Massive Plasmodium falciparum visceral sequestration: a cause of maternal death in Africa.

Sequestration of Plasmodium falciparum-infected erythrocytes (PfIE) in the capillaries of the central nervous system (CNS) is the pathognomonic feature of cerebral malaria, a condition frequently leading to death. Sequestration of PfIE in the placental intervillous spaces is the characteristic feature of malaria in pregnancy and is associated with low birthweight and prematurity. Although both patterns of sequestration are thought to result from the expression of different parasite proteins involved in cytoadhesion to human receptors, scant information exists on whether both conditions can coexist and whether this can lead to death. We conducted a prospective autopsy study including all consecutive pregnancy-related deaths in a tertiary-level referral hospital in Maputo, Mozambique, between October 2002 and December 2006. Extensive sampling of all major viscera was performed. All cases showing parasites in any of the viscera were included in the analysis. From 317 complete autopsies PfIEs were identified in ten women (3.2%). All cases showed massive accumulation of PfIE in small capillaries of the CNS but also in most visceral capillaries (heart, lung, kidney, uterus). Placental tissue, available in four cases, showed a massive accumulation of maternal PfIE in the intervillous space. Coma (six women) and dyspnoea (five women) were the most frequent presenting clinical symptoms. In conclusion, massive visceral sequestration of PfIE with significant involvement of the CNS is an infrequent but definite direct cause of maternal death in endemic areas of Africa. The PfIE sequestered in cerebral capillaries and the placenta coexist in these fatal cases.

Syphilis, gonorrhoea and chlamydial infection among women undergoing legal or illegal abortion in Maputo.

Our objectives were to compare the prevalence of sexually transmitted infections (STIs) in 103 women undergoing induced legal abortion (LA) and in 101 women with confirmed, recent illegal abortion (IA), in Maputo, Mozambique. For the purpose of this study, LA was considered the abortion provided in the Maputo Central Hospital with the approval of the Ministry of Health, and IA the one not provided through the approved facility, mentioned above. Women with IA were recruited in the outpatient gynaecology ward and women with LA in the emergency gynaecology ward in the Maputo Central Hospital, during the same time period. Serological tests for syphilis (rapid plasma reagin, ELISA-IgG and fluorescent treponemal antibody absorption), gonorrhoea (indirect haemagglutination) and chlamydia (microimmunofluorescence) were carried out. Direct immunofluorescence for detection of Chlamydia trachomatis antigen was done on endocervical smears from all the women. The prevalence of syphilis seropositivity in IA women is twice that of LA women (odds ratio [OR] 2.13; 95% confidence interval [CI] 0.55-9.95), with 10.9% and 4.9%, respectively. Exposure to gonorrhoea in these 2 groups is similar (OR 1.18; 95% CI 0.63-2.20), with seroprevalence of 31.1% in the LA and 34.7% in the IA group. The high titres are also similar in both groups. Serology findings for C. trachomatis indicate prevalence of seropositivity of 40.6% in the LA and 44.4% in the IA group with no significant difference (OR 1.17; 95% CI 0.64-2.13). In conclusion, STIs are highly prevalent in both IA and LA groups in Maputo. Urgent interventions are needed to reduce their prevalence and consequently their adverse consequences.

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.

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.

Reproductive characteristics and post-abortion health consequences in women undergoing illegal and legal abortion in Maputo.

In the Maputo Central Hospital 103 women undergoing induced legal abortion (LA), 103 women with confirmed, recent illegal abortion (IA), and 100 randomly recruited antenatal clinic (AC) attenders were compared in order to find characteristic features regarding obstetric history, reproductive performance and contraceptive knowledge, attitude and practice. Women with IA were younger, had almost never undergone LA, had more often their first sexual intercourse and their first pregnancy below 20 years of age, had less knowledge of contraceptives and more often had never used contraceptives, had fewer previous spontaneous abortions and fewer previous stillbirths than LA women. There were three maternal deaths, all in the IA group. The most frequent illegal abortionist was a health worker (38%). It is concluded that, in this first comparative African study on IA and LA regarding reproductive profile and post-abortion health consequences, the former are at a disadvantage regarding early unprotected sexual intercourse with first pregnancy at a young age and with almost no experience of safe, legal abortion.

Low-dose vaginal misoprostol for induction of labor with a live fetus.

