Prenatal diagnosis and postnatal outcome of closed spinal dysraphism.

OBJECTIVE: To evaluate the prenatal diagnosis of closed dysraphism (CD) and its correlation with postnatal findings and neonatal adverse outcomes. METHODS: A retrospective cohort study including pregnancies diagsnosed with fetal CD by prenatal ultrasound (US) and magnetic resonance imaging (MRI) at a single tertiary center between September 2011 and July 2021. RESULTS: CD was diagnosed prenatally and confirmed postnatally in 12 fetuses. The mean gestational age of prenatal imaging was 24.2 weeks, in 17% the head circumference was ≤fifth percentile and in 25% the cerebellar diameter was ≤fifth percentile. US findings included banana sign in 17%, and lemon sign in 33%. On MRI, posterior fossa anomalies were seen in 33% of cases, with hindbrain herniation below the foramen magnum in two cases. Mean clivus-supraocciput angle (CSA) was 74°. Additional anomalies outside the CNS were observed in 50%. Abnormal foot position was demonstrated prenatally in 17%. Neurogenic bladder was present in 90% of patients after birth. CONCLUSION: Arnold Chiari II malformation and impaired motor function can be present on prenatal imaging of fetuses with CD and may be associated with a specific type of CD. Prenatal distinction of CD can be challenging. Associated extra CNS anomalies are frequent and the rate of neurogenic urinary tract dysfunction is high.

Etiology of bacterial vaginosis and polymicrobial biofilm formation.

Microorganisms in nature rarely exist in a planktonic form, but in the form of biofilms. Biofilms have been identified as the cause of many chronic and persistent infections and have been implicated in the etiology of bacterial vaginosis (BV). Bacterial vaginosis is the most common form of vaginal infection in women of reproductive age. Similar to other biofilm infections, BV biofilms protect the BV-related bacteria against antibiotics and cause recurrent BV. In this review, an overview of BV-related bacteria, conceptual models and the stages involved in the polymicrobial BV biofilm formation will be discussed.

Autologous intrauterine transfusion in a case of anti-U.

BACKGROUND: Minor red blood cell antibodies are becoming a more common cause of hemolytic disease of the newborn. Anti-U are a rare alloantibody found almost exclusively in people of black descent. There is limited experience to guide the management of pregnancies complicated by anti-U. Furthermore, there is often no suitable cross-matched blood available for transfusion of a patient with anti-U. CASE REPORT: A 21-year-old P0G1 presented at 25 weeks' gestation with D- disease in pregnancy. She had a significant indirect antiglobulin test titer of 512. Anti-U were identified and no suitable cross-matched blood was available. Maternal blood was prepared for autologous intrauterine fetal transfusion. Two such transfusions were performed. RESULTS: A healthy fetus delivered at 32 weeks that did not require phototherapy or an exchange transfusion. CONCLUSION: Autologous transfusion of prepared maternal blood provides a safe option for intrauterine fetal therapy in pregnancies complicated by rare alloantibodies.

An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa.

BACKGROUND: Septic incomplete miscarriages remain a cause of maternal deaths in South Africa. There was an initial decline in mortality when a strict protocol based approach and the Choice of Termination of Pregnancy Act in South Africa were implemented in this country. However, a recent unpublished audit at the Pretoria Academic Complex (Kalafong and Steve Biko Academic Hospitals) suggested that maternal mortality due to this condition is increasing. The objective of this investigation is to do a retrospective audit with the purpose of identifying the reasons for the deteriorating mortality index attributed to septic incomplete miscarriage at Steve Biko Academic Hospital. METHODS: A retrospective audit was performed on all patients who presented to Steve Biko Academic Hospital with a septic incomplete miscarriage from 1(st) January 2008 to 31(st) December 2010. Data regarding patient demographics, initial presentation, resuscitation and disease severity was collected from the "maternal near-miss"/SAMM database and the patient's medical record. The shock index was calculated for each patient retrospectively. RESULTS: There were 38 SAMM and 9 maternal deaths during the study period. In the SAMM group 86.8% and in the maternal death group 77.8% had 2 intravenous lines for resuscitation. There was no significant improvement in the mean blood pressure following resuscitation in the SAMM group (p 0.67), nor in the maternal death group (p 0.883). The shock index before resuscitation was similar in the two groups but improved significantly following resuscitation in the SAMM group (p 0.002). Only 31.6% in the SAMM group and 11.1% in the maternal death group had a complete clinical examination, including a speculum examination of the cervix on admission. No antibiotics were administered to 21.1% in the SAMM group and to 33.3% in the maternal death group. CONCLUSION: The strict protocol management for patients with septic incomplete miscarriage was not adhered to. Physicians should be trained to recognise and react to the seriously ill patient. The use of the shock index in the identification and management of the critically ill pregnant patient needs to be investigated.

