Challenges in preterm birth research: Ghanaian perspective.

Preterm birth is highly prevalent in Ghana. It is a major public health concern because of the high burden as well as the associated immediate and long-term consequences including increased healthcare cost. Studies conducted in high-income countries may not be sufficiently generalizable in our context. Locally generated evidence-based interventions will be indispensable in improving the clinical management and prevention of preterm birth in the country. However, there are limited published literature on preterm birth and prematurity in the country. This review seeks to discuss the major challenges associated with preterm birth research in Ghana and proposes evidence-based strategies to improve biomedical and epidemiological research on preterm birth and prematurity. The limited high quality preterm birth research is partly attributable to a variety of challenges related to accurate gestational age estimation, research training, capacity and support including funding, efficient ethics committees, local and international collaboration as well as effective health management information systems. Other related challenges include unavailability of reliable internet connectivity, poor compensation for researchers and lack of conductive research environment. There is the need to expedite advocacy on implementation of practical interventions and strategies aimed at increasing high quality research in the area of preterm birth and prematurity in the country. A paradigm shift in preterm birth research with appropriate integration of concerted multidisciplinary research groups should be constituted to put basic science research to clinical practice as well as the prevention of preterm birth in the country.

Effects of factor v Leiden polymorphism on the pathogenesis and outcomes of preeclampsia.

BACKGROUND: Factor V Leiden polymorphism is a well-recognized genetic factor in the etiology of preeclampsia. Considering that Ghana is recording high incidence of preeclampsia, we examined if factor V Leiden is a contributory factor to its development and pregnancy outcomes. METHODS: STROBE consensus checklist was adopted to recruit eighty-one (81) consenting subjects after ethical clearance. Subjects were followed up till delivery to obtain outcomes of PE. Routine blood chemistry and proteinuria were done on all samples. Factor V Leiden was characterized by polymerase chain reaction and restriction fragment length polymorphism (RFLP). The data was captured as protected health information (PHI) and analyzed with SPSS version 22. RESULTS: Overall allelic frequencies found in FVL exon 10 were 0.67 and 0.33 for G and A alleles respectively. The FVL mutation was more in PE and hypertensive patients. Increased white blood cells, increased uric acid and a three - fold increment of AST / ALT ratio was observed in PE cases when stratified by FVL exons (exon 8 and 10). Significant differences were also observed between FVL and age, systolic blood pressure (SBP), diastolic blood pressure (DBP), liver enzymes, white blood cells (wbc), hemoglobin levels. CONCLUSION: FVL mutation allele frequency was 0.33, a first report. The mutation was associated with increased uric acid, liver enzymes and blood cell indices suggestive of acute inflammation.

Determinants and outcomes of preterm births at a tertiary hospital in Ghana.

INTRODUCTION: Preterm birth remains an important clinical challenge with significant short and long-term complications although its burden in the developing world is not adequately explored. This study determines the incidence, specific determinants and outcomes of preterm birth at a teaching hospital in Ghana. METHODS: Retrospective review of singleton births at Korle-Bu Teaching Hospital (KBTH) in Ghana between 1st January to 31st December, 2015. RESULTS: Preterm birth (PTB) occurred in 1478 (18.9%) out of 7801 single deliveries with etiological distribution of 879 (59.5%) spontaneous and 599 (40.5%) provider-initiated phenotypes. Gestational age categorization (WHO classification) of the preterm births included 68 (4.6%), 235 (15.9%) and 1175 (79.5%) below 28, between 28-31 and 32-36 weeks respectively. Adverse perinatal outcomes (low birth weight, perinatal deaths and poor Apgar scores) but not adverse maternal outcomes (cesarean and maternal deaths) were significantly higher in preterm compared to term births. Major factors associated with PTB include advanced maternal age (>35 years), poor antenatal care, hypertensive disorders and preterm premature rupture of membranes (PPROM) whiles obesity was protective. There were 156 stillbirths (105.6 per1000 births) comprising 93 macerated (62.9 per 1000 births) and 63 fresh stillbirths (42.6 per 1000 births), and perinatal mortality rate of 119.8 per 1000 births. DISCUSSION: Preterm birth is highly prevalent with significant adverse outcomes among singleton gestations at KBTH in Ghana, with disproportionately higher spontaneous etiology compared to provider-initiated phenotype. A paradigm shift in clinical management of preterm births/prematurity is urgently required with proactively dedicated multidisciplinary team and involvement of the global community.

