Pharmacokinetics and safety of first-line tuberculosis drugs rifampin, isoniazid, ethambutol, and pyrazinamide during pregnancy and postpartum: results from IMPAACT P1026s

Physiological changes during pregnancy may alter the pharmacokinetics (PK) of antituberculosis drugs. The International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1026s was a multicenter, phase IV, observational, prospective PK and safety study of antiretroviral and antituberculosis drugs administered as part of clinical care in pregnant persons living with and without HIV. We assessed the effects of pregnancy on rifampin, isoniazid, ethambutol, and pyrazinamide PK in pregnant and postpartum (PP) persons without HIV treated for drug-susceptible tuberculosis disease. Daily antituberculosis treatment was prescribed following World Health Organization-recommended weight-band dosing guidelines. Steady-state 12-hour PK profiles of rifampin, isoniazid, ethambutol, and pyrazinamide were performed during second trimester (2T), third trimester (3T), and 2-8 of weeks PP. PK parameters were characterized using noncompartmental analysis, and comparisons were made using geometric mean ratios (GMRs) with 90% confidence intervals (CI). Twenty-seven participants were included: 11 African, 9 Asian, 3 Hispanic, and 4 mixed descent. PK data were available for 17, 21, and 14 participants in 2T, 3T, and PP, respectively. Rifampin and pyrazinamide AUC0-24 and C max in pregnancy were comparable to PP with the GMR between 0.80 and 1.25. Compared to PP, isoniazid AUC0-24 was 25% lower and C max was 23% lower in 3T. Ethambutol AUC0-24 was 39% lower in 3T but limited by a low PP sample size. In summary, isoniazid and ethambutol concentrations were lower during pregnancy compared to PP concentrations, while rifampin and pyrazinamide concentrations were similar. However, the median AUC0-24 for rifampin, isoniazid, and pyrazinamide met the therapeutic targets. The clinical impact of lower isoniazid and ethambutol exposure during pregnancy needs to be determined.

Intrapartum human immunodeficiency virus transmission rate in a central hospital in the Western Cape province after universal antiretroviral therapy roll-out

The national human immunodeficiency virus (HIV) mother-to-child transmission rate at 6–10 weeks post-partum was 0.9% in 2016. There is a paucity of data about the intrapartum transmission rate after lifelong antiretroviral therapy was implemented in 2015. We assessed all pregnant women living with HIV who delivered at Tygerberg Hospital in 2017. Positive polymerase chain reactions (PCRs) at birth indicated an in utero transmission rate of 0.8%. One infant with a negative PCR at birth tested positive at 6–10 weeks. The intrapartum transmission rate was low (0.08%). About 25% of infants were lost to follow-up after birth.

A case series of post-partum haemorrhage managed using Ellavi uterine balloon tamponade in a rural regional hospital

Uterine balloon tamponade (UBT) should be attempted once emergency measures have been applied and medical treatment for post-partum haemorrhage (PPH) resulting from an atonic uterus has failed. Sinapi Biomedical (Pty) Ltd developed the Ellavi UBT, a free-flow pressure-controlled UBT unit. The device is affordable for use in lesser-resourced countries. A case series of Ellavi UBT used by medical officers in a rural regional hospital without specialist supervision was conducted. This case series was conducted in St Elizabeth’s Hospital in Lusikisiki, South Africa. The hospital serves as the regional hospital for the Ingquza Hill Subdistrict in the Eastern Cape Province. The Nelson Mandela Academic Hospital (NMAH) in Mthatha is the tertiary referral hospital. Workshops were conducted on the use of Ellavi UBT, and devices were made freely available to the hospital. The case series included 10 patients. Six patients delivered by caesarean section, and four had normal vertex deliveries. All patients had additional oxytocin infusions, and eight patients received misoprostol. Following the insertion and inflation of the Ellavi UBT, the PPH stopped in seven patients, was much reduced in one patient and reduced in one patient. In one case, the Ellavi UBT had no effect on the bleeding. All 10 patients were referred to the NMAH. All patients in the case series had good outcomes. The insertion of the Ellavi UBT and subsequent referral proved to be feasible in a rural regional hospital. All patients included in the case series arrived at the referral hospital and had a good outcome.

1387. Women Living with HIV (WLWH) Lose IFNγ Responses Diagnostic of Latent TB Infection (LTBI) during Pregnancy and after INH Prophylactic Treatment (IPT)

Background

TB is the most common opportunistic infection in PLWH. IPT is recommended for PLWH in endemic areas and for those with LTBI diagnosed by Quantiferon gold-in-tube (QGIT) or tuberculin skin test (TST) in other areas. We report on the performance of QGIT and TST in pregnant WLWH who received IPT antepartum (AP) or postpartum (PP).

Methods

WLWH participating in IMPAACT P1078, a randomized, double-blind, placebo-controlled study comparing 28 weeks of IPT AP vs. PP, were tested by QGIT at entry (14–34 weeks gestation) and by QGIT and TST at delivery (L&D) and 44 weeks PP. Serial QGIT positivity was assessed by logistic regression using generalized estimating equations.

