Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study

OBJECTIVE

To examine internal organ tissues and placentas of stillbirths for various pathogens.

DESIGN

Prospective, observational study.

SETTINGS

Three study hospitals in India and a large maternity hospital in Pakistan.

POPULATION

Stillborn infants delivered in a study hospital.

METHODS

A prospective observational study.

MAIN OUTCOME MEASURES

Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths.

RESULTS

Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%).

CONCLUSIONS

In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.

Effect of heat stable carbetocin vs oxytocin for preventing postpartum haemorrhage on post delivery hemoglobin-a randomized controlled trial

OBJECTIVE

To compare the effect of heat-stable carbetocin 100 μg IM versus oxytocin 10 IU IM on post-delivery hemoglobin level.

SETTING

Hospital based study in Southern India.

POPULATION

Women delivering vaginally who were enrolled in the WHO CHAMPION trial in a single facility in India. WHO CHAMPION Trial was a randomized, double-blind, noninferiority trial comparing intramuscular injections of heat-stable carbetocin with oxytocin administered immediately after vaginal birth in women across 23 sites in 10 countries.

METHODS

This was a nested randomized controlled trial designed to compare the effect of heat-stable carbetocin 100 μg IM versus oxytocin 10 IU IM, administered within one minute of vaginal delivery of the baby for prevention of postpartum hemorrhage, on post-delivery 48-72 h hemoglobin level, adjusted for pre-delivery hemoglobin level. 1,799 women from one hospital in India participated in this study.

RESULTS

Pre-delivery hemoglobin and postpartum blood loss were not significantly different between carbetocin and oxytocin. Post-delivery hemoglobin, unadjusted or adjusted for pre-delivery hemoglobin, was slightly lower for carbetocin (10.09 g/dL) compared to oxytocin (10.21) (p value of 0.0432). The drop in hemoglobin was slightly higher for carbetocin, although the difference was very small (1.2 g/dL for carbetocin, 1.1 g/dL for oxytocin) (p value of .0786). The proportion of participants with a drop in hemoglobin of 2 g/dL or more, adjusted for pre-delivery hemoglobin, was higher for carbetocin (RR = 1.29, 95% CI 1.02-1.63). From the regression coefficients it can be derived that post-delivery hemoglobin, adjusted for pre-delivery hemoglobin, decreases on average 0.12 g/dL for each dL of blood lost, for the two treatments combined.

CONCLUSION

The present ancillary study showed that intramuscular administration of 100 µg of heat stable carbetocin can result in a slightly lower post-delivery hemoglobin, slightly higher drop and higher percentage of women having a drop of 2 g/dL or larger, compared to 10 IU of oxytocin.

Preventable stillbirths in India and Pakistan: a prospective, observational study

OBJECTIVE

Stillbirths occur 10-20 times more frequently in low-income settings compared with high-income settings. We created a methodology to define the proportion of stillbirths that are potentially preventable in low-income settings and applied it to stillbirths in sites in India and Pakistan.

DESIGN

Prospective observational study.

SETTING

Three maternity hospitals in Davangere, India and a large public hospital in Karachi, Pakistan.

POPULATION

All cases of stillbirth at ≥20 weeks of gestation occurring from July 2018 to February 2020 were screened for participation; 872 stillbirths were included in this analysis.

METHODS

We prospectively defined the conditions and gestational ages that defined the stillbirth cases considered potentially preventable. Informed consent was sought from the parent(s) once the stillbirth was identified, either before or soon after delivery. All information available, including obstetric and medical history, clinical course, fetal heart sounds on admission, the presence of maceration as well as examination of the stillbirth after delivery, histology, and polymerase chain reaction for infectious pathogens of the placenta and various fetal tissues, was used to assess whether a stillbirth was potentially preventable.

MAIN OUTCOME MEASURES

Whether a stillbirth was determined to be potentially preventable and the criteria for assignment to those categories.

RESULTS

Of 984 enrolled, 872 stillbirths at ≥20 weeks of gestation met the inclusion criteria and were included; of these, 55.5% were deemed to be potentially preventable. Of the 649 stillbirths at ≥28 weeks of gestation and ≥1000 g birthweight, 73.5% were considered potentially preventable. The most common conditions associated with a potentially preventable stillbirth at ≥28 weeks of gestation and ≥1000 g birthweight were small for gestational age (SGA) (52.8%), maternal hypertension (50.2%), antepartum haemorrhage (31.4%) and death that occurred after hospital admission (15.7%).

