Routine ultrasound examination in early pregnancy: is it worthwhile in low-income countries?

Small vulnerable newborns-big potential for impact

Despite major achievements in child survival, the burden of neonatal mortality has remained high and even increased in some countries since 1990. Currently, most neonatal deaths are attributable to being born preterm, small for gestational age (SGA), or with low birthweight (LBW). Besides neonatal mortality, these conditions are associated with stillbirth and multiple morbidities, with short-term and long-term adverse consequences for the newborn, their families, and society, resulting in a major loss of human capital. Prevention of preterm birth, SGA, and LBW is thus critical for global child health and broader societal development. Progress has, however, been slow, largely because of the global community's failure to agree on the definition and magnitude of newborn vulnerability and best ways to address it, to frame the problem attractively, and to build a broad coalition of actors and a suitable governance structure to implement a change. We propose a new definition and a conceptual framework, bringing preterm birth, SGA, and LBW together under a broader umbrella term of the small vulnerable newborn (SVN). Adoption of the framework and the unified definition can facilitate improved problem definition and improved programming for SVN prevention. Interventions aiming at SVN prevention would result in a healthier start for live-born infants, while also reducing the number of stillbirths, improving maternal health, and contributing to a positive economic and social development in the society.

Gastrointestinal congenital malformations: a review of 230 cases at Albert Royer National Children’s Hospital Center in Senegal

Background

Congenital malformations are the third cause of mortality in children under five. We aimed to report sociodemographic and diagnostic aspects of gastrointestinal ones and their outcomes.

Methods

We conducted a descriptive cross-sectional study of patients admitted from January 2018 to January 2021 to our department at Albert Royer National Children’s Hospital Center in Dakar, Senegal. A total of 230 were included.

Results

The frequency of these malformations was 6.18%. The mean age was 1.9 years, with neonates representing 43.48% and males 59.56%. 64.35% of patients came from the Dakar area. Parental consanguinity was reported in 11.73%, prenatal diagnosis in 5.56% of 36 cases, and prematurity in 28.84% of 52 patients. The most typical reasons for referral or symptoms were constipation (23.91%), imperforated anus (23.91%), and vomiting (23.48%). In 93.91%, the malformation was isolated, of which Hirschsprung’s disease accounted for 30.56% and anorectal malformation for 30.09%. Esophageal atresia and anorectal malformations had more associated anomalies with 28.57% each. The VACTER-L association represented 21.42% of associated anomalies. Mortality was 27.83%, and lethality was 100% for intestinal atresia, 87.5% for esophageal atresia, and 85.71% for polymalformation. Causes of mortality were reported in 21%, with septic shock and respiratory distress in all esophageal atresia patients (Manama, Contribution à l’étude des malformations congénitales : à propos de 188 cas du service de néonatologie de l’Hôpital Aristide Le Dantec de Dakar, 1983) and hypovolemic shock in all patients with duodenal atresia (Wright et al., Lancet 398:325–39, 2021).

Conclusion

Congenital malformations of the gastrointestinal tract are still lately diagnosed in our environment, resulting in higher mortality. Further studies should analyze delayed presentation and mortality, and their risk factors in our settings.

Factors associated with mortality in congenital malformations of the gastrointestinal tract in a tertiary center in Senegal

Objective

Patients with congenital malformations (CMs) of the gastrointestinal tract (GIT) have a very high mortality. However, the literature on the factors associated with mortality in these patients is scarce in sub-Saharan Africa. The aim of this study is to identify independent risk factors for mortality in patients with CMs of the GIT at our pediatric surgical department.

Methods

We conducted a retrospective analysis of cases with CMs of the GIT managed at a tertiary center from 2018 to 2021. Patients were subdivided into two groups based on the outcomes, and variables with a significant difference were analyzed by logistic regression.

