The Perinatal Conference are held under the auspices of the Department of Obstetrics and Gynaecology, University of Pretoria and sponsored by Abbott Laboratories SA (Pty) Ltd
Editor's note:
An editorial board was appointed to look at the papers in this year's Proceedings. Where there were marked errors in the papers these were referred back to the author for correction. If, however, these were not corrected the paper has been printed in its original form. The editors thus accept no responsibility for any mistakes found. if corrections were suggested by the editorial board and these did not in any way affect the meanings intended in the paper, these changes were made without contacting the author. We apologise if this causes offence but, in view of the amount of administrative work involved in contacting the relevant authors, it was felt this was the easiest course to follow.
Table of Contents
ECLAMPSIA AT HARARE MATERNITY HOSPITAL: DETERMINANTS OF MATERNAL OUTCOME. Majoko F
MATERNAL MORTALITY AND SEVERE MORBIDITY ASSOCIATED WITH HYPERTENSION IN PREGNANCY. Buchmann EJ
AUTOMATED BLOOD PRESSURE MEASUREMENT IN THE ASSESSMENT OF METHYLDOPA THERAPY IN SEVERE PRE-ECLAMPSIA. Steyn DW
HELLP SYNDROME IN TYGERBERG HOSPITAL. Du Preez JP
AN HIV/AIDS SUPPLEMENT TO PEP. Woods D
DEVELOPING AND IMPLEMENTING KANGAROO MOTHER CARE (KMC) PRACTICE AT WITBANK HOSPITAL, MPUMALANGA (PHASE I).
Onyari S
PREGNANCY OUTCOME IN PATIENTS WITH CLINICALLY INCREASED MIDTRIMESTER DIASTOLIC BLOOD PRESSURE WHO RECEIVED ROUTINE ANTENATAL CARE. Carstens MH
COMPANIONSHIP DURING LABOUR (VIDEO). Huxtable L
MOTHERS' INTENDED METHOD OF FEEDING OF BABIES UPON DISCHARGE FROM THE NEONATAL UNIT AND FACTORS ASSOCIATED WITH THE CHOICE. Hallbauer U
MATERNAL MORTALITY AND 'NEAR MISS' INTERVIEWS: HOW EASY IS THIS APPROACH? Mdeni T
NON-INSTITUTIONAL DEATHS. Motsemai D
MATERNAL DEATHS AND 'NEAR MISSES': HOW MUCH DO INTERVIEWS ADD TO CLINICAL AUDIT. Cebekhulu Q
KNOWLEDGE OF WOMEN, MORE THAN 34 YEARS OF AGE, ABOUT THEIR RISKS OF PREGNANCY. Davies R, Keti V
CARDIACS AND PREGNANCY – A FATAL COMBINATION? Schoon MG
17 YEARS OF PERINATAL RESEARCH IN SOUTH AFRICA. Pattinson RC
DOES THE ADMINISTRATION OF OXYGEN BY NASAL CANNULAS TO LOW BIRTH WEIGHT INFANTS WITH RESPIRATORY DISTRESS DECREASE THEIR EFFORTS OF BREATHING? A PILOT STUDY. Frerich S
PROBLEMS IN SEEKING SOLUTIONS IN MIDDELBURG DISTRICT.
Muller M
PARTNERSHIP IN SAFE MOTHERHOOD. Moosa EZ
LOW PLATELET COUNTS AS MARKER OF HIV. Roux W
MAGNESIUM SULPHATE FOR TREATMENT OF PRE-ECLAMPSIA: A TRIAL TO EVALUATE THE EFFECTS ON WOMEN AND THEIR BABIES. (THE MAGPIE TRIAL). RESULTS OF THE PILOT STUDY AT KALAFONG HOSPITAL. Pattinson RC
ON-SITE SYPHILIS SCREENING AT PRIMARY HEALTH CARE CLINICS
Chaane T
A PILOT PROJECT TO IMPLEMENT IN GAUTENG THE PRINCIPLES AND PHILOSOPHY OF THE INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) – A WHO CHILD SURVIVAL STRATEGY. Rabosiwana M
AUDIT OF AN ANTENATAL CLINIC FOR WOMEN LIVING WITH HIV.