CONCLUSIONS

Most stillbirths in these sites were deemed preventable and were often associated with maternal hypertension, antepartum haemorrhage, SGA and intrapartum demise.

TWEETABLE ABSTRACT

Most stillbirths are preventable by better care for women with hypertension, growth restriction and antepartum haemorrhage.

Association of haemoglobin levels in the first trimester and at 26-30 weeks with fetal and neonatal outcomes: a secondary analysis of the Global Network for Women's and Children's Health's ASPIRIN Trial

OBJECTIVE

Limited data are available from low- and middle-income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes.

DESIGN

ASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6⁺⁰ -13⁺⁶  weeks and 26⁺⁰ -30⁺⁰  weeks of gestation with fetal and neonatal outcomes.

SETTING

Obstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala.

POPULATION

A total of 11 976 pregnant women.

METHODS

Generalised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes.

MAIN OUTCOME MEASURES

Preterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g.

RESULTS

The mean haemoglobin levels at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6⁺⁰ -13⁺⁶  weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70-89 g/l compared with haemoglobin of 110-129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26-30 weeks of gestation.

CONCLUSIONS

Both lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6⁺⁰ -13⁺⁶  weeks and at 26-30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger.

TWEETABLE ABSTRACT

Both lower and some higher haemoglobin concentrations were associated with adverse fetal and neonatal outcomes at 6-13 weeks and 26-30 weeks of gestation.

Maternal anaemia and maternal, fetal, and neonatal outcomes in a prospective cohort study in India and Pakistan

OBJECTIVE

To describe the association of maternal anaemia with maternal, fetal, and neonatal outcomes.

DESIGN

Prospective cohort study.

SETTING

Rural India and Pakistan.

POPULATION

Pregnant women residing in the study catchment area.

METHODS

We performed an analysis of a prospective pregnancy registry in which haemoglobin is commonly obtained as well as maternal, fetal, and neonatal outcomes for 42 days post-delivery. Women 40 years or older who delivered before 20 weeks or had a haemoglobin level of <3.0 g/dl were excluded. Our primary exposure was maternal anaemia, which was categorised in keeping with World Health Organization criteria based on a normal (≥11 g/dl), mild (>10-10.9 g/dl), moderate (7-9.9 g/dl) or severe (<7 g/dl). haemoglobin level. The primary maternal outcome was maternal death, the primary fetal outcome was stillbirth, and the primary neonatal outcome was neonatal mortality <28 days.

RESULTS

A total of 92 247 deliveries and 93 107 infants were included, of which 87.8% were born to mothers who were anaemic (mild 37.9%, moderate 49.1%, and severe 0.7%). Maternal mortality (number per 100 000) was not associated with anaemia: normal 124, mild 106, moderate 135, and severe 325 (P = 0.64). Fetal and neonatal mortality was associated with severe anaemia: stillbirth rate (n/1000)-normal 27.7, mild 25.8, moderate 30.1, and severe 90.9; P < 0.0001; 28-day neonatal mortality (n/1000)-normal 24.7, mild 22.9, moderate 28.1, and severe 72.6 (P < 0.0001). Severe maternal anaemia was also associated with low birthweight (<2500 and <1500 g), preterm birth, and postpartum haemorrhage.

CONCLUSION

Severe maternal anaemia is associated with higher risks of poor maternal, fetal, and neonatal outcomes but other degrees of anaemia are not. Interventions directed at preventing severe anaemia in pregnant women should be considered.

TWEETABLE ABSTRACT

Severe maternal anaemia is associated with adverse fetal and neonatal outcomes in low/middle-income countries.

Clindamycin to reduce preterm birth in a low resource setting: a randomised placebo-controlled clinical trial

OBJECTIVE

To determine whether oral clindamycin reduces the risk of preterm birth (PTB) in women with abnormal vaginal microflora as evidenced by a vaginal pH ≥5.0.

DESIGN

Randomised double-blind placebo-controlled trial.

SETTING

Rural southern India.

POPULATION

Pregnant women with a singleton fetus between 13^+0/7 weeks and 20^+6/7 weeks.

