Audit as a tool for improving obstetric care in low- and middle-income countries.

Maternal and/or perinatal death review or audits aim to improve the quality of health services and reduce deaths due to causes identified. A death review audit cycle identifies causes of deaths and possible modifiable factors, these can point to potential breaks in the continuity of health care and other health systems faults and challenges. It is an important function of audit cycles to develop, implement, monitor, and review action plans to improve the service. The WHO has produced two handbooks (Making Every Baby Count and Monitoring Emergency Obstetric Care) to guide maternal and perinatal death reviews. Health worker related factors accounts for two thirds of aspects that, if done differently may have prevented the adverse outcome. This emphasises the need for skilled health care workers at every delivery and for deliveries to take place in health facilities.

Delivery outcomes of patients with pre-eclampsia at 27 - 34 weeks' gestation at Tygerberg Hospital, Cape Town, South Africa: A retrospective observational study.

BACKGROUND: Obstetricians are cognisant of the serious nature of hypertensive disorders in pregnancy. Despite a 17% overall reduction in maternal deaths in South Africa between 2011 and 2016, there was a 14% increase in deaths due to hypertension. Delivery is the only known cure for pre-eclampsia, but the question regarding the safest route of delivery remains difficult to answer. OBJECTIVES: To determine the success rate of induction of labour (IoL) in patients with early-onset pre-eclampsia with severe features (EOPES) before 34 weeks' gestation. Furthermore, the data from the induction group were compared with those of the caesarean delivery (CD) groups where patients were not eligible for IoL. Additional objectives were to identify variables that could influence the success rate, to determine whether any delivery method was associated with increased morbidity, to assess the short-term maternal and neonatal outcomes, and to make recommendations for future decision-making regarding delivery for women with EOPES. METHODS: In this single-institution retrospective observational study, all cases in which a decision for delivery was made before 34 weeks 0 days of gestation (or the infant's birthweight was ≤2 000 g with uncertain gestation) at Tygerberg Hospital, Cape Town, between 1 January and 30 June 2017 were identified from the electronic birth register. The cohort fitting the inclusion criteria was subdivided into IoL and CD groups. RESULTS: From a total of 3 938 deliveries, 168 patients met the inclusion criteria. IoL was indicated in 55 cases, resulting in 20 vaginal deliveries (VDs) (36%) and 35 CDs (64%). The remaining 113 patients were not candidates for IoL; of these, 89 required emergency CDs and 24 had semi-elective CDs. In the IoL group with abnormal umbilical artery Dopplers (UADs) there was 1 VD, and 4 CDs were performed for fetal compromise. Of cases with an estimated fetal weight (EFW) ≤3rd centile, emergency CD was required in 24 (65%), and 8 (22%) were considered for IoL, in 6 of which CD was required. CONCLUSIONS: Of the EOPES population, 36% had successful IoL that culminated in VD. VD was more likely to occur with fetal growth appropriate for gestational age. The likelihood of CD increased if the UAD was abnormal, if the EFW was ≤3rd centile or if eclampsia was present. The decision to induce should be considered carefully in these circumstances.

The association between preterm labour, perinatal mortality and infant death (during the first year) in Bishop Lavis, Cape Town, South Africa.