LINKING UNINTENDED PREGNANCY TO THE BURDEN OF PRE-ECLAMPSIA IN A TERTIARY HOSPITAL IN GHANA.

BACKGROUND: Although pre-eclampsia remains a major public health challenge associated with significant adverse maternal outcomes especially in low-income countries, there are no well-defined screening and preventive measures. However, primary prevention of unintended pregnancy represents a viable and reliable measure for reducing the high maternal morbidity and mortality attributable to pre-eclampsia. OBJECTIVE: To determine and relate the proportion of unintended pregnancies among pre-eclamptic women to the burden of pre-eclampsia in Korle-Bu Teaching Hospital (KBTH), Accra, Ghana. METHOD: A cross-sectional study involving pregnant women with pre-eclampsia conducted at the KBTH, Accra, Ghana. Structured questionnaire was employed to obtain the required data regarding pregnancy intendedness and the use of modern contraception. Data on maternal mortality were also collected to determine maternal deaths related to pre-eclampsia. The data obtained were analyzed using SPSS version 18. RESULTS: There were 269 women with hypertensive disorders in pregnancy with 177 (65.8%) having pre-eclampsia out of which 100 met the inclusion criteria and 86 gave informed consent. Most, 71(82.6%), were married and 69 (80.2%) had had at least Junior High School education with a mean age of 29.34±1.08 years. The prevalence of unintended pregnancy among the women with pre-eclampsia was 32.6% as 28 patients were affected with 12 (13.9%) women on modern contraception prior to the index pregnancy. However, 83 (96.5%) had adequate knowledge on modern contraception and 58 (67.4%) reported of a previous history of induced abortion. As many as 16 (57.1%) women of those whose pregnancies were unintended were not using any form of contraception. During the study period, 36 maternal deaths occurred and 14 (38.9%) were due to pre-eclampsia. CONCLUSION: Unintended pregnancy constitutes a significant proportion of the burden of pre-eclampsia in the Ghanaian population resulting in high maternal morbidity and mortality. Increasing contraceptive usage in general represents a viable and effective primary preventive measure in reducing maternal mortality attributable to pre-eclampsia.

ASSESSMENT OF OXIDATIVE STRESS IN EARLY AND LATE ONSET PRE-ECLAMPSIA AMONG GHANAIAN WOMEN.

BACKGROUND: Pre-eclampsia is a multisystem pregnancy-related disorder with multiple theories regarding its aetiology resulting in lack of reliable screening tests and well-established measures for primary prevention. However, oxidative stress is increasingly being implicated in the pathogenesi of pre-eclampsia although conflicting findings have been reported. AIM: To determine and compare the levels of oxidative stress in early and late onset pre-eclampsia by measuring urinary excretion of isoprostane and total antioxidant power (TAP) in a cohort of pre-eclamptic women at Korle Bu Teaching Hospital. METHODOLOGY: This was a cross-sectional study conducted at Korle-Bu Teaching Hospital, Accra, Ghana involving pre-eclamptic women between the ages 18 and 45 years who gave written informed consent. Urinary isoprostane levels were determined using an enzyme-linked immunosorbent assay (ELISA) kit whereas the Total Anti-oxidant Power in urine samples was determined using Total Antioxidant Power Colorimetric Microplate Assay kit. The data obtained were analyzed using MEGASTAT statistical software package. RESULTS: We included 102 pre-eclamptic women comprising 68 (66.7%) and 34 (33.3%) with early-onset and late-onset pre-eclampsia respectively. There were no statistically significant differences between the mean maternal age, haematological indices, serum ALT, AST, ALT, albumin, urea, creatinine uric acid and total protein at the time of diagnosis. The mean gestational age at diagnosis of early and late onset pre-eclampsia were 31.65 ± 0.41 and 38.03 ± 0.21 respectively (p ˂ 0.001). Also, there were statistically significant differences between the diastolic blood pressure (BP), systolic BP and mean arterial pressure (MAP) at diagnosis of pre-eclampsia in the two categories. The mean urinary Isoprostane excretion was significantly higher in the early onset pre-eclamptic group (3.04 ± 0.34 ng/mg Cr) compared to that of the late onset pre-eclamptic group (2.36 ± 0.45 ng/mg Cr), (p=0.019). Urinary total antioxidant power (TAP) in early onset PE (1.64 ± 0.06) was lower but not significantly different from that of late onset PE (1.74 ± 0.09) with p = 0.369. CONCLUSION: Significantly increased urinary isoprostane excretion was detected in early onset pre-eclampsia compared to late onset pre-eclampsia, suggestive of increased oxidative stress in the former. However, there was no significant difference in total anti-oxidant power between the two categories of pre-eclampsia women although there was a tendency of reduced total antioxidant power in the women with early onset pre-ecalmpsia.

