Pre- and post-COVID practice of interventional pulmonology in adults in Portugal

INTRODUCTION AND OBJECTIVES

There is a lack of information regarding bronchoscopy practice in adults in Portugal. Our objective was to obtain an overview of the characteristics, resources, techniques and behaviors in national interventional pulmonology (IP) units, before and after SARS-CoV-2 outbreak.

MATERIALS AND METHODS

An online survey was developed by an expert panel with a total of 46 questions comprising the specifications of each unit, namely physical space, equipment, staff, procedure planning, monitoring, technical differentiation, and numbers pre- and post-COVID-19. Forty-one interventional pulmonology centers were invited to participate between April and May 2021.

RESULTS

37 units (90.2%) responded to the survey. The majority (64.9%) have a fully dedicated space with a weekly presence of ≥3 chest physicians (82.1%) and support of an anesthesiologist on specific days (48.6%). There is marked heterogeneity in the IP unit's equipment, and 56.8% acquired disposable bronchoscopes after COVID-19 pandemics. Pre-bronchoscopy hemogram, platelet count and coagulation tests are regularly asked by more than 90% of the units, even when deep sedation or biopsies are not planned. In 97.3% of cases, topical anesthesia and midazolam are utilized. Propofol (21.6%) and fentanyl (29.7%) are occasionally employed in some institutions. Most units use ancillary sampling techniques to diagnose central or peripheral lesions, with radial EBUS being used for guidance of distal procedures in 37.8% of centers, linear EBUS and EUS-B-FNA for mediastinal diagnosis and/or staging in 45.9% and 27.0% of units, respectively. Cryobiopsies are used by 21.6% of respondents to diagnose diffuse lung diseases. Rigid bronchoscopy is performed in 37.8% of centers. There was a decrease in the number of flexible (p < 0.001) and rigid (p = 0.005) bronchoscopies and an upscale of personal protective equipment (PPE) during the COVID-19 outbreak.

CONCLUSIONS

IP units have variable bronchoscopic practices, but during the COVID-19 pandemic, they complied with most international recommendations, as elective procedures were postponed and PPE levels increased.

Recommendations for interventional pulmonology during COVID-19 outbreak: a consensus statement from the Portuguese Pulmonology Society

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by a novel SARS-CoV-2 pathogen. Its capacity for human-to-human transmission through respiratory droplets, coupled with a high-level of population mobility, has resulted in a rapid dissemination worldwide. Healthcare workers have been particularly exposed to the risk of infection and represent a significant proportion of COVID-19 cases in the worst affected regions of Europe. Like other open airway procedures or aerosol-generating procedures, bronchoscopy poses a significant risk of spreading contaminated droplets, and medical workers must adapt the procedures to ensure safety of both patients and staff. Several recommendation documents were published at the beginning of the pandemic, but as the situation evolves, our thoughts should not only focus on the present, but should also reflect on how we are going to deal with the presence of the virus in the community until there is a vaccine or specific treatment available. It is in this sense that this document aims to guide interventional pulmonology throughout this period, providing a set of recommendations on how to perform bronchoscopy or pleural procedures safely and efficiently.

Identification and assessment of COPD exacerbations

Chronic Obstructive Pulmonary Disease (COPD) exacerbations play a central role in the disease natural history of the disease, affecting its overall severity, decreasing pulmonary function, worsening underlying co-morbidities, impairing quality of life (QoL) and leading to severe morbidity and mortality. Therefore, identification and correct assessment of COPD exacerbations is paramount, given it will strongly influence therapy success. For the identification of exacerbations, several questionnaires exist, with varying degrees of complexity. However, most questionnaires remain of limited clinical utility, and symptom scales seem to be more useful in clinical practice. In the assessment of exacerbations, the type and degree of severity should be ascertained in order to define the management setting and optimize treatment options. Still, a consensual and universal classification system to assess the severity and type of an exacerbation is lacking, and there are no established criteria for less severely ill patients not requiring hospital assessment. This might lead to under-reporting of minor to moderate exacerbations, which has an impact on patients' health status. There is a clear unmet need to develop clinically useful questionnaires and a comprehensive system to evaluate the severity of exacerbations that can be used in all settings, from primary health care to general hospitals.