Results

Among 944 women with study entry mean (SD) of 29 (6) years of age, 521 (245) CD4+ cells/µL, on ART, including 63% with undetectable HIV plasma RNA, 284/944 (30%) were QGIT+ AP, 215/862 (25%) at L&D and 246/764 (32%) PP (P < 0.001), while 127 (15%) were TST+ at L&D and 126 (17%) PP. QGIT was more likely positive than TST at L&D (Odds ratio = 4.3; 95% CI = 2.8–6.8) and PP (6.4; 3.9–10.7; P < 0.001). QGIT and TST agreement coefficients (95% CI) were 0.4 (0.3–0.5) at L&D and 0.5 (0.4–0.5) PP. Among women QGIT+ AP, 59 (24%) reverted to QGIT- or indeterminate at L&D. However, 37 (63%) reverters recovered QGIT+ results PP, suggesting transient suppression of IFNg responses during pregnancy. Responses to the mitogen-positive QGIT kit control were absent in 60 (7%) women AP, 116 (16%) at L&D, but only 3 (0.4%) PP (P < 0.01), supporting the notion of transient immune suppression during pregnancy. Among women QGIT- AP, 33 (7%) converted to QGIT+ PP. Among AP QGIT+ women, 24 (11%) reverted to QGIT- PP after finishing IPT. None of the results differed between treatment arms (P ≥ 0.13).

Conclusion

In WLWH on ART, the loss of IFNγ responses to TB antigen and mitogen in pregnancy decreased the diagnostic value of QGIT. TST was similar at L&D and PP but was less sensitive than QGIT. QGIT conversions likely resulted from a combination of PP immune reconstitution and new TB infections. QGIT reversions might represent a change in TB-specific immunity in response to IPT. Reversions have been reported in adults without HIV after treatment of active TB. The clinical significance of QGIT reversions in PLWH needs further investigation.

Disclosures

All authors: No reported disclosures.

A blueprint to establish a four-bed obstetric critical care unit in the labor ward of a central hospital

Patients at risk of organ dysfunction or with established organ dysfunction should be referred to central or tertiary-level hospitals. However, even in central hospitals, intensive care unit (ICU) beds are often unavailable, which may contribute to maternal deaths. One pragmatic solution is to establish obstetric critical care units (OCCUs) in the labor wards of central hospitals; however, specific guidance on how to do this is limited. In addition, globally applicable standards of care are lacking, with uncertainty regarding who should lead obstetric critical care. In this article the specific OCCU infrastructure, equipment and human resources required to establish such units in central hospitals in low- and middle-income countries are described in sufficient detail for easy replication. Admission and discharge guidelines and operational recommendations that include quality indicators are also provided.

Delphi consensus statement on intrapartum fetal monitoring in low-resource settings

Objective

To determine acceptable and achievable strategies of intrapartum fetal monitoring in busy low‐resource settings.

Methods

Three rounds of online Delphi surveys were conducted between January 1 and October 31, 2017. International experts with experience in low‐resource settings scored the importance of intrapartum fetal monitoring methods.

Results

71 experts completed all three rounds (28 midwives, 43 obstetricians). Consensus was reached on (1) need for an admission test, (2) handheld Doppler for intrapartum fetal monitoring, (3) intermittent auscultation (IA) every 30 minutes for low‐risk pregnancies during the first stage of labor and after every contraction for high‐risk pregnancies in the second stage, (4) contraction monitoring hourly for low‐risk pregnancies in the first stage, and (5) adjunctive tests. Consensus was not reached on frequency of IA or contraction monitoring for high‐risk women in the first stage or low‐risk women in the second stage of labor.

Conclusion

There is a gap between international recommendations and what is physically possible in many labor wards in low‐resource settings. Research on how to effectively implement the consensus on fetal assessment at admission and use of handheld Doppler during labor and delivery is crucial to support staff in achieving the best possible care in low‐resource settings.

International fetal monitoring strategies are not achievable in many low‐resource settings. Consensus was reached that admission assessment and Doppler are the first steps towards acceptable surveillance.

Esomeprazole to treat women with preterm preeclampsia: a randomized placebo controlled trial

BACKGROUND

Preterm preeclampsia has a high rate of fetal death or disability. There is no treatment to slow the disease, except delivery. Preclinical studies have identified proton pump inhibitors as a possible treatment.

OBJECTIVE

The purpose of this study was to examine whether esomeprazole could prolong pregnancy in women who have received a diagnosis of preterm preeclampsia.

STUDY DESIGN

We performed a double-blind, randomized controlled trial at Tygerberg Hospital in South Africa. Women with preterm preeclampsia (gestational age 26 weeks+0 days to 31 weeks+6 days) were assigned randomly to 40-mg daily esomeprazole or placebo. The primary outcome was a prolongation of gestation of 5 days. Secondary outcomes were maternal and neonatal outcomes. We compared circulating markers of endothelial dysfunction that was associated with preeclampsia and performed pharmacokinetic studies.

RESULTS

Between January 2016 and April 2017, we recruited 120 participants. One participant was excluded because of incorrect randomization, which left 59 participants in the esomeprazole and 60 participants in the placebo group. Median gestational age at enrolment was 29+4 weeks gestation. There were no between-group differences in median time from randomization to delivery: 11.4 days (interquartile range, 3.6-19.7 days) in the esomeprazole group and 8.3 days (interquartile range, 3.8-19.6 days) in the placebo group (3 days longer in the esomeprazole arm; 95% confidence interval, -2.9-8.8; P=.31). There were no placental abruptions in the esomeprazole group and 6 (10%) in the placebo group (P=.01, P=.14 adjusted). There were no differences in other maternal or neonatal outcomes or markers of endothelial dysfunction. Esomeprazole and its metabolites were detected in maternal blood among those treated with esomeprazole, but only trace amounts in the umbilical cord blood.

CONCLUSION

Daily esomeprazole (40 mg) did not prolong gestation in pregnancies with preterm preeclampsia or decrease circulating soluble fms-like tyrosine kinase 1 concentrations. Higher levels in the maternal circulation may be needed for clinical effect.

Benefits and Risks of Antiretroviral Therapy for Perinatal HIV Prevention

BACKGROUND

Randomized-trial data on the risks and benefits of antiretroviral therapy (ART) as compared with zidovudine and single-dose nevirapine to prevent transmission of the human immunodeficiency virus (HIV) in HIV-infected pregnant women with high CD4 counts are lacking.