METHODS

Pregnant women were recruited during prenatal visits in Karnataka, India, from October 2013 to July 2015. Women were required to have a singleton fetus between 13^+0/7 weeks and 20^+6/7 weeks and an elevated vaginal pH (≥5.0) by colorimetric assessment. Participants were randomised to either oral clindamycin 300 mg twice daily for 5 days or an identical-appearing placebo.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of PTB, defined as delivery before 37^+0/7 weeks.

RESULTS

Of the 6476 screened women, 1727 women were randomised (block randomised in groups of six; clindamycin n = 866, placebo n = 861). The demographic, reproductive, and anthropomorphometric characteristics of the study groups were similar. Compliance was high, with over 94% of capsules being taken. The rate of PTB before 37 weeks was comparable between the two groups [clindamycin 115/826 (13.9%) versus placebo 111/806 (13.8%), between-group difference 0.2% (95% CI -3.2 to 3.5%, P = 0.93)], as was PTB at less than 34 weeks [clindamycin 40/826 (4.8%) versus placebo group 37/806 (4.6%), between-group difference 0.3% (95% CI -1.8 to 2.3%, P = 0.81)]. No differences were detected in the incidence of birthweight of<2500 g, <1500 g, miscarriage, stillbirth or neonatal death.

CONCLUSION

In this setting, oral clindamycin did not decrease PTB among women with vaginal pH ≥5.0.

TWEETABLE ABSTRACT

Oral clindamycin between 13^+0/7 and 20^+6/7 weeks does not prevent preterm birth in women with a vaginal pH ≥5.0.

Global Network for Women's and Children's Health Research: probable causes of stillbirth in low- and middle-income countries using a prospectively defined classification system

OBJECTIVE

We sought to classify causes of stillbirth for six low-middle-income countries using a prospectively defined algorithm.

DESIGN

Prospective, observational study.

SETTING

Communities in India, Pakistan, Guatemala, Democratic Republic of Congo, Zambia and Kenya.

POPULATION

Pregnant women residing in defined study regions.

METHODS

Basic data regarding conditions present during pregnancy and delivery were collected. Using these data, a computer-based hierarchal algorithm assigned cause of stillbirth. Causes included birth trauma, congenital anomaly, infection, asphyxia, and preterm birth, based on existing cause of death classifications and included contributing maternal conditions.

MAIN OUTCOME MEASURES

Primary cause of stillbirth.

RESULTS

Of 109 911 women who were enrolled and delivered (99% of those screened in pregnancy), 2847 had a stillbirth (a rate of 27.2 per 1000 births). Asphyxia was the cause of 46.6% of the stillbirths, followed by infection (20.8%), congenital anomalies (8.4%) and prematurity (6.6%). Among those caused by asphyxia, 38% had prolonged or obstructed labour, 19% antepartum haemorrhage and 18% pre-eclampsia/eclampsia. About two-thirds (67.4%) of the stillbirths did not have signs of maceration.

CONCLUSIONS

Our algorithm determined cause of stillbirth from basic data obtained from lay-health providers. The major cause of stillbirth was fetal asphyxia associated with prolonged or obstructed labour, pre-eclampsia and antepartum haemorrhage. In the African sites, infection also was an important contributor to stillbirth. Using this algorithm, we documented cause of stillbirth and its trends to inform public health programs, using consistency, transparency, and comparability across time or regions with minimal burden on the healthcare system.

TWEETABLE ABSTRACT

Major causes of stillbirth are asphyxia, pre-eclampsia and haemorrhage. Infections are important in Africa.

Conducting International Collaborative Research in Developing Nations

International research partnerships bring together some of the best and the brightest in an effort to tackle global health problems. Such collaborations also pose complex challenges, such as maintaining ethical principles in the conduct of research in developing nations. In implementing a randomized clinical trial to reduce postpartum hemorrhage (PPH) during childbirth in rural India, U.S. and Indian collaborators addressed three such issues: the appropriateness of an ethical randomized controlled trial in the developing world, the inclusion of a placebo arm, and the relevance of informed consent in a semiliterate rural population.

Refining the Journal Club Presentations of Postgraduate Students in Seven Clinical Departments for Better Evidence-based Practice

BACKGROUND

A gap between best practice and actual clinical care exists and this can be overcome by evidence-based practice (EBP), which is essential to improve the clinical decision making. A strategy to reduce deficits in care provision is to train the postgraduate students in the practice of EBP in the journal clubs as evidence from medical colleges in India reveals that current format of journal club presentations is unsatisfactory.

