Integrated growth assessment in the first 1000 d of life: an interdisciplinary conceptual framework.

OBJECTIVES: Prenatal growth affects short- and long-term morbidity, mortality and growth, yet communication between prenatal and postnatal healthcare teams is often minimal. This paper aims to develop an integrated, interdisciplinary framework for foetal/infant growth assessment, contributing to the continuity of care across the first 1000 d of life. DESIGN: A multidisciplinary think-tank met regularly over many months to share and debate their practice and research experience related to foetal/infant growth assessment. Participants' personal practice and knowledge were verified against and supplemented by published research. SETTING: Online and in-person brainstorming sessions of growth assessment practices that are feasible and valuable in resource-limited, low- and middle-income country (LMIC) settings. PARTICIPANTS: A group of obstetricians, paediatricians, dietitians/nutritionists and a statistician. RESULTS: Numerous measurements, indices and indicators were identified for growth assessment in the first 1000 d. Relationships between foetal, neonatal and infant measurements were elucidated and integrated into an interdisciplinary framework. Practices relevant to LMIC were then highlighted: antenatal Doppler screening, comprehensive and accurate birth anthropometry (including proportionality of weight, length and head circumference), placenta weighing and incorporation of length-for-age, weight-for-length and mid-upper arm circumference in routine growth monitoring. The need for appropriate, standardised clinical records and corresponding policies to guide clinical practice and facilitate interdisciplinary communication over time became apparent. CONCLUSIONS: Clearer communication between prenatal, perinatal and postnatal health care providers, within the framework of a common understanding of growth assessment and a supportive policy environment, is a prerequisite to continuity of care and optimal health and development outcomes.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Pregnancy in Sub-Saharan Africa: A 6-Country Retrospective Cohort Analysis.

BACKGROUND: Few data are available on COVID-19 outcomes among pregnant women in sub-Saharan Africa (SSA), where high-risk comorbidities are prevalent. We investigated the impact of pregnancy on SARS-CoV-2 infection and of SARS-CoV-2 infection on pregnancy to generate evidence for health policy and clinical practice. METHODS: We conducted a 6-country retrospective cohort study among hospitalized women of childbearing age between 1 March 2020 and 31 March 2021. Exposures were (1) pregnancy and (2) a positive SARS-CoV-2 RT-PCR test. The primary outcome for both analyses was intensive care unit (ICU) admission. Secondary outcomes included supplemental oxygen requirement, mechanical ventilation, adverse birth outcomes, and in-hospital mortality. We used log-binomial regression to estimate the effect between pregnancy and SARS-CoV-2 infection. Factors associated with mortality were evaluated using competing-risk proportional subdistribution hazards models. RESULTS: Our analyses included 1315 hospitalized women: 510 pregnant women with SARS-CoV-2, 403 nonpregnant women with SARS-CoV-2, and 402 pregnant women without SARS-CoV-2 infection. Among women with SARS-CoV-2 infection, pregnancy was associated with increased risk for ICU admission (adjusted risk ratio [aRR]: 2.38; 95% CI: 1.42-4.01), oxygen supplementation (aRR: 1.86; 95% CI: 1.44-2.42), and hazard of in-hospital death (adjusted sub-hazard ratio [aSHR]: 2.00; 95% CI: 1.08-3.70). Among pregnant women, SARS-CoV-2 infection increased the risk of ICU admission (aRR: 2.0; 95% CI: 1.20-3.35), oxygen supplementation (aRR: 1.57; 95% CI: 1.17-2.11), and hazard of in-hospital death (aSHR: 5.03; 95% CI: 1.79-14.13). CONCLUSIONS: Among hospitalized women in SSA, both SARS-CoV-2 infection and pregnancy independently increased risks of ICU admission, oxygen supplementation, and death. These data support international recommendations to prioritize COVID-19 vaccination among pregnant women.

Implementing antenatal care recommendations, South Africa.

Despite progress in reduction in maternal deaths in South Africa, deaths due to complications of hypertension in pregnancy remain high at 26 deaths per 100 000 live births in 2016. The South African health ministry modified its existing four-visit antenatal care model to align with the World Health Organization's (WHO) 2016 recommendations for the number and content of antenatal care contacts. Implementation of the eight-contact antenatal care recommendations began in April 2017, after adaptation to the national context and nationwide trainings. In this article, we describe the stages of implementation and the monitoring of key indicators. We share lessons, particularly from the important early stages of nationwide scale-up and an analysis of the early results. We analysed samples of maternity case records in four catchment areas in the first year of the updated care model. The mean number of antenatal care contacts among five monthly samples of 200 women increased steadily from 4.76 (standard deviation, SD: 2.0) in March 2017 to 5.90 (SD: 2.3) in February 2018. The proportion of women with hypertension detected who received appropriate action (provision of medical treatment or referral) also increased from 83.3% (20/24) to 100.0% (35/35) over the same period. South Africa's experiences with implementation of the updated antenatal care package shows that commitment from all stakeholders is essential for success. Training and readiness are key to identifying and managing women with complications and developing an efficient antenatal care system accessible to all women.

