Impact of fetal growth restriction on pregnancy outcome in women undergoing expectant management for preterm pre-eclampsia.

OBJECTIVES: To assess whether coexisting fetal growth restriction (FGR) influences pregnancy latency among women with preterm pre-eclampsia undergoing expectant management. Secondary outcomes assessed were indication for delivery, mode of delivery and rate of serious adverse maternal and perinatal outcomes. METHODS: We conducted a secondary analysis of the Pre-eclampsia Intervention (PIE) and the Pre-eclampsia Intervention 2 (PI2) trial data. These randomized controlled trials evaluated whether esomeprazole and metformin could prolong gestation of women diagnosed with pre-eclampsia between 26 and 32 weeks of gestation undergoing expectant management. Delivery indications were deteriorating maternal or fetal status, or reaching 34 weeks' gestation. FGR (defined by Delphi consensus) at the time of pre-eclampsia diagnosis was examined as a predictor of outcome. Only placebo data from PI2 were included, as the trial showed that metformin use was associated with prolonged gestation. All outcome data were collected prospectively from diagnosis of pre-eclampsia to 6 weeks after the expected due date. RESULTS: Of the 202 women included, 92 (45.5%) had FGR at the time of pre-eclampsia diagnosis. Median pregnancy latency was 6.8 days in the FGR group and 15.3 days in the control group (difference 8.5 days; adjusted 0.49-fold change (95% CI, 0.33-0.74); P < 0.001). FGR pregnancies were less likely to reach 34 weeks' gestation (12.0% vs 30.9%; adjusted relative risk (aRR), 0.44 (95% CI, 0.23-0.83)) and more likely to be delivered for suspected fetal compromise (64.1% vs 36.4%; aRR, 1.84 (95% CI, 1.36-2.47)). More women with FGR underwent a prelabor emergency Cesarean section (66.3% vs 43.6%; aRR, 1.56 (95% CI, 1.20-2.03)) and were less likely to have a successful induction of labor (4.3% vs 14.5%; aRR, 0.32 (95% CI, 0.10-1.00)), compared to those without FGR. The rate of maternal complications did not differ significantly between the two groups. FGR was associated with a higher rate of infant death (14.1% vs 4.5%; aRR, 3.26 (95% CI, 1.08-9.81)) and need for intubation and mechanical ventilation (15.2% vs 5.5%; aRR, 2.97 (95% CI, 1.11-7.90)). CONCLUSION: FGR is commonly present in women with early preterm pre-eclampsia and outcome is poorer. FGR is associated with shorter pregnancy latency, more emergency Cesarean deliveries, fewer successful inductions and increased rates of neonatal morbidity and mortality. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Delivery outcomes in women with morbid obesity, where induction of labour was planned to prevent post-term complications.

Morbid obesity and prolonged pregnancy are independently associated with adverse delivery and perinatal outcomes. We conducted a retrospective observational study on otherwise uncomplicated women with a body mass index (BMI) ≥ 40 kg/m2 where, having reached term, induction of labour (IOL) was planned, to prevent prolonged pregnancy. The primary aim was to describe delivery outcomes and short-term maternal and perinatal adverse events. Of 117 cases included, 69 (59%) laboured spontaneously before the induction date, while 48 (41%) required an IOL. Of 48 patients that underwent an IOL, 22 (45.8%) achieved vaginal delivery, compared to 55 (79.7%) who laboured spontaneously (p = <.001). Twenty-two (18.8%) of the 117 babies weighed more than 4000 g, with 13 of these delivered vaginally. Overall, term patients with morbid obesity who laboured spontaneously before requiring induction, had a high rate of vaginal delivery. However, when IOL was required, the rate of caesarean delivery rose dramatically.Impact statementWhat is already known on this subject? Morbid obesity and prolonged pregnancy are independently associated with adverse delivery and perinatal outcomes. Induction of labour (IOL) increases the workload in busy units.What do the results of this study add? These results help inform accurate counselling on delivery outcomes, which is integral to respectful care, for the continuously increasing numbers of morbidly obese pregnant women.What the implications are of these findings for clinical practice and/or further research? It is preferable to avoid semi- or urgent caesarean deliveries in morbidly obese women after IOL. The outcomes of earlier induction of labour from 39- or 40-weeks' gestation requires investigation. Earlier induction may reduce the numbers of caesarean deliveries for abnormal cardiotocograph during the process.