Trans-esophageal endobronchial ultrasound-guided needle aspiration (EUS-B-NA): A road map for the chest physician

The endobronchial ultrasound (EBUS) scope has been increasingly used in the gastrointestinal tract (EUS-B). Scientific data proves its efficacy and safety to provide a complete lung cancer staging, when combined with EBUS-TBNA, and in the diagnosis of para-esophageal lesions. There are multiple barriers to start performing EUS-B but probably the most important ones are related to knowledge and training, so new operators should follow a structured training curriculum. This review aims to reflect the best current knowledge regarding EUS-B and provide a road map to assist those who are incorporating the technique into their clinical practice.

COPD control: Can a consensus be found?

There are currently no reliable instruments for assessing the onset and progression of chronic obstructive pulmonary disease (COPD) or predicting its prognosis. Currently, a comprehensive assessment of COPD including several objective and subjective parameters is recommended. However, the lack of biomarkers precludes a correct assessment of COPD severity, which consequently hampers adequate therapeutic approaches and COPD control. In the absence of a definition of "well-controlled disease", a consensus regarding COPD control will be difficult to reach. However, COPD patient assessment should be multidimensional, and anchored in five points: control of symptoms, decline of pulmonary function, levels of physical activity, exacerbations, and Quality of Life. Several non-pharmacological and pharmacological measures are currently available to achieve disease control. Smoking cessation, vaccination, exercise training programs and pulmonary rehabilitation are recognized as important non-pharmacological measures but bronchodilators are the pivotal therapy in the control of COPD. This paper discusses several objective and subjective parameters that may bridge the gap between disease assessment and disease control. The authors conclude that, at present, it is not possible to reach a consensus regarding COPD control, essentially due to the lack of objective instruments to measure it. Some recommendations are set forth, but true COPD control awaits further objective assessments.

[Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer diagnosis and staging in 179 patients]

BACKGROUND

Linear endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an important minimally invasive procedure for non-small cell lung cancer (NSCLC) staging. It is also a valid method for diagnosing extraluminal lesions adjacent to the tracheobronchial tree.

AIM

To evaluate our EBUS-TBNA performance regarding diagnostic yield, safety and learning curve for lung cancer diagnosis and staging.

MATERIAL AND METHODS

All patients undergoing EBUS-TBNA for lung cancer diagnosis or staging were included. They were divided into three different groups: paratracheal and parabronchial masses sent for diagnosis (Group 1); peripheral lung lesions with abnormal mediastinal lymph nodes sent for diagnosis and staging (Group 2); NSCLC patients sent for mediastinal staging (Group 3). The learning curve was assessed for yield, accuracy, procedure time, size and number of lesions punctured per patient.

RESULTS

A total of 179 patients were included and 372 lesions were punctured. The overall yield and accuracy were 88% and 92.7%, respectively. In Group 1, EBUS-TBNA was performed in 48 patients and sensitivity was 86.1% and accuracy was 87.5%. For the 87 patients included in Group 2, yield was 86.7%, accuracy was 93.1% and cancer prevalence was 51.7%. The diagnostic yield and accuracy in Group 3 was 95% and 97.7% respectively. EBUS-TBNA practice led to an increase number of sites punctured per patient in a shorter time, without complications.

CONCLUSION

EBUS-TBNA is an effective method for diagnosing and staging lung cancer patients. The procedure is clearly safe. Handling and performance improves with the number of procedures executed.

Argon-plasma treatment in benign metastasizing leiomyoma of the lung: a case report

Benign metastasizing leiomyomas of the lung are rare smooth muscle cells tumours. We report the case of a 48 year-old female who was evaluated due to persistent cough, progressive dyspnoea and constitutional symptoms. Chest computed tomography revealed a left endobronchial mass, multiple parenchyma nodules and a pleural effusion. Bronchial biopsy histological features were consistent with benign metastasizing leiomyoma. The patient was successfully treated with argon-plasma and mechanical debulking. There was no disease relapse in the last four years.

[Video-assisted thoracic surgery in the diagnosis of interstitial diffuse pulmonary diseases]

Interstitial lung diseases are best diagnosed by surgical lung biopsy. Videoassisted thoracoscopy (VATS) is less aggressive than open lung thoracotomy and its development is associated with an increased number of lung biopsies. Between July 1994 and July 2004 we performed 70 VATS biopsies for interstitial lung disease patients. Only one biopsy was considered inconclusive (1.4%). The remainder 69 (98.6%) established a final diagnosis. The results in our series show that VATS lung biopsy is a safe method with low mortality and morbidity and an excellent rentability.