En dépit des progrès observés dans la diminution des décès maternels en Afrique du Sud, les complications causées par l'hypertension durant la grossesse entraînent encore des pertes élevées, à savoir 26 sur 100 000 naissances en 2016. Le ministère de la Santé sud-africain a modifié son modèle de soins prénatals en quatre visites afin de s'aligner sur les recommandations 2016 de l'Organisation mondiale de la Santé (OMS) relatives au nombre et au type de contacts de soins prénatals. La mise en œuvre des recommandations de soins prénatals prévoyant au moins huit contacts a débuté en avril 2017, après adaptation au contexte du pays et formation à l'échelle nationale. Dans cet article, nous décrivons chaque étape de cette mise en œuvre et la surveillance des principaux indicateurs. Nous partageons les enseignements tirés, en particulier lors des premières étapes cruciales d'intensification au niveau national et d'analyse des résultats initiaux. Nous avons étudié des échantillons de dossiers de maternité dans quatre circonscriptions au cours de la première année d'instauration du nouveau modèle de soins. Le nombre moyen de contacts de soins prénatals sur cinq échantillons mensuels de 200 femmes a augmenté de manière stable, passant de 4,76 (écart type: 2,0) en mars 2017 à 5,90 (écart type: 2,3) en février 2018. Le pourcentage de femmes chez qui une hypertension a été détectée et qui ont bénéficié d'une prise en charge adéquate (traitement médical ou renvoi vers un spécialiste) a également augmenté, de 83,3% (20/24) à 100,0% (35/35) sur la même période. L'expérience de l'Afrique du Sud dans la mise en œuvre du nouveau modèle de soins prénatals montre qu'un engagement de la part de tous les intervenants est essentiel à la réussite de l'initiative. La formation et la préparation sont indispensables pour identifier et prendre en charge les femmes présentant des complications, mais aussi pour développer un système de soins prénatals efficace et accessible à toutes.

A pesar de los progresos realizados en cuanto a la reducción de las muertes maternas en Sudáfrica, las muertes por complicaciones debido a la hipertensión durante el embarazo siguen siendo elevadas, con 26 muertes por cada 100.000 nacidos vivos en 2016. El Ministerio de Salud de Sudáfrica modificó su actual modelo de atención prenatal de cuatro visitas para ajustarlo a las recomendaciones de la Organización Mundial de la Salud (OMS) para 2016 en cuanto al número y el contenido de los contactos de atención prenatal. La aplicación de las recomendaciones de atención prenatal de ocho visitas comenzó en abril de 2017, tras su adaptación al contexto nacional y la formación a nivel nacional. En el presente artículo se describen las etapas de aplicación y el seguimiento de los indicadores clave. Compartimos las lecciones, en particular, las importantes etapas iniciales de la ampliación a escala nacional y un análisis de los primeros resultados. Analizamos muestras de registros de casos de maternidad en cuatro zonas de captación en el primer año del modelo de atención actualizado. El número medio de contactos de atención prenatal entre cinco muestras mensuales de 200 mujeres aumentó de forma constante de 4,76 (desviación estándar, SD: 2,0) en marzo de 2017 a 5,90 (SD: 2,3) en febrero de 2018. La proporción de mujeres con hipertensión detectada que recibieron medidas adecuadas (suministro de tratamiento médico o remisión) también aumentó del 83,3% (20/24) al 100,0% (35/35) en el mismo período. Las experiencias en Sudáfrica en cuanto a la aplicación del conjunto de medidas actualizadas de atención prenatal demuestran que el compromiso de todos los interesados es esencial para el éxito. La formación y la preparación son fundamentales para identificar y tratar a las mujeres con complicaciones, así como para desarrollar un sistema eficiente de atención prenatal accesible a todas las mujeres.

Instruments for assisted vaginal birth.