The impact of an obstetrician-led, labor ward critical care unit: A prospective comparison of outcomes before and after establishment.

OBJECTIVE: To investigate the outcomes of critically ill obstetric patients managed in a obstetric critical care unit in South Africa. METHODS: Patients with severe maternal morbidity managed in the labor ward of Tygerberg Hospital were studied over three months before the establishment of the obstetrician-led obstetric critical care unit. One year later, patients managed in the obstetric critical care unit were studied using the same methods. The primary outcome measures were maternal morbidity and mortality. RESULTS: In the before-obstetric critical care unit prospective audit 63 patients met criteria for obstetric critical care. During the second period 60 patients were admitted to the obstetric critical care unit. There were no significant differences between the groups in baseline characteristics, admission indications or Acute Physiology and Chronic Health Evaluation scores. Continuous positive airway pressure (p < 0.01) was utilized more in the second group. Seven deaths occurred in the first, but none in the second group (p = 0.01). CONCLUSION: The establishment of an obstetrician-led obstetric critical care unit facilitated a decrease in maternal mortality.Trial registration: Not applicable.

A comparison between point-of-care testing and venous glucose determination for the diagnosis of diabetes mellitus 6-12 weeks after gestational diabetes.

AIM: To evaluate point-of-care-testing (POCT) for the diagnosis of Type 2 diabetes mellitus 6-12 weeks post-partum in women with gestational diabetes (GDM). METHODS: Post-partum glucose assessment (75-mg oral glucose tolerance test, OGTT) was performed prospectively in 122 women with GDM (1 November 2015 to 1 November 2017) at Tygerberg Hospital, Cape Town, South Africa. Individuals with known pre-existing diabetes were excluded. The accuracy and clinical utility of POCT (capillary finger-prick) were compared with laboratory plasma glucose (hexokinase and glucokinase methods). The OGTT consisted of two time points (fasting and 2 h) during which concurrent glucose samples (POCT and laboratory) were obtained. Bland-Altman plots and paired analysis were used to assess the analytical accuracy of POCT, whereas its diagnostic performance was determined using positive and negative predictive values to calculate specificity and sensitivity. RESULTS: Spearman's ranked correlation analysis indicated a strong association between POCT and laboratory glucose values at both OGTT time points (fasting, r = 0.95, P < 0.0001; 2 h, r = 0.88, P < 0.0001). Thirty-six women were diagnosed with Type 2 diabetes based on gold standard laboratory glucose levels (fasting > 7 mmol/l; 2 h > 11.1 mmol/l). POCT correctly identified Type 2 diabetes in 78% of women (28 of 36) with a positive predictive value of 89.3% and a negative predictive value of 96.7% at the fasting time point. The sensitivity and specificity of POCT to diagnose Type 2 diabetes were 89% (fasting), 85.7% (2 h) and 96.7% (fasting), 98.5% (2 h) respectively. POCT proved less sensitive to diagnose pre-diabetes (69%) but displayed satisfactory specificity (92%) at both time points assessed. CONCLUSION: POCT accurately identifies women with Type 2 diabetes 6-12 weeks after GDM.

Avoiding paternalism but not moral perplexity.

Maternal autonomy has replaced medical paternalism, but conflicts between beneficence and autonomy persist.

