Perinatal metabolism of dichlorodiphenyldichloroethylene in Nicaraguan mothers.

Umbilical cord and venous blood samples were collected at the time of delivery from 52 mothers living in urban and rural areas of the Atoya River basin, Nicaragua. In a subsample of 24 mothers that delivered by Cesarean section, abdominal adipose tissue samples were also collected, as was breast milk later in lactation. Cord and venous blood sera were analyzed for 13 organochlorine pesticides: 1,1,1-trichloro-2,2-bis(4-chlorophenyl)ethane (pp'-DDT); 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (pp'-DDE); pp'-dichlorophenyldichlorodiene (pp'-DDD); alpha-hexachlorocyclohexane (alpha-HCH); beta-hexachlorocyclohexane (beta-HCH); gamma-hexachlorocyclohexane (gamma-HCH); delta-hexachlorocyclohexane (delta-HCH); toxaphene; dieldrin; endrin; aldrin; heptachlor; and heptachlor epoxide. In venous blood only pp'-DDE (100% of samples), pp'-DDT (1.92%), dieldrin (15.38%), heptachlor (15.38%), gamma-HCH (7.69%), beta-HCH (11.53%), and delta-HCH (1.92%) were found, whereas in cord blood only pp'-DDE (100%), pp'-DDT (3.84%), dieldrin (19.23%), and heptachlor (9.16%), were found. The persistent DDT metabolite pp'-DDE, present in all samples of blood serum, adipose tissue, and breast milk, was studied in relation to maternal characteristics such as body mass index (BMI), age, lactation experience, and fetal pesticide acquisition. Mean venous (7.12 microg/g) and cord (6.39 microg/g) pp'-DDE concentrations were not significantly different but were significantly correlated. pp'-DDE in maternal adipose tissue was positively correlated with pp'-DDE in cord blood (P=0.0001) and breast milk (P<0.0001) and marginally correlated with changes in BMI (r=-0.03088; P=0.06). There was a higher proportion of samples (58%) with a greater concentration of DDE in venous than in cord blood. Although DDE accumulation may be less during fetal development than during breast feeding, exposure during embryogenesis may be more important than during the postnatal period.

Adolescent maternal mortality in Mozambique.

PURPOSE: To describe adolescent maternal mortality and analyze its avoidability. METHODS: An audit approach was used to clarify the presence of avoidable factors in 239 maternal deaths, of which 22% were among adolescents. RESULTS: The main causes of adolescent death were malaria, pregnancy-induced hypertension, puerperal sepsis, and septic abortion. The audit classified as avoidable 75% of all maternal deaths. CONCLUSION: Adequate strategies addressing the special needs of adolescents are required to prevent currently high levels of maternal mortality in this age group.

Concentrations of organochlorine pesticides in milk of Nicaraguan mothers.

Breast-milk samples from 101 mothers from the basin of Rio Aloya, Nicaragua, were collected on two occasions within the first trimester of lactation. Milk samples were analyzed for 13 organochlorine pesticides: (1) p,p'-dichlorophenyldichloroethylene; (2) p,p'-dichlorophenyltrichloroethane; (3) p,p'-dichlorophenyldichlorodiene; (4) alpha-hexachlorocyclohexane; (5) beta-hexachlorocyclohexane; (6) gamma-hexachlorocyclohexane; (7) delta-hexachlorocyclohexane; (8) toxaphene; (9) dieldrin; (10) endrin; (11) aldrin; (12) heptachlor; and (13) heptachlor-epoxide. Organochlorines of the dichlorodiphenylethane class (i.e., p,p'-dichlorodiphenylethane and p,p'-dichlorodiphenylethane) were found in all samples and at the highest mean concentrations observed in the study. Chemicals in the hexachlorocyclohexane family (i.e., alpha- and delta-hexachlocyclohexane) were not found at all (0%), and the other hexachlorocyclohexane compounds (i.e., beta > gamma) were found in less than 6% of the samples. Twenty percent or less of the sample contained chlorInated cyclodienes (i.e., dieldrin > endrin > heptachlor-epoxide > heptachlor). No measurable concentrations of alpha-hexachlorocyclohexane, aldrin, p,p'-dichlorophenyldichlorodiene, and toxaphene were found in the breast milk samples. Analysis of variance demonstrated that only the concentration of p,p'-dichlorophenyldichloroethylene p,p'-dichlorophenyltrichloroethane, and endrin were affected significantly by maternal age. Overall, with the exception of p,p'-chlorophenyldichloroethylene, and p,p'-dichlorophenyltrichloroethane, the mean concentrations of the analyzed pesticides were low. Total p,p'-dichlorophenyltrichloroethane concentrations that exceeded the allowed daily intake set by the World Health Organisation were found in 5.9% of the samples.

Avoidability of maternal death in Mozambique: audit and retrospective risk assessment in 106 consecutive cases.