Dinat N
GASTROINTESTINAL DEVELOPMENT AND THE PREVENTION OF NECROTISING ENTEROCOLITIS. Newell SJ
THE USE OF GRANULOCYTE-COLONY STIMULATING FACTOR IN THE PREVENTION OF NOSOCOMIAL INFECTION IN NEUTROPAENIC INFANTS BORN TO WOMEN WITH SEVERE PRE-ECLMAPSIA. Kirsten GF
RANDOMISED CONTROLLED TRIAL OF RECOMBINANT GRANULOCYTE COLONY STIMULATING FACTOR (r-GCSF) IN NEONATES BORN TO WOMEN WITH PROTEINURIC HYPERTENSION TO PREVENT NOSOCOMIAL INFECTIONS. Price V
SERIAL INTERLEUKIN 6 MEASUREMENTS IN THE EARLY DIAGNOSIS OF NEONATAL SEPSIS. Ballot DE
A REVIEW OF EARLY ONSET GROUP B STREPTOCOCCAL DISEASE.
Bomela HN
NEONATAL BACTERAEMIA AND PSEUDOBACTERAEMIA AT CHRIS HANI BARAGWANATH HOSPITAL. Saloojee H
SAVING MOTHERS. REPORT ON CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS IN SOUTH AFRICA 1998 . Moodley J……………………………………61
AUDIT OF PERINATAL MORTALITY IN NORTHERN KWAZULU NATAL – PROBLEMS AND ANSWERS. Gandhi M
SOCIODEMOGRAPHIC PROFILE OF WOMEN IN THE MATERNAL MORTALITY STUDY. Rees HR
MAKING SENSE AND GETTING DIRECTION FROM NEAR MISS AND MATERNAL MORTALITY AUDITS. Pattinson RC
DOES MATENAL “NEAR MISS” AUDIT MAKE A DIFFERENCE? Mantel GD
DEVELOPMENT AND VALIDATION OF A SCALE TO MEASURE PATIENT SATISFACTION WITH ANTENATAL CARE. Steyn PS
DOES EPISIOTOMY BENEFIT THE LOW BIRTH WEIGHT BABY?.
Buchmann E
ACTIVE BIRTH UNIT STATISTICS. De Jager M
BIRTH ASPHYXIA: AN UNAVOIDABLE EXPERIENCE? Ballot DE
ARE DEATHS DUE TO BIRTH ASPHYXIA PREVENTABLE? THE RELATIONSHIP BETWEEN INTRA PARTUM ASPHYXIA AND NURSING STAFF ALLOCATIONS AT WITBANK HOSPITAL. Chegwidden R
REASONS FOR THE PROVEN INACCURACY OF THE PINARD STETHOSCOPE IN DETERMINING THE FETAL HEART RATE DURING LABOUR.
v/d Westhuizen CE
INTRAUTERINE GROWTH RETARDATION AND THE FETAL GUT: IMPLICATIONS FOR FEEDING THE PRETERM INFANT. Newell SJ
IMPROVING COMPLEMENTARY FEEDING PRACTICES IN CHILDREN AGED 3 TO 12 MONTHS IN THE HIGHVELD REGION, MPUMALANGA, SOUTH AFRICA. Malek E
RANDOMISED CONTROLLED TRIAL OF A BREAST MILK FORTIFIER TO SHORTEN HOSPITAL STAY IN LOW BIRTH WEIGHT INFANTS.
Honey EM
THE ADVANTAGES OF BREAST FEEDING. Newell SJ
TIDAL VOLUME AND ON-LINE RESPIRATORY COMPLIANCE MEASUREMENTS AS PREDICTORS FOR SUCCESSFUL EXTUBATION OF NEONATES BEING VENTILATED FOR HYALINE MEMBRANE DISEASE.
Pieper CH
THE ROLE OF KININS AND CYTOKINES IN HYPOXIC ISCHAEMNIC ENCEPHALOPATHY OF THE TERM NEWBORN. Adhikari M
THE LONG TERM NEURO-DEVELOPMENTAL OUTCOME OF INFANTS <1250G ELECTIVELY NOT ADMITTED TO THE NEONATAL INTENSIVE CARE UNIT. Kirsten GF
SHOULD WE VENTILATE THE NEWBORN EXTREMELY LOW BIRTHWEIGHT INFANT: OUTCOMES OVER THE LAST DECADE. Urban M
THE ETHICS OF SELECTING INFANTS FOR NEONATAL INTENSIVE CARE.
Cooper PA
IMPLEMENTING A NATIONAL NEONATAL RESUSCITATION PROGRAMME.