AIM

The aim of the present study was to refine the journal club presentations of postgraduate students of clinical departments and to study the effectiveness of EBP training in them for better EBP.

SUBJECTS AND METHODS

This study was conducted in S. Nijalingappa Medical College, Bagalkot, Karnataka, India, and it was a pre- and post-trial. This study was a pre- and post-trial done during the journal club presentations of postgraduate students from clinical departments. Postgraduate students' understanding of concepts about EBP was assessed using Fresno test questionnaire in traditional journal club presentation. A hands-on session incorporating steps of EBP was imparted to them. Soon after the session, each student was assessed. In the next journal club presentation, 1 week later, the students were assessed again with the same questionnaire by the same faculty. Scores of the postgraduate students, before and after intervention (immediate and 1 week later), were compared. Data were analyzed by paired t-test using SPSS.

RESULTS

An increase in mean posttest scores was seen immediately and also 1 week later as compared to the pretest scores. The scores also increased significantly, when each step of EBP was considered.

CONCLUSIONS

Incorporating teaching of EBP in journal club presentations improved the competencies of postgraduate students in clinical decision making.

Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial

OBJECTIVE

To assess whether secondary prevention, which preemptively treats women with above-average postpartum bleeding, is non-inferior to universal prophylaxis.

DESIGN

A cluster-randomised non-inferiority community trial.

SETTING

Health sub-centres and home deliveries in the Bijapur district of Karnataka, India.

POPULATION

Women with low-risk pregnancies who were eligible for delivery with an Auxiliary Nurse Midwife at home or sub-centre and who consented to be part of the study.

METHODS

Auxiliary Nurse Midwifes were randomised to secondary prevention using 800 mcg sublingual misoprostol administered to women with postpartum blood loss ≥350 ml or to universal prophylaxis using 600 mcg oral misoprostol administered to all women during the third stage of labour.

MAIN OUTCOME MEASURES

Postpartum haemoglobin ≤7.8 g/dl, mean postpartum blood loss and postpartum haemoglobin, postpartum haemorrhage rate, transfer to higher-level facilities, acceptability and feasibility of the intervention.

RESULTS

Misoprostol was administered to 99.7% of women as primary prevention. In secondary prevention, 92 (4.7%) women had postpartum bleeding ≥350 ml, of which 90 (97.8%) received misoprostol. The proportion of women with postpartum haemoglobin ≤7.8 g/dl was 5.9 and 8.8% in secondary and primary prevention clusters, respectively [difference -2.9%, one-sided 95% confidence interval (CI) <1.3%]. Postpartum transfer and haemorrhage rates were low (<1%) in both groups. Shivering was more common in primary prevention clusters (P = 0.013).

CONCLUSION

Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis based on the primary outcome of postpartum haemoglobin. Secondary prevention could be a good alternative to universal prophylaxis as it medicates fewer women and is an acceptable and feasible strategy at the community level.

TWEETABLE ABSTRACT

Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis.

Prevention of postpartum haemorrhage with sublingual misoprostol or oxytocin: a double-blind randomised controlled trial

OBJECTIVE

Sublingual misoprostol produces a rapid peak concentration, and is more effective than oral administration. We compared the postpartum measured blood loss with 400 μg powdered sublingual misoprostol and after standard care using 10 iu intramuscular (IM) oxytocin.

DESIGN

Double-blind randomised controlled trial.

SETTING

A teaching hospital: J N Medical College, Belgaum, India.

SAMPLE

A cohort of 652 consenting eligible pregnant women admitted to the labour room.

METHODS

Subjects were assigned to receive the study medications and placebos within 1 minute of clamping and cutting the cord by computer-generated randomisation. Chi-square and bootstrapped Student's t-tests were used to test categorical and continuous outcomes, respectively.

MAIN OUTCOME MEASURES

Measured mean postpartum blood loss and haemorrhage (PPH, loss ≥ 500 ml), >10% pre- to post-partum decline in haemoglobin, and reported side effects.

RESULTS

The mean blood loss with sublingual misoprostol was 192 ± 124 ml (n=321) and 366 ± 136 ml with oxytocin IM (n=331, P ≤ 0.001). The incidence of PPH was 3.1% with misoprostol and 9.1% with oxytocin (P=0.002). No woman lost ≥ 1000 ml of blood. We observed that 9.7% and 45.6% of women experienced a haemoglobin decline of >10% after receiving misoprostol and oxytocin, respectively (P ≤ 0.001). Side effects were significantly greater in the misoprostol group than in the oxytocin group.

