Cerebral palsy and its medicolegal implications in low- resource settings - the need to establish causality and revise criteria to implicate intrapartum hypoxia: A narrative review.

The objective of this study was to establish scientific causality and to devise criteria to implicate intrapartum hypoxia in cerebral palsy (CP) in low-resource settings, where there is potential for an increase in damaging medicolegal claims against obstetric caregivers, as is currently the situation in South Africa. For the purposes of this narrative review, an extensive literature search was performed, including any research articles, randomised controlled trials, observational studies, case reports or expert or consensus statements pertaining to CP in low-resource settings, medicolegal implications, causality, and criteria implicating intrapartum hypoxia. In terms of causation, there are differences between high-income countries (HICs) and low-resource settings. While intrapartum hypoxia accounts for 10 - 14% of CP in HICs, the figure is higher in low-resource settings (20 - 46%), indicating a need for improved intrapartum care. Criteria implicating intrapartum hypoxia presented for HICs may not apply to low-resource settings, as cord blood pH testing, neonatal brain magnetic resonance imaging (MRI) and placental histology are frequently not available, compounded by incomplete clinical notes and missing cardiotocography tracings. Revised criteria in an algorithm for low-resource settings to implicate intrapartum hypoxia in neonatal encephalopathy (NE)/ CP are presented. The algorithm relies first on specialist neurological assessment of the child, determination of the occurrence of neonatal encephalopathy (by documented or verbal accounts) and findings on childhood MRI, and second on evidence of antepartum and intrapartum contributors to the apparent hypoxia-related CP. The review explores differences between low-resource settings and HICs in trying to establish causation in NE/CP and presents a revised scientific approach to causality in the context of low-resource settings for reaching appropriate legal judgments.

Clinical practice.

Basal ganglia and thalamus (BGT) hypoxic-ischaemic brain injury is currently the most contentious issue in cerebral palsy (CP) litigation in South Africa (SA), and merits a consensus response based on the current available international literature. BGT pattern injury is strongly associated with a preceding perinatal sentinel event (PSE), which has a sudden onset and is typically unforeseen and unpreventable. Antepartum pathologies may result in fetal priming, leading to vulnerability to BGT injury by relatively mild hypoxic insults. BGT injury may uncommonly follow a gradual-onset fetal heart rate deterioration pattern, of duration ≥1 hour. To prevent BGT injury in a clinical setting, the interval from onset of PSE to delivery must be short, as little as 10 - 20 minutes. This is difficult to achieve in any circumstances in SA. Each case needs holistic, multidisciplinary, unbiased review of all available antepartum, intrapartum and postpartum and childhood information, aiming at fair resolution without waste of time and resources.

Right of Reply.

To the Editor: The article by Bhorat et al. [1] in the SAMJ, entitled 'Cerebral palsy and criteria implicating intrapartum hypoxia in neonatal encephalopathy - an obstetric perspective for the South African setting', starts off by raising concerns about 'steep rises in insurance premiums, placing service delivery under serious threat'. It does not acknowledge any service delivery issues that already exist in the public sector obstetric services in South Africa (SA). According to Whittaker,[2] in 2019, there were 303 obstetricians and gynaecologists employed in the SA public sector and 579 in the private sector, and of those employed in the public sector, 190 were performing private sector work. That a large number of the children with cerebral palsy (CP) were delivered in the public sector service was not noted by Bhorat et al.,[1] nor was the fact that the overwhelming majority of court cases are against the state (not against individual doctors) in provinces and hospitals with significant medical staffing and resource issues. For example, the liabilities for Eastern Cape Province in the 2019/20 period were ZAR36 751 207 v. only ZAR33 155 in Western Cape Province for the same period.[2].

Decreased severity of disease during the first global omicron variant covid-19 outbreak in a large hospital in tshwane, south africa.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) first reported in Wuhan, China in December 2019 is a global pandemic that is threatening the health and wellbeing of people worldwide. To date there have been more than 274 million reported cases and 5.3 million deaths. The Omicron variant first documented in the City of Tshwane, Gauteng Province, South Africa on 9 November 2021 led to exponential increases in cases and a sharp rise in hospital admissions. The clinical profile of patients admitted at a large hospital in Tshwane is compared with previous waves. METHODS: 466 hospital COVID-19 admissions since 14 November 2021 were compared to 3962 admissions since 4 May 2020, prior to the Omicron outbreak. Ninety-eight patient records at peak bed occupancy during the outbreak were reviewed for primary indication for admission, clinical severity, oxygen supplementation level, vaccination and prior COVID-19 infection. Provincial and city-wide daily cases and reported deaths, hospital admissions and excess deaths data were sourced from the National Institute for Communicable Diseases, the National Department of Health and the South African Medical Research Council. RESULTS: For the Omicron and previous waves, deaths and ICU admissions were 4.5% vs 21.3% (p<0.00001), and 1% vs 4.3% (p<0.00001) respectively; length of stay was 4.0 days vs 8.8 days; and mean age was 39 years vs 49,8 years. Admissions in the Omicron wave peaked and declined rapidly with peak bed occupancy at 51% of the highest previous peak during the Delta wave. Sixty two (63%) patients in COVID-19 wards had incidental COVID-19 following a positive SARS-CoV-2 PCR test . Only one third (36) had COVID-19 pneumonia, of which 72% had mild to moderate disease. The remaining 28% required high care or ICU admission. Fewer than half (45%) of patients in COVID-19 wards required oxygen supplementation compared to 99.5% in the first wave. The death rate in the face of an exponential increase in cases during the Omicron wave at the city and provincial levels shows a decoupling of cases and deaths compared to previous waves, corroborating the clinical findings of decreased severity of disease seen in patients admitted to the Steve Biko Academic Hospital. CONCLUSION: There was decreased severity of COVID-19 disease in the Omicron-driven fourth wave in the City of Tshwane, its first global epicentre.