METHODS

We randomly assigned HIV-infected women at 14 or more weeks of gestation with CD4 counts of at least 350 cells per cubic millimeter to zidovudine and single-dose nevirapine plus a 1-to-2-week postpartum "tail" of tenofovir and emtricitabine (zidovudine alone); zidovudine, lamivudine, and lopinavir-ritonavir (zidovudine-based ART); or tenofovir, emtricitabine, and lopinavir-ritonavir (tenofovir-based ART). The primary outcomes were HIV transmission at 1 week of age in the infant and maternal and infant safety.

RESULTS

The median CD4 count was 530 cells per cubic millimeter among 3490 primarily black African HIV-infected women enrolled at a median of 26 weeks of gestation (interquartile range, 21 to 30). The rate of transmission was significantly lower with ART than with zidovudine alone (0.5% in the combined ART groups vs. 1.8%; difference, -1.3 percentage points; repeated confidence interval, -2.1 to -0.4). However, the rate of maternal grade 2 to 4 adverse events was significantly higher with zidovudine-based ART than with zidovudine alone (21.1% vs. 17.3%, P=0.008), and the rate of grade 2 to 4 abnormal blood chemical values was higher with tenofovir-based ART than with zidovudine alone (2.9% vs. 0.8%, P=0.03). Adverse events did not differ significantly between the ART groups (P>0.99). A birth weight of less than 2500 g was more frequent with zidovudine-based ART than with zidovudine alone (23.0% vs. 12.0%, P<0.001) and was more frequent with tenofovir-based ART than with zidovudine alone (16.9% vs. 8.9%, P=0.004); preterm delivery before 37 weeks was more frequent with zidovudine-based ART than with zidovudine alone (20.5% vs. 13.1%, P<0.001). Tenofovir-based ART was associated with higher rates than zidovudine-based ART of very preterm delivery before 34 weeks (6.0% vs. 2.6%, P=0.04) and early infant death (4.4% vs. 0.6%, P=0.001), but there were no significant differences between tenofovir-based ART and zidovudine alone (P=0.10 and P=0.43). The rate of HIV-free survival was highest among infants whose mothers received zidovudine-based ART.

CONCLUSIONS

Antenatal ART resulted in significantly lower rates of early HIV transmission than zidovudine alone but a higher risk of adverse maternal and neonatal outcomes. (Funded by the National Institutes of Health; PROMISE ClinicalTrials.gov numbers, NCT01061151 and NCT01253538 .).

Acceptability and feasibility of mHealth and community-based directly observed antiretroviral therapy to prevent mother-to-child HIV transmission in South African pregnant women under Option B+: an exploratory study

OBJECTIVE

To examine the acceptability and feasibility of mobile health (mHealth)/short message service (SMS) and community-based directly observed antiretroviral therapy (cDOT) as interventions to improve antiretroviral therapy (ART) adherence for preventing mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT).

DESIGN AND METHODS

A mixed-method approach was used. Two qualitative focus group discussions with HIV-infected pregnant women (n=20) examined the acceptability and feasibility of two ART adherence interventions for PMTCT: 1) SMS text messaging and 2) patient-nominated cDOT supporters. Additionally, 109 HIV-infected, pregnant South African women (18-30 years old) receiving PMTCT services under single-tablet antiretroviral therapy regimen during pregnancy and breastfeeding and continuing for life ("Option B+") were interviewed about mobile phone access, SMS use, and potential treatment supporters.

SETTING

A community primary care clinic in Cape Town, South Africa.

PARTICIPANTS

HIV-infected pregnant women.

MAIN OUTCOMES

Acceptability and feasibility of mHealth and cDOT interventions.

RESULTS

Among the 109 women interviewed, individual mobile phone access and SMS use were high (>90%), and 88.1% of women were interested in receiving SMS ART adherence support messages such as reminders, motivation, and medication updates. Nearly all women (95%) identified at least one person close to them to whom they had disclosed their HIV status and would nominate as a cDOT supporter. Focus group discussions revealed that cDOT supporters and adherence text messages were valued, but some concerns regarding supporter time availability and risk of unintended HIV status disclosure were expressed.

CONCLUSION

mHealth and/or cDOT supporter as interventions to improve ART adherence are feasible in this setting. However, safe HIV status disclosure to treatment supporters and confidentiality of text messaging content about HIV and ART were deemed crucial.

The epidemiology of hepatitis B virus infection in HIV-infected and HIV-uninfected pregnant women in the Western Cape, South Africa

•

HIV-infected pregnant women have evidence of HBV escape compared to uninfected women.

•

One in six HBV-infected pregnant women is HBeAg seropositive, regardless of HIV status.

•

These data support the call to implement a birth dose of HBV vaccine.

Objectives

Persistent hepatitis B virus (HBV) infection is a major cause of morbidity and mortality in sub-Saharan Africa. The HIV epidemic has the potential to affect its biology. Immunisation protocols established in the pre-HIV era are based upon data showing predominantly horizontal infant transmission. This study aimed to determine whether HIV co-infection will change the epidemiology of HBV both by increasing infectivity and by favouring the escape of viruses bearing phenotypically altered HBsAg.

Methods

This retrospective cross-sectional study used antenatal samples from the 2008 Antenatal Sentinel HIV and Syphilis Prevalence Survey in the Western Cape, South Africa. All HIV-infected women were age and race-matched to HIV-uninfected women. Samples were tested for serological markers of HBV and HDV infection. HBV viral load, consensus sequencing and genotyping were performed. Luminex technology was used to determine HBsAg phenotype. All samples from HIV-infected women were tested for traces of antiretroviral drugs by mass spectrometry.

