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.

An Audit of PMTCT Services at a Regional Hospital in South Africa

Background : Prevention of mother-to-child transmission (PMTC) is a major intervention world-wide in the fight against the HIV pandemic; and has resulted in markedly reduced rates of mother-to-child transmission rates in well-resourced countries. However; our impression is that barriers to implementation of the programme exist at all levels of health care at all facilities providing maternal care. Aim To conduct a clinical audit of the PMTCT programme at a regional hospital. Methods Data was collected from an analysis of antenatal and medical records of women who attended antenatal care and delivered at a regional hospital from January-December 2007. Results :Of the 499 records analysed; 479 women (96) were offered testing; 473 accepted. Of those tested; 227 (48) were HIV positive. Only 15 (6.1) of the 246 who tested negative; were re-tested. CD4 counts were only done in 159 (70) of the 227 HIV-positive women. More importantly; only 134 (84.3) received their results. Of the 227 HIV positive women; only 131 were given 200mg Nevirapine at 28 weeks gestation; 185 (81.5) took Nevirapine before delivery; 143 took Nevirapine 2 hours before delivery and 84 (37) took Nevirapine 2 hours before delivery. 208 (91.6) of the babies were given Nevirapine at the correct time. Discussion This audit shows that progress has been made in the implementation of PMTCT of HIV at this regional hospital by the high uptake of HIV testing; however barriers to full implementation are caused by the lack of integration of testing; counselling and obtaining CD4 count results

Misoprostol for cervical ripening at and near term--a comparative study.

OBJECTIVE: To compare the safety and efficacy of misoprostol with that of dinoprostone for the induction of labour at term, or near term. DESIGN: Three hundred and ninety-six women with term pregnancies were randomised to receive either oral or vaginal misoprostol, or dinoprostone. Women who had had a previous caesarean section (CS) or those with a malpresentation or who were parity > or = 5, were excluded. The control group received dinoprostone 1 mg inserted in the posterior fornix and repeated 6-hourly to a maximum of three doses. The study group received either oral misoprostol 20 micrograms 2-hourly to a maximum of four doses (80 micrograms), or vaginal misoprostol 25 micrograms in the posterior fornix with a switch to the oral misoprostol regimen if there was no change in the Bishop's score or no palpable uterine contractions. RESULTS: There was no significant difference in vaginal delivery rate within 24 hours between the groups (58.1% v. 58%, p = 0.633). There were no significant differences in CS rates between the groups; however, more CSs were performed for fetal distress in the misoprostol group than in the dinoprostone group (28% v. 25%). There was a significantly higher incidence of hyperstimulation in the vaginal misoprostol group (21.4%) than in the other two groups (oral misoprostol 16.5%, dinoprostone 8.9%) (p = 0.004). The incidence of meconium staining of liquor was comparable between the groups. CONCLUSIONS: In selected women, the efficacy of misoprostol for the induction of labour at term is similar to that of dinoprostone but misoprostol is associated with a higher incidence of hyperstimulation.