not related to the maternal warfarin dosage. However, the risk for stillbirth was significantly increased with increasing doses of warfarin.

A rare case of idiopathic thrombocytopenia in association with an ovarian teratoma in pregnancy.

Thrombocytopenia complicates 6-7% of pregnancies. We present the case of a 26-year-old patient who presented with severe thrombocytopenia associated with an ovarian teratoma in the second trimester of pregnancy.

Cardiac disease in pregnancy: a 4-year audit at Pretoria Academic Hospital.

BACKGROUND: Pre-existing medical disease constitutes one of the five major causes of maternal death in South Africa. Increasing numbers of women with heart disease reach adulthood as a result of advances in diagnoses and treatment of heart disease in childhood. OBJECTIVE: To assess the profile of cardiac disease and the maternal and fetal outcome of pregnant patients at Pretoria Academic Hospital (PAH). METHODS: A retrospective analysis was carried out on 189 pregnant cardiac patients who delivered at PAH between January 2002 and December 2005. RESULTS: Nearly 1% of all mothers who delivered at PAH had underlying cardiac disease. Most cardiac lesions were valvular disease secondary to childhood rheumatic heart disease. Pulmonary oedema was associated with the greatest morbidity and mortality. The severe morbidity rate was 11.6% and the case fatality rate 3.3%. The mean gestational age at delivery was 35 weeks; 18 (9.7%) babies were born before 34 weeks. CONCLUSION: Cardiac disease in pregnancy is associated with high morbidity and mortality rates for mothers and their babies. Multidisciplinary evaluation with discussion of risk factors, appropriate family planning and optimising of the cardiac state before conception is advised.

Evaluation of a strict protocol approach in managing women with severe disease due to abortion.

AIM: To evaluate whether the introduction of a strict protocol approach based on the systemic evaluation of critically ill pregnant women with complications of abortion affected outcome. SETTING: Indigent South Africans managed in the regional and tertiary hospitals of the Pretoria Academic Complex. METHOD: Since 1997 a standard definition of severe acute maternal morbidity (SAMM) has been used in the Pretoria Academic Complex. All cases of SAMM and maternal deaths were entered on the Maternal Morbidity and Mortality Audit System programme. A comparison of outcome of severely ill women who had complications of abortion was made between 1997-1998 (original protocol) and 2002-2004 (strict protocol). OUTCOME MEASURES: The mortality index and prevalence of organ system failure or dysfunction. RESULTS: In 1997-1998 there were 43 women with SAMM who survived and a further 10 maternal deaths due to complications of abortion, compared with 107 women with SAMM and 7 maternal deaths during 2002-2004. The mortality index declined from 18.9% in 1997-1998 to 6.1% in 2002-2004 (p = 0.02, odds ratio 0.28, 95% confidence limits 0.10 - 0.79). Significantly more women had hypovolaemic shock in 2002-2004 compared with 1997-1998 (54.4% v. 35.8%, p = 0.04), but fewer women had immune system failure including septic shock (18.4% v. 47.2%, p = 0.0002) and metabolic dysfunction (0 v. 5.7%, p = 0.03) and there was a trend to less renal failure (10.5% v. 22.6%, p = 0.06) and cardiac failure (4.4% v. 13.2%, p = 0.08). CONCLUSION: The strict protocol approach based on systemic evaluation in managing critically ill pregnant women with complications of abortion, coupled with an intensive, regular feedback mechanism, has been associated with a reduction in the mortality index.

Severe acute maternal morbidity and maternal death audit--a rapid diagnostic tool for evaluating maternal care.