OBJECTIVE: To test the effectiveness and safety of low-dose vaginal misoprostol for induction of labor with a live fetus. METHODS: Labor was induced in 666 pregnant women with a live fetus in the cephalic position, who had no medical complications and no history of uterine surgery. One-fourth of a 200-micrograms tablet of misoprostol (50 micrograms) was placed in the posterior vaginal fornix every 12 h for a maximum of four doses or until active labor commenced. Time from induction to delivery, side effects and neonatal outcome were evaluated. RESULTS: Labor was successfully induced in all cases. The mean time from induction to delivery was 10.4 h. The cesarean section rate was 7.8%. There were eight perinatal deaths, six of which occurred in low birth weight fetuses. There was one case of abruptio placenta, which was less than that expected in the study population. CONCLUSION: Vaginal misoprostol, in very low doses, was a remarkably efficient and safe method for induction of labor with a live fetus.

Vaginal misoprostol as an alternative to oxytocin for induction of labor in women with late fetal death.

BACKGROUND: Induction of labor in women with late fetal death is often difficult in settings with scarce resources. The purpose of this study was to assess the value of vaginal misoprostol for induction of labor in women with such fetal death. METHODS: In Maputo 156 women with late fetal death were allotted in a non-randomised way to either vaginal misoprostol or intravenous infusion of oxytocin. Treatment outcomes were compared as to cost-effectiveness and safety. In the misoprostol group none received more than 800 micrograms. Oxytocin infusion followed an established routine. Statistical analyses were performed by EPI Info software. RESULTS: In cases with Bishop's score < 6 the induction-to-delivery interval averaged 14.8 hours in the misoprostol group and 31.0 hours in the oxytocin group (p = 0.001). The corresponding values for women with Bishop's score > or = 6 were 6.6 and 8.7 hours, respectively (p = 0.4). Women with intact membranes had an induction-to-delivery interval of 13.8 hours in the misoprostol group and 26.9 hours in the oxytocin group (p = 0.002). The corresponding values in women with ruptured membranes were 7.8 and 10.5 hours, respectively (p = 0.6). Successful induction was achieved in 81% of misoprostol-treated women at a dose of 100 micrograms or less. CONCLUSIONS: Vaginal misoprostol is a safe, low-cost drug particularly suitable in women of high average parity having late, fetal death.

A comparative study of vaginal misoprostol and intravenous oxytocin for induction of labour.

Fifty-two women who had labour induced by intravenous oxytocin were compared with 404 women in whom labour was induced by vaginal misoprostol (50-150 micrograms). The induction-to-delivery intervals in the oxytocin and misoprostol groups, respectively, had the following durations. With Bishop's score < 6, 24.3 vs. 14.4 h (p = 0.002), with Bishop's score > or = 6, 10.5 vs. 7.6 h (p = 0.02), with ruptured membranes, 8.8 vs. 8.5 h (p = 0.83), and with intact membranes, 19.6 vs. 13.1 h (p = 0.005). The Caesarean delivery rate was 17.3% in the oxytocin group and 8.7% in the misoprostol group (p = 0.09). Maternal complications were few and drug side effects rare. It is concluded that vaginal misoprostol is a valuable and cost-effective alternative to intravenous oxytocin infusion for induction of labour.

Induction of labor with intravaginal misoprostol in intrauterine fetal death.

OBJECTIVE: Our purpose was to evaluate the effectiveness and safety of intravaginal misoprostol for the induction of labor in intrauterine fetal death. STUDY DESIGN: Seventy-two women at 18 to 40 weeks of pregnancy with intrauterine fetal death, without abdominal scars, were treated with 100 micrograms of intravaginal misoprostol. The dose was repeated every 12 hours until effective uterine contractions and cervical dilatation were obtained, for up to 48 hours. RESULTS: The mean time from induction to delivery was 12.6 hours, and only six patients (8%) required between 24 and 48 hours, at the end of which all patients had been delivered. Only the Bishop's score was significantly associated with time from first dose to expulsion. No surgical procedure was required. Hypercontractility, sweating, fever, diarrhea, or other gastrointestinal effects were not detected. There was no need for analgesics. CONCLUSIONS: Intravaginal misoprostol at the dose of 100 micrograms every 12 hours appears to be a safe, effective, practical, and inexpensive new method for induction of labor in intrauterine fetal death.

