Perinatal outcomes of hypertensive disorders in pregnancy at a tertiary hospital in Ghana.

BACKGROUND: Hypertensive disorders in pregnancy remain a major global health issue not only because of the associated high adverse maternal outcomes but there is a close accompaniment of significant perinatal morbidity and mortality especially in Sub-Saharan Africa (SSA). However, the perinatal burden of HDP in Ghana has not been explored. We conducted this study to determine the perinatal outcomes of HDP at a tertiary hospital in Ghana. METHODS: A cross-sectional study conducted between January to February 2013 at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana. Data collection involved baseline review of all the obstetric population who had just delivered to identify those with HDP. An informed consent was obtained after which a structured questionnaire was adminstered to the hypertensive mothers. The medical records of the mothers and their babies were also reviewed to determine the perinatal outcome indicators of relevance to the study. Data obtained were analyzed using SPSS version 20. RESULTS: We included 368 women with HDP and singleton births with a mean gestational age at delivery of 37.4 ± 3.3 weeks. Adverse perinatal outcomes determined include the following: 91 (24.7%) neonates were admitted to the Neonatal Intensive Care Unit, 56 (15.2%) had neonatal respiratory distress/asphyxia with 14 (3.8%) requiring ventilatory support and 80 (21.7%) were delivered preterm. Also, stillbirth, early neonatal death, intrauterine growth restriction and low birth weight occurred in 25 (6.8%), 14 (3.8%), 23 (6.1%) and 91 (24.7%) respectively with a perinatal mortality rate of 106 per 1000 births. One and 5 minute APGAR scores <7 occurred in 125 (34.0%) and 55 (14.7%) neonates respectively. Most of the adverse perinatal outcomes were significantly more common in those with preeclampsia compared to the other hypertensive disorders. CONCLUSION: There is a significant burden of perinatal morbidity and mortality associated with HDP in the Ghanaian obstetric population and these adverse outcomes were more prevalent in preeclampsia compared to the other hypertensive disorders. Regular goal-oriented clinical audit into perinatal morbidity and mortality associated with HDP and an active multidisciplinary approach to the management of these disorders in the hospital might improve the clinical outcomes of women with maternal hypertension.

Lived experiences of women during induction of labour at a tertiary hospital in Ghana: A qualitative study.

Induction of labour (IOL) has become a major and vital maternal health intervention to facilitate childbirth and minimize the rising caesarean section rates globally. However, there is limited information to facilitate appropriate client counselling, birth preparedness and informed decision making although the procedure has inherent tendency for adverse maternal/perinatal outcomes. Given the need for optimal client education and shared decision making in maternal health, this study explored women's knowledge and their lived experiences of IOL. This qualitative study used in-depth interviews, conducted at the largest teaching hospital in Ghana. Purposive sampling was used to recruit the study participants. Data analysis was performed based on thematic content using inductive framework synthesis. We included 17 women who had undergone IOL, delivered and discharged. Most participants(52.9%) were ≥30 years old, married(88.2%), and 41.1% had no previous childbirth experience. The main indications of IOL were postdate(47%), pre-eclampsia(29%) and gestational diabetes mellitus(11.8%). Data synthesis resulted in three broad themes: women's knowledge on IOL, women's experiences of care and women's difficult experiences including coping mechanisms. We determined mixed responses concerning the themes explored: adequate versus inadequate knowledge; positive versus negative experiences of care and satisfaction. Nearly all women mentioned vaginal examination as their most difficult experience due to severe pain, extreme discomfort, and being psychologically traumatic. The main coping strategy the women developed to navigate the traumatic vaginal examination was by "psyching" themselves. Our study indicates women encounter significant negative and positive experiences during IOL and childbirth in Ghana with vaginal examination cited as the most painful experience. Appropriate antenatal counselling, women empowerment and pre-labour education on childbirth processes and expectations are recommended to enhance birth preparedness and complication awareness. Health system improvement and regular refreshers courses for health workers are urgently required to promote positive women's experiences of care during labour induction and childbirth.

Venous thromboembolism risk and prophylaxis in hospitalized obstetric patients at a tertiary hospital in Accra, Ghana: A comparative cross-sectional study.