Results

Our review included 226 patients, 63 of whom died (27.88%). Patient age ranged from 0 to 15 years. Taking into account statistical significance, mortality was more frequent in neonates than in older patients (57.30% vs 6.15%), in patients coming out of the Dakar area than in those from the Dakar area (43.75% vs 19.18%), in patients with abnormal prenatal ultrasound than in those with normal ultrasound (100% vs 26.67%), in premature children than in those born at term (78.57% vs 21.87%), in patients with an additional malformation than in those with an isolated malformation (69.23% vs 25.35%), and in those with intestinal, esophageal, duodenal and colonic atresia than in those with other diagnoses (100%, 89%, 56.25% and 50%, respectively). Referred patients died more than those who changed hospitals or came from home (55.29% vs 25% and 9.09%, respectively). On multivariable logistic regression, two independent factors of mortality were identified: presence of associated malformation [odds ratio (OR)=13.299; 95% Confidence interval (CI) 1.370 to 129.137] and diagnosis of esophageal atresia (OR=46.529; 95% CI 5.828 to 371.425).

Conclusion

The presence of an associated malformation or diagnosis of esophageal atresia increases mortality in patients with CMs of the GIT in our environment.

Routine ultrasound for fetal assessment before 24 weeks' gestation

BACKGROUND

Ultrasound examination of pregnancy before 24 weeks gestation may lead to more accurate dating and earlier diagnosis of pathology, but may also give false reassurance. It can be used to monitor development or diagnose conditions of an unborn baby. This review compares the effect of routine or universal, ultrasound examination, performed before 24 completed weeks' gestation, with selective or no ultrasound examination.  OBJECTIVES: To assess the effect of routine pregnancy ultrasound before 24 weeks as part of a screening programme, compared to selective ultrasound or no ultrasound, on the early diagnosis of abnormal pregnancy location, termination for fetal congenital abnormality, multiple pregnancy, maternal outcomes and later fetal compromise. To assess the effect of first trimester (before 14 weeks) and second trimester (14 to 24 weeks) ultrasound, separately.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform (ICTRP) on 11 August 2020. We also examined the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and RCTs published in abstract form. We included all trials with pregnant women who had routine or revealed ultrasound versus selective ultrasound, no ultrasound, or concealed ultrasound, before 24 weeks' gestation. All eligible studies were screened for scientific integrity and trustworthiness.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and risk of bias, extracted data and checked extracted data for accuracy. Two review authors independently used the GRADE approach to assess the certainty of evidence for each outcome MAIN RESULTS: Our review included data from 13 RCTs including 85,265 women. The review included four comparisons. Four trials were assessed to be at low risk of bias for both sequence generation and allocation concealment and two as high risk. The nature of the intervention made it impossible to blind women and staff providing care to treatment allocation.  Sample attrition was low in the majority of trials and outcome data were available for most women. Many trials were conducted before it was customary for trials to be registered and protocols published. First trimester routine versus selective ultrasound: four studies, 1791 women, from Australia, Canada, the United Kingdom (UK) and the United States (US). First trimester scans probably reduce short-term maternal anxiety about pregnancy (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.65 to 0.99; moderate-certainty evidence). We do not have information on whether the reduction was sustained.  The evidence is very uncertain about the effect of first trimester scans on perinatal loss (RR 0.97, 95% CI 0.55 to 1.73; 648 participants; one study; low-certainty evidence) or induction of labour for post-maturity (RR 0.83, 95% CI 0.50 to 1.37; 1474 participants; three studies; low-certainty evidence). The effect of routine first trimester ultrasound on birth before 34 weeks or termination of pregnancy for fetal abnormality was not reported. Second trimester routine versus selective ultrasound: seven studies, 36,053 women, from Finland, Norway, South Africa, Sweden and the US. Second trimester scans probably make little difference to perinatal loss (RR 0.98, 95% CI 0.81 to 1.20; 17,918 participants, three studies; moderate-certainty evidence) or intrauterine fetal death (RR 0.97, 95% CI 0.66 to 1.42; 29,584 participants, three studies; low-certainty evidence). Second trimester scans may reduce induction of labour for post-maturity (RR 0.48, 95% CI 0.31 to 0.73; 24,174 participants, six studies; low-certainty evidence), presumably by more accurate dating. Routine second trimester ultrasound may improve detection of multiple pregnancy (RR 0.05, 95% CI 0.02 to 0.16; 274 participants, five studies; low-certainty evidence). Routine second trimester ultrasound may increase detection of major fetal abnormality before 24 weeks (RR 3.45, 95% CI 1.67 to 7.12; 387 participants, two studies; low-certainty evidence) and probably increases the number of women terminating pregnancy for major anomaly (RR 2.36, 95% CI 1.13 to 4.93; 26,893 participants, four studies; moderate-certainty evidence). Long-term follow-up of children exposed to scans before birth did not indicate harm to children's physical or intellectual development (RR 0.77, 95% CI 0.44 to 1.34; 603 participants, one study; low-certainty evidence). The effect of routine second trimester ultrasound on birth before 34 weeks or maternal anxiety was not reported. Standard care plus two ultrasounds and referral for complications versus standard care: one cluster-RCT, 47,431 women, from Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia. This trial included a co-intervention, training of healthcare workers and referral for complications and was, therefore, assessed separately. Standard pregnancy care plus two scans, and training and referral for complications, versus standard care probably makes little difference to whether women with complications give birth in a risk appropriate setting with facilities for caesarean section (RR 1.03, 95% CI 0.89 to 1.19; 11,680 participants; moderate-certainty evidence).  The intervention also probably makes little to no difference to low birthweight (< 2500 g) (RR 1.01, 95% CI 0.90 to 1.13; 47,312 participants; moderate-certainty evidence). The evidence is very uncertain about whether the community intervention (including ultrasound) makes any difference to maternal mortality (RR 0.92, 95% CI 0.55 to 1.55; 46,768 participants; low-certainty evidence). Revealed ultrasound results (communicated to both patient and doctor) versus concealed ultrasound results (blinded to both patient and doctor at any time before 24 weeks): one study, 1095 women, from the UK. The evidence was very uncertain for all results relating to revealed versus concealed ultrasound scan (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Early scans probably reduce short term maternal anxiety.  Later scans may reduce labour induction for post-maturity. They may improve detection of major fetal abnormalities and increase the number of women who choose termination of pregnancy for this reason. They may also reduce the number of undetected twin pregnancies. All these findings accord with observational data.  Neither type of scan appears to alter other important maternal or fetal outcomes, but our review may underestimate the effect in modern practice because trials were mostly  from relatively early in the development of the technology, and many control participants also had scans. The trials were also underpowered to show an effect on other important maternal or fetal outcomes.