Antimicrobial susceptibility patterns of Ureaplasma species and Mycoplasma hominis in pregnant women.

BACKGROUND: Genital mycoplasmas colonise up to 80% of sexually mature women and may invade the amniotic cavity during pregnancy and cause complications. Tetracyclines and fluoroquinolones are contraindicated in pregnancy and erythromycin is often used to treat patients. However, increasing resistance to common antimicrobial agents is widely reported. The purpose of this study was to investigate antimicrobial susceptibility patterns of genital mycoplasmas in pregnant women. METHODS: Self-collected vaginal swabs were obtained from 96 pregnant women attending an antenatal clinic in Gauteng, South Africa. Specimens were screened with the Mycofast Revolution assay for the presence of Ureaplasma species and Mycoplasma hominis. The antimicrobial susceptibility to levofloxacin, moxifloxacin, erythromycin, clindamycin and tetracycline were determined at various breakpoints. A multiplex polymerase chain reaction assay was used to speciate Ureaplasma positive specimens as either U. parvum or U. urealyticum. RESULTS: Seventy-six percent (73/96) of specimens contained Ureaplasma spp., while 39.7% (29/73) of Ureaplasma positive specimens were also positive for M. hominis. Susceptibilities of Ureaplasma spp. to levofloxacin and moxifloxacin were 59% (26/44) and 98% (43/44) respectively. Mixed isolates (Ureaplasma species and M. hominis) were highly resistant to erythromycin and tetracycline (both 97% resistance). Resistance of Ureaplasma spp. to erythromycin was 80% (35/44) and tetracycline resistance was detected in 73% (32/44) of Ureaplasma spp. Speciation indicated that U. parvum was the predominant Ureaplasma spp. conferring antimicrobial resistance. CONCLUSIONS: Treatment options for genital mycoplasma infections are becoming limited. More elaborative studies are needed to elucidate the diverse antimicrobial susceptibility patterns found in this study when compared to similar studies. To prevent complications in pregnant women, the foetus and the neonate, routine screening for the presence of genital mycoplasmas is recommended. In addition, it is recommended that antimicrobial susceptibility patterns are determined.

Comparison of the new Mycofast Revolution assay with a molecular assay for the detection of genital mycoplasmas from clinical specimens.

BACKGROUND: Genital mycoplasmas are opportunistic bacteria that are associated with undesirable gynaecologic and reproductive events. Mycoplasmas are fastidious bacteria with increasing resistance to routine antimicrobials and often fail to grow on conventional culture methods. The commercial Mycofast Revolution assay permits the phenotypic detection and identification of genital mycoplasmas. Antimicrobial susceptibility testing against five antimicrobial agents with MICs corresponding to the CLSI guidelines can also be performed. This study aimed to compare the new commercially available Mycofast Revolution assay with a multiplex PCR assay. METHODS: Self-collected swabs were obtained from pregnant women attending the antenatal clinic of a tertiary academic hospital in Pretoria, South Africa from October 2012 to November 2012. These swabs were used to seed UMMt and modified Amies transport media. The seeded UMMt transported medium was used to inoculate the Mycofast Revolution assay for the identification, enumeration and antimicrobial susceptibility testing of genital mycoplasmas. Following DNA extraction from the modified Amies transport medium, specimens were subjected to a multiplex PCR assay for the detection of genital mycoplasmas. RESULTS: The Mycofast Revolution kit had a sensitivity and specificity of 77.3% (95% CI: 62.15% to 88.51%) and 80% (95% CI: 28.81% to 96.70%), respectively, against the PCR assay. The positive and negative predictive values were 97.1% (95% CI: 85.03% to 99.52%) and 28.6% (95% CI: 8.57% to 58.08%). Genital mycoplasmas were detected in 71.4% (35/49) of samples with the Mycofast Revolution assay with 49% (24/49) being Ureaplasma spp. and 22.4% (11/49) mixed strains. The multiplex PCR assay had a positivity rate of 89.8% (44/49) for genital mycoplasmas; mixed strains were present in 51% (25/49) of samples, Ureaplasma spp. in 16.3% (8/49) and M. hominis in 22.4% (11/49) of samples. CONCLUSIONS: There was a fair agreement (κ = 0.319) between the Mycofast Revolution assay and the mPCR assay. With the high prevalence rates of genital mycoplasmas, fast and efficient diagnostic methods are imperative to treat infections and minimise complications. The Mycofast Revolution assay is simple to use, has a short turn-around time and interpretation of results are straightforward. This assay circumvents common problems experienced with conventional culture and molecular methods in diagnostic laboratories where skilled personnel are limited and can be used as an alternative diagnostic assay.