Results

This study showed a trend toward loss of immune control of HBV in HIV-infected women with 3.4% of samples containing HBsAg, 18.9% contained HBeAg. In contrast, 2.9% of samples from HIV-uninfected women contained HBsAg and 17.1% of these HBeAg. The median HBV load in the HIV-infected group was 9.72 × 10⁷ IU/ml and in the HIV-uninfected group 1.19 × 10⁶ IU/ml. Genotyping showed 63/68 samples belonged to genotype A and the remainder genotype D. Mutations in the precore region were found in 35% and 33% of samples from HIV-infected and HIV-uninfected respectively. Although no major epitope ablation was found, marked variation in HBsAg profiles in HIV-infected group was demonstrated. No HDV infection was detected.

Conclusion

HIV-HBV co-infected women exhibit a degree of immune escape. One in six HBV-infected pregnant women, irrespective of HIV status is HBeAg seropositive. HBV immunization of newborns in sub-Saharan Africa should be implemented.

Prevalence of HIV among women entering labor who accepted or declined voluntary counseling and testing

OBJECTIVE

To assess whether there was a difference in HIV seroprevalence between eligible women who declined and those who agreed to participate in a study of voluntary counseling and testing among women entering labor with unknown HIV status in South Africa.

METHODS

Anonymous cord blood specimens were collected-as dried blood spots-from all women approached for participation in a cluster-randomized trial. No patient identifiers were included on the cord blood specimens. The dried blood spots were analyzed for HIV antibody via enzyme immunoassay and western blotting.

RESULTS

Of 7238 women screened for study participation, 1041 (14.4%) had undocumented HIV status; of these women, 542 were eligible for inclusion and 343 enrolled. Based on 513 evaluable samples, the overall seroprevalence was 13.3% (95% confidence interval [CI], 10.4-16.5), which was similar to the 13.1% (95% CI, 9.7-17.2) seroprevalence among the 343 enrolled women.

CONCLUSION

Seroprevalence among eligible women was similar to that among enrolled women, which indicates that study participation did not select for a group with an HIV seroprevalence substantially different from that among women who declined to enroll.

Morphologic changes in the placentas of HIV-positive women and their association with degree of immune suppression

OBJECTIVE

To provide baseline information regarding a possible association between specific histopathologic features of the placentas of HIV-positive women and the degree of immune suppression.

METHODS

A prospective single-blinded laboratory-based pilot study was conducted at Tygerberg Hospital, South Africa. The macroscopic and microscopic features of placentas from HIV-positive (n=91) and HIV-negative women (n=89) were compared and recorded using a standard template. Investigators were blinded to the participants' HIV status and CD4-positive cell count.

RESULTS

Placentas from the HIV-positive group were characterized by decreased weight and increased number of marginal infarcts relative to the HIV-negative group. The most important microscopic finding was the increased presence of villitis of unknown etiology (VUE) among the group of untreated HIV-positive women with CD4 cell counts of 200 cells/mm(3) or below.

CONCLUSION

Both macroscopic and microscopic differences relating to the degree of immune suppression were identified, which seemingly contradicts previous reports. Larger studies are warranted to define the function of antiretroviral therapy and VUE in the mechanism of mother-to-fetus transmission of HIV. Furthermore, the potential role of VUE in the pathophysiology of the compromised immune response observed among HIV-exposed but uninfected infants should be investigated.

Rapid intrapartum or postpartum HIV testing at a midwife obstetric unit and a district hospital in South Africa

OBJECTIVE

To compare the prepartum and postpartum feasibility and acceptance of voluntary counseling and rapid testing (VCT) among women with unknown HIV status in South Africa.

METHODS

Eligible women were randomized according to the calendar week of presentation to receive VCT either while in labor or after delivery.

RESULTS

Of 7238 women approached, 542 (7.5%) were eligible, 343 (63%) were enrolled, and 45 (13%) were found to be HIV infected. The proportions of eligible women who accepted VCT were 66.8% (161 of 241) in the intrapartum arm and 60.5% (182 of 301) in the postpartum arm, and the difference of 6.3% (95% CI, -1.8% to 14.5%) was not significant. The median times (44 and 45 minutes) required to conduct VCT were also similar in the 2 arms. In the intrapartum arm, all women in true labor received their test results before delivery and all those found to be HIV positive accepted prophylaxis with nevirapine before delivery.

CONCLUSIONS

Rapid testing in labor wards for women with an unknown HIV status is feasible and well accepted, and allows for a more timely antiretroviral prophylaxis than postpartum testing.

Zidovudine with nevirapine for the prevention of HIV mother-to-child transmission reduces nevirapine resistance in mothers from the Western Cape, South Africa

In the Western Cape province of South Africa, an intensified regimen for the prevention-of-mother-to-child-transmission-of-HIV consisting of zidovudine (AZT) from 34 weeks of pregnancy plus single dose (sd) nevirapine (NVP) during labor was instituted in 2004. The newborn baby receives a single dose of NVP and AZT for 7 days. Similar strategies in Thailand and Africa have been shown to be more effective in reducing transmission than NVP alone. The use of sd NVP only for the prevention-of-mother-to-child-transmission-of-HIV has a high risk of inducing resistance (25-69%) with an average of 35.7% by a recent meta-analysis and has been shown to adversely affect non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy when initiated within 6 months. In this study the prevalence of resistance to NVP and AZT in mothers who had received the intensified regimen was measured. Specimens collected from mothers were genotyped by in-house PCR and sequencing. In specimens obtained within 60 days of delivery, acquired NVP resistance mutations were detected in 13 of 76 patients (17.1%, 95% confidence interval: 8.7-25.6%), which appears to be lower than in studies with sd NVP alone (37.5%, 95% confidence interval: 23.0-50.6%).