Pregnancy-associated hypertension in Maputo. A study on maternal characteristics and perinatal outcome in 1275 consecutive cases

A total of 1275 consecutive cases of pregnancy-associated hypertension were registered in the Maputo Central Hospital (corresponding to 2.9% of a total of 43,794 city parturients). In the hypertensive and in the reference populations the following prevalence figures were registered, respectively: age below 25 years, 52% and 23% (P < 0.0005); nulliparity, 33% and 19% (P < 0.0005); twin pregnancies, 3.9% and 1.7% (P < 0.0005); stillbirths, 5.7% and 2.3% (P < 0.0005); and low birthweight (LBW), 22.9% and 10.7% (P < 0.0005). In the hypertensive population the prevalence of LBW newborns was 20.1% in the liveborn group, while it was 68.4% in the stillborn group (P < 0.0005). In the ongoing perinatal audit it was found useful to review hypertensive women separately, in order to assess current routines in cases of pregnancy hypertension.

Risk factors in Mozambican women with eclampsia: a case-referent study

In Maputo 133 consecutive eclamptic patients were compared with 393 non-eclamptic referent women. Significant risk factors for eclampsia were age < or = 18 years, household size < or = 3 individuals, unwanted pregnancy, walking to antenatal clinics and, in the thrid trimester, headache, foot oedema, hand or face oedema, epigastric pain, visual disturbance, ear buzzing and dizziness. Significantly more cases than referents reported no blood pressure measurements in antenatal clinics. It is concluded that the quality of antenatal clinics can be improved by enhanced community awareness of danger signs, by early recognition of risk factors and by better management of prodromal symptoms of eclampsia.

Misoprostol for prevention of postpartum hemorrhage

OBJECTIVE

To compare the effectiveness of 400 microg rectal misoprostol in 5 cm(3) of saline with oxytocin 10 IU, i.m., in reducing bleeding during the third stage of labor.

DESIGN

A double blind, randomized, clinical trial including 663 women with uncomplicated vaginal delivery who received misoprostol (n=324) or oxytocin (n=339).

MAIN OUTCOME MEASURES

Changes in hemoglobin and hematocrit from before to 72 h postpartum; blood loss during the third stage; duration of the third stage of labor; need for additional oxytocic drug; frequency of requisition and of administration of blood; changes in blood pressure; and occurrence of side effects.

RESULTS

No significant differences were observed between groups, before and 72 h postpartum, in mean hemoglobin and hematocrit, on volume of blood loss and duration of third stage of labor. The incidence of shivering and mean temperature (P<0.01) was significantly greater among women receiving misoprostol than oxytocin.

CONCLUSIONS

Misoprostol administered as a micro-enema, 400 microg in 5 ml of saline during the third stage of labor, appears to be as effective as oxytocin 10 IU, i.m., but misoprostol produced more side effects than oxytocin.

Termination of pregnancies of <6 weeks gestation with a single dose of 800 microg of vaginal misoprostol

This study evaluated the effectiveness of a single dose of the abortifacient effect of vaginal misoprostol followed by prolonged observation. Women with < or =42 days of amenorrhea, pregnancy confirmed by ultrasound, and approved request for termination received 800 microg of vaginal misoprostol once and were observed for 1 week. The gestational sac was measured before misoprostol administration, and 24 h and 7 days afterward. Women reported bleeding, expulsion of sac, and other complaints. After 1 week, those who had not aborted received a second dose of 800 microg. Those who had not aborted by 24 h later were treated by vacuum aspiration of the endometrial cavity. Twenty-four hours after treatment, 71.8% had aborted, and 87.1% aborted 3 days after treatment. After the second dose, 7 days later, the cumulative abortion rate reached 92.1%. None of the subjects who aborted required curettage or vacuum aspiration. The main complaints were pain (84.5%), nausea (21.4%), and headache (17.5%). No clinical differences between responders and nonresponders was found. Vaginal misoprostol, 800 microg, is effective in inducing early termination of pregnancy, and there is no need for an additional dose within 72 h after the first administration of misoprostol.