Weight-related quality of life in obese, pregnant women in South Africa

Objective: The global obesity pandemic includes pregnant women. Obesity may negatively impact quality of life (QOL). A validated, obesity-specific, QOL assessment tool was used to assess the impact of obesity on five specific domains. Methods: A prospective cohort study was performed at Tygerberg Academic Hospital in South Africa. Morbid obesity was defined as a body mass index (BMI) of 40­49.9 kg/m2 and super-obesity as BMI > 50 kg/m2, using the first recorded weight during the pregnancy. Pregnant women with a BMI ≥ 40 were approached in the high-risk antenatal clinic where written informed consent was taken before recruitment. Using the QOL tool they answered statements about their current experiences.Results: A total of 66 morbidly obese and 46 super-obese women were enrolled across an age range of 18­45 years. Physical function and self-esteem were the domains with the lowest QOL scores. When comparing morbid with super obesity, all scores were significantly lower in the latter group except for the domains of self-esteem and sexual life.Conclusion: Morbid and super-obesity occur across the full spectrum of the adult reproductive period. Physical function and self-esteem are most affected while QOL is linked to the degree of obesity

The effect of calcium supplementation on blood pressure in non-pregnant women with previous pre-eclampsia: An exploratory, randomized placebo controlled study.

BACKGROUND: Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP). METHODS: This exploratory sub-study of the WHO Calcium and Pre-eclampsia (CAP) trial aims to determine the effect of 500mg/day elemental calcium on the blood pressure of non-pregnant women with previous pre-eclampsia. Non-pregnant women with at least one subsequent follow-up trial visit at approximately 12 or 24weeks after randomization were included. RESULTS: Of 836 women randomized by 9 September 2014, 1st visit data were available in 367 women of whom 217 had previously had severe pre-eclampsia, 2nd visit data were available in 201 women. There was an overall trend to reduced BP in the calcium supplementation group (1-2.5mmHg) although differences were small and not statistically significant. In the subgroup with previous severe pre-eclampsia, the mean diastolic BP change in the calcium group (-2.6mmHg) was statistically larger than in the placebo group (+0.8mmHg), (mean difference -3.4, 95% CI -0.4 to -6.4; p=0.025). The effect of calcium on diastolic BP at 12weeks was greater than in those with non-severe pre-eclampsia (p=0.020, ANOVA analysis). CONCLUSIONS: There is an overall trend to reduced BP but only statistically significant in the diastolic BP of women with previous severe pre-eclampsia. This is consistent with our hypothesis that this group is more sensitive to calcium supplementation, however results need to be interpreted with caution.

Shoo fly, don't bother me! Efficacy of traditional methods of protecting cattle from tsetse.

Studies were made of the efficacy of using smoke and housing to protect cattle from tsetse (Diptera: Glossinidae) in Zimbabwe. The efficacy of smoke was assessed by its effect on catches in Epsilon traps baited with a blend of acetone, 1-octen-3-ol, 4-methylphenol and 3-n-propylphenol. The efficacies of different types of kraal (enclosure) were gauged according to the catches of electrocuting targets (E-targets), baited with natural ox odour, placed within various designs of kraal. Smoke from burning wood (Colophospermum mopane) or dried cow dung reduced the catch of traps by approximately 50-90%. Kraals with a continuous wooden or netting wall, 1.5 m high, reduced catches of E-targets by approximately 75%. Arrangements of electric nets were used to assess the numbers of tsetse attacking live cattle within kraals and/or near sources of smoke. The results confirmed findings with traps and E-targets: kraals reduced the numbers of tsetse that fed by approximately 80% and smoke reduced the numbers attracted by approximately 70%; the use of both reduced overall attack rates by approximately 90%. The inclusion of 4-methylguaiacol, a known repellent for tsetse and a natural component of wood smoke, halved the catches of traps and E-targets and the numbers of tsetse attacking cattle. The practical benefits and difficulties of using repellents and/or housing to manage trypanosomiases are discussed.

Does a patient information sheet lead to better understanding of pre-eclampsia? A randomised controlled trial.

