Tranexamic Acid for Postpartum Hemorrhage Treatment in Low-Resource Settings: A Rapid Scoping Review

Tranexamic acid (TXA) effectively reduces bleeding in women with postpartum hemorrhage (PPH) in hospital settings. To guide policies and practices, this rapid scoping review undertaken by two reviewers aimed to examine how TXA is utilized in lower-level maternity care settings in low-resource settings. Articles were searched in EMBASE, MEDLINE, Emcare, the Maternity and Infant Care Database, the Joanna Briggs Institute Evidence-Based Practice Database, and the Cochrane Library from January 2011 to September 2021. We included non-randomized and randomized research looking at the feasibility, acceptability, and health system implications in low- and lower-middle-income countries. Relevant information was retrieved using pre-tested forms. Findings were descriptively synthesized. Out of 129 identified citations, 23 records were eligible for inclusion, including 20 TXA effectiveness studies, two economic evaluations, and one mortality modeling. Except for the latter, all the studies were conducted in lower-middle-income countries and most occurred in tertiary referral hospitals. When compared to placebo or other medications, TXA was found effective in both treating and preventing PPH during vaginal and cesarean delivery. If made available in home and clinic settings, it can reduce PPH-related mortality. TXA could be cost-effective when used with non-surgical interventions to treat refractory PPH. Capacity building of service providers appears to need time-intensive training and supportive monitoring. No studies were exploring TXA acceptability from the standpoint of providers, as well as the implications for health governance and information systems. There is a scarcity of information on how to prepare the health system and services to incorporate TXA in lower-level maternity care facilities in low-resource settings. Implementation research is critically needed to assist practitioners and decision-makers in establishing a TXA-inclusive PPH treatment package to reduce PPH-related death and disability.

Implementing Heat-Stable Carbetocin for Postpartum Haemorrhage Prevention in Low-Resource Settings: A Rapid Scoping Review

Heat-stable carbetocin (HSC), a long-acting oxytocin analogue that does not require cold-chain transportation and storage, is effective in preventing postpartum haemorrhage (PPH) in vaginal and caesarean deliveries in tertiary-care settings. We aimed to identify literature documenting how it is implemented in resource-limited and lower-level maternity care settings to inform policies and practices that enable its introduction in these contexts. A rapid scoping review was conducted with an 8-week timeframe by two reviewers. MEDLINE, EMBASE, Emcare, the Joanna Briggs Institute Evidence-Based Practice Database, the Maternity and Infant Care Database, and the Cochrane Library were searched for publications in English, French, and Spanish from January 2011 to September 2021. Randomized and non-randomized studies examining the feasibility, acceptability, and health system considerations in low-income and lower-middle-income countries were included. Relevant data were extracted using pretested forms, and results were synthesized descriptively. The search identified 62 citations, of which 12 met the eligibility criteria. The review did not retrieve studies focusing on acceptability and health system considerations to inform HSC implementation in low-resource settings. There were no studies located in rural or lower-level maternity settings. Two economic evaluations concluded that HSC is not feasible in terms of cost-effectiveness in lower-middle-income economies with private sector pricing, and a third one found superior care costs in births with PPH than without. The other nine studies focused on demonstrating HSC effectiveness for PPH prevention in tertiary hospital settings. There is a lack of evidence on the feasibility (beyond cost-effectiveness), acceptability, and health system considerations related to implementing HSC in resource-constrained and lower-level maternity facilities. Further implementation research is needed to help decision-makers and practitioners offer an HSC-inclusive intervention package to prevent excessive bleeding among pregnant women living in settings where oxytocin is not available or of dubious quality.

Promoting adolescent health through integrated human papillomavirus vaccination programs: The experience of Togo

The introduction of the Human papillomavirus (HPV) vaccine has shown potential to not only prevent cervical cancer but also drive adolescents' access to other health care services, even in low-income countries. Few studies have been conducted to date to identify best practices and estimate the acceptance, operational challenges and benefits of including broader adolescent health interventions into immunization efforts, knowledge which is essential to supporting widespread integration. In this paper we review the efforts undertaken by the government of Togo to integrate adolescent health programming with the HPV vaccination roll out. With the support of partners (GAVI, WHO, UNFPA and UNICEF), the country successfully completed, in 2017, two years of an HPV vaccine demonstration project, which entailed vaccinating 10-year-old girls against HPV in two selected districts of the country and integrating a health education component focused on puberty education / menstrual hygiene and hand washing practice. Our study is a post-implementation program evaluation, using mixed methods to assess key questions of feasibility and acceptability of an integrated adolescent package of care. It showed that the HPV vaccination in conjunction with the health education sessions was well received by the majority of health care providers, teachers and parents. Our study confirmed that in Togo it proved feasible to combine education and HPV vaccination in school-based service delivery. However, more operational research is neded to understand how to increase the impact and sustainability of the co-delivery of interventions. We did not analyze the health impact and cost implications of the intervention, which will be an important consideration for scaling up such integration efforts alongside routine immunization.