Cerebral Palsy and Criteria Implicating Intrapartum Hypoxia in Neonatal Encephalopathy - An Obstetric Perspective for the South African Setting.

The science surrounding cerebral palsy indicates  that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway  to brain injury and later CP.  It is thus simplistic to base causation of cerebral palsy on only an intrapartum perspective with radiological 'confirmation', as is often the practice in medicolegal cases in South African courts. The present modalities (MRI and CTG when available) that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) are taken into account, success for plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this document to implicate acute intrapartum hypoxia in hypoxic ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medicolegal setting.

Metabolic syndrome at 6 weeks after delivery in a cohort of pre-eclamptic and normotensive women.

BACKGROUND: The association between pre-eclampsia and the subsequent development of metabolic syndrome has not been well documented in low- and middle-income countries. OBJECTIVES: To compare the prevalence of metabolic syndrome at 6 weeks after delivery among women with pregnancies complicated by pre-eclampsia with that in a normotensive, low-risk control group in an urban South African (SA) setting. METHODS: This was a prospective cohort study at two tertiary-level hospitals and one district-level hospital in Pretoria, SA. Women were recruited after delivery and were followed up 6 weeks later to confirm or exclude the diagnosis of metabolic syndrome. RESULTS: Metabolic syndrome was diagnosed in 48/150 women with pregnancies complicated by pre-eclampsia (32.0%), compared with 33/150 (22.0%) of the control group (p=0.05). CONCLUSIONS: Women who developed pre-eclampsia during pregnancy had an increased chance of metabolic syndrome being diagnosed 6 weeks after delivery. Guidelines should be developed to identify women with cardiometabolic risk, so that interventions may be implemented to modify this risk before and after pregnancy.

Hypertensive disorders in pregnancy: 2019 National guideline.

BACKGROUND: Hypertensive disorders of pregnancy (HDP), including pre-eclampsia/eclampsia, account for significant maternal and fetal mortality globally and especially in South Africa. Objective. To formulate clinical guidelines for the management of HDP in order to substantially reduce the number of maternal deaths from HDP. Methods. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used to formulate the guidelines and included six domains: scope and purpose; stakeholder involvement; rigour and development; clarity of presentation; applicability; and editorial independence. Recommendations. The guideline stipulates management strategies for all levels of care where women with hypertensive disorders in pregnancy are seen. It also has a detailed implementation plan. Conclusion. A clinical guideline that is of practical value has been formulated by a wide group of stakeholders. It is hoped that its dissemination and implementation by all doctors and nurses will reduce mortality and morbidity associated with HDP.

The effect of pre-eclampsia on retinal microvascular caliber at delivery and post-partum.

BACKGROUND: The retinal microcirculation provides a unique view of microvessel structure by means of non-invasive, retinal image analysis. The aim of the study was to compare the retinal vessel caliber at delivery and one-year post-partum between women who have had pre-eclampsia during pregnancy to a normotensive control group. METHODS: Digital photos of the eye were taken at delivery and one-year post-partum. Retinal vessels were analysed and summarised as the corrected central retinal arteriolar equivalent and corrected central retinal venular equivalent. RESULTS: The corrected central retinal arteriolar equivalent and corrected central retinal venular equivalent were significantly lower in the pre-eclamptic group compared to the control group both at delivery and one-year post-partum (p < 0.001). CONCLUSION: Retinal artery and venular caliber changes that occur during pregnancies affected by pre-eclampsia persist for up to one-year post-partum. These changes may reflect a permanent, long-term microvascular dysfunction and may be useful as a biomarker of future vascular risk.

Starvation ketoacidosis in pregnancy presenting as euglycaemic, high anion gap metabolic acidosis: A case report highlighting the significance of early recognition and prompt intervention.