Comparison between a newly developed PC-based Doppler umbilical artery waveform analyser and a commercial unit

OBJECTIVES

To determine the accuracy of the resistance index (RI) of flow velocity waveforms of the umbilical artery measured using a newly developed PC-based continuous wave Doppler device (Umbiflow) with regard to systematic and random variations when compared with a commercial standard (Vasoflow).

DESIGN

A cohort study.

SETTING

The fetal evaluation clinic (FEC) at Tygerberg Hospital.

SUBJECTS

Patients referred to the FEC at Tygerberg Hospital with suspected chronic placental insufficiency.

OUTCOME MEASURES

The correlation coefficients indicating the strength of the relationship between the two devices and their agreement using the method of Bland and Altman.

RESULTS

A total of 248 patients were studied. The mean RIs of the first Doppler assessment were 0.69 (standard deviation (SD) 0.11) and 0.67 (SD 0.11) using the Vasoflow and Umbiflow respectively. The Pearson's correlation coefficient comparing the RI of the first test was 0.85. The degree of agreement between the two methods was excellent, the mean differences being very small (< 0.024) with tight confidence intervals. One hundred and ninety-four patients (78.2%) of patients remained in the same percentile category with both the Vasoflow and Umbiflow.

CONCLUSIONS

The accuracy of the Umbiflow has been proved. A non-significant trend towards slightly lower values needs to be considered. This could be addressed by changing the percentile cut-off to slightly lower values.

A community-based obstetric ultrasound service

OBJECTIVES

To investigate the impact of an ultrasound dating service on obstetric services.

METHODS

A prospective trial with 3009 unselected women presenting for antenatal care at two Midwife Obstetric Units in a socioeconomically deprived urban area, South Africa. In the study unit, student ultrasonographers provided a basic ultrasound service. In the control unit, obstetric ultrasound was only available for specific indications. The main outcome measures were number of antenatal visits and referrals for fetal surveillance.

RESULTS

The two cohorts were comparable except for the number of primigravidas but stratified analysis according to parity did not affect the results. Ultrasonography did not alter pregnancy outcome but reduced the number of perceived preterm labors/ruptured membranes (12.0 vs. 16.7%, P<0.003), post-term deliveries (8.1 vs. 10.8%, P<0.04) and referrals for fetal surveillance [15.9 vs. 29.6%, P<0.000, RR 0.79 (0.71-0.88)].

CONCLUSIONS

This community-based basic ultrasound service significantly reduced referrals to a regional center for fetal surveillance and delivery.

The potential of midwives providing primary obstetric care to reduce perinatal deaths in a rural region

OBJECTIVE

To determine the proportion of perinatal deaths that could be reduced by midwives providing primary obstetric services.

METHOD

The study was conducted in a rural region of the Eastern Cape, South Africa. The primary obstetric and final causes of perinatal deaths and avoidable factors related to these deaths were determined in a large town and two small towns.

RESULTS

In the three towns 52 (48.6%) of the 107 avoidable factors were related to medical care while 20 (38.5%) of these had the potential to be prevented at the level of care rendered by midwives. In the large town 21 (20.6%) of 102 and in the smaller towns 15 (24.6%) of 61 perinatal deaths had potential for intervention by midwives.

CONCLUSION

The 22.1% of perinatal deaths potentially preventable by midwives presupposes complete patient cooperation within an optimally functioning health system.

Improved practical skills of midwives practicing in the Eastern Cape Province of the Republic of South Africa through the study of a self-education manual

OBJECTIVE

Changes in the ability of midwives to perform practical skills, after completion of the Maternal Care Manual of the Perinatal Education Program, were determined.

STUDY DESIGN

A prospective, controlled trial in a study town and two control towns. The practical skills of midwives caring for pregnant women in the towns were determined. Subsequently the Maternal Care Manual was studied by midwives in the study town, and the skills of all midwives were subsequently evaluated.

RESULTS

A total of 34 midwives in the study town and 39 midwives in the two control towns were studied. The marks showed a significant (p < or = 0.000) improvement in the study town when comparing the pre- and postintervention marks. The mean improvement in the study town was 36.6%.

DISCUSSION

The practical skills of midwives improved significantly. The Perinatal Education Program can be implemented with confidence as a distance learning program that is especially suited to the needs of health workers in remote regions.

The effect of the Maternal Care Manual of the Perinatal Education Programme on the attitude of midwives towards their work

OBJECTIVE

In this study the changes in attitude of midwives towards their work following completion of the Maternal Care Manual of the Perinatal Education Programme (PEP), were determined.

METHOD

A prospective, controlled trial was performed in a study, and two control towns in a region where PEP had not previously been used. All midwives caring for pregnant women in the three towns were included in the study. First the attitude of these midwives was determined by means of a questionnaire. Subsequent to this, the Maternal Care Manual was introduced and studied by the midwives in the study town. Following the completion of the Manual after 12 months, the attitude of all midwives was again evaluated using the same questionnaire.

RESULTS

A total of 40 midwives in the study town and 53 in the two control towns were included in the study. There were no differences on comparing the ages of the midwives in the study town to those in the control towns. The attitude of the midwives in the study town improved significantly (p < 0.001). The mean result in the study town improved by 6.1 (24.4%) marks from 14.5 (58.0%) to 20.6 (82.4%). A significant shift also occurred in the range of the marks from 0-25 to 13-25. No changes were observed in the control towns.

CONCLUSION

Most studies that have evaluated educational programmes measured improvement in health services, and did not evaluate changes in attitude. This study found that the attitude of midwives improved significantly in the study town. This positive attitude of midwives towards their work and their ability to perform their daily tasks must be an important component of any programme to improve the quality of care rendered to women during pregnancy, labour and the puerperium.