BACKGROUND: Assisted vaginal births are carried out to expedite birth for the benefit of mothers and babies but are sometimes associated with significant morbidity for both. Various instruments are available, broadly divided into forceps and vacuum cups, and choice may be influenced by clinical circumstances, operator preference, experience and availability.  OBJECTIVES: To evaluate the different instruments in terms of success in achieving a vaginal birth, and the risk of morbidity for mother and baby. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (14 May 2021), and reference lists of retrieved studies. SELECTION CRITERIA: We selected randomised controlled trials of assisted vaginal birth using different instruments. The review did not include quasi-randomised trials, cluster-randomised trials or cross-over designs. The review included trials for which abstracts alone were available as long as there was sufficient information to assess eligibility.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the GRADE approach to assess the certainty of evidence.  The main outcomes assessed included failed delivery with allocated instrument, any maternal trauma, third- and fourth-degree tears, postpartum haemorrhage, any neonatal trauma, low Apgar and low umbilical artery pH.  MAIN RESULTS: We included 31 studies involving a total of 5754 women.  Risk of bias criteria were largely assessed as 'unclear', due to a lack of detail in trial reports. Blinding would have been challenging for all trials due to their inability to conceal the type of instrument used from either the woman or the operator, which is reflected in the risk of bias assessment. Any type of forceps versus any type of vacuum cup (12 studies, 3129 women) Forceps may be less likely to fail in achieving vaginal birth: risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.88; 11 studies, 3080 women; low certainty. 'Any maternal trauma' may be slightly more likely with forceps: odds ratio (OR) 1.53, 95% CI 0.98 to 2.40; 5 studies, 1356 women; low certainty; and third- or fourth-degree tears may also be more likely with forceps: RR 1.83, 95% CI 1.32 to 2.55; 9 studies, 2493 women; low certainty. There is no evidence of a difference in the incidence of postpartum haemorrhage (PPH) between the two groups: RR 1.71, 95% CI 0.59 to 4.95; 2 studies, 523 women; low certainty, because the evidence is very imprecise due to a very wide CI.  More women in the forceps group reported requiring pain relief. There is probably no evidence of difference in rates of low Apgar: RR 0.83, 95% CI 0.46 to 1.51; 7 studies, 1644 women; moderate certainty; or low umbilical artery pH in the forceps group compared to any vacuum: RR 1.33, 95% CI 0.91 to 1.93; 2 studies, 789 women; low certainty; both of these outcomes are imprecise and have wide CIs that include both benefit and harm. There were also lower rates of fetal trauma with 'any forceps' (cephalhematoma, retinal haemorrhage and jaundice). The composite outcome of 'any neonatal trauma' was not reported. Low-cavity forceps versus any vacuum cup (2 studies, 218 women) We included two small studies with 218 participants in this comparison, but we judged most of the evidence as very low certainty, hence it was not feasible to make judgements on the difference in the rates of failed delivery, any maternal trauma or third- and fourth- degree tears. PPH and low umbilical artery pH were not reported. Soft vacuum cup versus any rigid cup (9 studies, 1148 women) Failed delivery may be more likely in the soft vacuum cup group: RR 1.62, 95% CI 1.21 to 2.17; 9 studies, 1148 women; low certainty. There may be no difference in the rates of 'any maternal trauma': OR 0.63, 95% CI 0.24 to 1.67; 2 studies, 348 women; low certainty, but the confidence interval is wide, indicating possible benefit or harm. There may be no difference in the rates of third- or fourth-degree tears: RR 0.93, 95% CI 0.35 to 2.44; 4 studies, 619 women; low certainty. There is probably no difference in the rates of PPH: RR 0.89, 95% CI 0.49 to 1.61; 5 studies, 737 women; moderate certainty between the soft and rigid cup groups.   There may be little or no difference in the incidence of low Apgar scores: RR 0.82, 95% CI 0.49 to 1.37; 9 studies, 1148; low certainty; or low umbilical artery pH: RR 0.80, 95% CI 0.47 to 1.36; 1 study, 100 women; low certainty. Handheld vacuum versus any vacuum cup (4 studies, 968 women) There may be no difference in the rates of failures with allocated instrument: RR 1.35, 95% CI 0.81 to 2.25; 4 studies, 962 women; low certainty, any maternal trauma: OR 1.16, 95% CI 0.71 to 1.88; 2 studies; 394 women; low certainty, PPH: RR 0.31, 95% CI 0.03 to 2.92; 1 study, 164 women; low certainty, low umbilical artery pH: RR 1.06, 95% CI 0.71 to 1.59; 1 study, 164 women; low certainty, or low Apgar scores: RR 1.25, 95% CI 0.34 to 4.61; 3 studies, 784 women; low certainty) between the two groups. There is probably no difference in the rates of third- or fourth-degree tears between the 'handheld vacuum' and 'any vacuum cup' groups: RR 1.15, 95% CI 0.62 to 2.12; 4 studies, 962 women; moderate certainty. AUTHORS' CONCLUSIONS: This review provides low-certainty evidence that forceps may be more likely to achieve vaginal birth and have lower rates of fetal trauma, but at a greater risk of perineal trauma and higher pain relief requirements compared with vacuum cups. There was low-certainty evidence that rigid vacuum cups may be more likely to achieve a vaginal birth than soft cups but with more fetal trauma, whilst handheld vacuum cups had similar success rates compared to other cups. There was no evidence of a difference in the rates of third- or fourth-degree tears or postpartum haemorrhages between types of cups, but wide confidence intervals around the estimates indicate further research is needed in this area.

Prevalence of abnormal umbilical arterial flow on Doppler ultrasound in low-risk and unselected pregnant women: a systematic review.

