<p>Perinatal outcomes for mothers with antenatal eclampsia, stroke, or hypertensive disorde... more <p>Perinatal outcomes for mothers with antenatal eclampsia, stroke, or hypertensive disorders of pregnancy causing death or intensive care unit (ICU) admission.</p
Malaria causes over 10000 maternal and 200000 neonatal deaths a year globally. Fifty million preg... more Malaria causes over 10000 maternal and 200000 neonatal deaths a year globally. Fifty million pregnant women are at risk of acquiring malaria of which half of them are in Sub-Saharan Africa. It is caused by the plasmodium parasite, which is transmitted by the vector female Anopheles mosquito. Plasmodium falciparum is the most prevalent and virulent. Pregnant women are more susceptible to malaria and malaria runs a more fulminant course in pregnancy. Primigravidae and to a lesser degree the secundigravidae are more susceptible to malaria infection than the higher parities. Women in endemic areas have greater premonition (a host response that protects against high numbers of parasite and illness without eliminating the infection) to malaria though they become anaemic and have placental parasitisation that disturbs fetal growth leading to poor perinatal outcomes. Women in epidemic areas have lower premunition to malaria resulting in severe infections and higher mortality. WHO (World Hea...
Haemorrhage, hypertension, sepsis and abortion complications (often from haemorrhage or sepsis) c... more Haemorrhage, hypertension, sepsis and abortion complications (often from haemorrhage or sepsis) contribute to 60% of all maternal deaths. Each is associated with vital signs (blood pressure (BP) and pulse) abnormalities, and the majority of deaths are preventable through simple and timely intervention. This paper presents the development and evaluation of the CRADLE Vital Signs Alert (VSA), an accurate, low-cost and easy-to-use device measuring BP and pulse with an integrated traffic light early warning system. The VSA was designed to be used by all cadres of healthcare providers for pregnant women in low-resource settings with the aim to prevent avoidable maternal mortality and morbidity. The development and the mixed-methods clinical evaluation of the VSA are described. Preliminary fieldwork identified that introduction of BP devices to rural clinics improved antenatal surveillance of BP in pregnant women. The aesthetics of the integrated traffic light system were developed throug...
Obstetric haemorrhage, sepsis and pregnancy hypertension account for more than 50% of maternal de... more Obstetric haemorrhage, sepsis and pregnancy hypertension account for more than 50% of maternal deaths worldwide. Early detection and effective management of these conditions relies on vital signs. The Microlife® CRADLE Vital Sign Alert (VSA) is an easy-to-use, accurate device that measures blood pressure and pulse. It incorporates a traffic-light early warning system that alerts all levels of healthcare provider to the need for escalation of care in women with obstetric haemorrhage, sepsis or pregnancy hypertension, thereby aiding early recognition of haemodynamic instability and preventing maternal mortality and morbidity. The aim of the trial was to determine whether implementation of the CRADLE intervention (the Microlife® CRADLE VSA device and CRADLE training package) into routine maternity care in place of existing equipment will reduce a composite outcome of maternal mortality and morbidity in low- and middle-income country populations. The CRADLE-3 trial was a stepped-wedge c...
We report three cases illustrating difficulties in diagnosis and challenges with management of th... more We report three cases illustrating difficulties in diagnosis and challenges with management of the placenta in a low-resource country where ultrasound scanning, methotrexate, interventional radiology or blood products are often not accessible for the majority of patients. Even in situations where an ultrasound scan is available prenatally as in our three cases, the diagnosis is often missed. All the cases presented with vague abdominal symptoms, which are common in pregnancy anyway. Only one case was correctly diagnosed before surgery by ultrasound scan. For the two cases in the second trimester as expected the fetuses did not survive. The one advanced pregnancy had a good perinatal outcome. Maternal morbidity and mortality usually results from perioperative hemorrhage from the placental attachment site. The most important aspect of management is the management of the placenta. In the two cases with second trimester pregnancies, it was possible to remove the placentas, even though b...