Starvation ketoacidosis (SKA) constitutes an important consideration in the pregnant patient who presents with profound metabolic acidosis. Pregnancy-related changes predispose the patient to develop SKA following relatively short periods (12 - 14 hours) of 'starvation'. Patients also typically look clinically well in relation to the significant metabolic derangements that accompany the condition. Prompt recognition and early institution of appropriate therapy is therefore extremely important in terms of optimising maternal and fetal outcome. We describe a pregnant patient with SKA who presented with profound euglycaemic ketoacidosis that resolved rapidly following the early initiation of appropriate therapy. Furthermore, appropriate therapy resulted in our patient avoiding the need for an emergency caesarean section, which is often reported in this scenario. The ensuing discussion addresses SKA in pregnancy, the unique features of our patient, and management considerations from a maternal and fetal perspective. We also discuss the various causes of ketoacidosis such as diabetic ketoacidosis (DKA), euglycaemic DKA, alcohol-induced euglycaemic ketoacidosis and SKA in pregnant patients.

Haemorrhage and other complications in pregnant women on anticoagulation for mechanical heart valves: a prospective observational cohort study.

OBJECTIVE: To document maternal and foetal morbidity and mortality in anticoagulated, pregnant patients with mechanical heart valves until 42 days postpartum. METHODS: In a tertiary single-centre, prospective cohort, 178 consecutive patients at the cardiac-obstetric clinic were screened for warfarin use between 1 July 2010 and 31 December 2015. Of 33 pregnancies identified, 29 were included. Patients received intravenous unfractionated heparin from six to 12 weeks' gestation and peripartum, and warfarin from 12 to 36 weeks. Maternal outcomes including death, major haemorrhage and thrombosis, and foetal outcomes were documented. RESULTS: There were two maternal deaths, five returns to theatre post-delivery, eight patients transfused, six major haemorrhages, one case of infective endocarditis and three ischaemic strokes. Ten pregnancies had poor foetal outcomes (six miscarriages, three terminations, one early neonatal death). Twenty patients required more than 30 days' hospitalisation, and 15 required three or more admissions. HIV positivity was associated with surgical delivery (p = 0.0017). CONCLUSION: Complication rates were high despite centralised care.

Cardiac diastolic function after recovery from pre-eclampsia.

BACKGROUND: Pre-eclampsia is associated with significant changes to the cardiovascular system during pregnancy. Eccentric and concentric remodelling of the left ventricle occurs, resulting in impaired contractility and diastolic dysfunction. It is unclear whether these structural and functional changes resolve completely after delivery. AIMS: The objective of the study was to determine cardiac diastolic function at delivery and one year post-partum in women with severe pre-eclampsia, and to determine possible future cardiovascular risk. METHODS: This was a descriptive study performed at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. Ninety-six women with severe preeclampsia and 45 normotensive women with uncomplicated pregnancies were recruited during the delivery admission. Seventy-four (77.1%) women in the pre-eclamptic group were classified as a maternal near miss. Transthoracic Doppler echocardiography was performed at delivery and one year post-partum. RESULTS: At one year post-partum, women with pre-eclampsia had a higher diastolic blood pressure (p = 0.001) and body mass index (p = 0.02) than women in the normotensive control group. Women with early onset pre-eclampsia requiring delivery prior to 34 weeks' gestation had an increased risk of diastolic dysfunction at one year post-partum (RR 3.41, 95% CI: 1.11-10.5, p = 0.04) and this was irrespective of whether the patient had chronic hypertension or not. CONCLUSION: Women who develop early-onset pre-eclampsia requiring delivery before 34 weeks are at a significant risk of developing cardiac diastolic dysfunction one year after delivery compared to normotensive women with a history of a low-risk pregnancy.

Cerebral white matter lesions after pre-eclampsia.

BACKGROUND: Women who have had pre-eclampsia in their previous pregnancies demonstrate a greater prevalence of cerebral white matter lesions several years after the pregnancy than women who have been normotensive during their pregnancy. Both the pathophysiology and the timing of development of these lesions are uncertain. White matter lesions, in the general population, are associated with an increased risk of stroke, dementia and death. AIMS AND OBJECTIVES: The objective of the study was to determine the prevalence of cerebral white matter lesions amongst women with severe pre-eclampsia at delivery, 6months and 1year postpartum and to establish the possible pathophysiology and risks factors. METHODS: This was a longitudinal study performed at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria South Africa. Ninety-four women with severe pre-eclampsia were identified and recruited during the delivery admission. Magnetic resonance imaging (MRI) of the brain was performed post - delivery and at 6months and 1year postpartum. RESULTS: Cerebral white matter lesions were demonstrated in 61.7% of women at delivery, 56.4% at 6months and 47.9% at 1year. Majority of the lesions were found in the frontal lobes of the brain. The presence of lesions at 1year post-delivery was associated with the number of drugs needed to control blood pressure during pregnancy (OR 5.1, 95% CI 2.3-11.3, p<0.001). The prevalence of WMLs at 1year was double in women with chronic hypertension at 1year compared to those women who were normotensive (65.1% vs 32.3%). CONCLUSION: Women who require 2 or more drugs to control blood pressure during pregnancy have an increased risk of developing cerebral white matter lesions after delivery.