BACKGROUND: While Doppler ultrasound screening is beneficial for women with high-risk pregnancies, there is insufficient evidence on its benefits and harms in low- and unselected-risk pregnancies. This may be related to fewer events of abnormal Doppler flow, however the prevalence of absent or reversed end diastolic flow (AEDF or REDF) in such women is unknown. In this systematic review, we aimed to synthesise available data on the prevalence of AEDF or REDF. METHODS: We searched PubMed, Embase, CINAHL, CENTRAL and Global Index Medicus with no date, setting or language restrictions. All randomized or non-randomized studies reporting AEDF or REDF prevalence based on Doppler assessment of umbilical arterial flow > 20 weeks' gestation were eligible. Two authors assessed eligibility and extracted data on primary (AEDF and REDF) and secondary (fetal, perinatal, and neonatal mortality, caesarean section) outcomes, with results presented descriptively. RESULTS: A total of 42 studies (18,282 women) were included. Thirty-six studies reported zero AEDF or REDF cases. However, 55 AEDF or REDF cases were identified from just six studies (prevalence 0.08% to 2.13%). Four of these studies were in unselected-risk women and five were conducted in high-income countries. There was limited evidence from low- and middle-income countries. CONCLUSIONS: Evidence from largely observational studies in higher-income countries suggests that AEDF and REDF are rare among low- and unselected-risk pregnant women. There are insufficient data from lower-income countries and further research is required.

Odon device for instrumental vaginal deliveries: results of a medical device pilot clinical study.

BACKGROUND: A prolonged and complicated second stage of labour is associated with serious perinatal complications. The Odon device is an innovation intended to perform instrumental vaginal delivery presently under development. We present an evaluation of the feasibility and safety of delivery with early prototypes of this device from an early terminated clinical study. METHODS: Hospital-based, multi-phased, open-label, pilot clinical study with no control group in tertiary hospitals in Argentina and South Africa. Multiparous and nulliparous women, with uncomplicated singleton pregnancies, were enrolled during the third trimester of pregnancy. Delivery with Odon device was attempted under non-emergency conditions during the second stage of labour. The feasibility outcome was delivery with the Odon device defined as successful expulsion of the fetal head after one-time application of the device. RESULTS: Of the 49 women enrolled, the Odon device was inserted successfully in 46 (93%), and successful Odon device delivery as defined above was achieved in 35 (71%) women. Vaginal, first and second degree perineal tears occurred in 29 (59%) women. Four women had cervical tears. No third or fourth degree perineal tears were observed. All neonates were born alive and vigorous. No adverse maternal or infant outcomes were observed at 6-weeks follow-up for all dyads, and at 1 year for the first 30 dyads. CONCLUSIONS: Delivery using the Odon device is feasible. Observed genital tears could be due to the device or the process of delivery and assessment bias. Evaluating the effectiveness and safety of the further developed prototype of the BD Odon Device™ will require a randomized-controlled trial. TRIAL REGISTRATION: ANZCTR ACTRN12613000141741 Registered 06 February 2013. Retrospectively registered.

Pelvimetry for fetal cephalic presentations at or near term for deciding on mode of delivery.

BACKGROUND: Pelvimetry assesses the size of a woman's pelvis aiming to predict whether she will be able to give birth vaginally or not. This can be done by clinical examination, or by conventional X-rays, computerised tomography (CT) scanning, or magnetic resonance imaging (MRI). OBJECTIVES: To assess the effects of pelvimetry (performed antenatally or intrapartum) on the method of birth, on perinatal mortality and morbidity, and on maternal morbidity. This review concentrates exclusively on women whose fetuses have a cephalic presentation. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2017) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (including quasi-randomised) assessing the use of pelvimetry versus no pelvimetry or assessing different types of pelvimetry in women with a cephalic presentation at or near term were included. Cluster trials were eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: Five trials with a total of 1159 women were included. All used X-ray pelvimetry to assess the pelvis. X-ray pelvimetry versus no pelvimetry or clinical pelvimetry is the only comparison included in this review due to the lack of trials identified that examined other types of radiological pelvimetry or that compared clinical pelvimetry versus no pelvimetry.The included trials were generally at high risk of bias. There is an overall high risk of performance bias due to lack of blinding of women and staff. Two studies were also at high risk of selection bias. We used GRADEpro software to grade evidence for our selected outcomes; for caesarean section we rated the evidence low quality and all the other outcomes (perinatal mortality, wound sepsis, blood transfusion, scar dehiscence and admission to special care baby unit) as very low quality. Downgrading was due to risk of bias relating to lack of allocation concealment and blinding, and imprecision of effect estimates.Women undergoing X-ray pelvimetry were more likely to have a caesarean section (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.19 to 1.52; 1159 women; 5 studies; low-quality evidence). There were no clear differences between groups for perinatal outcomes: perinatal mortality (RR 0.53, 95% CI 0.19 to 1.45; 1159 infants; 5 studies; very low-quality evidence), perinatal asphyxia (RR 0.66, 95% CI 0.39 to 1.10; 305 infants; 1 study), and admission to special care baby unit (RR 0.20, 95% CI 0.01 to 4.13; 288 infants; 1 study; very low-quality evidence). Other outcomes assessed were wound sepsis (RR 0.83, 95% CI 0.26 to 2.67; 288 women; 1 study; very low-quality evidence), blood transfusion (RR 1.00, 95% CI 0.39 to 2.59; 288 women; 1 study; very low-quality evidence), and scar dehiscence (RR 0.59, 95% CI 0.14 to 2.46; 390 women; 2 studies; very low-quality evidence). Again, no clear differences were found for these outcomes between the women who received X-ray pelvimetry and those who did not. Apgar score less than seven at five minutes was not reported in any study. AUTHORS' CONCLUSIONS: X-ray pelvimetry versus no pelvimetry or clinical pelvimetry is the only comparison included in this review due to the lack of trials identified that used other types or pelvimetry (other radiological examination or clinical pelvimetry versus no pelvimetry). There is not enough evidence to support the use of X-ray pelvimetry for deciding on mode of delivery in women whose fetuses have a cephalic presentation. Women who undergo an X-ray pelvimetry may be more likely to have a caesarean section.Further research should be directed towards defining whether there are specific clinical situations in which pelvimetry can be shown to be of value. Newer methods of pelvimetry (CT, MRI) should be subjected to randomised trials to assess their value. Further trials of X-ray pelvimetry in cephalic presentations would be of value if large enough to assess the effect on perinatal mortality.