and is often fatal (McCormick and Young, 1995). The first reported case of spontaneous splenic ca... more and is often fatal (McCormick and Young, 1995). The first reported case of spontaneous splenic capsular rupture in pregnancy seems to have been published in 1803, and to date there have been few reported cases of spontaneous splenic capsular rupture during pregnancy. This is the first case, to the best of our knowledge, that has co-existent conditions of spontaneous rupture of the splenic capsule and HELLP syndrome. Both conditions carry high morbidity and mortality rates. The entity of splenic artery aneurysm rupture is well established (Barrilleaux et al., 1999). The diagnostic criteria for spontaneous spontaneous splenic capsular rupture in pregnancy are strict. There should be no history of antecedent trauma, no evidence of systemic disease, no evidence of perisplenic adhesions or scarring of the spleen, and the spleen should be normal both macroscopically and histologically. Our patient had postpartum spontaneous splenic capsular rupture, and its presenting features were confused by the underlying HELLP syndrome complicated by DIC. She had no history of malaria, infectious mononucleosis, typhoid fever or leukaemia, where spontaneous splenic rupture may occur associated with massive splenomegaly (Bhagrath et al., 1993). As no free blood was found in the peritoneal cavity at caesarean section, it is clear that the capsular spontaneous splenic capsular rupture occurred as a delayed postpartum event. There was no specific organ damage found at the first laparotomy but an abrasive injury could have been caused to an already congested organ, such as the liver and spleen. At the second laparotomy, there was a tear identified in the ligamentum teres: however, no specific splenic injury or bleeding point was identified. Although she had a grossly normal spleen with capsule rupture, histological examination showed extramedullary haematopoiesis. Delayed spontaneous splenic capsular rupture is very difficult to diagnose, as was the case with our patient. Splenic capsular rupture was not evident until the third exploratory laparotomy. Due to the significant mortality rate, aggressive operative intervention is essential for a good outcome after splenic capsular rupture (Kaluarachchi and Krishnamurthy, 1995), even though recent literature reported conservative management of spontaneous splenic capsular rupture in pregnancy (Fletcher et al., 1989).
Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that ... more Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that 50% of women of childbearing age are either overweight (Body Mass Index [BMI] = 24.9–29.9kg/m2) or obese with 18% starting pregnancy as obese. Obesity prevalence has doubled over a decade from the early 1990’s. In the US it is estimated that 30% of reproductive-age women have a BMI greater than 30 kg/m while 7% have a BMI > 40 kg/m2. A recent report from the UK found that 5% of women had a BMI >35 kg/m2, 2% > 40 kg/m2 and 0.2%…
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2009
A latent GTN that remains dormant for long periods and becomes clinically evident in the postmeno... more A latent GTN that remains dormant for long periods and becomes clinically evident in the postmenopausal period is thought to be another mechanism [1,4]. In the case of a long-standing menopausal period a dormant GTN is the most likely cause of CHMs, but our patient had a short postmenopausal period, which suggests probable spontaneous ovulation followed by defective fertilization in the development of the CHM.
Bariatric surgery is highly effective for weight loss in morbid obesity. With the high prevalence... more Bariatric surgery is highly effective for weight loss in morbid obesity. With the high prevalence of severe obesity in the developed world, and the acknowledgement of the effectiveness of these procedures by National Institute for Clinical Excellence (in the UK) and the Food and Drug Administration (in the USA), women with severe obesity will increasingly seek such treatment. As the majority of these patients are women of reproductive age, obstetricians will encounter these patients frequently during pregnancy. It is therefore important for obstetricians to gain an insight into the types of surgery performed, the potential complications, including nutritional deficiency, and appropriate management of pregnancy following weight-loss surgery. In general, bariatric surgery is associated with a reduction in obesity related complication, with no apparent increased risk of adverse perinatal outcomes.