Labor induction by vaginal misoprostol in grand multiparous women

BACKGROUND

Grand multiparous women in poor and under-privileged settings run a high risk of uterine rupture at labor induction. The purpose was to elucidate whether vaginal misoprostol medication is a safe and cost-effective alternative induction method in grand multiparous women, in whom, under prevailing circumstances, induction by oxytocin is associated with high risk of adverse maternal outcome of pregnancy.

METHOD

One hundred and sixty-five grand multiparous parturient women with five or more previous deliveries were divided into two groups. The first group (n=134) had the fetus alive and the second (n=31) had late intrauterine fetal death. Both groups were subject to induction of labor by use of vaginal misoprostol in a dose of 50 microg (live fetus) and 100 microg (intrauterine fetal death). No additional oxytocin was utilised.

RESULTS

Labor induction by vaginal misoprostol was successful in grand multiparous women. The proportion of women requiring a Cesarean section was 6.0%, which is less than one third of the average Cesarean section rate in the setting studied. Women with fetus alive had significantly shorter application-to-expulsion interval (AEI) than women with fetal death (10.1 versus 15.4 hours; p=0.039). Significantly shorter AEI was recorded in women with prelabor rupture of membranes (9.1 hours) than in women with intact membranes (12.9 hours) (p=0.01). With Bishop's score > or = 5 and < 5 AEI was 8.7 hours and 14.4 hours, respectively (p=0.001). No significantly adverse neonatal or maternal outcomes of pregnancy were registered and it was specifically noted that no uterine rupture occurred among the 165 grand multiparous women induced.

CONCLUSIONS

Induction of under-privileged grand multiparous women with live fetus or with fetal death can be performed safely and cost-effectively by vaginal misoprostol.

Training medical assistants for surgery

A successful programme is reported from Mozambique for training middle-level health workers to perform fairly advanced surgical procedures in remote areas where the services of consultants are virtually unobtainable. Manpower and financial constraints obliged Mozambique to train medical assistants to perform surgical work in rural areas, where three broad priorities were identified: pregnancy-related complications, trauma-related complications, and emergency inflammatory conditions. Since 1984, 20 health workers have emerged from three-year courses to become técnicos de cirurgía (assistant medical officers), and it is expected that there will be 46 by 1999. The training comprises two years of lectures and practical sessions in the Maputo Central Hospital, and a practical internship lasting a year at a provincial hospital. Three workshops organized since 1989 suggest that the upgraded personnel are performing well. More detailed evaluation and follow-up are in progress. Throughout 1995 a follow-up was conducted on 14 assistant medical officers. They performed 10,258 surgical operations, some 70% of which were emergency interventions. Low rates of complication occurred and postoperative mortality amounted to 0.4% and 0.1% in emergency and elective interventions respectively.

A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique

OBJECTIVE

To evaluate the outcome of caesarean delivery performed by assistant medical officers and specialists in obstetrics and gynaecology with particular attention to post-operative complications.

DESIGN

We performed a nonrandomised analysis of 2071 consecutive caesarean deliveries at Maputo Central Hospital. Of these, 958 (46.3%) were performed by assistant medical officers (medical assistants trained for surgery) and the rest (53.7%) by specialists in obstetrics and gynaecology. The age and parity distributions of women in the two groups were almost identical.

SETTING

University Hospital in Maputo, covering all emergency obstetrics with about 48,000 deliveries per year.

POPULATION

Two thousand and seventy-one consecutive caesarean deliveries.

MAIN OUTCOME MEASURES

Post-operative complications and the duration of post-operative hospital stay.

RESULTS

There were no differences in the indications for caesarean delivery. The surgical interventions associated with caesarean delivery did not differ in the two groups. The only significant difference was in the group of superficial wound separation due to haematoma, which was slightly more common (0.35% vs 0.05%) in the group operated on by assistant medical officers (Odds Ratio 2.2; 95% Confidence Interval 1.3-3.9).

CONCLUSION

Training selected medical assistants to perform caesarean delivery, even on women in poor general condition, is justified in settings in which doctors are scarce.

