Perinatal outcome of maternal deaths at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, January 2014 - June 2019.

BACKGROUND: Maternal death is a tragic event. Of maternal deaths worldwide, 99% occur in low- and middle-income countries. Perinatal outcome is related to maternal wellbeing. Maternal death has a negative impact on fetal and neonatal outcome in the short and long term. OBJECTIVES: To determine the perinatal outcomes of pregnancies that ended in a maternal death at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, South Africa, over a 5-year period, to describe the causes of maternal death, and to determine the stillbirth rate (SBR) and early neonatal death (ENND) rate in this population. METHODS: This was a retrospective cross-sectional study of maternal deaths in women with a viable pregnancy from January 2014 to June 2019 at CHBAH. All maternal deaths with gestation >26 weeks or fetal weight >500 g were included in the study. Information on demographics, booking status, antenatal care, pregnancy outcome, and fetal and neonatal outcome was extracted from maternal and neonatal files. RESULTS: Of a total of 183 maternal deaths during the study period, 147 were included in the study. The institutional maternal mortality ratio was 135 deaths per 100 000 live births. Hypertension was the main direct cause of death (36.5%; n=27/74), followed by pregnancy related sepsis (27.4%; n=21/74) and obstetric haemorrhage (20.6%; n=15/74). Non-pregnancy-related infections, of which 91.4% were HIV and HIV-related complications, comprised 47.9% (n=35/73) of indirect causes of death, followed by medical and surgical disorders. Of a total of 151 babies, including two sets of twins and one set of triplets, 137 were delivered and 14 were undelivered at the time of maternal death. Ninety-one babies (61.9%) were born alive and 51 (34.6%) were stillbirths. Of the 91 liveborn infants, 6 (6.5%) had an ENND. Of the 51 stillbirths, 14 (27.5%) were undelivered and 11 (21.6%) were delivered by perimortem caesarean section. The SBR was 347 per 1 000 maternal deaths and the ENND rate 66 per 1 000 live births. The perinatal mortality rate (PMR) was 388 per 1 000 maternal deaths, which is 12 times higher than the PMR per 1 000 live births for the general population. CONCLUSION: Women who experience maternal death have babies with very poor perinatal outcomes, with a very high SBR, ENND rate and PMR. The health of the mother has a direct and significant effect on fetal and neonatal outcomes.

Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis.

AIM: To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation. METHODS: Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines. RESULTS: DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient. CONCLUSIONS: DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis.

AIM: Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation). METHODS: Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed. RESULTS: 25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes. CONCLUSIONS: Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Neurodevelopmental outcome in neonates with hypoxic-ischaemic encephalopathy managed with therapeutic hypothermia in a tertiary-level public hospital outside an intensive care unit setting.

BACKGROUND: Management of hypoxic-ischaemic encephalopathy (HIE) by therapeutic hypothermia (TH) is a major challenge in low- and middle-income countries (LMIC) because of the limited resources. Clinicians in LMIC offer this intervention outside neonatal intensive care units (NICU). The effect of this practice on neurodevelopmental outcome is not well known. AIM: To determine neurodevelopmental outcome in neonates with HIE managed with TH outside NICU settings. METHODS: : This was a retrospective descriptive study of neonates with HIE managed with TH and followed up for neurodevelopmental assessment at 12 and 18-24 months postnatal age. Patients were reviewed over a 24-month period. Outcome at 12 and 18-24 months was compared. RESULTS: Of 178 neonates with HIE attending the clinic, there was information on TH for 155 (87.1%), 113 of whom (72.9%) received TH. HIE was moderate in 88% and severe in 10%. Twenty-seven (23.9%) and 16 (14.1%) were assessed at one time-point at 12 or 18-24 months, respectively, 40 (35.3%) at both time-points, and 30 (26.6%) were not assessed. At 18-24 months, 32% had moderate-to-severe disability compared with 6% at 12 months, with the sensitivity and specificity of assessment at 12 months being 50% and 100%, respectively. The disability attrition rate at 18-24 months was 50%. CONCLUSIONS: The relatively low prevalence of disability (32%) at 18-24 months suggests that use of TH in a Level 2 nursery is feasible and possibly beneficial. More studies are needed to confirm these findings. ABBREVIATIONS: aEEG: amplitude electroencephalogram; CP: cerebral palsy; GMDS: Griffiths mental developmental scales; GQ: general quotient; HIC: high-income countries; HIE: hypoxic-ischaemic encephalopathy; LMIC: low- and middle-income countries; LTFU: loss to follow-up; NICU: neonatal intensive care unit; TH: therapeutic hypothermia; TOBY: total body hypothermia.