Case report A 38-year-old para 3 was booked in her fifth pregnancy at 13 weeks 2 days. Past medic... more Case report A 38-year-old para 3 was booked in her fifth pregnancy at 13 weeks 2 days. Past medical history revealed that she was a sufferer from myotonic dystrophy. Her first pregnancy ended with a normal vaginal birth following induction of labour at 41 weeks. The second child was delivered by caesarean section for breech presentation. In her third pregnancy, she was found to have grade 1 placenta praevia and was delivered at 37 weeks by caesarean section. Her fourth pregnancy ended at 10 weeks as a miscarriage and she required surgical evaluation of retained products of conception. The antenatal period was uneventful until about 35 weeks’ gestation, when she was found to have a high presenting part, and ultrasound scan at this stage revealed a Grade 3 anterior placenta praevia. She was informed of the risks of major placental praevia and the need for caesarean section for delivery. Because she had good support at home and lived not far from hospital she was advised to avoid intercourse and a decision for outpatient management was made at consultant level. Caesarean section was planned for 38 weeks and 4 days. Two senior consultants performed her caesarean section as haemorrhage and placenta accreta were predicted. At caesarean section, a lower segment uterine incision was made and the baby delivered through the placenta. The placenta was found to be uniformly stuck to the myometrium and removed in multiple pieces leaving the lower segment in a ragged state. Moderate haemostasis was achieved and a decision to conserve the uterus was made. The uterus was closed in two layers, the visceral peritoneaum was closed, and a retrovesical drain was left in situ. Haemostatis was achieved at the end of the operation. The estimated blood loss at operation was 2 l. In the immediate postoperative period, the haemoglobin was 7 g/dl and the patient remained stable. She was transfused 3 units of packed cells to replace intra-operative blood loss. Approximately 5 hours after caesarean section it was noticed that she had developed haematuria and the drain was gradually filling up with blood (there was about 1 l of blood in the drain). A further 4 units of packed cells and 4 units of fresh frozen plasma was transfused. Haemoglobin was checked and found to have only risen to 8.6 g/dl despite having received 7 units of blood. The initial clotting screen showed an elevated APTT (34.7 seconds) and PT (16.7 seconds). Fibrin degradation products (D-Dimers) were 1.8 mg/ml, which was within the normal range. A diagnosis of a mild disseminated intravascular coagulation was suspected at this stage and 6 units of cryoprecipitate was transfused. Because of the observed placental bed trauma recombination coagulation factor VIIa (NovoSeven; Novo Nordisk A/S Denmark) 12 mg based on body weight was also given. Over the next few hours, the blood loss via the drain slowed and stopped and the clotting screen reverted to normal. The patient subsequently made a full recovery.
Important foetal growth occur throughout pregnancy, including the last months and weeks of pregna... more Important foetal growth occur throughout pregnancy, including the last months and weeks of pregnancy. Preterm birth occurs when a newborn baby have not had adequate time to develop fully whilst in the mother’s womb. Preterm birth is one of the major challenges in the world. The objective of this analysis is to clarify meaning of preterm birth by identifying its attributes in order to increase understanding of the concept. Walker and Avant’s 2005 traditional method of concept analysis was used in the analysis of the concept. We searched 54 articles from databases including Google Scholar, PubMed, HINARI, MEDLINE and Google Search. Thirty of the articles were used in this analysis. The meaning of preterm birth has since shifted from the 18th century. Delivery of a newborn before 37 complete weeks was identified as one of the critical defining attributes of preterm birth. Preterm premature rupture of membranes is one of the important antecedents of preterm birth. Consequences of preter...
Objective: The aim of this study was to estimate prevalence of asymptomatic bacteriuria among pre... more Objective: The aim of this study was to estimate prevalence of asymptomatic bacteriuria among pregnant women registering for antenatal care. Methods: A cross sectional study was conducted at 4 purposively selected Harare Municipality primary care clinics. A total of 240 pregnant women asymptomatic for urinary tract infection, registering for antenatal care at 6 and 22 weeks gestation were included. Those unaware of their last menstrual period date, clinically unwell and those who declined to sign a consent form were excluded in this study. Participants were instructed to provide 20 mililiters of midstream urine samples in clean specimen bottles. All samples were screened for asymptomatic bacteriuria using Griess nitrite test. Samples that changed color from clear to purple were considered positive for asymptomatic bacteriuria. Positive samples were further sent for culture and sensitivity. A colony count of 103 similar bacterial species per mililiter of urine was considered signific...