Categorising interventions to levels of inpatient care for small and sick newborns: Findings from a global survey

Background

In 2017, 2.5 million newborns died, mainly from prematurity, infections, and intrapartum events. Preventing these deaths requires health systems to provide routine and emergency care at birth, and quality inpatient care for small and sick newborns. Defined levels of emergency obstetric care (EmOC) and standardised measurement of “signal functions” has improved tracking of maternal care in low- and middle-income countries (LMICs). Levels of newborn care, particularly for small and sick newborns, and associated signal functions are still not consistently defined or tracked.

Methods

Between November 2016-November 2017, we conducted an online survey of professionals working in maternal and newborn health. We asked respondents to categorise 18 clinical care interventions that could act as potential signal functions for small and sick newborns to 3 levels of care they thought were appropriate for health systems in LMICs to provide: “routine care at birth”, “special care” and “intensive care”. We calculated the percentage of respondents that classified each intervention at each level of care and stratified responses to look at variation by respondent characteristics.

Results

Six interventions were classified to specific levels by more than 50% of respondents as “routine care at birth,” three interventions as “special care” and one as “intensive care”. Eight interventions were borderline between these care levels. Responses were more consistent for interventions with relevant WHO clinical care guidelines while more variation in respondents’ classification was observed in complex interventions that lack standards or guidelines. Respondents with experience in lower-income settings were more likely to assign a higher level of care for more complex interventions.

Conclusions

Results were consistent with known challenges of scaling up inpatient care in lower-income settings and underline the importance of comprehensive guidelines and standards for inpatient care. Further work is needed to develop a shortlist of newborn signal functions aligned with emergency obstetric care levels to track universal health coverage for mothers and their newborns.

Monitoring and evaluation of disaster response efforts undertaken by local health departments: a rapid realist review

Background

Local health departments are often at the forefront of a disaster response, attending to the immediate trauma inflicted by the disaster and also the long term health consequences. As the frequency and severity of disasters are projected to rise, monitoring and evaluation (M&E) efforts are critical to help local health departments consolidate past experiences and improve future response efforts. Local health departments often conduct M&E work post disaster, however, many of these efforts fail to improve response procedures.

Methods

We undertook a rapid realist review (RRR) to examine why M&E efforts undertaken by local health departments do not always result in improved disaster response efforts. We aimed to complement existing frameworks by focusing on the most basic and pragmatic steps of a M&E cycle targeted towards continuous system improvements. For these purposes, we developed a theoretical framework that draws on the quality improvement literature to ‘frame’ the steps in the M&E cycle. This framework encompassed a M&E cycle involving three stages (i.e., document and assess, disseminate and implement) that must be sequentially completed to learn from past experiences and improve future disaster response efforts. We used this framework to guide our examination of the literature and to identify any context-mechanism-outcome (CMO) configurations which describe how M&E may be constrained or enabled at each stage of the M&E cycle.

Results

This RRR found a number of explanatory CMO configurations that provide valuable insights into some of the considerations that should be made when using M&E to improve future disaster response efforts. Firstly, to support the accurate documentation and assessment of a disaster response, local health departments should consider how they can: establish a culture of learning within health departments; use embedded training methods; or facilitate external partnerships. Secondly, to enhance the widespread dissemination of lessons learned and facilitate inter-agency learning, evaluation reports should use standardised formats and terminology. Lastly, to increase commitment to improvement processes, local health department leaders should possess positive leadership attributes and encourage shared decision making.

Conclusion

This study is among the first to conduct a synthesis of the CMO configurations which facilitate or hinder M&E efforts aimed at improving future disaster responses. It makes a significant contribution to the disaster literature and provides an evidence base that can be used to provide pragmatic guidance for improving M&E efforts of local health departments.

Trial registration

PROSPERO 2015:CRD42015023526.

The Impact of Healthcare Insurance on the Utilisation of Facility-Based Delivery for Childbirth in the Philippines

Objectives

In recent years, the government of the Philippines embarked upon an ambitious Universal Health Care program, underpinned by the rapid scale-up of subsidized insurance coverage for poor and vulnerable populations. With a view of reducing the stubbornly high maternal mortality rates in the country, the program has a strong focus on maternal health services and is supported by a national policy of universal facility-based delivery (FBD). In this study, we examine the impact that recent reforms expanding health insurance coverage have had on FBD.

Results

Data from the most recent Philippines 2013 Demographic Health Survey was employed. This study applies quasi-experimental methods using propensity scores along with alternative matching techniques and weighted regression to control for self-selection and investigate the impact of health insurance on the utilization of FBD.