OBJECTIVE: To analyse severe acute maternal morbidity (SAMM) and maternal mortality in the Pretoria region over a 2-year period (2000-2001). SETTING: Public hospitals in the Pretoria region, South Africa, serving a mainly indigent urban population. METHODS: A descriptive study was performed whereby women with SAMM and maternal deaths were identified at daily audit meetings and an audit form was completed for all cases fulfilling the definition of SAMM ('near miss') and for all maternal deaths. RESULTS: The number of maternal deaths declined slightly but not significantly from 18 deaths in 2000 to 16 in 2001. This represents a change in the maternal mortality ratio (MMR) from 130/100,000 live births in 2000 to a MMR of 100/100,000 live births in 2001. However, when data for women with SAMM and maternal deaths were combined, there was a significant increase in major maternal morbidity from 90 cases (SAMM and maternal death rate 649/100,000 live births) in 2000 to 142 cases (SAMM and maternal death rate 889/100,000 live births) in 2001 (p = 0.006). This increase was due to a significant increase in severe maternal morbidity related to abortions and obstetric haemorrhages. CONCLUSION: Analysis of maternal deaths only in the Pretoria region failed to identify abortions and haemorrhages as major maternal care problems. When data for women with SAMM were combined with data for maternal deaths, however, these problems were clearly identified, and remedial action could be taken. Including SAMM in maternal death audits increases the rapidity with which health system problems can be identified.

Aggressive or expectant management of labour: a randomised clinical trial.

OBJECTIVE: To compare labour outcomes using aggressive or expectant management protocols. DESIGN: Randomised trial. SETTING: Pretoria Academic Complex, South Africa. It serves an indigent urban population. POPULATION: Healthy nulliparous women in active labour, at term, with a health singleton pregnancy and cephalic presentation. METHODS: The women were randomised to either aggressive (n = 344) or expectant (n = 350) management protocols. Aggressive management entailed using a single line partogram, a vaginal examination every two hours and use of an oxytocin infusion if the line was crossed. Expectant management entailed using a two line partogram, with the alert line and a parallel action line four hours to the right, with a vaginal examination every four hours. If the action line was reached, oxytocin was started. The women were reassessed every two hours thereafter. Analgesia was prescribed on request. MAIN OUTCOME MEASURES: Mode of birth, use of oxytocin and analgesia and neonatal outcome. RESULTS: The groups were similar with respect to maternal age, cervical dilation at trial entry, number crossing the alert line and birthweight of the infants. Significantly fewer women managed aggressively had caesarean sections (16.0%) than those managed expectantly (23.4%) (relative risk [RR] 0.68, 95% confidence intervals [CI] 0.50, 0.93). Significantly more oxytocin was used in the aggressive management group, but there was no difference with respect to the use of analgesia or episiotomy or in neonatal outcome with respect to the Apgar score at 1 or 10 minutes. There were three perinatal deaths. One woman was found to have an intrauterine death before trial entry and the other two were in the aggressive management group but did not receive oxytocin. Compliance by staff was poor in the aggressive management group. CONCLUSIONS: Aggressive management of labour reduces the caesarean section rate in nulliparous women but requires more intensive nursing.

Severe acute maternal morbidity and mortality in the Pretoria Academic Complex: changing patterns over 4 years.

OBJECTIVE: To compare the severe acute maternal morbidity (SAMM) and maternal mortality in the Pretoria Academic Complex for the year 2000 and the years 1997-1999. STUDY DESIGN: SAMM and maternal mortality was identified at daily audit meetings. The audit was performed from 1 January 2000 to 31 December 2000 and compared with the data obtained from the original 2-year audit [Br J Obstet Gynecol 105 (1998) 985]. The mortality index (MI) was defined as Maternal Death (MD) divided by SAMM and MD. This index is used to assess the standard of care in specific maternal conditions. Data was assessed using the Chi square test. RESULTS: SAMM and maternal mortality has significantly declined in all patients with a reduction in abortion complications as the main contributor (268/100,000 births versus 94/100,000 births P<0.006). There is a non-significant trend to increased morbidity and mortality in hypertension, hemorrhage and infections. CONCLUSIONS: The standard of care was constant. An audit of SAMM and maternal mortality allows for early detection of trends and early changes in health strategies.

The use of dexamethasone in women with preterm premature rupture of membranes--a multicentre, double-blind, placebo-controlled, randomised trial. Dexiprom Study Group.