Comparison Study of Low-Cost Ultrasound Devices for Estimation of Gestational Age in Resource-Limited Countries

We investigated how accurately low-cost ultrasound devices can estimate gestational age (GA) using both the standard plane and the obstetric sweep protocol (OSP). The OSP can be taught to health care workers without prior knowledge of ultrasound within one day and thus avoid the need to train dedicated sonographers. Three low-cost ultrasound devices were compared with one high-end ultrasound device. GA was estimated with the head circumference (HC), abdominal circumference (AC) and femur length (FL) using both the standard plane and the OSP. The results revealed that the HC, AC and FL can be used to estimate GA using low-cost ultrasound devices in the standard plane within the inter-observer variability presented in the literature. The OSP can be used to estimate GA by measuring the HC and the AC, but not the FL. This study shows that it is feasible to estimate GA in resource-limited countries with low-cost ultrasound devices using the OSP. This makes it possible to estimate GA and assess fetal growth for pregnant women in rural areas of resource-limited countries.

Obstetric ultrasound use in low and middle income countries: a narrative review

INTRODUCTION

Although growing, evidence on the impact, access, utility, effectiveness, and cost-benefit of obstetric ultrasound in resource-constrained settings is still somewhat limited. Hence, questions around the purpose and the intended benefit as well as potential challenges across various domains must be carefully reviewed prior to implementation and scale-up of obstetric ultrasound technology in low-and middle-income countries (LMICs).

MAIN BODY

This narrative review discusses these issues for those trying to implement or scale-up ultrasound technology in LMICs. Issues addressed in this review include health personnel capacity, maintenance, cost, overuse and misuse of ultrasound, miscommunication between the providers and patients, patient diagnosis and care management, health outcomes, patient perceptions and concerns about fetal sex determination.