Evaluating the QuikRead® C-reactive protein test as a point-of-care test.

BACKGROUND: Available tests to diagnose infection in neonates often provide results after 12-24 hours. A bedside test that is reliable will facilitate earlier exclusion or diagnosis of infection. OBJECTIVE: To validate a bedside C-reactive protein (CRP) test against the currently available laboratory CRP test in neonates with suspected sepsis. METHODS: This was a prospective observational study where a bedside CRP was done concurrently with and validated against a laboratory CRP in neonates with suspected sepsis. The sensitivities, specificities and predictive values for the bedside CRP tests were calculated using the laboratory CRPs as the reference test. RESULTS: There were 209 measured CRP-sample pairs. Seventy per cent of these had suspected early-onset neonatal sepsis and 30% had suspected late-onset neonatal sepsis. Twelve per cent had culture-proven sepsis. At the recommended cut-off of 8.0 mg/L for the bedside CRP test, the sensitivity, specificity, positive and negative predictive values were 84%, 80%, 30% and 97%, respectively. Adjusting the cut-off value from 8.0 to 15.0 mg/L improved the specificity to 88%. The sensitivity, specificity and positive and negative predictive values were not different between early-onset and late-onset sepsis. The receiver operating characteristic curve had an area below the curve of 0.84 for the cut-off at 16.2 mg/L on the beside CRP test. CONCLUSIONS: The bedside CRP test may be used as a screening test to aid decisions to either commence or discontinue antibiotics in circumstances where the clinical diagnosis of sepsis is in doubt. By using a cut-off of 16.0 mg/L for the bedside CRP test, the possibility of a false negative result is minimised.

Mortality rate in neonates infected with extended-spectrum beta lactamase-producing Klebsiella species and selective empirical use of meropenem.

BACKGROUND: Infection with resistant gram-negative bacteria is a growing threat to hospitalised patients. AIM: To determine factors associated with mortality among infants infected by extended-spectrum beta-lactamase-producing Klebsiella species (Klebs-ESBL) and to assess whether selective empirical use of meropenem (MERO) is associated with high mortality. METHODS: Medical records of neonates admitted from January 2002 to December 2003 who had positive blood and/or cerebrospinal fluid (CSF) culture with Klebs-ESBL were reviewed for clinical, management and outcome information. Univariate and multivariate logistic regression analyses were performed to determine factors associated with mortality among infants with culture-proven Klebs-ESBL. RESULTS: A hundred patients had positive blood (n=97) and/or CSF cultures (n=9) owing to Klebs-ESBL. Overall mortality rate was 30%. The mortality rates among those who were empirically started on a combination of piperacillin-tazobactam and amikacin (Pip-Taz+Amik) (n=48), meropenem (MERO) (n=40) and in those not started on MERO or Pip-Taz+Amik) (n=12) were 25%, 32% and 42%, respectively. Non-survivors were younger (p=0.01), had cardio-respiratory compromise or required assisted ventilation at presentation (p<0.001), and were not started on antibiotics, MERO or Pip-Taz+Amik (p<0.001). On multivariate analysis, factors associated with mortality were vaginal delivery (OR -7.07, 95% CI 2.14-23.39), a need for assisted ventilation at onset of illness (OR -4.94, 95% CI 1.12-21.86) and not starting empirical MERO or Pip-Taz+Amik (OR -17.01, 95% CI 2.41-120.23). CONCLUSION: While empirical use of carbapenems for nosocomial sepsis might be appropriate in areas where Klebs-ESBL is prevalent, their use can be restricted to those with cardio-respiratory compromise or severe sepsis without an increase in mortality.