A feasibility study of the use of UmbiFlow™ to assess the impact of heat stress on fetoplacental blood flow in field studies.

OBJECTIVE: To evaluate the use of UmbiFlow™ in field settings to assess the impact of heat stress on umbilical artery resistance index (RI). METHODS: This feasibility study was conducted in West Kiang, The Gambia, West Africa; a rural area with increasing exposure to extreme heat. We recruited women with singleton fetuses who performed manual tasks (such as farming) during pregnancy to an observational cohort study. The umbilical artery RI was measured at rest, and during and at the end of a typical working shift in women at 28 weeks or more of pregnancy. Adverse pregnancy outcomes (APO) were classified as stillbirth, preterm birth, low birth weight, or small for gestational age, and all other outcomes as normal. RESULTS: A total of 40 participants were included; 23 normal births and 17 APO. Umbilical artery RI demonstrated a nonlinear relationship to heat stress, with indication of a potential threshold value for placental insufficiency at 32°C by universal thermal climate index and 30°C by wet bulb globe temperature. CONCLUSIONS: The Umbiflow device proved to be an effective field method for assessing placental function. Dynamic changes in RI may begin to explain the association between extreme heat and APO with an identified threshold of effect.

Accuracy of a smartphone application for blood pressure estimation in Bangladesh, South Africa, and Tanzania.

Undetected and unmonitored hypertension carries substantial mortality and morbidity, especially during pregnancy. We assessed the accuracy of OptiBPTM, a smartphone application for estimating blood pressure (BP), across diverse settings. The study was conducted in community settings: Gaibandha, Bangladesh and Ifakara, Tanzania for general populations, and Kalafong Provincial Tertiary Hospital, South Africa for pregnant populations. Based on guidance from the International Organization for Standardization (ISO) 81,060-2:2018 for non-invasive BP devices and global consensus statement, we compared BP measurements taken by two independent trained nurses on a standard auscultatory cuff to the BP measurements taken by a research version of OptiBPTM called CamBP. For ISO criterion 1, the mean error was 0.5 ± 5.8 mm Hg for the systolic blood pressure (SBP) and 0.1 ± 3.9 mmHg for the diastolic blood pressure (DBP) in South Africa; 0.8 ± 7.0 mmHg for the SBP and -0.4 ± 4.0 mmHg for the DBP in Tanzania; 3.3 ± 7.4 mmHg for the SBP and -0.4 ± 4.3 mmHg for the DBP in Bangladesh. For ISO criterion 2, the average standard deviation of the mean error per subject was 4.9 mmHg for the SBP and 3.4 mmHg for the DBP in South Africa; 6.3 mmHg for the SBP and 3.6 mmHg for the DBP in Tanzania; 6.4 mmHg for the SBP and 3.8 mmHg for the DBP in Bangladesh. OptiBPTM demonstrated accuracy against ISO standards in study populations, including pregnant populations, except in Bangladesh for SBP (criterion 2). Further research is needed to improve performance across different populations and integration within health systems.

Coronavirus and Pregnancy: The Challenges of the 21st Century: A Review.

Despite many advances in medicine we are still faced with emerging pathogens. Pregnant women have been disproportionately affected by previous coronavirus outbreaks. The COVID-19 pandemic has not affected pregnant women as greatly as SARS-CoV and MERS, but has posed other challenges such as the need for quarantine and isolation, limited access to antenatal care, use of personal protective equipment (PPE), vaccine hesitancy and inequities in vaccine access and therapeutics between rich countries and the global south. This review will describe the impact of the significant coronaviruses on pregnancy, with special focus on the challenges being encountered by the SARS-CoV-2 global pandemic.