OBJECTIVE: To determine the prevalence of venous thromboembolism risk and thromboprophylaxis among obstetric inpatients, comparing prenatal and postnatal women. METHODS: We assessed 546 obstetric inpatients at the Korle-Bu Teaching Hospital for the prevalence study. Out of this number, 223 were recruited, comprising 111 prenatal and 112 postnatal mothers. A structured interviewer-administered questionnaire was used to obtain data on participants' venous thromboembolism risk, which was categorized into high, intermediate, and low using the Royal College of Obstetricians and Gynaecologists guidelines. Data on thromboprophylaxis were also obtained and analyzed. Values were considered statistically significant at p < 0.05. RESULTS: Overall venous thromboembolism risk among the study population was 82/223 (36.8%). All patients at high risk were prenatal, 59/112 (52.7%) of postnatal mothers were at intermediate risk, compared with 20/111 (18.0%) of prenatal women (p < 0.001). Prevalence of thromboprophylaxis was 5/82 (6.1%). All prenatal high-risk patients received thromboprophylaxis, whereas only 2/20 (10.0%) of women with intermediate risk received thromboprophylaxis. The incidence of venous thromboembolism was 3/546 (0.6%) in the obstetric inpatients. CONCLUSION: Our study found a high prevalence of venous thromboembolism risk among obstetric inpatients at the Korle-Bu Teaching Hospital. However, thromboprophylaxis was low. Further research is needed to audit recent practice of thromboprophylaxis and perinatal outcome.

Cerebro-placental ratio as a prognostic factor of fetal outcome in pregnancy complicated by maternal sickle cell disease.

OBJECTIVES: To assess the role of the cerebro-placental ratio (CPR) in predicting adverse fetal outcomes among women with sickle cell disease (SCD). METHODS: A prospective cohort study at Korle-Bu Teaching Hospital, Accra, Ghana, between January and June 2016. Pregnant women with SCD at 34 gestational weeks or more underwent weekly fetal umbilical and middle cerebral artery Doppler assessment until delivery. Participants were categorized into two study arms based on CPR (<1.1 or ≥1.1). The primary outcome, a composite of adverse perinatal outcomes including intrauterine growth restriction, stillbirth, low birthweight, and neonatal intensive care unit admission, was compared between groups. RESULTS: Overall, 48 pregnant women with SCD were enrolled, and 5 had a fetus with CPR less than 1.1. Low CPR (<1.1) had a sensitivity and specificity of 29.4% and 100%, respectively, for predicting composite adverse perinatal outcomes. Sensitivity and specificity were, respectively, 100% and 93.5% for predicting stillbirth, and 40.2% and 97.4% for predicting low birthweight. Perinatal outcomes did not differ between the two major sickle cell genotypes (hemoglobin SS and hemoglobin SC). CONCLUSIONS: Among women with SCD, CPR less than 1.1 was associated with adverse perinatal outcomes, particularly low birthweight and stillbirth.

Obstetric ultrasonography in low-income countries.

The major issues in obstetric practice in developing countries are the high rates of maternal and perinatal mortality. In most low-income countries health financing systems are not well established so most people pay for health services at the service delivery points. This causes cost-related issues to be of major concern. The main questions that therefore need to be addressed about obstetric ultrasonography in low-income countries is whether the practice improves maternal and neonatal outcomes and whether the service is within the means of most people in these countries. The indications for obstetric ultrasound, guidelines for the use of obstetric ultrasound and the benefits of obstetric ultrasound in low-income countries are discussed and the future of obstetric ultrasound in developing countries is also briefly considered.

Contraceptive use by women in Accra, Ghana: results from the 2003 Accra Women's Health Survey.

The study was to determine the predictors of use of modern contraception among women in Accra, Ghana. Data were collected by trained interviewers using questionnaires. Complete data for 2199 women were analysed using Stata 8.2. The study showed that educational status was the most significant predictor of contraceptive use. Women with no formal education had a 48% reduction in the odds of having ever used contraception and a 66% reduction in the odds of currently using contraception. Regular use of health facilities did not affect contraceptive use. Female education should continue to be a priority of the Ghanaian government. Education about family planning and the effects of having large families should be integrated into the school curriculum. Ghanaian health workers need to be active in promoting the use of modern contraceptive methods.

Indications for gynecologic surgery and their implications for sexual function in menopausal women.