OBJECTIVE: To assess whether administration of dexamethasone in women with preterm premature rupture of membranes (PPROM) has an effect on the prevalence of maternal sepsis, neonatal respiratory distress syndrome (RDS), perinatal mortality and neonatal sepsis in a developing country. SETTING: Six public hospitals in South Africa that deal mainly with indigent women. METHOD: A multicentre, double-blind, placebo-controlled, randomised trial was performed on women with PPROM and fetuses of 28-34 weeks' gestation or clinically estimated fetal weight between 1,000 and 2,000 g if the gestational age was unknown. Women were randomised to receive either dexamethasone 24 mg intramuscularly or placebo in two divided doses 24 hours apart. All women received amoxycillin and metronidazole and were managed expectantly. Hexoprenaline was administered if contractions occurred within the first 24 hours after admission to the trial. OUTCOME MEASURES: The maternal outcome measures were clinical chorio-amnionitis and postpartum sepsis. The outcome measures for infants were perinatal death, RDS, mechanical ventilation, necrotising enterocolitis, and neonatal infection within 72 hours. RESULTS: One hundred and two women who delivered 105 babies were randomised to the dexamethasone group and 102 women who delivered 103 babies, to the placebo group. The groups were well balanced with regard to clinical features. There was a trend towards fewer perinatal deaths in the dexamethasone group: 4 compared with 10 (P = 0.16, odds ratio 0.37, 95% confidence intervals 0.09-1.34). A subanalysis of mothers who delivered more than 24 hours after admission to the study and their infants revealed a significant reduction in perinatal deaths; 1 death in the dexamethasone group and 7 in the placebo group, P = 0.047 (Fisher's exact test). No woman in either group developed severe sepsis, and the incidence of sepsis in the women did not differ significantly. Eleven infants in each group developed sepsis. CONCLUSION: This is the first randomised trial in women with PPROM to compare the effects of the use of corticosteroids with placebo, where all women received prophylactic antibiotics concomitantly with the corticosteroids. A trend towards an improved perinatal outcome was demonstrated in the women who received dexamethasone. There was no increased risk of infection in the women or their infants where dexamethasone was administered. Administration of corticosteroids to women with PPROM has more advantages than disadvantages in developing countries.

Reactions to issues concerning sexual orientations, identities, preferences, and choices.

Most etiological theories of homosexuality suffer from unomania, the preoccupation with single causes. Unomania, in MacDonald's terms, reflects a singularistic, as compared with a pluralistic cognitive set. It also reflects the rigid dichotomization of feminine roles for females and masculine roles for males. It is hoped that current research on bisexuality will be spared the unomania that has afflicted research on homosexuality.

Maternal alpha-fetoprotein screening: two years' experience in a low-risk district.

Over a two-year period, 3479 pregnant women in the Kings' Lynn Health District were screened for neural tube defects by estimation of maternal serum alpha-fetoprotein. Most pregnancies were scanned by sonar for fetal maturity. Eight women had fetuses with open neural tube defects; four with anencephaly were associated with very high alpha-fetoprotein values. Of the four with open neural tube defects without anencephaly, only one was detected by screening and confirmed after amniocentesis. One other had a raised serum alpha-fetoprotein but a normal amniotic fluid value. The other two affected fetuses were missed. This disappointing outcome was attributed to the poor predictive value of alpha-fetoprotein in detecting open neural tube defects (anencephaly apart) rather than to errors in its estimation or in assessment of fetal maturity by sonar scan. We question the validity of screening, particularly in areas of intermediate or low incidence.

Bisexuality: some comments on research and theory.

Though evidence suggests that bisexuals may outnumber homosexuals and that bisexuality is increasing, there is a paucity of research on this group. Further, because researchers have included large numbers of bisexuals as "homosexuals" in their studies of homosexuality, we cannot even be sure of what we know about homosexuals. The author examines a variety of issues: sex differences, life-styles, discrimination, changes in sexual orientation over the life span, etc. Four beliefs about bisexuals are presented and examined: Bisexuality as: (1) real and natural, (2) transitory (the bisexual will become exclusive at the orientation opposite to his or her original orientation), and (4) homosexual denial.