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.

Growth Forms of Gardnerella spp. and Lactobacillus spp. on Vaginal Cells.

Bacterial vaginosis (BV) is a common vaginal condition in women of reproductive age. During BV development, BV-associated bacteria may form a polymicrobial biofilm, which predispose women to recurrent BV. The aim of the study was to investigate the growth forms of Gardnerella spp. and Lactobacillus spp. and to determine the association between the bacterial growth forms and clinical characteristics [urinary tract infection (UTI) symptoms, human immunodeficiency virus (HIV) infection and abnormal vaginal discharge] in women attending a tertiary hospital in Pretoria, South Africa. A first-void urine specimen was collected from 196 women and BV was diagnosed using the Nugent scoring and the Ison-Hay criteria (vaginal smear microscopy). Fluorescence in situ hybridisation (FISH) was performed to classify the growth forms ["dispersed" or "biofilm"]. Bacterial cells were categorized as "dispersed" if cells were scattered separately and as "biofilm" if bacterial aggregates on the vaginal epithelial cells were observed. BV was detected in 52 women (52/196; 27%) and in these women, Gardnerella spp. were predominantly present in biofilms (46/52; 88% for Nugent scoring; and 45/50; 90% for Ison-Hay criteria), whereas Lactobacillus spp. were predominantly present in a dispersed form (38/52; 73% for Nugent scoring; and 37/50; 74% for Ison-Hay criteria). The odds of having BV increased when Gardnerella biofilms were present (p < 0.001), whereas the opposite was observed for Lactobacillus biofilms (p = 0.001). Neither Gardnerella spp. or Lactobacillus spp. (both dispersed or biofilms) had an association with the presence of UTI symptoms, HIV coinfection or abnormal vaginal discharge. In conclusion, this study demonstrated and confirmed that Gardnerella biofilms are associated with BV and that Lactobacillus spp. may form biofilms to protect against BV.

Discordant monoamniotic twins with Pena-Shokeir phenotype.

Pena-Shokeir phenotype is a rare disorder. However, its etiology is incompletely understood. It may be familial or may be due to anoxic-ischemic etiology. Although rare, it can affect one twin in a monoamniotic pregnancy, most likely due to early cord entanglement.

Evaluating current knowledge of legislation and practice of obstetricians and gynaecologists in the management of fetal remains in South Africa.

BACKGROUND: In the clinical setting, the main legislative provisions governing the management and 'disposal' of fetal remains in South Africa are the Choice on Termination of Pregnancy Act 92 of 1996 and the Births and Deaths Registration Act 51 of 1992. OBJECTIVES: To determine obstetricians' and gynaecologists' current knowledge of this legislation. Current practice with regard to certification of death and methods of disposal of fetal material was also reviewed. METHODS: A questionnaire-based study was conducted. The data collected included demographic details, qualifications, years of experience, working environment (public/private practice), responses to general questions reviewing knowledge of current legislation, and practical experience. RESULTS: Seventy-six questionnaires were returned, with practitioners from the private and public sectors nearly equally represented. It was found that there is a concerning gap in obstetricians' and gynaecologists' knowledge of the law, and that some practitioners are acting outside the scope of the law. The study further revealed that patients' needs are not properly accommodated under the current legislative provisions, because the law prevents certain remains from being respectfully managed. Conclusions. The study findings suggest that improved training of practitioners, together with possible law reform, are required to better serve the needs of patients.

Evaluation of a strict protocol approach in managing women with severe disease due to hypertension in pregnancy: a before and after study.