Findings

Our findings reveal that the likelihood of FBD for women who are insured is between 5 to 10 percent higher than for those without insurance. The impact of health insurance is more pronounced amongst rural and poor women for whom insurance leads to a 9 to 11 per cent higher likelihood of FBD.

Conclusions

We conclude that increasing health insurance coverage is likely to be an effective approach to increase women’s access to FBD. Our findings suggest that when such coverage is subsidized, as it is the case in the Philippines, women from poor and rural populations are likely to benefit the most.

Utilisation of health services and the poor: deconstructing wealth-based differences in facility-based delivery in the Philippines

BACKGROUND

Despite achieving some success, wealth-related disparities in the utilisation of maternal and child health services persist in the Philippines. The aim of this study is to decompose the principal factors driving the wealth-based utilisation gap.

METHODS

Using national representative data from the 2013 Philippines Demographic and Health Survey, we examine the extent overall differences in the utilisation of maternal health services can be explained by observable factors. We apply nonlinear Blinder-Oaxaca-type decomposition methods to quantify the effect of differences in measurable characteristics on the wealth-based coverage gap in facility-based delivery.

RESULTS

The mean coverage of facility-based deliveries was respectively 41.1 % and 74.6 % for poor and non-poor households. Between 67 and 69 % of the wealth-based coverage gap was explained by differences in observed characteristics. After controlling for factors characterising the socioeconomic status of the household (i.e. the mothers' and her partners' education and occupation), the birth order of the child was the major factor contributing to the disparity. Mothers' religion and the subjective distance to the health facility were also noteworthy.

CONCLUSIONS

This study has found moderate wealth-based disparities in the utilisation of institutional delivery in the Philippines. The results confirm the importance of recent efforts made by the Philippine government to implement equitable, pro-poor focused health programs in the most deprived geographic areas of the country. The importance of addressing the social determinants of health, particularly education, as well as developing and implementing effective strategies to encourage institutional delivery for higher order births, should be prioritised.

Overcoming Stagnation in the Levels and Distribution of Child Mortality: The Case of the Philippines

Background

Health-related within-country inequalities continue to be a matter of great interest and concern to both policy makers and researchers. This study aims to assess the level and the distribution of child mortality outcomes in the Philippines across geographical and socioeconomic indicators.

Methodology

Data on 159,130 children ever borne were analysed from five waves of the Philippine Demographic and Health Survey. Direct estimation was used to construct under-five and neonatal mortality rates for the period 1980–2013. Rate differences and ratios, and where possible, slope and relative indices of inequality were calculated to measure disparities on absolute and relative scales. Stratification was undertaken by levels of rural/urban location, island groups and household wealth.

Findings

National under-five and neonatal mortality rates have shown considerable albeit differential reductions since 1980. Recently released data suggests that neonatal mortality has declined following a period of stagnation. Declines in under-five mortality have been accompanied by decreases in wealth and geography-related absolute inequalities. However, relative inequalities for the same markers have remained stable over time. For neonates, mixed evidence suggests that absolute and relative inequalities have remained stable or may have risen.

Conclusion

In addition to continued reductions in under-five mortality, new data suggests that the Philippines have achieved success in addressing the commonly observed stagnated trend in neonatal mortality. This success has been driven by economic improvement since 2006 as well as efforts to implement a nationwide universal health care campaign. Yet, such patterns, nonetheless, accorded with persistent inequalities, particularly on a relative scale. A continued focus on addressing universal coverage, the influence of decentralisation and armed conflict, and issues along the continuum of care is advocated.

Cord blood chemerin: differential effects of gestational diabetes mellitus and maternal obesity

OBJECTIVE

Chemerin is a novel adipokine implicated in inflammation and obesity. We hypothesized that foetal chemerin would be elevated in gestational diabetes mellitus (GDM) and correlate with foetal and maternal adiposity.

DESIGN

Observational, longitudinal study.

SUBJECTS AND MEASUREMENTS

Foetal chemerin was measured separately in arterial and venous cord blood of 30 infants born to mothers with (n = 15) and without GDM (n = 15), in their mothers in early third trimester and at delivery and in amniotic fluid (week 32) of women with GDM. Expression of chemerin and its receptor in human foetal tissues commercially available and in placental cells was measured by quantitative PCR. Associations between foetal and maternal anthropometric and metabolic variables were assessed in multivariate regression models.

RESULTS

In GDM, foetal arterial but not venous cord blood chemerin levels were elevated by about 60% (P < 0·05). Venous cord blood chemerin was higher in infants of obese women (P < 0·01). In multivariate analyses, neither amniotic fluid nor cord blood chemerin levels correlated with birth weight or ponderal index. Both arterial and venous chemerin levels were related to maternal chemerin at birth, and arterial chemerin was associated with GDM status in addition. Maternal levels were unaltered in GDM, but higher in maternal obesity. Foetal liver produces fourfold more chemerin mRNA than other foetal tissues, whereas its receptor prevails in spleen.