<p>Perinatal outcomes for mothers with antenatal eclampsia, stroke, or hypertensive disorde... more <p>Perinatal outcomes for mothers with antenatal eclampsia, stroke, or hypertensive disorders of pregnancy causing death or intensive care unit (ICU) admission.</p
Malaria causes over 10000 maternal and 200000 neonatal deaths a year globally. Fifty million preg... more Malaria causes over 10000 maternal and 200000 neonatal deaths a year globally. Fifty million pregnant women are at risk of acquiring malaria of which half of them are in Sub-Saharan Africa. It is caused by the plasmodium parasite, which is transmitted by the vector female Anopheles mosquito. Plasmodium falciparum is the most prevalent and virulent. Pregnant women are more susceptible to malaria and malaria runs a more fulminant course in pregnancy. Primigravidae and to a lesser degree the secundigravidae are more susceptible to malaria infection than the higher parities. Women in endemic areas have greater premonition (a host response that protects against high numbers of parasite and illness without eliminating the infection) to malaria though they become anaemic and have placental parasitisation that disturbs fetal growth leading to poor perinatal outcomes. Women in epidemic areas have lower premunition to malaria resulting in severe infections and higher mortality. WHO (World Hea...
Haemorrhage, hypertension, sepsis and abortion complications (often from haemorrhage or sepsis) c... more Haemorrhage, hypertension, sepsis and abortion complications (often from haemorrhage or sepsis) contribute to 60% of all maternal deaths. Each is associated with vital signs (blood pressure (BP) and pulse) abnormalities, and the majority of deaths are preventable through simple and timely intervention. This paper presents the development and evaluation of the CRADLE Vital Signs Alert (VSA), an accurate, low-cost and easy-to-use device measuring BP and pulse with an integrated traffic light early warning system. The VSA was designed to be used by all cadres of healthcare providers for pregnant women in low-resource settings with the aim to prevent avoidable maternal mortality and morbidity. The development and the mixed-methods clinical evaluation of the VSA are described. Preliminary fieldwork identified that introduction of BP devices to rural clinics improved antenatal surveillance of BP in pregnant women. The aesthetics of the integrated traffic light system were developed throug...
Obstetric haemorrhage, sepsis and pregnancy hypertension account for more than 50% of maternal de... more Obstetric haemorrhage, sepsis and pregnancy hypertension account for more than 50% of maternal deaths worldwide. Early detection and effective management of these conditions relies on vital signs. The Microlife® CRADLE Vital Sign Alert (VSA) is an easy-to-use, accurate device that measures blood pressure and pulse. It incorporates a traffic-light early warning system that alerts all levels of healthcare provider to the need for escalation of care in women with obstetric haemorrhage, sepsis or pregnancy hypertension, thereby aiding early recognition of haemodynamic instability and preventing maternal mortality and morbidity. The aim of the trial was to determine whether implementation of the CRADLE intervention (the Microlife® CRADLE VSA device and CRADLE training package) into routine maternity care in place of existing equipment will reduce a composite outcome of maternal mortality and morbidity in low- and middle-income country populations. The CRADLE-3 trial was a stepped-wedge c...
We report three cases illustrating difficulties in diagnosis and challenges with management of th... more We report three cases illustrating difficulties in diagnosis and challenges with management of the placenta in a low-resource country where ultrasound scanning, methotrexate, interventional radiology or blood products are often not accessible for the majority of patients. Even in situations where an ultrasound scan is available prenatally as in our three cases, the diagnosis is often missed. All the cases presented with vague abdominal symptoms, which are common in pregnancy anyway. Only one case was correctly diagnosed before surgery by ultrasound scan. For the two cases in the second trimester as expected the fetuses did not survive. The one advanced pregnancy had a good perinatal outcome. Maternal morbidity and mortality usually results from perioperative hemorrhage from the placental attachment site. The most important aspect of management is the management of the placenta. In the two cases with second trimester pregnancies, it was possible to remove the placentas, even though b...