Early Childhood Growth Parameters in South African Children with Exposure to Maternal HIV Infection and Placental Insufficiency.

Maternal HIV exposure and intrauterine growth restriction (IUGR) due to placental insufficiency both carry major risks to early child growth. We compared the growth outcomes of children aged 18 months who had abnormal umbilical artery resistance indices (UmA-RI), as a marker of placental insufficiency, with a comparator group of children with normal UmA-RI during pregnancy, as mediated by maternal HIV infection. The cross-sectional study included 271 children, grouped into four subgroups based on HIV exposure and history of normal/abnormal UmA-RI, using available pregnancy and birth information. Standard procedures were followed to collect anthropometric data, and z-scores computed as per World Health Organization growth standards. Lower length-for-age z-scores (LAZ) were observed in children who were HIV-exposed-uninfected (CHEU) (-0.71 ± 1.23; p = 0.004) and who had abnormal UmA-RI findings (-0.68 ± 1.53; p < 0.001). CHEU with abnormal UmA-RI had lower LAZ (-1.3 ± 1.3; p < 0.001) and weight-for-age z-scores (WAZ) (-0.64 ± 0.92; p = 0.014) compared to the control group. The prevalence of stunting was 40.0% in CHEU with abnormal UmA-RI and 16.0% in CHEU with normal UmA-RI (p < 0.001; p = 0.016, respectively). In conclusion, maternal HIV exposure and placental insufficiency are independent risk factors for childhood stunting, with this risk potentiated when these two risk factors overlap.

Identifying the High-Risk Fetus in the Low-Risk Mother Using Fetal Doppler Screening.

Identifying the high-risk fetus in the low-risk pregnant mother (LRM) is a neglected area of research. Fetal growth restriction (FGR) is a major cause of stillbirths, especially in low- and middle-income countries (LMICs). FGR is very poorly detected particularly in healthy pregnant women classified as low risk. Umbiflow is an inexpensive continuous-wave Doppler ultrasound (CWDU) apparatus that is suitable for use by low-level health care providers for screening low-risk pregnant populations. It can easily detect umbilical artery blood flow in the cord, which correlates well with placental function, and poor placental function correlates well with FGR.Use of CWDU to screen an LMIC population of more than 7,000 LRMs has demonstrated a high prevalence of abnormal umbilical artery flow of 13%, and absent end-diastolic flow, which is associated with end-stage placental disease, was found in 1.2%. This is 10 times higher than previously reported in high-income countries. Screening with CWDU together with a standard protocol managing those pregnancies with abnormal placental blood flow resulted in a 43% reduction in stillbirths (risk ratio: 0.57; 95% confidence interval=0.29, 0.85) in this LRM population. Further, follow-up of infants who had abnormal umbilical artery blood flow showed that these infants had significantly less fat-free mass at ages 6 weeks, 10 weeks, 14 weeks, and 6 months, than those with normal umbilical artery blood flow (P<.015), confirming that CWDU was able to detect true FGR.Thus, screening with CWDU can detect the fetus at risk of stillbirth, and infants likely to have suboptimal growth and development postnatally. Screening with CWDU in LRMs opens the door to a step change in preventing stillbirths in LMICs.

Antenatal Doppler screening for fetuses at risk of adverse outcomes: a multicountry cohort study of the prevalence of abnormal resistance index in low-risk pregnant women.

INTRODUCTION: Few interventions exist to address the high burden of stillbirths in apparently healthy pregnant women in low- and middle-income countries (LMICs). To establish whether a trial on the impact of routine Doppler screening in a low-risk obstetric population is warranted, we determined the prevalence of abnormal fetal umbilical artery resistance indices among low-risk pregnant women using a low-cost Doppler device in five LMICs. METHODS: We conducted a multicentre, prospective cohort study in Ghana, India, Kenya, Rwanda and South Africa. Trained nurses or midwives performed a single, continuous-wave Doppler screening using the Umbiflow device for low-risk pregnant women (according to local guidelines) between 28 and 34 weeks' gestation. We assessed the prevalence of abnormal (raised) resistance index (RI), including absent end diastolic flow (AEDF), and compared pregnancy and health service utilisation outcomes between women with abnormal RI versus those with normal RI. RESULTS: Of 7151 women screened, 495 (6.9%) had an abnormal RI, including 14 (0.2%) with AEDF. Caesarean section (40.8% vs 28.1%), labour induction (20.5% vs 9.0%) and low birth weight (<2500 g) (15.0% vs 6.8%) were significantly more frequent among women with abnormal RI compared with women with normal RI. Abnormal RI was associated with lower birth weights across all weight centiles. Stillbirth and perinatal mortality rates were similar between women with normal and abnormal RI. CONCLUSION: A single Doppler screening of low-risk pregnant women in LMICs using the Umbiflow device can detect a large number of fetuses at risk of growth restriction and consequent adverse perinatal outcomes. Many perinatal deaths could potentially be averted with appropriate intervention strategies. TRIAL REGISTRATION NUMBER: CTRI/2018/07/01486.