BACKGROUND: We present further analyses from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigated. OBJECTIVES: To describe pregnancy and neonatal outcome in a large prospective study where information on the outcome of pregnancy was known in >98.3% of participants and ultrasound was used to determine gestational age (GA). METHODS: As part of the Safe Passage Study of the PASS Network in Cape Town, South Africa, the outcomes of 6 866 singleton pregnancies were prospectively followed from recruitment in early pregnancy until the infant was 12 months old to assess pregnancy outcome. Fetal growth was assessed by z-scores of the birth weight, and GA at birth was derived from early ultrasound assessments. The effects of fetal growth restriction and preterm delivery on pregnancy outcome were determined. RESULTS: There were 66 miscarriages, 107 stillbirths at ≥22 weeks' gestation, 66 stillbirths at ≥28 weeks' gestation, 29 and 18 neonatal deaths at ≥22 and ≥28 weeks' gestation, respectively, and 54 post-neonatal deaths (28 days - 12 months). The miscarriage rate was 9.6/1 000 and the infant mortality rate 12.4/1 000. Of the births, 13.8% were preterm. For deliveries at ≥22 and ≥28 weeks, the stillbirth rates were 15.7 and 9.8/1 000 deliveries, respectively. For deliveries at ≥22 and ≥28 weeks, the neonatal death rates were 4.3 and 2.7/1 000 live births, respectively. For these pregnancies the perinatal mortality rates were 20.0/1 000 (≥22 weeks) and 12.5/1 000 (≥28 weeks), respectively. Only 15.9% of stillbirths occurred during labour (in 15.9% of cases it was uncertain whether death had occurred during labour). In the majority of cases (68.2%) fetal death occurred before labour, and 82.2% of stillbirths and 62.1% of neonatal deaths occurred in deliveries before 37 weeks. Including the miscarriages, stillbirths and infant deaths, there were 256 pregnancy losses; 77.3% were associated with deliveries before 37 weeks. Only 1.8% of all the women were HIV-positive, whereas the HIV-positive rate was 3.7% among those who had stillbirths. Birth weight was below the 10th centile in 25.6% of neonatal and post-neonatal deaths compared with 17.7% of survivors. CONCLUSIONS: Preterm birth and fetal growth restriction play significant roles in fetal, neonatal and infant losses.

Failure to perform assisted deliveries is resulting in an increased neonatal and maternal morbidity and mortality: An expert opinion.

The need to perform assisted vaginal delivery (AVD) has been regarded as self-evident. In high-income countries, rates of AVD range between 5% and 20% of all births. In South Africa, the rate of AVD is only 1%. This has resulted in increased neonatal morbidity and mortality due to intrapartum asphyxia, and increased maternal morbidity and mortality due to a rise in second-stage caesarean deliveries. In this article, we address the possible causes leading to a decrease in AVD and propose measures to be taken to increase the rates of AVD and subsequently reduce morbidity and mortality.

Maternal deaths from bleeding associated with caesarean delivery: A national emergency.

Maternal deaths associated with caesarean deliveries (CDs) have been increasing in South Africa over the past decade. The objective of this report is to bring national attention to this increasing epidemic of maternal deaths due to bleeding associated with CD in the majority of provinces of the country. Individual chart reviews of women who died from bleeding at or after CD show that 71% had avoidable factors. Among the steps we can take are to improve surgical skills and experience, especially in rural hospitals, to improve clinical observations in the immediate postoperative period and in the postnatal wards, and to ensure that appropriate oxytocic agents are given to prevent postpartum haemorrhage. CEOs and medical managers of health facilities, district clinical specialists, heads of obstetrics and gynaecology, and midwifery training institutions must show leadership and accountability in providing an appropriate environment to ensure that women who require CD receive the procedure for the correct indications and in a safe manner to minimise risks.

Maternal death and caesarean section in South Africa: Results from the 2011-2013 Saving Mothers Report of the National Committee for Confidential Enquiries into Maternal Deaths.

