Incidence, causes and correlates of maternal near-miss morbidity: a multi-centre cross-sectional study.

OBJECTIVE: To explore the incidence and factors associated with maternal near-miss. DESIGN: Cross-sectional study with an embedded case-control study. SETTING: Three tertiary referral hospitals in southern Ghana. POPULATION: All women admitted to study facilities with pregnancy-related complications or for birth. METHODS: An adapted version of the WHO Maternal Near Miss Screening Tool was used to identify maternal near-miss cases. These were compared with unmatched controls (uncomplicated deliveries) in a ratio of 1:2. MAIN OUTCOME MEASURES: Incidence of maternal near-miss, maternal near-miss to maternal mortality ratio, and cause of and factors associated with maternal near-miss. RESULTS: Out of 8433 live births, 288 maternal near-miss cases and 62 maternal deaths were identified. In all, 454 healthy controls were recruited for comparison. Maternal near-miss and maternal death incidence ratios were 34.2 (95% CI 30.2-38.1) and 7.4 (95% CI 5.5-9.2) per 1000 live births, respectively with a maternal near-miss to mortality ratio of 4.6:1. Cause of near-miss was pre-eclampsia/eclampsia (41.0%), haemorrhage (12.2%), maternal sepsis (11.1%) and ruptured uterus (4.2%). A major factor associated with maternal near-miss was maternal fever within the 7 days before birth (OR 5.95, 95%CI 3.754-9.424). Spontaneous onset of labour was protective against near-miss (OR 0.09 95% CI 0.057-0.141). CONCLUSION: For every maternal death, there were nearly five maternal near-misses. Women having a fever in the 7 days before delivery were six times more likely to experience a near-miss than women not having fever. TWEETABLE ABSTRACT: Maternal near-miss exceeds maternal death by 5:1, with the leading cause of maternal near-miss was pre-eclampsia/eclampsia.

ASSESSMENT OF OXIDATIVE STRESS IN EARLY AND LATE ONSET PRE-ECLAMPSIA AMONG GHANAIAN WOMEN.

BACKGROUND: Pre-eclampsia is a multisystem pregnancy-related disorder with multiple theories regarding its aetiology resulting in lack of reliable screening tests and well-established measures for primary prevention. However, oxidative stress is increasingly being implicated in the pathogenesi of pre-eclampsia although conflicting findings have been reported. AIM: To determine and compare the levels of oxidative stress in early and late onset pre-eclampsia by measuring urinary excretion of isoprostane and total antioxidant power (TAP) in a cohort of pre-eclamptic women at Korle Bu Teaching Hospital. METHODOLOGY: This was a cross-sectional study conducted at Korle-Bu Teaching Hospital, Accra, Ghana involving pre-eclamptic women between the ages 18 and 45 years who gave written informed consent. Urinary isoprostane levels were determined using an enzyme-linked immunosorbent assay (ELISA) kit whereas the Total Anti-oxidant Power in urine samples was determined using Total Antioxidant Power Colorimetric Microplate Assay kit. The data obtained were analyzed using MEGASTAT statistical software package. RESULTS: We included 102 pre-eclamptic women comprising 68 (66.7%) and 34 (33.3%) with early-onset and late-onset pre-eclampsia respectively. There were no statistically significant differences between the mean maternal age, haematological indices, serum ALT, AST, ALT, albumin, urea, creatinine uric acid and total protein at the time of diagnosis. The mean gestational age at diagnosis of early and late onset pre-eclampsia were 31.65 ± 0.41 and 38.03 ± 0.21 respectively (p ˂ 0.001). Also, there were statistically significant differences between the diastolic blood pressure (BP), systolic BP and mean arterial pressure (MAP) at diagnosis of pre-eclampsia in the two categories. The mean urinary Isoprostane excretion was significantly higher in the early onset pre-eclamptic group (3.04 ± 0.34 ng/mg Cr) compared to that of the late onset pre-eclamptic group (2.36 ± 0.45 ng/mg Cr), (p=0.019). Urinary total antioxidant power (TAP) in early onset PE (1.64 ± 0.06) was lower but not significantly different from that of late onset PE (1.74 ± 0.09) with p = 0.369. CONCLUSION: Significantly increased urinary isoprostane excretion was detected in early onset pre-eclampsia compared to late onset pre-eclampsia, suggestive of increased oxidative stress in the former. However, there was no significant difference in total anti-oxidant power between the two categories of pre-eclampsia women although there was a tendency of reduced total antioxidant power in the women with early onset pre-ecalmpsia.

Ruptured uterus: a seven-year review of cases from Accra, Ghana.