Effect of the maternal care manual of the perinatal education programme on the ability of midwives to interpret antenatal cards and partograms

OBJECTIVE

To assess the ability of midwives to interpret antenatal cards and partograms correctly following completion of the Maternal Care Manual of the Perinatal Education Programme.

STUDY DESIGN

We conducted a prospective, controlled trial in a study town and two control towns in the Eastern Cape Province of South Africa. All 93 midwives caring for pregnant women in the three towns were included in the study. Samples were compared using the two-tailed Student's t-test.

RESULTS

The marks achieved by the study group for questions from the antenatal card and the partogram improved by 33.0% (p < 0.001) and 17.5% (p = 0.001), respectively. No changes were observed in the control group.

CONCLUSION

Midwives that studied the Maternal Care Manual significantly improved their ability to interpret clinical information and apply knowledge. If this ability is applied in clinical practice, a reduction in maternal and perinatal deaths is possible.

Improved cognitive knowledge of midwives practising in the eastern Cape Province of the Republic of South Africa through the study of a self-education manual

OBJECTIVES

To determine whether the Maternal Care manual of the Perinatal Education Programme (PEP) is effective in improving the cognitive knowledge of midwives.

DESIGN

A prospective controlled trial in a region where PEP was not previously used. The midwifery knowledge of all midwives caring for pregnant women in the three towns was tested before the commencement of the study. The Maternal Care manual was then introduced to the midwives in he study town and they worked through the programme. Following the completion of the manual, all midwives were tested again with the same test. The time interval between the pre and post testing was 12 months.

SETTING

Three towns on the Eastern Cape Province of South Africa.

PARTICIPANTS

All Midwives caring for pregnant women in three towns.

INTERVENTIONS

The Maternal Care manual of PEP was studied by the midwives in the study town.

MEASUREMENTS AND FINDINGS

Changes in cognitive knowledge were tested with multiple choice questions. A significant improvement (p < 0.0001) was achieved in the study town. The mean score (maximum 70) improved by 22.4 (32%) marks, from 35.9 (51%) to 58.3 (83%).

KEY CONCLUSIONS

The cognitive knowledge of midwives who completed the Maternal Care manual improved significantly.

IMPLICATIONS FOR PRACTICE

These findings are to particular importance as the method by which the Maternal Care manual of PEP was applied conforms to the method suggested for the its national use.

Hypermobility and peripartum pelvic pain syndrome in pregnant South African women

OBJECTIVE

To determine the incidence and correlation of joint hypermobility (HM) and peripartum pelvic pain (PPPP) in an homogeneous pregnant South African population.

STUDY DESIGN

A cross-sectional study among Cape Coloured pregnant women. Joint mobility was measured by Beighton score; PPPP with a specially developed PPPP score.

RESULTS

Using the Beighton scores with a cut-off point of HM > or = 5/9, only 4.9% of the 509 pregnant women were hypermobile. Hyperextension of the elbow was the largest contributor to HM (35.4%). No correlation of HM with the incidence of PPPP was established. Only 20 very mild cases of PPPP were recorded. Back pain increased significantly during pregnancy to a mean of 38%. Right handedness occurred in 95.9%. No significant relation was found between HM and the non-dominant side.

CONCLUSION

Hypermobility in pregnant Cape Coloured women was surprisingly low (4.9%) with a decrease with age, but no increase during pregnancy. Peripartum pelvic pain is virtually absent and has no correlation with joint laxity. Back pain increased during pregnancy to a mean of 38%. Right handedness was high (96%) in comparison with the world-wide figure of 85%. No correlation was found between the dominant body side and hypermobility.

The usefulness of a weight gain spurt to identify women who will develop preeclampsia

OBJECTIVE

The usefulness of adaptive centiles for weight gain as well as sudden weight gain spurts in identifying women who will develop preeclampsia was assessed.

METHODS

A study sample of 99 women who developed preeclampsia and a control sample of 675 women with normal pregnancies, were randomly selected. Weight gain spurts were identified by the upper bound of adaptive maternal weight centiles. Average changes in weight between successive clinic visits were also assessed.

RESULTS

Weight gain exceeding the 90th percentile of the adaptive centiles resulted in estimated sensitivity and specificity of 52% and 66% and weight gain >0.9 kg per week between visits in 76% and 29% respectively. Of women who would develop preeclampsia identified by the adaptive chart, 62.0% exhibited abnormal weight gain prior to the onset of abnormal clinical findings.

CONCLUSIONS

A sudden weight gain spurt is a far from reliable sign of impending preeclampsia. This reason for weighing women at antenatal visits appears to be unfounded.

Predictive value of conditional centile charts for weight and fundal height in pregnancy in detecting light for gestational age births

OBJECTIVE

To estimate the predictive value of weight and symphysis fundal height (SFH) in pregnancy to detect light for gestational age (LiGA) births.

STUDY DESIGN

New conditional centile charts for longitudinal monitoring of maternal weight and fundal height in pregnancy were developed based on the records of 676 women with singleton pregnancies and no complications. The records of these women and of a further sample of 102 women who had LiGA deliveries were used to assess the sensitivity and specificity of the charts in detecting LiGA during pregnancy.

RESULTS

Maternal weight is a poor predictor of LiGA births. Fundal height shows moderate predictive ability. The simple cross-sectional chart for fundal height at the 20th percentile cutoff has sensitivity and specificity of 66% in detecting LiGA births.

CONCLUSIONS

Monitoring via a cross-sectional chart of fundal height offers a potentially useful screening method. The results of this study add support to arguments that routine weighing in pregnancy should be abandoned.