BACKGROUND: In the latest (2011-2013) Saving Mothers report, the National Committee for Confidential Enquiries into Maternal Deaths in South Africa (SA) (NCCEMD) highlights the large number of maternal deaths associated with caesarean section (CS). The risk of a woman dying as a result of CS during the past triennium was almost three times that for vaginal delivery. Of all the mothers who died during or after a CS, 3.4% died during the procedure and 14.5% from haemorrhage afterwards. Including all cases of death from obstetric haemorrhage where a CS was done, there were 5.5 deaths from haemorrhage for every 10,000 CSs performed. OBJECTIVE: To scrutinise the contribution or effect of the surgical procedure on the ultimate cause of death by a cross-cutting analysis of the 2011-2013 national data. METHODS: Data from the 2011-2013 triennial review were entered into an Excel database and analysed on a national and provincial basis. RESULTS: There were 1,243 maternal deaths where a CS was the mode of delivery and 1 471 deaths after vaginal delivery. More mothers died as a result of CS in the provinces where there is a low overall CS rate. The following CS categories were identified as specific problems: bleeding during or after CS, pre-eclampsia and eclampsia, anaesthesia-related deaths, pregnancy-related sepsis and acute collapse and embolism. CONCLUSION: This is an area of concern, and a concentrated effort should be done to make CS in SA safer. Several recommendations are

Advanced extra-uterine pregnancy--a case of fimbrial expulsion of the fetus with complete placental development in the fallopian tube.

A case report is presented of a 30-year-old woman, gravida 3 para 2, presented with an advanced extra-uterine pregnancy with complete development of the placenta in the fallopian tube.

Combined heterozygosity for methylenetetrahydrofolate reductase (MTHFR) mutations C677T and A1298C is associated with abruptio placentae but not with intrauterine growth restriction.

OBJECTIVE: This study was undertaken to investigate the involvement of MTHFR gene mutations C677T and A1298C implicated in vascular disease, in patients with abruptio placentae and intrauterine growth restriction (IUGR). STUDY DESIGN: DNA was extracted from blood samples of 54 patients with placental vasculopathy (18 patients with abruptio placentae and 36 with IUGR) and 114 control patients and amplified by the polymerase chain reaction (PCR). The resulting fragments were subjected to restriction enzyme analysis and resolved by gel electrophoresis. RESULTS: A significant association could be demonstrated between mutation A1298C and both abruptio placentae and IUGR. Combined heterozygosity for mutations C677T and A1298C was detected in 22.2% of abruptio placentae cases. CONCLUSIONS: Combined heterozygosity for MTHFR mutations C677T and A1298C may represent a genetic marker for abruptio placentae.

A case of hydatid cyst associated with postpartum maternal death.

A young, apparently healthy woman from a rural area in South Africa presented in the third trimester of pregnancy with a symptomatic abdominal mass between the uterine fundus and liver. The etiology was established to be an echinococcus cyst of the liver and medical treatment was initiated. The fetal outcome was good but the mother died 3 days postpartum due to an unusual but devastating complication of the hydatid cyst.

Maternal and fetal single nucleotide polymorphisms in the epoxide hydrolase and gluthatione S-transferase P1 genes are not associated with pre-eclampsia in the Coloured population of the Western Cape, South Africa.

Oxidative stress is thought to play an important role in the pathophysiology of pre-eclampsia. A defect in certain enzymes responsible for detoxification may cause prolonged exposure to reactive by-products and contribute to maternal endothelial as well as placental damage. Two polymorphisms affecting the function of the biotransformation enzymes epoxide hydrolase and glutathione S-transferase P1 were shown previously to be associated with pre-eclampsia in a Dutch population. The aim of this study was to determine if these two polymorphisms (maternal or fetal) contribute to pre-eclampsia in an anthropologically distinct population (the Western Cape region of South Africa) with a high incidence of the disease. Genomic DNA of mother - infant pairs with severe pre-eclampsia (n = 144), a population control group (n = 156) and control mother - infant pairs with uncomplicated pregnancy outcome (n = 45) were analysed for the EPHX and GSTP1 polymorphisms by polymerase chain reaction amplification and restriction enzyme digestion. Each polymorphism had a similar distribution in case and control subjects (mother and infant). The Val105/Val105 genotype of GSTP1 occurred at a higher frequency than reported for other populations. Neither maternal nor fetal EPHX Tyr113His and GSTP1 Ile105Val polymorphisms appear to contribute significantly to the pathophysiology of pre-eclampsia in the Coloured population of the Western Cape region of South Africa.