OBJECTIVE: To determine the indications for gynecologic surgery and the effect of surgery on dyspareunia and sexual intercourse frequency in menopausal women in Accra, Ghana. METHOD: Women who had gynecologic surgery between January 2005 and December 2007 were invited for an interview about dyspareunia and frequency of intercourse before and after surgery. RESULTS: Of the 93 women interviewed who underwent hysterectomy, 29 (31.1%) had dyspareunia before surgery and 13 (14.0%) after (P=0.006). Of the 65 women who had benign tumors, before surgery 26 (40%) were sexually active, while after surgery 43 (66%) were sexually active (P=0.001). However, frequency of intercourse did not change for those with malignancies. The mean frequency of intercourse before surgery was 2.11 per week, compared with 2.46 per week after surgery (P=0.50). CONCLUSION: Gynecologic surgery reduced dyspareunia. More women became sexually active following surgery for benign but not malignant tumors, but the mean overall frequency of intercourse did not change significantly in the interviewed population.

Sexually transmitted infections and health seeking behaviour among Ghanaian women in Accra.

The study was to measure the prevalence of sexually transmitted infection (STI) symptoms among women in Accra, Ghana, to identify characteristics that predispose to STI symptoms and to identify factors that influence health-seeking behaviour of women with STI symptoms. Data were collected by trained interviewers through questionnaire interviews of 3183 women. Data analysis was restricted to 1329 women with complete data. Only 19% of our study group had STI symptoms. Only 35% of the women with STI symptoms received care. Having high wealth index, being older and having no history of condom use were protective factors for experiencing STI symptoms. Seeking care was associated with increased by high wealth index and the presence of an offensive vaginal odour. Income level on its own did not affect health seeking behavior. Wealth index is the most significant determinant of a woman having STI symptoms and seeking care in Accra.

A Liftless Intervention to Prevent Preterm Birth and Low Birthweight Among Pregnant Ghanaian Women: Protocol of a Stepped-Wedge Cluster Randomized Controlled Trial.

BACKGROUND: Preterm birth (PTB) is a leading cause of infant morbidity and mortality worldwide. Every year, 20 million babies are born with low birthweight (LBW), about 96% of which occur in low-income countries. Despite the associated dangers, in about 40%-50% of PTB and LBW cases, the causes remain unexplained. Existing evidence is inconclusive as to whether occupational physical activities such as heavy lifting are implicated. African women bear the transport burden of accessing basic needs for their families. Ghana's PTB rate is 14.5%, whereas the global average is 9.6%. The proposed liftless intervention aims to decrease lifting exposure during pregnancy among Ghanaian women. We hypothesize that a reduction in heavy lifting among pregnant women in Ghana will increase gestational age and birthweight. OBJECTIVE: To investigate the effects of the liftless intervention on the incidence of PTB and LBW among pregnant Ghanaian women. METHODS: A cohort stepped-wedge cluster randomized controlled trial in 10 antenatal clinics will be carried out in Ghana. A total of 1000 pregnant participants will be recruited for a 60-week period. To be eligible, the participant should have a singleton pregnancy between 12 and 16 weeks gestation, be attending any of the 10 antenatal clinics, and be exposed to heavy lifting. All participants will receive standard antenatal care within the control phase; by random allocation, two clusters will transit into the intervention phase. The midwife-led 3-component liftless intervention consists of health education, a take-home reminder card mimicking the colors of a traffic light, and a shopping voucher. The primary outcome are gestational ages of <28, 28-32, and 33-37 weeks. The secondary outcomes are LBW (preterm LBW, term but LBW, and postterm), compliance, prevalence of low back and pelvic pain, and premature uterine contractions. Study midwives and participants will not be blinded to the treatment allocation. RESULTS: Permission to conduct the study at all 10 antenatal clinics has been granted by the Ghana Health Service. Application for funding to begin the trial is ongoing. Findings from the main trial are expected to be published by the end of 2019. CONCLUSIONS: To the best of our knowledge, there has been no randomized trial of this nature in Ghana. Minimizing heavy lifting among pregnant African women can reduce the soaring rates of PTB and LBW. The findings will increase the knowledge of the prevention of PTB and LBW worldwide. TRIAL REGISTRATION: Pan African Clinical Trial Register (PACTR201602001301205); http://apps.who.int/trialsearch/ Trial2.aspx?TrialID=PACTR201602001301205 (Archived by WebCite at http://www.webcitation.org/71TCYkHzu). REGISTERED REPORT IDENTIFIER: RR1-10.2196/10095.

Two cases of Pentalogy of Cantrell diagnosed antenatally at Korle Bu Teaching Hospital, Accra.