Routine obstetric ultrasound examinations in South Africa: cost and effect on perinatal outcome--a prospective randomised controlled trial

OBJECTIVE

To compare routine midtrimester with selective obstetric ultrasonography concerning the Health Service cost and the effect on perinatal outcome.

DESIGN

A randomised controlled trial.

SETTING

Urban area served by Tygerberg Hospital, a tertiary referral centre in South Africa.

PARTICIPANTS

Pregnant patients without risk factors for congenital anomalies referred for ultrasonography between 18 and 24 weeks of gestation.

INTERVENTION

Between 18 and 24 weeks, a level one ultrasound examination was performed on study patients only. Except for the routine scan, both groups received the same antenatal care and could be referred later for additional scans as judged by their clinicians.

MAIN OUTCOME MEASURES

Overall adverse perinatal outcome and use of antenatal and neonatal services.

RESULTS

The groups did not differ significantly in their use of antenatal and neonatal services except for a greater number of ultrasound scans in the study group. More suspected postdate pregnancies occurred in control patients, as well as more amniocenteses for confirmation of lung maturity. More babies of low birthweight were born in the study group. The incidence of overall or major adverse perinatal outcome was comparable. Routine ultrasonography was accompanied by a considerable increase in costs.

CONCLUSION

Selective use of obstetric ultrasonography did not increase the use of antenatal and neonatal services. Not routinely performing ultrasonography has led to considerable Health Service savings without increasing the risk for adverse perinatal outcome. It saved 75% of selected patients a referral to an ultrasound unit. Specific problems related to inaccurate gestational age determination need to be addressed.

A centile chart for birth weight for an urban population of the Western Cape

Evidence from large epidemiological studies has supported concern that being born light for gestational age (LiGA) may be detrimental. The incidence of LiGA babies is an important indicator of the health of women of reproductive age in deprived communities. In the assessment of LiGA in the Western Cape, centile charts constructed for populations in other parts of the world are generally used. These charts, however, may not be appropriate. Patients residing in the area served by the Tygerberg Hospital obstetric service, who booked early with singleton pregnancies, had their gestational age confirmed by early ultrasound and delivered between 1 March 1989 and 28 February 1990 were included in the study. The sample consisted of 3,643 patients. The mean birth weight was 2,995 g (SD 573 g) and the range 760-5,080 g. The distribution of birth weight at each week of gestation from 28 to 42 weeks was not normal. The 4-parameter Johnson family of densities was used to model the distribution of birth weight at each gestational age. A comparison of the distribution of birth weight in the study relative to the perinatal growth chart for international reference constructed by Dunn was also made. In addition to considering an overall chart, the sample was subdivided according to a number of characteristics (e.g. gender, firstborn and latter-born babies, smoking habit, hypertensive disorders and induction of labour) in order to explore their impact on the distribution of birth weight. Having explored the potential impact of all these factors, it was concluded that a single chart including all patients could be constructed.

Improved perinatal mortality rates in 1001 patients with severe pre-eclampsia

OBJECTIVE

To ascertain the change in perinatal mortality (PNM) rate over a period of 10 years in 1001 patients with severe pre-eclampsia.

METHODS

Patients with severe pre-eclampsia before a gestational age of 34 weeks were managed expectantly. Initial treatment consisted of the administration of magnesium sulphate to prevent convulsions and dihydralazine to reduce blood pressure. Methyldopa alone or in combination with other oral antihypertensive drugs was started soon after admission. In order to prevent fetal death from abruptio placentae, the fetal heart rate was monitored at least four times per day. Patients were delivered either at 34 weeks' gestation or when fetal or maternal indications for immediate delivery were present. The 10-year study was divided into four successive time periods and the PNM rate was calculated separately for each of these time periods.

RESULTS

Perinatal survival was low if patients were delivered before or at 26 weeks' gestation but improved rapidly if delivered thereafter. There were only 33 intrauterine deaths of babies who weighed 1000 g or more. The majority of these deaths were due to abruptio placentae which had occurred prior to admission to hospital. The PNM rate for babies of 1000 g or more decreased from 61 in the first time phase and 83 in the second to 19 in the last. The overall PNM rate during the 10-year study was 62.

CONCLUSION

Improved knowledge about the management of patients with severe pre-eclampsia in early pregnancy resulted in a decline in the PNM rate. Although the exact cause of this reduction towards the end of the study is not known, several factors probably played a role. They are expectant management with a little gain in the gestational age, better fetal monitoring before and during labour, earlier detection of fetal distress, earlier referral to the tertiary hospital and improved neonatal care.

The impact of the Perinatal Education Programme on cognitive knowledge in midwives

OBJECTIVE

To determine whether the Maternal Care and Newborn Care manuals from the Perinatal Education Programme significantly improves the cognitive knowledge of midwives.

DESIGN

Assessment of cognitive knowledge by means of multiple-choice testing. These tests were conducted before and after each of the 30 units of the Programme. In addition, a multiple-choice examination was arranged on completion of each of the two manuals.

SETTING

Level I, II and III hospitals and level I clinics in urban and rural areas of South Africa.

PARTICIPANTS

One hundred and fourteen midwives from hospitals and clinics.

INTERVENTION

Maternal and Newborn Care manuals of the Perinatal Education Programme, studied at home and later discussed by the participants in groups every few weeks.

MAIN OUTCOMES MEASURED

Number of participants who completed a manual, mean results of the pretests and post-tests, mean results of the final examination, and percentage of participants achieving 80% or more in the pretests, post-tests and final examination.

RESULTS

Mean pretest and post-test results for the Maternal Care manual were 65% and 85% respectively. Mean pretest and post-test results for the Newborn Care manual were 72% and 93% respectively. The mean result for the final examination for the Maternal Care manual was 90%, while the mean result for the Newborn Care manual was 95%. There was a significant improvement in cognitive knowledge when either manual was used.