The ability of continuous-wave Doppler ultrasound to detect fetal growth restriction.

BACKGROUND: Fetal growth restriction (FGR), defined as a fetus failing to reach its genetic growth potential, remains poorly diagnosed antenatally. This study aimed to assess the ability of continuous-wave Doppler ultrasound of the umbilical artery (CWD-UmA) to detect FGR in healthy women with low-risk pregnancies. METHODS AND FINDINGS: This prospective longitudinal descriptive cohort study enrolled infants born to low-risk mothers who were screened with CWD-UmA between 28-34 weeks' gestation; the resistance index (RI) was classified as normal or abnormal. Infants were assessed at 6, 10, 14 weeks, and 6 months postnatally for anthropometric indicators and body composition using the deuterium dilution method to assess fat-free mass (FFM). Neonates in the abnormal RI group were compared with those in the normal RI group, and neonates classified as small-for-gestational age (SGA) were compared with appropriate-for-gestational age (AGA) neonates. Eighty-one term infants were included. Only 6 of 26 infants (23.1%) with an abnormal RI value would have been classified as SGA. The abnormal RI group had significantly reduced mean FFM and FFM-for-age Z-scores at 6, 10, 14 weeks, and 6 months compared with the normal RI group (P<0.015). The SGA group's FFM did not show this consistent trend when compared to AGA FFM, being significantly different only at 6 months (P = 0.039). The main limitation of the study was the small sample size of the infant follow-up. CONCLUSIONS: Abnormal RI obtained from CWD-UmA is able to detect FGR and is considered a useful addition to classifying the neonate only by SGA or AGA at birth.

Maternal characteristics and pregnancy outcomes of hospitalized pregnant women with SARS-CoV-2 infection in South Africa: An International Network of Obstetric Survey Systems-based cohort study.

OBJECTIVE: To describe risk factors and outcomes of pregnant women infected with SARS-CoV-2 admitted to South African healthcare facilities. METHODS: A population-based cohort study was conducted utilizing an amended International Obstetric Surveillance System protocol. Data on pregnant women with SARS-CoV-2 infection, hospitalized between April 14, 2020, and November 24, 2020, were analyzed. RESULTS: A total of 36 hospitals submitted data on 673 infected hospitalized pregnant women; 217 (32.2%) were admitted for COVID-19 illness and 456 for other indications. There were 39 deaths with a case fatality rate of 6.3%: 32 (14.7%) deaths occurred in women admitted for COVID-19 illness compared to 7 (1.8%) in women admitted for other indications. Of the women, 106 (15.9%) required critical care. Maternal tuberculosis, but not HIV co-infection or other co-morbidities, was associated with admission for COVID-19 illness. Rates of cesarean delivery did not differ significantly between women admitted for COVID-19 and those admitted for other indications. There were 179 (35.4%) preterm births, 25 (4.7%) stillbirths, 12 (2.3%) neonatal deaths, and 162 (30.8%) neonatal admissions. Neonatal outcomes did not differ significantly from those of infected women admitted for other indications. CONCLUSION: The maternal mortality rate was high among women admitted with SARS-CoV-2 infection and higher in women admitted primarily for COVID-19 illness with tuberculosis being the only co-morbidity associated with admission.

Effect of SARS-CoV-2 Infection in Pregnancy on Maternal and Neonatal Outcomes in Africa: An AFREhealth Call for Evidence through Multicountry Research Collaboration.

In the African context, there is a paucity of data on SARS-CoV-2 infection and associated COVID-19 in pregnancy. Given the endemicity of infections such as malaria, HIV, and tuberculosis (TB) in sub-Saharan Africa (SSA), it is important to evaluate coinfections with SARS-CoV-2 and their impact on maternal/infant outcomes. Robust research is critically needed to evaluate the effects of the added burden of COVID-19 in pregnancy, to help develop evidence-based policies toward improving maternal and infant outcomes. In this perspective, we briefly review current knowledge on the clinical features of COVID-19 in pregnancy; the risks of preterm birth and cesarean delivery secondary to comorbid severity; the effects of maternal SARS-CoV-2 infection on the fetus/neonate; and in utero mother-to-child SARS-CoV-2 transmission. We further highlight the need to conduct multicountry surveillance as well as retrospective and prospective cohort studies across SSA. This will enable assessments of SARS-CoV-2 burden among pregnant African women and improve the understanding of the spectrum of COVID-19 manifestations in this population, which may be living with or without HIV, TB, and/or other coinfections/comorbidities. In addition, multicountry studies will allow a better understanding of risk factors and outcomes to be compared across countries and subregions. Such an approach will encourage and strengthen much-needed intra-African, south-to-south multidisciplinary and interprofessional research collaborations. The African Forum for Research and Education in Health's COVID-19 Research Working Group has embarked upon such a collaboration across Western, Central, Eastern and Southern Africa.