and is often fatal (McCormick and Young, 1995). The first reported case of spontaneous splenic ca... more and is often fatal (McCormick and Young, 1995). The first reported case of spontaneous splenic capsular rupture in pregnancy seems to have been published in 1803, and to date there have been few reported cases of spontaneous splenic capsular rupture during pregnancy. This is the first case, to the best of our knowledge, that has co-existent conditions of spontaneous rupture of the splenic capsule and HELLP syndrome. Both conditions carry high morbidity and mortality rates. The entity of splenic artery aneurysm rupture is well established (Barrilleaux et al., 1999). The diagnostic criteria for spontaneous spontaneous splenic capsular rupture in pregnancy are strict. There should be no history of antecedent trauma, no evidence of systemic disease, no evidence of perisplenic adhesions or scarring of the spleen, and the spleen should be normal both macroscopically and histologically. Our patient had postpartum spontaneous splenic capsular rupture, and its presenting features were confused by the underlying HELLP syndrome complicated by DIC. She had no history of malaria, infectious mononucleosis, typhoid fever or leukaemia, where spontaneous splenic rupture may occur associated with massive splenomegaly (Bhagrath et al., 1993). As no free blood was found in the peritoneal cavity at caesarean section, it is clear that the capsular spontaneous splenic capsular rupture occurred as a delayed postpartum event. There was no specific organ damage found at the first laparotomy but an abrasive injury could have been caused to an already congested organ, such as the liver and spleen. At the second laparotomy, there was a tear identified in the ligamentum teres: however, no specific splenic injury or bleeding point was identified. Although she had a grossly normal spleen with capsule rupture, histological examination showed extramedullary haematopoiesis. Delayed spontaneous splenic capsular rupture is very difficult to diagnose, as was the case with our patient. Splenic capsular rupture was not evident until the third exploratory laparotomy. Due to the significant mortality rate, aggressive operative intervention is essential for a good outcome after splenic capsular rupture (Kaluarachchi and Krishnamurthy, 1995), even though recent literature reported conservative management of spontaneous splenic capsular rupture in pregnancy (Fletcher et al., 1989).
Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that ... more Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that 50% of women of childbearing age are either overweight (Body Mass Index [BMI] = 24.9–29.9kg/m2) or obese with 18% starting pregnancy as obese. Obesity prevalence has doubled over a decade from the early 1990’s. In the US it is estimated that 30% of reproductive-age women have a BMI greater than 30 kg/m while 7% have a BMI > 40 kg/m2. A recent report from the UK found that 5% of women had a BMI >35 kg/m2, 2% > 40 kg/m2 and 0.2%…
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2009
A latent GTN that remains dormant for long periods and becomes clinically evident in the postmeno... more A latent GTN that remains dormant for long periods and becomes clinically evident in the postmenopausal period is thought to be another mechanism [1,4]. In the case of a long-standing menopausal period a dormant GTN is the most likely cause of CHMs, but our patient had a short postmenopausal period, which suggests probable spontaneous ovulation followed by defective fertilization in the development of the CHM.
Bariatric surgery is highly effective for weight loss in morbid obesity. With the high prevalence... more Bariatric surgery is highly effective for weight loss in morbid obesity. With the high prevalence of severe obesity in the developed world, and the acknowledgement of the effectiveness of these procedures by National Institute for Clinical Excellence (in the UK) and the Food and Drug Administration (in the USA), women with severe obesity will increasingly seek such treatment. As the majority of these patients are women of reproductive age, obstetricians will encounter these patients frequently during pregnancy. It is therefore important for obstetricians to gain an insight into the types of surgery performed, the potential complications, including nutritional deficiency, and appropriate management of pregnancy following weight-loss surgery. In general, bariatric surgery is associated with a reduction in obesity related complication, with no apparent increased risk of adverse perinatal outcomes.