Evaluation of the effectiveness of vaginal misoprostol to induce first trimester abortion

Two doses, 200 and 400 micrograms, of misoprostol, administered vaginally every 12 hours, up to four times, were tested in 101 and 133 healthy women, respectively, for interruption of pregnancies with 35 through 77 days of amenorrhea. The proportion of women who aborted increased with longer duration of treatment and was significantly higher with 400 than with 200 micrograms (66 versus 46 percent at 48 hours). Significance was maintained after controlling by age, body weight, parity, previous abortion and gestational age. Abortions were classified as incomplete or complete, according to the presence or not of embryonic tissue in the uterine cavity, diagnosed by vaginal sonography. Vacuum aspiration was carried out in all cases not classified as complete abortion 48 hours after the initiation of treatment, or earlier in case of persistent bleeding or woman's request. The possibility of increasing effectiveness by using higher dose, shorter intervals or longer duration of treatment is discussed.

Uterine evacuation by vaginal misoprostol after second trimester pregnancy interruption

BACKGROUND

The purpose was to study the capacity of vaginal misoprostol in combination with methylergometrine to achieve complete evacuation of the uterus without ensuing surgical evacuation of the uterine cavity.

METHODS

We performed this trial on 228 women seeking pregnancy interruption. Vaginal misoprostol was given in a dosage of 800 micrograms in early second trimester. All women received concomitant treatment with peroral methlyergometrine from the moment of misoprostol application every 8 hours until uterine evacuation. Follow-up was continued until the first menstruation after interruption.

RESULTS

Complete uterine evacuation was achieved in 173/228 cases (76%) [group 1]. The remaining 55 women [group 2] underwent manual evacuation of placental remnants trapped in the cervix. In seven of these women a conventional curettage was carried out due either to ultrasound evidence of placental remnants or due to uterine bleeding. The interval between misoprostol application and fetal expulsion averaged 14.9 hours (s.d. 9.6) in group 1 and 21.0 hours (s.d. 14.5) in group 2 (p=0.006).

CONCLUSIONS

Misoprostol, in combination with methylergometrine, is a remarkably efficient drug in achieving uterine evacuation also in the absence of surgical evacuation of the uterine cavity. The present study provides justification for a more expectant attitude after vaginal misoprostol treatment for pregnancy interruption. The avoidance of close to 80% of otherwise conventional curettages would seem to represent a major advantage, particularly in settings where manpower and material resources are scarce.

Low-dose vaginal misoprostol for induction of labor with a live fetus

OBJECTIVE

To test the effectiveness and safety of low-dose vaginal misoprostol for induction of labor with a live fetus.

METHODS

Labor was induced in 666 pregnant women with a live fetus in the cephalic position, who had no medical complications and no history of uterine surgery. One-fourth of a 200-micrograms tablet of misoprostol (50 micrograms) was placed in the posterior vaginal fornix every 12 h for a maximum of four doses or until active labor commenced. Time from induction to delivery, side effects and neonatal outcome were evaluated.

RESULTS

Labor was successfully induced in all cases. The mean time from induction to delivery was 10.4 h. The cesarean section rate was 7.8%. There were eight perinatal deaths, six of which occurred in low birth weight fetuses. There was one case of abruptio placenta, which was less than that expected in the study population.

CONCLUSION

Vaginal misoprostol, in very low doses, was a remarkably efficient and safe method for induction of labor with a live fetus.

Vaginal misoprostol as an alternative to oxytocin for induction of labor in women with late fetal death

BACKGROUND

Induction of labor in women with late fetal death is often difficult in settings with scarce resources. The purpose of this study was to assess the value of vaginal misoprostol for induction of labor in women with such fetal death.

METHODS

In Maputo 156 women with late fetal death were allotted in a non-randomised way to either vaginal misoprostol or intravenous infusion of oxytocin. Treatment outcomes were compared as to cost-effectiveness and safety. In the misoprostol group none received more than 800 micrograms. Oxytocin infusion followed an established routine. Statistical analyses were performed by EPI Info software.

RESULTS

In cases with Bishop's score < 6 the induction-to-delivery interval averaged 14.8 hours in the misoprostol group and 31.0 hours in the oxytocin group (p = 0.001). The corresponding values for women with Bishop's score > or = 6 were 6.6 and 8.7 hours, respectively (p = 0.4). Women with intact membranes had an induction-to-delivery interval of 13.8 hours in the misoprostol group and 26.9 hours in the oxytocin group (p = 0.002). The corresponding values in women with ruptured membranes were 7.8 and 10.5 hours, respectively (p = 0.6). Successful induction was achieved in 81% of misoprostol-treated women at a dose of 100 micrograms or less.