Barriers to obstetric care among maternal near misses.

BACKGROUND: There are several factors in the healthcare system that may influence a woman's ability to access appropriate obstetric care. OBJECTIVE: To determine the delays/barriers in providing obstetric care to women who classified as a maternal near-miss. METHODS: This was a descriptive observational study at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. One hundred maternal near-misses were prospectively identified using the World Health Organization criteria. The 'three-delays model' was used to identify the phases of delay in the health system and recorded by the doctor caring for the patient. RESULTS: One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Phase I and III delays were the most important causes of barriers. Lack of knowledge of the problem (40%) and inadequate antenatal care (37%) were important first-phase delays. Delay in patient admission, referral and treatment (37%) and substandard care (36%) were problems encountered within the health system. The above causes were also the most important factors causing delays for the leading causes of maternal near-misses - obstetric haemorrhage, hypertension/pre-eclampsia, and medical and surgical conditions. CONCLUSIONS: Maternal morbidity and mortality rates may be reduced by educating the community about symptoms and complications related to pregnancy. Training healthcare workers to identify and manage obstetric emergencies is also important. The frequency of antenatal visits should be revised, with additional visits in the third trimester allowing more opportunities for blood pressure to be checked and for identifying hypertension.

Medical disease as a cause of maternal mortality: the pre-imminence of cardiovascular pathology.

Maternal mortality ratio in low- to middle-income countries (LMIC) is 14 times higher than in high-income countries. This is partially due to lack of antenatal care, unmet needs for family planning and education, as well as low rates of birth managed by skilled attendants. While direct causes of maternal death such as complications of hypertension, obstetric haemorrhage and sepsis remain the largest cause of maternal death in LMICs, cardiovascular disease emerges as an important contributor to maternal mortality in both developing countries and the developed world, hampering the achievement of the millennium development goal 5, which aimed at reducing by three-quarters the maternal mortality ratio until the end of 2015. Systematic search for cardiac disease is usually not performed during pregnancy in LMICs despite hypertensive disease, rheumatic heart disease and cardiomyopathies being recognised as major health problems in these settings. New concern has been rising due to both the HIV/AIDS epidemic and the introduction of highly active antiretroviral therapy. Undetected or untreated congenital heart defects, undiagnosed pulmonary hypertension, uncontrolled heart failure and complications of sickle cell disease may also be important challenges. This article discusses issues related to the role of cardiovascular disease in determining a substantial portion of maternal morbidity and mortality. It also presents an algorhitm to be used for suspected and previously known cardiac disease in pregnancy in the context of LIMCs.

Barriers to Obstetric Care among Maternal Near Misses

Background. There are several factors in the healthcare system that may influence a woman's ability to access appropriate obstetric care.Objective. To determine the delays/barriers in providing obstetric care to women who classified as a maternal near-miss. Methods. This was a descriptive observational study at Steve Biko Academic Hospital; a tertiary referral hospital in Pretoria; South Africa. One hundred maternal near-misses were prospectively identified using the World Health Organization criteria. The 'three-delays model' was used to identify the phases of delay in the health system and recorded by the doctor caring for the patient.Results. One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Phase I and III delays were the most important causes of barriers. Lack of knowledge of the problem (40%) and inadequate antenatal care (37%) were important first-phase delays. Delay in patient admission; referral and treatment (37%) and substandard care (36%) were problems encountered within the health system. The above causes were also the most important factors causing delays for the leading causes of maternal near-misses - obstetric haemorrhage; hypertension/pre-eclampsia; and medical and surgical conditions.Conclusions. Maternal morbidity and mortality rates may be reduced by educating the community about symptoms and complications related to pregnancy. Training healthcare workers to identify and manage obstetric emergencies is also important. The frequency of antenatal visits should be revised; with additional visits in the third trimester allowing more opportunities for blood pressure to be checked and for identifying hypertension

Takayasu arteritis in pregnancy.

Takayasu arteritis is a chronic, granulomatous arteritis affecting large and medium-sized arteries. During pregnancy, maternal and foetal complications are largely as a consequence of maternal arterial hypertension. We present a case of a 35-year-old para one gravida two patient with Takayasu arteritis (group III disease) complicated by chronic hypertension and a severely dilated ascending aorta. Good blood pressure control during pregnancy is an important measure in reducing obstetric morbidity.

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.