Saloojee H
A NEW EDUCATIONAL STRATEGY TOWARDS IMPROVING MATERNAL AND NEONATAL CARE. Hay IT
EVALUATION OF THE USE OF THE NEONATAL MANUAL OF THE PERINATAL EDUCATION PROGRAMME. Greenfield DH
THE POTENTIAL TO REDUCE PERINATAL DEATHS IN A RURAL REGION THROUGH STUDY OF THE MATERNAL CARE MANUAL OF THE PERINATAL EDUCATION PROGRAMME BY MIDWIVES. Theron GB
THE WHO REPRODUCTIVE HEALTH LIBRARY. Hofmeyr GJ
OBSTETRICAL HAEMORRHAGE – PREVENTABLE KILLER? Schoon MG
MISOPROSTOL VERSUS METHYLERGOMETRINE FOR THE PREVENTION OF POSTPARTUM HAEMORRHAGE: A DOUBLE BLIND RANDOMISED TRIAL
Amant F
MISOPROSTOL VERSUS SYNTOCINON: A RANDOMISED DOUBLE BLIND PLACEBO CONTROLLED PHYSIOLOGICAL STUDY OF INTRA-UTERINE PRESSURE DURING THE THIRD STAGE OF LABOUR. Nikodem C
TITRATED ORAL MISOPROSTOL SUSPENSION FOR INDUCTION OF LABOUR. A PILOT STUDY. Matonhodze BB
INFLUENCE OF BACTERIAL VAGINOSIS ON THE ABSORPTION OF MISOPROSTOL. Jivkov BI
THE IMPACT OF THE PREGNANCY CONFIRMATION CLINIC ON ANTENATAL CARE. Tsuari M
ROUTINE EXTERNAL VERSION FOR ABNORMAL PRESENTATION – THE SUCCESS RATE AND OUTCOME WITHIN AN OBSTETRIC SERVICE
Theron AM
DOES HIV SERO-POSITIVITY CHANGE THE POST-OPERATIVE MORBIDITY OF CAESAREAN SECTION PATIENTS? Urbani G, Goosen H
PRETORIA PASTEURISATION – A POTENTIAL METHOD FOR THE REDUCTION OF VERTICAL TRANSMISSION OF HUMAN IMMUNODEFICIENCY VIRUS VIA BREASTFEEDING. Jeffrey BS
LESSONS LEARNED IN ESTABLISHING A RANDOMISED CONTROLLED TRIAL TO INVESTIGATE THE EFFECTS OF VITAMIN A ON VERTICAL TRANSMISSION OF HIV-1. Steinberg WJ
INTERIM ANALYSIS OF EARLY EFFICACY OF VARIOUS SHORT-TERM ADV/3TC COMBINATION REGIMENS IN PREVENTING MOTHER-TO-CHILD TRANSMISSION OF HIV-1: THE PETRA TRIAL. McIntyre JA
ECLAMPSIA AT HARARE MATERNITY HOSPITAL: DETERMINANTS OF MATERNAL OUTCOME
Majoko F
Department of Obstetrics and Gynaecology, University of Zimbabwe Medical School
Introduction
Maternal mortality for the Greater Harare Maternity Unit (GHMU) remains unacceptably high at 370/100 000 live births. Eclampsia is a major contributor to maternal mortality, responsible for 20% of deaths in 1997.
Objectives
To study the presentation, management and outcome of women with eclampsia at Harare Maternity Hospital (HMH) aiming at identifying factors which influenced outcome.
Methods and Subjects
Patients admitted with or developing eclampsia at HMH during an 18 month period were included in the audit. A comparison was made between the women who died and those who survived. The effects of age, parity, booking status, gestational age, location of first seizure, number of fits prior to admission, seizure to delivery interval, ICU admission, maternal complications and the standard of care given on maternal outcome was examined.
Results
There were 25 425 women delivered at HMH during this period of whom 144 had a diagnosis of eclampsia (5.7 per 1000 births). The case fatality was 24.3%. The majority of fits (66.9%) occurred antenatally. The mothers who died were significantly older than the survivors, mean ages 26.1 vs 22.3 (p=0.007), and had a higher proportion of multiple seizures, 0.67 vs 0.39 (p=0.009) respectively. Fifty-five percent of eclamptics were in their first pregnancy (p=0.001). Delays in achieving delivery, inadequate clinical assessment and poor monitoring were common problems at the central level, with 26.8% of women still not delivered more than 12 hours after onset of convulsions. The booking status, gestational age, seizure to delivery interval and location at time of first seizure did not affect maternal outcome.
Conclusion
Eclampsia remains a significant cause of maternal mortality and there is scope for reducing these maternal deaths. The management should be aggressive with early delivery and close monitoring of the mother.