CONCLUSIONS

Based on multivariate analyses, foetal growth appears unrelated to foetal chemerin. Maternal obesity and GDM have differential effects on foetal chemerin levels. Site of major production (liver) and action (spleen) differ in human foetal tissues.

Matching diagnosis and management of diabetes in pregnancy to local priorities and resources: an international approach

The International Association of the Diabetes and Pregnancy Study Groups' (IADPSG) criteria for the diagnosis and classification of hyperglycemia in pregnancy are described and application of these in differing healthcare contexts on a worldwide basis is reported. Existing local protocols and known epidemiologic and clinical data regarding the detection and management of overt diabetes and gestational diabetes in the context of human pregnancy are considered. Although the IADPSG criteria are uniform, their introduction poses a variety of practical and technical challenges in differing healthcare contexts, both between and within countries. Knowledge of local factors will be vital in the implementation of the new guidelines and will require extensive liaison with local clinical and health policy groups. Resource availability will be critical in determining the type of treatment available in this context. The IADPSG criteria offer an important opportunity for a uniform approach to diabetes in pregnancy. Scaled implementation of these criteria adapted to a variety of local healthcare contexts should improve both research endeavors and patient care.

Quality of caesarean delivery services and documentation in first-line referral facilities in Afghanistan: a chart review

Background

Increasing appropriate use and documentation of caesarean section (CS) has the potential to decrease maternal and perinatal mortality in settings with low CS rates. We analyzed data collected as part of a comprehensive needs assessment of emergency obstetric and newborn care (EmONC) facilities in Afghanistan to gain a greater understanding of the clinical indications, timeliness, and outcomes of CS deliveries.

Methods

Records were reviewed at 78 government health facilities expected to function as EmONC providers that were located in secure areas of the country. Information was collected on the three most recent CS deliveries in the preceding 12 months at facilities with at least one CS delivery in the preceding three months. After excluding 16 facilities with no recent CS deliveries, the sample includes 173 CS deliveries at 62 facilities.

Results

No CS deliveries were performed in the previous three months at 21% of facilities surveyed; all of these were lower-level facilities. Most CS deliveries (88%) were classified as emergencies, and only 12% were referrals from another facility. General anesthesia was used in 62% of cases, and spinal or epidural anesthesia in 34%. Only 28% of cases were managed with a partograph. Surgery began less than one hour after the decision for a CS delivery in just 30% of emergency cases. Among the 173 cases, 27 maternal deaths, 28 stillbirths, and 3 early neonatal deaths were documented. In cases of maternal and fetal death, the most common indications for CS delivery were placenta praevia or abruption and malpresentation. In 62% of maternal deaths, the fetus was stillborn or died shortly after birth. In 48% of stillbirths, the fetus had a normal heart rate at the last check. Information on partograph use was missing in 38% of cases, information on parity missing in 23% of cases and indications for cesareans missing in 9%.

Conclusions

Timely referral within and to EmONC facilities would decrease the proportion of CS deliveries that develop to emergency status. While the substantial mortality associated with CS in Afghanistan may be partly due to women coming late for obstetric care, efforts to increase the availability and utilization of CS must also focus on improving the quality of care to reduce mortality. Key goals should be encouraging use of partographs and improving decision-making and documentation around CS deliveries.

Management of the placenta in advanced abdominal pregnancies at an East african tertiary referral center

OBJECTIVE

To review the diagnosis and treatment of 9 advanced abdominal pregnancies in a low-resource setting of a developing country, focusing on the management of the placenta.

METHODS

Abdominal pregnancies occurring between 1999 and 2007 were identified from hospital records in Tanzania. All patients were followed up for a median of 6 months after surgery (range 5-9 months).

RESULTS

At the time of diagnosis, pregnancies were between 20 and 42 weeks of gestation (median 27 weeks). All 9 mothers survived the abdominal pregnancy, and 7 fetuses died before delivery. The placenta was left completely in situ in 5 of the nine cases.

CONCLUSIONS

Abdominal pregnancy is often detected rather late in low-resource settings compared with higher-resource settings. We suggest that in the described low-resource setting where red blood cell transfusions are not always readily available, the placenta may be left in situ after removal of the fetus.

Comparison of obstetrical risk in adolescent primiparas at tertiary referral centres in Tanzania and Austria

PURPOSE

Adolescent childbearing is most prevalent in Sub-Saharan Africa. Deliveries in adolescent primiparas at an Austrian and an East African tertiary referral centre were compared to reveal differences in obstetric outcome.

METHODS

A total of 186 primiparas delivering at an age of 17 or less between 1999 and 2005 at the Austrian centre were compared with 209 adolescent primiparas who delivered between 2005 and 2007 at the African centre. The type of delivery and complications were studied.