A maternal mortality audit identified 106 cases of maternal death in Maputo (340 per 100 000 live births), caused by haemorrhage (31%), hypertensive diseases of pregnancy (15%), puerperal sepsis (12%) and septic abortion (9%). Puerperal uterine inertia (12%) and malaria (9%), respectively, were the most prevalent causes of direct and indirect maternal death. The maternal mortality audit analyses, indicated that health services research is fruitful in a more detailed, systematic study on maternal deaths at the community level wit ensuing analyses of avoidability aspects. Lack of transport and poor quality of antenatal and intrapartum care in peripheral maternity units implied that women with eclampsia, obstructed labor, post partum atonic haemorrhage and uterine rupture arrived late due to deficient transport.Shortage of blood and delay in access to operating theatre contributed significantly to fatal maternal outcome in several cases. The audit provided evidence that approximately 40% of the deaths would have been avoidable with existing resources. It is particularly significant that the analysis of antenatal cards revealed that only 30% had any high risk factors, implying that more than two thirds of women dying a maternal death are low risk women.

Avoidability of Maternal Death in Mozambique : Audit and Retrospective Risk Assessment in 106 Consecutive Cases

maternal mortality audit identified 106 cases of maternal death in Maputo (340 per 100 000 live births); caused by haemorrhage (31); hypertensive diseases of pregnancy (15); puerperal sepsis (12) and septic abortion (9). Puerperal uterine inertia (12) and malaria (9); respectively; were the most prevalent causes of direct and indirect maternal death. The maternal mortality audit analyses; indicated that health services research is fruitful in a more detailed; systematic study on maternal deaths at the community level wit ensuing analyses of avoidability aspects. Lack of transport and poor quality of antenatal and intrapartum care in peripheral maternity units implied that women with eclampsia; obstructed labor; post partum atonic haemorrhage and uterine rupture arrived late due to deficient transport.Shortage of blood and delay in access to operating theatre contributed significantly to fatal maternal outcome in several cases. The audit provided evidence that approximately 40of the deaths would have been avoidable with existing resources. It is particularly significant that the analysis of antenatal cards revealed that only 30had any high risk factors; implying that more than two thirds of women dying a maternal death are low risk women

Malaria-related maternal mortality in urban Mozambique.

All pregnancy-related maternal deaths that occurred at the central hospital of Maputo during the 5 years between 1989 and 1993 were reviewed. The 239 maternal deaths recorded represented a maternal mortality ratio of 320/100,000 live births. Overall, 15.5% of the deaths were directly attributable to malaria, and 19.7% of the women who died were found to be parasitaemic (with Plasmodium falciparum) prior to death. Autopsies on 161 of the women who died showed histological evidence of malarial infection in the spleens of 44 (27.3%). Many (37.8%) of the malaria-related deaths occurred in adolescent primigravidae, and most were associated with severe anaemia. Pregnancy outcome was generally poor. Unbooked deliveries, and poor antenatal care were identified as risk factors for maternal death from malaria. The current policy of prescribing antimalarials in pregnancy based on symptomatic malaria alone should be reviewed. Improved primary prevention is required in order to reduce the high risk of malaria-related mortality in all pregnant women in the urban study area, especially among adolescents.

Pregnancy-related changes in fat mass and total DDT in breast milk and maternal adipose tissue.

BACKGROUND: Changes in body fat mass during pregnancy and its effects on total DDT concentration i.e. the, sum of pp'-DDT (pp'-dichlorodiphenyltrichloroethane), and pp'-DDE (pp'-dichlorophenyldichloroethylene), in maternal milk and abdominal fat were studied in humans. METHODS: Forty mothers that delivered by Caesarean section and chose to breast feed consented in providing samples (abdominal fat and breast milk) for determination of organochlorine pesticides. Constitutional variables, such as the number of children, and estimators of body fat mass, based on height and body weight (before and after pregnancy), were measured. RESULTS: Body mass index before and after pregnancy, as well as percent change in body weight, showed no significant difference in total DDT concentration in abdominal fat or breast milk. The only variable to significantly affect either body load of pesticides (abdominal fat) or its excretion (milk fat) was the number of children (p = 0.0117 and p = 0.0324, respectively). Correlation coefficients between DDT (in adipose tissue and milk fat) and variables related to body fatness (body mass index) were low and not significant. However, a close relationship was found between total DDT in adipose tissue and milk fat (r = 0.709; p = 0.0001).

Uterine evacuation by vaginal misoprostol after second trimester pregnancy interruption.

BACKGROUND: The purpose was to study the capacity of vaginal misoprostol in combination with methylergometrine to achieve complete evacuation of the uterus without ensuing surgical evacuation of the uterine cavity. METHODS: We performed this trial on 228 women seeking pregnancy interruption. Vaginal misoprostol was given in a dosage of 800 micrograms in early second trimester. All women received concomitant treatment with peroral methlyergometrine from the moment of misoprostol application every 8 hours until uterine evacuation. Follow-up was continued until the first menstruation after interruption. RESULTS: Complete uterine evacuation was achieved in 173/228 cases (76%) [group 1]. The remaining 55 women [group 2] underwent manual evacuation of placental remnants trapped in the cervix. In seven of these women a conventional curettage was carried out due either to ultrasound evidence of placental remnants or due to uterine bleeding. The interval between misoprostol application and fetal expulsion averaged 14.9 hours (s.d. 9.6) in group 1 and 21.0 hours (s.d. 14.5) in group 2 (p=0.006). CONCLUSIONS: Misoprostol, in combination with methylergometrine, is a remarkably efficient drug in achieving uterine evacuation also in the absence of surgical evacuation of the uterine cavity. The present study provides justification for a more expectant attitude after vaginal misoprostol treatment for pregnancy interruption. The avoidance of close to 80% of otherwise conventional curettages would seem to represent a major advantage, particularly in settings where manpower and material resources are scarce.