CONCLUSION

As cost of obstetric ultrasound becomes more affordable in LMICs, it is essential to assess the benefits, trade-offs and potential drawbacks of large-scale implementation. Additionally, there is a need to more clearly identify the capabilities and the limitations of ultrasound, particularly within the context of limited training of providers, to ensure that the purpose for which an ultrasound is intended is actually feasible. We found evidence of obstetric uses of ultrasound improving patient management. However, there was evidence that ultrasound use is not associated with reducing maternal, perinatal or neonatal mortality. Patients in various studies reported to have both positive and negative perceptions and experiences related to ultrasound and lastly, illegal use of ultrasound for determining fetal sex was raised as a concern.

Routine antenatal ultrasound in low- and middle-income countries: first look - a cluster randomised trial

OBJECTIVE

Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centres in resource-limited countries.

DESIGN

Cluster randomised trial.

SETTING

Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia) METHODS: Clusters were randomised to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds.

MAIN OUTCOME MEASURES

The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality.

RESULTS

During the 24-month trial, 28 intervention and 28 control clusters had 24 263 and 23 160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa, and abnormal lie was within expected ranges. 9% were referred for an ultrasound-diagnosed condition, and 71% attended the referral. The ANC (RR 1.0 95% CI 1.00, 1.01) and hospital delivery rates for complicated pregnancies (RR 1.03 95% CI 0.89, 1.20) did not differ between intervention and control clusters nor did the composite outcome (RR 1.09 95% CI 0.97, 1.23) or its individual components.

CONCLUSIONS

Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome and the individual components were not reduced.

TWEETABLE ABSTRACT

Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.

Opportunities and Challenges in Realizing Universal Access to Obstetric Ultrasound in Sub-Saharan Africa

The potential benefits of obstetric ultrasound have yet to be fully realized in sub-Saharan Africa (SSA), despite the region bearing the greatest burden of poor perinatal outcomes. We reviewed the literature for challenges and opportunities of universal access to obstetric ultrasound and explored what is needed to make such access an integral component of maternity care in order to address the massive burden of perinatal morbidity and mortality in SSA. Original peer-reviewed literature was searched in various electronic databases using a 'realist' approach. While the available data were inconclusive, they identify many opportunities for potential future research on the subject within the region that can help build a strong case to justify the provision of universal access to ultrasound as an integral component of comprehensive antenatal care.

'Essential but not always available when needed' - an interview study of physicians' experiences and views regarding use of obstetric ultrasound in Tanzania

Background

The value of obstetric ultrasound in high-income countries has been extensively explored but evidence is still lacking regarding the role of obstetric ultrasound in low-income countries.

Objective

We aimed to explore experiences and views among physicians working in obstetric care in Tanzania, on the role of obstetric ultrasound in relation to clinical management.

Design

A qualitative study design was applied. Data were collected in 2015, through 16 individual interviews with physicians practicing in obstetric care at hospitals in an urban setting in Tanzania. Data were analyzed using qualitative content analysis.

Results

Use of obstetric ultrasound in the management of complicated pregnancy was much appreciated by participating physicians, although they expressed considerable concern about the lack of ultrasound equipment and staff able to conduct the examinations. These limitations were recognized as restricting physicians’ ability to manage complications adequately during pregnancy and birth. Better availability of ultrasound was requested to improve obstetric management. Concerns were also raised regarding pregnant women's lack of knowledge and understanding of medical issues which could make counseling in relation to obstetric ultrasound difficult. Although the physicians perceived a positive attitude toward ultrasound among most pregnant women, occasionally they came across women who feared that ultrasound might harm the fetus.

Conclusions

There seems to be a need to provide more physicians in antenatal care in Tanzania with ultrasound training to enable them to conduct obstetric ultrasound examinations and interpret the results themselves. Physicians also need to acquire adequate counseling skills as counseling can be especially challenging in this setting where many expectant parents have low levels of education. Providers of obstetric care and policy makers in Tanzania will need to take measures to ensure appropriate use of the scarce resources in the Tanzanian health care system and prevent the potential risk of overuse of ultrasound in pregnancy.