CONCLUSIONS

Vaginal misoprostol is a safe, low-cost drug particularly suitable in women of high average parity having late, fetal death.

A comparative study of vaginal misoprostol and intravenous oxytocin for induction of labour

Fifty-two women who had labour induced by intravenous oxytocin were compared with 404 women in whom labour was induced by vaginal misoprostol (50-150 micrograms). The induction-to-delivery intervals in the oxytocin and misoprostol groups, respectively, had the following durations. With Bishop's score < 6, 24.3 vs. 14.4 h (p = 0.002), with Bishop's score > or = 6, 10.5 vs. 7.6 h (p = 0.02), with ruptured membranes, 8.8 vs. 8.5 h (p = 0.83), and with intact membranes, 19.6 vs. 13.1 h (p = 0.005). The Caesarean delivery rate was 17.3% in the oxytocin group and 8.7% in the misoprostol group (p = 0.09). Maternal complications were few and drug side effects rare. It is concluded that vaginal misoprostol is a valuable and cost-effective alternative to intravenous oxytocin infusion for induction of labour.

Induction of labor with intravaginal misoprostol in intrauterine fetal death

OBJECTIVE

Our purpose was to evaluate the effectiveness and safety of intravaginal misoprostol for the induction of labor in intrauterine fetal death.

STUDY DESIGN

Seventy-two women at 18 to 40 weeks of pregnancy with intrauterine fetal death, without abdominal scars, were treated with 100 micrograms of intravaginal misoprostol. The dose was repeated every 12 hours until effective uterine contractions and cervical dilatation were obtained, for up to 48 hours.

RESULTS

The mean time from induction to delivery was 12.6 hours, and only six patients (8%) required between 24 and 48 hours, at the end of which all patients had been delivered. Only the Bishop's score was significantly associated with time from first dose to expulsion. No surgical procedure was required. Hypercontractility, sweating, fever, diarrhea, or other gastrointestinal effects were not detected. There was no need for analgesics.

CONCLUSIONS

Intravaginal misoprostol at the dose of 100 micrograms every 12 hours appears to be a safe, effective, practical, and inexpensive new method for induction of labor in intrauterine fetal death.

Application of vaginal misoprostol before cervical dilatation to facilitate first-trimester pregnancy interruption

OBJECTIVE

To study the capacity of vaginal misoprostol to soften the cervix and facilitate cervical dilatation in women undergoing first-trimester pregnancy interruption.

METHODS

We performed a double-blind, placebo-controlled study in 100 women opting for voluntary pregnancy interruption. The subjects were randomly allocated to two treatment groups, receiving either 200 micrograms misoprostol or placebo in the posterior vaginal fornix 6 hours before cervical dilatation. We noted the number of women with vaginal bleeding, with chorionic tissue in the vagina, or with no resistance to a Hegar 8 dilator, and recorded the total time in minutes for pregnancy interruption.

RESULTS

Vaginal bleeding from the cervix occurred in 70% of the misoprostol group and in 8% of the placebo group (odds ratio 26.83; 95% confidence interval [CI] 9.73-74.00). Almost one-fourth (22%) of the misoprostol-treated women had chorionic tissue in the vagina, compared to one woman (2%) in the placebo group (odds ratio 13.82; 95% CI 2.59-73.61). Cervical dilatation was achieved in 74 and 10% of the misoprostol- and placebo-treated women, respectively (odds ratio 25.62; 95% CI 9.61-68.28). The time required for pregnancy interruption was significantly shorter with misoprostol (P < .004).

CONCLUSION

Misoprostol is significantly more effective in facilitating cervical dilatation than is placebo. The average intervention time for pregnancy interruption was reduced by 35%.

Prevalence of syphilis infection in Mozambican women with second trimester miscarriage and women attending antenatal care in second trimester

OBJECTIVES

To elucidate whether recent syphilis infection is significantly more prevalent among women with mid-trimester miscarriage than among antenatal care attenders in midtrimester pregnancy.

