Maternal deaths from bleeding associated with caesarean delivery: A national emergency.

Maternal deaths associated with caesarean deliveries (CDs) have been increasing in South Africa over the past decade. The objective of this report is to bring national attention to this increasing epidemic of maternal deaths due to bleeding associated with CD in the majority of provinces of the country. Individual chart reviews of women who died from bleeding at or after CD show that 71% had avoidable factors. Among the steps we can take are to improve surgical skills and experience, especially in rural hospitals, to improve clinical observations in the immediate postoperative period and in the postnatal wards, and to ensure that appropriate oxytocic agents are given to prevent postpartum haemorrhage. CEOs and medical managers of health facilities, district clinical specialists, heads of obstetrics and gynaecology, and midwifery training institutions must show leadership and accountability in providing an appropriate environment to ensure that women who require CD receive the procedure for the correct indications and in a safe manner to minimise risks.

The Confidential Enquiry into Maternal Deaths in South Africa: a case study.

The Confidential Enquiry into Maternal Deaths (CEMD) in South Africa has been operational for 15 years. This case study describes the process of notification and independent assessment of maternal deaths, predominantly in facilities. In the earlier years of the Enquiry, institutional maternal mortality ratio increased and was 176.2 per 100 000 live births in the 2008-10 triennium; thereafter it decreased to 146.7 in the 2011/12 period. The slow progress was due to the significant contribution of HIV/AIDs to maternal mortality and challenges in implementing the recommendations that were devised from the findings of the Enquiry. Nevertheless, the CEMD process has been maintained and strengthened so it is currently able to perform routine maternal death surveillance at both national and district levels, identify deficiencies within the health system, generate reports and also provide early warning about alarming trends such as the increasing numbers of deaths due to caesarean-section-associated haemorrhage.

Poor maternal outcomes: a factor of poor professional systems design.

South Africa is struggling to improve maternal and perinatal outcomes, resulting in failure to achieve the Millennium Goal for maternal health. Staff attitudes and skills have been identified as a factor affecting deaths and adverse outcomes in mothers. Huge training efforts are required from health departments to ensure that staff have the required skills to provide the services. The integrated approach to training of nurse professionals, which includes midwifery as a part of undergraduate training, has a devastating effect on the quality of midwifery. Training of midwifery is unfocused and forced upon those who have no interest in improving maternal outcomes. Maternal care is provided in professional silos by professionals who are not equipped with appropriate skills. Unless this systems design error is corrected, and a single-output training model introduced to professionals providing maternal care, we are unlikely to see a a major change in our maternal outcomes. New models based on inter-professional training and task sharing need to be developed for the country, including redefining of professional accountability for maternal care.

Can enquiries into severe acute maternal morbidity act as a surrogate for maternal death enquiries?

OBJECTIVE: To assess whether severe acute maternal morbidity (SAMM, 'near misses') can be used as a surrogate of an analysis of maternal deaths to describe the pattern of severe maternal disease and avoidable factors related to it. DESIGN: Prospective, descriptive study. SETTING: A SAMM and maternal mortality audit was conducted in three clearly defined geographical areas, consisting of rural and urban settings in South Africa. POPULATION: Indigent black African pregnant women. METHOD: Cases of SAMM and maternal deaths were collected in the areas and a comparison was made of the disease profiles and avoidable factors, missed opportunities and substandard care. MAIN OUTCOME MEASURES: The proportion of primary obstetric causes and avoidable factors in women with SAMM and maternal deaths, and the mortality indices of the primary obstetric causes of death and organ system dysfunction. RESULTS: A total of 423 women with SAMM and 128 maternal deaths were collected over two years. Demographic factors were similar between the groups except that significantly more maternal deaths had not attended any antenatal care. The primary obstetric causes of SAMM and maternal death did not correlate. The four most common causes of SAMM were complications of hypertension (27.2%), postpartum haemorrhage (18.0%), antepartum haemorrhage (12.8%) and abortion (11.3%), whereas the four most common causes of maternal death were non-pregnancy related sepsis (26.6%), complications of hypertension (23.4%), pre-existing medical disease (14.1%) and abortion (10.9%). The types of avoidable factors were similar between both groups although administrative factors occurred significantly more frequently in the maternal death group as did poor problem identification and monitoring. CONCLUSION: Review of SAMM gives a different disease pattern to that obtained from maternal death audits. However, in diagnosing inadequacies in the health system, similar information was obtained.

Antinuclear antibody testing in obstetric patients.

OBJECTIVES: To assess possible associations between the presence of antinuclear antibodies (ANAs) and pregnancy outcome in order to determine the significance of this test in obstetric practice. METHODS: A case-control study was performed on 408 patients admitted to an obstetric high care unit and on whom ANA testing was consecutively performed. The study group consisted of 46 patients who tested positive for ANAs and a control group of 92 patients who tested negative for ANAs. In addition to demographic data, indications for admission and pregnancy outcome were compared between the two groups. RESULTS: Of the 46 patients with a positive ANA result, 28 had an antinuclear pattern, 13 an anticytoplasmic pattern and 5 an antinuclear and an anticytoplasmic pattern. No significant differences were observed between the two groups (ANA-positive and negative) with regard to demographic data, indication for admission, clinical and laboratory data, and pregnancy outcome. The patients were also tested for anticardiolipin antibodies, and significantly more patients with severe pre-eclampsia tested positive (24% versus 4.7%, p = 0.01). No difference in HIV status and presence of autoantibodies was found between the two groups. CONCLUSION: The presence of ANAs was not associated with adverse pregnancy outcome. Therefore routine patient testing for ANAs in an obstetric high-care unit is not recommended.

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.

Cardiac disease during pregnancy--a Free State perspective on maternal morbidity and mortality.

