Persistent maternal tachycardia: A clinical alert for healthcare professionals providing maternity care in South Africa.

Cardiac disease is one of the commonest causes of indirect maternal deaths globally. This brief report is a reminder that isolated maternal tachycardia at rest is a clinical alert and warrants a detailed history in relation to cardiac disorders, thorough clinical examination of all organ systems, relevant investigations such as imaging, and expert advice to avoid serious adverse events. We reflect on a belatedly investigated persistent maternal tachycardia resulting in a fatal postpartum collapse due to mitral stenosis. The lost window of opportunity for appropriate investigation and management of the tachycardia provides an insight into many similar maternal deaths in South Africa. Key clinical messages regarding persistent maternal tachycardia are presented for midwives and doctors caring for pregnant women.

An imperative to offer pregnant and lactating women access to the COVID-19 vaccination roll-out programme.

In view of the continuing worldwide spread of COVID-19 infection, the increased morbidity and mortality from the disease during pregnancy, and the current efficacy and safety of vaccines in non-pregnant individuals, vaccines should not be withheld from women simply because of pregnancy or lactation. All pregnant women, especially healthcare professionals, should be offered vaccination and counselled about its advantages and disadvantages by their maternity care providers. Complete eradication of COVID-19 infection will be possible if potential niduses of the infection, which may act as sources for future outbreaks, are protected against the pathogen. However, if a hypothetical medication is the only means yet proven of limiting severe compromise to maternal health, access to the medication should be at the pregnant woman's discretion. Shared decision-making requires physicians to actively engage with their patients and share their knowledge about the subject matter.

Severe hypertension in pregnancy: Using dynamic checklists to save lives.

Severe hypertension is a major cause of morbidity and mortality. The South African Saving Mothers report (2011 - 2013) indicates that cerebral injury due to severe hypertension is resulting in avoidable maternal deaths. This demands that management of severe hypertension in pregnancy needs to be improved. A rapid-acting antihypertensive is recommended for the initial management of severe hypertension during pregnancy. A single dose of a rapid-acting agent may be ineffective, in which case incremental doses of the same medication or another antihypertensive may be required for adequate blood pressure control. To ensure that appropriate antihypertensives at the correct doses are administered, the use of a guideline in a dynamic checklist format is advocated and discussed in this article. It is envisaged that the use of dynamic checklists will be valuable to all healthcare professionals providing care during pregnancy and the puerperium.

Ruptured subcapsular hematoma of the liver due to pre-eclampsia presenting as interstitial pregnancy and the role of intra-abdominal packing.

Ruptured subcapsular hematoma of the liver (RSHL) can mimic ruptured interstitial pregnancy because each of these conditions occasionally presents at the same gestational period and both do manifest hemodynamic instability. The similarities between the two conditions pose a diagnostic challenge, especially in an un-booked patient. We report a case of an un-booked primigravida, at 21 weeks of gestation, who arrived at a regional hospital with evidence of intra-abdominal bleeding and hypovolemic shock. She was diagnosed as potentially having a ruptured interstitial pregnancy. During the ensuing emergency laparotomy, RSHL was discovered, the area around the ruptured liver capsule was packed with large abdominal swabs, and the patient recovered. This case report illustrates the need to consider RSHL in patients presenting with features of ruptured interstitial pregnancy, as this will assist in the planning of intraoperative care. We also describe abdominal packing and highlight the need for this essential surgical intervention to be taught to doctors practising in low-resource settings.

Assigning appropriate and comprehensive diagnosis for scientific report.

The use of currently available guidelines such as the International Classification of Diseases, 10th Revision (ICD-10) and its clinical modification to assign a principal diagnosis to a patient who has multiple principal diagnoses appears unreliable. This is because these guidelines are complex and uses criteria that are highly subjective. Even when one main diagnosis is selected, the comprehensive list of other diseases that the patient has is often not reported such that the overall clinical condition of the patient is obscured. To address these issues, we have proposed: (i) a simple, potentially reliable and stepwise guide that can be used to assign the single most appropriate main principal diagnosis to each patient and illustrated this with case reports (ii) how to simultaneously report the main and other diagnoses in a scientific paper. It is hoped that our proposal (named NJ model for easy referencing) will help standardize how diagnosis is assigned to patients.

Maternal and fetal outcomes of HIV-infected and non-infected pregnant women admitted to two intensive care units in Pietermaritzburg, South Africa.

BACKGROUND: Outcomes of HIV-positive pregnant patients admitted to intensive care units (ICUs) are controversial. OBJECTIVE: To determine maternal and fetal outcomes of HIV-positive patients admitted to ICUs. METHODS: Pregnant patients admitted to ICUs were enrolled in the study. On admission, they were classified as having low (<50%) or high (≥50%) risk of death by GRAMPT stratification score. The primary maternal outcome was death or hypoxic-ischaemic brain injury (HIBI), while fetal outcomes recorded were Apgar score, birth weight, and delivery of the fetus to facilitate maternal care. RESULTS: There were 84 admissions to the ICUs: 66 (78.6%) were post-partum and 18 (21.4%) antepartum. The HIV sero-status was as follows: 11 (13.1%) HIV status unknown; 42 (50%) HIV-negative and 31 (36.9%) HIV-positive. The most common pre-ICU admission diagnoses were pneumonia (19.4%) in HIV-positive patients and eclampsia (31%) in HIV-negative patients. Maternal outcomes showed a worsening trend among the HIV-positive women when compared with those who were HIV-negative (high GRAMPT, 1.91 relative risk of death/HIBI in HIV-positive; 95% CI 0.57 - 6.44). Forty-two patients gave birth within 24 hours prior to ICU admission; 3 gave birth while in ICU and none gave birth within 24 hours following ICU discharge. Outcomes of the 45 infants born to HIV-positive women were worse than for those born to HIV-negative patients (except for Apgar scores 1 - 6). Performance of the GRAMPT model for prediction of maternal mortality/HIBI was best in hypertensive patients (ROC: AUC 0.72; 95% CI 0.48 - 0.96). CONCLUSION: With the exception of Apgar scores 1 - 6, all outcomes showed worsening trends among infants born to HIV-positive mothers. Large multicentre studies are needed to confirm our findings.