BACKGROUND: To evaluate whether the introduction of a strict protocol based on the systemic evaluation of critically ill pregnant women with complications of hypertension affected the outcome of those women. STUDY GROUP: Indigent South African women managed in the tertiary hospitals of the Pretoria Academic Complex. Since 1997 a standard definition of women with severe acute maternal morbidity (SAMM), also referred to as a Nearmiss, has been used in the Pretoria Academic Complex. All cases of SAMM and maternal deaths (MD) were entered on the Maternal Morbidity and Mortality Audit System programme (MaMMAS). A comparison of outcome of severely ill women who had complications of hypertension in pregnancy was performed between 1997-1998 (original protocol) and 2002-2003 (strict protocol). Data include women referred from outside the Pretoria Academic Complex area to the tertiary hospitals. RESULTS: Between 1997-1998 there were 79 women with SAMM and 18 maternal deaths due to complications of hypertension, compared with 91 women with SAMM and 13 maternal deaths in 2002-2003. The mortality index (MI) declined from 18.6% to 12.5% (OR 0.62, 95% CI 0.27-1.45). Statistically significant fewer women had renal failure (RR 0.37, 95% CI 0.21-0.66) and cerebral complications (RR 0.52, 95% CI 0.34-0.81) during the second period, and liver dysfunction (RR 0.27 95% CI 0.06-1.25) tended to be lower. However, there tended to be an increase in the number of women, who had immune system failure (RR 4.2 95% CI 0.93-18.94) and respiratory failure (RR 1.42 95% CI 0.88-2.29) although it did not reach significance. Cardiac failure remained constant (RR 0.84 95% CI 0.54-1.30). CONCLUSION: The strict protocol approach based on the systemic evaluation of severely ill pregnant women with complications of hypertension and an intensive, regular feedback mechanism has been associated with a reduction in the number of patients with renal failure and cerebral compromise.

Global obstetric medicine: Collaborating towards global progress in maternal health.

Globally, the nature of maternal mortality and morbidity is shifting from direct obstetric causes to an increasing proportion of indirect causes due to chronic conditions and ageing of the maternal population. Obstetric medicine can address an important gap in the care of women by broadening its scope to include colleagues, communities and countries that do not yet have established obstetric medicine training, education and resources. We present the concept of global obstetric medicine by highlighting three low- and middle-income country experiences as well as an example of successful collaboration. The article also discusses ideas and initiatives to build future partnerships within the global obstetric medicine community.

A cross-sectional study on the relationship of age, gestational age and HIV infection to bacterial vaginosis and genital mycoplasma infection.

OBJECTIVES: Pregnant women are especially at risk of developing complications when infected with reproductive tract infections (RTIs). The objective of this study was to determine the prevalence of bacterial vaginosis (BV) and genital mycoplasmas in pregnant women and investigate the associations between BV, genital mycoplasmas, HIV infection, age and gestational age. DESIGN: Cross-sectional study with descriptive and analytical components. SETTING: Antenatal clinic of a tertiary academic hospital in South Africa. PARTICIPANTS: 220 pregnant women older than 18 were included in the study and provided self-collected vaginal swabs. PRIMARY AND SECONDARY OUTCOMES: BV and genital mycoplasma colonisation and/or infection in women of differing age, gestational period and HIV status. RESULTS: The prevalence of BV was 17.7% (39/220) (95% CI 12.9 to 23.4), intermediate vaginal flora (IVF) 15% (33/220) (95% CI 10.56 to 20.42), and the overall prevalence of genital mycoplasmas was 84% (185/220) (95% CI 78.47 to 88.58). BV was significantly associated with HIV infection with an OR of 2.84 (95% CI 1.08 to 7.46 and p value=0.034). However, BV was inversely associated with gestational age with an OR of 0.08 (95% CI 0.01 to 0.42 and p value=0.003) for second trimester pregnancies and an OR of 0.03 (95% CI 0.01 to 0.17 and p value<0.001) for third trimester pregnancies using the first trimester as reference. IVF was significantly associated with HIV infection with an OR of 2.7 (95% CI 1.07 to 6.79 and p value=0.035) but not with age or gestational age. Genital mycoplasmas were not significantly associated with age, gestational age, HIV status, BV flora or IVF. CONCLUSIONS: The high infection rate of genital mycoplasmas and the association of BV with HIV found in this study reiterate the importance of screening for these RTIs in high-risk groups such as pregnant women.

Pilot social feasibility study for the establishment of a public human umbilical cord blood stem cell bank in South Africa.