DESIGN

Two categories of pregnant women were compared regarding serological signs of syphilis. Rapid Plasma Reagin (RPR) analyses were done in Mozambique and Veneral Disease Research Laboratory (VDRL) tests in Sweden. In case of RPR and/or VDRL positivity, Treponema pallidum haemagglutination (TPHA) and Captia Syphilis-M were performed.

SETTING

A suburban antenatal care clinic and the emergency ward at the Department of Obstetrics and Gynecology at the Central Hospital in Maputo, Mozambique, were studied June-August 1991.

SUBJECTS

Randomly selected women seeking antenatal care in midtrimester pregnancy (N = 202) were compared with 114 women consecutively entering with clinical signs of midtrimester miscarriage.

RESULTS

Among antenatal care attenders, 37/202 (18.3%), and among women with midtrimester miscarriage, 37/114 (32.5%), had syphilis confirmed with the Treponema pallidum haemagglutination test (p < 0.01). Significant titres of IgM antibodies tended to be more prevalent among women with miscarriage (7.0%) than among women attending antenatal care (4.5%), though the difference only approached statistical significance.

CONCLUSION

The findings suggest a potential association between syphilis seropositivity and midtrimester miscarriage. Present findings justify more extensive studies to establish whether or not recent syphilis infection is a risk factor for midtrimester miscarriage.

The effectiveness of intravaginal misoprostol (Cytotec) in inducing abortion after eleven weeks of pregnancy

At Maputo Central Hospital in Mozambique, intravaginal misoprostol, a PGE2 methyl-analogue, was used by 169 women whose request for interruption of pregnancy had been approved. The drug was used by women who had completed between 12 and 23 weeks of gestation. The initial dose was 800 micrograms, repeated 24 hours later if abortion had not occurred or was not in progress. The treatment was considered a failure when abortion was not advanced by 48 hours after the initial dose, and curettage was performed in all but one of such cases. During the course of the study, the dosage was successively reduced to 600, 400, and 200 micrograms. Abortion was successfully induced in 154 women (91.1 percent); there were 10 failures (5.9 percent), and five women (3.0 percent) dropped out of the study. The mean time from initial dose to abortion was 14.3 hours. No significant association of success rate and time from dosage to expulsion was found with age, parity, previous abortion, or gestational age. Preventive vacuum aspiration of the uterine cavity was carried out on all subjects.

Outcome of teenage pregnancy in Maputo, Mozambique

OBJECTIVE

To evaluate the perinatal outcome of teenage pregnancies in comparison with a population of older, high-risk women.

METHOD

Data about 15,207 high-risk women delivered during 1989 at the Central Hospital of Maputo, Mozambique, were collected retrospectively from the clinical records. Of these women 2185 were less than 19 years old. Frequencies were compared through the chi 2-test or, when required, Fisher's exact test. Odds ratios and 95% confidence intervals were computed.

RESULT

Frequency of operative vaginal deliveries (forceps and/or vacuum extraction), cesarean section rate and low birth rate were significantly higher among women under 19 than in the older ones. Also, maternal mortality and stillbirth rates were greater among teenagers, although the differences were not statistically significant.

CONCLUSION

Among the selected, high-risk hospital population of a developing country young maternal age, both by itself and in association with other risk factors, represents an important predictor of adverse perinatal outcome for mothers and babies. Implications for family planning and reproductive education programs are discussed.

Pregnancy interruption by vaginal misoprostol

A total of 132 pregnant women with average gestational age of 14.2 weeks (range 11-22 weeks) undergoing legal abortion volunteered for a trial utilizing vaginal administration of misoprostol. In 106 women a dose of 800 micrograms was utilized, whilst in 26 women 1,200-1,600 micrograms were given. Nonsurgical expulsion of the fetus was successful in 117 cases (88.6%). Four cases had to be excluded for various social reasons. A total of 11 did not achieve fetal expulsion within 56 h after application of misoprostol. These cases (11/132; 8.3%) were considered failures. Previous reports in the literature of toxicity trials on animals reporting no fetotoxic nor teratogenic effects of misoprostol at doses up to 10,000 micrograms/kg body weight seem to be of no validity in the human since we could demonstrate that almost 80% of pregnancies were interrupted at a dose of 10-15 micrograms/kg body weight. The conclusion is that vaginal administration of this prostaglandin analogue, not requiring cool temperature for storage, is remarkably effective in achieving safe interruption of pregnancy without any significant complications.