RESULTS

Adolescent primiparas accounted for 1.2% of the overall obstetric population at the Austrian centre, as compared with 2.3% at the East African centre (p<0.01). When comparing the adolescents' outcome at the Austrian centre with the outcome of 22-27 years old primiparas at the same institution, we noted that the rates of adverse obstetric outcomes were higher among the adult group. However, at the East African centre the opposite was observed.

CONCLUSIONS

In contrast to the results of Africa, data from Austria show that the obstetric outcome in adolescent pregnancies can be favourable. However, socioeconomic considerations have to be taken into account. Education and health knowledge seem critical for young females particularly in low-resource settings like East Africa.

Placental growth hormone, fetal growth and the IGF axis in normal and diabetic pregnancy

Gestational diabetes mellitus (GDM) and pre-gestational diabetes are known to pose risks to the mother and developing fetus, often related to abnormal fetal growth. One potential mediator of maternal effects on fetal growth is Placental Growth Hormone (PGH). PGH is produced by the syncytiotrophoblast and found predominantly in the maternal circulation. It progressively replaces pituitary growth hormone (hGH) in the human maternal circulation from mid-gestation onwards, peaking towards term. PGH appears to be an important potential regulator of maternal insulin resistance in human pregnancy and may influence fetal growth both by modifying substrate availability and through paracrine actions in the placental bed. The details of PGH regulation remain relatively poorly understood, but current evidence does suggest a central role in growth restricted pregnancies. There is currently less evidence of a pathophysiologic role in production of the macrosomic fetal phenotype commonly seen in response to hyperglycaemia, although our recent in vitro studies do raise the possibility of feto-placental feedback as a mechanism of growth modulation.

Delivery of a live newborn in a triplet pregnancy complicated by preeclampsia after intrauterine demise of two and expulsion of one triplet: a case report

Delayed interval delivery in twin pregnancies is an unusual occurrence, even more so in triplet pregnancies. We report on a delayed interval delivery in a dichorionic triamniotic triplet pregnancy after in vitro fertilization (IVF). Because of severe twin to twin transfusion syndrome (TTTS), two fetuses demised at 22 weeks of gestation. One of the two fetuses spontaneously aborted at 25 weeks of gestation. The remaining live fetus and the second demised fetus were delivered by cesarean section 9 weeks later because of the occurrence of preeclampsia. This case indicates that delayed interval delivery in triplets is possible and that preeclampsia can occur after intrauterine demise of two fetuses.

[Gestational diabetes in East Africa: a mostly disregarded disease?]

The majority of all deliveries worldwide take place in the so-called developing world. Most recent epidemiological data have shown that the number of cases of type 2 diabetes mellitus and diabetes in pregnancy is steadily increasing worldwide. However, little is known about the prevalence of gestational diabetes in East Africa. Intrauterine exposure to the metabolic environment of maternal diabetes increases the risk of altered glucose homeostasis in the offspring, producing a higher prevalence of gestational diabetes mellitus in the next generation. Our preliminary results from an East African tertiary referral center show that in the year 2007 3.1% of all newborns had a birth weight of more than 4,000 g (mean 4,300 g, range 4,000- 5,600 g). During the same time period, the mean birth weight in the general population was only 3,046 g (range 600-3,200 g). Hence, personal experience in East Africa has convinced the authors that diabetes in pregnancy is grossly neglected. Besides infectious diseases like HIV/AIDS, the African continent is increasingly facing metabolic diseases such as type 2 diabetes mellitus and diabetes in pregnancy.

[The dilemma of diabetes in pregnancy: worldwide differences in diagnosis and management]

OBJECTIVE

Type 1 and type 2 diabetes in pregnancy as well as gestational diabetes mellitus (GDM) pose major risks to mother and fetus. We assessed to which extent two obstetric centers on two different continents coincide in their management of diabetes in pregnancy.

METHODS

Within the scope of research activities between the Obstetric Department of the Medical University of Graz, Austria, and the Centre of Obstetric Medicine at the Mater Misericordiae Mothers' Hospital in Brisbane, Australia, current practices among the two obstetric centers in Austria and Australia were assessed.

RESULTS

The management of type 1 and type 2 diabetes in pregnancy was almost identical, whereas major differences were found in the management of GDM.

CONCLUSION

Standardization of screening methods in diabetes in pregnancy remains challenging. National and international consensus has yet to be achieved in order to put a hold to the 'diabetic epidemic' we are going to face in the future.

[Diagnosis and treatment of gestational diabetes--the Graz model]

OBJECTIVE

Despite the fact that gestational diabetes mellitus (GDM) is a common problem in pregnancy, a good proportion of cases of GDM is either not recognized or treated only inadequately. The main problems are a general trend of underestimating the risk of morbidity, the lack of integration into obstetric care regulations and heterogeneous guidelines regarding the screening and treatment of GDM.