Gestational Age Assessment in the Ghana Randomized Air Pollution and Health Study (GRAPHS): Ultrasound Capacity Building, Fetal Biometry Protocol Development, and Ongoing Quality Control

Background

Four million premature deaths occur yearly as a result of smoke from cooking fires. The Ghana Randomized Air Pollution and Health Study (GRAPHS) is underway in the Kintampo North municipality and South district of rural Ghana to evaluate the impact of improved cook stoves introduced during pregnancy on birth weight and childhood pneumonia. These hypotheses are being tested in a cluster-randomized intervention trial among 1415 maternal-infant pairs within 35 communities assigned to a control arm (traditional cooking) or one of two intervention arms (cooking with an improved biomass stove; cooking with liquefied petroleum gas stoves).

Objective

The trial is designed to ensure delivery of the stove intervention prior to the period of maximal fetal growth. To answer questions about the impact of household air pollution on pregnancy outcome, accurate gestational age assessment is critical. This manuscript describes in detail the development of the gestational dating protocol, intensive ultrasound training involved, ultrasound capacity building, and ultrasound quality control program.

Methods

Ultrasound training occurred in several phases over the course of 2 years. Training included a basic obstetric ultrasound course offered to all midwives performing antenatal care at the two study hospitals, followed by a more intense period of hands-on training focused on fetal biometry for a select group of providers demonstrating aptitude in the basic course. A standard operating procedure was developed describing how to obtain all fetal biometric measurements. Consensus was obtained on how biometric images are used in the trial to establish gestational age and estimate the delivery date. An ongoing ultrasound quality control program including the use of an image scorecard was also designed.

Results

Publication of trial results is anticipated in late 2016.

Conclusions

Use of ultrasound should be strongly considered in field-based trials involving pregnant women to accurately establish gestational age, as menstrual dates may be incorrect or unknown. The inclusion of ultrasound in areas where ultrasound capacity does not previously exist requires a significant investment of time and resources. Such investment ensures appropriate training, high quality images, and accurate dating pregnancies. We outline our ultrasound training, image acquisition, quality control, and dating protocols in detail.

Trial Registration

Clinicaltrials.gov NCT01335490; http://clinicaltrials.gov/ct2/show/NCT01335490 (Archived by WebCite at http://www.webcitation.org/6UbERJNO6).

First look: a cluster-randomized trial of ultrasound to improve pregnancy outcomes in low income country settings

BACKGROUND

In high-resource settings, obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve obstetric care. Whether or not ultrasound use will improve care and ultimately pregnancy outcomes in low-resource settings is unknown.

METHODS/DESIGN

This multi-country cluster randomized trial will assess the impact of antenatal ultrasound screening performed by health care staff on a composite outcome consisting of maternal mortality and maternal near-miss, stillbirth and neonatal mortality in low-resource community settings. The trial will utilize an existing research infrastructure, the Global Network for Women's and Children's Health Research with sites in Pakistan, Kenya, Zambia, Democratic Republic of Congo and Guatemala. A maternal and newborn health registry in defined geographic areas which documents all pregnancies and their outcomes to 6 weeks post-delivery will provide population-based rates of maternal mortality and morbidity, stillbirth, neonatal mortality and morbidity, and health care utilization for study clusters. A total of 58 study clusters each with a health center and about 500 births per year will be randomized (29 intervention and 29 control). The intervention includes training of health workers (e.g., nurses, midwives, clinical officers) to perform ultrasound examinations during antenatal care, generally at 18-22 and at 32-36 weeks for each subject. Women who are identified as having a complication of pregnancy will be referred to a hospital for appropriate care. Finally, the intervention includes community sensitization activities to inform women and their families of the availability of ultrasound at the antenatal care clinic and training in emergency obstetric and neonatal care at referral facilities.

DISCUSSION

In summary, our trial will evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings. The intervention includes training for ultrasound-naïve providers in basic obstetric ultrasonography and then enabling these trainees to use ultrasound to screen for pregnancy complications in primary antenatal care clinics and to refer appropriately.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT # 01990625).