MATERNAL MORTALITY AND
SEVERE MORBIDITY ASSOCIATED WITH HYPERTENSION IN PREGNANCY
Buchmann EJ and the Near Miss Study Group
Department of Obstetrics and Gynaecology, Baragwanath Hospital
Keywords: pre-eclampsia, maternal death, maternal near-miss
The multicentre Near Miss Study was undertaken in Pretoria, Soweto and the Free State to investigate whether primary obstetric causes, final causes, and avoidable factors were comparable between maternal deaths and near misses. Near misses are women who are pregnant or less than six weeks postpartum, and who suffer severe morbidity which, without intervention, would have resulted in death. The definition of a near miss has been published elsewhere and is based on an organ systems approach, using organ failure or severe dysfunction as a marker of near miss.
During the Near Miss Study, which included 702 near misses and 220 deaths, hypertension in pregnancy was
found to be the most frequent primary obstetric cause, accounting for 226 (32%) of near misses and 54 (25%) of
deaths. The objective of this part of the Near Miss Study was to determine whether near misses and deaths due to hypertension were comparable in patterns of organ dysfunction and in avoidable factors.
Methods
From the Near Miss Study data, all near misses and deaths which had hypertension as the primary obstetric cause were included. Cases where abruptio placentae was the primary obstetric cause, even in the presence of hypertension, were excluded. Audit teams from the three participating centres examined the case-notes of near misses and deaths and decided on the final causes (organ dysfunction) and avoidable factors (patient, administrative and medical) for each case.
Results
Patterns or organ system dysfunction are shown in Table 1. The conversion rate expresses the probability in this study of an organ system dysfunction progressing to maternal death (deaths/near misses + deaths). Thirty-eight percent of near-misses and 54% of deaths were avoidable in terms of patient-related factors (p=0.04). The most common patient-related avoidable factor was failure to book for antenatal
care (19% and 19%).
Administrative-related avoidable factors were present in 18% of near-misses and 35% of deaths (p=0.005). The most common administrative-related avoidable factor was a lack of
appropriate medical facilities (6% and 20%, p=0.001), most usually a shortage of intensive care units. Medical-related avoidable factors were present in 57%
of near misses and 80% of deaths (p=0.001). The most common medical-related avoidable factor was inappropriate management (24% and 35%, not significant).
Table 1Patterns of organ system dysfunction in maternal near misses and deaths
Dysfunction / Near miss(n=226) / Death
(n=54) / Conversion rate (%)
Cardiorespiratory / 116 / 25 / 18
Cerebral / 44 / 36 / 45
Renal / 86 / 9 / 9
Coagulation / 35 / 4 / 10
Hepatic / 29 / 5 / 15
Circulatory (shock) / 8 / 7 / 47
Discussion
Cerebral and cardiorespiratory dysfunction predominated amongst deaths, with the highest effective conversion rates from near miss to death. Renal and coagulation failure had the lowest conversion rates. This reflects the ability of the participating obstetric centres to treat these conditions. Cardiorespiratory failure in pre-eclampsia is potentially preventable
and treatable, and should be given prominence in protocols of management
for severe pre-eclampsia. Avoidable factors were found more frequently in women who died than in near misses. This suggests that appropriate management of women with severe pre-eclampsia may reduce the conversion of near-misses to deaths. There is a possibility in this study that the observers may have been biased and tended to find more fault with death (a negative outcome) than with near miss (a positive outcome).
Audit of near misses in hypertension in pregnancy does not give the same information as audit of maternal deaths. It gives supplementary data to that of deaths and allows us to identify problems in the management of severely ill women with pre-eclampsia.
AUTOMATED BLOOD PRESSURE MEASUREMENT IN THE ASSESSMENT OF METHYLDOPA THERAPY IN SEVERE PRE-ECLAMPSIA
Steyn DW, Odendaal HJ
Department of Obstetrics and Gynaecology, Tygerberg Hospital and University of Stellenbosch and MRC Unit for Perinatal Mortality, Tygerberg, South Africa
Keywords: pre-eclampsia, alpha-methyldopa, ambulatory blood pressure monitors
Expectant management of carefully selected patients with severe pre-eclampsia (PE) before 34 weeks gestation may benefit the fetus without harming the mother. Precise control of maternal blood pressure (BP) is an integral part of this approach. Methyldopa (MD) is well established as anti-hypertensive drug of choice in pregnancy because of its safety for the fetus. The recommended dosage varies from 2000 to 4000 gram per os per day, but should be as low as possible due to potentially hazardous maternal side effects. Conventional blood pressure measurement has several limitations in pregnancy which may influence accuracy. Ambulatory blood pressure measurements (ABPM) offer an alternative method of acquiring frequent
assessments in a way which may decrease the number of potential errors. We assessed the efficacy of MD to control BP in patients with severe PE using ABPM.