OBJECTIVE: To investigate whether a structured patient information sheet would improve women's satisfaction and understanding of pre-eclampsia, its management and risks. STUDY DESIGN: A randomised, controlled trial conducted in a referral centre in South Africa. Seventy-four women with early pre-eclampsia, who qualified for expectant management, were enroled. They all completed an anonymous, structured, and self-administered questionnaire before randomisation. Cases (n=37) received a patient information sheet addressing key features of pre-eclampsia; controls (n=37) received a welcome note. Within 5-7days, but still before delivery, they completed the same questionnaire again. MAIN OUTCOME MEASURES: Primarily assessing their general understanding and knowledge of pre-eclampsia, secondarily to assess their satisfaction and the impact of the information received. RESULTS: The patient information sheet improved their understanding of the immediate and long-term risks (p<0.01) and the chance of recurrence (p<0.01). Controls had good levels of understanding and appreciation. Most women in both groups felt well informed but levels of concern remained high. CONCLUSIONS: The structured information sheet improved patients' understanding and knowledge in a limited way but did not alleviate their anxiety. Although women appear to be generally well counselled in the study unit, measures to alleviate associated anxiety should be investigated.

Are early and late preeclampsia distinct subclasses of the disease--what does the placenta reveal?

OBJECTIVE: To compare histopathological differences in placentas from early- and late-onset preeclampsia, as well as late-onset preeclampsia and normal term deliveries. METHODS: This prospective study was performed at Tygerberg Hospital, a secondary and tertiary referral center in South Africa. Placentas from 100 women, 25 each with early and late-onset preeclampsia, and an equal number of controls matched for gestational age, underwent routine preparation and were evaluated independently by two pathologists in a strictly predetermined, standardized manner. RESULTS: Compared to late preeclampsia, placentas in the early preeclampsia group were smaller (p < 0.01), had more infarction (odds ratio [OR] = 4.03, 95% confidence interval [CI] = 1.2-13.5) and inappropriate maturation (OR = 16.62, 95% CI = 4.1-68.0). Placentas from the late-onset preeclampsia group showed increased decidual arteriopathy (OR = 5.09, 95% CI = 1.45-17.92) and abruptio placentae (OR = 5.41, 95% CI = 1.01-28.79) compared to controls. CONCLUSIONS: The early- and late-onset preeclampsia placentas showed clear histopathological differences, whereas late-onset preeclampsia and normal term placentas differed less. These findings support the contention that early- and late-onset preeclampsia are different subclasses of disease.

Late onset preeclampsia is not an innocuous condition.

OBJECTIVE: To describe the profile and outcome of late-onset preeclampsia (LOPE). METHODS: Retrospective study of 264 singleton pregnancies presenting before delivery at two referral centres in South Africa. RESULTS: Primigravid patients constituted 56.8% of the group, while 57.6% were graded as severe. Median gestational age at diagnosis was 37 (34-43) weeks. 30.7% of patients experienced >or=1 major maternal complication including 34 (12.9%) cases of eclampsia. There were no maternal or early neonatal deaths. Five intrauterine deaths occurred, all due to placental abruption. The perinatal mortality rate was 18.9 per thousand births. CONCLUSIONS: Late-onset preeclampsia often presents as severe disease.

Effect of progesterone on cervical shortening in women at risk for preterm birth: secondary analysis from a multinational, randomized, double-blind, placebo-controlled trial.