Amnioinfusion for meconium-stained liquor in labour

BACKGROUND

Amnioinfusion is thought to dilute meconium present in the amniotic fluid and so reduce the risk of meconium aspiration.

OBJECTIVES

To assess the effects of amnioinfusion for meconium-stained liquor on perinatal outcome.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013).

SELECTION CRITERIA

Randomised trials comparing amnioinfusion with no amnioinfusion for women in labour with moderate or thick meconium staining of the amniotic fluid.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed eligibility and trial quality, and extracted data.

MAIN RESULTS

Fourteen studies of variable quality (4435 women) are included.Subgroup analysis was performed for studies from settings with limited facilities to monitor the baby's condition during labour and intervene effectively, and settings with standard peripartum surveillance.Settings with standard peripartum surveillance: there was considerable heterogeneity for several outcomes. There was no significant reduction in the primary outcomes meconium aspiration syndrome, perinatal death or severe morbidity, and maternal death or severe morbidity. There was a reduction in caesarean sections (CSs) for fetal distress but not overall. Meconium below the vocal cords diagnosed by laryngoscopy was reduced, as was neonatal ventilation or neonatal intensive care unit admission, but there was no significant reduction in perinatal deaths or other morbidity. Planned sensitivity analysis excluding trials with greater risk of bias resulted in an absence of benefits for any of the outcomes studied.Settings with limited peripartum surveillance: three studies were included. In the amnioinfusion group there was a reduction in CS for fetal distress and overall; meconium aspiration syndrome (three studies, 1144 women; risk ratio (RR) 0.17, 95% confidence interval (CI) 0.05 to 0.52); perinatal mortality (three studies, 1151 women; RR 0.24, 95% CI 0.11 to 0.53) and neonatal ventilation or neonatal intensive care unit admission. In one of the studies, meconium below the vocal cords was reduced and, in the other, neonatal encephalopathy was reduced.

AUTHORS' CONCLUSIONS

Amnioinfusion is associated with substantive improvements in perinatal outcome only in settings where facilities for perinatal surveillance are limited. It is not clear whether the benefits are due to dilution of meconium or relief of oligohydramnios.In settings with standard peripartum surveillance, some non-substantive outcomes were improved in the initial analysis, but sensitivity analysis excluding trials with greater risk of bias eliminated these differences. Amnioinfusion is either ineffective in this setting, or its effects are masked by other strategies to optimise neonatal outcome.The trials reviewed are too small to address the possibility of rare but serious maternal adverse effects of amnioinfusion.

White paper report of the 2011 RAD-AID Conference on International Radiology for Developing Countries: integrating multidisciplinary strategies for imaging services in the developing world

The 2011 RAD-AID Conference on International Radiology for Developing Countries discussed data, experiences, and models pertaining to radiology in the developing world, where widespread shortages of imaging services significantly reduce health care quality and increase health care disparities. This white paper from the 2011 RAD-AID conference represents consensus advocacy of multidisciplinary strategies to improve the planning, accessibility, and quality of imaging services in the developing world. Conference presenters and participants discussed numerous solutions to imaging and health care disparities, including (1) economic development for radiologic service planning, (2) public health mechanisms to address disease and prevention at the population and community levels, (3) comparative clinical models to implement various clinical and workflow strategies adapted to unique developing world community contexts, (4) education to improve training and optimize service quality, and (5) technology innovation to bring new technical capabilities to limited-resource regions.

Quality of ultrasound biometry obtained by local health workers in a refugee camp on the Thai-Burmese border

OBJECTIVE

In a refugee camp on the Thai-Burmese border, accurate dating of pregnancy relies on ultrasound measurements obtained by locally trained health workers. The aim of this study was to substantiate the accuracy of fetal biometry measurements performed by locally trained health workers by comparing derived reference equations with those published for Asian and European hospitals.

METHODS

This prospective observational study included 1090 women who had a dating crown-rump length (CRL) scan and one study-appointed ultrasound biometry scan between 16 and 40 weeks of gestation. The average of two measurements of each of biparietal diameter, head circumference, abdominal circumference and femur length was used in a polynomial regression model for the mean and SD against gestational age (GA). The biometry equations obtained were compared with published equations of professional sonographers from Asian and European hospitals by evaluation of the SD and Z-scores of differences between models.