AIM: Description of maternal outcome of pregnancies complicated by cardiac disease. SETTING: Pelonomi Hospital, Bloemfontein. POPULATION: Black African women of low socio-economic background who presented with cardiac disease during pregnancy. SAMPLE: All patients who delivered from 1 January 1990 to 1 January 1995. DESIGN: Descriptive retrospective study. RESULTS: Cardiac disease complicated 0.6% of pregnancies. Rheumatic valvular disease dominated in this population. The maternal mortality rate was 9.5% while the maternal morbidity rate ranged from 50% to 100% for the various lesions. CONCLUSIONS: Cardiac disease in pregnancy has high maternal mortality and morbidity rates. Hypertension, anticoagulation therapy, late referrals and inadequate counselling were important contributing factors. A high priority should be given to meticulous contraceptive counselling in patients with cardiac disease. Collaboration between obstetricians, physicians and cardiothoracic surgeons in imperative.

Maternal deaths in Bloemfontein, South Africa--1986-1992.

OBJECTIVE: Determination of the maternal mortality ratio and the main causes of maternal death. SETTING: Pelonomi Hospital, a tertiary care and referral hospital in Bloemfontein. METHODS: Review of prospectively completed structured questionnaires on all maternal deaths from 1986 to 1992. RESULTS: The maternal mortality ratio at our institution was 171 per 100 000 live births. Haemorrhage (25%), infection (24%) and hypertensive disease (18%) were the most important causes of death. Seventy-one per cent were direct obstetric deaths and 23% indirect; in the remaining 6%, the cause was uncertain. Of all deaths, 35% were considered preventable. CONCLUSIONS: The maternal mortality ratio has decreased since our previous report for the period 1980-1985, and haemorrhage has replaced infection as the leading cause of death.

Blood pressure profiles and perinatal outcome in pregnant black women in Pelonomi Hospital, Bloemfontein, South Africa.

In a retrospective study, the antenatal records of 241 consecutive patients were analyzed. Maternal gravidity, age, blood pressure recordings, and fetal gestational age at birth, weight and perinatal deaths were recorded. Blood pressure recordings were done by the clinic staff with the patient in the supine position tilted 15 degrees to the right. Hypertension was defined as a diastolic pressure (Korotkoff phase 4) of 90 mmHg or more. Forty-one percent were classified as hypertensive. Hypertension before 33 weeks had a perinatal mortality of 264/1000.

Amisulpride versus haloperidol in treatment of schizophrenic patients--results of a double-blind study.

In a double-blind study, 41 schizophrenic patients (ICD, 9th rev.) were divided into two groups. With a flexible dose, twenty patients were treated with haloperidol, twenty-one with amisulpride. With respect to relevant criteria such as age, sex, length and degree of illness, the two groups were comparable. The study was conducted over 42 days. As early as within the first 14 days, both groups showed significant improvement with respect to their psychotic symptoms. When the two groups were compared on the basis of the BPRS subscore for the anxiety-depression syndrome, and the AMDP system subscores for the somatic-depressive syndrome and the hypochondriac syndrome, the amisulpride group showed significantly better results than the haloperidol group. The ratings on the EPS scales of Webster and Simpson revealed significantly fewer extrapyramidal side-effects in the amisulpride group. Psychotic symptoms were improved after both types of treatment. Amisulpride treatment showed better results with regard to depressive symptoms, and less tendency to generate extrapyramidal side-effects.

[Bing-Neel syndrome. Polyneuropathy within the scope of paraproteinemia]. / Bing-Neel-Syndrom. Polyneuropathie im Rahmen einer Paraproteinämie.

A rare cause of polyneuropathy, first described in 1936, is the Bing-Neel syndrome. This polyneuropathy develops on the basis of a paraproteinemia. Five patients in whom the symptom constellation presented, were examined. All patients complained of motor or sensory deficiencies affecting the limbs, but had no evidence of malignant disease. Four patients had IgM paraprotein, one an IgG paraprotein in the serum. In two patients, the bone marrow revealed lymphocytic infiltration in the sense of an immunocytoma, in one other patient, a plasmacytoma was detected in the bone marrow. Three patients were treated in accordance with the Knospe regimen, the patient with the plasmocytoma with the Alexanian regimen. In one case satisfactory regression of the symptoms was observed, in the other two cases a moderate improvement occurred.

The value of laparoscopy in the diagnosis of acute pelvic inflammatory disease.

A total of 40 patients with acute pelvic inflammatory disease (acute PID) were examined over a period of 7 months to determine the diagnostic value of laparoscopic examination in these cases. The most important findings were: the clinical diagnosis of acute PID was confirmed by laparoscopy in 55% of patients; laparoscopy was especially of value in differentiating potentially lethal conditions such as ectopic pregnancy and acute appendicitis from acute PID in 15% of patients; laparoscopically obtained microbiological specimens provide a more accurate means of determining the microbiological aetiology of acute PID than vaginally obtained specimens.

Diagnostic laparoscopy and management of patients with confirmed acute pelvic inflammatory disease.

The clinical success rate in the diagnosis of acute pelvic inflammatory disease (PID) is unacceptably low. There is an invaluable role for laparoscopy in the diagnosis, investigation and treatment of patients with suspected pelvic infection. PID at Ngwelezana Hospital is predominantly gonococcal and a combination of penicillin G and clindamycin has proved highly effective in the management of these patients.

Laparoscopic diagnosis of acute pelvic inflammatory disease.

At Ngwelezana Hospital, 103 patients admitted from the outpatient clinic with a diagnosis of pelvic infection were laparoscoped and in only 63 was the diagnosis confirmed. A disturbingly high incidence of ectopic pregnancy (8 patients) was found.