VAGINAL BIRTH AFTER A PREVIOUS CAESAREAN SECTION: CURRENT TRENDS AND OUTLOOK IN GHANA.

BACKGROUND: The optimal mode of subsequent delivery of women with prior caesarean birth remains a subject of intense research and debate in contemporary obstetric practice especially in low resource settings like West Africa where there are obvious systemic and management-related challenges associated with trial of scar. However, there is evidence that vaginal birth after caesarean section (VBAC) is safe in appropriately selected women in addition to adequate intrapartum monitoring and ready access to theatre when emergency CS is indicated. AIM & OBJECTIVES: The primary objective of the study was to determine the current trends and performance of VBAC in Ghana after decades of practice of trial of labour after caesarean section (TOLAC) in the mist of inherent challenges in deciding the optimal mode of childbirth for women with a previous caesarean birth. The secondary objective was to relate evidence based practice of TOLAC to obstetric practice in low resource settings like Ghana and provide recommendations for improving maternal and newborn health among women with prior caesarean birth. PATIENTS & METHODS: This was a retrospective study of the records of patients who had had a prior caesarean delivery and who then proceeded to deliver the next babies at the Korle Bu Teaching Hospital (KBTH) between Jan 2010 and Dec 2014. The data on demography, antenatal care, labour and delivery and outcomes were collected from the Labour and Recovery wards and the Biostatistics unit of the Maternity unit of the Hospital. Excluded were women with a previous CS who had multiple pregnancies and those with incomplete notes as well as those whose delivery plans were not predetermined antenatally.. The data were analyzed using SPSS version 20. RESULTS: There were 53,581 deliveries during the study period. Vaginal delivery was obtained in 31,870 (59.5%) pregnancies and 21,711(40.5%) had CS. Also, 6261 (11.7%) had had a prior CS and 2472 (39.5%) of these were selected for TOLAC while 2119 (33.8) were scheduled for planned repeat CS. There was an inverse trend between the annual caesarean sections rates and the proportion of women with one previous CS scheduled for TOLAC. There was a statistically significant difference between women who had successful or failed VBAC regarding maternal age, parity, number of ANC visits, gestational age at delivery, birth weight, Apgar score at 1 min and Apgar score at 5 min. Birth weights of less than 1.5kg, and 3.5Kg or greater were associated significantly with higher incidence failed TOLAC and emergency repeat CS. However, birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and emergency repeat CS. Birth weight of 2.5-2.99kg was associated with the lowest incidence of failed TOLAC and repeat CS. CONCLUSION: . There is a significantly high vaginal birth after caesarian section (VBAC) success rate among carefully selected women undergoing trial of scar in Ghana although a decreasing trend towards trial of labor after caesarian section (TOLAC) and a rising CS rate were determined. TOLAC remains a viable option for child birth in low resource settings like West Africa even though there are specific clinical and management related challenges to overcome. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remains the cornerstone to achieving high VBAC success rate with minimal adverse outcomes in such settings.