Pentalogy of Cantrell is a rare congenital malformation syndrome that may be associated with other congenital anomalies. The syndrome is said to affect males and females in equal numbers and the prognosis is generally poor. We report two cases of Cantrell's Pentalogy diagnosed antenatally at the Korle Bu teaching Hospital. The 2 cases described in this report demonstrate the complete and incomplete variant of the syndrome. The cases were referred as an omphalocoele and a detailed anomaly scan confirmed the diagnosis of Pentalogy of Cantrell. Both cases were females and neither survived beyond 24 hours. Although this condition is associated with a poor prognosis, there have been some reported cases of survival in the literature. Thus, accurate prenatal diagnosis and a multidisciplinary approach to the management may offer improved outcomes.

Fetal middle cerebral artery Doppler indices and clinical application at Korle Bu Teaching Hospital, Accra, Ghana.

OBJECTIVE: To determine normal ranges for various Doppler flow velocity indices of the fetal middle cerebral artery (MCA) and their trends in normal pregnancies at Korle Bu Teaching Hospital, Accra, Ghana. METHODS: A prospective cross-sectional study was conducted at Korle Bu Teaching Hospital in 2015. Included women had a singleton pregnancy of 20-40weeks' duration, dated using an early ultrasonography scan, and normal fetal growth. Interviews were conducted to collect data on sociodemographic characteristics, followed by Doppler ultrasonography of the MCA. The resistive index, pulsatility index, systolic-to-diastolic ratio, and peak systolic velocity of the MCA were determined for all participants. RESULTS: Overall, 458 pregnant women were recruited. The peak systolic velocity increased with advancing gestational age and a positive correlation of r=0.725 (P<0.001) was demonstrated between the peak systolic velocity and the gestational age. The resistive index, pulsatility index, and systolic-to-diastolic ratio of the MCA decreased with advancing gestational age in a parabolic pattern. CONCLUSION: The reference curve for the peak systolic velocity increases with gestational age, whereas the other indices decrease in a parabolic pattern.

Maternal outcomes of hypertensive disorders in pregnancy at Korle Bu Teaching Hospital, Ghana.

OBJECTIVE: To determine maternal outcomes of hypertensive disorders in pregnancy at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana. METHODS: A cross-sectional study was conducted between January 1 and February 28, 2013. All women delivering at KBTH whose pregnancies were complicated by hypertensive disorders were identified. A structured questionnaire was administered, and the women were followed up on a daily basis until discharge from hospital. Medical records were also reviewed to identify any complications of hypertensive disorders. RESULTS: A total of 368 women were analyzed. Of 10 maternal deaths, 3 (30.0%) were due to hypertensive disorders in pregnancy, and specifically pre-eclampsia. Overall, 168 (45.7%) women with hypertensive disorders in pregnancy delivered by cesarean, 16 (4.3%) had placental abruption, 11 (3.0%) had pulmonary edema, 3 (0.8%) had HELLP syndrome, 2 (0.5%) had acute renal failure, 3 (0.8%) had an intracerebral hemorrhage or cerebrovascular accident, 21 (5.7%) were admitted to the intensive care unit, 7 (1.9%) had disseminated intravascular coagulation, and 58 (15.8%) had eclampsia. Cesarean delivery, admission to intensive care unit, and eclampsia were significantly more common in women with pre-eclampsia than in those with other hypertensive disorders. CONCLUSION: Hypertensive disorders in pregnancy are associated with high incidences of adverse maternal outcomes in Ghana, with significantly increased frequencies in women with pre-eclampsia.

Association of maternal sleep practices with pre-eclampsia, low birth weight, and stillbirth among Ghanaian women.

OBJECTIVE: To assess sleep practices, and investigate their relationship with maternal and fetal outcomes, among pregnant Ghanaian women. METHODS: In a cross-sectional study conducted at Korle Bu Teaching Hospital, Accra, Ghana, between June and July 2011, postpartum women were interviewed within 48hours of delivery about sleep quality and practices during pregnancy. Interviews were coupled with a systematic review of participants' medical charts for key outcomes including maternal hypertension, pre-eclampsia, premature delivery, low birth weight, and stillbirth. RESULTS: Most women reported poor sleep quality during pregnancy. Snoring during pregnancy was independently associated with pre-eclampsia (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.4-8.5; P=0.007). The newborns of women who reported supine sleep during pregnancy were at increased risk of low birth weight (OR, 5.0; 95% CI, 1.2-20.2; P=0.025) and stillbirth (OR, 8.0; 95% CI, 1.5-43.2; P=0.016). Low birth weight was found to mediate the relationship between supine sleep and stillbirth. CONCLUSION: The present findings in an African population demonstrate that maternal sleep, a modifiable risk factor, has a significant role in pre-eclampsia, low birth weight, and subsequently stillbirth.