RESULTS

Reference equations of biometric parameters were found to fit cubic polynomial models. The observed SD values, for any given GA, of fetal biometric measurements obtained by locally trained health workers were lower than those previously reported by centers with professional sonographers. For nearly the entire GA range considered, the mean values of the Asian and European equations for all four biometric measurements were within the 90% expected range (mean ± 1.645 SD) of our equations.

CONCLUSION

Locally trained health workers in a refugee camp on the Thai-Burmese border can obtain measurements that are associated with low SD values and within the normal limits of published Asian and European equations. The fact that the SD values were lower than in other studies may be explained by the use of the average of two measurements, CRL dating or motivation of the locally trained sonographers.

Refugee and migrant women's views of antenatal ultrasound on the Thai Burmese border: a mixed methods study

Background

Antenatal ultrasound suits developing countries by virtue of its versatility, relatively low cost and safety, but little is known about women’s or local provider’s perspectives of this upcoming technology in such settings. This study was undertaken to better understand how routine obstetric ultrasound is experienced in a displaced Burmese population and identify barriers to its acceptance by local patients and providers.

Methodology/Principal Findings

Qualitative (30 observations, 19 interviews, seven focus group discussions) and quantitative methods (questionnaire survey with 644 pregnant women) were used to provide a comprehensive understanding along four major themes: safety, emotions, information and communication, and unintended consequences of antenatal ultrasound in refugee and migrant clinics on the Thai Burmese border. One of the main concerns expressed by women was the danger of childbirth which they mainly attributed to fetal malposition. Both providers and patients recognized ultrasound as a technology improving the safety of pregnancy and delivery. A minority of patients experienced transitory shyness or anxiety before the ultrasound, but reported that these feelings could be ameliorated with improved patient information and staff communication. Unintended consequences of overuse and gender selective abortions in this population were not common.

Conclusions/Significance

The results of this study are being used to improve local practice and allow development of explanatory materials for this population with low literacy. We strongly encourage facilities introducing new technology in resource poor settings to assess acceptability through similar inquiry.

Ultrasound evidence of early fetal growth restriction after maternal malaria infection

Background

Intermittent preventive treatment (IPT), the main strategy to prevent malaria and reduce anaemia and low birthweight, focuses on the second half of pregnancy. However, intrauterine growth restriction may occur earlier in pregnancy. The aim of this study was to measure the effects of malaria in the first half of pregnancy by comparing the fetal biparietal diameter (BPD) of infected and uninfected women whose pregnancies had been accurately dated by crown rump length (CRL) before 14 weeks of gestation.

Methodology/Principal Findings

In 3,779 women living on the Thai-Myanmar border who delivered a normal singleton live born baby between 2001–10 and who had gestational age estimated by CRL measurement <14 weeks, the observed and expected BPD z-scores (<24 weeks) in pregnancies that were (n = 336) and were not (n = 3,443) complicated by malaria between the two scans were compared. The mean (standard deviation) fetal BPD z-scores in women with Plasmodium (P) falciparum and/or P.vivax malaria infections were significantly lower than in non-infected pregnancies; −0.57 (1.13) versus −0.10 (1.17), p<0.001. Even a single or an asymptomatic malaria episode resulted in a significantly lower z-score. Fetal female sex (p<0.001) and low body mass index (p = 0.01) were also independently associated with a smaller BPD in multivariate analysis.

Conclusions/Significance

Despite early treatment in all positive women, one or more (a)symptomatic P.falciparum or P.vivax malaria infections in the first half of pregnancy result in a smaller than expected mid-trimester fetal head diameter. Strategies to prevent malaria in pregnancy should include early pregnancy.

Review: indications for ultrasound use in low- and middle-income countries

OBJECTIVE

To determine the indications for using ultrasound, in low- and middle-income countries (LMICs) and to assess whether its use alters clinical management.

METHODS

Literature review. We conducted a Pubmed search on the clinical use of ultrasound in LMIC for articles published between January 2000 and December 2010, recording country of origin, speciality and whether ultrasound use led to a change in management.