OBJECTIVES: To determine whether progesterone supplementation alters cervical shortening in women at increased risk for preterm birth. METHODS: We performed a planned secondary analysis from a large, multinational preterm birth prevention trial of daily intravaginal progesterone gel, 90 mg, compared with placebo in women with a history of spontaneous preterm birth or premature cervical shortening. Transvaginal cervical length measurements were obtained in all randomized patients at baseline (18 + 0 to 22 + 6 weeks' gestation) and at 28 weeks' gestation. For this secondary analysis, the difference in cervical length between these time points was compared for the study population with a history of spontaneous preterm birth and for a population with premature cervical shortening (< or = 30 mm) at randomization. Differences between groups in cervical length for the 28-week examination were analyzed using ANCOVA, including adjustment for relevant clinical parameters and maternal characteristics. RESULTS: Data were analyzed from 547 randomized patients with a history of preterm birth. The progesterone-treated patients had significantly less cervical shortening than the placebo group (difference 1.6 (95% CI, 0.3-3.0) mm; P = 0.02, ANCOVA). In the population of 104 subjects with premature cervical shortening at randomization, the cervical length also differed significantly on multivariable analysis, with the treatment group preserving more cervical length than the placebo group (difference 3.3 (95% CI, 0.3-6.2) mm; P = 0.03, ANCOVA), with adjustment for differences in cervical length at screening. A significant difference was also observed between groups for categorical outcomes including the frequency of cervical length progression to < or = 25 mm and a > or = 50% reduction in cervical length from baseline in this subpopulation. CONCLUSIONS: Intravaginal progesterone enhances preservation of cervical length in women at high risk for preterm birth.

Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester. METHODS: This was a planned, but modified, secondary analysis of our multinational, multicenter, randomized, placebo-controlled trial, in which women were randomized between 18 + 0 and 22 + 6 weeks of gestation to receive daily treatment with 90 mg of vaginal progesterone gel or placebo. Cervical length was measured with transvaginal ultrasound at enrollment and at 28 weeks of gestation. Treatment continued until either delivery, 37 weeks of gestation or development of preterm rupture of membranes. Maternal and neonatal outcomes were evaluated for the subset of all randomized women with cervical length < 28 mm at enrollment. The primary outcome was preterm birth at

Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Preterm birth is the leading cause of perinatal morbidity and mortality worldwide. Treatment of preterm labor with tocolysis has not been successful in improving infant outcome. The administration of progesterone and related compounds has been proposed as a strategy to prevent preterm birth. The objective of this trial was to determine whether prophylactic administration of vaginal progesterone reduces the risk of preterm birth in women with a history of spontaneous preterm birth. METHODS: This randomized, double-blind, placebo- controlled, multinational trial enrolled and randomized 659 pregnant women with a history of spontaneous preterm birth. Between 18 + 0 and 22 + 6 weeks of gestation, patients were assigned randomly to once-daily treatment with either progesterone vaginal gel or placebo until either delivery, 37 weeks' gestation or development of preterm rupture of membranes. The primary outcome was preterm birth at

Low-loss passive alignment of single-mode fibers in low-temperature cofired ceramics using CO2 laser fabricated U-grooves.

We report a step toward optoelectronic integration on low-temperature cofired ceramics substrates in the form of fiber alignment U-grooves. The precision of the CO2 laser machining of green state ceramic for this purpose is investigated. The groove-writing process with a speed of 1 mm/s was carried out in air at room temperature and ambient pressure. The process is to a large extent self-cleaning without any gas jet assist. By analysis of groove profiles after firing of a near-zero shrinkage green tape formulation, it is shown that the cutting accuracy is approximately 2 microm, which is at the fundamental limit set by the particle size (1-5 microm). We demonstrate low-loss butt coupling of <1 dB for single-mode fibers using the laser written U-grooves. The technique exhibits a potential for fabrication of low-cost fiber ribbon and fiber array connectors.

High-throughput sample handling and data collection at synchrotrons: embedding the ESRF into the high-throughput gene-to-structure pipeline.

An automatic data-collection system has been implemented and installed on seven insertion-device beamlines and a bending-magnet beamline at the ESRF (European Synchrotron Radiation Facility) as part of the SPINE (Structural Proteomics In Europe) development of an automated structure-determination pipeline. The system allows remote interaction with beamline-control systems and automatic sample mounting, alignment, characterization, data collection and processing. Reports of all actions taken are available for inspection via database modules and web services.