PIP: Physicians at the Maputo Central Hospital in Mozambique inserted at least 100 mcg misoprostol into the vaginas of 72 women with intrauterine fetal death at 18-40 weeks pregnancy to induce labor. They inserted another dose every 12 hours up to 48 hours if a patient had not begun labor. The mean time between induction of labor to delivery stood at 12.6 hours. 92% delivered within 24 hours. All had delivered by 48 hours. The time between 1st dose and expulsion was significantly lower for women with a Bishop's score of more than 5 than for those with a score of 5 and lower (7.6 vs. 13.7 hours; p = .028). Bishop's score was the only variable associated with time to expulsion. (It is used to estimate the prospects of labor by evaluating the extent of cervical dilatation, effacement, station of the head, consistency of the cervix, and cervical position in relation to the vaginal axis.) No one died, needed surgery either before or after delivery, or suffered side effects. The physicians noted that this regimen greatly reduced costs, staff workload, and time. These findings suggest that intravaginal misoprostol at a dose of 100 mcg/12 hours is a safe, effective, practical, and inexpensive new way to induce labor in cases of intrauterine fetal death.

Audit of uterine rupture in Maputo: a tool for assessment of obstetric care.

Records of 96 women who had rupture of the uterus in labor were audited to find circumstances significantly associated with pregnancy outcome. The prevalence was 1 rupture in 424 deliveries. In 74 cases (77.1%) uterine rupture occurred after hospitalization, the remaining 22 cases being emergency transfers with rupture secondary to a delivery attempt elsewhere. History of a previous cesarean section was present in 46%, whereas 54% of the women had an unscarred uterus. Maternal mortality was 7.3% whilst perinatal mortality was 62.9%. Adverse outcome for the mother was associated with ruptures occurring in unscarred uteri (p < 0.02) and outside the Maternity (p < 0.01); this latter condition also contributed to higher fetal mortality (p < 0.002). The findings confirm that delay in reaching medical care is an aggravating factor in the evolution of uterine rupture in developing countries and suggest the need for better medical attention and timely diagnosis in laboring women with unscarred uterus.

Intrauterine infections and their association with stillbirth and preterm birth in Maputo, Mozambique.

Subclinical intrauterine infections during pregnancy in Mozambican women were studied in an attempt to elucidate their potential association with adverse pregnancy outcome, particularly stillbirth and preterm birth. A total of 39 stillbirths and 21 preterm live births were compared with 121 term live births. Extraplacental membranes and amniotic fluid were studied to ascertain the presence or absence of chorioamnionitis and of antibacterial activity in amniotic fluid. It was found that signs of maternal subclinical disease in extraplacental membranes in combination with an absence of antibacterial activity in amniotic fluid was overrepresented in stillbirths and preterm births in relation to term live births. A tentative conclusion is that a lack of antibacterial activity in amniotic fluid and established chorioamnionitis represent a vicious combination with strongly negative significance for the fetal outcome.

Outcome of teenage pregnancy in Maputo, Mozambique.

OBJECTIVE: To evaluate the perinatal outcome of teenage pregnancies in comparison with a population of older, high-risk women. METHOD: Data about 15,207 high-risk women delivered during 1989 at the Central Hospital of Maputo, Mozambique, were collected retrospectively from the clinical records. Of these women 2185 were less than 19 years old. Frequencies were compared through the chi 2-test or, when required, Fisher's exact test. Odds ratios and 95% confidence intervals were computed. RESULT: Frequency of operative vaginal deliveries (forceps and/or vacuum extraction), cesarean section rate and low birth rate were significantly higher among women under 19 than in the older ones. Also, maternal mortality and stillbirth rates were greater among teenagers, although the differences were not statistically significant. CONCLUSION: Among the selected, high-risk hospital population of a developing country young maternal age, both by itself and in association with other risk factors, represents an important predictor of adverse perinatal outcome for mothers and babies. Implications for family planning and reproductive education programs are discussed.

Management of labour following caesarean section in a developing country.

During recent years, the observed rise of the CS rate (17% in 1989) led the medical staff of the Maputo Central Hospital to consider the opportunity of admitting to trial of labour selected pregnant patients following one previous CS. The present study retrospectively evaluates maternal and fetal outcome following the adoption of this policy. 94 (52.51%) of 179 study group patients, having one previous CS, delivered vaginally after trial of labour. No maternal deaths were recorded among these patients. A very low (1.67%) maternal morbidity rate was observed. Five stillbirths and one early neonatal death occurred among the study group, accounting for a perinatal mortality rate of 33.52%, much lower than the overall hospital perinatal mortality recorded figure (68%).