CONCLUSION

The cognitive knowledge of both maternal and newborn care can be significantly improved when midwives use the Perinatal Education Programme in an outreach, co-operative learning course.

Does a nonreactive fetal heart rate pattern really mean fetal distress?

The aim of the study was to compare three different fetal heart rate (FHR) patterns, namely, a nonreactive pattern with good long-term variability (fluctuation of 5 or more beats/min), a reactive pattern, and a nonreactive pattern with poor long-term variability (less than 5 beats/min). For this purpose, nonstress tests done less than 24 hours before delivery and FHR patterns recorded during labor were separately assessed. Endpoints for comparison were 5-minute Apgar scores, intrauterine growth retardation, and umbilical blood gas values at birth. Regarding the nonstress test, the prevalence of low 5-minute Apgar scores in reactive, good variability, and in poor variability patterns were 7.2%, 5.3%, and 24%, respectively. The prevalences of small for gestational age newborns were 8%, 17.6%, and 60.6%, respectively. Blood gas values did not differ significantly. Regarding the FHR patterns during labor, using the same sequence, the prevalences of low 5-minute Apgar scores were 3.5%, 6%, and 23%, respectively. Small for gestational age babies occurred in 8.8%, 15.6%, and 80% of the different FHR patterns, respectively. Regarding umbilical artery blood gas values, the only significant difference was a lower pH in the poor variability group. No difference was found between the blood gas values of babies with a reactive pattern and a nonreactive pattern with good variability.

The usefulness of weight gain in predicting pregnancy complications

The usefulness of recently constructed centile charts for weight gain during pregnancy was studied. The association of weight gain in pregnancy with pregnancy complications was investigated. The incidence of pre-eclampsia and small for gestational age babies both had a significant relationship with weight gain. Use of the charts to screen for pregnancy complications on a selected population had both a sensitivity and specificity of about 50 per cent. The positive and negative predictive values of the charts ranged from 49 to 53 per cent. The question arises as to whether the routine recording of maternal weight at each antenatal visit is necessary.

Management of patients with poor symphysis pubis-fundus growth by Doppler flow velocimetry of the umbilical artery--an effective method to detect the fetus at risk

This study evaluated Doppler flow velocimetry of the umbilical artery in patients with suspected intrauterine growth retardation as detected by poor symphysis-fundus growth (SFG). The sensitivity of Doppler in detecting light for gestational age babies and intrauterine growth retardation was poor. Antenatal complications, neonatal morbidity and perinatal mortality occurred significantly more frequently in patients with abnormal flow. Doppler flow velocimetry is an excellent test to identify babies at high risk for perinatal morbidity and mortality, when poor SFG is present.

Maximum likelihood estimation of reference centiles

We propose the use of centile estimates which are based on the fitting of appropriate densities by maximum likelihood. In the case of cross-sectional centile estimation, we show that this approach will generally lead to more precise estimates than would result from the use of non-parametric centile estimates. When longitudinal data are available or a series of cross-sectional data at different time points, the maximum likelihood approach can be used to simultaneously fit densities to each cross-section, subject to constraints (for example, smoothness constraints) on the parameters. The variances of these centile estimates are readily obtained and missing values and unequally spaced records are easily accommodated. We illustrate the procedure by means of an application using the Johnson family of densities to a study of weight gain in pregnancy.

Inter-observer variation in symphysis-fundus measurements. A plea for individualised antenatal care

Two groups of midwives were compared with regard to ability to detect small-for-gestational-age (SGA) babies using symphysis-fundus (S-F) measurements. The patients were all low-risk obstetric patients. In group A 2 midwives provided antenatal care to 97 patients; 14 delivered SGA babies, of which 12 were identified by S-F measurements (sensitivity 85.7%). In group B 15 midwives provided antenatal care to 126 patients, 12 delivered SGA babies, and 5 of these were identified (sensitivity 41.2%). It is considered that this difference was due to inter-observer variability. A plea is made for individualised antenatal care.

Doppler ultrasonography of the fetoplacental circulation--normal reference values

Normal reference values for the resistance index, A/B ratio and pulsatility index of the umbilical artery obtained by Doppler ultrasonography are presented. The resistance index and A/B ratio values are very similar to those previously published, indicating no need to formulate normal values for different populations. The pulsatility index differed from other published values, probably reflecting different calculation methods built into the spectrum analysers rather than differences in waveforms. The resistance index had the lowest coefficient of variation and showed least inter-observer variation. For routine use the resistance index is preferable to other indices.

Primary causes of total perinatally related wastage at Tygerberg Hospital

The primary obstetric cause of total perinatally related wastage (TPRW) (i.e. all antepartum or postpartum deaths of infants greater than or equal to 500 g and who died before hospital discharge) was studied in a clearly defined population in the western Cape over a 1-year period. There were 302 deaths from 7,923 singletons and 31 deaths from 65 pairs of twins delivered from patients cared for by Tygerberg Hospital maternity services. Thirty per cent of the deaths were late abortions, 42% stillbirths, 18% early neonatal deaths, 7% late neonatal deaths and 4% perinatally related infant deaths. The major primary obstetric events leading to TPRW in singletons were antepartum haemorrhage (27.8%), spontaneous preterm labour (24.8%), unexplained intra-uterine deaths (11.9%), infections (9.3%) and fetal abnormalities (7.9%). Multiple pregnancies accounted for 9.3% of the TPRW of all deliveries. The cause, risk factors associated and methods of prevention of abruptio placentae, spontaneous preterm labour and infections should receive priority in perinatal research in the western Cape.