Case report A 38-year-old para 3 was booked in her fifth pregnancy at 13 weeks 2 days. Past medic... more Case report A 38-year-old para 3 was booked in her fifth pregnancy at 13 weeks 2 days. Past medical history revealed that she was a sufferer from myotonic dystrophy. Her first pregnancy ended with a normal vaginal birth following induction of labour at 41 weeks. The second child was delivered by caesarean section for breech presentation. In her third pregnancy, she was found to have grade 1 placenta praevia and was delivered at 37 weeks by caesarean section. Her fourth pregnancy ended at 10 weeks as a miscarriage and she required surgical evaluation of retained products of conception. The antenatal period was uneventful until about 35 weeks’ gestation, when she was found to have a high presenting part, and ultrasound scan at this stage revealed a Grade 3 anterior placenta praevia. She was informed of the risks of major placental praevia and the need for caesarean section for delivery. Because she had good support at home and lived not far from hospital she was advised to avoid intercourse and a decision for outpatient management was made at consultant level. Caesarean section was planned for 38 weeks and 4 days. Two senior consultants performed her caesarean section as haemorrhage and placenta accreta were predicted. At caesarean section, a lower segment uterine incision was made and the baby delivered through the placenta. The placenta was found to be uniformly stuck to the myometrium and removed in multiple pieces leaving the lower segment in a ragged state. Moderate haemostasis was achieved and a decision to conserve the uterus was made. The uterus was closed in two layers, the visceral peritoneaum was closed, and a retrovesical drain was left in situ. Haemostatis was achieved at the end of the operation. The estimated blood loss at operation was 2 l. In the immediate postoperative period, the haemoglobin was 7 g/dl and the patient remained stable. She was transfused 3 units of packed cells to replace intra-operative blood loss. Approximately 5 hours after caesarean section it was noticed that she had developed haematuria and the drain was gradually filling up with blood (there was about 1 l of blood in the drain). A further 4 units of packed cells and 4 units of fresh frozen plasma was transfused. Haemoglobin was checked and found to have only risen to 8.6 g/dl despite having received 7 units of blood. The initial clotting screen showed an elevated APTT (34.7 seconds) and PT (16.7 seconds). Fibrin degradation products (D-Dimers) were 1.8 mg/ml, which was within the normal range. A diagnosis of a mild disseminated intravascular coagulation was suspected at this stage and 6 units of cryoprecipitate was transfused. Because of the observed placental bed trauma recombination coagulation factor VIIa (NovoSeven; Novo Nordisk A/S Denmark) 12 mg based on body weight was also given. Over the next few hours, the blood loss via the drain slowed and stopped and the clotting screen reverted to normal. The patient subsequently made a full recovery.
Important foetal growth occur throughout pregnancy, including the last months and weeks of pregna... more Important foetal growth occur throughout pregnancy, including the last months and weeks of pregnancy. Preterm birth occurs when a newborn baby have not had adequate time to develop fully whilst in the mother’s womb. Preterm birth is one of the major challenges in the world. The objective of this analysis is to clarify meaning of preterm birth by identifying its attributes in order to increase understanding of the concept. Walker and Avant’s 2005 traditional method of concept analysis was used in the analysis of the concept. We searched 54 articles from databases including Google Scholar, PubMed, HINARI, MEDLINE and Google Search. Thirty of the articles were used in this analysis. The meaning of preterm birth has since shifted from the 18th century. Delivery of a newborn before 37 complete weeks was identified as one of the critical defining attributes of preterm birth. Preterm premature rupture of membranes is one of the important antecedents of preterm birth. Consequences of preter...
Objective: The aim of this study was to estimate prevalence of asymptomatic bacteriuria among pre... more Objective: The aim of this study was to estimate prevalence of asymptomatic bacteriuria among pregnant women registering for antenatal care. Methods: A cross sectional study was conducted at 4 purposively selected Harare Municipality primary care clinics. A total of 240 pregnant women asymptomatic for urinary tract infection, registering for antenatal care at 6 and 22 weeks gestation were included. Those unaware of their last menstrual period date, clinically unwell and those who declined to sign a consent form were excluded in this study. Participants were instructed to provide 20 mililiters of midstream urine samples in clean specimen bottles. All samples were screened for asymptomatic bacteriuria using Griess nitrite test. Samples that changed color from clear to purple were considered positive for asymptomatic bacteriuria. Positive samples were further sent for culture and sensitivity. A colony count of 103 similar bacterial species per mililiter of urine was considered signific...
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