Screening and managing a low-risk pregnant population using continuous-wave Doppler ultrasound in a low-income population: A cohort analytical study.

BACKGROUND: In South Africa (SA), the largest category of perinatal deaths is unexplained stillbirths. Two-thirds of these occur in the antenatal period and most fetuses are macerated, but at antenatal clinics the mothers were generally regarded as healthy, with low-risk pregnancies. Innovative methods are urgently required to detect fetuses at risk of stillbirth and manage the mothers appropriately. OBJECTIVES: To determine the prevalence of raised resistance indices (RIs) of the umbilical artery in a low-risk, low-income population and ascertain whether use of this information can prevent perinatal deaths. METHODS: A descriptive study was performed in Mamelodi township, east of Pretoria, SA, on pregnant women attending antenatal clinics draining to two community health centres (CHCs). These women, classified as having low-risk pregnancies, were screened for placental insufficiency using a continuous-wave Doppler ultrasound apparatus (Umbiflow) between 28 and 32 weeks' gestation. When a raised RI was detected, the mother was referred to a high-risk clinic and managed according to a standard protocol. A cohort analytical study compared women who attended antenatal care at the same clinics as the Umbiflow group but did not have an Umbiflow test with those who had an Umbiflow test. The outcomes of all the deliveries in Mamelodi were recorded. The prevalences of abnormal RIs, absent end-diastolic flow (AEDF), stillbirths and neonatal deaths were the main outcome measures. RESULTS: An Umbiflow RI was performed in 2 868 women, and pregnancy outcome was available for 2 539 fetuses (88.5%); 297 fetuses (11.7%) were regarded as at high risk. AEDF was found in 1.5% of the population screened with an outcome. There were 29 perinatal deaths in the Umbiflow group (low risk n=18, high risk n=11). The perinatal mortality rate for 12 168 women attending the CHCs and the antenatal clinics draining to the CHCs who did not have an RI was 21.3/1 000 births, significantly higher than that in the Umbiflow group (11.4/1 000 births) (risk ratio 0.58, 95% confidence interval 0.42 - 0.81). CONCLUSIONS: The prevalence of AEDF in this low-risk population is ~10 times higher than that previously recorded. Use of the information prevented a number of perinatal deaths, most of which would have been macerated stillbirths. Screening a low-risk pregnant population using continuous-wave Doppler ultrasound may substantially reduce the prevalence of unexplained stillbirths in SA.

Hyperferritinemia and markers of inflammation and oxidative stress in the cord blood of HIV-exposed, uninfected (HEU) infants.

OBJECTIVES: The purpose of this study was to evaluate markers of iron status and inflammation/oxidative stress in maternal and cord blood (CB) of HIV-infected and HIV-uninfected women as potential mechanisms for poor outcomes among HIV-exposed, uninfected (HEU) infants. METHODS: Maternal venous blood and CB specimens were obtained from 87 pregnant women (45 HIV-infected and 42 HIV-uninfected) enrolled at Kalafong Hospital, Pretoria, South Africa. Iron status [serum iron, ferritin and transferrin concentrations, transferrin saturation, soluble transferrin receptor (sTfR) concentration and the sTfR/log ferritin (sTfR/F) index], antenatal exposure to inflammation (CB C-reactive protein and interleukin-6 concentrations and haptoglobin switch-on status) and oxidative stress [total radical trapping ability of CB plasma (TRAP) and chronic oxidative stress (soluble receptor of advanced glycation end-products (sRAGE) concentration] were assessed in laboratory studies. RESULTS: There were no differences between the HIV-infected and HIV-uninfected groups in maternal haematological and iron indices, except that HIV-infected mothers had decreased white blood cell counts (P = 0.048) and increased serum ferritin concentrations (P = 0.032). Ferritin levels were significantly higher in CB than in maternal blood (P < 0.001) in both groups and further elevated in the CB of HEU infants (P = 0.044). There was also an inverse relationship between CB sTfR/F index and sRAGE (r = -0.43; P = 0.003) in the HIV-infected but not in the HIV-uninfected group. CONCLUSIONS: Our study showed for the first time that ferritin was significantly elevated in CB of HEU infants. The inverse relationship between sTfR/F index and sRAGE in CB suggests that chronic oxidative stress or RAGE axis activation in HIV-infected mothers may play a role in modulating ferritin levels.