Patients and Methods
38 patients with severe PE before 34 weeks gestation were managed expectantly if no indication for immediate delivery existed. Patients received MD, either as 500mg qid or 750mg tds with the aim of maintaining diastolic BP (DBP) between 90 and 109mm Hg as determined by sphygmomanometer assessment. BP was also monitored every 30 minutes with the pregnancy validated Spacelabs 90207 monitor. The main measures of comparison were DBP >109mm Hg, mean 24 hour DBP and day-night variability. All results were unavailable to the clinician.
Results
Table 1 summarises the distribution of BP values obtained in 89 recordings (3870 measurements) in 38 patients. The mean diastolic blood pressure and the day-night differences are depicted in Figures 1-3.
Table 1The distribution of blood pressure values obtained in the two treatment groups
Dosage / Patients / 24 hour Records / Recordings / <90mm Hg / 90-109mmHg / > 109mm
Hg
500mg qid / 25 / 50 / 1733 / 1289
(60%) / 793
(37%) / 55
(2.6%)
750mg tds / 13 / 39 / 2137 / 1392
(80%) / 336
(19%) / 5
(0.2%)
Figure 1The mean diastolic blood pressure over the 24 hour period in the two treatment groups
Figure 2The distribution of individual diastolic blood pressure values in the two treatment groups
Figure 3The distribution of day-night differences in diastolic blood
pressure in the two treatment groups. (Mean diastolic blood pressure during the day minus mean diastolic pressure during the night for each recording)
Mean DBP was significantly lower at night in both groups. The mean DBP was higher at night time in 41% of recordings in both groups.
Conclusions
The use of alpha-methyldopa is associated with 1.5% diastolic blood pressure values >110mm Hg. Two thirds of mean 24 hour values <90mm Hg. DBP values above 109mm Hg occurred significantly more often in patients receiving MD 6 hourly. There were some patients with a reversed diurnal pattern of blood pressure, but this was not influenced by the dosage of MD. However, the therapeutic goal may have to be redefined when using ABPM.
HELLP SYNDROME IN TYGERBERG HOSPITAL
Du Preez JP, Steyn DW, Kirsten GF
Department of Obstetrics and Gynaecology, Tygerberg Hospital and the University of Stellenbosch and the MRC Unit for Perinatal Mortality, Tygerberg
Keywords: HELLP Syndrome, perinatal mortality, prematurity
Pre-eclampsia is a major cause of maternal and perinatal mortality and morbidity in South Africa. The HELLP syndrome was described as a combination of haemolysis, increased liver enzymes and thrombocytopaenia in patients with severe pre-eclampsia. The initial opinion was that this was a particularly severe form of the disease which almost always requires prompt delivery. We usually follow these
guidelines locally, irrespective of gestational age. While this approach should be beneficial to the mother, it will not necessarily improve perinatal outcome and may indeed be harmful to the neonate. Some authors have indeed questioned the need for immediate delivery recently. Expectant management of carefully selected patients with severe pre-eclampsia may
benefit the fetus without harming the mother. This may also be true for some patients with HELLP syndrome. We report the results of a descriptive study which we undertook to assess the clinical impact of HELLP syndrome in Tygerberg Hospital.
Patients and Methods
We prospectively collected the names of 90 consecutive patients who presented to the labour ward in Tygerberg Hospital with HELLP syndrome. The folders of these patients were reviewed, the relevant data collected and entered onto a data sheet. All patients were initially admitted to the labour ward for assessment of both mother and fetus. The obstetric firm on call attended to
the patients. The gestational age at presentation as well as the fetal condition determined the approach to management. In the absence of fetal distress, patients presenting after 34 weeks gestation were stabilised and delivered as soon as possible. Between 28 and 34 weeks gestation, we administered betamethasone and attempted to gain 48 hours before
delivery. Patients presenting after 28
weeks gestation with fetal distress were delivered. Termination of pregnancy was recommended to mothers with non-viable fetuses. Obstetric considerations determined the route of delivery.
Pre-eclampsia was defined according to the guidelines of the ISSHP. To make the diagnosis of HELLP syndrome, we required confirmation of increased liver enzymes, thrombocytopaenia and haemolysis. (Serum aspartate aminotransferase > 70E/L, platelet count <100 000/mm, lactate dehydrogenase >600 E/L or a peripheral smear indicative of haemolysis). Neonatal deaths were defined as deaths during the first 28 days of life and were considered early when occurring during the first 7 days. Any one of the following complications was considered