METHODS

For decades, the Graz concept of diagnosis and therapy of GDM has offered a 1-step general screening of all pregnant women between gestational weeks 24 and 28; in addition, the option of measuring the amniotic fluid insulin concentration via amniocentesis at gestational weeks 31-32 allows to detect hyperinsulinemic fetuses who represent an obstetric high-risk group.

CONCLUSION

Lower cutoff levels in the oral glucose challenge test as well as the measurement of amniotic fluid insulin concentrations, which have been implemented in the Graz model for a long time, offer a higher detection rate of GDM and allow a targeted therapy of fetuses at high risk. Screening and therapy of GDM are cost-effective instruments to improve obstetric outcomes, therefore obligatory screening and treatment for GDM should be recommended emphatically.

Adolescent primiparas: changes in obstetrical risk between 1983-1987 and 1999-2005

AIMS

Teenage pregnancies have always been considered at increased risk for obstetric complications. Deliveries in adolescent primiparas in the 5-year time periods 1983-1987 and 1999-2005 were compared against each other, the general population and against primiparas aged 20-29 years in order to reveal trends and differences in obstetric outcome.

METHODS

A total of 186 primiparas delivering at an age of 17 or less between October 1999 and October 2005 were compared with 353 adolescent primiparas delivered between 1983 and 1987. Type of delivery and complications such as low birthweight, pre-eclampsia, breech presentation and third stage complications were studied.

RESULTS

The percentage of adolescents in the overall obstetric population decreased. The cesarean section rate remained the same in the adolescents while increasing in the general population. Rates of low birthweight and operative vaginal delivery increased in the adolescent group and overall. Third stage complications (abnormally adherent or incomplete placentas) decreased in both groups. There were no intrauterine fetal deaths in adolescent pregnancies in either time period. Other obstetric variables were unchanged in the adolescent as well as in the general population between 1999 and 2005. When comparing the adolescents' outcome with the outcome of the 20-29-year-old primiparas between 1999 and 2005, it was noted that the rates of abstracted obstetric variables were higher in the population of the 20-29-year-olds.

CONCLUSIONS

The obstetric outcome of adolescent pregnancies has remained favorable over the last 18 years. We do not consider adolescence as an obstetrical risk. We suggest that adolescent pregnancy is more a public health issue than a clinical problem.

Gestational diabetes in rural East Africa: a call to action

The number of cases of diabetes worldwide has increased significantly in the last decade. Characteristically, the incidence of gestational diabetes (GDM) reflects the incidence of type 2 diabetes mellitus (T2DM) in the background population, which is a warning that a rapid increase in the incidence is to be expected concomitant with the already observed increase in the incidence of T2DM. Although the majority of all deliveries worldwide take place in the so-called developing world, little is known about the prevalence of diabetes in pregnancy in rural areas of East Africa. Diabetes in pregnancy has effects on prospects for marriage, motherhood, and the role of women in East African society. Furthermore, intrauterine exposure to the metabolic environment of maternal diabetes, or GDM, is associated with increased risk of altered glucose homeostasis in the offspring, beginning in childhood and producing a higher prevalence of GDM in the next generation with all burdens and complications being associated with this disease. It is reasonable to conclude that more newborn infants each year are being exposed to the metabolic environment of diabetes during intrauterine development as a result of changing incidence and demographics of diabetes and pregnancy. We believe that programs and policies have to be established, including organization of the health system to provide care, medicines, and other tools necessary for diabetes in pregnancy management, consideration of accessibility and affordability of care, education for healthcare workers, and education of pregnant and nonpregnant women of reproductive age.

Regulation of placental growth hormone secretion in a human trophoblast model--the effects of hormones and adipokines

Placental growth hormone (PGH) is secreted from the human placental syncytiotrophoblast into the maternal circulation. PGH levels in pregnant women correlate with the birth weight of their offspring. We hypothesized that metabolic regulators may alter PGH secretion. BeWo cells as human trophoblast models were treated for 24, 48, and 72 h with insulin, insulin-like growth factor (IGF)-1, cortisol, ghrelin, leptin and visfatin. Cyclic-adenosinmonophosphate treatment served as positive control. PGH concentrations in culture media were measured. Insulin reduced (p < 0.008; analysis of variance) PGH secretion from BeWo cells after 72 h. No effect was found when treating cells with IGF-1. Cortisol reduced PGH secretion after 48 h (p < 0.00118; analysis of variance) and 72 h (p < 0.015). Leptin and ghrelin both suppressed (p < 0.027 and p < 0.017, paired t test) whereas visfatin increased (p < 0.014, paired t test) PGH secretion at 72 h. Cyclic adenosinmonophosphate increased (p < 0.003) PGH secretion at 72 h. Our results indicate that in vitro PGH secretion by BeWo cells is regulated by hormonal factors and adipokines. We speculate on the existence of a maternal-placental regulatory loop, in which elevated insulin and leptin levels might down-regulate PGH secretion.