Screening for anemia in pregnancy with copper sulfate densitometry.

OBJECTIVE: The copper sulfate method of screening for anemia was evaluated to determine its accuracy in antenatal patients. METHODS: In an antenatal clinic in a tertiary referral center, which also serves a local urban black community, 100 antenatal patients were prospectively tested for anemia by Coulter hemoglobin analysis in comparison with the copper sulfate test. The respective accuracy and costs of the tests were evaluated. RESULTS: Once initial technical difficulties had been overcome, the copper sulfate test proved accurate in detecting a hemoglobin level < 10 g% in pregnancy (sensitivity 94%, specificity 95%, positive predictive value 80%, negative predictive value 99%). The cost of the copper sulfate test is estimated to be less than 0.3% that of the Coulter test. CONCLUSION: The copper sulfate test is accurate and inexpensive, and can be recommended for screening for anemia in pregnancy.

The use of Doppler velocimetry of the umbilical artery before 24 weeks' gestation to screen for high-risk pregnancies.

OBJECTIVE: To describe the prevalence and natural history of absent end-diastolic velocities (AEDV) in the umbilical artery of the fetus between 16 and 24 weeks' gestation, and to evaluate its role as a screening test. DESIGN: Population-based descriptive study. SETTING: Tygerberg Hospital, Tygerberg, South Africa. The hospital serves a population from the lower socio-economic bracket. SUBJECTS: Doppler velocimetry was performed at routine ultrasound examinations for confirmation of gestational age in 496 women. MAIN OUTCOME MEASURES: The occurrence of perinatal death, small-for-gestational-age (SGA) babies and proteinuric hypertension. RESULTS: Forty-four (8.9%) patients had AEDVs at the first examination, but AEDV persisted in only 1. In this case, severe proteinuric hypertension developed unexpectedly at 29 weeks' gestation and the fetus needed delivery because of persistent late decelerations of the fetal heart rate pattern. There was a significant association between the group with AEDV at first examination and the development of proteinuric hypertension (P < 0.05), but no association with SGA babies. The association with proteinuric hypertension was too weak to be of clinical use. CONCLUSION: Doppler velocimetry of the umbilical artery, performed along with routine ultrasound examination to confirm gestational age, is not of use as a screening test for identifying high-risk pregnancies.

Management and outcome in tibial dysplasia.

Tibial dysplasia is a rare congenital deformity which must be distinguished from the more common fibular dysplasia. We have reviewed 24 patients with 35 affected legs. The classification system of Kalamchi and Dawe (1985) was found to be preferable to that of Jones, Barnes and Lloyd-Roberts (1978) as a guide to prognosis and management. We discuss the outcome of surgical treatment, recommending selective amputation for most cases.

Complications in 8509 laparoscopic Falope ring sterilizations performed under local anaesthesia.

During the 3-year period 1 January 1980-31 December 1982, 8509 laparoscopic Falope ring sterilizations were performed under local anaesthesia in rural areas of the Cape Province by the Sterilization Service of Tygerberg Hospital. Despite the fact that 476 of the patients had undergone previous lower abdominal surgery, major complications (anaphylactic shock after injection of lignocaine and inadvertent perforation of the bladder by the trocar) occurred in only 2 cases. It was not possible to complete the sterilization under local anaesthesia in 98 cases, resulting in a technical failure rate of 1.15%. A prospective study of the minor complications encountered among the 193 patients sterilized during November 1982 showed that torn tubes occurred in 3.1% and uterine perforation in 2.1%. This can be partially explained by the fact that evidence of previous pelvic infection was seen during laparoscopy in 9.3% of cases. The pregnancy rate after sterilization was 0.28% for the group as a whole.