Postmenopausal hormone therapy and quality of life.

OBJECTIVE: To evaluate whether hormonal therapy (HT) had any significant effect on quality of life (QoL) in a selected group of postmenopausal women. METHODS: The study was conducted in a specialist private practice in Tygerberg, Cape Town, South Africa, over an 18-month period ending in July 2003. A questionnaire using the Utian Quality of Life (UQoL) scale was posted to all women with established postmenopausal status, seen over this period. 541 questionnaires were posted, 421 returned and 398 could be used. Women gave written informed consent. RESULTS: The average age of the women was 60 years. 313 women (78.6%) were using hormone therapy (HT) while 275 women (69.1%) reported concomitant medical problems. HT users had significantly higher scores in three of the four QoL domains, namely, occupational (p=0.046), emotional (p=0.03), and sexual (p=0.009). There was no significant difference in the health domain (p=0.2). CONCLUSION: This study found that post-menopausal South African women experienced that HT had a positive effect on global quality of life.

Localized CO2 laser damage repair of fused silica optics.

A technique has been developed for the localized treatment of laser damage sites in fused silica optics by CO2 laser melt-flow smoothing, by using a 50 to 125 microm diameter beam in a regime that avoids mass removal by ablation. A detailed calibration of the laser irradiance for the threshold ablation of craters was carried out for a range of beam diameters and pulses in the 20 micros to 200 ms range. The results agree with a thermal model that also provides estimates of the melt depth for the different irradiation conditions. Smoothing trials for glass melting at irradiance values just below the ablation threshold irradiance were conducted to determine the optimum conditions and limits for the smoothing process. The technique has been found to remove damage pits up to a depth of 0.5 microm, while the small melt depth associated with localized treatment limits the smoothing to a

Identification of components of male-produced pheromone of coffee white stemborer, Xylotrechus quadripes.

The coffee white stem borer, Xylotrechus quadripes Chevrolat (Coleoptera: Cerambycidae), is the foremost pest of arabica coffee in India, Sri Lanka, China, Vietnam, and Thailand. Previous work showed that female beetles were attracted to traps baited with male beetles. Analyses of volatiles from male X. quadripes of Indian origin by gas chromatography (GC) linked to electroantennographic (EAG) recording from a female beetle antenna showed three male-specific components comprising more than 90% of the volatiles, two of which elicited EAG responses. The major EAG-active component was produced at up to 2 microg hr(-1) insect(-1) and was identified as (S)-2-hydroxy-3-decanone (I) by comparison of GC data, and mass (MS), infrared, and nuclear magnetic resonance (NMR) spectra with those of synthetic standards. The second component was identified as 3-hydroxy-2-decanone (II) produced in part by isomerization of I under the conditions of the GC analysis, although the NMR spectrum suggested it is naturally produced at up to 7% of I. The minor component that elicited an EAG response, present at 7% of the amount of I, was identified as (S,S)-2,3-dihydroxyoctane (III) from GC and MS data. 2-Hydroxy-3-octanone (0.2-0.5% of I), 2,3-decanedione (2% of I), 2-phenylethanol (3% of I), and octanoic acid (4% of I) were also identified in volatiles from male beetles. A general, stereospecific synthetic route to the enantiomers of 2-hydroxy-3-alkanones from the enantiomers of ethyl lactate was developed. The enantiomers of III were synthesized from (E)-2-octene by Sharpless asymmetric dihydroxylation. (S)-(I) was attractive to male X. quadripes in laboratory bioassays, but addition of (S,RS)-(III) at 10% of I reduced attractiveness. In field trials carried out in India with sticky, cross-vane traps, (S)- and (RS)-(I) attracted male X. quadripes and addition of (S,S)-(III) at 10% of I reduced attractiveness. Significant numbers of female Demonax balyi Pascoe (Coleoptera: Cerambycidae) were sometimes caught in traps baited with (S)-(I) alone.