Obstetric medical care and training in South Africa.

Obstetric medicine as a speciality is yet to be developed in South Africa. South Africa is regarded as a developing country. The burden of HIV and metabolic syndrome creates a need for advanced maternal care. An increase has been noted in hypertension and gestational diabetes due to increasing maternal age and increasing prevalence of obesity. The South African National Committee on Confidential Enquiry into Maternal Deaths' 2015 Saving Mothers Report identified non-pregnancy-related infections as the leading cause of maternal deaths. Obstetric medicine care includes pre-conception, antepartum and postpartum care. This article aims to highlight the importance of obstetric medicine, even in a resource-poor setting. The current internal medicine and obstetrics and gynaecology training is discussed and emphasis is placed on the opportunity to create an obstetric medicine programme.

Preeclampsia and Long-term Renal Function in Women Who Underwent Kidney Transplantation.

OBJECTIVE: Preeclampsia often complicates pregnancies after maternal kidney transplantation. We aimed to assess whether preeclampsia is associated with kidney function decline either during the pregnancy or in the long term. METHODS: We performed an international multicenter retrospective cohort study. Renal function at conception, pregnancy outcomes, and short- and long-term graft outcomes were collected for women who were pregnant after renal transplantation and had transplant and obstetric care at the participating centers. In women who had multiple pregnancies during the study period, only the last pregnancy was included. Univariate and multivariable analyses were performed. RESULTS: We retrieved pregnancy outcomes and long-term renal outcomes for 52 women. Chronic hypertension was present at baseline in 27%. Mean estimated glomerular filtration rate (GFR) at start of pregnancy was 52.4±17.5 mL/min/1.73 m. Mean estimated GFR at delivery was 47.6±21.6 mL/min/1.73 m, which was significantly lower than at conception (P=.03). Twenty women (38%) developed preeclampsia. In multivariable analysis, women who developed preeclampsia had a 10.7-mL/min/1.73 m higher drop in estimated GFR between conception and delivery than women who did not develop preeclampsia (P=.02). Long-term estimated GFR follow-up was obtained at a median of 5.8 years (range 1.3-27.5 years). Mean estimated GFR at last follow-up was 38±23 mL/kg/1.73 m. Seventeen women (33%) experienced graft loss over the follow-up period. Incidence of graft loss was similar in women with and without preeclampsia in their last pregnancy (30% and 34%, respectively; P=.99). In multivariable analysis, the decrease in estimated GFR between conception and last follow-up was similar in women who experienced preeclampsia during pregnancy and those who did not (difference -2.69 mL/min/1.73 m, P=.65). CONCLUSION: Preeclampsia commonly complicates pregnancies after renal transplantation but is not associated with long-term renal dysfunction or graft loss.

Internal Herniation in Pregnancy After Gastric Bypass: A Systematic Review.

OBJECTIVE: To assess maternal and fetal outcomes of pregnancies complicated by internal herniation after Roux-en-Y gastric bypass. DATA SOURCES: Articles were identified through searches in online databases (ClinicalTrials.gov, MEDLINE, EMBASE, PubMed, and Google Scholar) from January 1980 to March 2015 for the following terms: [gastric bypass OR bariatric surgery] AND [pregnancy] AND [complication OR herniation OR obstruction]. Reference lists of relevant articles were hand-searched. Additionally, we searched our own hospital's obstetric database for cases of internal herniation after Roux-en-Y gastric bypass. METHODS OF STUDY SELECTION: Only articles in English and studies in humans were selected. Cases of internal herniation outside of pregnancy or internal herniation without a history of Roux-en-Y gastric bypass were excluded. Of 384 articles identified by the initial search, 22 were retained for further analysis. TABULATION, INTEGRATION, AND RESULTS: All retrieved articles were case reports or case series. There were no interventional studies. We retrieved 47 cases from the literature and five cases from our own database. The mean gestational age at diagnosis was 28.4±7.3 weeks. All women presented with abdominal pain. Nausea and vomiting were present in only 65%. Ultrasonography and laboratory results are usually noninformative, and computed tomography or magnetic resonance imaging confirmed the diagnosis in only 75% of cases. Nine of 52 women (17.3%) required bowel resections. There were two maternal deaths and three perinatal deaths, all in women treated later than 48 hours after onset of the symptoms. CONCLUSION: Internal herniation complicating pregnancy after Roux-en-Y gastric bypass typically presents with subtle signs in the third trimester of pregnancy. Timely recognition and early surgical intervention are associated with a reduced risk of bowel ischemia and maternal and fetal adverse outcomes.