There is a large unmet need in South Africa for bone marrow transplantation. Umbilical cord blood (UCB) is an important source of stem cells for the treatment of haematological and non-haematological diseases. Access to the two existing private umbilical cord blood stem cell banks (UCB SCBs) in South Africa is limited to individuals that can afford it, which further aggravates the ever increasing divide between families from different socio-economic classes. The problem is compounded by a severe global shortage of genetically compatible samples, representative of the South African demographics. Establishing a public human UCB SCB in South Africa would provide more South Africans with access to previously unavailable treatment in the form of affordable, genetically compatible stem cells for bone marrow transplantation. A public UCB SCB has many facets to consider, one of which is public preparedness and support for the bank. This was assessed in a social feasibility pilot study which is reported here. In addition to the findings of this social feasibility study, other important considerations for establishing a public human UCB SCB in SA include; (a) testing the samples for HIV and other infectious diseases (required for compliance with international regulatory standards); (b) flow cytometric analysis for enumeration of CD34+ UCB stem cells; (c) mapping of HLA genotypes/alleles; and (d) a study of the economic feasibility of this endeavour.The social feasibility study was conducted to gauge public preparedness and support for a public SCB through patient interviews and questionnaires. The process was dynamic due to its novel nature for interviewers and interviewees alike. Many obstacles were met and dealt with which lead to the compilation of results discussed here in the form of a pilot social feasibility study.In the South African context, we are faced with unique and rich challenges relating to cultural and religious differences that are further augmented by linguistic constraints, educational insufficiencies and logistical and administrative limitations. Complicating factors encountered during the informed consent process included cultural differences, religious practices, traditions and superstitions together with language constraints and an educational disparity.Despite many initial obstacles, preliminary results from the informed consent questionnaire were favourable with regard to the establishment of a public UCB SCB. These initial results prompted the revision of the questionnaire and interview process and the compilation of a more succinct and coherent definitive social feasibility study which will form a separate study and which we hope will ultimately assist in the decision of whether or not to establish a public UCB SCB in South Africa. Nevertheless, results from this pilot study appear to be favourable and highlight particular areas which could influence community support for a public SCB. Educating the general public with regard to the workings and benefits of public stem cell banking is the first step in determining the viability of such an undertaking-a unique and rich challenge in the South African context.

Common errors and remedies in managing postpartum haemorrhage.

Postpartum haemorrhage (PPH) is a major contributor to maternal morbidity and mortality. By only examining mortality, the full extent of the problem is not revealed and also it is important to evaluate the avoidable factors. This will identify the areas that need attention. The common errors include not treating anaemia in pregnancy, not practicing active management of the third stage of labour, delay in recognition, substandard care and lack of skills. The remedies include the correct medical treatment of PPH and the use of uterine tamponade. Cell savers can help to reduce the need for transfusion and transfusion associated complications. There are new treatment modalities such as embolisation that can be of value in certain settings.

Managing acute collapse in pregnant women.

The most important causes of acute collapse in pregnancy are pulmonary embolism, amniotic fluid embolism, acute coronary syndrome, thrombosed mechanical prosthetic heart valves, acute aortic dissection, cerebrovascular incidents and anaesthetic complications like failed intubation, anaphylaxis, and problems relating to regional or local anaesthetic agents. The management is based on supporting the different organ systems that are affected. The diagnosis of pulmonary embolism is based on a clinical suspicion supported by certain diagnostic test. Tests like D-dimers have their limitations and cannot be used alone to exclude the diagnosis especially when there is a high clinical suspicion. The choice of the best diagnostic tool is based upon weighing long-term risks to both mother and foetus on the one side and delaying the diagnosis on the other side. The management of acute coronary syndrome is based on immediate angiography and percutaneous coronary intervention. Although there are reports of the use of clopidrogel in pregnancy, there are few data on its effect on the foetus. There is no clinical evidence for fibrinolytic therapy as a reperfusion strategy in pregnancy and it is best avoided as the risk of haemorrhage outweighs the possible benefit of treatment. Patients with a prosthetic heart valve that present with a disappearance of the prosthetic heart sounds or a new murmur should get an urgent cardiac ultrasound to rule out a thrombosed prosthetic valve. Anaesthesia-related causes are an increasing cause of maternal morbidity and mortality.

Underlying medical conditions.

More than half of maternal deaths in the UK are due to pre-existing medical conditions, and medical emergencies often mimic acute obstetric conditions. An acute flare of systemic lupus erythaematosus, a thyroid storm or a phaeochromocytoma have many of the signs and symptoms of imminent eclampsia. Similarly, severe postpartum haemorrhage can result in diagnostic difficulties of medical conditions such as Addison's syndrome or acute renal failure. An acute collapse can be due to a pulmonary embolus, myocardial infarction, tachyarrhythmia or myasthenia gravis. These conditions are rare; however, unless they are considered in a differential diagnosis, they will not be diagnosed, to the detriment of the woman and her infant. This chapter deals with acute medical conditions occurring uncommonly in pregnant women. An obstetrician should know the initial steps to take in the emergency management of these cases.

The obstetrician's view: ethical and societal implications of non-invasive prenatal diagnosis.

We believe non-invasive prenatal diagnosis is about to have a massive impact on the way fetal medicine is practised. There will be many great advantages and improvements, but the technology also has the potential to be used for non-medical reasons such as sex selection and paternity testing. We discuss some of the issues that may face obstetricians in the future as a result of this emerging technology.