Value of perinatal audit in obstetric care in the developing world: a ten-year experience of the Maputo model

A decade of perinatal audit in the Maputo Central Hospital is reviewed with the objective of addressing the potential value of the audit process in monitoring the different constituents of morbidity and mortality in the perinatal period. The perinatal mortality showed a significant but transient change during the observation period 1982-1991, while intrapartum fetal mortality was significantly reduced from 10.9 to 3.9 per thousand (p < 0.0005). Staff members were sensitized towards immediate and long-term effects of implemented surveillance routines by regular feedback of perinatal data on visible wall charts and by weekly conferences. The advantages of a comprehensive audit approach in perinatal medicine comprising both maternal and fetal/infant aspect are underscored. An ethical commitment to nonconfidential straight-forwardness and open-mindedness in critical discussions regarding mismanagement is emphasized for a successful audit strategy.

Perinatal audit of one hundred consecutive vacuum extractions in Maputo

The extraordinary demands on obstetrical services that prevail in many developing countries necessitate critical reviews of existing norms for obstetrical management. Vacuum extractions were studied in this context as a part of the regular perinatal audit carried out at the Maputo Central Hospital, the only hospital in Maputo with emergency surgery catering to the 43,000 annual deliveries. Extractions performed with the fetal head above the ischiatic spines were associated with a high number of complications and an 81% risk of neonatal asphyxia and also with a number of severe neonatal traumas. The risk of intracranial hemorrhage tended to be higher with extractions of fetuses with the head at or above the ischiatic spines, particularly when there was concomitant intrapartum asphyxia. It is concluded that a frequent perinatal audit of selected risk deliveries is a useful monitoring tool for examining prevailing indications for various obstetric interventions.

[Schistosomiasis: possible cause of ectopic pregnancy. Four clinical cases]

The Authors describe 4 cases of ectopic pregnancy associated with foci of schistosomiasis and point out the relevance of mass screening on urine, stool and vaginal secretions in those areas where schistosomiasis is endemic and frequent the involvement of female genital tract. Utilization of laparoscopy in all cases where as adnexal mass and/or a history of unexplained infertility is found is finally advocated.

[The influence of lunar phases on the frequency of deliveries]

Common tradition encourages the belief that deliveries take place more frequently during some phases than others. It is known that multiple factors (also medical) may influence birth timing postponing or anticipating it. To verify the veracity of this belief, we studied the frequency of home deliveries of Maputo (Mozambique), without any medical assistance according to lunar cycle. A study of 5226 births in 37 lunar cycles didn't show a significative increase of deliveries during specific lunar phases and week days. The same result has been achieved expanding the examination period to 2 days before and after lunar phase. Therefore, on the basis of this study, the hypothesis that lunar phase may influence the process of birth is disproved.

Extrauterine pregnancy in Mozambique

Epidemiologic, clinical and management information was collected from the case histories of 103 women operated on for an extrauterine pregnancy at the Department of Obstetrics and Gynaecology of the Central Hospital in Maputo (Mozambique) from April 1st, 1987 to March 31st, 1988. We observed a decline in extrauterine pregnancies (9.76%), an association of pelvic schistosomiasis (3.9%), and a high percentage of women with ruptured tubes and subsequent hemoperitoneum (75.7%).

Outcomes of twin pregnancies at the Hospital Central of Maputo: retrospective study of 315 consecutive twin deliveries, January 1-September 30, 1987

Between January 1 and September 30, 1987, 315 (3.53% of total deliveries) consecutive twin gestations were delivered at the Department of Obstetrics and Gynaecology of the Hospital Central in Maputo Mozambique. There were 42 perinatal deaths (stillbirths + early neonatal deaths) among the 630 infants born (66.7 per 1000) and 21 early neonatal deaths among the 609 live-born infants (34.5 per 1000). Early neonatal death frequency was higher among second twins than among first ones (50 per 1000 versus 19.7 per 1000), but the difference did not reach statistical significance. Most of the second twin early neonatal deaths (11/15) were associated with a breech vaginal delivery of the first twin.