OBJECTIVE: To determine the incidence, causes, management, and the means of prevention of uterine rupture, as well as the characteristics of women with the condition, recorded in the Department of Obstetrics and Gynaecology at Korle-Bu Teaching Hospital in Accra, Ghana. DESIGN: A retrospective study between January 1, 1995, and December 31, 2001. RESULTS: During the study period, of 82061 deliveries at the Korle-Bu Teaching Hospital, 193 women developed uterine rupture, an incidence of 2.4 per 1000 deliveries. Of these 193 women, 24.6% had had a previous Caesarean section. The most frequent associated factor of uterine rupture was prolonged labour (33.6%). The perinatal mortality rate was 74.3%. Almost 70% (66.9%) of women underwent a total abdominal hysterectomy as management. The case fatality rate was 1.0%. CONCLUSION: A more vigilant approach to preventing prolonged and obstructed labour in delivery units within and around Accra, Ghana, is required to reduce the incidence of this condition.

Uterine perforation from induced abortion at Korle Bu Teaching Hospital, Accra, Ghana: a five year review.

A total of 79 cases of perforated uterus from termination of pregnancy in Accra, an incidence of 3.6% of induced abortion were managed at Korle Bu Teaching Hospital during the period 1990-1994. The mean age and parity of patients who had perforated uterus were 21.6 +/- 2.3 years and 1.97 +/- 0.28 respectively. The specific case mortality associated with this calamity was 227.8 per 1000. The need to prevent unwanted pregnancies through improved contraceptive measures and sex education must be emphasised in developing countries.

Advanced maternal age and pregnancy.

Advanced maternal age pregnancies are still prevalent due to ignorance and lack of effective contraception. These pregnancies have a poorer maternal and perinatal outcome.

PIP: In Ghana, obstetricians analyzed data on 624 pregnant women 40 years or older, who were admitted to Korle-Bu Teaching Hospital in 1993, to determine why women of advanced age still become pregnant and the effect of advanced maternal age on pregnancy outcome. 428 (68.6%) delivered after 28 weeks gestational age. 188 (30.1%) had complicated abortions. Eight (1.3%) had gestational trophoblastic disease. Only 11.4% of the 624 women really wanted to be pregnant. 59.8% definitely did not want to be pregnant. Only 11 (1.8%) women used contraception. 30.3% had been married more than once. The 428 women who delivered after 28 weeks gestational age comprised 3.6% of all deliveries at the hospital. Their mean age was 41.7 years (40-50). This was the first pregnancy for only 1 woman. Mean parity was 5.6 (range 0-12). The advanced maternal age women had a significantly lower cesarean section rate than younger women (14.7% vs. 18.2% for all age groups combined; p 0.05). They were also less likely to experience instrumental deliveries (1.4% vs. 2.6%; p 0.05). On the other hand, the advanced maternal age group was more likely to have a fetal malpresentation delivery than the younger group (7.5% vs. 3.2%; p 0.05). The premature birth rate was 9.2% for the advanced age group, which was not significantly different from that of the younger group. The advanced age group had a higher stillbirth rate than the younger group (13.7% vs. 6.7%; p 0.05). The older mothers faced a higher risk of maternal mortality than the younger mothers (21 vs. 9.3/1000 deliveries; p 0.05), reflecting the nonattendance and irregular attendance for prenatal care, late booking, and later reporting in labor among these women. The leading reasons for continued childbearing at 40 and beyond included ignorance, low use of contraceptive methods, and remarriage.

Eclampsia: 134 consecutive cases.

OBJECTIVE: A retrospective analysis of all cases of eclampsia (134) at Korle Bu Teaching Hospital, Accra, Ghana, in 1991, was undertaken to determine future directions in prevention and management. METHODS: One hundred and thirty-four consecutive cases of eclampsia were reviewed to assess possible risk factors, associated medical impact, and the usefulness of prenatal care. RESULTS: Risk factors for the development of eclampsia include: young age, delivery in the rainy season, nulliparity, multiple pregnancy, prolonged labor, and lack of prenatal care. Eclampsia is associated with high maternal and perinatal mortality. CONCLUSIONS: Future emphasis on prenatal clinics, and earlier detection and management of pre-eclampsia should lessen the incidence of this severe obstetric emergency.

Diagnosing unruptured ectopic pregnancy.

OBJECTIVE: A retrospective analysis of the management of ectopic pregnancy at Korle Bu Teaching Hospital in Accra, Ghana, to assess the impact of the introduction of ultrasonography as a diagnostic tool. METHODS: All charts of patients with ectopic pregnancies from 1 January 1986 to 31 December 1990 were analyzed. The management of those patients who had transabdominal ultrasonography was compared with those who had not. RESULTS: The use of ultrasonography increased the number of unruptured ectopic pregnancies from 0.3% to 8.5% (P < 0.001). This also reflected a reduction in misdiagnoses, blood transfusions, and maternal deaths. CONCLUSIONS: The reasonable use of modern technology can be of great assistance even in developing countries, as shown by the positive impact of the use of ultrasonography to aid in the diagnosis of ectopic pregnancy in Ghana, West Africa.