External cephalic version in singleton pregnancies at term: a retrospective analysis

BACKGROUND/AIMS

The outcomes of external cephalic versions (ECV) performed at the University Hospital Graz in Austria were analyzed to determine to what extent the cesarean section rate can be reduced by an ECV program.

METHODS

All women who were admitted to the hospital with breech presentation at 37 weeks or later and underwent an attempt of ECV between 2002 and 2004 were recorded and retrospectively analyzed.

RESULTS

Of 136 cases 51% were successful. Among these, the cesarean section rate was 13%. The cesarean section rate among all not successful cases was 82%. Of the successful cases which remained in cephalic presentation 92% were delivered vaginally and 5 were delivered by cesarean section. The cesarean section rate (8%) was slightly higher than in fetuses with cephalic presentation observed at the onset of contractions in 2004 (5.9%). No maternal or fetal complications or side effects occurred.

CONCLUSION

Successful ECV beyond 37 weeks of gestation significantly decreases the cesarean section rate. ECV reduces the cesarean section rate among breech positions and decreases the risks related to breech delivery, when correctly performed and adequately monitored. ECV reduces higher costs connected with cesarean section.

Management of diabetes in pregnancy: comparison of guidelines with current practice at Austrian and Australian obstetric center

AIM

To compare Austrian and Australian national guidelines for gestational and pre-gestational diabetes and estimate the level to which physicians comply with their country's guidelines.

METHODS

Austrian (ODG, Austrian Diabetes Society) and Australian guidelines (ADIPS, Australasian Diabetes in Pregnancy Society) for the treatment of gestational diabetes and pre-gestational diabetes were systematically reviewed. Current practices in two obstetric centers in Austria and Australia were assessed by interviewing key stakeholders through questionnaires assessing different components of diabetes care. For gestational diabetes, these components were screening, abnormal oral glucose tolerance test values (mmol/L), abnormal values for diagnosis, further management when abnormal values are detected, monitoring/glucose targets (mmol/L), further management and indications for insulin therapy, route and timing of delivery, and postpartum management and counseling. For pre-gestational diabetes, the components were management during the preconceptional period, glucose target values, medical surveillance, obstetric surveillance, medication used, route and timing of delivery, and postpartum management and counseling.

RESULTS

More variation was found in the management of gestational than pre-gestational diabetes. There were differences in oral glucose tolerance test and cut-off levels for diagnosing gestational diabetes in both centers and guidelines. Australian guidelines recommended two-stage screening for gestational diabetes, while Austrian guidelines recommended one-stage screening. At the Austrian obstetric center, amniocentesis was recommended for determining the start of insulin treatment in pregnant women with gestational diabetes. This approach was neither used at the Australian obstetric center nor recommended by any of the two guidelines.

CONCLUSION

Our study showed that it was difficult to standardize screening criteria and diagnostic methods for gestational and pre-gestational diabetes. National and international consensus has yet to be achieved in the management of diabetes in pregnancy.

Lessons learned from four advanced abdominal pregnancies at an East African Health Center

AIMS

To analyze diagnosis and treatment of four advanced abdominal pregnancies in a low-resource setting of a developing country.

METHODS

Extrauterine pregnancies occurring between 1997 and 2003 were identified from hospital records of the Mikumi Health Center in Tanzania/East Africa.

RESULTS

A total of 45 extrauterine pregnancies were diagnosed four of which were advanced and located in the abdominal cavity. At the time of diagnosis, pregnancies were at 33, 34, 36 and 39 weeks of gestation, respectively. All four mothers survived but three of four fetuses died. One child is alive and well three years after delivery.

CONCLUSION

Abdominal pregnancy is rather difficult to detect in a low-resource setting of a developing country. Persistent abdominal pain and tenderness, as well as fetal movements in the upper abdomen associated with abnormal fetal lie, may lead to its diagnosis. Localizing the fetal heart sounds in the maternal epigastrium especially in patients with abdominal pain may also be helpful in diagnosing an abdominal pregnancy. In addition, the lack of cervical changes or a displaced cervix should lead to the suspicion of an abdominal pregnancy.

Impact of adolescent pregnancy on the future life of young mothers in terms of social, familial, and educational changes

PURPOSE

We analyze the impact of adolescent pregnancy in terms of social, familial, and educational changes during the subsequent years.

METHODS

Study participants included all adolescents delivering at an age of 17 years or less within a time frame of 5 years. A telephone interview was performed by using 16 self-developed questions as well as a well-recognized questionnaire on Life Satisfaction (FLZ(M)-A). Out of these 186 adolescents, 131 (70%) adolescents were available for the study. The adolescents were split in two study subsamples: 0-2.5 years after delivery and 2.5-5 years after delivery.

RESULTS

We found significant differences concerning relationship/partner, education/educational level, employment status, means of subsistence, person in a position of trust, close friends and current contraceptive use. Apart from the domain "leisure time/hobbies" study participants were more satisfied compared with a population reference group of the same age.