CONCLUSION

Unlike other studies, this trial found sublingual misoprostol more effective than intramuscular oxytocin in reducing PPH, with only transient side effects being greater in the misoprostol group. The sublingual mode and/or powdered formulation may increase the effectiveness of misoprostol, and render it superior to injectable oxytocin for the prevention of PPH. Further research is needed to confirm these results.

Consanguinity, prematurity, birth weight and pregnancy loss: a prospective cohort study at four primary health center areas of Karnataka, India

OBJECTIVE

To determine whether consanguinity adversely influences pregnancy outcome in South India, where consanguinity is a common means of family property retention.

STUDY DESIGN

Data were collected from a prospective cohort of 647 consenting women, consecutively registered for antenatal care between 14 and 18 weeks gestation, in Belgaum district, Karnataka in 2005. Three-generation pedigree charts were drawn for consanguineous participants. χ (2)-Test and Student's t-test were used to assess categorical and continuous data, respectively, using SPSS version 14. Multivariate logistic regression adjusted for confounding variables.

RESULT

Overall, 24.1% of 601 women with singleton births and outcome data were consanguineous. Demographic characteristics between study groups were similar. Non-consanguineous couples had fewer stillbirths (2.6 vs 6.9% P=0.017; adjusted P=0.050), miscarriages (1.8 vs 4.1%, P=0.097; adjusted P=0.052) and lower incidence of birth weight <2500 g (21.8 vs 29.5%, P=0.071, adjusted P=0.044). Gestation <37 weeks was 6.2% in both the groups. Adjusted for consanguinity and other potential confounders, age <20 years was protective of stillbirth (P=0.01), pregnancy loss (P=0.023) and preterm birth (P=0.013), whereas smoking (P=0.015) and poverty (P=0.003) were associated with higher rates of low birth weight.

CONCLUSION

Consanguinity significantly increases pregnancy loss and birth weight <2500 g.

Standardized Visual Estimation of Blood Loss during Vaginal Delivery with its Correlation Hematocrit Changes—A Descriptive Study

Introduction

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. Traditionally, visual method with variations in accuracy is followed, because it is quick, simple and noninvasive. To rely on this method accuracy is of vital importance. This study was aimed to improve accuracy of visual estimation of blood loss during vaginal delivery by standardizing (using similar sized mops and a fixed container) and correlating with hematocrit changes.

Methods design

A descriptive study.

Sample size

250 women. Single fixed collecting container and similar sized mops were used in the third stage of labor. Blood was drained into the container and was visually calibrated by a single trained observer. The soaking characteristics of the mops were used to estimate total blood loss. Blood spillage on delivery table, garments and floor were approximately assessed. Total blood loss was calculated from the above three sources. Hemoglobin and hematocrit measurements were done at the time of admission and, at 24 and 72 hours postpartum and its correlation was done with blood loss.

Analysis

By paired and unpaired ‘t’ test.

Results

250 out of 269 women completed the study. Incidence of PPH (> 500 ml) was 11.2%. The estimated blood loss correlated well with the hemoglobin and hematocrit changes postpartum.

Conclusion

Standardized visual method (fixed container and mops) with trained observer improves the accuracy of estimation. This may assist clinicians to accurately estimate blood loss thus preventing hemorrhage related complications.

Drape estimation vs. visual assessment for estimating postpartum hemorrhage

OBJECTIVE

To compare (1) visual estimation of postpartum blood loss with estimation using a specifically designed blood collection drape and (2) the drape estimate with a measurement of blood loss by photospectrometry.

METHODS

A randomized controlled study was performed with 123 women delivered at the District Hospital, Belgaum, India. The women were randomized to visual or drape estimation of blood loss. A subsample of 10 drape estimates was compared with photospectrometry results.

RESULTS

The visual estimate of blood loss was 33% less than the drape estimate. The interclass correlation of the drape estimate to photospectrometry measurement was 0.92.

CONCLUSION

Drape estimation of blood loss is more accurate than visual estimation and may have particular utility in the developing world. Prompt detection of postpartum hemorrhage may reduce maternal morbidity and mortality in low-resource settings.