RESULTS

Fifty-eight articles were identified from 32 countries and represented nine specialties. Ultrasound was most commonly used for assisting with the diagnosis of obstetrical conditions, followed by intra-abdominal conditions such as liver abscesses and intussusceptions. Clinical management was altered in >30% of cases.

CONCLUSION

Ultrasound is a highly valuable diagnostic tool in LMICs and its use should be considered essential for all district medical facilities. The use could be applied more widely, eg., for tropical and non-communicable diseases. Additional research is needed to further characterize the impact of task shifting on ultrasound use in LMICs.

Estimation of gestational age from fundal height: a solution for resource-poor settings

Many women in resource-poor settings lack access to reliable gestational age assessment because they do not know their last menstrual period; there is no ultrasound (US) and methods of newborn gestational age dating are not practised by birth attendants. A bespoke multiple-measures model was developed to predict the expected date of delivery determined by US. The results are compared with both a linear and a nonlinear model. Prospectively collected early US and serial symphysis-pubis fundal height (SFH) data were used in the models. The data were collected from Karen and Burmese women attending antenatal care on the Thai–Burmese border. The multiple-measures model performed best, resulting in a range of accuracy depending on the number of SFH measures recorded per mother (for example six SFH measurements resulted in a prediction accuracy of ±2 weeks). SFH remains the proxy for gestational age in much of the resource-poor world. While more accurate measures should be encouraged, we demonstrate that a formula that incorporates at least three SFH measures from an individual mother and the slopes between them provide a significant increase in the accuracy of prediction compared with the linear and nonlinear formulae also using multiple SFH measures.

Amnioinfusion for meconium-stained liquor in labour

BACKGROUND

Amnioinfusion is thought to dilute meconium present in the amniotic fluid and so reduce the risk of meconium aspiration.

OBJECTIVES

To assess the effects of amnioinfusion for meconium-stained liquor on perinatal outcome.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009).

SELECTION CRITERIA

Randomised trials comparing amnioinfusion with no amnioinfusion for women in labour with moderate or thick meconium-staining of the amniotic fluid.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality, and extracted data, independently.

MAIN RESULTS

Thirteen studies of variable quality (4143 women) are included.Subgroup analysis was performed for studies from settings with limited facilities to monitor the baby's condition during labour and intervene effectively, and settings with standard peripartum surveillance.Settings with standard peripartum surveillance: there was considerable heterogeneity for several outcomes. There was no significant reduction in the primary outcomes meconium aspiration syndrome, perinatal death or severe morbidity, and maternal death or severe morbidity. There was a reduction in caesarean sections (CSs) for fetal distress but not overall. Meconium below the vocal cords diagnosed by laryngoscopy was reduced, as was neonatal ventilation or neonatal intensive care unit admission, but there was no significant reduction in perinatal deaths or other morbidity. Planned sensitivity analysis excluding trials with greater risk of bias resulted in an absence of benefits for any of the outcomes studied.Settings with limited peripartum surveillance: two studies (855 women) were included. In the amnioinfusion group there was a reduction in CS for fetal distress and overall; meconium aspiration syndrome (RR 0.25, 95% CI 0.13 to 0.47), and neonatal ventilation or neonatal intensive care unit admission; and a trend towards reduced perinatal mortality (RR 0.37, 95% CI 0.13 to 1.01). In one of the studies, meconium below the vocal cords was reduced and, in the other, neonatal encephalopathy was reduced.

AUTHORS' CONCLUSIONS

Amnioinfusion is associated with substantive improvements in perinatal outcome only in settings where facilities for perinatal surveillance are limited. It is not clear whether the benefits are due to dilution of meconium or relief of oligohydramnios.In settings with standard peripartum surveillance, some non-substantive outcomes were improved in the initial analysis, but sensitivity analysis excluding trials with greater risk of bias eliminated these differences. Amnioinfusion is either ineffective in this setting, or its effects are masked by other strategies to optimise neonatal outcome.The trials reviewed are too small to address the possibility of rare but serious maternal adverse effects of amnioinfusion.