CONCLUSION

Our study did not support the common assumption that adolescent pregnancy may be a disadvantage for young women. In our study a considerable number does achieve a higher level of education. Furthermore we have shown that adolescents are more satisfied in certain areas of life compared with a population reference group.

Does a change in obstetric management influence the incidence of traumatic birth lesions in mature, otherwise healthy newborn infants?

AIM

The incidence of lesions due to birth trauma can be generally regarded as a characteristic of obstetric management; since obstetric management has changed through the years, one might expect a decrease or increase of lesions due to birth trauma in mature newborn infants.

METHODS

In a retrospective study, the incidence of lesions due to birth trauma was recorded in the year 2000. In 1989, an identical study had already been carried out in the same department, employing the same criteria. The new findings were compared with the historical data.

RESULTS

In the year 1989 24.6% and in 2000 13.2% showed lesions due to obstetric trauma. The episiotomy rate and lesions due to birth trauma had significantly decreased. A decline regarding the traumas per se was noticed in caput succedaneum traumas, in hematomas due to birth trauma and in clavicle fracture. The cesarean section rate among the study group increased. The cesarean section rate among the traumatized newborns decreased.

CONCLUSION

Episiotomy does not prevent newborns from traumatic lesions. Gestational age and birthweight have not significantly changed throughout the years; therefore an increase in the cesarean section rate must have contributed to the decrease of birth traumas. Even during abdominal operative delivery, obstetric traumas in newborns do occur. However, an increase in cesarean sections alone can not thoroughly explain the reduction of birth lesion among newborns. Improvement in prenatal diagnostic tools and procedures, respectively, and a goal-oriented use of labor induction might also play a major role.

Lessons learned from maternal deaths at an East African health center

AIMS

To analyze maternal deaths occurring at the Mikumi Health Center in Tanzania, East Africa, to discuss causes for the high maternal mortality rate at the Health Center, and to define possible strategies for the reduction of maternal deaths.

METHODS

Between 2002 and 2003, a total of nine maternal deaths were identified and analyzed from hospital records of the East-African Mikumi Health Center.

RESULTS

During the two-year period, the total number of deliveries was 977 including two maternal deaths during pregnancy and seven deaths during labor or postpartum (0.7% of total deliveries). The maternal mortality ratio (MMR) was 921 per 100,000 live births. The maternal average age was 27 years (range 18-37). The average interval between the first contact with the Health Center and maternal death was 3.5 days.

CONCLUSION

The main cause for maternal complications and subsequent deaths might have been the patient's delayed presentation at the Health Center. Aggravating circumstances such as long distance from the health services and hospital fees hinder patients from a timely and eventually life-saving presentation. The womens' low educational level affects their health as well as their nutritional state and thus increases the maternal death rate. Strategies to prevent maternal deaths at the Mikumi Health Center include measures to raise awareness about consequences of poor maternal health, to improve general education especially for young women, to increase the number of professional birth attendants in the region, to improve family planning services and sexual education with special reference to HIV/AIDS. Additionally, improvement of the first referral facilities around the Mikumi Health Center according to the "essential obstetric functions" recommended by the WHO seems crucial.

In vivo characterization of the mechanics of human uterine cervices

The uterine cervix has to provide mechanical resistance to ensure a normal development of the fetus. This is guaranteed by the composition of its extracellular matrix, which functions as a fiber-reinforced composite. At term a complex remodeling process allows the cervical canal to open for birth. This remodeling is achieved by changes in the quality and quantity of collagen fibers and ground substance and their interplay, which influences the biomechanical behavior of the cervix but also contributes to pathologic conditions such as cervical incompetence (CI). We start by reviewing the anatomy and histological composition of the human cervix, and discuss its physiologic function and pathologic condition in pregnancy including biomechanical aspects. Established diagnostic methods on the cervix (palpation, endovaginal ultrasound) used in clinics as well as methods for assessment of cervical consistency (light-induced fluorescence, electrical current, and impedance) are discussed. We show the first clinical application of an aspiration device, which allows in vivo testing of the biomechanical properties of the cervix with the aim to establish the physiological biomechanical changes throughout gestation and to detect pregnant women at risk for CI. In a pilot study on nonpregnant cervices before and after hysterectomy we found no considerable difference in the biomechanical response between in vivo and ex vivo. An outlook on further clinical applications during pregnancy is presented.

Delivery of a healthy twin after intrauterine demise and expulsion of a first twin

We report on a diamniotic-dichorionic twin pregnancy after in vitro fertilization. The first twin was diagnosed with Down syndrome and spontaneously aborted at 24 weeks of gestation after intrauterine death at week 18. The second healthy twin was delivered by cesarean section 11 weeks later. We discuss management aspects and review the literature.